ChanBeDu/relevant_section_length · Datasets at Hugging Face

73,682

101,131

35585

Discharge summary

report

Admission Date: [**2111-2-18**] Discharge Date: [**2111-3-18**] Date of Birth: [**2037-11-1**] Sex: F Service: NEUROLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 8850**] Chief Complaint: Mental status changes. Major Surgical or Invasive Procedure: Brain biopsy [**2111-2-23**] Central line placement [**2111-2-28**] Portacath placement [**2111-3-12**] G-tube placement [**2111-3-12**] History of Present Illness: This is a 73 year old female with history of alcohol abuse, cirrhosis, bipolar disorder, and hypothyroidism, who was transferred to [**Hospital1 18**] with mental status change, aphasia, left sided weakness and facial droop, and encephalopathy. She was found at outside hospital to have multiple brain lesions with mass effect on CT scan. Here an MRI of the head showed multiple, likely metastatic lesions of the brain. CT abd showed suspicious low attenuation lesion in dome of liver. CT head repeat showed multiple enhancing lesions including the largest in the right frontal lobe measuring 15 mm, most consistent with metastatic disease. Unchanged cerebral edema in the right frontal lobe with associated mass effect upon right lateral ventricle, and no interval development of hemorrhage or hydrocephalus. The patient underwent bipsy on 2/209 which has confirmed CNS lymphoma. Overnight ([**2111-3-3**]) the patient was transferred to the [**Hospital Unit Name 153**] after triggering for hypoxia, for closer observation given O2 sats in the 80's to low 90's while on a non re-breather venti mask. On CXR on [**2111-3-3**] the patient was found to have new collapse of the RML and RLL, in addition to enlarging pleural effusions compared to prior AP films. On repeat imaging, the RML and RLL collapse had resolved and the patient's oxygenation status improved. It is possible that the patient's hypoxia and RML/RLL collapse were due to her expanding pleural effusion or to a mucous plug. Given her improved clinical status, she was transferred back to the OMED floor. Past Medical History: - Bipolar disorder - Anxiety - Hypothyroidism - Chronic ETOH use - Left distal radial fracture in [**2110-8-22**], chronic back pain, recent fall with chin laceration and facial contusion, recent hospital admission for failure to thrive. Social History: Smokes 1 pack of cigarettes per day. There is a history of about half pint vodka per day but has stopped. She has home health aid for care for her 5 days/week. Family History: Non-contributory. Physical Exam: VITAL SIGNS: T 95.4 F, BP 94/48, HR 59, RR 20, O2sat 99% on RA. GENERAL: NAD. Oriented x3. SKIN: Full turgor. HEENT: NCAT. Sclera anicteric. Left sided facial droop improved. Thrush. Conjunctiva pink, no pallor or cyanosis of the oral mucosa. CARDIOVASCULAR: regular, normal S1, S2. PULMONARY: No chest wall deformities. Respirations were unlabored, decreased breath sounds at bases. Crackles on right base. ABDOMEN: Soft, non-tender, slightly-distended. g-tube site clean, dry, intact. EXTREMITIES: No clubbing or cyanosis. Radial and DP pulses 2+ NEUROLOGICAL EXAMINATION: Her Karnofsky Performance Score is 50. She is awake, alert, and oriented to person and hospital only. She cannot name this place or the date, season, or year. There is no right-left confusion but she cannot show me her thumb. She has psychomotor slowing. Her language apears fluent with good comprehension. Cranial Nerve Examination: Her pupils are equal and reactive to light, 3 mm to 2 mm bilaterally. Extraocular movements appears full; there is saccadic intrusion. She blinks to threat in the right, but not the left, visual field. She has a left facial droop. Corneal reflexes are intact bilaterally. Her hearing is grossly intact. Her tongue is midline. Palate goes up in the midline. Sternocleidomastoids and upper trapezius appear strong. Motor Examination: She moves the left side less well than the right. Her muscle strengths are, in general, [**5-26**] on the right and 4+/5 on the left. Her muscle tone is normal. Her reflexes are 3+ bilaterally. Her ankle jerks are absent. Her toes are down going. Sensory examination is notable for grimace to pinch applied to all 4 extremities. Coordination examination does not reveal gross appendicular dysmetria. She cannot walk. Pertinent Results: Labs on admission: [**2111-2-18**] 09:35PM AMMONIA-11* [**2111-2-18**] 06:50PM URINE HOURS-RANDOM [**2111-2-18**] 06:50PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG [**2111-2-18**] 06:50PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]->1.050 [**2111-2-18**] 06:50PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-15 BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG [**2111-2-18**] 06:08PM LACTATE-1.0 [**2111-2-18**] 06:00PM GLUCOSE-128* UREA N-19 CREAT-0.8 SODIUM-141 POTASSIUM-4.3 CHLORIDE-103 TOTAL CO2-29 ANION GAP-13 [**2111-2-18**] 06:00PM estGFR-Using this [**2111-2-18**] 06:00PM ALT(SGPT)-6 AST(SGOT)-12 LD(LDH)-142 CK(CPK)-30 ALK PHOS-80 TOT BILI-0.3 [**2111-2-18**] 06:00PM CK-MB-2 cTropnT-<0.01 [**2111-2-18**] 06:00PM TSH-0.88 [**2111-2-18**] 06:00PM T3-62* FREE T4-1.2 [**2111-2-18**] 06:00PM PHENYTOIN-9.3* VALPROATE-41* [**2111-2-18**] 06:00PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2111-2-18**] 06:00PM WBC-7.5 RBC-3.57* HGB-12.4 HCT-35.8* MCV-100* MCH-34.9* MCHC-34.8 RDW-12.7 [**2111-2-18**] 06:00PM NEUTS-84.3* LYMPHS-10.3* MONOS-3.6 EOS-1.3 BASOS-0.4 [**2111-2-18**] 06:00PM PLT COUNT-432 [**2111-2-18**] 06:00PM PT-14.2* PTT-28.7 INR(PT)-1.2* Labs on discharge: [**2111-3-18**] 12:00AM BLOOD WBC-3.4* RBC-2.72* Hgb-9.3* Hct-27.2* MCV-100* MCH-34.1* MCHC-34.1 RDW-14.1 Plt Ct-368 [**2111-3-18**] 12:00AM BLOOD Glucose-100 UreaN-21* Creat-0.3* Na-132* K-4.1 Cl-101 HCO3-26 AnGap-9 [**2111-3-17**] 12:00AM BLOOD ALT-37 AST-17 LD(LDH)-146 AlkPhos-60 TotBili-0.3 [**2111-3-18**] 12:00AM BLOOD Calcium-8.8 Phos-2.9 Mg-2.0 Tissue pathology [**2111-2-23**]: A) "-5": Gliotic brain tissue. "-4": Smear - Gliotic brain tissue. B) "-3": Gliotic brain tissue with scattered atypical round cells. "-2": Smear - Gliotic brain possibly with some necrosis. C) "-1": Gliotic brain tumor with reactive astrocytes, endothelial proliferation, and infiltration by atypical cells. "TP": Smear - Gliotic brain with atypical cells - could be met or infiltrating neoplasm. D) "+1": Gliotic brain tissue endothelial proliferation, a minute focus of necrosis, and infiltration by lymphoid cells. "+2": Smear - Gliotic brain tissue. focus of possible necrosis and heterogeneous round cell infiltrate. Favor lymphoma but would also consider inflammatory process, or metastatic neoplasm. E) "+3": High grade non-Hodgkin lymphoma, in keeping with a primary diffuse large B-cell lymphoma of the CNS, see note. "+4": Smear - Gliotic brain tissue. with heterogeneous small round cell infiltrate. Favor lymphoproliferative but would also consider inflammatory process, or other metastatic neoplasm. F) "+5":High grade non-Hodgkin lymphoma, in keeping with a primary diffuse large B-cell lymphoma of the CNS, see note. G) "Right brain lesion": Minute fragment of atypical glial cells, inflammatory cells and necrosis. The diagnostic lesion is best seen in Specimens E and F, although it is likely that there is some infiltration by lymphoma in B, C and D. Hematopathology note: (E), (F): High grade non-Hodgkin lymphoma, in keeping with a primary diffuse large B-cell lymphoma of the CNS, see note. Note: Sections E and F show similar features. There is a diffuse dense infiltrate of atypical mononuclear cells comprised of predominantly large cells, within finely dispersed chromatin and multiple small nucleoli. There are focal areas of necrosis/apoptosis, frequent mitosis as well as perivascular cuffing noted (see slide F). Reticulin stain highlights multiple vessel walls. By immunohistochemistry performed on blocks E and F, the large atypical cells are diffusely immuno reactive for leucocyte common antigen LCA (CD45) as well as pan B cell marker, CD20, and co-express bcl-6 and MUM-1. They do not aberrantly express CD10 or TdT. By MIB-1 staining, the proliferative fraction among the neoplastic cells is nearly 100%. CD3 highlights few admixed T cells. EBV encoded RNA in situ hybridization stain for [**Doctor Last Name 3271**] [**Doctor Last Name **] virus is negative. Overall, the findings are of a high grade B-cell non-Hodgkin lymphoma in keeping with a primary diffuse large B cell lymphatic of the CNS. CT head [**2111-2-18**]: Multiple enhancing cerebral lesions, with vasogenic edema surrounding the largest of these in the right frontal lobe. Findings are concerning for metastatic disease. MRI head [**2111-2-20**]: Multiple enhancing masses suggesting most likely malignant neoplasm, metastatic or primary. Diffuse white matter infiltration and cortical infiltration raises the possibility of either glial infiltration, or swelling related to recent seizure activity. ECHO [**2111-3-2**]: The left atrium is mildly dilated. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). The estimated cardiac index is normal (>=2.5L/min/m2). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets appear structurally normal with good leaflet excursion. There is no aortic valve stenosis. No aortic regurgitation is seen. The anterior mitral valve leaflet is mildly thickened. Mild (1+) mitral regurgitation is seen. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. IMPRESSION: Normal biventricular cavity sizes with preserved global and regional biventricular systolic function. Mitral leaflet thickening with mild mitral regurgitation. Video swallow [**2111-3-13**]: Moderate oropharyngeal dysphagia, including aspiration of thin liquid. The patient is at significant risk for aspiration of other consistency if eating too quickly. Patient should repeat bedside swallow evaluation in one to two weeks. The swallowing pattern correlates to a dysphagia outcome severity scale (DOSS) rating of 3, moderate dysphagia. Please refer to the speech therapist's note for full evaluation and recommendation. Brief Hospital Course: This is a 73 year old female with history of alcohol abuse, cirrhosis, bipolar disorder, and hypothyroidism, who was transferred to [**Hospital1 18**] with mental status change, aphasia, left sided weakness and facial droop, and encephalopathy. She was found at outside hospital to have multiple brain lesions with mass effect on CT scan. Here an MRI of the head showed multiple, likely metastatic lesions of the brain. CT abd showed suspicious low attenuation lesion in dome of liver. CT head repeat showed multiple enhancing lesions including the largest in the right frontal lobe measuring 15 mm, most consistent with metastatic disease. Unchanged cerebral edema in the right frontal lobe with associated mass effect upon right lateral ventricle, and no interval development of hemorrhage or hydrocephalus. The patient underwent biopsy on [**2111-2-23**] which has confirmed CNS lymphoma. Overnight ([**2111-3-3**]) the patient was transferred to the [**Hospital Unit Name 153**] after triggering for hypoxia, for closer observation given O2 sats in the 80's to low 90's while on a non re-breather venti mask. On CXR on [**2111-3-3**] the patient was found to have new collapse of the RML and RLL, in addition to enlarging pleural effusions compared to prior AP films. She was diuresed and started on vanc/unasyn on [**2111-3-4**] for aspiration. On [**2111-3-4**], on repeat imaging, the RML and RLL collapse had resolved and the patient's oxygenation status improved. It is possible that the patient's hypoxia and RML/RLL collapse were due to her expanding pleural effusion or to a mucous plug. Given her improved clinical status, she was transferred back to the OMED floor. The patient received a G-tube and PORT placement on [**2111-3-12**]. She also received her second round of Methotrexate chemotherapy after these procedures and Methotrexate levels followed until clear. Her renal function remained normal throughout this treatment. At the time of discharge, she is alert and oriented x 3 with increasing function of her left upper and lower extremities to 4/5 strength. She will be returning in two-weeks for her next methotrexate treatment. Medications on Admission: 1. Synthroid 88 mcg daily 2. depakote 250mg daily 3. Ativan prn 4. lasix 20mg daily 5. folate 1mg daily 6. KCl 40meq daily 7. Vit B1 100mg daily 8. Colace 100mg [**Hospital1 **] 9. Prilosec 20mg [**Hospital1 **] 10. MOM prn 11. Dulcolax prn Discharge Medications: 1. Dexamethasone 2 mg Tablet Sig: One (1) Tablet PO once a day: Give by g-tube. Tablet(s) 2. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day): DVT prophylaxis. 3. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed: give by g-tube. 4. Insulin Regular Human 100 unit/mL Solution Sig: sliding scale Injection ASDIR (AS DIRECTED). 5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 6. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2 times a day). 7. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal [**Hospital1 **] (2 times a day) as needed. 8. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 9. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 10. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Polyethylene Glycol 3350 100 % Powder Sig: Seventeen (17) g PO DAILY (Daily) as needed. 12. Midodrine 5 mg Tablet Sig: Two (2) 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. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day) as needed. 15. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush Peripheral line: Flush with 3 mL Normal Saline every 8 hours and PRN. 16. Famotidine 20 mg IV Q12H 17. LeVETiracetam 1000 mg IV BID 18. Lorazepam 0.5-2 mg IV Q4H:PRN for sz > 3 min or 3 per hour 19. Heparin Flush (10 units/ml) 1 mL IV PRN line flush Temporary Central Access-Floor: Flush with 10 mL Normal Saline followed by Heparin as above daily and PRN. 20. Heparin Flush (10 units/ml) 5 mL IV PRN line flush Indwelling Port (e.g. Portacath), heparin dependent: Flush with 10 mL Normal Saline followed by Heparin as above daily and PRN per lumen. 21. Heparin Flush (100 units/ml) 5 mL IV PRN DE-ACCESSING port Indwelling Port (e.g. Portacath), heparin dependent: When de-accessing port, instill Heparin as above per lumen. Discharge Disposition: Extended Care Facility: [**Hospital 169**] Center Discharge Diagnosis: Central Nervous System Lymphoma. Discharge Condition: Stable, afebrile. Discharge Instructions: You were admitted for altered mental status and weakness and were found to have a lymphoma in your brain. This was treated with neurosurgery and two rounds of chemotherapy (methotrexate). You are scheduled to return in two weeks for your next round of chemotherapy (see appointment below). In the meantime, you will continue your physical therapy and rehabilitation. Please see you medication list for details. You are on dexamethasone, a steroid which helps with swelling in the brain. Please return to the hospital or call your doctor if you have temperature greater than 101, shortness of breath, worsening difficulty with swallowing, chest pain, abdominal pain, diarrhea, or any other symptoms that you are concerned about. Followup Instructions: You will be contact[**Name (NI) **] for follow up in two weeks for your next Methotrexate treatment. Please call [**Telephone/Fax (1) 1844**] for exact appointment and directions. Completed by:[**2111-3-26**]

[ "342.90", "285.9", "934.9", "305.1", "571.2", "202.80", "348.5", "518.81", "276.1", "296.80", "511.9", "345.00", "348.30", "518.0" ]

icd9cm

[ [ [] ] ]

[ "43.11", "96.71", "96.04", "03.31", "86.07", "38.93", "96.6", "99.25", "01.13" ]

icd9pcs

[ [ [] ] ]

14966, 15018

10410, 12579

339, 477

15094, 15113

4380, 4385

15895, 16105

2540, 2559

12870, 14943

15039, 15073

12605, 12847

15137, 15872

2574, 4361

277, 301

5694, 10387

505, 2083

4399, 5675

2105, 2344

2360, 2524

24,221

159,757

25969+57471

Discharge summary

report+addendum

Admission Date: [**2192-12-30**] Discharge Date: [**2193-1-14**] Date of Birth: [**2130-4-12**] Sex: F Service: SURGERY Allergies: Imodium A-D / Penicillins Attending:[**First Name3 (LF) 5880**] Chief Complaint: Pseudomembranous colitis Major Surgical or Invasive Procedure: Subtotal colectomy and ileostomy History of Present Illness: The patient is a 62 year-old female, transferred from [**Hospital1 5109**] after a four day bout of progressive colitis which did not respond to antibiotic therapy. She was initially transferred to the medicine service and we were consulted. She had a high white count, lactate level and a very tender, distended abdomen. The decision was made to proceed with a subtotal abdominal colectomy. Past Medical History: PMH: COPD, GERD, Barrett's esophagus, diverticulitis, IBD, colon polyp, hypertension, hyperlipidemia, hidradenitis, s/p anterior cervical fusion C5-C7, TMJ, Raynaud's, depression, anxiety. Pertinent Results: Pathology: 1. Pseudomembranous colitis, due to C. difficile infection. 2. There is diffuse disease of the cecum and colon, extending to the distal margin. 3. Ileal segment, within normal limits. Echocardiogram [**12-31**]: Limited views. The LV is not seen well enough to make a reasonable assessment of either LV function or size. There is a large pleural effusion present. CTA chest [**1-10**]: IMPRESSION: 1. No PE. 2. Small left pneumothorax. 3. Diffuse emphysematous changes. 4. Moderate bilateral pleural effusions and associated basilar atelectasis. Brief Hospital Course: Ms. [**Known lastname 20825**] is a 62-year-old woman s/p rx with Augmentin for URI 2-3 weeks ago who was admitted to [**Hospital1 2436**]([**2192-12-24**]) with c. diff pancolitis. On [**2192-12-26**] she was transferred to the ICU with hypotension (MAP 60)/sepsis and intubated on [**2192-12-27**] with metabolic acidosis (HCO3 10). On [**2192-12-28**] she had thoracentesis to remove bilateral pleural effusions (600 mL left, 800 mL right). She was transferred to [**Hospital1 18**] for ?toxic megacolon and ?ischemic colitis. She received a subtotal colectomy with ileostomy on [**2192-12-30**], with no immediate complications and 100 cc blood loss. The morning after the operation sedation was held and she remained unresponsive without spontaneous movement or withdrawal of her extremities to pain. Neurology was consulted. [**12-31**] CT head: No evidence for intracranial hemorrhage. [**12-31**] CT C-spine w/o contrast: Significant spinal stenosis with cervical spinal cord compression is present at the C6-C7 level secondary to a large left-sided posterior spondylytic ridge. MRI head No evidence of an acute hemorrhage. No acute infarct identified. Findings consistent with chronic small vessel ischemia or infarct in the pons and cerebral deep white matter. Patient's responsiveness improved over the next several days and lumbar puncture was held. She eventually made a full neurological recovery, delerium cleared, and it is ultimately unclear what the pons pathology seen on MRI is attributed to. Ortho spine was also consulted and did not see any need for surgical intervention given the c-spine findings. Patient was started on TPN. Imaging revealed a right-sided pneumothorax as well as rather large pleural effusion, and a right-sided chest tube was placed that drained several liters of fluid over the first several days. This enabled vent weaning and eventual extubation. She was transferred out of the ICU on [**2193-1-7**]. Once bowel function returned she was gradually started on a diet and her TPN was discontinued. Her chest tube was removed and she continued to improve clinically. Several days prior to discharge she lost IV access and a picc line was placed in IR. Later that day the patient became increasingly dyspneic and her hypoxic. CTA was performed that did not reveal a PE, and she ruled out for an MI. Her picc line was eventually pulled back 4 cm to good effect. CT did however show that her pleural effusions remained and she continues to have an oxygen requirement now at baseline. She is being discharged to rehab on POD11 afebrile, with stable cardiopulmonary, tolerating a full diet, delerium nearly 100% gone. She has completed 12 days of flagyl for cdifficile and is no longer cdiff positive. She will continue for 2 additional days to complete a 2 week course. Follow-up with Dr. [**Last Name (STitle) **] is outlined below. Discharge Medications: 1. Artificial Tear Ointment 0.1-0.1 % Ointment Sig: One (1) Appl Ophthalmic PRN (as needed). 2. Polyvinyl Alcohol 1.4 % Drops Sig: 1-2 Drops Ophthalmic PRN (as needed). 3. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb Inhalation Q6H (every 6 hours). 4. Albuterol Sulfate 0.083 % Solution Sig: One (1) neb Inhalation Q4-6H (every 4 to 6 hours) as needed for SOB, wheeze. 5. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 6. Insulin NPH Human Recomb 100 unit/mL Cartridge Sig: Five (5) units Subcutaneous twice a day. 7. Insulin Regular Human 100 unit/mL Solution Sig: AS DIREC UNITS Injection four times a day: PER ISS PROTOCOL AT REHAB. 8. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 9. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 10. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 11. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 12. Aluminum-Magnesium Hydroxide 225-200 mg/5 mL Suspension Sig: 15-30 MLs PO QID (4 times a day) as needed. 13. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. Heparin (Porcine) 5,000 unit/0.5 mL Syringe Sig: 5000 (5000) units Injection three times a day. 15. Venlafaxine 75 mg Capsule, Sust. Release 24HR Sig: Two (2) Capsule, Sust. Release 24HR PO DAILY (Daily). 16. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 2 days. Discharge Disposition: Extended Care Facility: [**Hospital1 2436**] Nursing Center - [**Hospital1 2436**] Discharge Diagnosis: Pseudomembranous colitis, due to C. difficile infection Discharge Condition: Stable Discharge Instructions: Go to an Emergency Room if you experience new and continuing nausea, vomiting, fevers (>101.4 F), chills, or shortness of breath. Also go to the ER if your wound becomes red, swollen, warm, or produces pus. If you experience clear drainage from your wounds, cover them with a clean dressing and stop showering until the drainage subsides for at least 2 days. No heavy lifting or exertion for at least 6 weeks. No driving while taking pain medications. Narcotics can cause constipation. Please take an over the counter stool softener such as Colace or a gentle laxative such as Milk of Magnesia if you experience constipation. Be sure to take your complete course of antibiotics. You may resume your regular diet as tolerated. You may take showers (no baths) after your dressings have been removed from your wounds. Please resume all your home, pre-hospital medications. Followup Instructions: Please follow-up with Dr. [**Last Name (STitle) **] in [**1-11**] weeks in clinic. You will need to call ahead of time to make an appointment.([**Telephone/Fax (1) 6449**] Completed by:[**2193-1-11**] Name: [**Known lastname 3471**],[**Known firstname **] Unit No: [**Numeric Identifier 11391**] Admission Date: [**2192-12-30**] Discharge Date: [**2193-1-14**] Date of Birth: [**2130-4-12**] Sex: F Service: SURGERY Allergies: Imodium A-D / Penicillins Attending:[**First Name3 (LF) 813**] Addendum: Patient remained at the hospital over the weekend due to lack of a bed at rehab facility. She had a quiet weekend, no new events and continues to do well. She is being discharged today, [**2193-1-14**], now that a bed is definitely available. Thank you. Discharge Disposition: Extended Care Facility: [**Hospital1 8750**] Nursing Center - [**Hospital1 8750**] [**First Name11 (Name Pattern1) 801**] [**Last Name (NamePattern4) 815**] MD [**MD Number(2) 816**] Completed by:[**2193-1-14**]

[ "496", "311", "038.3", "564.1", "518.81", "V45.4", "995.92", "511.9", "293.0", "344.81", "556.6", "721.1", "512.1", "276.6", "305.1", "280.9", "008.45", "401.9", "789.5" ]

icd9cm

[ [ [] ] ]

[ "34.04", "99.15", "46.21", "00.17", "96.72", "45.79", "38.93" ]

icd9pcs

[ [ [] ] ]

7998, 8241

1587, 2431

311, 346

6227, 6236

998, 1564

7164, 7975

4487, 6019

6148, 6206

6260, 7141

247, 273

374, 767

2440, 4464

789, 979

30,549

102,051

34448

Discharge summary

report

Admission Date: [**2105-7-27**] Discharge Date: [**2105-7-28**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 330**] Chief Complaint: Hypotension Major Surgical or Invasive Procedure: Central Venous line (Right IJ) Arterial line (Left) History of Present Illness: Mr. [**Known lastname **] is a [**Age over 90 **] year old male with a history of atrial fibrillation, systolic heart failure, chronic kidney disease who presents from NH with altered mental status. Per report, pt was noted by staff at NH yesterday to be difficult to arouse and having labored breathing. His vitals at the time included BP 112/57, and O2 sats and temperature were not obtainable due likely to hypothermia. He was sent to the [**Hospital1 18**] ED for further revaluation. Of note, per his daughter, he was recently hospitalized ([**2015-7-16**]) from [**Hospital3 **] Hospital with congestive heart failure. During this hospitalization he was noted to have deteriorating mental status and delirium, which is why he had been discharged to NH. In the ED, VS T 92.1 axillary, BP 100/50, HR 50, RR 21 88% 6L initially then placed 99% NRB. He received vancomycin, ceftriaxone, and flagyl for aspiration pneumonia. Also received vitamin K IV 10 mg for coagulopathy with INR to 7.2. With CT head negative for acute intracranial process. Also received 1 L IVF total in ED. On arrival to MICU, he was noteedd to be bradycardic to HRs to 30s and hypotensive to SBP 80s with MAPS 50s. He was given 1 mg atropine with HR to 50s. He was given 500 cc fluid bolus x 2 and SBP came up to 90s. Past Medical History: Systolic Heart Failure with EF 30% Hypertension Atrial Fibrillation Hypothyrodism Chronic kidney disease, stage III Dysphagia Dementia? Social History: Currently lives in a nursing home. Has a daughter and son. [**Name (NI) 3003**] to being in the nursing home, he lived with his daugther. Family History: NC Physical Exam: VS: HR 46 96/49 RR 18 100% NRB GEN: On NRB, difficult to arouse, non-verbal, opens eyes to painful stimuli, unable to follow commands HEENT: AT, NC, EOMI, no conjuctival injection, anicteric, MM dry, right pupil reactive 3 to 2 mm, left pupil unreactive CV: Irreg irreg, nl s1 s2 PULM: Diffuse crackles anteriorly ABD: soft, mild distension, + BS, no HSM EXT: cool, b/l lateral malleolus venous stasis ulcers NEURO: Unable to assess due to mental status Pertinent Results: [**2105-7-26**] 10:40PM BLOOD WBC-4.8 RBC-3.30* Hgb-10.5* Hct-32.1* MCV-98 MCH-32.0 MCHC-32.8 RDW-17.6* Plt Ct-124* [**2105-7-27**] 05:10PM BLOOD WBC-5.9 RBC-3.06* Hgb-10.0* Hct-30.5* MCV-100* MCH-32.7* MCHC-32.8 RDW-17.2* Plt Ct-100* [**2105-7-26**] 10:40PM BLOOD Neuts-85.0* Bands-0 Lymphs-9.2* Monos-4.7 Eos-0.6 Baso-0.5 [**2105-7-26**] 10:40PM BLOOD PT-60.4* PTT-67.9* INR(PT)-7.2* [**2105-7-27**] 04:49AM BLOOD Fibrino-405* D-Dimer-686* [**2105-7-26**] 10:40PM BLOOD Glucose-61* UreaN-50* Creat-2.0* Na-137 K-4.8 Cl-100 HCO3-27 AnGap-15 [**2105-7-26**] 10:40PM BLOOD ALT-23 AST-40 CK(CPK)-175* AlkPhos-164* TotBili-0.8 [**2105-7-26**] 10:40PM BLOOD CK-MB-17* MB Indx-9.7* cTropnT-0.12* proBNP-5749* [**2105-7-27**] 03:32AM BLOOD Albumin-2.8* Calcium-7.5* Phos-4.1 Mg-1.9 [**2105-7-27**] 03:32AM BLOOD TSH-20* [**2105-7-27**] 04:55PM BLOOD T4-5.9 calcTBG-0.82 TUptake-1.22 T4Index-7.2 [**2105-7-26**] 11:01PM BLOOD Lactate-1.4 Relevant Imaging: CT Head FINDINGS: There is no intra- or extra-axial hemorrhage, mass effect, or shift of normally midline structures. Extensive bilateral periventricular as well as subcortical white matter hypoattenuation related to chronic microangiopathic ischemic changes is evident. The ventricles and sulci are moderately prominent, appropriate for age- associated involutionary changes. Bilateral basal ganglia calcification and extensive calcification along the tentorium and falx cerebri are evident. The osseous and soft tissue structures are unremarkable. A nonspecific focus of hyperdense focus is noted in the left pre-zygomatic soft tissue. Clinical correlation is advised. IMPRESSION: No acute intracranial process. A small hyperdense focus in the left pre-zygomatic soft tissue could represent calcification and clinical correlation is advised. ECHO The left atrium is moderately dilated. The right atrium is markedly dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size. There is mild regional left ventricular systolic dysfunction with severe hypokinesis of the basal half of the inferior and inferolateral walls. The remaining segments contract normally (LVEF = 40 %). Right ventricular chamber size and free wall motion are normal. The ascending aorta is dilated at the sinus level. The descending thoracic aorta is mildly dilated. The aortic valve leaflets are severely thickened/deformed. Significant aortic stenosis is present (not quantified). No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Mild symmetric left ventricular hypertrophy with regional systolic dysfunction c/w CAD. Aortic stenosis. Dilated ascending aorta. If clinically indicated, a follow-up study to assess aortic stenosis is suggested when the patient can be transported to the Echo laboratory. Brief Hospital Course: [**Age over 90 **] year old male with a history of systolic congestive heart failure, atrial fibrillation, who presented with hypoxia, hypotension, and hypothermia. Upon admission to the MICU, agressive therapy was initiated keeping a broad differential diagnosis. Patient however continued to deteriorate and abruptly became profoundly bradycardic, unresponsive to atropine or increasing doses of pressors, culminating in asystole; patient was pronounced dead at 1:05am on [**2105-7-28**]. Below are the details leading to these events, arranged by problem: 1)Hypotension / Hypothermia: On initial presentation on the floor SBP 80s, given 500cc fluid bolus x 2 with SBP to 90s. Meets SIRS criteria with hypothermia and tachpnea and hypotension concerning for sepsis, with pneumonia as the most likely source. Also on differential was hypovolemic hypotension for occult blood loss, cardiogenic shock, adrenal insuffiency and myxedema coma. Cooling blanket placed on patient upon arrival. Patient was given fluid boluses and central access was obtained. Echocardiogram was obtained and revealed mildly depressed ejection fraction (40%) with inferolateral wall hypokinesis and moderate tricuspid regurgitation. Central venous pressure was measured and found to be elvated to 24mmHg, which even in the setting of TR was felt to rule out hypovolemia. Patient was initiated on Dopamine in hopes of supporting both blood pressure and heart rate. Arterial line was placed for accurate assessment of arterial pressure. Hematocrit remained stable and pressure responded to pressor support. Patient started on stress dose steroids for possible adrenal insufficiency. 2)Hypoxia: With bilateral infiltrates and likely superimposed fluid overlaod. Given recent hospitalization and extent of O2 requirement, high suspicion for Hospital Acquired Pneumonia (HAP) with vancomycin and zosyn. This was later changed to Vancomycin and Cefepime. Patients blood gas was concerning for hypercarbia, and after re-discussing goals of care with family and confirming patient did not want to be intubated, non invasive ventillation was initiated. Patient tolerated NIPPV well and hypoxia / hypercarbia / respiratory acidosis improved until his sudden decompensation. 3)Bradycardia: With baseline bradycardia per history, unclear etiology. On arrival to MICU, bradycardic to HR in 30s, gave 1 mg atropine with HR to 50s. All nodal agents were stopped and heart rate improved with Dopamine administration. 4)Meningitis: Given patients poor baseline mental status and findings of significant nuchal rigidity, concern for meningitis was raised. Given patients decompensated status, lumbar puncture was not pursued and empiric coverage with Ampicillin for listeria, Vancomycin/Cefepime for Staph/Strep were initiated. 5)Hypothyroidism: TSH of 20, difficult to interpret in this setting as sick euthyroid may have impacted laboratory results. Given decompensated state, endocrine consult was placed and thyroid hormone was supplemented intravenously at higher doses than per outpatient regimen. Free T3, T4 and Thyroid binding protein were ordered but were not available before patient decompensated. Per endocrine team recommendations, T3 was not given due to concerns for arrythmia and cardiac side effects, and given very poor level of evidence for its efficacy. 6)Coagulopathy: INR 7.2 on admission in setting of anticoagulation. Given vitamin K and FFP. DIC labs negative. 7)Chronic kidney disease: With known baseline CKD stage III, likely exacerbated in the setting of hypotension. Medications on Admission: Acetaminophen 325 mg PRN [**Doctor Last Name **] Milk of Magnesia PRN Dulcolax 10 mg Rectal Suppository PRN Fleet Enema PRN Albuterol INH PRN Coumadin 2.5 mg DAILY Flomax 0.4 mg DAILY Ferrous Sulfate 325 mg DAILY Levothyroxine 125 mcg DAILY Lasix 20 mg DAILY Lisinopril 2.5 mg DAILY Magnesium Oxide 400 mg DAILY Calcium 500 with Vitamin D DAILY Proscar 5 mg DAILY Ranitidine 150 mg DAILY Zyprexa 2.5 mg [**Hospital1 **] Discharge Disposition: Expired Discharge Diagnosis: Patient expired Discharge Condition: Patient expired Discharge Instructions: Patient expired Followup Instructions: Patient expired

[ "518.81", "585.3", "V58.61", "995.92", "255.41", "244.9", "790.92", "427.31", "507.0", "038.9", "E934.2", "428.0", "428.22", "322.9", "403.90" ]

icd9cm

[ [ [] ] ]

[ "38.91", "38.93" ]

icd9pcs

[ [ [] ] ]

9536, 9545

5494, 9066

273, 326

9604, 9621

2486, 3418

9685, 9703

1991, 1995

9566, 9583

9092, 9513

9645, 9662

2010, 2467

222, 235

3437, 5471

354, 1660

1682, 1819

1835, 1975

45,871

178,380

35202

Discharge summary

report

Admission Date: [**2192-10-22**] Discharge Date: [**2192-10-30**] Date of Birth: [**2119-1-11**] Sex: F Service: CARDIOTHORACIC Allergies: Ciprofloxacin / Nickel Sulfate Attending:[**First Name3 (LF) 1505**] Chief Complaint: Dyspnea Major Surgical or Invasive Procedure: [**2192-10-25**] Off Pump Coronary Artery Bypass Grafting Surgery utilizing the LIMA to LAD, SVG to OM, and SVG to PDA [**2192-10-22**] Cardiac Catheterization History of Present Illness: Ms [**Known lastname 34850**] is a 73-y/o lady w PMHx sig for DM2, known CAD (s/p cath in [**2185**] and [**2189**] - occluded LAD, 50-70% lcx, 60%rca, tx'd medically), chronic systolic CHF (LVEF ~35%), and recent hospital admission at [**Hospital1 2177**] in [**8-/2192**] for similar sxs (found to have NSTEMI, CHF exacerbation and PNA, s/p viability study showing inferior infarct and basal inferior ischemia, scheduled for ICD placement in [**10/2192**], but pt decided to switch care). Pt was in his USOH after discharge, but about a week PTA, she began experiencing progressive SOB at rest, but no chest pain. She was admitted to OSH on [**10-18**], and was found have CHF exacerbation (BNP 1550), treated subsequently with furosemide diuresis. Found to have troponin 0.58, and EKG showing anterolateral and inferior ST depressions. Pt was transferred to [**Hospital1 18**] for cath. Past Medical History: Coronary Artery Disease, Chronic Systolic Heart Failure NIDDM Hypertension COPD Dyslipidemia Rheumatoid Arthritis Descending thoracic aortic aneurysm (4.8 cm) History of Pneumonia Pulmonary Nodules Diverticulosis s/p Ventral Hernia Repair Social History: Lives with daughter. [**Name (NI) 6934**] with walker. Independent in ADLs. Smoking: 50-70 py, quit in [**8-/2192**] EtOH: denies Drugs: denies Family History: Multiple siblings had CAD. Physical Exam: Admit PE - 98.2, 103/48, 70, 18 Gen: Elderly lady in NAD, back HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. Neck: Supple with normal JVP. 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 anteriorly, no crackles, wheezes or rhonchi. Abd: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. Ext: No c/c/e. No femoral bruits. Skin: No stasis dermatitis, ulcers, scars, or xanthomas. Discharge: vitals: T98.4 HR 96 BP 131/63 RR 20 O2sat 99%-RA Gen: WF, NAD, appears stated age HEENT: NCAT, EOMI Lungs: crackles b/l bases, otherwise clear CV: RRR, no murmur or rub Abd: NABS, soft, non-tender, nondistended Ext: trace edema Incisions: sternotomy- c/d/i no erythema or drainage, LEVH- minimal serous drainage from inferior stab incision, knee site c/d/i Pertinent Results: [**2192-10-22**] 04:15PM BLOOD WBC-8.2 RBC-3.77* Hgb-11.3* Hct-32.9* MCV-87 MCH-29.9 MCHC-34.2 RDW-14.0 Plt Ct-329 [**2192-10-22**] 04:15PM BLOOD PT-14.9* PTT-21.7* INR(PT)-1.3* [**2192-10-22**] 04:15PM BLOOD Glucose-114* UreaN-24* Creat-0.7 Na-139 K-4.0 Cl-101 HCO3-29 AnGap-13 [**2192-10-22**] 04:15PM BLOOD ALT-14 AST-17 AlkPhos-71 Amylase-45 TotBili-0.6 [**2192-10-22**] 04:15PM BLOOD Albumin-3.6 [**2192-10-24**] 05:05AM BLOOD Calcium-9.3 Phos-4.0 Mg-2.2 [**2192-10-22**] 04:15PM BLOOD %HbA1c-6.1* [**2192-10-23**] 05:20AM BLOOD Digoxin-0.5* [**2192-10-30**] 05:48AM BLOOD WBC-12.0* RBC-3.11* Hgb-9.0* Hct-26.3* MCV-85 MCH-28.8 MCHC-34.1 RDW-17.9* Plt Ct-345# [**2192-10-30**] 05:48AM BLOOD Plt Ct-345# [**2192-10-25**] 03:40PM BLOOD PT-16.2* PTT-31.3 INR(PT)-1.4* [**2192-10-28**] 07:50AM BLOOD Glucose-91 UreaN-16 Creat-0.7 Na-136 K-4.4 Cl-98 HCO3-25 AnGap-17 [**2192-10-23**] CT CHEST WITH CONTRAST 1. 9 x 11 right upper lobe nodule is adjacent to the tracheal wall with no residual fat plane on one image, worrisome for primary lung cancer, should be further evaluated with PET CT. Scattered borderline lymph nodes up to 8 mm in the right upper paratracheal region. 2. Mild emphysema. Diffuse bronchial wall thickening. 3. Focal areas of fibrosis and bibasilar atelectasis. 4. Severely atherosclerotic aorta with aneurysmal dilatation of the descending aorta. Rim-like calcification of the aorta with asymmetric thrombus of the descending thoracic aorta. 5. Coronary artery calcifications. 6. Fluid-density lesion in the right cardiophrenic angle, could be a pericardial cyst, could also be further evaluated by PET CT. [**2192-10-23**] CAROTID SERIES Moderate plaque with a left 60-69% carotid stenosis. On the right, there is a less than 40% stenosis. 1. Coronary angiography of this left dominant system revealed severe native three vessel coronary disease. The LMCA had no obstructive coronary disease. The LAD was totally occluded proximally. The LCX had a 95% mid vessel stenosis. OM1 had an ostial 60% and 90% mid stenosis. The LPDA was non-obstructed. The RCA had severe diffuse disease up to 80% in the mid-portion with collaterals to the LAD. 2. Limited resting hemodynamics revealed normal systemic arterial pressure with an SBP of 133 mm Hg. Brief Hospital Course: From the ED, the patient went to cardiac catheterization which showed severe 3vCAD - LMCA had no obstructive; LAD was totally occluded proximally; LCX had a 95% mid vessel stenosis; OM1 had an ostial 60% and 90% mid stenosis; LPDA was non-obstructed; RCA had severe diffuse disease up to 80% in the mid-portion with collaterals to the LAD. No stenting was done. Cardiac surgery was consulted to evaluate for CABG. CT chest, carotid ultrasound, PFTs and urinalysis were performed to assess the candidate's status for surgery. CT chest revealed a 1cm nodule, noted previously at the OSH. Thoracic surgery and pulmonology evaluated the nodule and felt it could be worked up as an outpatient. She was brought to the operating room on [**10-25**] where she underwent a coronary artery bypass graft x 3. Please see operative report for surgical details. In summary she had an off pump CABGx3 with LIMA-LAD, SVG-OM, SVG-PDA. . She tolerated the operation well and following surgery she was transferred to the CVICU for invasive hemodynamic monitoring in stable condition. She remained hemodynamically stable in the immediate post-op period, her anesthesia was reversed she was weaned from sedation, awoke neurologically intact and extubated. She was transferred to the step down unit on POD 1. Chest tubes and pacing wires were discontinued without complication. On POD 3 the patient developed rapid atrial fibrillation to the 140s. She was given a loading dose of oral amiodarone, 600mg, and electrolytes were repleted. Beta blocker was titrated as tolerated and the patient did convert to sinus rhythm. The remainder of her hospital course was uneventful and on POD5 she was discharged to rehabilitation at Lifecare [**Location (un) 5165**]. Medications on Admission: Aspirin 325mg PO daily, Digoxin 0.125mg daily, Metoprolol succinate 50mg PO daily, Lisinopril 20mg PO daily, Isosorbide Mononitrate SR (Imdur) 30mg PO daily, Metformin 500mg PO BID, Simvastatin 10mg PO daily, Furosemide 40mg PO daily, Magnesium Oxide daily, Esomperazole 40mg PO daily, Colace 100mg PO daily, Hydroxychloroquine 200mg PO daily, RISS, Heparin SQ TID, Was also on ceftriaxone on transfer (?) Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) for 1 months. 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. Esomeprazole Magnesium 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:*0* 4. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) as needed for off pump for 3 months. Disp:*30 Tablet(s)* Refills:*2* 5. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 6. Metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*0* 7. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed. Disp:*60 Tablet(s)* Refills:*0* 8. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): 200mg twice daily for 1 week, then 200 mg daily. Disp:*60 Tablet(s)* Refills:*0* 9. Pravastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*0* 10. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed. Disp:*60 Tablet(s)* Refills:*0* 11. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day). Disp:*270 Tablet(s)* Refills:*1* 12. Potassium Chloride 10 mEq Tablet Sustained Release Sig: Two (2) Tablet Sustained Release PO once a day. Disp:*60 Tablet Sustained Release(s)* Refills:*2* 13. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Extended Care Facility: Life Care Center of [**Location (un) 5165**] Discharge Diagnosis: Coronary Artery Disease - s/p Off Pump CABG Chronic Systolic Heart Failure NIDDM Hypertension COPD Dyslipidemia Rheumatoid Arthritis Pulmonary Nodule Carotid Diseases Discharge Condition: Good Discharge Instructions: 1) Monitor wounds for signs of infection. These include redness, drainage or increased pain. In the event that you have drainage from your sternal wound, please contact the [**Name2 (NI) 5059**] at ([**Telephone/Fax (1) 1504**]. 2) Report any fever greater then 100.5. 3) Report any weight gain of 2 pounds in 24 hours or 5 pounds in 1 week. 4) No lotions, creams or powders to incision until it has healed. You may shower and wash incision. Gently pat the wound dry. Please shower daily. No bathing or swimming for 1 month. Use sunscreen on incision if exposed to sun. 5) No lifting greater then 10 pounds for 10 weeks. 6) No driving for 1 month or while taking narcotics for pain. 7) Call with any questions or concerns. Followup Instructions: [**Hospital 409**] clinic in 2 weeks Dr. [**Last Name (STitle) **] in 4 weeks, call for appt Dr. [**Last Name (STitle) **] [**Last Name (STitle) **] [**1-29**] weeks, call for appt Dr. [**Last Name (STitle) 17321**] in [**1-29**] weeks, call for appt Completed by:[**2192-10-30**]

[ "496", "428.0", "441.2", "427.31", "414.01", "426.4", "428.23", "412", "440.0", "E878.2", "562.10", "250.00", "997.1", "518.89", "V45.89", "272.4", "401.9", "714.0" ]

icd9cm

[ [ [] ] ]

[ "37.22", "88.56", "36.12", "39.64", "99.69", "99.29", "99.62", "36.15" ]

icd9pcs

[ [ [] ] ]

9113, 9184

5237, 6981

307, 468

9395, 9402

2948, 5214

10179, 10462

1828, 1856

7437, 9090

9205, 9374

7007, 7414

9426, 10156

1871, 2929

260, 269

496, 1388

1410, 1651

1667, 1812

24,115

158,051

21524

Discharge summary

report

Admission Date: [**2177-10-12**] Discharge Date: [**2177-10-14**] Service: MEDICINE Allergies: Aspirin / Indocin Attending:[**First Name3 (LF) 2880**] Chief Complaint: elective cath Major Surgical or Invasive Procedure: cardiac catheterization History of Present Illness: 83yo F presented for aspirin desensitization prior to elective cath [**2177-10-13**]. Patient was being w/u for DOE and found to have CAD on cath [**10-1**] where she was discovered to have LAD 90% and RCA 80%. Patient was documented to have face and lip swelling with ASA and indomethacin. Past Medical History: 1. MV regurgitaion 2. pulmonary HTN, uses 2L O2 NC at home 3. CRI 4. moderate MR 5. CAD 6. s/p appy 7. s/p CCY 8. s/p TAH Social History: no tob/ETOH lives alone, widowed Family History: noncontributory Physical Exam: BP 121-137/51-60 P71-93 R20 98%1L Gen-NAD HEENT-xanthelesma, oral mucosa dry, neck supple CVS-nl S1, S2, no S3/S4/murmur, no pedal edema, 1+DP bilaterally, JVP flat resp-cannot assess, patient post cath and has to be supine GI-benign knee-bilateral knee has big boggy mass, right knee oozing pus like/yellowish d/c neuro-A+O x3 Pertinent Results: [**2177-10-14**] 06:35AM BLOOD WBC-7.2 RBC-3.48* Hgb-10.5* Hct-30.3* MCV-87 MCH-30.2 MCHC-34.7 RDW-13.9 Plt Ct-354 [**2177-10-13**] 05:39AM BLOOD WBC-6.3 RBC-3.64* Hgb-10.8* Hct-31.6* MCV-87 MCH-29.7 MCHC-34.2 RDW-13.9 Plt Ct-337 [**2177-10-14**] 06:35AM BLOOD Plt Ct-354 [**2177-10-14**] 06:35AM BLOOD Glucose-103 UreaN-26* Creat-1.3* Na-136 K-4.2 Cl-101 HCO3-27 AnGap-12 [**2177-10-13**] 05:39AM BLOOD Glucose-102 UreaN-33* Creat-1.4* Na-137 K-4.8 Cl-102 HCO3-26 AnGap-14 [**2177-10-14**] 06:35AM BLOOD CK(CPK)-16* [**2177-10-13**] 09:40PM BLOOD CK(CPK)-24* [**2177-10-13**] 08:00AM BLOOD CK(CPK)-11* [**2177-10-14**] 06:35AM BLOOD CK-MB-NotDone cTropnT-0.10* [**2177-10-13**] 09:40PM BLOOD CK-MB-NotDone cTropnT-0.11* [**2177-10-13**] 08:00AM BLOOD CK-MB-1 cTropnT-<0.01 [**2177-10-14**] 06:35AM BLOOD Calcium-9.1 Phos-3.9 Mg-1.8 [**2177-10-13**] 05:39AM BLOOD Calcium-9.1 Phos-4.1 Mg-1.9 Brief Hospital Course: 1. CAD Patient underwent elective cardiac catheterization on [**10-13**] s/p ASA desensitization which showed LMCA had a 30% ostial and a 20% distal stenosis, ostial LAD had a 70% stenosis, mid LAD had a 90% stenosis and the distal LAD had mild diffuse disease. The proximal LCX had a 40%stenosis, RCA was the dominant vessel and had a 40-50% ostial stenosis and a 30% mid stenosis.Successful stenting of the mid LAD. She was continued on ASA, plavix, ACEI, BB, high dose lipitor. Post cath was uneventful. Medications on Admission: 1. altace 10mg 2. atenolol 25mg 3. KCL 10 mEq 4. Lasix 40mg 5. tylenol 6. vit E 7. plavix 8. aciphex Discharge Medications: 1. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 2. Atenolol 25 mg Tablet Sig: One (1) Tablet PO QD (). Disp:*30 Tablet(s)* Refills:*2* 3. Furosemide 40 mg Tablet Sig: One (1) Tablet PO QD (). Disp:*30 Tablet(s)* Refills:*2* 4. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO QD (). Disp:*30 Tablet(s)* Refills:*2* 5. Ramipril 5 mg Capsule Sig: Two (2) Capsule PO QD (). Disp:*60 Capsule(s)* Refills:*2* 6. Aspirin 325 mg Tablet Sig: One (1) Tablet PO QD (). 7. Atorvastatin Calcium 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: coronary artery disease Discharge Condition: good Discharge Instructions: please return to the hospital or call your doctor if you have further chest pain or if there are any concerns at all. please take all your prescribed medication especially the medication by the name of plavix. It is absolutely crucial that you do not stop taking plavix until you have spoken to a cardiologist. Followup Instructions: 1. please follow up with your cardiologist within one month of your discharge [**First Name11 (Name Pattern1) 900**] [**Last Name (NamePattern1) 2882**] MD, [**MD Number(3) 2883**] Completed by:[**2177-10-17**]

[ "593.9", "424.0", "719.66", "V14.8", "416.8", "414.01", "401.9" ]

icd9cm

[ [ [] ] ]

[ "88.56", "36.07", "36.05", "37.22", "99.12" ]

icd9pcs

[ [ [] ] ]

3492, 3498

2094, 2603

241, 266

3566, 3572

1178, 2071

3931, 4173

798, 815

2754, 3469

3519, 3545

2629, 2731

3596, 3908

830, 1159

188, 203

294, 586

608, 732

748, 782

11,018

180,836

217

Discharge summary

report

Admission Date: [**2152-2-15**] Discharge Date: [**2152-3-2**] Date of Birth: [**2084-12-30**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1070**] Chief Complaint: shortness of breath Major Surgical or Invasive Procedure: Endotracheal Intubation Arterial line placement Internal Jugular line placement History of Present Illness: Mr. [**Known lastname 2150**] is a 67M with HIV (Cd4 183, VL 96 copies/mL) and end stage COPD on 3-4L home O2 with a FEV1 of 0.5 who presented to the emergency room on [**2152-2-15**] with increased shortness of breath. Three days prior to presentation he developed nasal congestion and rhinorrhea which made it difficult for him to use his supplemental oxygen at home. He had subjective fevers and chills but did not check his temperature. He had minimal cough productive of dark yellow sputum. He was feeling more short of breath despite increasing oxygen use. He was concerned about pneumonia and presented to the emergency room. . In the emergency room his initial vitals were T: 98.1 HR: 86 RR: 107/72 RR: 22 O2: 100% on RA. He had a chest xray which showed significant hyperinflation but no acute cardiopulmonary process. He received levofloxacin 750 mg IV x 1, duonebs, solumedrol 125 mg IV x 1 and aspirin 81 mg. He was initially admitted to the floor. . While on the floor he was started on azithromycin, solumedrol 125 mg IV TID, albuterol and ipratropium nebulizers. He did well on hospital day 1 but overnight his shortness of breath worsened. He had a repeat CXR which was similar to priors. He had an ABG on a non-rebreather which was 7.37/57/207/34. He had increased work of breathing and asked to be placed on "a machine for breathing." He is transferred to the MICU for non-invasive ventilatory support. n the MICU he was intubated an an A-line was placed due to increased WOB. Blood pressure was elevated while in respiratory distress and he was treated with hydralazine. He had one episode of hypotension responsive to IVF. A right IJ central line placed. ABG on [**2-18**] was 7.32/54/104. Methylprednisolone was decreased to 60mg IV BID. He was extubated on ICU day 3 and initially appeared in stress but did well after small dose IV morphine.He was transferred to the floor on ICU day 4. Prior to transfer he reviewed his code status and decided to be DNR/DNI. . On the floor, he is doing relatively well. He reports he is still somewhat short of breath but not in any distress. He reports back pain secondary to old back injury. He will be spending time with family and friends who are coming in from around the country to see him. Reports lack of appetite but no n/v. Denies F/C cough, chest pain. Past Medical History: - HIV/AIDS - most recent CD4 count 183, viral load 96 copies/ml - COPD - FVC 2.34 (63%), FEV1 0.50 (20%), FEV1/FVC 21 (31%) [**7-/2151**] - GERD - Hypertension - h/o GI bleed - Leukopenia - Anemia (baseline hct 36) - Inguinal hernia - Homocysteinemia - Chronic back pain - Granulmatous disease in spleen- seen on ct scan - Esophagitis- egd [**11-21**] - Schatzki's ring- seen on egd [**7-/2143**] - SBO obstruction in past requiring partial bowel resection - H/o of drug use (Cocaine) Social History: Previously a truck driver, now disabled/retired. Lives in [**Location 669**] by himself. EtOH: former heavy etoh, quit [**2135**] Tob: quit tobacco in [**2135**], 2ppd between [**2100**]-93. Illicit drugs: smoked crack [**2135**] Family History: 1. Father: deceased, EtOH 2. Mother: deceased, CVA in 60s 3. Brother: lung cancer 4. Sister: HTN 5. Sister: CVA in 60s Brothers x7 (now only two), Sister x2 (both still alive) Physical Exam: Vitals T: 97.0 HR: 113 BP: 153/96 RR: 19 O2: 100% on BIPAP General Thin elderly man, tachypneic, using accessory muscles for respiration HEENT sclera anicteric, conjunctiva pink, mucous membranes moist, no lymphadenopathy Neck: JVP not elevated Pulmonary: Poor air movement bilaterally, scarce wheezes bilaterally, mild inspiratory crackles at bases, hyperexpansion Cardiac: Tachycardic, normal s1 + s2, no murmurs, rubs, gallops Abdominal: Soft, non-tender, non-distended, +BS Extremities: Warm and well perfused, 2+ distal pulses, no clubbing, cyanosis or edema Pertinent Results: LABS ON ADMISSION: [**2152-2-15**] 09:15PM BLOOD WBC-3.5* RBC-3.98* Hgb-11.8* Hct-35.9* MCV-90 MCH-29.6 MCHC-32.8 RDW-15.6* Plt Ct-149* [**2152-2-15**] 09:15PM BLOOD Neuts-55.0 Lymphs-33.9 Monos-6.1 Eos-4.2* Baso-0.8 [**2152-2-15**] 09:15PM BLOOD Glucose-145* UreaN-20 Creat-1.1 Na-143 K-3.8 Cl-103 HCO3-32 AnGap-12 [**2152-2-17**] 06:05AM BLOOD Calcium-9.3 Phos-3.1 Mg-2.0 [**2152-2-17**] 08:02AM BLOOD Type-ART pO2-207* pCO2-57* pH-7.37 calTCO2-34* Base XS-6 . MICROBIOLOGY: Bl Cx ([**2152-2-15**]) - NGTD . RADIOLOGY: CXR ([**2152-2-16**]): 1. No pneumonia. 2. Unchanged severe emphysema. Stable right hilar calcified lymph node. . Other Labs: [**2152-3-2**] 06:36AM BLOOD WBC-6.6 RBC-2.42* Hgb-7.1* Hct-21.9* MCV-90 MCH-29.3 MCHC-32.4 RDW-15.8* Plt Ct-191 [**2152-3-1**] 06:26AM BLOOD WBC-6.5 RBC-2.41* Hgb-7.0* Hct-22.3* MCV-93 MCH-28.9 MCHC-31.3 RDW-16.1* Plt Ct-143* [**2152-2-29**] 05:19AM BLOOD WBC-10.2 RBC-2.70* Hgb-7.9* Hct-24.8* MCV-92 MCH-29.4 MCHC-31.9 RDW-15.7* Plt Ct-161 [**2152-2-28**] 09:06AM BLOOD WBC-10.2 RBC-2.76*# Hgb-8.3*# Hct-24.7*# MCV-90 MCH-30.0 MCHC-33.6 RDW-16.0* Plt Ct-160 [**2152-2-28**] 05:00AM BLOOD WBC-7.0 RBC-2.12*# Hgb-6.4*# Hct-19.0*# MCV-90 MCH-30.1 MCHC-33.6 RDW-15.7* Plt Ct-113* [**2152-2-27**] 05:34AM BLOOD WBC-9.3 RBC-2.91* Hgb-8.7* Hct-26.4* MCV-91 MCH-30.0 MCHC-33.0 RDW-15.8* Plt Ct-149* [**2152-2-25**] 05:09AM BLOOD WBC-15.9* RBC-3.39* Hgb-10.1* Hct-30.6* MCV-90 MCH-29.8 MCHC-33.0 RDW-16.2* Plt Ct-187 [**2152-2-24**] 05:09AM BLOOD WBC-13.9* RBC-3.55* Hgb-10.5* Hct-32.0* MCV-90 MCH-29.5 MCHC-32.8 RDW-16.1* Plt Ct-216 [**2152-2-23**] 05:29AM BLOOD WBC-9.8 RBC-3.16* Hgb-9.1* Hct-28.7* MCV-91 MCH-28.9 MCHC-31.9 RDW-16.0* Plt Ct-180 [**2152-2-22**] 05:44AM BLOOD WBC-10.2 RBC-3.30* Hgb-9.8* Hct-29.9* MCV-91 MCH-29.9 MCHC-33.0 RDW-15.7* Plt Ct-182 [**2152-2-21**] 04:36AM BLOOD WBC-8.1 RBC-3.27* Hgb-9.4* Hct-28.9* MCV-88 MCH-28.8 MCHC-32.6 RDW-15.3 Plt Ct-167 [**2152-2-20**] 05:39AM BLOOD WBC-8.7 RBC-3.37* Hgb-9.8* Hct-30.2* MCV-90 MCH-29.0 MCHC-32.4 RDW-15.2 Plt Ct-179 [**2152-2-19**] 05:52AM BLOOD WBC-6.6 RBC-3.47* Hgb-10.3* Hct-31.3* MCV-90 MCH-29.5 MCHC-32.8 RDW-15.4 Plt Ct-180 [**2152-2-18**] 05:06AM BLOOD WBC-6.5 RBC-3.58* Hgb-10.3* Hct-32.0* MCV-89 MCH-28.8 MCHC-32.3 RDW-15.6* Plt Ct-201 [**2152-2-28**] 09:06AM BLOOD PT-12.9 PTT-27.0 INR(PT)-1.1 [**2152-2-20**] 05:39AM BLOOD PT-13.3 PTT-33.0 INR(PT)-1.1 [**2152-3-2**] 06:36AM BLOOD Glucose-198* UreaN-8 Creat-0.7 Na-136 K-4.3 Cl-103 HCO3-27 AnGap-10 [**2152-3-1**] 06:26AM BLOOD Glucose-138* UreaN-9 Creat-0.7 Na-141 K-3.3 Cl-107 HCO3-29 AnGap-8 [**2152-2-29**] 05:19AM BLOOD Glucose-99 UreaN-12 Creat-0.8 Na-138 K-3.3 Cl-101 HCO3-31 AnGap-9 [**2152-2-28**] 05:00AM BLOOD Glucose-84 UreaN-15 Creat-0.8 Na-135 K-3.4 Cl-97 HCO3-28 AnGap-13 [**2152-2-27**] 05:34AM BLOOD Glucose-83 UreaN-18 Creat-0.8 Na-138 K-3.7 Cl-98 HCO3-31 AnGap-13 [**2152-2-25**] 05:09AM BLOOD Glucose-74 UreaN-28* Creat-1.0 Na-137 K-4.6 Cl-95* HCO3-32 AnGap-15 [**2152-2-24**] 06:00PM BLOOD Glucose-108* UreaN-31* Creat-1.1 Na-140 K-4.8 Cl-97 HCO3-36* AnGap-12 [**2152-2-24**] 05:09AM BLOOD Glucose-112* UreaN-30* Creat-1.0 Na-146* K-4.7 Cl-103 HCO3-37* AnGap-11 [**2152-2-23**] 05:29AM BLOOD Glucose-120* UreaN-33* Creat-0.9 Na-144 K-4.7 Cl-105 HCO3-35* AnGap-9 [**2152-2-22**] 05:44AM BLOOD Glucose-176* UreaN-34* Creat-1.1 Na-143 K-4.5 Cl-106 HCO3-33* AnGap-9 [**2152-2-21**] 04:36AM BLOOD Glucose-213* UreaN-35* Creat-1.0 Na-145 K-3.7 Cl-107 HCO3-33* AnGap-9 [**2152-2-20**] 05:39AM BLOOD Glucose-115* UreaN-40* Creat-0.9 Na-146* K-4.2 Cl-108 HCO3-31 AnGap-11 [**2152-2-18**] 05:06AM BLOOD Glucose-120* UreaN-36* Creat-1.2 Na-142 K-4.8 Cl-103 HCO3-28 AnGap-16 [**2152-2-17**] 06:05AM BLOOD Glucose-137* UreaN-18 Creat-0.9 Na-141 K-3.8 Cl-104 HCO3-28 AnGap-13 [**2152-2-15**] 09:15PM BLOOD Glucose-145* UreaN-20 Creat-1.1 Na-143 K-3.8 Cl-103 HCO3-32 AnGap-12 [**2152-2-24**] 05:09AM BLOOD ALT-25 AST-26 AlkPhos-57 TotBili-0.4 [**2152-2-20**] 05:39AM BLOOD ALT-21 AST-29 LD(LDH)-209 AlkPhos-56 TotBili-0.7 [**2152-2-15**] 09:15PM BLOOD CK(CPK)-77 [**2152-2-15**] 09:15PM BLOOD cTropnT-0.03* [**2152-3-2**] 06:36AM BLOOD Calcium-8.0* Phos-1.9* Mg-1.7 [**2152-2-29**] 05:19AM BLOOD Calcium-7.9* Phos-1.5* Mg-1.7 [**2152-2-28**] 05:00AM BLOOD Calcium-7.4* Phos-2.0* Mg-1.9 Iron-16* [**2152-2-27**] 05:34AM BLOOD Calcium-7.6* Phos-2.2* Mg-1.9 [**2152-2-28**] 05:00AM BLOOD calTIBC-127* VitB12-GREATER TH Folate-GREATER TH Ferritn-206 TRF-98* Brief Hospital Course: In summary, Mr. [**Known lastname 2150**] is a 67M with HIV (on HAART) and end-stage COPD (on home O2), who presented [**2152-2-15**] with worsening shortness of breath in the setting of likely [**Hospital 2170**] transferred to MICU for worsening respiratory distress. . # End-stage COPD/Respiratory Distress: End-stage baseline COPD (FEV1 20% predicted and on home O2). Admitted w likely COPD exacerbation triggered by viral URI. Nasal complaints and absence of infiltrate go against a bacterial PNA. MI and PE also considered. Pt treated with nebulizers, steroids, azithromycin. ABG shows chronic respiratory acidosis which appears compensated. Pt oxygenated well on O2 by nasal canula, but developed respiratory distress w accessory muscle use, tachypnea and tachycardia, which required MICU transfer on [**2-17**] for increasing respiratory distress. He was subsequently intubated that same night as his respiratory status continued to worsen. He remained stable on the vent and was extubated without complications on [**2-19**]. His respiratory status continued to be stable post-extubation. He was continued on azithromycin for a three day course and continued on steroids. He was then transferred back to the medical floor the following day after extubation with stable respiratory status. Followed by Dr [**Last Name (STitle) 2171**]. On the floor his steroid regimen was kept as IV until patient's SBO resolved. With resolution of SBO patient was transitioned to PO steroids. Pt was discharged with a steroid taper. His last dose of Prednisone 10mg [**3-6**]. . On the floor his dyspnea continued and he required 4-5 L of nasal O2. He was evaluated by palliative care after he made the decision to become DNR/DNI. Based on their recommendations he was switched from ATC morphine to MS contin and ativan for dyspnea related anxiety. He was noted to have mental status changes including confusion, somnolence so MS contin was discontinued with return to normal mentation. His respiratory continued to improve with decrease in anxiety noted. Patient's pain was well controlled with liquid morphine, fentanyl patch, and tylenol #3 as needed. . # HIV/AIDS: Patient on HAART with recent decrease in CD4 count to below 200, hence on bactrim ppx. Followed by Dr [**Last Name (STitle) 1057**]. HAART was temporarily discontinued in the setting of SBO with nausea and vomiting. With resolution of SBO, HAART was restarted on [**2152-2-29**]. . #Small bowel obstruction: Patient developed acutely worsening abdominal pain on the [**Hospital1 **] associated with nausea and vomiting. CT of the abdomen and pelvis demonstrated a partial SBO. He was made NPO and a nasogastric tube was placed. Patient's nausea, vomiting, and abdominal distention improved steadily. His NGT was clamped and eventually discontinued on [**2-28**] with advancement of his diet to a regular diet. He tolerated that well. . #Pneumonia: Patient was found to have a left lower lobe pneumonia incidentally on chest xray evaluating PICC placement. Labs at the time were remarkable for leukocytosis. He was started on Zosyn and vancomycin for presumed Hospital associated pneumonia. Patient's vancomycin was stopped on [**2-27**]. He was continued on Zosyn and then transitioned to PO levoquin on [**2-29**] and discharged on this medication to complete an 8 day course of antibiotics with last day of antibiotics to be [**2152-3-4**]. . # Hypertension: Normotensive on admission, mild elevation in blood pressures in the setting of respiratory distress. Patient was continued on his home dose of doxazosin while in house. . # GERD: Stable. Continued H2 blocker. . # Anemia: Hematocrit dropped slightly during hospital admission from patient's baseline of 36 to 22. Iron studies demonstrated most likely anemia of chronic disease and iron deficiency anemia coupled with dilutional effect of IV hydration and daily blood draws as reasonable explanation of drop in hematocrit. Patient was always hemodynamically stable with no signs or symptoms of active bleeding. Patient was started on PO Iron. Medications on Admission: Epzicom 600mg-300mg daily Tylenol w/codeine PRN Albuterol 0.083% nebulizers TID Albuterol Inhaler Q4H:PRN Atazanvir 400 mg daily Symbicort 2 puffs [**Hospital1 **] Doxazosin 2 mg QHS Folic Acid 1 mg daily Fosamprenavir 1400 mg daily Nitroglycerin 0.4 mg PRN Ranitidine 150 mg [**Hospital1 **] Spiriva 18 mcg daily Tizanidine 2 mg TID Tramadol 50 mg Q6H:PRN Trazodone 50 mg QHS:PRN Bactrim DS 800 mg-160 mg three times per week Aspirin 81 mg daily B12 250 mcg daily Colace 100 mg [**Hospital1 **] Ferrous Gluconate 325 mg daily Boost TID Oxygen 2-3 L Senna PRN Discharge Medications: 1. Abacavir 300 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 2. Lamivudine 150 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 3. Doxazosin 1 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 4. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Atazanavir 200 mg Capsule Sig: Two (2) Capsule PO DAILY (Daily). 6. Fosamprenavir 700 mg Tablet Sig: Two (2) Tablet PO Q12H (every 12 hours). 7. Tizanidine 2 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 8. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain. 9. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for insomnia. 10. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1) Tablet PO MWF (Monday-Wednesday-Friday). 11. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 12. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Cyanocobalamin 250 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. Docusate Sodium 100 mg Capsule Sig: Two (2) Capsule PO BID (2 times a day). 15. Senna 8.6 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 16. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q2H (every 2 hours) as needed. 17. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 18. Prednisone 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 19. Fentanyl 25 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr Transdermal Q72H (every 72 hours). Disp:*10 Patch 72 hr(s)* Refills:*2* 20. Prednisone 10 mg Tablet Sig: 1-2 Tablets PO once a day: *Please take 2 tabs on [**2152-3-3**] *Please take 1 tab, [**3-4**], [**3-5**], and [**3-6**] *The last day of medication is [**3-6**]. Disp:*5 Tablet(s)* Refills:*0* 21. Levofloxacin 250 mg Tablet Sig: Three (3) Tablet PO Q24H (every 24 hours) for 2 days. Disp:*6 Tablet(s)* Refills:*0* 22. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q4H (every 4 hours). Disp:*20 * Refills:*2* 23. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1) Tablet PO MWF (Monday-Wednesday-Friday). Disp:*30 Tablet(s)* Refills:*2* 24. Tylenol-Codeine #3 300-30 mg Tablet Sig: One (1) Tablet PO every four (4) hours: Do not exceed 4g tylenol in 24hours. do not drink or drive while on this mediction. Disp:*30 Tablet(s)* Refills:*0* 25. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: PRIMARY * COPD * HIV * High blood sugar SECONDARY * Constipation * Chronic back pain Discharge Condition: Stable Discharge Instructions: You were admitted with shortness of breath due to exacerbation of your COPD most likely by a viral respiratory infection. It became increasingly difficult for you to breath so you were intubated and transferred to the intensive care unit. . After the breathing tube was removed and transferred to the wards you continued to experience shortness of breath and anxiety. You were seen by the palliative care doctors who recommended that we treat you receive morphine and ativan to make you more comfortable. Your pain has been well controlled with morphine, tylenol #3, and a fentanyl patch. We are also giving you steroids for your COPD exacerbation. You will continue to take the steroids until [**2152-3-6**]. . You also developed an pneumonia while in the hospital. We are currently giving you antibiotics for this pneumonia. Your last day of antibiotics will by [**2152-3-4**]. . You also developed a partial small bowel obstuction while in the hospital. You were treated with a nasogastric tube and nothing by mouth. You obstruction resolved and you are now tolerating a regular diet. . Medication changes include: * Fentanyl Patch * Prednisone * Levofloxacin Followup Instructions: Please keep the following appointments Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2152-3-8**] 11:00 Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2152-4-24**] 9:30 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1085**], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2152-3-8**] 10:00

[ "530.81", "V15.82", "305.03", "564.00", "288.50", "530.3", "276.52", "305.63", "560.9", "401.9", "550.90", "276.2", "458.9", "V46.2", "530.10", "285.29", "486", "491.21", "042", "724.2", "799.4", "270.4", "293.0" ]

icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

16038, 16096

8782, 12866

335, 417

16225, 16234

4323, 4328

17453, 17886

3543, 3721

13477, 16015

16117, 16204

12892, 13454

16258, 17430

3736, 4304

276, 297

445, 2769

4342, 4958

2791, 3279

3295, 3527

4971, 8759

15,504

164,202

44735

Discharge summary

report

Admission Date: [**2116-11-18**] Discharge Date: [**2116-11-29**] Date of Birth: [**2039-12-2**] Sex: F Service: MEDICINE Allergies: Sulfa (Sulfonamides) Attending:[**First Name3 (LF) 2698**] Chief Complaint: Xfer from MICU Major Surgical or Invasive Procedure: n/a History of Present Illness: 76F with cardiomyopathy [**1-8**] CAD (EF 20%, s/p CABG w/LIMA + SVG to RCA) severe AS ([**Location (un) 109**] 0.5 and mean grad of 46) who initially presented to [**Hospital1 **] [**11-17**] with 2-3 weeks of worsening productive cough, SOB/DOE X 1 month. Felt to have bilateral PNA (bilateral pulmonary infiltrates on CXR, no effusion) and was treated with Ceftrix/Azithro and Solumedrol along with nebulizers and lasix. During the admission, she developed chest pressure and pulmonary edema with hypotension and hypoxia requiring intubation. Patient was noted to vomit during intubation. . [**2026-11-17**] patient ruled in for MI w/CK37-->58, trop .5-->1.2. . Pt became hypotensive (SBP - 70s) and then placed on dopamine gtt transition to levophed and vasopressin. Hydrocort/fludrocort started for poor response to [**Last Name (un) 104**] stim. Patient was given amiodarone for afib. She has been diuresed in the CCU recently, although remains net positive for length of hospital stay. . She had fevers on HOD4. She came in on ctx/azithro changed to ctx/vanco w/fevers. Now on zosyn d4 and vanco d5. Through her time in the CCU, her creatinine has ranged 1.3-->1.1-->1.6 and her HCO3 has risen 22-->44. . [**Hospital 95702**] transfer to MICU requested for primary problem being pulmonary. Past Medical History: . PMHx: CABG x 2 ([**2101**]) - LIMA-> LAD, SVG-> PDA Pacer - dual chamber, A/V - [**1-8**] high grade AV block CVA HTN Hyperlipidemia Gout Obeisity Physical Exam: PE: 99.2 afib@70 95/39 (95-125/22-49) LOS 2L+ 24h 2500/3150 today 1600/2200 AC 350 X 16 FIO2 .4, PEEP 5 with last ABG 7.48/57/87 Intubated, awake but very HOH MMM, tlc c/d/i mild ant ronchi Irreg irreg; [**2-9**] loudest @ usb Soft, nt, nd, numerous point ecchymoses Warm x 4 w/trace bipedal edema Pertinent Results: [**2116-11-29**] 02:37PM BLOOD WBC-23.4* RBC-3.24* Hgb-8.7* Hct-27.1* MCV-84 MCH-26.9* MCHC-32.1 RDW-15.3 Plt Ct-278 [**2116-11-18**] 07:19PM BLOOD WBC-20.1* RBC-4.34 Hgb-12.4 Hct-36.7 MCV-85 MCH-28.6 MCHC-33.8 RDW-15.1 Plt Ct-263 [**2116-11-28**] 03:09AM BLOOD Neuts-89.7* Lymphs-5.6* Monos-1.6* Eos-3.0 Baso-0.1 [**2116-11-18**] 07:19PM BLOOD Neuts-70 Bands-21* Lymphs-8* Monos-1* Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 [**2116-11-28**] 03:09AM BLOOD Microcy-1+ [**2116-11-21**] 05:20PM BLOOD Microcy-1+ [**2116-11-29**] 02:37PM BLOOD Plt Ct-278 [**2116-11-29**] 02:37PM BLOOD PT-14.1* PTT-50.2* INR(PT)-1.3 [**2116-11-18**] 07:19PM BLOOD Plt Ct-263 [**2116-11-18**] 07:19PM BLOOD PT-27.4* PTT-34.6 INR(PT)-5.6 [**2116-11-29**] 02:37PM BLOOD Fibrino-590* D-Dimer-3157* [**2116-11-29**] 10:10AM BLOOD FDP-10-40 [**2116-11-29**] 02:37PM BLOOD Glucose-157* UreaN-61* Creat-1.6* Na-142 K-3.6 Cl-96 HCO3-36* AnGap-14 [**2116-11-18**] 07:19PM BLOOD Glucose-143* UreaN-34* Creat-2.0* Na-138 K-4.4 Cl-101 HCO3-23 AnGap-18 [**2116-11-29**] 02:37PM BLOOD ALT-47* AST-40 LD(LDH)-539* CK(CPK)-20* AlkPhos-108 Amylase-85 TotBili-0.8 [**2116-11-18**] 07:19PM BLOOD CK(CPK)-263* [**2116-11-29**] 02:37PM BLOOD CK-MB-NotDone cTropnT-1.05* Brief Hospital Course: . [**11-19**]: Echo: [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 3841**] dilated, EF 20-30%, Aortic Valve velocity: 4.3 m/sec, Aortic Valve area 0.5cm^2, Akinesis of the anterior septum and anterior free wall and dyskinesis of the apex, focal hypokinesis of the apical free wall of the right ventricle, (2+) mitral regurgitation is seen. The mitral regurgitation jet is eccentric. Tricuspid gradient 30mmHg (elevated). . [**11-28**] CT 1. Diffuse ground-glass opacity suggests the presence pulmonary edema. More confluent areas of parenchymal opacity are suggestive of superimposed aspiration or pneumonia within the right upper lobe and left lower lobe. 2. Moderate-sized bilateral pleural effusions without evidence of loculation. 3. Cholelithiasis. . A/P: 76W w/CAD, severe AS, cardiomyopathy with respiratory failure likely [**1-8**] multifocal pna and pulmonary edema and hypotension likely [**1-8**] combined cardiogenic and septic shock. Patient appropriate for transfer to MICU; appreciate ongoing input from cardiology regarding pt care. . Respiratory failure- Likely contributors include multifocal PNA including VAP, pulmonarey edema [**1-8**] heart failure. PaO2 / FIO2 is 217.5 but multifocal infiltrates have been actually increasing with diuresis, raising ? of ARDS. Patient has been on heparin and ppx part of her hospital stay, but difficulty w/oxygenation raises ? of PE. ARF raises concern for CTA and infiltrates would make VQ more difficult. Will check LENIs, D-Dimer for initial investigation. While fungal infection doubted, will check galactomanin, bglucan, fungal bcx. By ideal body weight, ideal tidal volume 312 by ARDSnet. Will decrease TV and use increased RR as needed to maintain MV. Will increase PEEP. Will obtain repeat sputum cultures and will consider bronch, thoracentesis. As PCWP 28, will continue diuresis with goal negative 1-2L today. Will cont vanc/zosyn/cipro, nebs. Will check vanco levels. Will need trache/PEG given 2w mechanical ventilation if to continue. Will review vent records and if appropriate, conduct 5/0 SBT. . Hypotension- At baseline, patient has poor EF and severe AS. As inpatient, patient had cardiac enzyme leak raising ? of acute event and likely sepsis. Will recheck cardiac enzymes, QD ECG, tsh. Will cont levophed and vasopressin as needed to maintain MAP>60. Will change sedation from propofol to fentanyl/midazolam. . AFib-Cont amio. Patient has DDD AV pacer adjusted today by EP. . CAD- Has likely had some recent ischemia. Rechecking enzymes as above. Would ultimately benefit from cath once more stable. . Crit drop- Elevated coags raise concern for DIC. Will recheck crit now. Will check smear, fibrinogen, hapto, fdp. Will guaic all stools. Will perform NGT lavage to r/o UGIB. . [**Name (NI) 10271**] Etiology unclear. Contributors may include sepsis, diuresis, multiple meds. Will check UA, UCx, Ulytes. [**Month (only) 116**] check RUS. Will consult renal for assitance with ARF, metabolic alkalosis. . FEN- Metabolic alkalosis may be [**1-8**] diuresis, ATN. Checking UA/lytes. Diuresing as above. Replete/deplete lytes PRN. . PPX- bowel reg, PPI, sq heparin . Code Status- Full Code per discussion by CCU team with husband who is health care proxy. . Contact- [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 95703**]: Daughter: [**Telephone/Fax (1) 95704**] who husband agrees will be point person for conducting information. Family meeting 5PM today to discuss status, prognosis, plan, goals of care. . Dispo- MICU One hour after above plan, patient had VFib arrest. Had periods PEA during code. Code attempts unsuccesful X 40m. Code run by CCU resident. Medications on Admission: . Home Meds: Coumadin, Diovan, Lipitor . Meds on Admission: (From OSH): ASA 81mg daily, Lopressor 12.5mg PO, Nitro gtt @ 10mcg, Heparin 500U/hr, Ceftriaxone 1gm IV q24, Azithro 500mg IV daily, Solumedrol 30mg IV q6, Advair 500/50 1 puff [**Hospital1 **], Albuterol/Atrovent 2.5/0.5 NEB q6hr, SSI, Tussinex 5mL PO, Lasix, Zofran, Morphine PRN . Allergies: Sulfa, IV contrast Discharge Disposition: Expired Discharge Diagnosis: Deceased Discharge Condition: Deceased Discharge Instructions: n/a Followup Instructions: n/a

[ "995.92", "785.52", "276.3", "507.0", "424.1", "518.81", "785.51", "038.9", "427.31", "V45.01", "V45.81", "412", "428.0" ]

icd9cm

[ [ [] ] ]

[ "38.93", "96.72", "99.04", "96.6", "99.61" ]

icd9pcs

[ [ [] ] ]

7515, 7524

3394, 7091

298, 303

7576, 7586

2146, 3371

7638, 7644

7545, 7555

7117, 7163

7610, 7615

1824, 2127

244, 260

331, 1636

7177, 7492

1658, 1809

28,797

122,770

33420

Discharge summary

report

Admission Date: [**2155-2-2**] Discharge Date: [**2155-2-12**] Date of Birth: [**2104-5-5**] Sex: M Service: MEDICINE Allergies: Antihistamine Classifier Attending:[**First Name3 (LF) 458**] Chief Complaint: Transfer from outside hospital for NSTEMI Major Surgical or Invasive Procedure: None. History of Present Illness: Mr. [**Known lastname **] is a 50 year old man with a history of CAD, PVD, and EtOH abuse who was transferred from [**Hospital3 **] ICU for cardiac evaluation. According to a discharge summary from [**Hospital1 2177**] (on [**2155-1-30**]), he was recently seen at [**Hospital6 6640**] where he received a cardiac cath. That cath showed a large diffuse restenosis of his LAD stent and well as moderate disease in his LCx and RCA. He was transferred to [**Hospital1 2177**] where he was evaluated and felt to be a poor surgical candidate. Overlapping stents to his LAD were also considered. However, the patient refused both options and left AMA, due to withdrawal symptoms according to his wife. Since that time, he reported increasing SL NTG requirements and worsening SOB. He then presented to [**Hospital3 **] with significantly increased recurrent CP. CP began on [**2155-2-1**], substernal radiating to both arms. He took 6 SL NTGs without relief. He also noted coughing up blood for ~30 minutes. . In [**Hospital3 **] ED, he reportedly had ST depressions in V3-6 and ruled in for NSTEMI. Peak cardiac enzymes available in OSH records showed TropI 29.74, CK 422, MB 71.1. Per report from [**Hospital3 **] Hospital, he has been CP free since the [**Hospital3 **] ER with morphine and nitro gtt. He had been on asa/plavix but received no heparin due to thrombocytopenia. Heme/Onc was consulted and agreed with holding heparin given high bleeding risk. He had hemoptysis/UGIB there and received he may have received blood transfusion today. He is a heavy drinker and his last drink was on [**2-1**]. At [**Hospital3 **] he was tremulous and hallucinating and was started on an ativan gtt. Patient requested an increase in his gtt from 3 mg/hr to 5 mg/hr. . On arrival to CCU, he appeared comfortable. However, he noted that he had continuous chest pain since leaving [**Hospital1 2177**]. He denied any relief of his CP at the OSH. He noted that his CP is currently [**5-3**] radiating to both arms. He also noted SOB and nausea. On reevaluation soon after, without further medication, patient denies CP. He describes "throwing up blood" on the morning of admission. He thinks this was the first time it happened. He also noted coughing up some blood prior to presenting to the OSH. He complained of chronic bilateral leg and back pain. He also reported a 30 lb weight loss in the last 3 weeks. Further history and review of systems was difficult to obtain due to his altered mental status on arrival. Past Medical History: Two vessel coronary artery disease - s/p BMS to 90% LAD [**8-/2154**], OM2 50%, 50% mRCA - surgical dz per recent eval at [**Hospital1 2177**] PVD - s/p bilat fem-[**Doctor Last Name **] bypass [**2151**] - s/p bilat external iliac stents [**10-31**], L 90% occl., R 70% occl. - bilat. LE pain S/P repair of R groin pseudoaneurysm and disruption of [**Doctor Last Name **] of R fem-[**Doctor Last Name **] graft [**2153-12-26**] EtOH abuse - h/o withdrawal - last detox attempt at VA in [**2150**] Borderlin diabetes mellitus Hypertension Hyperlipidemia Hepatitis B, Hepatitis C Thrombocytopenia - BL plts 50 Social History: Married. Lives with wife. Disabled electrician. Current heavy EtOH abuse (15-30 beers/day). He has tried to stop drinking on his own but he gets tremulous, has hallucinations, and cannot tolerate the symptoms. 1 ppd x 40 years. H/o heroin, cocaine abuse. Family History: Fam hx sig for father w/ MI @ 52, mother w/ MI @ 76. Physical Exam: ADMISSION PHYSICAL EXAMINATION: VS: T 98.7, BP 114/56, HR 68, RR 18, O2 100% on 4LNC. 98% on RA Gen: Jaundiced middle aged male drowsy but in NAD, resp or otherwise. HEENT: NCAT. + scleral icterus. PERRL, EOMI. Stye on R upper eyelid. Poor dentition. OP clear. Neck: Supple with JVP of ~ 8 cm H20. CV: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. No S4, no S3. Soft [**1-29**] holosys murmur at LLSB. Chest: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. Scattered wheezes bilaterally. Fine bibasilar rales. Abd: +BS. Mildly distended. No obvious fluid wave but slightly bulging flanks. Soft, NTND. No HSM. No abdominial bruits. Groin: healed R groin surgical incision. Mild bruising on L groin with scabbed puncture site but no hematoma. Soft femoral bruits bilat. 2+ fem pulses bilat. Ext: No c/c/e. No femoral bruits. No palmar erythema. 1+ PT and Dp pulses bilat. Skin: + jaundice. No spider angiomas. No caput. Neuro: A+Ox1.5. Knows in hospital but cannot state which one. Knows year is [**2154**] but states month in [**Month (only) **]. + asterixis. EOMI. PERRL. Face symmetric. Palate elevates symmetrically. Moving all extremities without difficulty. Pertinent Results: ADMISSION LABS: [**2155-2-2**] 09:48PM BLOOD WBC-2.3* RBC-3.78* Hgb-9.7* Hct-27.5* MCV-73* MCH-25.6* MCHC-35.2* RDW-17.9* Plt Ct-39* [**2155-2-2**] 09:48PM BLOOD Neuts-64 Bands-0 Lymphs-25 Monos-6 Eos-0 Baso-1 Atyps-4* Metas-0 Myelos-0 [**2155-2-2**] 09:48PM BLOOD Hypochr-1+ Anisocy-1+ Poiklo-1+ Macrocy-NORMAL Microcy-1+ Polychr-1+ Ovalocy-1+ Target-1+ Schisto-OCCASIONAL [**2155-2-2**] 09:48PM BLOOD PT-15.0* PTT-34.1 INR(PT)-1.3* [**2155-2-2**] 09:48PM BLOOD Plt Smr-VERY LOW Plt Ct-39* [**2155-2-2**] 09:48PM BLOOD Glucose-118* UreaN-23* Creat-1.2 Na-134 K-4.2 Cl-102 HCO3-24 AnGap-12 [**2155-2-2**] 09:48PM BLOOD ALT-28 AST-75* LD(LDH)-237 CK(CPK)-126 AlkPhos-53 TotBili-3.9* [**2155-2-2**] 09:48PM BLOOD Albumin-3.2* Calcium-8.9 Phos-3.9 Mg-1.7 Cholest-62 [**2155-2-2**] 09:48PM BLOOD Triglyc-95 HDL-25 CHOL/HD-2.5 LDLcalc-18 LDLmeas-LESS THAN CARDIAC ENZYMES: [**2155-2-2**] 09:48PM BLOOD CK-MB-20* MB Indx-15.9* cTropnT-1.55* [**2155-2-3**] 04:12AM BLOOD CK-MB-14* MB Indx-14.3* cTropnT-1.31* ECG [**2155-2-1**] from OSH: Sinus tach @ 124. Nl axis and intervals. 3-[**Street Address(2) 5366**] depressions in V4-6. 1mm ST depressions in 1, aVL. [**Street Address(2) 2051**] elevation in aVR. [**Street Address(2) 4793**] elevation in V1. ECG [**2155-2-2**] from OSH: NSR @ 70. Nl axis and intervals. [**Street Address(2) 4793**] depressions in V5-6. <1mm ST elevation in aVR, V1. 2D-ECHOCARDIOGRAM performed on TTE [**2155-2-2**] from OSH demonstrated: Nl LV size. EF 55-60%. Apical septal wall is hypokinetic. LA and RA nl in size. RV size and function nl. Moderate subvalvular thickening of mitral valve. Mild MR. [**First Name (Titles) **] [**Last Name (Titles) **]. RVSP calc @ 30 mmHg. [**2155-2-2**] TTE (at [**Hospital1 18**]): The left atrium is mildly dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (LVEF>55%). Tissue Doppler imaging suggests a normal left ventricular filling pressure (PCWP<12mmHg). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets appear structurally normal with good leaflet excursion. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are structurally normal. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. IMPRESSION: Mild symmetric left ventricular hypertrophy with preserved global and regional biventricular systolic function. Mild mitral regurgitation. [**2155-2-3**] Head CT: Vascular calcifications. Mild prominence of the sulci for age. The brain otherwise appears normal. [**2155-2-3**] Abdominal US: 1. The liver is somewhat heterogenous. No focal lesion is identified. 2. Splenomegaly and trace ascites [**2155-2-10**] URINE CULTURE: ENTEROCOCCUS SP >100,000 ORGANISMS/ML. SENSITIVITIES: MIC expressed in MCG/ML AMPICILLIN------------ <=2 S NITROFURANTOIN-------- <=16 S TETRACYCLINE---------- =>16 R VANCOMYCIN------------ <=1 S [**2155-2-4**] EGD: Gastric antral vascular ectasia (GAVE) with no active bleeding Brief Hospital Course: CORONARY ARTERY DISEASE: Mr. [**Known lastname **] had a known restenosis of the bare metal stent in his LAD per recent cathterization at the OSH. He was considered to be a poor surgical candidate for CABG given his comorbidities, but was in the process of being evaluated by cardiac surgery when he was discharged from the hospital (see below). He was continued on aspirin, simvastatin, and lisinopril during his hospital stay. He was initially put on a nitroglycerin IV drip, but was then transitioned to SLNG PRN. He was not heparinzed given his thrombocytopenia and concern for upper GI bleed. Home clopidogrel was discontinued due to thrombocytopenia and bleeding risk; he was told to discuss when to restart clopidogrel with his out-pateint cardiologist. Cardiac catheterization was recommended on [**2155-2-12**] when Mr. [**Known lastname **] developed further chest pain and ST depression, but the patient refused catheterization and requested to leave the hospital with close out-patient follow-up. TTE from [**2155-2-3**] showed a preserved EF and he had no clinical evidence of CHF. ETOH WITHDRAWAL: Mr. [**Known lastname **] has a history of drinking 15-30 beers per day, and upon admission he required large amounts of benzodiazepines to control withdrawal symptoms. Psychiatry was consulted to assist with management of his withdrawal symptoms, and he was placed on haldol for control of aggitation. He was also treated with folic acid and thiamine. Social work was consulted for support of the patient and his wife during the admission. UPPER GI BLEED: Mr. [**Known lastname **] gave a history of coughing up blood prior to admission, and there was concern for gastric varices given suspicion for cirrhosis with his history of EtOH abuse and Hep B/C. The gastroeneterology service was consulted, and an EGD was performed on [**2155-2-4**] which showed gastric antral vascular ectasia (GAVE) with no active bleeding. He was continued on a high dose H2-blcoker while in the hospital and upon discharge. His thrombocytopenia was thought to be secondary to cirrhosis, but no liver biopsy was performed yet to show cirrhosis. URINARY TRACT INFECTION: Urine culture from [**2155-2-10**] grew Enterococcus, and urinalysis was consistent with UTI. He was placed on a seven day course of nitrofurantoin. ***** CIRCUMSTANCES OF DISCHARGE ***** On [**2155-2-12**], Mr. [**Known lastname **] developed transient chest pain with ST depressions It was recommended that he have a cardiac catheterization performed on [**2155-2-13**], but he refused the catheterization and chose to go home with out-patient follow-up. It was discussed at length with the patient and his wife that this decision was not medically advised and that it was preferred that he remain in the hospital for further management of his unstable angina. The full risks of leaving the hospital at this point in his care were discussed, and he agreed and understood that risks of leaving the hospital included but were not limited to myocardial infarction, stroke, and death if he were to return home on [**2155-2-12**]. Despite this, he insisted on being discharged with out-patient cardiology follow-up. PENDING ISSUES: (1) Clopidogrel was held due to concern for thrombocytopenia and bleeding risk. Please reevaluate need for restarting this medication. (2) The issue of a catheterization and CABG should be readdressed with the patient at his next cardiology and primary care appointments. Medications on Admission: atenolol 25 mg daily lisinopril 10 mg daily lovastatin 40 mg daily Imdur 30 mg daily plavix 75 mg daily ECASA 325 mg daily ranitidine 150 mg [**Hospital1 **] fentanyl patch 12 mcg/hr Q72 HR oxycodone 5/325 mg Q4H prn NTG prn Discharge Medications: 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 2. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 3. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3 times a day). Disp:*2700 ML(s)* Refills:*2* 4. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 5. Fentanyl 25 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr Transdermal Q72H (every 72 hours). Disp:*10 Patch 72 hr(s)* Refills:*2* 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. Nitrofurantoin (Macrocryst25%) 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) for 7 days. Disp:*14 Capsule(s)* Refills:*0* 9. Atenolol 100 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 10. Ranitidine HCl 150 mg Capsule Sig: One (1) Capsule PO twice a day. Disp:*60 Capsule(s)* Refills:*2* 11. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) tablet Sublingual Up to three at a time as needed for chest pain: This medication is for chest pain and you may take up to three at a time. Disp:*60 tablets* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Primary Diagnoses: 1. NSTEMI 2. Alcohol withdrawl 3. Hepatitis Discharge Condition: Hemodynamically stable; ambulating and mentating as normal. Discharge Instructions: You were adnitted to the hospital for a heart attack. During your hospitalization you had alcohol withdrawal which required a breathing tube to be placed. Please take all of your medications as directed on the list we give you. Some of the medications that you used to take do not need to be taken any more-- please follow the new list carefully. Please notice that your plavix was discontinued; you should discuss with your out-patient cardiologist whether you need to go back onto this. You should refrain from using alcohol for your heart and liver health. If you devlop chest pain, shortness of breath, dizziness, palpitations, fevers, bleeding or any other concerning symptoms, you should call your doctor or come to the emergency room. Followup Instructions: You should either see your main cardiologist Dr. [**Last Name (STitle) 7047**] in the next two - three weeks, or you should call ([**Telephone/Fax (1) 5909**] to set up a new appointment with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at [**Hospital1 **] Hospital. Please make sure to see them in the next couple weeks because it is important for them to see how your heart is doing. You should also make an appointment to see your primary care doctor in the next two - three weeks.

[ "428.0", "599.0", "292.81", "414.01", "E939.4", "V17.3", "250.00", "578.0", "291.0", "272.4", "411.1", "070.30", "410.71", "284.1", "571.2", "303.91", "571.1", "070.70", "996.72", "443.9", "537.82", "401.9" ]

icd9cm

[ [ [] ] ]

[ "96.71", "96.04", "45.13" ]

icd9pcs

[ [ [] ] ]

13335, 13341

8329, 11812

325, 333

13448, 13510

5140, 5140

14306, 14821

3804, 3859

12087, 13312

13362, 13427

11838, 12064

13534, 14283

3874, 3884

3906, 5121

6009, 7742

243, 287

361, 2881

7751, 8306

5156, 5992

2903, 3514

3530, 3788

76,709

115,291

548

Discharge summary

report

Admission Date: [**2107-5-26**] Discharge Date: [**2107-6-9**] Date of Birth: [**2029-5-6**] Sex: F Service: SURGERY Allergies: Cortisone / Percocet / Prednisone / Advair Diskus Attending:[**First Name3 (LF) 3376**] Chief Complaint: Abdominal pain Major Surgical or Invasive Procedure: [**2107-5-26**]: Exploratory laparotomy with ileocolectomy History of Present Illness: 78F s/p laparoscopic converted to open right hemicolectomy for Stage 1 (T1N0) right colon cancer on [**2106-10-29**], now being transferred from OSH with diffuse abdominal pain and guarding on exam. She started with diffuse abdominal pain at 9am yesterday and went to [**Hospital3 4485**] at 9pm. She had some nausea and bilious emesis x5, but had been passing flatus and bowel movements. A non-contrast CT was performed and she was sent here as her abdominal exam was concerning. In ED with A.fib w/RVR, hypertension up to 200/100. Past Medical History: CAD s/p PCI (last '[**02**]), pAFib, CHF, HTN, hyperchol, interstitial lung disease, GIB, GERD, CRI (baseline Cr 1.3-1.8), NIDDM, hypothyroid, TIA, parkinson's, low back pain Past Surgical History: Diverting transverse loop colostomy after colonic perforation from colonoscopy,, colostomy reversal, ventral hernia repair with mesh, Laparoscopic converted to open right hemicolectomy [**2106-11-15**]. Social History: Patient is retired, lives at home with husband. Former [**Name2 (NI) 1818**]. Denies alcohol or other drugs. Family History: NC Physical Exam: On admission: Vitals: T 101.1 HR 160 BP 120/90 RR 20 SO2 96% GEN: A&O, NAD HEENT: No scleral icterus, mucus membranes moist CV: RRR, No M/G/R PULM: Clear to auscultation b/l, No W/R/R ABD: Firm, nondistended, severely tender diffusely, mild rebound tenderness and voluntary guarding. DRE: normal tone, no gross or occult blood Ext: 1+ LE edema b/l, LE warm and well perfused On Discharge: Pertinent Results: ADMISSION LABS -------------- [**2107-5-26**] 12:30AM BLOOD WBC-29.3*# RBC-4.63# Hgb-13.3# Hct-42.3# MCV-91 MCH-28.8 MCHC-31.5 RDW-15.8* Plt Ct-263# [**2107-5-26**] 12:30AM BLOOD PT-30.3* PTT-23.7 INR(PT)-3.0* [**2107-5-26**] 12:30AM BLOOD Glucose-182* UreaN-40* Creat-1.6* Na-143 K-6.0* Cl-107 HCO3-19* AnGap-23* [**2107-5-26**]: TEE No intracardiac thrombus. Mild mitral regurgitation. [**2107-5-26**]: CT abd/pelvis: - Diffuse bowel wall dilatation, with lack of mural enhancement in the distal ileum, concerning for bowel ischemia or necrosis. There is an occlusion of an ileal branch of the superior mesenteric artery suggesting an embolic cause for bowel ischemia upstream of affected areas. - Extensive atherosclerotic disease of the aorta and iliac arteries. [**2107-5-30**]: MRI Head - Acute infarction in the left middle cerebral artery distribution involving the left parietal lobe. - Small old infarct in the right cerebellum. - No evidence of susceptibility artifact to suggest intracranial hemorrhage. [**2107-6-3**]: KUB - ileus [**2107-6-4**]: KUB - There has been no significant change. There remains air and stool seen throughout the colon and some mildly prominent loops of small bowel. Left side down decubitus radiograph, shows no free intra-abdominal gas present. Surgical skin staples are seen projecting over the midline. [**2107-6-4**]: CT HEAD: - Evolving left parietal infarct. No evidence of hemorrhagic transformation. - Global atrophy and chronic small vessel change. - Small old right cerebellar infarct. [**2107-6-8**] 05:10AM BLOOD WBC-7.8 RBC-3.43* Hgb-10.1* Hct-31.3* MCV-91 MCH-29.6 MCHC-32.4 RDW-15.6* Plt Ct-454* [**2107-6-7**] 05:22AM BLOOD WBC-7.6 RBC-3.28* Hgb-9.5* Hct-30.5* MCV-93 MCH-29.1 MCHC-31.3 RDW-15.8* Plt Ct-438 [**2107-6-6**] 05:00AM BLOOD WBC-7.8 RBC-3.15* Hgb-9.3* Hct-29.0* MCV-92 MCH-29.4 MCHC-32.0 RDW-15.9* Plt Ct-361 [**2107-6-5**] 05:37PM BLOOD WBC-8.8 RBC-3.24* Hgb-9.2* Hct-29.2* MCV-90 MCH-28.4 MCHC-31.5 RDW-16.3* Plt Ct-313 [**2107-6-5**] 09:24AM BLOOD WBC-8.0 RBC-3.16* Hgb-9.3* Hct-28.5* MCV-90 MCH-29.3 MCHC-32.5 RDW-16.2* Plt Ct-310 [**2107-6-5**] 01:42AM BLOOD WBC-7.3 RBC-3.02* Hgb-9.2* Hct-26.5* MCV-88 MCH-30.6 MCHC-34.9 RDW-15.9* Plt Ct-268 [**2107-6-4**] 12:11AM BLOOD WBC-7.1 RBC-3.61* Hgb-10.6* Hct-32.7* MCV-91 MCH-29.5 MCHC-32.5 RDW-16.3* Plt Ct-307 [**2107-6-3**] 05:12AM BLOOD WBC-5.3 RBC-3.42* Hgb-10.0* Hct-31.5* MCV-92 MCH-29.3 MCHC-31.8 RDW-15.9* Plt Ct-245 [**2107-6-2**] 05:25AM BLOOD WBC-4.1 RBC-3.44* Hgb-10.1* Hct-31.5* MCV-92 MCH-29.4 MCHC-32.1 RDW-15.8* Plt Ct-200 [**2107-6-1**] 05:20AM BLOOD WBC-3.0* RBC-3.64* Hgb-10.9* Hct-32.8* MCV-90 MCH-29.8 MCHC-33.1 RDW-15.8* Plt Ct-157 [**2107-5-31**] 05:10AM BLOOD WBC-4.0# RBC-3.83* Hgb-11.4* Hct-34.1* MCV-89 MCH-29.8 MCHC-33.5 RDW-15.9* Plt Ct-132* [**2107-5-26**] 12:30AM BLOOD Neuts-93* Bands-0 Lymphs-2* Monos-5 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 [**2107-5-26**] 12:30AM BLOOD Hypochr-NORMAL Anisocy-NORMAL Poiklo-1+ Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL Ovalocy-1+ Tear Dr[**Last Name (STitle) 833**] [**Name (STitle) 4486**] [**2107-6-9**] 11:10AM BLOOD PT-24.3* PTT-26.1 INR(PT)-2.3* [**2107-6-8**] 05:10AM BLOOD Plt Ct-454* [**2107-6-8**] 05:10AM BLOOD PT-25.3* PTT-28.1 INR(PT)-2.4* [**2107-6-7**] 05:22AM BLOOD Plt Ct-438 [**2107-6-7**] 05:22AM BLOOD PT-39.7* PTT-29.9 INR(PT)-4.1* [**2107-6-6**] 05:00AM BLOOD Plt Ct-361 [**2107-6-6**] 05:00AM BLOOD PT-39.0* PTT-29.5 INR(PT)-4.0* [**2107-6-5**] 05:37PM BLOOD Plt Ct-313 [**2107-6-5**] 09:24AM BLOOD Plt Ct-310 [**2107-6-5**] 01:42AM BLOOD Plt Ct-268 [**2107-6-5**] 01:42AM BLOOD PT-39.8* PTT-28.6 INR(PT)-4.1* [**2107-6-4**] 12:11AM BLOOD Plt Ct-307 [**2107-6-4**] 12:11AM BLOOD PT-38.6* PTT-26.7 INR(PT)-3.9* [**2107-6-3**] 05:12AM BLOOD PT-38.4* PTT-27.4 INR(PT)-3.9* [**2107-6-2**] 11:20AM BLOOD PT-34.5* PTT-68.9* INR(PT)-3.5* [**2107-6-1**] 12:58PM BLOOD PT-17.7* PTT-45.5* INR(PT)-1.6* [**2107-6-1**] 05:20AM BLOOD Plt Ct-157 [**2107-6-1**] 05:20AM BLOOD PT-16.7* PTT-44.1* INR(PT)-1.5* [**2107-5-31**] 05:10AM BLOOD PT-16.1* PTT-26.0 INR(PT)-1.4* [**2107-5-30**] 03:20PM BLOOD PT-17.6* PTT-25.5 INR(PT)-1.6* [**2107-5-28**] 03:10AM BLOOD PT-16.8* PTT-28.7 INR(PT)-1.5* [**2107-5-27**] 12:26PM BLOOD Plt Ct-120* [**2107-5-27**] 12:26PM BLOOD PT-23.0* PTT-32.7 INR(PT)-2.1* [**2107-5-27**] 03:29AM BLOOD PT-31.2* PTT-35.1* INR(PT)-3.1* [**2107-5-26**] 07:22AM BLOOD PT-19.8* PTT-29.8 INR(PT)-1.8* [**2107-5-26**] 12:30AM BLOOD PT-30.3* PTT-23.7 INR(PT)-3.0* [**2107-6-9**] 11:10AM BLOOD Glucose-90 UreaN-13 Creat-1.3* Na-146* K-3.6 Cl-111* HCO3-23 AnGap-16 [**2107-6-8**] 05:10AM BLOOD Glucose-90 UreaN-13 Creat-1.2* Na-141 K-3.1* Cl-112* HCO3-21* AnGap-11 [**2107-6-7**] 05:22AM BLOOD Glucose-93 UreaN-16 Creat-1.3* Na-141 K-3.8 Cl-108 HCO3-21* AnGap-16 [**2107-6-6**] 05:00AM BLOOD Glucose-91 UreaN-15 Creat-1.3* Na-142 K-4.1 Cl-111* HCO3-21* AnGap-14 [**2107-6-5**] 05:37PM BLOOD Glucose-110* UreaN-15 Creat-1.3* Na-140 K-4.2 Cl-111* HCO3-20* AnGap-13 [**2107-6-5**] 07:23AM BLOOD Creat-1.3* Na-140 K-4.2 Cl-113* [**2107-6-5**] 01:42AM BLOOD Glucose-125* UreaN-17 Creat-1.4* Na-139 K-4.0 Cl-110* HCO3-21* AnGap-12 [**2107-6-4**] 12:11AM BLOOD Glucose-136* UreaN-16 Creat-1.1 Na-141 K-3.4 Cl-110* HCO3-22 AnGap-12 [**2107-6-3**] 05:12AM BLOOD Glucose-94 UreaN-17 Creat-1.2* Na-143 K-3.4 Cl-111* HCO3-21* AnGap-14 [**2107-6-2**] 05:25AM BLOOD Glucose-109* UreaN-23* Creat-1.3* Na-143 K-3.3 Cl-111* HCO3-21* AnGap-14 [**2107-6-1**] 12:44PM BLOOD Glucose-118* UreaN-29* Creat-1.4* Na-142 K-3.4 Cl-108 HCO3-23 AnGap-14 [**2107-6-1**] 05:20AM BLOOD Glucose-102* UreaN-30* Creat-1.4* Na-142 K-3.3 Cl-107 HCO3-23 AnGap-15 [**2107-5-31**] 05:10AM BLOOD Glucose-120* UreaN-36* Creat-1.4* Na-143 K-3.6 Cl-107 HCO3-24 AnGap-16 [**2107-5-29**] 07:55PM BLOOD Glucose-121* UreaN-36* Creat-1.4* Na-140 K-3.5 Cl-105 HCO3-20* AnGap-19 [**2107-5-29**] 01:35AM BLOOD Glucose-97 UreaN-39* Creat-1.8* Na-142 K-3.8 Cl-110* HCO3-21* AnGap-15 [**2107-5-28**] 03:10AM BLOOD Glucose-90 UreaN-36* Creat-1.7* Na-141 K-4.6 Cl-108 HCO3-22 AnGap-16 [**2107-6-6**] 05:00AM BLOOD ALT-9 AST-13 LD(LDH)-178 AlkPhos-40 TotBili-0.3 [**2107-5-26**] 12:30AM BLOOD ALT-14 AST-42* AlkPhos-41 TotBili-0.3 [**2107-6-7**] 05:50PM BLOOD CK-MB-5 cTropnT-0.04* [**2107-5-29**] 01:35AM BLOOD CK-MB-2 cTropnT-0.05* [**2107-6-9**] 11:10AM BLOOD Calcium-8.4 Phos-3.9 Mg-1.8 [**2107-6-8**] 05:10AM BLOOD Calcium-8.0* Phos-3.5 Mg-1.9 [**2107-6-7**] 05:22AM BLOOD Calcium-8.0* Phos-4.0 Mg-1.9 [**2107-6-6**] 05:00AM BLOOD Calcium-7.8* Phos-4.2 Mg-2.0 [**2107-6-5**] 05:37PM BLOOD Calcium-7.9* Phos-3.7 Mg-2.0 [**2107-6-4**] 12:11AM BLOOD Calcium-8.2* Phos-3.3 Mg-2.0 [**2107-6-3**] 05:12AM BLOOD Calcium-7.8* Phos-2.9 Mg-2.3 [**2107-6-2**] 05:25AM BLOOD Calcium-8.0* Phos-2.5* Mg-1.9 [**2107-6-1**] 12:44PM BLOOD Calcium-8.1* Phos-3.1 Mg-2.0 [**2107-5-31**] 05:10AM BLOOD Calcium-7.9* Phos-3.9 Mg-2.1 Cholest-97 [**2107-5-30**] 05:35AM BLOOD Calcium-8.3* Phos-4.2 Mg-2.1 [**2107-5-29**] 01:35AM BLOOD Calcium-8.2* Phos-3.7# Mg-2.3 [**2107-5-28**] 03:10AM BLOOD Calcium-8.7 Phos-5.5* Mg-2.1 [**2107-5-27**] 12:26PM BLOOD Calcium-7.9* Phos-4.5 Mg-2.0 [**2107-6-2**] 05:25AM BLOOD Triglyc-193* [**2107-5-31**] 05:10AM BLOOD Triglyc-212* HDL-16 CHOL/HD-6.1 LDLcalc-39 [**2107-5-31**] 05:10AM BLOOD Vanco-19.5 [**2107-5-28**] 06:00AM BLOOD Vanco-13.7 [**2107-6-6**] 05:00AM BLOOD Digoxin-0.9 [**2107-5-28**] 03:10AM BLOOD Digoxin-0.7* Brief Hospital Course: Ms. [**Known lastname **] was taken emergently to the OR for exploratory laparatomy on [**2107-5-26**]. She was transferred to the SICU in fair condition postoperatively, intubated and sedated. Her hospital course is discussed below by system: Neuro: Patient's pain was controlled with PCA and transitioned to IV and po pain medications when appropriate. During her ICU stay, she was noted to have word finding difficult and sundowning. Family felt that patient was confused but otherwise at baseline and her neurologic exam was nonfocal. As her overall condition improved and sundowning resolved, her word finding difficulty became more apparent and an MRI of her head was performed on [**2107-5-30**] with acute infarction in the left middle cerebral artery distribution involving the left parietal lobe noted. She was started on a heparin drip and her afib was controlled as below. Over the following 48 hours, her speech improved and a speech and swallow evaluation was performed prior to starting po intake. Patient improved daily until [**2107-6-3**] when she developed hypertension into the 200s with associated worsening speech. A CT head was performed which showed no hemorrhagic conversion and evolving stroke. She was continued on coumadin once therapeutic on heparin, and her dose of this was titrated to an appropriate level. She had been initially supratherapeutic with a maximum INR during her admission of 4.1, following which her coumadin was held. This was restarted on 0.5mg of Warfarin at discharge with a plan to follow her INR at rehab. CV: Patient was in Afib RVR upon admission. IV metoprolol was used for rate control. TEE showed no evidence of intracardiac thrombus to explain her synchronous embolization to her small bowel and brain. Patient required multiple IV antihypertensives (metop, labetalol, hydralazine) for BP control. On [**2107-6-3**], patient's hypertensive episode prompted a transfer to ICU where she was controlled with a labetalol drip to maintain systolic blood pressure <140. Patient was eventually transitioned to PO metoprolol and IV metoprolol PRN and transferred back to the general surgery service. Following transfer she was started on lisinopril and her blood pressure remained stable and appropriate and continued on an increased dose of Lopressor. Her blood pressure was improved and appropriate. Resp: Patient showed evidence of moderate pulmonary edema and was diuresed with IV lasix. She was given nebulizer treatments and encourage to use her IS. Her O2 was weaned. Abd: Patient's abdomen was distended with a prolonged ileus postoperatively. Initial attempts at diet advanced with speech and swallow recommendations were met with abdominal distension and pain. On [**2107-6-3**], patient complained of severe abdominal pain with nausea. KUB showed an ileus. NG tube was placed with 500 cc of bile drained and improvement in pain. NG tube was removed while patient in ICU and abominal distension was improved. Her diet was advanced to a regular diet and calorie counts were followed. She was given supplementation with ensure and was instructed to continue this on discharge. Wound: The midline surgical incision was closed with staples post-operatively. The inicsion line was intact without signs of infection. These staples were removed on discharge and replaced with steri-strips. The patient was to wear an abdominal binder when out of bed. Renal: Patient's mild renal insufficiency was unchanged throughout admission. Heme: Patient received one unit of FFP prior to ex lap on [**5-27**], one unit of PRBC on [**2107-5-29**] and one unit of PRBC on [**2107-6-3**] for low Hct. Her INR rose from 1.4 to 3.5 with one dose of coumadin once therapeutic on heparin. Her INR peaked at 4.1 and then trended down. She was kept therapeutic on her coumadin thereafter with a low dose. Patient was also kept on Heparin SC with venodynes for DVT prophylaxis. ID: The patient was ruled out for C. Diff suring this admission. Consulting teams: During this admission the patient was followed closely by neurology, geriatric medicine, speech and swallow, phyiscal therapy, and social work. Medications on Admission: Coumadin 2', ASA 81', toprol XL 75', digoxin 0.125qod, lipitor 40', omeprazole 20', glipizide 2.5', fentanyl patch 50, topamax 25', sinemet 25/100''', seroquel 25'am-50'pm-100'hs, remeron 30'hs, divalproex 250am/500pm, ativan 0.5'''prn, ambien 10'prn, MVI, colace 100", CaCarb 1000''', Fe 65', fish oil, ?lasix 20', toprol 75', mirtazapine 30', Omeprazole 20', Discharge Medications: 1. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 2. furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 4. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 5. digoxin 125 mcg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY (Every Other Day). 6. atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. glipizide 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 8. topiramate 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. carbidopa-levodopa 25-100 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 10. quetiapine 25 mg Tablet Sig: One (1) Tablet PO QAM (once a day (in the morning)). 11. quetiapine 50 mg Tablet Sig: One (1) Tablet PO QPM (once a day (in the evening)). 12. quetiapine 100 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)). 13. mirtazapine 30 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 14. divalproex 250 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO QAM (once a day (in the morning)). 15. divalproex 500 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO QPM (once a day (in the evening)). 16. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for anxiety. 17. multivitamin,tx-minerals Tablet Sig: One (1) Tablet PO DAILY (Daily). 18. lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 19. metoprolol tartrate 25 mg Tablet Sig: 2.5 Tablets PO BID (2 times a day). Disp:*150 Tablet(s)* Refills:*2* 20. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain. Disp:*50 Tablet(s)* Refills:*0* 21. warfarin 1 mg Tablet Sig: [**1-30**] Tablet PO QHS (once a day (at bedtime)) for 1 doses: Please give at 1600 on [**2107-6-9**] and recheck INR on [**2107-6-10**]. Goal INR 2.0-3.0, pt have been difficult to manage, very sensitive to warfarin. Discharge Disposition: Home With Service Facility: [**Hospital6 **] in [**Location (un) **] Discharge Diagnosis: Mesenteric Ischemia Ileal Resection CVA Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: You were admitted to the hospital after a an open colectomy for surgical management of your mesenteric ischemia. It is thought that this mesenteric ischemia was caused by a blood clot in the membranes attatched to your intestine caused by your heart condition atrial fibrillation. During this time, it is thought that you also suffered from a stroke related to a blood clot which traveled to your brain. It is very important that you continue your coumadin therapy which ahs been difficult to manage, however, will be managed by the [**Hospital 4487**] hospital providers. You have recovered from this surgery well and you are now ready to be discharged to rehabilitation. From the stoke, you have difficulty saying words and it is our hope as well as the hope of the neurology team that this will improve over time with the help of occpational therapy and speech therapy. Please continue to hope and work for improvement in your symptoms. Please participate in physical therapy to regain your strength. You have tolerated a regular diet, passing gas and your pain is controlled with pain medications by mouth. Please monitor your bowel function closely. You have had a bowel movement. After anesthesia it is not uncommon for patient??????s to have some decrease in bowel function but your should not have prolonged constipation. Some loose stool and passing of small amounts of dark, old appearing blood are explected however, if you notice that you are passing bright red blood with bowel movments or having loose stool without improvement please call the office or go to the emergency room if the symptoms are severe. If you are taking narcotic pain medications there is a risk that you will have some constipation. Please take an over the counter stool softener such as Colace, and if the symptoms does not improve call the office. If you have any of the following symptoms please call the office for advice or go to the emergency room if severe: increasing abdominal distension, increasing abdominal pain, nausea, vomiting, inability to tolerate food or liquids, prolonges loose stool, or constipation. You have a long vertical incision on your abdomen the staples have been removed prior to your discharged and steri-strips have been applied. This incision can be left open to air or covered with a dry sterile gauze dressing if the incision becomes irritated from clothing. Please monitor the incision for signs and symptoms of infection including: increasing redness at the incision, opening of the incision, increased pain at the incision line, draining of white/green/yellow/foul smelling drainage, or if you develop a fever. Please call the office if you develop these symptoms or go to the emergency room if the symptoms are severe. You may shower, let the warm water run over the incision line and pat the area dry with a towel, do not rub. Please wear an abdominal binder provided to you at all times while out of bed. No heavy lifting for at least 6 weeks after surgery unless instructed otherwise by Dr. [**Last Name (STitle) 1120**] or Dr. [**Last Name (STitle) **]. You may gradually increase your activity as tolerated but clear heavy excersise after follow up. You may take Tylenol as recommended for pain. Please do not take more than 4000mg of Tylenol daily. Do not drink alcohol while taking narcotic pain medication or Tylenol. You will take 0.5mg coumadin today [**2107-6-9**]. Your INR today [**2107-6-9**] is 2.3. The rehab facility will need to check daily INRs until your INR is stable and therapeutic, with a goal INR of 2.0-3.0. Thank you for allowing us to participate in your care! Our hope is that you will have a quick return to your life and usual activities. Good luck! Followup Instructions: Please plan to follow up in Dr. [**Last Name (STitle) 4488**] clinic in approximately 2 weeks. Call ([**Telephone/Fax (1) 3378**] to make an appointment. Completed by:[**2107-6-9**]

[ "585.9", "V45.82", "250.00", "787.22", "276.2", "557.0", "428.0", "515", "428.31", "560.1", "790.01", "997.4", "V58.61", "427.31", "244.9", "E878.2", "434.11", "332.0", "V10.05", "272.0", "293.0", "567.21", "784.3", "997.02", "403.90" ]

icd9cm

[ [ [] ] ]

[ "88.72", "45.73", "99.77", "45.93" ]

icd9pcs

[ [ [] ] ]

16059, 16130

9367, 13517

322, 382

16214, 16214

1941, 3310

20135, 20320

1512, 1516

13929, 16036

16151, 16193

13543, 13906

16397, 20112

1165, 1369

1531, 1531

1922, 1922

268, 284

410, 944

3319, 9344

1545, 1907

16229, 16373

966, 1142

1385, 1496

75,536

139,446

43549

Discharge summary

report

Admission Date: [**2117-11-25**] Discharge Date: [**2117-12-1**] Date of Birth: [**2060-1-2**] Sex: F Service: SURGERY Allergies: Morphine Attending:[**First Name3 (LF) 668**] Chief Complaint: Fevers, left lower quadrant pain Major Surgical or Invasive Procedure: none History of Present Illness: 57 year-old lady with history of acute aortic occlusion in [**8-/2117**], now s/p emergent axillary [**Hospital1 **]-femoral bypass complicated by acute mesenteric ischemia requiring ex lap and L hemicolectomy & transverse colostomy presents with LLQ pain and fevers to 103. The patient started developing slight LLQ pain 3 weeks ago. She was seen by Dr. [**First Name (STitle) **] in clinic when she was having the pain. During this appt, her ostomy and G tube were functioning well. She didn't have any fevers at that time. Over the past two weeks she has had decreased appetite, but she states she has been tolerating her tube feeds without any problem and her ostomy has been functioning normally. She saw Dr. [**Last Name (STitle) **] in clinic today for evaluation of her fasciotomy wounds that were created during her operation in [**Month (only) **]. Her wounds were found to be very clean and healing well. They did not at all appear infected. She was sent back to [**Hospital **] Rehab after her clinic visit this afternoon, and she developed a temp to 103 and severe abdominal pain in her LLQ. The rehab sent her to the ED here at [**Hospital1 18**]. At the present time, her temp is 102.2. She is mentating normally and reports abdominal pain, most severe on the left side and more severe than it has been in the past few weeks. She has nausea but no vomiting. She is emptying her ostomy 3-4 times per day. She denies any burning upon urination. Patient received a dose of levaquin and flagyl and 4 L of crystalloid in the ED. Of note, she reports a history of C Diff at [**Hospital1 **] that was treated by Abx. Past Medical History: Depression s/p intentional Ambien overdose and subsequent hospitalization at [**Doctor First Name 1191**], no previous known psych history. Hypertension Hypercholesterolemia CAD - s/p AICD placement Renal insufficiency - s/p renal artery stents Chronic low back pain Past Surgical History: renal artery stents, AICD, Right axillary-bifemoral bypass w/8mm PTFE; Bilateral EIA thrombectomies, Right femoral-popliteal thrombectomy, Bilateral 4-compartment Lower extremity fasciotomies ([**9-2**]), flexible-sigmoidoscopy ([**9-2**], [**9-3**]), exploratory laporatomy, Left colectomy, transverse colostomy ([**9-4**]), placement Left Internal Jugular Hemodialysis catheter ([**9-10**]) Social History: Lives in [**Location 3786**] with her husband, various jobs in past, but not currently employed, one son who lives in the area. She smoked 1 ppd x 40 years. She denies any illicit or IV drug use. Family History: Father with diabetes mellitus and CAD Physical Exam: VS: 98.5, 83, 105/73, 20, 94%RA GEN: NAD, A&O x 3 LUNGS: Clear B/L CV: sinus tach, nl S1 and S2 ABD: Soft, minimal tenderness, nondistended, +bowel sounds WOUND: wound vac right leg intact EXT: 1+ lower extremity edema Pertinent Results: Admission labs [**2117-11-24**] 07:25PM BLOOD WBC-23.9*# RBC-2.57* Hgb-7.4* Hct-23.0* MCV-89 MCH-28.7 MCHC-32.2 RDW-16.6* Plt Ct-854* [**2117-11-25**] 02:34AM BLOOD WBC-23.8* RBC-2.55* Hgb-7.6* Hct-23.0* MCV-90 MCH-29.8 MCHC-33.0 RDW-15.4 Plt Ct-712* [**2117-11-24**] 07:25PM BLOOD Neuts-90.8* Lymphs-4.3* Monos-4.0 Eos-0.6 Baso-0.2 [**2117-11-25**] 02:34AM BLOOD Neuts-93.1* Lymphs-3.4* Monos-2.9 Eos-0.5 Baso-0.1 [**2117-11-24**] 07:25PM BLOOD Glucose-112* UreaN-16 Creat-0.9# Na-135 K-4.1 Cl-98 HCO3-30 AnGap-11 [**2117-11-25**] 02:34AM BLOOD Glucose-103 UreaN-11 Creat-0.7 Na-137 K-3.6 Cl-108 HCO3-21* AnGap-12 [**2117-11-24**] 07:25PM BLOOD ALT-11 AST-10 AlkPhos-78 TotBili-0.2 [**2117-11-25**] 02:34AM BLOOD CK(CPK)-61 [**2117-11-25**] 02:34AM BLOOD CK-MB-NotDone cTropnT-0.22* [**2117-11-25**] 10:39AM BLOOD CK-MB-NotDone cTropnT-0.29* [**2117-11-25**] 04:41PM BLOOD cTropnT-0.24* [**2117-11-25**] 09:07PM BLOOD CK-MB-NotDone cTropnT-0.23* [**2117-11-26**] 04:15AM BLOOD CK-MB-NotDone cTropnT-0.21* [**2117-11-24**] 07:25PM BLOOD Albumin-2.4* Phos-4.1 Mg-1.6 [**2117-11-25**] 02:34AM BLOOD Calcium-6.9* Phos-4.1 Mg-1.4* [**2117-11-25**] 04:41PM BLOOD calTIBC-108* Ferritn-408* TRF-83* [**2117-11-25**] 04:41PM BLOOD Triglyc-103 [**2117-11-24**] 07:32PM BLOOD Lactate-1.2 [**2117-11-24**] 11:46PM BLOOD Lactate-1.0 [**2117-11-25**] 02:58AM BLOOD Lactate-0.8 Discharge labs [**2117-12-1**] 04:56AM BLOOD WBC-14.9* RBC-3.41* Hgb-9.8* Hct-30.8* MCV-91 MCH-28.9 MCHC-31.9 RDW-15.9* Plt Ct-702* [**2117-11-30**] 06:20AM BLOOD WBC-14.7* RBC-3.15* Hgb-9.4* Hct-28.7* MCV-91 MCH-29.8 MCHC-32.8 RDW-16.1* Plt Ct-648* [**2117-11-30**] 06:20AM BLOOD Glucose-106* UreaN-27* Creat-0.9 Na-142 K-4.3 Cl-109* HCO3-25 AnGap-12 [**2117-11-30**] 06:20AM BLOOD Calcium-8.7 Phos-4.7* Mg-2.0 Brief Hospital Course: 57F presented on [**2117-11-24**] from [**Hospital1 **] with a fever of 103, left lower quadrant abdominal pain, HR110s and SBP low 80s. She was fluid resuscitated and BP increased. IV Levofloxacin and flagyl were also given. Blood, urine cultures were sent and CT of abdomen and pelvis were ordered, which showed colitis. Patient was started on PO flagyl and vancomycin, levofloxacin was continued. Patient was admitted to the Surgical ICU for cardiac monitoring. Cardiology was consulted to help manage HR and blood pressures. Cardiology determined the patient had demand related ischemia with troponins peaked at 0.3. Records from recent cardiac cath from outside hospital were reviewed. Cardiology recommended resolving infection first and continue beta-blocker, aspirin. Vascular surgery was also consulted given her history of aortic occlusion and axillary bifemoral bypass surgery. [**11-26**] Vac dressing was placed on right leg fasciotomy site and changed every three days. Echo of the heart showed no changes since last echo in [**Month (only) 462**]. TPN was started Wound care was consulted to manage sacral decubitus ulcers. [**11-27**] levofloxacin was discontinued. IV vancomycin was started for [**12-23**] Bx with coagulase negative staphlococcus. Chronic pain service was consulted to manage pain. [**11-28**] Patient's vitals, diarrhea, pain improved and patient was transferred to floor. Diet was advanced. [**11-29**] Regular diet was started, TPN was decreased to [**12-23**] bag then discontinued after bag was infused. Physical therapy worked with patient on a daily basis. Foley catheter was removed. [**11-30**] IV vanco discontinued only [**12-25**] blood cultures positive. Foley catheter was reinserted for bladder scan with 450cc. [**12-1**] Patient was discharged in stable condition, afebrile, tolerating diet, pain well controlled. Patient sent to [**Hospital1 **] to complete 4 more days of total 14 day course of PO vancomycin and flagyl Medications on Admission: Albuterol 90 mcg - 4 puffs q4hr prn Atorvastatin 10 mg qd Beclomethasone Dipropionate 80 mcg 1 puff [**Hospital1 **] Calcium Acetate 2 caps tid Citalopram 20 mg qd Fentanyl 50 mcg/hour patch q72 hrs Fluticasone 50 mcg INH [**Hospital1 **] Advair 250-50 INH [**Hospital1 **] Gabapentin 100 mg tid Heparin 5000units tid Ativan 1 mg qhs prn Metoprolol 12.5 mg [**Hospital1 **] Nyastatin s&s Percocet prn Pantoprazole 40 qd Vit C 500 qd Acetaminophen q6hrs prn ASA 81 qd Miconazole Nitrate 2% cream qid MVI qd Senna 1 tab [**Hospital1 **] Zinc 220 mg qd Discharge Medications: 1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 2. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation Q6H (every 6 hours). 3. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 5. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 6. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 7. Insulin Regular Human 100 unit/mL Solution Sig: One (1) Injection ASDIR (AS DIRECTED). 8. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 9. Vancomycin 125 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours) for 4 days: [**12-1**] Day [**10-5**]. Capsule(s) 10. Oxycodone 5 mg Tablet Sig: Four (4) Tablet PO Q2H (every 2 hours) as needed. 11. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours). 12. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours). 13. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 4 days: [**12-1**] Day [**10-5**]. 14. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). 15. Collagenase 250 unit/g Ointment Sig: One (1) Appl Topical DAILY (Daily). 16. Gabapentin 300 mg Capsule Sig: Two (2) Capsule PO Q8H (every 8 hours). 17. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 18. Fentanyl 100 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr Transdermal Q72H (every 72 hours). 19. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily). Discharge Disposition: Extended Care Facility: [**Hospital **] Health Care Center Discharge Diagnosis: Primary diagnosis: bacteremia, C. difficile enterocolitis, hypotension, demand cardiac ischemia h/o Depression h/o paraplegia (from acute aortic occlusion) h/o HTN, h/o Hypercholesterolemia h/o CAD (s/p AICD placement) h/o Renal insufficiency h/o chronic low back pain s/p renal artery stents, s/p Right ax-bifem bypass w/8mm PTFE; s/p bilateral EIA thrombectomies s/p Right femoral-popliteal thrombectomy s/p bilateral 4-compartment lower extremity fasciotomies ([**9-2**]), s/p flexible-sigmoidoscopy ([**9-2**], [**9-3**]) s/p exploratory laporatomy s/p Left colectomy, transverse colostomy ([**9-4**]), s/p placement Left Internal Jugular Hemodialysis cathether ([**9-10**]) Discharge Condition: stable Discharge Instructions: Please call your doctor or return to the ER for any of the following: * You have shaking chills, or a fever greater than 101.5 (F) degrees or 38(C) degrees. * trouble with urination * excessive diarrhea * 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. * 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. Followup Instructions: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2118-2-10**] 1:20 Provider: [**Name10 (NameIs) 251**] [**Last Name (NamePattern4) 1490**], MD Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2117-12-22**] 11:00 Completed by:[**2117-12-1**]

[ "458.9", "V44.1", "V44.3", "338.29", "403.90", "724.2", "707.25", "707.09", "276.51", "585.9", "008.45", "707.22", "V45.02", "790.7", "424.1", "707.05" ]

icd9cm

[ [ [] ] ]

[ "38.93", "99.15", "93.59" ]

icd9pcs

[ [ [] ] ]

9294, 9355

5009, 6999

300, 307

10080, 10089

3207, 4986

11382, 11708

2914, 2953

7600, 9271

9376, 9376

7025, 7577

10113, 11359

2287, 2683

2968, 3188

228, 262

335, 1974

9395, 10059

1996, 2264

2699, 2898

12,330

161,034

6120

Discharge summary

report

Admission Date: [**2134-4-3**] Discharge Date: [**2134-4-21**] Date of Birth: [**2085-5-29**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 6195**] Chief Complaint: Abdominal distention and scleral icterus Major Surgical or Invasive Procedure: Intubation Blood exchange History of Present Illness: 48yo with HepC on IFN (Neg VL [**3-5**]), sickle cell anemia who presents with abdominal pain, nausea, vomiting x 3-4 weeks. Takes APAP #3 2 pills a day. Went to dentists 1 week ago and had crown placed--> bloody secretion. Notable labs: Cr 1.8 (bl 0.6) T bili 59.7 (direct 43.6) INR 1.8 PTT 100.2 WBC 18.1 HCT 20.7 (21-23) Tylenol 25. In ED given 8mg MSO4, Vanc, levo, flagyl, anzemet, 1u pRBC. RUQ US: heptamegaly, no potal vein thrombosis; some ascites, untappable. Non-con CT abd: bilat subdiaphrag masses- extramedullary hematopoeisis vs varices. small jejunal-jejunal intusseception in LUQ. Admitted to floor. Persistent abd pain. given 6mg MSO4 and 1mg ativan--> somnolent. Narcan given-> awakens. Repeat labs: Cr 3.3 INR 2.5 . Deteriorated within 12 hours into admisission with decreased MS (did receive narcs/benzos to add to this)and worsening renal fcn. Heme iniated treatment for sickle crisis with plasma exchange. Being covered broadly with IV ABX and on IV NAC. He did undergo dental work last week increasing chance of overwhelming infx as contributor. However, all cx negative and unclear cause of his decompensation. Liver failure may in part be due to sickle cell crisis in setting of Hep C and tylenol use. He was extubated [**4-9**] and looks better but liver and kidney still not recovered. Past Medical History: sickle cell disease hepatitis C, on IFN alpha s/p cholecystectomy hemorrhoids PPD + ([**2121**]) Social History: Patient works as a pharmacy tech in a hospital. He denies EtOH, tobacco, and drug use. Physical Exam: VS; 97.2, 75, 118/71, 23, 100%4L, +3090 x 24hrs. HEENT: esotropia, perrla, icterus, MMM with yellow plaque on tongue neck: soft, right IJ in place lungs: CTAB ant heart: RR, nl s1 s2, V/VI holosystolic murmur throughout precordium abd: distended, +BS, soft, NT, ext: 1+/2+ pitting edema neuro: A&Ox3 Pertinent Results: RUQ U/S [**2134-4-3**]: 1. Enlarged micronodular liver, consistent with known hepatis C. 2. Small amount of ascites. No fluid pocket suitable for paracentesis. 3. Normal right upper quadrant Doppler, however the left hepatic vein was not imaged. Abd CT [**2134-4-3**]: 1. Hepatomegaly and hepatic nodularity, consistent with known hepatitis C. The enlarged left hepatic lobe probably corresponds to the palpable abnormality in the left upper quadrant. 2. New moderate ascites. 3. Bilateral paraspinal masses likely represent extramedullary hematopoesis. CXR [**2134-4-5**]: 1. Stable to slightly improved appearance of bilateral patchy infiltrate , possible related to edema in view of its rapid appearance yesterday and evidence of some clearing already today. 2. Cardiomegaly 3. Improved positioning of endotracheal tube. EKG [**4-10**]: Sinus rhythm Borderline first degree A-V block Left ventricular hypertrophy Inferior and lateral ST elevation - repeat if myocardial injury is suspected Since previous tracing, ST wave changes less prominent than previous - consider ischemia Echo [**2134-4-12**]: Conclusions: 1. The left atrium is mildly dilated. The left atrium is elongated. 2.The right atrium is moderately dilated. 3.Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Overall left ventricular systolic function is low normal. 4. Right ventricular chamber size is normal. 5.The aortic root is mildly dilated. The ascending aorta is mildly dilated. 6.The aortic valve leaflets (3) appear structurally normal with good leaflet excursion. Trace aortic regurgitation is seen. 7.The mitral valve leaflets are structurally normal. Trivial mitral regurgitation is seen. 8.There is mild pulmonary artery systolic hypertension. 9.There is a small pericardial effusion. Peritoneal Fluid Cytology: NEGATIVE FOR MALIGNANT CELLS. Small Bowel Follow Through: Barium flows freely throughout the small bowel reaching the colon in approximately 90 minutes. The small bowel is normal in caliber and mucosal pattern. There is no evidence of small bowel obstruction, or mucosal abnormalities to suggest a tumor. There are surgical clips in the left upper quadrant. The osseous structures are grossly unremarkable. [**2134-4-19**] 06:00AM BLOOD WBC-25.9* RBC-3.31* Hgb-9.0* Hct-27.7* MCV-84 MCH-27.1 MCHC-32.4 RDW-18.5* Plt Ct-237 [**2134-4-6**] 03:53PM BLOOD Hgb F-5.2* [**2134-4-4**] 03:30PM BLOOD Hgb A-30.7 Hgb S-57.7* Hgb C-0 Hgb F-11.6* [**2134-4-19**] 06:00AM BLOOD Plt Ct-237 [**2134-4-11**] 05:30AM BLOOD PT-15.5* PTT-43.8* INR(PT)-1.5 [**2134-4-9**] 01:11PM BLOOD FDP-0-10 [**2134-4-9**] 04:18AM BLOOD Fibrino-327 D-Dimer-2357* [**2134-4-4**] 03:30PM BLOOD Sickle-POS [**2134-4-6**] 04:21AM BLOOD Ret Man-5.2* [**2134-4-19**] 06:00AM BLOOD Glucose-53* UreaN-35* Creat-1.0 Na-148* K-3.4 Cl-120* HCO3-16* AnGap-15 [**2134-4-19**] 06:00AM BLOOD ALT-39 AST-64* AlkPhos-431* TotBili-47.6* [**2134-4-5**] 04:22PM BLOOD TotBili-62.1* DirBili-40.5* IndBili-21.6 [**2134-4-4**] 12:20AM BLOOD Lipase-52 [**2134-4-17**] 05:38AM BLOOD TotProt-5.4* Albumin-2.6* Globuln-2.8 Calcium-9.7 Phos-4.3 Mg-2.5 [**2134-4-9**] 04:18AM BLOOD Hapto-<20* [**2134-4-4**] 10:45AM BLOOD Ammonia-<10 [**2134-4-14**] 05:51AM BLOOD Prolact-17 [**2134-4-12**] 10:30AM BLOOD TSH-0.19* [**2134-4-13**] 05:06AM BLOOD T4-2.9* Free T4-0.7* [**2134-4-3**] 08:00PM BLOOD HBsAg-NEGATIVE HAV Ab-POSITIVE IgM HBc-NEGATIVE IgM HAV-NEGATIVE [**2134-4-4**] 10:45AM BLOOD AFP-5.0 [**2134-4-4**] 12:20AM BLOOD Acetmnp-25.7* Brief Hospital Course: Mr. [**Known lastname 23951**] is a 48 yo male with sickle cell anemia and HCV (undetectable VL, no prior liver bx) who has been on IFN tiw since at least '[**31**] presented with multi-organ dysfcn including profound hepatic dysfcn with a total bilirubin of 60, INR to 3. AST, ALT not far from baseline and MS was initially intact. 1. Acute Liver Failure, likely d/t to sickle cell crisis of the liver, with tylenol use a possible contributor. Pt was initially treated with NAC for an acetaminophen level of 25. His total bilirubin was markedly elevated to 60, predominately direct bili. Pt was admitted to the MICU for his acute liver failure and eventual obtundation after narcotics, which responded to Narcan. He underwent exchange transfusion on [**4-4**]. His Hep C viral load was undetectable, and he only had evidence of old EBV and CMV infections. Pt was initially intubated in the MICU for airway protection. His acute liver failure was complicated by acute tubular necrosis, with a peak creatinine of 5. His renal function quickly returned to baseline. Supportive care was continued in the MICU with slow turning of his total bilirubin, trending down to 48 on discharge. His WBC count remained elevated. Pt was extubated on [**4-9**] and transferred to the floor. Paracentesis on [**4-12**] revealed "jelly belly", or gelatinous amber fluid, not infected. The prospect of pseudomyxedema peritoneii was raised. Ab CT and small bowel follow through was negative for masses sugesstive of cancer. Though his free T4 and TSH were slightly low, this was thought to be due to sick euthyroid, and unlikely to be central process given his normal prolactin. Cytology of the peritoneal fluid was negative for malignant cells. At this point, pt's empiric ceftriaxone and flagyl were discontinued with stably elevated WBC and total bili. A repeat paracentesis on [**4-17**] withdrew 3 liters of clear amber fluid, not infected. Pt was discharged to rehab in stable condition. 2. Leukocytosis: Blood, urine, and peritoneal cultures negative. No SBP per paracentesis x 2. His leukocytosis was felt to be due to his acute liver failure, and was stable at 26,000 for at least a week before discharge. 3. Sickle cell anemia: Pt underwent exchange transfusion in the MICU. His baseline Hct is in the low 20's. He was transfused to keep his Hct > 21. 4. Acute renal failure: Pt had prerenal azotemia/ATN with metabolic acidosis in the MICU. Renal function improved to baseline with IVFs. U/S showed echogenic kidneys. 5. Coagulopathy: Not active, but pt had a recent hx of bloody nose, coughing up blood, bleeding gums. Pt received 2 units FFP and Vit K in the MICU without further signs of bleeding. 6. Altered Mental Status: Pt was intially somnolent on admission after receiving narcotics, improved with Narcan. Pt receive morphine prn for pain thereafter and the prn dose was decreased when pt showed signs of lethargy. 7. Subdiaphragmatic masses: due extramedullary hematopoeisis 8. FEN: Pt was seen by nutrition. After extubation, he tolerated clear liquids which was advanced to a low sodium diet with Boost supplementation. He was drinking reasonably well, and his feeding was beginning to increase. His potassium and magnesium were repleted as needed, nearly daily. 9. GI: Pt was initially constipated in the MICU, and then was having about 1 loose stool per day. He is on GI meds titrated to 1BM daily. 10. Prophylaxis: heparin until ambulating, PPI, GI 11. Dispo: Pt was discharged to rehab, which he will likely need for one week or so before returning home. Medications on Admission: Interferon 3mmU 3x/wk Protonix 40 qd Tylenol with codeine prn pain Viagra 100mg po prn Folate 1 mg qd Discharge Medications: 1. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 2. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 3. Metoclopramide HCl 10 mg Tablet Sig: One (1) Tablet PO QID (4 times a day) as needed for nausea. 4. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO Q8H (every 8 hours) as needed for constipation. 5. Simethicone 80 mg Tablet, Chewable Sig: 0.5-1 Tablet, Chewable PO QID (4 times a day) as needed. 6. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Chlorhexidine Gluconate 0.12 % Liquid Sig: One (1) ML Mucous membrane TID (3 times a day) as needed for white plaque on tongue. 8. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily). 9. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day): until pt is ambulating regularly. 10. Ursodiol 300 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 11. Morphine Sulfate 15 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed. 12. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 13. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day as needed for Potassium < 4.0. Discharge Disposition: Extended Care Facility: Bostonian - [**Location (un) 86**] Discharge Diagnosis: Primary: 1. Acute Liver Failure, likely due to sickle cell hepatopathy, tylenol use possibly another contributor 2. ATN, resolved 3. Narcotic Overdose Secondary: 1. sickle cell disease 2. hepatitis C, on IFN alpha 3. s/p cholecystectomy 4. hemorrhoids 5. PPD + ([**2121**]) Discharge Condition: Pt was in fair condition, with normal vital signs, significant ascites, able to ambulate with assistance, tolerating diet. Discharge Instructions: Please continue taking your medications as prescribed. Do not take any tylenol. Call your doctor or return to the hospital if you experience bleeding, fever, worsening abdominal pain, blood in your stool, or other symptoms of concern. Followup Instructions: Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 19547**], RNP Where: [**Hospital6 29**] [**Hospital **] Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2134-4-29**] 9:40 Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**Name Initial (NameIs) **].D. Where: [**Hospital6 29**] [**Hospital3 249**] Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2134-6-25**] 4:30 [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 6198**] MD, [**MD Number(3) 6199**]

[ "518.81", "E850.4", "276.7", "286.9", "584.5", "070.70", "570", "282.60", "276.0" ]

icd9cm

[ [ [] ] ]

[ "38.94", "99.01", "96.72", "99.04", "54.91" ]

icd9pcs

[ [ [] ] ]

10953, 11014

5835, 8568

355, 383

11332, 11456

2289, 5812

11742, 12288

9590, 10930

11035, 11311

9464, 9567

11480, 11719

1969, 2270

275, 317

411, 1729

8583, 9438

1751, 1849

1865, 1954

48,706

135,096

37754

Discharge summary

report

Admission Date: [**2179-11-19**] Discharge Date: [**2179-12-1**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 18794**] Chief Complaint: s/p unwitnessed fall Major Surgical or Invasive Procedure: Mechanical Debridement of Pressure Ulcers at bedside History of Present Illness: This is an 87 year old female with unclear medical history who presented to the ED after being found down prone in her apartment. EMS was called by neighbors due to smell emanating from her senior apartment. The patient was found down, prone, laying in her own urine and feces on left side with multiple decubitus ulcers (including zygoma, chest, ear) with other signs of self neglect, including extremely long toenails. Patient was unable to provide any history on admission and was oriented only to her name. Her apartment was very poorly tended per report. . In the ED, she had chest, spine, head, and abdomen CT showing no acute abnormalities. Cultures were drawn, but there were no localizing signs of infection. She was admitted to the Trauma ICU for overnight monitoring and hydration. . Patient did not have a primary care physician. [**Name10 (NameIs) **] only family she reports is a cousin in [**State 15946**] and a cousin in [**State 2748**]. She kept to herself and was not well known to her neighbors or to members of her church. She had stopped going to church weeks to months earlier due to increased generalized weakness, per patient. Past Medical History: Polio Patient was not followed by a primary care physician Social History: Reports she graduated college at [**Hospital1 **] and had polio as a child. Born in [**Location (un) 5450**], NH. Lived with her parents until they died. No children. No siblings living. Reports closets relative was [**Name (NI) **] [**Name (NI) 71663**] who is a cousin who apparently works at [**University/College **] [**Location (un) **], sometimes lives in [**State 1727**] and sometimes in [**State 15946**]; [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 71663**] has a sister. Reports living alone and being independent. Per Social Work note from initial Trauma admission, patient used to attend church but had not been attending for weeks-months because she had been feeling weak. Family History: Unknown Physical Exam: On transfer from Trauma SICU to Medicine Floor: Vitals: 97.0 130/60 87 16 98%RA GEN: cachectic elderly female, patient lying stiffly in bed in NAD, left eye open, responsive verbally HEENT: alopecia, head atraumatic except face; sluggishly reactive pupils, symmetric; dry mucus membranes ; bandage over left cheek ; left ear with greenish exudate from ulceration on inferior cartilage CV: RRR, no M/R/G; DP, PT, Radial, and carotid pulses 2+ bilaterally PULM: anteriorly clear to auscultation bilaterally ABD: Soft, nontender except on ulceration site, nondistended, BS+ EXTREM: Warm and well perfused, no clubbing/cyanosis/edema; long, thick toenails, right arm contracted and stiff. NEURO: Alert, oriented to self and month; sensation equal on both sides of face; left side paralysis of facial muscles; cannot actively close left eye SKIN: pressure ulcers with eschar on anterior left chest about 6cm diameter; other ulcers bandaged including: right posterior shoulder, left anterior shoulder, lower abdomen, bilateral hips, right knee, left knee, left zygomatic process ; scratches on back and knees Pertinent Results: [**2179-11-19**] 12:25PM BLOOD WBC-13.5* RBC-4.54 Hgb-14.3 Hct-43.1 MCV-95 MCH-31.6 MCHC-33.2 RDW-14.0 Plt Ct-411 [**2179-11-19**] 05:30PM BLOOD WBC-10.0 RBC-4.08* Hgb-12.6 Hct-38.6 MCV-95 MCH-31.0 MCHC-32.8 RDW-14.0 Plt Ct-324 [**2179-11-29**] 06:35AM BLOOD WBC-6.7 RBC-3.07* Hgb-9.3* Hct-29.2* MCV-95 MCH-30.2 MCHC-31.8 RDW-14.7 Plt Ct-334 [**2179-11-19**] 12:25PM BLOOD PT-13.9* PTT-23.1 INR(PT)-1.2* [**2179-11-19**] 12:25PM BLOOD Fibrino-663* [**2179-11-19**] 05:30PM BLOOD Glucose-147* UreaN-53* Creat-0.8 Na-149* K-3.2* Cl-110* HCO3-32 AnGap-10 [**2179-11-28**] 07:00AM BLOOD Glucose-100 UreaN-21* Creat-0.5 Na-139 K-4.7 Cl-102 HCO3-32 AnGap-10 [**2179-11-29**] 06:35AM BLOOD Glucose-93 UreaN-18 Creat-0.6 Na-140 K-4.6 Cl-103 HCO3-32 AnGap-10 [**2179-11-30**] 06:30AM BLOOD Glucose-102 UreaN-17 Creat-0.5 Na-138 K-4.7 Cl-103 HCO3-28 AnGap-12 [**2179-11-19**] 12:25PM BLOOD CK(CPK)-204* [**2179-11-20**] 01:23PM BLOOD CK(CPK)-331* [**2179-11-22**] 06:55AM BLOOD ALT-38 AST-33 LD(LDH)-303* CK(CPK)-158* AlkPhos-89 TotBili-0.3 [**2179-11-24**] 05:48AM BLOOD ALT-38 AST-39 LD(LDH)-282* AlkPhos-82 TotBili-0.3 [**2179-11-19**] 12:25PM BLOOD CK-MB-11* MB Indx-5.4 [**2179-11-19**] 05:30PM BLOOD CK-MB-14* MB Indx-5.5 cTropnT-0.02* [**2179-11-20**] 03:19AM BLOOD CK-MB-11* MB Indx-4.6 cTropnT-0.03* [**2179-11-20**] 01:23PM BLOOD CK-MB-12* MB Indx-3.6 cTropnT-0.04* [**2179-11-22**] 06:55AM BLOOD CK-MB-9 cTropnT-0.03* [**2179-11-19**] 12:25PM BLOOD Albumin-3.2* Calcium-9.9 Phos-3.5 Mg-2.4 [**2179-11-19**] 05:30PM BLOOD Calcium-8.9 Phos-1.9*# Mg-2.1 [**2179-11-20**] 03:19AM BLOOD Calcium-8.9 Phos-2.9 Mg-2.1 [**2179-11-29**] 06:35AM BLOOD Calcium-8.2* Phos-3.6 Mg-2.0 [**2179-11-21**] 01:25AM BLOOD calTIBC-172* Ferritn-395* TRF-132* [**2179-11-26**] 06:35AM BLOOD VitB12-755 Folate-16.0 [**2179-11-21**] 01:25AM BLOOD PREALBUMIN- 5 mg/dL [**2179-11-26**] 06:35AM BLOOD PREALBUMIN- 10 mg/dL Brief Hospital Course: The patient is an 85 year old woman with past medical history significant only for polio who was found down, prone, for two to three days status post unwitnessed fall in her apartment. She was admitted to the Trauma Surgical Intensive Care Unit overnight for observation then transferred to the medical floor. In the Trauma SICU, tube feeds and IV fluids were started. The patient was found to have multiple decubitus ulcers on her body. She was completely hemodynamically stable and had remained afebrile. Just prior to transfer to the medical floor, the patient was alert and oriented to self, intermittently oriented to month and year but not oriented to place. She had no complaints of pain at rest but had severe pain with dressing changes. She complained also of feeling very stiff in both her arms and legs. She stated that she remembered having fallen in her apartment and did not think that she lost consciousness. She did not know how long she was down. # Status post fall: Patient received a Head CT in the ED which ruled out any acute processes including hemorrhage and stroke. The patient did not have any history of seizures and was not believed to have experienced seizure activity. She was monitored on telemetry for forty-eight hours, and no events of concern were observed. Transesophageal echocardiogram showed nothing of concern; it showed preserved EF, mild mitral regurgitation, and small pericardial effusion with no signs of hemodynamic instability. She was ruled out for myocardial infarction with stable cardiac enzymes; of note, her troponin-Ts were mildly elevated at 0.03-0.04 but stable. Ms. [**Known lastname 25922**]' fall was thought to be mechanical, and she was unable to pick herself up due to chronic deconditioning and malnutrition. Upon further questioning, she remembers having collapsed first into a chair due to weakness in her left knee, then tried to get up but fell onto her knees on the ground; she then fell prone onto the ground. She later remembered calling for help over and over again from the ground in her apartment with no response. She does not remember much of the next couple of days lying on the ground and thinks she may have lost consciousness for some of that time. With improved nutrition in addition to physical and occupational therapy, Ms. [**Known lastname 25922**] greatly improved in strength. On presentation, her right arm was contracted against her abdomen and very stiff; upon discharge, she was able to extend the right arm almost fully and lift it to a 45 degree angle from the ground while supine. On discharge, she had increased strength of her lower extremities, able to lift them further off of the bed, and she had an improved ability to lift her shoulders off the bed from a supine position, though she was still very deconditioned. She practices arm exercises daily while lying in bed and will continue to need significant physical and occupational therapy. . # Delirium: The patient presented with intermittent delirium which has significantly improved. She appears to have poor short term memory, but she has good attention and can recite the months of the year backwards with no difficulties. She has been alert and oriented to self, "hospital," month and year at baseline. For the first week of her hospitalization on the medicine floor, she frequently called out for "help" both during the day and night. In responding to her calls, she occasionally appeared to be feeling as if she were falling off of a cliff or falling off the bed, seemingly traumatized from her fall at home, but she was redirected with encouragement. The patient remained afebrile with negative urine and negative blood cultures and no signs or symptoms for pneumonia. She did have multiple significant pressure ulcers, but the ulcers showed no signs of infection. Her foley was discontinued, and efforts were made to decrease frequency of sleep disruption overnight to decrease chances of risks for delirium. She was given seroquel 12.5mg at night as needed for agitation. # Pressure Ulcerations: The patient presented with Stage III ulcerations on 1.) her chest, 2.) her lower abdomen, 3.) Left Hip (two small wounds), 4.) Right Hip, 5.) Left Anterior shoulder, 6.) Right Posterior shoulder, 7.) Left mid abdomen (two small wounds), 8.) Right knee, 9.) Left Ear cartilage and 10.) a Stage IV ulceration of her Left zygomatic area, for which she was followed by Plastic Surgery. The left zygomatic ulceration was thought to have caused facial nerve injury, because of which the patient is unable to close her left eyelid completely. Most of her ulcerations had become unstageable due to thick eschar. The left ear healed on its own. Per Plastics recommendations, her wounds were dressed with silver sulfadiazine twice daily for the first week for chemical debridement, then with wet to dry gauze with collagenase and Santylform dressing. On [**2179-11-30**], the left sided zygomatic arch ulcer and the anterior chest ulcer were mechanically debrided at the bedside by Plastic Surgery. All of the wounds are now stageable and should be dressed with wet to dry gauze twice daily. The left zygomatic ulcer does have exposed bone, but it should still be dressed with wet to dry dressing twice daily as the other wounds, and the patient will follow up with Plastic Surgery for further management as an outpatient as noted below. The patient does complain of pain prior to dressing changes, particularly of the zygomatic ulcer, but pain is controlled well with one Tylenol#3 tablet about twenty minutes prior to bandage changes. The patient will need to return for followup with Plastics in clinic on Friday [**2179-12-10**]. She may get a wound VAC to the Left zygomatic wound depending on plastics recommendations. The left zygomatic wound and chest wound may need to be further debrided in the OR. # Facial Nerve Injury and Left Eye Open Patient unable to close left eye due to left facial nerve injury secondary to zygomatic pressure ulcer. She has been receiving Artificial Tears drops and ointment to protect her eye. She was seen by ophthalmology who recommended adding Erythomycin 0.5% Ophthalmologic ointment 0.5 in left eye three times per day, which started on [**2179-11-22**], to the left eye, and discontinued on [**2179-11-30**]. She continues to get Artificial Tear ointment to the left eye four times daily as well and should follow up in [**Hospital 8183**] Clinic at [**Hospital1 18**] with Dr. [**First Name (STitle) **]. # Hypernatremia: The patient initially presented with hypernatremia which peaked with serum sodium of 153, likely secondary to fluid losses while down; she had been incontinent of feces for several days with no per oral intake. The hypernatremia resolved overnight in the Trauma SICU with intravenous fluids. This was not a problem during her time on the medical floor. # Anemia: The patient was noted to have a stable anemia after hydration with a hematocrit of 29 on discharge. Her first bowel movement was guaiac positive and dark, and her BUN was mildly elevated for most of her hospitalization, but all subsequent stools have been light brown and guaiac negative. Her MCV is in the mid-90s, and her B12 level is normal. # Nutrition: Malnutrition likely contributed to the patient's chronic deconditioning. Improving her nutritional status was a primary goal in her care in order to help with wound healing. Her prealbumin was low at 5 mg/dL on admission and trended upwards. The patient had decreased nutritional intake at home and no oral intake for at least two to three days while down on the floor of her apartment. She was started initially on tube feeds via Dobhoff tube, then transitioned to a pureed diet with about a week of overlap. She was followed by the Speech and Language Pathologists, who recommended only small amounts of thin liquids and keeping the pureed diet; they also recommended 1:1 supervision with meals. She was started on multivitamins, Vitamin B complex, and thiamine to help replete her vitamin and mineral stores, particularly in a patient at risk for refeeding syndrome. She was monitored closely for refeeding syndrome but only had mildly decreased phosphorous, which was repleted aggressively. Her nasogastric tube was taken out and tube feeds were stopped after calorie count showed her daily caloric intake ranging from 1200-1400kcals with her goal being about 1400kcals/day. She was started on Vitamin A 20,000 units, Zinc sulfate 220mg, and Ascorbic Acid on [**2179-11-29**], each to be given for ten days total, per Nutrition team recommendations, last day to be [**2179-12-8**]. She also continues on 2 Neutra-phos packets per day, which can be discontinued as felt appropriate. It is recommended that she have her electrolytes checked Q3-5 days including phos levels to adjust repletion. The patient continues to need 1:1 supervision with meals due to occasional episodes of coughing with eating, even on the pureed diet. Her pills are crushed and mixed with food. She will likely need to be re-evaluated by Speech and Swallow therapists. # Incontinence: The patient has been incontinent of urine since removal of the foley catheter. She denies having had this problem previously. Bladder scans six to eight hours after removal of the foley x2 showed 400-600ccs of urine in the bladder, but the patient began having episodes of urinary incontinence afterwards and appeared to be emptying out fairly well. She does also have episodes of stool incontinence and reports that she had been having these prior to hospitalization and prior to her fall. # History of Polio Myelitis Patient reports a history of polio while she was in college, at which time she had to be hospitalized for four weeks and home for months. She believes she has some residual weakness in her right hip from her polio and some difficulties swallowing certain types of foods. She will likely need another re-evaluation by Speech and Language specialists during her rehab stay. # Self Neglect: When the patient was found by EMS, her apartment was noted to be very disheveled, requiring a path to be made to get to the patient, suggesting that she had not been keeping up with cleaning her apartment and was likely neglecting herself. The patient was reclusive, per neighbors and fellow church members. She reports that she has no family except for two [**Month/Day/Year 12232**], [**Name (NI) **] [**Last Name (NamePattern1) 71663**] in [**State 15946**] and a female cousin in [**State 2748**]. Efforts were made to contact these [**Name2 (NI) 12232**] with no success in contacting these family members. The patient is just beginning to undergo guardianship appointment process at this time of discharge. All discharge papers to start out the guardianship process have been filed through our legal department [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Last Name (NamePattern1) **], MD. Of note, the patient has alopecia and was self-conscious about not having a wig. A wig was given to her by the team social worker to make her more comfortable. # The patient was Presumed Full Code during this admission. In the setting of delirium, we were unable to have a coherent conversation about code status, and we were unable to contact her family members. Medications on Admission: None Discharge Medications: 1. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Therapeutic Multivitamin Liquid Sig: One (1) Tablet PO DAILY (Daily). 3. Acetaminophen-Codeine 300-30 mg Tablet Sig: One (1) Tablet PO BID: PRN as needed for pain: Given 20 min prior to bandage changes. 4. Potassium & Sodium Phosphates 280-160-250 mg Powder in Packet Sig: Two (2) Powder in Packet PO QDAY (). 5. Zinc Sulfate 220 mg Capsule Sig: One (1) Capsule PO DAILY (Daily) for 7 days. 6. Vitamin A 10,000 unit Capsule Sig: Two (2) Capsule PO DAILY (Daily) for 7 days. 7. Ascorbic Acid 90 mg/mL Drops Sig: Five (5) drops PO DAILY (Daily) for 7 days. 8. B-Complex with Vitamin C Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) ml Injection [**Hospital1 **] (2 times a day). 10. White Petrolatum-Mineral Oil 42.5-56.8 % Ointment Sig: One (1) Appl Ophthalmic PRN (as needed) as needed for eye care. 11. Docusate Sodium 50 mg/5 mL Liquid Sig: One Hundred (100) mg PO BID (2 times a day) as needed for constipation. 12. Artificial Tears Drops Sig: 1-2 drops Ophthalmic PRN as needed for eye care. Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - MACU Discharge Diagnosis: Primary Diagnosis: Mechanical fall Secondary Diagnoses: Self neglect Malnourishment Pressure Ulcers, Stage IV and III Delirium Anemia of Chronic Disease Discharge Condition: Stable, Good Condition. Discharge Instructions: Ms. [**Known lastname 25922**], You were admitted to the hospital after you had fallen in your apartment and were too weak to get up. You were found to have many pressure ulcers on your body which are now healing. You will need to follow up with the Plastic Surgeons in clinic regarding the ulcer on your left face and on your chest. While in the hospital, you were getting good nutrition and physical therapy. You started to get stronger and were discharged in stable condition to [**Hospital3 **] Center in order to continue getting stronger. We are also in the process of finding somebody that can help you make medical decisions from now on. You were not on any medications previously, but now you will be taking many new vitamin supplements as shown in your paperwork below. Please be sure to keep your followup appointments as listed below. You will be in excellent care at the [**Hospital3 **] Center. Please return to the hospital if you are having any symptoms concerning to you. Followup Instructions: Please follow up in the Plastics Surgery clinic at [**Hospital1 18**] ([**Hospital Ward Name 23**] Building, [**Location (un) 470**]) on [**2179-12-10**] at 2:30pm. Please follow up with Dr. [**First Name (STitle) **] at [**Hospital1 18**] for an ophthalmology appointment on [**1-3**] at 3pm ([**Hospital Ward Name 23**] Building, [**Location (un) 6332**]).

[ "293.0", "707.04", "285.29", "507.0", "707.02", "276.0", "707.09", "950.9", "707.23", "799.4", "707.24", "E885.9", "263.9", "138", "788.39" ]

icd9cm

[ [ [] ] ]

[ "96.6", "86.22" ]

icd9pcs

[ [ [] ] ]

17985, 18051

5436, 16771

285, 340

18249, 18275

3513, 5413

19321, 19684

2358, 2367

16826, 17962

18072, 18072

16797, 16803

18299, 19298

2382, 3494

18129, 18228

225, 247

368, 1531

18091, 18108

1553, 1614

1630, 2342

7,336

156,583

29431

Discharge summary

report

Admission Date: [**2132-11-10**] Discharge Date: [**2132-11-18**] Date of Birth: [**2110-10-21**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1377**] Chief Complaint: Transfer from OSH with tylenol overdose. Major Surgical or Invasive Procedure: None. History of Present Illness: 22 year-old female with past medical history of depression, back pain, history of Vicodin abuse, who was transferred from Cape Code Hospital on [**11-10**] status post tylenol overdose. The patient took 20 Percogesic Extra Strength tablets over 4 hours for back pain on [**11-9**]. The patient presented to the OSH after developing lethargy, nausea, and abdominal pain. In ED at OSH patient received charcoal 25 gm and Mucomyst 140 mg/kg x1. Her tylenol level on admission was 77, decreasing to 56 two hours later, and down to <5 prior to transfer to [**Hospital1 18**]. Her initial INR was within normal limits, increasing to 3.6 24 hours later and 3.8 prior to transfer. AST and ALT on presentation were 388 and 338, respectively. These increased to [**2111**] and [**2115**], respectively, prior to transfer. Her initial bilirubin of 1.9 increased to 3.5 prior to transfer. [**Year (4 digits) 5937**] on admission was 510 ms. [**Name14 (STitle) 5937**] corrected to 456 ms prior to transfer. ABG prior to transfer: 7.37/36/103 on room air. . Upon admission in the MICU the patient complained of nausea, diarrhea and mid-sternal chest pain that was reproducible on palpation. She had LLQ tenderness. The patient was started on NAC at 17.5 mg/kg/hr on admission. Liver transplant service and toxicology services were consulted. LFTs peaked on [**11-11**] with ALT 6242 AST 6031 LDH 5466 AP 136. INR was 10.8 on [**11-11**] and trended down to 3.9 today. Her hepatitis panel was negative. The patient had Grade II encephalopathy on hospital day 2, so the transplant service added the paient to the transplant list. She was started on empiric Vancomycin, Levofloxacin, and Nystatin. The patient's LFTs and synthetic function began to improve as did the patient's encephalopathy, so she was taken off the transplant list and antibiotics were discontinued. The patient was also noted to have pancreatitis by laboratories during her stay in the MICU. Amylase and lipase have been trending up but patient has been afebrile and abdominal pain has been improving. Liver/gallbladder ultrasound showed some gallbladder edema and a 7 mm non-obstructing stone. . On transfer to the floor, the patient complained of mild abdominal pain and nausea/vomiting after receiving mucomyst. She is able to tolerate clear liquids. She also describes urethral pain/dysuria after having the foley catheter removed today. Past Medical History: 1. Depression 2. Chronic back pain 3. Narcotic abuse in the past: Two years ago took 6 Vicodin and was seen in ER but not admitted Social History: Drinks every night 1-5 drinks per night. Denies illicit drug use (MICU notes states marijuana use). No tobacco. Family History: Non-contributory. Physical Exam: On arrival to the MICU: VITALS: T 98.2 BP 119/50 HR 126 R 20 Sat 94% room air GENERAL: Fatigued, jaundiced, pleasant and NAD HEENT: Dry MM NECK: Supple, no JVD HEART: Tachycardic, regular, no m/r/g, mid sternum ttp LUNGS: CTAB ABDOMEN: Soft, direct tenderness to palp in LLQ, EXTREMITIES: No c/c/e NEUROLOGIC: A and Ox3, no asterixis . On arrival to the floor: VITALS: T 98.9 HR 125 BP 105/70 RR 20 O2 sat 94% RA GENERAL: Tired appearing female, in pain when tries to move HEENT: Icteric sclera, dry MM NECK: Supple HEART: Tachycardic, regular rhythm, nl S1 S2, no m/r/g LUNGS: CTAB ABDOMEN: Soft, mildly distended, mild epigastric tenderness, hypoactive BS EXTREMITIES: 1+ peripheral edema, especially in hands NEUROLOGIC: A and Ox3, no asterixis Pertinent Results: Labwork on admission: [**2132-11-10**] 11:05PM WBC-14.3* RBC-4.09* HGB-13.2 HCT-37.8 MCV-93 MCH-32.3* MCHC-34.9 RDW-13.6 [**2132-11-10**] 11:05PM PLT COUNT-271 [**2132-11-10**] 11:05PM GLUCOSE-78 UREA N-5* CREAT-0.5 SODIUM-141 POTASSIUM-4.6 CHLORIDE-110* TOTAL CO2-19* ANION GAP-17 [**2132-11-10**] 11:05PM ALT(SGPT)-4748* AST(SGOT)-6404* CK(CPK)-324* ALK PHOS-113 TOT BILI-3.5* [**2132-11-10**] 11:05PM ALBUMIN-3.2* CALCIUM-8.1* PHOSPHATE-1.8* MAGNESIUM-2.2 [**2132-11-10**] 11:05PM PT-71.6* PTT-53.4* INR(PT)-9.2* [**2132-11-10**] 11:05PM FIBRINOGE-197 [**2132-11-11**] 08:59AM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE, HBcAb-NEGATIVE HAV Ab-NEGATIVE [**2132-11-11**] 12:40PM BLOOD HBsAg-NEGATIVE HBcAb-NEGATIVE [**2132-11-11**] 08:59AM BLOOD HCV Ab-NEGATIVE [**2132-11-12**] 09:07AM BLOOD AFP-1.5 . LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT [**2132-11-11**] IMPRESSION: Cholelithiasis without acute cholecystitis. Mild edema in the gallbladder wall which is likely related to the liver disease. . ECG Study Date of [**2132-11-11**] 6:44:58 AM Sinus tachycardia Extensive ST-T changes are nonspecific Clinical correlation is suggested . DUPLEX DOPP ABD/PEL [**2132-11-12**] IMPRESSION: 1. Normal Doppler examination of the liver. 2. Gallbladder wall edema concordant with patient's liver failure, unchanged from the earlier study. . CHEST (PORTABLE AP) [**2132-11-12**] FINDINGS: No prior comparisons. The heart, mediastinum and hilar regions are unremarkable. No pulmonary infiltrates. There is some vague generalized haziness overlying the right lower lung field, which is felt more likely to represent overlying soft tissues rather than a significant right pleural effusion. . ECHO Study Date of [**2132-11-12**] Conclusions: 1. The left atrium is normal in size. 2.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. No mitral regurgitation is seen. 6.There is no pericardial effusion. . CT ABD W&W/O C [**2132-11-14**] IMPRESSION: 1. Diffuse pancreatic edema, diffuse peripancreatic and mesenteric edema, and small amount of intraperitoneal free fluid, compatible with the stated history of pancreatitis. No organized fluid collection. No evidence of pancreatic necrosis or splenic vein thrombosis. 2. Nonobstructing 1-mm stone in the left kidney. 3. Anasarca . Labwork on discharge: [**2132-11-18**] 04:57AM BLOOD WBC-9.6 RBC-2.90* Hgb-9.6* Hct-27.8* MCV-96 MCH-33.0* MCHC-34.4 RDW-15.1 Plt Ct-182 [**2132-11-18**] 04:57AM BLOOD Glucose-75 UreaN-4* Creat-0.5 Na-141 K-4.2 Cl-109* HCO3-27 AnGap-9 [**2132-11-18**] 04:57AM BLOOD PT-18.3* PTT-38.2* INR(PT)-1.7* [**2132-11-18**] 04:57AM BLOOD ALT-797* AST-67* LD(LDH)-255* AlkPhos-141* Amylase-180* TotBili-6.6* [**2132-11-18**] 04:57AM BLOOD Albumin-2.3* Calcium-8.3* Phos-4.6*# Mg-1.9 [**2132-11-18**] 04:57AM BLOOD Lipase-374* Brief Hospital Course: 22 year-old female with history of depression, back pain, Vicodin abuse transferred from OSH status post tylenol overdose on [**11-9**] now with decreasing LFTs and amylase/lipase. . 1. Tylenol overdose. The patient presented after unintentional tylenol overdose. On admission to [**Hospital1 18**] the patient's INR was 9.2 with ALT 4748 and AST 6404. The patient was initially placed on the liver transplant list as her liver function initially worsened and she became encephalopathic. The patient's peak LFTs were INR 10.8, ALT 6980, AST 6404, Total bilirubin 7.0. Her encephalopathy subsequently resolved and LFTs trended down on mucomyst drip. The patient was initially treated with lactulose while encephalopathic but this was discontinued prior to discharge. The patient's MELD score was 19 on transfer to the floor and patient was taken off the transplant list. The patient's hepatitis panel was negative. The patient was followed by toxicology throughout admission. . 2. Pancreatitis. The patient's amylase and lipase were elevated on admission and initially trended up but improved prior to discharge. The etiology of the pancreatitis was likely related to Tylenol and less likely alcohol or gallstones. RUQ US showed cholelithiasis without cholecystitis. CT abdomen with evidence of pancreatic inflammation but without pancreatic necrosis; cholelithiasis was not visualized. The patient tolerated a regular diet prior to discharge. . 3. Fluid overload. The patient was extravascularly fluid overloaded but intravascularly euvolemic. This was likely secondary to aggressive fluid repletion in the setting of capillary leak from pancreatitis and hypoalbuminemia from liver failure. The patient was given lasix with good effect. . 4. Dysuria/labial edema. The patient complained of dysuria and labial pain after her foley catheter was removed. The patient's urinalysis and urine culture were negative. The patient was given lasix for fluid overload with good effect. The patient was also given [**Last Name (un) **] baths and pain control with oxycodone. The patient was symptomatically improved prior to discharge. . 5. Leukocytosis. The patient had leukocytosis to 14.3 on admission. This most likely represented a stress response. This was resolved prior to discharge. The patient had no signs or symptoms of infection. CXR negative for infection. Urinalysis and urine culture negative for infection. . 6. Tachycardia. The patient remained tachycardic throughout the majority of her admission but was improved on discharge. EKG showed sinus tachycardia. The differential included pain (abdominal, labial) versus benzodiazepine/ETOH withdrawal. This was unlikely secondary to pulmonary embolus with stable oxygen saturations and no pleuritic chest pain. . 7. Nonobstructive renal stone. A 1-mm nonobstructing stone was visualized in the left kidney on CT abdomen. The patient was asymptomatic. Hydration was encouraged on discharge when the patient was less fluid overloaded. . 8. Psychiatric. The patient was followed by psychiatry during admission. It was believed the overdose was unintentional. The patient's outpatient psychiatric regimen of zoloft and klonapin was discontinued at the OSH and was not restarted prior to discharge. The patient will follow-up with psychiatric counselling and psychopharmacology as an outpatient. Medications on Admission: Zoloft 25 mg qd Klonopin 0.5 mg po bid Discharge Medications: 1. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO ONCE (Once) for 7 days. Disp:*21 Tablet(s)* Refills:*0* 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO twice a day as needed for constipation for 7 days. Disp:*14 Capsule(s)* Refills:*0* 3. Senna 8.6 mg Capsule Sig: One (1) Capsule PO twice a day for 7 days. Disp:*14 Capsule(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Primary: 1. Tylenol-induced liver toxicity 2. Acute pancreatitis . Secondary: 1. Depression 2. Narcotic abuse 3. Chronic back pain Discharge Condition: Afebrile, vital signs stable. Liver function tests and amylase/lipase trending down. Discharge Instructions: You were hospitalized with a tylenol overdose. Your liver tests are improved but you should not take tylenol until you follow-up with your primary care doctor. [**First Name (Titles) 2172**] [**Last Name (Titles) **] was inflammed during hospitalization but is also improved. . Please contact a physician if you experience fevers, chills, abdominal pain, nausea, black stools or blood in your stools, or any other concerning symptoms. . Please take your medications as prescribed. - Your klonapin and zoloft were discontinued until your liver recovers. - You can take oxycodone 5 mg every eight hours as needed for pain. - You should take colace and senna as needed for constipation while taking oxycodone. . Please keep your follow-up appointments as below. Followup Instructions: Follow-up with your primary care doctor, Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 30878**], on Thursday, [**11-27**] at 9:45 am. Please call [**Telephone/Fax (1) 30879**] if you have any questions or concerns. . You have an appointment for therapy with [**Last Name (un) **] Alforo, LICSW, on [**12-12**] at 2:00 pm. The phone number is [**Telephone/Fax (1) 70660**] or [**Telephone/Fax (1) 70661**] if you have any questions or concerns. The address is: [**Street Address(2) 70662**], [**Location (un) **], MA. . You have a psychopharmacology appointment with [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 70663**], Advanced Practice RN, CS on [**12-26**] at 10:00 am. The phone number and address are the same as above. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(1) 1379**]

[ "592.0", "574.20", "789.09", "E849.0", "724.5", "304.91", "965.4", "577.0", "E850.4", "785.0", "300.4" ]

icd9cm

[ [ [] ] ]

[ "38.93" ]

icd9pcs

[ [ [] ] ]

10900, 10906

7090, 10435

359, 367

11081, 11168

3895, 3903

11975, 12863

3093, 3112

10524, 10877

10927, 11060

10461, 10501

11192, 11952

3127, 3876

6572, 7067

279, 321

395, 2793

3917, 6558

2815, 2948

2964, 3077

11,177

169,183

25319

Discharge summary

report

Admission Date: [**2197-9-19**] Discharge Date: [**2197-9-25**] Date of Birth: [**2138-3-15**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 281**] Chief Complaint: cc:[**CC Contact Info 63343**] Major Surgical or Invasive Procedure: Bronchoscopy with stent placement Central line placement Arterial line placement History of Present Illness: 59 yo M with non-small cell lung CA obstructing RLL s/p chemo/XRT, esophageal stricture/stent admitted to [**Hospital 1474**] hospital on [**9-15**] with hemoptysis, epigastric discomfort. Chest CT with no PE, R pleural effusion, ? pericardial effusion. Started on tequin. EGD on [**9-17**] complicated by desat--> elective intubation for bronch/EGD on [**9-18**] which revealed no UGIB, bronch with severe main bronchus narrowing and bleeding during procedure. Hypotensive since then and started on neo. Transfused 3 units PRBCs. Femoral line placed on [**9-18**]. Echo on [**2197-9-18**] with ? clear space at apex/posterior wall, normal EF, no valvular disease. Also receiving decadron. No recent weight loss. NO melena, hematochezia at home. Upon arrival, pt intubated and sedated. Past Medical History: NSCLC w/ obstruction of RLL s/p chemotx/XRT (Onc: Dr. [**Last Name (STitle) 21628**], NIDDM, hyperchol, Esophageal stricture [**3-15**] radiation s/p esophageal dilatation and stent ([**Doctor Last Name 9955**]), Hypothyroidism, h/o syncope--? vasovagal, chronic [**Last Name **] problem Social History: Lives with wife. Daughter [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 16599**] is HCP ([**Telephone/Fax (1) 63344**]) Tobacco 2ppd x many years --Quit 2 yrs ago. Used to work in construction. Family History: Brother- CAD Physical Exam: On transfer: PE: 99.8 118/71 101 28 99% 67 kg [SIMV: 600 x 10 +15 (TV 550) PEEP 5, FIO2 1.0, PIP: 20 Plat: 17] Pulsus: 8 mm Hg Gen: intubated, sedated, responds to painful stimuli HEENT: anicteric, pupils sluggish, ET tube in place, NG tube in place CV: Reg, tachy S1, S2, no M/R/G lungs: coarse BS bilaterally Abd: NABS, soft, NT/ND Ext: R femoral line, warm, trace edema in LE bilaterally Neuro: sedated, withdraws to painful stimuli in UE Rectal: guaiac + Pertinent Results: [**2197-9-19**] 07:42PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.014 [**2197-9-19**] 07:42PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-1000 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG [**2197-9-19**] 07:13PM TYPE-ART PO2-238* PCO2-39 PH-7.42 TOTAL CO2-26 BASE XS-1 [**2197-9-19**] 07:13PM LACTATE-1.4 [**2197-9-19**] 07:13PM O2 SAT-98 [**2197-9-19**] 05:51PM GLUCOSE-254* UREA N-14 CREAT-0.9 SODIUM-139 POTASSIUM-3.8 CHLORIDE-105 TOTAL CO2-24 ANION GAP-14 [**2197-9-19**] 05:51PM ALT(SGPT)-12 AST(SGOT)-12 ALK PHOS-68 TOT BILI-0.5 [**2197-9-19**] 05:51PM CALCIUM-8.4 PHOSPHATE-2.9 MAGNESIUM-2.2 [**2197-9-19**] 05:51PM WBC-16.4* RBC-3.79* HGB-10.6* HCT-30.1* MCV-79* MCH-28.0 MCHC-35.2* RDW-14.4 [**2197-9-19**] 05:51PM NEUTS-96.6* BANDS-0 LYMPHS-1.8* MONOS-1.5* EOS-0.1 BASOS-0 [**2197-9-19**] 05:51PM HYPOCHROM-NORMAL ANISOCYT-NORMAL POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-1+ POLYCHROM-NORMAL [**2197-9-19**] 05:51PM PLT SMR-NORMAL PLT COUNT-347 [**2197-9-19**] 05:51PM PT-12.6 PTT-22.9 INR(PT)-1.1 [**Hospital1 **]: Lab data: Sputum ([**9-17**]): many WBCs, gm+ cocci/bacilli Iron studies([**9-16**]): Iron 25, TIBC 308, Ferritin 241 CTA ([**9-15**]): No PE. Increase in soft tissue density in RUL suspicious for tumor vs radiation fibrosis. Moderate pericardial effusion increased since prior study. [**Hospital1 18**]: Echo [**9-20**]: Left ventricular wall thickness, cavity size, and systolic function are normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. The estimated pulmonary artery systolic pressure is normal. There is a small pericardial effusion. There are no echocardiographic signs of tamponade. EKG: sinus tach @ 102, nl axis, PR depression, poor R wave progression, no ischemic changes CBC on discharge: [**2197-9-25**] 03:07AM BLOOD WBC-9.2 RBC-3.77* Hgb-10.1* Hct-30.5* MCV-81* MCH-26.9* MCHC-33.2 RDW-14.4 Plt Ct-321 Electrolytes on discharge: Na 143 K 3.2 (pre-repletion) Cl 109 HCO3 29 BUN 9 Cr 0.8 Gluc 88 [**2197-9-20**] 5:29 pm SPUTUM Site: ENDOTRACHEAL Source: Endotracheal. **FINAL REPORT [**2197-9-22**]** GRAM STAIN (Final [**2197-9-20**]): >25 PMNs and <10 epithelial cells/100X field. 3+ (5-10 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS AND CLUSTERS. RESPIRATORY CULTURE (Final [**2197-9-22**]): OROPHARYNGEAL FLORA ABSENT. STAPH AUREUS COAG +. MODERATE GROWTH. Oxacillin RESISTANT Staphylococci MUST be reported as also STAPH AUREUS COAG + | ERYTHROMYCIN---------- =>8 R GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- =>8 R OXACILLIN------------- =>4 R PENICILLIN------------ =>0.5 R RIFAMPIN-------------- <=0.5 S TETRACYCLINE---------- <=1 S VANCOMYCIN------------ <=1 S All blood cultures taken at [**Hospital1 18**] were negative Brief Hospital Course: The patient was transferred to [**Hospital1 18**] for hemoptysis/transfer for ? tracheal stent placement. Hospital course was significant for the following issues: 1. Fever/leukocytosis: Likely secondary to post-obstructive PNA. Gram positive cocci on sputum cx from OSH. Sputum culture obtained at [**Hospital1 18**] with > 25 PMNs, culture with + MRSA. Bronchoscopy noted purulent sputum in L lung which was suctioned. Blood cultures with no growth to date at discharge. UA, urine culture negative. The patient spiked to 103 on [**9-20**] and was started on vancomycin and zosyn. His L femoral line was removed and the tip was sent for culture--there was no growth to date. A new subclavian central line was placed under sterile conditions on [**2197-9-21**]. 2. Hemoptysis/respiratory failure: Bronchoscopy performed on [**9-22**] revealed a tortuous and macerated trachea with significant tumor infiltration along the length of trachea extending into the right and left mainstem bronchi. Three stents were placed: 14x2 mm stent in R mainstem bronchus, 12x4 mm stent in L mainstem bronchus and 20x4mm tracheal stent. The patient continued to have small amounts of blood in the ET tube. Serial hct were stable. The patient remained intubated after the procedure and required high doses of sedation to remain comfortable. After the bronchoscopy with stent placement, his sedation began to be weaned. His ABG's were good on minimal ventilatory support. His ABG on [**2197-9-22**] was 7.46/39/120 on AC 600 x 18, PEEP 8, FIO2 .60. Over the next two days s/p the procedure he was slowly weaned off his fentanyl and midazolam drips along with the pressor support with neo-synephrine. By post-procedure day 3, [**9-25**] the pressor was completely weaned off and breathing well on pressure support ventilation. He was therefore extubated on [**9-25**]. This was well tolerated with good oxygen saturation post extubation. The patient did exhibit anxiety subsequent to extubation and discontinuation of sedation. This was chiefly managed via ativan given per the CIWA protocol. The patient also remained somewhat drowsy after stoppage of sedation but has slowly grown more alert. 3. Anemia: The hct stable at 30. He required no transfusions. He remained intermittently guaiac positive on exam and would likely benefit from outpatient colonoscopy in the future. 4. Hypotension: The patient was initially weaned off pressors; however, as his sedation requiremnt increased, his BP required more support and neo was re-started. Given his fever spike, there was some concern for septic physiology and he was started on antibiotics as above. His BP also increased with fluid boluses. Echocardiogram was performed on [**2197-9-20**]: Left ventricular wall thickness, cavity size, and systolic function are normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. The estimated pulmonary artery systolic pressure is normal. There is a small pericardial effusion. There are no echocardiographic signs of tamponade. Pt was ruled out for adrenal insufficiency by cosyntropin stimulation test. 5. Small cell lung CA: Patient is s/p chemo, XRT. Per Dr. [**Last Name (STitle) 63345**], oncologist, pt presented in [**1-13**] with weight loss, scapular pain. Found to have met to T3-T4. He received XRT to spine, chest in addition to weekly carboplatin/taxotere (had reaction to taxol). As of [**2196-12-12**], just receving bisphosphonate for bone disease. Plan was to re-start Rx if progression of disease. Dysphagia was biggest concern which improved s/p esophageal stent. Now with progression into R mainstem bronchus. Per Dr. [**Last Name (STitle) 21628**], the patient will be candidate for more chemotherapy if we can get him back to his baseline. 5. NIDDM: The patient was maintained on an insulin sliding scale. His sliding scale was adjusted as needed for tight glucose control. Eventually his glucose control required insulin drip. After extubation and discontinuation of tube feeds, insulin drip was discontinued. 6. FEN: The patient was started on tube feeds which he tolerated well. His NG tube was replaced with an OG tube out of concern for sinusitis. On extubation, tube feeds were discontinued. Speech and swallow evaluation revealed pt remained still too sedated to safely take solid and recommended starting him on small sips of clears. The patient did requirement repletion of electrolytes including potassium, magnesium, and phosphate. 7. PPX: The patient was continued on SC heparin, pneumoboots, PPI. 8. ACCESS: Right subclavian line placed [**2197-9-21**], discontinued on [**2197-9-23**]. Left arterial line placed on [**2197-9-19**], discontinued on [**2197-9-25**]. Has two peripheral IVs. 9. The patient remained FULL CODE. 10. Communication was maintained with the patient's wife and daughter (daughter is HCP: [**Name (NI) **] [**Name (NI) 16599**]: [**Telephone/Fax (1) 63344**]) Medications on Admission: Meds (transfer): Neo gtt @ 32, propofol, versed gtt, decadron 8 mg q6, glyburide, actos, synthroid 0.1, advair, tessalon perles, serax, zocor, tequin 400 iv daily, aco Home meds: Glyburide, Serax, Lipitor, Actos, Roxicet, Levoxyl, Albuterol, Advair, Tessalon Perles, Omeprazole Discharge Medications: 1. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: One (1) injection Injection TID (3 times a day). 2. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 3. Albuterol Sulfate 0.083 % Solution Sig: One (1) 1 neb inhalation Inhalation Q6H (every 6 hours) as needed. 4. Levothyroxine Sodium 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb inh Inhalation Q6H (every 6 hours) as needed. 6. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig: One (1) suspension PO DAILY (Daily). 7. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 8. Piperacillin-Tazobactam 4.5 g Recon Soln Sig: One (1) Recon Soln Intravenous Q8H (every 8 hours). 9. Vancomycin 1,000 mg Recon Soln Sig: One (1) recon solution Intravenous Q 12H (Every 12 Hours). 10. Lorazepam 2 mg/mL Syringe Sig: 0.25-1 injection Injection Q4-6H (every 4 to 6 hours) as needed. 11. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 12. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 13. Docusate Sodium 150 mg/15 mL Liquid Sig: Ten (10) mL PO BID (2 times a day). 14. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation QID (4 times a day). 15. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q4H (every 4 hours) as needed. Discharge Disposition: Extended Care Discharge Diagnosis: Near total obstruction of right bronchus secondary to non-small cell lung cancer stage 4. Status-post stent placement to trachea and to left and right bronchus. Hemoptysis secondary to invasive lung cancer. Methicillin-Resistant Staph. Aureus Discharge Condition: Fair, status post tracheal and bronchial stent, status post extubation; breathing without mechanical ventilatory support.No pressor requirement.Off sedation, showing improved mentation. Discharge Instructions: Return to acute hospital ([**Hospital 1474**] Medical Intensive Care Unit) Followup Instructions: MICU [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 286**]

[ "518.83", "162.8", "280.0", "V09.0", "482.41", "530.3", "786.3", "V15.3", "272.0", "250.00", "198.5", "244.9", "458.9" ]

icd9cm

[ [ [] ] ]

[ "31.99", "96.04", "38.93", "00.17", "96.6", "96.05", "33.91", "38.91", "96.72" ]

icd9pcs

[ [ [] ] ]

12465, 12480

5515, 10689

344, 426

12767, 12954

2320, 4325

13077, 13176

1802, 1816

11019, 12442

12501, 12746

10715, 10996

12978, 13054

1831, 2301

4483, 5492

275, 306

454, 1245

1267, 1556

1572, 1786

68,217

190,167

48015

Discharge summary

report

Admission Date: [**2197-1-7**] Discharge Date: [**2197-1-12**] Date of Birth: [**2119-3-13**] Sex: M Service: MEDICINE Allergies: Aspirin / Penicillins / Ampicillin / Motrin / Naproxen Attending:[**First Name3 (LF) 30**] Chief Complaint: BRBPR Major Surgical or Invasive Procedure: flexible sigmoidoscopy, colonoscopy History of Present Illness: 77M with a history of recent LGIB who underwent a colonoscopy the day prior to admission during which 7 polyps were resected presented to the ED with BRBPR x 2. He denies CP, palpitations, sweats, nausea, abdominal pain, or SOB. He denies taking any NSAIDs or ASA. He reports that he is an easy bleeder. . In the ED his initial vital signs were T 98.4 P 88 BP 186/83 R 26 O2 sat 100% on RA. An initial HCT was at his baseline of 41. He was also hyponatremic, likely from his bowel prep. Coagulation profile was not done. He was bolused 1 L NS despite his hypertension and stable HCT. He had an additional episode of BRBPR in the ED. A second PIV was placed at that time. GI was consulted, and recommended no transfusions for now and colonoscopy in the near future. He was admitted to the MICU to facilitate colonoscopy. . In the MICU the patient feels well and continues to deny fevers, chills, sweats, palpitations, chest pain, shortness of breath, or abdominal pain. He is refusing bowel prep. GI was contact[**Name (NI) **], and agreed to hold off on bowel prep until the morning. He will be monitored overnight in the MICU. Past Medical History: 1. GERD 2. R arthritis 3. Hypertension 4. Glaucoma 5. BPH 6. Depression Social History: Home: Lives in [**Location **], MA with wife Occupation: Retired Presbyterian minister, PhD from BU and was a fellow at [**University/College **] Divinity School. EtOH: Denies Drugs: Denies Tobacco: Denies Family History: - Mother with lung cancer, but never smoked - Father with cirrhosis Physical Exam: VS: 97.5, 98, 22, 136/74, 100%RA GEN: NAD, Awake alert and conversant HEENT: EOMI, MMM CV: RRR, S1S2 normal, no M/R/G PULM: CTABL ABD: NABS, S, NT, ND, PR: Dark bloody stool, guiaic positive, no masses felt Ext: Pulses 2+, no edema Pertinent Results: ADMISSION LABS: [**2197-1-6**] 10:43PM BLOOD WBC-8.0 RBC-4.66 Hgb-14.3 Hct-41.8 MCV-90 MCH-30.7 MCHC-34.2 RDW-13.6 Plt Ct-306 [**2197-1-7**] 03:11AM BLOOD WBC-8.0 RBC-4.32* Hgb-13.3* Hct-38.7* MCV-90 MCH-30.9 MCHC-34.4 RDW-13.6 Plt Ct-298 [**2197-1-7**] 09:19AM BLOOD WBC-7.8 RBC-3.78* Hgb-11.3* Hct-33.8* MCV-89 MCH-29.8 MCHC-33.4 RDW-13.7 Plt Ct-329 [**2197-1-6**] 10:43PM BLOOD Glucose-92 UreaN-18 Creat-1.1 Na-128* K-4.8 Cl-92* HCO3-25 AnGap-16 [**2197-1-7**] 03:11AM BLOOD Calcium-8.3* Phos-3.3 Mg-2.0 Iron-43* [**2197-1-7**] 03:11AM BLOOD calTIBC-282 VitB12-1117* Folate-GREATER TH Ferritn-149 TRF-217 === DISCHARGE LABS: [**2197-1-12**] WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct 7.3 3.35* 9.9* 29.9* 89 29.6 33.1 15.6* 328 Glucose UreaN Creat Na K Cl HCO3 AnGap 165* 8 1.0 136 3.5 101 27 12 ---- KUB [**1-7**]: Stool filling of the ascending colon, air filling of multiple non-distended or slightly distended small bowel loops. Sparse small air-fluid levels. No evidence of free air, no evidence of pathological calcifications. . Colonoscopy [**2197-1-5**]: Findings: Protruding Lesions A single sessile 12 mm polyp of benign appearance was found in the cecum. A single-piece polypectomy was performed using a hot snare. The polyp was completely removed. Two sessile 8mm polyps of benign appearance were found in the ascending colon. Single-piece polypectomy was performed using a cold snare on one and cold biopsy forcepts on the other. The polyps were completely removed. A single sessile 10 mm polyp of benign appearance was found in the transverse colon. A single-piece polypectomy was performed using a hot snare. The polyp was completely removed. Two sessile 10mm polyps of benign appearance were found in the distal transverse colon. Single-piece polypectomies were performed using a hot snare. The polyps were completely removed. A single sessile 18 mm polyp of benign appearance was found in the descending colon. A single-piece polypectomy was performed using a hot snare. The polyp was completely removed. Grade 1 internal & external hemorrhoids were noted. Excavated Lesions Multiple diverticula were seen in the sigmoid colon and ascending colon. Diverticulosis appeared to be of mild severity. Impression: Diverticulosis of the sigmoid colon and ascending colon Grade 1 internal & external hemorrhoids Polyp in the cecum (polypectomy) Polyps in the ascending colon (polypectomy) Polyp in the transverse colon (polypectomy) Polyps in the distal transverse colon (polypectomy) Polyp in the descending colon (polypectomy) Recommendations: Follow-up biopsy results colonoscopy in 3 years due to multiple polyps . Flexible sigmoidoscopy [**2197-1-7**]: Clotted blood was seen in the colon. The distal polypectomy site could not be located due to clot and stool, however there appeared to be less blood more proximal to the decending colon suggesting that this is the bleeding source. No active bleeding was seen. Impression: Blood in the colon Recommendations: serial hematocrits; golytely prep for colonoscopy now. If pt rebleeds, colonoscopy once prep is complete. If no rebleeding will follow conservatively . Colonoscopy [**2197-1-8**]: Fresh and clotted blood was seen throughout the colon. No active bleeding was seen. 3 post polypectomy sites were located which may have been the source of bleeding. The cecal and decending colon sites were both large clean based ulcers at the site of >1cm hot snare polypectomies. The splenic flexure site had and adherant clot which could not be removed. All sites were clipped with no evidence of bleeding, in addition the splenic flexure and decending colon sites were cauterized. . GI Bleeding Study [**2197-1-10**]: 1. No source for lower gastrointestinal bleeding localized at 90 minutes. 2. Tortuous aorta with collateralization of vessels compatible with atherosclerotic changes. Brief Hospital Course: 77M s/p colonoscopy with polypectomies presented with rectal bleeding requiring another colonoscopy for post-polypectomy cauterization and clipping. # Lower GI bleed: Bleeding related to recent polypectomies. The patient underwent sigmoidoscopy and then colonoscopy with clips placed and polepectomy sites sclerosed, as noted in above colonoscopy reports. Serial hematocrits following this second colonscopy remained stable. Patient had large amount of bloody stool on [**1-10**] prompting nuclear GI bleeding study that was negative for active bleeding. Hct trending up at time of discharge. Patient given rx to have CBC checked at PCP's office on [**2197-1-16**]. He will follow up with his gastroenterologist on [**2197-1-18**]. # Hypertension: Patient had isolated episode of hypertension with SBP of 170. Following this pressure stable on outpatient regimen of lisinopril. # Depression and anxiety: Patient continued on home Prozac 20mg PO daily and Lorazepam. . # BPH: Continue home finasteride 5mg PO daily code status FULL Medications on Admission: - Finasteride 5 mg PO DAILY - Pantoprazole 40 mg PO Q24H - Lisinopril 5 mg PO DAILY - Lorazepam 0.5 mg PO HS:PRN - Prozac 20 mg PO DAILY Discharge Medications: 1. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 3. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for insomnia. 5. Fluoxetine 20 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 6. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at bedtime). 7. Outpatient Lab Work Please check a CBC and forward results to Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2204**] Office Phone: [**Telephone/Fax (1) 2205**] Office Fax: [**Telephone/Fax (1) 7922**] Discharge Disposition: Home Discharge Diagnosis: Primary: Lower gastrointestinal bleed Secondary: Colon polyps, benign prostatic hypertrophy, hypertension Discharge Condition: Mental Status:Clear and coherent Level of Consciousness:Alert and interactive Activity Status:Ambulatory - Independent Discharge Instructions: You were admitted to the hospital due to rectal bleeding which we believed was due to bleeding from the sites where you had polyps removed. You had a repeat colonoscopy and the bleeding sites were clipped on [**1-8**]. Your blood counts have remained stable. On [**1-10**] you had another bloody bowel movement but a nuclear scan did not indicate any active bleeding. Since that bowel movement your blood counts have remained stable. You are tolerating a solid diet. No medication changes were made. Followup Instructions: Please go to Dr.[**Name (NI) 2935**] office on [**2197-1-16**] and have blood drawn anytime after 9am. You are being provided with a lab slip. Dr. [**Last Name (STitle) 2204**] will get this lab result. We made you an appointment with gastroenterology: Provider: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) 10314**], MD and Dr. [**Last Name (STitle) 9916**] Phone:[**Telephone/Fax (1) 463**] Date/Time:[**2197-1-18**] 2:30 You were previously scheduled to see: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2204**] [**2196-2-1**] at 2:40PM Completed by:[**2197-1-12**]

[ "600.00", "455.3", "530.81", "300.4", "285.1", "365.9", "714.0", "998.11", "401.9", "E878.8", "562.10", "V12.72", "276.1", "455.0", "785.0" ]

icd9cm

[ [ [] ] ]

[ "45.23", "45.24" ]

icd9pcs

[ [ [] ] ]

8011, 8017

6054, 7090

318, 355

8167, 8167

2184, 2184

8837, 9440

1847, 1916

7277, 7988

8038, 8146

7116, 7254

8312, 8814

2812, 6031

1931, 2165

273, 280

383, 1512

2200, 2796

8181, 8288

1534, 1607

1623, 1831

1,973

109,935

20695

Discharge summary

report

Admission Date: [**2117-7-12**] Discharge Date: [**2117-7-22**] Service: NEUROLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2569**] Chief Complaint: Intracerebral hemorrhage Major Surgical or Invasive Procedure: PERCUTANEOUS PLACEMENT JEJUNOGASTROSTOMY TUBE CT HEAD W/O CONTRAST Neurophysiology EEG CTA HEAD W&W/O C & RECO History of Present Illness: Pt is a 83 yo RHF with h/o pacemaker, AF, multiple valve replacements, COPD, and anemia who is transferred with a large ICH. She was reportedly in her USOH this morning and then was noted around 11:30 am to be confused and not herself. She was still able to walk with her walker though. She went to an OSH and CT showed 4x4.3 cm ICH in the right parietal lobe without ventricular spread. She is on coumadin and her INR was 3. She was given FFP (either 2 or 4 units, records are unclear), vitamin K, and then transferred here. INR here was 1.8. Head CT here showed a fairly stable hemorrhage, shift of 2mm(up from 1mm earlier) with increased effacement of right lateral ventricle, and no herniation. She was given Profilnine and started on Nipride for her BP. She was loaded with dilantin. Her family felt she was more tired and groggy than at the OSH, but otherwise unchanged. She was switched to labetalol for BP control and admitted to the ICU. Neurosurgery saw her as well. ROS: Patient denies HA, but is unable to go through full ROS Past Medical History: s/p L craniectomy for traumatic SDH 30 yrs ago s/p pacemaker placement s/p porcine aortic valve replacement s/p porcine mitral valve replacement atrial fibrillation COPD h/o thyroid nodules iron deficiency anemia B12 deficiency hyperlipidemia osteoporosis Social History: Lives with her daughter. Several other family members in the area. Walks with a walker. Family History: Unknown Physical Exam: Vitals:T:97.2 BP:192/83-->140s/70s HR: 101 R 16 O2Sats 93 on 4L Gen:NAD. HEENT:MMM. Sclera clear. OP clear Neck: No Carotid bruits CV: RRR, Nl S1 and S2, no murmurs/gallops/rubs Lung: Clear to auscultation bilaterally Ext:No cyanosis/edema Neurologic examination: Mental status: Awake and alert, moderately cooperative with exam. Orientation: Oriented to person, and [**Hospital 1474**] Hospital. Attention: Somewhat inattentive. Language: Fluent with good comprehension and repetition. Naming moderately intact. No dysarthria or paraphasic errors No apraxia Dense left sided neglect [**Location (un) **] intact to the right [**2-9**] of sentences. Cranial Nerves: I: not tested II: Pupils equally round and reactive to light, 4 to 3 mm bilaterally. She a left hemianopsia vs hemineglect. Fundi normal bilaterally. III, IV, VI: She has right eye deviation and will not look to even midline. She does have some up and downgaze. V, VII: Facial sensation intact and symmetric. Face symmetric. VIII: Hearing intact to finger rub bilaterally. IX, X: Palatal elevation symmetrical XII: Tongue midline without fasciculations, intact movements Motor: Normal bulk and tone bilaterally No tremor Full strength on right UE and LE. She has Left sided paresis vs neglect(slight withdraw of LE to nox and minimal withdrawal of UE to nox). Sensation: Intact to light touch, pinprick throughout all extremities. Reflexes: B T Br Pa Ankle Right 2 2 2 1 0 Left 2 2 2 1 0 Toes were downgoing on right, up left. Coordination: Normal on finger-nose-finger on right. Gait: Unable Pertinent Results: [**2117-7-12**] 06:40PM BLOOD WBC-8.9 RBC-3.96*# Hgb-13.2# Hct-38.4# MCV-97 MCH-33.4* MCHC-34.5 RDW-14.9 Plt Ct-175 [**2117-7-12**] 06:40PM BLOOD Neuts-68.9 Lymphs-20.6 Monos-6.4 Eos-3.9 Baso-0.1 [**2117-7-12**] 06:40PM BLOOD PT-18.9* PTT-29.4 INR(PT)-1.8* [**2117-7-12**] 06:40PM BLOOD Glucose-180* UreaN-25* Creat-0.8 Na-138 K-3.8 Cl-100 HCO3-31 AnGap-11 [**2117-7-12**] 06:40PM BLOOD CK(CPK)-66 [**2117-7-14**] 03:40AM BLOOD CK(CPK)-49 [**2117-7-12**] 06:40PM BLOOD CK-MB-NotDone cTropnT-<0.01 [**2117-7-14**] 03:40AM BLOOD CK-MB-4 cTropnT-<0.01 [**2117-7-13**] 03:23AM BLOOD Phos-2.9 Mg-2.4 [**2117-7-14**] 03:40AM BLOOD Albumin-3.6 Calcium-7.3* Phos-1.3*# Mg-2.4 [**2117-7-13**] 03:23AM BLOOD Phenyto-9.4* [**2117-7-13**] 03:28AM BLOOD Type-ART pO2-128* pCO2-51* pH-7.39 calTCO2-32* Base XS-5 138 100 25 180 ------------< 3.8 31 0.8 CK: 66 MB: Notdone Trop-T: <0.01 8.9\13.2/175 /38.4\ N:68.9 L:20.6 M:6.4 E:3.9 Bas:0.1 PT: 18.9 PTT: 29.4 INR: 1.8 CTA:4.3 x 4.6 cm intraparenchymal right parietal bleed, with effacement of the right ventricle (increased from outside study), minimal midline shift (2 mm). No obvious AVM or mass, though large bleed limits evaluation of underlying structural and vascular abnormalities. Brief Hospital Course: Patient is a 83RHW with h/o pacemaker, AF, multiple valve replacements with porcine aortic and mitral valves, on coumadin, COPD, and anemia with a large right parietal bleed. Exam is significant for inattention, left neglect and left sided weakness arm>leg. . 1. Neuro: Patient was admited to neuro ICU [**7-12**] -> transferred to stepdown [**7-13**]. Q2h neuro checks. Kept head of bed >30 degrees. Repeat head CT in am [**7-13**] showed area of hemorrhage was stable. Neurosurgery was following and no surgical intervention was indicated. Dilantin was continued for 1 week as seizure prophylaxis. EEG [**7-14**] was negative for epileptiform features. She was started on Provigil to improve her alertness with good effect. Patient will need a follow up CT with contrast after she recovers from this admission. Mechanism of bleed was likely secondary to amyloid angiopathy. . 2. Cards: Kept systolic BP<150 with metoprolol 5 IV Q6 + hydral PRN. Continued Lasix with strict I/Os keeping fluid status -500cc over 24 hours. Ruled out for MI. Atrial fibrillation was well rate controlled on metoprolol. . 3. Heme: Patient received additional FFP to keep INR<1.3 and Vitamin K 10 mg daily x3 days. Patient was resumed on aspirin 81 after 1 week as stroke prophylaxis in setting atrial fibrillation given risk of bleeding on warfarin. . 4. Pulm: Continued Advair and Nebs PRN. Received additional Lasix 20mg IV as needed to keep fluid status negative for mild CHF. . 5. Endo: Covered insulin sliding scale. TSH and T4 were normal. . 6. FEN: Kept NPO and placed GJ tube due to failing swallow evaluation. . 7. GU: Continued Ditropan . 8. PPX: RISS. PPI. Tylenol prn. Pneumoboots . 9. CODE: Full code per discussion with her daughters tonight . 10. Other: History of Etoh nightly so on CIWA, thiamine, MVI, folate replacement Medications on Admission: coumadin lasix 80 daily calcium 1g [**Hospital1 **] ditropan 5 daily magnesium oxide 250 daily verapamil 360 daily potassium 30 daily iron 325 daily colace vitamin B12 Discharge Medications: 1. Insulin Regular Human 100 unit/mL Solution [**Hospital1 **]: PER SLIDING SCALE UNITS Injection ASDIR (AS DIRECTED). 2. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device [**Hospital1 **]: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 3. Oxybutynin Chloride 5 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily). 4. Acetaminophen 160 mg/5 mL Solution [**Hospital1 **]: 325-650 mg PO Q4-6H (every 4 to 6 hours) as needed: Not to exceed 4g/day of APAP. 5. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily). 6. Folic Acid 1 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily). 7. Thiamine HCl 100 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily). 8. Calcium Carbonate 1,250 mg/5 mL(500 mg) Suspension [**Last Name (STitle) **]: Ten (10) ML PO BID (2 times a day). 9. Magnesium Oxide 140 mg Capsule [**Last Name (STitle) **]: Two (2) Capsule PO DAILY (Daily). 10. Docusate Sodium 100 mg Capsule [**Last Name (STitle) **]: One (1) Capsule PO BID (2 times a day). 11. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Last Name (STitle) **]: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 12. Cyanocobalamin 100 mcg Tablet [**Last Name (STitle) **]: 0.5 Tablet PO DAILY (Daily). 13. Miconazole Nitrate 2 % Powder [**Last Name (STitle) **]: One (1) Appl Topical TID (3 times a day) as needed for groin rash. 14. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID (2 times a day): Dc on [**7-22**]. 15. Furosemide 40 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO DAILY (Daily). 16. Modafinil 100 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO QD (). 17. Metoprolol Tartrate 50 mg Tablet [**Month/Year (2) **]: 0.5 Tablet PO BID (2 times a day): Hold for SBP<100 or HR<55. 18. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution [**Month/Year (2) **]: One (1) Neb Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. 19. Ipratropium Bromide 0.02 % Solution [**Month/Year (2) **]: One (1) Neb Inhalation Q6H (every 6 hours). 20. Strict I/Os daily Goal negative 500cc daily. Give additional Lasix 20mg IV x1 PRN to achieve fluid goal. 21. Aspirin 81 mg Tablet, Chewable [**Month/Year (2) **]: One (1) Tablet, Chewable PO DAILY (Daily). Discharge Disposition: Extended Care Facility: [**Hospital1 700**] - [**Location (un) 701**] Discharge Diagnosis: Primary diagnosis: Right parietal hemorrhage Amyloid angiopathy Secondary diagnosis: Atrial fibrillation History of left subdural hemorrahge status post craniotomy Status post pacemaker placement Status porcine aortic and mitral valve replacement Chronic obstructive pulmonary disease History of thyroid nodules Iron deficiency anemia B12 deficiency Hyperlipidemia Osteoporosis Discharge Condition: Vocalizes with moderate dysarthria. Inattentive. Exam is significant for left neglect and left sided weakness arm>leg Discharge Instructions: You have bled into your head. You will need to follow-up with a stroke neurologist. Please take medications as prescribed and keep your follow-up appointments. Do not take aspirin or motrin. If you have any worsening headaches, weakness, numbness/tingling or any other worrying symptoms, please call your primary care physician or return to the emergency department. Followup Instructions: PCP: [**Name10 (NameIs) 29557**] [**Last Name (NamePattern4) 29558**], MD Phone: [**Telephone/Fax (1) 3183**] Date/Time: [**2117-7-30**] 11:15am Stroke neurologist: [**Name6 (MD) 4267**] [**Last Name (NamePattern4) 4268**], MD, PHD[**MD Number(3) 708**]:[**Telephone/Fax (1) 657**] Date/Time:[**2117-8-18**] 3:00 [**First Name8 (NamePattern2) **] [**Name8 (MD) 162**] MD [**MD Number(2) 2575**] Completed by:[**2117-7-22**]

[ "041.4", "272.4", "342.92", "599.0", "V45.01", "496", "459.9", "733.00", "286.9", "277.39", "799.02", "V42.2", "280.9", "V58.61", "432.9", "787.2", "427.31" ]

icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

9264, 9336

4781, 6626

289, 402

9759, 9881

3515, 4758

10300, 10756

1885, 1895

6845, 9241

9357, 9357

6652, 6822

9905, 10277

1910, 2153

224, 251

430, 1482

2579, 3496

9443, 9738

9376, 9422

2192, 2563

2177, 2177

1504, 1762

1778, 1869

60,130

108,363

34916

Discharge summary

report

Admission Date: [**2188-11-25**] Discharge Date: [**2188-12-2**] Date of Birth: [**2153-10-17**] Sex: M Service: CARDIOTHORACIC Allergies: Erythromycin Base Attending:[**First Name3 (LF) 1505**] Chief Complaint: dyspnea Major Surgical or Invasive Procedure: [**2188-11-28**] mitral valve repair (28mm [**Company 1543**] CG Future Ring) History of Present Illness: This 35 year old pediatrician is visiting from [**Country 6607**] and developed severe dyspnea on exertion, orthopnea, dry cough, and questionable fever and chills. He presented to the ER and a CXR showed RUL pulmonary edema. A loud systolic murmur was noted. Echocardiography showed wide open mitral regurgitation and he was referred for surgical evalualtion. Blood culture from the ER were notable for one culture which grew a gram negative rod and infectious disease was consulted. Past Medical History: asthma ( mild and intermittent) OSA (wears mouthguard, no CPAP) inguinal herniorrhaphy Social History: works as a pediatrician lives with wife in [**Name (NI) 6607**] no tobacco use no ETOH Family History: father with MI in early 50's, died of CVA in late 70's Physical Exam: Admission VS T 98.7 HR 110-120ST BP 107/54 RR 20 O2sat 97%-RA Gen NAD HEENT PERRL/EOMI, anicteric, MMM. neck supple, no JVD Chest RUL diminished BS CV RRR, 5/6 SEM Abdm soft, NT Ext no edema, palpable pulses Discharge VS T 98.9 HR 86SR BP 114/64 RR 20 O2sat Gen NAD Neuro A&Ox3, nonfocal exam Pulm CTA bilat CV RRR< no murmur. Sternum stable, incision CDI Abdm soft, NT/ND/+BS Ext warm, + pedal edema bilat Pertinent Results: [**2188-11-25**] 04:30AM GLUCOSE-113* UREA N-18 CREAT-1.0 SODIUM-141 POTASSIUM-3.6 CHLORIDE-108 TOTAL CO2-24 ANION GAP-13 [**2188-11-25**] 04:30AM proBNP-1356* [**2188-11-25**] 04:30AM WBC-11.1* RBC-4.45* HGB-14.0 HCT-39.0* MCV-88 MCH-31.5 MCHC-36.0* RDW-12.9 [**2188-11-25**] 04:30AM PLT COUNT-285 [**2188-11-30**] 06:40AM BLOOD WBC-9.1 RBC-3.24* Hgb-10.0* Hct-28.4* MCV-88 MCH-30.8 MCHC-35.1* RDW-12.7 Plt Ct-200 [**2188-12-1**] 05:20AM BLOOD PT-12.8 INR(PT)-1.1 [**2188-11-30**] 06:40AM BLOOD Plt Ct-200 [**2188-12-1**] 05:20AM BLOOD UreaN-16 Creat-0.8 Na-139 K-4.1 [**2188-11-27**] 08:15PM BLOOD ALT-33 AST-22 LD(LDH)-200 AlkPhos-59 TotBili-0.4 [**2188-11-27**] 08:15PM BLOOD %HbA1c-5.7 PRE-BYPASS: 1. The left atrium is mildly dilated. No atrial septal defect is seen by 2D or color Doppler. 2. The left ventricular cavity size is normal. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is normal (LVEF>55%). 3. Right ventricular chamber size and free wall motion are normal. 4. There are three aortic valve leaflets. There is no aortic valve stenosis. No aortic regurgitation is seen. 5. The mitral valve leaflets are mildly thickened. The mitral valve leaflets are myxomatous. There is partial mitral leaflet flail of P2 scallop. An eccentric, posterior directed jet of The effective regurgitant orifice is >=0.40cm2 The mitral regurgitation vena contracta is >=0.7cm. Severe (4+) mitral regurgitation is seen. Mitral Annulus is dilated. 6. There is no pericardial effusion. Dr. [**Last Name (STitle) **] was notified in person of the results. POST-BYPASS: For the post-bypass study, the patient was receiving vasoactive infusions including Phenylephrine andf in Sinus rhythm. 1. A well-seated mitral annuloplasty ring is seen with normal leaflet motion and gradients (mean gradient = 5 mmHg). There is no valvular systolic anterior motion ([**Male First Name (un) **]). No mitral regurgitation is seen. A small echogenic structure is noted to be in the left atrial wall, near where the native P1 and 2 would have been, about 1 cm cephalad to the mitral annuloplasty ring. Discussed with Dr. [**Last Name (STitle) **], most likely a pledgetted suture that was placed as part of the valve repair. 2. LV function is Normal. 3. Aorta is intact post decannulation 4. Other findings are unchanged I certify that I was present for this procedure in compliance with HCFA regulations. Electronically signed by [**Name6 (MD) 928**] [**Name8 (MD) 929**], MD, MD, Interpreting physician [**Last Name (NamePattern4) **] [**2188-11-28**] 10:45 [**Known lastname **],[**Known firstname 275**] [**Medical Record Number 79901**] M 35 [**2153-10-17**] Radiology Report CHEST (PORTABLE AP) Study Date of [**2188-12-1**] 12:28 PM [**Last Name (LF) **],[**First Name3 (LF) **] R. CSURG FA6A [**2188-12-1**] SCHED CHEST (PORTABLE AP) Clip # [**Clip Number (Radiology) 79902**] Reason: folowup RT ptx on [**12-1**] film [**Hospital 93**] MEDICAL CONDITION: 35 year old man with REASON FOR THIS EXAMINATION: folowup RT ptx on [**12-1**] film Final Report CHEST PORTABLE AP: REASON FOR EXAM: 35-year-old man with follow up right pneumothorax. Since earlier today, sternotomy wires for MVR are unchanged. Left pleural effusion with associated atelectasis is also stable. Right pneumothorax persists and may be slightly smaller. There is overall no other change since earlier today. The study and the report were reviewed by the staff radiologist. DR. [**First Name8 (NamePattern2) 4078**] [**Name (STitle) 4079**] DR. [**First Name8 (NamePattern2) 1569**] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 11006**] Approved: MON [**2188-12-1**] 5:46 PM Brief Hospital Course: He was admitted on [**11-25**]. Diuresis was begun and he did not require intubation. Pre-op workup was completed and he underwent surgery with Dr. [**Last Name (STitle) **] on [**11-28**]. Please see OR report for details in summary. Patient had MV repair w/28MM [**Company 1543**] ring. His bypass time was 61 minutes with a crossclamp of 45 minutes. He tolerated the operation well and was transferred to the CVICU in stable condition on phenylephrine and propofol drips. He remained hemodynamically stable in the immediate post operative period, was weaned from the pressors and was extubated without difficulty. ID was consulted on [**2188-11-28**] due to [**2-15**] blood cultures on [**2188-11-25**] growing gram negative rods. He was started on IV Zosyn and Vancomycin post-op day 0. Later that afternoon Zosyn was discontinued and Meropenem was started. Vancomycin was continued until [**2188-11-30**] after negative blood cultures. Final ID recommendations were made on [**2188-12-2**]. Patient will take Flagyl 500MG PO three times daily for 6 weeks, follow up with ID in 4 weeks. On POD1 he was begun on beta blockers and diuretics. He was also transferred to the step down floor. On the floors he developed atrial fibrillation transiently for which his beta blocker dose was increased. Anticoagulation was begun, in the event dysrhythmia persisted. He converted to sinus rhythm and maintained this at discharge. Warfarin was discontinued on POD 4 due to normal sinus rhythm for greater than 24 hours. His hospital course was otherwise uneventful. He was discharged home on POD 4. Medications on Admission: bronchodilators (MDI) prn Discharge Medications: 1. Ibuprofen 400 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8 hours) as needed for pain. Disp:*180 Tablet(s)* Refills:*0* 2. Oxycodone 20 mg Tablet Sustained Release 12 hr Sig: One (1) Tablet Sustained Release 12 hr PO Q12H (every 12 hours) as needed for pain. Disp:*30 Tablet Sustained Release 12 hr(s)* Refills:*0* 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day): Please take as long as you take narcotics. Disp:*60 Capsule(s)* Refills:*0* 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:*0* 5. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:*90 Tablet(s)* Refills:*0* 6. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 6 weeks. Disp:*126 Tablet(s)* Refills:*0* 7. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 5 days. Disp:*5 Tablet(s)* Refills:*0* 8. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO DAILY (Daily) for 5 days. Disp:*5 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0* Discharge Disposition: Home with Service Discharge Diagnosis: severe mitral regurgitation s/p mitral valve repair asthma obsructive sleep apnea s/p inguinal herniorraphy Discharge Condition: good Discharge Instructions: shower daily and pat incisions dry. No baths or swimming no lotions, creams or powders on any incision call for fever greater than 100.5 no driving for one month and off all narcotics no lifting greater than 10 pounds for 10 weeks report any redness of, or drainage from incisions report any weight gain greater than 2 pound a day or 5 pounds in a week Followup Instructions: see your primary care physician [**Last Name (NamePattern4) **] [**2-13**] weeks cardiologist follow up in [**3-16**] weeks Dr. [**Last Name (STitle) **] in 4 weeks [**Telephone/Fax (1) 170**] ( or get a referral for a cardiac surgeon to follow you in Winnipeg for a postop visit in 4 weeks) Follow up in [**Hospital **] clinic on 4 weeks with Dr [**Last Name (STitle) 438**] ([**Telephone/Fax (1) 6732**] Completed by:[**2188-12-2**]

[ "997.1", "424.0", "790.7", "E878.1", "518.0", "327.23", "512.1", "486", "493.90", "511.9", "427.31" ]

icd9cm

[ [ [] ] ]

[ "35.12", "39.61" ]

icd9pcs

[ [ [] ] ]

8241, 8260

5372, 6974

294, 374

8412, 8419

1627, 4595

8820, 9258

1118, 1174

7050, 8218

4635, 4656

8281, 8391

7000, 7027

8443, 8797

1189, 1608

247, 256

4688, 5349

402, 888

910, 998

1014, 1102

4,787

199,221

2558

Discharge summary

report

Admission Date: [**2128-10-20**] Discharge Date: [**2128-10-23**] Date of Birth: [**2044-1-3**] Sex: M Service: MEDICINE Allergies: Meropenem / Penicillins / Carbapenem Attending:[**First Name3 (LF) 3853**] Chief Complaint: "hypotension." Major Surgical or Invasive Procedure: None History of Present Illness: 84 year old male with history of ESRD on HD, CAD, a. fib, and CVA with residual right-sided weakness presents from [**First Name3 (LF) 2286**] with hypotension. . Patient presented for regular outpatient HD today, and was found to have a BP of 77/47. HD was deferred, and patient was transferred to [**Hospital1 18**] ED for further evaluation. . Patient reports feeling intermittently lightheaded with DOE for the past few months. Denies cough, fevers, chills. No chest pain. No orthopnea, no PND. No diarrhea. He reports minimizing fluid intake while on [**Hospital1 2286**], and is thirsty now. He currently has no other complaints. . In the ED, initial VS were: 96.4 60 73/51 97% RA, asymptomatic - EKG: per report, unremarkable - received 1 liter NS - Bedside ultrasound showing no pericardial effusion - chest x-ray unremarkable - given broad-spectrum antibiotics of vancomycin, levofloxacin and Flagyl - repeat FSBG 115 at 16:00 (glucose 67 on initial labs) - Nephrology fellow consulted, will dialyze this admission - admission vitals: 66 92/53 17 96% RA . Review of systems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies cough 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: - ESRD on HD - CAD s/p MI - Afib, not anticoagulated - CVAs x2, residual R sided weakness, from 12 yrs then 5 yrs ago - Hx of GI Bleed - Nephrolithiasis - OSA, not using CPAP - Iron Deficiency Anemia - Depression - Hx of C.diff - Restrictive Ventalatory Pulmonary Defect - Pelvic and wrist fractures [**1-30**] - Recurrent UTIs, including VRE and klebsiella - Multiple episodes of line related bacteremia: - MRSA in [**2125-9-6**] treated for 6 weeks of vanc given possible clot in fistula. Line removed. TTE negative for vegetation. TEE not performed. - ESBL E.coli bacteremia in [**2125-9-26**] thought to be line related. - ESBL E.coli bacteremia in [**2125-11-26**]. Thought to be line related. s/p total 4-week course of meropenem/ertapenem. ([**Date range (1) 12915**]) for likely endovascular infection in setting of R IJ clot. - ESBL E.coli x 2 types, E. faecium [**Name (NI) 12916**] unclear source despite extensive work-up ([**2126-6-27**]). s/p 4 weeks of Vancomycin and Meropenem. - ESBL E. coli and E. faecium [**Month/Day/Year 12916**] ([**2126-7-28**]) thought to be line related s/p 2 weeks Vancomycin/Meropenem. - Pansusceptible Klebsiella pneumoniae [**Month/Day/Year 12916**] thought [**1-21**] 7mm CBD stone. s/p ERCP and stenting. Due for repeat ERCP . Past Surgical History - [**2127-7-31**] C2 fracture dislocation with progressive collapse s/p ORIF C2 and posterior instrumentation C1-C5 and left iliac crest bone graft placement, complicated by osteomyelitis. - [**2127-4-28**] Right popliteal thrombosis s/p popliteal and tibial embolectomy and R below the knee popliteal and tibial vein path angioplasty - R AVF placement [**1-29**] - L UE fistulogram/angioplasty [**8-27**] - LUE fistulagram [**10-26**] - LUE fistulogram and angioplasty of central venous stenosis [**7-26**] - L AV brachiocephalic fistula [**5-26**] - cataract surgery [**4-25**] - R ureteral stent placement [**5-24**] - I&D R wrist [**5-24**] - R shoulder surgery [**6-18**] - L cataract surgery [**11/2117**] - L knee surgery Social History: Lives with wife [**Name (NI) **], has been home for a while now after prolonged stay in rehab; see is his primary caregiver. [**Name (NI) **] is wheelchair bound but has a nurse to help with showering, daughter lives downstairs -h/o smoking [**12-21**] PPD for 50 years, quit 20 years ago, occasional beer, none recently, no drugs. -Of note, his wife recently had a panick attack and was hospitalized on cc7. Family History: Non-contributory. Physical Exam: Vitals: 96.5 HR 67 BP 104/65 RR 16 97% RA General: Alert, oriented, no acute distress. Hard of hearing HEENT: Sclera anicteric, dry mucous membranes, oropharynx clear, EOMI, PERRL Neck: supple, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Chest: tunnelled HD line in left chest, very minimal surrounding erythema Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi Abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CNII-XII intact, 5/5 strength left extremeties, [**3-23**] in right extremities, grossly normal sensation, 2+ reflexes bilaterally, gait deferred On discharge: A&Ox3. Hard of hearing, wheelchair bound. Pertinent Results: [**2128-10-23**] 09:25AM BLOOD WBC-8.0 RBC-3.65* Hgb-11.6* Hct-34.4* MCV-94 MCH-31.9 MCHC-33.8 RDW-17.6* Plt Ct-144* [**2128-10-23**] 09:25AM BLOOD Plt Ct-144* [**2128-10-20**] 01:05PM BLOOD Neuts-73.6* Lymphs-20.0 Monos-4.2 Eos-1.4 Baso-0.7 [**2128-10-23**] 09:25AM BLOOD Glucose-88 UreaN-23* Creat-3.7*# Na-139 K-4.3 Cl-94* HCO3-36* AnGap-13 [**2128-10-23**] 09:25AM BLOOD Cortsol-26.7* . CXR: EXAM: Chest, single supine AP portable view. CLINICAL INFORMATION: 84-year-old male with history of hypotension. COMPARISON: [**2128-5-20**]. FINDINGS: Single AP supine portable view of the chest was obtained. There are low lung volumes. There is elevation of the right hemidiaphragm with overlying atelectasis. Minimal left base atelectasis is also seen. No definite focal consolidation is seen. There is no pleural effusion or pneumothorax. Dual-lumen left-sided [**Year (4 digits) 2286**] catheter is seen, unchanged in position, terminating in the right atrium. Vascular stent is noted along the brachiocephalic vein, unchanged. There is mild cardiomegaly. The mediastinal contours are unchanged. IMPRESSION: Bibasilar atelectasis and elevation of the right hemidiaphragm. Brief Hospital Course: 84 year old male with history of ESRD on HD, CAD, a. fib, and CVA with residual right-sided weakness presents from [**Year (4 digits) 2286**] with hypotension. . # Hypotension- Reassuring that BP has normalized after one liter of NS, and BP is normal now in ICU. Differential broad. Favor hypovolemia, but must consider sepsis with indwelling HD line. No other evidence of infection. Bedside ultrasound in ED without evidence of tamponade. No VTE risk factors. No evidence of bleeding. Culture data remainded negative. Held empiric antibiotic therapy, and patient remainded afebrile. BP in arm was [**Location (un) 1131**] SBP 60-70 at times, but as pt mentating well, favor thigh pressures, which were [**Location (un) 1131**] SBP 110 throughout. Beta blocker held, midodrine started upon discharge. . # ESRD on HD- M, W, F schedule, tolerated HD during stay. . # History of CAD- no evidence of active ischemia. Continued statin, ASA. Held BB as above. . # Pulmonary Hypertension- noted on TTE in 2/[**2127**]. Has known severe OSA, not on therapy. No evidence of right heart failure on exam. . # Physical deconditioning: patient declined physical thearpy evaluation or home services during this stay. Medications on Admission: CALCIUM ACETATE - 667 mg TID with meals FLUOXETINE - 20 mg daily GABAPENTIN - 300 mg Capsule HS IPRATROPIUM BROMIDE HFA - 17 mcg/Actuation Q4H PRNLIDOCAINE LIDODERM patch METOPROLOL SUCCINATE - 25 mg daily MIDODRINE - 10 mg Tablet - 1 Tablet(s) by mouth 1 hr post [**Year (4 digits) 2286**] Pt. states that he does not take this. NORTRIPTYLINE - 10 mg Capsule OMEPRAZOLE - 20 mg [**Hospital1 **] OXYCODONE-ACETAMINOPHEN - 1 tab [**Hospital1 **] PRN pain SIMVASTATIN - 20 mg daily TIOTROPIUM BROMIDE one puff daily ACETAMINOPHEN - Dosage uncertain ASCORBIC ACID [VITAMIN C] daily ASPIRIN - 81 mg CYANOCOBALAMIN 100 mcg daily Discharge Medications: 1. calcium acetate 667 mg Capsule Sig: One (1) Capsule PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 2. fluoxetine 20 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 3. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 4. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 5. oxycodone-acetaminophen 5-325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. 6. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 7. gabapentin 300 mg Capsule Sig: One (1) Capsule PO at bedtime. 8. midodrine 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 9. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 10. ascorbic acid 1,000 mg Tablet Sig: One (1) Tablet PO once a day. 11. docusate sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2 times a day). 12. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for Constipation. 13. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain. 14. cyanocobalamin (vitamin B-12) 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 15. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 16. nortriptyline 10 mg Capsule Sig: One (1) Capsule PO HS (at bedtime). Discharge Disposition: Home Discharge Diagnosis: hypovolemia hypotension 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 to the hospital with hypotension (low blood pressure). Our testing showed that you did not have an infection in your blood or in your lungs. When we gave you additional fluid your blood pressure returned to [**Location 213**]. You declined any home services or physical therapy during this visit. Medication changes: 1) STOP taking metoprolol 2) START taking midrodrine Follow up with Dr. [**Last Name (STitle) **] next week. Followup Instructions: Department: [**Hospital1 18**] [**Location (un) 2352**] When: THURSDAY [**2128-10-28**] at 1:50 PM With: [**First Name4 (NamePattern1) 1575**] [**Last Name (NamePattern1) 1576**], MD [**Telephone/Fax (1) 1144**] Building: [**Location (un) 2355**] ([**Location (un) **], MA) [**Location (un) 551**] Campus: OFF CAMPUS Best Parking: Free Parking on Site Completed by:[**2128-10-25**]

[ "414.01", "327.23", "438.89", "416.0", "V45.11", "280.9", "412", "427.31", "585.6", "276.52", "780.79", "458.29" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

9701, 9707

6431, 7644

313, 320

9775, 9775

5229, 6408

10433, 10821

4365, 4384

8318, 9678

9728, 9754

7670, 8295

9960, 10279

4399, 5153

5167, 5210

1446, 1871

10299, 10410

259, 275

348, 1427

9790, 9936

1893, 3921

3937, 4349

18,673

126,834

26383

Discharge summary

report

Admission Date: [**2130-9-6**] Discharge Date: [**2130-9-19**] Date of Birth: [**2058-10-26**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 545**] Chief Complaint: SOB Major Surgical or Invasive Procedure: none History of Present Illness: hpi: 71 yo Farsi- speaking female who presented to [**Hospital1 18**] ED today complaining of SOB x 1 week, along with general malaise and weakness. History obtained through daughter as pt sleeping and speaks limited english. Daughter states that the VNA recommmended she go to the hospital 4 days ago, but the patient refused. VNA was concerned as the patient was becoming increasingly dyspneic and lethargic. Daughter denies any new cough, no fevers or chills. No chest pain or pleuritic pain. Worsening DOE, able to go from room to room in her apartment but becomes winded. States the urinary incontinence has happened in the past, currently attributes this to recently increased lasix dose. The daughter is also wondering if her mother is worse because of the increased oxygen that she was sent home on after her last hospitalization (hospitalized for falls thought to be secondary to mental status changes from hypercapnea). Denies any new or missed doses of her medications. At baseline the patient ambulates with a walker but very rarely leaves her home. Is still able to do ADLs/ independent ADLs including dressing herself, bathing herself, does some of her own cooking. . In the ED the patient's vitals were 99.6/ bp 155/70/ hr 88/ 86% on 4L NC. Chest x-ray was done, and the patient was given SL nitro, combivent nebs, and lasix. The patient was started on BI-PAP for respiratory distress, ABG 7.28/ 84/ 70/41. The patient was admitted to [**Hospital Unit Name 153**] for further management. . Past Medical History: 1. CAD: s/p 4-vessel CABG [**2119**] 2. CHF: ECHO [**1-3**] w/ 1+ MR, minimal AS, EF 40% w/ regional wall motion abnormalities 3. DM Type 2 4. HTN 5. COPD: on home O2 3.5L/m, BIPAP (settings 14/10) with multiple past admissions w/ pCO2 in the 70-80 range 6. Schizophrenia: initially symptomatic w/ paranoia and hallucinations, well controlled w/ meds 7. L3 fracture: [**2127**] 8. Symptomatic VT: s/p ICD in [**1-2**] 9. Hypothyroidism Social History: lives alone in [**Hospital3 **] apartment; has home health aide daily; meals are prepared by the pt's daughter; walks independently but sometimes uses walker; uses home O2 at all times and BiPAP at night; smoked 60 pack-years but quit in [**2123**]; no alcohol, IVDU, or cocaine use. Family History: 1. CAD: mother died of MI at unknown age Physical Exam: GEN: obese female, sleeping, [**Last Name (LF) 18248**], [**First Name3 (LF) **] follow commands HEENT: atraumatic, anicteric, BI-PAP mask in place NECK: large, +JVD, no LAD, no carotid bruits CV: soft precordium, RRR, 2/6 systolic murmur, best at LSB LUNGS: distant breath sounds, rales at bases ABD: distended, soft, NT, NABS, no organomegaly EXT: warm, dry. No [**Location (un) **] edema. DP pulses palpable B/L SKIN: no rashes NEURO: sleepy but [**Last Name (LF) 18248**], [**First Name3 (LF) **] follow commands, responds to voice, moves all extremities Pertinent Results: [**2130-9-6**] 06:15PM WBC-9.8 RBC-3.19* HGB-9.5* HCT-28.9* MCV-91 MCH-30.0 MCHC-33.0 RDW-17.1* [**2130-9-6**] 06:15PM CK-MB-NotDone cTropnT-0.01 proBNP-6099* [**2130-9-6**] 06:57PM TYPE-ART O2-40 PO2-70* PCO2-84* PH-7.28* TOTAL CO2-41* BASE XS-9 COMMENTS-VENTIMASK [**9-6**] CXR (prelim): IMPRESSION: Cardiomegaly with moderate interstitial pulmonary edema. . EKG: sinus rhythm, normal axis, normal intervals, TW flattening in multiple leads, unchanged from prior. No actue ST changes . Discharge Labs: [**2130-9-19**] 06:55AM BLOOD WBC-8.3 RBC-3.68* Hgb-11.1* Hct-33.1* MCV-90 MCH-30.1 MCHC-33.4 RDW-16.3* Plt Ct-247 [**2130-9-19**] 06:55AM BLOOD Glucose-141* UreaN-30* Creat-0.9 Na-135 K-3.9 Cl-93* HCO3-36* AnGap-10 [**2130-9-19**] 06:55AM BLOOD Ammonia-62* . Other Labs: [**2130-9-15**] 05:01AM BLOOD TSH-2.9 [**2130-9-12**] 06:20AM BLOOD Digoxin-1.8 [**2130-9-15**] 05:01AM BLOOD Valproa-21* Blood Cultures ([**9-6**], [**9-12**] x2) - No growth Urine Culture ([**9-11**]) - Coag negative staph. . Studies: Portable CXR ([**9-15**]) - Interval worsening of perihilar and upper lung field vascular engorgement and cardiomegaly, suggesting cardiac decompensation. Atelectasis of right lower lung. Head CT ([**9-13**]): FINDINGS: There is no evidence of intra- or extra-axial hemorrhage. There is no mass effect, hydrocephalus, or shift of the normally midline structures. Similar minimal prominence of the ventricular system is noted. There are also unchanged ill-defined areas of relative hypodensity in the white matter in the frontal lobes, probably chronic small vessel infarcts. The visualized paranasal sinuses and mastoid air cells are clear. The osseous structures are unremarkable. IMPRESSION: Resolution of fluid in the right maxillary sinus. No other change. Brief Hospital Course: 1) Shortness of Breath Likely secondary to hypercarbic respiratory failure. The patient has a history of hypercapnea, has been admitted numerous times with CO2 in the 70-80's. Admission ABG demonstrates a chronic respiratory acidosis with compensatory metabolic alkalosis. However, BNP also significantly more elevated than prior, CXR with B/L effusions, cardiomegaly suggestive of component of heart failure. The patient was ruled out for an MI with 2 sets of neg. cardiac enzymes, also with no significant EKG changes on admission. Pt was continued on supplemental oxygen with BI-PAP overnight on home settings ([**11-12**]) on HD1. She was diuresed aggressively to neg. 5L and given standing nebs with improvement in respiratory function. Patient is currently at goal CO2 (65-75 range) and O2sat (89-92%) with pH at 7.41. On [**9-10**] she was transitioned back to her home Lasix dose of 60mg PO and transferred to the floor. She was maintained on lasix 60mg daily and given extra dose on [**9-11**] as thought mild overload. Oxygen sats high 80's to low 90's on four liters. Patient non compliant with bipap at night and more somnolent over [**Date range (1) 28751**]. Nursing unable to keep patient on bipap at night. ABG by [**9-13**] revealed hypercarbia. Transferred back to [**Hospital Unit Name 153**] for somnolence with hypercarbia. . Transferred back to [**Hospital Unit Name 153**] [**9-13**]: Patient diuresed another [**1-31**] liters and BIPAP maintained. Placed on steroids for possible copd exacerbation. By [**9-15**] patietn's pC02 down in 50's to 60's and back to floor on [**9-15**] PM. . On [**9-16**] and [**9-17**] patient maintained on bipap at night with restraints as needed for compliance as well as steroids. Oxygen saturation low 90's on 4 liters which is baseline. Lasix dosing to 60mg daily, outpatient dosing . On [**7-16**], prior to discharge, pt maintained her Oxygen saturation in 90-93% range on 2-3L O2. . 2) COPD History of COPD, but no PFTs on record here. Pt has upcoming appt scheduled with pulmonologist. As above, started on steroid taper, plan two weeks given copd exacerbation, severe COPD. Currently on Prednisone 30mg daily (started [**9-19**]). Should continue on this until [**9-22**]. Should then change to 20mg daily for 4 days, then 10mg daily for 4 days, then 5mg daily for 4 days, then 2.5mg daily for 4 days, then off. . 3) Cardiac a. Vessels- history of CABG x4 in [**2119**], no acute issues. The patient was continued on her home beta-blocker, aspirin, statin b. Pump- history of CHF, preserved EF on echo in 5/[**2130**]. The patient appeared somewhat volume overloaded on admission, which improved with diuresis. She was continued on her home dose of digoxin and beta-blocker. Lisinopril 2.5mg was added on [**9-10**] given patient's history of heart failure and diabetes. This was titrated to 5mg. Patient diuresed 3-4 liters over course of admission. Lasix outpatient 60mg dosing re-started on [**9-15**]. Digoxin stopped on [**9-14**] in ICU, not re-started. This could potentially be restarted as an outpatient. c. Rhythm- currently sinus, history of VT, s/p ICD placement. Was bradycardic to 40s-50s on [**9-18**], so Toprol XL changed to 12.5mg daily (down from 25). Her heart rate should be monitored and if still bradycardic, B-blocker could be stopped. d. Valves- aortic stenosis on echo . 4) Hypertension: Stable with above medication changes. 5) Diabetes Last hgb A1c 7.1% in [**8-5**], controlled with oral hypoglycemics. During the hospitalization she was covered with SSI and Lantus 5U daily was added (particularly given patient on steroids). Home medications being held at present. Once she is transitioned off steroids, home medications can be restarted and insulin could be stopped. . 6) Anemia Baseline hct 28-35, currently stable. No history of GI w/u in record, iron studies in [**2129**] w/ normal ferritin and iron. She was continued on iron supplementation. . 7) Hypothyroidism Continued on levoxyl. TFTs checked in [**8-5**] were normal . 8)Altered Mental Status/intermittent lethargy: Initially thought secondary to hypercarbia although mental status did not always correlate with level of hypercarbia. Over [**Date range (1) 51030**] very somnolent. HEad CT, infectious w/u, TSH, dig levels unrevealing. On [**9-13**] transferred to [**Hospital Unit Name 153**], co2 blown down by bipap, but did not clearly improve secondary to this intervention. Psych consulted, medications changed. Patient then returne to baseline over [**Date range (1) 65255**]. Unclear if secondary to adjusment of meds, improvement of hypercarbia. At baseline on discharge. Also started on steroids for COPD over this time, and diuresed as above, unclear if improvement of resp status helped with somnolence. Also, alteration of day wake cycle, hospital delirium playing role. Had ammonia level checked prior to discharge which was 62. Her lactulose had been held, but she is now being continued on this with a goal of [**3-4**] bowel movements per day. . 9) Code Status DNR/DNI (though has ICD) Medications on Admission: Furosemide 60 mg DAILY Digoxin 250 mcg DAILY Glyburide 5 mg [**Hospital1 **] Toprol 25 mg daily Aspirin 81 mg Levothyroxine 125 mcg Medroxyprogesterone 10 mg DAILY Atorvastatin 10 mg Sertraline 50 mg Aripiprazole 40 mg daily Risperidone 2 mg at bedtime Divalproex 125 mg daily Hexavitamin DuoNeb QID Fluticasone 110 mcg 4 puffs [**Hospital1 **] Fluticasone 50 mcg 1 spray [**Hospital1 **] Ferrous Sulfate 325 daily colace senna lactulose Discharge Medications: 1. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000) Units Injection TID (3 times a day): Please discontinue if patient ambulating regularly. 2. Levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily). 4. Fluticasone 110 mcg/Actuation Aerosol Sig: Four (4) Puff Inhalation [**Hospital1 **] (2 times a day). 5. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 6. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Aripiprazole 10 mg Tablet Sig: Four (4) Tablet PO QAM (once a day (in the morning)). 8. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for headache. 9. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**1-31**] Sprays Nasal [**Hospital1 **] (2 times a day) as needed. 10. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed for indigestion. 11. Medroxyprogesterone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Pramoxine-Mineral Oil-Zinc 1-12.5 % Ointment Sig: One (1) Appl Rectal [**Hospital1 **] (2 times a day). 13. Fluticasone 50 mcg/Actuation Aerosol, Spray Sig: Two (2) Spray Nasal [**Hospital1 **] (2 times a day). 14. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 15. Sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 16. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 17. Insulin Glargine 100 unit/mL Cartridge Sig: Five (5) Units Subcutaneous Daily at lunchtime. 18. Divalproex 125 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 19. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 20. Risperidone 0.5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 21. Risperidone 0.5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for agitation. 22. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: One (1) Nebulized Solution Inhalation Q6H (every 6 hours). 23. Ipratropium Bromide 0.02 % Solution Sig: One (1) Nebulized Solution Inhalation Q6H (every 6 hours). 24. Furosemide 20 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 25. Prednisone 10 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily) for 2 days: Will then need to taper to 20mg for 4 days, 10mg for 4 days, 5mg for 4 days, 2.5mg for days, then off. 26. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr Sig: 0.5 Tablet Sustained Release 24 hr PO DAILY (Daily): hold for HR<55 or sbp<95. Discharge Disposition: Extended Care Facility: [**Hospital3 105**] - [**Location (un) 86**] Discharge Diagnosis: 1. Hypercarbic respiratory failure 2. Altered Mental Status 3. Diastolic Heart Failure 4. COPD 5. OSA 6. Central hypoventilation syndrome 7. Bradycardia (?-medication induced) Secondary: 1. Schizophrenia 2. Hypothyroid 3. Diabetes Mellitus, Type II 4. Hyperlipidemia Discharge Condition: Stable, baseline mental status and respiratory status. O2 Sat 93% (on 2L). Discharge Instructions: Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs. Adhere to 2 gm sodium diet Fluid Restriction:2 liters. . Follow up as below. Contact your doctor if you have fevers, chills, if you become more confused or if you develop any other new concerning symptoms. . All medications as prescribed. We have made changes to your medications. Make sure you take the medications as prescribed. Be sure to use your BiPap every night and oxygen during the day to maintain your Oxygen saturation between 88 and 92%. Your digoxin was stopped during this admission. This could be restarted as needed as an outpatient. You are being placed on a steroid taper for your COPD. Currently you are on Prednisone 30mg. This should be until [**9-22**]. You will then take Prednisone 20mg for 4 days, 10mg for 4 days, 5mg for 4 days, and then 2.5mg for days. The medication can then be stopped. Followup Instructions: Follow up with your PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 4922**]. His number is [**Telephone/Fax (1) 65256**]. Please call him for a follow up appointment within 1 week of discharge. Follow up with Dr. [**Last Name (STitle) 575**] for your lung disease: Provider: [**Name10 (NameIs) 1571**] BREATHING TESTS Phone:[**Telephone/Fax (1) 612**] Date/Time:[**2130-9-29**] 9:40 Provider: [**First Name11 (Name Pattern1) 1569**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. Phone:[**Telephone/Fax (1) 612**] Date/Time:[**2130-9-29**] 10:00 Provider: [**Name10 (NameIs) 1570**],INTERPRET W/LAB NO CHECK-IN [**Name10 (NameIs) 1570**] INTEPRETATION BILLING Date/Time:[**2130-9-29**] 10:00

[ "401.9", "V45.81", "414.01", "276.4", "428.30", "250.00", "V45.02", "424.1", "285.9", "327.23", "428.0", "518.81", "491.21", "244.9", "295.90" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

13285, 13356

5096, 10197

318, 324

13667, 13745

3285, 3783

14693, 15426

2647, 2689

10685, 13262

13377, 13646

10223, 10662

13769, 14670

3799, 4059

2704, 3266

275, 280

352, 1871

1893, 2330

2346, 2631

4071, 5073

25,466

144,778

11676+56268+56269

Discharge summary

report+addendum+addendum

Admission Date: [**2194-12-11**] Discharge Date: Date of Birth: [**2145-6-10**] Sex: M Service: [**Hospital1 **] (This is an interim discharge summary, for [**Hospital 228**] hospital course through [**2194-12-19**]; remainder of [**Hospital 228**] hospital course to be dictated in a subsequent addendum) CHIEF COMPLAINT: Shortness of breath. HISTORY OF THE PRESENT ILLNESS: [**Known firstname **] [**Known lastname 21432**] is a 49-year-old male with a history of hypertension, gout, obesity, and history of osteoarthritis, status post right total knee replacement on [**2194-11-28**] at an outside hospital. He presented to the emergency department from his nursing home with acute onset of shortness of breath. The patient noted that over the last two days prior to admission the worsening on the day of presentation, leading to his transferred to the emergency department. The patient denied any chest pain, fevers, chills, abdominal pain or back pain. On arrival to the emergency department the patient's oxygen saturation was 70 to 80 off supplemental oxygen. Given the patient's shortness of breath and postoperative state, the suspicion for pulmonary embolism was high and Heparin was started. The CT angiogram was performed, which was negative for proximal pulmonary embolism. Subsequently, the patient had blood work returned, which showed an INR of 4.0 and a creatinine of 11. A CT scan of the abdomen was subsequently performed to look for retroperitoneal hemorrhage, which was negative. The patient was thought to possibly be septic given his postoperative state. He was started on IV antibiotics. Echocardiogram was performed after transfer to the medical Intensive Care Unit which showed no evidence of pericardial effusion or tamponade physiology, nor did it show any evidence of right heart strain. PAST MEDICAL HISTORY: 1. Hypertension. 2. Gout. 3. Obesity. 4. Osteoarthritis. ALLERGIES: The patient has no known drug allergies. MEDICATIONS: 1. Coumadin 10 mg q.d. 2. Colace. 3. Senna. 4. OxyContin. 5. Celebrex. 6. Uniretic 15/25 one p.o.q.d. 7. Procardia XL 90 mg p.o.q.d. 8. Colchicine. 9. Lopressor 50 mg q.d. 10. Ativan p.r.n. SOCIAL HISTORY: The patient reports smoking cigars. The patient is a resident of [**Hospital3 2558**]. PHYSICAL EXAMINATION: Examination revealed the following: Temperature 99.3, heart rate 100, blood pressure 80 to 100/40 to 80. Respiratory rate 30. Oxygen saturation of 92 to 94% on 100% nonbreather mask. GENERAL: The patient was an alert, but tachypneic young man in moderate respiratory distress. He was not able to speak in complete sentences. He was also obese. HEENT: Examination revealed the neck, which was supple with pupils equal, round, and reactive to light and extraocular muscles are intact. There was dried blood around his oropharynx. PULMONARY: Examination revealed lungs which were clear to auscultation bilaterally with the exception of scattered crackles and wheezes at the bases. CARDIAC: Examination revealed regular tachycardia with normal S1 and S2 and no murmurs, rubs, or gallops appreciated. JVP was difficult to assess secondary to obesity. Abdominal examination revealed a belly, which was soft, nontender, nondistended, with distant bowel sounds. EXTREMITIES: Examination revealed 2+ edema to the mid shin. The patient had right knee incision, which was without erythema or fluctuance. NEUROLOGICAL: Examination revealed the patient who was alert and oriented responding to questions appropriately. He produced occasional myoclonic jerks. The patient was able to move all four extremities without difficulty. SKIN: Examination revealed no rash. RECTAL: Examination was guaiac positive per the emergency department. LABORATORY DATA: Pertinent laboratory findings revealed the following: The patient had a white blood cell count of 31.5 with a hematocrit of 27.0, and platelets of 1037. MCV was 85. The patient had an INR of 4.0. The patient had a sodium of 125, potassium of 7.3, which was hemolyzed. Chloride was 86, bicarbonate 17, BUN 174, creatinine 11, glucose 124. The patient had an initial CK of 761 with MB of 7 and a troponin of less than 0.3. The patient had an ABG, which revealed pH of 7.39, CO2 of 32, and oxygen of 70. Urinalysis revealed small blood, no nitrates, no protein, no glucose, no ketones, no red blood cells and no white blood cells. The EKG revealed sinus tachycardia at 100 with slightly widened QRS and peak T waves. Chest x-ray: The patient had low lung volumes, possible left lower lobe infiltrate, otherwise, clear without evidence of CHF. Chest, abdominal pain, and pelvic CT revealed no evidence of pulmonary embolism, bibasilar atelectasis, no peritoneal hemorrhage. SUMMARY OF HOSPITAL COURSE: The patient was a critically ill, 49-year-old male with tachycardia, hypotension, hypoxemia, two weeks status post a right total knee replacement with a two-day history of worsening shortness of breath. The patient presented in respiratory distress with hypotension and acute renal failure. However, placement of a Foley catheter resulted in three liters of urine output. The patient was transferred to the Intensive Care Unit for initial management and stabilization. The patient had a Swan-Ganz catheter placed, which revealed the cardiac output of 13.8 with SVR of 272. This was consistent with distributive shock. Blood, urine, and knee joint cultures were obtained. These were all negative. However, the patient was initially started on empiric Levofloxacin and Vancomycin for a suspected sepsis (he received Levofloxacin/ampicillin/metronidazole x 1, in the E.D., PRIOR to obtaining blood cultures). The R knee joint fluid did reveal 3,000 WBC's (poly predominant), with a positive crystal examination, with monosodium urate crystals that were negatively birefringent. The Renal Department was consulted to evaluate the patient's acute renal failure. Given the quantity of urine removed after Foley placement, it was thought that the patient's acute renal failure was post renal secondary to obstruction. The consult team recommended review of the abdominal CT for possible bilateral nephrolithiasis, ureteral obstruction, or pelvic pathology. Two days after admission to the ICU a decubitus pressure ulcer was documented. This was thought to be stage II. Skin care and surgery was consulted. CT was recommended to evaluate for perirectal abscess. This was read as negative. The patient also had an SPEP AND UPEP, as part of the work-up for his acute renal failure. In the ICU these returned positive. The patient also had one episode of slight coffee grounds from NG tube aspirate. He was intermittently guaiac-positive in the ICU. Gastroenterology was consulted and recommended Protonix 40 mg p.o. b.i.d. and following of the patient's hematocrit. They also recommended considering and EGD if the patient's hematocrit continued to fall. In the ICU the patient developed a right joint swelling in his first and second toes consistent with gouty exacerbation. The patient was started on Colchicine and Ibuprofen. After six days in the ICU the patient's status had improved sufficiently enough to allow the patient to be transferred to the General Medicine Floor. #1. INFECTIOUS DISEASE: The patient presented with suspected sepsis after a total knee replacement in [**2194-11-20**]. The Swan-Ganz number suggested distributive shock, which would be consistent with sepsis. However, the patient was pan-culture negative and gave no focal findings suggesting infection. It was thought that transient hypotension and decreased vascular resistance may have been secondary to a systemic inflammatory response, possibly related to the patient's gout. The patient received a total of six days of Levofloxacin and Vancomycin. After all cultures returned negative, these antibiotics were discontinued. Wound care was consulted to follow the patient's stage II decubitus ulcer. WBC had trended down to 12-13, and patient remained hemodynamically stable (off antibiotics) and he remained afebrile. #2. CARDIOVASCULAR: The patient remained hemodynamically stable in the ICU after initial admission. He had one episode of nonsustained ventricular tachycardia of five beats. Echocardiogram revealed a normal ejection fraction of greater than 55%. Cardiology had been consulted and recommended no further workup. The patient was continued on his hypertensive regimen. He did have marked hypertension the day after transfer from the ICU. The Lopressor was increased to 50 mg p.o.b.i.d. He showed excellent response to this. #3. NEUROLOGICAL: The patient had episodes of delirium in the ICU. These resolved upon arrival to the floor. The patient was given Ativan for anxiety. #4. PULMONARY: The patient has unclear cause of oxygen requirement while in the ICU. The ICU team did not feel that this was secondary to ARDS, instead felt that this was most likely associated with atelectasis. The patient was treated with incentive spirometry and gradually weaned off oxygen. #5. RENAL: The patient showed marked improvement in his creatinine following Foley placement. Acute renal failure was thought to be secondary to obstruction possibly from benign prostatic hypertrophy or urinary retention secondary to medications. There was no evidence of nephrolithiasis. The patient was started on an alpha blocker, Flomax 0.4 mg p.o. q.day. A voiding trial was attempted, however after an overnight trial without Foley catheter, the patient was unable to urinate, and the Foley catheter was replaced, resulting in almost 2 liters of urine output. Urology was informally consulted, and their recommendations included keeping the Foley catheter in for another 1-2 weeks, and having the patient follow-up as an outpatient in [**Hospital 159**] clinic. #6. The patient has positive NG aspirate, intermittent guaiac positivity in the ICU. Hematocrit remained stable upon arrival to the floor. The Gastrointestinal Department had been consulted and elected to do an EGD on the patient, which was obtained while the patient was still in- house. EGD was essentially unremarkable. Protonix was continued. #7. RHEUMATOLOGIC: The patient presented with exacerbation of gout, while in the ICU. He was successfully treated with colchicine and NSAIDS. Breakthrough pain was handled with morphine. The patient's colchicine dose was gradually tapered. Possible outpatient Rheumatology follow-up was being considered, given patient's h/o recurrent attacks, and his tophaceous gout. #8. HEMATOLOGIC/ONCOLOGIC: The patient was found to haves a positive UPEP and SPEP with the present of Bence-[**Doctor Last Name **] proteins in the urine and a kappa spike. Hematology/ Oncology was consulted. Skeletal survey and beta 2 microglobulin were ordered. Bone marrow biopsy was also performed on patient, results pending at the time of this dictation. DIAGNOSES: 1. Distributive shock. 2. Gouty exacerbation. 3. Acute renal failure. 4. Hypertension. 5. Obesity. 6. History of osteoarthritis. 7. History of anxiety. 8. Microcytic anemia. The remainder of this dictation will be completed as the [**Hospital 228**] hospital course continues. DR. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] 12-951 Dictated By:[**Dictator Info **] MEDQUIST36 D: [**2194-12-18**] 15:24 T: [**2194-12-18**] 15:31 JOB#: [**Job Number 36980**] Name: [**Known lastname 6610**], [**Known firstname 422**] Unit No: [**Numeric Identifier 6611**] Admission Date: [**2194-12-11**] Discharge Date: [**2194-12-30**] Date of Birth: [**2145-6-10**] Sex: M Service: [**Hospital1 248**] ADDENDUM: 1. Infectious Disease: Following discontinuation of empiric levofloxacin and vancomycin, after six days of treatment and no growth in multiple blood culture bottles, the patient remained afebrile for approximately three days and then began to spike temperatures up to 102 F. These temperatures were also in conjunction with a flare of the patient's gout in his bilateral ankles and left knee. It was therefore felt that the most likely source of the patient's fever was his gout inflammation as opposed to a recurrent infection. However, the patient was pancultured with blood and urine cultures, as well as chest x-rays obtained during his temperature spikes over three days in succession. All cultures showed no growth to date, except for one bottle out of fifteen which demonstrated Staphylococcus epidermitis which was thought most likely to be a contaminant. The patient was not started on antibiotics and as his gout inflammation improved, his fevers subsided. At the time of discharge, the patient had been afebrile with a normal white blood cell count for five days. Therefore, at the time of discharge it was still unclear exactly what organism was causing the picture of distributive shock which the patient presented with. However, there was felt to be no further infection. The wound care team followed the patient over the course of the hospital stay for evaluation and treatment of his stage II decubitus ulcer. The patient was maintained on appropriate air mattress and dressing changes were performed [**Hospital1 **]. At the time of discharge, the patient's decubitus ulcer was still present; however, had improved somewhat. He will need to have further dressing changes at rehabilitation. 2. Cardiovascular: The patient remained hemodynamically stable over the course of the hospital stay. He was continued on Lopressor 50 mg po bid with excellent blood pressure control. He did demonstrate some tachycardia which responded well to fluids, pain control, and temperature control. He had no further cardiovascular events over the course of the hospital stay. 3. Neurological: The patient had an episode of fecal incontinence during the course of the hospital stay. A complete neurological examination was performed, demonstrating no neurological complaints and normal rectal tone. He had no further issues of bladder or bowel incontinence and no further suggestion of any neurological disorder. 4. Pulmonary: The patient had no further need for oxygen therapy over the course of the hospital stay. 5. Renal: The patient's Foley was maintained in place for two weeks as suggested by Urology. The patient has a follow up appointment at the [**Hospital 6612**] Clinic on [**2194-12-31**]. His BUN and creatinine remained within normal limits over the course of the hospital stay and were followed carefully, given that he was started back on higher doses of Indomethacin. The patient had no further renal issues over the course of the hospital stay. 6. Gastrointestinal: The patient had an esophagogastroduodenoscopy performed which demonstrated some mild gastritis, but no other evidence of ulcers or any active bleeding. It was suggested that he be maintained on Protonix as an outpatient. The patient's stools were guaiaced over the course of the hospital stay and remained negative and his hematocrit remained stable without need of transfusion. 7. Rheumatologic: At the time of the prior discharge summary, the patient's gout exacerbation had been well controlled with once daily Colchicine and prn NSAIDs. However, on hospital day twelve, the patient began experiencing and acute exacerbation of his gout with increased pain and decreased mobility in his bilateral ankles and his left knee. The patient's Colchicine was tapered up to tid for approximately four days and then backed off to [**Hospital1 **]. He was also started on Celebrex which did a poor job of managing his pain and was therefore switched to Indomethacin 50 mg tid. During this course, the patient's left knee effusion was tapped and analysis demonstrated negatively birefringent crystals and 3,000 white blood cells with a negative gram stain, consistent with gout inflammation. At the time of discharge, the patient's gout exacerbation had improved dramatically and his Colchicine had been tapered to a [**Hospital1 **] dose which he can continue as an outpatient for prophylaxis. This patient will likely need to be on allopurinol as an outpatient as a prophylactic measure against further gout attacks. This can be started approximately four to six weeks after discharge, once the patient's acute gout attacks have completely resolved. 8. Hematologic / Oncologic: A bone marrow biopsy was performed while the patient was in the hospital; however, the quality was too poor to adequately assess for the existence of multiple myeloma. His beta II microglobulin also came back positive. A skeletal survey was performed which did not demonstrate any lytic lesions at all. Therefore, the Hematology / Oncology Consult Service determined that the patient most likely has monoclonal gammopathy of undetermined significance and therefore required no further work up at this time. However, they did wish to follow him up in Hematology / [**Hospital 788**] Clinic in three months to assess for any further progression of this disease. DISCHARGE DIAGNOSES: 1. Distributive shock. 2. Gouty exacerbation. 3. Acute renal failure. 4. Hypertension. 5. Obesity. 6. History of osteoarthritis. 7. History of anxiety. 8. Microcytic anemia. 9. Monoclonal gammopathy of undetermined significance. 10. Status post right knee replacement. 11. Stage II decubitus ulcer. DISCHARGE MEDICATIONS: Indocin 50 mg po bid, heparin 5,000 units subcutaneous [**Hospital1 **], Tylenol 650 mg po q four hours prn, Colchicine 0.6 mg po bid, Senna one tablet po q HS prn, Ativan 1.0 mg to 2.0 gm po q six hours prn anxiety, Dulcolax one tablet po prn, Lactulose 30 cc po q four hours prn, Nystatin powder to the groin area [**Hospital1 **] prn, zinc sulfate 220 mg po q day, Neutra-Phos 500 mg po tid, Boost supplement one po tid, multivitamin one tablet po q day, magnesium oxide 500 mg po q day, vitamin C 500 mg po q day, Colace 100 mg po bid, Lisinopril 20 mg po bid, Lopressor 50 mg po bid, Ambien 10 mg po q HS prn. FOLLOW UP: 1. The patient is to follow up in [**Hospital 1976**] Clinic on [**2194-12-31**] at 08:00 AM. 2. He is to follow up with his primary care physician, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 6613**], at [**0-0-**] on [**2195-2-4**] at 02:30 PM. 3. He is also to follow up at the Hematology / [**Hospital 788**] Clinic and will be called with that appointment date. [**Last Name (LF) 6614**],[**Name8 (MD) 77**] M.D. [**MD Number(1) 3645**] Dictated By:[**Name8 (MD) 6288**] MEDQUIST36 D: [**2194-12-29**] 15:50 T: [**2194-12-30**] 08:31 JOB#: [**Job Number **] .................... Name: [**Known lastname 6610**], [**Known firstname 422**] Unit No: [**Numeric Identifier 6611**] Admission Date: [**2194-12-11**] Discharge Date: [**2195-1-9**] Date of Birth: [**2145-6-10**] Sex: M Service: [**Name6 (MD) 77**] [**Name8 (MD) 3638**], M.D. [**MD Number(1) 3645**] Dictated By:[**Name8 (MD) 6288**] MEDQUIST36 D: [**2195-1-9**] 14:28 T: [**2195-1-15**] 14:14 JOB#: [**Job Number 6615**]

[ "274.9", "518.0", "584.9", "600.0", "785.59", "427.1", "788.20", "707.0", "458.9" ]

icd9cm

[ [ [] ] ]

[ "89.64", "41.31", "86.22", "45.13" ]

icd9pcs

[ [ [] ] ]

17200, 17509

17533, 18149

18160, 19316

4804, 17179

2329, 4775

344, 1849

1871, 2200

2217, 2306

72,672

144,683

37648

Discharge summary

report

Admission Date: [**2152-11-9**] [**Month/Day/Year **] Date: [**2152-11-15**] Date of Birth: [**2070-9-23**] Sex: F Service: SURGERY Allergies: Penicillins Attending:[**First Name3 (LF) 598**] Chief Complaint: s/p Motor vehicle crash Major Surgical or Invasive Procedure: [**2152-11-9**] Suture lip laceration History of Present Illness: 82 y.o. female unrestrained driver of motor vehicle, struck another car at low speed, veered off and struck a stone wall head on. Denies LOC, but does not recall events. Transported to [**Hospital1 18**] for further care. Past Medical History: PMH: emphysema, TIA 3y ago, CHF, crtical aortic stenosis PSH: tonsillectomy, appy,carpal tunnel release X2, cataract surgery X2 Family History: Noncontributory Physical Exam: Upon admission: O: T:98.7 BP: 130/80 HR: 62 R:16 O2Sats: 96%RA Gen: WD/WN, comfortable, NAD. HEENT: Pupils: 3 to 2 mm, bilaterally. EOMIs intact. Face: 4cm laceration upper lip, sutured Neck: Posterior neck pain on palpation. C-collar in place Lungs: CTA bilaterally. Cardiac: RRR. S1/S2. Abd: Soft, NT, obese Extrem: Warm and well-perfused. Neuro: Mental status: Awake and alert, cooperative with exam, normal affect. Orientation: Oriented to person, place, and date. Motor: D B T WE WF IP Q H AT [**Last Name (un) 938**] G R 5 5 5 5 5 5 5 5 5 5 5 L 5 5 5 5 5 5 5 5 5 5 5 Sensation: Intact to light touch, propioception, pinprick and vibration bilaterally. Reflexes: B Pa Ac Right 2 2 2 Left 2 2 2 Propioception intact Pertinent Results: [**2152-11-10**] 12:00AM CK(CPK)-140 [**2152-11-10**] 12:00AM CK-MB-6 cTropnT-0.03* [**2152-11-9**] 02:00PM CALCIUM-9.9 PHOSPHATE-3.2 MAGNESIUM-2.3 [**2152-11-9**] 02:00PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2152-11-9**] 02:00PM WBC-7.5 RBC-3.91* HGB-12.1 HCT-36.7 MCV-94 MCH-31.1 MCHC-33.1 RDW-14.2 [**2152-11-9**] 02:00PM PLT COUNT-236 [**2152-11-9**] 02:00PM PT-31.4* PTT-22.5 INR(PT)-3.1* Micro/Imaging: [**2152-11-14**] Impression: Right ICA stenosis <40% . Left ICA with stenosis <40% . [**2152-11-12**] ucx 10,000-100,000 ORGANISMS alpha strep or lactobacillus [**2152-11-11**] MR [**Last Name (Titles) 12784**] C4-5 herniation, mod-severe spinal stenosis, spinal cord compress [**2152-11-10**] CT sinus no facial bone fracture, upper lip laceration [**2152-11-10**] Left knee no fracture [**2152-11-10**] TTE [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 1915**], LVEF 70%, AV stenosis <.8cm2, AV mod thickened [**2152-11-9**] CT-Head No acute intracranial injury. [**2152-11-9**] CT-Neck Disc bugling at C3/4, with central canal narrow [**2152-11-9**] CT-Torso ?Pulm contusion, thrombus in coronary sinus, old left rib fx Brief Hospital Course: She was admitted to the Trauma service. Her lip laceration was sutured by Plastic surgery in the ED. Neurosurgery was consulted for disc bulging at level of C3,4 and an MRI was recommended, she was kept in a hard collar until final [**Location (un) 1131**] of the MRI. Final [**Location (un) 1131**] revealed large central disc herniation at C4-5 level resulting in moderate-to- severe spinal stenosis and extrinsic indentation on the spinal cord; mild-to-moderate spinal stenosis due to small disc herniation at C3-4 level; no abnormal signal within the spinal cord and multilevel degenerative changes at other levels. The collar was then removed and no further neurosurgery follow up is being recommended at this time. The patient will however be given the name and number of Dr. [**Last Name (STitle) 548**], Neurosurgery if she has any concerns regarding her cervical spine after [**Last Name (STitle) **]. She was noted with a hypotensive and bradycardic episode while on the regular nursing unit triggering a transfer to the trauma ICU. She was given IVF bolus and started on a Levophed drip. She was eventually weaned off, adjustments in her cardiac meds were made and she was transferred back to the regular nursing unit. She was evaluated by Cardiology because of concerns that motor vehicle crash was related to syncopal episode. She was ruled out for MI with serial CK's and troponin and underwent ECHO and TTE. Her ECHO revealed the left atrium mildly dilated; moderate symmetric left ventricular hypertrophy with left ventricular cavity size normal. Overall left ventricular systolic function is normal (LVEF 70%). Right ventricular chamber size and free wall motion are normal. Aortic valve leaflets are moderately thickened. There is critical aortic valve stenosis (valve area <0.8cm2). The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Trivial mitral regurgitation is seen. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. The carotid series revealed <40% right ICA and left ICA stenosis. Several recommendations were made for continuing the beta blockade for her atrial fibrillation and anticoagulation with Coumadin for thromboembolic prophylaxis. She received Coumadin 2.5 mg on [**11-14**], her INR on [**11-15**] was 2.6. She will need to follow up with her primary cardiologist Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at [**Hospital 1411**] Medical after [**Hospital **] from hospital. Cardiac surgery was consulted for AVR given the critical AS, it was discussed with patient and her son to that surgery was indicated. The patient at this time has declined any surgical intervention. Physical and Occupational therapy were consulted and have recommended rehab after her acute hospital stay. Medications on Admission: detrol LA 4', spirinolactone 12.5', ranexa 500:, toprol 100', Fe 325", Dilt 240', coumadin 5' ALL: PCN [**Hospital **] Medications: 1. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as needed for sleep. 2. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours). 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for Constipation. 5. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO HS (at bedtime) as needed for Constipation. 6. Ranolazine 500 mg Tablet Sustained Release 12 hr Sig: One (1) Tablet Sustained Release 12 hr PO bid (). 7. Spironolactone 25 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 8. Gabapentin 300 mg Capsule Sig: Two (2) Capsule PO BID (2 times a day). 9. Tolterodine 2 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 10. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 11. Diltiazem HCl 240 mg Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO DAILY (Daily). 12. Bimatoprost 0.03 % Drops Sig: One (1) drop Ophthalmic once a day: OU. 13. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO ONCE (Once) for 1 doses: Goal INR [**3-14**]. 14. Insulin Regular Human 100 unit/mL Solution Sig: One (1) dose Injection four times a day as needed for per sliding scale: see attached sliding scale for dosing. [**Month/Day (3) **] Disposition: Extended Care Facility: [**Location (un) 86**] Center - [**Location (un) 2312**] [**Location (un) **] Diagnosis: s/p Motor vehicle crash C3,4 disc bulging w/ central canal narrowing Lip laceration Secondary disgnosis: Syncopal episode Critical Aortic Stenosis [**Location (un) **] Condition: Hemodynamically stable, tolerating a regular diet, pain adequately controlled. [**Location (un) **] Instructions: DO NOT drive until you are given medical clearance to do so from your cardiologist. Followup Instructions: Follow up with your primary cardiolost Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] within a week after dicharge from rehab. You will need to call for an appointment. Follow up with your primary care doctor [**First Name (Titles) **] [**Last Name (Titles) **] from rehab, you will need to call for an appointment. For any concerns related to your cervical spine disc bulge you may follow up with Dr. [**Last Name (STitle) 548**], Neurosurgery by calling [**Telephone/Fax (1) 2992**] if an appointment is needed. [**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD [**MD Number(2) 601**] Completed by:[**2152-11-21**]

[ "585.9", "424.1", "492.8", "V12.54", "V58.61", "861.21", "458.29", "427.31", "428.0", "V10.05", "365.9", "839.04", "427.89", "412", "E812.0", "780.2", "E855.6", "790.29", "971.3", "839.03", "873.43" ]

icd9cm

[ [ [] ] ]

[ "27.59" ]

icd9pcs

[ [ [] ] ]

2894, 5725

307, 346

1672, 2871

7753, 8431

765, 782

5751, 7317

797, 799

7349, 7498

244, 269

7530, 7610

7645, 7730

374, 597

813, 1153

1168, 1653

619, 749

50,721

152,382

20063

Discharge summary

report

Admission Date: [**2104-2-6**] Discharge Date: [**2104-2-10**] Date of Birth: [**2019-1-28**] Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 1145**] Chief Complaint: STEMI Major Surgical or Invasive Procedure: Cardiac Catheterization with placement of two drug-eluting stents History of Present Illness: Mrs. [**Known lastname 54011**] is an 85 year old female with a PMH significant for CAD s/p PCI with DES to LAD, PDA, and RCA in [**2097**] transferred from OSH with STEMI now s/p PCI with DES x2 to mid-LAD. The patient reports two weeks of intermitent "arm heaviness" that has also been occuring at rest with episodes lasting anywhere from a few minutes to several hours. She denies any associated chest pain, shortness of breath, palpitations, nausea, vomiting, or pain radiating to the arm, back, or jaw. She states that yesterday evening she was woken up with bilateral [**8-13**] arm pain, for which she presented to an OSH. At that time, she was noted have ST elevations in the anterior leads with with flat CK and CK-MB. She received lopressor, heparin gtt, and was transferred to [**Hospital1 18**] for further management. Of note, the patient reports that in [**2097**] prior to her cardiac catheterization, she had similar symptoms. . The patient underwent cardiac catheterization on arrival demonstrating late-instent thrombosis of her LAD s/p thrombectomy and DES x2 with proximal and distal overlap.. She received [**Last Name (LF) 54012**], [**First Name3 (LF) **] 325, and clopidogrel 600 prior during her procedure, and was then transferred to the CCU for further management. . Currently, the patient is resting comfortably without complaints. Denies any CP/SOB or other anginal equivalents. . ROS: As above, otherwise negative. Past Medical History: - CAD s/p PCI ([**2097**]): DES to PDA, LAD, mid-RCA x2 - HTN - Hyperlipidemia Social History: Lives with son, husband recently died. Tobacco - none. EtOH - none. Denies IV, illicit, or herbal drug use Family History: No early CAD. Physical Exam: ADMISSION PHYSICAL EXAM: VS: 96.4 90 132/73 18 99%RA Gen: Supine, elderly female in NAD HEENT: Perrl, eomi, sclerae anicteric. MMM, OP clear without lesions, exudate or erythema. Neck supple without LAD CV: Nl S1+S2, no m/r/g. Pulm: CTAB anteriorly Abd: S/NT/ND +bs Groin: right femoral venous sheath in place. Ext: Trace edema bilaterally, unchanged per patient. 2+ pt bilaterally. . DISCHARGE PHYSICAL EXAM: Afebrile, VSS Gen: elderly female in NAD, lying down in bed, smiling, appears comfortable HEENT: Perrl, eomi, sclerae anicteric. MMM, OP clear without lesions, exudate or erythema. Neck supple without LAD CV: RRR, Nl S1+S2, no m/r/g. Pulm: no use of accessory mm of breathing, faint crackles at bases bilaterally, no wheezes or rhonchi Abd: +BS, soft, non-tender, non-distended Groin: no hematoma, no femoral bruit Ext: Trace edema at ankles bilaterally, unchanged per patient. 2+ DP pulses bilaterally Pertinent Results: ADMISSION LABS: [**2104-2-6**] 07:30AM BLOOD WBC-7.7 RBC-3.62* Hgb-11.7* Hct-32.7* MCV-90 MCH-32.4* MCHC-35.9* RDW-13.3 Plt Ct-246 [**2104-2-6**] 09:40AM BLOOD PT-52.1* PTT-150* INR(PT)-5.7* [**2104-2-6**] 07:30AM BLOOD Glucose-166* UreaN-15 Creat-0.9 Na-142 K-4.0 Cl-109* HCO3-22 AnGap-15 . CARDIAC ENZYMES: [**2104-2-7**] 06:15AM BLOOD CK(CPK)-327* [**2104-2-6**] 08:09PM BLOOD CK(CPK)-634* [**2104-2-6**] 01:15PM BLOOD CK(CPK)-760* [**2104-2-6**] 07:30AM BLOOD CK(CPK)-52 [**2104-2-7**] 06:15AM BLOOD CK-MB-28* MB Indx-8.6* cTropnT-2.79* [**2104-2-6**] 08:09PM BLOOD CK-MB-77* MB Indx-12.1* cTropnT-4.16* [**2104-2-6**] 01:15PM BLOOD CK-MB-115* MB Indx-15.1* [**2104-2-6**] 07:30AM BLOOD CK-MB-6 cTropnT-0.02* . DISCHARGE LABS: [**2104-2-9**] 05:25AM BLOOD WBC-7.3 RBC-3.46* Hgb-11.0* Hct-31.1* MCV-90 MCH-31.8 MCHC-35.4* RDW-13.5 Plt Ct-211 [**2104-2-10**] 04:40AM BLOOD PT-29.9* PTT-108.1* INR(PT)-3.0* . CARDIAC CATHETERIZATION COMMENTS: 1. Coronary angiography in this right dominant system demonastrated triple vessel CAD. The LMCA had a 40% stenosis at the distal segment. The LAD was totally occluded with thrombus suggestive of very late stent thrombosis with right to left collaterals. The LCX had a 50% stenosis at its origin with a proximal hazy 50% lesion. THE RCA had a patent stent with a distal 50% stenosis. 2. Limited resting hemodyanamics revealed normotension. 3. Successful export thrombectomy of proximal LAD. 4. Successful PTCA and stenting of LAD (3.0x18mm Endeavor drug eluting stent proximal LAD; 2.5x18mm Endeavor drug eluting stent in mid LAD distal to prior cypher stent postdilated with 2.5 balloon). . FINAL DIAGNOSIS: 1. Three vessel coronary artery disease with anterior STEMI due to very late stent thrombosis. 2. Successful export thrombectomy of LAD. 3. Successful PCI of LAD with DESx2 . Echo [**2104-2-7**]: The left atrium is normal in size. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Overall left ventricular systolic function is severely depressed (LVEF= 25 %) secondary to severe hypokinesis/akinesis of the septum, anterior wall, and apex, with relative preservation of basal inferior, posterior, and lateral segments. No definite masses or thrombi are seen in the left ventricle. There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. There is a sinus of Valsalva aneurysm. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis. Mild to moderate ([**1-6**]+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. The left ventricular inflow pattern suggests impaired relaxation. Moderate [2+] tricuspid regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. Brief Hospital Course: HOSPITAL COURSE: Mrs. [**Known lastname 54011**] is an 85 year old female with a PMH significant for CAD s/p PCI with [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **], PDA, and RCA in [**2097**] transferred from OSH with STEMI now status post PCI with DES x2 to mid-LAD. . ACTIVE ISSUES: # ST-Elevation Myocardial Infarction: Patient with prior history of CAD status post PCI with DES x2 to mid-LAD presented with late-instent thrombosis of stent to LAD status post PCI with DES x2 placed overlapping proximal and distal to prior DES. CK peaked at 760, and MB 115. The patient was started on aspirin, plavix, atorvastatin and metoprolol. An ace-inhibitor was held peri-procedure given dye load. She was on [**First Name8 (NamePattern2) **] [**Last Name (un) **] prior to admission with no known contraindication to an ace-inhibitor. She was seen by a physical therapist who recommended outpatient cardiac rehab. An echo was performed post STEMI to assess for LV thrombus and apical akinesis. TTE demonstrated no thrombus, but an EF of 25%, and she was started on Coumadin with a heparin bridge. Her INR was therapeutic on discharge. She was started on Lisinopril 5mg daily, and metoprolol 25mg tid. She was discharged on Metoprolol succinate 100mg daily. She will follow-up with her cardiologist and PCP. . # Rhythm: Presented in sinus with 1:1 conduction. No events on telemetry. She was started on metoprolol as above. . # Depressed EF: She had an echo on [**2104-2-7**] as above that demonstrated a severely depressed EF of 25%, with severe hypokinesis/akinesis of the septum, anterior wall, and apex. Given these findings, the risks and benefits of anticoagulation were discussed. She understood the risks of bleeding, and Coumadin was started with heparin gtt bridge. She will follow-up with her PCP for anticoagulation and monitoring of PT/INR. . # HLD: She was started on Atorvastatin 80mg daily. . # HTN: She was started on metoprolol and Lisinopril 5mg daily as above. . TRANSITIONAL ISSUES - Medical Management: started on Lisinopril 5mg daily (instructed to discontinue Losartan), started on Coumadin, started on Metoprolol XL 100mg daily, Plavix 75mg daily and [**Date Range **] 325mg daily, Atorvastatin 80mg daily. - Follow-up: PCP and Cardiology. ***DC summary was faxed to PCP's office, to make PCP aware of starting anticoagulation and need for PT/INR checks. - Code Status: Full Medications on Admission: - Nadolol 50 mg daily - Losartan 50 mg daily - Potassium daily - [**Date Range **] 81 mg daily - "Statin" - Vitamin B12 - Vitamin D/Ca Discharge Medications: 1. warfarin 2 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM. Disp:*30 Tablet(s)* Refills:*2* 2. aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily): please take this medication daily, and one hour prior to other anti-inflammatory pain medications. You may buy this over the counter. Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 3. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 4. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 5. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 6. metoprolol succinate 100 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2* 7. Outpatient Lab Work Check INR on [**2-12**]. Fax results to Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1968**] at [**Telephone/Fax (1) 54013**]. 8. nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Sublingual q5mins as needed for chest pain. Disp:*30 tablets* Refills:*0* Discharge Disposition: Home With Service Facility: All Care VNA of Greater [**Location (un) **] Discharge Diagnosis: Primary Diagnoses: 1. Acute ST segment Elevation Myocardial Infarction Secondary Diagnoses: 1. Hypertension 2. Hyperlipidemia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mrs. [**Known lastname **], You were recently admitted to the [**Hospital1 18**] Cardiac Intensive Care Unit after having a heart attack, and undergoing a cardiac catheterization where they placed two stents into the blood vessels that supply blood to your heart. It is very important that you continue to take Aspirin and Plavix daily to keep these stents open. We also obtained a picture of your heart called an echocardiogram that showed it is not pumping strongly. For this reason we are starting you on a blood thinner called Coumadin, which you will need to take daily. It is important to have your INR monitored while you are on Coumadin to help with dosing. If you have any questions regarding your care please call your Cardiologist or Primary Care Physician. . We are making the following changes to your outpatient medication regimen: - STOP Nadolol 50mg daily - STOP Losartan 50mg daily - STOP the other "statin" medication you were on prior (we are starting you on a high dose statin medication as listed below called Atorvastatin) - The dose of your Aspirin has changed from 81mg daily to Aspirin 325 mg daily (if you need to take other pain medication, please make sure to take it one hour after your daily aspirin) -Please START Plavix 75 mg daily -Please START Warfarin (Coumadin) 2 mg daily -Please START Metoprolol XL 100mg by mouth daily -Please START Lisinopril 5 mg daily -Please START Atorvastatin 80 mg daily . It was a pleasure taking care of you during this hospitalization Followup Instructions: Please call your primary care physician [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1968**] at [**Telephone/Fax (1) 27093**] to book a 1 week follow up appointment for your hospitalization. . You will also need to start having your INR monitoring for Coumadin dosing at the [**Hospital3 **] [**Hospital **] (phone number [**Telephone/Fax (1) 54014**]). . With: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 5686**] Department: Cardiology Location:[**Street Address(2) 54015**] [**Location (un) 1468**], [**Numeric Identifier 5689**] Phone: [**Telephone/Fax (1) 11554**] Appointment: Thursday [**2104-2-21**] 1:30pm If you would also like to see a cardiologist at [**Hospital3 **] in ~2 months after seeing Dr. [**Last Name (STitle) 5686**], please call ([**Telephone/Fax (1) 54016**] to make an appointment with Dr. [**Last Name (STitle) **]. Completed by:[**2104-2-10**]

[ "996.72", "V70.7", "E849.9", "401.9", "V45.82", "272.4", "E878.1", "410.11", "414.01" ]

icd9cm

[ [ [] ] ]

[ "36.07", "00.40", "00.46", "00.66", "88.55" ]

icd9pcs

[ [ [] ] ]

9797, 9872

6003, 6003

309, 377

10042, 10042

3060, 3060

11724, 12670

2095, 2111

8600, 9774

9893, 9964

8440, 8577

6020, 6285

4718, 5980

10193, 11701

3791, 4701

2151, 2511

9985, 10021

3369, 3775

264, 271

6300, 8414

405, 1852

3076, 3352

10057, 10169

1874, 1955

1971, 2079

2536, 3041

29,967

192,763

7546

Discharge summary

report

Admission Date: [**2143-10-2**] Discharge Date: [**2143-10-9**] Date of Birth: [**2071-5-31**] Sex: F Service: SURGERY Allergies: Iodine; Iodine Containing / Gadolinium-Containing Agents Attending:[**First Name3 (LF) 2597**] Chief Complaint: Bilateral claudication and rest pain Major Surgical or Invasive Procedure: [**10-2**] OR: Aplasty prox anastomosis Left Ax-Fem; Jump Graft (6mm PTFE) from Ax-Fem to SFA History of Present Illness: 72 female with bilateral LE claudication and rest pain admitted for Angiogram. Past Medical History: PMH: rheumatoid arthritis, cad, mi, osteoarthritis, lung ca with rul resection s/p chem and xrt. gerd, HTN, PSH: 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, RCIA to bifemoral BPG with 6mm dacron PTFE [**2137**] / complicated by thrombus then had Left axillary to fem - fem BPG [**2137**], benign growth removal colon Social History: lives at home, uses wheel chair Family History: n/c Physical Exam: Vs: 98.2 HR:58 BP 120/60 RR:18 Spo2 97% RA Gen: NAD Neuro: Alert and oriented x3 CV: [**Last Name (un) **] Resp: CTA Abd: soft, NT, ND Pulses: Fem [**Doctor Last Name **] DP PT [**Name (NI) 2325**] palp palp dop dop Right palp palp dop dop Extremities without cyanosis. Resloving ecchymosis to left anterior thigh. Left groin incision intact with dermabond. Pertinent Results: [**2143-10-9**] 04:51AM BLOOD WBC-5.6 RBC-2.88* Hgb-8.5* Hct-26.1* MCV-91 MCH-29.7 MCHC-32.7 RDW-14.4 Plt Ct-252 [**2143-10-9**] 04:51AM BLOOD Plt Ct-252 [**2143-10-9**] 04:51AM BLOOD Glucose-101 UreaN-13 Creat-1.5* Na-139 K-3.8 Cl-104 HCO3-30 AnGap-9 [**2143-10-9**] 04:51AM BLOOD Calcium-8.4 Phos-2.7 Mg-2.3 [**2143-10-4**] 8:55 pm URINE Source: CVS. **FINAL REPORT [**2143-10-6**]** URINE CULTURE (Final [**2143-10-6**]): <10,000 organisms/ml. OPERATIVE REPORT [**Last Name (LF) 1111**],[**First Name3 (LF) 1112**] B. Signed Electronically by [**Last Name (LF) 1111**],[**First Name3 (LF) 1112**] B. on MON [**2143-10-7**] 6:38 PM Name: [**Known lastname 27574**], [**Known firstname **] Unit No: [**Numeric Identifier 27575**] Service: Date: [**2143-10-2**] Date of Birth: Sex: Surgeon: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], MD 2287 PREOPERATIVE DIAGNOSIS: Malfunction of left axillary- bifemoral graft. POSTOPERATIVE DIAGNOSIS: Malfunction of left axillary- bifemoral graft. PROCEDURE: Left axillary artery angioplasty with 6-mm balloon, arteriography, and jump graft from left axillary- femoral graft to superficial femoral artery with 6-mm, thin- walled, ringed PTFE graft. ASSISTANT: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 27576**], M.D. ANESTHESIA: General endotracheal. ESTIMATED BLOOD LOSS: 150 mL. COMPLICATIONS: None. INDICATIONS: This 72-year-old lady with severe peripheral vascular disease has previously had a left axillary-bifemoral graft. This has been revised a couple of times. She recently developed recurrent symptoms of claudication and early, mild ischemic rest pain in her left foot. Duplex ultrasound suggested a stenosis at the proximal anastomosis of the axillary graft to the axillary artery and also a focal high- grade stenosis in the superficial femoral artery just distal to the distal anastomosis on the left side. This was confirmed by arteriography through a left brachial approach a couple of weeks ago. She is now undergoing definitive treatment. DESCRIPTION OF PROCEDURE: Under adequate general endotracheal anesthesia, the left groin was prepped and draped in the usual sterile fashion. A lateral incision was made through the old incision, incising the deep fascia and reflecting the proximal sartorius muscle. The superficial femoral artery was then dissected free underneath the muscle and encircled with vessel loops proximally and distally. The artery had no pulse present within it at all but was very soft. A longitudinal incision was made just proximal to the groin incision, directly over the axillary femoral graft, at about the level of the iliac crest before it entered the groin. The graft was dissected free here and encircled with vessel loops proximally and distally. A number of rings were removed from the graft, and a subcutaneous tunnel was created across the inguinal ligament and down to the level of the femoral dissection done previously. The C-arm was then draped and rolled into place. The axillary-femoral graft was punctured with a Cook needle, a wire advanced into the graft under fluoroscopy, and a 7-French sheath placed. We then directed an angled glide wire into the axillary artery proximal to the proximal anastomosis and, over this, advanced a Omni Flush catheter, which was then connected to the power injector. Arteriography confirmed the presence of what appeared to be only about a 50%-60% stenosis of the anastomosis into the origin of the left axillary graft; however, the ultrasound had suggested a far more significant stenosis, and we had noted a weak pulse in the axillary- femoral graft when dissecting it free. We then did an exchange for a stiffer wire and advanced a 6 x 40 angioplasty balloon up, so that most was in the graft, with just a small amount crossing into the axillary artery. This balloon was then inflated to a high pressure of about 20 atmospheres. We then replaced the Omni Flush catheter and shot a completion arteriogram, which showed complete resolution of the waist previously seen in the graft. A catheter was then placed and connected to a pressure transducer and a pull-back pressure done, which showed about a 5-mm systolic pressure gradient across the anastomosis, with no change in diastolic blood pressures, and about a 2- to 3-mm drop in the mean arterial pressure. We thought that this was satisfactory. We then returned our attention to the groin. Proximal and distal control was obtained on the axillary-femoral graft. The sheath was removed and the sheath puncture extended proximally and distally into an arteriotomy. A 6-mm, thin- walled, ringed PTFE graft was taken and spatulated and an end- to-side anastomosis fashioned between the new graft and old graft with running continuous 6-0 [**Doctor Last Name 4726**]-Tex sutures from either end. When this anastomosis was completed, the suture holes were sealed with BioGlue. Flow was tested through the new conduit and found to be excellent. It was pulled through the tunnel at the proximity with the superficial femoral artery, where proximal-distal control was again obtained, and a longitudinal arteriotomy was made. Antegrade bleeding was extremely poor, but backbleeding was brisk. The distal end of the graft was trimmed and spatulated appropriately and a 2nd end-to-side anastomosis fashioned, again with 6-0 [**Doctor Last Name 4726**]-Tex sutures. Flow was reestablished without difficulty. The superficial femoral artery plumped up nicely and had a strongly triphasic Doppler signal noted within it. Hemostasis was then secured, the heparin was fully reversed with protamine, and the wounds were closed in layers with 3-0 Vicryl and 4-0 Monocryl subcuticular sutures. Dermabond skin dressing was applied over the wounds. The patient tolerated this procedure well and, upon awakening, being extubated, was taken to the recovery room in stable condition. All counts reported correct. Brief Hospital Course: [**2143-10-2**] Taken to the OR for Angioplasty of Left Proximal Anastomosis Ax-Bifem and Jump Graft Ax-Fem SFA with 6mm PTFE (see Op note)Tolerated procedure well. Transferred to VICU. Left DP, PT pulses dopperable. PCA for pain management. [**2143-10-3**] Vitals stable. Hct 22.3 OOB to chair. Foley, PCA. [**2143-10-4**] Vitals stable. Continue pain management. Foley and PCA DC'ed. Restarted on Coumadin. [**2143-10-5**] Tmax 102.6 Blood cultures drawn. UA negative. Started on empiric antibiotics [**2143-10-6**] Tmax 100.3 No acute events. Blood cultures pending. Cardiology consult for nausea and stomach "fullness" without CP or SOB. + ECG changes. Rec included continuation of ASA, statin, BBlocker. Serial CE negative. [**2143-10-7**] NO acute events. VSS. [**2143-10-8**] Additional episodes of nausea. Afebrile. Blood cx and portacath cultures show no growth. [**2143-10-9**] DC home with [**Location (un) 86**] [**Location (un) 269**] . No antibiotics. Follow-up with Dr. [**Last Name (STitle) **] in [**1-19**] weeks Follow-up with Dr. [**Last Name (STitle) 11679**] in Cardiology next week- patient is aware and plans to schedule appointment Follow-up with Dr. [**Last Name (STitle) **] outpatient. Will continue follow INR levels for goal [**1-19**]. A copy of this discharge summary will be sent to Dr. [**Last Name (STitle) **] Medications on Admission: doxepin 25'', tenormin 12.5', lipitor 40', asa 81', prilosec 20'', colace 100'', iron, B6, meclizine 12.5'(4pm), coumadin 4' (last dose 10/13), ativan 0.5' qhs, aldactazide 25 MWF, lasix 20 T Th Sat, lidoderm patch, fentanyl patch 25 and 50 q72hrs, oxycodone. . Discharge Medications: 1. Doxepin 25 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. Tenormin 25 mg Tablet Sig: One (1) one half Tablet PO once a day. 3. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 5. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO twice a day. 6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 7. Iron (Ferrous Sulfate) 325 (65) mg Tablet Sig: One (1) Tablet PO once a day. 8. Pyridoxine 25 mg Tablet Sig: One (1) Tablet PO once a day: take your usual dosage per PCP. 9. Meclizine 12.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Coumadin 4 mg Tablet Sig: One (1) Tablet PO once a day: INR goal is [**1-19**] / Have Dr. [**Last Name (STitle) **] your Oncologist to monitor your INR in the usual fashion. 11. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed. 12. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO QMOWEFR (Monday -Wednesday-Friday). 13. Furosemide 20 mg Tablet Sig: One (1) Tablet PO QTUTHSA (TU,TH,SA). 14. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical 11PM TO 11AM (). 15. Outpatient Lab Work Have your INR checked Friday [**2143-10-11**] and weekly and have the results sent to Dr. [**Last Name (STitle) **] ([**Telephone/Fax (1) 27577**] fax:[**Telephone/Fax (1) 27578**] 16. Coumadin dose 10/24 DO NOT TAKE COUMADIN TONIGHT [**10-9**], you will have your blood checked on Friday [**10-11**] Discharge Disposition: Home With Service Facility: [**Location (un) 86**] [**Location (un) 269**] Discharge Diagnosis: Graft stenosis Discharge Condition: Good Discharge Instructions: Division of Vascular and Endovascular Surgery Lower Extremity Angioplasty/Stent Discharge Instructions Medications: ?????? Take Aspirin 325mg (enteric coated) once daily ?????? If instructed, take Plavix (Clopidogrel) 75mg once daily ?????? 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 [**1-19**] 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 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 [**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: call Dr [**Last Name (STitle) **] office at [**Telephone/Fax (1) 3121**]. Schedule an appointment for 4 weeks. Follow-up with your Cardiologist Dr. [**Last Name (STitle) 11679**] in 1 Week Follow-up with Dr. [**Last Name (STitle) **] for your INR level weekly Completed by:[**2143-10-9**]

[ "V10.11", "V58.61", "780.6", "996.74", "414.01", "440.22", "530.81", "401.9", "998.89", "E878.2", "714.0" ]

icd9cm

[ [ [] ] ]

[ "88.44", "88.48", "39.29", "39.49" ]

icd9pcs

[ [ [] ] ]

10902, 10979

7627, 8983

353, 449

11038, 11045

1553, 7604

13656, 13948

1120, 1125

9296, 10879

11000, 11017

9009, 9273

11069, 13059

13085, 13633

1140, 1534

277, 315

477, 557

579, 1054

1070, 1104

852

113,216

45514

Discharge summary

report

Admission Date: [**2160-12-30**] Discharge Date: [**2161-1-1**] Date of Birth: [**2108-5-5**] Sex: M Service: MEDICINE Allergies: Phenergan / Zofran Attending:[**First Name3 (LF) 1711**] Chief Complaint: Torsades, ICD firing Major Surgical or Invasive Procedure: None History of Present Illness: Mr [**Known lastname 97106**] is a 52M with recent admission for Vtach [**2-5**] QT prolongation s/p ICD placement and h/o narcotics abuse who presented to [**Hospital1 18**] [**Location (un) 620**] for SOB concerning for COPD exacerbation as well as N/V and was found to have QT prolondation to 510. He was given steroids, abx, zofran. He was given mag sulfate 2g IV preemptively for long QT of 510, Mg 1.8 and plans were made for admission for COPD exacerbation. Shortly after Mag was hung, pt reports feeling short of breath and lightheaded and had a witnessed episode of torsades, with subsequent ICD firing. He was given lidocaine 100mg IV, 1mg drip which was increased to 2mg. He had 4 episodes total. Per [**Hospital1 **] cards, pacer rate was increased to 80 and he was transferred to [**Hospital1 18**] for further management. . On arrival to our ED, vitals were 97.9 80 146/111 17 100% ra. Labs were notable for phos of 1.8 and K of 3.3 without any other abnormalities. QTc was 460. He was given additional Mg, 40meq K in IVF, Ativan for anxiety and nausea. Lidocaine was continued. He had another episodes of torasdes and his ICD fired for the second time. On transfer to the CCU, VS: HR 92, 150/99, 20 98% 2L NC. . Currently, the patient denies any symptoms other than significant diffuse chest pressure which he experienced both after the first ICD firing and following the second ICD firing. He continues to experience the chest pressure/pain without change. He denies shortness of breath or lightheadedness, denies arm or jaw pain, n/v. . Of note, the patient does note he had been experiencing green loose stool x1-2 days, abdominal pain, and nausea/vomiting. He reports experiencing these same symptoms every other week since his gastric bypass, and denies any sick contacts, unusual food intake, fevers, or changes to his typical GI symptoms. . On review of systems, he denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, cough, hemoptysis, black stools or red stools. He denies recent fevers, chills or rigors. He denies exertional buttock or calf pain. All of the other review of systems were negative. . Cardiac review of systems is notable for absence of baseline dyspnea on exertion or exertional chest pain or pressure, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations. Past Medical History: 1. CARDIAC RISK FACTORS: +Dyslipidemia, +Hypertension 2. CARDIAC HISTORY: -CABG: none -PERCUTANEOUS CORONARY INTERVENTIONS: none -PACING/ICD: s/p pacemaker/ICD placed [**2160-11-7**] during prior episode of torsades [**2-5**] prolonged QT 3. OTHER PAST MEDICAL HISTORY: -Asthma vs COPD -Bronchitis -Morbid obesity -Gout -Obstructive Sleep Apnea -Depression/Anxiety -Narcotic dependence/abuse Social History: Quit tobacco [**2154**], 30 pack-year history. Wife reports patient is still currently smoking. Social EtOH Dependence on prescribed narcotics Family History: Father with CAD, s/p CABT in 40's; otherwise non-contributory. Physical Exam: VS: T=37.2 BP=145/107 -> 160/80 HR=97 R=15 PO2=100%RA GENERAL: Alert, interactive, in NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa, white plaque on tongue. No xanthalesma. NECK: Supple with JVP of ~11 cm. No carotid bruits. CARDIAC: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. EXTREMITIES: No c/c/e. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: Carotid 2+ DP 2+ PT 2+ Left: Carotid 2+ DP 2+ PT 2+ Pertinent Results: [**2161-1-1**] 06:10AM BLOOD WBC-12.2* RBC-5.01 Hgb-14.7 Hct-42.5 MCV-85 MCH-29.3 MCHC-34.6 RDW-15.7* Plt Ct-434 [**2160-12-31**] 09:38AM BLOOD WBC-14.8* RBC-4.74 Hgb-14.0 Hct-40.5 MCV-85 MCH-29.6 MCHC-34.6 RDW-15.9* Plt Ct-456* [**2160-12-31**] 06:08AM BLOOD WBC-13.0* RBC-4.47* Hgb-13.3* Hct-38.7* MCV-87 MCH-29.7 MCHC-34.3 RDW-15.9* Plt Ct-453* [**2160-12-30**] 11:47AM BLOOD WBC-10.4 RBC-5.38# Hgb-15.8# Hct-46.6# MCV-87 MCH-29.3 MCHC-33.9 RDW-15.9* Plt Ct-471* [**2160-12-30**] 11:47AM BLOOD Neuts-91.6* Lymphs-7.0* Monos-0.4* Eos-0.5 Baso-0.5 [**2161-1-1**] 06:10AM BLOOD PT-13.3 PTT-25.3 INR(PT)-1.1 [**2160-12-30**] 11:47AM BLOOD PT-12.9 PTT-23.2 INR(PT)-1.1 [**2161-1-1**] 06:10AM BLOOD Glucose-87 UreaN-2* Creat-0.5 Na-130* K-3.9 Cl-95* HCO3-24 AnGap-15 [**2160-12-31**] 09:38AM BLOOD Glucose-109* UreaN-3* Creat-0.5 Na-134 K-4.0 Cl-99 HCO3-26 AnGap-13 [**2160-12-31**] 06:08AM BLOOD Glucose-95 UreaN-3* Creat-0.5 Na-137 K-4.0 Cl-101 HCO3-26 AnGap-14 [**2160-12-30**] 10:30PM BLOOD Na-137 K-4.1 Cl-104 [**2160-12-30**] 11:47AM BLOOD Glucose-120* UreaN-2* Creat-0.7 Na-138 K-3.3 Cl-99 HCO3-25 AnGap-17 [**2161-1-1**] 06:10AM BLOOD CK(CPK)-49 [**2160-12-31**] 05:35PM BLOOD CK(CPK)-59 [**2161-1-1**] 06:10AM BLOOD CK-MB-2 cTropnT-<0.01 [**2160-12-31**] 05:35PM BLOOD CK-MB-2 cTropnT-<0.01 [**2161-1-1**] 06:10AM BLOOD Calcium-8.4 Phos-2.8 Mg-1.9 [**2160-12-30**] 11:47AM BLOOD Calcium-9.3 Phos-1.8*# Mg-2.1 [**2160-12-30**] 10:30PM BLOOD TSH-0.99 . [**2160-12-30**] ECG Atrial paced, ventricular sensed rhythm with atrial premature beats. Since the previous tracing the atrial pacing then was associated with a P wave and there is no longer ventricular pacing. Perhaps the pateint was in atrial fibrillation on the prior two tracings. Clinical correlation is suggested. . [**2160-12-31**] ECG Atrial paced, ventricular sensed rhythm with a single atrial premature beat. Since the previous tracing the Q-T interval is shorter. Otherwise, unchanged. Brief Hospital Course: 52 yo gentleman with history of ventricular arrhythmias in the setting of prolonged QT presents with torsades and ICD firing in the setting of medication prolonging QT. . # RHYTHM: Mr. [**Known lastname 97106**] presented in [**Month (only) **] in the setting of prolonged QT, believed to be secondary to Zofran and had an ICD placed during that time. He presented again dyspneic and developed torsades de [**Last Name (un) **] after receiving zofran. QT interval was 510 at outside hospital and 460 in [**Hospital1 18**] ED after receiving magnesium repletion prior to transfer. Episodes of torsades appear to be provoked by QT-prolonging medications, and threshold may also have been lowered by electrolyte abnormalities. He was additionally repleted with magnesium and potassium and was initially put on a lidocaine drip for continued anti-arrythmic effect overnight. Daily EKGs performed to monitor QT interval. He was discharged with close follow up and no changes were made to his medications. He was instructed to continue avoiding QT prolonging medications. . # CORONARIES: On recent catheterization prior to admission, no intervenable lesions however patient with several narrowed vessels as well as evidence of microvascular disease. No history of chest pain on admission and cardiac enzymes cycled and were unremarkable. He was continued on aspirin, statin , betablocker and ace inhibitor at home dose. . # Chronic CHF: History of mild systolic CHF post-torsades (last EF 45%). Euvolemic on admission without evidence of exacerbation. He was continued on home dose of betablocker and lisinopril and put on a low sodium diet. . # HTN: Mildly blood pressures on admission. He was continued on home regimen as outlined above. . # HLD: Continued Simvastatin. . # Thrush: White plaque on tongue consistent with flush. He was started on nystatin swish and swallow. . # Hx COPD/Asthma: No wheeze or evidence of active flare. Albuterol, flovent and ventolin were available. . # Depression/Anxiety: He was continued on celexa daily with ativan as needed. He was encouraged to follow-up with his primary care physician and former psychiatrist to address underlying anxiety. . # Chronic pain: Continued on tylenol and cyclobenzaprine for chronic pain in setting of past history of narcotics abuse. . Medications on Admission: Zocor 20mg daily Aspirin 81mg daily Lisinopril 5mg daily Lopressor 25mg [**Hospital1 **] Celexa 40mg daily Docusate 100mg [**Hospital1 **] Miralax 1 packet daily Ambien prn Discharge Medications: 1. Zocor 20 mg Tablet Sig: One (1) Tablet PO once a day. 2. aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day. 3. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. Celexa 40 mg Tablet Sig: One (1) Tablet PO once a day. 6. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO twice a day. 7. Miralax 17 gram Powder in Packet Sig: One (1) PO once a day. 8. zolpidem 5 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as needed for insomnia. Discharge Disposition: Home Discharge Diagnosis: Ventricular Tachycardia/Torsades de Pointes related to prolonged QT interval Acute Systolic Dysfunction Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: You were admitted to the hospital for management of an abnormal cardiac rhythm, ventricular tachycardia or torsades de pointes that caused your internal cardiac defibrillator (ICD)to fire. This abnormal rhythm was likely caused by a medication that you took for symptoms of nausea (zofran). You should avoid any medicines that make you more prone to ventricular tachycardia, please continue to avoid these medications, you have been given a list of these medications. No changes were made to your medications. Weigh yourself every morning, please call Dr. [**Last Name (STitle) **] if weight goes up more than 3 lbs. Followup Instructions: Name: [**Last Name (LF) 97107**],[**First Name8 (NamePattern2) 306**] [**Last Name (NamePattern1) **] Address: [**Location (un) **]., [**Apartment Address(1) 25389**], [**Location (un) **],[**Numeric Identifier 1700**] Phone: [**Telephone/Fax (1) 74684**] Appt: [**1-7**] at 3pm ***Please ask dr [**Last Name (STitle) **] to assist you in establishing with a psychiatrist during this office visit.**** Department: CARDIAC SERVICES When: [**Last Name (STitle) **] [**2161-1-16**] at 10:00 AM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5855**], NP [**Telephone/Fax (1) 285**] Building: [**Hospital6 29**] [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage

[ "305.90", "428.22", "414.00", "426.82", "V45.86", "427.1", "276.9", "787.01", "278.01", "274.9", "112.0", "272.4", "E933.0", "327.23", "428.0", "496", "401.9" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

9349, 9355

6247, 8562

299, 306

9504, 9504

4265, 6224

10330, 11051

3329, 3393

8785, 9326

9376, 9483

8588, 8762

9687, 10307

3408, 4246

2831, 2998

239, 261

334, 2735

9519, 9663

3029, 3152

2757, 2811

3168, 3313

42,185

178,088

50823

Discharge summary

report

Admission Date: [**2182-7-30**] Discharge Date: [**2182-8-5**] Date of Birth: [**2125-1-15**] Sex: F Service: MEDICINE Allergies: Compazine / Darvocet-N 100 / Sulfa (Sulfonamide Antibiotics) / Penicillins / Methadone / Levaquin Attending:[**First Name3 (LF) 15397**] Chief Complaint: Overdose Major Surgical or Invasive Procedure: None History of Present Illness: 57 yo female with history of substance abuse and chronic pain on narcotics found down on the floor. She reports vomiting into her toilet and changing the trash before she fell asleep on the floor in her bedroom. She denies any CP, SOB, palps, LH, or dizziness prior to falling asleep. Denies LOC or head strike. Per EMS, her nephew noticed that she was acting different last night, and then found her on the floor at 0830 this morning. When he called EMS at 1430, she was moaning with sluggish pupils, but responded to painful stimuli. At [**Hospital1 **], she was noted to be confused and combative. She was reportedly unable to follow commands. Initial rectal temp was 92.3. She was given 3L of IVF with 1600cc of UOP. Head and neck CT were unremarkable. Tox screen was positive for barbs, benzos, opiates, TCA, and cannibanoids. CK 1300, trop flat. Prior to transfer, nursing notes report that she was awake, yelling out of her room, and demanding to change her head position. In the ED here at [**Hospital1 18**], initial VS were afeb, 77, 146/73, [**1-4**], 99% on RA. She is reportedly confused and intermittently drowsy with no memory of events except being at [**Location (un) 620**]. On arrival to the MICU, she is awake and alert complaining of back pain, bilateral knee pain, and bilateral leg and requesting pain medication. Past Medical History: Spinal stenosis L4/L5 Disc herniation Chronic pain - seen at [**Doctor Last Name 1193**] pain, lumbar spine injections at [**Hospital1 336**] GERD Migraines Hyperlipidemia H/o Bells palsy Hysterectomy Cholecystectomy Social History: The patient occasionally drinks alcohol, has smoked for the past 40 years, is single and does not have children. The patient is unemployed. Formerly worked for a transportation company and in advertising. Stopped working and driving [**2-21**] back pain. Currently on SSI since [**2161**]. Family History: No history of stroke, hemorrhage or aneurysm. Father-CAD and DM. Brother-DM. Mother-Parkinsons. Physical Exam: Admission: Vitals: afeb 86 141/100 14 99% on RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: supple, JVP not elevated, no LAD CV: RRR, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi Abdomen: +BS, soft, non-tender, non-distended, no organomegaly Back: no CVA tenderness, tenderness over lumbar spine GU: +foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CNII-XII intact, 5/5 strength upper/lower extremities, grossly normal sensation Discharge: Vitals: 98.7 130/76 p77 R18 98%RA General: Awake, oriented, no acute distress, lying comfortably in bed HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: supple, JVP not elevated, no LAD CV: RRR, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes Abdomen: +BS, soft, non-tender, non-distended, Back: no CVA tenderness, tenderness over lumbar spine and lower back Ext: warm, well perfused, no clubbing, cyanosis or edema Neuro: Alert and fully oriented. Speech clear, appropriate CNII-XII intact, 5/5 strength upper/lower extremities, grossly normal sensation Pertinent Results: Admission: [**2182-7-30**] 10:35PM BLOOD WBC-6.5 RBC-3.45* Hgb-11.4* Hct-33.2* MCV-96 MCH-32.9* MCHC-34.3 RDW-12.9 Plt Ct-235 [**2182-7-30**] 10:35PM BLOOD Neuts-68.8 Lymphs-25.5 Monos-3.2 Eos-1.6 Baso-0.8 [**2182-7-30**] 10:35PM BLOOD PT-10.4 PTT-28.5 INR(PT)-1.0 [**2182-7-30**] 10:35PM BLOOD Glucose-79 UreaN-11 Creat-0.5 Na-147* K-3.4 Cl-109* HCO3-28 AnGap-13 [**2182-7-31**] 02:06AM BLOOD CK(CPK)-2605* [**2182-7-31**] 05:40PM BLOOD CK(CPK)-2243* [**2182-8-1**] 05:55AM BLOOD CK(CPK)-1654* [**2182-7-31**] 02:06AM BLOOD CK-MB-38* MB Indx-1.5 cTropnT-<0.01 [**2182-7-30**] 10:35PM BLOOD Calcium-8.8 Phos-2.5* Mg-1.8 [**2182-7-30**] 10:35PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2182-7-30**] 10:43PM BLOOD Lactate-1.1 [**2182-7-30**] 10:35PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.009 [**2182-7-30**] 10:35PM URINE Blood-MOD Nitrite-NEG Protein-TR Glucose-NEG Ketone-10 Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-TR [**2182-7-30**] 10:35PM URINE RBC-3* WBC-2 Bacteri-NONE Yeast-NONE Epi-<1 [**2182-7-30**] 10:35PM URINE UCG-NEGATIVE [**2182-7-30**] 10:35PM URINE bnzodzp-POS barbitr-POS opiates-POS cocaine-NEG amphetm-NEG mthdone-NEG [**2182-8-5**] 06:00AM BLOOD UreaN-10 Creat-0.7 Na-142 K-3.8 Cl-104 HCO3-31 AnGap-11 [**2182-8-5**] 06:00AM BLOOD CK(CPK)-436* URINE CULTURE (Final [**2182-8-1**]): NO GROWTH. Blood Culture, Routine (Final [**2182-8-5**]): NO GROWTH Sinus rhythm. Same [**Location (un) 1131**] as tracing #2 with no interval change Brief Hospital Course: 57 yo female with history of substance abuse and chronic pain on narcotics found down with a tox screen positive for benzos, barbs, opiates. Taken to [**Location (un) 620**] and transfered to ICU at [**Hospital1 18**] because she was unable to follow commands, confused and combative, cardiac enzymes flat. On arrival to ED, drowsy with no memory of events, in the MICU more alert and requesting pain medication. Eventually transferred to floor stable for further monitoring of mental status and social work/psych eval. # Overdose: Tox screen with multiple substances not prescribed to her. Tylenol and aspirin were negative, serum tox screen negative for all substances, unclear if positive barbituates in urine is cross-reaction or if patient has access to barbituates and not disclosing this to team. She has a history of substance abuse in the past. She denied taking any additional medications than those prescribed to her initially, but later admitted that she took about two extra doses because she felt her pain was excruciating and she thought she hadn't taken her medication yet because the pain was so bad. Social work and psychiatry saw patient and spoke with nephew [**Name (NI) **]. [**Name2 (NI) **] nephew reports that she is found passed out 3-4 times per week, but feels he cannot intervene because she is his landlord. Psychiatry saw patient and offered inpatient detox, which patient refused. She is depressed but not found to be a threat to herself or others, and psych recommended close follow up with outpatient providers for monitoring. Per social work, patient would like help at home with homemaking but is not concerned for her safety. Patient counseled at length by primary team and social work about the importance of taking medications as directed, dangers of taking opiates, and other options for treatment. Patient verbalized understanding. Team and social work also expressed concern for patient's safety at home, patient states she is fine, denies there is a safety problem or an addiction problem and wants to go home. Communicated with primary care provider [**Last Name (NamePattern4) **]. [**Last Name (STitle) 13075**] the events of hospitalization and arranged follow up with her, psychiatrist, and pain clinic. To prevent overdoses in the future the patient is going to keep a log when she takes her medications. # Elevated CK: No evidence of [**Last Name (un) **], but reported muscle weakness initially. Differential included rhabdo secondary to fall v. statin effect. Statin and naproxen held while giving fluids and trending CK, on day of discharge CK 436, much improved from >2600 on arrival. Restarting naproxen and statin at discharge. # Hypernatremia: Likely related to poor PO intake plus administration of 3L of IVF as evidenced by elevated chloride. Free water deficit of 1.18L. She was given 1/2NS and Na normalized on hospital day 1. No further issues during the hospitalization. Inactive issues: # HTN: continued atenolol. # Normocytic Anemia: Hct 33 at admission, near recent baseline in OMR. Needs outpt anemia workup. # Migraines: continued amitripyline. # Chronic pain: continued home pain medications including oxycontin, baclofen, diazepam, promethazine, wellbutrin, gabapentin # Communication: [**Name (NI) 1022**] niece [**Telephone/Fax (1) 105696**], friend [**Name (NI) 53228**] [**Telephone/Fax (1) 105697**] Transitional Issues: -follow up CK, BUN/Cr to confirm resolution after restarting naproxen and statin with PCP [**Name9 (PRE) **] up with PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 13075**] [**Name (STitle) **] up with therapist, psychiatrist Dr. [**First Name (STitle) 20246**] [**Name (STitle) **] up with pain clinic Dr. [**Last Name (STitle) 62095**] Medications on Admission: 1. Baclofen 20 mg PO TID 2. Lortab *NF* (HYDROcodone-acetaminophen) 10-500 mg Oral qid: prn pain 3. Oxycodone SR (OxyconTIN) 60 mg PO Q12H 9am, 6pm 4. Oxycodone SR (OxyconTIN) 40 mg PO HS 5. Promethazine 25 mg PO Q6H:PRN with pain meds 6. Diazepam 10 mg PO Q12H:PRN anxiety 7. BuPROPion 150 mg PO BID 8. Amitriptyline 50 mg PO HS 9. Atenolol 75 mg PO DAILY 10. Naproxen 500 mg PO Q8H:PRN pain 11. Fluticasone Propionate NASAL 2 SPRY NU DAILY 12. Atorvastatin 80 mg PO DAILY 13. Klor-Con M20 *NF* (potassium chloride) 20 mEq Oral daily 14. Gabapentin 300 mg PO TID Discharge Medications: 1. Amitriptyline 50 mg PO HS 2. Atenolol 75 mg PO DAILY 3. Baclofen 20 mg PO TID 4. BuPROPion 150 mg PO BID 5. Fluticasone Propionate NASAL 2 SPRY NU DAILY 6. Gabapentin 300 mg PO TID 7. Oxycodone SR (OxyconTIN) 60 mg PO Q12H 9am, 6pm 8. Oxycodone SR (OxyconTIN) 40 mg PO HS 9. Promethazine 25 mg PO Q6H:PRN with pain meds 10. HydrOXYzine 25-50 mg PO Q6H:PRN anxiety RX *hydroxyzine HCl 25 mg 1-2 tablets by mouth every 6 hours Disp #*30 Tablet Refills:*0 11. Atorvastatin 80 mg PO DAILY 12. Klor-Con M20 *NF* (potassium chloride) 20 mEq Oral daily 13. Lortab *NF* (HYDROcodone-acetaminophen) 10-500 mg Oral qid: prn pain 14. Naproxen 500 mg PO Q8H:PRN pain 15. Docusate Sodium 100 mg PO BID RX *Colace 100 mg 1 capsule(s) by mouth twice a day Disp #*30 Capsule Refills:*0 16. Senna 1 TAB PO BID:PRN Constipation RX *senna 8.6 mg 1 tablet by mouth twice a day Disp #*30 Tablet Refills:*0 Discharge Disposition: Home With Service Facility: [**Hospital **] Health Systems Discharge Diagnosis: Altered mental status secondary to drug overdose Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. [**Known lastname 105698**], You were admitted to the hospital because you took too much of your pain medication and became altered and were not responding appropriately. In the ICU, your mental status improved with time and you became more alert, and you were found to have a high level of muscle breakdown products, which happens when you fall and are unconscious or sleepy for long periods of time. There was concern that you were taking too much pain medication at home, and we discussed this with you. It is very important that you take you medications exactly as prescribed and no more to make sure that this does not happen again. You were evaluated by psychiatry because you mentioned you were feeling depressed and they recommended close follow up with your outpatient psychiatrist and therapist, primary care provider and your pain clinic. They also recommended that you consider joining a pain support group since it is very difficult to deal with pain on your own. Pleas make sure you follow up with your outpatient providers, it is very important for your health. Please take your medications exactly as prescribed. We made the following changes to your medications: Please STOP taking valium Please STOP taking ambien Please START taking hydroxyzine 25-50mg every 6 hours by motuh for anxiety instead of valium Please START taking senna 1 tab twice a day as needed for constipation Please START taking colace 100mg twice a day as needed for constipation Followup Instructions: Please make sure to follow up with all of your doctors [**First Name (Titles) **] [**Name5 (PTitle) 105699**]. Completed by:[**2182-8-6**]

[ "304.70", "E980.0", "790.5", "E980.1", "401.9", "304.30", "E852.8", "305.1", "E849.0", "338.29", "965.00", "272.4", "967.0", "780.97", "276.0", "722.10", "969.6", "285.9", "969.4", "E980.3" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

10499, 10560

5212, 8152

367, 373

10653, 10653

3675, 5189

12311, 12452

2317, 2415

9586, 10476

10581, 10632

8997, 9563

10804, 11968

2430, 3656

8620, 8971

11997, 12288

319, 329

401, 1752

8170, 8599

10668, 10780

1774, 1993

2009, 2301

20,778

144,159

45687

Discharge summary

report

Admission Date: [**2180-12-16**] Discharge Date: [**2180-12-25**] Date of Birth: [**2105-9-2**] Sex: F Service: MEDICINE Allergies: Penicillins Attending:[**First Name3 (LF) 898**] Chief Complaint: Delirium, hypoxia Major Surgical or Invasive Procedure: None History of Present Illness: Ms. [**Known lastname 97368**] is a 75 yo female with COPD on 2L of home oxygen, with recently diagnosed PE on coumadin (INR 1.9 today), who presents to the ER from [**Hospital1 **] with acute respiratory failure as well as confusion, agitation and tremors. Her respiratory status had acutely declined. An ABG on the morning of admission on 3L O2 was 7.42/51/24 (O2 sat was 42% at that time). The pt was placed on 35% O2 by venti mask and her ABG improved to 7.45/43/74 with O2 sats of 95%. Her son states she has been confused for 4 days, confirmed by [**Hospital1 **]. She had been given ativan on day PTA for agitation (<2mg) and [**Hospital1 **] was concerned that her MS changes could be due to medication. Of note, haldol and morphine had been discontinued 2 days PTA. . She was admitted to [**Hospital1 18**] from [**Date range (2) 97369**] for left ankle fracture (medial malleolus, tibia and fibula) after a fall at home and underwent an ORIF on [**2180-12-8**]. During her hospital stay, she was intermittently delirious for a few days and her delirium at that time had been attributed to morphine use and possible ETOH withdrawal. She was also more hypoxic during that hospitalization, from a baseline of high 80s on room air to 70s on room air. She was also tachycardic at that time, so a CTA had been done and demonstrated multiple subsegmental pumonary emboli. She was treated with heparin and then d/c'd to rehab ([**Hospital1 **]) on [**2180-12-11**] on lovenox and coumadin. . Additionally, during her previous hospitalization, she was treated for a COPD flare with IV -> PO steroids, along with her baseline inhalers. Her HTN was harder to control, requiring increasing her lisinopril and adding metoprolol. She also required 2units of pRBC for a drop in Hct (is anemic at baseline). The new medications she was started on included metoprolol, haldol, protonix, warfarin, tramadol, thiamine and folate. She was not taking folic acid and thiamine at rehab. . In ED, she was placed on a nonrebreather. An ABG was 7.45/45/426. She had an abnormal UA and was started on levofloxacin for a UTI. She was also transfused 2 units of pRBC for an HCT of 22.5 (Hct on d/c [**2180-12-11**] was 30). She was admitted to the ICU for closer monitoring. Past Medical History: # COPD - on 2L home O2 (pulmonologist Dr. [**Last Name (STitle) 23427**] at [**Hospital1 112**]) # PE - mutliple subsegmental PEs dx [**12-8**], therapeutic on coumadin # HTN - started ACE-i [**3-7**], started BB [**12-8**] # Anxiety - on imipramine # Fibrocystic breast dz # Polycystic ovarian syndrome # h/o syncope 3 years ago (negative w/u) # Left knee cyst # Osteoporosis # Complete gastric outlet obstruction in [**6-6**] # Babinski and clonus on RLE during [**12-8**] hospitalization # Anemia - chronic, has been on Fe, B12 for years # UTIs # Declining cognitive function over past year Social History: Widow. Lived alone until last admission, now has been at Rehab. Using bivalve cast at rehab. 120 pack year smoking history (quit [**2145**]). Extensive etoh use. Family History: Mother c anxiety d/o, fa was alcoholic. Sister and 2 children all in psychiatric tx (details unknown). Physical Exam: PE: wt 65.3kg, 98.4, 81, 163/86, 27, 97%on 10l 50% cool neb White elderly female in mild respiratory distress. Perrl. Neck supple. Flat JVP. Distant heart sounds Poor air flow, expiratory wheezes Soft, nt, nd Left lower extremity with ecchymoses and edema compared to right. Air cast in place. Awake, oriented to person only, confused. Asking to go home. Trying to get out of bed. guaiac negative in ED Foley in place from rehab. Pertinent Results: Labs on admission: WBC 17.8, Hgb 7.6, Hct 22.5, Plt 547 (diff: 95% PMNs, 2.6% L, 1.7% M) PT 16.4, PTT 35.6, INR 1.9 Na 138, K 5.2, Cl 101, HCO3 29, BUN 19, Cr 0.8, Glu 108 ALT 23, AST 23, AP 73, amylase 51, TB 0.5, CPK 280, MB 4, TropT <0.01 albumin 3.3, Ca 8.4, phos 4.5, mg 2.1 abg: 7.45/45/426, lactate 0.8 U/A: 1.015, trace leuk, large blood, >50 RBCs, [**10-22**] WBC, few bacteria, 0-2 epi Fe 52, hapto <20, ferritin 333, TRF 192, TIBC 250 B12 275, folate >20 . Pertinent labs during her hospitalization: Cardiac enzymes negative x3 on [**2180-12-23**] Retic 2.6 TSH 2.8 . Micro: [**2180-12-16**]: URINE CULTURE (Final [**2180-12-18**]): KLEBSIELLA PNEUMONIAE. >100,000 ORGANISMS/ML.. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ KLEBSIELLA PNEUMONIAE | AMPICILLIN/SULBACTAM-- 4 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CEFUROXIME------------ 4 S GENTAMICIN------------ <=1 S IMIPENEM-------------- <=1 S LEVOFLOXACIN----------<=0.25 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- 64 I PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S . [**2180-12-16**]: blood cx x2 negative . [**2180-12-17**]: URINE CULTURE (Final [**2180-12-18**]): GRAM POSITIVE BACTERIA. ~3000/ML. SUGGESTING STAPHYLOCOCCI. GRAM POSITIVE BACTERIA. ~1000/ML. SECOND MORPHOLOGY SUGGESTING STAPHYLOCOCCI. . [**2180-12-17**]: blood cx x2 negative [**2180-12-23**]: urine cx <10,000 orgs/ml [**2180-12-24**]: stool cx neg for Cdiff [**2180-12-24**]: urine cx negative [**2180-12-24**]: blood cx x2 negative . Imaging: [**2180-12-16**] CXR - The heart is enlarged, but there is no definite pulmonary edema. There are emphysematous changes of the lungs. Small calcified granuloma is again demonstrated in the right upper lobe. Allowing for limitations of this study, there are no gross areas of consolidations or there is evidence for presence of pneumonia. . [**2180-12-16**] CTA - 1. The previously noted tiny nonocclusive possible pulmonary emboli within the subsegmental branches of the left lung are not as well visualized. There has been no interval extension of these, or new occlusive pulmonary emboli. 2. Tiny nodules noted within the right upper and lower lobes which are again seen. In the absence of a known primary malignancy, followup evaluation should be obtained in six months' time. . [**2180-12-16**] CT abd/pelvis - 1. No retroperitoneal hemorrhage is seen. 2. Hypodensities within the kidneys are seen, which likely represent cysts, and are better characterized on the prior exam. 3. There is an 8-mm nodule within the right lower lobe. In the absence of a known malignancy, followup evaluation should be obtained in six months' time to evaluate for interval change. . [**2180-12-16**] CT head - There is no intracranial hemorrhage or mass effect. Ventricles are symmetric, and there is no shift of normally midline structures. The [**Doctor Last Name 352**]-white matter differentiation is preserved. There is decreased attenuation in the periventricular white matter, consistent with chronic small vessel ischemic infarct. Soft tissue and osseous structures are stable in appearance. . [**2180-12-21**] L ankle XR - Status post ORIF of bimalleolar fracture with some callus healing. . [**2180-12-21**] LLE U/S - No evidence of left lower extremity deep vein thrombosis. . [**2180-12-22**] CXR - Unchanged mild cardiomegaly. A small calcified granuloma is again seen in the right upper lobe. There is no pneumothorax. There is no evidence of pleural effusion. There are no areas of consolidations. Ther is no evidence of pneumonia. . [**2180-12-24**] CXR - The cardiac silhouette and mediastinum is unchanged. There of calcifications of the thoracic aorta. A calcified granuloma is seen within the right mid lung zone. There is no evidence for focal infiltrates. Calcifications are seen at the right base as well. There is no signs of pulmonary edema. No interval change since the previous study. No definite evidence for acute cardiopulmonary process. Brief Hospital Course: 75yo F w/ COPD, recent DVTs/PEs now on anticoagulation, and recent L ORIF for ankle fx, comes in with delirium and hypoxic respiratory distress likely due to a UTI and COPD exacerbation/anemia respectively. . # COPD - On admission, Ms. [**Known lastname 97368**] was started on IV steroids for hypoxia/COPD flare. Once her respiratory status appeared stable, she was switched to PO prednisone and placed on a two week taper to be completed as an outpatient. She was continued on her nebulizers (albuterol and ipratroprium RTC). She was given combivent inhalers to be used prn for SOB with exertion as well as her flovent inhaler [**Hospital1 **]. When she became acutely agitated, or with any type of activity, she frequently dropped her O2 sats to the low 80s/high 70s. She was continued on oxygen via nasal canula with a stable O2 requirement at rest. . # ANEMIA - Ms. [**Known lastname 97368**] had a chronic anemia, for which she has been on iron and B12 in the past. On admission, however, her Hct was 22.5, which was down from her discharge Hct of 30 a week prior. Labs on admission were suspicious for hemolysis (low haptoglobin and high LDH), but a full workup could not be done because the patient was given a transfusion in the ER. Her coumadin was held on admission and she was put on a heparin gtt (for nonocclusive bilateral PEs found during her last admission). Her stools were guaiac negative and she had no overt signs of bleeding. She was noted to have a large ecchymosis on the posterior aspect of her L leg, likely from her anticoagulation and compression from her cast. An U/S of her LLE was negative for hematoma. After receiving 2u pRBC, her Hct bumped to 30.9, but then trended back down to 24.2. She was given an additional 1u pRBC and orthopedics was consulted to see if it was possible that she was losing blood into her leg. Orthopedics did not feel that she had an active bleed into her leg. Heme-Onc was consulted to see if she could be hemolyzing after her transfusions, but the patient refused to speak to the attending hematologist. It was felt that hemolysis was unlikely based on her labwork, but that she should have a GI workup to r/o an occult malignancy (which she adamantly refused). Per heme's recommendations, she was started on B12 injections and PO tablets. She was transfused up to a Hct of 31 during the final 24 hours before she coded. . # DELIRIUM/AGITATION - Her delirium on admission was likely multifactorial, with UTI, medication changes, and hypoxia being the main components. We treated her UTI with levofloxacin originally, then switched to Bactrim once sensitivities were known. Her hypoxia improved with treatment of her COPD. We attempted to control her pain with non-narcotic medications like tylenol and tramadol, but she did require some prn doses of oxycodone for L foot and hip pain. She was given oxycodone and ativan for L thigh pain, and that made her intermittently delirious. The team then decided not to give any narcotics to her as she seemed very sensitive to them. She was given IV haldol when she was agitated. However, she continued to remain agitated and began to have episodes where she would become acutely tachypneic and breathe very shallowly through her mouth, hyperventilating. Her sat's would drop to the mid 70's. Talking with the patient to help her relax and reassuring her seemed to work best during these episodes, and her O2 sats would improve back to the mid 90's with no other intervention. Psych was consulted and suggested that she not receive any benzodiazepines but to place her on standing Haldol four times daily. Her response to haldol was mixed. Her mental status continued to fluctuate between alertness, somnolence, and agitation, but overall it was felt that she was more alert and awake with fewer episodes of acute agitation while taking haldol. Her ECGs did not show any QTc prolongation with the haldol. . # UTI - Her urine culture from admission grew Klebsiella, which was virtually pansensitive. She was started on levaquin originally, then was switched to Bactrim once sensitivities were known. She was later switched back to Levaquin and then to clindamycin as the orthopedics team wanted to insure coverage of any possible skin flora that might be involving her L ankle incision. . # HTN - Her antihypertensives were held on admission due to her mental status changes and concern for infection. Once her mental status cleared, she was restarted on lisinopril. She was not restarted on a beta-blocker as it was felt that it could be worsening her COPD symptoms. . # PULMONARY EMBOLI - CT scan during her last admission found multiple bilateral nonocclusive PEs, which were still visualized on repeat imaging during this hospitalization. On admission, her coumadin was held ([**1-4**] her Hct of 22.5) and she was put on a heparin gtt for anticoagulation. She was restarted on coumadin 5mg PO QHS with a lovenox bridge until her INR was therapeutic (goal [**1-5**]). . # h/o ETOH USE: Ms. [**Known lastname 97368**] had a h/o of heavy EtOH use, but since she came from rehab, it was not felt necessary to place her on a CIWA scale for withdrawal. She was given thiamine, folate and MVI daily. . # L BIMALLEOLAR FRACTURE: Orthopedics were consulted as Ms. [**Known lastname 97368**] had extensive ecchymosis and swelling in her LLE. They removed her cast and gave her a bigger bivalve cast to accomodate her swelling. U/S was performed and was negative for DVT and for gross hematoma formation. An XR was also performed and showed early signs of healing. She was advised to remain non-weight bearing on that foot. PT was made aware of that recommendation. They also recommended changing her antibiotic to clindamycin, in case of a mild infection at the incision site of her L ankle fracture. . # PPX: She was given a PPI for ? GI bleed. She was on an insulin sliding scale while in the ICU for tight glycemic control, but it was discontinued once she was transferred out to the floor. She was given an aggressive bowel regimen to prevent constipation. For anticoagulation, she was originally started on a heparin gtt and was then switched to lovenox as a bridge to therapeutic INR (goal [**1-5**]) on coumadin. She was also put on fall precautions given her recent ankle fracture and cast. . # FEN: She was given a regular, cardiac, heart healthy diet. No IVF were needed. Her electrolytes were checked daily and repleted prn. . # CODE - At 0348 on [**2180-12-25**], Ms. [**Known lastname 97368**] was found to be in respiratory arrest. The nurse described her as cyanotic and pulseless. A code blue was called and CPR was initiated. She was intubated by anesthesia who found a large amount of emesis in her pharynx and trachea. She was given atropine and epinephrine x2 without any effect. Central access was obtained through femoral vein. Another two rounds of epinephrine and atropine were given with establishment of a wide complex rhythm. Bicarbonate (1 amp) x2 given x2, along with IVF (NS) wide open. At that time, breath sounds were felt to be decreased on the left side. Intubation had been confirmed by direct visualization. Needle thoracentesis decompression was attempted x2 without success. At 4:12am, after being unable to establish a pulse or a viable rhtyhm, the code was called. Immediate cause of death was cardiopulmonary arrest, felt to be due to hypoxia. Ms. [**Known lastname 97370**] family was contact[**Name (NI) **] and declined an autopsy. Medications on Admission: 1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H as needed. 2. Albuterol Sulfate 0.083 % Solution Sig: One (1) newb Inhalation Q2H as needed for shortness of breath or wheezing. 3. Albuterol Sulfate 0.083 % Solution Sig: One (1) neb Inhalation Q6H 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID 5. Enoxaparin 60 mg/0.6mL Syringe Sig: Sixty (60) mg Subcutaneous Q12H: continue until patient has been therapeutic on coumadin (INR [**1-5**]) for 48 hours. 6. Fluticasone-Salmeterol 100-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] 7. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY 8. Haloperidol 1 mg Tablet Sig: 1-2 mg PO TID (3 times a day) as needed for severe agitation or confusion. 9. Imipramine HCl 25 mg Tablet Sig: Four (4) Tablet PO BID 10. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb Inhalation Q6H 11. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY 12. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID 13. Morphine 15 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain: Please hold if sedated. 14. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H 15. Prednisone 20 mg day 6 of taper 16. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY 17. Warfarin 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 18. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed. Discharge Medications: Not applicable Discharge Disposition: Extended Care Facility: [**Hospital3 7**] & Rehab Center - [**Hospital1 8**] Discharge Diagnosis: Cardiopulmonary arrest Discharge Condition: Expired Discharge Instructions: Not applicable Followup Instructions: Not applicable

[ "V54.16", "427.5", "401.9", "V58.65", "293.0", "V58.61", "507.0", "280.9", "491.21", "300.00", "415.19", "599.0", "518.82" ]

icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

17164, 17243

8128, 15603

290, 297

17309, 17318

3981, 3986

17381, 17398

3408, 3512

17125, 17141

17264, 17288

15629, 17102

17342, 17358

3527, 3962

233, 252

325, 2591

4000, 8105

2613, 3209

3225, 3392

31,369

170,740

31687

Discharge summary

report

Admission Date: [**2176-8-25**] Discharge Date: [**2176-9-7**] Date of Birth: [**2103-1-9**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1973**] Chief Complaint: Hematemesis, melena, syncope Major Surgical or Invasive Procedure: endoscopy, colonoscopy, capsule endoscopy, paracentesis, omentum core biopsy. History of Present Illness: 73M h/o CAD s/p PTCA [**2-14**] (on plavix), UGIB/LGIB (s/p EGD, colonoscopy, SB enteroscopy), who presents after an episode of melena and hemetemesis. . Pt awoke on morning of admission and noted dark tarry stool. While returning to bed, he had a syncopal episode (unwitnessed). After regaining consciousness, he had n/v x 1 of dark red blood. Of note, pt notes increasing abdominal girth x 1wk, and increasing abdominal discomfort and pain x 2d. . He was taken to OSH where VS=98.3 75 100+60 18, HCT=25 (had been 32 previously per pt), cre=1.8, K=5.8. He was started on PPI, CT HEAD (occipatal scalp hematoma) and SPINE (no fx, djd), were unremarkable per wet [**Location (un) 1131**]. CT ABD/PELV showed ascites with mesenteric cake and nodules, large heterogeneity in posterior right liver, enlarged left common femoral vein ?thrombosis. pt given 1U PRBC prior to transfered to [**Hospital1 18**]. . Pt presented to the ED with VS: 97.4 72 102/45 18 99%RA. No hypotension while in ED. He received 1L NS. IV PPI, and foley placed. LENIs obtained as pt had ?DVT at OSH. . In the ED, NGL was negative. 2 PIV were placed, initial HCT was 27 (obtained while 1st unit PRBC still running in). GI consult was obtained given ?GIB. 2 PIV in place. CT ABD/PELVIS showed ?liver mass/omental cake/laceration. A general surgery consult was obtained given ?liver laceration. . ROS +40lb wt loss unintentional over past 6 months, poor po intake x 1 month. denies f/c/ns/cp/sob/hematuria. Past Medical History: - CAD s/p MI s/p PTCA (cypher stents placed [**2-14**] in ralegh NC) s/p PM, AICD (indication unclear), ?h/o CABG. - h/o UGIB/LGIB - s/p extensive w/u, multiple EGD, colonoscopy, small bowel enteroscopy revealing gastric ulcer, colon polyps, proximal jejunum with bleeding vessels on push enteroscopy which were cauterized. - DM2 - on oral meds. - chronic right shuolder bursitits - hyperlipidemia - chronic renal insufficiency (baseline creatine unknown) Social History: 30 years x 2 ppd tobbacco,quit 15y ago, +alcohol (12 beer/day x 20 yrs, quit 8yr ago), denies IVDU. Family History: + colon ca (brother age 69). Physical Exam: PE: VS: 97.4 71 (paced) 114/52 66 21 95% RA GEN: NAD HEENT: PERRLA, EOMI, sclera anicteric, OP clear, MMM, no LAD, no carotid bruits. No JVD. CV: regular, nl s1, s2, no r/g. 3/6 SEM radiates to carotids. PULM: CTA B, no r/r/w. ABD: soft, NT, +markedly distended, +shifting dullness, + BS, no HSM. no spider telangiectasia. EXT: warm, 2+ dp/radial pulses BL, no femoral bruits. NEURO: alert & oriented x 3, CN II-XII grossly intact. [**4-13**] strength symmetric @ triceps, biceps, delts, hip flexion, dorsoflexion, plantarflexion. sensation grossly intact. no flap. Pertinent Results: [**2176-8-25**] 11:23PM WBC-16.1*# RBC-2.99* HGB-9.6* HCT-28.1* MCV-94 MCH-32.1* MCHC-34.2 RDW-17.6* [**2176-8-25**] 11:23PM PLT COUNT-476* [**2176-8-25**] 05:01PM UREA N-52* CREAT-1.6* POTASSIUM-5.1 [**2176-8-25**] 05:01PM WBC-10.6 RBC-2.81* HGB-8.9* HCT-27.1* MCV-96 MCH-31.5 MCHC-32.7 RDW-17.4* [**2176-8-25**] 05:01PM PLT COUNT-475* [**2176-8-25**] 02:55PM COMMENTS-GREEN [**2176-8-25**] 02:55PM LACTATE-1.9 [**2176-8-25**] 02:45PM PT-14.7* PTT-27.9 INR(PT)-1.3* [**2176-8-25**] 01:20PM GLUCOSE-65* UREA N-48* CREAT-1.6* SODIUM-140 POTASSIUM-5.3* CHLORIDE-103 TOTAL CO2-23 ANION GAP-19 [**2176-8-25**] 01:20PM estGFR-Using this [**2176-8-25**] 01:20PM ALT(SGPT)-35 AST(SGOT)-75* LD(LDH)-120 CK(CPK)-41 ALK PHOS-177* AMYLASE-20 TOT BILI-0.7 [**2176-8-25**] 01:20PM LIPASE-35 [**2176-8-25**] 01:20PM CK-MB-NotDone cTropnT-0.01 [**2176-8-25**] 01:20PM ALBUMIN-2.9* [**2176-8-25**] 01:20PM WBC-8.6 RBC-2.77* HGB-9.0* HCT-27.3* MCV-99* MCH-32.4* MCHC-32.9 RDW-17.1* [**2176-8-25**] 01:20PM NEUTS-78.7* LYMPHS-15.1* MONOS-5.4 EOS-0.3 BASOS-0.4 [**2176-8-25**] 01:20PM PLT COUNT-476* . U/s:IMPRESSION: No evidence of left lower extremity deep vein thrombosis. . EKG:A-V sequentially paced rhythm with capture and occasional atrial ectopy with ventricular paced rhythm. Otherwise, compared with tracing of [**2176-8-25**] no diagnostic interim change. . Omentum core biopsy: Metastatic hepatocellular carcinoma (see note). Note: The tumor is positive for HepPar 1, CAM5.2, AE1/AE3 (focally), CK7( focally); CD10 and unabsorbed CEA, positive in a canalicular pattern; negative CK20.. PAX2 will be sent in an addendum. . Cardiac Echo [**9-5**] The left atrium is mildly dilated. The right atrium is moderately dilated. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%) Right ventricular chamber size and free wall motion are normal. There is abnormal septal motion/position. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. There is no aortic valve stenosis. The mitral valve leaflets are mildly thickened. Mild to moderate ([**12-12**]+) mitral regurgitation is seen. There is borderline pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Normal biventricular cavity sizes and regional/global systolic function. Mild-moderate mitral regurgitation. No structural cardiac cause of syncope identified. . [**2176-9-6**] 06:20AM BLOOD WBC-12.6* RBC-3.12* Hgb-9.9* Hct-31.6* MCV-101* MCH-31.7 MCHC-31.3 RDW-17.0* Plt Ct-456* [**2176-9-6**] 06:20AM BLOOD Glucose-64* UreaN-21* Creat-1.9* Na-139 K-3.5 Cl-103 HCO3-25 AnGap-15 [**2176-9-6**] 06:20AM BLOOD ALT-57* AST-103* AlkPhos-239* TotBili-0.7 [**2176-8-28**] 06:10AM BLOOD CEA-1.9 AFP-2895* [**2176-9-4**] 06:00AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE HBcAb-NEGATIVE [**2176-9-4**] 06:00AM BLOOD VitB12-682 Folate-6.8 Ferritn-202 [**2176-9-4**] 06:00AM BLOOD HCV Ab-NEGATIVE Brief Hospital Course: 73M h/o UGIB/LGIB, CAD, Type 2 DM presents w/ new dx of metastatic hepatocellular carcinoma and massive UGI bleeding (with undetermined source). . Brief hospital course is summarized by plan: . # Hepatocellular Carcinoma Patient's CT scan on presentation was concerning for omental "caking" and metastatic cancer. Omentum core biopsy was taken and showed hepatocellular carcinoma. Oncology was consulted and initially recommended workup for hemochromatosis and viral hepatitis. Hepatitis viral serology was negative. Iron studies were not revealing for hemachromatosis. Oncology considers future treatment with sorafenib, however given GI bleeding may not be a good candidate for this therapy. The family was provided with the contact for a local oncologist and primary care doctor to follow up with after rehabilitation. Overall family was informed that prognosis is poor and patient as on the order of months to live. Patient did not accept news well and became depressed and withdrawn. Low dose methylphenidate was provided to help improve affect. Palliative Care was consulted. . # Moderate Malnutrition / Failure to thrive Patient had poor appetite given abdominal pain and likely secondary effects of cancer. He was started on appetite stimulants / antidepressants of mirtazipine and megace. IV therapy was continued into rehabilitation to provide IVFs for maintainance. Reglan at meals was added to assist in gi upset and motility to improve intake. . # Acute Blood Loss Anemia due to Gastrointestinal Bleeding Patient was admitted to the MICU and stabilized. He was transfused 3 units of PRBC's from [**8-25**] - [**8-26**]. EGD was performed x 2 and swallow endoscopy was performed x 3 without revealing source of bleeding. Hematocrit stabilized in the 30-33 range after transfusions. Patient remained with occasional bright red blood per rectum and melena without dropping his hematocrit. HCT should continue to be followed. . # CAD, s/p stent placement in [**2-14**]. *ischemia: aspirin and plavix were held given massive GI bleeding. *pump: Echo was performed with EF of 60%. Patient did experience lower leg edema. This may be related to overall low albumin state as well. Was not diuresed given worsened renal function. . # Acute Renal Failure on CKD III Unknown baseline, however clearly with some element of chronic kidney dysfunction. IVFs were provided and creatinine stabilized. Patient was discharged with IVF's to provide maintainance fluid given poor PO intake. . # Type 2 DM Controlled Sugars have been stable without need for insulin. Likely due to impaired liver function. . Patient was discharged to rehabilitation. He will follow up with outpatient oncology for determination of HCC treatment. He should follow up with gastroenterology at either [**Hospital3 **] or [**Hospital6 1708**]. His aspirin and plavix were discontinued. Carvedilol dose was reduced. He was started on mirtazipine, megace, oxycodone long acting, and oxycodone short acting. He will require IVF's at maintainance until he initiates improved PO intake. Medications on Admission: altace 10mg po qdaily plavix 75mg po qdaily bumex 2mg po qdaily pravastatin 40mg po qdaily coreg 12.5mg po qdaily glucophage 1000mg po qdaily prevacid 30mg po qdaily PT DOES NOT TAKE ASPIRIN ([**1-12**] h/o GIB) Discharge Medications: 1. Clotrimazole 1 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day). 2. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 5. Oxycodone 10 mg Tablet Sustained Release 12 hr Sig: Three (3) Tablet Sustained Release 12 hr PO Q12H (every 12 hours). Disp:*60 Tablet Sustained Release 12 hr(s)* Refills:*2* 6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 7. Mirtazapine 15 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime). Disp:*30 Tablet(s)* Refills:*2* 8. Megestrol 40 mg/mL Suspension Sig: Ten (10) mL PO BID (2 times a day). Disp:*600 mL* Refills:*2* 9. Methylphenidate 5 mg Tablet Sig: 0.5 Tablet PO QAM (once a day (in the morning)). Disp:*30 Tablet(s)* Refills:*2* 10. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed. Disp:*30 Tablet(s)* Refills:*0* 11. Metoclopramide 5 mg Tablet Sig: One (1) Tablet PO QIDACHS (4 times a day (before meals and at bedtime)). Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Extended Care Facility: Sippican - [**Location (un) 730**] Discharge Diagnosis: Major: 1. Hepatocellular carcinoma 2. Gastrointestinal bleeding Minor: 1. CAD 2. DM Type 2 3. CKD, baseline ~ 2.0 Discharge Condition: good Discharge Instructions: You were admitted because you were experiencing dark stools, vomiting blood, and had a low hematocrit. You received blood transfusions and underwent endoscopy, colonoscopy, and paracentesis. . You were also diagnosed with metastatic hepatocellular carcinoma. You had a biopsy of your omentum (fat on stomach), and several paracenteses (fluid withdrawal from abdomen). . You should see your outpatient oncologist in the next 1-2 weeks. Additionally, it is best for you to establish care with your primary care doctor. . If you develop fever, chills, chest pain, shortness of breath, abdominal pain, nausea, vomiting, diarrhea, constipation, dark or bloody stools, or vomiting blood please contact your doctor or go to the emergency room. Please take all your medications as prescribed and follow up with the appointments below. Followup Instructions: You will need to contact your oncologist and primary care doctor to establish an appointment. If you require assistance, [**First Name8 (NamePattern2) 2270**] [**Last Name (NamePattern1) 1764**], can be reached via the operator at [**Hospital3 **] Hospital [**Telephone/Fax (1) 74457**]. . [**Hospital3 3583**] Oncology [**0-0-**] Primary Care - Dr [**Last Name (STitle) 42306**] [**Telephone/Fax (1) 13266**]

[ "155.0", "272.4", "250.00", "584.9", "585.3", "789.5", "263.0", "578.9", "V45.02", "285.1", "V45.01", "414.01", "197.6" ]

icd9cm

[ [ [] ] ]

[ "45.13", "54.91", "54.24" ]

icd9pcs

[ [ [] ] ]

10761, 10822

6210, 9292

342, 422

10980, 10987

3196, 6187

11866, 12280

2562, 2593

9555, 10738

10843, 10959

9318, 9532

11011, 11843

2608, 3177

274, 304

450, 1948

1970, 2428

2444, 2546

54,534

183,316

52604

Discharge summary

report

Admission Date: [**2192-11-29**] Discharge Date: [**2192-12-1**] Date of Birth: [**2146-1-19**] Sex: M Service: MEDICINE Allergies: Vicodin / AndroGel / gabapentin / Amoxicillin / Levaquin Attending:[**Last Name (NamePattern4) 290**] Chief Complaint: dyspnea, chest pain Major Surgical or Invasive Procedure: pericardiocentesis [**2192-11-30**] History of Present Illness: 46 y/o M h/o metastatic melanoma (BRAF V600E s/p radiation to spinal metastatis, on zelboraf), who presented with shortness of breath. Recent dx of pericarditis, given motrin and colchicine. Colchicine stopped [**12-20**] diarrhea, prednisone started [**2192-11-20**]. [**2192-11-29**] seen by Dr. [**First Name (STitle) **] in clinic, dyspneic and pulsus of 12. Echo showed circumferential pericardial effusion, no evidence of tamponade. . On arrival to the floor pt seemed confused and lethargic. c/o pains in arms, trapezius muscles, and chest pain but changes his story frequently. Appears that SOB worsening over weeks with significant decline in the last 2 days. . When asked what his normal functional status was before this event, they state that he is not normally able to do much at baseline, but his SOB is definitely worse. The patietn denies any rashes, but admits to decrease in appetite. Denies nausea and vomiting. Denies fevers or chills. Also, the patient has not had a BM in 2 days and has increased his pain medications. REVIEW OF SYSTEMS On review of systems, s/he denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, cough, hemoptysis, black stools or red stools. S/he denies recent fevers, chills or rigors. S/he denies exertional buttock or calf pain. All of the other review of systems were negative. . Cardiac review of systems is notable for absence of paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. Past Medical History: -metastatic melanoma BRAF positive -blindness from optic atrophy at age 16 -depression -migraines -chronic pain with a long history of opioid dependence -prurigo nodularis -candidial esophagitis, -"psychological and emotional instability documented by previous providers" - pericarditis Social History: The patient lives with his wife in [**Name (NI) 3786**], [**State 350**]. He does not have a significant history of smoking, drinking. Previously worked as an arts entertainer reporter for the brail news. Family History: blindness on his mother's side of the family. Mother had [**Name2 (NI) 499**] cancer. Father had lung cancer. Physical Exam: ON ADMISSION: VS: T= 98.5 BP= 135/73 HR= 107 RR= 18 O2 sat= 92% RA GENERAL: extremely lethargic, easily distracted/forgetful. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: external jugulars are easily visible and engorged. JVD to the ear CARDIAC: PMI located in 5th intercostal space, midclavicular line. tachycardia, 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 abdominial bruits. EXTREMITIES: minimal pitting edema but definite non-pitting edema bilaterally. legs are warm and well perfused 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+ . AT DISCHARGE: exam unchanged. Pertinent Results: [**2192-11-29**] 09:15PM BLOOD WBC-8.3 RBC-2.64* Hgb-7.9* Hct-24.7* MCV-94 MCH-30.0 MCHC-32.1 RDW-20.6* Plt Ct-63*# [**2192-11-30**] 10:30PM BLOOD WBC-10.0 RBC-2.79* Hgb-8.4* Hct-26.5* MCV-95 MCH-30.0 MCHC-31.6 RDW-21.2* Plt Ct-59* [**2192-12-1**] 05:08AM BLOOD WBC-9.9 RBC-2.80* Hgb-8.2* Hct-26.6* MCV-95 MCH-29.3 MCHC-30.9* RDW-21.1* Plt Ct-60* [**2192-11-29**] 09:15PM BLOOD Neuts-87* Bands-0 Lymphs-10* Monos-3 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 NRBC-1* [**2192-11-29**] 09:15PM BLOOD PT-22.9* PTT-32.0 INR(PT)-2.2* [**2192-11-30**] 03:30PM BLOOD PT-29.6* PTT-33.6 INR(PT)-2.9* [**2192-12-1**] 05:08AM BLOOD PT-22.2* PTT-30.9 INR(PT)-2.1* [**2192-11-29**] 09:15PM BLOOD Glucose-115* UreaN-17 Creat-0.8 Na-137 K-3.9 Cl-97 HCO3-28 AnGap-16 [**2192-11-29**] 09:15PM BLOOD ALT-176* AST-296* LD(LDH)-4630* AlkPhos-751* TotBili-5.2* [**2192-12-1**] 05:08AM BLOOD ALT-170* AST-319* LD(LDH)-4440* AlkPhos-596* TotBili-5.0* [**2192-11-29**] 09:15PM BLOOD Albumin-3.3* Calcium-8.2* Phos-1.7*# Mg-1.7 [**2192-11-30**] 06:20AM BLOOD Hapto-69 [**2192-12-1**] 05:08AM BLOOD Hapto-79 . ECHO [**2192-12-1**] LEFT VENTRICLE: Normal LV wall thickness, cavity size, and global systolic function (LVEF>55%). RIGHT VENTRICLE: Normal RV chamber size and free wall motion. PERICARDIUM: Small pericardial effusion. Effusion circumferential. Effusion echo dense, c/w blood, inflammation or other cellular elements. No echocardiographic signs of tamponade. No evidence of constriction. Conclusions Left ventricular wall thickness, cavity size, and global systolic function are normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. There is a small, partially echo filled circumferential pericardial effusion most promient anterior to the apical right ventricle. There are no echocardiographic signs of tamponade or of constriction. Compared with the prior post-pericardiocentesis study (images) reviewed of [**2192-11-30**], the findings are similar. . . ECHO [**2192-11-30**] (TTE) .PERICARDIUM: Small pericardial effusion. Effusion circumferential. No echocardiographic signs of tamponade. Conclusions There is a small pericardial effusion. The effusion appears circumferential. There are no echocardiographic signs of tamponade. Compared with the findings of the prior study (images reviewed) of [**2193-12-1**], the pericardial effusion is much smaller and cardiac tamponade is no longer present. Brief Hospital Course: 46 YO gentleman with metastatic melanoma presents with SOB, CP found to have circumferential pericardial effusions and pulsus of 14. . # pericardial effusion - patient was found to have a pulsus of 12 on admission. Chest pain persisted and pulsus went up to 14 overnight. Imaging showed pericardial effusions. Pt underwent emergent pericardiocentesis on [**2192-11-30**] and 570 ccs were drained. Thoracic surgery was consulted for possible pericardial window procedure but it was felt the pt was too high risk and with severely poor prognosis. Drain put out roughly 1.5 L of bloody fluid overnight. F/u echo showed no reaccumulation of fluid. Drain was pulled [**2192-12-1**] as output had trailed off and plan was for pt to go home with hospice care. . #DIC - fibrinogen of 90 on presentation, plts of 63, INR 2.2, elevated Tbili. FDB 160-320. Fibrinogen went up to 140 overnight and INR up to 2.9 then down to 2.1 on [**2192-12-1**]. DIC could be [**12-20**] malignancy itself or [**12-20**] zelboraf use. DIC labs monitored and pt given 1 unit of FFP along with vitamin K. No evidence of bleeding other than bloodly fluid from pericardial drain. . # Melanoma- patient started on zelboraf recently. The medication is known to lead to melanoma flair if stopped for prolonged periods of time if stopped for prolong period of time. zelboraf was held on admission. Pt with metastatic disease. Zelboraf serum levels sent to genentech. Palliative care and oncology were following. Pt requested to go home with palliative care. Pain controlled with home regimen while in house along with IV dilaudid. On discharge pt was sent with fentanyl patch, liquid dilaudid, liquid ativan, and home dose oxycontin and klonipin. . TRANSITIONAL ISSUES: needed followup: pericardial fluid studies zelboraf blood levels Medications on Admission: 1. oxycodone 40 mg Tablet Extended Release Two (2) Tablet Extended Release q8r 3. clonazepam 2 mg Tablet Sig: One (1) Tablet PO twice a day prn anxiety. 4. hydromorphone 4 mg Tablet Sig: 3-4 Tablets PO Q3H (every 3 hours) as needed for pain. 5. vemurafenib 240 mg Tablet Sig: Four (4) Tablet PO BID (2times a day). 7. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 8. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 9. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1) PO DAILY (Daily) as needed for constipation. 10. Zomig 5 mg Tablet Sig: One (1) Tablet PO QD () as needed for migraine. 11. citalopram 20 mg Tablet Sig: 1 Tablet PO DAILY 14. Zofran 8 mg Tablet Sig: One (1) Tablet PO every eight (8) hours as needed for nausea. 15. Reglan 10 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for nausea. 16. esomeprazole magnesium 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. Discharge Medications: 1. ibuprofen 400 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8 hours) as needed for pain. 2. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. oxycodone 40 mg Tablet Extended Release 12 hr Sig: Two (2) Tablet Extended Release 12 hr PO Q6H (every 6 hours). Disp:*50 Tablet Extended Release 12 hr(s)* Refills:*0* 4. clonazepam 1 mg Tablet Sig: Two (2) Tablet PO twice a day as needed for anxiety. Disp:*20 Tablet(s)* Refills:*0* 5. metoclopramide 10 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for nausea. 6. fentanyl 100 mcg/hr Patch 72 hr Sig: Two (2) Patch 72 hr Transdermal Q72H (every 72 hours). Disp:*10 Patch 72 hr(s)* Refills:*0* 7. Dilaudid-5 1 mg/mL Liquid Sig: 12-16 mg PO q3h:prn as needed for pain. Disp:*500 ML* Refills:*0* 8. Lorazepam Intensol 2 mg/mL Concentrate Sig: [**11-19**] PO every six (6) hours as needed for agitation/discomfort/pain. Disp:*50 mL* Refills:*0* 9. Zofran 8 mg Tablet Sig: One (1) Tablet PO q8hr as needed for nausea. 10. senna 8.6 mg Capsule Sig: [**11-19**] Capsules PO twice a day as needed for constipation. 11. docusate calcium 240 mg Capsule Sig: One (1) Capsule PO twice a day as needed for constipation. Discharge Disposition: Home With Service Facility: [**Hospital 269**] Hospice Care Discharge Diagnosis: PRIMARY pericardial effusion pericarditis SECONDARY metastatic melanoma 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: It was a pleasure taking care of you during your recent hospitalization. You came in with chest pain and we found there was a sizeable amount of fluid around the heart. We drained this fluid. the following CHANGES were made to your medications: STARTED fentanyl patch STARTED liquid dilaudid STARTED liquid ativan STOPPED omeprazole Followup Instructions: Department: HEMATOLOGY/ONCOLOGY When: MONDAY [**2192-12-10**] at 1:30 PM With: DRS. [**Name5 (PTitle) **]/[**Doctor Last Name **] [**Telephone/Fax (1) 13016**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]

[ "V10.90", "423.3", "338.29", "377.10", "197.0", "311", "286.6", "369.00", "423.9", "198.5", "698.3", "346.90", "V49.86" ]

icd9cm

[ [ [] ] ]

[ "37.0" ]

icd9pcs

[ [ [] ] ]

10193, 10255

6105, 7820

345, 383

10372, 10372

3669, 6082

10911, 11353

2501, 2614

8982, 10170

10276, 10351

7934, 8959

10552, 10888

2629, 2629

3633, 3650

7841, 7908

286, 307

411, 1949

2643, 3619

10387, 10528

1971, 2261

2277, 2485

3,333

171,785

8291

Discharge summary

report

Admission Date: [**2144-5-30**] Discharge Date: [**2144-6-9**] Date of Birth: [**2096-7-8**] Sex: M Service: CARDIOTHORACIC Allergies: Zyban Attending:[**First Name3 (LF) 2969**] Chief Complaint: c/o fever, chills, shortness of breath 3 weeks post RUL lobectomy en bloc w/ SVC and brachiocephalic resection w/ gortex reconstruction Major Surgical or Invasive Procedure: none History of Present Illness: 47 yo M w/ h/o StageIIIB NSCLCA s/p RUL lobectomy en bloc w/ SVC & brachiocephalic veins resection/[**Doctor Last Name 4726**]-tex reconstruction [**5-6**], s/p R thoracentesis [**5-15**], now returns w/ increasing SOB/cough/fever/sweats/chills x2-3 days Past Medical History: -Stage IIIB (T4) NSCLCA -s/p RUL lobectomy en bloc w/ SVC and brachiocephalic veins resection and [**Doctor Last Name 4726**]-tex reconstruction of SVC and brachiocephalic veins [**2144-5-6**] -s/p radiation and chemotherapy right thoracentesis [**5-15**] Social History: History of 1ppd tobacco use. Patient lives with his partner in [**Location (un) 538**]. He works for a company that sells scientific research equipment. Family History: Notable for extensive CAD in multiple relatives in their 50's, including his father, who had an MI at age 52. Physical Exam: general: pale anxious man w/ shortness of breath at rest HEENT: unremarkable Chest: coarse breath sounds bilat left>right. sternal incision C/D/I- sternum stable COR: RRR S1, S2 ABD; soft, NT, ND, +BS extrem: No C/C/E neuro: intact-very anxious Pertinent Results: [**2144-5-30**] chest CT scan: IMPRESSION: 1. No evidence of pulmonary embolism. 2. A significant interval worsening and development of new areas of airspace opacities in the both lung fields, that likely represent multi-focal infection, however given increase in size of mediastinal lymph nodes, progression of malignancy remains a possibility. Differential diagnosis also includes interstitial edema. 3. Unchanged appearance of small left pleural effusion, and pericardial effusion, and slight decrease in the size of the right pleural effusion. 4. Status post thoracotomy and right upper lobe resection with reconstruction of SVC, with stable appearance of postoperative changes. Brief Hospital Course: Pt was admitted for SOB, fever, chills. CTA was done and r/o'd out for PE, LUL, LLL opacities were seen consistant w/ infectious process. Admitted to the ICU for high oxygen requirement and resp compromise. Pt was started on broad spectrum IVAB- vanco, cipro, flagyl. His leukocytosis improved and oxygen requirement decreased. He was transferred from the ICU to the floor for ongoing management. He was seen by psych for anxiety and depression- he was started on xanax and remeron. He had a positive response to both these medications. Serial CXR's, although somewhat improved on abx, continued to reveal overall inflammation. Given previous XRT, Dr. [**Last Name (STitle) **] was contact[**Name (NI) **] and recommended steroid course. Pt was started on 60mg po prednisone. cxr showed little improvement after 4 days of therapy but pt was clinically and subjectively much improved. IVAB were d/c'd and started on 10 day course of po clinda and levo. Oxygen requirement was weaned down to 2 liters w/ sats of 94%. Desat to 84% on roomair w/ ambulation. Pt was d/c/'d to home w/ VNA, on home O2, oral abx and po prednisone. Medications on Admission: metoprolol 50", oxycodone prn, ASA 325', ambien 5 qhs Discharge Medications: 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Alprazolam 0.25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for anxiety. Disp:*60 Tablet(s)* Refills:*0* 3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 4. Ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for fever, pain. Disp:*90 Tablet(s)* Refills:*0* 5. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). Disp:*30 Tablet(s)* Refills:*2* 6. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as needed. Disp:*30 Tablet(s)* Refills:*0* 7. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**2-11**] Sprays Nasal QID (4 times a day) as needed. 8. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed for pain. Disp:*75 Tablet(s)* Refills:*0* 9. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). Disp:*30 Tablet(s)* Refills:*2* 10. Prednisone 20 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily) for 1 months: then check w/ Dr. [**Last Name (STitle) **]. Disp:*90 Tablet(s)* Refills:*0* 11. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 9 days. Disp:*9 Tablet(s)* Refills:*0* 12. Clindamycin HCl 150 mg Capsule Sig: Two (2) Capsule PO Q6H (every 6 hours) for 9 days. Disp:*72 Capsule(s)* Refills:*0* 13. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1) Tablet PO 3X/WEEK (MO,WE,FR). Disp:*90 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: PNA after RUL lobectomy enbloc resection w/ SVC reconstruction w/ gortex Discharge Condition: good-oxygen dependent Discharge Instructions: call Dr.[**Doctor Last Name 4738**] office [**Telephone/Fax (1) 170**] if you develop chest pain, shortness of breath, fever or chills. Followup Instructions: call Dr.[**Doctor Last Name 4738**] office [**Telephone/Fax (1) 170**] to schedule a follow up appointment [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 23481**], MD Phone:[**Telephone/Fax (1) 1387**] Date/Time:[**2144-6-17**] 11:00- [**Hospital Ward Name 452**] 2 clinic, Psychiatry Provider [**Name9 (PRE) **] [**Name8 (MD) 490**], MD, PHD[**MD Number(3) 708**]:[**0-0-**] Date/Time:[**2144-6-25**] 9:00 Completed by:[**2144-6-9**]

[ "511.9", "486", "E878.6", "309.28", "997.3", "V10.11", "V15.3" ]

icd9cm

[ [ [] ] ]

[ "99.04" ]

icd9pcs

[ [ [] ] ]

5102, 5159

2263, 3390

406, 412

5276, 5300

1553, 2240

5484, 5939

1162, 1273

3496, 5079

5180, 5255

3416, 3473

5324, 5461

1288, 1534

231, 368

440, 696

718, 975

991, 1146

69,574

116,613

4706

Discharge summary

report

Admission Date: [**2190-6-22**] Discharge Date: [**2190-7-1**] Date of Birth: [**2136-9-11**] Sex: F Service: CARDIOTHORACIC Allergies: Codeine / Benadryl / Morphine / Percocet / Carboplatin / Red Dye Attending:[**First Name3 (LF) 4679**] Chief Complaint: Admission to [**Hospital1 18**] for left-side hemothorax Major Surgical or Invasive Procedure: [**6-23**] Left video-assisted thoracoscopy, evacuation of hemothorax; placement of left-sided chest tube, placement of left-sided pleurex catheter [**6-23**] Placement of A-line [**6-24**] Placement of CVL R IJ History of Present Illness: HISTORY OF PRESENT ILLNESS: 53 yo F w/extensive metastatic invasive ductal right breast ca (liver, bone, lung, brain, pleura) s/p right partial mastectomy with lymph node dissection in [**2179**] and multiple chemo cycles most recently complicated by pathologic fracture of left femur s/p IM nail c/b infection, PE on lovenox, s/p thoracentesis x2 in [**3-15**] and [**5-15**] for pleural effusion (cytology with +malignant adenoca) on the left just having completed 3 cycles of c3d15 treatment with abraxane not on home O2 who developed shortness of breath at rest and weakness four days prior to admission. The patient was doing okay at home, walking around the house, starting PT, when Friday she developed a rather sudden onset of shortness of breath at rest, being unable to complete a full sentence. The dyspnea was accompanied concurrently with "rib" pain around her chest that felt like a pressure and tightness preventing her from fully breathing; this pain was similar to that which she developed with her pleural effusions though at those times the pain was of gradual onset. She also felt extremely weak. Of note, she has been on lovenox for her history of PE, diagnosed in [**Month (only) 958**]. She saw her oncologist on Monday; CXR revealed "Complete opacification of the left hemithorax with right mediastinal shift...mostly consistent with interval accumulation of large amount of pleural effusion" and her Hct was low at 23.5. She received one unit of pRBC and underwent CT scan of the chest today [**6-22**], which was concerning for large new hemothorax, multiple areas of pleural loculations concerning for metastatic deposits with internal areas of necrosis, and unchanged extensive metastases of the spine. She was referred to thoracic surgery for drainage of her hemothorax. Past Medical History: PAST MEDICAL/PAST SURGICAL HISTORY: Invasive ductal right breast cancer, metastatic to liver, bone, lung, pleura, brain -s/p right partial mastectomy with lymph node dissection in [**2179**] (stage 2 at diagnosis) -received 3 cycles of CMF and XRT to right breast post-op -Received additional 5 cycles of CMF then tamoxifen for 5 years. -Found to have rib metastases in [**2184**]; treated with Lupron and Arimidex from [**2184-7-6**] to [**2186-7-7**] -progressed on numerous chemotherapy regimens including Taxotere, gemcitabine, Navelbine, Doxil, carboplatin, and, most recently, Velban; received three cycles of Velban from [**2189-12-24**], to [**2190-2-17**] -Recent course complicated by hypercalcemia treated with zoledronate -Now s/p three cycles of c3d15 treatment with abraxane (starting fourth cycle week of [**6-22**]) -IM nail L femur for pathologic fracture [**3-15**] complicated by left thigh wound infected hematoma; s/p I and D of hematoma, deep culture of hematoma, debridement down to and inclusive of vastus lateralis muscle surface and placement of vacuum sponge in [**4-15**]; treated by ID initially with ctx and vancomycin now on standing levaquin - found to have PE in [**3-15**], s/p IVC filter placement, maintained on lovenox - s/p thoracentesis for SOB; found to have metastatic pleural effusion in [**3-15**] and [**5-15**] (noted to have trapped lung in [**5-15**]) - ORIF of traumatic ankle fracture in [**2187**] - Port placement in [**2188**] - L posterior rib biopsy [**3-23**] path fx Social History: No IVDU, no smoking, social EtOH; patient is married, lives w/husband and son, daughter lives w/[**State 8449**], just had new baby; pt worked as bookeeper, likes to do outdoor activities (camping, hiking, kayaking Family History: Per chart review: Two paternal aunts had breast cancer. One sister developed breast cancer and died in her 50s and the other sister developed breast cancer in her late 50s, outcome is unknown. The patient has six sisters without breast cancer. Physical Exam: Upon discharge: T: 96.4 HR: 102 SR BP: 130/84 Sats: 96 4L General: fragile appearing 53 year-old sitting in chair no apparent distess Card: RRR Resp: decreased breath sounds with faint crackles on left GI: benign Extr: warm no edema Skin: left hip non-healing ulcer Pertinent Results: Imaging: CT [**6-22**] Significant interval increase in pleural effusion causing complete collapse of the left lung and right mediastinal shift. Areas of high density consistent with hemorrhage within the pleural effusion. Potential presence of large bulk metastatic deposits on the pleura. Extensive metastatic disease of the spine, not significantly changed since the prior study. Patient is known to have pulmonary embolism seen on the prior chest CT that cannot be assessed on the current study due to lack of contrast enhancement. CXR [**6-21**] Complete opacification of the left hemithorax with right mediastinal shift [**2-8**] pleural effusion. The opacity projecting over the right upper lobe is unchanged and it most likely represents the extensive metastatic disease within the entire skeleton. CXR [**7-1**] A left subclavian Mediport remains in place with tip terminating in the right atrium. A left-sided pleural chest drain courses posteriorly and then superiorly and terminates in the upper lung region, which is unchanged. Small bilateral pleural effusions are likely not changed. No new pneumothorax is seen. Extensive bilateral areas of consolidation and pulmonary metastases which is greater on the left appear similar to that seen one day prior. An IVC filter is again noted. Extensive heterogeneous bony mineralization is noted, consistent with history of bony metastases, as well as multiple anterior compression deformities in the mid-to-lower thoracic spine with exaggerated kyphosis. CT Chest [**6-24**] Severe reexpansion pulm edema of left lung, new ground glass opacities on pleural surface, R lung small right pleural effusion [**2190-7-1**] WBC-8.5 RBC-4.39 Hgb-12.9 Hct-39.9 Plt Ct-306 [**2190-6-30**] WBC-9.2 RBC-4.11* Hgb-11.9* Hct-36.5 Plt Ct-252 [**2190-6-21**] WBC-7.7 RBC-2.64* Hgb-7.5* Hct-23.4* Plt Ct-401 [**2190-7-1**] Glucose-104 UreaN-12 Creat-0.6 Na-142 K-3.5 Cl-105 HCO3-29 [**2190-6-30**] Glucose-93 UreaN-13 Creat-0.5 Na-138 K-3.7 Cl-101 HCO3-28 [**2190-6-23**] Glucose-103 UreaN-9 Creat-0.4 Na-133 K-4.1 Cl-97 HCO3-28 [**2190-7-1**] Calcium-11.5* Phos-3.1 Mg-2.0 Brief Hospital Course: OPERATIONS DURING ADMISSION [**6-23**] Left video-assisted thoracoscopy, evacuation of hemothorax, placement of left-side chest tube, placement of pleurex catheter. BRIEF HOSPITAL COURSE BY PROBLEM: 1. LEFT-SIDE HEMOTHORAX The patient presented to [**Hospital1 18**] on [**6-23**] with left-side hemothorax, left-side loculated pleural effusions, and a low Hct as discussed in HPI. She was given 1 u pRBC (had 1 unit as outpatient), and her Hct jumped to 27 from 23. She did remain and appear short of breath at rest even on nasal cannula. She was taken to the OR on [**6-23**] for the above-mentioned procedure, which she tolerated well. 2. RE-EXPANSION PULMONARY EDEMA Unfortunately, while still in the O.R. after being extubated she was noted to be extremely short of breath, tachypneic, and with decreased breath-sounds on the left. She was thus re-intubated intra-operatively and sent to the ICU. CXR was concerning for re-expansion pulmonary edema and non-expanded left lower lobe. She had a high pressor requirement and was brought to the ICU on Neo at 2.0. That evening she required multiple fluid boluses (crystalloid and colloid) given her hypotension. Unfortunately, her CXR the following morning showed severe re-expansion pulmonary edema on the left worse since prior exam. She concurrently had a decreased Hct; that day she received 2 u PRBC, 2 FFP. She remained with a pressor requirement. She underwent Chest CT (results listed above) concerning for re-expansion pulmonary edema, and also underwent bronchoscopy that did reveal inflated lungs bilaterally. She underwent placement of a R CVL (IJ) on [**6-24**]. She was also started on tube feeds. 3. FLUID OVERLOAD Given her pressor requirements and need for crystal and colloid the patient became fluid overloaded and, with a high CVP, was started on gentle diuresis. She was started on a lasix gtt on [**6-25**] with much improvement in her overall fluid status, though she still remained with a pressor requirement. By [**6-27**] she had diuresed and was off her vasopressors. She was placed on CPAP from CMV, which she tolerated well, initially at PS/Peep [**8-14**] and then weaned down to 5/5. She was successfully extubated on [**6-28**]. Wean to nasal cannula 2-4 Liters oxygen saturations 985-98% with aggressive pulmonary toilet and nebs. The left chest tube was placed to water-seal once drainage decreased. It was removed on [**6-30**]. The pleureX catheter was capped. On [**2187-7-1**] her chest film showed no re-accumalation of fluid. No drainage from the pleureX catheter. Skin: Left hip with small ongoing non-healing wound. Wet-Dry packing [**Hospital1 **]. Site clean. Kyphotic spine with abrasion. Mepilex intact. Dispositon: She was discharged to home on [**7-1**] on home oxygen (as previous) with her husband. She continued on her home pain regime with good control. She will follow-up with Dr. [**First Name (STitle) **] and [**First Name8 (NamePattern2) 14163**] [**Last Name (NamePattern1) 11710**] NP for pleueX catheter drainage in 2 weeks. Medications on Admission: MEDICATIONS:dilaudid 4 q3 PRN, gabapentin 100 TID, lovenox 60 mg q12h (last taken [**6-21**]), fentanyl 100 mcg TP q72h, levaquin 500 PO q24h, ondansetron 4 mg q8 Discharge Medications: 1. Fentanyl 50 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr Transdermal Q72H (every 72 hours). 2. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. 3. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO three times a day. 4. Zofran 4 mg Tablet Sig: One (1) Tablet PO every eight (8) hours as needed for nausea. Discharge Disposition: Home With Service Facility: [**Hospital1 1474**] VNA Discharge Diagnosis: Chronic left pleural effusion Discharge Condition: stable Discharge Instructions: [**Name6 (MD) **] IP NP [**First Name8 (NamePattern2) 14163**] [**Last Name (NamePattern1) 11710**] with questions or concerns regarding Pleurex catheter. [**Telephone/Fax (1) 10651**] Followup Instructions: Follow-up with [**First Name8 (NamePattern2) 14163**] [**Last Name (NamePattern1) 11710**] NP regarding Pleurex Catheter [**Telephone/Fax (1) 10651**] Follow-up with Dr. [**First Name4 (NamePattern1) **] [**2192-7-14**]:00am on the [**Hospital Ward Name 516**] Sharpiro Clinical Center [**Location (un) 24**]. Report to the 4th Radiology Department for a Chest X-Ray 45 minutes before your appointment Completed by:[**2190-7-1**]

[ "197.0", "198.3", "V15.3", "V87.41", "707.03", "197.7", "707.05", "511.89", "518.4", "V10.3", "V12.51", "518.0", "707.22", "518.5", "511.81", "198.5", "197.2", "799.4", "V45.71" ]

icd9cm

[ [ [] ] ]

[ "38.93", "33.24", "96.6", "38.91", "96.72", "34.06", "96.04", "34.04" ]

icd9pcs

[ [ [] ] ]

10590, 10645

6934, 7106

387, 601

10719, 10728

4791, 6911

10962, 11394

4236, 4484

10218, 10567

10666, 10698

10031, 10195

10752, 10939

2497, 3988

4499, 4499

291, 349

7134, 10005

4515, 4772

658, 2439

2461, 2474

4004, 4220

29,459

152,537

33769

Discharge summary

report

Admission Date: [**2182-1-22**] Discharge Date: [**2182-1-25**] Date of Birth: [**2124-9-29**] Sex: F Service: MEDICINE Allergies: Cephalosporins / Vancomycin / Quinolones / Sulfa (Sulfonamides) / Latex / Adhesive Tape / Vantin / Cefpodoxime Attending:[**First Name3 (LF) 492**] Chief Complaint: Inability to decannulate trach Major Surgical or Invasive Procedure: [**2182-1-23**] Bronchoscopy [**2182-1-24**] Rigid Bronchoscopy with Y-stent placement, trach tube replacement [**2182-1-25**] Bronchoscopy, Tracheostomy tube changed to #7 cuffed History of Present Illness: Ms. [**Known lastname 78098**] presents for evaluation of tracheobronchomalacia and possible decannulation of tracheostomy tube. Past Medical History: s/p trach (7 years ago, failed to extubate p hip surgery), COPD, DJD, MRSA PNA ([**10-11**]), Vtach ([**7-/2174**]), s/p multiple hip surgeries, GERD, DMII, atrial stenosis, +Ab for transfusions Social History: Married lives with family Tobacco: 30 pack-year quit [**2174**] Family History: non-contributory Physical Exam: 97.1, HR 107, BP 107/60, RR17, 02 100% with trach mask General: 57 year-old female trached in no apparent distress HEENT; normocephalic Neck: trach in place site clean dry intact, no erythema or discharge Card: A-fib/A-flutter Resp: breathing comforbably with trach GI: obese, bowel sounds positive, abdomen soft NT/ND Extr - severe edema BLE, R leg open wound w/d dressing s/p hematoma evacuation Incision: RLE Neuro: non-focal Pertinent Results: On [**2182-1-23**] pt underwent a flexible bronchoscopy showing thick secretions in all airways (bloody in RUL), severe TBM in R and L MS bronchi as well as a focal area of increased malacia in mid-trachea Brief Hospital Course: Pt was admitted to interventional pulmonology on [**2182-1-22**] for inability to decannulate her tracheostomy as well as evaluation of tracheo bronchomalacia. On arrival pt was admitted to the ICU and noted to have shortness of breath and orthopnea. Pt had been started on prednisone and was switched to Solu-Medrol on admission. Ceftazidime and clindamycin were also started upon admission for pneumonia. On [**2182-1-23**] pt underwent a flexible bronchoscopy showing thick secretions in all airways (bloody in RUL), severe TBM in R and L MS bronchi as well as a focal area of increased malacia in mid-trachea. Pt tolerated the procedure well and was transferred to the surgical floor later that day. On [**2182-1-24**] pt underwent flexible and rigid bronchoscopy with Y-stent placement and trach stent as well as tracheostomy tube replacement. Pt was transferred to the ICU on [**1-24**] for increased PCO2 on ABG for which she was placed on BiPAP. On [**2182-1-25**] pt was doing well, she once again underwent a flexible bronchoscopy with exchange of tracheostomy tube to #7 cuffed tube. Pt was transferred to [**Hospital2 **] [**Hospital3 6783**] hospital on [**2182-1-25**] Medications on Admission: Meds at Home: OxyContin 30", Protonix 40', Duragesic 100mcg q72h, Lasix 60', Coumadin 2', Robaxin 500' x 10d, glimepiride 4", Duoneb q6, KLor 20", Klonopin 1', Percocet prn, Combivent prn, Mylanta prn, albuterol prn, Proventil prn, ferrous sulfate 325', Cardizem 360' Meds on Transfer: Compazine prn, Lopressor 50", prednisone 20", Lovenox 130", Lasix 60', Neurontin 300", Ativan prn, OxyContin 30", ferrous sulfate 325', Cardizem 360', clonazepam 1', Xopenex prn, Atrovent prn, NG 0.4 prn, Lantus 20U qhs, clinda 600''' ([**1-18**]), ceftaz 1''' ([**1-18**]), prochlorperazine prn, ISS, Duragesic 100mcg q72h, Protonix 40', KLor 20" Discharge Medications: 1. PredniSONE 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed. 4. Oxycodone 30 mg Tablet Sustained Release 12 hr Sig: One (1) Tablet Sustained Release 12 hr PO every twelve (12) hours. 5. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Diltiazem HCl 360 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO DAILY (Daily). 7. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)) as needed. 8. Guaifenesin 1,200 mg Tablet Sustained Release 12 hr Sig: One (1) Tablet Sustained Release 12 hr PO BID (2 times a day). 9. Nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) Tablet, Sublingual Sublingual PRN (as needed). 10. Ipratropium Bromide 0.02 % Solution Sig: 0.2 MG/ML Inhalation Q6H (every 6 hours). 11. Benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 12. Fentanyl 100 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr Transdermal Q72H (every 72 hours). 13. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 14. Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization Sig: 2.5mg/3ml MG/ML Inhalation Q2H (every 2 hours) as needed. 15. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 16. Acetylcysteine 20 % (200 mg/mL) Solution Sig: 1-2 MLs Miscellaneous Q6H (every 6 hours). 17. Enoxaparin 150 mg/mL Syringe Sig: One (1) Subcutaneous Q12H (every 12 hours). 18. Guaifenesin 600 mg Tablet Sustained Release Sig: Two (2) Tablet Sustained Release PO BID (2 times a day). 19. Insulin RISS 20. Clindamycin Phosphate 600 mg/4 mL Solution Sig: One (1) Intravenous every eight (8) hours. 21. Ceftazidime 1 gram Recon Soln Sig: One (1) Recon Soln Intravenous Q8H (every 8 hours). Discharge Disposition: Extended Care Facility: [**First Name8 (NamePattern2) 1495**] [**Hospital3 6783**] Hospital Discharge Diagnosis: Trachaelbronchomalacia s/p Y stent [**1-11**] Trach (7 years ago, failed to extubate p hip surgery), COPD, DJD, MRSA PNA ([**10-11**]), Vtach ([**7-/2174**]), Atrial Stenosis, Diabetes Mellitus T2 GERDs, A. Flutter s/p cardioversion, Pulmonary Embolism s/p multiple hip surgeries Right leg hematoma evacuation [**12-11**] +Ab for transfusions Discharge Condition: Stable, deconditioned Discharge Instructions: Call Dr.[**Name (NI) 5070**] office [**Telephone/Fax (1) 7769**] if experience: -Fever > 101 or chills -Increased cough, shortness of breath, or sputum production -Chest pain Continue Guaifenesin 1200mg twice daily while stent in place. Followup Instructions: Follow-up with Dr.[**Name (NI) 5070**] office in 4 weeks [**Telephone/Fax (1) 7769**] Follow-up with your PCP [**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD [**Doctor First Name 494**]

[ "530.81", "427.31", "V44.0", "338.18", "715.90", "250.00", "V15.82", "427.32", "519.19", "729.5", "424.1", "V12.51", "327.23", "496" ]

icd9cm

[ [ [] ] ]

[ "97.23", "33.24", "33.21", "96.05" ]

icd9pcs

[ [ [] ] ]

5596, 5690

1770, 2954

402, 583

6077, 6101

1540, 1747

6387, 6612

1058, 1076

3639, 5573

5711, 6056

2980, 3248

6125, 6364

1091, 1521

331, 364

611, 742

764, 961

977, 1042

3266, 3616

21,869

175,870

18193

Discharge summary

report

Admission Date: [**2179-11-13**] Discharge Date: [**2179-12-15**] Date of Birth: [**2133-1-26**] Sex: F Service: MEDICINE Allergies: Sulfa (Sulfonamides) Attending:[**First Name3 (LF) 99**] Chief Complaint: direct admit for work up of pulmonary nodules Major Surgical or Invasive Procedure: None History of Present Illness: * Mrs. [**Known lastname **] is a 46 yo female with a h/o myocardial infarction ([**4-12**] s/p stents now on ASA/[**Month/Year (2) **]) who is s/p matched unrelated allogeneic BMT for acute monocytic leukemia 3 years ago who presents for work-up of pulmonary nodules found on CT scan at OSH. Mrs. [**Known lastname **] was diagnosed with M4 AML in 05/[**2175**]. She was initially treated with daunorubicin, Ara-c and etoposide. She was then referred to [**Hospital 4415**] for further evaluation, where she received further induction on chemotherapy with daunorubicin and cytarabine in 07/[**2175**]. She underwent a MUD transplant on [**2176-10-4**]. Her transplant course was complicated by grade 1 acute graft versus host disease of the skin as well as acute renal failure. Reportedly, following her transplant, she developed chronic graft versus host disease of the GI tract, lungs and eyes. * Mrs. [**Known lastname **] was in remission but her course has been complicated by GVHD of the skin (scleroderma reaction). She has been treated for this with Rituxan and more recently with Pentostatin. Recently, her most noticable complaint has been progressively worsening dyspnea on exertion. She was admitted for this in [**State 1727**] one month ago and has felt to have a component of diastolic heart dysfuntion with an elevated BNP in the 400's. PFT's performed at that time revealed a significant obstructive defect with mininal response to bronchodilators felt consistent with interstitial lung disease. Since this time, she notes that her symptoms have been worsening with increasing more rapidly. Now, she becomes SOB walking approximately 100ft or climbing [**4-14**] steps. In addition, over the past 3-4 days, she notes that she has been coughing up brown-rust colored sputum. She has also developed some pain on deep inspiration at her left costal margin. * Her oncologist at [**Hospital1 18**] (Dr. [**First Name (STitle) 1557**] referred her to see a pulmonologist (Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1007**]) at [**Hospital1 336**] the day prior to admission. A CT of her chest was performed showing bilateral pulmonary nodules. Because of these findings, there was concern for Aspergillus, and she was subsequently referred to [**Hospital1 18**] given the majority of her care is under Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1557**]. The patient decided that she would come in the following morning. * At the time of admission, the denies any fevers, chills, change in weight or appetite over the past several months. She reports persistent nausea as well as bouts of constipation interspersed with diarrhea. She has also had a persistent ulceration in her right upper buccal mucosa which has not healed despite a course of famvir and oral diflucan. She additionally has been followed for persistent conjunctivitis believed to be ocular GVHD. She reports a sensation of facial pressure but denies any nasal drainage, visual or hearing changes, headache, dizziness, or any focal neurologic symptoms. Past Medical History: 1) Acute monomyelocytic leukemia s/p allo-MUD transplant 3 years ago as above. 2) CAD: s/p MI and stentx2 one year ago in [**State 1727**]. 3) GVHD: mostly cutaneous, questionably ocular. 4) Intersitial lung disease 5) Diastolic heart dysfunction Social History: Lives in [**State 1727**], smoked 1 PPD x 30 years but quit in [**4-12**] after having MI, denies any ETOH or drug abuse. Family History: NC Physical Exam: VS: WT 133lbs, T 98.7, HR 98, RR 16, BP 130/84, O2 Sat 94% RA GEN: comfortable, very cushinghoid appearance. HEENT: PERRL, mild bilateral scleral injection sparing the [**Doctor First Name 2281**], oropharynx significant for a 2cm ulceration with minimal whitish exudate in the left upper buccal mucosa. NECK: +buffalo hump, supple, no LAD. CV: RRR, no m,r,g RESP: bilateral late expiratory wheezes in the lower lung zones, otherwise CTA, poor aeration ABD: Obese, firm, non-tender, no appreciable HSM. EXT: lower extremities show scant proximal muscle mass, 1+ pedal edema to above the ankle bilaterally. SKIN: erythematous serginious rash involving the upper extremities and upper chest. NEURO: CN II-XII intact bilat, decreased sensation on the left UE and left LE Pertinent Results: [**2179-11-13**] 11:53AM WBC-2.3* RBC-3.56* HGB-11.8* HCT-35.2* MCV-99* MCH-33.0* MCHC-33.4 RDW-15.1 [**2179-11-13**] 11:53AM NEUTS-49* BANDS-5 LYMPHS-3* MONOS-32* EOS-0 BASOS-0 ATYPS-0 METAS-8* MYELOS-3* NUC RBCS-1* [**2179-11-13**] 11:53AM PLT SMR-NORMAL PLT COUNT-269 [**2179-11-13**] 11:53AM HYPOCHROM-NORMAL ANISOCYT-NORMAL POIKILOCY-NORMAL MACROCYT-2+ MICROCYT-NORMAL POLYCHROM-NORMAL [**2179-11-13**] 11:53AM GLUCOSE-247* UREA N-42* CREAT-1.0 SODIUM-136 POTASSIUM-5.0 CHLORIDE-98 TOTAL CO2-26 ANION GAP-17 [**2179-11-13**] 11:53AM ALBUMIN-3.6 CALCIUM-9.4 PHOSPHATE-2.2* MAGNESIUM-1.9 [**2179-11-13**] 11:53AM PT-12.0 PTT-21.7* INR(PT)-0.9 [**2179-11-13**] 11:53AM ALBUMIN-3.6 CALCIUM-9.4 PHOSPHATE-2.2* MAGNESIUM-1.9 [**2179-11-13**] 11:53AM GRAN CT-1476 * CT Scan [**2179-11-12**] @ OSH (no report available): multiple bilateral pulmonary nodules, 2 in the left upper lobe (approximately 3 cm), one in the left lower lobe possibly with cavitation. Brief Hospital Course: * Mrs. [**Known lastname **] is a 46 yo female 3 years s/p matched related allogeneic BMT AML now severely immunosuppressed, who presented with multiple bilateral pulmonary nodules in the setting of persitently worsening dyspnea on exertion and brown-rust colored sputum. * 1) PULMONARY NODULES: The patient was significantly immunocompromised on predisone, cellcept, prograf, and pentostatin. Therefore, opportunistic infections were considered on admission. Mrs. [**Known lastname **] was initially started on Ambisome for empiric coverage of fungal infection such as aspergillus. She was also started on levofloxacin. She was taken for VATS on [**2179-11-15**] for biopsy of the lung nodules seen on chest CT. A bronchoscopy with lavage was also performed during the procedure. The tissue biopsy obtained during VATS was negative; however, the BAL was positive for Aspergillus. Her antifungal regimen was changed from Ambisome to Voriconazole and Caspofungin. The levofloxacin was later discontinued. Follow up CT scans of the chest showed findings consistent with invasive aspergillosis. * 2) PLEURITIC PAIN: Throughout her admission, the patient continued to complain of right sided pleuritic pain. The patient also has chronic pain on top of this acute pain for which she takes a very low dose of MSIR as an outpatient. She was started on MS contin 15 mg PO BID, which was later titrated up to 30 mg PO BID. The pain service was consulted and recommended starting a lidoderm patch as well as neurontin. These recommendations were implemented. The acute pleuritic pain was on the same side of the VATS, so it was thought to be post-procedural pain, possibly from nerve injury. She also had an effusion and pleural thickening, so it may have been pain due to pleural inflammation related to the VATS. A CTA was performed on [**11-28**] which was negative for pulmonary embolism. The Pulmonary Service was consulted and their impression was that her pleuritic pain was due to post-procedural pleural inflammation. They recommended starting NSAIDS for anti-inflammatory effect. The patient was started on Ibuprofen 400 mg PO BID and her pain significantly improved. A thoracentesis was considered to remove fluid from her effusion; however, it was decided that there was an insignificant amount of fluid for the procedure to be performed safely. * 3) MUCOSAL ULCER: The patient had an oral ulcer on admission, which was thought to be secondary to graft vs. host disease. At one point, this ulcer became worse and appeared to have an exudate. There was some concern for was concern for spreading infection, which may have been involving her sinuses. A sinus CT was obtained and was negative with exception of mucosal thickening. She was already on antifungal coverage for aspergillus. ID was also consulted. She was followed radiographically with another sinus CT which was unchanged. The appearance of the ulcer gradually improved. * 4) EDEMA: The patient had swelling in her left upper and bilateral lower extremities. She had been net positive since admission (up 10 pounds), therefore likely it was thought to be due to fluid overload. There was also concern for CHF given the patient had an MI in [**4-12**], and there was no echo on file since [**11-11**]. A TTE was performed [**11-21**] and revealed normal EF. The lower extremity edema was likely due to GVHD. She was given gentle diuresis. A left upper extremity doppler U/S was also performed for the finding of unilateral upper extremity edema. This study was positive for a left IJ clot. This was reportedly chronic, and has been followed with serial U/S in the past. She was not anticoagulated due to her high risk for bleeding given cavitary lung nodules due to invasive aspergillus. * 5) ERYTHEMATOUS LEFT FOREARM RASH: During her hospitalization, the patient had redness on her left forearm. This was concerning for cellulitis. She was started on vancomycin and the rash resolved. Vanco was discontinued [**11-29**]. * 6) CAD: The patient has a history of MI in [**2179-4-10**]. She was stented at that time and was put on [**Year (4 digits) **] and Aspirin. During this admission, the patient needed to be taken off of these medications so she could have surgical procedures performed. Cardiology was contact[**Name (NI) **] to see if the aspirin and [**Name (NI) **] could be held. Cardiology stated that holding the aspirin and [**Name (NI) 4532**] temporarily would would be reasonable, given the stents have likely had time to re-epithelialize over the last 6 months. She was continued on her beta-blocker. Her aspirin was restarted on [**11-30**]. The [**Month/Year (2) 4532**] will be restarted at a later time. * 7) ACCESS: A right IJ was placed during the VATS procdure on [**11-14**]. Later, a Hickman catheter was placed on [**11-28**] and the right IJ was removed. * 8) RML PNEUMONIA: Later in her hospital course, a chest x-ray was performed showing a RML pneumonia. She was restarted on levofloxacin and Flagyl was added for presumed aspiration pneumonia. On [**11-30**], the patient had had increased secretions and poor O2 saturation. A repeat CXR was performed and showed a worsening RML pneumonia. Antibiotics were continued and she was started albuterol and atrovent nebulizers. Humidified air and chest PT were used to break up secretions. * 9) RESPIRATORY DISTRESS: On [**11-30**], the patient desatted to the mid 80's on 1 liter O2 via nasal cannula. After titrating her O2 up to 5-6 liters via NC, her sats improved to the mid 90's. She was now having more difficulty moving her secretions. Over the next 48 hours, she had several more episodes of desaturation. She was started on albuterol and atrovent nebs, as well as humidified air and chest PT to break up secretions. Eventually, the patient had episode of desaturation requiring 100% non-rebreather to maintain saturation in the mid 90's. At this point in her hospital course, she was transferred to the ICU for further managment. * ICU course: Mrs. [**Known lastname **] was admitted to the [**Hospital Unit Name 153**] for respiratory distress with an increasing O2 requirement, felt to be secondary to an aspiration event. In the [**Hospital Unit Name 153**], she was unable to intubated because of significant upper airway anatomical obstruction from her GvHD, so an emergent tracheostomy was performed. 1.)Respiratory failure -- Multiple factors were felt to contribute, including aspiration, GvHD/capillary leak syndrome, invasive aspergillois, and decreased chest wall compliance (from GvHD/anasarca/obesity). For aspiration, she was intially treated with piperacillin/tazobactam, though this was stopped because of thrombocytopenia and vancomycin. For GvHD, her mycophenylate and tacrolimus were continued, and for aspergilossis, her caspofungin and voriconazole were continued, and for chest wall compliance, a gentle diuresis was effected. On this regimen, her oxygenation and ventilation gradually improved and she was switched to pressure support ventilation, that was gradually weaned down. 2.)Hypotension -- On admission to the [**Hospital Unit Name 153**], Mrs. [**Known lastname **] was hypotensive, with numerous factors influencing her blood pressure. In addition to possible sepsis, she was also felt to be intravascularly dry despite massive total body volume overload. In addition, sedation and high pressures of mechanical ventilation played a role. Initially on phenylephrine, norepinephrine was added. With antibiotics, stress dose steroids, and decreasing sedation/positive pressure, these were both weaned off, and she was able to maintain adequate pressures on her own. 3.)Thrombocytopenia -- This developed in the midst of her [**Hospital Unit Name 153**] course. The most likely etiologies, piperacillin/tazobactam and lansoprazole were stopped, as were all heparing products (and a HIT Ig was sent). Within a few days her platelets began to climb again. Eventually, the patient was unable to be weaned off the ventilator. She had severe third-spacing, and after a family discussion, she was made comfort measures only. She passed away with her family at her bedside. Medications on Admission: predisone 30mg once daily, Bactrim DS three times a week, CellCept [**Pager number **] mg b.i.d., Prograf five milligrams, one milligrams in the a.m., 1.5 mg in the p.m., Nexium 40 mg b.i.d., metoprolol 100 mg t.i.d., [**Pager number **] 75 mg daily, Zocor 40 mg daily, aspirin 81 mg daily, lisinopril five milligrams daily, Lasix 20 mg daily, Famvir 500 mg t.i.d., folic acid one milligram a day, and Ambien 30 mg q.h.s., morphine sulfate for pain 15 mg p.r.n. Discharge Medications: none Discharge Disposition: Expired Discharge Diagnosis: Respiratory distress Discharge Condition: Deceased Discharge Instructions: None Followup Instructions: None

[ "996.85", "041.3", "117.3", "786.3", "205.01", "710.1", "518.84", "517.2", "284.8", "515", "453.8", "507.0", "528.9", "484.6", "682.3", "369.3", "428.30" ]

icd9cm

[ [ [] ] ]

[ "96.6", "86.09", "99.04", "33.24", "38.93", "00.17", "31.1", "33.28", "99.28" ]

icd9pcs

[ [ [] ] ]

14446, 14455

5694, 13904

327, 333

14519, 14529

4695, 5671

14582, 14589

3888, 3892

14417, 14423

14476, 14498

13930, 14394

14553, 14559

3907, 4676

242, 289

361, 3459

3481, 3732

3748, 3872

9,356

170,892

26997

Discharge summary

report

Admission Date: [**2117-9-26**] Discharge Date: [**2117-10-7**] Date of Birth: [**2063-3-16**] Sex: M Service: MEDICINE Allergies: Tenofovir Disoproxil Fumarate Attending:[**First Name3 (LF) 4393**] Chief Complaint: bright red blood per rectum and bilateral LE edema Major Surgical or Invasive Procedure: Colonoscopy [**2117-10-1**], [**2117-10-2**], [**2117-10-6**] EGD [**2117-10-1**] History of Present Illness: 54M with h/o HIV (CD4 28 in [**6-5**]), HCV cirrhosis, s/p OLT in [**2112**], HCV recurrence, DM2, recently admitted thrice for rising LFTs, multiple biopsies concerning for acute cellular rejection presenting with BLE edema and BRBPR x2 weeks. He states that for the past 2 weeks he has had worsening BLE edema and BRBPR. His prograf was stopped several weeks ago and per liver note, it appears that he had rejected his transplant. He had upper and lower endoscopies [**2117-9-21**] that showed esophageal, gastric and rectal varices, but no active bleeding. He has had mild crampy abdominal pain that is intermittent, increasing abdominal girth as well as orthopnea for the past 2-3 weeks. He denies fever, chills, confusion or h/o SBP. He has been taking valacyclovir for rectal HSV and antiretrovirals for his HIV. . In the ED, initial VS were: 97.8 82 102/58 18 100%. RUQ ultrasound was performed which showed patent portal vasculature, CXR showed pleural effusion, labs notable for HCT 20 (baseline mid to upper 20s). LENIs negative for DVT. Guaiac neg on rectal (but brown stool, not melena). Received 1 unit PRBC, post HCT checked immediately after transfusion showed inappropriate rise in HCT. Hepatology was consulted who may do EGD in AM. Overall, hepatology emphasized paucity of options for this gentleman. Most recent set of vitals afebrile, 62, 103/61, 20 100% RA. ED to get additional PIV prior to transfer to MICU. . In the MICU, the initial vitals were T-96.9, BP-106/65 P-56 R-18 O2:100% on RA. A repeat hct was 22.9. Past Medical History: HIV HCV cirrhosis HCC s/p RFA [**3-31**] (4.5x3.4 cm hepatoma, which was biopsy-proven hepatocellular carcinoma (HCC).) OLT [**6-1**] c/b portal vein thrombectomy and roux en y [**2113-6-25**]; c/b acute rejection vs HSV infection in [**6-5**] - treated with steroids, ATG, IVIg, Acyclovir, and Foscarnet Recurrent HCV Portal vein thrombosis - on coumadin DM II Appendectomy at age 18 multiple R inquinal hernia repairs x4 PTC [**2113-11-23**] [**2114-1-1**] dilatation of hepaticojejunostomy site Fanconi's syndrome [**1-27**] Tenofovir HSV Social History: - lives alone in an apartment in [**Location 57226**]. No children - high school graduate, previously worked as disk jockey in [**Location (un) 86**] area - on medical disability, unemployed - denies current ETOH, tobacco or drug abuse (prior IV cocaine use) Family History: non-contributory Physical Exam: On Admission Vitals: T:96.9 BP:106/65 P:56 R:18 O2:100% General: Alert, oriented, no acute distress, jaundice HEENT: Sclera icteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD CV: normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi Abdomen: soft, non-tender, distended, organomegaly could not be appreciated secondary to the distention GU: no foley, edematous scrotum, with erythema on L side of scrotem Ext: thin, warm, well perfused, 2+ pulses, 3+ edema with some weeping serious fluid on right On Discharge: VSS- Afebrile BP 90s/40s, HR 60s, 100%RA General: AAOx3, NAD, agitated HEENT: Scleral icterus with moist mucous membranes. Cardiac: RRR< no MRG appreciated Lungs: CTAB, no wheezes or crackles appreciated Abdomen: markedly distended, +fluid shift, +BS, nontender, soft, no rebound or guarding. GU- mild scrotal swelling Extremities: Shinny skin with 2+ pitting edema to the knees bilaterally 2+DP pulses bilaterally Neuro: AAOx3, no asterixis Pertinent Results: Admission Labs: [**2117-9-26**] 05:00PM BLOOD WBC-5.6# RBC-2.25* Hgb-6.3* Hct-20.5* MCV-91 MCH-27.8 MCHC-30.9* RDW-20.4* Plt Ct-144*# [**2117-9-26**] 05:00PM BLOOD Neuts-91.0* Bands-0 Lymphs-6.6* Monos-1.9* Eos-0.2 Baso-0.3 [**2117-9-26**] 10:24PM BLOOD Hypochr-2+ Anisocy-2+ Poiklo-OCCASIONAL Macrocy-1+ Microcy-1+ Polychr-NORMAL Burr-OCCASIONAL Fragmen-OCCASIONAL [**2117-9-26**] 05:00PM BLOOD PT-17.1* PTT-29.3 INR(PT)-1.5* [**2117-9-26**] 05:10PM BLOOD Glucose-330* UreaN-35* Creat-1.5* Na-136 K-4.3 Cl-108 HCO3-14* AnGap-18 [**2117-9-26**] 05:10PM BLOOD ALT-81* AST-91* AlkPhos-946* TotBili-40.0* DirBili-29.7* IndBili-10.3 [**2117-9-26**] 05:10PM BLOOD Lipase-42 [**2117-9-26**] 05:10PM BLOOD Albumin-2.9* Discharge Labs: [**2117-10-7**] 06:07AM BLOOD WBC-5.5 RBC-2.76* Hgb-8.6* Hct-24.7* MCV-89 MCH-31.2 MCHC-35.0 RDW-18.9* Plt Ct-80* [**2117-10-7**] 06:07AM BLOOD PT-16.8* PTT-31.6 INR(PT)-1.5* [**2117-10-7**] 06:07AM BLOOD Glucose-228* UreaN-18 Creat-1.3* Na-135 K-3.8 Cl-109* HCO3-19* AnGap-11 [**2117-10-7**] 06:07AM BLOOD ALT-88* AST-96* AlkPhos-1021* TotBili-29.0* [**2117-10-7**] 06:07AM BLOOD Albumin-2.1* Calcium-7.5* Phos-2.0* Mg-1.9 [**2117-10-7**] 06:07AM BLOOD tacroFK-PND Pertinent Labs: [**2117-9-30**] 05:25AM BLOOD WBC-2.5* RBC-2.66* Hgb-8.2* Hct-24.3* MCV-92 MCH-30.7 MCHC-33.5 RDW-19.0* Plt Ct-136* [**2117-9-30**] 09:25PM BLOOD Hct-18.3* [**2117-10-1**] 05:06AM BLOOD WBC-10.8# RBC-2.60* Hgb-8.1* Hct-23.4*# MCV-90 MCH-30.9 MCHC-34.5 RDW-17.7* Plt Ct-259# [**2117-9-27**] 06:41AM BLOOD tacroFK-8.9 [**2117-10-4**] 06:30AM BLOOD tacroFK-5.1 [**2117-10-2**] 05:12AM BLOOD Type-ART pO2-83* pCO2-28* pH-7.46* calTCO2-21 Base XS--1 [**2117-10-1**] 11:33AM URINE Color-DkAmb Appear-Clear Sp [**Last Name (un) **]-1.014 [**2117-10-1**] 11:33AM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-LG Urobiln-NEG pH-6.0 Leuks-NEG [**2117-10-1**] 11:33AM URINE RBC-<1 WBC-4 Bacteri-MANY Yeast-NONE Epi-<1 [**2117-10-1**] 11:33AM URINE Mucous-RARE Micro: [**2117-9-26**] Blood culture x2 NEGATIVE [**2117-10-1**] Blood culture x 2 PENDING Imaging: EKG [**2117-9-26**]: Sinus rhythm. Normal tracing. Compared to the previous tracing the findings are similar. RUQ U/S [**2117-9-26**]: IMPRESSION: 1. Patent hepatic and portal venous vasculature. 2. Trace bilateral lower quadrant ascites. 3. Splenomegaly. Bilateral Lower Extremity Doppler venous Ultrasound [**2117-9-26**]: IMPRESSION: No DVT. [**2117-9-26**] CXR: Low lung volumes similar to prior exam. There is pleural effusion. It is unclear whether it is unilateral or on which side or possibly bilateral. In either case, if not new, this is unlikely to have enlarged recently. Alternatively, this could be a new development. [**2117-10-6**]: CT angiogram of abdomen and pelvis Preliminary Report !! WET READ !! No large bleed detected. CT sensitivity for a slow-flow GI bleed is very low. A RBC-tagged nuclear scan can be considered if a more sensitive test is desired. Moderate simple ascites. Small bilateral pleural effusions. s/p liver transplant. Mild pneumobilia secondary to hepaticojejunostomy, without evidence of biliary obstruction. Patent portal veins. no concerning hepatic lesions detected. Splenomegaly and splenic and gastric varices, compatible with chronic portal hypertension. Fat-containing left inguinal hernia (2:99). 12 mm RLQ intrapelvic node, unchanged in size since [**2114**], with interval calcification, likely a lymph node. Endoscopies: [**2117-10-1**]: EGD: Varices at the lower third of the esophagus Ulcer in the antrum. Varices at the antrum. Otherwise normal EGD to third part of the duodenum [**2117-10-1**]: Unable to visualize the rectum due to poor prep. Significant amount of dark bloody stool and clots were seen in the rectum. Otherwise normal sigmoidoscopy to sigmoid colon. [**2117-10-2**]: The scope was advanced to the mid-transverse colon but could not be advanced further due to significant looping. Further attempts to advance to scope were limited by the fact that the patient was unsedated because of his marginal blood pressures. Blood and clots were seen mostly in the distal colon (distal sigmoid and rectum). By the mid-trasnverse, there was no blood seen. No obvious bleeding site or source was identified. There was a single rectal varix withoutbleeding or stigmata of recent bleeding. Otherwise normal colonoscopy to mid-transverse colon [**2117-10-6**]: Colonoscopy: The terminal ileum was easily entered and appeared normal. There was bilious non bloody fluid in the terminal ileum. Edema and loss of the normal vascular pattern consiistent with portal enteropathy in the mid-sigmoid colon Two nonbleeding large rectal varices were seen in the rectum upon retroflexion. There were no stigmata of recent bleeding Thus, the decison was made not to inject as per Hepatology attending Dr. [**Last Name (STitle) **]. The distal rectum was somehow friable consistent with portal enteropathy. Grade 1 internal hemorrhoids There was a small area of mucosal irregularity in the distal rectum, suggestive of condyloma. Otherwise normal colonoscopy to cecum and terminal ileum Brief Hospital Course: 54M with h/o HIV (CD4 28 in [**6-5**]), HCV cirrhosis, s/p OLT in [**2112**], HCV recurrence, DM2, recently admitted thrice for rising LFTs, multiple biopsies concerning for acute cellular rejection presenting with BLE edema and BRBPR Hematochezia- patient had hematochezia at home with a 7 point HCT drop. He was admitted to the MICU but had no further bleeding so was just given transfusions and once stable was transferred to the floor. On the floor the patient was stable,but on his third hospital day large bloody bowel movement with a HCt drop to 18, and he was transferred back to the unit. In the MICU he received a trauma line and 4 units of blood and 1 [**Location **]. There he underwent a colonoscopy and endocsocpy which showed no active bleeding and no interventions were taken. He was then transferred back to the floor. He had another episode of hematochezia but colonscopy the next day showed no evidence of bleeding. As it was felt this may be from his small bowel he udnerwent a CT angiogram of his abdomen which showed no bleeding sites that could be intervened upon palliatively. His HCT was stable at the time of discharge at 24. Goals of Care- patient had multiple discussions with his primary hepatologist Dr. [**Last Name (STitle) 497**] as well as the [**Doctor Last Name 3271**] [**Doctor Last Name **] team about the prognosis of his condition (rejection of the liver). Palliative care was consulted and the patient changed his code status to DNR/DNI. His HCP met with the MICU team and palliative care. He will be discharge to home with hospice with Good [**Last Name (un) 3952**]. Edema- patient came in with anasarca, with 3+pitting edema of the legs and scrotal edema. He was diruresed with 40po lasix [**Hospital1 **] and had response to this, however still was markedly edematous. His scrotal edema improved during his stay however he continued to have 3+ pitting edema on the legs bilaterally and was limiting his ability to walk. s/p liver transplant- he was continued on his current course of treatment. His bilirubin was markedly elevated at 40 on admission, and his LFTs were worsening. His tacro level became subtherapeutic during this admission (was being held) so he was given one dose and will continue weekly dose of 0.5mg po qwednesday Renal failure- patient had elevated Cr at 1.7 (with his baseline being around 0.6). He was started on treatment for HRS with midodrine and octreotide.He will be sent home on midodrine to help with his blood pressure as well. HIV- he was continued on his home regimen. This will be stopped as he is being discharged to home with hospice and this treatment is not expected to extend his life expectancy Diabetes- patient was continued on his home NPH regimen and he will continue this at home. . HCV- last viral load 3,733,519 copies on [**2117-7-27**]. not actively being treated . HSV- s/p acyclovir and Foscarnet. lesion on his sacrum- HSV II confirmed by DFA. He will not be on his valtrex on discharge. . hypothyroidism-this was stable during this admission and he will be discharged on his home dose of levothyroxine 25mcg daily Transitional Issues: You will be going home with hospice. We have started several new medications including some skin creams. Please refer to the medication list for names and doses. Medications on Admission: 1. azithromycin 600 mg Tablet Sig: Two (2) Tablet PO 1X/WEEK (TH). 2. levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. mycophenolate mofetil 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. prednisone 10 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 5. sulfamethoxazole-trimethoprim 400-80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. valacyclovir 500 mg Tablet Sig: Two (2) Tablet PO three times a day. 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:*2* 8. ciprofloxacin 250 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 9. NPH insulin human recomb 100 unit/mL Suspension Sig: Thirty Five (35) Units Subcutaneous each morning. 10. NPH insulin human recomb 100 unit/mL Suspension Sig: Ten (10) Units Subcutaneous each night. 11. insulin regular human 100 unit/mL Solution Injection 12. calcium carbonate-vitamin D3 Oral 13. nadolol 20 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 14. abacavir 300 mg Tablet Sig: One (1) Tablet PO twice a day. 15. raltegravir 400 mg Tablet Sig: One (1) Tablet PO twice a day. 16. lopinavir-ritonavir 200-50 mg Tablet Sig: Two (2) Tablet PO twice a day. Discharge Medications: 1. azithromycin 600 mg Tablet Sig: Two (2) Tablet PO 1X/WEEK (TH). Disp:*60 Tablet(s)* Refills:*2* 2. levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 3. mycophenolate mofetil 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*30 Tablet(s)* Refills:*2* 4. sulfamethoxazole-trimethoprim 400-80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 5. hydrocortisone 0.5 % Ointment Sig: One (1) Appl Topical TID (3 times a day) as needed for puritus. Disp:*1 tube* Refills:*0* 6. camphor-menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical TID (3 times a day) as needed for puritus. Disp:*1 tube* Refills:*0* 7. midodrine 5 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). Disp:*60 Tablet(s)* Refills:*2* 8. trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as needed for insomnia. Disp:*60 Tablet(s)* Refills:*2* 9. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 10. tacrolimus 0.5 mg Capsule Sig: One (1) Capsule PO once a week: take on Wednesdays. Disp:*30 Capsule(s)* Refills:*2* 11. morphine concentrate 100 mg/5 mL (20 mg/mL) Solution Sig: 2-20 mg PO Q1h as needed for pain. Disp:*30 mL* Refills:*0* 12. prednisone 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 13. abacavir 300 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 14. lopinavir-ritonavir 200-50 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 15. raltegravir 400 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 16. valacyclovir 500 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). Disp:*180 Tablet(s)* Refills:*2* 17. ciprofloxacin 250 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 18. nadolol 20 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 19. calcium carbonate-vitamin D3 Oral 20. furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day as needed for leg swelling. Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: Hospice of Good [**Last Name (un) 3952**] Discharge Diagnosis: Primary: Rectal varices, portal gastropathy, acute on chronic rejection Secondary:HIV, Hepatitis C, Cirrhosis, Type II diabetes mellitus, Anemia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Mr. [**Known lastname 34850**], It was a pleasure caring for you during your stay at [**Hospital1 18**]. You were admitted to the hospital because you were having rectal bleeding and your blood counts had dropped significantly, and you had a lot of swelling in your legs. You were initially in the ICU receiving blood products and then monitored on the medical [**Hospital1 **]. On your third day of your admission you had a very large bloody bowel movememnt and your blood counts dropped and you were transferred back to the ICU where you received more blood transfusions and you underwent two colonoscopies and one upper endoscopy. You were no longer having bloody bowel movements and transferred back to the floor. You had another episode of bleeding and underwent another colonoscopy on [**10-6**] which did not see any areas of active bleeding. You were also noted to have worsening liver function tests and it was felt that this was a sign of rejection of your body against the liver transplant. We felt that there were no further treatment options to prevent this from progressing and palliative care became involved and helped to set you up with home hospice. Transitional Issues: YOu will be going home with hospice. We have stopped many of your medications as we are trying to get your medications just down to the few that you will need right now. Your medications when you leave will be: Followup Instructions: Please call Dr.[**Name (NI) 948**] office with any questions about your medications or if you have any problems Phone number is ([**Telephone/Fax (1) 16686**] [**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD [**MD Number(2) 4407**]

[ "571.5", "250.00", "572.3", "V08", "456.21", "V49.86", "570", "578.1", "244.9", "E878.0", "V02.59", "054.9", "070.70", "V10.07", "584.9", "V66.7", "V09.80", "285.1", "789.59", "455.0", "996.82", "572.4" ]

icd9cm

[ [ [] ] ]

[ "38.91", "45.23", "45.24", "45.13", "38.97" ]

icd9pcs

[ [ [] ] ]

16026, 16098

9102, 12228

342, 426

16287, 16287

3945, 3945

17904, 18174

2861, 2880

13784, 16003

16119, 16266

12439, 13761

16470, 17648

4674, 5141

2895, 3469

3483, 3926

17669, 17881

251, 304

454, 2003

3961, 4658

16302, 16446

5157, 9079

2025, 2568

2584, 2845

23,156

172,068

8192

Discharge summary

report

Admission Date: [**2176-6-10**] Discharge Date: [**2176-6-18**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 3283**] Chief Complaint: Dyspnea Major Surgical or Invasive Procedure: Placement of tunneled catheter for hemodialysis History of Present Illness: 84 y/o M w/hx of DM, ESRD approaching HD, HTN, presented to the ED with 2 days of increasing dyspnea. Per admitting team, "states he woke up in the middle of the night with SOB. Denied CP. Has been having worsening DOE over the past few months, now would be dyspneic if he walked up a flight of stairs. Also has had worsening LE edema over the past few months. Has never had CP with this. Did have stress in [**2169**] that was normal. In terms of renal disease, had AVF placed [**1-21**] in anticipation of HD but has not required it as of yet. . In the ED, was initially hypertensive in the 200s. Was hypoxic to 96% on 4L. CXR showed moderate to severe pulmonary edema, so he was placed on bipap. He received lasix 80 mg IV x1, and put out 80 cc. He was placed on a nitro gtt. EKG showed ST elevations in V2-V3 which were worse from prior. His troponin was 0.18 with a CK of 1135 (although MB negative) so he was given aspirin and placed on a heparin gtt. He was seen by cardiology who performed a bedside echo; it did not show any wall motion abnormalities, so they felt this was not a cardiac problem and recommended admission to the MICU. Renal saw him in the ED and recommended lasix 160 mg IV with diuril 500 mg IV, to which he put out 60 cc." Past Medical History: - ESRD felt [**2-16**] DM and HTN, had AVF placed [**1-21**] in anticipation of needing HD soon -Hypertension -DM -Hyperlipidemia -Severe DJD of the cervical spine with resultant gait disturbance -Gout -Known thyroid cancer (Patient declined resection) -Probable renal cell cancer (noted by MRI, not biopsied) Social History: Lives with wife, worked in social work supervising children with drug problems. [**Name (NI) **] tobacco, EtOH, drugs Family History: Heart problems, HTN, stroke Physical Exam: VS - 98.2, 60, 157/64, 20, 92%RA --> 98% 4L NC Gen: middle aged male in very mild respiratory distress. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Arcus senilis. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. CV: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. II/VI systolic murmur at apex. No thrills, lifts. No S3 or S4. Chest: No chest wall deformities, scoliosis or kyphosis. Minimal abdominal breathing, no other respiratory muscle use. Mild-mod rales bilateral bases Abd: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. Ext: No c/c/e. No femoral bruits. Skin: No stasis dermatitis, ulcers, scars, or xanthomas. Pulses: Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Neuro: CN II-XII intact, 5/5 strength, NL sensation all ext . Pertinent Results: [**2176-6-10**] 09:03PM GLUCOSE-209* UREA N-83* CREAT-5.3* SODIUM-141 POTASSIUM-3.8 CHLORIDE-106 TOTAL CO2-24 ANION GAP-15 [**2176-6-10**] 09:03PM CK(CPK)-760* [**2176-6-10**] 09:03PM CALCIUM-9.4 PHOSPHATE-3.1 MAGNESIUM-2.1 [**2176-6-10**] 09:03PM CALCIUM-9.4 PHOSPHATE-3.1 MAGNESIUM-2.1 [**2176-6-10**] 09:03PM PT-14.2* PTT-112.5* INR(PT)-1.3* [**2176-6-10**] 01:22PM CK(CPK)-950* [**2176-6-10**] 01:22PM CK-MB-4 cTropnT-0.17* proBNP-[**Numeric Identifier 29118**]* [**2176-6-10**] 04:56AM URINE HOURS-RANDOM [**2176-6-10**] 04:56AM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.013 [**2176-6-10**] 04:56AM URINE GR HOLD-HOLD [**2176-6-10**] 04:56AM URINE BLOOD-LG NITRITE-NEG PROTEIN-500 GLUCOSE-1000 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [**2176-6-10**] 04:56AM URINE HYALINE-0-2 [**2176-6-10**] 04:20AM GLUCOSE-365* UREA N-78* CREAT-5.4* SODIUM-146* POTASSIUM-4.2 CHLORIDE-108 TOTAL CO2-23 ANION GAP-19 [**2176-6-10**] 04:20AM estGFR-Using this [**2176-6-10**] 04:20AM CK(CPK)-1135* [**2176-6-10**] 04:20AM cTropnT-0.18* [**2176-6-10**] 04:20AM CK-MB-5 [**2176-6-10**] 04:20AM WBC-6.4 RBC-3.95* HGB-11.0* HCT-34.0* MCV-86# MCH-27.9 MCHC-32.4 RDW-18.0* [**2176-6-10**] 04:20AM PLT COUNT-234 [**2176-6-10**] 04:20AM PT-13.3* PTT-31.2 INR(PT)-1.2* Brief Hospital Course: In the ED, was initially hypertensive in the 200s. Was hypoxic to 96% on 4L. CXR showed moderate to severe pulmonary edema, so he was placed on bipap. He received lasix 80 mg IV x1, and put out 80 cc. He was placed on a nitro gtt. EKG showed ST elevations in V2-V3 which were worse from prior. His troponin was 0.18 with a CK of 1135 (although MB negative) so he was given aspirin and placed on a heparin gtt. He was seen by cardiology who performed a bedside echo; it did not show any wall motion abnormalities, so they felt this was not a cardiac problem and recommended admission to the MICU. Renal saw him in the ED and recommended lasix 160 mg IV with diuril 500 mg IV, to which he put out 60 cc." Patient's respiratory status and symptoms improved while in MICU, so he was weaned from bipap to nasal cannula, then weaned off nitro gtt and called out to floor. At the time of arrival to the floor, patient said his dyspnea had improved somewhat, and this continued to resolve over the next few days. # Hypoxia: Resolved quickly with diuresis, nitro. Most likely diagnosis was flash pulmonary edema, given the sudden onset, symptoms of orthopnea/PND, worsening renal failure and LE edema, and findings on physical exam. CXR read questions aspiration, but pt gives no hx of this and has no signs or symptoms of infection on exam. The underlying question is why he suddenly flashed overnight: ? if he became hypertensive and then flashed vs the hypertension as a response to the hypoxia. Most likely diagnosis is myocardial ischemia, given his numerous risk factors, EKG findings, and cardiac enzymes. Other possibility is that his EKG findings and cardiac enzymes are a result of (and not the cause of) his hypertension. Likely has volume overload related to worsening renal failure. - now on RA with no respiratory symptoms - will likely be less problem[**Name (NI) 115**] now that patient has started HD as below. - TTE with NL EF, mild aortic regurgitation - on discharge, patient will continue aspirin, beta-blocker, CCB, statin # Fever: Two days prior to discharge, patient had T to 100.9, then to 101.1 the following night. No new sx, nothing on exam to suggest etiology. Tunneled line site without erythema or TTP. -Patient was found to have UTI by UA/Cx which was felt to explain fever given otherwise very well-appearing patient with no other clinical findings -CXR with no infiltrate -Blood cx pending, negative at time of discharge Discharged on cipro for total course of 7 days for UTI. # Anemia: Likely due to renal disease. However, acute drop from 29.3 to 25.3 from [**Date range (1) 5568**]/07. Given 1uPRBC per renal recs, with appropriate response. - guaiac negative - cont aranesp remained stable throughout rest of hospitalization. #. Neck Mass: patient with known thyroid CA. CXR revealed tracheal shift, but this was stable compared to prior CXR's, and was present prior to line placement. Currently asymptomatic. # ESRD: Access attempt made on fistula, but infiltrated. HD tunneled line placed and HD initiated with this line. Patient tolerated well. Now s/p dialysis on Friday, Saturday, Monday. Pt. tolerating well. - outpt dialysis arranged for pt. # DM: Fingersticks had been poorly controlled. Avandia recently discontinued, ? if due to new data regarding increased risk of MI. Pt was controlled on SSI while in hospital; outpatient glipizide regimen resumed upon discharge. . # HTN: Patient required nitro gtt, lasix gtt in addition to his usual antihypertensive regimen until HD was initiated, at which point BP's became easier to control. However, still with SBP's as high as 140's-150's, HR in 70's, so beta blockade and nifedipine were increased slightly. # Hyperlipidemia: Cont atorvastatin. . # FEN: Diabetic, low sodium diet. # Ppx: SQH # Dispo: Patient discharged to rehab in order to work on strength and gait training per PT recommendation. Medications on Admission: allopurinol 300 mg daily amlodipine 10 mg daily aranesp 60 mcg/0.3 ml q week atenolol 100 mg [**Hospital1 **] calcitriol 0.25 micrograms daily candesartan 32 mg daily clonidine 0.3 mg/24 hr, 2 patches weekly ferrous sulfate 325 mg daily flomax 0.4 mg qhs lasix 120 mg [**Hospital1 **] glipizide 5 mg [**Hospital1 **] lipitor 80 mg daily lisinopril 40 mg daily nifedipine 60 mg daily Discharge Medications: 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 2. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 3. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO HS (at bedtime). Disp:*30 Capsule, Sust. Release 24 hr(s)* Refills:*2* 4. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 5. Candesartan 16 mg Tablet Sig: Two (2) Tablet PO daily (). Disp:*60 Tablet(s)* Refills:*2* 6. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 7. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* 8. Glipizide 5 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). Disp:*30 Tablet(s)* Refills:*2* 9. Aluminum-Magnesium Hydroxide 225-200 mg/5 mL Suspension Sig: 15-30 MLs PO QID (4 times a day) as needed. Disp:*1000 ML(s)* Refills:*0* 10. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed. 11. Ciprofloxacin 250 mg Tablet Sig: Two (2) Tablet PO Q24H (every 24 hours) for 6 days. Disp:*12 Tablet(s)* Refills:*0* 12. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO DAILY (Daily). Disp:*30 Tablet Sustained Release(s)* Refills:*2* 13. Toprol XL 100 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2* 14. Glipizide 5 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:*60 Tablet(s)* Refills:*2* Discharge Disposition: Extended Care Facility: Park Place - [**Street Address(1) **] Discharge Diagnosis: Congestive heart failure Chronic renal failure Dyspnea Discharge Condition: Good Discharge Instructions: Please continue taking prescribed medications (attached). Your metoprolol and nifedipine doses have been increased in order to control your high blood pressure. You have a urinary tract infection and have been started on a 7-day course of treatment with antibiotics (ciprofloxacin). Please call your doctor and/or return to the ER for: *Fevers higher than 102 degrees *Feeling ill, weak, or dizzy *Shortness of breath *Nausea, vomiting, or diarrhea *Any other concerning symptoms Followup Instructions: You have dialysis arranged as discussed with you. This information has been given to you already. Additionally, you have the following appointments: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2540**], RN Phone:[**Telephone/Fax (1) 435**] Date/Time:[**2176-7-3**] 8:00 [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 435**] Date/Time:[**2176-8-5**] 2:30 Completed by:[**2176-6-18**]

[ "414.8", "428.0", "428.30", "250.00", "585.6", "403.91", "285.21", "599.0", "276.8", "V45.1", "272.4", "799.02" ]

icd9cm

[ [ [] ] ]

[ "38.95", "39.95" ]

icd9pcs

[ [ [] ] ]

10415, 10479

4435, 8338

270, 319

10577, 10583

3095, 4412

11115, 11569

2085, 2114

8771, 10392

10500, 10556

8364, 8748

10607, 11092

2129, 3076

223, 232

347, 1600

1622, 1933

1949, 2069

31,173

125,009

32893

Discharge summary

report

Admission Date: [**2124-2-28**] Discharge Date: [**2124-3-5**] Date of Birth: [**2062-8-4**] Sex: F Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1283**] Chief Complaint: decreased energy level Major Surgical or Invasive Procedure: s/p MI MVR (36 mm Band) [**2-28**] History of Present Illness: 61 yo F with long standing history of a heart murmur diagnosed at age 18. Most recent echo showed [**3-21**] + MR with a slightly more dilated and hypokinetic LV. Referred for surgery. Past Medical History: MR, lipids, chole, thyroid nodule s/p negative thyroid biopsy Social History: works as hairdresser quit 20 years ago [**1-19**] etoh/month Family History: mother with aortic replacement, MI at age 61 father with MI at 75 Physical Exam: WDWN F in NAD HR 48 Reg RR 18 BP 160/70 Lungs CTAB Heart RRR, 2-3/6 late systolic snap and murmur Abdomen soft/NT/ND Extrem 1+LE edema, +pp Anterior Varicosities on L, right with superficial varicosities Pertinent Results: [**2124-3-2**] 06:30AM BLOOD WBC-9.6 RBC-2.78* Hgb-8.6* Hct-25.2* MCV-91 MCH-30.8 MCHC-33.9 RDW-12.8 Plt Ct-135* [**2124-3-2**] 06:30AM BLOOD Plt Ct-135* [**2124-2-29**] 02:24AM BLOOD PT-12.7 PTT-27.0 INR(PT)-1.1 [**2124-3-2**] 06:30AM BLOOD Glucose-118* UreaN-9 Creat-0.7 Na-135 K-4.0 Cl-100 HCO3-32 AnGap-7* CHEST (PORTABLE AP) [**2124-3-1**] 2:06 PM CHEST (PORTABLE AP) Reason: eval for pneumo s/p chest tube removal [**Hospital 93**] MEDICAL CONDITION: 61 year old woman s/p MV repair REASON FOR THIS EXAMINATION: eval for pneumo s/p chest tube removal CHEST RADIOGRAPH INDICATION: Status post mitral valve repair. COMPARISON: [**3-1**] at 9:07 a.m. FINDINGS: After removal of the right-sided chest tube, there still is a small right-sided pneumothorax that is unchanged in extent. The left-sided basal atelectasis and small pleural effusion are also unchanged. The size of the cardiac silhouette is identical to previous radiograph. IMPRESSION: Unchanged extent of the small right-sided pneumothorax after removal of the right-sided chest tube. Otherwise unchanged. [**Hospital1 18**] ECHOCARDIOGRAPHY REPORT [**Known lastname 76561**], [**Known firstname 539**] [**Hospital1 18**] [**Numeric Identifier 76562**] (Complete) Done [**2124-2-28**] at 11:44:22 AM FINAL Referring Physician [**Name9 (PRE) **] Information [**Last Name (Prefixes) 413**], [**First Name3 (LF) 412**] Division of Cardiothoracic [**Doctor First Name **] [**First Name (Titles) **] [**Last Name (Titles) **] [**Hospital Unit Name 4081**] [**Location (un) 86**], [**Numeric Identifier 718**] [**Last Name (LF) **], [**First Name3 (LF) **] Division of Cardiothoracic [**Doctor First Name **] [**First Name (Titles) **] [**Last Name (Titles) **] [**Hospital Unit Name 4081**] [**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2062-8-4**] Age (years): 61 F Hgt (in): BP (mm Hg): / Wgt (lb): HR (bpm): BSA (m2): Indication: Mitral valve disease. Murmur. Shortness of breath. ICD-9 Codes: 786.05, 440.0, 424.0 Test Information Date/Time: [**2124-2-28**] at 11:44 Interpret MD: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5209**], MD Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 6507**], MD Doppler: Full Doppler and color Doppler Test Location: Anesthesia West OR cardiac Contrast: None Tech Quality: Adequate Tape #: 2008AW2-: Machine: Echocardiographic Measurements Results Measurements Normal Range Left Atrium - Four Chamber Length: *6.0 cm <= 5.2 cm Left Ventricle - Ejection Fraction: 45% to 50% >= 55% Aorta - Sinus Level: 3.4 cm <= 3.6 cm Aorta - Ascending: 2.7 cm <= 3.4 cm Aortic Valve - Peak Gradient: 5 mm Hg < 20 mm Hg Findings LEFT ATRIUM: Moderate LA enlargement. Depressed LAA emptying velocity (<0.2m/s) No thrombus in the LAA. RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. 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 and cavity size. Mildly depressed LVEF. [Intrinsic LV systolic function likely depressed given the severity of valvular regurgitation.] 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. AORTIC VALVE: Three aortic valve leaflets. No AS. No AR. MITRAL VALVE: Moderately thickened mitral valve leaflets. Mild mitral annular calcification. No MS. Moderate to severe (3+) MR. TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with physiologic PR. [**Last Name (STitle) **]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 patient received antibiotic prophylaxis. The TEE probe was passed with assistance from the anesthesioology staff using a laryngoscope. No TEE related complications. patient. Conclusions PRE-CPB:1. The left atrium is moderately dilated. The left atrial appendage emptying velocity is depressed (<0.2m/s). No thrombus is seen in the left atrial appendage. No atrial septal defect is seen by 2D or color Doppler. 2. Left ventricular wall thicknesses and cavity size are normal. Overall left ventricular systolic function is mildly depressed (LVEF= 45 %). [Intrinsic left ventricular systolic function is likely more depressed given the severity of valvular regurgitation.] 3. Right ventricular chamber size and free wall motion are normal. 4. There are simple atheroma in the descending thoracic aorta. 5. There are three aortic valve leaflets. There is no aortic valve stenosis. No aortic regurgitation is seen. 6. The mitral valve leaflets are moderately thickened. There is bileaflet prolapse with the posterior leaflet more prolapsed. The jet is central with a late systolic anterior component. Moderate to severe (3+) mitral regurgitation is seen. The mitral annulus measures 4.2 at the commisure and 3.4 cm at the A-P diameter. Dr. [**Last Name (Prefixes) **] was notified in person of the results. Dr. [**Last Name (STitle) 168**] present to pass coronary sinus catheter. POST-CPB: On infusion of phenylephrine. Well-seated annuloplasty ring in the mitral position. Trace MR. [**First Name (Titles) **] [**Last Name (Titles) **]. [**First Name (Titles) **] [**Last Name (Titles) 66799**]r systolic function.Aortic contour normal post decannulation. Brief Hospital Course: She was taken to the operating room on [**2-28**] where she underwent a minimally invasive mitral valve repair. She was transferred to the ICU in stable condition. She was extubated later that same day. She was transferred to the floor on POD #1. Her chest tube was dc'd with stable tiny right pneumothorax.She did well postoperatively and she was ready for discharge home on POD #4. On POD for pt experienced afib. Bolused with amio IV. Pt converted to NSR. PO amio taper on DC. No coumadin. Medications on Admission: asa, MVI 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. 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. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily). Disp:*30 Cap(s)* Refills:*0* 5. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 6. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). Disp:*30 Tablet(s)* Refills:*0* 7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*0* 8. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 5 days. Disp:*30 Tablet(s)* Refills:*0* 9. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day): take as directed x 1 week. Then taper as follows. 200 2x a day for a week. then 200 a day . Disp:*120 Tablet(s)* Refills:*2* 10. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO ONCE (Once) for 5 days. Disp:*5 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital1 **] VNA, [**Hospital1 1559**] Discharge Diagnosis: MR now s/p MVR AFIB post operative / converted to NSR with AMIO lipids, chole, thyroid nodule s/p negative thyroid biopsy 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 driving for 2 weeks or while taking narcotic pain medicine. [**Last Name (NamePattern4) 2138**]p Instructions: Dr. [**Last Name (Prefixes) **] 4 weeks Dr. [**Last Name (STitle) **] 2 weeks Dr. [**Last Name (STitle) 3321**] 2 weeks Completed by:[**2124-3-5**]

[ "E878.8", "424.0", "241.0", "427.31", "997.1", "272.4" ]

icd9cm

[ [ [] ] ]

[ "35.33", "39.61" ]

icd9pcs

[ [ [] ] ]

8651, 8724

6770, 7264

342, 379

8890, 8898

1080, 1505

772, 840

7323, 8628

1542, 1574

8745, 8869

7290, 7300

8922, 9164

9215, 9365

855, 1061

280, 304

1603, 6747

407, 593

615, 678

694, 756

13,117

182,950

26043

Discharge summary

report

Admission Date: [**2190-4-5**] Discharge Date: [**2190-4-10**] Date of Birth: [**2158-1-26**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1283**] Chief Complaint: Asymptomatic Major Surgical or Invasive Procedure: [**2190-4-5**] - Redo Sternotomy, Bental Procedure with 33mm St. [**Male First Name (un) 923**] Mechanical Valve, PFO closure. History of Present Illness: This is a 32 year-old male who had a ventricular septal defect closure at age 6. He also had an aortic valvuloplasty performed. He has had mild aortic insufficiency since then and has been followed up at the [**Hospital3 1810**]. Recently, his aortic root was noted to have dilated, measured at 4.97 cm. He had moderate aortic insufficiency. He was subsequently referred for aortic valve replacement as well as a root replacement. After the risks and benefits were explained to him, he has agreed to proceed and desired a mechanical valve. Past Medical History: History of prolonged bleeding VSD closure as child GERD HTN ? Connective Tissue disorder Social History: Database manager. Lives with wife and child. Drinks 20+ beers weekly. Family History: Father with diabetes and AAA rupture @65 Grandfather with AAA rupture @70 Physical Exam: 72 Regular 136/86 75" 190 GEN: WDWN in NAD Skin: Warm, dry, well healed sternotomy NECK: Supple, no JVD LUNGS: Clear HEART: RRR, Nl S1, split S2, I-II/VI diastolic murmur ABD: Benign EXT: warm, dry, well perfused, no edema NEURO: Nonfocal Pertinent Results: [**2190-4-5**] ECHO PRE-BYPASS: No spontaneous echo contrast or thrombus is seen in the body of the left atrium/left atrial appendage or the body of the right atrium/right atrial appendage. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thicknesses and cavity size are normal. Overall left ventricular systolic function is low normal (LVEF 50-55%). Right ventricular chamber size and free wall motion are normal. The sinuses of Valsalva are dilated. The ascending aorta is mildly dilated. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion. There is no aortic valve stenosis. Moderate (2+) aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no pericardial effusion. POST-BYPASS: A mechanical prosthesis with an aortic graft is seen in the native aortic position, stable and moving well with no leaks. Aortic contour is maintained. Preserved biventricular systolic function. LVEF 55%. [**2190-4-8**] 06:00AM BLOOD WBC-9.5 RBC-3.06* Hgb-9.8* Hct-27.5* MCV-90 MCH-31.9 MCHC-35.5* RDW-12.6 Plt Ct-181 [**2190-4-8**] 06:00AM BLOOD PT-16.5* PTT-31.6 INR(PT)-1.5* [**2190-4-8**] 06:00AM BLOOD Plt Ct-181 [**2190-4-7**] 05:50AM BLOOD Glucose-119* UreaN-13 Creat-1.0 Na-136 K-4.3 Cl-96 HCO3-31 AnGap-13 Brief Hospital Course: Mr. [**Known lastname **] was admitted to the [**Hospital1 18**] on [**2190-4-5**] for surgical management of his aortic root aneurysm and aortic insufficiency. He was taken to the operating room where he underwent a redo sternotomy with a bental procedure using a 33 mm [**First Name8 (NamePattern2) 1495**] [**Male First Name (un) 923**] mechanical valve and a 34 J-prong conduit. Closure of a patent foramen ovale was also performed. Postoperatively he was taken to the cardiac surgical intensive care unit for monitoring. On postoperative day one, Mr. [**Known lastname **] [**Last Name (Titles) 5058**] neurologically intact and was extubated. Coumadin was started for his mechanical aortic valve. Later on postoperative day one, Mr. [**Known lastname **] was transferred to the cardiac surgical step down unit for further recovery. He was gently diuresed towards his preoperative weight. The physical therapy service was consulted for assistance with his postoperative strength and mobility. His drains and pacing wires were removed per protocol without complication. Coumadin was begun and monitored daily with an INR of 2.1, with an upward trend, on discharge day. Medications on Admission: atenolol 12.5 mg daily zantac 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. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*1* 3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 4. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q2H (every 2 hours) as needed. Disp:*50 Tablet(s)* Refills:*0* 5. Coumadin 4 mg Tablet Sig: One (1) Tablet PO at bedtime. Disp:*30 Tablet(s)* Refills:*2* 6. Atenolol 25 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Location (un) 932**] Area VNA Discharge Diagnosis: s/p redo sternotomy/ Bentall procedure ? Connective Tissue disorder History of prolonged bleeding s/p VSD repair as child GERD HTN Sternal wire removal in [**2168**] Discharge Condition: Good Discharge Instructions: 1) Monitor wounds for signs of infection. These include redness, drainage or increased pain. 2) Report any fever greater then 100.5. 3) Report any weight gain of 2 pounds in 24 hours or 5 pounds in 1 week. 4) You may wash incision and gently pat dry. No swimming or bathing until wound has healed. No lotions, creams or powders to incision until it has healed. 5) No driving for 1 month. 6) No lifting greater then 10 pounds for 10 weeks. 1) Monitor wounds for signs of infection. These include redness, drainage or increased pain. 2) Report any fever greater then 100.5. 3) Report any weight gain of 2 pounds in 24 hours or 5 pounds in 1 week. 4) You may wash incision and gently pat dry. No swimming or bathing until wound has healed. No lotions, creams or powders to incision until it has healed. 5) No driving for 1 month. 6) No lifting greater then 10 pounds for 10 weeks. 7) Must have your INR (coumadin level) checked on Monday or Tuesday, and have either your cardiologist or PCP receive the report and adjust your coumadin dose accordingly. [**Last Name (NamePattern4) 2138**]p Instructions: Follow-up with Dr. [**Last Name (Prefixes) **] in 4 weeks. Follow-up with Dr. [**Last Name (STitle) 1924**] or Dr. [**First Name (STitle) **] in [**11-16**] weeks. Follow-up with Dr. [**Last Name (STitle) 64678**] in 2 weeks. Call all providers for appointments.

[ "745.5", "747.29", "300.01", "424.1" ]

icd9cm

[ [ [] ] ]

[ "35.22", "39.61", "35.39", "35.52" ]

icd9pcs

[ [ [] ] ]

4922, 4985

2955, 4130

333, 462

5195, 5202

1600, 2932

1250, 1325

4214, 4899

5006, 5174

4156, 4191

5226, 6277

6328, 6594

1340, 1581

281, 295

490, 1035

1057, 1147

1163, 1234

29,138

150,194

26595

Discharge summary

report

Admission Date: [**2168-12-5**] Discharge Date: [**2168-12-10**] Date of Birth: [**2099-2-16**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**Last Name (NamePattern4) 290**] Chief Complaint: fever, cough, confusion Major Surgical or Invasive Procedure: Bronchoscopy History of Present Illness: A 69-year-old gentleman with a history of diffuse large B-cell lymphoma with CNS involvement undergoing XRT, PCP ([**2168-7-28**]), DVT s/p IVC filter placement, was admitted for hypoxia, shortness of breath, fever, fatigue. His wife called the clinic for concern that the patient has had shortness of breath, new oxygen requirement, fatigue and weakness, and with temperature of 101.6 3 days PTA. He has had decreased activity tolerance (before could ambulate with walker) and shortness of breath which required 2L NC at home for comfort when normally he is not on oxygen. In clinic, he was noted for a decreased oxygen saturation to 88-90% on room air which improved to 95% on oxygen at 2-3 liters via NP. He was admitted to the BMT service to workup his hypoxia, fever, and fatigue/weakness. He had his dose of inhaled pentamidine on [**2168-11-23**] and was previously on atorvaquone for PCP prophylaxis until [**2168-10-14**]. . On admission, the patient denies chest pain, palpitations, cough, sputum production, urinary symptoms, URI symptoms, night sweats. He notes decreased PO intake, constipation, and decreased LE edema after his IVC filter placement. He has noted some bruising on his hands but no other bleeding particularly any blood in his urine or stool, epistaxis or gum bleeding. Past Medical History: ONCOLOGIC HISTORY: His diagnosis was in [**3-/2167**] when he palpated a lymph node in the right groin area. He underwent biopsy by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] that showed diffuse large B-cell lymphoma. He then received R-CHOP for six cycles, which completed as of 06/[**2167**]. He was well until [**10/2167**] to [**11/2167**] when he developed right lower extremity weakness. Followup PET scan for his R-CHOP showed no evidence for lymphoma. However, his lower extremity weakness and pain radiating down his right leg increased. He underwent repeated MRI scanning with his first on [**2167-12-10**], which showed a partially enhancing lesion within the posterior L4 vertebrae suggestive of an atypical hemangioma. He subsequently was admitted in [**1-/2168**] for workup of his right lower extremity weakness as the concern was for CNS involvement or a cord compression. He was evaluated by additional MRIs and lumbar puncture, which did not show any evidence for malignancy, although noted the same question atypical hemangioma in the lumbar spine area. He was extensively followed by his primary oncologist as well as the neurologic service. On [**2168-2-17**], his CSF cytology did show evidence for malignant cells. MRI also demonstrated increased uptake in the sacral plexus with evidence of possible right lumbosacral plexopathy. In mid-[**2-/2168**], he received radiation therapy to the sacrum with improvement in his pain complaint and at that time he also was initiated on Decadron. Since [**3-/2168**], he has received intrathecal high-dose methotrexate as well as systemic methotrexate with leucovorin rescue for treatment of his CNS disease. At the end of [**8-/2168**], it was felt that Mr. [**Known lastname **] had shown some progression of his systemic disease as his last CT had shown some evidence of bony erosion and he was having some increasing lower extremity weakness. He subsequently began on Gemzar and Navelbine and received two cycles of treatment with his last treatment on [**2168-11-3**], which was day eight of Gemzar, Navelbine, and prednisone. He has remained on a low dose of Decadron during this time. Unfortunately, in [**10/2168**], Mr. [**Known lastname **] was admitted due to blurry vision that had progressed over the past month. He noted a decreased visual acuity and unfortunately a head MRI showed a new 1.5 cm suprasellar mass likely representing progression of his CNS disease. He subsequently has initiated whole brain radiation. . 1. Non-Hodgkin's lymphoma as noted above, complicated by lymphomatous meningitis and a new recent CNS lesion. 2. Right lower extremity weakness secondary to plexopathy. 3. Bilateral upper extremity weakness. 4. Right lower extremity DVT. 5. Hives intermittently over the last couple of years. 6. Raynaud's phenomenon. 7. LUL lesion in [**2129**] status post INH times one year. 8. Status post appendectomy. Social History: Pt. is married, retired and worked as a marine engineer for the merchant marines, travelling around the world on ships for 20 years and then working in a land-based office for the last 10 years of his 30 year career in the merchant marines. As a marine engineer he was responsible for working on and repairing ship engines and machinery. Now lives in a small town outside of [**Location (un) 29158**]; grew up in the area. His wife, [**Name (NI) **] [**Name (NI) **], is very supportive. . No h/o smoking or recreational drugs. . Pt has a chart history of 3 drinks/night EtOH, but says that since [**Month (only) 359**]/[**Month (only) **] of last year he has mostly not been drinking; not drinking at all while in the midst of chemo regimens. Family History: Mother died at 93 ("old age"). Father died at 75 (heart failure). His sister is 65 and has diabetes and hypertension. Physical Exam: VITALS: T 98.6, BP 100/64, HR 116, RR 20, 94% on 3L NC GENERAL: Pleasant tired-appearing gentleman lying comfortably in bed but with increased dyspnea with movement. HEENT: PERRL with anicteric sclerae. EOMI. Oropharynx is dry without erythema, lesions, or thrush. NECK: Supple. LUNGS: With crackles/rales up to mid right lung, at lower left lung. HEART: Regular rate and rhythm. ABDOMEN: Soft, rounded, and nontender, with hypoactive bowel sounds and without hepatosplenomegaly or other masses appreciated. EXTREMITIES: 1+ bilateral edema markedly improved from his prior examination. NEUROLOGIC: Mr. [**Known lastname **] is alert and oriented x 3, but he is more somnolent. CN II-XII intact. He can recall recent evants but his wife reports recent difficulties with memory and carrying out tasks at hand. His conversation is fluent with good comprehension. [**Name8 (MD) **] NP examination: His muscle strength is most notable for his left upper extremity [**5-5**] with right upper extremity 2-3/5. He can lift his left arm above his head, but not his right. His right leg continues with poor proximal strength. He does have right abduction of his hip. Pertinent Results: [**2168-12-5**] 01:10PM GRAN CT-2700 [**2168-12-5**] 01:10PM NEUTS-78.6* BANDS-1.9 LYMPHS-2.9* MONOS-5.8 EOS-0 BASOS-1.0 ATYPS-1.9* METAS-1.0* MYELOS-2.9* PROMYELO-3.9* NUC RBCS-2* [**2168-12-5**] 01:10PM WBC-3.2*# RBC-2.95* HGB-9.4* HCT-29.9* MCV-102* MCH-32.0 MCHC-31.5 RDW-18.7* [**2168-12-5**] 01:10PM ALBUMIN-2.9* CALCIUM-10.4* PHOSPHATE-4.3 MAGNESIUM-2.2 [**2168-12-5**] 01:10PM ALT(SGPT)-61* AST(SGOT)-67* LD(LDH)-1584* ALK PHOS-150* TOT BILI-0.5 . Bronchoalveolar lavage fluid: no PMNs, negative for PCP, [**Name10 (NameIs) **] positive rods c/w oropharyngeal flora . beta-glucan 139, galactomannan negative . pheripheral blood smear with blast forms (flow cytometry pending) . Chest CT In the four days since the previous CT chest, there has been collapse/consolidation of the apicoposterior segment of the left upper lobe. The superior segment of the left lower lobe is now opacified, and the remainder of the left lower lobe is also collapsed/consolidated. There is increased left pleural effusion to account for atelectasis and volume loss of the left lung, however there is also likely consolidation concerning for an infectious process in the left lung. The right lung now demonstrates pleural effusion with relaxation atelectasis and volume loss at the lung base. There is also a ground-glass opacity in the right upper lobe that is concerning for an infectious process. Extensive mediastinal lymphadenopathy is not significantly changed, the largest node measures 2.7 x 1.6 cm in the prevascular region (3:20), which is not a significant change. No supraclavicular or axillary lymphadenopathy is identified. The heart, pericardium, and great vessels are unremarkable. There has been interval intubation and nasogastric tube placement. CT OF ABDOMEN WITH IV CONTRAST: There has been interval placement of an IVC filter. The liver demonstrates slight increase in size of hypoattenuating lesions in segment VII (2.3 x 2.5 cm, 3:40) and segment VIII (1.2 x 1.5 cm, 3:44). A previously identified hypoattenuating lesion in segment [**Doctor First Name **] is not well visualized in this scan due to a difference in timing of contrast administration. There has been interval atrophy and fatty replacement of the pancreas, with a slight diffuse increase in fatty appearance of the mesentery. There is splenomegaly with the spleen measuring 18.2 cm in the superoinferior dimension on the coronal plane. There is clot in the inferior vena cava inferior to the filter, extending far inferiorly into the iliac veins. There are paraaortic lymph nodes. Brief Hospital Course: A 69-year-old gentleman with a history of diffuse large B-cell lymphoma with CNS involvement undergoing XRT, PCP ([**2168-7-28**]), DVT s/p IVC filter placement, was admitted for hypoxia, shortness of breath, fever, fatigue found to have pneumonia, leukemic transformation of his lymphoma, and septic shock. . Mr. [**Known lastname **] was admitted for with presumptive diagnosis of pneumonia. He was was started on broad spectrum antibiotics (vancomycin, cefipime, and steroids/primaquine/clindamycin for presumed PCP) but clinically worsened. All cultures were negative so ID and Pulmonary were consulted. A broncho-alveolar lavage was performed and was negative for PCP by DFA and grew only OP flora. PCP therapy was withdrawn. The patient continued to decline with increasing oxygen requirement and the morning of [**11-7**] he was noted to be tachypneic to 30-40 breaths/min on 100% non-rebreather oxygen. He was transferred to the medical ICU where he was emergently intubated when he began to desaturate on 100% oxygen and went into an SVT with HR 180. He was started back on empiric PCP therapy given his rising LDH, however Mr. [**Known lastname **] continued to decline. He went into septic shock with hypotension refractory to fluid resuscitation and required central venous line placement and vasopressive medications to maintain MAP>65. Discussions were held with the family and the Dr. [**Last Name (STitle) **] of oncology because the patient was found to have blast forms on his peripheral smear, consistent with leukemic transformation of his lymphoma. Due to his overall very poor prognosis the family decided to extubate Mr. [**Known lastname **] and change the focus of his care toward comfort measures. He died the next morning. Medications on Admission: DEXAMETHASONE 1mg PO daily PENTAMIDINE 300 mg IHN last given [**2168-11-23**] ALLOPURINOL 300MG--One by mouth every day AMBIEN 10 mg--1 tablet(s) by mouth at bedtime ATIVAN 0.5MG--One by mouth three times a day as needed COMPAZINE 10MG--One by mouth three times a day as needed COUMADIN 1 mg--per lab value/ tablet(s) by mouth once a day take dosage as recommended by md COUMADIN 2.5 mg--1 tablet(s) by mouth once a day DIFLUCAN 200 mg--1 tablet(s) by mouth once a day DILAUDID 2 mg--[**2-2**] tablet(s) by mouth every 3 to 4 hours as needed as needed for pain LACTULOSE 10 [**Month/Day (2) **]/15 mL--1 once solution(s) by mouth every 4 hours as needed for constipation LASIX 20 mg--1 tablet(s) by mouth once a day LIDODERM 5 % (700 mg/patch)--1 apply to affected area in the morning remove at bed time LYRICA 50 mg--2 capsule(s) by mouth three times a day MEPRON 750 mg/5 mL--1 suspension(s) by mouth twice a day NEUPOGEN 300MCG/0.5--As directed OXYCONTIN 20 mg--2 tablet(s) by mouth once a day PERCOCET 5MG-325MG--1-2 tablets Q4-6hours REGLAN 10 mg--1 tablet(s) by mouth three times a day as needed for nausea ZANTAC 150 mg--1 tablet(s) by mouth twice a day physical therapy --for right lumbosacral plexopathy DOCUSATE SODIUM 100 mg--1 capsule(s) by mouth twice a day Levothyroxine 75 mcg--1 tablet(s) by mouth once a day SENNA 8.6 mg--1 tablet(s) by mouth twice a day Discharge Disposition: Expired Discharge Diagnosis: lymphoma leukemia pneumonia septic shock Discharge Condition: expired Discharge Instructions: expired Followup Instructions: expired [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]

[ "518.81", "443.0", "785.52", "486", "288.00", "287.5", "208.90", "V12.51", "202.80", "038.9", "995.92" ]

icd9cm

[ [ [] ] ]

[ "96.71", "00.17", "96.04", "33.24" ]

icd9pcs

[ [ [] ] ]

12563, 12572

9378, 11141

347, 361

12656, 12665

6774, 9355

12721, 12867

5449, 5568

12593, 12635

11167, 12540

12689, 12698

5583, 6755

284, 309

389, 1691

1713, 4671

4687, 5433

55,049

107,842

30643

Discharge summary

report

Admission Date: [**2142-4-5**] Discharge Date: [**2142-4-10**] Date of Birth: [**2084-9-17**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 7651**] Chief Complaint: Admission for elective drainage of pericardial effusion Major Surgical or Invasive Procedure: [**2142-4-5**] Pericardiocentesis History of Present Illness: 57 year old male with past medical history of mild hyperlipidemia, who presents for drainage of enlarging pericardial effusion. Serial ECHO today showed moderate-large pericardial effusion with elevated intracardial pressures, persistent brief right atrial collapse. Right heart catheterization today showed early tamponade physiology and 430cc of bloody fluid was drained by left posterior approach with a pericardial drain left in place. . Patient had been recently hospitalized [**Date range (1) **]/[**2142**] for concern of STEMI vs. pericarditis. Briefly, he had developed acute retrosternal chest pain while talking on the phone, improved with leaning forward, worse when leaning back/upper body movement/deep inspiration and had presented to [**Hospital **] Hospital. He was transferred to [**Hospital1 18**] given concern for STEMI by EKG, with mild leukocytosis (WBC 14.3) and negative troponin X1. CTA was negative for pulmonary emboli and cardiac enzymes remained flat during his [**Hospital1 18**] stay. Post-catheterization, patient was kept on prasugrel PO, integrillin gtt and heparin gtt given concern for proximal left circumflex lysed thrombus/STEMI vs. pulmonary emboli. His course was complicated by significant retroperitoneal bleed requiring urgent covered stenting of right common femoral artery by left femoral approach. ECHOs prior to discharge were notable for enlarging pericardial effusion with initial right atrial and ventricular dysfunction suggestive of early tamponade. As follow-up ECHOs showed less right-sided dysfunction and patient never had pulsus paradoxus, he was discharged with close follow-up with new primary cardiologist. . Of note, the patient presented to the [**Hospital1 18**] ED yesterday evening with abdominal pain which his wife described as severe, preventing him from tolerating POs, with new back/bilateral flank pain and low grade fevers. As CT abdomen/pelvis with contrast showed no signs of hematoma superinfection or worsening bleed, it was felt his pain was likely due to ongoing presence of retroperitoneal blood and he was discharged with Percocet. . On review of systems, he endorses intermittent left shoulder and left lateral chest incision site pain. He endorses abdominal discomfort, especially with palpation but denies any more abdominal or flank pain. He denies prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, myalgias, joint pains, cough, hemoptysis, black stools, or red stools. He denies recent fevers, chills or rigors, runny nose, cough, sore throat. All of the other review of systems were negative. . Cardiac review of systems is notable for absence of dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. He has had some positional retrosternal chest pain presumably due to pericarditis which has responded at home to advil>tylenol. Past Medical History: 1. CARDIAC RISK FACTORS: (-)Diabetes, (+)Dyslipidemia, (+)Hypertension, previously on Diovan, off this past year after blood pressures improved with weight loss 2. CARDIAC HISTORY: - PERCUTANEOUS CORONARY INTERVENTIONS: [**2142-3-29**] Right dominant. LMCA with no obstructive disease. LAD has bridge in proximal LAD. LCx thrombus after first OM but no lesion. RCA without obstructive disease. 3. OTHER PAST MEDICAL HISTORY: - Duodenal ulcer, H.pylori positive treated 14 years ago - ?OSA, had sleep study but not formally diagnosed, not on CPAP Social History: Pt with lives his wife. [**Name (NI) **] has two grown children 30 and 35yo, and 4 grandchildren. He works full-time as a software engineer for [**Company 378**]. His wife states that he tries to adhere to a South Beach diet and to eat healthy. -Tobacco history: denies -ETOH: once per week, 2 shots of whiskey or glass of wine -Illicit drugs: denies Family History: His grandmother had an MI at 64yo. Great-aunt with CVA. Otherwise no early MI, DVT's, or PE's. No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Physical Exam: Admission: VS: T=101.3 BP=146/73 HR=104 --> 91 RR=19 O2 sat= 97% on RA GENERAL: NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. EOMI. Conjunctiva pink, no pallor of the oral mucosa. NECK: Supple with no JVD. CARDIAC: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. No murmurs/gallops/rubs LUNGS: No chest wall deformities, scoliosis or kyphosis. Respirations unlabored but patient endorses left incision site pain with deep breaths. CTAB, no wheezes/rhonchi/rales ABDOMEN: Soft, nontender, nondistended although uncomfortable with palpation. EXTREMITIES: No c/c/e. No femoral bruits. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. Left lateral chest drain site c/d/i with sutures and drain in place. Large right groin ecchymosis (3X6 inches) without fluctuance, warmth, skin breakdown. Mildly tender to gentle palpation. PULSES: Right: DP 2+ PT 2+, Left: DP 2+ PT 2+ Pertinent Results: [**2142-4-6**] Pericardial Fluid: NEGATIVE FOR MALIGNANT CELLS. CT Abdomen [**2142-4-5**]: 1. Resolving right retroperitoneal hematoma without radiographic evidence of superinfection, or active extravasation. 2. Moderate-sized pericardial effusion, stable. ECHO: [**2142-4-5**] Regional left ventricular wall motion is normal. Overall left ventricular systolic function is normal (LVEF>55%). There is a moderate to large sized pericardial effusion (1.8 cm outside of mid-RV free wall in diastole in the subcostal view). There is brief right atrial diastolic collapse, without RV diastolic collapse. IMPRESSION: Moderate to large pericardial effusion with evidence of elevated intrapericardial pressures but no frank tamponade ECHO [**2142-4-6**]: Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. There is a small pericardial effusion, primarily lateral to the left ventricle. The effusion is echo dense, consistent with blood, inflammation or other cellular elements. There are no echocardiographic signs of tamponade. There is significant, accentuated respiratory variation in mitral/tricuspid valve inflows, which togetgher with a septal "bounce" and absence of a large pericardial effusion suggests pericardial constrictive physiology. IMPRESSION: Small residual pericardial effusion with evidence of effusive-constrictive physiology. [**2142-4-7**]: Regional left ventricular wall motion is normal. Overall left ventricular systolic function is normal (LVEF>55%). There is abnormal septal motion/position. There is a small pericardial effusion. The effusion appears loculated. IMPRESSION: Residual small pericardial effusion located at the lateral and inferior left ventricular wall. The effusion appears loculated. There is abnormal septal motion likely reflecting effusive-constrictive physiology. This phenomenon can be seen shortly after pericardiocentesis and usually resolves within a few weeks. Brief Hospital Course: 57 year old male with past medical history of hyperlipidemia and likely recent pericarditis (?viral etiology) who presented for large pericardial effusion drainage. # PERICARDIAL EFFUSION: Patient had a recent admission and had known pericardial effusion without tamponade physiology. On repeat echo, the pericardial effusion was larger and he was admitted for pericardial drain placement. Etiology of effusion is unclear but is most likely viral. Autoimmune, neoplastic, tuberculosis and Dressler's are much less likely given presentation. Pericardial effusion was consistent with exudate, likely from inflammatory process. Cytology did not show any malignant cells. TSH was negative. Pleural fluid cultures were negative. His pericardial drain output was monitored and it was removed on [**2142-4-6**]. He was transferred from the CCU to the floor on [**2142-4-7**]. He has several repeat echos which did showed effusive-constrictive physiology and only small amount of residual fluid. He initially had pleuritic chest pain which was improved after drainage of fluid and initiation of NSAIDS. Pt initially started on colchicine as well to help prevent recurrance but in light of below GI symptoms which were possibly due to the colchicine, this medication was stoppped and should be readdressed as an outpatient. #FEVERS: Patient had several fevers during this admission (Tm 101.7). His pericardial effusion and pericarditis were thought be the most likely etiology of his fevers. Blood cultures, urine cultures and percardial fluid cultures were also sent and returned negative. CXR did not show signs of pneumonia. CT abdomen did not show any sign of infection. He began to have nausea and vomiting on [**2142-4-8**] as well as diarrhea. His fevers may have been related to GI source. C. diff was sent and was negative. #NAUSEA/ VOMITING/ DIARRHEA: Patient began having nausea, vomiting, diarrhea on [**2142-4-8**] which was likely secondary to his colchicine and high dose aspirin use. He was treated with zofran and simethicone with some improvement in his symptoms. He then developed diarrhaa on [**2142-4-8**]. His famotidine was changed to pantoprazole for improved GI prophylaxis. C. diff was sent and was negative. His colchicine was stopped and he was discharged home only on high dose aspirin. # COMMON FEMORAL ARTERY INJURY WITH HEMMORHAGE: Patient had recent post-operative course complicated by active right common femoral artery bleed resulting in hypovolemic shock, stabilized by coated stent placement. During this admission, the patient was hemodynamically stable and his hematocrit was stable. He was continued on aspirin, but at an increased dose for his pericarditis. # Hyperlipidemia: Lipid panel with LDL 64 during last hospitalization. He was continued on atorvastatin 10mg daily and omega 3 fatty acids daily. #Code: Full (confirmed with patient) Medications on Admission: * Aspirin EC 325mg daily * Omega 3 fatty acids twice daily * Vitamin D 1000 units daily * Atorvastatin 10mg daily * Acetaminophen 325mg 1-2 tablets every 4 hours daily PRN pain * Percocet 5-325mg q4-6 hours PRN pain (started [**2142-4-4**] for abdominal pain) * prevacid prn Discharge Medications: 1. aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO BID (2 times a day). Disp:*120 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 2. omega-3 fatty acids Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. Vitamin D 1,000 unit Capsule Sig: One (1) Capsule PO once a day. 4. atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Percocet 5-325 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for pain. 6. Prevacid Oral Discharge Disposition: Home Discharge Diagnosis: Primary: Pericardial Effusion Secondary: Retroperitoneal Bleed Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to the hospital because you had a fluid collection in the sac that surrounds your heart called a pericardial effusion. The fluid was drained by a procedure called pericardiocentesis and this decreased the pressure around the heart. You will need to have a repeat echocardiogram (ultrasound of the heart) in one week to evaluate the fluid collection. The following changes were made to your medications: -INCREASED aspirin from 325 mg once a day to 650 mg twice a day You will need to have your liver function tests rechecked when you see Dr. [**Last Name (STitle) 171**]. Followup Instructions: You will need to follow up with Dr. [**Last Name (STitle) 171**] next week. His office will call you to reschedule your appointment. If you do not hear from them, please call [**Telephone/Fax (1) 1989**].

[ "423.3", "272.4", "786.09", "420.91", "787.01", "787.91" ]

icd9cm

[ [ [] ] ]

[ "37.0", "89.64" ]

icd9pcs

[ [ [] ] ]

11207, 11213

7476, 10359

359, 394

11321, 11321

5459, 7453

12089, 12297

4279, 4489

10684, 11184

11234, 11300

10385, 10661

11472, 12066

4504, 5440

3525, 3738

264, 321

422, 3322

11336, 11448

3769, 3891

3344, 3505

3907, 4263

20,069

156,229

24844

Discharge summary

report

Admission Date: [**2186-9-16**] Discharge Date: [**2186-10-6**] Date of Birth: [**2127-6-21**] Sex: F Service: SURGERY Allergies: Sulfa (Sulfonamides) Attending:[**First Name3 (LF) 1556**] Chief Complaint: Back pain Major Surgical or Invasive Procedure: none History of Present Illness: 60 F car vs tree with unstable T4 fx involving all 3 columns with compression, T7 fracture, sternal fracture s/p transfer to the ICU with intubation for worsening sats and collapse of lower lobes on chest CT Past Medical History: asthma, COPD Social History: Smoker, no drugs, occasional EtOH Family History: non-contributory Physical Exam: upon arrival in ER: 96 85 105/64 18 95%on 3L HEENT: R lateral canthus laceration NEck: C-collar in place Chest: CTAB, RRR Abd: Sort, NT, ND Pelvis: stable GU: Guiac neg Ext: [**5-4**] stregnth b/l LE's, no deformities or ecchymosis Pertinent Results: [**2186-9-16**] 06:40AM NEUTS-84.2* BANDS-0 LYMPHS-12.1* MONOS-2.5 EOS-0.9 BASOS-0.3 [**2186-9-16**] 06:40AM WBC-12.8* RBC-3.66* HGB-12.3 HCT-36.2 MCV-99* MCH-33.6* MCHC-34.0 RDW-13.6 [**2186-9-16**] 06:40AM CALCIUM-8.7 PHOSPHATE-3.7 MAGNESIUM-1.6 [**2186-9-16**] 06:40AM LIPASE-54 [**2186-9-16**] 06:40AM ALT(SGPT)-32 AST(SGOT)-50* ALK PHOS-66 AMYLASE-34 TOT BILI-0.4 [**2186-9-16**] 06:40AM GLUCOSE-112* UREA N-7 CREAT-0.8 SODIUM-138 POTASSIUM-4.1 CHLORIDE-103 TOTAL CO2-22 ANION GAP-17 [**2186-9-16**] 08:20PM HCT-36.7 RADIOLOGY Final Report CT RECONSTRUCTION [**2186-9-16**] 7:15 PM CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Reason: high speed [**Month/Day/Year 39447**] with sternal fracture and T4 fracture. Would Field of view: 38 Contrast: OPTIRAY [**Hospital 93**] MEDICAL CONDITION: 59 year old woman with REASON FOR THIS EXAMINATION: high speed [**Hospital 39447**] with sternal fracture and T4 fracture. Would like to evaluate chest and abdomen with IV contrast. NO PO contrast. CONTRAINDICATIONS for IV CONTRAST: None. CT SCAN OF THE CHEST, ABDOMEN AND PELVIS WITH CONTRAST DATED [**2186-9-16**]. CLINICAL HISTORY: Status post high speed [**Month/Day/Year 39447**] with sternal fracture and T4 fracture. Please evaluate chest and abdomen with IV contrast. TECHNIQUE: CT scan evaluation of the chest, abdomen and pelvis was performed with IV contrast using 5 mm collimation. Images were reformatted and evaluated in both the coronal and sagittal planes. COMPARISON: Comparison is made to prior CT scans of the cervical, thoracic and lumbar spines. FINDINGS: There is a nondisplaced fracture through the manubrium. A small amount of retromanubrial hematoma is identified. As seen in the recent CT examination, there is a complex fracture involving the T4 vertebral body. There is approximately 80% compression of this vertebral body and 25 degrees of kyphosis at this level. Bilateral pars fractures are also identified at T4, representing posterior column injury. Moderate canal narrowing and angulation is noted at this level. A small amount of paraspinal hematoma is noted. There is also a compression fracture involving the T7 vertebral body with approximately 30% loss of vertebral body height. The fracture does not appear to extend to the posterior column. No significant canal narrowing is identified at this level. There is no evidence for mediastinal hematoma. The aorta is normal in contour and there is no evidence for contrast extravasation. Heart and great vessels are unremarkable. There are small bibasilar consolidations and small bilateral effusions. No significant lymphadenopathy is identified within the chest. The liver, gallbladder, pancreas, spleen and adrenal glands are unremarkable. Both kidneys enhance symmetrically and are otherwise unremarkable. There is no free fluid or significant lymphadenopathy within the abdomen or pelvis. A Foley catheter is noted within the bladder. IMPRESSION: 1. Nondisplaced fracture through the manubrium. 2. Complex fracture involving the T4 vertebral body with involvement of the posterior column and 25 degrees of kyphosis. This results in moderate narrowing and angulation of the spinal canal at this level. 3. Compression fracture involving the T7 vertebral body with loss of approximately 30% of vertebral body height. 4. No evidence for aortic injury. 5. No evidence for free fluid in the abdomen or pelvis. Findings were discussed with Dr. [**Last Name (STitle) 62533**] at the time of the examination. The study and the report were reviewed by the staff radiologist. DR. [**Known lastname **] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) 62534**] DR. [**First Name (STitle) 3934**] [**Name (STitle) 3935**] DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 7832**] Approved: SUN [**2186-9-17**] 8:35 AM RADIOLOGY Final Report CT T-SPINE W/O CONTRAST [**2186-9-16**] 7:18 AM CT T-SPINE W/O CONTRAST; CT RECONSTRUCTION Reason: evaluate known T4 fx [**Hospital 93**] MEDICAL CONDITION: 59 year old woman s/p MVA REASON FOR THIS EXAMINATION: evaluate known T4 fx CONTRAINDICATIONS for IV CONTRAST: None. INDICATION: 59-year-old female status post MVA with T4 acute fracture. COMPARISONS: No comparisons are available. TECHNIQUE: Multiple CT axial images of the thoracic spine were obtained without IV contrast. Coronal and sagittal reformations were performed. Coronal and sagittal reformations of the sternum were also performed. FINDINGS: There is compression fracture of T4 with retropulsion of the superior corner of the body into the spinal canal. There are bilateral fractures at the bases of the pedicles, pars interarticularis and transverse processes and the left lamina. There is approximately 25% narrowing of the canal. There is 30 degrees of kyphosis. There is also a mild compression fracture of the T7 vertebral body. No other thoracic spine fractures were identified. The spinal canal contents are not well evaluated. There are small paraspinal hematomas associated with the above- described fractures. IMPRESSION: 1. Unstable fracture of T4 with features as discussed above. 2. Compression fracture of T7 3. Subjacent to the xiphoid process of the sternum is a small density, probably a vein, but there could be a small hematoma. The study and the report were reviewed by the staff radiologist. DR. [**First Name8 (NamePattern2) 16699**] [**Name (STitle) 16700**] DR. [**First Name (STitle) 23303**] [**Doctor Last Name **] Approved: MON [**2186-9-18**] 8:25 AM RADIOLOGY Final Report CTA CHEST W&W/O C &RECONS [**2186-9-18**] 5:14 PM CTA CHEST W&W/O C &RECONS; CT 100CC NON IONIC CONTRAST Reason: HYPOXIA, EVAL FOR PE Contrast: OPTIRAY [**Hospital 93**] MEDICAL CONDITION: 59 year old woman with h/o asthma, COPD; admitted to hosp following [**Last Name (LF) 39447**], [**First Name3 (LF) **] spine fracture now with hypoxia and left pulmonary artery fullness on CXR. REASON FOR THIS EXAMINATION: PE? CONTRAINDICATIONS for IV CONTRAST: None. INDICATION: 59-year-old female with asthma admitted status post [**First Name3 (LF) 39447**] now presenting with hypoxia, left pulmonary artery fullness on the chest x-ray. COMPARISON: Comparison is made to [**2186-9-16**]. TECHNIQUE: MDCT axial images of the chest were obtained without and with IV contrast. Nonionic IV contrast was used as a rapid bolus as necessary for this study. 100 cc of Optiray 250 were used. Multiplanar reconstructions were performed. CT OF THE CHEST: There are no significant axillary lymph nodes. There are multiple small AP window lymph nodes that do not meet CT criteria for pathology. There is no pericardial effusion. The heart is mildly enlarged. The aorta appears to be intact. The pulmonary artery is slightly enlarged measuring 2 cm, which may represent chronic pulmonary artery hypertension. Clinical correlation is recommended. This is unchanged to [**2186-9-16**]. The pulmonary artery branches are patent. There are no filling defects which suggest pulmonary embolism. There are mild calcifications of the coronary arteries. The suggestion of enlargement of the left pulmonary artery as seen in the chest radiograph is likely due to atelectasis of left upper lobe posteriorly and superior segment of left lower lobe. The appearance of the pulmonary artery is unchanged compared to the prior study. Examination of the lung windows again demonstrate paraseptal emphysema with multiple subpleural blebs. There is interval worsening of the atelectasis of the posterior aspect of the bilateral upper lobes and lower lobes. There is basically complete atelectasis of the bilateral lower lobes. Most of the segmental branches, however, are patent with the exception of the superior segment of the left lower lobe where you can see an abrupt cut off.. There are very small bilateral pleural effusions. There are minimal atelectasis in the right middle lobe. Limited images of the upper abdomen do not demonstrate significant abnormality. BONE WINDOWS: Again noted complex unstable fracture of T4 which is unchanged in appearance when compared to the prior study. The degree of angulation also appears to be unchanged. As is the narrowing of the spinal canal. Note that this fracture involves the anterior, medial and posterior columns as described in detail in the CT of the thoracic spine. Also the appearance of the compression fracture of T7 is also unchanged when compared to the prior study. No definite sternal fracture can be seen. Multiplanar reconstructions were important to better evaluate the bone alignment. IMPRESSION: 1. No evidence of pulmonary embolism. 2. The apparent enlargement of the left pulmonary artery is secondary to the overlapping of the atelectasis of the posterior aspect of the left upper lobe and superior segment of the left lower lobe. 3. Interval worsening of bilateral atelectasis involving the posterior aspect of the upper lobes and the bilateral lower lobes. This is described above in detail. 4. Unchanged appearance of fractures of the thoracic spine. 5. The aorta is intact. 6. Mildly enlarged main [**MD Number(3) 62535**] be secondary to pulmonary artery hypertention. It is unchanged when compared to the prior study. The study and the report were reviewed by the staff radiologist. DR. [**First Name8 (NamePattern2) 16699**] [**Name (STitle) 16700**] DR. [**First Name (STitle) 8085**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 8086**] Approved: TUE [**2186-9-19**] 10:10 AM RADIOLOGY Final Report CHEST (PORTABLE AP) [**2186-9-26**] 11:19 AM CHEST (PORTABLE AP) Reason: consolidation? [**Hospital 93**] MEDICAL CONDITION: 59 year old woman with hypoxia and productive cough REASON FOR THIS EXAMINATION: consolidation? INDICATION: Hypoxia, cough. COMPARISON: Chest x-ray from [**2186-9-19**]. SINGLE PORTABLE AP SEMI-UPRIGHT CHEST RADIOGRAPH: There is persistent left lower lobe collapse with an associated small left pleural effusion. There is right lower lobe atelectasis with a small right pleural effusion. There is no pneumothorax. The cardiac and mediastinal contours are within normal limits. Spinal stabilization device obscures the midline chest. IMPRESSION: Persistent lower lobe atelectasis, left worse than right with associated small bilateral pleural effusions. The study and the report were reviewed by the staff radiologist. DR. [**First Name (STitle) 15097**] L. [**Doctor Last Name **] DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 3891**] Approved: TUE [**2186-9-26**] 8:51 PM Brief Hospital Course: 60 F car vs tree transferred to [**Hospital1 18**] ER from OSH. Pt. was immediately evaluated by the Emergency Medicine and Trauma Surgery teams. CT scans during initial evaluation revealed an unstable T4 fx involving all 3 columns with compression, T7 fracture, and a manubrium fracture. The pt. was kept immobilized and put on log roll precautions, and orthopedics-spine service was consulted. The pt. was admitted to the step down unit for decreased O2 sats due to COPD,asthma, started on CIWA protocol, given asthma meds and aggressive pulmonary toilet. Pt. was subsequently intubated for decreasing O2 sats and increasing O2 demand and sent to TSICU for management. Pulmonary service was consulted who recommended continued chest PT and steroid administration. Ortho-spine service changed plan at this time from operative to non-operative management of unstable T-spine fractures considering pt's pulmonary status. Pt. to remain in TLSO brace at all times. Pt had repeated pulm eval including a CTA that was negative for thrombus, but showed bilateral collapse of lower lobes with effusions. Pt.'s respiratory status slowly improved over course with eventual uneventful extubation and transfer to step down and then to floor with increasing saturations and decreasing O2 demand. She was treated with Levofloxacin for a presumed pneumonia and developed diarrhea at the end of this 7 day course. Stool specimen x3 for C-diff were obtained and sent; thus far 2 cultures have come back as negative; the 3rd specimen pending at time of this report. Imodium has been started after 2nd negative report came back. Pt. also became delirious over length of hospital stay, but with increased O2 status, mental status has slowly improved. Pt. has been on regular floor for a number of days off any O2, satting well, clear mental status, and has been receiving daily PT. Pt. ready for d/c to rehab facility for continuation of PT and respiratory therapy. Pt. to follow up with ortho-spine and orthopedics after her discharge. Her home regimen of Wellbutrin, Spiriva, Singulair, Advair and prn Albuterol MDI were restarted prior to her discharge. Medications on Admission: albuterol Spiriva Advair Singulair Discharge Medications: 1. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed for pain. Disp:*60 Tablet(s)* Refills:*0* 2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation for 7 days. Disp:*14 Tablet(s)* Refills:*0* 3. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as needed for insomnia. Disp:*30 Tablet(s)* Refills:*0* 4. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily). 5. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). Disp:*30 Cap(s)* Refills:*2* 6. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). Disp:*60 Disk with Device(s)* Refills:*2* 7. Montelukast 10 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). Disp:*30 Tablet(s)* Refills:*2* 8. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q6H (every 6 hours) as needed for SOB/wheezing. Disp:*1 1* Refills:*0* 9. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Wellbutrin 100 mg Tablet Sig: 1 [**1-1**] Tablet PO twice a day. Discharge Disposition: Extended Care Facility: [**Location (un) 26478**] - [**Location (un) 1157**] Discharge Diagnosis: s/p Motor vehicle crash T4 compression fracture T7 fracture Sternal fracture Discharge Condition: Stable Discharge Instructions: Keep your brace on at all times! Followup Instructions: 1) Please make an appointment to follow up with the ortho-spine service in clinic in 3 weeks: [**Telephone/Fax (1) 3573**] 2) Please make an appointment to follow up with the trauma surgery service in clinic in 3 weeks: [**Telephone/Fax (1) 6439**] 3) Follow up with your primary doctor, Dr. [**Last Name (STitle) 37133**] after your dicharge; you will need to have an evaluation by a Pulmonologist; this referral will need to be made by your PCP. 4) Follow up with your primary Allergists after your discharge. Completed by:[**2186-10-6**]

[ "305.1", "E815.0", "486", "807.2", "850.9", "276.3", "518.5", "305.00", "805.2", "787.91", "V10.79", "493.20", "307.9" ]

icd9cm

[ [ [] ] ]

[ "94.62", "88.43", "96.04", "38.93", "96.6", "38.91", "96.71" ]

icd9pcs

[ [ [] ] ]

15040, 15119

11580, 13725

290, 297

15240, 15249

922, 1700

15330, 15873

637, 655

13810, 15017

10627, 10679

15140, 15219

13751, 13787

15273, 15307

670, 903

241, 252

10708, 11557

325, 534

556, 570

586, 621

51,780

199,075

13200

Discharge summary

report

Admission Date: [**2101-5-18**] Discharge Date: [**2101-6-1**] Date of Birth: [**2055-4-3**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 4691**] Chief Complaint: Urosepsis Major Surgical or Invasive Procedure: right internal jugular line placement PICC line placement takedown colostomy [**2101-5-27**] History of Present Illness: Mr [**Known lastname 8840**] is a 46 year-old man with a history of complex pelvic fracture and ruptured bladder after an MVA, who presents with fever/sepsis. . Recently admitted ([**4-19**] - [**4-21**]) after a 56 day hospitalization in [**State 4565**] following an MVA complicated by open book pelvic fracture and right T12-L5 transverse process fracture. While in [**State 4565**], he had a cystogram and CT cystogram that showed extraperitoneal bladder rupter to bladder neck (repaired by a suprapubic tube). That stay was complicated by ARDS requiring intubation. Following extubation, he developed a soft tissue infection of his perineum involving his scrotum with subsequent debridement and exploration for a necrotizing infection, followed by ex-lap with diverting sigmoid colonostomy. . Since discharge to [**Location (un) 38**], he has been feeling improved. He remains non-weight bearing on his right hip and has had resulting lower extremity weakness. . Seen by Dr. [**Last Name (STitle) **] on [**5-3**]; the [**Location (un) 1661**]-[**Location (un) 1662**] drain was removed at this appointment. Seen by urology on [**5-4**], after having failed a clamping of the suprapubic tube due to penile pain. Per Dr.[**Initials (NamePattern4) 825**] [**Last Name (NamePattern4) **] note, the SPT was unable to be extracted, felt to be due ot calcificatoins of the balloon. . On the day prior to admission, he underwent OR replacement of his SPT by urology. The tube was clamped at that time. On the morning of admission, he started having shaking chills at rehab and was febrile to 104. Also noted nausea and increasing dysuria (has mild urethral dysuria at baseline). After placing foley he reports that the pain worsened. He was transferred to the [**Hospital1 18**] ER. . In the ED, initial vitals included T 102.8, HR 116, BP 141/80. He was treated with vancomycin IV and zosyn IV. For pain, morphine, then dilaudid were given. After his BP dropped to the 80s, a CVL was placed. . At the time of arrival to the MICU, he was feeling signicantly better. Past Medical History: 1. History of MVA with multiple surgery: - Open book pelvic fracture, s/p ORIC - Prophylactic IVF filter placed - Right T12-L5 transverse process fracture - Extraperitoneal bladder rupter to bladder neck, s/p pelvic binder and SPT placement - Ex-lap with no evidence of intra-abdominal injuries - Diverting sigmoid colonostomy - Right gracilis flap followed by split thickness skin graft - Multiple split-thickness skin grafts - Reimplantation of the left testicle into a neoscrotum. 2. Fourniers gangrene 3. History of ARDS 4. GERD 5. Depression 6. History of sacroiliitis Social History: Worked as a curator for city of [**Location (un) 86**]. Smoked 1ppd from age 18-40. Drinks 2 beers per night. Currently living at [**Hospital 38**] Rehab. Has a girlfriend. Mother is medical decision maker but not official HCP. Family History: Noncontributory Physical Exam: VITALS: BP 102/55, HR 113, O2 95% GEN: Awake, alert. Shaking chills during exam. HEENT: Anicteric. No pallor. RIJ in place. Dry MM. CV: Tachycardic and regular. No murmurs. PULM: Clear. ABD: Soft. Midline scar noted. Left sided ostomy noted with air but without stool. GU: 22F SPT draining yellow urine; site is slightly erythematous; perineum without crepitus, minimal tenderness; RECTAL (performed in ED by surgery): Normal tone. No masses. No gross or occult blood. EXT: Warm. No edema. NEURO: Alert. Oriented to person, "[**Hospital1 18**]", "[**5-18**]". CNII-XII intact. Strength 5/5 in upper extremities. RLE [**4-10**] at hip and knee and 5-/5 at ankle. LLE is 4-/5 at hip and 5-/5 at knee and ankle. Patellar refexes are 1+ and equal. Pertinent Results: LABS ON ADMISSION: . [**5-18**] CT ab/pelvis w/ contrast CT ABDOMEN WITH CONTRAST: The lung bases are clear. Cardiac apex is unremarkable. The stomach, proximal small bowel, adrenal glands, pancreas, spleen, gallbladder, liver are unremarkable. Small hypodensity at the upper pole of the left kidney (2:21) is too small to characterize. The kidneys are otherwise unremarkable. Note is made of an infrarenal IVC filter. There is no retroperitoneal or mesenteric lymphadenopathy. A linear hyperdensity at the midline ventral abdominal wall (2:30) most likely represents suture material or post-op calcification. CT PELVIS WITH CONTRAST: A suprapubic catheter is positioned with its tip in the bladder. The urinary bladder and distal ureters are unremarkable. Post- surgical defects of the scrotum are noted. There is no subcutaneous gas. There is no pelvic or inguinal lymphadenopathy. Along the lower pelvic anterior wall just above the level of the pubic symphysus, there is heterogeneous soft tissue thickening along. In the same area is a 28 x 17mm fluid collection (300b:34), ?? seroma versus abscess. There is a left lower quadrant diverting colostomy with mucus fistula. The rectum contains a small amount of barium. The appendix is normal. Steak artifact from pelvic hardware limits evaluuation at the symphysis pubis. OSSEOUS FINDINGS: Patient is status post ORIF of a diastasis of the symphysis pubis and surgical hardware appears in appropriate position. A fixation screw also transverses both sacroiliac joints, also appearing in appropriate position. Old fracture of the left femoral head is unchanged. There is new lucency at the posterior aspect of the left femoral head with adjacent soft tissue calcification (2:83). The cortex of bone is ill-defined in this region, raising concern for osteomyelitis. IMPRESSION: 1. Extensive post-surgical changes following scrotal debridement without definite evidence of Fournier gangrene. Heterogeneous thickening along the lower anterior pelvic wall with small seroma versus small abscess. Evaluation limited due to streak artifact from ORIF hardware. 2. Osseous lucency at the left posterior femoral head. Findings are worrisome for osteomyelitis. Recommend clinical correlation. 3. Status post diverting colostomy with mucus fistula. 4. Old pelvic fractures s/p ORIF, left femoral head fracture, old right lumbar transverse process fractures. . [**5-18**] CXR FINDINGS: Frontal view of the chest is obtained. Right IJ central venous catheter is seen with its tip in the expected region of the SVC. Lungs are clear bilaterally without evidence of consolidation or pneumothorax. Cardiomediastinal silhouette is normal. Bony structures appear intact. The very upper portion of the IVC filter is noted at the lower edge of the film. IMPRESSION: Right IJ central venous catheter in appropriate position. No pneumothorax. [**2101-5-18**] 04:10PM URINE COLOR-Amber APPEAR-Hazy SP [**Last Name (un) 155**]-1.010 [**2101-5-18**] 04:10PM URINE BLOOD-LG NITRITE-POS PROTEIN-100 GLUCOSE-NEG KETONE-TR BILIRUBIN-SM UROBILNGN-1 PH-8.0 LEUK-MOD [**2101-5-18**] 04:10PM URINE RBC-[**11-25**]* WBC-21-50* BACTERIA-MOD YEAST-NONE EPI-0 [**2101-5-18**] 03:58PM LACTATE-2.6* [**2101-5-18**] 03:55PM GLUCOSE-101 UREA N-12 CREAT-0.8 SODIUM-137 POTASSIUM-3.2* CHLORIDE-101 TOTAL CO2-25 ANION GAP-14 [**2101-5-18**] 03:55PM WBC-8.2# RBC-3.99* HGB-11.1* HCT-32.3* MCV-81* MCH-27.9 MCHC-34.4 RDW-15.5 [**2101-5-18**] 03:55PM NEUTS-85.6* LYMPHS-12.5* MONOS-1.6* EOS-0.2 BASOS-0.1 Brief Hospital Course: In brief, Mr [**Known lastname 8840**] is a 46M w h/o recent MVA resulting complex pelvic fx, bladder rupture requiring SPT, admitted for Pseudomonas urosepsis, w MICU stay c/b HAP. . # Pseudomonas UTI: Pt w prior bladder trauma/surgeries, w recent suprapubic tube replacement, p/w F/C, found to have urosepsis. S/p MICU stay. Urine cx grew Pseudomonas (Cipro resistant, Zosyn sensitive), treated w a 14-day course of Zosyn ([**Date range (1) 40253**]). Outpatient urology f/u scheduled (Dr [**Last Name (STitle) 770**]. 3-day course of pyridium, as well as tolterodine and percocet for bladder/urinary discomfort. Clear urine on discharge. . # Hospital-Acquired PNA: Pt developed mild hypoxemia while in the MICU, w possible new RLL infiltrate on CXR. Treated w zosyn for 7 days. Vanc course ([**Date range (1) 40254**]), stopped early given low suspicion for MRSA. Zosyn continued through [**5-31**] for Pseudomonas UTI. Afebrile, SaO2 > 95% on RA on discharge. . # Pain control: Chronic back pain, abdominal and penile discomfort, likely [**2-7**] prior trauma, prolonged bed-stay, bladder spams. Given dilaudid IV PRN in hospital, transitioned to Percocet PRN. . # s/p Pelvic fx: Pt has IVC filter and was systemically anticoagulated prior to SPT replacement. Held coumadin throughout stay. Discharged on 1mg coumadin for PPx, patient has IVC filter . # Anemia: Baseline Hct ~30. Mildly microcytic and stable from [**Month (only) 547**] admission. On iron as outpatient. No transfusions required as inpatient. . # Diverting colostomy: Required s/p MVA earlier in [**2100**]. Pt had barium enema as inpatient to evaluate for rectal pouch, colostomy revision done on [**5-27**] and patient tolerated diet well after surgery. He had multiple small bowel movements with relief. He did complain of some minor gas pain throughout his postoperative course but responded well with simethicone wafers. He was tolerating a normal diet on discharge and not on any antibiotics. Medications on Admission: 1. Citalopram 20mg daily 2. Omeprazole 20mg daily 3. Trazodone 50mg QHS 4. Oxybutynin ER 10mg daily 5. Penazopydridine 100mg TID 6. Diazepam 5mg daily PRN muscle spasm 7. Ferrous Sulfate 325 mg TID 8. Colace 200mg [**Hospital1 **] 9. Senna 10. Bisacodyl 11. Multivitamin daily 12. Simethicone 80mg Q4H PRN 13. Ondansetron 4mg Q4H PN 14. Oxycodone 5mg Q4H PRN Discharge Medications: 1. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Omeprazole 20 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO q4h:prn as needed for pain for 30 days. Disp:*30 Tablet(s)* Refills:*0* 4. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily) as needed for pain. Disp:*25 Adhesive Patch, Medicated(s)* Refills:*0* 5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID:prn as needed for constipation. 7. Tolterodine 2 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 8. Warfarin 1 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM: as directed by Dr. [**Last Name (STitle) **]. Disp:*30 Tablet(s)* Refills:*2* 9. Multivitamin Tablet Sig: One (1) Tablet PO once a day. 10. Iron (Ferrous Sulfate) 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO once a day. 11. Alum-Mag Hydroxide-Simeth 200-200-20 mg/5 mL Suspension Sig: 15-30 MLs PO QID (4 times a day) as needed for indigestion. Disp:*200 ML(s)* Refills:*0* 12. Phenazopyridine 100 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 3 days. Disp:*9 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Pseudomonas urosepsis Hospital acquired pneumonia . diverting colostomy s/p closure s/p bladder rupture w suprapubic tube anemia GERD depression Discharge Condition: improved Discharge Instructions: You were admitted to the hospital with a urinary tract infection. While you were in the hospital, you also developed a lung infection. We treated you with antibiotics for both. Surgery and urology evaluated you as well, they will continue seeing you as an outpatient for further management of your suprapubic tube. Your colostomy was taken down by Dr. [**Last Name (STitle) **] and you are now able to have bowel movements on your own. You completed your course of antibiotics as deemed necessary by the Urology Team. . We changed your medications as follows: 1. Started antibiotics - vancomycin and zosyn 2. Continued your coumadin - you will need to have your INR checked regularly 3. Percocet and lidocaine patch for pain 4. Tolterodine for bladder spasms . If you have fevers, chills, shortness of breath, chest pain, abdominal pain, or any other concerning symptoms, please call your physician [**Name Initial (PRE) 2227**]. Followup Instructions: Appointment #1 MD: Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] Specialty: Surgery - re: colostomy reversal Date and time: call for an appointment, follow up in [**1-7**] weeks Location: [**Hospital **] medical Building, [**Hospital Unit Name **] Phone number: [**Telephone/Fax (1) 6429**] . Appointment #2 MD: Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 770**] Specialty: Urology Date and time: follow up in [**1-7**] weeks after discharge, call for an appointment Location: [**Hospital Ward Name 23**] Clinical Center, [**Location (un) 470**] Phone number: [**Telephone/Fax (1) 5727**] . Follow up with Dr. [**Last Name (STitle) **] in 4 weeks, orthopaedic Surgery, ([**Telephone/Fax (1) 2007**] Completed by:[**2101-6-1**]

[ "599.0", "996.65", "338.21", "596.8", "530.81", "905.1", "038.43", "V55.3", "131.09", "995.91", "311", "E929.0", "607.9", "280.9", "789.07", "724.5", "E878.3", "486" ]

icd9cm

[ [ [] ] ]

[ "46.52", "38.93" ]

icd9pcs

[ [ [] ] ]

11460, 11518

7721, 9692

322, 416

11707, 11718

4170, 4175

12696, 13470

3372, 3389

10101, 11437

11539, 11686

9718, 10078

11742, 12673

3404, 4151

273, 284

444, 2509

4190, 7698

2531, 3107

3123, 3356

30,192

116,899

6480

Discharge summary

report

Admission Date: [**2191-7-3**] Discharge Date: [**2191-7-14**] Date of Birth: [**2155-6-10**] Sex: M Service: SURGERY Allergies: Cortisone / Prednisone / Adhesive Tape Attending:[**First Name3 (LF) 1**] Chief Complaint: BRBPR Major Surgical or Invasive Procedure: Total Colectomy History of Present Illness: 36 yo with UC pan colitis found recently to have rectosigmoid adenocarcinoma, with local extension planned for total colectomy has been undergoing neoadjuvant chemotherapy, on day 4 of 5FU and 3 days of XRT presents after significant BRBPR and lightheadedness. . He states that he has had relatively poorly controlled UC over the past 10 years, complications of rash and perianal fistula in past but not currently, on salicylates (not tolerated), steroids (not effective and steroid psychosis) and remicaide in past- now on rifaximin as well as [**Doctor First Name 130**] and cromolyn to control his GI symptoms. His UC has been relatively stable recently, a "few" painful bowel movements in the a.m. with some blood and mucous. Baseline mild nausea. . This morning he awoke and began having LLQ and RLQ abdominal pain in addition to profusely bloody bowel movements- initially slightly formed stool then progressing to stool consisting mainly of blood. He describes it as bright red, without clots, and roughly 1 liter in total. He felt very lightheaded with the BMs and needed to lay on the ground to prevent passing out. By the time he was admitted he states he had about 50 bowel movements and the bleeding had significantly decreased and his RLQ and LLQ abd pain was subsiding. Mild nausea. Pain was cramping and would fluctate in severity. . No chest pain, shortness of breath, fevers, chills, or other symptoms. Currently feels very mildly lightheaded Past Medical History: Rectosigmoid Adenocarcinoma- T3 lesion on MRI and enlarged lymph nodes (not clearly mets vs. IBD associated)- extensive local extension into mesorectal fat- planned for neoadjuvant chemo and concurrent chemoradiation. 5FU and XRT with plans for subsequent surgery- began 5FU on [**6-29**]. Ulcerative Colitis- diagnosed 10 years ago- c/b perianal fistula Colon CMV infection Mitral Valve Prolapse Migraines Osteoporosis- secondary to steroids Hyperparathyroidism Social History: Lives alone, has PhD in biomedical engineering and molecular biology, post doc studies at BU. No tob, ETOH or drug use. Family History: Father with Ulcerative Colitis. Father w/ CAD, stroke at 69. Died at 69. Mother alive, hypothyroidism and migraines. Healthy Brother. Physical Exam: Tmax: 37.9 ??????C (100.2 ??????F) Tcurrent: 37.9 ??????C (100.2 ??????F) HR: 97 (87 - 97) bpm BP: 147/66(88) {130/66(85) - 147/71(88)} mmHg RR: 16 (15 - 16) insp/min SpO2: 100% Physical Examination General Appearance: Well nourished, Thin Eyes / Conjunctiva: PERRL Head, Ears, Nose, Throat: Normocephalic Cardiovascular: (S1: Normal), (S2: Normal), No(t) S3, No(t) S4, (Murmur: No(t) Systolic, No(t) Diastolic) Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed) Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : ) Abdominal: Soft, Bowel sounds present, No(t) Distended, Tender: RLQ tenderness without rebound, no masses or organomegaly Extremities: Right: Absent, Left: Absent Skin: Not assessed Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone: Not assessed . At Discharge: AVSS Gen: NAD, A/Ox3 CV: RRR RESP: CTAB ABD: +BS, soft, ND, appropriately TTP, RLQ stoma beefy red, viable with liquid brown stool, +flatus Incision: midline OTA CDI Extrem: no c/c/e Pertinent Results: [**2191-7-3**] 11:10AM WBC-4.4 RBC-5.38 HGB-12.7* HCT-41.6 MCV-77* MCH-23.7* MCHC-30.7* RDW-14.4 [**2191-7-3**] 11:10AM NEUTS-80.1* LYMPHS-18.0 MONOS-0.6* EOS-1.1 BASOS-0.2 [**2191-7-3**] 11:10AM PLT COUNT-446* [**2191-7-3**] 11:10AM PT-12.5 PTT-26.2 INR(PT)-1.1 [**2191-7-3**] 11:10AM LIPASE-22 [**2191-7-3**] 11:10AM ALT(SGPT)-12 AST(SGOT)-24 ALK PHOS-115 TOT BILI-1.9* DIR BILI-0.2 INDIR BIL-1.7 [**2191-7-3**] 11:10AM GLUCOSE-167* UREA N-15 CREAT-1.1 SODIUM-137 POTASSIUM-4.7 CHLORIDE-102 TOTAL CO2-20* ANION GAP-20. [**2191-7-12**] 04:39AM BLOOD WBC-5.3 RBC-4.00* Hgb-10.3* Hct-31.6* MCV-79* MCH-25.7* MCHC-32.5 RDW-17.1* Plt Ct-422 [**2191-7-11**] 05:14AM BLOOD Glucose-96 UreaN-6 Creat-0.8 Na-141 K-3.8 Cl-105 HCO3-26 AnGap-14 [**2191-7-11**] 05:14AM BLOOD Calcium-8.1* Phos-3.8 Mg-2.0 . [**2191-7-3**] CXR - SINGLE UPRIGHT VIEW OF THE CHEST AT APPROXIMATELY 1:40 P.M.: IMPRESSION: No free air under the diaphragm. No acute cardiopulmonary abnormalities. . Pathology Examination Procedure date [**2191-7-5**] DIAGNOSIS: Colon, abdominal colectomy: 1. Well-differentiated colonic adenocarcinoma, see synoptic report. 2. Chronic active and inactive colitis, consistent with ulcerative colitis, with diffuse epithelial atypia, favor reactive. 3. Focal active enteritis with villous atrophy. 4. Multiple fissures of distal colon with focal perforation and peri-colic abscess formation. 5. Appendix with fibrous obliteration and focal surface epithelium with atypia, favor reactive. Colon and Rectum: Resection Synopsis MACROSCOPIC Specimen Type: Colonic resection. Location: Abdominal. Specimen Size Greatest dimension: 70.5 cm. Additional dimensions: 6 cm. Tumor Site: Rectum. Tumor configuration: Infiltrative. Tumor Size Greatest dimension: at least 5.2 cm. Additional dimensions: 0.6 cm; see comment. MICROSCOPIC Histologic Type: Adenocarcinoma. Histologic Grade: Low-grade (well or moderately differentiated). EXTENT OF INVASION Primary Tumor: At least pT1: Tumor invades submucosa; see comments. Regional Lymph Nodes: pN2: Metastasis in 4 or more lymph nodes. Lymph Nodes Number examined: 27. Number involved: 5. Distant metastasis: pMX: Cannot be assessed. Margins Proximal margin: Uninvolved by invasive carcinoma: Distance of tumor from closest margin: 700 mm. Distal margin: Involved by invasive carcinoma. Circumferential (radial) margin: Uninvolved by invasive carcinoma: Distance of tumor from closest margin: 35 mm. Lymphatic Small Vessel Invasion: Absent. Venous (large vessel) invasion: Absent. Perineural invasion: Absent. Tumor border configuration: Infiltrating. Additional Pathologic Findings: Two tumor nodules are found in peri-colic adipose tissue that lack residual nodal architecture or capsule. Comments: The exact size and depth of invasion (T stage) cannot be determine as the tumor is present at the distal margin and the entire tumor is not examined. Clinical: Clinical diagnosis and data: Lower GI bleed. Patient with history of ulcerative colitis and rectal carcinoma. Brief Hospital Course: 36 yoM w/ a h/o ulcerative colitis and recent diagnosis of rectosigmoid adenocarcinoma on neoadjuvant chemo (5FU and XRT x 3-4 days) presents with profuse BRBPR and lightheadedness. Plan for colectomy but leaving tumor ?????? colectomy will allow for chemotherapy in setting of severe UC. . 1. GI bleed: s/p total colectomy- sparing rectum and colon CA for further neoadjuvand chemo. Hartmanns pouch and ileostomy on [**2191-7-5**] with Dr. [**Last Name (STitle) **]. Operative course uncomplicated. Patient remained in [**Hospital Unit Name 153**] for close monitoring of Hct's, and associated hypotension. -+ ostomy output and rectal ouput post-op -hypoactive bowel sounds, no nausea -pain moderate, not very well controlled, per surgery switched to morphine pca for more long acting pain control with better control. Pain control switched to oral agents once tolerating clear liquids. Reported pain <[**6-11**]. Dishcarged home with pain medications. -Diet advanced as bowel function resumed. Tolerated regular diet without nausea/vomiting prior to discharge. -Hct followed closely. Treated accordingly with transfusions. HCT's remained stable for many days prior to discharge. No further evidence of GI bleeding. . 2. Ulcerative colitis: patient on a regimen of [**Doctor First Name 130**] 360mg daily, rifaximin 800mg daily and cromolyn 400mg daily (when he eats), -GI and Onc following: Per GI recommendations, d/c'd rifaximin & restarted on home dose of [**Doctor First Name 130**] & Cromolyn for management of rectal bleeding. . 3. Fever -no clinical evidence of DVT, high fever w/o leukocytosis however s/p chemo, not neutropenic, continue to follow ANC -on cipro / flagyl, remained afebrile with normal WBC, discontinued prior to discharge home. -Blood cultures all with no growth. Urine cx from [**7-4**] grew enterococcus which was treated with IV Cipro. -Medical & radiation Oncology involved-recommended follow-up Monday after discharge for re-assessment. Plan to resumes Chemo/XRT depending on physical exam, and labowrk data. . Physical Therapy: Due to prolonged ICU stay, and deconditioning, patient was evaluated by PT. PT worked with patient for a few sessions, and cleared him for discharge home without PT services. He continued to ambulate halls of 12 [**Hospital Ward Name **] independently. . Ostomy: Patient followed by ostomy RN specialists during admission. Competent with emptying pouch. Visiting RN services set up for home to continue teaching, and assessment of stoma/surgical wound. In addition to follow-up with Med/Rad Oncology, patient advised to follow-up with Dr. [**Last Name (STitle) **] in [**3-6**] weeks. Medications on Admission: Zinc Vitamin D B complex Codeine 7.5mg daily prn diarrhea Cromolyn 400mg daily [**Doctor First Name **] 360mg daily Rifaximin 800mg daily Vitamin D 6000 units qod MVI daily Discharge Medications: 1. Cromolyn 100 mg/5 mL Solution Sig: One (1) 20mL PO daily (): Take with food. 2. [**Doctor First Name **] 180 mg Tablet Sig: Three (3) Tablet PO once a day: Prevention of rectal bleeding. 3. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for fever or pain: Do not exceed 4000mg/24hrs. 4. Zofran 8 mg Tablet Sig: One (1) Tablet PO every eight (8) hours as needed for nausea. 5. Centrum 0.4-162-18 mg Tablet Sig: One (1) Tablet PO once a day. 6. Vitamin D 1,000 unit Tablet Sig: Six (6) Tablet PO every other day. 7. Morphine 15 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO Q12H (every 12 hours) as needed for pain for 2 weeks: Take with food. Disp:*35 Tablet Sustained Release(s)* Refills:*0* 8. Morphine 15 mg Tablet Sig: One (1) Tablet PO Q3-4H () as needed for breakthrough pain for 2 weeks: Take with food. Disp:*45 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Primary: Flared ulcerative colitis with low abdominal peritonitis (perforation of the rectum) Anemia . Secondary: UC, rectosigmoid adenoca w/CEA 1.9, [**5-25**] sig w/nodular heaped up mucosa seen in the proximal rectum, PATHT well diff adenoca, mitral valve prolapse, migraines Discharge Condition: Stable Tolerating a regular diet Adequate pain control with oral medication 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. * 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 becoming progressively worse, or inadequately controlled with the prescribed pain medication. * 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. Incision Care: *You may shower. Pat incision dry. *Avoid swimming and baths until further instruction at your followup appointment. *Leave the steri-strips on. They will fall off on their own, or be removed during your followup. *Please call the doctor if you have increased pain, swelling, redness, or drainage from the incision sites. Monitoring Ostomy Output / Prevention of Dehydration: *Keep well hydrated. *Replace fluid loss from ostomy daily. *Avoid only drinking plain water. Include Gatorade and/or other vitamin drinks to replace fluid. *Try to maintain ostomy output between 500mL to 1000mL per day. *If Ostomy output exceeds 1 liter, take 4mg of Imodium, repeat 2mg with each episode of loose stool. Do not exceed 16mg in 24 hours. Followup Instructions: Please call the office of Dr. [**Last Name (STitle) **] to make a follow up appointment in [**3-6**] weeks. [**Telephone/Fax (1) 9**] . Please make a follow-up appointment with your PCP, [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) 3613**] [**Last Name (NamePattern1) 5085**] [**Telephone/Fax (1) **] in 1 week and as needed. . You have an appointment on Monday [**7-18**] with Radiation Oncology service ([**Telephone/Fax (1) 8082**] at 8:30am located in [**Hospital Ward Name 332**] basement. . Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 6050**], MD Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2191-7-25**] 11:00 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 593**], MD Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2191-7-25**] 11:00 Completed by:[**2191-7-18**]

[ "346.90", "154.8", "556.6", "578.1", "V15.3", "567.22", "424.0", "338.18", "733.09", "569.49", "E932.0", "276.2" ]

icd9cm

[ [ [] ] ]

[ "45.8", "46.21", "99.15" ]

icd9pcs

[ [ [] ] ]

10666, 10724

6861, 8909

300, 317

11047, 11124

3732, 6838

12749, 13597

2455, 2594

9741, 10643

10745, 11026

9543, 9718

11148, 11978

11993, 12726

2609, 3514

8927, 9517

3528, 3713

255, 262

345, 1813

1835, 2301

2317, 2439

68,663

165,128

19909

Discharge summary

report

Admission Date: [**2119-8-22**] Discharge Date: [**2119-9-23**] Date of Birth: [**2074-8-24**] Sex: M Service: SURGERY Allergies: Penicillins Attending:[**First Name3 (LF) 695**] Chief Complaint: Ascites and lower extremity edema. Major Surgical or Invasive Procedure: Paracentesis. History of Present Illness: 44yo male w/ Down Syndrome, hepatitis C cirrhosis who comes in from liver transplant clinic with decompensated cirrhosis. He feels generally well, but says that his abdomen has been more distended over the last six days. He says that his lower extremity swelling is uncomfortable but that there has not been any acute change. He denies fevers, chills, nausea, vomiting, but is generally a poor historian. He has still been working without difficulty by his report. He says that [**Doctor First Name **], the house manager at his group home will be in tomorrow, and that she knows more about his medications and recent history. [**Doctor First Name **] called his liver specialist today given the patient's weight gain, and was told to take him to the ED. . Per the note from clinic one week ago, he has recently been more fluid overload than normally. He is not adherent to a sodium-restricted diet and is unable to tolerate diuretics due to renal insufficiency. He has since been on diuretic therapy with spironolactone 50 mg daily plus lasix 40 mg daily, though lasix was discontinued on [**2119-7-28**] due to elevated Cr and concern that it is exacerbating his chronic thrombocytopenia. . In the ED, initial vitals were 99.4 62 112/46 18 100% RA. He was given vancomycin for potential LE cellulitis. Labs notable for ALT 115, AST 235, Lipase 127 (no abd pain), Tbili 3.2, INR 1.4, Cr 1.5. Diagnostic para did not show SBP. Vitals prior to transfer were 99.4 hr 56 b/p 116 /64 rr 20 02 sat 99. Past Medical History: 1. Hepatitis C virus. 2. Cirrhosis. 3. Ascites. 4. Chronic kidney disease. 5. Hypertension. 6. Gout. Past Surgical History: Denies. Social History: Nonsmoker, nondrinker, non-IV drug abuser. Lives in group home. Is employed. Has a 61-year-old brother in [**State 15946**] and another brother somewhere in [**State 350**]. Both parents are deceased. Family History: No known liver disease or cardiac disease. Physical Exam: ADMISSION EXAM Vitals: 98.6 113/60 57 18 100% RA General: Well-appearing man sitting comfortably in NAD HEENT: Sclerae minimally icteric, EOMI. Oropharynx clear. Neck: Supple, no cervical LAD, mild JVD Heart: RRR, II/VI systolic murmur loudest at L lower sternal border. No rubs or gallops. Lungs: Clear except for decreased breath sounds at the bilateral bases. Abdomen: Distended with bulging flanks and + fluid wave. Non-tender. Extremities: 2+ pitting edema to above the knees. Multiple wet appearing venous stasis ulcers, some with surrounding erythema. On the right shin, there is a round, erythematous plaque. Neurological: CNII-XII intact, 5/5 strength, sensation grossly intact. Pertinent Results: ADMISSION LABS: [**2119-8-22**] 02:30PM BLOOD WBC-6.9 RBC-3.46* Hgb-12.7* Hct-37.5* MCV-108* MCH-36.7* MCHC-33.9 RDW-18.0* Plt Ct-43* [**2119-8-22**] 02:30PM BLOOD PT-16.3* PTT-35.3* INR(PT)-1.4* [**2119-8-22**] 02:30PM BLOOD Glucose-140* UreaN-37* Creat-1.5* Na-137 K-6.6* Cl-113* HCO3-21* AnGap-10 [**2119-8-22**] 02:30PM BLOOD ALT-115* AST-235* TotBili-3.2* [**2119-8-22**] 02:30PM BLOOD Phos-3.1 Mg-2.0 OTHER STUDIES -cystatin C: 3.4 -vitamin D: 5 URINE [**2119-8-22**] 02:30PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.009 [**2119-8-22**] 02:30PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG [**2119-8-29**] 04:20PM URINE Hours-RANDOM UreaN-1054 Creat-157 Na-22 K-52 Cl-<10 [**2119-9-6**] 09:16PM URINE pH-6 Hours-24 Volume-2925 UreaN-262 Creat-41 [**2119-9-6**] 09:16PM URINE 24Creat-1199 PERITONEAL FLUID [**2119-8-22**] 04:30PM PLEURAL WBC-355* RBC-3050* Polys-1* Lymphs-32* Monos-0 Meso-5* Macro-62* [**2119-8-22**] 04:30PM PLEURAL TotProt-0.6 Glucose-156 LD(LDH)-57 Albumin-<1 [**2119-8-28**] 11:45AM ASCITES WBC-200* RBC-1425* Polys-2* Lymphs-19* Monos-0 Atyps-1* Mesothe-2* Macroph-76* [**2119-8-28**] 11:45AM ASCITES TotPro-0.7 LD(LDH)-50 Albumin-<1.0 IMAGING: CXR: Mild pulmonary edema with small bilateral pleural effusions. R. LOWER LEG PUNCH BIOPSY: Increased dermal capillaries with red cell extravasation and extensive (pan-dermal) hemosiderin deposition (see note). Note: No leukocytoclastic or lymphocytic vasculitis is seen. The changes are consistent with chronic stasis, and in the context of the described clinical lesion, suggest acroangiodermatitis of [**Country **]. CT ABDOMEN [**2119-8-24**]: 1. No concerning liver lesions. Multiple hepatic hemangiomas and a single segment II liver cyst are unchanged. 2. Cirrhotic liver, with stigmata of portal hypertension including splenomegaly, ascites, and numerous splenorenal shunts and varices. CT ABDOMEN [**2119-9-18**]: 1. Moderate bilateral pleural effusions with compressive atelectasis. 2. Patent portal venous system. 3. Cirrhosis with ascites, splenomegaly, and gastroesophageal varices. Brief Hospital Course: 45yo male with Down syndrome, hep C with cirrhosis currently undergoing evaluation for transplant who presents volume overloaded with ascites and lower extremity edema. . # Cirrhosis: Patient presented very fluid overloaded with ascites and lower extremity edema. He was found on recent CT to have indeterminate lesiosn in his liver with elevated AFP and currently undergoing transplant evaluation. Labs on admission significant for transaminitis, bili of 3, low albumin, thrombocytopenia and elevated INR. Fluid overload likely secondary to absence of diuretics for several weeks. Repeat CT showed lesions likely hemangiomas. Diagnostic paracentesis showed no evidence of SBP. Patient was started on diuretic regimen of lasix and spironolactone however given bump in Cr diuretics were stopped. Renal was consulted for further management and question of possible ultrafiltration (please see below). Also during admission, ethics meeting was held and the decision to complete transplant evaluation was made. Patient completed transplant evaluation during admission. Patient was continued on propranolol for prophylaxis for variceal bleed. He was also started on cipro for SBP ppx. . # LE skin changes and lesions - Pt has chronic venous stasis changes. Also has large violaceous plaque on RLE. Few wounds are open with some serosanguinous drainage. Some surrounding erythema although not warm. No fever or leukocytosis. Derm consulted for violaceous plaque. Patient underwent skin biopsy. Results c/w venous stasis change called acrodermatitis of [**Country **]. Initially he was started on vancomycin for possible cellulitis but this was discontinued as infection was unlikely. Wound care and dermatology made specific recommendations for dressing changes while in house. . #acute on chronic renal insufficiency: Baseline Cr around 1.3 with recent jump to 2.1 likely in the setting of diuresis and contrast from recent CT. Patient was initially started on lasix of spironolactone. However, given increase in Cr, renal was consulted for possible ultrafiltration. Renal recommended that patient continue to be diuresed and that ultrafiltration would further damage his kidney. Per renal recs he was started on torsemide [**Hospital1 **] with albumin. He diuresed [**12-25**] kg per day and his Cr remained stable around 2. He had a 24 hour urine collection to calculate GFR and a cystatin C level. He was evaluated for possible liver-kidney transplant and given 2 weeks of reduced GFR he was thought to meet criteria to qualify. Patient then spiked fever and Cr jumped from 2.2 to 3.7. . # Fever - Patient spiked fever up to 103.4 with chills. Also with cough and dyspnea. CXR concerning for pneumonia. Peritoneal fluid with no evidence of SBP. Patient was started on broad spectrum antibiotics. His respiratory status further decompensateda nd he was transferred to the SICU. . # Gout: continue allopurinol . The above summarizes his hospital course from [**2119-8-22**] to [**2119-9-14**]. On [**2119-9-14**], he developed respiratory distress, with intermittent need for high flow supplemental oxygen and he was transferred to the SICU on the transplant surgery service. CXR showed LLL pneumonia and worsening pulmonary edema. He was treated empirically with broad-spectrum antibiotics, although around the time of transfer, blood/urine/sputum cultures and stool samples and broncheoalveolar lavage grew no pathogen. There was yeast in his sputum on [**2119-9-18**] and this was treated with fluconazole. . On [**2119-9-16**], he was intubated for respiratory distress. On [**2119-9-17**], he was started on CVVH for renal failure, and he became hypotensive requiring norepinephrine gtt. His medical condition continued to deteriorate and ICU, hepatology, and liver transplant surgery teams agreed his medical derangements were unlikely to be reversed sufficiently to allow him to tolerate liver transplantation, to treat his underlying decompensated cirrhosis. On [**2119-9-22**], this was discussed with his family and his state guardian, who agreed to render him DNR. On [**2119-9-23**], he was rendered CMO and he expired. Medications on Admission: 1. Inderal 20 mg twice daily. 2. Spironolactone 50 mg on hold. 3. Furosemide 20 mg on hold. 4. Zyloprim 200 mg once daily. 5. Tylenol p.r.n. 6. Robitussin p.r.n. Discharge Medications: None. Discharge Disposition: Expired Discharge Diagnosis: Decompensated hepatitis C cirrhosis Chronic kidney disease Hepatorenal syndrome Venous stasis ulcers Discharge Condition: Expired. Discharge Instructions: He who has gone, so we but cherish his memory. Followup Instructions: None. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**] MD, [**MD Number(3) 709**] Completed by:[**2119-9-23**]

[ "276.2", "V49.86", "274.9", "228.04", "070.54", "518.4", "459.81", "486", "584.9", "758.0", "572.3", "789.59", "571.5", "686.8", "287.5", "585.9", "707.12", "518.82", "572.4", "276.7", "V02.54", "V66.7", "403.90" ]

icd9cm

[ [ [] ] ]

[ "96.72", "38.91", "96.04", "38.93", "33.24", "86.11", "39.95", "54.91", "96.6" ]

icd9pcs

[ [ [] ] ]

9560, 9569

5183, 9318

305, 320

9713, 9723

3004, 3004

9818, 9981

2236, 2280

9530, 9537

9590, 9692

9344, 9507

9747, 9795

1993, 2002

2295, 2985

231, 267

348, 1846

3020, 5160

1868, 1970

2018, 2220

18,982

190,161

3192

Discharge summary

report

Admission Date: [**2138-7-6**] Discharge Date: [**2138-7-19**] Date of Birth: [**2069-8-5**] Sex: F Service: MEDICINE Allergies: Captopril / Neurontin / Shellfish / Nsaids / Promethazine Attending:[**First Name3 (LF) 1881**] Chief Complaint: fall, abdominal pain Major Surgical or Invasive Procedure: Place of right subclavian central line History of Present Illness: The patient is a 68-year-old woman with multiple medical problems including DM, HTN, CHF, hypercholesterolemia, COPD, GERD, and seizure disorder who recently underwant ex-lap repair of an incarcerated ventral hernia on [**6-23**], admitted to the surgery service after falling at her [**Hospital3 **] home. Per ED and surgery notes, she developed nausea (but no vomiting), mild abdominal pain, and some diarrhea. She had been told to hold her Lasix on discharge [**7-2**]. She had not been eating much but did take her glipizide. The night before admission she went to the bathroom and fell but did not hit her head. She could not get up 2/2 weakness and was on the floor ~6 hours. She was unsure of LOC but denied CP/palpitations/SOB. On arrival to the ED, her BS was found to be 18. She was given glucagon, OJ, and dextrose with good response. She was admitted to the [**Month/Year (2) 10115**] for possible C. diff colitis. Her PCP ([**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) **]) has requested med consult follow along for her multiple comorbidities. . In the [**Last Name (LF) 10115**], [**First Name3 (LF) **] NGT and a central line was placed and the CVP was noted to be 20. The patient as diuresed with 10mg IV Lasix with improvement of the CVP to 11. She was on a diltiazem drip for about 4 hours while in sinus tach with improvement of her HR from 110s to 102. Past Medical History: 1. CVA x2: - Frontal with minimal residual LLE and right facial weakness. 2. Diabetes mellitus w/ diabetic gastroparesis 3. Pulmonary embolism (history of) - s/p IVC filter [**2135**] 4. Hypertension 5. Congestive heart failure, LVEF 50% 3/06. 6. Hypercholesterolemia 7. COPD: - Multiple hospitalizations for flares including in [**1-/2131**], [**4-/2131**], [**3-/2131**], [**11/2133**], [**11-14**], [**8-15**] Baseline peak flow of 250-190. Uses 2L O2 at night. 8. Asthma 9. Trochanteric bursitis ([**5-/2136**]) 10. Recurrent C diff colitis ([**2135**]) 11. Functional obstruction necessitating laparotomy in [**2135**]; complicated by long healing course and abdominal hematoma. 12. Question of seizures; found to have hyperammonemia from valproate. 13. Lipomatous mass extending into the chest ([**6-/2134**]) 14. Chronic lumbar back pain, s/p lumbar laminectomy ([**2128**]) 15. DJD of knees 16. Depression 17. Severe GERD, s/p treatment for H pylori 18. MRSA PNA 19. h/o hypomagnesemia 20. x-lap/ventral hernia repair '[**35**] 21. x-lap repair of incarcerated ventral hernia [**6-23**] Social History: Mrs [**Known lastname **] was born in [**State 3908**]. She worked for many years as a waitress. She has lived in an assisted facility for the last several years. She has four children, who are supportive and live nearby. Former 30+ pack-year smoker, quit 5 years ago. Former EtOH use. No illicit drug use. Family History: HTN in relatives, malignancy including pancreas, larynx. Diabetes and asthma. Physical Exam: VS: 99.3, 129/48, 102, 11, 99% 2L NC, CVP 11 Gen: somnolent but arousable, answers questions appropriately HEENT: PERRL, EOMI, MMM, OP clear Neck: supple, difficult to assess JVP Lungs: diffuse expiratory wheezes, diffuse rhonchi bilaterally CV: tachycardic, RR, nl S1S2, difficult exam due to breath sounds Abd: +BS, large vertical abdominal surgical incision with staples, indurated skin around incision but otherwise soft, distended, tenderness to deep palpation diffusely but greatest at LLQ Ext: trace edema to knees bilaterally, no c/c Neuro: AAOx3, CN II-XII intact, strength 4/5 in all extremities, sensation grossly intact Pertinent Results: Labs on admission: [**2138-7-6**] 12:30PM BLOOD WBC-24.6*# RBC-2.66* Hgb-8.0* Hct-24.2* MCV-91 MCH-30.1 MCHC-33.0 RDW-17.3* Plt Ct-450* [**2138-7-6**] 12:30PM BLOOD Neuts-85* Bands-7* Lymphs-5* Monos-3 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 [**2138-7-6**] 12:30PM BLOOD PT-11.4 PTT-23.0 INR(PT)-1.0 [**2138-7-6**] 12:30PM BLOOD Glucose-131* UreaN-19 Creat-1.6* Na-142 K-4.0 Cl-107 HCO3-25 AnGap-14 [**2138-7-6**] 12:30PM BLOOD ALT-22 AST-23 LD(LDH)-413* AlkPhos-63 Amylase-168* TotBili-0.2 [**2138-7-6**] 12:30PM BLOOD TotProt-5.7* Albumin-3.6 Globuln-2.1 [**2138-7-6**] 12:30PM BLOOD Hapto-109 [**2138-7-6**] 12:53PM BLOOD Lactate-1.6 Microbiology: Urine culture ([**7-6**]): 12:30 pm Site: CLEAN CATCH **FINAL REPORT [**2138-7-8**]** URINE CULTURE (Final [**2138-7-8**]): ENTEROCOCCUS SP.. 10,000-100,000 ORGANISMS/ML.. PSEUDOMONAS AERUGINOSA. 10,000-100,000 ORGANISMS/ML.. SENSITIVITIES: MIC expressed in MCG/ML _______________________________________________ ENTEROCOCCUS SP. | PSEUDOMONAS AERUGINOSA | | AMPICILLIN------------ <=2 S CEFEPIME-------------- 8 S CEFTAZIDIME----------- 4 S CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ =>16 R IMIPENEM-------------- 8 I MEROPENEM------------- 0.5 S NITROFURANTOIN-------- <=16 S PIPERACILLIN---------- <=4 S PIPERACILLIN/TAZO----- <=4 S TETRACYCLINE---------- =>16 R TOBRAMYCIN------------ =>16 R VANCOMYCIN------------ 2 S Urine cultures ([**7-7**], [**7-9**], [**7-13**]) all with Pseudomonas Blood culture ([**7-6**]): diphtheroids (likely contaminant, [**2-11**] bottles) blood culture ([**7-7**]): no growth stool negative for C diff ([**7-8**]) Imaging: CXR ([**7-6**]): No acute process is demonstrated. Placement of right-sided subclavian line with no pneumothorax. CT abdomen/pelvis ([**7-6**]): 1. Post-ventral hernia repair. Limited study due to lack of intravenous contrast [**Doctor Last Name 360**]. Diffusely dilated small and large bowel, without evidence of obstruction or recurrent hernia. Fat stranding and soft tissue and fluid surrounding the postoperative bed, most likely representing post operative changes seroma. 2. Multiple hypodense lesions in both kidneys, unchanged since the prior study, for which MRI will provide further information. 3. 8-mm hypodense lesion in the uncinate process of the pancreas, as noted on the prior study. Again, this could be further evaluated with MRI. 4. Intramuscular fat containing lesion of the right adductor musclature of the proximal leg. This is incompletely evaluated on the current study. This lesion could be further evaluated with MR to exclude the presence of soft tissue nodularity or enhancement when clinically appropriate. 5. New patchy opacities in the right lower lobe, likely inflammatory since they are new since the previous CT from [**6-23**]. CT head ([**7-6**]): Unchanged appearance of the brain without acute intracranial hemorrhage. CT chest ([**7-8**]): Development of right upper lobe infiltrate most consistent with pneumonia or other acute inflammatory process. Atherosclerotic calcification. Small right pleural effusion. Possible small left pleural effusion. ECHO ([**7-8**]): The left atrium is normal in size. Left ventricular wall thickness, cavity size, and systolic function are normal (LVEF>55%). Regional left ventricular wall motion is normal. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. There is mild pulmonary artery systolic hypertension. There is an anterior space which most likely represents a fat pad. Compared with the report of the prior study (images unavailable for review) of [**2137-4-30**], the findings are similar. T spine xray ([**7-9**]): There is no evidence of a compression fracture. There is scoliosis as seen on the [**2134-3-22**] MRI. Labs at discharge: Brief Hospital Course: Ms. [**Known lastname **] is a 68 year old female w/ multiple medical problems including DM, HTN, CHF, hypercholesterolemia, COPD, GERD, and seizure disorder here with abdominal pain following surgery and PNA found to have esophagitis. . ## Esophagitis: The patient was found to have severe esophagitis on EGD which may represent acute necrotic esophagits. There were also some yeast forms seen on pathology. We plan to continue fluconazole X total 2 weeks (start date [**7-11**]). She has also been maintained on [**Hospital1 **] PPI and nystatin swish and swallow. Sucralfate was added for pain control. - The patient has follow up scheduled with Dr. [**Last Name (STitle) 9746**] for [**8-18**], [**2138**] at 3:30 pm on the [**Location (un) 861**] of the [**Hospital Unit Name **]. She is planned for repeat EGD in [**7-18**] weeks. - She is currently on treatment for [**Female First Name (un) **] with fluconazole (for now IV as she has pain with swallowing); can transition to PO once pain is less for total 14 day treatment. - She should continue magic MW (including viscous lidocaine), sucralfate, and morphine prior to meal times to increase PO intake. - Nutrition is following the patient. Would recommend continued supplementation with Boost/Ensure/etc. - Should be on guard for signs of esophageal stricture which may present after esophageal necrosis. Signs/symptoms would include trouble swallowing, coughing, aspiration, or any sensation of food "sticking." . ## Leukocytosis: The patient has transiently had a leukocytosis throughout her course. She has known pseudomonas in the urine, but repeat UA with 0 WBCs. Most recent CXR is clear. WBCs in normal range on [**7-18**]. Confounding all of this, the patient is also on steroids chronically. - Due to known pseudomonas in the urine, consider treating with cefepime or zosyn should the patient have a temperature spike. Could repeat UA prior to initiating treatment. -- Alternatively, should the patient have a temperature given her recent abdominal surgery and known esophageal necrosis, could consider CT torso (with contrast, so would need prehydration with bicarb fluids for renal protection) to rule out abscesses. -- She has been treated for C diff colitis (last treatment day [**7-20**]). . # Bacteruria: Foley catheter has been removed. Likely that pseudomonas is a contaminant. If concern for true infection, treat as above. . ## Anemia: Her hematocrit is low but stable (~ 30). . ## Pneumonia/COPD: The patient was treated with vancomycin X 7 days with relief of hypoxia. No sign of pneumonia on repeat CXR. Oxygenation continues to be good. - We continued her albuterol/atrovent nebs, advair, and current dose of prednisone. . ## Status post hernia repair: Staples removed on [**7-15**]. Abdomen is benign. . ## Hypertension: Now on norvasc 10 daily. Also on diltiazem 120 [**Hospital1 **] sustained release (increased from prior dose 60 [**Hospital1 **]). - Continue to monitor BPs. . ## abdominal pain: This issue resolved and could have been due to C. diff colitis vs. post-surgical pain. LFTs were normal. -- Treating C diff with flagyl X 14 day course. -- Abdominal pain improved & no further diarrhea so no further specimens sent. -- Patient now with normal BMs. . ## hypoxia, CHF: The patient was weaned to room air. Was previously clinically volume overloaded in setting of holding Lasix. -- Now on lasix 10 mg IV daily. Can consider changing back to PO dose (40 daily) when taking pills less painful. . ## hypoglycemia: Resolved and occurred in setting of poor PO intake but still taking meds -- resolved with glucagon and D50 in ED -- monitor FS -- continue RISS for now -- Previously on glipizide 10 mg daily (home regimen). . ## tachycardia: Likely multifactorial, given possible infectious colitis, anemia, being off CCB. No evidence of PE on EKG. Improved with treatment of infection and back on home medications. . ## hyperkalemia: Resolved. . ## FEN: Liquid diet for now with boost supplements/puddings. Replete lytes prn. . ## Proph: IV PPI [**Hospital1 **]. On hep SC TID until patient is ambulatory. . ## Dispo: Likely to go to rehab facility for reconditioning, further monitoring of ongoing medical issues. Medications on Admission: 1. Aspirin 81 mg daily 2. Lipitor 20 mg daily 3. Diltiazem 60 mg [**Hospital1 **] 4. Norvasc 10 mg daily 5. Lasix 40 mg daily (instructed not to take after discharge on [**7-2**]) 6. Glipizide 10 mg daily 7. Advair 250/50 1 puff [**Hospital1 **] 8. Albuterol neb q 4 hours prn 9. Tripleptal 300 mg [**Hospital1 **] 10. Desiprimine 2 tablets 10mg QHS 11. Prednisone 20 mg daily 12. MS Contin 15 mg po qd 13. MS Contin 30 mg po qd 14. Reglan 10 mg qid 15. Colace 100mg [**Hospital1 **] 16. Senna 1 tab po bid . Meds on transfer: RISS Fluticasone-Salmeterol (250/50) 1 INH IH [**Hospital1 **] Albuterol 0.083% Neb Soln 1 NEB IH Q2H:PRN Aspirin 81 mg PO DAILY Desipramine HCl 10 mg PO DAILY PredniSONE 20 mg PO DAILY HYDROmorphone (Dilaudid) 2-6 mg IV Q1-2H:PRN pain Pantoprazole 40 mg IV Q24H Magnesium Sulfate IV Sliding Scale Calcium Gluconate IV Sliding Scale Ondansetron 4-8 mg IV Q4H:PRN nausea Morphine Sulfate 2 mg IV Q4H:PRN Heparin 5000 UNIT SC TID Vancomycin Oral Liquid 250 mg PO Q6H MetRONIDAZOLE (FLagyl) 500 mg IV Q8H Discharge Medications: 1. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) puff Inhalation [**Hospital1 **] (2 times a day). 2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 3. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 4. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000) U Injection TID (3 times a day): continue while patient nonambulatory. 5. Desipramine 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 6. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: One (1) treatment Inhalation every four (4) hours as needed for wheezing/COPD. 7. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day). 8. Oxcarbazepine 300 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 9. Ipratropium Bromide 0.02 % Solution Sig: One (1) treatment Inhalation Q6H (every 6 hours). 10. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed for constipation. 11. Lidocaine Viscous 2 % Solution Sig: Fifteen (15) mL Mucous membrane every four (4) hours as needed for pain: Swish & swallow as needed for esophageal pain. Not to exceed 8 doses daily. 12. Prednisone 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Maalox 200-200-20 mg/5 mL Suspension Sig: Five (5) mL PO every six (6) hours as needed for indigestion. 14. Lipitor 20 mg Tablet Sig: One (1) Tablet PO once a day. 15. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day. 16. Senna 8.6 mg Capsule Sig: One (1) Capsule PO twice a day. 17. Diltiazem HCl 120 mg Capsule, Sust. Release 12 hr Sig: One (1) Capsule, Sust. Release 12 hr PO twice a day. 18. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 2 days. 19. PICC care Picc line care per protocol please. 20. Sucralfate 1 g Tablet Sig: One (1) Tablet PO QID (4 times a day). 21. Fluconazole in Saline(Iso-osm) 200 mg/100 mL Piggyback Sig: One Hundred (100) mg Intravenous Q24H (every 24 hours) for 6 days. 22. Insulin Regular Human 100 unit/mL Solution Sig: as directed U Injection ASDIR (AS DIRECTED): see attached sliding scale. 23. Morphine 2 mg/mL Syringe Sig: Two (2) mg Injection Q3-4H (Every 3 to 4 Hours) as needed for pain. 24. Furosemide 10 mg/mL Solution Sig: Ten (10) mg Injection DAILY (Daily). 25. Ondansetron HCl (PF) 4 mg/2 mL Solution Sig: Four (4) mg Injection every eight (8) hours as needed for nausea. 26. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO twice a day. Discharge Disposition: Extended Care Facility: [**Hospital3 7**] & Rehab Center - [**Hospital1 8**] Discharge Diagnosis: Esophagitis Pneumonia, resolved Abdominal pain, resolved Status post incarcerated hernia repair Secondary: Chronic obstructive pulmonary disease Diabetes mellitus type 2 Hypertension History of recurrent C diff colitis History of stroke Discharge Condition: Afebrile, normotensive, comfortable on room air Discharge Instructions: You have been evaluated for your abdominal pain, chest pain, and difficulty breathing. When you were initially admitted, you were evaluated by surgery who did not believe there was a surgical problem. [**Name (NI) **] had difficulty breathing which was attributed to pneumonia and fluid overload. This was treated with a course of antibiotics (vancomycin) as well as your diuretic (lasix). Your breathing improved and you have been comfortable on room air. You were later found to have esophagitis (inflammation of your esophagus). We have treated this with an antibiotic aimed at fungus (fluconazole) as well as a proton pump inhibitor for inflammation (protonix). Please call your doctor or return to the emergency room should you develop any of the following symptoms: fever > 101, chills, nausea or vomiting, inability to pass gas or inability to move your bowels, abdominal pain, blood in your stools, increased pain with swallowing, pain with urination, dizziness or lightheadedness, or any other concerns. Followup Instructions: Please follow up with your primary care doctor, Dr. [**Last Name (STitle) **], within 1-2 weeks. Please call [**Telephone/Fax (1) 250**] to make this appointment. Please follow up with the gastroenterologists on [**2138-8-18**] at 3:30 pm (Dr. [**First Name4 (NamePattern1) 14992**] [**Last Name (NamePattern1) 9746**]). This appointment is in [**Hospital Unit Name **] on the [**Location (un) **]. You will need a follow up endoscopy in [**7-18**] weeks. Please keep these other already-scheduled appointments: Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 435**] Date/Time:[**2138-7-22**] 8:00 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1882**], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2138-8-19**] 12:30 [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1882**] MD, [**MD Number(3) 1883**] Completed by:[**2138-7-22**]

[ "V18.0", "285.9", "112.84", "962.3", "250.80", "V17.5", "V58.67", "V16.0", "438.83", "E849.0", "428.0", "E885.9", "535.50", "E858.0", "585.9", "536.3", "250.60", "272.0", "V16.2", "008.45", "V12.51", "493.20", "V17.4", "715.96", "V15.82", "486", "403.90" ]

icd9cm

[ [ [] ] ]

[ "99.21", "99.04", "88.72", "96.07", "45.16", "38.93" ]

icd9pcs

[ [ [] ] ]

16133, 16212

8335, 12546

337, 377

16494, 16544

4006, 4011

17607, 18578

3259, 3338

13626, 16110

16233, 16473

12572, 13081

16568, 17584

3353, 3987

277, 299

8312, 8312

405, 1800

4025, 8291

1822, 2919

2935, 3243

13099, 13603

28,223

187,916

12929

Discharge summary

report

Admission Date: [**2190-5-20**] Discharge Date: [**2190-5-30**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2387**] Chief Complaint: gangrenous toe Major Surgical or Invasive Procedure: Lower extremity angiogram with balloon angioplasty and placement of stent History of Present Illness: Mr. [**Known lastname 39714**] is an 89yo gentleman with dementia, PVD, diastolic CHF, and AFib on coumadin admitted for work-up of gangrenous toe and mental status changes. Of note, he had been taking increased doses of percocet for the painful foot, and he had been increasingly withdrawn in the setting of his son's death on [**5-6**]. Shortly after admission to the floor, he was noted to be unresponsive except to sternal rub; ABG was 7.07/120/225. A Code Blue was called, and the patient was intubated for hypercarbic respiratory failure. In the MICU, he was found to be febrile; cultures were significant for a positive UA, and he was started on cipro. He self-extubated himself during a spontaneous breathing trial and did well without need for reintubation. Per his family, his mental status at baseline is that he responds to questions but is not oriented. Past Medical History: Chronic Diastolic CHF (EF 45%) PVD s/p R SFA stent [**2-/2190**], s/p PTA peroneal, s/p R tarsometatarsal amputation Tachy-brady syndrome s/p PPM Atrial fibriallation on coumadin CAD CRI (baseline Cr 1.5-2.0) h/o locally advanced prostate cancer Anemia of chronic disease (colonoscopy and EGD unremarkable) h/o lung nodules (recent CT scan with unchanged nodules on chest CT - likely silicosis vs malignancy) ?? h/o miner's lung Gout dementia CVA Allergies: NKDA PCP: [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5456**] Cardiologist: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] Social History: Worked as a coal miner. Has 24/7 care at home for daily activities; 15 children. Not ambulating since his recent amputation of toes on right foot. Needs help with daily activities (eating, dressing). Family History: Non-contributory. Physical Exam: VS- 100.0 158/52 54 20 100% RA Gen- Awake, pleasant, responds slowly to some questions, not at all to others, oriented to self but not to place or time. Heent- MMM, anicteric, missing teeth Neck- Supple, no LAD, healing IV wound L neck, JVP not elevated. Heart- S1, S2, RRR, I/VI systolic murmur. Chest- Moving air well, no crackles. Abd- soft, NT, ND, pos BS, no palpable masses Ext- [**Last Name (un) **] bed pallor, no clubbing, no edema. Right toes have been amputated; Left big toe is gangrenous, but no frank pus or warmth. No LE edema. Neuro- UE somewhat rigid with superimposed tremor. Head slumped to the side. Pertinent Results: [**2190-5-20**] 01:15PM BLOOD WBC-8.6 RBC-3.51* Hgb-9.5* Hct-31.2* MCV-89 MCH-27.0 MCHC-30.3* RDW-17.5* Plt Ct-431 [**2190-5-23**] 03:15AM BLOOD WBC-13.8*# RBC-3.49* Hgb-9.7* Hct-31.0* MCV-89 MCH-27.6 MCHC-31.1 RDW-17.6* Plt Ct-196 [**2190-5-30**] 05:00AM BLOOD WBC-5.9 RBC-3.20* Hgb-8.7* Hct-27.5* MCV-86 MCH-27.2 MCHC-31.6 RDW-18.0* Plt Ct-381 [**2190-5-20**] 01:15PM BLOOD PT-19.3* PTT-34.1 INR(PT)-1.8* [**2190-5-30**] 05:00AM BLOOD PT-14.6* PTT-33.4 INR(PT)-1.3* [**2190-5-20**] 01:15PM BLOOD Glucose-155* UreaN-43* Creat-2.5* Na-147* K-5.6* Cl-105 HCO3-29 AnGap-19 [**2190-5-30**] 05:00AM BLOOD Glucose-81 UreaN-16 Creat-1.5* Na-145 K-4.0 Cl-106 HCO3-27 AnGap-16 [**2190-5-20**] 01:15PM BLOOD ALT-63* AST-90* AlkPhos-99 TotBili-0.2 [**2190-5-22**] 05:20AM BLOOD ALT-120* AST-121* LD(LDH)-404* AlkPhos-68 TotBili-0.2 [**2190-5-28**] 07:25AM BLOOD ALT-29 AST-22 [**2190-5-20**] 01:15PM BLOOD Lipase-24 [**2190-5-20**] 05:18PM BLOOD CK-MB-6 cTropnT-0.16* [**2190-5-21**] 03:23AM BLOOD CK-MB-NotDone cTropnT-0.17* [**2190-5-20**] 01:15PM BLOOD Albumin-3.6 Calcium-8.7 Phos-5.6*# Mg-2.6 [**2190-5-30**] 05:00AM BLOOD Calcium-8.2* Phos-3.2 Mg-1.8 [**2190-5-21**] 06:09PM BLOOD VitB12-GREATER TH Folate-GREATER TH [**2190-5-24**] 05:50AM BLOOD %HbA1c-5.5 [**2190-5-25**] 08:05AM BLOOD Triglyc-60 HDL-36 CHOL/HD-2.8 LDLcalc-51 [**2190-5-21**] 06:09PM BLOOD TSH-2.9 [**2190-5-20**] 01:15PM BLOOD ASA-NEG* Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2190-5-21**] 01:28AM BLOOD Type-ART Temp-36.7 pO2-240* pCO2-106* pH-7.11* calTCO2-36* Base XS-0 Intubat-NOT INTUBA [**2190-5-21**] 02:09AM BLOOD Type-ART pO2-225* pCO2-120* pH-7.07* calTCO2-37* Base XS-0 [**2190-5-23**] 06:06AM BLOOD Type-ART pO2-180* pCO2-48* pH-7.37 calTCO2-29 Base XS-2 [**2190-5-20**] 01:10PM BLOOD Lactate-2.2* [**2190-5-23**] 06:06AM BLOOD Lactate-1.0 [**2190-5-21**] 02:09AM BLOOD freeCa-1.20 Urine Cx [**5-22**] Citrobacter freundii sensitive to cipro Blood Cx [**5-20**], [**5-22**] negative Resp Cx: no significant growth ECG: Paced, no acute changes Studies~ Left foot plain film [**2190-5-20**]: Transverse fracture of the mid diaphysis of the second proximal phalanx. CXR [**2190-5-20**]: Bilateral parenchymal opacities, for which CT of the chest is recommended for further evaluation and to exclude malignancy. CT Head [**2190-5-21**]: There is no evidence of acute intracranial hemorrhage or mass effect. Unchanged low-attenuation areas in the subcortical white matter and focal low attenuations likely consistent with small vessel disease and lacunar ischemic changes. Persistent and unchanged right frontal subcortical area of low density, likely consistent with sequela of an old ischemic event. If there is no clinical contraindication, MRI of the head with diffusion-weighted sequences may provide better characterization of these findings. RUQ Ultrasound [**5-21**]: 1. Cholelithiasis with no signs of cholecystitis. 2. Trace of ascites. 3. Atrophic kidneys. Renal US [**5-24**]: 1. Bilateral atrophic kidneys without evidence of hydronephrosis or renal calculi. 2. Right upper pole simple cyst measuring up to 1.2 cm. CXR [**5-25**]: 1. Interval worsening of the mild pulmonary edema. Unchanged bilateral multifocal pneumonia. 2. Increasing moderate right pleural effusion. LE Angiogram [**5-27**]: 1. Access was obtained in a treograde fashion in teh right common femoral artery. AN omniflush catheter was advanced to the level of L2/L3 and a dstal abdominal aortogram was prefromed. The abdominal aorta had moderate diffuse disease. The renal arteries were poorly seen. The RCIA, IIA and EIA were patent. The RCFA was patent and teh RLE was not imaged beyond that point. The LCIA, EIA and IIA were patent as was the L CFA. The LSFA had a 70% stenosis. The ominiflush catheter was then advanced over the [**Doctor Last Name 534**] over an angled gluide wire and selective angiography of the LLE was preformed. The popliteal artery was patent with mild diffuse disease. There was a high grade stenosis of the TPT and the AT and the PT were 100% occluded. There were diffuse high grade stenoses of the peroneal artery. The left DP and foot filled via collaterals from the PA artery. 2. Successful PTA of the L PA with a 3.0 balloon. Final angiography revealed a 20% residual stenosis and no dissection. (See PTA comments) 3. Successful stenting of the LSFA with a 6.0 x 60 mm protege stent which was post dilate dto 6.0 with a admiral balloon. Final angiography revealed no residual stenosis in the stent, no dissection and normal flow. (See PTA comments) FINAL DIAGNOSIS: 1. Peripheral vascular disease. 2. Stenting of the LSFA. 3. Successful PTA of the L PA Brief Hospital Course: 89yo gentleman with dementia, HTN, PVD, CAD, AFib (s/p PPM for tachy-brady syndrome), and CKD who admitted with gangrenous toe, found to have mental status changes upon arrival to the floor. # Mental status change/Hypercarbic respiratory failure Shortly after admission to the hospital floor, the patient was noted to be obtunded. An ABG showed significant hypercarbia to 120 and a code blue was called. The patient was intubated and transferred to the MICU for further care. Within 48 hours of intubation, the patient self-extubated during a spontaneous breathing trial and did well on his own; he did not require re-intubation. The precipitating event for his hypercarbic respiratory failure was unclear. A CT of his head did not show any acute event. It was noted that he had been taking increasing doses of percocet just prior to his presentation, and there was concern that he might have had narcotic induced hypoventilation. Through the rest of his course, his mental status was oriented to person only. He responded to most simple questions. His family felt that he was at his baseline. # Fevers: The patient was febrile on [**5-22**], shortly after presentation to the MICU. His cultures were significant for Citrobacter freundi in his urine. He was started on ciprofloxacin for his UTI on [**5-22**] x a 2 week course to be completed [**6-4**]. His blood cultures were negative. Although subsequent CXRs were read as possible pneumonia, his fevers resolved with treatment of his UTI and he did not have clinical manifestations of pneumonia. Upon review of his prior chest films and CT chest, he has a long history of nodules and pulmonary opacities due to silicosis. # Acute Renal Failure on Chronic Renal Insufficiency/ Acute on chronic diastolic heart failure: Patient's baseline creatinine ranges 1.5-2.0. At the time of admission, his Cr was 2.5. His diuretics were held and he was given several liters of fluid in the MICU and transfused one unit of pRBCs. Renal ultrasound showed no evidence of obstruction. His creatinine improved to 1.4 prior to his cath and was 1.5 on the day of discharge. Although he initially appeared dehydrated on admission, Mr. [**Known lastname 39714**] developed lower extremity edema and crackles on his exam in the setting of receiving IV fluids for ARF and prior to his catheterization. He was kept in the hospital after the angiogram for diuresis. He was given IV lasix and then transitioned to PO lasix. His home lasix dose was increased from 40mg daily to 80mg daily to continue diuresis for his lower extremity edema. **His blood will be drawn [**6-2**] and a BUN/Cr should be sent to his primary care doctor so that his dose of lasix can be adjusted as appropriate. He will likely need to be put back on 40mg lasix daily once his lower extremity has improved.** # Gangrenous left big toe/Peripheral vascular disease: After the patient's renal function returned to baseline, he was brought to the cath lab and underwent LE angiography with balloon angioplasty and a stent to his LSFA. He was continued on aspirin and plavix was started. There was no evidence of infection in his lower extremities. He had recently completed 2 weeks of keflex prior to his admission. Wound care was provided per wound care nursing recommendations. The patient should follow-up with Dr. [**Last Name (STitle) **]. # Hypertension: Mr. [**Known lastname 39714**] developed hypertensive urgency during his hospital stay. The trigger for his elevated BPs was not clear, though his systolic blood pressure was noted to be elevated 150s-170s even before he became acutely hypertensive to 200 and was transferred to the CCU. His pressures were acutely controlled with hydralazine. His metoprolol was increased and he was started on norvasc. At the time of discharge, his blood pressures were greatly improved on this regimen with systolic pressures in the 130s to 150s. His blood pressure regimen should continue to be adjusted as needed as an outpatient. # Transaminitis: Patient was noted to have a transaminitis upon admission. He had a RUQ ultrasound that showed gallstones but no evidence of cholecystitis. His transaminitis resolved with IV fluids and his ALT/AST were normal at the time of discharge. # Anemia: Patient's Hct was stable at 28-31. He received 1 unit of packed red cells in the setting of ARF while he was in the MICU with an appropriate increase in his Hct. His iron supplementation was continued. # Coronary artery disease: There was no evidence of active coronary disease. His ASA, atorvastatin, and metoprolol were continued. # History of Atrial fibrillation: Patient is s/p PPM for tachybrady syndrome. He was V-paced on telemetry. His coumadin was initially held in anticipation of angiography. At the time of discharge, his coumadin was restarted. His INR will be drawn on Wednesday to allow his coumadin to be adjusted as needed since he is being sent home on ciprofloxacin, which interacts with coumadin. # Dementia/Delirium: After his extubation, the patient was felt to be at his baseline as discussed above. His valproate, which he takes at home for behavioral control, was continued. His wife was advised to avoid narcotics because of the concern that the percocet had been responsible for his hypoventilation. # Neurotic excoriations on neck: Dermatology was consulted for ulcerated lesions on the patient's neck and head. They felt that he had neurotic excoriations and that the lesions would heal if he would stop picking at them. He was given mitts to wear and the sores should be covered with vaseline and then gauze to help prevent him from scratching them. # Gout: continued allopurinol # Nutrition: Soft/dysphagia diet with nectar thickened liquid per speech and swallow # Code: full (confirmed with wife) # Dispo: He was discharged to home, where he has 24 hour care as well as a hospital bed and VNA. # Communication: Wife [**Name (NI) 382**] [**Name (NI) **] [**Telephone/Fax (1) 39715**]. # Note that the following medication changes were made: - increased metoprolol to 150mg daily - increased lasix to 80mg daily*** Please note that this dose will probably need to be decreased down to 40mg daily in the next week. - started norvasc (amlodipine) 5mg daily - started plavix (clopidogrel) 75mg daily - started ciprofloxacin 500mg twice a day for 5 more days to treat urine infection (last day to take is [**6-4**]) - stop taking percocet or oxycodone as these medications may have been responsible for making your breathing dangerously slow. Medications on Admission: ASA 81mg PO daily Iron 65mg daily Allopurinol 100mg PO daily Colchicine .6mg PO daily Divalproex 250mg PO bid Tolterodine LA 4mg daily Montelukast 10mg PO daily Metoprolol XL 50mg daily Atorvastatin 10mg PO daily Docustate 100mg PO bid Warfarin 2.5mg PO qhs Lasix 40mg daily oxycodone 1tab q4-6hours prn megace 1 teaspoon daily MVI Keflex course [**2190-5-11**] Discharge Medications: 1. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Valproate Sodium 250 mg/5 mL Syrup Sig: Two [**Age over 90 1230**]y (250) mg PO Q12H (every 12 hours). 5. Multivitamins Tablet, Chewable Sig: One (1) Tablet, Chewable PO once a day. 6. Iron 27 mg (Elemental) Tablet Sig: Two (2) Tablet PO once a day. 7. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day. 8. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM: adjust dose as directed by your primary doctor. 9. Docusate Sodium 50 mg/5 mL Liquid Sig: One Hundred (100) mg PO BID (2 times a day). 10. Megestrol 400 mg/10 mL Suspension Sig: One (1) teaspoon PO DAILY (Daily). 11. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr Sig: Three (3) Tablet Sustained Release 24 hr PO once a day. Disp:*90 Tablet Sustained Release 24 hr(s)* Refills:*0* 12. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*1* 13. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*1* 14. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 5 days: Last day to take is [**6-4**]. Disp:*10 Tablet(s)* Refills:*0* 15. Furosemide 40 mg Tablet Sig: Two (2) Tablet PO ONCE (Once): **you will probably need to decrease your dose to 40mg sometime in the next week as directed by your physician**. Disp:*60 Tablet(s)* Refills:*0* 16. Colchicine 0.6 mg Tablet Sig: One (1) Tablet PO once a day. 17. Tolterodine 4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO once a day. Discharge Disposition: Home With Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: Primary Diagnosis: Peripheral vascular disease Secondary Diagnoses: Dry gangrene, Hypercarbic respiratory failure, Mental status change, Hypertension, Atrial fibrillation Discharge Condition: Afebrile, vital signs stable, mental status at baseline (oriented to person but not place or time) Discharge Instructions: You were admitted with dry gangrene of your big toe. There is no sign of infection. The gangrene is there because of poor blood flow to the foot. You had an angiogram and a stentwas placed to help the blood flow to your foot. 1. Please take all medications as prescribed. Note that the following medication changes were made: - increased metoprolol to 150mg daily - increased lasix to 80mg daily*** Please note that this dose will probably need to be decreased down to 40mg daily in the next week. - started norvasc (amlodipine) 5mg daily - started plavix (clopidogrel) 75mg daily - started ciprofloxacin 500mg twice a day for 5 more days to treat urine infection (last day to take is [**6-4**]) - stop taking percocet or oxycodone as these medications may have been responsible for making your breathing dangerously slow. 2. Please attend all follow-up appointments. 3. Please call your doctor or return to the hospital if you develop chest pain, palpitations, fevers, any change in the wounds on your feet (including redness or pus), or any other concerning symptom. ***You need to call Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 34604**] office on the afternoon of Wednesday, [**6-2**] to follow up on your bloodwork. Dr. [**Last Name (STitle) 5456**] may adjust your dose of coumadin (also called warfarin) or your dose of lasix depending on the results of your bloodwork.*** Followup Instructions: 1. Please call your primary doctor and set up an appointment for the next 2-3 weeks: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5456**] [**Telephone/Fax (1) 5457**]. 2. Please call Dr. [**Last Name (STitle) **] for an appointment in the next 4 weeks: [**Telephone/Fax (1) 7960**]. 3. Please keep your previously scheduled appointments: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1244**], MD Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2190-6-18**] 10:15 Completed by:[**2190-5-30**]

[ "427.31", "428.0", "274.9", "584.9", "599.0", "440.24", "428.32", "997.69", "401.0", "E935.8", "585.9", "272.0", "V45.01", "502", "285.29", "518.81", "292.81", "276.0", "790.5" ]

icd9cm

[ [ [] ] ]

[ "88.48", "96.04", "96.71", "00.41", "39.50", "99.04", "39.90", "00.45" ]

icd9pcs

[ [ [] ] ]

16258, 16315

7541, 14114

277, 353

16532, 16633

2843, 7413

18093, 18638

2167, 2186

14526, 16235

16336, 16336

14140, 14503

7430, 7518

16657, 18070

2201, 2824

16406, 16511

223, 239

381, 1252

16356, 16384

1274, 1932

1948, 2151

26,262

156,723

18157

Discharge summary

report

Admission Date: [**2182-1-15**] Discharge Date: [**2182-1-22**] Date of Birth: [**2116-11-23**] Sex: F Service: Cardiothoracic Surgery HISTORY OF PRESENT ILLNESS: This is a 65-year-old woman with a history of mitral stenosis, recent increasing dyspnea on exertion, as well as paroxysmal nocturnal dyspnea. Followup echocardiogram has revealed 3+ mitral regurgitation, mitral valve area of 1.1 cm squared, and a left ventricular ejection fraction of 50%. She underwent cardiac catheterization on [**2181-10-25**] which revealed mitral stenosis and mitral regurgitation with normal coronary arteries. She is referred for mitral valve replacement. PAST MEDICAL HISTORY: 1. Status post tubal ligation. 2. Status post rectal tear. 3. Hypercholesterolemia. MEDICATIONS PRIOR TO SURGERY: 1. Lipitor 10 mg p.o. q.d. 2. Aspirin 81 mg p.o. q.d. 3. Vitamins. ALLERGIES: Patient states no known drug allergies. The patient was admitted as an outpatient directly to the operating room on [**2182-1-15**], where she underwent a minimally invasive mitral valve replacement. Her valve was replaced with a #25 mm St. Jude valve. Postoperatively, she was on insulin, milrinone, and Neo-Synephrine drip. She was transported from the operating room to the Cardiac Surgery Recovery Unit in good condition. Patient received 2 units of packed red blood cells on the night of surgery due to a hematocrit of 22% and need for vasopressors due to hypotension. Patient also had some anxiety issues in the initial postoperative period. On the night of surgery, she was weaned from mechanical ventilation and successfully extubated. On postoperative day one, she remained on Neo-Synephrine, but was stable on that. On postoperative day two, that had been weaned off and she was transferred from the Cardiac Surgery Recovery Unit to the telemetry floor in good condition. Her chest tubes had been discontinued at that point and she was begun on Coumadin for mechanical valve. On postoperative day three, the patient was placed on a Heparin drip. She was continuing on her Coumadin. She was begun diuresis on Lasix and had stable vital signs. Was beginning to ambulate with the assistance of nursing and Physical Therapy services. Patient had brief episode of atrial fibrillation on postoperative day three, which resolved spontaneously. She had begun on low dose beta blockers and tolerating those well. On postoperative day five, patient remained hemodynamically stable with a hematocrit of 25.6%. She had been placed on iron and vitamin C due to her anemia as well as multivitamins, and she was noted to have a small right pneumothorax with some subcutaneous emphysema. She remained on room air not requiring supplemental oxygen at the time. Serial chest x-ray revealed decrease in size in the pneumothorax at that time. On [**1-21**], postoperative day six, the patient was noted to have a short run of supraventricular tachycardia to the 140s. She was given IV Lopressor and her oral dose of Lopressor was increased from 25 mg p.o. b.i.d. to 50 mg p.o. b.i.d. Patient remains hemodynamically stable today, [**2182-1-22**] postoperative day seven and ready to be discharged home. PHYSICAL EXAMINATION: She is afebrile with stable vital signs. Her weight today is 53.8 kg, which is below her preoperative weight of 59 kg. Regular, rate, and rhythm cardiac examination. Her wounds are clean, dry, and intact. Her bilateral breath sounds are clear to auscultation. Abdomen was soft and nontender. She has trace pedal edema bilaterally. Her INR today is 2.8 and she is receiving 3 mg of Coumadin. She had previously received 3 mg followed by 5 mg, but her INR then bumped to 3.4. The following day her dose was held, and she has subsequently received 3 mg a day for the past three days with an INR today of 2.8. DISCHARGE MEDICATIONS: 1. Coumadin 3 mg p.o. q.d. She is ordered to have a PT/INR check tomorrow to be drawn by the visiting nurse and they should be called into Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5894**] office, and we have communicated with Dr.[**Name (NI) 33490**] office and they will be following her Coumadin dosing upon discharge. 2. Lipitor 10 mg p.o. q.d. 3. Lopressor 50 mg p.o. b.i.d. 4. Lasix 20 mg p.o. b.i.d. x1 week. 5. Potassium chloride 20 mEq p.o. b.i.d. x1 week. 6. Tylenol #3 q.3-4h. prn pain. 7. Colace 100 mg p.o. b.i.d. prn. 8. Multivitamin. 9. Folate. 10. Vitamin C. 11. Xanax prn. FO[**Last Name (STitle) **]P INSTRUCTIONS: Patient is to followup with Dr. [**Last Name (Prefixes) 2545**] in one month for a postoperative check. She is to followup with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in [**2-1**] weeks, her cardiologist. She is also to follow INRs, and they will be dosing her Coumadin. She is also to followup with her primary care doctor, Dr. [**Last Name (STitle) 2093**] in [**2-1**] weeks. DISCHARGE DIAGNOSES: 1. Mitral stenosis. 2. Mitral regurgitation. 3. Status post mitral valve replacement with a #[**Street Address(2) 17009**]. [**Male First Name (un) 923**] mitral valve. CONDITION ON DISCHARGE: Good. The patient is discharged home today and she will having visiting nurses follow her post discharge. [**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**] Dictated By:[**Name8 (MD) 964**] MEDQUIST36 D: [**2182-1-22**] 11:40 T: [**2182-1-22**] 12:16 JOB#: [**Job Number 50207**]

[ "427.89", "394.2", "272.0", "997.1", "300.00", "512.1", "285.9", "427.31" ]

icd9cm

[ [ [] ] ]

[ "35.24", "39.61" ]

icd9pcs

[ [ [] ] ]

4958, 5128

3863, 4937

3226, 3840

185, 671

693, 3203

5153, 5509

20,431

136,430

20735

Discharge summary

report

Admission Date: [**2185-3-21**] Discharge Date: [**2185-3-29**] Date of Birth: [**2140-9-1**] Sex: M Service: GENERAL SURGERY HISTORY OF PRESENT ILLNESS: This is a 44-year-old male, transferred from [**Hospital3 3583**] diagnosed with ischemic bowel, portal veinous air and pneumatosis of the colon and stomach who had presented with complaints of nausea, melena, diarrhea and abdominal pain. Positive for acute renal failure- creatinine 2.5, acidosis. Initial systolic blood pressure 80, up to 100-110 systolic status post resuscitation. The patient was given Zosyn, vancomycin and Protonix. The patient is mentally impaired, autistic. White count was 18 at 12:00 am upon presentation, 12.6 at pm after fluid. Three liters of solution was used to resuscitate the patient. ALLERGIES: Tegretol. PAST MEDICAL HISTORY/SURGICAL HISTORY: Significant for mental retardation/autism. SOCIAL HISTORY: Lives at a group home. MEDICATIONS: 1. Risperdal 5 [**Hospital1 **]. 2. Trazodone. 3. Depakote 250 tid. PHYSICAL EXAM: Vitals - afebrile. Vital signs were stable. A&O. The patient was alert to place. Extraocular movements were intact. Cardiac exam revealed a regular rhythm with tachycardia, no murmurs, rubs or gallops. Abdomen was soft, but distended with very mild tenderness upon palpation, right lower quadrant greater than left lower quadrant. No rebound. No guarding. Rectal was heme positive. Extremities were warm, moving all four. LABS AT [**Hospital3 **]: White count 18, crit 48, platelets 22. After resuscitation, the white count was down to 12.9, crit 38.5 and 192. ASSESSMENT AND PLAN: A 44-year-old male, with a question of a diagnosis of bowel ischemia at outside hospital, transferred here with bradycardia, though the patient appeared to be making improvement with systolics of 120, and he was clinically stable. No obvious evidence of clinical peritonitis, or urgent need for the OR since the resuscitation. HOSPITAL COURSE: The patient was taken to the SICU where he was stable. He continued to be aggressively hydrated. It was decided later on, however, to take the patient to the OR. The patient was taken to the operating room after CT abdomen was reviewed with radiology which revealed dilated small bowel with pneumatosis, and some portal venous air, colon with thickening, some free-fluid in the abdomen, as well. The patient was taken back. The procedure was ex-lap, CCY, appendectomy. The findings were a moderately dilated bowel throughout, all viable however, without any complication. The patient was then taken to the ICU where he was given many fluid boluses to keep his urine output at goal. The patient continued to do well in the ICU. His urine started to pick up. He was eventually transferred to the floor where he continued to improve. The patient began to tolerate sips, then clears, and a regular diet, and was passing flatus and bowel movements. The patient had a baseline exam of abdominal distention, which though at first was worrisome, but when correlated with the clinical picture of the patient tolerating his diet and not having any recurrence of his nausea or vomiting, it was felt safe to proceed to advance the patient's diet. Finally, on postop day #7 the patient will be discharged back home to his group home, where he will then follow-up with Dr. [**First Name (STitle) 2819**] within a week or two. The patient is to have his staples removed by Dr. [**First Name (STitle) 2819**] in the office. DISCHARGE MEDICATIONS: 1. Trazodone 50 mg tabs, 2 tabs po hs. 2. Valproate sodium 250 mg/5 ml syrup, 5 ml po tid. 3. Risperidone 1 mg/ml solution, 5 ml po bid. 4. Famotidine 20 mg tabs, 1 tab po bid. 5. Percocet 1-2 tabs po q 4-6 h prn pain. DISCHARGE DIAGNOSES: 1. Ischemic bowel 2. Hypovolemia with acidosis 3. Status post exploratory laparotomy, cholecystectomy, and appendectomy. 4. Autism [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 19318**] Dictated By:[**Name8 (MD) 8276**] MEDQUIST36 D: [**2185-3-29**] 09:51 T: [**2185-3-29**] 10:01 JOB#: [**Job Number 55337**]

[ "276.2", "584.9", "276.5", "557.9", "319", "574.10", "299.00" ]

icd9cm

[ [ [] ] ]

[ "51.22", "47.19", "38.91", "54.11" ]

icd9pcs

[ [ [] ] ]

3776, 4172

3534, 3754

1990, 3511

1048, 1972

176, 909

926, 1032

23,830

132,738

12535

Discharge summary

report

Admission Date: [**2110-12-23**] Discharge Date: [**2110-12-29**] Service: CT Surgery HISTORY OF PRESENT ILLNESS: The patient is a [**Age over 90 **] year old female who was admitted to [**Hospital3 3583**] on [**2110-12-20**] after having a syncopal episode at home. Workup revealed sinus dysfunction with long pauses, longest documented at eight seconds. A permanent pacemaker was placed on [**2110-12-22**]. A post procedure CT scan revealed a pneumothorax on the left side and, as a result, a chest tube was placed. The patient was noted to have desaturation and hypotension. An echocardiogram revealed moderate pericardial effusion and the patient was therefore transferred to [**First Name4 (NamePattern1) 3867**] [**Last Name (NamePattern1) **] [**First Name (Titles) **] [**Last Name (Titles) **] on [**2110-12-23**]. PAST MEDICAL HISTORY: 1. Syncope. 2. Seizure disorder. 3. Labile hypertension. 4. Hyponatremia. 5. Noninsulin dependent diabetes mellitus, diet controlled. 6. Hypothyroidism. 7. Breast cancer. MEDICATIONS ON ADMISSION: Aspirin, Tegretol, Synthroid, Norvasc 5 mg p.o.q.d., hydrochlorothiazide 25 mg p.o.q.d., and potassium chloride. ALLERGIES: ACE inhibitors, Levoxyl, Tenex. PHYSICAL EXAMINATION: On physical examination, the patient had a heart rate of 67, ventricular paced, with remainder of vital signs stable. Chest: Clear to auscultation bilaterally. Cardiovascular: Regular rate and rhythm. Abdomen: Soft, nontender, nondistended. Extremities: 1 to 2+ peripheral edema. HOSPITAL COURSE: The patient was taken to the Operating Room emergently on [**2110-12-23**], where she had a mediastinal exploration and large blood clot removal. She was transferred to the Intensive Care Unit postoperatively, where she was rapidly extubated. On postoperative day number one, the patient had a mild drop in the hematocrit and received a total of three units of packed red blood cells. On postoperative day number two, chest tube output was minimal and the chest tubes were removed. A post chest tube pull chest x-ray revealed no pneumothorax and minimal bilateral pleural effusions. On postoperative day number two, the patient was transferred to the floor in stable condition. The electrophysiology service team was involved in the patient's care during this admission. Her pacemaker was interrogated on [**2118-12-24**] and 11, [**2110**]. Each time, interrogation revealed that the pacemaker was functioning well. On the floor, the patient had minimally elevated blood sugars, from 120 to 200. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3208**] consult was obtained and they recommended starting Glucophage XR 500 mg daily. The patient was tolerating a regular diet and was ambulating at a minimal level. CONDITION ON DISCHARGE: Stable. DISCHARGE MEDICATIONS: Norvasc 5 mg p.o.b.i.d. Percocet one p.o.q.4-6h.p.r.n. Colace 100 mg p.o.b.i.d. Tegretol 400 mg p.o.b.i.d. Synthroid 0.075 mcg p.o.q.d. Caltrate 1,200 mg p.o.q.d. Aspirin 81 mg p.o.q.d. Hydrochlorothiazide 12.5 mg p.o.q.d. Potassium chloride 10 mEq p.o.q.d. Glucotrol XL 500 mg p.o.q.d. DISCHARGE STATUS: It was highly encouraged that the patient go to a rehabilitation facility, however, she refused and will be going home. She has a son and granddaughter who will be actively involved with her care. They were made aware that we recommended rehabilitation for the disposition of this patient. The patient will have visiting nurses for blood sugar checks, wound checks and aid with ambulation. FOLLOW-UP: The patient will follow up with her primary care physician or cardiologist in three weeks. The patient will follow up with Dr. [**Last Name (STitle) 70**] in four weeks. DISCHARGE DIAGNOSES: 1. Pericardial tamponade, status post mediastinal exploration and clot evacuation. 2. Noninsulin dependent diabetes mellitus. [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 75**] Dictated By:[**Name8 (MD) 1308**] MEDQUIST36 D: [**2110-12-29**] 12:37 T: [**2110-12-29**] 12:35 JOB#: [**Job Number 16510**]

[ "401.9", "423.9", "V45.01", "244.9", "998.2", "250.00", "780.39" ]

icd9cm

[ [ [] ] ]

[ "96.04", "34.1", "37.0", "96.71", "37.21" ]

icd9pcs

[ [ [] ] ]

3765, 4189

2859, 3744

1078, 1237

1566, 2802

1260, 1548

127, 845

868, 1051

2827, 2836

40,442

131,151

37343

Discharge summary

report

Admission Date: [**2102-1-6**] Discharge Date: [**2102-1-20**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 5123**] Chief Complaint: Dyspnea Major Surgical or Invasive Procedure: Intubation and mechanical venillation Central Venous Line placement PICC line placement Arterial catheter placement History of Present Illness: 85 y/o M with hx of DM, CHF, dementia and sacral ulcers was transferred from his nursing home to the [**Hospital 56335**] Hospital by request of his daughter for decreased consciousness and decreased BP. . Initial vitals at OSH were 100.4, P 65, R 44, 94% on NRB, 88/55. He was intubated in the ED and went into afib with RVR and dropped his BP, so dilt gtt was started as well as peripheral dopamine. He was noted to have a K of 7.3, was treated with CaCl, NS IVFs, and kayexcelate. He was presumed to be septic secondary to his low grade fever, hx of sepsis and high lactate. He was given a total of 4L NS and cefepime 1gm and levofloxacin 750 mg. A Femoral CVL was placed. Family requested transfer to [**Location (un) 86**]. . He was transported via ambulance on propofol 20 mg IV prn, dopmaine 40 mg/kg/min, and cardizem 10 mg/hr. He was intubated and sedated, thus there was no more history available. Past Medical History: COPD CHF HTN afib with RVR DM dementia depression stage 3-4 sacral decub . [**2101-12-19**] was hospitalized for proteus urosepsis with course complicated by c.diff colitis Social History: Living at nursing home for last two years with hx of dementia, wife [**Name (NI) 2048**] and daughter involved. Family History: Noncontributory Physical Exam: On arrival to floor Vitals 97 HR 88 BP 122/66 RR 29 Sats 98 RA FSBS 204 Gen: Awake and alert, non-verbal. Non-toxic. NAD. HEENT: Normocephalic, anicteric, OP benign, MMM Neck: No masses or lymphadenopathy CV: heart sounds faint, irregular. Pulm: Diffuse rhonci b/l. Good aeration. Abd: Soft, NT, ND, BS+ Extrem: Warm and well perfused, 1+ pitting edema hands b/l and ankles b/l. Neuro: Moving all 4 extremities. On Discharge: General: awake, responsive to simple questions, NAD HEENT: OP clear, PERRL Neck: supple CV: Irregular, no murmur Pulm: Decreased breath sounds in left lower lung, otherwise good aeration Abd: soft, NT/ND, +BS Ext: warm, 1+ b/l LE edema Neuro: follows simple commands Pertinent Results: On Admission: [**2102-1-6**] 04:26AM BLOOD WBC-27.5* RBC-3.60* Hgb-10.3* Hct-33.5* MCV-93 MCH-28.8 MCHC-30.8* RDW-15.7* Plt Ct-359 [**2102-1-8**] 03:09AM BLOOD PT-14.6* PTT-34.8 INR(PT)-1.3* [**2102-1-6**] 04:26AM BLOOD Glucose-268* UreaN-89* Creat-3.2* Na-152* K-6.2* Cl-120* HCO3-20* AnGap-18 [**2102-1-6**] 04:26AM BLOOD ALT-143* AST-68* LD(LDH)-299* CK(CPK)-579* AlkPhos-320* TotBili-0.4 [**2102-1-6**] 04:26AM BLOOD CK-MB-32* MB Indx-5.5 cTropnT-0.30* Interval Labs: [**2102-1-9**] 04:45AM BLOOD CK-MB-NotDone cTropnT-0.16* [**2102-1-9**] 05:12AM BLOOD Lactate-1.8 [**2102-1-11**] 03:36AM BLOOD WBC-12.5* RBC-2.99* Hgb-8.4* Hct-26.4* MCV-88 MCH-28.1 MCHC-31.9 RDW-16.2* Plt Ct-304 [**2102-1-16**] 06:15AM BLOOD WBC-17.1* RBC-3.39* Hgb-9.5* Hct-30.1* MCV-89 MCH-27.9 MCHC-31.5 RDW-17.5* Plt Ct-546* [**2102-1-10**] 04:51AM BLOOD ALT-43* AST-23 LD(LDH)-198 AlkPhos-255* TotBili-0.4 [**2102-1-10**] 04:51AM BLOOD Albumin-1.7* Calcium-8.9 Phos-2.7 Mg-1.7 [**2102-1-11**] 03:36AM BLOOD Glucose-195* UreaN-34* Creat-1.3* Na-150* K-3.0* Cl-123* HCO3-19* AnGap-11 On Discharge: [**2102-1-20**] 05:22AM BLOOD WBC-13.4* RBC-3.09* Hgb-8.7* Hct-26.9* MCV-87 MCH-28.4 MCHC-32.6 RDW-17.6* Plt Ct-363 [**2102-1-20**] 05:22AM BLOOD PT-20.8* PTT-29.7 INR(PT)-1.9* [**2102-1-20**] 05:22AM BLOOD Glucose-122* UreaN-19 Creat-1.0 Na-141 K-3.5 Cl-107 HCO3-29 AnGap-9 [**2102-1-20**] 05:22AM BLOOD Calcium-8.1* Phos-2.8 Mg-2.2 TTE: The left atrium is mildly dilated. Left ventricular wall thickness, cavity size, and global systolic function are normal (LVEF>55%). Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. The aortic root is mildly dilated at the sinus level. The ascending aorta is mildly dilated. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. There is mild pulmonary artery systolic hypertension. IMPRESSION: poor technical quality due to patient being on a ventilator. Left ventricular function is probably normal, a focal wall motion abnormality cannot be fully excluded. The right ventricle is not well seen. No pathologic valvular abnormality seen. CXR: 1. Bibasilar air space opacities, could represent pneumonia. 2. Additional opacity in the left infrahilar region, could represent additional focus of infection. Attention is recommended to this region on follow up studies to assess for resolution. 3. Endotracheal tube is in satisfactory position. CT Torso: . Left basal effusion and scattered ground-glass opacities in both lungs with more confluent focal opacities in the lower lobes are highly suggestive of areas of infection and pneumonic consolidation. Please ensure follow-up to clearance. 2. Bilateral renal lesions, some of which are likely simple cysts but others are more dense and a mass cannot be excluded. A dedicated renal ultrasound would help clarify further. 3. Distended gallbladder, without evidence of wall thickening or pericholecystic fluid or inflammatory change. [**2102-1-6**] 8:17 am Rapid Respiratory Viral Screen & Culture Source: Nasopharyngeal swab. **FINAL REPORT [**2102-1-8**]** Respiratory Viral Culture (Final [**2102-1-8**]): No respiratory viruses isolated. Culture screened for Adenovirus, Influenza A & B, Parainfluenza type 1,2 & 3, and Respiratory Syncytial Virus.. Detection of viruses other than those listed above will only be performed on specific request. Please call Virology at [**Telephone/Fax (1) 6182**] within 1 week if additional testing is needed. Respiratory Viral Antigen Screen (Final [**2102-1-6**]): Negative for Respiratory Viral Antigen. Specimen screened for: Adeno, Parainfluenza 1, 2, 3, Influenza A, B, and RSV by immunofluorescence. Refer to respiratory viral culture for further information Brief Hospital Course: 85 y/o M with hx of CHF, DM, sacral decubs, afib and dementia who presented with pneumonia and septic shock including altered mental status and hypotension, complicated by afib with RVR during presentation. #. Respiratory failure and pneumonia: Initially intubated and admitted to the MICU where he was started on broad spectrum antibiotics and vasopressors. Weaned from the vent and extubated without incident. Was ruled out for flu. Blood pressure normalized and was weened of pressors. Antibiotics continued for HAP and complicated by aspiration. Received 14d course vancomycin and cefepime and 6 days of Flagyl. Respiratory status was complicated by a component of volume overload and received several doses of IV lasix with good results, which was continued for a daily dose of 40mg PO Lasix. This medication is new and may need to be decreased or stopped in the future when back to dry weight. Also with underlying COPD, which likely further reduced respiratory function. Since arrival to the floor respiratory status has been stable on NC, intermittantly with some decreased saturations that improved with deep suctioning. Tube feeds were also adjusted for a lower volume so that aspiration risk is minimized and Hyoscyamine was started to decrease secreations. Patient is unable to tolerate anything by mouth. # Afib with RVR: In MICU with heart rates in the 190s with drop in BPs. Started on a diltiazem drip and eventually hemodynamics normalized. Likely exacerbated with dopamine used as initial pressor. Transitioned to levophed with improvement. After weening of vasopressors, restarted on home metoprolol amd amiodarone doses with good effect. On day of discharge, metoprolol was decreased from QID to TID for HR in the 60s. On coumadin for anticoagulation with INR 1.9-2.1. Dose adjusted to 6mg daily, but will need continued monitoring and adjustment. . #. CHF: history of CHF, echo in MICU with mild PA htn and EF >55%. Also episode of demand NSTEMI with elevated trops but an unchanged EKG, likely related to demand in setting of septic shock. Started on lasix as above with good effect. Continued on Aspirin and statin. . # Hypernatremia: likely from poor PO intake and free water deficit. Given IV D5W and adjusted free water flushes in tube feeds. At time of discharge, sodium normalized, but should be monitored with free water adjusted accordingly. . # ARF: On admission had a rising creatinine to a peak of 3.2. Etiology likely prerenal given it improved quickly with IVF and resolution of septic shock. Now creatinine normalized and with good urine output. unknown baseline for patient, peaked at 3.2 but improved rapidly to 1.3 after IVF and resolution of shock . # Dementia - Mostly non-verbal at baseline. On presentation more altered likely due to underlying infeciton. On discharge at baseline according to family. . # DM - Well controlled on basic sliding scale and home latus 18qHS. . # Anemia: Hct stable throughout hospitalization without evidence of gross bleeding or hemorhage. Likely combination of anemia of chronic disease and dilutional effect with copious fluids given throughout hospitalization. . #. Goals of care: There were several family meetings thoughout the hospitalization with the patient's daughter and wife (who is healthcare proxy). The decision was made to make patient DNR/DNI although antibiotics were continued for a full course. There seems to be a difference in opinion of what treatments to pursue among family members. Wife who is at home and is the actual proxy also agrees with DNI and just wants him to be comfortable, with minimal invasive procedures and avoiding painful procedures. The daughter is more willing to have some aggressive measures taken, including potential for rehospitalization. At time of discharge, family was in agreement that patient would receive hospice services at the nursing facility. Medications on Admission: Jevity 1.5 at 83ml/hr for 20hrs; 380 cc H2O q8hr Coumadin 5 mg daily Morphine liquid PRN Paxil 30 mg daily Lantus 18 u qHS Novalog sliding scale Scopolamine patch 1.5mg q72hrs ASA 81 mg daily Captopril 50 mg q8hr Meotprolol 25 mg q6hr SQ heparin TID Amiodarone 400 mg daily Discharge Medications: 1. Warfarin 2 mg Tablet Sig: Three (3) Tablet PO Once Daily at 4 PM. 2. Morphine Concentrate 20 mg/mL Solution Sig: Fifteen (15) mg PO q2hours as needed for severe dyspnea. 3. Morphine Concentrate 20 mg/mL Solution Sig: Five (5) mg PO q2hours as needed for mild dyspnea. 4. Paroxetine HCl 30 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Insulin Glargine 100 unit/mL Cartridge Sig: Eighteen (18) units Subcutaneous at bedtime. 6. Insulin Lispro 100 unit/mL Cartridge Sig: Per sliding scale Subcutaneous four times a day: Glucose range: <70: Give 12.5gm D50, 70-150: No intervention, 151-200: 2 units, 201-250: 4 units, 251-300: 6 units, 301-350: 8 units, 351-400: 10 units, >400: Contact MD. 7. Hyoscyamine Sulfate 0.125 mg Tablet, Sublingual Sig: One (1) Tablet, Sublingual Sublingual QID (4 times a day). 8. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 9. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day): Hold for SBP<100, HR<60. 10. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 11. Furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day. 12. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q4H (every 4 hours) as needed for wheezing. 13. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed for wheezing. Discharge Disposition: Extended Care Facility: Pheasant [**Doctor Last Name **] Discharge Diagnosis: Primary: Healthcare associated pneumonia resulting in respiratory failure and septic shock Acute renal failure Secondary: Dementia Atrial fibrillation Diabetes mellitus Chronic diastolic heart failure Discharge Condition: Mental Status:Minimally verbal Level of Consciousness:Lethargic but arousable Activity Status:Bedbound Discharge Instructions: You were admitted to [**Hospital1 18**] for pneumonia and kidney injury. Your kidneys improved with fluids. We treated you with antibiotics and gradually your infection improved. We later gave you furosemide, a diuretic, to help remove extra fluid that had built up in your body. You are being discharged to a nursing facility where the primary focus of your care will be comfort. We have made the following medication changes: - Decreased your metroprolol from 4x per day to 3x per day. - Stopped your captopril. - Stopped your heparin injection. - Changed scopolamine patch to hyoscyamine for secretions. - Started nebulizers as needed for wheezing. - Increased your warfarin dose from 5mg daily to 6mg daily. - Started furosemide 40mg daily. Followup Instructions: Please follow up with the physicians at your skilled nursing facility.

[ "584.9", "428.33", "427.31", "486", "707.23", "276.0", "428.0", "276.7", "V44.1", "250.00", "785.52", "038.9", "496", "707.03", "410.71", "518.81", "285.9", "294.8", "401.9", "995.92" ]

icd9cm

[ [ [] ] ]

[ "86.22", "96.6", "96.72", "38.93", "38.91" ]

icd9pcs

[ [ [] ] ]

12004, 12063

6370, 10277

269, 386

12309, 12309

2419, 2419

13208, 13282

1672, 1689

10601, 11981

12084, 12288

10303, 10578

12438, 12847

1704, 2118

3496, 6347

12867, 13185

222, 231

414, 1331

2433, 3482

12323, 12414

1353, 1527

1543, 1656

67,465

102,575

36283

Discharge summary

report

Admission Date: [**2148-4-29**] Discharge Date: [**2148-5-17**] Date of Birth: [**2102-3-28**] Sex: M Service: NEUROSURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 78**] Chief Complaint: atraumatic subarachnoid hemorrhage Major Surgical or Invasive Procedure: [**4-29**]: Bedside placement of External Ventricular Drain, emergent craniotomy for aneurysm clipping [**4-30**]: Angiogram History of Present Illness: 46M s/p syncopal event; found down; agitated and moving all extremities per report; taken to OSH where he was intubated and CT head showed diffuse SAH, he was then transferred to [**Hospital1 18**] for definitive treatment. Past Medical History: Hypertension Social History: question of drug use Family History: history of neice with [**Name2 (NI) 82223**] aneurysm Physical Exam: On Admission: BP: 165/103 HR: 47 R: 20 O2Sats: 100% Intubated, sedated and paralyzed (meds halted but still in effect Pupils equally pinpoint, non reactive; No corneal reflex; No motor response to stimulation; On Discharge: Alert, oriented to person and place. Misses date. Able to follow brief, simple commands. Moves all extremities with full strength and power Pertinent Results: Labs on admission: [**2148-4-29**] 06:45PM [**Month/Day/Year 3143**] WBC-10.7 RBC-6.25* Hgb-14.4 Hct-44.2 MCV-71* MCH-23.0* MCHC-32.6 RDW-16.1* Plt Ct-103* [**2148-4-29**] 06:45PM [**Month/Day/Year 3143**] Neuts-86.0* Lymphs-10.0* Monos-2.9 Eos-0.8 Baso-0.3 [**2148-4-29**] 06:45PM [**Month/Day/Year 3143**] PT-14.7* PTT-26.2 INR(PT)-1.3* [**2148-4-29**] 06:45PM [**Month/Day/Year 3143**] Glucose-110* UreaN-12 Creat-1.3* Na-140 K-4.4 Cl-105 HCO3-25 AnGap-14 [**2148-4-30**] 10:40AM [**Month/Day/Year 3143**] Calcium-8.6 Phos-3.0 Mg-2.0 Imaging: CT/A of Heat [**4-30**]: HEAD CT: On pre-contrast images, there is extensive subarachnoid hemorrhage, particularly in the right sylvian fissure as well as prepontine and perimesencephalic regions. No evidence for hydrocephalus. No shift of normally midline structures. [**Doctor Last Name **]-white matter differentiation is grossly preserved, and there is no evidence for acute territorial infarction. Patient is intubated, and there is opacification of the ethmoid air cells and right maxillary sinus. Osseous structures appear intact. Mastoid air cells are well aerated. CT ANGIOGRAM: There is a 7 x 5 mm saccular aneurysm arising at the branch point of M1 and M2 in the right MCA. This saccular aneurysm has an irregular contour. Flow was seen distally within the right MCA branches. There is tortuosity to the basilar artery, which may represent a fusiform aneurysm. In addition, in the area of the left PCOM near the choroidal artery is potentially a 2-mm infundibular dilation or aneurysm; however, an infundibular aneurysm arising off the left anterior choroidal artery cannot be excluded. No other areas of vascular narrowing or aneurysm were identified. IMPRESSION: 1. Extensive subarachnoid hemorrhage in the area of the right sylvian fissure as well as in the prepontine and perimesencephalic spaces. No hydrocephalus, and no shift of midline. 2. 7 x 4 mm saccular aneurysm of the right MCA at the M2 bifurcation. 3. Tortuosity of the basilar artery and fusiform aneurysm cannot be excluded. 4. Possible 2 mm infundibular dilation or aneurysm at the left PCOM, however, an infundibular aneurysm at the left anterior choroidal artery at this site cannot be excluded. Recommend correlation with angiography performed on [**2148-4-30**], at 7:13 a.m. 5. Opacification of the right maxillary sinus and bilateral ethmoid air cells, likely related to patient's intubated status. CTA/Perfusion Study [**5-3**]: increased hypodensity in right temporal/parietal lobe concering for ischemia, but with large peneumbral territory in the right inferior MCA territory on perfusion maps. paucity of vessels in region of inferior branch right MCA concerning for spasm or occlusion. remaning intracranial vessels patent. 10mm leftward midline shift with early subfalcine and uncal herniation. decreased size of lateral ventricles. decreased right subarachnoid hemorrhage. Final Report HISTORY: 46-year-old man with subarachnoid hemorrhage. Perform CTA brain with perfusion to evaluate for infarction, vasospasm or other interval change. CTA HEAD WITH PERFUSION: Contiguous axial imaging was performed through the brain without contrast. An axial MDCT perfusion was performed. Subsequently rapid helical axial MDCT imaging was performed from the aortic arch through the brain after uneventful administration of intravenous contrast. Images were processed on a separate workstation with display of mean transit time, relative cerebral [**Name2 (NI) **] volume, and cerebral [**Name2 (NI) **] flow maps for the CT perfusion study, and curved reformations, volume-rendered images, and maximum- intensity projection images for the CTA. COMPARISON: Carotid and cerebral angiogram [**2148-4-30**], CT head [**2148-4-30**], CTA head [**2148-4-29**]. CT HEAD: Compared to prior study, there has been significant further interval progression of large territory of hypodensity in the right temporoparietal lobe. This area is concerning for progression of cytotoxic edema, related to infarction. There is decreased volume of hyperdense subarachnoid hemorrhage seen along the right cerebral convexity. There is an 8-mm thick hypodense subdural collection layering along the right frontal convexity (2:19) causing mild sulcal effacement, as before. Compared to the prior study, there is new 8-mm leftward shift of normally-midline structures, with subfalcine herniation and probable early uncal herniation (2:13). The lateral ventricles have been further effaced since the prior study. A ventriculostomy catheter remains present in the region of the third ventricle, and an aneurysm clip is seen in the region of the bifurcation of the right MCA. Evidence of prior right temporal craniotomy with overlying soft tissue swelling is present. There has been significant interval resorption of previous pneumocephalus. Mucosal thickening is seen in bilateral frontal, ethmoid, and sphenoid sinuses, which may be related to patient's prior intubation and supine positioning. CT PERFUSION: Perfusion maps demonstrate a large territory of increased mean transit time and with largely corresponding zone of increased cerebral [**Year (4 digits) **] volume, particularly in the inferior division of the right MCA vascular territorial distribution, highly concerning for tissue at risk for infarction. Focally decreased [**Year (4 digits) **] volume seen in the distribution of the right MCA corresponds to region of subarachnoid hemorrhage seen on non- contrast CT study. CT ANGIOGRAM: The study is limited by patient-motion artifact. Corresponding to the conventional angiogram, there is marked paucity of arterial vascular flow corresponding to the inferior division of the right MCA, whereas flow is seen within its superior division. No flow into the clipped right MCA bifurcation aneurysm, and no new aneurysm is seen. Compared to the prior CT angiogram, the vessels of both the anterior and posterior circulation appear somewhat smaller in caliber and demonstrate slight mural irregularity, diffusely (some of which may relate to patient- motion artifact); the findings are suspicious for new vasospasm, in this context. The basilar artery remains highly irregular and lobulated in contour, with likely fusiform aneurysm which appears stable since the prior study. Again demonstrated are "triplex" ACA and fetal origin of the right PCA, both normal variants. IMPRESSION: 1. Enlarging hypodense territory in the left temporoparietal lobe which likely represents further cytotoxic edema corresponding to a region of ischemia with "tissue-at-risk" seen on CT perfusion study. 2. Paucity of vascularity in the territory of the inferior division of the right MCA, corresponding to the angiographic finding of three days earlier, which may related to occlusion of the inferior division. 3. Increased leftward shift of midline structures with early subfalcine and uncal herniation. Further effacement of the lateral ventricles with stable position of ventriculostomy catheter. 4. Decreased volume of subarachnoid hemorrhage in the right temporoparietal lobe. 5. Apparent caliber change with irregularity of the vessels of both the anterior and posterior circulation, some of which may be technical. However, the findings remains suspicious for diffuse cerebral vasospasm, in this context. 6. Likely fusiform aneurysm of the basilar artery, as before. CTA [**5-14**]: IMPRESSION: 1. Stable irregularity to the right M1 and M2 segments consistent with persistent areas of mild spasm. 2. There is focal fusiform dilation of the right M2 segment just distal to the aneurysm clip, which may be the result of spasm in this area. 3. Unchanged appearance to fusiform aneurysm of the basilar, more prominent in the mid basilar section. 4. Stable small left PCOM aneurysm. 5. Evolution of infarction involving the right temporal lobe. 6. Stable post-surgical changes involving the right craniotomy with MCA aneurysm clipping. Small volume right frontal extra-axial fluid collection. 7. Overall improvement in appearance of prior subarachnoid hemorrhage with no new areas of hemorrhage present. Brief Hospital Course: Pt was admitted to the hospital for eval of SAH. He was found down at home after doing the dishes. Pt famiy reports question of ilicit drug use prior to event. Pt was originally brought to an OSH and then transfered to [**Hospital1 18**]. On hospital day number one the pt underwent a cerebral angiogram and a Right MCA aneurysm was noted. He was started on Keppra, mannitol and nimodipine. He was then taken to the OR for open clipping of the same and a external ventricular drain was placed. Post-operative Angiogram was positive for cerebral vasospasm and was treated aggressively with medical management (triple-H therapy). He was extubated on [**5-3**] and was following commands. His cervical collar was maintained in the early hospital course because he was unreliable to assist in clearing his c-spine. His mannitol was weaned to off on [**5-6**] and his HHH therapy continued. On [**5-8**] he underwent a CTA to eval for vasospasm and the results were negative for vasospasm, but an evolving right MCA territory infarction was noted along with improved leftward shift of midline structures, with mild subfalcine herniation, but no evidence of uncal herniation, slight improvement in the caliber of the lateral ventricles. [**5-9**], Patient became more lethargic and less verbally interactive, under the assumption that the patient was in vasospasm at this time, levophed was started and new goal for sbp to 180s was set. With this new goal and elevated systolics, patient became more alert and interactive. the ventricular drain was also clamped on this day, a CT scan the following morning did not show any evolving hydrocephalus, so the EVD was discontinued. The patient has remained afebrile since [**5-12**] all cultures have shown no growth to date. The patient remains in a hard cervical, refusing a full exam. On [**5-15**], patient was transfered to floor and monitored on telemetry for tachycardia. He was seen on c-spine CT to have a rotational subluxation of his C1/2 and was told to remain in C-collar. He denied point tenderness and Dr. [**Last Name (STitle) 548**] reviewed scan and examined patient and felt it was appropriate to remove c-collar. He was seen by physical and occupational therapy who determined that he would be an appropriate rehab candidate, and discharged on XXXXXXXXXXXXXXXXX. Medications on Admission: None Discharge Medications: 1. Insulin Regular Human 100 unit/mL Solution Sig: One (1) Injection ASDIR (AS DIRECTED). 2. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 3. Nimodipine 30 mg Capsule Sig: Two (2) Capsule PO Q4H (every 4 hours) for 5 days. 4. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal HS (at bedtime) as needed for constipation. 5. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipatoin. 7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. 8. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Discharge Disposition: Extended Care Facility: [**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**] Discharge Diagnosis: Atraumatic subarachnoid hemorrhage Right MCA aneurysm Discharge Condition: Neurologically Stable Discharge Instructions: General Instructions ?????? Have a friend/family member check your incision daily for signs of infection. ?????? Take your pain medicine as prescribed. ?????? Exercise should be limited to walking; no lifting, straining, or excessive bending. ?????? You may wash your hair only after sutures have been removed(on or about [**5-19**]). ?????? You may shower before this time using a shower cap to cover your head. ?????? Increase your intake of fluids and fiber, as narcotic pain medicine can cause constipation. We generally recommend taking an over the counter stool softener, such as Docusate (Colace) while taking narcotic pain medication. ?????? Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, Aspirin, Advil, and Ibuprofen etc. ?????? Clearance to drive and return to work will be addressed at your post-operative office visit. ?????? Make sure to continue to use your incentive spirometer while at home, unless you have been instructed not to. CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING ?????? New onset of tremors or seizures. ?????? Any confusion or change in mental status. ?????? Any numbness, tingling, weakness in your extremities. ?????? Pain or headache that is continually increasing, or not relieved by pain medication. ?????? Any signs of infection at the wound site: redness, swelling, tenderness, or drainage. ?????? Fever greater than or equal to 101?????? F. Followup Instructions: Follow-Up Appointment Instructions ??????Please return to the office in [**6-21**] days(from your date of surgery-on or about [**5-19**]) for removal of your sutures and a wound check. This can be done at rehab, or an appointment can be made with the Nurse Practitioner. Please make this appointment by calling [**Telephone/Fax (1) 1669**]. If you live quite a distance from our office, please make arrangements for the same, with your PCP. ??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr. [**First Name (STitle) **], to be seen in 4 weeks. ??????You will need a CT scan of the brain without contrast. Completed by:[**2148-5-17**]

[ "427.89", "780.39", "305.1", "430", "401.9", "518.81", "564.00", "435.9", "348.5" ]

icd9cm

[ [ [] ] ]

[ "96.6", "02.39", "39.51", "96.71", "88.41", "96.04" ]

icd9pcs

[ [ [] ] ]

12547, 12644

9413, 11752

352, 479

12742, 12766

1282, 1287

14269, 14937

822, 877

11807, 12524

12665, 12721

11778, 11784

12790, 14246

892, 892

1121, 1263

278, 314

507, 732

5078, 9390

1863, 5069

1301, 1854

754, 768

784, 806

15,122

159,465

1767

Discharge summary

report

Admission Date: [**2177-9-7**] Discharge Date: [**2177-9-16**] Date of Birth: [**2096-11-6**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 3043**] Chief Complaint: Lethargy, hyperglycemia Major Surgical or Invasive Procedure: None History of Present Illness: 80 yo W with PMH of insulin dependent DM brought in by EMS for worsening lethargy, hypotension, dehydration and poor PO intake. hypernatremia and DKA. Per nursing home, was not eating for 10 days. Was receiving D51/2NS maintenance fluids. NH was holding insulin as patient was taking minimal PO. This AM, her FS was unreadable. She was complaining of nausea. Her T was 99.3, HR 104 BP 102/54 22 98%RA. She was transferred to [**Hospital1 18**] for further management. . In the ED, VS: T98.2 P 107 121/69 RR 17 98%RA FS was 478. She received 2L of NS and 6U of insulin and started on insulin gtt. Labs were notable for sodium of 174 with correction, AG of ~36, lactate of 3.9. K was 3.5 so 40mEq were added to IVFs. Her EKG showed ST depression from V4-V6. Pt received ASA 325mg. CE's were sent and notable for Tn 0.03. CT abd/pelvis showed no acute process/ ? right lower lobe opacity. UA was notable for glucose and ketones. Blood cultures were sent and pt received ceftriaxone and levaquin. Pt was transferred to the MICU for further management. . On arrival to the unit, the patient is able to follow commands, able to answer questions intermittently. She responds yes to all ROS questions, but appears to not understand questioning. . Past Medical History: Type 1 DM Hypertension Dementia Anemia of Chronic Disease Social History: Currently lives at [**First Name4 (NamePattern1) 1188**] [**Last Name (NamePattern1) **]. Sister is health care proxy. Denies alcohol, tobacco, illicit drug use Family History: Non-contributory Physical Exam: On admission: VS: HR 93 BP 117/43 RR 19 93%RA GEN: Elderly African American female sitting up in bed in NAD HEENT: EOMI, PERRL, anicteric NECK: Supple no JVD CHEST: Decreased BS at right base, otherwise clear CV: RRR, S1S2, no m/r/g ABD: Soft, TTP in LLQ, hyperactive BS EXT: no c/c/e SKIN: no rashes or excoriations NEURO: AAOx0, able to follow commands, responds appropriately to some questioning; Can count from [**1-11**]; unable to name all months of year ([**Month (only) **]-[**Month (only) 205**]); CN ii-xii intact; no focal deficits; gait deferred; toes downgoing . On discharge: VS: Tm98.4 Tc98.0 HR 65 (65-87) BP 130/66 RR 16-18 97%RA BS: 2am 79, 7:40am 287, 11:45am 236, 5pm 145, 10pm 92, 2am 55 (poor dinner intake, given 1.2 amp D50), 4am 167, 6am 178 GEN: elderly African American female sleeping in bed. NAD, A&OX2 HEENT: EOMI, moist mucus membranes NECK: Soft, supple, no JVD CV: RRR, normal S1/S2, no murmurs/gallops/rubs PULM: CTAB, no wheezing/rhonchi/rales ABD: Soft, non-tender, non-distended, +BS EXT: No cyanosis/ecchymosis/edema SKIN: No rashes or excoriations Pertinent Results: Chem 10: GLUCOSE-500* UREA N-51* CREAT-1.8* SODIUM-168* POTASSIUM-3.8 CHLORIDE-118* TOTAL CO2-18* ANION GAP-36* . CBC: WBC-11.4*# RBC-4.01* HGB-10.6* HCT-36.4 MCV-91 MCH-26.4* MCHC-29.1*# RDW-15.0 NEUTS-88.7* LYMPHS-8.6* MONOS-1.9* EOS-0.2 BASOS-0.5 . Iron: 27 calTIBC: 202 Ferritn: 206 TRF: 155 . Urinalysis: BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-1000 KETONE-150 BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG . CT abd/pelvis: 1. No evidence of bowel obstruction. No pneumoperitoneum or pneumatosis. Moderate stool in the colon. 2. Ground-glass patchy opacity in the right lung base, incompletely evaluated, likely related to infectious or inflammatory etiology. 3. Tiny non-obstructing left renal stone. Additional left renal hypodense lesion too small to characterize. . CXR: ([**2177-9-7**]) Minimal opacity at the right costophrenic angle, likely atelectasis although an early developing pneumonia cannot be entirely excluded. . CXR: ([**2177-9-11**]) Small bilateral pleural effusions have increased since [**Month (only) **]. Mild cardiomegaly, increased slightly since [**2175-11-2**]. No focal pulmonary abnormality. No evidence of pneumonia. . EKG: Sinus tachycardia. Left ventricular hypertrophy. Possible left atrial abnormality. One millimeter of upsloping ST segment depression in leads V5-V6 and minimal changes in the inferior leads which are most likely tachycardia related. Compared to the previous tracing of [**2175-11-18**] the heart rate is slower and there are now ST segment depressions in the inferolateral leads. Brief Hospital Course: 80 yo woman with PMHx of Type 1 DM, hypertension, dementia who presented in Diabetic Ketoacidosis and severe hypernatremia secondary to poor oral intake. . Diabetic Ketoacidosis: Likely precipitating factors include poor PO intake, receiving intravenous fluids with dextrose but not receiving insulin. Patient was also initially noted to have significant constipation on CT scan. There was also an initial concern for an infectious etiology for this episode of diabetic ketoacidosis secondary to a questionable pulmonary process seen on CT chest and chest x-ray. Clinical exam, however, was not convincing for pneumonia and the urinalysis was negative. Patient did not have any indwelling lines to raise concern for skin source. Blood cultures ultimately came back negative as did urine gram stain and cultures. Patient was empirically treated on admission with Levaquin which was discontinued after one day. Patient's DKA was treated with an insulin drip and 5 liters of fluid while in the MICU. Patient was eventually transitioned to fixed dose insulin (NPH) and sliding scale after her anion gap (from metabolic acidosis) closed. - Please continue patient on insulin sliding scale and fixed dose insulin dose (NPH 4 units in the morning and 5 units at dinner) even when she is not taking in much by mouth, as she is Type 1 diabetic and requires exogenous insulin at all times. . Poor PO Intake: Patient was initially brought to the hospital in DKA likely secondary to poor PO intake. Patient's appetite remained poor while in the MICU, with one episode of mild emesis when taking applesauce with medications. Patient's diet was advanced from clears to regular but she persisted with very poor PO intake (bites per day). Geriatrics was consulted while patient was on the floor and they felt her poor PO intake was likely multifactorial: recent choking episode ~ 2 weeks ago, taking Levaquin for ?aspiration pneumonia, hyperglycemia/DKA, depressed mood. Of note, this was not patient's baseline. Per collateral reports from the nursing home, she used to be "one of the first residents in line for meals." Nutrition and Speech and Swallow were consulted; Speech and Swallow felt she was swallowing safely and capable of doing so. Patient was placed on Calorie Counts. Per Geriatric recommendations, patient was started on Remeron 15mg before bed daily with improvement of her appetite. It was also found that patient preferred to eat socially, with prompting and visitors around. She also enjoyed cream of wheat and Boost shakes (Glucose Control). - Continue Remeron 15mg before bed; may consider titrating up as outpatient - Continue Boost Shakes (Glucose Control) and Cream of Wheat - Encourage/prompt patient to eat - Have sitter/visitors with patient while she eats as she responds well to social eating situations. . Type 1 Diabetes Mellitus: Patient was initially maintained on an insulin drip and then transitioned to insulin sliding scale with fixed doses of NPH. - Please continue the Insulin Sliding Scale with fixed NPH (4 units with breakfast, 5 units with dinner) created for patient while in-patient. - Please make sure patient follows up in [**Hospital **] Clinic with a diabetes nurse practitioner and her former endocrinologist/diabetes physician, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 9978**]. The appointments for both have been scheduled and are in the discharge papers. . Hypertension: Patient's antihypertensives were initially held given her hypotension and renal failure. Patient was restarted on her home Lisinopril and Diltiazem Extended Release one day after leaving the MICU, with good control of her blood pressures. She was transitioned to Diltizem 30mg four times daily as she was found cheeking her medications a number of times during this admission, with concern that she woud concentrate the effect of the medication. - Please continue Lisinopril 12.5mg daily but STOP Diltiazem Extended Release (120mg daily) . Hypernatremia: Likely secondary to dehydration from poor oral intake and osmotic diuresis as patient's fingerstick initially showed a significantly elevated blood sugar. Her hypernatremia of 174 gradually trended down on D51/2NS and then D5W. Her free water deficit was noted to be ~5.5 liters on admission that slowly improved with careful monitoring and repletion. By the time patient was called out of the MICU, her hypernatremia was almost resolved. . Acute Renal Failure: Was likely prerenal in etiology. Her last creatining prior to this admission was from [**12/2175**] and showed a creatinine of 1.0. Patient's acute renal failure resolved with fluids. . Constipation: Patient was given an aggressive bowel regimen while in the MICU and patient had a bowel movement prior to call-out. Since arrival to the floor, patient has had regular bowel movements, approximately one every other day. . FEN: Patient was initially on D5W and transitioned to D51/2 for better management of her hypernatremia. Once the electrolyte imbalance resolved, her diet was advanced to clears and then a regular diet (due to poor PO) with Boost Glucose Control. - Patient does well with taking her medications crushed in applesauce. . CODE: FULL CODE [**First Name8 (NamePattern2) **] [**Last Name (un) 1188**] house report Medications on Admission: ASA 81mg PO daily Diltiazem 120mg PO daily Lisinopril 2.5mg PO daily Multivitamin 1 tab daily Simvastatin 20mg PO daily Novolog 70/30 14U SC q evening ISS Discharge Medications: 1. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 2. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 3. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 4. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day. 5. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day. 6. Multivitamin Tablet Sig: One (1) Tablet PO once a day. 7. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Four (4) units Subcutaneous breakfast: Please half dose if not taking PO. 8. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Five (5) units Subcutaneous dinner: Please half dose if not taking PO. Discharge Disposition: Extended Care Facility: [**First Name4 (NamePattern1) 1188**] [**Last Name (NamePattern1) **] Discharge Diagnosis: Primary: Diabetic Ketoacidosis Secondary: Type 1 Diabetes Mellitus, Hypertension, Dementia, Anemia of Chronic Disease Discharge Condition: Improved. Vital signs are stable, patient ambulation and eating are improved. Discharge Instructions: -You were admitted in Diabetic Ketoacidosis, a condition in which the lack of insulin in your body causes your blood sugar to become so high that the sugar is converted into toxins called ketones. You were started on intravenous insulin and specialized fluids to treat this condition; you were later restarted on injected insulin when your diabetic ketoacidosis resolved. . You were kept in the hospital for a few more days because of your lack of appetite. It was noticed that you did better when prompted to eat and when eating in social settings. You also seemed to enjoy Cream of Wheat and the Boost Glucose Control drinks. Please continue to eat as much as you can, and in social environments. . -It is important that you continue to take your medications as directed. We made the following changes to your medications during this admission: --> START Omeprazole 20mg daily --> START Remeron 15mg before bed daily --> STOP Diltizem Extended Release 120mg daily --> RESTART Simvastatin 20mg daily, Aspirin 81mg daily and Multivitamin --> CONTINUE the Insulin regimen we designed for you during this admission. This includes a sliding scale (Humalog) especially created to manage your Type 1 diabetes. It also includes a fixed doses of NPH, 4 units with breakfast and 5 units with dinner. . -Contact your doctor or come to the Emergency Room should your symptoms return. Also seek medical attention if you develop any new fever/chills, confusion, trouble breathing, chest pain, nausea/vomiting, dehydration or unusual stools. Followup Instructions: Please follow-up with your primary care physician [**Name Initial (PRE) 176**] [**1-3**] weeks. You can reach Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at: [**Telephone/Fax (1) 250**]. . Please also follow-up at the [**Hospital **] Clinic with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1557**], NP on Wednesday, [**9-17**] at 9:30am. You can reach her office at: [**Telephone/Fax (1) 2384**]. . It is also important that you follow-up with your diabetes physician, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 9978**] at the [**Last Name (un) **] Center. You have an appointment for Tuesday, [**10-21**] at 10:00am. You can reach her office at: [**Telephone/Fax (1) 2384**]

[ "294.8", "584.9", "250.13", "285.9", "276.0", "401.9", "293.9" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

10823, 10919

4596, 9909

338, 344

11081, 11161

3031, 4573

12738, 13513

1889, 1907

10115, 10800

10940, 11060

9935, 10092

11185, 12715

1922, 1922

2512, 3012

275, 300

372, 1613

1936, 2498

1635, 1695

1711, 1873

9,402

174,146

2635

Discharge summary

report

Admission Date: [**2154-2-26**] Discharge Date: [**2154-3-1**] Date of Birth: [**2084-3-11**] Sex: F Service: MEDICINE Allergies: Aspirin / Aleve Attending:[**First Name3 (LF) 4219**] Chief Complaint: Hematemesis Major Surgical or Invasive Procedure: EGD with APC of angioectasias Hemodialysis History of Present Illness: (Amended ICU admission HPI) .. Ms. [**Known lastname 13224**] is a 69yo F with ESRD on HD, CAD, DM, HTN, CHF (EF 60-70%, 3+ MR) and GAVE who presents following an episode of hematemesis and maroon stools at home. She was recently admitted to [**Hospital1 18**] [**2-17**] - [**2-22**] after developing "dark" BM that were guaiac positive. At that time, she was found to be more anemic than usual and was given IVF and 2u pRBC in the ER, after which she developed flash pulmonary edema and required intubation and a short stay in the MICU. She was then scoped and underwent an Argon plasma coagulation procedure after which she did very well. Hct upon d/c on [**2-22**] was 31%. At that time, the plan per GI was to repeat EGD on [**2154-3-7**]. Of note, during her last hospital stay, she was noted to have lateral TW depressions and + troponins which were felt to be due to demand ischemia. .. Reports that she felt well after discharge until this past Monday ([**2-25**]), when she reports she had to be taken off of her dialysis treatment b/c she didn't feel well. She states that she first felt tingling and pain in her fingers and toes, to the point where she was unable to put her feet on the ground. She felt generally weak and tired following dialysis and needed to be assisted back to her apartment. She spent the evening and most of the next morning in bed. Her nurse came to assist her the next day and offered her an oxycodone which she took, but then vomited what she described as brown liquid w/ white specks in it. No nausea prior to her vomiting. Her nurse said that it looked like blood, but denied that it was coffee ground emesis. After vomiting, Ms. [**Known lastname 13224**] immediately felt better. The nurse then called the pt's PCP who advised the pt to come to the ER. 15-20 mins later, Ms. [**Known lastname 13224**] then felt the sudden urge to have a BM and had a liquid maroon stool which was guaiac positive. She denies any abdominal pain associated w/ the BM. At that point, EMS arrived and transported her to the ER. On ROS, Ms. [**Known lastname 13224**] [**Last Name (Titles) 13230**]d any lightheadedness, dizziness, CP, SOB, or diaphoresis. + persistent burping, but that has actually decreased in frequency since her last admission. Between her last discharge and now, she had been eating normally and having normal brown, formed stools. She has never had an episode of hematemesis before. .. In the ED, she was tachycardic but normotensive. Her NG lavage showed brown fluid that cleared with 200 cc and her rectal exam revealed guaiac negative brown stool. Her Hct on admsiion was 38% and she received lL of NS and 1u pRBCs. She also received Anzemet 12.5 mg IV X 1 and pantoprazole 40 mg IV X 1. She was evaluated by GI and taken for an EGD which showed findings c/w GAVE. Her angiodysplasias were coagulated w/ an argon laser and the pt was transfered to the [**Hospital Unit Name 153**] for monitoring of fluid status and serial Hct's. She remained hemodynamically stable in the [**Hospital Unit Name 153**] w/o any further episodes of hematemesis or melena, and her Hct remained stable, so she was transferred to the medical floor for futher monitoring. . Past Medical History: 1. DM type II - c/b nephropathy and neuropathy 2. ESRD - on HD since [**11-30**] 3. CAD - suspected by stress test ([**Doctor Last Name 4001**]) in [**2153-5-22**]: Mild global hypokinesis. LVEF 43%. Normal myocardial perfusion at the level of stress achieved. 4. CHF: TTE [**2153-11-1**] showed LVEF 60-70% with 3+ MR and 2+ TR 5. Anemia: multifactorial (ESRD + iron deficiency [**12-27**] GIB) - colonoscopy on [**2153-8-7**] -> two nonbleeding polyps in sigmoid - EGD [**2153-8-7**] -> sig for erythema, edema, and erosion in the antrum c/w gastritis in addition to erythema in the proximal bulb c/w duodenitis - EGD [**12-31**] demonstated GAVE 6. Occult GI bleed [**7-/2153**] with studies as above 7. Gout Social History: Pt lives alone in an [**Hospital3 **] community. She has a visiting nurse [**First Name (Titles) **] [**Last Name (Titles) 13222**]. Son lives close by and helps mother. [**Name (NI) **] ETOH, tobacco, or drugs. Family History: [**Name (NI) 1094**] son and daughter have DM. Her son also has HTN. She has no family history of CAD. Physical Exam: PE (on transfer to the floor): VS: Tm + Tc 98.9, BP 118/62 (127-147/51-101), HR 88 (94-110), RR 20, sats 98% on RA FS 57 I/O: none recorded yet GEN: Pleasant, elderly AfAm female in NAD. Moving around bed very comfortably. HEENT: NCAT, sclera anicteric, PERRL, EOMI. MMM w/ thrush on tongue, improved since last admission. Has dark circles around her eyes, nonpuffy. NECK: Neck supple, no JVD. CV: RR, normal S1, S2. III/VI soft systolic murmur heard at RUSB, II/VI holosystolic murmur heard at LLSB. CHEST: CTAB, except for few crackles at bases bilaterally. ABD: Soft, protuberant abdomen, no fluid wave, no ascites; + BS; obvious ventral hernia, otherwise no masses; no hepatomegaly. EXT: 2+ radial/PT pulses bilaterally. At tips of index fingers bilaterally, skin is cool, [**Doctor Last Name 352**]. R index finger has ? necrotic vs. blood blister on tip. Nontender. No edema. Skin dry, warm, wrinkled. NEURO: CN II-XII grossly intact. Pertinent Results: Labs on admission: WBC 7.8, Hct 38.5, MCV 94, Plt 229 (DIFF: Neuts-89.1* Bands-0 Lymphs-7.2* Monos-2.4 Eos-1.2 Baso-0.1) PT 12.2, PTT 27.1, INR 1.0 Na 139, K 4.9, Cl 98, HCO3 23, BUN 53, Cr 5.9 . Labs on discharge: WBC 7.7, Hct 33.5, MCV 93, Plt 239 PT 12.2, PTT 29.8, INR 1.0 Na 139, K 3.9, Cl 104, HCO3 24, BUN 33, Cr 5.0, Glu 78 Calcium 8.1, Phos 3.1, Mg 1.7 calTIBC 161, Ferritin 437, TRF 124* PTH 81* . Urinalysis: [**2154-2-26**] 08:45PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.019 Blood-NEG Nitrite-NEG Protein-30 Glucose-NEG Ketone-15 Bilirub-SM Urobiln-NEG pH-8.0 Leuks-NEG RBC-0-2 WBC-[**5-4**]* Bacteri-FEW Yeast-NONE Epi-[**10-14**] . Micro: none . Imaging: EGD [**2154-2-21**]: - Normal esophagus. - Stomach: Flat Lesions Multiple angiodysplasias/watermelon stomach was seen in the antrum compatible with GAVE. An Argon-Plasma Coagulator was applied for hemostasis successfully. - Duodenum: Angiodysplasias distributed in a linear pattern was noted in the first part of the duodenum. - Impression: Watermelon stomach in the antrum, Angiodysplasias in the first part of the duodenum, Otherwise normal egd to second part of the duodenum . CXR [**2154-2-26**]: No evidence of CHF or other acute cardiopulmonary process. . EGD [**2154-2-27**]: Mild erythema in the first part of the duodenum Angioectasia in the antrum Erosion in the cardia Otherwise normal egd to second part of the duodenum .. Brief Hospital Course: 69yo F with ESRD on HD, CAD, DM, HTN, CHF and h/o UGIB/GAVE, now presenting with hematemesis and melena. . # UGIB: Her NG lavage in the ER was positive, but cleared with 200cc. She was placed on protonix IV for UGIB and 2 large bore IVs were placed. She was given 1L NS as well as 1u pRBCs. An EGD was performed which showed bleeding in gastric antrum, likely due to GAVE. The angioectasias were cauterized with Argon laser and she had no further episodes of bleeding. Her Hct remained stable at 36. She was discharged with plans for a repeat elective EGD and Argon laser cauterization on [**2154-3-7**]. . # THRUSH: Ms. [**Known lastname 13224**] has thrush, but it appeared improved since her last hospitalization. She was continued on nystatin swish and swallow. . # CAD: Ms. [**Known lastname 13224**] [**Last Name (Titles) 13231**] has CAD, given that she had a stress MIBI that showed EKG changes but no perfusion defects at normal workload. She has no h/o of MI, but does have elevated troponins at baseline. During her last admission, she experienced lateral TW depressions as well as a troponin leak felt to be due to demand ischemia. She was continued on a beta-blocker and statin, but was not given an aspirin due to her UGIB. . # CHF: Her CHF appeared stable during this admission. She had crackles at her L lung base on exam but no shortness of breath or hypoxia. She was continued on her regular HD schedule and her volume status was managed by renal. The team discussed whether an ACE-inhibitor would be beneficial in her, but it was discontinued for unclear reasons in [**2145**]. The team decided to defer this decision to her PCP. . # DM II: Her fingersticks were monitored QID and she originally was on her regular glipizde dose as well as a regular insulin sliding scale for additional coverage. However, she actually was hypoglycemic and her glipizide does was held. She was not put on glipizide upon discharge, as she continued to be hypoglycemic. . # ESRD: Ms. [**Known lastname 13224**] has been receiving HD since [**2153-11-25**]. She was continued on HD per her regular M/W/F schedule. Renal consulted on her while she was in-house. She was continued on phoslo and nephrocaps daily. . # GOUT: She was continued on allopurinol. . # FINGER LESIONS: It was noted prior to discharge that Ms. [**Known lastname 13224**] has some lesions on the tips of her fingers. Our differential diagnosis included gout (less likely given appearance, lack of warmth or effusion), vascular (though has strong bilateral radial pulses), or a CTD (like lupus or Raynaud's, though unusual to present for first time at her age). Further workup was deferred to the outpatient setting as it was not acute, per the patient. . # FEN: She was given a regular [**Doctor First Name **] diet. No IVF were needed. Her electrolytes were checked daily and were repleted to keep K>4, Mg>2. . # PPX: She was given a PPI for GI prophylaxis, pneumoboots for DVT ppx, and a bowel regimen to prevent constipation. . # ACCESS: Peripheral IV . # COMM: with her son, [**Name (NI) **] at #[**Telephone/Fax (1) 13227**] . # DISPO: To home with services. Medications on Admission: Allopurinol 100 mg PO QD Atorvastatin 80 mg PO QD Toprol XL 50mg PO QD Nystatin 100,000 unit/mL Suspension 10 ML PO QID Protonix 40mg PO QD Glipizide 2.5mg PO QD PhosLo 667mg PO TID Folic Acid 1mg PO QD Multivitamin 1 tab PO QD Vitamin B Complex 1 tab PO QD Colace 100mg PO BID Senna 8.6mg PO BID Tylenol 325-650 PO Q4-6 prn Oxycodone 5mg PO Q6 prn Discharge Medications: 1. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY (Every Other Day). 2. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Calcium Acetate 667 mg Capsule Sig: One (1) Capsule PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 5. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 6. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 9. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. 10. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day) as needed. 11. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 12. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. Discharge Disposition: Home With Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: Primary diagnosis: 1. GIB . Secondary diagnosis: 1. ESRD on HD 2. Diabetes 3. HTN Discharge Condition: Afebrile, Hct stable, BP stable Discharge Instructions: Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs. Adhere to 2 gm sodium diet Fluid Restriction: 1.5 L . Please call your PCP or go to the nearest ER if you develop any of the following symptoms: fever, chills, chest pain, dizziness, lightheadhedness, dark, tarry or bloody stools, burning on urination, abdominal pain or tenderness, or any other worrisome symptoms. . You should take all your medications as prescribed. The only change in your medications is to take Toprol XL 50mg daily. . You should follow-up with the GI department as previously scheduled for a repeat EGD on [**2154-3-7**]. . Please have a hematocrit (a measure of your red blood cells) checked at each hemodialysis session. Per your GI doctors, you should be transfused for any hematocrit less than 25. Followup Instructions: Already scheduled: Provider: [**Name10 (NameIs) 13228**] [**Name11 (NameIs) 13229**], [**First Name3 (LF) **] Phone:[**Telephone/Fax (1) 2226**] Date/Time:[**2154-3-5**] 12:00 Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1982**], MD Phone:[**Telephone/Fax (1) 1983**] Date/Time:[**2154-3-7**] 8:00 Provider: [**Name10 (NameIs) **] WEST,ROOM ONE GI ROOMS Date/Time:[**2154-3-7**] 8:00 . Please call your PCP [**Last Name (NamePattern4) **] [**11-26**] weeks for f/u from this admission. . Please continue dialysis as reccomended by your nephrologist. [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 4231**]

[ "537.83", "403.91", "585.6", "428.0", "285.21", "274.9", "250.60", "250.40", "357.2" ]

icd9cm

[ [ [] ] ]

[ "99.04", "39.95", "44.43" ]

icd9pcs

[ [ [] ] ]

11707, 11764

7075, 10211

287, 332

11890, 11924

5625, 5630

12771, 13443

4543, 4648

10611, 11684

11785, 11785

10237, 10588

11948, 12748

4663, 5606

236, 249

5840, 7052

360, 3561

11834, 11869

11804, 11813

5644, 5821

3583, 4297

4313, 4527

28,792

148,479

1486

Discharge summary

report

Admission Date: [**2122-2-3**] Discharge Date: [**2122-2-5**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**Last Name (NamePattern4) 290**] Chief Complaint: fever, shortness of breath Major Surgical or Invasive Procedure: none History of Present Illness: Ms. [**Known lastname 8774**] is an 83-year-old Russian-speaking woman with PMH of DM2 and HTN who presents to the ED from [**Hospital 100**] Rehab with nausea/vomiting, fever, and shortness of breath. Via interpretation, patient states that she began to feel short of breath with a worsening dry cough approximately 1 week ago. Denies fevers but endorses chills. She developed nausea and vomited several times, without relation to food intake. No diarrhea. She does endorse dysuria and suprapubic abdominal pain which has been intermittnent and ongoing for approximately one month. At [**Hospital 100**] Rehab, she was noted to vomiting 3 times on the day prior to admission, when she was also found to be drowsy and weak. She had a CXR there which was read as no acute changes from prior. Her BP was noted to be 210/110, her O2 sat was as low as 88% RA, and she developed a low grade temp. She was sent to the [**Hospital1 18**] ER for further evluation. During transport she received SL nitro and lasix. In the ED initial vitals were 101.6, 175/104, 116, 93% on NRB eventually improving to 98%. She did not tolerate BiPAP as she vomited a small amount of coffee ground emesis into the mask. She was then switch to a NRB. A nitro gtt was started for BP as high as 194/131. An EKG showed sinus tach with LAD and no acute ST changes or Q waves. A CT-A was done which was negative for PE. She was given tylenol, combivent nebs x 3, levaquin 750mg IV x 1, cefepime 1g IV x 1, flagyl 500mg IV x1, and protonix 40mg IV x1. Given her emesis, GI was made aware and pt was admitted to [**Hospital Unit Name 153**] for further care. Past Medical History: HTN Type II Diabetes L CVA with residual R weakness Hypothyroidism Fatty Liver Disease Degenerative Joint Disease GERD diverticulosis dyspahgia Legally blind Hard of Hearing Social History: lives at [**Hospital 100**] Rehab x 1 year. No history of tobacco, EtOH, or drugs. Family History: non-contributory Physical Exam: T: 98.4 BP: 158/87 P: 119 RR: 21 O2 sat: 96% on NRB Gen: elderly, frail female in mild respiratory distress HEENT: NC/AT, PERRL, MM dry. Oropharynx with dried brownish-red emesis Neck: no carotid bruits, JVP not elevated, supraclavicular retractions CV: tachycardic and regular, no M/R/G, nl S1, S2 Resp: inspiratory crackles b/l at bases and [**1-1**] way up, minimal traces wheezes Abd: soft, non-distended, with suprapubic tenderness on palpation. + BS Back: no CVA tenderness Rectal: Guaiac negative per ED Ext: WWP, no C/C/E, 2+ symmetric pedal pulses Skin: No rashes, lesions, or ulcers noted Neuro: A+O x 3. Pertinent Results: [**2-3**] ADMISSION LABS CBC: WBC-7.8 RBC-4.68 Hgb-13.2 Hct-39.4 MCV-84 MCH-28.1 MCHC-33.4 RDW-12.7 Plt Ct-238 Neuts-85.0* Lymphs-11.3* Monos-3.4 Eos-0.2 Baso-0 . Glucose-240* UreaN-17 Creat-1.1 Na-135 K-3.8 Cl-89* HCO3-28 AnGap-22* . ABG: pH-7.47* pCO2-34* pO2-63* calTCO2-25 Base XS-1 Intubat-INTUBATED Lactate-3.8* . [**2-3**] CXR SINGLE VIEW CHEST, AP UPRIGHT: The aorta is tortuous and the cardiomediastinal contour is otherwise within normal limits. Degenerative changes are seen within the thoracic spine. The lungs are clear without focal pulmonary opacity. Calcifications within the left upper lobe likely represent chronic granulomatous disease. There are no definite pleural effusions. . IMPRESSION: Chronic granulomatous disease changes of the left upper lobe. No acute cardiopulmonary disease. . [**2-3**] CT-A: IMPRESSION: 1. No evidence of pulmonary embolus. 2. Lower lobe predominant bronchiectasis, mucoid impaction and centrilobular nodular density, which could all be explained by recurrent aspiration. Superimposed bronchopneumonia would have similar features. Hilar and mediastinal adenopathy may in part be reactive in nature. 3. Left upper lobe calcified scarring and calcified left hilar lymph nodes suggests prior TB or granulomatous disease. . [**2-3**] EKG Sinus tachycardia. Left ventricular hypertrophy . [**2-4**] EKG Sinus rhythm with slowing of the rate as compared with tracing of [**2122-2-3**]. Left ventricular hypertrophy. Otherwise, no diagnostic interim change. . [**2-4**] TT Echo The left atrium and right atrium are normal in cavity size. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%) Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (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 borderline pulmonary artery systolic hypertension. There is no pericardial effusion. There is an anterior space which most likely represents a fat pad. IMPRESSION: Normal biventricular cavity sizes with preserved global and regional biventricular systolic function. Aortic valve sclerosis. ***********MICRO************** [**2-3**] BCx: no growth by discharge . [**2122-2-4**] 1:07 am URINE Source: Catheter. **FINAL REPORT [**2122-2-5**]** URINE CULTURE (Final [**2122-2-5**]): NO GROWTH. . [**2122-2-4**] 1:07 am URINE Source: Catheter. **FINAL REPORT [**2122-2-4**]** Legionella Urinary Antigen (Final [**2122-2-4**]): NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN. . [**2122-2-4**] 1:09 pm ASPIRATE Source: Nasopharyngeal aspirate. **FINAL REPORT [**2122-2-4**]** DIRECT INFLUENZA A ANTIGEN TEST (Final [**2122-2-4**]): Negative for Influenza A viral antigen. DIRECT INFLUENZA B ANTIGEN TEST (Final [**2122-2-4**]): NEGATIVE FOR INFLUENZA B VIRAL ANTIGEN. . DISCHARGE LABS: 139 | 101 | 14 | ---------------- 117 4.0 | 28 | 0.9 | Ca: 9.0 freeCa:1.17 Mg: 2.4 Phos: 2.8 . WBC: 6.9 HCT: 32.3 Plt: 230 Brief Hospital Course: 84 y/o female with T2DM, HTN, hyperlipidemia, and OA who presented to the ED with fever and SOB, found to be hypoxic with one episode of coffee ground emesis. . # hypoxia ?????? DDx included infectious, embolic, pulmonary, and cardiac etiologies. A CT-A was performed which was negative for PE. Given lack of leukocytosis, productive cough, or evidence of infiltrate on CXR, a bacerial PNA was unlikely. No further antibiotics were given, although pt did receive 1 dose of levaquin, cefepime, and flagyl in the ED. A urine legionella antigen was negative. We ruled out influenza while maintaining droplet precautions. There was no picture of pulmonary edema on CXR or any type of heart failure on clinical exam, so cardiac etiology was unlikely. We checked an echocardiogram and proBNP to further evaluate. proBNP was unimpressive at 500, and her echo showed preserved systolic function with no clinically significant failure or valvular disease. We continued supplemental oxygen weaned down to 2L NC by discharge. PRN nebs were given for comfort. The most likely cause for her presentation was a viral syndrom NOS, with the febrile syndrome perhaps causing transient LV dysfucntion with resultant transient pulmonary edema and hypoxia with resultant hypertension. . # HTN ?????? pt??????s SBP was in the 190s on presentation. As above, may represent some mild flash pulmonary edema in setting of febrile viral illness. A nitro gtt was started in the ED and quickly weaned off. We briefly started metoprolol 12.5mg tid as we held her ACE-I initially (concern for elevated creatiine). As creatinine normalized by discharge, ACEI was resumed and metoprolol was discontinued. She was normotensive on this regimen. . # Coffee ground emesis x 1 - Had an episode of coffee ground emesis in ED, and upon ICU arrival pt had dried [**Year/Month/Day **] in mouth. DDx included PUD vs [**Doctor First Name 329**] [**Doctor Last Name **] from retching/vomiting in week leading up to admission. Put on po PPI [**Hospital1 **]. GI was aware, decided no need for scope. HCTs did trend down after receiving IVF and after hypoxia resolved. Guaiac negative. . # AG acidosis - lactate was elevated on presentation, with AG of 18. This was most likely due to her lactic acidosis, but may have been exacerbated by mild ARF/uremia, with Cr of 1.1 (although a normal value, mildly elevated for her). She was given 1.5 liters of IVF and the gap acidosis resolved, as did her creatinine. . # Dysuria - pt c/o suprapubic tenderness and dysuria. U/A was negative. Culture was also negative. Could consider further outpt w/u as clinically needed. . # T2DM - held metformin for 48-72 hours after IV dye for CT-A. to be restarted [**2122-2-6**] in rehab. In meantime, covered with Regular Insulin SS. Monitored FSBG qid, ate a diabetic diet. . # Hypothyroidism - TSH was WNL at 1.5, continued levothyroxine . # FEN- as previously discussed, ate diabetic dysphagia diet. Repleted ltyes prn . # PPx -received sQ heparin tid, bowel regimen, and [**Hospital1 **] PPI . # CODE - DNR/DNI . # Dispo - remained called out to floor for days, improved substantially and was able to be d/c'ed directly back to rehab form ICU Medications on Admission: metformin 100mg [**Hospital1 **] ASA 81mg Dipyridamole 50mg [**Hospital1 **] levothyroxine 25 mcg lisinopril 5mg daily simvastatin 20mg daily omeprazole 10mg [**Hospital1 **] calcium 650mg [**Hospital1 **] vitamin D 1000 units daily colace senna guaifenacin Discharge Medications: 1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 2. Dipyridamole 25 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 3. Levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily): give 30 minutes before food. Do not give within 4 hours of calcium, simethicone, iron, or sulcralfate. 4. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 5. Guaifenesin 600 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO twice a day for 2 weeks. 6. Calcium Carbonate 650 (1,625) mg Tablet Sig: One (1) Tablet PO twice a day. 7. Cholecalciferol (Vitamin D3) 1,000 unit Tablet Sig: One (1) Tablet PO once a day. 8. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO twice a day. 9. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed: max dose = 4 grams/day. 10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 11. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO at bedtime as needed. 12. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day. 13. Metformin 1,000 mg Tablet Sig: One (1) Tablet PO twice a day: first dose to be given on [**2122-2-6**]. 14. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - MACU Discharge Diagnosis: Primary: viral syndrome NOS . Secondary: HTN Type II Diabetes L CVA Hypothyroidism Fatty Liver Disease Degenerative Joint Disease GERD dyspahgia/laryngopharyngeal reflux diverticulosis Legally blind Hard od hearing Discharge Condition: stable Discharge Instructions: You were admitted to the hospital with fever and shortness of breath. You came to the ICU for close monitoring because your oxygen levels were quite low and you vomited some [**Hospital6 **] tinged material in the emergency room. As per your previously expressed wishes, you were never intubated. In the ICU, you had no further vomiting or bleeding. You [**Hospital6 **] counts were stable, so our gastroenterologists decided you did not need an endoscopy. . We gave you supplemental oxygen and your oxygen levels improved. We checked to make sure you did not have a clot in your lungs, which you did not. We also checked to see if you had the flu, which you did not. There was no evidence of a pneumonia or bacteria in your lungs or [**Last Name (LF) **], [**First Name3 (LF) **] you did not receive or need antibiotics. You never had any fevers during your ICU stay. Finally, we looked at your heart, which looked like it was working well. Therefore the most probable cause for your symptoms was a viral syndrome. . Please resume taking your home medicines. We are continuing your diabetes and [**First Name3 (LF) **] pressure medicines as before. We have inreased the dose of an acid suppressing medicine to prevent any further bleeding from your stomach. . Please take all of your medicines as prescribed. Please keep all followup appointments. If you experience any symptoms which disturb you, such as fevers, chills, or shortness of breath, please call your doctor or go to the ER. Followup Instructions: Please make an appointment to see your PCP in the next [**12-31**] weeks: [**Last Name (LF) 585**],[**First Name3 (LF) 586**] L [**Telephone/Fax (1) 589**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]

[ "799.02", "276.2", "787.20", "584.9", "530.81", "276.52", "250.00", "715.90", "780.79", "389.9", "244.9", "571.8", "369.4", "401.9", "079.99", "438.89", "562.10", "788.1" ]

icd9cm

[ [ [] ] ]

[ "93.90" ]

icd9pcs

[ [ [] ] ]

11130, 11196

6267, 9452

294, 301

11455, 11464

2939, 6099

13001, 13296

2271, 2289

9760, 11107

11217, 11434

9478, 9737

11488, 12978

6116, 6244

2304, 2920

228, 256

329, 1958

1980, 2155

2171, 2255

69,941

185,156

39580

Discharge summary

report

Admission Date: [**2161-10-17**] Discharge Date: [**2161-10-26**] Date of Birth: [**2131-1-2**] Sex: F Service: NEUROSURGERY Allergies: Penicillins Attending:[**First Name3 (LF) 1835**] Chief Complaint: Unresponsiveness Major Surgical or Invasive Procedure: R craniectomy for evacuation of clot [**2161-10-17**] EVD placement [**2161-10-17**] History of Present Illness: This is a 30 year old right handed woman with history of HTN not currently on medication who suddenly became unresponsive while at a tailgate party with her husband. [**Name (NI) **] husband, she was in her usual state of health except for some nighttime coughing. She and her husband were at a tailgate party and the patient went to grab some food. She suddenly grabbed her husband than muttered something about R side not feeling right. She sat down and did not hit her head. She soon became unresponsive and 911 was called. Per 911, she was unresponsive and possibly foaming at the mouth. She was found to have dilated R pupil and she was emergently transported to the [**Hospital1 18**] ED. Her O2 sat was dropping into 80's hence and she was not following any commands hence she was emergently intubated in the ED. Around intubation, she became as hypertensive as 240's/150's. She underwent emergent imaging including CT of head and CTA of head and neck which showed large R cortical/subcortical hemorrhage with extensions into all ventricles and some midline shift. She was seen per Dr. [**Last Name (STitle) **] and was emergently taken to the OR where she underwent R craniectomy. She also received 100g of mannitol prior to the OR. Past Medical History: 1. HTN - not on any meds currently 2. Asthma Social History: Architect and lives with her husband. [**Name (NI) **] smoking or drugs. Occasional/rare EtOH Family History: unknown Physical Exam: On admission: O: BP:240/150 Gen: Intubated and sedated. MSE: No opening of eyes or following commands. Some spontaneous movements of legs no purposeful movements. CN: R pupil 7->6mm and L pupil 3->2mm. No blinking to visual threat. No obvious facial asymmetry. Motor: Withdraws on L briskly to noxious stim but only triple flexion on R. No obvious asymmetry in tone in [**Initials (NamePattern4) 87358**] [**Last Name (NamePattern4) **]: LE's intact to noxious stim. Reflexes: Upgoing toes bilaterally. On Discharge: deceased Pertinent Results: CT HEAD W/O CONTRAST [**2161-10-17**] 1. Status post right-sided craniectomy with post-surgical pneumocephalus. 2. Partial right intraparenchymal hematoma evacuation. There is residual hematoma posteriorly within the site of intraparenchymal hemorrhage. 3. Stable intraventricular blood extending into the lateral ventricles and the fourth ventricle. 4. New left frontal approach shunt catheter. 5. Stable ventricular size and midline shift. 6. Herniation with effacement of the quadrilateral plate. CT HEAD W/O CONTRAST [**2161-10-18**] 1. Status post right frontotemporal craniectomy with unchanged appearance of blood products in the surgical bed, right basal ganglia hemorrhage and intraventricular hemorrhage. 2. Unchanged leftward shift of the normally midline structures and mass effect compared to study performed earlier the same day. MRI brain [**10-19**]: 1. Unchanged large right intraparenchymal hemorrhage with new foci of acute embolic infarctions scattered bilaterally including the brainstem, cerebellum in bilateral frontoparietal hemispheres. 2. Unchanged subfalcine and mild uncal herniation. 3. Unchanged foci of hemorrhage within the brainstem, in the setting of slight downward transtentorial herniation, raising the possibility of duret hemorrhage ECHO [**2161-10-20**] Mild to moderate spontaneous echo contrast is seen in the left atrial appendage. No mass/thrombus is seen in the left atrium, left atrial appendage, right atrium, or right atrial. appendage. The left atrial appendage emptying velocity is depressed (<0.2m/s). No atrial septal defect or patent foramen ovale is seen by 2D, color Doppler or saline contrast with maneuvers. Overall left ventricular systolic function is borderline (LVEF= 55 %). There is moderate LVH.No masses or thrombi are seen in the left ventricle. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis. No masses or vegetations are seen on the aortic valve. 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 or the tricuspid valve. There is a trivial/physiologic pericardial effusion. IMPRESSION: There is mild to moderate spontaneous echo contrast in the left atrial appendage (and low emptying velocity) without intracardiac thrombus seen (? Prior/recent atrial fibrillaiton?). There is no evidence of vegetations or abscesses. There is no ASD or PFO. There is no evidence of aortic atheroma. There is moderate left ventricular hypertrophy and the overall left ventricular systolic function is borderline. [**2161-10-19**]: LE doppler No evidence of DVT seen in either lower extremity. [**2161-10-19**] Renal US No gross hydronephrosis. [**2161-10-21**] CT head 1. Stable to decreased hemorrhagic products within the right cerebral hemisphere and ventricular system, with no new hemorrhage. 2. Increased hypodensity in the right cerebral hemisphere compatible with evolving encephalomalacia. 3. Multifocal evolving left cerebral and brainstem infarcts. 4. Stable ventricular catheter. Stable effacement of the ambient cisterns. Again demonstrated is the small hemorrhagic focus in the paramedian ventral aspect of the upper pons; given this pattern, in the setting of persistent downward transtentorial herniation, this likely represents a Duret hemorrhage, associated with a poor prognosis. CXR [**2161-10-21**] Now mild pulmonary edema has markedly improved. Mild-to-moderate cardiomegaly is accentuated by low lung volumes. Bibasilar opacity left greater than right are likely atelectasis. There is no evident pneumothorax. The lines and tubes remain in place in their standard position. CT HEAD W/O CONTRAST Study Date of [**2161-10-23**] 2:00 AM Final Report FINDINGS: Compared to the earlier examination, there is little change in the appearance of a right frontoparietal craniectomy with herniation of the brain to the calvarial defect. There are extensive hemorrhagic products within the right cerebral hemisphere, tracking into the lateral ventricles, the distribution of which appears similar to the prior study. This evaluation is limited by streak artifact from patient motion, particularly in the posterior fossa. The appearance of the posterior fossa, however, appears grossly similar with effacement of the ambient cisterns. There is hemorrhage within the brainstem, compatible with a hemorrhage. There are multifocal low-attenuation lesions within the left cerebral hemisphere compatible with evolving infarcts. A left frontal approach ventriculostomy catheter is stable in position. The visualized paranasal sinuses are clear. IMPRESSION: 1. Little overall change in appearance of extensive right cerebral intraparenchymal hemorrhage with intraventricular extension. 2. Limited evaluation by streak artifact, but the appearance of the posterior fossa with brainstem hemorrhage, ambient cistern effacement and downward transtentorial herniation is unchanged. CXR [**2161-10-23**]: IMPRESSION: Progression of left lower lobe/retrocardiac opacity indicating left lower lobe consolidation, possible additional right lower lobe consolidation. Pulmonary vascular engorgement and moderate cardiomegaly. Brief Hospital Course: This is a 30 y/o F with PMHx significant for HTN presents unresponsive after a tailgate party. Patient stated that she did not feel her R side, sat down, then became unresponsive. 911 was contact[**Name (NI) **] and she was brought to [**Hospital1 18**]. She underwent emergent CT and CTA which showed R SDH. She was taken to the OR emergently and had a R sided craniectomy and EVD placement. On [**10-18**], post operative head CT was stable. EVD was at 10 and clamped when patient's exam worsened to extensor posturing in BUE and triple flexion in BLE. She was transfused 3 units of blood and hypothermia was initiated. On [**10-19**], patient's exam did not improve, MRI head was done which revealed punctate infarcts in b/l frontal, parietal, occipital and brainstem. Echo was ordered as well as blood cultures. EVD remains at 10 and open and draining bloody CSF. On [**10-20**], patient's exam remained the same. Echocardiogram showed no vegetation/emboli. Renal US and LE dopplers were negative. On [**10-21**] she had ICP elevations to 27-29. Hypertonic saline was started. She was being cooled to 96 degrees so she was pan cultured to monitored for infection. CSF was also sent on [**2161-10-21**]. On [**10-22**], she continued to have ICP readings in the 20's. Mannitol was ordered but was held at times for NA/OSM elevations. Overnight her drained was clamped to obtain accurate [**Location (un) 1131**] and she was suctioned at the same time. Her ICP increased to low 40's and she became briefly asystolic. THe drain was reopened and her ICP decreased to mid 20's and her HR returned to [**Location 213**]. A stat head ct obtained showed no change from her previous exam. [**10-23**] Her sedation was increased and her ICP did improve. On a.m rounds her ICP was 18-21 and decreased from the previous day. Her cultures remained negative on this day. [**10-24**] there was a family meeting with the attending Neurosurgeon and care and comfort measures was discussed. [**10-25**] The patients family decided to make the patient care and comfort measures. The patient was officially made Care and comfort measures at 2300 and the patient was electively extubated at 2300. [**2161-10-26**] The patient's time of death was declared at 0315 due to respiratory distress and large previously known intraparenchymal hemorhage. Medications on Admission: None Discharge Medications: deceased Discharge Disposition: Extended Care Discharge Diagnosis: deceased Discharge Condition: deceased Discharge Instructions: deceased Followup Instructions: none Completed by:[**2161-10-26**]

[ "348.4", "780.01", "V66.7", "431", "434.11", "518.81", "342.90", "493.90", "276.0", "401.9" ]

icd9cm

[ [ [] ] ]

[ "01.39", "96.72", "96.04", "38.93", "02.2", "38.91", "96.6" ]

icd9pcs

[ [ [] ] ]

10264, 10279

7839, 10176

295, 382

10332, 10342

2438, 7816

10399, 10435

1862, 1871

10231, 10241

10300, 10311

10202, 10208

10366, 10376

1886, 1886

2409, 2419

238, 257

410, 1664

1900, 2395

1686, 1733

1749, 1846

8,396

142,060

7935

Discharge summary

report

Admission Date: [**2192-3-29**] Discharge Date: [**2192-5-2**] Date of Birth: [**2114-12-18**] Sex: M Service: MEDICINE Allergies: Diphenhydramine Attending:[**First Name3 (LF) 2485**] Chief Complaint: Syncope. Major Surgical or Invasive Procedure: 1. Thoracentesis ([**2192-3-30**]) 2. Endotracheal intubation ([**2192-4-3**]) 3. Bronchoscopy ([**2192-4-5**]) History of Present Illness: Mr. [**Known lastname **] is a 77 year old male with depressed LV function and ESRD on dialysis who presented to [**Hospital3 **] on [**3-26**] with witnessed syncope at dialysis. CPR was administered; from vague report, it sounds as though he had an AED placed but was not in shockable rhythm. He was admitted to [**Hospital3 417**] and continued to have runs of VT so transferred here for ICD. On [**3-28**], he was noted to have a 12 beat run of NSVT. He has been referred to Dr. [**Last Name (STitle) **] for ICD placement. Of note, he was dialyzed on Tues and WED this week so did not have dialysis today, Thurs, one of his normal dialysis days. He was transferred for ICD placement. On arrival to [**Hospital1 18**], he was noted to be hypoxic with RA sats in low 80's, pleural effusion on right crackles on left, JVP up. Past Medical History: 1. Cardiac History: a. CAD s/p CABG b. Ischemic CM, EF 30% c. Atrial fibrillation d. Hypertension e. 3rd degree heart block s/p dual chamber [**Company 1543**] Prodigy (DR7860) placed [**2184-7-27**] 2. CVA [**3-15**] yrs ago with residual speaking difficulty 3. ESRD, HD M/W/F x 6 years 4. Type II Diabetes-runs low in the am 5. S/P right BKA 5 yrs ago-has a dry scab on bka site r/t poorly fitting prosthesis, no drainage 6. COPD Social History: Patient resides with son [**Name (NI) **] who is his primary caretaker. [**Name (NI) **] has been aphasic since his stroke 4 years ago. He never smoke or drank alcohol. Family History: Non-contributory. Physical Exam: T 96.3, BP 97/49, HR 66, RR 18, SpO2 100% on 3.5L NC O2 Gen: elderly ill-appearing [**Male First Name (un) 4746**], supine in bed, in NAD HEENT: OP clear, mmm, perrl Neck: supple, no jvp, no carotid bruits CV: irregular rhythm, distant heart sounds, nl s1 s2, 2/6 SEM Resp: Decreased breath sounds right base with scant crackles over RLL and RML Abdomen: +bs, abd soft Extrem: s/p R bka, left LE with no, 2+ femoral pulses Skin: no tenderness at R IJ HD cath, dressing intact and clean Neuro: Expressive aphasia, otherwise nonfocal Pertinent Results: ADMIT LABS: [**2192-3-29**] . CBC: WBC-5.1 RBC-4.47*# Hgb-12.4*# Hct-40.8# MCV-91# MCH-27.8 MCHC-30.4* RDW-16.6* Plt Ct-126* . COAGS: PT-15.1* PTT-31.1 INR(PT)-1.4* . CHEMISTRIES: Glucose-68* UreaN-33* Creat-5.1*# Na-138 K-5.3* Cl-99 HCO3-27 AnGap-17 Calcium-8.9 Phos-5.4* Mg-2.7* . MISC: [**2192-4-5**] calTIBC-130* Hapto-267* Ferritn-872* TRF-100* [**2192-3-29**] TSH-1.8 [**2192-4-3**] TSH-2.7 [**2192-4-3**] Free T4-0.92* . 2D-ECHOCARDIOGRAM performed on [**2192-4-2**] demonstrated: The left atrium is elongated. The estimated right atrial pressure is 11-15mmHg. There is mild symmetric left ventricular hypertrophy with normal cavity size with moderate global hypokinesis. Regional left ventricular wall motion is normal.The right ventricular cavity is mildly dilated. Right ventricular systolic function is normal. [Intrinsic right ventricular systolic function is likely more depressed given the severity of tricuspid regurgitation.] The aortic valve leaflets are moderately thickened. There is a minimally increased gradient consistent with minimal aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. Moderate [2+] tricuspid regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. . IMPRESSION: Mild symmetric left ventricular hypertrophy with moderate global hypokinesis c/w diffuse process (toxin, metabolic; cannot fully exclude multivessel CAD but less likely). Moderate pulmonary artery systolic hypertension. Minimal aortic valve stenosis. Compared with the prior report (images unavailable for review) of [**2184-8-2**], minimal aortic valve stenosis, symmetric left ventricular hypertrophy, and pulmonary artery systolic hypertension are now identified. Global left ventricular systolic function appears similar. In the absence of a history of hypertension, the presence of symmetric hypertrophy raises the possibility of an infiltrative process (e.g., amyloid). . CHEST CT ([**2192-4-2**]): 1. Multiple dense masses within complex large right effusion are atypical in appearance for pleural tumor, more likely hematoma, but malignancy is still the top diagnostic consideration. A change in position with prone imaging would favor hematoma. If not, transthoracic needle aspiration is indicated, and should be feasible, for presumed mass. 2. Right middle and lower bronchial occlusion with possible occlusive mass. Evaluation with contrast by CT (or MR if patient cannot tolerate iodinated contrast) would be helpful. 3. Bilateral airspace consolidation, pneumonia or atelectasis. 4. Small volume of ascites. . CAROTID U/S ([**2192-4-2**]): 1. Left ICA - 100% occlusion 2. Right ICA - 40-59% occlusion Brief Hospital Course: Pt is a 77 year old male with CAD s/p 5v CABG, ICM with depressed LV function EF 30%, ESRD on HD, atrial fibrillation, CHB s/p PPM, initially transferred for ? ICD placement, found to be in pulseless arrest and transferred to the CCU post-resuscitation. Patient remains intubated and workup of intrapulmonary issues are underway. Patient has collapsed right lung with possible mass vs. hematoma, now s/p VATS and chest tube placement. . 1. PEA Arrest: Initially presented to [**Hospital1 18**] for possible ICD placement. While in-house, had PEA arrest with possible respiratory etiology. Telemetry showed inability of PPM to capture during code possibly due to metabolic derangement vs. pacer lead dislodgement. EP interrogated pacer and believes lead is in place - increased voltage that pacer lead is putting out. During the code, the patient was intubated. Patient remained intubated for a prolonged period but with improved mental status when off sedation. Neurology signed off. He was continued on amiodarone for h/o VT. He will continue on 400 mg of amiodarone for 1 more week then decrease to 200 mg daily thereafter. . 2. Hypotension: This was initially felt likely secondary to aspiration pneumonia/hospital acquired pneumonia for he completed a course of antibiotics. Over the course of his hospital stay, he had persistent pressor requirements. Ultimately this was felt to be due to a combination of poor inotropy from his cardiomyopathy and from poor peripheral vascular tone from his diabetes and renal failure. For this combination, he was started on digoxin and midodrine with adequate stablization of his blood pressures. . 3. Respiratory failure: Admitted s/p respiratory arrest c/b PEA. Unclear whether initial respiratory event precipitated his cardiac arrest. Etiology likely multifactorial including baseline COPD, large R pleural effusion, collapsed R lung due to possible lung mass. Bronchoscopy unable to obtain tissue for diagnosis. Now s/p VATS, tissue biopsy on [**4-10**]. VATS revealed thickened parietal pleura and dense fibrothorax. Within dense fibrothorax there was 400cc of old blood which was evacuated. Gram stain negative, biopsies sent to path, cytology and micro. He completed rx with Vanco/Zosyn x 14 days for post obstructive/aspiration pneumonia. He was kept intubated for a prolonged period because of overbreathing each time an SBT has been performed. After the VATS, he was tolerating PS 18/5. Pulmonary was also consulted at this point and performed another SBT which the patient tolerated with improvement in his ABG. At this point a decision was made to extubate the patient on [**4-12**]. He tolerated the extubation initially, however after 2 hours he became progressively more tachypneic and hypoxic with Os sats 90% on 100% oxygen. ABG at this time revealed a significant respiratory acidosis and the patient required reintubation. Given his primary medical issues were pulmonary in nature it was felt that transfering the patient to the MICU service would be more appropriate. The patient underwent tracheostomy and was able to begin gradually weaning from the ventilator. On discharge he was comfortable on pressure support ventilation with 8 of PS, 8 of PEEP, FIO2 of 0.4. The patient's respiratory alkalosis was felt likely secondary to a central drive as he was without fever, pain, or hypoxia as alternative explanations. . 4. Anemia: This was felt secondary to intermittent phlebotomy, the bleeding from the chest tube and VATS in a patient with underlying low EPO state from his renal failure. He continued on epoetin with his HD sessions. There was no evidence of iron deficiency. . 5. CAD: No evidence of ACS per EKG or biomarkers. In evaluation of his hypotension as above, he was found to have a new anterior septal wall motion abnormality. The change in his LV function could be related to a peri-VATS MI although this could not be confirmed. Given his lack of chest pain and his overall co-morbidities, proceeding to cardiac cath was deferred. His LV apex was found to be akinetic but without thrombus. He will be anticoagulated for this indication as well. Beta-blockers and ACEi were discontinued secondary to the hypotension. As he recovers from his acute illness and his midodrine can be weaned, an ACE inhibitor can be restarted. . 6. Rhythm: a) Afib. Was on Heparin gtt for anticoagulation which was held b/o Hct drop after VATS procedure and significant serosanquinous fluid drainage from chest tube. He remained pacer dependent at ~70 bpm. He will be discharged on a heparin drip which will be used to bridge him to therapeutic INR with coumadin. . b) H/o VT. Continued Amiodarone as above. c) CHB, s/p PPM. V-paced rhythm. . 7. Head CT finding: On presentation a head CT was notable for a potential subacute infarct. There was no clear evidence of neurologic compromise. He will continue anti-coagulation as above. . 8. ESRD: Patient is anuric, HD schedule was changed from M/W/F to T/Th/Sa schedule. Continued Nephrocaps. Renally dosed meds. He should continue to receive his EPO with his HD. . 9. DM II: glucoses under moderate control. He will continue regular insulin sliding scale. . 10. Hyperlipidemia: Continued statin . 11. FEN: tube feeds . 12. PPX: anti-coagulated, PPI . 13. Code: FULL . 14. Dispo: the patient was discharged to LTAC for vent weaning, INR titration, and rehab. Medications on Admission: 1. ASA 81mg daily 2. Plavix 75mg daily 3. Coreg 3.215mg [**Hospital1 **] 4. Lisinopril 10mg qSTThSat 5. Imdur 30mg daily 6. Zocor 80mg daily 7. Coumadin 8. Ceclor 250mg po bid 9. Phos-lo 667 tid 10. Folic acid 1mg daily 11. Nephrocaps Discharge Medications: 1. Amiodarone 200 mg Tablet [**Hospital1 **]: Two (2) Tablet PO DAILY (Daily) for 7 days. 2. Amiodarone 200 mg Tablet [**Hospital1 **]: One (1) Tablet PO once a day: to start after 400 mg dosing completed. 3. Albuterol 90 mcg/Actuation Aerosol [**Hospital1 **]: Four (4) Puff Inhalation Q6H (every 6 hours). 4. Aspirin 81 mg Tablet, Chewable [**Hospital1 **]: One (1) Tablet, Chewable PO DAILY (Daily). 5. Clopidogrel 75 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily). 6. Digoxin 125 mcg Tablet [**Hospital1 **]: [**12-13**] Tablet PO DAILY (Daily). 7. Warfarin 2.5 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO at bedtime. 8. Folic Acid 1 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO DAILY (Daily). 9. Nephrocaps 1 mg Capsule [**Month/Day (2) **]: One (1) Capsule PO once a day. 10. Simvastatin 80 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO once a day. 11. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily). 12. Docusate Sodium 50 mg/5 mL Liquid [**Last Name (STitle) **]: Ten (10) mL PO BID (2 times a day). 13. Acetaminophen 160 mg/5 mL Solution [**Last Name (STitle) **]: Fifteen (15) mL PO Q4-6H (every 4 to 6 hours) as needed for fever. 14. Heparin (Porcine) in D5W 100 unit/mL Parenteral Solution [**Last Name (STitle) **]: 1250 (1250) units Intravenous ASDIR (AS DIRECTED): titrate to PTT 60-100 until INR >2. 15. Lorazepam 0.5 mg Tablet [**Last Name (STitle) **]: 1-2 Tablets PO Q4H (every 4 hours) as needed for anxiety. 16. Insulin Regular Human 100 unit/mL Solution [**Last Name (STitle) **]: 2-8 units Injection ASDIR (AS DIRECTED): per attached sliding scale. 17. Ipratropium Bromide 17 mcg/Actuation Aerosol [**Last Name (STitle) **]: Four (4) Puff Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. 18. Metoclopramide 10 mg Tablet [**Last Name (STitle) **]: 0.5 Tablet PO Q 12H (Every 12 Hours). 19. Midodrine 5 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO TID (3 times a day). 20. B Complex-Vitamin C-Folic Acid 1 mg Capsule [**Last Name (STitle) **]: One (1) Cap PO DAILY (Daily). 21. Potassium & Sodium Phosphates [**Telephone/Fax (3) 4228**] mg Packet [**Telephone/Fax (3) **]: Two (2) Packet PO twice a day: continue until serum phosphate >2.7. 22. Olanzapine 5 mg Tablet, Rapid Dissolve [**Telephone/Fax (3) **]: One (1) Tablet, Rapid Dissolve PO BID (2 times a day) as needed for agitation. 23. Senna 8.6 mg Tablet [**Telephone/Fax (3) **]: One (1) Tablet PO BID (2 times a day) as needed for constipation. 24. Simvastatin 40 mg Tablet [**Telephone/Fax (3) **]: Two (2) Tablet PO DAILY (Daily). 25. Warfarin 2.5 mg Tablet [**Telephone/Fax (3) **]: One (1) Tablet PO HS (at bedtime): adjust dose to achieve INR [**1-14**]. Discharge Disposition: Extended Care Facility: [**Hospital3 105**] Northeast - [**Location (un) 701**] Discharge Diagnosis: Primary: Ventricular tachycardia cardiac arrest Fibrothorax Respiratory Failure hemodialysis line infection hospital acquired pneumonia Secondary: End-stage renal failure congestive heart failure coronary artery disease peripheral vascular disease diabetes mellitus type 2 - controlled stroke atrial fibrillation Discharge Condition: hemodynamically stable. tolerated mechanical ventilation by tracheostomy. Discharge Instructions: You have been evaluated and treated for an abnormal heart rhythm. Your hospital course was complicated by a cardiac arrest likely secondary to severe breathing difficulty. The breathing difficulty was felt related to a large amount of your right lung being trapped by scar tissue. As it you were unable to completely breath on your own, a breathing tube was placed in your neck so that your breathing could be periodically supported. . You were discharged to a long-term acute care facility to work on building up your strength and for gradual weaning from breathing support. . Please take the medications as prescribed. . Please make (or have someone make) the appointments recommended. . If you develop any new or concerning symptoms such as significant shortness of breath, chest pain or fever to greater than 101F; please seek medical attention at the rehab facility. Followup Instructions: The physicians at the long-term care facility will evaluate you and arrange follow-up care.

[ "518.0", "414.8", "585.6", "507.0", "438.11", "250.70", "707.03", "996.62", "250.40", "425.4", "V58.67", "V53.31", "511.0", "427.1", "443.81", "427.5", "110.5", "285.21", "428.0", "583.81", "427.31", "518.81", "V49.76", "403.91", "V45.81" ]

icd9cm

[ [ [] ] ]

[ "96.72", "96.6", "99.04", "88.67", "34.24", "34.04", "34.91", "31.1", "33.24", "43.11", "39.95", "96.04", "38.93" ]

icd9pcs

[ [ [] ] ]

13869, 13951

5361, 10749

285, 399

14309, 14385

2515, 5338

15308, 15403

1929, 1948

11034, 13846

13972, 14288

10775, 11011

14409, 15285

1963, 2496

237, 247

427, 1256

1278, 1727

1743, 1913

20,326

105,475

28501

Discharge summary

report

Admission Date: [**2137-9-19**] Discharge Date: [**2137-10-12**] Date of Birth: [**2075-12-7**] Sex: M Service: CARDIOTHORACIC Allergies: Penicillins / Iodine; Iodine Containing Attending:[**First Name3 (LF) 922**] Chief Complaint: chest pain Major Surgical or Invasive Procedure: s/p CABGx5(LIMA->LAD, SVG-.pLAD, Ramus, PDA, LCX) [**2137-9-19**] Reexploration for bleeding. Cardiac catherization History of Present Illness: 61 year old male with angina over last year relieved with rest. Presented to OSH when angina did not relieve with rest and ruled in for NSTEMI. Transferred for cardiac catherization Past Medical History: Hypertension Angina Heart Failure Atrial Fibrillation Skin Cancer Social History: Works at [**Company **] globe, is married Tobacco - denies ETOH - [**2-16**]/day Family History: Non contributory Physical Exam: Discharge Neuro: alert, oriented x3, strength R=L [**3-20**], no vision left eye, normal vision right eye Pulmonary: lungs clear to auscultation bilaterally Cardiac: RRR +murmur 2/6 SEM, no rub/gallop Sternal incision: healing no erythema, no drainage, sternum stable Abdomen: soft, nontender, nondistended, +bowel sounds last BM [**10-12**] Extremeties: warm, edema +1 nonpitting, pulses palpable Leg incision: endovascular harvest, healing, no drainage, no erythema Pertinent Results: RENAL U.S.; DUPLEX DOP ABD/PEL LIMITED Reason: r/o RAS [**Hospital 93**] MEDICAL CONDITION: 61 year old man s/p CABGx5 with acutely increased creatinine REASON FOR THIS EXAMINATION: r/o RAS INDICATION: Status post CABG with acutely increased creatinine. Rule out renal artery stenosis. RENAL ULTRASOUND: No prior examinations. The kidneys are normal in size and appearance. The right kidney measures 13.6 cm and left kidney measures 13.2 cm. There are normal arterial waveforms in the parenchyma bilaterally. The maximum RI on the right is 0.76 and on the left is 0.8 (both of which are minimally elevated). There is no evidence of renal artery stenosis. No hydronephrosis, stone, or mass. The bladder is filled with fluid and shows no wall thickening or focal masses. IMPRESSION: Minimally elevated resistive indices in both kidneys, with no evidence of renal artery stenosis. The study and the report were reviewed by the staff radiologist. DR. [**First Name (STitle) 18394**] [**Name (STitle) 18395**] CHEST (PA & LAT) [**2137-10-11**] 6:30 PM CHEST (PA & LAT) Reason: evaluate pleural effusion [**Hospital 93**] MEDICAL CONDITION: 61 year old man s/p CABG REASON FOR THIS EXAMINATION: evaluate pleural effusion INDICATION: Status post CABG, evaluate pleural effusion. PA AND LATERAL CHEST: Compared to [**2137-10-10**]. Left-sided PICC line is unchanged in position with its tip in the distal SVC. There is no pneumothorax. There remains a small left pleural effusion not significantly changed and a small amount of linear atelectasis at the left mid lung base. Calcified left hilar adenopathy again seen. Heart remains upper limits of normal in size. No significant short interval change. The study and the report were reviewed by the staff radiologist. DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] GENERAL COMMENTS: Suboptimal image quality - poor echo windows. Conclusions: The left atrium is mildly dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size. Overall left ventricular systolic function is moderately depressed (EF 35-40%). Due to the suboptimal image quality, a regional wall motion abnormality cannot be excluded. Right ventricular chamber size is normal. There is mild global right ventricular free wall hypokinesis. The ascending aorta is mildly dilated. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is a small pericardial effusion. The effusion is echo dense, consistent with blood, inflammation or other cellular elements. There are no echocardiographic signs of tamponade. IMPRESSION: Small echodense pericardial effusion without echocardiographic signs of tamponade. Moderate left ventricular systolic dysfunction. Mild aortic regurgitation. Compared with the prior study (images reviewed) of [**2137-10-3**], the pericardial effusion is smaller. The other findings are similar. Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 171**], MD on [**2137-10-10**] 14:51. MRA head IMPRESSION: 1. No evidence of orbital abnormality on limited sections through the orbits. 2. Evidence of atherosclerotic disease, but without marked stenoses or occlusion among the major arteries of the circle of [**Location (un) 431**]. Because of the limitations of the study, the ophthalmic arteries are not well visualized on either side. 3. Multiple small foci of T2 hyperintensity suggestive of prior tiny infarcts in the cerebral white matte bilaterally. A few of these demonstrate faintly increased signal also on diffusion-weighted imaging, suggesting that they may be either subacute or chronic. Brief Hospital Course: Transferred in from OSH and underwent cardiac catherization that resulted in intra aortic balloon pump placement and transferred to operating room emergently [**9-19**]. Please see catherization report for further details. He underwent coronary artery bypass graft x5, please see operative report for further details. He was transferred to the CSRU on Neo and propofol with IABP. He received FFP, protamine, and platlets for post operative bleeding, and then returned to operating room for reexploration, please see operative report for further details. He was transferred to CSRU for continued management. He continued with tachycardia not responsive to esmolol was changed to cardizem with better control, required vasopressors for hypotension. On postoperative day [**1-16**] the IABP was weaned and removed, he continued on vasopressors, cardizem was discontinued and he was started on beta blockers. He remained intubated due to hemodynamics and agitation. Agitation continued with weaning of sedation, diuresed, and betablocker increased. Postoperative day [**4-18**] tolerated CPAP and was extubated but was confused moving all extremeties. Blood pressure and heart rate labile, labetolol started. Postoperative [**6-20**] he went into atrial fibrillation and treated with Amiodarone and beta blockers. He remained in the CSRU due to agitation on CIWA d/t ETOH withdrawal, hemodynamic, and respiratory management. Psychiatry consulted due to continued delirium and medications adjusted. Anticoagulation was started for atrial fibrillation with coumadin on POD [**11-25**]. On postoperative 14/13 he was ready for transfer to [**Hospital Ward Name **] 2 with a sitter, he continued with confusion at times, in/out atrial fibrillation. He continued to progress and physical activity increased, he became more oriented, and was able to wean off ativan and sitter. On posterative day 20/19 he complained of not being able to see out of left eye - opthamology evaluated with question of posterior ischemic optic neuropathy which is diagnosis by exclusion and he underwent MRI. Plan for follow up with opthamology in clinic no medical intervention at this time. On postoperative day 21/20 creatinine elevated with decreased sodium. Fluid intake was increased, renal consulted, echocardiogram (EF 35-40%). All diuretics, ACE inhibitors, and NSAID discontinued. Creatinine decreased on Postoperative day 23/22 but sodium remained decreased and placed on free water restriction with plan for chemistry to be rechecked [**10-14**] at rehab. He was ready for discharge to rehab with plan for lab checks. Medications on Admission: lopressor, lipitor, ASA, pepcid, Solumedrol, Plavix, Discharge Medications: 1. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day). 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 4. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed. 5. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily). 7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 8. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [**Hospital1 **] (2 times a day). 11. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation QID (4 times a day). 12. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Diltiazem HCl 180 mg Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO DAILY (Daily). 14. Haloperidol 1 mg Tablet Sig: Three (3) Tablet PO HS (at bedtime). 15. Ferrous Gluconate 300 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 16. Outpatient Lab Work please check SMA 7 and HCT [**10-14**] 17. Warfarin 1 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily): please give 0.5mg [**10-13**] and check INR [**10-14**] . Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - [**Location (un) 550**] Discharge Diagnosis: Coronary artery disease. HTN Delirium. Discharge Condition: Good Discharge Instructions: Follow medications on discharge instructions. Do not drive for 4 weeks. Do not lift more than 10 lbs for 2 months. Shower daily, let water flow over wounds, pat dry with a towel. Do not use lotions, powders, or creams on wounds. Call our office for sternal drainage, temp>101.5. Please have SMA 7, HCT, INR checked [**10-14**] Free water restriction for hyponatremia Followup Instructions: Make an appointment with Dr. [**Last Name (STitle) 131**] for 1-2 weeks. Make an appointment with Dr. [**Last Name (STitle) 4469**] for 2-3 weeks. Make an appointment with Dr. [**Last Name (STitle) 914**] for 4 weeks. Make an appointment to see your local opthamologist after discharge. Make an appointment to see Dr. [**Last Name (STitle) 22897**] with Neuro-opthamology after discharge. Phone #[**Telephone/Fax (1) 253**]. Please have SMA 7, HCT, and INR drawn [**10-14**] Completed by:[**2137-10-12**]

[ "780.52", "429.4", "311", "997.1", "427.89", "401.9", "414.01", "E939.4", "292.81", "287.5", "377.49", "428.0", "451.84", "427.31", "410.11", "E944.4", "285.9", "584.9", "998.11", "458.29", "416.8" ]

icd9cm

[ [ [] ] ]

[ "97.44", "99.04", "37.23", "36.14", "99.20", "36.15", "99.05", "88.72", "34.03", "99.07", "00.17", "88.56", "88.53", "39.61", "38.93", "37.61", "96.71" ]

icd9pcs

[ [ [] ] ]

9388, 9473

5188, 7809

317, 435

9556, 9563

1372, 1429

9978, 10484

850, 868

7912, 9365

2517, 2542

9494, 9535

7835, 7889

9587, 9955

883, 1353

267, 279

2571, 5165

463, 647

669, 736

752, 834

46,125

152,394

54856

Discharge summary

report

Admission Date: [**2126-7-14**] Discharge Date: [**2126-7-29**] Date of Birth: [**2068-1-4**] Sex: M Service: ORTHOPAEDICS Allergies: Cipro Attending:[**First Name3 (LF) 3190**] Chief Complaint: Cyclist struck by car with polytrauma Major Surgical or Invasive Procedure: Anterior/posterior cervical decompression and fusion with instrumentation C3-4 Bilateral nasal bone repair History of Present Illness: Mr. [**Known lastname 36931**] is a 58M bicyclist struck by a car, w/ C3-4 anterior spinal cord contusion w/ prevertebral hematoma, facial lacerations, bilateral nasal bone fractures, hyoid bone fracture, right posterior rib fractures 2 and 9. No LOC. Patient has a history of a prior nasal bone fracture from playing college football. Past Medical History: PMH: Prostate CA c/b incontinence, Hx MVC w/ rib fx PSH: Prostatectomy ([**1-/2125**]), Tonsillectomy (childhood) Social History: SH: -tob, -etoh, -illicits Family History: N/C Physical Exam: Upon admission: Exam: afebrile, VSS, AAOx3, NAD, in c-collar Head normocephalic, atraumatic Scalp without lacerations or contusions. CN II-XII intact Multiple facial abrasions. Forehead lacerations: 3cm laceration over left superior portion of forehead. 4cm V-shaped laceration over the glabella. these are through the dermis, not involving frontalis. Eyes: EOMI, pupils equally round and reactive, no periorbital ecchymosis, no subconjunctival hemorrhage Nose: Obvious deviation of the nose to the right. Stellate laceration over the dorsum of the nose, with some soft tissue loss centrally. Nasal bones are palpable at the base of the wound. No exposed cartilage. there is another 0.5 cm laceration over the left lateral side wall, not involving cartilage. No septal hematoma. No rhinorrhea. No telecanthus. Face: No midface instability. Mouth: Difficult to fully asses while in C-collar. no evidence of TMJ tenderness. No apparent intraoral lacerations. No malocclusion. Good dentition. Vascular Radial DP PT R 2 2 2 L 2 2 2 Sensory UE C5 (Ax) C6 (MC) C7 (Mid finger) C8 (MACN) T1 (MBCN) T2-L2 Trunk R intact diminshed diminished diminished diminshed diminshed L intact diminished diminished diminished diminshed diminshed Sensory LE L2 Groin) L3 (Leg) L4 (Knee) L5 (Grt Toe) S1 (Sm toe) S2 (Post Thigh) R intact intact intact intact intact intact (all w/ slight parasthesias) L diminshed diminshed diminished diminished diminshed diminished (all w/ parasthesias which are more severe than the right) Motor UE Deltoid (C5)Ax Biceps (C6)MC WE (C6)R Triceps (C7)R WF (C7)M FF (C8)AIN Fing Abd (T1)U R 4 0 0 0 0 0 0 L 4 0 0 0 0 0 0 Motor LE Add (L2) IP (L3) Quad (L3) Ham (L4) Ant Tib (L4/DP) [**Last Name (un) 938**]/GM (L5/SG) Peroneal (S1/SP) GS (S1-2/T) L 4 4 4 4 4 4 4 4 R 3 1 1 0 0 0 0 0 Reflexes Triceps (C6-7) Patellar (L3-4) Achilles (L5-S1) R 2 2 2 L 2 2 2 Straight Leg Raise Test: negative Babinski: downgoing toes bilaterally Clonus: none Perianal sensation: intact Rectal tone: normal Upon discharge: Pertinent Results: [**2126-7-22**] 10:33AM BLOOD WBC-6.6 RBC-2.95* Hgb-10.0* Hct-28.6* MCV-97 MCH-33.8* MCHC-34.8 RDW-12.6 Plt Ct-168 [**2126-7-20**] 05:27AM BLOOD WBC-8.4# RBC-3.09* Hgb-10.3* Hct-30.0* MCV-97 MCH-33.4* MCHC-34.4 RDW-12.4 Plt Ct-139* [**2126-7-19**] 04:39AM BLOOD WBC-5.5 RBC-3.48* Hgb-11.5* Hct-32.9* MCV-95 MCH-33.2* MCHC-35.0 RDW-12.1 Plt Ct-165 [**2126-7-16**] 12:22AM BLOOD WBC-5.6 RBC-3.20* Hgb-10.7* Hct-31.3* MCV-98 MCH-33.5* MCHC-34.2 RDW-12.1 Plt Ct-137* [**2126-7-14**] 08:10AM BLOOD WBC-4.4 RBC-4.04* Hgb-13.2* Hct-40.1 MCV-99* MCH-32.6* MCHC-32.9 RDW-12.1 Plt Ct-188 [**2126-7-20**] 05:27AM BLOOD Glucose-120* UreaN-20 Creat-0.7 Na-135 K-4.3 Cl-102 HCO3-27 AnGap-10 [**2126-7-17**] 06:39AM BLOOD Glucose-90 UreaN-12 Creat-0.7 Na-139 K-3.7 Cl-105 HCO3-29 AnGap-9 [**2126-7-15**] 02:12AM BLOOD Glucose-92 UreaN-19 Creat-0.8 Na-138 K-4.2 Cl-104 HCO3-25 AnGap-13 [**2126-7-20**] 05:27AM BLOOD Calcium-8.2* Phos-3.5 Mg-2.0 [**2126-7-17**] 06:39AM BLOOD Calcium-8.5 Phos-2.8 Mg-1.9 [**2126-7-15**] 02:12AM BLOOD Calcium-9.0 Phos-3.4 Mg-1.9 [**2126-7-14**] 08:24AM BLOOD Glucose-132* Lactate-1.7 Na-135 K-4.3 Cl-99 calHCO3-25 Brief Hospital Course: After exam and imaging review, Mr. [**Known lastname 36931**] was found to have the following injuries: b/l open nasal bone fxs (plastics f/u) Hyoid bone fx R [**3-2**] posterior rib fx R rib [**9-6**] deformity (old fx) Facial lacs/abrasions C3-4 spinal cord contusion Left elbow lac (sutured) C2-4 prevertebral hematoma w PLC injury He was admitted to the Trauma SICU. Plastics surgery and orthopedic spine surgery were also following. Plastic surgery recommended follow-up 7 days from injury for suture removal (of all facial lacerations) and operative intervention for nasal bone fracture. Orthopedic spine recommended a circumfrential cervical decompression and fusion. By systems: Neuro: He had a C3-C4 spinal contusion with C2-4 prevertebral hematoma with PLC injury. Ortho spine initially recommended non-operative observation for recovery of neuro function, but upon reassessment, it was determined that he would undergo an anterior/posterior C3-4 decompression and fusion He remained in the c-collar and showed stepwise improvement daily in his neuro function. He remained AAOx3 and overall in good spirits, though very anxious. His pain was controlled with tylenol and dilaudid IV then switched to oral meds when appropriate. CV: He was initially on a neosynephrine drip into HD 2. This was weaned off and he remained hemodynamically stable. Resp: The patient has rib fractures of the right [**3-2**] posterior ribs. They were treated non-operative, and he was placed on an aggressive pulmonary toilet. He was did well with the incentive spirometer. GI: He passed a bedside swallow eval initially; however, failed another after his cervical fusion. A PICC line was placed and he received TPN. GU: His foley catheter was changed to a condom catheter on HD 3. He had a history of a prostatectomy and baseline urinary incontinence and so had a condom catheter for convenience due to his multiple injuries. ID: He was put on unasyn per plastic surgery recs for antibiotic coverage x 7 days for his nasal fracture. He was transited to augmentin when tolerating POs. He was afebrile and otherwise had no acute ID issues. Mr. [**Known lastname 36931**] was taken to the OR for an anterior/posterior cervical fusion with instrumentation. Please see the operative report for procedure in detail. Post-operatively he was given pain medicatioin and antibiotics. He was able to work with physical therapy for strength which slowly improved. He subsequently was taken to the OR with the Plastic Surgery service for repair of his nasal fractures. Please see operative note for procedure in detail. His hospital course was complicated by difficult swallowing due to the cervical decompression and fusion procedures. He failed a speach and swallow study. A nutrition consult was obtained and TPN recommended. A PICC line was placed and he began receiving TPN on [**7-25**]. Subsequently, a Dobhoff was placed by the plastic surgery service and the PICC line discontinued. Tube feeds will continue at rehab with administration over night 6pm-6am to allow for participation in PT during the day. A follow up speach and swallow study will be conducted at rehab. The remainder of his hospital course was unremarkable. He was discharged to rehab in stable condition and will follow up with Orthopaedics and Plastics. Medications on Admission: Imipramine 75 HS ASA 81 Vit B12 CoQ10 100 Discharge Medications: 1. Acetaminophen 650 mg PO Q6H:PRN pain 2. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheezing, shortness of breath 3. Artificial Tears 1-2 DROP BOTH EYES PRN dryness 4. Bacitracin Ointment 1 Appl TP [**Hospital1 **] to face and left elbow lacs/abrasions 5. Bisacodyl 10 mg PO/PR DAILY:PRN constipation 6. Docusate Sodium (Liquid) 100 mg PO BID 7. HYDROmorphone (Dilaudid) 2-4 mg PO Q4H:PRN pain 8. Senna 1 TAB PO BID:PRN constipation 9. Imipramine 75 mg PO HS 10. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN anxiety 11. Insulin SC Sliding Scale Fingerstick Q6h Insulin SC Sliding Scale using REG Insulin 12. Amoxicillin-Clavulanic Acid 500 mg PO Q12H Duration: continue for 7 Days after discharge from hospital 13. coenzyme Q10 *NF* 100 mg Oral Daily Reason for Ordering: Wish to maintain preadmission medication while hospitalized, as there is no acceptable substitute drug product available on formulary. 14. Diazepam 5 mg PO Q6H:PRN anxiety 15. Heparin 5000 UNIT SC BID 16. Heparin Flush (10 units/ml) 2 mL IV PRN line flush PICC, heparin dependent: Flush with 10mL Normal Saline followed by Heparin as above daily and PRN per lumen. Discharge Disposition: Extended Care Facility: [**Hospital6 85**] - [**Location (un) 86**] Discharge Diagnosis: Central cord syndrome, hemiplegia C3-4 anterior spinal cord contusion w/ prevertebral hematoma, facial lacs, b/l nasal bone fx, hyoid bone fx, R posterior rib fx 2 and 9. Discharge Condition: Good Discharge Instructions: You have undergone the following operation: ANTERIOR/POSTERIOR Cervical Decompression With Fusion Immediately after the operation: -Activity: You should not lift anything greater than 10 lbs for 2 weeks. You will be more comfortable if you do not sit or stand more than ~45 minutes without getting up and walking around. -Rehabilitation/ Physical Therapy: o2-3 times a day you should go for a walk for 15-30 minutes as part of your recovery. You can walk as much as you can tolerate. oLimit any kind of lifting. -Diet: Eat a normal healthy diet. You may have some constipation after surgery. You have been given medication to help with this issue. -Brace: You have been given a collar. This is to be worn for when you are walking. You may take it off when sitting in a chair or while lying in bed. -Wound Care: Remove the dressing in 2 days. If the incision is draining cover it with a new sterile dressing. If it is dry then you can leave the incision open to the air. Once the incision is completely dry (usually 2-3 days after the operation) you may take a shower. Do not soak the incision in a bath or pool. If the incision starts draining at anytime after surgery, do not get the incision wet. Cover it with a sterile dressing. Call the office. -You should resume taking your normal home medications. No NSAIDs. -You have also been given Additional Medications to control your pain. Please allow 72 hours for refill of narcotic prescriptions, so please plan ahead. You can either have them mailed to your home or pick them up at the clinic located on [**Hospital Ward Name 23**] 2. We are not allowed to call in or fax narcotic prescriptions (oxycontin, oxycodone, percocet) to your pharmacy. In addition, we are only allowed to write for pain medications for 90 days from the date of surgery. Please call the office if you have a fever>101.5 degrees Fahrenheit and/or drainage from your wound. Physical Therapy: Activity: Activity: Out of bed w/ assist Cervical collar: when OOB Treatments Frequency: Please continue to change the dressings daily. Followup Instructions: With Dr. [**Last Name (STitle) 363**] in 10 days. Call [**Telephone/Fax (1) **] for an appointment . Please follow up with Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 76782**] for Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3228**] on Friday, [**8-2**] at 2PM, in the Plastic Surgery Clinic. The clinic is located on the [**Hospital Ward Name **], [**Hospital Unit Name **], [**Location (un) 442**], [**Hospital Unit Name **]. Completed by:[**2126-7-29**]

[ "873.49", "300.00", "787.29", "E813.6", "807.5", "952.03", "788.30", "807.03", "847.0", "V10.46", "802.1" ]

icd9cm

[ [ [] ] ]

[ "21.71", "80.51", "81.62", "96.6", "99.15", "81.03", "81.02", "86.59" ]

icd9pcs

[ [ [] ] ]

8797, 8867

4195, 7537

307, 417

9082, 9089

3041, 4172

11231, 11724

983, 988

7630, 8774

8888, 9061

7563, 7607

9113, 9214

1003, 1005

11063, 11138

11160, 11208

9250, 9443

230, 269

9479, 9933

9945, 11045

3022, 3022

445, 784

1020, 3004

806, 922

938, 967

2,725

133,512

17467

Discharge summary

report

Admission Date: [**2136-7-10**] Discharge Date: [**2136-7-11**] Date of Birth: [**2059-1-19**] Sex: M Service: NEURO ICU DIAGNOSIS: Status post generalized tonic-clonic seizures. HISTORY OF PRESENT ILLNESS: At admission, an MRI was performed which showed on T1 images a large area of hypodensity within the left temporal and occipital lobes with associated brain atrophy and sulcal effacement. This was interpreted to be the area of stroke that the patient suffered several years ago. On the MRI, there was also evidence of periventricular white matter changes seen as T2 hyperintensity predominantly in the left hemisphere consistent with chronic microvascular ischemic changes. In addition, lacunar infarcts were also seen in both cerebellar hemispheres. No evidence of acute stroke or hemorrhage could be found. MRA of the brain showed decreased low signal within the left BCA. However, the right vertebral and basilar arteries appeared normal. The left vertebral artery also had decreased flow. The remaining vessels of intracranial and extracranial carotid arteries and the circle of [**Location (un) 431**] were normal. HOSPITAL COURSE: Mr. [**Known lastname **] was slightly obtunded and lethargic on the night of admission. This was interpreted to be the result of medications he had received in the Emergency Department for his witnessed seizures. On the day after admission, [**7-11**], Mr. [**Known lastname **] was attentive, had normal memory, language and cognitive functions in the limited Mini- Mental Status Examination. No signs of apraxia or frontal release symptoms could be found. The patient did not show any neglect symptoms either. Cranial nerve examination showed a blind left eye and hemianopsia on the temporal side of the right visual fields. Oculomotor, trochlear abducens, facial and auditory, as well as vestibular function were normal. Glossopharyngeal and vagus complexes were also found to be normal. The patient showed normal strength on spinal accessory exam, as well as hypoglossal exam. Motor exam, however, revealed decrease of strength on the right side involving both upper and lower extremities. On the upper extremities, the patient had decreased strength in biceps and wrist extensors, as well as flexors. His finger extensors and flexors were also weaker on the right than left. In the lower extremities, however, the patient had more weakness in the proximal musculature involving the hip flexors, but normal strength in the foot musculature, such as plantar flexors and foot dorsal flexors. The patient's coordination was normal. His gait was unstable at first because of the weakness on the right side. The patient, however, had normal finger-to-nose and heel-to-shin exam. The evening of [**7-11**], the patient gained strength in his musculature, and the physical therapy service assessed him to be safe during their home safety eval examination. The patient was dismissed to his [**Hospital3 **] in [**Hospital1 8**] in good health. DISCHARGE DIAGNOSIS: Generalized tonic-clonic seizures involving the right side of his body. DISCHARGE MEDS: No changes were made on his medications except for Trileptal which was increased to 600 mg [**Hospital1 **]. This is an increase from 600 and 300 mg qd that the patient was receiving prior to admission. [**First Name8 (NamePattern2) 4224**] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. Dictated By:[**Last Name (STitle) 48781**] MEDQUIST36 D: [**2136-7-12**] 11:46 T: [**2136-7-12**] 10:58 JOB#: [**Job Number 48782**]

[ "V45.82", "438.89", "401.9", "780.39", "V10.46", "414.01" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

3057, 3632

1177, 3035

231, 1159

14,448

172,699

18974

Discharge summary

report

Admission Date: [**2196-8-13**] Discharge Date: [**2196-8-16**] Date of Birth: [**2148-4-8**] Sex: M Service: CCU HISTORY OF PRESENT ILLNESS: Patient is a 47-year-old male with recent inferior myocardial infarction. He is status post successful right coronary artery stenting x2 in the mid RCA secondary to a finding of 90% stenosis. Patient states that he was involved in a sell of an automobile when he began to have chest pain. Pain radiated down left arm, became to feel clammy and within 15 minutes after onset of symptoms, EMS was called. He does not remember what happened next. He was found unresponsive by EMS, no radial pulse, faint carotids, and shallow breathing. Blood pressure at that time was 70/40. He was given a 500 cc bolus. Blood pressure increased to 76/42. Additional bolus was given. Blood pressure increased to 80/44. Initially, it was opted to give dopamine, however, because of the response to the additional bolus, none was given. Patient was then taken to [**Hospital 1474**] Hospital, where he received Heparin NTNK. At that time an electrocardiogram showed ST elevations in the inferior leads. After one hour of receiving the [**Last Name (LF) 51858**], [**First Name3 (LF) **] elevations resolved, however, the patient continued to have 10/10 chest pain. The patient was then transferred from [**Hospital 1474**] Hospital to [**Hospital3 **] for emergency stent placement. Stents were placed in the mid RCA secondary to findings of a 90% stenosis. The patient arrived at CCU at approximately 8 pm. Patient at that time was found to have mild chest pain and shortness of breath that was gradually worsening. It was later found that patient had a history of asthma, and was therefore opted to give patient ipratropium via nebulizer. Patient was given cardiac protocol medications for acute myocardial infarction which consisted of Plavix 75 mg, metoprolol which was started at 12.5 mg, aspirin 325 mg, and Lipitor 10 mg. Patient was started on IV fluids at 100 cc per hour. MEDICATIONS AT HOME: None. Occasional use of albuterol for asthma. PAST MEDICAL HISTORY: Asthma. ALLERGIES: None. PAST SURGICAL HISTORY: Knee surgery secondary to fracture. SOCIAL HISTORY: Two packs of cigarettes per day x20 years. No alcohol use for 15 years. FAMILY HISTORY: Mother: Congestive heart failure. Father: Five major heart attacks, first heart attack at age 51. REVIEW OF SYSTEMS: Generally, fairly normal asymptomatic. HEENT: Positive history of headaches/blurriness of vision x3-4 months. Heart: No pedal edema, no palpitations. Positive PND, subscapular pain times the last four days. Lungs: No cough, pneumonia, tuberculosis, positive for yearly bronchitis. Abdomen: No recent weight loss or gain, no melena. Hematology: No history of anemia, thrombocytopenia, or hemophilia. PHYSICAL EXAMINATION: Patient's vital signs on admission: Pulse 57, respirations 16, blood pressure 100/55. He was sating 100% on 2 liters of O2 via nasal cannula. HEENT: Within baseline. Heart: Normal S1, S2, no S3, S4 noted, no murmur appreciated. Lungs: Bilateral wheezing, no crackles. Abdomen: Positive bowel sounds, nondistended, and nontender. Extremities: No edema, right groin area and area of catheterization incision site, positive small hematoma, no drainage, and mild tenderness. Good DP/PT pulses. Neurological within baseline. LABORATORIES ON ADMISSION: White blood cell count 15.5, hemoglobin 14.5, hematocrit 43.4, platelet count of 279, MCV of 88, neutrophils 83.3, PT of 12.3, PTT of 37.4. Chem-7: sodium 139, potassium 5.3, and later potassium [**Location (un) 1131**] was 3.9. Chloride 108, bicarb 22, BUN 14, creatinine 0.9, glucose 96. CK 184, CK MB 11, index 6.0, troponin-T 0.26. Arterial blood gas showed a pH of 7.26, CO2 42, O2 104, bicarb of 20. ELECTROCARDIOGRAM: Showed a prolonged P-R interval, sinus rhythm, no ST elevations in inferior leads. Secondary to prolonged P-R interval, Lopressor was then held. SUMMARY OF HOSPITAL COURSE: Patient on [**8-14**] at approximately 7:30 am, was found to be very hypotensive with a blood pressure of 60/40. No pulses were noted. It was then noted that in the right arm, patient had a blood pressure of 80/40. The 20 point difference was noted. Chest x-ray was ordered. Electrocardiogram showed no changes. Chest x-ray was found to be within normal limits. Patient was given 2 mg of dopamine and a 500 cc bolus of normal saline. Patient's blood pressure responded well to this and we were able to start the Lopressor at 12.5 mg [**Hospital1 **]. Patient was later found to have chest pain described as [**4-4**]. Electrocardiogram was done, and showed no ST elevations. No change from electrocardiogram done on admission. Pain was relieved with Morphine and nitroglycerin. Echocardiogram was done on patient on [**8-15**]: Showed 40% ejection fraction with mild biventricular hypokinesis, normal sized right and left ventricle, normal sized right and left atrium, mild mitral regurgitation. Patient was later found to have complaint of back pain. This pain was, however, reproducible with pressure. The patient states that he had a history of this same pain and it was treated with NSAIDs. The patient was advised that he would not be able to use NSAIDs at home status post with his history of myocardial infarction. On [**8-16**], the patient was found to have 20 point difference in systolic blood pressure. Brachial pulses were both dopplerable. Radial pulses were +2. Good DP and PT pulses in both feet described as +2. It was decided that patient was stable and able to go home. DISCHARGE MEDICATIONS: 1. Lisinopril 5 mg. 2. Lopressor 50 mg [**Hospital1 **]. 3. Aspirin 325 q day. 4. Lipitor 10 mg. 5. Plavix 75 mg po q day x30 days. FOLLOW-UP INSTRUCTIONS: The patient is to followup with Dr. [**First Name4 (NamePattern1) 3613**] [**Last Name (NamePattern1) **] at 10:15 am on [**8-22**], and follow up with Dr. [**First Name4 (NamePattern1) 919**] [**Last Name (NamePattern1) 911**] at [**9-5**] at 1 o'clock pm. DISCHARGE DIAGNOSIS: Inferior myocardial infarction. DISCHARGE STATUS: Discharged today. CONDITION ON DISCHARGE: Excellent. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3184**], M.D. [**MD Number(1) 5211**] Dictated By:[**Name8 (MD) 51859**] MEDQUIST36 D: [**2196-8-16**] 14:59 T: [**2196-8-24**] 09:23 JOB#: [**Job Number 51860**]

[ "724.5", "414.01", "427.1", "493.90", "V17.3", "305.1", "410.41" ]

icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

2332, 2433

5681, 5814

6119, 6190

2065, 2113

2188, 2225

4048, 5658

2884, 2906

2453, 2861

160, 2043

3442, 4020

5839, 6098

2136, 2164

2242, 2315

6215, 6492

45,646

137,058

19005

Discharge summary

report

Admission Date: [**2196-7-22**] Discharge Date: [**2196-7-27**] Date of Birth: [**2118-3-24**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2610**] Chief Complaint: fever Major Surgical or Invasive Procedure: none History of Present Illness: Ms. [**Known lastname **] is a 78 y/o with h/o Raynauds, [**Hospital **] transfered from [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 4117**] for management of fever and SOB with positive smear for Babesioses. Pt went to [**Hospital3 635**] end, returning [**6-26**]. During that trip she found a tick behind her left knee. Within days of returning pt had chills, fevers, and general malaise. Presented to PCP [**7-4**]. Presentation felt consistent with influenza. Lyme titer [**7-4**] was negative. Pt had resolution of her fevers and partial improvement in fatigue over the next week, but reports chronic malaise. Then last weekend had return of fevers to 101. ON [**7-17**] also had intermittant sharp right mid back pain. Seen at PCP [**7-18**]. Felt likely viral illness. Lyme titer resent and still pending. EKG WNL. Started on doxycycline 100mg [**Hospital1 **] for potential lympe pericarditis causing CP. On [**7-20**] pt had fever > 102 and presented to [**Hospital3 4107**]. At [**Name (NI) **] pt had smear Positive for babesiosis. Started on Atovoqoune and Azithro. Also continued on doxycycline. PT continued to spike fevers. Received "gentle" IVF for fevers and developed hypoxia. No blood transfusion given. CXR remarkable for pulm edema. Also with new onset PAF. Diuresed with 2L UO with IV lasix. ABG on 4L NC 7.49 /39 / 69. CXR [**7-22**] with ? infiltrate R base. Transfered for management of ongoing hypoxia. Initial vs (direct admit to ICU) were: T 102.3 P 86 BP 134/55 R 20 O2 sat 95 3LNC. Pt appeared comforatalbe without resp distress. Review of systems: + fever, chills. No night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denied cough. + mild SOB which pt compares to nasal congestion. + right posterior back pain, last episode prior to admit to [**Hospital1 **]. Denies palpitations. Denied nausea, vomiting, diarrhea, constipation or abdominal pain. Poor appetite. No recent change in bowel or bladder habits. No dysuria. Denied arthralgias or myalgias. No rash. Past Medical History: Osteoarthritis Osteopenia Raynauds syndrone seasonal allergies insomia s/p tonsillectomy s/p mastoidectomy bilaterally Social History: Lives in [**Hospital1 **] in 2 apt house. Has roommate. Son lives down the block. Independent in ADLs. Avid hiker. Non-smoker. Social drinker. No illicit drug use. Family History: Notable for heart disease and arthritis. Mother had leukemia. Grandfather colon cancer. Sister with breast cancer. Physical Exam: Vitals: T 102.3 P 86 BP 134/55 R 20 O2 sat 95 3LNC General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP 5cm above clavicle, no LAD Lungs: Crackles BL to upper lung fields with decreased BS on bases. no wheezes or ronchi CV: Regular rate and rhythm, normal S1 + S2, 2/6 SEM, LUSB, 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. trace edema. Neuro: A+Ox3, CN intact, [**5-10**] strengh, NL finger to nose, Sensation intact. Pertinent Results: Labs on Admission [**2196-7-22**]: WBC-6.2# RBC-2.85*# Hgb-8.4*# Hct-24.9*# MCV-87 MCH-29.6 Plt Ct-129* Neuts-51 Bands-11* Lymphs-27 Monos-5 Eos-0 Baso-0 Atyps-4* Metas-1* Myelos-0 Plasma-1* PT-14.5* PTT-29.3 INR(PT)-1.3* Glucose-108* UreaN-10 Creat-0.7 Na-120* K-4.5 Cl-93* HCO3-22 AnGap-10 ALT-36 AST-45* LD(LDH)-267* AlkPhos-92 TotBili-1.0 Albumin-2.4* Calcium-7.5* Phos-1.4*# Mg-1.8 Hapto-67 Osmolal-256* Digoxin-1.1 Fibrino-778* URINE Blood-MOD Nitrite-NEG Protein-TR Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-8.0 Leuks-NEG URINE RBC-0-2 WBC-0-2 Bacteri-NONE Yeast-NONE Epi-<1 URINE Hours-RANDOM UreaN-389 Creat-47 Na-65 URINE Osmolal-334 HCT trend: 24.9 -> 32.7 -> 27.9 -> 25.6 -> 29.8 -> 25.2 WBC trend: 6.2 -> 5.5 -> 4.7 -> 3.4 -> 3.9 Plt trend: 129 -> 111 -> 117 -> 117 -> 156 Retic count: 2.4 Haptoglobin: 67 -> 28 TSH: 5.4 Free T4: 1.4 Micro: Parst S-POSITIVE [**2196-7-22**] Urine culture: no growth [**2196-7-22**] Blood culture: No growth to date [**2196-7-22**] Smear - 2% parasitemia [**2196-7-25**] Smear - 0.1% parasitemia [**2196-7-26**] Smear - negative [**2196-7-27**] Smear - negative [**2196-7-18**] Lyme IgM positive [**2196-7-24**] Erlichia - negative Other Studies: [**2196-7-22**] Portable AP CXR: The cardiomediastinal silhouette is unchanged. There are new bibasilar opacities, which could represent a combination of infection, aspiration, or atelectasis with pleural effusion. There is no pneumothorax. [**2196-7-23**] TTE Echo: The left atrium is mildly dilated. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF 60-70%). There is no left ventricular outflow obstruction at rest or with Valsalva. There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Mild to moderate ([**1-8**]+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. Compared with the findings of the prior report (images unavailable for review) of [**2190-10-20**], the aortic regurgitation may be slightly increased; otherwise no obvious change. [**2196-7-25**] CXR: There is significant interval improvement seen as decrease in pulmonary edema, improvement of the bilateral basal aeration and decrease in still present small bilateral pleural effusions. There is still present left perihilar opacity that might represent residual of prior abnormalities. There are no new areas of consolidation. There is no mediastinal widening with stable appearance of the cardiac silhouette which is mildly enlarged. There is no pneumothorax. DISCHARGE LABS (722/09): BLOOD WBC-4.3 RBC-3.14* Hgb-9.1* Hct-27.4* MCV-87 MCH-29.1 MCHC-33.3 RDW-15.9* Plt Ct-189 Glucose-102 UreaN-13 Creat-0.9 Na-131* K-4.6 Cl-99 HCO3-24 AnGap-13 03:20PM BLOOD Na-132* Calcium-8.8 Phos-4.8* Mg-2.1 Brief Hospital Course: Ms. [**Known lastname **] is a 78 y/o with Raynaud's, no significant heart or lung history who presented from [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] with intermittent fevers and fatigue for 3 weeks and parasite smear + for babesiosis and SOB. # Fevers, malaise: The patient had a parasite smear at [**Hospital1 **] positive for babesiosis. Fatigue and fevers were consistent with Babesiosis, as was recent tick exposure. New onset anemia and thrombocytopenia were also consistent. The patient was treated with Atovaquone and Azithro for Babesiosis. She was also treated with Doxycycline for possibly Lyme disease - it was continued when her Lyme titer came back positive. The patient's fevers trended down and malaise improved during hospitalization. Abx were continued after discharge. Erlichia smear is negative. # Pulmonary edema: The patient was admitted with dyspnea, which developed in setting of IVF and new onset PAF. The patient likely had flash pulmonary edema, given her lung findings, elevated JVP, h/o valvulopathy, and new onset arrthymia. ECHO showed moderate aortic regurgitation. She diuresed well with lasix. ARDS was possible in the setting of Babesiosis, but unlikely since the patient had other signs of heart failure and had minimal oxygen requirement. When the patient was transferred from the MICU to the floor, she no longer had SOB and did not require oxygen. Diuresis was held, as the patient was breathing at baseline, but she was kept on fluid restriction. # Hyponatremia: The patient was admitted with Na level 120. Her exam was consistent with hypervolemic hyponateremia. The Na level trended up with diuresis and fluid restriction, and was 132 on discharge. # PAF: The patient had new onset Afib [**7-21**] and spontaneously converted back to NSR. She was started on Lovenox in the MICU, but it was discontinued since she developed afib in the setting of an infection and spontaneously converted back to NSR. On transfer to the floor, the patient was back in atrial fibrillation with RVR, HR 130-140s. She was treated with Metoprolol IV and responded well both times. The patient spontaneously converted back to NSR again. She was kept on PO Metoprolol. Due to low CHADS2 score, the patient was kept on ASA for anticoagulation. # Anemia: The patient had a low HCT during her hospitalization. There was no obvious GI bleed. This was likely [**2-8**] to hemolysis in the setting of Babesiosis. Her HCT was monitored, and she did not require any transfusions during her hospitalization. Medications on Admission: HOme meds: Alendronate-VIt D3 70mg / 2800 U po weekly amoxicillin 2000mg prn prior to dental work doxycycline 100mg PO BID (Started [**7-18**]) glucosamine Chondriotin PO BID nifedipine 30mg SR PO BID Aspirin 81mg PO daily Calcium +D 600mg-200 U 1 tab PO BID with food Ginkgo Biloba 1 tab daily Multivitation 1 tab daily Naproxen 250mg PO prn Discharge Medications: 1. Alendronate-Vitamin D3 70-2,800 mg-unit Tablet Sig: One (1) Tablet PO once a week. 2. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). Tablet(s) 3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 4. Metoprolol Succinate 50 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* 5. Glucosamine-Chondroitin Oral 6. Calcium 600 + D(3) 600 mg(1,500mg) -200 unit Tablet Sig: One (1) Tablet PO twice a day: with food. 7. Ginkgo Biloba Oral 8. Naproxen 250 mg Tablet Sig: One (1) Tablet PO once a day. 9. Nifedipine 30 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO twice a day. 10. Atovaquone 750 mg/5 mL Suspension Sig: One (1) PO BID (2 times a day) for 3 days. Disp:*6 * Refills:*0* 11. Azithromycin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 3 days. Disp:*3 Tablet(s)* Refills:*0* 12. Doxycycline Hyclate 100 mg Capsule Sig: One (1) Capsule PO Q12H (every 12 hours) for 2 weeks. Disp:*28 Capsule(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital3 **] VNA Discharge Diagnosis: Primary diagnoses Babesiosis Lyme disease Atrial fibrillation Secondary Diagnoses Anemia Pulmonary edema Discharge Condition: Stable, improved, afebrile, normal sinus rhythm Discharge Instructions: You were treated in the hospital for Babesiosis and Lyme disease, which are infections that were in your blood. You were continued on Azithromycin and Atovaquone to treat Babesiosis and Doxycycline to treat Lyme disease. You have been improving on the antibiotics and are no longer having fevers. The Babesiosis has caused you to have a low blood count, also known as anemia, but this has been stable for several days prior to discharge. You were having trouble breathing when you were admitted, which was due to fluid in your lungs. You were given medication (Lasix) to decrease the fluid in your lungs, and you were subsequently able to breathe more comfortably. You were placed on fluid restriction to prevent this from happening again. You were also found to have an abnormal heart rhythm, called atrial fibrillation, likely due to the infections. You were treated with metoprolol to help control your fast heart rate. You converted spontaneously back into normal sinus rhythm. You will be discharged on metoprolol and aspirin to help control your heart rate and prevent clots. The following changes have been made to your medications: 1. Azithromycin 250mg daily x 3days 2. Atovaquone 750mg every 12 hours x 3days 3. Doxycycline 100mg every 12 hours x 2weeks 4. Metoprolol (Toprol) 50mg daily 5. Aspirin 81mg daily If you experience fevers, chills, shortness of breath, chest pain, palpitations, or any other concerning symptoms, please call your physician or return to the emergency department. It was a pleasure meeting you and taking part in your care. Followup Instructions: Please follow up at the following appointments that have already been scheduled for you: [**2196-8-1**] 9:30a Dr. [**First Name (STitle) **] [**Last Name (NamePattern4) 13171**], MD - Primary Care Phone:[**Telephone/Fax (1) 719**] [**2196-8-2**] 10:00a Dr. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 13896**], MD - Infectious Disease Phone:[**Telephone/Fax (1) 457**] You can cancel this appointment if you'd rather follow with Dr. [**Last Name (STitle) 51919**] at [**Hospital3 **].

[ "285.9", "715.90", "427.31", "276.1", "V45.71", "518.4", "088.81", "088.82", "401.9", "443.0" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

10693, 10744

6621, 9174

321, 327

10894, 10944

3542, 6598

12558, 13068

2766, 2885

9569, 10670

10765, 10873

9200, 9546

10968, 12535

2900, 3523

1959, 2426

276, 283

355, 1940

2448, 2569

2585, 2750

3,426

125,247

26970

Discharge summary

report

Admission Date: [**2168-5-21**] Discharge Date: [**2168-5-25**] Date of Birth: [**2095-6-10**] Sex: M Service: MEDICINE Allergies: Novocain Attending:[**First Name3 (LF) 5755**] Chief Complaint: weakness Major Surgical or Invasive Procedure: central line History of Present Illness: 72 yo M with DM2, HTN, h/o L carotid artery stenosis now p/w shortness of breath. The patient was in his usual state of health until yesterday when he had poor PO intake due to anorexia. He was driving when he noted marked weakness. States his vision has been fluctuating recently (due to L cataract) but seemed worse. Upon returning to his house he had significant difficulty ambulating up a flight of stairs. The patient had to sit on the steps and states it was difficult for him to raise his head up or his arms. States he tried to "scoot" up the stairs but felt that he pulled a muscle in his L side. . On ROS he notes that he took antibiotics a couple of months ago for an upper resp infection. States this initially improved, but then for the last month he has noted some yellow sputum production. He denies any abdominal complaints, including no nausea, vomiting or diarrhea. At baseline he has severe DOE and it takes him "awhile" to get up his stairs to his apartment. Denies PND, orthopnea, chest pain. No LE edema. No fevers, chills, night sweats. . In the ED, T 98.4 at presentation with a spike to 101.4, hr 78, bp 81/40, rr 22, 94% RA improving to 99% 3L. He received aspirin 325mg po, levofloxacin 500mg IV, flagyl 500mg IV, Acetominophen 1g, and was started on Norepinephrine for persistent hypotension. Past Medical History: -HTN -Carotid artery disease, prior TIA's. -DM2 -COPD -R cataract surgery -L cataract - states no one wants to take him off of plavix and ASA to operate. -Glaucoma -R wrist tendon injury -CAD - 3VD seen on cath in [**10-31**] after NSTEMI. Referred for CABG - was supposed to see surgeon at [**Hospital3 **] on [**5-24**] - hasn't f/u x 2 despite preop work-up -PVD Social History: Used to work for school busing contract and also was a gang leader when younger. Lives alone but has a girlfriend. Quit smoking 20 years ago. Prior to that held cig in hand 5 packs/day for 20 years. Social drinker. Past marijuana use but quit 45 years ago. Family History: Mother DM, HTN. Never knew father. Brother ?cancer Physical Exam: VS: 97.8 80 140/64 16 100% 3L CVP 12 GEN: Lying in bed, talkative, NAD HEENT: PERRL, EOMI, MM dry, OP clear CV: Distant heart sounds [**1-29**] to habitus but RRR without m/r/g. Pulm: Small amount of basilar crackles L>R. Otherwise clear to auscultation. Abd: Obese, soft, NT, ND, +bs. Ext: No edema/cyanosis. Distal pulses intact. Neuro: A&Ox3. Pertinent Results: admission WBC 17.5, 85% N 10% L, Hct 44.1, Lactate 2.4. Most recent WBC 11.1, Hct 37.1, Lactate 1.1, LFT's within normal limits. Na 146, BUN/Cr 30/2.5. iron 54, tibc 231, ferritin 200, folate > 20, b12 629 cortisol 13.0 . Micro: Blood culture ([**2168-5-21**]) x2 sets: no growth Urine culture ([**2168-5-21**]): no growth . EKG ([**2168-5-21**]): Sinus rhythm with a rate of 78. Normal axis. Less than 1mm ST depressions in V4-6, unchanged from prior. . Imaging: CXR ([**2168-5-21**]) x2: Linear atelectasis at left lung base. Emphysema. Comparison is made to the study from five hours earlier. New left subclavian central venous line tip is in the upper SVC. No pneumothorax is identified. Cardiac size, mediastinal contours, and pulmonary vessels are within normal limits. . CT abd/pelvis ([**2168-5-21**]): 1. Limited examination without intravenous contrast. No intra-abdominal or pelvic fluid collection or abscess. Normal appendix. Diverticulosis without evidence of diverticulitis. 2. Anterior wedging and superior endplate depression in the L3 vertebral body likely represents a compression deformity of unknown chronicity. Clinical correlation is requested. . Echo ([**2166-10-31**]): The left atrium is elongated. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Overall left ventricular systolic function is moderately depressed. Resting regional wall motion abnormalities include anterior, lateral, and inferior hypokinesis. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild to moderate ([**12-29**]+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is a trivial/physiologic pericardial effusion. Brief Hospital Course: # Hypotension/bacterial pneumonia. Low bp and lactate elevation on presentation were concerning for sirs/sepsis physiology. Most likely source was pulmonary given complaints of cough with sputum production, though imaging not conclusive. Unlikely abdominal source given negative CT. Urine culture was negative. Patient was quickly weaned off levophed. Of note, cortisol showed no evidence of underlying adrenal insufficiency. He completed a 5 day course of high dose levofloxacin for treatment and is stable on room air. . # Acute renal failure. Likely hypovolemia, resolved with IVF. . # CAD: Patient has known 3 vessel CAD and has been referred for CABG but does not follow-up. Most recently he completed the preop work-up at [**Hospital1 756**] but then did not follow through, per his surgeon Dr. [**Last Name (STitle) 66293**], with the surgery. He now states he is finally ready to go through with the surgery given he is scooter-bound due to his baseline dyspnea. No evidence that patient's hypotension was cardiac in origin. ECHO shows improved EF from prior and patient ruled out with serial enzymes. He reports stable exertional dyspnea which has not recently changed. He was thus referred back to his surgeon, Dr. [**Last Name (STitle) 66293**], to pursue CABG. He was urged to avoid significant exertion in the interim but is scooter-bound at baseline due to his dyspnea. He is on an ASA, statin, BB, and ACEI. . # Visual changes: Patient described pre-syncope like visual changes (blacking out of both eyes) in the setting of an extreme urge to pass a bowel movement prior to admission with no recurrence of these symptoms in house. Given a history of carotid disease Carotid ultrasounds were pursued and show 60-70% bilateral disease. No clear indication for surgical intervention at this time. Patient instructed to follow-up with his primary if he develops monocular vision loss or any TIA symptoms. He was continued on his ASA, plavix, and statin. . # PVD. No acute issues. Outpatient follow-up. . # COPD. Stable on room air. Patient encouraged to take his albuterol and atrovent inhalers. Incentive spirometry was reviewed and encouraged in anticipation of future surgery. He does not smoke. . # DM2: Patient covered with insulin in house but was restarted on his home glyburide prior to discharge. . # Opthalmic. History of glaucoma and s/p right sided cataract surgery. - outpatient follow up. . # Anemia: Labs unrevealing. Needs continued work-up outpatient. . # Hematuria: Likely due to trauma from foley placed in ED. Needs repeat urinalysis outpatient and cystoscopy if this persists. . # Access: Left subclavian placed in ED for pressors . # Code: DNR/DNI . # Dispo: discharged to home Medications on Admission: Aspirin 325 mg PO DAILY Atorvastatin 80 mg PO DAILY Clopidogrel 75 mg PO DAILY Nitroglycerin 0.4 mg PRN Metoprolol Succinate 50 mg Sustained Release PO DAILY Lisinopril 5 mg PO DAILY Glyburide 10 mg PO twice a day Discharge Medications: 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Toprol XL 50 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. 5. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Glyburide 5 mg Tablet Sig: Two (2) Tablet PO twice a day. 7. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation QID (4 times a day). 8. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation every 4-6 hours as needed for shortness of breath or wheezing. Discharge Disposition: Home Discharge Diagnosis: primary: community acquired pneumonia CAD with known 3 vessel disease, noncompliant with follow-up for CABG acute renal failure dehydration with hypotension secondary: chronic obstructive pulmonary disease carotid disease, seen by [**Last Name (un) 60919**] in the past type 2 diabetes, well controlled without insulin Discharge Condition: good: hemodynamically stable, afebrile, 90-92% on room air with ambulation, stable exertional dyspnea w/ improved EF from [**10-31**] by ECHO Discharge Instructions: Please call your doctor or go to the emergency room if you experience chest pain, worsening shortness of breath with walking or other exertion, dizziness, change in your vision, or other concerning symptoms. Please be sure to follow-up with Dr. [**First Name4 (NamePattern1) 12584**] [**Last Name (NamePattern1) 66293**] who will be coordinating your bypass surgery preparation. You will need to have a cardiac catheterization before undergoing his surgery. His office will contact you with an appointment with Dr. [**First Name8 (NamePattern2) 1022**] [**Last Name (NamePattern1) **] who will do your cardiac catheterization. Please follow-up with Dr. [**Last Name (STitle) 28549**], as scheduled below, to have your urine rechecked for blood. If there is still blood, he may wish to refer you for a cystoscopy for bladder cancer screening. Please avoid significant exertion including sexual intercourse or vigorous exercise until you have your bypass surgery. Please continue to use the atrovent and albuterol inhalers, as prescribed. Followup Instructions: Please follow-up with Dr. [**Last Name (STitle) 28549**] on [**Last Name (LF) 2974**], [**2168-6-3**] at 8:40 AM to discuss a possible re-referral to Dr. [**Last Name (STitle) 60919**], to have your urine rechecked for blood, and to continue management of your diabetes. Location: [**Street Address(2) 34126**], [**Location 1268**] [**Numeric Identifier **]. Dr.[**Name (NI) 66294**] office will be contacting you with an appointment for a cardiac catheterization which will need to be done prior to your bypass surgery. If you do not hear from his office by Thursday, please call on [**Name (NI) 2974**] to confirm the time and date of your appointment. Phone: [**Telephone/Fax (1) 66295**]

[ "412", "486", "276.52", "250.00", "496", "433.10", "038.9", "584.9", "285.9", "443.9", "995.92", "401.9", "414.01" ]

icd9cm

[ [ [] ] ]

[ "38.93" ]

icd9pcs

[ [ [] ] ]

8343, 8349

4664, 7398

278, 292

8713, 8857

2755, 4641

9949, 10647

2322, 2374

7662, 8320

8370, 8692

7424, 7639

8881, 9926

2389, 2736

230, 240

320, 1642

1664, 2032

2048, 2306

30,881

171,958

43342+58615

Discharge summary

report+addendum

Admission Date: [**2155-7-31**] Discharge Date: [**2155-8-22**] Date of Birth: [**2097-3-16**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 613**] Chief Complaint: Fever and mental status changes Major Surgical or Invasive Procedure: 1. Lumbar Puncture 2. Percutaneous Gastric Jeujonstomy Tube Placement History of Present Illness: Patient is difficult to obtain history from and therefore most was obtained from chart, partner, and [**Name (NI) **] notes. Patient is a 58 y/o male with a history of HIV (CD4 36, VL 14,700 on [**7-9**]), T2DM, and HTN s/p recent admission with brain lesions who presented with confusion and fevers. He was recently admitted from [**Date range (3) 93327**] for mental status changes. He was found to have a new lesion on brain MRI and new seizures. Brain biopsy was non-diagnostic and he had a post-op sub-arachnoid hemorrhage that was stable on serial CT scans. He was thought to be doing better at home and his partner went away for a couple days. When she returned, she found him to be lethargic, slow to respond, febrile and non-compliant with his meds. He was brought in on the day of admission with temp to 102 and worsening confusion/lethargy. No focal neuro defecits per neuro on admission. . In the ED: He was febrile to 100.7. He received ceftriaxone and vancomycin. He had a Head CT that showed a new large region of hypodensity of the left frontal white matter adjacent to the previously identified subcentimeter lesion near the left frontal [**Doctor Last Name 534**]. Patient was initially sent to the floor for further work up but was minimally responsive, febrile, tacchycardic and shaking and was sent to the MICU. The shaking was thought to be due to fever and rigor and not seizure activity. . In the MICU, neurology and ID were consulted. Lumbar puncture was eventually done (see below for results). Patient treated with vancomycin, ceftriaxone and acyclovir empirically while the cultures were pending, but those were stopped. MRI was also done while in the MICU showing multiple new enhancing lesions and T2 abnormalities are seen in both cerebral hemispheres as well as the right inferior cerebellum. . On transfer from the MICU to the floor, patient was in sinus tacc with SBP 140s and afebrile. He was slow to respond to questions but would eventually answer most of them. The patient did not remember why he was admitted. He knew his name, he knew this was a hospital when we gave him choices and he knew if was [**2154**] but thought it was [**Month (only) **]. Patient denied HA, vision changes, nausea, chest pain, shorntess of breath, abdominal pain. Past Medical History: -HIV diagnosed [**3-14**]: CD4 count 17 in [**5-15**], VL<50; started on HAART earlier this year, with reduction in VL -History of PCP PNA [**Name9 (PRE) 93328**]/HAV -History of knife wound in Montserrat in [**2135**]. -Diabetes Mellitus -Hypertension Social History: He was born in Montserrat and moved to [**Country 6607**] in [**2127**], back to Montserrat in [**2132**], then in [**Location (un) 86**] since [**2135**]. He has also traveled to [**Last Name (LF) 4194**], [**First Name3 (LF) 32814**], [**Country 26467**], and New [**Country 6679**]. He formerly worked as a welder. Two cats at home. Currently lives with female partner of many years and two children (aged 13 and 15), planning on getting married. Family History: Non-contributory. Physical Exam: T 98.1 P 110 BP 142/76 R 18 O2 sat 98% RA, FSBG 120 Gen- lethargic, slow to respond HEENT- NCAT, anicteric, no injections, pupils small and symmetrical, equally round and reactive to light, OP +thrush- scrapes off with tongue blade, MMM Cor- 3/6 SEM heard best at LUSB, RR, tacchycardic Lungs- poor insp effort, clear anteriorly Abd- +bs, soft, nt, nd, no masses or hsm Extrem- no cce, pedal pulses 2+ b/l Neuro- difficult to assess due to patient cooperation, cn 2-12 intact although patient reports decreased sensation on left side of face, right arm and leg strength 3/5 vs [**3-13**] on left. Pertinent Results: [**2155-7-31**]: CT Head w/out Contrast: IMPRESSION: 1. New large region of hypodensity of the left frontal white matter adjacent to the previously identified subcentimeter lesion near the left frontal [**Doctor Last Name 534**]. These findings are nonspecific but are likely in part due to edema possibly from progression of the lesion at this site. Alternatively, this could indicate superimposed infection. This appearance would be unusual for infarction as it does not conform to a vascular territorial distribution. Further evaluation with gadolinium enhanced MR is suggested. 2. No evidence of acute intracranial hemorrhage. 3. Stable CT appearance of hypodensity near the right frontal lesion and of the left cerebellar hemisphere. 4. Resolution of bleeding at the right-sided biopsy site. . MRI/MRA [**2155-8-1**]: MRI IMPRESSION: Multiple new enhancing lesions and T2 abnormalities are seen in both cerebral hemispheres as well as the right inferior cerebellum. Differential diagnosis includes toxoplasmosis, tuberculosis, or cryptococcus infection. Previously noted inferior left cerebellar atrophic changes and signal changes are again identified. MRA OF THE HEAD: The head MRA demonstrates normal flow signal within the arteries of anterior and posterior circulation. No evidence of vascular occlusion, stenosis or an aneurysm greater than 3 mm in size are seen. IMPRESSION: Normal MRA of the head. MRV OF THE HEAD: Head MRV demonstrates normal flow signal in the superior sagittal and transverse sinuses. Normal flow signal is also seen in the deep venous system. IMPRESSION: Normal MRV of the head. [**2155-8-5**]: CT Head W/out Contrast IMPRESSION: 1. Unchanged appearance of hypodensity extending from the left frontal white matter to the left basal ganglia, with associated effacement of the frontal [**Doctor Last Name 534**] of the left lateral ventricle. 2. Hypodensity in the region of the right thalamus. Although this area did not enhance on previous MRI, there was significant FLAIR abnormality in this region. Differential considerations include evolving infectious process such as toxoplasmosis, tuberculosis, or cryptococcus. . [**2155-8-14**]: CT Head W/out contrast IMPRESSION: 1. Unchanged confluent areas of hypodensity within the frontal lobes with associated effacement of the frontal [**Doctor Last Name 534**] of the left lateral ventricle. Unchanged rounded hypodensities within the right frontal subcortical white matter, right thalamus, and left basal ganglia. As previously mentioned, the differential includes infectious processes such as toxoplasmosis, tuberculosis or cryptococcus. 2. Two new hyperdense rounded foci within the left frontal subcortical white matter/[**Doctor Last Name 352**] matter. These may reflect the patient's underlying infectious process. Other differential diagnoses would include hemorrhagic metastases and septic emboli. Small parenchymal hemorrhages are less likely but cannot be excluded. . Laboratory Results: [**2155-8-22**] 04:31a Source: Line-PICC Sodium 133 Chloride 103 BUN 18 Glucose 83 AGap=13 Potassium 4.3 HCO3 21 Crt 1.8 Ca: 9.9 Mg: 1.9 P: 3.2 Source: Line-PICC WBC 4.1 Hemoglobin 8.5 Platelets 131 HCT 24.5 Brief Hospital Course: The patient is a 58 year old man with HIV/AIDs (CD4 count 34) who presented to the emergency room with fevers and change in mental status, with imaging and microbiology results most consistent with cerebral toxoplasmosis. . 1. Brain lesions most consistent with Toxoplasmosis: . During the hospital stay the lumbar puncture was performed (6WBC (1% Polys, 78%Lymphocytes, 21% Monocytes; 0Atypicals) 0 RBC; Elevated Protien: 135; glucose 79; Opening Pressure: 33cm H20). CSF fluid was negative for [**Male First Name (un) 2326**] Virus (by PCR), HSV 1&2 (PCR), Syphillis VDRL, CMV and Toxoplasmosis IgG/IgM. However, Toxoplasmosis DNA was found in the CSF via PCR. . Treatment for presumed cerebral toxoplasmosis was started in the hospital. He was started on intravenous Bactrim in the MICU but was switched to oral Pyrimethamine/Sulfadiazine once nasogastric tube was placed due to concern over rising creatinine and worsening renal function. Throughout the hospital stay, the patient pulled out his nastrogastric tube several times and would spit up or vomit medications; therefore, treatment was changed from oral Pyrimethamine/Sulfadiazine to IV Bactrim several times depending on his renal function and ability to tolerate oral intake. As a result, the patient did not initially receive consistent treatment of for toxoplasmosis. Consistent therapy was initiated [**2155-8-15**] with IV Bactrim, with stable creatinine, and was switched to PO Pyrimethamine/Sulfadiazine, with leucovorin calcium, on [**2155-8-21**] once GJ-tube was placed. The patient is now on day 8 of consistent treatment for toxoplasmosis, and should complete a total of 14 days. . Of note, EBV DNA in the CSF via PCR was found to be "equivocal" meaning that the test was neither definitively positive or negative, and trace monoclonal IgG kappa was found in the CSF fluid. This could be suggestive of possible PCNSL, although the nature of the cereberal lesions are more suggestive of toxoplasmosis than a lymphomatous process. A repeat image of his brain after completing treatment for toxoplasmosis will be helpful to futher evaluate this, and has been scheduled for [**2155-9-1**] at [**Hospital1 18**] in the Clinical Center of the [**Hospital Ward Name 517**] at 7am in the basement. . Imaging was repeated a various times throughout his stay due to lethargy, waxing and [**Doctor Last Name 688**] mental status, as well as vomiting and nausea, all of which subsequently improved greatly. The imaging showed new lesions, however it was felt that this was not yet a failure of treatment for his toxoplasmosis, given he had not consistently been getting medications. . At the time of discharge to rehab, the patient's mental status and motor function had been improving on the consistent toxoplasmosis therapy. After about 2 weeks of consistent toxoplasmosis therapy, the patient's brain will be re-imaged via MRI w/ gadollinium. If the patient's lesions have not improved after therapy, primary CNS lymphoma may be re-visited as a possibility. The patient will be followed by HIV/AIDS neurologist Dr. [**First Name (STitle) **] [**Name (STitle) 2340**] and infectious disease team at [**Hospital1 **], Dr. [**Last Name (STitle) 724**]. . Seizure prophylaxis was continued with Keppra. . 2. Cryptococcus Antigen was detected in the blood stream, but not in the CSF. The patient was started on IV ambisome, but therapy was switched to Fluconazole after the patient's renal function worsened. The patient remained on Fluconazole throughout the hospital stay, and should continue until advised to stop by infectious disease doctors an [**Name5 (PTitle) **] outpatient. . 3. HBV. During the hospital stay, the patient's serum HBV viral load was measured as 2,460,000 IU/mL. His liver enzymes were also initially elevated, likely in part to the hepaitis B, but they trended down to the normal range. . 4. HIV/AIDS (CD4: 36, VL 14,700 in [**2155-7-9**]) During the hospital stay, patient was on Truvada/Kaletra. These medications were stopped partway through the hospital course because of increasing creatinine and inability to administer PO medications consistently ([**1-10**] patient refusal or vomiting). Truvada/Kaletra were were started [**8-22**] with renal dosing. * His creatinine should be monitored closely, every one to two days, now that his HAART medications have been restarted. . Patient also has been receiving [**Doctor First Name **] prophylaxis weekly on Wednesdays with azithromycin 1200 mg. . 5. Acute Renal failure Patient's Cr rose during the hospital stay from 1.5 on admission to as high as 2.3. Cr on discharge was 1.8. It was thought that the rise was most likely secondary to drug effect, especially Ambisone, and to a less degree Truvada and Bactrim. * His creatinine should be monitored every day or every other day since he has just recently restarted his HAART medications--their dosing may need to be adjusted accordingly. . 6. Blood pressure Patient was continued on medications for his hypertension, and has been titrated up to 100mg metoprolol [**Hospital1 **], now that he can reliably get PO medications. He may need further titration of his medication or additional [**Doctor Last Name 360**], such as amlodipine. . 7. Diabetes Patient's blood sugars were under good control- 100's to 140's range, however he was taking very little PO during most of his stay. He was kept on a sliding scale of insulin, however may need a baseline insulin or additional [**Doctor Last Name 360**] as he restarts his tube feeds. . 8. Poor appetite Speech and swallow have evaluated patient due to poor intake, as there was concern he was having dysphagia or other neurological problems with eating. It was found that he does not appear to have any risk of aspiration or other difficulties eating or swallowing--however, he does not appear to be interested in eating many of the hospital foods. Given his other medical co-morbidities, we deferred initiating any appetite stimulant, however this is something that may be considered in the future. Another option would be to decrease the rate of his tube feeds to stimulate hunger, although patient denies feeling hungry all of the time. . A gastric-jeujonostomy tube was placed on [**2155-8-20**], and tube feeds were initiated, working up to a goal of 95mL/hr with Replete with fiber, full strength, and he was at 75mL/hr at time of discharge, going up by 10mL/hr every 6 hours as tolerated. He was receiving 50mL of free water for flushes as well every 6 hours. Reglan and a PPI was continued to assist with reflux, bowel motility and any nausea. . For the GJ tube site, intraventional radiology recommended changing dressing daily. Gently cleanse around the skin entry site of the catheter with dilute hydrogen peroxide. Dry and apply sterile gauze dressing. An abdominal binder is being used to keep it in place. . 9. Anemia: His anemia has been stable. Iron studies were consistent with anemia of chronic disease, and it was also thought that a number of his medications, especially bactrim, were contributing to his anemia. . 10. Health care proxy: His health care proxy was determined to be long time partner, [**Name (NI) 93329**] [**Last Name (NamePattern1) 31853**], and the HCP form was signed. . 11. Vascular Access: PICC line was left in for ease of daily lab draws. Medications on Admission: (Per last discharge, patient did not know medications and per family had not been taking them.) 1. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). Disp:*180 Tablet(s)* Refills:*2* 2. Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO QAM. Disp:*30 Tablet(s)* Refills:*2* 3. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). Disp:*60 Tablet(s)* Refills:*2* 4. Nifedipine 30 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO DAILY (Daily). Disp:*30 Tablet Sustained Release(s)* Refills:*2* 5. Emtricitabine-Tenofovir 200-300 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 6. Lopinavir-Ritonavir 200-50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 7. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) as needed for pcp [**Name Initial (PRE) 1102**]. Discharge Disposition: Extended Care Facility: [**Hospital3 672**] Hospital Discharge Diagnosis: Primary Diagnosis: - Toxoplasmosis Secondary Diagnoses: - HIV/AIDS - Hepatitis B - Hypertension - Diabetes Mellitus, Type 2 Discharge Condition: Stable. Discharge Instructions: You were admitted due to fever and decreased mental status. A number of tests were done, including blood test, tests on your cerebral spinal fluid, and imaging, which demonstrated it was likely you had an infection in your [**Doctor Last Name **]. You should continue to take all of your medications as prescribed in order to treat the infection, as well as your underlying medical conditions and other illnesses. During your stay, you had difficulty eating enough and taking your medications, so a tube was placed to assist with getting you medications and nutrition. . You will need a follow up MRI of your brain to assess how well the treatment is working. This has been scheduled for you on [**2155-9-1**] on the [**Hospital Ward Name 517**] of [**Hospital1 1170**], at 7am in the basement. You can call ([**Telephone/Fax (1) 6713**] (#1) if you need to reschedule. You will need to follow up with neurology to discuss these results: Neurology Appointment: Dr. [**First Name (STitle) **] [**Name (STitle) 2340**] [**2155-9-17**] at 3:30pm, 330 [**Hospital Ward Name 23**] Building, [**Hospital Ward Name 516**], [**Location (un) **], [**Location (un) 86**], MA. . Follow up appointments with your primary care provider's covering physician (Dr. [**Last Name (STitle) 47097**] [**Name (STitle) **]) and your infectious disease doctor, Dr. [**Last Name (STitle) 724**], have also been set up: - [**2155-8-26**], 11:30 am with Dr. [**First Name8 (NamePattern2) 1528**] [**Last Name (NamePattern1) **], [**Hospital1 **] Community Health Center at [**Hospital1 26957**], [**Location (un) 669**], MA. - [**2155-8-27**], 9:00 am with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 724**], [**Hospital1 **] Community Health Center at [**Hospital1 26957**], [**Location (un) 669**], MA. . Please contact your primary care doctor or go to the emergency room if you experience fever, chills, drowsiness, new weakness, numbness, or tingling, chest pain, shortness of breath, abdominal pain, or other concerning symptoms. Followup Instructions: Primary Care Physcian: Dr. [**Last Name (STitle) **] at [**Hospital1 **] Community Health. Phone: [**Telephone/Fax (1) 3581**]. Date/Time: [**2155-8-26**] at 11:30am. [**Hospital1 26957**], [**Location (un) 669**], MA. . Infectious Disease Physcian: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 724**], at [**Hospital1 **] Community Health. Phone: [**Telephone/Fax (1) 3581**]. Date/Time [**2155-8-27**] at 9:00am, [**Hospital1 26957**], [**Location (un) 669**], MA. . MRI Appointment: [**2155-9-1**], [**Hospital Ward Name 517**] of [**Hospital1 1170**], 7:00 am, basement level. . Neurology Appointment: Dr. [**First Name (STitle) **] [**Name (STitle) 2340**] [**2155-9-17**] at 3:30pm, 330 [**Hospital Ward Name 23**] Building, [**Hospital Ward Name 516**], [**Location (un) **], [**Location (un) 86**], MA. [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**] Name: [**Known lastname **],[**Known firstname **] Unit No: [**Numeric Identifier 14738**] Admission Date: [**2155-7-31**] Discharge Date: [**2155-8-22**] Date of Birth: [**2097-3-16**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1472**] Addendum: Upon further discussion with Infectious Disease team, it is clear that patient should continue treatment for toxoplasmosis for approximately 4-6 weeks after symptoms improve. Dr. [**Last Name (STitle) 25**] will be following Mr. [**Known lastname **] as an outpatient and may further dictate the treatment time of his toxoplasmosis therapy. Discharge Disposition: Extended Care Facility: [**Hospital3 **] Hospital [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 1473**] Completed by:[**2155-8-22**]

[ "250.00", "130.7", "117.5", "276.2", "285.29", "584.9", "E930.1", "112.0", "042", "070.32", "263.9", "401.9" ]

icd9cm

[ [ [] ] ]

[ "03.31", "44.32", "38.93", "96.6" ]

icd9pcs

[ [ [] ] ]

19749, 19952

7406, 14749

347, 419

15949, 15959

4147, 5318

18044, 19726

3495, 3514

15802, 15802

14775, 15703

15983, 18021

3529, 4128

15858, 15928

275, 309

447, 2731

5336, 7383

15821, 15837

2753, 3007

3023, 3479

68,389

113,481

51687

Discharge summary

report

Admission Date: [**2163-10-5**] Discharge Date: [**2163-10-14**] Date of Birth: [**2108-8-14**] Sex: F Service: MEDICINE Allergies: Penicillins / Erythromycin / Compazine / Bactrim Ds / Sulfa (Sulfonamides) / Dapsone / Levaquin / Lisinopril Attending:[**Last Name (NamePattern4) 290**] Chief Complaint: fever Major Surgical or Invasive Procedure: None History of Present Illness: Ms. [**Known lastname **] is a 55 year old woman with h/o NHL (27 years ago), complicated by lung toxicity [**1-25**] to Bleomycin treatment, sarcoidosis, Factor V Leiden, systolic CHF (EF 30%, adriamycin toxicity), CKD, recently discharged to rehab after a complicated hospital course for respiratory distress, requiring trach and PEG placement, s/p treatment for PNA, currently being treated for Cdiff colitis, now presents with fever. Patient was recently admitted [**Date range (1) 107084**] for respiratory failure, requiring intubation. The patient was unable to be weaned from the [**Last Name (LF) **], [**First Name3 (LF) **] trach and PEG were placed. During this hospitalization, the patient was persistently febrile, despite treatment with Abx. She was treated for an 9d course of Vanc/Cefepime for presumed HAP. Given an Abx holiday for 48-72 hrs given concern for drug fevers, but fevers persisted. She was restarted on Vanc/Cefepime with addition of IV Flagyl and PO Vanc for positive Cdiff. Prior to d/c, sputum culture grew gram negative rods, so IV Vanc was d/c'd and Cefepime was changed to Meropenem. Meropenem was continued until [**2163-9-29**] at rehab. The patient is currently still on PO Vanc and PO Flagyl for Cdiff treatment. The patient was noted to have low grade fevers for the past week at rehab. She was restarted on Vanc and Meropenem. Temp was up to 102.6 today, so she was transferred to the ED for further care. The patient currently feels well. She notes some R wrist pain/tendinitis. There have been no changes in her [**Month/Day/Year **] settings. She is currently on Flagyl and PO Vanc for Cdiff colitis. She continues to have loose stools, although improved from when she intially went to rehab. No chills, sweats, increased cough, worsening shortness of breath, chest pain, abdominal pain, nausea, vomiting. In the ED, initial vs were: T 102.2 P 119 BP 143/83 RR 43 O2 sat 100% [**Month/Day/Year **]. The patient was tachycardic to 110, but BP remained stable. CXR unchanged from prior. UA unremarkable. Patient was given Tylenol, Vancomycin, and Meropenem. Vitals on transfer: P 97 BP 108/54 RR 30 O2sat 100% [**Month/Day/Year **]. On the floor, the patient remains comfortable. She notes R wrist pain, but otherwise has no complaints. Past Medical History: - s/p trach/PEG [**9-2**] -Sarcoidosis: treatment History: methotrexate [**12-31**], stopped [**1-31**] due to reaction, prednisone 10-20-10-7.5mg [**Date range (1) 107077**] stopped due to Cushingoid side effects in [**11-1**]. - Non-Hodgkin's lymphoma (27 years ago) s/p chemotherapy c/b bleo lung tox, autologous BMT, and high-dose myeloablative total body irradiation. - Pulmonary embolism with Factor-5 Leiden- long term coumadin goal INR [**1-26**] therapy - Status post CVA with memory deficit. - Stage III-IV chronic kidney disease. - Systolic CHF- [**1-25**] adriamycin from large cell lymphoma several years ago. Recent Echo 30%. - Hypertension. - Hyperlipidemia - Mild sleep apnea. - Anxiety - Gout. - Anemia - on Aranesp - Iron overload. - Multiple environmental allergies Social History: Currently living at [**Hospital 100**] Rehab x2 weeks. She has been on disability for the past 15 years, but used to work in a hotel as a reservations consultant. - Tobacco: None - Alcohol: None - Illicits: None Family History: - Maternal: clots, PE, TIA, Factor V Leiden, dementia at 92 - Paternal: CAD, pancreatic CA - Siblings: sister died [**2162-12-24**] from complications of DM, another sister with thyroid problems and high cholesterol - Children: one healthy daughter without [**Name2 (NI) **] V Leiden - Uncle: colon cancer Physical Exam: Vitals: T 100.1 P 96 BP 102/60 RR 22 O2sat 98% General: Alert, oriented, no acute distress, trach in place, mechanically ventilated HEENT: Sclera anicteric, dry MM, oral thrush Neck: supple, JVP not elevated, no LAD Lungs: coarse breath sounds bilaterally anteriorly CV: tachycardic, S1 + S2, no murmurs, rubs, gallops appreciated given coarse breath sounds Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly, PEG site c/d/i - no erythema/induration/pus GU: foley Skin: redness in groin area, lower back/buttocks, under breasts Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema, no calf tenderness, RUE PICC c/d/i - no erythema, induration, pus Pertinent Results: ADMISSION LABS: [**2163-10-5**] 12:40PM BLOOD WBC-16.7*# RBC-2.73* Hgb-8.4* Hct-24.9* MCV-91 MCH-30.7 MCHC-33.6 RDW-15.7* Plt Ct-430 [**2163-10-5**] 12:40PM BLOOD Neuts-81.5* Lymphs-11.9* Monos-5.5 Eos-0.7 Baso-0.3 [**2163-10-5**] 12:40PM BLOOD PT-27.8* PTT-30.5 INR(PT)-2.7* [**2163-10-5**] 12:40PM BLOOD Glucose-110* UreaN-55* Creat-1.5* Na-125* K-4.3 Cl-86* HCO3-29 AnGap-14 [**2163-10-5**] 12:40PM BLOOD ALT-19 AST-27 AlkPhos-143* TotBili-0.2 [**2163-10-5**] 12:40PM BLOOD Albumin-3.2* Phos-4.3 Mg-2.8* [**2163-10-5**] 12:54PM BLOOD Glucose-118* Lactate-0.8 [**2163-10-5**] 12:40PM BLOOD Lipase-66* OTHER PERTINENT LABS: [**2163-10-6**] 05:00PM BLOOD Ret Aut-1.1* [**2163-10-6**] 05:00PM BLOOD LD(LDH)-161 TotBili-0.2 [**2163-10-6**] 05:00PM BLOOD Hapto-521* URINE: [**2163-10-5**] 12:40PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.006 [**2163-10-5**] 12:40PM URINE Blood-TR Nitrite-NEG Protein-25 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-TR [**2163-10-5**] 12:40PM URINE RBC-0-2 WBC-0-2 Bacteri-FEW Yeast-NONE Epi-0-2 [**2163-10-5**] 04:20PM URINE Hours-RANDOM UreaN-296 Creat-24 Na-10 K-12 Cl-<10 [**2163-10-5**] 04:20PM URINE Osmolal-177 MICRO: [**10-5**] BCx: negative [**10-5**] UCx: negative [**10-5**] SputumCx: sparse yeast, GNR [**10-5**] PICC catheter tip Cx: negative [**10-12**] Feces negative for C.difficile toxin A & B by EIA. IMAGING: [**10-5**] CXR: Low lung volumes and overall stable interstitial opacities. Given differences in technique and patient position, left pleural effusion is likely without significant change. [**10-12**] CXR: In comparison with the study of [**10-10**], there is still diffuse bilateral pulmonary opacifications bilaterally in a patient with known sarcoidosis. No definite evidence of acute focal pneumonia. Tracheostomy device remains in place. [**10-10**] Upper Extremity Doppler: Deep venous thrombosis involving the right subclavian and axillary veins, with extension into one of two brachial veins. The internal jugular, basilic and cephalic veins remain patent. [**10-6**] CT abd/pelvis: 1. No acute intra-abdominal or pelvic process. 2. Redemonstration of interstitial and peribronchial thickening consistent with the patient's history of sarcoidosis with new areas of ground-glass opacity within the medial lower lobes bilaterally. While this could be related to sarcoidosis, superimposed infection or aspiration cannot be excluded and clinical correlation is recommended 3. Small bilateral pleural effusions 4. Hyperenhancing 1.8 mm region within segment VIII of the liver peripherally, which likely represents a benign perfusion abnormality. 5. Hypodensities within the kidneys bilaterally, which are incompletely characterized, but likely represent renal cysts, some of which were present on the prior non-contrast study. DISCHARGE LABS: [**2163-10-14**] 03:25AM BLOOD WBC-7.3 RBC-2.78* Hgb-8.5* Hct-25.6* MCV-92 MCH-30.4 MCHC-33.0 RDW-15.9* Plt Ct-487* [**2163-10-14**] 03:25AM BLOOD Glucose-106* UreaN-24* Creat-0.8 Na-136 K-4.2 Cl-102 HCO3-27 AnGap-11 [**2163-10-14**] 03:25AM BLOOD Calcium-9.0 Phos-3.4 Mg-1.9 Brief Hospital Course: Ms. [**Known lastname **] is a 55 year old woman with h/o restrictive lung disease (bleomycin toxicity), sarcoidosis, systolic CHF (EF 30%, adriamycin toxicity), Factor V Leiden, s/p trach and PEG placement, here with recurrent fevers. #. Fever: Patient was admitted with fever and leukocytosis. Infectious considerations initially included VAP vs line infection vs UTI vs Cdiff. On admission PICC line was removed and foley was replaced. Patient was transiently on Meropenem and IV Vanco however was discontinued on [**10-10**], as there was low suspicion for active infection. Sputum cultures grew gram negative rods (ACHROMOBACTER DENTRIFICANS) which was though to be a colonizer. Patient remained on PO vanco throughout stay and will continue on it until [**10-21**]. Rheumatology and ID were consulted however no source for the fever could be found. She had a DVT in her right upper extremity that may be causing her fevers. She was started on enoxaparin for DVT therapy, as she developed a clot despite Coumadin therapy. This should be continued at therapeutic dose lifelong, given the patient's h/o Factor V Leiden. # Upper Extremity DVT: Pt with new RUE DVT seen on U/S at the site of her PICC. She developed this despite being therapeutic on Coumadin. She was started on Lovenox, which should be continued lifelong as above. # Transient hypotension: SBP transiently dropped to 80s, typically while she was sleeping. Responded to IVF boluses. No other intervention was necessary. # Diarrhea: Had C. diff infection since late [**9-2**] and was being treated with PO Vanco. Patient will remain on PO Vanco until [**10-21**]. Last C. diff toxin in stool was negative. Patient was started on banana flakes to bulk stool which seemed to help stool output. # Hyponatremia: On admission hyponatremia was considered likely secondary to hypovolemia. It resolved in 12 hours of admission. # Skin rash: Pt presented with fungal rash under breasts, groin, and lower back/buttocks. She was treated w/miconazole powder and PO diflucan. # Thrush: Pt noted to have oral thrush on exam. She was treated with PO diflucan. # Respiratory failure: Secondary to bleomycin toxicity. Pt arrived trached and on [**Month (only) **]. Weaning process was started during this hospitalization. Pt tolerated several hours a day on trach mask. Does get anxious when on the trach mask - Ativan is effective for relief. # CHF: [**Last Name **] problem. [**Name (NI) **] interventions were necessary. # CKD: [**Last Name **] problem. [**Name (NI) **] interventions were necessary. # Factor V Leiden: H/o Factor V Leiden. Pt was on Coumadin for life-long anticoagulation. Coumadin was discontinued given that patient developed a DVT on coumadin. Pt should continue on therapeutic dose of Lovenox lifelong. # HTN: Prior h/o hypertension, although had hypotension during last admission. Coreg was held given normal blood pressures. Meds should be restarted upon outpatient assessment and uptitrated as necessary. #. Psych: continued Ativan prn for agitation/anxiety #. Anemia: HCT was as low as 21 and received 2 unit pRBC. No clear source of bleeding and patient's hct remained stable. Receives Aranesp as an outpatient. #. Sarcoidosis: Followed by Dr. [**Last Name (STitle) 575**]. Stable on this admission. Ventilation requirements should be weaned as tolerated. Medications on Admission: Meropenem 500mg IV q8h x7days - completed [**2163-9-29**], restarted [**10-5**] Vancomycin 1000mg IV q24h - restarted [**10-4**] Vancomycin 125mg PO q6h x21 days Flagyl 500mg PO q8h x21days Warfarin 5mg PO daily Coreg 12.5mg PO BID White Petrolatum-Mineral Oil Ophthalmic TID prn redness Bisacodyl 10mg PO daily prn Maalox PO QID prn Miconzaole powder [**Hospital1 **] prn Tylenol solution 650mg PO q6h prn Chlorhexidine 1mL [**Hospital1 **] Famotidine 20mg PO q24h Heparin 5000units SC TID Discharge Medications: 1. vancomycin 125 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours) for 9 days. 2. chlorhexidine gluconate 0.12 % Mouthwash Sig: One (1) ML Mucous membrane [**Hospital1 **] (2 times a day). 3. sertraline 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. simvastatin 40 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)). 5. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day). 6. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain/fever. 7. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. 8. enoxaparin 60 mg/0.6 mL Syringe Sig: One (1) Subcutaneous Q12H (every 12 hours). 9. famotidine 40 mg/5 mL Suspension Sig: One (1) PO once a day. 10. Maalox Advanced 200-200-20 mg/5 mL Suspension Sig: One (1) PO four times a day as needed for indigestion. 11. bisacodyl 5 mg Tablet Sig: Two (2) Tablet PO once a day as needed for constipation. 12. ipratropium bromide 17 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) Puff Inhalation Q4H (every 4 hours) as needed for shortness of breath or wheezing. 13. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: 6-8 Puffs Inhalation Q4H (every 4 hours) as needed for Wheezing. 14. Ativan 1 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for anxiety. 15. darbepoetin alfa in polysorbat 25 mcg/mL Solution Sig: Twenty Five (25) mcg Injection once a week: last received [**2163-10-5**] at prior rehab. Discharge Disposition: Extended Care Facility: [**Hospital3 105**] - [**Location (un) 1121**] - [**Location (un) 1456**] Discharge Diagnosis: Upper Extremity Deep Venous Thrombosis Chronic respiratory failure Upper Extremity Deep Venous Thrombosis Chronic respiratory failure 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: Dear Ms. [**Known lastname **], You were admitted because you were having fevers. After extensive work-up, we do not believe you were having an active infection causing the fever. You will remain on the Vancomycin for your prior C. difficile infection. You had a clot in your right arm vein. You were started on a new blood thinner called Lovenox. Many changes were made to your medications; please see attached list. Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more than 3 lbs. Followup Instructions: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2722**], MD Phone:[**Telephone/Fax (1) 1971**] Date/Time:[**2163-10-28**] 1:30 Provider: [**Name10 (NameIs) 1571**] FUNCTION LAB Phone:[**Telephone/Fax (1) 609**] Date/Time:[**2163-11-22**] 11:30 Provider: [**Name10 (NameIs) 1570**],INTERPRET W/LAB NO CHECK-IN [**Name10 (NameIs) 1570**] INTEPRETATION BILLING Date/Time:[**2163-11-22**] 11:30 [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**] Completed by:[**2163-10-14**]

[ "611.79", "453.85", "453.84", "518.83", "V44.0", "300.00", "428.0", "112.0", "428.20", "585.4", "276.1", "403.90", "E930.7", "008.45", "V42.81", "V58.61", "782.1", "286.3", "V46.11", "135" ]

icd9cm

[ [ [] ] ]

[ "96.72", "96.6" ]

icd9pcs

[ [ [] ] ]

13388, 13488

7971, 11327

383, 389

13667, 13667

4826, 4826

14376, 14961

3757, 4064

11868, 13365

13509, 13646

11353, 11845

13843, 14353

7671, 7948

4079, 4807

338, 345

417, 2704

4842, 5430

5452, 7655

13682, 13819

2726, 3512

3528, 3741

17,191

108,378

9948

Discharge summary

report

Admission Date: [**2140-5-31**] Discharge Date: [**2140-6-14**] Date of Birth: [**2071-3-21**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1505**] Chief Complaint: Chest Pain Major Surgical or Invasive Procedure: CABG History of Present Illness: 69 y/o male with HTN, DM2, CAD, ESRD on HD presents as transfer from [**Hospital3 417**] Hospital after presenting with sudden onset of substernal chest pain, not pressure, begining at rest while lying down, described as sharp, [**6-20**] in intensity, not radiating, not relieved with nitroglycerin originally, lasting one and a half hours, and finally resolving with a second nitroglycerin and oxygen. It was associated with diaphoresis and shortness of breath, but no nausea or vomiting. At [**Hospital 6451**] EKG with ST depresions in II, III, aVF, and V3-V6 and CK 179 and trop I 0.67 (0045) CK 163 and Trop I 0.89 (0635). He is on a nitro drip and heparin drip, and since then he has been chest pain free and without shortness of breath. He has 3 vessel CAD by cath in [**7-16**] at which time he had cypher stent to ostial 90% LCX lesion. He has been on plavix since then. He recently had a cardiac catheterization on [**2140-5-26**], for abnormal ETT showing inferolateral ischemia, which showed focal midsegment LAD 85% stenosis, 100% stenosis of D1, and severe diffuse 95% instent restenosis of proximal stent segement of LCX, and 100% stenosis of RPDA. . [**Last Name (NamePattern4) 33329**] here for consideration of CABG, as he was to be evaluated in the coming days by Dr. [**Last Name (Prefixes) **]. Past Medical History: 1. Coronary artery disease, status post small myocardial infarction in [**2119**], status post catheterization in [**2134**] for congestive heart failure with no intervention, status post Persantine MIBI in [**2131**] with a reversible defect in the inferior wall. LCX stent placed. 3v disease on [**2140-5-26**] catheterization. 2. Non-insulin-dependent diabetes mellitus. 3. Congestive heart failure. 4. End stage renal disease on hemodialysis T/H/Sat 5. Chronic anemia with a baseline HCT in the high 20s. 6. Multiple myeloma-in remission 7. Hypertension, difficult to control. 8. Hyperlipidemia. 9. Gout. Social History: Patient lives with his wife, has 3 sons and 1 daughter. Quit smoking in [**2115**], 35-pack-year history. Denies recent alcohol. No drug use. Family History: +DM, +HTN, no CAD, no stroke, MGM with stomach cancer Mother died at 64 from renal cell carcinoma. Father died in his 30s of unknown causes. Three siblings with elevated cholesterol, diabetes, and hypertension. Physical Exam: EXAM: T 99.6 BP 101/40 HR 72 RR 12 SAT 97% 3L O2 by NC General: well apearing male in no distress HEENT: PERRL, EOMI, Sclera anicteric NECK: No JVP elevation, no carotid bruitss, normal carotid pulses CHEST: Lungs clear with out rales HEART: RRR. 2/6 systolic murmur over entire precordium BACK: No sacral edema ABD: Normal active bowel sounds, soft, NT, ND, no masses EXT: Equal femoral pulses B/L, weak [**Doctor Last Name **] and DP pulses b/l with hairless, wasted ext below the knees NEURO: Non focal Pertinent Results: [**2140-6-14**] 06:20AM BLOOD WBC-7.3 RBC-2.84* Hgb-8.7* Hct-25.3* MCV-89 MCH-30.6 MCHC-34.4 RDW-18.7* Plt Ct-168 [**2140-6-12**] 04:30AM BLOOD WBC-9.0 RBC-3.23* Hgb-9.8* Hct-28.4* MCV-88 MCH-30.5 MCHC-34.7 RDW-19.6* Plt Ct-128* [**2140-6-14**] 06:20AM BLOOD Plt Ct-168 [**2140-6-14**] 06:20AM BLOOD Glucose-100 UreaN-40* Creat-4.6* Na-135 K-4.4 Cl-101 HCO3-25 AnGap-13 Brief Hospital Course: 69 y/o male with HTN, DM2, ESRD on HD, 3V CAD s/p Stent to LCX, with resolved chest pain, on heparin drip. He was taken to the operating room on [**2140-6-9**] where he underwent a CABG x 3 and MVRing. He was transferred to the SICU in critical but stable condition. He was extubated and weaned from his vasoactive drips by POD #1. He was followed by renal who continued his hemodialysis.He was transferred to the step down unit by POD #3. He did well postoperatively and was ready for discharge on POD #5. Medications on Admission: Lasix 20 mg QD Diovan 160mg QD Imdur 15mg QD SL nitro 0.4 mg prn Hydralazine 20 mg [**Hospital1 **] Minoxidil 10 mg QD Toprol 200 mg QD Lipitor 80 mg QHS ASA 325 mg QD Allopurinol 100 mg [**Hospital1 **] Prandin 1 mg QD Plavix 75 mg QD Iron 325 mg QD Renagel 800 mg [**Hospital1 **] Epogen with Dialysis Discharge Medications: 1. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 2. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). Disp:*60 Tablet(s)* Refills:*2* 3. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two (2) Capsule, Sustained Release PO Q12H (every 12 hours). Disp:*120 Capsule, Sustained Release(s)* Refills:*2* 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 5. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 6. 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* 7. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* 8. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Location (un) 701**] VNA Discharge Diagnosis: Coronary Artery Disease Mitral Valve Regurgitation Hypertension Diabetes mellitus End stage renal disease on hemodialysis Anemia of Chronic Disease Epistaxis Discharge Condition: Good. Followup Instructions: Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 170**] Follow-up appointment should be in 1 month Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) 177**] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 33330**] Appointment should be in [**6-20**] days Completed by:[**2140-6-15**]

[ "203.01", "274.9", "585.6", "784.7", "403.91", "414.01", "250.00", "424.0", "285.29", "428.0" ]

icd9cm

[ [ [] ] ]

[ "35.33", "39.95", "38.93", "36.15", "39.61", "36.12" ]

icd9pcs

[ [ [] ] ]

5546, 5604

3649, 4160

332, 339

5806, 5813

3255, 3626

5836, 6188

2497, 2711

4515, 5523

5625, 5785

4186, 4492

2726, 3236

282, 294

367, 1687

1709, 2321

2337, 2481

74,376

105,868

9376

Discharge summary

report

Admission Date: [**2162-7-11**] Discharge Date: [**2162-7-16**] Date of Birth: [**2093-4-2**] Sex: F Service: MEDICINE Allergies: Shellfish Attending:[**First Name3 (LF) 1253**] Chief Complaint: Confusion Major Surgical or Invasive Procedure: none History of Present Illness: Ms. [**Known lastname 31853**] is a 69 year old female with past medical history significant for longstanding type II DM, HTN, hypothyroidism, h/o small cell lung cancer (in remission) and PVD who presented to ED with worse confusion from baseline, weakness and new inability to ambulate for "past few days." FSBS's at home 600's despite home insulin which includes 22 Units Lantus and sliding scale. She is followed at [**Last Name (un) **] by Dr. [**First Name8 (NamePattern2) 712**] [**Name (STitle) 713**] for her type II diabetes management. Of significance, patient's daughter states patient has poor compliance with prescribed SSI at home. She also explains that her mother gets very sleepy and more confused when she gets UTIs and she has noticed these symptoms over the past week. Daughter also states her mother is incontinent of urine most of time but has been going more frequently x 1 week. . Of note, patient was recently admitted to the vascular surgical service from [**Date range (1) 32029**] for further assessment of a left heel ulcer and she underwent left lower extremity arteriogram. She was found to have Left stenosis at the aortobifem/CFA anastamosis and left SFA occlusion. No intervention was performed and it was decided to medically manage patient at this juncture. During this admission she also had a UTI recognized and was treated with 5 days of Ciprofloxacin. Urine cultures grew out group B Beta Streptococcus species but no R/S data performed. . . In the ED, initial vs were: T 98.7F, P 80, BP 112/43, RR 18 and O2 saturation was 100% RA. CXR showed no infiltrates or effusions. UA revealed 11-20 wbcs, few bacteria, moderate leukocytes, negative nitrites, >1000 glucose and ketones. Blood cultures and urine cultures sent in ED. EKG showed peaked T waves so she was given 2g calcium gluconate and t-waves were less prominent on telemetry prior to transport per report. While in ED, she was given IV Zofran for mild nausea, 1g IV ceftriaxone for UTI , 10 Units regular insulin followed by placement on an insulin drip for DKA management. Labs notable for an elevated K 6.1, HCO3 17, lactate 2.2 and serum glucose of 701. Cr was 1.4 which is up from usual baseline of .9 range. She had an initial anion gap of 24 which came down to 18 by time of transfer from ED. Also received total of 3L IVFs while in ED. . On arrival to the [**Hospital Unit Name 153**], initial vitals were: T 97.7, HR 90, BP 130/46, RR 17 and O2 sat 95-96% RA. She appeared to be in no apparent distress but very tired. Also was confused and alert and oriented to person only. Per patient's daughter she has progressing dementia and she is near usual baseline with exception of her extreme fatigue. . . Review of systems: - Limited due to patient's dementia. - Denies sore throat, cough, diarrhea, abd pains, dysuria, headaches and photophobia. Refused to cooperate with rest of ROS. . Past Medical History: 1. Insulin dependent Diabetes type 2 (for past 30 years) 2. Hypertension. 3. Hypothyroidism. 4. Hyperlipidemia. 5. Osteoporosis. 6. Pyelonephritis. 7. Status post hip replacement. 8. PVD s/p Fem-[**Doctor Last Name **] bypass. 9. Bilateral cataract surgery. 10. Hand surgery for carpal tunnel. 11. Lumpectomy. 12. Lung Cancer: Small cell lung cancer, limited stage, s/p etoposide/carboplatin, XRT completed [**6-/2159**] 13. s/p left femur fracture PSH: Status post hip replacement, s/p aorto-bifem bypass, Bilateral cataract surgery, Hand surgery for carpal tunnel, Lumpectomy. 12. Lung Cancer: Small cell lung cancer, limited stage, s/p etoposide/carboplatin, XRT completed [**6-/2159**] Social History: Social History: Patient lives alone in [**Location (un) 2312**]. She previously worked as a typist but is now retired. She has 3 children, one son died 2 [**Name2 (NI) 1686**] ago and he had been her primary caretaker in past. Now her daughter [**Name (NI) 32030**] helps a few times a week with shoppping and cooking and ADLs. [**Name (NI) **] sisters live nearby and also help. She does not have home VNA now. She currently smokes 1ppd x 45 years, but no current EtOH use or illicits. She walks with walker at baseline and is incontinent of urine and sometimes stool per daughter. Family History: Emphysema in her father. Mother had head and neck cancer. Physical Exam: Admission physical: Physical Exam: Vitals: T 97.7, HR 90, BP 130/46, RR 17 and O2 sat 95-96% RA. General: Alert and oriented x1, no acute distress, very tired appearing with pallid complexion HEENT: PERRLA EOMI. Anicteric sclerae. Very dry MM, oropharynx clear but poor dentition noted. Neck: supple, JVP at 5-6cm , no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: vertical well healed scar at midline, soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: foley in place Ext: warm, 1+ PT pulses and 2+ DP pulses bilaterally, no clubbing or overt cyanosis but [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 32031**] below the ankles. Small left heel ulcer with depth of about 5-7mm and diameter of 2cm, no bleeding/scabs or discharge expressed, appears clean. Neuro: exam limited due to AMS, but CNs [**2-5**] in tact and sensation to light touch in tact over face and upper extremities, unable to cooperate with motor testing . . Discharge VS: 97 178/85 (prior to Rx); 109-178/56-85 82 18 100RA GEN: non-toxic, awake interactive. RESP: CTA B CV: RRR. No mrg. ABD: Benign. Neuro: A+O x 2; self/location. No focal defecits. Pertinent Results: Admission labs: [**2162-7-10**] 10:50PM GLUCOSE-701* UREA N-39* CREAT-1.4* SODIUM-118* POTASSIUM-6.1* CHLORIDE-77* TOTAL CO2-17* ANION GAP-30* [**2162-7-10**] 11:14PM LACTATE-2.2* [**2162-7-10**] 11:14PM TYPE-[**Last Name (un) **] PO2-63* PCO2-36 PH-7.30* TOTAL CO2-18* BASE XS--7 COMMENTS-GREEN TOP . [**2162-7-10**] 10:50PM WBC-8.3# RBC-3.86* HGB-11.9* HCT-35.9* MCV-93 MCH-31.0 MCHC-33.2 RDW-14.4 [**2162-7-10**] 10:50PM NEUTS-82.1* LYMPHS-15.1* MONOS-2.3 EOS-0.3 BASOS-0.3 [**2162-7-10**] 10:50PM PLT COUNT-297 [**2162-7-11**] 12:50AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-1000 KETONE-50 BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-MOD [**2162-7-11**] 12:50AM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.020 . Most recent labs: [**2162-7-14**] 07:15AM BLOOD WBC-3.0* RBC-3.20* Hgb-9.8* Hct-29.3* MCV-92 MCH-30.6 MCHC-33.4 RDW-14.5 Plt Ct-253 [**2162-7-14**] 07:15AM BLOOD Glucose-114* UreaN-11 Creat-0.8 Na-134 K-4.3 Cl-96 HCO3-32 AnGap-10 [**2162-7-14**] 07:15AM BLOOD Calcium-8.5 Phos-3.4 Mg-1.7 . [**2162-7-12**] 04:13AM BLOOD %HbA1c-10.2* eAG-246* [**2162-7-12**] 04:13AM BLOOD TSH-4.1 . Urine CX [**7-10**]: [**2162-7-11**] URINE CULTURE (Final [**2162-7-13**]): LACTOBACILLUS SPECIES. >100,000 ORGANISMS/ML.. . CXR [**2162-7-10**]: No acute process. . Pending: [**7-10**], [**7-11**] Blood cultures: no growth to date; pending Brief Hospital Course: 69 year old female with past medical history significant for longstanding type II DM, HTN, hypothyroidism, h/o small cell lung cancer (in remission) and PVD who presented to ED with worse confusion from baseline, weakness and new inability to ambulate for "past few days." Pt was found to have HONC with hyperglycemia to 700's, and ititially managed in the ICU. . . #Hyperosmolar Non-Ketotic Coma: Patient with long history of type II diabetes on home Lantus and sliding scale insulin. She states she complies with home medication, although the reliability of this has been questioned. She was admitted to the ICU and treated with IV fluids, insulin drip and consulted by the [**Last Name (un) **]. Presumed cause of HONK was UTI (although recently treated with 5 days of cipro) and possible poor compliance with A1C of 10%. [**Last Name (un) **] continued Lantus 20 units, and prandial coverage doses were titrated. Please see insulin sliding scale from discharge below: . Breakfast Glargine 20 Units Insulin SC Sliding Scale Breakfast Lunch Dinner Bedtime Humalog Humalog Humalog Humalog Glucose Insulin Dose Insulin Dose Insulin Dose Insulin Dose 0-70 Proceed with hypoglycemia protocol 71-90 0 Units 0 Units 0 Units 0 Units 91-150 4 Units 2 Units 2 Units 0 Units 151-200 6 Units 4 Units 4 Units 0 Units 201-250 8 Units 6 Units 6 Units 2 Units 251-300 10 Units 8 Units 8 Units 3 Units 301-350 12 Units 10 Units 10 Units 4 Units 351-400 14 Units 12 Units 12 Units 5 Units > 400 mg/dL Notify M.D. . #Urinary Tract Infection: Patients UTI dates back to her last admission 1.5 weeks ago when she was noted to have group B Beta Streptococcus species >100k colonies. On admission, she was afebrile with no leukocytosis but UA with evidence of persistent infection. She is s/p 5 days of Cipro completed on [**7-5**]. Urine culture grew out lactobacillus, > 100K. - continue ampicillin for 10 day course. Complete [**2162-7-22**]. . #Acute renal failure: Baseline Cr is .9 and now up to 1.2-1.4 range in setting of polyuria and DKA. Acute renal failure was attributed to dehydration. Returned to baseline with hydration. . #Hyponatremia: She was admitted with hyponatremia, with combination of pseudohyponatremia from hyperglycemia, but with persistent hyponatremia after correction. Hyponatremia was initially attributed to dehydration and hypovolemic state. Hyponatremia resolved with glucose control and IV hydration. . # Acute encephalopathy in setting of chronic Alzheimer's dementia. She was admitted with acute delirium in the setting of hyperglycemia and UTI. She improved but remains with baseline dementia. - resolved to baseline with treatment of UTI and glucose control . #Hypertension: She was normotensive on admission, and captopril was held due to hyperkalemia on admission. Her blood pressure gradually increased with hydration, and captopril was restarted on [**7-13**]. - contin Captopril at increased dose 37.5 mg TID, Metoprolol 50 mg po bid . #Hypothyroidism: TSH within normal limits at 4.1. -continue home 100mcg daily levothyroxine therapy . #Heel Ulcer / PVD: She had recent admission for left heel ulcer, with workup that revealed stenosis at the aortobifem/CFA anastamosis and left SFA occlusion. Medical management was pursued. After admission on this occasion, she was seen by the wound service, who recommended wound care. There was no evidence of infection. --continue [**Hospital1 **] wound dressings . #hyperlipidemia: -continue daily aspirin 325mg -continue daily atorvastatin therapy . #GERD: --continue home omeprazole therapy --Misoprostol 200 mcg PO QID . # FEN: diabetic diet # Prophylaxis: Subcutaneous heparin # Communication: Patient & daughter (HCP) [**Name (NI) 32030**] [**Name (NI) **] at #[**Telephone/Fax (1) 32032**] # Code: DNR/DNI, confirmed with HCP . # Disposition: To [**Location (un) 582**] [**Location (un) 583**] today Medications on Admission: Home medications: Aspirin 325 mg Daily Atorvastatin 20 mg Daily Becaplermin 0.01 % Gel: Apply to left heel ulcer at bedtime. Captopril 25 mg PO TID Fludrocortisone 0.1 mg daily Levothyroxine 100 mcg daily Misoprostol 200 mcg PO QID Omeprazole 40 mg once a day. Metoprolol Tartrate 50 mg PO BID Metoclopramide 10 mg PO QID Insulin Glargine - 22 Units SC daily Fosamax 70 mg PO once a week. Oxycodone 5 mg PO once a day in P.M. as needed for pain Acetaminophen 325 mg, 1-2 Tablets PO q6hrs PRN Multivitamin supplement Senna tablet PRN constipation . Medications at transfer: Ampicillin 500 mg po q6 hours Aspirin 325 mg Daily Atorvastatin 20 mg Daily Becaplermin 0.01 % Gel: Apply to left heel ulcer at bedtime. Captopril 25 mg PO TID Fludrocortisone 0.1 mg daily Levothyroxine 100 mcg daily Misoprostol 200 mcg PO QID Omeprazole 40 mg once a day. Metoprolol Tartrate 50 mg PO BID Metoclopramide 10 mg PO QID Insulin Glargine - 20 Units SC daily (decreased from 22 units daily) and sliding scale Fosamax 70 mg PO once a week. Acetaminophen 325 mg, 1-2 Tablets PO q6hrs PRN Multivitamin supplement Senna tablet PRN constipation Discharge Medications: 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day. 3. Becaplermin 0.01 % Gel Sig: One (1) Appl Topical DAILY (Daily) as needed for lle ulcer . 4. Captopril 12.5 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day). 5. Fludrocortisone 0.1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Misoprostol 100 mcg Tablet Sig: Two (2) Tablet PO QIDPCHS (4 times a day (after meals and at bedtime)). 8. Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 9. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 10. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QIDACHS (4 times a day (before meals and at bedtime)). 11. Fosamax 70 mg Tablet Sig: One (1) Tablet PO once a week. 12. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain . 13. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. 14. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation . 15. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 16. Ampicillin 250 mg Capsule Sig: Two (2) Capsule PO Q6H (every 6 hours) for 6 days. 17. Insulin Glargine 100 unit/mL Solution Sig: Twenty (20) units Subcutaneous Q Breakfast. 18. Humalog 100 unit/mL Solution Sig: as per sliding scale provided units Subcutaneous QACHS. Discharge Disposition: Extended Care Facility: [**Location (un) 582**] of [**Location (un) 583**] Discharge Diagnosis: # Hyperosmolar non-ketotic coma; with confusion and glucose >700 # Urinary tract infection # Acute renal failure # Hyponatremia # Acute encephalopathy # Alzheimer's dementia # Hypertension # PVD, heel ulcer # GERD Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: You were admitted with confusion and extremely elevated blood sugar levels. You were initially managed in the ICU. You were also found to have a urinary tract infection, and were treated with antibiotics for this. Please complete your course of antibiotics as prescribed, and take your insulin as prescribed. You will need to follow up with your endocrinologist as an outpatient. Followup Instructions: Department: GERONTOLOGY When: MONDAY [**2162-7-19**] at 11:30 AM With: [**Name6 (MD) **] [**Last Name (NamePattern4) 13171**], MD [**Telephone/Fax (1) 719**] Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage Department: RADIOLOGY When: THURSDAY [**2162-7-22**] at 11:30 AM With: CAT SCAN [**Telephone/Fax (1) 327**] Building: Ra [**Hospital Unit Name 1825**] ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) **] Campus: EAST Best Parking: Main Garage Department: HEMATOLOGY/ONCOLOGY When: THURSDAY [**2162-7-29**] at 11:30 AM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 593**], MD [**0-0-**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage

[ "530.81", "707.23", "294.10", "584.9", "733.00", "250.22", "244.9", "331.0", "276.1", "348.30", "707.07", "V43.64", "V10.11", "401.9", "599.0" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

14119, 14196

7346, 11381

279, 286

14454, 14454

5937, 5937

15042, 15963

4544, 4604

12558, 14096

14217, 14433

11407, 11407

14636, 15019

4654, 5918

11425, 12535

3045, 3211

230, 241

314, 3026

5953, 7323

14469, 14612

3233, 3926

3959, 4528

61,739

131,681

38885+58243

Discharge summary

report+addendum

Admission Date: [**2180-3-14**] Discharge Date: [**2180-3-22**] Date of Birth: [**2101-5-30**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1505**] Chief Complaint: coronary artery disease Major Surgical or Invasive Procedure: coronary artery bypass grafts x3(LIMA-LAD, SVG-diag,svg-OM),repair diapragmatic hernia with core matrix patch [**2180-3-17**] History of Present Illness: This 78 year old white male with a history of hypertension is status post permanent pacemaker for symptomatic bradycardia 1-1/2 years ago. On [**3-11**] he developed retrosternal chest pain, which was waxing and [**Doctor Last Name 688**] and finally crescendoed 2 days later. He was admitted to an outside hospital with a STEMI and underwent further cardiac cath. A 600 mg Plavix bolus was given. Catheterization revealed 100% RCA occlusion, 60-70% LM, 90% LAD lesion, and 90% Circumflex with LVEF 45%. Stenting was performed and 2 bare metal stents were placed in the RCA. Mr.[**Known lastname 86296**] was transferred to [**Hospital1 18**] for evaluation for coronary revascularization. Past Medical History: hypertension s/p permanent pacemaker anxiety/depression s/p prostatectomy Social History: Race: Last Dental Exam:*full upper dentures/partial lower Lives with:his wife Occupation:retired Tobacco: one pack per week for 20 years, quit age 40 ETOH:occasional Family History: noncontributory Physical Exam: Admission: Pulse: 72 Resp: 20 O2 sat: 95%RA B/P Right: 126/72 Left: Height:5'7" Weight:90 Kg General: Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [] Neck: Supple [x] Full ROM [] Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur Abdomen: Soft x[] non-distended [x] non-tender [x] bowel sounds + [x] Extremities: Warm [x], well-perfused [x] Edema Varicosities: (R)LE medial nodule-NT. No varicosities None [] Neuro: Grossly intact Pulses: Femoral Right: Left: DP Right: Left: PT [**Name (NI) 167**]: Left: Radial Right: 2+ Left:2+ Carotid Bruit-no bruits- 2+ Right: 2+ Left: Pertinent Results: [**2180-3-20**] 05:10AM BLOOD WBC-14.4* RBC-3.52* Hgb-10.8* Hct-31.3* MCV-89 MCH-30.6 MCHC-34.3 RDW-13.5 Plt Ct-219 [**2180-3-14**] 04:05PM BLOOD Glucose-194* UreaN-20 Creat-1.0 Na-138 K-3.8 Cl-100 HCO3-30 AnGap-12 [**2180-3-20**] 05:10AM BLOOD Glucose-166* UreaN-33* Creat-1.1 Na-136 K-4.5 Cl-101 HCO3-30 AnGap-10 [**2180-3-22**] 06:20AM BLOOD WBC-9.9 RBC-3.26* Hgb-10.0* Hct-29.5* MCV-91 MCH-30.9 MCHC-34.0 RDW-13.5 Plt Ct-300 [**2180-3-22**] 06:20AM BLOOD PT-26.6* INR(PT)-2.6* [**2180-3-22**] 06:20AM BLOOD Glucose-128* UreaN-28* Creat-1.0 Na-140 K-4.3 Cl-102 HCO3-28 AnGap-14 [**Hospital1 18**] ECHOCARDIOGRAPHY REPORT [**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 86297**] (Complete) Done [**2180-3-17**] at 11:03:35 AM FINAL Referring Physician [**Name9 (PRE) **] Information [**Name9 (PRE) **], [**First Name3 (LF) **] R. [**Hospital1 18**], Division of Cardiothorac [**Hospital Unit Name 4081**] [**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2101-5-30**] Age (years): 78 M Hgt (in): 67 BP (mm Hg): 123/67 Wgt (lb): 180 HR (bpm): 70 BSA (m2): 1.94 m2 Indication: Intraoperative TEE for CABG. Aortic valve disease. Chest pain. Coronary artery disease. Left ventricular function. Mitral valve disease. Myocardial infarction. Preoperative assessment. Right ventricular function. ICD-9 Codes: 786.51, 424.1, 424.0, 424.2 Test Information Date/Time: [**2180-3-17**] at 11:03 Interpret MD: [**Name6 (MD) 1509**] [**Name8 (MD) 1510**], MD Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 1510**], MD Doppler: Full Doppler and color Doppler Test Location: Anesthesia West OR cardiac Contrast: None Tech Quality: Adequate Tape #: 2010AW2-: Machine: [**Doctor Last Name **] Echocardiographic Measurements Results Measurements Normal Range Left Ventricle - Septal Wall Thickness: *1.3 cm 0.6 - 1.1 cm Left Ventricle - Ejection Fraction: 35% >= 55% Aorta - Annulus: 2.2 cm <= 3.0 cm Aorta - Ascending: *3.5 cm <= 3.4 cm Findings RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is seen in the RA and extending into the RV. No ASD by 2D or color Doppler. LEFT VENTRICLE: Moderate regional LV systolic dysfunction. Moderately depressed LVEF. RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Normal aortic diameter at the sinus level. Normal ascending aorta diameter. Normal descending aorta diameter. Simple atheroma in descending aorta. AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. Mild to moderate ([**12-18**]+) AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild to moderate ([**12-18**]+) MR. TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. 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. REGIONAL LEFT VENTRICULAR WALL MOTION: N = Normal, H = Hypokinetic, A = Akinetic, D = Dyskinetic Conclusions Prebypass No atrial septal defect is seen by 2D or color Doppler. There is moderate regional left ventricular systolic dysfunction with hypokinesia of the apex, apical and midportions of the anterior septum and inferior wall.. Overall left ventricular systolic function is moderately depressed (LVEF= 35 %). Right ventricular chamber size and free wall motion are normal. There are simple atheroma in the descending thoracic aorta. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Mild to moderate ([**12-18**]+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild to moderate ([**12-18**]+) mitral regurgitation is seen. There is no pericardial effusion. Dr. [**Last Name (STitle) **] was notified in person of the results on [**2180-3-17**] at 1045am. Post bypass Patient is receiving epinephrine and phenylephrine infusions. LVEF= 35% . Mild mitral regurgitation persists. Aorta is intact post decannulation. I certify that I was present for this procedure in compliance with HCFA regulations. Electronically signed by [**Name6 (MD) 1509**] [**Name8 (MD) 1510**], MD, Interpreting physician [**Last Name (NamePattern4) **] [**2180-3-17**] 17:16 ?????? [**2172**] CareGroup IS. All rights reserved. Brief Hospital Course: Following admission the usual preoperative workup was undertaken. On [**3-17**] he was taken to the Operating Room where coronary revascularization was performed. A diaphragmatic hernia was found at surgery with dense adhesions to the left ventricle. After dissection of the adhesions and control of surface bleeding, the defect was closed using core matrix patch. See operative note for details. He weaned from bypas on Propofol, Epinephrine and Neo Synephrine infusions. Amiodarone was given for perioperative ventricular ectopy. He tolerated the procedure well and transferred intubated and sedated in critical but stable condition to the CVICU. EP was consulted for PPM interrogation and perioperative ectopy/arrythmias. Mr.[**Known lastname 86296**] [**Last Name (Titles) **]e neurologically intact and on POD# 1 he was extubated without difficulty. Pressors were weaned off. All lines and drains were discontinued in a timely fashion. Anticoagulation was intitiated for postoperative atrial fibrillation. Beta blockade and diuresis was initiated. EP reprogrammed the pacemaker to a slower rate as well as decreased the pacing output on his PPM. The temporary pacing wires were then removed. POD#2 he was transferred to the step down unit for further monitoring. Physical therapy was consulted for evaluation of strength and mobility. He continued to progress. Post-pull chest tube CXRs showed persistent right pneumothorax without signs or symptoms of respiratory comprimise. On POD# 5 Dr.[**Last Name (STitle) **] cleared Mr.[**Known lastname 86296**] for discharge to rehab. All follow up appointments were advised. Medications on Admission: Amlodipine 10mg daily Trazodone 100mg HS prn sleep Paroxetine 20mg daily Discharge Medications: 1. Aspirin 81 mg [**Known lastname 8426**], Delayed Release (E.C.) Sig: One (1) [**Known lastname 8426**], Delayed Release (E.C.) PO DAILY (Daily). 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. Acetaminophen 325 mg [**Known lastname 8426**] Sig: Two (2) [**Known lastname 8426**] PO Q4H (every 4 hours) as needed for pain. 4. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) as needed for constipation. 5. Atorvastatin 80 mg [**Known lastname 8426**] Sig: One (1) [**Known lastname 8426**] PO DAILY (Daily). 6. Metformin 500 mg [**Known lastname 8426**] Sig: One (1) [**Known lastname 8426**] PO BID (2 times a day). 7. Tramadol 50 mg [**Known lastname 8426**] Sig: One (1) [**Known lastname 8426**] PO Q4H (every 4 hours) as needed for pain for 4 weeks. 8. Clopidogrel 75 mg [**Known lastname 8426**] Sig: One (1) [**Known lastname 8426**] PO DAILY (Daily). 9. Paroxetine HCl 20 mg [**Known lastname 8426**] Sig: One (1) [**Known lastname 8426**] PO DAILY (Daily). 10. Trazodone 50 mg [**Known lastname 8426**] Sig: Two (2) [**Known lastname 8426**] PO HS (at bedtime) as needed for sleep. 11. Metoprolol Tartrate 100 mg [**Known lastname 8426**] Sig: One (1) [**Known lastname 8426**] PO twice a day. 12. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12 hours). 13. Amlodipine 5 mg [**Known lastname 8426**] Sig: Two (2) [**Known lastname 8426**] PO DAILY (Daily). [**Known lastname 8426**](s) 14. Warfarin 1 mg [**Known lastname 8426**] Sig: [**Name8 (MD) **] MD [**First Name (Titles) 8426**] [**Last Name (Titles) **] Once Daily at 4 PM: INR goal >2.0 FOR Atrial Fibrillation. 15. Warfarin 5 mg [**Last Name (Titles) 8426**] Sig: One (1) [**Last Name (Titles) 8426**] PO ONCE (Once) for 1 doses. 16. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q2H (every 2 hours) as needed for wheezing. Discharge Disposition: Extended Care Facility: [**Location (un) 582**] - [**Location (un) 7658**] Discharge Diagnosis: coronary artery disease s/p coronary artery bypass grafts permanent pacemeker depression/anxiety s/p coronary stents diapragmatic hernia hypertension noninsulin dependent diabetes Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. pain well controlled on Ultram 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**] Followup Instructions: Please call to schedule appointments Surgeon: Dr. [**Last Name (STitle) **] on [**2180-4-20**] at 1PM ([**Telephone/Fax (1) 170**]) Primary Care: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] ([**Telephone/Fax (1) 63259**]) in [**12-18**] weeks Cardiologist: Dr. [**Last Name (STitle) 67060**] in [**12-18**] weeks Completed by:[**2180-3-22**] Name: [**Known lastname 13661**],[**Known firstname **] R Unit No: [**Numeric Identifier 13662**] Admission Date: [**2180-3-14**] Discharge Date: [**2180-3-22**] Date of Birth: [**2101-5-30**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 741**] Addendum: Follow up right pneumothorax: PA and lateral CXR done prior to discharge showed the right pneumothorax to be stable. Dr[**Last Name (STitle) **] administrative assistant scheduled a follow up CXR prior to the 1pm clinic appointment on [**4-20**]. Mr.[**Known lastname **] was advised to have this done prior to his clinic appointment. Discharge Disposition: Extended Care Facility: [**Location (un) 176**] - [**Location (un) 2570**] [**Name6 (MD) **] [**Name8 (MD) 747**] MD [**MD Number(2) 748**] Completed by:[**2180-3-22**]

[ "V15.82", "300.4", "E878.2", "401.9", "997.1", "568.0", "410.41", "E929.0", "427.31", "552.3", "V45.82", "250.00", "427.1", "600.00", "512.8", "V45.01", "414.01" ]

icd9cm

[ [ [] ] ]

[ "53.84", "36.15", "36.12", "39.61", "54.59" ]

icd9pcs

[ [ [] ] ]

12671, 12871

6793, 8420

345, 473

10850, 10850

2198, 5372

11549, 12648

1489, 1506

8544, 10526

10647, 10829

8446, 8521

11032, 11526

5421, 6770

1521, 2179

282, 307

501, 1193

10865, 11008

1215, 1290

1306, 1473

20,760

133,786

51149

Discharge summary

report

Admission Date: [**2162-7-26**] Discharge Date: [**2162-8-3**] Service: VASCULAR SURGERY HISTORY OF PRESENT ILLNESS: The patient is an 89 year-old male without significant past medical history who presented with a right leg pain for approximately two days. The patient's wife actually noticed that his right leg was noticeably colder then his left leg. However, the patient could not communicate his symptoms appropriately. The patient denied fevers or chills. The patient apparently is able to walk up the stairs and is able to ambulate, though he could not tell how far. Of note, eight years ago the patient was seen at [**Hospital1 69**] for left lower extremity claudication. The angiogram was performed at that time, which showed atherosclerosis in the superficial femoral artery and possible clot. These clots were apparently lysed with Urokinase and the patient did well and regained full function of his left lower extremity. PAST MEDICAL HISTORY: Psoriasis. PAST SURGICAL HISTORY: The patient could not remember. SOCIAL HISTORY: Use of tobacco. ALLERGIES: No known drug allergies. MEDICATIONS: None. PHYSICAL EXAMINATION: Vital signs temperature 95.9. Pulse 75. Blood pressure 140/69. Respiratory rate 18. 100% on room air. The patient appears to be an elderly gentleman in no acute distress. He was oriented times three. HEENT examination was without any abnormalities. Chest examination clear to auscultation bilaterally. Cardiac examination regular rate and rhythm. Normal S1 and S2. Abdomen soft, nontender, nondistended. Extremities cold bilaterally, but right slightly colder then left. Palpable dorsalis pedis pulse, posterior tibial pulse, popliteal and femoral pulses in the left lower extremity. Palpable femoral pulse in the right lower extremity. Dopplerable popliteal pulse in the right lower extremity, which appeared to be biphasic, nondopplerable pulse in the dorsalis pedis and posterior tibial areas in the right lower extremity. LABORATORY: White blood cell count 15.9, hematocrit 39.4, platelets 350. INR 1.3. Glucose 102, urea 32, creatinine 1.0, sodium 147, potassium 4.7, chloride 109. Other tests, an ultrasound of the right lower extremity was performed, which showed no evidence of a deep venous thrombosis. In addition, no blood flow was identified in a right popliteal artery. HOSPITAL COURSE: The patient was admitted to Vascular Surgery for observation and possible intervention. The patient was originally placed on intravenous heparin. His physical examination of the lower extremity did not change overnight. On hospital day two the patient underwent an angiogram of the right lower extremity. The angiogram of the right lower extremity showed complete occlusion of the entire superficial femoral and popliteal arteries as well as occlusion of the proximal anterior tibia and posterior tibia arteries. Reconstitution of the entire peroneal and distal anterior and posterior tibial arteries with patent dorsalis pedis and plantar branches were visualized. In addition, the patient had an ultrasound of the right lower extremity performed, which showed no evidence of deep venous thrombosis. The patient tolerated the angiography procedure well. He was adequately rehydrated and Mucomyst was administered according to protocol. At that point, it was felt that a surgical intervention was needed to revascularize the right lower extremity. On [**2162-7-29**] the patient underwent right common femoral artery-peroneal bypass in the right lower extremity. The patient tolerated the procedure well. His cardiac examinations were negative and his other laboratory studies were stable except for the white blood cell count of 18.8. The patient remained in the PACU overnight after which he was transferred to the Surgical Intensive Care Unit. The patient was transiently placed on Phenylephrine for blood pressure control to maintain graft patency. After the procedure the patient had dopplerable posterior tibial and dorsalis pedis pulses in the right lower extremity. His foot felt warmer. On hospital day six and seven the patient continued to have strong biphasic pulses in the posterior tibial and dorsalis pedis areas of the right lower extremity. The patient's central line was removed. Chest x-ray was within normal limits. The patient was ambulating with assistance. Physical therapy was consulted, which recommended rehabilitation placement. The patient was discharged to the rehabilitation center on [**2162-8-3**] in stable condition. CONDITION ON DISCHARGE: Stable. DISCHARGE DISPOSITION: To a rehabilitation center. DISCHARGE DIAGNOSIS: Partial occlusion of blood supply to the right lower extremity status post right common femoral artery-peroneal bypass. DISCHARGE MEDICATIONS: 1. Aspirin 325 mg po q.d. 2. Heparin subQ 5000 units q 12 hours. 3. Percocet one to two tabs po q 4 to 6 hours prn pain. 4. Protonix 40 mg po q.d. DISCHARGE INSTRUCTIONS: The patient is to see Dr. [**Last Name (STitle) 1476**] his vascular surgeon in about one to two weeks for a follow up. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1477**], M.D. [**MD Number(1) 1478**] Dictated By:[**Last Name (NamePattern1) 45631**] MEDQUIST36 D: [**2162-8-3**] 10:41 T: [**2162-8-3**] 12:55 JOB#: [**Job Number **]

[ "396.3", "V15.82", "458.2", "440.21", "263.9" ]

icd9cm

[ [ [] ] ]

[ "88.48", "39.29" ]

icd9pcs

[ [ [] ] ]

4615, 4644

4810, 4964

4665, 4786

2386, 4557

4989, 5385

1014, 1047

1163, 2368

130, 955

978, 990

1064, 1140

4582, 4591

1,660

136,296

25787

Discharge summary

report

Admission Date: [**2122-6-2**] Discharge Date: [**2122-6-22**] Date of Birth: [**2077-7-4**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2186**] Chief Complaint: shortness of breath Major Surgical or Invasive Procedure: PICC Bronchoscopy Lumbar Puncture x 2 Arterial line Tongue biopsy History of Present Illness: Mr. [**Known lastname 64232**] is a 44 year old man with no significant past medical history who presents as a transfer from [**Hospital **] Clinic with hypoxia. Patient reports a dry cough for the past two weeks. He was treated with a five day course of zithromax which he completed [**5-25**]. Three days prior to admission he began to experience dyspnea on exertion. He also had increasing cough with exertion. He developed fevers to 104. Two days prior to admission he began to have sweats. He had one episdoe of chest pain in the center of his chest which has since resolved. His shortness of breath has been increasing. He has no PCP. [**Name10 (NameIs) **] presented to episodic clinic today with shortness of breath. In clinic his oxygen saturation was 85-87% on RA and 90% on 4L. A CXR showed diffuse bilateral infiltrates. On review of systems the patient reports loose stools and abdominal discomfort while on Zithromax. He denies rash, hemoptysis, blood in his stool. Denies sick contacts. On arrival to our ED he was noted to have a temperature of 103.7. He was tachycardic with a HR of 124, RR was 26 and his oxygen saturation was 97% on 5 liters. Patient intially admitted to floor but subsequently transferred to [**Hospital Unit Name 153**] for worsening respiratory distress on [**2122-6-4**]. [**Hospital Unit Name 153**] course remarkable for: *Hypoxia/Fever -PCP found on BAL. Several induced sputum cultures were obtained that were negative for PCP and AFB by stain, but the patient was continued on empiric PCP [**Name Initial (PRE) 31304**] (bactrim 400mg IV Q6hrs and prednisone 40mg PO BID). TB was ruled out by three negative sputum AFB stains. No microorganisms were seen, but the samples were contaminated with oral and upper respiratory flora so cultures were not performed. He was started on ceftriaxone and azithromycin for CAP coverage; ceftriaxone was discontinued as his presentation was more severe than expected for CAP, but azithromycin was continued for atypical coverage. Liposomal amphotericin was added on [**2122-6-6**] when blood cultures began to grow yeast. BAL on [**2122-6-8**] was positive for PCP. [**Name10 (NameIs) **] patient's respiratory status stabilized and improved throughout his stay in the [**Hospital Unit Name 153**]. *Transaminitis - The patient had elevated transaminases found upon adission to [**Hospital Unit Name 153**]. No previous values were available for comparison. Hepatitis serologies were sent and HAV Ab and HepB core Ab were positive. He is HCV Ab negative. His AST, ALT, and total bili all trended downward during his admission, but his alk phos remained somewhat elevated. *Cryptococcemia - The patient had two blood cultures on admission which grew cryptococcus. He was started on liposomal amphotericin on [**2122-6-6**] and flucytasine on [**2122-6-8**]. The patient was asymptomatic, but an LP was performed to r/o cryptococcal meningitis. An LP was performed prior to transfer to the floor and showed 0 WBC, 2 RBC, 28 protein, and 63 glucose. 7P/80L/13M. + yeast. Gram stain of CSF showed no polys, no microorganisms. *?HIV - The patient is at high risk for HIV given his multiple risk factors, and current presentation with an opportuninstic infection. HIV viral load was >100,000 and CD4 was 27. HIV Ab is still pending, but the patient is aware that he is likely HIV positive. His CMV PCR was also detectable, at <600 copies. Ophthamology consulted on this patient while admitted and did a full ocular exam which was within normal limits, with no evidence of fungal endophthalmitis or CMV retinitis. They recommended dilated retinal exams q1-2 mo for CMV retinitis if he is HIV+ and CD4 <50. *Increased creatinine - [**Month (only) 116**] be at risk for acute renal failure while on flucytasine. Cr was 0.8 on [**2122-6-8**] and jumped to 1.3 on [**2122-6-9**]. The only change in medication was the addition of flucytasine. UA and urine cx was resent on [**6-9**], as well as urine electrolytes, to check for prerenal or ATN as possible etiologies of his increased creatinine. These studies are still pending *Oral thrush - The patient had oral thrush on admission. He was started on fluconazole, but that was discontinued once liposomal amphotericin was started on [**2122-6-6**]. It was also noted that he had an approximately 1.5cm lesion on the right lateral aspect of his tongue which was [**Location (un) 2452**] in color, circular, and still had the normal papilla over it. Derm was consulted and was unsure what the lesion was, but felt that it needed to be biopsied. Recommend contacting ENT for bx of tongue lesion *h/o diarrhea- The patient reported having loose stools over the months prior to admission, but while in the [**Hospital Unit Name 153**], this seemed to resolve. Stool cultures were negative for cryptosporidium, salmonella, shigella, O+P, and giardia. C. diff toxin was negative. *Anemia - The patient has anemia of chronic disease based on iron studies, but his baseline Hct is unknown. It was stable throughout his admission with a Hct between 30 and 36. Upon arrival to the floor, patient denies any fevers or chills. He denies any HA or blurry vision. He denies any N/V/D. Tolerating full diet. No CP, cough or SOB in bed. He gets mildly SOB while walking to the bathroom. No abdominal pain. He denies any hematuria, dysuria or change in frequency. Nl BM yesterday, no blood. No numbness or tingling in his extremities. He states his fatigue is improved but not quite baseline. Past Medical History: Bronchitis 6 years ago Tonsillectomy Social History: Patient was born in [**Country 25091**]. He does not smoke but has been exposed to second hand smoke. He has never used IV drugs. He does occasionally use cocaine. He has sex with men. He has not been sexually active in the last year. He had a negative HIV test 5 years ago. He has "mostly" had protected sex since then. He works as a legal translator. He did work in jails five years ago. He has never had a blood transfusion or a tattoo. He lives with a roomate who has not been sick. He does not live with birds. He has cats. Family History: Mother has pre diabetes. Father is well. Grandmother had stomach cancer. Physical Exam: HR 90 BP 109/56 97% on 15L nonreb, RR 19 Gen: pleasant, breathing with 80% Nonrebreather, NAD. taking in full sentences. Fatigued and diaphoretic but comfortable. Able to talk in complete sentances on 6 L of oxygen. HEENT: PERRL, EOMI, sclera anicteric. Unable to appreciate any residual thrush. He has nontender, non-erythematous lesion on the dorsum of his tongue. Neck: No cervical or supraclavicular lad. Lungs: CTA bilaterally, no W/R/R CV: regularRR with no MRG Abd: soft, NT, ND active bowel sounds, no HSM. Ext: no clubbing, cyanosis or edema, no calf pain, +1 DP. No inguinal lymphadenopathy appreciated. Pertinent Results: Lactate:2.0 134 | 98| 7/ 105 AGap=18 4.3 | 22| 0.5\ MCV 84 7.1\13.0/618 /35.9\ N:86.8 L:7.9 M:4.1 E:1.0 Bas:0.1 Poiklo: 1+ CXR: Diffuse bilateral infiltrate R>L. [**2122-6-2**] 04:20PM BLOOD WBC-6.3 RBC-3.91* Hgb-11.4* Hct-33.6* MCV-86 MCH-29.2 MCHC-34.0 RDW-11.8 Plt Ct-675* [**2122-6-3**] 06:25AM BLOOD WBC-14.5*# RBC-4.23* Hgb-12.6* Hct-36.1* MCV-85 MCH-29.8 MCHC-35.0 RDW-11.9 Plt Ct-798* [**2122-6-8**] 07:23AM BLOOD WBC-11.4* RBC-4.24* Hgb-12.2* Hct-35.1* MCV-83 MCH-28.9 MCHC-34.9 RDW-12.5 Plt Ct-624* [**2122-6-22**] 04:17AM BLOOD WBC-5.7 RBC-3.28* Hgb-9.8* Hct-27.8* MCV-85 MCH-29.8 MCHC-35.2* RDW-14.2 Plt Ct-154 [**2122-6-1**] 10:00PM BLOOD Neuts-86.8* Lymphs-7.9* Monos-4.1 Eos-1.0 Baso-0.1 [**2122-6-8**] 07:23AM BLOOD Neuts-90* Bands-2 Lymphs-4* Monos-4 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 [**2122-6-3**] 06:25AM BLOOD WBC-14.5* Lymph-6* Abs [**Last Name (un) **]-870 CD3%-89 Abs CD3-774 CD4%-3 Abs CD4-27* CD8%-85 Abs CD8-736* CD4/CD8-0.0* [**2122-6-17**] 07:30AM BLOOD QG6PD-8.5 [**2122-6-9**] 07:45AM BLOOD Ret Aut-3.0 [**2122-6-3**] 06:25AM BLOOD Ret Aut-0.6* [**2122-6-5**] 04:51AM BLOOD Glucose-111* UreaN-10 Creat-0.6 Na-134 K-5.1 Cl-100 HCO3-23 AnGap-16 [**2122-6-7**] 05:09AM BLOOD Glucose-126* UreaN-11 Creat-0.6 Na-133 K-5.3* Cl-98 HCO3-22 AnGap-18 [**2122-6-20**] 04:30AM BLOOD Glucose-85 UreaN-18 Creat-1.3* Na-137 K-4.5 Cl-108 HCO3-22 AnGap-12 [**2122-6-22**] 04:17AM BLOOD Glucose-93 UreaN-23* Creat-1.1 Na-140 K-4.0 Cl-107 HCO3-22 AnGap-15 [**2122-6-17**] 07:30AM BLOOD Glucose-89 UreaN-27* Creat-1.7* Na-133 K-4.5 Cl-99 HCO3-23 AnGap-16 [**2122-6-10**] 08:05AM BLOOD Glucose-83 UreaN-26* Creat-1.9* Na-132* K-4.8 Cl-95* HCO3-26 AnGap-16 [**2122-6-3**] 12:59PM BLOOD ALT-317* AST-341* LD(LDH)-823* AlkPhos-263* Amylase-68 TotBili-0.5 [**2122-6-8**] 07:23AM BLOOD ALT-231* AST-82* LD(LDH)-319* AlkPhos-255* Amylase-96 TotBili-0.2 [**2122-6-21**] 04:40AM BLOOD ALT-28 AST-24 AlkPhos-95 TotBili-0.3 [**2122-6-3**] 12:59PM BLOOD Lipase-29 [**2122-6-8**] 07:23AM BLOOD Lipase-68* [**2122-6-2**] 04:20PM BLOOD cTropnT-<0.01 [**2122-6-19**] 05:08AM BLOOD Calcium-8.7 Phos-5.7* Mg-1.7 [**2122-6-22**] 04:17AM BLOOD Calcium-8.3* Phos-6.6* Mg-1.4* [**2122-6-3**] 12:59PM BLOOD calTIBC-179* VitB12-395 Folate-10.6 Ferritn-GREATER TH TRF-138* [**2122-6-2**] 04:20PM BLOOD Triglyc-183* HDL-18 CHOL/HD-6.9 LDLcalc-70 [**2122-6-5**] 04:51AM BLOOD IgM HAV-NEGATIVE [**2122-6-3**] 12:59PM BLOOD HAV Ab-POSITIVE [**2122-6-2**] 04:20PM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE HBcAb-POSITIVE [**2122-6-3**] 03:36PM BLOOD HIV Ab-POSITIVE [**2122-6-2**] 04:20PM BLOOD HCV Ab-NEGATIVE . . [**2122-6-9**] 03:36PM CEREBROSPINAL FLUID (CSF) WBC-0 RBC-2* Polys-7 Lymphs-80 Monos-13 Other-0 [**2122-6-12**] 10:17AM CEREBROSPINAL FLUID (CSF) WBC-2 RBC-19* Polys-0 Lymphs-0 Monos-0 [**2122-6-12**] 10:17AM CEREBROSPINAL FLUID (CSF) WBC-1 RBC-11* Polys-0 Lymphs-0 Monos-100 Other-0 [**2122-6-9**] 03:36PM CEREBROSPINAL FLUID (CSF) TotProt-28 Glucose-63 [**2122-6-12**] 10:17AM CEREBROSPINAL FLUID (CSF) TotProt-18 Glucose-56 . . Pleural fluid: [**2122-6-8**] 01:42PM OTHER BODY FLUID WBC-0 RBC-0 Polys-8* Lymphs-4* Monos-72* Mesothe-4* Macro-12* . Cx: [**6-1**]: Blood: Cryptococcus Neoformans HIV load 1 mln. [**6-6**] Sputum: [**Doctor First Name **] [**6-7**] [**Doctor Last Name **] Crypto Ag in Blood: 1:>64 [**6-9**] BAL: CMV like virus Cryptococcus 2 morphologies PCP [**6-10**] CSF Crypto Ag : 1:256 [**6-10**] Tongue Swab: HSV 1 [**6-16**] CSF crypto + [**6-21**] HCV/HBV viral load undetectable. [**6-21**]: blood Crypto Ag: 1:1024 <- 1:4096 [**6-7**] Brief Hospital Course: A/P: 44M with no significant PMH, presenting with progressive hypoxia and dysnpea. Bilateral pulmonary infiltrates present on CXR. On empiric treatment for PCP pneumonia and bacterial pneumonia, he was transferred to [**Hospital Unit Name 153**] on [**6-3**] for closer monitoring due to severe hypoxia and respiratory distress. Transfered back to the floor on [**2122-6-9**]. 1. Hypoxia/PCP/Cryptococcal pneumonia - Patient presented with progressive dyspnea, bilateral pulmonary infiltrates on CXR, fevers, and significant hypoxia (sats dropped to 88% on 4L and only 93-96% on a NRB) and A-a gradient on ABG (7.49/31/76). With multiple HIV risk factors and clinical symptoms, his presentation was highly suspicious for PCP [**Name Initial (PRE) 1064**]. ID followed him through his admission. Several induced sputum cultures were obtained that were negative for PCP and AFB by stain, but the patient was continued on empiric PCP [**Name Initial (PRE) 31304**] (Bactrim 400mg IV Q6hrs and prednisone 40mg PO BID). TB was ruled out by three negative sputum AFB stains. No microorganisms were seen, but the samples were contaminated with oral and upper respiratory flora so cultures were not performed. He was started on ceftriaxone and azithromycin for CAP coverage; ceftriaxone was discontinued as his presentation was more severe than expected for CAP, but azithromycin was continued for atypical coverage. Liposomal amphotericin was added on [**2122-6-6**] when blood cultures began to grow yeast. BAL on [**2122-6-8**] was positive for PCP. [**Name10 (NameIs) **] patient's respiratory status stabilized and improved throughout his stay in the [**Hospital Unit Name 153**]. He did well post-bronchoscopy and was able to be titrated down to FiO2 of 60% by face mask on transfer to the floor. On the floor patient was continued to be treated for Cryptococcus in his lungs and CSF (Ambisome & Flucytosine) and PCP(Bactrim). He was also continued on Azithromycin for [**Doctor First Name **]. He was also started on steroids for PCP. [**Name10 (NameIs) **] experienced ARF with his medications. Flucytosine was d/c, Bactrim as well and Pentamidine was started. Dapsone couldn't be started [**1-7**] to unknown G6PD status at the time. So patient was started on IV Pentamidine. Pt G6PD was negative. Ambisome was continued with 500 cc IVF bolus around the dose. His oxygen requirement was gradually titrated down. Initially he was quite hypoxic with exertion but with persistent PT, his exercise tolerance increased gradually. Upon d/c he is sating 97-100% on RA, his sats are >95% upon exertion. His Pentamidine was d/c and he is d/c home on PO Atovaquone and Fluconazole. He is to continue Prednisone taper. . 2. Cryptococcemia - The patient had two blood cultures on admission which grew cryptococcus. He was started on liposomal amphotericin on [**2122-6-6**] and flucytosine on [**2122-6-8**]. The patient was asymptomatic, but an LP was performed, showed 0 WBC, 2 RBC, 28 protein, and 63 glucose, and was positive for Cryptococcal antigen. Gram stain of CSF showed no polys, no microorganisms. Pt's flucytosine was d/c [**1-7**] to renal failure. Pt was afebrile throughout his stay, his WBC remained suppressed around 5. His BCx before DC showed a fourfold decrease in his Cryptococcal Ag, and it was felt safe to d/c ambisome and d/c patient on fluconazole PO. He was also continued on steroids. To continue fluconazole and steroid taper as outpatient. . 3. Transaminitis - The patient had elevated transaminases found upon admission to [**Hospital Unit Name 153**]. No previous values were available for comparison. Hepatitis serologies were sent and HAV Ab and HepB core Ab were positive. He is HCV Ab negative. The cause may have been reactivation of Hep B vs medications. With supportive treatment his AST, ALT, and total bili all trended downward and were wnl upon d/c. . 4. HIV - The patient is at high risk for HIV given his multiple risk factors, and current presentation with an opportunistic infection. HIV viral load was >100,000 and CD4 was 27. HIV Ab was also positive. His CMV PCR was also detectable, but at <600 copies, his BAL also showed CMV like virus. Ophthalmology consulted on this patient while admitted and did a full ocular exam which was within normal limits, with no evidence of fungal endophthalmitis or CMV retinitis. They recommended dilated retinal exams q1-2 mo for CMV retinitis if he is HIV+ and CD4 <50. Pt had HSV on his tongue lesion, being continued on prophylactic acyclovir. He is on Azithromycin for [**Doctor First Name **] prophylaxis and + sputum Cx for [**Doctor First Name **] on [**6-6**], although unclear if it is a contaminant. Pt is to take Atovaquone for his PCP [**Name Initial (PRE) 1102**]. Pt is to follow up with [**Hospital 778**] Healthcare center or Dr. [**First Name (STitle) 2505**] in [**Hospital **] clinic where HAART will be initiated. . 5. ARF - Pt developed acute renal failure while on flucytosine and ambisome. Cr was 0.8 on [**2122-6-8**] and jumped to 1.3 on [**2122-6-9**] and 1.9 on [**6-10**]. The only change in medication at the time was the addition of flucytosine. Urine electrolytes with FeNA 0.7% also suggested prerenal causes, no muddy brown casts were seen. Flucytosine was d/c, IVF started and Cr returned to 1.3 but rose again a few days later to 1.6-1.7. At this point fluid boluses were started around the ambisome and Bactrim was d/c with Pentamidine IV as a substitution. His Cr slowly returned to nl and is 1.1 upon d/c. . 6. Oral thrush/HSV - The patient had oral thrush on admission. He was started on fluconazole, but that was discontinued once liposomal amphotericin was started on [**2122-6-6**]. It was also noted that he had an approximately 1.5cm lesion on the right lateral aspect of his tongue which was [**Location (un) 2452**] in color, circular, and still had the normal papilla over it. Derm was consulted and was unsure what the lesion was, but felt that it needed to be biopsied. ENT bx tongue lesion and sent the Cx. It showed HSV1 and patient was started on acyclovir. It resolved upon his d/c. 7. Diarrhea - The patient reported having loose stools over the months prior to admission, but while in the [**Hospital Unit Name 153**], this seemed to resolve. Stool cultures were negative for cryptosporidium, salmonella, shigella, O+P, and giardia. C. diff toxin was negative. 8. Anemia - The patient has anemia of chronic disease based on iron studies, but his baseline Hct is unknown. It was stable throughout his admission with a Hct between 30 and 36. 9. FEN ?????? He was placed on a regular diet. 10. PPX - PPI, SC heparin; no bowel regimen given diarrhea on admission 11. FULL CODE 12. Contact- [**Name (NI) 64233**] [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 13474**] = HCP ([**Telephone/Fax (1) 64234**]) Medications on Admission: None Discharge Medications: 1. Prednisone 2.5 mg Tablet Sig: Eight (8) Tablet PO once a day for 14 days: Take 8 tablets for 1 more day, then 4 tablets per day for 4 days, then 2 tablets per day for 4 days, then 1 tablet per day for 5 days, then stop. Disp:*37 Tablet(s)* Refills:*0* 2. Acyclovir 200 mg Capsule Sig: Two (2) Capsule PO Q12H (every 12 hours). Disp:*120 Capsule(s)* Refills:*2* 3. Azithromycin 600 mg Tablet Sig: Two (2) Tablet PO 1X/WEEK (FR). Disp:*8 Tablet(s)* Refills:*2* 4. Atovaquone 750 mg/5 mL Suspension Sig: Five (5) ml PO BID (2 times a day). Disp:*300 ml* Refills:*2* 5. Fluconazole 200 mg Tablet Sig: Four (4) Tablet PO once a day. Disp:*120 Tablet(s)* Refills:*2* 6. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Primary: 1. Cryptococcal Meningitis. 2. Pneumocystis Carinii Pneumonia. 3. HIV/AIDS CD4 28 , VL ~ 1,000,000. 4. Transaminitis NOS. 5. HSV 1 Stomatitis. 6. FTA-Antibody Positive. 7. Acute Renal Failure. 8. Hypoproliferative Anemia. 9. Cryptococcal Meningitis (RPR Negative,HBV/HCV/CMV Viral Load Negative) Discharge Condition: good, ambulating well without hypoxia, orthostasis Discharge Instructions: Take all your medications as directed. Follow up with your new primary care physician as [**Telephone/Fax (1) 1988**]. Follow up with Dr. [**First Name (STitle) 2505**]. Followup Instructions: Follow up with your primary care doctor [**First Name (Titles) 3**] [**Last Name (Titles) 1988**] later this week ([**2122-6-25**]) Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 4340**], MD Where: LM [**Hospital Unit Name 4341**] DISEASE Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2122-7-7**] 11:30 Completed by:[**2122-7-26**]

[ "070.30", "117.9", "321.0", "054.2", "584.9", "042", "136.3", "518.81", "112.0", "285.29", "117.5" ]

icd9cm

[ [ [] ] ]

[ "03.31", "25.01", "33.24" ]

icd9pcs

[ [ [] ] ]

18726, 18732

10926, 17807

333, 401

19082, 19134

7303, 10903

19353, 19716

6577, 6651

17862, 18703

18753, 19061

17833, 17839

19158, 19330

6666, 7284

274, 295

429, 5955

5977, 6015

6031, 6561

3,917

173,759

5974

Discharge summary

report

Admission Date: [**2103-1-1**] Discharge Date: [**2103-1-6**] Date of Birth: [**2055-7-29**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2641**] Chief Complaint: chest pain, etoh withdrawal Major Surgical or Invasive Procedure: none History of Present Illness: This is an unfortunate 47yo M with ETOH abuse c/b dilated cardiomyopathy (EF49% 9/07), HCV, h/o lung aspergillosis c/b cavitary lesion who p/w etoh withdrawal and his chronic reproducible chest pain. Pt has had mutliple ED visits at our institution and others for similar complaints. He currently drinks [**1-3**] gallon of vodka daily, his last drink was 2pm yesterday. He also notes that he fell 3 days ago while cleaning his apt. He landed on his back and has some residual back pain from the fall. He denies cough/F/C. no brbpr/melena. no n/v/d/c or abdominal pain. He has an exercise tolerance of 2 to 3 flights of stairs limited by shortness of breath. No orthopnea/PND/palpitations. Last stress [**9-9**] negative for ischemia. He notes that he takes his meds ~every other day. . In the [**Name (NI) **], pt received Thiamine IV, FoLIC Acid IV, Multivitamin IV and Acetaminophen 650mg for his chronic chest pain. His serum etoh level 274, +benzos, o/w tox screen (-) head CT- negative; EKG was unchanged from baseline and first set of cardiac enzymes negative. He received IV valium 10mg. . On the floor, he was hypertensive to 190s. He has been given a total of 30 mg of valium, his last dose at 6:30 am of valium 10 mg PO. Past Medical History: Past Medical History: - EtOH abuse - h/o withdrawl seizures - Alcoholic Dilated Cardiomyopathy (EF 25%) - cocaine abuse (last use ~ 3 weeks ago) - hypothyroidism - h/o head and neck cancer s/p resection and radiation in [**2093**] - bilateral cavitary lung lesions; bx demonstrated Aspergillous fumigatus and [**Female First Name (un) 564**] albicans [**2-/2102**] - h/o C. diff colitis - h/o IVDA per OSH records (pt denies) . Social History: Smokes < [**1-3**] ppd recently; prior to that he smoked 1 ppd x30 years. Heavy EtOH use (usually >1 gallon vodka per day). Sober x10 years up until ~2 years ago; more recently, reports several months of sobriety. +Cocaine abuse; last use several wks ago. He denies IVDA. Sexually active with his girlfriend. . Family History: Mother with CAD. Sister with h/o CVA. . Physical Exam: T 99.5 BP 140/91 - 181/110 HR 91 RR Sat 95% on ra General: pleasant, cooperative, tremulous [**Month/Day (2) 4459**]: symmetric periorbital edema; no icterus, conjunctival erythema, pupils 5mm and symmetric Neck: supple; s/p resection of left SCM muscle Chest: clear to auscultation throughout CV: rrr, II/VI systolic murmur at RUSB Abdomen: soft, NTND, normal BS, no HSM Extr: no edema, 2+ PT pulses Skin: no rashes or jaundice, face is flushed; + back wound Neuro: alert& oriented x 3, cooperative; CN 2-12 intact; [**5-7**] strength in both arms and legs Pertinent Results: EKG: NSR at 74 unchanged compared to [**2102-12-15**] CXR: Stable radiograph with known cavitary lesions in both lung apices and associated changes Imaging: CT head on admission: No hemorrhage. Sinus mucosal disease. [**2103-1-1**] 07:00PM CK-MB-5 cTropnT-<0.01 [**2103-1-1**] 07:00PM ALT(SGPT)-49* AST(SGOT)-82* CK(CPK)-235* ALK PHOS-59 TOT BILI-0.4 [**2103-1-1**] 07:00PM GLUCOSE-70 UREA N-13 CREAT-0.9 SODIUM-140 POTASSIUM-3.4 CHLORIDE-100 TOTAL CO2-23 ANION GAP-20 [**2103-1-1**] 07:00PM WBC-3.1* RBC-3.32* HGB-10.7* HCT-31.3* MCV-94 MCH-32.3* MCHC-34.4 RDW-15.7* Brief Hospital Course: # Alcohol withdrawal - He was initially tremulous on admission and required increasing CIWA scale. He was transferred to the MICU on hospital day #2. While in the MICU he required valium q1 hours. When transferred back to the floor, he was tapered off of valium. By hospital day #4, valium was tapered to 5 mg [**Hospital1 **] and on discharge valium was discontinued. He was also continued on MVI, thiamine, folate. He was also seen by SW prior to discharge. He was discharged home as he stated that he wished to go home to pay rent prior to seeking treatment in inpatient rehab. . # Chest pain - His chest pain is chronic, reproducible and sharp. His EKG on admission was unchanged from baseline, and he had 3 sets of negative cardiac markers. CXR remained stable from previous showing known cavitary lesions unchanged from baseline. His exercise MIBI from [**9-9**] without evidence of ischemia. . # Hypertension- On admission he had labile blood pressures ranging between 100s to 200s requiring IV hydralazine in the MICU. By hospital day #4, his blood pressures normalized and he was continued on home regimen of lisnopril 30, toprol 150 daily . # Dilated Cardiomyopathy (EF 25%)- He appeared euvolemic on exam. He was continued on ASA, BB and ACE-I. . # Hypothyroidism- He was continued on his outpatient regimen levothyroxine . # Dysphagia- This is chronic as per his history. This is likely secondary to XRT, but recurrence of neck ca is a possibility. He will schedule an outpatient appointment with his PCP and will likely need an EGD. Medications on Admission: Aspirin 81 mg PO DAILY Levothyroxine 75 mcg PO DAILY Buspirone 10 mg PO BID Toprol XL 150 mg Tablet PO once a day Lisinopril 30 mg PO DAILY Trazodone 50 mg PO HS Olanzapine 5 mg PO HS vit B1 vit B12 Hexavitamin Discharge Medications: 1. Lisinopril 10 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 3. Olanzapine 2.5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 4. Buspirone 10 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr Sig: Three (3) Tablet Sustained Release 24 hr PO DAILY (Daily). 6. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed. 7. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 9. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 5 days. Disp:*30 Tablet(s)* Refills:*0* 10. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily). Disp:*30 Cap(s)* Refills:*2* 11. B-Complex with Vitamin C Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Hospital3 **] VNA Discharge Diagnosis: Primary: Alcohol withdrawal Secondary: Anxiety Hypertension Alcoholic cardiomyopathy Discharge Condition: stable Discharge Instructions: You were admitted to the hospital for alcohol withdrawal. You should continue to abstain from drinking. Please take all medications as prescribed. If you develop chest pain, shortness of breath, persistent fever > 101, please return to the nearest emergency room. Followup Instructions: We have scheduled a follow up appointment for you in the [**Hospital 191**] clinic. Your appointment information is as below: [**2103-2-5**] 02:30p [**Last Name (LF) **],[**First Name3 (LF) 156**] [**Doctor First Name **] [**Hospital6 29**], [**Location (un) **] [**Hospital 191**] MEDICAL UNIT Completed by:[**2103-1-31**]

[ "787.29", "E879.2", "244.9", "948.00", "304.21", "V10.89", "117.3", "275.3", "303.01", "E924.8", "786.59", "942.14", "428.32", "425.4", "E849.8", "291.81", "428.0", "401.9" ]

icd9cm

[ [ [] ] ]

[ "94.62" ]

icd9pcs

[ [ [] ] ]

6483, 6534

3642, 5202

341, 348

6663, 6672

3041, 3206

6990, 7322

2406, 2447

5464, 6460

6555, 6642

5228, 5441

6696, 6967

2462, 3022

274, 303

376, 1610

3220, 3619

1654, 2061

2077, 2390

80,008

160,519

9701

Discharge summary

report

Admission Date: [**2156-4-26**] Discharge Date: [**2156-5-1**] Date of Birth: [**2086-12-6**] Sex: M Service: MEDICINE Allergies: Niacin / aspirin / Codeine Attending:[**Last Name (NamePattern4) 290**] Chief Complaint: GI Bleed Major Surgical or Invasive Procedure: enteroscopy [**2156-4-29**] and [**2156-4-30**] History of Present Illness: HMED ATTENDING ADMISSION NOTE . ADMIT DATE: [**2156-4-26**] ADMIT TIME: 2345 . PCP: [**Name10 (NameIs) **],[**Name11 (NameIs) 1575**] [**Name Initial (NameIs) **]. Address: [**Doctor Last Name 32771**], [**Location (un) **],[**Numeric Identifier 17464**] Phone: [**Telephone/Fax (1) 8340**] Fax: [**Telephone/Fax (1) 8341**] . Cardiology: Dr. [**First Name4 (NamePattern1) 2855**] [**Last Name (NamePattern1) 32772**] Address: [**Location (un) **] [**Apartment Address(1) 32773**]. [**Location (un) 936**] Phone: [**Telephone/Fax (1) 14967**] . 69 yo M with CAD s/p CABG complicated be restenosis requiring multiple stents, mechanical aortic valve on coumadin, recurrent GI bleeding and IDDM who is transferred from [**Hospital3 **] for advanced endoscopy for management of active upper GI bleed. . Patient was admitted to [**Hospital6 33**] approximately one week ago with melena and hematocrit of 22, found to have a NSTEMI (medical management per cardiology, restarted on plavix - d/c'ed in [**2154**] given recurrent gi bleeds, 1 month after BMS placed). Upper endoscopy was unrevealing except for mild gastritis. Colonoscopy last done one year ago which was unremarkable except for benign polyps. Patient was transfused 4 units of pRBCs, hematorcrit increased to 27 and discharged three days ago. Of note, he required diuresis for decompensated CHF. Was seen in the ED on [**4-21**] for chest pain, no EKG changes, resolved with nitro, discharged home. . Patient was re-admitted to [**Hospital3 **] today ([**2156-4-26**]) with recurrent melena. Last night he had two black/tarry stools. He also endorsed some mild chest pain. His hematocrit on admission was 26.2. Patient transfused 1 unit of packed cells. He ruled out for ACS by three sets of negative cardiac enzymes and non-ischemic EKG. Patient underwent a CT angiogram which revealed 3 small bowel foci of hemorrhage likely in the proximal ileum. Given the location of the bleeding decision made by gastroenterologist to transfer to [**Hospital1 18**] for single balloon enteroscopy. Patient has been continued on plavix given his significant cardiac comorbidities. He has been bridged with a heparin gtt for a subtherapeutic INR of 1.9. . Of note, patient had recurrent GI bleeding at site of anastamosis from sigmoid colectomy in [**2154**], requiring multiple transfusions. Was on asa/plavix/coumadin with recent BMS placed in diagonal. ASA stopped and plavix discontinued 1 month after BMS placement given recurrent bleeding. He had no further bleeding issues until this past week. . Currently patient has no complaints. Denies any current chest pain, sob, lightheadedness or dizziness. No nausea, vomiting or abdominal pain. Reports one episode of black stool prior to transfer. . ROS as per HPI, 10 pt ROS otherwise negative. Past Medical History: -CAD s/p CABG 2v [**2135**], restenosis requiring multiple stents, [**2151**] DES for RCA stenosis, [**2152**] NSTEMI medically managed, [**2154**] BMS diagonal -St. [**Male First Name (un) 923**] aortic valve replacement [**2135**] -IDDM -COPD -Diverticulitis s/p sigmoid colectomy complicated by unstable angina, s/p cardiac cath and BMS to diagonal, then developed recurrent bleeding on asa/plavix/coumadin therefore plavix d/c'ed after 1 month -HTN -Hypothyroidism -CHF -Anxiety -S/p knee replacement [**2152**] complicated NSTEMI and CHF exacerbation -Hernia repair Social History: Lives with wife, [**Name (NI) 32774**] and grandson in [**Name (NI) 32775**], MA. Retired heavy lift mechanic. + tobacco, 1 ppd x 55 yrs. No etoh or illicits. Family History: + CAD and DM, no hx of gi bleeds Physical Exam: ON ADMISSION: VS: 97.9 138/79 56 20 96%RA Appearance: alert, NAD, obese Eyes: eomi, perrl, anicteric ENT: OP clear s lesions, mmd, no JVD, neck supple Cv: +s1, s2 mechanical aortic click, no peripheral edema, 2+ dp/pt bilaterally Pulm: clear bilaterally, diminished at bases Abd: soft, obese, midline scar, nt, nd, +bs Msk: 5/5 strength throughout, no joint swelling, no cyanosis or clubbing Neuro: cn 2-12 grossly intact, no focal deficits Skin: no rashes Psych: appropriate, pleasant Heme: no cervical [**Doctor First Name **] Pertinent Results: [**Hospital6 33**] labs: . [**2156-4-26**] . 6.3> [**10-20**] <148 . 138 100 18 ------------< 161 3.2 28 1.0 . LFTs wnl . [**Hospital6 33**] Images: . [**2156-4-26**] CT angio a/p: three small foci of hemorrhage, located in proximal ileum with extravasation of intraluminal intravenous contrast may be due to angiodysplasia, no evidence for underlying mucosal masses; colonic diverticulosis without diverticulitis, mild splenomegaly . [**2156-5-1**]: WBC 3.1 HCT 24.6 PLT 95 [**2156-4-30**] HCT 25.7 PLT 105 [**2156-4-28**] 05:05AM BLOOD WBC-3.6* RBC-3.02* Hgb-10.1* Hct-29.2* MCV-97 MCH-33.6* MCHC-34.7 RDW-17.8* Plt Ct-129* [**2156-4-27**] 09:04PM BLOOD Hct-29.9* [**2156-4-27**] 03:16PM BLOOD Hct-30.9* [**2156-4-27**] 09:00AM BLOOD Hct-28.5* [**2156-4-27**] 05:15AM BLOOD WBC-3.7* RBC-2.72* Hgb-9.5* Hct-26.8* MCV-99* MCH-34.8* MCHC-35.3* RDW-17.2* Plt Ct-134* [**2156-4-27**] 12:40AM BLOOD WBC-4.0# RBC-2.84*# Hgb-9.5*# Hct-27.7* MCV-98# MCH-33.4*# MCHC-34.3 RDW-17.1* Plt Ct-134* [**2156-4-27**] 12:40AM BLOOD Neuts-55 Bands-0 Lymphs-35 Monos-8 Eos-2 Baso-0 Atyps-0 Metas-0 Myelos-0 [**2156-4-27**] 12:40AM BLOOD Hypochr-NORMAL Anisocy-2+ Poiklo-2+ Macrocy-2+ Microcy-NORMAL Polychr-NORMAL Ovalocy-1+ Pencil-OCCASIONAL Ellipto-OCCASIONAL [**2156-5-1**]: INR 1.7 [**2156-4-28**] 06:40PM BLOOD PT-19.7* PTT-75.3* INR(PT)-1.9* [**2156-4-28**] 05:05AM BLOOD Plt Ct-129* [**2156-4-28**] 05:05AM BLOOD PT-19.2* PTT-109.9* INR(PT)-1.8* [**2156-4-28**] 02:48AM BLOOD PT-19.0* PTT-112.8* INR(PT)-1.8* [**2156-4-27**] 08:55PM BLOOD PT-18.9* PTT-56.0* INR(PT)-1.8* [**2156-4-27**] 01:00PM BLOOD PT-20.7* PTT-42.6* INR(PT)-2.0* [**2156-4-27**] 05:15AM BLOOD Plt Ct-134* [**2156-4-27**] 05:15AM BLOOD PT-22.3* PTT-150* INR(PT)-2.1* [**2156-4-27**] 12:40AM BLOOD Plt Smr-LOW Plt Ct-134* [**2156-4-27**] 12:40AM BLOOD PT-23.0* PTT-45.1* INR(PT)-2.2* RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap [**2156-5-1**] 02:22 glu131* urea N9 cr0.9 na140 k3.5 cl108 hco3 24 AG12 [**2156-4-28**] 05:05AM BLOOD Glucose-85 UreaN-13 Creat-1.1 Na-141 K-3.9 Cl-105 HCO3-25 AnGap-15 [**2156-4-27**] 05:15AM BLOOD Glucose-95 UreaN-11 Creat-0.9 Na-142 K-3.4 Cl-104 HCO3-26 AnGap-15 [**2156-4-27**] 12:40AM BLOOD Glucose-80 UreaN-12 Creat-1.0 Na-143 K-3.7 Cl-105 HCO3-28 AnGap-14 [**2156-4-27**] 12:40AM BLOOD Lipase-29 [**2156-5-1**] ca8.0* mg2.4* phos1.8 [**2156-4-28**] 05:05AM BLOOD Calcium-8.4 Phos-3.2 Mg-2.3 [**2156-4-27**] 05:15AM BLOOD Calcium-8.4 Phos-3.0 Mg-2.4 [**2156-4-27**] 12:40AM BLOOD Calcium-8.5 Phos-3.1 Mg-1.0* . [**4-28**] ECHO: The left atrium is mildly dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size and global systolic function (LVEF>55%). Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. The ascending aorta is mildly dilated. The aortic arch is mildly dilated. A mechanical aortic valve prosthesis is present. The transaortic gradient is higher than expected for this type of prosthesis. Trace aortic regurgitation is seen. [Normal for this prosthesis.] The mitral valve leaflets are mildly thickened. A mitral valve annuloplasty ring is present. The gradient across the mitral valve is slightly increased (mean = 3-4 mmHg) resulting in trivial/minimal mitral stenosis. No mitral regurgitation is seen. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Suboptimal image quality. Well seated mechanical aortic valve but with increased gradient. Well seated mitral annuloplasty ring with trivial mitral stenosis. Mild symmetric left ventricular hypertrophy with preserved global biventricular systolic function. Pulmonary artery hypertension. Dilated thoracic aorta. Compared with the report of the prior study (images unavailable for review) of [**2144-12-25**], the aortic valve gradient is increased and minimal mitral stenosis is now identified. If clinically indicated, a TEE may be better able to define the cause of the increased gradient across the aortic valve. . [**2156-4-30**] small bowel enteroscopy report: (from above) Healthy surgical anastomosis at left colon corresponding to the previous colectomy. Moderate to severe diverticulosis in the entire colon. The terminal ileum was entered and the scope was advanced to the proximal/mid ileum. A few tiny red spots were seen. But there was no active bleeding. No AVM or mass lesions were seen. Otherwise normal small bowel enteroscopy to third part of the duodenum. . [**2156-4-29**] small bowel enteroscopy report: (from below) The examined proximal ileum was normal. No active bleeding or AVM or mass was seen. Impression: Normal esophagus; A tiny nonbleeding erosion seen at the antrum; Mild and pathy erythema seen at duodenal bulb; Normal jejunum. No active bleeding or AVM or mass seen. Itattooed for marking; Normal proximal ileum. No active bleeding or AVM or mass seen. Otherwise normal small bowel enteroscopy to distal jejunum/proximal ileum. Brief Hospital Course: REASON FOR ICU ADMISSION: Pt is a 69 y.o male with h.o CAD s/p CABG complicated by restenosis requiring multiple stents and recent NSTEMI, mechanical aortic valve on coumadin, recurrent GI bleeds and IDDM who was transferred from OSH with melena and CTA showing active bleeding in proximal ileum. . #upper GI bleed/acute blood loss/anemia-CTA per OSH report showed active bleeding in the proximal ileum. Pt with recent EGD with non-bleeding gastritis. Last colonoscopy 1 yr ago with polyps. UGIB in the setting of restarting plavix 1 week ago for NSTEMI. PT also on couamdin for mechanical valve, and started on heparin ggt as coumadin was held in setting of procedure. Hct remained stable. Pt was placed on a protonix gtt. Plavix was continued up until transfer to [**Hospital1 18**], then restarted. Discussed anticoagulation with patient's cardiologist Dr. [**Last Name (STitle) 32772**] who felt as though pt should be on heparin gtt as long as deemed safe from GI procedure prospective. Would prefer to restart ASAP after any procedure. In addition, outpt cardiologist felt as though pt should be on plavix unless there is presence of hemodynamically significant GI bleeding. He agreed that pt does not tolerate dual anti-platelet therapy (per pt, ASA caused bleeding). Enteroscopy was performed at [**Hospital1 18**] [**2156-4-29**] which showed no evidence of bleeding via approach from above. Small bowel enteroscopy/colonoscopy was performed [**2156-4-30**] which was similarly unremarkable. Pt was restarted on warfarin and heparin gtt. Pt went home [**2156-5-1**] on lovenox as bridge, with INR checks planned for [**2156-5-3**] and [**2156-5-5**]. . #CORONARY ARTERY DISEASE: s/p CABG and PCI x2, severe CAD with chronic angina medically managed. Recent NSTEMI with decision to restart plavix after being held x2 years due to recurrent GI bleeds. At [**Hospital1 18**] plavix was held initially as GI team was uncomfortable doing procedure on plavix as interventions for bleeding (ex. clipping, cauterization could lead to more bleeding while on plavix). In addition, it was felt that at the time plavix effects would still be in his system as there was no complete washout period. As above, discussed case with pt's outpatient cardiologist who felt that pt would need to remain on plavix unless life hemodynamically significant GI bleeding. Pt was continued on imdur, statin, beta blocker held, see bradycardia below. He was ruled out for MI at OSH prior to transfer. He was monitored on tele. Without events. . # MECHANICAL AORTIC VALVE: placed at St. [**Male First Name (un) 1525**]. Patient's goal INR 3.5 for mechanical valve. Was switched to heparin which was stopped 6 hours prior to procedures. Given significant risk of thrombosis, heparin was restarted after procedures, despite patient's known GI bleed. HCT was monitored closely and remained stable. Heparin gtt was changed to lovenox on discharge, see above. . # Bradycardia: Patient noted to be bradycardic after procedure. Thought to be related to sedation for procedure. Improved as the patient woke up from sedation. Still, HR remained in the 50-60 range throughout hospitalization. Initially home beta blocker was held. Pt was monitored on telemetry without events. He was asymptomatic. Home atenolol restarted on discharge. . #DIABETES MELLITUS - type 2, with complications, peripheral neuropathy. Placed on conservative insulin regimen while NPO. Pt resumed meformin and glyburide upon discharge. Continued gabapentin for neuropathy. . #HYPERTENSION - benign; initially held beta blocker in setting of bradycardia. Continued imdur. Held lisinopril while NPO. On the morning of discharge his blood pressure was elevated in the 170s systolic. We then restarted his home medications (atenolol, lisinopril) which we had been holding and felt these would be adequate for blood pressure control. . #DIASTOLIC HEART FAILURE - chronic, but with recent acute exacerbation. Lasix was held while pt was NPO, and also was given with 1u pRBCs. . #hypothyroidism-continued synthroid . #HL-continued simvastatin . #GERD-on PPI ggt for c/f GI bleed as above, transitioned to PO PPI on discharge . #leukopenia/thrombocytopenia-unclear etiology. Could be due to acute process. Thrombocytopenia could be consumptive. PLT count was monitored closely and remained stable. . Pt was maintained as FULL CODE throughout the course of this hospitalization. . TRANSITIONAL ISSUES: anticoagulation: pt sent home on warfarin (subtherapeutic after holding for procedures) and lovenox. He will need INR checked Monday [**2156-5-3**] and Wednesday [**2156-5-5**] likely to DC lovenox [**2156-5-5**] as ideally he would have a 48 hour therapeutic overlap. Pt was instructed to follow up with PCP regarding this issue. Medications on Admission: Medications on Transfer: Vicodin 5/500 q6h prn Ativan 2mg po TID prn Morphine 2mg iv prn NTG 0.4 q5 mins prn Protonix gtt Atenolol 25mg po bid Plavix 75mg daily Ferrous sulfate 325mg [**Hospital1 **] Gabapentin 600mg QID Humalog sliding scale Synthroid 50mcg daily Kdur ? dose daily Simvastatin 20mg daily Heparin gtt Imdur ER 60mg [**Hospital1 **] Lasix 40mg daily Lantus 10 units qam Lisinopril 20mg daily . Outpatient Medications Lantus 20 units qam Metformin 850mg [**Hospital1 **] Glyburide 10mg [**Hospital1 **] Atenolol 25mg [**Hospital1 **] Plavix 75mg daily Tylenol prn vicodin 1 tablet q6h prn Ativan 2mg tid prn NTG prn Lasix 40mg daily Gabapentin 600mg qid Isosorbide mononitrate 60mg daily Levoxyl 50mcg daily Lisinopril 20mg daily Simvastatin 20mg daily Coumadin 5mg all days except 2.5mg on M or F Omeprazole 40mg daily KCl 20 meq daily Ferrous sulfate 325mg [**Hospital1 **] Discharge Medications: 1. enoxaparin 40 mg/0.4 mL Syringe Sig: One (1) Subcutaneous once a day for 5 days: Continue until INR is therepeutic. . Disp:*5 syringes* Refills:*2* 2. lorazepam 1 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8 hours) as needed for anxiety. 3. gabapentin 300 mg Capsule Sig: Two (2) Capsule PO QID (4 times a day). 4. insulin glargine 100 unit/mL Solution Sig: Twenty (20) Units Subcutaneous once a day. 5. metformin 850 mg Tablet Sig: One (1) Tablet PO twice a day. 6. atenolol 25 mg Tablet Sig: One (1) Tablet PO twice a day. 7. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO once a day. 8. glyburide 5 mg Tablet Sig: Two (2) Tablet PO twice a day. 9. Vicodin 5-500 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for pain. 10. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day. 11. isosorbide mononitrate 60 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO once a day. 12. Levoxyl 50 mcg Tablet Sig: One (1) Tablet PO once a day. 13. lisinopril 20 mg Tablet Sig: One (1) Tablet PO once a day. 14. simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day. 15. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 16. potassium chloride 20 mEq Tablet, ER Particles/Crystals Sig: One (1) Tablet, ER Particles/Crystals PO once a day. 17. ferrous sulfate 325 mg (65 mg iron) Capsule, Extended Release Sig: One (1) Capsule, Extended Release PO twice a day. Capsule, Extended Release(s) 18. Outpatient Lab Work please have INR drawn [**2156-5-3**] and [**2156-5-5**] Discharge Disposition: Home Discharge Diagnosis: Acute blood loss anemia from gastrointestinal bleeding CAD s/p stenting and mechanical aortic valve Recent NSTEMI HTN Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Mr. [**Known lastname 32776**], You were admitted for further evaluation of gastrointestinal bleeding. For this, you had endoscopic procedures both from above and below the level of the stomach, both which were unrevealing for a source of bleeding. This likely occurred in the presence of multiple blood thinners, causing leaking of a vessel which stopped once we held your blood thinners. We discussed the risks and benefits of being on blood thinners. Given your cardiac history, including stents and mechanical heart valves, it is necessary that your remain on warfarin and an antiplatelet [**Doctor Last Name 360**] (such as aspirin or clopidogrel AKA Plavix), to prevent a stroke and a heart attack respectively. You will be discharged on warfarin at your usual home dose as well as clopidogrel (Plavix). Please note to follow up with your cardiologest within the week to assure you are on the most appropriate therapy for your cardiac health. As you know, your INR was below goal prior to discharge (goal 2.5-3.5), since we held your warfarin in the hospital so you could have procedures. You will be going home on enoxaparin (AKA Lovenox)injections to keep your blood thin while your INR becomes therepeutic. Medication changes: Please START taking Clopidogrel (AKA Plavix) 75mg po qday Please START taking Enoxaparin subcutaneous injections until your INR is therepeutic Please continue taking the rest of your medications as prescribed. . It has been a pleasure taking care of you Mr. [**Known lastname 32776**]! Followup Instructions: Please arrange follow up with your primary care doctor and your cardiologist within 1 week of discharge. You will need to have your INR on Monday [**2156-5-3**] and Wednesday [**2156-5-5**]. Speak to your primary care physician but you should stop lovenox on Wednesday [**2156-5-5**] if Dr. [**Last Name (STitle) 26652**] approves. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]

[ "244.9", "428.0", "E935.3", "287.5", "E934.8", "562.10", "V58.67", "414.02", "285.1", "496", "578.1", "410.72", "V43.65", "401.1", "530.81", "E937.8", "V12.72", "250.60", "428.32", "288.50", "V58.61", "300.00", "357.2", "413.9", "V45.82", "427.89", "V43.3", "V45.72" ]

icd9cm

[ [ [] ] ]

[ "45.13" ]

icd9pcs

[ [ [] ] ]

16991, 16997

9684, 14101

302, 352

17159, 17159

4587, 9661

18865, 19337

3983, 4017

15395, 16968

17018, 17138

14480, 14480

17310, 18535

4032, 4032

14122, 14454

18555, 18842

254, 264

380, 3194

4046, 4568

17174, 17286

14505, 15372

3216, 3788

3804, 3967

62,731

114,008

45214

Discharge summary

report

Admission Date: [**2151-1-28**] Discharge Date: [**2151-2-1**] Date of Birth: [**2105-5-25**] Sex: M Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 1505**] Chief Complaint: coronary artery disease Major Surgical or Invasive Procedure: [**2151-1-28**] Coronary Artery Bypass Graft x 5 (LIMA->LAD,free RIMA->RI,SVG-> Diagonal,SVG-OM,SVG-dRCA) History of Present Illness: This 45 year old male noticed a few months ago that he was developing chest discomfort while exercising at his home gym. He states after walking on treadmill with an incline after a couple of minutes he was noticing a tightening in his chest. After slowing the treadmill down and lowering the incline, within 25 minutes the pain would subside. He also noted chest discomfort with exertion after walking up two flights of stairs and unloading the cars with groceries, with resting the pain subsided within one minute. He states during these episodes they would also feel lightheadedness and shortness of breath. He was referred for a cardiac catheterization after a positive stress test and was found to have coronary artery disease. He is now being referred to cardiac surgery for revascularization. Past Medical History: Unilateral inguinal hernia Lumbago Sacroiliitis Hyperlipidemia history of fracture to clavicle and ribs secondary to motorcycle accident possible sleep apnea Social History: Race:Caucasian Last Dental Exam:>1 year ago Lives with:wife and 4 children Contact: [**Name (NI) **] [**Name (NI) 96621**] (wife) cell # [**Telephone/Fax (1) 96622**] Occupation:self employed Cigarettes: Smoked no [x] yes [] Other Tobacco use:denies ETOH: < 1 drink/week [] [**2-16**] drinks/week [x] >8 drinks/week [] Illicit drug use:denies Family History: Premature coronary artery disease- sister had an MI at the age of 46, mother with hypertension Physical Exam: Pulse:83 Resp:16 O2 sat:100/RA B/P Left:124/83 Height:5'8" Weight:175 lbs General: Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur [] grade ______ Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Extremities: Warm [x], well-perfused [x] Edema [] _____ Varicosities: None [x] Neuro: Grossly intact [x] Pulses: Femoral Right: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: [**2151-1-30**] 10:09AM BLOOD Hct-26.7* [**2151-1-30**] 03:35AM BLOOD WBC-11.3* RBC-3.03* Hgb-8.8* Hct-25.5* MCV-84 MCH-28.9 MCHC-34.4 RDW-12.6 Plt Ct-151 [**2151-1-29**] 03:23AM BLOOD WBC-13.2* RBC-3.52* Hgb-10.2* Hct-29.1* MCV-83 MCH-29.0 MCHC-35.0 RDW-13.0 Plt Ct-172 [**2151-1-30**] 03:35AM BLOOD Glucose-95 UreaN-14 Creat-0.7 Na-136 K-3.8 Cl-100 HCO3-30 AnGap-10 [**2151-1-29**] 12:22PM BLOOD Na-138 K-3.9 Cl-104 [**2151-1-31**] 04:55AM BLOOD WBC-9.1 RBC-3.04* Hgb-8.8* Hct-25.6* MCV-84 MCH-29.0 MCHC-34.3 RDW-12.6 Plt Ct-172 [**2151-1-31**] 04:55AM BLOOD Glucose-90 UreaN-10 Creat-0.6 Na-139 K-3.9 Cl-103 HCO3-29 AnGap-11 [**2151-1-28**] TTE PREBYPASS: Normal LV systolic function with LVEF > 55% with no SWMA. The left atrium is normal in size. Left ventricular wall thicknesses and cavity size are normal. Right ventricular chamber size and free wall motion are normal. The ascending, transverse and descending thoracic aorta are normal in diameter and free of atherosclerotic plaque. 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. Normal RV chamber dimensions and function. Normal RA size.Trace TR. Normal PV function. Normal coronary sinus. No clot in LAA. Normal diastolic function with lateral mitral annular e' = 13 cm/sec. POSTBYPASS: Normal LV systolic function LVEF > 55%, no segmental wall motion abnormalities. Normal valves. No dissection seen after cannula out. No other changes. [**2151-2-1**] 04:41AM BLOOD WBC-8.2 RBC-3.13* Hgb-9.0* Hct-26.1* MCV-83 MCH-28.8 MCHC-34.6 RDW-12.9 Plt Ct-221 [**2151-2-1**] 04:41AM BLOOD Na-139 K-3.5 Cl-100 Brief Hospital Course: The patient was admitted to the hospital and brought to the Operating Room on [**2151-1-28**] where he underwent Coronary Artery Bypass Graft x 5 with left internal mammory artery to the LAD, free right internal mammory artery to the Ramus, Reverse saphenous vein graft to the Obtuse marginal, diagnoal and distal right coronary artery. Overall the patient tolerated the procedure well and post-operatively was transferred to the CVICU in stable condition for recovery and invasive monitoring. POD 1 found the patient extubated, alert and oriented and breathing comfortably. The patient was neurologically intact and hemodynamically stable on no inotropic or vasopressor support. Beta blocker was initiated and the patient was gently diuresed toward the preoperative weight. He was placed on Imdur ER to prevent spasms having had the the free RIMA used as conduit. The patient was transferred to the telemetry floor for further recovery. Chest tubes and pacing wires were discontinued without complication. Beta blocker was titrated up for tachycardia. 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 independently, the wound was healing well, he was tolerating a full oral diet and pain was controlled with oral analgesics. The patient was discharged home with visitng nurse services in good condition with appropriate follow up instructions. Medications on Admission: VITAMIN D2 50,000 unit Capsule weekly for 8 weeks METOPROLOL TARTRATE 25 mg [**Hospital1 **] SIMVASTATIN 20 mg daily ASPIRIN 81 mg daily Discharge Medications: 1. simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 2. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for pain. 3. ibuprofen 200 mg Tablet Sig: Two (2) Tablet PO every [**4-16**] hours as needed for pain. 4. ergocalciferol (vitamin D2) 50,000 unit Capsule Sig: One (1) Capsule PO 1X/WEEK ([**Doctor First Name **]). 5. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*50 Tablet(s)* Refills:*0* 6. metoprolol tartrate 100 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:*60 Tablet(s)* Refills:*2* 7. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) as needed for constipation. 8. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 9. isosorbide mononitrate 30 mg Tablet Extended Release 24 hr Sig: 0.5 Tablet Extended Release 24 hr PO DAILY (Daily). Disp:*30 Tablet Extended Release 24 hr(s)* Refills:*2* 10. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day for 7 days. Disp:*7 Tablet(s)* Refills:*0* 11. potassium chloride 20 mEq Tablet, ER Particles/Crystals Sig: One (1) Tablet, ER Particles/Crystals PO ONCE (Once) for 7 days. Disp:*7 Tablet, ER Particles/Crystals(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital3 **] VNA Discharge Diagnosis: Coronary Artery Disease Unilateral inguinal hernia Lumbago Sacroiliitis Hyperlipidemia history of fracture to clavicle and ribs secondary to motorcycle accident possible sleep apnea Discharge Condition: Alert and oriented x3 nonfocal Ambulating with steady gait Incisional pain managed with Percocet Incisions: Sternal - healing well, no erythema or drainage Leg Left - healing well, no erythema or drainage. Edema Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Followup Instructions: You are scheduled for the following appointments Surgeon: Dr [**Last Name (STitle) **]([**Telephone/Fax (1) 170**]) on [**2151-3-3**] at 1:15pm Cardiologist: Dr. [**Last Name (STitle) 96623**] [**Name (STitle) 42388**] on [**2151-2-22**] at 2:20PM Wound check at Cardiac Surgery office on [**2151-2-9**] at 10:15 am Please call to schedule appointments with your Primary Care Dr. [**Last Name (STitle) **] in [**4-15**] weeks ([**Telephone/Fax (1) 17663**]) **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:[**2151-2-1**]

[ "V17.3", "V85.22", "720.2", "413.9", "782.1", "V17.49", "V15.82", "414.01", "401.9", "272.4", "V70.7", "327.23" ]

icd9cm

[ [ [] ] ]

[ "36.13", "36.16", "39.61" ]

icd9pcs

[ [ [] ] ]

7365, 7416

4382, 5851

333, 441

7641, 7855

2595, 4359

8696, 9349

1833, 1930

6040, 7342

7437, 7620

5877, 6017

7879, 8673

1945, 2576

270, 295

469, 1271

1293, 1453

1469, 1817

59,210

163,785

10521

Discharge summary

report

Admission Date: [**2191-10-24**] Discharge Date: [**2191-10-28**] Date of Birth: [**2120-2-14**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 2763**] Chief Complaint: Hypoxia Major Surgical or Invasive Procedure: None History of Present Illness: 71 yo man with Enterococcus MV endocarditis with blown posterior mitral leaflet s/p six weeks of ampicillin, Coag neg Staph bactermia on IV vanc, stage III NSCLC, hepatitis C, COPD, and hx of right axillary vein/IJ thrombosis, presenting from [**Hospital1 **] for worsening renal function, hyperkalemia ([**Hospital1 **] labs Cr 2.4 K, 6.1), hypotension, and hypoxia. . Patient recently discharged from OMED on [**2191-10-20**] with diagnosis of coag negative staph bacteremia/?endocarditis for which he was being treated with 6 weeks of IV vanc. Creatinine upon discharge was 2.2 up from 1.8 - etiology of increase not well understood but postulated secondary to previous nephrotoxin. . Baseline home O2 requirement is 4L NC. Since d/c, patient reports decreased urine production but denies dysuria, hematuria. Increased DOE and productive cough of yellow sputum though denies SOB at rest, pleuritic chest pain, or worsening LE edema. PND, orthopnea. No F/C. No abd pain/N/V/D/blood in stool changes in bowel habits. . Yesterday, [**Hospital1 **] labs notable for worsening renal function and vitals signs with new hypotension with SBPs in to 80s so decision was made to transfer to the ED for further eval and potential initiation of CVVH/HD. . In the ED, initial VS: Exam notable for expiratory wheeze, 3+ LE edema. ECG without hyperacute t waves; SR at 94. NANI, TWi V1-V3, no changes from prior. CXR with bilateral pleural effusions, stable extensive opacification of right lung with rll collapse, hazy opacity in LLL, ? infiltration, PICC line coiled on itself in SVC. UA with 44WBC. Foley placed with only 5cc of fluid drained. Patient received levofloxacin for possible PNA, CTX for UTI and admitted to medicine for further eval of [**Last Name (un) **]. Patient given 3 combi nebs with improvement in respiratory status. VS prior to transfer 98.5 82 96/61 20 95% 4L Past Medical History: ONCOLOGIC HISTORY: - [**4-/2189**]: presented to an outside hospital with severe back pain, with CXR showing right upper lobe lung mass. PET scan revealed FDG avidity at the periphery of the mass, with an FDG-avid paratracheal lymph node - [**2189-7-31**] cervical mediastinoscopy, multiple lymph nodes neg for malignancy (report not available). - [**2189-8-5**] transthoracic biopsy at [**Hospital1 18**], nondiagnostic. Pt declined RUL lobectomy - [**2189-11-3**] new moderate right-sided pleural effusion; right lung nodule increased from 6.6 to 7.7 cm and was again noted to have broad contact with the chest wall - [**2189-12-2**]: Dr. [**First Name (STitle) **] again saw the patient and recommended a right thoracotomy and RUL lobectomy. Surgery was scheduled but was canceled by the patient - [**2190-1-1**] chest CT revealed further increase in the known necrotic RUL lung mass, now measuring 8.1 x 7.5 cm. It was in direct contact with the peripheral pleural surface, with loss of a normal intercostal fat plane between the adjacent ribs, suggesting possible chest wall invasion. The epicenter of the mass was in the right upper lobe but crossed the fissure to extend into the adjacent right middle lobe. Prevascular and right paratracheal and precarinal lymph nodes were again demonstrated, with a slight interval increase in the size of the enlarged precarinal node. In the multidisciplinary thoracic oncology conference, it was felt that the patient would most likely require a right pneumonectomy given the extent of his tumor. However, due to his poor pulmonary function, with a DLCO of 60%, it was felt that he would not tolerate a pneumonectomy. - [**2190-2-4**]: A repeat bronchoscopy and endobronchial ultrasound was performed for diagnostic purposes, with a biopsy of the right upper lobe mass revealing poorly differentiated adenocarcinoma with immunostains positive for P63 and CK7 (weak), negative for TTF-1. Squamous cell carcinoma was favored. A transbronchial needle aspiration of station 7, 4R, and R11 lymph nodes revealed no malignant cells. Two sets of washings were negative, but brushings were positive for malignant cells. - [**2190-2-18**]: A repeat PET scan demonstrated no evidence of bony metastatic disease. The previously biopsy-negative right paratracheal lymph node was noted to be FDG-avid (SUV 4.7). Thus, the patient was felt to have likely Stage IIIA (T3N1M0) squamous cell carcinoma of the lung. - [**2190-3-4**]: The patient began weekly carboplatin (AUC 2) and paclitaxel (50mg/m2) given concurrently with radiation therapy. Finished chemoradiation in [**3-/2190**], last dose of chemo on [**2190-4-8**]. Required prednisone taper due to severe radiation pneumonitis. . [**2190-12-7**] CT torso showing a mildly enlarged cavitating lesion in the right upper lobe, which is now 6.5 x 4.4 cm, increased from 6.3 x 3.7 cm. There are two new right hilar lymph nodes, both measuring approximately 2 cm . [**Month (only) **]-[**2191-1-25**]: Treated with carboplatin, gemcitabine, with doses intermittently held for LFT abnormalities. [**2191-2-25**]: CT chest without contrast showing slightly enlarged right upper lung mass, measuring 7.5 x 5.2 cm, with slightly enlarged soft tissue component at the right middle lobe bronchus, measuring 3 x 3 cm [**2191-2-22**]: Palliative chemo with taxotere, with doses held due to dehydration and cytopenias. . [**2191-4-3**]: Admitted to [**Hospital1 18**] because of uncontrolled nausea and emesis, dehydration, volume depletion. Patient [**Hospital1 34676**] on [**2191-4-4**] [**2191-4-12**]: discontinue taxotere due to intolerable nausea, emesis, decreased appetite . [**2191-4-24**]: Chemo with vinorelbine . [**2191-7-14**] CT chest: decreased size in primary mass, measuring 6.5 x 4.1 cm, as compared to 7.4 x 5.2 cm previously. The previously noted thickening of the medial wall has also decreased, measuring 2.1 x 1.9 cm compared to 2.9 x 1.6 cm previously. No new nodules are present. Severe traction bronchiectasis related to post-radiation therapy changes has mildly improved. Severe paraseptal emphysema is unchanged. . [**Date range (3) 34677**]: Hospitalized at [**Hospital1 18**] for enterococcus mitral valve endocarditis and T12-L1 diskitis/osteomyelitis. Treated initially with ampicillin and gentamicin, with gentamicin discontinued due to impaired renal function. Six-week course of ampicillin is scheduled to end on [**2191-9-16**]. He had a right internal jugular and axillary vein thrombosis, associated with his right sided port-a-cath, which was initially diagnosed at [**Hospital3 34678**] on [**2191-7-29**], and has continued on Lovenox for treatment. He was seen by cardiology for NSVT, mitral valve endocarditis, and was started on metoprolol for rate control. He was seen by cardiothoracic surgery for consideration of mitral valve repair, with outpatient followup planned. He was discharged to the MACU unit of [**Hospital 100**] Rehab, where he has been since discharge. . [**2191-8-2**] CT angio of the chest showed a 4.5 cm x 3 cm thick-walled mixed solid and cystic structure in the right upper lobe corresponding to interval necrosis of treated tumor. There is no pulmonary embolism. Severe paraseptal emphysema was seen, along with post-radiation changes in the right lung. There is an enlarged and irregular substernal thyroid goiter, with features concerning for malignancy. [**2191-8-5**] MRI of the L-spine showed resolution of previously noted diskitis and osteomyelitis at T12 and L1. There were multilevel degenerative changes throughout the lumbar spine, stable, causing moderate-to-severe canal stenosis. [**2191-8-15**] MRI of the brain showed no intraparenchymal findings, but there was a new clivus mass, most likely representing an osseous metastasis. . Other PMHx: -Enterococcus mitral valve endocarditis -Hepatitis C, acquired in prison, not treated, stable. -Hx intravenous drug use, stable. -History of gunshot wound for which a large abdominal surgery was required -Hypertension, stable. -Emphysema/COPD -right internal jugular and axillary vein thrombosis, associated with his right sided port-a-cath Social History: [**12-27**] ppd x 30 years currently still smoking, social alcohol use, history IV heroin use and cocaine use. Family History: Hypertension in mother. Diabetes in father and aunt. [**Name (NI) **] other known family history. Physical Exam: VS - afebrile BP 100/73 HR 99 RR 18 93% on 6 liters n/c GENERAL - stable man in NAD speaking in full sentences though winded after movement, comfortable HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear NECK - supple, no thyromegaly, JVD to mandible, LUNGS - Decreased bs at bilateral bases with overlying crackles R>L, tachypneic with belly breathing with movement. course breath sounds over right thorax HEART - PMI non-displaced, RRR, nl S1-S2 with soft SEM appreciated at LUSB ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no rebound/guarding EXTREMITIES - WWP, 3+ symmetric pitting edema of LE, 2+ peripheral pulses (radials, DPs), RUE with 1-2+ pitting edema SKIN - no rashes or lesions LYMPH - no cervical, axillary, or inguinal LAD NEURO - awake, A&Ox2(though [**Hospital1 **] was [**Hospital1 **]), CNs II-XII grossly intact, muscle strength 5/5 throughout, sensation grossly intact throughout Pertinent Results: Admission Labs: [**2191-10-24**] 05:20PM WBC-8.5 RBC-3.14* HGB-8.7* HCT-28.4* MCV-91 MCH-27.6 MCHC-30.4* RDW-18.7* [**2191-10-24**] 05:20PM NEUTS-88.9* LYMPHS-5.8* MONOS-4.2 EOS-0.9 BASOS-0.2 [**2191-10-24**] 05:20PM PLT COUNT-172 [**2191-10-24**] 05:20PM GLUCOSE-108* UREA N-79* CREAT-5.0*# SODIUM-136 POTASSIUM-5.0 CHLORIDE-92* TOTAL CO2-28 ANION GAP-21* [**2191-10-24**] 05:26PM GLUCOSE-103 LACTATE-2.6* K+-5.0 [**2191-10-24**] 05:20PM proBNP-[**Numeric Identifier 34680**]* [**2191-10-24**] 11:54PM CALCIUM-8.3* PHOSPHATE-7.4* MAGNESIUM-2.1 . Renal Labs: [**2191-10-24**] 05:20PM UreaN-79* Creat-5.0*# [**2191-10-25**] 04:13AM UreaN-80* Creat-5.3* [**2191-10-25**] 06:57PM UreaN-85* Creat-5.9* [**2191-10-27**] 03:24AM UreaN-90* Creat-6.5* . LFTs: [**2191-10-25**] 04:13AM BLOOD ALT-937* AST-2137* AlkPhos-310* TotBili-0.7 . MICRO: [**2191-10-24**] 5:20 pm BLOOD CULTURE #1. Blood Culture, Routine (Preliminary): ENTEROCOCCUS SP.. PRELIMINARY SENSITIVITY. These preliminary susceptibility results are offered to help guide treatment; interpret with caution as final susceptibilities may change. Check for final susceptibility results in 24 hours. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ENTEROCOCCUS SP. | AMPICILLIN------------ R LEVOFLOXACIN---------- R VANCOMYCIN------------ R Anaerobic Bottle Gram Stain (Final [**2191-10-25**]): GRAM POSITIVE COCCI IN PAIRS AND CHAINS. Reported to and read back by [**Doctor First Name **] [**Doctor Last Name 10280**] (CC6D) 1638 [**2191-10-25**]. . IMAGING: . CT CHEST W/O CONTRAST [**2191-10-25**]: MDCT imaging was performed from the thoracic inlet to the upper abdomen without contrast. Sagittal and coronal reformats were performed. Axial 5- and 1.25-mm reconstructions were performed. . COMPARISON: CTA chest, [**2191-8-2**]. FINDINGS: A left-sided PICC catheter has an aberrant course with the tip extending into the azygos vein (2:19). Compared to the prior examination, a cavitary necrotic right upper lobe mass is now nearly fluid-filled (2:22). There is near-complete consolidation of the right upper lobe and right middle lobe. Partial consolidation of the right lower lobe is present with peribronchial wall thickening. There is copious debris within the right main stem bronchus (4:84). A new right-sided small pleural effusion is present. . A new small-to-moderate sized left pleural effusion is present with compressive atelectasis; however, other areas of consolidation at the left base (4:129) appear separate from the pleural effusion and atelectasis and are worrisome for pneumonia. Severe left upper lobe emphysema with a blebs is little changed. Numerous blebs at the right upper lobe are also stable. No pneumothorax appears present. . Although less well evaluated without IV contrast, extensive mediastinal lymphadenopathy with aortopulmonary window lymph nodes measuring 10 mm and right pretracheal lymph nodes measuring 10 mm appear little changed. . A small-to-moderate sized pericardial effusion is present. Dense coronary artery calcifications are present. The main pulmonary artery is enlarged, measuring 3.8 cm, which previously measured 3.5 cm. . The left lobe of the thyroid remains markedly enlarged and heterogeneous in appearance with a focus of calcification. . Although not tailored for subdiaphragmatic evaluation, the upper abdomen contains a small amount of ascitic fluid which is new. Cholecystectomy clips are present in the gallbladder fossa. The partially visualized upper pole right renal cyst is present. . BONE WINDOWS: No suspicious bone lesions are present. . IMPRESSION: 1. Progressive consolidation of a right upper, right middle and right lower lobes and the left lower lobe. Findings may be due to post-obstructive pneumonia as there are extensive secretions within the right main stem bronchus. 2. Previously air-filled cavitary necrotic mass in the right upper lobe is now nearly entirely fluid-filled. This finding is worrisome for infection. 3. New moderate-sized left pleural effusion, new small right pleural effusion. New moderate-sized pericardial effusion. 4. Interval increase in size of main pulmonary artery, previously 3.5 cm, now 3.8 cm. The significance of this is difficult to evaluate in the absence of IV contrast, but may be due to the new lung consolidations. 5. Malpositioned PICC catheter with the tip extending into the azygos vein. 6. Persistent enlargement of the left lobe of the thyroid. When clinically appropriate, further evaluation with ultrasound should be performed. 7. Extensive emphysema with numerous blebs. No pneumothorax. Brief Hospital Course: Primary Reason for Hospitalization: 71M with hx of endocarditis on IV vanc, NSCLC, hepC, COPD, and hx of right axillary vein/IJ thrombosis, presenting from rehab facility with progressive hypoxia and acute on chronic renal failure. Brief Hospital Course: Following admission, patient had worsening hypoxia, with 5-6 liters n/c required to maintain O2 sat in 90s. Trial of furosemide 120 mg IV x 1 did not improve UOP. Patient was transferred to ICU for initiation of CVVH per nephrology consult. On HD#2 pt had CT chest which showed extensive consolidation of R lung [**1-26**] progression of his known malignancy. The nephrology service reviewed the findings and felt that dialysis would not be beneficial given that his respiratory failure was likely [**1-26**] his malignancy, as well as his bacteremia. After discussion with pt, he elected to change his goals of care to DNR/DNI with comfort-measures only. The palliative care team was consulted and offered support for patient as well as recommendation for hospice care at [**Hospital1 1501**]. On transfer to [**Hospital1 1501**], all non-palliative meds including antibiotics for enterococcus infection were discontinued. He is being discharged to [**Hospital 3005**] Hospice with medications including senna, docusate, albuterol, ipratropium, scopolamine, concentrated morphine oral solution, ativan, oxycodone, and 4-6L supplemental oxygen. His goals of care are DNR/DNI/comfort care. Please [**Hospital 34681**] health care proxy as [**Name2 (NI) **], Reverend [**Name (NI) 34682**], given patient's mental status. Thank you. Medications on Admission: 1. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) 5,000 unit injection Injection TID (3 times a day). 2. levalbuterol HCl 0.63 mg/3 mL Solution for Nebulization Sig: One (1) 3 ML(s) nebulization Inhalation every four (4) hours. 3. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for Constipation. 4. senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day) as needed for Constipation. 5. morphine 15 mg Tablet Extended Release Sig: One (1) Tablet Extended Release PO Q12H (every 12 hours). 6. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. ipratropium bromide 0.02 % Solution Sig: One (1) 3ML nebulizatio Inhalation Q6H (every 6 hours) as needed for dyspnea, wheeze. 8. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 9. hydralazine 10 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours). 10. codeine-guaifenesin 10-100 mg/5 mL Syrup Sig: 5-10 MLs PO Q4H (every 4 hours) as needed for cough. 11. trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as needed for insomnia. 12. isosorbide mononitrate 30 mg Tablet Extended Release 24 hr Sig: Two (2) Tablet Extended Release 24 hr PO DAILY (Daily). 13. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 14. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. 15. metoprolol tartrate 25 mg Tablet Sig: 0.25 Tablet PO BID (2 times a day). 16. ZOFRAN ODT 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO every eight (8) hours as needed for nausea. 17. Furosemide 40 mg IV DAILY Start: In am start on [**2191-10-21**] Discharge Medications: 1. 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* 2. docusate sodium 50 mg/5 mL Liquid Sig: One Hundred (100) mg PO BID (2 times a day). Disp:*30 units* Refills:*2* 3. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) NEB Inhalation every 4-6 hours as needed for dyspnea. Disp:*20 units* Refills:*0* 4. ipratropium bromide 0.02 % Solution Sig: One (1) NEB Inhalation every 4-6 hours as needed for shortness of breath or wheezing. Disp:*20 units* Refills:*0* 5. scopolamine base 1.5 mg Patch 72 hr Sig: One (1) patch Transdermal every seventy-two (72) hours as needed for secretions. Disp:*1 unit* Refills:*2* 6. morphine concentrate 100 mg/5 mL (20 mg/mL) Solution Sig: 5-10 mg PO Q1H as needed for shortness of breath or pain: please use only if oxycodone elixir is unavailable. Disp:*50 ml* Refills:*0* 7. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO every four (4) hours as needed for anxiety. Disp:*30 Tablet(s)* Refills:*0* 8. oxycodone 9. SUPPLEMENTAL OXYGEN Please provide 4-6 liters of supplemental oxygen via nasal cannula. Titrate to comfort. Indication - lung cancer. Discharge Disposition: Extended Care Facility: [**First Name4 (NamePattern1) 3504**] [**Last Name (NamePattern1) **] Rehabilitation & Nursing Center - [**Location (un) 538**] Discharge Diagnosis: Acute renal failure Non-small cell lung cancer Bacteremia Chronic diastolic heart failure 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: It was a pleasure to take care of you during your hospitalization. You were admitted to the intensive care unit because you were having difficulty breathing and kidney failure. The renal service saw you and do not feel that dialysis would be beneficial. You met with the palliative care specialists who are working with you to ensure that you are most comfortable. Your health care proxy will be Reverend [**Name (NI) 34682**], [**First Name3 (LF) **] your request and wishes. We made the following changes to your medications: STOP heparin injections STOP hydralazine isosorbide mononitrate STOP omeprazole STOP metoprolol tartrate STOP furosemide STOP antibiotics START oxycodone and morphine concentrate for your pain. Also START scopolamine patch every 72 hours as needed for secretions. CONTINUE ipratropium bromide and albuterol for your shortness of breath, senna and docusate for your bowel regimen, and lorazepam for anxiety. Followup Instructions: N/A [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 2764**] Completed by:[**2191-10-28**]

[ "790.7", "162.3", "486", "585.9", "041.19", "403.90", "421.0", "427.1", "518.0", "428.32", "428.0", "V58.61", "305.1", "584.9", "V12.51", "799.02", "276.7", "V49.86", "492.8", "070.54" ]

icd9cm

[ [ [] ] ]

[ "00.14" ]

icd9pcs

[ [ [] ] ]

18991, 19145

14685, 16025

314, 321

19279, 19279

9604, 9604

20417, 20544

8549, 8650

17779, 18968

19166, 19258

16051, 17756

19455, 19955

8665, 9585

10550, 14406

19984, 20394

267, 276

349, 2232

9620, 10506

19294, 19431

2254, 8404

8420, 8533

43,776

177,704

39202

Discharge summary

report

Admission Date: [**2144-8-31**] Discharge Date: [**2144-9-4**] Date of Birth: [**2069-6-6**] Sex: M Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 3200**] Chief Complaint: Fever and shortness of breath Major Surgical or Invasive Procedure: None History of Present Illness: 75M w/ hx arthritis, HTN, gout s/p hernia repair [**8-21**], presented with 4 day history of intermittent dyspnea and one day of fever and chills. The patient underwent a right direct inguinal, epigastric, and umbilical hernia repair, w/o immediate complication. Post-op course was complicated by urinary retention for which a foley catheter was placed requiring overnight obs. he was discharged with foley catheter in place, which was removed [**8-26**] at his PCPs office. At discharge on [**8-22**] pt's vitals were 98.7, 83, 140/83, 16, 92% RA. [**Name (NI) **] pt presented to rheumatologist [**8-28**] with 3 days of left knee pain. An arthrocentesis was attempted by OP rheumatologist, but there was no fluid to aspirate. He was referred to the ED for r/o DVT. In the ED, LLE doppler was negative for DVT. At this time, his leukocytosis had improved to 18K and his cr was 1.8. He was discharged home from the ED. He returned on [**8-31**] with fever and shortness of breath. As per daughter (documented in [**Name (NI) **] signout) pt was c/o vague dysuria, and occsional difficulty voiding. He denied cough, DOE, PND, pleuritic CP. No N/V, diarrhea, constipation, dysuria, urinary retention, night sweats, sore throat, headache, vision changes, increased redness or drainage from surgical site. Past Medical History: Past medical history is significant for: 1. Arthritis. 2. Hypertension. 3. Gout. Past Surgical History: R inguinal hernia, epigastric and umbilical hernia repair ([**2144-8-21**]) Social History: From central america. Lives at home with wife/ family and 6 daughters + rest of family. - Tobacco: 14 pack years - quit 40 years ago - Alcohol: used to drink 4 beers/day, stopped 40 years ago - Illicits: no Family History: Family history significant for breast cancer. Physical Exam: UPON ADMISSION: Vitals: 103 90 110/67 30 92% ra General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: supple, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi Abdomen: soft, non-tender, slightly distended. Well healing surgical incisions. Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: grossly intact aox3 UPON DISCHARGE: Vitals: 99.1 98.0 63 136/76 20 98%RA Gen: AAOx3, NAD HEENT: anicteric sclera, MMM, oropharynx clear, EOMI, PERRL Neck: supple, no LAD, no JVD CV: RRR, +S1/S2, no m/r/g Resp: CTAB, no w/c/r Abd: soft, NT, ND, well-healing surgical incisions, +BS, no r/r/g Inc: c/d/i, no erythema/drainage/induration Ext: warm, well-perfused, no c/c/e Neuro: CN2-12 grossly intact, [**5-2**] motor exam throughout, normal sensory exam throughout Pertinent Results: ADMISSION LABS: [**2144-8-31**] 02:40PM WBC-40.0*# RBC-4.25* HGB-13.3* HCT-39.2* MCV-92 MCH-31.3 MCHC-33.9 RDW-14.2 [**2144-8-31**] 02:40PM NEUTS-94.7* LYMPHS-2.8* MONOS-2.3 EOS-0 BASOS-0.2 [**2144-8-31**] 02:40PM PT-13.9* PTT-33.3 INR(PT)-1.3* [**2144-8-31**] 10:30AM TYPE-[**Last Name (un) **] TEMP-38.9 PO2-41* PCO2-37 PH-7.35 TOTAL CO2-21 BASE XS--4 INTUBATED-NOT INTUBA [**2144-8-31**] 10:30AM LACTATE-2.4* [**2144-8-31**] 07:56AM ALT(SGPT)-76* AST(SGOT)-65* LD(LDH)-248 CK(CPK)-56 ALK PHOS-101 TOT BILI-1.6* [**2144-8-31**] 02:55AM URINE BLOOD-SM NITRITE-POS PROTEIN-30 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-4* PH-5.5 LEUK-LG [**2144-8-31**] 02:55AM URINE RBC-8* WBC->182* BACTERIA-MANY YEAST-NONE EPI-0 TRANS EPI-<1 [**2144-8-31**] 02:55AM URINE WBCCLUMP-FEW MUCOUS-RARE [**2144-8-31**] 02:30AM cTropnT-<0.01 CXR ([**8-31**]): Basilar atelectasis, although in the appropriate clinical setting, an underlying pneumonia cannot be excluded. CT ABDOMEN PELVIS ([**8-31**]): 1. Heterogeneous enhancement of the right kidney with right periureteric stranding, compatible with right pyelonephritis and ureteritis, given history of known UTI. 2. Status post right inguinal and umbilical hernia repairs. No intra-abdominal fluid collection or pneumoperitoneum. 3. Small bilateral pleural effusions. ECHOCARDIOGRAM ([**9-1**]): The left atrium is mildly dilated. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. There is probable mild regional left ventricular systolic dysfunction with mid to distal inferior hypokinesis (see clip [**Clip Number (Radiology) **]) although views of regional wall motion are technically suboptimal. Right ventricular chamber size and free wall motion are probably normal (not fully visualized). The ascending aorta is mildly dilated. 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. The tricuspid valve leaflets are mildly thickened. There is mild pulmonary artery systolic hypertension. There is a trivial/physiologic pericardial effusion. DISCHARGE LABS: [**2144-9-4**] 03:49AM BLOOD WBC-13.3* RBC-4.83 Hgb-14.8 Hct-44.0 MCV-91 MCH-30.7 MCHC-33.7 RDW-14.5 Plt Ct-338 [**2144-9-2**] 05:17AM BLOOD Glucose-96 UreaN-21* Creat-1.4* Na-138 K-3.6 Cl-107 HCO3-23 AnGap-12 Brief Hospital Course: The patient was admitted to the hospital for evaluation and treatment of his fever and shortness of breath. In the ED, initial vital signs were 103 90 110/67 30 92% ra. Labs were notable for WBC 15.9, lactate 2.3, Cr. 1.9, trop negative x1, ddimer was 1014 and urinalysis with many bacteria, nitrite positive and >185WBC. CXR showed low lung volumes/ bibasilar atelectasis. Blood cultures were sent x 2. Patient received 3L NS, 1g tylenol, vancomycin 1g and ampicillin/sulbactam 3g, albuterol and ipratropium nebs. He was initially admitted to medicine floor, but around 6am he began rigoring and became tachycardic to 130s in the setting of receiving nebulizers. Due to persistent tachycardia he was admitted to MICU. Shortly after arrival to the ICU, his care was transferred to the Surgical ICU (SICU) team. His workup was continued with a CT abdomen/pelvis, serial laboratory studies, and followup of the microbiology sent earlier (reader referred to 'Pertinent Results' section for details). He was aggressively hydrated, kept NPO for diet, and given IV antibiotics. He transiently required pressor support for his blood pressure, and was successfully weaned off pressor support on [**8-31**] itself. His urine output was closely monitored. On [**9-1**], his care was continued in this manner. His diet was slowly advanced to clear liquids and then a regular diet. His antibiotics were continued, and catered to his blood and urine cultures (GNRs, ultimately growing out zosyn-susceptible and ciprofloxacin-susceptible E.coli). IVF rehydration was continued. On the evening of this day, given his significantly improved clinical presentation, he was transferred to the general surgical floor. On [**8-14**], and [**9-4**], his IV fluids were discontinued upn achievement of sufficient oral intake of food and liquids. Antibiotic treatment was continued. He was encouraged to ambulate. His WBC count was noted to improve every day, and he remained afebrile since and including the day of [**9-1**]. He expressed feeling significantly improved and prepared to continue his recovery at home. He was explained the neccessity of completing a full course of his prescribed antibiotics (ciprofloxacin 500 mg Q12H for 11 days after discharge, to make for a complete 2 week course of antibiotics). He was also explained the importance of eating a healthy diet, and ambulating regularly. Finally, he was clearly explained the link between his urinary health and his recent illness; he was scheduled for a 1-week appointment with Urology to discuss and evaluate this further. Throuhgout his hospital stay, vital signs were routinely monitored. Good pulmonary toilet, early ambulation and incentive spirometry were encouraged throughout hospitalization. Electrolytes were routinely followed, and repleted when necessary. The patient's white blood count and fever curves were closely watched for signs of infection. Wound care was performed regularly and thoroughly. The patient's blood sugar was monitored throughout his stay; insulin dosing was adjusted accordingly. The patient received subcutaneous heparin and venodyne boots were used during this stay; was encouraged to get up and ambulate as early as possible. At the time of discharge, the patient was doing well, afebrile with stable vital signs. The patient was tolerating a regular diet, ambulating, voiding without assistance, and pain was well controlled. The patient received discharge teaching and follow-up instructions with understanding verbalized and agreement with the discharge plan. Medications on Admission: Discharge medications: ([**8-22**]) 1. Tamsulosin 0.4 mg PO HS RX *tamsulosin 0.4 mg 1 capsule(s) by mouth once a day Disp #*40 Capsule Refills:*0 2. Oxycodone-Acetaminophen (5mg-325mg) [**12-30**] TAB PO Q4H pain RX *oxycodone-acetaminophen 5 mg-325 mg [**12-30**] tablet(s) by mouth every four (4) hours Disp #*45 Tablet Refills:*0 3. Allopurinol 300 mg PO DAILY 4. Colchicine 0.6 mg PO EVERY OTHER DAY 5. Losartan Potassium 25 mg PO DAILY - of note, was on ASA 81 on admission, but this was held at discharge Discharge Medications: 1. Ciprofloxacin HCl 500 mg PO Q12H RX *ciprofloxacin [Cipro] 500 mg 1 tablet(s) by mouth every twelve (12) hours Disp #*22 Tablet Refills:*0 2. Finasteride 5 mg PO DAILY RX *finasteride 5 mg 1 tablet(s) by mouth once a day Disp #*40 Tablet Refills:*1 3. Tamsulosin 0.4 mg PO HS 4. Allopurinol 300 mg PO DAILY 5. Colchicine 0.6 mg PO EVERY OTHER DAY 6. Losartan Potassium 25 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: Fever, tachypnea and tachycardia in the setting of a post-operative Foley cathether, most concerning for urosepsis. Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to the surgery service at [**Hospital1 18**] for evaluation and treatment of your fever and shortness of breath. You have done well in the hospital and are now safe to return home to complete your recovery with the following instructions: Please resume all regular home medications, unless specifically advised not to take a particular medication. Also, please take any new medications as prescribed. Please get plenty of rest, continue to ambulate several times per day, and drink adequate amounts of fluids. Avoid lifting weights greater than [**5-7**] lbs until you follow-up with your surgeon, who will instruct you further regarding activity restrictions. Avoid driving or operating heavy machinery while taking pain medications. Please follow-up with your surgeon and Primary Care Provider (PCP) as advised. Incision Care: *Please call your doctor or nurse practitioner if you have increased pain, swelling, redness, or drainage from the incision site. *Avoid swimming and baths until your follow-up appointment. *You may shower, and wash surgical incisions with a mild soap and warm water. Gently pat the area dry. *If you have 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. Please call your doctor or nurse practitioner if you experience the following: *You experience new chest pain, pressure, squeezing or tightness. *New or worsening cough, shortness of breath, or wheeze. *If you are vomiting and cannot keep down fluids or your medications. *You are getting dehydrated due to continued vomiting, diarrhea, or other reasons. Signs of dehydration include dry mouth, rapid heartbeat, or feeling dizzy or faint when standing. *You see blood or dark/black material when you vomit or have a bowel movement. *You experience burning when you urinate, have blood in your urine, or experience a discharge. *Your pain is not improving within 8-12 hours or is not gone within 24 hours. Call or return immediately if your pain is getting worse or changes location or moving to your chest or back. *You have shaking chills, or fever greater than 101.5 degrees Fahrenheit or 38 degrees Celsius. *Any change in your symptoms, or any new symptoms that concern you. Followup Instructions: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4653**], MD Phone:[**Telephone/Fax (1) 5727**] Date/Time:[**2144-9-10**] 4:20 PM Location: [**Hospital Ward Name **] 3, [**Hospital1 18**] Provider: [**First Name11 (Name Pattern1) 177**] [**Last Name (NamePattern4) 13365**], MD Phone:[**Telephone/Fax (1) 3201**] Date/Time:[**2144-9-16**] 9:45 AM Location: [**Hospital1 18**], [**Hospital Ward Name **] 3 - SURGICAL SPECIALTIES OFFICE Provider: [**First Name8 (NamePattern2) 11595**] [**Last Name (NamePattern1) 11596**], MD Phone:[**Telephone/Fax (1) 2226**] Date/Time:[**2145-1-7**] 9:30 AM Completed by:[**2144-9-4**]

[ "593.89", "799.02", "273.8", "E879.6", "790.4", "V45.89", "997.5", "274.9", "V16.3", "787.91", "276.1", "590.10", "788.20", "V15.82", "585.9", "403.90", "584.9", "715.90", "996.64", "785.52", "787.01", "995.92", "038.42" ]

icd9cm

[ [ [] ] ]

[ "38.93" ]

icd9pcs

[ [ [] ] ]

10122, 10128

5589, 9147

331, 338

10288, 10288

3164, 3164

12786, 13436

2127, 2174

9710, 10099

10149, 10267

9173, 9173

10439, 11278

5355, 5566

11293, 12763

1809, 1886

2189, 2191

262, 293

2711, 3145

366, 1679

3181, 5338

2205, 2695

10303, 10415

1701, 1786

1902, 2111

73,645

197,104

38717

Discharge summary

report

Admission Date: [**2105-8-2**] Discharge Date: [**2105-8-8**] Date of Birth: [**2076-2-7**] Sex: F Service: MEDICINE Allergies: Phenothiazines / Depakote / Thorazine Attending:[**First Name3 (LF) 7744**] Chief Complaint: Calcium Channel Blocker overdose Major Surgical or Invasive Procedure: Triple Lumen CVL, Right IJ History of Present Illness: Ms. [**Known lastname 10162**] is a 29 YOF with a history of bipolar d/o with multiple suicidal attempts, recently admitted to [**Hospital1 **] 4 [**7-9**] to [**7-27**] for suicidal ideation following discharge from [**Hospital1 **] for cutting her arms. During her recent admission to [**Hospital1 18**] she demonstrated self destructive behavior with picking at her cut sutures and creating a noose with bedsheets when she was told she would be discharged. Her outpatient psychiatrists did not want her on antidepressants because of fear of precipitating mania. ECT was considered, but the pt was too scared to have this done. She reported suicidal ideation/plan on the day of discharge. She was sent to her Mass Mental Partial program at the [**Hospital1 **] with a plan to go to her DBT house after that. . The patient reports that after discharge she went to [**Hospital1 2177**] where she requested a prescription for verapamil. She told the medical providers there that she was on this medication and was going out of town and needed a refill. She was given a rx of verapamil 180 mg SR tablets. Of note, the two pharmacies at [**Hospital1 2177**] were called and reported no record of the pt in their pharmacy records or dispensations. On [**8-2**] around 4 pm she took 20 tablets of this medication because she felt her psychiatrists do not listen to her and she thought this might get their attention. She states that she is sad, and wants to be on antidepressants but she has been told by her psychiatrists that she cant take them due to fear of precipitating mania. She also is discouraged that her psych providers frequently change because they are residents. Prior to taking the verapamil, she premedicated with Zofran 4 mg and Ativan 1 mg. She denies any other ingestions. . In the ED, VS were 98.7 102 161/90 20 97% RA. Labs were significant for negative CBC, Chem 7, LFTs, and urine and serum tox screens. Toxicology was consulted. The patient received activated charcoal. She refused placement of a tube for gastric lavage or whole bowel irrigation. Psych was curbsided for capacity, and given the fact that these interventions were not shown to have strong data for outcomes, they were not performed. However, it was determined that the patient We cannot refuse EKGs, IV access, fingersticks. She received 1 L NS. 99.3 FS 150 -->163--> 188 . In MICU Green, the patient was comfortable but was crying. She stated she did not want to die and she was scared. She was not in pain. She admitted to overdosing on benadryl and klonopin last week (went to [**Hospital1 112**]). She was put on levophed briefly which was d/c'd when the insulin gtt was started; her HR remained stable. She was given lasix 20mg IV [**1-14**] hypoxia in setting of +10L [**Location 10226**] she recieved repeat dose with improvement in o2 sats to 98% on 4L. She also had intermittant CP with EKG showing no ischemic changes, prolonged QTc 462, t wave flattening. As per toxicology recs, her insulin gtt was weaned. She was continued on her home psych Rx and pain Rx, and had a sitter. Her transfer vitals upon call-out were 96.9, 96, 145/76, 26, 96%RA, I/O was LOS positive 6.7L. . On the medical floor, she said that she was feeling fine and does not c/o pain. She denied dizziness/lightheadedness when standing up, fever, HA, CP, SOB, N/V, D/C. She says that she is feeling somewhat anxious. She says that she chose to use verapamil b/c she has used it in the past and it almost worked to end her life before. Her current mood is "OK", and she does not currently have thoughts of hurting herself. Past Medical History: * Borderline Personality Disorder * Eating DO NOS (restricting, laxative use, binging/purging) Hospitalizations: Multiple. Most recently: * [**Hospital1 18**] [**Date range (3) 86012**] * [**Hospital1 18**] [**2105-6-17**] - [**2105-6-26**] * [**Hospital1 18**] [**3-/2105**] * [**Last Name (un) 3671**] [**1-/2105**] * NWH [**1-/2105**] * [**Hospital1 18**] 1/[**2104**]. SA/SIB: Numerous suicide attempts in the past including 7 by means of overdose and one by means hanging; most recent attempt was in [**2105-6-12**]; has had a suicide attempt by means of verapamil x2, acetaminophen which required ICU admission. Longstanding history of SIB by means of cutting. Outpatient Program: DBT Program at Mass Mental Therapist: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] Psychiatry Resident: [**First Name4 (NamePattern1) 1022**] [**Last Name (NamePattern1) 16417**] Psychiatry Attending: Dr. [**Last Name (STitle) **] . PAST MEDICAL HISTORY: * Morbid Obesity * OSA * GERD * Fibromyalgia * Hyperlipidemia * Gastroparesis Social History: Patient is currently living in the DBT house in [**Location (un) **] and is attending the DBT partial hospital program at Mass Mental. Unemployed and currently on SSDI. Denies tobacco, etoh, or other drug use. Is not sexually active. Family History: mother - borderline personality disorder per patient both parents - substance abuse maternal aunt - completed suicide by means of heroin and BDZ overdose Physical Exam: ADMISSION PHYSICAL EXAM: Vitals: 98.7 102 161/90 20 97% RA General: Obese, Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, unablt to appreciate JVP secondary to body habitus Lungs: Clear to auscultation bilaterally CV: Regular rate and rhythm Abdomen: soft, non-tender, non-distended, bowel sounds present GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema . DISCHARGE PHYSICAL EXAM: Unchanged from previous except for the following: VS - Temp 97.4F, BP 134/80, HR 90, R 18, O2-sat 95% RA GENERAL - obese woman in NAD, comfortable, appropriate HEENT - R eye lateral strabismus, NC/AT, PERRL, EOMI, sclerae anicteric, MMM, OP clear LUNGS - Mild crackles at bases bilat, no r/rh/wh, good air movement, resp unlabored, no accessory muscle use PSYCH - Her current mood is "fine", and she does not currently have thoughts of hurting herself. Pertinent Results: Admission Labs: [**2105-8-2**] 05:30PM BLOOD WBC-9.5 RBC-4.89 Hgb-13.0 Hct-37.3 MCV-76* MCH-26.7* MCHC-35.0 RDW-14.9 Plt Ct-332 [**2105-8-3**] 05:04AM BLOOD PT-13.9* PTT-35.1* INR(PT)-1.2* [**2105-8-2**] 05:30PM BLOOD Glucose-153* UreaN-9 Creat-0.6 Na-138 K-4.3 Cl-102 HCO3-26 AnGap-14 [**2105-8-2**] 05:30PM BLOOD ALT-14 AST-16 AlkPhos-78 TotBili-0.1 . DISCHARGE LABS: [**2105-8-6**] 06:00AM BLOOD WBC-5.9 RBC-4.01* Hgb-10.7* Hct-31.1* MCV-77* MCH-26.7* MCHC-34.5 RDW-15.3 Plt Ct-271 [**2105-8-6**] 06:00AM BLOOD Plt Ct-271 [**2105-8-6**] 06:00AM BLOOD Glucose-112* UreaN-16 Creat-0.7 Na-140 K-3.8 Cl-102 HCO3-32 AnGap-10 [**2105-8-6**] 06:00AM BLOOD Calcium-8.9 Phos-4.9* Mg-1.7 . MICROBIOLOGY: -[**8-2**] Urine Cx: URINE CULTURE (Final [**2105-8-3**]): MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. . IMAGING: -[**8-3**] ECG: Normal sinus rhythm at a rate of 77. There is slight QTc interval prolongation. There appears to be a U wave potentially superimposed on the T wave. -[**8-4**] ECG: Normal sinus rhythm at a rate of 91. Non-specific ST-T wave changes are present which are unchanged compared with the previous tracing. -[**8-5**] CXR: FINDINGS: As compared to the prior examination, there appears to be decreased vascular congestion. Aeration at the right base may be slightly improved with some residual atelectasis and pleural effusion. No pneumothorax is seen. The heart size is normal. A right-sided central line is unchanged with tip in the SVC. Brief Hospital Course: Ms. [**Known lastname 10162**] is a 29yo woman with a h/o bipolar d/o with multiple suicidal attempts who had a brief MICU stay for treatment of intentional verapamil ingestion. In summary, she was treated in the MICU with levophed, IV fluids, and insulin gtt; she never became bradycardic. She was called out to the floor on [**8-4**] and was stable, and did not endorse suicidal ideation while on the medical floor. . ACTIVE ISSUES: . # Calcium channel blocker (verapamil) toxicity: She was thought to have ingested about 3600 mg of extended release verapamil. While the pharmacies at [**Hospital1 2177**] said that they had no record of the pt and had not given her the verapamil; and thus it is unclear where she obtained it from. In the MICU, she was not bradycardic and had no ECG changes but was on levophed for a short time. She was monitored for bradycardia and PR interval prolongation, neither of which was observed. She was hypotensive and received 10L of IVF in the first 10 hours of her hospitalization. She required levophed for a short period of time in the ICU for blood pressure support, and was treated with an insulin drip of 100units/hour overnight and supported with D10W at 100/hr while on the drip. Her glucose was monitored q30min, and she was transitioned to insulin and glucose gtt which was subsequently weaned. She was able to be taken off the insulin gtt as well as the D10 gtt prior to transfer to the floor. On the regular medical floor, she was clinically stable with stable VS. She was slightly fluid-overloaded and was diuresed well with lasix 20mg IV BID. . # Suicidal Ideation: She has a h/o bipolar disorder and anxiety, and has had multiple psychiatric admissions for suicidal attempts and ideation in the past. She has had unsuccessful hospitalizations and has not been started on anti-depressants because of fear of mania. Psychiatry was consulted and followed to help manage her medications prior to her transfer to an inpatient hospitalization. Social work was also consulted to help with her management. . INACTIVE ISSUES: . # OSA: on CPAP at home. This was maintained while in house. . #Back pain and fibromyalgia: Home oxycodone was continued. . # Gastroparesis: NPO in the MICU. Reglan, zofran, simethicone were restarted when she was stable and safely taking POs. . # GERD: Restart omeprazole when she started taking PO. . TRANSITIONS OF CARE: -Transfer to psychiatry on [**Hospital1 **] 4 Medications on Admission: HOME MEDICATIONS: 1. neomycin-bacitracnZn-polymyxin Qday (not currently used) 2. simethicone 80 mg [**Hospital1 **] 3. ondansetron 4 mg Tablet,TIDAC 4. oxycodone 10 mg Tablet Extended Release Q12 PRN 5. pregabalin 75 mg [**Hospital1 **] 6. propranolol 10 mg TID 7. ibuprofen 600 mg Q8 PRN 8. trazodone 100 mg QHS 9. omeprazole 40 mg Delayed Release(E.C.) Q day 10. senna 8.6 mg [**Hospital1 **] 11. metoclopramide 10 mg [**Hospital1 **] 12. hyoscyamine sulfate [**Hospital1 **] 13. hydroxyzine HCl 25 mg TID 14. hydroxyzine HCl 50 mg Q dAY PRN anxiety 15. lorazepam 1 mg Q 8 PRN 16. clonazepam 2 mg PO QHS 17. lamotrigine 250 mg Qday 18. clonazepam 1 mg Qday 19. haloperidol 1 mg TID Discharge Medications: 1. simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO twice a day as needed for gas. 2. ondansetron 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO TIDAC (3 times a day (before meals)). 3. oxycodone 10 mg Tablet Extended Release 12 hr Sig: One (1) Tablet Extended Release 12 hr PO Q12H (every 12 hours). 4. pregabalin 75 mg Capsule Sig: One (1) Capsule PO twice a day. 5. propranolol 10 mg Tablet Sig: One (1) Tablet PO three times a day. 6. ibuprofen 600 mg Tablet Sig: One (1) Tablet PO every eight (8) hours as needed for pain. 7. trazodone 100 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 8. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 9. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 10. metoclopramide 10 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 11. hyoscyamine sulfate 0.125 mg Tablet Sig: One (1) Tablet PO twice a day. 12. hydroxyzine HCl 25 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily) as needed for anxiety. 13. hydroxyzine HCl 25 mg Tablet Sig: One (1) Tablet PO three times a day. 14. lorazepam 1 mg Tablet Sig: One (1) Tablet PO every eight (8) hours as needed for anxiety. 15. clonazepam 1 mg Tablet Sig: Two (2) Tablet PO QHS (once a day (at bedtime)). 16. clonazepam 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 17. lamotrigine 100 mg Tablet Sig: 2.5 Tablets PO DAILY (Daily). 18. haloperidol 1 mg Tablet Sig: One (1) Tablet PO three times a day. Discharge Disposition: Extended Care Discharge Diagnosis: Primary Diagnosis: Calcium Channel blocker toxicity Suicide Attempt Major Depression Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent Discharge Instructions: Dear Ms. [**Known lastname 10162**], It was a privilege to provide care for you here at the [**Hospital1 **] Hospital. You were admitted for treatment of a verapamil overdose. In the intensive care unit, you were treated with fluids and other medicines, and when your condition stabilized you were transferred to the regular medical floor. You were given diuretics to help get some of your excess fluid off, and you were stable. You were followed closely by the Psychiatry team. Your condition has improved and you can be discharged to an inpatient psychiatric treatment facility. The following changes were made to your medications: NEW: none CHANGED: none STOPPED: none Please keep your follow-up appointments as scheduled below. Followup Instructions: Department: MEDICAL SPECIALTIES When: WEDNESDAY [**2105-9-9**] at 8:00 AM With: [**Name8 (MD) 3300**] RRT/DR. [**Last Name (STitle) **] [**Telephone/Fax (1) 612**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Completed by:[**2105-8-10**]

[ "301.83", "300.00", "251.1", "296.80", "536.3", "327.23", "729.1", "296.20", "530.81", "278.01", "V15.41", "972.4", "E950.4", "307.50", "272.4" ]

icd9cm

[ [ [] ] ]

[ "38.93" ]

icd9pcs

[ [ [] ] ]

12737, 12752

8003, 8423

329, 357

12881, 12881

6467, 6467

13794, 14130

5360, 5516

11176, 12714

12773, 12773

10468, 10468

13031, 13771

6837, 7980

5556, 5968

10486, 11153

256, 291

8438, 10053

385, 3991

10070, 10374

6483, 6821

12792, 12860

12896, 13007

10395, 10442

5000, 5090

5106, 5344

5993, 6448

10,425

164,083

48321+48322

Discharge summary

report+report

Admission Date: [**2194-4-16**] Discharge Date: [**2194-4-16**] Date of Birth: [**2138-9-5**] Sex: M Service: [**Last Name (un) **] NARRATIVE SUMMARY: The patient was admitted to the hospital pretransplantation for possible pancreatic transplantation. The pancreatic transplantation was aborted due to aberrancy with abnormal anatomy in the donor organ. The patient, Mr. [**Known firstname 1692**] [**Known lastname 7324**], was then informed that the donor organ was unsuitable and therefore, for this reason, he was discharged home in stable condition status post potential pancreatic transplant. [**Name6 (MD) **] [**Name8 (MD) **], [**MD Number(1) 4841**] Dictated By:[**Last Name (NamePattern1) 7823**] MEDQUIST36 D: [**2194-4-16**] 19:11:38 T: [**2194-4-19**] 10:22:16 Job#: [**Job Number 101795**] Admission Date: [**2194-4-17**] Discharge Date: [**2194-5-15**] Date of Birth: [**2138-9-5**] Sex: M Service: [**Last Name (un) **] ADMITTING DIAGNOSIS: Type 1 diabetes mellitus called in for a possible pancreas transplant. HISTORY OF PRESENT ILLNESS: The patient is a 55-year-old male status post living-unrelated kidney transplant [**2193-7-7**] for end-stage renal disease secondary to type 1 diabetes. He had a baseline creatinine of 1.5. He experienced increase in creatinine in [**2193-7-7**]. Needle biopsy positive for ACR with foci of mild endotheliitis. He was treated with OKT3. Creatinine decreased to 1.1. He was placed on Prograf and Rapamune without steroids. On [**2194-4-1**], he called to report mouth sores. Rapamune dose was lowered to 1 mg for a level of 9.3. His mouth sores improved. Last creatinine and BUN on [**2194-4-11**] were 1.4/29. Stress test performed [**2193-11-5**] for complaints of fatigue and chest pain. Fair functional exercise capacity. Borderline ischemic EKG. BP responds to exercise. Stress echo - no 2-D echocardiogenic evidence of ischemia. Ejection fraction greater than 55%. The patient has been doing very well, and no chest pain, not actively taking blood pressure medications. No lower extremity edema. No abdominal pain, no fevers, no chills, no nausea, vomiting, no change in urine or bowel movements, eating well without problems. PAST MEDICAL HISTORY: End-stage renal disease secondary to type 1 diabetes, living-unrelated kidney transplant [**2193-7-23**], ACR [**2193-8-6**] treated with OKT3 x5 days, history of anemia, history of syncope, history of asthma, celiac sprue, TIA in [**2190**], history of hypotension, history of atrial fibrillation, H. pylori, history of psoriasis, history of osteoarthritis, [**2190**] cardiac catheterization, history of murmur. ALLERGIES: Captopril and iron. MEDS ON ADMISSION: 1. Aspirin 325 mg once daily. 2. Lantus 12 units once daily. 3. Sertraline 100 mg once daily. 4. Bactrim SS 1 once daily. 5. Asacol 500 mg once daily. 6. Alendronate 30 mg q week. 7. Plavix 75 once daily. 8. Humalog SS. 9. Prograf 1.5 b.i.d. 10. Rapamune 1 mg once daily. PAST SURGICAL HISTORY: Left AV wrist fistula [**2193-4-6**], status post cardiac catheterization with right coronary stent [**2193-5-7**], left cataract removed from eye [**2193-7-7**], right cataract removed [**2193-7-7**], living-unrelated kidney transplant, status post T and A, status post deviated septum surgery, status post cholecystectomy, status post bladder tumor excision. SOCIAL HISTORY: Married with 1 child, electrical engineer. No alcohol. No tobacco. FAMILY HISTORY: Noncontributory. PHYSICAL EXAM: Patient, awake, alert, sitting up in bed in no acute distress. Temperature 98.8, heart rate 79, BP 140/68, respirations 20 on 98% room air, weight 61.36 kg. HEENT: Atraumatic, normocephalic. EYES: Pupils equal, round, react to light. EOMS are full. MOUTH: Tongue midline, no exudates. NECK: Supple, no palpable nodes, no thyromegaly, no carotid bruits bilaterally. Full range of motion. LUNGS: Clear to A and P bilaterally. CV: Regular rate and rhythm, a systolic ejection murmur of II/VI. ABDOMEN: Positive bowel sounds, well-healed left lower quadrant incision, soft, nontender, no organomegaly. EXTREMITIES: No C/C/E, +1 pulses AT and DP, +2 groin pulses bilaterally. NEUROLOGIC: Cranial nerves II through XII intact. Motor [**4-10**] bilaterally. LABS ON ADMISSION: 3.7, hematocrit 33.3, platelets 236, PT 13.3, INR 1.2, PTT 32.4, AST 39, ALT 52, alkaline phosphatase 214, amylase 103, total bilirubin 0.4. EKG shows normal sinus rhythm, no ST changes. Chest x-ray compared to [**2194-3-10**] continued to be clear, no acute pulmonary process. HOSPITAL COURSE: On [**2194-4-16**], the patient was waiting for the donor, but the donor's organ was not acceptable for this patient. The patient was discharged on [**2194-4-16**]. The patient did return on [**2194-4-17**] for potential transplant. Compared to [**2194-4-16**], there was no change in his physical exam, no fevers, no chills, no abdominal pain, no swelling to lower extremities, no cough, no chest pain. The patient went to surgery on [**2194-4-17**] for pancreas transplant, Y-graft to left lower quadrant, and bowel anastomosis performed by Dr. [**Last Name (STitle) **] and [**Doctor Last Name **]. There were no complications. The patient was stable and went to recovery room. Please see detailed documentation of the operative note in the computer. The patient went to the regular floor postoperatively. The patient was placed on thymo, MMF and FK. [**Last Name (un) **] was consulted on [**2194-4-18**] for blood sugar control and had continued to follow him while he was a patient in the hospital. The patient continued on FK, ATG, MMF, Simulect. Blood sugars have decreased significantly. The patient had an NG tube placed. The patient was n.p.o., taking meds p.o., and clamping NG tube. The patient had a JP drain in place which was draining sanguineous fluids. Labs have been stable. The patient was placed on a PCA postoperatively for pain control. Foley was removed on [**2194-4-20**]. On [**2194-4-21**], the patient had an acute hematocrit drop. On [**4-19**], hematocrit was 31 and this slowly decreased to 29, to 28, to 26 that day. So, it was decided to get a CT abdomen with IV contrast, as well as a CT pelvis. The findings demonstrated that there was nothing to explain the significant hematocrit drop. Postoperative changes around the new pancreas and bowel anastomosis. Findings were discussed with Dr. [**Last Name (STitle) **]. The patient continued to do well with this blood sugars. PCA was discontinued. Postoperatively, the patient had atelectasis bilaterally, but no signs of acute infiltrate from a chest x-ray that was done on [**2194-4-27**]. The patient's hematocrit continued to drop requiring packed red blood cell transfusions and FFP for an INR of 4.9 on [**2194-4-29**]. The patient continued to have JP intact, but has had bloody output from drain. PT and OT were consulted. He continued to be afebrile. Vital signs stable. On [**2194-5-1**], the patient was brought to the OR for abdominal washout with removal of pancreatic hematoma. The old incision was opened, and a significant amount of old blood and hematoma were present. Please see OR note for detailed information about the procedure that was done on [**2194-5-1**]. On [**2194-5-1**], labs were the following: WBC 13.8, hematocrit 32.3, platelets 353, PT 13.8, PTT 33.8, INR 1.3. The patient continued to be on tacrolimus and rapamycin during this hospitalization. On [**2194-5-6**], the patient had a CT abdomen status post washout and complained of abdominal pain, diarrhea and elevated white blood cell count. CT abdomen and pelvis demonstrated no evidence of small bowel obstruction, or drainable fluid collection abdomen; interval slight increase in amount of free fluid in the abdomen and pleural effusions after abdominal irrigation. The patient had 2 JP drains, as well as 2 JP drains after the washout surgery. The patient continued to need intermittent transfusions for a low hematocrit. The patient was restarted on aspirin and Plavix. The patient continued to see physical therapy and occupational therapy. On [**2194-5-7**], the patient had PICC line placement for parenteral nutrition. On [**2194-5-8**], the patient had a lower extremity ultrasound, for right lower extremity edema, demonstrating no evidence of deep venous thrombosis. Throughout his hospitalization, the patient has been making good urine output. The patient had a low-grade temperature on [**2194-5-9**] with diarrhea and was cultured for that temperature. A swab culture that was finalized demonstrated that there was staph coag-negative. All of his multiple stool cultures have been sent-off which have been unremarkable, no growth, no fungus, no microbacteria. On [**2194-5-12**], the patient had a Dobbhoff tube placed under fluoroscopy. TPN was switched to tube feeds, and the reason behind that was that the diarrhea may be due to the actual TPN. On [**2194-5-12**] around 5 o'clock in the evening, the patient had dyspnea without any reason. An ABG was obtained demonstrating a pH 7.42, PO2 82, PCO2 33, bicarbonate 22. The patient was transferred to SICU just for close monitoring. CT obtained. CTA was obtained to rule out PE. CT chest with CTA was performed, demonstrating bibasilar atelectasis, or consolidations with effusions. No evidence of a pulmonary embolism. The renal team continued to see patient, while patient was hospitalized, making excellent recommendations. On [**5-13**], the patient was transferred from the ICU to the regular floor since he was stable. The patient had repeat gases on [**2194-5-12**], and his pH was 7.44, PO2 190, CO2 30, bicarbonate 21. He did have cardiac enzymes obtained which were all unremarkable, and so the patient was transferred to Far-10, very somnolent, very low-energy. Psychiatry came to see patient and felt that he should continue on his antidepressant medication, which was Zoloft at the present dose, and had recommended giving him a trial of Ritalin, which they recommended starting at 5 mg in the morning. They felt that while he is at rehab, he should be followed by psychiatrist there. The patient continues to do well, although very somnolent, but awake and ambulating with physical and occupational therapy. He has been afebrile. Vital signs stable. His labs have been stable too. He continues on tube feeds, and he is on rapamycin and tacrolimus for immune suppression medications. He has no swelling. No lower extremity edema. His wounds continues to be clean, dry and intact. He has good bowel sounds. He has mild atelectasis at both bases. So, the patient is going to go to rehab, continue on antibiotics for 2 weeks, and continue fluconazole for 2 weeks. DISCHARGE MEDICATIONS: 1. Tylenol 650 q. [**3-12**] h p.r.n. 2. Albuterol nebs q. [**3-12**] h. p.r.n. 3. Anzemet 12.5 IV q 8 h. p.r.n. 4. Fludrocortisone acetate 0.1 b.i.d. 5. Heparin 5,000 units subcutaneous t.i.d. 6. Insulin sliding scale. 7. Loperamide HCl 2 mg b.i.d. 8. Lopressor 25 b.i.d. 9. Flagyl 500 mg t.i.d. 10. Miconazole powder 2% 1 application TP t.i.d. 11. Nystatin oral suspension 5 ml p.o. q.i.d. 12. Percocet [**12-8**] p.o. q. [**3-12**] h. p.r.n. 13. Protonix 40 q. 12. 14. Zosyn 4.5 IV q. 8 for 2 weeks. It will be discontinued on [**2194-5-28**]. 15. Zoloft 150 mg p.o. once daily. 16. Sirolimus 1 mg once daily. 17. Bactrim SS 1 tab once daily. 18. Tacrolimus possibly will leave on 2 mg b.i.d. 19. Valganciclovir HCl 450 once daily. 20. Ritalin 5 mg q a.m. FOLLOW UP: The patient is going to be following up with Dr. [**Last Name (STitle) **] on [**2194-5-8**] at 9:10 a.m. at the [**Hospital Ward Name **] Bldg., transplant office, on the 7th Fl., telephone# ([**Telephone/Fax (1) 3618**], and also Mr. [**Known lastname 7324**] is going to follow-up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] on [**2194-5-16**] at 9:10 a.m. She is also in the [**Hospital Ward Name **] Bldg, transplant office, on the 7th Fl., telephone# ([**Telephone/Fax (1) 3618**], and also patient is going to follow-up with Dr. [**Last Name (STitle) **] on [**2194-5-22**] at 11:40 a.m. in [**Hospital Ward Name **] Bldg, 7th Fl. The patient should follow-up with psychiatrist while patient is at rehab. The patient or staff at the rehab facility should call transplant surgery immediately if there are any fevers, chills, nausea, vomiting, inability to take medications, decreased urine output, increased glucose, redness, bleeding from incision, or any questions. He should have labs q. Monday and Thursday for CBC, chem-7, calcium, phosphorus, AST, total bilirubin, lipase, amylase, urinalysis, and a Prograf, and a rapamycin level. Results should be faxed to transplant office, ([**Telephone/Fax (1) 12146**]. No driving while taking medications. [**Month (only) 116**] take showers, but no heavy lifting. For the past 7 days, the patient's tacrolimus level has been ranging from 9 to 19. The last one was on [**2194-5-14**] which was 19. Rapamycin levels: The last one was on [**2194-5-13**], and it was 4.5. They have been ranging from 5 to 8. The patient is currently on rapamycin 1 mg once daily. So, levels are pending for today, and the discharge medications may change according to the levels. FINAL DIAGNOSES: 1. Type 1 insulin dependent diabetes mellitus. 2. Status post pancreas transplant [**2194-4-17**]. 3. Second surgery was washout of the abdomen on [**2194-5-1**]. [**Name6 (MD) **] [**Name8 (MD) **], [**MD Number(1) 4841**] Dictated By:[**Last Name (NamePattern1) 4835**] MEDQUIST36 D: [**2194-5-15**] 11:16:06 T: [**2194-5-15**] 13:02:19 Job#: [**Job Number 101796**]

[ "560.1", "997.3", "V45.82", "493.90", "696.1", "414.01", "579.0", "285.1", "401.9", "250.61", "518.0", "311", "V12.59", "276.8", "998.12", "250.41", "357.2", "787.91", "583.81", "V42.0", "715.90" ]

icd9cm

[ [ [] ] ]

[ "52.80", "54.12", "96.6", "38.93", "00.93", "99.04", "96.07", "54.25", "99.15", "99.07" ]

icd9pcs

[ [ [] ] ]

3529, 3547

10780, 11599

4632, 10757

3065, 3427

3563, 4320

13374, 13778

11611, 13357

1135, 2271

4335, 4614

1034, 1106

2294, 2748

3444, 3512

32,125

174,557

51401

Discharge summary

report

Admission Date: [**2115-9-20**] Discharge Date: [**2115-10-9**] Date of Birth: [**2053-12-12**] Sex: F Service: MEDICINE Allergies: Aspirin / Penicillins / Biaxin / Azithromycin / Heparin Agents Attending:[**First Name3 (LF) 1493**] Chief Complaint: increased abdominal girth Major Surgical or Invasive Procedure: placement of tunnelled dialysis cathether History of Present Illness: This is a 61 y/o woman with PMH notable for WPW s/p triple valve replacement (MV, AV, TV) on chronic coumadin, cirrhosis [**12-22**] heart failure, and chronic renal insufficiency (renal Cr ~ 3) who presents with increased abdominal girth and dyspnea. Patient has been at home for several weeks following a stay at [**Hospital3 **]. She states that there she had C diff colitis but is no longer on antibiotics. . In the ED, initial vs were: P 65 BP 137/66 R 16 O2 sat 98%. Patient was given no medications in the ED. Her BP did transiently decrease to 88/48 but came back up to 101/53 without intervention. Temperature was noted to be 94.7. . Call in note states patient has had INR 7 for past few days so coumadin has been held. . On the floor, the patient states that she has no dyspnea when not walking. She [**Hospital3 **] any chest pain. She endorses increased abdominal girth but [**Hospital3 **] abd pain or fevers. She notes recently decreased urine output but no dysuria. [**Hospital3 4273**] recent changes in her meds or antibiotic use. No nausea or vomiting; normal PO intake for her. She reports she took 2.5 mg coumadin yesterday after taking 5 mg X 1 week with resultant INR 7.3. . ROS: As above. No headaches, slurred speech, confusion. No sore throat, congestion, difficulty swallowing. No cough or sputum production. No hematemesis or blood in stool. Chronically has diarrhea ("IBS" per her report). Has chronic edema from knees to midchest. No joint pains, rash, or myalgias. Past Medical History: Notes for dates: [**Date range (3) 106558**] [**Doctor Last Name 3271**]-[**Doctor Last Name 679**] A - Last Updated by [**Last Name (LF) **],[**First Name3 (LF) 1037**] on [**2115-9-21**] @ 1328 Patient Location: FA10-1001-01 Intern Accept Note . PCP: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD Hepatologist: Dr. [**Last Name (STitle) 696**] . Intern Accept Note: . CC: increased abdominal pain . Please see admission H&P for full details of history. HPI: Ms. [**Known lastname 38403**] is a 61 yo woman with a hx of CRI and WPW s/p valve replacement on coumadin who presents with anasarca and acute on chronic renal failure. She has noted increasing girth for 3 weeks. For the past week she also noticed decreased urine output. . Of note, coumadin had been held for 2 days for increased INR to 7. . In the ED, initial vs were: T 94.7 P 65 BP 137/66 R 16 O2 sat 98%. Patient was given no medications in the ED. Her BP did transiently decrease to 88/48 but came back up to 101/53 without intervention. US notable for large ascites, labs notable for creatinine 5.9 and LFTs WNL. . On acceptance to the medicine service, Ms. [**Known lastname 38403**] [**Last Name (Titles) **] dyspnea at rest but does have it with exertion. Further [**Last Name (Titles) **] chest pain, abdomonial pain, fevers or chills. No dysuria, no nausea or vomitting. No blood in stools . . Pmhx: * H/o HIT * Chronic renal insufficiency (baseline Cr ~ 3) * h/o diastolic congestive heart failure * Cirrhosis (thought [**12-22**] heart failure) * S/p MVR, AVR, TVR (on chronic coumadin), last valve replacement in [**2085**] * h/o WPW syndrome status post multiple surgeries with resultant valve replacements as above, s/p AICD placement * h/o parathyroid tumor s/p resection * h/o C diff colitis (several weeks ago at [**Hospital3 **]) * h/o gout * h/o PVD with chronic leg ulcers * h/o PUD with GI bleeding * chronic anemia * h/o subdural hematoma ([**3-28**]) in setting of supratherapeutic INR Social History: Divorced. Son died 4 years ago from cardiomyopathy. Has one daughter. Previously lived alone and was independent in ADLS; recently in rehab but back at home. Previously smoked, one alcoholic drink per week and [**Month/Year (2) **] illicit drug use. Previously worked as an aide in nursing homes and hospitals. Family History: N/C Physical Exam: VS: T 97.8 HR 62 BP 104/69 RR 22 Sat 100% on RA Gen: NAD HEENT: mucous membranes moist Neck: supple, no lad CV: RRR, loud S1, S2, 2/6 systolic murmur Resp: L>R crackles in the bases Abd: distended, nontender, bowel sounds present. Extrem: 2+ pitting edema, thighs>calves/feet. B/l venous stasis changes on anterior shins Breasts: asymmetrical, with L breast edema Skin: no rash Neuro: A&O x3, coherent Pertinent Results: [**9-20**] US IMPRESSION: Large amount of ascites, largest pocket in the left lower and mid quadrants of the abdomen. [**2115-9-20**] 07:40PM GLUCOSE-105 UREA N-100* CREAT-6.2* SODIUM-141 POTASSIUM-4.5 CHLORIDE-116* TOTAL CO2-10* ANION GAP-20 [**2115-9-20**] 07:40PM WBC-5.4 RBC-3.55* HGB-10.7* HCT-34.2* MCV-96 MCH-30.0 MCHC-31.2 RDW-19.1* [**2115-9-20**] 07:40PM NEUTS-77.1* BANDS-0 LYMPHS-12.8* MONOS-7.1 EOS-2.7 BASOS-0.3 [**2115-9-20**] 07:40PM PLT COUNT-82* [**2115-9-20**] 07:40PM PT-48.3* PTT-47.2* INR(PT)-5.5* [**2115-9-20**] 05:50AM GLUCOSE-79 UREA N-98* CREAT-5.8* SODIUM-143 POTASSIUM-4.2 CHLORIDE-116* TOTAL CO2-12* ANION GAP-19 [**2115-9-20**] 05:50AM ALT(SGPT)-4 AST(SGOT)-13 LD(LDH)-295* ALK PHOS-140* TOT BILI-0.7 [**2115-9-20**] 05:50AM CALCIUM-7.8* PHOSPHATE-5.5* MAGNESIUM-2.5 [**2115-9-20**] 05:50AM WBC-4.7 RBC-3.46* HGB-10.6* HCT-33.7* MCV-97 MCH-30.7 MCHC-31.6 RDW-19.4* [**2115-9-20**] 05:50AM NEUTS-75.7* LYMPHS-13.6* MONOS-6.8 EOS-3.6 BASOS-0.3 [**2115-9-20**] 05:50AM PLT COUNT-87* [**2115-9-20**] 05:50AM PT-47.2* PTT-50.2* INR(PT)-5.3* [**2115-9-20**] 05:34AM URINE HOURS-RANDOM UREA N-563 CREAT-114 SODIUM-15 TOT PROT-38 PROT/CREA-0.3* [**2115-9-20**] 05:34AM URINE OSMOLAL-341 [**2115-9-20**] 02:45AM URINE BLOOD-TR NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [**2115-9-20**] 02:45AM URINE RBC-0-2 WBC-0-2 BACTERIA-NONE YEAST-NONE EPI-0-2 [**2115-9-20**] 02:45AM URINE AMORPH-MOD [**2115-9-20**] 02:45AM URINE EOS-NEGATIVE [**2115-9-20**] 12:40AM GLUCOSE-112* UREA N-100* CREAT-5.9* SODIUM-142 POTASSIUM-4.0 CHLORIDE-115* TOTAL CO2-14* ANION GAP-17 [**2115-9-20**] 12:40AM ALT(SGPT)-5 AST(SGOT)-13 ALK PHOS-162* TOT BILI-0.7 [**2115-9-20**] 12:40AM LIPASE-74* [**2115-9-20**] 12:40AM CALCIUM-8.1* [**2115-9-20**] 12:40AM AMMONIA-43 [**2115-9-20**] 12:40AM WBC-5.9 RBC-3.93* HGB-11.9* HCT-37.5 MCV-96 MCH-30.2 MCHC-31.7 RDW-19.6* [**2115-9-20**] 12:40AM NEUTS-76.4* LYMPHS-13.1* MONOS-5.9 EOS-4.1* BASOS-0.5 [**2115-9-20**] 12:40AM AMMONIA-43 [**2115-9-20**] 12:40AM WBC-5.9 RBC-3.93* HGB-11.9* HCT-37.5 MCV-96 MCH-30.2 MCHC-31.7 RDW-19.6* [**2115-9-20**] 12:40AM NEUTS-76.4* LYMPHS-13.1* MONOS-5.9 EOS-4.1* BASOS-0.5 [**2115-9-20**] 12:40AM PLT SMR-LOW PLT COUNT-86* [**2115-9-20**] 12:40AM PT-52.6* PTT-46.8* INR(PT)-6.1* [**2115-9-19**] 10:40PM GLUCOSE-113* UREA N-97* CREAT-5.9*# SODIUM-142 POTASSIUM-4.3 CHLORIDE-116* TOTAL CO2-11* ANION GAP-19 [**2115-9-19**] 10:40PM estGFR-Using this [**2115-9-19**] 10:40PM ALT(SGPT)-8 AST(SGOT)-15 ALK PHOS-151* TOT BILI-0.7 [**2115-9-19**] 10:40PM LIPASE-66* [**2115-9-19**] 10:40PM ALBUMIN-3.8 Brief Hospital Course: A 61 yo woman with CRI, WPW s/p 3 mechanical valves, cirrhosis thought to be cardiac in etiology, presents with acute on chronic renal failure and ascites. . # Renal failure: Creatinine rose from 2.8 to 5.9 in the month prior to admission. Exam was consistent with anasarca and volume overload of 20-30 liters. The likely contributing factors were felt to be poor forward flow (from cardiac failure and from overdiuresis) with possibly a lesser component of hepatorenal syndrome. Urinalysis and smear for eosinophils was negative, the sediment was bland, and there was trivial protein in the urine. Albumin was given initially, but renal failure persisted and continued to worsen. Diuretics were held. Plans were made for dialysis. Given that she was so volume overloaded and had systolic BP 90-100, CVVH was the preferred initial dialysis route. After placement of a R tunneled HD catheter, she was transferred to the ICU for CVVH on [**2115-9-24**]. . On presenation to the ICU pt was severely fluid overloaded, with an estimated 30kg weight gain. She was diuresed agressively at a rate of 300-500ml/hr net, with a total diuresis of approximately 16L. Pt tolerated the fluid removal very well and remained hemodynamically stable throughout, with SBPs >80s. She was transferred back to the hepato-renal service. . The patient was mildly hypotensive after starting dialysis, and midodrine treatment was initiated, which improved SBP to 100-110 consistently and helped with orthostatic symptoms. This medication was continued on discharge. . Planning for outpatient dialysis was undertaken, including a negative PPD and hepatitis panel. The physical therapy team saw the patient, and her functional status improved considerably. # cirrhosis/ascites: On admission, the patient appeared to have worsening diuretic-resistent ascites. SBP was unlikely given absence of fever or tenderness. Diagnostic paracentesis was not done secondary to elevated INR and whole-body anasarca. Nadolol was held given her borderline blood pressures. . # Mechanical MV/TV/AV: INR was supratherapeutic on admission. Given her very high risk for thromboembolism and the absence of evidence of bleeding, her INR was allowed to drift down slowly. When the need for a tunneled HD line became apparent, argatroban was begun so that warfarin effects could be reversed with Vitamin K. The argatroban was stopped briefly prior to the procedure and restarted soon after. Warfarin was subsequently restarted and uptitrated with an ongoing argatroban bridge until INR was therapeutic at 4-5 (as argatroban falsely elevates INR by 2.) At that point argatroban was stopped, and the INR drifted down into the therapeutic range. She was discharged on 5 mg daily with plans to continue checking her INR at home and have dose adjustments over the phone as she had been doing prior to admission. . # Atrial fibrillation: During this admission, the patient developed new atrial fibrillation. She was already undergoing therapeutic anticoagulation (as above). . # History of HIT: All heparin products were avoided, and argatroban bridge was used instead as above. A non-heparin dependent tunneled line was placed, and sodium citrate flushes were used. # Thrombocytopenia: Platelets were near recent baseline and likely related to liver dysfunction. . # h/o GI bleeding: [**Hospital1 **] PPI was continued . # gout: In the CCU, pt developed gout of her right fifth digit. She was initially treated with Colchicine without response, and later started on a short course of steroids with rapid improvement. Medications on Admission: coumadin 5 mg daily (X 1 week --> INR to 7), took 2.5 on [**9-19**] epogen 40,000 U weekly lasix 120 mg daily nadolol 20 mg [**Hospital1 **] potassium 20 mEq daily protonix 40 mg [**Hospital1 **] renagel 1600 mg TID Discharge Disposition: Home With Service Facility: [**Hospital **] Hospice and VNA Discharge Diagnosis: primary: end-stage renal disease, atrial fibrillation, gout secondary: cirrhosis, [**Doctor Last Name 79**]-Parkinson-White syndrome Discharge Condition: stable, dialysis-dependent Discharge Instructions: You were admitted to the hospital because you had increased fluid on your body. This was because your kidneys were not functioning well. In the hospital, a catheter was placed and dialysis was started to remove the fluid. You were also found to have an irregular heart rhythm called atrial fibrillation. The following medications were changed: lasix was stopped nadolol was stopped potassium was stopped renagel (sevelamer) was stopped nephrocaps (B-vitamin-B12-folate) were started midodrine was started. Please call your physician or return to the ED if you have worsening swelling, shortness of breath, chest pain, or other symptoms that are concerning to you. Please adhere to a low sodium (<2 gm/day) diet. Followup Instructions: For your Coumadin, please take 5 mg today ([**10-9**]) and test your INR on Thursday, [**10-10**]. Call the coumadin clinic as usual. They will change your dosing as needed. . Please follow up for dialysis on [**10-11**] as you discussed with the renal team. . Please follow up with Dr. [**Last Name (STitle) **] on Thursday, [**10-10**], at 2:15. If you need to reschedule call [**Telephone/Fax (1) 106559**]. . We also scheduled an appointment with Dr. [**Last Name (STitle) 696**]: [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) 3688**] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 2422**] Date/Time:[**2115-10-31**] 4:40 Completed by:[**2115-10-9**]

[ "E879.1", "276.7", "459.81", "274.9", "585.6", "276.2", "428.33", "V45.02", "285.21", "789.59", "426.7", "V43.3", "V58.61", "571.5", "584.9", "287.5", "428.0", "427.31", "458.21" ]

icd9cm

[ [ [] ] ]

[ "39.95", "38.95" ]

icd9pcs

[ [ [] ] ]

11280, 11342

7432, 11014

350, 393

11521, 11550

4725, 7409

12318, 12999

4283, 4288

11363, 11500

11040, 11257

11574, 12295

4303, 4706

285, 312

422, 1919

1941, 3939

3955, 4267

8,271

190,265

2581+55390+55391

Discharge summary

report+addendum+addendum

Admission Date: [**2154-12-10**] Discharge Date: [**2154-12-18**] Date of Birth: [**2085-1-11**] Sex: F Service: HISTORY OF PRESENT ILLNESS: Mechanical aortic valve replacement and she had a large gastrointestinal bleed. ALLERGIES: No known drug allergies. PHYSICAL EXAMINATION: On admission to the medicine floor, vital signs, 98.9, blood pressure 128/70, heart rate 80, respiratory rate 18, 93% O2 sat on room air. In general she appeared her stated age, had pale skin. On neuro exam she was alert and oriented times three, pleasant, loquacious, had no complaints. Her pupils were equal, round and reactive to light and accommodation. On HEENT exam, she had no carotid bruits appreciated. She had moist mucus membranes and degenerated dentition. On cardiovascular she had regular rate and rhythm, normal S1, mechanical S2 and a [**3-13**] holosystolic murmur heard best at the left upper sternal border with radiation to her neck. On pulmonary exam she was clear to auscultation bilaterally. On abdominal exam, nontender, positive bowel sounds and no masses appreciated. Her extremities, she had pedal callouses, crust on the pedal surface skin, appearance consistent with fungal infection and her dorsalis pedis pulses were within normal limits. LABORATORY DATA: Pertinent labs include an INR of 1.2 on [**12-13**]. Rule out for MI by enzymes and EKG. An esophagogastroduodenoscopy study, upper GI study showed duodenitis, contact bleeding noted and Epinephrine injection into the site of contact bleeding gave successful hemostasis. A colonoscopy done on [**12-16**] that showed non bleeding diverticula in her large bowel and a transthoracic echo that showed a greater than normal AV gradient. Also an EF of a greater than 55% and she had a chest x-ray that showed an incidental finding of a right hilar mass. She had a follow-up CT of her chest that showed a hilar mass that was 2.4 cm long on its long axis. HOSPITAL COURSE: This is a 69-year-old woman with obesity, prosthetic mechanic AVR on Coumadin, osteoarthritis, four days prior to admission the patient syncopated without head trauma. After loss of consciousness of short duration, that is, less than 5 minutes, the patient was unable to rise, attributing this to fatigue, and remained prone overnight; overnight she noted bright red blood per rectum plus melena; she did not call EMS out of embarrassment regarding her situation and body habitus. Later (after approximately 24-36 hours down), answering a phone call from a friend who arranged for ambulance pick-up. She was taken to [**Hospital3 13049**], noted to have bright red blood per rectum, a hematocrit of 23.5, troponin I of less than 0.3, given a transfusion of packed red blood cells, given normal saline, and was nasogastric tube lavage negative. She was then transferred to the [**Hospital1 69**] MICU on [**12-10**] and she denied chest pain, shortness of breath, nausea, vomiting, diaphoresis, fever, chills, back pain, confusion or recent weight loss. She has no prior history of bleeds. However, patient is status post aortic valve replacement with mechanical valve, on Coumadin, and had not had a follow-up visit for approximately one year. Her INR on admission to the [**Hospital1 69**] MICU was approximately 6. She had a right IJ line placed under ultrasound guidance. Coumadin was discontinued. Vitamin K was given. She received fresh frozen plasma and over a two day period, 11 units of packed red blood cells. Nasogastric tube study lavage was positive for red blood on [**12-11**]; her hematocrit has been stable at 30 or greater since the morning of [**12-13**]. She had an EGD that showed gastroduodenitis. Contact bleeding was noted and Epinephrine injection gave successful hemostasis. Gastritis and a large antral clot that went unroofed did not reveal bleeding ulcer were noted. She had an IV contrast bleeding scan that showed no active bleeding source. She ruled out for MI by EKG and cardiac enzymes. For her higher than normal AV gradient, it was planned to reevaluate with TEE (transesophageal echo) when patient stable. Now that patient is stable, she does not want the study performed during this admission siting the stresses of her hospital course. On pulmonary the patient had some upper airway mucous suctioned in advanced of the EGD procedure. Because of body habitus and prior history, the patient was a concern for aspiration. The patient had no complaints of shortness of breath or dyspnea in the hospital. However, she was put on aspiration precautions. Also, as mentioned under images, there was an incidental finding on chest x-ray, that of a right hilar mass. A follow-up chest CT showed a hilar mass with a long axis of 2.4 cm in the right hilum. It is expected that the patient will have a CT angiogram in the future, possibly likely as an outpatient. The patient's renal function has been good. The patient, when admitted, had an elevated white blood cell count, likely a response to physiologic stress of the GI bleed. Her white blood cell count is now 10.5 and has been 10.5, 10.4 in house since [**12-13**]. She has also been afebrile during her entire course. She has had no chills. Urine culture showed no growth and patient is serum antibody negative for Helicobacter pylori. This patient has a known GI bleed from undetermined source by bleeding scan but one source seemed likely to be the gastroduodenal based on the results of her EGD. For evaluation of additional GI sources, a colonoscopy was repeated on the morning of [**12-16**]. She was found to have non bleeding colonic diverticula and NSAIDs were withheld during her entire hospital course. It is recommended that she have a follow-up visit with the GI service. She is going to see Dr. [**Last Name (STitle) **] within 1-2 weeks and then within a period of 4 weeks have a repeat colonoscopy. Ideally, the patient would have an upper GI series with small bowel follow through as well. However, patient is not currently willing to tolerate this. The patient had an anemia secondary to GI bleed and had a hematocrit of 23.5 when at [**Hospital3 2063**]. Her hematocrit has been stable since the morning of [**12-13**] and the patient was transfused with a total of 11 units of packed red blood cells. Her hematocrit on the [**6-17**] was 33.5. The patient has also degenerative joint disease, osteoarthritis for which prn Morphine has been given. Prophylactically the patient had been given Pantoprazole and while off of Coumadin, pneumoboots, the patient is now on a full low fat diet. Her contact source is [**Name (NI) 2048**] [**Name (NI) 2643**], her sister in [**Name (NI) 620**], [**State 350**], [**Telephone/Fax (1) 13050**]. CONDITION ON DISCHARGE: Good. DISCHARGE STATUS: Stable. DISCHARGE DIAGNOSIS: Gastrointestinal bleed. DISCHARGE MEDICATIONS: Pantoprazole 20 mg po q 12 hours, Ipratropium bromide neb prn q 3-6 hours, Zolpidem tartrate 5-10 mg po h.s. for insomnia. FOLLOW-UP: As previously described and also she is to have a follow-up visit with Dr. [**Last Name (STitle) **] within 1-2 weeks. Dr. [**Last Name (STitle) **] will schedule a [**Hospital 702**] [**Hospital **] clinic appointment for her. Within 4 weeks she is to have a repeat colonoscopy. Also she is to have a follow-up visit with Dr. [**First Name (STitle) 2031**], her cardiologist, within the next few weeks and she is also to have a follow-up visit with Dr. [**First Name (STitle) 2031**] regarding discussion of her hilar mass as well. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4582**], M.D. [**MD Number(1) 4992**] Dictated By:[**Dictator Info 13051**] MEDQUIST36 D: [**2154-12-17**] 17:14 T: [**2154-12-17**] 19:36 JOB#: [**Job Number 13052**] cc:[**Hospital1 13053**] Name: [**Known lastname 1939**], [**Known firstname 1940**] Unit No: [**Numeric Identifier 1941**] Admission Date: [**2154-12-10**] Discharge Date: [**2154-12-18**] Date of Birth: Sex: F Service: Medicine DISCHARGE MEDICATIONS: Correction to pantoprazole, it is 40 mg po q day, and she will also be discharged on a Heparin drip with an initial infusion rate 2700 units/hour, and also on her medications Warfarin 5 mg po hs. DR.[**First Name (STitle) **],[**First Name3 (LF) **] 11-691 Dictated By:[**Dictator Info **] MEDQUIST36 D: [**2154-12-18**] 08:41 T: [**2154-12-18**] 08:51 JOB#: [**Job Number 1942**] Name: [**Known lastname 1939**], [**Known firstname 1940**] P Unit No: [**Numeric Identifier 1941**] Admission Date: [**2154-12-10**] Discharge Date: [**2154-12-18**] Date of Birth: [**2085-1-11**] Sex: F Service: MEDICINE Per recommendations of cardiology service, anticoagulation was held in the setting of gastrointestinal bleed and elevated INR reversed. Once hematocrit stable, restarted on Heparin drip and Coumadin on [**2154-12-17**]. Will continue Heparin drip until INR is between 2.5 and 3.5. Hematocrit at discharge 31.8. MEDICATIONS ON DISCHARGE: 1. Protonix 40 mg p.o. once daily. 2. Heparin drip titrate to goal partial thromboplastin time 60 to 100. 3. Coumadin 5 mg p.o. q.h.s. times two days (she may need an increased dose, titrate to goal INR 2.5-3.5; prior dose 8.0-9.0 mg once daily). 4. No Aspirin. 5. No nonsteroidal anti-inflammatory drugs. Heparin infusion guidelines (goal partial thromboplastin time 60 to 100). For partial thromboplastin time less than 40, 5900 unit bolus, then increase rate by 600 units per hour. For partial thromboplastin time between 40 and 60, 2900 unit bolus, then increase rate by 300 units per hour. For partial thromboplastin time between 61 and 100, no change. For partial thromboplastin time 101 to 120, decrease infusion rate by 300 units per hour. For partial thromboplastin time greater than 120, hold for sixty minutes, then decrease infusion rate by 300 units per hour. FOLLOW-UP: 1. Follow-up with primary care physician/cardiology in one month, date set for [**2154-1-20**], at 4:30 p.m. on the seventh floor of the [**Hospital Ward Name **] Building, [**Hospital1 1943**]. 2. Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1313**], telephone number [**Telephone/Fax (1) 1944**] or [**Telephone/Fax (1) 1945**]. Dr. [**First Name (STitle) 1313**] will arrange follow-up esophagogastroduodenoscopy and transesophageal echocardiogram (he will also arrange follow-up CT scan to evaluate right hilar mass). 3. Follow-up at [**Location (un) 729**] [**Hospital3 1946**] to check INRs at discharge or alternatively follow-up at [**Hospital 1947**] [**Hospital3 1946**] to check INRs at discharge. INSTRUCTIONS: 1. Discontinue Heparin drip once INR is between 2.5 and 3.5; discontinue triple lumen line at that time. 2. Check once daily hematocrit times three to four days. Please fax results of hematocrit to Dr. [**First Name (STitle) 1313**] (cardiology/ primary care physician [**Last Name (NamePattern4) **] [**Telephone/Fax (1) 1948**]). [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1949**], M.D. [**MD Number(1) 1950**] Dictated By:[**Name8 (MD) 1951**] MEDQUIST36 D: [**2154-12-18**] 14:13 T: [**2154-12-21**] 10:38 JOB#: [**Job Number 1952**]

[ "535.50", "285.1", "728.89", "276.0", "V43.3", "786.6", "562.10", "578.9", "278.01" ]

icd9cm

[ [ [] ] ]

[ "44.43", "45.23", "38.93", "96.34" ]

icd9pcs

[ [ [] ] ]

8132, 9125

6833, 6858

9151, 11397

1973, 6751

304, 1955

162, 281

6776, 6811

63,941

126,602

41502

Discharge summary

report

Admission Date: [**2196-4-22**] Discharge Date: [**2196-4-27**] Date of Birth: [**2121-5-24**] Sex: F Service: MEDICINE Allergies: Carboplatin Attending:[**First Name3 (LF) 106**] Chief Complaint: chest pressure Major Surgical or Invasive Procedure: cardiac catheterization on [**4-26**] showing clean coronaries History of Present Illness: 74yo F with stage IV lung CA complicated by recurrent pleural effusions who was originally admitted to [**Hospital3 3583**] on [**2196-4-15**] with progressive shortness of breath and LLL pneumonia. On [**2196-4-16**], she developed chest pain and anteroseptal ST elevation. Troponon peaked at 4.5. Treated conservatively with IV heparin, aspirin, plavix, beta blockers. She has had recurrent episodes x 2 since then, one episode of flash pulmonary edema, and another episode of chest pain and CHF yesterday. Echo showed LVEF 35%, and anteroseptal wall motion abnormalities. Diursed 4000 cc's yesterday after 20mg IV Lasix. Due to recurrent episodes of chest pain, patient was transferred for cath. . Upon transfer, she was reported to be afebrile on antibiotics and was able to lie flat. Pleurx catheter draining minimal fluid. She is still having chest discomfort which she describes as pressure. She denies any change in breath with cough. Her pain has not improved with nitro gtt. Recent ECG reported as Q waves across precordium. . Vitals on transfer were T 98.2, HR 74, BP 119/68, RR 18, 94% on 4L NC . On arrival to the floor, patient continues to have chest pressure. She denies change in intensity with cough. . REVIEW OF SYSTEMS On review of systems, she endorses chronic cough that is occasionally productive of yellow sputum. She is SOB chronically. She endorses "choking" which is a chronic issue. She denies N/V/D, but endorses sons[**Name (NI) **]. She has leg pain which is chronic, related to disc disease. Otherwise, ROS negative except as noted above. Past Medical History: Anterior wall STEMI with Trop peak to 4, treated medically given prognosis, however cathed [**2196-4-26**] for continued chest pain which showed no angiographically apparent CAD COPD Stage IV NSCLC with liver mets and recurrent effusions s/p pluerex catheter placement [**2196-3-26**] at [**Hospital3 **] chemo-induced neuropathy anemia, neutropenia chronic back pain GERD chronic cough Social History: Lives at home with husband. [**Name (NI) **] 2 living children, one desceased -Tobacco history: + -ETOH: none -Illicit drugs: none Family History: Mother died in her 80s, fathe at 90. Both were considered to be generally healthy. Physical Exam: VS: T=98, BP=137/76, HR=95, RR=18, O2 sat= 94% on 4L GENERAL: Cachectic, frial-appearing elderly female in mild distress [**3-9**] SOB and chest discomfort. Slow to answer questions but altert and appropriate. Blunted affect. HEENT: NCAT. Sclera anicteric. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. CARDIAC: Difficult to auscultate given course breath sounds. S1, S2, RR, tachycardia. LUNGS: Convex chest wall, left port-a-cath. No accessory muscle use. Coarse crackles diffusely. ABDOMEN: Soft, NTND. EXTREMITIES: Warm, no c/c/e. Vitals on discharge: SBP ranging 99-122 for at least several days, pulses 80's to low 100's. 99% 2L to 100% on 3L Her initially very rhonchorous breath sounds cleared up by day 2 of hospitalization; clear without crackles but with only poor to fair air movement, heart RRR, no BLE edema. Pertinent Results: WBC on admission 17.8 which decreased to 10.3 by discharge Hct 43.9 --> 37.0 Plts 535 --> 369 Coags reflected Heparin gtt while admitted but this was stopped after cath, INR 1.1 on discharge. Chemistry on admission: 136 92 30 -------------- 155 4.6 32 0.6 . Chemistry on discharge: 133 93 16 --------------- 82 3.7 35 0.3 . Cal, Mg, Phos unremarkable. . Cardiac enzymes: Trop at OSH in the 4's and was 0.08, declined to 0.03 by discharge, MB fraction was negative through out, BNP 8699 . UA negative, UCx negative . [**2196-4-22**] EKG Sinus rhythm. [**Hospital1 **]-atrial abnormality. Anterior ST segment elevations with Q waves in the same leads consistent with evolving/recent anteroseptal myocardial infarction. No previous tracing available for comparison. TRACING #1 Read by: [**Last Name (LF) **],[**First Name3 (LF) **] V. Intervals Axes Rate PR QRS QT/QTc P QRS T 93 172 74 [**Telephone/Fax (2) 90275**] 73 . [**4-23**] CXR IMPRESSION: Findings in the upper right chest likely representing postsurgical change. A mass-like density is projected within an air cavity in the upper right chest. Its relationship to the cavity and underlying lung parenchyma is unclear in one projection. There is additional streaky density consistent with fibrotic scarring and subsegmental atelectasis. Prominent interstitial markings are likely chronic. There is no definite focal consolidation. Blunting of the left costophrenic sulcus is consistent with pleural thickening and/or fluid. Comparison with previous chest x-rays or further evaluation with CT is recommended. . [**2196-4-25**] echo The left atrium and right atrium are normal in cavity size. Left ventricular wall thicknesses and cavity size are normal. There is mild regional left ventricular systolic dysfunction with focal hypokinesis of the mid anterior septum. The remaining segments contract normally (LVEF = 55-60 %). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Normal left ventricular cavity size with mild regional systolic dysfunction but preserved global ejection fraction. Mild pulmonary artery systolic hypertension. . [**4-26**] cath Coronary angiography: right dominant LMCA, LAD, LCX, RCA: No angiographically-apparent CAD. Assessment & Recommendations 1. Medical Management 2. Discontinue Clopidogrel Brief Hospital Course: Pt's course is complicated as she has received care at several hospitals ([**Last Name (LF) **], [**First Name3 (LF) 46**]) and documentation was not fully provided on transfer here, but in brief: 74yoF with stage IV metastatic (to liver) NSCLC including recurrent effusions requring Pleurex catheter transfered from OSH where she had an anterior STEMI [**2196-4-16**] which was medically treated for a week (? given poor prognosis from metastatic lung ca) who was transferred for evaluation for cardiac cath given ongoing chest pain. 1. Acute STEMI: Likely had an acute LAD occlusion given distibution of STE on ECG at the time of event. Pt medically managed at OSH. On arrival, pt was treated with ACS protocol including BB, ASA, Plavix, Heparin gtt, Nitro gtt. She continued to have chest tightness through her course which was ? multifactorial but possibly from continued cardiac ischemia without further enzyme leak or worsening on EKG. She eventually went to cath which was surprisingly without any angiographically apparent disease. Therefore, Heparin gtt, statin, and Plavix were discontinued and pt should continue on ASA and BB only, and could consider adding ACEi if bp/Cr tolerate. She was transferred to [**Hospital1 18**] on captopril, which was d/ced during her admission and not resumed. However, given prognosis, it is quite reasonable to down-titrate the number of meds she needs and leave ACEi off. By the time of discharge, pt had been free of chest tightness for several days. Of note, she received an echo which showed EF 55-60%, normal [**Doctor Last Name 1754**], 1+ MR, mild PA sHTN, and focal hypokinesis of mid anterior septum consistent with ACS territory. 2. Brief episode of hypoxia: On admission, pt with normal O2 sats on 4-5L NC however day after admission had acute hypoxia, to mid 80s on 5L, during which she was also having chest tightness. She was transitioned to a NRB with improvement in oxygenation to normal. Nitro was up-titrated, but pain was ultimately relieved by 0.5mg Dilaudid. She was transferred to CCU and oxygenation improved without really any intervention, back to mid-high 90's on 4-5L. She was nevertheless diuresed with 20 mg IV Lasix and called back out to the floor with stable oxygenation, and had no further issues. She was not continued on daily standing Lasix but if oxygenation becomes an issue, would consider diuresis gently. Unclear exact etiology of such acute hypoxia but DDx considered included mild CHF, mucus plugging, aspiration; less likely PE given that she was on Heparin gtt at that time. 3. NSCLC/pleural effusions: Patient likely has a prognosis of weeks-months to live from the standpoint of her malignancy as discussed with her primary Oncologist Dr. [**Last Name (STitle) 38058**]. There was question of re-starting chemotherapy, and this can be addressed in follow up with Dr. [**Last Name (STitle) 38058**]. She recently had a left sided Pleurex catheter for malignant effusions, which over time has tapered off. Chest X-rays here did not show any significant effusion, and we did not drain it. We discussed with the patient that she should follow up with the doctor who placed the catheter for further management. She was continued on her pain regimen with Oxycontin, oxycodone PRN. 4. ? COPD exacerbation vs PNA and apparently new cavitating lesion: Extremely unclear on admission as we received no d/c summary, but she was apparently being treated for COPD exacerbation with IV Solumedrol and Zosyn/Levaquin. We continued these on admission and eventually switched her to a Prednisone taper, outlined on med reconciliation. Through her course, we obtained records from [**Hospital1 46**], a CTA dated [**4-17**] that showed: 7-8cm cavity in RUL which contains 5cm mass with some calcification within it probably consistent with fungus ball. Some associated RUL atelectasis with dense LLL atelectasis and obstruction/thrombosis of L subclavian with colateralization. Paratracheal and bilateral hilar adenopathy with chest tube at left base noted. This was apparently new compared to a CT chest that was done at another hospital [**Hospital3 417**] [**3-/2196**], and the DDx for subacute cavitating lung lesion included sub-acute infectious process (? fungus vs bacterial) vs malignancy. We were also able to obtain a sputum Cx from [**Hospital3 **] [**2196-4-18**] that shows pt was growing Enterobacter cloacae, which can cavitate. At that point, based on sensitivities, pt was switched to Cefepime, and should continue for at least a 8d course. She improved clinically, with decrease in her WBC count and was afebrile through her admission. Per ID, should she decompensate, would consider switch to Merrem or Imipenem. We also continued Xopenex, Ipratropium nebs. This issue should be followed up with her primary oncologist vs PCP, [**Name10 (NameIs) **] would consider repeat scan in the future to further assess, if within patient's goals of care. As mentioned above, complicated the matter is that these CT scans are done at different hospitals. 5. Code status: On transfer to the CCU, code-status was re-discussed with the patient and family determining that her status should be DNR/DNI, and paperwork was filled out to this effect. The palliative care team talked to the patient and her husband. The patient is still considering palliative chemotherapy and are not ready for Hospice. Of note, her current home care service agency does offer Hospice services should she desire them in the future. She will be following up with her primary oncologist. Medications on Admission: home meds: Oxycontin 40mg TID oxycodone 5mg q4 hours PRN nortriptyline 50mg qHS omeprazole 40mg daily compazine 10mg q6 hours Advil 200mg po q4 hours marinol 2.5mg TID ferrous sulfate 325mg [**Hospital1 **] vitamin C mutlivitamin folic acid 1mg daily . Meds on transfer oxycodone SR, oxycodone prn, zosyn, atrovent, captopril, marinol, zopinex, iron, levaquin IV, solumedrol IV, Metoprolol, nortriptyline, Omeprazole, zocor, asa 81mg, folate, MVI, imdur, plavix, Albuterol inhaler, lasix PRN. Plans are for KCL replacement today. Discharge Medications: 1. ipratropium bromide 0.02 % Solution Sig: One (1) neb Inhalation Q6H (every 6 hours) as needed for SOB. 2. oxycodone 20 mg Tablet Extended Release 12 hr Sig: Two (2) Tablet Extended Release 12 hr PO Q8H (every 8 hours). 3. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. 4. nortriptyline 25 mg Capsule Sig: One (1) Capsule PO HS (at bedtime). 5. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 6. dronabinol 2.5 mg Capsule Sig: One (1) Capsule PO Q 8H (Every 8 Hours). 7. ferrous sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO twice a day: with meals. 8. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 11. levalbuterol HCl 0.63 mg/3 mL Solution for Nebulization Sig: One (1) neb Inhalation q4h prn () as needed for SOB. 12. prednisone 5 mg Tablet Sig: One (1) Tablet PO once a day: Take 4 tablets (20mg) on [**4-28**]. Then take 2 tablets (10mg) on [**2111-4-30**]. Then, take 1 tablet on [**2113-5-2**], then stop. . Tablet(s) 13. cefepime 1 gram Recon Soln Sig: One (1) g Injection Q24H (every 24 hours) for 5 days. 14. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO once a day. 15. Heparin Flush (10 units/ml) 5 mL IV PRN line flush Indwelling Port (e.g. Portacath), heparin dependent: Flush with 10 mL Normal Saline followed by Heparin as above daily and PRN per lumen. 16. Heparin Flush (100 units/ml) 5 mL IV PRN DE-ACCESSING port Indwelling Port (e.g. Portacath), heparin dependent: When de-accessing port, flush with 10 mL Normal Saline followed by Heparin as above per lumen. Discharge Disposition: Extended Care Facility: Life Care Center - [**Location (un) 3320**] Discharge Diagnosis: Primary: ST elevation myocardial infarction s/p cath Secondary: non-small cell lung cancer with metastases to liver; RUL cavitating lesion noted on CTA from [**Hospital3 3583**] [**4-/2196**], ? Enterobacter PNA 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: Mrs. [**Known lastname 17435**], It has been a pleasure having you here at [**Hospital1 827**]. You were transfered here because the doctors [**First Name8 (NamePattern2) **] [**Name5 (PTitle) 90276**] thought you would benefit from a cardiac catheterization. You had a short stay in the Coronary Care Unit for low blood pressure and low oxygen saturations, which improved after some fluid was removed. You had a cardiac catheterization that did not show any coronary disease, so you did not get any stents. . We made the following changes to your medications: - Please START taking aspirin 81mg daily - Please START taking metoprolol succinate 25mg daily - You are being tapered off of steroids. Please take 20mg of prednisone [**4-28**], 10mg on [**2111-4-30**], and 5mg [**2113-5-2**]. Then, stop taking prednisone. - You should recieve cefepime, an antibiotic, for 5 more days to treat a lung infection that was diagnosed at [**Hospital3 3583**]. - You may use nebulizer treatments: iprtroprium every 6 hours and Xoponex (levalbuterol) every 4 hours as needed for shortness of breath or cough. . Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more than 3 lbs. Followup Instructions: Name: [**Last Name (LF) **],[**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern1) **] (Oncology) Address: [**Street Address(2) 90277**], [**Hospital1 **],[**Numeric Identifier 8728**] Phone: [**Telephone/Fax (1) 19099**] Appt: [**5-4**] at 3:15pm . When you leave rehab, please call your primary care doctor's office to make an appointment at [**Telephone/Fax (1) 28095**].

[ "357.6", "799.02", "285.9", "410.11", "263.8", "338.3", "V10.11", "707.03", "288.60", "338.29", "564.09", "530.81", "V49.86", "428.21", "511.81", "707.22", "E933.1", "482.83", "496", "V15.82", "197.7", "V85.0", "428.0" ]

icd9cm

[ [ [] ] ]

[ "88.56", "37.22" ]

icd9pcs

[ [ [] ] ]

14172, 14242

6185, 11749

286, 351

14498, 14498

3508, 3710

15894, 16312

2529, 2613

12330, 14149

14263, 14477

11775, 12307

14681, 15213

2628, 3206

3798, 3878

15242, 15871

3895, 6162

232, 248

379, 1952

3724, 3784

14513, 14657

1974, 2363

2379, 2513

82,073

197,360

39537+58301+58303

Discharge summary

report+addendum+addendum

Admission Date: [**2160-8-16**] Discharge Date: [**2160-9-18**] Date of Birth: [**2088-9-1**] Sex: F Service: SURGERY Allergies: Spiriva Attending:[**First Name3 (LF) 158**] Chief Complaint: Status epilepticus and fever Major Surgical or Invasive Procedure: central line CTAP History of Present Illness: Mrs. [**Known lastname 87311**] is a 71 year old female with a PMH significant for SLE on chronic steroids, COPD, CVA, DM 2, and multiple admissions for left subdiaphragmatic abscess s/p exlap with diverting ileostomy complicated by prolonged mechanical ventilation, volume overload, and watershed CVA with residual weakness discharged to rehab on broad spectrum antimicoribals re-admitted for altered mental status found to be in status epilepticus. . The patient initially presented in [**7-1**] for fevers and rigors and was found to have a subdiaphragmatic abscess and underwent IR drain placement with cultures demonstrating polymicrobial growth including Bacteroides and pan-sensitive Pseudomonas treated with ciprofloxacin, metronidazole, and fluconazole subsequently changed to amox/clav. She was readmitted in mid-[**Month (only) 216**] for persistent nausea, and cultures then demonstrated polymicrobial growth with budding yeast speciated as [**First Name5 (NamePattern1) 564**] [**Last Name (NamePattern1) **] and Krusei. On [**7-16**], she underwent open left colectomy with colorectal anastamosis and diverting loop ileostomy, with stool noted in the abscess. Of note, no cultures were sent from the OR. Her post-operative course was then complicated by a prolonged [**Hospital Unit Name 153**] stay for volume overload requiring mechanical ventilation and a left-sided watershed CVA, and was ultimately discharged to rehab on [**2160-8-13**] with persistent weakness on vanco, meropenem, and micafungin with plan for continuation of antibiotics for at least 7 days after drain was pulled. . The patient was readmitted to [**Hospital1 18**] under the [**Last Name (un) **]-rectal service on [**8-16**] for altered mental status. Her current hospital course has been notable for intermintent delirium described as being ambulatory to being difficult to control. Two nights ago, she received 12.5 trazodone, and EEG yesterday was noted to have persistent epileptiform activity concerning for status epilepticus. Neuro is following, and the patient has received a total of 1500 mg fosphenytoin with most recent trough pending and standing ativan Q6H. Cultures during this admission including blood and urine have been NGTD. Of note, PICC line placed during prior admission has not yet been removed. The patient also underwent CTAP on [**8-18**] with stable RUQ fluid collection, midline fluid collection, and improvement in LUQ fluid collection. LUQ drain was subsequently removed, and CT guided aspiration of midline and RUQ fluid collections unsuccessful. Also of note, the patient also developed a new 3L O2 requirement yesterday. [**Hospital Unit Name 153**] transfer requested for status epilepticus and fevers. Past Medical History: -Lupus -HTN -H/o stroke x 3: 1st ~10 years ago [**12-25**] CEA with residual left-sided weakness, 2nd [**9-30**] without new deficits, 3rd recently noted at last admission ([**8-1**]) resulting in likely Gerstman's syndrome (agraphia, acalculia, right/left confusion and finger agnosia) -DM type 2 -COPD -s/p CEA -Neurogenic bladder -Hypercholesterolemia -Diverticulosis -Spinal stenosis -Right rotator cuff injury/tear Social History: Married, lives in [**Location 53428**], NH. 1 EtOH drink per day. No tobacco Family History: Father- esophageal ca, monther- CVA, brother- CAD Physical Exam: Gen: NAD, arousable, opens eyes/moves feet to command HEENT: NC in place, PERRL, EOMI, OP clear CV: Nl S1+S2, no m/r/g Pulm: Coarse BS anteriorly & laterally, no W/R/R Abd: Drains and ostomy c/d/i. Soft, +bs, no tenderness to palp Ext: no peripheral edema, 2+ DP pulses bilaterally Neuro: intermittently following commands wiggles feet to command Pertinent Results: [**2160-8-16**] 10:40PM GLUCOSE-116* UREA N-11 CREAT-0.7 SODIUM-136 POTASSIUM-4.3 CHLORIDE-99 TOTAL CO2-26 ANION GAP-15 [**2160-8-16**] 10:40PM estGFR-Using this [**2160-8-16**] 10:40PM TOT PROT-5.6* ALBUMIN-3.1* GLOBULIN-2.5 CALCIUM-10.1 PHOSPHATE-3.3 MAGNESIUM-1.5* [**2160-8-16**] 10:40PM WBC-12.6* RBC-3.92* HGB-11.9* HCT-36.9 MCV-94 MCH-30.4 MCHC-32.2 RDW-16.6* [**2160-8-16**] 10:40PM PLT COUNT-409 [**2160-8-16**] 10:40PM PT-12.5 PTT-25.0 INR(PT)-1.0 [**2160-8-16**] 09:30PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.008 [**2160-8-16**] 09:30PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-NEG Lupus Anticoag: pos ACA IgG/IgM: pnd [**Doctor First Name **]: Neg DsDNA: Neg Phenytoin: 13.3 (20.8 corrected) Free Phenytoin: 2.7 Stool studies [**8-23**]: neg Bcx [**8-22**]: Pnd Catheter tip [**8-23**]: neg HSV PCR: neg UE ultrasound: no DVT Brief Hospital Course: Mrs. [**Known lastname 87311**] is a 71 year old female with a PMH significant for SLE on chronic steroids, COPD, CVA, DM2, and multiple admissions for left sub-diaphragmatic abscess s/p exlap with diverting ileostomy complicated by prolonged mechanical ventilation, volume overload, and watershed CVA with residual weakness discharged to rehab on broad spectrum antibiotics re-admitted for altered mental status found to be in status epilepticus with multiple strokes on MRI. . # Status epilepticus: Extubated successfully. No seizure activity since [**8-22**] at 18:00. Likely secondary to chronic or new infarcts seen on MRI (ischemic vs. embolic from carotids vs. lupus vasculitis). Changed anti-epileptic meds to PO, dosing per neuro. On discharge the patient is on 200mg of Phenytoin (Suspension) every 8 hours at set times. She will need a dilantin level on [**2160-9-21**] with an albumin for a corrected dilantin level. # Stroke: TEE ruled out endocarditis. Also multiple strokes and seizure bring up the possibility of a CNS vasculitic etiology such as lupus cerebritis or ACLA syndrome ?????? lupus anticoagulant positive which explains hypercoaguability. Anti-cardiolipin IgG/IgM pending. C3/C4 wnl, dsDNA negative. Neuro recommends anticoagulation then d/c plavix (surgery okay with this). Carotid dopplers showed no change from prior. LENI??????s negative. Heparin started [**8-27**] with plan to bridge to coumadin. However, given no IV access in the ICU was changed to plavix bridge to Coumadin. The patient had been therapeutic on the inpatient [**Hospital1 **] with a goal INR of [**12-26**], Had been therapeutic however since [**2160-9-8**] we have needed to titrate the Warfarin dose. Neurology agreed that it was appropriate to start the patient on 325mg of Aspirin Therapy daily and continue Coumadin. Today on discharge her INR is 1.8 and she is written to recieve 7.5 mg of Warfarin today [**2160-9-18**] which is an increase from [**2160-9-17**] when she recieved 5mg of Warfarin for an INR of 1.4. She will need a repeat PT/INR on [**2160-9-19**] for dose adjustment. Please see neurology note attached to this summary for further details. # Fever/leukocytosis: leukocytosis 11.3 and 13.2. Potential sources include: evolving pneumonia, abdominal source given recent history and temporal association with drain removal. TEE negative for endocarditis, and HSV PCR neg. Vancomycin, Meropenem, and Micafungin discontinued on [**8-27**]. The patient was noted to have some increased adjitation and a urinalysis and urine culture was sent on [**2160-9-9**] which showed possible VRE, infectious disease was consulted and it seemed as though the specimen was possibly contaminated, her foley catheter was removed and a repeat UA was then sent which again showed enterococus. It was decided that at the recommendation of infectious disease to give the patient a one time dose of fofomycin 3gm by mouth and follow-up in 48 hours with a urinalysis and culture. On discharge urinalysis continued to show small amount bacteria moderate leukocytes. The patient was started on linezolid by mouth for possible VRE in the urine. When results of the urine culture are obtained we will follow-up with you so that the antibiotic can be stopped if it is not needed. #Nutrition: Speech & swallow cleared her for pureed diet with thin liquids. Given that she will not be able to take in adequate nutrition PO, surgery requested that we place a dobhoff. IR guided dophoff placed. The patient was again seen by speech and approved for regular mechianical soft diet which she tolerated well. Because she was unable to maintain her nutrition with food, she was started on supplemental TPN. After close follow-up with nutrition and calorie counts the patient was unable to maintain enough calories and a PEG tube was surgically placed. She was taking all medications by mouth at discharge with cycled tube feedings overnight. # SLE: Patient on chronic steroids, unclear history. Anti dsDNA & [**Doctor First Name **] negative, but lupus anticoagulant positive. Continue prednisone 10mg daily. . # BP: Patient has been progressively more hypertensive so we restarted beta blocker. Given complete R carotid occlusion and L partial occlusion, pt likely needs the blood pressure for cerebral perfusion so we will maintain SBPs 120. Restarted metoprolol 25mg qd by mouth [**8-27**]. . # COPD: Albuterol MDI prn . # DM 2: Per recommendation by geriatrics the patient was started on the following insulin regimen. Ensure pt receives NO INSULIN on sliding scale if blood sugar <160, and then 2U for 160-180, 4U 180-200, etc. Continue regular 6U q6 x2 during tube feeds and Lantus 8U standing at bedtime. Ensure sliding scale is only used q6h, as yesterday pt received doses off the sliding scale <2h apart. Please adjust sliding scale as needed. # Anemia: HCT stabilized. Adgitation: The patient has serious waxing and [**Doctor Last Name 688**] adjitated delerium. She has required seroquel at 8pm. Last dose on [**2160-9-17**] was 37.5mg and she needed an addition 6.25mg with minimal effect. She has not required additional medication during the day. Medications on Admission: MEDICATIONS (On transfer): 20 mEq Potassium Chloride / 1000 mL D5 1/2 NS Continuous at 100 ml/hr Albuterol Inhaler 2 PUFF IH Q4H:PRN SOB Aspirin 300 mg PR DAILY Fosphenytoin 1000 mg PE IV ONCE Fosphenytoin 500 mg PE IV ONCE Heparin 5000 UNIT SC TID HydrALAzine 5 mg IV PRN SBP>160 Hydrocortisone Na Succ. 15 mg IV Q8H Lorazepam 1 mg IV Q6H Meropenem 500 mg IV Q6H Metoprolol Tartrate 10 mg IV Q4H Micafungin 100 mg IV Q24H Pantoprazole 40 mg IV Q24H Vancomycin 1000 mg IV Q36H . MEDICATIONS (ON ADMISSION): -Albuterol 90 mcg 1-2 puffs q 4hrs prn -ASA 325mg daily -Prednisone 10mg daily -Pantoprazole 40mg daily -Dronabinol 2.5mg [**Hospital1 **] -Simvastatin 10mg daily -Metoprolol 25mg TID -Micafungin 100mg IV q daily -Meropenem 500mg IV q 8hrs -Vancomycin 1000mg IV q 36hrs -Insulin SS Discharge Medications: 1. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: Three (3) ml Inhalation Q6H (every 6 hours) as needed for wheezing or SOB. 2. prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 4. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO Q6H (every 6 hours). 5. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day) as needed for peri-stoma skin irriation. 6. phenytoin 125 mg/5 mL Suspension Sig: Eight (8) ml PO Q4PM (): 200mg of phenytoin at 1600 daily. 7. phenytoin 125 mg/5 mL Suspension Sig: Eight (8) ml PO QMIDNIGHT (): 200mg of phenytoin at midnight daily. 8. phenytoin 125 mg/5 mL Suspension Sig: Eight (8) ml PO QAM (once a day (in the morning)): 200mg of phenytoin daily at 0800. 9. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. polyvinyl alcohol 1.4 % Drops Sig: 1-2 Drops Ophthalmic PRN (as needed) as needed for pink eye. 11. oxcarbazepine 150 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). 12. quetiapine 25 mg Tablet Sig: 1.5 Tablets PO QHS (once a day (at bedtime)). 13. warfarin 5 mg Tablet Sig: 1.5 Tablets PO ONCE (Once): Please give 7.5mg of Warfarin on [**2160-9-18**] at 1600. Pt will need PT/INR check am of [**2160-9-19**]. Goal INR [**12-26**]. 14. insulin regular human 100 unit/mL Solution Sig: Six (6) units Injection WHEN TUBE FEEDS START AT 8PM, REPEAT 2AM (). 15. insulin regular human 100 unit/mL Solution Sig: One (1) unit Injection per sliding scale: please see sliding scale. 16. Regular Insulin Sliding Scale Breakfast Lunch Dinner Bedtime Regular Regular Regular Regular Glucose Insulin Dose Insulin Dose Insulin Dose InsulinDose 0-70mg/dL Proceed with hypoglycemia protocol 71-100mg/dL 0 Units 0 Units 0 Units 0 Units 101-120mg/dL 0 Units 0 Units 0 Units 0 Units 121-140mg/dL 0 Units 0 Units 0 Units 0 Units 141-160mg/dL 2 Units 2 Units 2 Units 2 Units 161-180mg/dL 4 Units 4 Units 4 Units 4 Units 181-200mg/dL 6 Units 6 Units 6 Units 6 Units 201-220mg/dL 8 Units 8 Units 8 Units 8 Units 221-240mg/dL 10Units 10Units 10 Units 10 Units 241-260mg/dL 12Units 12Units 12 Units 12Units 261-280mg/dL 14Units 14Units 14 Units 14Units 281-300mg/dL 16Units 16Units 16 Units 16 Units > 300 mg/dL Notify M.D. Notify M.D. 17. Lantus 100 unit/mL Solution Sig: Eight (8) units Subcutaneous at bedtime. 18. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush PICC, non-heparin dependent: Flush with 10 mL Normal Saline daily and PRN per lumen. 19. linezolid 600 mg Tablet Sig: One (1) Tablet PO every twelve (12) hours for 14 days. Discharge Disposition: Extended Care Facility: [**Hospital3 **] Discharge Diagnosis: Electrical status on EEG.She was given PHT and Keppra and was found to have new strokes. Stroke with positive Lupus Anticoagulant. Based on her multiple strokes and the fact that they appear embolic we started Coumadin. Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Frequently out of bed to char with walker, using bedside commode to void. Discharge Instructions: You were admitted to the hospital after being discharge to rehab from your long hospitalization after your Laparoscopic converted to open extended left colectomy with colorectal anastomosis and diverting loop ileostomy for surgical managment for perforated diverticulitis with abscess. When you were admitted to the hospital, you were being watched closely and there was a morning that you became unresponsive and you were found to be having siezures. You were transferred to the intensive care unit and after many images and tests of your brain and neurologic work-up it was determined that you had a stroke, and this was the cause of your siezures. You have been followed closely by the neurology, geriatric, and surgical teams. You have not had any additional siezures and you are now taking medications that prevent siezures and you need to continue taking these and your blood must be monitored as prescribed by neurology. You have had aggitated delerium, it is unclear at this time how this will improve however we are hopeful that with continued medical managment that your mood, sleep-wake cycle, and mental status will improve. You will be given medications to assist you to sleep and help your mood. You should have your Dilantin level checked in three days on [**2160-9-21**] at rehab. today [**2160-9-18**] and should have your INR checked tomorrow your goal INR is [**12-26**]. Attached to your discharge summary will be details of your neurologic process. From a surgical standpoint, you are much improved. The wound in your left lower quadrant continues to improve with VAC dressing therapy which will continue to be changed every 3 days. The wound above your umbilicus has improved with wet to dry dressing changes and these should continue. On [**9-13**], you were diagnosed with a urinary tract infection, we treated this with one dose of an antibiotic called fosfomycin. You need to have a repeat urinalysis and urine culture on [**9-18**]. You should be monitored for signs and symptoms on urinary tract infection including: increased adjitation or confusion, pain with urination, increased urinary frequency, if you develop a fever, or if you have foul smelling urine. You will be treated with linezolid by mouth. A PEG tube was placed in your stomach to supplement your nutrition. This should continue at night as ordered. Please continue to eat small frequent meals and take all of your medications by mouth. There should be a nutritionist following you at the rehabilitation facility. You will recieve your tube feedings over night and get insulin during this time to control your blood sugar. The PEG tube will be cared for daily per the nursing protocol at the rehabilitation facility. Please continue to care for your ostomy as instructed by the wound/ostomy nursing team. Monitor your ileostomy output, this should be no less than 500cc or more than 1200cc daily. Keep yourself well hydrated. Please monitor yourself for the following abdominal symptoms and call Dr.[**Name (NI) 10065**] clinic if you develop any of these symptoms or go to the emergency room if they are severe: increased abdominal pain, increased abdominal distension, nausea, vomiting, or inability to tolerate foods or liquids. Please continue to take all of your medications by mouth, you have done well swallowing. You have required some magnesium supplements through the IV. We will sned you to rehab with some supplements by mouth. Also your sodium have been borderline and you should restrict your water intake to 1 liter daily. You will have your electrolytes monitored periodically at the rehabilitation hospital and they will manage your lab values appropriately. Followup Instructions: Please make an appointment to see Dr. [**Last Name (STitle) **] in [**12-26**] weeks. Call [**Telephone/Fax (1) 160**] to make this appointment. It is very important that you make an appointment at the neurology clinic to be followed for your dilantin level and other siezure medications in 3 weeks with Dr. [**Last Name (STitle) 87312**] epilepsy clinic ([**Telephone/Fax (1) 5563**], you have an appointment [**2160-10-1**] at 3pm, [**Hospital Ward Name **] building 4rd [**Hospital Ward Name **] here at [**Hospital1 18**]. If delirium continues in Dr.[**Name (NI) 33727**] cognitive neurology clinic ([**Telephone/Fax (1) 87313**], you may call to make this appointment. Please update your primary care doctor and notify your other providers of your hospitalization. Provider: [**Name10 (NameIs) **] [**Last Name (NamePattern4) 13171**], MD Phone:[**Telephone/Fax (1) 719**] Date/Time:[**2160-9-30**] 10:00 Geriatrics Clinc. Provider: [**Last Name (NamePattern5) 9155**], MD Phone:[**Telephone/Fax (1) 876**] Date/Time:[**2160-10-1**] 3:00 Completed by:[**2160-9-18**] Name: [**Known lastname 13838**],[**Known firstname 779**] Unit No: [**Numeric Identifier 13839**] Admission Date: [**2160-8-16**] Discharge Date: [**2160-9-18**] Date of Birth: [**2088-9-1**] Sex: F Service: SURGERY Allergies: Spiriva Attending:[**First Name3 (LF) 94**] Addendum: Lab Results. Pertinent Results: [**2160-9-16**] 05:00AM BLOOD WBC-7.8 RBC-2.80* Hgb-8.7* Hct-25.7* MCV-92 MCH-31.1 MCHC-33.8 RDW-16.6* Plt Ct-760* [**2160-9-12**] 05:50AM BLOOD WBC-8.3 RBC-2.78* Hgb-8.6* Hct-27.2* MCV-98 MCH-31.0 MCHC-31.7 RDW-16.2* Plt Ct-568* [**2160-9-11**] 05:50AM BLOOD WBC-10.3 RBC-2.81* Hgb-8.8* Hct-26.8* MCV-96 MCH-31.4 MCHC-32.9 RDW-16.7* Plt Ct-547* [**2160-9-9**] 06:00AM BLOOD WBC-9.7 RBC-2.88* Hgb-9.1* Hct-27.5* MCV-96 MCH-31.6 MCHC-33.1 RDW-16.8* Plt Ct-534* [**2160-9-8**] 01:00PM BLOOD WBC-14.7* RBC-3.08* Hgb-9.7* Hct-29.1* MCV-95 MCH-31.5 MCHC-33.3 RDW-17.0* Plt Ct-557* [**2160-9-3**] 04:10PM BLOOD WBC-16.9* RBC-3.41* Hgb-10.7* Hct-33.1* MCV-97 MCH-31.3 MCHC-32.2 RDW-17.4* Plt Ct-571* [**2160-9-8**] 01:00PM BLOOD Neuts-85.9* Lymphs-6.0* Monos-7.1 Eos-0.8 Baso-0.3 [**2160-9-1**] 09:15AM BLOOD Neuts-81* Bands-0 Lymphs-8* Monos-6 Eos-5* Baso-0 Atyps-0 Metas-0 Myelos-0 [**2160-8-21**] 04:32PM BLOOD Neuts-93.5* Lymphs-2.5* Monos-3.4 Eos-0.5 Baso-0.1 [**2160-9-1**] 09:15AM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-3+ Macrocy-1+ Microcy-NORMAL Polychr-1+ Spheroc-1+ Target-OCCASIONAL Schisto-1+ Burr-3+ How-Jol-1+ Pappenh-1+ Acantho-1+ Fragmen-OCCASIONAL [**2160-9-18**] 04:50AM BLOOD PT-19.7* PTT-23.6 INR(PT)-1.8* [**2160-9-17**] 04:27AM BLOOD PT-16.3* PTT-25.2 INR(PT)-1.4* [**2160-9-16**] 06:22AM BLOOD PT-14.0* PTT-22.1 INR(PT)-1.2* [**2160-9-16**] 05:00AM BLOOD Plt Ct-760* [**2160-9-15**] 06:00AM BLOOD PT-13.0 PTT-22.7 INR(PT)-1.1 [**2160-9-15**] 06:00AM BLOOD PT-13.0 PTT-22.7 INR(PT)-1.1 [**2160-9-13**] 05:30AM BLOOD PT-12.3 PTT-21.3* INR(PT)-1.0 [**2160-9-12**] 05:50AM BLOOD Plt Ct-568* [**2160-9-12**] 05:50AM BLOOD PT-12.9 PTT-24.2 INR(PT)-1.1 [**2160-9-11**] 05:50AM BLOOD Plt Ct-547* [**2160-9-11**] 05:50AM BLOOD Plt Ct-547* [**2160-9-11**] 05:50AM BLOOD PT-12.4 PTT-22.2 INR(PT)-1.0 [**2160-9-10**] 06:00AM BLOOD PT-13.2 PTT-22.7 INR(PT)-1.1 [**2160-9-9**] 06:00AM BLOOD Plt Ct-534* [**2160-9-9**] 06:00AM BLOOD PT-14.9* PTT-28.0 INR(PT)-1.3* [**2160-9-8**] 01:00PM BLOOD Plt Ct-557* [**2160-9-8**] 06:00AM BLOOD PT-26.8* PTT-30.6 INR(PT)-2.6* [**2160-9-7**] 10:55AM BLOOD PT-37.2* PTT-30.6 INR(PT)-3.9* [**2160-9-6**] 03:20PM BLOOD PT-33.0* PTT-26.9 INR(PT)-3.3* [**2160-9-4**] 09:00AM BLOOD PT-30.6* PTT-30.2 INR(PT)-3.1* [**2160-9-3**] 11:45AM BLOOD PT-24.7* PTT-26.1 INR(PT)-2.4* [**2160-9-2**] 08:55AM BLOOD PT-25.0* PTT-26.7 INR(PT)-2.4* [**2160-9-1**] 09:15AM BLOOD Plt Smr-HIGH Plt Ct-562* [**2160-9-1**] 06:00AM BLOOD PT-29.8* PTT-30.6 INR(PT)-3.0* [**2160-8-30**] 11:20AM BLOOD PT-38.5* PTT-31.0 INR(PT)-4.0* [**2160-8-29**] 06:00AM BLOOD Plt Ct-510* [**2160-8-29**] 06:00AM BLOOD PT-23.1* PTT-25.1 INR(PT)-2.2* [**2160-9-18**] 04:50AM BLOOD Glucose-140* UreaN-12 Creat-0.3* Na-130* K-4.5 Cl-98 HCO3-27 AnGap-10 [**2160-9-17**] 04:27AM BLOOD Glucose-145* UreaN-12 Creat-0.4 Na-130* K-4.3 Cl-97 HCO3-28 AnGap-9 [**2160-9-16**] 05:00AM BLOOD Glucose-116* UreaN-12 Creat-0.4 Na-132* K-4.7 Cl-98 HCO3-28 AnGap-11 [**2160-9-13**] 05:30AM BLOOD Glucose-138* UreaN-6 Creat-0.3* Na-134 K-4.3 Cl-102 HCO3-25 AnGap-11 [**2160-9-12**] 05:50AM BLOOD Glucose-144* UreaN-7 Creat-0.4 Na-137 K-4.1 Cl-106 HCO3-25 AnGap-10 [**2160-9-11**] 05:50AM BLOOD Glucose-135* UreaN-6 Creat-0.3* Na-139 K-4.7 Cl-107 HCO3-23 AnGap-14 [**2160-9-10**] 06:00AM BLOOD Glucose-153* UreaN-6 Creat-0.4 Na-135 K-4.1 Cl-102 HCO3-24 AnGap-13 [**2160-9-9**] 06:00AM BLOOD Glucose-111* UreaN-7 Creat-0.3* Na-135 K-3.9 Cl-102 HCO3-24 AnGap-13 [**2160-9-8**] 06:00AM BLOOD Glucose-138* UreaN-6 Creat-0.4 Na-136 K-3.8 Cl-103 HCO3-22 AnGap-15 [**2160-9-7**] 06:45AM BLOOD Glucose-122* UreaN-5* Creat-0.4 Na-137 K-3.5 Cl-103 HCO3-24 AnGap-14 [**2160-9-5**] 06:00AM BLOOD Glucose-105* UreaN-6 Creat-0.6 Na-133 K-4.0 Cl-97 HCO3-26 AnGap-14 [**2160-9-8**] 01:00PM BLOOD ALT-17 AST-20 LD(LDH)-265* AlkPhos-95 Amylase-25 TotBili-0.3 [**2160-8-22**] 12:14PM BLOOD ALT-12 AST-15 LD(LDH)-238 CK(CPK)-25* AlkPhos-71 TotBili-0.7 [**2160-8-21**] 04:32PM BLOOD CK(CPK)-42 [**2160-8-21**] 11:20AM BLOOD CK(CPK)-44 [**2160-8-21**] 10:06AM BLOOD ALT-21 AST-28 LD(LDH)-290* AlkPhos-96 TotBili-0.9 [**2160-9-18**] 04:50AM BLOOD Albumin-2.6* Calcium-8.2* Phos-3.3 Mg-1.4* [**2160-9-17**] 04:27AM BLOOD Calcium-8.3* Phos-4.5 Mg-1.7 [**2160-9-16**] 05:00AM BLOOD Calcium-9.3 Phos-4.7*# Mg-1.4* [**2160-9-15**] 06:00AM BLOOD Albumin-2.5* [**2160-9-13**] 05:30AM BLOOD Albumin-2.6* Calcium-9.4 Phos-3.0 Mg-1.6 Iron-42 [**2160-9-12**] 05:50AM BLOOD Calcium-9.2 Phos-4.4 Mg-1.8 [**2160-9-11**] 05:50AM BLOOD Albumin-2.4* Calcium-8.7 Phos-4.4 Mg-1.8 [**2160-9-10**] 06:00AM BLOOD Calcium-8.9 Phos-4.6* Mg-1.7 Brief Hospital Course: Please see original d/c summary. Please follow magnesium oxide daily and sodium as she has been low. please limit PO free water to 1000cc daily. Discharge Disposition: Extended Care Facility: [**Hospital3 **] [**Name6 (MD) **] [**Last Name (NamePattern4) 97**] MD [**MD Number(2) 98**] Completed by:[**2160-9-18**] Name: [**Known lastname 13838**],[**Known firstname 779**] Unit No: [**Numeric Identifier 13839**] Admission Date: [**2160-8-16**] Discharge Date: [**2160-9-18**] Date of Birth: [**2088-9-1**] Sex: F Service: SURGERY Allergies: Spiriva Attending:[**First Name3 (LF) 94**] Addendum: Dilantin with Albumin Levels Major Surgical or Invasive Procedure: Endoscopic-guided percutaneous gastrostomy tube placement on [**2160-9-11**] Pertinent Results: [**2160-9-18**] 04:50AM BLOOD Albumin-2.6* Calcium-8.2* Phos-3.3 Mg-1.4* [**2160-9-15**] 06:00AM BLOOD Albumin-2.5* [**2160-9-13**] 05:30AM BLOOD Albumin-2.6* Calcium-9.4 Phos-3.0 Mg-1.6 Iron-42 [**2160-9-11**] 05:50AM BLOOD Albumin-2.4* Calcium-8.7 Phos-4.4 Mg-1.8 [**2160-9-9**] 09:15AM BLOOD Albumin-2.6* [**2160-9-9**] 06:00AM BLOOD Calcium-8.8 Phos-4.1 Mg-1.8 Iron-18* [**2160-9-8**] 06:00AM BLOOD Albumin-2.6* Calcium-8.7 Phos-2.8 Mg-2.1 [**2160-9-7**] 06:45AM BLOOD Calcium-8.8 Phos-4.0 Mg-1.6 [**2160-9-5**] 06:00AM BLOOD Albumin-2.7* [**2160-9-18**] 04:50AM BLOOD Phenyto-6.6* [**2160-9-15**] 06:00AM BLOOD Phenyto-9.7* [**2160-9-15**] 06:00AM BLOOD Phenyto-11.3 [**2160-9-14**] 05:30AM BLOOD Phenyto-4.2* [**2160-9-11**] 05:50AM BLOOD Phenyto-6.2* [**2160-9-9**] 09:15AM BLOOD Phenyto-6.5* [**2160-9-8**] 06:00AM BLOOD Phenyto-7.4* [**2160-9-7**] 06:40AM BLOOD Phenyto-7.7* [**2160-9-6**] 01:56PM BLOOD Phenyto-9.5* [**2160-9-5**] 06:00AM BLOOD Phenyto-4.2* [**2160-9-3**] 06:00AM BLOOD Phenyto-8.8* [**2160-9-1**] 06:00AM BLOOD Phenyto-10.2 [**2160-8-31**] 07:05AM BLOOD Phenyto-9.0* Discharge Disposition: Extended Care Facility: [**Hospital3 **] [**Name6 (MD) **] [**Last Name (NamePattern4) 97**] MD [**MD Number(2) 98**] Completed by:[**2160-9-18**]

[ "401.9", "710.0", "V85.25", "041.04", "V58.65", "276.51", "294.9", "496", "348.89", "599.0", "V44.2", "041.7", "345.70", "780.60", "250.00", "686.9", "263.9", "434.11", "348.39", "289.81" ]

icd9cm

[ [ [] ] ]

[ "54.91", "96.6", "38.93", "96.72", "96.04", "88.72", "97.49", "43.11", "38.97", "03.31" ]

icd9pcs

[ [ [] ] ]

26263, 26441

24291, 24437

25046, 25125

14286, 14286

25144, 26240

18243, 19676

3634, 3686

11057, 13954

14041, 14265

10243, 11034

14542, 18220

3701, 4058

226, 256

342, 3079

14301, 14518

3101, 3522

3538, 3618

40,911

108,351

3893

Discharge summary

report

Admission Date: [**2122-1-6**] Discharge Date: [**2122-1-14**] Date of Birth: [**2055-10-31**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 1115**] Chief Complaint: dyspnea and cough Major Surgical or Invasive Procedure: None History of Present Illness: Mr. [**Known lastname **] is a 66 y/o male with a history of CAD (VF arrest post CABG with ICD/PPM inserted), systolic CHF (EF 20%), PVD s/p bilat fem-[**Doctor Last Name **] bypasses, AF s/p DC cardioversion [**2120**], DM2 on insulin and gout post recent admission with gout flare and prednisone course in [**2121-10-15**] presents with one week of shortness of breath with associated cough. He notes subjective fevers and chills with associated night sweats. Over the past day he has developed confusion and difficulty with concentration which was noticed by his daughter. [**Name (NI) **] has been having associated headaches and chest pain. The chest pain was described as squeezing in nature and without radiation. He also notes some increased lower exteremity swelling which has been increasing over the past week. . Of note, recently saw his rheumatologist who started him on methylprednisone as well as increased his allopurinol due to an elevated uric acid. He was also admitted in [**Month (only) 1096**] for about a week for a significant gout flare. . In the ED, initial vs were: T 102.9 P 100 BP 131/69 R 20 O2 sat 100% RA. Labs were noteable for a WBC of 26.8 and a glucose of 45. Patient was given an amp of D50, levofloxacin, ceftriaxone and vancomycin. Vitals upon transfer were Temp 100.3, HR 100, 100% 2L. . On the floor, he appeared comfortable but in no acute distress. He was oriented to self, place and time however he appeared to have difficulty answering questions. He was complaining of left sided chest pain which his wife noted had been occurring over the past 2 weeks. The pain was nonradiating and was relieved with nitro tab x1. . Review of systems: (+) Per HPI (-) Denies recent weight loss or gain. Denies sinus tenderness, rhinorrhea or congestion. Denies 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. Severe CAD s/p 4vCABG [**2107**] 2. V-Fib arrest 4-days post-CABG s/p pacemaker/ICD [**2107**] - Generator change and pocket revision in [**2120-1-14**] to right side of chest secondary to pain 3. Ischemic cardiomypoathy / systolic CHF, EF 25% 4. Peripheral vascular disease s/p bilateral femoral-popliteal bypass 5. multiple lower extremity catheterizations 6. Diabetes Type II - followed at [**Last Name (un) **] 7. Obstructive sleep apnea 8. Gout 9. Asthma 10. Mild sigmoid colonic thickening on recent CT-Abd/Plv, colonoscopy showing sessile polyps, biopsy will have to happen off plavix 11. Esophagitis, gastritis, peptic ulcer disease 12. Afib s/p TTE cardioversion [**1-/2121**] Social History: Married, lives at home with wife. Former 70 pack years tobacco use but quit in [**2107**]. Denies alcohol or IVDA. Family History: Mother with kidney problems. Father died of unknown causes. One sister died of stomach cancer, another sister also with stomach cancer. Diabetes is prevalent throughout the family. There is no family history of premature coronary artery disease or sudden death. Physical Exam: General: patient appeared uncomfortable but in NAD AAOx3 HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP unable to be appreciated, no LAD Lungs: bibasilar crackles noted bilaterally, no wheezing or rhonchi CV: Irregular, SEM in the LUSB no rubs or gallops Abdomen: distended abdomen GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Pertinent Results: ADMISSION LABS: [**2122-1-6**] 07:30PM WBC-26.8*# RBC-3.93* HGB-8.8* HCT-28.3* MCV-72* MCH-22.5*# MCHC-31.2 RDW-17.5* [**2122-1-6**] 07:30PM NEUTS-90* BANDS-5 LYMPHS-0 MONOS-5 EOS-0 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 [**2122-1-6**] 07:30PM PLT COUNT-358 [**2122-1-6**] 07:30PM HYPOCHROM-2+ ANISOCYT-1+ POIKILOCY-OCCASIONAL MACROCYT-NORMAL MICROCYT-2+ POLYCHROM-1+ OVALOCYT-OCCASIONAL STIPPLED-OCCASIONAL ACANTHOCY-OCCASIONAL [**2122-1-6**] 07:30PM PT-15.5* PTT-24.6 INR(PT)-1.4* [**2122-1-6**] 07:30PM GLUCOSE-45* UREA N-44* CREAT-1.3* SODIUM-139 POTASSIUM-3.7 CHLORIDE-101 TOTAL CO2-27 ANION GAP-15 [**2122-1-6**] 07:30PM CALCIUM-8.1* PHOSPHATE-2.6*# MAGNESIUM-1.7 [**2122-1-6**] 07:30PM cTropnT-0.17* [**2122-1-6**] 07:30PM CK-MB-4 [**2122-1-6**] 07:30PM CK(CPK)-85 [**2122-1-6**] 07:34PM GLUCOSE-44* LACTATE-1.9 K+-3.6 [**2122-1-6**] 08:00PM URINE HOURS-RANDOM [**2122-1-6**] 08:00PM URINE GR HOLD-HOLD [**2122-1-6**] 08:00PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.009 [**2122-1-6**] 08:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG DISCHARGE LABS: [**2122-1-14**] 06:15AM BLOOD WBC-7.6 RBC-4.12* Hgb-8.9* Hct-30.6* MCV-74* MCH-21.6* MCHC-29.1* RDW-18.2* Plt Ct-301 [**2122-1-14**] 06:15AM BLOOD PT-28.9* INR(PT)-2.9* [**2122-1-14**] 06:15AM BLOOD Glucose-221* UreaN-40* Creat-1.4* Na-133 K-4.6 Cl-97 HCO3-27 AnGap-14 [**2122-1-14**] 06:15AM BLOOD Calcium-8.3* Phos-3.5 Mg-2.1 MICRO: [**2122-1-9**] URINE URINE CULTURE-FINAL {YEAST} INPATIENT [**2122-1-7**] Influenza A/B by DFA DIRECT INFLUENZA A ANTIGEN TEST-FINAL; DIRECT INFLUENZA B ANTIGEN TEST-FINAL INPATIENT [**2122-1-7**] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT [**2122-1-7**] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT [**2122-1-6**] MRSA SCREEN MRSA SCREEN-FINAL INPATIENT [**2122-1-6**] BLOOD CULTURE Blood Culture, Routine-FINAL EMERGENCY [**Hospital1 **] [**2122-1-6**] BLOOD CULTURE Blood Culture, Routine-FINAL EMERGENCY [**Hospital1 **] STUDIES: [**2122-1-8**] CXR: Study is limited due to patient's respiratory motion and the superior aspect of the lung apices excluded from the field of view. The patient is status post median sternotomy and CABG. Right-sided AICD/pacemaker device is noted with lead terminating in the right ventricle. Abandoned pacer leads are also noted within the left chest wall, with the tip from one of these abandoned leads terminating in the region of the right ventricle. The cardiac silhouette remains moderately enlarged. There are low inspiratory lung volumes. This likely causes accentuation and crowding of the pulmonary vascular markings, but mild pulmonary vascular congestion is likely present. No focal consolidation is seen. There are no large pleural effusions. Assessment for pneumothorax is limited. Abdominal clips are seen in the right upper quadrant of the abdomen. There are no acute osseous findings. [**2122-1-8**] ECHO: Conclusions The left 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 is moderately dilated. Overall left ventricular systolic function is severely depressed (LVEF= 20-25 %). [Intrinsic left ventricular systolic function is likely more depressed given the severity of valvular regurgitation.] A left ventricular mass/thrombus cannot be excluded. Diastolic function could not be assessed. Right ventricular chamber size is normal with borderline normal free wall function. [Intrinsic right ventricular systolic function is likely more depressed given the severity of tricuspid regurgitation.] There are three aortic valve leaflets. The aortic valve leaflets are moderately thickened. There is no aortic valve stenosis. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. Moderate [2+] tricuspid regurgitation is seen. There is 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. IMPRESSION: Dilated left ventricle with severely depressed systolic function secondary to septal and anterior akinesis and hypokinesis of the remaining segments. Depressed RV systolic function. Mild mitral and moderate tricuspid regurgitation. At least moderate pulmonary artery systolic hypertension. Compared with the prior study (TEE - images reviewed) of [**2121-4-8**], regional LV wall motion abnormalities can be better appreciated on the current study. Valvular abnormalities are similar. IMPRESSION: Limited exam. Probable mild pulmonary vascular congestion. Low lung volumes. [**2122-1-8**]: LENI IMPRESSION: Negative Doppler ultrasound of both lower extremities, no evidence for DVT. Incidental left popliteal fossa [**Hospital Ward Name 4675**] cyst with internal hemorrhage. [**2122-1-11**]: CT LE (left) IMPRESSION: 1. No fracture detected. 2. Moderately severe diffuse soft tissue swelling. Small joint effusion and [**Hospital Ward Name 4675**] cyst. 3. Mild tricompartmental degenerative change. 4. Atherosclerotic vascular calcification. 5. Unusual cystic change in the superolateral aspect of the [**Last Name (LF) 15219**], [**First Name3 (LF) **] be degenerative, but could also be seen in the setting of gout. Clinical correlation requested. 6. Faint calcification along popliteus tendon - ? chondrocalcinosis. [**2122-1-11**]: US Extremity Nonvascular Left INDICATION: Fell on to left arm with painful fluid pouch. COMPARISON: None. FINDINGS: Grayscale, and color ultrasound imaging was performed over the area of tenderness in the left elbow. Within the superficial soft tissues, there is a 3.0 x 1.2 x 2.0 cm ovoid heterogeneously hypoechoic collection with enhanced through transmission and multiple internal septations, but no internal vascularity. Additionally, there is mild internal echogenicity noted in this collection. IMPRESSION: Multiseptated fluid collection overlying the left elbow within the subcutaneous tissues, likely representing a hematoma. Brief Hospital Course: Mr. [**Known lastname **] is a 66-year-old male with a history of CAD (VF arrest post CABG with ICD/PPM inserted), systolic CHF (EF 20%), PVD s/p bilateral fem-[**Doctor Last Name **] bypasses, AF s/p DC cardioversion [**2120**], DM2 on insulin and gout post recent admission with gout flare and prednisone course in [**2121-10-15**] who presented with one week of shortness of breath with associated cough with primary diagnoses of acute on chronic systolic heart failure with demand ischemia and health-care acquired pneumonia. Secondary issues during hospitalization were gout flare and hyperglycemia. # Acute on chronic systolic heart failure (EF 20 %) The patient's admission weight was 202 lbs, which is above his last dry weight in clinic in [**2121-10-15**] (181.6 lbs). Decompensation is likely secondary to infectious process with possible contribution of medication non-adherence. He had predominantly had right-sided heart failure pathophysiology given relatively clear lung exam and preponderance of lower extremity edema. He underwent diuresis with IV furosemide with discharge weight of 200.2 lbs. His creatinine fluctuated throughout hospitalization from 1.3 to 1.6 notably with diuresis with baseline Cr of 1.3. He was converted to his home furosemide 120 mg PO BID. He was continued on metoprolol succinate 50 mg PO qD. His spironolactone was discontinued, and his lisinopril was decreased from 10 mg to 5 mg given past issues with hyperkalemia and concurrent usage of digoxin. He was also continued on statin for CAD. He has a pacemaker for primary prevention. His diuretic regimen should continued to be optimized on an outpatient basis. If the patient does not maintain a stable weight on oral furosemide, torsemide could be considered. He will follow-up with Dr. [**Last Name (STitle) **], his primary cardiologist. In addition, the patient likely had demand ischemia given troponin elevation from 0.17 to 0.24 (baseline troponin T appears to be 0.03 based on measurement on [**2121-4-5**]) with negative CK-MB fraction and troponin downtrend to 0.14. He was treated for NSTEMI briefly with a heparin gtt, which was discontinued given low clinical suspicion. ECG showed only non-specific ST-T changes. ECHO did not show any new regional or global wall motion abnormalities. # Health-care acquired pneumonia Patient was noted to have an elevated WBC with a left shift, fever up to 102.9 and a RR >20 fulfilling SIRS criteria in addition to new cough. CURB-65 score was 3 based on confusion, BUN > 19, and Age > 65 with brief MICU course. Chest radiography did not show a definitive infiltrate. The patient was initially started on treatment for health-care acquired pneumonia with cefepime, vancomycin, and azithromycin. Influenza test was negative. Blood cultures did not suggest bacteremia. He was transitioned to room air with adequate oxygen saturation and completed an 8-day course of vancomycin, cefepime, and azithromycin for presumed pneumonia ([**2122-1-7**] to [**2122-1-14**]). . # Altered Mental Status: According to his family he developed confusion prior to admission, which has now resolved. Etiology was likely encephalopathy / delerium in the setting of acute infection. His sensorium cleared within a day. His insulin regimen was optimized by [**Last Name (un) **] as discussed below. . #. Type 2 Diabetes (A1c 9.8), controlled with complications: Home regimen on admission was Lantus 88 units qAM and lispro SSI. [**Last Name (un) **] was consulted secondary to hypoglycemia on admission (glucose 45) with secondary issue of persistent hyperglycemia after regimen was changed to glargine 10 units. There was some question about the etiology of hypoglycemia on admission as steroid usage and counter-regulatory hormones from infection would cause hyperglycemia. Consideration of adrenal axis testing should be considered based on pattern of steroid usage. [**Last Name (un) **] followed closely and his later hospital course was complicated by persistant hyperglycemia. His insulin regimen at discharge with insulin glargine 40 units SC qAM and insulin lispro 10 units SC AC. He will keep a log of blood glucose measurements at home and call [**Last Name (un) **] if his blood glucose is greater than 400. He will require ongoing close follow up for this. . #. Atrial Fibrillation: He remained in normal sinus rhythm during hospitalization. He was continued on metoprolol. His INR (1.4) was sub-therapeutic on admission consistent with known non-adherence to regimen. He was treated with warfarin during hospitalization, which was discontinued after supra-therapeutic INR with discharge INR of 2.9. Per his primary cardiologist, he was recently changed to pradaxa. He will have an INR check on [**2122-1-16**], which Dr. [**Last Name (STitle) **] will follow-up. When his INR is below 2, he will start pradaxa. . #. Gout with fall He was recently seen by rheumatology, and his allopurinol was increased to 600mg daily given hyperuricemia. During his hospitalization, he experienced a fall with trauma to his left elbow and knee. US of left elbow suggested a hematoma given supratherapeutic INR at time of fall. Imaging of left knee showed known [**Hospital Ward Name 4675**] cyst, degenerative changes, faint calcification suggestive of chondrocalcinosis, and effusion. Arthrocentesis of the left knee was considered but was deferred in setting of his INR. Septic joint was a consideration but unlikely given concurrent therapy with broad spectrum antimicrobials. Clinically, he had a convincing story for gout flare given trauma and recent withdrawal of corticosteroids. He was treated with colchicine 1.2 mg PO x 1, naproxen x 1, and colchicine 0.6 mg PO BID from [**1-12**] to [**1-16**] with return to home dosage on [**1-17**]. He improved rapidly on this regimen with resolution of flare by discharge. Prednisone and standing NSAIDs were not utilized given comorbid conditions including diabetes and congestive heart failure. He will follow-up with rheumatology. # Chronic kidney disease, Stage 3 His creatinine experienced fluctuations during hospitalization as mentioned above. His renal function should be assessed within one week of discharge. # Microcytic Anemia Admission Hgb was 9.5 with discharge Hgb of 8.5. Iron studies should be performed on outpatient basis. Some component may be from CKD. # Nutrition His albumin was 2.8 with normal synthetic function given liver function tests. He should be assessed for nutritional status. # Communication: HCP [**Name (NI) 17380**],[**Name (NI) **] (HCP) [**Telephone/Fax (1) 17381**] # Code: Full # Transitions of care 1. For his acute on chronic systolic heart failure, assess maintenance of discharge weight (200.2 lbs) and volume status. Further optimization of cardiovascular regimen such as diuretic conversion from furosemide to torsemide if not maintaining weight on oral furosemide and conversion of metoprolol to carvedilol given depressed ejection fraction. 2. Although he did not have a discrete infiltrate on chest radiography, repeat PA and Lateral CXR in [**2-18**] weeks may be judicious given likely pulmonary process. 3. His outpatient insulin regimen needs continual optimization from [**Last Name (un) **] given changes made during hospitalization. His blood glucose measurement log should be reviewed. He will call [**Last Name (un) **] for blood glucose > 400 or low glucose readings. 4. Given hypoglycemia on admission in the setting of infection and steroid usage, consider testing for relative or absolute adrenal insufficiency. 5. Patient will have INR check followed by Dr. [**Last Name (STitle) **] on [**2122-1-16**] and will need to start Pradaxa once INR < 2. 6. For gout, he will follow-up with rheumatology for further assessment and optimization of gout therapy. NSAIDs and corticosteroids should be used sparingly in a patient with heart failure and diabetes given fluid retention, aforementioned labile blood glucose measurements, and confusion. 7. Patient will need chemistry panel including creatinine to assess for stability of renal function on home furosemide regimen within one week of discharge. 8. He should be assessed for nutrition given albumin. 9. He should have iron studies to work-up his microcytic anemia. Medications on Admission: 1. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 2. atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO BID (2 times a day). 4. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain. 5. metoprolol succinate 50 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 6. furosemide 40 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). 7. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 8. spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. warfarin 7.5 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*5 Tablet(s)* Refills:*0* 10. pregabalin 75 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 11. Lantus 88 units at morning 12. Lispro sliding scale Discharge Medications: 1. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 2. atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO BID (2 times a day). 4. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for Pain/Fever. 5. metoprolol succinate 50 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO once a day. 6. Lasix 80 mg Tablet Sig: 1.5 Tablets PO twice a day. Disp:*90 Tablet(s)* Refills:*0* 7. pregabalin 75 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 8. allopurinol 300 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 9. colchicine 0.6 mg Tablet Sig: One (1) Tablet PO twice a day for 2 days: Take on [**1-15**] and [**1-16**]. On [**1-17**], return to your normal home dose. 10. lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*0* 11. colchicine 0.6 mg Tablet Sig: One (1) Tablet PO once a day: start your normal colchicine dose on [**1-17**]. 12. Pradaxa 75 mg Capsule Sig: One (1) Capsule PO twice a day: You will get an INR test. Do NOT start this medication now. Dr. [**Last Name (STitle) **] will call by next Tuesday to tell you when to start this medication. Disp:*60 Capsule(s)* Refills:*2* 13. Outpatient Lab Work Check INR on [**2122-1-16**] (FRIDAY) at [**Hospital6 **] laboratory. LAB: Please fax results to Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] office (cardiology), fax # [**Telephone/Fax (1) 17382**] 14. insulin glargine 100 unit/mL Solution Sig: Forty (40) units Subcutaneous qAM. Disp:*[**2110**] units* Refills:*2* 15. insulin lispro 100 unit/mL Solution Sig: Ten (10) units Subcutaneous AC. Disp:*1000 units* Refills:*0* 16. digoxin 125 mcg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Primary: pneumonia, acute on chronic heart failure exacerbation, gout Secondary: Diabetes, chronic kidney disease Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Mr. [**Known lastname **], It was a pleasure taking care of you in the hospital. You were admitted with cough and shortness of breath. We were concerned that you had a pneumonia and treated you with antibiotics for which you have completed a course. You also were given lasix to remove some excess fluid from your body. It is very important to follow a LOW SALT diet, or you will develop more fluid and have heart problems. Your gout worsened during hospitalization, and you were started on a higher dosage of colchicine for the next few days for your gout. Medication changes: -STOP coumadin -STOP spironolactone -START pradaxa when Dr. [**Last Name (STitle) **] instructs you to start this medication. You will need to have your *INR* checked on [**2122-1-16**]. This result will be faxed to Dr.[**Name (NI) 5452**] office. If you do not hear from Dr. [**Last Name (STitle) **] by [**2122-1-19**], please call his office and ask when to start the pradaxa. - START Colchicine 0.6 mg by mouth TWICE daily for 2(two) days on [**1-15**] and [**1-16**] for your gout flare. - THEN on [**1-17**], START your regular home dose (colchicine 0.6 mg by mouth ONCE daily) - CHANGE lisinopril from 10 mg to 5 mg - CHANGE your insulin regimen: Take lantus 40 units in the morning Take humalog 10 units before meals *** Your blood sugar was high during hospitalization. Please continue to check your blood sugars three times per day and bring a record of them to your [**Last Name (un) **] visit. If your glucose level is > 400, please call [**Hospital **] clinic. Please go to the followup appointment scheduled below. ***Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more than 3 lbs. Followup Instructions: INR check at [**Hospital6 **] lab on [**2122-1-16**]. Department: [**Hospital3 249**] When: THURSDAY [**2122-1-22**] at 9:10 AM With: [**Company 191**] POST [**Hospital 894**] CLINIC [**Telephone/Fax (1) 250**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage This is a follow up of your hospitalization. You will become established with your primary care physician after this visit. Department: [**Hospital3 249**] When: MONDAY [**2122-2-2**] at 3:25 PM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 13530**], MD [**Telephone/Fax (1) 250**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage This will be your new primary care physician within [**Name9 (PRE) 191**]. Department: RHEUMATOLOGY When: THURSDAY [**2122-1-29**] at 12:30 PM With: [**First Name8 (NamePattern2) 11595**] [**Last Name (NamePattern1) 11596**], MD [**Telephone/Fax (1) 2226**] Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) 861**] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage Name: [**Last Name (LF) 11712**], [**First Name3 (LF) **] Location: [**Last Name (un) **] DIABETES CENTER Address: ONE [**Last Name (un) **] PLACE, [**Location (un) **],[**Numeric Identifier 718**] Phone: [**Telephone/Fax (1) 2378**] When: Monday, [**2-2**], 11AM Name: [**Last Name (LF) **], [**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] Location: [**Doctor Last Name **] BLDG, [**Apartment Address(1) 17383**] Address: [**Last Name (NamePattern1) 8541**], [**Location (un) **],[**Numeric Identifier 8542**] Phone: [**Telephone/Fax (1) 7960**] When: Wednesday, [**2-4**], 1:30PM

[ "493.90", "719.46", "274.9", "V15.81", "348.30", "V15.82", "414.00", "403.90", "V45.01", "V45.81", "486", "719.42", "585.3", "250.02", "428.23", "428.0", "E884.4", "263.0", "V58.67" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

21468, 21526

10302, 13330

322, 329

21684, 21684

3912, 3912

23563, 25427

3232, 3495

19577, 21445

21547, 21663

18601, 19554

21835, 22395

5078, 10279

3510, 3893

2039, 2371

22415, 23540

265, 284

357, 2020

3928, 5062

21699, 21811

2393, 3083

3099, 3216

16,551

128,939

29885+57670+57671

Discharge summary

report+addendum+addendum

Admission Date: [**2145-6-22**] Discharge Date: [**2145-6-26**] Date of Birth: [**2077-5-2**] Sex: F Service: CARDIOTHORACIC Allergies: Aspirin / Heparin Agents / Lisinopril Attending:[**First Name3 (LF) 165**] Chief Complaint: Back Pain Major Surgical or Invasive Procedure: None History of Present Illness: 68 year old female awoke at 3am with back pain between shoulders, denies SOB, Cough Past Medical History: Type A Aortic dissection s/p Replacement of Ascending Aorta (26mm Gelweave graft) and resuspension of aortic valve [**2143-1-15**] GERD DVT HTN Asthma Bronchiectasis RLL Heart failure, filated cardiomyopathy Chronic Kidney disease stage 3 IVC filter Anemia Arthritis Vitamin D deficiency Retinal detachment HITT Depression Social History: No ETOH or tobacco use. Family History: Noncontributory Physical Exam: Pulse:97 Resp: 12 O2 sat: 99 B/P 151/84 Right: Left: Height: Weight: General: Skin: Dry [x] intact [x] healed mid line sternal incision HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [] coarse right lower, left clear Heart: RRR [x] Irregular [] Murmur no Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Extremities: Warm [x], well-perfused [x] Edema no Varicosities: None [x] Neuro: Grossly intact alert and oriented x3 nonfocal Pulses: Femoral Right: +2 Left: +2 DP Right: +2 Left: +1 PT [**Name (NI) 167**]: +2 Left: +2 Radial Right: +2 Left: +2 Carotid Bruit Right: no bruit Left: no bruit Pertinent Results: [**2145-6-22**] CTA Torso IMPRESSION: 1. Status post ascending aortic replacement, with unchanged appearance of the graft compared to [**2142**]. Neck vessels are perfused from the true lumen and demonstrate good contrast opacification. Persistent type B dissection is noted, with marked increase compared to [**2143-1-10**] in the diameter of the false lumen of the thoracic aorta, as well as a large focal aneurysmal bulge extending into the left lung apex. There is significant clot burden in the false lumen, with sluggish flow and poor contrast opacification, making full evaluation of clot burden difficult. If further evaluation is desired, delayed CTA imaging or MRA could be considered. 2. Extension of type B dissection into the abdominal aorta. Renal arteries are perfused from the true lumen, demonstrate good opacification. The celiac axis and SMA are primarily arising from the false lumen, demonstrate poor contrast opacification. The same is true for the [**Female First Name (un) 899**]. While this may be secondary to early phase of imaging relative to contrast bolus, clinical correlation to exclude ischemia is recommended. 3. Dependent atelectasis in the lungs, including adjacent to the thoracic aorta secondary to mass effect, which also causes deviation of the trachea and central airways, with compression of the left mainstem bronchus. 4. Bronchiectasis, most predominant at the bases. 5. IVC filter in adequate position. 6. Unchanged renal cysts. 7. Diverticulosis with no evidence for diverticulitis. Brief Hospital Course: Ms. [**Known lastname 71435**] was admitted to the [**Hospital1 18**] via transfer for further management of her back pain and aortic dissection. Upon review of her CT scan, she was status post repair of a type A aortic dissection however had a chronic and somewhat larger type B dissection. Please see report from [**2145-6-22**] CTA. Her blood pressure was tightly controlled. Her at home medications were resumed. An attempt to reach Dr. [**Last Name (STitle) 22833**] was made regarding her coumadin however he was on vacation. It is unclear if coumadin needs to be continued on her given her distant history of heparin induced thrombocytopenia and DVT. She remained on it during her hospital stay and will resume follow-up with Dr. [**Last Name (STitle) 22833**] for anticoagulation as an outpatient. Her blood pressure remained stable and equal in both arms. Her distal extremities were well perfused. Her medications otherwise remained the same and she was discharged home with a visiting nurse on [**2145-6-24**]. Prescriptions were given only for her coreg and losartan. She will need a repeat CT scan in 6 months with echocardiogram and follow-up with Dr. [**First Name (STitle) **], her primary care physician [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] and Dr. [**Last Name (STitle) 22833**] for coumadin dosing as an outpatient. Medications on Admission: Prilosec 20 mg daily Lasix 40 mg daily Vitamin D 1200 IU daily Spiriva 18 micrograms 1 puff daily Flonase nasal spray [**12-11**] sprays each nostril LosaRTAN 100 MG daily Calcium citrate plus D [**Hospital1 **] Guaifenesin 1200 mg [**Hospital1 **] Carvedilol 25 mg [**Hospital1 **] Advair diskus 500/50 [**Hospital1 **] Ferrous sulfate 325 mg [**Hospital1 **] Albuterol 2 puffs 4x/day Mirtazapine 15 mg HS Tylenol with codiene prn pain Albuterol neb prn Coumadin 4.5 mg daily Discharge Medications: 1. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 2. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Three (3) Tablet PO DAILY (Daily). 4. Spiriva with HandiHaler 18 mcg Capsule, w/Inhalation Device Sig: One (1) cap Inhalation once a day. 5. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1) Spray Nasal DAILY (Daily). 6. Advair Diskus 500-50 mcg/Dose Disk with Device Sig: One (1) puff Inhalation twice a day. 7. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO twice a day. 8. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: 2-4 Puffs Inhalation Q6H (every 6 hours). 9. Carvedilol 25 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:*60 Tablet(s)* Refills:*2* 10. Losartan 100 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 11. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 12. Acetaminophen-Codeine 300-30 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. Disp:*30 Tablet(s)* Refills:*0* 13. Guaifenesin 1,200 mg Tablet Sustained Release 12 hr Sig: One (1) Tablet Sustained Release 12 hr PO twice a day. 14. Calcium Citrate + D 315-200 mg-unit Tablet Sig: One (1) Tablet PO twice a day. 15. Coumadin 1 mg Tablet Sig: As instructed by Dr [**Last Name (STitle) 22833**] Tablet PO once a day: Monitor PT/INR. . Discharge Disposition: Home With Service Facility: All Care VNA of Greater [**Location (un) **] Discharge Diagnosis: s/p Type A dissection repair with chronic Type B aortic dissection GERD DVT HTN Asthma Bronchiectasis RLL Heart failure, filated cardiomyopathy Chronic Kidney disease stage 3 IVC filter Anemia Arthritis Vitamin D deficiency Retinal detachment Heparin Induced thrombocytopenia Depression Discharge Condition: Stable Discharge Instructions: 1) Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight has increased by 2 pounds in 24 hours or 5 pounds in 1 week. 2) Adhere to 2 gm sodium diet. Fluid restriction 2 liters 3) Monitor blood pressure daily. Maintain systolic blood pressure less then 125mmHg. 4) Continue your at home medications as per prior to admission. Prescriptions have been given to you for for Coreg, Losartan and your pain medications. 5) Please resume your coumadin as per preadmission. You were taking 4.5mg daily. Have your blood work (PT/INR) checked with results called to Dr. [**Last Name (STitle) 22833**] for coumadin dosing. 6) Call with any questions or concerns. Followup Instructions: Please follow-up with Dr. [**First Name (STitle) **] in 1 month ([**Telephone/Fax (1) 1504**] Please follow-up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in 2 weeks. [**Telephone/Fax (1) 2632**] Follow-up with Dr. [**Last Name (STitle) 22833**] for coumadin dosing. Phone ([**Telephone/Fax (1) 71439**] Fax ([**Telephone/Fax (1) 71440**] Resume your preadmission dose. PT/INR may be checked by the visiting nurse and called to Dr. [**Last Name (STitle) 22833**]. [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**] Completed by:[**2145-6-24**] Name: [**Known lastname 12010**],[**Known firstname 5494**] Unit No: [**Numeric Identifier 12011**] Admission Date: [**2145-6-22**] Discharge Date: [**2145-6-26**] Date of Birth: [**2077-5-2**] Sex: F Service: CARDIOTHORACIC Allergies: Aspirin / Heparin Agents / Lisinopril Attending:[**First Name3 (LF) 265**] Addendum: Upon receiving discharge instructions on [**6-24**], Ms. [**Known lastname **] developed [**9-18**] sub-scapular pain. She was treated with morphine with good relief. CXR revealed widened mediastinum when compared to [**2142**] (there is not a more recent CXR for comparison). CTA of the chest was performed and did not reveal any change in chronic dissection from [**2145-6-22**]. Discharge was put on hold for further pain and blood pressure control. Additionally, orthopedics was consulted to further evaluate scapular pain. X-ray did not reveal any acute abnormality. Ortho recommended that the patient wear a left arm sling and follow up with PCP. [**Name10 (NameIs) **] was cleared for discharge to home with instructions to follow up with PCP as well as Dr. [**First Name (STitle) **] in 6 months with a CT scan and echo. Chief Complaint: Left scapular pain Major Surgical or Invasive Procedure: None History of Present Illness: Please see discharge summary from this admission for info in this addendum Past Medical History: Type A Aortic dissection s/p Replacement of Ascending Aorta (26mm Gelweave graft) and resuspension of aortic valve [**2143-1-15**] GERD DVT HTN Asthma Bronchiectasis RLL Heart failure, filated cardiomyopathy Chronic Kidney disease stage 3 IVC filter Anemia Arthritis Vitamin D deficiency Retinal detachment HITT Depression Social History: No ETOH or tobacco use. Family History: Noncontributory Physical Exam: Please see admission physical exam from full discharge summary to this addendum Pertinent Results: [**2145-6-26**] 07:20AM BLOOD WBC-9.5 RBC-3.92* Hgb-9.9* Hct-31.5* MCV-81* MCH-25.2* MCHC-31.3 RDW-13.5 Plt Ct-486* Radiology Report SCAPULA LEFT Study Date of [**2145-6-25**] 3:32 PM [**Last Name (LF) **],[**First Name3 (LF) **] CSURG FA6A [**2145-6-25**] 3:32 PM SCAPULA LEFT Clip # [**Clip Number (Radiology) 12012**] Reason: eval left shoulder for possible rotater cuff injury [**Hospital 5**] MEDICAL CONDITION: 68 year old woman s/p type A dissection repair 2 yrs ago now w back pain REASON FOR THIS EXAMINATION: eval left shoulder for possible rotater cuff injury, ?acute sharp pain Final Report HISTORY: Prior dissection repair, now with back pain, to evaluate for rotator cuff injury. FINDINGS: No previous images. Two views show the bony structures and joint spaces to be essentially within normal limits with no evidence of calcification. Extensive opacification in the upper left lung, presumably related to the previous surgical procedure. DR. [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2586**] Approved: FRI [**2145-6-25**] 5:01 PM Imaging Lab Brief Hospital Course: Please see full discharge summary to this addendum Medications on Admission: 1. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 2. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Three (3) Tablet PO DAILY (Daily). 4. Spiriva with HandiHaler 18 mcg Capsule, w/Inhalation Device Sig: One (1) cap Inhalation once a day. 5. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1) Spray Nasal DAILY (Daily). 6. Advair Diskus 500-50 mcg/Dose Disk with Device Sig: One (1) puff Inhalation twice a day. 7. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO twice a day. 8. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: 2-4 Puffs Inhalation Q6H (every 6 hours). 9. Carvedilol 25 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:*60 Tablet(s)* Refills:*2* 10. Losartan 100 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 11. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 12. Acetaminophen-Codeine 300-30 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. Disp:*30 Tablet(s)* Refills:*0* 13. Guaifenesin 1,200 mg Tablet Sustained Release 12 hr Sig: One (1) Tablet Sustained Release 12 hr PO twice a day. 14. Calcium Citrate + D 315-200 mg-unit Tablet Sig: One (1) Tablet PO twice a day. 15. Coumadin 1 mg Tablet Sig: As instructed by Dr [**Last Name (STitle) 12013**] Tablet PO once a day: Monitor PT/INR. . Discharge Medications: 1. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 2. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Three (3) Tablet PO DAILY (Daily). 4. Spiriva with HandiHaler 18 mcg Capsule, w/Inhalation Device Sig: One (1) cap Inhalation once a day. 5. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1) Spray Nasal DAILY (Daily). 6. Advair Diskus 500-50 mcg/Dose Disk with Device Sig: One (1) puff Inhalation twice a day. 7. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO twice a day. 8. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: 2-4 Puffs Inhalation Q6H (every 6 hours). 9. Carvedilol 25 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:*60 Tablet(s)* Refills:*2* 10. Losartan 100 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 11. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 12. Acetaminophen-Codeine 300-30 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. Disp:*30 Tablet(s)* Refills:*0* 13. Guaifenesin 1,200 mg Tablet Sustained Release 12 hr Sig: One (1) Tablet Sustained Release 12 hr PO twice a day. 14. Calcium Citrate + D 315-200 mg-unit Tablet Sig: One (1) Tablet PO twice a day. 15. Coumadin 1 mg Tablet Sig: As instructed by Dr [**Last Name (STitle) 12013**] Tablet PO once a day: Monitor PT/INR. . Discharge Disposition: Home With Service Facility: All Care VNA of Greater [**Location (un) 102**] Discharge Diagnosis: s/p Type A dissection repair with chronic Type B aortic dissection GERD DVT HTN Asthma Bronchiectasis RLL Heart failure, filated cardiomyopathy Chronic Kidney disease stage 3 IVC filter Anemia Arthritis Vitamin D deficiency Retinal detachment Heparin Induced thrombocytopenia Depression Discharge Condition: Stable Discharge Instructions: 1) Weigh yourself every morning, [**Name8 (MD) 233**] MD if weight has increased by 2 pounds in 24 hours or 5 pounds in 1 week. 2) Adhere to 2 gm sodium diet. Fluid restriction 2 liters 3) Monitor blood pressure daily. Maintain systolic blood pressure less then 125mmHg. 4) Continue your at home medications as per prior to admission. Prescriptions have been given to you for for Coreg, Losartan and your pain medications. 5) Please resume your coumadin as per preadmission. You were taking 4.5mg daily. Have your blood work (PT/INR) checked with results called to Dr. [**Last Name (STitle) 12013**] for coumadin dosing. 6) Call with any questions or concerns. Followup Instructions: Please follow-up with Dr. [**First Name (STitle) **] in 1 month ([**Telephone/Fax (1) 2092**] Please follow-up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 6471**] in 2 weeks. [**Telephone/Fax (1) 6472**] Follow-up with Dr. [**Last Name (STitle) 12013**] for coumadin dosing. Phone ([**Telephone/Fax (1) 12014**] Fax ([**Telephone/Fax (1) 12015**] Resume your preadmission dose. PT/INR may be checked by the visiting nurse and called to Dr. [**Last Name (STitle) 12013**]. [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 266**] Completed by:[**2145-6-26**] Name: [**Known lastname 12010**],[**Known firstname 5494**] Unit No: [**Numeric Identifier 12011**] Admission Date: [**2145-6-22**] Discharge Date: [**2145-6-26**] Date of Birth: [**2077-5-2**] Sex: F Service: CARDIOTHORACIC Allergies: Aspirin / Heparin Agents / Lisinopril Attending:[**First Name3 (LF) 265**] Addendum: Fter discharge from the hospital the final read of the chest CT was ammended to reflect a fill filling defect of the left Pulmonary artery that was no longer present. This finding could be consistant with a pulmonary embolus. The patient was anticoagulated on discharge from hospital and this finding required no change in her disposition or medication regime. Ct report below: [**Known lastname 12010**],[**Known firstname 5494**] [**Medical Record Number 12016**] F 68 [**2077-5-2**] Radiology Report CTA CHEST W&W/O C&RECONS, NON-CORONARY Study Date of [**2145-6-24**] 5:42 PM [**Last Name (LF) **],[**First Name3 (LF) **] CSURG FA6A [**2145-6-24**] 5:42 PM CTA CHEST W&W/O C&RECONS, NON- Clip # [**Clip Number (Radiology) 12017**] Reason: evaluate chronic dissection for acute rupture [**Hospital 5**] MEDICAL CONDITION: 68 year old woman with s/p type A dissection repair [**2142**], now with chronic type B dissection- sudden onset pain, widened mediastinum REASON FOR THIS EXAMINATION: evaluate chronic dissection for acute rupture CONTRAINDICATIONS FOR IV CONTRAST: None. [**Last Name (LF) **],[**First Name3 (LF) **] CSURG FA6A [**2145-6-24**] 5:42 PM CTA CHEST W&W/O C&RECONS, NON- Clip # [**Clip Number (Radiology) 12017**] Reason: evaluate chronic dissection for acute rupture Final Report STUDY: CTA torso with and without contrast and reconstructions. INDICATION: Evaluate dissection, severe back pain. COMPARISON: CTA torso [**2145-6-22**], CT torso with contrast [**2143-1-27**]. TECHNIQUE: MDCT helically acquired images were obtained from the thoracic inlet to the sacral promontory after the uneventful intravenous administration of Optiray 350 contrast material. Multiplanar reformatted images were obtained and reviewed. FINDINGS: CTA CHEST: Again demonstrated is ascending aortic graft placement and aortic dissection, little overall change since recent comparison. Appearance of a small focal dissection/pseudoaneurysm just proximal to the graft is unchanged from multiple prior studies. Increased contrast enhancement of the false lumen when compared to prior, likely reflects differences in bolus timing versus new fenestration within the dissection flap. No evidence of new mediastinal hematoma or rupture is identified. Mediastinal soft tissue and soft tissue involving the left apex is little overall changed and likely reflects pseudoaneurysm versus contained rupture. Aneurysmal appearance of the right innominate artery (up to 1.5cm) and the right common carotid artery (up to 1.7cm) have been present on multiple prior studies. Left brachiocephalic artery is essentially obliterated by mass effect from the aneurysmal aortic arch; there is suggestion of a small focus of residual thrombus/filling defect just before its compression by the aortic arch (series 3, image 13-15). No pericardial or pleural effusions are identified. Bibasilar atelectasis vs consolidation again demonstrated, left greater than right. Calcified hilar lymph nodes again noted. On the prior study, there appeared to be filling defect in the left lobe pulmonary artery, but is no longer evident on this study, which has better contrast bolus opacification of the pulmonary arteries--question resolving embolus. Given this suggestion, possibility of pulmonary infarct relating to the left basilar opacities cannot be excluded. Cardiomegaly remains present. CT ABDOMEN WITH CONTRAST AND RECONSTRUCTIONS: No focal liver lesions are identified. Infrarenal IVC filter is in stable position. 1.4-cm cyst within the posterior cortex of the right kidney, little overall change. No renal mass is identified. Spleen, pancreas, adrenal glands, and abdominal large and small bowel appear unremarkable. No appreciable overall change is detected to the abdominal aortic dissection which extends partially into the left renal vein with false lumen supplying the celiac axis and SMA/[**Female First Name (un) **]. The dissection flap also extends into the left external iliac artery. No free fluid or free air is present within the abdomen. OSSEOUS STRUCTURES: No suspicious lytic or sclerotic lesions. Sternotomy wires remain intact. IMPRESSION: 1) Little overall change to appearance of the torso since recent comparison two days previous. Complex aortic dissection as extensively detailed on recent prior report. 2) Suggestion of sequellae from recent pulmonary embolism, possibly from the left brachiocephalic vein (see details above). At the time of this scan, all segmental pulmonary arteries appear patent. The study and the report were reviewed by the staff radiologist. DR. [**First Name (STitle) **] [**Doctor Last Name 12018**] DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] Approved: SUN [**2145-6-27**] 12:45 AM Final Addendum Findings from finalized report were relayed to and acknowledged by Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] [**2145-6-30**] by E-mail. The study and the report were reviewed by the staff radiologist. DR. [**First Name (STitle) **] [**Doctor Last Name 12018**] DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] Approved: [**Doctor First Name **] [**2145-7-1**] 11:47 AM Discharge Disposition: Home With Service Facility: All Care VNA of Greater [**Location (un) 102**] [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 266**] Completed by:[**2145-7-1**]

[ "V64.1", "268.9", "518.0", "285.9", "428.20", "716.90", "493.90", "425.4", "724.5", "494.0", "562.10", "441.2", "311", "415.19", "441.01", "403.10", "585.3", "V12.51", "428.0", "530.81", "V58.61", "719.41" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

21831, 22028

11373, 11425

9565, 9572

14820, 14829

10213, 10602

15538, 17332

10081, 10098

12931, 14388

14510, 14799

11451, 12908

14853, 15515

10113, 10194

9507, 9527

17545, 21808

17371, 17513

9600, 9676

9698, 10023

10039, 10065

1,198

151,608

13909

Discharge summary

report

Admission Date: [**2142-5-23**] Discharge Date: [**2142-6-1**] Date of Birth: [**2066-12-20**] Sex: M Service: CARDIAC SURGERY CHIEF COMPLAINT: Coronary artery disease. HISTORY OF PRESENT ILLNESS: The patient is a 65 year old male with hypertension, diabetes mellitus, hypercholesterolemia and a past smoker, who had recent onset of chest pain and a positive stress test. He was admitted to the Cardiac Medicine service on [**2142-5-23**], for catheterization. PAST MEDICAL HISTORY: 1. Coronary artery disease. 2. Diabetes mellitus. 3. Renal insufficiency. 4. Sleep apnea. 5. Hypercholesterolemia. MEDICATIONS ON ADMISSION: 1. Cartia 120 mg p.o. q.d. 2. Lipitor 10 mg q.d. 3. Univasc 15 mg p.o. q.d. 4. Atenolol 25 mg q.d. 5. Diovan 160 mg q.d. 6. Humulin N 30 units q.a.m. and 30 units q.p.m. 7. Humulin R 14 units q.a.m. and 8 units q.p.m. ALLERGIES: Penicillin. HOSPITAL COURSE: The patient was admitted to the Cardiac Medicine service on [**2142-5-23**], prior to his catheterization for prehydration. He underwent catheterization which revealed three vessel disease. Cardiac surgery was consulted and the decision to go to the operating room was made. The patient underwent a coronary artery bypass graft times three on [**2142-5-26**], with left internal mammary artery to left anterior descending, saphenous vein graft to OM, saphenous vein graft to posterior descending artery. He had an uneventful operative course and was transferred to the CSRU. He was extubated on the same day. Postoperatively, his creatinine did rise from baseline of 2.5 to 3.3. On postoperative day three, he had an episode of atrial fibrillation for which he was treated with Amiodarone which initially reverted to normal sinus rhythm and then reverted back to atrial fibrillation. He was stable for transfer to the floor on postoperative day three and his rhythm had changed from atrial fibrillation to a junctional rhythm at this point. Subsequently on the floor, he had a smooth postoperative course. His pacing wires were discontinued on postoperative day four. He was ambulating well and was cleared by physical therapy. His pain was under control with p.o. analgesics. He was ready for discharged on postoperative day six. He was discharged home. MEDICATIONS ON DISCHARGE: 1. Lopressor 25 mg p.o. b.i.d. 2. Colace 100 mg b.i.d. 3. Aspirin Enteric Coated 325 mg q.d. 4. Humulin N 30 units q.a.m. and 30 units q.p.m. 5. Humulin R 14 units q.a.m. and 8 units q.p.m. 6. Lipitor 10 mg q.d. 7. Amiodarone 400 mg q.d. 8. Niferex 150 mg q.d. 9. Percocet one to two tablets q4-6hours p.r.n. FO[**Last Name (STitle) **]P: The patient is to follow-up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], primary care physician, [**Name10 (NameIs) **] two weeks and with Dr. [**Last Name (Prefixes) **] in four weeks. He is being discharged home with VNA for wound check. [**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**] Dictated By:[**Last Name (NamePattern1) 2209**] MEDQUIST36 D: [**2142-6-1**] 17:00 T: [**2142-6-2**] 19:29 JOB#: [**Job Number 41661**]

[ "411.1", "272.0", "427.31", "780.57", "593.9", "997.1", "E878.2", "414.01", "401.9" ]

icd9cm

[ [ [] ] ]

[ "42.23", "88.72", "39.61", "36.15", "37.22", "36.12", "88.56" ]

icd9pcs

[ [ [] ] ]

2316, 3200

652, 903

921, 2290

162, 188

217, 483

505, 626

5,738

103,909

22261

Discharge summary

report

Admission Date: [**2112-9-12**] Discharge Date: [**2112-10-5**] Date of Birth: [**2049-6-22**] Sex: M Service: [**Hospital Unit Name 196**] Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 9554**] Chief Complaint: Transferred to [**Hospital1 18**] for STEMI/cardiogenic shock Major Surgical or Invasive Procedure: Cardiac catheterization, placement of two stents in the left dircumflex coronary artery. Placement of intra-aortic balloon pump. Placement of Swan-Ganz catheter via femoral access. Cardioversion x 3 for ventricular tachycardia. Emergent repeat cardiac catheterization. History of Present Illness: The patient is a 63 year old male transfered to [**Hospital1 18**] from an OSH for STEMI, in cardiogenic shock on pressors. Pt initially presented to [**Hospital3 3583**] on [**2112-9-11**] with SOB and chest pain of approximately 1 wk duration. In OSH ED, was found to have RML PNA. He also reported fall one week prior with facial ecchymosis, found to have nasal fx by CT. EKG showed sinus tach in the 130s with Qs in II,III,aVF with nl. axis and intervals and T-waves inverted in inferior leads and ST depressions in the lateral leads. Pt received ASA, b-blockers, morphine, nitro paste, levaquin and was pain-free with sats in the 90%s on 100%NRB. Troponin was 0.525 with flat CK. T max 99.1. WBC 15.9, Hct 44.5%. Received lovenox sq, with last dose at 12am [**2112-9-12**]. On [**9-12**] at noon, pt became SOB and diaphoretic with pain, and sats fell to 77% on 100%NRB with HR120. Received 40mg of lasix, 4mg morphine, and was intubated at 12:30pm. At 1pm, EKG showed sinus at 100, nl intervals and axis with Qs in III & aVF, ST elevations in III>II, and ST depressions in I,aVL. Blood pressure fell s/p intubation to 60s/20s requiring fluid resuscitation and dopamine 10mcg/kg/min. O2 sats rose to 88% on AC700mlx14/min + 5PEEP. CXR showed worsening of a R lung alveolar process with extrusion to the L side, with a differential of infection vs R>L pulmonary edema. Patient was then transferred to [**Hospital1 18**]. Past Medical History: 1. Gout 2. EtOH abuse 3. Hypercholesterolemia Social History: History of EtOH abuse. No PCP. Physical Exam: Gen: intubated, sedated. Not responsive to calling name or sternal rub. Skin: Abdominal rash resolved. Feet less mottled. +posterior scrotal excoriations. + 3 bullae filled with clear liquid on L ventral wrists and L thumb - improving. HEENT: PERRL, MM moist. Heart: RRR. II/VI Holosystolic murmur at apex. Lungs: slight crackles B vs. upper airway noise (ant auscultation). Abd: soft. hypoactive bowel sounds. Extrem: tr pitting edema B LE. Neuro/Psy: Not following commands. Access: R IJ swan in place. L wrist with A-line. Pertinent Results: [**2112-9-12**] 07:58PM WBC-16.5* RBC-4.43* HGB-13.7* HCT-40.3 MCV-91 MCH-31.0 MCHC-34.1 RDW-13.2 [**2112-9-12**] 07:58PM PLT COUNT-217 [**2112-9-12**] 07:58PM PT-13.9* PTT-32.9 INR(PT)-1.2 [**2112-9-12**] 06:46PM GLUCOSE-189* LACTATE-2.2* K+-3.9 [**2112-9-12**] 03:07PM TYPE-ART PO2-57* PCO2-45 PH-7.33* TOTAL CO2-25 BASE XS--2 INTUBATED-INTUBATED [**2112-9-12**] 07:58PM ALT(SGPT)-14 AST(SGOT)-33 LD(LDH)-361* CK(CPK)-214* ALK PHOS-140* AMYLASE-49 TOT BILI-0.8 [**2112-9-12**] 07:58PM GLUCOSE-179* UREA N-24* CREAT-1.5* SODIUM-136 POTASSIUM-4.1 CHLORIDE-101 TOTAL CO2-22 ANION GAP-17 [**2112-9-12**] 11:49PM URINE BLOOD-TR NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [**2112-9-12**] 11:49PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.015 [**2112-9-12**] 11:49PM URINE RBC-[**3-25**]* WBC-0-2 BACTERIA-MANY YEAST-NONE EPI-0-2 CATH [**2112-9-12**]: LMCA had a 40% lesion. LAD had diffuse luminal irregularities but was free of significant stenoses and supplied 2 moderate-sized diagonal branches which were also free of significant disease. LCX had a hazy 60% lesion in the mid vessel and a hazy 80% lesion in the distal vessel. The RCA was a small vessel and was totally occluded in the mid segment. A R-PDA was seen filling via L-R collaterals. Resting hemodynamics revealed evidence of cardiogenic shock with an aortic pressure of 94/53 mmHg, a cardiac index of 1.3 L/min/m2 and a PCWP of 30 mmHg on an infusion of dopamine at 10 mcg/kg/min. stented with a 3.5 x 13 mm cypher [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 55492**] and 3.0 x 13 mm cypher [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 22595**] at 14 atms with no residual stenosis, no dissection and timi 3 flow. Transthoracic Echo [**2112-9-13**]: EF 70% The overall left ventricular ejection fraction is normal (borderline hyperdynamic) but the lateral wall and adjacent segments of anterior free wall are hypokinetic relative to the frankly hyperdynamic inferior and posterior walls. Right ventricular systolic function appears depressed. There is a trivial/physiologic pericardial effusion. Compared with the findings of the prior study (tape reviewed) of [**2112-9-12**], the cardiac rhythm is atrial fibrillation with ventricular tachycardia; the lateral wall (which now appears relatively hypokinetic) was not well-visualized on the prior study; therefore no direct comparison of contractile function in this territory can be made. Transesophageal Echo [**2112-9-13**]: No spontaneous echo contrast or thrombus is seen in the body of the left atrium/left atrial appendage or the body of the right atrium/right atrial appendage. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thickness, cavity size, and systolic function are normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The ascending, transverse and descending thoracic aorta are normal in diameter and free of atherosclerotic plaque. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. The mitral leaflets are myxomatous. There is moderate/severe posterior mitral leaflet prolapse. There is partial mitral leaflet flail. There is moderate thickening of the mitral valve chordae. Severe (4+) mitral regurgitation is seen. Brief Hospital Course: The patient was admitted to the CCU service after his catheterization. Overall the following weeks the pt was determined to be extremely sick with multiple organ system failure. He needed a mitral valve replacement surgery, however, in order to have this surgery he would need to be extubated and afebrile. He was treated with hemodialysis and further diuresis was attempted with IV diuretics and BNP, however the pt's respiratory status remained tenuous. Furthermore, he did not wake up when sedation was weaned. He was evaluated by Neuro with an EEG that showed only diffuse slowing and a head CT that showed no acute changes. It was felt likely that due to his episodes of hypotension with the VT and other hemodynamic instability later that he had sustained anoxic brain injury. This was all discussed with the family who felt that the pt would not have wanted to be kept alive on a ventilator long-term when any hope of recovery was extremely slim. As all attempts to wean him from the ventilator were unsuccessful he was made CMO and made comfortable with morphine. He died shortly after. Medications on Admission: unknown Discharge Medications: pt expired. Discharge Disposition: Home Discharge Diagnosis: Pt expired of respiratory failure. Discharge Condition: expired Discharge Instructions: none Followup Instructions: none [**First Name8 (NamePattern2) 2064**] [**Last Name (NamePattern1) **] MD [**MD Number(2) 2139**]

[ "427.31", "424.0", "410.31", "518.5", "428.0", "785.51", "557.0", "584.5", "486" ]

icd9cm

[ [ [] ] ]

[ "96.6", "36.07", "00.13", "88.56", "99.62", "38.95", "88.72", "89.64", "36.01", "86.11", "37.61", "37.23", "39.95", "99.15" ]

icd9pcs

[ [ [] ] ]

7458, 7464

6266, 7364

397, 667

7542, 7551

2804, 6243

7604, 7737

7422, 7435

7485, 7521

7390, 7399

7575, 7581

2256, 2784

296, 359

695, 2124

2146, 2193

2209, 2241

32,436

193,293

45159

Discharge summary

report

Admission Date: [**2130-6-20**] Discharge Date: [**2130-6-30**] Date of Birth: [**2060-11-1**] Sex: M Service: MEDICINE Allergies: Flomax / Shellfish Derived / Fish Product Derivatives / Zolpidem Attending:[**First Name3 (LF) 1936**] Chief Complaint: Altered mental status Major Surgical or Invasive Procedure: Elective endotracheal intubation [**2130-6-20**] Foley catheter fragment removal [**2130-6-23**] History of Present Illness: Mr. [**Known lastname 69629**] is a 69 y.o. Spanish-speaking male with multiple myeloma, ESRD on HD, history of right PICA CVA, HTN who presents with gradually worsening mental status with agitation, inability to walk and disorientation x 1 week. Patient was brought in by family for concern of mental status. In the ED, he was seen by neurology and was only able to follow minimal commands. His labs were notable for a creatinine of 10.6 (baseline varies, but recently 5 - 6; last HD session on [**6-17**]) and a calcium of 15.7. Mental status was felt to be due to hypercalcemia, but patient could not get fluids because of concern of fluid overload, suggested by desaturation to high 80s on room air, improved with 3 liters. CXR was consistent with fluid overload. As a result, fluid resuscitation was held and Lasix was also held because patient is anuric. [**Month/Year (2) 2793**] was consulted and recommended Calcitonin and IV steroids with plans to dialyze first thing in the morning. Given a low-grade temperature of 100.9 and altered mental status, an LP was considered, but deferred since patient's INR was mildly elevated to 1.9 (anticoagulated because of PAF) and because FFP to reverse it would have added to his fluid burden. CT head was unremarkable. He was given Vancomycin, Zosyn and Acyclovir per neuro for empiric CNS coverage. Ampicillin was also given, since patient is immunosuppresed from chronic steroids as an outpatient. Patient otherwise received Labetalol to control SBP recording as high as 220s, prior to being admitted to the ICU for further management. Past Medical History: IgA Multiple myeloma s/p 11 cycles velcade/dex ESRD [**2-27**] to MM - Tu/Th/Sa R PICA CVA [**5-27**] - ataxic @ baseline PAF PE [**9-2**] Mild-mod AR Mod MR [**Name13 (STitle) **] TR C. diff Strep pneumo PNA PCP PNA HTN HL Diverticulosis H. pylori gastritis Anemia of B12/Fe-deficiencies, CKD Anxiety and depression Social History: Formerly worked at [**Hospital1 **] and [**Hospital6 **]. Married, 3 children. Son is HCP. Wife has [**Name2 (NI) 499**] CA. 20 pack-year smoking hx. Drinks ETOH socially. Family History: Mother and father died of lung CA. Physical Exam: ADMISSION PHYSICAL EXAM Vitals: T: 99.3, BP: 175/77, P: 89, R:18 O2: 96% 3L General: Sleeping, but arousable, oriented to person and place (hospital); follows simple commands HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: reg rate nl S1S2 III/VI SEM at base 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: ADMISSION LABS: [**2130-6-19**] 07:00PM BLOOD WBC-5.6 RBC-3.22* Hgb-11.0* Hct-33.5* MCV-104* MCH-34.1* MCHC-32.8 RDW-16.6* Plt Ct-141* [**2130-6-19**] 07:00PM BLOOD Neuts-81.6* Lymphs-9.9* Monos-3.9 Eos-4.4* Baso-0.3 [**2130-6-19**] 07:00PM BLOOD PT-20.4* PTT-38.5* INR(PT)-1.9* [**2130-6-19**] 07:00PM BLOOD Glucose-110* UreaN-38* Creat-10.6*# Na-137 K-5.0 Cl-93* HCO3-24 AnGap-25* [**2130-6-19**] 07:00PM BLOOD ALT-7 AST-18 LD(LDH)-143 CK(CPK)-61 AlkPhos-94 TotBili-0.2 [**2130-6-19**] 07:00PM BLOOD Albumin-3.5 Calcium-15.7* Phos-9.0*# Mg-2.4 [**2130-6-26**] 07:20AM BLOOD %HbA1c-5.3 [**2130-6-26**] 07:20AM BLOOD Triglyc-266* HDL-25 CHOL/HD-4.8 LDLcalc-41 LDLmeas-<50 DISCHARGE LABS: [**2130-6-28**] 09:00AM BLOOD WBC-3.6* RBC-2.83* Hgb-9.9* Hct-29.6* MCV-105* MCH-34.8* MCHC-33.3 RDW-16.4* Plt Ct-185 [**2130-6-26**] 07:20AM BLOOD Neuts-61.9 Lymphs-19.2 Monos-6.2 Eos-12.3* Baso-0.4 [**2130-6-28**] 09:00AM BLOOD Glucose-86 UreaN-25* Creat-7.8*# Na-138 K-4.6 Cl-94* HCO3-29 AnGap-20 [**2130-6-28**] 09:00AM BLOOD Calcium-13.0* Phos-7.1* Mg-2.4 [**2130-6-19**] NON-CONTRAST HEAD CT: No edema, masses, mass effect, hemorrhage or infarction is detected. The ventricles and sulci are mildly prominent consistent with involutional changes. Wedge shaped hypodensity of the right cerebellum is most likely sequale of prior infarct. Periventricular white matter hypodensities are compatible with chronic microvascular infarction. The visualized part of the paranasal sinuses and mastoid air cells are clear. No fracture is detected. IMPRESSION: No acute intracranial pathology including no hemorrhage. . [**2130-6-20**] MR HEAD W/O CONTRAST FINDINGS: There is a tiny area of restricted diffusion in the body of the right caudate with correlate on ADC map, consistent with an acute infarct. Chronic cerebellar and other bilateral lacunar infarcts are seen. There is no hemorrhage, edema, mass or hydrocephalus. Periventricular white matter hyperintensities are again seen and compatible with changes of small vessel ischemic disease. There is no midline shift. There is no evidence of venous sinus thrombosis. There is poor flow void identified in the right distal vertebral artery, as before. IMPRESSION: 1. Tiny lacunar infarct in the body of the right caudate. Solitary lesion is not typical for embolic phenomenon, but is considered. Acute ischemic infarction is another consideration. 2. Stable appearance of chronic cerebellar and a lacunar infarct. 3. Diminished flow void in the right vertebral artery, as before. 4. No venous sinus thrombosis. . [**2130-6-21**] CT ABDOMEN W/O CONTRAST IMPRESSION: 1. 3.3 cm segment of retained Foley catheter within the bladder. No evidence for bladder wall injury. 2. Tortuous and ectatic aorta, with maximal diameter of 3.6 cm at the level of diaphragmatic hiatus. 3. Diverticulosis without evidence for diverticulitis. . [**2130-6-25**] EEG: This is an abnormal routine EEG due to the slow and disorganized background and the bursts of generalized slowing. This abnormality suggests a widespread encephalopathy of both cortical and subcortical structures. Medications, metabolic disturbances, and infections are among the most common causes. There were no lateralized or epileptiform features seen in this recording. . [**2130-6-28**] RIGHT CLAVICLE: There are no signs for acute fractures or dislocations. There are no focal lytic or blastic lesions within the right clavicle. There is AC joint osteoarthritic changes with some spurring consistent with osteoarthritis. There is a portion of the central venous catheter within the right upper lung field. The lung apices are grossly clear. . [**2130-6-29**] CXR FINDINGS: AP single view of the chest has been obtained with patient in sitting upright position. Analysis is performed in direct comparison with a preceding similar study of [**2130-6-28**]. Findings of this single plain AP chest examination does not include a new parenchymal infiltrate or pleural effusion that reaches the lateral pleural sinuses. Previously described [**Year (4 digits) 2286**] line in unchanged position and no evidence of pneumothorax. IMPRESSION: No evidence of new infiltrates or advanced CHF. . Brief Hospital Course: #Hypercalcemia - Improved initially with calcitonin, IV steroids, and [**Year (4 digits) 13241**]. Low calcium bath used for subsequent HD sessions. Pamidronate 30 mg IV was given [**6-23**] and [**6-28**]. Recommended that daily calcium levels be checked after discharge and that consideration be given to re-dosing bisphosphonate if Ca >13 mg/dL. Heme/Onc was consulted for evaluation of multiple myeloma as etiology for hypercalcemia, and for definitive management of myeloma. Plan per Onc is for Decadron 20mg IV daily x 5 days (last day [**2130-7-2**]), then follow-up with Dr. [**Name (NI) 410**], pt's primary oncologist on [**Name (NI) 766**] [**2130-7-3**]) for possible IV Cytoxan. Pt will receive Calcitonin 250units [**Hospital1 **] PRN daily serum calcium >14. Calcium had improved to 11.7 (alb 3.2) on [**2130-6-30**]. . #Fever - Empirically started on vanco/ceftazidime. No clear source was identified, as chest x-ray, abdominal CT, and urine and blood cultures were negative. Antibiotics were discontinued after 72 hours. . #Altered mental status - Attributed to hypercalcemia as mental status improved with treatment. As the likelihood of suspicion for meningoencephalitis or myelomatous CNS involvement were low, and since the patient rapidly improved, LP was deferred. While non-contrast head MR [**6-20**] (for which the patient was electively intubated and sedated) revealed a tiny lacunar infarct in the body of the right caudate, the consulting neurology team felt that this was most likely not acute and would not likely explain the current clinical picture. EEG showed some slowing but no signs of seizure activity. On [**6-29**], pt had recurrence of confusion with concommitant hypoxia to mid-upper 80s on RA and lethargy. This was thought to be most likely seconary to his rising calcium levels. Pt did not have leukocytosis or fever. Mental status cleared by [**6-30**] am, and calcium and phosphorus levels had improved. Pt was AOx3 on day of discharge. . # Hypoxia- On [**6-29**], pt had recurrence of confusion with concommitant hypoxia to mid-upper 80s on RA and lethargy. He was placed on 2L O2 with sats up to mid-90s. ABG showed a metabolic alkalosis with likely concommitant AG acidosis and non-gap acidosis. CXR did not show signs of new pneumonia or fluid overload. Pt has had occasional desats to high 80s during admission, responsive to supplemental O2. On [**6-30**], hypoxia had resolved, with pt satting in mid-90s on RA at rest and 88% on RA with ambulation. . #Retained foley fragment - The patient removed his foley catheter with the balloon inflated and abdominal CT [**6-21**] revealed a 3.3 cm segment of retained catheter within the bladder without evidence of bladder wall injury. Urology surgically removed this fragment under general anaesthesia on [**6-23**] without complication. . #AFib - Coumadin was resumed after urological procedure. Heparin bridge was deferred given the low faily risk of stroke and a history of recurrent GI bleeding. Rate was well-controlled with metoprolol. On [**6-30**] Warfarin dose was decreased to 4mg PO daily with am INR 2.6. . #ESRD on HD - Continued to receive [**Month/Day (1) 13241**] with Low Ca2+ bath on Tues/Thurs/Sat. Pt is on a LOW PHOSPHORUS [**Month/Day (1) **] diet. . #HTN - Metoprolol was increased to 100 mg TID. Per [**Month/Day (1) **], higher BPs are tolerable. Hydralazine standing was discontined. Hydralazine was also made available PRN SBP>160. Aggressive blood pressure control was avoided due to a history of recurrent falls and tendency to become hypotensive after [**Month/Day (1) 2286**]. [**Month/Day (1) 2793**] may consider removing additional fluid PRN. . #Anemia (macrocytic) [**2-27**] B12 deficiency- Hematocrit remained stable and transfusion was not required. Iron and B12 supplementation were continued. Medications on Admission: 1. Allopurinol 100 mg PO QOD 2. Nephrocaps 1 tab PO QD 3. Sevelamer 1600 mg PO TID 4. Toprol XL 100 mg PO QD 5. Bactrim SS PO QD 6. Albuterol 90 mcg 1-2 puffs Q 4-6 PRN 7. Folic Acid 1 mg PO QD 8. Cyanocobalamin 1000 mcg PO QD 9. Omeprazole 20 mg PO QD 10. Guaifenesin with Codeine PRN 11. Coumadin 4 mg PO QD 12. Acetaminophen PRN 13. Benadryl 25 mg IV w/ [**Month/Day (2) 2286**] 14. Loratadine 10 mg PO QD 15. Iron 325 mg PO QD 16. Docusate 100 mg PO BID 17. Midodrine 2.5 mg PO Qdialysis Discharge Medications: 1. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY (Every Other Day). 4. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: 1-2 puffs Inhalation every 4-6 hours as needed for shortness of breath or wheezing. 6. Cyanocobalamin 500 mcg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 8. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Loratadine 10 mg Tablet Sig: One (1) Tablet PO once a day. 10. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for Fever/Pain. 11. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) injection Injection TID (3 times a day): Please administer while non-ambulatory for DVT prophylaxis. 12. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 13. Mirtazapine 15 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime). 14. Tramadol 50 mg Tablet Sig: One (1) Tablet PO every twelve (12) hours. 15. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 16. Hydralazine 25 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for PRN SBP>160. 17. Sevelamer HCl 400 mg Tablet Sig: Six (6) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 18. Dexamethasone Sodium Phosphate 10 mg/mL Solution Sig: Twenty (20) mg Injection once a day: Last day [**2130-7-2**]. (total 5-day coursre). 19. Insulin Lispro 100 unit/mL Solution Sig: as directed Subcutaneous ASDIR (AS DIRECTED): see sliding scale. 20. Pamidronate 30 mg Recon Soln Sig: Sixty (60) mg Intravenous once a week: Please give every Friday. 21. Calcitonin (Salmon) 200 unit/mL Solution Sig: Two Hundred Fifty (250) units Injection twice a day as needed for when daily serum calcium >14: Please re-evaluate dose according to daily calcium level. 22. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 23. Warfarin 4 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM: Please check INR every 2 days (first day [**2130-7-1**]) until at goal INR 2.0-3.0, followed by biweekly. Please adjust coumadin dose accordingly to maintain therapeutic INR 2.0-3.0. 24. Acetaminophen 500 mg Capsule Sig: Two (2) Capsule PO Q 8H (Every 8 Hours). 25. Oxycodone 5 mg Capsule Sig: One (1) Capsule PO every six (6) hours as needed for pain: Hold for sedation or RR <10. Discharge Disposition: Extended Care Facility: [**Hospital3 7**] & Rehab Center - [**Hospital1 8**] Discharge Diagnosis: Primary Diagnoses: 1) Hypercalcemia of malignancy 2) Retained foley catheter fragment 3) Cerebrovascular disease Secondary Diagnoses: 1) Multiple myeloma 2) End-stage [**Hospital1 **] disease on [**Hospital1 13241**] 3) Atrial fibrillation Discharge Condition: Clinically improved with stable vital signs. Discharge Instructions: You were admitted to the hospital with disorientation and difficulty with walking. The calcium level in your blood was found to be very high. You will be starting chemotherapy with Dr. [**Last Name (STitle) 410**] next week in an attempt to improve your multiple myeloma and high calcium levels. The following medication changes were recommended: 1) Metoprolol (lopressor) was increased to 100 mg three times daily. 2) Warfarin (coumadin) was adjusted to 4 mg daily (now back on home dose). 3) Midodrine was discontinued. 4) Mirtazapine (remeron) was started to help with sleep. 5) Tramadol was started for pain 6) Hydralazine also available PRN SBP>160 7) Standing Tylenol was started for pain 8) Oxycodone is available as needed for breakthrough pain 9) Dexamethasone 5-day course was started, last day [**2130-7-2**] Please weigh yourself daily and call your physician if your weight increases by more than 3 pounds. Please adhere to a diet consistent of less than 2 grams of sodium daily. Please attend all of your follow-up [**Month/Day/Year 4314**]. Please call your physician or return to the Emergency Department if you experience fever, chills, sweats, dizziness, lightheadedness, vision changes, chest pain, palpitations, cough, shortness of breath, abdominal pain, vomiting, diarrhea, bloody or dark stools, numbness, weakness, tingling, difficulty with speech or walking, or any other worrisome symptoms. Followup Instructions: You have the following [**Month/Day/Year 4314**]: Heme/Oncology *Provider: [**First Name8 (NamePattern2) 539**] [**Last Name (NamePattern1) 9816**], RN Phone:[**Telephone/Fax (1) 3241**] Date/Time:[**2130-7-3**] 12:30 *Provider: [**Name10 (NameIs) 3242**] [**Apartment Address(1) 9575**] Date/Time:[**2130-7-3**] 12:30 *Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 3749**], MD Phone:[**Telephone/Fax (1) 3241**] Date/Time:[**2130-7-3**] 1:00 Cardiology *Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2908**], MD Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2130-7-6**] 3:20 PCP *Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**Name Initial (NameIs) **].D. Date/Time:[**2130-7-17**] 10:00 [**Month/Day/Year 2793**] You will see your [**Month/Day/Year **] doctors [**First Name (Titles) **] [**Last Name (Titles) 13241**] [**Name5 (PTitle) **]/Thurs/Sat. Completed by:[**2130-6-30**]

[ "403.91", "V12.54", "285.21", "274.9", "437.9", "V12.51", "427.31", "585.6", "293.0", "275.42", "V87.41", "799.02", "272.0", "562.10", "V58.61", "275.3", "781.3", "939.0", "311", "276.3", "300.00", "203.00", "780.52", "E915", "V12.72" ]

icd9cm

[ [ [] ] ]

[ "57.0", "39.95" ]

icd9pcs

[ [ [] ] ]

14462, 14541

7433, 11266

347, 446

14827, 14873

3230, 3230

16342, 17320

2607, 2643

11808, 14439

14562, 14676

11292, 11785

14897, 16319

3919, 4310

2658, 3211

14697, 14806

286, 309

474, 2062

4319, 7410

3246, 3903

2084, 2402

2418, 2591

22,659

159,352

6214

Discharge summary

report

Admission Date: [**2193-2-8**] Discharge Date: [**2193-2-14**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1711**] Chief Complaint: SOB, chest pain Major Surgical or Invasive Procedure: Cardiac catheterization w/ [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 5175**] to LMCA, LAD and LCx IABP placement Swan-Ganz catheter placement Intubation and mechanical ventilation R IJ placement History of Present Illness: 82 yo F with known CAD (details unknown) who is reported to have developed SOB without chest pain/pressure on [**2193-2-7**] p.m. although with GERD like symptoms. Per discussion with the patient's family, the patient had episodes of shortness of breath starting one week prior that were self limiting. Early morning on [**2193-2-8**] the patient's symptoms persisted and EMS was called. The patient was found to be dyspneic with respiratory rate in the 40s, but was reported to be A+O x3. The patient was taken to [**Hospital 487**] Hospital and given lasix and SL nitro on arrival. In the ED the patient's ECG was remarkable for NSR at 115bpm with LBBB (presumed to be new, but not definitely known given none for comparison) with BP 144/77, O2 Sat 90% on NRB with rales bilaterally with 1+ LE edema. The patient was intubated for respiratory failure with subsequent development of hypotension with SBP in the 90's. Given LBBB and hypotension there was concern for ACS for which the patient was given a 25cc bolus of integrillin with subsequent gtt, Heparin, Plavix 300mg, ASA and transferred to [**Hospital1 18**] for emergent cath. In the cath lab the patient was noted to have pressure of 60/48 for which she was started on double pressor therapy with Dopamine gtt (13mcg/kg/min) and Levophed (12mcg/min) with an ABG notable for 7.13/53/86 on AC 100%, PEEP 2.5 600 x 12. . Cardiac enzymes from OSH were noted to be CK - 45, Trop 0.73. In the cath lab Right heart cath was performed with the following pressures: RA 26 ; RV 63/25 ; PCWP 46 ; PA 66/44/54 with hemodynamic measurements revealing a CO of 4.26 and CI 1.96 on pressors. The patient had an emergent echo that revealed EF 25%, 3+ MR, [**12-17**]+ TR, with apical hypokinesis/akinesis. Given the patient's depressed CI and CO an IABP was placed. . Left heart Cath revealed the following on arteriography: (225 dye) Left Main: 70% at origin, 90% distal LAD: 90% at origin, Mid 100%, Left Cx: 80% at origin, long 95% mid RCA: 70% mid lesion, PDA 90% , posterolateral 70% . CT surgery was consulted given the extensive CAD but did not feel the patient was an operative candidate given the hypotension, acidosis and poor distal targets. Therefore, the left main and LAD were stented with DES with good flow. The LCx initially appeared worse after stenting but improved with wire passage down vessel. . Repeat Right cath pressures after intervention revealed CO of 6.21 with CI of 2.91 on Pump and 10 Dopamine. The patient's course was additionally complicated by episode of VT in the cath lab x 1 minutem which terminated before DCCV was performed. The patient was bolused with 150mg amiodarone and 100mg Lidocaine and initially continued on lido gtt which was discontinued on transfer to the floor. Of note, the patient had 800cc urine output at the end of the case without diuresis Past Medical History: Hypercholesterolemia Hypertension Acid reflux disease Peptic ulcer disease Hypothyroidism Diverticulosis Social History: (per OMR) Pt lives alone. She gets a daily phone call from her son who lives in [**Name (NI) 86**]. She reports that she is afraid to travel due to concerns about running into health issues while traveling, although at home, she remains active, cooking, [**Location (un) 1131**], and watching TV as well as other activities. Family History: NC Physical Exam: Vitals: T-96.5 BP: 105/54, HR - 94, CVP - 12 PA: 53/27/38 . Gen: Patient is an obese female, intubated and sedated HEENT: ETT in place, small bleeding at corner of mouth Neck: JVP difficult to assess secondary to ETT and securing straps Chest: Transmitted breath sounds from vent, otherwise geenrally CTA Anterior and Lat Cor: RRR, Normal S1/S2. No M/R/G Abdomen: Obese, soft, NT. Hypoactive bowel sounds Ext: Right groin: IABP line in place, dressing saturated with sanguinous fluid Left groin: Dressing in place over swan and a-line - mod/severely stained with sanguinous fluid. Pulse audible over both groin without bruit. No hematoma/ecchymosis Pulses: Not palpable bilaterally, + Dopplers. Extremities cool to touch. Pertinent Results: Labs on admission: WBC 16.0, Hct 32.8, MCV 88, Plt 183# (DIFF: Neuts-66 Bands-1 Lymphs-11* Monos-10 Eos-0 Baso-0 Atyps-11* Metas-0 Myelos-0 Other-1 Hypochr-1+ Anisocy-1+ Poiklo-1+ Macrocy-NORMAL Microcy-NORMAL Polychr-1+ Ovalocy-1+ Stipple-OCCASIONAL) PT 15.8*, PTT 36.1*, INR(PT) 1.4* Fibrinogen 446* Na 141, K 3.8, Cl 110, HCO3 17, BUN 28, Cr 1.2, Glu 176 ALT 24, AST 93*, LD(LDH) 773*, AlkPhos 69, TBili 0.8 Calcium 7.9*, Phos 3.7, Mg 1.7 ABG: 7.09/46/81 (on vent Vt 600, FiO2 100%) Lactate 7.7* freeCa 1.16 . Cardiac enzymes: [**2193-2-8**] 02:35PM BLOOD CK(CPK)-739* CK-MB-74* MB Indx-10.0* cTropnT-3.39* [**2193-2-8**] 09:41PM BLOOD CK(CPK)-1215* CK-MB-124* MB Indx-10.2* [**2193-2-9**] 03:00AM BLOOD CK(CPK)-1058* CK-MB-86* MB Indx-8.1* cTropnT-4.68* [**2193-2-9**] 06:21PM BLOOD CK-MB-19* [**2193-2-10**] 04:05AM BLOOD CK(CPK)-844* CK-MB-11* MB Indx-1.3 cTropnT-2.65* . Micro: . Imaging: CATH [**2193-2-8**]: RA 28(a)/25(v)/26(m) RV 63(s)/30 (ed) PA 66(s)/44(d)/54(m) PWCP 44(a)/54(v)/46(m) AORTA 106(a)/76(d)/87(m) . Hemodynamics: HR 130, sinus w/ LBBB CO/CI (fick) 4.3/1.96 SVR 1136 PVR 149 . Anatomy: MID RCA - diffusely diseased, 70% stenosis R PDA- diffusely diseased, 90% stenosis R POST-LAT - diffusely diseased, 70% stenosis LMCA - discrete, 90% stenosis PROX LAD - discrete, 90% stenosis MID LAD - discrete, 100% stenosis PROXIMAL LCX - discrete, 80% stenosis MID LCX - tubular, 95% stenosis . COMMENTS: 1. Selective coronary angiography in this critically ill patient revealed severe three vessel CAD. The LMCA had a 70% origin stenosis and a 90% distal stenosis extending into the LAD. The LAD also had a mid 100% occlusion and supplies a one large septal. The LCX was diffusely disease with a 80% origin stenosis and a long 95% mid stenosis. The rest of the vessel was diffusely diseased as well. The RCA was diffusely diseased with 70% mid stenosis, 90% PDA stenosis and a 70% posterolateral. 2. Initial resting hemodynamics revealed severe cardiogenic shock with elevation of right and left sided pressures (RA mean 26 and PCWP mean 46mmHG). There was severe pulmonary hypertension with mean of 54mmHG. The cardiac index was low at 1.96 despite pressors. Initial PH was 7.09 with metabolic and respiratory acidosis. Initial blood pressure was 100/80. 3. Intra aortic was placed with improvement of augmented pressures to 121/53 and cardiac index to 2.91. 4. Echo was performed during the case showing EF about 25% with moderately severe mitral regurgitation and akinesis in LAD territory. The wall motion was best at the base. 5. Urgent surgical consult was obtained and patient was declined due to poorly amenable anatomy and severe metabolic and hemodynamic derangements. . FINAL DIAGNOSIS: 1. Three vessel coronary artery disease with critical left main disease. 2. Severe cardiogenic shock. . ECHO [**2193-2-8**]: The left atrium is moderately dilated. Left ventricular wall thicknesses are normal. The left ventricular cavity is moderately dilated. There is severe regional left ventricular systolic dysfunction. Overall left ventricular systolic function is severely depressed. Resting regional wall motion abnormalities include mid to distal anteroseptal akinesis, apical akinesis, lateral hypokinesis, and anterior hypokinesis. No apical thrombus seen but cannot exclude. Right ventricular chamber size is normal. Right ventricular systolic function is borderline normal. The aortic valve leaflets are mildly thickened. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Moderate to severe (3+) mitral regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. . CXR [**2193-2-8**]: 1. Endotracheal tube tip 3 cm from the carina. NG tube courses through the stomach. 2. Left upper and lower lobe consolidation/atelectasis. . CXR [**2193-2-9**]: The endotracheal tube is at the level of the aortic knob and unchanged. Left-sided nasogastric tube, which is below the gastroesophageal junction. There is a Swan-Ganz catheter entering from inferior approach. The distal tip is within the origin of the right pulmonary artery and has migrated more proximally since the previous study. The opacity within the left upper lobe is less well seen on today's study. There remains a left retrocardiac opacity and subsegmental atelectasis at the left base. Blunting of bilateral costophrenic angles are identified consistent with pleural effusions. . CXR [**2193-2-10**]: The Swan-Ganz catheter entering from a femoral approach has been pulled back and the tip is now in the RA. The endotracheal tube and nasogastric tube are appropriate sited and unchanged in position. There remains some cardiomegaly. There are bilateral pleural effusions. There is a left retrocardiac opacity. These findings have not changed. Brief Hospital Course: 82 F with PMH hyperchol, HTN with STEMI not amenable to CABG ([**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **], LAD), with cardiogenic shock, who eventually passed away. # STEMI and cardiogenic shock: (1) Ischemia: Patient had significant CAD on cath s/p DES to LMain, LAD, LCX. During cath, results showed 3VD with critical left main disease, and severe cardiogenic shock. Successful placement of an IABP, and successful PCI of the LMCA into the LAD were performed. Cardiac enzymes were elevated with CK peak 1215, MB 124, Trop 4.68, but EKG was unchanged. A balloon pump was placed in the CCU for cardiogenic shock, and the balloon pump was successfully removed with good hemodynamic control. The patient remained sedated and intubated, so whether the patient was experiencing CP or symptoms could not be assessed. Patient was maintained on ASA, plavix, statin. She was not given BB/ACE because of cardiogenic shock. . (2) Pump: ECHO revealed EF 25% with 3+MR. [**Name13 (STitle) **] was maintained on dopa and IABP in the CCU. Dopamine was switched to levophed because of signs of sepsis, and was gradually weaned off. Because of signs of sepsis, the IABP and PA catheter were removed, and an IJ line was used for CVP monitoring, which was kept around 12. MAP was maintained >65. UO was maintained at >30cc/hr. . (3) Rhythm: In the cath lab, the patient had 1 episode of VTach x 1 minute, and was loaded with amio and lido, and the patient did not require DCCV. The patient was in NSR for the remainder of admission with no events on tele. . #. Resp Failure: Pt was intubated at OSH for resp failure, presumed [**1-17**] to CHF and 3+ MR. [**Name13 (STitle) **] maintained good oxygenation and ventilation, patient had a difficult time being weaned from the vent. Swan-Ganz was placed in the CCU for monitoring. . #. Heme: Hct decreased from baseline of 30 to 28 -> 24 -> 28, and received several units RBC to maintain Hct >28. Platelets were stable at around 100. On smear were monocyte blasts and NRBC, and MDS was considered. Patient was HIT negative, DIC and hemolysis labs were negative. . #. ARF: Baseline Cr for patient was 1.1, and Cr was up to 1.4. Etiology was likely multifactorial, due to prerenal state, ATN and contrast nephropathy contributing. . #. ID: Patient had signs of sepsis in the CCU, with temp spikes, low SVR, and hyperdynamic CO/CI. Patient was on levophed, which was difficult to wean. Patient was given antibiotics including Ceftriaxone, Levo, Vanco, Flagyl. Sputum culture was negative, but showed 3+ GPC. Source of sepsis was not found, and IABP and PA catheter were appropriately removed. . #. Hypothyroidism: Stable at baseline. Patient was not given synthroid inhouse because of ventricular arrhythmia early during admission. . # Death: On [**2193-2-14**] at 8 PM, the patient's HCP, son [**Name (NI) 892**] [**Name (NI) 24222**], and his sister, wished to make the patient [**Name (NI) 3225**] and withdraw care. This was discussed with the patient's PCP, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) **], who spoke with the family regarding withdrawal of care. The HCP agreed to withdraw care, morphine gtt was started, and patient passed in comfort surrounded by family. Medications on Admission: Levoxyl 75 QD Lipitor 20 QD Metoprolol 50 [**Hospital1 **] Ranitidine 300 QD Salsalate 750 [**Hospital1 **] Triamcinolone 0.025% [**Hospital1 **] Discharge Medications: Patient passed away. Discharge Disposition: Expired Discharge Diagnosis: x Discharge Condition: x Discharge Instructions: x Followup Instructions: x Completed by:[**2193-6-6**]

[ "428.0", "574.20", "518.81", "530.81", "577.0", "V66.7", "238.7", "427.1", "410.71", "426.3", "584.9", "424.0", "414.01", "785.51", "486", "428.40", "997.1" ]

icd9cm

[ [ [] ] ]

[ "88.56", "00.66", "00.41", "99.04", "36.07", "37.23", "96.6", "99.15", "96.72", "00.45", "99.62", "37.61" ]

icd9pcs

[ [ [] ] ]

13011, 13020

9475, 12770

277, 485

13065, 13068

4609, 4614

13118, 13149

3847, 3851

12966, 12988

13041, 13044

12796, 12943

7337, 9452

13092, 13095

3866, 4590

5139, 7320

222, 239

513, 3358

4628, 5122

3380, 3487

3503, 3831

76,899

174,664

23815

Discharge summary

report

Admission Date: [**2142-8-8**] Discharge Date: [**2142-8-31**] Date of Birth: [**2081-4-1**] Sex: M Service: SURGERY Allergies: Hayfever Attending:[**First Name3 (LF) 148**] Chief Complaint: Chronic abdominal pain Major Surgical or Invasive Procedure: 1. Pylorus-preserving Whipple's resection [**2142-8-23**]. 2. Extended adhesiolysis [**2142-8-23**]. History of Present Illness: This 61-year-old gentleman is well-known to me, as I have cared for him for the last 6 months. He presented at that time with a multiple month history of chronic abdominal pain and flare-up of pancreatitis. These were biochemically proven flare-ups. He, however, did not have good evidence of this on imaging, and ultimately we went to an operative exploration to assess the quality of the pancreas to determine if he truly had pancreatitis. What we found at that endeavor was a totally normal body and tail of the pancreas and a firm, hard mass effect of the head and neck. We placed a J-tube at that point, as this was a surprise finding, and we were unprepared to do a Whipple procedure at that point in time. He continued to get imaging which suggested a stricturing effect in the genu of his pancreatic duct. He has festered and lost weight for a significant amount of time now, and has been basically hospitalized for a few months with chronic pain from this. He now requires a definitive operation for his abnormal pancreatic head. Past Medical History: 1. Acute on chronic pancreatitis with multiple admissions 2. Nephrolithiasis 3. Hypertension 4. CAD, bare metal stent to proximal LAD placement [**2142-4-12**] by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 25699**] at [**Hospital1 3278**] [**Telephone/Fax (1) 47432**] 5. s/p cholecystectomy 6. h/o RLE DVT in setting of cholecystectomy (completed 3 months coumadin) 7. History of knee surgery Social History: The patient lives in [**Location 246**], he currently manages a transportation company. The patient is married with 4 children and 2 grandchildren. Tobacco: None; ETOH: none, Illicits: None. Family History: No family history of pancreatic pathology; Father: Died of Liver cancer at age 62; Mother Died of heart disease in her 60's Physical Exam: On Admission: VS: 98.1 65 133/70 18 99 GEN: In NAD LUNGS: CTA(B) COR: RRR ABD: TTP in RLQ no overt peritoneal signs with some [**Last Name (un) **] in left lower quadrant. Soft, ND. EXTREM: No c/c/e. NEURO: A+Ox3. Non-focal/grossly intact. . AT Discharge: VS: 99.1 PO, 73, 133/87, 18, 98% RA GEN: Appears well in NAD. HEENT: Sclerae anicteric. O-P clear. NECK: Supple. No [**Doctor First Name **]. LUNGS: CTA(B). COR: RRR ABD: Subcostal chevron incision with steri-strips OTA c/d/i. Appropriately TTP along incision, otherwise soft/NT/ND. EXTREM: No c/c/e. NEURO: Comfortable. A+Ox3. Non-focal/grossly intact. SKIN: As above, otherwise intact. Pertinent Results: [**2142-8-8**] 07:05AM GLUCOSE-85 UREA N-15 CREAT-0.7 SODIUM-142 POTASSIUM-4.2 CHLORIDE-106 TOTAL CO2-31 ANION GAP-9 [**2142-8-8**] 07:05AM ALT(SGPT)-39 AST(SGOT)-36 ALK PHOS-71 AMYLASE-40 [**2142-8-8**] 07:05AM LIPASE-50 [**2142-8-8**] 07:05AM CALCIUM-8.4 PHOSPHATE-3.1 MAGNESIUM-2.1 [**2142-8-8**] 07:05AM WBC-5.8 RBC-4.25* HGB-12.2* HCT-36.7* MCV-86 MCH-28.7 MCHC-33.3 RDW-13.8 [**2142-8-8**] 07:05AM PLT COUNT-248 [**2142-8-7**] 11:30PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.017 [**2142-8-7**] 11:30PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [**2142-8-7**] 07:08PM GLUCOSE-110* UREA N-20 CREAT-0.8 SODIUM-140 POTASSIUM-4.0 CHLORIDE-103 TOTAL CO2-27 ANION GAP-14 [**2142-8-7**] 07:08PM ALT(SGPT)-32 AST(SGOT)-28 ALK PHOS-82 TOT BILI-0.3 [**2142-8-7**] 07:08PM LIPASE-75* . [**2142-8-13**] CXR: Chronic pancreatitis. The heart size is normal. The lungs demonstrate bilateral lower lung linear opacities involving the inferior aspect of the middle lobe and both lower lobes. No pleural effusions are identified. Postoperative changes are present in the cervical spine. . [**2142-8-22**] ECHO: LEFT ATRIUM: Elongated LA. RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. Normal interatrial septum. No ASD by 2D or color Doppler. LEFT VENTRICLE: Normal LV wall thickness, cavity size and regional/global systolic function (LVEF >55%). No resting LVOT gradient. No VSD. RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Normal aortic diameter at the sinus level. AORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR. MITRAL VALVE: Normal mitral valve leaflets with trivial MR. TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Borderline PA systolic hypertension. PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS. Physiologic PR. PERICARDIUM: No pericardial effusion. Conclusions: The left atrium is elongated. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. There is borderline pulmonary artery systolic hypertension. There is no pericardial effusion. . [**2142-8-22**] ECG: Sinus rhythm. Baseline artifact. Non-specific intraventricular conduction delay. Non-specific inferior T wave changes. Compared to the previous tracing of [**2142-8-13**] inferior T wave changes and artifact are new. Bradycardia is absent. Intervals Axes: Rate PR QRS QT/QTc P QRS T 80 190 104 376/411 49 2 2 . [**2142-8-23**] PATHOLOGY - SPECIMEN SUBMITTED: Jejunum, BLUE STITCH PANCREATIC NECK MARGIN LONG GREEN STITCH AT SMA MARGIN LONG SILK AT BILE DUCT: DIAGNOSIS: 1. Segment of jejunum: no diagnostic abnormalities. 2. Whipple resection: duodenum and partial pancreas: A. Focal acute and chronic pancreatitis with focal fat necrosis. No evidence of malignancy. B. Acute and chronic inflammation of common bile duct and focally of pancreatic ducts. C. Focal pancreatic intraepithelial neoplasia, low grade. D. Six lymph nodes with no evidence of malignancy. Clinical: Chronic pancreatitis. Gross: The specimen is received fresh in two containers, both labeled with the patient's name "[**Known firstname **] [**Known lastname **]" and the medical record number. Specimen 1: The specimen is additionally labeled "jejunum". It consists of a segment of small bowel which is stapled at both ends. It is 15.2 cm in length and 2.5 cm in average diameter. The intestine is opened and reveals an unremarkable mucosa. The serosal surfaces are grossly unremarkable. Representative sections are submitted as follows: A=distal and proximal margins, B=random sections. Specimen 2: The specimen is received in a container additionally labeled "blue stitch at pancreatic neck margin, long green stitch at SMA margin, long silk at bile duct". It consists of a pancreaticoduodenectomy specimen. The pancreatic portion is composed of the head and neck of the pancreas and measures 2.8 x 4.5 x 2.5 cm. The duodenal segment measures 9.5 cm in length and 2.2 cm in average diameter. The posterior retroperitoneal margin and pancreatic margin and uncinate margins are identified and inked. The duodenum is opened along its length, opposite the pancreas to reveal unremarkable tan mucosa. The ampulla is identified and is probe patent. The common bile duct is identified and is probe patent and opened along its length. The pancreas is serially sliced to reveal tan cut surfaces. There is a focal fibrotic area located in the distal neck of the pancreas with an associated cystic area which abuts the peritoneal margin and is 0.3 x 0.3 x 0.3 cm. This cystic area is filled with a yellow soft substance. The remainder of the pancreatic parenchyma is unremarkable. The peripancreatic adipose tissue is removed and entirely submitted for potential lymph nodes. Representative sections are submitted as follows: C=bile duct margin, D=duodenal end, E=pancreatic neck margin, F=uncinate/SMA margin, G=retroperitoneal margin, H=pancreas with duct, I=ampulla, J-K=random pancreatic sections, L-W=peripancreatic adipose tissue. W=contains the cystic area. . [**2142-8-29**] KUB/upright: The visualized lung bases and heart appear normal. No free air or ectopic gas is seen. No bowel distention is obvious without any air-fluid levels present. Stool is seen within the ascending colon and descending colon. Staples are seen that traverse transversely across the abdomen. Clips in the right upper quadrant suggest status post cholecystectomy. A peritoneal drain is seen ending within the abdomen. No abnormal calcification or ectopic gas is seen. The osseous structures appear unremarkable. . [**2142-8-29**] CXR: There is no evidence of free air below the diaphragms, within the limitations of this study technique. The air-fluid level on the left is most likely within the stomach. The abdominal drain is partially imaged. The upper lungs are clear. Bibasilar opacities in the lungs are linear most likely consistent with atelectasis. There is no appreciable pleural effusion. There is no pneumothorax. The left PICC line tip is at the level of mid SVC. Brief Hospital Course: Mr. [**Known lastname **] was admitted to the General Surgical Service on [**2142-8-8**] for recurrent pancreatitis associated with chronic pain, which was poorly controlled as an outpatient, and poor nutrition. Upon initial admission, he was made NPO, started on IV fluids, and given either IV Morphine or Dilaudid for pain control. The patient was hemodynamically stable. During the initial stage of this admission, pain management was a major issue. The Chronic Pain Services was consulted early on, and they followed the patient throughout his stay. Their recommendations were greatly appreciated. Pre-operatively, the patient's pain was ultimately well controlled on Dilaudid 8-12mg PO Q3-4 Hours with episodic use of IV Morphine for breakthrough pain. IV Dilaudid was substituted for PO Dilaudid when the patient was NPO. On [**2142-8-9**], an EGD/EUS was performed by Dr. [**Last Name (STitle) **] (GI), which revealed an ill-defined hypoechoic area was noted surrounding the PD stent in the head of the pancreas (this was mostly likely secondary to stent related changes, however, neoplasm cannot be ruled out) and a FNA was performed. On [**2142-8-10**], the patient then underwent an [**Date Range **] with stent removal. The previously described 8mm stricture in the genu was still present. The patient recovered from the procedure without complication. Post-procedural pancreatic enzymes remained stable. A PICC line was placed on [**2142-8-15**] for possible parenteral nutrition, given poor nutritional intake prior to admission. With improved pain control, the patient was able to advance his diet pre-operatively to regular with fair to good intake. TPN was ultimately not required. Pre-operative screening, labwork, diagnotics, and consent were accomplished. On [**2142-8-22**], the patient was brought to the OR for planned pylorus-preserving Whipple's resection, which was aborted due to asystolic arrest occurring at induction of anesthesia, likely due to a transient vagal episode. He responded quickly to rescusitation efforts, was transferred to the SICU, where he was extubated shortly thereafter without residual complication. Cardiology was consulted, and cleared the patient for surgery the next day. On [**2142-8-23**], the patient was again taken to the OR from the SICU for planned pylorus-preserving Whipple's resection and included extended adhesiolysis, which went well without complication (reader referred to Operative Note for further details). After a brief, uneventful stay in the PACU, the patient arrived on the floor NPO with an NG tube, on IV fluids, with a foley catheter and a JP drain in place, and a IV Ketamine for pain control with good effect. Telemetry monitoring was continued post-operatively without event. The patient was hemodynamically stable. On [**Date Range **]#1, the IV Ketamine infusion was adjusted, a Dilaudid PCA was added, a Fentanyl patch was applied, and the patient was started on IV Toradol for 2 days in consultation with the Pain Service. His immediate post-operative pain was well controlled on this regimen. The Ketamine infusion was discontinued by [**Date Range **]#2. He experienced severe, crampy abdominal pain on [**2142-8-29**], which did not respond well to his pain regimen. Blood and urine cultures ordered were unremarkable. The PICC was discontinued with the tip sent for culture. Labwork stable. A KUB/upright did not revealed an obstruction or free air, but stool was seen within the ascending colon and descending colon. After initial attempt at stimulating a bowel movement with oral agents and both dulcolax PR and enemas, the patient finally experienced a large bowel movement and complete relief of his abdominal pain with digital disimpaction. A vigorous bowel regimen was prescribed for constipation prophylaxis without further problem. On [**Name2 (NI) **]#7, the Dilaudid PCA was discontinued, and the patient was started on Dilaudid PO PRN in addition to the Fentanyl patch with excellent pain control. It was this regimen with which he was discharged. After the NGT was discontinued, he was started on sips on [**Name2 (NI) **]#3. His diet was progressively advanced to regular with good tolerability. Foley catheter was discontinued on [**Name2 (NI) **]#3; he voided without a problem. Telemetry was discontinued on [**Name2 (NI) **]#3; he remained hemodynamically stable without further cardiac complaint. The patient ambulated frequently, was adherent with respiratory toilet. On [**Name2 (NI) **]#8, staples were removed, and steri-strips placed. At the time of discharge on [**2142-8-31**], the patient was doing well, afebrile with stable vital signs. The patient was tolerating a regular diet, ambulating, voiding without assistance, and pain was well controlled. The patient was discharged home without services. He will follow-up with his own Pain Management Specialist as an outpatient. The patient received discharge teaching and follow-up instructions with understanding verbalized and agreement with the discharge plan. Medications on Admission: Multivitamin 1 tab PO daily, Omeprazole 20mg PO daily, Hydromorphone 4mg 1-2 tabs PO Q3-4Hours PRN pain, Amlodipine 5mg PO daily, Miralax 17gm in 8oz water daily PRN constipation, Colace 100mg 1 cap PO BID, Metoprolol 25mg [**1-19**] tab PO BID, Clopidorel 75mg PO daily, ASA 81mg PO daily. Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO every [**4-23**] hours as needed for fever or pain. 2. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QID (4 times a day). Disp:*120 Tablet(s)* Refills:*0* 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*0* 4. Fentanyl 25 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr Transdermal Q72H (every 72 hours) as needed for Acute on Chronic Pain. Disp:*10 Patch 72 hr(s)* Refills:*0* 5. Polyethylene Glycol 3350 17 gram (100 %) Powder in Packet Sig: One (1) packet in 8oz water or juice PO once a day as needed for constipation. Disp:*30 packets* Refills:*2* 6. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). Disp:*30 Tablet(s)* Refills:*2* 7. Hydromorphone 4 mg Tablet Sig: 1-2 Tablets PO Q3-4HOURS as needed for pain. Disp:*100 Tablet(s)* Refills:*0* 8. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 9. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO once a day. 10. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO once a day. 11. Multivitamin Tablet Sig: One (1) Tablet PO once a day. 12. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home Discharge Diagnosis: 1. Chronic pancreatitis with chronic abdominal pain. 2. Dense adhesions of the bowel and liver and upper abdomen. 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 is not improving within 8-12 hours or is not gone within 24 hours. Call or return immediately if your pain is getting worse or changes location or moving to your chest or back. *You have shaking chills, or fever greater than 101.5 degrees Fahrenheit or 38 degrees Celsius. *Any change in your symptoms, or any new symptoms that concern you. Please resume all regular home medications , unless specifically advised not to take a particular medication. Also, please take any new medications as prescribed. Please get plenty of rest, continue to ambulate several times per day, and drink adequate amounts of fluids. Avoid lifting weights greater than [**5-27**] 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. Followup Instructions: Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD (Surgery). Date/Time: [**2142-9-14**], 10:00am. Phone: ([**Telephone/Fax (1) 2828**]. Location: [**Hospital Ward Name 23**] 3, [**Hospital Ward Name 516**]. Please contact your [**Name2 (NI) 1194**] Management Specialist to arrange a follow-up appointment in the next 2-3 weeks. Please call ([**Telephone/Fax (1) 60785**] to schedule a follow-up appointment with Dr. [**Last Name (STitle) 60786**] (PCP) in 2 weeks. Completed by:[**2142-8-31**]

[ "E938.2", "780.2", "568.0", "780.09", "V45.89", "577.8", "577.1", "577.0", "401.9", "V12.51", "338.29", "V45.82", "414.01", "427.5", "564.00" ]

icd9cm

[ [ [] ] ]

[ "38.93", "96.04", "52.99", "88.74", "54.59", "45.13", "52.7", "99.60" ]

icd9pcs

[ [ [] ] ]

16120, 16126

9460, 14509

288, 391

16288, 16297

2931, 9437

18304, 18833

2126, 2251

14851, 16097

16147, 16267

14535, 14828

16321, 17776

17792, 18281

2266, 2266

2522, 2912

226, 250

419, 1460

2280, 2508

1482, 1901

1917, 2110

40,000

129,338

22614

Discharge summary

report

Admission Date: [**2188-1-14**] Discharge Date: [**2188-2-19**] Date of Birth: [**2137-12-1**] Sex: F Service: MEDICINE Allergies: NSAIDS Attending:[**First Name3 (LF) 10293**] Chief Complaint: Hyponatremia, pain, liver transplant evaluation Major Surgical or Invasive Procedure: Dobhoof placement Paracentesis History of Present Illness: Ms. [**Known firstname **] [**Known lastname **] is a 50 year-old woman with decompensated cirrhosis (ascites, encephalopthy), Hep C (genotype 1, dx [**2176**], Peg/Riba nonresponse in [**2177**], intolerance with decompensation in [**2183**]), reported iron overload with phlebotomy, presents with HypoNa, Pain and for OLT eval. . Ms [**Known lastname **] was intermitently followed by a hepatologist for the past 10-12 years. Her most recent course is summarized per her report as follows: . [**2187-3-6**]: Clinical ascites. AST 170, ALT 122, albumin 2.6, T bili 1.9, INR 1.3. AFP 12.3, iron 239 with saturation of 84%. HCV vl 792,000, platelets 49,000. US showing splenomegaly to 17.5 cm, but no [**Male First Name (un) **] [**2187-9-3**]: Faring well, losing weight. Was in [**State 4565**], trying to find a place. [**2187-10-4**]: Began feeling "weird", developed abdominal pain. Seen in an ED 3 times with one inpatient admission. Placed on lactulose, aldactone. [**2187-11-3**]: 4 large volume [**Doctor First Name 4397**], furosemide was started. . Her principle complaint has been abdominal pains, diffuse and movement limitting. They are not associated with BM's or eating. She has experienced the most reflief from dilaudid. Stools are loose on lactulose but no blood, melena. She endorses significant water intake. . [**2188-1-4**] - seen in [**Hospital3 **] hospital for abdominal pain. Diagnosed with SBP on history and treated with Cipro 500 mg [**Hospital1 **]. Para was performed and removed 6 litres with 32 WBCs. No notes regarding albumin at this time. Discharged on Cipro. . [**1-8**] - readmitted to [**Hospital3 **] for pain. Found to hyponatremic. Given NS at 100cc/hr on [**11-2**] and at 125cc/hr from [**Date range (1) 9395**]. Lasix and aldactone were given from [**Date range (1) 16032**] when they were dc'd. On [**1-13**] was fluid restricted to 1L and given 40mg of IV lasix twice. They could not place a foley. Throughout they treated pain with oral dilaudid and anxiety with ativan. She was then transferred to the [**Hospital1 18**]. . She was admitted to the hapatology service where a 30mL diagnostic paracentesis did not identificy SBP. She was given 50g of albumin. Subseqently, the patient became oliguric with an increase in Cr from 1.5 to 1.6 and a decrease in serum sodium from 112 to 111. The decision was then made to transfer the patient to the MICU for further care. . ROS: + per HPI, denies fever, chills, night sweats, headache, vision changes, rhinorrhea, congestion, sore throat, cough, shortness of breath, nausea, vomiting, diarrhea, constipation, BRBPR, melena, hematochezia, dysuria, hematuria. Past Medical History: Decompsenated cirrhosis Chronic HCV ETOH abuse Knee surgery Depression, with a suicide attempt one and a half years ago Social History: The patient is single, has never been married, has four children and ten grandchildren, oldest child is 27. She currently lives with her mother, who is her healthcare proxy (Faith [**Name (NI) **] [**Telephone/Fax (1) 58631**]). -Tobacco history: Quit [**10/2187**]; used to smoke less than one pack a day for 43 years. -ETOH: She does not drink alcohol currently over the past 25 years, but for 20+ years, she was drinking a bottle plus of vodka daily. -Illicit drugs: She also used heroin, cocaine, and marijuana last approximately four years ago. She is not currently in a program. Family History: No family history of liver disease or hepatitis Physical Exam: ADMISSION EXAM: VS: T: 97.6, P: 87, BP: 114/56, RR: 17, 99% on RA GENERAL: A chronically ill, jaundiced appearing female in no acute distress. HEENT: Sclera jaundiced, scleral icterus. Mucous membranes moist. Nose ring. NECK: Supple, without lymphadenopathy. Spider angiomas CARDIAC: Regular rate and rhythm, no murmurs, rubs, or gallops. LUNGS: CTAB, no w/r/r ABDOMEN: Obese, shifting dullness noted. Marked splenomegaly noted and hepatomegaly noted. Spider nevi noted on skin. Pitting edema of abd wall EXTREMITIES: Lower extremities 2+ pitting edema up to abdomen, jaundice, palmar erythema. NEURO: no asterixies, fully oriented . DISCHARGE EXAM: Vitals: Tm 98 120-150/50-60, 70-100s 16-18 98-99% 2L General: Middle aged female, NAD HEENT: Sclera mildly icteric Skin: jaundiced Neck: supple, no lad Heart: 2/6 SEM loudest at LUSB, S1, S2 Lungs: Mild crackles B/l bases, decreased breath sounds at R base Abdomen: soft, distended, obese, +BS, mild tenderness Extremities: lower extremity edema resolved Neurological: AAOx3, no asterixis Pertinent Results: Admission: [**2188-1-14**] 09:20PM BLOOD WBC-12.9*# RBC-2.61* Hgb-10.2* Hct-29.8* MCV-114* MCH-38.9* MCHC-34.2 RDW-13.2 Plt Ct-75* [**2188-1-14**] 09:20PM BLOOD Neuts-89* Bands-0 Lymphs-6* Monos-5 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 [**2188-1-14**] 09:20PM BLOOD PT-17.9* INR(PT)-1.7* [**2188-1-14**] 09:20PM BLOOD Glucose-93 UreaN-31* Creat-1.5* Na-112* K-5.0 Cl-87* HCO3-20* AnGap-10 [**2188-1-14**] 09:20PM BLOOD ALT-31 AST-62* AlkPhos-98 TotBili-5.1* [**2188-1-14**] 09:20PM BLOOD Albumin-2.7* Calcium-8.6 Phos-4.6* Mg-1.9 [**2188-1-14**] 09:20PM BLOOD Osmolal-251* . DISCHARGE LABS: [**2188-2-19**] 06:45AM BLOOD WBC-8.8 RBC-2.31* Hgb-8.6* Hct-26.2* MCV-113* MCH-37.0* MCHC-32.7 RDW-22.1* Plt Ct-52* [**2188-2-19**] 06:45AM BLOOD Glucose-118* UreaN-37* Creat-1.0 Na-135 K-4.2 Cl-103 HCO3-28 AnGap-8 [**2188-2-19**] 06:45AM BLOOD ALT-45* AST-72* AlkPhos-62 TotBili-4.6* [**2188-2-19**] 06:45AM BLOOD Albumin-3.9 Calcium-8.8 Phos-3.1 Mg-1.8 . Blood culture: STAPHYLOCOCCUS, COAGULASE NEGATIVE | CLINDAMYCIN----------- =>8 R ERYTHROMYCIN---------- =>8 R GENTAMICIN------------ 8 I LEVOFLOXACIN---------- =>8 R OXACILLIN------------- =>4 R RIFAMPIN-------------- =>32 R TETRACYCLINE---------- 2 S VANCOMYCIN------------ 2 S . Urine culture: ENTEROCOCCUS FAECIUM. 10,000-100,000 ORGANISMS/ML SPECIATION REQUESTED BY [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] #[**Numeric Identifier 58632**]. SENSITIVITIES: MIC expressed in MCG/ML _______________________________________________________ ENTEROCOCCUS FAECIUM | AMPICILLIN------------ =>32 R LINEZOLID------------- 2 S NITROFURANTOIN-------- 64 I TETRACYCLINE---------- <=1 S VANCOMYCIN------------ =>32 R . ECHO [**2188-1-17**] The left atrium is normal in size. No atrial septal defect is seen by 2D or color Doppler. The estimated right atrial pressure is at least 15 mmHg. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). Right ventricular chamber size and free wall motion are normal. There is abnormal diastolic septal motion/position consistent with right ventricular volume overload. The aortic valve leaflets (?#) appear structurally normal with good leaflet excursion. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are structurally normal. Mild (1+) mitral regurgitation is seen. The tricuspid regurgitation jet is eccentric and may be underestimated. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Normal left ventricular cavity size and wall thickness with preserved global and regional biventricular systolic function. Mild mitral regurgitation. Mild to moderate tricuspid regurgitation. Moderate pulmonary artery systolic hypertension. Extensive abdominal ascites. Renal US: FINDINGS: A large amount of ascites is noted within the abdomen. The right kidney measures 9.0 cm and the left kidney measures 9.5 cm. Note is made that visualization of the left kidney is somewhat limited due to overlying bowel gas. No hydronephrosis is seen. No gross renal mass is identified. The urinary bladder could not be imaged as a Foley catheter is in place. IMPRESSION: No hydronephrosis. Large amount of ascites. . Spirometry: Impression: Moderate restrictive ventilatory defect with a severe gas exchange defect. The reduced FEV1/FVC ratio may indicate a coexisting obstructive ventilatory defect. There are no prior studies available for comparison. . Cardiac Perfusion Study: IMPRESSION: No perfusion defects detected. Normal cavity size. . ABD MRI: IMPRESSION: 1. Severely limited study, no definite concerning liver lesion seen; however, sensitivity of this study is severely limited by the patient's difficulty with breath holding and the moderate ascites. 2. Evidence of portal hypertension with splenomegaly and ascites. 3. The vascular structures are insufficiently well visualized to define the arterial or venous anatomy. . LENI IMPRESSION: No deep vein thrombosis in either lower extremity. . ECHO [**1-30**] A patent foramen ovale is suggested (right to left shunting of agitated saline contrast at rest b/w 3 and 4 beats after opacification of the RA). Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) 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. Compared with the prior study (images reviewed) of [**2188-1-17**], no change. IMPRESSION: Patent foramen ovale suggested. . Mammogram The breasts show scattered fibroglandular densities. There are no spiculated masses, suspicious clustered microcalcifications, or areas of architectural distortion. No interval change. IMPRESSION: No evidence of malignancy.Limited films as patient wheelchair bound. [**Hospital1 **]-RADS 1 - negative. . Brief Hospital Course: Ms. [**Known firstname **] [**Known lastname **] is a 50 yo woman with decompensated cirrhosis (ascites, encephalopthy), Hep C who presents with hyponatremia, acute kidney injury, abdominal pain and for evaluation for liver transplantation. #. Acute Kidney Injury - Creatinine increased from 1 to peak of 3.7 during hospitalization. Was thought to be from hepatorenal syndrome. She was started on treatment for hepatorenal syndrome with midodrine, octreotide and albumin. Her renal function did not improve and she was started on the terlipressin study drug. Her kidney function returned to her baseline on Terlipressin study drug and we were able to remove a significant amount of ascites with diuretic medications. However when her diuretics were increased her creatine again increased and she was restarted on the study drug. Her creatinine returned to [**Location 213**]. She was discharged on furosemide 20 mg PO daily. Any diuretic changes should be discussed with [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 497**], MD in the [**Hospital1 18**] liver center. . #. Hyponatremia: Hypervolemic hyponatremia primarily related to disordered fluid homeostasis secondary to decompensated liver disease. This improved with resolution of her [**Last Name (un) **]. . #. Decompensated cirrhosis: Secondary to hepatitis C, reported history of iron overload and history of ETOH abuse. Repeated paracenteses x3 was performed and 3-4L of serous fluid was removed. After treatment for SBP (see below) she was continued on ciprofloxacin for SBP prophylaxis. She underwent transplant workup which included PFTs, Echo, screening EGD, stress test, abd MRI, panorex scan and an MRI. Records of recent colonoscopy were obtained. Tube feeds were also started per nutrition recomendation. She is currently on the transplant list. . #. Bacteremia: She was found to have 2 bottles of coagulase negative staph bacteremia. She was treated with a seven day course of vancomycin. Her fevers and leukocytosis resolved. . #. History of SBP - was treated for SBP for 10 days with Cipro 500 mg [**Hospital1 **] based on reported findings from an outside hospital. There was never any evidence of SBP on paracentesis at [**Hospital1 18**]. Afterwards she was continued on cipro prophylaxis once a day. . #Urinary tract infection: She developed a urinary tract infection that grew 10,000-100,000 vancomycin resistant enterococus which was treated with seven days of doxycycline which it was sensitive to. She was never symptomatic. . # Hypokalemia/NSVT: In the setting of aggressive diuresis, the patient began developing hypokalemia with increasing ectopy, as well as frequent runs of NSVT. In spite of aggressive repletion, her NSVT runs continued and the patient was transferred to the MICU overnight for closer monitoring. On transfer back from the MICU, her potassium was better, and ectopy markedly decreased. She should have electrolytes checked as an outpatient. . #. Diarrhea: The patient had profuse amount of diarrhea while on the floor, and her lactulose was initially held. She was continued on her rifaxamin. Stool studies including c. diff were all negative, and the patient was given PRN lomotil to help with her diarrhea. A med rec was done, and mag oxide was d/ced, as it was thought it may have been contributing to her diarrhea. Later she became encephalopathic and her lactulose was restarted, encephalopathy resolved. . #. Abd pain - Patient has chronic abdominal pain. She developed acute small bowel ileus on [**2188-1-16**] likely secondary to opiate use. Ileus resolved with decompression, keeping her NPO, and giving Methylnaltrexone to reverse effects of opiates. She had persistent abdominal pain throughout admission which was treated with tramadol and oxycodone. . CHRONIC ISSUES: #. Pancytopenia: Likely secondary to malnutrition/ESLD. No active signs of bleeding and macrocytic anemia stable. . #. Anxiety/Depression: No outpatient therapy. On lorazepam for anxiety in the ICU but this was stopped in the setting of encephalopathy. Concerning history of SI and attempts previously. [**Doctor First Name **] Grimschaw, social worker, was aware and discussed this with the patient in terms of impact of above on transplant candidacy. . . TRANSITIONAL ISSUES: #Liver transplant List: She is currently on the liver transplant list. She will need to follow up with Dr. [**Last Name (STitle) 497**] at the transplant center. She will also need to continue tube feeds for now. . #Ascites/HRS: She has ascites requiring multiple paracenteses. Her diuretics should not be uptitrated because of the risk of hepatorenal syndrome. She will likley need serial paracenteses. She has also had intermittent leaking from the paracenteses sites, even days after the procedure, but no stitch was placed to reduce risk of infection. Pediatric ostomy bag was put in place for drainage and removed as able. Medications on Admission: Furosemide 40 mg Tablet, 1 Tablet(s) by mouth daily Lactulose 10 gram/15 mL Solution, 15 ml by mouth three times a daily Spironolactone 100 mg Tablet, 1 Tablet(s) by mouth daily Omeprazole 20 mg daily Cipro 500 mg [**Hospital1 **] Mag Oxide 400 [**Hospital1 **] Dilaudid PO 4 mg q4 prn (hx of combivent) MEDICATIONS on TRANSFER: Omeprazole 20 mg PO daily Ciprofloxacin HCl 500 mg PO/NG daily Multivitamins W/minerals daily FoLIC Acid 1 mg PO/NG daily Acetaminophen 500 mg PO/NG Q6H Rifaximin 550 mg PO/NG [**Hospital1 **] Heparin 5000 UNIT SC TID Lorazepam 0.5 mg PO/NG HS:PRN insomnia, anxiety HYDROmorphone (Dilaudid) 4 mg PO/NG Q4H:PRN pain Lactulose 30 mL PO/NG Q4H:PRN Confusion Lactulose 30 mL PO/NG TID Discharge Medications: 1. rifaximin 550 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 2. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. multivitamin,tx-minerals Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. tramadol 50 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for Pain. 5. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 6. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. 7. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. lactulose 10 gram/15 mL Syrup Sig: Fifteen (15) ML PO BID (2 times a day). 9. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical TID (3 times a day) as needed for Pannus. 10. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: [**2-4**] Inhalation every six (6) hours as needed for shortness of breath or wheezing. 11. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Extended Care Facility: [**Hospital1 700**] - [**Location (un) 701**] Discharge Diagnosis: Hepatitis C Cirrhosis Acute Kidney Failure Hyponatremia 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 hospital with kidney failure which happened because your liver was not functioning well. We are glad to say that your kidneys recovered after you went on the Terlipressin study. However, when we gave your normal doses of furosemide and spironolactone your kidneys did not respond well so we restarted the terlipressen study. Your kidneys recovered again. We restarted your furosemide at a lower dose and stopped the spironolactone. In the future you will probably need repeated paracenteses to remove fluid from your abdomen and should be careful about how much furosemide and spironolactone you take. . You were also placed on the liver transplant list. You will be contact[**Name (NI) **] when a liver is found that is suitable for you. As part of the preparation for the transplant the nutritionist recommended that you continue tube feeds for now to make sure you will be strong enough to undergo the operation and recovery. You should follow up with Dr. [**Last Name (STitle) 497**] as directed. . You were also treated for an infections in your blood, urine and abdomen. These infections have resolved. You should continue to take ciprofloxacin to prevent future infections. . Summary of Medication Changes: Please decrease Furosemide to 20 mg daily Please decrease Ciprofloxacin to 500 mg daily Please stop Spironolactone Please stop magnesium oxide Please stop dilaudid Please stop omeprazole Please start tramadol 50 mg every 6 hours as needed for pain Please start oxycodone every 6 hours as needed for pain Please start rifaxamin 550 mg twice daily Please start multivitamin daily Please start folic acid daily Please start pantoprazole 40 mg daily Please start miconazole powder three times a day under the folds of your skin as needed Please start zofran 4 mg by mouth as needed for nausea Please start albuterol inhaler 1-2 puffs every 6 hours as needed for shortness of breath or wheezing Followup Instructions: Department: TRANSPLANT When: MONDAY [**2188-3-3**] at 11:20 AM With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 673**] Building: LM [**Hospital Unit Name **] [**Location (un) **] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage . You should make sure to see your primary doctor within one week of leaving the rehabilitation facility.

[ "427.0", "572.4", "284.19", "275.03", "305.53", "041.04", "V49.83", "263.9", "787.91", "572.3", "276.1", "V70.7", "584.5", "070.54", "789.59", "599.0", "E947.8", "560.1", "300.9", "276.8", "V15.82", "571.5", "E935.2", "305.63", "041.12", "790.7", "070.41", "276.69", "E958.9", "305.23", "303.93", "311", "300.00" ]

icd9cm

[ [ [] ] ]

[ "96.6", "38.93", "54.91" ]

icd9pcs

[ [ [] ] ]

16885, 16957

10208, 13999

316, 348

17057, 17057

4922, 5496

19188, 19558

3793, 3843

15883, 16862

16978, 17036

15148, 15453

17208, 18454

5512, 10185

3858, 4493

4509, 4903

14493, 15122

18474, 19165

229, 278

376, 3029

17072, 17184

14015, 14472

15478, 15860

3051, 3173

3189, 3777

23,870

133,506

49967

Discharge summary

report

Admission Date: [**2183-11-21**] Discharge Date: [**2183-11-27**] Service: MED Allergies: No Drug Allergy Information on File Attending:[**First Name3 (LF) 30**] Chief Complaint: melena Major Surgical or Invasive Procedure: EGD [**11-21**] History of Present Illness: Patient is an 88 year old female with hsitory of hypertension, constipation,and atypical chest pain, who was in her usual state of health until she and was dizzy on standing after waking in the morning. Shortly thereafter she began to vomit coffee ground emesis with no preceeding nausea. She had [**5-5**] total episodes of moderate coffe ground emesis throuhgout day. No chest pain, shortness of breath, dizziness, no palp, or dyspnea on exertion. Otherwise the patient has been constipated for 3 days without bowel movement. She was initially unsure of melena and on repeat questioning reports small amount of melena x 1. The patient does use ASA as needed but no recurrent use. No other NSAID use or alcohol use. She also reported weakness/fatigue, lower extremity edema, increased shortness of breath, and difficulty walking. In the emergency department, the patient had a hematocrit of 30 which changed to 27.4 4 hours later. NG lavage with 320ml coffee ground emesis that did not clear. Not orthostatic on admission to ED, 99% RA, BP 104/76, HR 74 in Ed. Recieved 2 L NS in ED, 2 PIVS, protonix. Past Medical History: HTN constipation Raynauds ?dementia Social History: lives alone, nonsmoker, nondrinker Family History: father with h/o MI Physical Exam: Tc 97.3 Tm 98.3 BP 120/72 HR 63 RR 18 O2 98% RA Gen - Alert, awake, pleasant in NAD HEENT - anicteric, mucous membranes moist and intact Neck - supple, no jugular venous distention Chest - clear to auscultation bilaterally, no crackles/rhonchi CV - Normal S1/S2, regular rate and rhythm, no murmurs, rubs or gallops, 2+ pulses throughout Abd - soft, nondistended, nontender with normoactive bowel sounds,no masses Extr - warm, no clubbing, cyanosis, or edema Neuro - Alert, oriented to self and hospital. ambulating well. denies loss of sensation, face symmetric, tongue non-deviated Pertinent Results: [**2183-11-22**] HELICOBACTER PYLORI ANTIBODY TEST (Final [**2183-11-24**]): POSITIVE BY EIA. . [**2183-11-22**] ECG: Sinus rhythm. Right bundle-branch block. Compared to the previous tracing of [**2173-12-16**] bradycardia is no longer present. Right bundle-branch block patterning persists. . [**2183-11-27**] 06:15AM BLOOD Hct-31.4* [**2183-11-26**] 04:00PM BLOOD Hct-34.9* [**2183-11-26**] 06:25AM BLOOD WBC-3.8* RBC-3.48* Hgb-10.6* Hct-31.2* MCV-90 MCH-30.3 MCHC-33.9 RDW-15.5 Plt Ct-153 [**2183-11-25**] 06:55AM BLOOD WBC-3.7* RBC-3.56* Hgb-10.9* Hct-31.2* MCV-88 MCH-30.6 MCHC-34.9 RDW-15.2 Plt Ct-155 [**2183-11-24**] 08:45PM BLOOD Hct-32.3* [**2183-11-24**] 06:30AM BLOOD WBC-4.5 RBC-3.15* Hgb-9.6* Hct-27.6* MCV-88 MCH-30.4 MCHC-34.6 RDW-15.2 Plt Ct-140* [**2183-11-23**] 07:00PM BLOOD Hct-30.1* [**2183-11-23**] 12:34PM BLOOD Hct-31.5* [**2183-11-23**] 06:30AM BLOOD WBC-5.2 RBC-3.31* Hgb-10.2* Hct-29.0* MCV-88 MCH-30.7 MCHC-35.1* RDW-15.0 Plt Ct-134* [**2183-11-22**] 10:48PM BLOOD Hct-26.2* [**2183-11-22**] 12:42PM BLOOD Hct-29.6* [**2183-11-22**] 04:21AM BLOOD WBC-7.4 RBC-3.44* Hgb-10.0* Hct-30.5* MCV-89 MCH-29.2 MCHC-32.8 RDW-14.6 Plt Ct-155 [**2183-11-21**] 08:04PM BLOOD Hct-26.8*# [**2183-11-21**] 01:06PM BLOOD Hct-18.5*# [**2183-11-21**] 02:45AM BLOOD WBC-5.7 RBC-3.03* Hgb-8.7* Hct-25.8* MCV-85 MCH-28.8 MCHC-33.8 RDW-14.4 Plt Ct-178 [**2183-11-20**] 11:15PM BLOOD WBC-7.4 RBC-3.24* Hgb-9.4* Hct-27.4* MCV-84 MCH-29.0 MCHC-34.4 RDW-13.4 Plt Ct-201 [**2183-11-20**] 07:40PM BLOOD WBC-6.3 RBC-3.53* Hgb-10.2* Hct-30.3* MCV-86 MCH-28.8 MCHC-33.6 RDW-13.4 Plt Ct-196 [**2183-11-26**] 06:25AM BLOOD Glucose-81 UreaN-12 Creat-0.8 Na-141 K-3.8 Cl-113* HCO3-24 [**2183-11-25**] 06:55AM BLOOD TotProt-5.3* Calcium-8.5 Phos-3.9 Mg-1.6 [**2183-11-25**] 06:55AM BLOOD VitB12-626 Folate-16.8 . Brief Hospital Course: 88 year old female with history of hypertension who presented with gastrointestinal bleeding likely due to gastroesophageal junction ulceration. . Gastrointestinal bleeding: Patient was brought to the ICU from the ED with #2 PIVs. She was on protonix iv bid and was made npo for procedure. She self discontinued her NG tube overnight. Her hematocrit dropped from 30 on admission to ED to 18 overnight and she was transfused 2 units with good results. On [**11-21**], she underwent uncomplicated EGD which demonstrated ulcerations at GE junction, likely source of bleeding. Gastroenterology suggested pantoprazole [**Hospital1 **] for 8 weeks, them once daily and scheduled her for a repeat EGD [**1-15**] as outpatient (already arranged). Also, future outpatient colonoscopy was suggested. Anti-hypertensive medication, NSAIDS, and ASA were held. The patient was transfered to the regular medicine floor on [**11-23**] and overnight, her hematocrit dropped from 29 to 26. She was again transfused 1 u PRBCs with increase to 29. Patient was tolerating clears at this point with no nausea, vomiting, dizziness. She received another unit of PRBCs on [**11-24**] to increase her hematocrit above 30. Since, her hematocrit has remained stable above 30. She continues to report having black stools but denies gross bleeding, lightheadedness, or weakness. She will follow up with the GI service for evaluation and repeat EGD. She was started on clarithromycin and amoxicillin on [**11-24**] for positive testing for H. pylori serologies and will finish a two week course of antibiotics at home. She should continue the protonix twice daily for a total of two months. Her hematocrit should be followed as an outpatient to help monitor for blood loss. First draw is scheduled for [**2183-12-1**]. She was educated to return to the hospital for signs or symptoms of blood loss. The patient is ambulating well and has good oral intake. She has been afebrile throughout her hospital stay and has an unremarkable physical exam. She received physical therapy and assistance with strength building before discharge and will be getting home nursing physical therapy, occupational therapy, and social work assistance. She needs a home safety evaluation since there is concern for dementia and ability to continue caring for herself at home alone safely. She has a follow up appointment with her PCP in about [**Name Initial (PRE) **] week and will need further neuropsychiatric evaluation for dementia. She was discharged to home in good condition with the assistance of her health care proxy. Medications on Admission: combipres 0.1 mg, oxazepam 10 mg qhs, colace, prn ASA Discharge Medications: 1. Oxazepam 10 mg Capsule Sig: One (1) Capsule PO HS (at bedtime). 2. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO twice a day: Continue for 8 weeks then take one pill per day. Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 3. Chlorthalidone 15 mg Tablet Sig: One (1) Tablet PO once a day. Tablet(s) 4. Outpatient Lab Work CBC. 5. Clarithromycin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 10 days. Disp:*20 Tablet(s)* Refills:*0* 6. Amoxicillin 500 mg Capsule Sig: One (1) Capsule PO Q12H (every 12 hours) for 10 days. Disp:*20 Capsule(s)* Refills:*0* 7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO twice a day. Discharge Disposition: Home With Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: Primary: 1. Blood Loss Anemia. 2. Gastro-Esophageal Ulceration. 3. Upper GI Bleed. Secondary: 1. Hypertension. 2. Constipation. Discharge Condition: Good. Discharge Instructions: Continue to take all medications as directed. Please attend your doctor [**First Name (Titles) 4314**] [**Last Name (Titles) 104351**] below. If you experience worsening nausea, vomiting more blood or coffee grounds material, dizziness, or other concerning symptoms, please call your doctor or return immediately to the ER. You should avoid Aspirin as well as Motrin, ibuprofen, advil, naproxen, other "NSAID" medications. Followup Instructions: 1. Provider: [**First Name8 (NamePattern2) 870**] [**Last Name (NamePattern1) **], MD Where: [**First Name8 (NamePattern2) **] [**Hospital Ward Name **] BUILDING ([**Hospital Ward Name **]/[**Hospital Ward Name **] COMPLEX) ENDOSCOPY SUITE Phone:[**Telephone/Fax (1) 463**] Date/Time:[**2184-1-15**] 7:30 2. Provider: [**Name Initial (NameIs) **] SUITE GI ROOMS Where: GI ROOMS Date/Time:[**2184-1-15**] 7:30 3. Follow up with Dr. [**First Name8 (NamePattern2) 122**] [**Last Name (NamePattern1) 123**] ([**Telephone/Fax (1) 104352**]. You have an appointment scheduled for [**2183-12-11**] at 10AM.

[ "287.5", "531.40", "041.86", "294.8", "564.00", "285.1", "401.9", "786.59" ]

icd9cm

[ [ [] ] ]

[ "96.33", "45.13", "99.04" ]

icd9pcs

[ [ [] ] ]

7412, 7469

3994, 6583

245, 263

7641, 7648

2164, 3971

8120, 8725

1524, 1544

6687, 7389

7490, 7620

6609, 6664

7672, 8097

1559, 2145

199, 207

291, 1396

1418, 1456

1472, 1508

56,201

104,808

38629

Discharge summary

report

Admission Date: [**2107-1-10**] Discharge Date: [**2107-2-1**] Date of Birth: [**2036-6-12**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 898**] Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: Pericardial drain placement and removal PEG placement PICC placement Intubation/extubation, mechanical ventilation Thoracentesis X2 (bilaterally) History of Present Illness: The patient is a 70 yo man with ho DM2, HTN, and recent diagnoses of AFib who was transferred from OSH on [**2107-1-10**] for evaluation of pericardial effusion. Around [**2106-12-17**], pt had CHF-like symptoms, and he was started on diuretics. Four days prior to admission patient had new onset Atrial flutter and was started on Coumadin. On [**12-27**], the patient was admitted to [**Hospital1 3325**] for a worsening dyspnea over 4 weeks. He was intubated in the ED and transferred to the CCU, where he was started on a Dilt gtt and was eventually extubated on [**1-6**]. Then pt had AMS, thought to be metabolic and had a CT-chest showing a large pericardial effusion and bilateral upper lobe and RML air space disease. He started Imipenem and continued Levofloxacin. TTE at that time showed LVEF of 25%. He underwent a TEE with attempt to cardiovert, but he was found to have an atrial thrombus, so this was not attempted. He was transferred to [**Hospital1 18**] for further care and possible pericardiocentesis since effusion appears to progress. At OSH he also had ARF, hematuria, and anemia (hct 24). . On transfer his echo showed tamponade changes and he was transfered to the CCU for pericardial drainage. Repeat echo [**1-13**] showed no reaccumulation of fluid. Due to his garbled speech and dysphagia, neurology was consulted and felt he had a left parietal cardioembolic stroke (h/o A. fib). After failing S&S eval, decision has been made to pursue PEG after transfer to the floor. He was also found to have a pneumonia, so is being treated with Zosyn. On the floor he has had more agitation and has been given haldol 1mg and zyprexa 5mg. Then pt became more somulent and a ABG showed 7.19/92/56 on a shovel mask with 2 liters. HR was in the 80s and BP in 120s. He was transfered to MICU for airway concern and hypercabic resp failure. . On arrival to the MICU he was unresponsive. He did not tolerate placement of a BIPAP, so was intubated. On intubation he was noted to have a large amount of material in the thorat, possible food. He had some transient runs of bradycarida that quickly recovered to 90s without intervention. . Review of Systems: Unable to obtain due to solmulence and intubation. Past Medical History: DM2 HTN BPH Congestive Heart Failure Anxiety Disorder Atrial Fibrillation Alcohol dependance and abuse Social History: Per OSH medical records, the patient smokes 2 cigars and one cigarette daily. He drinks a six pack of beer daily. He lives with his wife. . Family History: Non-contributory Physical Exam: GEN: Middle aged man, AAOx1, in NAD VS: 126/70, P 66, R 16, O2 99% on 4L HEENT: PERRL, EOMI, Mucous membranes dry CV: Distant heart sounds. JVD elevated to angle of jaw. PULM: Coarse breath sounds throughout lung fields bilaterally ABD: +BS, NT, ND LIMBS: No edema. 5/5 strength bilaterally SKIN: No rashes or ecchymoses NEURO: AAOx1, Moving all extremities. Unable to follow commands. . On transfer to the MICU: Vitals: T: 96.9 BP: 97/38 P: 53-90 R: 19 O2: 97% on bag mask, then 100% on vent General: responsive to pain, solument HEENT: Sclera anicteric, dry MM, OP with debris Neck: supple, JVP not elevated, no LAD Lungs: rhonchi B, decreased left breath sounds, no crackles CV: Regular rate and rhythm, no murmurs, 2+ pulses Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: foley with clear urine Ext: warm, well perfused, no clubbing, cyanosis or edema Pertinent Results: ADMISSION LABS: [**2107-1-11**] 03:49AM BLOOD WBC-12.6* RBC-2.82* Hgb-8.8* Hct-26.6* MCV-95 MCH-31.1 MCHC-32.9 RDW-16.0* Plt Ct-751* [**2107-1-11**] 03:49AM BLOOD Neuts-76* Bands-1 Lymphs-15* Monos-7 Eos-1 Baso-0 Atyps-0 Metas-0 Myelos-0 NRBC-2* [**2107-1-11**] 03:49AM BLOOD PT-27.8* PTT-36.9* INR(PT)-2.7* [**2107-1-11**] 03:49AM BLOOD Glucose-171* UreaN-114* Creat-2.0* Na-143 K-4.1 Cl-100 HCO3-32 AnGap-15 [**2107-1-11**] 03:49AM BLOOD ALT-32 AST-41* LD(LDH)-288* CK(CPK)-88 AlkPhos-105 TotBili-0.8 [**2107-1-11**] 03:49AM BLOOD Albumin-3.4* Calcium-8.7 Phos-4.8* Mg-3.3* Iron-43* [**2107-1-11**] 03:49AM BLOOD calTIBC-229* VitB12-862 Folate-16.0 Ferritn-1190* TRF-176* ----------------- DISCHARGE LABS: ----------------- STUDIES: . PERICARDIAL FLUID: NEGATIVE FOR MALIGNANT CELLS. Lymphocytes, monocytes, and mesothelial cells. . RHCath and Pericardiocentesis: 1. Right heart catheterization prior to pericardiocensis showed elevation and equalization of diastolic filling pressures (20-22mmHg) that were similar to the opening pericardial pressure (19mmHg). Pulsus paradoxus recorded via the a-line tracing was approximately 20mmHg. 2. Pericardiocentesis was performed with needle entry from the subxiphoid position. The opening pericardial pressure was 19 mmHg. 3. Subsequent to removal of 920 cc of blood fluid (all sent for studies) and confirmation by echocardiography of complete fluid removal, the pericardial pressure decreased to -2 to 1 mmHg and RA pressure decreased to 15 mmHg. 4. Anesthesia was present during the case to manage the patient's airway given his tenuous respiratory status. He was maintained on 100% oxygen therapy. FINAL DIAGNOSIS: 1. Pericardial tamponade with improvement in hemodynamics after removal of 920 cc of bloody fluid. 2. Pericardial drain in place. . CT HEAD [**1-11**]: There is no evidence of hemorrhage, edema, masses, mass effect, or infarction. The [**Doctor Last Name 352**]-white matter differentiation is preserved. The ventricles and sulci are prominent, most compatible with atrophic change. Note is made of bilateral atherosclerotic calcification within the carotid siphons. The visualized portions of the paranasal sinuses and mastoid air cells are well aerated. . ECHO [**1-11**] #1: No atrial septal defect is seen by 2D or color Doppler. The estimated right atrial pressure is 10-15mmHg. There is mild symmetric left ventricular hypertrophy with normal cavity size. Overall left ventricular systolic function is low normal (LVEF 50-55%). with borderline normal free wall function. The aortic valve leaflets are moderately thickened. There is mild aortic valve stenosis (valve area 1.2-1.9cm2). No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. The pulmonary artery systolic pressure could not be determined. There is a large pericardial effusion. The effusion appears circumferential. The effusion is echo dense, consistent with blood, inflammation or other cellular elements. There is right ventricular diastolic compression, consistent with impaired fillling/tamponade physiology. IMPRESSION: Large pericardial effusion with echo evidence of impaired filling/tamponade physiology. . ECHO [**1-11**] #2: Overall left ventricular systolic function is normal (LVEF>55%). RV with borderline normal free wall function. There is no residual pericardial effusion. There are no echocardiographic signs of tamponade. Compared with the prior study (images reviewed) of [**2107-1-11**], pericardial effusion (post tap) has resolved. There is no longer evidence of RV compression. . ECHO [**1-13**]: The left atrium is moderately dilated. The right atrium is moderately dilated. No atrial septal defect or patent foramen ovale is seen by 2D, color Doppler or saline contrast with maneuvers. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity is mildly dilated. Overall left ventricular systolic function is normal (LVEF 60-70%). Right ventricular chamber size is normal. with depressed free wall contractility. The aortic root is mildly dilated at the sinus level. The aortic valve leaflets are moderately thickened. There is mild aortic valve stenosis (valve area 1.2-1.9cm2). No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. . MR head without contrast: There is no acute infarct, hemorrhage, edema, or mass effect. The ventricles and sulci are prominent, consistent with age-related atrophy. Scattered T2 hyperintense periventricular and supratentorial white matter abnormalities represent mild chronic small vessel ischemic disease. The patient is intubated. Mild mucosal sinus thickening is seen in the bilateral maxillary, ethmoid, and frontal sinuses. The osteomeatal units appear patent bilaterally. There is partial opacification of the bilateral mastoid air cells. IMPRESSION: No acute intracranial process. . CT chest [**1-19**]: 1. Massive bilateral pleural effusions, responsible for severe atelectasis of the adjacent lung. 2. Severe aortic valvular calcifications, which represent severe aortic stenosis until proven otherwise. 3. Enlarged pulmonary arterial trunk, suggestive of pulmonary arterial hypertension. 4. No evidence of aspiration. . CT chest [**1-27**]: 1. Substantial improvement in previously large bilateral pleural effusions, stable pericardial effusion. No indication of malignant implants in the pleural space or development of tamponade. 2. New predominantly right lower lobe pneumonia or hemorrhage. 3. Marked improvement in previous lower lobe collapse. 4. Global cardiomegaly, probable pulmonary hypertension, probable calcific aortic stenosis, severe coronary and innominate artery atherosclerosis. 5. Mild emphysema. . ECHO [**1-24**]: The left atrium and right atrium are normal in cavity size. There is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets are moderately thickened. There is mild aortic valve stenosis (valve area 1.2-1.9cm2). No aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. The pulmonary artery systolic pressure could not be determined. Significant pulmonic regurgitation is seen. There is an anterior space which most likely represents a fat pad. There are prominent bilateral pleural effusion. . ECHO [**1-28**]: The left and right atrium are moderately dilated. The estimated right atrial pressure is 0-10mmHg. There is mild symmetric left ventricular hypertrophy with normal cavity size. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is low normal (LVEF 50%). The estimated cardiac index is normal (>=2.5L/min/m2). Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). Right ventricular chamber size is normal 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 are moderately thickened. There is moderate aortic valve stenosis (valve area 1.2cm2). The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. There is a trivial/physiologic pericardial effusion. Compared with the prior study (images reviewed) of [**2107-1-24**], global biventricular systolic function is less vigorous (now low normal), c/w diffuse process. The heart rate is also slightly lower. In the absence of a history of hypertension, an infiltrative process (e.g., amyloid) should be considered. Brief Hospital Course: 70 yo man with h/o HTN and recently diagnosed AFlutter who presented from OSH with pericardial effusion, AMS, and ARF. He was intubated for 10 days after presentation to OSH. A CT showed a pericardial effusion and RML PNA. He was transfered to [**Hospital1 18**] on Imipenem and Levofloxacin for management of the effusion. The effusion was bloody and large (1L), though he was on anticoagulation. After extubation, he had AMS with a notable Wernicke's aphasia with preserved repetition and limited but largely intact comprehension and direction following. After failing multiple speech and swallow evaluations, the plan was for the patient to receive a PEG (once his INR was within acceptable limits). In the interim, patient was found to have a pneumonia and was started on Zosyn. He became more agitated on the Medicine floor, and received Haldol 1mg and Zyprexa 5mg. He then became somnolent, hypercarbic and acidotic and was transferred to the MICU where he did not tolerate BiPap, so he was intubated. Upon intubation, large amounts of tube feeds were found in his throat, so that his acute respiratory failure was felt due to his chronic large bilateral pleural effusions in conjunction with an aspiration event. . # Altered Mental Status/CVA/Thrombocytosis: The patient has had AMS, waxing and [**Doctor Last Name 688**] delirium, since extubation at OSH. EEG was c/w metabolic encephalopathy, but common metabolic causes ruled out (normal folate/B12). An urgent head CT was ordered that did not demonstrate e/o of an acute intracranial process. Neurology was consulted and was concerned for CVA. Carotid U/S demonstrated <40% stenosis on L and 40-60% on R. Recommended MRI, but patient could not tolerate MRI without sedation. Neuro recommended anticoagulation, speech therapy, outpatient follow-up. Of note, patient was found to have a right atrial thrombus on OSH imaging and MRI/MRA once patient was intubated confirmed periventricular and supratentorial white matter abnormalities suggestive of cerebroembolic event; this was consistent with Neurology's findings on physical exam. Patient also had markedly elevated platelets, which in the setting of pneumonia can result in a hypercoagulable state (Arch Neurol. [**2106**];67(1):33-38) resulting in a thrombotic, small vessel CVA. At the same time, he has thrombocytosis (Platelets between 760-960), possibly myelodysplastic in origin, which could also cause a thrombo/embolic CVA. The workup of essential thrombocytosis was not pursued inpatient since it is very low yield (JAK2 mutations being positive in no more than 50% of ET cases) and the damage (stroke) had already been wrought. The patient was continued on a heparin drip in the MICU and started on bridge to Coumadin on [**1-28**], upon transfer back to the regular floors. At the time of discharge, the patient was taking 6mg of Coumadin with a subtherapeutic INR, compensated by Heparin gtt. . # Respiratory Distress/Pleural effusions: Patient's initial hypercarbic, respiratory acidotic episode was felt likely due to the exacerbation of his pulmonary status with the large pleural effusions by aspiration of food contents. Haldol and Zyprexa may have also slightly contributed. Patient was trialed on Bipap on admission to the MICU without significant improvement and was shortly intubated. Diagnostic thoracentesis showed exudative processes. Patient was extubated on [**1-22**] after Lasix diuresis but developed hypercarbic, respiratory acidosis 10 hours later. Etiology unclear - ?flash pulmonary edema as patient was hypertensive to SBP190s during this vs. tiring off the ventilator vs. continued significant pleural effusions. Ultimately, thoracenteses were done bilaterally, removing 3.5-4 liters total. All the fluid studies came back suggestive of exudative processes. Rheumatology was consulted in the setting of significantly elevated ESR and CRP but did not feel the patient had an underlying rheumatologic processes. Repeat CT chest & a CXR performed on the day of discharge did not show signs of infection, malignancy or reaccumulation of fluid. Etiology for patient's large pleural effusions remains unclear but the patient may benefit from anti-histone serology or cardiac MRI for further work-up if his effusions recur. . Patient also noted to have multiple apneic episodes as long as 20 seconds at a time. Pulmonology was consulted and felt that the patient's apnea was likely secondary to both a central and obstructive process. They felt that he was safe for discharge, but felt he would benefit from a sleep study to further evaluate the etiology of his apnea and determine whether he could benefit from CPAP once his delirium improved. . #. Pericardial effusion: Patient was transferred to [**Hospital1 18**] for pericardial effusion and tamponade physiology. Pericardial drain was placed, and bloody effusion was noted. Pericardial fluid is negative for malignant cells. No microorganism was isolated. Repeat TTE demonstrated no reaccumulation of the effusion, so drain was pulled on [**1-13**]. Repeat ECHOs showed no reaccumulation of pericardial effusion and patient's physical exam remained benign. The etiology of his pericardial effusion remained unclear, possibly due to a viral syndrome given his concurrent pleural effusions. Repeat ECHO on [**1-28**], after removal of large pleural effusions (and pericardial effusion), showed global biventricular systolic function was less vigorous (now low normal), consistent with a diffuse process. If patient's hypertension has not been long-standing, amyloidosis is on the differential and may explain both the pericardial and pleural effusions (per cardiology). Given the patient's functional baseline, however, myocardial biopsy was not pursued as an inpatient. A CXR on [**2-1**] did not demonstrate evidence of pericardial or pleural effusions. . #. Multifocal Pneumonia: The patient was found to have a suggestion of multifocal PNA on a CT dated [**1-9**]. He was transferred on Imipenem and Levofloxacin. Given the fact that the patient was intubated for 10 days, he may have had a HAP, but sputum cultures from OSH taken on [**1-4**] were negative. CXR demonstrated bilateral pleural effusions consistent with overload, but no obvious consolidation. Patient did not spike during this admission, but temperatures and WBC remained mildly elevated before normalizing. Upon admission to [**Hospital1 18**], he was treated with Zosyn for 8 day course from [**1-10**], last day [**1-20**] (given aspiration found when intubated). A PEG was ultimately placed with good effect while patient was intubated. Of note, multiple blood, urine and sputum cultures were drawn which were all no growth to date for an infectious etiology to his symptoms. Patient's EBV/CMV were also negative for acute infection. . #. Atrial Flutter/Atrial Fibrillation: Patient was initially in atrial flutter, but later during this hospital stay, he was in and out of atrial fibrillation. His RA thrombus noted at OSH is a contraindication to cardioversion. Digoxin & Cardizem were held and Metoprolol was continued. He was anticoagulated with Coumadin after pericardial drain was pulled. Patient had a number of bradycardic episodes initially while in the MICU that Cardiology felt was due to a vasovagal response to ETT placement. These episodes resolved, but he also had intermittent episodes of AF with RVR that responded to IV Metoprolol. Patient may benefit from discussions with EP as an outpatient regarding need for ablation for his AFib or pacer placement if he has recurrent episodes of bradycardia. . # Hypernatremia: Patient's Na was 143 on admission, which went up to 153 the next day. Urine Osm??????s and electrolytes supported a hypovolemic hyponatremia. Patient was given free water flushes with TF. His Na improved on this regimen. Once the PEG tube was placed, the patient was continued on small volumes of free water flushes with good effect. His sodium normalized and he was discharged with serum Na of 140. . #. Acute renal failure: The patient's creatinine increased at the OSH from his baseline of 0.5 to 2.6, in the setting of extensive diuresis. Cr quickly normalized to baseline after admission to [**Hospital1 18**]. Upon transfer out of the MICU back to the floor, patient's creatinine was back to baseline at 0.4 where it continued to be until discharge. . #. Hematuria: The patient was found to have hematuria at OSH while on anticoagulation, and there was concern for bladder cancer, given his history of smoking. Urology was consulted and recommended an outpatient cystoscopy. His hematuria improved after anticoagulation was held, but resumed with restarting Coumadin. The patient will need follow up with Urology as an outpatient and his home Flomax should be restarted prior to discontinuation of his Foley which was in place at the time of discharge. . #. Anemia: Patient with an anemia on admission. Guaiac was negative at OSH. B12 and folate were normal. Fe studies showed 19% saturation, Fe 43, and Ferritin 1190, consistent with ongoing inflammation and possible mild Fe deficiency. Ferrous Sulfate 325mg PO daily was continued. His hematocrit did intermittently decrease to lows of 23, felt likely due to the procedures he underwent. He did not require any pRBC transfusions while in the MICU or on the medicine floor and was discharged with a Hct of 24.8. . # Hypertension: Patient's home regimen is Lopressor 25mg twice daily and Nifedipine 30mg daily. While in the hospital, patient was kept on Amlodipine 10mg daily and his Lopressor was titrated to 50mg TID. His blood pressures were well-controlled on this regimen. . # Dysphagia: Patient developed dysphagia, likely secondary to stroke. PEG placed on [**1-18**] without any complications, but he continued to fail speech and swallow evaluations until the day of discharge and was recommended to remain NPO. . # CODE: Full Medications on Admission: Home Medications: Lasix 40 mg PO daily Lopressor 25 mg PO BID Flomax 0.4 mg PO daily Glucophage 500 mg PO BID Nifedipine 30 mg PO daily Coumadin 5 mg PO daily Ativan 1 mg TID prn . Medications on Transfer: Fluconazole 100 mg PO daily Imipenem 500 mg PO IV q12h Levofloxacin 500 mg IV qod Protonix 40 mg IV daily Combivent nebulizer qid Digoxin 0.25 mg via NG daily Cardizem 90 mg via NG q6h Lactobacillus 1 pack via NG TID with meals Metoprolol 25 mg NG TID Modafinil 200 mg NG daily Lovenox 100 mg SQ daily SSI Zyprexa 7.5 mg IM q4h prn Reglan 5-10 mg IV q6h prn Combivent nebulizers q2h prn Tylenol prn Colace prn Milk of Magnesia prn Zantac 150 mg NG daily prn Senna prn Artificial tears 1 gtt each eye prn Discharge Disposition: Extended Care Facility: [**Hospital1 700**] - [**Location (un) 701**] Discharge Diagnosis: Primary diagnoses: - pericardical effusion/tamponade - respiratory failure requiring intubation - stroke - atrial flutter/atrial fibrillation . Secondary diagnoses: - diabetes - hypertension Discharge Condition: Mental Status:Confused - sometimes Level of Consciousness:Alert and interactive, with expressive aphasia Activity Status:Bedbound Discharge Instructions: It was a pleasure to be involved in your care, Mr. [**Known lastname **]. You were admitted to [**Hospital1 18**] for fluid around your heart. A drain was placed, which provided sufficient drainage of the fluid. The drain was pulled out 3 days later after an echocardiogram confirmed no more accumulation of fluid. Furthermore, you were treated with antibiotics for your pneumonia. Your heart rhythm showed atrial flutter / atrial fibrillation, which are arrythmias coming from the top of your heart. You had some trouble with your speech and you had some mental status changes, so you were evaluated by our Neurology service. The Neurology consult concluded that you had a stroke. You will need to be on blood thinners for further stroke prevention. You were also seen by the Speech and Swallow service, who noted that you have a high risk of aspirations, so a gastric tube was placed by the Gastroenterology service. You will get tube feeds through this gastric tube. Your medications have been changed and are as follows: Acetaminophen 325-650 mg PO/NG Q6H:PRN pain/ fever Lansoprazole Oral Disintegrating Tab 30 mg PO/NG DAILY Metolazone 5 mg PO DAILY Amlodipine 10 mg PO/NG DAILY Metoprolol Tartrate 50 mg PO/NG TID Artificial Tears 1-2 DROP BOTH EYES PRN dry eyes Docusate Sodium (Liquid) 100 mg NG [**Hospital1 **] Ferrous Sulfate 300 mg PO/NG DAILY Senna 1 TAB NG [**Hospital1 **]:PRN constipation Warfarin 4 mg PO/NG QHS Followup Instructions: Please follow-up with a neurologist, Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 162**], MD on [**2107-2-14**] at 2:00PM. To reschedule, please call:[**Telephone/Fax (1) 44**]. Please follow-up with your primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 1617**], on [**2-16**] at 3:00PM. His offices are located at [**Last Name (un) 85842**]. [**Apartment Address(1) **], [**Location (un) **],[**Numeric Identifier 85843**]. To reschedule, please call: [**Telephone/Fax (1) 85844**]. Please schedule a pulmonology appointment at your convenience by calling: ([**Telephone/Fax (1) 513**]. Please scheduled a follow-up appointment with your regular cardiologist, but if you would like to see a [**Hospital1 18**] cardiologist, please call [**Telephone/Fax (1) 62**] to schedule an appointment.

[ "276.0", "423.3", "600.00", "263.9", "486", "427.32", "401.9", "428.0", "423.9", "427.31", "584.9", "511.9", "434.91", "428.20", "276.2", "349.82", "V46.11", "285.9", "250.00", "599.70", "518.81" ]

icd9cm

[ [ [] ] ]

[ "34.91", "37.21", "38.93", "96.72", "33.23", "96.71", "37.0", "43.11", "96.6", "96.04" ]

icd9pcs

[ [ [] ] ]

22626, 22698

11950, 21865

333, 481

22933, 22933

4015, 4015

24555, 25393

3031, 3049

22719, 22863

21891, 21891

5686, 11927

23089, 24532

4724, 5669

3064, 3996

22884, 22912

21909, 22072

2678, 2730

274, 295

509, 2659

4031, 4707

22947, 23065

22097, 22603

2752, 2857

2873, 3015

8,563

104,805

24406

Discharge summary

report

Admission Date: [**2117-4-30**] Discharge Date: [**2117-5-2**] Date of Birth: [**2046-12-1**] Sex: F Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 4748**] Chief Complaint: Back and bilateral lower leg pain Major Surgical or Invasive Procedure: Axillary bifemoral bypass graft with PTFE History of Present Illness: The patient is a 70 y/o F with known h/o AAA who has had increasing lumbar and bilateal lower extremity [**Last Name (un) **] for 1.5 months. She has had recent accelerating with progression of her symptoms. Pt reports pain, numbness, back pain, and cool mottled extremities below the waist. Past Medical History: HTN, AAA x 5 cm, Chronic lower back pain Social History: Pt is married with children Family History: Non contributory Physical Exam: HR 94 BP 126/78 Elderly woman in pain. Speaks appropriately. RRR CTAB Abd soft, nontender, no hernias Palpable radial pulses bilaterally R femoral pulse -- None L femoral pulse -- Weak R > L leg mottled Legs cold Brief Hospital Course: Pt was taken from the ER straight to the operating room where an emergent R axillary-bifemoral bypass graft was performed with PTFE to restore blood flow to the lower extremities after an acute aortic occlusion. Postopreatively, the patient initially did well. She was quickly extubated. Within a short amount of time the patient began to have problems maintaining adequate blood pressure requiring the use of pressors. She was found to have an acute metabolic acidosis for which the patient was placed on a bicarbonate drip. Over the course of the next 12 to 18 hours the patients condition worsened. A swan ganz catheter was placed to better monitor the patient's needs. She was found to have low SVO2's, High SVR's, low PAD's/CVP's/Wedges. The patient was bolused many liters of fluid. Because the patient's cardiac output/index were low she was tried on milrinone. This did not in effect help. It only made her tachycardic. Meanwhile the patient began to have respiratory distress. Emergent tracheostomy was performed as endotracheal intubation was not an option due to pharyngeal edema. Persistent lactic acidosis and developing renal failure then prompted consultation with the general surgery service. The patient was then taken to the OR for abdominal exploration. The patient had ischemic right colon but it did not appear dead. No resection was performed. Furthermore, the pt's hemodynamics improved with abdominal decompression indicating abdominal compartment syndrome. Over the next day the patient required large amounts of fluid and began to develop further problems with hemodynamic stability. In the early morning of [**2114-5-2**] the patient was being turned and became suddenly unable to be ventilated. The patient was amboo'd. Airway resistence was strikingly high. Auscultation revealed decreased breath sounds on the L lung field. An emergent chest tube was placed with immediate drainage of about 1400 cc of serosanguinous fluid. CO2 detectors were used to insure CO2 exchange which was confirmed present. A stat blood gas showed a PCO2 in the 20's and a PO2 in the 200's. Meanwhile, the pt began to brady down and become asystolic. CPR was performed for approximately 20 minutes while numerous chemical modalities were tried to revive the patient. Ultimately we were unsuccessful, and the patient was declared dead at 443 am on [**2117-5-2**]. Medications on Admission: Lipitor, Tamoxifen, Motrin, Atenolol, HCTZ, ASA Discharge Medications: None Discharge Disposition: Expired Discharge Diagnosis: Aortic occlusion Axillary bifemoral bypass graft with PTFE Ischemic colon Respiratory failure Cardiac arrest Metabolic acidosis Abdominal compartment syndrome Pleural effusion Shock AAA Mesenteric ischemia Exploratory laparotomy Coagulopathy Acute renal failure Discharge Condition: Deceased Discharge Instructions: Post mortem exam requested by family Followup Instructions: None

[ "557.9", "250.00", "511.9", "401.9", "276.8", "785.51", "276.2", "584.9", "444.0", "518.81", "441.4" ]

icd9cm

[ [ [] ] ]

[ "31.1", "34.04", "89.64", "54.11", "99.04", "96.71", "39.29" ]

icd9pcs

[ [ [] ] ]

3631, 3640

1109, 3504

347, 390

3945, 3955

4040, 4047

838, 856

3602, 3608

3661, 3924

3530, 3579

3979, 4017

871, 1086

274, 309

418, 713

735, 777

793, 822

79,556

115,717

1428

Discharge summary

report

Admission Date: [**2125-11-3**] Discharge Date: [**2125-11-12**] Date of Birth: [**2064-4-22**] Sex: F Service: MEDICINE Allergies: Demerol / Codeine / Zocor / Crestor / Lescol / Fosamax / Percocet / Advair Diskus / Azulfidine / Celexa / Cymbalta Attending:[**First Name3 (LF) 2387**] Chief Complaint: NSTEMI Major Surgical or Invasive Procedure: [**2125-11-3**] - Central venous line insertion [**2125-11-8**] - Cardiac catheterization with four stents placed [**2125-11-11**] - PICC line placement History of Present Illness: Ms. [**Known lastname 8529**] is a 61 y/o f with h/o of CAD s/p multiple stents, most recently [**2125-7-19**] ostial RCA Promus and RPDA promus, LCX Taxus, PCI ostial LAD promus for instent restenosis of the RCA, RPDA, LCX and LAD, HTN, hyperlipidemia, rheumatoid arthritis, restrictive lung disease who was transferred from OSH for possible cholangitis. Patient complained of some chest discomfort on the night of [**11-2**] while eating dinner and was noted to have elevated cardiac biomarkers. . Patient reports on [**11-2**] she was eating dinner when she developed sudden onset of head ache [**10-29**] which radiated to her back. She became anxious and then developed throat "heaviness" that subsequently radiated to her chest, which pt states is consistent with her previous anginal and heart attack symptoms. She took NTG and after 5 minutes the pain did not subside so she took another nitroglycerine and then a third which improved the CP slightly. She said the entire episode lasted about 20 minutes. The chest pressure was associated with diaphoresis and SOB but pt denied palpitations, dizziness, nause, vomiting. She was taken to the hospital by her husband and by the time she reached [**Name (NI) 8530**] her chest pressure had subsided completely but she did have some abdominal discomfort. In [**Location (un) **], she was hypotensive and central line was placed. No EKG shown. She was given stress dose steroids and put on pressors. Per report, there were some gallbladder thickening and the initial thought was hypotension/sepsis from a gallbladder source prompting her transfer to [**Hospital1 18**] with for management of possible cholangitis. The week prior she endorsed increasing orthopnea having to sleep upright and also noticed some increase LE swelling for which she was taking [**2-22**] additional lasix 20 mg pills on top of her morning 20 mg lasix. . On presentation to [**Hospital1 1516**], she denies any chest pain or shortness of breath. She also denied abdominal pain. She was also finishing her last day of azithromycin for an upper respiratory infection. She reports that over the last 6 days, she has also noticed increasing LE edema for which she has been taking increasing doses of Lasix. She also complains of worsening orthopnea. She is able to walk [**1-21**] blocks with no chest pain. She can go up 1 flight of stairs but sometime has to stop for SOB. On cardiac review of symptoms as stated above. All other ROS negative. Past Medical History: CAD: [**2125-7-19**]: 4 [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 8531**] RCA, PDA- ISR, CX- ISR and LAD. Cath [**6-27**] w/ PCI/[**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 8532**] RCA. Cath [**7-26**] PTCA/[**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] circumflex. [**10-23**] stenting of the LAD and RCA. - Carotid stenosis s/p CEA - HTN - Hyperlipidemia - h/o pericarditis x 1 - Rheumatoid arthritis on DMARDs - s/p wrist fusion - s/p multiple joint replacements - C4-5 neck fusion - Restrictive lung disease (rheumatoid lung) - Asthma questionable - s/p TAH for precancerous uterine lesion . PAST SURGICAL HISTORY: - s/p wrist fusion - s/p multiple joint replacements - carotid endardectomy Social History: Lives with husband. Denies etoh or tobacco use. No illicits, disabled since [**2092**]. Family History: Dad- MI in 40s. Mom MI in 50s. Physical Exam: ADMISSION PHYSICAL EXAMINATION: Vitals: T: 98.2, BP: 117/69 (yesterday 110-130/50-60) HR 80 RR 18 93/RA Gen: Awake, alert NAD HEENT: Pale. No icterus. moist mucus membranes. OP clear. NECK: Supple, JVP ~ 9 cm. Normal carotid upstroke without bruits. R IJ central line, dressing c/d/i. CV: PMI in 5th intercostal space, mid clavicular line. RRR. normal S1,S2. II/Vi holosystolic murmur apex LUNGS: Crackles bilaterally 2/3 up the back. No wheezes, rales, rhonchi. ABD: Soft, NT, ND. No HSM. Central abdominal bruit heard. EXT: [**1-21**]+ lower extremity edema below the knees. Left leg erythematous, warm and tender half way up the shin. SKIN: No rashes/lesions, ecchymoses. NEURO: A&Ox3. CN 2-12 grossly intact. Preserved sensation throughout. 5/5 strength throughout. [**1-21**]+ reflexes, equal BL. Normal coordination. . DISCHARGE PHYSICAL EXAMINATION Gen: Awake, alert NAD HEENT: Pale. No icterus. moist mucus membranes. OP clear. NECK: Supple, JVP low. Normal carotid upstroke without bruits. CV: PMI in 5th intercostal space, mid clavicular line. RRR. S1,S2 clear and of good quality. [**2-25**] holosystolic murmur best over apex LUNGS: Lungs CTAB, No wheezes, rales, rhonchi. ABD: Soft, NT, ND. No HSM. EXT: Left leg erythema, warm and tenderness vastly improved though still present. LLEE no RLEE NEURO: A&Ox3. CN 2-12 grossly intact. Preserved sensation throughout. 5/5 strength throughout. [**1-21**]+ reflexes, equal BL. Normal coordination. Pertinent Results: ADMISSION LABS: [**2125-11-3**] 03:47PM BLOOD WBC-42.4*# RBC-2.59* Hgb-7.9* Hct-25.3* MCV-98 MCH-30.7 MCHC-31.4 RDW-14.6 Plt Ct-236 [**2125-11-4**] 02:21PM BLOOD Neuts-96.8* Bands-0 Lymphs-2.2* Monos-0.6* Eos-0.4 Baso-0 [**2125-11-6**] 07:52AM BLOOD WBC-12.1* RBC-3.61* Hgb-11.1* Hct-34.5* MCV-96 MCH-30.7 MCHC-32.1 RDW-15.3 Plt Ct-216 [**2125-11-3**] 03:47PM BLOOD PT-13.8* PTT-29.3 INR(PT)-1.2* [**2125-11-3**] 03:47PM BLOOD Glucose-101* UreaN-27* Creat-1.3* Na-137 K-4.3 Cl-108 HCO3-19* AnGap-14 [**2125-11-3**] 03:47PM BLOOD ALT-52* AST-123* CK(CPK)-606* AlkPhos-90 Amylase-31 TotBili-0.2 [**2125-11-4**] 02:21PM BLOOD CK(CPK)-485* [**2125-11-3**] 03:47PM BLOOD CK-MB-64* MB Indx-10.6* cTropnT-1.33* proBNP-[**Numeric Identifier 8533**]* [**2125-11-3**] 03:47PM BLOOD Albumin-2.8* Calcium-7.4* Phos-2.9 Mg-1.1* [**2125-11-4**] 02:21PM BLOOD calTIBC-185* VitB12-1266* Folate-14.4 Ferritn-801* TRF-142* [**2125-11-4**] 02:21PM BLOOD Triglyc-174* HDL-25 CHOL/HD-6.2 LDLcalc-96 [**2125-11-4**] 02:21PM BLOOD TSH-2.7 . MICROBIOLOGY: -[**2125-11-3**] 4:14 pm MRSA SCREEN Source: Rectal swab. **FINAL REPORT [**2125-11-6**]** MRSA SCREEN (Final [**2125-11-6**]): No MRSA isolated. -[**2125-11-3**] 4:14 pm SWAB Source: Rectal swab. **FINAL REPORT [**2125-11-5**]** R/O VANCOMYCIN RESISTANT ENTEROCOCCUS (Final [**2125-11-5**]): No VRE isolated. -[**2125-11-3**] 4:45 pm URINE Source: Catheter. **FINAL REPORT [**2125-11-5**]** URINE CULTURE (Final [**2125-11-5**]): NO GROWTH. -[**2125-11-5**] 12:22 am STOOL CONSISTENCY: WATERY Source: Stool. **FINAL REPORT [**2125-11-8**]** CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2125-11-5**]): Feces negative for C.difficile toxin A & B by EIA. (Reference Range-Negative). -[**2125-11-6**] 11:45 am THROAT CULTURE VIRAL CULTURE: R/O HERPES SIMPLEX VIRUS (Preliminary): No Herpes simplex (HSV) virus isolated. -[**2125-11-7**] 10:04 am URINE Source: Catheter. **FINAL REPORT [**2125-11-8**]** URINE CULTURE (Final [**2125-11-8**]): NO GROWTH. . Blood Cx: Negative x3 Discharge Labs: [**2125-11-12**] 06:21AM BLOOD WBC-8.8 RBC-2.92* Hgb-8.7* Hct-28.0* MCV-96 MCH-29.8 MCHC-31.1 RDW-14.1 Plt Ct-250 [**2125-11-12**] 06:21AM BLOOD Creat-0.9 Na-140 K-3.9 Cl-102 [**2125-11-12**] 06:21AM BLOOD Mg-1.7 IMAGING: -[**11-3**] RUQ US: IMPRESSION: Collapsed gallbladder, with pericholecystic fluid and gallbladder wall edema but no distention or son[**Name (NI) 493**] [**Name2 (NI) 515**] sign, decreasing the likelihood of acute cholecystitis. The gallbladder findings may be secondary to third-spacing from volume overload. There is no intra- or extra-hepatic bile duct dilation. Trace ascites. . -[**11-4**] CTA Chest: IMPRESSION: 1. No evidence of aortic dissection or aneurysm as questioned. Atherosclerotic change and ulcerated plaque throughout the imaged aorta. 2. Dilated air and fluid-containing esophagus which is unchanged. The appearance could be seen with a connective tissue disorder such as scleroderma. 3. New, extensive and diffuse peribronchovascular, ground-glass and nodular bilateral lung opacities which likely represent pulmonary edema and/or superimposed atypical infectious or inflammatory process. Bibasilar fibrosis that was demonstrated on prior chest CT is largely obscured by this process. 4. 1.3-cm hyperdense left renal lesion which is slightly larger than in [**2121**] and does not clearly enhance. Features are most suggestive of a hemorrhagic cyst, however, as some types of renal cell carcinoma could have a similar appearance, further follow up is recommended. Renal ultrasound could provide additional information or MRI could be obtained in [**3-25**] months. 5. Mild stenosis of the left subclavian artery at its origin. . -[**11-5**] TTE: The left atrium and right atrium are normal in cavity size. The estimated right atrial pressure is 0-5 mmHg. Left ventricular wall thicknesses and cavity size are normal. There is mild regional left ventricular systolic dysfunction with hypokinesis of the basal 2/3rds of the inferior and inferolateral walls. The remaining segments contract normally (LVEF = 40-45 %). 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. The mitral valve leaflets are structurally normal. There is no mitral valve prolapse. Mild to moderate ([**1-21**]+) mitral regurgitation is seen. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. IMPRESSION: Normal left ventricular cavity size with regional systolic dysfunction c/w CAD (PDA distribution). Mild-moderate mitral regurgitation most likely due to papillary muscle dysfunction. Compared with the prior report (images unavailable for review) of [**2119-1-10**], the left ventricular regional dysfunction is new and c/w interim ischemia/infarction. . -[**11-7**] LLE Doppler: IMPRESSION: No evidence of deep vein thrombosis in the left leg. . -[**11-7**] ABI: IMPRESSION: Mild left common iliac arterial inflow insufficiency and mild right popliteal outflow arterial disease. Brief Hospital Course: Ms. [**Known lastname 8529**] is a 61F with significant history of CAD with multiple stents presenting from OSH with abdominal pain initially concerning for cholangitis and hypotensive episode requiring pressors, transferred from [**Hospital1 18**] SICU for NSTEMI. . ACTIVE ISSUES: . #. NSTEMI: After transfer to [**Hospital1 18**], she was found to have troponin elevated to 1.33->.1.23-> 1.24, likely ACS vs demand ischemia in the setting of the hypotensive episode at the OSH. EKGs remained normal and unchanged from previous, and pt was chest pain free. She was kept on a heparin gtt for 48hrs, and was continued on ASA, Plavix, pravastatin. TTE showed new left ventricular regional dysfunction c/w interim ischemia/infarction. Pt does have a history of in-stent restenosis, and she received cath on [**11-8**] (DES -> mid RCA, DES -> distal RCA, DES x2 -> mid LAD, POBA -> mid LCx). Her enalapril and nifidipine were held during admission given recent hypotensive episode and multiple doses of contrast. #. CHF- echo [**2118**] showed EF> 55 percent but exam notable for bilateral crackles, elevated JVP, and lower extremity edema. She also had an elevated BNP. She was diuresed with PO and IV lasix. . # New onset atrial fibrillation at OSH - etiology may be secondary to infectious process (UTI or pneumonia) vs. secondary to ischemia from NSTEMI. We continued metoprolol tartrate 25 mg TID for rate control. Her CHADS2 score is 2, but because she is already on ASA and Plavix, warfarin was not indicated at this time. Furthermore, she remained in sinus throughout the remaineder of admission and the afib was likely paroxysmal. . #. Widened mediastinum on xray [**11-3**]: CTA was obtained and aortic dissection was ruled out. . #. Leukocytosis: on admission to [**Location (un) **], she received stress dose steroids and had a WBC of 44K on admission to [**Hospital1 18**], likely secondary to stress dose of steroids. The outside hospital noted gall bladder thickening but US done at [**Hospital1 18**] on [**11-3**] did not show evidence of acute cholecystitis and abdominal exam is benign so evolving cholangitis was unlikely (see below). . # UTI- Ucx were negative, but initial UA showed UTI. Vanc and unasyn were switched on the cardiology floor to PO bactrim and ampicillin, but the pt spiked fevers and her cellulitis worsened (see below). Thus, she was switched back to vanc and zosyn. . # left leg cellulitis: erythematous and warm upon admission. Vanc and unasyn were switched on the cardiology floor to PO bactrim and ampicillin, but the pt spiked fevers and her cellulitis worsened. Thus, she was switched back to vanc and zosyn. Discharged on Vancomycin/Cefepime for 3 more days to switch to PO Doxycyline for 5 days. . # anemia- hct was 30.0 after being transfused 2 units prbcs after admission. stool guaic in icu was negative. Fe studies were c/w anemia of chronic dz. . CHRONIC ISSUES: . #RA: Continued prednisone taper; in the context of possible infection leflunomide and simponi were held. . #GERD: cont pantoprazole. . TRANSITIONS OF CARE: -Pt had PICC line placed [**2125-11-11**]. -Vanc/Cefepime to continue for 3 more days -Doxycyline to start after IV Abx, complete 5 day course Medications on Admission: Atenolol 25 mg qam and 12.5 mg qpm Plavix 75 mg/day Enalapril 2.5 daily Montelukast 10 mg daily Nifedipine 30 mg daily Niacin 500 [**Hospital1 **] Pantoprazol 40 mg daily Prednisone 5 mg daily Asa 325 mg daily bupropion 300 mg daily Leflunomide 20 mg daily Simponi (golimubab injections) Lasix 20mg PO daily Discharge Medications: 1. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). [**Hospital1 **]:*120 Tablet(s)* Refills:*2* 2. enalapril maleate 2.5 mg Tablet Sig: One (1) Tablet PO once a day. 3. montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. niacin 500 mg Tablet Sig: One (1) Tablet PO twice a day. 5. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 6. prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. bupropion HCl 300 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO once a day. 9. Simponi 50 mg/0.5 mL Pen Injector Sig: One (1) Subcutaneous once a month: Use as directed by your rheumatologist. 10. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day. [**Hospital1 **]:*30 Tablet(s)* Refills:*2* 11. nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Sublingual once a day: 1 Tablet(s) sublingually every five minutes for chest discomfort. Take up to a total of 3 pills. Call 911 if pain persists longer than 15 minutes. 12. pravastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain. 14. vancomycin in D5W 1 gram/200 mL Piggyback Sig: One (1) gram Intravenous Q 12H (Every 12 Hours) for 6 doses: End Date:[**2125-11-15**]. [**Month/Day/Year **]:*6 gram* Refills:*0* 15. leflunomide 20 mg Tablet Sig: One (1) Tablet PO once a day. 16. doxycycline hyclate 100 mg Tablet Sig: One (1) Tablet PO twice a day for 7 days: Please start [**11-16**] End Date: Per your outpatient PCP. [**Name Initial (NameIs) **]:*14 Tablet(s)* Refills:*0* 17. cefepime in D5W 2 gram/50 mL Piggyback Sig: Two (2) grams Intravenous every twelve (12) hours for 6 doses: End Date: [**2125-11-15**]. [**Month/Day/Year **]:*12 grams* Refills:*0* 18. metoprolol succinate 50 mg Tablet Extended Release 24 hr Sig: 1.5 (75 mg) Tablet Extended Release 24 hrs PO once a day. [**Month/Day/Year **]:*45 Tablet Extended Release 24 hr(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Hospital1 6136**] VNA Discharge Diagnosis: Primary diagnosis: Non ST-elevation myocardial infarction Lower extremity cellulitis New onset paroxysmal atrial fibrillation Secondary diagnoses: Coronary artery disease Carotid stenosis Hypertension Hyperlipidemia Rheumatoid arthritis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Ms. [**Known lastname 8529**], It was a privilege to provide care for you here at the [**Hospital 61**] Hospital. You were transferred to [**Hospital1 18**] because you were sick with very low blood pressures. You were treated in the intensive care unit, and were then moved to the cardiology floor because you were found to have blood tests suggestive of a type of heart attack called an NSTEMI (non ST-elevation myocardial infarction). You were treated with a blood thinner (heparin), and also received cardiac catheterization with four stents placed on [**11-8**]. You also continued to receive antibiotics for your left leg skin infection and a urinary tract infection. Your condition has improved and you can be discharged to home. The following changes were made to your medications: NEW: 1. START Metoprolol Succinate 75 mg PO/NG daily 2. START Vancomycin 1000 mg IV Q 12Hrs x3days -[**Date range (1) 8534**] 3. START Cefepime 2gm IV Q12Hrs x3days - [**Date range (1) 8534**] STOPPED: 1. Atenolol 2. Nifedipine Please keep your follow-up appointments as scheduled below. Followup Instructions: Name: [**Last Name (LF) 8535**],[**First Name8 (NamePattern2) 768**] [**Doctor Last Name 162**] Location: ASSOCIATES IN INTERNAL MEDICINE Address: [**State 8536**], [**Apartment Address(1) 8537**], [**Location (un) **],[**Numeric Identifier 8538**] Phone: [**Telephone/Fax (1) 8539**] Appointment: Monday [**2125-11-26**] 11:00am *You have any issues or concerns before your appointment please call the office. Name: [**Last Name (LF) 2912**], [**First Name7 (NamePattern1) 2174**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] Location: [**Hospital1 **] BLDG, [**Apartment Address(1) 8540**] Address: [**Last Name (NamePattern1) 8541**], [**Location (un) **],[**Numeric Identifier 8542**] Phone: [**Telephone/Fax (1) 8543**] Appointment: Thursday [**2125-12-6**] 3:30pm You already have a scheduled appointment with Dr. [**Last Name (STitle) 2912**], please keep that appointment as previously scheduled.

[ "410.71", "054.9", "285.29", "714.81", "599.0", "996.72", "272.4", "682.6", "401.9", "427.31", "E878.1", "428.21", "414.01", "428.0" ]

icd9cm

[ [ [] ] ]

[ "36.07", "00.66", "00.42", "00.48", "88.56", "37.21" ]

icd9pcs

[ [ [] ] ]

16416, 16471

10711, 10979

383, 538

16753, 16753

5435, 5435

18048, 18975

3912, 3944

14287, 16393

16492, 16492

13955, 14264

16936, 18025

7617, 10688

3714, 3791

3959, 3969

16640, 16732

3991, 5416

337, 345

10994, 13610

566, 3040

5451, 7601

16511, 16619

16768, 16912

13785, 13929

13626, 13764

3062, 3691

3807, 3896

4,267

169,329

51354

Discharge summary

report

Admission Date: [**2169-4-3**] Discharge Date: [**2169-4-9**] Date of Birth: [**2118-4-16**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1283**] Chief Complaint: exertional angina Major Surgical or Invasive Procedure: AVR/ repl. asc. aorta [**2169-4-3**] ( 27 mm [**Company 1543**] Mosaic porcine valve/ 26 mm Gelweave graft) History of Present Illness: 50 yo female with known bicuspid AV. Followed by cardiologist for 30 years. Noticed increase in exertional angina recently and routine echos have shown worsening AS. Past Medical History: bicuspid AV AS parox. atrial tachycardia dilated asc. aorta Social History: works as electrician occasional ETOH never used tobacco married, lives with wife no IVDA Family History: non-contrib. Physical Exam: 67" 180# HR 72 RR 12 right 128/56 left 130/88 NAD skn unremarkable EOMI, PERRLA, NC/AT, OP benign neck supple, full ROM, no JVD CTAB RRR 4/6 murmur soft, NT, ND, + BS warm, well-perfused, no edema ; very large varicosities right leg below knee MAE, neuro grossly intact no bruit right carotid, left radiation of murmur Pertinent Results: [**2169-4-6**] 06:25AM BLOOD WBC-9.7 RBC-3.46* Hgb-9.8* Hct-28.5* MCV-82 MCH-28.2 MCHC-34.2 RDW-14.4 Plt Ct-169 [**2169-4-6**] 06:25AM BLOOD Plt Ct-169 [**2169-4-6**] 06:25AM BLOOD Glucose-106* UreaN-19 Creat-0.8 Na-140 K-4.0 Cl-100 HCO3-31 AnGap-13 RADIOLOGY Final Report CHEST (PORTABLE AP) [**2169-4-5**] 11:38 AM CHEST (PORTABLE AP) Reason: r/o ptx [**Hospital 93**] MEDICAL CONDITION: 50 year old man with AVR/Asc Aorta Replacement and ct removal REASON FOR THIS EXAMINATION: r/o ptx INDICATION: Status post AVR and ascending aorta replacement with chest tube removal. Rule out pneumothorax. COMPARISON: [**2169-4-3**]. SINGLE SEMI UPRIGHT AP BEDSIDE CHEST RADIOGRAPH: All invasive lines and tubes have been removed including right-sided chest tube. No evidence of pneumothorax. Lung volumes are low and retrocardiac opacification likely represents atelectasis in this postoperative patient, though consolidation is also a possibility. Moderate left pleural effusion is new. Cardiac, mediastinal, and hilar contours are normal. The patient is status post median sternotomy. IMPRESSION: No evidence of pneumothorax after chest tube removal. Moderate left pleural effusion and retrocardiac opacity (likely atelectasis in this postoperative patient) are new compared to [**2169-4-3**]. The study and the report were reviewed by the staff radiologist. DR. [**First Name (STitle) 18394**] [**Name (STitle) 18395**] DR. [**First Name11 (Name Pattern1) 3347**] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) 5034**] Approved: WED [**2169-4-5**] 3:36 PM Cardiology Report ECHO Study Date of [**2169-4-3**] PATIENT/TEST INFORMATION: Indication: Intraoperative TEE for AVR and ascending aorta replacement Height: (in) 67 Weight (lb): 184 BSA (m2): 1.95 m2 BP (mm Hg): 135/78 HR (bpm): 67 Status: Inpatient Date/Time: [**2169-4-3**] at 10:11 Test: TEE (Complete) Doppler: Limited Doppler and color Doppler Contrast: None Tape Number: 2007AW4-: Test Location: Anesthesia West OR cardiac Technical Quality: Adequate REFERRING DOCTOR: DR. [**First Name (STitle) 412**] [**Last Name (Prefixes) 413**] MEASUREMENTS: Left Ventricle - Septal Wall Thickness: *1.6 cm (nl 0.6 - 1.1 cm) Left Ventricle - Diastolic Dimension: 4.6 cm (nl <= 5.6 cm) Left Ventricle - Ejection Fraction: 55% (nl >=55%) Left Ventricle - Peak Resting LVOT gradient: 8 mm Hg (nl <= 10 mm Hg) Aorta - Valve Level: *3.7 cm (nl <= 3.6 cm) Aorta - Ascending: *3.9 cm (nl <= 3.4 cm) Aortic Valve - Peak Velocity: *4.0 m/sec (nl <= 2.0 m/sec) Aortic Valve - Peak Gradient: 65 mm Hg Aortic Valve - Mean Gradient: 44 mm Hg Aortic Valve - Valve Area: *1.1 cm2 (nl >= 3.0 cm2) Mitral Valve - E Wave: 0.9 m/sec Mitral Valve - A Wave: 0.7 m/sec Mitral Valve - E/A Ratio: 1.29 Mitral Valve - E Wave Deceleration Time: 142 msec INTERPRETATION: Findings: RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is seen in the RA and extending into the RV. No ASD or PFO by 2D, color Doppler or saline contrast with maneuvers. LEFT VENTRICLE: Wall thickness and cavity dimensions were obtained from 2D images. Moderate symmetric LVH. Normal LV cavity size. Normal regional LV systolic function. Overall normal LVEF (>55%). No resting LVOT gradient. RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Mildly dilated aortic sinus. Focal calcifications in aortic root. Mildly dilated ascending aorta. Normal descending aorta diameter. AORTIC VALVE: Bicuspid aortic valve. Severely thickened/deformed aortic valve leaflets. Moderate AS (AoVA 0.8-1.19cm2). Mild to moderate ([**1-17**]+) AR. MITRAL VALVE: Normal mitral valve leaflets. No MR. TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with physiologic PR. PERICARDIUM: Small pericardial effusion. GENERAL COMMENTS: A TEE was performed in the location listed above. I certify I was present in compliance with HCFA regulations. No TEE related complications. The patient was under general anesthesia throughout the procedure. The patient appears to be in sinus rhythm. Results were personally Conclusions: Prebypass 1.No atrial septal defect or patent foramen ovale is seen by 2D, color Doppler or saline contrast with maneuvers. 2. There is moderate symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is normal (LVEF>55%). 3.Right ventricular chamber size and free wall motion are normal. 4.The aortic root is mildly dilated at the sinus level. The ascending aorta is mildly dilated. 5.The aortic valve is bicuspid. The aortic valve leaflets are severely thickened/deformed. There is moderate aortic valve stenosis (area 0.8-1.19cm2) Mild to moderate ([**1-17**]+) aortic regurgitation is seen. 6. The mitral valve leaflets are structurally normal. No mitral regurgitation is seen. 7. There is a small pericardial effusion. Post Bypass 1. Patient is in sinus rhythm and receiving an infusion of phenylephrine. 2. Left ventricular systolic function is mildly depressed globally. 3. Right ventricular systolic function is unchanged. 4. Bioprosthetic valve seen in the aortic position. Leaflets move well and the valve appears well seated. No aortic insufficiency seen. Mean gradient across the aortic valve is 12 mm Hg. 5. Graft material seen in the ascending aorta. Electronically signed by [**Name6 (MD) 1509**] [**Name8 (MD) 1510**], MD on [**2169-4-3**] 16:45. [**Location (un) **] PHYSICIAN: ([**Numeric Identifier 106498**]) Brief Hospital Course: Admitted [**4-3**] and underwent AVR/repl. asc. aorta with Dr. [**Last Name (STitle) 1290**]. Transferred to the CSRU in stable condition on titrated phenylephrine and propofol drips. Extubated that evening. Chest tubes removed without incident. Transferred to the floor on POD #2 to begin increasing his activity level. He had fevers of unknown source post op, all his workup was negative. Has hiostroy of these. He continued to do well postoperatively. He had some atrial fibrillation which converted to normal sinus with beta blockade. He was ready for discharge to home on [**4-9**]. Medications on Admission: atenolol 25 mg daily ASA 162 mg daily Vit. E Co-Q 10 Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) for 1 months. Disp:*60 Capsule(s)* Refills:*0* 2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 1 months. Disp:*30 Tablet(s)* Refills:*0* 3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 4. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q2H (every 2 hours) as needed. Disp:*40 Tablet(s)* Refills:*0* 5. Captopril 12.5 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). Disp:*180 Tablet(s)* Refills:*0* 6. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 7. Metoprolol Tartrate 25 mg Tablet Sig: Four (4) Tablet PO TID (3 times a day). Disp:*360 Tablet(s)* Refills:*0* 8. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 5 days. Disp:*5 Tablet(s)* Refills:*0* 9. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO DAILY (Daily) for 5 days. Disp:*5 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: AVR/repl. asc. aorta [**2169-4-3**] asc. aortic aneurysm aortic stenosis paroxysmal atrial tachycardia Discharge Condition: stable Discharge Instructions: may shower over incisons and pat dry no driving for one month no lotions, creams or powders on any incision 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 [**1-17**] weeks see Dr. [**First Name (STitle) **] in [**2-18**] weeks see Dr. [**Last Name (STitle) 1290**] in 4 weeks [**Telephone/Fax (1) 170**]

[ "441.2", "427.0", "998.89", "746.4", "401.9", "780.6" ]

icd9cm

[ [ [] ] ]

[ "35.21", "99.05", "88.72", "99.07", "38.45", "39.61", "99.04" ]

icd9pcs

[ [ [] ] ]

8713, 8771

6866, 7457

337, 448

8918, 8927

1225, 1585

9186, 9375

848, 862

7560, 8690

1622, 1684

8792, 8897

7483, 7537

8951, 9163

2881, 6769

877, 1206

280, 299

1713, 2855

476, 643

6804, 6843

665, 726

742, 832

71,093

161,963

29553

Discharge summary

report

Admission Date: [**2201-2-25**] Discharge Date: [**2201-2-27**] Date of Birth: [**2147-7-29**] Sex: M Service: MEDICINE Allergies: Haldol Attending:[**First Name3 (LF) 562**] Chief Complaint: nausea, vomiting, diarrhea, dizziness Major Surgical or Invasive Procedure: Placement of a peripherally inserted central catheter Placement of a femoral line History of Present Illness: Mr. [**Known lastname **] is a 53 year-old man with a history of HIV, Hep C, and extensive substance abuse who presented to the ED with nausea, vomiting, diarrhea, and dizziness. He reports that for the past month he has been dehydrated from working out and not drinking enough fluids. Two days ago he ate lunch at 12:30pm, including a strawberry Ensure and a brownie with M&Ms, and began feeling nauseated and vomiting by 2:30pm. The emesis was non-bloodly, non-bilious. Shortly after this, he began having diarrhea, which he describes as pink in color. He denies dark red or black bowel movements. He does report having chills, diaphoresis, palpitations, and cramps in his legs. He also felt mildly short of breath. At around 6:30pm, he got up from bed to see if he could drink some water. He became dizzy and fell down. His right forehead lightly hit the door handle, but he denies losing consciousness or bleeding. At this point, he called EMS who took him to the [**Hospital1 18**] ED. . In the ED, his vitals were 98.7, 100/64, 14, and 100% on non-rebreather. Patient's BP dropped to 60/P without response to 6L NS and required Levophed via femoral line. The patient was given vancomycin and Zosyn and admitted to the MICU for monitoring. . Past Medical History: - Severe peanut allergy- nausea, vomiting, and diarrhea - Polysubstance dependence (EtOH, cocaine, and heroine, morphine, methadone) -- no use in > 35 days. Currently uses suboxone bought on the streets. - HIV - recent CD4 [**2201-1-16**] 581. - Left lateral tibial plateau fracture [**9-17**] - Folliculitis of face. - Cellulitis of legs. - Hepatitis C - followed by Dr. [**Last Name (STitle) **]. According to patient, had ~3 months of IFN/RBV treament in [**2198**]/[**2199**], but stopped when his CD4 count began to decline (HCV genotype 1a, stage III fibrosis as of [**2199**]). - Question of dyspepsia. - History of weight loss. - Mesenteric lymphadenopathy. - Splenomegaly. - Genital warts. - Polyps on colonoscopy. - Peripheral neuropathy / Foot drop. Social History: Mr. [**Known lastname **] is currently on disability. He smokes [**1-10**] pack of cigarettes per day. He lives by himself in an apartment [**Street Address(1) 70872**]. in [**Location (un) 86**]. He denies current sexual activity. He has an extensive substance abuse history (see PMH above). He is scheduled for an intake interview with Dr. [**Last Name (STitle) 49834**] at [**Location (un) 70873**] House/[**Hospital1 2177**], so he can get involved into a Suboxone treatment program at [**Hospital1 2177**]. He has an appointment with Dr. [**Last Name (STitle) 49834**] on [**2201-3-6**] at 9:45am. Family History: History of colon cancer in his mother and two grandmothers. [**Name (NI) **] also notes an uncle with liver failure secondary to alcoholic liver disease. 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 Rectal guaiac positive, brown stool (per ED) Pertinent Results: [**2201-2-24**] 09:00PM PLT COUNT-243 [**2201-2-24**] 09:00PM NEUTS-92.6* LYMPHS-3.0* MONOS-3.8 EOS-0.2 BASOS-0.3 [**2201-2-24**] 09:00PM WBC-13.5*# RBC-4.43* HGB-14.0 HCT-41.3 MCV-93 MCH-31.5 MCHC-33.8 RDW-13.3 [**2201-2-24**] 09:00PM CORTISOL-56.6* [**2201-2-24**] 09:00PM ALT(SGPT)-73* AST(SGOT)-75* ALK PHOS-107 TOT BILI-0.5 [**2201-2-24**] 09:00PM GLUCOSE-117* UREA N-23* CREAT-1.6* SODIUM-140 POTASSIUM-4.5 CHLORIDE-105 TOTAL CO2-26 ANION GAP-14 [**2201-2-24**] 11:30PM URINE BLOOD-SM NITRITE-NEG PROTEIN-75 GLUCOSE-TR KETONE-TR BILIRUBIN-SM UROBILNGN-NEG PH-5.0 LEUK-NEG [**2201-2-25**] 12:25PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG [**2201-2-27**] 06:41AM BLOOD WBC-3.3* RBC-3.30* Hgb-10.2* Hct-30.2* MCV-92 MCH-31.0 MCHC-33.9 RDW-13.0 Plt Ct-167 [**2201-2-25**] 08:16AM BLOOD WBC-6.3 Lymph-13* Abs [**Last Name (un) **]-819 CD3%-83 Abs CD3-678 CD4%-28 Abs CD4-227* CD8%-53 Abs CD8-431 CD4/CD8-0.5* [**2201-2-27**] 06:41AM BLOOD Glucose-88 UreaN-11 Creat-0.8 Na-142 K-3.6 Cl-108 HCO3-24 AnGap-14 [**2201-2-25**] 08:16AM BLOOD ALT-49* AST-50* LD(LDH)-125 AlkPhos-70 TotBili-0.5 DirBili-0.2 IndBili-0.3 [**2201-2-27**] 06:41AM BLOOD Calcium-8.6 Phos-4.1 Mg-1.4* . Microbiology [**2201-2-27**] Stool Cx for Cryptosporidium, Cyclospora, Microsporidium, Yersinia, Giardia, C. dif, E. coli -- Pending at time of discharge. [**2201-2-25**] Stool Cx: NO OVA AND PARASITES SEEN. (This test does not reliably detect Cryptosporidium, Cyclospora or Microsporidium. While most cases of Giardia are detected by routine O+P, the Giardia antigen test may enhance detection when organisms are rare.) CMV Viral Load (Final [**2201-2-27**]): CMV DNA not detected. (Performed by PCR. Detection Range: 600 - 100,000 copies/ml. FOR RESEARCH USE ONLY. NOT FOR USE IN DIAGNOSTIC PROCEDURES. This test has been validated by the Microbiology laboratory at [**Hospital1 18**].) [**2201-2-24**] Urine Cx - no growth [**2201-2-24**] Blood Cx - no growth x 48 hours . EKG - normal sinus rhythm, WNL, unchanged from previous study . Echo - The left atrium is mildly dilated. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF>55%). Tissue Doppler imaging suggests a normal left ventricular filling pressure (PCWP<12mmHg). Right ventricular chamber size and free wall motion are normal. The aortic root is mildly dilated at the sinus level. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. . CXR ([**2-24**]) - IMPRESSION: No acute cardiopulmonary abnormality. . CT Abd - Multiple enlarged mesenteric lymph nodes, with a "[**Doctor First Name 9189**] mesentery appearance," as seen on multiple prior studies, but slightly more prominent compared to the most recent study. No other acute abdominal abnormalities. . [**2201-2-25**] Chest xray: IMPRESSION: 1. Left PICC tip projects over the mid SVC. No pneumothorax. 2. New right basilar atelectasis compared to radiograph obtained earlier today. Brief Hospital Course: Mr. [**Known lastname **] is a 53 year old man with HIV and Hepatitis C who presented with an acute onset of diarrhea, vomiting, and hypotension. He required pressor support for hypotension and a brief stay in the MICU. . # DIARRHEA / VOMITING: On admission multiple etiologies were thought to be possibly responsible for Mr. [**Known lastname 50840**] symptoms. The most likely possibilities included an allergic reaction to peanuts or infection. He was known to have a history of nausea and vomiting with peanuts and had possible exposure to peanuts before his symptoms started. Several stool studies were ordered to look for various pathogens. However, not enough stool could be collected because he stopped having bowel mom[**Name (NI) 70874**]. Of the studies that came back, the ova and parasite exam was negative. He had briefly been placed on vancomycin, metronidazole and ceftriaxone for empiric coverage. CMV viral load was undetectable. Blood and urine cultures were negative at the time of discharge. Because peanut allergy was in the differential, an appointment was made for the patient to see an allergist within 2-3 weeks of discharge. He was given a prescription for EpiPen to take home with him. . # HYPOTENSION: On admission he was hypotensive. The hypotension did not immediately resolve with aggressive fluid repletion. It required brief pressor support. His blood pressure was stable by the time he was transferred to the floor. It remained stable through time of discharge. Given that it did not immediately resolve with fluids, this was thought to support the theory that his symptoms may have been related to an allergic response. . # ANEMIA: Mr. [**Known lastname **] presented with a decreased hematocrit. He had received several liters of fluid. His hematocrit was 30.9 on discharge, slightly down from his baeline. There was no evidence of bleeding during the hospitalization. He was guiac positive on admission. . # SUBSTANCE DEPENDENCE: Mr. [**Known lastname **] had a long history of polysubstance abuse. In the MICU he was verbally abusive and agitated. He reported using suboxone daily. He was scheduled for an intake at a [**Hospital 12695**] clinic. This was confirmed. Given his significant agitation and symptoms of withdrawal he was continued on suboxone. He was not given a prescription at the time of discharge. He was given a nicotine patch on the floor, but did not want a prescription. He met with social work. . # DEPRESSION: Home sertraline was continued throughout the hospitalization. . # ACUTE RENAL FAILURE: On admission Mr. [**Known lastname 50840**] creatinine was 1.6. After IV fluids, it decreased to 0.8 at the time of discharge. Treatment was IV hydration. . # Hepatitis C: LFTs mildly elevated on admission (ALT 73, AST 75) and decreased slightly before discharge (ALT 49 AST 50). . # HIV: Mr. [**Known lastname **] had a recent drop in his CD4 count. However, his CD4% is 28%. He reported adherence to his medication regimen at home. His home regimen was continued during this admission. . Medications on Admission: 1. Atripla, 1 tablet daily (Efavirenz-Emtricitabin-Tenofovir 600 mg-200 mg-300 mg) 2. Zoloft (Sertraline) 100 mg tablet 1.5 tablets daily Discharge Medications: 1. Sertraline 50 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 2. Efavirenz 600 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Emtricitabine 200 mg Capsule Sig: One (1) Capsule PO Q24H (every 24 hours). 4. Tenofovir Disoproxil Fumarate 300 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. EpiPen 0.3 mg/0.3 mL Pen Injector Sig: One (1) injection Intramuscular as needed as needed for allergic reaction. Disp:*1 pen* Refills:*3* Discharge Disposition: Home Discharge Diagnosis: Primary: Acute gastrointestinal illness, possibly from food poisoning or peanut allergy . Secondary: HIV Hepatitis C Discharge Condition: Mental Status:Clear and coherent Level of Consciousness:Alert and interactive Activity Status:Ambulatory - Independent Discharge Instructions: You were admitted to the hospital because of low blood pressure and dehydration associated with vomiting and diarrhea. You were treated with IV fluids and a medicine to increase your blood pressure. You were also given antibiotics because we thought an infection might be causing your symptoms. We did tests of your blood, urine, and stool and found no definite source of infection. We do not know for sure what caused your symptoms. They may have been from an infection or from your peanut allergy. . Your symptoms improved, and you were able to eat regular food and to walk around without need for support. . After you are discharged from the hospital, please follow up with the doctor appointments mentioned below. . We have provided you with an Epi-Pen in case you have a severe reaction to the peanuts. . If you develop any of the symptoms listed below or any other symptoms that are concerning to you, please call your primary care doctor or go to your local emergency room. Followup Instructions: Please follow up with your primary care doctor, Dr. [**Last Name (STitle) **], within 1 week of leaving the hospital. You can call [**Telephone/Fax (1) 2776**] to make an appointment with him. . In addition, we have made an appointment for you at the [**Hospital 9039**] Clinic at [**Location (un) 8170**] ([**Location (un) 895**], [**Apartment Address(1) 70875**]) with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 9313**]. The appointment is on [**3-12**] at 1pm. Please call the clinic at [**Telephone/Fax (1) 9316**] if you have any questions or need to reschedule. . Please keep you appointment with Dr. [**Last Name (STitle) 49834**] on [**2201-3-6**] at 9:45am.

[ "736.79", "355.8", "304.00", "558.3", "305.1", "584.9", "V15.01", "785.6", "005.9", "V08", "311", "070.54" ]

icd9cm

[ [ [] ] ]

[ "38.93" ]

icd9pcs

[ [ [] ] ]

10794, 10800

7090, 10141

304, 387

10960, 10960

3799, 7067

12114, 12809

3098, 3253

10330, 10771

10821, 10939

10167, 10307

11105, 12091

3268, 3780

227, 266

415, 1673

10974, 11081

1695, 2457

2473, 3082

74,433

136,665

47989

Discharge summary

report

Admission Date: [**2175-8-30**] Discharge Date: [**2175-9-9**] Date of Birth: [**2107-1-24**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1505**] Chief Complaint: Atypical chest pain Major Surgical or Invasive Procedure: [**2175-8-30**] Aortic Valve Replacement(27mm [**Company 1543**] Mosaic Porcine Valve) and Single Vessel Coronary Artery Bypass Grafting with vein graft to obtuse marginal branch. History of Present Illness: This is a 68 year old male with history of coronary artery disease s/p LAD stent in [**2165**] and followed for aortic insufficiency with serial echocardiograms for the last 10 years. He has felt well over past year with intermittent episodes of atypical chest discomfort. Most recent echo revealed worsening of his aortic insufficiency (now severe). Cardiac cath revealed some coronary disease along with dilated aortic root. He has been referred for surgical evaluation. Past Medical History: - Bicuspid Aortic Valve with Severe Aortic Insufficiency - Dilated Aortic Root - Coronary artery disease s/p LAD stent [**2165**] - History of Supraventricular tachycardia s/p Ablation - History of Non-Hodgkins Lymphoma, currently in remission for the past 14years, no history of radiation or chemotherapy - Benign prosatic hypertrophy - Gastroesophageal reflux disease - Sleep Apnea(per wife), no official sleep study Social History: Lives with: Wife Occupation: Retired Tobacco: Denies ETOH: Social Family History: Denies premature coronary artery disease Physical Exam: Preop Exam: General: WDWN male in no acute distress Skin: Dry [x] intact [x] HEENT: NCAT [x] PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] JVD - none Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur - [**4-18**] diastolic murmur best heard at the RUSB Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] - small ventral hernia noted Extremities: Warm [x], well-perfused [x] Edema - none Varicosities: None [x] 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 Carotid Bruit Right: none Left: none Pertinent Results: [**2175-8-30**] Intraop TEE PREBYPASS The left atrium is mildly dilated. The left atrium is elongated. No spontaneous echo contrast is seen in the body of the left atrium or left atrial appendage. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular systolic function is normal with normal free wall contractility. The aortic root is moderately dilated at the sinus level. The ascending aorta is moderately dilated. There are simple atheroma in the aortic arch. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion. There is no aortic valve stenosis. Severe (4+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. There is no pericardial effusion. POSTBYPASS The patient is A-paced on a phenylephrine infusion. The new bioprosthetic valve is well-seated without perivalvular leaks. The mean gradient through the new valve is 4 mmHg. There is no aortic regurgitation. Trivial mitral regurgitation remains. Left ventricular function is preserved. The thoracic aorta is intact. Brief Hospital Course: Mr. [**Known lastname 101249**] was admitted and underwent aortic valve replacement and coronary artery bypass grafting surgery by Dr. [**Last Name (STitle) **]. For surgical details, please see operative note. Following the operation, he was brought to the CVICU for invasive monitoring. Within 24 hours, he awoke neurologically intact and was extubated without incident. He maintained stable hemodynamics and transferred to the step down unit on postoperative day one. On postoperative day two, he experienced atrial fibrillation. Amiodarone was initiated per protocol and beta blockade was advanced for rate control. He had no further episodes of Afib while on amiodarone drip and was converted to oral amiodarone. He received 2 doses of coumadin whcih was stopped due to resolution of atrial fibrillation. Mr. [**Known lastname 101249**] did develop bilateral upper extremity phlebitic areas from amiodarone infusions and was started on po keflex with gradual improvement but not full resolution at the time of discharge. Mr. [**Known lastname 101249**] hospital course was prolonged due to a postoperative ileus. He was kept NPO for several days while intravenous fluids were maintained. He was followed closely with serial physical examinations and KUB films. Ileus was extremely slow to resolve and general surgery was consulted with no additional recommendations other than present conservative measures. Ileus resloved on POD#9. At the time of discharge he was tolerating po's, passing stool and flatus. Incisional pain was controlled with tylenol. He was cleared for discharge to home with VNA services and all instructions given and appointments advised. Medications on Admission: Aspirin 81mg daily, Pantoprazole 40mg daily, Atenolol 25mg daily, Flomax 0.4mg daily, Proscar ?mg daily, HCTZ ?mg daily Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for pain or fever . 2. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) as needed for constipation. 3. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 4. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO HS (at bedtime). 5. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 7. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO twice a day. 8. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). Disp:*30 Tablet, Chewable(s)* Refills:*2* 9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 10. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:*90 Tablet(s)* Refills:*2* 11. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily): 2 tablets for 7 days then 1 tablet daily. Disp:*75 Tablet(s)* Refills:*2* 12. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q8H (every 8 hours) for 7 days. Disp:*21 Capsule(s)* Refills:*0* 13. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day for 10 days. Disp:*10 Tablet(s)* Refills:*0* 14. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: Two (2) Tab Sust.Rel. Particle/Crystal PO once a day for 10 days. Disp:*20 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Company 1519**] Discharge Diagnosis: - s/p Aortic Valve Replacement and Coronary Artery Bypass - Postoperative Ileus - Postoperative Atrial Fibrillation - Bicuspid Aortic Valve with Severe Aortic Insufficiency - Dilated Aortic Root - Coronary artery disease s/p LAD stent [**2165**] - History of Supraventricular tachycardia s/p Ablation - History of Non-Hodgkins Lymphoma, currently in remission for the past 14years, no history of radiation or chemotherapy - Benign prosatic hypertrophy - Gastroesophageal reflux disease Discharge Condition: Alert and oriented x3 nonfocal Ambulating with steady gait Incisional pain managed with tylenol Incisions: Sternal - healing well, no erythema or drainage Leg Left - healing well, no erythema or drainage. Trace Edema Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month until follow up with surgeon No lifting more than 10 pounds for 10 weeks Warm packs to both arms and elevate left arm on pillows while sitting or in bed. Please call with any questions or concerns [**Telephone/Fax (1) 170**] **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Followup Instructions: The follwoing appointments have been made for you: Dr. [**Last Name (STitle) **] [**2175-10-5**] at 1:00 PM - office # [**Telephone/Fax (1) 170**] Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 8421**] [**2175-10-17**] at 2:30pm Dr. [**First Name8 (NamePattern2) 3075**] [**Last Name (NamePattern1) 11270**] in [**2-15**] weeks, call for appt Completed by:[**2175-9-9**]

[ "202.80", "780.57", "427.31", "451.82", "560.1", "997.4", "E878.2", "E942.0", "999.2", "414.01", "997.1", "V45.82", "746.4", "600.00", "530.81" ]

icd9cm

[ [ [] ] ]

[ "35.21", "36.15", "39.61" ]

icd9pcs

[ [ [] ] ]

6908, 6957

3538, 5206

341, 523

7487, 7706

2320, 3515

8541, 8933

1568, 1611

5377, 6885

6978, 7466

5232, 5354

7730, 8518

1626, 2301

281, 303

551, 1026

1048, 1469

1485, 1552

24,099

109,304

11701

Discharge summary

report

Admission Date: [**2194-6-9**] Discharge Date: [**2194-6-19**] Date of Birth: [**2125-1-13**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2297**] Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: Fiberscopic intubation Tracheostomy [**2194-6-17**] Post-pyloric dobhoff placement [**2194-6-18**] PICC line placement [**2194-6-18**] History of Present Illness: 69 yo male with h/o asthma, OSA, pulmonary HTN, HTN, and DM who woke up yesterday morning feeling like he was getting a cold. He says he felt similar to how he did prior to his last admission. He has been feeling chills, tired, and short of breath. He has had one day of non-productive cough. He has not had any sick contacts. [**Name (NI) **] has been taking all of his medications and tried to use his inhalers with no improvement in his symptoms. He uses his oxygen intermittently during the day but does use his bipap at night. According to his wife he has been more disoriented for the last 2 days. He states he has not had any increased edema recently but his wife says he seems to be more swollen to her. He denies orthopnea, PND, no increased salt intake recently. He has not had any recent chest pain, nausea, vomiting, or abdominal pain. He has not had any urinary pain, frequency or urgency. . In the ED he was found to have an O2sat in the 60s. He was placed on a NRB and had intermittant hypoxia to the 70s, then improved to the 90s. He was treated with Combivent nebulizer, Solumedrol, Lasix 20mg IV X2, and Levofloxacin 750mg IV X1. . He was recently admitted to the [**Hospital1 756**] ICU for respiratory failure secondary to presumed viral pneumonia. He has been seen frequently in pulmonary clinic and has had an increasing O2 requirement. Past Medical History: Past Medical History: 1. Asthma, pulmonary HTN, and severe OSA at home on 3L at baseline and 4L with exertion, according to him his home sat is 92-95%, previously trached. 2. HTN 3. DM 4. Hyperlipidemia 5. PUD 6. CHF - diastolic heart failure (documented on Echo in [**2192**]) Social History: Social history: Lives with his wife, used to work in Demolition, Never smoked, no EtOh, no IVDU Family History: Family history: Father had an MI at 49, Mother with MI at 44, Brother with MI at 75 Physical Exam: VS: Temp 98.0, Pulse 90, BP 139/75, RR 29, 89% on 50% FM Gen: alert, oriented, cooperative male in mild respiratory distress, not using accessory muscles HEENT: MMM, OP clear, PERRL Neck: JVD at 5cm above sternoclavicular notch, no lymphadenopathy Lungs: Crackles bilaterally at the bases, no wheezing CV: decreased cardiac sounds, nl S1S2, no murmer Abd: obese, non-tender, non-distended, positive BS Ext: 2+ edema on left, 1+ edema on right Neuro: grossly intact Pertinent Results: Imaging: CXR [**6-16**] Mild interstitial edema and moderate cardiomegaly are stable. Lung volumes remain quite low, so that focal opacification at the right lung base could be either atelectasis or pneumonia. Region of right juxtahilar previously questioned as pneumonia on [**6-14**] is no longer present and may have been fissural pleural effusion, since at least a small right pleural effusion is present. ET tube is in standard placement and a nasogastric tube passes into the stomach and out of view. No pneumothorax. . Echo [**2194-6-10**]: The left atrium is elongated. There is severe symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Overall left ventricular systolic function is normal (LVEF>55%). Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). The ascending aorta is moderately dilated. The aortic valve leaflets are mildly thickened. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. There is no systolic anterior motion of the mitral valve leaflets. Trivial mitral regurgitation is seen. There is borderline pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Severe symmetric left ventricular hypertrophy with preserved left ventricular function and suggestion of increased left ventricular filling pressures. Inability to fully visualize right ventricle due to suboptimal image quality. . [**2194-6-18**]: CHEST, ONE VIEW: Comparison with [**2194-6-17**], 15:50 p.m. New right PICC is seen looping in the axillary vein and terminating at approximately the junction of the axillary and subclavian veins. No pneumothorax. Tracheostomy tube and nasogastric tube remain in place. Low lung volumes and an improving appearance of pulmonary vascular congestion. Left lower lobe atelectasis remains. Please note that the left extreme costophrenic angle was excluded from this study. . [**2194-6-12**]: [**2194-6-12**] 3:09 pm SPUTUM Source: Endotracheal. **FINAL REPORT [**2194-6-14**]** GRAM STAIN (Final [**2194-6-12**]): >25 PMNs and <10 epithelial cells/100X field. 4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS, CHAINS, AND CLUSTERS. RESPIRATORY CULTURE (Final [**2194-6-14**]): OROPHARYNGEAL FLORA ABSENT. STAPH AUREUS COAG +. MODERATE GROWTH. OF TWO COLONIAL MORPHOLOGIES. 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. 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 PENICILLIN------------ =>0.5 R RIFAMPIN-------------- <=0.5 S TETRACYCLINE---------- <=1 S VANCOMYCIN------------ <=1 S . [**2194-6-12**] 11:27 pm BLOOD CULTURE Source: Line-a line. **FINAL REPORT [**2194-6-18**]** AEROBIC BOTTLE (Final [**2194-6-18**]): NO GROWTH. ANAEROBIC BOTTLE (Final [**2194-6-18**]): NO GROWTH. . [**2194-6-17**] 6:30 am SPUTUM Source: Endotracheal. **FINAL REPORT [**2194-6-19**]** GRAM STAIN (Final [**2194-6-19**]): >25 PMNs and <10 epithelial cells/100X field. 3+ (5-10 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS, CHAINS, AND CLUSTERS. SMEAR REVIEWED; RESULTS CONFIRMED. RESPIRATORY CULTURE (Final [**2194-6-19**]): OROPHARYNGEAL FLORA ABSENT. 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. 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 PENICILLIN------------ =>0.5 R RIFAMPIN-------------- <=0.5 S TETRACYCLINE---------- <=1 S VANCOMYCIN------------ <=1 S . [**2193-6-19**]: CBC: WBC 6.0, Hct 44.3, plt 189 Chem 10: Na 141, K 2.4, Cl 93, CO2 41, BUn 40, creat 0.9. Ca 8.6, Mg 2.0, phos 3.3 Brief Hospital Course: # Respiratory failure - hypercarbic/hypoxemic, appeared to be [**2-21**] CHF by evidence of volume overload on CXR, also contributed by his OSA and pulmonary HTN. Was initially treated with nebs and steroids, but with little improvement. He was intubated urgently by fibroscope (difficult airway) for hypoxic/hypercarbic respiratory failure. In the interim, was diuresed with IV lasix. He began spiking temperatures on [**2194-6-12**] and there was concern that this may be a vent-associated PNA. He was started empirically on Vanc and Zosyn for broad coverage. He was then discovered to have MRSA PNA in his sputum, so zosyn was discontinued and vancomycin was continued for a planned 2-week course (end date [**2194-6-26**]). Given his diastolic CHF, OSA, pulmonary HTN, ongoing PNA, he was difficult to wean from the ventilator and plans were made for a tracheostomy. The patient was transferred to the [**Hospital Ward Name **] MICU and underwent a trach by IP on [**2194-6-17**] without any complications. He also received a post-pyloric Dobhoff and a PICC line for long-term antibiotics on [**2194-6-18**]. The vent setting was weaned off to [**10-29**] (ABG 7.46/61/156) which can be further weaned to a eventual trach mask at the rehab. Of note, his baseline PCO2 is in 60-70s. . # CHF - patient was diuresed while in-house and responded well to 80 mg IV bid of lasix, with goal I/O even to -500 cc at this point. His TTE during this admission confirmed diastolic CHF, with a normal EF>55% and elevvated PCWP. He was ruled out for an AMI during this admission given his multiple RF and was continued on ASA, BB, Ace-I. Pt was initially aggressively diuresed and then required lasix 200mg [**Hospital1 **] to maintain even I/O daily. He was also started on standing KCL for hypokalemia from diuresis. His K needs to be monitored and make any KCL changes if needed to avoid hyper/hypokalemia. . # DM - on [**Hospital1 9889**] and Glucotrol as an outpatient, was maintained on a RISS while in-house for tighter control. Recommend continuing this until patient at goal with his tube feeds, then can possibly resume oral agents. . # Hyperlipidemia - Continue on Lipitor . # Hypertension - continued on b-blocker, ACE-I. BB was titrated up for better BP control as pulse allowed. CCB was held during his course, but with BB increase, his BP was well controlled. If he were to become more hypertensive, consider adding CCB. # FEN - tube feeds via NGT initially and then post-pyloric Dobhoff was placed after tracheostomy. Tube feeding goal was started per nutrition recs. Pt will need speech and swallow evaluation at the [**Hospital1 **]. Please adjust KCL/prn to avoid hypo/hyperkalemia while getting lasix. . # PPx - PPI, bowel regimen, SC Heparin then can d/c heparin until fully ambulatory at the rehab. . Full code - per discussion with patient . Communication with wife - [**Name (NI) 4115**] - [**Telephone/Fax (1) 37036**] Medications on Admission: Albuterol Lisinopril 40mg 1-2 times per day Nifedipine 90mg daily Lovastatin 20mg QHS HCTZ 25mg daily Toprol XL 100mg Daily (sometimes takes [**Hospital1 **] per his wife) [**Name (NI) 9889**] 8mg daily Aspirin 81mg Daily Discharge Medications: 1. Lovastatin 20 mg Tablet Sustained Release 24 hr [**Name (NI) **]: One (1) Tablet Sustained Release 24 hr PO at bedtime. 2. Senna 8.6 mg Tablet [**Name (NI) **]: One (1) Tablet PO BID (2 times a day) as needed. 3. Albuterol 90 mcg/Actuation Aerosol [**Name (NI) **]: Four (4) Puff Inhalation every 4-6 hours as needed for shortness of breath or wheezing. 4. Ipratropium Bromide 17 mcg/Actuation Aerosol [**Name (NI) **]: Four (4) Puff Inhalation every six (6) hours. 5. Metoprolol Tartrate 50 mg Tablet [**Name (NI) **]: One (1) Tablet PO TID (3 times a day). 6. Heparin (Porcine) 5,000 unit/mL Solution [**Name (NI) **]: 5000 (5000) units Injection TID (3 times a day): until fully ambulatory. 7. Docusate Sodium 50 mg/5 mL Liquid [**Name (NI) **]: One Hundred (100) mg PO BID (2 times a day). 8. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily). 9. Lisinopril 20 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO DAILY (Daily). 10. Furosemide 80 mg Tablet [**Last Name (STitle) **]: 2.5 Tablets PO BID (2 times a day). 11. Potassium Chloride 10 mEq Capsule, Sustained Release [**Last Name (STitle) **]: Four (4) Capsule, Sustained Release PO DAILY (Daily). 12. Aspirin 81 mg Tablet, Chewable [**Last Name (STitle) **]: One (1) Tablet, Chewable PO DAILY (Daily). 13. Fentanyl 25 mcg/hr Patch 72 hr [**Last Name (STitle) **]: One (1) Patch 72 hr Transdermal Q72H (every 72 hours): while still on ventilation. 14. Lorazepam 0.5 mg Tablet [**Last Name (STitle) **]: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed for aggitation: while still on ventilation. 15. Vancomycin in Dextrose 1 g/200 mL Piggyback [**Last Name (STitle) **]: One (1) gm Intravenous Q 12H (Every 12 Hours) for 7 days: until [**2194-6-26**]. 16. Regular Insulin Per sliding scale attached Discharge Disposition: Extended Care Facility: [**Hospital1 **] [**Location (un) 686**] Discharge Diagnosis: Primary diagnoses: MRSA pneumonia CHF exacerbation Pulmonary hypertension obstructive sleep apnea . Secondary diagnoses: Diabetes mellitus Hypertension Hyperlipidemia Discharge Condition: Stable. Vent setting PS 10/5 Discharge Instructions: Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs. Adhere to 2 gm sodium diet . Please call your doctor [**First Name (Titles) **] [**Last Name (Titles) **] if you develop any chest pain, shortness of breath, fevers, chills, diarrhea, or any other worrisome symptoms. . Take medications as instructed and keep your follow-up appointments. Followup Instructions: Provider: [**Name10 (NameIs) 1571**] BREATHING TESTS Phone:[**Telephone/Fax (1) 612**] Date/Time:[**2194-6-27**] 10:50 Provider: [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] & DR. [**Last Name (STitle) **] Phone:[**Telephone/Fax (1) 612**] Date/Time:[**2194-6-27**] 11:10 Provider: [**Name10 (NameIs) 1570**],[**Name11 (NameIs) 2162**] [**Name12 (NameIs) 1570**] INTEPRETATION BILLING Date/Time:[**2194-6-27**] 11:10

[ "250.00", "518.84", "272.4", "V42.2", "799.02", "493.90", "327.23", "416.8", "428.30", "276.3", "V09.0", "482.41", "518.0", "428.0" ]

icd9cm

[ [ [] ] ]

[ "96.04", "33.23", "33.22", "93.90", "38.91", "88.72", "96.08", "96.72", "31.1" ]

icd9pcs

[ [ [] ] ]

13041, 13108

7929, 10875

334, 470

13319, 13350

2877, 7906

13759, 14193

2307, 2376

11148, 13018

13129, 13229

10901, 11125

13374, 13736

2391, 2858

13250, 13298

275, 296

498, 1859

1904, 2162

2194, 2275

73,684

144,564

42793

Discharge summary

report

Admission Date: [**2195-1-31**] Discharge Date: [**2195-2-14**] Date of Birth: [**2130-4-3**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 4358**] Chief Complaint: Broken left arm Major Surgical or Invasive Procedure: Left Humerus Open Reduction Internal Fixation ([**First Name3 (LF) 24785**]) Cricothyroidotomy, Tracheostomy Placement and Removal Esophagogastroduodenoscopy (EGD) Percutaneous gastrostomy tube placement History of Present Illness: 64-year old male with pmhx of EtOH abuse, h/x alcoholic withdrawl seizures, HTN and [**Hospital 982**] transferred from [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] Hospital s/p mechanical fall while getting up from couch with a comminuted left proximal humerus fracture/dislocation. His last drink was this morning ([**2195-1-31**]). . He was admitted to the orthopedic service for semi urgent repair of this fracture. On pre op labs today was found to have a Hct drop from 32 at the OSH to 20. BUN noted to be 63. Type and crossed 2 units and transferred to the MICU. . On arrival to the MICU, 98 123/73 96 18 97 % RA. He endorses coughing up cofee ground material during this hosital stay, but denies any vomiting, nausea, dyspepsia, abdominal pain, diarrhea. He does not know the color of his stool. The patient has never recieved a EGD, last colonoscopy 5 years ago and was normal. . 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 dysuria, frequency, or urgency. Denies arthralgias or myalgias. Denies rashes or skin changes. Past Medical History: H/o alcoholic seizures EtOH abuse Tobacco use Pulmonary nodules -followed by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1492**] Squamous cell carcinoma of piriform sinus, stage IV -s/p XRT and chemo Diabetes Mellitus (diet controlled) Vocal cord leukoplakia GERD BPH Prior tonsillectomy Social History: Lives with wife Occupation: Retired airplane mechanic Tobacco: 1 pack/week for many years EtOH: 1 pint of vodka daily Family History: nc Physical Exam: Admission Exam VS: 98 123/73 96 18 97 % RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: supple, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi Abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CNII-XII intact, 5/5 strength upper/lower extremities, grossly normal sensation, 2+ reflexes bilaterally, gait deferred, finger-to-nose intact Rectal: brown stool,external hemorrhoids . Discharge exam notable for: -Anterior cervical stoma (trach site) clean and dry, with no surrounding erythema or tenderness -L shoulder + steristrips, surgical site c/d/i, nontender; L arm in sling -G-tube site well-appearing, no erythema, min surrounding tenderness Pertinent Results: ADMISSION LABS [**2195-1-31**] 11:13PM HCT-19.1* [**2195-1-31**] 07:00PM estGFR-Using this [**2195-1-31**] 07:00PM GLUCOSE-179* UREA N-63* CREAT-1.0 SODIUM-140 POTASSIUM-4.2 CHLORIDE-102 TOTAL CO2-28 ANION GAP-14 [**2195-1-31**] 07:00PM ALT(SGPT)-18 AST(SGOT)-26 LD(LDH)-130 ALK PHOS-41 TOT BILI-0.6 [**2195-1-31**] 07:00PM ALT(SGPT)-18 AST(SGOT)-26 LD(LDH)-130 ALK PHOS-41 TOT BILI-0.6 [**2195-1-31**] 07:00PM ALBUMIN-3.4* [**2195-1-31**] 07:00PM HAPTOGLOB-145 [**2195-1-31**] 07:00PM WBC-10.1 RBC-2.14* HGB-6.9* HCT-20.9* MCV-98 MCH-32.3* MCHC-33.0 RDW-13.7 [**2195-1-31**] 07:00PM PT-11.1 PTT-24.0* INR(PT)-1.0 [**2195-1-31**] 07:00PM PLT COUNT-195 . DISCHARGE LABS [**2195-2-14**] 06:00AM BLOOD WBC-5.7 RBC-3.04* Hgb-9.2* Hct-28.3* MCV-93 MCH-30.3 MCHC-32.6 RDW-14.3 Plt Ct-403 [**2195-2-14**] 05:18AM BLOOD Glucose-132* UreaN-10 Creat-0.8 Na-140 K-3.8 Cl-99 HCO3-34* AnGap-11 [**2195-2-14**] 05:18AM BLOOD Calcium-8.7 Phos-3.9 Mg-1.8 . STUDIES . EGD [**2-2**] Impression: Normal mucosa in the esophagus Gastric ulcer Friability, erythema and nodularity in the duodenum compatible with duodenitis Otherwise normal EGD to third part of the duodenum EGD [**2-6**] Abnormal mucosa in the esophagus There was significant edema in the oropharynx and the adult endoscope was unable to pass despite multiple attempts. The pediatric endoscope was able to be passed without difficulty. Erythema and nodularity in the duodenal bulb compatible with duodenitis (biopsy) Otherwise normal EGD to third part of the duodenum . [**2-5**] H. Pylori NEGATIVE . TTE [**2-2**] IMPRESSION: Suboptimal image quality. Right-to-left intracardiac shunt. Normal biventricular cavity sizes with preserved global biventricular systolic function. Dilated ascending aorta. . CXR [**2-5**] FINDINGS: In comparison with the study of [**2-4**], the tracheostomy tube remains in good position. Continued layering pleural effusions bilaterally, more prominent on the right. Bibasilar atelectatic change is seen. Indistinctness of pulmonary vessels is consistent with some elevated pulmonary venous pressure. . CXR [**2-13**] I see no radiopaque tracheostomy device. Moderate bilateral pleural effusions mask considerable bibasilar atelectasis, but there has been no change since [**2-9**]. Heart size is normal. Pulmonary vasculature is now normal caliber. Mediastinal veins are not dilated. Right PIC line ends in the mid-to-low SVC. No pneumothorax. . L SHOULDER FILMS [**2-11**] FINDINGS: Heterogeneous opacities seen at the left lung base with blunting of the left costophrenic angle, most likely representing atelectasis adjacent to a pleural effusion. The visualized ribs are normal. The AC joint is intact with mild degenerative change including spurring. Glenohumeral joint is intact. Status post [**Month/Day (4) 24785**] of the left proximal humerus with plate and screws. The hardware is intact and unchanged in position. No evidence of peri-hardware lucency. Unchanged alignment. The fracture line is slightly less distinct, indicating healing. Ossific fragments are seen inferior to the glenohumeral joint which may be from the fracture or intervention. IMPRESSION: 1. No hardware complication. 2. Mild AC joint osteoarthritis. 3. Probable left lower lobe atelectasis with adjacent left pleural effusion. Brief Hospital Course: 64M with PMH EtOH abuse, h/x alcoholic withdrawl seizures, HTN and [**Hospital 982**] transferred from [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] Hospital s/p mechanical fall resulting in left humeral fracture found to have Hct 20 presumed [**2-12**] to upper GI bleed, hospital course complicated by emergent cricothyroidotomy during intubation for EGD, and witnessed aspiration requiring percutaneous G-tube placement. . # Left humeral fracture s/p [**Name (NI) 24785**] Pt underwent [**Name (NI) 24785**] of left comminuted humeral fracture. Pain was controlled with oxycodone, tylenol and IV fentanyl in the MICU; transitioned to standing tylenol + occasional PRN oxycodone on the floor. PT and OT followed. There were no complications. Sutures removed by ortho; follow-up L shoulder films showed good alignment and evidence of active healing. . # Upper GI bleed Pt with coffee ground emesis with associated drop in hematocrit. Initially transfused 2 units of packed cells. Pantoprazole drip started. EGD revealed Gastric ulcer with blood vessel, however no active bleeding. Also, friability, erythema and nodularity in the duodenum compatible with duodenitis. No further bleeding episodes and was changed to protonix 40 IV BID. After transfer to the floor, however, he had melanotic stools and another Hct drop. Repeat EGD again revealed no active source of bleeding. Serum H pylori antibody was negative. Follow up of the GI biopsies showed only duodenitis. The patient's hematocrit stabiliized and subsequent stool was heme negative. Discharged on PPi and sucralfate. Patient needs EGD and colonoscopy in 6 weeks, to be arranged by family (with assistance of PCP) at [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] Hospital. (Will require fiberoptic nasogastric intubation.) . # Airway Intubation attempted prior to initial EGD and [**Last Name (NamePattern1) 24785**]. Pt had difficult airway. Cricothyroidotomy placed as pt unable to be ventilated via mask-valve-bag. Cricothyroidotomy converted to tracheostomy in the OR by ENT prior to [**Last Name (NamePattern1) 24785**] of left humerus. Pt underwent successful cap trial before removal of the trach on [**2195-2-8**]. Expect stoma to close in weeks-to-months. Pt's difficult airway most likely from post-radiation changes for treatment of previous piriform sinus tumor. Fiberoptic nasopharyngeal intubation by anaesthesia prior to IR-guided perc G-tube placement on [**2-12**] was c/b mucus plugging and transient hypoxia which resolved w/suctioning. Had difficulty swallowing and was made NPO with speech and swallow reccomending PEG placement. Taken to OR on [**2-12**] by IR for procedure. Prior to procedure had difficut intubation again but airway access was secured. He tolerated the procedure well and was extubated to 100% facemask and gradually weaned down to 3L nasal cannula with trach mask. Pain control has been an issue for this gentle man. Anesthesia tried to stay away from narctocis and gave him IV tylenol and ketamine with little effect. Gave 0.2 mg IV dilaudid x1 and he became apneic for 10seconds and set off apnea alarms. HD stable and no de-saturation. Transferred to mICU for paincontrol with tenuous airway status. In the MICU, patient was treated with small doses of IV morphine and tolerated them well without any further apneic events. He was transferred back to the floor on [**2-13**]. . # Hypotension [**2-12**] PNA The patient had hypotension with SBP on night of [**2-1**] in the 80??????s-90??????s with RLL infiltrate on CXR and fever to 100.6. Started on broad coverage for possible PNA with Vanc/Zosyn. BAL was negative for organisms and only remarkable for presence of 4+ PMNs; however this was after initiation of antibiotics. Although it was felt that this was most likely a chemical pneumonitis (vs aspiration PNA, see below), given the acuity of presentation he was continued on broad-spectrum antibiotics until he was afebrile x 48h then transitioned to unasyn to finish a total abx course of 7 days. . # Aspiration risk/Aspiration PNA Patient initially thought to have aspiration PNA/chemical pneumonitis with associated hypotension, as above. Treated w/7d antibiotics. Thereafter, he was witnessed aspirating. He underwent serial evaluation by speech & swallow by video swallow before and after trach collar removal. These confirmed worsening aspiration. Patient opted to proceed to G-tube placement. Tubefeeds initiated, plus small amounts of nectar-thick liquids for comfort. . # Volume status Patient noted to be volume o/l on [**1-10**] w/scrotal edema and b/l pleural effusions. This pulmonary congestion was likely the reason for persistent 2L O2 requirement after resolution of aspiration PNA. Diuresis w/20 IV lasix x1 clinically beneficial multiple times. An echo obtained on admission showed normal LVEF but was notable for right-to-left cardiac shunt. . # Alcohol abuse Has had past withdrawal seizures. Last drink was the morning before admission. He has been consistently drinking 1 pint of vodka daily. He was placed on CIWA protocol and continued on Multivitamins, folate and thiamine. His benzo requirements were minimal. . # Depression Continued Mirtazipine and Citalopram. . #BPH Continued Doxazosin . TRANSITIONAL ISSUES 1. Confirm ENT appt arranged, for trach site closure follow-up evaluation 2. Referral needed to GI at [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] for EGD/Colonoscopy in 6 weeks 3. Eventual re-evaluation of longer-term need for G-tube. Aspiration symptoms may improve as trach site closes, so repeat Speech&Swallow eval recommended. 4. Consider cardiology follow-up as outpatient given echo finding of intracardiac shunt Medications on Admission: Famotidine 20mg PO QD Doxazosin 4mg PO QHS Citalopram 60mg PO QD Mirtazapine 15mg PO QD Betamethasone 0.05% cream TP outer ear [**Hospital1 **] Vitamin B12 1 Tab PO QD Vitamin D3 1 Tab PO QD MVI Discharge Medications: 1. 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. 2. 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. 3. lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR PO BID (2 times a day). Disp:*60 Tablet,Rapid Dissolve, DR(s)* Refills:*2* 4. sucralfate 1 gram Tablet [**Last Name (STitle) **]: Two (2) Tablet PO BID (2 times a day). Disp:*120 Tablet(s)* Refills:*2* 5. docusate sodium 100 mg Capsule [**Last Name (STitle) **]: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 6. bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Last Name (STitle) **]: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 7. magnesium hydroxide 400 mg/5 mL Suspension [**Last Name (STitle) **]: Thirty (30) ML PO Q6H (every 6 hours) as needed for constipation. Disp:*500 ML(s)* Refills:*0* 8. doxazosin 4 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO HS (at bedtime). Disp:*30 Tablet(s)* Refills:*2* 9. mirtazapine 15 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO HS (at bedtime). Disp:*30 Tablet(s)* Refills:*2* 10. citalopram 20 mg Tablet [**Last Name (STitle) **]: Three (3) Tablet PO DAILY (Daily). Disp:*90 Tablet(s)* Refills:*2* 11. betamethasone dipropionate 0.05 % Cream [**Last Name (STitle) **]: One (1) Appl Topical [**Hospital1 **] (2 times a day). Disp:*1 30 ML TUBE (or closest available)* Refills:*2* 12. cyanocobalamin (vitamin B-12) 100 mcg Tablet [**Hospital1 **]: 0.5 Tablet PO DAILY (Daily). Disp:*15 Tablet(s)* Refills:*2* 13. folic acid 1 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 14. thiamine HCl 100 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 15. multivitamin Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 16. nicotine 14 mg/24 hr Patch 24 hr [**Hospital1 **]: One (1) Patch 24 hr Transdermal DAILY (Daily). Disp:*30 Patch 24 hr(s)* Refills:*2* 17. cholecalciferol (vitamin D3) 400 unit Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 18. senna 8.6 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 19. sodium chloride 0.65 % Aerosol, Spray [**Hospital1 **]: [**1-12**] Sprays Nasal QID (4 times a day) as needed for dry nose. Disp:*1 BOTTLE* Refills:*0* 20. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization [**Month/Day (2) **]: One (1) neb Inhalation Q4H (every 4 hours). Disp:*120 neb* Refills:*0* 21. ipratropium bromide 0.02 % Solution [**Month/Day (2) **]: [**1-12**] neb Inhalation Q6H (every 6 hours). Disp:*120 neb* Refills:*2* 22. acetaminophen 500 mg Tablet [**Month/Day (2) **]: Two (2) Tablet PO Q6H (every 6 hours). Disp:*240 Tablet(s)* Refills:*2* 23. oxycodone 5 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO every four (4) hours as needed for pain for 1 weeks Disp:*42 Tablet(s)* Refills:*0* 24. Outpatient Lab Work Please check potassium, creatinine on [**2195-2-15**]. If potassium call. 25. Outpatient Lab Work Please check HCT on [**2195-2-15**] and [**2195-2-18**]. If HCT < 25, 26. PICC Please consider removal of PICC line on [**2195-2-15**] if no further need anticipated. Thank you. Discharge Disposition: Extended Care Facility: [**Hospital6 1293**] - [**Location (un) 8957**] Discharge Diagnosis: Primary Diagnosis Left humerus fracture Secondary Diagnoses Upper Gastrointestinal Bleed Aspiration Pneumonia 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 18**] from another hospital for management of your left humerus fracture. You underwent surgery to repair your broken humerus. You had physical and occupational therapy during this hospitalization, to assist in your recovery. They recommended [**Hospital 3058**] rehabilitation. You also developed bleeding in your gastrointestinal tract, for which you underwent an EGD (esophagogastroduodenostomy) to visualize your stomach and esophages in an attempt to find and stop the source of bleeding. No active bleeding was seen. Your blood counts stabilized. The gastroenterologists recommend that you have another EGD and a colonoscopy at [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] Hospital in [**6-19**] weeks. During the EGD, you had a tracheostomy tube placed. There was emergent concern about your airway - because of your prior radiation therapy, it was difficult to to place a tube for anaesthesia. Cricothyroidotomy and tracheostomy tube placement protected your airway and maintained normal breathing. Your breathing improved over the next week, and the tube was removed. We expect the tube site to heal over the next several weeks, and have arranged an appointment with the ear-nose-throat doctors for follow-up. We also noticed that you were regurgitating food into your windpipe (aspirating). This may have been occurring at home before hospitalization, as we found pneumonia in multiple sites in your lungs. You were treated with antibiotics for pneumonia. Given the severity of your aspiration, you had a feeding tube placed surgically. You will continue tube feeds. The feeding tube will probably be temporary; your primary care doctor will help determine if and when the tube can be safely removed. Finally, we examined your heart's pump function by echocardiogram since you seemed to accumulate fluid, especially in your lungs. The echo showed right-to-left intracardiac shunt but normal pump function. We made numerous changes to your medications - please see the attached medication list. Please review this paperwork with your doctor at your next appointment.

[ "311", "305.1", "995.92", "486", "530.81", "608.86", "250.00", "496", "600.00", "812.01", "578.0", "401.9", "285.1", "933.1", "535.60", "E915", "531.90", "E884.2", "303.91", "507.0", "812.09", "V10.02", "038.9", "785.52" ]

icd9cm

[ [ [] ] ]

[ "45.13", "43.11", "45.16", "96.71", "96.6", "31.1", "33.24", "31.42", "79.31", "96.04", "38.97" ]

icd9pcs

[ [ [] ] ]

16194, 16268

6642, 12379

319, 525

16423, 16423

3309, 6619

2323, 2327

12624, 16171

16289, 16402

12405, 12601

16599, 18742

2342, 3290

1483, 1837

264, 281

553, 1464

16438, 16575

1859, 2172

2188, 2307

5,525

100,473

52670+59446+59450

Discharge summary

report+addendum+addendum

Admission Date: [**2115-2-12**] Discharge Date: [**2115-2-28**] Date of Birth: [**2050-4-3**] Sex: M Service: MEDICINE Allergies: Neupogen Attending:[**First Name3 (LF) 3624**] Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: [**2115-2-14**] Non-tunneled hemodialysis line placement [**2115-2-22**] Tunneled hemodialysis line placement History of Present Illness: 64 year old man with history of cadaveric kidney transplant in [**2109**] after acute tubular necrosis from a viral gastroenteritis whose kidney function has been slowly worsening of the past year who presents with shortness of breath for 1 week. Patient reports cough and shortness of breath, mainly with extertion for the past week. The symptoms started with runny noise and the patient thought he had a cold. He notice dyspnea on extertion when he was walking from his car to his house, a distance he is normally able to do without difficulty. He also has noted this dry cough, worse at night that makes him sit up off the side of the bed. He denies any chest pain or history of chest pain with extertion. He also denies recent fevers, chills, nausea, vomiting, abdominal pain, diarrhea, or constipation. He has noticed a progressive decrease in his urine output over the past year but no acute change recently. He does not occasional intermittent dysuria. He denies any recent medication non-compliance or change in his diet. Patient does feel like he has been gaining weight over the past few months. . The patient was also recently admitted at [**Hospital3 2568**] for a similar progressive shortness of breath. It was thought due to his worsening renal function. He was diuresed and he improved. . The patient also reports a fall two weeks prior to admission. Patient tripped on stairs at his home and fell. He did hit his head but denies any LOC. He denies any associated chest pain, weakness, dizziness, or palpitations. Past Medical History: #Atrial Fibrillation - s/p cardioversion in [**10-14**]. Was maintained on coumadin for 6 months. currently not anticoagulated . #Pericardial Effusion - s/p drainage, unclear etiology . #Kidney Disease - ESRD from ATN in setting of acute gastroenteritis, s/p cadaveric kidney transplant in [**2109**], worsening renal function over the last year. Has appointment in [**Month (only) **]. for AV fistula placement in anticipation of future dialysis . #Abdominal Wall Hernia - s/p repair after transplant . Multiple Knee surgeries 20 years ago Social History: Denies any history of Tob use, no EtOh use for 15 years, no drug use. Lives with his wife, now on disability. Used to work as a spray painter Family History: History of CAD, cancer, MS Physical Exam: Vitals: 96.9, 132/80, 92, 20, 97% on 4L GEN: Coughing repeatedly during interview with moderate distress, some difficulty completing sentences because of coughing HEENT: PERRL, EOMI, Clear OP with MMM Neck: no LAD, JVP difficutly to assess because of girth CV: [**Last Name (un) 3526**] [**Last Name (un) 3526**], otherwise heart sounds difficutly to interpret because of loud ronchi Lungs: diffuse ronchi throughout lung fields, few crackles apparent at bases ABD: +BS nt nd, soft, obese, large irregular ventral hernia appreciated Ext: [**1-9**]+ peripheral edema, r>l, erythema of right leg but without significant warmth or tenderness, some bruising at right ankle. 2+ DP pulses, ROM at right ankles seems full Neuro: CN 2-12 intact, 5/5 strength upper and lower extremities, sensation grossly intact throughout Pertinent Results: ============ LABORATORIES ============ LABORATORIES ON ADMISSION: [**2115-2-12**] WBC-3.7 (NEUTS-78 BANDS-0 LYMPHS-9 MONOS-9 EOS-3 BASOS-1 ATYPS-0 METAS-0 MYELOS-0) HGB-9.4 HCT-29.0 MCV-88 PLT COUNT-151 [**2115-2-12**] SODIUM-126 POTASSIUM-6.7* (hemolyzed)-->repeat K=4.1 CHLORIDE-93 TOTAL CO2-17 UREA N-103 CREAT-4.8 GLUCOSE-69 [**2115-2-12**] ALT(SGPT)-9 AST(SGOT)-46 CK(CPK)-233 ALK PHOS-24 TOT BILI-0.4 [**2115-2-12**] CK-MB-10 MB INDX-4.3 cTropnT-0.07 proBNP-[**Numeric Identifier **] [**2115-2-12**] ALBUMIN-3.6 [**2115-2-12**] LACTATE-0.7 . CARDIAC ENZYMES: [**2115-2-12**] 11:30AM BLOOD CK(CPK)-233 CK-MB-10 MB Indx-4.3 cTropnT-0.07 [**2115-2-12**] 07:30PM BLOOD CK(CPK)-187 CK-MB-12 MB Indx-6.4 cTropnT-0.09 [**2115-2-13**] 05:26AM BLOOD CK(CPK)-166 CK-MB-9 cTropnT-0.06 . OTHER LABORATORIES [**2115-2-15**] calTIBC-276 Ferritn-114 TRF-212 [**2115-2-15**] TSH-0.90 [**2115-2-15**] PTH-106 [**2115-2-14**] BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE HBcAb-NEGATIVE HCV Ab-NEGATIVE [**2115-2-25**] Cyclspr-69 . LABORATORIES UPON DISCHARGE: [**2115-2-27**] WBC-3.7 HGB=8.7 HCT-29.1 MCV-94 PLT COUNT-141 [**2115-2-28**] SODIUM-141 POTASSIUM-3.5 CHLORIDE-104 TOTAL CO2-17 UREA N-26 CREAT-3.7 GLUCOSE-97 . ======= STUDIES ======= UNILAT LOWER EXT VEINS RIGHT [**2115-2-12**] RIGHT LOWER EXTREMITY ULTRASOUND: The exam is technically limited, because pain limited the patient's ability to tolerate compression of the superficial femoral vein at its mid and distal portions. Grayscale and Doppler [**Year/Month/Day 108683**] were obtained of the right common femoral, proximal superficial femoral, and popliteal veins. Normal compressibility, color flow and waveforms are seen. Color flow and Doppler [**Name (NI) 108683**], without compression, were obtained for the mid and distal right superficial femoral vein. Normal color flow and waveforms are seen. The left common femoral vein demonstrates normal color flow and waveforms. IMPRESSION: DVT highly unlikely. However, cannot be completely ruled out due to technical limitations resulting from patient discomfort. If clinical concern persists, followup exam can be performed following appropriate pain control. . AP PORTABLE CHEST [**2115-2-12**] The study is limited secondary to AP portable technique and body habitus. The cardiomediastinal configuration remains markedly enlarged but stable. The cardiac silhouette is globular in morphology. There is no superimposed edema or consolidation evident. No effusion or pneumothorax is seen. Again noted and slightly exaggerated is a dextroconcave curvature of the thoracic spine likely at least in part positional. IMPRESSION: Low lung volumes; however, no focal consolidation seen. Stable marked cardiomegaly. . ECG Study Date of [**2115-2-12**] Atrial fibrillation with moderate ventricular response. Diffuse low voltage. Delayed precordial R wave transition. Diffuse non-specific ST-T wave changes. Compared to the previous tracing of [**2110-10-14**] atrial fibrillation has appeared. Rate 85, PR 0, QRS 88, QT/QTc 392/435, P 0, QRS 15, T 89 . Portable TTE (Complete) Done [**2115-2-14**] The left atrium is moderately dilated. The right atrium is moderately dilated. The estimated right atrial pressure is 10-15mmHg. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF 70%) Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. Compared with the findings of the prior report (images unavailable for review) of [**2109-10-22**], cardiac rhythm now atrial fibrillation; no pericardial effusion seen; otherwise findings similar. . CHEST (PORTABLE AP) [**2115-2-18**] The right supraclavicular catheter remains in place with tip in the right atrium. Bibasilar atelectasis are again seen, slightly worsened on today's examination with a lower lung volume than before. Small bilateral pleural effusion have not changed. There is cardiomegaly along with minimal vascular congestion. The abdomen is gasless. IMPRESSION: 1. Lower lung volume with more prominent bibasilar atelectasis. 2. Right central catheter still terminates in the right atrium, for which repositioning is required. . CTA CHEST W&W/O C&RECONS, NON-; CT ABDOMEN W/O CONTRAST, [**2115-2-20**] 1. No pulmonary embolism. There is CT evidence of pulmonary hypertension. 2. The lung parenchyma is not well evaluated given that the amount of respiratory motion present. There appear to be centrilobular nodules, ground- glass opacity and atelectasis. There are small bilateral pleural effusions. 3. Cardiomegaly and coronary artery calcifications. 4. Rounded hypodense liver lesions are not fully characterized on this study but not appear greatly changed from [**2109-12-2**]. 5. The spleen is generous in size. 6. Right lower quadrant renal transplant. 7. Right flank ecchymosis and focal right abdominal wall muscular enlargement, possibly representing a hematoma. This muscle enlarged should be followed to complete resolution to exclude an underlying mass. Consider targeted ultrasound for followup. . VENOUS DUP EXT UNI (MAP/DVT) LEFT [**2115-2-21**] The left basilic vein was not identified, presumably thrombosed. The left cephalic vein is patent and measures 0.23 cm in diameter superiorly and 0.37 cm in diameter in the forearm distally. In between, measurements range from 0.21-0.33, as charted on the vasculat lab diagram. The left brachial artery is patent with triphasic waveforms. There is respiratory phasicity of the left subclavian venous waveform. . [**2114-2-26**] EKG Atrial fibrillation, average ventricular rate 80-85. Generalized low voltage. Delayed precordial R wave progression - cannot exclude anterior myocardial infarction. Generalized non-specific repolarization changes most marked anteroseptally and laterally consistent with ischemia. Compared to the previous tracing of [**2115-2-13**] anteroseptal T wave inversions are new. Rate 83 PR 0, QRS 76, QT/QTc 386/426, P 0, QRS 18, T 109 . MICROBIOLOGY . [**2115-2-18**] Blood Culture (4 BOTTLES): NO GROWTH FINAL. [**2115-2-21**] NASOPHARYNGEAL ASPIRATE. Positive for Respiratory Syncytial viral antigen. CULTURE CONFIRMATION PENDING. SPECIMEN SCREENED FOR: ADENO,PARAINFLUENZA 1,2,3 INFLUENZA A,B AND RSV. VIRAL CULTURE (Final [**2115-2-27**]): HERPES SIMPLEX VIRUS TYPE 1. CONFIRMED BY MONOCLONAL FLUORESCENT ANTIBODY Brief Hospital Course: #. RESPIRATORY DISTRESS The patient's respiratory distress was likely multifactorial due to volume overload and RSV infection (by nasopharyngeal aspirate). In the MICU, the patient was also determined to have chronic CO2 retention likely secondary to obstructive sleep apnea given his habitus. Of note, pt did not tolerate BiPap trial in unit. Pt received 3 days of burst steroids for ? COPD exacerbation, was discontinued given lack of improvement and no known COPD (not a smoker). In addition, Mr. [**Known lastname 108684**] beta blocker was discontinued as uptitration of it was thought to exacerbate his wheezing. CT chest was negative for pulmonary embolism. Hemodialysis was initiated. The patient was diuresed to a net negative fluid balance of ~10 L on HD with significant improvement in wheezing/decreased O2 saturations/rhonchi after dialysis. However, wheezing persisted and low O2 saturations (~91% room air) persisted after significant volume removal. Nasopharyngeal aspirate showed patient had an RSV infection. Pulmonary was consulted and there was no indication for an antiviral medication for RSV. Supportive care was provided for viral pulmonary infection. Of note, viral cultures of the nasopharyngeal aspirate grew HSV 1, which was felt to be a normal colonizer of the patient's respiratory tract. By the time the HSV culture returned ([**2-27**]), the patient's respiratory status was at baseline; no antiviral for HSV was felt to be indicated. Upon discharge, the patient had clear lungs to auscultation bilaterally and had an normal O2 saturation on room air. Bactrim was continued for prophylaxis. Sleep study was recommended as an outpatient to evaluate the need for home BiPAP. . #. END-STAGE RENAL DISEASE ON HEMODIALYSIS See above. Failed cadaveric renal transplant in [**2109**], initiated on hemodialysis on this admission with successful placement of tunneled line on this admission. For renal transplant, continued low dose prednisone, and cyclosporine was decreased to 25 mg daily. He was maintained on a fluid restricted diet. Venogram was performed in anticipation of outpatient fistula placement. He was scheduled for a vascular surgery appointment as an outpatient for fistula placement. . #. ATRIAL FIBRILLATION The patient has a history of atrial fibrillation s/p cardioversion and re-presented in atrial fibrillation in the setting of metabolic derangements and fluid overload. Home betablocker was discontined (due to persistent wheezing), and diltiazem was provided for rate control. Of note, diltiazem elevates cyclosporin which could be problem[**Name (NI) 115**] in this patient. In the future if respiratory distress deemed not to be related, beta blocker may provide more cardiac benefit and also does not have cross reaction with cyclosporin; defer to outpatient PCP. [**Name10 (NameIs) **] cards, no cardioversion was indicated during this admission as the patient could not lie flat for procedure, which would require TEE. Per ther recs: outpatient cardiology f/u in [**2-11**] weeks with Dr. [**Last Name (STitle) 73**] for outpatient cardioversion once respiratory status improves. Coumadin was provided after HD line placed; he was bridged with heparin drip until then. Upon discharge, he was off the heparin drip and therapeutic on coumadin. He was in atrial fibrillation through admission with adequate rate control upon discharge. . #. ACIDEMIA The patien presented with mixed metabolic and respiratory acidosis. Respiratory component possibly due to CO2 retention (OSA vs obesity hypoventilation syndrome vs COPD); AG metabolic acidosis due to his renal failure. His acidemia improved with dialysis and adjustment of diasylate bath. . # F/E/N: Replete lytes PRN. Fluid restricted renal diet. . # PPx: Bowel regimen, PPI (on steroids) . # Access: PIV 22 X 2, temporary HD line. . # Dispo: pending further improvement in respiratory status. . # Code Status: Full Medications on Admission: Docusate Sodium 100 mg PO BID Pantoprazole 40 mg PO PredniSONE 5 mg PO QPM Furosemide 80mg PO daily Gengraf *NF* 100 mg Oral [**Hospital1 **] Mycophenolate Mofetil 250 mg PO TID Sulfameth/Trimethoprim SS 1 TAB PO MWF Amlodipine 10 mg PO DAILY Iron TID Calcium + Vitamin D Discharge Medications: 1. Atorvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 4. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1) Tablet PO Q MWF (). 6. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 8. Cyclosporine Modified 25 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 9. Diltiazem HCl 180 mg Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO DAILY (Daily). Discharge Disposition: Extended Care Facility: [**Location (un) 86**] Center for Rehab Discharge Diagnosis: Primary: End-stage renal disease Respiratory Syncytial Virus . Secondary: Atrial Fibrillation Discharge Condition: Hemodynamically stable, afebrile Discharge Instructions: You were admitted to the hospital with shortness of breath. Hemodialysis was initiated. Your shortness of breath improved with excess volume removal with hemodialysis. You were also found to have respiratory syncytial virus, and you were treated with supportive care. . Please keep all followup appointments. . 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. * 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. . Medication changes: 1. Cyclosporin dosage was decreased to 25 mg daily. 2. Toprol XL was discontinued as it was thought to contribute to your shortness of breath. . New medications: 1. Warfarin (coumadin) 2.5 mg by mouth daily. The dosage of your coumadin should be adjusted as an outpatient to maintain a therapeutic level. 2. Diltiazem 180 mg daily was added to control your heart rate. Followup Instructions: 1. For fistula placement for dialysis: Provider: [**Name10 (NameIs) **] [**Name8 (MD) 40164**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2115-3-14**] 2:30 PM. . 2. Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 7449**], MD Phone:[**Telephone/Fax (1) 1971**] Date/Time:[**2115-4-18**] 1:30 PM. . 3. Provider: [**First Name4 (NamePattern1) 971**] [**Last Name (NamePattern1) 970**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2115-5-7**] 11:10 AM. . 4. Please followup with you PCP: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 108685**], MD within 1 week of discharge from rehabilitation. Phone: [**Telephone/Fax (1) 100430**]. [**First Name4 (NamePattern1) 971**] [**Last Name (NamePattern1) 970**] MD [**MD Number(1) 3629**] Name: [**Known lastname 17775**],[**Known firstname 4076**] Unit No: [**Numeric Identifier 17776**] Admission Date: [**2115-2-12**] Discharge Date: [**2115-2-28**] Date of Birth: [**2050-4-3**] Sex: M Service: MEDICINE Allergies: Neupogen Attending:[**First Name3 (LF) 2670**] Addendum: . NEXT HEMODIALYSIS: SATURDAY, [**2115-3-2**] AT [**Hospital3 218**] [**Hospital 17777**] HOSPITAL. Please arrange for transfport to [**Hospital 17778**] on the morning of [**2115-3-2**]. . Then his regular outpatient dialysis will begin at [**Location (un) **] on Tuesday, [**2115-3-5**]. His scheduled slot will be T/TH/Saturday. Outpatient hemodialysis center: [**Location (un) **] [**Location (un) 382**] Dialysis [**Location 17779**] MA [**Telephone/Fax (1) 16610**] . Discharge Disposition: Extended Care Facility: [**Location (un) 42**] Center for Rehab [**First Name4 (NamePattern1) 460**] [**Last Name (NamePattern1) 461**] MD [**MD Number(1) 2671**] Completed by:[**2115-2-28**] Name: [**Known lastname 17775**],[**Known firstname 4076**] Unit No: [**Numeric Identifier 17776**] Admission Date: [**2115-2-12**] Discharge Date: [**2115-2-28**] Date of Birth: [**2050-4-3**] Sex: M Service: MEDICINE Allergies: Neupogen Attending:[**First Name3 (LF) 2670**] Addendum: The day after discharge [**2115-3-1**], I contact[**Name (NI) **] Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 17788**] at the [**Location (un) 42**] Center for Rehab [**Telephone/Fax (1) 17789**] to clarify the patient's coumadin regimen. His coumadin was being held as it was supratherapeutic prior to discharge (INR = 3.4). Therefore, coumadin was not on the active medication list when the patient was sent to rehab, though it is listed within the hospital course of the discharge summary. The need to continue coumadin and check INR daily was communicated to both Dr. [**Last Name (STitle) 17788**] and to nursing staff at [**Location (un) 42**] Center for rehabilitation. Goal INR was between [**2-10**], which was also communicated to Dr. [**Last Name (STitle) 17788**] and his team. Discharge Disposition: Extended Care Facility: [**Location (un) 42**] Center for Rehab [**First Name4 (NamePattern1) 460**] [**Last Name (NamePattern1) 461**] MD [**MD Number(1) 2671**] Completed by:[**2115-3-12**]

[ "276.2", "276.6", "585.6", "403.91", "518.81", "480.1", "427.31", "996.81", "584.9" ]

icd9cm

[ [ [] ] ]

[ "38.95", "39.95" ]

icd9pcs

[ [ [] ] ]

20495, 20718

10382, 14322

288, 400

15654, 15689

3597, 3649

17422, 19068

2717, 2745

14646, 15427

15537, 15633

14348, 14623

15713, 17008

2760, 3578

4162, 4620

17028, 17399

229, 250

4636, 10359

428, 1973

3663, 4145

1995, 2540

2556, 2701

12,305

182,152

25520

Discharge summary

report

Admission Date: [**2122-8-21**] Discharge Date: [**2122-8-28**] Date of Birth: [**2098-8-26**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 905**] Chief Complaint: chest pain Major Surgical or Invasive Procedure: Renal biopsy Right central cathater placement Plasmaphoresis History of Present Illness: 23yoF who presents with onset of intermittant, stabbing, left sided substernal chest pain x 10 days that became severe today. The pain is worse lying down, and better sitting forward or standing. She denies shortness of breath, nausea or vomiting, diaphoresis, palpatations, orthopnea or PND. Of note, 2-3 weeks ago pt had episode of gross, intermittant hematuria and was put on Bactrim, with resolution of hematuria. Pt tentatively recalls sore throat ~10 days prior to hematuria. She also notes hx nightly fevers for 10 days. Her history notable for previous chest pressure, SOB and "problems breathing" on OCP [**Doctor First Name **] 35 at the end of [**2121**]. Given these sx, she stopped this medication [**3-14**]. . Other medications include a course of Ketoconazole in [**7-12**], unknown antibiotic taken in [**Country 10363**] 2 months ago, and 6 month Accutane course [**5-12**]. Denies prior fevers, rashes, joint pain, rashes, melena, BRBPR, heavy menses. . In the ED, patient was found to be in renal failure (BUN 61, Cr 4.3) and D-dimer returned at 3400. Patient was hydrated and had CXR, which was normal, and a V/Q scan which did not show evidence for pulmonary embolism. Past Medical History: None Social History: Patient moved to US from [**Country 10363**] in [**Month (only) 116**] and is working as a waitress on [**Hospital3 **]. She denies smoking, relays rare EtOH use and states that she has never used recreational drugs. Family History: Reviewed; negative. Physical Exam: Vitals- Tm 98.7, Tc 98.3, HR 71-87, BP 113-122/55-69 without pulses paradoxus, RR 20-27, 97% ra HEENT: Oropharynx non-erythematous; ear canals clear, TMs non-erythematous. No oral lesions. Nodes: 1 small mobile LN in left and right inguinal region; no cervical or suprclavicular LAD Lungs: CTA bilaterally, decreased breath sounds at bases bilaterally Heart: RRR, nl S1, S2. No murmurs, rubs, gallops. No S3, S4. Abd: +BS. Tender to palpation in right upper quadrant. Palpable liver edge. No guarding, rebound. Mild suprapubic tenderness. Extr: No calf/thigh tenderness, edema, erythema. WWP. 2+ pulses. No petechiae. Neuro: AAO x3. CN II-XII intact. Strength, sensation intact. Pertinent Results: [**2122-8-21**] 09:46PM CREAT-3.8* POTASSIUM-5.0 [**2122-8-21**] 09:46PM CALCIUM-8.1* PHOSPHATE-5.2* MAGNESIUM-2.1 [**2122-8-21**] 09:46PM HCT-21.3* [**2122-8-21**] 08:44PM URINE HOURS-RANDOM CREAT-81 SODIUM-88 [**2122-8-21**] 08:44PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.015 [**2122-8-21**] 08:44PM URINE BLOOD-LGE NITRITE-NEG PROTEIN-100 GLUCOSE-TR KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [**2122-8-21**] 08:44PM URINE EOS-POSITIVE [**2122-8-21**] 04:10PM GLUCOSE-84 UREA N-52* CREAT-3.7* SODIUM-137 POTASSIUM-5.4* CHLORIDE-109* TOTAL CO2-19* ANION GAP-14 [**2122-8-21**] 04:10PM ALT(SGPT)-24 AST(SGOT)-21 CK(CPK)-44 ALK PHOS-113 TOT BILI-0.2 [**2122-8-21**] 04:10PM CK-MB-1 cTropnT-<0.01 [**2122-8-21**] 04:10PM calTIBC-243* VIT B12-262 FERRITIN-156* TRF-187* [**2122-8-21**] 04:10PM C3-119 C4-34 [**2122-8-21**] 04:10PM WBC-4.9 RBC-2.48* HGB-6.8* HCT-20.7* MCV-84 MCH-27.4 MCHC-32.7 RDW-12.1 [**2122-8-21**] 04:10PM PLT COUNT-196 [**2122-8-21**] 06:41AM CK-MB-NotDone cTropnT-<0.01 [**2122-8-21**] 06:41AM HAPTOGLOB-201* [**2122-8-21**] 06:41AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2122-8-21**] 06:41AM WBC-4.8 RBC-2.38* HGB-6.5* HCT-19.9* MCV-84 MCH-27.4 MCHC-32.8 RDW-12.2 [**2122-8-21**] 06:41AM PLT COUNT-201 [**2122-8-21**] 04:00AM URINE HOURS-RANDOM CREAT-95 SODIUM-33 POTASSIUM-59 [**2122-8-21**] 04:00AM URINE OSMOLAL-386 [**2122-8-21**] 04:00AM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG [**2122-8-21**] 04:00AM URINE COLOR-Straw APPEAR-Hazy SP [**Last Name (un) 155**]-1.014 [**2122-8-21**] 04:00AM URINE BLOOD-LG NITRITE-NEG PROTEIN-100 GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [**2122-8-21**] 04:00AM URINE GRANULAR-[**4-11**]* [**2122-8-21**] 01:45AM AMYLASE-72 [**2122-8-21**] 01:45AM LIPASE-25 [**2122-8-21**] 01:45AM VIT B12-261 FOLATE-10.8 [**2122-8-21**] 01:30AM GLUCOSE-95 UREA N-61* CREAT-4.2* SODIUM-133 POTASSIUM-5.4* CHLORIDE-104 TOTAL CO2-20* ANION GAP-14 [**2122-8-21**] 01:30AM LD(LDH)-146 AMYLASE-74 TOT BILI-0.1 DIR BILI-<0.1 [**2122-8-21**] 01:30AM TSH-9.9* [**2122-8-21**] 01:30AM T4-6.6 [**2122-8-21**] 01:30AM NEUTS-61.6 LYMPHS-28.5 MONOS-5.8 EOS-3.9 BASOS-0.2 [**2122-8-21**] 01:30AM PLT COUNT-206 [**2122-8-21**] 01:30AM D-DIMER-3397* [**2122-8-21**] 01:30AM RET AUT-0.6* Brief Hospital Course: 1. Crescentic anti-GBM Glomerulonephritis Patient had a 2 week history of hematuria. Urinalysis showed nephritic range proteinuria, red cells, white cells, and red cell casts. On admission, BUN was 61, creatinine was 4.2. Anti-glomerular basement membrane antibodies returned at 19 (positive is >3) and ANCA was positive. ASO, double stranded DNA were negative; complement levels were normal. Renal biopsy was performed [**8-24**] and confirmed glomerulonephritis. Immunofluoresence staining showed IgG deposition in a crescentic pattern, confirming anti-GBM disease. Renal recommended treatent with pulsed prednisone 500mg IV every 24 hours on [**7-19**], [**8-27**]. Central cathater was placed [**8-27**] and patient underwent plasmaphoresis [**8-27**], [**8-28**]. Cytoxan infusion was done [**8-28**]. Renal function improved over her stay in house; creatinine trended downward from 4.2 on admission to 2.7 on discharge. Follow-up arrangements were made for patient to undergo plasmaphoresis three times a week for 2 weeks at [**Hospital1 18**]. She was discharged on Prednisone 60mg daily. . 2. Pericarditis Transthoraic [**Hospital1 **] showed a small pericardial effusion witgh right ventricular diastolic collapse, consistent with impaired filling/tamponade. The patient was admitted to the MICU for hospital days [**2-8**], where she was hydrated with IV fluids. Throughout her stay, she did not manifest clinical signs of cardiac tamponade. Repeat transthoracic [**Month/Day (2) **] on [**8-24**] revealed a stable pericadial effusion. The etiology of the pericarditis was thought to be post-viral and unrelated to her anti-GBM glomerulonephritis. On hospital day 7 she was discharged and reported that her chest pain had resolved. Patient will follow up with a repeat transthoracic [**Month/Year (2) **] [**2122-9-10**]. . 3. Anemia On presentation, patient's hematocrit was 19.9. There was no evidence of blood loss and the patient was not symptomatic. Iron studies were consistent with an anemia of chronic inflammation. Hematocrit trended upwards while patient was in house, and was 21.4 on discharge. Patient did not recieve any blood transfusions during her stay. 4. RUQ Pain Was present on admission and resolved without therapy. LFTs, RUQ u/s, and Hep B/C serologies unrevealing. Medications on Admission: Ortho-35 Discharge Medications: 1. Calcium Carbonate 500 mg Tablet, Chewable Sig: Three (3) Tablet, Chewable PO TID w/ meals as needed: Calcium supplement. Disp:*60 Tablet, Chewable(s)* Refills:*2* 2. Vitamin D 400 unit Tablet Sig: Two (2) Tablet PO once a day. Disp:*60 Tablet(s)* Refills:*2* 3. Prednisone 20 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* 4. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed for insomnia. Disp:*30 Tablet(s)* Refills:*0* 5. Compazine 10 mg Tablet Sig: One (1) Tablet PO four times a day as needed for nausea for 5 days. Disp:*20 Tablet(s)* Refills:*0* 6. Prilosec OTC 20 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: anti-GBM/ANCA Glomerulonephritis Pericarditis with pericardial effusion Anemia Discharge Condition: Good; patient afebrile and not complaining of chest pain. Hematocrit improved from admission. Renal function significantly improved from admission. Discharge Instructions: Please follow up with your health care providers for plasmaphoresis and cytoxan infusions. If you notice blood in your urine, have worsening chest pain or any other symptoms that are concerning to you, please seek medical attention immediately. Followup Instructions: Cardiac: Provider: [**Name10 (NameIs) **] LAB TESTING Where: BA [**Hospital Unit Name **] ([**Hospital Ward Name **] COMPLEX) [**Hospital Ward Name **] LAB Phone:[**Telephone/Fax (1) 128**] Date/Time:[**2122-9-10**] 11:00 . Provider: [**Name10 (NameIs) 1248**],BED FIVE [**Name10 (NameIs) 1248**] ROOMS Where: [**Name10 (NameIs) 1248**] ROOMS Date/Time:[**2122-8-31**] 2:15. Phone: [**Telephone/Fax (1) 46376**] Provider: [**Name10 (NameIs) 1248**],BED FOUR [**Name10 (NameIs) 1248**] ROOMS Where: [**Name10 (NameIs) 1248**] ROOMS Date/Time:[**2122-9-2**] 9:15 Provider: [**Name10 (NameIs) 1248**],ISOLATION ROOM [**Name10 (NameIs) 1248**] ROOMS Where: [**Name10 (NameIs) 1248**] ROOMS Date/Time:[**2122-9-4**] 9:15 [**Name6 (MD) 251**] [**Name8 (MD) **] MD [**MD Number(1) 910**]

[ "285.9", "583.9", "276.7", "584.9", "423.9", "599.7" ]

icd9cm

[ [ [] ] ]

[ "99.71", "38.93", "55.23" ]

icd9pcs

[ [ [] ] ]

8240, 8246

5063, 7365

325, 388

8369, 8518

2624, 5040

8811, 9624

1887, 1908

7424, 8217

8267, 8348

7391, 7401

8542, 8788

1923, 2605

275, 287

416, 1609

1631, 1637

1653, 1871

5,617

173,402

6493

Discharge summary

report

Admission Date: [**2149-11-7**] Discharge Date: [**2149-11-12**] Service: MEDICINE, [**Doctor Last Name 1181**] FIRM CHIEF COMPLAINT: Upper gastrointestinal bleed. HISTORY OF PRESENT ILLNESS: The patient is an 80-year-old white male with a history of hypertension, peripheral vascular disease, stroke, poorly healing right heel ulcer, who was recently hospitalized, who now presents with upper gastrointestinal bleed. The patient had developed hematemesis with coffee-grounds. He has a history of upper GI bleed with NSAIDs in [**2143**] and [**2148**]. He recently started taking Aspirin. Esophagogastroduodenoscopy in [**2148**] showed multiple arteriovenous malformations which required cauterization. He presented from his rehabilitation center with hematemesis. His initial hematocrit was 31.2 with a systolic blood pressure in the 90-100s. Esophagogastroduodenoscopy was performed in the Emergency Department showing a large clot in the stomach with erosions at the fundus of the stomach. Gastroenterology recommended admission to the Intensive Care Unit. Additionally, Protonix and close monitoring of his hematocrit was suggested. PAST MEDICAL HISTORY: 1. Gastrointestinal bleed secondary to NSAIDs. 2. Hypertension. 3. Osteoarthritis. 4. Chronic obstructive pulmonary disease. 5. Stroke with left hemiparesis. 6. Cholecystectomy. 7. Abdominal aortic aneurysm repair. 8. Hip replacement on the right side which had to be removed secondary to infection. 9. Right heel ulcer which has grown pseudomonas and Penicillin resistant Staphylococcus aureus, currently being treated with Vancomycin and Ceftazidime. 10. Right femoral-tibial bypass. 11. Microcytic anemia. MEDICATIONS: Aspirin 325 mg p.o. q.d., Vitamin C 500 mg p.o. b.i.d., Zinc 320 mg p.o. q.d., Atenolol 25 mg p.o. q.d., Univasc 15 mg p.o. q.d., Heparin subcue 5000 U b.i.d., Morphine Sulfate 15 mg p.o. b.i.d., Tylenol, Peri-Colace, Neurontin 400 mg p.o. b.i.d., Iron Sulfate. ALLERGIES: PENICILLIN. SOCIAL HISTORY: The patient is a nursing home resident. He has smoked ................ but quit 20 years ago. PHYSICAL EXAMINATION: Vital signs: Temperature 98.2??????, pulse 80, blood pressure 94/56, respirations 18. General: The patient was a pleasant white male in no apparent distress. HEENT: Pupils equal, round and reactive to light. Extraocular movements intact. Sclerae anicteric. Moist mucous membranes. Neck: Supple. Pulmonary: Rhonchi, right greater than left. Good air movement bilaterally. Cardiovascular: S1 and S2 normal. No murmurs, rubs or gallops. Abdomen: Soft, nontender, nondistended. Normal bowel sounds. Extremities: Right heel ulcer with no purulent drainage. Neurological: The patient was alert and oriented times three. Cranial nerves II-XII grossly intact. No focal weakness. LABORATORY DATA: White count 9.0, hematocrit 31.2, platelet count 285; sodium 139, potassium 4.6, chloride 102, bicarb 27, creatinine 0.6, BUN 44, glucose 116; INR 1.0, PTT 31.7. EGD results in [**2148-12-27**] showed multiple gastric arteriovenous ulcerations which were cauterized. Esophagogastroduodenoscopy on [**2149-11-7**], showed large clot in the stomach, erosions on the fundus of the stomach. Abdominal CT was also obtained which showed abdominal aortic aneurysm at 5.6 x 4.6 cm. There was no evidence of aortoenteric fistula. Electrocardiogram showed normal sinus rhythm with a rate of 74, occasional premature atrial contractions, normal axis, poor R-wave progression. HOSPITAL COURSE: The patient had an upper gastrointestinal bleed as proven by the esophagogastroduodenoscopy. Because of the presence of the large clot which obscured visibility, the intervention was delayed at that time. He was sent to the Intensive Care Unit where his hematocrit was closely followed. 1. GI: The patient was noted to have an upper gastrointestinal bleed. After the esophagogastroduodenoscopy, it was decided that he would be made NPO and allow his stomach to clear. After 48 hours, repeat esophagogastroduodenoscopy was performed in an attempt to locate or assessing for any active bleeding. Also hematocrit was checked every six hours. Protonix was started at 40 mg p.o. b.i.d., and his Aspirin was discontinued promptly. In the setting of essential hypotension. His cardiac medications were also held, particularly his ACE inhibitors and beta-blockers were temporarily held. He received 2 U of blood in the Emergency Room and also received 2 U in the Intensive Care Unit. His subcue Heparin was also discontinued. A repeat esophagogastroduodenoscopy was performed on [**2149-11-9**]. During this procedure, an ulcer at the proximal less curvature of the stomach with surrounding blood was seen. Active bleeding was noted during exam, and it was cauterized followed by injection of Epinephrine. Successful hemostasis was achieved. No signs of bleeding occurred after the procedure was over. The patient remained in the Intensive Care Unit and received another unit of blood for a hematocrit of 29.8. On the following day, [**11-10**], the patient was considered stable enough to be transferred to the floor where he was transferred to the [**Doctor Last Name **] Firm. His hematocrit there was checked b.i.d. On [**11-10**], his hematocrit remained stable and was 32.9, and the evening check was similar. The following day, it was 33.3. His gastrointestinal bleed was considered to have stopped. His Protonix is to be continued at 40 mg p.o. b.i.d. His Aspirin will continue to be held in light of his recent GI bleed. 2. Infectious disease/extremities: The patient has a history of a right heel ulcer. He was seen by Plastic Surgery and Podiatry concerning this right heel ulcer. This had grown out pseudomonas and Methicillin resistant Staphylococcus aureus, so he is being treated with Vancomycin and Ceftazidime. His course is to be conducted for two weeks, ending on [**2149-11-15**]. He already has a .............. The antibiotics were continued during his admission. He was seen by Plastic Surgery where dressing changes were performed. He continued to complain of pain of his right lower extremity. He was initially placed on intravenous Morphine for pain control. Once he was transferred to the floor, he was switched to MS Contin which was his regular medication. Intravenous Morphine was used mainly during bed transfers. .................. to convert him to Morphine Sulfate for immediate relief for breakthrough pain. He is to continue with his antibiotic treatment until [**2149-11-15**]. He was also seen by Orthopedics for future surgery concerning his right hip. His right hip had been replaced but had to be taken out secondary to infection. X-rays were taken at this time for future event of surgery once his right heel ulcer infection has been treated. Cardiovascular: The patient's cardiac medications were initially held in the Intensive Care Unit since concerns of hypertension were possible. On the floor, the patient was restarted on his Captopril. On the following day, his Atenolol was restarted. He had no significant decrease in his blood pressure. He remained stable. The patient is going to be discharged back to his original rehabilitation center. He is to follow-up with Dr. [**Last Name (STitle) 24918**] of Plastic Surgery on [**2149-11-24**], on Monday, at 10:30 p.m. He is also to follow-up with Gastroenterology on [**1-12**], on the [**Location (un) **] of the [**Hospital Ward Name 516**], Main Building, at 9:45 a.m. for another esophagogastroduodenoscopy. At that time, he will have to be NPO after midnight except his medications and no foot during the day of the procedure. DISCHARGE MEDICATIONS: Protonix 40 mg p.o. b.i.d., MS Contin 15 mg p.o. b.i.d., Ceftazidime 1 g IV b.i.d., Vancomycin 1 g IV q.d. both to end on [**2149-11-15**], Captopril 25 mg p.o. t.i.d., Colace 100 mg p.o. b.i.d., Celexa 20 mg p.o. q.d., Neurontin 400 mg p.o. t.i.d., Atenolol 25 mg p.o. q.d., NSIR 10 mg p.o. q.4 hours p.r.n. as needed for breakthrough pain. FOLLOW-UP: He is to follow-up with Dr. [**Last Name (STitle) 24918**] of Plastic Surgery and Gastroenterology for esophagogastroduodenoscopy. During his stay at rehabilitation, his hematocrit should still be followed on a periodic basis in the recent of upper GI bleed. DISPOSITION: The patient is to be discharged to nursing home. DISCHARGE STATUS: The patient is in fair condition. DISCHARGE DIAGNOSIS: Gastric ulcer. [**Name6 (MD) 251**] [**Name8 (MD) **], M.D. [**MD Number(1) 1197**] Dictated By:[**Name8 (MD) 4523**] MEDQUIST36 D: [**2149-11-11**] 19:31 T: [**2149-11-11**] 19:19 JOB#: [**Job Number 24919**]

[ "041.11", "V09.0", "707.14", "996.4", "280.9", "531.00", "E935.9", "041.7", "458.9" ]

icd9cm

[ [ [] ] ]

[ "44.43", "96.33", "45.13" ]

icd9pcs

[ [ [] ] ]

7752, 8485

8507, 8758

3554, 7728

2156, 3536

147, 178

207, 1163

1186, 2019

2036, 2133

24,856

169,978

7382

Discharge summary

report

Admission Date: [**2104-2-16**] Discharge Date: [**2104-2-27**] Date of Birth: [**2044-8-27**] Sex: M Service: HISTORY OF THE PRESENT ILLNESS: This 59-year-old white male has a past medical history significant for hypertension, hypercholesterolemia, and a mitral valve mass. He has had prior strokes and presented with diplopia. He denied numbness, weakness, difficulty with speech and headache. He had a CVA in [**10-29**] which presented with unsteadiness and blurred vision and was found to have a right temporoparietal occipital stroke, an old stroke from the parietal occipital and frontal areas on the left. The TE showed a 1 cm mass on the mitral valve and Neurology recommended starting Coumadin. He had stopped the Coumadin in [**Month (only) 1096**], awaiting surgery and was stable until he presented with the diplopia. PAST MEDICAL HISTORY: 1. Status post CVA in [**2074**] and in [**10-29**]. 2. History of hypercholesterolemia. 3. History of peripheral neuropathy. 4. History of PVD. 5. History of CAD, status post MI, and a history of a mitral valve mass. ALLERGIES: The patient has no known drug allergies. ADMISSION MEDICATIONS: 1. Mavik. 2. Lipitor. 3. Aspirin. 4. Hydrochlorothiazide. SOCIAL HISTORY: He smoked two packs per day and has for 20 years. Drinks alcohol occasionally and lives with his wife. FAMILY HISTORY: Significant for coronary artery disease. REVIEW OF SYSTEMS: As above. PHYSICAL EXAMINATION ON ADMISSION: General: He is a well-developed, well-nourished white male in no apparent distress. Vital signs: Blood pressure 150/70, heart rate 68, afebrile. HEENT: Normocephalic, atraumatic. Extraocular movements intact. The oropharynx was benign. The neck was supple, full range of motion. No lymphadenopathy or thyromegaly. Carotids 3+ and equal bilaterally without bruits. Lungs: Clear to auscultation and percussion bilaterally. Heart: Regular rate and rhythm. Normal S1 and S2, no murmurs, rubs, or gallops. Abdomen: Soft, nontender with positive bowel sounds, masses. Extremities: Without clubbing, cyanosis or edema. Pulses were 2+ and equal bilaterally throughout. Neurologic: Horizontal diplopia and otherwise unremarkable, slightly ataxic on the left. HOSPITAL COURSE: He was admitted and had an LP which was negative. He had an MRI/MRA which revealed no obvious new strokes. Cardiac Surgery was consulted. On [**2104-2-19**], the patient underwent excision of a mitral valve mass. The cross clamp time was 31 minutes, total bypass time 49 minutes. He tolerated the procedure well. He was transferred to the CSRU on Neo and propofol. He was extubated and he required aggressive pulmonary therapy postoperatively. His neurological symptoms had resolved. The chest tube was discontinued on postoperative day number two. He continued to require aggressive pulmonary therapy and was started on Levaquin. On postoperative day number three, he was transferred to the floor in stable condition. He then went into A fib/A flutter. He was treated with Lopressor and then developed a first-degree AV block. He then converted to sinus on postoperative day number seven. He was being anticoagulated as the pathology from his mass came back as a clot. On postoperative day number eight, he was discharged to home in stable condition and was started on Lovenox along with his Coumadin per Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 696**]. DISCHARGE MEDICATIONS: 1. Aspirin 81 mg p.o. q.d. 2. Flovent two puffs b.i.d. 3. Atorvostatin 20 mg p.o. b.i.d. 4. Tri-Cor 54 mg p.o. q.d. 5. Metoprolol 75 mg p.o. b.i.d. 6. Lasix 20 mg p.o. q.d. for one week. 7. Potassium 20 mEq p.o. q.d. times one week. 8. Percocet one to two p.o. q. four to six hours p.r.n. pain. 9. Lovenox 90 mg subcutaneously b.i.d. until his INR is greater than 2 then it can be discontinued. 10. Coumadin 5 mg p.o. tonight and PT/INR on [**2104-2-28**] with the results called to Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] and he will dose appropriately. LABORATORY DATA ON DISCHARGE: Hematocrit 41.1, white count 8,600, platelets 350,000. Sodium 140, potassium 4.1, chloride 102, C02 28, BUN 42, creatinine 1.7, blood sugar 104. INR 1.2. He will be followed by Dr. [**Last Name (STitle) **] in four weeks and Dr. [**Last Name (STitle) **] in one to two weeks and Dr. [**Last Name (STitle) 696**] in three to four weeks. DISCHARGE DIAGNOSIS: 1. Cerebrovascular accident. 2. Mitral valve mass. 3. Hypercholesterolemia. 4. Peripheral vascular disease. 5. Coronary artery disease. [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3113**] Dictated By:[**Last Name (NamePattern1) 11726**] MEDQUIST36 D: [**2104-2-27**] 02:26 T: [**2104-2-27**] 15:15 JOB#: [**Job Number 27164**]

[ "427.31", "401.9", "424.0", "443.9", "414.01", "436", "426.11", "412", "272.0" ]

icd9cm

[ [ [] ] ]

[ "37.33", "39.61" ]

icd9pcs

[ [ [] ] ]

1382, 1424

3499, 4110

4486, 4908

2279, 3476

1180, 1243

4125, 4465

1444, 1476

1491, 2261

879, 1157

1260, 1366

16,023

186,243

23364

Discharge summary

report

Admission Date: [**2151-11-17**] Discharge Date: [**2151-11-20**] Service: SURGERY Allergies: Morphine / Meperidine / Nsaids / Indomethacin / Methyldopa Attending:[**First Name3 (LF) 1556**] Chief Complaint: Left Temporal Lobe SAH Major Surgical or Invasive Procedure: none History of Present Illness: 84 year old female post fall with question of syncope, loss of consciousness. Two days prior to admission patient had diarrhea and complaints of dizziness. She was taken to [**Hospital 8641**] Hospital where a head CT scan was performed revealing left subarachnoid hemorrhage. Patient has been on coumadin for atrial fibrillation; INR 2.4 on admission. She received 3 units of fresh frozen plasma and Vit K At [**Hospital 8641**] Hospital. Past Medical History: HTN Afib DM Type II Abdominal Hernia Social History: Lives with daughter Family History: Noncontributory Physical Exam: Vitals: 98.6, 82(AF), 120/46, 17, 100% on 2L NC Gen: A/0x3, NAD, sitting up in bed HEENT: supple neck, ecchymosis over posterior scalp, mucous membranes moist Pulmonary: LCTA Cardiovascular: irregularly irregular Abdomen: soft, NT and ND, abdominal hernia Skin: warm and well perfused, rash or cyanosis NEURO EXAM: MENTAL STATUS: Alert, and oriented to place, date, and person. Attention intact, able to spell WORLD backwards and do MOYB. Language flow, content, repetition and prosody normal. Comprehension intact. No paraphasic errors. Patient can register [**2-17**] and recall [**12-19**] after five minutes with category clue. Naming intact to high and low frequency objects. No visuospatial deficit. No problems calculating. [**Name2 (NI) **] apraxia. CRANIAL NERVES: Visual fields full. Decreased visual acuity bilaterally, R>L but able to read a sentence. Dipolpia not present. PERRL 4 3mm bilaterally. Accomodation intact. Gaze midline at rest. No ptosis. EOMs intact. No nystagmus. Patient hard of hearing but rigorous testing not performed to characterized deficit. Facial sensation intact for fine touch and temperature. No facial droop. Palate elevates symmetrically. Shrug [**4-21**]. Head version in all directions [**4-21**]. Tongue movement strong, and protrudes at midline. MOTOR: No atrophies or fasciculations. Patient moves all extremities. Tone normal. Pronator drift not present. Strength grossly normal in all limbs. More specifically: Upper extremities: bilateral deltoid, triceps, biceps, wrist and finger extensors, interosseous muscles [**4-21**]. Lower extremities: IP 4+/5 bilaterally, hamstrings, TA [**4-21**] bilaterally. REFLEXES: Normal and symmetric in UE and LE. No clonus. R toes mute. L toes equivocal. COORDINATION: No tremor. FTN normal. SENSATION: Fine touch and temperature sense intact and symmetric throughout. Very mildly diminished vibration and joint position sense to feet bilaterally. GAIT: Gait and Romberg not assessed as patient is confined to bedrest until Head CT. Pertinent Results: Pertinent laboratories upon admission: [**2151-11-17**] 08:04PM GLUCOSE-73 UREA N-26* CREAT-0.9 SODIUM-146* POTASSIUM-3.3 CHLORIDE-111* TOTAL CO2-25 ANION GAP-13 [**2151-11-17**] 08:04PM CK(CPK)-71 [**2151-11-17**] 08:04PM CK-MB-NotDone cTropnT-<0.01 [**2151-11-17**] 08:04PM CALCIUM-8.8 PHOSPHATE-2.6* MAGNESIUM-1.2* [**2151-11-17**] 08:04PM WBC-5.3 RBC-2.89* HGB-8.5* HCT-24.9* MCV-86 MCH-29.4 MCHC-34.1 RDW-14.0 [**2151-11-17**] 08:04PM PLT COUNT-206 [**2151-11-17**] 08:04PM PT-15.0* PTT-29.9 INR(PT)-1.4 Brief Hospital Course: This 84 year old woman was admitted with a history of atrial fibrillation, MI, HTN and NIDDM post unwitnessed fall with likely loss of consciousness in the setting of nausea, vomiting and diarrhea. The exam and history seemed most consistent with syncope in the setting of dehydration after GI upset. Her fall did not seem to be a result of neurologic pathology according to the neurology service that followed her during her stay. The short duration loss of consciousness and lack of any evidence of post-ictal state made seizure an unlikely etiology. Her condition was stable and she showed no mental status or neurologic deficits after the fall. Imaging via CT scan suggests that the SAH was not expanding during her stay. The patient was also followed closely by neurosurgery who suggested CT scan of the head on hospital day two to follow for any change in her subarachnoid hemorrhage of which there was none. The patient was also intially placed on hourly neurologic checks until after the repeat CT scan. Blood pressure was kept at a goal of under 140 systolically and a full syncopal workup was pursued. There were no significant findings in this workup. She ruled out for myocardial infarction and did not have any orthostasis. Patient also received dressing changes for a decubitus ulcer with duaderm, was frequently rolled and her nutritional status was fully assessed and found to be more than adequate. On the day of discharge her pain was well controlled, she was tolerating a full diet, was ambulating with some assistance and was discharged to her home after clearance from physical therapy. The case was discussed at great length with the family throughout her stay. Dr. [**First Name (STitle) **] was noted by the family to be particularly informative in regards to the plan of care and what would be required of the family after discharge. Although she was cleared by physical therapy to be discharged home, it was stressed thoroughly that Mrs. [**Known lastname **] was not to be left unsupervised for any period of time as she had a significant risk for a repeat fall. Medications on Admission: Coumadin, Lopressor, ASA, HCTZ, Prilosec, Imdur, Lasix and Glyburide Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 2. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 3. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 4. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 3 days. Disp:*3 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Location (un) **] VNA Discharge Diagnosis: Left temporal Subarachnoid Hemorrhage Discharge Condition: stable Discharge Instructions: Patient to be discharged to home with services for dressing changes for decubitus ulcer with duaderm, home physical and occupational therapy. Patient is to be supervised 24 hours a having worsening pain, fevers, chills, nausea, vomiting, dizziness, lightheadedness, or if there are any questions or concerns. Resume prilosec. Do not take aspirin or coumadin until further notice. Followup Instructions: Patient to follow up with primary doctor in [**1-19**] days and to call to schedule an appointment. Patient not to take coumadin or aspirin upon discharge until further follow up. Patient to follow up with radiology in 10 days for head CT scan as follow up, call to schedule at [**Telephone/Fax (1) 16718**]. Patient to follow up with neurosurgery, Dr. [**Last Name (STitle) 1327**] in [**9-27**] days at [**Telephone/Fax (1) 1669**], call to schedule an appointment. Patient to follow up with neurology in [**9-27**] days at [**Telephone/Fax (1) 44**], call to schedule an appointment.

[ "E884.9", "852.06", "401.9", "458.0", "250.00", "427.31" ]

icd9cm

[ [ [] ] ]

[ "99.04" ]

icd9pcs

[ [ [] ] ]

6152, 6207

3511, 5613

290, 297

6288, 6296

2963, 2988

6725, 7316

882, 899

5732, 6129

6228, 6267

5639, 5709

6320, 6702

914, 1231

228, 252

325, 768

1693, 2944

3003, 3488

1246, 1677

790, 829

845, 866