ChanBeDu/relevant_section_length · Datasets at Hugging Face

15,666

168,522

49360

Discharge summary

report

Admission Date: [**2182-12-25**] Discharge Date: [**2182-12-28**] Date of Birth: [**2141-9-16**] Sex: F Service: [**Location (un) **] Medicine HISTORY OF PRESENT ILLNESS: [**Known firstname 1453**] [**Known lastname **] is a 41-year-old female with a history of polysubstance abuse and new onset of one witnessed seizure episode four days prior, who now presents unresponsive by police in her car at the side of a road. The patient has a recent history of seizure-like fall, and found her daughter, "down on the ground, shaking head to toe, and foaming at the mouth." Mother witnessed shaking from head to toe. She was unresponsive to voice. Mother called EMS, and patient recovered before arrival, and refused to be taken to a hospital, and was to be seen by a neurologist as an outpatient. driving alone when her arm began shaking at which time, she moved to the side of the road. She was found later by police unresponsive in her car with Soma (carisoprodol) missing from a recently filled prescription. Her mother also reports a history of two episodes of Soma (carisoprodol) overdose and MICU observation at an outside hospital. She was brought to the Emergency Department at the [**Hospital1 **], where vital signs were stable, she was responsive to stimuli, but not to voice. Narcan IV 2 mg was administered in the Emergency Department without response, she was intubated for airway protection, fingerstick was 80, and she was given activated charcoal. Urinary tox screen was negative. Chest x-ray in the Emergency Department was negative x2. The patient was kept in the MICU overnight for observation and extubated on [**2182-12-26**] and transferred to the Medicine Service. PAST MEDICAL HISTORY: 1. Uterine cancer status post hysterectomy. 2. Chronic neck pain status post motor vehicle accident. 2. Depression. 3. Polysubstance abuse. 4. History of Soma (carisoprodol) overdose in spring of [**2181**] requiring Intensive Care Unit observation at [**Hospital 882**] Hospital after ingesting approximately 16 pills. SOCIAL HISTORY: Patient is a smoker with a 20 year pack history, currently smokes one pack per day. Patient has a positive alcohol history, last drink reportedly several months ago, and does have a history of blacking out. Positive history of cocaine abuse. Patient was most recently in a drug rehabilitation program at Bornwood of which today on her day of admission was to be her graduation day. She is currently unemployed, and living with her parents in their [**Location (un) 2312**] home. Her parents are in their 80s. She has a grown daughter, age 25, who lives separately. FAMILY HISTORY: Her father has diabetes mellitus. Mother has breast cancer x2, but still living, also history of uterine cancer. ALLERGIES: No known drug allergies. ADMISSION MEDICATIONS: 1. Soma (carisoprodol) 350 mg po tid. 2. Folic acid 1 mg po q day. 3. Thiamine 100 mg po q day. 4. Celexa 60 mg po q day. 5. Neurontin 300 mg po tid. ADMISSION PHYSICAL EXAMINATION: Vital signs were a temperature max of 100.8, blood pressure 98/51, pulse of 119, respiratory rate of 20, and O2 sat of 94% on room air. Neurologically, cranial nerves II through XII were intact. Patient was arousable by loud voice, and able to converse fluently. Somewhat lethargic. Oriented to hospital in [**Last Name (LF) 86**], [**First Name3 (LF) **] of winter in [**2182**], and to her person, 5/5 strength throughout. Downgoing toes bilaterally. Two plus deep tendon reflexes. HEENT: Sclerae are anicteric. Atraumatic, normocephalic. Benign. Heart examination was regular, rate, and rhythm with no murmurs, rubs, or gallops. No carotid bruits. Pulmonary: Bilateral breath sounds. No wheezes, crackles, or rhonchi. There were mild right basilar crackles. Abdominal examination had positive bowel sounds, nontender, and nondistended. There is no edema in the extremities with good peripheral pulses. LABORATORIES ON ADMISSION: Complete blood count: White blood cell count 9, hematocrit 34, platelets 240. Differential: 61 polys, 28 lymphocytes, 6 monocytes, 4 eosinophils, 0.4 basophils. Electrolytes: Sodium 136, potassium 3.1, chloride 102, bicarb 26, BUN 6, creatinine 0.6, glucose 82, magnesium 1.3, phosphorus 3.4. Liver function tests: ALT 16, AST 30, LDH 288, slightly elevated, alkaline phosphatase 28, total bilirubin 0.3. Microbiology: Blood cultures were negative. Urine tox screen was negative. CHEST X-RAY: On [**12-25**] negative. Chest x-ray on [**12-26**] negative. Head CT scan [**12-25**] negative with only mucosal thickening in the ethmoid sinus. ELECTROCARDIOGRAM: Sinus tachycardia at 90-100. Normal axis. Normal intervals. No evidence of ischemia. Poor R-wave progression, essentially normal electrocardiogram, interpreted with Dr. [**First Name (STitle) **] [**Name (STitle) 9835**]. ASSESSMENT AND PLAN: [**Known firstname 1453**] [**Known lastname **] is a 41-year-old female with a history of polysubstance abuse and reported by mother to have a history of two previous MICU admissions for Soma pill overdose and an initial history of witnessed seizure four days prior to admission, who presents to the [**Hospital1 346**] unresponsive at the side of the road in her car. The plan was to observe patient overnight in the MICU, and on further improvement, to explore underlying etiology of her initial unresponsiveness. 1. Cardiac: Placed on Telemetry. Electrocardiogram for possible cardiac origin. 2. Neurology: Neurology consulted when mental status improved, to consider electroencephalogram and Dilantin as seizure prophylaxis. 3. Polysubstance abuse: Monitor for signs of alcohol withdrawal. Also explore for further possible history of Soma overdose as etiology. 4. Psychiatry: Consult Psychiatry to evaluate for safety and question of suicide attempts. HOSPITAL COURSE: The patient was stabilized in the MICU on hospital day #1. There on Telemetry was unremarkable, and electrocardiogram was negative for any abnormalities. The patient was extubated on hospital day #2, and transferred to Medicine [**Location (un) **] team. On hospital day #2 and hospital day #3, mental status improved to baseline. The patient remained vague regarding events surrounding the day of admission. 1. Neurology: Neurology was consulted on hospital day #2 because of a witnessed episode of seizure four days prior to admission by patient's mother. Neurology believed history is consistent with possible seizure disorder. On hospital day #2, the patient was loaded on Dilantin 1 gram and maintained on Dilantin 300 mg q day. Patient tolerated it well without any side-effects or seizure activity. We checked potassium and magnesium levels on hospital day #2. Magnesium oxide 400 mg po and potassium chloride 40 mEq were repleted. Magnesium again was slightly low on hospital day #3, and again repleted. The patient received on [**12-27**] an electroencephalogram which was reported as generally encephalopathic without any focal findings. History suggested a focal lesion on the left hemisphere because seizure in this case reportedly began on the right hand and then generalized. It was recommended by Neurology the patient is to followup as an outpatient with Dr. [**First Name8 (NamePattern2) 333**] [**Last Name (NamePattern1) **] in [**Hospital 878**] Clinic to check Dilantin level, followup with a MRI, and discussion of her electroencephalogram results. It was also emphasized to patient by attending physician, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5717**], house staff and nursing, that patient by law, cannot drive following new diagnosis of seizure disorder for at least six months and pending further evaluation by Neurology. 2. Psychiatry. We consulted Psychiatry to evaluate for safety and possible suicide attempt to explain patient's presentation. Psychiatry determined patient was not at risk for self, the episode was not a suicide attempt. The patient does have a history of depression, and we continued the patient on citalopram 20 mg po q day on hospital day #2 and citalopram 40 mg po q day on hospital day #3, and 60 mg po q day on hospital day #4. The patient was discharged on her home regimen of 60 mg po q day. 3. Polysubstance abuse. The patient had no evidence of alcohol withdrawal. We started the patient on Thiamine 100 mg po q day and folic acid 1 mg po q day throughout her hospital stay. We also wanted to check B12 and folate levels which was still pending on the day of discharge. They will be followed up by Dr. [**First Name8 (NamePattern2) 333**] [**Last Name (NamePattern1) **] in [**Hospital 878**] Clinic. 4. Anemia. Patient had an admission hematocrit of 33 and on hospital day #2, hematocrit was 30 status post 3 liters of IV fluids. On hospital day #3, the hematocrit returned to 33. Hematocrit on hospital day #2 thought to be dilutional. Stools were guaiac negative throughout. 5. Infectious Disease. Patient on hospital day #2, had bibasilar crackles and complaint of cough. On hospital day #3, the patient had slight increase in white blood cell count. We checked a chest x-ray on hospital day #3 which was not an optimal film secondary to poor inspiratory effort, but had bibasilar findings consistent with either atelectasis, pneumonia, or aspiration. Given the patient's seizure history and recent intubation and extubation, we decided to begin on hospital day #3 antibiotic treatment with levofloxacin 500 mg po q day and metronidazole 500 mg po tid x14 day course. The patient received two doses of antibiotics, and discharged on enough medications for the remaining 12 day course. It was emphasized to patient the importance of finishing antibiotic treatment, and also disulfiram-like properties of metronidazole. Patient reports that she does not currently drink alcohol. DISPOSITION: The patient is to be transported by a friend to her home, where she resides with her parents. FOLLOWUP: The patient referred we did not contact her providers, and we respected her decision. The patient is to followup with Dr. [**First Name8 (NamePattern2) 333**] [**Last Name (NamePattern1) **] in [**Hospital 878**] Clinic. The patient is given phone number. It was also emphasized to patient the importance of following up in [**Hospital 878**] Clinic for a followup MRI and to check Dilantin level. Patient will followup with her own psychiatrist and substance abuse clinic at [**Hospital **] Rehab Facility. Patient will follow up with her primary care provider. CONDITION ON DISCHARGE: Good. DISCHARGE STATUS: Home. DIAGNOSIS: 1. Aspiration pneumonia. 2. Seizure disorder, not otherwise specified. 3. Uterine cancer status post a hysterectomy. 4. Chronic neck pain status post a motor vehicle accident. 5. Depression. 6. Polysubstance abuse. 7. History of Soma (carisoprodol) overdose in spring of [**2181**] requiring Intensive Care Unit observation at [**Hospital 882**] Hospital after ingesting 16 pills. DISCHARGE MEDICATIONS: 1. Phenytoin (Dilantin) 300 mg po q day. 2. Metronidazole 500 mg po tid x12 days. 3. Levofloxacin 500 mg po q day x12 days. 4. Pantoprazole 40 mg po q day. 5. Ibuprofen 400 mg po qid prn. 6. Acetaminophen 325-600 mg po prn. 7. Citalopram 40 mg po q day. DR.[**Last Name (STitle) **],[**First Name3 (LF) **] 12-ABH Dictated By:[**Name8 (MD) 103388**] MEDQUIST36 D: [**2182-12-30**] 00:07 T: [**2182-12-30**] 05:00 JOB#: [**Job Number **]

[ "311", "E980.4", "968.0", "427.89", "305.00", "507.0", "780.09", "780.39", "305.90" ]

icd9cm

[ [ [] ] ]

[ "96.04" ]

icd9pcs

[ [ [] ] ]

2665, 2818

11081, 11548

5884, 10607

2841, 3002

3025, 3958

192, 1717

3973, 5866

1739, 2060

2077, 2648

10632, 11058

145

198,161

23672+57366

Discharge summary

report+addendum

Admission Date: [**2144-3-29**] Discharge Date: [**2144-7-14**] Date of Birth: [**2089-3-31**] Sex: F Service: SURGERY Allergies: Penicillins / Heparin Agents Attending:[**First Name3 (LF) 2777**] Chief Complaint: Nausea/vomiting Major Surgical or Invasive Procedure: Abdominal aorta and bilateral pelvic run-off, aortic dissection fenestration including transluminal balloon angioplasty, superior mesenteric artery angiography and stenting and intervascular ultrasound of aorta and iliac arteries. [**2144-3-30**] Bilateral renal artery stent. [**2144-4-10**] Abdominal aorta and bilateral pelvic runoff, aortic dissection and fenestration, removal and replacement of right renal stent, intravascular ultrasound of aorta. [**2144-4-16**] Exploratory laparotomy, Ascending aorta to superior mesenteric artery bypass, Resection of distal ileum, right colon, and transverse colon, Ileostomy. [**2144-4-22**] Subtotal colectomy and small bowel resection. [**2144-4-22**] Reexploration of abdomen with distal colon resection and distal small-bowel resection and temporary abdominal closure. [**2144-4-24**] Exploratory laparotomy with abdominal washout and temporary closure. [**2144-4-27**] Exploratory laparotomy, small bowel resection with end-to-end small bowel anastomosis, revision of ileostomy, gastrojejunostomy tube placement and abdominal closure. [**2144-5-1**] tracheostomy [**2144-5-6**] Hickman catheter placemant, [**2144-6-4**] [**2145-6-8**] HIT positive postoperative sacral decubitus postoperative fevers ?? etology History of Present Illness: The patient is a 54 year old female with a history of hypertension and recent discharge from [**Hospital 1514**] hospital 14 days ago with a Type B aortic dissection treated medically who presented to [**Hospital **] hospital on [**3-29**] with persistent nausea and vomiting and intensified back pain radiating down her spine. At [**Hospital1 **], a CT-A was performed which showed no PE and a dissection extending below the diaphragm. The patient was transferred to [**Hospital1 18**] for further management. The patient's symptoms began 3 weeks ago with band-like chest pain radiating to her back with diaphoresis. She was found at [**Location (un) 1514**] to have a Type B dissection (unknown extension) and was admitted to the ICU and discharged 14 days ago on PO labetalol, nifedipine, protonix and clonidine (doses unknown). Since her discharge, the patient has been feeling increasingly weak with intermittent nausea and bilious vomiting and has been unable to tolerate a PO diet at home. She also noted hematemesis within the past few days. She denies any blood in her stool recently but notes green diarrhea x 14 days with a history of blood in her stool at [**Location (un) 1514**]. The patient states that she has been compliant with all her medications at home. She states her back pain recently intensified as well. At [**Hospital1 18**], the patient was having bilious emesis with specks of blood with a blood pressure of 160 systolic. She was placed on a labetalol drip at 1 mg but then developed sinus bradycardia to the 50s. As a result, nipride was started and was at 0.1 on exam. The blood pressure in her left arm was 100/58 and in the right, 160/68 with a HR of 79 on nipride alone. The patient was pain-free on exam. A repeat CT chest and A/P was performed that showed a large, well-perfused false lumen extending distal to the left subclavian with the left renal artery and inferior mesenteric artery branching from the false lumen. The superior mesenteric artery did extend from the true lumen, however, is partially occluded by the intimal flap. There was no bowel wall thickening. The dissection extends inferiorly into the bilateral external iliacs into the groin. Vascular and cardiac surgery was consulted. Vascular surgery decided to monitor medically for now. Past Medical History: Hypertension Hepatitis ?unknown type s/p appendectomy h/o right shoulder surgery Social History: The patient works as a manager for [**State 19827**] Fried Kitchen. She admits to smoking 1 ppd x 38 years but has not smoked since her admission to [**Location (un) 1514**] 3 weeks ago. She admits to a history of heavy alcohol use in the past x 1 year with 4-5 beer/hard liquor 4 x a week. She denies any history of illicit drug use. The patient is not married and has four children and lives alone. Family History: No family history of aortic dissection/Marfan's. Physical Exam: a/o x 3,nad ncat, perrl, eomi neg lesions nares, oral pharnyx, auditory supple, farom, neg lymphandopathy, supraclavicular nodes cta b/l rrr without murmers soft, nttp, neg cva, pos bs Palp DP/PT B/l Pertinent Results: ECHO [**2144-3-29**] Findings: LEFT ATRIUM: Normal LA size. No spontaneous echo contrast or thrombus in the LA/LAA or the RA/RAA. RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. LEFT VENTRICLE: Symmetric LVH. Mild regional LV systolic dysfunction. RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Normal ascending aorta diameter. Simple atheroma in ascending aorta. Normal aortic arch diameter. Simple atheroma in aortic arch. Moderately dilated descending aorta Descending aorta intimal flap/aortic dissection. Flow in false lumen. AORTIC VALVE: Normal aortic valve leaflets (3). Trace AR. MITRAL VALVE: Normal mitral valve leaflets with trivial MR. TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with physiologic PR. PERICARDIUM: No pericardial effusion. GENERAL COMMENTS: A TEE was performed in the location listed above. I certify I was present in compliance with HCFA regulations. The patient was monitored by a nurse [**First Name (Titles) **] [**Last Name (Titles) 9833**] throughout the procedure. The patient was sedated for the TEE. Medications and dosages are listed above (see Test Information section). Local anesthesia was provided by benzocaine topical spray. No TEE related complications. The patient appears to be in sinus rhythm. Results were personally reviewed with the MD caring for the patient. Conclusions: The left atrium is normal in size. No spontaneous echo contrast orthrombus is seen in the body of the left atrium/left atrial appendage or the body of the right atrium/right atrial appendage. There is symmetric left ventricular hypertrophy. LV systolic function appears mildly depressed with inferior/infero-lateral hypokinesis. There are simple atheroma in the ascending aorta and aortic arch without evidence of aortic dissection. The descending thoracic aorta is moderately dilated. A mobile density is seen in descending aorta consistent with an intimal flap/aortic dissection. There is flow in the large false lumen. There is a fenestration/communication between the true/false lumen at approx. 35 cm from the incisors that may represent the point of initial intimal tear. The dissection extends proximally and ends at the takeoff of the left subclavian artery without compromising subclavian flow. There is partial thombosis of the false lumen just distal to the left subclavian artery. The dissection extends distally to abdominal aorta and extends beyond what was visualized (50 cm from the incisors).The true lumen is significantly narrowed at times but distal flow is not clearly compromised. Both coronary artery ostia were visualized in their appropriate orientation with normal color doppler signal (pulse wave doppler was not performed).The aortic valve leaflets (3) appear structurally normal with good leaflet excursion. Trace aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no pericardial effusion. IMPRESSION: Thoracic aortic dissection limited to the descending aorta (type B). Large false lumen that is partially thrombosed proximally. There is no clear evidence of distal flow compromise but clinical correlation is suggested. RENAL U.S. [**2144-3-29**] Reason: AORTIC DISSECTION, ASSESS RENAL FLOW [**Hospital 93**] MEDICAL CONDITION: 54 year old woman with extensive descending dissection to external iliacs bilaterally with left renal off of false lumen now with decreased urine output REASON FOR THIS EXAMINATION:Please assess renal flow INDICATION: Assess renal vascular flow, s/p aortic dissection. RENAL ULTRASOUND: The right kidney measures 10.3 cm. The left kidney measures 10.3 cm. No hydronephrosis or stones. No perinephric fluid collection identified. DUPLEX ULTRASOUND: Color Doppler son[**Name (NI) 867**] was performed of the renal vasculature. Normal flow is demonstrated in the right and left renal arteries. Normal waveforms are identified within the left and right main renal arteries. IMPRESSION: Normal renal ultrasound. Normal flow and waveforms are demonstrated in the main renal arteries bilaterally. CTA CHEST W&W/O C & RECONS [**2144-3-29**] [**Hospital 93**] MEDICAL CONDITION: 54 year old woman with Type B aortic dissection by CT from OSH but scan did not find distal extent. REASON FOR THIS EXAMINATION: eval extent of dissection INDICATION: Type B aortic dissection by CT from outside hospital but scan did not find distal extent. Evaluate dissection. TECHNIQUE: Contiguous axial images through the chest were obtained without contrast. Subsequently, following the administration of 150 cc of Optiray contrast, contiguous axial images through the chest, abdomen, and pelvis were obtained during opacification of the aorta and its branches. Multiplanar reconstructions were obtained. CTA OF THE CHEST: There is a type B aortic dissection present. The dissection begins just distal to the left subclavian artery origin of the aorta. There is a large false lumen seen to the left and a smaller true lumen. There is a fenestration in the intimal flap seen on series 3, image 18. Thus, the true and false lumens communicate. The celiac axis arises from the true lumen, though the intimal flap is abutting the origin of the celiac axis. The dissection extends into the celiac axis. The SMA similarly arises from the true lumen, though the intimal flap is protruding into the ostium of the origin of the SMA. The dissection extends into the SMA and the SMA is quite small. The right renal artery arises from the true lumen, and the intimal flap extends slightly into the ostium of the right renal artery. This is best seen on series 4, image 295. The left renal artery arises from the false lumen. More inferiorly, the [**Female First Name (un) 899**] arises from the false lumen. The dissection extends into both common iliac arteries. The dissection extends into the common external and iliac arteries on the right side. The dissection also extends into the external and internal iliac arteries on the left side. The intimal flap extends through the right external iliac artery and is seen clearly to about the level of the acetabulum. Beyond this point, it is difficult to assess. The intimal flap is no longer seen definitely in the mid portion of the left external iliac artery. There is low-density material fill to the origin of the left subclavian artery. The dissection does not clearly extend into the left subclavian artery. CT OF THE CHEST WITHOUT AND WITH CONTRAST: There is atelectasis within the lungs dependently. No consolidations. There are very small pleural effusions at the bases posteriorly. No pericardial effusion. CT OF THE ABDOMEN WITH CONTRAST: The liver, gallbladder, spleen, pancreas, and adrenals are normal. The kidneys enhance symmetrically and excrete normally, despite the left renal artery arising from the false lumen. No free air or free fluid within the abdomen. The noncontrast opacified loops of bowel are containing some fluid but are otherwise unremarkable. CT OF THE PELVIS WITH CONTRAST: The bladder, uterus, rectum, and sigmoid are unremarkable. Within the cecum, there is a rounded enhancing structure of unclear etiology. No pathologically enlarged lymph nodes within the pelvis. BONE WINDOWS: There are no suspicious osteolytic or sclerotic lesions. Multiplanar reformatted images were essential in delineating the anatomy and pathology in this case. IMPRESSION: Extensive type B aortic dissection. The dissection arises distal to the left subclavian artery. There is a fenestration between the true and false lumen. The celiac and SMA arise from the true lumen, though the dissection extends into these vessels. The residual SMA is quite small. The right renal artery arises from the true lumen and the left renal artery from the false. The [**Female First Name (un) 899**] arises from the false lumen. The dissection extends into the external and internal iliac arteries bilaterally. Brief Hospital Course: The patient is a 54 year old female with a history of HTN, Type B descending dissection who presents with persistent nausea/vomiting with possible left renal and superior mesenteric artery involvement. 1. Type B dissection - Appreciate vascular and cardiac surgery input. The patient is at higher risk for bowel ischemia given the nature of the near occlusion of the SMA by the intimal flap. In addition, there is potential renal involvement of the left renal artery as it already extends from a large false lumen. At this time, the patient will be medically managed with a nipride drip with a goal SBP 100-120. Labetalol gtt was attempted in the ER without success and was limited by sinus bradycardia to the 50s. - We will continue to monitor for signs of renal failure or bowel ischemia. - On [**2144-3-29**], the patient's urine output dropped to 15-20 cc/hr from 60-70. A stat renal ultrasound with doppler flow was obtained to evalaute renal perfusion in the setting of a left renal artery previously seen to be coming from the false lumen. In addition, her lactate was checked TID which rose from 0.7 to 1.1 on [**2144-3-29**]. Vascular and cardiac surgery were called and made aware. Then the patient developed severe left arm pain and concern was that her dissection was extending proximally. - On [**2144-3-30**] the pt went to the angiography suite and underwent successful fenestration of her abdominal aortic false lumen, and fenestration and stenting of her SMA. - [**2064-4-9**]-- Pt underwent stenting of both renal arteries as the aortic dissection had spread and had stenosed both renal arteries. [**2144-4-16**]-- Abdominal aorta and bilateral pelvic runoff, aortic dissection and fenestration, removal and replacement of right renal stent, intravascular ultrasound of aorta. [**2144-4-22**]-- Pts. bowel ischemia worsened, went to the OR for exploratory laparotomy, ascending aorta to superior mesenteric artery bypass, Resection of distal ileum, right colon, and transverse colon, Ileostomy, and subtotal colectomy and small bowel resection. Over the next week the pt underwent several laparotomies/washouts and revisions of her ileostomy. Finally, a GJ tube was placed for enteral feeding. [**2144-6-29**]-- Pt underwent a CT angiogram which demonstrated a widely patent sma graft, and a stable aortic dissection. 2. CHF, EF unknown - The patient has 10 cm JVP on exam with no known EF. Meanwhile, we will keep the patient euvolemic. An echo was perfomed on [**2144-3-29**] which showed an inferior wall that was hypokinetic and there was concern that her right coronary artery was being affected by a dissection. As a result, a TEE was to be performed on [**2144-3-29**] and cardiac surgery was made aware. 3. Transaminitis - The patient reports a history of hepatitis that was contracted from eating food in a hospital during her delivery in [**2109**]. We will recheck a hepatitis panel and trend her LFTs. We do not know her baseline. If her LFTs continue to climb, we may consider a RUQ ultrasound with concern for ischemia with known celiac involvement. 4. Coffee-ground emesis - The patient will remain NPO for now with IV protonix [**Hospital1 **]. The patient is hemodynamically stable at present. We will check her Hct TID for now. Patient [**First Name9 (NamePattern2) **] [**Last Name (un) 834**] ICU to Vicu/floor after prolonged complicated postoperative course and trach removal [**2144-3-29**] -[**2144-6-20**]. Patient remined on TPN for nutritional support because of short bowel syndrome.Viedo swallow exams negative for aspiration. PT/OT continued to work with patient.await medicade application approval for final dipos planning to rehabiltitaion. [**2144-6-25**] ID consulted for persistant fevers.patient delined and line and blood cultures sent.finalization of cultrues negative. [**2144-7-7**] placement of hickman catheter and repositioning of GJ tube. TPN was restarted and cycling of tube feeds began. [**Date range (3) 60525**] patient continued to progress. [**Date range (3) 22925**] to Rehabilitation for continued care stable. Medications on Admission: Protonix QD, Labetalol 2 tablets [**Hospital1 **], Nifedipine 1 tablet PO BID, Clonidine 1 tablet TID Discharge Medications: 1. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**1-5**] Drops Ophthalmic QHS (once a day (at bedtime)). 2. Insulin Regular Human 100 unit/mL Solution Sig: as directed Injection ASDIR (AS DIRECTED). 3. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Clonidine 0.1 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. Aluminum-Magnesium Hydroxide 225-200 mg/5 mL Suspension Sig: 15-30 MLs PO QID (4 times a day) as needed. 6. Ursodiol 300 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 7. Acetaminophen 160 mg/5 mL Elixir Sig: [**1-5**] PO Q4-6H (every 4 to 6 hours) as needed. 8. Epoetin Alfa 3,000 unit/mL Solution Sig: 3000 (3000) units Injection QMOWEFR (Monday -Wednesday-Friday). 9. Albuterol 90 mcg/Actuation Aerosol Sig: Four (4) Puff Inhalation Q6H (every 6 hours) as needed. 10. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 11. Scopolamine Base 1.5 mg Patch 72HR Sig: One (1) Patch 72HR Transdermal Q3DAYS (). 12. Opium 10 % Tincture Sig: Twenty (20) Drop PO ASDIR [**Hospital1 **] (). 13. Levocarnitine 330 mg Tablet Sig: 1.5 Tablets PO q500cc tubefeeds (). 14. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 15. Papain-Urea 830,000-10 unit-% Spray, Non-Aerosol Sig: One (1) Appl Topical DAILY (Daily). 16. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed for agitation. 17. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed. 18. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed for PAIN. 19. Dolasetron Mesylate 12.5 mg IV Q8H:PRN NAUSEA 20. Insulin Regular Human 100 unit/mL Solution Sig: as directed Injection every four (4) hours: glucose <60 [**1-5**] AMP D50% glucoses 61-150/0u glucoses 151-200/2u glucoses 201-250/4u glucoses 251-300/6u glucoses >400 [**Name8 (MD) 138**] Md. Discharge Disposition: Extended Care Facility: [**Location (un) 4047**] Nursing & Rehabilitation Center - [**Location (un) 4047**] Discharge Diagnosis: 1) Aortic dissection with mesenteric ischemia, s/p aortic fenestration and sma grafting 2) B/L renal stenosis secondary to Aortic Dissection, s/p bil. stents 3) Bowel Ischemia, s/p multiple small bowel resections, ileostomy 4) sacreal decubitus ulcer 5) Short gut syndrome Discharge Condition: stable Followup Instructions: Follow up with Dr [**Last Name (STitle) **] as directed, please call [**Telephone/Fax (1) 2625**]. Completed by:[**2144-7-14**] Name: [**Known lastname **],[**Known firstname **] I Unit No: [**Numeric Identifier 11040**] Admission Date: [**2144-3-29**] Discharge Date: [**2144-7-14**] Date of Birth: [**2089-3-31**] Sex: F Service: SURGERY Allergies: Penicillins / Heparin Agents Attending:[**First Name3 (LF) 726**] Addendum: discharge dx: thromocytopenia, SMA agraft thrombosis D/c instructions: patient should never recieve Hepain. Discharge Disposition: Extended Care Facility: [**Location (un) 4186**] Nursing & Rehabilitation Center - [**Location (un) 4186**] [**First Name11 (Name Pattern1) 168**] [**Last Name (NamePattern4) 730**] MD [**MD Number(2) 731**] Completed by:[**2144-7-20**]

[ "518.5", "557.0", "E934.2", "996.74", "427.31", "569.62", "584.9", "579.3", "557.1", "440.1", "287.4", "707.03", "276.1", "997.1", "998.59", "441.01", "576.1" ]

icd9cm

[ [ [] ] ]

[ "88.42", "88.48", "88.56", "46.21", "39.54", "46.41", "45.79", "99.15", "45.74", "96.6", "39.50", "00.14", "31.1", "45.62", "38.93", "45.73", "44.39", "39.26", "37.22", "39.90" ]

icd9pcs

[ [ [] ] ]

20073, 20341

12792, 16881

304, 1577

19427, 19435

4726, 8091

19458, 20050

4440, 4490

17033, 18977

9004, 9104

19131, 19406

16907, 17010

4505, 4706

249, 266

9133, 12769

1605, 3902

3924, 4006

4022, 4424

74,533

133,792

41446

Discharge summary

report

Admission Date: [**2137-1-23**] Discharge Date: [**2137-2-1**] Date of Birth: [**2085-4-12**] Sex: F Service: NEUROLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**Last Name (NamePattern1) 1838**] Chief Complaint: code stroke Major Surgical or Invasive Procedure: none History of Present Illness: 51 yo F with hx of [**Hospital **] transferred from [**Hospital6 302**] with facial droop and transient dysarthria. She reports waking up with symptoms around 11 AM and was last known well last night (one note from OSH reports seen normal at 0300). Her daughter called her and thought her speech was slurred and garbled. Her son who lives with her noticed a left facial droop and she was taken to [**Hospital6 302**]. EMS noted BP 169/97 and upon arrival to OSH BP as high as 221/131 with P 110. She was noted to have a left forehead-sparing facial droop and intact strength. A CTA showed an acom aneurysm. She received labetalol 20 mg IV x2 and aspirin 325 mg daily and transferred to [**Hospital1 18**]. Upon arrival, a code stroke was called. Past Medical History: -HTN Social History: -smokes tobacco daily, no etoh or drugs. 35Pack year history Family History: -mother with cerebral aneurysm rupture Physical Exam: Gen; awake, alert, NAD CV; RRR, no murmurs Pulm; CTA anteriorly Abd; soft, nt, nd Extr; no edema Neuro; MS; A&Ox3, alert, interactive. Able to relate history without difficulty. Speech fluent. Naming, repetition, and comprehension intact. Follows midline and appendicular commands. CN; PERRL 4mm-->2mm, EOMI, no nystagmus. Face sensation intact V1-V3, forehead-sparing left facial droop, palate symmetric, hearing intact to finger-rub, trapezius symmetric, tongue midline. Motor; normal bulk and tone, no drift. 5/5 strength at R and L delt, bicep, tricp, WrE, FF, IP, ham, quad, TA, gastrocs Sensory; intact to light touch and pinprick throughout Coordination; no dysmetria on FNF b/l Reflexes; upgoing toe on left Gait; deferred On discharge her main deficit was the left extremity. Her Strength was [**1-5**] at wrist flexion and [**12-5**] at finger flexion. 0/5 of finger extension, Wrist extension. She had a left facial droop. Gait was stable with a walker. Pertinent Results: ECHO: The left atrium is mildly dilated. No atrial septal defect or patent foramen ovale is seen by 2D, color Doppler or saline contrast with maneuvers. However the image quality for the agitated saline contrast study was suboptimal so cannot definitively exclude an intracardiac shunt. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is borderline pulmonary artery systolic hypertension. There is no pericardial effusion. No cardiac source of embolus identified (cannot definitively exclude). MRI Brain: FINDINGS: In comparison with the most recent examination, again a 7 x 11 mm anterior communicating artery aneurysm is redemonstrated, there is no evidence of acute intracranial hemorrhage or mass effect. There is no evidence of hydrocephalus. An area of restricted diffusion is identified involving the posterior aspect of the right caudate nucleus, extending inferiorly along the posterior limb of the right internal capsule and right putamen with no evidence of hemorrhagic transformation. These areas demonstrate low signal intensity in the corresponding ADC confirming restricted diffusion. Few foci of high signal intensity are demonstrated in the subcortical white matter, which are nonspecific and may represent areas of small vessel disease. The orbits are unremarkable, the paranasal sinuses demonstrate mucosal thickening at the ethmoidal, sphenoid and maxillary sinuses with polypoid formations, possibly representing a mucous retention cyst. Brief Hospital Course: Pt [**Name (NI) 12330**] was admitted to the neurosurgery service after having been found a large ACOM aneurysm. After an MRI was completed a right sided stroke was also demonstrated on MRI. She was then transferred to the stroke service for further care. The stroke was in the distribution of the anterior choroidal artery. Her Echo was done but was suboptimal for evaluation of a PFO. On the stroke service her main problems was uncontrolled hypertension. She was started on simvastatin 40mg PO qDay and aspirin 325mg qDay. She was placed on metoprolol XR 100mg along with Norvasc 10mg and lisinopril 40mg. Her blood pressure ranged from low 110's and 170's. She was walking stairs with PT and her blood pressure did not reach above (systolic) 180. We could not continue to add medications for blood pressure without the fear of making her hypotensive. She was evaluated by physical therapy who cleared her for home with PT. She has a scheduled appointment with neurosurgery for aneurysm coiling. She is scheduled for an outpatient ECHO to be done with a bubble study. She was encouraged to buy a blood pressure cuff for home monitoring. She is instructed not lift heavy weights > 20 lbs. Medications on Admission: Metoprolol Unknown dose Discharge Medications: 1. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 2. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 3. metoprolol succinate 100 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily). Disp:*14 Tablet Extended Release 24 hr(s)* Refills:*2* 4. lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* 5. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: 1-2 Puffs Inhalation Q6H (every 6 hours) as needed for wheezing. Disp:*1 * Refills:*0* 6. Colace 50 mg Capsule Sig: One (1) Capsule PO twice a day for 2 weeks. Disp:*28 Capsule(s)* Refills:*1* 7. senna 8.6 mg Capsule Sig: One (1) Capsule PO once a day for 2 weeks. Disp:*14 Capsule(s)* Refills:*1* 8. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* 9. aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* Discharge Disposition: Home With Service Facility: VNA of Southeastern Mass. Discharge Diagnosis: Primary Diagnosis: Right Caudate/putamen/IC stroke ACOM aneurysm Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Ms. [**Known lastname 12330**], It was a pleasure taking care of you during your hospital admission. You were admitted after you developed a facial droop and difficulty with your speech. Since your admission, some of your neurological symptoms have improved. You continue to have residual weakness of your right arm. However, we recommend continuing physical therapy as an outpatient. Please follow up with your neurosurgeon, Dr. [**First Name (STitle) **] and your neurologist, Dr. [**Last Name (STitle) **] in the next month. Followup Instructions: You will need to follow up with Dr. [**First Name (STitle) **] in Neurosurgery ([**Telephone/Fax (1) 4296**]) on [**2-21**] at 10:45 in the [**Hospital Unit Name **], [**Location (un) 3202**], [**Hospital Unit Name 12193**]. You have a follow up echocardiogram on [**2-21**] at 1:00 in the [**Hospital Ward Name 23**] Clinical Center, [**Location (un) **] ([**Telephone/Fax (1) 62**]). You have a follow up appointment with Dr. [**Last Name (STitle) **] in Neurology ([**Telephone/Fax (1) 2574**]) on [**3-15**] at 3:00 in the [**Hospital Ward Name 23**] Building, [**Location (un) 6749**]. Completed by:[**2137-2-1**]

[ "434.91", "493.90", "272.4", "784.59", "305.1", "729.89", "781.94", "437.3", "401.9" ]

icd9cm

[ [ [] ] ]

[ "03.31" ]

icd9pcs

[ [ [] ] ]

6475, 6531

4084, 5277

325, 331

6640, 6640

2286, 4061

7385, 8008

1238, 1279

5351, 6452

6552, 6552

5303, 5328

6823, 7362

1294, 2267

273, 287

359, 1113

6571, 6619

6655, 6799

1135, 1142

1158, 1222

14,263

185,591

51501

Discharge summary

report

Admission Date: [**2176-6-3**] Discharge Date: [**2176-6-5**] Date of Birth: [**2135-5-20**] Sex: M Service: MICU CHIEF COMPLAINT: Bright red blood per rectum. HISTORY OF PRESENT ILLNESS: A 41-year-old African-American male with human immunodeficiency virus, hepatitis C cirrhosis, and grade III esophageal varices, status post an admission from [**5-8**] to [**2176-5-11**], for an upper gastrointestinal bleed. At the time the patient had a colonoscopy showing internal hemorrhoids but esophagogastroduodenoscopy showed grade III esophageal varices with signs of recent bleeding in the lower and middle one-third of the esophagus. The patient underwent banding on these lesions and was discharged home. The patient followed up as an outpatient and was doing well. The patient presents to the Emergency Department with bright red blood per rectum yesterday and nausea yesterday. He denies emesis, fevers or chills. He reports having two to three bowel movements per day on lactulose. Yesterday he reports having two bowel movements with blood. This morning the patient's bowel movement was normal without blood. This afternoon he had two further bowel movements with blood. He denies vomiting. He reports lightheadedness upon sitting up. He denies abdominal pain. PAST MEDICAL HISTORY: 1. Human immunodeficiency virus; last viral load 111,000 in [**2176-4-4**]; last CD4 of 529. The patient is off HAART therapy since [**2175-12-6**]. 2. Hepatitis C. 3. Esophageal varices secondary to cirrhosis. 4. History of spontaneous bacterial peritonitis. 5. Ascites. 6. Asthma. 7. Thrombocytopenia. ALLERGIES: The patient has no known drug allergies. MEDICATIONS ON ADMISSION: Ciprofloxacin 250 mg p.o. b.i.d., Aldactone 100 mg p.o. b.i.d., Lasix 20 mg p.o. b.i.d., Nadolol 20 mg p.o. b.i.d., Prilosec 20 mg p.o. b.i.d., lactulose two to three times per day, trazodone. SOCIAL HISTORY: The patient is married. He denies use of alcohol. He reports occasional use of tobacco and intravenous drug use. He has one child. FAMILY HISTORY: The patient denies a family history of coronary artery disease. He reports a family history of diabetes mellitus and hypertension. He also has a history of colon cancer. PHYSICAL EXAMINATION ON ADMISSION: Blood pressure supine 119/60, sitting 104/52, heart rate supine was 59, heart rate sitting was 66, respiratory rate of 16, oxygen saturation 97% on 2 liters. Generally, a pleasant African-American male in no acute distress. HEENT revealed positive scleral icterus. Pupils were equal, round and reactive to light and accommodation. Extraocular muscles were intact. Mucous membranes were moist. Lungs were clear to auscultation bilaterally. Cardiovascular revealed a regular rate and rhythm without murmurs, gallops or rubs. Abdomen revealed ascites, nontender. Extremities revealed 1+ edema at feet. Neurologically, alert and oriented times three, appropriate interaction to questions. Rectal, per Emergency Department medical doctor, revealed guaiac-positive bloody stool. Back had negative spinal tenderness. LABORATORY DATA ON ADMISSION: White blood cell count 4.9, hematocrit 31.6, platelets 28. PT 19.2, INR 2.5, PTT 45.7. Sodium 132, potassium 3.9, chloride 102, bicarbonate 26, BUN 11, creatinine 0.8, glucose 133. ALT 69, AST 118, alkaline phosphatase 224, amylase 100, total bilirubin 6.2. Urinalysis was notable for specific gravity of 1.013, negative red blood cells, negative white blood cells. Electrocardiogram revealed normal sinus rhythm at 60, left axis, normal intervals, T wave inversions in III, T wave flattening in F and V, small Q wave in lead L. Nasogastric lavage was negative for blood or bile. HOSPITAL COURSE: 1. CARDIOVASCULAR: The patient was admitted to the medical intensive care unit for evaluation and management of bright red blood per rectum. Throughout his stay in the Intensive Care Unit remained hemodynamically stable without chest pain or shortness of breath. 2. GASTROINTESTINAL: On the day following admission, the patient underwent an esophagogastroduodenoscopy procedure for further evaluation of his bright red blood per rectum. On esophagogastroduodenoscopy a single nonbleeding 3-mm ulcer was found in the gastroesophageal junction. This was felt to be likely from a prior banding site. Portal hypertensive gastropathy was also noted. No esophageal varices were noted. The patient's bright red blood per rectum was considered by the Medical Intensive Care Unit and Gastrointestinal services to be secondary to his internal hemorrhoids. The patient was restarted on his outpatient dosages of diuretic medications. CONDITION AT DISCHARGE: Stable. DISCHARGE STATUS: Discharged to home. MEDICATIONS ON DISCHARGE: 1. Ciprofloxacin 250 mg p.o. b.i.d. 2. Aldactone 100 mg p.o. b.i.d. 3. Lasix 20 mg p.o. b.i.d. 4. Nadolol 20 mg p.o. b.i.d. 5. Prilosec 20 mg p.o. b.i.d. 6. Lactulose two to three times per day. 7. Trazodone. DISCHARGE DIAGNOSES: 1. Gastrointestinal bleed. 2. Human immunodeficiency virus. 3. Hepatitis C. 4. Cirrhosis. 5. Esophageal varices. FOLLOWUP: The patient will have an ultrasound prior to his next followup in the Liver Clinic on [**6-10**] at 11:45 a.m. [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 5587**] Dictated By:[**Last Name (NamePattern1) 9280**] MEDQUIST36 D: [**2176-6-5**] 14:35 T: [**2176-6-6**] 05:40 JOB#: [**Job Number 32173**]

[ "578.9", "493.90", "571.2", "455.0", "531.90", "287.5", "V08" ]

icd9cm

[ [ [] ] ]

[ "45.13" ]

icd9pcs

[ [ [] ] ]

2078, 2272

5019, 5563

4781, 4998

1714, 1908

3743, 4690

4705, 4755

149, 179

208, 1298

3140, 3725

1320, 1687

1925, 2060

16,025

155,705

24494+24495

Discharge summary

report+report

Admission Date: [**2149-4-12**] Discharge Date: Date of Birth: [**2092-3-16**] Sex: F Service: [**Last Name (un) **] PREOPERATIVE DIAGNOSES: Left adrenal tumor/[**Location (un) **] syndrome. POSTOPERATIVE DIAGNOSES: Left adrenal tumor/[**Location (un) **] syndrome. PROCEDURE: Left adrenalectomy and splenectomy. DISCHARGE CONDITION: Good. HOSPITAL COURSE: Patient is a 57-year-old female with [**Location (un) **] syndrome who was diagnose with a left adrenal tumor noted to be a cortisol producing tumor. She also has a past medical history significant for an aortic valve replacement with a St. Jude valve as well as a pulmonary arteriovenous malformation, which had recently been embolized in preparation for surgery. She presented 2 days prior to surgery in order to undergo heparinization for the aortic valve while she was off Coumadin. She was taken to the operating room on Monday [**4-14**] and underwent attempted laparoscopic left adrenalectomy. The procedure needed to be converted to open due to difficult in visualization. The spleen was also removed at the time, because an injury to the spleen was noted and the patient's need for anticoagulation postop, it was felt that leaving an injured spleen in place was not prudent. Postoperatively, the patient was placed on high dosed steroid therapy. Her hospital course was complicated by steroid psychosis, which was resolved once steroid therapy was withdrawn. Low dose steroids were replaced. Her pulmonary status also remained an issue for a 1 week postoperatively as the patient was CPAP dependent and oxygen dependent at home. This required aggressive diuresis and BiPAP therapy during the hospital. Due to the aggressive diuresis, actually the patient did have an onset of acute renal insufficiency. This was corrected with replacement of IV fluid therapy. Regarding her anticoagulation, the patient was begun on heparin drip and was noted to have some bleeding, which was obvious from her drain left in place in the surgical bed. The heparin drip was stopped and the patient was just maintained on Coumadin therapy. Her INR levels were rather variable ranging from 1.2 to 5.8. Currently on discharge she is 1.8. Right now maintained on half her Coumadin dose of 2 mg a day. Her respiratory status has reverted back to normal. She is without CPAP during the day and just uses CPAP at night. Her renal function is also back to normal with a normal BUN and creatinine as were her baseline. She did have some diarrhea in the hospital due to the multiple antibiotics she had received. We had placed her critically on Flagyl therapy. However, she does have 3 C diff toxin A is negative and a toxin B culture is pending. This is now postop day 14 and near her baseline status and will likely be discharged home. Neurologically the patient is completely at baseline. There is no evidence of psychosis at this time. Cardiovascularly she has remained stable. She is on all her home medications for anti hypertension including atenolol and amlodipine. Pulmonary wise she has also reverted back to her baseline and there is no evidence of a pneumonia. She is without CPAP during the day and uses the CPAP at night. She has a marginal pulmonary status in general but refuses adamantly to go to a rehab location where more attention could be given to her lungs. GI, the patient is tolerating a cardiac regular diet. GU, patient's renal function has resolved back to normal. She is able to void without a Foley catheter. Infectious disease, the patient is maintained on a 14 day course of Flagyl. Her cultures have all been negative, however, clinically it seemed that she may have had C difficile, thus she will be sent home on 10 days of Flagyl therapy. Heme, patient's INR today is 1.8. She is maintained on half her Coumadin dose of 2 mg and this dose should be titrated to an INR of 2.0 to 2.5 for her aortic valve. Endocrine, the patient's sugars have been well controlled under 120. She has not required insulin for 2 days. Her prednisone dose is currently 10 mg once a day given in the morning. FEN. The patient's electrolytes have been relatively normal. She is not receiving any IV fluids. This patient will be discharged home with home VNA services and home PT services. She refuses to go to a rehab location despite our every attempt. [**Name6 (MD) **] [**Name8 (MD) **], [**MD Number(1) 23293**] Dictated By:[**Last Name (NamePattern4) 61917**] MEDQUIST36 D: [**2149-4-28**] 09:11:35 T: [**2149-4-28**] 09:33:22 Job#: [**Job Number 61918**] Admission Date: [**2149-4-30**] Discharge Date: [**2149-7-17**] Date of Birth: [**2092-3-16**] Sex: F Service: MEDICINE Allergies: Codeine / Talwin / Nafcillin Attending:[**First Name3 (LF) 398**] Chief Complaint: drainage at incision site and fever Major Surgical or Invasive Procedure: EGD s/p adrenalectomy and splenectomy History of Present Illness: The patient is a 57 yo female s/p left adrenalectomy and splenectomy on [**2149-4-14**], d/c'd [**2149-4-28**], who returned to the [**Hospital1 18**] ED on [**2149-4-30**] with fever and incision site discharge. Past Medical History: cushings syndrome, AVR [**2143**], pulmonary AVM repair [**2143**] Social History: NC Family History: NC Physical Exam: VS- Temp 102, HR 88, BP 122/60, RR 28, SO2 100 % on 12L FM Gen- NAD, pleasant Heart: RRR, loud SEM Lungs: CTA b/l Abd: soft, LLQ tenderness around incision site, + purulent drainage Neuro: AxOx3 Pertinent Results: MICRO: [**6-18**]: urine, stool, blood pending [**6-14**]: stool negative [**6-14**]: urine negative [**6-13**]: CSF negative [**6-9**]: BAL-acinetobacter, S only to gent and bactrim and GNR S to bactrim [**6-8**]-swab abd wound-enterocccus [**6-8**]-urine yeast [**6-6**]-urine yeast [**6-6**]-BAL-1+ yeast, MSSA [**6-6**] wound: no growth [**6-5**] sputum: yeast, GNR [**6-5**] UCx-neg [**6-5**]-BCx pending [**6-3**]-c.diff-neg [**6-2**] VRE rectal swab: heavy growth. [**6-2**] BAL: Staph aureus and GNR [**6-1**] sputum: staph aureus and enterobacter, pan sensitive [**6-1**]: blood cx NGTD, urine-neg [**5-29**]-urine neg [**5-22**] C Diff-neg [**5-21**] blood:NGTD [**5-21**] sputum:enterobacter, staph aureus [**5-20**] blood:[**12-25**] bottle coag neg staph [**5-20**] urine:Enterobacter [**5-19**] urine: enterobacter [**5-19**] blood:neg [**5-15**] Wound Cx: [**Female First Name (un) **] [**5-15**] C diff: Neg [**5-14**] cdiff: Neg [**5-13**] cath tip: Neg [**5-12**] MRSA: Neg . <b> Studies: </b> RADS: [**6-20**]: CXR: Dobbhoff catheter tip is not included on the radiograph. Stable widening of the cardiac silhouette with left lower lobe atelectasis and right mid and basilar consolidation. [**6-19**]; CT Chest /Abdomen and pelvis: 1. Patchy ground-glass opacity of the lungs may represent persistent volume overload but is concerning for superimposed pneumonia. 2. Small bilateral pleural effusions with persistent collapse of the left lower lobe. 3. No change in a 2 cm soft tissue density adjacent to the sternum, which is of uncertain etiology but may represent a lymph node. 4. Stable inflammatory stranding in the splenectomy bed. No fluid collection or abscess identified. [**6-17**]; CXR: . Possible acute aortic dilatation or mediastinal hematoma. Evaluation should begin with upright chest radiograph. 2. Improved severe pulmonary edema. 3. Worsening left upper lobe atelectasis. Unchanged left lower lobe atelectasis. [**6-13**]: MR head w/Gd: 1. No abnormal enhancement, intraaxial masses, or abnormal signal to suggest acute infarction. 2. Thin dural enhancement along the left parietal lobe that is nonspecific in origin, but could reflect the sequelae of prior trauma (resolved subdural hematoma) or prior lumbar puncture [**6-12**]: Ct Abd/Pelv: No significant change in abdominal findings compared to prior study. Slight improvement in ground glass opacity consistent with improving edema. Interval increase in size of bilateral pleural effusions, greater on the right side. [**6-12**]: Ct head: Limited examination due to patient motion artifact. No acute intracranial hemorrhage. Density seen in the right sylvian fissure region may represent prior Pantopaque administration or may be due to focal calcification in this area. [**6-8**]: US hepatic congestion and gallbladder edema without stones or sludge, though to be due to right sided heart failure [**6-6**] cxr-heterogenous diffuse appearance [**6-5**] cxr: mod CM, bibasilar consolidation, atelectasis, worse mod pulm edema. [**6-4**] CXR: pulm edema RUL improved, dense consolidation LLL, increased L pleural eff [**6-1**] CXR: significantly worsened bilateral pulmonary edema [**5-30**] CXR: consolidation and pleural effusions persist [**5-26**] CXR: feeding tube below diaphragm. [**5-24**] CXR: pulm edema and LLL consolidation unchanged. [**5-21**] CXR: moderate fluid overload [**5-16**] CT abd: Negative for collection; [**5-14**] RUQ U/S: no biiliary pathology; [**5-14**] KUB: dobhoff in antrum, [**5-7**] CXR: patchy right opacity [**5-4**] CT head: neg [**5-4**] CT [**Last Name (un) 103**]: incr standing panc tail; [**5-1**] CXR: unchanged patchy asymmetric B opacities, L basilar opacity [**4-30**] CT abd: postop changes, bibasilar atelectasis, small B pleural effusions . ECHO: [**6-5**]: EF 70%, symmetric LVH, increased left and right filling pressures, dilated R ventricle. . ABX [**Date range (1) 61919**] flagyl [**Date range (1) 61920**] vanc [**Date range (1) 61920**] zosyn [**Date range (1) 30469**] fluconazole [**Date range (1) **] ceftazidime [**Date range (1) 3046**] vanco [**Date range (1) 29219**] flagyl [**Date range (1) 61921**] cefepime [**2155-6-2**] vanc/cefepime [**Date range (1) 61922**] flagyl [**Date range (1) 61923**] Nafcillin [**Date range (1) 61924**] levo [**Date range (1) 25250**] ceftaz [**Date range (1) 10233**] vancomycin [**Date range (1) 61925**] cefepime [**6-11**] bactrim Brief Hospital Course: The patient was admitted to [**Hospital1 18**] on [**2149-4-30**] with a post operative fever and incision site drainage. She was pan cultured at that time and started on Zosyn and Flagyl empirically. A CXR at that time demonstrated patchy asymmetric opacities bilaterally, concerning for pneumonia. She refused a CPAP mask but accepted 12L face mask oxygen. She is home CPAP dependent. She was kept NPO. Her coumadin was held in case she needed an operation or drainage of an abscess. She was started on 10mg Prednisone, as she has known adrenal insufficiency. She tolerated her own CPAP machine overnight. A CT scan with contrast showed prominent inflammatory stranding in the left upper quadrant and around the pancreatic tail, most likely representing postoperative changes. There was also a tiny amount of fluid in the splenic fossa, but no drainable collections were identified. There was also bibasilar atelectasis and small bilateral pleural effusions. On HD 2 her diet was advanced. Zosyn was discontinued. PT/OT saw her and recommended rehab. We treated her with aggressive pulmonary toilet. A CXR was unchanged. Later that night the patient had an acute event- Her HR was in the 40's with decreased oxygen saturations and no palpable pulse. Chest compressions were begun and she was intubated emergently. She was given epinepherine X 1 and her HR improved to 100. She was saturating 100%. Her BP was 100/50. A right IJ TLC was placed. She was transferred to the ICU. She was sedated with propofol. On HD 3, A chest X-ray demonstrated severe pulmonary edema. Cardiac enzymes were cycled and were not elevated. An echocardiogram showed an EF > 55%, moderate TR, and mild-moderate pulmonary HTN. She was kept NPO. Her createnine bumped to 3.4, likely as a result of contrast nephropathy. She was started on Vancomycin and Zosyn in addition to her Flagyl, as she was febrile to 102 and may have gone into septic shock. Her TLC was changed to a Swann Ganz catheter for better monitoring of her fluid status given her new onset ARF and pulmonary edema. On HD 4, she was off of Levophed and she remained hemodynamically stable all day. Endocrinology saw the patient and started hydrocortisone at 100mg Q 8 hours for stress dose steroids. The renal service saw her and did not recommend dialysis at this time, but they did recommend limiting her fluid intake. She had only low grade temperatures that day. Her UOP was 91 for the day. On HD 5, her createnine was up to 4.0. Her WBC was 18. A CT of the head was negative. A repeat CT of the abdomen without contrast showed increased inflammatory stranding and possibly a small amount of fluid around the pancreatic tail, bilateral pulmonary effusions (worsening on the right), but no extravasation of prior contrast and no fluid collections around the surgical incision. Trophic tube feeds were started. Her Swann Ganz catheter [**Location (un) 1131**] were consistent witha septic picture (SVR 358, CI 6.10). She made 355 cc of urine and was afebrile. ON HD 6, her createnine was 4.0. Her WBC was 15.8. Her Hct was 23.7. She was transfused 2 units of RBC for blood loss anemia. Renal saw her and determined that she was much improved with no need for HD. Endocrine put her on 37.5 mg hydrocortisone QID. GI saw her for hematemesisand performed a bedside EGD, which was remarkable only for mild antral gastritis. Her Protonix was increased to 40mg [**Hospital1 **]. A heparin drip was started for aortic valve prophylaxis (goal PTT 40-60). She had a Tmax of 101. Her urine output was 1122 for the day. On HD 7, her Swann was changed to a TLC. TPN was started since she was not tolerating her tube feeds. Her createnine was down to 2.1. Her hydrocortisone was tapered to 25 mg QID. Her GI bleeding resolved. She made 520 cc of urine over the course of the day. On HD 8, her createnine was down to 0.9. Her WBC was 15 and her Hct was 25. Her ventillator was weaned to CPAP with PS. Diuresis was begun with Lasix. Fentanyl was changed to PO Oxycodone and Lopressor was changed to PO as well. On POD 30, the decision was made to continue abx until a 14 day course of vanco/zosyn and 10 day course of flagyl was completed. The patient was taken to the OR on POD 31 for an open trach and placement of RSC 3xCVL by Thoracic team. LFT's were tested and WNL except for elevated Alk-phos. Patient's foley was replaced based on +UA from POD30, and presence of yeast. On POD32 slow vent weaning was attempted with probable vent rehab being needed. Hydrocortisone was dropped to 25q8 and a RUQ US was done to because of elevated AP levels, but did not show pathology. Patient had tube feeds continued to goal as propofol was gradually weaned with initiation of Haldol prn for agitation. Attempts to diurese patient were started on POD33 with initiation of prn Lasix with good response by patient. Patient had propofol weaned off by POD34 with increased haldol requirements and occassional ativan for agitation. Patient was transfused for 1unit Prbc as Hct drifted to 20.8. WBC increased to 29.2 for which CT scan of abdomen was repeated with no new pathology/abscesses identified. Patient had continued vent weaning, agitation control, and TF's continued while sources of infection were worked up. Patient failed to tolerated vent weaning and was placed on CPAP/PS with increased PEEP/PS levels of 15/15 on POD39. For continued fevers and discover of 3+GNR in sputum and GNR in urine, ID was consulted with resultant institution of ceftaz and flagyl for empiric C.Diff, and the patients foley/CVL were exchanged. Ceftaz was converted to cefepime when urine cultures showed enterobacter resistance to ceftaz. Patient maintained this hospital course except for initiation of free water by feeding tube for hypernatremia, and continued Peep/Psupp wean. patient developed tachypnea and increased WOB overnight on [**5-31**] for which her Peep/Psupp was increased and patient was given 1unit pRBC. Patient improved over the course of [**6-1**] until she had a temperature spike to 103.1 (the first following antibiotic course completion) and sputum culture showing GPC pairs/clusters and GN diplocci. Because of poor defervesence throughout [**6-1**] the patient was empirically started on vanco/cefepime/flagyl. Patient noted to have a WBC of 24.3 on [**6-2**] and ID was reconsulted, who recommended Flagyl and Nafcillin as cultures from sputum showed MSSA. Renal was also consulted for isolated BUN increase in presence of stable Cr with recs c/w high protein TF concentration and steroid use in patient. #. Recurrent fevers: Patient had recurring fevers during her hospitalization. Recent BAL from [**6-9**] showed no MSSA, but GNR and acinetobacter sensitive to bactrim. Repeat BAL from [**6-23**] also showed bactrim-resistant acinetobacter, but no PMN's. Vancpmycin course completed for 14 days for MSSA pneumonia. Sputum cx showed Acinetobacter. Pt completed 14 day course of Bactrim. (D/Cd Cefepime when sensitivities returned). Infectious disease was consulted and when sputum culture grew aztreonam resistant acinetobacter, ID felt that it did not need to be treated with gentamycin. She completed a course of 7 days of Vancomycin, Levofloxacin, fluconazole and flagyl and has been off of these antibiotics several days prior to discharge from the hospital. She has been CDiff negative. Repeat CT abdomen [**6-12**] showed possible 2 cm organizing fluid collection which was not felt to be an abscess. Another CT scan on [**6-19**] showed stable inflammatory stranding of splenectomy bed, but no abscess. IR was contact[**Name (NI) **] and it was felt that this was not a drainable fluid collection. On [**6-21**], sent wound drainage from left chest wall at JP drain site for amylase, lipase to r/o pancreatitis as cause of persistent wound. Wound drainage did have amylase and lipase, however this was felt to be of unclear significance. The wound has since stopped draining. Patient also has a soft tissue mass near sternum (possible Lymph node) which has not changed in size from 1 year prior and was not FDG avid at that time. Bronchoscopy was repeated on [**6-26**] and grew acinetobacter. Per ID consult she repeated another course of will Flagyl, Levo and Vanc for a total of 14 days, last day was [**7-12**]. Transesophageal Echocardiogram was performed on [**7-8**] and did not show any valvular vegetations. On [**7-14**] Tmax over previous 24 hours was 100.5F, on [**7-15**], Tmax was 99.8F and on [**7-16**], Tmax was 100/0F. Her fever curve seems to be continually improving off antibiotics. The source of fevers continue to be unknown. . #. Delirium: Unclear etiology. Suspect steroid psychosis vs steroid withdrawl psychosis vs icu psychosis vs non conculsive seizure. EEG done, no epileptiform activity. CT head showed no acute pathology to account for mental status. MRI negative, LP negative. 24 hour EEG negative. Mental status had improved, now pt extremely tremulous and tachycardic (likely due to fever). Appreciate neuro recs. Gradually, klonopin, seroquel, olanzapine were discontinued. She received ativan 1mg iv prn (and received 1-3 times/day depending on her anxiety level. Her mental status seems much improved and she no longer seems delerious. . #. Respiratory Failure: Likely due to pneumonia, CHF, COPD. Patient remained on CPAP + PS -> [**2149-6-21**]: Not able to reduce PEEP from 8. Pt tolerated decreased PS of [**7-29**], but was occasionlly tachypneic and PS was increased. Her vent was weaned and she was receiving trach mask trials for a couple of hours a day to strengthen her respiratory muscles as it was felt that her difficulty with weaning from the vent was from deconditioning. She was continued on combivent, fluticasone. On [**7-11**] attempt trach mask trial again, NIF 16, RSBI 60s. . #. Anemia: Acute drop in hct from 24 to 19 on [**6-8**]. Guaiac positive brown stool and also with bloody respiratory secretions and blood on BAL. Had antral gastritis earlier in course. Now resolved. Pt had hemoccult + vomiting on [**6-18**] and [**6-9**]. She has been on anti-coagulation for her aortic valve replacement. Her Hematocrit has remained stable in the low 20's (mainly 22-24). . #. ARF: Secondary to AIN from Nafcillin. Prior to that had ATN from contrast dye. Creatinine has improved, urine output has been good and renal function appears back to baseline. . #. CV: Patient with no known CAD, at home was on atenolol, norvasc and dyazide for BP. Weaned clonidine. She was restarted on metoprolol 25mg [**Hospital1 **] -> titrated to 50mg [**Hospital1 **] on [**7-8**] and HR/BP are tolerating this. . #. Adrenal insufficiency: s/p adrenalectomy with presumed adrenal insufficiency due to suppression of other adrenal by a cortisol secreting adenoma. Now should have adrenal insufficiency regardless based on high doses of cortisol for 2 months. Began steroid wean with goal to reach physiologic doses over a very long wean period. Per Endocrinology a cortisol stim test would not be reliable at this point. Was on 25/10/10 of hydrocortisone and changed to equal dose of prednisone 10 qday as pt had at one point in [**Month (only) 547**] improved mental status on prednisone and wished to determine if mental status would improve. Has improved mental status since change with no hemodynamic abn, only increased temp. Would favor continuing prednisone and not switching to hydrocortisone. Appreciate endocrinology recommendations. PTH slightly low at 13, which is likely in response to elevated calcium. 25-hydroxy Vitamin D level was slightly low at 18 and Vitamin D [**1-15**] Dihydroxy was pending at time of discharge. . #. Hypercalcemia: Consulted endocrine and rechecked PTH, sent off 25-OH and 1,25-OH Vit D. PTH was slightly low at 13, 25-OH was slightly low at 18 and Vitamin D [**1-15**] OH was pending at time of discharge. Gave occasional doses of lasix 20 iv once with iv fluids to reduce calcium levels. . #. Anticoagulation: For St. Jude's valve. Heparin drip was transitioned to coumadin and her INR was supratherapeutic at time of discharge. Coumadin should be restarted when INR < 3.5. . #. Elevated Alkaline phosphatase with elevated GGT: trending down. US [**6-8**] showed only liver hemangiomas which are not new. [**Month (only) 116**] be due to secretion from small bowel or pancreas. R UQ remains unchanged. Appreciate Hep recs, considered MRCP to further evaluate liver lesions, and then possibly liver biopsy depending on results of MRCP. However, pt currently not able to hold breath for MRCP (would require paralysis). Will hold off on MRI for now. . #. PPX: PPI, IV heparin, pneumoboots. . #. FEN: tube feeds, repleted electrolytes prn. Consulted surgery for PEG, but holding until fevers resolve. Post pyloric tube placed. . #. Access: L PICC placed [**2149-5-27**], removed [**2149-6-18**]. R double lumen PICC placed [**2149-6-18**] by IR and no evidence of infection at this site. . #. Code: Full . #. Dispo: To rehab. On discharge to rehab, INR was supratherapeutic at 4.2. Coumadin needs to be restarted at rehab when INR < 3.5 (goal 2.5-3.5 for AVR). . #. Comm: with daughter Medications on Admission: Prednisone 10 daily atenolol 50 daily norvasc 10 daily dyazide 37.5/25 lipitor 20 lasix 40 [**Hospital1 **] coumadin 2 daily foradil 12 [**Hospital1 **] albuterol 2 puffs tid singulari 10 daily flagyl abmanex 220 daily Discharge Medications: 1. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID (4 times a day) as needed. 2. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [**Hospital1 **] (2 times a day). 3. Albuterol 90 mcg/Actuation Aerosol Sig: Six (6) Puff Inhalation Q4H (every 4 hours) as needed. 4. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Six (6) Puff Inhalation Q4H (every 4 hours). 5. Zinc Oxide-Cod Liver Oil 40 % Ointment Sig: One (1) Appl Topical PRN (as needed). 6. Lidocaine HCl 5 % Ointment Sig: One (1) Appl Topical PRN (as needed). 7. Polysaccharide Iron Complex 150 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 8. Acetaminophen 160 mg/5 mL Solution Sig: [**12-23**] PO Q4-6H (every 4 to 6 hours) as needed. 9. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) PO BID (2 times a day). 10. Prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 12. Insulin Regular Human 100 unit/mL Solution Sig: One (1) Injection ASDIR (AS DIRECTED). 13. Heparin Flush PICC (100 units/ml) 2 ml IV DAILY:PRN 10 ml NS followed by 2 ml of 100 Units/ml heparin (200 units heparin) each lumen Daily and PRN. Inspect site every shift. 14. Sodium Chloride 0.9% Flush 3 ml IV DAILY:PRN Peripheral IV - Inspect site every shift 15. Pantoprazole 40 mg IV Q24H 16. Morphine Sulfate 1-2 mg IV Q4H:PRN 17. Lorazepam 1 mg IV BID:PRN 18. Dolasetron Mesylate 12.5 mg IV Q8H:PRN coumadin currently on hold for supratherapeutic INR, should be restarted when INR < 3.5 Discharge Disposition: Extended Care Facility: [**Hospital1 700**] - [**Location (un) 701**] Discharge Diagnosis: Post operative wound infection, cardiopulmonary arrest, blood loss anemia, gastritis, acute renal failure, adrenal insufficency Discharge Condition: stable Discharge Instructions: Please call or come to the ED with fevers > 101, redness/warmth/drainage/tenderness around your incisions, nausea, vomiting, abdominal pain, shortenss of breath, chest pain, or any other unusual and worrisome event. Please continue with your CPAPO every night. You may shower and resume regular diet. . You should have you blood checked and coumadin should be restarted when INR < 3.5 for goal 2.5-3.5. Followup Instructions: Please follow-up with your primary care physician upon discharge from Rehab. You should have bloodwork checked every other day until INR < 3.5 when coumadin should be restarted (consider 1-2mg coumadin po qhs). INR on day of discharge was 4.2.

[ "599.0", "112.2", "482.83", "482.41", "293.0", "518.5", "255.4", "790.5", "276.0", "251.8", "428.0", "535.01", "584.5", "998.59", "E932.0", "280.0", "995.92", "038.9", "427.5", "275.42", "785.52", "V43.3", "790.92", "V58.65" ]

icd9cm

[ [ [] ] ]

[ "96.6", "96.04", "99.07", "99.60", "38.93", "00.17", "38.91", "99.04", "96.72", "99.15", "33.24", "03.31", "45.13", "89.64", "93.90", "31.1" ]

icd9pcs

[ [ [] ] ]

25072, 25144

10010, 23229

4906, 4946

25316, 25325

5549, 8079

25778, 26026

5314, 5318

23498, 25049

25165, 25295

23255, 23475

387, 4814

25349, 25755

5333, 5530

4831, 4868

4974, 5188

9113, 9987

5210, 5278

5294, 5298

23,380

178,082

9180

Discharge summary

report

Admission Date: [**2138-10-6**] Discharge Date: [**2138-10-20**] Date of Birth: [**2074-5-27**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 5552**] Chief Complaint: Unable to tolerate PO Major Surgical or Invasive Procedure: None History of Present Illness: 64 M metastatic esophageal CA, AF. Initially presented to [**Hospital6 12112**] with 20 lb weight loss over 3 weeks, emesis, inability to tolerate POs. In ED, noted to be in AF with RVR in 170-180s, SBP 90s. Received dig bolus, and started on dilt gtt. Approx 30-45 min later, spontaneously converted to SR in 80s. Transferred to [**Hospital1 18**] ED for further management. . In [**Hospital1 18**] ED, ECG confirmed SR. However, BPs noted to be mid-upper 80s systolic. Received 2L NS bolus with improvement in BP to low 90s. Started on Levophed gtt. Given vancomycin, cefepime, solumedrol 125 IV. Past Medical History: 1. Esophageal cancer: presented wtih severe indigestion which progressed to difficulty swallowing. Barium swallow [**5-21**] demonstrated esophageal lesion--8 cm infiltrating carcionma of distal esophagus. Biopsy demonstrated atpyical glandular proliferation. He started neoadjuvant 5FU and cisplatin and XRT from [**2137-5-23**]. [**8-21**] demonstrated total esophagogastretcomy. PET [**7-22**] showed multi-focal FDG avid left pleural nodular thickening and right medial upper pleural nodular thickening worrisome for metastatic disease. Left lung base nodule and right upper lobe nodule both FDG avid. Started Cisplatin, Irinotecan [**2138-8-14**]. Currently on day 22 Cis/irinotecan cycle. 2. History of diabetes but currently off insulin given significant weight loss. 3. Hypercholesterolemia which has resolved at this time. 4. Herniated disk. 5. DJD. . Past Surgical History 1. Operation for cholesteatoma at [**Hospital 31406**] 2. Multiple orthopaedics operations 3. Laparoscopy, laparoscopic jejunostomy and port placement under fluorscopic guidance Social History: He lives at a nursing home. He does not smoke or drink. He used to smoke a couple of packs a day for 40 years. He is currently on disability. He used to work for the City of [**Hospital1 8**] in their Sanitation Department. Family History: Father died of lung cancer Mother is [**Age over 90 **] [**Name2 (NI) **] and living in nursing home No other family history of malignancy Physical Exam: PE on admission: VS - T 95.4, BP 109/62, HR 88, RR 22, O2 sat 98% 2L NC General - cachectic male, in NAD, speaking full sentences HEENT - OP clr, MM sl dry CV - RRR, no mur Chest - CTAB Abdomen - mild diffuse tenderness to palp, soft, no g/r Extremities - no edema Neuro - A&Ox1 Pertinent Results: CT HEAD w/o [**2138-10-6**] No acute intracranial process. Please note that contrast- enhanced CT or MRI is more sensitive for evaluating intracranial metastatic lesions. . CT ABDOMEN/PELVIS w/o [**2138-10-6**]: 1. No intra-abdominal source of fever identified on this limited non-contrast examination. 2. Increased peribronchovascular opacities, centrilobular nodules and interstitial prominence within the visualized lower lobes. Differential diagnosis includes infectious/inflammatory, interstitial edema or lymphangitic carcinomatosis. Size of right pleural-based lesions may be slightly progressed since most recent examination. 3. Fluid fecal material within the majority of the large bowel, which displays air-fluid levels. Please correlate clinically for any signs of enteritis. . SWALLOW STUDY [**2138-10-10**] Pt is safe to take a PO diet of thin liquids and regular solids without oral or pharyngeal dysphagia . EGD [**2138-10-13**] Cervical esophagus/gastric anastomosis was patent. Suture line with metal clips was seen. Erythema and congestion in the stomach compatible with gastritis . GASTRIC EMPTYING STUDY [**2138-10-14**] Nearly no emptying within first hour and markedly delayed emptying at 4 hours involving the intrathoracic portion of the stomach. Normal tracer movement once it passes through the diaphragm . COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct [**2138-10-20**] 12:00AM 6.0 3.14* 9.0* 28.1* 90 28.8 32.2 16.7* 319 [**2138-10-18**] 12:00AM 7.0 3.23* 9.3* 28.6* 89 28.7 32.4 17.0* 307 [**2138-10-16**] 12:00AM 4.8 2.42* 7.1* 21.3* 88 29.2 33.2 16.5* 250 [**2138-10-15**] 07:45AM 5.5 3.03* 8.7* 26.2* 86 28.9 33.4 16.6* 203 [**2138-10-10**] 08:35AM 5.8 3.40* 9.8* 28.6* 84 28.6 34.2 16.1* 194 [**2138-10-9**] 10:05AM 6.3# 3.39* 9.8* 29.7* 88 29.0 33.0 15.7* 200 [**2138-10-8**] 05:49AM 3.6* 2.82* 8.1* 24.4* 87 28.8 33.2 17.2* 195 [**2138-10-6**] 09:00AM 2.3* 2.69* 7.7* 23.4* 87 28.8 33.1 16.8* 237 [**2138-10-6**] 01:45AM 2.5* 3.16* 9.1* 26.9* 85 28.9 33.9 16.7* 217 . RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap [**2138-10-20**] 12:00AM 116* 22* 0.6 135 4.8 106 22 12 [**2138-10-19**] 12:00AM 1121*1 19 0.8 130*2 7.0*3 1064 234 8 [**2138-10-11**] 03:00PM 100 3* 0.8 134 4.1 102 26 10 [**2138-10-11**] 08:15AM 107* 4* 0.8 132* 3.6 100 27 9 [**2138-10-10**] 07:29PM 119* 6 0.8 132* 4.0 101 28 7* [**2138-10-6**] 08:06PM 144* 32* 1.1 143 2.8*1 120* 11*1 15 [**2138-10-6**] 09:00AM 107* 45* 1.9* 137 3.6 111* 15* 15 [**2138-10-6**] 01:45AM 130* 58* 2.6* 134 3.8 103 15* 20 Brief Hospital Course: ASSESSMENT/PLAN: 64 yo M with esophageal CA, admitted with AF w/ RVR, hypotension, and bandemia, initial MICU stay, also with intractable emesis of unknown etiology at this point ?r/t progression of esophageal CA. . # Emesis: Pt admitted with progressively worsening heaving and inability to tolerate po's, regardless of if solid, liquids or softs. Most recent barium study [**8-/2138**] prior to admission without evidence of obstruction. Swallowing study as well as EGD were negative for cause of intractable emesis with associated nausea. Pt improved gradually during admission as oral food and medications were held. TPN was initiated for nutrition. Gastric emptying study showed slow emptying of stomach as possible etiology of emesis. At discharge, pt tolerating clear and full liquids, however would be unable to support pt nutritionally. Pt was discharged home with hospice. TPN was at goal prior to discharge. . # Aspiration pneumonia: In the setting of frequent vomiting, increased risk for aspiration, evidence of possible pneumonia on chest imaging. Pt completed 10d course of levofloxacin. . # Hypotension: Appeared to be related to dehydration in the setting of volume depletion due to poor po tolerated r/t severe emesis. Also r/t atrial fibrillation with RVR. There was a possibility of sepsis, thus pt was started on vancomycin and levofloxacin, but rapid improvement with fluid resusitation hence vancomycin was discontinued. Hypotension resolved prior to transfer to OMED service, no further episodes during admission. . # Paroxysmal atrial fibrillation: Initially admitted with symptomatic afib with RVR, resolved after initial treatment at outside hospital with diltiazem and fluid resusitation. pt remained in sinus rhythm during admission. No anticoagulation as pt with chronic disease and poor prognosis. . # Dirrhea: Initially worrisome for c.diff due to ?diarrhea, however pt unable to tolerate po's and since esophagectomy with pull through, has had loose stools. c.diff negative and pt denied diarrhea. . # Anemia: Chronic, consistent with anemia of chronic disease. Pt with some blood transfusions due to low HCT which he tolerated well. No other acute issues. . # Esophageal cancer: After further discussion, no further treatment and pt was discharged with hospice. Adequate pain control was provided with fentanyl patch as well as oral morphine. . # Electrolyte imbalance: Due to intractable emesis on admission with any oral intake, multiple electrolyte imbalances. Aggressive lyte repletion was employted as well as some correction per TPN. . Pt reached maximal hospital benefit, discharged home with hospice Medications on Admission: Protonix 40 daily Marinol 2.5 [**Hospital1 **] Ativan 0.5 Q6h prn KCl 20 meq PO BID Compazine 10 PO TID Oxycodone 10mg PO Q4h prn Nystatin sol'n 5cc PO QID Megace 400mg PO BID Heparin 500 SQ TID Fentanyl patch 125 mcg/hr Q72h Discharge Medications: 1. Fentanyl 100 mcg/hr Patch 72 hr Sig: One (1) patch Transdermal every seventy-two (72) hours. Disp:*5 5* Refills:*0* 2. Morphine Concentrate 20 mg/mL Solution Sig: 5-20 mg PO q 2 h as needed for pain/shortness of breath. Disp:*40 40ml* Refills:*0* 3. HOSPICE Other Medications provided per hospice Discharge Disposition: Home With Service Facility: Hospice Care Discharge Diagnosis: Atrial fibrillation with RVR Intractable emesis Recurrent esophageal CA Discharge Condition: Fair Discharge Instructions: You were admitted with a fast, irregular heart rate, low blood pressure and inability to tolerate PO's due to vomiting. These have all resolved. . You may follow up with your PCP or oncologist within 1-2 weeks of discharge. Please discuss any concerns or questions you may have Followup Instructions: You may follow up with your PCP or oncologist within 1-2 weeks of discharge. Please discuss any concerns or questions you may have.

[ "507.0", "285.22", "707.03", "276.51", "V10.03", "250.00", "427.31", "584.9", "536.3" ]

icd9cm

[ [ [] ] ]

[ "45.13", "38.93", "99.15" ]

icd9pcs

[ [ [] ] ]

8643, 8686

5399, 8042

338, 344

8802, 8809

2787, 5376

9135, 9270

2331, 2472

8318, 8620

8707, 8781

8068, 8295

8833, 9112

2487, 2490

277, 300

372, 973

2504, 2768

995, 2070

2086, 2315

11,861

170,341

22407

Discharge summary

report

Admission Date: [**2128-7-4**] Discharge Date: [**2128-7-10**] Date of Birth: [**2105-5-5**] Sex: F Service: MEDICINE Allergies: Morphine Attending:[**First Name3 (LF) 358**] Chief Complaint: diabetic ketoacidosis nausea/vomiting Major Surgical or Invasive Procedure: endoscopy History of Present Illness: 23 yo female with pmhx sig for type I DM who presents to the ED complaining of nausea/vomiting and crampy abdominal pain for three days. Glucose found to be >700, AG of 39. UA with 150 ketones. The patient also had an episode of coffee ground emesis, and NG lavage was done, cleared with 200 ccs of fluid. The patient was given 6 units of insulin and started on an insulin drip. A pelvic exam was done and cultures were sent, discharge suggestive of a yeast infection was seen and the patient was given one time dose of fluconazole. Blood and urine cultures were sent, and the patient was admitted to the ICU for DKA. . On arrival to the floor, the patient states that she was in her usual state of health up to Friday night, went to a party and had one beer and one shot. Following that, she developed persistent crampy abdominal pain along with nausea. States that she was eating normally and drinking adequate fluids including gatorade. Took her usual 31 units of Lantus last evening at her scheduled time of 10 pm. This morning she continued to feel poorly, had an episode of watery diarrhea, and came to the ED. On ROS, she complains of nausea and her typical "heartburn", pain in the epigastrum, also complains of thirst. Denies any chest pain or SOB. No headaches or changes in her vision. Denies any emesis prior to the episode in the ED, no melena. States she had not missed any of her insulin recently. Typically checks her fingersticks TID, ranges from 130's pre-prandially up to 270's. Further ROS negative. Pt states she is sexually active in a monogamous relationship, "sometimes" uses condoms but not regularly. . In [**Name (NI) 153**], pt's gap closed and she was switched from insulin drip to lantus and sliding scale. Pt however continues to have nausea and vomiting and gi's planned to scope in am. Past Medical History: - Diabetes Type I diagnosed in [**2120**] after her first pregnancy. Most recent Hgb A1C 13.4 % ([**1-/2128**]) - Hyperlipidemia -S/P MVA [**5-3**] - lower back pain since then. + back muscle spasm treated with tylenol. - Goiter - Depression - Multiple DKA admissions - G2P1Ab1, s/p miscarriage in 06/00 3rd trimester, s/p C-section in [**2122**], not menstruating secondary to being on Depo-Provera shots - Genital Herpes Social History: The patient was born and raised in [**Location (un) 669**], where she lived in house with siblings, mother, grandmother, and [**Name2 (NI) 12232**] when growing up. Currently lives in her own apartment. Attended job corp training following h.s., but presently unemployed feeling too overwhelmed between diabetes care and caring for three year old her son. She has a boyfriend. She is close to mother, sister, and [**Name2 (NI) 12232**] who live nearby. Denies abuse in childhood or adulthood. She denies tobacco, alcohol or illicit drug use. Family History: GM with Type I diabetes. Otherwise non-contributory. Relatives with "acid in blood" not related to diabetes. Physical Exam: PE: vitals: afebrile, otherwise stable GEN: thin young female, comfortable at rest HEENT: atraumatic, anicteric, dry mucosa, oropharynx clear NECK: no LAD, no thyromegaly, no JVD CV: tachy, regular, no murmurs or rubs LUNGS: CTA B/L with good inspiratory effort, no accessory muscle use or conversational dyspnea BACK: no CVA tenderness ABD: soft, nontender, +BS EXT: warm, dry. No LE edema SKIN: no rash, mildly diaphoretic NEURO: A/O X3, CN II-XII grossly intact, normal muscle tone and strength B/L in UE and LE Pertinent Results: [**2128-7-4**] 08:39AM GLUCOSE-644* LACTATE-5.1* NA+-140 K+-7.4* CL--103 TCO2-5* [**2128-7-4**] 08:39AM PH-7.08* [**2128-7-4**] 08:50AM ALT(SGPT)-47* AST(SGOT)-64* ALK PHOS-104 TOT BILI-0.5 [**2128-7-4**] 10:25AM URINE UCG-NEG [**2128-7-6**] Abd US: No focal intrahepatic lesion is seen. There is no biliary ductal dilatation or ascites. The gallbladder, pancreas, and spleen are unremarkable. There are no gallstones. Both kidneys are normal in appearance, without evidence of mass, stone, or hydronephrosis. IMPRESSION: Unremarkable abdominal ultrasound. [**2128-7-7**] H. Pylori Ab positive [**2128-7-10**] 04:52AM BLOOD Glucose-122* UreaN-5* Creat-0.8 Na-135 K-3.3 Cl-99 HCO3-29 AnGap-10 [**2128-7-4**] 05:18PM BLOOD Lactate-1.1 [**2128-7-4**] 10:25AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.028 [**2128-7-4**] 10:25AM URINE Blood-TR Nitrite-NEG Protein-TR Glucose-1000 Ketone-150 Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG [**2128-7-4**] 10:25AM URINE RBC-0-2 WBC-0-2 Bacteri-NONE Yeast-NONE Epi-0-2 HELICOBACTER PYLORI ANTIBODY TEST (Final [**2128-7-7**]): POSITIVE BY EIA. NEISSERIA GONORRHOEAE (GC), NUCLEIC ACID PROBE, WITH AMPLIFICATION (Final [**2128-7-5**]): Negative for Neisseria Gonorrhoeae by PCR. Chlamydia trachomatis, Nucleic Acid Probe, with Amplification (Final [**2128-7-5**]): Negative for Chlamydia trachomatis by PCR. Brief Hospital Course: # DKA/DM I, uncontrolled - Initially admitted to the [**Hospital Unit Name 27926**] transferred to the hospitalist general medicine team after glucose control and anion gap closed. [**Last Name (un) **] diabetes consult followed throughout her admissions. She did well on once daily Lantus with sliding scale aspart coverage. She did have two episodes of hypoglycemia (mild) for which she felt symptoms and responded well to crackers/juice. She was discharged with strict instructions for insulin administration and follow up with her [**Last Name (un) **] physician. [**Name10 (NameIs) **] will resume her ace inhibitor, aspirin and zetia/crestor upon discharge. # Abdominal pain/nausea/vomiting - As there was a question of coffee ground emesis, she underwent endoscopy, which revealed mild gastritis/esophagitis. H. pylori was positive. She was discharged with instructions to take pantoprazole 40 mg po bid, as well as 14 days of amoxicillin and clarithromycin. Perscriptions were given to the patient. By discharge, she was tolerating liquids/solids without nausea. # Leukocytosis- with bandemia, most likely secondary to infection as above. Patient received fluconazole for treatment of yeast infection in the ED, all other infectious workup negative. Bandemia and leukocytosis resolved rapidly (prior to transfer out of the ICU). # ARF- patient's creatinine elevated to 2.0 on admission, resolved to baseline 0.7 with IVFs. # depression- continue home medications. Medications on Admission: zetia lantus 31 units qhs with novolog sliding scale prilosec prozac aspirin 81 mg Discharge Medications: 1. Insulin Glargine 100 unit/mL Solution Sig: Fourteen (14) units Subcutaneous once a day. 2. 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* 3. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QIDACHS (4 times a day (before meals and at bedtime)). 4. Novolog 100 unit/mL Solution Sig: One (1) unit Subcutaneous qAC and qhs: as directed in previous sliding scale [**First Name8 (NamePattern2) **] [**Last Name (un) **] physician. 5. Zetia 10 mg Tablet Sig: One (1) Tablet PO once a day. 6. Crestor 20 mg Tablet Sig: One (1) Tablet PO at bedtime. 7. Amoxicillin 500 mg Tablet Sig: Two (2) Tablet PO once a day for 14 days. Disp:*28 Tablet(s)* Refills:*0* 8. Clarithromycin 500 mg Tablet Sig: One (1) Tablet PO once a day for 14 days. Disp:*14 Tablet(s)* Refills:*0* 9. Prozac 20 mg Capsule Sig: One (1) Capsule PO once a day. 10. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day. 11. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home Discharge Diagnosis: diabetic ketoacidosis esophagitis/gastritis Discharge Condition: stable, tolerating food/drink Discharge Instructions: You were hospitalized because of diabetic ketoacidosis and nausea/vomiting. Your sugars are well controlled right now on 14 units of Lantus daily. As your appetite increases, you will likely require more Lantus. Please give yourself 10 units of Lantus this evening. Increase to 20 units of Lantus tomorrow evening. Resume your previous carb counting regimen, as counseled by your diabetes physician (ratio 1:4, correction 40, goal 140). You do have inflammation of your esophagus and stomach, and a bacteria called H. pylori that requires antibiotics for 14 days. Please finish all of the antibiotics as instructed. Call your doctor or return to the hospital with uncontrolled sugars, increased nausea or vomiting, inability to eat/drink, low blood sugars, or any other concerns. Followup Instructions: Call your diabetes physician, [**Last Name (NamePattern4) **]. [**First Name (STitle) 4375**] [**Name (STitle) 3617**], at [**Telephone/Fax (1) 12068**] Monday morning to make a follow up appointment. You should see him within two weeks. Call your primary physician, [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 7538**], Monday morning for a follow up appointment.

[ "311", "241.0", "584.9", "041.86", "535.50", "112.1", "530.19", "250.13" ]

icd9cm

[ [ [] ] ]

[ "45.16" ]

icd9pcs

[ [ [] ] ]

7996, 8002

5272, 6760

304, 316

8090, 8122

3849, 5249

8957, 9380

3187, 3298

6894, 7973

8023, 8069

6786, 6871

8146, 8934

3313, 3830

227, 266

344, 2164

2186, 2610

2626, 3171

5,882

181,631

15833

Discharge summary

report

Admission Date: [**2144-9-22**] Discharge Date: [**2144-10-7**] Date of Birth: [**2082-11-29**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1377**] Chief Complaint: N/V/tachycardia Major Surgical or Invasive Procedure: none History of Present Illness: 61M w/ HCV cirrhosis s/p xplant (since failed and now s/p TIPS x2), DMII, HTN, and recent bacteremia (still on home abx) and DVT presenting from home with N/V, tachycardia, and hypotension. He was recently admitted to [**Hospital1 18**] from [**Date range (1) 45524**] with diarrhea in the setting of home ertapenem/daptomycin therapy for recent ESBL klebsiella bacteremia. He was treated empirically with a 14 day course of flagyl (finished [**9-18**]) though his stool cultures were cdiff negative and developed mild renal insufficiency prior to d/c home. At home, the patient continued his antibiotic therapy and was doing well until 5 days prior to admission when his wife noticed him having poor energy/appetite and malaise. He began having specific symptoms approx 24 hrs prior to arrival with no BM or flatus (as opposed to frequent flatus/diarrhea), nausea and bilious (non-projectile emesis), and mid-gastric and non-radiating pleuritic bilateral flank pain. He states that the pain is sharp and waxes/wanes. His VNA found him to be hypotensive to the high 80's and tachycardic (unclear how tachycardic) with a low-grade fever (unclear what his temperature was). They recommended he be admitted. In addition Mr. [**Known lastname **] notes that he has not urinated in nearly 24 hours and he is quite thirsty. On arrival to the medicine floor, the patient was persistently tachycardic. His labs were concerning for sepsis and he was transferred to the ICU. . ROS is negative for confusion, cough, URI symptoms, sick contacts, rash, [**Name2 (NI) 45525**], wt gain or loss. He has been compliant with his medications. Past Medical History: 1. HCV cirrhosis s/p xplant [**2140**] (c/b rejection and cholangitis) now w/ recurrent cirrhosis (TIPS [**5-21**] and [**6-20**]) -- [**8-/2141**] [**Year (4 digits) **] -- [**10/2141**] rejection -- [**12/2141**] cholangitis -- [**5-/2144**] TIPS for recurrent ascites -- [**6-/2144**] TIPS redo for occlusion -- 2 cords of grade II varices were seen in the lower third of the esophagus. 2. ESBL klebsiella, VRE, cdiff (currently on ertapenem/daptomycin) 3. Previous SBP (most recent [**7-21**]; while on [**Last Name (un) 2830**] and dapto thus tx'ed with tigecycline) 4. DMII c/b nephropathy 5. Hypertension 6. Depression 7. RUE DVT [**7-21**] Social History: Retired truck driver. Lives with wife [**Name (NI) **] [**Name (NI) **], [**First Name3 (LF) **] [**Name (NI) **]. 20 pack-year history; quit [**2125**]; Denies ETOH Family History: Noncontributory Physical Exam: T 95.2 BP 134/93 HR 140, RR 16 O2 100% on room air Gen: cachectic chronically-ill appearing man in no acute distress HEENT: mild scleral icterus; poor dentition; sunken face CV: tachycardic, hyperdynamic precordium without murmurs, rubs, or gallops Lungs: clear to auscultation and percussion bilaterally Abd: distended but not tense, + shifting dullenss and fluid wave. + hepatomegally with mild TTP. + Epigastric TTP. No rebound or guarding. Ext: warm and well-perfused; guant w/o edema Neuro: no asterixis. alert and oriented x 3 Skin: no rashes Pertinent Results: COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct [**2144-9-25**] 03:12AM 6.5 2.53* 7.8* 22.5* 89 30.9 34.7 16.3* 155 [**2144-9-22**] 08:23PM 8.0 3.58* 10.6 32.9* 92 29.6 32.2 15.1 310 . RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap [**2144-9-25**] 05:25PM 107* 61* 5.4* 140 4.2 105 18* 21* [**2144-9-22**] 08:23PM 71 46* 4.6*# 137 5.3* 110* 8*1 24* . ENZYMES & BILIRUBIN ALT AST LD(LDH) CK(CPK) AlkPhos TotBili [**2144-9-25**] 03:12AM 159* 1228* 342* 341* 92 1.5 [**2144-9-22**] 08:23PM 234* 1237* 33 514* 1.7* . Abdominal Ultrasound [**2144-9-23**] 1. Occluded TIPS, apparently new since the previous examination. 2. Large amount of ascites . [**9-23**] CT Chest/Abdomen:IMPRESSION: 1. No evidence of small bowel obstruction. 2. Right greater than left pleural effusion and large amount of ascites. 3. Right lower lobe collapse with mild superimposed consolidation. Unchanged pulmonary nodules. 4. Mild suggestion of wall thickening at the proximal cecum, and diverticula at the sigmoid colon, with otherwise unremarkable large bowel. While cecal findings may in part be due to under distention, typhlitis may be considered if clinically appropriate. Brief Hospital Course: 61 yo M s/p failed liver [**Month/Year (2) **] with cirrhosis and recent admission for C diff colitis and VRE/ESBL klebsiella bacteremia admitted with abdominal pain & tachycardia, found to have TIPS occlusion and acute renal failure. . 1. Bacteremia: Patient with history of VRE & ESBL Klebsiella bacteremia on indefinite daptomycin & meropenem IV at home. Admitted to the MICU shortly after admission for atrial fibrillation with RVR, severe metabolic acidosis, renal failure and concern for sepsis. He was continued on IV antibiotics initially, but after meeting that included ICU team, hepatology and his family, the decision was made to make pt DNR/DNI and enroll in hospice care which included no vital signs, labs draws, medications or antibiotics except meds to make patient comfortable. . 2. Acute Renal Failure: Appeared to be likely from ATN, initially appeared to be secondary to hypotension as well as aggressive fluid resusitation. Meeting with family as above, comfort measures were adopted. . 3. ESLD s/p [**Month/Year (2) **] c/b numerous infections, varicees and refractory ascites requiring TIPS. Patient with very poor prognosis due to severe transaminitis as well as occluded TIPS. Family meeting as above, decision for comfort care. . 3. Oral Thrush: Started Nystatin with swabs for patient's confort. . 4. Goals of Care: Due to patient's very poor prognosis, a meeting was held which included family, hepatology and the intensive care unit to withdraw aggressive care and provide comfort care only. The patient was transferred to the hepatology floor. He was too sick & unstable to be transferred to outpatient hospice, he continued on the hepatology floor with secretion control,and antiemetic, pain, agitation, and delerium medications to make the patient comfortable. He continued on the hepatology floor until [**10-7**] at 10:22 am when he suddenly died of respiratory failure. His family was notified. His wife [**Doctor Last Name **] was able to travel to [**Hospital1 18**] to say goodbye and consented to an autopsy. Medications on Admission: 1. Ursodiol 300 mg [**Hospital1 **] 2. Fluoxetine 20 mg daily 3. Ferrous Sulfate 325 mg daily 4. B Complex-Vitamin C-Folic Acid daily 5. Rifaximin 200 mg tid 6. Mirtazapine 15 mg qhs 7. Calcium Carbonate 500 mg tid 8. Sirolimus 1 mg daily 9. Metoprolol Tartrate 50 mg tid 10. Prilosec 20 mg daily 11. Daptomycin 400 mg IV daily 12. Insulin SS 13. Ertapenem 1 g daily 14. Metronidazole 500mg po tid Discharge Medications: none Discharge Disposition: Expired Discharge Diagnosis: primary: Liver failure C. difficile colitis Vancomycin resistant and Extended Spectrum Beta Lactamase Klebsiella bacteremia TIPS occlusion Acute Renal Failure Sepsis Respiratory Failure Discharge Condition: expired Discharge Instructions: none Followup Instructions: none [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(1) 1379**]

[ "008.45", "518.81", "112.0", "996.74", "276.2", "571.5", "584.5", "570", "401.9", "E878.0", "995.92", "250.00", "038.49", "996.82", "427.31" ]

icd9cm

[ [ [] ] ]

[ "54.91" ]

icd9pcs

[ [ [] ] ]

7264, 7273

4735, 6786

332, 338

7502, 7511

3467, 4712

7564, 7693

2864, 2882

7235, 7241

7294, 7481

6812, 7212

7535, 7541

2897, 3448

277, 294

366, 1993

2015, 2665

2681, 2848

65,364

128,701

37290

Discharge summary

report

Admission Date: [**2161-7-8**] Discharge Date: [**2161-7-16**] Date of Birth: [**2079-4-21**] Sex: M Service: NEUROSURGERY Allergies: Penicillins / Erythromycin / Quinidine Attending:[**First Name3 (LF) 78**] Chief Complaint: elective admit for left SDH evacuation Major Surgical or Invasive Procedure: Left Burr Holes for evacuation of SDH History of Present Illness: 83 yo M retired physician s/p CVA [**1-7**] with subsequent aphasia and seizure disorder had unwitnessed (but heard from another room) fall out of chair possibly due to seizure. he is on coumadin/ASA. EMS was called and pt was brought to [**Hospital6 45215**] where INR was found to be 3.0 and head CT revealed subacute Left SDH with 5mm shift. he was given FFP, vitamin K and factor 9. Dilantin level was 8.2 and 1 gm was also give. He was then transferred to [**Hospital1 18**] ED. Repeat INR here was 1.7 for which 2 more units FFP were ordered. He was discharged from [**Hospital1 18**] with plans for follow up imaging 2 weeks later to eval need for surgery. After discussion with his family he elected to have surgery sooner and presented electively. Past Medical History: CABG -Afib -hyperparathyroidism s/p resection -mitral valve repair -endocarditis -HTN -HLD -hx subdural hematoma s/p fall -BPH Social History: retired physician. [**Name10 (NameIs) 13802**] at home with spouse, has HHA. Recently dc/ed from [**Hospital1 **] [**2161-2-2**]. No hx etoh, tobacco or drugs. Family History: no history of stroke Physical Exam: Pre-Op: lethargic, awake, alert, and oriented to person, place, and date. Follows commands, slightly perseverative, full strength, no drift, pupils [**5-2**] bilaterally and brisk, face symmetric, tongue midline On Discharge: a&ox3 with prompting due to expressive aphasia PERRL 4-3mm bilaterally Face symmetrical, tongue midline Negative pronator drift, bilateral hand tremors R>L Motor: [**6-3**] throughout Incision: c/d/i. Pertinent Results: CT HEAD [**7-11**] Status post evacuation of left subdural hemorrhage with left craniectomy and extensive expected postoperative change including pneumocephalus and soft tissue swelling. There are several foci of high attenuation seen within the remainder of the collection, and close continued followup is recommended. Persistent associated midline shift of 4 mm to the right. CT HEAD W/O CONTRAST [**2161-7-12**] 1. No significant change compared to [**7-11**], moderate subacute left subdural fluid collection and pneumocephalus. 2. No evidence of new intracranial hemorrhage. 3. Unchanged 4-mm midline shift to the right Brief Hospital Course: Patient presented on [**7-8**] electively for evacuation of left subdural hematoma. On [**7-10**] his operation was completed without complications and he was transferred to the PACU for observation overnight. On the morning of [**7-11**] he was transferred to the floor. Patient was observed to have urinary retention and an attempt to insert foley was unsuccessful. Urology was called to insert foley. They were able to place a 14F catheter and determined that the cause of difficult insertion was due to a narrow neck at the entrance of the bladder. Urology's final recommendations were to send patient to rehab with foley in place and have the patient follow up with his primary urologist. On [**7-12**], dressing was removed and sutures from R forehead was removed. Incision was intact and patient was seen by PT. His exam is intact, but there remains some expressive aphasia. Neurology was consulted to evaluate patient for seizure activity. Their recommendations were that he is not having seizures and that his dilantin level should be kept at a low treshold for his gait instability. Patient will be discharged to rehab on [**7-16**]. He was told to follow up with his neurologist as an out patient in regards to dilantin. He will follow up with Dr. [**First Name (STitle) **] in 4 weeks with a non contrast head CT. Medications on Admission: Acetaminophen, Colace, Vitamin D3, Calcium Carbonate, MVI, Sertraline, Atorvastatin, Metoprolol Succinate, Digoxin, Lisinopril, Dilantin, Metoprolol tartrate, Prednisone Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 3. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). 4. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times a day). 5. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 12. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain. 13. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 14. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1) Capsule PO Q 8H (Every 8 Hours). 15. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 16. Loperamide 2 mg Capsule Sig: One (1) Capsule PO QID (4 times a day) as needed for diarrhea. 17. Morphine Sulfate 2-4 mg IV Q4H:PRN pain Discharge Disposition: Extended Care Facility: [**Hospital6 85**] - [**Location (un) 86**] Discharge Diagnosis: L SDH Urinary retention 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: ?????? 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 and/or staples have been removed. If your wound closure uses dissolvable sutures, you must keep that area dry for 10 days. ?????? 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. ?????? If you have been prescribed Dilantin (Phenytoin) for anti-seizure medicine, take it as prescribed and follow up with laboratory blood drawing in one week. This can be drawn at your PCP??????s office, but please have the results faxed to [**Telephone/Fax (1) 87**]. ?????? 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 have staples removed at rehab facility in [**8-8**] days(from your date of surgery) ??????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. ?????? Please follow up with your out patient urologist in regards to foley. Completed by:[**2161-7-16**]

[ "427.31", "414.00", "438.89", "852.20", "V85.0", "438.11", "348.30", "E888.9", "596.0", "345.90", "V58.61", "788.20", "600.01" ]

icd9cm

[ [ [] ] ]

[ "57.32", "01.31" ]

icd9pcs

[ [ [] ] ]

5568, 5638

2660, 3988

339, 379

5706, 5706

2009, 2637

7699, 8140

1521, 1544

4208, 5545

5659, 5685

4014, 4185

5889, 7676

1559, 1773

1787, 1990

261, 301

407, 1173

5721, 5865

1195, 1324

1340, 1505

9,403

175,096

15260

Discharge summary

report

Admission Date: [**2135-1-18**] Discharge Date: [**2135-4-5**] Date of Birth: [**2072-6-18**] Sex: F Service: MEDICINE Allergies: Percocet / Reglan / Fentanyl / Compazine / Levaquin Attending:[**First Name3 (LF) 3913**] Chief Complaint: Elective admit for MEC and DLI Major Surgical or Invasive Procedure: None History of Present Illness: 62-year-old female with secondary AML with deletion 7 chromosome abnormality who is s/p matched related reduced intensity allogeneic transplant in [**8-/2133**] with conditioning regimen of fludarabine, busulfan and ATG with recurrent disease who is being admitted for further treatment with MEC in hopes of getting her disease in better control prior to another DLI. Following her recurrence of AML, Ms. [**Known lastname **] has had treatment with low dose of cytarabine in [**2-/2134**] followed by her 1st DLI on [**2134-3-26**], complicated by acute GVHD of the liver. Her AML has persisted and she is s/p 6 total cycles of Decitabine last given on [**2134-11-25**] with a 2nd DLI given after her 4th cycle. She received a 3rd DLI on [**2134-12-14**]. Ms. [**Known lastname **] has remained pancytopenic requiring transfusion support and has required periodic admissions with fever and infections. Most recently, she was noted for acute increased pain and swelling around her left eye with fevers and she was admitted on [**2134-11-13**]. Clinical picture was initially concerning for orbital cellultis, which was ruled out by CT sinus imaging, showing only preseptal/periorbital involvement. She was treated with Zosyn/Vancomycin for six days while hospitalized and her cellulitis markedly improved. Wound swab of the left eye grew rare pseudomonas aeruginosa and sparse staph coagulase negative bacteria. Ms. [**Known lastname **] was discharged to home to complete a total 2 week course of Zosyn. She received her 6th cycle of Decitabine as planned on [**2134-11-25**] and her 3rd DLI on [**2134-12-14**]. She more recently has had episodes of stool incontinence which has mainly occurred at night. She underwent MRI imaging without contrast which did not show anything concerning outside of degenerative disc disease. She had an LP done on [**2134-12-28**] which was negative for CNS involvement of AML. These episodes have stopped. Her peripheral blast count has been increasing and she underwent bone marrow aspirate and biopsy on [**2135-1-10**] which unfortunately showed increasing blasts in the biopsy. After further discussion of treatment options, the decision was made to [**Year (4 digits) 10836**] froward with more intensive chemotherapy with MEC in hopes of getting her leukemia in better control and then move forward with another DLI. On the floor she reports progressive malaise over the past few weeks leading up to discovering her disease progression. She was very distressed to learn the result of her BMBx on [**1-10**]. She was hoping that the blasts would be better controlled by her past treatements and DLI. She also has been having mild bone pain of the legs for the past few weeks similar to past bone pain, but less severe. She has no other complaints and no recent illnesses. Review of Systems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies chest pain or tightness, palpitations. Denies cough, shortness of breath, or wheezes. Denies nausea, vomiting, diarrhea, constipation or abdominal pain. No recent change in bowel or bladder habits. No dysuria. Denies myalgias. Denies rashes or skin breakdown. No numbness/tingling in extremities. No feelings of depression or anxiety. All other review of systems negative. Past Medical History: 1. Pancreatic neuroendocrine tumor - s/p partial pancreatectomy/splenectomy in [**2126**], with recurrence in pancreatic tail in [**2129**] treated with octreotide then bevacizumab/Temodar until cycle 15, day 15 on [**2131-7-18**]; liver metastasis in [**2130**] treated with chemoembolization 9/[**2130**]. Follow up CT scans that have showed some persistent lesions in the liver, but no clear evidence of growth of her neuroendocrine tumor. Last scan was on [**2134-12-23**]. 2. End of [**Month (only) 958**]/beginning of [**2133-3-17**], ongoing workup for weakness and confusion at OSH, and noted to have low blood counts including anemia and thrombocytopenia. She was admitted to [**Hospital1 18**] and she underwent a bone marrow aspirate and biopsy on [**2133-4-28**], which revealed involvement by acute myeloid leukemia with monoblasts and monocytes accounting for 29% of the aspirate differential, categorized as AML, FAB subtype M5B. Cytogenetics revealed deletion 7 abnormality. 3. Treated with induction chemnotherpy on [**2133-5-5**] and achieved complete remission; subsequently received two cycles of high-dose ARA-C with continued remission. 4. Treatment course complicated by an episode of acute appendicitis with E. coli bacteremia and s/p appendectomy. 5. Neurologic workup during her admission to evaluate her symptoms of transient weakness, shakiness, and headaches were felt consistent with conversion disorder. MRI of the brain was negative, LP was negative, EEG results were negative for any seizures and her symptoms resolved during the course of her initial hospitalization. 6. Matched sibling reduced intensity allogeneic transplant with Fludarabine, Busulfan and ATG on [**2133-9-16**]. Her initial post transplant course was essentially uneventful. 7. CMV viremia in [**10/2133**], treated with Valcyte. Switched back to Acyclovir as of [**2133-11-24**]. 8. Bone marrow aspirate and biopsy on [**2133-12-11**], due to persistent low counts and increased monocytes on her peripheral blood did not show any evidence for leukemia although with possible dysplastic changes. 9. Admitted on [**2134-1-31**] due to worsening upper respiratory symptoms with temperature to 100.2, increased congestion/sinus pain and cough. Nasal washings were positive for parainfluenza with no pneumonia. She completed a 10 day course of Tamiflu and 5 day course of Zithromax. 10. In [**1-/2134**], platelet count continued to decrease and repeat bone marrow aspirate and biopsy on [**2134-2-18**] did not show any evidence for recurrent leukemia but was noted for Trisomy 8. Because of persistent drop in her neutrophil count and platelet count, she underwent repeat bone marrow aspirate and biopsy on [**2134-3-4**] which showed increased blasts with CD34-blasts comprising 10-15% of marrow cellularity. Trisomy 8 was evident and she was now 85% donor. 11. Ms. [**Known lastname **] received modified cytarabine therapy from [**Date range (2) 44392**] followed by her DLI on [**2134-3-26**]. Noted for increased liver function transaminases and bilirubin with acute GVHD, Grade III. Treated with high dose steroids with resolution. 12. Admitted on [**2134-3-27**] with fevers and right hand cellulits and sinus infection with conjunctivitis. Prolonged admission with IV antibiotics. Discharged on [**2134-5-15**]. 13. AML persisted despite the GVHD and with improvement of her liver function tests, Ms. [**Known lastname **] received 1st cycle Decitabine at 20mg/m2 for 5 days starting on [**2134-5-7**]. 14. Bone marrow aspirate and biopsy on [**2134-5-27**] showed no increased blasts in the marrow but with continued evidence for Trisomy 8 chromosome abnormality. Chimerism showed her to be 55% donor, increased from 20% in [**3-18**] cycle of Decitabine on [**2134-5-31**] with the plan to move forward with a second DLI. 15. Admitted on [**2134-6-9**] for fevers with pneumonia. Treated with IV antibiotics. She remained profoundly neutropenic, but because she was otherwise feeling well with no ongoing fevers, she was discharged home on [**2134-7-7**] to complete a course of Zosyn. 16. 2nd DLI on [**2134-6-23**]. Repeat BM biopsy on [**2134-6-30**] showed a markedly hypocellular marrow (5% cellularity) with erythroid dominant hematopoiesis with mild erythroid dyspoiesis. Diagnostic morphologic features of involvement by acute leukemia are not seen. 17. Readmitted on [**2134-7-15**], due to infected left toe in the setting of neutropenia. Received IV Vancomycin along with IV Zosyn. Podiatry removed part of the toenail and she was discharged home. 18. Repeat bone marrow biopsy on [**2134-7-15**] showed an erythroid dominant marrow with myloid hyperplasia and left shift. CD34/CD117 staining represent 5 - 10% of core cellularity. Chimerism showed that she was 55% donor. Repeat bone marrow biopsy on [**2134-8-9**] due to increasing circulating blasts showed increasing blast count. Her chimerism showed that she was 35% donor. 19. 3rd cycle of Decitabine on [**2134-9-2**], followed by a 4th cycle on [**2134-9-30**] as her overall peripheral blast count had markedly improved. 20. Bone marrow biopsy on [**2134-10-21**] showed residual blasts with same phenotype as seen before, both in peripheral blood (1%) and marrow (4-6%). By immunohistochemistry, CD34 highlights blasts which are 3-5% of marrow cellularity. CD117 enumerates immature myeloid precursors at 5-10% of marrow cellularity. Continues with Trisomy 8 abnormality. 5th cycle of Dacogen which was given on [**2134-10-28**]. 21. Admitted on [**2134-11-13**] with periorbital cellulitis. Treated with IV Zosyn with resolution. 22. 6th cycle of Decitabine on [**2134-11-25**]. 23. 3rd DLI on [**2134-12-14**]. 24. Increasing peripheral blast count with repeat bone marrow biopsy on [**2135-1-10**] shows a marrow cellularity of 20%. There is an interstitial infiltrate of immature cells consistent with blasts occurring in small clusters and in sheets occupying 60-70% of marrow cellularity. . Other Past Medical History 1. AML FAB subtype M5B, outlined above 2. Pancreatic neuroendocrine tumor status post partial pancreatectomy/splenectomy in [**2126**] with recurrence in the pancreatic tail in [**2129**] treated initially with octreotide then bevacizumab/Temodar until cycle 15 and day 15 on [**2131-7-18**] and was stopped due to decrease of tumor burden. She was then noted to have liver metastasis treated with chemoembolization in 09/[**2130**]. Her primary oncologist is Dr. [**First Name (STitle) **] [**Name (STitle) **]. 3. Appendectomy on [**2133-5-15**]. 4. Status post open cholecystectomy [**31**]/[**2131**]. 5. Insulin-dependent diabetes due to pancreatectomy. 6. Stress related migraines. 7. Restless legs syndrome. 8. Hypertension. 9. Depression. 10. Two benign breast cysts surgically removed. 11. Status post tonsillectomy. 12. History of fractured skull at age 3. 13. Carpal tunnel syndrome. 14. E. coli bacteremia. 15. Acute GVHD of the liver with increased bilirubin. Social History: Ms. [**Known lastname **] is divorced and has two children. She shares a house in [**Location (un) 5450**], [**Location (un) 3844**] with her friend [**Name (NI) 553**] who is her healthcare proxy. She was the principal of a high school until [**2129**] when she went on disability and retired permanently in [**2130**]. She does not drink alcohol and is a nonsmoker. Family History: Notable for history of pancreatic cancer and history of gastric cancer. There is coronary artery disease and diabetes mellitus in the family. Physical Exam: GEN: NAD, pleasant VS: 96.7 126/90 86 16 98% on RA HEENT: MMM, pale mucosae, neck is supple, no cervical, supraclavicular, or axillary LAD CV: RR, NL S1, loud S2, no S3S4 MRG PULM: CTAB with bibasilar crackles ABD: BS+, NTND, no masses or hepatomegaly LIMBS: No LE edema, no tremors or asterixis SKIN: No rashes, skin breakdown, or petechiae NEURO: PERRLA, EOMI, CN II-XII WNL, strength is diffusely 4+/5 on the R and 4-/5 on the L, toes are down bilaterally, gait is normal, no evidence of dysdiadokinesis of the upper or lower extremities Pertinent Results: Admission labs: 5.5>26.4<64 N10, L59, M13, E0, Atyp5, Blast 12, NRBC4 PT 11.8, PTT 25.4, INR 1.0 141/4.6/106/30/18/0.8<295 ALT 60, AST 44, LDH 448, AlkPhos 161, TB 0.3 Alb 3.9, Ca 8.4, Phos 3.8, Mg 2.1, UA 4.7 TSH 2.4 T4 6.2 CXR [**1-18**] Tip of the left PIC catheter ends in the region of the superior cavoatrial junction. No pneumothorax, pleural effusion or mediastinal widening. Lungs are grossly clear, heart size top normal. CXR [**1-22**] Changed position of the right-sided PICC line. Unchanged size of the cardiac silhouette. Minimal increase in diameter of the pulmonary vessels, potentially reflecting early overhydration. No interstitial markings, no focal parenchymal opacities suggesting pneumonia. No pleural effusions. CT neck [**1-27**]: Mild inflammatory changes and reactive nodes in right anterior neck. Given history of severe neutropenia, infection is a strong possibility. No drainable fluid collections. CT neck [**2-16**]: 1. No CT evidence of sialadenitis. However, prominent lymph node anterior to the right submandibular gland measures 13 x 8 mm, and in a patient with neutropenia, could reflect underlying infection. 2. No other acute abnormality compared to the prior study. Abdominal U/S [**2-21**] : 1. Status post splenectomy, as seen on prior CT examination. Small regenerative splenules are not visualized on this study, likely obscured by overlapping loops of bowel. 2. No mass is seen at the splenectomy bed. CT neck [**2-26**]: Unchanged CT examination of the neck compared to [**2135-2-15**]. No abscess or fluid collection is identified. No significant inflammatory change. A single prominent lymph node anterior to the right submandibular gland is unchanged in size and appearance. Bone marrow biopsy/cytogenetics [**2-27**]: **** CT Abd/Pelvis [**2-28**]: 1. No acute process identified with no evidence of hematoma. 2. Known liver lesions not appreciated on this non-contrast examination. CT L-Spine [**2-28**]: Mild-to-moderate degenerative disease within the lumbar spine, most pronounced at L4-5 and L5-S1, without significant spinal canal stenosis or neural foraminal narrowing. No clear radiographic explanation for clinical presentation. Micro: [**1-25**] URINE CULTURE: ESCHERICHIA COLI. 10,000-100,000 ORGANISMS/ML. AMPICILLIN------------ <=2 S AMPICILLIN/SULBACTAM-- <=2 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ 2 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- 32 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S Brief Hospital Course: Ms [**Known lastname **] was admitted for elective MEC followed by DLI for progression of disease on bone marrow biopsy on [**2135-1-10**] and progressive malaise and mild bone pain over the several weeks prior to admission. MEC treatment was initiated on [**2135-1-18**] and DLI was initiated on [**2135-2-17**]. Following her admission, she developed fevers for which she was started on broad spectrum antibiotics. She complained of neck and jaw pain for which she underwent a CT revealed stranding/lymphadenopathy concerning for infection in the neck. Her symptoms improved on these antibiotics and she remained afebrile. Her symptoms recurred again in [**Month (only) 958**], with continued blasts on peripheral smear after MEC and 1 week post-DLI with extreme fatigue and gum pain felt to be related to recurrent leukemia. Bone marrow biopsy was repeated on [**2-27**], revealing persistent involvement of her AML. She was started on a mylotarg/azacitadine regimen on [**3-3**], but was transferred to the [**Hospital Unit Name 153**] for fevers and hypotension later that night. Her chemotherapy was continued through her [**Hospital Unit Name 153**] stay and she completed her mylotarg/azacitadine course. Back on the floor, her ANC remained low (<100) throughout [**Month (only) 958**] and early [**Month (only) 547**]. Her fevers continued since her transfer from the ICU and a PICC line which was noted to be ~ 1 yr old was pulled, cultured, and a new PICC was placed. She had been on a PO antibiotics regimen and she was converted back to an IV regimen. Her fevers persisted through vancomycin + cefepime, although she did remain normotensive. Her neck and jaw pain were significantly improved although she did continue to complain of abdominal discomfort after eating. Fungal coverage was added with voriconazole in addition to flagyl but her fevers persisted. Repeated blood cultures revealed no infection; 1 urine culture from [**3-20**] showed < 10,000 colonies of Enterococcus resistant to vancomycin. She was initiated on daptomycin, and repeated urine cultures were negative. Ms [**Known lastname **] continued to have peripheral blasts (between [**1-22**] on peripheral diff); given continued blasts, decitabine was initiated on [**3-24**]. She tolerated decitabine therapy well. Her ANC continued to be < 100. Following completion of daptomycin course for 10 days, her fevers resolved and she was afebrile for 5 days prior to discharge. Her flagyl was discontinued and her cefepime was transitioned to PO cefpodoxime. After discontinuation of dapto and conversion to PO regimen of cefpodoxime, Ms [**Known lastname **] continued to be afebrile > 72 hours. She was discharged with close follow-up with Dr [**Last Name (STitle) **]. She was neutropenic at time of discharge, but afebrile. She was able to ambulate around the room with mild fatigue but no other complaints. Her energy was significantly improved. She was set up with an appointment for inhaled pentamidine, [**Hospital1 **]-weekly transfusions, and follow up with Hematology. Medications on Admission: - Lorazepam 0.5-1 mg PO Q4H:PRN - Acyclovir 400 mg PO Q8H - Mirtazapine 15 mg PO HS - Allopurinol 300 mg PO DAILY - Nystatin Oral Suspension 5 mL PO QID:PRN - Clonazepam 0.5 to 1 mg PO QHS:PRN - Docusate Sodium 100 mg PO TID - Oxycodone SR (OxyconTIN) 60 mg PO Q8AM - Oxycodone SR (OxyconTIN) 20 mg PO Q2PM - Oxycodone SR (OxyconTIN) 60 mg PO Q8PM - FoLIC Acid 1 mg PO DAILY - Esomeprazole 40 mg PO Q24H - Posaconazole Suspension 200 mg PO TID - HYDROmorphone (Dilaudid) 2-4 mg PO Q3H - Polyethylene Glycol 17 g PO/NG DAILY:PRN - Insulin SC Sliding Scale & Fixed Dose Levimir 20units HS Allergies: Percocet, although she is able to take oxycodone and Tylenol, Reglan, fentanyl, and Compazine. Intolerance to Levaquin. Discharge Medications: 1. Lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for nausea/anxiety/insomnia. Disp:*30 Tablet(s)* Refills:*0* 2. Acyclovir 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours). 3. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 4. Allopurinol 300 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 5. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day) as needed for mouth sores. 6. Clonazepam 0.5 mg Tablet Sig: 1-2 Tablets PO QHS (once a day (at bedtime)) as needed for insomnia. 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 TID (3 times a day). 9. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Esomeprazole Magnesium 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 11. Posaconazole 200 mg/5 mL (40 mg/mL) Suspension Sig: Five (5) mL PO TID (3 times a day). 12. Polyethylene Glycol 3350 17 gram/dose Powder Sig: One (1) pkt PO DAILY (Daily) as needed for constipation. 13. Insulin continue your home insulin sliding scale and fixed dose Levimir 20 units at night 14. Oxycodone 40 mg Tablet Sustained Release 12 hr Sig: One (1) Tablet Sustained Release 12 hr PO qAM: at 8 AM. Disp:*60 Tablet Sustained Release 12 hr(s)* Refills:*2* 15. Oxycodone 40 mg Tablet Sustained Release 12 hr Sig: One (1) Tablet Sustained Release 12 hr PO qPM: (at 8 pm). Disp:*60 Tablet Sustained Release 12 hr(s)* Refills:*2* 16. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for Breakthrough pain. Disp:*30 Tablet(s)* Refills:*0* 17. Saliva Substitution Combo No.2 Solution Sig: One (1) ML Mucous membrane TID (3 times a day). Disp:*90 ML(s)* Refills:*2* 18. Cefpodoxime 100 mg Tablet Sig: Two (2) Tablet PO Q12H (every 12 hours). Disp:*30 Tablet(s)* Refills:*0* 19. Oxycodone 20 mg Tablet Sustained Release 12 hr Sig: One (1) Tablet Sustained Release 12 hr PO q afternoon: 2 PM. Discharge Disposition: Home With Service Facility: Critical Care Systems Discharge Diagnosis: Primary: - Acute myeloid leukemia - Neutropenia Secondary: - Diabetes mellitus - Depression Discharge Condition: Mental Status: Clear and coherent Level of Consciousness: Alert and interactive Activity Status: Ambulatory - Independent Discharge Instructions: Dear Ms [**Known lastname **], You were admitted to [**First Name8 (NamePattern2) **] [**First Name4 (NamePattern1) 1675**] [**Last Name (NamePattern1) **] [**First Name (Titles) **] [**Last Name (Titles) **] for chemotherapy and donor lymphocyte infusion. You first received the MEC regimen (mitoxantrone, etoposide, and cytarabine) and donor lymphocyte infusions. Following these treatments, we waited for your bone marrow to recover, however you had continued numbers of blasts in your blood, suggesting that your AML needed further treatment. You also did develop a jaw infection and a low blood pressure with fevers for which we kept you on several antibiotics and briefly admitted you to the intensive care unit. Your blood pressure improved with antibiotics and we decided to start treating your AML again given continued blasts. Following a second round of chemotherapy with azacitadine/mylotarg, your blast count improved somewhat, however we did a third round with decitabine to keep your blast count low. You continued to have fevers which required us to keep you on antibiotics for several weeks. The source of your fevers may have been a urinary tract infection, which cleared with the antibiotics. At time of discharge, you had repeatedly clear blood and urine cultures with no fevers for five days prior to your discharge. . The medication changes we made during this hospitalization were: (1) Please discontinue dilaudid. (2) We decreased your morning oxycontin dose to 40 mg and we decreased your evening oxycontin dose to 40 mg. You should continue the 20 mg afternoon oxycontin. (3) We are giving you oxycodone for breakthrough pain - you can take [**12-18**] pills as needed every six hours. (4) You can apply caphasol gel to the mouth ulcers that you get to help decrease pain and irritation. (5) You can take Ativan as needed for nausea. (6) Please continue to take cefpodoxime twice a day for the next 15 days until Dr [**Last Name (STitle) **] indicates otherwise. You should continue your other antibiotics as usual (posaconazole and acyclovir). (7) You will need to get pentamidine administered on Thursday prior to your appointment with Dr [**Last Name (STitle) **] on Thursday (at 10:00 AM). Followup Instructions: You have a follow up appointment scheduled with Dr [**Last Name (STitle) **] at 130 PM on Thursday, [**4-7**]. Prior to this you will get a pentamidine treatment at 10:00 AM on the [**Hospital Ward Name **] ([**Location (un) 19201**], rm 116).

[ "346.80", "288.00", "780.79", "251.3", "311", "458.9", "V87.41", "V42.82", "780.60", "528.9", "333.94", "V58.67", "V10.91", "401.9", "205.02" ]

icd9cm

[ [ [] ] ]

[ "41.31", "99.25", "41.05", "38.93" ]

icd9pcs

[ [ [] ] ]

20589, 20641

14641, 17726

342, 348

20778, 20778

11929, 11929

23180, 23428

11196, 11340

18496, 20566

20662, 20757

17752, 18473

20926, 23157

11355, 11910

3216, 3738

272, 304

376, 3197

11945, 14618

20793, 20902

3760, 10792

10808, 11180

58,028

177,025

43564+58633

Discharge summary

report+addendum

Admission Date: [**2119-2-8**] Discharge Date: [**2119-2-11**] Date of Birth: [**2060-7-28**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**Last Name (NamePattern1) 1171**] Chief Complaint: Dyspnea Major Surgical or Invasive Procedure: None. History of Present Illness: The patient is a deaf 58 year old gentleman with a history of likely hypertensive dialated cardiomyopathy (EF 50%,) poorly controlled blood pressure, DM2 (last HbgA1c 9.5% in [**11-4**]), OSA who presented to the ED with complains of sudden onset SOB. The patient has had prior hospitalizations for acute pulmonary edema in the setting of hypertensive urgency. He is followed by Dr. [**First Name (STitle) 437**], with a recent improvement in cardiac function, with now improved systolic function (20% in [**2098**] to 50%), but dialated and hypertrophied ventricles. He was seen by his PCP one day prior to presentation with complaints of 3 days of conjunctivitis and rhinorhea with a slight, non-productive cough, which was felt to be a viral syndrome, but he was prescribed erythromycin ointment. . On the day of presenation, the patinet was waking and became markedly short of breath. EMS was activated, and the patient was placed on a NRB. On arrival to the ED, he was markedly hypertensive 242/11/ HR 106, and afebrile. The patinent was placed on BIPAP, was started on a nitro gtt, given ASA 325mg, and was 100mg IV lasix, to which he put out 400cc of urine. Cardiology was consulted in the ED, but felt that given recent URI symptoms, a MICU admission would be more appropriate. The patient was admitted to the MICU for further manegment. . The patient denies any fevers/chills, abdominal pain, diahrea, or dysuria. He has not had any worsening LE swelling, orthopnea, or PND. He reports to be compliant with home medication regimen. He complaints of b/l chest pain currently, similar to prior chest pain. Worse with palpation and deep inspiration. Past Medical History: 1. Hypertension 2. Type 2 Diabetes Mellitus, on insulin 3. Hyperlipidemia 4. OSA 5. Cardiomyopathy 6. Deaf Social History: The patient currently lives alone; his brother, with a significant drinking problem, had moved out of his home. He does not drink or smoke or use illicit drugs. His family is not involved with his care. He currently participates in a day program. Patient has a low education level (unclear how much school he has completed), and difficulty with [**Location (un) 1131**]. Family History: NC Physical Exam: VITALS: Afebrile BP 147/74 (137-204/58-100) HR 87 RR 11 O2 100% GEN: NAD, sitting up in bed comfortably, deaf, mute HEENT: PERRL, no scleral icterus, MMM, EOMI, oropharynx clear NECK: No JVD appreciated, No thyromegally, No LAD LUNGS: + bibasilar wheezes, bibasilar crackle L>R, no rhonchi or rales, good air movement CV: RRR, 2/6 systolic murmur best heard at RUSB, no gallops or rubs, no s3 or s4 ABD: soft, NT, ND, +BS, no HSM on exam EXT: No edema, cyanosis or edema. bilateral radial and DP pulses palpable bilaterally. NEURO: alert, unable to assess orientation, strength 5/5 in all 4 extremities, sensation intact throughout although minimally decreased in distal portions of feet. reflexes 2+ in bilateral patellar location. SKIN: no rashes or petechiae noted Pertinent Results: [**2119-2-8**] 06:35PM BLOOD WBC-5.4 RBC-4.98 Hgb-14.7 Hct-46.2 MCV-93 MCH-29.6 MCHC-31.9 RDW-12.8 Plt Ct-187 [**2119-2-10**] 06:35AM BLOOD WBC-7.8 RBC-4.15* Hgb-12.5* Hct-38.3* MCV-92 MCH-30.2 MCHC-32.7 RDW-12.6 Plt Ct-147* [**2119-2-8**] 06:35PM BLOOD Neuts-54.2 Lymphs-36.6 Monos-6.4 Eos-1.9 Baso-0.9 [**2119-2-8**] 06:35PM BLOOD Glucose-341* UreaN-15 Creat-1.1 Na-142 K-4.4 Cl-101 HCO3-31 AnGap-14 [**2119-2-10**] 06:35AM BLOOD Glucose-183* UreaN-17 Creat-1.1 Na-142 K-3.9 Cl-100 HCO3-36* AnGap-10 [**2119-2-8**] 06:35PM BLOOD CK(CPK)-386* [**2119-2-9**] 03:59AM BLOOD CK(CPK)-202 [**2119-2-9**] 12:59PM BLOOD CK(CPK)-184 [**2119-2-10**] 06:35AM BLOOD CK(CPK)-128 [**2119-2-8**] 06:35PM BLOOD cTropnT-0.03* [**2119-2-9**] 03:59AM BLOOD CK-MB-6 cTropnT-0.11* [**2119-2-9**] 12:59PM BLOOD CK-MB-5 cTropnT-0.14* [**2119-2-10**] 06:35AM BLOOD CK-MB-4 cTropnT-0.07* [**2119-2-9**] 03:59AM BLOOD Calcium-8.9 Phos-3.7 Mg-1.9 [**2119-2-11**] 06:10AM BLOOD WBC-5.6 RBC-4.10* Hgb-12.3* Hct-37.2* MCV-91 MCH-29.9 MCHC-33.0 RDW-12.5 Plt Ct-154 [**2119-2-11**] 06:10AM BLOOD Plt Ct-154 CHEST X-RAY [**2119-2-8**] - FINDINGS: There is mild cephalization of the pulmonary vasculature and prominence of the central pulmonary vasculature. There are no definite focal consolidations. Study is slightly limited by motion blurring. There is moderate cardiomegaly, stable. No pneumothorax or pleural effusion is present. Brief Hospital Course: # HTN: He has had multiple recent hospitalizations for similar systolic blood pressures. Initially he required a nitro drip to control his blood pressure, however with improvement in his blood pressure the drip was discontinued and, adjustments were made to his home medications for optimum blood pressure control. His lisinopril and carvedilol were at supratherapeutic doses without additional benefit in blood pressure control thus his carvedilol was decreased to 25 mg twice a day and lisinopril was decreased to 40mg daily. His lasix was increased to 40mg twice a day and his clonidine was increased to 0.3mg/q24 he once a week. Amlodipine 10mg daily was added to his regimen. Outpatient evaluation for obstructive sleep apnea is recommended, as well as addition of spironolactone by his primary care doctor if there are no contraindications. # Hypoxia: Patient had pulmonary edema on CXR on admission. He was initially placed on non-rebreather with good oxygen saturation. In the ED, he also recieved IV furosemide for diuresis. On arrival to the ICU, he was further diuresed and weaned to oxygen by nasal canula without difficulty. He had no oxygen requirement by the second hospital day. He was discharged on an increased diuretic dose. # Dilated Cardiomyopthy with CHF: Mr. [**Known lastname 805**] has a long-standing daignosis of dilated cardiomyopathy (EF 51%) in 10/[**2118**]. This was felt to be contributing to his hypoxia in setting of hypertensive urgency. He was diuresed as above. Continue carvedilol and lisinopril. He is to follow-up with his outpatient cardiologist after discharge. # Chest Pain: Mr. [**Known lastname 805**]' presented with chest pain in setting of hypertensive urgency. EKG unchanged, noted to have recent exercise MIBI without ischemia. Cardiac enzymes were cycled and were negative. He was continued on his aspirin, statin, beta blocker. # DM2: He was hypoglycemic in the early mornings and in the mid afternoons. This was likely due to his NPH dosing. His NPH am dose was decreased to 26 units and his pm dose was decreased to 18 units. Further titration should be continued as an outpatient. Medications on Admission: Lipitor 40mg hs carvedilol 50mg [**Hospital1 **] Clonidone 0.2mg qweek Erythromycin oilment qid Lasix 40mg daily Glipizide 10mg daily Lisinopril 8mg daily ASA 81mg daily NPH 28u qam 22un qhs Discharge Medications: 1. Amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*0* 2. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 3. Furosemide 40 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:*60 Tablet(s)* Refills:*2* 4. Glipizide 10 mg Tablet Extended Rel 24 hr Sig: One (1) Tablet Extended Rel 24 hr PO DAILY (Daily). 5. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 6. Carvedilol 25 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:*60 Tablet(s)* Refills:*2* 7. Lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 8. NPH Insulin Human Recomb 100 unit/mL Cartridge Sig: Twenty Six (26) units Subcutaneous in the mornings. 9. NPH Insulin Human Recomb 100 unit/mL Cartridge Sig: Eighteen (18) units Subcutaneous in the evenings. 10. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) patch Transdermal once a week: remove previous patch. Place new patch on Mondays. Disp:*4 patches* Refills:*2* Discharge Disposition: Home With Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: Hypertensive Urgency Discharge Condition: Mental Status:Clear and coherent Level of Consciousness:Alert and interactive Activity Status:Ambulatory - Independent Discharge Instructions: You were admitted to the hospital after developing shortness of breath and some chest pain. You did not have a heart attack. Your blood pressure was determined to be high and you were given medication to reduce it. You also recieved some medication to help your body get rid of excess fluid. You are being discharged home on 1 more blood pressure medication and changes have been made in the doses of your previous blood pressure medications. . CHANGES IN MEDICATION: START Amlodipine 10 mg by mouth daily Increase lasix to 40mg twice a day Increase Clonidine to 0.3mcg/24hr patch once a week (MONDAYS). Decrease carvedilol to 25 mg twice a day Decrease lisinopril to 40mg daily Please continue all other medications as previously prescribed Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more than 3 lbs. Followup Instructions: Please follow-up with your primary care physician, [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 34732**], at your previously scheduled appointment. Details are listed below: Provider: [**First Name11 (Name Pattern1) 1141**] [**Last Name (NamePattern4) 93720**], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2119-2-20**] 3:25 Name: [**Known lastname 183**],[**Known firstname 1937**] Unit No: [**Numeric Identifier 14795**] Admission Date: [**2119-2-8**] Discharge Date: [**2119-2-11**] Date of Birth: [**2060-7-28**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**Last Name (NamePattern1) 2539**] Addendum: The patient had previously been on Humulog 75/25 at home, taking 32 units in the morning, and 20 units at dinner time. He had been started on NPH in the ICU. This change likely accounted for his hypoglycemia in house. He resumed his home regimen on discharge. Medications on Admission: Lipitor 40mg hs carvedilol 50mg [**Hospital1 **] Clonidone 0.2mg qweek Erythromycin oilment qid Lasix 40mg daily Glipizide 10mg daily Lisinopril 8mg daily ASA 81mg daily NPH 28u qam 22un qhs addended to Humulog 75/25 32 units in the am, 20 units at night. Discharge Medications: 1. Amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*0* 2. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 3. Furosemide 40 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:*60 Tablet(s)* Refills:*2* 4. Glipizide 10 mg Tablet Extended Rel 24 hr Sig: One (1) Tablet Extended Rel 24 hr PO DAILY (Daily). 5. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 6. Carvedilol 25 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:*60 Tablet(s)* Refills:*2* 7. Lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 8. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) patch Transdermal once a week: remove previous patch. Place new patch on Mondays. Disp:*4 patches* Refills:*2* 9. insulin Please continue to take your Humulog 75/25. Please take 32 units in the morning and 20 units at night. Discharge Disposition: Home With Service Facility: [**Location (un) 42**] VNA [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**Name8 (MD) **] MD [**MD Number(1) 2541**] Completed by:[**2119-2-11**]

[ "319", "079.99", "250.00", "425.8", "402.91", "V58.67", "428.0", "428.32", "389.7", "327.23", "272.4" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

11605, 11831

4799, 6959

331, 339

8354, 8354

3368, 4776

9358, 10365

2559, 2563

10672, 11582

8310, 8333

10391, 10649

8499, 9335

2578, 3349

283, 293

367, 2024

8368, 8475

2046, 2155

2171, 2543

81,715

165,402

53929

Discharge summary

report

Admission Date: [**2157-5-11**] Discharge Date: [**2157-5-14**] Date of Birth: [**2089-11-10**] Sex: F Service: CARDIOTHORACIC Allergies: azithromycin Attending:[**First Name3 (LF) 165**] Chief Complaint: atrial mass Major Surgical or Invasive Procedure: [**2157-5-11**] Abdominal MRI [**2157-5-11**] Bilateral Lower Extremity Duplex [**2157-5-11**] Echocardgiogram History of Present Illness: [**Known lastname **] was treated at an OSH in [**2157-2-13**] for a presumed pneumonia. Her symptoms at that time consisted of cough, SOB and occasional chest pain. She completed a course of antibiotics but her symptoms have persisted and even worsened since that time. She was experiencing worsening SOB as well as worsening lethargy, DOE, and chest discomfort. She also reports that she has had a decreased appetite since [**Month (only) 404**] and has lost approximately 20 pounds. She was evaluated as an outpatient with a cardiac stress test which is reportedly normal. On f/u chest xray with her PCP [**Name Initial (PRE) **] large [**Name Initial (PRE) **] sided mass was discovered and she was subsequently sent for CTChest which confirmed presence of a large R atrial mass (thought to be within the atrium). She was sent to [**Hospital3 **] Hospital and subsequently transferred to [**Hospital1 18**] for further evaluation. During this admission she has undergone evaluation with TTE, MRI and 3D Echo in an effort to further localize the mass. Differential diagnosis at this juncture includes hematoma, lymphoma, aneurysm, psuedoaneurysm, thymoma or NSGCT. Thoracic surgery is consulted for consideration of biopsy for tissue diagnosis. Past Medical History: recent pneumonia [**2-/2157**] hysterectomy for hemorrhage following childbirth Social History: Cigarettes: [x] never [ ] ex-smoker [ ] current Pack-yrs:____ quit: ______ ETOH: [x] No [ ] Yes drinks/day: _____ Exposure: [x] No [ ] Yes [ ] Radiation [ ] Asbestos [ ] Other: Occupation: Marital Status: [x] Married [ ] Single Lives: [ ] Alone [x] w/ family [ ] Other: Other pertinent social history: Family History: Mother - CAD, MI Father - CAD, "metastatic cancer" Physical Exam: On discharge VS: T: 98.9 HR: 79 SR BP: 123/76 Sats: 96% RA General: 67 year-old female in no apparent distress HEENT: normocephalic, mucus membranes moist Cardiac: RRR normal S1,S2 GI: benign Extr: warm no edema Neuro: awake, alert oriented Pertinent Results: [**2157-5-14**] WBC-3.8* RBC-3.46* Hgb-10.3* Hct-31.9* MCV-92 MCH-29.9 MCHC-32.4 RDW-13.9 Plt Ct-228 [**2157-5-11**] WBC-6.5 RBC-3.81* Hgb-11.0* Hct-35.2* MCV-92 MCH-28.9 MCHC-31.4 RDW-14.1 Plt Ct-211 [**2157-5-11**] Neuts-76.2* Lymphs-14.9* Monos-6.7 Eos-1.7 Baso-0.5 [**2157-5-14**] Glucose-123* UreaN-9 Creat-0.7 Na-138 K-4.0 Cl-105 HCO3-27 [**2157-5-11**] Glucose-110* UreaN-15 Creat-0.7 Na-134 K-4.2 Cl-100 HCO3-22 [**2157-5-11**]: MRI abdomen: 1. Large 9.8 x 10.0 cm mass causing compression of the right atrium and superior vena cava which is either arising from the pericardium or the right atrium which will be further evaluated on planned echocardiogram performed today. The mass demonstrates heterogeneous signal intensity on T2-weighted imaging and heterogeneous enhancement post-contrast. Differential diagnostic considerations include both primary and metastatic masses. 2. 8-mm nodule in the left adrenal gland which is indeterminate given limitations of slice thickness and its small size. This may be further characterized with a dedicated adrenal mass protocol CT for further characterization. If CT cannot be performed MR may be repeated with dedicated adrenal protocol. 3. Likely benign osseous hemangiomas noted within the lumbar spine. However, these are incompletely characterized and given the clinical scenario, further evaluation with MR lumbar spine is recommended. [**2157-5-11**]: Bilateral lower extremity doppler: No evidence of DVT. 03/2/8/12: Echocardiogram: The left atrium is elongated. A very large (7 x 10 cm) mass is seen in or adjacent to the right atrium which compresses/distorts the right atrium and tricuspid valve apparatus. There are echolucent spaces within the mass, which itself appears well-circumscribed. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). Tissue Doppler imaging suggests a normal left ventricular filling pressure (PCWP<12mmHg). Right ventricular chamber size and free wall motion are normal. The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Mild (1+) aortic regurgitation is seen. Mitral valve leaflets are normal. There is no mitral valve prolapse. Moderate [2+] tricuspid regurgitation is seen. There is borderline pulmonary artery systolic hypertension. There is a very small pericardial effusion. IMPRESSION: A very large (7 x 10 cm) mass is seen in or directly adjacent to the right atrium which compresses/distorts the right atrium and tricuspid valve apparatus. There are echolucent spaces within the mass, which itself appears well-circumscribed. Moderate tricuspid regurgitation. Very small pericardial effusion. Mild aortic regurgitation. Preserved left ventricular systolic function. Brief Hospital Course: Mrs. [**Known lastname **] was transfer from [**Hospital3 **] Hospital on [**2157-5-11**] for a right 7 x 10 cm paracardial mass that has rapidly grown over the past 2 months. Upon arrival abdominal MRI, bilateral lower extremity duplex and echocardiogram (see above report) were obtained. Thoracic surgery was consulted and recommended tissue biopsy obtained via CT guided IR, mediastinoscopy, VATS or EBUS with IP. She was discharged to home on [**2157-5-14**] and will return for a CT-guided biopsy. Medications on Admission: celexa 20mg daily aspirin 81 mg daily multivitamin Discharge Medications: 1. lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily). 2. aspirin 81 mg Tablet, Delayed Release (E.C.) [**Last Name (STitle) **]: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 3. citalopram 20 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily). 4. multivitamin Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily). 5. lorazepam 0.5 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO twice a day as needed for anxiety. Disp:*3 Tablet(s)* Refills:*0* 6. camphor-menthol 0.5-0.5 % Lotion [**Last Name (STitle) **]: One (1) Appl Topical QID (4 times a day) as needed for itching: continue to apply to rash. Discharge Disposition: Home Discharge Diagnosis: Large paracardial mass s/p hysterectomy for hemorrhage following childbirth Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: **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: Dr. [**Last Name (STitle) **] [**Name (STitle) **] office will call on Monday [**5-16**] with instructions for the biopsy of the paracardial mass. [**Telephone/Fax (1) 170**] Please call Dr.[**Name (NI) 2347**] (Thoracic Surgeon) office [**Telephone/Fax (1) 2348**] for an appointment following the biopsy. [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**] Completed by:[**2157-5-14**]

[ "239.89", "786.09", "459.2", "786.59", "783.21", "783.0" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

6784, 6790

5401, 5907

291, 404

6910, 6910

2538, 5378

7248, 7678

2206, 2259

6009, 6761

6811, 6889

5933, 5986

7061, 7225

2274, 2519

240, 253

432, 1688

6925, 7037

1710, 1791

2190, 2190

71,220

144,522

47089

Discharge summary

report

Admission Date: [**2186-12-25**] Discharge Date: [**2187-1-15**] Service: MEDICINE Allergies: Penicillins / Sulfa (Sulfonamide Antibiotics) / Tetracycline Analogues Attending:[**First Name3 (LF) 2712**] Chief Complaint: fevers, hypotension Major Surgical or Invasive Procedure: intubation extubation placement of central line removal of central line removal of tunneled HD line and placement of a temporary HD line removal of temporary HD line and placement of a new tunneled line History of Present Illness: [**Age over 90 **]-year-old female with past medical history of ESRD on HD, pulmonary hypertension, chronic diastolic heart failure presents with fevers and respiratory distress. . Per notes and history from family, the patient had been doing well until 5-6 days prior to presentation. At that time the patient developed a "cough and a cold". They note a non-productive cough without fevers, chills or night sweats. At that time she was noted to have "some rhonchi" per HD nurse. The patient was thought to have a viral URI. Over the last few days the patient has been feeling worse and has had poor PO intake. She went to dialysis on the day of presentation and completed hemodyalysis. Upon returning home she became more lethargic. Her temperature and SaO2 were checked and were 101.5 and 85% on room-air, respectively. . She presented to the emergency department with initial vitals of T 101.5, HR 70, BP 133/60, RR 40 and SaO2 92% on NRB. The patient was intubated for respiratory distress. WBC was 12.3. CXR showed LLL opacity and patchy right pulmonary opacities. Given clinical picture the patient was started on vancomycin, cefepime and levofloxacin. After Versed bolus patient became hypotensive and was started on levophed with placement of triple lumen catheter. . Currently, the patient is sedated and intubated. . Review of Systems: Unable to obtain from patient. Past Medical History: - ESRD on T/Th/Sat HD followed by Dr. [**Last Name (STitle) 118**] at [**Location (un) **] [**Location (un) **] - metastatic breast carcinoma - afib on coumadin - tachy/brady syndrome s/p PPM [**2172**] - chronic diastolic dysfunction with EF 65%, 4+ TR, 2+ MR - hypothyroidism - HTN - anemia (baseline ~34) - gout - moderate pulmonary hypertension - IBS - h/o diverticulosis - squamous cell carcinoma of left shin and neck, s/p radiation in [**2183**] - "multiple other basal cell and squamous cell carcinomas treated with surgery" - Post herpetic neuralgia - osteoporosous - h/o right hip fracture requiring total hip replacement in [**2183-11-1**] - right inguinal herniorrhaphy in [**2180**] Social History: Lives at home in [**Location (un) 10059**]. She has a high school education and was a businesswoman. She is a widow. She does not smoke and she does not drink alcohol. She has 24 hour care at home. Family History: NC Physical Exam: VS: Temp: 99.5 BP: 109/48 HR: 63 RR: 19 O2sat: 100% AC 500 14 FIO2 .50 GEN: sedated, responsive to voice, elderly HEENT: PERRL, intubated, ETT with some bright red blood, no LAD, no JVD Resp: Coarse breath sounds bilateral, anterior exam, bilat crackles, limited exam CV: RR, II/VI murmur difficult to hear with vent, S1 and S2 wnl, no r/g appreciated ABD: nd, +b/s, soft, no masses or hepatosplenomegaly appreciated EXT: wwp, cool feet/hands, [**12-3**]+ peripheral edema SKIN: thin skin with multiple tears, lesion around anus NEURO: Sedated, pupils as above Pertinent Results: LABS ON ADMISSION: wbc 12.3, hct 37.5, plt 181 na 140, k 5.0, cl 97, hco3 28, bun 18, cr 2.6, gluc 176 lft peak: (3 days after admission) alt 304, ast 719, ldh 707 LABS ON DISCHARGE: wbc 11.1, hct 34.3, plt 66 na 138, k 5.3, cl 99, hco3 25, bun 82, cr 4.7, gluc 152 lfts alt 17, ast 42, ldh 601, alk phos 103, tbili 0.7 * will attach lab printout for more detail. Micro: [**2187-1-15**] STOOL CLOSTRIDIUM DIFFICILE TOXIN A & B TEST-PENDING [**2187-1-9**] STOOL CLOSTRIDIUM DIFFICILE TOXIN A & B TEST-FINAL -[**2187-1-6**] STOOL CLOSTRIDIUM DIFFICILE TOXIN A & B TEST-FINAL - [**2187-1-3**] CATHETER TIP-IV WOUND CULTURE-FINAL - [**2187-1-2**] CATHETER TIP-IV WOUND CULTURE-FINAL - [**2187-1-2**] CATHETER TIP-IV WOUND CULTURE-FINAL - [**2187-1-2**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY CULTURE-FINAL {STAPH AUREUS COAG +} | CLINDAMYCIN----------- R ERYTHROMYCIN---------- =>8 R GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- =>8 R OXACILLIN------------- =>4 R RIFAMPIN-------------- <=0.5 S TETRACYCLINE---------- <=1 S TRIMETHOPRIM/SULFA---- <=0.5 S VANCOMYCIN------------ 1 S [**2187-1-2**] BLOOD CULTURE Blood Culture, Routine-FINAL - [**2187-1-2**] BLOOD CULTURE Blood Culture, Routine-FINAL - [**2186-12-29**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY CULTURE-FINAL - [**2186-12-29**] BLOOD CULTURE Blood Culture, Routine-FINAL - [**2186-12-29**] BLOOD CULTURE Blood Culture, Routine-FINAL - [**2186-12-28**] BLOOD CULTURE Blood Culture, Routine-FINAL - [**2186-12-28**] CATHETER TIP-IV WOUND CULTURE-FINAL - [**2186-12-28**] BLOOD CULTURE Blood Culture, Routine-FINAL - [**2186-12-28**] BLOOD CULTURE Blood Culture, Routine-FINAL - [**2186-12-27**] BLOOD CULTURE Blood Culture, Routine-FINAL -[**2186-12-26**] Influenza A/B by DFA DIRECT INFLUENZA A ANTIGEN TEST-FINAL; DIRECT INFLUENZA B ANTIGEN TEST-FINAL - [**2186-12-26**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY CULTURE-FINAL; LEGIONELLA CULTURE-FINAL - [**2186-12-26**] BLOOD CULTURE Blood Culture, Routine-FINAL - [**2186-12-26**] BLOOD CULTURE Blood Culture, Routine-FINAL - [**2186-12-26**] BLOOD CULTURE Blood Culture, Routine-FINAL - [**2186-12-26**] BLOOD CULTURE Blood Culture, Routine-FINAL - [**2186-12-25**] BLOOD CULTURE Blood Culture, Routine-FINAL -[**2186-12-25**] BLOOD CULTURE Blood Culture, Routine-FINAL - Imaging: [**1-8**] CXR: NG tube tip is in the stomach. The central venous line tip is at the proximal right atrium. The pacemaker leads terminate in the expected location of right atrium and ventricle. There is no change in the cardiomediastinal silhouette, left retrocardiac consolidation which in part is representing atelectasis as well as pulmonary edema. No pneumothorax is seen. (Multiple other CXRs for line placement - all similar). [**12-31**] RUQ u/s: IMPRESSION: Normal gallbladder without stones, with normal caliber common bile duct. [**12-29**] CT torso: IMPRESSION: 1. No clear source of the patient's sepsis. Interval bilateral pleural effusions with associated atelectasis. No evidence of focal infiltration to suggest pneumonia. 2. No evidence of intra-abdominal abscess, bowel obstruction or fluid collection. 3. Soft tissue mass with lysis of the anterior left acetabulum as well as soft tissue mass arising from the right pleura with associated destruction in the posterolateral right fifth rib. 4. Multiple healed right-sided rib fractures. 5. Punctate, non-obstructing bilateral renal calculi. [**12-28**] ECHO: Conclusions The left atrium is mildly dilated. The right atrium is moderately dilated. Left ventricular wall thicknesses are normal. The left ventricular cavity is unusually small. Overall left ventricular systolic function is low normal (LVEF 50%). The right ventricular free wall is hypertrophied. The right ventricular cavity is dilated with depressed free wall contractility. There is abnormal septal motion/position consistent with right ventricular pressure/volume overload. There are three aortic valve leaflets. The aortic valve leaflets are moderately thickened. There is a minimally increased gradient consistent with minimal aortic valve stenosis. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. There is severe mitral annular calcification. Trivial mitral regurgitation is seen. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] The left ventricular inflow pattern suggests a restrictive filling abnormality, with elevated left atrial pressure. The tricuspid valve leaflets are mildly thickened. The tricuspid valve leaflets fail to fully coapt. The supporting structures of the tricuspid valve are thickened/fibrotic. Moderate to severe [3+] tricuspid regurgitation is seen. [Due to acoustic shadowing, the severity of tricuspid regurgitation may be significantly UNDERestimated.] There is moderate pulmonary artery systolic hypertension. The main pulmonary artery is dilated. The branch pulmonary arteries are dilated. There is no pericardial effusion. [**12-26**] Hip Xray: IMPRESSION: Enlarging metastasis left hemipelvis. [**12-25**] CXR: IMPRESSION: 1. Low lung volumes. Mild pulmonary vascular congestion and stable cardiomegaly. 2. Blunting of the left costophrenic angle is chronic and may be due to prominent paracardiac fat pad, although a trace effusion cannot be entirely excluded. Brief Hospital Course: [**Age over 90 **]-year-old female with ESRD on HD, pHTN, dCHF, presents with fevers, respiratory distress and hypotension of unknown etiology now resolved, although with persistent delerium. . # Hypotension: Unclear etiology. All infectious workup was negative except for MRSA in a sputum culture. Pt was initially on pressors for a prolonged period of time, then was eventually weaned off of them. Pt was still requiring vasopressin especially with dialysis sessions. Pt was emperically treated with 14 day course of vanc as well as an 8 day course of Meropenem for pneumonia and question of a line infection. TTE was performed which showed EF of 50% and no obvious vegetations. Pt was started on Hydrocortisone, which was gradually tapered off. Pt was also started on Midodrine as well as Fludricortisone for further BP support. The fludricotisone was stopped as she was continuing to retain fluid. Currently, pt is normotensive, off all pressors but still taking midodrine TID. Her BPs range in the 90s-100s, and dip into the 80s during HD. Pt remains afebrile, with no leukocytosis without signs of infection. Her WBC was 11 on discharge, which has been around 9 or 10 since admission, but there are no signs of infection. . # Hypoxic respiratory failure: Pt presented to the emergency department with respiratory distress and was satting 92% on NRB. The patient was intubated. Etiology was unclear, pneumonia vs volume overload. Pt was dialysed to maintain a euvolemic state. Pt was treated emperically for a possible pneumonia with Vanc/[**Last Name (un) **] though all cultures were negative and CXR without clear evidence of consolidation. Pt was eventually extubated and her respiratory status consistently imrpoved to now only on 2L NC. She still appears volume overload with peripheral edema, and HD is trying to remove fluid as blood pressure tolerates. . # ESRD: Pt is on hemodialysis as an outpt, followed by Dr. [**Last Name (STitle) 118**]. Renal followed pt closely and did HD as needed. Pt was also on CVVH at times to get fluid off as pt was often fluid overloaded. Pt's tunneled HD line was removed though low suspicion of a line infection. A temporary HD line was placed, and a few days later that was removed and a new HD tunneled line was placed. All cultures were negative. Pt is currently on a MWF HD schedule. She has dialysis [**12-15**] (the day of discharge). They recommended to consider giving albumin if hypotensive during dialysis for BP support. She is newly on nephrocaps as a vitamin supplement. . # Diarrhea: Pt had diarrhea, likely secondary to antibiotics. Tube feeds may have been contributing. There was no evidence of C. Difficile infection. The symptoms are gradually improving with addition of banana flakes in tube feeds, per Nutrition. She is sensitive to constipation medications and one dose of senna seemed to have given her diarrhea. On the day of discharge, she had a c.diff test pending because of this diarrhea. Her WBC were 11, which was only slightly above baseline. The c.diff will be back tomorrow which we will follow up and call [**Hospital 100**] Rehab if it is positive. . # Delirium/pain control: Pt was intially sedated while intubated. After extubation, pt mental status was slow to improve. Gradually though, pt has become more communicative. This was likely [**1-3**] to prologed ICU stay. Continue to orient often, minimize lines, avoid sedating medications. Pt was on Buproprion, which was later discontinued as it was giving no benefit. Pt was also receiving Zyprexa PRN, which was then discontinued due to concern that it may be adversly affecting her mental status. Pt does get frequent Oxycodone for pain control, which may be currently contributing to her mental status. Her pain is usually in her R breast. Her family refers to it as zoster pain, but there is a metastatic breast cancer mass on the rib in that area, which is likely the cause of the pain. [**Female First Name (un) 1634**] was consulted to help manage pain control and delerium. We put her on standing acetaminophen. We decided to continue her oxycodone on an as needed basis for now. It may need to be increased for comfort if her family tolerates somewhat increased sedation. We think delerium will hopefully clear with time and better sleep cycle. Of note, on her home meds, lyrica and her temazepam were stopped to see if her mental status would improve. It will likely be helpful to seek the aid of palliative care in the future to help manage pain and keep balance between pain and the side effects of pain meds. . # Thrombocytopenia: Unclear etiology. H2 blocker was discontinued. [**Month (only) 116**] have nbeen secondary to vanco. HIT antibody was sent and was negative. Plts now stable with no signs of bleeding. . # Transaminitis: Pt noted to have a rise in her LFTs. Unclear etiology. RUQ u/s was negative. LFTs gradually improved and have nearly normalized now. [**Month (only) 116**] have been secondary to mild shock liver in setting of initial hypotension. . # Hyperglycemia: Pt had elevated sugars, especially in the setting of steroids for her hypotension. Pt was maintained on an insulin sliding scale. Pt was also started on NPH 12 units qAM, 10units qHS but was weaned down to no standing long acting insulin. She is now just on a regular insulin sliding scale. . # Nutrition: An NGT was placed and tube feeds were started to give pt nutrition during this long ICU course. Pt is tolerating the tube feeds realtively well with low residuals. Pt did have diarrhea, thus banana flakes were added. As pt's mental status continues to improve, speech and swallow is evaluating pt, however, most recently recommeded that pt remain NPO for now. . # Atrial fibrillation/Tachy/Brady syndrome: Pt was supratherapeutic on Coumadin intially. Couamdin was held. INR trended down appropriatly and Coumadin was restarted. Pt was not bridged as the anti-coagulation was for Afib. Currently, pt is on 1.5mg daily. She is in normal sinus rhythm with heart rates in the 80s-90s on discharge. Rate control was not given because of her low blood pressures. . # Chronic diastolic CHF: Pt is getting UF with HD. No evidence of heart failure seen in her respiratory status, but is anasarcic. . # Metastatic breast carcinoma: Pt is s/p palliative radiation to hip, is followed by an oncologist at [**Hospital1 2025**] but currently off treatment due to GI intolerance. Hip films on admission showed enlarged hip metastasis but causing no pain or discomfort currently. She also has a rib met seen on CT chest. Her pain regimen is with oxycodone as above. . # Skin impairments: Pt has very sensitive skin, with multiple skin tears. Pt also has a stage II ulcer on coccyx. Pt also had an incident of contrast infiltration into left arm, which she is recovering from. Pt has appropriate wound care with dressing changes. She also has a fungal rash around her fingernails for which she is on antifungal powder. . # Hypothyroidism: we continued her levothyroxine. . # Hemorrhoids: bothered her while she was here, was treated with tucks pads; she had no bleeding problems while here. Pt was intially full code, however after extubation and after much discussion with pt's daughter [**Name (NI) **] [**Name (NI) 99825**] (HCP), pt was made DNR/DNI. We suggested palliative care briefly to the family, but they were resistant to having them see her at this time. *** ADDENDUM: The morning after the patient was discharged, the lab called to report a positive c.diff sample. [**Hospital 100**] Rehab was contact[**Name (NI) **] [**12-16**] at 730 am and informed of the results. Told to call Dr. [**First Name (STitle) 3441**] back with questions. Medications on Admission: albuterol sulfate 2.5 mg/3 mL (0.083 %) neb [**Hospital1 **] PRN albuterol sulfate [ProAir HFA] 90 mcg HFA Inh 1 puffs inhaled [**Hospital1 **] prn Anastrozole (dosage uncertain) atorvastatin 10 mg PO daily azithromycin [Zithromax Z-Pak] 250mg PO daily x5 days (500mg on Day 1) B complex-vitamin C-folic acid [Renal Caps] 1 mg PO daily bupropion HCl 75 mg Tablet [**12-3**] tab in AM, [**12-3**] tab at noon PO daily calcium acetate 667 mg PO every other day citalopram 10 mg PO daily epoetin alfa 40,000 unit inj q two weeks hydrocortisone acetate 25 mg Suppository [**Hospital1 **] prn hemorrhoids levothyroxine 50 mcg PO daily lidocaine 5 % (700 mg/patch) Adhesive Patch 1 daily nystatin 100,000 apply to rash under breast [**Hospital1 **] oxycodone 5-10mg liquid PO q4hours pantoprazole 40 mg PO BID polyethylene glycol 3350 [Miralax] 100 % Powder 1 tablespoon Powder(s) by mouth daily pregabalin [Lyrica] 25 mg Capsule PO 3 days per week temazepam 15 mg PO qhs tramadol 25mg PO BID prn pain warfarin 2 mg PO daily acetaminophen 650 mg PO TID ergocalciferol 400 unit PO daily Discharge Medications: 1. citalopram 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 2. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily) as needed for chronic pain. 3. polyvinyl alcohol-povidone 1.4-0.6 % Dropperette Sig: [**12-3**] Drops Ophthalmic PRN (as needed) as needed for dry eyes. 4. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) neb Inhalation Q6H (every 6 hours) as needed for SOB/wheezing. 5. midodrine 5 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 6. levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. triamcinolone acetonide 0.025 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day): apply to rash around fingers. 8. oxycodone 5 mg/5 mL Solution Sig: Two (2) ml PO Q2H (every 2 hours) as needed for pain: hold for sedation. 9. therapeutic multivitamin Liquid Sig: Five (5) ML PO DAILY (Daily). 10. warfarin 1 mg Tablet Sig: 1.5 Tablets PO Once Daily at 4 PM. 11. ketoconazole 2 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day) as needed for fungal rash: appply to rash around fingernails. 12. pramoxine-mineral oil-zinc 1-12.5 % Ointment Sig: One (1) Appl Rectal PRN (as needed) as needed for pain. 13. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical TID (3 times a day) as needed for fungal rash. 14. Normal Saline Flush 0.9 % Syringe Sig: One (1) syringe Injection PRN as needed for to flush line. 15. insulin regular human 100 unit/mL Solution Sig: One (1) unit Injection ASDIR (AS DIRECTED): sliding scale is attached. 16. Nephrocaps 1 mg Capsule Sig: One (1) Capsule PO once a day. 17. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO three times a day. Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - MACU Discharge Diagnosis: Primary Diagnosis: Sepsis Respiratory Failure Pneumonia ESRD on HD Delerium Metastatic breast cancer (to rib/hip) Afib on Coumadin Secondary diagnosis: Hypothyroidism Diastolic CHF Anemia Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Lethargic but arousable. Activity Status: Bedbound. Discharge Instructions: You were admitted to the hospital with low blood pressure and respiratory distress. You were treated for pnuemonia and a line infection with a course of antibiotics. During your initial presentation, you required intubation and special medications to keep your blood pressure up. Eventually, your breathing improved and you were able to be extubated. We changed your lines to help facilitate improvement of your line infection. You were getting dialysis while here because of your renal disease. You continue to have intermittent low blood pressures. We tried oral medications to help you. We will keep you on midodrine for this reason. Dialysis will continue to try to keep getting excess fluid off as your blood pressure tolerates. You also continue to have some confusion. This is likely related to ICU delerium and all the medications you had that have sedating side effects. We are trying to find a balance between pain control and confusion, and have you on oxycodone for now. Other problems included diarrhea, which was likely related to antibiotics and the tube feeds. You need to continue the tube feeds until your swallowing improves. You also had elevated liver enzymes, which were likely related to your low blood pressures. They were better when you were discharged. Your platelets were also low, likely from the acute illness. They were stable on discharge. You also had some sleeping problems. We had stopped your tempazepam and lyrica because you were too sleepy at times. The changes to your medications at this time are: - stopped lyrica and tempazepam - stopped wellbutrin - stopped atorvastatin (because of your liver) - stopped protonix (because of your platelets) - changed coumadin from 2 mg to 1.5 mg (your inr was 2.0 on discharge) - started insulin for high blood sugars - started midodrine for low blood pressures Followup Instructions: Please follow up with your rehab doctors. You can make appointments to see your primary care doctor once you are well enough to go home after rehab. Please follow up with the following appointments: Department: CARDIAC SERVICES When: TUESDAY [**2187-3-20**] at 3:30 PM With: DEVICE CLINIC [**Telephone/Fax (1) 62**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: CARDIAC SERVICES When: TUESDAY [**2187-3-20**] at 4:00 PM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1008**], M.D. [**Telephone/Fax (1) 62**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Completed by:[**2187-1-16**]

[ "403.91", "287.5", "V58.61", "585.6", "E912", "285.9", "486", "198.5", "349.82", "E849.7", "933.1", "244.9", "995.92", "V49.86", "038.9", "V45.11", "428.0", "416.8", "564.00", "707.22", "008.45", "427.31", "518.81", "785.52", "707.03", "V10.3", "428.32", "V45.01" ]

icd9cm

[ [ [] ] ]

[ "96.71", "96.6", "38.91", "38.95", "96.04", "38.97" ]

icd9pcs

[ [ [] ] ]

19505, 19571

8881, 16624

299, 504

19804, 19804

3465, 3470

21828, 22642

2864, 2868

17754, 19482

19592, 19592

16650, 17731

19943, 21805

2883, 3446

1878, 1911

240, 261

3649, 8858

532, 1859

19745, 19783

19611, 19724

3484, 3630

19819, 19919

1933, 2632

2648, 2848

7,315

180,991

30824

Discharge summary

report

Admission Date: [**2166-6-24**] Discharge Date: [**2166-7-1**] Date of Birth: [**2105-9-20**] Sex: F Service: CARDIOTHORACIC Allergies: Penicillins / Cephalosporins / Tegretol Attending:[**First Name3 (LF) 281**] Chief Complaint: Dyspnea Major Surgical or Invasive Procedure: Tracheostomy, PEG placement History of Present Illness: 60F transferred from outside hospital after presenting with acute onset of shortness of breath requiring intubation, subsequent extubation and re-intubation for stridor, and treatment for E coli pneumonia. Past Medical History: Dysphagia, GERD, ICD implantation, Diabetes type 2, Coronary artery disease, h/o herpes, Depression Physical Exam: T 99.0, HR 72, BP 160/62, RR 24, O2 sat 100% on controlled mechanical ventilation. No distress Lungs clear bilaterally Trach site clean Heart RRR, nl S1S2 Abd soft, PEG site clean, no distention Ext warm, trace pedal edema Pertinent Results: [**2166-6-24**] 09:47PM TYPE-ART RATES-20/ TIDAL VOL-500 PEEP-5 O2-30 PO2-71* PCO2-32* PH-7.53* TOTAL CO2-28 BASE XS-4 -ASSIST/CON INTUBATED-INTUBATED [**2166-6-24**] 08:47PM GLUCOSE-199* UREA N-11 CREAT-0.4 SODIUM-141 POTASSIUM-3.7 CHLORIDE-107 TOTAL CO2-26 ANION GAP-12 [**2166-6-24**] 08:47PM WBC-9.1 RBC-3.31* HGB-9.8* HCT-29.9* MCV-90 MCH-29.6 MCHC-32.8 RDW-16.6* Brief Hospital Course: 60F transferred from outside hospital to Interventional Pulmonology service intubated and being treated for pneumonia. A CT trachea was obtained showing tracheal narrowing at the level of the thyroid, confirmed by bronchoscopic exam. She underwent tracheostomy and PEG placement on [**2166-6-26**], recovered well from these procedures, and was deemed fit for discharge on [**2166-6-27**] with instructions to start tube feeding at 6pm (24 hours after surgery). Medications on Admission: Meds at nursing home prior to presentation: Lysine, Lorazepam, Aspirin, Lisinopril, Valproic acid, Novolin, Glucophage, Celexa, Protonix, Lipitor, Senna Discharge Medications: 1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 2. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2 times a day). 3. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 4. Valproate Sodium 250 mg/5 mL Syrup Sig: One (1) PO Q8H (every 8 hours). 5. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 7. Insulin Regular Human 100 unit/mL Solution Sig: Sliding scale Injection ASDIR (AS DIRECTED). 8. Ranitidine HCl 15 mg/mL Syrup Sig: One (1) PO BID (2 times a day). Discharge Disposition: Extended Care Facility: [**Hospital3 105**] Northeast - [**Location (un) 701**] Discharge Diagnosis: Dysphagia, GERD, Diabetes, Coronary artery disease, Depression Discharge Condition: Fair Discharge Instructions: Please call Dr.[**Name (NI) 56347**] office ([**Telephone/Fax (1) 10084**]) with any questions or concerns including abdominal distention, problems with the tracheostomy or PEG, fever >101.5, purulent drainage from incisions, etc. Followup Instructions: Call Dr.[**Name (NI) 56347**] office for follow-up, [**Telephone/Fax (1) 10084**]. Recommend Replete w/fiber with goal 60cc/hr: start at 10cc/hr and advance by 20cc q6h to goal, flushing with 30cc of water q6h. [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 286**] Completed by:[**2166-6-27**]

[ "482.82", "530.81", "518.81", "241.9", "414.01", "276.4", "428.0", "519.19", "V45.02", "250.00" ]

icd9cm

[ [ [] ] ]

[ "45.13", "31.1", "33.24", "96.6", "43.11", "96.72" ]

icd9pcs

[ [ [] ] ]

2719, 2801

1357, 1820

312, 342

2908, 2915

958, 1334

3194, 3527

2024, 2696

2822, 2887

1846, 2001

2939, 3171

715, 939

265, 274

370, 577

599, 700

68,389

176,409

51686

Discharge summary

report

Admission Date: [**2163-9-2**] Discharge Date: [**2163-9-22**] Date of Birth: [**2108-8-14**] Sex: F Service: MEDICINE Allergies: Penicillins / Erythromycin / Compazine / Bactrim Ds / Sulfa (Sulfonamides) / Dapsone / Levaquin / Lisinopril Attending:[**First Name3 (LF) 338**] Chief Complaint: Shortness of breath and confusion Major Surgical or Invasive Procedure: Intubation Arterial Line Placement Central Line Placement Tracheostomy History of Present Illness: Ms. [**Known lastname **] is a 54 y.o. F with a history of sarcoidosis and CHF and Factor V Leiden deficiency admitted for SOB and confusion. Pt was recently admitted to hospital twice in the last 2 months and several times during the last year with diagnosis of CHF exacerbation vs. sarcoidosis. Her most recent hospitalization on [**8-10**] she was found to have CHF exacerbation w/ elevated BNP to 12,000 for which she had her Lasix 20mg PO QOD restarted with improvement of her symptoms and she was sent home. She states that she has been feeling okay and to have ongoing SOB which seem worse in the last 2 days. She uses oxygen 2L at home, and as per ED report she was sating in the mid to low 80s% yesterday. She also has increase non-productive cough w/ occ sputum that feels "siment". She has orthopnea and does not tolerate laying flat. Her husband has also noticed that she also appears confused, asking repetitive questions and seem to be obsessing over certain subjects. She denies missing any doses of her lasix. She states that she felt febrile yesterday, but did not check a temp. She denies having any chest pain, no sick contacts or upper airway symptoms. . In the ED today her vitals were 99.0, 121, SBP 127, RR 20s-mid 40s- sating in 89% on RA, going to mid 80s, 4l comes up to Mid 90s. Her initial ABG was pH 7.35 pCO2 76 pO2 56 HCO3 44. PE noticible for crackles at bil bases. CXRAY Extensive fibrosis with no significant change from prior. No consolidations. She was given 20mg of IV lasix with good response in UO 100cc/hr with some improvement of symptoms. . Of note, patient reports that she is very concerned about this skin rash. She says she has the skin rash on her arms, legs, ears. The rash forms papules with clear exudate. When the exudate is released, she says her entire body feels the sensation, causing her to cough and feel mucus in her throat. She has spoken to her PCP about this who is arranging her to follow with dermatology. . On floor, Vitals: temp 98.7, HR in 120s, RR 30s-low 40s, sating in upper 90s%. Pt w/ increase work of breathing while speaking. Sleepy, but easily arousable to verbal stimuli. Past Medical History: -Sarcoidosis: baseline on 2L O2, 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 40-45% from 3/[**2162**]. - Hypertension. - Hyperlipidemia - Mild sleep apnea. - Anxiety - Gout. -Anemia- gets Aranesp - Iron overload. - Multiple environmental allergies Social History: Lives in [**Location 1268**] with husband and [**Name2 (NI) 107078**] and many cats. Non smoker, non drinker, no drugs. She has been on disability for the past 15 years, but used to work in a hotel as a reservations consultant. She mostly stays at home due to her chronic medical conditions. 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: Gen: breathing comfortably on trach; alert, attempting to communicate HEENT: EOMI, PERRL, trach in place Lungs: Course, shallow breath sounds bilaterally anteriorly with some scattered wheezes Heart: slightly tachy, no murmurs, rubs or gallops appreciated Abdomen:, soft/NT/ND, BS+ Extremitiesno LE edema, 2+ peripheral pulses Neuro: awake, alert, attempting to communicate Skin: Warm, dry Pertinent Results: Admission Labs: [**2163-9-2**] 10:55AM BLOOD WBC-10.6 RBC-3.47* Hgb-10.3* Hct-31.8* MCV-92 MCH-29.7 MCHC-32.4 RDW-16.1* Plt Ct-465* [**2163-9-2**] 10:55AM BLOOD Neuts-77.6* Lymphs-16.9* Monos-4.2 Eos-0.8 Baso-0.5 [**2163-9-2**] 10:55AM BLOOD PT-34.7* PTT-29.7 INR(PT)-3.5* [**2163-9-2**] 10:55AM BLOOD Glucose-151* UreaN-26* Creat-1.6* Na-137 K-6.5* Cl-96 HCO3-30 AnGap-18 [**2163-9-2**] 11:30AM BLOOD Glucose-157* UreaN-26* Creat-1.5* Na-138 K-4.8 Cl-95* HCO3-36* AnGap-12 [**2163-9-2**] 11:24PM BLOOD ALT-12 AST-17 LD(LDH)-193 AlkPhos-86 TotBili-0.3 [**2163-9-2**] 10:55AM BLOOD Calcium-9.5 Phos-2.9 Mg-2.2 [**2163-9-2**] 11:05AM BLOOD Type-[**Last Name (un) **] pO2-35* pCO2-66* pH-7.40 calTCO2-42* Base XS-12 Intubat-NOT INTUBA Comment-GREEN TOP [**2163-9-2**] 11:05AM BLOOD Glucose-148* Lactate-2.1* Na-138 K-6.2* Cl-87* [**2163-9-2**] 11:48AM BLOOD Glucose-151* Lactate-1.4 Na-140 K-4.8 [**2163-9-2**] 11:48AM BLOOD Glucose-151* Lactate-1.4 Na-140 K-4.8 [**2163-9-3**] 12:06AM BLOOD freeCa-1.11* Cardiology Labs/studies: [**2163-9-2**] 10:55AM BLOOD CK-MB-2 cTropnT-<0.01 proBNP-[**Numeric Identifier 30976**]* [**2163-9-3**] 04:27AM BLOOD CK-MB-3 cTropnT-0.01 [**2163-9-9**] 04:09AM BLOOD proBNP-3004* [**2163-9-19**] 03:51AM BLOOD proBNP-9012* ECHO [**9-5**]: The left atrium is normal in size. Left ventricular wall thicknesses and cavity size are normal. There is severe regional left ventricular systolic dysfunction with setpum and inferior akinesis and hypokinesis of the inferolateral walls. Overall left ventricular systolic function is moderately depressed (LVEF= 30 %). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. Compared with the prior study (images reviewed) of [**2163-9-4**], the left ventricular systolic function is similar. Endocrine Labs: [**2163-9-3**] 12:06AM BLOOD freeCa-1.11* [**2163-9-8**] 10:30PM BLOOD freeCa-1.17 [**2163-9-9**] 04:09AM BLOOD Cortsol-11.2 [**2163-9-5**] 05:12AM BLOOD TSH-3.0 [**2163-9-2**] 11:24PM BLOOD Albumin-3.0* Calcium-8.4 Phos-3.0 Mg-1.8 [**2163-9-17**] 03:45AM BLOOD Albumin-2.3* Calcium-8.7 Phos-3.4 Mg-2.0 Microbiology Labs: Negative Blood Cx: 9/10,12,13,19,20,21,22 Negative Urine Cx: 9/10,12,13,19,21,22,25 Negative Sputum Cx: 9/10,11,12 (all with resp flora). Sputum Cx: [**9-14**]: sparse yeast Rapid Resp Viral Screen: [**9-11**]: Negative Mini-BAL [**9-11**]: 2+ PMN, no organisms on GS, small yeast on Cx, negative for PCP via [**Name9 (PRE) 107082**], AFB smear negative. AFB/fungal Cx pending as of [**9-19**] Stool Studies: Positive for C. Diff toxin on [**9-18**] Neurology Studies: EEG [**9-8**] This EEG monitoring from 7:50 until 14:20 on [**2163-9-8**] showed a low voltage encephalopathic background with widespread alpha frequencies at times (likely representing medication effect) and periods of more widespread suppression. There were no focal abnormalities, but encephalopathies may obscure focal findings. There were no epileptiform features. EEG [**9-7**] This telemetry showed a slow background throughout, indicative of an encephalopathy. There were no areas of prominent focal slowing, but encephalopathies may obscure focal findings. There were no epileptiform features or electrographic seizures. There were no pushbutton activations. EEG [**9-6**] This telemetry captured no pushbutton activations. The background remained about the same throughout the entire recording, showing a slow background with bursts of generalized slowing, all indicating a widespread encephalopathy affecting both cortical and subcortical structures. There were no areas of prominent focal slowing although focal findings can be obscured by encephalopathies. The most common causes of such encephalopathies include metabolic disturbances, infection, and medications. There were no epileptiform features, and there were no electrographic seizures. . Head CTs [**9-2**] and [**9-6**]: negative for acute intracranial pathology Sinus CT [**9-16**]: IMPRESSION: 1. Fluid-filled left middle ear cavity and left mastoid antrum. 2. Increased fluid in the left mastoid air cells. 3. Nasopharyngeal air is obliterated by soft tissue and direct evaluation is recommended. Radiology: CT chest [**9-4**]: IMPRESSION: Fibrotic appearance of the lungs in a perihilar distribution consistent with known sarcoidosis. Increase in peripheral opacification as well as new bilateral small pleural effusions suggest superimposed fluid overload. CT chest [**9-12**]: IMPRESSION: Extensive severe parenchymal sarcoidosis and enlarging moderately severe left pleural effusion, decrease in moderate right pleural effusion. Diffuse ground glass attenuation has worsened, probably concomitant alveolar pulmonary edema. Stable moderate cardiomegaly Serial CXRs for ICU interval change, lines, and ET tube placement. Brief Hospital Course: Brief ICU Course ([**Date range (1) 107083**]): ID: 54 year old woman with a PMH significant for sarcoidosis with stage IV lung disease, CHF and Factor V Leiden deficiency, on warfarin, who presented to the ICU with SOB and confusion. . #DYSPNEA/Respiratory Failure: Initial question of CHF vs Sarcoid exacerbation vs PNA. Admission BNP elevated >17,000. Pt diuresed with lasix, still SOB despite good UOP. Poor toleration of BIPAP and climbing resp acidosis on NRB led to intubation after discussion with pt and HCP. Started on Abx to cover for HAP. Initial chest CT showed fibrotic lung Dz from sarcoid with bilat pleural effusions and some evidence of vol overload. Repeat chest CT week later showed worsening of effusions and some ground glass opacities likely consistent with fluid. Quickly developed resp alkalosis on vent and was sedated to encourage CO2 retention to near baseline. Repeat BNP was 3000. Unable to tolerate PS ventilation for many days with elevated RSBIs so [**Date range (1) 1834**] tracheostomy after 2 weeks on vent as no extubation in near future. Continued to need low TV ventilation with high RR 2/2 to restrictive lung disease. She was subsequently tried on CPAP trials but would often tire becoming tachypenic and requring her to be put back on AC. She also required occasional ativan for her agitation/tachypnea. . #Fever: Pt with continual fevers during ICU course despite broad spectrum Abx (cefepime, vanco) treating emperically for HAP. Large negative infectious work-up. Nine day course of Abx completed with pt still intermittently febrile. Abx holiday for 48-72hrs over concern for possible drug fevers. Pt status did not worsen during this time but fevers continued. Abx restarted with addition of IV metronidazole after holiday. On [**9-18**] C diff toxin sent despite benign abd exam and not loose stools. C. diff toxin positive. PO vanco was started in combo with po metronidazole and cefepime/IV vanco stopped. However she continued to spike fevers throughout [**9-19**] and was restarted on cefepime/vanco for HAP. Meanwhile, her sputum cx from [**9-18**] grew out sparse g- rods. Given continued fevers/leukocytosis on her current regimen with confimred g- rods, meropenem was started in place of cefepime to broaden g- coverage, and IV vanco d/c'd on [**9-21**]. . #CHF/tachycardia: Question if vol overload reason for initial presentation. ECHO on [**9-5**] showed EF somewhat reduced from previous ECHOs. Diuresed initially but then had to be held for multiple days due to low BPs. Eventually some diuresis on lasix gtt. Initial elevated BNP trended down but then back up 17k->3k->8k. Cardiology saw in consult initially and recommended starting carvediolol for CHF/tachycardia but this could not be started until [**9-17**] also due to tenuous BPs at times requiring pressors. by [**9-19**] she was able to be started on 6.5mg carvediol. . #CRF with decreased urine output: Baseline creatinine (1.5-2.2) secondary to HUS during chemotherapy treatment 27 yrs ago. Cr stayed in this range throughout hospitalization and lasix diuresis. Intermittent periods of decreased urine output in context of fluctuating hypotension. . #BP - Hyper and Hypotension: Despite Hx of HTN, initially hypotensive with concern for sepsis. Started on pressors and intermittently requiring pressors until [**9-9**]. Hypotensive episodes in context of sedation and diuresis were responsive to fluid bolus. Low BPs were the limiting factor to diuresis and initiation of carvedilol, but her pressures eventually normalizedl. . #Neuro/Psych: Pt with Hx of underlying anxiety. Early in ICU course abnormal eye movements and some body shaking while on vent raised the question of intracranial bleed or seizures. Head CT negative for bleed and 3 days of EEG monitoring showed no seizure activity or focus. Heavily sedated for 2 weeks on vent in order to prevent significant overbreathing. After tracheostomy completed and sedation weaned off, pt with waxing and [**Doctor Last Name 688**] agitation questionable for delerium. Started on haldol/quitiapine to good effect. Pt more agitated when family present and with vital sign abnormalities (more tachycardia and some HTN) in context of agitation. . #HYPERCOAGULABILITY: Known Factor V Leiden mutation on life long coumadin [**1-25**] prior PE. At presentation INR is supra therapeutic at 3.4 . Initial Hct drop and received 1 unit PRBC on [**9-6**]. Switched over to Heparin gtt (after head CT negative for acute bleed) for much of ICU course until after tracheostomy done. Episode of urethral bleeding lasting 3-4 days while on heparin gtt. Hct stable. Restarted Warfarin after tracheostomy and stopped heparin gtt. However, she became subtherapeutic throughout the week leading up to d/c and INR was 1.3 on [**9-21**] in the setting of 4mg daily. She was given a total of 10mg on [**9-21**] and daily dose subsequently increased to 5mg daily. . #SARCOIDOSIS: Long history of sarcoidosis for which she is closely followed by Dr. [**Last Name (STitle) 575**]. Last PFTs showed FVC of 18%. Prior trials of methotrexate and prednisone have been discontinued, and her primary management is her O2 therapy, 2L NC at home. Fibrotic disease likely main limiting factor to extubation and forced rapid shallow breathing pattern leading to difficulties with respiratory alkalosis. . Medications on Admission: 1. Atorvastatin 40 mg Tablet PO DAILY 2. Benzonatate 100 mg Capsule PO TID as needed for cough. 3. Furosemide 20 mg Tablet PO EVERY OTHER DAY 4. Lorazepam 0.5 mg Tablet PO TID PRN as needed for SOB. 5. Metoprolol Succinate 100 mg Tablet SR 24 hr PO DAILY (Daily). 6. Oxycodone 5 mg Tablet (1) Tablet PO Q6H as needed for severe pain. 7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) PO Q24H 8. Warfarin 2.5 mg Tablet One (1) Tablet PO DAILY 9. Loratadine-Pseudoephedrine 10-240 mg Tablet SR PO once a day. 10. Loratadine 10 mg Tablet PO once a day PRN as needed for post nasal drip, cough. 11. Benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID PRN as needed for cough. 12. Darbepoetin Alfa In Polysorbat 60 mcg/mL Solution Sig: One (1) Injection once a week. Discharge Medications: 1. Meropenem 500 mg Recon Soln Sig: One (1) Recon Soln Intravenous Q8H (every 8 hours) for 7 days. 2. Vancomycin 125 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours) for 21 days. 3. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) for 21 days. 4. Warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM. 5. Carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. White Petrolatum-Mineral Oil 56.8-42.5 % Ointment Sig: One (1) Appl Ophthalmic TID (3 times a day) as needed for redness. 7. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation/no stool. 8. Alum-Mag Hydroxide-Simeth 200-200-20 mg/5 mL Suspension Sig: 15-30 MLs PO QID (4 times a day) as needed for abd discomfort. 9. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day) as needed for rash, itching. 10. Acetaminophen 650 mg/20.3 mL Solution Sig: One (1) PO Q6H (every 6 hours) as needed for pain or fever. 11. Chlorhexidine Gluconate 0.12 % Mouthwash Sig: One (1) ML Mucous membrane [**Hospital1 **] (2 times a day). 12. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours). 13. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection three times a day. Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - MACU Discharge Diagnosis: Primary: Respiratory failure Clostridium dificile infection Hospital acquired pneumonia Congestive heart failure Secondary Chronic renal insufficiency Factor 5 lieden deficiency Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Ms. [**Known lastname **], You were admitted to the hosptial for shortness of breath likely from a combination of your sarcoidosis, congestive heart failure, and pneumonia. You were intubated (breathing tube placed) to help you with your breathing. You then had a tracheostomy placed (breathing tube through your throat) to allow for more long-term breathing support. You had continueed fevers while in the hospital, which was likely a result of you pneumonia and c. diff (infection of the colon). We are treating you for both of these infections and you should conintue your antibiotics as prescribed. You also had some low blood pressures which have since improved, and we are treating your congestive heart failure with carvediol. Please note that we have adjusted your coumadin dose to 5mg daily, as your INR has been low, and you should continue subcutaneous heparin injections at rehab until your INR normalizes Please keep all appointments below. Followup Instructions: Provider: [**First Name11 (Name Pattern1) 177**] [**Last Name (NamePattern4) 720**], M.D. Phone:[**Telephone/Fax (1) 721**] Date/Time:[**2163-9-27**] 3:30 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

[ "428.23", "V10.79", "517.8", "486", "372.03", "790.01", "515", "584.9", "V46.2", "V58.61", "135", "518.81", "780.93", "428.0", "585.4", "008.45", "V12.51", "425.9", "438.89", "V42.81", "286.3", "997.31", "403.90", "560.1" ]

icd9cm

[ [ [] ] ]

[ "96.6", "38.91", "96.72", "31.1", "96.04", "38.93", "43.11" ]

icd9pcs

[ [ [] ] ]

17236, 17302

9729, 15081

401, 473

17525, 17525

4538, 4538

18689, 19117

3797, 4104

15899, 17213

17323, 17504

15107, 15876

17703, 18666

4119, 4519

328, 363

501, 2649

4554, 9706

17540, 17679

2671, 3471

3487, 3781

27,777

113,094

34600

Discharge summary

report

Admission Date: [**2144-6-29**] Discharge Date: [**2144-7-7**] Date of Birth: [**2068-7-10**] Sex: M Service: MEDICINE Allergies: Codeine / Iodine; Iodine Containing Attending:[**First Name3 (LF) 2880**] Chief Complaint: MSSA bacteremia, pacemaker associated endocarditis and osteomyelitis Major Surgical or Invasive Procedure: s/p sternotomy and epicardial lead placement [**2144-7-1**] History of Present Illness: 75 yo male with CAD, h/o CHB who was in his USOH (= volunteering, drove, mild forgetfulness) was sent home for work with fever/flu-like sympt, chills, disorientation, and diarrhea. Pt was admitted for pneumonia, tx with abx, and sent home in a couple days. He however got much worse, could no longer stand up, not eating/drinking/high fevers, and very disoriented. Early [**Month (only) 958**] pt was readmitted, changed abx, and sent to nursing home rehab. When he left he was nearly at baseline, watching TV, conversing well. Then abruptly he began having back pain, vomitting, diarrhea, and dysphagia. Pt admitted 3rd time and EGD done. CXR/CT, no TEE done at that point, and sent to rehab on IV abx x6wks for PT/OT. Pt had a stroke at rehab, stayed with sister for a while, and then at an ID appointment suspected endocarditis. Also at that time infection was found at the spine. Pt was readmitted a couple days ago, and found to be s/p PPM with recurrent MSSA sepsis, prior CVA (likely septic emboli), L spine osteo. The pt had his pacing system explanted at OSH (leads positive for MSSA) on [**2144-6-15**] and now presents with temp wire in place for planned epicardial pacing system. Currently being treated with IV oxacillin. . On review of systems, he denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. He denies recent fevers, chills or rigors. He denies exertional buttock or calf pain. All of the other review of systems were negative. *** Cardiac review of systems is notable for absence of chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. Past Medical History: prostate CA bladder CA recurrent MSSA bacteremia CAD s/p stenting PUD depression chronic LBP HTN hyperlipidemia CRI, baseline Cr ~1.9 dementia Alzheimer's disease CHF anemia requiring transfusion FTT CVA, likely from septic emboli Social History: Retired telephone worker. Quit smoking 15 years ago. Drank 6pack/day of beer, and 30pack/yr hx (stopped 20y ago) Family History: nc Physical Exam: VS - 97.5, 96/68, 80, 18, 98%2L Gen: NAD. Oriented x3. Pt hearing impaired. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. Neck: Supple no 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: Crackles heard throughout. No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. wheezes or rhonchi. Abd: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. Ext: No c/c/e. No femoral bruits. Skin: No stasis dermatitis, ulcers, scars, or xanthomas. Pulses: Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Pertinent Results: [**2144-7-7**] 06:11AM BLOOD WBC-7.7 RBC-3.26* Hgb-10.3* Hct-29.8* MCV-92 MCH-31.7 MCHC-34.6 RDW-16.8* Plt Ct-342 [**2144-7-1**] 01:08PM BLOOD WBC-14.1* RBC-2.76* Hgb-8.5* Hct-25.7* MCV-93 MCH-30.9 MCHC-33.2 RDW-16.7* Plt Ct-460* [**2144-7-1**] 11:45AM BLOOD WBC-10.6# RBC-2.83* Hgb-8.8* Hct-26.5* MCV-93 MCH-31.1 MCHC-33.3 RDW-16.2* Plt Ct-433# [**2144-7-1**] 04:30AM BLOOD WBC-5.3 RBC-2.78* Hgb-8.7* Hct-25.9* MCV-93 MCH-31.4 MCHC-33.6 RDW-15.9* Plt Ct-233 [**2144-7-5**] 05:25AM BLOOD PT-18.9* PTT-36.2* INR(PT)-1.7* [**2144-7-1**] 01:08PM BLOOD Plt Ct-460* [**2144-6-30**] 11:27AM BLOOD PT-14.1* PTT-31.4 INR(PT)-1.2* [**2144-7-1**] 11:45AM BLOOD Fibrino-481* [**2144-7-7**] 06:11AM BLOOD ESR-71* [**2144-7-7**] 06:11AM BLOOD Glucose-82 UreaN-36* Creat-1.6* Na-140 K-3.4 Cl-105 HCO3-24 AnGap-14 [**2144-7-2**] 04:57PM BLOOD Glucose-132* UreaN-38* Creat-2.2* Na-133 K-3.9 Cl-99 HCO3-23 AnGap-15 [**2144-6-30**] 05:00AM BLOOD Glucose-88 UreaN-31* Creat-1.4* Na-132* K-3.9 Cl-97 HCO3-27 AnGap-12 [**2144-7-5**] 05:25AM BLOOD ALT-8 AST-9 LD(LDH)-185 AlkPhos-86 TotBili-1.3 [**2144-6-30**] 11:27AM BLOOD ALT-12 AST-18 AlkPhos-140* TotBili-0.6 [**2144-7-7**] 06:11AM BLOOD Calcium-8.7 Phos-3.4 Mg-2.1 [**2144-7-5**] 05:25AM BLOOD CRP-166.1* [**2144-7-4**] 02:03AM BLOOD CRP-195.1* Brief Hospital Course: The pt had his pacing system explanted at OSH (leads positive for MSSA) on [**2144-6-15**]. . Pt had operation on [**2144-7-1**] for apicardial lead placement via sternotomy. He was transferred to the CVICU for hemodynamic monitoring. He was weaned from sedation, awoke without any neurologucal changes, and was extubated without complications. During the ICU course pt had ARF and Cr increased to 2.2, with his baseline near 1.5. Pt was thought to have nephrotoxic vs. ischemic ATN. His renal function continued to improved and by discharge his Cr was 1.6 near his baseline. He continued to improve and was transferred back to the floor postop day 2. . Once back on the floor pt, pt continued to remain afebrile, and WBC normalized. Pt's blood culture remained negative. Pt was thought to be no longer infected through his pacer. . *** (very important) **** Pt did continue to have spine osteomyelitis. ID was consulted. Pt's pain improved over hospitalization. Pt revcieved IV Nafcillin, and needs to continue to get it for 6wks as outpt. Pt also needs weekly labs faxed to [**Hospital **] clinic. Pt has an outpt CT with contrast of the spine scheduled to f/u with the infection. Pt has a f/u appointment with ID outpt scheduled. . Due to the [**Doctor First Name 48**] pt needs mucomyst the day before and after the CT scan (prescribed- as noted in d/c paperwork). . Pt needs INR checked. Pt did not have significant elevation of liver enzymes, but continued to have incr. INR. Pt does not need to be anticoagulated - does not have Afib, from our knowledge. . Pt also had UTI growing proteus. Pt recieved cipro for which he recieved the full course, and when recultured after foley was removed. Pt no longer grew anything from urine culture. Cipro was also d/c. . Concering his dysphagia the etiology needs to be investigated as outpt. Plummer-[**Doctor Last Name **] syndrome (esophageal webs, iron-deficiency anemia, koilonychia (however no koilonychia seen)) was a thought. Please continue to follow swallow eval recs. - PO intake of nectar thick liquids and puree. - Pills crushed with puree. - 1:1 supervision for all pos when patient is awake and alert. - Alternate between bites and sips. Slow rate if intake. - If patient is noted with difficulty on this diet, decreased mental status/alertness, continued pain please make him NPO. . Iron-def anemia - continue iron . GERD stable on protonix . Mild cog impairment - continue aricept . Medications on Admission: Oxacillin 2 g IV until [**2144-7-30**] Metoprolol 50 mg [**Hospital1 **] Aricept 10 mg QHS Trazodone 175 mg QHS Paxil 60 mg daily Fe sulfate 325 mg [**Hospital1 **] Lasix 10 mg daily KCl 10 mEq daily Protonix 40 mg daily ASA 325 mg daily Lidoderm, 12 hours on/12 hours off Colace 100 mg [**Hospital1 **] Hep subq Dilaudid PRN Guaifenesin 600 mg q12 PRN Discharge Medications: 1. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO once a day. 2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Paroxetine HCl 20 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 5. Percocet 5-325 mg Tablet Sig: 1-2 Tablets PO every six (6) hours as needed for pain. Disp:*15 Tablet(s)* Refills:*0* 6. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for temperature >38.0. 7. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 8. Nafcillin in D2.4W 2 gram/100 mL Piggyback Sig: One (1) Intravenous Q4H (every 4 hours) for 6 weeks. 9. Donepezil 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 10. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily) as needed for pain for 5 days: 12 hours on, 12 hours off. Disp:*5 Adhesive Patch, Medicated(s)* Refills:*0* 11. Guaifenesin 600 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO every twelve (12) hours as needed for cough. 12. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 13. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 14. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO once a day. 15. Lasix 20 mg Tablet Sig: 0.5 Tablet PO once a day. Discharge Disposition: Extended Care Facility: [**Hospital **] Health Care Discharge Diagnosis: primary dx: - MSSA pacer infection - acute renal failure - ATN - urinary tract infection secondary dx: - thoracic vertebrae osteomyelitis - dysphagia - incr INR Discharge Condition: fair Discharge Instructions: You had a bacterial line infection and your pacer was removed because it was seeded by the bacteria. You had surgery for a new epicardial pacer, and in the ICU your course was complicated by acute renal failure. Your creatinine has improved and is close to your baseline. After coming back to the floor your blood cultures did not show any signs of infection from your vitals either. Please shower daily including washing incisions, no baths or swimming Monitor wounds for infection - redness, drainage, or increased pain Report any fever greater than 101 No creams, lotions, powders, or ointments to incisions No lifting more than 10 pounds for 10 weeks No driving for 4 weeks after sternal incision Followup Instructions: Dr [**Last Name (STitle) 914**] in 4 weeks [**Telephone/Fax (1) 170**] (please call to schedule appointment) Pt needs CBC, LFTs, Chem7 (lytes) checked weekly. Fax the results to [**Telephone/Fax (1) 432**] To [**Hospital **] Clinic CT spine [**7-13**] at 1:45, at [**Hospital Ward Name 452**] 3 at [**Hospital Ward Name **]. Please do not eat 3 hours prior. Please also take mucomyst 600mg [**Hospital1 **] x 4 doses. Take 2 doses day before procedure, take second two doses after procedure. Provider: [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2144-7-8**] 10:00 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 456**], MD Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2144-7-27**] 10:00 [**First Name11 (Name Pattern1) 900**] [**Last Name (NamePattern1) 2882**] MD, [**MD Number(3) 2883**] Completed by:[**2144-7-8**]

[ "730.28", "585.9", "V45.01", "414.01", "041.6", "787.20", "584.9", "280.9", "530.81", "426.0", "041.11", "331.0", "403.90", "294.10", "E878.1", "331.83", "599.0", "996.61", "420.90" ]

icd9cm

[ [ [] ] ]

[ "00.50", "37.74" ]

icd9pcs

[ [ [] ] ]

9136, 9190

4789, 7240

365, 427

9396, 9403

3486, 4766

10154, 11071

2622, 2626

7643, 9113

9211, 9375

7266, 7620

9427, 10131

2641, 3467

256, 327

455, 2222

2244, 2476

2492, 2606

82,432

156,068

48829

Discharge summary

report

Admission Date: [**2175-10-6**] Discharge Date: [**2175-10-20**] Date of Birth: [**2111-7-4**] Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**Last Name (NamePattern4) 290**] Chief Complaint: hematemesis, AMS Major Surgical or Invasive Procedure: EGD with banding of bleeding varices Intubation/Mechanical Ventilation History of Present Illness: History provided by patient's Husband [**Name (NI) 382**] and Son as well as medical records because patient is intubated and sedated. Ms. [**Known lastname 102584**] is a 64 year old female with h/o EtOH abuse who presented with confusion and hematemesis. The patient has a 6 year history of heavy alcohol abuse. She was reportedly diagnosed with fatty liver disease about 5 years ago by her primary care doctor but does not have a known diagnosis of cirrhosis. For the past week patient has had nausea/vomiting and was unable to tolerate any food other than water. Her husband also noticed that her abdomen became increasingly distended. 2 days ago she had an episode of coffee ground emesis but her mental status continued to be baseline, A+OX3. On the day of presentation she became disoriented and the family called EMS. She was brought to an OSH where she was given blood, protonix, and cefepime. Her ammonia level was in the 300's. NGT showed blood/coffee grounds and she was transferred to [**Hospital1 18**] for further management. . On arrival to the [**Hospital1 18**] ED, initial VS were: Temp: 97.1 HR: 123 BP: 127/79 Resp: 26 O2Sat: 95. She continued to have blood coming out of NGT. She was intubated for airway protection with etomidate and succ. Labs were notable for lactate of 17, total bili of 17.2. She had a triple lumen CVL placed in the right groin. Hepatology was consulted and PPI drip and octreotide drip were initiated. She received 1 unit of pRBCs in the ED and 3L fluid. Systolic BPs were in the 110's but had drops to 70-80's. She was in and out of Afib with RVR. She was admitted to the MICU for urgent endoscopy. . On arrival to the MICU, patient is intubated and sedated. She has a grossly distended abdomen. . Review of systems: Patient unable to provide ROS because of sedation/intubation Past Medical History: HTN ?CAD: Husband reports that patient had a silent MI 8-10 years ago. Depression GERD Social History: - Tobacco: Smokes 1 ppd for the last 15 years. - ETOH: Drinks [**1-22**] bottle of vodka every day. - Illicits: None - Lives with husband in [**Name2 (NI) **], MA. Family History: Unknown. Patient intubated Physical Exam: On arrival to MICU: General: intubated, sedated HEENT: Jaundiced, oropharynx clear Neck: supple, JVP not elevated, no LAD CV: Irregular, tachycardic, hyperdynamic precordium. normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi Abdomen: distended, ascitic abdomen. Caput medusae. bowel sounds present GU: foley Ext: palmar erythema bilaterally. 1+ pulses, no clubbing, cyanosis or edema Pertinent Results: LABS: On admission: [**2175-10-5**] 11:30PM BLOOD WBC-18.1* RBC-2.72* Hgb-10.0* Hct-28.8* MCV-106* MCH-36.7* MCHC-34.6 RDW-15.6* Plt Ct-172 [**2175-10-5**] 11:30PM BLOOD Neuts-85.2* Lymphs-10.4* Monos-3.9 Eos-0.4 Baso-0.1 [**2175-10-5**] 11:30PM BLOOD PT-21.6* PTT-34.0 INR(PT)-2.0* [**2175-10-6**] 11:41AM BLOOD Fibrino-217 [**2175-10-5**] 11:30PM BLOOD Glucose-111* UreaN-47* Creat-1.2* Na-138 K-4.6 Cl-89* HCO3-14* AnGap-40* [**2175-10-5**] 11:30PM BLOOD ALT-87* AST-312* AlkPhos-199* TotBili-17.2* [**2175-10-5**] 11:30PM BLOOD Lipase-1365* [**2175-10-6**] 03:56AM BLOOD Albumin-3.1* Calcium-8.1* Phos-3.1 Mg-2.2 Iron-181* [**2175-10-5**] 11:30PM BLOOD Ammonia-227* [**2175-10-5**] 11:34PM BLOOD Glucose-108* Lactate-17.1* Na-134 K-4.3 Cl-93* calHCO3-15* [**2175-10-5**] 11:34PM BLOOD freeCa-1.04* On discharge: Pertinent misc labs: [**2175-10-5**] 11:30PM BLOOD Lipase-1365* [**2175-10-6**] 04:09PM BLOOD Lipase-2045* [**2175-10-7**] 02:20AM BLOOD Lipase-1188* [**2175-10-8**] 03:27AM BLOOD Lipase-587* [**2175-10-9**] 03:08AM BLOOD Lipase-221* [**2175-10-10**] 04:00PM BLOOD Lipase-216* [**2175-10-11**] 02:00AM BLOOD Lipase-203* [**2175-10-5**] 11:30PM BLOOD ALT-87* AST-312* AlkPhos-199* TotBili-17.2* [**2175-10-7**] 08:55AM BLOOD ALT-101* AST-391* LD(LDH)-406* AlkPhos-132* TotBili-19.8* [**2175-10-11**] 02:00AM BLOOD ALT-86* AST-193* AlkPhos-170* Amylase-226* TotBili-20.1* [**2175-10-6**] 03:56AM BLOOD CK-MB-3 cTropnT-<0.01 [**2175-10-6**] 03:56AM BLOOD calTIBC-196* Ferritn-2101* TRF-151* [**2175-10-6**] 03:56AM BLOOD HBsAg-NEGATIVE HBsAb-BORDERLINE HBcAb-NEGATIVE HAV Ab-POSITIVE [**2175-10-6**] 03:56AM BLOOD AFP-4.6 [**2175-10-6**] 03:56AM BLOOD HCV Ab-NEGATIVE [**10-6**] Blood Culture, Routine (Preliminary): STAPHYLOCOCCUS, COAGULASE NEGATIVE. OF TWO COLONIAL MORPHOLOGIES. Isolated from only one set in the previous five days. SENSITIVITIES PERFORMED ON REQUEST.. IMAGING: [**10-5**] CXR: An endotracheal tube terminates at the origin of the right main stem bronchus and should be retracted. A nasogastric tube enters the stomach and travels beyond the field of view. The right costophrenic angle is excluded from the field of view. Lung volumes are low. Cardiac, mediastinal and hilar contours are unremarkable, and there is no focal consolidation or pneumothorax. [**10-6**] RUQ US: Technically limited examination, with findings concerning for cirrhosis as indicated above, and limited vascular evaluation. If concern persists for in-depth evaluation of the patency of the hepatic and portal venous systems, these could be evaluated via multiphasic MRI or CT imaging [**10-6**] EGD: Varices at the lower third of the esophagus Blood in the fundus and stomach body (ligation) Otherwise normal EGD to third part of the duodenum Brief Hospital Course: Ms. [**Known lastname 102584**] is a 64 year old female with known EtOH abuse who presented with hepatic encephalopathy and hematemesis. EGD performed emergently upon arrival to the MICU revealed 4 cords of grade II varices in the lower third of the esophagus with stimata of recent bleeding, all 4 were banded. She received a total of 3 units PRBCs for her acute blood loss and was started on octreotide, pantoprazole, and ceftriaxone. Post-banding, hematocrit was closely monitored initially remained stable. She was extubated and called out to the floor where her acute alcoholic hepatitis was further managed with lactulose, rifaximin, and pentoxyphyline. However mental status worsened and workup of further infectious etiology was pursued. She received 3 separate ascitic fluid drainages, all of which were not convincing for SBP. Amylase and lipase remained elevated and together with reported abdominal pain, CT abdomen was pursued on [**2175-10-19**] and showed worsening pancreatitis with suspicion for necrosis in the head of the pancreas. On the night of [**2175-10-19**], trigger was initiated for increased respiratory rate from 18 to 32. Labs revealed WBC increased from 20 to 32, HCT dropped from 28 to 22 and elevated lactate of 9.7. She was emergently transferred back to the MICU where NG tube was placed which immediately drained copious red blood, indicating most likely repeat esophageal variceal bleed, this time catastrophic. She was intubated for airway protection, the massive transfusion protocol was started. She received 4 units PRBC and 2 FFP with loss of >1L bright red blood. Antibiotics were broadened to vancomycin and zosyn for coverage of likely worsening pancreatitis. GI was [**Name (NI) 653**], but they preferred supportive management with blood products and planned on EGD in the AM. Transplant surgery was also consulted. Family meeting was held and poor prognosis was relayted. The bleeding tapered off slowly, but she then became difficult to ventilate with elevated peak pressures. This was suspected to be due to increasing intraabdominal pressure due to worsening ascites after receiving large amounts of blood products. Bladder pressures were elevated and abdominal compartment syndrome was suspected. A 4L paracentesis was then preformed with improvement in bladder pressures and lowered peak pressures. Her blood pressures then began to drop and pressors were started (levophed, then phenylephrine, then dopamine). She then developed further hematemesis, requiring additional 2 units PRBC and 2 units FFP. Repeat family meeting was held and due to poor prognosis and lack of improvement despite heroic measures. Aggressive care was discontinued and she was made comfort measures only. She died with her husband and her son at the bedside. Autopsy was declined. Medications on Admission: Husband did not know doses 1. Oxybutin ER 2. Atenolol 3. Amlodipine 4. Prozac 5. Prevacid 6. Aspirin 81 mg 7. Vitamin D 8. Tums Discharge Medications: not applicable Discharge Disposition: Expired Discharge Diagnosis: esophageal variceal bleeding acute severe alcoholic hepatitis pancreatitis Discharge Condition: deceased Discharge Instructions: not applicable Followup Instructions: not applicable [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**] Completed by:[**2175-10-22**]

[ "276.0", "785.59", "305.1", "401.9", "567.23", "285.1", "518.81", "572.2", "571.2", "311", "530.81", "571.1", "V46.11", "789.59", "584.9", "427.31", "276.2", "456.0", "303.01", "577.0", "V66.7" ]

icd9cm

[ [ [] ] ]

[ "38.93", "96.04", "42.33", "96.6", "54.91", "38.91", "96.72" ]

icd9pcs

[ [ [] ] ]

8942, 8951

5886, 8724

329, 401

9070, 9080

3076, 3083

9143, 9325

2568, 2596

8903, 8919

8972, 9049

8750, 8880

9104, 9120

2611, 3057

4815, 5863

3895, 4771

2196, 2259

272, 291

429, 2177

3097, 3880

2281, 2370

2386, 2552

10,090

176,805

7268

Discharge summary

report

Unit No: [**Numeric Identifier 26877**] Admission Date: [**2124-1-12**] Discharge Date: [**2124-1-14**] Date of Birth: [**2096-2-27**] Sex: M Service: MED HISTORY OF PRESENT ILLNESS: A 27-year-old male with a history of depression, panic attacks and multiple suicide attempts was found down by his father on the day of admission. His father spoke to him at 7:00 a.m. that morning when he sounded groggy and had a slurred speech. He did not show up at work and that is when his father went to his apartment and found down with a bag over his head snoring. He called the emergency services. At that time, the patient started vomiting pills. The pill bottles were found with the patient. These were as follows: Seroquel 200 mg tablets last filled [**2124-1-5**], 28 tablets, no tabs left in the pill bottle, carisoprodol 350 mg tablets last filled [**2124-1-5**], 56 tablets were filled at that time, none left in the bottle, lorazepam 1 mg tablets last filled [**2124-1-5**], 42 tablets, none left in the bottle, cyclobenzaprine 10 mg tablets last filled [**1-10**], #30 in number, 10 left in the bottle, Cymbalta 60 mg tablets last filled [**2123-12-17**], 30 in number, only 4 left in the bottle. In the emergency department, his vitals were temperature of 35.2 with a bear hugger, initially it was unable to register, pulse of 79, blood pressure 90/59, after 4 liters of IV fluids. He was intubated for airway protection and given his vomiting. He received 50 grams of charcoal with sorbitol. He had a negative head CT and a C-spine CT as well. EKG was within normal limits. He was admitted to the intensive care unit for further care. PAST MEDICAL HISTORY: 1. Depression. He was discharged from a psychiatric facility 1 week ago. 2. Panic attacks. 3. Multiple suicide attempts. Per chart, he has had at least 7 suicide attempts since [**2118**], most recently 10 days ago by cutting himself. He has also tried to stab himself in [**2123-10-24**], with an Exacto knife, overdose with Seroquel, Zanaflex and Klonopin. MEDICATIONS: Seroquel, carisoprodol, lorazepam, cyclobenzaprine, Cymbalta. ALLERGIES: No known drug allergies. SOCIAL HISTORY: He works at [**Hospital3 1196**] in nuclear medicine. No alcohol use. History of tobacco use. Has a girlfriend with bipolar disorder. PHYSICAL EXAMINATION: On admission, temperature was 97.8 without a bear hugger, blood pressure 108/67, pulse 76. These vitals were taken in the intensive care unit. He was saturating 100% on the ventilator. Good urine output. Appeared intubated, sedated but followed commands. Head and neck exam were mild pallor, NG tube and endotracheal tube were in place. The pupils were bilaterally reactive, equal. Neck: C-spine collar was in place. Lungs clear to auscultation bilaterally. Cardiovascular exam: Regular rate and rhythm, no murmurs, rubs or gallops. Abdomen soft, nontender, hypoactive bowel sounds. Extremities: No edema, 2+ distal pulses. Neurologic exam: PERRL, intermittently following commands. Skin warm and dry. LABORATORY DATA: On admission, he had a hematocrit of 29 that remained stable throughout the admission ranging from 27 to 29. There was 1 spurious value of 23.8, however, on repeating a few hours later it was back up to 29. Normal coagulation panel. Chem7 was unremarkable. ALT, AST were normal. Alkaline phosphatase was normal. Amylase was 318. Normal lipase. Cardiac enzymes remained normal. Calcium at admission was 7.9, however, it could be corrected with albumin of 3.3. Ionized calcium was normal at 1.16. Normal TSH, normal haptoglobin. Serum toxicology showed positive for tricyclics. Normal lactate. UA was normal. Urine toxicology was normal. Urine culture at the time of discharge was pending and was normal. Blood culture sent out the day prior to discharge was normal at the time of dictating this discharge summary. Chest x-ray, PA and lateral, showed no evidence of pneumonia. This was done the day prior to discharge. CT of the cervical spine revealed no fracture, anything suggestive of trauma. CT head revealed no signs of intracranial bleed or infarct or mass effect or fractures. Chest x-ray on admission did not reveal any infiltrate. PROCEDURES PERFORMED: Intubation, extubation. HOSPITAL COURSE: Severe depression and history of multiple suicide attempts: The patient after being initially intubated for airway protection he was extubated within less than 24 hours later and tolerated that well. He was given Charcoal in the emergency room. No EKG changes suggestive of Q-T prolongation were noted. No signs or symptoms suggestive of serotonin syndrome were noted. As well as toxicology followed the patient while in the intensive care unit. After stabilization, he was transferred to the floor with 1 to 1 sitter. He displayed ongoing suicidal ideation during the hospitalization. All further medications that he had overdosed on were withheld during the hospital course. Psychiatry evaluation was obtained who recommended inpatient psychiatry admission. He is eventually being discharged to an inpatient psychiatric facility ([**Hospital1 **] 4) for further management of his severe depression and history of multiple suicidal attempts and the current ideation. Anemia. His hematocrit except for the spurious value of 23 remained stable between 27 and 29. There was no acute evidence of bleeding, however, what was noted was the patient had multiple bruises and cuts on his extremities in various stages of development. These probably were from past suicide attempts that could have led to chronic blood loss causing his anemia. There was no evidence of hemolysis on his blood work and no evidence of acute GI or other bleeding. His hematocrit should be followed up as an outpatient. There is no acute need for blood transfusion at the time of discharge. Fever. The day prior to discharge the patient had a fever up to 101.9. A fever workup was initiated. Chest x-ray revealed no pneumonia or infiltrate. Urinalysis was normal. Urine culture was normal at the time of discharge. Blood cultures were drawn as well which were normal at the time of discharge. The patient had no symptoms suggestive of any infection. The fever defervesced overnight with resolution. The patient was afebrile for 24 hours prior to discharge. Hypocalcemia. The initial blood tests revealed hypocalcemia, however, after correction with the low albumin this was correctable. His ionized calcium was also confirmed to be normal. There were no symptoms or signs suggestive of hypocalcemia but this could have been a spurious value. The patient is being be discharged for further care to the inpatient psychiatric facility. At the time of discharge, the patient was medically stable to be discharged for his further psychiatry needs. CONDITION ON DISCHARGE: Stable from medical point of view. DISCHARGE INSTRUCTIONS: Further care to be taken over by the physicians at the psychiatry unit. The patient should call and follow-up with the primary care physician after discharge. DISCHARGE MEDICATIONS: 1. Nicotine patch. 2. Sumatriptan subcutaneous dose once daily as needed for migraine headaches. 3. Naproxen 250 mg tablets, 2 tablets every 8 hours as needed for migraine headaches. 4. Pantoprazole 40 mg p.o. daily. DISCHARGE DIAGNOSES: 1. Severe depression. 2. Suicidal attempt, drug overdose. 3. Anemia. 4. Fever-resolved. [**Name6 (MD) **] [**Name8 (MD) 21386**], MD [**MD Number(2) 26878**] Dictated By:[**Name8 (MD) 26879**] MEDQUIST36 D: [**2124-1-14**] 11:32:50 T: [**2124-1-14**] 12:56:47 Job#: [**Job Number 26880**]

[ "969.4", "969.3", "285.1", "296.33", "E950.4", "968.0", "780.6", "E950.3" ]

icd9cm

[ [ [] ] ]

[ "96.71", "96.04" ]

icd9pcs

[ [ [] ] ]

7305, 7629

7054, 7284

4267, 6785

6871, 7031

2341, 2965

190, 1646

2982, 4250

1668, 2166

2183, 2318

6810, 6846

24,831

116,494

15300

Discharge summary

report

Admission Date: [**2175-11-20**] Discharge Date: [**2175-12-12**] Date of Birth: [**2109-4-9**] Sex: M Service: SURGERY Allergies: Meperidine Attending:[**First Name3 (LF) 1481**] Chief Complaint: Status post motor vehicle collision. Major Surgical or Invasive Procedure: 1. Anterior pelvic ring external fixator. 2. Left posterior ring fixation with sacroiliac screw. 3. Suprapubic catheter placement History of Present Illness: Mr. [**Known lastname 4894**] is a 68 y/o male who was "T" boned, struck on drivers side, by a car at an unknown speed, requiring prolonged extraction with Jaws of Life. He was conscious at the scene but on arrival to the emergency department at [**Hospital 8641**] hospital in New [**Location (un) **], he was disoriented and found to have a ruptured spleen. He was brought to the OR at [**Location (un) 8641**] for a splenectomy. He also had an open book fracture of his pelvis and ruptured urethra, as well as a left humerus fracture. Per report he had bilateral frontal contusions. He was transferred to [**Hospital1 18**] for further care. Past Medical History: Prostate CA s/p radical prostatectomy [**2165**], XRT [**2173**]; GERD, hiatal hernia, [**Last Name (un) 865**] esophagus, colon polyps, TKA [**8-/2174**] Family History: Noncontributory. Physical Exam: VS: 92.1--> 94.8, 100 (ns), 136/77, 20, 99% AC 0.6/600x14/5 GEN: intubated, sedated SKIN: scrotal swelling and hematoma, diffuse mottling at hands/feet, no other appreciable skin breaks BACK: no step-offs, no ecchymoses, no skin breaks HEENT: no scalp compromise, EOMI, PERRL bilat 4-->2mm, MMM, soft neck, +c-collar CARDIAC: RRR, no m/r/g LUNGS: CTAB ABD: +BS, soft, distended, dressings c/d/i, no appreciable ecchymoses. PVASC: mottled cool feet/hands. +doppler PT/DP pulses bilat. MSK: L humerus fracture, displaced. NEURO: deferred. Pertinent Results: [**2175-11-20**] 11:42PM TYPE-ART PO2-298* PCO2-47* PH-7.16* TOTAL CO2-18* BASE XS--11 [**2175-11-20**] 11:42PM LACTATE-7.6* [**2175-11-20**] 11:42PM O2 SAT-99 [**2175-11-20**] 11:42PM freeCa-1.12 [**2175-11-20**] 11:30PM GLUCOSE-153* UREA N-17 CREAT-1.1 SODIUM-143 POTASSIUM-4.2 CHLORIDE-113* TOTAL CO2-17* ANION GAP-17 [**2175-11-20**] 11:30PM CALCIUM-7.3* PHOSPHATE-5.2* MAGNESIUM-1.4* [**2175-11-20**] 11:30PM WBC-16.7* RBC-4.88 HGB-15.4 HCT-43.8 MCV-90 MCH-31.7 MCHC-35.3* RDW-14.0 [**2175-11-20**] 11:30PM PLT COUNT-131* [**2175-11-20**] 11:30PM PT-13.6* PTT-25.2 INR(PT)-1.2* [**2175-11-20**] 11:30PM FIBRINOGE-178 ---------------- PELVIS (AP ONLY) PORT Clip # [**Clip Number (Radiology) 44491**] IMPRESSION: Diastasis of the pubic symphysis with associated fractures through the bilateral superior and inferior pubic rami and left sacral ala are better seen on subsequent CT examination. Subcutaneous emphysema involving the soft tissues overlying the low pelvis. CHEST (PORTABLE AP) Clip # [**Clip Number (Radiology) 44492**] FINDINGS: Portable radiograph of the chest. Endotracheal tube is appropriately positioned with its tip approximately 4.1 cm from the carina. NG tube is seen with its tip within the stomach and a side port below the diaphragm. Of note, the left costophrenic angle and many of the left-sided ribs are cut off from this film and therefore the rib fractures on the left side that are identified on later radiographs are not seen on this film. However, we are seeing pleural thickening possibly representing hemorrhage extending up the lateral costal pleural margin. Possible left apical pleural cap, with a generally widened mediastinum and rightward deviation of the trachea is identified. There is a possibility of mediastinal hemorrhage/aortic injury. This was discussed with the team caring for this patient according to a dictation performed for a later chest radiograph on [**11-21**]. Opacification in the left mid lung zone may represent contusion versus edema. HUMERUS (AP & LAT) LEFT PORT Clip # [**Clip Number (Radiology) 44493**] IMPRESSION: Old fracture of the left mid humeral diaphysis. Bridging callus formation is present and there is residual lateral displacement and varus angulation of the distal fracture fragment. CT HEAD W/O CONTRAST Clip # [**Clip Number (Radiology) 44494**] IMPRESSION: Ovoid hyperdense focus is present in the right anterior frontal lobe that may represent hemorrhage or mineralization. Followup is recommended. Note added at attending review: The prior study is now available for review. The right frontal high density is slightly larger than the prior study. The left frontal high density is slightly more diffuse and less evident. There are no definite new findings. There is a left posterior subgaleal hematoma. CTA CHEST W&W/O C &RECONS Clip # [**Clip Number (Radiology) 44495**] IMPRESSION: 1. No evidence of aortic dissection or pulmonary embolus. 2. Multiple left-sided rib fractures post motor vehicle accident. 3. Bilateral pleural effusions and atelectasis in intubated patient. Mild interstitial edema. Subcentimeter mediastinal lymphadenopathy. ---------------- CT L-SPINE W/O CONTRAST Clip # [**Clip Number (Radiology) 44496**] IMPRESSION: 1. Left sacral and iliac fractures with diastasis of the left sacroiliac joint. Left eleventh rib fracture. 2. Severe chronic degenerative changes at the L5-S1 level with moderate degenerative changes at the upper lumbar spine. ------------------ CT T-SPINE W/O CONTRAST Clip # [**Clip Number (Radiology) 44497**] IMPRESSION: 1. Multiple left-sided rib fractures posteriorly. 2. Left transverse process fracture T6 vertebra. 3. Bilateral pleural effusion and atelectasis. ----------------- CT PELVIS W/O CONTRAST Clip # [**Clip Number (Radiology) 44498**] IMPRESSION: 1. Suprapubic tube in the bladder, which demonstrate signs consistent with a bladder rupture, most likely extraperitoneal. Extravasation of contrast along the urethra, which may be consistent with urethral injury 2. Multiple pelvic fractures in relation to the superior and inferior ramus on the left, the left sacrum, the left iliac bone. 3. Multiple clips in the pelvis, which may be consistent with patient's status post prostatectomy. 4. Free fluid in the right paracolic gutters. ------------------- RENAL U.S. Clip # [**Clip Number (Radiology) 44499**] IMPRESSION: No evidence of hydronephrosis or significant interval change. ------------------- BILAT LOWER EXT VEINS Clip # [**Clip Number (Radiology) 44500**] IMPRESSION: No evidence of venous thrombosis in the bilateral lower extremities. ------------ WRIST, AP & LAT VIEWS LEFT PORT [**2175-12-5**] 5:44 PM IMPRESSION: Marked degenerative changes of the carpal bones and at the radiocarpal joint, in a distribution which is atypical for osteoarthritis. Query post- traumatic arthritis or seronegative spondyloarthropathy. ------------ CT PELVIS W/O CONTRAST [**2175-12-9**] 10:59 AM IMPRESSION: 1. Evidence of active contrast extravasation into the patient's perineum and scrotal sac as described above. 2. New subcutaneous emphysema along the dorsum of the penis - while this may be related to injection of contrast, an underlying infection should be considered. ------------ Brief Hospital Course: Mr. [**Known lastname 4894**] was trasnferred to [**Hospital1 18**], s/p splenectomy, with a left humerus fracture, a complicated open-book pelvic fracture, a urethral disruption, and a presumed bladder rupture. He was intubated, sedated. He was admitted to the Trauma Surgical Intensive Care Unit where he was shortly seen by the orthopedics and urology services. On hospital day #1, a suprapubic catheter was placed and he was started on ampicillin/gentamicin. He was evaluated by neurosurgery for report from OSH of bilateral frontal contusions, which were felt to be stable. Mr. [**Known lastname 4894**] initially had issues with low urine output and his initial pigtail SPC was replaced with a larger catheter to facilitate drainage of urine and decompression of the bladder. A chest tube was placed on hospital day 4 for a right pleural effusion. On hospital day 5, he returned to the OR with orthopedics for external fixation of his pelvic fractures. Urology recommended against attempt for immediate urethral repair given his scar tissues/clips from his prostatectomy. Mr. [**Known lastname 4894**] was extubated successfully post-operatively and continued to improve. His cervical collar was cleared when his mental status improved. He was transferred to the floor on hospital day 11 where he continued to improve. Recognizing the need for continued DVT prophylaxis, Mr. [**Known lastname 4894**] was evaluated by vascular surgery for an IJ-approached IVC filter. The procedure was cancelled, however, as the day of surgery Mr. [**Known lastname 44501**] creatinine unexpectedly rose to 3. He was evaluated by the urology and nephrology services. A renal ultrasound was negative for frank obstruction and/or hydronephrosis. He persistently had adequate urine output. His creatinine bump was felt to be related to hypovolemia and he was started on a strict regimen of IV fluids. At the same time, Mr. [**Known lastname 4894**] was noted to be febrile, with a rising WBC. His groin erythema worsened during this time and spread to involve his lower back. A fever workup resulted in a negative chest xray and no positive blood cultures. He was treated empirically with broad spectrum antibiotics and improved. On [**2175-12-6**], Mr. [**Known lastname 4894**] was noted to have significant pain and swelling over his left wrist. Upon examination, the wrist was red, swollen, and exquisitely tender to palpation. An aspiration of the joint revealed frank pus and rhomboid crystals. Hand was consulted and he was started on vancomycin for presumed septic joint and taken to the OR the next morning for a formal washout. He was started on colchicine for pseudogout and he readily improved. Final cultures were negative for any organism. Mr. [**Known lastname 4894**] had a repeat CT cystogram on [**2175-12-9**], revealing persistent small extravasation from his bladder rupture. In discussion with urology, this extravasation was consistent with his previous scan and they recommended continuation of the suprapubic catheter until definitive repair in [**6-15**] weeks from the date of injury. On hospital day 22 ([**2175-12-11**]), Mr. [**Known lastname 4894**] had an IVC filter placed by the vascular surgery service via a right IJ approach, necessitated by his pelvic fixation. He tolerated the procedure well and should no longer require anticoagulation. Mr. [**Known lastname 4894**] will require daily pin care at his external fixator as well as [**Hospital1 **] flushing of his suprapubic tube to avoid obstruction. He has made great strides in transfers with physical therapy but will need extensive rehabilitation given his prolonged immobility secondary to his injuries. Medications on Admission: celecoxib, lansoprazole Discharge Disposition: Extended Care Facility: [**Hospital6 1293**] - [**Location (un) **] Discharge Diagnosis: 1. Status post motor vehicle collision. 2. Bifrontal contusions 3. L humerus fx. 4. grade IV splenic lac s/p splenectomy at OSH 5. complicated pelvic fx. 6. ruptured urethra 7. ruptured bladder 8. multiple L rib fx. (>6) 9. R pleural effusion 10. Left wrist infection. 11. Left septic extensor tenosynovitis. Discharge Condition: Stable. Discharge Instructions: You are being discharged to an extended care facility for further care and rehabilitation of your injuries. If you have any new or concerning symptoms, please call your doctor [**First Name (Titles) **] [**Last Name (Titles) 3584**] housestaff immediately. Call if you experience fever, nausea or vomiting that precludes eating or drinking, chest pain, worsening abdominal pain, or any new or concerning symptom. Followup Instructions: You will need to follow up with urology, Dr. [**Last Name (STitle) 44502**], in 3 weeks; call ([**Telephone/Fax (1) 10941**] for an appointment. You will also need to be seen by orthopedics, Dr. [**Last Name (STitle) 1005**], in [**3-11**] weeks. Call [**Telephone/Fax (1) 1228**] for an appointment. Please schedule an appointment with the Trauma Surgery clinic in two weeks; call [**Telephone/Fax (1) 6429**] for an appointment. Finally, you will need to call the plastics and reconstructive surgery hand clinic for a follow up appointment in one to two weeks; call [**Telephone/Fax (1) 4652**] for an appointment.

[ "682.2", "805.2", "530.85", "727.05", "V43.65", "808.3", "608.86", "867.1", "274.0", "511.9", "584.9", "805.6", "807.07", "958.4", "E812.0", "293.0", "V10.46", "851.02" ]

icd9cm

[ [ [] ] ]

[ "78.19", "79.19", "57.17", "03.53", "82.21", "38.7", "84.71", "00.17", "38.93", "81.91", "57.94", "34.04", "96.6" ]

icd9pcs

[ [ [] ] ]

11022, 11092

7254, 10948

308, 443

11445, 11455

1904, 7231

11916, 12539

1313, 1331

11113, 11424

10974, 10999

11479, 11893

1346, 1885

232, 270

471, 1119

1141, 1297

9,137

134,983

9891+56078

Discharge summary

report+addendum

Admission Date: [**2147-4-18**] Discharge Date: [**2147-4-26**] Service: HISTORY OF PRESENT ILLNESS: This is an 85 year-old male with multiple medical problems including diabetes, congestive heart failure with an EF of 25%, coronary artery disease with known reversible ischemia, chronic obstructive pulmonary disease and chronic renal failure who was sent from his nursing home with mental status changes, leukocytosis and increase in his creatinine and respiratory congestion. The patient had self discontinued his Foley three days prior to admission. He had been recently hospitalized from [**4-3**] to [**4-14**] for a congestive heart failure exacerbation and acute renal failure requiring Natrecor and Dopamine. He was also found at that time to have reversible ischemia on a PMIBI, but catheterization was deferred given his acute renal failure. In the Emergency Room on admission the patient was found to have a systolic blood pressure of 79/31, which initially improved to 129/31 with intravenous fluids, but then fell. His white blood cell count was found to be 28, creatinine 3.5. His urinalysis was suggestive of a urinary tract infection. He was entered into the sepsis protocol and started on pressors. The patient at that time was somnolent, but denies any complaints. Specifically he denied chest pain, shortness of breath, nausea, vomiting, fevers or chills. He did not recall the events leading up to this presentation in the Emergency Room, but he did recall that he had been in his nursing home earlier that day. He was unable to provide any other history. Per the family the patient had been delirious for two to three days starting around the time of pulling the Foley with poor appetite and no po intake for the last two to three days. PAST MEDICAL HISTORY: 1. Type 2 diabetes. 2. Gout. 3. Congestive heart failure with an EF of 25%. 4. Coronary artery disease status post angioplasty. PMIBI in [**2147-4-12**] showing severe partially reversible basilar inferior wall and inferior lateral wall defects. No catheterization given the acute renal failure. 5. Chronic renal insufficiency. 6. Hypothyroidism. 7. Hyperlipidemia. 8. Peripheral vascular disease. 9. Mitral regurgitation. 10. Benign prostatic hypertrophy status post transurethral resection of the prostate. 11. Cataracts. 12. Chronic obstructive pulmonary disease. 13. Esophagitis. 14. Chronic hiccups. 15. Urinary incontinence. 16. Anemia. 17. Osteoarthritis. MEDICATIONS AT HOME: 1. Multivitamins. 2. Aspirin 325 q.d. 3. Calcium carbonate 500 t.i.d. 4. Levothyroxine 75 q.d. 5. Protonix 40 q.d. 6. Colace 100 q.d. 7. Maalox. 8. Isosorbide mononitrate 30 SR. 9. Plavix 75 q day. 10. Carvedilol 12.5 b.i.d. 11. Flomax 0.4 prn. 12. Lasix 80 mg q.a.m. and 60 mg q.p.m. 13. 70/30 20 units q.a.m. and 10 units q.h.s. 14. Sliding scale insulin. 15. Detrol 2 mg b.i.d. 16. Allopurinol 100 mg q.d. 17. Albuterol inhaler prn. 18. Heparin 5000 units b.i.d. ALLERGIES: No known drug allergies. FAMILY HISTORY: Noncontributory. SOCIAL HISTORY: He smoked 20 plus pack years. Was unable to get any other history at that time. PHYSICAL EXAMINATION: On admission his temperature was 99.9. His blood pressure was 79/31, which improved to 100/43 prior to starting Dopamine. His heart rate was 104 to 110. Respiratory rate 30. Sat 91% on room air. In general, he was a somnolent elderly man in no acute distress with mild tachypnea. HEENT his mucous membranes were dry. Oropharynx was clear. He was anicteric. Neck his JVP was about 10 cm, supple, no lymphadenopathy. Thorax course bilateral breath sounds, diffuse expiratory wheezes. Cardiovascular tachycardiac. No murmurs, rubs or gallops. Abdomen soft, nontender, nondistended. Extremities he had 2+ bilateral lower extremity edema. He had a 2+ sacral decube. Neurological he was oriented to himself, [**Month (only) 958**] and [**2147**], but not to the place. He thought he was at the [**Hospital3 2576**]. He moved all four extremities to command. LABORATORIES ON ADMISSION: White blood cell count was 28.7 with 87 neutrophils, 12 bands, hematocrit 29.6, platelets 351. His chem 7 was within normal limits with the exception of a BUN of 123 and a creatinine of 3.5. His liver function tests were within normal limits. His lactate was 3.7. Urinalysis moderate leukocyte esterase, nitrate positive, 11 to 20 white blood cells, many bacteria. Electrocardiogram was sinus tachycardia at 108. QTC was 456. There were no acute ST or T wave changes. Chest x-ray showed mild cardiomegaly, mild congestive heart failure, left lower lobe collapse versus consolidation. HOSPITAL COURSE: The patient was admitted to the Medical Intensive Care Unit. 1. Sepsis: The patient was initially started on Levaquin given that they thought this was urosepsis. One out of four blood cultures were positive for gram positive cocci. Vancomycin was started. The urine culture began growing out coag positive staph aureus Methicillin sensitive. The blood cultures subsequently grew out Methicillin sensitive staph aureus so the patient's antibiotic regimen was changed to Oxacillin. Vancomycin had been discontinued. The patient during his hospital course on [**4-19**] developed a pneumonia for which he was started on Levaquin. He completed a short course of Levaquin. The patient had a renal ultrasound done to exclude an abscess in his kidneys and there was no abscess. He had an echocardiogram done on [**4-25**], which showed no valvular abnormalities, however, there were 4 to 5 little regurgitant jets. They could not see these coursing through a perforation, but this could be suggestive of endocarditis so the patient will be continued on six weeks of intravenous antibiotics. 2. Cardiovascular: The patient did have a troponin leak likely secondary to demand ischemia. He was continued on his aspirin, Plavix, beta-blocker. No ace secondary to his creatinine and no statin secondary to his history of myositis. Myocardium: Initially the patient when he was admitted to the MICU was volume repleted, however, during hospital course he developed worsening congestive heart failure so that the patient was diuresed in the Intensive Care Unit on a Lasix drip. When he was discharged to the floor he was euvolemic. The volume goal for him was to remain even. 3. Pulmonary: Chronic obstructive pulmonary disease, the patient was continued on his regular inhaler regimen. 4. Renal: The patient had acute renal failure on admission, which was worsened after the Lasix drip. However, the patient's creatinine has now improved to his baseline. 5. Hematology: Anemia, during his unit stay the patient did develop some hematuria around the Foley site. His hematocrit drop to 24 to 25. The patient was transfused 3 units of packed red blood cells. Stool guaiacs were negative. The patient's hematocrit remained stable after the 3 units of blood in the Intensive Care Unit. Coagulopathy, his INR was slightly elevated on admission. It was felt that this was likely secondary to a nutritional deficiency. The patient was given three days of oral vitamin K and his INR subsequently improved. 6. Skin: The patient had a grade 2 sacral decube. He was seen by plastic surgery who recommended wet to dry dressings b.i.d. On [**4-25**] the decube appeared to have a black appearance to it. Plastics was called. They said that this was the eschar formation of the decube and it was normal so they recommended continuing Duoderm or Adaptic dressing b.i.d. and keeping the area clean. 7. Electrolytes: The patient had persistent hypocalcemia during his hospital stay, which was repleted. 8. The patient had complained of leg pain during his hospital course. There was no localizing signs or symptoms. It was felt that this could likely be a neuropathic pain. The patient was started on Neurontin 100 mg po q.h.s. This will be followed by his outpatient primary care physician. DISCHARGE STATUS: The patient was discharged to the [**Hospital 24979**] [**Hospital **] Nursing Home. DISCHARGE INSTRUCTIONS: Take all medications as prescribed. Intravenous antibiotics for five more weeks. Follow up with your primary care physician. FINAL DIAGNOSES: 1. Congestive heart failure. 2. Coronary artery disease. 3. Chronic renal failure. 4. Chronic obstructive pulmonary disease. 5. Endocarditis. 6. Staph aureus urinary tract infection. 7. Bacteremia. RECOMMENDED FOLLOW UP: Follow up with you primary care physician within the next two weeks. Call to schedule an appointment. Follow up with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] on [**5-2**] at 10:00 a.m. MAJOR SURGICAL/INVASIVE PROCEDURES: Central line placement and a transesophageal echocardiogram. DISCHARGE CONDITION: Stable. DISCHARGE MEDICATIONS: 1. Aspirin 81 mg q.d. 2. Levothyroxine 75 mg q.d. 3. Protonix 40 mg q.d. 4. Plavix 75 mg q.d. 5. Allopurinol 100 mg po q.o.d. 6. Albuterol nebulizers. 7. Tylenol prn. 8. Nitroglycerin 0.3 prn chest pain. 9. Carvedilol 6.25 po b.i.d. 10. Ipatropium nebulizers q six. 11. Senna. 12. Colace. 13. Lasix 60 mg po b.i.d. 14. Oxacillin 2 grams intravenously q 6 hours for the next five weeks. 15. Insulin, NPH 20 units q.a.m., 9 units q.p.m. and an insulin sliding scale. 16. Neurontin 100 mg po q.h.s. 17. Calcium 500 mg po q.i.d. [**Name6 (MD) 251**] [**Name8 (MD) **], M.D. [**MD Number(1) 1197**] Dictated By:[**Name8 (MD) 8736**] MEDQUIST36 D: [**2147-4-26**] 07:42 T: [**2147-4-26**] 07:43 JOB#: [**Job Number 33184**] Name: [**Known lastname **], [**Known firstname 2381**] Unit No: [**Numeric Identifier 5792**] Admission Date: [**2147-4-18**] Discharge Date: [**2147-4-27**] Date of Birth: [**2062-9-15**] Sex: M Service: [**Company 112**] HOSPITAL COURSE ADDENDUM: The patient remained in house for one more day to receive one more unit of packed red blood cells for a hematocrit of 28 secondary to his coronary artery disease and congestive heart failure prior to discharge. Also the patient remained in house for repletion of his calcium, which had dropped to an ionize of .97. These were repleted and the patient was otherwise set for discharge on the morning of [**2147-4-27**]. DISCHARGE DIAGNOSES: 1. Congestive heart failure. 2. Coronary artery disease. 3. Chronic renal failure. 4. Chronic obstructive pulmonary disease. 5. Endocarditis. 6. Staph aureus urinary tract infection. 7. Urosepsis. 8. Bacteremia. FOLLOW UP: The patient is to follow up with his primary care physician within the next two weeks and to call to schedule an appointment. He is to follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] on [**5-2**] at 10:00 a.m. DISCHARGE MEDICATIONS: 1. Aspirin 81 mg q day. 2. Levothyroxine 75 mg po q day. 3. Protonix 40 mg po q day. 4. Plavix 75 mg po q day. 5. Allopurinol 100 mg po q day. 6. Albuterol nebulizers. 7. Tylenol prn. 8. Nitroglycerin .3 prn for chest pain. 9. Carvedilol 6.25 po b.i.d. 10. Ipratropium nebulizers. 11. Senna. 12. Colace. 13. Lasix 60 mg po b.i.d. 14. Oxacillin 2 grams intravenously q 6 hours for the next five weeks. 15. Insulin NPH 20 units q.a.m. and 9 units q.p.m. With a sliding scale. 16. Neurontin 100 mg po q.h.s. 17. Calcium 500 mg po q.i.d. DR.[**Last Name (STitle) **],[**First Name3 (LF) **] 12-766 Dictated By:[**Name8 (MD) 1404**] MEDQUIST36 D: [**2147-4-27**] 07:46 T: [**2147-4-27**] 07:46 JOB#: [**Job Number 5793**]

[ "496", "486", "599.0", "707.0", "428.0", "038.11", "995.91", "584.9", "421.0" ]

icd9cm

[ [ [] ] ]

[ "38.93", "88.72", "99.04" ]

icd9pcs

[ [ [] ] ]

8848, 8857

3050, 3068

10388, 10609

10893, 11662

4696, 8115

8140, 8267

2510, 3033

8284, 8502

10621, 10870

3190, 4071

113, 1784

4086, 4678

1806, 2489

3085, 3167

70,516

100,866

53491

Discharge summary

report

Admission Date: [**2189-2-2**] Discharge Date: [**2189-2-11**] Date of Birth: [**2147-1-22**] Sex: F Service: MEDICINE Allergies: Aspirin / Penicillins / Sulfonamides / Biaxin / Levaquin / Cefzil / Motrin / Erythromycin Base Attending:[**First Name3 (LF) 358**] Chief Complaint: abdominal pain Major Surgical or Invasive Procedure: PICC line placement History of Present Illness: For full HPI please see admission note. Briefly, this is a 42F with CVID on IVIg, HepC, Tyoe 1 DM, distant IBD > 20 yrs ago last flare, recent cryptospordial infection, c/o increasing voluminous nonbloody diarrhea (up to 20 BMs daily) and worsening diffuse [**7-3**] sharp abdominal pain. Seen at [**Hospital 107**] Hospital, treated with IV fluids and discharged. The following morning abdominal pain, palpiations and diarrhea and fever of 103.5. In the ED she was found to be febrile to 101.5 88 120/38 16 100 RA, with tense abdomen and CT A/P was notable for pancolitis without a vascular distribution. She was started on broad spectrum abx, surgical consultation noted patient was not a surgical candidate. She was admitted to the ICU. In the ICU, vancomycin and cefepime were continued as were fluids. -Of note she has been followed by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in ID for cryptosporidium, which was diagnosed in [**2188-9-24**] and she was started on Nitazoxanide. She was on therapy until the end of [**Month (only) 1096**] at which time her insurance would no longer pay for the medications and was prescribed Flagyl for treatment, but did not start the medication. She denies raw foods, recent travel, NSAID use, EtOH use. She currently feels better. Her diarrhea has decreased today, she has had 1 BM that was a little less watery and more formed today. She continues to have abdominal pain but less so than yesterday. She tolerated a small ginger ale without nausea/vomiting. Past Medical History: 1)Type 1 Diabetes, difficult to control, she has frequent admissions for AMS from hypoglycemia. Followed at [**Last Name (un) **]. 2)CVID: treated with IVIG q2 weeks, last [**10-14**] 3)UTIs 4)Asthma 5)CBP 6)HCV: diagnosed in [**10-31**]. Most recent VL [**8-1**] 7,980,000 IU/mL Biopsy [**9-1**] showed Grade 2 inflammation, stage 2 fibrosis: 1. Marked portal, periportal, and lobular mixed-cell inflammation with focal bridging (Grade 3). 2. Marked bile duct proliferation with neutrophils (see note) 3. Trichrome stain: Moderate increase of portal and septal fibrosis (Stage 2). 7) cryptosporidium, as above 8) ? inflammatory bowel disease (UC)--per patient, last flare many years ago, not on any treatment Social History: lives with fiancee and daughter, smokes [**12-26**] pack per day, denies any alcohol since [**7-1**], formerly used IV drugs but none since [**2184**] Family History: No family history of diabetes. Multiple family members with [**Name2 (NI) 109976**] anemia. Mother has hypercholesterolemia and diverticular disease, father has peripheral vascular disease Physical Exam: Vitals - T: 94.9 BP:106/58 HR:83 RR:18 02 sat: 100% RA GENERAL: NAD SKIN: warm and well perfused, no excoriations or lesions, no rashes HEENT: NCAT anicteric sclera, pink conjunctiva, MMM, CARDIAC: RRR, S1/S2, no mrg LUNG: crackles at bilateral bases otherwise clear ABDOMEN: nondistended, +BS, tender to palpation throughout, worst in RLQ, + rebound tenderness but no guarding, no hepatosplenomegaly EXT: moving all extremities well, no cyanosis, [**12-26**]+ pitting edema in bilateral extremities to mid-shin, PULSES: 2+ DP pulses bilaterally NEURO: grossly intact, gait not assessed Pertinent Results: [**2189-2-2**] 02:30PM PT-17.6* PTT-35.4* INR(PT)-1.6* [**2189-2-2**] 02:30PM PLT COUNT-144* [**2189-2-2**] 02:30PM NEUTS-82.4* LYMPHS-14.5* MONOS-2.0 EOS-0.8 BASOS-0.3 [**2189-2-2**] 02:30PM WBC-14.2*# RBC-3.98* HGB-12.9 HCT-38.4 MCV-97 MCH-32.5* MCHC-33.6 RDW-17.2* [**2189-2-2**] 02:30PM TOT PROT-5.9* ALBUMIN-3.4 GLOBULIN-2.5 [**2189-2-2**] 02:30PM CK-MB-NotDone [**2189-2-2**] 02:30PM cTropnT-<0.01 [**2189-2-2**] 02:30PM LIPASE-32 [**2189-2-2**] 02:30PM ALT(SGPT)-343* AST(SGOT)-389* CK(CPK)-59 ALK PHOS-222* TOT BILI-2.9* [**2189-2-2**] 02:30PM estGFR-Using this [**2189-2-2**] 02:30PM GLUCOSE-179* UREA N-13 CREAT-1.0 SODIUM-135 POTASSIUM-4.3 CHLORIDE-102 TOTAL CO2-20* ANION GAP-17 [**2189-2-2**] 02:30PM GLUCOSE-179* UREA N-13 CREAT-1.0 SODIUM-135 POTASSIUM-4.3 CHLORIDE-102 TOTAL CO2-20* ANION GAP-17 [**2189-2-2**] 02:37PM LACTATE-2.6* K+-3.9 [**2189-2-2**] 02:37PM COMMENTS-GREEN TOP [**2189-2-2**] 09:36PM PT-19.6* PTT-41.8* INR(PT)-1.8* [**2189-2-2**] 09:36PM PLT COUNT-107* [**2189-2-2**] 09:36PM NEUTS-72.9* LYMPHS-22.6 MONOS-2.8 EOS-1.5 BASOS-0.2 [**2189-2-2**] 09:36PM WBC-11.4* RBC-3.27* HGB-10.4* HCT-31.1* MCV-95 MCH-31.9 MCHC-33.5 RDW-17.1* [**2189-2-2**] 09:36PM CALCIUM-7.6* PHOSPHATE-3.0 MAGNESIUM-1.4* [**2189-2-2**] 09:36PM ALT(SGPT)-253* AST(SGOT)-244* LD(LDH)-203 ALK PHOS-173* TOT BILI-2.4* [**2189-2-2**] 09:36PM GLUCOSE-144* UREA N-11 CREAT-0.8 SODIUM-136 POTASSIUM-3.8 CHLORIDE-108 TOTAL CO2-20* ANION GAP-12 Brief Hospital Course: # Pan-colitis: Differential included cryptosporidium, c.diff, multiple bacterial/viral etiologies given CVID, and IBD. Broad spectrum antibiotics were intiated on admission including PO/IV vancomycin, cefepime and flagyl. The patient was started on IV fluids; leukocytosis and lactate were trended in the ICU. CT abdomen/pelvis showed diffuse severe pancolitis, small ileocolic intussiception wihtout evidence of obstruction. The surgical service was consulted but saw no acute indication for surgery and followed the patient with serial abdominal exams. The patient remained afebrile and hemodynamically stable in the ICU and was subsequently tranferred to the regular medical floor. The GI service was consulted and recommended a flexible sigmoidoscopy, stool cultures and labs to evaluate the etiology of her diarrhea. Thus far all stool labs for infectious causes are negative. The biopsy upon flexible sigmoidoscopy showed mild dysplasia and inflammation. It was recommended the patient continue her PO flagyl for a 2 week course and follow up with GI for a colonoscopy after discharge. . # Bacteremia: the patient was found to have S.pneumoniae on blood culture while on vancomycin. The Infectious Disease service was consulted. TTE and TEE were negative for endocarditis. Ceftriaxone was initiated and PICC placed for IV treatment for a 2 week course. The remainder of the blood cultures are negative to date. The patient remained afebrile during her admission. She has ID follow-up with Dr.[**First Name (STitle) **] in several weeks. . # Chronic Hepatitis C: LFTs were elevated above baseline on admission. Initially cholestyramine, ursodiol and spironolactone were held. Her LFTs were trended and slowly returned back to baseline. After transfer to the medical service, given agressive fluid resuscitation in the ICU, the patient was fluid overloaded and required diuresis. Spironolactone was restarted and lasix 20mg po daily was added. An abdominal US showed a moderate amount of ascites which was tapped via ultrasound guidance. Approximately 500cc of fluid was removed, and labs were consistant with SBP, althought the patient was asymptomatic and already on ceftriaxone at that time. She will need follow-up for her ascites as an outpatient to ensure it does not reaccumulate. Her cholestyramine, ursodiol were restarted prior to discharge. A follow-up appointment was scheduled with Dr.[**Last Name (STitle) 497**] (hepatology). . # DM Type I: Patient reportedly hypoglycemic was hypoglycemic in the ICU, glargine was discontinued while the patient was NPO. Once her diet was advanced her home DM was restarted and fingersticks monitored. No changes were made to her regimen prior to discharge. . # Asthma: Home regimen of albuterol, pulmicort and tiotropium were continued. . # Coagulopathy: at baseline probably due to underlying liver disease. . # Follow-up: the patient has follow-up with the GI service, Infectious Disease, Hepatology and her PCP (which she will make on her own). Medications on Admission: ALBUTEROL - (Prescribed by Other Provider) - 90 mcg Aerosol - 2 puffs inhaled four times per day BUDESONIDE [PULMICORT] - (Prescribed by Other Provider) - Dosage uncertain CHOLESTYRAMINE-ASPARTAME [CHOLESTYRAMINE LIGHT] - 4 gram Packet - 1 packet by mouth once a day FLUTICASONE-SALMETEROL [ADVAIR DISKUS] - 250 mcg-50 mcg/Dose Disk with Device - 1 Disk(s) inhaled twice a day INSULIN ASPART [NOVOLOG] - (Prescribed by Other Provider) - 100 unit/mL Cartridge - as per sliding scale INSULIN GLARGINE [LANTUS] - 100 unit/mL Solution - 16 unit in the morning and 12 units at night as directed MORPHINE - (Prescribed by Other Provider) - 60 mg Tablet Sustained Release - 1 Tablet(s) by mouth at night NITAZOXANIDE [ALINIA] - 500 mg Tablet - 1 Tablet(s) by mouth po [**Hospital1 **] OMEPRAZOLE - (Prescribed by Other Provider) - 20 mg Capsule, Delayed Release(E.C.) - 1 Capsule(s) by mouth once a day OXYCODONE - (Prescribed by Other Provider: [**Name10 (NameIs) **] [**Last Name (STitle) 67537**] - 5 mg Capsule - 1 Capsule(s) by mouth two times per day as needed for pain PROMETHAZINE [PROMETHEGAN] - (Prescribed by Other Provider) - Dosage uncertain SPIRONOLACTONE - 50 mg Tablet - 1 Tablet(s) by mouth once a day TIOTROPIUM BROMIDE [SPIRIVA WITH HANDIHALER] - (Prescribed by Other Provider) - 18 mcg Capsule, w/Inhalation Device - URSODIOL [[**Last Name (un) 390**] 250] - 250 mg Tablet - 1 Tablet(s) by mouth twice a day with meals Medications - OTC BLOOD SUGAR DIAGNOSTIC [ONE TOUCH ULTRA TEST] - Strip - 10 x day - No Substitution INSULIN SYRINGE-NEEDLE U-100 [BD INSULIN SYRINGE ULT-FINE II] - 31 gauge X [**5-9**]" Syringe - 8 x day LANCETS [ONE TOUCH ULTRASOFT LANCETS] - Misc - 8 x day Discharge Medications: 1. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation Q6H (every 6 hours). 2. Spiriva with HandiHaler 18 mcg Capsule, w/Inhalation Device Sig: One (1) Inhalation once a day. 3. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 4. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 5. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) for 5 days. Disp:*15 Tablet(s)* Refills:*0* 6. Spironolactone 25 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 7. NEHT NEHT per protocol 8. Ceftriaxone in Dextrose,Iso-os 2 gram/50 mL Piggyback Sig: One (1) Intravenous Q24H (every 24 hours) for 14 days: last day [**2189-2-18**]. Disp:*7 * Refills:*0* 9. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. Disp:*30 Tablet(s)* Refills:*2* 10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 11. Cholestyramine-Sucrose 4 gram Packet Sig: One (1) Packet PO DAILY (Daily). 12. Ursodiol 250 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 13. Budesonide 0.5 mg/2 mL Suspension for Nebulization Sig: One (1) Inhalation once a day: take as prescribed by Dr.[**Last Name (STitle) **]. 14. Novolog 100 unit/mL Cartridge Sig: One (1) Subcutaneous once a day: use as directed. 15. Lantus 100 unit/mL Solution Sig: One (1) Subcutaneous twice a day: 16U in the morning, 12U at night. 16. Morphine 60 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO at bedtime. 17. Oxycodone 5 mg Capsule Sig: One (1) Capsule PO twice a day as needed for pain. 18. Promethazine 12.5 mg Tablet Sig: One (1) Tablet PO once a day: take as directed by your doctor. Discharge Disposition: Home With Service Facility: All Care VNA of Greater [**Location (un) **] Discharge Diagnosis: Diarrhea Chronic hepatitis C Discharge Condition: hemodynamically stable Discharge Instructions: You were admitted to the hospital for abdominal pain, diarrhea and fever. You were initially treated in the ICU for low blood pressure and infection with IV fluids and antibiotics. Your stool studies are negative for an infectious process. On flexible sigmoidoscopy you had a biopsy of the colon shows inflammation and mild dysplasia, which needs to be further evaluated by the GI physicians. You were also found to have bacterial infection in your blood for which you need to be treated with IV antibiotics. A PICC line was placed to allow for a full 2 weeks of antibiotics (ceftriaxone). You will also need to complete the course of flagyl (antibiotic) for which you have a prescription. Your Alinia has been discontinued. Please make sure to keep your appointments below with the [**Hospital **] clinic, Infectious disease clinic and make sure to see your primary care doctor at your earliest convenience for follow-up. If you experience worsening abdominal pain, nausea/vomiting, no bowel movements for more than one day with abdominal distension, fevers, chills, chest pains, or any other concerning symptoms please return to the ER or call your doctor. Followup Instructions: Please make an appointment to see your primary care doctor within 1-2 weeks of your discharge. Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 8507**], MD Phone:[**Telephone/Fax (1) 2422**] Date/Time:[**2189-2-20**] 8:40 Provider: [**First Name8 (NamePattern2) 3722**] [**Name11 (NameIs) 3723**], MD Phone:[**Telephone/Fax (1) 463**] Date/Time:[**2189-3-3**] 3:00 Provider: [**First Name11 (Name Pattern1) 1037**] [**Last Name (NamePattern4) 2335**], MD Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2189-2-18**] 10:30

[ "584.9", "279.06", "567.23", "789.59", "493.90", "250.81", "560.0", "790.7", "572.3", "041.09", "070.54", "556.6", "276.6", "276.2", "276.8", "286.9" ]

icd9cm

[ [ [] ] ]

[ "54.91", "38.93", "88.72", "45.25" ]

icd9pcs

[ [ [] ] ]

11788, 11863

5196, 8207

368, 390

11936, 11961

3686, 5172

13171, 13720

2871, 3063

9957, 11765

11884, 11915

8233, 9934

11985, 13148

3078, 3667

314, 330

418, 1951

1973, 2685

2701, 2855

1,344

130,931

2630

Discharge summary

report

Admission Date: [**2109-12-14**] Discharge Date: [**2109-12-20**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2901**] Chief Complaint: transfer from OSH for pericardial effusion drainage Major Surgical or Invasive Procedure: percutaneous pericardiocentesis s/p pericardial drainage History of Present Illness: Patient is an 86 yo female w/ h/o CAD, CHF (normal EF), chronic AF, and HTN who presents as transfer from an OSH for drainage of pericardial effusion. Patient reports dyspnea on exertion x 1 week. Initially, only occured with ambulation/exertion. She was scheduled to see a pulmonologist for evaluation, but on the day before admission, she experienced an episode at rest which was more severe than before. No CP, diaphoresis, N/V. Also denies LE edema, orthopnea, or PND. She reports "shaking" uncontrollably on the evening prior to admission. Subjective fever. Of note, the patient had been treated for UTI several days prior (?cipro), which had be switched to nitrofurantoin on the day prior to admission. . Due to worsening SOB and rigors, pt called EMS, went to OSH. Evaluated and found to be in CHF. Given Lasix with good effect. Patient admitted, had TTE done showing large pericardial effusion (1.8cm). Of note, patient known to have chronic pericardial effusion. Was seen on CTA [**9-22**] as moderate pericardial effusion. She continued on lasix for diuresis. Was transferred to [**Hospital1 18**] for possible drainage of pericardial effusion on Monday. Past Medical History: 1. CAD (s/p cath [**2100**]: 2VD, prior PTCA in LPDA) 2. A fib: chronic, on coumadin 3. Breast Cancer s/p XRT and lumpectomy (6 years ago) 4. h/o CHF (EF reportedly normal on last echo) 5. HTN 6. Hyperchol 7. DM2 8. s/p CCY Social History: Lives w/ husband. [**Name (NI) 3003**] smoking hx: 30 pack years; quit 30 yrs ago. No EtOH or drug use. Family History: No Premature CAD Physical Exam: VS: T=100.5; BP=151/61; HR=72; RR=28; O2=95% (2L); Pulsus=8 mmHg Gen: pleasant, elderly woman, in NAD HEENT: anicteric, EOMI, PERRL, MMM, clear OP, NECK: no carotid bruits, no JVD appreciated CV: RRR, nl s1s2, 2/6 Systolic Murmur @ LUSB and at apex. No S3/S4 Lungs: Minimal bibasilar crackles, slightly decreased BS at bases, otherwise CTA B Abd: NABS, NT/ND, no hsm, no abdominal bruits Ext: no edema, no cyanosis, warm, pink well perfused; Pulses: 2+ carotid, Femoral, DP/PT bilat; no femoral bruits b/l Pertinent Results: [**2109-12-14**] 09:44PM URINE BLOOD-SM NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [**2109-12-14**] 09:44PM URINE RBC-[**3-23**]* WBC-[**6-28**]* BACTERIA-RARE YEAST-NONE EPI-0 TRANS EPI-0-2 [**2109-12-14**] 08:25PM GLUCOSE-161* UREA N-28* CREAT-1.0 SODIUM-133 POTASSIUM-3.9 CHLORIDE-93* TOTAL CO2-29 ANION GAP-15 [**2109-12-14**] 08:25PM CK(CPK)-60 [**2109-12-14**] 08:25PM TSH-2.0 [**2109-12-14**] 08:25PM HYPOCHROM-NORMAL ANISOCYT-NORMAL POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL [**2109-12-14**] 08:25PM PLT SMR-NORMAL PLT COUNT-168 [**2109-12-14**] 08:25PM PT-15.7* PTT-37.2* INR(PT)-1.7 . CATHETERIZATION [**12-16**] 1. Initial resting hemodynamics demonstrated elevated right atrial pressures with intermittant loss of the y-descent. The RVEDP was elevated at 18 mmHg as was the PCWP. 2. Pericardial pressures were elevated at 10 mmHg but were not equalized with RA pressures. After drainage of ~350 cc of serosanguinous pericardial fluid, the pericardial pressure fell to 0 mmHg and the mean RA fell from 16 mmHg to 10 mmHg. . ECHO [**12-16**] Large circumferential pericardial effusion as described above. (There is a large, circumferential relatively echolucent pericardial effusion extending 1.5cm anterior to the right ventricle, around the apex, 2cm lateral to the left ventricle, and >3cm inferior to the left ventricle. There are no echocardiographic signs of tamponade. No right atrial or right ventricular diastolic collapse is seen) Minimal aortic valve stenosis. Preserved global and regional biventricular systolic function. . ECHO [**12-18**] Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets are mildly thickened. The mitral valve leaflets are mildly thickened. There is a moderate-sized, posterior pericardial effusion. Cannot exclude fluid loculation. There are no echocardiographic signs of tamponade. Compared to the prior study (images reviewed) dated [**2109-12-16**], the pericardial effusion is significantly smaller. . ECHO [**12-19**] The left atrium is markedly dilated. The right atrium is markedly dilated. Left ventricular wall thicknesses are normal. The left ventricular cavity is unusually small. Left ventricular systolic function is hyperdynamic (EF>75%). The mitral valve leaflets are mildly thickened. The tricuspid valve leaflets are mildly thickened. There is a small to moderate sized pericardial effusion. There are no echocardiographic signs of tamponade. Compared with the findings of the prior study (images reviewed) of [**2109-12-18**], no major change is evident. . CXR [**12-14**] PA/LAT IMPRESSION: Cardiomegaly with bilateral pleural effusions. Brief Hospital Course: Patient is an 86 year-old female with CAD, CHF (preserved EF), chronic AF, and HTN who was transferred from an OSH for pericardiocentesis after presenting with progressive dyspnea - ECHO at OSH showed pericardial effusion without evidence of tamponade. The following issues were addressed during her hospital stay: . 1. PERICARDIAL EFFUSION: Patient was taken to the catheterization laboratory where elevated right atrial pressures were seen and 350cc of serosanguinous fluid were drained (see full report under "Pertinent Results") - there was no evidence of tamponade. Patietn was admitted to the CCU for close monitoring. Subsequent ECHO 1 day later showed improvement in size of pericardial effusion - loculated posterior collection was also seen which was not accessible by pericardial catheter. Drain was kept in place for two days. Patient received repeat ECHO 1 day after drain removal and no re-accumulation of pericardial fluid was seen. Patient remained afebrile and hemodynamically stable throughout hospital course. Cytology was negative for malignanct cells. Fluid chemistry was consistent with exudative picture. Per PCP/Cardiologist records, pericardial effusion is a chronic phenomenon, and etiology is still unknown. PPD, [**Doctor First Name **], TSH, and RF were all unremarkable here. If pericardial effusion recurs, patient likely to need pericardial windown (percutaneous vs. operative). Patient to receive repeat ECHO in 1 week at [**Hospital6 **] and to follow-up with Dr. [**Last Name (STitle) 1295**]. . 2. DYSPNEA/CHF On arrival to the intensive care unit, patient had 1 episode of mild shortness of breath which responded to 10 IV Lasix. Of note, patient had not received home Lasix dose that day. Progressive dyspnea that led to presentation at OSH was likely due to combination of pericardial effusion and CHF exacerbation - these issues were addressed with pericardiocentesis and diuresis, respectively. Patient was subsequently without breathing difficulty or other respiratory complaints, and O2 Sats were in the mid 90s on room air. Outpatient Lasix 20mg PO qd was continued with good effect. Following pericardial drainage, outpatient Digoxin was resumed (0.125 mg PO qd) and BB continued. . 3. CHEST PAIN/CAD Patient experienced 2 isolated episodes of sub-xiphoid chest pain during hospital course, other VSS. Pain was in location of pericardial drain, and resolved without issue once drain was removed. First episode was associated with 0.5mm ST depressions in V1-V3 ? demand ischemia, though not conclusive. Second episode without EKG changes, and both responded to 0.5 mg IV morphine, Per Cardiologist records, patient had MIBI ~1 year ago which showed no reversible disease. Episodes were attributed to epicardial irritation secondary to pericardial catheter. If necessary, issue to be addressed further as outpatient. Patient was continued on home regimen of Aspirin, Coumadin, BB. . 4. RHYTHM Patient with history of chronic Atrial Fibrillation. Coumadin and Digoxin were held in setting of pericardiocentesis, and re-started once drain was pulled. . 5. DM2 Patient was kept on RISS with good glycemic control. Patient to resume outpatient oral hypoglycemics on discharge. . 6. FEVER Patient with isolated low-grade temperature of 100.5 on admission. Recently treated with Cipro for UTI as outpatient, then switched to Nitrofurantoin. Patient was placed on Ceftriaxone as inpatient by admitting team for concern of incomplete treatment of UTI. CXR was negative for focal infiltrates, chronic bilateral pleural effusions were seen. UA was negative. Patient without leukocytosis or susbequent febrile episodes. Patient discharged home without leukocytosis. . Medications on Admission: MEDS ON TRANSFER: Nitrofurantoin 50 mg PO QID Atenolol 75 mg PO DAILY Pantoprazole 40 mg PO Q24H Digoxin 0.125 mg PO DAILY Rosuvastatin 10 mg PO DAILY RISS . OTHER OUTPATIENT MEDS BEING HELD AT OSH: glipizide 7.5 mg PO daily Lutein 75 mg PO daily Coumadin 5 mg PO daily Arimidex 1 mg PO dialy Lasix 20 mg PO daily Discharge Medications: 1. Rosuvastatin 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 2. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 5. Warfarin 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime): 1 tablet M,T,W,Th,F [**1-20**] tablet [**Last Name (LF) **],[**First Name3 (LF) **]. 6. Atenolol 50 mg Tablet Sig: 1.5 Tablets PO once a day. 7. Glipizide 5 mg Tablet Sig: 1.5 Tablets PO once a day. 8. Lutein 6 mg Capsule Sig: One (1) Capsule PO once a day. 9. Arimidex 1 mg Tablet Sig: One (1) Tablet PO once a day. 10. Caltrate-600 Plus Vitamin D3 600-200 mg-unit Tablet Sig: One (1) Tablet PO twice a day. 11. Actonel 35 mg Tablet Sig: One (1) Tablet PO once a week. 12. Detrol 2 mg Tablet Oral 13. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Discharge Disposition: Home With Service Facility: [**Hospital1 **] home care Discharge Diagnosis: Primary 1. Pericardial Effusion without evidence of tamponade Secondary 1. CAD 2. Hyperlipidemia 3. Chronic Atrial Fibrillation 4. Breast Cancer s/p XRT and lumpectomy (6 years ago) 5. CHF (preserved EF) 6. HTN 7. DM II Discharge Condition: stable, ambulating without oxygen requirement, chest pain free, without breathing difficulty Discharge Instructions: 1. Please take all medications as prescribed. 2. Please make all follow-up appointments -- see below. 3. If you develop difficulty breathing, chest pain, bleeding, dizziness, or any other concerning signs/symptoms, please contact your PCP [**Name Initial (PRE) **]/or report to the nearest Emergency medical facility Followup Instructions: 1. Your follow-up ECHO is scheduled for [**12-26**], 8:45 AM at [**Hospital6 1109**], [**Location (un) **] 2. You have a follow-up appointment scheduled with Dr. [**Last Name (STitle) 1295**] on [**12-31**] at 10:30 AM. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2908**] MD, [**MD Number(3) 2909**] Completed by:[**2110-3-10**]

[ "401.9", "416.8", "428.0", "599.0", "427.31", "423.9", "414.01", "250.00", "428.33", "511.9", "272.4", "V10.3", "V45.82" ]

icd9cm

[ [ [] ] ]

[ "37.0", "88.55", "37.21" ]

icd9pcs

[ [ [] ] ]

10422, 10479

5337, 9039

316, 374

10744, 10839

2513, 5314

11204, 11585

1953, 1971

9404, 10399

10500, 10723

9065, 9065

10863, 11181

1986, 2494

225, 278

402, 1569

1591, 1816

1832, 1937

9083, 9381

83,342

162,088

1951

Discharge summary

report

Admission Date: [**2144-7-28**] Discharge Date: [**2144-8-6**] Date of Birth: [**2098-1-9**] Sex: F Service: MEDICINE Allergies: Compazine Attending:[**First Name3 (LF) 1943**] Chief Complaint: Abdominal pain, nausea, vomiting Major Surgical or Invasive Procedure: None History of Present Illness: 46 yo F with h/o chronic pancreatitis due to hypertriglyceremia, NASH, admitted [**1-7**] for pancreatitis flare requiring TPN, who presents with recurrent abdominal pain. She has done very well over the last few months until friday, when she developed sharp epigastric/RUQ pain radiating to the back. She described the pain as [**9-8**]. It initially began with food, but did not dissipate. She also experienced n/v, and was unable to tolerate POs. She denies change in bowel movements, dysuria, travel or sick contacts, or med changes. She also denies f/c, HA, CP, SOB, palps, leg pain, joint swelling. She is adherent with her medications. She denies dietary changes. She visited with her GI Dr. [**Last Name (STitle) 174**], who referred her to the ED. In the ED, VS: 97.3, 113, 134/86, 16, 96%RA. Received morphine, dilaudid, antiemetics with little improvement. CT scan performed. Trig levels >4000. Review of systems: 10 point review of systems negative except as listed above Past Medical History: - Hypertriglyceridemia c/b recurrent pancreatitis. Recent episodes [**1-7**] and [**8-8**] and was on TPN both times. Diagnosed in [**2138**] and treated initially with combo of lifesyle modifications and lipid lowering meds in absence of known coronary heat dis at that time. Was evaluated in [**10/2143**] by Dr. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 2201**] for dysipidemia; hyperTG and hyperchol: D/C'd gemfibrozil and started on TriCor, continued on Crestor 5mg. - Chronic pancreatitis w/recurrent acute - admitted in [**2143-12-19**] for 7 days with TG 834 that improved to 188 and discharged on TPN. Admitted on [**2143-9-2**] for 4 days after failing outpatient treatment with TG 1500 1 week prior to admission and TG 245 upon admission and 160 upon discharge. [**2-7**]- received MRCP for recurrent acute pancreatitis with possible pancreatic pseudocyst at OSH exam. Evidence of chronic pancreatitis and no pseudocyst (atrophic body and tail of pancreas w/o mass or ductal abnormality or inflammatory changes) and normal GB/intra/extrahepatic ducts. 3 admissions in [**2141**]- on 2nd admission, started on Tricor. [**12-6**] - admitted for recurrent acute pancreatitis with [**Doctor First Name **] 130 and lip 258, abd CT with pancreatic head inflammation. TG up to 2902 and after 1 week decreased to 445 while NPO and on tricor 145mg. Had TPN. [**2140**] Dr [**Last Name (STitle) 10759**] started her on Lopid and was ineffective. [**3-/2130**]: gemfibrozil - Mild Coronary Disease - cardiac cath [**2139**] - NASH- liver biopsy in [**7-/2130**] with extensive fatty changes - Anxiety/Panic Attacks d/o - Psoriasis - treated with topical emolients. - DM - insulin-requiring x 15 years, always on insulin. - Rotator cuff tear Social History: Is a manager of an HR department. She is married and has one 28yo son. [**Name (NI) **] [**Name2 (NI) 1818**] of 1ppd x3 years. She denies alcohol or other drugs. Family History: Significant for triglyceridemia in her aunt, type [**Name2 (NI) **] diabetes mellitus in her maternal grandmother as well as first cousin. Uncle died at age 50 from and MI. Physical Exam: VS: T 96.5, BP 142/89, HR 112, RR 18, 98%RA Gen: awake and alert, well appearing, NAD HEENT: MM dry, EOMI, anicteric sclera Neck: supple no LAD Heart: Tachy, regular no m/r/g Lung: CTAB no wheezes or crackles Abd: protruberant, soft, +TTP over epigastrium -> RUQ, no rebound or clear guarding, + BS Ext: warm well perfused Skin: white scaly plaques over extensor surfaces of elbows, knees, ankles Neuro: no focal deficits Pertinent Results: 136 / 98 / 12 / 247 5.0 / 18 / 0.5 UCG: Neg 10.0 \ / 404 / 38.5 \ N:72.0 L:22.0 M:3.4 E:1.3 Bas:1.2 ALT: 26 AP: 87 Tbili: 0.2 Alb: AST: 16 LDH: Dbili: TProt: [**Doctor First Name **]: 37 Lip: 26 Triglyc: 4701 U/A: 0 bact, 100 gluc CT Abd/Pelvis [**7-27**]: 1. No CT evidence of acute pancreatitis. No pancreatic pseudocyst. 2. Fatty liver. 3. Borderline splenomegaly. 4. Short segmental thickening of the jejunum, non-specific could represent enteritis or a normal contracted bowel. 5. Fibroid uterus. 1.7 cm right adenxal cyst, within physiologic range for follicle. 6. Normal appendix. Brief Hospital Course: Ms. [**Name14 (STitle) 10760**] is a 46yo woman with hx of chronic pancreatitis secondary to hypertriglyceremia, NASH, prior hospitalization for acute pancreatitis requiring TPN, who presented with recurrent abdominal pain for 5 days with radiation to mid-back, nausea, and vomiting. Her gastroenterologist, Dr [**Last Name (STitle) 174**], referred the patient to the ED since these symptoms were very similar to her prior events of acute pancreatitis. She had normal amylase and lipase levels. Abdominal CT demonstrated a sentinel loop with segmental thickening of the jejunum, although no evidence of acute pancreatitis. Her triglyceride levels were markedly elevated to 4701 indicating a precipitating factor for acute pancreatitis. She was admitted for pain control and not tolerating po's. # Pain control: the patient's pain was difficult to control well during this hospitalization. She was given IV dilaudid and trialed on a variety of doses and frequencies. Pain management was consulted and recommended an IV dilaudid PCA, which she was on for approximately 24 hours resulting in excellent pain control. She was then given oral hydromorphone resulting in good pain control. She was also started on gabapentin for pain control. # Nausea: the patient had a great deal of nausea and did not tolerate po diet. She was given IV fluids for hydration. She was kept NPO due to pain and nausea. TPN was initiated on [**2144-8-1**] after not tolerating po diet for approximately 1 week. She kept on TPN while being advanced to a clear diet, which she tolerated with some nausea, even when taking anti-nausea medications before meals. She was advised to limit the variety of foods during meals in order to minimize nausea. # Hypoxia: had an episode of hypoxia overnight on [**2144-7-30**] where she complained of shortness of breath on awakening. Her O2 sat was 69% on room air, was given supplemental oxygen, and transferred to the [**Hospital Unit Name 153**]. She was given lasix for suspected volume overload and was diuresed. EKG showed sinus tachycardia. She had a normal CXR and normal chest CTA ruling out pulmonary edema or effusion and ruling out PE. An echo revealed normal LVEF>55%, normal R and L ventricular size and function, and only revealing mild 1+ mitral regurgitation but no mitral valve prolapse. She intermittently required supplemental oxygen and was transferred back to the medicine [**Hospital1 **] 1 day later. We think hypoxia was due to narcotic-induced sleep apnea. # Hypertriglyceridemia: she was continued on tricor and an increased dose of crestor during this hospitalization. Her TG levels decreased significantly. # Diabetes: given a decreased dose of glargine twice daily while she was NPO and was on a regular insulin sliding scale. # Acid reflux: patient complained of acid reflux symptoms and was given pantoprazole and maalox. # Constipation: Approximately 1 week into hospitalization, her abdominal exam demonstrated increased distension and she had not had a bowel movement while here. She was passing flatus. A KUB demonstrated normal bowel gas pattern with relative paucity of gas; there was no evidence of ileus, obstruction, or free air. Miralax was added to her bowel regimen, after which the patient's abdominal exam began to improve. Upon discharge, she was sent home with visiting nurse assistance, on TPN, and on oral pain medication. She will follow up with her gastroenterologist, who will need to manage her nutrition and pain while outpatient. She will also need to follow up with her Primary Care Physician for this hospitalization, acute pancreatitis, hypertriglyceridemia, and diabetes. Medications on Admission: FENOFIBRATE NANOCRYSTALLIZED [TRICOR] - 145 mg Tablet - 1 (One) Tablet(s) by mouth once a day HYDROMORPHONE [DILAUDID] - (Prescribed by Other Provider) - 2 mg Tablet - 2 Tablet(s) by mouth every four hours as needed for pain INSULIN ASPART [NOVOLOG] - (Prescribed by Other Provider: [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] - 100 unit/mL Solution - sliding scale INSULIN DETEMIR [LEVEMIR] - (Prescribed by Other Provider: [**Last Name (NamePattern4) **]. [**Last Name (STitle) 10761**] at [**Hospital3 **]) - 100 unit/mL Solution - 24 units twice a day OMEGA-3 ACID ETHYL ESTERS [LOVAZA] - 1 gram Capsule - 2 Capsule(s) by mouth twice a day PANTOPRAZOLE [PROTONIX] - (Prescribed by Other Provider: [**First Name4 (NamePattern1) 10762**] [**Last Name (NamePattern1) 10763**]) - 40 mg Tablet, Delayed Release (E.C.) - 1 Tablet(s) by mouth twice a day PAROXETINE HCL [PAXIL] - (Prescribed by Other Provider) - 20 mg Tablet - 1 (One) Tablet(s) by mouth once a day ROSUVASTATIN [CRESTOR] - 5 mg Tablet - 1 Tablet(s) by mouth once a day Trazodone 50mg HS:prn Medications - OTC ASPIRIN - (Prescribed by Other Provider) - 81 mg Tablet, Delayed Release (E.C.) - Tablet(s) by mouth Discharge Medications: 1. Fenofibrate Micronized 145 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3 hours) as needed for pain. Disp:*64 Tablet(s)* Refills:*0* 3. Levemir 100 unit/mL Solution Sig: One (1) Subcutaneous twice a day: 12 UNITS in AM and 12 UNITS in PM while on TPN. 4. Novolog 100 unit/mL Solution Sig: ASDIR Subcutaneous ASDIR: sliding scale. 5. Lovaza 1 gram Capsule Sig: Two (2) Capsule PO twice a day. 6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 7. Paroxetine HCl 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Rosuvastatin 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 9. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. 10. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 11. Alum-Mag Hydroxide-Simeth 200-200-20 mg/5 mL Suspension Sig: 15-30 MLs PO TID (3 times a day) as needed for reflux. Disp:*1 month supply* Refills:*0* 12. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q8H (every 8 hours). Disp:*30 Capsule(s)* Refills:*0* 13. Zofran 4 mg Tablet Sig: 1-2 Tablets PO three times a day: has allergy to compazine. Disp:*30 Tablet(s)* Refills:*0* 14. total parenteral nutrition Sig: One (1) once a day for 2 weeks: Start at total volume per 24hr. Wean down gradually to total volume per 12hours. Vol 1400ml/d, Amino acids 80g/d, dextrose 320g/d, Fat 0g/d, NaCl 90, NaAc 0, NaPO4 10, KCl 60, KAc 0, KPO4 0, MgSO4 18, CaGlu 5. . Disp:*1 14* Refills:*0* Discharge Disposition: Home With Service Facility: Home Solutions Discharge Diagnosis: PRIMARY DIAGNOSES: - Acute pancreatitis from hypertriglyceridemia - Hypertriglyceridemia - Flash pulmonary edema SECONDARY DIAGNOSES: - Mild coronary artert disease - Non-alcoholic steatohepatitis - Anxiety - Psoriasis - Diabetes mellitus Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Abdominal exam: Vitals: Discharge Instructions: Dear Ms. [**Known lastname 10764**], You were admitted to the hospital for abdominal pain from acute pancreatitis that likely occurred because of a high blood levels of triglycerides. You had abdominal pain that was difficult to control on IV dilaudid and after 1 week of different combinations of dosage and timing, we had a pain management doctor see you. We followed his recommendations to start you on a PCA of dilaudid and start you on gabapentin for pain. You used the PCA of dilaudid for 1 day. Afterwards, we started giving you oral doses of hydromorphone for pain. You had a lot of nausea while you were in the hospital and we gave you zofran for nausea. We also gave you IV fluids to make sure you did not become dehydrated because of the pancreatitis and because you were not eating. We kept you on a plan to not feed you because of pain and nausea, but gave you total parenteral nutrition (TPN), which is nutrition through an IV, starting on [**2144-8-1**]. You were able to tolerate clear fluids without pain although you continued to have some nausea. You should continue to take your anti-nausea meds as needed prior to your meals. Try to stick with one type of clear (broth for example) that works for you, and drink small portions throughout the day. We made the following medication changes during this hospitalization: (1) For pain, please take dilaudid 2-4 mg q3 hours as needed for pain. Don't operate machinery or take this medication if you are sleepy. (2) We DECREASED levemir to 12 units in the morning and at night. (3) We INCREASED rosuvostatin to 10 mg daily. (4) We STARTED Zofran which you can take up to three times a day for nausea, especially around mealtimes. (5) We STARTED Gabapentin 300 mg three times a day to help you with pain control - do not take this medicine if you feel sleepy. (6) We STARTED TPN which is to ensure you have good nutrition while you are still having trouble eating. Followup Instructions: 1) Please follow up with your primary care physician [**8-10**] Monday at 1115 AM. 2) Please follow up with your gastroenterologist (Dr [**Last Name (STitle) 174**] on Wed [**8-12**] at 945 AM. Completed by:[**2144-8-8**]

[ "518.4", "577.1", "530.81", "696.1", "327.23", "V58.67", "799.02", "571.8", "276.2", "424.0", "300.01", "272.1", "414.01", "E935.2", "300.00", "577.0", "564.09", "250.82" ]

icd9cm

[ [ [] ] ]

[ "38.93", "99.15" ]

icd9pcs

[ [ [] ] ]

11133, 11178

4578, 8245

301, 307

11461, 11461

3944, 4555

13599, 13822

3313, 3487

9492, 11110

11199, 11313

8271, 9469

11635, 13576

3502, 3925

11334, 11440

1274, 1334

229, 263

335, 1255

11476, 11611

1356, 3116

3132, 3297

8,492

184,650

48515

Discharge summary

report

Admission Date: [**2117-4-16**] Discharge Date: [**2117-4-20**] Date of Birth: [**2038-9-24**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2485**] Chief Complaint: Altered mental status Major Surgical or Invasive Procedure: A-line placement Midline placement Mechanical ventilation via trach History of Present Illness: 78 yo woman with multiple medical problems including hypertension and diabetes mellitus and multiple recent hospitalizations who was admitted from [**Hospital 100**] Rehab with altered mental status. Patient had been discharged from [**Hospital1 18**] on [**2117-4-6**] after an admission for GI bleed. She was discharged to [**Hospital 100**] Rehab. While at [**Hospital 100**] Rehab her course was complicated by C. diff infection for which she was started on metronidazole. Her WBC continued to rise and she was started on vancomycin PO. On the morning of admission, patient was noted by her physician to be lethargic and she had an O2 sat of 93% on TM. Due to her altered mental status and rising WBCs, she was transferred to [**Hospital1 18**]. Upon arrival in the ED, temp 98.2, HR 95, BP 110/70, RR 20, and pulse ox 96% RA. While in the ED, her vital signs were notable for one blood pressure measured 72/47 but was 96/40 on recheck. Exam was unremarkable. She received vancomycin, zosyn, and metronidazole. Of note, she has had multiple recent hospital admissions. She was admitted in [**Month (only) 956**] was recently admitted to the intensive care unit from 4/9-14/09 with a lower GI bleed requiring 6 units pRBCs. No source of bleed was identified during angiography or colonoscopy, although her hematocrit remained stable after blood transfusions. Her warfarin was discontinued, and she was discharged to [**Hospital 100**] Rehab. Past Medical History: 1. Hypertension 2. Diabetes Mellitus 3. Breast Cancer - Infiltrating ductal carcinoma 4. Obstructive Sleep Apnea - s/p tracheostomy [**2089**] 5. Osteoarthritis 6. s/p multiple falls 7. Congestive Heart Failure 8. Atrial Flutter 9. Atrial Septal Defect 10. Mitral Regurgitation 11. Cor Pulmonale 12. s/p Stroke 13. Obesity 14. Spinal Stenosis 15. Lower GI bleed Social History: Normally lives at home, but has been at rehab since last hospitalization. Denies alcohol, drug or current tobacco use. Per her sister, she is a former smoker, but unclear what her pack year smoking history is. Family History: Diabetes mellitus. Physical Exam: On admission: Gen: tired appearing elderly female, obese, no acute distress, resting in bed HEENT: Clear OP, dry mucous membranes NECK: Supple, No LAD, No JVD CV: RR, NL rate. NL S1, S2. No murmurs, rubs or gallops LUNGS: CTA, BS BL, No W/R/C ABD: Obese, Soft, NT, ND. NL BS. No HSM EXT: No edema. 2+ DP pulses BL SKIN: No lesions NEURO: A&Ox3. Appropriate but lethargic. CN 2-12 grossly intact. 5/5 strength throughout. Normal coordination. Gait assessment deferred On discharge: Gen: increasingly alert, responding to simple commands HEENT: clear OP, moist mucous membranes NECK: supple; no LAD CV: RRR, normal S1/S2. LUNGS: clear to auscultation in anterior fields bilaterally EXT: 1+ pitting edema to knee bilaterally. L arm midline in place, non-erythematous and non-tender Pertinent Results: [**2117-4-16**] 01:00PM BLOOD WBC-36.3*# RBC-3.36* Hgb-9.6* Hct-33.0* MCV-98 MCH-28.7 MCHC-29.2*# RDW-16.1* Plt Ct-383# [**2117-4-18**] 04:10AM BLOOD Neuts-90.5* Lymphs-6.0* Monos-3.3 Eos-0 Baso-0.2 [**2117-4-16**] 01:00PM BLOOD Neuts-94.4* Lymphs-3.7* Monos-1.7* Eos-0.1 Baso-0.1 [**2117-4-16**] 09:10PM BLOOD Hypochr-2+ Anisocy-1+ Poiklo-1+ Macrocy-1+ Microcy-NORMAL Polychr-1+ Spheroc-OCCASIONAL Schisto-OCCASIONAL Burr-OCCASIONAL [**2117-4-16**] 01:00PM BLOOD PT-24.3* PTT-45.8* INR(PT)-2.4* [**2117-4-16**] 01:00PM BLOOD Glucose-95 UreaN-28* Creat-2.2*# Na-146* K-3.5 Cl-102 HCO3-36* AnGap-12 [**2117-4-16**] 01:00PM BLOOD Calcium-8.0* Phos-4.3 Mg-1.5* [**2117-4-16**] 01:00PM BLOOD ALT-9 AST-13 CK(CPK)-15* AlkPhos-93 TotBili-0.3 [**2117-4-16**] 01:00PM BLOOD ALT-9 AST-13 CK(CPK)-15* AlkPhos-93 TotBili-0.3 [**2117-4-17**] 03:16PM BLOOD CK(CPK)-31 [**2117-4-18**] 04:10AM BLOOD ALT-11 AST-17 CK(CPK)-22* AlkPhos-81 [**2117-4-16**] 01:00PM BLOOD cTropnT-0.13* [**2117-4-17**] 03:16PM BLOOD CK-MB-3 cTropnT-0.11* [**2117-4-18**] 04:10AM BLOOD CK-MB-3 cTropnT-0.10* [**2117-4-16**] 02:12PM BLOOD Type-ART pO2-70* pCO2-67* pH-7.33* calTCO2-37* Base XS-5 Intubat-NOT INTUBA [**2117-4-17**] 06:59AM BLOOD freeCa-1.13 [**2117-4-16**] 05:20PM URINE Color-Amber Appear-Cloudy Sp [**Last Name (un) **]-1.022 [**2117-4-16**] 05:20PM URINE Blood-MOD Nitrite-NEG Protein-100 Glucose-NEG Ketone-15 Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-MOD [**2117-4-16**] 05:20PM URINE RBC-[**11-12**]* WBC->50 Bacteri-MOD Yeast-NONE Epi-[**6-2**] TransE-2 RenalEp-3 [**2117-4-16**] 5:20 pm URINE CULTURE (Final [**2117-4-18**]): KLEBSIELLA PNEUMONIAE. >100,000 ORGANISMS/ML. Sensitive to ceftriaxone CT abdomen and pelvis ([**4-16**]) 1. Tiny bilateral effusions and left basilar atelectasis. 2. Cardiomegaly. 3. Distended gallbladder. Clinical correlation is recommended, and an ultrasound can be obtained for further evaluation. 4. Right adrenal nodule not meeting CT criteria for an adenoma. MRI could be performed for further evaluation. 5. Vascular calcifications. 6. Diverticulosis without evidence of acute diverticulitis. Evaluation for colitis is limited without the administration of oral or IV contrast, however, mild diffuse pericolonic fat stranding is seen, which may suggest an underlying colonic process. 7. Diffuse anasarca. CT Head ([**4-16**]): IMPRESSION: No evidence of acute hemorrhage. Brief Hospital Course: 78 yo woman with history of multiple medical problems including type 2 diabetes mellitus, hypertension, obstructive sleep apnea s/p trach placement, and breast cancer was admitted with leukocytosis most likely related to C. diff and acute renal failure. # C diff: She was found to be c diff positive at [**Hospital 100**] Rehab. She was afebrile overnight and her white count continued to trend down. She was treated with IV metronidazole and po vancomycin with plan to complete 14 day course after last dose of antibiotics for UTI, last dose on [**2117-5-8**]. We have switched the PPI to H2 blocker due to increased risk of C dif with PPI. # Klebsiella UTI: Sensitive to Ceftriaxone. Plan for 7-day course of ceftriaxone, last dose on [**2117-4-24**]. # Hypotension: Pt dropped SBP to high 70s responding to repeated fluid bolus; baseline BPs 110-130s. Cardiac enzymes negative. Concern for sepsis. Given borderline need for pressor, given FFP for INR 2.4 prior to placement of RIJ and A-line on [**4-17**]. However, not started on pressors despite poor urine output not responding to fluids with CVP >10 as MAPs stayed above 60 overnight. Subsequently remained hemodynamically stable with improving urine output. # Hypercarbic respiratory failure: Patient has been trach dependent since [**2087**]. Could be secondary to mental status with neuromuscular component from obesity, OSA, and deconditioning. Pt placed on vent during hospitalization with attempt made to wean off; able to tolerate trach collar for most of day but placed back on pressure support overnight. # AMS: Patient??????s mental status is improved, unclear what her true basline is. Pt more responsive to family than physicians and thus it is difficult to access her mental status. Patient opens her eyes to commands and is able to move her distal extremities. [**Month (only) 116**] have resulted from hypercarbia, UTI or C. diff infection. # Acute Renal Failure: H/o CRF [**1-25**] hypertensive nephrosclerosis with atrophic left kidney. Likely pre-renal from C. diff colitis as well as with klebsiella UTI. Resolving with fluids and antibitoics. # Hypernatremia: Resolved with free water boluses via OG tube. # H/o Breast Cancer: Intially held arimidex given pt was on vent and not taking POs. Can restart at rehab. # Type 2 Diabetes Mellitus: Patient has a history of T2DM and was only on insulin sliding scale. Continued on humalog sliding scale in-house with good glycemic control. # GERD: Stable on PPI. # Hyperlipidemia: Stable on simvastatin # Atrial Fibrillation: She was recently restarted on coumadin after her recent admission for GI bleed. Coumadin was held during this admission due to supratherapeutic levels. Her INR on day of discharge is 4.2 and we have not restarted coumadin. # FEN: Lytes repleted prn. Should consider adding nutritional supplements to her meals, and consider calorie count at rehab. # Stage II sacral decub: Monitored. Medications on Admission: 1. Acetazolamide 250mg PO bid 2. Arimidex 1mg PO daily 3. Calcitriol .25mcg PO daily 4. D5 1/2 NS at 50mL / hour x 1 L 5. Insulin sliding scale 6. Ipratropium 2 puffs q6h inh 7. Lactobacillus 2 tab PO bid 8. Metronidazole 500mg PO tid (Day 1 - [**2117-4-14**]) 9. Omeprazole 20mg PO bid 10. Potassium Chloride 20mEq daily 11. Simvastatin 10mg Po daily 12. Vancomycin 125mg PO qid (Day 1 - [**2117-4-16**]) 13. Coumadin 5mg PO daily 14. Tylenol prn 15. Albuterol prn 16. Epi neb prn 17. Ondansetron 4mg PO q8h prn 18. Nystatin topical cream prn . Discharge Medications: 1. Vancomycin 125 mg Capsule Sig: One (1) Capsule PO every six (6) hours: Last dose [**2117-5-8**]. 2. MetRONIDAZOLE (FLagyl) 500 mg IV Q8H 3. Insulin Lispro 100 unit/mL Solution Sig: One (1) Subcutaneous ASDIR (AS DIRECTED). 4. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed. 5. Ceftriaxone in Dextrose,Iso-os 1 gram/50 mL Piggyback Sig: One (1) Intravenous Q24H (every 24 hours): Last dose on [**4-24**]. 6. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Nystatin 100,000 unit/g Cream Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day). 8. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q6H (every 6 hours) as needed for Q4 PRN. 9. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: 1-2 Puffs Inhalation Q4H (every 4 hours) as needed. 10. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours). 11. Anastrozole 1 mg Tablet Sig: One (1) Tablet PO daily (). 12. Ondansetron HCl (PF) 4 mg/2 mL Solution Sig: One (1) Injection Q8H (every 8 hours) as needed. Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - MACU Discharge Diagnosis: Primary diagnosis: - C. difficile colitis - Klebsiella urinary tract infection - Altered mental status - Acute renal failure - Discharge Condition: Stable Discharge Instructions: You were admitted for altered mental status requiring admission to the ICU. You were noted to have worsening of kidney function. These all improved with treatment of C. difficle and urinary tract infection as well as IV fluids. You needed to be ventilated for low oxygen, thought to be due to your altered mental status in the setting of chronic obstructive sleep apnea and obesity. This is improving at the time of your discharge. The following changes were made to your medications: - Vancomycin and intravenous flagyl for C. difficile diarrhea - Ceftriaxone for urinary tract infection Followup Instructions: Please follow up with your PCP at [**Hospital 100**] Rehab Completed by:[**2117-4-20**]

[ "V12.54", "403.90", "585.9", "518.84", "041.3", "715.90", "427.32", "458.9", "276.0", "424.0", "599.0", "428.0", "V15.88", "V44.0", "327.23", "707.03", "008.45", "278.00", "250.00", "745.5", "707.22", "584.9" ]

icd9cm

[ [ [] ] ]

[ "96.71" ]

icd9pcs

[ [ [] ] ]

10415, 10481

5782, 8731

337, 406

10652, 10661

3350, 5759

11299, 11389

2514, 2534

9328, 10392

10502, 10502

8757, 9305

10685, 11276

2549, 2549

3031, 3331

276, 299

434, 1883

10521, 10631

2563, 3017

1905, 2269

2285, 2498

55,901

119,641

42713

Discharge summary

report

Admission Date: [**2102-1-19**] Discharge Date: [**2102-1-31**] Service: MEDICINE Allergies: Codeine / fentanyl / Sulfa(Sulfonamide Antibiotics) / Penicillins / Zithromax / Cephalexin / Levaquin / Zocor / Cipro / Darvon / Zovirax / Septra Attending:[**Male First Name (un) 4578**] Chief Complaint: cold right foot Major Surgical or Invasive Procedure: [**2102-1-20**] Angiography, Right External Iliac Artery Stent placement, Right Superficial Artery Stent placement x3 History of Present Illness: [**Age over 90 **] year old female with history dementia and PVD s/p LLE bypass 2 years ago, now being transferred from [**Hospital3 **] Hospital with a painful cold right foot for the past 2 days. She started with right foot pain 2 days ago and then started to look progressively worse with cyanosis and cold. She had a similar situation on the left foot 2 years ago and underwent a LLE bypass at [**Hospital3 **] Hospital. Has a history of paroxysmal a.fib, but has been on sinus rythm here and at [**Hospital3 **]. She walks with a walker at baseline and also uses wheelchair when she goes to church. She has been able to move her toes with mild weakness and feels mild numbness as well. Past Medical History: Past Medical History: PVD, CAD s/p cardiac stents [**2092**], HTN, dementia, recent GI bleed, h/o R hip fx 3 years ago, h/o colonic polyps, diverticular disease, hypothyroidism, hyperlipidemia, chronic constipation, CHF, h.o gastric angioectasias, h/o ischemic colitis, osteoporosis, GERD, ARF, paroxysmal a.fib Past Surgical History: Left carotid stent, TAH, open CCY, tonsillectomy, LLE bypass 2 years ago Social History: Social History: Retired, lives at home with husband across the street from his son's house. Denies any tobacco or EtOH use. Family History: NC Physical Exam: At admission: Physical Exam: Vitals: T 99.2 HR 101 BP 149/119 RR 18 SO2 95% GEN: A&Ox3, 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: Soft, nondistended, nontender, no rebound or guarding, normoactive bowel sounds, no palpable masses DRE: normal tone, no gross or occult blood Ext: No LE edema. Right foot cyanotic, colder than left foot, with mild weakness and numbness. No signals. Pulses: Fem [**Doctor Last Name **] DP PT graft Left 2+ 1+ 1+ dop 2+ Right 1+ dop - - Discharge Exam: General: waking; oriented to person, slightly tachypneic but overall improved work of breathing HEENT: Sclera anicteric, dry MM, oropharynx clear Neck: supple, JVP elevated above clavicle though difficult to assess with mask on CV: irreg irreg, normal S1 + S2, 3/6 systolic murmur Lungs: decreased BS at bases bilaterally with crackles, good aeratin Abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly Ext: warm, faint DP pulses bilaterally with 1+ edema to midshin, no calf tenderness, groin sites without hematoma Neuro: moving all extremities, toes downgoing Pertinent Results: ADMISSION LABS: [**2102-1-19**] 08:30PM BLOOD WBC-8.0 RBC-4.53 Hgb-14.0 Hct-40.9 MCV-90 MCH-30.9 MCHC-34.3 RDW-14.1 Plt Ct-308 [**2102-1-19**] 08:30PM BLOOD PT-11.7 PTT-31.9 INR(PT)-1.1 [**2102-1-19**] 08:30PM BLOOD Glucose-102* UreaN-35* Creat-1.3* Na-139 K-5.0 Cl-106 HCO3-21* AnGap-17 [**2102-1-21**] 03:43AM BLOOD WBC-10.1 RBC-3.95* Hgb-12.4 Hct-35.6* MCV-90 MCH-31.3 MCHC-34.8 RDW-13.9 Plt Ct-257 [**2102-1-21**] 12:25PM BLOOD Glucose-149* UreaN-24* Creat-1.4* Na-139 K-3.7 Cl-104 HCO3-26 AnGap-13 . DISCHARGE LABS: [**2102-1-29**] 06:34AM BLOOD WBC-8.2 RBC-3.44* Hgb-10.5* Hct-31.2* MCV-91 MCH-30.5 MCHC-33.7 RDW-15.3 Plt Ct-289 [**2102-1-31**] 04:57AM BLOOD Glucose-89 UreaN-31* Creat-1.5* Na-144 K-3.3 Cl-105 HCO3-28 AnGap-14 [**2102-1-31**] 04:57AM BLOOD Calcium-7.9* Phos-3.0 Mg-1.9 [**2102-1-28**] 05:55PM BLOOD Triglyc-243* HDL-26 CHOL/HD-7.7 LDLcalc-126 LDLmeas-134* [**2102-1-29**] 06:34AM BLOOD %HbA1c-6.2* eAG-131* . TTE: The left atrium is normal in size. The estimated right atrial pressure is at least 15 mmHg. There is mild-moderate symmetric left ventricular hypertrophy. The left ventricular cavity is unusually small. Left ventricular systolic function is hyperdynamic (EF>75%). The right ventricular cavity is mildly dilated 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). Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is severe mitral annular calcification. There is mild-moderate functional mitral stenosis (mean gradient 6 mmHg) due to mitral annular calcification. Moderate [2+] tricuspid regurgitation is seen. There is severe pulmonary artery systolic hypertension. There is a trivial/physiologic pericardial effusion. IMPRESSION: Mild-moderate symmetric left ventricular hypertrophy with hyperdynamic left ventricular function and no LVOT gradient at rest. Mild aortic stenosis and regurgitation. Mild-moderate functional mitral stenosis. Severe pulmonary artery systolic hypertension. Left pleural effusion. Brief Hospital Course: Ms. [**Known lastname 6632**] is a [**Age over 90 **]yo F with extensive PVD, CAD, dCHF (EF~75%), paroxysmal a-fib (not on coumadin), and CKD who presented with an ischemic RLE POD from angiography, angioplasty, and stenting on [**2102-1-20**] transferred to the ICU in setting of Afib with RVR. Patient was found to have pulmonary edema and was subsequently diauresed to euvolemia with return of NSR. . # Ischemic Right Foot The patient was admitted to the vascular surgery service under Dr. [**Last Name (STitle) 1391**] on [**2102-1-19**] after being transferred from an OSH with a cold right foot. The patient was premedicated for angiography that was performed on [**2102-1-20**]. The patient was found to have an occluded right external iliac artery that was then stented. The patient's right superficial femoral artery was also stented x3. The patient's sedation was lightened on POD 1 and the patient was extubated. The patient tolerated the extubation well. The patient was then transferred to the VICU for continued monitoring. The patient was started on plavix and kept on her home dose full aspirin. . # Acute on Chronic Kidney Failure On POD 3 the patient's foley was removed. The patient failed to void and replacement of foley catheter yielded 40 cc of urine. Patient was bolused with IVF and urine lytes showed a FeNa of 0.2. On POD 4 the patient was oliguric despite fluid boluses. DDx includes ATN vs. CIN vs poor forward flow in setting of volume overload. Pt was hypotensive post-op predisposing to ATN and also received dye load in setting of angiography making CIN possible. The fluid boluses likely exacerbated patient's underlying heart failure leading to poor forward flow, evidenced by the fact that patient's kidney injury improved with aggressive diuresis. Patient was diuresed and had improvement in her creatinine near her base line of 1.4-1.6. . # Respiratory distress: MICU was consulted for respiratory distress that developed on POD 5 with oxygen saturations dropping into the high 80s, and using accessory breathing muscles. An echo was performed that showed severe pulmonary hypertension but no evidence of right ventricular strain. The patient was stablizied on a face mask at FiO2 35% with oxygen saturations in the mid 90s. There was strong suspicsion for PE given her S1Q3T3, troponin elevation, new Chest X ray findings demonstrating pulmonary arterial hypertension though V/Q scan was very low likelihood. Her respiratory distress was ultimately felt to be from pulmonary edema and patient's hypoxia resolved with diuresis. Patient responded well to 80 mg torsemide which was held at the time of discharge as the cause of her edema was felt to be largely iatrogenic and did not respresent a need for on-going diuresis. . # Afib with RVR Patient developed Afib with RVR on POD 5 with pressures transiently in the 60s. The rhythm did not respond to IV lopressor so patient was transferred to the MICU for further management. Trigger for dysrrhytmia likely enlarged right atrium in the setting of heart failure as well as beta-blocker withdrawal. Additional etiology could have been PE, however patient had been systemically anticoagulated peri-procedure and placed on ppx SQ heparin post-procedure. Patient was successfully rate controlled on a diltiazem drip and gradually transitioned to an oral regimen. She spontaneously converted to sinus and was restarted on her home dose of labetalol. She will not be discharged on coumadin in agreement with family goals of care as the patient has had GI bleed requiring transfusion in the past. Stroke prophylaxis will be aspirin and Plavix which she will require for her femoral stent. . # Urinary Tract Infection: UA and urine culture revealed evidence of an infection later found to be E.coli sensitive to ceftriaxone. Patient completed a three day course of ceftriaxone on [**1-28**]. . # Nutrition: Speech and swallow evaluated patient and initially she seemed to lethargic to safely swallow. A Dobhoff was placed to initiate tube feeds but patient self-discontinued this. She subsequently passed repeat speech and swallow evaluation so her diet was advanced to thickened liquids and soft foods. . # Dementia/Delirum: Responded well to low-dose zyprexa. Benzos and sedating medications were avoided. . # CAD: Continued on ASA. Imdur and labetolol initially held for low blood pressures but gradually restarted. Lisinopril was held in the setting of [**Last Name (un) **]. This may be restarted as an outpatient. . # Hypothyroidism: - continue levothyroxine . # CODE: FULL . TRANSITIONAL ISSUES -Anticoagulation: Per vascular, patient will need to be on aspirin and plavix for her right foot. Whether patient would benefit from coumadin for her paroxysmal atrial fibrillation/flutter should be addressed with her PCP. [**Name10 (NameIs) **] does have diverticula and a history of GI bleeds, so the risks and benefits should be weighed. -patient is currently a full code, given her comorbidities this issue should continue to be readdressed with her family. -If hypoxic would restart torsemide 80 mg. - Lisinopril is being held secondary to acute kidney injury. This may need to be restarted as an outpatient. Medications on Admission: vicodin q4hrs prn nitroquick 0.4 mg ativan 0.5 qhs and prn cymbalta 20 daily senna daily prn constipation acidiphilous 1 tab qd tylenol 650 prn pain fish oil isosorbide mononitrate 60 daily lisinopril 10 daily mvi calcium-vit D 600-200 [**Hospital1 **] labetalol 50 [**Hospital1 **] synthroid 75 daily prilosec 20 [**Hospital1 **] Discharge Medications: 1. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 2. isosorbide mononitrate 60 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily). 3. levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. duloxetine 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 5. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day. 7. docusate sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2 times a day). 8. methyl salicylate-menthol Ointment Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day) as needed for back pain. 9. labetalol 100 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 10. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO BID (2 times a day). 11. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Disposition: Extended Care Facility: Eagle [**Hospital **] Rehabilitation Center - [**Location 23723**] Discharge Diagnosis: PRIMARY Right lower extermity ischemia Pulmonary Edema Acute on chronic diastolic heart failure Urinary tract infection Atrial fibrillation with rapid ventricular response SECONDARY: -peripheral vascular disease -coronary artery disease -hypertension -dementia -hypothyroidism -hyperlipidemia -gastric angioectasias -ischemic colitis -osteoporosis -GERD Discharge Condition: Mental Status: Confused - always. 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 while you were in the hospital. You were initially admitted to Vascular Surgery for stenting and angioplasty of your right leg. You tolerated this procedure well and had improvement in your circulation. Post-operatively you had worsening kidney function and were given fluids due to the poor function of your heart you developed a syndrome called pulmonary edema which means fluid in the lungs. You were then transfered to cardiology for treatment of your heart failure and abnormal heart rhythm. Your heart rhythm ultimately returned to [**Location 213**] and you were discharged to a rehab hospital to continue to regain your strength. The following changes were made to your medications: -START Aspirin 325 mg daily -START Clopidogrel 75 mg daily -STOP Lisinopril 10 mg daily -CONTINUE Tylenol 650 mg three times a day as needed for pain -CONTINUE Bengay as needed for back pain -CONTINUE Atorvastatin 80 mg daily -CONTINUE Duloxetine 20 mg daily -CONTINUE Isosorbide Mononitrate 60 mg daily -CONTINUE Levothyroxine 75 mcg daily -CONTINUE Labetalol 50 mg twice daily -CONTINUE Omeprazole 20 mg daily -CONTINUE calcium-vit D 600-200 mg twice daily Division of Vascular and Endovascular Surgery Lower Extremity Angioplasty/Stent Discharge Instructions ?????? 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 [**1-6**] pillows or a recliner) every 2-3 hours throughout the day and at night ?????? Avoid prolonged periods of standing or sitting without your legs elevated ?????? 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 [**Month/Day (3) **] an appointment to be seen in [**2-5**] 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: Please call Dr.[**Name (NI) 1392**] office ([**Telephone/Fax (1) 4852**] to [**Telephone/Fax (1) **] a follow up appointment in [**2-5**] weeks. Please call you primary care doctor [**First Name (Titles) **] [**Last Name (Titles) **] a follow up appointment about a week after you are discharged from rehab. [**Last Name (un) **],CORMAC F. [**Telephone/Fax (1) 14888**]

[ "294.20", "427.31", "E879.8", "272.4", "733.00", "V45.82", "244.9", "447.0", "584.8", "041.49", "416.8", "428.33", "564.00", "440.4", "414.01", "585.3", "403.90", "530.81", "458.9", "276.0", "443.29", "E849.7", "428.0", "427.32", "599.0", "998.2", "440.20" ]

icd9cm

[ [ [] ] ]

[ "00.41", "39.50", "38.97", "96.6", "00.60", "00.48", "88.42" ]

icd9pcs

[ [ [] ] ]

11715, 11808

5142, 10346

374, 494

12207, 12207

3020, 3020

15946, 16320

1807, 1811

10727, 11692

11829, 12186

10372, 10704

12384, 15349

15375, 15923

3541, 5119

1574, 1649

1855, 2393

2409, 3001

318, 336

522, 1215

3036, 3525

12222, 12360

1259, 1550

1681, 1791

13,606

130,112

22981

Discharge summary

report

Admission Date: [**2172-1-19**] Discharge Date: [**2172-1-26**] Date of Birth: [**2139-9-9**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 5880**] Chief Complaint: S/p ATV accident, transferred from [**Hospital 8641**] Hospital. Major Surgical or Invasive Procedure: [**2172-1-19**] Left chest thoracostomy History of Present Illness: Pt. is a 32-year-old male who was driving his ATV at moderate speed and hit a tree. The patient had loss of consciousness at the scene. Past Medical History: Multiple prior left shoulder injuries s/p orthopedic repair. Hepatitis C Cirrhosis R hand surgery Depression Poly-substance abuse Social History: + cocaine abuser + alcohol use, unknown quantity, unknown frequency + smoker, 19 pack-years Family History: Non-contributory Physical Exam: V/S: 100.2F 113 150/85 17 100%RA Gen - moderate distress HEENT - NC/AT, TMs clear bilat., PERRL/EOMI bilat., midline trachea, no rhinorrea, soft neck Skin - L medial thigh - old ecchymosis Cor - RRR, no JVD Pulm - equal chest rise, equal breath sounds bilat. CT in place on L side, no crepitus, no flail segment [**Last Name (un) **] - +BS soft Rectal - good tone, no gross blood, normal prostate position Pelvis - stable PVasc - palp. pulses throughout, good cap. refill. Musc/Skel - L arm limited ROM, all other sites full ROM Neuro - grossly intact, L hand and forearm intact Pertinent Results: [**2172-1-19**] 10:20PM URINE bnzodzpn-POS barbitrt-NEG opiates-POS cocaine-POS amphetmn-NEG mthdone-NEG Brief Hospital Course: The patient sustained the following injuries: L scapula and glenoid fossa fracture, comminuted L ribs [**3-31**] fracture L hemopneumothorax s/p chest tube placement, with 400cc output initially He was admitted to the trauma ICU on HD#1. He was hemodynamically stable overnight. Pain was controlled with a hydromorphone PCA. On HD#2, a thoracic level epidural was placed by the Acute Pain Service for optimal pain control. The patient was seen by the Orthopedic service. The recommended non-operative management for the patient's L shoulder fractures. A sling was provided from comfort. The patient was seen by the Substance Abuse team of social workers throughout his hospital course. On HD#3, the patient underwent CT of the thoracic, lumbar and sacral spine, which revealed no fractures. His entire spine was then able to be cleared. On HD#4, he was seen by the Physical Therapy department and was cleared for home dismissal. On HD#5, the thoracic epidural was removed and the patient was transitioned to oral pain medications. On HD#6, the patient's chest tube was removed. On HD#7, the patient's pain control regimen was optimized in anticipation of discharge. The patient was discharged home on HD#8 in good condition. He is to follow up in [**Hospital **] Clinic with Dr. [**Last Name (STitle) 2719**] in 2 weeks. He is to follow up in Trauma clinic in 2 weeks with Dr. [**Last Name (STitle) **]. Medications on Admission: oxycodone prn Discharge Medications: 1. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 3. Oxycodone 5 mg Tablet Sig: Three (3) Tablet PO Q3H (every 3 hours) as needed for pain. Disp:*80 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: s/p ATV crash Left comminuted left scapular fracture Left rib fractures [**3-31**] Left pneumothorax Discharge Condition: Stable Discharge Instructions: Return to the Emergency room if you develop any fevers, chills, chest pain, increased shortness of breath, nausea, vomiting, diarrhea and/or any other symptoms that are concerning to you. Followup Instructions: Follow up with Dr. [**Last Name (STitle) 2719**], Orthopeidcs in 2 weeks. Call [**Telephone/Fax (1) 1228**] for an appointment. Follow up in Trauma Clinic in 2 weeks, call [**Telephone/Fax (1) 6429**] for an appointment. Completed by:[**2172-1-26**]

[ "070.70", "811.03", "571.5", "E823.0", "860.4", "807.08", "807.4" ]

icd9cm

[ [ [] ] ]

[ "34.04", "03.90" ]

icd9pcs

[ [ [] ] ]

3468, 3474

1627, 3041

378, 420

3619, 3628

1497, 1604

3864, 4117

864, 882

3105, 3445

3495, 3598

3067, 3082

3652, 3841

897, 1478

274, 340

448, 585

607, 739

755, 848

27,900

131,172

1108

Discharge summary

report

Admission Date: [**2108-6-23**] Discharge Date: [**2108-6-24**] Service: MEDICINE Allergies: No Drug Allergy Information on File Attending:[**First Name3 (LF) 443**] Chief Complaint: Chest Pain Major Surgical or Invasive Procedure: central line change over a wire-- triple lumen catheter to swan ganz catheter History of Present Illness: Pt is an 87 yo M with h/o severe 3 vessel CAD per cath in [**2094**] (50% LMCA stenosis, LCx 90% stenosis, prox RCA occlusion, prox LAD occlusion), s/p CABG in [**2094**] (LIMA -> LAD, SVG -> PDA, SVG -> OM), moderate AS (grad 30), CKD who presents from an OSH with episode of chest pain. Patient developed SSCP with radiation to his arms on the day of admission x2-3hrs, and had n/diarrhea 1 day prior. Pt was given nitro x3 without relief but CP resolved spontaneously. EKG in the ED showed ST depr anterolaterally, with ST elevations in V1-2, stable on repeat EKGs. Pt was given ASA, plavix, heparin gtt and treated for NSTEMI. Per report, Pt subsequently went into VF arrest on the night PTA, was shocked (50J ?)and started on Amio gtt (no rhytm strips). Post arrest Pt required pressor support with neo/dopa. With concern for aspiration the patient was intubated. CK was 1390, MP 290, TropI 9 ->21 ->60 . Pt also spiked fever to 101.5, concerning for aspiration PNA for which he was started on broad spectrum antibiotics. On transfer his BP was 100 sys, HR 80s, adequate UOP. . On arrival to [**Hospital1 18**], patient was intubated and sedated and unable to provide history . Unable to obtain ROS given patient is intubated and sedated Past Medical History: 1. CAD: diffuse 3 vessel disease per cath in [**2094**] (see below) s/p 3 vessel CABG (LIMA -> LAD, SVG -> PDA, SVG -> OM). 2. Moderate AS with mean gradient 30mmhg, ECHO [**9-22**] EF 45%, 3. CKD, baseline around 2.5 4. Hyperlipidemia 5. DM2 6. Chronic anemia 7. Glaucoma Social History: Married, lives with wife in [**Name (NI) 7168**]. Works about 25hrs/week at race track in [**Location (un) 5165**]. Quit smoking a few yrs ago (1 ppd x 20yrs). No EtOH or recreational drugs. Family History: Family history notable for father with MI at 67yrs old. Mother died at 67 yrs old with DM2 Physical Exam: VS: T 99.5, BP 113/54, HR 112, RR 16, O2 100% on AC Gen: Intubated, sedated, unresponsive HEENT: Eyes slightly deviated laterally. Cataracts appreciated, anicteric sclera Neck: Supple, RIJ intact, difficult to appreciate JVP CV: Tachy, regular 3/6 SEM heard best at base Chest: Symmetric movement bilat. Clear ant/lat with mechanical sounds, decr at bases Abd: soft NT/ND + BS Ext: Ext cool. Pulses dopplerable, no pitting edema Skin: No stasis dermatitis, ulcers, scars, or xanthomas. Pertinent Results: ADMISSION LABS: [**2108-6-23**] 07:19PM BLOOD WBC-18.1* RBC-3.38* Hgb-11.3* Hct-34.5* MCV-102* MCH-33.4* MCHC-32.8 RDW-14.1 Plt Ct-145* [**2108-6-24**] 06:15AM BLOOD Neuts-86* Bands-0 Lymphs-9* Monos-5 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 [**2108-6-23**] 07:19PM BLOOD PT-16.7* PTT-150* INR(PT)-1.5* [**2108-6-23**] 07:19PM BLOOD Glucose-207* UreaN-59* Creat-3.4* Na-138 K-4.4 Cl-103 HCO3-19* AnGap-20 . [**2108-6-23**] 07:19PM BLOOD CK-MB-181* MB Indx-17.0* cTropnT-6.52* [**2108-6-23**] 07:19PM BLOOD ALT-32 AST-164* LD(LDH)-803* CK(CPK)-1066* AlkPhos-69 TotBili-0.4 [**2108-6-24**] 06:15AM BLOOD CK-MB-125* MB Indx-16.6* cTropnT-6.63* [**2108-6-24**] 06:15AM BLOOD CK(CPK)-754* . [**2108-6-23**] 07:57PM BLOOD Type-ART pO2-131* pCO2-36 pH-7.31* calTCO2-19* Base XS--7 [**2108-6-23**] 07:57PM BLOOD Lactate-2.3* . CXR [**2108-6-23**]: Mild-to-moderate CHF. Brief Hospital Course: 87 yo M with CAD s/p CABG, DM2, dyslipidemia presenting from OSH after chest pain/NSTEMI complicated by cardiac arrest and aspiration event. The patient had rising cardiac enzymes and EKG changes concerning for NSTEMI at the outside hospital. By arrival at [**Hospital1 18**], cardiac enzymes had peaked but the EKG changes were persistent. He was treated medically for his CAD with ASA, Plavix, heparin and high dose statin. Plans for eventual coronary angiography after initial stabilization were made and discussed with interventional attending, Dr. [**Known firstname 122**] [**Last Name (NamePattern1) **] on the night of transfer. . The patient had mildly depressed EF per past ECHO with valvular abormalities. CXR was suggestive of edema. He was clinically cool and hypotensive requiring pressor support, which was suggestive of cardiogenic shock. A Swan Ganz catheter was placed for improved hemodynamic monitoring. . The patient was stable overnight. The morning following admission, ventricular tachycardia ensued, and rapidly degenerated into ventricular fibrillation. ACLS protocols were instituted immediately, and followed for 35 minutes, with multiple attempts and defibrillation, as well as administration of large doses of epinephrine, sodium bicarbonate, amiodarone, vasopressin and atropine. Despite these attempts, a perfusing rhythm could not be reestablished, and the patient expired. The patient's attending physician was present for the code at bedside. The patient's family was notified by telephone and they subsequently came to the hospital. . Medications on Admission: Medications Outpatient: Lasix 40mg daily Toprol XL 50mg daily ASA 81mg daily Niaspan 26mg daily Zocor 80mg daily . Medications on transfer: Dopamine 7.5 Heparin 1300 units/hr Lasix 20mg/hr Amio 0.5mg/min Versed prn Plavix 75mg daily tylenol 325-650 q4-6 RISS Metoprolol 2.5mg IV q6 Imipenem 250mg q12 ASA 325mg daily Albuterol/Ipratropium Vanco 1g q48hrs . ALLERGIES: NKDA Discharge Medications: Not applicable Discharge Disposition: Expired Discharge Diagnosis: Ventricular Tachycardia --> Ventricular Fibrillation arrest non-ST elevation myocardial infarction coronary artery disease diabetes dyslipidemia chronic kidney disease Discharge Condition: Expired Discharge Instructions: Not applicable Followup Instructions: Not applicable

[ "585.3", "507.0", "427.1", "785.51", "250.00", "410.71", "414.01", "427.41" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

5660, 5669

3621, 5198

253, 332

5880, 5889

2737, 2737

5952, 5969

2124, 2216

5621, 5637

5690, 5859

5224, 5339

5913, 5929

2231, 2718

203, 215

360, 1604

2753, 3598

5364, 5598

1626, 1900

1916, 2108

64,384

140,458

42782

Discharge summary

report

Admission Date: [**2153-2-22**] Discharge Date: [**2153-2-27**] Date of Birth: [**2090-3-20**] Sex: M Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 1505**] Chief Complaint: mitral regurgitation Major Surgical or Invasive Procedure: mitral valve repair (36mm annuloplasty ring) History of Present Illness: The patient is a 63-year-old male who has a known history of mitral valve prolapse and regurgitation. He is having worsening symptoms and changing the dimensions, presenting for mitral valve repair. Past Medical History: hypertension Social History: Last Dental Exam:>1 year ago, will call to set up an appointment with Dentist and have clearance faxed to office Lives with:Wife Contact: [**Name (NI) 1439**] (wife) Phone #[**Telephone/Fax (1) 92431**] Occupation:Works as accountant at Fidelity Cigarettes: Smoked no [x] yes [] Other Tobacco use:denies ETOH: [**12-4**] glasses of wine/week Illicit drug use:denies Family History: Family History:Premature coronary artery disease- Father had a CVA in his 70's Race:Caucasian Physical Exam: Pulse:68 Resp:18 O2 sat:98/RA B/P 139/95 Height:5'1" Weight:168 lbs General: Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [] Chest: Lungs clear bilaterally [x] decreased left base, scattered crackles Heart: RRR [x] Irregular [] Murmur [x] grade IV/VI Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Extremities: Warm [x], well-perfused [x] Edema [x] 2+ bilaterally 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:cath site Left:2+ Carotid Bruit Right:none Left:none Pertinent Results: [**2153-2-27**] 04:50AM BLOOD WBC-9.1 RBC-3.58* Hgb-10.4* Hct-33.7* MCV-94 MCH-29.0 MCHC-30.9* RDW-13.0 Plt Ct-250# [**2153-2-27**] 04:50AM BLOOD Plt Ct-250# [**2153-2-27**] 04:50AM BLOOD PT-23.5* PTT-30.8 INR(PT)-2.2* [**2153-2-26**] 12:40PM BLOOD PT-20.3* PTT-30.7 INR(PT)-1.9* [**2153-2-25**] 04:40AM BLOOD PT-11.7 INR(PT)-1.1 [**2153-2-27**] 04:50AM BLOOD Glucose-132* UreaN-15 Creat-0.9 Na-135 K-4.0 Cl-100 HCO3-27 AnGap-12 [**2153-2-27**] 04:50AM BLOOD Mg-2.0 TECHNIQUE: MRI brain, MRA brain and neck. INDICATION: 62-year-old man. Evaluate for stroke. COMPARISON: None. FINDINGS: There are areas of slow diffusion involving the right PCA territory in the right occipital lobe and right genu of the corpus callosum. There are also areas of slow diffusion in the superior aspect of the right frontal lobe and right parietal lobe in a watershed distribution. There is corresponding increased T2, FLAIR signal. There is no evidence of susceptibility artifact to represent hemorrhagic transformation. There is mild mass effect over the occipital [**Doctor Last Name 534**] of the right lateral ventricle. The major intracranial flow voids are preserved. Incidentally noted there is a cavum septum pellucidum. The orbits are within normal limits. There is a mucus retention cyst in the right posterior ethmoid air cells, otherwise the paranasal sinuses are unremarkable. MRA CIRCLE OF [**Location (un) **]: The internal carotid arteries, ophthalmic arteries, anterior, middle and posterior cerebral arteries are normal in course and caliber. The vertebral arteries are codominant. The basilar artery appears to terminate as superior cerebellar arteries. There are prominent bilateral posterior communicating arteries which may represent persistent fetal circulation. MRA NECK: The left common carotid artery arises from the right brachiocephalic trunk representing a bovine arch. There is a questionable mild narrowing at the origin of the right vertebral artery. The origin of the right common carotid, left common carotid, bilateral subclavian and vertebral arteries are patent. The common carotid arteries are normal in course and caliber without evidence of bifurcation disease. The internal carotid arteries are normal in course and caliber. The external carotid arteries are normal in course and caliber. IMPRESSION: 1. Early subacute infarctions involving the right PCA territory as well as the superior aspect of the right frontal and right parietal lobes in a watershed distribution. 2. Questionable mild narrowing at the origin of the right vertebral artery, otherwise unremarkable MRA of the head and neck. Report to the stroke fellow 12.45 pm -[**2153-2-26**]. REASON FOR EXAMINATION: Evaluation of the patient after mitral valve repair. [**2-24**] PCXR Cardiomegaly appears to be slightly enlarged than on the prior study, which might be related to lower lung volumes, followup is recommended with chest radiograph to exclude the possibility of developing pericardial effusion. Tubes and lines have been removed. Mediastinum is unremarkable. There is interval substantial improvement in pulmonary edema, currently mild. Small bilateral pleural effusions are most likely present. No definitive pneumothorax is demonstrated. [**2-22**] EKG Normal sinus rhythm. Left anterior hemiblock. Compared to the previous tracing of [**2153-1-30**] left anterior hemiblock is new. Brief Hospital Course: Patient was a same day admit and was taken to the Operating Room where he underwent a mitral valve repair on [**2-22**]. See operative note for details. He tolerated the operation well and weaned and extubated without difficulty. He transferred to he step down unit on POD 1. On POD #1 he complained of left hand numbness which was attributed to a-line placement. However it was also noted once he started to work with PT that his gait was shuffling in nature and he was leaning to his left and on occasion was bumping into an objects on his left side as if he did not see them. On examination his whole left hand was numb and clumsy. Neurology was consulted regarding left hand numbness and shuffling gait. His exam was noted to be significant for a left sided field cut, left hemi sensory loss, left hemiplegia, hypomimia. The Reglan that he was on may have made things worse as it can induce parkinsonism and this was dc'd. MRI/MRA revealed right PCA stroke with involvement of the right occipital, corpus callosum, right frontal and right parietal areas. He has continued to show improvement in symptoms. On POD#2 he developed a-fib and was started on amiodarone which has been since dc'd at the request of his cardiologist. He developed a left arm phlebitis from amio infusion. He has remained hemodynamically stable in rate controlled a-fib. Pacing wires were removed without difficulty. He was started on Coumadin for his a-fib and his INR was therapeutic at discharge. INR goal 2.0-2.5. He has continued to progress and in light of his continued medical needs he is being discharged to [**Hospital **] Health care on POD#5 for continued PT/OT and medical management. Medications on Admission: FUROSEMIDE 40 mg Daily POTASSIUM CHLORIDE 20 mEq Daily Discharge Medications: 1. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for pain, fever. 2. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. Disp:*50 Tablet(s)* Refills:*0* 3. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 4. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) as needed for constipation. 5. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 6. potassium chloride 10 mEq Tablet Extended Release Sig: Two (2) Tablet Extended Release PO Q12H (every 12 hours) for 5 days: then decrease to 20meq's daily for 2 weeks then dc. 7. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 8. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO once a day: while on coumadin . 9. warfarin 1 mg Tablet Sig: [**Name8 (MD) **] md order daily Tablet PO Once Daily at 4 PM. 10. furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 5 days: then decrease to 40mg daily x 2 weeks then dc. 11. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Discharge Disposition: Extended Care Facility: [**Hospital **] health care center Discharge Diagnosis: mitral regurgitation hypertension s/p mitral valve repair Discharge Condition: Alert and oriented x3, nonfocal Ambulating with assist Incisional pain managed with oral meds Incisions: Sternal - healing well, no erythema or drainage Edema +1 lower ext 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 [**2153-3-28**] at 2pm Cardiologist:Dr.[**Last Name (STitle) 92432**] on [**2153-3-6**] at 10;30am Please call to schedule appointments with: Primary Care: Dr.[**First Name7 (NamePattern1) 16883**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 58756**]([**Telephone/Fax (1) 644**]) in [**3-8**] weeks **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Labs: PT/INR for Coumadin ?????? indication atrial fibrillation Goal INR [**1-5**] First draw Results to [**Hospital 2274**] [**Hospital 197**] clinic phone: [**Telephone/Fax (1) 55854**] fax Completed by:[**2153-2-27**]

[ "999.2", "997.02", "342.91", "434.11", "451.82", "424.0", "401.9", "427.31", "E878.1" ]

icd9cm

[ [ [] ] ]

[ "39.61", "35.12" ]

icd9pcs

[ [ [] ] ]

8255, 8316

5289, 6970

331, 378

8418, 8598

1865, 5266

9438, 10258

1062, 1143

7076, 8232

8337, 8397

6996, 7053

8622, 9415

1158, 1846

271, 293

406, 608

630, 644

660, 1031

15,491

114,803

22162

Discharge summary

report

Admission Date: [**2194-7-16**] Discharge Date: [**2194-7-24**] Date of Birth: [**2121-10-22**] Sex: M Service: TSURG Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**Last Name (NamePattern1) 1561**] Chief Complaint: right-sided chest pain and shortness of breath Major Surgical or Invasive Procedure: s/p apical wedge/talc pleuredhesis on [**2194-7-7**] and axillary thoracotomy with drainage on [**2194-7-16**]. History of Present Illness: 72M admitted to an outside hospital with a diagnosis of right-sided spontaneous pneumothorax. A chest tube was placed but the patient continued to have a persistent air leak. On [**2194-7-7**] he underwent broncoscopy and VAWR of the right upper lobe with talc pleuredhesis for a bronchopleural fistula. He was found to have a bulla on the apical segment of the RUL. During this admission he was diagnosed with MRSA and started on vancomycin and tobramycin. He also developed new onset afib. V/Q scan was indeterminate and head CT (obtained for a change in mental status) was negative for acute changes. He was transferred to [**Hospital1 18**] for further evaluation. Past Medical History: probably COPD high cholesterol s/p appy umbilical hernia s/p hemmoroidectomy afib Social History: quit smoking 21 years ago drinks EtOH daily Family History: n/c Physical Exam: T 96.9 HR 95-129 and afib BP 110/64 oxygen 93% HEENT: PERRLA, no JVD Lungs: left CTA, right decreased at base, chest tube draining Heart: irregularly irregular Abdomen: + BS, NT/ND Neuro: A + O x 3 Pertinent Results: [**2194-7-16**] 02:17AM WBC-14.3* RBC-3.88* HGB-11.9* HCT-34.1* MCV-88 MCH-30.7 MCHC-34.9 RDW-13.7 [**2194-7-16**] 02:17AM PLT COUNT-187 [**2194-7-16**] 02:17AM PT-13.8* PTT-28.3 INR(PT)-1.3 Brief Hospital Course: The patient was s/p for a R VAWR/talc pleuredhesis/bleb resection. He was taken to the operating room on [**2194-7-16**] for a right axillary thoracotomy and drainage of empyema. He tolerated the procedure wellHe was admitted to the ICU and remained intubated. CT revealed a dominant apical fluid collection. He continued to be weaned from his sedation, his pressors, and was extubated. He was trasferred to the floor on [**2194-7-19**]. He continued to drain fluid from both chest tubes. His heparin was discontinued and he was placed first on 3mg of coumadin, and later down to 2.5mg. He continued to void and ambulate appropriately. On [**2194-7-23**] one of his chest tubes was removed and his central line was removed. A PICC line was placed as well. On [**2194-7-24**] the patient pulled out his PICC line by accident and it had to be replaced. His second chest tube was converted to a drain and he was discharged to [**Hospital 5503**] rehab facility. Medications on Admission: vancomycin 1g q12 tequin Discharge Medications: 1. Amiodarone HCl 200 mg Tablet Sig: Two (2) Tablet PO three times a day. Disp:*180 Tablet(s)* Refills:*2* 2. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. Disp:*60 Tablet(s)* Refills:*0* 3. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. Disp:*60 Tablet(s)* Refills:*0* 4. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO Q12H (every 12 hours). Disp:*30 Tablet(s)* Refills:*2* 5. Warfarin Sodium 2.5 mg Tablet Sig: One (1) Tablet PO QD (once a day). Disp:*30 Tablet(s)* Refills:*2* 6. Vancomycin HCl 10 g Recon Soln Sig: 1 vial Recon Soln Intravenous Q12H (every 12 hours) for 4 weeks: 1g q12h. Disp:*qs Recon Soln(s)* Refills:*2* 7. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day for 5 days. 8. Potassium Chloride 20 mEq Packet Sig: One (1) PO once a day. Discharge Disposition: Extended Care Facility: TBA Discharge Diagnosis: status/post apical wedge/talc pleuredhesis on [**2194-7-7**] and axillary thoracotomy with drainage on [**2194-7-16**]. hypercholesterolemia umbilical hernia status/post hemmorhoidectomy appendectomy new atrial fibrillation Discharge Condition: good Discharge Instructions: Go to an Emergency Room if you experience new and continuing nausea, vomiting, fevers (>101.5 F), chills, or shortness of breath. Also go to the ER if your wound becomes red, swollen, warm, or produces pus. You may remove your dressings 2 days after your surgery if they were not removed in the hospital. Leave the steri strips on until they begin to peel, then you may remove them. 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. Followup Instructions: Call to set up an appointment with Dr. [**Last Name (STitle) **] in 1 week. Call to schedule a follow up appointment in [**12-27**] weeks with Dr. [**Last Name (STitle) 952**] ([**Telephone/Fax (1) 1504**]). The patient's primary care physician will follow him for his coumadin therapy as well as the drain care. The drain should be withdrawn [**12-27**] inches per week until it is out. PCP is [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 15170**] MD, ([**Telephone/Fax (1) 50234**].

[ "E878.8", "427.31", "998.59", "496", "272.0", "510.9" ]

icd9cm

[ [ [] ] ]

[ "96.6", "89.64", "38.93", "34.09" ]

icd9pcs

[ [ [] ] ]

3767, 3797

1834, 2806

368, 482

4065, 4071

1613, 1811

5121, 5630

1367, 1372

2881, 3744

3818, 4044

2832, 2858

4095, 5098

1387, 1594

282, 330

510, 1185

1207, 1290

1306, 1351

29,401

133,533

31272

Discharge summary

report

Admission Date: [**2146-7-1**] Discharge Date: [**2146-7-22**] Date of Birth: [**2077-8-29**] Sex: F Service: NEUROSURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1835**] Chief Complaint: Right frontal bleed Major Surgical or Invasive Procedure: [**7-4**]: Right-sided frontotemporal craniotomy for frontal lobectomy, evacuation of hematoma, microscopic dissection and duraplasty. [**7-7**]: Now left sided high frontal EVD placement. [**7-12**]: 1. Tracheostomy. 2. Percutaneous endoscopic gastrostomy (PEG). History of Present Illness: 68yo right-handed woman with PMH significant for hypertension, stroke in [**2135**], vascular dementia, and recent shingles, presents as a transfer from an outside hospital for headache. She reports that she was in her USOH until the morning of presentation, when she awoke with headache at 4:41am. The headache was frontal and sharp. She was found to have a right frontal bleed approximately 3cmX3cm. Pt was admitted to the Neurology service and followed by serial exams she was acting impulsive but awake, alert and orientated x3, inattentive with some left hand coordination problems. She underwent an MRI but was inconclusive due to patient movement. At approximately 0430 this am the RN caring for the patient noticed a spike in BP to 190s followed by decrease mental status, left hemiparesis and left sided neglect. A repeat CT showed enlargement of the right frontal bleed. Was on aspirin until two days ago Past Medical History: stroke, details unknown - approx [**2135**] presumed vascular dementia hypertension shingles 2 weeks prior with lesions on her abdomen and buttocks, now healed Social History: denies tobacco and drug use, drinks [**12-7**] glasses of wine 3-4x/week Family History: father with [**Name (NI) 2481**] disease and a series of strokes, daughter with lupus Physical Exam: Vitals: BP 159/99 HR 71 R 17 97% RA HEENT: NCAT, MMM, OP clear Neck: no bruits CV: RRR, nl S1, S2, no m/r/g Chest: CTA bilaterally Abd: soft, NTND, BS+, erythematous marks on abd presumably healed vesicles Ext: warm and dry Awakes to name, hospital, [**6-11**] but falls back to sleep easily Pupils [**3-7**] equal bilaterally gaze is deviated to the right and cannot be overcome. Right facial droop Face is symmetric. She holds her right arm anti-gravity but the left falls to the bed, flaccid; the left arm has some withdrawal to pain. Withdraws bilateral lower extremities right>left CT: Right frontal intraparenchymal hemorrhage has markedly increased in size measuring 6.1 x 5.5 cm and extending superiorly towards the vertex. There is surrounding vasogenic edema and increased leftward subfalcine herniation, now measuring 13 mm compared to 8 mm previously. Labs: PT: 11.5 PTT: 26.5 INR: 1.0 WBC 10.2 plt 239 crit 40.7 Pertinent Results: [**2146-7-1**] 08:59PM GLUCOSE-126* UREA N-16 CREAT-0.7 SODIUM-137 POTASSIUM-3.7 CHLORIDE-103 TOTAL CO2-23 ANION GAP-15 [**2146-7-1**] 08:59PM ALT(SGPT)-14 AST(SGOT)-21 ALK PHOS-45 AMYLASE-28 TOT BILI-0.6 [**2146-7-1**] 08:59PM CALCIUM-9.0 PHOSPHATE-4.3 MAGNESIUM-2.1 [**2146-7-1**] 08:59PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2146-7-1**] 08:59PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG [**2146-7-1**] 08:59PM WBC-9.4 RBC-4.03* HGB-13.1 HCT-37.3 MCV-93 MCH-32.4* MCHC-35.0 RDW-14.9 [**2146-7-1**] 08:59PM NEUTS-80.5* LYMPHS-13.3* MONOS-4.2 EOS-1.9 BASOS-0.2 [**2146-7-1**] 08:59PM PLT COUNT-244 [**2146-7-1**] 08:59PM PT-12.2 PTT-30.3 INR(PT)-1.0 [**2146-7-1**] 08:59PM URINE BLOOD-SM NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [**2146-7-1**] 08:59PM URINE RBC-0-2 WBC-<1 BACTERIA-FEW YEAST-NONE EPI-<1 CT [**7-1**]: 1. A large right frontal area of intraparenchymal hemorrhage with surrounding edema and associated minimal mass effect. No other foci of acute hemorrhage identified. Differential diagnosis includes hemorrhagic transformation of underlying brain mass or metastasis. Other less likely etiologies would include amyloid angiopathy and hemorrhagic conversion of a previous area of infarction. Vascular anomalies such as arteriovenous malformations could also be considered. An MRI/MRA is recommended for further characterization. 2. High-density material located within the sphenoid sinus. Differential includes inspissated secretions versus hemorrhage versus fungal infection. Clinical correlation is recommended. MR [**7-2**]: Incomplete study with motion, limited FLAIR images. Complete study could not be acquired as patient was unable to continue. Right frontal hematoma with surrounding edema is again seen. A repeat study can be obtained with sedation. CT [**7-4**]: After the right frontal craniotomy and partial evacuation of the right intraparenchymal hematoma, there has been moderate improvement in the mass effect, with an improvement in the shift of normally midline structures. There are post-surgical changes with an air-fluid level located anterior to the right frontal lobe and a small extraaxial fluid collection seen overlying the right cerebral convexity. MR/MRA [**7-4**]: 1. Compared to the prior study, there has been a slight increase in the size of the right frontal intraparenchymal hemorrhage, with associated subfalcine herniation. 2. There has been interval development of marked intraventricular extension of hemorrhage and associated hydrocephalus. 3. There is no definite evidence of aneurysm or AV malformation. There is no definite evidence of underlying tumor, there is prominent enhancment along the margins of the hematoma which may be related to the acute hematoma, less likely this could be neoplastic leptomeningeal enhancement. 4. Medial to the area of the right superior frontal intraparenchymal hemorrhage, there is an area of increased diffusion-weighted image signal in the parasagittal white matter. However, ADC maps are not available to confirm whether this may represent an acute infarct. CT [**7-4**]: 1. Marked increased in size of right frontal intraparenchymal hemorrhage with 13 mm leftward subfalcine herniation and mass effect on the lateral ventricles and suprasellar cistern. Pathology [**7-4**]: Acute-subacute hematoma and secondary ischemic necrosis of nearby neurons.ARTERIOLOSCLEROSIS, indicative of hypertensive cerebrovascular angiopathy.Rigid, eosinophilic superficial cortical and leptomeningeal small arteries and arterioles, consistent with CONGOPHILIC AMYLOID ANGIOPATHY.Scattered neocortical amyloid plaques and neurofibrillary tangles, commensurate with ALZHEIMER'S DISEASE. CT [**7-5**]: 1. Since prior study, there has been an interval decrease in the degree of mass effect with mild decrease in the blood and pneumocephalus seen within the operative bed. 2. Mild decrease in the amount of intraventricular blood. 3. The right intraparenchymal hematoma and the small amount of subarachnoid hemorrhage are stable compared to prior examinatio n. CT [**7-6**]: 1. Mild interval increase in size of right extra-axial low attenuation fluid collection. 2. No change in right intraparenchymal hematoma and small amount of subarachnoid hemorrhage. 3. Stable hydrocephalus and layering blood within the posterior horns of the lateral ventricles CT [**7-7**]: 1. Compared to prior study, there has been interval placement of a ventriculostomy catheter with tip within the left frontal [**Doctor Last Name 534**]. 2. There has been no significant interval change in the size of the intraparenchymal, subarachnoid, and intraventricular hemorrhages. 3. There is minimal increase in the size of the lateral ventricles compared to prior examination. MAP/DVT ([**7-12**]): No evidence for DVT with the right or left lower extremity CT [**7-12**]: 1. No significant change in the size of the intraparenchymal and subarachnoid hemorrhage. Minimal decrease in the size of the intraventricular hemorrhage. 2. No new areas of hemorrhage. 3. Unchanged appearance of the ventricular catheter and the size of the ventricles. 4. Increased opacification of the sphenoid sinus, especially on the right side. CT [**7-13**]: 1. No significant change in the size of the intraparenchymal and subarachnoid hemorrhage. Minimal decrease in the size of the intraventricular hemorrhage. 2. No new areas of hemorrhage. 3. Unchanged appearance of the ventricular catheter and the size of the ventricles. 4. Increased opacification of the sphenoid sinus, especially on the right side. CT [**7-15**]: 1. Compared to the prior study from [**2146-7-13**], the ventricular system appears stable. 2. There is a stable appearance of the right frontal intraparenchymal hemorrhage as well as the subarachnoid hemorrhage. 3. There is a slight decrease in the hemorrhage layering within the lateral ventricles bilaterally. 4. There are no new foci of hemorrhage. CT [**7-18**]: 1. The position of the ventriculostomy catheter is stable. The ventricular system also appears stable. 2. There is stable appearance of the right frontal intraparenchymal hemorrhage, the subarachnoid hemorrhage, and the intraventricular hemorrhage. There are no new foci of hemorrhage. There is a small focus of pneumocephalus in the right frontal region. CT [**7-19**]: 1. There has been interval removal of the left ventricular drain. There is no air in bilateral lateral ventricles. Otherwise, the sizes of the ventricles are unchanged from the prior study. 2. There is stable appearance of the right frontal lobe intraparenchymal hemorrhage, subarachnoid hemorrhage, and intraventricular hemorrhage. There is no evidence of new hemorrhage or mass effect. CT [**7-20**]: 1. There has been interval development of new hemorrhage in the precentral gyrus along the motor cortex. There is no change in the slight leftward shift of normally midline structures. 2. Patient is status post removal of the left ventricular drain. There continues to be air in the lateral ventricles but less than the prior study. The size of the ventricles is unchanged compared with the prior study. 3. The appearance of the prior right frontal lobe intraparenchymal hemorrhage, subarachnoid hemorrhage, and intraventricular hemorrhage are unchanged from the prior exam. CT [**7-21**]: Overall there has been no significant interval change. No new hemorrhage is identified. There is stable appearance of the right frontal lobe hemorrhage as well as of the hemorrhage along the _____ cortex on the right side. No change in the slight leftward shift of the normally midline structures. Decreased amount of air within the lateral ventricles. Stable appearance of the intraventricular hemorrhage. CT [**7-22**]: final report pending, CT stable Brief Hospital Course: The patient was transferred from an OSH after presenting with a headache, and was found to have a right frontal hemorrhage on a CT. She was sent to the [**Hospital1 18**] Er for further evaluation and care. The patient was evaluated by neurology as well as neurosurgery; she was admitted to neurology for further investigation, and the differential includedamyloid, sinus venous thrombosis, hypertensive hemorrhagiv stroke, metastatic lesion, and vascular anomaly. Further imaging was suggested, including CT, MR/MRA, as well as Keppra for seizure prophylaxis, Mannitol and nicardipine for blood pressure control < 160. The patient was intubated to protect her airway, sent to the neuro ICU, and kept NPO for possible resection. On [**7-4**], the patient was taken tot he operating room for a right craniectomy for a right-sided frontotemporal craniotomy, for frontal lobectomy, evacuation of hematoma, microscopic dissection and duraplasty. On [**7-5**], her decadron dosage was decreased to 4 mg [**Hospital1 **], and a CT of the head was stable. Also, the MRI/MRA was negative for aneurysm, AVM, or masses. On the first of [**Month (only) 216**], the decadron wean was continued, and serial CTs were followed; her ventricles were increased in size on the first. Pathological results returned as amyloid angiopathy. On the second day of [**Month (only) 216**], a left sided high frontal EVD was placed intraoperatively, with a stable post-operative CT. A sputum culture revealed gram positive cocci in pairs, chains, and clusters (subsequently noted to be haemophilus ingluenzae, beta lactamase negative), and vancomycin as well as ampicillin were started for tracheobronchitis; the patient was pan-cultured as she was febrile overnight. Her CSF had 40 WBCs, [**Numeric Identifier **] RBCs, however the final culture had no growth. The infectious disease team was involved for management of antibiotics, and infectious evaluation. Serial blood cultures were obtained, as well as serial CSF cultures. On [**7-10**], the CSF smear was negative, with 100WBC:3675RBC 16 Polys, 60MP's. Persistent fevers were questionable attributed blood in the CSF/ventricles rantehr than infectious. On [**7-12**], the patient had negative LENIs for DVT , as part of the evaluation for continued fevers, and was restarted on Cefazolin, and ampicillin was stopped for h. influenzae coverage as well as for EVD coverage. She was also sent to the operating room for a tracheostomy and PEG tube placement. Mannitol was weaned, and Decadron was finally weaned to a stop. Though the patient remained febrile at times, her neurologic exam and reactions improved, and the patient appeared brighter. Serial blood cultures as well as sputum cultures were routinely followed; c.diff was also sent, which eventually returned as negative. On [**7-13**], a CT showed less ventricular hemorrhage, but still enlarged in size; the patient failed a clamp trial of her EVD. On [**7-14**], her drain was clamped. On the tenth of [**Month (only) 216**], her antibiotic regimen was changed as per the infectious disease recommendations; ampicillin was stopped, and levofloxacin was started. The CT remained stable, and the patient was prepared for transfer to the stepdown unit from the ICU. On [**7-18**], the EVD was removed; a subsequent CT revealed slightly larger temporal horns, but the patient's neurological examination remained stable. On [**7-20**], however, the patient was slightly less responsive, and a CT showed continued high right frontal intraparenchymal hemorrahge on [**Last Name (un) 29828**] [**7-20**] and 16. The neurology stroke team made blood pressure recommendations of less than 140 mm Hg systolic, and less than 130 mm Hg MAP, and continued Keppra for seizure prophylaxis. The bleed was stabilized with no worsening of the patient's condition. During her stay, physical therapy was consulted to evaluate and care for the patient. The patient was discharged to a rehabilitation facility in stable condition, afebrile, having finished a course of multiple antibiotics. Medications on Admission: Senna, Colace, Lisinopril, Donepril, Keppra, Heparin and Escitropram Discharge Medications: 1. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2 times a day). 2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. Donepezil 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 4. Escitalopram 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Albuterol 90 mcg/Actuation Aerosol Sig: Six (6) Puff Inhalation Q6H (every 6 hours) as needed for wheezing. 6. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Six (6) Puff Inhalation QID (4 times a day) as needed for wheezing. 7. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs PO Q4H (every 4 hours) as needed. 8. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). 9. Potassium & Sodium Phosphates [**Telephone/Fax (3) 4228**] mg Packet Sig: Two (2) Packet PO DAILY (Daily). 10. Acetaminophen 160 mg/5 mL Solution Sig: [**12-7**] PO Q4H (every 4 hours) as needed for fever. 11. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day) as needed. 12. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID (4 times a day) as needed. 13. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 15. Insulin Regular Human 100 unit/mL Solution Sig: sliding scale sliding scale Injection ASDIR (AS DIRECTED). 16. Levetiracetam 500 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). 17. Sodium Chloride 0.9% Flush 3 ml IV DAILY:PRN Peripheral IV - Inspect site every shift 18. Potassium Chloride 20 mEq/50 mL Piggyback Sig: sliding scale Intravenous PRN (as needed). 19. Magnesium Sulfate 4 % Solution Sig: sliding scale Injection PRN (as needed). 20. Fentanyl Citrate 50-100 mcg IV Q2H:PRN 21. Calcium Gluconate 100 mg/mL (10%) Solution Sig: sliding scale Intravenous ASDIR (AS DIRECTED). 22. HydrALAzine 20 mg IV Q6H hold if SBP <120 23. Sodium Chloride 0.9% Flush 3 ml IV DAILY:PRN Peripheral IV - Inspect site every shift Discharge Disposition: Extended Care Facility: [**Hospital6 85**] - [**Location (un) 86**] Discharge Diagnosis: Amyloid angiopathy Discharge Condition: stable Discharge Instructions: ?????? Have a family member check your incision daily for signs of infection ?????? Take your pain medicine as prescribed ?????? Exercise should be limited to walking; no lifting, straining, excessive bending ?????? You may wash your hair only after sutures and/or staples have been removed ?????? You may shower before this time with assistance and use of a shower cap ?????? Increase your intake of fluids and fiber as pain medicine (narcotics) can cause constipation ?????? Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, aspirin, Advil, Ibuprofen etc. ?????? If you have been prescribed an anti-seizure medicine, take it as prescribed and follow up with laboratory blood drawing as ordered ?????? Clearance to drive and return to work will be addressed at your post-operative office visit CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING: ?????? New onset of tremors or seizures ?????? Any confusion or change in mental status ?????? Any numbness, tingling, weakness in your extremities ?????? Pain or headache that is continually increasing or not relieved by pain medication ?????? Any signs of infection at the wound site: redness, swelling, tenderness, drainage ?????? Fever greater than or equal to 101?????? F Followup Instructions: YOU WILL NEED A REPEAT CEREBRAL ANGIOGRAM IN 6 WEEKS (AROUND [**9-4**]). PLEASE CALL [**Telephone/Fax (1) **] TO ARRANGE THIS. YOU WILL NEED A NON CONTRAST CAT SCAN OF THE HEAD IN 2 WEEKS. PLEASE CALL [**Telephone/Fax (1) **] TO ARRANGE THIS YOU HAVE A SUTURE IN YOUR HEAD FROM THE VENTRICULAR DRAIN SITE - THIS NEEDS TO BE REMOVED ON [**2146-7-28**]

[ "348.4", "437.0", "331.0", "277.30", "331.4", "401.9", "290.40", "518.84", "348.8", "041.5", "431", "466.0" ]

icd9cm

[ [ [] ] ]

[ "96.72", "96.04", "96.6", "01.59", "02.39", "31.1", "38.93", "99.05" ]

icd9pcs

[ [ [] ] ]

17012, 17082

10835, 14913

339, 608

17144, 17152

2906, 10812

18487, 18843

1850, 1939

15033, 16989

17103, 17123

14939, 15010

17176, 18464

1954, 2887

279, 301

636, 1559

1581, 1744

1760, 1834

16,346

124,884

11973

Discharge summary

report

Admission Date: [**2184-2-15**] Discharge Date: [**2184-2-19**] Date of Birth: [**2146-8-20**] Sex: M Service: MICU CHIEF COMPLAINT: Unresponsiveness, apnea, bradycardia. HISTORY OF PRESENT ILLNESS: The patient is a 37 year-old male who the night of admission had been at a party during which he drank alcohol and possibly used other illict substances. The patient went home approximately 2:00 a.m. with his girlfriend. [**Name (NI) **] report from the girlfriend the patient began gargling and having rhoncherous breath sounds in his sleep. The girlfriend then moved to another room so she could sleep. Later in the morning she found the patient pale, [**Doctor Last Name **] and with white foam around his mouth. She called EMS immediately who found the patient to be apneic. The patient was intubated in the field and provided pressor ventilation and transported to [**Doctor First Name **] On arrival to the Emergency Department the patient was obtunded responding only to deep suction. The patient's initial arterial blood gases on 100% FIO2 was 7.03/33/48. The patient was given 2 amps of bicarbonate and repeat arterial blood gases was 7.15, 36, 419. As the patient was intubated requiring ventilatory support he was admitted to the Intensive Care Unit. A toxicology screen was positive for ethanol, cocaine, and opiates. PAST MEDICAL HISTORY: None. MEDICATIONS: None. ALLERGIES: No known drug allergies. SOCIAL HISTORY: The patient lives with his girlfriend for the past month. She has a 10 year-old son in the house. The patient drinks alcohol heavily in the weekends and denies known other drug use. PHYSICAL EXAMINATION: Temperature 97.4. 111. 115/41. 100% oxygen saturation on assisted control. 25 times 850 with FIO2 of 100%. In general, the patient was intubated, somnolent with eyes opening to sternal rub. HEENT pin point pupils. Face symmetrical. Neck was thick, supple. No lymphadenopathy. Chest revealed equal breath sounds bilaterally. Cardiac examination S1 and S2. Regular rhythm. Tachycardic. No murmur. Abdomen was soft, nontender. No guarding or rebound. Extremities no edema with 2+ peripheral pulses. Skin revealed no rash. LABORATORIES ON ADMISSION: White blood cell count 23.4, hematocrit 46.7, platelets 345. Differential 72 neutrophils, 4 bands, 20 lymphocytes, 4 monocytes. INR 1.7, PTT 49.9, sodium 143, K 4.9, chloride 100, bicarb 13, BUN 17, creatinine 2.4, glucose 110, anion gap was 30. ALT 872, AST 638, alkaline phosphatase 122, bilirubin .3, amylase 311, lipase 202, albumin 4.4, ionized calcium 1.07. The patient's CK was 300 with an MB of 13 and an MB index of 4.3. Serum calcium 8.7, phosphate 17.8, magnesium 3.9. Urinalysis greater then 300 protein, moderate blood, 3 to 5 white cells, nitrate negative, 0 to 2 white blood cells. Tox screen, ethanol level 179. Urine tox screen positive for opiates and cocaine. Head CT was negative for acute process. Chest x-ray revealed a question of a developing right lower lobe process. Electrocardiogram revealed no acute ST or T wave changes and narrow QRS complex and sinus tachycardia. HOSPITAL COURSE: The patient's initial arterial blood gas was very concerning for the degree of acidosis. The mode was switched to AC 28 times 850 and he was weaned to 50% oxygen to which the patient's gas improved 7.26/27/100. The ET tube was in place with equal breath sounds bilaterally. The patient continued to be somewhat hypotensive in the Emergency Department and required Dopamine at 10 micrograms per kilograms per minute for support of blood pressure. In the setting of the patient's history and laboratory values the patient's profound acidosis was felt to be secondary to a lacticacidemia from both hypotension and the possible rhabdomyolysis. Additionally, the patient had consumed alcohol, which may have been contributing to his anion gas acidosis. The decision was made to hyperventilate the patient to correct his acidosis as well as to slowly replete bicarbonate by intravenous fluids. From a cardiovascular standpoint the patient's elevated CK with negative MB were consistent with rhabdomyolysis, however, there was a slightly elevated troponin value of .9. This was thought to be a result of a troponin leak due perhaps to hypoperfusion of the coronary arteries. Serial cardiac enzymes were followed. Pulmonary: there was concern for an aspiration pneumonia versus pneumonitis on the initial chest x-ray. The patient was started on Levaquin and Flagyl. Sputum cultures were sent. From a GI standpoint the patient's transaminases increases were felt to be a result of shock liver from prolonged hypoperfusion. Liver function tests were checked serially during the [**Hospital 228**] hospital stay. On hospital day two ([**2184-2-16**]) the patient was extubated. Arterial blood gas at that time 7.4/39/116. The patient's mental status gradually improved. The patient was able to begin answering questions about his own history. The patient continues to assert that he had been drinking the evening of his apneic episode, but denied additional substance abuse. By hospital day two the patient's CK value had reached [**2172**]. The ALT had reached 3615 and the AST 3910. The patient's total bilirubin was .5 and alkaline phosphatase was 17. Additionally the patient's troponin level peaked at 18.4. These laboratory findings were consistent with the previously considered ideas of shock liver as well as a mild rhabdomyolysis with lactacidosis. The patient continued fluid resuscitation. Additionally the patient continued Levaquin and Flagyl for a possible right lower lobe pneumonia. The patient was transferred to the floor in stable condition on the evening of the [**10-16**] (hospital day two). The patient's repeat liver function tests on the evening of hospital day two, ALT was down to 2607, AST 1288, CK, however had continued to course upward at 3673. On [**2184-2-17**] hospital day three the patient's troponin value decreased from 18.4 to 5.3. Additionally the patient's CK value had trended down from 3673 to 2803, with ALT 2282, AST 897. Clinically the patient continued to improve. The patient was ambulatory and began taking po intake. Intravenous rehydration continued as a result of the patient's elevated CK and picture of rhabdomyolysis. Additionally on hospital day three arrangements were made for the patient to be seen by the Addiction Recovery Service, as he now admitted to alcohol use and "some cocaine use" on the evening prior to admission. The patient was continued on Levaquin and Flagyl for a likely aspiration pneumonia. On hospital day four ([**2184-2-18**]) the patient's clinical status continued to improve. The patient underwent an echocardiogram, which was unremarkable, with normal LV systolic and valvular function. The patient remained on telemetry and the CK and troponin values in addition to liver enzymes were rechecked. The patient's CK value was down from 2803 to 1119. The patient's troponin was down from 5.3 to 2.9, ALT was down from 2282 to 1094, and AST was down from 1897 to 360. The patient's bilirubin had increased slightly to 1.9. Alkaline phosphatase remained normal at 82. Intravenous fluid resuscitation continued and the patient was continued on Levaquin and Flagyl. On hospital day five [**2184-2-19**] the patient was feeling well, ambulatory in the [**Doctor Last Name **] and eating solid foods. The patient was eager for discharge. Telemetry was discontinued. At this time, AST 128, ALT 917, alkaline phosphatase 76, total bilirubin down 2.9. The patient's CPK value was down to 399. Additionally on the 31st the patient was seen by the Addiction Service, which offered the patient some resources. The patient had indicted that he would be following up with Alcoholic's Anonymous meetings. The patient is discharged on [**2184-2-19**] with his girlfriend in good condition. The patient is discharged to home. DISCHARGE DIAGNOSES: 1. Shock liver. 2. Troponin leak secondary to myocardial hypoperfusion. 3. Acute polysubstance intoxication. 4. Aspiration pneumonia. DISCHARGE MEDICATIONS: 1. Flagyl 500 mg po t.i.d. times three days. 2. Levaquin 500 po q.d. times three days. FOLLOW UP: The patient is instructed to follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1557**] at the [**Hospital 191**] Clinic within the next two weeks. [**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(2) 4814**] Dictated By:[**First Name3 (LF) 37675**] MEDQUIST36 D: [**2184-2-19**] 14:46 T: [**2184-2-23**] 10:15 JOB#: [**Job Number 37676**]

[ "965.00", "980.0", "E850.2", "728.89", "305.00", "276.2", "507.0", "518.81", "E860.0" ]

icd9cm

[ [ [] ] ]

[ "96.71", "96.04" ]

icd9pcs

[ [ [] ] ]

8007, 8146

8170, 8261

3160, 7986

8273, 8689

1670, 2220

150, 189

218, 1356

2235, 3142

1379, 1445

1462, 1647

822

124,634

48270+48291+59073

Discharge summary

report+report+addendum

Admission Date: [**2174-7-19**] Discharge Date: [**2174-8-4**] Date of Birth: [**2145-10-30**] Sex: M Service: [**Location (un) 259**] MEDICINE HISTORY OF PRESENT ILLNESS: Patient is a 28-year-old male with T12 paraplegia and decubitus ulcers, chronic renal insufficiency, who presented with fever and hypotension. Patient is status post recent admission to [**Hospital1 346**] Plastics Service from [**6-26**] to [**7-11**] for treatment of Stage IV right greater trochanter necrotizing ulcer and underwent operative procedure including closure to that area. He was also noted to have Enterobacter urinary tract infection. Patient's wound cultures grew Enterococcus and presumptive MRSA. He was treated with linezolid, cefepime, and Flagyl, and ultimately discharged on linezolid alone. Per the discharge summary, the patient was taking linezolid, however, the patient does not report taking this at home. The patient reports feeling somewhat fatigued three days prior to admission. On the day prior to admission, he noted fever to 104 while at home. He felt slightly nauseous, did not vomit, and denies abdominal pain. He had loose stools for one day, which is unchanged from his baseline. He denied shortness of breath or cough. Denied chest pain. Denied headache or mental status changes. He denied dysuria. He notes that he has not been straight cathing 4x a day as directed. In the Emergency Room, the patient was febrile to 103.7, and initially noted to be tachycardic to the 100's with a blood pressure of 128/60. Large decubitus ulcers were also noted and a white blood cell count of 12,000 was noted. A chest x-ray and urinalysis were negative. Hematocrit was found to be 18. He was transfused 2 units of packed red blood cells. Early in the morning, the patient was noted to have an oral temperature of 93.5 with a blood pressure of 64/32 and heart rate in the 70's. He was given 4 liters of normal saline, and his blood pressure improved into the 90's. He had appropriate urine output to this. The patient was also given linezolid at that time. The patient was then transferred to the MICU for further treatment of his presumed sepsis. PAST MEDICAL HISTORY: 1. T12 paraplegia from MVA in [**2165**]. 2. Decubitus ulcers Stage IV right greater trochanter, Stage II right ischial, Stage III left greater trochanter, Stage II left heel, Stage IV coccyx. 3. Status post flap closure bilaterally two trochanteric ulcers. 4. Recurrent urinary tract infections. 5. Chronic renal insufficiency secondary to obstructive uropathy, baseline creatinine of 2.7. 6. Seizure disorder with a normal electroencephalogram in [**2174-6-26**]. 7. Question of Clostridium difficile colitis. 8. MRSA. ALLERGIES: 1. Dilantin, seizing. 2. Vancomycin and levofloxacin which gives severe hives. 3. Bactrim hives and throat culture. MEDICATIONS ON ADMISSION: 1. Xanax one tid. 2. OxyContin 40 [**Hospital1 **]. 3. Percocet 1-2 tablets po q4-6h prn. 4. Depakote 1,000 [**Hospital1 **]. SOCIAL HISTORY: The patient lives in [**Location **] with his mother. Denies tobacco. Denies alcohol. Denies IV drug use. Denies HIV risk factors. PHYSICAL EXAMINATION: On physical exam, the patient was a thin white male sitting upright in bed in no acute distress. Alert and oriented. Temperature max 103.7, T current 93.4, pulse of 80, blood pressure 105/63, respirations 16. HEENT: normocephalic, atraumatic. Pupils are equal, round, and reactive to light. Extraocular movements are intact. Oropharynx was significant for some white patches on the tongue. Neck was supple. Neck veins were flat. Lungs were clear to auscultation and percussion. Cardiovascular examination: Regular, rate, and rhythm, normal S1, S2, no murmurs, rubs, or gallops. Abdominal examination: Bowel sounds present, nondistended, and nontender, soft and flat. Extremities: Warm, wasting noted in the lower extremities, flaccid lower extremities. Decubitus ulcers included right and left ulcers over the greater trochanters, ulcer on the coccyx, and also bilateral heel ulcers. Neurologic: The patient was alert and oriented times three. Cranial nerves II through XII were intact. Absent sensation in the lower extremities. Speech was fluent. LABORATORIES ON ADMISSION: Significant for a white count of 12.2, hematocrit 18.4, with 2 units, this increased to 22.4. Platelets of 404. Chem-7 was significant for a creatinine of 3.8. Urinalysis was negative, 0-2 white blood cells, less than 1 red blood cell, and no ketones. Blood cultures and urine cultures were drawn on admission. On admission to the MICU, the patient was supported with fluids as needed. Patient was also started on linezolid and meropenem empirically for presumed sepsis. Patient remained stable overnight and on [**2174-7-20**], the patient was transferred from the MICU to the [**Location (un) **] Medicine Firm. SUMMARY OF HOSPITAL COURSE: 1. Fever and hypotension, presumed sepsis. Although initially the source of infection was not known, patient was started empirically on meropenem and linezolid for presumed sepsis secondary to osteomyelitis. Although the patient originally declined MRI to evaluate for osteomyelitis on [**2174-7-21**], the patient underwent a MRI to evaluate which showed right ischium and right greater trochanter osteomyelitis and also a right greater trochanteric fracture. In addition, there was evidence for a left greater trochanter osteomyelitis, this is evidenced by bone marrow edema as well as enhancement. The patient's wounds were cultured and these revealed coagulase-positive Staphylococcus aureus, three colonies. Sensitivities on these later revealed that one colony was linezolid resistant MRSA. Upon this finding, the patient was switched from linezolid to Synercid. In addition, the patient's wound revealed gram-negative rods pansensitive to Klebsiella and additionally rare yeast. Prior to his change to Synercid, the patient did have one spiking temperature on [**2174-7-22**] to 101.3. The patient was again cultured. All cultures remained negative on this patient. Given the patient's history of recurrent urinary tract infections, an additional source of infection was considered, however, urine cultures were also negative for this patient. The patient remained stable, afebrile with blood pressures in the 110s/60s to the time of transfer to the Plastic Service on [**2174-8-4**]. Patient will continue on his antibiotics, meropenem and Synercid. 2. Chronic renal insufficiency: Patient was admitted with a creatinine of 3.8. Patient was hydrated and this improved throughout his hospital course, and on the time of transfer to the Plastic Service, the patient's creatinine was stable at 2.6. This was much improved for this patient and well within the patient's baseline. MRI which had been performed had suggested hydronephrosis as a consequence of this on [**2174-7-22**], a renal ultrasound was performed to evaluate the patient's kidneys. Renal ultrasound showed mild right hydronephrosis unchanged from prior. In addition to this, there was moderate to severe left hydronephrosis, possibly increased from prior. Dr. [**Last Name (STitle) **], the patient's nephrologist, was aware of these results. Given the patient's improvement in renal function and the chronic nature of his hydronephrosis, this was not deemed to be an acute inpatient issue. The patient will follow up with Dr. [**Last Name (STitle) **] further for complete followup of his bilateral hydronephrosis. 3. Decubitus ulcers: The ulcers were evaluated and followed by the Plastics Service. She will need further debridement of these wounds, which will be followed up upon his further hospital course on transfer to the Plastics Service. 4. Osteomyelitis: Patient with MRI confirmed osteomyelitis, also requiring surgical debridement. The Plastics and Orthopedic Surgery teams are coordinating for a surgical date. By request for surgical planning and further evaluation of the osteomyelitis, in addition to the MRI on [**7-21**], a CT scan of the patient's pelvis was obtained on [**7-26**] as well as plain films. This again, will be managed further as his hospital course continues on the Plastics Service. 5. Seizures: The patient had a history of seizures last in [**2174-5-26**]. The patient was admitted on Depakote for seizure prophylaxis, however, valproic acid levels were checked while in house, and these remained consistently low. A trial of IV valproic acid was attempted, however, the valproic acid levels remained low. This is possibly due to a medication which is inducing the T450 system and altering the clearance of valproic acid. As a result, the Neurology service was consulted due to his need for change in seizure prophylaxis and also a completed workup given the fact the patient had missed outpatient appointments with Neurology due to his admission. They suggested the patient start on Keppra. Renal dosing for this was considered, and the patient remains on a dose of 750 mg [**Hospital1 **] of Keppra for seizure prophylaxis. The patient tolerated this change well. There have been no seizures while on service. The Neurology team evaluated the patient, and a MRI of the patient's head was obtained on [**7-27**]. There were no focal abnormalities. The neurologic team signed off on this patient, and the patient should follow up in [**Hospital 875**] Clinic with Dr. [**Last Name (STitle) 101691**] or Dr. [**Last Name (STitle) 851**]. 6. Right shoulder pain: The patient complained of pain in his right shoulder after the [**7-26**] CT scan of his pelvis, when he said during movement for this scan, he injured his right shoulder. The patient had an old right shoulder injury as well. Patient's shoulder was somewhat swollen, and he had decreased range of motion secondary to pain. On [**2174-7-27**], a shoulder MRI was obtained which revealed no bony abnormalities, no soft tissue or ligamentous injury. The patient was given Ultram as an additional pain medication in an effort to make him more comfortable. The patient can followup for this right shoulder pain with Orthopedics during this hospital course. 7. Chronic pain: Patient with multiple decubitus ulcers requiring outpatient pain medications. The patient was continued on his oxycodone and also oxycodone acetaminophen prn. The patient was not utilizing any maximum doses of these medications while in-house. 8. Anemia: The patient was admitted with a hematocrit of 18. He was transfused 2 units of packed red blood cells. Patient's hematocrit increased from this and remains stable at a hematocrit of 28 while on the Medicine Service. Patient's stool was guaiacked, and the patient was guaiac negative. There was no evidence for blood loss anemia was presumed secondary to anemia of chronic disease. The patient was started on Epogen shots for further management of his anemia. 9. FEN: The patient was taking good po while in house. He occasionally required repletion of magnesium and required phosphate binders. The patient's potassium rose to 5.3 on occasion while in-house. This was deemed to be due to excessive drinking of Gatorade, and the patient was encouraged to minimize this intake. 10. Psychiatric: Patient is followed by Social Work for psychiatric issues surrounding his diagnosis and paraplegia. The patient declined any further intervention by Psychology at this time. This is a summary of hospital course up until [**2174-8-4**] when the patient was transferred to the Plastic Service for further surgical planning for debridement of his wounds and underlying osteomyelitis. On transfer to the Plastic Service, the patient was stable. He was afebrile and had not been hypotensive for well over a week. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 1211**], M.D. [**MD Number(1) 1212**] Dictated By:[**Name8 (MD) 12502**] MEDQUIST36 D: [**2174-8-4**] 18:37 T: [**2174-8-9**] 08:38 JOB#: [**Job Number 101692**] Admission Date: [**2174-7-19**] Discharge Date: [**2174-9-6**] Date of Birth: [**2145-10-30**] Sex: M Service: PLASTIC SURGERY Of note, this discharge summary will only entail the dates from [**2174-8-4**] to the discharge date of [**2174-9-6**]. Previous to that, the patient was on the Medicine Service and a discharge summary can be found covering those dates. Also, refer to that discharge summary for history of present illness and past medical history in completion. HOSPITAL COURSE: 1. DECUBITUS ULCERS: In brief, this is a 28-year-old male who is paraplegic T12 from a MVA accident in [**2165**]. He presented initially with fever and hypotension and the source was found to be multiple decubitus ulcers in the buttock region. After stabilization on the Medicine Team, he was transferred to the Plastics Team for repair of these ulcers. HOSPITAL COURSE: The decubitus ulcers entail the bilateral greater trochanters, stage IV, right ischial, stage II, coccyx, stage IV, and left heel, stage II. On [**2174-8-8**], the patient was taken to the OR for debridement of these decubitus ulcers as well as closure of the ischial ulcer and a gluteal flap was placed for the bilateral trochanter ulcers. He was taken once again to the OR on [**2174-8-18**] for debridement of the right trochanter wound and readvancement of the gluteal flap. The patient followed a normal postoperative course where he was in the SICU with the exception of prolonged intubation. He was extubated on [**2174-8-17**] and it was thought that intubation should be prolonged to maintain sedation to keep the prone position. The prone position was essential for the healing of the ulcers and in prior operations the patient had not been able to comply with this. Thus, it was felt that keeping his intubated as long as appropriately possible would aid in the healing. Extubation occurred on [**2174-8-20**]. The patient was transferred to the floor on [**2174-8-23**]. The remaining wounds were initially treated with wet-to-dry dressing changes upon discharge. Once granulation tissue was present, the trochanter wounds were placed on high suction vacuum which was changed every three to five days. The sacral wound continued to be changed twice a day with wet-to-dry dressings. This type of wound care will continue as the patient is discharged into rehabilitation. On discharge, all wound sites look healthy with good tissue, no signs of infection. Sutures and drains have been removed and the skin is healing well. 2. OSTEOMYELITIS: As the patient presented with fever to the Medicine Team, cultures were taken of these areas in the OR. Both Orthopedics and Infectious Disease were consulted to evaluate the continued osteomyelitis condition of this patient. Cultures of the bones indicated that this patient had MRSA resistant to linazolid and also Klebsiella. Soft tissue showed the presence of yeast. Based on these findings, per ID recommendations, the patient was placed on a six week course of meropenem and Synercid which he will finish in rehabilitation and completed in-house a two week course of fluconazole. A PICC line was placed in the patient's arm prior to discharge for administration of these antibiotics. On discharge, the patient had been afebrile for greater than two weeks. Weekly LFTs were drawn and within normal limits during the course of antibiotic treatment. 3. RENAL: The patient is known to have chronic renal insufficiency secondary to his paraplegia. At baseline, he requires straight catheterization. He was transferred to the Plastics Team with a creatinine of 1.8, although it was documented in his records that he does run as high as 2.3 as baseline at times. In the week prior to discharge, it was noted that his creatinine bumped from 1.8 up to 2.3 and as high as 2.6. A Renal consult was obtained. It was thought that this increase was due in part to a Foley that was in the patient's bladder during his hospital stay that relieved his baseline hydronephrosis as well as some dehydration. Per Renal recommendations, the patient was bolused with fluids for a period of 48 hours and continued on maintenance dose. A renal ultrasound was performed which showed mild hydronephrosis of the left kidney. The right kidney was not visualized secondary to the patient's positioning and uncooperative with examination. This was thought to be an improving condition as Renal had suspected from his baseline condition. During this time period, his potassium became elevated as high as 5.6. EKGs continued to remain normal. On discharge, potassium was within normal range at 4.6. Per Renal recommendations, the patient was placed on Florinef. He will follow-up with his own nephrologist, Dr. [**Last Name (STitle) 98846**], upon discharge. According to Renal recommendations, the patient has been receiving weekly Epogen shots. Also, with the increased creatinine, medication adjustments were made according to renal consults regarding the antibiotics. 4. ANEMIA: Of note, the patient received multiple transfusions throughout his hospital stay for low hematocrit secondary to postoperative course. Specifically, he received 2 units of packed red blood cells on [**2174-8-9**], 2 units on [**2174-8-12**], 2 units on [**2174-8-17**], and 4 units on [**2174-8-8**]. The patient remained stable following these blood transfusions and the last hematocrit was approximately 30. 5. PERIANAL ABSCESS: A perianal abscess was noted on [**2174-8-18**] because of the proximity to his flap as well as remaining ulcers. A General Surgery consult was obtained. This was closely watched and followed and was noted to spontaneously open in continuity with the anus on [**2174-8-17**]. This spontaneous fistulotomy required no operative care and the issue is resolved. 6. SEIZURES: The patient has a history of seizures. He was maintained on Keppra 500 b.i.d. This was not an issue during his time on the Plastic Surgery Service. Per the Medicine discharge note, he is to follow-up with Neurology and the [**Hospital 875**] Clinic for further workup. 7. RIGHT SHOULDER PAIN: This was previously noted as an issue on the Medicine Service. The patient had mild right shoulder pain, most likely from the required position that he needed to be in to optimize healing his wounds. He was given appropriate pain medications and he is to follow-up with Orthopedics as needed. 8. PSYCHIATRIC: At times, the patient was found to be withdrawn and occasionally refusing services that would be beneficial to his health. A Psychiatry consult was sought on [**2174-8-25**]. The psychiatric team was familiar with this patient, calling this episode and adjustment disorder with disturbance of mood and conduct and there were no active issues and care remained optimal. CONDITION ON DISCHARGE: Good. DISCHARGE STATUS: The patient will be discharged to [**Hospital **] Rehabilitation for the remaining course of his antibiotics which is 12 days, at which point he can be discharged to home with nursing care. DISCHARGE MEDICATIONS: 1. Meropenem 1 gram IV q. 12. 2. Synercid 400 mg IV q. eight. The patient needs these for 12 more days to complete a six week course. 3. Oxycodone 40 mg q. 12 p.r.n. 4. Percocet one to two tablets q. four to six hours p.r.n. 5. Florinef 0.1 mg p.o. q.d. 6. Keppra 500 mg b.i.d. 7. Metoprolol 50 mg b.i.d. 8. Pepcid 20 mg b.i.d. 9. Xanax 0.5 t.i.d. p.r.n. 10. The patient also received an Epogen every week as well as b.i.d. heparin 5,000 units. NURSING HOME CARE: 1. Antibiotics will be administered for 12 more days through the PICC. Vacuumed. 2. Vacuum changes are required every three to five days. 3. Wet-to-dry dressing changes are needed on the sacral area twice a day. 4. Weekly LFTs are required to be drawn while the patient is on the antibiotics. FOLLOW-UP PLANS: The patient is to follow-up with Dr. [**First Name (STitle) **] one week after discharge from rehabilitation center. The patient is to follow-up with his nephrologist, Dr. [**Last Name (STitle) 98846**]. The patient is to follow-up with the Neurology [**Hospital 875**] Clinic for full workup of seizures of new onset in [**2174-7-26**]. The patient is to follow-up with Orthopedics as needed for further evaluation of right shoulder pain. DR.[**Last Name (STitle) **],[**First Name3 (LF) **] 24-143 Dictated By:[**Last Name (STitle) 101731**] MEDQUIST36 D: [**2174-9-5**] 07:32 T: [**2174-9-5**] 19:35 JOB#: [**Job Number 101732**] Name: [**Known lastname 16370**], [**Known firstname **] P./JR. Unit [**Name2 (NI) **]: [**Numeric Identifier 16371**] Admission Date: [**2174-7-19**] Discharge Date: [**2174-9-6**] Date of Birth: [**2145-10-30**] Sex: M Service: The patient was discharged to [**Hospital3 14**], not [**Hospital3 16372**]. DR.[**Last Name (STitle) 16373**],[**First Name3 (LF) **] 24-143 Dictated By:[**Dictator Info **] MEDQUIST36 D: [**2174-9-6**] 18:37 T: [**2174-9-6**] 19:48 JOB#: [**Job Number 16374**]

[ "907.2", "730.09", "344.1", "780.39", "285.1", "276.5", "566", "591", "707.0" ]

icd9cm

[ [ [] ] ]

[ "99.15", "77.89", "96.04", "00.14", "86.72", "86.22", "96.72", "83.82" ]

icd9pcs

[ [ [] ] ]

19163, 19936

2887, 3014

12954, 18898

4935, 12558

3190, 4271

19954, 21188

190, 2189

4286, 4907

2211, 2861

3031, 3167

18923, 19140

57,735

122,898

26931

Discharge summary

report

Admission Date: [**2109-10-15**] Discharge Date: [**2109-10-17**] Service: NEUROLOGY Allergies: Penicillins / Brimonidine Attending:[**First Name3 (LF) 618**] Chief Complaint: difficulty with speech, LOC Major Surgical or Invasive Procedure: none History of Present Illness: CODE STROKE EVALUATION by fellow: [**Age over 90 **] year old left-handed lady with a history of left atrial myxoma, paroxysmal atrial fibrillation on aspirin (large rectus sheath hematoma while on coumadin), diastolic heart failure, s/p pacemaker placement for sick sinus syndrome, history of DVT, CHF, Alzheimer's dementia, HTN, CRI, and hypothyroidism. At 11:30AM, she was eating lunch and had "lost consciousness for 5 minutes." She was unable to answer questions appropriately. She denied any chest pain but did complain of weakness. Vitals included BP 100/60, Heart rate 60, RR 18 and sats 99% on RA. She was alert but not oriented. This event was also referred to as "syncopy" by [**Hospital 100**] Rehab. EMS was called and noted a left facial droop. She was then taken to [**Hospital1 18**] ED. Unfortunately, she is not able to provide any details of the events. Her daughters were notified that she was being transferred to [**Hospital1 18**] but was not with her at the time. Patient was evaluated and had an NIHSS 4. Per radiology, the well-circumscribed hyderdense lesion at the right cerebellar hemisphere is more consistent with meningioma rather than bleed. Her initial CT evaluation did not show an acute bleed. Past Medical History: Left atrial myxoma, pericardial effusion status post pericardiocentesis, paroxysmal atrial fibrillation on aspirin (large rectus sheath hematoma while on coumadin), diastolic heart failure, s/p Guidant pacemaker placement for sick sinus syndrome, history of DVT, CHF, Alzheimer's dementia, HTN, CRI, hypothyroidism, aspiration PNA, right eye glaucoma, lung cancer on CT scan. Social History: Per [**Hospital 100**] Rehab where she lives, at baseline, she has dementia and difficulty with short term memory. She is able to ambulate independently with a walker. She is able to feed herself. Family History: Non-contributory Physical Exam: Exam on admission: Limited due to patient being Russian speaking and interpreter having difficulty understanding her speech. Vitals: AF HR 60 RR 18 BP 130/103 100% on RA No carotid bruits or thyromegaly. Lungs are clear to auscultation bilaterally. Heart: Regular rate and rhythm with normal S1, normal S2, no murmurs Abdomen soft, nontender, nondistended, no hepatomegaly, 1+ pedal edema bilaterally, palpable peripheral pulses. Awake and alert, knew that she was in the hospital but could not name her birth year. EOM intact, visual fields full, right lower facial droop (per daughters present, they think this is new), LT intact V1 to V3, palate symmetric, tongue midline, trap [**4-9**] bilaterally. Confrontational testing limited by shoulder pain but was able to hold up arms for 10 seconds and legs for 5 seconds. There was no neglect and sensation to light touch and pinprick intact. There was no ataxia with FNF. Bilateral toes downgoing. Examination at time of discharge: Tachypneic. [**Age over 90 **]F 138/64 50s 20-30 100% on shovel mask w/ humidified air. Pulm: decr. brth snds on L, crackles [**12-7**] way up on the right. Eyes closed, but opens eyes to command. She is unable to answer questions with more than one to two words. She is able to follow axial commands. She is oriented to hospital. Inattentive. Speech hypophonic and dysarthric. Pupils 4->2 b/l, right more sluggish R vs. L. VFF to confrontation. R NLF flattening. tongue midline, shoulder shrug intact. L ptosis. Motor: decreased bulk throughout. RUE w/ UMN weakness distribution, with wrist and FEs antigravity only. Otherwise symmetrically weak throughout, but likely due to giveway/effort/attention impairment. DTRs hyperreflexic on RUE, crossed adductor in LEs with increased tone. Otherwise 2, w/ exception of achilles, where it is 0. Sensory: inattentive, can not distinguish R vs. L. Coordination and gati, could not assess. Right toe extensor, L toe flexor. Pertinent Results: labs on admission and discharge: [**2109-10-15**] 01:02PM BLOOD WBC-9.0 RBC-3.82* Hgb-11.1* Hct-32.6* MCV-85 MCH-29.0 MCHC-33.9 RDW-15.7* Plt Ct-157 [**2109-10-17**] 09:10AM BLOOD WBC-8.5 RBC-3.88* Hgb-11.2* Hct-33.0* MCV-85 MCH-28.8 MCHC-33.9 RDW-15.7* Plt Ct-164 [**2109-10-16**] 01:29AM BLOOD PT-12.6 PTT-23.5 INR(PT)-1.1 [**2109-10-15**] 01:02PM BLOOD UreaN-45* Creat-1.4* [**2109-10-16**] 01:29AM BLOOD Glucose-143* UreaN-42* Creat-1.4* Na-145 K-3.9 Cl-104 HCO3-28 AnGap-17 [**2109-10-16**] 09:30PM BLOOD UreaN-32* Creat-1.3* Na-148* K-3.3 [**2109-10-17**] 09:10AM BLOOD Glucose-168* UreaN-32* Creat-1.3* Na-150* K-3.8 Cl-106 HCO3-33* AnGap-15 [**2109-10-16**] 01:29AM BLOOD ALT-13 AST-15 LD(LDH)-210 CK(CPK)-83 AlkPhos-57 TotBili-0.6 [**2109-10-15**] 01:02PM BLOOD CK(CPK)-79 [**2109-10-16**] 01:29AM BLOOD CK-MB-NotDone cTropnT-0.02* [**2109-10-15**] 01:02PM BLOOD cTropnT-0.02* [**2109-10-15**] 01:02PM BLOOD Lipase-57 [**2109-10-16**] 01:29AM BLOOD Albumin-4.5 Calcium-9.3 Phos-4.3 Mg-2.3 [**2109-10-17**] 09:10AM BLOOD Calcium-9.6 Phos-3.1 Mg-2.4 Cholest-PND [**2109-10-17**] 09:10AM BLOOD %HbA1c-5.7 [**2109-10-16**] 08:15AM BLOOD Triglyc-125 HDL-54 CHOL/HD-3.4 LDLcalc-104 [**2109-10-15**] 01:02PM BLOOD ASA-4 Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG Urine studies [**2109-10-17**] 07:34AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.009 [**2109-10-17**] 07:34AM URINE Blood-NEG Nitrite-NEG Protein-TR Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG [**2109-10-17**] 07:34AM URINE RBC-0-2 WBC->50 Bacteri-MANY Yeast-NONE Epi-[**2-7**] [**2109-10-15**] 02:00PM URINE RBC-0 WBC-0-2 Bacteri-0 Yeast-NONE Epi-0 [**2109-10-15**] 02:00PM URINE Blood-SM Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG [**2109-10-15**] 02:00PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.006 Urine lytes: [**2109-10-17**] 07:34AM URINE Hours-RANDOM UreaN-558 Creat-49 Na-64 [**2109-10-17**] 07:34AM URINE Osmolal-403 Imaging studies: EKG on admission: Ventricular paced rhythm. Atrial mechanism is probably atrial fibrillation of [**2109-3-25**] there is no significant change. TRACING #1 Intervals Axes Rate PR QRS QT/QTc P QRS T 59 0 136 470/468 0 -56 117 CT head on admission: IMPRESSION: 29 x 21 mm hyperattenuated rounded focus in the right posterior fossa. Given the relatively well-defined margins, lack of edema, and attenuation slightly low for acute hemorrhage, a hyperattenuated mass with indolent growth is favored. A hemorrhage is not excluded, in light of the presenting symptoms. However, there is no significant mass effect, midline shift, or herniation. As patient cannot undergo MRI (pacemaker), short interval followup head CT would be useful to assess for attenuation stability (hemorrhage evolves rapidly) and exclude rapid enlargement. CT head [**10-16**]: IMPRESSION: 1. Stable high attenuation lesion in the right posterior fossa, most likely consistent with meningioma, less likely corresponds to hemorrhage. However, followup study is recommended with CTA or contrast CT for further characterization. CXR [**10-16**] FINDINGS: In comparison with study of [**2109-3-26**], there is persistent enlargement of the cardiac silhouette with bilateral pleural effusions and elevated pulmonary venous pressure. Pacemaker device remains in place. IMPRESSION: Little overall change EEG [**10-17**] - Preliminary - mild encephalopathy, no epileptiform discharges. Brief Hospital Course: [**Age over 90 **] year old left-handed woman with left atrial myxoma, pAfib on aspirin (large rectus sheath hematoma while on coumadin), diastolic heart failure, s/p pacemaker placement for sick sinus syndrome, history of DVT, CHF, Alzheimer's dementia, HTN, CRI, and hypothyroidism, who presented with an episode of altered level of consciousness (no recorded witness account of what actually happened). On admission her neurological examination was significant for a right facial droop and dysarthria, and this progressed to RUE weakness in UMN distribution on morning after day of admission, along with hypophonic speech, motor aphasia but intact comprehension. NEURO: Given NIHSS score of 4 and initial improvement in the ED, she did not receive tPA. Inintial Head CT was consistent with a meningioma (mass arising from dura), which did not match her neurological exam findings. The possible etiologies included a Sz leading to alteration in level of consciousness (she is at increased risk given history of AD) or a small stroke. She was admitted to neurology service and was treated with IVF, her BP medications were held and blood pressure was allowed to autoregulate. She underwent a repeat head CT which confirmed the findings of a meningioma and also revealed a L posterior IC/thalamus hypodensity, most likely consistent with an acute stroke. Given the location, the most likely etiology was felt to be ischemic, although she is at a high risk of an embolic event (myxoma and afib). Given prior significant bleeding with coumadin, she was maintained on ASA 325mg daily. Her IVF were discontinued give CHF (see below). She underwent EEG to evaluate for encephalopathy which showed mild encephalopathy without epileptiform activity/evidence of NCSE. On the day of discharge, patient remained encephalopathic, aphasic and dysarthric. Encephalopathy was felt to be toxic/metabolic causes (hypernatremia, renal failure and/or possible UTI). PULM/RENAL/CV: Pt was hypoxemic on admission. She has a history of dCHF and was found to be tachypneic on morning of admission, likely due to IVF administration for stroke protocol. EKG was not concerning for ischemia and CXR was consistent w/ CHF, likely an acute on chronic dCHF exacerbation She was maintained on home dose of lasix and provided with IV boluses. Her respiratory status improved mildly o/n, however she developed hypernatremia, admitted with Na 145 which increased to 150. K was repleted. . Urine lytes are shown above, Uosm was 400. Given worsening encephalopathy, Lasix at this time was held and she was given 500cc D5W. Patient was noted to have aspiration by nursing even with nectar thick liquids. She will require aspriation precautions and a repeat S&S evaluation. Patient will require careful volume status monitoring and hyponatremia monitoring. She is felt to be overall volume overloaded but intravascularly volume depleted. She should obtain Chem 7 on admission. GOALS OF CARE. Given patient's underlying dementia, recent stroke and CV comorbidities a goals of care discussion was held with the family. It was confirmed that patient is DNR/I. It was also confirmed that patient would not have wanted tube feeds. Family desired to continue medical management at this time, although they expressed that at some point goals of care would have to be readressed. Hospice care was explained to the family as an option as well. Medications on Admission: Aspirin 325mg QD Calcium Carbonate 650mg PO QD Vitamin D 1000U PO QD Ferous Gluconate 324mg QD Fluticasone 110mcg 2 puffs [**Hospital1 **] Furosemide 20mg PO QD Levoxyl 112mcg QD Metoprolol 12.5mg PO BID Senna 8.6mg PO QHS Travoprost 0.004% eye drops QHS Tylenol 650mg [**Hospital1 **] Diet: 2gm NA, diabetic diet, no peas, rice, or corn Discharge Medications: 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO BID (2 times a day). 3. Cholecalciferol (Vitamin D3) 1,000 unit Tablet Sig: One (1) Tablet PO once a day. 4. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [**Hospital1 **] (2 times a day). 5. Levothyroxine 112 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO twice a day: hold for HR < 60, SBP < 100. 7. Travoprost 0.004 % Drops Sig: One (1) Ophthalmic at bedtime. 8. Acetaminophen 500 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for fever or pain: < 3g in 24 hrs. 9. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 11. 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. 12. Hydralazine 20 mg/mL Solution Sig: Ten (10) mg Injection Q6H (every 6 hours) as needed for SBP > 160. Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - MACU Discharge Diagnosis: Primary: L thalamic and internal capsule stroke; right cerebellum meningioma. Secondary: atrial myxoma, atrial fibrillation, HTN, hypothyroidism. Discharge Condition: Tachypneic. [**Age over 90 **]F 138/64 50s 20-30 100% on shovel mask w/ humidified air. Pulm: decr. brth snds on L, crackles [**12-7**] way up on the right. Eyes closed, but opens eyes to command. She is unable to answer questions with more than one to two words. She is able to follow axial commands. She is oriented to hospital. Inattentive. Speech hypophonic and dysarthric. Pupils 4->2 b/l, right more sluggish R vs. L. VFF to confrontation. R NLF flattening. tongue midline, shoulder shrug intact. L ptosis. Motor: decreased bulk throughout. RUE w/ UMN weakness distribution, with wrist and FEs antigravity only. Otherwise symmetrically weak throughout, but likely due to giveway/effort/attention impairment. DTRs hyperreflexic on RUE, crossed adductor in LEs with increased tone. Otherwise 2, w/ exception of achilles, where it is 0. Sensory: inattentive, can not distinguish R vs. L. Coordination and gati, could not assess. Right toe extensor, L toe flexor. Discharge Instructions: You were admitted to [**Hospital1 18**] with altered conscioussness, new right sided weakness and difficulty with speech. You were found to have an incidental finding of a meningioma. This was not felt to be the cause of your symptoms. You were also found to have a stroke that was contributing to your symptoms. You were continued on aspirin for this. You were also noted to be in heart failure and with elevated sodium. You required use of multiple medications for this. You will continue treatment for these conditions. Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more than 3 lbs. You were discharged to an acute care facility requiring for further care. Should you develop any concerning symptoms, please contact the physician responsible for your care at this facility or go to the emergency room. Followup Instructions: Please call the office of Dr. [**Last Name (STitle) **],[**First Name3 (LF) **] at [**Telephone/Fax (1) 2634**] to set up your follow up appointment. Please call the office of Dr. [**First Name (STitle) **] [**Name (STitle) **] at ([**Telephone/Fax (1) 19129**] to set up a follow up appointment within one month of your discharge from the hospital. Provider: [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2110-1-10**] 11:00 Provider: [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2110-6-4**] 2:30 Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2110-6-4**] 3:00 [**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 632**] Completed by:[**2109-10-17**]

[ "349.82", "244.9", "428.0", "365.9", "225.2", "212.7", "V12.51", "428.33", "276.1", "V10.11", "427.31", "331.0", "V45.01", "784.51", "434.91", "403.90", "294.10", "351.8", "585.9" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

12685, 12751

7727, 11158

263, 269

12941, 13925

4210, 6231

14814, 15649

2172, 2190

11548, 12662

12772, 12920

11184, 11525

13949, 14791

2205, 2210

196, 225

297, 1539

6499, 7704

1561, 1939

1956, 2156

6249, 6253

27,708

170,228

53395

Discharge summary

report

Admission Date: [**2199-10-17**] Discharge Date: [**2199-11-1**] Date of Birth: [**2135-5-2**] Sex: M Service: NEUROLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2569**] Chief Complaint: Slurred speech Major Surgical or Invasive Procedure: endotracheal intubation central venous line insertion radial arterial line insertion History of Present Illness: 64yo RH M h/o HTN, frontal dysfunction who was last known well at 1:30pm. At 6:10pm, he was seen to slump over by his son, who was alarmed that his speech was markedly slurred and he was difficult to arouse for 3-4 minutes. He wheeled him to the couch and called EMS. On their arrival, their exam was notable for "altered mental status", saying he was 29yo and also for mild slurred speech and their screen for stroke was negative, with no significant droop or lateralized weakness. Per the patient, he was "attacked by 4 naked women." On repeat questioning about what happened, he said that his son became alarmed that he had had a stroke. At present, the patient denies all complaints. He says his speech is now normal. He recalls the entire episode, which was not preceeded by any prodrome of feeling faint, palpitations, chest pain or alteration in his thinking. He denies vertigo, diplopia or visual changes, weakness, tingling/numbness, gait difficulty. This morning, he reports that he had a "migraine". These are preceeded by flashing white lights and followed by a retroorbital, throbbing headache. They are a/w photophobia and now occur 3-4 times a week. They first occurred in adolescence then remitted until he was in an MVA a few years ago (with no associated LOC). ROS: On review of systems, the pt denied recent fever or chills. No night sweats or recent weight loss or gain. Denied cough, shortness of breath. Denied chest pain or tightness, palpitations. Denied nausea, vomiting, diarrhea, constipation or abdominal pain. No recent change in bowel or bladder habits. No dysuria. Denied arthralgias or myalgias. Denied rash. Past Medical History: Atrial fibrillation, treated with flecainide, which caused atrial flutter; now s/p two ablations, first in [**2190**], another in [**2195**] h/o migraines Hyperlipidemia h/o MVA with frontal lobe dysfunction: deficits of attention/executive function on recent testing h/o TGA h/o 1mm MCA aneurysm No h/o HTN, DM or CAD PSH: s/p appendectomy Social History: lives at home independently. No h/o tob/etoh/illicit drugs. Former mortgage broker Family History: mother died at 86 of PNA, CHF. Father is unknown to him. Physical Exam: CODE STROKE SCALE: Neurologic (NIHSS): 5 1a. LOC: alert, responsive (0) 1b. LOC questions: knew age and name of month (0) 1c. LOC commands: closed eyes and gripped with **(nonparetic) hand (0) 2. Best gaze: No gaze palsy (0) 3. Visual: left inferior quadrantanopsia (1) 4. Facial Palsy: left facial asymmetry (1) 5a. Left arm: mild drift (1) 5b. Right arm: no drift (0) 6a. Left leg: No drift (0) 6b. Right leg: no drift (0) 7. Limb ataxia: absent (0) 8. Sensory: left face/arm sensory loss (1) 9. Language: No aphasia, normal (0) 10. Dysarthria: None (0) 11. Extinction/inattention: extinguishes visual and tactile stimuli (1) PE VS 97.9 64 134/82 12 98% Gen Awake, cooperative, NAD HEENT NC/AT, no scleral icterus noted, MMM, no lesions noted in oropharynx Neck Supple, no carotid bruits appreciated. No nuchal rigidity Lungs CTA bilaterally CV RRR, nl S1S2, no M/R/G noted Abd soft, NT/ND, normoactive bowel sounds, no masses or organomegaly noted Ext No C/C/E b/l Skin no rashes or lesions noted NEURO MS Awake, alert. Fully oriented. Recites [**Doctor Last Name 1841**] forwards but only two backwards then trails off. Disinhibited and reaches to poke my eyes (like the three Stooges). Impaired luria sequencing. Unable to perform go-no go properly. Speech fluent, with normal naming, [**Location (un) 1131**], writing, comprehension and repetition. Normal prosody. There were no paraphasic errors. Able to follow both midline and appendicular commands. No apraxia. Interprets cookie theft picture appropriately. No dysarthria. CN CN I: not tested CN II: L inferior quadrantanopsia to confrontation, with extinction on the left to DSS. Pupils 3->2 b/l. Fundi clear. CN III, IV, VI: EOMI no nystagmus or diplopia CN V: LT/PP decreased on the left CN VII: mild L facial droop (not on prior neuro eval) CN VIII: hearing intact to FR b/l CN IX, X: palate rises symmetrically CN [**Doctor First Name 81**]: shrug [**4-27**] and symmetric CN XII: tongue midline and agile Motor Normal bulk and tone. No pronator drift D B T WE FE FF IP Q H DF PF TE Sensory intact to LT, PP, JPS, vibration throughout the right side; the left face and arm have decreased LT/PP. Reflexes Br [**Hospital1 **] Tri Pat Ach Toes L 2+ 2+ 2+ 2+ 2+ down R 2+ 2+ 2+ 2+ 2+ down Coordination FFM, RAMs, FTN, HTS all normal Gait deferred, due to need for CT Pertinent Results: Labs [**2199-10-17**] 07:50PM WBC-11.4* RBC-4.45* HGB-14.3 HCT-42.7 MCV-96 MCH-32.1* MCHC-33.5 RDW-14.4 [**2199-10-17**] 07:50PM PLT COUNT-274 [**2199-10-17**] 07:50PM GLUCOSE-109* UREA N-12 CREAT-1.2 SODIUM-141 POTASSIUM-4.0 CHLORIDE-104 TOTAL CO2-28 ANION GAP-13 [**2199-10-17**] 10:05PM PT-11.5 PTT-34.5 INR(PT)-1.010/26/07 06:05AM BLOOD Triglyc-97 HDL-69 CHOL/HD-2.9 LDLcalc-114 [**2199-11-1**] 06:20AM BLOOD PT-24.7* PTT-41.9* INR(PT)-2.5* EKG [**2199-10-17**]: Probable atrial fibrillation. Voltage changes and ST-T wave abnormalities are consistent with left ventricular hypertrophy. Clinical correlation is suggested. Compared to previous tracing the patient is now in atrial fibrillation. Imaging CT/CT-P/ CTA head and neck ([**2199-10-17**]): HEAD CT: There is no evidence of hemorrhage, mass, mass effect or shift of the normally midline structures. The [**Doctor Last Name 352**]- white differentiation is maintained. CT PERFUSION: There is decreased blood flow and increased transit time in the right temporal and right frontal regions in the distributions of teh inferior division of the right middle cerebral artery and the right anterior cerebral artery. There is moderate reduction of the blood volume in these areas, suggesting irreversible injury. CT OF THE HEAD AND NECK: Dental artifact limits visualization of the cervical portion of the carotid arteries and the cervical vessels, which are apperently irregular only in this area. Otherwise, the visualized portions of the carotid and vertebral arteries are unremarkable without evidence of stenosis. The left vertebral artery is hypoplasic. Scattered lymphadenopathy in the anterior neck is not enlarged by CT size criteria. IMPRESSION: 1) Ischemia in the territory of the inferior division of the right middle cerebral artery and the right anterior cerebral artery. This distribution is suggestive of embolic phenomenon. There is moderate reduction in blood volume in these regions, raising a concern that some of the tissue may be irreversibly injured. 2) limited evaluation of the vascular structures in the neck without cervical area MRI ([**2199-10-19**]): MRI OF THE BRAIN: Diffusion abnormalities are noted in the right MCA territory consistent with acute/subacute stroke. There is no shift of normally midline structures, intra- or extra-axial hemorrhage. The orbits, paranasal sinuses and mastoid air cells within normal limits MRA OF THE CIRCLE OF [**Location (un) **]: There is occlusion of the distal branches of the posterior right MCA. The previously demostrated 1 mm aneurysm in the right M1 segment of the middle cerebral artery is again noted just proximal to the bifurcation and unchanged. Multiple bilateral FLAIR hyperintensity foci likely represent chronic microvascular ischemic changes. MRA OF THE CAROTIDS AND VERTEBRAL ARTERIES: The carotids and vertebral arteries are visualized from the origins to the intracranial courses. Hypoplastic left vertebral artery. No significant carotid stenosis. IMPRESSION: 1. Occlusion of the distal branches of the right MCA with large acute stroke. 2. Unchanged 1 mm right M1 MCA aneurysm. Transthoracic echocardiogram: [**2199-10-18**] The left atrium is moderately dilated. No left atrial mass/thrombus seen (best excluded by transesophageal echocardiography). No atrial septal defect or patent foramen ovale is seen by 2D, color Doppler or saline contrast with maneuvers. Left ventricular wall thickness, cavity size, and systolic function are normal (LVEF>55%). Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Tissue Doppler imaging suggests a normal left ventricular filling pressure (PCWP<12mmHg). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are structurally normal. Very mild (1+) mitral regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. Compared with the prior study (images reviewed) of [**2195-2-16**], the rhythm is now atrial fibrillation and mild mitral regurgitation is now identified. The severity of aortic regurgitation is similar. CT OF THE PELVIS WITH INTRAVENOUS CONTRAST ([**2199-10-19**]): The rectum, sigmoid colon, bladder, prostate, seminal vesicles, ureters are within normal limits. The bladder contains a foley balloon . BONE WINDOWS: No suspicious lytic or sclerotic lesion is detected. Degenerative changes are seen, most notably at L5-S1 endplates. IMPRESSION: 1. Bilateral lower lobe atelectasis/consolidation. 2. Patchy areas of low attenuation within both kidneys, some of which appear wedge-shaped concerning for renal infarction. 3. Linear opacity within the proximal SMA which is most concerning for dissection.* No evidence of bowel ischemia at this time. * Was no borne out clinically on hospitalization Brief Hospital Course: Mr. [**Known lastname 95655**] is a 64 year old right handed gentleman with history of atrial fibrillation on antiarrhythmic s/p ablation, hyperlipidemia who had transient, severe dysarthria that resolved. His Neuro exam at presentation, in addition to frontal lobe dysfunction that appears to be chronic, was significant for new onset left facial asymmetry, as well as either primary visual field defects (left homonymous inferior quadrantanopsia) and left face/arm sensory loss; or alternatively neglect (although cookie jar picture interpretation at presenation was intact). 1) Right inferior division MCA infarction- The patient was found to have a R inferior division MCA infarct by CT perfusion images. He presented out of the window for IV tPA. IA tPA or merci retrieval was not justified due to the nature of his deficits risks of the procedure. The etiology of his infarct was likely embolic in the setting of recurrent atrial fibrillation. He was admitted to the stroke service where he was started on heparin IV goal PTT 50-70 given suspected cardioembolic source of the infarct. The morning following admission the patient developed transient worsening of left facial droop and dysarthria. Repeat head CT was stable in appearance. This recurred later in the afternoon, and his PTT was noted to be above therapeutic range at 97.5. Repeat head CT revealed stable size of hyperdense R MCA parietal territory however [**12-25**] microhemorrhages vs. hyperdense MCA sign consistent with vessel occlusion. His blood pressures were noted to be SBP's 110's and it was thought the infarct penumbra may be hypoperfused given loss of cerebral blood autoregulation s/p infarction. He was transferred to the ICU for tighter blood pressure regulation, with goal SBP's > 140 and closer neurological monitoring given concern for early hemorrhagic conversion. In the ICU the patient underwent central line placement and aterial line placement and was started on neosynephrine to maintain SBP's > 140mmHg. The patient became markedly agitated on ICU day #2 and required four point restraints, leading to intubation. On HD #4 pressors were weaned and the patient was intubated. He was started on vancomycin and zosyn on [**10-22**] for fevers in setting of RML infiltrate by chest x ray for presumed aspiration pneumonia; he completed a 10-day course of these antibiotics. He was transferred to the neuroscience step-down unit for further care. Neurologically, his exam improved over time: he had significant improvement of the strength and attention to his left arm and by the time of discharge, the facial droop was barely noticable. His walking remained mildly unsteady, thus physical therapy recommended rehab. His course in the stepdown unit was initially notable for agitation and confusion at night (consistent with sundowning), sometimes with hallucinations. This was felt to be a combination of reversal of his sleep-wake cycle, his underlying frontal lobe dysfunction (chronic, question of frontotemporal dementia) and the new stroke. Initially he required medications for sleep and a 1:1 sitter. This improved with time and with orientation via family members involved in his care, and by the time of discharge he was sleeping well at night. Of note, Mr. [**Known lastname 95655**] was discovered to have vocal cord paralysis and oropharyngeal paresis, likely a result of the intubation in the ICU. He worked with the speech pathologists and should continue at rehab to work on vocalization exercises. Initially he was unable to swallow safely due to incomplete vocal cord closure and thus risk of poor cough. He was reassessed by the swallow specialists and approved for a modified diet the week of discharge. No further signs of aspiration were seen, and the swallowing function was not felt to have been damaged by the stroke. Periodically he complained of mild, dull headaches and was treated with tylenol, ibuprofen (discontinued after rising creatinine), and fioricet. The headaches responded to Percocet at times. There were no changes in his neuro exam or other symptoms associated with these headaches. Of note, he has R frontal headaches at baseline and has so for many years, many with visual scotomata, suggestive of migraines. He had no similar headaches in the last week of his hospital stay. 2) Atrial Fibrillation- He had failed ablative therapy and pharmacotherapy on flecainide, and had presented with this acute R MCA infarction. He will require life long anticoagulation on coumadin for secondary prevention of stroke. Metoprolol was started for rate control, and eventually he was restarted on anticoagulation with heparin and then coumadin. On the day of discharge, his rhythm was again normal sinus. At the time. In response to this, cardiology recommended restarting his calcium channel blocker and flecanide. He should follow up with his cardiologist as an outpatient following discharge. Of note, cardiology had concerns about anticoagulation in this patient, who was found incidentally to have a possible 1mm aneurysm at the RMCA; however, the neurology service felt that the benefits of prevention of further strokes outweighed the minimal risks associated with a small vascular anomaly, and he was anticoagulated after discussion with the family. 3) Renal infarcts and possible SMA occlusion- The patient complained of abdominal pain on ICU day #2. He underwent contrasted CT of the abdomen revealing concern for wedge shaped renal infarcts and partial superior mesenteric artery occlusion. Vascular surgery was consulted and did not deem the SMA partial occlusion a surgical condition; further imaging revealed this to be potentially artifactual. Renal infarcts were felt to be likely embolic in nature relating to afib and will require coumadin anticoagulation. Further in his hospital course on the floor, he developed an elevated creatinine. He was seen by the renal specialists for this problem (below). 4) Renal failure- He was found to have a rising creatinine and was seen by the renal service for this while he was on the floor. Though he had been on some renally cleared medications and ibuprofen at time for headaches, renal felt ultimately after checking urine eosinophils (negative) and urine lytes (unremarkable) that the most likely explanation was damage incurred with the renal infarcts and possible dehydration. Of note, his foley was discontinued periodically with some difficulty urinating, likely the result of prostate hypertrophy. The day of discharge, he had trouble voiding; nursing recommended timed voids attempted with straight-catheterization if necessary every 6 hours once he arrives at rehab. He was hypernatremic to 147, then receiving D5W over 2 days at 55 cc/hr to correct a free water deficit. On the day of discharge, his sodium was 146 and he received addition free water, per renal recommendations. His sodium should be checked periodically at rehab. 5) FEN- NG tube was attempted multiple times, in addition to assistance from interventional radiology without initial success, but later with success. He eventually was able to swallow following the vocal cord paralysis (as above), and he resumed a modified diet. 6) ID- His aspiration pneumonia was treated with ten days of antibiotics (as above); on the day of discharge, his white blood cell count was stably high (12-13,000 range) with no fevers and no abnormal blood or urine cultures. Medications on Admission: ASA 325 Lipitor 10 Flecanide 150mg [**Hospital1 **] Cartia 120 Zoloft 100mg [**Hospital1 **] Discharge Medications: 1. Sertraline 100 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 2. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Ipratropium Bromide 0.02 % Solution Sig: 1-2 puffs Inhalation Q6H (every 6 hours) as needed. 4. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical QID (4 times a day) as needed. 5. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours). 6. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO DAILY16 (Once Daily at 16). 7. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for headache. 8. Flecainide 50 mg Tablet Sig: Two (2) Tablet PO Q12H (every 12 hours). 9. Diltiazem HCl 120 mg Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO DAILY (Daily). Discharge Disposition: Extended Care Facility: [**Location (un) **] Discharge Diagnosis: -Right MCA stroke -Atrial fibrillation -Renal failure in the setting of bilateral renal infarcts -Aspiration pneumonia -Vocal cord paralysis and pharyngeal paresis possibly related to intubation Discharge Condition: Good. Neurologically, his exam improved over time: he had significant improvement of the strength and attention to his left arm and by the time of discharge, the facial droop was barely noticable. His walking remained mildly unsteady. Discharge Instructions: Please take your medications as prescribed and follow up with appointments as scheduled. You are on warfarin to thin your blood for stroke given your history of atrial fibrillation. The INR should be checked regularly (daily at first), with the target range between [**1-26**]. Should you have any additional concerning, worsening, or new symptoms, such as new visual changes (loss), dysarthria, or weakness, then please contact Dr. [**First Name8 (NamePattern2) 2530**] [**Name (STitle) 2531**] office ([**Telephone/Fax (1) 7394**] or the on-call [**Hospital3 **] neurologist at ([**Telephone/Fax (1) 2529**]. Of note, the patient voided on the morning of hospitalization, but not thereafter. A straight-cath revealed 250cc of urine in the afternoon. If the patient does not urinate, he should be bladder-scanned (and straight-cathed, if necessary) every 6 hours until he does so on his own. Furthermore, his sodium was mildly elevated on the day of discharge at 146; the sodium level should be checked daily until it is stably within normal limits. The patient may require additional free water to correct this hypernatremia. Followup Instructions: 1) Please call the office of Dr. [**First Name8 (NamePattern2) 2530**] [**Name (STitle) **] at ([**Telephone/Fax (1) 19129**] to set up an appointment with him in the neurology stroke clinic in the next 2-4 weeks. 2) You have the following appointment cardiologist in approximately 4 weeks. please call his office to determine if he would like to see you sooner. Provider: [**Name10 (NameIs) 1918**] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 902**] Date/Time:[**2199-12-5**] 3:20 3) Please call your primary care physician, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2903**] at ([**Telephone/Fax (1) 2941**], to arrange follow up after your hospitalization. He should be seen in the next 2-4 weeks, if possible. [**First Name8 (NamePattern2) **] [**Name8 (MD) 162**] MD [**MD Number(2) 2575**]

[ "276.2", "348.30", "507.0", "403.90", "346.90", "599.69", "434.11", "784.5", "593.81", "427.31", "600.91", "V58.61", "478.30", "276.51", "585.3", "781.94", "272.4", "787.29", "443.29", "584.9", "041.19", "442.81" ]

icd9cm

[ [ [] ] ]

[ "38.91", "96.6", "96.71", "99.21", "87.03", "96.04", "38.93" ]

icd9pcs

[ [ [] ] ]

18458, 18505

10069, 17522

332, 418

18744, 18982

5042, 5807

20166, 21063

2583, 2642

17666, 18435

18526, 18723

17548, 17643

19006, 20143

2657, 5023

277, 294

446, 2100

5817, 10046

2122, 2466

2482, 2567

26,408

102,983

18070

Discharge summary

report

Admission Date: [**2143-2-6**] Discharge Date: [**2143-4-5**] Service: HISTORY OF PRESENT ILLNESS: The patient is an 88 year old woman status post an episode of dizziness and headache and found to have a cerebellar hemorrhage at an outside hospital. Patient had dizziness and vomiting at a bank in the afternoon on the day of admission and was driving erratically. She was brought to [**Hospital **] Hospital where she vomited coffee ground material and head CT showed a cerebellar bleed. Patient then deteriorated neurologically, became sleepy with slurred speech, was intubated and sedated and transferred to [**Hospital1 1444**] for further management. PAST MEDICAL HISTORY: AAA. Hypertension. COPD. Hypothyroidism. Status post right ankle ORIF in [**2142-12-19**]. MEDICATIONS: Levoxyl, Lipitor, Evista, Diovan, Dyazide, folic acid. ALLERGIES: Aspirin and ACE inhibitors. PHYSICAL EXAMINATION: Blood pressure was 110/50, heart rate 65, respiratory rate 14, sat 100% she was intubated. In general, she responded to painful stimuli. Chest was clear to auscultation. Heart regular rate and rhythm. Abdomen was soft, nondistended, nontender. She had mild leg edema. She was decerebrate posturing and unresponsive neurologically when she came in. LABORATORY DATA: White count 14, hematocrit 36.1, platelets 205. Sodium 137, chloride 102, CO2 30, BUN 25, creatinine 1.3. INR 1.0. CPK 174, MB 7.6, troponin less than 0.2. Head CT showed a 4 cm left to midline cerebellar hemorrhage with compression of the fourth ventricle. HOSPITAL COURSE: The patient was admitted to the neurosurgical intensive care unit where a ventricular drain was placed without complications. Neurologically post drain patient was following commands, showing two fingers, left arm maybe slightly weaker than the right. Pupils were 6 down to 3.5 mm. She had possible doll's eyes. On [**2143-2-8**] patient was awake, attentive. Speech with mild slurring. She was oriented times three. Pupils left 6 down to 3, right 4.5 down to 2.5. EOMs were full. She had severe left upper extremity ataxia without significant drift. Moving all extremities with good strength. She was neurologically stable. Her vent drain was leveled at 10 cm above the tragus, keeping her systolic blood pressure less than 140. She was on steroids to assist with brain swelling. She had a repeat head CT on [**2143-2-8**] that showed good placement of the ventricular catheter. Ventricles were slightly smaller, although the fourth ventricle was still clotted with blood. The patient continued to remain neurologically stable. On [**2143-2-10**] the vent drain was not working and it was replaced. Patient was extubated on the 19th after vent drain placement and patient's neurologic status improved. Patient continued to remain stable and the vent drain was replaced on [**2143-2-10**]. Patient was on ceftriaxone for vent drain prophylaxis. On [**2143-2-12**] patient again was awake, alert, slight slurred speech. No drift, but mild ataxia. Moving all extremities with good strength. The patient continued to remain stable until [**2143-2-13**] when she had the sudden onset of left sided weakness and agitation. Repeat head CT was basically unchanged. Her weakness eventually resolved. She was seen by the stroke service who felt the CT was basically unchanged. Patient also had an MRI after the CT scan which did not show any infarct. Patient's left sided weakness eventually resolved. On [**2-14**] patient was awake, alert and oriented times three. EOMs were full. Smile was symmetric. She had no drift at that point. She was back to her baseline. Vent drain continued to drain clear CSF. She was seen by physical therapy and occupational therapy and was followed closely by the rehab service. On [**2-18**] patient was awake, alert and oriented times three. Patient did have slight left pronator drift. Her IPs were [**4-22**]. She remained neurologically stable. We began weaning the ventricular drain. It was raised to 15 cm above the tragus on [**2-18**]. She was weaned off steroids and remained on 2 liters of O2 via nasal cannula. On [**2143-2-21**] the patient had a repeat head CT after having had her vent drain clamped for 24 hours. It did show dilated ventricles, therefore, the drain was opened and left at 20 cm above the tragus. Patient remained neurologically stable despite hydrocephalus. She was awake, alert and oriented with no drift. On [**2143-2-28**] patient developed the acute onset of left hemiparesis and lethargy. Repeat head CT showed extension of the bleed in the right frontal area where the vent drain had been placed. Therefore, patient was taken to the O.R. for evacuation of this intracranial hemorrhage. Post-op vital signs were stable. She was intubated and sedated. Pupils were equal, round and reactive to light. On the 14th patient opened her eyes to stimulation. She moved her right leg, wiggled her right toes. She had left hemiparesis. She withdrew slightly to pain on the left. Pupils were 5 down to 3.5 mm and briskly reactive. She continued to have the vent drain and now at 10 cm above the tragus. From a neurologic standpoint she was ready to be weaned from the ventilator as tolerated. On [**2143-3-2**] the patient had a repeat head CT which showed no change. Patient remained on Nipride. Blood gases were stable with an elevated CO2 level. Patient was arousable and oriented, following commands and moving all extremities to command. MRA screening test was negative. Patient again had an attempt at weaning her ventricular drain which she did not tolerate the second time. Therefore, she was scheduled for VP shunt placement. On [**2143-3-5**] patient's respiratory status deteriorated and she required reintubation. On [**2143-3-8**] patient had right VP shunt placed. Intra-op there were no complications. Patient's post-op course was complicated by patient's inability to wean from the vent. She was arousable, wiggled her toes. Pupils were 6 down to 5 mm and brisk. On [**3-14**] patient was moving all extremities to sternal rub, following commands, squeezing on the right, although weakly. Moving the left side. The patient was extubated and had rising CO2 on her blood gas. On [**3-16**] patient was arousable, following commands, moving all extremities to command, right greater than left. Continued to have rising CO2 of 70 on her blood gas. She continued to be extubated and was on cool mist face mask at 4 liters. Due to the rising CO2, patient became more lethargic. At that time family was approached for code status. A family meeting was held on [**2143-3-18**]. They wished for patient to be DNR/DNI, although as far as trach and PEG, patient's family wanted to discuss it and would get back to the team. The patient's family ultimately decided that she should be trached. Therefore, she had trach placement. Neurologically on [**2143-3-21**] patient's pupils were 6 down to 5 mm. She opened her eyes. She moved all extremities and lifted both arms up off the bed to command. Patient's family did decide on trach and PEG. Patient had a trach placed on [**2143-3-26**] without complications. A PEG was placed the following day without complications. Patient was transferred to the floor on [**2143-3-31**] where she has remained neurologically stable. She was awake. She was easily arousable, opened eyes, followed commands, moved all extremities. Has been out of bed to chair. Patient's O2 requirements began climbing on [**2143-4-2**] and, therefore, repeat chest x-ray was obtained. Patient had bilateral pleural effusions which she has had since early in her admission. She had pleural tap done in the ICU and was looking like she was going to require a second pleural tap. The interventional pulmonary service was consulted on [**2143-4-4**] and a pleural effusion tap was done on [**4-4**] without complications. The patient's condition has remained neurologically stable. She is awake, alert and oriented times three, moving all extremities. Is at times sleepy, but easily arousable. Has been out of bed to chair. Has been continuously followed by the rehab service and is felt to require a rehab stay prior to discharge to home. DISCHARGE MEDICATIONS: 1. Vancomycin 1 gm IV q.24 hours for line infection. 2. Epogen 40,000 units subcu q.Monday. 3. Synthroid 100 mcg p.o. q.day. 4. Zantac 150 mg p.o. b.i.d. 5. Miconazole powder 2% one application topically t.i.d. 6. Insulin sliding scale. 7. Colace 100 mg p.o. b.i.d. 8. Hydralazine 10 mg p.o. q.six hours p.r.n. for systolic blood pressure greater than 160. 9. Metoprolol 25 mg p.o. t.i.d., hold for systolic blood pressure less than 95, heart rate less than 60. CONDITION ON DISCHARGE: Stable. FOLLOWUP: She will follow up with Dr. [**Last Name (STitle) 1132**] in one month with repeat head CT at that time. [**Name6 (MD) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 1133**] Dictated By:[**Last Name (NamePattern1) 344**] MEDQUIST36 D: [**2143-4-4**] 14:28 T: [**2143-4-4**] 16:52 JOB#: [**Job Number 50007**]

[ "331.4", "496", "424.1", "435.9", "998.59", "511.9", "431", "599.0", "518.5" ]

icd9cm

[ [ [] ] ]

[ "01.39", "96.72", "38.93", "31.1", "43.11", "02.42", "96.6", "02.2", "34.91" ]

icd9pcs

[ [ [] ] ]

8304, 8776

1576, 8281

923, 1558

111, 671

694, 900

8801, 9183

32,611

141,765

44370

Discharge summary

report

Admission Date: [**2192-7-7**] Discharge Date: [**2192-7-12**] Date of Birth: [**2124-2-25**] Sex: F Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 7760**] Chief Complaint: Transfer from [**Hospital1 18**]-[**Location (un) 620**] for an acute desaturation s/p small bowel resection requiring intubation. Major Surgical or Invasive Procedure: Small bowel resection with primary anastomosis History of Present Illness: Ms. [**Known lastname 95131**] is a transfer from [**Hospital1 18**]-[**Location (un) 620**]. The day prior to arrival she underwent a small bowel resection with primary anastomosis for a GI bleed from jejunal diverticulae. Post-operatively she had to be re-intubated for an acute oxygen desaturation. She was transfered to the surgical ICU at [**Hospital1 18**] for further treatment. Past Medical History: 1. Hypertension 2. Hypothyroidism 3. Hyperlipidemia 4. H/O uterine prolapse Social History: She denies tobacco use and admits to occasional alcohol use. Family History: Non-contributory Physical Exam: On discharge: Gen: no acute distress CV: RRR, no murmurs Pulm: clear bilaterally Abd: soft, nontender, nondistended, normal bowel sounds Ext: 2+ distal pulses, no edema, moves all extremities well Pertinent Results: Chest x-ray: IMPRESSION: Hazy density at the lung bases probably represent small pleural effusions. Subsegmental atelectasis. The nasogastric tube is somewhat high. Admission CBC [**2192-7-7**] 10:42AM BLOOD WBC-14.8* RBC-3.37*# Hgb-10.6*# Hct-30.1*# MCV-89 MCH-31.4 MCHC-35.1* RDW-14.9 Plt Ct-177 [**2192-7-8**] 03:13AM BLOOD WBC-13.3* RBC-2.74* Hgb-8.8* Hct-24.4* MCV-89 MCH-31.9 MCHC-35.9* RDW-14.9 Plt Ct-142* [**2192-7-8**] 11:14AM BLOOD Hct-24.4* [**2192-7-8**] 04:59PM BLOOD Hct-23.2* [**2192-7-9**] 05:23AM BLOOD WBC-10.4 RBC-2.28* Hgb-7.4* Hct-21.1* MCV-93 MCH-32.3* MCHC-34.8 RDW-14.6 Plt Ct-161 Post-transfusion CBC [**2192-7-9**] 11:22PM BLOOD WBC-9.6 RBC-3.19*# Hgb-9.9*# Hct-27.9*# MCV-88 MCH-31.1 MCHC-35.5* RDW-15.3 Plt Ct-172 [**2192-7-10**] 09:44AM BLOOD WBC-10.0 RBC-3.49* Hgb-10.9* Hct-31.5* MCV-90 MCH-31.1 MCHC-34.5 RDW-15.1 Plt Ct-215 Discharge CBC [**2192-7-12**] 05:20AM BLOOD WBC-8.4 RBC-3.55* Hgb-11.0* Hct-31.4* MCV-88 MCH-31.0 MCHC-35.1* RDW-15.5 Plt Ct-247 [**2192-7-7**] 10:42AM BLOOD Glucose-142* UreaN-14 Creat-0.5 Na-144 K-4.0 Cl-114* HCO3-25 AnGap-9 [**2192-7-9**] 05:23AM BLOOD Glucose-79 UreaN-14 Creat-0.4 Na-140 K-3.3 Cl-106 HCO3-29 AnGap-8 [**2192-7-10**] 09:44AM BLOOD Glucose-128* UreaN-20 Creat-0.5 Na-142 K-3.3 Cl-107 HCO3-25 AnGap-13 [**2192-7-12**] 05:20AM BLOOD Glucose-109* UreaN-11 Creat-0.5 Na-141 K-3.6 Cl-106 HCO3-29 AnGap-10 [**2192-7-11**] 10:51AM URINE Blood-MOD Nitrite-NEG Protein-NEG Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-8.0 Leuks-SM [**2192-7-11**] 10:51AM URINE RBC-2 WBC-46* Bacteri-OCC Yeast-NONE Epi-<1 Brief Hospital Course: Ms. [**Known lastname 95131**] was transferred from [**Hospital1 18**]-[**Location (un) 620**] intubated and in stable condition. She was transferred due to an acute oxygen desaturation requiring re-intubation. The day prior to transfer she underwent a small bowel resection with primary anastomosis for a GI bleed from jejunal diverticulae. She did very well upon arrival and was extubated shortly thereafter. She remained NPO and was gently diuresed to improve her respiratory status. She was transferred out of the ICU in good condition. Her hematocrit dropped a low of 21.1 on HD3. Her vital signs remained stable, she did not become tachycardic or hypotensive, and her urine output remained more than adequate. She was transfused with 2 units of packed RBCs and her post-transfusion hematocrit was 27.9. Her hematocrit remained stable throughout the duration of her hospital stay and it was 31.4 on the day of discharge. Her diet was slowly advanced when it was evident that her bowel function had returned. On the day of discharge she was tolerating a soft diet without complaints or difficulty. All of her home medications were restarted without difficulty. She reported a recent history of recurrent UTI's and had complaints of some urinary frequency/urgency. A urinalysis was obtained that showed many WBC's in the sediment. She was started on a 3 day course of levaquin. Her potassium remained low despite repletion so she was discharged on oral potassium tablets with instructions to follow up with her PCP for [**Name Initial (PRE) **] workup. She was able to ambulate on her own and she ambulated up and down a flight of stairs without difficulty. She was discharged in good condition. Medications on Admission: 1. Levothyroxine 75mcg daily 2. HCTZ 25mg daily 3. Atorvastatin 10mg daily 4. Lisinopril 10mg daily Discharge Medications: 1. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Hydrochlorothiazide 25 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 3. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed. 5. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Levaquin 500 mg Tablet Sig: One (1) Tablet PO once a day for 3 days. Disp:*3 Tablet(s)* Refills:*0* 7. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two (2) Capsule, Sustained Release PO once a day for 7 days. Disp:*14 Capsule, Sustained Release(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: 1. GI Bleed s/p small bowel resection with primary anastomosis 2. UTI 3. Hypokalemia Discharge Condition: Good Discharge Instructions: Please call your surgeon if you develop chest pain, shortness of breath, fever greater than 101.5, foul smelling or colorful drainage from your incisions, redness or swelling, severe abdominal pain or distention, persistent nausea or vomiting, inability to eat or drink, BRIGHT RED BLOOD from your rectum, or any other symptoms which are concerning to you. No tub baths or swimming. You may shower. If there is clear drainage from your incisions, cover with a dry dressing. Activity: No heavy lifting of items [**9-24**] pounds until the follow up appointment with your doctor. Medications: Resume your home medications. You should take a stool softener, Colace 100 mg twice daily as needed for constipation. You may take Tylenol as needed for pain. You will be given a prescription for potassium pills to take daily. Followup Instructions: Follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 6633**] in 1 week. Call her office at ([**Telephone/Fax (1) 6347**] to schedule your appointment. Follow up with your primary care physician as soon as possible to have your potassium level checked.

[ "276.8", "244.9", "997.3", "562.02", "V45.89", "599.0", "518.0", "E878.2", "285.9", "272.4", "401.9" ]

icd9cm

[ [ [] ] ]

[ "96.71" ]

icd9pcs

[ [ [] ] ]

5484, 5490

2961, 4677

444, 493

5619, 5626

1354, 2938

6496, 6781

1103, 1121

4828, 5461

5511, 5598

4703, 4805

5650, 6473

1136, 1136

1151, 1335

274, 406

521, 910

932, 1009

1025, 1087

62,613

131,571

46624

Discharge summary

report

Admission Date: [**2122-1-13**] Discharge Date: [**2122-1-19**] Date of Birth: [**2071-3-22**] Sex: M Service: NEUROSURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 3227**] Chief Complaint: Headache, nausea. Major Surgical or Invasive Procedure: [**2122-1-15**]: Right sided craniotomy for mass resection History of Present Illness: 50 year old male with known GBM diagnosed with biopsy by Dr. [**Last Name (STitle) **] last year present with severe headache on the night of [**1-12**], which was associated with nausea. He went to his radiation appointment on [**1-13**] in the morning and was sent for a stat head CT. The scan showed significant edema around the area of the mass. His wife also reports that he has had difficulty with depth perception recently. For example, when opening the cabinet to get a coffee cup, he would hit his head on the cabinet door. Similarly, he runs into polls that are right in front of him. The patient was given 4 mg of decadron and sent to the ER. Past Medical History: 1. Recurrent left spontaneous pneumothoraces with left apical blebs, s/p left upper lobe bleb resection, pleurodesis, and sclerosis in [**2105**]; had post operative air leak requiring exploratory thoracotomy 2. Right tension pneumothorax, s/p bullectomy with mechanical pleurodesis in [**2108**] 3. Childhood strabismus, s/p multiple corrective procedures, last at age 14 4. Benign connective tissue nevus Social History: Lives with wife and two children. Former smoker, 1-2 packs daily for 10 years but quit years ago. He denies a history of illicit drug use. He drinks "an occasional beer." Family History: Son had a febrile seizure at age eight. Has a niece with generalized seizures, now ~age 27. No stroke, hemorrhage, or aneurysm. Physical Exam: On Admission: T:97.9 BP:138/96 HR:89 RR:14 O2Sats:100% RA Gen: WD/WN, comfortable, NAD. HEENT: Pupils:PERRL EOMs-intact Neck: Supple. Lungs: CTA bilaterally. Cardiac: RRR. S1/S2. Abd: Soft, NT, BS+ Extrem: Warm and well-perfused. Neuro: Mental status: Awake and alert, cooperative with exam, normal affect. Orientation: Oriented to person, place, and date. Language: Speech fluent with good comprehension and repetition. Naming intact. No dysarthria or paraphasic errors. Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light, to 3-2 mm bilaterally. Visual fields are full to confrontation. III, IV, VI: Extraocular movements intact bilaterally without nystagmus. V, VII: Facial strength and sensation intact and symmetric. VIII: Hearing intact to voice. IX, X: Palatal elevation symmetrical. [**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally. XII: Tongue midline without fasciculations. Motor: Normal bulk and tone bilaterally. No abnormal movements, tremors. Strength full power [**4-21**] throughout. No pronator drift. Sensation: Intact to light touch bilaterally. Toes downgoing bilaterally On Discharge: NEURO EXAM IS INTACT HOWEVER HE LISTS TO THE LEFT WHEN AMBULATING AND HAS A BILATERAL HOMONYMOUS HEMIANOPSIA ON THE LEFT Pertinent Results: Labs on Admission: [**2122-1-13**] 12:10PM BLOOD WBC-15.8*# RBC-4.67 Hgb-14.9 Hct-40.4 MCV-87 MCH-31.9 MCHC-36.9* RDW-13.4 Plt Ct-322 [**2122-1-13**] 12:10PM BLOOD Neuts-86.7* Lymphs-9.8* Monos-2.0 Eos-1.1 Baso-0.4 [**2122-1-14**] 02:19AM BLOOD PT-13.9* PTT-30.6 INR(PT)-1.2* [**2122-1-14**] 02:19AM BLOOD Calcium-9.2 Phos-3.5 Mg-2.1 IMAGING: Head CT [**1-13**]: FINDINGS: While the known right parietal mass is suboptimally evaluated on this noncontrast head CT, it appears significantly larger than on [**2121-12-7**]. A hyperdense rim within the mass may indicate blood products. There is a marked increase in vasogenic edema surrounding the mass. There is a mild shift of the septum pellucidum and the third ventricle to the left. There is near-complete effacement of the atrium of the right lateral ventricle. The temporal [**Doctor Last Name 534**] of the right lateral ventricle is newly dilated, suggestive of trapping.A right parietal burr hole is again seen. The imaged portions of the paranasal sinuses and mastoid air cells are normally aerated. [**Known lastname **],[**Known firstname **] K [**Medical Record Number 98999**] M 50 [**2071-3-22**] Radiology Report MR HEAD W & W/O CONTRAST Study Date of [**2122-1-16**] 10:06 AM [**Last Name (LF) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 12630**] TSICU [**2122-1-16**] SCHED MR HEAD W & W/O CONTRAST Clip # [**0-0-**] Reason: please evaluate for residual tumor burden. Must be completed Contrast: MAGNEVIST [**Hospital 93**] MEDICAL CONDITION: 50 year old man with REASON FOR THIS EXAMINATION: please evaluate for residual tumor burden. Must be completed within 36hrs post-op CONTRAINDICATIONS FOR IV CONTRAST: None. Provisional Findings Impression: DBH [**First Name9 (NamePattern2) **] [**2122-1-16**] 4:20 PM PFI: Status post resection of glioblastoma with no evidence of residual enhancing tumor. Final Report MR HEAD WITHOUT AND WITH CONTRAST [**2122-1-16**] HISTORY: Evaluate for residual after tumor resection. Sagittal and axial short TR, short TE spin echo imaging was performed through the brain. After administration of 14 ml of Magnevist intravenous contrast, axial imaging was performed with FLAIR, gradient echo, long TR, long TE fast spin echo, diffusion, and short TR, short TE spin echo technique. Sagittal MP-RAGE images were obtained and reformatted into axial and coronal orientations. Comparison to a brain MR [**First Name (Titles) **] [**2122-1-13**]. FINDINGS: In the interval, the patient has undergone resection of the right temporal and deep white matter masses noted on the prior study. Although there is a thin rim of enhancement surrounding the surgical site, the best radiologic evidence is that the enhancing neoplasm has been completely resected. Again seen is high signal intensity on the FLAIR images, extending across the splenium of the corpus callosum, presumably reflecting tumor infiltration. There is expected postoperative hemorrhage at the surgical site and a tiny fluid collection is noted. There is mild dural thickening, again presumably related to surgery. Although the enhancing portion of the tumor appeared to reach the ependymal surface of the right lateral ventricle, there is no evidence of intraventricular enhancement to suggest seeding of the tumor. CONCLUSION: Status post resection of glioblastoma with no evidence of residual enhancing tumor. DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) 7415**] Approved: SAT [**2122-1-17**] 4:22 PM Imaging Lab [**Known lastname **],[**Known firstname **] K [**Medical Record Number 98999**] M 50 [**2071-3-22**] Radiology Report CT HEAD W/O CONTRAST Study Date of [**2122-1-15**] 3:19 PM [**Last Name (LF) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 12630**] TSICU [**2122-1-15**] SCHED CT HEAD W/O CONTRAST Clip # [**Clip Number (Radiology) 99000**] Reason: please evaluate for post-op bleeding; must be completed with [**Hospital 93**] MEDICAL CONDITION: 50 year old man with REASON FOR THIS EXAMINATION: please evaluate for post-op bleeding; must be completed within 4hrs post-op CONTRAINDICATIONS FOR IV CONTRAST: None. Provisional Findings Impression: [**First Name9 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**2122-1-15**] 7:56 PM No major vascular territorial infarction or other acute intracranial abnormality. Final Report HISTORY: 50-year-old male status post resection of mass. Evaluate for postoperative bleed. TECHNIQUE: Contiguous axial images were obtained through the brain. No contrast was administered. FINDINGS: The patient is status post right parietal craniotomy and resection of a right parietal mass. There is a small amount of expected post-surgical pneumocephalus and hemorrhage seen in the resection bed. In addition there is expected bifrontal pneumocephalus. There is persistent stable edema in the resection bed. Subgaleal soft tissue edema is noted over the right parietal vertex. No acute major vascular territory infarction is noted. The visualized portion of the paranasal sinuses and mastoid air cells are well aerated. IMPRESSION: Expected post-surgical appearance with minimal post-surgical hemorrhage in the resection bed. No evidence of major vascular territory infarction or new shift of the normally midline structures. The study and the report were reviewed by the staff radiologist. DR. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) 7415**] Approved: [**First Name9 (NamePattern2) **] [**2122-1-16**] 10:01 AM Imaging Lab [**Hospital1 69**] [**Location (un) 86**], [**Telephone/Fax (1) 15701**] Pathology Examination Name Birthdate Age Sex Pathology # [**Hospital1 18**] [**Known lastname 99001**],[**Known firstname **] K [**2071-3-22**] 50 Male [**Numeric Identifier 99002**] [**Numeric Identifier 99003**] Report to: DR. [**Last Name (STitle) **]. [**Doctor Last Name **] Gross Description by: DR. [**Last Name (STitle) **]. [**Doctor Last Name **]/dif SPECIMEN SUBMITTED: Right Temporal Tumor, Right Temporal Tumor. Procedure date Tissue received Report Date Diagnosed by [**2122-1-15**] [**2122-1-15**] [**2122-1-18**] DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]/vf Previous biopsies: [**-7/4988**] 0 TP , -9, -10, -11, -12, -13, -14, -1, -2, -3, -4, -5, [**-7/2553**] R BUTTOCK (1 JAR). [**-5/1959**] RIGHT APEX UPPER LOBE AND POSTERIOR WEDGE RIGHT UPPER [**Numeric Identifier 99004**] RT-LT VAS/in. (and more) DIAGNOSIS: Right temporal tumor, biopsies: 1. Frozen section (A):Malignant glioma with palisading necrosis and diffuse infiltration. 2. Permanent (B-D):Glioblastoma, WHO grade IV (See note). Note: Highly atypical glial cells are present, along with microvascular proliferation and necrosis. Scattered mitotic figures are found. [**Known lastname **],[**Known firstname **] K [**Medical Record Number 98999**] M 50 [**2071-3-22**] Radiology Report CHEST (PORTABLE AP) Study Date of [**2122-1-14**] 2:43 PM [**Last Name (LF) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 12630**] TSICU [**2122-1-14**] SCHED CHEST (PORTABLE AP) Clip # [**Clip Number (Radiology) 99005**] Reason: please eval for cardio-pulm process [**Hospital 93**] MEDICAL CONDITION: 50 year old man with GBM and mental status changes scheduled for OR [**2122-1-15**] for resection REASON FOR THIS EXAMINATION: please eval for cardio-pulm process Provisional Findings Impression: LCpc WED [**2122-1-14**] 7:08 PM No signs of acute cardiopulmonary process. Final Report CHEST PORTABLE AP REASON FOR EXAM: 50-year-old man with GBM and mental status changes scheduled for OR for resection. Please evaluate for cardiopulmonary process. Since [**2121-12-4**], lungs remain clear. Relative lucency of the left lung is only technical. Scarring at the left apex is unchanged with prior wedge resection. The cardiomediastinal silhouette and hilar contours are normal. There is no pleural effusion. The study and the report were reviewed by the staff radiologist. DR. [**First Name8 (NamePattern2) 4078**] [**Name (STitle) 4079**] DR. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4130**] Approved: WED [**2122-1-14**] 7:53 PM Brief Hospital Course: 50 year old male with known GBM diagnosed with biopsy by Dr. [**Last Name (STitle) **] last year present with severe headache last night which was associated with nausea. Work up revealed tumor progression with increased vasogenic edema. He was brought the the OR for tumor debulking. His neurologic examination remained unchanged relative to his preoperative neurologic status. He was in the PACU overnight and then transferred to the floor. His diet and activity were advanced. His steroids were tapered appropriately. He was seen by PT OT and deemed safe for discharge with services at home. He was neurologically non-focal at the time of discharge. Medications on Admission: FIORICET - 50 mg-325 mg-40 mg Tablet - 1-2 Tablets by mouth q4-6 hrs as needed for for headaches. try not to take more than 2/day DEXAMETHASONE - 4 mg Tablet by mouth three times a day LEVETIRACETAM - 500 mg Tablet - 2 Tablet(s) by mouth twice daily ZOFRAN - 8 mg Tablet - 1 Tablet(s) by mouth once a day take one hour before Temodar PROPRANOLOL - 60 mg Capsule,Sustained Action 24 hr - Start at one tab qD, then in 2 weeks increase up to 2 tabs qD if not enough effect SUMATRIPTAN SUCCINATE - 100 mg Tablet - 1 Tablets by mouth PRN severe h/a take at onset of severe h/a. [**Month (only) 116**] repeat x 1 in 2 hrs if not enough effect. Not to exceed 2 tabs in a 24 hr period TEMOZOLOMIDE - 140 mg Capsule - 1 Capsule(s) by mouth once a day take on empty stomach one hour before radiation. Take 7 days/week IBUPROFEN - 200 mg Tablet - 2 Tablet(s) by mouth PRN Discharge Medications: 1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 2. Butalbital-Acetaminophen-Caff 50-325-40 mg Tablet Sig: [**12-19**] Tablets PO Q4H (every 4 hours) as needed for headache: DO NOT DRIVE WHILE ON THIS MEDICATION. Disp:*40 Tablet(s)* Refills:*0* 3. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 4. Propranolol 60 mg Capsule,Sustained Action 24 hr Sig: One (1) Capsule,Sustained Action 24 hr PO DAILY (Daily). 5. Dexamethasone 2 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day) as needed for brain edema. Disp:*90 Tablet(s)* Refills:*2* 6. Colace 100 mg Capsule Sig: [**12-19**] Capsules PO twice a day. Disp:*60 Capsule(s)* Refills:*2* Discharge Disposition: Home With Service Facility: Partners [**Name (NI) **] [**Name2 (NI) **] Discharge Diagnosis: Glioblastoma Anxiety Discharge Condition: Neurologically stable Discharge Instructions: General Instructions/Information ?????? 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 and/or staples have been removed. If your wound closure uses dissolvable sutures, you must keep that area dry for 10 days. ?????? 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. ?????? You have been discharged on Keppra (Levetiracetam), you will not require blood work monitoring. ?????? If you are being sent home on steroid medication, make sure you are taking a medication to protect your stomach (Prilosec, Protonix, or Pepcid), as these medications can cause stomach irritation. Make sure to take your steroid medication with meals, or a glass of milk. ?????? Clearance to drive and return to work will be addressed at your post-operative office visit. ?????? Make sure to continue to use your incentive spirometer while at home. 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: increasing redness, increased swelling, increased tenderness, or drainage. ?????? Fever greater than or equal to 101?????? F. Followup Instructions: Follow-Up Appointment Instructions ??????Please return to the office in [**6-26**] days (from your date of surgery) for a wound check. This 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. ??????THE BRAIN [**Hospital **] CLINIC WILL CALL YOU TO ASSIST IN SCHEDULING YOUR APPOINTMENT FOR FOLLOW UP. The Brain [**Hospital 341**] Clinic is located on the [**Hospital Ward Name 516**] of [**Hospital1 18**], in the [**Hospital Ward Name 23**] Building. Their phone number is [**Telephone/Fax (1) 1844**]. Please call if you need to change your appointment, or require additional directions. ??????You will not need an MRI of the brain. Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2308**], MD Phone:[**Telephone/Fax (1) 2309**] Date/Time:[**2122-6-23**] 9:15 Completed by:[**2122-1-19**]

[ "191.3", "348.5", "300.00", "345.10" ]

icd9cm

[ [ [] ] ]

[ "01.59" ]

icd9pcs

[ [ [] ] ]

14198, 14272

11772, 12432

337, 398

14337, 14361

3196, 3201

16325, 17317

1716, 1849

13344, 14175

10781, 10882

14293, 14316

12458, 13321

14385, 16302

1864, 1864

3055, 3177

280, 299

10914, 11749

426, 1081

2375, 3041

3216, 4733

2138, 2359

1103, 1512

1528, 1700

19,095

163,273

8624+8625

Discharge summary

report+report

Admission Date: [**2143-12-7**] Discharge Date: [**2143-12-16**] Service: CARDIOTHORACIC Allergies: Strawberry Attending:[**First Name3 (LF) 1505**] Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: [**2143-12-9**] Video Swallow Study [**2143-12-11**] Replacement of Dobbhoff Feeding Tube History of Present Illness: Mrs. [**Known lastname **] was recently discharged from the [**Hospital1 18**] after undergoing coronary artery bypass grafting, a tricuspid valve repair, periardial patch to left ventricular wall, and Maze procedure on [**2143-11-12**] by Dr. [**First Name (STitle) **] [**Name (STitle) **]. Her hospital course was complicated by aspiration pneumonia, pleural effusions, renal failure and atrial fibrillation. She required prolonged mechanical ventilatory support and inotropic support for some time. With medical therapy and nutritional support, she gradually made clinical improvements over several weeks. She was discharged to rehab on POD#24. Within 24 hours after discharge, she became increasing short of breath with increasing oxygen requirements. She returned to the [**Hospital1 18**] EW. CXR was notable for mild-to-moderate pulmonary edema, and bilateral pleural effusions, right greater than left. Her symptoms improved with diuresis. She was subsequently admitted for further evaluation and treatment. Past Medical History: Congestive Heart Failure; Pleural Effusions; Atrial Fibrillation; Status post coronary artery bypass grafting, tricuspid valve repair, periardial patch to left ventricular wall, and Maze procedure on [**2143-11-12**]; Hypertension; Hyperlipidemia; History of stroke; Mild carotid disease; Prior RCA stenting; History of NQWMI; Gout; History of Shingles; s/p Hysterectomy; s/p Appendectomy; s/p Cholecystectomy; s/p Thoracentesis Social History: She lives alone at home. She is widowed. She has family in the area. Independent ADLs. She does have a past tobacco history but quit 30 years ago (one pack per day times 30 years). She drinks alcohol socially about two drinks per night. Family History: Mother with cerebrovascular accidents, with a stroke in the 60s, diabetes mellitus. There is a family history of hypertension and coronary artery disease. She has 10 brothers all with CAD. Oldest brother had first MI at age 33, other brothers had their MIs in their 50s. Father passed at age 59 of an MI. Physical Exam: Vitals: T 96.9, BP 108/42, HR 86, RR 18, SAT 89% 4L General: Elderly female in mild respiratory distress HEENT: Oropharynx benign Neck: Supple, no JVD Heart: Irregular rate, s1s2, no rub or murmur Lungs: Bibasilar rales Abd: Soft, nontender, nondistended Ext: Warm, 1+ edema bilaterally Pulses: 1+ distally Neuro: Non focal, Alert and oriented Pertinent Results: [**2143-12-16**] 05:45AM BLOOD WBC-9.7 RBC-3.80* Hgb-10.7* Hct-32.2* MCV-85 MCH-28.0 MCHC-33.1 RDW-19.1* Plt Ct-199 [**2143-12-6**] 04:00AM BLOOD WBC-14.2* RBC-3.73* Hgb-10.5* Hct-31.6* MCV-85 MCH-28.3 MCHC-33.4 RDW-19.0* Plt Ct-277 [**2143-12-16**] 05:45AM BLOOD UreaN-30* Creat-0.8 Na-146* K-4.2 Cl-113* HCO3-25 AnGap-12 [**2143-12-12**] 07:00PM BLOOD UreaN-88* Creat-1.8* Na-153* Cl-121* HCO3-22 [**2143-12-6**] 04:00AM BLOOD Glucose-141* UreaN-62* Creat-1.4* Na-148* K-4.1 Cl-110* HCO3-28 AnGap-14 [**2143-12-14**] 03:09AM BLOOD Calcium-8.1* Phos-2.1* Mg-2.4 Brief Hospital Course: Mrs. [**Known lastname **] was admitted to cardiac surgical service. Over several days, she was diuresed with improvements in symptoms. She eventually became hypotensive and was noted to have a concomitant decline in renal function. She was transferred to the CSRU for arterial line placement. Her BUN and creatinine peaked to 88 and 1.8. Sodium was noted to be as high as 155. With intravenous fluids and free water via feeding tube, her hemodynamics and renal function gradually normalized. She did not require inotropic support. Diuretics were temporarily withheld as medical therapy was optimized. She eventually returned to the SDU, where she worked daily with physical therapy to regain strength and mobility. At time of discharge, she remained deconditioned but was able to get out of bed with assistance. At discharge chest chest x-ray showed no evidence of acute congestive heart failure with improvement in bilateral pleural effusions. She remained in a rate controlled atrial fibrillation and maintained stable hemodynamics. Oxygen saturations at time of discharge were 94% on 4 liters nasal cannula. Warfarin was continued and dosed for a goal INR between 1.5 - 1.8. During her hospitalization, she had a repeat swallow examination on [**2143-12-9**] which revealed moderate oral and mild pharyngeal dysphagia. There was however significant improvement in her swallowing study since prior evaluation. She was able to use compensatory techniques which effectively eliminated aspiration. Based on the above, a PO diet of ground solids and thin liquids was recommended. While the NG tube is in place, PO medications should be crushed whole in puree. At time of discharge, her diet was downgraded to nectar thick liquids as a precaution. On note, she required replacement of her Dobbhoff Feeding tube on [**2143-12-11**] as her original one clogged. This was performed at Interventional Radiology without complication. Medications on Admission: 1. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [**Hospital1 **] (2 times a day). 2. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) PO BID (2 times a day). 3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 4. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Furosemide 40 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 6. Ferrous Sulfate 300 mg/5 mL Liquid Sig: One (1) PO DAILY (Daily). 7. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation Q6H (every 6 hours). 8. Metoprolol Tartrate 50 mg Tablet Sig: 1.5 Tablets PO BID (2 times a day). 9. Potassium Chloride 20 mEq/50 mL Piggyback Sig: One (1) Intravenous PRN (as needed) as needed for K<4.4 and CR<2.0. 10. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet PO every 4-6 hours as needed for pain. 11. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day) as needed. ML(s) 12. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for temperature >38.0. 13. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 7 days. 14. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 15. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig: One (1) PO once a day. 16. Coumadin 3 mg Tablet Sig: One (1) Tablet PO once a day: INR goal 2-2.5. 17. Lipitor 80 mg Tablet Sig: One (1) Tablet PO once a day. 18. Colchicine 0.6 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Medications: 1. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [**Hospital1 **] (2 times a day). 2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 3. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig: One (1) PO DAILY (Daily). 6. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [**2-3**] Puffs Inhalation Q6H (every 6 hours). 7. Ferrous Sulfate 300 mg/5 mL Liquid Sig: One (1) PO DAILY (Daily). 8. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 9. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) PO BID (2 times a day). 11. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 12. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID (3 times a day) as needed. 13. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day) as needed. 14. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical TID (3 times a day) as needed. 15. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed. 16. Warfarin 1 mg Tablet Sig: One (1) Tablet PO qpm for 1 doses: Daily dose may vary according to INR. Dose for INR between 1.5 - 1.8. 17. Lasix 20mg QD 18. Lisinopril 5mg QD Discharge Disposition: Extended Care Facility: [**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**] Discharge Diagnosis: Dehydration with hypernatremia; Congestive Heart Failure; Pleural Effusions; Atrial Fibrillation; Status post coronary artery bypass grafting, tricuspid valve repair, periardial patch to left ventricular wall, and Maze procedure on [**2143-11-12**]; Hypertension; Hyperlipidemia; History of stroke; Mild carotid disease; Prior RCA stenting; History of NQWMI Discharge Condition: Good Discharge Instructions: Aspirations precautions - continue speech therapy and current tube feedings, Promote with Fiber - goal rate 55cc per hour. Continue nectar thickened purreed diet. d/c Tube feeds when PO caloric intake sufficient. Continue Warfarin - dose should be adjusted for goal INR between 1.5 - 1.8. Continue physical therapy. Please arrange Warfarin follow up prior to discharge from rehab. Continue free water boluses/flushes - 100 cc per shift. Followup Instructions: Dr. [**First Name (STitle) **] [**Name (STitle) **] - call for appt, approximately 4 weeks Dr. [**First Name8 (NamePattern2) 450**] [**Last Name (NamePattern1) **](PCP)- call for appt, approximately 2 weeks Completed by:[**2143-12-16**] Admission Date: [**2143-12-7**] Discharge Date: [**2143-12-16**] Service: CARDIOTHORACIC Allergies: Strawberry Attending:[**First Name3 (LF) 1505**] Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: [**2143-12-9**] Video Swallow Study [**2143-12-11**] Replacement of Dobbhoff Feeding Tube History of Present Illness: Mrs. [**Known lastname **] was recently discharged from the [**Hospital1 18**] after undergoing coronary artery bypass grafting, a tricuspid valve repair, periardial patch to left ventricular wall, and Maze procedure on [**2143-11-12**] by Dr. [**First Name (STitle) **] [**Name (STitle) **]. Her hospital course was complicated by aspiration pneumonia, pleural effusions, renal failure and atrial fibrillation. She required prolonged mechanical ventilatory support and inotropic support for some time. With medical therapy and nutritional support, she gradually made clinical improvements over several weeks. She was discharged to rehab on POD#24. Within 24 hours after discharge, she became increasing short of breath with increasing oxygen requirements. She returned to the [**Hospital1 18**] EW. CXR was notable for mild-to-moderate pulmonary edema, and bilateral pleural effusions, right greater than left. Her symptoms improved with diuresis. She was subsequently admitted for further evaluation and treatment. Past Medical History: Congestive Heart Failure; Pleural Effusions; Atrial Fibrillation; Status post coronary artery bypass grafting, tricuspid valve repair, periardial patch to left ventricular wall, and Maze procedure on [**2143-11-12**]; Hypertension; Hyperlipidemia; History of stroke; Mild carotid disease; Prior RCA stenting; History of NQWMI; Gout; History of Shingles; s/p Hysterectomy; s/p Appendectomy; s/p Cholecystectomy; s/p Thoracentesis Social History: She lives alone at home. She is widowed. She has family in the area. Independent ADLs. She does have a past tobacco history but quit 30 years ago (one pack per day times 30 years). She drinks alcohol socially about two drinks per night. Family History: Mother with cerebrovascular accidents, with a stroke in the 60s, diabetes mellitus. There is a family history of hypertension and coronary artery disease. She has 10 brothers all with CAD. Oldest brother had first MI at age 33, other brothers had their MIs in their 50s. Father passed at age 59 of an MI. Physical Exam: Vitals: T 96.9, BP 108/42, HR 86, RR 18, SAT 89% 4L General: Elderly female in mild respiratory distress HEENT: Oropharynx benign Neck: Supple, no JVD Heart: Irregular rate, s1s2, no rub or murmur Lungs: Bibasilar rales Abd: Soft, nontender, nondistended Ext: Warm, 1+ edema bilaterally Pulses: 1+ distally Neuro: Non focal, Alert and oriented Pertinent Results: [**2143-12-16**] 05:45AM BLOOD WBC-9.7 RBC-3.80* Hgb-10.7* Hct-32.2* MCV-85 MCH-28.0 MCHC-33.1 RDW-19.1* Plt Ct-199 [**2143-12-6**] 04:00AM BLOOD WBC-14.2* RBC-3.73* Hgb-10.5* Hct-31.6* MCV-85 MCH-28.3 MCHC-33.4 RDW-19.0* Plt Ct-277 [**2143-12-16**] 05:45AM BLOOD UreaN-30* Creat-0.8 Na-146* K-4.2 Cl-113* HCO3-25 AnGap-12 [**2143-12-12**] 07:00PM BLOOD UreaN-88* Creat-1.8* Na-153* Cl-121* HCO3-22 [**2143-12-6**] 04:00AM BLOOD Glucose-141* UreaN-62* Creat-1.4* Na-148* K-4.1 Cl-110* HCO3-28 AnGap-14 [**2143-12-14**] 03:09AM BLOOD Calcium-8.1* Phos-2.1* Mg-2.4 Brief Hospital Course: Mrs. [**Known lastname **] was admitted to cardiac surgical service. Over several days, she was diuresed with improvements in symptoms. She eventually became hypotensive and was noted to have a concomitant decline in renal function. She was transferred to the CSRU for arterial line placement. Her BUN and creatinine peaked to 88 and 1.8. Sodium was noted to be as high as 155. With intravenous fluids and free water via feeding tube, her hemodynamics and renal function gradually normalized. She did not require inotropic support. Diuretics were temporarily withheld as medical therapy was optimized. She eventually returned to the SDU, where she worked daily with physical therapy to regain strength and mobility. At time of discharge, she remained deconditioned but was able to get out of bed with assistance. At discharge chest chest x-ray showed no evidence of acute congestive heart failure with improvement in bilateral pleural effusions. She remained in a rate controlled atrial fibrillation and maintained stable hemodynamics. Oxygen saturations at time of discharge were 94% on 4 liters nasal cannula. Warfarin was continued and dosed for a goal INR between 1.5 - 1.8. During her hospitalization, she had a repeat swallow examination on [**2143-12-9**] which revealed moderate oral and mild pharyngeal dysphagia. There was however significant improvement in her swallowing study since prior evaluation. She was able to use compensatory techniques which effectively eliminated aspiration. Based on the above, a PO diet of ground solids and thin liquids was recommended. While the NG tube is in place, PO medications should be crushed whole in puree. At time of discharge, her diet was downgraded to nectar thick liquids as a precaution. On note, she required replacement of her Dobbhoff Feeding tube on [**2143-12-11**] as her original one clogged. This was performed at Interventional Radiology without complication. Medications on Admission: 1. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [**Hospital1 **] (2 times a day). 2. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) PO BID (2 times a day). 3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 4. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Furosemide 40 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 6. Ferrous Sulfate 300 mg/5 mL Liquid Sig: One (1) PO DAILY (Daily). 7. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation Q6H (every 6 hours). 8. Metoprolol Tartrate 50 mg Tablet Sig: 1.5 Tablets PO BID (2 times a day). 9. Potassium Chloride 20 mEq/50 mL Piggyback Sig: One (1) Intravenous PRN (as needed) as needed for K<4.4 and CR<2.0. 10. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet PO every 4-6 hours as needed for pain. 11. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day) as needed. ML(s) 12. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for temperature >38.0. 13. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 7 days. 14. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 15. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig: One (1) PO once a day. 16. Coumadin 3 mg Tablet Sig: One (1) Tablet PO once a day: INR goal 2-2.5. 17. Lipitor 80 mg Tablet Sig: One (1) Tablet PO once a day. 18. Colchicine 0.6 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Medications: 1. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [**Hospital1 **] (2 times a day). 2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 3. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig: One (1) PO DAILY (Daily). 6. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [**2-3**] Puffs Inhalation Q6H (every 6 hours). 7. Ferrous Sulfate 300 mg/5 mL Liquid Sig: One (1) PO DAILY (Daily). 8. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 9. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) PO BID (2 times a day). 11. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 12. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID (3 times a day) as needed. 13. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day) as needed. 14. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical TID (3 times a day) as needed. 15. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed. 16. Warfarin 1 mg Tablet Sig: One (1) Tablet PO qpm for 1 doses: Daily dose may vary according to INR. Dose for INR between 1.5 - 1.8. 17. Lasix 20mg QD 18. Lisinopril 5mg QD Discharge Disposition: Extended Care Facility: [**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**] Discharge Diagnosis: Dehydration with hypernatremia; Congestive Heart Failure; Pleural Effusions; Atrial Fibrillation; Status post coronary artery bypass grafting, tricuspid valve repair, periardial patch to left ventricular wall, and Maze procedure on [**2143-11-12**]; Hypertension; Hyperlipidemia; History of stroke; Mild carotid disease; Prior RCA stenting; History of NQWMI Discharge Condition: Good Discharge Instructions: Aspirations precautions - continue speech therapy and current tube feedings, Promote with Fiber - goal rate 55cc per hour. Continue nectar thickened purreed diet. d/c Tube feeds when PO caloric intake sufficient. Continue Warfarin - dose should be adjusted for goal INR between 1.5 - 1.8. Continue physical therapy. Please arrange Warfarin follow up prior to discharge from rehab. Continue free water boluses/flushes - 100 cc per shift. Followup Instructions: Dr. [**First Name (STitle) **] [**Name (STitle) **] - call for appt, approximately 4 weeks Dr. [**First Name8 (NamePattern2) 450**] [**Last Name (NamePattern1) **](PCP)- call for appt, approximately 2 weeks Completed by:[**2143-12-16**]

[ "996.59", "707.03", "427.31", "428.0", "276.0", "285.9", "401.9", "584.9", "V45.81", "276.51" ]

icd9cm

[ [ [] ] ]

[ "96.6", "99.04" ]

icd9pcs

[ [ [] ] ]

17925, 18022

12960, 14890

9823, 9915

18424, 18431

12373, 12937

18916, 19155

11686, 11994

16456, 17902

18043, 18403

14916, 16433

18455, 18893

12009, 12354

9764, 9785

9943, 10961

10983, 11413

11429, 11670

48,038

183,358

8834

Discharge summary

report

Admission Date: [**2145-6-21**] Discharge Date: [**2145-7-15**] Date of Birth: [**2112-9-1**] Sex: F Service: NEUROSURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 1835**] Chief Complaint: Brain mass compressing brain stem Major Surgical or Invasive Procedure: -Diagnostic cerebral angiogram with embolization -Left sided craniotomy with placement of EVD catheter -Left suboccipital craniotomy for mass resection History of Present Illness: 32 year old woman with past medical history significant for nonhodgkins lymphoma and basal cell carcinoma who presents after being referred by her PCP after an MRI scan showed a brain lesion. She describes that about 3 years ago she started to experience dizziness with postural changes which was felt to be related to vertigo. More recently over the past few months she had episodes of choking, increasing dizziness, vertiginous symptoms, and abnormal echoing in her left ear. She had been followed by her PCP for these symptoms and after her last visit on [**4-23**] it was felt that an MRI to assess for any intracranial pathology that was contributing to her symptoms was warranted. She had her MRI which showed a dural based lesion compressing the pons. She was seen in the emergency room on Friday [**5-7**] for evalaution and was discharged to home and returns today for follow-up and discussion regarding treatment options. She complains only of dizziness, she denies nausea, vomiting, headache, blurry vision, difficulty with bowel or bladder function. Past Medical History: NonHodgkins lymphoma diagnosed at birth, stomach tumor diagnosed at age 2.5years s/p chemo and radiation, prophylactic brain radiation, basal cell carcinoma s/p excision in [**2144**] as well as [**2145-5-5**], genital herpes, reverse cataracts. Social History: PCT in newborn nursery at [**Hospital1 18**], no tobacco, social ETOH Family History: Diabetes Physical Exam: PHYSICAL EXAM: Gen: WD/WN, comfortable, NAD. HEENT: Pupils: PERRL EOMs: intact without nystagmus Neck: Supple. Lungs: CTA bilaterally. Cardiac: RRR. S1/S2. Abd: Soft, NT, BS+ Extrem: Warm and well-perfused. Neuro: Mental status: Awake and alert, cooperative with exam, normal affect. Orientation: Oriented to person, place, and date. Language: Speech fluent with good comprehension and repetition. Naming intact. No dysarthria or paraphasic errors. Cranial Nerves: I: Not tested II: Pupils Right [**4-7**] Left [**5-9**] s/p cataract surgery. Visual fields are full to confrontation. III, IV, VI: Extraocular movements intact bilaterally without nystagmus. V, VII: Facial strength and sensation intact and symmetric. VIII: Hearing intact to voice. IX, X: Palatal elevation symmetrical. [**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally. XII: Tongue midline without fasciculations. Motor: Normal bulk and tone bilaterally. No abnormal movements, tremors. Strength full power [**6-10**] throughout. No pronator drift Sensation: Intact to light touch, proprioception, pinprick and vibration bilaterally. Toes downgoing bilaterally Coordination: normal on finger-nose-finger, rapid alternating movements, heel to shin Romberg Mildly positive Difficulty with Tandem Gait Discharge exam: Trach, Left 3rd nerve palsy left pupil 6mm fixed, right pupil [**5-9**]. LUE wiggles fingers, moves left lower spont. spont slight R LE mvmt.no move R UE Pertinent Results: MRI [**6-23**] Wand study: IMPRESSION: Unchanged large dural-based mass lesion, apparently extra-axial, causing severe mass effect in the pons, displacement of the basilar artery and narrowing of the fourth ventricle with dural-based along the clivus, left cavernous sinus as well as the left internal carotid artery, likely consistent with a meningioma, however given the history of lymphoma this is also an alternate possible diagnosis. Fiducial markers are in place. MRI [**6-23**] postop: IMPRESSION: 1. Status post left frontotemporal craniotomy, with a small surgical fluid collection extending from the anterior aspect of the left temporal region throughout the convexity, there is mild-to-moderate mass effect and shifting of the midline structures towards the right with approximately 4.4 mm of deviation and left frontal pneumocephalus. 2. Residual mass lesion with surgical changes and partial debulking, extending along the clivus and causing significant mass effect within the pons, mid brain and left cerebral peduncle. 3. The diffusion-weighted sequences demonstrates a new area of possible restricted diffusion, within the medial aspect of the mid brain and pons, suggesting edema. 4. There is also moderate restricted diffusion in the anterior aspect of the left temporal lobe, suggesting post-surgical edema. MRI head +/- contrast [**7-1**]: IMPRESSION: 1. Unchanged appearance of the petroclival extra-axial mass with unchanged compression and rightward displacement of the brainstem. Rightward displacement of the basilar artery is also not significantly changed. 2. Postoperative changes within the left temporal lobe. 3. Increased T2 signal within the brainstem, consistent with edema, is not significantly changed. 4. Decreased compression of the left lateral ventricle and interval resorption of previously seen pneumocephalus. CT Head [**7-1**]: Status post resection of a left petroclival extra-axial mass lesion, with expected post-surgical changes including moderate amount of pneumocephalus and a small extraaxial fluid collection in the left posterior cranial fossa and middle cranial fossa. Hypodensity/edema in the left temporal lobe, and brainstem. Chest Xray [**7-1**]: The ET tube tip is 6.5 cm above the carina. The NG tube tip is in the stomach. Left lung is essentially clear. Within the right lung there is newly developed right lower lung consolidation most likely consistent with right middle lobe and partial right lower lobe collapse especially giving the right mediastinal shift. No interval increase in pleural effusion and no pneumothorax is noted. MRI Brain postop [**7-2**]: New acute infarcts in the left thalamus, left internal capsule, left posterolateral pons/midbrain junction, left middle cerebellar peduncle, and left cerebellar hemisphere. Subacute infarcts in the brainstem and temporal lobes are again noted. The extra-axial mass at the interpenducular cistern is significantly decreased in size and there is decreased mass effect on the midbrain and decreased rightward displacement of the basilar artery. An extra-axial collection at the left cerebellopontine angle is not unexpected status post surgery. Temporal lobe and brainstem edema are again noted. Rightward midline shift and cerebellar tonsilar heriation are not signicantly changed. Lower Extremity venous dopplers [**7-2**]: Occlusive thrombus within the left posterior tibial veins. However, no evidence for clot elsewhere in either the left, or right lower extremity. [**7-3**]: CT Head 1. No change from the [**7-2**] MRI and the [**7-1**] CT, with subacute infarcts in the left thalamus, internal capsule, left hemipons, midbrain, cerebellar hemisphere and temporal lobe. 2. Extensive temporal lobe and brainstem edema causing cerebellar tonsillar herniation and effacement of the left-sided basal cisterns. 3. No new acute infarction or intracranial hemorrhage. [**7-6**] ECHO- The left atrium and right atrium are normal in cavity size. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). No masses or thrombi are seen in the left ventricle. Right ventricular chamber size and free wall motion are normal. The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. IMPRESSION: No large ASD or left ventricular thrombus seen. Normal global and regional biventricular systolic function. [**7-6**] LENI's- IMPRESSION: 1. Occlusive thrombus within the left lesser saphenous vein. 2. Resolution of previously noted thrombus within the left posterior tibial veins. 3. Otherwise, no thrombus in the left, or right leg. CT Head [**2145-7-7**]: IMPRESSION: 1. Unchanged size and configuration of the ventricles. Unchanged positioning of the right ventriculostomy catheter, terminating near the foramen of [**Last Name (un) 2044**]. 2. No significant change in the appearance of extensive infarction involving the left temporal lobe, left thalamus, left internal capsule, pons, mid brain, and left cerebellar hemisphere. 3. No significant change in the degree of edema within the left cerebral hemisphere and mid brain. 4. Persistent cerebellar tonsillar herniation, unchanged over the series of studies, may relate to the original posterior fossa mass. 5. No evidence of new acute large vascular territorial infarction or acute intracranial hemorrhage. CT Head [**2145-7-8**]: IMPRESSION: No significant interval change. LENIS [**2145-7-9**]: CONCLUSION: No evidence of DVT in right or left lower extremity CXR [**2145-7-9**] In comparison with the study of [**7-9**], there is decreasing opacification at the right base with a small residual. Cardiac silhouette is within normal limits and there is no evidence of vascular congestion. Monitoring and support devices remain in good position. Brief Hospital Course: Ms [**Known lastname 174**] was admitted electively for diagnostic cerebral angiogram with embolization by Dr [**First Name (STitle) **]. She toelrated the embolization well and approximately 40% of the vessels feeding the lesion were embolized. The remaining 60% was not able to be done given the territory. On 5.17 she remained stable and on 5.18 she underwent craniotomy for resection of her petraclinoid lesion as well as placement of a rigth sided EVD. She tolerated the procedure well and was brought to the ICU intubated given the length of surgery. She underwent MRI scan of the Brain a few hours psot-oepratively to assess teh resection. The MRI showed approximately 30% of the lesion had been resected. Attemtps at extubating her were held as she was unabel to protect her airway. On [**6-24**] her EVD remained at 10cm H2O and she was following commands with her left side but not the right, and opened her right eye to command, [**Last Name (un) **] left pupil was nonreactive consistent with a possible 3rd nerve palsy. She remeianed hemodynamically stable into [**6-25**] and her exam was stable as well. On [**6-26**], her EVD was raised to 15cmH20 and then to 20cm H20 the following day. On [**6-28**], she was extubated without incident. She continued to require a shovel mask for her respiratory status. On [**6-29**], her EVD was increased to 25 cmH20. She remain neurologically stable. On [**7-1**] she underwent left supoccipital craniotomy for second debulking of tumor. Heparin SC was held prior to procedure. Immediate postoperative head CT demonstrated no acute blood with minimal pneumocephalus. EVD was left at 10cm above the tragus. She remained intubated post procedure. She was placed on Vanco and gentamycin for perioperative prophylaxis. POD1 from this second debulking she started to open her right eye spontaneously and moving her left side minimally and purposefully but had further defecits on her right side. She had minimal withdrawal of her right lower extremity. She had no withdrawal in her right upper extremity. On [**7-2**] the patient was febrile to 101.6 and a fever workup was initiated with blood, urine and sputum cultures. CSF was sent for gram stain and culture. LENIs were requested. Chest Xray demonstrated rightsided consolidation and lower lobe collapse and so she was started on the VAP protocol. She was started on unasyn until [**7-10**]. Postoperative MRI demonstrated new infarcts within the left thalamus and internal capsule. SC Heparin was resumed after MRI. Lower extremity doppler US on [**7-2**] demonstrated thrombus in left posterior tibial veins. Pneumatic boot was removed from left leg and she was started on Aspirin with a plan for repeat dopplers in 7 days to evaluate for propagation of clot. IVC filter was not indicated due to small size of thrombus. An attempt was made to wean her ventricular drain on [**7-3**] which was not tolerated. ICPs rose to 20 after a few hours. We opened her EVD and allowed her drain for a few more days. Aggressive diuresis was started on [**7-3**] in attempt to even out her fluid status and to wean her support on the ventilator to move towards extubation. On [**7-4**] she remained stable in the unit on the ventilator on CPAP. She was following commands sluggishly with the left side. On 5.30 she was extubated, following commands on the left and her EOM's were much less restricted on the Right side. She continued with her Left 3rd and 6th nerve palsy's. On [**7-6**] she remained neurologicaly stable. Her EVD was increased to 20cm H20. Repeat LENI's were performed revealing a 5mm x 10mm clot in the lesser saphenous vein and resolution of the previous clot. In the afternoon she had a mucous plug that was cleared via bronchoscopy. At approximately 6 am on [**7-7**] she was noted to have difficutly breathing and using accessory muscles. It was noticed that she had increased swelling in her neck therefore it was decided to intubate her. A head CT was performed for baseline evaluation prior to EVD clamp. Her EVD was clamped after a stable Head CT. On [**7-8**] a head CT was done which showed no changed and her EVD was discontinued. On [**7-9**] a family meeting was had to discuss plan of care. A trach and PEG was discussed, but no decision was made. [**Date range (1) 7218**] Family meeting and trach/PEG was planned for on [**7-12**]. Her tubefeeds were held on the evening of [**7-11**] in preparation but due to OR availability it was postponed. [**7-13**] She underwent an uncomplicated tracheostomy/PEG on this day. She worked with PT and OT in anticipation of discharge to rehab. Medications on Admission: Aviane, ibuprofen Discharge Medications: 1. acetaminophen 650 mg/20.3 mL Solution Sig: [**2-7**] PO Q6H (every 6 hours) as needed for Pain or fever. 2. docusate sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2 times a day). 3. insulin regular human 100 unit/mL Solution Sig: One (1) Injection ASDIR (AS DIRECTED). 4. senna 8.8 mg/5 mL Syrup Sig: One (1) Tablet PO DAILY (Daily). 5. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 6. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 7. famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). 8. levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 9. ondansetron HCl (PF) 4 mg/2 mL Solution Sig: One (1) Injection Q8H (every 8 hours) as needed for nausea. 10. dexamethasone 2 mg Tablet Sig: One (1) Tablet PO every twelve (12) hours. Discharge Disposition: Extended Care Discharge Diagnosis: Dural based brain [**Hospital **] Hospital Acquired Pneumonia Respiratory insufficiency Right sided hemiparesis Left calf DVT Discharge Condition: Trach, Left 3rd nerve palsy left pupil 6mm fixed, right pupil [**5-9**]. LUE wiggles fingers, moves left lower spont. spont slight R LE mvmt.no move R UE Discharge 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 and/or staples have been removed. If your wound closure uses dissolvable sutures, you must keep that area dry for 10 days. ?????? 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. Followup Instructions: Follow-Up Appointment Instructions ??????Please remove one suture at rehab on [**7-17**] (Right side of head EVD suture) ??????You have an appointment in the Brain [**Hospital 341**] Clinic on [**8-16**] @1155am MRI [**Hospital Ward Name 516**] then go to the Brain [**Hospital 341**] Clinic at 2pm which is located on the [**Hospital Ward Name 516**] of [**Hospital1 18**], in the [**Hospital Ward Name 23**] Building, [**Location (un) **]. Their phone number is [**Telephone/Fax (1) 1844**]. Please call if you need to change your appointment, or require additional directions. Completed by:[**2145-7-15**]

[ "348.89", "997.2", "453.6", "909.2", "E879.2", "434.91", "378.51", "997.31", "V10.79", "348.5", "V18.0", "225.2", "518.5", "V10.83", "E879.8", "348.4", "342.80" ]

icd9cm

[ [ [] ] ]

[ "43.11", "02.39", "96.6", "31.1", "02.12", "38.93", "96.72", "99.21", "39.72", "88.41", "33.24", "01.51", "01.24" ]

icd9pcs

[ [ [] ] ]

15243, 15258

9669, 14305

341, 495

15428, 15584

3485, 9646

16686, 17299

1962, 1972

14374, 15220

15279, 15407

14331, 14351

15608, 16663

2002, 2203

3310, 3466

268, 303

523, 1588

2455, 3294

2218, 2439

1610, 1858

1874, 1946

1,944

157,104

7609

Discharge summary

report

Admission Date: [**2110-4-25**] Discharge Date: [**2110-5-3**] Date of Birth: [**2055-5-19**] Sex: M Service: MEDICINE Allergies: Ciprofloxacin / Aldactone Attending:[**Last Name (NamePattern1) 1167**] Chief Complaint: Dyspnea Major Surgical or Invasive Procedure: intubation hemodialysis central line placement arterial line placement History of Present Illness: 54 year-old man with a history of CHF (LVEF 25%), DM1 s/p panc/kidney transplant, CAD s/p CABG was recently hospitalized for DOE thought [**1-10**] to a RLL PNA, CHF, and possible amiodarone toxicity, he was discharged on [**4-16**] to rehab with a 3L oxygen requirement. He refused to go to rehab so went home instead but ended up back in the ER and was eventually sent to rehab at [**Hospital1 **]. Per his wife, he has been going down-[**Doctor Last Name **] ever since he entered rehab where they continued to fluid-restrict and diurese him to the point of him feeling very dehydrated. He did not have any fevers as far as she knows. He complained of SOB at the nursing home today and was found to be hypoxic to the 80s on RA, and satting 90% on 6L, was noted to have a bandemia on his WBC, and set to the ED. . In the ED, he was noted to be febrile to 101.2 BP 106/70 and was 88% on RA, and placed on 6L O2 with sats 93-100, in addition a RIJ was placed with a CVP of 4. He was given Vancomycin, levaquin, flagyl, and sent to the ICU. . On arrival to the MICU, he was complaining of lower abd pain X 2 wks. No N/V/diarrhea. + constipation. No cough. No f/c. Past Medical History: -Type 1 DM for 30+ years: complicated by neuropathy of bladder (he self-catheterizes), retinopathy and peripheral neuropathy -S/P Pancreas and Kidney Transplant [**2094**] -CHF- EF 25-30% on ECHO [**2109-12-31**] -CAD: status post multiple MIs -Status post CABG [**2104**]: LIMA to LAD, SVG to right PDA, SVG to SVG to OM -Ventricular tachycardia status post pacer/AICD placement, followed by Dr. [**Last Name (STitle) 27765**] Interrogated [**2110-1-1**] -Peripheral [**Month/Day/Year 1106**] disease: status post fem-[**Doctor Last Name **] bypass, subclavian stenosis bilaterally -Chronic kidney disease: baseline Cr (2.5-2.8) -Multiple prior UTIs: enterococcus ([**Last Name (un) 36**] to vanco), Ecoli (resistant to levofloxacin) -Hypertension -Cataract surgery and multiple laser surgery on both eyes - Hard of hearing Social History: Prior to current illness, lived in [**Location **] MA with his wife and 30 year old daughter. Quit smoking cigarettes 20 years ago (20-30 pack years) but does smoke cigars, no EtOH or recreational drugs. He is currently on disability. He does not drive. Family History: Mother died of an MI at 59 and had diabetes and hypertension. Father died from esophageal cancer. Three brothers and one sister, all with diabetes. Sister has cerebral palsy. Physical Exam: Vitals: 97.2, BP 116/55, 72, 18, 99% on a non-rebreather Gen: Lethargic but responds quietly to simple questions with 1-2 word answers. HEENT: dry MM, pupils 2 mm and reactive; RIJ in place obscuring JVP, no adenopathy, neck supple Skin: ecchymotic patches over both arms, chest and abdomen, arms with several skin tears CV: rrr, S3, RV heave, midline scar Pulm: relatively clear anteriorly, bibasilar crackles, no wheezes Abd: TTP over lower abdomen, no organomegaly, soft, NT, ND, [**Month (only) **] BS, no rebound or guarding Ext: no edema, feet and hands cool, trace radial pulses, L knee and R ankle wrapped in gauze Pertinent Results: [**2110-4-25**] 04:02PM BLOOD WBC-29.4*# RBC-4.88 Hgb-11.9* Hct-35.6* MCV-73* MCH-24.4* MCHC-33.4 RDW-19.5* Plt Ct-374 [**2110-4-25**] 04:02PM BLOOD Neuts-91* Bands-4 Lymphs-0 Monos-3 Eos-0 Baso-0 Atyps-0 Metas-2* Myelos-0 NRBC-1* [**2110-4-25**] 04:02PM BLOOD Hypochr-NORMAL Anisocy-2+ Poiklo-1+ Macrocy-NORMAL Microcy-2+ Polychr-OCCASIONAL Ovalocy-OCCASIONAL Schisto-OCCASIONAL Tear Dr[**Last Name (STitle) 833**] [**Name (STitle) 18670**] [**2110-4-25**] 04:02PM BLOOD PT-12.6 PTT-29.6 INR(PT)-1.1 [**2110-4-25**] 04:02PM BLOOD Glucose-166* UreaN-167* Creat-3.0* Na-121* K-5.7* Cl-84* HCO3-21* AnGap-22* [**2110-4-25**] 04:02PM BLOOD ALT-33 AST-81* AlkPhos-121* Amylase-264* TotBili-0.5 [**2110-4-25**] 04:02PM BLOOD Lipase-81* [**2110-4-25**] 04:02PM BLOOD GGT-33 [**2110-4-25**] 04:02PM BLOOD proBNP-[**Numeric Identifier 27767**]* [**2110-4-25**] 08:30PM BLOOD Phos-7.6*# Mg-2.0 [**2110-4-25**] 04:02PM BLOOD Acetone-NEGATIVE Osmolal-321* [**2110-4-25**] 04:02PM BLOOD Cortsol-225.8* [**2110-4-25**] 04:02PM BLOOD CRP-265.9* [**2110-4-25**] 08:30PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-POS Barbitr-NEG Tricycl-NEG [**2110-4-26**] 01:00AM BLOOD rapmycn-PND [**2110-4-25**] 04:07PM BLOOD Type-MIX pO2-36* pCO2-38 pH-7.32* calTCO2-20* Base XS--5 [**2110-4-25**] 09:24PM BLOOD Type-ART O2 Flow-15 pO2-233* pCO2-37 pH-7.36 calTCO2-22 Base XS--3 Intubat-NOT INTUBA . EKG: 70bpm NA, LBBB, unchanged from previous . CXR [**2110-4-25**] The patient is after median sternotomy and CABG with broken lower sternal wires broken, unchanged. The left-sided pacemaker with its two leads terminating in the right atrium and right ventricle is unchanged. The heart size is enlarged but stable. There is slight worsening of left lower lobe opacity which is kmown to be partially due to round atelectasis but a new overlying infection or aspiration cannot be excluded. In addition, there is worsening of the right lower lobe consolidation, thus a combination of this finding is strongly suggestive for aspiration, although bilateral infection process is a possibility. . Gallbladder US [**2110-4-25**]: 1. No son[**Name (NI) 493**] evidence of cholecystitis. 2. Small right-sided pleural effusion. . Echo [**2110-5-3**] Conclusions: There is severe global left ventricular hypokinesis (EF 20%), with more prominent septal hypokinesis. Due to limited views, more precise regional wall motion abnormalities cannot be assessed. Right ventricular chamber size is normal. There is moderate global right ventricular free wall hypokinesis. Moderate (2+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no pericardial effusion. IMPRESSION: No pericardial effusion. Severe left ventricular systolic dysfunction. Moderate aortic regurgitation. Compared with the prior study (images reviewed) of [**2110-4-14**], no change. Brief Hospital Course: Hospital course: Mr. [**Known lastname **] was a 54 yo male with pmh of CHF (EF 25%), DM1 s/p pancreatic/ kidney transplant, CAD s/p CABG, admitted for SOB/hypoxia, found to have asp. PNA. He was transferred to the CCU [**1-10**] to VT/VF. In the CCU he had several episodes of VT/VF s/p multiple shocks. He was started on CVVH [**1-10**] to ARF. He remained ventilator dependent. He had intermittent pressor requirements and was maintained on a lidocaine GTT. He was made DNR/DNI and expired from cardiac arrest. . 1. VT/VF: Pt. has a h/o of VT in the past for which an ICD was placed. On day of transfer to the CCU, the patient had several episodes of VT/VF and was shocked numerous time by his ICD unsuccessfully, requiring external shocks as well. Etiology of the current episode is likely due to his pre-disposition to this arrythmia in combination with metabolic derrangements (hyperkalemia, acidosis). Pt. was given lidocaine boluses, his metabolic derrangements were corrected and burst pacing was used to terminate his VT. He was kept on a lidocaine drip transiently. While weaning off the lidocaine drip, mexiletine has been started. Despite antiarrythmics, he continued to have episodes of VT which again req. several external shocks. Because of his rapidly deteriorating condition, he was made DNR/DNI. He expired surrounded by his family. . 2) Hypovolemia: Pt. appeared dry on admission, with high BUN/CRT ratio. He was also several pounds below his dry weight. He received aggressive re-hydration. His volume status was monitored by clinical exam and by CVP. . 3) SOB/Hypoxia: Multifactoral etiology. He had amiodarone-induced pulm fibrosis and aspiration PNA. It was felt that his SOB was not due to CHF. He remained intubated since the VT/VF event and developed MRSA pneumonia (VAP)/bacteremia contributing further to hypoxia. He was continued on Vanc and Zosyn. Flagyl was discontinued. As an outpatient he was receiving HD steroids for amiodarone toxicity. He was started on stress dose steroids in the CCU, these were being slowly weaned. . 4) Hypotension- during episodes of VT/VF the pt. became hypotensive [**1-10**] to arrythmia, pressors were started (neo, dopamine). Once the arrythmia was terminated, pressors were weaned. He was also started on stress dose steroids. He had several more episodes of hypotension which were treated with IVF and pressors. On the night prior to his death, he became hypotensive and received IVF, vassopressin, levophed, neosynephrine. Despite this, he became progressively hypotensive. He had several more episodes of VT and became hemodynamically unstable despite external shocks and pressors. He was made DNR/DNI and expired. . 5) Presumed adrenal insufficiency: Pt. was on high-dose steroids for amiodarone toxicity. Therefore, he was likely adrenally insuff. due to long term steroid use. As he was critically ill and hypotensive, stress dose steroids were started. He was started on a steroid taper. . 6) Metabolic Acidosis:This was likely due to ARF on CKD . Initially he had a non-AG and mild AG metabolic acidosis with complete respiratory compensation. His acidosis slowly resolved with bicarb infusions and correction of fluid status. He was started on CVVH. . 7) DM s/p panc/kidney transplant: Tx in [**2097**]. Baseline Cr 2.5-2.8. Patient was continued on Sirolimus 1 mg QD. Prednisone 5mg daily was held while stress dose steroids were given. . 8) ARF- Chronic kidney disease: His baseline Cr (2.5-2.8) with Cr 3.0 on transfer to CCU. His creatinine slightly improved and he remained largely around baseline thereafter. However, BUN baseline was around 60 and was significantly elevated indicating acute on chronic [**Year (4 digits) **] failure. Initial metabolic AG and non-AG acidosis was corrected. Calcitriol 0.25 mcg qd was continued. Tunneled HD catheter was placed in right IJ on [**5-2**]. CVVH was initiated. . 9) CHF- EF 25-30% on ECHO [**2109-12-31**]. Patient was initially dry but accumulated up to 10 L throughout his CCU stay. He received IVF or Lasix as needed to keep him euvolemic clinically. Lopressor was restarted once his blood pressure was stable. Isosorbide dinitrate and hydral were held. . 10) CAD: status post multiple MIs. He had a h/o ventricular tachycardia status post pacer/AICD placement. Patient was continued on aspirin and statin. BB was held while hypotensive, then added back. ISDN was held. . 11) Anemia - due to CKD. Ferritin wnl. Patient was continued on Epo (increased dose per [**Month/Day/Year **]). His stools were guaiac positive but without gross blood. He also developed bloody sputum (streaks) during intubation. His Hct dropped during his CCU stay and he received 3U of PRBC with appropriate response on [**4-30**]. . 12) Thrombocytopenia - Platelets dropped since this admission from the 300s to 70s. DIC labs were initially checked and came back negative. Heparin products were d/c'd and HIT Ab test sent which was also negative. . 13) FEN: TFs while intubated. . # PPX: Protonix, SC Heparin initially, was d/c'd when platelets fell. Then on pneumoboots. . # Access: Right SC CVL, Right IJ tunneled catheter. . # CODE: full code (confirmed with family during CCU stay) . # Contact: HCP [**Name (NI) **] T Daughter C -[**Telephone/Fax (1) 27768**], H [**Telephone/Fax (1) 27769**] Wife [**Name (NI) 6739**] C [**Telephone/Fax (1) 27770**] . Dispo- expired. Medications on Admission: Per last d/c: Home oxygen 2-4L per nasal canula continuous X 3 wks Sirolimus 1 mg QD Calcitriol 0.25 mcg Qd Atorvastatin 80 mg QD Aspirin 325 mg QD Pantoprazole 40 mg QD Ipratropium Bromide 0.02 % Q6Hrs Albuterol Sulfate 0.083 % Q6Hrs Tramadol 50 mg Q8hrs PRN Fluticasone-Salmeterol 250-50 mcg/Dose [**Hospital1 **] Isosorbide Dinitrate 20 mg Q6H Hydralazine 20 mg Q6H Gabapentin 300 mg QD Acetaminophen 325 mg Q4H PRN Spironolactone 25 QD Furosemide 120 mg [**Hospital1 **] Hydrochlorothiazide 25 mg QD Potassium Chloride 20 mEq Tab SR QD Metoprolol Succinate 200 mg Tablet SR QD Solumedrol 60mg QD Procrit 5k t/th/sat Discharge Medications: expired Discharge Disposition: Expired Discharge Diagnosis: Primary: congestive heart failure Ventricular tachycardia status post pacer/AICD placement [**Hospital1 **] failure coronary artery disease . secondary: -Type 1 DM since [**21**] yo, s/p pancreas/kidney transplant. DM c/b bladder neuropathy, retinopathy, peripheral neuropathy -S/P Pancreas and Kidney Transplant [**2094**] -Status post CABG [**7-/2105**]: LIMA to LAD, SVG to right PDA, SVG to SVG to OM -Peripheral [**Year (4 digits) 1106**] disease: status post fem-[**Doctor Last Name **] bypass, subclavian stenosis bilaterally -Chronic kidney disease: baseline Cr (2.5-2.8) -Multiple prior UTIs: enterococcus ([**Last Name (un) 36**] to vanco), Ecoli (resistant to levofloxacin) -Hypertension -Cataract surgery and multiple laser surgery on both eyes -Hard of hearing Discharge Condition: expired Discharge Instructions: expired Followup Instructions: expired Completed by:[**2110-5-3**]

[ "427.5", "255.4", "038.11", "507.0", "585.3", "362.01", "285.21", "276.7", "276.2", "V45.81", "584.9", "515", "482.41", "995.92", "357.2", "403.91", "250.51", "518.81", "250.61", "428.0", "E878.0", "427.1", "E942.0", "996.81", "276.52", "V45.02", "V42.83", "287.5", "E932.0", "337.1" ]

icd9cm

[ [ [] ] ]

[ "96.72", "96.6", "96.04", "38.91", "39.95", "38.93", "99.04", "38.95", "34.91" ]

icd9pcs

[ [ [] ] ]

12515, 12524

6430, 6430

301, 374

13343, 13353

3552, 6407

13409, 13447

2714, 2893

12483, 12492

12545, 13322

11838, 12460

6447, 11812

13377, 13386

2908, 3533

254, 263

402, 1575

1597, 2424

2440, 2698

56,960

149,518

35035+57969

Discharge summary

report+addendum

Admission Date: [**2118-3-21**] Discharge Date: [**2118-3-26**] Date of Birth: [**2057-1-13**] Sex: M Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 4748**] Chief Complaint: left lower extremity ischemia Major Surgical or Invasive Procedure: LLE thombectomy with fem & [**Doctor Last Name **] cutdowns History of Present Illness: 61 M DM-2, CAD, COPD, PVD h/o L femoral -> AK popliteal bpg using PTFE [**11/2114**] presents with one week of LLE pain found to have pulseless left foot. Patient reports falling one week ago on both knees after feeling uneasy on his feet. He has had increasing LLE pain since then, from his thigh down. This has been associated with numbness and inability to move his foot. He has been unable to ambulate. He has had some issues with dizziness and confusion over the past week, and at times has forgotten the date. His daughter was concerned so brought him to an OSH ED where he was found to have no pulses in his left foot with mottling. He was sent to [**Hospital1 18**] ED for further evaluation and vascular surgery was consulted. Patient denies fevers, chills, nausea, emesis. He has had some diarrhea. Of note, he has been self-treating his chronic non-healing ulceration of his R foot ulceration. He has been followed by Dr. [**Last Name (STitle) **] in the past, but reports not having a ride and not going to the hospital for evaluation for about a year. Past Medical History: PMH: CAD -3 vessel by cath [**6-3**] w/ 100% stenosis of 1 art & >80% stenosis of 2 others, CHF, DM2, neuropathy, COPD, HTN, PVD, Chronic back pain s/p ruptured disk in [**2113**] PSH: [**-5/2011**] Exostectomy, right foot (Dr. [**Last Name (STitle) **] [**8-/2115**] Hallux interphalangeal joint arthroplasty (Dr. [**Last Name (STitle) **] [**12/2114**] STSG to right TMA [**11/2114**] L femoral -> AK popliteal bpg using PTFE [**10/2114**] R TMA [**10/2114**] R femoral-> BK [**Doctor Last Name **] BPG with in situ saphenous vein graft [**10/2114**] [**1-28**] met head resection and toe amputations [**5-/2114**] Carpal tunnel release on Rt x2 [**5-/2114**] cardiac cath Social History: Former tobacco use Denies ETOH use Family History: Non-contributory Physical Exam: At time of discharge: afebrile, vital signs stable NAD, alert and oriented RRR Breathing easily Abd soft nontender RLE s/p TMA, no erythema or wound breakdown left groin/leg incisions c/d/i, no erythema or hematoma left shin with improving erythema and exfoliating skin, compartments soft, minimal tenderness with active/passive ROM Pulses: PT/DP doppler signal bilaterally Pertinent Results: CT LLE [**2118-3-2**]: 1. No large abscess is identified. Absence of IV contrast limits assessment for small abscess or subtle inflammatory change. 2. Symmetrical subcutaneous edema. The possibility of associated cellulitis cannot be excluded. 3. Symmetrical small joint effusions in the knees [**2118-3-26**] 06:29AM BLOOD WBC-6.5 Hgb-837* Hct-28.2* Plt Ct-495* [**2118-3-26**] 06:29AM BLOOD PT 23.6, PTT 36.9, INR 2.3 [**2118-3-26**] 06:29AM BLOOD Na 136 K 4.0 Cl 99 CO2 30 BUN 17 Cr 1.3 glu 173 Ca 7.7 Mg 1.7 P 3.9 [**2118-3-26**] 06:29AM BLOOD vanco trough 23.8 [**2118-3-25**] 04:57AM BLOOD WBC-6.8 RBC-3.34* Hgb-9.1* Hct-29.7* MCV-89 MCH-27.2 MCHC-30.7* RDW-15.9* Plt Ct-490* [**2118-3-24**] 05:29AM BLOOD WBC-9.1 RBC-3.59* Hgb-9.5* Hct-32.2* MCV-90 MCH-26.4* MCHC-29.5* RDW-15.9* Plt Ct-492* [**2118-3-25**] 04:57AM BLOOD PT-26.1* PTT-39.3* INR(PT)-2.5* [**2118-3-24**] 11:21AM BLOOD PT-41.9* PTT-49.8* INR(PT)-4.1* [**2118-3-24**] 05:29AM BLOOD PT-43.6* PTT-71.8* INR(PT)-4.3* [**2118-3-23**] 04:14AM BLOOD PT-34.3* PTT-72.0* INR(PT)-3.3* [**2118-3-22**] 10:01AM BLOOD PT-30.3* PTT-65.5* INR(PT)-2.9* [**2118-3-25**] 04:57AM BLOOD Glucose-138* UreaN-12 Creat-1.1 Na-136 K-3.7 Cl-101 HCO3-28 AnGap-11 [**2118-3-24**] 05:29AM BLOOD Glucose-157* UreaN-10 Creat-1.1 Na-138 K-4.0 Cl-105 HCO3-24 AnGap-13 [**2118-3-23**] 04:14AM BLOOD Glucose-198* UreaN-17 Creat-1.1 Na-137 K-4.1 Cl-106 HCO3-25 AnGap-10 [**2118-3-22**] 04:06AM BLOOD Glucose-162* UreaN-27* Creat-1.6* Na-135 K-4.6 Cl-103 HCO3-20* AnGap-17 [**2118-3-22**] 10:01AM BLOOD CK-MB-4 cTropnT-0.07* [**2118-3-22**] 04:06AM BLOOD CK-MB-4 cTropnT-0.08* [**2118-3-21**] 04:18PM BLOOD CK-MB-5 cTropnT-0.11* [**2118-3-21**] 08:15AM BLOOD CK-MB-6 cTropnT-0.12* Brief Hospital Course: The patient was admitted to the vascular surgery service for emergent left femoral and popliteal cutdown and thrombectomy for acute ischmia. He was also noted to have a significant cellulitis of the left lower extremity upon admission. He tolerated the procedure well. Please see the operative report for further details. During the case he was anticoagulated with heparin, but his PTT did not appropriately increase. He was switched to Argatroban drip due to his resistance to heparin. He was transferred to the ICU intubated where his left lower extremity was monitored closely for signs of compartment syndrome. He was started on broad spectrum IV antibiotics for his cellulitis. A wound culture was taken that eventually grew coagulase negative staphylococcus. He remained intubated until his compartments remained soft for >6 hours and a CT scan of his left lower extremity was negative for a deep leg infection. He was weaned off the ventilator and extubated uneventfully. His left leg was improved and he was transferred to the floor. The patient's home medications were restarted. The remainder of the post-operative course was uncomplicated as follows: . Neuro: Pain was controlled with IV medications while NPO and was transitioned to PO pain medications when tolerating a diet. The patient takes methadone for chronic back pain and was continued on this once he was tolerating po. . CV: Patient was monitored closely. He was given metoprolol IV and po to maintain his blood pressure within goal. He will be continued on this increased dose as an outpatient. The patient was maintained on other home cardiovascular medications. He may restart his lisinopril upon return to rehab, but this may require further titration of his metoprolol dose. . Pulm: Patient maintained normal O2 saturations and was encouraged to use incentive spirometry frequently. GI: Patient was initially NPO. His diet was advanced when appropriate and he tolerated it without nausea or vomiting. Renal: Patient was voiding independently without any issues. He was given IV lasix for diuresis as necessary and responded appropriately. . Endo: The patient was continued on his home insulin regimen. While his po intake was poor his lantus dose was decreased to half of the original value. . Heme: The patient's argatroban drip was continued with a goal PTT of 60-80. Coumadin was started and the argatroban was turned off on [**3-24**] and his INR was 4.1. His coumadin was held and decreased to 2.5 the next day. His coumadin was resumed and will be further managed at rehab. . ID: Patient received IV antibiotics for presumed cellulitis. He was continued on these during this hospitalization and will complete a 14 day course of outpatient IV antibiotics due to the severity of his left lower extremity cellulitis. On the day of discharge, his vanco trough returned 23.8, and his dose was reduced to 750 mg [**Hospital1 **]. This will require reassessment and possibly retitration after 3 doses. . PPX: argatroban, coumadin, aspirin . Physical therapy worked with the patient and recommended discharge to rehab. The patient will follow-up with Dr. [**Last Name (STitle) 1391**] in clinic for further evaluation and staple/suture removal in 2 weeks. Medications on Admission: Lantus' (50u qhs), Advair Diskus 250 mcg-50 mcg inh'', Spiriva 18 mcg inh', Aspirin 81', Lisinopril 20', Metoprolol Tartrate 25'', Lactulose', gabapentin 400'''', omeprazole 20', methadone 20 TID, pravastatin 40', furosemide 20', insulin lispro SSI, amitriptyline 25 QHS Discharge Medications: 1. glucagon (human recombinant) 1 mg Recon Soln Sig: One (1) Recon Soln Injection Q15MIN () as needed for hypoglycemia protocol. 2. senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day) as needed for constipation. 3. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain. 4. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. 5. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 6. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. methadone 10 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 8. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): may need to re-dose (had been on 50 [**Hospital1 **] at hospital, but had been holding lisinopril, which he may now restart). 9. gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 10. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO DAILY (Daily) as needed for constipation. 12. amitriptyline 25 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 13. pravastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 14. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 15. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 16. insulin glargine 100 unit/mL Solution Sig: Fifty (50) units Subcutaneous at bedtime. units 17. heparin, porcine (PF) 10 unit/mL Syringe Sig: Two (2) ML Intravenous PRN (as needed) as needed for line flush. 18. vancomycin in D5W 1 gram/200 mL Piggyback Sig: Seven Hundred Fifty (750) mg Intravenous Q 12H (Every 12 Hours) for 2 weeks: check trough after 3rd dose, keep 15-20. 19. ciprofloxacin 400 mg/40 mL Solution Sig: Four Hundred (400) mg Intravenous every twelve (12) hours for 2 weeks. 20. metronidazole in NaCl (iso-os) 500 mg/100 mL Piggyback Sig: Five Hundred (500) mg Intravenous Q8H (every 8 hours) for 2 weeks. 21. warfarin 1 mg Tablet Sig: Four (4) Tablet PO ONCE (Once): Please titrate for INR [**1-28**]. 22. lisinopril 20 mg Tablet Sig: One (1) Tablet PO once a day. 23. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. Discharge Disposition: Extended Care Facility: [**Hospital **] Hospital - [**Hospital1 8**] Discharge Diagnosis: ischemic left lower extremity 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: What to expect when you go home: 1. It is normal to feel tired, this will last for 4-6 weeks ?????? You should get up out of bed every day and gradually increase your activity each day ?????? Unless you were told not to bear any weight on operative foot: you may walk and you may go up and down stairs ?????? Increase your activities as you can tolerate- do not do too much right away! 2. It is normal to have swelling of the leg you were operated on: ?????? Elevate your leg above the level of your heart (use [**1-28**] pillows or a recliner) every 2-3 hours throughout the day and at night ?????? Avoid prolonged periods of standing or sitting without your legs elevated 3. It is normal to have a decreased appetite, your appetite will return with time ?????? You will probably lose your taste for food and lose some weight ?????? Eat small frequent meals ?????? It is important to eat nutritious food options (high fiber, lean meats, vegetables/fruits, low fat, low cholesterol) to maintain your strength and assist in wound healing ?????? To avoid constipation: eat a high fiber diet and use stool softener while taking pain medication What activities you can and cannot do: ?????? No driving until post-op visit and you are no longer taking pain medications ?????? Unless you were told not to bear any weight on operative foot: ?????? You should get up every day, get dressed and walk ?????? You should gradually increase your activity ?????? You may up and down stairs, go outside and/or ride in a car ?????? Increase your activities as you can tolerate- do not do too much right away! ?????? No heavy lifting, pushing or pulling (greater than 5 pounds) until your post op visit ?????? You may shower (unless you have stitches or foot incisions) no direct spray on incision, let the soapy water run over incision, rinse and pat dry ?????? Your incision may be left uncovered, unless you have small amounts of drainage from the wound, then place a dry dressing over the area that is draining, as needed ?????? Take all the medications you were taking before surgery, unless otherwise directed ?????? Take one full strength (325mg) enteric coated aspirin daily, unless otherwise directed ?????? Call and schedule an appointment to be seen in 2 weeks for staple/suture removal Followup Instructions: Please contact Dr.[**Name (NI) 1392**] office at [**Telephone/Fax (1) 1393**] to schedule a follow-up appointment for 2 weeks Completed by:[**2118-3-26**] Name: [**Known lastname 12862**],[**Known firstname **] L Unit No: [**Numeric Identifier 12863**] Admission Date: [**2118-3-21**] Discharge Date: [**2118-3-26**] Date of Birth: [**2057-1-13**] Sex: M Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 231**] Addendum: Pt was discharged on PO ciprofloxacin 500mg q12h x 14 days and PO Flagyl 500mg q8h x 14 days. Discharge Disposition: Extended Care Facility: [**Hospital **] Hospital - [**Hospital1 15**] [**First Name11 (Name Pattern1) 77**] [**Last Name (NamePattern1) 237**] MD [**MD Number(1) 238**] Completed by:[**2118-3-26**]

[ "414.01", "041.10", "428.0", "996.74", "V15.82", "444.22", "428.22", "V58.67", "250.00", "355.9", "682.6", "E878.2", "496", "416.8", "443.9", "707.15" ]

icd9cm

[ [ [] ] ]

[ "88.48", "88.42", "39.49", "38.08" ]

icd9pcs

[ [ [] ] ]

13641, 13870

4436, 7675

333, 395

10495, 10495

2695, 4413

12987, 13618

2267, 2285

7997, 10327

10442, 10474

7701, 7974

10678, 12964

2300, 2676

264, 295

423, 1499

10510, 10654

1521, 2198

2214, 2251

79,177

196,074

35252

Discharge summary

report

Admission Date: [**2161-1-23**] Discharge Date: [**2161-2-12**] Date of Birth: [**2109-4-16**] Sex: M Service: SURGERY Allergies: Shellfish Derived Attending:[**First Name3 (LF) 3376**] Chief Complaint: Leukocytosis and free air in abdomen on CT scan at OSH-found to have pneumatosis Major Surgical or Invasive Procedure: Right colectomy, end ileostomy, hartmann's pouch for perforated colon and obstructed small bowel at ileoileostomy site History of Present Illness: This is a 51 year-old male with a history of stage IV rectal cancer s/p chemo/XRT s/p lap-assisted protectomy with coloanal anastomosis and diverting loop ileostomy [**2160-12-1**] s/p ileostomy takedown on [**2161-1-14**] who is admitted to the [**Hospital Unit Name 153**] from the OR after resection of ischemic right colon, end-ileostomy, and long Hartmann's pouch (left colon is blindly attached, from [**Last Name (un) **]-anal anastomosis to transverse colon). Pt intermittently required phenylephrine during procedure, despite resuscitation with 4L LR, 3L NS, 600cc albumin (total 50g); intra-op EBL as 150cc and Hct 30, so has not received blood. . The patient originally presented to the ED at [**Hospital 27217**] Hospital with abd pain. He was transferred to our ED after he was found to have pneumatosis and was taken directly to the OR to have a partial coletomy and diverting ileostomy, as above. Past Medical History: Medical Hx: 1) Rectal Cancer Stage IV 2) Skin cancer on shoulder Surgical Hx: None All: NKDA Social History: He currently smokes one pack of cigarettes a day and used to drink three to four alcoholic beverages a day, but now drinks one a day. He works as a printer and has maintained work schedule pretty well throughout his treatment. Family History: His past family history includes a mother with colorectal cancer and a maternal grandmother who may have had colon cancer. Physical Exam: At Admission: Vitals: T: BP: HR: RR: O2Sat: GEN: Well-appearing, well-nourished, no acute distress HEENT: EOMI, PERRL, sclera anicteric, no epistaxis or rhinorrhea, MMM, OP Clear NECK: No JVD, carotid pulses brisk, no bruits, no cervical lymphadenopathy, trachea midline COR: RRR, no M/G/R, normal S1 S2, radial pulses +2 PULM: Lungs CTAB, no W/R/R ABD: Soft, NT, ND, +BS, no HSM, no masses EXT: No C/C/E, no palpable cords NEURO: alert, oriented to person, place, and time. CN II ?????? XII grossly intact. Moves all 4 extremities. Strength 5/5 in upper and lower extremities. Patellar DTR +1. Plantar reflex downgoing. No gait disturbance. No cerebellar dysfunction. SKIN: No jaundice, cyanosis, or gross dermatitis. No ecchymoses. . At Discharge: Vitals: 98.7, 109, 133/83, 20, 96%RA GEN: NAD, A/Ox3 CV: RRR RESP: CTAB Incision: Midline, abdominal with white/black sponge with vacuum dressing at 125mmHG. pink-red granulation tissue mid to distal portion of wound. minimal fibrinous tissue. The upper portion of the wound tracks up to 9 cm at 1 - 2 o'clock and as little as 3 cm at 12 - 12 o'clock. Ostomy: beefy red viable with thick brown effluence. +gas. Extrem: no c/c/e Pertinent Results: [**2161-1-23**] 07:05AM BLOOD WBC-25.4*# RBC-3.19*# Hgb-10.0* Hct-30.1* MCV-94 MCH-31.5 MCHC-33.4 RDW-17.4* Plt Ct-1470*# [**2161-1-24**] 01:22AM BLOOD WBC-18.4*# RBC-3.80*# Hgb-12.0*# Hct-34.9*# MCV-92 MCH-31.5 MCHC-34.3 RDW-17.5* [**2161-1-25**] 04:50AM BLOOD WBC-37.3* RBC-2.97* Hgb-9.2* Hct-28.4* MCV-96 MCH-31.0 MCHC-32.4 RDW-17.4* Plt Ct-909* [**2161-1-31**] 05:38AM BLOOD WBC-12.5* RBC-2.55* Hgb-7.8* Hct-23.3* MCV-92 MCH-30.6 MCHC-33.4 RDW-17.0* Plt Ct-640* [**2161-2-1**] 05:06AM BLOOD WBC-12.2* RBC-2.85* Hgb-8.9* Hct-26.6* MCV-93 MCH-31.3 MCHC-33.5 RDW-17.0* Plt Ct-852* [**2161-2-2**] 04:32AM BLOOD WBC-10.5 RBC-2.68* Hgb-8.0* Hct-25.0* MCV-93 MCH-29.8 MCHC-32.0 RDW-17.1* Plt Ct-989* [**2161-2-6**] 06:51AM BLOOD WBC-12.6* RBC-2.30* Hgb-6.9* Hct-21.4* MCV-93 MCH-30.0 MCHC-32.2 RDW-17.6* Plt Ct-1222* [**2161-2-7**] 05:59AM BLOOD WBC-14.2* RBC-3.09*# Hgb-9.0*# Hct-27.7*# MCV-90 MCH-29.2 MCHC-32.5 RDW-18.2* Plt Ct-1154* [**2161-2-11**] 04:51AM BLOOD WBC-9.1 RBC-2.73* Hgb-7.9* Hct-25.1* MCV-92 MCH-29.1 MCHC-31.7 RDW-17.6* Plt Ct-1215* [**2161-2-12**] 05:27AM BLOOD WBC-10.3 RBC-2.44* Hgb-7.3* Hct-21.8* MCV-89 MCH-29.7 MCHC-33.3 RDW-17.2* Plt Ct-1149* [**2161-2-1**] 05:06AM BLOOD PT-15.3* PTT-31.1 INR(PT)-1.4* [**2161-2-11**] 04:51AM BLOOD Glucose-105 UreaN-14 Creat-0.5 Na-136 K-4.5 Cl-101 HCO3-28 AnGap-12 [**2161-2-10**] 10:33AM BLOOD Glucose-107* UreaN-14 Creat-0.5 Na-135 K-4.6 Cl-101 HCO3-28 AnGap-11 [**2161-2-9**] 06:10AM BLOOD Glucose-105 UreaN-17 Creat-0.5 Na-137 K-4.3 Cl-104 HCO3-25 AnGap-12 [**2161-2-7**] 05:59AM BLOOD Glucose-102 UreaN-15 Creat-0.5 Na-137 K-4.4 Cl-108 HCO3-25 AnGap-8 [**2161-1-23**] 09:15PM BLOOD Glucose-107* UreaN-20 Creat-1.1 Na-136 K-3.8 Cl-106 HCO3-19* AnGap-15 [**2161-1-23**] 05:59PM BLOOD Glucose-104 UreaN-20 Creat-1.1 Na-136 K-3.9 Cl-107 HCO3-20* AnGap-13 [**2161-1-23**] 07:05AM BLOOD Glucose-98 UreaN-17 Creat-0.8 Na-135 K-3.7 Cl-97 HCO3-25 AnGap-17 [**2161-1-27**] 03:18AM BLOOD ALT-15 AST-26 AlkPhos-112 TotBili-0.4 [**2161-1-23**] 09:15PM BLOOD ALT-7 AST-14 AlkPhos-97 Amylase-10 TotBili-0.7 [**2161-1-23**] 07:05AM BLOOD ALT-15 AST-15 AlkPhos-310* TotBili-0.5 [**2161-2-11**] 04:51AM BLOOD Calcium-7.9* Phos-3.9 Mg-1.9 [**2161-2-10**] 10:33AM BLOOD Calcium-7.6* Phos-3.4 Mg-1.9 [**2161-2-9**] 06:10AM BLOOD Albumin-2.4* Calcium-7.9* Phos-4.1 Mg-1.9 Iron-10* [**2161-2-6**] 06:51AM BLOOD Calcium-7.5* Phos-3.3 Mg-2.0 [**2161-1-28**] 03:22AM BLOOD Albumin-2.0* Calcium-6.8* Phos-3.5 Mg-1.9 Iron-8* [**2161-1-27**] 03:18AM BLOOD Albumin-1.9* Calcium-7.4* Phos-4.1 Mg-1.9 [**2161-1-23**] 05:59PM BLOOD Albumin-2.4* Calcium-7.8* Phos-5.2* Mg-1.6 [**2161-1-23**] 07:05AM BLOOD Albumin-2.9* Calcium-8.4 [**2161-2-9**] 06:10AM BLOOD calTIBC-126* Ferritn-249 TRF-97* [**2161-2-4**] 05:42AM BLOOD VitB12-1257* Folate-6.6 [**2161-2-2**] 04:32AM BLOOD calTIBC-112* Ferritn-275 TRF-86* [**2161-1-28**] 03:22AM BLOOD calTIBC-107* Ferritn-262 TRF-82* [**2161-2-9**] 06:10AM BLOOD Triglyc-159* [**2161-2-2**] 04:32AM BLOOD Triglyc-76 [**2161-1-28**] 03:22AM BLOOD Triglyc-89 [**2161-2-4**] 05:42AM BLOOD TSH-5.1* [**2161-2-5**] 06:17AM BLOOD T4-7.5 T3-75* . [**2161-2-9**] 06:10AM PREALBUMIN Test Result Reference Range/Units PREALBUMIN 10 L 21-43 MG/DL . [**2-4**] RPR - non reactive [**1-26**] AM CXR- bilateral pleural effusions; [**1-26**] PM CXR - improved effusions [**1-31**] CT A/P: 1. diffuse peritonitis ,concerning for leak possibly involving the proximal or distal colonic sutures. 2. Large subcapsular splenic hematoma, possibly due to retraction injury. [**1-31**] KUB - Continued SBO; no change in position of drain in pelvis [**2-9**] CT: 1. Interval decrease amt of intra-abdominal fluid and air. intra-abdominal fluid, air directly contiguous with the midline anterior abdominal wall soft tissue defect. persistent thickening, enhancement of the peritoneum. Multiple loops of dilated small bowel measuring up to 5 cm with a relative decrease in small bowel caliber from the region of SB anastamosis to RLQ stoma. . Brief Hospital Course: Mr. [**Known lastname 26442**] was transferred to [**Hospital1 18**] from [**Hospital **] Hospital after CT scan revealed free air in abdomen with WBC above 20. He was urgently taken to OR per Dr. [**Last Name (STitle) 1120**] upon arrival to hospital. His operative course was prolonged. Patient required IV pressor support and hydration to maintain blood pressure due to shock symptoms from ischemic bowel. Post-op he was transferred to medical ICU for close monitoring: ventilation support, hydration, and blood pressure support with pressors. He continued on antibiotics, and labwork was trended during ICU stay. His condition gradually improved-weaned from Vent, and able to maintain blood pressure. He then became fluid overloaded and required aggressive pulmonary toilet and diuresis. He remained on nasal cannula, and demonstrated S/S of Respiratory decompensation with minimal activity. He was aggressively diuresed. Respiratory status improved, and he was transferred to Stone 5 for post-op care. . On Stone 5, patient continue to diurese. His mental status remained slightly compromised, but he remained A/Ox3. Physical was consulted due to lower extremity edema, and compromised respiratory status. TPN started for supplemental nutrition support and to promote wound healing due to low albumin levels, and decreased appetite. Advanced to regular diet once ostomy began to function. Calorie counts initiated. Labwork, including nutrition labs trended closely. . Incision noted to have erythema and draining purulent fluid. Opened at bedside and packed with moist gauze. Drainage was copiuous, and required suction. Vacuum dressing applied to midline abdominal incision to promote granulation tissue. Continued with IV Meropenem, and Flagyl switched to oral once tolerating regular food. Pain well controlled with oral oxycodone, tylenol, and fentanyl patch. Foley removed once patient hemodynamically stable. Able to urinate without difficultly. Ostomy RN continued teaching patient re: ostomy care. . His ostomy output increased to 3 liters once he was eating a regular diet. Imodium was started, and titrated up to 4 times per day with adequate effects. Metamucil wafer was also started, but discontinued once osotmy output decreased to about 600cc in 24hrs. He was advised to titrate his Imodium at home based on discharge instruction parameters. He is aware to call Dr. [**Name (NI) 14120**] office with concerns. . Mr. [**Known lastname 39129**] physical, surgical, & medical status improved dramatically. His diet improved, tolerated adequate amounts of PO intake to meet daily nutritional needs. TPN stopped prior to discharge. He was independent with ADL's and activity. Antibiotics discontinued on [**2161-2-10**], remained afebrile with normal WBC for 48hrs. He was discharge home with VNA for management of vacuum dressing to abdominal wound, ostomy care, and fluid/electrolyte management. Vacuum dressing changed on [**2161-2-12**] and switched to portable (home) vacuum pump prior to discharge. He will follow-up with Dr. [**Last Name (STitle) 1120**] in [**2-3**] weeks. Discharge information discussed with patient in detail. Medications on Admission: oxycodone, colace Discharge Medications: 1. Outpatient Lab Work Weekly CBC & Chem-10 Please fax results to Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1120**] ([**Telephone/Fax (1) 77616**]. 2. Loperamide 2 mg Capsule Sig: Two (2) Capsule PO QID (4 times a day) as needed for excessive ostomy output: Do not exceed 16mg in 24hrs. Disp:*240 Capsule(s)* Refills:*2* 3. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 4. Ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for pain for 10 days: Take with food. Disp:*45 Tablet(s)* Refills:*0* 5. Percocet 7.5-325 mg Tablet Sig: 1-2 Tablets PO every four (4) hours as needed for pain for 2 weeks: Do not exceed 4000mg of acetaminophen in 24hrs. Disp:*60 Tablet(s)* Refills:*0* 6. Fentanyl 100 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr Transdermal Q72H (every 72 hours) for 1 months. Disp:*10 Patch 72 hr(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Company 1519**] Discharge Diagnosis: Primary: Ischemia of colon perforation of the right colon post-op septic shock Post-op hypotension post-op wound infection post-op malnutrition post-op fluid overload post-op delirium . Secondary: Rectal CA stage IV s/p chemo and XRT 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: * If you are vomiting and cannot keep in fluids or your medications. * You are getting dehydrated due to continued vomiting, diarrhea or other reasons. Signs of dehydration include dry mouth, rapid heartbeat or feeling dizzy or faint when standing. * You see blood or dark/black material when you vomit or have a bowel movement. * Your pain is not improving within 8-12 hours or not gone within 24 hours. Call or return immediately if your pain is getting worse or is changing location or moving to your chest or back. *Avoid lifting objects > 5lbs until your follow-up appointment with the surgeon *Avoid driving or operating heavy machinery while taking pain medications. * You have shaking chills, or a fever greater than 101.5 (F) degrees or 38(C) degrees. * Any serious change in your symptoms, or any new symptoms that concern you. * Please resume all regular home medications and take any new meds as ordered. * Continue to ambulate several times per day. . Vacuum dressing/Incision Care: -[**Name Initial (MD) **] visiting RN will continue to manage your vacuum dressing at home. Changing dressing every 3 days. -Keep vacuum pressure at 125mmhg at all times to promote healing. -Please call VNA or Dr. [**Last Name (STitle) 1120**] if vacuum machine not functioning properly or leaking. -You may shower, and wash surgical incisions. Coordinate with VNA dressing changes. -Avoid swimming and baths until your follow-up appointment. -Please call the doctor if you have increased pain, swelling, redness, or drainage from the incision sites. . Monitoring Ostomy output/Prevention of Dehydration: -Keep well hydrated. -Replace fluid loss from ostomy daily. -Avoid only drinking plain water. Include Gatorade and/or other vitamin drinks to replace fluid. -Try to maintain ostomy output between 1000mL to 1500mL per day. -If Ostomy output >1.5 liter, please call Dr. [**Last Name (STitle) 1120**]. Continue to take your Imodium as advised. Do not exceed 16mg/24 hours. -If osotomy output decreases under 500cc in 24hrs, please inform Dr. [**Last Name (STitle) 1120**]. . Swelling of feet: -Continue to walk at least 3-4 times per day to help with circulation of fluid in legs. -While resting, keep your legs elevated. Try to elevate above level of your heart when sleeping. Followup Instructions: 1. Please follow-up with Dr. [**Last Name (STitle) 1120**] [**Telephone/Fax (1) 160**] in [**2-3**] weeks. 2. Follow-up with ostomy RN as advised. Call to make appointments ([**Telephone/Fax (1) 12537**]. 3. Follow-up with Dr. [**Last Name (STitle) **] (Liver surgeon) ([**Telephone/Fax (1) 3618**] as needed. SUMMARY NEITHER DICTATED NOR READ BY ME Completed by:[**2161-2-12**]

[ "518.5", "785.52", "V10.06", "567.22", "276.6", "E870.0", "998.59", "263.9", "197.7", "997.4", "998.2", "038.9", "995.92", "293.9" ]

icd9cm

[ [ [] ] ]

[ "99.15", "38.93", "45.73", "46.21", "45.74" ]

icd9pcs

[ [ [] ] ]

11396, 11445

7227, 10380

358, 478

11722, 11800

3140, 7204

14197, 14578

1800, 1925

10448, 11373

11466, 11701

10406, 10425

11824, 12876

12891, 14174

1940, 2677

2691, 3121

238, 320

506, 1420

1442, 1538

1554, 1784

18,082

164,053

11813

Discharge summary

report

Admission Date: [**2155-10-29**] Discharge Date: [**2155-11-29**] Service: MEDICINE Allergies: Sulfa (Sulfonamides) / Erythromycin Base / Lactose Intolerance Attending:[**First Name3 (LF) 348**] Chief Complaint: Left foot ulcer/cellulitis Major Surgical or Invasive Procedure: Picc line History of Present Illness: Mrs. [**Known lastname 31102**] is a [**Age over 90 **] yo with MMM who was admitted on [**2155-10-29**] with a left foot ulcer. She was treated w/ PO abx as outpt without much improvement and, thus, was admitted for IV abx and eval for possible osteo. MR foot on [**11-1**] without clear evidence of osteo, though it could not be ruled out. ESR & CRP elevated in past (not checked on this admission). Superficial cx + for MRSA. Podiatry & vascular consulted. Non-invasives performed, revealing severe PVD of left foot. Angio/possible surgical tx was being discussed when pt fell while in hospital. Unfortunately, on [**2155-11-4**], pt found "slumped in bathroom", apparently after trying to ambulate on her own. No reported LOC/loss of bowel or bladder conintence. Fall thought to be mechanical. Head CT showed acute left frontal subdural hematoma, without evidence of shift of midline structures, as well as left frontal subgaleal hematoma. Neurosurgery saw pt, no intervention recommended. Anti-coagulants/anti-platelet agents held. Platelets transfused (?). Repeat head CT on [**11-5**] showed expansion from 4mm to 8mm. Neurosurg still felt no intervention necessary given risk. Repeat scan on [**11-6**] & [**11-7**] showed stable SDH. On [**11-7**] PM, following repeat CT head, pt reportedly had decreased MS, desaturation to 88% on RA, and fevers to 101.9. Triggered for desaturation to 88% on RA. O2 sats improved to 92-93% on 2-3L NC. She was described as rousable to sternal rub. Pt given ethacrynic acid to diurese. Morning of [**11-8**], pt received her metoprolol, then had BP 70s/30s. Was noted to be unrousable to painful stimuli. Peripheral dopamine was started and the MICU team was contact[**Name (NI) **] for transfer Pt arrived in MICU on dopamine. She received bolus of ~1L and pressure improved to 110s to 120s systolic. Dopamine was stopped. A-line was place. She was eventually transferred back out to the medicine floor. She was started on levofloxacin/flagyl for presumed aspiration PNA and screened for rehab. She was discharged to rehab the morning of [**2155-11-29**]. Past Medical History: 1) Diabetes mellitus (Hgb A1C 5.8% in [**2-8**]) 2) Frequent UTI 3) Gastroesophageal reflux disease 4) S/p CVA w/residual mild R hemiparesis 5) Osteoporosis 6) Mild cognitive impairment 7) Depression/Anxiety 8) Osteoarthritis 9) Hypothyroidism (last TSH 2.8 in [**11-7**]) 10) Chronic diarrhea 11) COPD, on night O2 at home (FEV1 0.88 (73% pred), FVC 1.2, elevated EV1/VC ratio in [**1-6**]), no prior intubations, was placed on steroid taper at last admission in [**3-11**]. 12)Diastolic CHF 13)Coronary Artery Disease with cath [**1-8**], no intervention 14)s/p admission for fall at home discharged on [**2155-8-29**] Social History: Smoked 2ppd until [**2131**]. [**2-4**] glass of wine 3-4x/week. Worked as a secretary. Independent with ADLs, not IADL. Has 24 hour caretaker. [**Name (NI) **] (daughter) is the Healthcare proxy. Family History: Non-contributory Physical Exam: Vitals: T 95.6 HR 74 BP 89/38 R 20 97% 3LNC Gen: pale, elderly cachectic female lying in bed, does not respond to voice, but does withdraw to painful stimuli HEENT: NCAT, sclerae anicteric/noninjected, EOMI, PERRL, OP clear, uvula midline, dry MM Neck: JVP ~5 cm, no LAD CV: distant heart sounds, nl S1/S2, [**2-8**] diastolic and systolic non radiating murmur noted Lungs: decreased breath sounds at the bases, otherwise CTA, no wheezes Ab: soft, NTND, NABS, no HSM by percussion, no rebound or guarding Extrem: no c/c/e Skin: warm, lef foot, inner surface of big toe w/ mild erythema surround scabbed area, no fluctance or drainage Neuro: not speaking, does not allow her eyes to be opened, will move all extremities when stimulated by pain Pertinent Results: [**2155-10-29**] Foot MR - Edema involving the lateral aspect of the first metatarsal head and to a lesser extent the base of the first toe proximal phalanx. The appearance is nonspecific. Considerations include changes related to altered mechanics and trauma. Osteomyelitis is not excluded. [**2155-11-4**] CT Head - Study limited by motion artifact. New acute left frontal subdural hematoma seen, without evidence of shift of midline structures. Left frontal subgaleal hematoma. [**2155-11-9**] MR [**Name13 (STitle) 430**] - 1. Left subdural hematoma. 2. No evidence of acute infarct. 3. Marked cerebral atrophy. 4. Multiple nonspecific FLAIR hyperintense foci in the periventricular and deep white matter likely represent chronic microvascular ischemic changes. [**2155-11-24**] CT Head - Appropriate evolution of the left frontal subdural hematoma without evidence of new hemorrhage. [**2155-11-25**] LENI - No deep vein thrombosis seen in either leg. Brief Hospital Course: [**Age over 90 **] F with with COPD on home 02, h/o CVA, DM II, diastolic CHF, MRSA +, admitted with foot ulcer, hospitalization complicated by fall w/ SDH, fevers, & worsening mental status. # SDH: [**Hospital **] hospital course was complicated by SDH which was sustained s/p fall. Initial CT showed 4mm hematoma, next CT on [**11-5**] showed expansion to 8mm, repeats on [**11-6**] & [**11-7**] have been stable. Neurosurgery recommended supportive care only. Held anti-coagulation/anti-platelet agents. Repeated CTs showed no changes. EEG no signs of seizure ativity. Keppra given for seizure prophlaxis but stoped as it was thought to be contributing to MS changes. Repeat CT scans stable and examined by neurosurgery. Patient was restarted on ASA per NSG recs. She was seen by neurosurgery prior to discharge and had plans to see them in clinic in [**2-4**] weeks. At that time the patient will need a repeat head CT. # Altered mental status: per family pt has been "unresponsive"/ minimally responsive for two days, since her fall. At baseline, pt is interactive & talkative, though demented. Has been minimally responsive voice & painful stimili for ~24hr. [**2155-11-8**] AM not responding to painful stimuli. Suspect that some of MS change is due to effect of SDH, though there is no shift/mass effect. Could be some infectious component, though no clear source apart from her L foot ulcer, which appears to be improving. No metabolic abnormalities to explain change. Could be related to hypothyroidism. Treated for potential infections. Pt became more alert without any intervention. At the time of discharge, the patient was answering questions with yes or no answers and following basic commands. # Hypotension: Patient had episode of hypotension while in the hospital. She was transfered to the ICU briefly where she recieved fluids and was briefly on dopamine. Thought to be related to hypovolemia / antihypertension medications. She was rehydrated in the MICU and her blood pressures improved. She was slowly restarted on her home BP meds as her BP tolerated. #Pneumonia: Patient was noted to have episodes of tachypnea and tachycardia. Cxray revealed a infiltrate. Suspicion for aspiration pneumonia and patient was started on flagyl and levoquin on [**2155-11-27**]. She will need to complete a 10 day course (last day should be [**2155-12-6**]). #Foot ulcer: MRI w/o definitive evidence of osteo. She will be treated with a 6 week total course of Vancomycin for the infection. Wound swab postive for MRSA. Course to end on [**2155-12-10**]. Dosing based on levels (goal vanco trough >15; currently on q 36hr dosing). # COPD: on home O2, 2L, w/ baseline 02 sats 90-95% per family. She was continued on Nebs and O2 as needed while hospitalized. # CAD: Patient was ruled out during hypotensive episode. Cardiac enzymes remained negative and her EKGS were without evidence of acute events. She was continued on ASA but plavix was held per neurosurgery recs. # Anemia: Has anemia of chronic disease at baseline--confirmed by iron studies this admission. Hct has slowly dropped from ~37 on admission to 24 and stabilized at 27. Causes likely include possible slow GIB, repeated phlebotomy, and acute illness. No gross hemorrhage, apart from SDH, which is stable. Hemolysis labs negative. She was noted to be guiac positive during this admission which will need futher workup as an outpatient. She did not require any tranfusions. # Diastolic CHF: EF 50-55%. JVP ~5. Appears euvolemic on exam. Patient's metoprolol was held after her transfer to the ICU. She was continued on her lisinopril without signs of volume overload. Her metoprolol was restarted on the day of discharge. # Hyponatremia - patient was noted to be mildly hyponatermic at times during admission. Sodium responded to gentle IV hydration with normal saline. # Hypothyroid: She was continued on her home levothyroxine. # DM2: At home patient controlled with diet and glipizide. She was covered with sliding scale while in house. Sugars were well controlled. Because her sugars were well controlled her glipizide was not restarted at the time of discharge. # FEN: Patient was started on tube feeds. She failed multiple speech and swallow evaluations. After discussion with patient's family, a G/J tube was placed. Medications on Admission: Ipratropium Bromide Neb 1 NEB IH Q8H Fluticasone-Salmeterol (100/50) 1 INH IH [**Hospital1 **] Aspirin 81 mg PO daily Fluoxetine HCl 20 mg PO daily Glipizide 2.5 mg PO daily Metoprolol 12.5 mg PO BID Levothyroxine Sodium 50 mcg PO daily Lisinopril 2.5 mg PO daily Lorazepam 0.5 mg PO daily Discharge Medications: 1. Docusate Sodium 50 mg/5 mL Liquid Sig: One Hundred (100) mg PO BID (2 times a day). 2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 3. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). 4. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO BID (2 times a day). 5. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 6. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 7. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily). 9. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 10 days: Please continue until [**12-7**]. 10. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 10 days: Please continue until [**12-7**]. 11. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb Inhalation every eight (8) hours as needed. 12. PICC Care PICC care per protocol 13. Vancomycin in Dextrose 1 gram/200 mL Piggyback Sig: One (1) gm Intravenous Q36H (every 36 hours): Please continue until [**12-10**]. Please check troughs - goal 15-20. 14. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO twice a day: please hold for SBP<90 or HR<55. 15. Fluoxetine 20 mg Capsule Sig: One (1) Capsule PO once a day. Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - MACU Discharge Diagnosis: Primary: 1. Traumatic left parietal SDH. 2. Delirium. 3. LLE 1st MTP cellulitis/ulcer. 4. Cachexia Secondary: 1. Diabetes Mellitus Type II. 2. Anemia of Chronic Disease. 3. Diastolic Heart Failure. 4. Moderate RCA and D1 coronary artery disease. 5. Hypertension. 6. Gastroesophageal reflux disease 7. S/P Pontine CVA w/residual mild right hemiparesis 8. Osteoporosis 9. Dementia. 10. Depression/Anxiety 11. Osteoarthritis 12. Hypothyroidism 13. COPD on Home 02 14. Chronic diarrhea. 15. MRSA Discharge Condition: Stable, maintaining oxygen saturation, mental status improved Discharge Instructions: You were seen in the hospital for treatment of cellulitis. During the hospitalization you had a subdural hemorrhage. Neurosurgery followed you while in the hospital and no surgery was indicated. You will follow up with Dr. [**First Name (STitle) **] from neurosurgery in two weeks and have a repeat CT scan. You were also treated for aspiration pneumonia. Please finish your course of antibiotics. Please keep the appointments listed below Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs. The following changes have been made to your home medications. 1. Your lisinopril was increased from 2.5mg to 5mg daily 2. We have been holding your glipizide while you were in the hospital. Your sugars have been well controlled. 3. We also have been holding your ativan. 4. You have 2 new antibiotics that need to be continued to another 7 days after you are discharged. These antibiotics are called levofloxacin and flagyl. 5. You are on vancomycin for a total of 6 weeks for a foot ulcer. If you have any change in mental status, new neurological symptoms, shortness of breath, or other concerning symptoms, please call your PCP or go to the emergency room. Followup Instructions: Please call Dr. [**Last Name (STitle) **] office and make an appointment to see him on or about [**12-8**]. She will also need a repeat CT scan on that same day. His office number is [**Telephone/Fax (1) 1669**]. They can also help schedule the CT Scan.

[ "707.15", "E888.9", "784.7", "E942.6", "682.7", "250.80", "440.23", "414.01", "E849.7", "787.91", "507.0", "730.27", "733.00", "041.11", "530.81", "731.8", "851.81", "V09.0", "458.29", "285.29", "428.0", "250.70", "300.4", "496", "428.32" ]

icd9cm

[ [ [] ] ]

[ "43.11", "38.93", "38.91" ]

icd9pcs

[ [ [] ] ]

11187, 11253

5129, 6070

299, 310

11803, 11867

4141, 5106

13098, 13358

3345, 3363

9818, 11164

11274, 11782

9503, 9795

11891, 13075

3378, 4122

232, 261

338, 2469

6085, 9477

2491, 3114

3130, 3329

56,855

150,289

38028

Discharge summary

report

Admission Date: [**2144-6-28**] Discharge Date: [**2144-7-4**] Date of Birth: [**2058-10-28**] Sex: F Service: MEDICINE Allergies: Penicillins / Lisinopril / Hydrochlorothiazide / Tetracycline / Zocor / Clindamycin Attending:[**First Name3 (LF) 30**] Chief Complaint: Upper GI bleed Major Surgical or Invasive Procedure: Urinary Foley Placement PICC Placement Midline Placement History of Present Illness: 85 year old woman with history of coronary artery disease s/p CABG X3 in [**2142**], CHF (ECHO [**11/2143**] w/ EF 30%), NSTEMI, GERD, DVT s/p IVC filter in [**2138**], hypertension, renal insufficiency, hyperlipidemia, osteopenia who presents with upper GI bleed. Of note, the aptient had been at rehab after ruptured thoracic aortic dissection s/p endovascular repair at [**Hospital1 80463**] on [**2144-6-15**]. The patient developed bright red blood per rectum at rehab and was sent to [**Hospital **] Hospital where she was found to be hypotensive SBP89 in ED with Hct 20.9 and WBC 11.5. CT angio at the time showed increased density in the colon with edematous duodenal wall and ?ulcerations suggestive of blood. There was no noted extravasation near the endovascular stent although the IVC filter was noted to extend beyond the vessel wall. GI was consulted and the patient started on protonix gtt. . The patient received [**2-9**] units pRBC in the ED and then another 2 units in the MICU with appropriate bump. GI performed EGD on [**2144-6-25**] which showed two large and one smaller duodenal ulcer without active bleeding. The patient was also found to have white patches suggestive of esophageal [**Female First Name (un) **]. Of note, the patient became hypotensive (SBP50s), brady (HR40s), and hypoxic (O2 sat 60s) shortly after the EGD and had received 50mcg Fentanyl and 2mg Versed. She responded to Narcan 0.4mg and Romazicon 0.2mg. . On [**2144-6-26**], the patient became thrombocytopenic to 85 and so subQ heparin was discontnued. Octreotide was started. On [**6-27**], the patient's Hct continued to remain low at 25 and she received 3 units pRBC. Taggeed RBC scan showed active bleeding in the proximal duodenum so repeat EGD was performed which showed active arterial bleeding of the duodenal ulcers which were clipped, cauterized and injected with epinephrine. The patient, who had returned to [**Location 213**] sinus, flipped back into atrial fibrillation with some RVR. The patient continued to pass maroon stools. The patient was started on two more units pRBC and MedFlighted to [**Hospital1 18**] for further management. In total, the patient reportedly received 11 units pRBC and 6 units platelets, 1 unit FFP, 2.5mg lopressor "around the clock" and octreotide 50mcg/hr gtt, Protonix 8mg/hr gtt. FFP since admission. . On transfer the patient's vitals were: afebrile, BP124/80, HR126 AFib, 97% on 2L nasal cannula, RR 15. . ROS: Patient resting comfortably in bed, speaks mainly Cantonese. Daughter and grandaughter at bedside, speak fluent English. Patient denies discomfort except from NGT and would like it removed. States breathing, pain, edema not bothersome right now. Past Medical History: * Ruptured thoracic type B aortic dissection s/p endovascular repair w/ stenting graft ([**Hospital3 **] [**2144-6-14**]) * ?Abdominal aortic aneurysm repair * Coronary Artery disease s/p Coronary Artery Bypass Graft x 3 (LIMA to LAD, SVG to DIAG, SVG to OM) * Congestive heart failure (ECHO [**11/2143**]) w/ EF 30% * h/o cervical neck pain * NSTEMI * Bilateral knee replacement secondary to MVA * Anemia * Tremor * GERD * Prior atrial fibrillation for post-op knee replacements * DVT s/p IVC filter placement s/p MVA [**2138**] * GIB s/p MVA [**2138**] * Hypertension * Chronic renal insufficiency * Hypercholesterolemia * Osteopenia Social History: Lives alone, does not work. Never smoked and quit alcohol many years ago. Family History: Noncontributory Physical Exam: Admission: VS: Temp: 98.5 BP: 165/82 HR: 131 in Afib RR: 18 O2sat 96% on 2L NC GEN: Pleasant, speaks some Mandarin, fluent in Cantonese, generally comfortable, NAD HEENT: PERRL, EOMI, pale conjunctiva, MMM, op without lesions, ?no jvd, NGT in place RESP: Bibasilar crackles, good air movement, no wheezing/rhonchi/rales CV: RR, S1 and S2 wnl, no murmurs/gallops/rubs ABD: Non-tender, non-distended, +BS, soft EXT: No cyanosis/ecchymosis, 2+ edema in all extremities SKIN: No rashes or lesions NEURO: AAO. Cn II-XII intact. Strength and sensation grossly intact . Discharge: Physical Exam: VS: Temp:97.1 P-94, BP-114/62, 96% RA, weight [**6-30**]- 182 Ibs In/out: 1000/2400-negative 1410cc Oriented X 2 (knows she is in Hospital but does not know name) GEN: Pleasant, Cantonese speaking, generally comfortable, NAD HEENT: PERRL, EOMI, pale conjunctiva, MMM, op without lesions, no jvd, NGT in place RESP: good air movement, no wheezing/rhonchi. Insp crackles at the b/l bases. CV: irregularly irregular, S1 and S2 wnl, no murmurs/gallops/rubs ABD: Non-tender, non-distended, +BS, soft EXT: No cyanosis/ecchymosis,nonpitting to 1 + pitting edema in the lower extremities to the knees b/l SKIN: No rashes or lesions NEURO: AAO. Cn II-XII intact. Strength and sensation grossly intact . Pertinent Results: [**2144-6-28**] 09:47AM HCT-27.6* [**2144-6-28**] 05:21AM WBC-13.7* RBC-3.35* HGB-10.4* HCT-29.0* MCV-87 MCH-31.2 MCHC-36.0* RDW-17.9* [**2144-6-28**] 05:21AM PLT COUNT-120* [**2144-6-28**] 05:21AM PT-13.8* PTT-28.0 INR(PT)-1.2* [**2144-6-28**] 01:02AM GLUCOSE-129* UREA N-27* CREAT-1.1 SODIUM-142 POTASSIUM-4.6 CHLORIDE-108 TOTAL CO2-25 ANION GAP-14 [**2144-6-28**] 01:02AM estGFR-Using this [**2144-6-28**] 01:02AM CALCIUM-7.1* PHOSPHATE-3.3# MAGNESIUM-2.1 [**2144-6-28**] 01:02AM WBC-12.6* RBC-2.84* HGB-8.7* HCT-24.7* MCV-87# MCH-30.8 MCHC-35.4* RDW-17.1* [**2144-6-28**] 01:02AM PLT COUNT-139*# [**2144-6-28**] 01:02AM PT-14.5* PTT-28.6 INR(PT)-1.3* . CXR:[**6-28**] The patient is status post median sternotomy and aortic graft placement. Nasogastric tube terminates below the diaphragm, and right PICC terminates in the lower SVC. Widening of cardiomediastinal contours is present, accompanied by mild pulmonary vascular congestion. Bilateral pleural effusions are present, small on the right and small-to-moderate on the left, with improvement on the left compared to the prior radiograph. A cluster of calcified granulomas is present in the left upper lobe. A homogeneous opacity above this level in the region of the left first anterior rib may reflectconfluence of structures, but attention to this area on followup radiograph would be helpful to exclude a pleural or parenchymal abnormality in this region. . EKG: Atrial fibrillation with RVR, HR 122, normal axis, normal intervals, QTc 420, T wave flattening in all leads, generalized low voltage. Similar to priors although V4-V6 flattening more pronounced. . Discharge Labs [**2144-7-4**] 04:21AM BLOOD WBC-8.2 RBC-3.50* Hgb-11.0* Hct-33.4* MCV-96 MCH-31.5 MCHC-33.0 RDW-21.0* Plt Ct-114* [**2144-7-3**] 06:28AM BLOOD WBC-7.4 RBC-3.25* Hgb-10.4* Hct-30.5* MCV-94 MCH-31.9 MCHC-34.0 RDW-21.2* Plt Ct-100* [**2144-7-2**] 06:27AM BLOOD WBC-10.4 RBC-3.58* Hgb-11.4* Hct-34.1* MCV-95 MCH-31.9 MCHC-33.5 RDW-21.0* Plt Ct-105* [**2144-7-1**] 03:30PM BLOOD Hct-30.0* [**2144-6-30**] 12:53PM BLOOD Hct-30.2* [**2144-6-30**] 05:15AM BLOOD WBC-10.2 RBC-3.19* Hgb-10.1* Hct-29.2* MCV-92 MCH-31.8 MCHC-34.7 RDW-21.0* Plt Ct-102* [**2144-6-29**] 03:10PM BLOOD Hct-27.8* [**2144-6-29**] 03:27AM BLOOD WBC-11.1* RBC-3.17* Hgb-10.0* Hct-28.5* MCV-90 MCH-31.4 MCHC-35.0 RDW-20.2* Plt Ct-111* [**2144-7-4**] 04:21AM BLOOD Plt Ct-114* [**2144-7-3**] 06:28AM BLOOD Plt Ct-100* [**2144-7-1**] 06:33AM BLOOD Plt Ct-100* [**2144-7-4**] 04:21AM BLOOD Glucose-119* UreaN-20 Creat-1.3* Na-137 K-3.8 Cl-93* HCO3-38* AnGap-10 [**2144-7-3**] 06:28AM BLOOD Glucose-111* UreaN-15 Creat-1.3* Na-138 K-3.8 Cl-95* HCO3-40* AnGap-7* [**2144-7-2**] 06:27AM BLOOD Glucose-207* UreaN-15 Creat-1.4* Na-136 K-3.9 Cl-94* HCO3-34* AnGap-12 [**2144-7-4**] 04:21AM BLOOD Calcium-7.9* Phos-3.9 Mg-2.3 [**2144-7-3**] 06:28AM BLOOD Calcium-7.6* Phos-3.9 Mg-2.4 [**2144-7-2**] 03:25PM BLOOD Calcium-7.5* Phos-3.4 Mg-1.8 [**2144-7-2**] 06:27AM BLOOD Calcium-8.0* Phos-3.8 Mg-2.0 [**2144-6-29**] 03:27AM BLOOD ALT-12 AST-22 LD(LDH)-245 AlkPhos-30* [**2144-6-29**] 10:47AM BLOOD Type-[**Last Name (un) **] pH-7.26* . Micro MRSA negative HELICOBACTER PYLORI ANTIBODY TEST (Final [**2144-6-29**]): NEGATIVE BY EIA. Brief Hospital Course: A/P: 85 year old woman with history of coronary artery disease s/p CABG X3 in [**2142**], CHF (ECHO [**11/2143**] w/ EF 30%), NSTEMI, GERD, DVT s/p IVC filter in [**2138**], hypertension, renal insufficiency, hyperlipidemia, osteopenia who presented with ongoing upper GI bleed from OSH, and now being transferred to the floor with a stable Hct. . #Acute on Chronic Systolic heart failure: The patient had small bilateral pleural effusions with signs of mild pulmonary edema and no signs of pulmonary infiltrates or consolidations on imaging. She remained afebrile and denied any cough or dyspnea. She was not on home Lasix before admission and pleural effusions most likely represent element of acute on chronic systolic heart dysfunction in combination with massive liters of transfused blood the patient has recently received. Her weight in [**2144-4-7**] was 175 Ibs and on arrival to the floor from the ICU was 210 pounds. Recent echocardiogram showed a EF of approx. 50% though it was a limited study. In the past her EF was as low as 30%. Currently the patient is tolerating room air with no difficulties.Enocouraged incentive spirometer. Diuresed actively with 10mg IV Bolus's of Lasix [**Hospital1 **], and diuresed to 182 Ibs ([**7-4**]) from 212 Ibs.-Restarted Diovan for afterload reduction and placed her on Metoprolol Succinate 150mg daily. Blood pressure remained stable around 100-120/60-80 and HR stable under 100 beats /min. . # Duodenal Ulcers/Melena: Given initial hypotension and EGD findings of duodenal ulcers, most likely upper GI/small intestinal bleed. Potential Etiology included H. pylori (though serum ab negative), stress ulcers (given recent aortic aneurysm rupture), aspirin (half full dose). The patient does have a history of GI bleeds in the past also although circumstances around the [**2138**] episode are unclear. Continued to have melena, likely represents residual blood from recent Upper GI bleed given lack of abdominal pain and stable Hct from 29-34.Maintaned a active type and screen. Checked Hct once a day and on [**7-4**] her Hct was 33.4. Has a Power PICC in place on the right arm which was removed on [**7-4**]. Placed on Pneumo boots, no SQ heparin given recent bleed. Continued oral Pantoprazole 40mg [**Hospital1 **] . # Atrial fibrillation: With RVR to 120's at times when standing. At rest her HR is 70-80's.Likely in setting of volume shifts (overload, bleed). Known history of Atrial Fibrillation episodes after her CABG surgery in [**2142**]. She has a CHADS2 score of 3. Thus, patient should be anticoagulated in terms of risk for stroke. Additional information obtained from the PCP has revealed the patient does not carry a diagnosis of atrial fibrillation at his office. Continued Metoprolol Succinate 150mg daily today and rate controlled under HR of 100. As of [**7-4**] the patient was still in rate controlled atrial fibrilliation.Held off on anticoagulation given recent GI bleeds. Also did not restart aspirin given recent bleeds. Will need to be reassessed when aspirin can be restarted for her CAD and if she should be placed on Coumadin. . # IVC filter erosion: DVT in [**2138**] after relative immobilization after [**Name (NI) 39447**]. Erosion into soft tissue vs. out of vessel on CT abdomen .Should not be contributing to current GI bleed given vascular anatomy. Vascular recs include no need for intervention at this time . #Left cephalic vein clot- Midline removed and ultrasound was carried out which showed Occlusive thrombus within the left cephalic vein. Given recent GI bleeds cannot anticoagulate. Left UE swelling has decreased significantly with midline removal. . # Esophageal candidiasis: Seen on EGD at OSH Nystatin 500,000 UNIT PO/[**Known lastname **] Q8H was continued and discontinued during the admission given lack of symptoms of dysphagia. . # Thrombocytopenia: At the OSH, resolved with cessation of SQ heparin. Negative HIT antibodies .Platelet count-stable above 100 Avoid SQ heparin for now, pneumoboots only . # Ruptured thoracic aortic dissection: Type B, s/p endovascular repair with stenting graft in early [**2144-6-7**]. Stable. . # Coronary artery disease: Stable, s/p CABG X3 in [**2142**], prior NSTEMI.Held home aspirin given acute bleed .Continued Metoprolol Succinate and aspirin per above. . # Hypertension: Stable, Normotensive. Continued Metoprolol succinate and Diovan per above . # Chronic renal insufficiency: creatinine near baseline, increasing slightly in the setting of diuresis up to 1.3. Fluctuated between 1.1-1.3 during the latter parts of the admission did peak to 1.7 early on the admission most likely to recent hypotension. . # Hyperlipidemia: Continued Pravastatin . # GERD: Stable, may have developed stress ulcers peri-operatively recently. Continued PPI . # Osteopenia: Not on medications at home Outpatient follow up - did not restart aspirin given recent bleeds. Will need to be reassessed when aspirin can be restarted for her CAD and if she should be placed on Coumadin for atrial fibrillation. - Gastroenterology follow up for duodenal ulcers Medications on Admission: Medications at home: * Aspirin 162mg daily * Heparin SQ every 8 hours? * Hydralazine 25mg every 8 hours * Isosorbide 30mg daily * Lopressor 150mg twice daily * Oxycodone PRN * Pravastatin 80mg daily * Trazodone 50mg daily . Meds on transfer: * Octreotide 50mcg/hr gtt * Protonix 8mg/hr gtt * Lopressor 2.5mg PRN . Discharge Medications: 1. pravastatin 20 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). 2. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 3. metoprolol succinate 50 mg Tablet Extended Release 24 hr Sig: Three (3) Tablet Extended Release 24 hr PO DAILY (Daily). 4. valsartan 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. Lasix 20 mg Tablet Sig: 0.5 Tablet PO Mon, Wed, Fri . 6. Outpatient Lab Work Please carry out daily weights Please Monitor basic metabolic panel every week or as appropiate and replete electrolytes after reporting results to a doctor Please Monitor Hematocrit weekly and report results to a doctor Please reassess the need for standing oral lasix in the near future. Discharge Disposition: Extended Care Facility: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] Rehab & Nursing Center - [**Location (un) 47**] Discharge Diagnosis: Primary: - Bleeding duodenal ulcer - Acute blood loss anemia - Acute heart failure; likely diastolic but suboptimal ECHO - LUE cephalic vein thrombosis - Thrombocytopenia NOS Secondary: - Ruptured thoracic type B aortic dissection s/p endovascular repair ([**Hospital3 **] [**2144-6-14**]) - CAD s/p Coronary Artery Bypass Graft x 3 (LIMA to LAD, SVG to DIAG, SVG to OM) - NSTEMI - Systolic heart failure - Atrial fibrillation - DVT s/p IVC filter placement s/p MVA [**2138**] - GIB s/p MVA [**2138**] - Hypertension - Hypercholesterolemia 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 **], It was a pleasure caring for you at [**Hospital1 18**]. You were admitted to the ICU with a GI bleed. You were found to have an ulcer in your duodenum. During your stay here, you had 1 unit of blood. Your bleeding stopped, and your blood counts were stable. You also developed shortness of breath from too much fluid in your body. We gave you medications to urinate, to help remove this fluid. You were found to have a clot in your left cephalic vein because of the IV that was in your arm. This IV was removed. You were also found to have an irregular heart beat called atrial fibrillation. You will need to speak with your primary care doctor about whether to start a blood thinner for this. The following changes were made to your medications: We STOPPED Aspirin STOP Hydralazine STOP Isosorbide START Valsartan START Metoprolol Succinate START Lasix 10mg daily Monday, Wednesday, Friday. START Pantoprazole twice a day to protect the lining of your stomach Please weight yourself daily and let your primary care physician know if your weight increases by more than 3 pounds in 1 day. Followup Instructions: Please make an appointment with your primary care doctor once you are discharged from rehab.

[ "428.0", "403.90", "532.40", "112.84", "285.1", "585.9", "428.33", "530.81", "272.4", "453.81", "427.31", "V45.81", "287.5", "V43.65", "412", "414.00", "733.90" ]

icd9cm

[ [ [] ] ]

[ "38.93" ]

icd9pcs

[ [ [] ] ]

14780, 14920

8538, 13637

358, 416

15506, 15506

5259, 8515

16836, 16932

3922, 3940

14002, 14757

14941, 15485

13663, 13663

15689, 16813

13684, 13887

4544, 5240

303, 320

444, 3152

15521, 15665

3174, 3812

3829, 3905

13905, 13979

6,428

136,010

16891

Discharge summary

report

Admission Date: [**2116-5-27**] Discharge Date: [**2116-6-1**] Date of Birth: [**2095-5-6**] Sex: F Service: MEDICINE Allergies: Sulfamethizole / Zosyn Attending:[**First Name3 (LF) 348**] Chief Complaint: Fever, hypotension. Major Surgical or Invasive Procedure: [**2116-5-29**] - replacement of hemodialysis catheter. History of Present Illness: 21F ESRD of unknown etiology, BOOP, here with fever. Last admitted here with initial concern for line sepsis (hemodialysis line, which was changed), and during that admission underwent VATS lung biopsy/RML wedge resection after CT chest revealed numerous nodules in the chest. Biopsy results revealed BOOP, however, unclear etiology (anti-GBM negative). Continued to be febrile and sinus tachy to 140s despite broad-spectrum antibiotics, but cultures remained negative and all serologies were negative (w/ exception of b-glucan which can be false-positive in HD patients). Pt was discharged on [**5-18**] with continued low grade temperatures of 100-101. . Pt returned [**2116-5-27**] with two day history of fever/chills which began during hemodialysis two days prior to admission. Remainder of ROS is negative (except persistent cough productive of mild sputum since after VATS, mild RUQ tenderness), denies diarrhea, vomiting, dysuria, headache. Continues to have mild chest pain which is positional. Does state that she felt lightheaded over last two days. . Found to be slightly orthostatic in ED and received 2L NS. Abd u/s negative, CXR revealed sm R pleural effusion. Past Medical History: 1. Hypertension [**2107**], changed diet and received no further treatment. 2. Genital herpes in [**7-4**]. 3. Renal failure, etiology unclear, diagnosed [**2115-12-22**]. Now on HD. 4. BOOP of unclear etiology diagnosed during [**2116-5-13**] admission. Social History: Works as a waiter with [**Last Name (un) 47587**] Puck catering. She was a student at [**First Name4 (NamePattern1) 392**] [**Last Name (NamePattern1) 1688**] . She reports no tobacco or alcohol use and reports no other drug use. Sexually active with boyfirend, monogamous. Family History: Sister with lupus. Mother with asthma, cousin with [**Name2 (NI) 14165**] cell trait; no other issues. No history of bleeding diatheses. Physical Exam: Exam on admission: VS 130 97/30 41 97%RA Pulsus = 4mm Hg. GENERAL: Slightly ill appearing, slender African-American female in no acute distress HEENT: OM tacky NECK: Supple, tender shotty LAD, no JVD. CARDIOVASCULAR: S1, S2, tachy, reg, prominent S4 vs rub. LUNGS: CTAB except RML area w/ absent breath sounds. ABDOMEN: Extremely tender RUQ, hepatomegaly to ~3cm below rib. o/w active bowel sounds, nontender, nondistended. EXTREMITIES: Warm, no CCE. NEURO: A/Ox3, strength/sensation grossly intact. Pertinent Results: [**2116-5-26**] 09:34PM WBC-6.6 RBC-3.51* HGB-8.8* HCT-27.9* MCV-79* MCH-25.1* MCHC-31.7 RDW-19.7* [**2116-5-26**] 09:34PM LIPASE-438* [**2116-5-26**] 09:34PM ALT(SGPT)-6 AST(SGOT)-19 ALK PHOS-70 AMYLASE-191* TOT BILI-0.4 [**2116-5-26**] 09:34PM GLUCOSE-88 UREA N-20 CREAT-8.1*# SODIUM-136 POTASSIUM-4.5 CHLORIDE-102 TOTAL CO2-25 ANION GAP-14 [**2116-5-27**] 09:50AM WBC-11.6*# RBC-3.40* HGB-8.7* HCT-27.0* MCV-80* MCH-25.5* MCHC-32.1 RDW-19.6* [**2116-5-27**] 09:50AM LIPASE-596* [**2116-5-27**] 04:01PM GLUCOSE-91 UREA N-13 CREAT-4.6*# SODIUM-143 POTASSIUM-3.9 CHLORIDE-108 TOTAL CO2-27 ANION GAP-12 [**2116-6-1**] 05:50AM BLOOD WBC-3.9* RBC-3.33* Hgb-8.3* Hct-26.1* MCV-78* MCH-24.8* MCHC-31.7 RDW-19.5* Plt Ct-248 [**2116-5-29**] 03:34AM BLOOD PT-13.9* PTT-36.5* INR(PT)-1.2* [**2116-6-1**] 05:50AM BLOOD Glucose-91 UreaN-30* Creat-9.5*# Na-139 K-4.6 Cl-102 HCO3-29 AnGap-13 [**2116-5-30**] 07:00AM BLOOD ALT-10 AST-46* AlkPhos-93 Amylase-79 TotBili-0.3 [**2116-5-29**] 03:34AM BLOOD ALT-11 AST-53* LD(LDH)-319* AlkPhos-94 Amylase-107* TotBili-0.2 [**2116-5-30**] 07:00AM BLOOD Lipase-107* [**2116-6-1**] 05:50AM BLOOD Calcium-8.4 Phos-3.5 Mg-2.0 [**2116-5-28**] 03:30AM BLOOD Cortsol-21.9* [**2116-5-26**] 09:34PM BLOOD HCG-<5 [**2116-5-29**] 04:13PM BLOOD ANCA-PND [**2116-5-28**] 03:30AM BLOOD [**Doctor First Name **]-POSITIVE Titer-1:320 [**2116-5-30**] 09:30PM BLOOD Vanco-37.9 [**2116-6-1**] 10:44AM BLOOD Vanco-<2.0* [**2116-5-27**] 05:55PM BLOOD Type-[**Last Name (un) **] Temp-37.2 pO2-38* pCO2-38 pH-7.46* calTCO2-28 Base XS-2 Intubat-NOT INTUBA [**2116-5-27**] 05:55PM BLOOD Lactate-1.5 [**2116-5-29**] 04:13PM BLOOD CONFIRMATORY ANCA-PND [**2116-5-31**] 02:18PM URINE Color-Red Appear-Cloudy Sp [**Last Name (un) **]-1.009 [**2116-5-31**] 02:18PM URINE Blood-LG Nitrite-NEG Protein-500 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-8.0 Leuks-NEG [**2116-5-31**] 02:18PM URINE RBC->50 WBC-0-2 Bacteri-RARE Yeast-NONE Epi-0-2 TransE-0-2 . Date 6 Specimen Tests Ordered By All [**2116-5-26**] [**2116-5-27**] [**2116-5-31**] All BLOOD CULTURE URINE All EMERGENCY [**Hospital1 **] INPATIENT [**2116-5-31**] URINE URINE CULTURE-FINAL INPATIENT [**2116-5-27**] BLOOD CULTURE AEROBIC BOTTLE-PENDING; ANAEROBIC BOTTLE-PENDING INPATIENT [**2116-5-27**] BLOOD CULTURE AEROBIC BOTTLE-PENDING; ANAEROBIC BOTTLE-PENDING INPATIENT [**2116-5-26**] BLOOD CULTURE AEROBIC BOTTLE-FINAL; ANAEROBIC BOTTLE-FINAL EMERGENCY [**Hospital1 **] [**2116-5-26**] BLOOD CULTURE AEROBIC BOTTLE-FINAL; ANAEROBIC BOTTLE-FINAL EMERGENCY [**Hospital1 **] Brief Hospital Course: Ms. [**Known lastname 47590**] is a 21 yo female who developed ESRD in [**2115-12-1**] and was subsequently diagnosed with BOOP. She was admitted because she was found at HD to have hypotension and fevers. Upon admission to the MICU, pt was found to have stable vital signs, but febrile. An extensive prior workup had been performed for fever of unknown origin by ID. Blood cultures were nonetheless drawn, and the pt was begun on broad spectrum antiobiotic coverage with levoquin/vancomycin pending sensitivies. . 1. Fever: Because she remained afebrile since the antibiotics were started, she will continue a two week course of vancomycin and levofloxacin. Her blood cultures show NGTD as well as a UCx-NGTD. . 2)Renal failure: The patient had her HD line pulled on admission for concern of infection. Unfortunately, cultures of the tip were not taken. A temporary line was placed so that she could receive HD. On [**2116-6-1**] a permanent line was placed by IR. She received dialysis on [**2116-5-30**] and on [**2116-6-1**]. She should continue with her regularly schedule HD Mon., Wed., Fri. as prior to admission. Her antibiotics are being renally dosed and she is receiving nephrocaps. Her calcium acetate was stopped secondary to her low phosphorous. . 3) SOB: she has a h/o of BOOP/Pulm nodules. No further w/u for now since CXR shows decreasing opacities. A P-ANCA is pending for recheck despite her previously negative one. Per pulmonology request, she has been scheduled for an out-patient CT scan on [**2116-6-18**], and Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 7474**] will see her about one week afterwards in pulmonology clinic. . 4) Tachycardia: Baseline HR appears to be from the 90 to 110. She occasionally has palpatations with this tachycardia but all this is unchanged since prior to this admission. . 5) anemia: Her Hct remained stable. She receives epoetin during dialysis. Her anemia is likely due to her ESRD and anemia of chronic disease. . 6) RUQ pain/epigastric pain: Her pain had decreased significantly since admission. She had elevated amylase and lipase on admission which have both decreased significantly (lipase 109 and amylase 79). This may be a cause of her abdominal pain, which is getting better. Of note, she has been worked up for gallbladder and liver and pancreas problems earlier this month and everything was negative. . 7)Prophylaxis: Heparin SC for DVT prophylaxis was given while in the hospital. . 8) FEN: She was on a renal diet . 9) Code status: Full . Medications on Admission: 1. Cinacalcet 30 mg 2. Lisinopril 5 mg 3. Amlodipine 10mg 4. Calcium Carbonate 500 mg TID 5. B Complex-Vitamin C-Folic Acid 1 mg Discharge Medications: 1. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times a day). Disp:*90 Tablet, Chewable(s)* Refills:*2* 2. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). Disp:*30 * Refills:*2* 3. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 4. B Complex Plus Vitamin C Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 5. Cinacalcet 30 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* 6. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 7. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. Disp:*60 Tablet(s)* Refills:*0* 8. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for insomnia. Disp:*10 Tablet(s)* Refills:*0* 9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 10. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q48H (every 48 hours) for 5 doses. Disp:*5 Tablet(s)* Refills:*0* 11. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1) Intravenous QHD (each hemodialysis) for 10 days. Discharge Disposition: Home Discharge Diagnosis: Primary: Possible hemodialysis line infection Secondary: End stage renal disease, BOOP Discharge Condition: good. Discharge Instructions: Please take your medications as prescribed. . Please continue with dialysis on Mon, Wed, and Fri as you were prior to discharge. . Please notify your physician or go to the emergency department if you develop a fever >101.5, chills, chest pain, shortness of breath, severe headache, change in vision, or any other symptoms which conern you. . You had some blood in your urine. If this continues and it is not your menses, please see your primary care physician. Followup Instructions: You are scheduled for a CT scan on [**2116-6-18**] at 11:30am. Please go to the [**Location (un) **] of the [**Hospital Ward Name 23**] building for this appointment. Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] from Pulmonology will call you to set up an appointment about one week after this CT scan is done. Her clinic phone number is [**Telephone/Fax (1) 612**]. . Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2116-6-22**] 3:00 . Primary care with [**Name6 (MD) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2116-6-24**] 2:00 . Completed by:[**2116-6-1**]

[ "996.62", "285.21", "038.9", "995.91", "511.9", "516.8", "585.6", "403.91" ]

icd9cm

[ [ [] ] ]

[ "39.95", "38.95" ]

icd9pcs

[ [ [] ] ]

9467, 9473

5426, 7972

300, 358

9606, 9614

2836, 5403

10125, 10829

2157, 2298

8152, 9444

9494, 9585

7998, 8129

9638, 10102

2313, 2318

241, 262

386, 1569

2332, 2817

1591, 1848

1864, 2141

13,593

113,326

51098

Discharge summary

report

Admission Date: [**2116-3-22**] Discharge Date: [**2116-5-8**] Date of Birth: [**2057-12-26**] Sex: F Service: MEDICINE Allergies: Heparin Agents / Cefazolin / Nelfinavir / Morphine / vancomycin / Nafcillin Attending:[**First Name3 (LF) 2763**] Chief Complaint: upper back/neck pain Major Surgical or Invasive Procedure: Mechanical Intubation HD line insertion Arterial Line Insertion History of Present Illness: Ms. [**Known lastname 11182**] is a 55 yo f with HIV ([**2-13**] CD4 375), [**Month/Year (2) **] [**Month/Year (2) 106114**] pneumonitis, pulmonary HTN, ESRD on HD, cardiomyopathy and emphysema on O2 at home who presents with 2 weeks of cough and increased SOB, and 3 days of upper back/neck pain. She is more concerned about the back pain than the cough, which did not bother her too much. She denies F/C at home. She has produced some sputum; is on 3L home O2 at baseline. Last rec'd HD on [**3-20**]. As to her back pain, it started gradually 3 days PTA, and is located around her b/l shoulders, neck, and part of her L arm. No trouble holding objects or moving the L arm. No h/o lifting heavy objects or trauma. No lower back pain or trouble walking. No photophobia although she says she has cataracts. Endorses HA that she has had for 2 weeks or so, b/l frontal HA. She tried using [**Doctor First Name **]-gay for her shoulders to no avail. . In the ED, initial vitals were 102.4, 116, 113/81, 20, 99% 4L . Fiven Levaquin, was wheezing on arrival, received nebulizers and prednisone, with improvement of wheezing. Given her significant comorbidities, admitted to medicine for pneumonia. Got Tylenol, also Percocet for chronic back pain. . Currently, she c/o persistent upper back/neck pain. No vomiting, dysuria, diarrhea. Is hungry. Past Medical History: -HIV ([**2-13**] CD4 375) -ESRD on HD MWF -HTN -severe Pulmonary HTN -Cardiomyopathy [**12-10**] LVEF 31%, severe MR/TR -[**Month/Year (2) 106113**] [**Month/Year (2) 106114**] pneumonitis (LIP) followed by Dr. [**Last Name (STitle) **] [**Last Name (STitle) **] at [**Hospital1 2177**] ([**Telephone/Fax (1) 7799**] #6564 -anemia of chronic disease -AVNRT diagnosed at [**Hospital1 2177**] -Recent vaginal bleed s/p conization -HCV - untreated -Asthma/COPD on home O2 -h/o [**Hospital1 8974**] bacteremia and vertebral osteomyelitis PAST SURGICAL HISTORY -C-section -R knee surgery -Ovarian cysts removed Social History: She lives in [**Location 669**] with her 18 year old son. She has three sons and one daughter. Currently smokes a few cigarettes every few days. She has a 30-40 pack year smoking history. Has used "every drug" including cocaine. Last drug use was "eight years ago). She has never used IV drugs. She has a history alcohol abuse and has not drank in many years. Family History: Her mother is living in her 70s and had a stroke, hypertension and diabetes. Her uncle died of kidney disease. She never met her father. [**Name (NI) **] sister was killed in a motor vehicle crash. Her children are healthy. Her daughter has a single kidney. Physical Exam: ADMISSION PHYSICAL EXAM: VITALS: 99.2, 115, 101/69, 24, 95% 3L NC GEN: in NAD, resting in bed. alert. responds appropriately to questions. HEENT: PERRl, OP clear, MMM CV: RRR, could not appreciate murmurs; tachycardic PULM: CTAB but decreased breath sounds throughout ABD: umbilical hernia, normal BS, no tenderness to palpation, soft. EXT: no clubbing or cyanosis, 1+ edema b/l. 1+ pedal pulses Skin: diffuse dry and flaky skin on trunk, arms, scalp and less so on legs. Neuro: A/O x 3; CN2-12 intact b/l, strength 5/5 throughout b/l . DISCHARGE PHYSICAL EXAM: Tcurrent: 36.7 ??????C (98 ??????F) HR: 119 (104 - 125) bpm BP: 124/55(70) {72/29(45) - 124/67(75)} mmHg RR: 17 SpO2: 97% on 3LNC GENERAL - Chronically ill appearing, no acute respiratory distress at the time of my exam HEENT - PERRL, EOMI, sclera icteric, Dry mucous membranes with and cracked lips, OP clear, wrapped pressure ulcer on occiput. NECK - supple, no [**Doctor First Name **] no thyromegaly, no JVD, no carotid bruits, left IJ with mild oozing of blood but site non-tender, area of soft fullness slightly larger to area on corresponding side and disappears when she lays flat LUNGS - Coarse breath sounds and crackles b/l, reasonable movement throughout HEART - Tachycardic, nl S1 S2 clear and of good quality, RR ABDOMEN - NABS, soft/NT/ND, no rebound/guarding EXTREMITIES - WWP, no c/c/e, soft but palpable peripheral pulses NEURO - awake, A&Ox3, CNs II-XII grossly intact. Denies sensation of her feet and decreased sensation of her lower legs, describes burning sensation in her hands, diminished strength but function grossly. Pertinent Results: ADMISSION LABS: . [**2116-3-22**] 03:00AM BLOOD WBC-6.2# RBC-3.95* Hgb-11.4* Hct-36.4 MCV-92 MCH-28.8 MCHC-31.3 RDW-17.7* Plt Ct-65* [**2116-3-22**] 03:00AM BLOOD Neuts-73.8* Lymphs-22.7 Monos-2.4 Eos-0.7 Baso-0.4 [**2116-3-23**] 06:25AM BLOOD ESR-36* [**2116-3-22**] 03:00AM BLOOD Glucose-95 UreaN-23* Creat-7.4*# Na-137 K-7.3* Cl-101 HCO3-26 AnGap-17 [**2116-3-23**] 06:25AM BLOOD ALT-14 AST-26 AlkPhos-139* TotBili-0.6 [**2116-3-22**] 03:00AM BLOOD cTropnT-0.05* [**2116-3-22**] 03:00AM BLOOD proBNP-[**Numeric Identifier **]* [**2116-3-23**] 06:25AM BLOOD Calcium-7.9* Phos-2.3*# Mg-1.7 [**2116-3-23**] 06:25AM BLOOD CRP-38.1* [**2116-3-23**] 08:49AM BLOOD Lactate-1.9 [**2116-3-24**] 11:23AM BLOOD Lactate-1.1 [**2116-3-23**] 08:49AM BLOOD Type-ART pO2-111* pCO2-43 pH-7.38 calTCO2-26 Base XS-0 [**2116-3-24**] 11:23AM BLOOD Type-ART pO2-96 pCO2-48* pH-7.44 calTCO2-34* Base XS-6 . DISCHARGE LABS: . [**2116-5-8**] 04:05AM BLOOD WBC-4.9 RBC-2.60* Hgb-7.8* Hct-27.3* MCV-105* MCH-30.0 MCHC-28.6* RDW-21.4* Plt Ct-92* [**2116-5-8**] 04:05AM BLOOD Glucose-105* UreaN-18 Creat-3.1*# Na-137 K-3.8 Cl-98 HCO3-31 AnGap-12 [**2116-5-8**] 04:05AM BLOOD Calcium-9.3 Phos-2.5* Mg-1.9 [**2116-5-7**] 04:17AM BLOOD Type-MIX pO2-178* pCO2-61* pH-7.30* calTCO2-31* Base XS-2 Comment-GREEN TOP . PERTINENT MICRO/PATH: BLOOD CULTURES: [**2116-3-22**]: 3 of 3 sets positive as below [**2116-3-23**]: 1 of 1 set positive as below Dates [**2116-3-24**] - [**2116-5-2**]: 17 of 17 sets negative . [**2116-3-22**] 3:00 am BLOOD CULTURE Blood Culture, Routine (Final [**2116-3-30**]): STAPH AUREUS COAG +. FINAL SENSITIVITIES. Consultations with ID are recommended for all blood cultures positive for Staphylococcus aureus, yeast or other fungi. BACTRIM (=SEPTRA=SULFA X TRIMETH) sensitivity testing confirmed by [**First Name8 (NamePattern2) 3077**] [**Last Name (NamePattern1) 3060**]. DOXYCYCLINE AND RIFAMPIN SENSITIVITIES REQUESTED BY [**First Name4 (NamePattern1) 2482**] [**Last Name (NamePattern1) **],[**2116-3-28**]. SENSITIVE TO DOXYCYCLINE , sensitivity testing performed by [**First Name8 (NamePattern2) 3077**] [**Last Name (NamePattern1) 3060**]. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPH AUREUS COAG + | CLINDAMYCIN-----------<=0.25 S ERYTHROMYCIN----------<=0.25 S GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- =>8 R OXACILLIN------------- 0.5 S RIFAMPIN-------------- <=0.5 S TRIMETHOPRIM/SULFA---- =>16 R . ABSCESS CULTURE: [**2116-3-25**] 10:30 am ABSCESS NECK/ABSCELL FOR CULTURE. STAPH AUREUS COAG + CLINDAMYCIN-----------<=0.25 S ERYTHROMYCIN----------<=0.25 S GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- =>8 R OXACILLIN-------------<=0.25 S TRIMETHOPRIM/SULFA---- =>16 R . PREVERTEBRAL TISSUE CULTURE: STAPH AUREUS COAG + CLINDAMYCIN-----------<=0.25 S ERYTHROMYCIN----------<=0.25 S GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- =>8 R OXACILLIN------------- 0.5 S TRIMETHOPRIM/SULFA---- =>16 R . ANAEROBIC CULTURE (Final [**2116-3-29**]): NO ANAEROBES ISOLATED. . BAL Culture [**2116-4-17**]: No growth, negative for PCP . PICC Tip Cx: [**2116-4-8**]: No growth [**2116-4-21**]: No growth . HIV VL [**2116-3-26**]: 183 copies . RPR [**4-20**]: Non-reactive . MRSA SCREEN [**3-24**] & [**4-13**]: Negative . SPUTUM: [**4-5**]: PSEUDOMONAS AERUGINOSA AMIKACIN-------------- 8 S CEFEPIME-------------- 8 S CEFTAZIDIME----------- 16 I CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ =>16 R MEROPENEM------------- 4 S PIPERACILLIN/TAZO----- R TOBRAMYCIN------------ =>16 R . [**4-6**]: PSEUDOMONAS AERUGINOSA AMIKACIN-------------- 16 S CEFEPIME-------------- 16 I CEFTAZIDIME----------- 8 S CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ =>16 R MEROPENEM------------- 4 S PIPERACILLIN/TAZO----- R TOBRAMYCIN------------ =>16 R . [**4-15**]:PSEUDOMONAS AERUGINOSA AMIKACIN-------------- <=2 S CEFEPIME-------------- 8 S CEFTAZIDIME----------- 8 S CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ =>16 R MEROPENEM------------- 4 S PIPERACILLIN/TAZO----- R TOBRAMYCIN------------ 8 I . [**4-16**]: PSEUDOMONAS AERUGINOSA AMIKACIN-------------- S CEFEPIME-------------- 16 I CEFTAZIDIME----------- =>32 R CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ =>16 R MEROPENEM------------- 8 I PIPERACILLIN/TAZO----- =>128 R TOBRAMYCIN------------ 8 I . [**5-5**]: LEGIONELLA CULTURE (Preliminary): NO LEGIONELLA ISOLATED. . STOOL: [**3-29**]: Cdiff Negative [**4-30**]: Cdiff Negative . PATHOLOGY: OR SPECIMEN OF PREVERTEBRAL TISSUE: [**2116-3-25**] DIAGNOSIS: 1. Prevertebral tissue, excision (A): A. Fibrocartilage with focal acute and chronic inflammation and necrosis. See note. B. Fragments of bone. 2. Intervertebral disc, C4-C7, excision (B): A. Fibrocartilage with degenerative change and crushed cells, cannot exclude inflammatory cells. B. Fragments of bone. . IMAGING STUDIES: -CARDIOLOGY: TTE [**3-26**]: IMPRESSION: no echo evidence of endocarditis. Relatively small, hyperdynamic, left ventricle. Dilated and hypokinetic right ventricle with moderate to severe pulmonary hypertension. Mild mitral and moderate tricuspid regurgitation. . Compared with the prior study (images reviewed) of [**2114-4-16**], the degree of mitral regurgitation has increased. The right ventricle appears similar - moderately dilated with mild hypokinesis. The degree of tricuspid regurgitation has increased. Left ventricular function is more hyperdynamic on the current study. . TTE [**4-16**]: IMPRESSION: No echocardiographic evidence of endocarditis. Cannot exclude due to suboptimal image quality. Normal regional left ventricular systolic function. Mildly dilated and mildly hypokinetic right ventricle. If clinically indicated, a transesophageal echocardiogram may better assess for valvular vegetations. . Compared with the prior study (images reviewed) of [**2116-3-26**], pulmonary artery pressures could not be estimated on the current study. The other findings are similar. . RADIOLOGY: -[**2116-3-22**] CXR: IMPRESSION: Overall similar appearance of mild [**Month/Day/Year 106114**] edema and bibasilar scarring and/or atelectasis. Correlate clinically for possibility of early infection. No radiographic evidence of confluent consolidation. . -[**2116-3-23**] C-spine MRI: IMPRESSION: 1. C4-5: Marked narrowing of the disc space, with kyphosis and a disc osteophyte complex indenting the thecal sac with mild-to-moderate canal stenosis. Multilevel foraminal narrowing as described above. New small area of increased signal intensity in the C6-C7 intervertebral disc, -?edema/inflammation/infection. 2. Extensive pre, paravertebral and retropharyngeal T2 hyperintense signal which relates to fluid with or without abnormal enhancement from inflammation or infection. Assessment is limited given the lack of post-contrast images. This is seen to extend from the level of the clivus extending into the thorax, lower limit is not included. There is also mild increased signal intensity in the lateral atlantoaxial joints. . [**2116-3-23**] C-spine CT: IMPRESSION: 1. Findings consistent with C6-7 discitis/osteomyelitis with 1.4 x 1.0- cm prevertebral abscess anterior to C6 vertebral body. Massive likely reactive prevertebral effusion/phlegmon spanning the entire extent of cervical spine without rim enhancement. 2. Evaluation of epidural space is highly limited on CT. When patient able, recommend repeat MRI with gadolinium for further assessment of the epidural space and cord. 3. Prior C4-5 osteomyelitis with disc space destruction and fusion of vertebral bodies with mild 3 mm retropulsion of posterior inferior corner of C4, narrowing the canal at this level. 4. Medialization of internal carotid arteries, which are immersed within the prevertebral fluid/phlegmon. Vascular structures appear patent at this time. 5. Right maxillary mucosal disease. 6. Emphysema and evidence of mild [**Month/Day/Year 106114**] edema. . -[**2116-3-23**] T and L-spine CT: IMPRESSION: 1. Known large prevertebral fluid collection does not extend below cervicothoracic junction. 2. No definite CT evidence of acute process within the thoracic and lumbar spine. 3. Multilevel degenerative disease, worst at L4-5. 4. Precarinal adenopathy and splenomegaly, which may be related to HIV status. 5. Pulmonary arterial hypertension. 6. Small bilateral pleural effusions. 7. Moderate centrilobular emphysema with mild fluid overload. . CT Abdomen/Pelvis [**3-26**]: 1. Cirrhosis, ascites, and splenomegaly. 2. Renal atrophy and multiple hypodense lesions, consistent with cysts in keeping with prior ultrasound. 3. Cholelithiasis. 4. Bilateral adnexal cystic lesions, which should be evaluated by pelvic ultrasound. . Liver/Gallbladder U/S [**3-26**]: 1. Coarse nodular liver, consistent with underlying chronic liver disease with findings of portal hypertension. No definite hepatic lesion, though periphery of the liver was incompletely evaluated. 2. No intra- or extra-hepatic biliary ductal dilatation. 3. Bilateral pleural effusions and moderate ascites. 4. Stable splenomegaly. . CXR ([**2116-3-27**]): 1. Moderate pulmonary edema, not significantly changed since [**2116-3-26**]. 2. Moderate bilateral pleural effusions, slightly increased since prior. 3. Left lung base consolidation, likely atelectasis. . CT Neck/Spine ([**2116-3-31**]): 1. The small residual fluid collection in the cervical spine does not extend below the cervicothoracic junction. No acute abnormality identified in the thoracic spine. 2. Bilateral pleural effusions, increased in size compared to [**2116-3-23**]. . CXR ([**2116-4-1**]): 1. Interval placement of left subclavian line with tip at the mid to distal SVC. Right-sided PICC line in right atrium is withdrawn 3 cm to terminate at the cavoatrial junction. 2. Nasogastric tube with side port at GE junction could be advanced 3-4 cm. 3. Significantly worsened pulmonary edema with worsened bilateral pleural effusions. . CXR ([**2116-4-3**]): Lung volumes have improved, and mild pulmonary edema has decreased. Small right pleural effusion, moderate cardiomegaly and generalized pulmonary vascular congestion persist. Tracheostomy tube in standard placement. Dual-channel left subclavian catheter ends in the mid SVC and a right PICC line extends to or just beyond the superior cavoatrial junction. . CXR ([**2116-4-5**]): There are low lung volumes. Cardiomegaly is stable. There is improved aeration in the lower lobes bilaterally. Small bilateral pleural effusions have decreased. Lines and tubes are in unchanged position including a right central catheter with tip in the upper right atrium. There are no new lung abnormalities or evident pneumothorax. There is mild vascular congestion. Rounded opacities in the right upper lobe could be due to vessels on end and/or lung nodules. Attention in followup studies is recommended, and if they are truly lung nodules they will be suspicious for septic emboli. . CXR ([**2116-4-8**]): Improved bibasilar atelectasis with improved lung volumes. Unchanged mild pulmonary edema. . RUQ U/S [**2116-4-13**]: IMPRESSION: 1. Nodular liver consistent with the patient's known cirrhosis with portal hypertension signs that include splenomegaly and ascites. 2. Cholelithiasis without signs of cholecystitis. 3. No evidence of intra- or extra-hepatic biliary duct dilatation. 4. Right adnexal cyst for which a dedicate pelvis US or MR are recommended. . CTA CHEST [**2116-4-16**]: IMPRESSION: 1. No pulmonary embolism or aortic pathology. No focal opacification concerning for pneumonia. 2. Malignant course of the right coronary artery that is seen passing between the aorta and pulmonary artery, but is not definitively seen arising from the left coronary sinus. 3. Bilateral pleural effusions, both small right greater than left. Findings consistent with provided history of [**Month/Day/Year **] [**Month/Day/Year 106114**] pneumonitis as well as background emphysematous changes. 4. Partially imaged perihepatic ascites. 5. Soft tissue swelling evident in the anterior tissues of the neck, similar to [**3-31**] neck CT. . CT CHEST Non-Con [**4-21**]: IMPRESSION: 1. Small bilateral pleural effusions, right larger than left, are increased in size from [**2116-4-16**]. RLL consolidation very little aerated right lower lobe due to a combination of atelectasis and pneumonia has also worsened in the last 5 days. 2. Atelectasis or scarring in the lingula and left lower lobe is unchanged. 3. Mild centrilobular emphysema is unchanged. Right thin-walled cysts are compatible with provided history of [**Year (4 digits) **] [**Year (4 digits) 106114**] pneumonitis, though not to the degree expected for this diagnosis. 4. Increased perihepatic ascites since [**2116-4-16**]. . RUE U/S & Doppler [**4-21**]: IMPRESSION: Non-occlusive thrombus (DVT) seen surrounding the PICC line within one of the two brachial veins. Findings of non-occlusive thrombus were noted at 2:00 p.m. on [**2116-4-21**] and conveyed by telephone to Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 106124**] at 2:48 p.m. on the same day. . CT Torso with Contrast [**2116-5-3**]: IMPRESSION: 1. Stable to minimally improved right lower lobe consolidation. 2. Bilateral pleural effusions and small pericardial effusion. 3. Cholelithiasis. 4. Multiple renal hypodensities lesions incompletely characterized in this study, previously noted to represent cysts. 5. Right adnexal cystic lesion, for which pelvic ultrasound is recommended. 6. Cirrhosis, ascites, and splenomegaly with splenic varices consistent with portal hypertension. 7. Nonspecific ileal thickening which may represent sequelae of portal hypertension. . Brief Hospital Course: Ms. [**Known lastname 11182**] is a 55 yo f with HIV ([**2-13**] CD4 375), [**Month/Year (2) **] [**Month/Year (2) 106114**] pneumonitis, pulmonary HTN, ESRD on HD, cardiomyopathy and emphysema on O2 at home admitted for [**Month/Year (2) 8974**] sepsis from a prevertebral abscess s/p anterior discetomy with a hospital course complicated by pseudomonal pneumonia, multiple intubations, and 40+ day MICU stay. . ACTIVE ISSUES: . # [**Month/Year (2) 8974**] Sepsis from Prevertebral Abscess s/p Anterior Cervical Diskectomy: Patient was found to have blood cultures positive for [**Month/Year (2) 8974**] on [**3-22**] so she was initially started on daptomycin due to potential allergy to vancomycin but then switched to nafcillin, cefepime, and flagyl for broad coverage. Source was felt to be prevertebral fluid collection noted on CT of the neck on [**3-23**]. She triggered on the floor for hypotension with SBP 80 which was initially fluid responsive but eventually persisted despite boluses so she was transferred to the ICU for further management. After discussion between ENT, ortho spine, and neurosurgery, the patient went for anterior neck exploration by ENT and ortho spine and anterior cervical diskectomy and fusion was performed at C5-6 and C6-7 along with incision and drainage of prevertebral abscess on [**3-25**]. Patient remained intubated post-procedure due to significant procedure-related edema and her antibiotics were narrowed to nafcillin single-[**Doctor Last Name 360**] therapy. Patient's blood pressures were persistently low and she remained pressor dependent until [**2116-4-7**], when she was extubated. Due to patient's persistent hypotension despite resolution of bacteremia and drainage of abscess, studies were undertaken to evaluate for other potential sources of infection and she was broadened to Dapto/Meropenem. U/S of the fistula showed no signs of thrombus, TTE showed no vegetations, and CT Abdomen/Pelvis showed no abscesses or other acute infectious process. Despite persistent hypotension and elevated lactate, patient remained arousable and consistently able to follow commands. After 5 days of Dapto/[**Last Name (un) **] her antibiotics were changed to Nafcillin monotherapy due to improving BP, absence of a 2nd infectious source and decreasing pressor requirement. However, she developed a cholestatic hepatitis and her Nafcillin was switched back to Daptomycin. ID then recommended transitioning Daptomycin to Cefazolin. The pt has a documented Cefazolin allergy, so desensitization was undertaken but the patient developed anaphylaxis (see below). She was planned to have a 8 week total course (last day = [**5-19**]) of Daptomycin for her abscess and will follow up with Ortho Spine and ID for ongoing management. Her surgical wound had intermittent trace bleeding, though her HCT remained stable and her incision appeared well healing at the time of discharge. . #Cefazolin Desensitization/Anaphylaxis: Patient developed cholestatic hepatitis thought to be secondary to nafcillin therapy prompting switch to daptomycin to cover [**Month/Year (2) 8974**] sepsis. Patient had documented cefazolin allergy and desensitization protocol was attempted which she tolerated initially but she then developed anaphylaxis to 1mg of Cefazolin characterized by wheezing, SOB, tripoding, stridor and received Epinephrine, Hydrocortisone, Benadryl and Ranitidine with resolution of her symptoms without recrudescence of symptoms in 48 hours. . # Pseudomonal Pneumonia c/b Respiratory Failure and Sepsis: Pt became stridorous in the setting of a retropharyngeal abscess and was intubated on [**2116-3-24**] for airway protection. She required massive fluid recussitation for sepsis and developed pulmonary edema, which may also have contributed to her failure. She also has underlying COPD, which was a likely contributing factor to her poor pulmonary substrate and respiratory failure. Her abscess was evacuated and she had ACDF of C5-C6 and C6-C7 with ortho spine. She remained intubated due to concern for airway edema until [**2116-4-7**], when she was extubated without event. She then developed fevers, relative hypotension, and respiratory distress with sputum cultures growing pseudomonas. She ultimately required a second intubation and pressors for a priod of time. She was treated with a course of meropenem and amikacin per ID recommendation and improved. She was extubated without further significant issues and weaned off pressors for >2 weeks prior to discharge. She was satting well on nasal cannula, afebrile, and without respiratory distress at the time of discharge. . # Cholestatic Hepatitis: Patient's direct bilirubin and transaminases started to acutely rise on [**3-27**]. On exam, patient was also noted to have increased distention and tenderness. U/S of the gallbladder and CT of the Abdomen showed only cirrhosis and no acute pathology. Cefepime was discontinued due to concern for liver toxicity. Etiology was initially thought to be due to acute hepatic decompensation in the setting of critical illness. Her LFTs remained persistently elevated, and acutely worsened with initiation of Nafcillin therapy, which was subsequently discontinued (see above). Her hepatitis was felt to be [**3-5**] medication effect, though would note that she has underlying HCV. HBV serologies were negative. . # Multifactorial Anemia: Likely anemia of chronic disease and anemia of ESRD. She required intermittent blood transfusions throughout her course, though had no evidence of active bleeding. Stool guiac was repeatedly negative. She should continue receiving Epo with HD per renal. . # Ileus: In the setting of her acute illness and opiate use for pain control, Ms [**Known lastname 11182**] developed an ileus. For this she received Naloxone x1 as well as an aggressive bowel regemin. Her ileus was intermittent and resolved; at the time of discharge she was tolerating her tube feeds and a PO diet of clear liquids. . # Hypotension: Ms [**Known lastname 11182**] was intermittently hypotensive and requiring pressors throughout her course. Initially, her hypotension was almost certainly due to sepsis, which was treated with appropriate antibiotics. Later in her course she continued to require pressors with HD and her Midodrine was increased to 15mg TID. She was also started on high dose Thiamine due to concern for dry Beri-Beri, with marked improvement in her BPs. . # PICC Associated RUE DVT: Given her Heparin allergy, Ms [**Known lastname **] was started on an Argatroban gtt for her DVT after her PICC was removed. Hematology was consulted and recommended an Argatroban normogram, which was continued for the duration of her MICU stay. . # HIV versus Critical Illness Neuropathy: Given her multiple medical problems, poor nutrition, prolonged hospital course and peipheral neuropathy, there was concern for dry Beri-Beri. For this she was started on high dose Thiamine with initial improvement in her neuropathy. However, her neuropathy subsequently returned and neurology was consulted who felt it may be consistent with critical illness polysneuropathy. Her primary team felt her symptoms were likely related to her chronic HIV. She was trialed on low dose gabapentin but intermittently appeared sedated so that medication was discontinued. . CHRONIC ISSUES: . # HIV ([**2-13**] CD4 375): Her home HAART regemin was continued throughout her course. Viral load early on in her admission was 183. . # LIP/COPD/Asthma: Her home Albuterol/Ipratroprium were continued throughout her course. At the time of discharge, she was breathing comfortably on nasal cannula. . # Pulm HTN: Her Sildenafil 50mg PO TID was initially held for hypotension, but was restarted once she was off pressors. . # ESRD: Started on CVVH while on pressor support. She had a L subclavian temp HD line placed and received intermittent CVVH until weaned off pressors. Her temp HD line was pulled on [**2116-4-7**] she thereafter she received intermitted HD through her fistula in order to take off acumulated volume. She was transistioned to T/Th/Sat schedule prior to discharge. . # Chronic Thrombocytopenia: Ms [**Known lastname 11182**] is chronically thrombocytopenic, though her platelet counts on this admission were markedly lower. Her chronic thrombocytopenia may be related to her liver disease, and her acute decompensation may be multifactorial and due to acute hepatic decompensation and CVVH. She had intermittent, small volume bleeding through her surgical incision and from her occipital pressure ulcer. . # Elevated INR: Felt to be partly due to decompensation of patient's underlying cirrhosis but also due to antibiotic use. Patient was intermittently repleted with vitamin K. . TRANSITIONAL ISSUES: . #GOALS OF CARE: After significant discussions with the patient's family (primarily her daughter), she was remained FULL CODE throughout this admission. . #Consider outpatient pelvic US for 4.3 x 3.8 cm right ovarian cyst seen on abdominal CT, which is unchanged since [**2113**]. . #Please follow Q3 month CD4 counts and re-initiate bactrim prophylaxis for CD4 count below 200. Medications on Admission: Discharge Medications from [**11-12**] (pt does not recall any of her Rx, but says takes 4 HIV Rx and then a number of other Rx) 1. sildenafil 25 mg Tablet Sig: Two (2) Tablet PO QAM (once a day (in the morning)). 2. sildenafil 20 mg Tablet Sig: Five (5) Tablet PO QPM (once a day (in the evening)). 3. sulfamethoxazole-trimethoprim 800-160 mg Tablet Sig: One (1) Tablet PO QMON,WED,FRI (). 4. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable Sig: One (1) Tablet, Chewable PO BID (2 times a day). 5. lamivudine 100 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 6. calcitriol 0.5 mcg Capsule Sig: One (1) Capsule PO QTUE,[**Last Name (un) **],SAT (). 7. cinacalcet 30 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. etravirine 100 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 9. quetiapine 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 10. raltegravir 400 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 11. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) nebs Inhalation Q6H (every 6 hours) as needed for SOB. Disp:*35 nebs* Refills:*0* 12. ipratropium bromide 0.02 % Solution Sig: One (1) neb Inhalation Q6H (every 6 hours). Disp:*35 nebs* Refills:*0* 13. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q48H (every 48 hours) for 4 doses: Tale: Sat [**11-23**], Mon [**11-25**], Wed [**11-27**], Fri [**11-29**]. Disp:*4 Tablet(s)* Refills:*0* 15. lidocaine-prilocaine 2.5-2.5 % Cream Sig: One (1) Appl Topical QHD (each hemodialysis). 16. tenofovir disoproxil fumarate 300 mg Tablet Sig: One (1) Tablet PO QFRI (every Friday). 17. prednisone 10 mg Tablet Sig: One (1) Tablet PO once a day for 7 days: 40mg on [**11-17**] and [**11-25**] 20mg daily on [**11-26**] and [**11-27**] 10mg daily on [**11-28**] and [**11-29**] Discharge Medications: 1. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable Sig: One (1) Tablet, Chewable PO BID (2 times a day). 2. raltegravir 400 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. etravirine 100 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 4. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8 hours) as needed for pain/fever. 5. lidocaine-diphenhyd-[**Doctor Last Name **]-mag-[**Doctor Last Name **] 200-25-400-40 mg/30 mL Mouthwash Sig: 15-30 mL Mucous membrane four times a day as needed for mouth pain. 6. lamivudine 10 mg/mL Solution Sig: 2.5 mL PO DAILY (Daily): Total daily dose is 25 mg. . 7. tenofovir disoproxil fumarate 300 mg Tablet Sig: One (1) Tablet PO QMON (every Monday). 8. sildenafil 20 mg Tablet Sig: 2.5 Tablets PO TID (3 times a day). 9. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 10. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 11. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) neb Inhalation Q2H (every 2 hours) as needed for wheeze. 12. guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6 hours) as needed for cough. 13. phenol 1.4 % Aerosol, Spray Sig: One (1) Spray Mucous membrane Q6H (every 6 hours) as needed for irritation. 14. petrolatum Ointment Sig: One (1) Appl Topical TID (3 times a day) as needed for Rash. 15. ipratropium bromide 0.02 % Solution Sig: One (1) neb Inhalation Q2H (every 2 hours) as needed for wheezing, SOB. 16. quetiapine 25 mg Tablet Sig: Two (2) Tablet PO QHS (once a day (at bedtime)). 17. thiamine HCl 100 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 18. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 19. midodrine 5 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day). 20. lidocaine HCl 5 % Ointment Sig: One (1) Appl Topical Q DIALYSIS, FOR NEEDLE INSERTION (). 21. lidocaine HCl 5 % Ointment Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day). 22. loperamide 2 mg Capsule Sig: Two (2) Capsule PO QID (4 times a day) as needed for diarrhea. 23. quetiapine 25 mg Tablet Sig: 0.5 Tablet PO QAM (once a day (in the morning)) as needed for anxiety/agitation. 24. daptomycin 500 mg Recon Soln Sig: Four Hundred (400) Recon Soln Intravenous Q48H (every 48 hours): To be given AFTER dialysis on the day of dialysis. Last dose is [**2116-5-19**]. . Discharge Disposition: Extended Care Facility: [**Hospital **] Hospital - [**Hospital1 8**] Discharge Diagnosis: Prevertebral Abscess [**Hospital1 8974**] Bacteremia Hypoxic Respiratory Failure Hepatitis 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: Ms. [**Known lastname 11182**]: You were admitted to [**Hospital1 **] with an infection in your neck. An operation was performed to remove this infection. You also developed a blood stream infection from a bacteria. Lastly, your hospitialziation was complicated by respiratory distress. You were in the intensive care unit for many weeks and are being discharged to a rehab center. . The following changes were made to your medications: 1. Your Sildenafil was changed to 50 mg by mouth three times a day. 2. You were started on Daptomycin 400 mg by IV infusion to be given after each dialysis session. The final dose is to be given on [**2116-5-19**]. 3. Prednisone was stopped. 4. Bactrim (Sulfamethoxazole-Trimethoprim) was stopped as well because your CD4 count has improved. 5. Calcitriol was stopped per renal recommendations. 6. Lamivudine was decreased to 25 mg by mouth daily. 7. Cinacalcet was stopped per renal recommendations. 8. Quetiapine was changed to 12.5 mg by mouth each morning as needed for anxiety and 50 mg by mouth at night. 9. Nephrocaps were started. Take 1 capsule by mouth daily. 10. Folic acid was stopped. 11. Tenofovir was changed to every Friday to every Monday. The dose was not changed. 12. You were started on Midodrine 15 mg by mouth three times a day to increase your blood pressure. Followup Instructions: ** Right adnexal cyst for which a dedicate pelvis US or MR are recommended in the outpatient setting. ** . Department: INFECTIOUS DISEASE When: TUESDAY [**2116-5-12**] at 9:30 AM With: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4091**], MD [**Telephone/Fax (1) 457**] Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Hospital 1422**] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage . Please make an appointment to see Dr. [**Last Name (STitle) 363**] in Orthopaeidc Surgery PH: [**Telephone/Fax (1) 106125**] once you are in better condition [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 2764**] Completed by:[**2116-5-8**]

[ "427.1", "573.8", "E879.8", "285.9", "996.74", "V08", "V46.2", "041.7", "722.91", "V45.11", "682.1", "492.8", "997.31", "785.52", "038.11", "560.1", "403.91", "707.09", "287.5", "453.82", "518.81", "425.4", "707.25", "585.6", "995.92", "416.8", "E930.0", "730.28" ]

icd9cm

[ [ [] ] ]

[ "83.09", "80.51", "39.95", "96.72", "38.95", "96.04", "81.02", "38.93", "02.94", "81.62" ]

icd9pcs

[ [ [] ] ]

32241, 32312

18720, 19133

357, 422

32447, 32447

4725, 4725

33967, 34698

2819, 3080

29774, 32218

32333, 32426

27886, 29751

32623, 33944

5628, 9887

3120, 3633

27479, 27860

297, 319

19148, 26037

450, 1792

4741, 5612

32462, 32599

26053, 27458

1814, 2424

2440, 2803

3658, 4706

9904, 18697

5,795

104,320

27478

Discharge summary

report

Admission Date: [**2123-6-9**] Discharge Date: [**2123-6-15**] Date of Birth: [**2099-2-9**] Sex: M Service: CARDIOTHORACIC Allergies: Zithromax Attending:[**First Name3 (LF) 1283**] Chief Complaint: SOB, fatigue, headaches Major Surgical or Invasive Procedure: [**6-9**] AVR (OnX Mechanical) & Ascending Aorta History of Present Illness: 24 yo with known bicuspid valve & AI since childhood, with recent increase in symptoms. Past Medical History: Charcot-[**Doctor Last Name **]-Tooth s/p Umbilical hernia repair s/p RIH repair s/p foot injury/surgery Social History: [**1-11**] ppd x 10 years, quit [**1-15**] No etoh lives with Mother unemployed Family History: maternal grandfather deceased from MI age 55 father deceased from MI age 30 Physical Exam: On admission: NAD RR20 HR 84 BP 146/82 RRR SEM Lungs CTAB Extremeties warm, no edema Pertinent Results: [**2123-6-15**] 06:20AM BLOOD Hct-24.4* Plt Ct-405 [**2123-6-14**] 01:30PM BLOOD Hct-24.2* Plt Ct-322# [**2123-6-13**] 04:40AM BLOOD Hct-23.5* [**2123-6-12**] 04:45AM BLOOD WBC-8.4 RBC-2.79* Hgb-8.2* Hct-22.7* MCV-82 MCH-29.2 MCHC-35.9* RDW-13.2 Plt Ct-181 [**2123-6-15**] 06:20AM BLOOD Plt Ct-405 [**2123-6-15**] 06:20AM BLOOD PT-29.3* INR(PT)-3.1* [**2123-6-14**] 01:30PM BLOOD PT-30.9* INR(PT)-3.3* [**2123-6-14**] 06:00AM BLOOD PT-24.5* PTT-53.5* INR(PT)-2.5* [**2123-6-13**] 04:40AM BLOOD PT-13.3* PTT-23.1 INR(PT)-1.2* [**2123-6-12**] 04:45AM BLOOD PT-11.8 PTT-24.2 INR(PT)-1.0 [**2123-6-12**] 04:45AM BLOOD Glucose-97 UreaN-16 Creat-0.8 Na-133 K-4.4 Cl-98 HCO3-25 AnGap-14 Brief Hospital Course: Mr. [**Known lastname **] was taken to the operating room on [**2123-6-9**] where he underwent an AVR with a #23 Onyx mechanical valve, and an ascending aortic replacement with a #22 gelweave sidearm graft (8mm). He was transferred to the CSRU in critical but stable condition. He was extubated by POD #1 and transferred to the floor on POD #2. He was started on coumadin and a heparin bridge for his mechanical valve. He awaited therapeutic anticoagulation and was ready for discharge on [**2123-6-15**]. His goal INR is [**2-12**]. Medications on Admission: None. Discharge Medications: 1. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*0* 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*0* 3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 4. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*0* 5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed. Disp:*50 Tablet(s)* Refills:*0* 6. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 7. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 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 10 mEq Capsule, Sustained Release Sig: Two (2) Capsule, Sustained Release PO DAILY (Daily) for 5 days. Disp:*5 Capsule, Sustained Release(s)* Refills:*0* 10. Warfarin 1 mg Tablet Sig: Four (4) Tablet PO HS (at bedtime): Check INR [**2123-6-17**] can call results to Dr. [**First Name (STitle) **] . Disp:*100 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital1 11485**] VNA Discharge Diagnosis: Charcot [**Doctor Last Name **] tooth s/p Umbilical hernia s/p RIH s/p surgery for foot injury 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 heavy lifting or driving until follow up with surgeon. [**Last Name (NamePattern4) 2138**]p Instructions: PCP [**Last Name (NamePattern4) **]. [**First Name (STitle) **] 2 weeks Cardiac Surgeon Dr. [**Last Name (Prefixes) **] 4 weeks Completed by:[**2123-6-15**]

[ "389.9", "746.4", "441.2", "780.6", "356.1", "V58.61", "511.9" ]

icd9cm

[ [ [] ] ]

[ "38.45", "39.61", "88.72", "35.22" ]

icd9pcs

[ [ [] ] ]

3526, 3582

1610, 2145

298, 349

3721, 3729

906, 1587

708, 785

2201, 3503

3603, 3700

2171, 2178

3753, 3993

4044, 4203

800, 800

235, 260

377, 466

814, 887

488, 594

610, 692

8,799

100,914

18752

Discharge summary

report

Admission Date: [**2140-1-28**] Discharge Date: [**2140-2-8**] Date of Birth: [**2104-9-10**] Sex: F Service: MEDICINE Allergies: Tape [**1-25**]"X10YD / Augmentin / Hydrocodone / Levofloxacin / Ciprofloxacin / fentanyl / Keflex / ceftriaxone / Ativan Attending:[**Doctor First Name 3298**] Chief Complaint: Nausea Major Surgical or Invasive Procedure: None History of Present Illness: 35 yo F with T1DM complicated by retinopathy/nephropathy/ gastroparesis and recent admission for nausea and vomiting and DKA, who presents to the ED for recurrent nausea/vomiting. Per ED note, patient's symptoms started the day after discharge ([**2140-1-23**]). Diarrhea started the evening she returned home. Diarrhea lasted one and a half days. She also started having a cold with nasal congestion and cough, taking nyquil. She had associated chills, but no fevers. Her blood sugars have been runing high for the last 5 days despite whether or not she eats. She has not had abdominal pain, nausea or vomiting until this morning when she was dizzy and nauseaus. She has had minimal eating, but she has been drinking apple juice (not sugar free). She had eaten a different type of grape. She was also eating tabouli the same day she at the grapes. Then she woke up yesterday with the face swollen, but swelling improved by afternoon. On the day prior to admission, she had a headache, by afternoon feeling better. Went to dinner with her son, ate a salad. At 9pm, BG was low 40s, made an english muffin and ate half. Then she went to bed. This morning blood sugar was 182. She came to the hospital because she was feeling dizzy and getting nauseous again at 7:30 and came to the ED. Above history from patient's mother who lives with her. Pt had recent hospitalization for nausea and vomiting thought likely [**2-25**] gastroparesis, DKA placed on insulin drip in MICU, CONS UTI given ceftriaxone and completed a 3 day course. In the ED, initial vs were: 99.8 107 117/64 18 95%. Patient was given 4mg Zofran, 2mg Ativan, 650mg Tylenol PO with improvement in nausea, pain. FS 345 on arrival, 240's by lab. UA with few bacteria and WBC, given Nitrofurantoin 100mg. Vitals prior to transfer HR 110, BP 137/86, RR 16, 95% RA. . On the floor, pt initially unresponsive to command, voice, touch, arouse briefly to sternal rub. BG ~500, given 12 U humalog. Trigger was called. ABG demonstrated no acidosis, though ph 7.49. Pt was also noted to be hypoxic to 49% unclear if accurate pleth, easily weaned off O2 to RA when awake. Low grade temp to 100.3 noted. BP, HR, remained stable. No tachypnea. . Review of systems: (+) per HPI. Headache yesterday morning, took an excedrin resolved. when seen by mother subsequently, looked great. (-) Denies fever, night sweats, recent weight loss or gain. Denies sinus tenderness, rhinorrhea or congestion. Denied shortness of breath. Denied chest pain or tightness, palpitations. No recent change in bladder habits. No dysuria. Denied arthralgias or myalgias. Past Medical History: - Type 1 diabetes: c/b retinopathy, nephropathy, and gastroparesis, diagnosed at age 11. Poorly controlled per recent records, with the exception of during her pregnancy when she required TPN (with insulin it) for hyperemesis. She has had multiple episodes of diabetic ketoacidosis. A1c was 10.6 on [**2139-8-17**]. Last eye exam [**5-1**] - "quiescent" PROLIFERATIVE diabetic retinopathy. - Barrett's esophagitis - GERD, antral ulcer - Normocytic Anemia - HLD - HTN - dCHF EF > 60% in [**8-/2139**] - Accquired hemophilia (FVIII inhibitor in [**2132**]) treated with steroids and rituximab - Depression - Migraines - Anti-E and warm autoantibody but recent negative Coombs Test - Hydronephrosis - Osteoporosis ([**2138-11-12**] T-score L spine -2.2, femoral neck -3.1) - h/o avascular necrosis - H/o severe hyperemesis gravidarum requiring TPN. - s/p C section at 33 weeks because of hyperemesis - s/p repair for ruptured [**Last Name (un) 18863**] tendon - s/p ORIF of right distal radius Social History: The patient does not smoke or drink alcohol, transfusion in [**2132**]. Married, living with her mother, husband and one son. A homemaker currently. On disability since [**2132**]. Exercises regularly at a gym Family History: Has 1 sister, no hx of cancer or bleeding/ blood disorders in family but positive IBD history in grandfather and [**Name2 (NI) 12232**] Physical Exam: Admission exam: Vitals: T:98.2 BP:136/71 P:112 R:18 O2:94% NRB General: Alert, oriented, anxious, speaking in full sentences, not using accessory muscles of respiration HEENT: Mild conjunctival injection, no icterus or pallor, MMM, oropharynx clear, EOMI, PERRL Neck: supple, JVP not elevated, no LAD CV: Tachycardic, regular, normal S1 + S2, no murmurs, rubs, gallops Lungs: Diffuse rhonchi bilaterally, with occasional expiratory wheeze. No crackles. 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: 5/5 strength upper/lower extremities, grossly normal sensation, 2+ reflexes bilaterally, gait deferred Discharge exam: Vitals: T: 98 BP: 166/88 P: 66 R:18 O2: 96% General: Alert, oriented, speaking in full sentences, not using accessory muscles of respiration HEENT: Mild conjunctival injection, no icterus or pallor, 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: No wheezes, rales, rhonchi 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: A&Ox3, CN II - XII intact Pertinent Results: Admission labs [**2140-1-28**] 09:45AM BLOOD WBC-12.3*# RBC-2.90* Hgb-8.7* Hct-26.7* MCV-92 MCH-30.0 MCHC-32.7 RDW-13.1 Plt Ct-380 [**2140-1-28**] 09:45AM BLOOD Neuts-82.2* Lymphs-14.5* Monos-2.3 Eos-0.6 Baso-0.4 [**2140-1-28**] 09:45AM BLOOD PT-11.0 PTT-32.0 INR(PT)-1.0 [**2140-1-28**] 09:45AM BLOOD Glucose-274* UreaN-25* Creat-2.2* Na-133 K-5.0 Cl-97 HCO3-27 AnGap-14 [**2140-1-28**] 09:45AM BLOOD ALT-14 AST-16 AlkPhos-99 TotBili-0.1 [**2140-1-28**] 04:40PM BLOOD Calcium-7.6* Phos-4.8* Mg-1.8 [**2140-1-28**] 04:18PM BLOOD Lactate-1.2 Discharge labs: [**2140-2-8**] 06:50AM BLOOD WBC-7.2 RBC-3.61* Hgb-10.9* Hct-32.6* MCV-90 MCH-30.1 MCHC-33.4 RDW-13.6 Plt Ct-672* [**2140-2-8**] 06:50AM BLOOD Glucose-297* UreaN-18 Creat-1.2* Na-135 K-5.0 Cl-98 HCO3-26 AnGap-16 Studies CXR [**2140-1-28**]: Low lung volumes with patchy opacities in the left lung base, likely atelectasis, but infection cannot be ruled out in the correct clinical setting. CXR [**2140-2-1**]: Severe bilateral pneumonia has not improved since [**1-31**]. There is also a component of mild pulmonary edema which is probably worsened. Heart size is top normal. No pneumothorax. At least a moderate left pleural effusion is presumed. Chest CT w/o contrast [**2140-2-1**]: 1. Bilateral asymmetrically distributed ground-glass and consolidative opacities involving the left lung to greater degree than the right, accompanied by smooth septal thickening and bilateral pleural effusions. These findings likely represent a combination of multifocal pneumonia and pulmonary edema. 2. Small pericardial effusion. 3. Anasarca and small amount of ascites. 4. Healing sternal fracture and several anterior rib fractures, which are not appreciated on the older CT of [**2139-9-15**] but are age indeterminate. CArdiac ECHO: IMPRESSION: Normal left ventricular cavity size and wall thickness with preserved global and regional biventricular systolic function. At least mild mitral regurgitation. Very small to small, circumferential pericardial effusion without echocardiographic evidence of tamponade. Left pleural effusion. Indeterminate pulmonary artery systolic pressure. Compared with the prior study (images reviewed) of [**2140-9-1**], a very small to small pericardial effusion is present. The pulmonary artery systolic pressure was not able to be determined on the current study. Previously, at least borderline pulmonary artery systolic hypertension was appreciated. The left pleural effusion is new. Brief Hospital Course: 35 y/o F with hx of T1DM with severe gastroparesis, prior episodes of DKA, acquired hemophilia, htn, multiple recent admissions for nausea and vomiting, initially presented with nausea, vomiting, diarrhea found to have multifocal pneumonia requiring ICU monitoring, acute exacerbation of diastolic heart failure, difficult to control blood sugars, and acute kidney injury. Pt was s/p 2mg IV ativan in the ED for management of nausea and she initially presented to the floor extremely lethargic and barely responsive. She triggered for hypoxia 46% on RA but was never cyanotic and rapidly improved to 100% on RA. She was also hyperglycemic to 500 which improved with insulin and IVF. ABG did not demonstrate hypoxia or hypercarbia or acidosis. Her symptoms improved over half an hour when she was mildly lethargic but responding to questions appropriately and conversant, falling easily into sleep but arousable. When awake patient endorsed symptoms of dysuria and diarrhea. She was started on bactrim for UTI. For renal failure IVF were given and home diuretics held. The following day, her lethargy was resolved and she was having fever to 101, productive cough and diarrhea. CXR demonstrated multifocal PNA. Given numerous allergies to antibiotics she was started on meropenem and vancomycin for hospital acquired pneumonia, though aspiration pneumonia remained on the differential. Legionella was considered and urine legionella sent and ultimately returned negative twice. She remained on 3L O2 with sats dropping to high 80s and low 90s. On [**2-6**] she desaturated to low 80s on 4L requiring nonrebreather and transferred to the ICU. In the ICU, she was observed to be volume overloaded and treated with diuretics in addition to broadening her antibiotics to include antiviral treatment and azithromycin for legionella. During her ICU course she was diuresed with 40mg IV lasix, her O2 requirement improved. ID was consulted who recommended discontinuation of antiviral treatment after negative influenza swab. She was also found to have hypoglycemia, [**Last Name (un) **] was consulted, who recommended reducing insulin. She continued to have intermittent diarrhea and nausea/vomiting. After 3 days in the ICU and addressing the above issues, she was transferred back to the floor. On the floor, her oxygen requirement continued to improve such that she was on room air. She continued to have fevers to 101, for which drug fever was a concern per ID. So per their recommendation Meropenem and Vancomycin were discontinued after a 7 day course. Per ID recommendations Azithroymycin was discontinued on day 9 due to thrombocytosis. Upon return to the floor she continued to have fluctuating high and low blood sugars requiring frequent and daily adjustments of her lantus dose and sliding scale. At time of discharge she was on 4units of lantus [**Hospital1 **] with sliding scale recommended by [**Last Name (un) 387**]. During her hospitalization she required 2 units of blood products for hematocrit of 21 thought to be secondary to acute illness and phlebotomization. Hct was 25 at time of admission dropped to 21 during the course of her ICU stay. Her Hct remained stable at 32 for several days prior to her discharge. She was also given IV Iron given concern for occult GIB. Unclear remain the cause of her diarrhea which may have been viral in nature. Stool studies were all negative. Though this had resolved by time of discharge. Nausea vomiting, initially thought to be gastroparesis were minimal during this hospitalization compared to prior. She was tolerating regular diet at time of discharge. Renal failure had improved to creatinime of 1.2 on day of discharge. She was restarted on her home diuretics at time of d/c. She was not started on ACE/[**Last Name (un) **] due to history of hyperkalemia. Hospital course was also complicated by a number of social issues. Her mother and grandfather continued to be major supports. Pt admitted to not feeling supported by her husband with her medical issues. She was very stressed and was in a low mood during her hospitalization with flat affect. She was never suicidal or homicidal. She was seen by social work who did not feel that an inpatient psychiatry evaluation was needed. She was started on buspar and continued on zoloft. TRANSITIONAL ISSUES: - nutrition consult for gastroparesis - [**Last Name (un) 387**] follow up with classes for nutrition classes and learning carb counting. - CT scan in [**3-27**] weeks for resolution for pneumonia, per ID recommendation (vs CXR given the severity of her PNA and concern for cavitation) - Follow up depression - Social work follow up, consider referral to psychiatry - follow up of hematocrit and renal function - will need repeat endoscopy and possibly capsule endoscopy for evaluation of occult GIB. Medications on Admission: 1. amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day. 2. torsemide 20 mg Tablet Sig: One (1) Tablet PO once a day: please stop taking if you are unable to tolerate food or liquid. 3. sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. simvastatin 40 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 5. ferrous sulfate 325 mg (65 mg iron) Tablet Sig: One (1) Tablet PO once a day: do not take if constipation or stomach upset. 6. metoprolol tartrate 25 mg Tablet Sig: 1.5 Tablets PO twice a day. 7. Ambien 5 mg Tablet Sig: One (1) Tablet PO at bedtime as needed for insomnia. 8. Vitamin D 50,000 unit Capsule Sig: One (1) Capsule PO once a week. 9. gabapentin 800 mg Tablet Sig: One (1) Tablet PO at bedtime. 10. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO twice a day. Disp:*60 Capsule, Delayed Release(E.C.)(s)* Refills:*0* 11. ondansetron 4 mg Tablet, Rapid Dissolve Sig: [**1-25**] Tablet, Rapid Dissolves PO every eight (8) hours as needed for nausea. Disp:*90 Tablet, Rapid Dissolve(s)* Refills:*0* 12. metoclopramide 5 mg Tablet Sig: 1-2 Tablets PO three times a day: with meals. Disp:*180 Tablet(s)* Refills:*0* 13. Lantus 100 unit/mL Solution Sig: ASDIR Subcutaneous twice a day: take 6 units int he morning and 4 units at bedtime. . 14. Humalog 100 unit/mL Solution Sig: ASDIR Subcutaneous QACHS: per sliding scale. 15. Ativan 0.5 mg Tablet Sig: One (1) Tablet PO every 6-8 hours as needed for nausea. Disp:*30 Tablet(s)* Refills:*0* Discharge Medications: 1. amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day. 2. torsemide 20 mg Tablet Sig: One (1) Tablet PO once a day: stop taking if you are not eating or drinking well. 3. sertraline 50 mg Tablet Sig: One (1) Tablet PO once a day. 4. simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day. 5. ferrous sulfate 325 mg (65 mg iron) Tablet Sig: One (1) Tablet PO once a day. 6. Ambien 5 mg Tablet Sig: One (1) Tablet PO once a day as needed for insomnia. 7. Vitamin D 50,000 unit Capsule Sig: One (1) Capsule PO once a week. 8. gabapentin 800 mg Tablet Sig: One (1) Tablet PO once a day. 9. omeprazole 20 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO twice a day. 10. ondansetron 4 mg Tablet, Rapid Dissolve Sig: [**1-25**] Tablet, Rapid Dissolves PO once a day. 11. metoclopramide 5 mg Tablet Sig: 1-2 Tablets PO three times a day: with meals when for gastroparesis if needed. 12. insulin glargine 100 unit/mL Solution Sig: One (1) 4 IU in am and 4 IU in pm Subcutaneous twice a day. 13. Humalog 100 unit/mL Solution Sig: One (1) Subcutaneous sliding scale. 14. buspirone 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): twice a day for one week, then increase to three times a day. THIS IS A NEW MEDICATION FOR LOW MOOD AND ANXIETY. Disp:*60 Tablet(s)* Refills:*0* 15. metoprolol tartrate 25 mg Tablet Sig: 1.5 Tablets PO twice a day. Discharge Disposition: Home Discharge Diagnosis: Pneumonia Acute kidney injury Diabetes mellitus Decompensated diastolic heart failure Normocytic anemia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: It was a pleasure taking care of you. You came because of nausea and vomiting. After you came you developed the lung infection and impairment of the kidney function. The lung infection was treated with antibiotics. Kindey inpairment was treated with the intravenous fluid. During the hospital stay you started having difficulty breathing and were transferred to the intensive care unit and when you were able to breath without difficulties you were transferred back to the [**Hospital1 **]. . We have made the following changes in your medication: CONTINUE azithromycin for the next 10 days CONTINUE your home medication. . Followup Instructions: Please contact Dr.[**Name2 (NI) 51374**] office for an appointment on Tuesday or Wednesday to check your blood pressure, sugars, oxygen level. Department: HEMATOLOGY/ONCOLOGY When: WEDNESDAY [**2140-2-24**] at 2:30 PM With: [**First Name11 (Name Pattern1) 2295**] [**Last Name (NamePattern4) 11222**], MD [**Telephone/Fax (1) 22**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Completed by:[**2140-2-10**]

[ "507.0", "799.02", "311", "286.0", "583.81", "238.71", "250.53", "599.0", "250.63", "584.9", "038.9", "276.1", "733.00", "403.90", "362.01", "787.91", "V58.67", "486", "536.3", "428.0", "285.21", "428.33", "272.4", "585.9", "250.43" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

16109, 16115

8272, 12603

389, 395

16263, 16263

5770, 6312

17064, 17571

4283, 4420

14697, 16086

16136, 16242

13153, 14674

16414, 17041

6328, 8249

4435, 5161

5177, 5751

12624, 13127

2642, 3025

343, 351

423, 2623

16278, 16390

3047, 4040

4056, 4267

29,034

132,494

46744+58941

Discharge summary

report+addendum

Admission Date: [**2199-5-26**] Discharge Date: [**2199-5-28**] Date of Birth: [**2140-4-3**] Sex: F Service: MEDICINE Allergies: Lisinopril / Penicillins / Codeine Attending:[**First Name3 (LF) 1711**] Chief Complaint: transfer for anterior STEMI Major Surgical or Invasive Procedure: Cardiac cath with placement of Cypher stent Temporary pacemaker x 2 Intra-aortic balloon pump Pulmonary artery catheter History of Present Illness: Ms. [**Known lastname 1007**] is a 59yo woman with h/o discoid lupus admitted to OSH on [**5-22**] with dyspnea and wheeze felt to be from asthma vs CHF; although she initially reported 2 days of symptoms, on further questioning, she reports feeling congested ever since her knee surgery in [**Month (only) 547**]. Upon presentation, she was in NSR, but she developed AFib with RVR to 160. She was ruled out for MI with serial cardiac enzymes. Echo demonstrated EF 75% with LVH but no atrial enlargement. She was started on lovenox and coumadin and put on digoxin and diltiazem for rate control. Given concern for volume overload, she received lasix. She was also put on steroids briefly. Shortly after lunch on [**5-26**], the patient complained of chest pain and palpitations. Although she was initially in VTach, she was coded for VFib/arrest and had CPR and then DCCV x 200J once. She was started on lidocaine gtt and transferred to the ICU for persistent VTach; amiodarone gtt was started. 12-lead EKG revealed >10mm ST elevations in V3-V6 as well as 4mm STE in I. She was transferred to [**Hospital1 18**] for emergent cath. In the cath lab, she was maintained on amiodarone, lidocaine, and neosynephrine drips and continued to be in AFib with aberrancy with RVR; her systolic pressures did not drop below 80. Her LAD was found to be totally occluded and Cypher stent was placed. Thrombus was identified in her first diag; she had thrombectomy followed by POBA of D1. Hemodynamic measurements were significant for LVEDP of 22 and PCWP of 22. Cardiac index was calculated to be 1.35 l/min/m2 by Fick method, and IABP was placed. She received a total of 180cc of contrast. Her blood pressures improved with the IABP and her neosynephrine and lidocaine drips were stopped. She also received plavix 600mg. Upon arrival in the CCU, she had some right lower back pain, [**5-30**]. She was on heparin, integrillin, and amiodarone gtt. She denied any chest pain or dyspnea. On review of symptoms, she 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. She denies recent fevers, chills or rigors. She denies exertional buttock or calf pain. She has had 2 miscarriages. Past Medical History: HTN Discoid lupus erythematosis--facial scarring, hair loss Pseudotumor cerebri Legally blind caused by chloroquine GERD s/p b/l knee replacement s/p CCY s/p Tonsillectomy s/p C section Allergies: Lisinopril--lip swelling/angioedema Penicillin--rash Tetracycline--GI upset Codeine--GI upset OUTPATIENT CARDIOLOGIST: ? Dr. [**Last Name (STitle) 31187**] at [**Hospital1 **] PCP: [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) 553**] [**Last Name (NamePattern1) 99217**] of [**Location (un) 5110**] Social History: Social history is significant for the absence of current tobacco use: she smoked 39 years x 1 PPD; quit in [**2191**]. There is no history of alcohol abuse. Family History: There is a questionable family history of premature coronary artery disease or sudden death: one of her sons died at age 17 of a [**Last Name **] problem which she is unable to clarify at this time. Physical Exam: VS: T 96.3, BP 102/72, HR 101, RR 14, O2 % on 4L Gen: Pleasant, middle aged woman, somewhat tired but easily rousable and oriented, answering all questions appropriately. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. Neck: Supple with JVP of 5 cm. CV: PMI located in 5th intercostal space, midclavicular line. Irreg irreg and slightly tachycardic. No S4, no S3. No murmur. Chest: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. No crackles, wheeze, rhonchi. Abd: Obese, soft, NTND, No HSM or tenderness. No abdominial bruits. Reproducible back pain on palpation. Ext: No c/c/e. No femoral bruits. Skin: No stasis dermatitis, ulcers, scars, or xanthomas. Pulses: Right: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP Left: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP Pertinent Results: [**2199-5-26**] Cardiac Cath: 1. Selective coronary angiography of this right dominant system demonstrated single vessel coronary artery disease. There was a total occlusion at the bifurcation of the proximal LAD and a large D1 vessel. The LMCA, LCx, and RCA were all patent. 2. Resting hemodynamic measurement demonstrated an elevated left sided filling pressure with an LVEDP of 22 mmHg and a mean PCWP of 22 mmHg. The RVEDP was mildly elevated at 12 mmHg. The mean PAP was normal at 25 mmHg. Systemic arterial pressure was low at 96/64 mmHg while on a neosynephrine gtt. The Fick calculated cardiac index was low at 1.35 l/min/m2 consistent with cardiogenic [**Month/Day/Year **]. Pullback of the catheter across the aortic valve did not demonstrate a pressure gradient. 3. Due to persistent cardiogenic [**Last Name (LF) **], [**First Name3 (LF) **] IABP was inserted with marked improvement in blood pressure. 4. Successful PTCA and stenting of the proximal LAD with a 3.0x 13 mm CYPHER DES. Final angiography revealed no residual stenosis in the stent, no dissection and TIMI II flow. 5. Successful thrombectomy of the Diagonal and PTCA with a 2.5 mm balloon. Final angiography revealed no residual stenosis in the diagonal, loss of a sidebranch and TIMI II flow (See PTCA comments) FINAL DIAGNOSIS: 1. One vessel coronary artery disease. 2. Anterior-Lateral STEMI with cardiogenic [**First Name3 (LF) **]. 3. Successful placement of a DES to the LAD. 4. Successful placement of an IABP. TTE [**2199-5-27**]: The left atrium is mildly dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size. There is moderate to severe regional left ventricular systolic dysfunction with near akinesis of the anterior septum and anterior wall, distal lateral and inferior walls, and apex. The remaining segments contract normally (LVEF = 25 %). No masses or thrombi are seen in the left ventricle. The estimated cardiac index is depressed (<2.0L/min/m2). Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). Right ventricular chamber size is normal. with focal hypokinesis of the apical free wall. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve appears structurally normal. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is a trivial/physiologic pericardial effusion. IMPRESSION: Mild symmetric left ventricular hypertrophy with extensive regional systolic dysfunction c/w CAD with right ventricular infarction. Mild mitral regurgitation. Mild pulmonary artery systolic hypertension. CT Abd/Pelvis without contrast [**2199-5-27**]: (done for concern of RP bleed) PRELIM READ--FINAL READ PENDING Patchy hypodensities in the right kidney are suspicious for infarct. Air in the kidney may represent post surgical change but post infectuous air cause is also a possibility, recommend correlation with urinalysisis and CBC. No retroperitoneal bleed. CXR [**2199-5-27**]: Single AP chest radiograph without comparison shows bibasilar opacity which may represent atelectasis vs. aspiration. More focal opacity in the right suprahilar region extending to the apex may also represent aspiration, although mass lesion cannot be entirely excluded and therefore recommend followup with PA and lateral radiographs. The heart size is mildy enlarged. There is no pleural effusion or evidence of CHF. The tip of intra-aortic balloon pump terminates 2 cm below the aortic arch. Discussed with Dr.[**First Name (STitle) **]. Abdominal fluoro [**5-27**]: A single spot fluoroscopic examination was obtained without a radiologist present. This demonstrates partial visualization of aortic balloon pump catheter and a newly placed femoral approach pacing wire with its tip projecting in the region of the right ventricle. PRELIM CXR [**2199-5-27**]: IABP partially retracted, now 2.8 cm below aortic arch. PA catheter terminates in right interlobar artery. No change in bibasilar or right suprahilar oapcities. D/W Dr. [**First Name8 (NamePattern2) 6303**] [**Last Name (NamePattern1) **]. -[**Doctor Last Name **] PRELIM CXR [**2199-5-28**]: As compared to the previous examination, the intra-aortic balloon pump projects with its tip higher than on the previous examination, presumably due to patient position the tip is now located 5 mm below the upper margin of the aortic arch. Otherwise, the monitoring and support devices are unchanged. Higher lung volumes than on yesterday's examination, the perihilar opacities have slightly decreased, but a right upper lobe opacity persists. There is no evidence of pleural effusion. Subtle deviation of the trachea to the left is likely to be the manifestation of a goiter, but should be monitored closely to excluded other potential causes such as mediastinal hematoma. Labs from [**Hospital1 **] at time of transfer: Hct 38.5 BUN/Cr 15/1.3 Labs during hospital course: WBC [**5-26**]: 14; [**5-28**]: 22 Hct [**5-26**]: 35.7; [**5-28**]: 25 Plt [**5-26**]: 234; [**5-28**]: 188 Cr [**5-26**]: 2.0 Cr [**5-28**]: 3.9 Na [**5-26**]: 136 Na [**5-28**]: 131 Gluc 152-166 K [**5-28**]: 4.0 Mg [**5-28**]: 2.3 PTT 39.3-54.6; [**5-28**]: 45.2 INR 1.2 TSH 0.69 CK [**5-26**]: 11,135 with MB >500, Trop > 25 CK [**5-27**]: 7759 with MB 459 CK [**5-28**]: 3327 with MB 85 LFT [**5-27**]: ALT 186 AST 667 LDH 3528 Alk phos 50 Tbili 0.6 Vanc level pending Anti-cardiolipin pending ABG from [**5-26**]: 7.38/39/92 ABG from [**5-27**] at MN: 7.48/29/61 ABG [**5-28**]: 7.42/31/156 Lactate [**5-28**] 1.2 (has ranged 1.1-1.2) UA showed large blood with UCx negative (final) Brief Hospital Course: 59yo woman with h/o discoid lupus and HTN initially admitted with dyspnea and new AFib/RVR transferred after VFib/arrest in setting of anterior STEMI, now complicated by severe cardiac [**Month/Year (2) **]. # Cardiogenic [**Month/Year (2) **]/Anterior STEMI: Patient was hypotensive in the cath lab requiring neosynephrine to support blood pressure; neosynephrine was weaned once IABP placed in cath lab. Her PCWP and LVEDP were elevated in the cath lab suggesting fluid overload; it is likely that she has myocardial stunning in the setting of her recent MI as well as fluid overload. At the time of transfer out of the cath lab, she was on heparin, integrillin, and amiodarone gtt. She never completed a full amio load; she has received approximately 2-3g of amiodarone at the time of transfer. In regards to her STEMI, she was loaded on plavix in the cath lab. She has been continued on ASA, plavix, high dose statin, and she had integrillin x 18 hours post-procedure. She had Cypher stent to LAD and thrombectomy with POBA to D1. Cath report is included. TTE morning after her cath showed EF 25% with marked regional wall motion abnormalities consistent with infarct (images included). Note that she has angioedema with ACE inhibitors. The morning after her cath, she had complete heart block with ventricular standstill. Temp wire was emergently placed via femoral sheath; later that day a screw-in temporary pacemaker was placed in the cath lab. She received 1g vancomycin x 1 in the setting of the urgent procedures. Her MAPs were in the 50s with poor urine output, so she was sent back to the lab and PA catheter was placed for milrinone titration. Overnight, dopamine was added to support her MAPs, after which she quickly developed increased ectopy. Dopamine was switched to levophed, which she initially tolerated well. Though levophed was kept low at 0.25, she developed increasing ectopy with frequent short bursts of VTach the morning of transfer to [**Hospital1 2025**]. As her frequent arrhythmias were limiting titration of her pressors, she was transferred to [**Hospital1 2025**] for LVAD. Although her MAPs were in the 50s, she had warm extremities with good peripheral pulses and was mentating. She had become anuric in the setting of recent renal infarct and likely ATN. There was question regarding a possible pro-thrombotic state given that she had coronary thrombus without significant CAD or risk factors other than HTN and remote smoking history. She does report 2 miscarriages in the past, but no other history of clot. Anti-cardiolipin was sent and is pending at the time of discharge. # Anuria/Renal infarct/Acute renal failure: The night after her cath, she complained of right back and flank pain. In the setting of 6 point Hct drop, she had non-contrast CT, which was negative for RP bleed but demonstrated right renal infarct (prelim read). Renal was consulted, and felt her renal dysfunction was multifactorial in setting of renal infarct and ATN (likely due to hypotension). # Atrial fibrillation with aberrant conduction: Although she was in NSR when she presented to [**Hospital1 **], it is unclear how long she has had AFib given her vague complaint of "chest congestion" which she dates back to [**Month (only) 547**]. She was on lovenox and coumadin at the OSH, but it is unclear what date these were started (sometime between [**5-22**] and [**5-26**]). She has been on heparin gtt throughout her course at [**Hospital3 **]. Of note, although she was started on amiodarone and lidocaine at [**Hospital1 **] for VTach, it was unclear whether this was AFib with aberrancy. Records from [**Hospital1 **] were requested but had not been sent by the time of transfer to [**Hospital1 2025**]. # HTN: Patient's home norvasc and doxazosin were held. Note that she had angioedema with lisinopril. # Leukocytosis: On the morning of transfer, she was noted to have [**Known lastname **] count of 22. CXR following her complete heart block on [**5-27**] demonstrated possible infiltrate/aspiration, and her PA catheter pressures were significant for SVR in the 300s. There was concern that she may be developing septic [**Month/Year (2) **] in addition to her cardiogenic [**Month/Year (2) **]. She had received vancomycin 1g x 1 on [**5-27**], which was not redosed given her GFR of 14. She has an allergy to penicillin (rash), so she was given a dose of aztreonam No other evidence of infection; most likely elevated in setting of recent steroids and new MI. # Anemia: Patient had a hematocrit of 36 at the time of her cath, which dropped to 25 in the setting of multiple interventions. CT pelvis on [**5-27**] ruled out RP bleed. She was continued on a heparin gtt while on the IABP. She was noted to be oozing from her femoral sheath from the subclavian access site. Platelets were stable, so she was not felt to be in DIC. She was not transfused RBCs because of concern for volume overload. # Code: FULL # Communication: with son [**Name (NI) **] [**Telephone/Fax (1) 99218**] and pastor [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] Medications on Admission: Ranitidine ?mg Norvasc 2.5mg daily Doxazosin 4mg daily MVI daily Medications on transfer: ASA Neosynephrine gtt Amiodarone gtt Lidocaine gtt Discharge Medications: 1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain: hold for sedation. 5. Norepinephrine Bitartrate 1 mg/mL Solution Sig: currently at 0.25 mcg/kg/min Intravenous TITRATE TO (titrate to desired clinical effect (please specify)). 6. Atropine 1 mg/mL Solution Sig: 0.5 mg Injection X1 (ONE TIME) as needed for symptomatic bradycardia & hypotension. 7. Amiodarone 50 mg/mL Solution Sig: One (1) mg/min Intravenous INFUSION (continuous infusion). 8. Milrinone in D5W 200 mcg/mL Piggyback Sig: 0.5 mcg/kg/min Intravenous INFUSION (continuous infusion). 9. heparin IV at 500 units/hr 10. Aztreonam 1g IV x 1 currently being given 11. vancomycin 1g IV given [**5-27**] Discharge Disposition: Extended Care Discharge Diagnosis: Primary Diagnosis: Anterior STEMI Secondary Diagnoses: Cardiogenic [**Month/Year (2) **], Acute renal failure, Anemia, Cardiac arrest, Atrial fibrillation, Ventricular tachycardia, Episode of Complete Heart Block Discharge Condition: Hypotensive with MAPs in 50s but warm extremities, mentating well. 98.9 77/40 (art line) 110s-120s in AFib with RBBB pattern with frequent runs of NSVT, RR 21 sats 95-100% on NRB. Latest PA pressures: PA mean 24, wedge 17, CVP 7, CO (Fick) 6.6, CI 3.37, SVR 424. Latest ABG: 7.42/31/136 Discharge Instructions: Patient was admitted for STEMI. Being transferred to [**Hospital1 2025**] for LVAD. Please follow-up and take your medications as directed at the time of discharge from [**Hospital1 2025**]. Followup Instructions: As directed by doctors [**First Name (Titles) **] [**Last Name (Titles) 2025**]. Completed by:[**2199-5-28**] Name: [**Known lastname **],[**Known firstname 2219**] Unit No: [**Numeric Identifier 15887**] Admission Date: [**2199-5-26**] Discharge Date: [**2199-5-28**] Date of Birth: [**2140-4-3**] Sex: F Service: MEDICINE Allergies: Lisinopril / Penicillins / Codeine Attending:[**First Name3 (LF) 713**] Addendum: # Acute systolic heart failure: Please note that patient was not discharged on an ACE I or [**Last Name (un) **] because she has an allergy to lisinopril (angioedema) and because she was in cardiogenic shock at the time of transfer to [**Hospital1 2239**]. # Question lung mass: One of Ms. [**Known lastname 15888**] CXRs from [**2199-5-27**] was read as a possible suprahilar mass in her right lung. It was unclear if this was due to atelectasis, fluid, or overlying hematoma. She does have a smoking history. This information was shared with the team at [**Hospital1 2239**] assuming care of the patient. [**First Name8 (NamePattern2) 251**] [**Last Name (NamePattern1) 15889**], MD Discharge Disposition: Extended Care [**First Name11 (Name Pattern1) 77**] [**Last Name (NamePattern4) 714**] MD [**MD Number(1) 715**] Completed by:[**2199-5-29**]

[ "E931.4", "428.0", "410.01", "584.5", "427.5", "427.1", "275.3", "285.9", "426.0", "V15.82", "E849.9", "414.01", "V43.65", "695.4", "585.9", "785.51", "427.31", "428.21", "288.60", "530.81", "403.90", "786.6", "369.4" ]

icd9cm

[ [ [] ] ]

[ "37.78", "00.45", "99.20", "88.56", "00.44", "36.07", "89.64", "00.66", "37.61", "37.22", "88.72", "00.41" ]

icd9pcs

[ [ [] ] ]

18717, 18889

10418, 15553

322, 444

16987, 17285

4624, 5914

17526, 18694

3485, 3685

15746, 16690

16749, 16749

15579, 15645

9663, 10395

5931, 9646

17309, 17503

3700, 4605

16806, 16966

255, 284

472, 2757

16769, 16784

15670, 15723

2779, 3295

3311, 3469

68,035

145,990

37366

Discharge summary

report

Admission Date: [**2198-2-11**] Discharge Date: [**2198-2-12**] Date of Birth: [**2179-1-29**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 3556**] Chief Complaint: Nausea, vomiting Major Surgical or Invasive Procedure: None History of Present Illness: 19 y/o F DM 1 who presents with nausea and vomiting of 1 week duration. Last Monday patient started experiencing myalgias, malaise, headache, nausea, diarrhea and vomiting. [**Name (NI) **] father had [**Name2 (NI) 84027**] symptoms. Denies fever, increased sputum, cough, dysuria, increased frequency or urgency. Patient then redeveloped symptoms this Saturday (most notable nausea, myalgia and vomiting) and was concerned she was entering "DKA" so consequently presented to the ED. In the ED, initial vs were: T 97.1 P 96 BP 141/79 R 16 O2 sat 100% RA. Blood sugar found to be 393 and labs pertinent for anion gap 23, small amount acetone and ketones 150. Patient was started on insulin drip, given 1L NS and then 1L D5 1/2 NS. Patient admitted to the ICU for further monitoring. Past Medical History: Type 1 DM (HA1C 10.6) GERD Vitamin D Lactose Intolerance Social History: Student at [**University/College 16939**]. - Tobacco: Denies - Alcohol: Denies - Illicits: Denies Family History: No family history of DM. Physical Exam: 98.4 106/58 86 16 99/RA 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, mild tenderness throughout, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Pertinent Results: [**2198-2-11**] 02:55PM WBC-8.5 RBC-4.91 HGB-14.5 HCT-44.9 MCV-92 MCH-29.4 MCHC-32.2 RDW-12.4 [**2198-2-11**] 02:55PM NEUTS-83.2* LYMPHS-15.2* MONOS-1.3* EOS-0.1 BASOS-0.1 [**2198-2-11**] 06:20PM GLUCOSE-246* UREA N-17 CREAT-0.8 SODIUM-131* POTASSIUM-4.2 CHLORIDE-98 TOTAL CO2-19* ANION GAP-18 [**2198-2-11**] 06:20PM ALT(SGPT)-18 AST(SGOT)-19 LD(LDH)-152 ALK PHOS-94 TOT BILI-0.8 [**2198-2-11**] 06:20PM LIPASE-14 [**2198-2-12**] 12:16 am Influenza A/B by DFA Source: Nasopharyngeal swab. **FINAL REPORT [**2198-2-12**]** DIRECT INFLUENZA A ANTIGEN TEST (Final [**2198-2-12**]): Negative for Influenza A. DIRECT INFLUENZA B ANTIGEN TEST (Final [**2198-2-12**]): Negative for Influenza B. Brief Hospital Course: # Diabetic Ketoacidosis: Trigger most likely viral gastroenteritis versus influenza. Unlikely UTI as no symptoms and Ua negative. Unlikely pneumonia as no cough or increased sputum production. No recent antibiotic use for C. Diff risk factor. Negative pregnancy test. Influenza was ruled out by DFA. Treated nausea with Zofran and given aggressive volume resuscitation while not taking adequate oral. As anion gap has almost closed (14) she was given evening Lantus (1/2 dose as poor po intake) and covered with insulin drip until BS 200. [**Last Name (un) **] was then consulted and advised slight changes in her insulin dosing. Once tolerating food, she was transitioned to SC insulin alone without difficulty. Discharged with plan to follow-up with [**Last Name (un) **]. # Diabetes: Most recent hemoglobin A1C [**2198-1-23**] 9.9%. Follow up [**Last Name (un) **] as an outpatient. # Vitamin D defiency: Continue Vitamin D. # Lactose intolerance: Lactose free diet. Medications on Admission: Vitamin D Yaz Insulin regimen: Lantus 42 units. Humalog sliding scale correction factor 120 / 30. Insulin carb ratio 1:5. Discharge Medications: 1. YAZ 28 3-20 mg-mcg Tablet Sig: One (1) Tablet PO qd (). 2. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Insulin Dosing Fingerstick QACHS, QPC2H, HS, QAM Dinner Glargine 42 Units Insulin SC Sliding Scale Breakfast Lunch Dinner Bedtime 0-70 mg/dL Treat for low blood sugar 71-100 mg/dL 12 Units 12 Units 20 Units 0 Units 101-120 mg/dL 12 Units 12 Units 21 Units 0 Units 121-150 mg/dL 13 Units 13 Units 22 Units 0 Units 151-180 mg/dL 14 Units 14 Units 23 Units 1 Units 181-210 mg/dL 15 Units 15 Units 24 Units 2 Units 211-240 mg/dL 16 Units 16 Units 25 Units 3 Units 241-270 mg/dL 17 Units 17 Units 26 Units 4 Units 271-300 mg/dL 18 Units 18 Units 27 Units 5 Units 301-330 mg/dL 19 Units 19 Units 28 Units 6 Units 331-360 mg/dL 20 Units 20 Units 29 Units 7 Units 361-390 mg/dL 21 Units 21 Units 30 Units 8 Units 391-400 mg/dL 22 Units 22 Units 31 Units 9 Units > 400 mg/dL 23 Units 23 Units 32 Units 10 Units Instructons for NPO Patients: please allow patient to carb count and adjust her meal time insulin doses if her meal is not 60g carbs (which is what this scale is based on). Patient should be using a 1:5 insuin to carb ratio and a 1:30 correction factor (target 120) Discharge Disposition: Home Discharge Diagnosis: Primary: Diabetic Ketoacidisos, Diabetes Mellitus Discharge Condition: Hemodynamically stable, eating a regular diet and tolerating SC insulin [**First Name8 (NamePattern2) **] [**Last Name (un) **] guidelines. Discharge Instructions: You were admitted with nausea, vomiting, elevated blood sugar and evidence of diabetic ketoacidosis. You were treated with IV insulin and monitored closely in the Intensive Care Unit. Once your blood sugar and electrolytes improved to normal, you were seen by [**Last Name (un) **] physicians to recommend further medications. You were then discharged home for further recovery. Please take medications as prescribed. Please keep all outpatient appointments. Followup Instructions: Please follow-up with your primary care physician in the next 1-2 weeks to monitor your symptoms and address any questions you may have. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3559**] MD, [**MD Number(3) 3560**]

[ "271.3", "250.13", "530.81", "V58.67", "268.9" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

5271, 5277

2712, 3692

332, 339

5371, 5513

1932, 2689

6025, 6294

1362, 1388

3864, 5248

5298, 5350

3718, 3841

5537, 6002

1403, 1913

276, 294

367, 1151

1173, 1231

1247, 1346

720

100,753

46425

Discharge summary

report

Admission Date: [**2160-5-4**] Discharge Date: [**2160-5-21**] Date of Birth: [**2108-8-25**] Sex: F Service: MEDICINE Allergies: Zosyn Attending:[**First Name3 (LF) 30**] Chief Complaint: hypoxia, seizure Major Surgical or Invasive Procedure: Intubation and mechanical ventilation History of Present Illness: 51 y/o F with h/o Hep C, COPD, and sz disorder presents from home w/ hypoxia and ?seizure. Recent MICU admit [**Date range (2) 98617**] with respiratory failure requiring intubation and subsequent tracheostomy attributed to ARDS (suspected viral etiology). She was treated w/ broad spectrum antibiotics and steroids. Course c/b VAP due to Klebsiella and Serratia ([**Last Name (un) 36**] meropenem; res cephalosporins), coag (-) staph line infection (s/p vanco X 14 days). Pt was discharged to rehab [**2160-4-7**]; trach removed and pt d/c home [**2160-4-25**]. She initially went to in-laws with husband for 4-5 hours, the three of whom were recently diagnosed with bronchitis. She then went to stay with her sister and mother for 1 week were she received VNA services. On [**2160-5-2**], she went to her home with her husband, who she had not been exposed to in 1 week. On [**5-3**], she c/o being tired. On day of admission, [**5-4**]. per family, pt awoke feeling "[**Last Name (un) 98618**]" and short of breath. Because she felt like she was going to have a seizure, she presented to OSH, where she was noted to be hypoxic 84% RA -> 90s on 100% NRB. An x-ray shwed bilateral infiltrates, and she received levofloxacin 500 mg IV X 1 and was transferred to [**Hospital1 18**] for further management. In [**Name (NI) **] pt 96% 100% NRB, sbp 80s-90s. She was initially conversant, however then she had episodes where her eyes rolled up in her head, and she began posturing her upper extremities. Each episode lasted 10-15 seconds, occurring every 1-2 minutes for a total of 20 minutes. She received 2 mg IV Ativan for suspected seizure, after which she was somnolent. Neuro was consulted, who was concerned for status epilepticus and pt received 20 mg/kg IV Fosphenytoin. Further history/ROS could not be obtained [**3-5**] patient's mental status. . She had a course in the MICU which was complicated by failed extubation on [**5-5**] and [**5-13**]. and had bronchoscopy which on microbiology but not pathology showed viral cytopathic changes, possibly c/w CMV pneumoitis, but no immunostains had been done. She has had a history in the past of klebsiella and serratia VAP (pan-sensitive) and one [**2-6**] Klebs blood cx which was ESBL, but on this admission has not had any positive cultures for blood, sputum, BAL, CSF, urine, c diff tox, flu, or legionella. TTE has shown diastolic dysfunction with EF 60% and 1+ MR and mild-mod pulmonary artery HTN. BB have been controlling her rate well. . She has been on moerately high doses of benzodiazepines for sedation. and on prednisone for stress dosing, and has been weaning off of both. She also recently had her NGT removed and with a (+) gag reflex was started on a nectar thick diet until video swallow assessment could be made. In the meantime, her glargine has been held due to low oral intake. . Her subclavian and arterial lines have been removed and she is maintained by peripheral iv's. Past Medical History: 1) COPD 2) Hepatitis C 3) Seizure disorder 4) Depression 5) Recent admission w/ ARDS c/b VAP and line infection (see above) 6) Percutaneous tracheostomy ([**2160-3-11**]) 7) EGD with PEG placement ([**2160-3-11**]) Social History: + Tob, 1.5 ppy X many years, no EtOH, lives with husband though recently stayed with mother and sister after rehab, has a 25yo son Physical Exam: ADMISSION PHYSICAL EXAM: PE: Tc 99.7 (rectal), pc 94, bpc 91/53, resp 16, 100% NRB Gen: middle-aged female, initially somnelent, not responsive to sternal rub, then opens eyes and answers simple questions (oriented only to self), follows simple commands HEENT: PERRL, EOMI, anicteric, pale conjunctiva, OMM slightly dry, OP clear, neck supple, no LAD, no JVD Cardiac: RRR, II/VI SM at RUSB, no R/G Pulm: crackles at bases bilaterally. Occasional upper-airway ronchi Abd: NABS, soft, NT/ND, no masses Ext: 1+ pedal edema Neuro: PERRL, EOMI, face symmetrical, (+) gag, moves all 4 extremities in response to painful stimuli. 2+ DTR [**Name (NI) **] bilaterally, 3+ DTR LE bilaterally. Pertinent Results: [**2160-5-4**] 12:55PM PT-14.6* PTT-33.2 INR(PT)-1.3 [**2160-5-4**] 12:55PM PLT COUNT-175 [**2160-5-4**] 12:55PM HYPOCHROM-3+ POIKILOCY-1+ [**2160-5-4**] 12:55PM NEUTS-82.1* LYMPHS-13.8* MONOS-3.8 EOS-0.2 BASOS-0.2 [**2160-5-4**] 12:55PM WBC-25.9*# RBC-3.59* HGB-9.6* HCT-31.4* MCV-88 MCH-26.8*# MCHC-30.6* RDW-14.0 [**2160-5-4**] 12:55PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2160-5-4**] 12:55PM TSH-0.75 [**2160-5-4**] 12:55PM VIT B12-780 FOLATE-7.0 [**2160-5-4**] 12:55PM ALBUMIN-3.4 CALCIUM-8.4 PHOSPHATE-3.5 MAGNESIUM-1.6 [**2160-5-4**] 12:55PM CK-MB-9 cTropnT-0.05* proBNP-585* [**2160-5-4**] 12:55PM LIPASE-11 [**2160-5-4**] 12:55PM ALT(SGPT)-50* AST(SGOT)-77* CK(CPK)-225* ALK PHOS-100 AMYLASE-21 TOT BILI-0.3 [**2160-5-4**] 12:55PM GLUCOSE-127* UREA N-11 CREAT-0.4 SODIUM-142 POTASSIUM-3.7 CHLORIDE-106 TOTAL CO2-32* ANION GAP-8 [**2160-5-4**] 01:02PM LACTATE-1.4 [**2160-5-4**] 01:27PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [**2160-5-4**] 01:27PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.016 [**2160-5-4**] 01:27PM URINE GR HOLD-HOLD [**2160-5-4**] 01:27PM URINE HOURS-RANDOM [**2160-5-4**] 02:40PM TYPE-ART PO2-139* PCO2-76* PH-7.24* TOTAL CO2-34* BASE XS-2 [**2160-5-4**] 02:10PM AMMONIA-83* [**2160-5-4**] 04:10PM PO2-80* PCO2-80* PH-7.22* TOTAL CO2-34* BASE XS-1 [**2160-5-4**] 04:10PM LACTATE-1.0 [**2160-5-4**] 04:10PM %HbA1c-6.0* [Hgb]-DONE [A1c]-DONE [**2160-5-4**] 04:30PM PHENYTOIN-24.1* [**2160-5-4**] 09:05PM TYPE-ART TEMP-37.2 PO2-172* PCO2-60* PH-7.29* TOTAL CO2-30 BASE XS-1 INTUBATED-INTUBATED [**2160-5-4**] 10:00PM CORTISOL-13.2 [**2160-5-4**] 10:00PM CALCIUM-8.1* PHOSPHATE-2.3* MAGNESIUM-1.4* [**2160-5-4**] 10:00PM CK-MB-6 cTropnT-0.04* [**2160-5-4**] 10:00PM GLUCOSE-115* UREA N-10 CREAT-0.3* SODIUM-142 POTASSIUM-3.0* CHLORIDE-107 TOTAL CO2-31* ANION GAP-7* [**2160-5-4**] 10:35PM CORTISOL-16.1 [**2160-5-4**] 11:05PM CORTISOL-16.5 Brief Hospital Course: NOTE: THE PATIENT WAS DISCHARGED AGAINST MEDICAL ADVICE. PLEASE SEE THE SECTION "DISPOSITION" FOR THE RELEVANT DETAILS. THE HOSPITAL COURSE UP TO THIS POINT IS SUMMARIZED FIRST: A/P: 51 yoF w/ h/o COPD, seizure disorder recent admit w/ ARDS presents w/ leukocytosis, hypoxia, and episodes concerning for seizure. Intubated with ARDS of unclear etiology, failed extubation x2 ([**5-5**] and [**5-13**]) with hypoxic resp failure of unclear etiology. * 1) Hypoxic/Hypercarbic respiratory failure and ARDS: Unclear cause. All cultures were negative, including blood, sputum, BAL, CSF, urine, c dif, flu, legionella. Intubated in ED with ABG of 7.26/76/139. On nebs, flovent. Pt was covered for 1 week with meropenum, azithro, vanco until [**5-10**] (pt has h/o klebsiella/serretia VAP and ESBL Klebs bacteremia). Second attempt at extubation was attempted [**5-13**], and the patient did well initially, but then acutely desaturated and was reintubated. Aspiration vs. flash pulm edema were considered as factors complicating extubation. . Pt was beta-blocked and a Swan-Ganz catheter was in place before the third extubation attempt on [**5-16**] in order to diagnose and manage acute manifestations of heart failure upon extubation. BAL microbiology but not pathology showed cytopathic changes but viral and bacterial cultures as well as CMV immunology were negative. . 2) Seizure: Pt has a h/o seizure disorder, the precipitant of which may be proximate to inadequate treatment on a single [**Doctor Last Name 360**] (dilantin) in the setting of fever and hypoxia. Head CT and urine tox were neg. An EEG showed diffuse encephalopathy without status epilepticus. Additional history obtained from outpt neurologist Dr. [**First Name (STitle) **] [**Telephone/Fax (1) 98619**] showed that the pt presented to [**Location (un) 5871**] Regional with generalized tonic-clonic seizure on [**4-30**] with Dilantin level of 22, started on Zonegran because she failed a single [**Doctor Last Name 360**], and was discharged on HD#2 with normal mental status. At the [**Hospital1 18**], she required successive reloading of Dilantin [**5-14**]-20, before the patient left against medical advice. Despite leaving against medical advise before a therapeutic serum level of dilantin could be achieved, the patient was nevertheless scheduled with her primary care physician for dilantin dose adjustment. She was also scheduled in seizure clinic at the [**Hospital1 18**] for follow-up of her seizure disorder. Zonegran was increased to 300mg qd (on [**4-26**]) after 2 weeks of 200mg. * 3) Leukocytosis and Fever: Pulmonary source was initially suspected (ddx: HAP, aspiration pneumonia/pneumonitis) given the patient's hypoxia and bilateral infiltrates. U/A negative, BCx NGTD, CSF neg, BAL and sputum neg. C Dif neg x 4. Empiric oral vanco d/c'd [**5-8**]. Covered w/ meropenem/azithro empirically to cover HAP/aspiration pneumonia x 1 week until [**5-10**]. Spiked on [**5-14**] to 101 and re-cultured without any growth in culture. * 4) Sepsis/Hypotension/Adrenal Insufficiency: Pt was initially on levophed, weaned off after fluid resusitation. Minor troponin leak to 0.05. EF by ECHO [**5-6**] 60% with 1+MR. Pt was on steroids for ARDS during last recent admission, and was started on hydrocortixone for a positive cortisol stim test, which showed adrenal insufficiency with a maximal cortisol of 16-17. Her hypotension did resolve with stress-dose steroids in a few days. She has been on a prednisone taper, receiving 7.5 mg on [**5-19**], and due to receive 5 mg on [**5-20**]. Because of the adrenal insufficiency documented by absolute value as well as a relative value, the patient was scheduled for follow-up in endocrinology clinic within 1 month from discharge. She was discharged on prednisone 10mg until this appointment. * 5) Pulm Edema: EF 60%. Pt with pulm edema on [**5-5**] after extubation resulting in reintubation. [**Month (only) 116**] have been due to post-negative pressure pulm edema or flashing due to possible diastolic dysfunction. Diuresed but again showed signs of CHF after fluid resusitation. Swan placed [**5-7**] with mixed picture before diuresis. Decreased SVR and high CI supported a septic physiology, but a high CVP supportive of CHF. Pt developed upper and lower extremity edema that started to resolve with gradual diruesis. She has been euvolemic on exam for over 4 days preceding discharge. * 5) Anemia of Chronic Disease: The paient's baseline 26-28 from prior admission. Vit B12 and folate WNL. Transfused 2 Units [**5-8**] but otherwise has not required any blood products. Hct remained stable and >28 without additional transfusions. . 6) Thrombocytopenia: HIT negative, LFTs unchanged. Platelets improved with improvement of acute illness. * 7) Borderline Type II DM: HBA1C = 6.0. Pt was temporarily on an insulin drip while on TPN and hydrocortisone, transitioned to insulin glargine with sliding scale, but since the patient had poor oral intake, she had glargine held x 5 days and did not require dosing in the hospital. The patient was instructed to hold any additional insulin and covered with RISS until 1 day prior to admission when the patient's glood sugar. She began taking better oral intake before discharge. * 8) NSVT: Documented on evening of [**2160-5-11**]. Multiple 3-4 beat runs over a minute with sinus beats in between. Likely due to concurrent medical illness, resolveing The etiology was not clear. Electrolytes were normal. Pt was asymptomatic without further events. * 9) Diastolic dysfunction: EF 60% with 1+ MR, mild-mod pulmonary artery HTN. BB has been controlling her rate well. * 10)Hepatitis C: mild transaminitis, not significantly changed from prior admission * 11)Depression: Will restart prozac [**2160-5-20**]. 12)F/E/N: Tube feeds by nasogastric tube started [**5-6**]. -Once the NG tube was removed, the pt was noted to have a (+) gag reflex and was advanced to nectar thickened diet until video swallowing study could confirm that she could safely swallow. The patient was seen on the video study to have aspiration with thin liquids. She nevertheless refused to maintain a diet of thickened liquids, despite numerous conversations informing her that this diet may only be for a limited time until her swallow improved and informing her of the risks of swallowing thin liquids such as recurrent aspiration, pneumonia, intubation, or death. - electrolytes monitored and repleted as needed * 13)Ppx: Heparin SQ, pneumoboots, IV Lansoprazole. * 14)Access: Left Subclavian and right a-line d/c'd after patient transferred to the medical floor from the ICU. Afterwards, the patient was maintained with PIVs. * 15)Code: FULL CODE, confirmed by sister. * 16)Comm: [**Name (NI) 4906**] [**Name (NI) **] [**Name (NI) 9973**] [**Telephone/Fax (1) 98620**] (home), [**Telephone/Fax (1) 98621**] (his mother's home where he is staying), Sister [**Name (NI) 2048**] [**Name (NI) **] [**Telephone/Fax (1) 98622**] (home), [**Telephone/Fax (1) 98623**] (work). . 17)Dispo: The patient was seen by PT who, along with the medical and nursing staff, felt that the patient was not safe for independent discharge because of weakness, imbalance, and because of low dilantin level which would require further loading with dilantin. The patient refused discharge to rehabilitation, stating that she had spent too much time already in the hospital and rehabilitation hospital. Multiple conversations informed her of the risks of aspiration, seizure, fall, head injury, and death, but the patient nevertheless demanded to sign out of the hospital against medical advice and left in this manner despite recruiting the patient's husband and daughter to convince the patient. Mrs. [**Known lastname 9485**] was discharge against medical advice on [**2160-5-21**], and refused to wait until services could be set up for the patient, noting that she would set them up herself. Medications on Admission: Prozac 20 [**Hospital1 **] Oxybutynin Patch Monday and Thursday Protonix 40 qd Dilantin 450 qd Combivent two puffs qid Albuterol 1 prn Tylenol prn an anti-epileptic started recently starting with "Z", ?Zonergan Discharge Medications: 1. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation Q6H (every 6 hours). Disp:*1 inhaler* Refills:*2* 2. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation Q2H PRN (). Disp:*1 inhaler* Refills:*2* 3. Fluticasone Propionate 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [**Hospital1 **] (2 times a day). Disp:*1 inhaler* Refills:*2* 4. Albuterol Sulfate 0.083 % Solution Sig: One (1) nebulizer treatment Inhalation Q6H (every 6 hours) as needed. Disp:*25 nebulizer treatment* Refills:*0* 5. Ipratropium Bromide 0.02 % Solution Sig: One (1) nebulizer treatment Inhalation Q6H (every 6 hours). Disp:*50 nebulizer treatment* Refills:*2* 6. Zonisamide 100 mg Capsule Sig: Two (2) Capsule PO DAILY (Daily). Disp:*60 Capsule(s)* Refills:*2* 7. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:*90 Tablet(s)* Refills:*2* 8. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily). Disp:*30 Cap(s)* Refills:*2* 9. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed for headache. Disp:*50 Tablet(s)* Refills:*0* 10. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day): Because you left the hospital AMA, you are not yet at the correct blood level of this medication. You should be mointored on it. Disp:*90 Capsule(s)* Refills:*2* 11. 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* 12. Prednisone 10 mg Tablet Sig: One (1) Tablet PO once a day: You should not stop this medication until you are tested in the endocrine clinic. Disp:*30 Tablet(s)* Refills:*2* 13. Fluoxetine HCl 20 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 14. Diphenoxylate-Atropine 2.5-0.025 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours). Disp:*120 Tablet(s)* Refills:*2* 15. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for insomnia. Disp:*30 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Primary: 1. Recurrent Respiratory Failure. 2. Seizure. 3. Hospital Acquired Pneumonia. 4. Diastolic Heart Failure. 5. Adrenal Insufficiency. 6. Non-Sustained Ventricular Tachycardia. 7. Non-Immune Mediated Thrombocytopenia. 8. Diarrhea NOS. 9. Aspiration with thin liquids Secondary/Past Medical History: 1. COPD. 2. Hepatitis C. 3. Seizure Disorder. 4. Adult Respiratory Distress Syndrome. 5. Ventilator Associated Pneumonia. 6. Coagulase Negative Line Sepsis. 7. Diabetes Mellitis Type II. 8. Percutaneous Gastrostomy Tube. Discharge Condition: Fair. Discharge Instructions: Patient is leaving against medical advice. We have explained to her in detail our recommendations for inpatient rehabilitation, but she refuses. We have also made clear that she is at increased risk for morbidity, rehospitalization, or mortality. She was lucid and understood the implications of her decision. INSTRUCTIONS TO PATIENT: Continue taking prednisone for adrenal insufficiency until instructed otherwise by your physician. [**Name10 (NameIs) **] loperamide for diarrhea. Follow-up on Friday (the next available appointment) with Dr. [**First Name (STitle) **] for adjustment of your seizure medicine--because you left the hospital early against medical advice, you have not reach the correct blood levels of the medicine and are at risk for seizure because you cannot be appropriately monitored and have your medications appropriately adjusted. Followup Instructions: You must see your physician [**Last Name (NamePattern4) **]. [**First Name (STitle) **] on FRIDAY at 12:45pm, the next available appointment, to have your dilantin level checked. It is low and you are at risk of seizure by leaving the hospital with a low level despite increasing the dose. Additionally, you have been made a follow-up in neurology clinic on Friday [**6-13**] at 9am for an appointment with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 437**] of the Neurology Department Seizure Division. You need to call [**Telephone/Fax (1) 876**] to give your registration information. Provider: [**First Name11 (Name Pattern1) 1216**] [**Last Name (NamePattern4) 1217**], MD Where: [**Hospital6 29**] NEUROLOGY Phone:[**Telephone/Fax (1) 32084**] Date/Time:[**2160-6-13**] 9:00 Finally, please follow-up in endocrine clinic to determine whether you have adrenal insufficiency. Do not stop taking prednisone until you are instructed otherwise. Provider: [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) 44382**] [**Name (STitle) **] Where: [**Hospital6 29**] MEDICAL SPECIALTIES Phone:[**Telephone/Fax (1) 1803**] Date/Time:[**2160-5-27**] 10:00

[ "078.5", "482.1", "428.0", "428.30", "285.29", "276.2", "416.8", "070.70", "780.39", "V15.81", "493.20", "038.9", "427.1", "799.0", "305.01", "287.5", "518.81", "285.9", "250.00", "995.91", "484.1", "507.0", "255.4" ]

icd9cm

[ [ [] ] ]

[ "89.64", "96.72", "03.31", "89.14", "99.04", "38.91", "33.24", "96.04" ]

icd9pcs

[ [ [] ] ]

16824, 16830

6489, 14457

280, 320

17401, 17408

4414, 6466

18316, 19506

14718, 16801

16851, 17135

14483, 14695

17432, 18293

3736, 4395

224, 242

348, 3309

17157, 17380

3563, 3695

12,258

125,667

6440

Discharge summary

report

Admission Date: [**2184-12-18**] Discharge Date: [**2184-12-29**] Date of Birth: [**2155-4-28**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 5644**] Chief Complaint: unresponsiveness Major Surgical or Invasive Procedure: intubation History of Present Illness: Pt is a 29 yo caucasian female w/ PMHx significant for narcotics abuse, physical abuse, and ? seizures who was found down unconscious in her apartment by her father. Family members had not heard from patient in a couple of days. [**Name (NI) 1094**] father went to her home and saw living room screen torn off. Father cliMbed through the window and found patient lying in bed, unresponsive, covered in urine and feces. Pt had dried blood around nares. There were also methadone and klonopin bottles found at the scene. Unclear if patient had been assaulted or if this was a suicide attempt. On arrival to ER pt was disoriented and writhing. Vitals were Temp 100.8, BP 100/palp, HR 140, GCS 10, BS 119. She had a head CT that showed b/l basal ganglia infarcts. She was admitted to the MICU. Pt was intubated for combativeness. She was found to have CK . 38,000 thought to be from rhabdomyolysis. She received 10 L of fluid over 24 hours. Pt also had elevated transaminases in the 1000's. She eventually stabilized and transferred to the floor. Past Medical History: migraines substance abuse car accident '[**83**] mood disorder Social History: Lives alone with her son in an apartment in [**Name (NI) 745**]. Graduated college. She has a restraining order against the father of her 3 yo son. Family History: non-contributory Physical Exam: Temp 100.5/98.6 BP 131/82 HR 78 RR 23 100% RA Gen: thin caucasian female, lying in bed wearing cervical collar HEENT: PERRL, EOMI, mmm Resp: CTA b/l Abd: soft, NT, ND + BS GU: foley Ext: no c/c/e Skin: L arm ecchymosis Neuro: A&O x3, moving all 4 extremities Pertinent Results: [**2184-12-18**] 09:33PM PO2-241* PCO2-35 PH-7.46* TOTAL CO2-26 BASE XS-2 [**2184-12-18**] 09:33PM LACTATE-3.4* [**2184-12-18**] 09:33PM HGB-10.8* calcHCT-32 O2 SAT-99 CARBOXYHB-0 MET HGB-0 [**2184-12-18**] 08:25PM GLUCOSE-106* LACTATE-4.8* NA+-141 K+-4.3 CL--99* TCO2-30 [**2184-12-18**] 08:03PM URINE HOURS-RANDOM [**2184-12-18**] 08:03PM URINE UCG-NEG [**2184-12-18**] 08:03PM URINE bnzodzpn-POS barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-POS [**2184-12-18**] 08:03PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.018 [**2184-12-18**] 08:03PM URINE RBC-[**4-16**]* WBC-0-2 BACTERIA-MOD YEAST-NONE EPI-0-2 [**2184-12-18**] 08:03PM URINE HYALINE-0-2 [**2184-12-18**] 07:54PM UREA N-45* CREAT-1.1 [**2184-12-18**] 07:54PM ALT(SGPT)-1576* AST(SGOT)-2252* LD(LDH)-2068* ALK PHOS-75 AMYLASE-326* TOT BILI-0.5 [**2184-12-18**] 07:54PM CK(CPK)-[**Numeric Identifier 24779**]* AMYLASE-315* [**2184-12-18**] 07:54PM LIPASE-19 [**2184-12-18**] 07:54PM CK-MB-284* MB INDX-0.7 [**2184-12-18**] 07:54PM CALCIUM-9.0 PHOSPHATE-2.5* MAGNESIUM-2.7* [**2184-12-18**] 07:54PM OSMOLAL-299 [**2184-12-18**] 07:54PM ASA-NEG ETHANOL-NEG ACETMNPHN-9.9 bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2184-12-18**] 07:54PM WBC-17.8* RBC-5.35 HGB-16.0 HCT-45.7 MCV-85 MCH-29.8 MCHC-35.0 RDW-12.9 [**2184-12-18**] 07:54PM PLT COUNT-346 [**2184-12-18**] 07:54PM PT-18.6* PTT-29.4 INR(PT)-2.2 [**2184-12-18**] 07:54PM FIBRINOGE-627* Brief Hospital Course: 29 yo female w/ hx of substance abuse, physical abuse, admitted for unconsciousness for unknown period of time secondary to ? assault vs. suicide found to be in rhabdomyolysis, w/ decreased UOP, transaminitis, and b/l basal ganglia infarcts Rhabdomyolysis - Pt had markedly elevated CKs upon admission to the MICU. They eventually resolved with hydration and over the course of her hospitalization. Surprisingly, her renal function was never markedly compromised despite the elevatd CKs Transaminitis - The patients' LFTs were also markedly elevated upon hospitalization. Hepatology was consulted. Per hepatology increased LFTs likely from tylenol ingestion and the patient was given 19 doses of mucomyst. LFts also eventually normalized. There was some thought that the elevated transaminases could have been the result of rhabdomyolysis, however her INR was also elevated impaired hepatic function. Hepatitis serologies were also sent and showed no acute infectious process. Basal Ganglia Infarcts - Patient was found to have bilateral basal ganglia infarcts of unclear age. Neurology was consulted and they commented that the infarcts could be from either toxic or anoxic injury. The patient had an EEG study to evaluate the possibilty of a seizure focus, given the unclear circumstances of her condition before hospitalization and the past report of seizures. EEG showed some slowing consistent with a toxic metabolic process. Her mental status steadily improved after transfer from the MICU to the floors. However she did have some residual cognitive defecits upon repeated examinations by neurology and psychiatry. Also she had limited recall of the events at home. It was deemed that she would benefit from neuropsychology testing in [**4-15**] weeks post-discharge. Ulnar neuropathy - the patient had some decreased sensation of her left upper extremity thought to be secondary to compression from being down for an extended period of time. Per neurology, the expectation is that she would gain full recovery of sensation over time. Assault/Suicide - The patient had past reports of a mood disorder. She eventually reported to social work a problem with narcotic abuse. She expressed a desire to get help in order to get her life back in order. Custody of her son was given to her parents by DSS. The patient was not allowed to stay with parents upon discharge as a result of this. She was amenable to placement in a dual diagnosis facility for both her drug abuse and psychiatric issues, in particular anxiety. Due to the unclear nature of the patient's circumstances prior to hospitalization she was started on Combivir for HIV prophylaxis given the possibility of sexual assault that was considered in the Emergency Department. This treatment was initiated specifically because there was a question of assualt with no other information. She will require a one month treatment of the Combivir and will then need a followup HIV test. Placement was made at [**Hospital3 8063**]. Discharge Medications: 1. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily). 2. Lamivudine-Zidovudine 150-300 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 18 days. Discharge Disposition: Extended Care Facility: [**Hospital3 8063**] - [**Location (un) **] Discharge Diagnosis: rhabdomyolysis/drug abuse Discharge Condition: stable Discharge Instructions: Please alert your healthcare provider if you experience confusion, abdominal pain, itching w/ green discoloration of eyes, muscle pain, markedly decreased urine production. Followup Instructions: Please schedule an appointment with [**Hospital1 **] [**First Name (Titles) 4038**] [**Last Name (Titles) **]c within 2-3 weeks ([**Telephone/Fax (1) 2528**]. Please schedule an appointment for neuropsychologic testing with the [**Hospital1 **] Psychiatry Department within 3-4 weeks ([**Telephone/Fax (1) 24780**].

[ "965.02", "707.03", "507.0", "276.5", "276.2", "349.82", "728.88", "965.4", "E980.0", "354.2", "969.4", "434.91", "E980.3", "276.3", "584.5", "E849.0" ]

icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

6739, 6809

3512, 6529

334, 346

6878, 6886

2018, 3489

7107, 7427

1701, 1719

6552, 6716

6830, 6857

6910, 7084

1734, 1999

278, 296

374, 1432

1454, 1518

1534, 1685

29,054

104,043

49320

Discharge summary

report

Admission Date: [**2147-3-7**] Discharge Date: [**2147-3-11**] Date of Birth: [**2097-8-23**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 5552**] Chief Complaint: Hypotension Major Surgical or Invasive Procedure: Central line placement, peritoneal dialysis, lumbar puncture History of Present Illness: 49 yo F w/met colon ca, ESRD on PD s/p transplant with diarrhea N/V/D x 5 days who was found to be hypotensive and tachycardic in IR the day admission after coming in for large volume LP to evaluate for possible leptomeningeal spread of her cancer. Sent to ER for hypotension. In the ED, initial vitals 66/55, 20, 100%. Rectal temp 101.8. Received 6L NS, Vancomycin and Ceftazidime, R IJ placed. Started on levophed. Admitted to ICU for septic shock. PD fluid sent for anaylsis but no obvious source. Lactate 2.4 -- > 1.3. On arrival to the MICU, she stated that she feels tired and did feel light-headed in the IR suite. She also endorses nausea and vomiting for the past few days but no other localizing sympotms. No fevers although some chills. No sore throat, runny nose, cough, abdominal pain, diarrhea, SOB. Confirms anorexia. States that she had a similar admission with similar symptoms but this time she does not have a headache. During her short ICU admission, she had Levophed weaned off, recieved further boluses of IVF, continued ceftazidime and repleted K. The day after admission she was transferred to the OMED service once hemodynamically stable. Upon arrival to the floor she confirms a recent history of N/V/D that has all since resolved the day priot to admission except one epsidoe of emesis [**2-18**] pain while in the ICU. Denies any other localizing symptoms. Confirms poor po intake for several weeks due to swallowing difficulties. Intermittently gets lightheaded with prolonged standing and has been very weak - only able to go from bed to couch most of the day. Eager to have LP performed and get 'an answer'. Past Medical History: -ESRD on PD -SLE and associated renal failure status post two kidney transplants with recent worsening of her kidney function concerning for transplant failure. -peritoneal dialysis catheter placed in preparations to begin peritoneal dialysis. -seizure disorder status post CVA in [**2137**] -osteoporosisarthritis status post bilateral lower extremity fracture in [**2144**] after a fall -Metastatic Colon CA: C1D1 of xeloda, xelox, and oxiplatin on [**2147-1-23**]. Her original colon cancer,diagnosed in [**2143**], presented with a bowel obstruction. -Multiple CN palsies -Dysphagia Social History: Lives in [**Location **] alone, independent w/ ADLs, works as med records librarian and pharmacy manager. Denies smoking. Drinks 6 drinks/month. No illicit drugs. Family History: Multiple relatives with cancer, including GM with stomach cancer and grandfather with unknown type of cancer. Physical Exam: VS: Temp: 97.9 BP: 127/82 HR:117 RR: 18 O2sat 99% on RA GEN: tired appearing, NAD, A & O, able to relate history without difficulty HEENT: PERRL, EOMI, anicteric, MMM, op without lesions NECK: no supraclavicular or cervical lymphadenopathy, no jvd RESP: CTA b/l anteriorly with occasional rhonchi posteriorly CV: tachy, RR, S1 and S2 wnl, III/VI systolic murmur at LUSB ABD: nd, +b/s, soft, nt, no masses or hepatosplenomegaly; PD cath w/ clean dry dressing EXT: no c/c/e, warm, good pulses SKIN: no rashes/no jaundice NEURO: L-sided facial paralysis Pertinent Results: [**2147-3-7**] 08:45AM WBC-18.2*# RBC-3.48* HGB-11.4*# HCT-32.9* MCV-95 MCH-32.6* MCHC-34.5 RDW-16.2* [**2147-3-7**] 08:45AM NEUTS-80.7* LYMPHS-14.1* MONOS-4.9 EOS-0.3 BASOS-0.1 [**2147-3-7**] 08:45AM PLT COUNT-435 [**2147-3-7**] 08:45AM GLUCOSE-123* UREA N-10 CREAT-3.6* SODIUM-142 POTASSIUM-3.4 CHLORIDE-100 TOTAL CO2-29 ANION GAP-16 [**2147-3-7**] 10:03AM LACTATE-2.4* [**2147-3-7**] 02:00PM ASCITES WBC-6* RBC-2* POLYS-5* LYMPHS-39* MONOS-43* MACROPHAG-10* OTHER-3* [**2147-3-7**] 02:00PM ASCITES TOT PROT-<0.2 GLUCOSE-174 LD(LDH)-29 [**2147-3-7**] 04:12PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.016 [**2147-3-7**] 04:12PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG [**2147-3-7**] 04:12PM URINE RBC-0-2 WBC-[**3-22**] BACTERIA-OCC YEAST-NONE EPI-0-2 [**2147-3-11**] 05:35AM BLOOD Glucose-85 UreaN-12 Creat-2.3* Na-139 K-3.4 Cl-111* HCO3-25 AnGap-6* [**2147-3-11**] 05:35AM BLOOD WBC-7.7 RBC-3.30* Hgb-10.2* Hct-30.5* MCV-93 MCH-30.9 MCHC-33.4 RDW-15.5 Plt Ct-310 [**2147-3-11**] 05:35AM BLOOD Plt Ct-310 CSF Analysis WBC, CSF 14 #/uL RBC, CSF 3* #/uL 0 - 0 Polys 0 % Lymphs 93 % Monocytes 7 % [**2147-3-9**] 2:57 pm CSF;SPINAL FLUID Source: LP #3. GRAM STAIN (Final [**2147-3-9**]): NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. This is a concentrated smear made by cytospin method, please refer to hematology for a quantitative white blood cell count.. FLUID CULTURE (Final [**2147-3-12**]): NO GROWTH. LUMBAR PUNCTURE [**2147-3-9**] 12:39 PM The patient was placed prone on the procedure table. Access to the lumbar subarachnoid space at L3/4 was obtained with a 22-gauge spinal needle under fluoroscopic guidance, using aseptic precautions and 1% lidocaine for local anesthesia. Approximately 12 cc of clear fluid were collected. The needle was removed, and hemostasis was achieved by manual compression. The patient tolerated the procedure well without any immediate complications. The patient was sent back to the floor with post-procedure orders. The fluid was sent for laboratory analyses as requested by the referring physician. Brief Hospital Course: A/P: 49 female with PMH of metastatic colon cancer, ESRD on peritoneal dialysis presents with recurrent fever, hypotension, nausea and vomiting. # Fever: Unclear etiology. DDX initially included pneumonia vs peritoneal cavity vs urine vs line infection but no evidence of any of these. Presentation with nausea and vomiting consistent with a viral gastroenteritis. Symptoms resolved with aggressive rehydration and seem most consistent with a self-limiting viral gastroenteritis. Continued initial antibiotics of Vancomycin and Ceftazidime for 48 hrs (dosed for GFR < 10), and then discontinued given that cultures were negative. Afebrile for 48 hours prior to discharge. # Hypotension: DDX septic shock vs cardiogenic vs hypovolemic. Initially considered to be most consistent with septic shock based on CVP being low and fever. Received 5 L of NS in the ED and received additional IVF in ICU for MAP > 65 and UOP > 50cc/hr. Given rapid improvement after volume resuscitation with little evidence for persistent infection, likely hypovolemia from vomiting and diarrhea and prolonged poor po intake. Blood pressure was monitored and she was normotensive throughout her floor stay. # ESRD on peritoneal dialysis, s/p transplant: Renal following. Peritoneal dialysis per Renal. Continued immunosuppression with Rapamune and prednisone. Continued Bactrim for PCP [**Name Initial (PRE) 1102**]. # Anemia: Anemic at baseline likely due to chronic kidney disease. Monitored Hct throughout her inpatient stay. # HTN: Held nifedipine given hypotension, and did not require prior to discharge. Instructed to follow-up with primary oncologist prior to restarting medication. # Metastatic colon cancer: Was to have a large volume LP the day of admission by IR to evaluate for meningeal spread in setting of bulbar palsy. Previously had extensive work-up on prior admission including consults from ID, Rheum and Neurology. Only work-up remaining on discharge was large volume LP for cytology, though leptomeningeal spread from colon cancer is exceedingly rare. Large volume LP performed by Interventional Neuroradiology [**3-9**] without complication. Cytology pending on discharge and will follow-up with primary oncologist to discuss results. # Dysphagia: Patient states that this is at her baseline. Given inability to eat larger quantities of food, and with complaint of weight loss, she was given supplemental shakes while inpatient. Per ENT consult obtained on last admission, vocal [**Last Name **] problem may resolve with time. They additionally recommended outpatient follow-up (patient was unable to keep appointment). ENT re-evaluated patient while in the hospital and reported no interval improvement. Rescheduled for outpatient appointment upon discharge. Medications on Admission: Rapamune 2 mg qam Prednisone 5 mg daily ASA 81 mg daily Bactrim three times per week Nifedipine 60 mg daily Iron daily Supposed to be taking nephrocaps Discharge Medications: 1. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 2. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Sirolimus 1 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily): Daily dose to be administered at 6am . 4. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 5. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1) Tablet PO 3X/WEEK (MO,WE,FR). Discharge Disposition: Home Discharge Diagnosis: Primary: Metastatic colon cancer, sepsis Secondary: End Stage Renal Disease, prior renal transplant Discharge Condition: Hemodynamically stable and afebrile. Discharge Instructions: You were admitted following a viral illness that left you very dehydrated, and subsequently you had very low blood pressure during your outpatient procedure. You were treated with antibiotics and IV fluids until your blood pressure improved. Given no bacterial culture growth, you were not continued on antibiotics. You also had a lumbar puncture for further evaluation of your neurological problems and the results of this study were pending at the time of your discharge. Please take all medications as prescribed. Your nifedipine has been held while you were in the hospital. You should not restart this medication until discussing it with Dr. [**Last Name (STitle) 4253**]. Please keep all outpatient appointments. Return to a hospital or seek medical advice if you notice fever, chills, shortness of breath, progressive weakness, cough or any other symptom which is concerning to you. Followup Instructions: Provider: [**Name10 (NameIs) 5005**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], MD Phone:[**Telephone/Fax (1) 44**] Date/Time:[**2147-3-17**] 9:30 You should also have follow-up with Dr. [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 1837**] for your vocal cord issues. Please call his office at ([**Telephone/Fax (1) 72400**] on Monday [**3-13**] to confirm you appointment date/time for the following week.

[ "038.9", "276.52", "V45.1", "345.90", "438.89", "996.81", "V10.05", "585.6", "715.90", "197.0", "995.92", "285.21", "787.20", "198.7", "785.52", "403.91", "008.8", "710.0" ]

icd9cm

[ [ [] ] ]

[ "03.31", "54.98", "99.04" ]

icd9pcs

[ [ [] ] ]

9329, 9335

5809, 8594

326, 389

9479, 9518

3570, 5786

10463, 10946

2873, 2984

8796, 9306

9356, 9458

8620, 8773

9542, 10440

2999, 3551

275, 288

417, 2067

2089, 2677

2693, 2857

16,278

116,342

2246

Discharge summary

report

Admission Date: [**2116-7-27**] Discharge Date: [**2116-8-6**] Date of Birth: [**2040-11-16**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 4153**] Chief Complaint: chest discomfort, dyspnea Major Surgical or Invasive Procedure: Intubated [**Date range (1) 11879**] Central line placed Dialysis History of Present Illness: 75 y/o male with HTN, DM2, CAD s/p PCI to distal RCA with Cypher stent([**2116-4-28**]), ESRD on HD, presented for HD and had SSCP. In the ED, during procedure to place central line, he was put into trendelenburg and he became dyspneic, with desat and required intubation. He was dialyzed and became hypotensive, briefly required dopamine. Transferred to CCU for management of decompensated CHF. Past Medical History: 1. HTN 2. DM2 (IDDM, triopathy) 3. Nephrolithiasis, s/p bilateral ureteral stents in [**2110**] 4. ESRD on HD (M,W,F) since [**2114-12-16**] 5. Atrophic L kidney 6. Possible sarcoidosis (Liver biopsy c/w granulomatous hepatitis, bilat hilar mediastinal adenopathy, LUL scarring) 7. h/o infected R IJ permacath s/p removal [**1-17**] 8. L forearm AVG [**1-17**] 9. OA Left knee, back 10. Recurrent UTIs Social History: Haitian immigrant. Denies alcohol, smoking, or drug use. Married to second wife. Family History: non-contributory Physical Exam: Vitals Stable and afebrile. Intubated and sedated. Bleeding from mouth and puncture sites. Good air entry bilaterally. Heart tahcycardic without murmurs, extra heart sounds, or rubs. Abdomen with good bowel sounds, soft, NT, ND, no organomegaly. Extremities cool with weak distal pulses. Neuro exam limited by sedation. Pertinent Results: Admission Labs: [**2116-7-27**] 12:30PM WBC-11.3* RBC-3.93* HGB-13.4* HCT-40.2 MCV-103* MCH-34.1* MCHC-33.3 RDW-14.5 [**2116-7-27**] 12:30PM NEUTS-71.6* LYMPHS-20.4 MONOS-5.7 EOS-1.9 BASOS-0.4 [**2116-7-27**] 12:30PM PLT COUNT-275 [**2116-7-27**] 12:30PM PT-12.2 PTT-27.2 INR(PT)-1.0 [**2116-7-27**] 12:30PM GLUCOSE-359* UREA N-42* CREAT-7.8*# SODIUM-119* POTASSIUM-7.3* CHLORIDE-81* TOTAL CO2-22 ANION GAP-23* [**2116-7-27**] 04:11PM K+-6.6* [**2116-7-27**] 04:11PM TYPE-ART PO2-375* PCO2-44 PH-7.31* TOTAL CO2-23 BASE XS--4 INTUBATED-INTUBATED [**2116-7-27**] 07:15PM LACTATE-2.6* [**2116-7-27**] 07:15PM TYPE-ART PO2-128* PCO2-53* PH-7.33* TOTAL CO2-29 BASE XS-1 INTUBATED-INTUBATED [**2116-7-27**] 08:28PM PT-15.6* PTT-150* INR(PT)-1.7 [**2116-7-27**] 08:28PM WBC-18.0*# RBC-3.94* HGB-13.5* HCT-39.8* MCV-101* MCH-34.3* MCHC-34.0 RDW-14.5 [**2116-7-27**] 08:28PM PLT COUNT-274 [**2116-7-27**] 12:30PM CK-MB-6 cTropnT-0.06* [**2116-7-27**] 08:28PM CK-MB-7 cTropnT-0.25* [**2116-7-27**] 08:28PM ALT(SGPT)-65* AST(SGOT)-46* CK(CPK)-232* ALK PHOS-245* TOT BILI-0.7 [**2116-7-27**] 08:28PM GLUCOSE-181* UREA N-24* CREAT-5.1*# SODIUM-134 POTASSIUM-4.1 CHLORIDE-92* TOTAL CO2-21* ANION GAP-25* [**2116-7-27**] 10:52PM FIBRINOGE-491* [**2116-7-27**] 10:52PM PT-13.8* PTT-60.9* INR(PT)-1.3 [**2116-7-27**] 11:57PM CORTISOL-27.8* [**2116-7-28**] CT ABD and Pelvis IMPRESSION: 1. Findings consistent with right lower lobe pneumonia. There are also bilateral pleural effusions 2. There are bilateral hilar lymphadenopaties, which is increased in size when compared to [**2113**]. Largest lymph node in the right hilum measures 1.7 x 1.7 cm. At minimum this requires follow up, since possibility of lymphoma or metastatic malignancy cannot be excluded. 3. Multiple mesenteric and retroperitoneal lymphnodes. 4. Bilateral renal stones (right greater than left without evidence of hydronephrosis). The stones on the right are probably unchanged when compared to the prior study. 5. No intraabdominal abscess is identified. 6. Mild thickening of the colon is likely due to collapsed colon, but possibility of mild colitis cannot be excluded. Echo([**2116-7-28**]): Ejection Fraction: 20% to 25% moderate symmetric left ventricular hypertrophy severe global left ventricular hypokinesis with some preservation of basal posterior wall motion Overall left ventricular systolic function is severely depressed [**2116-8-1**] CT Head IMPRESSION: 1. No evidence of intracranial hemorrhage or edema. 2. Findings consistent with chronic small vessel ischemic changes and cerebral atrophy. [**2116-8-3**] LENIS IMPRESSION: No acute deep vein thrombosis. Likely subacute or chronic thrombus inhibiting wall to wall blood flow within the right superficial femoral vein. [**2116-8-3**] VQ Scan IMPRESSION: low likelihood ratio for recent pulmonary embolism. Brief Hospital Course: 75 y/o male came into hospital because of need for dialysis. Complained of substeranl chest pain and was sent to the emergency room where he was placed in trendelenberg to have central line placed. During procedure had severe dyspnea and desaturation requiring intubation. Admitted to CCU service where he was emergently dialysed for elevated potassium and volume overload. While on dialysis he became hypotensive and shortly developed a fever. He was found to have a right lower lobe pneumonia for which he was started on antibiotic treatment. In the CCU he was dialysed and volume status was watched closely as he was known to have both systolic and diastolic cardiac dysfunction. He was shortly extubated and after several sessions of dialysis was stable for transfer to step down floor. Throughout his stay he had periods of sinus tachycardia, of which the cause was not discovered. He continued to have tachycardia on the step down floor and so work up for PE was undertaken. Evidence of chronic, non-occlussive clot in superficial femoral vein was found on doppler of legs, but VQ scan showed low probability of pulmonary embolus. His workup for sinus tachycardia was negative and he eventually was discharged with without tachycardia, on coumadin for prevention of PE, with follow up of his INR, regularly scheduled diayisis, and follow up with a cardiologist. Medications on Admission: Per OMR records Discharge Medications: 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*5* 2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*5* 3. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*5* 4. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). Disp:*30 Cap(s)* Refills:*5* 5. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*5* 6. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*5* 7. Carvedilol 12.5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Disp:*120 Tablet(s)* Refills:*2* 8. 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:*5* 9. Renagel 800 mg Tablet Sig: One (1) Tablet PO three times a day. Disp:*90 Tablet(s)* Refills:*2* 10. Diltiazem HCl 60 mg Tablet Sig: One (1) Tablet PO every twelve (12) hours. Disp:*60 Tablet(s)* Refills:*0* 11. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times a day). 12. Warfarin 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*7 Tablet(s)* Refills:*0* 13. Insulin NPH Human Recomb 100 unit/mL Cartridge Sig: One (1) 23 units Subcutaneous once a day. 14. Outpatient Lab Work Check PT, PTT, INR. The pt is taking Coumdain. Please have results reviewed by a nurse practitioner [**First Name (Titles) **] [**Last Name (Titles) 11880**]n at Dr.[**Name (NI) 11881**] clinic Discharge Disposition: Home With Service Facility: [**Hospital1 **] Family & [**Hospital1 1926**] Services Discharge Diagnosis: Decompensated CHF Discharge Condition: Stable Discharge Instructions: Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs. Adhere to 2 gm sodium diet Fluid Restriction: Less than 1.5L total daily of juices, water, soda Pls take all meds as prescribed Resume dialysis on Friday [**8-7**]. Pls call dialysis center to confirm. . Please make sure to check your blood sugar 4 times a day. If your blood sugar is low and does not rise with taking [**Location (un) 2452**] juice, please call your doctor. Followup Instructions: Saturday, [**8-8**] Come in during the morning(before 1pm) to have your blood check, since you started coumandin. Sister [**Name (NI) **], NP at [**Hospital1 7975**] ST. INTERNAL MEDICINE Phone:[**Telephone/Fax (1) 7976**]. . [**8-12**] 2:30 with Sister [**Name (NI) **], NP at [**Hospital1 7975**] ST. INTERNAL MEDICINE Phone:[**Telephone/Fax (1) 7976**]. . Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 10134**], MD Where: [**Hospital1 7975**] INTERNAL MEDICINE Phone:[**Telephone/Fax (1) 7976**] Date/Time:[**2116-9-2**] 2:00 . Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD Where: LM [**Hospital Unit Name 3126**] CENTER Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2116-9-17**] 2:00 . Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] TRANSPLANT SOCIAL WORK Where: TRANSPLANT SOCIAL WORK Date/Time:[**2116-9-17**] 3:00 [**Name6 (MD) **] [**Last Name (NamePattern4) 4156**] MD, [**MD Number(3) 4157**] Completed by:[**2116-9-11**]

[ "286.6", "427.89", "486", "428.0", "428.40", "V45.82", "424.0", "285.9", "250.00", "558.9", "404.93", "787.2" ]

icd9cm

[ [ [] ] ]

[ "99.04", "39.95", "96.6", "96.71", "96.04" ]

icd9pcs

[ [ [] ] ]

7712, 7798

4650, 6020

341, 409

7860, 7869

1748, 1748

8367, 9408

1374, 1392

6086, 7689

7819, 7839

6046, 6063

7893, 8344

1407, 1729

276, 303

437, 834

1764, 4627

856, 1259

1275, 1358

57,738

161,448

41330

Discharge summary

report

Admission Date: [**2162-2-25**] Discharge Date: [**2162-3-4**] Date of Birth: [**2083-3-17**] Sex: M Service: MEDICINE Allergies: Sulfa (Sulfonamide Antibiotics) / Allopurinol Attending:[**First Name3 (LF) 2758**] Chief Complaint: Fall with LOC Major Surgical or Invasive Procedure: 1. intubation History of Present Illness: 78 generally active gentleman with a history of DM2, HTN, HL, who was transferred to [**Hospital1 18**] after he was found unconscious by his wife at home. The patient was at home earlier today in his kitchen when his wife (watching television in the other room) heard a thump and went to investigate. She found him down on the floor unconscious and began chest compressions; he quickly came to and sputtered and vomited a small amount. His wife called EMS who brought the patient to [**Hospital3 1280**]. There, he was noted to be agitated and moving all extremities, but combative. He was intubated for airway protection though it was a difficult intubation; gross blood was subsequently suctioned from his stomach.Head CT showed a small pontine hemorrhage. Troponin was 0.9. He received Protonix and Unasyn but no aspirin or heparin. He was transferred to [**Hospital1 18**] for neurosurgical evaluation. . On arrival to [**Hospital1 18**], he was given propofol and briefly dropped pressures; transitioned to fentanyl/versed with improvement in pressures. Repeat head CT showed small bleed in pons; neurology, neurosurgery and cardiology teams were consulted with recs to hold off on anticoagulation including aspirin, control BP, no need for neurosurgical intervention. . Vitals prior to transfer to the MICU were: BP 125/68, pressure support [**4-8**] on 100% FiO2, T 99.6, HR 120s, sinus tach. . On arrival to the floor, patient is intubated and sedated. He is unable to answer questions at this time. Two sons [**Last Name (LF) **], [**Name (NI) **]) are with him. Past Medical History: - Type II diabetes mellitus, previously on insulin - Hypertension - Hyperlipidemia - Recent ? echocardiogram (diastolic dysfunction, aortic stenosis and LVH per OSH ppwk) - Peripheral vascular disease - Shoulder surgery (R) after crushing injury in youth; repeat surgery to same shoulder ~10 years ago Social History: Lives with his wife. [**Name (NI) **] three grown sons (two in this area, one in [**State 2690**]). Walks up to 2 hours per day for exercise. Retired electrician. Smoked cigars years ago (none recent) but no cigarettes. No alcohol, no drugs. Family History: Multiple siblings with MI/heart diseae; per sons, he is "the healthy one." Physical Exam: ADMISSION PHYSICAL EXAM: GEN: Sedated and not responsive to commands HEENT: Pupils small (2mm) but reactive. Clear OP with average dentition for age. Intubated. NECK: JVP difficult to assess given cervical collar but does not appear elevated. PULM: Referred noise from ventillator; coarse at bases. CARD: Tachycardic to ~130s at time of exam; soft holosystolic murmur throughout precordium loudest at apex ABD: Soft, non-distended, no apparent TTP, rebound or guarding EXT: Varices of LE bilaterally. Palpable DP pulses. + Pitting edema of LE bilaterally. SKIN: Generally clear . DISCHARGE PHYSICAL EXAM: VS - 99.1 98.3 118/62 (118-139)/(55-66) 59 57-60 96%RA GENERAL - pleasant male, awake, comfortable, appropriate HEENT - slight swelling on posterior aspect of scalp, EOMI, sclerae anicteric, MMM, OP clear NECK - supple, JVP difficult to appreciate LUNGS - CTA bilat, decreased BS at bases, faint crackles at L base HEART - PMI non-displaced, RRR, III/VI systolic murmur loudest at RUSB with radiation to carotids, nl S1-S2 ABDOMEN - +BS, soft, NT/ND, no masses or HSM, no rebound/guarding EXTREMITIES - WWP, no c/c/e, 2+ DP pulses SKIN - no rashes or lesions NEURO - awake, A&Ox3, CNs II-XII grossly intact, moving all extremities, 5/5 strength throughout, gait not assessed Pertinent Results: ADMISSION LABS: [**2162-2-25**] 07:45PM BLOOD WBC-11.9* RBC-3.78* Hgb-12.6* Hct-35.6* MCV-94 MCH-33.2* MCHC-35.2* RDW-12.9 Plt Ct-144* [**2162-2-25**] 07:45PM BLOOD PT-12.5 PTT-27.6 INR(PT)-1.1 [**2162-2-25**] 07:45PM BLOOD Fibrino-286 [**2162-2-25**] 07:45PM BLOOD UreaN-38* Creat-2.0* [**2162-2-26**] 02:19AM BLOOD Glucose-155* UreaN-37* Creat-1.9* Na-141 K-4.8 Cl-108 HCO3-22 AnGap-16 [**2162-2-26**] 02:19AM BLOOD Calcium-8.5 Phos-3.1 Mg-1.7 Cholest-112 . PERTINENT LABS: [**2162-2-26**] 02:19AM BLOOD CK(CPK)-1308* [**2162-2-26**] 11:02AM BLOOD CK(CPK)-1318* [**2162-2-27**] 04:01AM BLOOD CK(CPK)-1109* [**2162-2-26**] 02:19AM BLOOD CK-MB-36* MB Indx-2.8 cTropnT-0.98* [**2162-2-27**] 04:01AM BLOOD CK-MB-18* MB Indx-1.6 cTropnT-0.59* . [**2162-3-1**] 03:43AM BLOOD calTIBC-209* Ferritn-368 TRF-161* [**2162-3-1**] 03:43AM BLOOD Calcium-9.1 Phos-3.7 Mg-1.8 Iron-28* [**2162-2-26**] 02:19AM BLOOD Triglyc-46 HDL-58 CHOL/HD-1.9 LDLcalc-45 LDLmeas-52 . DISCHARGE LABS: [**2162-3-4**]: Na 139 K 4.5 Cl 106 HCO3 25 BUN 49 Cr 1.8 BG 210 WBC 8.1 Hgb 10.4 HCt 28.4 Plt 194 MCV 92 . STUDIES: CT T-spine [**2162-2-25**]: No acute T-spine fracture. Bilateral dependent consolidations in both lungs, likely atelectasis, superimposed aspiration cannot be excluded. ET and NG tubes inn optimal position. . CT C-spine [**2162-2-25**]: No acute C-spine fracture. . CT Head [**2162-2-25**]: Left posterior mid-brain hemorrhage measuring approx 6 mm, likely hemorrhagic contusion, other differential includes, underlying vascular malformation. Left parietal scalp contusion. No fractures. . CXR [**2162-2-25**]: The ET tube tip is impinging the left tracheal wall and is located 6 cm above the carina. The NG tube tip is in the stomach. The right upper lobe atelectasis, the partial left upper lobe and right basal areas of atelectases are demonstrated. Minimal interstitial edema is most likely present. There is no significant interval change demonstrated since the prior image. . CXR [**2162-2-27**]: FINDINGS: Frontal view of the chest compared to prior study from [**2162-2-26**]. Endotracheal tube and nasogastric tube removed. Heart slightly enlarged. Mediastinum within normal limits. Patchy multifocal airspace opacities unchanged, likely reflective of interstitial edema, possibly volume overload. . ECG: ST depressions in V4-V6, less so in II, III, AVF. Tachycardic. MRI/A [**2162-2-26**]: Small area of hemorrhage in the left mid brain tegmental region with edema and extension to the left superior cerebellar peduncle. This could be related to reported history of trauma in presence of left scalp hematoma. No underlying enhancing mass lesion is seen. A followup study could help to exclude an underlying lesion, however. The neck MRA demonstrates normal flow in the carotid and vertebral arteries without stenosis or occlusion. No significant abnormalities on MRA of the head. . MICRO: BLOOD CX [**2162-2-25**], X2: NO GROWTH URINE CX [**2162-2-25**]: NO GROWTH SPUTUM CX [**2162-2-26**]: [**2162-2-26**] 10:11 am SPUTUM Site: ENDOTRACHEAL Source: Endotracheal. GRAM STAIN (Final [**2162-2-26**]): >25 PMNs and <10 epithelial cells/100X field. NO MICROORGANISMS SEEN. RESPIRATORY CULTURE (Final [**2162-2-28**]): RARE GROWTH Commensal Respiratory Flora. LEGIONELLA CULTURE (Preliminary): NO LEGIONELLA ISOLATED. Brief Hospital Course: HOSPITAL COURSE: Mr. [**Known lastname 89979**] is a pleasant 78 M with DM2, HTN, HL presents after fall with LOC and found to have probably NSTEMI, ICH, and atrial flutter. Pt was intubated briefly for airway protection and extubated without event. Evaluated by cardiology who recommended Metoprolol, but given risks of ICH, held off on antiplatelet medications. Neurology evaluated and recommended holding on Aspirin for 7 days. Pt monitored closely and had no neurologic change. [**Known lastname **] 81mg was started on [**2162-3-4**]. Evaluated by PT and OT. Cleared by OT cognitively, and PT recommended acute rehab given unsteady gait and far from baseline. . # Syncope, FALL: Likely due to ACS vs atrial flutter in setting of known mild-moderate aortic stenosis. Biomarkers peaked [**2-26**]. Per discussion with PT, pt not cleared to home with PT, as far from baseline and unsteady on feet. Pt discharged to acute rehab. . #. Atrial Flutter with RVR: Started after admission but patient was largely asymptomatic and may have had this as an outpatient as above. Initially started on dilt gtt, and metoprolol IV. Titrated both to orals. Pt converted to sinus rhythm morning of transfer to floors. No systemic anticoagulation given ICH. Dilt discontinued on [**3-3**] given sinus bradycardia to mid 50s. Switched to Toprol XL 150mg daily from 200 initially given bradycardia. Pt was in sinus rhythm on discharge. On aspirin 81mg for stroke prophylaxis. #. ACUTE CORONARY SYNDROME: Pt had troponin leak with ST depressions in inferolateral leads. Biomarkers peaked [**2-26**], with CK 1318. As discussed in ICU, given CNS bleed, plan was to start [**Month/Year (2) **] 7 days after admission. Echo demonstrates EF 50% 2/2 inferior posterior hypokinesis/akinesis which is new from TTE of [**11/2161**] compared to OSH records. Cardiology and Neurology evaluation during MICU stay, with decision to hold on diagnostic/therapeutic cardiac catheterization given inability to anticoagulate or start [**Year (4 digits) **]/clopidogrel. Was started on metoprolol and atorvastatin. Cardiology was re-consulted on the floors and recommended [**Year (4 digits) **] 81mg daily, but no indication for starting plavix. Pt was started on [**Year (4 digits) **] 81mg on [**3-4**], as he was 8 days out from ICH. At time of discharge, pt feeling well without any chest pain, SOB, or palpitations. He will follow-up with his cardiologist to discuss further evaluation for ischemia. #. INTRACRANIAL HEMORRHAGE: Found to have pontine hemorrhage confirmed on imaging here. Neurology evaluated and recommended holding antiplatelet medication. [**Month/Day (4) **] held for 7 days and then started per neuro recs. Pt had no residual deficits and was discharged with neurology follow-up. . # Aspiration pneumonia: Thick secretions after extubation concerning for aspiration PNA. Pt treated with renally dosed Levofloxacin and completed course. Cough improved and remained afebrile. . #. Stage III CKD: Baseline 1.8-2.0 per OSH records. Remained stable during this admission, with Cr 1.8 on discharge. . # Anemia: Normocytic, thought to be multifactorial [**1-6**] ACD given Diabetes, traumatic intubation and possible iron deficiency. No signs or symptoms of bleeding during the admission, though pt reportedly had traumatic intubation at OSH with reported guaiac positive. Iron studies suggest Fe def anemia. Stool was dark brown and guaiac negative here. However, Pt reported history of gastric ulcer, and was started on Omeprazole given new aspirin indication. Pt instructed to follow-up with PCP for further management with consideration of future studies, including colonoscopy, endoscopy, etc. . #. DIABETES TYPE II: Per sons, had recently been exercising/walking to improve his glucose control and get off of insulin, which he was able to do a few months ago. Placed on ISS while in-house. Discharged on Glipizide 5 mg extended release given renal failure and concern for hypoglycemic episodes reported by pt at home on renally-cleared glyburide.. Instructed to check BG frequently on discharge. Instructed to follow-up with Endocrinologist and PCP for close management. . # HYPERLIPIDEMIA: Increased atorvastatin to 80 mg daily given possible acute coronary syndrome. . # HTN: On lisinopril at home (40mg daily), which was held initially given concern for hypotension in setting of starting rate controlling agents for aflutter as above. Lisinopril 5mg daily started when transferred to medical floors. As above, also started on Toprol XL as above. Normotensive on discharge. . TRANSITIONAL CARE: 1. CODE: FULL 2. FOLLOW-UP: PCP [**Last Name (NamePattern4) **]. [**First Name (STitle) **], CARDIOLOGIST DR. [**Last Name (STitle) 89980**], AND ENDOCRINOLOGIST DR. [**First Name (STitle) **], NEURO WITH DR. [**Last Name (STitle) **] 3. MEDICAL MANAGEMENT: Started on Toprol [**Last Name (LF) 8864**], [**First Name3 (LF) **] 81mg daily, and low-dose Lisinopril (dose change), Switched from Glyburide to Glipizide ER, started Omeprazole 4. BARRIERS TO RE-HOSPITALIZATION: unsteady on feet Medications on Admission: lisinopril 40 mg Tab Oral Once Daily glyburide 2.5 mg Tab Oral Twice Daily Vitamin C 500 mg Chewable Tab Oral Once Daily Fish Oil 1,200 mg-144 mg-216 mg Cap Oral 1 Capsule(s) Once Daily simvastatin 20 mg Tab Oral 1 Tablet(s) Once Daily, at bedtime Vitamin B-6 200 mg Tab Oral Once Daily folic acid 1 mg Tab Oral 3 Tablet(s) Once Daily calcium 1 Capsule(s) Once Daily vitamin E 1,200 unit Cap Oral 1 Capsule(s) Once Daily Vitamin D-3 1,000 unit Chewable Tab Oral ferrous sulfate 325 mg (65 mg Iron) Tab Oral 1 Tablet(s) Once Daily Discharge Medications: 1. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 2. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 3. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Vitamin C 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO once a day. 5. Fish Oil 1,200-144-216 mg Capsule Sig: One (1) Capsule PO once a day. 6. Vitamin B-6 200 mg Tablet Sig: One (1) Tablet PO once a day. 7. Calcium 500 500 mg (1,250 mg) Tablet Sig: One (1) Tablet PO once a day. 8. vitamin E 1,000 unit Capsule Sig: One (1) Capsule PO once a day. 9. Vitamin D-3 1,000 unit Tablet, Chewable Sig: One (1) Tablet, Chewable PO once a day. 10. ferrous sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO once a day. 11. aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 12. metoprolol succinate 100 mg Tablet Extended Release 24 hr Sig: 1.5 Tablet Extended Release 24 hrs PO once a day. Disp:*45 Tablet Extended Release 24 hr(s)* Refills:*2* 13. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2* 14. glipizide 5 mg Tablet Extended Rel 24 hr Sig: One (1) Tablet Extended Rel 24 hr PO once a day. Disp:*30 Tablet Extended Rel 24 hr(s)* Refills:*2* Discharge Disposition: Extended Care Facility: [**Hospital3 15644**] Healthcare Center -[**Location (un) 47**] Discharge Diagnosis: Primary Diagnoses: 1. Pontine Hemorrhage 2. Atrial flutter with RVR 3. Anemia Secondary Diagnoses: 1. Diabetes type 2 2. Hypertension 3. Chronic renal failure Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Unsteady on feet. Discharge Instructions: Dear Mr. [**Known lastname 89979**], It was a pleasure taking care of you during this admission. You were admitted after loss of consciousness and bleeding in the brain. MRI imaging showed bleeding in the brain. You also had some elevated cardiac enzymes, suggesting there was some strain on the heart. You were intubated in the ICU initially, and were extubated without problem. Neurology followed you and recommended to hold off on Aspirin initially to prevent bleeding, but that it is likely safe to start again. On the medical floors you were seen by the physical therapists, who recommended continued physical therapy. . THE FOLLOWING CHANGES WERE MADE TO YOUR MEDICATIONS: STOP Simvastatin 20mg by mouth daily STOP Glyburide 5mg [**12-6**] tablet by mouth twice daily START Glipizide ER 5mg tablet by mouth once daily **This medication is better for patients with renal failure to help avoid hypoglycemia START Atorvastatin 80mg by mouth daily START Metoprolol XL 150mg by mouth daily START Aspirin 81mg by mouth daily START Omeprazole 20mg by mouth daily CHANGE the dose of Lisinopril you were taking from 40mg by mouth daily to 5mg by mouth daily Please continue all other medications you were taking prior to admission. You were found to be anemic during this hospitalization. There was concern at the outside hospital that there was blood in your stools. However, your stools showed no blood here. We started you on Omeprazole (an acid blocker) because of your history of ulcer. Please discuss this with your primary care doctor for further follow-up. You may need a colonoscopy and possible endoscopy for further management if bloody or black stools are seen in the future. Followup Instructions: Please follow-up with the following appointments: We were unable to make an appointment with your primary care doctor Dr. [**First Name (STitle) **] given that you were going to rehabilitation for physical therapy. When you are discharged, please give his office a call at [**Telephone/Fax (1) 26926**] to schedule a follow-up appointment. Name: [**Last Name (LF) **], [**Name8 (MD) **] MD Specialty: Cardiologist Location: [**Doctor Last Name **] RIVER MEDICAL ASSOCIATES Address: [**Hospital1 **], STE#410, [**Location (un) **], [**Numeric Identifier 8057**] Phone: [**Telephone/Fax (1) 89981**] Appointment: Tuesday [**3-16**] at 2PM Name: [**Location (un) **],[**Name8 (MD) **] MD Specialist: Endocrinologist Location: [**Doctor Last Name **] RIVER MEDICAL ASSOCIATES Address: [**Hospital1 25492**], [**Location (un) **],[**Numeric Identifier 7398**] Phone: [**Telephone/Fax (1) 63334**] Appointment: Tuesday [**3-30**] at 9:45AM Department: NEUROLOGY When: WEDNESDAY [**2162-4-14**] at 1 PM With: [**Name6 (MD) 4267**] [**Last Name (NamePattern4) 4268**], MD, PHD [**Telephone/Fax (1) 657**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 858**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage **Please talk to your PCP for to get an insurance referral for this visit** Completed by:[**2162-3-4**]

[ "424.0", "507.0", "585.3", "414.00", "285.9", "853.02", "E885.9", "403.90", "272.4", "427.32", "443.9", "410.71", "250.42" ]

icd9cm

[ [ [] ] ]

[ "96.71" ]

icd9pcs

[ [ [] ] ]

14377, 14467

7318, 7318

320, 336

14671, 14671

3934, 3934

16585, 17936

2541, 2618

12980, 14354

14488, 14567

12425, 12957

7335, 12399

14872, 16562

4905, 7295

2658, 3213

14588, 14650

266, 282

364, 1939

3950, 4394

14686, 14848

4410, 4889

1961, 2265

2281, 2525

3238, 3915

28,293

149,247

42759

Discharge summary

report

Admission Date: [**2169-4-3**] Discharge Date: [**2169-4-6**] Date of Birth: [**2088-10-27**] Sex: M Service: MEDICINE Allergies: Sulfa (Sulfonamides) / [**Year (4 digits) 7130**] / Haldol / Aspirin Attending:[**First Name3 (LF) 800**] Chief Complaint: shortness of breath Major Surgical or Invasive Procedure: Left thoracentesis History of Present Illness: Mr. [**Known lastname 92234**] is a 80 yo greek M with h/o chronic bilateral pleural effusions (exudative, uremic pleurisy) s/p bilat thoracentesis and pleural bx with pleurex cath placement on [**3-6**], CAD s/p MI, CHB s/p pacer, diabetes, HTN, ESRD on HD who presents with shortness of breath over the last 24hrs. He noted the increase gradually over the course of the day, symptomatically improved with home 02. He endorses a mild non-productive cough, but denies hemoptysis. He denies CP, n/v, f/c, or change in BMs. Furthermore, he denies any lightheadedness or dizziness. His pleurex cath was drained today without output (drained every other day, no output over the last 5 drainages). Patient reports good adherence to medications and has not missed a dialysis session. . In the ED, VS T 99.2, HR 64, BP 153/42, RR 32, 87% on RA -> 97%4L. EKG non-ischemic. CXR with large L pleural effusion. IP consulted and performed thoracentesis. Given CTX 1g and levaquin 750mg for ? PNA. Cont to show labored breathing so was admitted to the MICU for further monitoring. . Allergies: Sulfa, Haldol, [**Last Name (LF) 7130**], [**First Name3 (LF) **] Past Medical History: -h/o recent chronic lymphocytic exudative pleural effusions secondary to chronic uremic pleurisy: s/p thoracentesis [**4-21**] (transudative), [**2169-2-10**] (right, 1700 ml, exudative, symptomatic relief, poor lung expansion"trapped"), [**2169-2-13**] (left, 300ml, exudate, no symptomatic releif, poor lung expansion). Right sided pleuroscopy with drainage of 1200 ml of serious fluid and parietal pleural biopsy and pleurex catheter placement on [**3-6**] . -Colonic adenoma with high grade dysplasia / intramucosal carcinoma; no mucosal invasion, all LN negative, s/p right colectomy [**3-22**] -CAD: NSTEMI in [**2150**], no perfusion defects [**3-/2168**] MIBI. -Mod Pulm HTN, EF >70% 3/09 Echo -Complete Heart Block S/P [**Company 1543**] Sigma DR [**Last Name (STitle) 26019**] PPM in [**6-/2167**] -Left internal carotid artery stenosis: (Carotid US in [**3-19**] showed a L ICA 70-79% stenosis with [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3098**]/LCCA index of 3.6, no right ICA stenosis with a [**Country **]/RCCA index of 1. in [**2164**]) on clopidogrel. -ESRD: [**1-16**] HTN and diabetes, on HD, Receives hemodialysis on Tuesday, Thrusday and Saturday via a left AV fistula at [**Location (un) 1468**] Dialysis Center. -Type 2 DM: (last A1c 6% in [**7-22**]) on oral agents -Hypertension -Chronic anemia (baseline hct ~ 35) -Hyperlipidemia -Secondary hyperparathyroidism -Bilateral cataracts s/p surgical intervention -s/p ERCP for bile duct stenosis -Mild dementia -h/o urinary retention requiring discharge home with Foley/leg bag Social History: Lives with wife and son. [**Name (NI) **] another son who lives in downstairs apartment. He worked as a bricklayer for many years. Reports a 45 pk/yr h/o tobacco but quit over 20 yrs ago. Has glass of wine with lunch and dinner. Occasional beer on a hot day. Family History: Mother-DM, CAD Physical Exam: On Transfer from MICU: Vital signs: T 97.6 BP 177/51 76 SaO2100% on 2L Gen: lying flat in bed, pleasant, talking without labored breathing HEENT: EOMI, pinpoint pupils, symmetric, anicteric sclera NECK: supple, no LAD Heart: Regularly irregular, 2/6 SEM at base Lung: decreased BS bilaterally, L>R with crackles Abd: thin, soft, NT/ND + BS no rebound or guarding Ext: warm, no rash, 2+ DP pulses Skin: no bruising Neuro: alert and oriented, no focal deficits Pertinent Results: [**2169-4-3**] 06:40PM BLOOD WBC-7.2 RBC-4.02* Hgb-11.0* Hct-34.9* MCV-87 MCH-27.4 MCHC-31.6 RDW-16.1* Plt Ct-487* [**2169-4-4**] 03:05AM BLOOD WBC-6.9 RBC-3.27* Hgb-9.2* Hct-28.6* MCV-88 MCH-28.1 MCHC-32.1 RDW-16.5* Plt Ct-428 [**2169-4-4**] 08:59AM BLOOD Hct-29.9* [**2169-4-3**] 06:40PM BLOOD Neuts-76.3* Lymphs-15.8* Monos-5.7 Eos-2.1 Baso-0.2 [**2169-4-3**] 06:40PM BLOOD PT-12.6 PTT-26.5 INR(PT)-1.1 [**2169-4-4**] 04:00AM BLOOD PT-13.7* PTT-27.8 INR(PT)-1.2* [**2169-4-3**] 06:40PM BLOOD Glucose-228* UreaN-37* Creat-4.4*# Na-139 K-4.2 Cl-95* HCO3-29 AnGap-19 [**2169-4-4**] 03:05AM BLOOD Glucose-153* UreaN-41* Creat-4.6* Na-137 K-4.1 Cl-98 HCO3-28 AnGap-15 [**2169-4-3**] 06:40PM BLOOD cTropnT-0.14* [**2169-4-4**] 03:05AM BLOOD CK-MB-NotDone cTropnT-0.15* [**2169-4-3**] 06:40PM BLOOD TotProt-7.0 Albumin-3.7 Globuln-3.3 Calcium-9.0 Phos-3.6# Mg-2.2 [**2169-4-4**] 03:05AM BLOOD Calcium-8.1* Phos-4.1 Mg-2.2 [**2169-4-3**] 06:47PM BLOOD Lactate-2.3* . CXR [**2169-4-3**]: 1. Interval increase in the left basal effusion with progressive left lower lobe collapse when compared to the chest radiograph of [**2169-3-13**]. 2. Stable right basal effusion with areas of added density in the right lower lobe suggestive of superimposed infection. Brief Hospital Course: In the ED, the patient had a left thoracentesis, one liter removed and was symptomatically imprved. He was admitted to the ICU for tachypnea with RR 40, but then improved to RR 20's. Initially, he had a high O2 requirement - 87% RA in the ED, 92% on 4L, 98% on 5L. He received dialysis in the ICU and his oxygen levels improved to 100% on 3LNC. The interventional pulmonary service consulted on this patient - as he is followed by them closely as an outpt- and recommended removal of right pleurex and placement on a new left pleurex after plavix wash out. The patient was tranfered to the floor in stable condition. While on the floor, he remained stable, with his O2 saturation 95-97% on 2-3L NC. He had no tachypnea or pleuritic chest pain while on the floor. He had dialysis x1 on the floor. He is being d/c home with home VNA for daily vital signs/lung exam to be sure effusion not returning while patient at home. Medications on Admission: RENAL CAPS 1 cap daily CLOPIDOGREL 75mg daily GLIPIZIDE 5mg daily METOPROLOL TARTRATE 25mg [**Hospital1 **] NIFEDIPINE 30 mg SR [**Hospital1 **] Darvocet 50mg-325 [**Hospital1 **] prn SIMVASTATIN 20mg daily TERAZOSIN 2mg daily Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. 2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID PRN as needed for constipation. 4. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet, Sublingual Sublingual PRN (as needed). 5. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 6. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. Nifedipine 30 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO BID (2 times a day). 8. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 9. Terazosin 1 mg Capsule Sig: Two (2) Capsule PO HS (at bedtime). 10. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) nebulizer Inhalation Q6H (every 6 hours) as needed. 11. Glipizide 5 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home With Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: recurrent left pleural effusion Discharge Condition: stable. vital signs normal. patient is s/p hemodyalisis today ([**4-6**]) Discharge Instructions: You were admitted for shortness of breath that was associated with a recurrent pleural effusion (fluid on your lungs) on the left side. This effusion was drained and your shortness of breath improved over the following two days. You will need an additional drainage of this fluid and a placment of a temporary catheter next week and this will be done be interventional pulmonology. Until that time, you will have the visiting nurse come by and check on you daily to be sure that this fluid does not rapidly accumulate and cause you trouble again. . Please stop taking your Plavix and aspirin at home to prepare for this procedure. You can likely re-start these medicines after you see Dr [**Last Name (STitle) **] - be sure to clarify this with him at your next visit (next [**Last Name (STitle) 766**]). . You can use your home oxygen if you feel that you need it but if you start to need larger and larger amounts or have a lot of difficulty breathing, please return to the hospital. . The catheter on your right side does not appear to be functioning at this time but the interventional pulmonology physicians do not feel that it needs to be removed during this visit (they may remove it at your follow up appointment). You do not need to try and drain this catheter while you are at home. . Please return to the Emergency Department or call your primary care physician if you develop any of the following: * fever, chills, redness or tenderness over the catheter site * increasing shortness of breath, chest pain, pain when you take a deep breath * any other symptoms that are concerning to you Followup Instructions: Please call Dr[**Name (NI) 5070**] office (inteventional pulmonology) today at [**Telephone/Fax (1) 3020**] to schedule an appointment for [**Last Name (LF) 766**], [**4-10**]. . Please also keep the following appointments that are already scheduled for you: Provider: [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2169-5-1**] 8:30 Provider: [**Name10 (NameIs) 900**] [**Name8 (MD) 901**], M.D. Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2169-5-1**] 10:20 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4853**], M.D. Phone:[**Telephone/Fax (1) 253**] Date/Time:[**2169-5-10**] 10:00 [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 810**] MD, [**MD Number(3) 811**]

[ "511.9", "585.9", "V45.01", "433.10", "250.00", "285.21", "403.90", "416.8" ]

icd9cm

[ [ [] ] ]

[ "34.91", "39.95" ]

icd9pcs

[ [ [] ] ]

7409, 7466

5226, 6147

347, 368

7542, 7618

3949, 5203

9265, 10042

3439, 3455

6424, 7386

7487, 7521

6173, 6401

7642, 9242

3470, 3930

288, 309

396, 1555

1577, 3146

3162, 3423

4,646

102,441

22586+57306

Discharge summary

report+addendum

Admission Date: [**2169-4-19**] Discharge Date: [**2169-4-24**] Date of Birth: [**2108-9-15**] Sex: M Service: MEDICINE Allergies: Vancomycin Attending:[**First Name3 (LF) 2160**] Chief Complaint: Transfer from rehab for hematocrit drop Major Surgical or Invasive Procedure: Esophagogastroduodenoscopy [**2169-4-21**] History of Present Illness: Mr. [**Known lastname **] is a 60 year-old male with ERD s/p DCD transplant in [**10/2167**] on Prograf/MMF, DM type 2, HTN, PVD s/p TMA with skin graft from left thigh, and CAD s/p PCI, who was initially admitted from [**Hospital3 **] following a hematocrit drop. Of note, he was recently discharged from [**Hospital1 18**] on [**2169-4-13**] following an admission for wound debridement after a recent right TMA, further complicated by ARF treated with pulse steroids. A transplant biopsy returned negative for rejection. At [**Hospital1 **], his hematocrit dropped from 30 to 27 to 24.8 and his stools were reportedly guaiac positive. A ROS was largely negative. He was transferred to [**Hospital1 18**] for further evaluation. In ED, Hct 27, stools guaiac negative, NGL negative. However, his blood pressure repeatedly dropped to the 80s. He responded to IVF (NS) and was transfused 1 unit of PRBCs. He was also found to be mildly hypoglycemic with a FS 74, and given 1 amp of D50. He was subsequently admitted to the ICU for further care. In the ICU, his usual medications were continued. He remained hemodynamically stable, infectious work-up negative. Repeated stool guaiacs are documented as negative. A hemolysis work-up was negative. An EGD was performed today, remarkable for esophagitis and gastritis without bleeding. He is being transferred to the floor for further care. Past Medical History: 1. ESRD status post DCD transplant [**10/2167**], followed by Dr. [**Last Name (STitle) **] 2. Hypertension 3. DM type 2, last HbA1c 7.2% on [**2169-4-13**] 4. History of retinal hemorrhage status post vitrectomy 5. CAD status post PTCA (cath [**3-/2167**] 70% stenosis in small RCA, LAD 50% lesion, 90% PM3, PDA 80%, EF LV gram 50%, 2 cypher stents in LCx) 6. Mixed systolic and diastolic dysfunction, EF 40% 7. Peripheral vascular disease s/p right TMA with skin graft from left thigh 8. Polyneuropathy 9. Statust post appendectomy Social History: Lives with wife, former [**Name2 (NI) 1818**] 1.5 ppd stopped in [**2145**]. Denies alochol use. Family History: Not reviewed with patient. Physical Exam: Physical examination on day of transfer from ICU: VITALS: T 97.4, BP 125/70, HR 78, RR 16, Sat 100% on RA. GEN: In NAD. Lying in bed. HEENT: Anicteric. NECK: JVP not elevated. RESP: Mostly CTAB, few basilar crackles that clear with cough. CVS: RRR. Normal S1, S2. No S3, S4. No murmur appreciated. GI: BS NA. Abdomen soft, non-tender. Transplant kidney in RLQ. EXT: Without edema. Left thigh site with clean base, no dressing. Right foot wound clean, no odor, no purulent drainage. Pertinent Results: Relevant laboratory data on admission: CBC: WBC-4.7 RBC-3.16* HGB-9.1* HCT-27.2* MCV-86 MCH-28.8 MCHC-33.5 RDW-16.0* NEUTS-54.4 BANDS-0 LYMPHS-35.3 MONOS-7.6 EOS-2.0 BASOS-0.8 PLT COUNT-188 Chemistry: GLUCOSE-84 UREA N-7 CREAT-0.8 SODIUM-137 POTASSIUM-3.6 CHLORIDE-107 TOTAL CO2-22 ANION GAP-12 CK(CPK)-37*, CK-MB-NotDone cTropnT-0.03* LACTATE-1.1 Tacrolimus level on day of discharge: 3.2 on Tacrolimus 2.5 mg PO BID Relevant imaging data: [**2169-4-19**] CXR: No failure, no infiltrate. [**2169-4-21**] EGD: Grade 1 esophagitis in the lower third of the esophagus. Erosion and erythema in the antrum compatible with gastritis. Otherwise normal EGD to second part of the duodenum. [**2169-4-24**] ECHO: Report pending. Brief Hospital Course: 60 year-old male status post DCD kidney transplant in [**10/2167**] on tacrolimus and MMF, also with DM2, CAD and PVD statust post recent TMA with skin graft from left thigh, initially admitted with episodes of hypotension responsive to IVF, and anemia. His hospital course will be briefly reviewed by problems. 1. Hypotensive episodes, resolved: He initially responded to IVF and transfusion of one unit of PRBCs in the Emergency Department. He was admitted to the ICU for close hemodynamic monitoring, and remained hemodynamically stable. Cardiac enzymes were not cycled given low suspicion. His stools were guaiac negative, without evidence of bleeding. An infectious work-up was performed with negative U/A, urine culture, CXR and blood cultures. A cosyntropin stimulation test showed an appropriate cortisol response. A repeat echocardiogram was obtained, report pending at the time of discharge. A recent study in [**12/2168**] showed EF 30-35%. His Metoprolol was resumed on [**2169-4-20**], and continued throughout his hospital stay. 2. Anemia: His hematocrit was at baseline at 27 when he arrived to the ED. Repeated stool guaiacs were negative. However, he was reportedly guaiac positive at the rehab facility. An EGD was performed on [**2169-4-21**], notable for mild esophagitis and gastritis without bleeding. He was placed on PPI [**Hospital1 **] for 1 week, then return to daily dose. Other work-up included iron studies not suggestive of iron deficiency, hemolysis work-up negative, folate and B12 normal, reticulocyte inappropriate. As noted above, he was given 1 unit of PRBCs in the ED, with subsequently stable hematocrit. Hematocrit at D/C 27.5. We recommend a repeat colonoscopy as an out-patient. Given his concomitant leukopenia, consideration was given to Bactrim-induced myelosuppression. Consideration could be given to changing to a different prophylactic medication as an out-patient. Other possibilities include a primary bone marrow process. Follow-up with hematology was arranged on [**2169-5-29**] with Dr. [**Last Name (STitle) 6160**]. 3. Status post DCD kidney transplant: His creatinine remained at baseline. His tacrolimus level was at goal, and he was continued on his usual dose 2.5 mg PO BID. He was also continued on MMF 1gm PO BID. A CMV viral load is pending at the time of discharge. 4. Status post recent TMA with graft from left thigh: His wound was clean on exam at [**Hospital1 18**]. However, he was reportedly placed on Levofloxacin at [**Hospital3 **] on [**2169-4-18**] with plan to complete a 14-day course (last dose on [**2169-5-1**]). This was continued in the hospital. Given non-compliance with touch weight-bearing, he is to remain non weight-bearing on his RLE until vascular follow-up. 5. CAD: No acute issues in hospital. He was continued on Ezetimibe 10 mg daily, ASA. Metoprolol was transiently held on admission, resumed on day #2. 6. DM type 2: His oral regimen was held on admission, resumed on [**4-21**]/0/7. Fair glycemic control in hospital. Medications on Admission: Protonix 40mg qday Calcium carbonate 500mg tid:prn Tacrolimus 2.5mg [**Hospital1 **] Glipizide 10mg qday Rosiglitazone 4mg qday Regular insulin sliding scale Ambien 5mg qhs Mycophenolate mofetil 1gm [**Hospital1 **] Tamsulosin 0.4mg qhs Metoprolol 12.5mg [**Hospital1 **] Cholecalciferol 400 units qday Ca carbonate 500mg qday Bactrim SS 1 tab qday Zetia 10mg qday Oxycodone 10mg prn MVI Senna, bisacodyl, colace, MgOH Levofloxacin 500mg qday Simvastatin 20mg qhs ASA 81mg qday Discharge Medications: 1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours) for 5 days: To complete on [**2169-4-28**] . 2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day: To begin on [**2169-4-29**]. 3. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 5. Glipizide 10 mg Tab,Sust Rel Osmotic Push 24hr Sig: One (1) Tab,Sust Rel Osmotic Push 24hr PO DAILY (Daily). 6. Rosiglitazone 2 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 7. Insulin Regular Human 100 unit/mL Solution Sig: sliding scale Injection ASDIR (AS DIRECTED). 8. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 9. Mycophenolate Mofetil 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 10. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO at bedtime. 11. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 12. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. Oxycodone 5 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed. 15. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily). 16. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 17. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO twice a day as needed for constipation. 18. Psyllium 1.7 g Wafer Sig: One (1) Wafer PO DAILY (Daily) as needed for constipation. 19. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 7 doses: To be completed on [**2169-5-1**]. 20. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 21. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 22. Tacrolimus 5 mg Capsule Sig: 0.5 Capsule PO BID (2 times a day). Discharge Disposition: Extended Care Facility: [**Hospital6 85**] - [**Location (un) 86**] Discharge Diagnosis: Primary: Hypotension Anemia Secondary: 1. ESRD status post DCD transplant [**10/2167**], followed by Dr. [**Last Name (STitle) **] 2. Hypertension 3. DM type 2, last HbA1c 7.2% on [**2169-4-13**] 4. History of retinal hemorrhage status post vitrectomy 5. CAD status post PTCA (cath [**3-/2167**] 70% stenosis in small RCA, LAD 50% lesion, 90% PM3, PDA 80%, EF LV gram 50%, 2 cypher stents in LCx) 6. Mixed systolic and diastolic dysfunction, EF 40% 7. Peripheral vascular disease s/p right TMA with skin graft from left thigh 8. Polyneuropathy Discharge Condition: Stable, normotensive Discharge Instructions: You were admitted with a low blood pressure and a low blood count. There was no evidence of bleeding, and the reason for your low blood pressure is unknown. Please take all of your medications as prescribed. Please keep all of your follow-up appoinments. Please call your doctor or return to the hospital if you experience bleeding, chest pain, shortness of breath, fevers or anything else of concern. Followup Instructions: Please follow up with Hematology ([**Telephone/Fax (1) 14703**] (Dr. [**Last Name (STitle) 6160**] on [**5-29**] at 9am. Hematology is located on the [**Hospital Ward Name **] of [**Hospital1 18**] on the [**Location (un) **] of the [**Hospital Ward Name 23**] building. Please follow up with Dr. [**Last Name (STitle) **] (primary care doctor's office) on Thursday, [**4-27**] at 2pm. Please follow with Dr. [**Last Name (STitle) 1391**] of vascular surgery on [**5-10**] at 10:15am located in the [**Hospital Unit Name **], suite 5C. Appointments scheduled prior to this hospitalization: 1. Provider: [**Name10 (NameIs) 251**] [**Last Name (NamePattern4) 252**], M.D. Phone:[**Telephone/Fax (1) 253**] Date/Time:[**2169-5-30**] 10:00am 2. Provider: [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 542**], DPM Phone:[**Telephone/Fax (1) 543**] Date/Time:[**2169-6-7**] 8:40am Completed by:[**2169-4-24**] Name: [**Known lastname 571**],[**Known firstname **] Unit No: [**Numeric Identifier 10809**] Admission Date: [**2169-4-19**] Discharge Date: [**2169-4-24**] Date of Birth: [**2108-9-15**] Sex: M Service: MEDICINE Allergies: Vancomycin Attending:[**First Name3 (LF) 1455**] Addendum: Status post DCD kidney transplant: A tacrolimas trough should be drawn on Thursday, [**4-27**] and results called and/or faxed to Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 619**] of the renal division at [**Hospital1 8677**]. Review of this lab will guide subsequent dose adjustment if needed. Office phone [**Telephone/Fax (1) 2593**], fax [**Telephone/Fax (1) 10810**]. Discharge Disposition: Extended Care Facility: [**Hospital6 41**] - [**Location (un) 42**] [**Name6 (MD) **] [**Last Name (NamePattern4) 1456**] MD [**MD Number(2) 1457**] Completed by:[**2169-4-24**]

[ "250.50", "V42.0", "362.01", "530.10", "V45.82", "414.01", "280.0", "250.60", "401.9", "357.2" ]

icd9cm

[ [ [] ] ]

[ "45.13" ]

icd9pcs

[ [ [] ] ]

12184, 12393

3755, 6778

311, 355

9990, 10013

3006, 3031

10466, 12161

2460, 2488

7306, 9309

9423, 9969

6804, 7283

10037, 10443

2503, 2987

232, 273

383, 1772

3045, 3732

1794, 2329

2345, 2444

65,364

138,255

37289

Discharge summary

report

Admission Date: [**2161-6-30**] Discharge Date: [**2161-7-3**] Date of Birth: [**2079-4-21**] Sex: M Service: NEUROSURGERY Allergies: Penicillins / Erythromycin / Quinidine Attending:[**First Name3 (LF) 78**] Chief Complaint: fall out of chair at home this AM Major Surgical or Invasive Procedure: None History of Present Illness: 83 yo M retired physician s/p CVA [**1-7**] with subsequent aphasia and seizure disorder had unwitnessed (but heard from another room) fall out of chair possibly due to seizure. he is on coumadin/ASA. EMS was called and pt was brought to [**Hospital6 45215**] where INR was found to be 3.0 and head CT revealed subacute Left SDH with 5mm shift. he was given FFP, vitamin K and factor 9. Dilantin level was 8.2 and 1 gm was also give. He was then transferred to [**Hospital1 18**] ED. Repeat INR here was 1.7 for which 2 more units FFP were ordered. Past Medical History: CABG -Afib -hyperparathyroidism s/p resection -mitral valve repair -endocarditis -HTN -HLD -hx subdural hematoma s/p fall -BPH Social History: retired physician. [**Name10 (NameIs) 13802**] at home with spouse, has HHA. Recently dc/ed from [**Hospital1 **] [**2161-2-2**]. No hx etoh, tobacco or drugs. Family History: no history of stroke Physical Exam: O: T:98.3 BP: 145/75 HR65 R 18 O2Sats97 Gen: thin alert male with large blood stained head wrap and eccymotic R eye examined in ED in NAD. HEENT: Pupils:[**5-2**] bilat EOMs full L eye, difficult to fully assess R eye secondary to swelling Neck: Supple. Extrem: Warm and well-perfused. Neuro: Mental status: Awake and alert, cooperative with exam, normal affect. Orientation: Oriented to person, place, and date. Language: very soft spoken Speech fluent with good comprehension and slightly slowed repetition. Naming intact. No dysarthria or paraphasic errors. Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light, 4to3 mm bilaterally. III, IV, VI: Extraocular movements intact bilaterally without nystagmus. V, VII: Facial strength and sensation intact and symmetric. VIII: Hearing intact to voice. IX, X: Palatal elevation symmetrical. [**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally. XII: Tongue midline without fasciculations. Motor: Normal bulk and tone bilaterally. No abnormal movements, tremors. Strength full power [**6-3**] throughout except slightly decreased (5-/5) R biceps.Slight right pronator drift appreciated Sensation: Intact to light touch bilaterally. Toes mute bilaterally On Discharge: lethargic, awake, alert, and oriented to person, place, and date. Follows commands, slightly perseverative, full strength, no drift, pupils [**5-2**] bilaterally and brisk, face symmetric, tongue midline Pertinent Results: CT HEAD W/O CONTRAST [**2161-6-30**] Left subdural hematoma, subacute, similar in size to prior study, but now with evidence of acute on subacute bleeding. These findings were posted to the emergency department dashboard at the time of dictation. CT HEAD W/O CONTRAST [**2161-7-3**] Stable appearance of left Subdural hematoma Brief Hospital Course: 82 y/o M on coumadin for CVA in [**Month (only) 1096**] presented to ED s/p fall. Upon examination, patient was neuro intact, but with some word finding difficulty. Head CT showed L SDH. He was admitted to neurosurgery ICU for further workup. [**Name (NI) **] son, who is a physician, [**Name10 (NameIs) **] [**Name (NI) 653**] and the decision to treat the patient conservatively was made. On [**7-1**], patient remained intact with some speech difficulty, a prednisone taper was ordered and he was transferred to step down. On [**7-2**], his speech was improved and exam intact. A repeat head CT was done on [**7-3**] which was stable. the pna goign forward wwas discussed between Dr. [**First Name (STitle) **] and the patient and his family. the decision was made to follow up in 2 weeks witha head CT to evalaute if he is improving. he was discharged to home with home PT services Medications on Admission: dilantin, zoloft 25'lipitor 5',toprol xl 50', digoxin 0.125', asa 81', lisinopril 20', coumadin 3.5' Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain,fever. 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*0* 3. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). 4. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times a day). 5. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Sertraline 50 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 7. Atorvastatin 10 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 8. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 9. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). Disp:*90 Capsule(s)* Refills:*0* 12. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO ONCE (Once) for 1 doses. 13. Prednisone 5 mg Tablet Sig: 1-2 Tablets PO once a day for 2 days: Take 2 tablets (10 mg)on [**2161-7-4**] then take 1 tablet(5mg) on [**2161-7-5**]. Disp:*3 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: L SDH Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: ?????? Take your pain medicine as prescribed. ?????? Exercise should be limited to walking; no lifting, straining, or excessive bending. ?????? Increase your intake of fluids and fiber, as narcotic pain medicine can cause constipation. We generally recommend taking an over the counter stool softener, such as Docusate (Colace) while taking narcotic pain medication. ?????? Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, Aspirin, Advil, or Ibuprofen etc. ?????? If you were on a medication such as Coumadin (Warfarin), or Plavix (clopidogrel) prior to your injury, you may safely resume taking this after discussion with dr. [**First Name (STitle) **] at your follow up appointment ?????? You have been prescribed Dilantin (Phenytoin) for anti-seizure medicine, take it as prescribed and follow up with laboratory blood drawing in one week. This can be drawn at your PCP??????s office, but please have the results faxed to [**Telephone/Fax (1) 87**]. If you haven been discharged on Keppra (Levetiracetam), you will not require blood work monitoring. CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING ?????? New onset of tremors or seizures. ?????? Any confusion, lethargy or change in mental status. ?????? Any numbness, tingling, weakness in your extremities. ?????? Pain or headache that is continually increasing, or not relieved by pain medication. ?????? New onset of the loss of function, or decrease of function on one whole side of your body. Followup Instructions: Follow-Up Appointment Instructions ??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr. [**First Name (STitle) **], to be seen in 2 weeks. ??????You will need a CT scan of the brain without contrast as well as a Dilantin level prior to your appointment. This can be scheduled when you call to make your office visit appointment. Completed by:[**2161-7-3**]

[ "438.11", "432.1", "873.42", "345.90", "E849.0", "427.31", "V64.2", "V58.61", "E884.2" ]

icd9cm

[ [ [] ] ]

[ "86.59" ]

icd9pcs

[ [ [] ] ]

5486, 5544

3185, 4076

335, 342

5594, 5594

2831, 3162

7289, 7678

1274, 1297

4228, 5463

5565, 5573

4102, 4205

5745, 7266

1312, 1627

2605, 2812

261, 297

370, 926

1912, 2591

5609, 5721

948, 1077

1093, 1258

7,670

131,440

1332

Discharge summary

report

Admission Date: [**2178-5-5**] Discharge Date: [**2178-5-13**] Service: CME HISTORY OF PRESENT ILLNESS: The patient is a [**Age over 90 **]-year-old gentleman with a past medical history significant for hypertension who was transferred from [**Hospital 882**] Hospital for substernal chest pain with a plan catheterize. The patient had originally had been to [**Hospital 882**] Hospital for 30 minutes of substernal chest pain on [**5-4**]. The patient denied shortness of breath, nausea, vomiting, or diaphoresis at that time. At [**Hospital 882**] Hospital, he had been treated with nitroglycerin, morphine, intravenous Lopressor and was started on a heparin drip. PAST MEDICAL HISTORY: (The patient has a past medical history significant for) 1. Hypertension. 2. History of a cerebrovascular accident in [**2175**]. 3. History of right hip fracture repaired by open reduction internal fixation six months ago. 4. History of pacemaker placement four years ago. 5. History of Waldenstrom's macroglobulinemia. 6. History of chronic renal failure. MEDICATIONS ON ADMISSION: (The patient was on the following medications at home prior to admission) 1. Ambien. 2. Protonix. 3. Colace. 4. Flomax. 5. Atenolol 25 mg by mouth once per day. 6. Iron. 7. Folate. 8. Celebrex. ALLERGIES: The patient reports and allergy to PHENOBARBITAL. SOCIAL HISTORY: Significant for the patient living at home with 24-hour nursing assistance. The patient denies alcohol or tobacco use. PHYSICAL EXAMINATION ON PRESENTATION: Because the patient went directly to the Catheterization Laboratory, there are no vital signs or physical examination available immediately upon admission. PERTINENT LABORATORY VALUES ON PRESENTATION: White blood cell count was 10,600 (with a differential of 82.2 percent neutrophils and 11.2 percent lymphocytes), his hematocrit was 31.6 percent, with a mean cell volume of 92, and a red cell distribution of 14.8. The patient had a platelet count of 252. SMA-7 was as follows; sodium was 137, potassium was 5.7, chloride was 108, bicarbonate was 20, blood urea nitrogen was 29, creatinine was 1.9, and his blood glucose was 112. Creatine kinase was 71 with a troponin of 0.19. Calcium was 7.9 (unfortunately, an albumin was never drawn to determine the significance of the low calcium), his phosphate was 3.9, and his magnesium was 2.3. PERTINENT RADIOLOGY-IMAGING: The patient had a chest x-ray which was an AP portable. The patient was rotated, but the heart was within normal limits. There was a pacemaker visualized in the chest wall with one lead terminating in the right atrium and a second lead terminating in the right ventricular. A coronary angiography revealed no critical coronary artery disease. The left main coronary artery was not obstructed. The left anterior descending and left circumflex arteries had mild-to-moderate nonobstructive diffuse disease. In summary, there was noncritical coronary artery disease, moderately severe aortic stenosis, with an aortic valve area of 0.7 cm2 as well as elevated left heart filling pressures and normal cardiac output. An electrocardiogram on admission revealed a ventricularly paced rhythm with ectopy. The rate was 66. SUMMARY OF HOSPITAL COURSE BY ISSUES-SYSTEMS: 1. CARDIOVASCULAR ISSUES: (a) Coronary artery disease: As stated above, the patient was initially admitted for cardiac catheterization secondary to substernal chest pain. The cardiac catheterization showed moderate disease which was noncritical with a recommendation for medical management. The patient was initially maintained on a regimen of atenolol 12.5 mg by mouth every day as medical management in house; however, the patient had some post catheterization mental status changes, and the beta blocker was held. Aspirin was started on [**5-8**] and was then held when the patient began to have evidence of a gastrointestinal bleed on [**5-10**]. The patient was then restarted on a beta blocker at 25 mg by mouth once per day prior to discharge after confirmation of resolution of gastrointestinal bleed by a second endoscopy. (b) Pump: The patient had an echocardiogram on [**5-8**] which revealed a normal sized left atrium, moderate symmetric left ventricular hypertrophy, normal left ventricular cavity size, overall mild-to-moderate depression of left ventricular systolic function with a 40 percent ejection fraction, some apical and anteroseptal hypokinesis, suspected hypokinesis of the inferolateral wall, metastasis aortic stenosis, with moderate-to-severe mitral regurgitation. (c) Rhythm: As stated above, the patient had a ventricular pacemaker. The patient was continued on telemetry throughout most of the hospitalization. Toward the end of the admission, the patient had some episodes of nonsustained ventricular tachycardia in the setting of a low potassium and low magnesium. Once the potassium and magnesium were repleted, the patient did not have further episodes of ventricular tachycardia. (d) Hypertension: The patient's blood pressure remained stable. As stated above, atenolol was held temporarily for a gastrointestinal bleed. Atenolol was restarted at 25 mg by mouth once per day prior to discharge, and the patient tolerated that well. 1. GASTROINTESTINAL ISSUES: As stated above, the patient had an episode of hematemesis. The patient had an esophagogastroduodenoscopy showing the likelihood of an ulceration that was thought to be secondary to aspirin use. The area of concern contained a clot and could not be fully visualized. As a result, the decision was made to scope again in the future if the patient bled prior to discharge home versus as an outpatient if stable. On [**5-12**], the patient went for a repeat esophagogastroduodenoscopy. This was concerning for an area submucosal bright red blood at 25 cm in the upper esophagus. The source of this bleeding could not be identified. There was some concern that this could reflect an aortoesophageal fistula. As a result, the patient went for a computed tomography angiogram of the chest to evaluate for aortoesophageal fistula. There was no evidence of extravasation of contrast to suggest an aortoesophageal fistula. Of note, the esophagogastroduodenoscopy on [**5-12**] also showed some granulation tissue in the upper third of the esophagus thought to be due to nasogastric tube trauma, a small hiatal hernia, some angioectasia in the antrum of the stomach, some erosion in the stomach body (also probably due to nasogastric tube trauma). There was no blood in the stomach and an otherwise normal esophagogastroduodenoscopy to the third part of the duodenum. They recommended avoiding anti-platelet agents in this patient. The patient also had some mental status changes after the cardiac catheterization and a question of a right facial droop. The patient had a chest x-ray that was not consistent with aspiration pneumonia, but nevertheless received two to three days of levofloxacin for presumed aspiration pneumonia. Neurologically was consulted. They felt that the patient had mental status changes secondary to a change in environments and was likely delirium. However, a computer tomography of the head a carotid ultrasounds were performed to rule out stroke. The computer tomography of the head showed old ischemic changes. The ultrasound of the carotids showed pacific plaques of the carotid bulbs bilaterally. There was no significant internal carotid or common carotid stenosis bilaterally. The patient's mental status then improved, and he was felt to be at his baseline prior to admission to the hospital at the time of discharge. 1. GENITOURINARY ISSUES: The patient has a history of benign prostatic hypertrophy. The patient was continued on his Flomax and had no genitourinary issues throughout this admission. 1. RENAL ISSUES: The patient has a history of chronic renal insufficiency. At the time of discharge, the patient's creatinine was stable at 1.6. The patient had received intravenous contrast for the computed tomography angiogram on the evening prior to discharge. The patient received 250 cc of intravenous fluids as prophylaxis prior to the computed tomography angiogram. The decision was made not to give the patient one liter of fluid at 75 cc an hour as well as two doses of Mucomyst prior to computed tomography angiogram because of the urgency of the diagnosis of aortoesophageal fistula. It was felt to be more important to have the computed tomography angiogram than to protect the kidneys in this patient with only mild renal insufficiency. The patient then received two doses of Mucomyst after the computed tomography angiogram. The patient's creatinine remained stable at 1.6 both before and after the procedure. 1. FLUIDS/ELECTROLYTES/NUTRITION ISSUES: The patient was maintained on a cardiac/heart healthy, 2-gram sodium diet. The patient received a transfusion of a total of three unit of packed red blood cells in the face of the gastrointestinal bleeding. CONDITION ON DISCHARGE: The patient was felt to be at his baseline mental status. He was not requiring supplemental oxygen. He was able to feed himself and was felt to be safe to return to his home environment with 24-hour assistance. DISCHARGE DIAGNOSES: 1. Hypertension. 2. Chest pain. 3. Aortic stenosis. 4. Upper gastrointestinal bleed. 5. History of stroke. 6. Delirium. 7. Chronic renal failure. 8. Benign prostatic hypertrophy. 9. Arrhythmia; status post pacemaker placement. MEDICATIONS ON DISCHARGE: 1. Flomax (continued). 2. Protonix 40 mg by mouth once per day. 3. Atenolol 25 mg by mouth twice per day. 4. Colace by mouth twice per day. The patient was not to use any Celebrex or aspirin because of fear of further gastrointestinal bleeding. DISCHARGE INSTRUCTIONS-FOLLOWUP: 1. The patient was instructed to follow up with Gastroenterology in one to two weeks or as needed. The telephone number was provided. 2. The patient was also instructed to follow up with his primary care physician or Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in one to two weeks. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 8158**], [**MD Number(1) 8159**] Dictated By:[**Last Name (NamePattern1) 8160**] MEDQUIST36 D: [**2178-5-14**] 19:28:12 T: [**2178-5-16**] 11:08:53 Job#: [**Job Number 8161**]

[ "414.01", "707.15", "396.2", "427.1", "401.9", "273.3", "507.0", "533.40", "599.0" ]

icd9cm

[ [ [] ] ]

[ "37.23", "88.56", "96.07", "45.13", "99.04" ]

icd9pcs

[ [ [] ] ]

9399, 9628

9654, 10527

1097, 1357

117, 684

707, 1070

1374, 9138

9163, 9378

81,242

168,897

41871+58484

Discharge summary

report+addendum

Admission Date: [**2101-10-4**] Discharge Date: [**2101-10-11**] Date of Birth: [**2040-2-10**] Sex: M Service: CARDIOTHORACIC Allergies: Penicillins Attending:[**First Name3 (LF) 1505**] Chief Complaint: chest pain, hypertensive urgency Major Surgical or Invasive Procedure: [**2101-10-6**] Redo sternotomy and mitral valve repair with a 28-mm Physio II annuloplasty ring. History of Present Illness: Mr. [**Known lastname 48684**] is a 61 year old gentleman, with a history of CAD s/p MI and VSD repair in [**2094**], and recently diagnosed 2-vessel disease and moderate-severe mitral regurgitation with plan for CABG and MVR on [**10-6**] by Dr. [**Last Name (STitle) **], who presented with fatigue, chest pain and elevated blood pressure. . The patient had recently been admitted [**Date range (1) 6958**] at [**Hospital1 5979**] for pre-op work-up for his upcoming surgery. At that time cardiac cath showed OM with 70% proximal lesion, LAD with 40% mid lesion and RCA with 100% occlusion, as well as LVEF 50%. Echo was notable for LVEF 45-50%, moderate regional LV systolic dysfunction with basal inferior hypokinesis/akineis and hypokinesis/akinesis of the inferoseptal and inferolateral walls, as well as mitral posterior leaflet tethering with moderate to severe mitral regurgitation. . He had been feeling well until the morning of admission when he got up and felt "lousy." He reports that he felt tired with unclear thinking and went back to bed. He was awakened in the late morning by VNA, who measured his blood pressure to be 200/85. The patient went out to run errands and felt tired after returning. He then began to experience brief tingling "sparkler" sensation in his chest, accompanied by lightheadedness, diffuse sweating and intermittent nausea. He had no visual changes, headaches, vomiting or abdominal pain. Dr.[**Name8 (MD) 5572**] NP then called to encourage him to go to the hospital. At [**Hospital6 3105**], he wasa given nitro paste and started on a nitro drip, with which his chest discomfort dissipated. He was also given lorzepam. He was then transferred to [**Hospital1 18**]. On arrival to the [**Hospital1 18**] ED, the patient had initial vital signs were 97.6 64 186/86 98% 4L NC. He was continued on a nitro drip. On initial evaluation by Dr. [**Last Name (STitle) **], it was noted that the patient had increased creatinine, in the context of recently restarting lisinopril 10 mg daily. There was concern for renal artery stenosis. It was recommended that he wean down on his nitro drip and start Imdur. On transfer, vital signs were 97.8 61 142/45 13 96% on 2L Past Medical History: Coronary artery disease-s/p inf. MI with s/p VSD repair [**2094**] HTN hyperlipidemia anxiety /bipolar disorder s/p VSD repair [**2094**] Social History: Lives with: cat (alone) Occupation: writer, actor, retired Cigarettes: Smoked no [] yes [x] last cigarette _8/7____ Hx: Other Tobacco use: 2 ppd for 20 years, 1 ppd for the past 7 years ETOH: quit 20 years ago Family History: Heart disease in grandmother's siblings, with MI's in late 50s/early 60s. Grandmother with stroke at 63, deceased one day later on her 64th birthday. Great-grandfather with MI at 75. Physical Exam: Admission Physical Exam: 86 kg VS: 97.9 138/70 [129-166/45-70] 55 [55-61] 15 98%2L [96-100] GENERAL: Well-appearing man in NAD, comfortable, appropriate. Very pleasant and talkative. HEENT: NCAT, PERRLA, EOMI, sclerae anicteric, MMM, clear oropharynx. NECK: Supple, no thyromegaly, no JVP 2 cm above jugular notch, no carotid bruits. HEART: RRR, Nl S1-S2. Two murmurs: II/VI crescendo-descrensceno murmur loudest at RUSB with radiation to LLSB (no radiation to carotids); III/VI blowing systolic murmur loudest at the apex with radiation to the axilla. LUNGS: CTAB, no r/rh/wh, good air movement, resp unlabored. ABDOMEN: Soft/NT/ND, no masses or HSM, no rebound/guarding, no abdominal bruits. EXTREMITIES: WWP, no c/c/e, decreased pulses in feet. 2+ radial and carotid pulses. SKIN: No rashes or lesions. LYMPH: No cervical LAD. NEURO: Awake, A&Ox3. CNs II-XII intact. Strength equal and intact bilaterally, sensation equal and intact bilaterally. Pertinent Results: Pertinent results: EKG on admission [**2101-10-3**]: Q waves inferiorly and 0.[**Street Address(2) 1755**] elevation in II and aVF. LVH with repolarization changes. No change from prior. Renal artery ultrasound [**2101-10-4**]: Normal sized kidneys, without evidence of hydronephrosis or renal artery stenosis. PRE-BYPASS: The left atrium is mildly dilated. Mild spontaneous echo contrast is seen in the body of the left atrium. No spontaneous echo contrast is seen in the left atrial appendage. No atrial septal defect is seen by 2D or color Doppler. There is moderate symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. There is mild to moderate regional left ventricular systolic dysfunction with akinesis of the basal and mid inferoseptal walls. There is hypokinesis of the basal and mid inferior wall. Overall left ventricular systolic function is mildly depressed (LVEF= 40-45%). Intrinsic LV function is likely further depressed given degree of mitral regurgitation. The remaining left ventricular segments contract normally. There is an echogenic density in the interventricular septum that may represent a prior VSD patch repair. Right ventricular chamber size is normal. with moderate global free wall hypokinesis. Tricuspid annular plane systolic excursion is depressed consistent with right ventricular systolic dysfunction. There are simple atheroma in the ascending aorta. There are complex (>4mm) atheroma in the aortic arch. There are simple atheroma in the descending thoracic aorta. The aortic valve leaflets (3) are mildly thickened. There is calcium on the left and non-coronoary cusps. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are moderately thickened. There is restricted motion of the P3 segment of the posterior leaflet. An eccentric, posteriorly directed, wall-hugging jet of at least moderate to severe (3+) mitral regurgitation is seen. There is no pericardial effusion. Dr. [**Last Name (STitle) **] was notified in person of the results at time of surgery. POST-BYPASS: The patient is on milrinone and epinephrine infusions. There is a mitral annuloplasty ring in place. There is a jet of moderate (2+) mitral regurgitation originating from outside of the annuloplasty ring near the posteromedial commisure. There is no central mitral regurgitation. A peak gradient across the mitral valve is 8 mmHg with a mean gradient of 5 mmHg at a cardiac output of 5.2 L/min. Left ventricular function is moderately depressed (LVEF = 35-40%). Right ventricular appears marginally improved. No aortic regurgitation is seen. The aorta is intact after removal of the aortic bypass cannula. [**2101-10-10**] 06:23AM BLOOD WBC-8.4 RBC-3.28* Hgb-9.5* Hct-26.5* MCV-81* MCH-28.9 MCHC-35.7* RDW-16.4* Plt Ct-121* [**2101-10-3**] 10:25PM BLOOD WBC-7.4 RBC-4.62 Hgb-13.3* Hct-37.6* MCV-81* MCH-28.9 MCHC-35.5* RDW-16.9* Plt Ct-175 [**2101-10-10**] 06:23AM BLOOD Plt Ct-121* [**2101-10-8**] 01:55AM BLOOD PT-13.7* PTT-27.7 INR(PT)-1.2* [**2101-10-3**] 10:25PM BLOOD PT-12.9 PTT-26.8 INR(PT)-1.1 [**2101-10-3**] 10:25PM BLOOD Plt Ct-175 [**2101-10-11**] 05:44AM BLOOD UreaN-31* Creat-0.8 Na-137 K-4.1 Cl-101 [**2101-10-3**] 10:25PM BLOOD Glucose-102* UreaN-21* Creat-1.7* Na-139 K-4.3 Cl-100 HCO3-31 AnGap-12 [**2101-10-4**] 01:25PM BLOOD Glucose-92 UreaN-25* Creat-1.3* Na-139 K-4.1 Cl-100 HCO3-30 AnGap-13 [**2101-10-5**] 06:55AM BLOOD Glucose-93 UreaN-27* Creat-1.0 Na-139 K-4.0 Cl-102 HCO3-26 AnGap-15 [**2101-10-4**] 01:25PM BLOOD CK(CPK)-59 [**2101-10-5**] 06:55AM BLOOD CK-MB-2 cTropnT-<0.01 [**2101-10-4**] 01:25PM BLOOD CK-MB-2 cTropnT-<0.01 [**2101-10-3**] 10:25PM BLOOD cTropnT-<0.01 [**2101-10-11**] 05:44AM BLOOD Mg-2.4 [**2101-10-9**] 04:12AM BLOOD Calcium-8.3* Phos-2.1* Mg-2.3 [**2101-10-4**] 01:25PM BLOOD Calcium-8.7 Phos-3.8 Mg-2.3 Cholest-143 [**2101-10-4**] 01:25PM BLOOD HDL-35 CHOL/HD-4.1 LDLmeas-73 Brief Hospital Course: Admitted from emergency department due to hypertension with blood pressure > 200 requiring intravenous vasodilators. His blood pressure improved with nitroglycerin drip and he was transitioned to oral agents. His home lisinopril was not resumed due to acute kidney injury with Cr 1.7 on admission. It was trended and was back to 1.1 prior to surgery. He underwent rule out and enzymes were negative. On [**10-6**] he was brought to the operating room for mitral valve and coronary artery bypass graft surgery. See operative report for further details however he had mitral valve repair but there was no coronary bypass due to marginal branch and his right coronary artery supplying an infarcted territory as per operative note. He was brought to the intensive care unit post operatively on milrinone, epinephrine, phenylephrine and propofol drips. On post operative day one he was weaned from sedation, awoke neurologically intact and was extubated without complications. Additionally he was weaned off epinephrine and milirone was weaned down. Nicardipine was added for hypertension management, and on post operative day two he was weaned off milirone. He continued to progress and oral medications were adjusted for blood pressure and he was weaned off nicardipine. He remained in the intensive care unit until post operative day three and then was transferred to the floor for the remainder of his care. Physical therapy worked with him on strength and mobility. He continued to progress and was ready for transfer to rehab at [**Location (un) 582**] in [**Location (un) 4693**]. Medications on Admission: 1. divalproex 500 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO BID 2. trazodone 50 mg Tablet Sig: One (1) Tablet PO HS 3. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID 4. aspirin, buffered 325 mg Tablet Sig: One (1) Tablet PO DAILY 5. simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY 6. nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) Sublingual PRN (as needed) as needed for chest pain 7. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY 9. wellbutrin 250 mg PO BID Discharge Medications: 1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 3. divalproex 500 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO BID (2 times a day). 4. bupropion HCl 100 mg Tablet Sig: 2.5 Tablets PO BID (2 times a day): 250 mg . 5. atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. trazodone 50 mg Tablet Sig: One (1) Tablet PO at bedtime. Disp:*7 Tablet(s)* Refills:*0* 7. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day. 9. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig: Three (3) Tablet Extended Release 24 hr PO DAILY (Daily): 75 mg total daily . 10. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO every four (4) hours as needed for fever or pain. 11. Outpatient Lab Work please check Potassium, Magnesium, BUN and Creatinine on friday [**10-14**] to evaluate electrolytes Discharge Disposition: Extended Care Facility: [**Location (un) 582**] at [**Location (un) **] Discharge Diagnosis: Mitral regurgitation s/p Mitral valve repair Acute on chronic systolic heart failure Preoperative Acute kidney injury Coronary artery disease - blockages to infarcted areas not bypassed Hypertension hyperlipidemia anxiety bipolar disorder ventricular septal defect repaired in [**2094**] Discharge Condition: Alert and oriented x3 nonfocal Ambulating with 1 assist Incisional pain managed with tylenol as needed Incisions: Sternal - healing well, no erythema or drainage Edema trace lower extremity 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**] Date/Time:[**2101-11-16**] 1:15 Cardiologist:Dr. [**Last Name (STitle) 4922**] [**11-3**] at 3:15pm Please call to schedule appointments with your Primary Care Dr [**Last Name (STitle) **] in [**5-17**] weeks **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Completed by:[**2101-10-11**] Name: [**Known lastname 4926**],[**Known firstname 1558**] Unit No: [**Numeric Identifier 14349**] Admission Date: [**2101-10-4**] Discharge Date: [**2101-10-11**] Date of Birth: [**2040-2-10**] Sex: M Service: CARDIOTHORACIC Allergies: Penicillins Attending:[**First Name3 (LF) 741**] Addendum: Of additional note in relation coronary artery disease, due to significant adhesions and infarcted tissue he was not bypassed. He is referred back to his cardiologist by Dr [**Last Name (STitle) **] for further evaluation of coronary artery disease. Discharge Disposition: Extended Care Facility: [**Location (un) 176**] at [**Location (un) 4415**] [**Name6 (MD) **] [**Name8 (MD) 747**] MD [**MD Number(2) 748**] Completed by:[**2101-10-11**]

[ "424.0", "428.23", "412", "300.00", "411.1", "272.4", "401.9", "584.9", "414.01", "296.80", "428.0" ]

icd9cm

[ [ [] ] ]

[ "39.61", "38.97", "35.12" ]

icd9pcs

[ [ [] ] ]

14023, 14225

8187, 9784

312, 412

11841, 12033

4261, 8164

12872, 14000

3065, 3252

10365, 11412

11530, 11820

9810, 10342

12057, 12849

3292, 4223

240, 274

440, 2659

2681, 2821

2837, 3049

25,115

119,787

43875

Discharge summary

report

Admission Date: [**2209-7-14**] Discharge Date: [**2209-7-15**] Date of Birth: [**2131-4-11**] Sex: M Service: MEDICINE Allergies: Penicillins Attending:[**Last Name (un) 11974**] Chief Complaint: s/p VT ablation Major Surgical or Invasive Procedure: Ventricular Tachycardia Ablation [**7-14**] History of Present Illness: Mr. [**Known lastname **] is a 78M with h/o CAD s/p LAD stenting [**2197**], ischemia related CM (EF 20%), VT ablation in [**10/2208**] who was seen in EP device clinic today, found to have 43 episodes of VT noted on ICD interrogation and who is now s/p VT ablation. Of note, the patient has not been getting shocked, as VT has been slow and below the threshold for shocking. The patient tolerated the procedure without any trouble; was performed under MAC anesthesia. Was found to have anterior LV scar s/p substrate ablation. During the procedure he was given Lasix 40 mg and another 20 mg prior to transfer to the unit. On arrival to the floor, the patient reports feeling well. His only complaint is having back pain secondary to lying flat on his back for a prolonged period of time. Denies any chest pain, no shortness of [**Last Name (un) 6250**], no abdominal pain. Denies any new numbness or tingling. Past Medical History: PAST MEDICAL HISTORY: 1. CARDIAC RISK FACTORS: - Diabetes, + Dyslipidemia, + Hypertension 2. CARDIAC HISTORY: -CABG: -PERCUTANEOUS CORONARY INTERVENTIONS: s/p stent to LAD [**4-/2197**], PTCA of stent occlusion in 10/00, MI with PTCA of stent occlusion in [**4-16**] -PACING/ICD: s/p AICD 3. OTHER PAST MEDICAL HISTORY: - HTN - CAD s/p anterior wall MI in [**2188**] with VF arrest, s/p stent to LAD [**4-/2197**], PTCA of stent occlusion in 10/00, MI with PTCA of stent occlusion in [**4-16**] - hypercholesterolemia - glucose intolerance - lower back pain - h/o recurrent olecranon bursitis - insomnia - vitamin B12 deficiency - h/o acute diverticulitis - h/o colonic polyps - h/o prostate cancer - s/p radioactive seed implantation, on flomax and hormonal therapy, followed by Dr. [**Last Name (STitle) 986**] - h/o Afib s/p electrocardioversion, on amio and warfarin - h/o peptic ulcer disease - h/o recurrent squamous and basal cell carcinoma of skin - h/o cataracts s/p extraction OS in [**6-19**] and OD in [**2199**] - s/p splenectomy - removed when damaged during partial gastrectomy secondary to PUD Social History: Remote tobacco history; quit 40+ yrs ago. Widower, lives with daughter in [**Name (NI) **] [**Doctor Last Name **]. Family History: MIs in uncles in their 60s. Physical Exam: On Admission VS: 97.5 126/74 60 100% on RA GENERAL: well appearing, pleasant gentleman, NAD, lying comfortably in bed HEENT- NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. NECK- Supple with JVP to edge of mandible CARDIAC- RRR S1, S2, no murmurs/rubs/gallops appreciated LUNGS- anterior lung fields clear to auscultation b/l, good air movement, no wheezes/rhonchi/crackles noted ABDOMEN- Soft, nontender, nondistended, +BS EXTREMITIES- warm, well perfused, no LE edema note, 2+ DP pulses; b/l femoral sites with dressings clean/dry/intact, no tenderness to palpation, no hematoma appreciated, no bruits heard Neuro: CN 2-12 grossly intact, muscle strength and sensation grossly intact throughout On Discharge Exam Unchanged Pertinent Results: On Admission [**2209-7-14**] 10:30PM GLUCOSE-101* UREA N-21* CREAT-1.2 SODIUM-141 POTASSIUM-4.1 CHLORIDE-106 TOTAL CO2-27 ANION GAP-12 [**2209-7-14**] 10:30PM CALCIUM-7.8* PHOSPHATE-3.1 MAGNESIUM-2.0 [**2209-7-14**] 10:30PM WBC-11.8* RBC-3.56* HGB-12.0* HCT-36.4* MCV-102* MCH-33.7* MCHC-33.0 RDW-13.9 [**2209-7-14**] 11:39AM PLT COUNT-269 [**2209-7-14**] 11:39AM PT-25.7* INR(PT)-2.5* On Discharge [**2209-7-15**] 05:15AM BLOOD WBC-8.6 RBC-3.48* Hgb-11.6* Hct-35.2* MCV-101* MCH-33.3* MCHC-32.9 RDW-13.9 Plt Ct-205 [**2209-7-15**] 05:15AM BLOOD Plt Ct-205 [**2209-7-15**] 05:15AM BLOOD Glucose-85 UreaN-20 Creat-1.2 Na-141 K-4.1 Cl-108 HCO3-25 AnGap-12 [**2209-7-15**] 05:15AM BLOOD Calcium-8.2* Phos-3.4 Mg-2.0 [**2209-7-15**] 05:15AM BLOOD PT-28.4* PTT-40.6* INR(PT)-2.7* Brief Hospital Course: Mr. [**Known lastname **] is 78M with h/o CAD s/p LAD stenting [**2197**], ischemia related CM (EF 20%), VT ablation in [**10/2208**] who was seen in EP device clinic today, found to have 43 episodes of VT noted on ICD interrogation and who is now s/p VT ablation. Recurrent VT: The patient has history of recurrent VT and underwent a successful elective VT ablation during this admission with no complications. Electrolytes remained stable and the patient had no significant events on tele after the procedure. Atrial fibrillation: The patient has history of atrial fibrillation, on atenolol and amiodarone. His amiodarone was continued during hospitalization. PTT on discharge was therpeutic (2.7). He was sent home on his home coumadin regimen (3mg Mon and Fri and 2mg all other days). CAD: The patient has CAD s/p LAD stenting in [**2197**], which was later complicated by instent thrombosis and VF arrest. Currently asymptomatic, denying any chest pain or shortness of breath. Atenolol, lovastatin, and aspirin were continued during hospitalization. Ischemic related CM: Most recent ECHO with EF 20% with moderate LV cavity dilation with severe regional LV systolic dysfunction c/w multivessel CAD. The patient was given furosemide 40 mg during the procedure, and another 20 mg prior to transfer to the CCU. Patient remained euvolemic during hospitalization. He was discharged on home furosemide dose. No changes were made to the patient's medication during hospitalization. He is scheduled to FU with Dr [**Last Name (STitle) **] and in Device Clinic Friday, [**7-21**]. He can have his INR checked at that time. Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from Patient. 1. Aspirin 81 mg PO DAILY 2. Atenolol 25 mg PO DAILY 3. Amiodarone 200 mg PO DAILY 4. Furosemide 20 mg PO DAILY 5. Lisinopril 20 mg PO DAILY 6. Atorvastatin 20 mg PO DAILY 7. Warfarin 2 mg PO DAILY16 Currently taking 3mg on [**Month (only) 766**]/Friday, 2mg all other days. 8. Nitroglycerin SL 0.4 mg SL PRN chest pain 9. traZODONE 50 mg PO HS:PRN insomnia 10. Cyanocobalamin 50 mcg PO EVERY OTHER DAY 11. Ascorbic Acid 1000 mg PO DAILY Discharge Medications: 1. Amiodarone 200 mg PO DAILY 2. Aspirin 81 mg PO DAILY 3. Atenolol 25 mg PO DAILY 4. Furosemide 20 mg PO DAILY 5. Lisinopril 20 mg PO DAILY 6. Ascorbic Acid 1000 mg PO DAILY 7. Cyanocobalamin 50 mcg PO EVERY OTHER DAY 8. Nitroglycerin SL 0.4 mg SL PRN chest pain 9. traZODONE 50 mg PO HS:PRN insomnia 10. Atorvastatin 20 mg PO DAILY 11. Warfarin 2 mg PO DAILY16 Currently taking 3mg on [**Month (only) 766**]/Friday, 2mg all other days. Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis Ventricular Tachycardia s/p ablation Secondary Diagnosis Atrial Fibrillation Systolic Congestive Heart Disease 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 when you were evaluated by your cardiologist it was noted that you were having a concerning arrhythmia called ventricular tachycardia. You were taken to the electrophysiology lab and had an ablation to prevent this arrythmia from returning. There is no guarantee that this rhythm will not return. You tolerated the procedure well and discharged the following day. You should follow up with Dr. [**Last Name (STitle) **] and at the Device clinic on Friday [**7-21**]. You should get in touch with Ms [**Last Name (Titles) 94205**], Dr. [**Name (NI) 94206**] secretary, for more details. You have had episodes of low blood pressure while you were in the hospital. Please DO NOT take you lisinopril this evening. You can restart all of your medications tomorrow. Please call your Doctor if you begin to feel dizzy or lightheaded. Please continue to weigh yourself every morning, call your cardiologist if your weight goes up more than 3 lbs. No changes have been made to your daily medications. Followup Instructions: You should follow up with Dr. [**Last Name (STitle) **] and at the Device clinic on Friday [**7-21**]. You should get in touch with Ms [**Last Name (Titles) 12524**], Dr. [**Name (NI) 94206**] secretary, for more details. Department: CARDIAC SERVICES When: WEDNESDAY [**2209-10-4**] at 9:00 AM With: DEVICE CLINIC [**Telephone/Fax (1) 62**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: CARDIAC SERVICES When: WEDNESDAY [**2209-10-4**] at 9:40 AM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], MD [**Telephone/Fax (1) 62**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 11975**]

[ "428.0", "414.01", "V12.72", "401.9", "V10.46", "V12.71", "427.1", "428.22", "427.31", "414.8", "V58.61", "272.4", "V10.83", "412", "V45.82" ]

icd9cm

[ [ [] ] ]

[ "37.26", "37.34", "37.27" ]

icd9pcs

[ [ [] ] ]

6903, 6909

4223, 5854

287, 333

7083, 7083

3410, 4200

8296, 9195

2564, 2593

6440, 6880

6930, 7062

5880, 6417

7234, 8273

2608, 3391

1413, 1592

232, 249

361, 1281

7098, 7210

1623, 2414

1325, 1393

2430, 2548

66,017

135,364

144

Discharge summary

report

Admission Date: [**2150-6-19**] Discharge Date: [**2150-6-26**] Date of Birth: [**2099-8-8**] Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 1515**] Chief Complaint: s/p Cardiac Arrest Major Surgical or Invasive Procedure: Endotracheal intubation ICD placement History of Present Illness: 50F with hx of coronary vasospasm, HTN that presents from an OSH after having suffered a cardiac arrest in the field, s/p CPR with shock x1. Of note the pt was admitted to the [**Hospital1 1516**] service at [**Hospital1 18**] from [**Date range (3) 1517**] after a month of increasing chest discomfort concerning for coronary ischemia. While hospitalized, she had dynamic ST depressions in V3-V6 during anginal episodes and elevated trop to 0.16. At that time workup included both cardiac cath (X2) and CT of the coronary arteries. Cath suggested isolated bilateral coronary ostial stenosis. CTA was without evidence of atherosclerosis. At the time it was thought the pt suffered from cardiac vasospasm and not CAD. The pt was placed on diltiazem, Imdur, and amlodipine. The pt followed up in cardiology clinic [**5-25**] and at the time was feeling with only 2 lesss severe episodes of retrosternal chest pressure, [**4-12**], that occurred spontaneously without exertion, lasting 10 min with complete resolution. The pt had been able to participate in aerobic exercise, 45 minutes and endorsed 40lbs wt loss while on Weight Watchers program. The pt was last seen by her PCP [**Last Name (NamePattern4) **] [**2150-6-8**], Dr. [**Last Name (STitle) 1057**], at which time she was feeling well. At the time she reported LE edema since initiating amlodipine. This morning the pt was bringing her children to school. Family notes that patient has had increased chest discomfort this week and using nitroglycerin at work. Her daughter notes chest pain this morning which resolved prior to taking her daughter to school. EMS reports that arrived on scene with bystander CPR in progress (approx 7:45). Arrest was confirmed. The pt was shocked once. CPR was continued and on second analysis, no shock was advised. At that time the pt was noted to move, Amiodarone 150mg was loaded and subsequently transferred to an OSH. On arrival to the OSH, (hx obtained by [**Hospital 1281**] Hospital ED physician [**Last Name (NamePattern4) **]. [**Last Name (STitle) 1518**] via phone), initial vitals 108/55 HR 147, Wt 99.7kg. The pt was intubated (two attempts made). HR ranged from 123 to 151, with SBPs 108/55 to 174/74. 140's to 150's. Exam was notable for pt as unresponsive but was reaching for the tube. She did not respond to commandy prior to being intubated with Succinylcholine 150mg, Versed 4mg, Vecuronium 10mg and put on a propofol gtt. No acute EKG changes. Wbc 20. ck/trop neg. CXR/CT of chest shows large aspiration pneumonia CT Head/CT C-spine unremarkable. The pt was given Ceftiaxone 1gm, Clindamycin 600mg, Azithromycin 500mg. 18G. Small lac to back of head- going to get some staples prior to transfer. Vitals prior to transfer were HR 124 117/57. In the CCU, the patient is intubated. When propofol is weaned patient moves all extremities however does not respond to commands or follow directions. On review of systems, unable to be obtained from patient. Family reports that she was in her usual state of health and went to the beach this past weekend. Besides chest pain episodes noted above no other symptoms were reported by the patient. Family notes patient to be a non reporter. Past Medical History: 1. CARDIAC RISK FACTORS: (-)Diabetes, (-)Dyslipidemia, (-)HTN 2. CARDIAC HISTORY: -CABG: None. -PERCUTANEOUS CORONARY INTERVENTIONS: None. -PACING/ICD: None. 3. OTHER PAST MEDICAL HISTORY: h/o cholecystitis s/p cholecystectomy Social History: Works in NICU at [**Hospital1 18**] -Tobacco history: none -ETOH: none -Illicit drugs: none Family History: Paternal grandfather with MI at age 50. Father with hypertension. Physical Exam: Admission Labs VS: 122/58 95 100% GENERAL: Intubated, Sedated HEENT: NCAT. Sclera anicteric. PERRL. Laceration on back of head with staples in place. NECK: Supple with JVP at base of neck. 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, obese, NTND. No HSM or tenderness. EXTREMITIES: No c/c/e. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ On discharge: GENERAL: comfortable, NAD HEENT: NCAT. Sclera anicteric. PERRL. CARDIAC: 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. EXTREMITIES: 2+ pitting edema in BLE SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. Pertinent Results: On admission: [**2150-6-19**] 12:51PM BLOOD WBC-25.6*# RBC-4.47 Hgb-12.3 Hct-34.9* MCV-78* MCH-27.6 MCHC-35.3* RDW-14.5 Plt Ct-355 [**2150-6-20**] 05:14AM BLOOD WBC-15.7* RBC-4.16* Hgb-11.5* Hct-31.9* MCV-77* MCH-27.6 MCHC-35.9* RDW-14.7 Plt Ct-218 [**2150-6-26**] 05:20AM BLOOD WBC-6.3 RBC-3.24* Hgb-9.1* Hct-25.7* MCV-79* MCH-28.0 MCHC-35.3* RDW-16.0* Plt Ct-223 [**2150-6-19**] 12:51PM BLOOD Glucose-154* UreaN-18 Creat-0.5 Na-141 K-3.5 Cl-110* HCO3-20* AnGap-15 [**2150-6-20**] 12:45AM BLOOD Glucose-99 UreaN-17 Creat-0.4 Na-139 K-4.9 Cl-111* HCO3-19* AnGap-14 [**2150-6-20**] 02:00PM BLOOD Glucose-84 UreaN-16 Creat-0.3* Na-140 K-3.5 Cl-112* HCO3-18* AnGap-14 [**2150-6-20**] 08:30PM BLOOD Glucose-127* UreaN-17 Creat-0.3* Na-143 K-2.8* Cl-113* HCO3-18* AnGap-15 [**2150-6-21**] 02:08AM BLOOD Glucose-81 UreaN-16 Creat-0.4 Na-140 K-4.5 Cl-112* HCO3-20* AnGap-13 [**2150-6-19**] 12:51PM BLOOD CK-MB-20* MB Indx-14.8* cTropnT-0.71* [**2150-6-19**] 06:43PM BLOOD CK-MB-24* cTropnT-0.32* [**2150-6-20**] 05:14AM BLOOD CK-MB-23* cTropnT-0.18* [**2150-6-20**] 08:30PM BLOOD CK-MB-18* MB Indx-6.1* cTropnT-0.11* [**2150-6-19**] 12:51PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG On discharge: [**2150-6-26**] 05:20AM BLOOD WBC-6.3 RBC-3.24* Hgb-9.1* Hct-25.7* MCV-79* MCH-28.0 MCHC-35.3* RDW-16.0* Plt Ct-223 [**2150-6-26**] 05:20AM BLOOD Glucose-97 UreaN-7 Creat-0.4 Na-144 K-3.4 Cl-110* HCO3-24 AnGap-13 [**2150-6-23**] 03:10AM BLOOD ALT-30 AST-21 AlkPhos-89 TotBili-0.8 [**2150-6-26**] 05:20AM BLOOD Calcium-8.7 Phos-3.4 Mg-1.9 [**Month/Day/Year **] ([**2150-6-19**]) Normal biventricular cavity sizes with preserved global and regional biventricular systolic function. Mild to moderate mitral regurgitation with normal valve morphology. Pulmonary artery systolic hypertension. Increased PCWP. Upper Extremity Ultrasound ([**2150-6-25**]) Nonocclusive thrombus seen within one of the superficial veins, the cephalic vein, in a segment of the left upper arm. There is no evidence of deep vein thrombosis in the left arm. CXR ([**2150-6-25**]) In comparison with study of [**6-22**], there has been placement of a pacemaker device with leads in the region of the right atrium and apex of the right ventricle. The degree of pulmonary vascular congestion has substantially improved. Mild blunting of the right costophrenic angle persists. No evidence of acute focal pneumonia or pneumothorax. Right subclavian catheter extends to the lower portion of the SVC. microbiology: RESPIRATORY CULTURE (Final) - [**2150-6-19**] MODERATE GROWTH Commensal Respiratory Flora. STAPH AUREUS COAG +. MODERATE GROWTH. SENSITIVITIES: MIC expressed in MCG/ML STAPH AUREUS COAG + CLINDAMYCIN----------- R ERYTHROMYCIN---------- =>8 R GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- 0.5 S OXACILLIN------------- 0.5 S TRIMETHOPRIM/SULFA---- <=0.5 S GRAM STAIN (Final [**2150-6-21**]): >25 PMNs and <10 epithelial cells/100X field. 1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS. RESPIRATORY CULTURE (Final [**2150-6-23**]): RARE GROWTH Commensal Respiratory Flora. Blood cultures [**6-21**] and [**6-22**]: NGTD [**6-19**] final: NG Urine culture final ([**6-19**] and [**6-21**]): NG Brief Hospital Course: 50 year old female with history of coronary vasospasm presents following a cardiac arrest of unclear etiology. # s/p Cardiac Arrest: Witnessed VF arrest in the field with bystander CPR. EMS confirmed pulselessness and AED advised shock. ECG here without concerning ECG changes for ischemia. Given history of vasospasm may be secondary to vasospasm leading to ischemia and subsequent VT/VF arrest. She was placed on arctic cooling to protect cerebral function s/p cardiac arrest. [**Month/Year (2) **] showed normal structure and function. EEG showed abnormal temporal lobe epileptiform but otherwise normal. She was started on aspirin, amlodipine, isosorbide mononitrate, and simvastatin. She was noted to have ST elevation in V2-V4 on [**2150-6-20**] during rewarming phase with subsequent VF arrest s/p 1 round of CPR and shock with ROSC - K returned at 2.7. She was following commands and thus decision was made not to reinitiate cooling protocol. She was started on IV nitro and diltiazem drip which resolved the ST elevation in anteroseptal leads. After extubation and improvement in her mental status, her regimen was transitioned to nifedipine 60 mg po qdaily, imdur 60 mg po qdaily, verapamil ER 360 mg [**Hospital1 **]. EP was consulted and felt the presentation could be due to long QT syndrome. She underwent ICD placement on [**6-24**] - infectious prophylaxis was with Vancomycin. CXR showed no evidence of pneumothorax. . # Neuroprotection s/p arrest: Interval between arrest and initiation of cooling was 5 hours. On presentation with propofol wean patient without purposeful movement. CT head negative from OSH. Artic Sun therapeutic cooling protocol with goal core body temperature 33 degrees x 18 hours. Patient sedated with fentanyl and midazolam and eventually need paralysis with cisatracurium. She was warmed per protocol and was oriented and following commands appropriately within 48 hours. . # CORONARIES: Prior cardiac caths in [**Month (only) **] x2 both suggestive of coronary vasospasm without flow limiting lesions. Has been on amlodipine 10mg, dilt 240mg, and imdur 30mg as outpatient. ECG at OSH unchanged from baseline. Regimen was changed to above (see #1). # PUMP: No prior [**Month (only) **] or LV gram in [**Hospital1 18**] system. Pt with hx of HTN that was potentially thought to be white coat but unclear. [**Name2 (NI) **] showed normal function. # RHYTHM: No prior hx of arrhythmias however likely VF/VT arrest on presentation and subsequent episode of VF in ICU. Thought to be [**2-4**] coronary vasospasm. Long QT syndrome was also considered and genetic testing will be pursued by EP and discussed and followed up. # Pulmonary Infiltrates: Pt with evidence of diffuse infiltrates on OSH CXR and CT. Right upper load with air bronchograms concerning for pneumonia, however bilateral pathcy infiltrates concerning for early ARDS. Was placed on CTX/Clindamycin/Azithromycin at OSH for suspected CAP/Aspiration. Transitioned to IV unasyn and then IV nafcillin. Nafcillin was changed to Augmentin on [**6-24**] and again to Bactrim on [**6-25**]. Patient discharged wtih 7 day course of Bactrim [**Hospital1 **]. # Cloudy Urine: Urine appears "dirty" when foley catheter placed. Continued on IV unasyn. Urine cultures were negative. No further antibiotic coverage needed and patient remained asymptomatic. #dizziness: Pt complained of dizziness consistent with vertigo. Pt received meclizine with improvement in her symptoms. No evidence of orthostasis. Pt was ambulating without difficulty prior to discharge. Pt will follow up with PCP regarding these symptoms. #hypokalemia: Mild evidence of hypokalemia requiring po potassium supplementation. Pt was discharged with oral potassium supplementation and spironolactone were started to help maintain a normal postassium level. Pt planned follow potassium level 2 days after discharge. #lower extremity edema: [**Location (un) **] likely secondary to calcium channel blocker use stable from admission. She was kept on subQ heparin for DVT prophylaxis. She remained full code. Communication was with her husband. Medications on Admission: Aspirin 81mg daily (7am [**2150-6-19**]) Zocor 40mg daily (7am [**2150-6-19**]) Norvasc 10mg daily (7am [**2150-6-19**]) Diltiazem HCL 240mg daily (7am [**2150-6-19**]) Isosorbide mononitrate 30mg daily (7am [**2150-6-19**]) NTG Discharge Medications: 1. nifedipine 60 mg Tablet Extended Release Sig: One (1) Tablet Extended Release PO at bedtime. Disp:*30 Tablet Extended Release(s)* Refills:*2* 2. isosorbide mononitrate 60 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily). Disp:*30 Tablet Extended Release 24 hr(s)* Refills:*2* 3. acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for ICD pain. 4. sulfamethoxazole-trimethoprim 800-160 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 7 days. Disp:*14 Tablet(s)* Refills:*0* 5. spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 6. verapamil 360 mg Cap,Ext Release Pellets 24 hr Sig: One (1) Cap,Ext Release Pellets 24 hr PO twice a day. Disp:*60 Cap,Ext Release Pellets 24 hr(s)* Refills:*2* 7. meclizine 12.5 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) as needed for dizziness. Disp:*30 Tablet(s)* Refills:*0* 8. Outpatient Lab Work Please check Chem-7 and CBC on Monday [**6-29**] with results to Dr. [**Last Name (STitle) **] at [**Telephone/Fax (1) 62**] 9. potassium chloride 20 mEq Tablet, ER Particles/Crystals Sig: One (1) Tablet, ER Particles/Crystals PO once a day. Disp:*30 Tablet, ER Particles/Crystals(s)* Refills:*2* 10. nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) tablet Sublingual as directed as needed for chest pain. Discharge Disposition: Home With Service Facility: [**Company 1519**] Discharge Diagnosis: Coronary Vasospasm Ventricular fibrillation Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You had more spasm in your coronary arteries and had a ventricular fibrillation arrest. You were brought to [**Hospital 1281**] hospital initially and then transferred to [**Hospital1 18**] for care. You underwent an arctic sun cooling protocol and have recovered well from the episode. There may be some correlation with a prolonged QT and hypokalemia as well. Your telemetry shows only short runs of VT (3-4 beats) that are rare. You had an ICD placed that will shock you out of any prolonged runs of VT. Please call the EP fellow on call if this happens. You had a staph pneumonia that is being treated with antibiotics. . We made the following changes in your medicines: 1. STOP taking aspirin, norvasc, diltiazem and zocor. 2. START taking Verapamil to prevent coronary vasospasm 3. START taking Nifedipine to prevent coronary vasospasm, please take this at night 4. Increase the Imdur to 60 mg daily 5. Start taking spironolactone to increase your potassium 6. STart taking potassium supplements to keep your potassium up 7. Take meclizine as needed to prevent dizziness. 8. Take Bactrim twice daily for one week to treat the pneumonia 9. Take acetaminophen as needed for ICD pain. Followup Instructions: Department: [**Company 191**] POST [**Hospital 894**] CLINIC [**Telephone/Fax (1) 250**] When: WEDNESDAY [**2150-7-1**] at 9:30 AM With: Dr [**First Name4 (NamePattern1) 1060**] [**Last Name (NamePattern1) 1520**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**] South [**Hospital **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage NOTE: A) Please discuss at this appt if you need to come in for your previously scheduled appt for next week [**7-9**]. B) This appointment is with a hospital-based doctor as part of your transition from the hospital back to your primary care provider. [**Name10 (NameIs) 616**] this visit, you will see your regular primary care doctor in follow up. Department: [**Hospital3 249**] When: THURSDAY [**2150-7-9**] at 11:00 AM With: [**First Name11 (Name Pattern1) 1521**] [**Last Name (NamePattern1) 1522**], NP [**Telephone/Fax (1) 250**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: CARDIAC SERVICES When: MONDAY [**2150-7-27**] at 3:40 PM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1523**], MD [**Telephone/Fax (1) 62**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: CARDIAC SERVICES When: TUESDAY [**2150-8-4**] at 1:40 PM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1008**], M.D. [**Telephone/Fax (1) 62**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: CARDIAC SERVICES When: WEDNESDAY [**2150-7-1**] at 9:00 AM With: DEVICE CLINIC [**Telephone/Fax (1) 62**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Completed by:[**2150-6-26**]

[ "427.41", "507.0", "482.41", "413.1", "401.9", "427.1", "276.8" ]

icd9cm

[ [ [] ] ]

[ "96.71", "37.94", "38.93" ]

icd9pcs

[ [ [] ] ]

14315, 14364

8511, 12628

322, 362

14452, 14452

5182, 5182

15815, 17814

3967, 4034

12908, 14292

14385, 14431

12654, 12885

14603, 15792

4049, 4755

3694, 3770

6408, 8488

264, 284

390, 3590

5196, 6394

14467, 14579

3801, 3841

3612, 3674

3857, 3951

63,176

134,974

9775

Discharge summary

report

Admission Date: [**2181-3-11**] Discharge Date: [**2181-3-11**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**Last Name (NamePattern4) 290**] Chief Complaint: found down Major Surgical or Invasive Procedure: none. History of Present Illness: [**Age over 90 **] yo female with hx dementia, HTN, Chronic renal disease presenting from nursing home after found to be unresponsive and hypotensive. Patient was transferred to [**Hospital1 18**] for evaluation and treatment, where she was found to have pyuria, suggesting current condition to be most likely due to urosepsis. ED senior resident discussed goal of care with Granddaughter, who is health care proxy. [**Name (NI) **] is DNR/DNI and HCP does not want pt to have central line but pressor and antibiotic per perigheral. . In the ED, T97.6, HR 106, on exam patient was non-responsive. Patient was given vanco/zosyn, 1L NS, morphine, and started on levophed peripherally. ECG was sinus tachycaria w/ premature Atrial beats. . On arrival, BP 122/73, HR 92, O2 sat 93-95%%, T92.9. Past Medical History: 1. Hypertension. 2. Mild chronic renal insufficiency with a baseline creatinine of 1 to 1.2. 3. Dementia 4. Anxiety Social History: Never smoker She lives alone in elder housing in [**Location (un) 583**]. She has three PCAs for ADLs 7 days a week. She also attends daycare at [**Hospital1 100**] Senior Life. She ambulates with a cane and walker. Her granddaughter [**Name (NI) 32938**] is her only remaining relative. Family History: Unknown Physical Exam: Tmax: 33.8 ??????C (92.9 ??????F) Tcurrent: 33.8 ??????C (92.9 ??????F) HR: 38 (38 - 100) bpm BP: 69/37(42) {69/30(42) - 132/60(73)} mmHg RR: 1 (1 - 26) insp/min SpO2: 6% Heart rhythm: SB (Sinus Bradycardia) General Appearance: Thin Eyes / Conjunctiva: PERRL Head, Ears, Nose, Throat: Normocephalic Cardiovascular: (S1: Normal), (S2: Normal), No(t) S3, No(t) S4, No(t) Rub Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed) Respiratory / Chest: (Breath Sounds: Bronchial: ) Abdominal: Soft, Non-tender, Bowel sounds present Extremities: Right: Trace, Left: Trace Skin: Not assessed Neurologic: No(t) Attentive, No(t) Follows simple commands, Responds to: Not assessed, No(t) Oriented (to): , Movement: Not assessed, Tone: Not assessed Pertinent Results: [**2181-3-11**] 10:26AM URINE COLOR-Yellow APPEAR-Cloudy SP [**Last Name (un) 155**]-1.016 [**2181-3-11**] 10:26AM URINE BLOOD-LG NITRITE-NEG PROTEIN-100 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-8.0 LEUK-MOD [**2181-3-11**] 10:26AM URINE RBC->50 WBC->50 BACTERIA-MANY YEAST-NONE EPI-21-50 [**2181-3-11**] 10:24AM LACTATE-2.5* [**2181-3-11**] 10:15AM GLUCOSE-112* UREA N-149* CREAT-7.7*# SODIUM-161* POTASSIUM-7.6* CHLORIDE-122* TOTAL CO2-21* ANION GAP-26* [**2181-3-11**] 10:15AM estGFR-Using this [**2181-3-11**] 10:15AM ALT(SGPT)-27 AST(SGOT)-35 ALK PHOS-83 TOT BILI-0.4 [**2181-3-11**] 10:15AM LIPASE-17 [**2181-3-11**] 10:15AM cTropnT-0.10* [**2181-3-11**] 10:15AM ALBUMIN-3.4 CALCIUM-9.7 PHOSPHATE-6.9*# MAGNESIUM-3.8* [**2181-3-11**] 10:15AM WBC-19.2*# RBC-4.27 HGB-12.7 HCT-40.1 MCV-94 MCH-29.8 MCHC-31.7 RDW-13.5 [**2181-3-11**] 10:15AM NEUTS-93.0* LYMPHS-5.2* MONOS-1.5* EOS-0.1 BASOS-0.1 [**2181-3-11**] 10:15AM PLT COUNT-172 [**2181-3-11**] 10:15AM PT-15.3* PTT-24.9 INR(PT)-1.4* -------- Fluid analysis / Other labs: WBC count 19, Hct 40, Cr 7.7, K+ 7.6, BUN 149, Na 161, Cl 122, CO2 21 Imaging: CXR: ?retrocardiac opacity Microbiology: Pending ECG: Sinus tach with occasional PAC's Brief Hospital Course: [**Age over 90 **] y/o F w/ h/o dementia, HTN, presented to ED after being found unresponsive. Patient treated for pneomonia and urosepsis on arrival with IVF's, abx. . #Sepsis: ?pneumonia vs. urosepsis - continue antibiotics - wean pressors, and IVF's as needed - use dopamine peripherally . #Respiratory Failure: Likely [**2-12**] to pneumonia or to resuscitation. - nebs . # Acute Renal Failure: Likely severe volume depletion given hypernatremia. . #Hyperkalemia: treat with calcium gluconate, insulin, glucose . #Dementia/HTN: Obtain input from family. . Patient was admitted to the medicine service after clear discussion about goals of care in ED with granddaughter. [**Name (NI) **] was for IVF's, antibiotics, and peripheral pressors, but no central access, CPR, defibrillation or intubation. On arrival, patient was weaned off levophed which was running through a peripheral IV. Plan was to treat hyperkalemia and continue antibiotics/volume boluses and replace free water. Patient was on 100% NRB on arrival to mICU. Then began to desaturate in in course of less than 10 minutes had become completely apneic. Impression was for mucous plug vs. pulmonary edema. Patient showed no signs of distress. Given goals of care, no aggressive measures were undertaken to resuscitate the patient. She expired at 2:20pm approximately 2 hours after admission. Medications on Admission: 1. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours). 2. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed. 3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 4. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 5. Docusate Sodium 50 mg/5 mL Liquid Sig: Five (5) mL PO BID (2 times a day) as needed for constipation. Discharge Medications: None, expired Discharge Disposition: Expired Discharge Diagnosis: Pneumonia Urosepsis Dementia Hypertension Discharge Condition: expired Followup Instructions: expired [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]

[ "038.8", "403.90", "584.9", "995.91", "585.9", "294.8", "518.81", "276.7" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

5665, 5674

3737, 5105

280, 287

5759, 5768

2475, 3530

5791, 5937

1574, 1583

5627, 5642

5695, 5738

5131, 5604

1598, 2456

230, 242

315, 1112

1134, 1252

1268, 1558

3542, 3714

17,977

145,710

503

Discharge summary

report

Admission Date: [**2160-1-8**] Discharge Date: [**2160-1-16**] Date of Birth: [**2090-1-18**] Sex: F Service: MEDICINE Allergies: Losartan / Aspirin / Lisinopril-Hctz Attending:[**First Name3 (LF) 4162**] Chief Complaint: fever, hypotension Major Surgical or Invasive Procedure: Hemodialysis MWF History of Present Illness: Pt is a 69 y/o female with ESRD, bed bound, humeral and femoral fracture who was recently admitted to ICU with enterobacter/ klebsiella/Pseudomonas UTI and bacteremia on Gent, Cefepime via PICC who was admitted with increased change in mental status, less responsive and fever x 1 day. Patient got HD on [**2160-1-7**] and when she came to the ED on [**1-8**], her SBP was found to be in the 80s. Patient got 1.5L NS and BP returned to SBP 120s. Her lactate was 1.0. ID and renal consulted and ID recommended continuing patient on meropenum, linezolid, and Gentamycin. Patient got vancomycin in ED. . History obtained from son on Transfer, he states that pt was discharged on saturday, sunday she felt weak and was somnolent. After dialysis on monday she became more lethargic and unresponsive and was transferred to [**Hospital1 18**] ED. She got "antibiotics" and IVF in ED and ICU and she became more responsive. In [**Name (NI) 153**], pt remained afebrile and pressures improved with IVF. She was transferred to the regular floor for further management. Past Medical History: 1. Type 2 diabetes mellitus 2. Diabetic nephropathy resulting in ESRD for which she is on HD Mon, Wed, and Fri. 3. Status post left femur fracture 4. Hyponatremia 5. Hypercholesterolemia 6. Unsteady gait 7. Cataracts 8. Back pain 9. Hypertension 10.Anemia of chronic disease 11. S/P L shoulder hemiarthroplasty following a left humeral fracuture in [**10/2159**]- Course was complicated by a PEA arrest secondary to PE. [**11-24**] new humerus fracture 12. PE [**2159-10-27**] leading to PEA arrest 13. Hospitalization [**11-24**] for Sepsis (negative work-up) treated empricially with Vanc 14. h/o C-diff [**2159-11-22**], Urine citrobacter (tx w/Cipro) . Social History: Lives with son who is very involved and well informed regarding her care needs. Non smoker. No EtOH. Pt most recently at [**Hospital **] rehab prior to transfer here. Pt has family members at [**Name2 (NI) 4171**] bedside 24 hours per day. Family History: Noncontributory Physical Exam: Vitals Tmax/Tc 99.1 BP 102/54 HR 107 RR 20 O2sat 92%RA . GEN: HEENT: anicteric bilateral cataracts, OP clear Neck: no LAD Chest: diffuse rhonci bilaterally ant and laterally. CVR: Regular rhythm, tachy, nl S1, S2, no murmor ABD: obese, NT/ND EXT: Left UE in sling. 3+ pitting edema in LUE, RUE with trace edema. Bilaterally lower extremities with 2+ edema. Neuro: Pt awake and alert, not very talkative. Skin: very thin skin, multiple areas of LINES: R AC PICC site without warmth,erythema or tenderenss. R chest HD line without erythema or tenderenss. Pertinent Results: CT Head: No intracranial hemorrhage or mass effect is identified. No interval change from the prior study. . CXR: No evidence of pneumonia. [**2160-1-8**] 05:21PM GLUCOSE-180* UREA N-25* CREAT-2.7* SODIUM-141 POTASSIUM-4.9 CHLORIDE-102 TOTAL CO2-29 ANION GAP-15 [**2160-1-8**] 05:21PM CALCIUM-8.1* [**Month/Day/Year **]-4.1 MAGNESIUM-1.6 [**2160-1-8**] 08:17PM LACTATE-1.0 [**2160-1-8**] 05:21PM WBC-10.5 RBC-3.42* HGB-10.8* HCT-33.1* MCV-97 MCH-31.7 MCHC-32.8 RDW-21.1* [**2160-1-8**] 05:21PM NEUTS-66 BANDS-3 LYMPHS-9* MONOS-10 EOS-7* BASOS-0 ATYPS-2* METAS-2* MYELOS-1* Tagged WBC scan [**2160-1-15**]: IMPRESSION: Mild increased tracer activity in the distal portion of left femur and left humerus likely consistent with either mild infection or a healing fracture. Femur XRAy:INDICATION: End-stage renal disease with femur fracture. Two images of the left femur were compared to [**2160-1-4**]. There has been no significant change from the previous study which includes a healing supracondylar fracture that is impacted with some mild medial displacement. The left hip joint appears unchanged with resorption of the femoral neck without a demonstrable fracture line. Per discussion with nuclear medicine, the tagged white blood cell study suggests osteomyelitis of the distal femur at the fracture site. On plain radiograph, there is no discrete evidence for osteomyelitis but the significant diffuse osteopenia limits the sensitivity of detection. IMPRESSION: Unchanged healing supracondylar fracture and marked osteopenia Humerus Xray (bilateral): Two images of the left humerus and two images of the right humerus were reviewed. There has been increased angulation and further displacement of the left comminuted distal periprosthetic humerus fracture. Evaluation for osteomyelitis is limited by diffuse osteopenia. Given this limitation, no signs of osteomyelitis are present. The right humerus appears normal apart from the significant osteopenia and again, no signs of osteomyelitis are present. CXR [**2160-1-12**]: right after ?aspiration (labored breathing) Compared with [**2160-1-8**] and allowing for differences in positioning, there is probable mild cardiomegaly. The aorta is unfolded. The superior mediastinal silhouette is prominent and the trachea at the level of the neck may be narrowed. There is no CHF, focal infiltrate or effusion. A dual lumenright- sided catheter, dual lumen, is present. CXR [**2160-1-13**] (1 day after ?aspiration):1. Subsegmental atelectasis, without other evidence for acute pulmonary process. 3. Small pulmonary nodule at left base, of uncertain significance. This was not visible on prior x-rays and was not described on the [**2159-12-12**] torso CT. Recommend attention to this area on followup films. Brief Hospital Course: 69 y/o female with PMH notable for ESRD on HD present with recent episodes of sepsis of unclear source. Pt was originally admitted to the ICU with hypotension and fevers,. She quickly responded to IVF and was pancultured and imaged. She was stable and thus transferred to the wards for further management and diagnosis. Her course was complicated by a period of AMS and tachypnea to the 40s likely precipated by an aspiration event. The spontaneously resolved after 2 days and was not radiographically evident. Of note, the patient aspirates all but fluids per the last swallow evaluation. However, the patient clearly refused NG tube and feedign tube and she and her family wish for her to eat. She may require furhter evaluation, but swallow eval had to be aborted at [**Hospital1 18**] due to vomiting prior to evaluation. 1) Fever/Hypotension - Initial ddx includes sepsis vs. volume depletion at dialysis. BP responeded to IVF. She was started on meropenum/linezolid in the ICU. Quickly after presentation pt was normotensive and was transferred to the floor. AFter blood cultures were negative for >48 hours, linezolid was discontinued. Per ID recs, pt underwent a tagged WBC scan to see if there was another source of infection. Repeat u/a and culture were also sent. Plastic surgery was consulted regarding her decub wounds on the calfs, they did not recommend doing a debridement. *Patient does not make much urine, and her symptoms are likely secondary from urinary tract infections -> urosepsis given poor hygine. Spoke with [**Hospital **] rehab and family regarding the need for good hygeine which may help with recurrent infections. * Now ? whether multifocal osteomyleitis has incited these multiple episodes of sepsis. Treatment is medical -Continue to treat with meropenem per ID x 1 week. 2) ?Osteo: See tagged wbc scan above. Ortho consult suggests that to definitively differentiate btw tumor and healing fracture is MRI. Given that she has no known right humeral fx, this is likely osteo vs tumor. Orthopedics deems pt poor operative candidate this the treatment is medical; will not pursue MRI at this time. Continue meropenem x 1 week. 3) ESRD - Renal followed patient in house with TIW dialysis. 4) Diabetes - Continued outpatient regimine of glargine and RISS. 5) History of PE - On coumadin 2mg qhs, INR subtherapeutic on admission however last admission INR of 14.6 on 5 mg coumadin so coumadin was increased gently to 3 mg qhs. Will require monitoring. 6) Anasarca/humeral fracture/bilateral calf decub ulcers - Chronic issues in this essentially bed bound patient. Unchanged during this admission. Please refer to previous discharge summaries for previous workups. Continue wound care, plastics will not debride. 7) FEN: Hypernatremia likely due to dialysis (dehydration); will require free water orally versus IV to manage. Nectar prethickened liquids and purees for food (see page 1) 8) Code: Full 9) Communication - son [**Name (NI) **] [**Telephone/Fax (1) 4172**] Medications on Admission: Meds on transfer: Linezolid 600 mg IV Q12H Acetaminophen 325-650 mg PO Q4-6H:PRN Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN Meropenem 500 mg IV Q24H Ascorbic Acid 500 mg PO BID Multivitamins 1 CAP PO DAILY Calcium Acetate 667 mg PO TID W/MEALS Heparin 5000 UNIT SC TID Warfarin 2 mg PO HS Insulin SC (per Insulin Flowsheet) Zinc Sulfate 220 mg PO DAILY Ipratropium Bromide Neb 1 NEB IH Q6H:PRN . Meds on admission: 1. Ascorbic Acid 500 mg PO BID 2. Folic Acid 1 mg Tablet PO DAILY 3. Zinc Sulfate 220 mg Capsule PO DAILY 4. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 5 to 6 hours) as needed for fever or pain. 6. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily). 7. Warfarin 2 mg Tablet PO HS 8. Ipratropium Bromide 0.02 % One (1) neb Q6H 9. Albuterol Sulfate 0.083 % Solution (1) neb Q6H (every 6 hours) as needed. 10. Insulin Glargine Fifteen (8U) units Subcutaneous at bedtime. 12. Gentamicin 13. Cefepime 1 g 14. Phoslo 667 mg tid w/ meals Discharge Medications: 1. Zinc Sulfate 220 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 2. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed. 4. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily). 5. Albuterol Sulfate 0.083 % Solution Sig: One (1) neb Inhalation Q6H (every 6 hours) as needed. 6. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb Inhalation Q6H (every 6 hours) as needed. 7. Warfarin 1 mg Tablet Sig: Three (3) Tablet PO HS (at bedtime). 8. Prochlorperazine 10 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. 9. Clotrimazole 10 mg Troche Sig: One (1) Troche Mucous membrane QID (4 times a day). 10. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) inj Injection TID (3 times a day). 11. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: Two (2) ML Intravenous DAILY (Daily) as needed: 2 ml IV DAILY:PRN 10 ml NS followed by 2 ml of 100 Units/ml heparin (200 units heparin) each lumen Daily and PRN. Inspect site every shift. . 12. Meropenem 500 mg Recon Soln Sig: Five Hundred (500) mg Intravenous once a day for 7 days. Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - Acute Rehab Discharge Diagnosis: Sepsis Hypotension Osteomyelitis ESRD Diabetes Mellitus type 2 Obesity Discharge Condition: Stable Discharge Instructions: * Return to hospital for change in respiratory status, chest pain, change in mental status or other concernign symptoms. * Follow-up with your appoitnments * Take all medications as described Followup Instructions: 1) Dr. [**Last Name (STitle) **]: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3404**], MD Date/Time:[**2160-1-22**] 11:30 [**Hospital Ward Name 23**] Center [**Location (un) **] ([**Telephone/Fax (1) 1300**] need to bring family member to interpret 2) Dr. [**Last Name (STitle) 1860**]: Provider: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) **], [**Name Initial (NameIs) **].D., PH.D. Date/Time:[**2160-2-18**] 1:30 [**Hospital Ward Name 23**] Center [**Location (un) 436**], medical specialties ([**Telephone/Fax (1) 773**] Completed by:[**2160-1-16**]

[ "250.40", "276.0", "707.09", "730.25", "599.0", "V58.67", "782.3", "263.9", "403.91", "250.80", "278.00", "585.6", "731.8", "995.92", "V12.51", "458.9", "285.21", "583.81", "038.9" ]

icd9cm

[ [ [] ] ]

[ "00.14", "39.95" ]

icd9pcs

[ [ [] ] ]

11066, 11139

5811, 8846

315, 334

11254, 11263

2994, 2994

11505, 12092

2383, 2400

9867, 11043

11160, 11233

8872, 8872

11287, 11482

2415, 2975

257, 277

362, 1426

3003, 5788

9288, 9844

1448, 2107

2123, 2367

8890, 9274

3,100

191,209

53790

Discharge summary

report

Admission Date: [**2118-10-30**] Discharge Date: [**2118-11-9**] Date of Birth: [**2066-10-13**] Sex: F Service: MEDICINE Allergies: Ace Inhibitors / Lisinopril Attending:[**First Name3 (LF) 1973**] Chief Complaint: unresponsiveness Major Surgical or Invasive Procedure: central venous line placement History of Present Illness: THis is a 52 year old spanish speaking (minimal history given the decreased mental status and unable to reach family for corroboration of contact) female w/ history of OSA on BIPAP at home, restrictive lung disease, pulmonary hypertension, cognitive impairment, CHF, was found down and unresponsive at home. She was in her usual state of health until 3 days pta when she was not feeling well (per her family). Her family found her to be lying in bed incoherent and febrile to 104. She was recently admitted here on [**8-29**] for CHF/COPD and was intubated in the MICU. . ED course: INitial VS T 104.8 P 106 BP 103/50 RR 14 O2 93 on 3L -> BP dropped to 84/34 w/ 94$ on 3L RR 17 and slightly labored breathing Bld, urine and sputum cx sent vanco/CTX/azithro/dexmethasone IVF 3L NS given alb/atrovent R IJ placed CT abd/pelvis Numerous attempts at LP but held as pt desats ->mid 80s on 3L w/ laying flat on side-> O2 sat came back to 94 on 3L Past Medical History: 1) HTN 2) Hypothyroidism: TSH [**1-2**] 0.87 3) OSA: on BiPAP 16/10 at home - was supposed to also be on 2L NC at home 4) Restrictive lung disease - [**4-2**] PFTs: FVC 39%, FEV1 37%, FEV1/FVC 96%, TLC 59%, DLCO markedly reduced. Consistent with moderate restrictive ventilatory defect 5) Pulmonary artery hypertension: attributed to COPD/OSA 6) ASD with shunt: shunt study demonstrated R-> L shungt with 12% shunt fraction (precluding meaningful repair) 7) Central diabetes insipidis - ? pan- hypo pit: on prednisone 5 mg daily, levothyroxine, desmopressin 8) Cognitive Impairment (patient does not have Down Syndrome) 9) h/o CHF - [**1-1**] TTE: LVEF >55%, RV dilated, abnl septal motion c/w right ventricle pressure/volume overload, 2+ MR, 3+ TR, moderate pulmonary systolic hypertension, ASD vs stretched PFO on bubble study Social History: Lives with daughter, who is her primary care-giver and 2 grand children. Prior 45 pk-yr smoking history, quit [**2112**]. No EtOH or other drug use. Family History: NC Physical Exam: PE Vitals: 98.4, 113/75, 59, 20, 97% HEENT: NC/AT, EOMI, PERRLA, nares with no secretions, OP nonerythematous Neck: supple, no lymphadenopathy COR: RRR, S1, S2 , II/VI holosystolic murmur heard best at LUSB CTA B/L - wheezing or rhonchi, scattered crackles Abd: soft, NT, ND, + BS Ext: no c/c/ trace edema derm: fungal rash R axilla Neuro: drowsy but arousable and follows command intermittentl Pertinent Results: [**2118-11-8**] 05:03AM BLOOD WBC-10.5 RBC-3.56* Hgb-10.4* Hct-32.7* MCV-92 MCH-29.2 MCHC-31.7 RDW-15.6* Plt Ct-244 [**2118-11-9**] 06:28AM BLOOD UreaN-19 Creat-0.9 Na-140 K-3.7 [**2118-11-8**] 05:03AM BLOOD Glucose-91 UreaN-20 Creat-1.0 Na-141 K-3.7 Cl-100 HCO3-35* AnGap-10 [**2118-10-31**] 01:36PM BLOOD ALT-36 AST-27 AlkPhos-119* TotBili-0.3 [**2118-11-9**] 06:28AM BLOOD Phos-4.3 Mg-2.1 [**2118-11-8**] 05:03AM BLOOD Calcium-9.9 Phos-4.6*# Mg-2.3 [**2118-11-2**] 05:08AM BLOOD VitB12-648 Folate-19.2 [**2118-10-30**] 11:35AM BLOOD calTIBC-329 Ferritn-123 TRF-253 [**2118-10-30**] 08:00PM BLOOD TSH-0.60 [**2118-10-30**] 08:00PM BLOOD Free T4-0.49* [**2118-10-30**] 05:40PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2118-10-31**] 06:28AM BLOOD freeCa-1.14 EEG: IMPRESSION: Abnormal EEG due to the slow and disorganized background and bursts of generalized slowing. These findings indicate a widespread encephalopathic condition affecting both cortical and subcortical structures. Medications, metabolic disturbances, and infection are among the most common causes. No focal abnormalities were evident, but encephalopathies can obscure focal findings. There were no epileptiform features. MRI OF THE BRAIN WITHOUT INTRAVENOUS CONTRAST: There are no abnormal areas of slow diffusion or susceptibility. The signal intensities of the brain parenchyma are stable again demonstrating minimal scattered white matter hyperintensities, rarely significant as an isolated finding. There is no shift of normally midline structures, mass effect or hydrocephalus. Note is made of motion artifact limiting several sequences. There is again note of a partially empty sella as described previously. Normal vascular flow voids are present. The visualized paranasal sinuses and osseous structures are unremarkable. IMPRESSION: 1. No evidence of acute infarction. Stable appearance of the brain. ECHO: Conclusions: The left atrium is dilated. The right atrium is markedly dilated. No atrial septal defect or patent foramen ovale is seen by 2D, color Doppler or saline contrast with maneuvers (but cannot exclude; views are technically suboptimal). There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Overall left ventricular systolic function is normal (LVEF>55%). 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. Moderate (2+) mitral regurgitation is seen. The mitral regurgitation jet is eccentric. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion CT ABD: IMPRESSION: 1. No evidence of renal stones. 2. Allowing for limitations of study performed without IV oral contrast, bowel appears grossly unremarkable. No evidence of free air or free fluid within the abdomen. Brief Hospital Course: 52 year old female, cognitive impairment, history of OSA and COPD, pulm hypertension, found unresponsive on bed and febrile and concerning for infection/dehydration and decreased mental status of unclear etiology. #Mental status changes - Felt to be due to both hypotension and medication non-compliance Hypotension - Felt to be be due to adrenal crisis and DI Renal insuffiency - felt to be ATN due to hypotension OSA -will put pt back on CPAP at nite History of CHF-no evidence of CHF on admission CXR -will monitor O2 sats, I/O, daily wts Hypothyroid-continue on home dosage hypernatremia -2.6L free water deficit Patient appeared to be hypovolemic. Also has history of central DI and was to be on desmopression at home. This is likely in setting of non-compliance with DDAVP. WIll try to given back free water w/ D5 1/2 NS IVF. Anemia-chronic anemia - Last ferritin 26 in [**2-4**] was suggestive of iron defiency. Medications on Admission: Med (from last d/c summary): Outpatient Medications: Ranitidine HCl 150 mg DAILY Prednisone 20 mg DAILY Aspirin 81 mg Tablet Gabapentin 81 mg po qd Calcium 600 mg Tramadol 50 mg Famotidine 50 mg Potassium Chloride 20 mEq Furosemide 40 mg DAILY (per d/c summary but not on the list) Valsartan 160 mg DAILY (per d/c summary but not on the list) Levothyroxine 75 mcg DAILY (per d/c summary but not on the list) Desmopressin 0.1 mg [**Hospital1 **] (per d/c summary but not on the list) . Meds (per list from home) gabapentin 100 mg asa 81 mg calcium 600 tramadol 50 mg ranitidine 150 mg prednisone 20 mg famotidine 20 mg KCL 20 meq Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 2. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Desmopressin 0.1 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 5. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000) units Injection TID (3 times a day). 6. Prednisone 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Albuterol Sulfate 0.083 % Solution Sig: One (1) neb Inhalation Q6H (every 6 hours) as needed. 8. Ipratropium Bromide 0.02 % Solution Sig: One (1) puff Inhalation Q6H (every 6 hours). 9. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times a day). 10. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 11. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Valsartan 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Nystatin 100,000 unit/g Cream Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day). Discharge Disposition: Extended Care Facility: [**Location (un) 38**] Landing Discharge Diagnosis: Panhypopituitirism Adrenal Crisis Diabetes Insipidus Discharge Condition: Good Discharge Instructions: Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs. Adhere to 2 gm sodium diet Fluid Restriction: Followup Instructions: recheck TSH and FT4 2weeks, consider BMD

[ "253.5", "745.5", "428.0", "319", "255.4", "285.29", "253.2", "518.83", "244.9", "327.23", "401.9", "780.6", "V58.65", "584.5", "416.8", "493.20", "V15.81" ]

icd9cm

[ [ [] ] ]

[ "93.90", "38.93" ]

icd9pcs

[ [ [] ] ]

8629, 8686

5859, 6788

307, 338

8782, 8788

2780, 5836

8955, 8998

2345, 2349

7469, 8606

8707, 8761

6814, 6843

8812, 8932

2364, 2761

6867, 7446

251, 269

366, 1309

1331, 2162

2178, 2329

76,165

151,105

48279

Discharge summary

report

Admission Date: [**2116-9-12**] Discharge Date: [**2116-9-13**] Date of Birth: [**2053-4-14**] Sex: F Service: MEDICINE Allergies: Erythromycin Base / Lactose Attending:[**First Name3 (LF) 7333**] Chief Complaint: DOE Major Surgical or Invasive Procedure: None History of Present Illness: 63yo F w hx of HTN, s/p liver transplant w refractory afib/RVR on coumadin and amiodarone, recently hosp'd for afib [**2116-8-24**], and diagnosed by pcp with PNA on [**9-9**] (Rx: bactrim and doxy) as outpatient, admitted through ED with c/o increasing dyspnea, [**Location (un) **], 10 pound weight gain over 10 days. Denies CP. Failed cardioversion x 2 on last admission and Amiodarone loaded at time of discharge. Pt reports that she was in slow afib for 17days after discharge and self-converted on Friday [**9-4**]. 2 days later, she started to feel like she had "pneumonia without fever or cough" a/w DOE, [**Location (un) **], wt gain. Also reports nasal congestion, green post-nasal drip, headache, 1 week of loose stool. No sick contacts. She has been on oral [**Location (un) 621**] for pna vs sinus infection (rx'd by pcp) since Wed [**9-9**]. Low grade temps 99-100.0 over past week. Pt came to ED w worsening SOB that she attributes to the amiodarone. Of note, pt planned ablation for afib this Thursday [**9-17**] by Dr. [**Last Name (STitle) **]. . In the ED, vitals on intake 98.6 56 125/74 16 100%. She c/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] L>R and CTA obtained which was negative for PE. Labs: BNP is 950, trop<0.01, K 3.1 repleted to 4.0, INR 3.4. Given aspirin 325mg. Chest xray: minimal interstitial prominence/edema suggesting fluid overload. Not hypoxic. Pt admitted for CHF exacerbation and tune up prior to ablation. . On transfer to the floor, confirms 10days of DOE, [**Location (un) **], orthopnea (3 pillow), fatigue. +Weight gain from 143lb to 153lb on admission. Denies any CP or palpitations. She believes that these symptoms are related to the amiodarone and did not take it this AM. She also reports symptoms consistent with URI: dry cough, low grade fever, nasal congestion w green mucus, HA, and 1 week loose stool. . On review of systems, s/he denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias. 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 chest pain, or syncope or presyncope. Past Medical History: Liver transplant [**2095**], [**1-21**] primary biliary cirrhosis (vs. atresia-- records contradict) Paroxysmal Afib Hypertrophic cardiomyopathy, normal EF Ascending aortic aneurysm, 4.2 x 4.3 cm in [**3-28**] Hypertension Thyroid colloid cyst Stable Lung nodules Rosacea Retroperitoneal adenopathy Skin cancer Raynaud's syndrome Cellulitis of thumb and left lower extremity Keratosis on Left LE which has tract Hernia repair Portal shunt C-section Social History: distant smoker; denies ETOH and IVDU; married with two sons; elementary school social worker Family History: non-contributory Physical Exam: VS: 97.5 124/56 56 21 99/RA GENERAL: WDWN caucasian female appears anxious and tearful. Oriented x3. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple with normal JVP. 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. bibasilar crackles at lateral bases ABDOMEN: Soft, NTND. No HSM or tenderness. +BS all quadrants EXTREMITIES: No c/c. pitting edema to mid calves. SKIN: +Chronic venous stasis changes. No ulcers, scars, or xanthomas. PULSES: Right: Carotid 2+ DP 2+ Left: Carotid 2+ DP 2+ Pertinent Results: [**2116-9-12**] 06:30AM BLOOD WBC-3.9* RBC-4.51 Hgb-14.0 Hct-42.6 MCV-95 MCH-31.0 MCHC-32.8 RDW-14.7 Plt Ct-127* [**2116-9-13**] 07:05AM BLOOD WBC-3.5* RBC-4.32 Hgb-13.3 Hct-40.8 MCV-94 MCH-30.7 MCHC-32.5 RDW-14.8 Plt Ct-117* [**2116-9-12**] 06:30AM BLOOD Neuts-62.0 Lymphs-26.8 Monos-7.7 Eos-1.7 Baso-1.7 . [**2116-9-12**] 06:30AM BLOOD PT-33.9* PTT-34.6 INR(PT)-3.4* [**2116-9-13**] 07:05AM BLOOD PT-36.4* PTT-36.0* INR(PT)-3.8* . [**2116-9-12**] 06:30AM BLOOD Glucose-79 UreaN-11 Creat-0.7 Na-145 K-3.1* Cl-106 HCO3-30 AnGap-12 [**2116-9-13**] 12:50AM BLOOD UreaN-13 Creat-0.6 Na-141 K-3.2* Cl-104 HCO3-29 AnGap-11 [**2116-9-13**] 07:05AM BLOOD Glucose-83 UreaN-11 Creat-0.7 Na-143 K-3.5 Cl-105 . HCO3-28 AnGap-14 . [**2116-9-13**] 07:05AM BLOOD ALT-31 AST-41* LD(LDH)-278* AlkPhos-146* TotBili-0.8 [**2116-9-12**] 06:30AM BLOOD proBNP-950* [**2116-9-12**] 06:30AM BLOOD cTropnT-<0.01 [**2116-9-12**] 02:26PM BLOOD cTropnT-<0.01 . [**2116-9-12**] 06:30AM BLOOD Calcium-9.1 Phos-3.0 Mg-1.6 [**2116-9-13**] 12:50AM BLOOD Calcium-8.7 Phos-2.6* Mg-2.4 [**2116-9-13**] 07:05AM BLOOD Albumin-3.6 Calcium-8.9 Phos-3.1 Mg-2.0 [**2116-9-13**] 07:05AM BLOOD TSH-4.6* [**2116-9-13**] 07:05AM BLOOD tacroFK-10.1 . [**9-12**] LE dopplers FINDINGS: [**Doctor Last Name **]-scale and color Doppler son[**Name (NI) 867**] was performed of the bilateral common femoral and left-sided superficial femoral, popliteal and calf vessels. Vessels demonstrated normal flow, compressibility and augmentation. There is a prominent greater saphenous vein, which compresses normally. There is edema within the ankle. IMPRESSION: No DVT in the left lower extremity. Prominent, patent superficial vein. . Chest xray FINDINGS: Frontal and lateral views of the chest were obtained. Mild blunting of bilateral costophrenic angles persists, consistent with small bilateral pleural effusions. Mild diffuse prominence of the interstitial markings suggests minimal interstitial edema. Prominence of the ascending aorta persists. The cardiac silhouette remains enlarged. The aorta is calcified and tortuous. No new focal consolidation is seen. Surgical clips are noted in the midline of the upper abdomen. IMPRESSION: Small bilateral pleural effusions and minimal interstitial prominence/edema suggesting fluid overload. Stable enlargement of the cardiac silhouette. . CTA Chest FINDINGS: There is adequate opacification of the pulmonary arterial tree, with no filling defects identified to the subsegmental level to suggest pulmonary embolus. The main pulmonary artery is prominent, measuring 3.1 cm, which may reflect mild pulmonary hypertension. The ascending aorta is again dilated, measuring up to 4.3 cm, though this is stable from [**2116-3-23**]. The heart is enlarged. There is prominence of the right atrium, with reflux of contrast into the IVC, hepatic and azygous veins. There is no pericardial effusion. There are small bilateral simple pleural effusions, with associated atelectasis. There is minimal septal thickening. There is a subcentimeter per-carinal lymph node. The trachea and central airways are patent to the subsegmental level. The esophagus is normal. There is a small sliding-type hiatal hernia. The lung parenchyma is clear, without focal consolidation. There is no pneumothorax. There are no pulmonary nodules or masses. There is no acute abnormality identified in the visualized portion of the upper abdomen. The bones demonstrate no suspicious lytic or sclerotic osseous lesions. IMPRESSION: 1. No pulmonary embolus or acute aortic syndrome. No pneumonia. 2. Stable prominence of the ascending aorta, measuring up to 4.3 cm. 3. Findings compatible with mild interstitial pulmonary edema. The study and the report were reviewed by the staff radiologist. Brief Hospital Course: 63 yoF s/p liver transplant with refractory AFib/RVR s/p self-conversion on amiodarone presenting w DOE, orthopnea, [**Location (un) **], and PND. . # Dyspnea: Likely acute on chronic diastoic heart failure secondary to HTN induced LVH and hypertrophic cardiomyopathy, exacerbated by recent 17day run of atrial fibrillation. Chest xray and CTA suggestive of volume overload. PNA unlikely given lack of findings on chest xray, afebrile, no sputum/cough. URI symptoms likely unrelated to dyspnea - likely viral infection vs sinus infection. Trop <0.01 on admission - ACS unlikely. BNP 950. She was given diuresis with IV lasix 20mg IV boluses with good urine output. Her symptoms of DOE were relieved and LE swelling noticeably reduced. She was discharged on PO lasix. . #. Sinus infection: low grade temps at home and symptoms of URI. Started on outpt regimen: doxycyline and augmentin by pcp. [**Name10 (NameIs) **] [**Name11 (NameIs) 621**] do not prolong QT interval. She was continued on same [**Name11 (NameIs) 621**] regimen as inpatient for total of 10 day course to be cont'd after d/c. Afebrile during admission. Chest xray on admission not suggestive of pna. . #. ATRIAL FIBRILLATION with RVR: s/p 2 failed cardioversions at prior hospitalization and amiodarone loaded - now on 200mg daily. Self converted after building basal level on Friday [**9-4**]. Pt reporting malaise and attributing respiratory symptoms to antiarrhythmic. She was continued on amiodarone. Noted prolonged QTc on admission EKG but since attributed to amiodarone did not feel concerned for risk torsades given diffuse distribution QT prolongation per EP. cont amiodarone at discharge to be managed post-procedure on Thursday [**9-17**] by Dr. [**Last Name (STitle) **] as outpatient. . # prolonged QT: noted 491 on EKG from [**2116-8-23**] pre-amiodarone loading. Now w QTc 518 on admission EKG. QT prolongation meds include amiodarone, tacrolimus. Monitored lytes and repleted liberally in setting of diuresis. Pt monitored on telemetry and QTc staffed w EP who felt non-concerning [**1-21**] amiodarone. . # Anticoagulation: Patient's INR supertherpaeutic at 3.4 at time of admission. Likely increased [**1-21**] amiodarone therapy. Doses held during hospitalization and restarted at 2mg daiy (50% of what pt had been taking prior to admission). INR to be checked on Tues [**9-15**] as outpatient at [**Hospital 620**] [**Hospital 263**] clinic. . # s/p LIVER TRANSPLANT: Primary liver doctor is at [**Hospital 36653**] Clinic, Dr. [**First Name (STitle) **] at ([**Telephone/Fax (1) 13527**]. Dosing confirmed at prior hospitalization. Tacrolimus level checked daily and she was continued on prednisone and mycophenolate mofetil. . #. HTN: home regimen: atenolol, quinapril - continued. . ACCESS: PIV's . PROPHYLAXIS: -DVT ppx with supratherapeutic on coumadin -Pain management with prn tylenol (LIMIT 2g s/p transplant) -Bowel regimen with docusate . CODE: FULL CODE Medications on Admission: 1. Mycophenolate Mofetil 1500 mg [**Hospital1 **] (2 times a day). 2. Tacrolimus 1 mg Capsule Sig: One (1) Capsule PO Q12H 3. Atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Warfarin 4 mg Tablet Sig: One (1) Tablet PO once a day. 5. Amiodarone 200 mg Tablet daily 6. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID 7. Multivitamin 8. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Quinapril 40 mg Tablet Sig: One (1) Tablet PO twice a day. 10. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID 11. Magnesium Oxide 400 mg PO twice a day. Discharge Medications: 1. Mycophenolate Mofetil 500 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). 2. Tacrolimus 1 mg Capsule Sig: One (1) Capsule PO Q12H (every 12 hours). 3. Atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Quinapril 40 mg Tablet Sig: One (1) Tablet PO twice a day. 7. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Coumadin 2 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 10. Magnesium Oxide 400 mg Tablet Sig: One (1) Tablet PO twice a day. 11. Outpatient Lab Work Check INR on Tuesday [**2116-9-15**] at [**Hospital1 18**] [**Location (un) 620**] lab, fax result to [**Hospital **] [**Hospital3 **] and PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 3649**] Phone: [**Telephone/Fax (1) 3070**] Fax: [**Telephone/Fax (1) 18820**] 12. Senna 8.6 mg Tablet Sig: One (1) Tablet PO twice a day. 13. Furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 14. Doxycycline Hyclate 100 mg Capsule Sig: One (1) Capsule PO twice a day for 7 days. 15. Augmentin 875-125 mg Tablet Sig: One (1) Tablet PO twice a day for 7 days. Discharge Disposition: Home Discharge Diagnosis: Acute diastolic CHF Atrial fibrillation Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. [**Known lastname 101707**], It was a pleasure taking care of you at [**Hospital1 18**]. You were admitted to the hospital with shortness of breath, leg swelling, and your chest xray showed mild fluid overload of your lungs as well. Your chest xray did not show a pneumonia. We attribute your symptoms to acute heart failure of unknown reason although it is most likely that you were going in and out of afib in the last week which caused the excess fluid to build up in your body. Excess fluid was taken off your body with medication and you felt better. You should continue the amiodarone until directed to do otherwise by Dr. [**Last Name (STitle) **]. This medication will continue to build up to a level that will help optimize your conversion to normal rhythm after your procedure on Thursday. You were also continued on the oral antibiotic regimen started by your PCP as an outpatient for a sinus infection. Your coumadin was held given the elevated INR 3.8 (goal 2.0-3.0) which is due to the amiodarone and the antibiotics. Please continue the decreased dose of coumadin and start it tomorrow. Have your INR checked at [**Hospital1 18**] [**Location (un) 620**] lab and f/u the INR level with the [**Hospital3 **] on Tues [**2116-9-15**]. . The following changes were made to your medications: STARTED Lasix 40mg oral, daily DECREASED Coumadin 2mg daily, start tomorrow [**2116-9-14**] CONTINUE Augmentin 875mg twice daily until [**2116-9-19**] for a 10 day course CONTINUE Doxycycline 100mg twice daily until [**2116-9-19**] for a 10 day course Please continue all other home medications. . Please follow with your doctors as specified below. Followup Instructions: Please keep your appointment for your ablation this Thursday, [**9-17**]. You will schedule follow up with Dr. [**Last Name (STitle) **] after your procedure.

[ "486", "794.31", "E942.4", "V58.61", "790.92", "427.31", "441.2", "V15.82", "473.9", "443.0", "518.89", "401.9", "V58.65", "E942.0", "E941.2", "787.02", "402.91", "458.29", "428.0", "V10.83", "459.81", "425.4", "V42.7", "428.33" ]

icd9cm

[ [ [] ] ]

[ "37.24" ]

icd9pcs

[ [ [] ] ]

12700, 12706

7754, 10711

292, 299

12790, 12790

3971, 7731

14627, 14789

3153, 3172

11335, 12677

12727, 12769

10737, 11312

12941, 14604

3187, 3952

249, 254

327, 2553

12805, 12917

2575, 3026

3042, 3137

1,985

135,108

7612

Discharge summary

report

Admission Date: [**2108-2-20**] Discharge Date: [**2108-2-22**] Date of Birth: [**2026-5-18**] Sex: F Service: MEDICINE Allergies: Ace Inhibitors Attending:[**First Name3 (LF) 443**] Chief Complaint: shortness of breath Major Surgical or Invasive Procedure: - History of Present Illness: 81 year-old female with history of CAD s/p multiple MIs, CABG x4v [**2101**], LAD [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] 2 [**2104**], presented to OSH with SOB. Patient was found there to have a new lung mass and possible post obstructive pneumonia c/b tachycardia and chest pain. The patient was treated for her shortness of breath with nebs and developed chest discomfort. Pt described chest pain as band like tightening around chest radiating to both arms with no associated nausea or vomiting. Patient was given SL NTG, heparin gtt - became hypotensive, had continuing chest pain and was transferred to [**Hospital1 18**] for cardiac catheterization. . Cardiac review of systems was notable for absence of chest pain. Reported dyspnea on exertion (20 ft), 2 pillow orthopnea. Denied ankle edema, palpitations, syncope or presyncope. Past Medical History: 1. CAD s/p MI, CABGx4v [**2101**] (LIMA-LAD; VG-diag; VG2-OMs), PCI DESx2 LAD [**2104**] 2. Hypertension 3. Hypercholesterolemia 4. Diabetes mellitus type II 5. Ischemic cardiomyopathy - EF 35% 6. LBBB 7. Right carotid endarterectomy 8. osteomyelitis 9. s/p cataract surgery Social History: Soc Hx: widowed, 1.5 ppd tobacco x 50 yrs. Two daughters Family History: Non-contributory Physical Exam: GENERAL: NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. No xanthalesma. NECK: JVP of 8cm. CARDIAC: RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. LUNGS: Poor air movement at bases, diffuse wheezes ABDOMEN: Soft, NTND. No HSM or tenderness. EXTREMITIES: No c/c/e. PULSES: Right: DP 1+ PT 1+ Left: DP 1+ PT 1+ Pertinent Results: [**Known lastname **], [**Known firstname 247**] [**Hospital1 18**] [**Numeric Identifier 27774**]Portable TTE (Complete) IMPRESSION: Suboptimal image quality. Extensive left ventricular systolic dysfunction with severe systolic dysfunction. Elevated estimated PCWP. Moderate mitral regurgitation. Moderate pulmonary hypertension. Compared with the prior study (images reviewed) of [**2104-1-9**], the severity of mitral and tricuspid regurgitation have increased. . Radiology Report CHEST (PORTABLE AP) Study Date of [**2108-2-20**] 10:41 PM IMPRESSION: New right lung mass measures 5.5 x 4.8 cm. Recommend CT for further characterization. . [**2108-2-20**] 10:23PM BLOOD WBC-8.9 RBC-3.69* Hgb-11.3* Hct-33.8* MCV-92 MCH-30.7 MCHC-33.5 RDW-13.5 Plt Ct-305 [**2108-2-22**] 02:32AM BLOOD WBC-22.5* RBC-3.50* Hgb-10.7* Hct-32.4* MCV-93 MCH-30.5 MCHC-32.9 RDW-13.2 Plt Ct-292 [**2108-2-20**] 10:23PM BLOOD PT-12.3 PTT-30.3 INR(PT)-1.0 [**2108-2-20**] 10:23PM BLOOD Glucose-245* UreaN-62* Creat-1.9* Na-140 K-5.5* Cl-102 HCO3-25 AnGap-19 [**2108-2-22**] 02:32AM BLOOD Glucose-118* UreaN-68* Creat-1.8* Na-141 K-5.1 Cl-102 HCO3-29 AnGap-15 [**2108-2-20**] 10:23PM BLOOD ALT-23 AST-18 CK(CPK)-98 AlkPhos-81 TotBili-0.2 [**2108-2-22**] 02:32AM BLOOD CK(CPK)-157 [**2108-2-20**] 10:23PM BLOOD CK-MB-5 cTropnT-0.02* [**2108-2-21**] 02:25PM BLOOD CK-MB-13* MB Indx-7.6* cTropnT-0.05* [**2108-2-22**] 02:32AM BLOOD CK-MB-10 MB Indx-6.4* cTropnT-0.04* [**2108-2-21**] 01:39PM BLOOD Type-ART pO2-69* pCO2-56* pH-7.27* calTCO2-27 Base XS--1 Intubat-NOT INTUBA [**2108-2-22**] 01:59AM BLOOD Type-ART pO2-318* pCO2-74* pH-7.26* calTCO2-35* Base XS-3 [**2108-2-21**] 03:13PM BLOOD Lactate-1.4 [**2108-2-22**] 01:59AM BLOOD Lactate-0.8 K-5.0 Brief Hospital Course: Ms. [**Known lastname 2031**] was an 81 year old woman with history of CAD s/p multiple MIs, CABG 4v, presented to outside hospital with new lung mass, post obstructive pneumonia, who subsequently developed chest pain after albuterol nebulization treatment and was transferred to [**Hospital1 18**] Cardiac Intensive Care Unit for concern of acute coronary syndrome. #Hypoxic respiratory failure: Patient was hemodynamically stable on presentation to the CCU, requiring 4L O2 by NC. CXR showed a likely large lung mass in the right lung field. An ABG showed the patient had a large A-a gradient. The patient had intermittend hypoxic episodes that became increasingly frequent associated with chest pain. There was concern for PE, and heparin was started. Antibiotics were started as well for a post-obstructive pneumonia. Lasix was given for possible CHF exacerbation, and nebulizers and methylprednisolone was given for possible COPD exacerbation. Despite these measures, the patient however continued to deteriorate rapidly and she became delirious. The family was [**Name (NI) 653**], who indicated that the primary goal of the patient and the family was comfort. A family meeting was held, and the patient all interventions with the exception of comfort measures were discontinued. A morphine drip was started, and the patient expired on [**2108-2-22**] at 3:15pm. Medications on Admission: 1. Albuterol 90mcg INH q4H PRN 2. Amlodipine 10mg PO DAILY 3. Clopidogrel 75mg PO DAILY 4. Digoxin 0.125mg PO DAILY 5. Ezetimibe/Simvastatin 10/10mg PO DAILY 6. Fluticasone-salmeterol dosage unknown 7. Folic Acid 1mg PO DAILY 8. Furosemide 40mg PO BID 9. Glyburide 2.5mg PO DAILY 10. Ipratropium-albuterol 18 mcg-103 mcg INH PRN 11. Lisinopril 5mg PO DAILY 12. Metoprolol succinate 100mg PO BID 13. Pravastatin 80mg PO BID 14. Aspirin 325mg PO DAILY 15. Albuterol-ipratropium dose unknown INH PRN 16. Nitroglycerin 0.4mg/hr 1 patch TD PRN Discharge Medications: None Discharge Disposition: Expired Discharge Diagnosis: - Discharge Condition: Expired Discharge Instructions: None Followup Instructions: - Completed by:[**2108-2-23**]

[ "414.8", "250.00", "585.9", "403.90", "V45.81", "412", "485", "428.0", "162.3", "272.0", "428.31", "518.81", "276.7", "426.3", "305.1", "491.21" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

5754, 5763

3755, 5136

294, 298

5809, 5819

1995, 3732

5872, 5905

1579, 1597

5725, 5731

5784, 5788

5162, 5702

5843, 5849

1612, 1976

235, 256

326, 1189

1211, 1487

1503, 1563

13,891

143,903

918

Discharge summary

report

Admission Date: [**2115-1-21**] Discharge Date: [**2115-1-23**] Service: MEDICAL ICU/[**Hospital1 212**] HISTORY OF PRESENT ILLNESS: The patient is an 83 year-old white male with a history of large left sided lung mass who recently had a biopsy who presented with mental status changes and vomiting followed by hypoxemia. He had a biopsy of his lung mass on [**2115-1-18**]. On the day prior to admission the patient complained of pain at his biopsy site, which is controlled with Percocet. On the morning of admission he developed a fever to 101.7 degrees Fahrenheit rectally. His O2 sats were 90% on 2.5 liters nasal cannula. A chest x-ray revealed left upper lobe and right lower lobe infiltrates and the patient was started on Levofloxacin for presumed pneumonia. Later that day he gradually became more lethargic and required more pain medication. After the one episode of vomiting the patient's O2 sats fell to the 80s on 2.5 liters per minute nasal cannula and he was 92% on 8 liters of nasal cannula. He was then transferred to the [**Hospital1 1444**] for further management. On arrival the patient required 100% nonrebreather face mask to keep his O2 sats in the high to mid 90s. A chest x-ray revealed left lower lobe collapse and consolidation with an additional infiltrate around the mass and a moderate sized left pleural effusion. He was given a dose of Levofloxacin and Flagyl in the Emergency Department. Arterial blood gas on a nonrebreather mask revealed pH at 7.2 on oxygen, CO2 of 80 and oxygen of 125. A trial of BIPAP was attempted, however, the patient could not tolerate the mask. He was then placed back on a nonrebreather with almost identical arterial blood gas of 7.20, 79, and 125. The MICU team was then called to evaluate the patient. PAST MEDICAL HISTORY: 1. Chronic obstructive pulmonary disease on 2 liters nasal cannula at home. Pulmonary function tests in [**2107**] showed an FEV of 0.62, FVC of 1.3 and FEV/FVC of 45%. 2. Peripheral vascular disease status post right femoral popliteal bypass graft. 3. Coronary artery disease status post percutaneous transluminal coronary angioplasty and myocardial infarction. 4. Hypertension. 5. Type 2 diabetes. 6. Benign prostatic hypertrophy status post transurethral resection of the prostate. 7. Depression. 8. Essential tremor. 9. Bladder cancer. 10. Benign positional vertigo. 11. Lung cancer metastatic to the liver. Recent biopsy performed with biopsy results pending. ALLERGIES: Sulfa rash. MEDICATIONS ON ADMISSION: Heparin, Tylenol #3, aspirin, Lactulose, Fluoxetine, Isosorbide mononitrate, Imdur, Lisinopril, Fluticasone, Atrovent, Albuterol, Senna and Colace. HOSPITAL COURSE: The [**Hospital 228**] hospital course was complicated by his continued respiratory distress. The patient continued to request no invasive measures including no intubation, no resuscitation and no chest tube placement. Essentially the patient wanted to die peacefully and not have any invasive measures done to sustain his life. At that point the patient was transferred to the MICU to the medical floor. He continued to have respiratory decline and was eventually unresponsive and made comfort measures only by his family whose daughter [**Name (NI) 4051**] [**Name (NI) 6203**] who is his health care proxy. The patient passed on [**2115-1-23**] at around 5:00 p.m. He died of respiratory failure secondary to lung cancer secondary to pneumonia. The patient's family declined a post mortem examination. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 4263**] Dictated By:[**Doctor Last Name 6204**] MEDQUIST36 D: [**2115-1-24**] 10:01 T: [**2115-1-24**] 10:23 JOB#: [**Job Number 6205**]

[ "491.21", "507.0", "412", "511.9", "197.7", "518.81", "401.9", "250.00", "162.8" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

2546, 2695

2713, 3790

144, 1793

1815, 2519

45,213

149,134

34659

Discharge summary

report

Admission Date: [**2106-2-17**] Discharge Date: [**2106-3-1**] Date of Birth: [**2064-7-4**] Sex: F Service: CARDIOTHORACIC Allergies: Penicillins / Aspirin / Motrin / Tylenol / Codeine / Plavix / Percocet / Zofran / Morphine / Optiray 320 / Visipaque / Tramadol / Ketorolac / Metoclopramide Attending:[**First Name3 (LF) 922**] Chief Complaint: Chest pain and dyspnea Major Surgical or Invasive Procedure: [**2106-2-17**] 1. Drainage of Pericardial Effusion. 2. Right atrial exploration. 3. Cardiopulmonary resuscitation. 4. Pulmonary artery exploration. History of Present Illness: This is a 41 year old female with recurrent pericardial effusion & tamponade of unknown etiology presents with acute onset chest pain and dyspnea. EMS noted her to be hypertensive to 250/109 and in CHF by exam. In ED, EKG & enzymes were (-) for ischemia, and she was diuresed with symptomatic improvement prior to admission to the floor with SaO2 97% on 4L O2. Chest CTA contraindicated due to severe dye reaction and she was started empirically on a heparin gtt in ED but d/c'd this am. Patient has a previous history of recurrent PE despite IVC filter and describes her presentation as similar to these prior episodes. She was recently admitted to [**Hospital1 18**] for the same symptoms and a chronic pericardial effusion, present since [**2105-1-14**] but not hemodynamically significant until an echo performed on [**2-3**] demonstrated tamponade physiology. She underwent a pericardiocentesis on [**2-3**] and ~400cc of sterile transudative fluid was drained with significant improvement of her symptoms. She was subsequently discharged on [**2-7**]. Her orthopnea resumed within 36hrs post discharge and progressed until her presentation last night which was precipitated by the acute, non-radiating chest pain. Past Medical History: # DM type I - since age 12 # CAD s/p NSTEMI - recent cath [**3-/2304**] at [**Hospital1 2177**] w/ 50% LCX lesion, 40% RCA lesion (though original reports not available) # Migraines # HTN # ? of TIA # h/o PE in [**4-/2104**], [**7-/2104**] at [**Hospital 1474**] Hospital - s/p IVC filter in [**4-/2104**] but date unclear (? [**2104-4-28**]). # [**Name2 (NI) **]onic chest pain: Patient also had multiple admissions for chest pain at [**Hospital1 18**], [**Hospital1 2177**] and other hospitals with chest pain of undiagnosed etiology (not PE-related) # Hyperlipidemia # Erosive Gastritis # Gastroparesis # h/o dCHF - ? flash pulm edema [**8-/2104**] normal ECHO in [**1-/2105**] # s/p ccy [**2104-5-3**] # s/p ovarian cyst removal in [**2097**] - c/b staph infection - was a 3 month hospitalization # anemia - s/p several transfusions, dates back to [**2099**] # Rentinal Hemmorahge w/ initation of laser treatment Social History: She is married and lives with her husband [**Name (NI) 6409**]. She is on disability due to her diabetes. She previously worked as a pharmacist. She denies any tobacco use or EtOH use ever. She does not have any children but did have one spontaneous miscarriage at 2 months in [**2097**]. Family History: Father has a history of MI, is s/p 4V CABG, and has a pacer. Her mother died at age 56 of cardiac arrest. She also had DM and was on dialysis. Her mother's dialysis line was "blocked" and during the attempt to clear the blockage, she arrested and died. She has one sister who is in good health. A paternal uncle had a blood clot to his heart and died. She has one cousin who died of a stroke at age 47. She does not know any medical history about her grandparents on either side. Physical Exam: Pulse: 87 Resp: 20 O2 sat: 100/4L BP Right: 138/54 Height: Weight: 108.4 kg General: Skin: Dry [] intact [x] HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] (-)carotid bruits Chest: Lungs (+)bilateral expiratory wheezes (+)basilar rales Heart: RRR [x] III/VI SEM at LUSB, (-)pericardial rub Abdomen: Soft [x] non-distended [x] non-tender [x] Extremities: Warm [x], well-perfused [x] 2+ pitting edema Neuro: Grossly intact Pulses: PT [**Name (NI) 167**]: + Left: + Radial Right: + Left: + Pertinent Results: [**2106-2-17**] Intraop TEE Pre-CPB: Before the pericardium was opened: The RV is full and failing with global severe hypokinesis. There is a small pericardial effusion, measuring less than 1 cm. There is no collapse of the RV or RA. The LV is underfilled. There is clot on the end of the CVP catheter. There is a question of clot in the right atrium with extension into the left atrium. There are periods of obvious open cardiac massage with good ejection of blood from an otherwise near-asystolic heart. [**2106-2-17**] Intraop TEE Post-CPB: The patient is on low dose Epi which was quickly weaned, and low dose Milrinone and is in SR. There is good biventricular systolic fxn. No MR, no TR, no AI. Aorta intact. [**2106-2-17**] LENIS: 1. No evidence of DVT within the lower extremity vessels. [**2106-2-18**] Head CT Scan: 1. Limited study secondary to motion artifact. Questionable area of hypodensity within the left centrum semiovale. 2. Focal hypodensity in the region of the right choroidal fissure, unchanged from the most recent prior study. Differential diagnosis includes a choroidal fissure cyst versus a prominent perivascular space. [**2106-2-19**] Head CT Scan: 1. No evidence of acute intracranial hemorrhage or edema. 2. Improved paranasal sinus opacification. Brief Hospital Course: Mrs. [**Known lastname **] was initially admitted under cardiology with recurrent pericardial effusion. Given signs of early cardiac tamponade by echocardiogram, cardiac surgery was urgently consulted for pericardial window, and she was urgently brought to the operating room. Upon induction of anesthesia, the patient became hypotensive and had a cardiac arrest. The patient was therefore resuscitated. CPR was initiated with compressions to the sternum but the sternum was quickly opened and internal cardiac massage was performed. The patient was systemically anticoagulated and placed on partial cardiopulmonary bypass. For further surgical details, please see dictated operative note. Following the operation, she was brought to the CVICU for invasive monitoring. On postoperative day one, she was initially unresponsive with flaccid extremities. The stroke service was consulted and head CT scan was performed which showed no acute pathology - see result section for details. Over the next 24 hours, her neurological exam greatly improved. Repeat head CT scan was negative for acute infarct. Given continued clinical neurological improvements, she was extubated without incident on postoperative day two. Her CVICU course was otherwise uneventful and she transferred to the SDU on postoperative day four. Warfarin anticoagulation was resumed for hypercoaguable state. Blood pressure was well controlled on Lopressor and Norvasc. She did require Dilaudid for adequate pain control. She had sternal drainage which had improved but was started on Ciprofloxacin for a open groin incision, whcih was healing well at the time of discharge. On post operative day # 12 she had a therapuetic INR on coumadin and was to be continue with lifetime anticoagulation for history of deep vein thrombosis. Her lantus was titrated down with low blood sugars. She had adequate pain control and was felt safe to transfer to rehab at this time. Medications on Admission: Medications at home: Citalopram 20, Clonazepam 0.5, Metoprolol 25'', Coumadin 5, Lasix 40, Lantus 60 hs, Lispro SS, Colchicine 0.6, Pravastatin 20 Discharge Medications: 1. Outpatient Lab Work INR will be followed by the [**Location (un) 76489**] [**Hospital **], as it was pre-operatively. INR goal for pulmonary embolism is [**3-10**]. INR should be drawn on [**2106-3-3**] with results called to [**Telephone/Fax (1) 10413**]. 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*1* 3. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*1* 4. Pravastatin 20 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). Disp:*30 Tablet(s)* Refills:*1* 5. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*1* 6. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:*90 Tablet(s)* Refills:*2* 7. Warfarin 5 mg Tablet Sig: One (1) Tablet PO ONCE (Once): INR goal for pulmonary embolism is [**3-10**]. Disp:*30 Tablet(s)* Refills:*2* 8. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 9. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 10 days. 10. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 10 days. 11. Ferrous Sulfate 300 mg (60 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO every six (6) hours as needed for pain for 1 months. 14. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 15. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO ONCE (Once) for 1 doses: Dose for [**3-2**]. 16. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO once a day: Take as directed for goal INR [**3-10**]. 17. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day: Start after twice a day lasix course is completed. 18. Insulin Glargine 100 unit/mL Solution Sig: 12 units Subcutaneous at bedtime. Discharge Disposition: Extended Care Facility: [**Hospital6 79490**] Discharge Diagnosis: Pericardial Tamponade/Cardiac arrest History of Pulmonary Embolism Diabetes Mellitus Type I Hypertension Discharge Condition: Alert and oriented x3 nonfocal Ambulating, gait steady Sternal pain managed with percocet prn Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming, and look at your incisions Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month until follow up with surgeon No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] Females: Please wear bra to reduce pulling on incision, avoid rubbing on lower edge Followup Instructions: Please call to schedule appointments Surgeon Dr. [**Last Name (STitle) 914**] in 4 weeks [**Telephone/Fax (1) 170**] [**3-30**] at 1:30 PM Primary Care Dr. [**First Name (STitle) **] [**Name (STitle) **] [**Doctor Last Name **] in [**2-6**] weeks [**Telephone/Fax (1) 9251**] Cardiologist Dr. [**Last Name (STitle) **] in [**2-6**] weeks Wound check appointment - [**Hospital Ward Name 121**] 6 ([**Telephone/Fax (1) 3071**]) - your nurse will schedule INR will be followed by the [**Location (un) 76489**] [**Hospital **], as it was pre-operatively. INR goal for pulmonary embolism is [**3-10**]. INR should be drawn on [**2106-3-3**] with results called to [**Telephone/Fax (1) 10413**]. ***ANTICIPATED LENGTH OF STAY < 30 DAYS***** Completed by:[**2106-3-1**]

[ "428.0", "E878.8", "427.5", "403.90", "799.02", "585.9", "V12.51", "250.61", "285.9", "536.3", "V64.1", "428.32", "E849.7", "423.9", "997.1", "423.3" ]

icd9cm

[ [ [] ] ]

[ "37.0", "38.93", "39.61", "38.05", "99.60" ]

icd9pcs

[ [ [] ] ]

9521, 9569

5460, 7395

443, 594

9718, 9814

4152, 5437

10438, 11205

3108, 3589

7593, 9498

9590, 9697

7421, 7421

9838, 10415

7442, 7570

3604, 4133

381, 405

622, 1844

1866, 2785

2801, 3092

44,255

154,621

39605

Discharge summary

report

Admission Date: [**2145-9-27**] Discharge Date: [**2145-10-11**] Date of Birth: [**2074-3-4**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**Doctor First Name 3290**] Chief Complaint: Small bowel obstruction & sepsis [**1-26**] pneumonia Major Surgical or Invasive Procedure: None History of Present Illness: This is a 71 year old male with history of severe PD, mild cognitive impairment, COPD and HTN who presents with 12 hours of abdominal pain and vomiting of 1000cc of black emesis. He was in his USOH until one day PTA when he complained of some abdominal pain and lack of appetite. Later that night he was discovered to have black (coffee ground?) emesis on his chest. He was brought to an OSH where there were no ICU beds available, and transferred to [**Hospital1 18**]. On arrial O2 sat was 85% RA, he was in some respiraory distress, lactate was 4.7, creatinine 2.6, normal wbc with 48% bands, BCx taken, EKG done, CT scan of the abdomen without contrast was performed, he was intubated for CT scan then extubated. Final read of CT scan showed small bowel obstruction. Also had a patchy opacity at the right base. Given Cefepime, Vanco and Flagyl. Received 4mg IV morphine. He was given IV PPI for UGIB. Surgery evaluated the patient and diagnosed him with small bowel ischemia. The patient's daughter and daughter in law are both physicians, understood his poor prognosis and made the pt [**Name (NI) 3225**]. Several hours later upon learning of the final radiology read of the CT abdomen which did not see evidence of bowel ischemia, the family wanted the patient to be reassessed and code status was reversed. After much discussion with the surgical team, medical team, and medical ICU team, the family had decided to opt for medical management, and forgo future surgical procedures. He was made DNR/DNI with the plan to observe him for improvement in the ICU. Past Medical History: HTN Severe Parkinson's Disease COPD Depression Anxiety Hip replacements bilaterally Mild cognitive decline B12 deficiency Hx lacunar infarcts on imaging No hx abdominal surgery Social History: Recently arrived from [**Country 9819**]. Daughter [**Name (NI) 87395**] is an internal medicine physician from [**Country 9819**] who has not practiced since arriving in the US. Son-in-law is a practicing physician in US. Schooled in [**Location (un) **]; fluent in English. Does not smoke or drink alcohol. Family History: Noncontributory. Physical Exam: Tmax: 38.6 ??????C (101.4 ??????F) Tcurrent: 38.3 ??????C (101 ??????F) HR: 101 (98 - 112) bpm BP: 105/54(70) {71/40(51) - 108/54(71)} mmHg RR: 28 (18 - 34) insp/min SpO2: 96% Gen: responsive to name, spontaneous eye opening, in some distress HEENT: MMM Lungs: Decreased breath sounds at bases bilaterally, transmitted upper airway sounds, has mild expiratory wheezes at midnight but none appreciate this AM. Cor: Heart sounds distant, tachycardic, normal rhythm, no m/r/g Abd: Rare hypokinetic bowel sounds, distended but not taught, no rebound appreciated. Ext: Warm, was diaphoretic on admission. 2+ peripheral pulses throughout. Pertinent Results: Initial ([**9-27**]) WBC 9.6 Hb 15.9 Hct 48.3 Plts 268 48% bands INR 1.2 144 109 40 -------------------< 80 4.6 22 2.0 LFTs wnl Ca 7.1 Phosphate 2.8 Mg 1.8 Lactate 7.3 (up from 4.7 on admission) UA: [**2-26**] hyaline casts, 2+ bilirubin Lactate 7.3 Second septic episode ([**10-5**]) WBC 20.0 Hb 10.7 Hct 31.5 Plts 213 Peaked at 13% bands ([**10-4**]) 134 98 33 4.0 24 2.0 Alb 2.3 Lactate peak 5.2 (on [**10-4**]) MICRO: [**9-27**] BCx: negative [**9-27**] MRSA screen: negative [**9-28**] BCx: negative [**9-29**] Cdiff: negative [**10-1**] Hpylori: negative [**10-1**] UCx: negative [**10-3**] BCx: no growth to date [**10-3**] UCx: negative [**10-4**] UCx: negative [**10-5**] Cdiff: negative [**10-8**] Cdiff: negative IMAGING: [**9-27**] CXR: The lungs are clear. Trace left pleural effusion is noted. There is no pneumothorax. Heart size is normal. There is tortuosity of the thoracic aorta with atherosclerotic calcification. The mediastinal silhouette is otherwise unremarkable. Hilar contours and pulmonary vasculature are normal. Nasogastric tube follows a normal course projecting over the left upper abdomen but the distal end is not visualized. [**9-27**] CT abd/pelvis: 1. Multiple dilated fluid-filled loops of small bowel with fecalization. Limited evaluation, but no definite evidence of pneumatosis. No definite transition point, although the bowel tapers in the right mid abdomen. Findings suggest small-bowel obstruction. No confirmatory signs of bowel ischemia (wall thickening/pneumatosis) identified within confines of noncontrast enhanced CT. 2. Patchy opacity at the right lung base could represent aspiration or infection. 3. Compression deformity of the L4 vertebral body, likely chronic. 4. Atherosclerotic disease in the coronary arteries and abdominal aorta. [**9-29**] KUB: 1. Nonspecific mild bowel dilation are improved compared to prior. However, persistent small-bowel obstruction cannot be definitively excluded. 2. Enteric tube with tip overlying the stomach. [**10-5**] CT torso: 1. Interval worsening of bibasilar opacities with development of small bilateral pleural effusions. This is suggestive of worsening pneumonia, possibly related to underlying aspiration. Some scattered pulmonary nodules are noted, which should be followed up in [**6-5**] months given size and underlying moderate centrilobular emphysema. 2. Resolved small-bowel obstruction with normal appearance to the bowel. 3. Atherosclerotic disease involving the aorta with dense calcification of the coronary arteries. 4. Bilateral gynecomastia of unclear etiology. [**10-9**] CXR: Rotated positioning. An NG type tube is in place, tip extending beneath the diaphragm. There is a small left effusion with left lower lobe collapse and/or consolidation, similar to [**2145-10-8**]. The effusion may be slightly larger. Again seen is atelectasis in the right cardiophrenic region. No CHF or right-sided effusion is identified. Ununited right clavicular fracture again noted. DISCHARGE LABS: [**2145-10-10**] 05:08AM BLOOD WBC-16.4* RBC-2.97* Hgb-8.4* Hct-25.1* MCV-84 MCH-28.1 MCHC-33.3 RDW-15.7* Plt Ct-250 [**2145-10-10**] 05:08AM BLOOD Plt Ct-250 [**2145-10-10**] 05:08AM BLOOD Glucose-133* UreaN-35* Creat-2.0* Na-136 K-3.6 Cl-97 HCO3-35* AnGap-8 [**2145-10-10**] 05:08AM BLOOD Calcium-7.3* Phos-3.2 Mg-1.9 Brief Hospital Course: Mr. [**Known lastname **] is a 71yo man with advanced Parkinson's Disease, HTN and COPD who presented with small bowel obstruction and sepsis, then developed a pneumonia from which he did not recover. . # Abdominal pain: CT scan on admission indicated ischemic bowel initially, but hten was confirmed to be a small bowel obstruction. It was decided to be managed medically. It resolved after suction NGT decompression and being held NPO for 24 hours. He put out a large quantity of liquid stool which was guaiac negative and c diff toxin was negative. He tolerated tube feeds during the hospitalization and SBO eventually resolved. Pt's tube feeds were eventually discontinued after a discussion with family regarding pt's goals of care. . # Sepsis: Pt had an elevated lactate which trended down quickly with IVF and antibiotics. He was started on vanc/cefepime/metronidazole for a presumed abdominal infection and microperforation. He received 12L fluid over the first 24 hours of hospitalization. He was hypotensive and managed with pressors peripherally for his first 12 hours on the floor, at which point he was weaned and he continued to improve. His lactate and WBC trended down eventually. Antibiotics were narrowed to vanc/unasyn for presumed intraabdominal infection. On HD#10 however he became newly septic; a CT scan suggested aspiration pneumonia and showed no abdominal processes. He was then empirically treated with vanc/cipro/zosyn for a hospital acquired pneumonia. His lactate increased to 5.2 and he had a 9% bandemia. His blood pressure was tenuous over 48 hours but he did not require pressors. His clinical status did not improve in spite of the antibiotcis. After discussion with family regarding goals of care at this point, antibiotics were discontinued. . # Hypoxia: After sepsis and the SBO resolved, pt was noted to have large amounts of secretions which required frequently suctioning and nursing attention. Pt has O2 desaturations to 70-80% on room air. He is currently satting well on 50% face mask. His CHF required diuresis when he was not receiving fluid resuscitation for hypotension. He received IV doses of lasix as needed. . # Mental status change: Pt was agitated, anxious and nonverbal for the first two days of hospitalization, after which his agitation resolved. The family indicated his mental status was improving. However, during the second septic episode he became minimally responsive. His mental status has not recovered. It is likely multifactorial, but most likely a toxic-metabolic encephalopathy vs. Parkinson's related dementia. Ammonia levels, LFTs, and other lab testing did not reveal a reversible etiology. . # Parkinson's disease: Pt recently was brought to the US by his family for evaluation of his parkinson's disease. His pre-admission regimen included Bromocriptine, Amantadine and Ropinorole. A neurology consultation was pursued and they recommended beginning Sinemet, which the pt was receiving through the NG tube. However, once the artificial feeds were discontinued, pt was not receiving the medication. Pt was also maintained on IV Valproate for myoclonic jerks. Pt was switched to IV Keppra 250mg [**Hospital1 **] in preparation for discharge as IV valproate not available on LTAC formulary. . # [**Last Name (un) **]. Pt's creatinine on presentation was 2.0, and decreased to 0.8 over the first several days of hospitalization. During his second septic episode, his creatinine spiked to 2.2. Although a FENa was suggestive of a prerenal cause, ATN was favored due to lack of response to fluids. Cr improving slowly on discharge to 2.0. . # HTN: Pt's hypertensive regimen was held throughout his hospitalization, except Lasix that was used in IV form to manage his volume overload state. Lasix was eventually discontinued after discussion with family regarding goals of care. . # GIB: Initial NGT suctioning was guaiac positive and his hct dipped slightly at admission. However, it quickly stabilized at 35. This was thought to be either due to some luminal bleeding at site of SBO or due to gastric irritation/tears with retching. A workup demonstrated a positive H pylori antibody, however, treatment was deferred regarding given poor clinical prognosis. . # Code status: Pt was initially full code, then transitioned to DNR/DNI given sepsis and poor recovery in the ICU. After transfer to the floor, a family meeting was held to discuss overall goals of care in the setting of pt's unresponsiveness and poor prognosis. Family confirmed that pt is [**Name (NI) 3225**]. Pt's daughter and son-in-law were present at the meeting and later discussed the decision with wife. Family did enquire about possibility of resuming tube feeds for nutrition, however, after hearing that it would not improve pt's chances for full recovery, they agreed not to pursue it. Medications on Admission: Amantadine Bromocriptine Norvasc Aldactone Plavix PPI Risperdal Citalopram Valproic Acid (500mg qAM 750 qHS) daily for myoclonus Discharge Medications: 1. carbidopa-levodopa 25-100 mg Tablet Sig: One (1) Tablet PO TID (3 times a day): OK to hold if unable to tolerate po. 2. scopolamine HBr 0.25 % Drops Sig: One (1) Drop Ophthalmic QID (4 times a day). 3. scopolamine base 1.5 mg Patch 72 hr Sig: One (1) Patch 72 hr Transdermal EVERY 3 DAYS (Every 3 Days). 4. hyoscyamine sulfate 0.125 mg Tablet, Sublingual Sig: One (1) Tablet, Sublingual Sublingual QID (4 times a day). 5. morphine 5 mg/mL Solution Sig: One (1) Injection Q2H (every 2 hours) as needed for shortness of breath, discomfort. 6. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed for wheezing. 7. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q2H (every 2 hours) as needed for wheezing. 8. acetylcysteine 20 % (200 mg/mL) Solution Sig: One (1) ML Miscellaneous Q6H (every 6 hours) as needed for secretions in lung. 9. Keppra 500 mg/5 mL Solution Sig: Two [**Age over 90 1230**]y (250) mg Intravenous twice a day. 10. pantoprazole 40 mg Recon Soln Sig: Forty (40) mg Intravenous once a day. Discharge Disposition: Extended Care Facility: [**Hospital1 700**] - [**Location (un) 701**] Discharge Diagnosis: Primary Diagnosis: Small bowel obstruction [**Hospital **] Healthcare-associated pneumonia Parkinson's Disease Discharge Condition: Level of Consciousness: Lethargic and not arousable. Occasionally opens eyes however nonverbal and unresponsive. Activity Status: Bedbound. Discharge Instructions: Dear Mr. [**Known lastname **], . It was a pleasure taking care of you here at [**Hospital1 18**]. You were admitted for abdominal pain, vomiting, and distention, which was caused by a small bowel obstruction. With decompression of your bowels and bowel rest, your obstruction resolved without the need for surgical intervention. . Meanwhile, you developed a serious infection, likely aspiration pneumonia given that you are unable to clear your secretions. In spite of broad spectrum IV antibiotics, you deteriorated clinically and your mental status did not recover. Antibiotics and other medications were eventually discontinued, while other measures were started to ensure comfort. You were then discharged to another facility where your comfort-focused care will be continued. . The following changes were made to your medication regimen: #. STOP Amantadine and Bromocriptine, per Neurology #. Sinemet was started for Parkinson's, however, you are not able to tolerate anything mouth currently. If he regains swallowing capacity, it can be given. #. The rest of your home medications are also on hold because you are not able to tolerate anything by mouth. # START scopolamine eye drops, scopolamine patch and hyoscyamine sublingual tablets to help control secretions # START morphine 5 mg IV every 2 hours as needed for shortness of breath, discomfort # CHANGE your home valproate tablets to Keppra (leviteracitam) 250mg IV every 12 hours # START ipratropium, albuterol and acetylcysteine treatments as needed for wheezing Followup Instructions: If leaves LTAC, follow up care can be arranged by Hospice.

[ "401.9", "437.9", "V12.54", "V66.7", "486", "584.9", "V49.86", "038.9", "578.0", "507.0", "311", "518.82", "332.0", "349.82", "300.00", "V43.64", "276.3", "995.91", "790.29", "331.83", "560.9" ]

icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

12760, 12832

6598, 11464

370, 376

12986, 13128

3219, 6238

14710, 14772

2531, 2549

11643, 12737

12853, 12853

11490, 11620

13152, 14687

6254, 6575

2564, 3200

277, 332

404, 1985

12872, 12965

2007, 2185

2201, 2515

68,651

122,672

42798+58556

Discharge summary

report+addendum

Admission Date: [**2103-4-3**] Discharge Date: [**2103-4-17**] Date of Birth: [**2025-11-20**] Sex: F Service: CARDIOTHORACIC Allergies: morphine / Oxycodone Attending:[**First Name3 (LF) 1505**] Chief Complaint: chest pain Major Surgical or Invasive Procedure: left heart cardiac catheterization Coronary Artery Bypass x 3 (LIMA-LAD, SVG-diagonal, SVG-OM) [**2103-4-10**] History of Present Illness: 77 year old female has a cardiac history notable for a remote MI in [**2071**]. She had been doing well from a cardiac standpoint over the years until about 3 weeks ago when she started to notice exertional chest burning. She describes chest burning with activity such as climbing stairs. More recently, she has also had a few episodes of chest pain occurring at rest that have woken her from sleep and lasted for 10 minutes. She was referred to cardiology and had a nuclear stress test done that was notable for lateral ischemia. She was then referred for a cardiac catheterization and was found to have coronary artery disease and is now being referred to cardiac surgery for revascularization. Past Medical History: CAD PMH: MI [**2071**]-age 45; had a temporary pacemaker/? arrest per pt description. asthma-not a current issue back pain skin cancer gout hypertension hyperlipidemia hyperthyroidism s/p radioactive iodine lumbar disc disease osteoporosis bladder cancer ->diagnosed 3 years ago s/p direct bladder treatment; followed by [**Last Name (un) **]/[**Hospital3 **]/[**Hospital1 **]. hx of falls, uses a cane PRN TIA Past Surgical History: c section x 3 hysterectomy parathyroid tumor resection s/p left knee replacement s/p left carotid endarterectomy bowel resection with partial removal of right colon and cecum for benign mass left eyelid surgery Cholecystectomy Social History: Widow, son currently staying with her. Has 4 children, who are very involved. Tobacco: quit [**2071**]. No ETOH. No home services Family History: No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Physical Exam: Admission exam VS: T=98.6 BP= 133/47 HR= 55 RR= 16 O2 sat= 96% ra GENERAL: elderly caucasian female in NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple with JVP of 9cm. CARDIAC: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. [**3-12**] holosystolic murmur best heard at apex. 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: 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+ Discharge exam Pertinent Results: Admission labs [**2103-4-3**] 03:00PM BLOOD WBC-4.8 RBC-3.28* Hgb-9.9* Hct-28.9* MCV-88 MCH-30.0 MCHC-34.1 RDW-15.5 Plt Ct-201 [**2103-4-3**] 03:00PM BLOOD PT-11.3 INR(PT)-1.0 [**2103-4-3**] 03:00PM BLOOD Glucose-90 UreaN-38* Creat-1.4* Na-137 K-4.6 Cl-111* HCO3-14* AnGap-17 [**2103-4-3**] 03:00PM BLOOD ALT-7 AST-18 AlkPhos-100 TotBili-0.3 [**2103-4-3**] 03:00PM BLOOD Albumin-3.8 Cholest-172 [**2103-4-3**] 03:00PM BLOOD %HbA1c-6.0* eAG-126* [**2103-4-3**] 03:00PM BLOOD Triglyc-173* HDL-43 CHOL/HD-4.0 LDLcalc-94 Discharge labs [**2103-4-17**] 04:35AM BLOOD WBC-7.4 RBC-3.09* Hgb-9.2* Hct-27.1* MCV-88 MCH-29.8 MCHC-34.0 RDW-14.4 Plt Ct-264 [**2103-4-16**] 04:40AM BLOOD WBC-7.5 RBC-2.87* Hgb-8.5* Hct-25.2* MCV-88 MCH-29.7 MCHC-33.8 RDW-14.4 Plt Ct-222 [**2103-4-17**] 04:35AM BLOOD Glucose-106* UreaN-47* Creat-1.8* Na-143 K-5.0 Cl-102 HCO3-31 AnGap-15 [**2103-4-16**] 04:40AM BLOOD Glucose-105* UreaN-44* Creat-1.7* Na-141 K-4.7 Cl-100 HCO3-32 AnGap-14 [**2103-4-15**] 05:10AM BLOOD Glucose-100 UreaN-44* Creat-1.8* Na-141 K-4.8 Cl-103 HCO3-34* AnGap-9 [**2103-4-14**] 06:30AM BLOOD Glucose-95 UreaN-43* Creat-1.9* Na-136 K-4.5 Cl-100 HCO3-31 AnGap-10 Studies Cardiac cath [**2103-4-3**]: COMMENTS: 1. Coronary angiography in this right dominant system demonstrated two vessel coronary artery disease. The LMCA was patent. The LAD had a 70% mid vessel stenosis. THe first diagonal branch had an ostial 70%. The Lcx had an 80% eccentric lesion that wasn't ammenable to PCI. THe RCA was non-obstructed with a mild amount of proximal plaque with a possibe non-flow limiting chronic dissection in the proximal portion of the vessel. 2. Limited resting hemodynamics reveal elevated left sided filling pressures with an LVEDP of 17mm Hg. Systemic pressures were normal. 3. Left ventriculography demonstrated an ejection fraction of 65% with no wall motion abnormality. FINAL DIAGNOSIS: 1. Three vessel coronary artery disease. 2. Normal ejection fraction. 3. Moderately elevated left sided filling pressure. CXR [**2103-4-4**]: No previous images. Cardiac silhouette is within normal limits and there is no evidence of vascular congestion, pleural effusion, or acute focal pneumonia. Opacification in the supraclavicular region on the right medially could be an artifact or represent some area of calcification. [**2103-4-10**] Intra-op TEE Conclusions Pre-CPB: No spontaneous echo contrast is seen in the left atrial appendage. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. There are complex (>4mm) atheroma in the descending thoracic aorta. The aortic valve leaflets (3) are moderately thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are moderately thickened. Mild (1+) mitral regurgitation is seen. There is no pericardial effusion. Post-CPB: The patient is AV-Paced, on no inotropes. Preserved biventricular systolic fxn. Aorta intact. Trace MR, no AI. Brief Hospital Course: MEDICAL COURSE: Ms. [**Known lastname **] is a 77yoF with h/o remote MI in [**2071**], HTN, HLD, hypothyroidism, gout, who presented with worsening chest pain, found to have 3 vessel disease on [**2103-4-3**] cath, admitted for management prior to CABG. . # CORONARIES: Cath on [**2103-4-3**] showed prox OM 80% not a great candidate for stenting. mid 70% LAD, mid 30% diag lesion. 2 vessel disease, rec. CABG. Plavix was held starting on [**4-3**]. She initially was doing well, chest pain free. However on [**4-8**] she started developing chest pain after going to the bathroom, EKG unchanged. On [**4-9**] she developed chest pain at rest, EKG with ST depressions in lateral leads. This pain was responsive immediately to nitro 0.4mg SL x1, and a heparin gtt was started. She went for CABG on #### . # Acidosis: Pt persistently has low bicarb, ~16-18. ABG on [**4-6**] showed 7.26/39/76/18. This represents a mixed metabolic acidosis and respiratory acidosis. Differential for non-AG metabolic acidosis is GI losses of HCO3- (possible, given 18" colon resected [**2101**] for villous adenoma, when this issue arose, and has chronic watery diarrhea as a result), renal tubular acidosis (potential), early renal failure (less likely as GFR is in 30's). Urine anion gap is +17, which suggests a failure of kidneys to excrete NH4+, as opposed to bicarb losses. Suggests type I or IV RTA. Persistent hyperkalemia suggests type IV, as type I usually has hypokalemia. Also FeHCO3- is <5%, which also supports type IV RTA. Renin/aldosterone levels were sent which showed #####. She was started on sodium bicarb 325mg PO BID, which improved her serum bicarb. Prior to surgery, she was infused 1L D5W with 150meq NaHCO3. If truly type 4 RTA, may benefit from fludrocortisone in the future. . # Acute on chronic kidney injury: baseline creatinine 1.4, briefly up to 1.7 during admission. Possible CIN from cath [**4-3**]. Gentle hydration was given, and ACEi (benazapril) was held. [**Last Name (un) **] resolved. . # PUMP: no evidence of CHF. Dry weight 145lbs on admission. . # HTN: held carvedilol, amlodipine, and benazapril during admission for mild hypotension and bradycardia. On discharge ####### . # HLD: continued crestor 40mg daily. . # GOUT: continued allopurinol 100mg PO daily ================================ TRANSITIONAL ISSUES # incidentalomas on CT chest: 1) Multiple hypodense kidney lesions, statistically likely cysts, but not fully characterized on this non-contrast study. Recommend ultrasound examination on an outpatient basis. 2) Bilateral adrenal adenomas. To be further worked-up in outpatient setting. # SURGICAL COURSE: Pulmonary was consulted preoperatively for elevated AA gradient. There were no recommendations for further testing or treatment. The patient was brought to the Operating Room on [**2103-4-10**] where the patient underwent CABG x 3 with Dr. [**Last Name (STitle) **]. Overall the patient tolerated the procedure well and post-operatively was transferred to the CVICU in stable condition for recovery and invasive monitoring. She was initially A-paced with no spontaneous rhythm out of the OR. POD 1 found the patient extubated, alert and oriented and breathing comfortably. The patient was neurologically intact. She remained in the CVICU a few days for hemodynamic support. Hemodynamics stabilized and rhythm recovered to sinus. She did require supplemental oxygen for several days post-operatively. Beta blocker was initiated and the patient was gently diuresed toward the preoperative weight. Renal was consulted for history of renal insufficiency. Diuretics and nephrotoxins were minimized. The patient was transferred to the telemetry floor for further recovery. Chest tubes and pacing wires were discontinued without complication. The patient was evaluated by the physical therapy service for assistance with strength and mobility. By the time of discharge on POD 7 the patient was ambulating with assistance, the wound was healing and pain was controlled with oral analgesics. The patient was discharged to [**Location (un) 582**], [**Location (un) 5176**] in good condition with appropriate follow up instructions. She will require supplemental oxygen on discharge. Medications on Admission: Medications - Prescription ALLOPURINOL - (Prescribed by Other Provider) - 300 mg Tablet - 0.5 (One half) Tablet(s) by mouth daily AMLODIPINE-BENAZEPRIL - (Prescribed by Other Provider) - 10 mg-20 mg Capsule - 1 Capsule(s) by mouth daily CARVEDILOL - (Prescribed by Other Provider) - 12.5 mg Tablet - 2 Tablet(s) by mouth daily CLOPIDOGREL [PLAVIX] - (Prescribed by Other Provider) - 75 mg Tablet - 1 Tablet(s) by mouth daily GABAPENTIN - (Prescribed by Other Provider) - 300 mg Capsule - 2 Capsule(s) by mouth daily LEVOTHYROXINE - (Prescribed by Other Provider) - 150 mcg Tablet - 1 Tablet(s) by mouth daily MOXIFLOXACIN [VIGAMOX] - (Prescribed by Other Provider) - 0.5 % Drops - 1 gtt OS three times a day ROSUVASTATIN [CRESTOR] - (Prescribed by Other Provider) - 40 mg Tablet - 1 (One) Tablet(s) by mouth daily ASPIRIN - (Prescribed by Other Provider) - 81 mg Tablet, Chewable - 1 Tablet(s) by mouth daily Discharge Disposition: Extended Care Facility: [**Location (un) 582**] Of [**Location (un) 5176**] Discharge Diagnosis: CAD PMH: MI [**2071**]-age 45; had a temporary pacemaker/? arrest per pt description. asthma-not a current issue back pain skin cancer gout hypertension hyperlipidemia hyperthyroidism s/p radioactive iodine lumbar disc disease osteoporosis bladder cancer ->diagnosed 3 years ago s/p direct bladder treatment; followed by [**Last Name (un) **]/[**Hospital3 **]/[**Hospital1 **]. hx of falls, uses a cane PRN TIA Past Surgical History: c section x 3 hysterectomy parathyroid tumor resection s/p left knee replacement s/p left carotid endarterectomy bowel resection with partial removal of right colon and cecum for benign mass left eyelid surgery Cholecystectomy Discharge Condition: Alert and oriented x3 nonfocal Ambulating, deconditioned Sternal pain managed with oral analgesics Sternal Incision - healing well, no erythema or drainage Trace edema Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming, and look at your incisions Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Females: Please wear bra to reduce pulling on incision, avoid rubbing on lower edge Followup Instructions: Please call to schedule the following: Surgeon Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 170**] Cardiologist Dr. [**Last Name (STitle) 7526**] Primary Care Dr. [**Last Name (STitle) 5448**] in [**5-10**] weeks **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Completed by:[**2103-4-17**] Name: [**Known lastname 12105**],[**Known firstname **] Unit No: [**Numeric Identifier 14535**] Admission Date: [**2103-4-3**] Discharge Date: [**2103-4-17**] Date of Birth: [**2025-11-20**] Sex: F Service: CARDIOTHORACIC Allergies: morphine / Oxycodone Attending:[**First Name3 (LF) 741**] Addendum: Discharge medications as below. Discharge Medications: 1. allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. levothyroxine 75 mcg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 3. rosuvastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 4. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 5. gabapentin 300 mg Capsule Sig: One (1) Capsule PO HS (at bedtime). 6. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 7. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for fever/pain. 8. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) as needed for constipation. 10. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed for constipation. 11. carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 12. polyethylene glycol 3350 17 gram Powder in Packet Sig: One (1) Powder in Packet PO DAILY (Daily). 13. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q6H (every 6 hours) as needed for constipation. 14. polyvinyl alcohol-povidon(PF) 1.4-0.6 % Dropperette Sig: [**2-5**] Drops Ophthalmic PRN (as needed) as needed for dry eyes. 15. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q4H (every 4 hours) as needed for for SOB. 16. furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day for 7 days. 17. Outpatient Lab Work Please check BUN, Creatinine on [**2103-4-20**] 18. oxygen supplemental oxygen via nasal cannula for goal SaO2 >92% Discharge Disposition: Extended Care Facility: [**Location (un) 176**] Of [**Location (un) 13063**] [**Name6 (MD) **] [**Name8 (MD) 747**] MD [**MD Number(2) 748**] Completed by:[**2103-4-17**]

[ "285.9", "V10.51", "585.9", "733.00", "V10.83", "272.4", "V43.65", "584.9", "412", "274.9", "276.4", "327.23", "413.9", "493.90", "276.7", "414.01", "403.90" ]

icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

15614, 15816

6119, 10352

298, 411

12103, 12273

3083, 4961

13145, 13952

1986, 2101

13975, 15591

11419, 11830

10378, 11297

4978, 6096

12297, 13122

11853, 12082

2116, 3064

248, 260

439, 1137

1159, 1570

1838, 1970

18,174

174,691

14129

Discharge summary

report

Admission Date: [**2114-7-24**] Discharge Date: [**2114-9-25**] Service: VASCULAR CHIEF COMPLAINT: Worsening toe gangrene HISTORY OF PRESENT ILLNESS: The patient was seen in the Emergency Room on [**2114-7-24**] for increasing right foot pain and gangrenous changes of his right foot. He is an 84-year-old disease with stenting to LAD and diagonal prior to consideration of vascular surgery for bilateral blue toe syndrome. Surgery was delayed because the patient had undergone cardiac catheterization and was placed on Plavix secondary to his angioplasty and stent. He returns now with progressive foot and leg ischemic changes. 1. Hypertension 2. Coronary artery disease 3. Chronic renal insufficiency failure on dialysis since [**Month (only) **] of this year secondary to cholesterol embolization from cardiac catheterization 4. History of congestive failure with an ejection fraction of 25% 5. History of aortic stenosis with a valve area of 0.8 cm square 6. History of left renal artery stenosis 7. Hypercholesterolemia 8. Gastroesophageal reflux disease on dialysis Monday, Wednesday and Friday, status post angioplasty to the LAD and diagonal with stents in [**Month (only) **] of this year MEDICATIONS: 1. Zestril 2.5 mg qd 2. Lipitor 20 mg qd 3. Tums with meals 4. Plavix 75 mg qd, last dose was [**7-27**]. 5. Epogen 4000 units at dialysis 6. Dilaudid 0.5 prn 7. Prevacid 30 mg [**Hospital1 **] 8. Lopressor 100 mg [**Hospital1 **] 9. Nephrocaps qd 10. Neurontin 200 mg qd 11. Enteric coated aspirin 325 mg qd ALLERGIES: The patient has no known drug allergies. SOCIAL HISTORY: He presently is a resident at [**Hospital1 **] Rehabilitation. Denies drinking or smoking. PHYSICAL EXAM: VITAL SIGNS: 98.6??????, 125, 139/114, 20, O2 saturation 97%. GENERAL APPEARANCE: Frail elderly male, older than stated age. HEAD, EARS, EYES, NOSE AND THROAT: Unremarkable. CHEST: Clear to auscultation bilaterally. HEART: Irregularly irregular rhythm. ABDOMEN: Unremarkable. MUSCULOSKELETAL: Left foot with middle gangrenous toe, dark discoloration of the distal foot which is cool with a 1+ pedal pulse. The right foot second, third and fourth toes are gangrenous changes with moderate skin on the dorsal surface of the foot. There are no palpable pulses. There is no edema. He has a stage II sacral ulcer. STUDIES: Electrocardiogram obtained in the Emergency Room showed a regular sinus rhythm. This was compared with the previous electrocardiogram. He was admitted to the vascular service for further evaluation and treatment. LAB WORK: CBC with a white count of 19.8, hematocrit 28.7 and platelets 270. INR was 1.7. PTT was 28.6. BUN was 47, creatinine 5.7. Potassium was 4.3. Cardiology was notified of the admission and felt that there was nothing from a cardiac standpoint that they had to offer. The rest was medical management. The patient underwent dialysis on the day of admission. The patient was preopped for femoral AT. His chest x-ray showed mild pleural effusions. Electrocardiogram was a regular rhythm. LABS: CBC: White count 19.7, hematocrit 36.1, platelets 307. INR was 1.5. PTT was 47.7. BUN 49, creatinine 6.0, potassium 4.2, ALT 147, AST 54, alkaline phosphatase 16, total bilirubin 0.7. Albumin 2.9, calcium 8.2, phos 3.9, magnesium 2.1. The patient underwent on [**7-25**], a right BK [**Doctor Last Name **] to AT bypass with reverse saphenous vein with intraoperative arteriogram. He tolerated the procedure well and was transferred to the PACU in stable condition. Postoperatively, he was hemodynamically stable. His incisions were clean, dry and intact. He had a palpable graft pulse. His postoperative hematocrit was 35. His potassium was 4.4. Chest x-ray was without pneumothorax and electrocardiogram as without changes. The patient continued to do well and was transferred to the VICU for continued monitoring and care Postoperative day 1, there were no overnight events. He remained hemodynamically stable. His hematocrit remained stable. His extremities showed cool, cyanotic, necrotic tips of the right toes. He had a palpable graft pulse and a dopplerable DP. His lungs were clear to auscultation. His diet was advanced as tolerated. He was continued on perioperative antibiotics. His heparin was adjusted to meet a therapeutic PTT of 60 to 80. He remained in the VICU. Cardiology was reconsulted. His serial CK was 439. MB was 10. His troponin was 1.4. Cardiology was consulted regarding elevated troponin in relevance to the patient. They felt that he did not have acute coronary syndrome, was most likely the troponin was secondary to congestive heart failure. They recommended to continue cycling his CKs for a total of three, continue aggressive medical management of his coronary artery disease, perioperative beta blocking and hemodialysis as indicated. Renal followed the patient during his hospitalization and managed his hemodialysis needs. On [**2114-7-27**], he underwent arterial Duplex. It was a limited study. The graft was demonstrated to be patent. Postoperative day 2, he was D-lined. He was transferred to the regular nursing floor for continued management and care. The patient continued to remain stable from a cardiac standpoint and a renal standpoint. On [**2114-8-1**], the patient underwent a right transmetatarsal amputation and a left third toe amputation. He tolerated the procedure well and was transferred to the PACU in stable condition. He continued to do well and was transferred to the regular nursing floor. His hematocrit remained stable at 31.4, BUN 24, creatinine 3.7, potassium 4.2. He was noted on postoperative day 1 to have some ectopy. He was placed back in the VICU for rule out. Serial CKS were obtained which were 46 and 44. His vancomycin was monitored and dosed according to random level. Physical therapy was requested to see the patient for non weight bearing ambulation on the transmetatarsal amputation site. This would be needed to be done for a total of four weeks. The initial dressing was removed on postoperative day #2. The wounds were clean, dry and intact. Coumadin conversion was started on postoperative day 10 and 3. The amputation site looked good, but there were cyanotic changes of toes 2 and 4 on the left. The left toes continued to demarcate and on [**8-6**], the transmetatarsal amputation site showed erythema. Three sutures were removed. The wound was explored. There was old hematoma. Cultures were obtained. The wound was packed. He was continued to be monitored. Coumadinization was continued. His antibiotics were discontinued on [**2114-8-7**]. The left toes continued to demarcate, wound eventually require amputation. The graft was palpable and the eschar on the wounds remained stable. Physical therapy was requested to see the patient and begin non weight bearing ambulation. Case management began screening for rehabilitation potential versus discharge to home. Cultures obtained on the transmetatarsal amputation site on [**8-6**], gram stain with 2+ polys. There were no organisms. The finalization of the culture was pending at the time of dictation. Blood cultures obtained on [**8-5**] x2 were no growth but not finalized. Wound cultures from [**8-2**] tissue grew Staphylococcus coagulase negative, rare yeast, presumptively not C. albicans, isolated from broth media only. Enterococcus isolated from broth media only. Enterococcus was sensitive to vancomycin, resistant to levofloxacin, sensitive to penicillin and ampicillin. There were no anaerobes. Stool culture for Clostridium difficile on [**7-29**] was negative. Chest x-ray was unremarkable. White count on [**8-7**] was 15.8, hematocrit 32.2, platelets 483, PT 15.4, INR 1.7, PTT 55.6. The patient's electrolytes: Sodium 137, potassium 4.8, chloride 99, CO2 25, BUN 37, creatinine 5.2, glucose 82. Ultimately his C.diff was positive. He was treated with flagyl po, however, did not seem to improve as rapidly as expected. Therefore, he was changed to po vanco and IV flagyl. He improved with respect to his abdominal pain as well as his mental status. His blood cultures came back positive for gram negative bacteria, likely secondary to translocation. As a result, we were concerned about mesenteric ischemia. A colonoscopy was completed which demonstrated resolving ischemic colitis. As it was resolving, we opted for conservative management at this time. Mr. [**Known lastname **] [**Last Name (Titles) 27836**] extremely well. At hemodialysis, he developed acute onset of shortness of breath with hypotension. Hemodialysis was stopped and the patient transferred back to the floor. His ABg at that time was extremely acidotic and would ultimately require intubation. In conjunction with the medical team, we discussed the option of intubation with the family. They opted for conservative care only. He expired shortly thereafter. DISCHARGE DIAGNOSES: 1. Bilateral toe syndrome with gangrene, status post right popliteal pedal bypass graft 2. Toe amputations, left second toe and right transmetatarsal amputation 3. Hypertension controlled 4. End stage renal disease on hemodialysis [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 7252**] Dictated By:[**Last Name (NamePattern1) 1479**] MEDQUIST36 D: [**2114-8-7**] 12:18 T: [**2114-8-7**] 13:49 JOB#: [**Job Number 42093**]

[ "530.81", "V45.1", "414.01", "V45.82", "583.81", "250.40", "272.0", "585", "440.24" ]

icd9cm

[ [ [] ] ]

[ "43.11", "45.25", "39.29", "84.12", "86.22", "39.95", "99.15", "84.11", "86.69" ]

icd9pcs

[ [ [] ] ]

8987, 9492

1736, 8966

110, 134

163, 1611

1628, 1721

13,316

147,952

10597

Discharge summary

report

Admission Date: [**2111-12-17**] Discharge Date: [**2111-12-30**] Date of Birth: [**2050-1-7**] Sex: F Service: MEDICINE Allergies: Penicillins Attending:[**First Name3 (LF) 2736**] Chief Complaint: Fever Major Surgical or Invasive Procedure: BAL Intubation and Ventilation RIJ Central Venous Line History of Present Illness: Patient is 61 yo female with h/ of CAD, CABG ([**2104-2-12**], LIMA->LAD, SVG-> OM, SVG-> left posterior descending artery, SVG-> diagonal), Hypertension/Hyperlipidemia, and anemia, who has been having subjective fevers, chills, malaise since 3 weeks. Given no resolution of her symptoms patient decided to present to [**Hospital3 **] ED, where she was found to have an intermediate Trop I of 0.18 and worsening of her in lead I, II, V3-V6 on repeat EKG. Given significant past cardiac disease, Aspirin was given and heparin drip was started. Patient was transferred to [**Hospital1 18**] for further evaluation and possible cath. Upon arrival to ED her biomarkers were: CK198, MB3 TropT<0.01. Her St depressions with T-wave inversions had improved and almost returned to baseline. Throughout the course pt had no cardiac symptoms, which she had prior to CABG. Her baseline functional capacity remains unchanged. She is very active, no DOE, SOB, orthopnea. No lightheadedness, dyzziness. No HA, visual changes, anddominal pain, n/v/d. No BRBPR or melena. . Cardiac review of systems is notable for absence of chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. . The morning after admission ([**2110-12-17**]) she went into rapid afib with HR 150s, which was new for her. Got metoprolol 5 mg IV x 3, HR down to 100s. Became acutely short of breath with O2 in mid 80s. CXR showed mild pulmonary edema. Put on NRB this morning. After 4 hours on NRB, ABG was 7.37/27/53. Of note, she had received 2.5 L of IVF and 1 unit of pRBCs in the ED by the time of the onset of the afib with RVR. Heparin gtt was continued. Received 40 mg of furosemide which yielded 500 cc of urine output. She was Transferred to CCU for further management. . Upon arrival to the CCU, patient was still on NRB, claiming that breathing was "better" than this morning. Past Medical History: -CABG: [**2104-2-12**], [**2104-2-12**], LIMA->LAD, SVG-> OM, SVG-> left posterior descending artery, SVG-> diagonal. Complicated by a cerebrovascular accident with subsequent resolution of symptoms. PAST MEDICAL HISTORY: High grade left carotid artery stenosis (Left carotid endarterectomy [**2104-1-10**]), carotid stenting was done in [**Month (only) 404**] [**2104**]. hypertension hypothyroidism pernicious anemia gastroesophageal reflux disease. Social History: 2ppd smoking hx in past - none since several years. no current alcohol use. Family History: No family history of early MI, otherwise non-contributory. Physical Exam: VS: 99.3 97/61 77 18 98%RA GENERAL: pale female NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pale, NECK: Supple with JVP flat. CARDIAC: RR, normal S1, S2. 2/6 SEM. 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. No abdominial bruits. EXTREMITIES: No c/c/e. No femoral bruits. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Pertinent Results: Cardiology Report ECG Study Date of [**2111-12-17**] 6:49:26 PM Sinus rhythm. ST-T wave abnormalities. Since the previous tracing of [**2107-12-20**] no significant change in previously noted findings. ECG [**2112-10-26**] Sinus rhythm with bigeminal ventricular premature beats. Non-specific anterior and lateral ST-T wave changes. Compared to the previous tracing of [**2111-12-19**] more frequent ventricular premature beats are seen in a bigeminal fashion. The other findings are similar. [**2111-12-17**] PA AND LATERAL VIEWS OF THE CHEST: The patient is status post median sternotomy and CABG. The heart is normal in size. The mediastinal and hilar contours are normal. The lungs are clear. No focal consolidation, pleural effusions or pneumothorax is identified. Clips in the right upper quadrant of the abdomen are compatible with prior cholecystectomy. Osseous structures are unremarkable. IMPRESSION: No acute cardiopulmonary abnormality. . [**2111-12-19**]: CXR Study performed earlier the same day. Single portable AP view of the chest was performed. Again seen are sternotomy wires and overlying cardiac leads. There is persistent diffuse bilateral interstitial and ground-glass opacities, more prominent within the mid and lower lung zones suggestive of pulmonary edema. There may be a small right effusion which could be better seen on a lateral view. The cardiopericardial silhouette is enlarged. IMPRESSION: Persistent and unchanged pulmonary edema. [**2111-12-18**]: The left atrial volume is markedly increased (>32ml/m2). Left ventricular wall thicknesses and cavity size are normal. There is severe regional left ventricular systolic dysfunction with severe hypokinesis of the basal segments and near akinesis of the basal to mid anterior wall and septum. [Intrinsic left ventricular systolic function is likely more depressed given the severity of valvular regurgitation.] Right ventricular chamber size is normal. with borderline normal free wall function. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No masses or vegetations are seen on the aortic valve, but cannot be fully excluded due to suboptimal image quality. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. No mass or vegetation is seen on the mitral valve. Mild to moderate ([**12-18**]+) mitral regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Severe focal LV systolic dysfunction consistent with multi-vessel CAD. Mild to moderate MR. Mild pulmonary artery systolic hypertension. . [**2111-12-19**] CT Torso CHEST: There is mild-to-moderate coronary artery calcification. Otherwise, the heart and great vessels are unremarkable. There are no filling defects within the main, segmental, or subsegmental pulmonary artery branches. There are multiple mediastinal lymph nodes measuring up to 8 mm in maximum short axis. No hilar or axillary lymphadenopathy is demonstrated. There are no pleural or pericardial effusions. Lung window images demonstrate diffuse bilateral ground-glass opacities throughout both lungs with areas of interlobular septal thickening compatible with a" crazy paving" pattern. There is mild bibasilar atelectasis. Bone window images are unremarkable. ABDOMEN AND PELVIS: Patient is status post cholecystectomy. The liver, spleen, pancreas, and adrenals are unremarkable. There are multiple bilateral hypodensities noted within both kidneys, some of which have a wedge- shaped appearance which may be secondary to infarctions. There is no free intraperitoneal air or free abdominal fluid. There are scattered mediastinal and retroperitoneal nodes which are not pathologically enlarged. There is moderate calcification of the descending aorta. Loops of small bowel are unremarkable without bowel wall thickening or obstruction. Multiple sigmoid diverticula are identified without diverticulitis. The colon is otherwise unremarkable. There is no free pelvic fluid or bulky pelvic lymphadenopathy. Foley catheter is seen within an unremarkable bladder. Calcifications are seen within the uterus suggestive of uterine fibroids. Bone window images are unremarkable. IMPRESSION: 1. Diffuse bilateral ground-glass opacities throughout both lungs, some of which have a "crazy paving" pattern with areas of interlobular septal thickening. The differential is wide including infection, ARDS, or pulmonary alveolar proteinosis. Pulmonary edema is thought to be less likely secondary to the lack of pleural effusions or cardiomegaly. 2. Multiple hypodensities throughout both kidneys, which are nonspecific and may be secondary to previous infarcts. Differential also includes focal areas of pyelonephritis and clinical correlation is suggested. 3. No pulmonary embolus. 4. Diverticulosis without diverticulitis. Brief Hospital Course: 61 yo female with CAD s/p CABG, who who presents with 3 wk history of chills and malaise and is found to have afib with RVR . # Hypoxia: The patient was febrile on admission and had 3 weeks of malaise and chills. CXR on admission was unremarkable The patient became acutely hypoxic on the floor in the setting of atrial fibrillation with rapid ventricular rates. Her hypoxia was thought secondary to acute congestive heart failure secondary to atrial fibrillation. She was likely also fluid overloaded as she had previously received 2 liters of IV fluid and one unit of blood in the ED. Her atril fibrillaiton was with RVR was slowed down with two doses of metoprolol 5mg IV. and she was transferred ot the CCU. The patient was hypoxic and was therefore placed on Bipap. A repeat chest X-Ray was performed which appeared like a multifocal pneumonia. She was started on levofloxacin and ceftriaxone. The patient was oxygenating and ventilating well on Bipap, however she remained tachypneic with respiratory rates in the 30-40's. She remained on Bipap for 35 hours, and her respiratory rate remained in the 30-40's. After 35 hours, she got a chest CT which revealed extensive bilateral ground glass opacities encompassing nearly all of her lung parenchyma, most suggestive of multifocal pneumonia or ARDS. She was therefore intubated. The infctious disease service was consulted for reccomendations regarding antibiotic coverage, and pulmonary was consulted for recommendations regarding treatment of her unknown pulmonary process. Sputum cultures were collected and did not grow microorganisms, but did show >25 neutrophils per high powered field. The patient underwent a mini bronchoalveolar lavage which also did not reveal any microorganisms. Her course of antibiotics included levofloxacin [**Date range (3) 34844**], ceftriaxone [**Date range (1) 34845**], ceftazidime [**Date range (1) 34846**], and vancomycin [**Date range (1) 29554**]. The patient was intubated on [**12-20**] and extubated three days later on [**12-24**]. She remained on 4L NC after extubation. The overall consensus is that the patient presented with a viral pneumonia and superimposed bacterial pneumonia. The patient was weaned to room air with O2 saturations >95% with ambulation. # CORONARIES: Patient with diffuse ST depressions in II, aVF, V3-V6 and ST elevation in aVR. These non-specific st and t wave changes were thought to be most consistent with demand ischemia. She underwent a nuclear perfusion stress test, however this imaging study was not completed because she was urgently transferred to the CCU. Her coronary artery disease was medically managed with metoprolol, aspirin, and lipitor. Her indicaiton for clopidogrel is a carotid artery atent. Her ramipril was restarted once her renal function improved. . # RHYTHM: The patient was initially in atrial fibrillaiton. Her rhythm converted to sinus spontaneously. For the majority of her stay, she remained NSR with periods of bigeminy. She was continued on IV heparin for several days before discussion with her PCP revealed their desire not to anticoagulate with coumadin, given that she is already on aspirin for coronary artery disease and clopidogrel for her carotid artery stent. However, given her depressed EF 25-30% on her ECHO and after extensive discussion with the patient it was determined to start anti-coagulation. She was initiated on coumadin with lovenox bridge on [**12-28**]. The patient's INR on discharge was 2.4 and was continued on 1mg coumadin. The patient will follow-up with Dr. [**Last Name (STitle) 31187**] who will manage her anti-coagulation. Additionally. she will follow-up with Dr. [**Last Name (STitle) **] per Dr.[**Name (NI) 34847**] request to determine whether she should undergo ICD implantation (if repeat echocardiogram does not show improvement in EF after 9 months as an outpatient). . #Pump: ECHO was performed on [**12-18**] that showed depressed EF of 25-30% in the setting of a-fib w/ RVR. The patient was diuresed and continued on lasix 40mg daily as an outpatient. The patient will follow-up with her primary cardiologist. It is recommended that repeat ECHO be performed in 4-6wks. . # Acute renal failure: Cr on admission 1.5 with elevated BUN. After fluid resuscitation her creatinine decreased to 0.5. Her ramipril was restarted once her creatinine recovered. Her creatinine on discharge was 0.7. . # Anemia: Patient with a history of pernicious anemia on b12 injections and additionally is on iron as an outpatient. On admission had Crit of 23 got 1 unit of pRBCs. Unlikely hemolysing or acutely bleeding given elevated haptoglobin, normal bilirubin. Anemia labs with iron 11 (low), TIBC 229 (low), B12 > assay, folate > assay, haptoglobin 360 (elevated), ferritin 1063 (high) transferrin 176 (elevated). Given markedly elevated ferritin suggests anemia of chronic disease. She received one unit of packed red blood cells in the emergency room. She was also started on ferrous sulfate and continued on vitamin B12 injections. . # Hypothyroidism: Patient is on thyroid replacement therapy as an outpatient. TSH 0.024 on admission (very low) with normal T4 1.0. Difficult to interpret this in the setting of other active issues. She was continued on levothyroxine 75mcg daily. Medications on Admission: Synthyroid 137 mcg PO DAILY Metoprolol Tartrate 50 (? exact dose unknown) mg PO TID Aspirin EC 81 mg PO DAILY Niacin 500 mg PO DAILY Atorvastatin 80 mg PO DAILY Paroxetine 20 mg PO DAILY Clopidogrel 75 mg PO DAILY Omeprazole 20 mg PO Q24H Cyanocobalamin injections weekly Ferrous Sulfate 325 mg PO DAILY Ramipril 10 mg PO DAILY Discharge Medications: 1. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 2. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 3. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 4. Cyanocobalamin Injection 5. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Ramipril 5 mg Capsule Sig: Two (2) Capsule PO DAILY (Daily). 7. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day. 8. Paroxetine HCl 20 mg Tablet Sig: One (1) Tablet PO once a day. Tablet(s) 9. 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:*2* 10. Warfarin 1 mg Tablet Sig: One (1) Tablet PO once a day: Please follow-up with your PCP regarding dosing. . Disp:*30 Tablet(s)* Refills:*2* 11. Outpatient Lab Work Please draw labs for PT [**Name (NI) 263**] to monitor coumadin anti-coagulation. Please fax results to Cardiologist Dr. [**Last Name (STitle) 31187**]. PCP: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Telephone/Fax (1) 31188**] Fax: [**Telephone/Fax (1) 34848**] Discharge Disposition: Home With Service Facility: [**Hospital3 **] VNA Discharge Diagnosis: Primary: Pneumonia A-fib w/ RVR CHF CAD Hpertension. Hpothyroidism. Pernicious anemia. GERD Discharge Condition: stable, O2 sat 95% on RA with ambulation, afebrile Discharge Instructions: It was a pleasure taking care of you while you were in the hospital. You were admitted to [**Hospital1 18**] because of an infection in your lungs. You spent a short period of time in the ICU and you were intubated because of difficulty breathing. You improved and were treated with a complete course of antibiotics. You also had a rapid irregular heart rate that reverted back into a normal rhythm. You were started on anti-coagulation. *** You should have follow-up regarding repeat ECHO in [**3-21**] wks to assess your cardiac function and your Cardiologist will continue to follow your anti-coagulation. Please follow the medications prescribed below. 1) You will be taking Atorvastatin 80mg daily 2) Your levothyroxine was changed to 75mcg/day 3) Your Toprol was changed to Toprol XL 50mg daily 4) You were started on Coumadin 1mg daily and will follow-up with Dr. [**Last Name (STitle) 31187**] regarding your INR. Please follow up with the appointments below. Please call your PCP or go to the ED if you experience chest pain, palpitations, shortness of breath, nausea, vomiting, fevers, chills, or other concerning symptoms. Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs. Adhere to 2 gm sodium diet Fluid Restriction: Followup Instructions: You have a follow-up appointment with Dr. [**Last Name (STitle) 31187**] on [**2112-1-5**] 12:15pm. PCP: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Telephone/Fax (1) 31188**] Fax: [**Telephone/Fax (1) 34848**] *** You should have follow-up regarding repeat ECHO to assess your cardiac function and managmeent of your anti-coagulation You have an appointment by EP Cardiology on [**2112-1-8**] at 3pm [**Last Name (LF) **], [**First Name3 (LF) 251**], E., M.D. Phone: ([**Telephone/Fax (1) 2037**] *** You should have repeat ECHO in [**3-21**] weeks. Completed by:[**2112-1-3**]

[ "414.00", "401.9", "486", "244.9", "518.81", "584.9", "276.2", "285.9", "276.1", "272.4", "443.9", "428.22", "458.9", "428.0", "V45.81", "427.31" ]

icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

15483, 15534

8537, 13841

279, 336

15670, 15723

3638, 8514

17033, 17620

2863, 2923

14220, 15460

15555, 15649

13867, 14197

15747, 17010

2938, 3619

234, 241

364, 2276

2522, 2754

2770, 2847

32,759

158,709

32144

Discharge summary

report

Admission Date: [**2169-10-5**] Discharge Date: [**2169-10-23**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 358**] Chief Complaint: acute on chronic renal failure and urinary tract infection Major Surgical or Invasive Procedure: [**10-5**] Left craniotomy for evaculation of left SDH [**10-6**] Extubated [**10-15**] placement of bilateral 8-French percutaneous nephrostomy tubes History of Present Illness: 82 yo Portuguese speaking male with known metastatic prostate cancer origininally presentated to [**Hospital3 **] in [**Location (un) 5503**] on [**10-3**] with nausea, vomiting, poor PO intake, and coffee ground emesis. He was found to be in acute on chronic renal failure (SCr 6.3) thought to be prerenal in etiology secondary to dehyration; a foley was placed. CT of the abdomen and pelvis at [**Hospital3 **] found bilateral hydronephrosis, increased on left and new on right with new bilateral nephrolithiasis compared to CT [**2169-7-31**]. On admission to [**Hospital3 **] the patient was also found to have an MI with positive cardiac enzymes, though EKG unchanged, ie ST depressions in prior EKG. Lovenox was begun at [**Hospital3 15402**] in setting of MI. The patient was not felt to be a candidate for cardiac catheterization, and his MI was medically managed. . While an inpatient at [**Hospital3 **], he struck his L posterior skull while on aspirin, plavix, and lovenox; he developed an acute subdural hematoma and was transferred from [**Hospital3 **] in [**Location (un) 5503**] to [**Hospital1 18**] via [**Location (un) **] for a left occiptal evacuation of acute SDH s/p mechanical fall; he received vecuronium en route. He then received a L occipital craniotomy at [**Hospital1 18**] without complication on [**10-6**] and post-op CT head was stable. On the 14th his FeNa was 18.6. His renal function improved on the neurosurgery service with hydration over the enxt several days. On [**10-7**] he was found to be hypernatremic (Na 155), free H2O was increased per NGT and 0.5NS IVF given. Repeat Head CT showed a predominantly low fluid density within the subdural spaces bilaterally with areas of higher density again noted, suggestive of more acute bleeding. On [**10-8**] dilantin level was 12.8 which corrected to approx. 20. He was transferred from ICU to floor on [**10-10**] (Na 149). C. Diff was negative. [**10-12**] CXR showed CHF, the patient was given lasix- Lasix 20x1. Pt developed respiratory distress (RR 35, labored, but 96% 2L, other vitals normal, 5 beats VT self resolved, no LE edema). He improved with upright positioning and tube feeds were stopped; stat CXR showed worsening edema, though cannot r/o pneumonia R side. T spike 101.3 axillary and cultures were sent. UA revealed UTI. He was placed on ciprofloxacin. His creatinine increased from 1.6-->2.9. Also he developed a cough and appeared fluid overloaded on CXR. His symptoms improved somewhat with Lasix. Past Medical History: metastatic prostate CA (diagnosed in [**2162**]). He underwent XRT with Dr.[**Name (NI) 14072**], developed PSA recurrence in [**2168**] to 12.7 from 2.7 the year prior. He underwent bilateral orchiectomy by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 75209**] at [**Hospital3 **] in [**9-28**]. Metastases to spine. s/p bilateral orchiectomy ([**9-28**]) DM HTN CKD with baseline SCr approximately 1.6 hydronephrosis bilateral renal stents Alzheimer's dementia anemia hypercholesterolemia DJD CVA Social History: He is married and retired. He quit all tobacco usage when he was 28 year old and uses EtOH rarely. . His daughter=HC proxy [**Name (NI) **] [**Name (NI) 75210**] [**Telephone/Fax (2) 75211**]h, [**Telephone/Fax (2) 75212**]c Daughter [**Name (NI) **] closely involved in care, nurse. Family History: Noncontributory Physical Exam: VITAL SIGNS: Tmax: Tcur: HR: BP: RR: 36 SaO2: Gen: thin elderly male on supplemental oxygen. HEENT: PERRLA, Left corona with healing surgical wound s/p staple removal today Neck: Supple. Lungs: CTAB Cardiac: RRR. nl S1/S2. Abd: +BS, NT/ND, radiation tattoos present on lower abdomen Extrem: Warm and well-perfused. No clubbing, cyanosis, or edema. Neuro: Mental status: alert and oriented to person only. Could not participate in recall protions of exam. CNII-XII grossly intact. Babinskis upgoing bilaterally. Motor: Moves LUE and BLE well. RUE weak; 0/5 motor strength. LUE with 3/5 motor strenghth. Asymmetric grip left grip intact. Right grip could not assess. Pt did not participate in LE motor exam. Genitalia: Phallus uncircumcized, no phimosis; testes absent Pertinent Results: LABORATORIES: . [**2169-10-13**] 05:35a Na: 146; Cl: 111; BUN: 62 131 AGap=22 K: 4.1; Bicarb: 17 Cr: 2.9 Ca: 8.2 Mg: 1.7 P: 2.8 Phenytoin: 2.5 . WBC: 14.9; Hgb: 12.2; HCT: 38.4; Plts: 207 . ALT: 72 AP: 388 Tbili: 0.5 Alb: 2.5 AST: 74 LDH: 590 [**Doctor First Name **]: 75 Lip: 37 Phenytoin: 2.2 Other Blood Chemistry: proBNP: Pnd [**2169-10-13**] 6:24p pH 7.44 pCO2 23 pO2 98 HCO3 16 Type:Art Lactate:1.8 . [**2169-10-13**] 5:48p . Urine chemistry: UreaN:297 Creat:50 Na:48 Osmolal:274 . Source: Catheter Color Appear Cloudy SpecGr 1.009 pH 5.0 Urobil Neg Bili Neg Leuk Mod Bld Lge Nitr Neg Prot Tr Glu Neg Ket Neg RBC 216 WBC >1000 Bact Rare Yeast None Epi <1 Other Urine Counts Mucous: Occ . . _ _ _ _ _ _ _ _ _ _ _ ________________________________________________________________ IMAGING: . [**2169-10-6**]: TTE: LVEF 50%, Inferior Hypokinesis, Mild MR CT [**10-5**]: L acute SDH max thickness 2.7cm, 3mm MLS. 5mm high density focus along L side of falx, could represent focus of SDH vs SAH. No OSH CT available for comparison. OSH CT report max thickness 2.3cm. . [**2169-10-7**] RUS Moderate bilateral hydronephrosis. . [**2169-10-7**] CT HEAD WITHOUT CONTRAST: As before, patient is status post left parietal craniectomy and evacuation of the left subdural space. There is overall less pneumocephalus along the anterior aspect of the frontal lobes and left temporal lobe compared to a day prior with foci of air along the falx cerebri. Low- density fluid within the left subdural space measures 7 mm in widest dimension with persistent foci of high density mostly near the area of craniotomy but also along the left temporal lobe. There is more low- density fluid within the right subdural space compared to a day prior, measuring approximately 8 mm in largest axial dimension. The appearance of the ventricles is unchanged with layering blood within the posterior horns of the lateral ventricles bilaterally. There is no significant subfalcine herniation. Extensive periventricular white matter hypodensity and right basilar ganglia and bilateral thalamic lacunes are unchanged. Surrounding soft tissues again reveal postoperative changes and skin staples in the left parietal region. Imaged portions of the paranasal sinuses demonstrate mild mucosal thickening and mastoid air cells appear well aerated in the setting of a right sided nasogastric tube. Atherosclerotic calcifications of carotid and vertebral arteries bilaterally are again noted. IMPRESSION: Predominantly low fluid density within the subdural spaces bilaterally. Blood in the lateral ventricles as before. . [**2169-10-13**] RUS (REPEAT) COMPARISON: Renal ultrasound [**2169-10-7**]. FINDINGS: The examination was limited due to the patient's inability to cooperate. The right kidney measures 10.7 cm and the left kidney measures about 12.6 cm. There is persistent hydronephrosis bilaterally which appears to be unchanged from the prior exam. A partially distended bladder is identified which shows layering amount of sludge in the dependent portion. IMPRESSION: Bilateral persistent hydronephrosis which appears unchanged from the prior exam. . [**2169-10-14**] HEAD CT WITHOUT CONTRAST: Comparison was made to the prior head CT dated [**2169-10-7**]. The patient is status post evacuation of left subdural hematoma, with bifrontal subdural collection, with crescent-shaped subdural hematoma with hyperattenuating material along the left parietal lobe. The overall size and appearance of the subdural hematoma is unchanged. The pneumocephalus seen on prior study has near completely resolved. There is no shift of normally midline structures. There is periventricular hypoattenuation with small prior lacunar infarcts. The surrounding osseous and soft tissue structure is unremarkable. There is minimal mucosal thickening in the maxillary sinuses. IMPRESSION: Overall unchanged appearance of the subdural hematoma with bifrontal subdural collection post evacuation. Chronic small vessel ischemia and lacunar infarct. . [**2169-10-15**] CXR COMPARISON: [**2169-10-13**]. INDICATION: Worsening shortness of breath. Volume overload. Nasogastric tube remains in standard position. Cardiomediastinal contours are stable. There has been improvement in degree of pulmonary vascular engorgement and diffuse pulmonary edema has also improved. Apparent focal opacity in left lower lung likely represents confluence of inferior scapular border and adjacent rib, but attention to this area on a followup radiograph would be helpful to exclude a focal parenchymal abnormality in this region. . EEG [**10-18**]: Abnormal EEG due to the persistent left parasagittal slowing and due to the bursts of generalized slowing. The left parasagittal slowing indicates a focal subcortical dysfunction in the left hemisphere although the tracing cannot specify the etiology. The bursts of generalized slowing imply a dysfunction in midline structures, possibly related to the first abnormality. Nevertheless, the background appeared normal at other times. There were no clearly epileptiform features. . Abdominal ultrasound [**10-18**]: 1. No evidence for cholecystitis or biliary abnormalities. 2. Fusiform abdominal aortic aneurysm with maximal diameter of 4.0 cm. 3. Grossly abnormal bladder with an irregular thickened wall. This cannot be fully evaluated as there is virtually no fluid in the bladder lumen. Further imaging is recommended either by cystoscopy or pelvic MRI. . Brief Hospital Course: 82M s/p L occupital craniotomy and evacuation of acute SDH s/p fall on lovenox, plavix. Now with UTI, worsening renal function, and fluid overload. . # Acute on chronic renal failure with increasing SCr (1.6-->2.9). The primary process of the acute renal failure was likely from obstructive metastatic prostate cancer. Renal US showed moderate hydronephrosis with bilateral stents placed [**7-29**](known bilateral hydronephrosis). Originally Cr had improved from 3.9 to 2.3 with hydration as a component of the ARF was thought to be prerenal; however, the creatinine began to rise again and the worsening renal function was likely obstructive in etiology representing advancing prostate cancer. Bilateral percutaneous nephrostomy tubes were placed and the patient's Cr improved to 1.0. He continued to have good urine output from his nephrostomy tubes. The patient was advised to follow-up with his outpatient Urologist, Dr. [**First Name (STitle) **], for removal of his ureteral stents. His percutaneous nephrostomies can be in place up to 3 months; if needed, his outpatient urologist can pursue revision. . #. UTI: UA was suggestive of UTI and urine cultures grew enterococcus sensitive to amoxicillin and pan-sensitive to all antibiotics on culture and sensitivities. The patient was asymptomatic but his dementia limited his report of symptoms. The patient was intermittently febrile. He was treated with 10 days of ampicillin. . # RUE weakness: RUE weakness was present prior to SDH evacuation but improved with surgery. RUE weakness was intermittently present s/p surgery. On exam, he showed decreased motor strength and repeat CT head showed overall unchanged appearance of the subdural hematoma post evacuation. Therefore, the intermittent RUE weakness was likely due to deconditioning. . #. SDH s/p L occiptal craniotomy: The patient was continued on seizure prophylaxis with dilantin. He was found to have a low dilantin level, re-loaded, and then dilantin levels were closely monitored. As it was difficult to maintain therapeutic dilantin levels, neurology advised that he be switched to keppra. At the time of discharge, his Keppra dose was being titrated up. As outlined in his discharge paperwork, his keppra dose should be 500mg po bid x 2 more days. Then increase to 750mg po bid for [**10-26**], then increase to 1000mg po bid on [**10-30**] and continue until instructed to stop by neurosurgery. To avoid withdrawal seizures, he should continue on dilantin 100mg po tid until the keppra is at goal, at which time the dilantin can be tapered. Thus, on [**10-31**] and 10, his dilantin should be decreased to 100mg po bid. On [**11-2**] and 12, he should be given dilantin 100mg daily. On [**11-4**], his dilantin can be stopped. . # s/p MI w/ increased biomarkers. At OSH prior to transfer, the patient was found to have an elevated troponin and CK-MB X1. EKG showed RBBB with lateral ST depressions (old from [**July 2169**]). Echo at OSH had shown posterior, anterior wall HK, EF 40-45%. At [**Hospital1 18**], echo to confirm WMA and EF for prognostic reasons showed inferobasal hypokinesis and an EF of 50%. Cardiology was consult and the patient was found not to be a candidate for either cardiac catheterization secondary to cormobities or IV heparin secondary GI bleed. Medical management for MI was provided with BB and ASA. Plavix was held in the setting of his SDH, and he should not restart plavix unless cleared to do so by neurosurgery. . # Hypernatremia: Was likely secondary to dehydration, lack of access to free water, decreased thirst sensation. His HCTZ was held and his electrolytes monitored; he improved with free water flushes. It is important that his sodium and potassium be monitored at least every three days until he is stable on his tube feeds. . # Wound assessment: The patient had a coccygeal pressure ulcer (Size: 2 x 0.7 cm). Incontinence care was provided with barrier creams. He was turned and reposition frequently and treated for a fungal infection with topical therapy. . # Abnormal bladder on ultrasound of abdomen: Patient is known to have metastatic bladder cancer. It is recommended that his PCP address the possibility of further imaging of the bladder as appropriate. . # Elevated transaminases: patient noted to have AST and ALT increase to 200s; elevated alk phos to 600s. Although the alk phos was attributed to his prostate cancer, the transaminases appeared to decline after stopping his statin. Abdominal ultrasound negative. . # Medication changes: Many of the patient's home meds were altered during hospitalization: - Flomax stopped as no longer necessary given nephrostomy tubes - HCTZ and Norvasc replaced with metoprolol in setting of recent NSTEMI - Lipitor stopped as patient had elevated transaminases, appeared to decrease after holding statin. - Lisinopril stopped for ARF, restarted at 5mg daily at discharge - plavix held b/c of SDH; do not restart without clearing with Neurosurgery Medications on Admission: aricept 10 ativan 0.5 prn flomax 0.4 hctz 12.5 isodil 30 lipitor 40 lisinopril 20 glucophage 500" norvasc 5 percocet prn PLAVIX 75 LOVENOX 40 Discharge Medications: 1. Docusate Sodium 50 mg/5 mL Liquid Sig: [**6-1**] ml PO BID (2 times a day) as needed for constipation. 2. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for agitation. 3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 2 days: to be taken on [**10-24**] and [**10-25**]. 5. Levetiracetam 750 mg Tablet Sig: One (1) Tablet PO twice a day for 4 days: to be taken on [**9-1**], [**10-28**], [**10-29**]. 6. Levetiracetam 1,000 mg Tablet Sig: One (1) Tablet PO twice a day: Start taking this dose on [**10-30**]. Please do not discontinue without discussing with Neurosurgery (Dr. [**Last Name (STitle) **]. 7. Potassium Chloride 20 mEq Packet Sig: One (1) packet PO twice a day. 8. Phenytoin 100 mg/4 mL Suspension Sig: Four (4) ml PO twice a day for 2 days: On [**10-31**] and [**11-1**]. 9. Phenytoin 100 mg/4 mL Suspension Sig: Four (4) ml PO once a day for 2 days: On [**11-2**] and [**11-3**], then stop phenytoin. 10. Phenytoin 100 mg/4 mL Suspension Sig: Four (4) ml PO three times a day for 1 weeks: [**Date range (1) 75213**]. 11. Aricept 10 mg Tablet Sig: One (1) Tablet PO once a day. 12. Imdur 30 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. 13. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day. 14. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO twice a day. 15. Glucophage 500 mg Tablet Sig: One (1) Tablet PO twice a day. Discharge Disposition: Extended Care Facility: [**Hospital **] rehab hospital Discharge Diagnosis: PRIMARY 1. Left sided subdural hematoma s/p craniotomy 2. Acute renal failure SECONDARY Diabetes, HTN, Chronic Kidney Disease (baseline 1.6), Alzheimer's dementia, metastatic prostate Discharge Condition: Neurologically stable and kidney function had normalized after placement of his nephrostomy tubes. He was tolerating tube feeds well through his PEG. He was afebrile and vital signs stable. Discharge Instructions: 1. Take all medications as prescribed 2. Make all follow-up appointments 3. Watch incision for any redness, drainage, bleeding, swelling at site - if so, please contact your provider or report to the Emergency Department 4. If you develop fevers, chills, weakness, lethargy, nausea, vomiting, or other concernin symptoms, please contact your provider or report to the Emergency Department Followup Instructions: 1. Please follow up with Dr [**Last Name (STitle) **] in 4 weeks with a head CT, call [**Telephone/Fax (1) 2731**] for an appointment. 2. Please arrange to see your PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 44432**] in 2 weeks. We will fax him a copy of your discharge summary to facilitate coordination of care. 3. Please see your urologist Dr. [**First Name (STitle) **] in [**Location (un) 5503**] in [**2-26**] weeks. You will need to have your stents removed; the nephrostomy tubes are good for 2-3 months. Completed by:[**2169-10-23**]

[ "428.0", "250.00", "263.0", "852.26", "294.10", "787.20", "V10.46", "112.0", "276.0", "592.0", "427.1", "198.5", "410.71", "396.3", "331.0", "441.4", "E849.7", "276.2", "276.51", "041.04", "E884.4", "707.03", "437.0", "584.9", "348.8", "599.0", "403.91", "591", "285.9", "428.33", "585.6" ]

icd9cm

[ [ [] ] ]

[ "89.14", "96.07", "96.71", "55.03", "01.31", "99.04", "88.72", "44.32" ]

icd9pcs

[ [ [] ] ]

16953, 17010

10212, 14743

321, 474

17238, 17432

4725, 10189

17869, 18432

3895, 3912

15404, 16930

17031, 17217

15237, 15381

17456, 17846

3927, 4287

14763, 15211

223, 283

502, 3029

4302, 4706

3051, 3576

3592, 3879

77,128

165,533

46103

Discharge summary

report

Admission Date: [**2158-6-1**] Discharge Date: [**2158-6-6**] Date of Birth: [**2089-6-2**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1936**] Chief Complaint: Dyspnea Major Surgical or Invasive Procedure: blood t/f 2U and plt t/f 1 packet History of Present Illness: 68M with history of splenectomy, CAD s/p CABG, myelodysplasia, presenting with dyspnea, fever and chills x 1 day. Has had been well until 3 days ago, when developed a few hours of chills that self resolved. Then last night had N/V with nonbloody emesis. Few episodes overnight and again this morning. This AM also became very dyspneic and had chills and ?rigors, did not take temp at home. Coughing also overnight, productive of ?whitish sputum. Presented to an OSH where he looked unwell - T101.5, BP 100s, HR 110s, RR 20s, 88% RA. CXR with multifocal pneumonia. Hct 25. Given levo/flagyl and transferred to [**Hospital1 18**] for further care. . In the [**Hospital1 18**] ED, initial vs were: T99.1 HR 104, BP90/40, 20 99% on NRB. CXR confirmed multifocal opacities. BPs maintained in 90s. Labs notable for Hct 22.3, lactate 1.4. Patient was given ceftriaxone, 1 unit PRBCs, and 4 L IVFs. Respiratory status remained adequate even with supine positioning. Admit to MICU given tenuous hemodynamic status. . On the floor, patient reports feeling well; wife endorses that seems better than this AM. Still with some breathing difficulty. No CP, no HA, abd pain, diarrhea, dysuria. . Review of sytems: (+) Per HPI (-) Denies recent weight loss or gain. No edema. Denies headache, sinus tenderness, sore throat, rhinorrhea or congestion. Denied cough, shortness of breath. Denied chest pain or tightness, palpitations. Denied diarrhea, constipation or abdominal pain. No dysuria. Denied arthralgias or myalgias. No bleeding anywhere. . Past Medical History: - Myelodysplasia, followed with weekly Hct checks and transfusions (2 units) few times per year; otherwise on weekly procrit. - s/p splenectomy - for management of Hodgkin's lymphoma. Yearly flu vax, has had pneumovax in past (perhaps few years ago), does not recall meningovax. - h/o Hodgkins lymphoma - diagnosed [**2129**], managed with XRT to neck and chest alone. No chemo. Had splenectomy as part of treatment but did not seem that spleen involved with lymphoma. - CAD s/p CABG [**2141**] (4 vessel). No known PCI. - HTN - History of prostate cancer - treated with radiation seeds. - ?Afib - describes tachycardia and ?ablation or cardioversion in [**2137**]. - Hypothyroidism - Gout Social History: Lives with wife. [**Name (NI) **] [**Name2 (NI) **] contacts. [**Name (NI) **] significant outdoor/[**Doctor Last Name 6641**] exposures; no tick bites. Past smoker - 60 pack years, quit [**2141**]. Rare alcohol. No illicits. Worked as a foundry worker, +past asbestos exposures. Family History: Father had brain cancer, o/w NC. Physical Exam: Vitals: T: BP: P: R: 18 O2: General: Alert, oriented, slightly tachypneic HEENT: Sclera anicteric, PERRL, EOMI, MMM, oropharynx clear Neck: supple, JVD approx 3 cm ASA, no LAD. R EJ in place; L IJ in place. Lungs: Decreased air entry on R; few crackles on R with more inspiratory/exp rales on L and rare wheeze. CV: Regular rate and rhythm, harsh SM heard throughout precordium, ?max in RUSB, some radiation to carotids. Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly. Ext: slightly cool, well perfused, 2+ pulses, no clubbing, cyanosis or pitting edema. Neuro: CN II-XII intact. Distal strength 5/5 in UE and LE. ./ on dishcarge Vitals: 97.0 94/64 98 18 97%RA Pain: [**12-25**] PIP and lateral feet (improved) Access: PIVs Gen: nad, speaking full sentences HEENT: mmm CV: RRR, [**2-18**] SM heard all over Resp: CTAB, improved crackles, no wheezing or rhonchi Abd; soft, nontender, obese, +BS Ext; no edema Neuro: A&OX3, grossly nonfocal MS: Improved swelling/erythema/pain of b/l 3rd PIP, R 1st MCP, b/l lateral feet (were worse last PM) Skin: no changes other than above psych: appropriate Pertinent Results: wbc 6-->10->[**5-23**] hgb 6.7->8.6 (s/p 2U prbc) HCT 22-> 27.4 (s/p 2U prbc) ([**Month/Day (3) 5348**] 25-28) plt 63->53-->43->36->48 (got 1pack plts on [**6-2**]) INR 1.4, PTT wnl Retic 5.3 fibrinogen wnl Chem: BUN/creat 27/0.8 (was 44/1.3 on admission) trop <0.01->0.05, CKMBs normal alb 3.1 TSH 4.4 . UA [**6-1**] wnl, UCx neg Urine legionella neg . Blood cx [**6-1**] X3 NTD MRSA screen neg sputum GS neg, Cx sparse OP flora . . EKG: Sinus tach at 103. Borderline IVCD. Q wave in III. <1mm STD in V5-V6 with TWI or biphasic Ts in I, avL, V6. Poor RWP. With exception of V5-V6 ST/T changes, unchanged from prior dated [**2157-6-1**]. ECG from OSH at 7am: notable for more significant STD/TWI in V5-V6, borderline STD in III and aVF. . Imaging/results: CXR [**6-1**] Single AP frontal view of the chest was obtained. The patient is status post median sternotomy. The upper two sternotomy wires are broken. Consolidations in the right upper lobe as well as in the lingula, inferior left upper lobe and likely left lower lobe are highly worrisome for multifocal pneumonia. Trace bilateral pleural effusions may be present. No pneumothorax is seen. The cardiac silhouette is top normal to mildly enlarged. The aorta is calcified. . CXR [**6-2**] 1. Bilateral lung opacities, in similar distribution compared to prior, appear more organized on the left, concerning for multifocal pneumonia. Central lucency in the left perihilar opacity, could be small cavitation; although to early to tell. 2. Appropriate positioning of the left IJ catheter height. 3. No pleural effusion or pneumothorax. . CXR [**6-6**] repeat 1. Interval improvement in multifocal pneumonia. 2. Stable mass-like right upper lobe opacity concerning for malignancy as suggested on recent CT. . CT contrast [**6-3**] w/o contrast: prelim 1. Right upper lobe mass as well as findings compatible with multifocal pneumonia. The mass in the right upper lobe may also represent pneumonia, but short interval followup is recommended to exclude a mass lesion. 2. Mediastinal adenopathy. 3. Small bilateral effusions. 4. No cavitary lesions within the lungs. 5. Renal cysts. 6. Status post splenectomy. Brief Hospital Course: 68 year old man with h/o Hodkins s/p XRT/splenectomy, transfusion dependent MDS with anemia/thrombocytopenia, CAD/CABG, Gout, hypothyroidism admitted with acute onset fever/chills/cough/hypoxia, found to have multifocal PNA with mild sepsis. Initially admitted to MICU with pneumosepsis. Recieved 4L fluids and broad spectrum Abx. Stabilized and transfered out of MICU [**6-2**]. Please see plan below by problem: . Multifocal PNA with resolved pneumosepsis: Acute onset in asplenic patient with MDS. Presented with mild sepsis and admitted ICU initially. Recieved fluids, oxygen, and 72hours of broad Abx: Vanc, levo/flagyl, CTx to cover for severe CAP with MRSA coverage. Was transferd to floor day after admission. He continued to improve and his oxygen was weaned off. Since he remained afebrile and his Blood Cx remain negative after 72hours, his Abx were narrowed to Levo only on [**6-4**] with plan for 7days course (has one more day left on discharge). His sputum gram stain showed GPCs in pair but culture showed sparse OP flora. By time of discharge, his cough was improved, he had good sats on RA, and was afebrile for several days. Of note, he underwent a CT scan shortly after admission given concern for mass/cavitation on CXR in RUL. This showed multifocal PNA but also showed a more dense RUL mass. While this is most likely also the PNA, pt does have a h/o XRT to chest. He reports h/o R lung "nodule" but cant clarify details as PCP was out of town. We repeated a CXR on discharge which showed an improvement in his PNA but stable RUL mass concerning for PNA. He needs a short term repeat CT to make sure this resolves, and if not, needs to discuss further w/u with patient. I have relayed this to covering PCP as well as patient. . MDS with anemia and thrombocytopenia: per covering PCP, [**Name10 (NameIs) 5348**] hct 25-28 and plt 30s). His HCT was 22 on admission, he recieved total of 2U prbc during hospital stay with improvement in his energy. HCT on d/c was 27. His Plt counts initally were in 60s but dropped to 30-40s but remained stable X3days! He had some mild hematuria (with foley) in ICU and got 1Pack of plts, but this dropped his counts rather than improved. He had no more bleeding/petichia so he did not get any more transfusions. He will continue outpt procrit. He has heme f/u in 3days after discharge. . Gout flare: During the later part of the hospitalization, pt developed pain/swelling of his R 1st and 3rd PIP and b/l lateral feet. This was typical for patient's gout symptoms. While aware of the potential side effect of BM supression with colchine, we were limited with options for treatment (did not tolerate NSAIDs in past and had active infection and DM so didnt want to do prolonged steroids). He recieved one dose of colchicine 0.6mg on [**6-4**] and one dose on [**6-5**]. He recieved prednisone 40mg X1 [**6-4**], 20mg X1 [**6-5**] and [**6-6**]. He had significant improvement with this regimen and no symptoms on discharge. Thus, he did not require any steroids on discharge. We continued his allopurinol 300mg daily through flare . ARF: creat 1.3 on admission. in setting of fever/sepsis. Resolved with fluids to 0.8. . CAD/CABG: Initial EKGs had some lateral ST changes c/w with some demand related changes which improved on repeat EKG. He had a mild trop leak (0.05) but no ACS. This was consistent with underlying CAD. Given his issues of severe TCP, we decreased his ASA from 325mg to 81mg. This was discussed with covering PCP. [**Name10 (NameIs) **] he was continued on simva 80, zetia 10, metoprolol 50mg [**Hospital1 **], lisinopril 10mg. OF note, his HR was around 90s while here. Given tachycardia at [**Hospital1 5348**], consider titrating down lisinopril so that can titrate up metoprolol (limited by BP currently). Defer to PCP. . Hypothyroidism: tsh wnl. continued on synthroid 125mcg daily . Dispo/Code: full code. PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 10543**] is on vacation but covering MD updated of plan [**6-5**]. Pt has f/u with Dr. [**Last Name (STitle) 10543**] on [**6-15**]. discharged home in good condition. cleared by PT. family updated on plan. . Medications on Admission: ASA 325 mg daily Simvastatin 80 mg daily Lisinopril 10 mg daily Metoprolol 50 mg twice daily Levothyroxine 125 mcg daily Allopurinol 300 mg daily Zetia 10 mg daily Procrit [**Numeric Identifier 961**] units once weekly Discharge Medications: 1. Acetaminophen 650 mg PO/NG Q6H:PRN fever, pain give before blood 2. Allopurinol 300 mg PO/NG DAILY 3. Aspirin 81 mg PO/NG DAILY 4. Calcium Carbonate [**Telephone/Fax (1) 1999**] mg PO/NG QID:PRN heart burn 5. Ezetimibe 10 mg PO DAILY 6. Levofloxacin 750 mg PO/NG DAILY Disp #*1 Dose(s) Refills:*0 7. Levothyroxine Sodium 125 mcg PO/NG DAILY 8. Lisinopril 10 mg PO/NG DAILY Start: In am 9. Metoprolol Tartrate 50 mg PO/NG [**Hospital1 **] Please hold for SBP <100 and HR<60 10. Simvastatin 80 mg PO/NG DAILY 11. Epoetin Alfa 10,000 U SC EVERY WEEK resume your prior schedule Discharge Disposition: Home Discharge Diagnosis: Multifocal Pneumonia with pneumosepsis RUL mass of unclear etiology-possibly [**Name (NI) 98096**] f/u CT scan MDS with severe anemia/thrombocytopenia s/p 2U prbc and 1pack platelets CAD/CABG hypothyroidism s/p splenectomy ARF resolved Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted with acute onset of fevers, cough, chills. You were diagnosed with severe pneumonia. Given how [**Name (NI) **] you were, you initally went to the ICU where you were treated with broad coverage IV antibiotics. You improved with this. Once your cultures were negative, we were able to narrow your antibiotics to Levofloxacin oral alone. YOu did well on this. Your oxygen was weaned down. Your CAT scan showed that you have a large mass in your right upper lung. While this may very well be due to the pneumonia, it could also be something else. We do not have prior xrays from you to know if this is new mass. You need to have a repeat CAT scan of your lung in 2weeks to make sure this gets better. If it doesnt, you can have further discussions with Dr. [**Last Name (STitle) 10543**] on whether you are interested in working this up further. . You also have myelodysplastic syndrome which causes severe anemia and low platelet counts. You were slightly lower than your [**Last Name (STitle) 5348**] so you got 2 Units of blood while here. There was no bleeding. You also recieved some platelets because you had slight pinkish urine. However, it doesnt appear that the platelets respond to transfusion. Due to your increased risk of bleeding with low plateles, we have decreased your aspirin to BABY aspirin 81mg. Please discuss whether you should stop altogether with Dr. [**Last Name (STitle) 10543**] or your cardiologist. You dont have a spleen which predisposes you to some infections. Please makes sure you are up to date with all your vaccines for pneumonia, meningitis etc . You also had a gout flare while you were here. You were treated with two doses of colchicine and 3doses of prednisone and you improved. . Your other medications are all the same for your heart, gout, and hypothyroidism. . It was a pleasure caring for you. I am glad you are feeling better. Happy Anniversary to you and your wife! Best of luck to you! Followup Instructions: Name: [**Last Name (LF) **],[**First Name3 (LF) **] B. When: Thursday, [**6-15**], 11am Location: [**Hospital3 **] INTERNAL MEDICINE ASSOCIATES Address: [**Street Address(2) 4472**], [**Apartment Address(1) 4473**], [**Hospital1 **],[**Numeric Identifier 9331**] Phone: [**Telephone/Fax (1) 4475**]

[ "486", "414.00", "401.9", "285.9", "238.75", "786.6", "V10.46", "V45.81", "287.5", "V10.72", "274.00", "995.92", "038.9", "584.9" ]

icd9cm

[ [ [] ] ]

[ "38.93" ]

icd9pcs

[ [ [] ] ]

11428, 11434

6398, 10557

320, 356

11714, 11714

4208, 6375

13841, 14143

2969, 3003

10826, 11405

11455, 11693

10583, 10803

11865, 13818

3018, 4189

273, 282

1597, 1933

384, 1579

11729, 11841

1955, 2649

2665, 2953

21,312

196,842

4085

Discharge summary

report

Admission Date: [**2181-2-10**] Discharge Date: [**2181-2-14**] Date of Birth: [**2105-5-21**] Sex: F Service: MEDICINE Allergies: Vancomycin Attending:[**First Name3 (LF) 99**] Chief Complaint: GI bleed Major Surgical or Invasive Procedure: Upper endoscopy and treatment of esophageal bleed with epinephrine and BiCAP cauterization. History of Present Illness: 75 y/o female with PMH sig for DM, [**First Name3 (LF) 1291**], s/p [**Hospital3 **] valve, HTN, CAD (no caths at [**Hospital1 **]), diastolic dysfxn, who presented from Heb Reb on [**2181-2-9**] with 2 episodes of melanotic stool and coffee-ground emesis. Denies abd pain, N/V, BRBPR. Per pt's son, no odynophagia, dysphagia, or GERD. Pt was found to have a positive NGT lavage, with a HCT of 23.7. GIB was felt to have recurrent UGIB in setting of supratherapeutic INR (4.0); pt has a history of bleeding esophageal ulcers in [**2178**] with elevated INR). . Coagulopathy was reversed with a total of 6U of FFP. Pt received 3U pRBC total over [**2181-2-10**] to keep hct > 30, with a hct increase from 20 to 30.7. An NGT was placed and the pt began to receive 40mg IV bid and sulcrafate suspension 1gr qid. On [**2-10**], EGD showed: 1) Grade II esophagitis with a visible vessel in the GE jxn; hemostasis was achieved with epi and bicap cauterization, and 2) erosion in gastric cardia. She was placed on a clear liquid diet and advanced. Hct remained stable. Also of note, Cr went from 1.7 on admission to 1.1 on [**2-11**] (baseline). U lytes showed a FeNA of .3% and the pt was felt to have been prerenal from low flow state. The patient had a mild elevation in cardiac enzymes, with peak CK 111, peak CKMB 4, and peak Trop .06. Past Medical History: DM [**Month/Year (2) 1291**] St Jude's valve HTN CAD. S/p cardiac cath in [**6-2**] and has been on plavix since then. Unclear if stent was placed at that time. Diastolic dysfunction Dementia Dyslipidemia H/o esophageal ulcers Depression Expressive aphasia H/o R heel osteo CVA [**2169**] Gallstones Spinal stenosis H/o pulmonary sarcoid PVD ?H/o PBC H/o C diff H/o VRE urinary infection Physical Exam: 96.8 132/43 75 24 96%RA -2080 at 4pm (24hr I/O) Alert and talkative, oriented to person, mumbles, lying in bed, NAD JVD approx 7, neck supple, dry MM Chest No wheezing appreciated, few crackles heard - difficult to appreciate d/t body habitus CV RRR with metallic 2nd heart sound Soft, +BS, NT/ND Extr - 1+ edema, R foot ulcer with a small amount of purulent exudate Pertinent Results: EKG: LBBB at 87, PR prolongation, no significant change from prior Echo from [**2-3**]: Nl EF, moderate [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 17972**], mod symm LVH, dilated RV cavity . PORT CXR: Linear opacity at L base could be atelectasis vs. early infiltrate. . UA: Mod leuk's, trace blood, 100 glucose, [**3-3**] RBC, [**11-18**] WBC, many bacteria . ADMISSION LABS: [**2181-2-9**] 09:56PM WBC-12.3* RBC-2.56*# HGB-7.8*# HCT-23.7*# MCV-93 MCH-30.6 MCHC-33.1 RDW-13.8 [**2181-2-9**] 09:56PM PLT COUNT-164 [**2181-2-9**] 09:56PM NEUTS-85.7* LYMPHS-9.7* MONOS-3.7 EOS-0.7 BASOS-0.2 [**2181-2-9**] 09:56PM PT-25.3* PTT-30.3 INR(PT)-4.0 [**2181-2-9**] 09:56PM GLUCOSE-275* UREA N-124* CREAT-1.7* SODIUM-136 POTASSIUM-5.6* CHLORIDE-101 TOTAL CO2-29 ANION GAP-12 [**2181-2-9**] 09:56PM ALBUMIN-3.1* CALCIUM-8.7 PHOSPHATE-2.9 MAGNESIUM-2.0 [**2181-2-9**] 09:56PM CK-MB-4 [**2181-2-9**] 09:56PM cTropnT-0.04* [**2181-2-9**] 09:56PM ALT(SGPT)-15 AST(SGOT)-14 LD(LDH)-225 CK(CPK)-111 ALK PHOS-94 AMYLASE-41 TOT BILI-0.2 [**2181-2-9**] 09:56PM LIPASE-33 . DISCHARGE LABS: [**2181-2-14**] 06:30AM BLOOD WBC-9.8 RBC-3.46* Hgb-10.4* Hct-30.0* MCV-87 MCH-30.0 MCHC-34.6 RDW-16.7* Plt Ct-144* [**2181-2-14**] 06:30AM BLOOD Plt Ct-144* [**2181-2-14**] 06:30AM BLOOD Glucose-145* UreaN-50* Creat-1.4* Na-139 K-4.4 Cl-103 HCO3-27 AnGap-13 [**2181-2-14**] 06:30AM BLOOD Calcium-8.7 Phos-4.1 Mg-2.0 . [**2181-2-12**] 08:00PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.013 [**2181-2-12**] 08:00PM URINE Blood-MOD Nitrite-NEG Protein-TR Glucose-1000 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-TR [**2181-2-12**] 08:00PM URINE RBC-[**3-3**]* WBC-[**3-3**] Bacteri-OCC Yeast-NONE Epi-0-2 . URINE CULTURE (Final [**2181-2-13**]): PROTEUS MIRABILIS. >100,000 ORGANISMS/ML.. Trimethoprim/sulfa sensitivity confirmed by [**Doctor Last Name 3077**]-[**Doctor Last Name 3060**]. CITROBACTER FREUNDII COMPLEX. >100,000 ORGANISMS/ML.. Trimethoprim/sulfa sensitivity confirmed by [**Doctor Last Name 3077**]-[**Doctor Last Name 3060**]. This organism may develop resistance to third generation cephalosporins during prolonged therapy. Therefore, isolates that are initially susceptible may become resistant within three to four days after initiation of therapy. For serious infections, repeat culture and sensitivity testing may therefore be warranted if third generation cephalosporins were used. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ PROTEUS MIRABILIS | CITROBACTER FREUNDII COMPLEX | | AMPICILLIN------------ =>32 R AMPICILLIN/SULBACTAM-- =>32 R CEFAZOLIN------------- 16 I CEFEPIME-------------- <=1 S <=1 S CEFTAZIDIME----------- <=1 S <=1 S CEFTRIAXONE----------- <=1 S <=1 S CEFUROXIME------------ 16 I CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ 8 I <=1 S IMIPENEM-------------- <=1 S LEVOFLOXACIN---------- =>8 R 1 S MEROPENEM-------------<=0.25 S <=0.25 S NITROFURANTOIN-------- <=16 S PIPERACILLIN---------- 32 I <=4 S PIPERACILLIN/TAZO----- <=4 S <=4 S TOBRAMYCIN------------ 8 I <=1 S TRIMETHOPRIM/SULFA---- =>16 R <=1 S Brief Hospital Course: A/P: 75yo F with DM, HTN, diastolic dysfunction, [**Hospital3 **] [**Hospital3 1291**] on coumadin, p/w UGIB from Heb Reb in setting of esophageal ulceration and supratherapeutic INR. . 1. UGIB, likely [**1-31**] increased INR and esophageal ulceration, s/p Epi/BiPAP cauterization. - 2 large bore IV's were maintained and the hct was checked every 8 hours. The hct was stable. Her transfusion goal was hct > 30 but she had no requirement for transfusion on the floor. - She was maintained on po PPI and carafate 1gr qid. - On [**2-11**], she was begun on coumadin and heparin drip. She was loaded with 10mg coumadin qhs on [**3-19**], and [**2-13**]. At the time of her discharge, her AM INR was 2.1 (goal [**2-1**]), but in the setting of a very elevated PTT of 150. - Her diet was advanced as of [**2-11**] without difficulty. - She had no further episodes of GIB. . 2. CAD. On admission she was noted to have had a small increase in her cardiac enzymes, likely related to demand ischemia. No EKG changes (but pt does have a LBBB). - Betablocker and statin were continued. The pt was not on an ACE or aspirin. - Plavix and coumadin were held initially. Coumadin was restarted on [**2-11**], and plavix was restarted on [**2-13**] (loading dose 300mg, then 75mg qd). - Incidentally, the pt was placed on a heparin gtt for her [**Hospital3 17973**] valve, which would also be the medical management of an ischemic event as well. . 3. Diastolic dysfunction - Outpatient diuretics (100mg lasix qd) were initially held in the setting of GIB, then restarted. . 4. HTN - BB was initially held in the setting of GIB, then restarted. . 4. [**Hospital3 1291**]. Coumadin was held in the setting of GIB, and the patient received Vitamin K in the ER. After her hct was stable and GIB was resolved, the heparin drip was started on [**2-11**] along with coumadin. INR goal 2.0-3.0. It was difficult to maintain an appropriate PTT (goal 60-80) and the patient had several episodes of epistaxis in the setting of elevated PTT. Her hct trended down very slowly and this was attributed to her multiple episodes of epistaxis and her frequent phlebotomy. . 5. UTI - Proteus, resistant to levoquin. The patient was initially treated with levoquin (begun [**2-10**]), but sensitivities showed resistance. On [**2181-2-12**], she was begun on ceftriaxone 1gr qd and should remain on that for at least 7 days. . 6. Psych - Continued risperdal and paxil . 7. FEN - Diabetic/Consistent Carbohydrate; Nectar prethickened liquids. Monitor for signs of aspiration. . 8. R foot ulcer. Pt has had R2-4 toe amps, now with distal ulceration. The patient was last seen by podiatry at [**Hospital1 18**] on [**5-2**], at which time she was referred for a necrotic 3rd toe (which did not probe to bone), to vascular surgeon Dr. [**Last Name (STitle) 17974**] at [**Hospital1 112**], as the podiatrist did not feel her ulcer would heal with conservative wound care/abx or with local debridement. Dr. [**Last Name (STitle) 17974**] has overseen the pt's wound care since. Her most recent appointment with him was at the beginning of [**2181-1-30**]. The patient is also followed closely by the wound care nurse [**First Name (Titles) **] [**Hospital1 7338**] Rehab. - The patient's ulcerations did not appear infected on admission. She was treated with duoderms to both sites, qd. She was placed in a multipodus splint bilaterally. . 9. Access - 2 PIV's were maintained . 10. FC, per [**Hospital 100**] Rehab records re: discussions with pt's son . 11. Precautions: Aspiration, MRSA, h/o C diff . Medications on Admission: Coumadin 7mg qhs, NPH 8U SQ qPM, 28 SC qAM, albuterol, CaCarb 650 [**Hospital1 **], plavix 75qd, prozac 20 qd, lasix 100 qam, lopressor 12.5mg [**Hospital1 **], MVI, risperdal 1mg qhs, zocor 10mg qd, actigall 600 [**Hospital1 **] . ALLERGY: Vancomycin Discharge Medications: 1. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q6H (every 6 hours) as needed. 2. Fluoxetine HCl 20 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 3. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Ursodiol 300 mg Capsule Sig: Two (2) Capsule PO BID (2 times a day). 5. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily). 6. Risperidone 1 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 7. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 8. Sucralfate 1 g Tablet Sig: One (1) Tablet PO QID (4 times a day). 9. Furosemide 40 mg Tablet Sig: 2.5 Tablets PO DAILY (Daily). 10. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Ceftriaxone Sodium in D5W 20 mg/mL Piggyback Sig: One (1) gr Intravenous Q24H (every 24 hours) for 3 days: Last day of 7-day course on [**2181-2-18**]. 12. Warfarin Sodium 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): ** This dose will need to be adjusted depending on patient's INR. 13. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 14. Insulin NPH Human Recomb 100 unit/mL Cartridge Sig: 28 Units each AM; 8 Units each PM Units Subcutaneous twice a day. 15. Insulin Regular Human 300 unit/3 mL Syringe Sig: As per sliding scale, attached Units Subcutaneous QID (at each meal and at bedtime). 16. Heparin Sod (Porcine) in D5W 100 unit/mL Parenteral Solution Sig: As per heparin drip protocol, attached Units Intravenous ASDIR (AS DIRECTED): Please see attached protocol. Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - Acute Rehab Discharge Diagnosis: 1. Upper GI bleed from esophagitis. S/p epinephrine and BiCAP cauterization. 2. [**First Name8 (NamePattern2) **] [**Male First Name (un) 1525**] [**Male First Name (un) 1291**], on coumadin 3. HTN 4. DM 5. CAD 6. Dementia 7. R heel ulcerations Discharge Condition: Stable and improved Discharge Instructions: Please call your doctor or return to the ER if you have any further episodes of bleeding from your rectum, or if you vomit blood. Also, if you have any weakness, fatigue, fevers, chills, chest pain, abdominal pain, or difficulty breathing. . Please take all your medications as directed. Followup Instructions: Please have the patient follow up with Dr. [**First Name (STitle) **] (PCP at [**Name9 (PRE) **] Reb) within the next week. . Please continue to have the patient followed by the wound care nurse. . FROM PAGE ONE: . 1. [**First Name8 (NamePattern2) **] [**Initials (NamePattern4) 1525**] [**Last Name (NamePattern4) 1291**] - Patient is not yet therapeutic on coumadin. INR goal is between 2 and 3. She has been on a heparin drip and receiving 10mg coumadin every night since [**2181-2-11**]. Her last INR checked was 2.1 on the morning of [**2-14**], but this was difficult to interpret in the setting of an elevated PTT. --> Adjust coumadin dose depending on INR. Check INR daily until therapeutic. --> Once therapeutic, the patient will need more frequent INR checks than she was receiving previously; her INR on admission to the [**Hospital1 18**] was 4.0 and she had a significant bleed. --> Heparin drip. Goal PTT is between 60 and 80. The protocol is attached. She is currently at 450U/hr. The next PTT will be drawn at 5pm at the [**Hospital1 18**], and the rate will be changed according. If there is a change made to the rate, 1) The [**Hospital1 18**] nurse will call the [**Hospital6 459**], and 2) The next PTT should be drawn at midnight. . 2. The patient will need aggressive physical therapy after a prolonged hospitalization. . 3. The patient will need better sugar control. At the [**Hospital1 18**], her sugars have been high (occasionally 200's), perhaps because of the sugar in the thickened water at the [**Hospital1 18**]. She will need close glucose control (finger sticks at breakfast, lunch, dinner, and bedtime) and adjustment of her standing glucose and sliding scale as appropriate, depending on her diet at the Rehab Center. . 4. The patient will need wound care for the R foot and posterior R ankle sites, with continued attention from the [**Hospital 100**] Rehab wound care nurse. . Site: 1) R foot medial ulceration 2) Superficial ulceration on distal [**1-1**] of leg Type: Leg ulcer Cleansing [**Doctor Last Name 360**]: Other Dressing: Duoderm Change dressing: qd Comment: Duoderm gel to both sites qd . 5. The patient has a UTI and is being treated with ceftriaxone qd IV. Course was started on [**2-12**] and should be continued for at least 7 days. . 6. The patient has a foley intact and will need the foley removed with voiding trial. This should be done as soon as possible to prevent further infection (would have been done today but did not want to initiate voiding trial if patient was being discharged).

[ "530.82", "V09.0", "599.0", "731.8", "790.92", "401.9", "041.6", "707.07", "414.01", "730.27", "530.19", "250.80", "518.0", "V43.3", "784.7", "440.23", "535.40", "041.11", "250.70" ]

icd9cm

[ [ [] ] ]

[ "42.33", "99.04" ]

icd9pcs

[ [ [] ] ]

11508, 11581

6037, 9600

278, 372

11869, 11890

2548, 2920

12226, 14789

9902, 11485

11602, 11848

9626, 9879

11914, 12203

3649, 6014

2161, 2529

230, 240

400, 1735

2936, 3633

1757, 2146

23,318

169,689

44214

Discharge summary

report

Admission Date: [**2155-6-26**] Discharge Date: [**2155-6-28**] Date of Birth: [**2080-11-30**] Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**Last Name (un) 32349**] Chief Complaint: SOB Major Surgical or Invasive Procedure: none History of Present Illness: Patient is a 74yo female with history of sarcoidosis, interstitial lung disease, COPD with FEV1/FVC ratio 43%, heart failure, and pulmonary hypertension who presented to the ED today with three days of worsening SOB, cough, green sputum. She states that her daughter recently returned from a vacation and was having upper respiratory symptoms last week. She started to feel SOB above her baseline and was having increased sputum. She increased her inhalers and her home prednisone dose from 20 mg (where she had been tapering it) to 40 mg. She denied fevers. She denied any chest pain, palpitations, lower extremity edema. Due to her persistent dyspnea her daughter elected to bring her to the [**Name (NI) **] today. In the ED T 99.2, P 115, BP 142/50, RR 26, O2 96% 2L Nasal Cannula. Pt received levofloxacin, albuterol, ipratroprium, and 125 mg methylprednisolone. CXR showed no deviiation from prior. On the floor, patient remained SOB, but improved, sating 95% on 3 L, conversationally dyspneic. . . <h3>[**Hospital1 139**] A PGY1 Daily Progress Note, [**2155-6-27**], [**2074**]</h3> . <h3>Accept Note:</h3> . <b>Brief HPI:</b> . I have received verbal signout from the ICU resident, reviewed pertinent notes and data, and have seen and examined the patient; please see MICU admission note for details of the history. . Briefly, this is a 74 year-old female with stage IV sarcoidosis with combined restrictive/obstructive disease, asthma, dCHF, pulmonary HTN a/w COPD flare, called out from ICU [**6-27**]. . She had three days of subjective fevers and cough with green sputum with known [**Month/Year (2) **] contacts (daughter). At home she had increased her use of inhalers, increased prednisone from 5mg to 40mg, and increased O2 from 0.4L at baseline to 2L. . She has increased her dose of steroids to 60mg with slow tapers twice since last admit for respiratory issues 12/[**2154**]. Of note, she has had difficulty obtaining her med on regular basis due to financical constraints, including her inhalers. . In the ED T 99.2, P 115, BP 142/50, RR 26, O2 96% 2LNC. Remained stable in the ICU. Past Medical History: 1. Stage IV sarcoidosis - Chronic and fibrotic. The patient has significant pulmonary manifestations, but no history of ophthalmologic, hepatic, dermatologic, or renal manifestations. She continues to be followed by Dr. [**Last Name (STitle) **] in pulmonary clinic. 2. COPD with combined obstructive/restrictive lung disease 3. Asthma 4. Diastolic congestive heart failure - The patient is followed in cardiology clinic by Dr. [**Last Name (STitle) 73**]. 5. Pulmonary hypertension 6. Osteoporosis 7. Anemia 8. Hypertension 9. Pneumonia - [**12/2154**] PAST SURGICAL HISTORY: 1. Status post hysterectomy for fibroids 2. Status post bilateral breast implants - [**2114**] 3. Status post right rotator cuff repair Social History: -No alcohol -No tobacco -From the South; grew up on a cotton farm; picked cotton then moved up North to work in a foam manufacturing facility, where she was exposed to marked amounts of dust. -The patient continues to live with her daughter and reports that this continues to be a good situation for her. -She does not utilize an assistive device. Family History: mother with breast cancer sister with uterine cancer son with hip cancer in 20's, now in 40's. Physical Exam: Physical Exam: 97.2 125/68 86-101 19-36 94-100% 2L Gen: very pleasant, speaking in full sentences, comfortable, NAD HEENT: anicteric, mmm, EOMI Neck: supple, no LAD, normal thyroid CV: tachy, regular rhythm Pulm: diffuse I/E wheezes bilaterally ABD: soft, NABS, NT GU: + foley Ext: no edema Skin: no rashes Neuro: alert, oriented x 3, intact attention, linear thoughts, no tremor, normal tone . Discharge Exam: 96 AF 104/52 99 22 98 0.5L Gen: Thin elderly woman appears appropriate for age in NAD HEENT: NCAT PERRL MMMs OP clear Neck: Supple Pulm: Expiratory wheezes throughout, no rhonci, no rales; no accessory muscle use CV: SEM radiating to clavicles; RRR nml S1/2 no m/r Ab: +BS soft NTND Ext: No edema no rashes Neuro: CN2-12 intact UE/LE 5/5 strength no rhomberg Pertinent Results: At admission: [**2155-6-26**] 12:48PM BLOOD WBC-17.7* RBC-4.63 Hgb-13.6 Hct-43.0 MCV-93 MCH-29.3 MCHC-31.6 RDW-14.4 Plt Ct-188 [**2155-6-26**] 12:48PM BLOOD Neuts-87* Bands-1 Lymphs-4* Monos-4 Eos-0 Baso-0 Atyps-2* Metas-2* Myelos-0 [**2155-6-26**] 12:48PM BLOOD Glucose-202* UreaN-20 Creat-0.7 Na-139 K-4.6 Cl-97 HCO3-33* AnGap-14 [**2155-6-26**] 12:48PM BLOOD Calcium-8.5 [**2155-6-26**] 12:56PM BLOOD Lactate-2.4* K-4.6 [**2155-6-27**] Rapid Respiratory Viral Screen & Culture Respiratory Viral Culture-PRELIMINARY; Respiratory Viral Antigen Screen-FINAL INPATIENT [**2155-6-26**] BLOOD CULTURE Blood Culture, Routine-PENDING EMERGENCY [**Hospital1 **] [**2155-6-27**] FINDINGS: Single AP frontal view of the chest was obtained. Overall, there has been little significant interval change. Calcified breast implants are again noted projecting over the lower thorax bilaterally. There is persistent architectural distortion with fibrosis in the lung apices, superior traction of the bilateral hila and extensive calcified mediastinal and hilar lymph nodes, without significant interval change from the prior study. Blunting of the costophrenic angles and tenting of the hemidiaphragms bilaterally are chronic and stable. The lungs are again hyperinflated, consistent with chronic pulmonary disease. Apical pleural thickening is again seen. Partially imaged right humeral metallic hardware is again noted. IMPRESSION: No significant interval change. Discharge Labs: [**2155-6-28**] 07:30AM BLOOD WBC-14.7* RBC-4.33 Hgb-12.7 Hct-41.1 MCV-95 MCH-29.4 MCHC-31.0 RDW-14.4 Plt Ct-183 [**2155-6-28**] 07:30AM BLOOD Glucose-181* UreaN-29* Creat-0.7 Na-143 K-4.7 Cl-97 HCO3-39* AnGap-12 [**2155-6-28**] 07:30AM BLOOD Calcium-8.7 Phos-3.4 Mg-2.5 [**2155-6-26**] 12:56PM BLOOD Lactate-2.4* K-4.6 [**2155-6-28**] 01:09PM BLOOD Lactate-2.6* Brief Hospital Course: 74 year-old female with stage IV sarcoidosis with combined restrictive/obstructive disease, asthma, dCHF, pulmonary HTN a/w COPD flare. . # COPD Flare, pulmonary sarcoidosis, pulmonary hypertension: The patient was admitted to the ICU in respiratory distress attributed to a COPD flare. She improved with steroids, nebulizer treatments, and Levofloxacin and was transferred to the floor where these therapies continued; she was never intubated. She was discharged on home dose advair and montelukast unchanged. Sarcoidosis contributed to the presentation by decreasing pulmonary reserve; pulmonary hypertension also contributed and sildenafil was continued. . # Hypertrophic C.Myopathy, dCHF, HTN: Continued home verapamil and furosemide 20. . INACTIVE ISSUES: . # Osteoporosis: Continued Ca/Vit D, alendronate . TRANSITIONAL ISSUES: # Prednisone taper will be overseen by PCP. Medications on Admission: ALBUTEROL SULFATE - 2.5 mg/3 mL (0.083 %) Solution for Nebulization - one ampule(s) inhaled every 4 hours Use with nebulizer machine ALBUTEROL SULFATE [PROAIR HFA] - 90 mcg HFA Aerosol Inhaler - 2 puffs(s) inhaled four times daily as needed for shortness of breath ALENDRONATE [FOSAMAX] - 70 mg Tablet - 1 Tablet(s) by mouth weekly AZITHROMYCIN - 250 mg Tablet - 1 Tablet(s) by mouth qday Take two tablets by mouth on day one and one tablet per day for each of the next four. CLOTRIMAZOLE - 10 mg Troche - 1 tab on tongue up tp 4 times daily FLUTICASONE [FLOVENT HFA] - 220 mcg Aerosol - 1 puff(s) inhaled Twice daily Rinse well after each use FLUTICASONE-SALMETEROL [ADVAIR DISKUS] - 500 mcg-50 mcg/Dose Disk with Device - 1 puff inhaled twice a day rinse after use FUROSEMIDE [LASIX] - 20 mg Tablet - one Tablet(s) by mouth every third day IPRATROPIUM BROMIDE - 0.2 mg/mL (0.02 %) Solution - 1 neb inhaled every six (6) hours MONTELUKAST [SINGULAIR] - 10 mg Tablet - one Tablet(s) by mouth Take in the evening PANTOPRAZOLE - 40 mg Tablet, Delayed Release (E.C.) - 1 Tablet(s) by mouth once a day PREDNISONE - 20 mg Tablet - 3 Tablet(s) by mouth qday - No Substitution RESPIRATORY VISIT - - To be fitted for full facemask and head gear. As needed for lifetime. For CPAP. SILDENAFIL [REVATIO] - (Not Taking as Prescribed: Not covered by insurance) - 20 mg Tablet - 1 (One) Tablet(s) by mouth three times a day SYRINGE - - 31g/5cc as directed TERIPARATIDE [FORTEO] - (Not Taking as Prescribed: Has not yet started) - 20 mcg/dose (600 mcg/2.4 mL) Pen Injector - 20 mcg sc at bedtime VERAPAMIL - 240 mg Tablet Extended Release - 1 Tablet(s) by mouth daily Medications - OTC ACETAMINOPHEN - 500 mg Tablet - 2 Tablet(s) by mouth three times a day PRN BLOOD SUGAR DIAGNOSTIC [ONE TOUCH ULTRA TEST] - Strip - Please test finger stick (blood sugar) four times a day CALCIUM CARBONATE - 500 mg (1,250 mg) Tablet - 1 Tablet(s) by mouth three times a day CHOLECALCIFEROL (VITAMIN D3) [VITAMIN D-3] - 1,000 unit Tablet, Chewable - 1000 Tablet(s) by mouth daily COENZYME Q10 - 100 mg Capsule - 1 Capsule(s) by mouth daily FERROUS SULFATE - 325 mg (65 mg Elemental Iron) Tablet - 1 Tablet(s) by mouth daily FOOD SUPPLEMENT, LACTOSE-FREE [ENSURE] - (OTC) - Dosage uncertain INSULIN NEEDLES (DISPOSABLE) [PEN NEEDLE] - 31 gauge X [**1-21**]" Needle - Use as directed once a day INSULIN REGULAR HUMAN [HUMULIN R] - 100 unit/mL Solution - 0 units daily Use as needed per sliding scale. OMEGA-3 FATTY ACIDS - 1,000 mg Capsule - 1 Capsule(s) by mouth daily Discharge Medications: 1. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) treatment Inhalation Q4H (every 4 hours). 2. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: One (1) Puff Inhalation four times a day as needed for shortness of breath or wheezing. 3. ipratropium bromide 0.02 % Solution Sig: One (1) treatment Inhalation Q6H (every 6 hours). 4. prednisone 20 mg Tablet Sig: Three (3) Tablet PO once a day for 2 weeks: Take 60mg for 5 days, then 40mg for 3 days, then 20mg for 3 days, then 10mg ([**1-19**] tablet) for three days. Continue 10mg daily until you see your pulmonary doctor. [**Last Name (Titles) **]:*42 Tablet(s)* Refills:*2* 5. fluticasone 220 mcg/Actuation Aerosol Sig: One (1) Puff Inhalation twice a day. 6. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 7. sildenafil 20 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 8. montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. alendronate 70 mg Tablet Sig: One (1) Tablet PO once a week. 10. furosemide 20 mg Tablet Sig: One (1) Tablet PO Every 3 days. 11. verapamil 120 mg Tablet Extended Release Sig: Two (2) Tablet Extended Release PO Q24H (every 24 hours). 12. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 13. acetaminophen 500 mg Tablet Sig: One (1) Tablet PO three times a day as needed for pain, fever. 14. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times a day). 15. cholecalciferol (vitamin D3) 1,000 unit Tablet Sig: One (1) Tablet PO once a day. 16. coenzyme Q10 100 mg Capsule Sig: One (1) Capsule PO once a day. 17. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 18. insulin regular human 100 unit/mL Solution Sig: One (1) unit Injection three times a day: Per sliding scale. 19. Omega 3-6-9 Fatty Acids 400-400-200 mg Capsule Sig: One (1) Capsule PO once a day. 20. levofloxacin 750 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 3 days. [**Hospital1 **]:*3 Tablet(s)* Refills:*0* 21. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day. [**Hospital1 **]:*60 Capsule(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: PRIMARY: -COPD flare SECONDARY: -None Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: It has been a privilege to take care of you at [**Hospital1 18**]. . You were hospitalized for a COPD flare-up. You were briefly treated in the ICU where your condition remained stable and then you were transferred to the floor to continue your treatment. . Your condition improved with steroids, nebulizer treatments, and antibiotics - the usual management of COPD flare-ups. . No changes were made to your medications other than as detailed below: CHANGE: -Increase Prednisone from 20mg daily to 60mg daily; continue this dosage until you follow-up with your pulmonary doctor START: -Levofloxacin antibiotics until the prescription is complete for treatment of COPD flare -Colace to prevent constipation . Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more than 3 lbs. Followup Instructions: Call your pulmonary physician [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] at ([**Telephone/Fax (1) 514**] to schedule an appointment within 1 week; you already have an appointment for [**Month (only) 205**], but it is important to schedule an earlier appointment that he can re-dose your prednisone. Department: MEDICAL SPECIALTIES When: THURSDAY [**2155-7-3**] at 11:20 AM With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2164**], MD [**Telephone/Fax (1) 1803**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: PULMONARY FUNCTION LAB When: WEDNESDAY [**2155-7-30**] at 9:40 AM With: PULMONARY FUNCTION LAB [**Telephone/Fax (1) 609**] Building: [**Hospital6 29**] [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: [**Hospital Ward Name 1570**] When: WEDNESDAY [**2155-7-30**] at 10:00 AM

[ "515", "V88.01", "733.42", "285.9", "401.9", "416.8", "493.22", "733.00", "135", "276.2", "V49.86", "428.0", "493.90", "288.60", "428.32", "425.4" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

12130, 12136

6353, 7097

308, 314

12218, 12218

4493, 5949

13190, 14212

3590, 3686

9832, 12107

12157, 12197

7259, 9809

12369, 13167

5966, 6330

3068, 3209

3716, 4097

4113, 4474

7188, 7233

265, 270

342, 2458

7114, 7166

12233, 12345

2480, 3045

3225, 3574

57,545

148,488

1183

Discharge summary

report

Admission Date: [**2126-11-28**] Discharge Date: [**2126-12-2**] Date of Birth: [**2054-9-6**] Sex: M Service: CARDIOTHORACIC Allergies: Flagyl / Statins-Hmg-Coa Reductase Inhibitors Attending:[**First Name3 (LF) 1505**] Chief Complaint: Chest/Back pain Major Surgical or Invasive Procedure: [**2126-11-28**] Coronary Artery Bypass Grafting x5 (LIMA to LAD, SVG to DIAG, SVD to OM1, SVG to OM2, SVG to PDA) History of Present Illness: 72 year old retired pharmacist who had a large 6 unit diverticular GI bleed and subsequent myocardial infarction in [**2125-9-19**] in the setting of NSAID use. He was treated at [**Hospital3 3765**] and did not have a cardiac catheterization at that time due to the fact that the patient's creatinine level rose from a baseline of 1.4-1.6 up to 2.5mg/dl. Since that time, he has been followed by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] from nephrology at [**Hospital1 18**] and his creatinine has remained elevated but is stable at 1.9-2.0mg/dl. He occassionally gets some upper back pain with exertion however has remained relatively inactive. He denies any dyspnea but does report a decreased energy level. He finally underwent cardiac catheterization on [**2126-8-6**] which revealed multivessel coronary artery disease and is now referred for surgery. Past Medical History: Coronary artery disease, s/p CABG PMH: History of GI bleed due to gastritis/diverticular bleed Prior MI [**9-/2125**] due to demand ischemia in setting of GI bleed Hypertension Chronic Renal insufficiency Bullous pemphigoid Social History: Lives with: [**Location (un) **] with Wife Contact: Phone # Occupation: Retired pharmacist Cigarettes: Smoked no [] yes [X] Hx: [**2075**]-[**2082**] 2ppd. Other Tobacco use: ETOH: < 1 drink/week [X] [**2-25**] drinks/week [] >8 drinks/week [] Illicit drug use: None Family History: No premature coronary artery disease. Father with aortic aneursym at age 76. Physical Exam: Pulse: 85 Resp: 16 O2 sat: 100% B/P Right: 147/100 Left: 160/100 Height: 5'8" Weight: 167 lbs General: WDWN in NAD. Skin: Warm, Dry and intact. Quarter size macular lesions noted on chest and neck. Mild erythema, urticaria and scale noted. One cyst noted. Well healed abdominal incision. HEENT: NCAT, PERRLA, EOMI, sclera anicteric, OP benign. Teeth in poor repair. Sebaceous cyst on mid back Neck: Supple [X] Full ROM [X] No JVD Chest: Lungs clear bilaterally [X] Heart: RRR, Nl S1-S2, No M/R/G Abdomen: Soft [X] non-distended [X] non-tender [X] bowel sounds + [X] Extremities: Warm [X], well-perfused [X] No Edema Varicosities: None [X] Neuro: Grossly intact [X] Pulses: Femoral Right:2 Left:2 DP Right:1 Left:1 PT [**Name (NI) 167**]:1 Left:1 Radial Right:2 Left:2 Carotid Bruit Right: ? quiet Left: None Pertinent Results: [**2126-11-28**] Echo: PRE-BYPASS: The left atrium is mildly dilated. No spontaneous echo contrast or thrombus is seen in the body of the left atrium or left atrial appendage. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thicknesses are normal. The left ventricular cavity is mildly dilated. There is mild regional left ventricular systolic dysfunction with basal and mid inferior wall hypokinesis. Overall left ventricular systolic function is mildly depressed (LVEF= 40-50 %). The remaining left ventricular segments contract normally. The right ventricular cavity is mildly dilated with borderline normal free wall function. The descending thoracic aorta is mildly dilated. There are complex (>4mm) atheroma in the descending thoracic aorta. There are three aortic valve leaflets. The aortic valve leaflets are mildly thickened . There is no aortic valve stenosis. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. There is no pericardial POST CPB: 1. Improved [**Hospital1 **]-ventricular systolic function (EF = 50%). 2. No change in valve structure and function. [**2126-12-2**] 06:10AM BLOOD WBC-7.6 RBC-3.02* Hgb-9.2* Hct-26.6* MCV-88 MCH-30.3 MCHC-34.4 RDW-13.9 Plt Ct-142* [**2126-12-1**] 06:30AM BLOOD WBC-10.9 RBC-3.26* Hgb-9.6* Hct-28.5* MCV-87 MCH-29.6 MCHC-33.9 RDW-13.6 Plt Ct-127* [**2126-12-2**] 06:10AM BLOOD Glucose-129* UreaN-41* Creat-2.2* Na-141 K-3.9 Cl-101 HCO3-29 AnGap-15 [**2126-12-1**] 06:30AM BLOOD Glucose-121* UreaN-35* Creat-2.3* Na-139 K-4.2 Cl-100 HCO3-31 AnGap-12 Brief Hospital Course: Mr. [**Known lastname 7524**] was a same day admit and on [**11-28**] was brought directly to the operating room where he underwent a coronary artery bypass graft x 5. Please see operative report for surgical details. Following surgery he was transferred to the CVICU for invasive monitoring in stable condition. POD 1 found the patient extubated, alert and oriented and breathing comfortably. The patient was neurologically intact and hemodynamically stable, weaned from inotropic and vasopressor support. Beta blocker was initiated and the patient was gently diuresed toward the preoperative weight. He has a history of bowel dismotility. He did develop an ileus on POD 2. Reglan was started along with an aggressive bowel regimen. Narcotics held. Ileus resolved and the patient had subsequent bowel movements. The patient was transferred to the telemetry floor for further recovery. Chest tubes and pacing wires were discontinued without complication. The patient was evaluated by the physical therapy service for assistance with strength and mobility. He is not discharged on a statin, as he has a history of myalgias. By the time of discharge on POD 4 the patient was ambulating freely, the wound was healing and pain was controlled with oral analgesics. The patient was discharged home with VNA in good condition with appropriate follow up instructions. Medications on Admission: ALPRAZOLAM [XANAX] - (Prescribed by Other Provider) - 0.5 mg Tablet - 1 Tablet(s) by mouth once a day AMLODIPINE - 2.5 mg Tablet - 1 Tablet(s) by mouth daily BUTALBITAL-ACETAMINOPHEN-CAFF - 50 mg-325 mg-40 mg Tablet - 2 Tablet(s) by mouth every 4 hours as needed LORAZEPAM - 1 mg Tablet - One Tablet(s) by mouth four times daily METOPROLOL SUCCINATE [TOPROL XL] - 50 mg Tablet Extended Release 24 hr - 1 Tablet(s) by mouth once a day SILDENAFIL [VIAGRA] - 50 mg Tablet - 1 Tablet(s) by mouth once a day as needed Medications - OTC ACETAMINOPHEN - (Prescribed by Other Provider) - 500 mg Tablet - 1 Tablet(s) by mouth 2 or 3 times a day ASPIRIN - (Prescribed by Other Provider) - 81 mg Tablet, Delayed Release (E.C.) - 1 Tablet(s) by mouth once a day MULTIVITAMIN-MINERALS-LUTEIN [HIGH POTENCY MULTIVIT-MULTIMIN] - (Prescribed by Other Provider) - Tablet - 1 Tablet(s) by mouth once a day OMEPRAZOLE - (OTC) - 20 mg Capsule, Delayed Release(E.C.) - 1 Capsule(s) by mouth once a day Discharge Medications: 1. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:*90 Tablet(s)* Refills:*0* 2. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 3. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. Disp:*60 Tablet(s)* Refills:*0* 5. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*0* 6. lorazepam 1 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for anxiety. Disp:*40 Tablet(s)* Refills:*0* 7. furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day for 5 days. Disp:*5 Tablet(s)* Refills:*0* 8. potassium chloride 20 mEq Tablet, ER Particles/Crystals Sig: One (1) Tablet, ER Particles/Crystals PO once a day for 5 days. Disp:*5 Tablet, ER Particles/Crystals(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Last Name (LF) 486**], [**First Name3 (LF) 487**] Discharge Diagnosis: Coronary artery disease s/p coronary artery bypass graft x 5 Past medical history: - GI bleed due to gastritis/diverticular bleed - Perforated colon and small bowel s/p bowel resection [**3-27**] - MI [**9-/2125**] due to demand ischemia in setting of GI bleed - Hypertension - Renal insufficiency: stage IV chronic kidney disease - Creat 1.9 - Anxiety - Insomnia - ? new onset depression - [**Last Name (un) 7525**] pemphigoid - Diverticulosis/Diverticulitis - Chronic neck pain Past Surgical History: - s/p bowel resection [**3-27**] - s/p Hernia repair - Right inguinal hernia repair x2 - Tonsillectomy Discharge Condition: Alert and oriented x3 nonfocal Ambulating with steady gait Incisional pain managed with Tramadol Incisions: Sternal - healing well, no erythema or drainage Left - healing well, no erythema or drainage. Edema trace Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] Females: Please wear bra to reduce pulling on incision, avoid rubbing on lower edge **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Followup Instructions: The cardiac surgery office will call you with the following appointments: Wound Check: Surgeon: [**Doctor First Name **] [**Doctor Last Name **] [**Telephone/Fax (1) 170**] Cardiologist: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 7526**] Please call to schedule appointments with your Primary Care Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 172**] in [**4-23**] weeks **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Completed by:[**2126-12-2**]

[ "560.1", "585.4", "E878.2", "694.5", "412", "414.01", "403.90", "413.9" ]

icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

7960, 8043

4538, 5911

328, 445

8692, 8908

2906, 3955

9831, 10436

1930, 2009

6949, 7937

8064, 8125

5937, 6926

8932, 9808

8567, 8671

2024, 2887

273, 290

473, 1361

8147, 8544

1625, 1914

3965, 4515

2,049

137,603

14622

Discharge summary

report

Admission Date: [**2182-5-11**] Discharge Date: [**2182-5-24**] Date of Birth: [**2116-8-2**] Sex: F Service: SURGERY Allergies: Dilaudid Attending:[**First Name3 (LF) 4111**] Chief Complaint: Abdominal pain Major Surgical or Invasive Procedure: None History of Present Illness: Pt is a 65F well-known to our service who presented to the [**Hospital1 18**] with approximately a 24hr history of colicky abdominal pain that had progressively worsened and she now rated it an [**2187-8-6**]. She noted nausea and copious vomiting, and could not recall recent flatus, and had had no bowel movements for 24h. She denied fevers/chills. She denied dysuria. Past Medical History: CHF enterocutaneous fistula s/p appendectomy s/p sigmoid colectomy s/p aorto-bifemoral bypass graft s/p right colectomy s/p cholecycectomy in [**9-2**] Social History: non-contributory Family History: non-contributory Physical Exam: Physical exam on discharge: VS: RRR CTAB Soft, Non-distended, minimally tender Pertinent Results: [**2182-5-11**] 08:02AM BLOOD Lactate-4.1* [**2182-5-12**] 02:15AM BLOOD Lactate-2.7* [**2182-5-13**] 03:48AM BLOOD Lactate-1.2 [**2182-5-14**] 04:15AM BLOOD Lactate-1.1 [**2182-5-22**] 05:56AM BLOOD Lactate-1.5 CT of [**5-11**]: IMPRESSION: Findings highly suggestive of ischemic small bowel with evidence of free mesenteric fluid and free air, with dilated wall thickened loops. There is no evidence of venous or arterial occlusion. These findings were discussed with Dr. [**Last Name (STitle) 955**] and Dr. [**Last Name (STitle) 43107**] at 10:00 p.m. on [**2182-5-11**]. CT [**5-15**]: IMPRESSION: Considerable improvement of previously described abnormal left lower quadrant loops of small bowel, which now demonstrate less inflammatory changes, and no definite evidence of free air or pneumatosis. Brief Hospital Course: Pt admitted to surgical service through ER. Given ominous CT findings and concerning physical exam, she was watched closely through the initial phase of her admission. Of great concern to the surgical team was the patient's initial refusal of the nasogastric tube. However, she was subsequently persuaded of the necessity of the nasogastric tube, and it was successfully placed with good relief of the patient's pain. The team was in constant contact with Dr [**Name (NI) 957**], in discussions of whether or not an emergent operation was needed. As the patient stabilized it was felt that an operation could wait. She was maintained in the SICU with vigorous resuscitation and serial abdominal exams. Her pattern of tenderness did not significantly change. She was started on intravenous antibiotics. A repeat CT scan on [**5-15**] showed significant improvement. It became apparent that the patient would need parenteral nutrition, and a central line was placed on [**5-16**]. She continued to improve, and on [**5-20**] was trialed on sips of clear liquids, which she tolerated well. Her diet was advanced in a slow and stepwise fashion, and by the evening of [**5-23**] she was tolerating a regular diet without pain, nausea, or bloating. She was discharged to home on [**5-24**] in good condition. Medications on Admission: None noted at admission. Discharge Medications: 1. Loperamide HCl 1 mg/5 mL Liquid Sig: Ten (10) mL PO BID (2 times a day). Disp:*600 mL* Refills:*2* 2. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 3. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 4. Augmentin 875-125 mg Tablet Sig: One (1) Tablet PO twice a day for 5 days. Disp:*10 Tablet(s)* Refills:*0* 5. Percocet 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours. Disp:*40 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Partial small bowel obstruction, possible small bowel ischemia Discharge Condition: Good. Discharge Instructions: Take all medications as prescribed. Do not drive while taking a narcotic pain medication such as percocet. You may eat your regular diet. If you develop fevers, chills, nausea/vomiting, severe abdominal pain, absence of flatus or stools, distended abdomen, or other concerning symptoms, please contact our office or a local emergency room. Please call Dr[**Name (NI) 6275**] office to schedule your follow up appointment. Followup Instructions: Please call Dr[**Name (NI) 6275**] office to schedule your follow up appointment. Completed by:[**2182-7-31**]

[ "736.79", "560.9", "V45.79", "557.0", "428.0" ]

icd9cm

[ [ [] ] ]

[ "96.07", "38.93", "99.15" ]

icd9pcs

[ [ [] ] ]

3801, 3807

1881, 3185

282, 289

3914, 3921

1049, 1858

4392, 4504

916, 934

3260, 3778

3828, 3893

3211, 3237

3945, 4369

949, 949

978, 1030

228, 244

317, 689

711, 865

881, 900

18,459

194,109

22620

Discharge summary

report

Admission Date: [**2172-5-1**] Discharge Date: [**2172-5-15**] Date of Birth: [**2100-4-20**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 613**] Chief Complaint: Chest pain, tachycardia, pleural effusion Major Surgical or Invasive Procedure: Thoracentesis, right-sided chest tube placement VATS procedure History of Present Illness: Briefly, Mr. [**Known lastname **] is a 72 yo man with ESRD on HD, DM2, HTN, PVD, diastolic dysfunction and CMML who initially presented [**5-1**] with chest pain and SOB while at outpt HD. He ruled out for MI. His initial CXR demonstrated evidence of a new R pleural effusion. CT scan demonstrated a R-sided pleural effusion and 2 new pulmonary nodules. Past Medical History: 1. ESRD on HD, began dialysis [**2166**]. AV graft placed in LUE on [**2171-1-10**]. Congenital absence of one kidney. Gets HD MWF in [**Location (un) **]/[**Location (un) 4265**]--followed by Dr. [**First Name (STitle) 805**]. On [**2171-2-13**], underwent attempted thrombectomy, left upper arm AV graft. Ligation of left upper arm AV graft and placement of right femoral Quinton catheter. 2. HTN 3. Hypercholesterolemia 4. DM, type 2 5. Diastolic CHF, EF >55% 6. COPD 7. h/o GI bleeding 8. unilateral kidney 9. s/p cataract surgery [**73**] H/o gastric lipoma, 11. PVD, s/p angioplasty. 12. h/o VRE UTI 13. Restless legs syndrome 14. CMML - diagnosed 6 months ago, pt of Dr. [**Last Name (STitle) 6944**]. Diagnosed by bone marrow biopsy, did not have any symptoms. Not being treated. 15. excision of LUE AVG, infected Social History: Lives with 1 daughter. 120 PY hx, quit 20 years ago. No EtOh. No drug use. Pt was in the Army from [**2118**]-79 and did have significan pesticide exposure. Family History: M: Died at 64 of MI; DM F: Died at 41 of MI Aunts maternal and paternal with DM. Physical Exam: Vitals: T: 98.6 BP: 120/55 P: 107 R: 20 SaO2: 94%RA General: chronically ill-appearing, awake, alert, NAD, pleasant, appropriate, cooperative HEENT: NCAT, EOMI, no scleral icterus Neck: supple, no significant JVD Pulmonary: Decreased BS on R, upper airway wheeze, no rales Cardiac: Distant heart sounds, no significant murmurs Abdomen: soft, NT, ND, normoactive bowel sounds, no masses or organomegaly noted Extremities: No edema Pertinent Results: [**2172-5-1**] 09:10PM CK(CPK)-30* [**2172-5-1**] 09:10PM CK-MB-NotDone cTropnT-0.07* [**2172-5-1**] 09:10PM WBC-11.0 RBC-3.95* HGB-11.4* HCT-35.1* MCV-89 MCH-28.8 MCHC-32.5 RDW-17.3* [**2172-5-1**] 12:12PM LACTATE-2.3* [**2172-5-1**] 12:12PM LACTATE-2.3* [**2172-5-1**] 10:28AM GLUCOSE-169* UREA N-34* CREAT-7.1*# SODIUM-142 POTASSIUM-3.9 CHLORIDE-100 TOTAL CO2-26 ANION GAP-20 [**2172-5-1**] 10:28AM estGFR-Using this [**2172-5-1**] 10:28AM CK(CPK)-36* [**2172-5-1**] 10:28AM cTropnT-0.07* [**2172-5-1**] 10:28AM CK-MB-5 proBNP-GREATER TH [**2172-5-1**] 10:28AM CALCIUM-9.4 PHOSPHATE-3.0 MAGNESIUM-1.8 [**2172-5-1**] 10:28AM WBC-16.6*# RBC-4.50* HGB-13.0* HCT-39.9* MCV-89 MCH-28.9 MCHC-32.6 RDW-17.3* [**2172-5-1**] 10:28AM NEUTS-64.5 LYMPHS-15.5* MONOS-17.8* EOS-1.8 BASOS-0.4 [**2172-5-1**] 10:28AM PLT COUNT-106* [**2172-5-1**] 10:28AM PT-13.1 PTT-28.0 INR(PT)-1.1 IMAGING [**5-1**]-CXR-Right basilar pleural effusion with consolidation which could reflect atelectasis or pneumonia. . [**5-3**]-chest CT-1. Two new pulmonary nodules within the right lung. Given patient's high- risk status of emphysema, a CT chest in 3 months after drainage of right pleural effusion is recommended for further evaluation. 2. Cholelithiasis. Probable distal CBD stones in which ERCP would be both confirmatory and theraputic. 3. Three-vessel coronary artery calcification. Prominent left axillary lymph node. 4. Right-sided pleural thickening presumably associated with old rib fractures. . cytology pleural fluid-Pleural fluid: NEGATIVE FOR MALIGNANT CELLS. Mesothelial cells, histiocytes, and lymphocytes. . CT chest 5/19-1. Persistent moderate-to-large right-sided pleural effusion. 2. Persistent pulmonary nodules within the right lung. Followup CT within three months is recommended. 3. Cholelithiasis, unchanged. 4. Three vessel coronary artery calcification. 5. Left axillary and pretracheal lymph node which is enlarged. 6. Stable old rib fractures, some of which demonstrate nonunion . CTA 5/21-1. There is significant interval increase in the multi-loculated right pleural effusion with almost complete atelectasis of the right lower lobe and to a lesser extent of the right upper lobe as described above. 2. No pulmonary embolism or aortic dissection. There is extensive coronary atherosclerosis noted. . echo [**5-15**]-The left atrium is normal in size. There is moderate 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%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Trivial mitral regurgitation is seen. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. IMPRESSION: Symmetric left ventricular hypertrophy with preserved global and regional biventricular systolic function. Compared with the prior study (images reviewed) of [**2171-10-29**], the findings are similar. Brief Hospital Course: A/P: 72M with ESRD on HD, HTN, DM2, PAD, CMML, diastolic dysfunction presented with pleural effusion. Decompensated in setting of SVT during dialysis, now resolved. . On the day of admission, while at HD, the pt became very tachycardic (SVT to the 150s, ? atrial flutter) and had associated chest pain radiating to the jaw and diaphroesis. His tachycardia converted back to sinus rhythm. . He underwent thoracentesis [**5-2**]. Results were consistent with an exudative pleural effusion. Repeat chest CT demonstrated persistent pleural effusion, and a CTA on the day of transfer to the ICU demonstrated significant interval increase in pleural effusion with almost complete atelectasis of the RLL. . Upon transfer to the ICU, the pt did not have any complaints other than some mild wheezing. He denied chest or jaw pain, shortness of breath, diaphroesis or nausea. . #Pleural effusion: Was found to be exudative by Light's criteria. Ddx included PE, TB, malignancy, parapneumonic effusion, hemothorax. There was no evidence of PE on CTA. He had a significant travel history, but reports a negative PPD in the past. This, coupled with the lack of cavitary lesion(s) on CT, makes TB unlikely. There was no pneumonic infiltrate, no fever and no white count to suggest an underlying pneumonia. His Hct has been stable, although the fluid did reaccumulate so fast that a hemothorax [**1-18**] a complication of the initial thoracentesis. Given his significant smoking hx, malignancy is high on the differential. Exactly why the effusion reaccumulated so quickly is unclear, although it does suggest a possible hemothorax. IP performed thoracentesis with chest tube placement and obtained 1.5L of red/blood-like fluid he was then taken to the OR one day later for VATs. While in the ICU he became hypotensive to 70's requiring 3L of IVF and also was noticed to have a HCT to 24 for which he was transfused 2 units PRBCs. He was started on vanc/zosyn for broad coverage but this was discontinued after his BP stabilized and there was no evidence of infection. In addition CXR showed possible recumulation of fluid in the R.lung field. His vitals stabilized and he was transferred to the medical floor where he remained on 2l nc. He had his chest tube removed without inciddent and a follow up CXR did not show reaccumulation. Wet read on his pathology from VATS showed reactive histiocytosis, fibrinous changes, no evidence of CMML involvement or pulmonary/mesothelial malignancy. . #hypotension-pt was hypotensive to 70's one night in ICU after HD and after OR procedures. Etiology likely secondary to hypovolemia. Other possibilities included infection/sepsis and/or med effect from OR. He was temporarily on broad spectrum antibiotics but they were discontinued after his cultures were negative. He was given midodrine prior to HD and did well. He continued to be normotensive for the duration of his hospitalization. . #atrial flutter: Pt had chest discomfort, jaw pain when HD began, HR increased to SVT at 150s (likely atrial flutter). SVT broke spontaneously, and pt's sxs improved with SL nitro and morphine. Blood pressure was stable throughout. That his sxs appear to correlate with his atrial flutter would suggest demand ischemia. There are no ischemic changes on EKG, and his cardiac enzymes are at his baseline. A primary coronary process such as plaque rupture is unlikely, and I suspect that his sxs were related to his rate. . #NSVT-pt had a 40 beat run of NSVT, asymptomatic, hemodynamically stable. EKG was done with no ischemic changes. His lytes were closely monitored and aggressively repleted. He had an echo to look for wall motion abnormalities, which showed an EF of >55%, no new wall motion abnormalities. This dc summary will be faxed to his PCP and will need to have cards follow up . # ESRD: Has not been able to undergo adequate HD sessions due to atypical CP and then hypotension recently. He started receiving midodrine prior to HD and tolerated HD well. He was continued Nephrocaps, sevelamer, calcium acetate -needs one unit of PRBCs and iron studies as per renal on day of discharge . # DM2: He was continued NPH at reduced dose (10 qhs) and sliding scale. . # CMML: not active, unlikely to cause pleural effusion . # RLS: continued ropinirole 0.25 [**Hospital1 **] . # FEN/Lytes: Diabetic, cardiac, renal diet replete lytes prn . # Prophylaxis: Heparin SC 5000 tid, on home PPI, bowel reg . # Code status: FULL CODE ********* On day of discharge pt's WBC 16, had been fluctuating during hospitalization, possibly due to CMML. . . Medications on Admission: Fosinopril 20 daily Metoprolol succinate 25 qhs Aspirin 81 daily Albuterol 4-6x/day prn Tiotropium daily Nephrocaps Daily Calcium acetate 1334 tid with meals Sevelamer 1600 tid with meals Insulin NPH 15U qhs Omeprazole 40 daily Ropinirole 0.25 [**Hospital1 **] Docusate twice daily Vitamin E 400 daily Discharge Medications: 1. Fosinopril 20 mg Tablet Sig: One (1) Tablet PO once a day. 2. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. Ropinirole 0.25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. Insulin NPH Human Recomb 100 unit/mL Cartridge Sig: Fifteen (15) units Subcutaneous at bedtime. 6. Vitamin E 400 unit Capsule Sig: One (1) Capsule PO DAILY (Daily). 7. Calcium Acetate 667 mg Capsule Sig: Two (2) Capsule PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 8. Levalbuterol HCl 0.63 mg/3 mL Solution for Nebulization Sig: One (1) ML Inhalation q4hrs () as needed for dyspnea, wheezing. 9. Humalog 100 unit/mL Cartridge Sig: as per sliding scale units Subcutaneous qachs. 10. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO BID (2 times a day). 11. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 12. Morphine 2 mg/mL Syringe Sig: 1-2 mg Injection Q4H (every 4 hours) as needed for pain. 13. Ropinirole 0.25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 14. Ondansetron HCl (PF) 4 mg/2 mL Solution Sig: Two (2) mg Injection Q8H (every 8 hours) as needed for n/v. 15. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: [**12-18**] Adhesive Patch, Medicateds Topical DAILY (Daily) as needed for prn hip pain. 16. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 17. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 18. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb Inhalation Q6H (every 6 hours). 19. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 20. Vitamin E 400 unit Capsule Sig: One (1) Capsule PO DAILY (Daily). 21. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 22. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 23. Sevelamer HCl 800 mg Tablet Sig: Two (2) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). Discharge Disposition: Extended Care Facility: [**Hospital3 105**] Northeast - [**Hospital1 **] Discharge Diagnosis: Exudative Pleural Effusion Hemothorax status post VATS End Stage Renal Disease on Hemodialysis Hypertension Diabetes Mellitus, Type II Diastolic Congestive Heart Failure, EF>55% Restless Leg Syndrome Chronic Monomyelocytic Leukemia Discharge Condition: Stable, afebrile, O2 sat 97% 2L Discharge Instructions: You were admitted to the hospital for chest pain and shortness of breath. You were found to have a fluid collection at your right lung base. While you were hospitalized you had a thoracentesis, a procedure to remoce some of that fluid from your lungs for therapeutic relief and diagnosis. You had repeat shortness of breath, had a chest tube placed which found bloody fluid. You were transferred to the medical ICU and had a VATS. Your pathology is pending at the time of discharge although preliminarily it does not appear that the tissue obtained from the VATS was malignant. You had a temporary run of an irregular heart rhythm (NSVT). Your EKG was unchanged and you had an echo that showed good heart function. . Continue taking your medications as prescribed. . Please seek medical attention if you have any chest pain, shortness of breath, dizzyness, coughing or any other concerning symptoms. . Please follow up as outlined below. Followup Instructions: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2172-7-9**] 1:20 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 6952**], MD Phone:[**Telephone/Fax (1) 3241**] Date/Time:[**2172-7-15**] 4:00 [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**] Completed by:[**2172-5-17**]

[ "585.6", "205.10", "333.94", "413.9", "427.32", "280.0", "305.1", "403.91", "511.8", "753.0", "443.9", "428.0", "427.89", "518.0", "496", "428.32" ]

icd9cm

[ [ [] ] ]

[ "34.91", "34.20", "39.95", "34.09", "34.52", "34.04", "34.06", "99.04" ]

icd9pcs

[ [ [] ] ]

12722, 12797

5689, 10262

355, 420

13073, 13107

2389, 5666

14099, 14553

1841, 1923

10615, 12699

12818, 13052

10288, 10592

13131, 14076

1938, 2370

274, 317

448, 805

827, 1651

1667, 1825

1,785

138,749

20062

Discharge summary

report

Admission Date: [**2139-12-16**] Discharge Date: [**2140-2-6**] Date of Birth: [**2066-7-23**] Sex: M Service: ADMISSION DIAGNOSES: 1. Aortic stenosis. 2. Coronary artery disease. DISCHARGE DIAGNOSES: 1. Aortic stenosis. 2. Coronary artery disease. 3. Death. HISTORY OF PRESENT ILLNESS: The patient is a 73-year-old gentleman who was found to have critical aortic stenosis as well as coronary artery disease. He presented for aortic valve repair as well as coronary artery bypass grafting. The patient had complained of dyspnea on exertion over the past several months eventually progressing to shortness of breath after only 20 feet to 30 feet of ambulation. The patient had an echocardiogram demonstrating an aortic valve area of 0.7 cm2 with an ejection fraction of 55%. Cardiac catheterization demonstrated 1-vessel coronary artery disease. PAST MEDICAL HISTORY: 1. Hypertension. 2. Diabetes mellitus. 3. Atrial fibrillation. 4. History of abdominal aortic aneurysm; status post abdominal aortic aneurysm repair. 5. Permanent cardiac pacemaker. MEDICATIONS ON ADMISSION: (Medications at home included) 1. Glyburide 5 mg by mouth in the morning and 2.5 mg by mouth in the evening. 2. Amiodarone 200 mg by mouth once per day. 3. Diovan/hydrochlorothiazide 160/1.5 mg by mouth in the morning. 4. Coumadin 2 mg by mouth once per day. PHYSICAL EXAMINATION ON PRESENTATION: General physical examination on admission revealed the patient was in no acute distress. A thin white male. The chest was clear to auscultation bilaterally. Cardiovascular examination revealed a regular rate and rhythm with a systolic ejection murmur. The abdomen was soft, nontender, and nondistended. No masses or organomegaly. The extremities were warm and well perfused with trace peripheral edema. BRIEF SUMMARY OF HOSPITAL COURSE: On [**12-18**], the patient was brought to the operating room and had an aortic valve replacement done with #23 [**Last Name (un) 3843**]-[**Doctor Last Name **] tissue valve. He concomitantly had a coronary artery bypass graft with a saphenous vein graft to the obtuse marginal artery. For details of the operation, please see the previously dictated Operative Report. Postoperatively, the patient was transferred to the Cardiothoracic Surgery Recover Unit on a Neo-Synephrine drip for blood pressure control. The patient was transfused appropriately. The patient was extubated on postoperative day one. Over the next few days, the patient exercised increasing respiratory distress despite diuresis with Lasix. The patient was reintubated on the morning on postoperative day three. A transesophageal echocardiogram was performed which showed unchanged aortic valve function from preoperatively. A chest x-ray and computed tomography scan seemed to demonstrate an acute respiratory distress syndrome picture. The patient was sedated and paralyzed and on a prolonged ventilatory wean. The patient also began to have multiple arrhythmia issues beginning on postoperative day five. He was treated with beta blockade as well as an amiodarone drip. The patient also did begin to develop some element of renal failure. Over the next two weeks, the patient slowly weaned from the ventilator as well as maintained on multiple different pressors for blood pressure and arrhythmia. Ultimately, the patient was extubated on [**2140-1-4**]. He was reintubated on [**2140-1-7**] for respiratory distress. A repeat computed tomography scan on [**2140-1-8**] demonstrated acute respiratory distress syndrome as well as bilateral pneumonia. A sputum culture confirmed methicillin-resistant Staphylococcus aureus pneumonia. A tracheostomy and percutaneous gastrostomy were performed at the bedside on [**2140-1-12**]. A transesophageal echocardiogram on [**2140-1-13**] demonstrated a large fluid collection by the right atrium by the right atrium. On [**2140-1-14**] the patient was taken back to the operating room for re-exploration. A mini right anterior thoracotomy was performed, and the pericardial window and drain of pericardial effusion were performed. For details of this operation, please see the previously dictated Operative Report. This was performed by thoracic surgeon Dr. [**First Name4 (NamePattern1) 951**] [**Last Name (NamePattern1) 952**]. On [**2140-1-15**] continuous venovenous hemofiltration was begun by the Nephrology Service for the patient's ongoing and worsening renal failure. The patient continued to have multiple arrhythmias over the next several days. The patient was noted to have a worsening metabolic acidosis with a high lactate level. The patient's liver enzymes bumped and was thought to be secondary to cardiogenic shock and hypoperfusion of the liver. The patient had worsened hemodynamics. A bronchoscopy with bronchoalveolar lavage was performed on [**2140-1-23**]. This demonstrated yeast of three different types. The patient was placed on fluconazole as well as empiric antibiotics. Over the next two weeks, the patient's hemodynamics worsened. On [**2140-1-31**], the patient was two blood cultures positive for [**Female First Name (un) 564**] parapsilosis. The patient's macrobacterial coverage broadened to include AmBisome. On [**2140-2-3**], the patient had a bronchoscopy performed with two different bronchoalveolar lavages. These were positive for yeast as well as methicillin-resistant Staphylococcus aureus. Also on this date, the patient grew out [**3-2**] blood culture bottles for methicillin-resistant Staphylococcus aureus. The patient had worsening sepsis with increasing metabolic acidosis over the next few days. He was on multiple pressors for hemodynamic support. He also continued to have multiple hemodynamically significant arrhythmias which required electrical cardioversion. On [**2140-2-6**], after a long discussion between the family and Dr. [**First Name (STitle) **] [**Last Name (Prefixes) **] (the attending physician) the patient was made do not resuscitate/do not intubate status and pressors were withdrawn. The patient expired within 10 minutes after support was withdrawn. DISCHARGE DISPOSITION: Death. DISCHARGE DIAGNOSES: 1. Aortic stenosis. 2. Coronary artery disease. 3. Aortic valve replacement/coronary artery bypass graft. 4. Acute respiratory distress syndrome. 5. Methicillin-resistant Staphylococcus aureus pneumonia. 6. Renal failure. 7. Liver failure. 8. Fungemia. 9. Bacteremia. 10. Sepsis. 11. Asystole. [**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**] Dictated By:[**Last Name (NamePattern1) 5745**] MEDQUIST36 D: [**2140-2-6**] 16:13 T: [**2140-2-6**] 16:53 JOB#: [**Job Number 54010**]

[ "584.5", "287.4", "424.1", "482.41", "038.11", "570", "518.5", "785.51", "427.5" ]

icd9cm

[ [ [] ] ]

[ "37.23", "96.04", "38.93", "39.95", "37.12", "36.11", "39.61", "43.11", "31.1", "96.72", "99.15", "00.14", "35.21", "96.6" ]

icd9pcs

[ [ [] ] ]

6166, 6174

6196, 6773

1111, 1829

1859, 6142

148, 199

311, 874

896, 1084

3,061

141,649

28131

Discharge summary

report

Admission Date: [**2103-11-7**] Discharge Date: [**2103-11-11**] Date of Birth: [**2051-12-5**] Sex: F Service: NEUROSURGERY Allergies: Acetaminophen Attending:[**First Name3 (LF) 2724**] Chief Complaint: Trauma Transfer from [**Location (un) 8641**] NH with epidural hematoma Major Surgical or Invasive Procedure: s/p Right EDH evacuation History of Present Illness: 51 year old female school teacher presents s/p fall for unknown reason. She had LOC initially and when she woke up was combative and then wanted to leave OSH against medical advice. She was found to have close to 2cm right epidural hematoma. She was intubated for airway protection and med flight brought her to [**Hospital1 18**]. She was sedated initially during intubation and then received no further meds during flight. Past Medical History: None S/P 5 Child births Social History: School teacher Non smoker Occasional Wine Family History: Mother with [**Name2 (NI) 68387**] Grandfather with hx of anuerysm Physical Exam: Gen: pt. intubated but opens eyes to command HEENT:+ subgaleal collection right posterior parietal, + small abrasion posterior parietal-occipital region. (-) battle sign, raccoon sign. External auditory canal + blood, TMs not visualized Pupils:right [**4-16**], left [**3-15**] EOMs-intact Neck: in collar Lungs: CTA bilaterally. Cardiac: RRR. S1/S2. Abd: Soft, NT, BS+ Extrem: Warm and well-perfused. No C/C/E. Neuro: Mental status: Patient opens eyes to command. Is intubated currently. GCS = 10T Cranial Nerves: I: Not tested II: Pupils: right 4-3 mm, left 3-2mm. III, IV, VI: Extraocular movements intact bilaterally without Remainder of CN not examined due to patient being intubated. Motor: moving all extremities, localizes to pain Sensation: Intact to light touch bilaterally. Reflexes: Pa Right 2+ Left 2+ Toes downgoing bilaterally CT OSH: Pertinent Results: [**2103-11-7**] 01:55PM FIBRINOGE-310 [**2103-11-7**] 01:55PM PT-12.0 PTT-29.6 INR(PT)-1.0 [**2103-11-7**] 01:55PM PLT COUNT-113* [**2103-11-7**] 01:55PM WBC-15.2* RBC-4.36 HGB-12.0 HCT-34.1* MCV-78* MCH-27.5 MCHC-35.2* RDW-16.4* [**2103-11-7**] 01:55PM WBC-15.2* RBC-4.36 HGB-12.0 HCT-34.1* MCV-78* MCH-27.5 MCHC-35.2* RDW-16.4* [**2103-11-7**] 01:55PM CALCIUM-8.5 PHOSPHATE-1.3* MAGNESIUM-2.0 [**2103-11-7**] 01:55PM CK-MB-5 [**2103-11-7**] 01:55PM LD(LDH)-222 AMYLASE-49 [**2103-11-7**] 02:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-NEG Brief Hospital Course: Ms [**Known lastname **] was taken emergently to the OR where she underwent an evacuation of a right sided epidural hematoma. Post operatively she was brought to the trauma ICU where she followed closely with Q1 neurochecks and blood pressure control. She was extubated early am of POD#1 she had a repeat CT that showed: The remaining hyperattenuating sliver represents either a minute amount of hemorrhage verus focal dural thickening. There is no evidence of reaccumulation of significant hemorrhage within this region. No new areas of hemorrhage, mass lesion, hydrocephalus, shift of normally midline structures, or infarction is identified. She had a wound drain that was removed and she was transferred to the surgical floor. She had a full cardilogy work up which included an ECHO: 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. There is no left ventricular outflow obstruction at rest or with Valsalva. 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 leaflets are mildly thickened. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. The estimated pulmonary artery systolic pressure is normal. There is a small pericardial effusion. The effusion appears circumferential. Carotid arteries showed: No evidence of internal carotid artery stenosis on either side. Cardilogy felt that she had unexplained syncope. She should follow up as an outpatient with cardiology for possible EP testing or stress testing. Neurologically she remained intact with amnesia of events of injury. She had some periods of headaches, nausea and dizziness. She was tolerating a regular diet, voiding without difficulty. Her incision was clean and dry. She worked with physical therapy and was found to be safe to go home with 24 hour supervision. Medications on Admission: None Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day): Use while on pain medication. Disp:*60 Capsule(s)* Refills:*0* 2. Dilantin 100 mg Capsule Sig: One (1) Capsule PO three times a day for 1 months: use until follow up with Dr [**Last Name (STitle) 548**]. Disp:*90 Capsule(s)* Refills:*1* 3. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed for pain. Disp:*60 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: s/p EDH evacuation Discharge Condition: neurologically stable Discharge Instructions: Keep incision, clean and dry Watch incision for redness, drainage, swelling, bleeding or fevers greater than 101.5 any neurologic changes or severe headaches call Dr[**Name (NI) 2845**] office When first getting up from sitting or laying position go slowly allow your body time to adjust. DO NOT DRIVE UNTIL FOLLOW UP WITH CARDIOLOGY Followup Instructions: Return to have staples removed on [**11-19**] between 0900-1200 at Dr[**Name (NI) 2845**] office. [**Hospital Unit Name 31391**] Then follow up at Dr[**Name (NI) 2845**] office in 6 weeks with a non contrast head CT call [**Telephone/Fax (1) 2992**] for an appointment Please follow up with a cardiologist either here or in N.H. If you choose to stay here, please make appointment with Dr. [**Last Name (STitle) 5543**] ([**Telephone/Fax (1) 29517**] in the next 2 weeks. Have primary care physcian monitor dilantin level in next week. Completed by:[**2103-11-11**]

[ "E888.9", "800.26", "424.0", "780.2" ]

icd9cm

[ [ [] ] ]

[ "96.71", "96.04", "01.24" ]

icd9pcs

[ [ [] ] ]

5126, 5132

2563, 4603

351, 378

5195, 5219

1918, 2540

5602, 6171

955, 1023

4658, 5103

5153, 5174

4629, 4635

5243, 5579

1038, 1459

240, 313

406, 833

1557, 1899

1474, 1541

855, 880

896, 939

28,973

158,953

31266

Discharge summary

report

Admission Date: [**2159-2-13**] Discharge Date: [**2159-3-15**] Date of Birth: [**2095-1-27**] Sex: F Service: MEDICINE Allergies: Tetracycline / Tape / Metal Can/Brush Top Applicat Attending:[**Doctor First Name 16571**] Chief Complaint: SOB Major Surgical or Invasive Procedure: bronchoscopy PICC line placement History of Present Illness: The patient is a 64 year-old female with a PMH significant for ASD repair with patch in [**11/2158**] complicated by sternal wound infection, post-op afib, and C. diff colitis; tobacco use, COPD, and HTN presenting with intermittent back pain and worsening SOB from baseline. The back pain has been present for several weeks-it was initially intermittent and then became constant. For the last several days she has complained of increasing shortness of breath. She denies having chest pain, fever/ chills or cough. She has constant nausea, which is her baseline for several weeks. She denied any infectious contacts. She usually takes lasix for lower extremity edema but has not had worsening edema recently; however, stopped taking her Lasix several days ago because of aggravation with the frequent urination. She was referred to an OSH ER where CXRs were obtained. On her way home from the OSH ER she was contact[**Name (NI) **] by her primary care physician who told her to go to [**Hospital1 18**] ER because her CXR was concerning for a mass in her chest. . In the [**Hospital1 18**] ED, she was afebrile. CT chest demonstrated diffuse LAD (+/- mass) and postobstructive pneumonia. This is a new finding, although there are no other CT scans in our system. Her sternal wound has continued nonunion. She was seen by the CT [**Doctor First Name **] PA who thought there was no active CSurg issues. She was seen by the plastics team who also thought there were no active wound issues. She came in with a HR 170 in atrial fibrillation with ST depressions in the lateral leads. Cardiology was consulted who thought the PAF was related to the pneumonia. She was initially rate controlled with IV diltiazem, but her home po metoprolol was not started. She received IV vancomycin and IV levofloxacin for her postobstructive pneumonia. She refused flagyl given previous history of GI side effects, but is willing to reconsider if her clinical status worsens. . On initial MERIT evaluation, she was in NSR with rates in the 90s. She had not received po vancomycin since ED arrival. She was restarted on home medications including nebs. Per discussion with ID, the antibiotics she received were acceptable. She has C.difficle infection, and she was restarted on po vancomycin. She continues to complain of mild shortness of breath, although is overall improved. She has continued nausea. She spits up white sputum. Past Medical History: ASD now s/p Gortex patch closure [**2158**] COPD (not on home O2) Sternal wound infection s/p surgery (completed course Nafcillin [**1-/2159**]) Hyperlipidemia c. diff colitis (current [**2-/2159**]) HTN s/p appendectomy R Femoral artery damage and repair (operative complication) Atrial fibrillation, rate controlled, never been on coumadin (use to be on digoxin, temporarily on amiodarone in [**11/2158**] for post op AF) Histoplasmosis of eyes Social History: retired 45 pack year smoking history, quit [**2158-10-30**]. no EtOH or other illicits Family History: NC Physical Exam: GENERAL: She is a chronically ill-appearing female in no acute distress. HEENT: Unremarkable. LYMPHATICS: She has no cervical, axillary, or supraclavicular adenopathy. HEART: She has a regular rate and rhythm with no murmurs, rubs, or gallops. LUNGS: Clear with decreased breath sounds anteriorly. She has a midline sternal scar, which is healing by secondary intention. ABDOMEN: She has no hepatosplenomegaly, no ascites. EXTREMITIES: No peripheral edema. Pertinent Results: STUDIES: ECG Study Date of [**2159-2-14**] 2:40:38 AM Sinus rhythm with frequent atrial premature beats. Compared to tracing #1 frequency of atrial premature beats has significantly increased. Intervals Axes Rate PR QRS QT/QTc P QRS T 97 0 82 398/462 0 42 60 . [**2159-2-13**] CXR: IMPRESSION: Large region of post-obstructive consolidation in the left lung with left hilar mass. Mild pulmonary edema and a small right-sided pleural effusion are seen, without overt congestive heart failure. . [**2159-2-13**] CTA OF THE CHEST: IMPRESSION: 1. No central or segmental pulmonary embolism. 2. Newly apparent marked lymphadenopathy in the mediastinum with mass and/or lymphadenopathy in the left hilum, highly concerning for a left hilar neoplasm with metastatic lymph nodes. Endobronchial biopsy could be performed for further evaluation. The infiltrate in the left lower lobe could represent post- obstructive consolidation, given that the bronchial obstruction of segmental lower lobe branches. Small amount of loculated left pleural fluid. 3. Sternal non-[**Hospital1 **], with unchanged appearance of multiple sternotomy wires, and pectoralis flap. No adjacent fluid collections. . [**2159-2-14**] Head CT: IMPRESSION: Normal head CT without and with contrast without evidence of hemorrhage, or masses. . [**2159-2-14**] TTE: The left atrium and right atrium are moderately dilated. No atrial septal defect or patent foramen ovale is seen by 2D, color Doppler or saline contrast with maneuvers. The estimated right atrial pressure is 0-5 mmHg. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%) Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild to moderate ([**1-3**]+) mitral regurgitation is seen. There is moderate pulmonary artery systolic hypertension. The end-diastolic pulmonic regurgitation velocity is increased suggesting pulmonary artery diastolic hypertension. There is a trivial/physiologic pericardial effusion. Compared with the prior study (images reviewed) of [**2158-12-25**], the severity of tricuspid regurgitation and the estimated pulmonary artery systolic pressure are reduced. No residual atrial septal defect flow identified. . [**2159-2-15**] CT ABDOMEN/ PELVIS WITH CONTRAST: IMPRESSION: 1. Indeterminate 1.4 cm lesion in segment [**Doctor First Name **] of the liver. Differential includes a benign entity such as a hemangioma, though hypervascular metastasis is an important consideration. Further imaging with MR recommended. 2. Multiple scattered hypodense lesions in the liver, measuring smaller than 9 mm. These are also indeterminate, though it could potentially represent cysts or metastases. Further imaging recommended. 3. Indeterminate 14 mm left adrenal nodule. Further evaluation with MR recommended. Differential includes metastasis versus benign adenoma. Further imaging with MR recommended. 4. Further partial collapse of the left lower lobe with partially enhancing left pleural effusion. 5. 2 cm fluid collection at surgical site in right groin, likely seroma, though infection (abscess) should be considered in proper clinical setting. 5. Rectal distention with stool. 6. Multiple hypodense lesions in both kidneys, likely cysts. Ultrasound (or MR) could evaluate this finding, though these likely represent cysts. . [**2159-2-16**] CXR FINDINGS: In comparison with study of [**2-13**], there is now almost complete opacification of the left hemithorax. Although some of this may reflect pleural fluid, the shift of the mediastinum to the left indicates that most of the opacification relates to volume loss. The expanded right hemithorax shows no evidence of acute pneumonia. . [**2159-2-16**] MRI ABDOMEN: IMPRESSION: 1. 16-mm enhancing lesion in segment IV-A of the liver along the anterior liver margin. This lesion does not have characteristics of a benign lesion. Additional small 7-mm segment IV-B lesion along the anterior liver margin of similar enhancement characteristics which could also represent metastases. There are several additional foci which are too small to be characterized, for which metastases cannot be excluded. Hepatic ultrasound could be performed to assess as to whether the dominant lesion is amenable to ultrasound-guided biopsy, and whether further characterization of any of the smaller lesions is possible. 2. Nodular left adrenal gland, consistent with hyperplasia, without discrete lesion identified. 3. Consolidation of visualized left lung with associated effusion. . [**2159-2-28**] CXR: IMPRESSION: 1. Significant improvement in aeration of the left upper lung as well as the lingular region, most likely secondary to resolution of an intrabronchial mucous plug. 2. Persistent mediastinal and hilar masses encasing and narrowing the left main bronchus. 3. Bilateral small pleural effusion with persistent left lower lobe collapse. . PATHOLOGY: [**2159-2-16**] Flow Cytometry: INTERPRETATION: Non-diagnostic study. Cell marker analysis was attempted, but was non-diagnostic in this case due to insufficient numbers of cells for analysis. Correlation with clinical findings and morphology (see separate cytology report C08-6163G) is recommended. If clinically indicated, we recommend a repeat specimen be submitted to the flow cytometry laboratory. . MICRO: [**2159-2-12**] BCX: neg x 2 [**2159-2-13**] UCX: neg [**2159-2-13**] urinary legionella Ag neg [**2159-2-14**] cryptococcal ag neg . LABORATORY DATA: Admission labs, [**2159-2-12**]: CBC: White Blood Cells 8.9 K/uL Red Blood Cells 3.74*# m/uL Hemoglobin 11.3*# g/dL Hematocrit 33.4* % MCV 89 fL MCH 30.3 pg MCHC 33.9 % RDW 17.1* % DIFFERENTIAL Neutrophils 75.5* % Lymphocytes 15.5* % Monocytes 6.7 % Eosinophils 1.8 % Basophils 0.4 % Platelet Count 428 K/uL . Electrolytes: Glucose 133* mg/dL Urea Nitrogen 13 mg/dL Creatinine 1.2* mg/dL Sodium 135 mEq/L Potassium 3.9 mEq/L Chloride 97 mEq/L Bicarbonate 26 mEq/L Anion Gap 16 mEq/L Calcium, Total 11.0* Phosphate 3.6 mg/dL Magnesium 1.8 mg/dL . Discharge labs, [**2159-3-15**]: CBC: White Blood Cells 3.6* K/uL Red Blood Cells 2.88* m/uL Hemoglobin 9.0* g/dL Hematocrit 25.9* % MCV 90 fL MCH 31.1 pg MCHC 34.7 % RDW 19.3* % Platelet Count 251 K/uL . Electrolytes: Glucose 87 mg/dL Urea Nitrogen 9 mg/dL Creatinine 0.9 mg/dL Sodium 138 mEq/L Potassium 4.1 mEq/L Chloride 104 mEq/L Bicarbonate 26 mEq/L Anion Gap 12 mEq/L . Other labs: Gran count: [**2159-3-9**] 12:00AM 2470 [**2159-3-8**] 12:00AM 2140* [**2159-3-7**] 12:01AM 2840 [**2159-3-5**] 12:00AM 5170 . Brief Hospital Course: The patient is a 64 year-old female with a PMHx sx for open ASD repair c/b sternal wound infection and post-operative AF who was initially admitted through the ED with SOB and back pain, with CTA in the ED demonstrating diffuse LAD and post-obstructive PNA concerning for malignancy. . #) Post Obstructive PNA - The patient was treated with a 2 week course of vancomycin and zosyn to cover for hospital acquired organisms, which ended on [**2-26**]. She remained afebrile with no recurrence of symptoms for the remainder of her hospital course. The patient showed improved aeration on pulmonary exam for remainder of hospital course. . # Large Cell Lung CA - As below, the pulmonary service performed a bronchoscopy which showed external compression of her left mainstem bronchus. The patient underwent biopsy/FNA, which showed large cell carcinoma. Oncology was consulted for further recommendations on workup/ management. Of note, the patient also has a liver lesion suspicious for metastasis. The patient underwent palliative XRT for an 11-session course. She also initiated [**Doctor Last Name **]/taxol therapy on [**2-23**]. The patient became neutropenic on [**3-1**] to nadir ANC of approx. 300 and was started on Neupogen 300 sc daily until [**3-5**]. Gran ct > 5000 by time of discharge with no recurrence of neutropenia. The patient will follow-up in clinic for restaging and further discussion of chemotherapy regimen in 2 weeks. . # Atrial fibrillation - etiology was thought to be multifactorial, in setting of a post-obstructive pneumonia and atrial irritation from invasive and expansive pulmonary masses. This was controlled initially in the [**Hospital Unit Name 153**], and the patient was then transferred to the floor on metoprolol 50 mg tid. While on the floor, she had a bronchoscopy performed which showed external compression of her left mainstem bronchus, and she had a biopsy/FNA performed, which showed large cell carcinoma. She was then readmitted to the [**Hospital Unit Name 153**] with atrial fibrillation with HR 130s, and was started on a diltiazem gtt. In the [**Hospital Unit Name 153**], she was started on po diltiazem, which was rapidly uptitrated to 60 mg qid with good effect. She was briefly called out, but developed HR 160s, w/EKG c/w AF with RVR, for which she received metoprolol 5 mg IV x2, followed by diltiazem 10 mg IV x2 without conversion. She denied chest pain, SOB, tachypnea. She was put back on a dilt gtt, and shortly thereafter an amiodarone gtt was begun with plan to continue with po load. Cardiology was consulted and recommended against amiodarone. She was put on po metoprolol and po diltiazem which was aggressively uptitrated with good effect. However, she experienced an acute respiratory decompensation which precluded her from taking her po medications, and in that setting experienced RVR to the 140-150s again. The patient was again transferred to the floor on regimen of diltiazem 120mg q8h and metoprolol 100mg po tid, where she remained somewhat tachycardic. Her blood pressure was low-normal on this regimen (90s-100s/ 50s-60s), so she was started on digoxin 0.0625mg for additional HR control with good effect (HR ~ 100 by time of discharge). Anticoagulation was not pursued as the patient has a high risk of bleeding given large tumor burden and a CHADS score of 0. . # Hypoxia - The patient began to suffer worsening oxygenation with desaturations on [**2-23**]. She also became agitated and delirious. CXR was consistent with worsening edema in the remaining lung (known L lung collapse). The patient was diuresed with marginal effect. She required BiPaP for an ABG which showed hypercarbia to 60. Cardiogenic etiology for edema was felt to be unlikely given NL echo on this admission, and EKGs without ischemic changes. Central etiology for decreased respiratory drive was also felt to be unlikely. Low suspicion for PE given that she was on a heparin gtt for afib at that time. She was also treated for a COPD exacerbation, including nebs and incidental administration of high dose steroids (from chemotherapy for nausea ppx) without much success. Her code status was briefly changed from DNR/DNI to focus on comfort measures, but this was reversed as the patient spontaneously had a return in mental status towards baseline and an improvement in O2 saturations. By the time the patient was discharged to rehab, she was saturating in the mid-90%s on 0.5-1L NC. . # C diff colitis - The patient was continued on po vanc for an additional 2 weeks after resolution of broad spectrum treatment for post-obstructive PNA. This course was completed while inhouse with no further diarrhea. . # Anemia: The patient has a stable hct ~25. The patient was transfused a total of 2u PRBC per oncology recommendations to keep hct > 22. This was well-tolerated with appropriate increase in hct. Hct on discharge was 25.9. . # Dyspepsia: The patient began experiencing symptoms of dyspepsia, likely secondary to XRT. She treated with a PPI [**Hospital1 **] and H2 blocker with magic mouthwash before meals. . # Nausea: This was also felt to be secondary to XRT. The patient was continued on a PPI, H2 blocker, and reglan. Low dose dexamethasone may be started if symptoms persist. . # Dysphagia: Also likely secondary to XRT. The aptient was continued on magic mouthwash and liquid oxycodone prior to meals. PO meds were changed to liquid when possible. . # The patient was discharged to rehab on [**3-15**] in good condition, VSS, ambulating well and tolerating po. Follow-up in heme/onc clinic was arranged for 2 weeks. Medications on Admission: Advair (unknown dose) Spiriva (unknown dose) Albuterol prn Zantac 150 mg po qam aspirin 81 mg po qam Promethazine 25 mg po q6h prn Metoprolol 50 mg po tid Zocor 40 mg po qpm Oxazepam 15 mg po qhs Vancomycin 250 mg po q6h Discharge Medications: 1. Morphine Concentrate 20 mg/mL Solution [**Month/Year (2) **]: [**5-17**] mL PO Q2H (every 2 hours) as needed for SOB, pain. 2. Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization [**Month/Year (2) **]: One (1) treatment Inhalation Q4H (every 4 hours) as needed for SOB, wheezing. 3. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device [**Month/Year (2) **]: One (1) puff Inhalation [**Hospital1 **] (2 times a day). 4. Aspirin 81 mg Tablet, Chewable [**Hospital1 **]: One (1) Tablet, Chewable PO DAILY (Daily). 5. Heparin (Porcine) 5,000 unit/mL Solution [**Hospital1 **]: One (1) injection Injection TID (3 times a day). 6. Acetaminophen 325 mg Tablet [**Hospital1 **]: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain, fever. 7. Levalbuterol HCl 0.63 mg/3 mL Solution for Nebulization [**Hospital1 **]: One (1) treatment Inhalation q6hrs prn (). 8. Docusate Sodium 100 mg Capsule [**Hospital1 **]: One (1) Capsule PO BID (2 times a day). 9. Senna 8.6 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times a day) as needed. 10. Ipratropium Bromide 0.02 % Solution [**Hospital1 **]: One (1) treatment Inhalation Q6H (every 6 hours) as needed. 11. Clotrimazole 10 mg Troche [**Hospital1 **]: One (1) Troche Mucous membrane QID (4 times a day). 12. Digoxin 125 mcg Tablet [**Hospital1 **]: 0.5 Tablet PO DAILY (Daily). 13. Metoprolol Tartrate 50 mg Tablet [**Hospital1 **]: Two (2) Tablet PO TID (3 times a day). 14. Diltiazem HCl 60 mg Tablet [**Hospital1 **]: Two (2) Tablet PO Q8H (every 8 hours). 15. Ondansetron 8 mg Tablet, Rapid Dissolve [**Hospital1 **]: One (1) Tablet, Rapid Dissolve PO Q8H (every 8 hours) as needed. 16. Ranitidine HCl 150 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times a day). 17. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR PO BID (2 times a day). 18. Aluminum-Magnesium Hydroxide 225-200 mg/5 mL Suspension [**Last Name (STitle) **]: 15-30 MLs PO QID (4 times a day) as needed: please give prior to meals. 19. Metoclopramide 10 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO TID (3 times a day). 20. Oxycodone 5 mg/5 mL Solution [**Last Name (STitle) **]: [**5-12**] mL PO Q6H (every 6 hours) as needed: please give 30min prior to meals. Discharge Disposition: Extended Care Facility: Guardian [**Name (NI) **] - [**Name (NI) 1474**] Discharge Diagnosis: Primary: - Large cell lung cancer - Atrial Fibrillation - post-obstructive pneumonia - anemia - neutropenia . Secondary: - COPD/Emphysema - Hyperlipidemia - Hypertension Discharge Condition: good, afebrile and VSS, ambulating and tolerating po well Discharge Instructions: You were admitted with shortness of breath that ultimately lead to a diagnosis of lung cancer. You were treated with chemotherapy and radiation therapy for this. You are being set up with a new oncologist, Dr. [**Last Name (STitle) 4149**], for further treatment of your lung cancer. . You were also diagnosed with atrial fibrillation, or an irregular heart rhythm. You have been started on several new medications for this: metoprolol, diltiazem, and digoxin. You should take these as scheduled to prevent a rapid heart rate. . Please take all of your medications as prescribed. Several changes have been made, so you should take all medications as instructed on the updated list provided. Please attend all of your follow-up appointments. . If you experience any fevers > 100.5, chills, chest pain, shortness of breath, palpitations, dizziness, abdominal pain, nausea/ vomiting/ diarrhea, or any other concerning symptoms please contact your PCP or go to the ER for further evaluation. Followup Instructions: Please follow-up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4149**] (oncology) in 2 weeks from discharge. Contact: [**Name (NI) 8771**] [**Last Name (NamePattern1) **], [**MD Number(3) 20833**]: [**0-0-**]. . You will need a CT scan of the torso before this appointment. This has been scheduled tentatively for [**2159-4-3**], but you should reschedule this for the same day (just before your appointment) that you will follow-up with Dr. [**Last Name (STitle) 4149**]. Phone: [**Telephone/Fax (1) 327**]. You will need a blood test to evaluate your renal function (BUN, creatinine) before this test. . Please follow-up with your primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 6402**], within 1-2 weeks of discharge to discuss the events of your hospitalization. Phone: [**Telephone/Fax (1) 73656**]

[ "272.4", "486", "787.01", "782.3", "E878.8", "V15.82", "115.90", "564.00", "276.3", "E879.2", "255.9", "285.9", "491.21", "692.3", "593.2", "275.42", "787.20", "530.81", "162.2", "V66.7", "584.9", "V45.89", "288.03", "704.09", "E933.1", "008.45", "416.8", "401.9", "427.31", "196.1", "799.02", "998.89", "518.81", "197.7" ]

icd9cm

[ [ [] ] ]

[ "93.90", "92.29", "38.93", "33.23", "33.26", "99.25" ]

icd9pcs

[ [ [] ] ]

18810, 18885

10656, 16243

317, 352

19099, 19159

3883, 5082

20195, 21058

3384, 3388

16515, 18787

18906, 19078

16269, 16492

19183, 20172

3403, 3864

274, 279

380, 2793

5091, 10480

2815, 3263

3279, 3368

10492, 10633

53,181

170,490

179

Discharge summary

report

Admission Date: [**2172-3-5**] Discharge Date: [**2172-3-8**] Date of Birth: [**2109-10-8**] Sex: F Service: NEUROSURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 1835**] Chief Complaint: Meningioma Major Surgical or Invasive Procedure: Right Craniotomy History of Present Illness: [**Known firstname 622**] [**Known lastname 1836**] is a 62-year-old woman, with longstanding history of rheumatoid arthritis, probable Sweet's syndrome, and multiple joint complications requiring orthopedic interventions. She was found to hve a right cavernous sinus and nasopharyngeal mass. She underwent a biopsy of hte nasopharyngeal mass by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1837**] and the pathology, including flow cytometry, was reactive for T-cell lymphoid hyperplasia only. She has a longstanding history of rheumatoid arthritis that involved small and large joints in her body. Her disease is currently controlled by abatacept, hydroxychloroquine, and methotrexate. She also has a remote history of erythematous nodules at her shins, dermatosis (probable Sweet's disease), severe holocranial headache with an intensity of [**9-28**], and dysphagia. But her symptoms resolved with treatment for autoimmune disease. Please refer additional past medical history, past surgical history, facial history, and social history to the initial note on [**2171-11-4**]. She cam to the BTC for discussion about management of her right cavernous sinus mass that extends into the middle cranial fossa. She had a recent head CT at the [**Hospital1 756**] and Woman's Hospital on [**2171-11-29**], when she went for a consultation there. She is neurologically stable without headache, nausea, vomiting, seizure, imbalance, or fall. She has no new systemic complaints. Her neurological problem started [**9-/2171**] when she experienced frontal pressure-like sensations. There was no temporal pattern; but they may occur more often in the evening. She had fullness in her ear and she also had a cold coinciding to the onset of her headache. By late [**Month (only) 359**] and early [**2171-10-21**], she also developed a sharp pain intermittently in the right temple region. She did not have nausea, vomiting, blurry vision, imbalance, or fall. A gadolinium-enhanced head MRI, performed at [**Hospital1 346**] on [**2171-10-30**], showed a bright mass involving the cavernous sinus. Past Medical History: She has a history of rheumatoid arthritis unspecified dermatosis, right knee replacement, left hip replacement, and fusion of subtalar joint, and resection of a benign left parotid gland tumor. Social History: She is married. She had smoked for approximately a year and a half when she was younger, but is not currently smoking. She has approximately one glass of wine per week. She is retired but was employed as a teacher. Family History: Cancer, diabetes, hearing loss, and heart disease. Physical Exam: AF VSS HEENT normal no LNN Neck supple. RRR CTA NTTP warm peripherals Neurological Examination: Her Karnofsky Performance Score is 100. She is neurologically intact. Pertinent Results: MRI [**3-5**] Right middle cranial fossa mass likely represents a meningioma and is stable since MRI of [**2172-2-11**]. The previously seen midline nasopharyngeal mass has decreased in size since MRI of [**2168-2-11**]. Direct visual inspection would be helpful for further assessment of the nasopharyngeal mass. Brief Hospital Course: Patient presented electively for meningioma resection of [**3-5**]. She tolerated the procedure well and was extubated in the operating room. She was trasnported to the ICU post-operatively for management. She had no complications and was transferred to the floor and observed for 24 hours. Prelim path is consistent with meningioma. She has dissolvable sutures, and will need to come to neurosurgery clinic in [**6-28**] days for wound check only. She will need to be scheduled for brain tumor clinic. She will complete Decadron taper on [**3-10**] and then restart her maintenance dose of prednisone. She will also be taking Keppra for seizure prophlyaxis. Her neurologic examination was intact with no deficits at discharge. She was tolerating regular diet. She should continue to take over the counter laxatives as needed. Medications on Admission: bactrim, famotidine,folic acid, fosamax, lorezapam, methotrexate, mvi, orencia, plaquenil, prednisone 20qd Discharge Medications: 1. hydroxychloroquine 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 3. prednisone 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily): start the day after Decadron taper is complete-. 4. dexamethasone 0.5 mg Tablet Sig: Four (4) Tablet PO q6h () for 2 days: take 4 tabs every 6 hours on [**3-9**] and take 2 tabs every 6 hours on [**3-10**] then stop. Disp:*20 Tablet(s)* Refills:*0* 5. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: brain lesion Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Neuro exam intact. Discharge 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 have dissolvable sutures, you must keep that area dry for 10 days. ?????? 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. ?????? If you have been prescribed Dilantin (Phenytoin) for anti-seizure medicine, take it as prescribed and follow up with laboratory blood drawing in one week. This can be drawn at your PCP??????s office, but please have the results faxed to [**Telephone/Fax (1) 87**]. If you have been discharged on Keppra (Levetiracetam), you will not require blood work monitoring. ?????? If you are being sent home on steroid medication, make sure you are taking a medication to protect your stomach (Prilosec, Protonix, or Pepcid), as these medications can cause stomach irritation. Make sure to take your steroid medication with meals, or a glass of milk. ?????? Clearance to drive and return to work will be addressed at your post-operative office visit. ?????? Make sure to continue to use your incentive spirometer while at home. 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: increasing redness, increased swelling, increased tenderness, or drainage. ?????? Fever greater than or equal to 101?????? F. Followup Instructions: ?????? Please return to the office in [**6-28**] days (from your date of surgery) for a wound check. This 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.

[ "710.2", "225.2", "V43.64", "714.0", "443.0", "530.81", "V43.65" ]

icd9cm

[ [ [] ] ]

[ "01.51", "02.12", "00.34" ]

icd9pcs

[ [ [] ] ]

5162, 5168

3553, 4381

317, 336

5224, 5224

3214, 3530

7474, 7807

2956, 3009

4539, 5139

5189, 5203

4407, 4516

5393, 7451

3024, 3195

267, 279

364, 2486

5239, 5369

2508, 2704

2720, 2940

24,394

161,966

30466

Discharge summary

report

Admission Date: [**2194-3-4**] Discharge Date: [**2194-3-18**] Date of Birth: [**2146-7-20**] Sex: F Service: MEDICINE Allergies: Latex / Ivp Dye, Iodine Containing Attending:[**First Name3 (LF) 1974**] Chief Complaint: Orbital cellulitis Major Surgical or Invasive Procedure: none History of Present Illness: This is 47yo F with a history of HTN, CVA, Hep C, Anemia of chronic disease, CRI, h/o renovascualr disease with L angio stenting, renal osteodystrophy, depression, and membranoproliferative glomerulonephritis who presented to OSH for ankle pain and swelling, hypotension and syncope in PCPs office. . The patient reports that three weeks prior to admission, she had a frontal tooth replacement after an accident, and since that dental procedure had intermittent fevers to 101.1 and drenching night sweats at home, as well as difficulty swallowing. She later developed right ankle pain, involvement of her Left ankle, knee and R elbow so severe that she was confined to a wheelchair, which was consistent with her prior gout flair. She went to her PCP in [**State 2748**] with hopes of receiving a steroid injection and was found to be hypotensive, and had a syncopal episode. She was admitted on [**2194-2-27**] to [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 10315**] Hospital in [**Location (un) 14078**], CT for the syncope eval. . At the OSH, her right ankle was aspirated, showing "rare WBC's, no organisms, culture was negative," and she was started on high dose steroids. Over 24 hours, she developed increasing swelling in her left eye, so much that it was shut closed. Steroids were increased and the patient's swelling and erythema progressed over her ear, neck and had ecchymoses and drainage from eye. She spiked to 103.3, was started initially on vanc/zosyn + acyclovir and then switched to linezolid and meropenem. She was subsequently transferred here. Blood and wound cultures were positive for group a strep (strep pyogenes). Patient was initially in ICU for several days before being transferred to floor. Past Medical History: h/o nasal surgery hepatitis C MPGN CKD HTN Sz secondary to poorly controlled HTN depression cryoblobulinemia hyperuricemia gout Renal Artery Stenosis- s/p L sided stent placement Social History: lives with daughter and husband, has a dog. Denies tobacco/Etoh. Has 2 other children. Born in [**Male First Name (un) 1056**], grew up in New Jersey. Family History: Mother had DM, Father had HTN, she is one of 15 children (unsure of other siblings health Physical Exam: Vitals: T 98.4, BP 140/80, 100, 22, 97%2L NC Gen: ill-appearing, visibly uncomfortable, NAD HEENT: deep erythematous L superior eyelid with massive, edema, weeping clear yellow transudate with 3x2cm area of ecchymosis on eyelid. Area of edema extending around the left ear with deformity, and down left neck. Neck: Diffuse tender LAD with multiple regional enlarged nodes L > R. CV: Irregularly Irregular, no MRG, JVP not visible. CHEST: CTAB Abd: mild soft tissue tenderness to left of umbilicus, otherwise, soft, NT, ND, BS+ Extrem: no CCE, bilateral LE icthyosis, 2+ DP, PT pulses. L arm tenderness near prior IV insertion site. Pertinent Results: OSH: 2/2 blood cx bottles + for Group A Strep, Wound Culture positive for Group A strep. . . [**2194-3-4**] 10:46PM WBC-17.2* RBC-3.32* HGB-9.9* HCT-28.4* MCV-86 MCH-29.9 MCHC-34.9 RDW-13.9 [**2194-3-4**] 10:46PM NEUTS-93* BANDS-3 LYMPHS-3* MONOS-1* EOS-0 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 [**2194-3-4**] 10:46PM PLT SMR-VERY LOW PLT COUNT-71* [**2194-3-4**] 10:46PM ALT(SGPT)-23 AST(SGOT)-19 ALK PHOS-92 TOT BILI-0.5 [**2194-3-4**] 10:46PM GLUCOSE-149* UREA N-95* CREAT-2.1* SODIUM-140 POTASSIUM-3.6 CHLORIDE-105 TOTAL CO2-24 ANION GAP-15 [**2194-3-4**] 10:46PM ALBUMIN-2.6* CALCIUM-8.5 PHOSPHATE-3.1 MAGNESIUM-3.2* IRON-58 . . [**2194-3-17**] 03:05AM BLOOD WBC-4.4 RBC-2.77* Hgb-8.7* Hct-25.1* MCV-91 MCH-31.3 MCHC-34.5 RDW-14.5 Plt Ct-405 [**2194-3-17**] 03:05AM BLOOD UreaN-16 Creat-1.1 [**2194-3-17**] 03:05AM BLOOD ALT-18 AST-18 . . [**Month/Day/Year 4338**] ORBIT ([**3-14**]): No significant change in the size of the abscess just lateral to the left lateral rectus muscle. Unchanged large superficial soft tissue abscess just inferior to and lateral to the left orbit. Unchanged appearance of the left periorbital pre- and post-septal cellulitis. Again, there is abnormally slow diffusion within the left optic nerve (?ischemic optic neuritis). Unchanged appearance of the left temporal mandibular joint with enhancement and edema concerning for infection. . . CT SINUS ([**3-10**]): 1. Left orbital and periorbital inflammatory changes, slightly less extensive, compared to the prior study. 2. There is an increase in the opacification of the left maxillary sinus. 3. Irregular left temporomandibular joint, with evidence of prior surgery in this region. There has been no change since the prior study. See above report for additional discussion. . CT CHEST: 1. No evidence of mediastinal mass. 2. Moderate pericardial effusion. 3. Noncalcified lower lobe nodules measuring up to 6 mm. Statistically as an incidental finding, they are most likely benign. However, if the patient has risk factors for neoplasm, followup CT in six months may be helpful to confirm stability if warranted clinically. Brief Hospital Course: 1) Orbital cellulitis: Unclear where this originated. Likely progressed due to bolus steroids for gout at outside hospital. Treated with IV PCN and clinda. Oculoplastics, ENT, plastics, and ID all assisted with management. Oral surgery was consulted for possible seeding of the TMJ given hardware from previous surgery. By imaging, no changes and clinically asymptomatic so this was not pursued further. With treatment of group A strep with PCN and clinda, the cellulitis improved dramatically. The swelling decreased and an eschar was formed over the periorbital area. Pt had intermittent sharp pain. However, several repeat MRIs didn't demonstrate worsening of infection. Her pain was likely neuropathic but resolved by several days prior to discharge. 1d prior to discharge she was changed to PO amoxicillin. She will continue on this for at least 3 weeks with full duration to determined at follow up with ID. Per optho consulatation, prognosis for return of vision in left eye extremely poor. She will continue to apply bacitracin ophthalmic to the entire area. She will follow-up with plastics for likely reconstruction, as well as oculoplastics. She will need repeat [**Month/Year (2) 4338**] orbit in [**11-26**] weeks prior to f/u with ENT and ID. All of these appointments were arranged for her. . 2) Anemia: PT developed significant anemia, as low as 21 Hct. No evidence of bleeding, iron def, hemolysis. Likely due to combination of BM suppression from acute ilness and meds. Hematocrit stabilized with treatment of infection, discontinuation of possible contributing medications (requip, hydral, and valsartan), and initiation of epogen. Patient will need outpatient follow-up with hematology to discuss need for further testing and long-term management. Her Hct was in the mid 20s for most of her hospital stay. SPEP unremarkable. . 3) Hypertension: Valsartan discontinued due to risk of anemia. Instead, started lisinopril, amlodipine, and increased beta blocker. Her BP remained elevated but per pt better than baseline at home. She will continue to need uptitration of these meds as outpt. . 4) Gout: No symptoms on colchicine. Allopurinol was not restarted at this time, but can be once infectious issues are resolved. . 5) PULM NODULES: On chest CT, incidental finding of pulmonary nodules, likely benign, but can be followed up in 6mo to demonstrate stability. . 6) Acute renal failure: On admission from OSH, pt's Cr was 2.1 Her baseline was not known but with treatment of infection and hydration, improved to 1.1. So she was in ARF likely from infection and hypovolemia. . 7) Thrombocytopenia: Plt dropped from 200s at OSH to around 50 in ICU here. Concern for HIT so all heparin was stopped. HIT ab sent and negative x 2. No evidence of DIC. Platelets rebounded spontaneously without any other intervention. Medications on Admission: MVI zoloft toprol xl 150 [**Hospital1 **] prednisone 10 mg (last dose last week) diovan/HCTZ 160/25 QD allopurinol 150 QD vicodin torsemide 150 mg QD ambien 10 HS ropinerole 1 mg HS flonase 2 sprays QD Discharge Medications: 1. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO BID (2 times a day): take with 50mg tablet for total 150mg twice a day. Disp:*60 Tablet Sustained Release 24 hr(s)* Refills:*0* 2. Toprol XL 50 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO twice a day: take with 100mg tablet for total 150mg twice daily. Disp:*60 Tablet Sustained Release 24 hr(s)* Refills:*0* 3. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily). 4. Sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 6. Epoetin Alfa 10,000 unit/mL Solution Sig: [**Numeric Identifier 961**] ([**Numeric Identifier 961**]) UNITS Injection QMOWEFR (Monday -Wednesday-Friday). Disp:*10 INJ* Refills:*0* 7. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*0* 8. Zolpidem 5 mg Tablet Sig: 1-2 Tablets PO HS (at bedtime) as needed for insomnia. 9. Amoxicillin 500 mg Capsule Sig: One (1) Capsule PO Q8H (every 8 hours) for 20 days. Disp:*60 Capsule(s)* Refills:*0* 10. Bacitracin 500 unit/g Ointment Sig: One (1) Appl Ophthalmic TID (3 times a day) for 3 weeks: left eye. Disp:*QS * Refills:*0* 11. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO every [**2-28**] hours as needed for pain for 2 weeks. Disp:*30 Tablet(s)* Refills:*0* 12. Colchicine 0.6 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 13. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 14. Nasal 0.05 % Aerosol, Spray Sig: [**11-26**] sprays Nasal three times a day for 1 months. Disp:*QS * Refills:*0* 15. Outpatient Lab Work Weekly CBC, chem-7, AST/ALT/alk phos/total bili starting week of [**3-24**]. REsults faxed to Dr. [**First Name4 (NamePattern1) 4850**] [**Last Name (NamePattern1) **] (Infectious Diseases, [**Hospital1 18**]) at [**Telephone/Fax (1) 1419**]. Discharge Disposition: Home Discharge Diagnosis: PRIMARY: orbital cellulitis, strep anemia, NOS hypertension SECONDARY: recent gout hep c w/ h/o cryoglobulins - on plaquenil in past for this given h/o kidney involvement history of secondary hyperparathyroidism Discharge Condition: Good--afebrile, vital signs stable. Discharge Instructions: 1. Take medications as prescribed. Please note, some changes made in your BP medications. 2. Follow up as below. Please make all the appointments and if unable to do so contac the appropriate doctor. 3. Sleep with head of bed elevated. Use bacitracin ointment liberally to the left eye. 4. Please call your doctor or go to the emergency room if you experience temperature > 100.5, worsening eye pain, worsening swelling around your eye, diarrhea, vomiting/inability to take your antibiotics, or other concerning symptoms. Followup Instructions: 1. Please call Dr. [**Last Name (STitle) 72399**] to schedule a follow up appointment with her in [**11-26**] weeks for monitoring of BP, GOUT, ANEMIA and other issues. 2. ENT: [**4-1**] at 2pm with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1837**] ([**Telephone/Fax (1) 72400**]. --You should have an [**Telephone/Fax (1) 4338**] of the eye and CT of the sinuses prior to that visit. They are scheduled as follows: Provider: [**Name10 (NameIs) **] SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2194-3-29**] 11:15 [**Hospital Ward Name **] [**Location (un) 470**]. Provider: [**Name10 (NameIs) 4338**] Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2194-3-29**] 12:00 [**Hospital Ward Name **] basement. 3. Provider: [**Name10 (NameIs) **] SURGERY CLINIC Phone:[**Telephone/Fax (1) 4652**] Date/Time:[**2194-3-28**] 1:00. [**Hospital **] Medical Building, [**Hospital Ward Name **]. 4. INFECT DISEASE: You have an appointment with Dr. [**First Name4 (NamePattern1) 4850**] [**Last Name (NamePattern1) **] on [**4-3**] at 10am. Please call ([**Telephone/Fax (1) 4170**] if there are any problems. [**Name (NI) **] will need weekly labs sent to Dr. [**First Name (STitle) **] at fax#[**Telephone/Fax (1) 1419**]. I have included prescription but please contact Dr. [**Last Name (STitle) 72401**] to arrange the blood tests. 5. OCULOPLASTICS: Dr. [**Last Name (STitle) 12044**] ([**Telephone/Fax (1) 12045**]) at [**Hospital 39111**] ([**Last Name (NamePattern1) **], [**Location (un) 453**]) on [**3-20**] at 2:30pm. OTHER ISSUES: You will need a follow up chest CT in 6 months to monitor pulmonary nodules seen on CT here. PLease ask Dr. [**Last Name (STitle) 72401**] to set this up.

[ "070.54", "276.52", "041.01", "285.29", "790.7", "584.9", "274.9", "287.5", "427.31", "440.1", "373.13", "585.9", "403.90", "376.01" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

10561, 10567

5421, 8288

313, 320

10824, 10862

3270, 5398

11438, 13171

2511, 2602

8541, 10538

10588, 10803

8314, 8518

10886, 11415

2617, 3251

255, 275

348, 2124

2146, 2327

2343, 2495

28,726

114,139

31081

Discharge summary

report

Admission Date: [**2191-7-29**] Discharge Date: [**2191-8-10**] Date of Birth: [**2122-8-26**] Sex: M Service: MEDICINE Allergies: Heparin Agents / Abciximab Attending:[**First Name3 (LF) 2297**] Chief Complaint: dyspnea Major Surgical or Invasive Procedure: diagnostic paracentesis History of Present Illness: Mr. [**Known lastname 9063**] is a 68 M with h/o CAD, MI, CVA, HTN who presents with 3 months history of dyspnea, cough, and leg swelling. His exercise tolerance has decreased dramatically over the last 3 months to the point where he cannot walk from room to room without getting SOB. His cough is occasionally productive of varying sputum quality and is sometimes associated with coughing fits that lead to vomiting. It is worse with laying down. Leg swelling has been present over the same time period with more recent reddening at the ankles. Patient is sleeping upright but states [**2-25**] cough and not feelings of orthopnea or PND. No CP, dizziness, abd pain, diarrhea, dysuria, fevers. Large EtOH history ([**1-25**] gallon whiskey per day). . Of note, the patient is at times a poor historian who has had little medical care in at least the previous 3 years. Past Medical History: CAD; MI x 3, s/p RCA placement CVA x 2 with R sided weakness, reportedly resolved HTN Hypercholesterolemia Inguinal hernia repair Alcohol abuse Social History: Lives with wife (but separated currently). Retired construction worker. Denies smoking, illicit drug use. Heavy EtOH use as above. No h/o DTs. Family History: Etoh abuse in father and brothers; mother with DM, brother with CAD Physical Exam: Admission: VS: 97.9,BP 146/88, HR 74, RR 18, O2 sat 94% RA General: Pleasant, slightly disheveled, NAD HEENT: NC, AT, sclera anicteric, PERRL. MMM, pharynx clear. Heart: RRR, S1, S2. No murmur appreciated Lungs: CTA bilat, slightly diminished. Abd: + BS. Distended, soft. Mild diffuse periumbilical tenderness. + hepatomegaly with spleen 5-6 cm below costal margin, ?splenomegaly also. No scrotal edema Extrem: 2+ pitting edema equal bilat to knees. Erythema and mild tenderness- skin over bilateral ankles. Not significant increased warmth. Neuro: Alert and oriented. CN II-XII intact, strength grossly normal. Normal pedal sensation. Pertinent Results: [**2191-7-29**] 03:30PM WBC-21.1* RBC-3.51* HGB-12.1* HCT-36.9* MCV-105* MCH-34.4* MCHC-32.8 RDW-17.1* [**2191-7-29**] 03:30PM PLT COUNT-330 [**2191-7-29**] 03:30PM NEUTS-84.5* LYMPHS-9.8* MONOS-4.4 EOS-0.8 BASOS-0.5 [**2191-7-29**] 03:30PM GLUCOSE-108* UREA N-17 CREAT-0.7 SODIUM-133 POTASSIUM-4.8 CHLORIDE-94* TOTAL CO2-25 ANION GAP-19 [**2191-7-29**] 03:30PM ALT(SGPT)-53* AST(SGOT)-235* CK(CPK)-150 ALK PHOS-459* AMYLASE-61 TOT BILI-2.2* DIR BILI-1.4* INDIR BIL-0.8 [**2191-7-29**] 03:30PM LIPASE-48 [**2191-7-29**] 03:30PM ALBUMIN-2.7* CALCIUM-10.2 PHOSPHATE-4.1 MAGNESIUM-2.2 [**2191-7-29**] 03:30PM ASA-4 ETHANOL-136* bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2191-7-29**] 03:30PM ACETONE-NEGATIVE [**2191-7-29**] 03:30PM cTropnT-<0.01 [**2191-7-29**] 03:30PM CK-MB-3 proBNP-441* . ECG: NSR at 100. Normal axis and intervals. Inferior Qwaves, poor RWP. . CXR: The heart is borderline in size, at the upper limits of normal. The lungs are clear. There are no pleural effusions or pneumothorax. Brief Hospital Course: A&P: 68 M with CAD, HTN, CVA, chronic EtOH use presents with 3 month h/o worsening dyspnea, cough, leg edema. He has not been in the medical system for many years. . His dyspnea was worked up and CHF/MI/pna were ruled out as causes. The patient was put on a CIWA scale as precaution for heavy alcohol abuse. The patient was found to have a large, fatty liver on US, and on exam demonstrates many of the stigmata of EtOH abuse. . The patient also had b/l LE edema and erythema for which he received levaquin to treat a possible cellulitis. Both ankles improved with treatment and it was d/ced after seven days. . Pt was improving on the floor, ready for discharge to an acute reharb facility when he experienced several episodes of bilious vomiting. Initial CT scan appeared to show a small bowel obstruction. A NG tube was dropped, with bilious return. Lactulose was held secondary to SBO. Patients mental status continued to deteriorate over the course of the day, he became tachypneic, and somnolent. He also became anuric, with little output after 2.5 liters in 24 hours. Hepatology and renal were consulted. The patient was eventually transferred to the unit with increasing ammonia levels, changes in mental status and decreased urine output. . In the MICU, pt's delirium and abdominal pain were believed to be a combination of untreated hepatic encephalopathy and SBO, with possible bowel perforation and SBP. He was treated with lactulose and rifaximin for hepatic encephalopathy, Vanc and CTX for possible SBP with Flagyl for anaerobic coverage in case of perforation, and IV Albumin for likely hepatorenal syndrome. Serial ammonia levels and lactates were followed, daily KUBs were done, as well as daily abdominal US to identify fluid collection for possible tap. His acute renal failure was treated as hypovolemia vs. hepatorenal syndrome, so he was given albumin as above, plus fluids. A macrocytic anemia was identified, and he was started on Vit B12 and folate. He had supportive care for his cirrhosis. As the patient became increasingly hemodynamically unstable with episodic hypotension and episodes of NSVT, the team decided to perform paracentesis to help better guide his therapy. The tap showed > 400 wbcs with few polys, c/w sbp. In spite of continued agressive antibiotics and supportive care, the patient's overall coneition contined to deteriororate with continued hypotension, ARF and ESLD.In discussion with the patient's family, the patient was made CMO and died from cardiopulmonary arrest on [**2192-8-10**]. . Medications on Admission: ASA Discharge Medications: NA Discharge Disposition: Expired Discharge Diagnosis: NA Discharge Condition: death Discharge Instructions: NA Followup Instructions: NA

[ "V45.82", "427.1", "303.01", "560.9", "592.0", "276.0", "414.01", "281.9", "571.1", "572.3", "571.2", "496", "584.9", "572.2", "486", "401.9", "291.81", "428.0", "466.0", "458.9" ]

icd9cm

[ [ [] ] ]

[ "96.07", "38.93", "93.90", "54.91", "96.09", "38.91", "94.62" ]

icd9pcs

[ [ [] ] ]

6010, 6019

3371, 5929

295, 320

6065, 6072

2322, 3348

6123, 6128

1572, 1641

5983, 5987

6040, 6044

5955, 5960

6096, 6100

1656, 2303

248, 257

348, 1226

1248, 1393

1409, 1556

66,549

191,462

44254

Discharge summary

report

Admission Date: [**2134-10-15**] Discharge Date: [**2134-10-18**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 6195**] Chief Complaint: dyspnea/wheezing Major Surgical or Invasive Procedure: none History of Present Illness: Ms. [**Known lastname 65014**] is a [**Age over 90 **] yo female with hypertension who presents with dyspnea and wheezing. The patient has been feeling sob for the past 2 weeks. She has noted cough (non-productive) and chest congestion but denies rhinorrhea, sore throat or headache. She reports swelling in her ankles, fatigue and poor PO intake. She denies chest pain, palpitations, fevers, orthopnea. She reports one possible episode of PND last week. She denies sick contacts, recent periods of immobilization or long travel. In the ED, initial vs were: T 98.3 P 75 BP 156/91 R 75 O2 sat 99% ra. Patient was given levofloxacin, normal saline 500ml, solumedrol, nebs x3, lasix 20mg IV, and aspirin as well. Patient with rales on exam and diffuse expiratory wheezes. Patient with 600cc urine out after lasix. In ED, the patient went into rapid Afib with HR in 130s, no decrease in blood pressure. Dilt 10mg x1 150->120s. The patient became more tachpneic and required CPAP transiently. She was never hypoxic. Her most recent vitals are BP 114/64 HR 130s RR 22 98% ra. . On the floor, she is breathing comfortably, pleasant and conversant. She reports a history of an irregular heart beat and states that it comes and goes. She cannot feel her fast heart rate at this time. . Review of systems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denied cough, shortness of breath. Denied chest pain or tightness, palpitations. Denied nausea, vomiting, diarrhea, constipation or abdominal pain. No recent change in bowel or bladder habits. No dysuria. Denied arthralgias or myalgias. Past Medical History: # Hypertension # Atrial fibrillation - uncertain duration, no anticoagulation # Dyspepsia # Depression # Legally blind in right eye # h/o Herpes Zoster # Anemia Social History: Lives alone. Her brother and grand niece live close by. She is accompanied by her niece. She is independent of ADLs. She has meals on wheels and assistance with shopping. She smokes [**4-7**] cigarettes/day. She smoked when she was younger and had quit for many years and resumed smoking 1 year ago. She drinks 2 small glasses of wine per night. no drug use. Family History: non contributory. Physical Exam: General: Alert & oriented x3, HOH & legally blind, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP 9, no LAD Lungs: bilat crackles at the bases. CV: irreg irreg and tachy, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: Warm, well perfused, 2+ edema to mid-tibia, 2+ pulses, no clubbing, cyanosis Neuro: CN grossly intact, strength 5/5 in ue & le bilat, sensation intact. Pertinent Results: [**2134-10-15**] 06:30PM WBC-8.1 RBC-3.64* HGB-8.9* HCT-29.1* MCV-80* MCH-24.4* MCHC-30.6* RDW-18.8* [**2134-10-15**] 06:30PM PLT COUNT-358 [**2134-10-15**] 05:29PM GLUCOSE-189* UREA N-13 CREAT-0.9 SODIUM-140 POTASSIUM-2.8* CHLORIDE-100 TOTAL CO2-27 ANION GAP-16 [**2134-10-15**] 05:29PM CK(CPK)-66 [**2134-10-15**] 05:29PM CK-MB-NotDone cTropnT-<0.01 [**2134-10-15**] 12:07PM LACTATE-1.2 [**2134-10-15**] 11:00AM CK(CPK)-70 [**2134-10-15**] 11:00AM cTropnT-0.01 [**2134-10-15**] 11:00AM CK-MB-NotDone proBNP-8552* Micro: [**2134-10-15**] BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT [**2134-10-15**] BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT Imaging: CXR: 1. Mild interstitial pulmonary edema. 2. Small right pleural effusion with loculated fluid in the right minor fissure. 3. Linear opacities in both lung bases, likely atelectasis. Infection is not completely excluded in these regions. . Echo: [**2134-10-16**]. The left atrium is elongated. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. There is moderate to severe global left ventricular hypokinesis (LVEF = 30 %). Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). Right ventricular chamber size and free wall motion are normal. There are focal calcifications in the aortic arch. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild to moderate ([**2-5**]+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. Brief Hospital Course: Ms. [**Known lastname 65014**] is a [**Age over 90 **] year old female with a few week history of dyspnea found to be secondary to atrial fibrillation with rapid ventricular response and congestive heart failure. . Congestive Heart Failure. Patient was admitted to the MICU for shortness of breath secondary to atrial fibrillation with a rapid ventricular response. She briefly required CPAP in the ED, but was quickly weaned to room air. She was rate controlled with metoprolol. She was diuresed with lasix and started on lasix 20 mg PO daily. She was started on Lisinopril as wel. Her echo showed an EF of 30%. . Atrial fibrillation. Patient reportedly had a history of paroxysmal atrial fibrillation though her PCP was unable to confirm this. Her heart rate was in the 150s upon presentation though her blood pressure remained normal. She was rate controlled with metoprolol but remained in atrial fibrillation. She did nto want cardioversion as her and her family felt this was inconsistent with her goals of care. Given her CHADS2 score of 2 and her high falls risk, she was started on aspirin 325 for stroke prevention. . Code: DNR/DNI discussed with patient & family Communication: [**Name (NI) **] (niece) [**Telephone/Fax (1) 94919**], [**Female First Name (un) 94920**] (grandneice) [**Telephone/Fax (1) 94921**], [**Name (NI) **] (brother) [**Telephone/Fax (1) 94922**] Medications on Admission: Medications on admission: Hydrochlorothiazide 25 mg PO daily Pilocarpine HCl 1 % Drops 1 drop in the left eye twice a day Zymar 1 drop 2x/day Alphagan 1 drop 2x/day Xalatan 1 drop QHS Discharge Medications: 1. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for Constipation. 2. Hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 3. Pilocarpine HCl 1 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2 times a day). 4. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 6. Atrovent HFA 17 mcg/Actuation Aerosol Sig: One (1) puff Inhalation four times a day as needed for shortness of breath or wheezing. 7. Nicotine 7 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr Transdermal DAILY (Daily). 8. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 9. Brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2 times a day). 10. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at bedtime). 11. Olanzapine 5 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO QHS (once a day (at bedtime)) as needed for agitation. 12. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Ciprofloxacin 0.3 % Drops Sig: 1-2 Drops Ophthalmic [**Hospital1 **] (2 times a day). 14. Lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Extended Care Facility: [**Location (un) **] house Discharge Diagnosis: Pulmonary edema Atrial fibrillation with rapid ventricula response . Secondary diagnosis: Hypertension Depression Discharge Condition: Good. Patient is ambulating. She is on room air. Discharge Instructions: You were admitted for shortness of breath. You were found to have fluid in your lungs (pulmonary edema) and you were found to have an irregular heart rythmn (atrial fibrillation) at a rapid rate. You were given a diuretic to remove fluid from your lungs. You were given metoprolol to improve your heart rate. . The following changes were made to your medications: * You were started on lasix 20 mg daily * You were started on metoprolol 25 mg three times daily for improved heart rate * You were started on lisinopril 2.5 mg daily for you blood pressure * You were started on Aspirin 325 daily for Atrial Fibrillation . Please come to the emergency department or call your PCP if you have chest pain, shortness of breath, difficulty breathing, leg swelling, fevers, chills or any other concerns. Followup Instructions: You have the following appointment schedule: 1. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2134-11-10**] 6:40 [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 6198**] MD, [**MD Number(3) 6199**]

[ "285.9", "428.0", "599.0", "300.00", "427.31", "369.4", "311", "428.41", "401.9" ]

icd9cm

[ [ [] ] ]

[ "93.90" ]

icd9pcs

[ [ [] ] ]

7829, 7882

4946, 6338

281, 287

8040, 8093

3145, 4923

8940, 9258

2569, 2588

6572, 7806

7903, 7972

6390, 6549

8117, 8917

2603, 3126

1612, 1992

225, 243

315, 1593

7993, 8019

2014, 2177

2193, 2553

16,560

188,711

49942

Discharge summary

report

Admission Date: [**2113-9-7**] Discharge Date: [**2113-9-8**] Date of Birth: [**2027-9-7**] Sex: F Service: MEDICINE Allergies: Codeine / Keflex / Clindamycin / adhesive tape / Gentamicin / Zosyn / Cefepime Attending:[**First Name3 (LF) 2297**] Chief Complaint: respiratory failure/hypoxia Major Surgical or Invasive Procedure: none History of Present Illness: 86 year old female with multiple medical problems including past PEA arrest, pneumonia requiring intubation and trach and PEG, dCHF, a-fib who presents from [**Hospital 100**] Rehab after unresponsive event. At 11:30 she was awake and interactive. 30 minutes later, she appeared "blue" to staff, was unresponsive, and had a faint to no pulse. Ten chest compressions were performed and she became arousable, and BP was 145/80. During the code, her Paci Muir valve was removed and she was bagged, though they did not inflate the cuff. In the ambulance, she had a desaturation to 80%, though the cuff was never inflated. She was suctioned and her sats improved to 100%. . In the ED: initial vitals were 94/54, 75, 20, 100% bagged. Her cuff was inflated, and she was placed on CMV with TV of 420, PEEP 5, RR20, FiO2 100%. She was given 1L NS, 1gm vancomycin, and 400mg IV cipro. CXR and CT head done, EKG showed NSR at 76, RAD, 1st degree AV block, TWI in II and aVL. Transfer vitals: 97.6, BP 125/56, HR 69, RR 20, 429, 100% on CMV, 50% FiO2. . On the floor, she is making mouth movements. Nodding her head, and responding to commands. She is mildly sluggish. Denies any feeling of SOB. . Review of systems: unatainable. Past Medical History: # PEA Arrest # Massive UGIB # Diastolic CHF # Atrial Fibrillation s/p Ablation # Dilated Ascending Aorta # Osteoporosis # Hypothyroidism # Dysphagia for several years with Weight Loss s/p G-tube placement # History of PNA requiring VATS pleural effusion drainage and decortication on the right side # Diverticulosis/Diverticulitis # Cerebral Palsy # Macular degeneration # Ventral Hernias # Rosacia . Past Surgical History: # Status post removal of bowel obstruction due to diverticulitis requiring a temporary colostomy # Status post surgical repair of a prolapsed uterus # Status post total hysterectomy # Status post abdominal surgery secondary to complications of prolapsed uterus surgery - The patient developed multiple hernias. # Status post surgery for exposed keratoses # Status post G-tube placement Social History: Lives alone in [**Location (un) **], recently in MACU at [**Hospital 100**] Rehab. No tobacco, alcohol, or drug use. Family extremely involved in care. Family History: Non-Contributory Physical Exam: General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Pertinent Results: CBC [**2113-9-7**] 02:45AM BLOOD WBC-15.8* RBC-3.55* Hgb-10.5* Hct-32.5* MCV-92 MCH-29.6 MCHC-32.3 RDW-15.8* Plt Ct-268 [**2113-9-8**] 06:01AM BLOOD WBC-7.7# RBC-3.19* Hgb-9.3* Hct-28.2* MCV-89 MCH-29.1 MCHC-32.9 RDW-15.4 Plt Ct-223 . Chem 7 [**2113-9-8**] 06:01AM BLOOD Glucose-113* UreaN-13 Creat-0.4 Na-144 K-3.5 Cl-108 HCO3-30 AnGap-10 . Other chemistry [**2113-9-8**] 06:01AM BLOOD Calcium-8.6 Phos-3.5 Mg-1.7 [**2113-9-8**] 06:01AM BLOOD Vanco-16.2 [**2113-9-7**] 02:45AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-12 Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2113-9-7**] 02:47AM BLOOD Glucose-209* Lactate-4.3* Na-140 K-4.4 Cl-97* [**2113-9-7**] 12:57PM BLOOD Lactate-0.9 . UA [**2113-9-7**] 03:00AM URINE RBC-91* WBC->182* Bacteri-FEW Yeast-NONE Epi-3 [**2113-9-7**] 03:00AM URINE Blood-SM Nitrite-NEG Protein-300 Glucose-70 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-LG [**2113-9-7**] 03:00AM URINE Color-Yellow Appear-Cloudy Sp [**Last Name (un) **]-1.018 . MICROBIOLOGY [**2113-9-7**] 8:37 am URINE Source: Catheter. URINE CULTURE (Pending): . [**2113-9-7**] 11:12 am SPUTUM Source: Endotracheal. GRAM STAIN (Final [**2113-9-7**]): >25 PMNs and <10 epithelial cells/100X field. 4+ (>10 per 1000X FIELD): GRAM NEGATIVE ROD(S). 3+ (5-10 per 1000X FIELD): GRAM POSITIVE ROD(S). 2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS AND CLUSTERS. RESPIRATORY CULTURE (Preliminary): pending . IMAGING: CXR [**2113-9-7**]: FINDINGS: The tracheostomy tube is appropriately positioned. Left mid lung and right basilar scarring and/or atelectasis is noted. There are no consolidations concerning for pneumonia. The heart size is normal. Calcification is seen of the aorta. The mediastinal contours are normal. There are no pleural effusions. No pneumothorax is seen. IMPRESSION: 1. Left mid lung and right basilar scarring and/or atelectasis. No other acute pulmonary or cardiac process. . Head CT [**2113-9-7**]: IMPRESSION: Study limited due to artifacts- in particular in the posterior fossa and F. magnum. 1. No acute intracranial hemorrhage or mass effect. Correlate clinically to decide on further workup. 2. Age-related cerebral atrophy. Prominence of the ventricles out of proportion to sulcal enlargement raises the possibility of superimposed normal pressure hydrocephalus/central volume loss. Clinical correlation is recommended. Brief Hospital Course: 86 year old female with multiple medical problems including past PEA arrest, pneumonia requiring intubation and trach and EPG, dCHF, a-fib who presented from [**Hospital 100**] Rehab after unresponsive event. . # Uresponsive event: Likely PEA given her history, though there is no strip from the event to analyze. She had spontaneous return of circulation after a short period of resuscitation. She had low O2 sat at the time and responded to suctioning. Likely precipitating factor was hypoxia. Of note, per report from patient's family, she had red cap placed on her trach during the day of the even and had done relatively well, but had some mild discomfort/distress. That night was the first night she slept with the red cap on therefore it is highly propable that her respiratory event was related. Other causes that were entertained were infectious and profound hypotension secondary to urosepsis, as she did have an initially elevated WBC of 15. However, her CXR showed no evidence of pnaumonia and she appeared clinically well without increased respiratory secretions or fever. She was weaned from the ventilator to trach mask the morning she was admitted and continued to have O2 saturations in the high to mid 90s on FiO2 40%. Her vitals remained stable otherwise. Given the patient has had multiple presentations to the ED, it is probably premature to consider decannulating her at this time. We would recommend that if she is going to have her trach capped, she should have her trach tube downsized to allow air to move around the tube as this may have contributed to her hypoxic event. . # Sepsis: The patient was hypotensive initially, though this may have been in the setting of starting her on mechanical ventilation with PEEP and underlying dehydration reported by family. She was give IV fluids and maintained her pressures without pressors. Her UA indicated urinary tract infection. Given her history of UTIs and multiple antibiotic allergies, she was started on vancomycin/meropenem. She should complete a 10 day course to end on [**9-17**]. In addition, a sputum gram stain showed multiple organisms (GNR, Gm pos rods, GPCs) but the cultures are pending. This was thought to be respiratory contamination and not from a pneumonia as the patient was quickly weaned from her vent and did not have increased secretions. However, should she have a pneumonia, this would be covered by broad antibiotics with vanc/[**Last Name (un) 2830**]. She was going to have a PICC line placed, however the PICC team was unable to do this in a timely manner so it was determined that the pt could have a PICC line placed at [**Hospital 100**] Rehab. She also had a femoral central line breifly, bu this was pulled prior to her discharge to rehab. She is leaving with a peripheral IV for access until she can get her PICC at rehab. . # CHF: The patient appeared dry on exam and not currently in failure. She was given IV fluids for resuscitation. Of note, the family mentioned that the patient's secretions have been thickened lateley and they were concerned that she has been dehydrated. This may have developed in the setting of her urinary tract infection. They were concerned about Ms. [**Known lastname 104301**] developing dehydration at rehab. The patient may be sensitive to dehydration from insensible losses with her open mouth and decreased access to PO and close clinical monitoring with blood pressure, urine output, and skin tugur surrogates at rehab is recommended. . # Corneal abrasion: The patient was continued on her multiple eye drops. . Full Code Medications on Admission: aspirin 81 mg Tab: One Tab, PO DAILY acetaminophen 650 mg/20.3 mL: 650mg PO Q6H as needed for fever. polyvinyl alcohol-povidone 1.4-0.6 % Dropperette: 1-2 Drops ophthalmic PRN (as needed) as needed for dry eyes. Lovenox 30mg SQ daily moxifloxacin 0.5 % Drops: One Drop Ophthalmic TID 4X/WEEK bacitracin-polymyxin B 500-10,000 unit/g: One Appl Ophthalmic 4X/WEEK ([**Doctor First Name **],TU,TH,SA). omeprazole 40 mg Capsule: One Cap, PO Daily acetylcysteine 100mg PO HS Ammonium Chloride 486mg TID through g-tube levalbuterol 0.63mg nebs Q6H Amphotericin B 1.5mg/ml Opthalmic Levothyroxine 50mcg PO daily Tobrex 0.3% opthalmic 2 gtts Q4H (2, 6, 10) to left eye Hydroxyzine 10mg PO TID prn Ipratropium Nebs Q6H prn Lorazepam 1mg PO TID prn Ondansetron 8mg Q8H prn nausea Discharge Medications: 1. aspirin 81 mg Tablet, Chewable [**Doctor First Name **]: One (1) Tablet, Chewable PO DAILY (Daily). 2. acetaminophen 325 mg Tablet [**Doctor First Name **]: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain. 3. polyvinyl alcohol-povidone 1.4-0.6 % Dropperette [**Doctor First Name **]: [**1-22**] drops Ophthalmic three times a day as needed for dry eyes. 4. Lovenox 30 mg/0.3 mL Syringe [**Month/Day (2) **]: One (1) Subcutaneous once a day. 5. moxifloxacin 0.5 % Drops [**Month/Day (2) **]: Three (3) Ophthalmic 4 x a week. 6. omeprazole 40 mg Capsule, Delayed Release(E.C.) [**Month/Day (2) **]: One (1) Capsule, Delayed Release(E.C.) PO once a day. 7. acetylcarnitine Oral 8. ammonium chloride (bulk) Granules Miscellaneous 9. levalbuterol HCl 0.63 mg/3 mL Solution for Nebulization [**Month/Day (2) **]: One (1) Inhalation every six (6) hours. 10. amphotericin b (bulk) Miscellaneous 11. levothyroxine 50 mcg Tablet [**Month/Day (2) **]: One (1) Tablet PO DAILY (Daily). 12. tobramycin sulfate 0.3 % Drops [**Month/Day (2) **]: Two (2) Drop Ophthalmic 6 TIMES PER DAY (). 13. bacitracin-polymyxin B 500-10,000 unit/g Ointment [**Month/Day (2) **]: One (1) Appl Ophthalmic QHS (once a day (at bedtime)). 14. hydroxyzine HCl 10 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO three times a day. 15. ipratropium bromide 0.02 % Solution [**Month/Day (2) **]: One (1) Inhalation Q6H (every 6 hours) as needed for sob/wheeze. 16. lorazepam 1 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO three times a day. 17. ondansetron 4 mg Tablet, Rapid Dissolve [**Month/Day (2) **]: Two (2) Tablet, Rapid Dissolve PO Q8H (every 8 hours) as needed for nausea. 18. meropenem 500 mg Recon Soln [**Month/Day (2) **]: One (1) Recon Soln Intravenous Q6H (every 6 hours) for 9 days: to end on [**9-17**]. Disp:*36 Recon Soln(s)* Refills:*0* 19. vancomycin 500 mg Recon Soln [**Month (only) **]: One (1) Recon Soln Intravenous Q 12H (Every 12 Hours) for 9 days: to end on [**9-17**] (10 day course). Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - MACU Discharge Diagnosis: Urinary tract infection Acute hypoxic event Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: You were brought to the hospital after you were found to be unresponsive and have low oxygen levels at rehab. You were placed back on a ventilator and eventually you were able to be weaned off and breathe on your own. We do not think you have a pneumonia. However, you were found to have a urinary tract infection and are being treated with antibiotics for this. You will need to receive IV antibiotics for a total of 10 days. You will have a PICC placed at your rehab to receive these antibiotics. Please weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more than 3 lbs. Followup Instructions: You should follow up with your doctors [**First Name (Titles) **] [**Last Name (Titles) 100**] rehab.

[ "707.22", "599.0", "369.4", "458.9", "518.81", "707.03", "276.51", "799.02", "733.00", "V44.0", "V44.1", "244.9", "553.20", "412", "428.32", "343.9", "428.0" ]

icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

12048, 12114

5603, 9194

364, 371

12202, 12202

3157, 4588

13004, 13109

2639, 2657

10016, 12025

12135, 12181

9220, 9993

12380, 12981

2065, 2453

2672, 3138

4623, 5580

1604, 1619

297, 326

399, 1585

12217, 12356

1641, 2042

2469, 2623

19,131

143,492

7082

Discharge summary

report

Admission Date: [**2109-4-15**] Discharge Date: [**2109-4-18**] Date of Birth: [**2055-11-17**] Sex: F Service: NEUROSURGERY Allergies: Latex Attending:[**First Name3 (LF) 2724**] Chief Complaint: right arm and neck pain Major Surgical or Invasive Procedure: 1)ACDF C4-5, [**4-7**] 2) re-exploration cerv wound with hematoma evacuation History of Present Illness: This 54-year-old woman had a history of right upper extremity radiculopathy. An MRI demonstrated foraminal stenosis at both C4-C5 and C5-C6. Conservative therapy has been unsuccessful in addressing her symptoms. Past Medical History: [**Last Name (un) **] [**Doctor First Name **] left knee [**Doctor First Name **] x 4 restless leg syndrome Social History: quit smoking 2 wk ago no EtOH Family History: noncontributory Physical Exam: NAD AAOx3 Neck rom limited ht: RRR Lungs: distant sounds, no rhonchi/wheeze ext: R biceps [**3-7**] Brief Hospital Course: Pt was admitted electively and brought to the OR where under general anesthesia ACDF C4-5 and C5-6 was performed. Pt tolerated this procedure well, was extubated, transferred to the PACU and then floor when stable. Post op was stable. Post op morning #1 she was OOB, tolerating fluids and taking PO pain meds. She developed swollen neck and stridorous breathing. She was brought to the OR emergently for intubation and evacuation of hematoma. JP drain was placed intra-op. She tolerated procedure, remained intubated and transferred to SICU. Post op she was moving all 4 extremities well and following commands. She continued to do well. She was extubated [**4-17**] afternoon. She was OOB ambulating in halls. JP was removed [**4-18**] morning. Foley was removed and she voided. Medications on Admission: colace mirtazapine requip potassium xanax percocet Discharge Medications: 1. Alprazolam 0.25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 2. Mirtazapine 45 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 3. Ropinirole 1 mg Tablet Sig: Four (4) Tablet PO QPM (once a day (in the evening)). 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day): take while on narcotics. Disp:*60 Capsule(s)* Refills:*0* 5. Diazepam 2 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. Disp:*40 Tablet(s)* Refills:*0* 6. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3-4H (Every 3 to 4 Hours) as needed for pain. Disp:*60 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Cervical stenosis Discharge Condition: Neurologically stable Discharge Instructions: DISCHARGE INSTRUCTIONS FOR SPINE CASES ?????? Do not smoke ?????? Keep wound clean, begin daily showers on [**2109-4-20**] / No tub baths or pools until seen in follow up. ?????? Remove dressing on [**2109-4-19**]. You have steri-strips in place ?????? keep dry x 72 hours. Do not pull them off. They will fall off on their own or be taken off in the office ?????? No pulling up, lifting> 10 lbs., excessive bending or twisting ?????? Limit your use of stairs to 2-3 times per day ?????? Have a family member check your incision daily for signs of infection ?????? Take pain medication as instructed; you may find it best if taken in the a.m. when you wake for morning stiffness and before bed for sleeping discomfort ?????? Do not take any anti-inflammatory medications such as Motrin, Advil, aspirin, Ibuprofen etc. unless directed by your doctor ?????? Increase your intake of fluids and fiber as pain medicine (narcotics) can cause constipation CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING: ?????? Pain that is continually increasing or not relieved by pain medicine ?????? Any weakness, numbness, tingling in your extremities ?????? Any signs of infection at the wound site: redness, swelling, tenderness, drainage ?????? Fever greater than or equal to 101?????? F ?????? Any change in your bowel or bladder habits Followup Instructions: Follow up with Dr. [**Last Name (STitle) 548**] in 2 wks Follow up with Dr. [**Last Name (STitle) 548**] in 6 wks with xrays, call [**Telephone/Fax (1) 2992**] for appt. Completed by:[**2109-4-18**]

[ "305.1", "E878.8", "721.0", "998.12", "278.00", "E849.7", "722.0", "333.94" ]

icd9cm

[ [ [] ] ]

[ "86.04", "80.51", "81.62", "81.02" ]

icd9pcs

[ [ [] ] ]

2477, 2483

966, 1750

295, 374

2545, 2569

3966, 4166

810, 827

1851, 2454

2504, 2524

1776, 1828

2593, 3943

842, 943

232, 257

402, 616

638, 747

763, 794

50,762

194,353

41345

Discharge summary

report

Admission Date: [**2149-9-4**] Discharge Date: [**2149-9-15**] Date of Birth: [**2091-10-13**] Sex: M Service: MEDICINE Allergies: Penicillins Attending:[**First Name3 (LF) 2181**] Chief Complaint: Wound infection Major Surgical or Invasive Procedure: Right below the knee amputation ([**2149-9-8**]) Endotracheal intubation ([**2149-9-9**]) Peripherally inserted central catheter placed ([**2149-9-11**]) History of Present Illness: 57 M w/ diabetes, morbid obesity, with interstitial pulmonary fibrosis on steroids who recently was treated for MRSA osteomyelitis of the right ankle but then had his antibiotics stopped 3 weeks ago because of renal problems returns with pain, redness, swelling and open ulceration of R ankle. One week ago he fell, sustaining an injury to his r ankle and right shoulder. The ankle began to swell in the last few days become erythematous and a new wound developed over the side of his osteomyelitis of the ankle, draining cloudy yellow pus. The shoulder, which had not been assessed by a physician, [**Name10 (NameIs) **] been very painful with decreased range of motion since the fall. Pt had R ankle surgery in [**Month (only) 216**] for a fracture sustained from falling, which became infected one month later, requiring surgery to remove devices. Wound infection was identified as MRSA, and PT was diagnosed with osteomyelitis later in the year. Pt has dyspnea at baseline from his IPF, but states that he feels well-controlled of late. He has a home O2 requirement of 2L at baseline. . In the ED, the patient was admitted for what appears to be cellulitis and osteomyelitis of his right ankle. Per ED, he has no sign of necrotizing fascitis. He was seen by ortho who will follow closely. He received IV vancomycin (1g) for the infection and stress dose steroids (200mg hydrocortisone), as well as morphine and percocet for pain. Past Medical History: 1) Interstitial lung disease on prednisone 20 daily 2) Diabetes II 3) Osteomyelitis of right ankle on daptomycin (s/p vanc failure) 4) HTN 5) HLP 6) PAF on coumadin 7) Provoked DVT in remote past 8) Obesity Hypoventilation syndrome on BIPAP Social History: Former businessman, on disability at present. Does not smoke, drink, or use drugs. Good social support from wife. Family History: No family hx of lung disease. Mother with MI at age 48. Physical Exam: on admission: VS - Temp 97.6F 164/74BP , 88HR , 22R , O2-sat 99% 3L GENERAL - conversational obese man in NAD, comfortable, appropriate HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear NECK - limited exam [**3-12**] obesity, very large panus over neck LUNGS - good air movement b/l, w/ scattered coarse breath sounds HEART - distant heart sounds, RRR, no MRG, nl S1-S2 ABDOMEN - Obese abdomen notable for pale striae, NABS, soft/NT EXTREMITIES - large pitting edema to b/l lower extremities, equal in girth above ankles. R ankle with patches of erythema extending from dorsum of foot/ankle to ~9cm superior. Ankle and foot are significantly swollen, with an open ulcer with yellow cloudy pus draining from lateral malleolus. Foot w/ intact sensation, pulses. Pt has limited range of motion to L shoulder and wrist, with strength limited by pain. No swelling, deformity, crepitus, or ecchymosis. SKIN - no rashes except as above LYMPH - no cervical, axillary, or inguinal LAD NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength [**6-12**] in extremities but deferred in RUE [**3-12**] pain and RLE below shin [**3-12**] infection. Sensation diminished to touch at feet b/l, DTRs 2+ and symmetric. On discharge: S- t97.5 bp132/54 p84 r18 s95%on 2L GENERAL - conversational obese man in NAD, comfortable, appropriate HEENT - NC/AT, EOMI, sclerae anicteric, MMM, OP clear LUNGS - good air movement b/l, mild crackles on R mid and lower lung fields, unchanged. HEART - distant heart sounds, RRR, no MRG, nl S1-S2 ABDOMEN - NABS, soft/NT/ND +obese EXTREMITIES - ----L-LE: 3+ pitting edema, sensation intact ----R-LE: BKA, dressing appears c/d/i. NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength [**6-12**] Pertinent Results: [**2149-9-4**] 03:00PM BLOOD WBC-17.4* RBC-3.64* Hgb-9.8* Hct-30.7* MCV-84 MCH-26.9* MCHC-31.9 RDW-16.7* Plt Ct-351 [**2149-9-4**] 03:00PM BLOOD Neuts-94.7* Lymphs-2.6* Monos-1.8* Eos-0.6 Baso-0.2 [**2149-9-4**] 03:00PM BLOOD Plt Ct-351 [**2149-9-4**] 03:00PM BLOOD Glucose-72 UreaN-64* Creat-1.6* Na-142 K-5.4* Cl-97 HCO3-38* AnGap-12 [**2149-9-5**] 07:15AM BLOOD Calcium-11.5* Phos-4.3 Mg-2.6 [**2149-9-12**] 06:00AM BLOOD WBC-15.3* RBC-3.21* Hgb-8.3* Hct-26.6* MCV-83 MCH-25.9* MCHC-31.3 RDW-16.9* Plt Ct-333 [**2149-9-9**] 05:30AM BLOOD Neuts-85* Bands-1 Lymphs-7* Monos-2 Eos-5* Baso-0 Atyps-0 Metas-0 Myelos-0 [**2149-9-12**] 06:00AM BLOOD PT-19.3* PTT-136.8* INR(PT)-1.7* [**2149-9-12**] 06:00AM BLOOD Glucose-201* UreaN-43* Creat-1.7* Na-139 K-4.3 Cl-95* HCO3-36* AnGap-12 [**2149-9-12**] 06:00AM BLOOD Mg-1.9 [**2149-9-8**] Pathology from RIGHT BELOW THE KNEE AMPUTATION Right below knee amputation: A) Gangrene. B) Acute osteomyelitis. C) Marked atherosclerosis. D) Margins appear viable. TEE (Complete) Done [**2149-9-8**] 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. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. There are simple atheroma in the ascending aorta. There are simple atheroma in the descending thoracic aorta. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No masses or vegetations are seen on the aortic valve. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. No mass or vegetation is seen on the mitral valve. Mild (1+) mitral regurgitation is seen. Dr. [**Last Name (STitle) 1005**] was notified in person of the results in the operating room at the time of the study. MR CALF W&W/O CONTRAST RIGHT [**2149-9-7**] 1. Interval progression of osteomyelitis involving the distal tibia, fibula, talus, and calcaneus with probable septic arthritis involving the posterior and middle subtalar joints, the tibiotalar joint, and the tibiofibular syndesmosis. 2. Improving anterior tibial subperiosteal abscess. 3. Improvement of post-traumatic and post-surgical changes of the distal tibia. 4. Interval improvement in subcutaneous edema and fluid collections, in keeping with improving cellulitis. Skin thickening, however, is worse. 5. Persistent myositis. 6. Longitudinal split tears of the distal posterior tibialis tendon, peroneus brevis, peroneus longus. 7. Tenosynovitis of posterior tibial tendon, flexor digitorum longus, and flexor hallucis longus tendons. 8. Achilles tendinosis. 9. No drainable collection. 10. Possible partial tear of the plantar fascia. 11. Multiple ligamentous tears, not well assessed on this examination. ART DUP EXT LO UNI;F/U RIGHT [**2149-9-5**] Normal arterial waveforms throughout the right lower extremity except for dorsalis pedis artery, which demonstrates monophasic flow with low peak systolic velocity as specified above. Brief Hospital Course: 57 M w/ diabetes, morbid obesity, with interstitial pulmonary fibrosis on steroids who recently was treated for MRSA osteomyelitis of the right ankle but then had his antibiotics stopped 3 weeks ago because of renal problems who was admitted for reucrrent MRSA osteomyelitis of right ankle, complicated with MRSA bacteremia. Ankle osteomyelitis: Likely was acute on chronic from previous treated osteomyelitis, unclear whether recent fall was a contributing factor. Pt received IV abx with vancomycin. He was evaluated by ortho and had right lower extremity amputation. As per ID, the patient is to receive antibiotic therapy with vancomycin for 4 weeks following his amputation, which was on [**2149-9-8**]. Hypoxemia/hypercarbia: Pt had acute respiratory event on the night of surgery ([**2149-9-8**]). He returned from surgery without any complications. At around midnight while asleep, pt was found by nursing staff to be unresponsive with O2 sat =50%. A code blue was called and pt was emergently intubated and sent to the MICU. It was felt that this event was secondary to a combination of: post-operative state, post-anesthesia, using a nasal non invasive positive pressure ventilation when he may require a full face mask, and insufficient pressure settings on the non invasive positive pressure ventilation mask. Being a pt with severe OSA, he is at risk of post-op respiratory complications. He recovered while in the MICU and was extubated the following morning. The settings on his non invasive positive pressure ventilation unit were adjusted and the patient was transfered to the regular medical floor. At time of discharge he was using a full face BIPAP with settings: 18/8 with 7L of oxygen. Interstitial pulmonary fibrosis: Continued his home regimen of steroids. He was maintained on his home O2 baseline of 2L requirement, however, he would occasionally require more oxygen levels through the nasal cannula. On discharge his O2 sats were stable on 2L O2 NC. DM2: Pt on sliding scale at home. Continued home regimen with divided glargine dose and sliding scale. Diabetic diet. Paroxysmal A-fib/remote hx of DVT: Pt was in sinus rhythm throughout hospitalization. He was switched to heparin drip pre and post surgery and then transitioned to coumadin. HTN: Continued home meds coreg and norvasc Pain - home dosing gabapentin/nortriptylene, oxycodone _______________ Pending: -Blood Cx: [**9-6**], [**9-7**], [**9-8**], [**9-9**], [**9-10**], [**9-11**] -Tissue culture: [**9-8**] _____________ Transition of care: -Pt will follow up with ID regarding completion of therapy for MRSA bacteremia and osteomyelitis. -BIPAP: pt should follow up with his pulmonologist to get repeat sleep study and ensure his BIPAP settings are appropriate. Pt had Code Blue for post-hospitalization apneic episode. Medications on Admission: -carvedilol 25 mg Tab; 1 Tablet(s) by mouth twice a day -pantoprazole 40 mg Tab, Delayed Release, 1 Tablet(s) by mouth once a day -bumetanide 2 mg Tab, 1 Tablet(s) by mouth twice a day -warfarin 5 mg Tab, 1 Tablet(s) by mouth Once Daily at 4 PM -amlodipine 5 mg Tab, 2 Tablet(s) by mouth DAILY (Daily) -Lantus 100 unit/mL Sub-Q Subcutaneous, 75units in am Solution(s) 55units at dinner -Humalog 100 unit/mL Sub-Q Subcutaneous -prednisone -- 30mg Powder(s) Once Daily -gabapentin 100 mg Tab Oral, 1 Tablet(s) Three times daily -paroxetine 40 mg Tab Oral, 1 Tablet(s) Once Daily -nortriptyline 25 mg Cap Oral, 1 Capsule(s) Twice Daily -levothyroxine 100 mcg Tab Oral, 1 Tablet(s) Once Daily -tramadol 50 mg Tab Oral, [**2-9**] Tablet(s) Every 4-6 hrs, as needed -Omega 3-6-9 -- Unknown Strength, [**2-9**] Capsule(s) Once Daily -ferrous sulfate 300 mg (60 mg iron) Tab Oral, 1 Tablet(s) Once Daily -nortriptyline 25 mg Cap Oral, 1 Capsule(s) Twice Daily Discharge Medications: 1. amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day. 2. carvedilol 12.5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 3. insulin glargine 100 unit/mL Solution Sig: Seventy Five (75) units Subcutaneous qam: Please refer to sliding scale. 4. insulin glargine 100 unit/mL Solution Sig: Fifty Five (55) units Subcutaneous at dinner: Please refer to sliding scale. 5. insulin lispro 100 unit/mL Solution Sig: 0-25 units Subcutaneous with meals: Please . 6. nortriptyline 25 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 7. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 8. paroxetine HCl 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 9. prednisone 10 mg Tablet Sig: Three (3) Tablet PO once a day. 10. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 4 days: please take until [**2149-9-19**]. Disp:*8 Tablet(s)* Refills:*0* 11. levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation for 30 days. Disp:*30 Capsule(s)* Refills:*3* 13. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation for 30 days. Disp:*60 Tablet(s)* Refills:*3* 14. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation for 30 days. Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*3* 15. gabapentin 100 mg Capsule Sig: One (1) Capsule PO three times a day. 16. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q 8H (Every 8 Hours) as needed for pain: Please do not exceed 4 gm daily. 17. oxycodone 10 mg Tablet Extended Release 12 hr Sig: One (1) Tablet Extended Release 12 hr PO Q12H (every 12 hours) for 3 days. Disp:*6 Tablet Extended Release 12 hr(s)* Refills:*0* 18. fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1) Spray Nasal [**Hospital1 **] (2 times a day). 19. vancomycin in D5W 1 gram/200 mL Piggyback Sig: 1.250 gram Intravenous Q 24H (Every 24 Hours) for 24 days: Final dose = [**2149-10-9**] unless other wise directed. Disp:*30 grams* Refills:*0* 20. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO every four (4) hours as needed for pain for 7 days: Do not take more than 12 tablets a day. Disp:*60 Tablet(s)* Refills:*0* 21. 3 in 1 drop arm bariatric drop arm commode 22. BIPAP Settings Please change BIPAP settings to 18 inspiratory/8 expiratory. 23. warfarin 5 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home With Service Facility: [**Hospital **] Home Health Care Discharge Diagnosis: Primary Diagnosis: Osteomyelitis MRSA bacteremia Respiratory Distress- apnea, requiring emergent intubation post-op Secondary Diagnoses: Intertitial pulmonary fibrosis Obstructive sleep apnea Atrial fibrillation Insulin dependant diabetes mellitus 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 Mr. [**Known lastname **], It was a pleasure taking care of you during this hospitalization. You were admitted to the hospital because you had an infection in the bone (osteomyelitis) and wound on your right ankle. The infection also spread to your blood stream. You are being treated with an antibiotic called vancomycin. You will need to continue this antibiotic for 4 weeks. You had surgery on [**2149-9-8**]. The orthopedic surgeon's amputated your right leg below the knee because we did not feel there was another way to treat your infection and were concerned that the wound would not heal properly. The surgery went well and you are healing nicely. During your hospitalization, you had a respiratory arrest. You stopped breathing and an intubation tube was placed to help you breath. You were sent to the intensive care unit where you were closely monitored. While in the medical intensive care unit, you began to recover and the tube was removed and you were breathing normally. It was felt that this reason this occured was possibly because you were using a nasal non invasive positive pressure ventilation mask and you may require a full face mask. It was also felt that the settings on the noninvasive positive pressure ventilation mask, which were based on settings you were using at home, might not have been correct for you, especially in the post-op setting. You continued to improve in the medical intensive care unit and they felt you were well enough to be transferred to the main medical floor. We also gave you medications to try and remove extra fluid from your body, as you left leg remains very swollen. A peripherally inserted central catheter (PICC) was placed on [**2149-9-11**] because you will need continued antibiotics. You were found to have an infection found in your urine, affecting your bladder. You were started on the appropriate antibiotic for this infection and will require a totally of 10 days of therapy. We hope you continue to feel better and medical improve. Medication Changes: START: Vancomycin 1.25 g administered through your picc, once daily for 4 weeks- this is a medication for your blood/bone infection Ciprofloxacin 500 mg by mouth, twice daily until [**2149-9-19**]- this is a medication for your urine infection Docusate 100 mg by mouth once daily as needed for constipation Senna 8.6 mg by mouth twice daily as needed for constipation Bisacodyl 10 mg by mouth once daily as needed for constipation Acetaminophen [**Telephone/Fax (1) 1999**] mg by mouth every eight hours as needed for pain (do not exceed 4000 mg a day) Oxycodone Extended Release 10 mg by mouth twice daily Hydromorphone 2mg-4mg by mouth every four hours as needed for pain Fluticasone 50 mcg spray, one spray per nostril twice daily as needed for nasal congestion. STOP: Tramadol Continue all other home medications as usual. Followup Instructions: Name: [**Last Name (LF) **], [**Name8 (MD) 20**] MD Location: FAMILY MEDICINE ASSOCIATES Address: [**State 14083**], [**Location (un) 14084**],[**Numeric Identifier 14085**] Phone: [**Telephone/Fax (1) 14086**] Appointment: Thursday [**9-18**] at 11:30AM ----Please ask your doctor to check your INR at this appointment. Department: ORTHOPEDICS When: TUESDAY [**2149-9-23**] at 10:00 AM With: ORTHO XRAY (SCC 2) [**Telephone/Fax (1) 1228**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 551**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: ORTHOPEDICS When: TUESDAY [**2149-9-23**] at 10:20 AM With: [**First Name11 (Name Pattern1) 2191**] [**Last Name (NamePattern4) 2192**], NP [**Telephone/Fax (1) 1228**] Building: [**Hospital6 29**] [**Location (un) 551**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Name: [**Last Name (LF) **],[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD Specialty: PULMONARY Location: [**Hospital **] MEDICAL ASSOCIATES Address: [**Street Address(2) 90015**], [**Location (un) **],[**Numeric Identifier 42074**] Phone: [**Telephone/Fax (1) 79324**] Appointment: Wednesday [**10-1**] at 1:30PM

[ "427.31", "V85.43", "V12.51", "595.9", "V58.61", "E935.2", "401.9", "041.4", "518.81", "041.12", "731.8", "682.7", "730.07", "428.0", "250.82", "278.01", "584.9", "515", "790.7", "327.23" ]

icd9cm

[ [ [] ] ]

[ "96.04", "38.97", "84.15" ]

icd9pcs

[ [ [] ] ]

13765, 13828

7350, 10173

288, 444

14121, 14121

4156, 7327

17198, 18417

2320, 2377

11176, 13742

13849, 13849

10199, 11153

14297, 16325

2392, 2392

13987, 14100

3629, 4137

16345, 17175

233, 250

472, 1908

13868, 13966

2406, 3615

14136, 14273

1930, 2172

2188, 2304

22,534

158,691

1055

Discharge summary

report

Admission Date: [**2130-12-14**] Discharge Date: [**2130-12-16**] Date of Birth: [**2057-1-13**] Sex: M Service: MEDICINE Allergies: Penicillins Attending:[**First Name3 (LF) 2932**] Chief Complaint: transient hypotension Major Surgical or Invasive Procedure: None History of Present Illness: 73 year old male with a history of Type II diabetes, CAD s/p CABG, PVD who presented to the [**Hospital1 18**] ED with fever and weakness. Patient reports that he was in his USOH until 1 night PTA when his son noted that his "face looked red". At that time he found the patient's temp to be 102. The patient reports also feeling fatigued and diaphoretic. Reports that overnight he had subsequent fever episodes (101 range) and in the morning came in to the ED. He denies rigors, rash, headache, neck stiffness, sore throat, cough, shortness of breath, nausea, vomiting, diarrhea, or changes in bowel or bladder habits. By notes the patient endorsed anorexia in the ED, denies on MICU admisison. Reports he does have occasional chills. Denies new medications or changes in medication regimen. No orthopnea/PND/LE swelling. He further denies LH, dizziness, syncope, chest pain, shortness of breath, or palpitations., In the Emergency Department, initial VSS (sinus) but febrile to 102.3. Developed hypotension to bp 94/43, hr 104, patient asymptomatic. ECG noted to be atrial fibrillation. By notes, rec'd 2L NS with good response. Rec'd tylenol 650mg x2 and started on levofloxacin 500mg. Past Medical History: 1. HTN 2. NIDDM - hgb A1c [**2129-8-17**] = 7.2% 3. CAD s/p CABG x 4 in '[**19**]: LIMA->LAD, SVG-> PDA, OM, and PL-RCA - stress [**2129-1-3**]: 74% max hr (avg work effort), 9.5 min on modified [**Doctor First Name **], stopped due to fatigue, no sx, 1.5-[**Street Address(2) 1766**] dep inferolat that resolved w/in 7 min of rest, no perfusion defect - ECHO [**2128-12-28**]: EF 55-60%, PASP < 25, mild biatrial enlargement, 1+ AR, 1+ MR 4. HYPERCHOLESTEROLEMIA Social History: + Etoh: 1 glass of wine daily h/o tob: 2ppd x 45 yrs, quit 15 yrs ago Lives w/ his wife and son. [**Name (NI) **] also has another son and daughter who are married. He is a retired construction worker. Family History: NC Physical Exam: t98.7, bp 115/50, hr 73, rr 15, 98% ra Well appearing, elderly, pleasant male in NAD. PERRL. OP clr 8cm JVP. Thyroid benign. 4cm scar of R lateral neck. Midline sternotomy scar. Non-displaced PMI. Irregularly, irregular. S1,S2. No m/r/g Good air entry and inspiratory effort. b/l basilar crackles. +bs. soft. nt. nd. +dry scaly skin with multiple excoriations of L lateral thigh. No c/c/e. No splinter hemorrhages. No osler/[**Last Name (un) **] lesions. Pertinent Results: [**2130-12-13**] 09:50PM WBC-4.1 RBC-4.04* HGB-11.5* HCT-34.1* MCV-84 MCH-28.5 MCHC-33.8 RDW-14.4 [**2130-12-13**] 09:50PM NEUTS-73.3* LYMPHS-14.8* MONOS-6.7 EOS-4.3* BASOS-0.8 [**2130-12-13**] 09:50PM PLT COUNT-130* [**2130-12-13**] 09:50PM GLUCOSE-109* UREA N-34* CREAT-1.4* SODIUM-132* POTASSIUM-6.9* CHLORIDE-102 TOTAL CO2-21* ANION GAP-16 [**2130-12-13**] 09:56PM LACTATE-1.5 [**2130-12-13**] 10:43PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [**2130-12-14**] 10:13AM CK-MB-3 cTropnT-0.03* [**2130-12-14**] 10:13AM LIPASE-38 [**2130-12-14**] 10:13AM ALT(SGPT)-14 AST(SGOT)-28 LD(LDH)-250 CK(CPK)-216* ALK PHOS-92 AMYLASE-84 TOT BILI-0.3 [**2130-12-14**] 10:15AM LACTATE-1.1 [**2130-12-14**] 04:01PM TSH-0.83 [**2130-12-14**] 04:01PM CK-MB-4 cTropnT-0.03* [**2130-12-14**] 10:28PM CK-MB-6 cTropnT-0.04* [**2130-12-14**] 10:28PM CK(CPK)-331* Radiology [**12-13**] CXR: Increased linear opacity in the lower lobe, best seen on frontal radiograph, concerning for early pneumonia. Calcified pleural plaques suggestive of prior asbestosis exposure. Brief Hospital Course: 73 yo m w/ h/o CAD s/p CABG, PVD, and h/o atrial fibrillation presents with fever, transient hypotension, and atrial fibrillation. Given hypotension, he was initially admitted to the medical ICU. Given he remained stable, he was transferred to the general medical floor. ABx were held because transient fever thought to be [**1-12**] viral etiology. # [**Name (NI) **] Unclear etiology. Possible that patient is preload sensitive and episode of A.Fib precipitated drop in BP. Sepsis less likely- no leukocytosis, lactate 1.1, cortisol WNL. Possible component of decreased p.o. intake and low vol status, 2L IVF while inpt. Monitored on telemetery throughout admission. # Fever- The patient was afebrile on transfer to the floor. The etiology remained unclear, although a viral illness is most likely. Although initial CXR showed possible early left lower lobe pneumonia, this was felt to be less likely, given lack of corresponding sings/symptoms. He remained stable off antibiotics. # Atrial fibrillation- Likely induced by fever. Has a history of in the setting of stress event. Discussed with primary cardiologist who recommended anticoagulation. HD 1: Heparin Gtt started, coumadin started after PTT therapeutic, d/c on Lovenox until therapeutic on coumadin; continued rate control with metoprolol; no indication for rhythm control at this time since it remains unclear if hypotension was related to onset of afib. # thrombocytopenia- likely [**1-12**] acute infectious etiology- improved HD 2. No evidence of medication effect (no recent changes) although concomitant eosinophilia concerning. No recent heparin prior to admission # ARF on CRI- baseline Cr 1.2 in [**5-16**]. Probable prerenal etiology. Improved w/fluid. # CHF- likely [**1-12**] fluid resuscitation in the setting of atrial fibrillation. CE's (-)x3. # Anemia- iron studies [**10-16**] show iron deficiency anemia, pt was started on iron therapy outpt, repeat iron studies [**12-17**] showed iron improved; last colonoscopy [**1-16**] showed Grade 1 internal hemorrhoids, Otherwise normal colonoscopy to cecum. # full code Medications on Admission: ASA 325mg plavix 75mg qday diovan 80mg qay iron lipitor 20mg qday toprol xl 50mg [**Hospital1 **] metformin 1000mg qday Discharge Medications: 1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Atorvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 4. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO twice a day. 5. Warfarin 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 6. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Metformin 1,000 mg Tablet Sig: One (1) Tablet PO twice a day. 8. Lovenox 30 mg/0.3 mL Syringe Sig: One (1) injection Subcutaneous twice a day for 10 days. Disp:*20 syringes* Refills:*2* 9. Diovan 80 mg Tablet Sig: One (1) Tablet PO once a day. 10. Vitamin C 500 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home Discharge Diagnosis: fever, hypotension Discharge Condition: stable Discharge Instructions: Please present to the hospital if you have headache/dizzyness, fever/chills, or chest pain/shortness of breath. Please note that you will be taking 2 new medications, one is called Lovenox, it is an injection that you must take twice daily until you are therapeutic on coumadin. The other is called coumadin, it must be taken once daily and you must have lab tests(PT/INR) done every 3 days until it is at a therapeutic level. Please follow up with your appointments and take all of your medications as directed. Followup Instructions: You have the following appointments: Provider: [**Name10 (NameIs) **] Phone:[**Telephone/Fax (1) 128**] Date/Time:[**2130-12-20**] 9:00 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4450**], M.D. Phone:[**Telephone/Fax (1) 4451**] Date/Time:[**2130-12-20**] 10:20 Please note pt had transient hypotension while inpt, episode of A.Fib. Also, pt is being bridged on Lovenox until therapeutic on coumadin. Please check PT/INR on Tuesday of this week. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 2937**]

[ "250.00", "V15.82", "458.9", "V45.81", "440.20", "V58.61", "427.31", "280.9", "272.0", "428.0", "412", "414.01", "780.6", "585.9", "287.5", "276.52", "584.9", "403.90" ]

icd9cm

[ [ [] ] ]

[ "99.29" ]

icd9pcs

[ [ [] ] ]

6965, 6971

3915, 6020

296, 302

7034, 7043

2751, 3892

7604, 8205

2257, 2261

6191, 6942

6992, 7013

6046, 6168

7067, 7581

2276, 2732

235, 258

330, 1531

1553, 2021

2037, 2241

30,183

111,909

32880

Discharge summary

report

Admission Date: [**2155-4-22**] Discharge Date: [**2155-4-24**] Date of Birth: [**2120-11-19**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 613**] Chief Complaint: Chest pain Major Surgical or Invasive Procedure: Hemodialysis History of Present Illness: Mr. [**Known lastname 4702**] is a 34M with ESRD on HD and poorly controlled blood pressure who presents with increased SOB. Of note, he was recently admitted [**Date range (1) 58652**] with CP in the setting of HTN requiring ICU admission and a labetalol drip. . He reports that over the last weekend he had some nausea and non-bloody emesis. Last HD was [**Last Name (LF) 766**], [**First Name3 (LF) **] his report was uneventful. Upon return from HD he noticed that he felt short of breath with activity. He felt discomfort in his chest "like he was being punched" associated with palpitations. This would go away over a few minutes if he rested. The pain was non-radiating, and not related to position, breathing, or PO intake. He had some associated nausea, without lightheadedness or diaphoresis. The CP felt similar to his prior CP, in fact less intense. Denies any fevers, chills, sweats, coughing, abdominal or back pains. Has had some pruritis, but denies any abnormal taste in his mouth. Had constipation over the weekend, no diarrhea or dysuria. Reports taking all his home antihypertensives and denies any substance use. . In the emergency department, initial vitals were 98.3 110 196/143 28 97% on RA -> NRB. On exam, tachypneic and wheezy. EKG showed SR with lateral STD. CXR showed mild pulmonary edema. He was given atrovent, aspirin 325mg, nitroglycerin, and lasix 200mg with little urine output. Started on a nitroglycerin drip. Renal evaluated him in the ER, felt he did not urgently need HD. 98 103 169/106 31 94 on 4L, still on nitroglycerin drip, SOB and CP improved. Access 22g PIVx1. . On evaluation in the MICU, he reported continued CP up to [**6-6**] as well as a headache that started after he got nitroglycerin in the ER. Past Medical History: - ESRD secondary to HTN - started on dialysis in [**12/2152**] - HTN - h/o medication non-compliance - h/o substance abuse - h/o right internal jugular vein thrombus associated with HD catheter - h/o pulmonary edema in the setting of hypertensive urgency - h/o intubation in the setting of hypertensive urgency/flash pulmonary edema - dyslipidemia on statin - s/p appendectomy - s/p ex-lap Social History: He used to work as a plasterer, but is now on disability. Mother died 4 months ago. Tobacco: 1PPD x 20 years, currently 3 cigarettes a day. EtOH/Drugs: Denies recent alcohol, cocaine and marijuana use. Family History: There is no family history of premature coronary artery disease or sudden death. Father - Died at age 36 from unknown cancer Mother - Died at age 58 of MI, had HTN Maternal grandmother - on hemodialysis for end-stage renal disease. Physical Exam: Vitals 97.9 88 139/90 27 92% on labetalol drip General Uncomfortable appearing young man, in moderate distress. Coughing occasionally. HEENT Sclera anicteric conjunctiva pink MMM Neck No JVD Pulm Lungs with diminished breath sounds a few rales at bases, no wheezing or rhonchi CV Regular S1 S2 no m/r Abd Mildly distender no rigitiy or guarding +bowel sounds nontender Extrem Warm palpable pulses, L AV fistula with palpable thrill Neuro CN 2-12 intact, full strength in bilateral extremities, normal sensation to light touch Pertinent Results: LABS: CBC 5.6>35.2<267 CK 351 MB 4 Tropn 0.20, was 0.10 on [**4-6**] Chem 140/4.8/96/25/69/10.9<85 INR 1.2 PTT 26.4 . ECG: SR @82 nl axis and intervals, poor R wave progression with deep S waves in precordial leads. <1mm STD with TWI in V6 and vF. TWI in III more prominent today. q's in vL and I. In comparison to [**2155-4-1**] EKG, the TWI in v6 is new (but seen previously [**2155-3-19**]) . STUDIES: . CXR UPRIGHT AP VIEW OF THE CHEST: Moderate cardiomegaly is stable from prior. The mediastinal and hilar contours are similar. Bilateral hazy air space opacities are present, with indistinctness of the pulmonary vascularity suggestive of mild pulmonary edema. No pleural effusions are seen. There is no pneumothorax. Rounded calcification within the right upper quadrant is unchanged from prior which was previously noted to be a calcified renal mass. IMPRESSION: 1. Mild pulmonary edema. 2. Unchanged cardiomegaly. 3. Unchanged calcified lesion in the right upper quadrant corresponding to a calcified renal mass seen on previous CT from [**2155-3-18**]. . CTA chest [**4-1**] IMPRESSION: 1. No pulmonary embolus. No aortic dissection. 2. Diffuse ground-glass opacity with air trapping at bases suggests small airways disease and/or poor respiratory effort. Mild pulmonary edema. 3. Right chest wall collaterals suggest stenosis, occlusion of the right subclavian vein. 4. Persistent coronary artery calcifications. 5. Stable appearance of calcified right renal mass. 6. Pulmonary hypertension given enlarged diameter of pulmonary artery. 7. Dilated ascending aorta, stable from prior. 8. Stable cardiomegaly. . Echo [**11-4**] EF 40-45%, Moderate LVH, moderate HK inferior septum and inferior wall, [**11-29**]+ AR, 2+ MR Brief Hospital Course: * Hypertensive urgency Chest pain in setting of marked hypertension with abnormal EKG consistent with hypertensive emergency. He has had multiple admissions for similar complaints. The reason for these repeated presentations is not certain but according to [**Name (NI) **] pt has history of poor medication compliance. Given ESRD, volume is likely a contributor to his hypertension but renal team feels that HD not needed emergently. Patient was started on labetalol gtt then transitioned to PO meds with better BP control. * Chest discomfort [**Month (only) 116**] have cardiac ischemia in setting of marked hypertension. Think a primary plaque rupture event is less likely. Patient said he would not be able to take daily medication (including plavix) even knowing the risk of blood clot without it. So he was deemed not to be an appropriate candidate for stress test since, if positive, he would not comply with therapy that would be needed after therapeutic catheterization. Was continued on [**Month (only) **], imdur, and statin. Also not a candidate for beta blocker given cocaine abuse. Cardiac enzymes were checked and trended down from 0.20->0.15 (baseline for him). He had a follow up appointment in cardiology on the day of discharge and was discharged in time to make it to that appointment for further discussion of the best management of his presumed coronary artery disease. * Nausea [**Month (only) 116**] have been from coronary ischemia in setting of HTN-emergency. Resolved with BP control and HD. KUB was WNL. * ESRD on HD. Received dialysis [**2155-4-23**]. Unclear how often he has been going to HD as outpatient although he reported going to HD on Friday prior to admission. He was continued on phos binders. FEN regular PPX PPI Code full Medications on Admission: (per [**3-29**] DC summary) sevelemer 1600mg TID phoslo 1334mg TID imdur 30mg daily lisinopril 40mg daily simvastatin 80mg qhs nifedipine 90mg daily terazosin 1mg qhs MVI [**Month/Day (2) **] 325 daily ferrous sulfate 325mg daily percocet prn ibuprofen 800mg tid prn, colace, senna Discharge Medications: 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Sevelamer Carbonate 800 mg Tablet Sig: Two (2) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 3. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 4. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 5. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO DAILY (Daily). 6. Terazosin 1 mg Capsule Sig: One (1) Capsule PO HS (at bedtime). 7. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 8. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. PhosLo 667 mg Capsule Sig: Two (2) Capsule PO three times a day. 10. Multivitamin Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home Discharge Diagnosis: Hypertensive emergency Secondary ESRD on HD hx cocaine abuse Discharge Condition: Afebrile. Hemodynamically stable. Discharge Instructions: You were admitted to the hospital with chest pain and a high blood pressure. You received medications for this and your chest pain went away when your blood pressure came down. It is very important that you should continue taking your medications every day exactly as they are prescribed to keep your blood pressure under control. Medication Changes: None Please come back to the hospital or call your primary care doctor if you have fevers, chills, chest pain, palpitations, shortness of breath, abdominal pain, nausea, vomiting, or any other concerning symptoms. Followup Instructions: Provider: [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2155-4-24**] 2:00 Please follow up with the nurse practitioner who works with your primary care provider, [**First Name8 (NamePattern2) 2048**] [**Last Name (NamePattern1) 3817**] ([**Telephone/Fax (1) 250**]) on [**2155-5-1**] at 12:20. She is located in the Atrium Suite on the [**Location (un) 448**] of the [**Hospital Ward Name 23**] building on the [**Hospital Ward Name 516**] of [**Hospital3 **] Medical Center. Please continue to keep your dialysis appointments at [**Location (un) 76539**] on Mondays, Wednesdays, and Fridays. Their phone number is ([**Telephone/Fax (1) 76547**]. [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**] Completed by:[**2155-4-24**]

[ "416.8", "272.4", "403.01", "414.01", "285.21", "585.6" ]

icd9cm

[ [ [] ] ]

[ "39.95" ]

icd9pcs

[ [ [] ] ]

8261, 8267

5323, 7095

326, 340

8372, 8408

3568, 5300

9023, 9928

2773, 3006

7428, 8238

8288, 8351

7121, 7405

8432, 8764

3021, 3549

8784, 9000

276, 288

368, 2122

2144, 2536

2552, 2757

17,125

191,331

4494

Discharge summary

report

Admission Date: [**2101-10-25**] Discharge Date: [**2101-11-1**] Service: [**Doctor Last Name 1181**] PRINCIPAL DIAGNOSES: 1. COPD exacerbation. 2. Pneumonia. CHIEF COMPLAINT: Confusion, shortness of breath. HISTORY OF PRESENT ILLNESS: This is an 87 year old woman with a history of COPD with two to three days of worsening confusion and worsening dyspnea. She denies cough, congestion or fever. She had sweats on the day prior to admission. Sick contact positive for family member at home with a cough and temperature of 102. In the emergency department the patient had an arterial blood gas of 7.24/126/259. She had pulse oximetry saturation of 76% on 3 liters of O2. BiPAP was attempted, but the patient was unable to tolerate it. She was intubated and transferred to the medical intensive care unit. PAST MEDICAL HISTORY: Chronic obstructive pulmonary disease on 2 to 3 liters of O2 at home. PFTs in 7/98 showed FVC of 56%, FEV1 49%, FEV/FVC ratio 127% with decreased diffusing capacity. SIADH. Headaches. Anxiety. Rectal adenocarcinoma status post lower anterior resection in [**2098**]. MEDICATIONS: Atrovent two puffs t.i.d., albuterol one puff b.i.d., propoxyphene (Darvon) 65 mg t.i.d. p.r.n. headache, hydromorphone 1 mg b.i.d., Klonopin 0.5 mg in a.m. and 1 mg in p.m., ranitidine 150 mg b.i.d., Megace one teaspoon b.i.d., lactulose syrup one to three tablespoons b.i.d. SOCIAL HISTORY: The patient states that she lives in [**Location 19208**] in her house with seven children. Quit smoking 20 years ago. PHYSICAL EXAMINATION: On admission temperature was 100.6, heart rate 96, blood pressure 157/63, oxygen saturation 97% on 2 liters. Current physical exam temperature 99.1, pulse 93, blood pressure 140/80, oxygen saturation 94% on 3 liters. HEENT: oropharynx moist. Chest: trace crackles at the left base, otherwise clear to auscultation bilaterally. Cardiovascular regular rate and rhythm, normal S1, S2, no murmur. Abdomen soft, nontender, nondistended, positive bowel sounds. Extremities no edema. LABORATORY DATA: White blood cell count 18, hematocrit 41.4, platelets 307. Sodium 136, potassium 4.3, chloride 84, CO2 52, BUN 12, creatinine 0.5. In 7/00 cardiac echo normal left ventricular systolic function, normal wall motion. On [**2101-10-25**] chest x-ray increased lung volume, flat diaphragm, infiltrates in lower lobe. On [**10-28**] chest x-ray small bilateral pleural effusions with patchy consolidation of the left base. On [**2101-10-28**] white blood cells 13.8, hemoglobin and hematocrit 11.5 and 36.2, platelets 290. Sodium 138, potassium 3.7, chloride 95, bicarbonate 36, BUN 13, creatinine 0.5, glucose 113. Calcium 8.6, phosphate 2.5, magnesium 1.8. Arterial blood gas on 5 liters of O2 per minute was 7.38/59/98. On [**10-31**] white blood cell count 13.5 (patient on steroids), hemoglobin and hematocrit 12.1 and 38.4, platelets 347. Sodium 131, potassium 4.2, chloride 88, CO2 40, BUN 19, creatinine 0.5. HOSPITAL COURSE: In short, this is a woman with chronic obstructive pulmonary disease exacerbated by pneumonia and intubated for respiratory failure. In the medical ICU she was started on Solu-Medrol 40 mg IV t.i.d., Atrovent and albuterol nebulizers. The patient's sputum showed gram negative rods and she was empirically started on ceftazidime. She received 2 gm of Ceftaz, followed by 5 gm of 1 gm ceftriaxone IV q.24 hours and then was switched to 500 mg p.o. q.d. of levofloxacin on [**10-31**] for a seven day course of levofloxacin. She was not febrile during this admission. She was still complaining of an occasional cough. Ventilator dependence was minimal and she was extubated without complications on [**10-26**]. Intravenous steroids were stopped on [**10-28**] and she was started on prednisone taper 60 mg q.d. On day of discharge, [**11-1**], it was the first day of prednisone 30 mg q.d. She was on 2 liters of nasal prong oxygen at home and this is what she was receiving at discharge. The patient was often confused, belligerent and anxious, but this apparently is her baseline. She complained of occasional headache. She has a history of chronic headaches for which she receives Darvon (propoxyphene) 65 mg q.four hours p.r.n. and this was restarted. On discharge the patient had crackles to 1/3 up the lungs, but she did not have rales nor stigmata of congestive heart failure. Given her pneumonia, these crackles make take a fair amount of time to resolve even if the active infection has already cleared. Regarding her labs, sodium was around 130. She has a history of SIADH secondary to lung disease and at times in the past has been on oral salt tablets 500 mg three times a day. Because her sodium has been stable here off sodium tablets, they were not restarted. CO2 was high at around 40, but looking at her past discharge summaries, this appears to be her baseline. She is likely CO2 retaining from COPD. DISCHARGE MEDICATIONS: 1. Levofloxacin 500 mg p.o. q.d., last dose [**2101-11-6**]. 2. Darvon (propoxyphene) 65 mg p.o. q.four p.r.n. headache. 3. Colace 100 mg p.o. b.i.d. 4. Klonopin 0.5 mg in a.m., 1 mg in p.m. 5. Ranitidine 150 mg p.o. b.i.d. 6. Lactulose syrup one to three tablespoons b.i.d. p.r.n. constipation. 7. Atrovent inhaler two puffs t.i.d. 8. Albuterol inhaler one puff b.i.d. 9. Prednisone taper [**11-1**] to 9/36 30 mg p.o. q.d., [**11-3**] to [**11-4**] 20 mg p.o. q.d., [**11-5**] to [**11-6**] 10 mg p.o. q.d., [**11-7**] to [**11-8**] 5 mg p.o. q.d., [**11-9**] off prednisone. CONDITION ON DISCHARGE: Stable. DISCHARGE STATUS: The patient is a full code. DISPOSITION: To [**Location 1268**] Manor for rehabilitation. DISCHARGE DIAGNOSES: 1. Chronic obstructive pulmonary disease exacerbation. 2. Pneumonia. The patient was being followed in the hospital by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1266**], who is also her primary care physician. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 4263**] Dictated By:[**Doctor Last Name 19209**] MEDQUIST36 D: [**2101-11-2**] 19:20 T: [**2101-11-5**] 18:04 JOB#: [**Job Number 19210**]

[ "486", "733.00", "491.21", "428.0", "V10.05", "300.00" ]

icd9cm

[ [ [] ] ]

[ "93.90", "96.71" ]

icd9pcs

[ [ [] ] ]

5731, 6236

4976, 5564

3018, 4953

1577, 3000

190, 223

252, 828

851, 1416

1433, 1554

5589, 5710

9,828

101,146

52388

Discharge summary

report

Admission Date: [**2200-1-23**] [**Month/Day/Year **] Date: [**2200-2-8**] Date of Birth: [**2149-10-17**] Sex: F Service: [**Year (4 digits) 662**] Allergies: Penicillins / Ampicillin / Motrin / Bactrim / Lithium / Doxycycline Attending:[**First Name3 (LF) 5755**] Chief Complaint: Shortness of Breath, Hemoptysis Major Surgical or Invasive Procedure: None History of Present Illness: 50 female with h/o COPD on 4L home 02, idopathic cardiomyopathy, CRI and bipolar d/o who presented to the ED today with acute onset SOB, which started this am, hemoptysis, chronic mucopurulent cough and tachycardia. THe hemoptysis was about "the bottom of a cup" and is present every time she coughs something up. At baseline she has a greenish sputum, that is unchanged from prior. She denies any CP, other than her usual CP. She reports fevers several days prior for two days. She had one episode of vomiting yesterday, when she brought up food contents, but denies any hematemesis. She denies headaches, abd pain, nausea, diarrhea, melena, dysuria. She has occ orthopnea and sleeps on 3 pillows. She has stable atypical CP, unchanged from prior. She reports a "40lb weight loss over 40 days". she reports her granddaughter was recently sick with "pneumonia". . In the ED the pt was satting 88% on her home 4L. She received combivent, prednisone 60 and azithromycin in ED. An ABG was done and showed 7.34/60/106 which is close to the patient's baseline. The pt was also found to be in acute renal failure and a CT was not advisable. A VQ scan was ordered and the pt was started on a Heparin gtt. 1L NS was given. Past Medical History: - COPD: on home O2 at 4 L PFTs [**8-31**]: FEV1 0.61 (30%), FVC 1.66 (60%), FEV1/FVC 37 (48%), h/o intubation x 2, h/o steroid tapers [**3-30**] x per year - atypical CP - DM2 - HgbA1c 5.8% on [**2198-11-12**] - h/o small pulomonary microemboli - finished coumadin x 6 months - CRI (baseline 1.5) - Bipolar d/o - HTN - no BB due to copd - CHF - EF 35-40% with impaired LV relaxation - DI- nephrogenic - chronic anemia Social History: Patient lives with her daughter She smoked [**5-1**] PPD x 20 yrs and quit one year ago Denies drug use Family History: Father- MI at 41, died at 72 Son -died at 31 of MI Mother- DM and multiple other medical problems, died at 73 of stroke Brother-prostate Ca Physical Exam: VS 99.1 BP 117/67 HR 84 20 94%4L Gen: well appearing female in NAD HEENT: NC, AT, anicteric sclera, dry mm Neck: no LAD, JVP flat Cardio: tachycardic, distant heart sounds, nl S1 S2, no m/r/g audible Pulm: expiratory rhonchi bilaterally, R >L Abd: soft, NT, ND, + BS, possible midline hernia Ext: 2+ DP pulses, no lower ext edema Neuro: PERRLA, moving all extremities, initially oriented to place, person and day (not to year), President of the USA: [**Doctor Last Name **]. Sluggish speech dosing off. Pertinent Results: [**2200-1-23**] 08:15PM WBC-15.1*# RBC-3.45* HGB-9.8* HCT-30.2* MCV-88 MCH-28.4 MCHC-32.3 RDW-15.8* [**2200-1-23**] 08:15PM NEUTS-75.5* LYMPHS-16.2* MONOS-5.5 EOS-2.0 BASOS-0.7 [**2200-1-23**] 08:15PM PLT COUNT-286 [**2200-1-23**] 08:15PM CK(CPK)-535* [**2200-1-23**] 08:15PM CK-MB-5 cTropnT-<0.01 [**2200-1-23**] 08:15PM GLUCOSE-207* UREA N-28* CREAT-3.1*# SODIUM-144 POTASSIUM-3.9 CHLORIDE-101 TOTAL CO2-30 ANION GAP-17 [**2200-1-23**] 08:35PM LACTATE-1.8 . GRAM STAIN (Final [**2200-1-24**]): >25 PMNs and <10 epithelial cells/100X field. 2+ (1-5 per 1000X FIELD): MULTIPLE ORGANISMS CONSISTENT WITH OROPHARYNGEAL FLORA. RESPIRATORY CULTURE (Final [**2200-1-26**]): MODERATE GROWTH OROPHARYNGEAL FLORA. LEGIONELLA CULTURE (Final [**2200-1-31**]): NO LEGIONELLA ISOLATED. . BLOOD CX [**2200-1-23**]: NO GROWTH URINE CX [**2200-1-24**]: < 10K ORGANISMS URINE LEGIONELLA ANTIGEN: NEGATIVE SPUTUM CYTOLOGY: NONDIAGNOSTIC . EKG: Sinus arrhythmia with atrial and ventricular premature beats. Compared to the previous tracing of [**2199-5-29**] baseline artifact is not seen and rhythm change is new. . Echo The left atrium is normal in size. Left ventricular wall thickness, cavity size, and systolic function are normal (LVEF>55%). Transmitral Doppler imaging is consistent with normal LV diastolic function. 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 leaflets are mildly thickened. Trivial mitral regurgitation is seen. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. Compared with the report of the prior study (images unavailable for review) of [**2198-4-20**], the left ventricular function has normalized. . CHEST, ONE VIEW: Comparison with [**2199-5-31**], [**2199-5-29**]. Cardiac, mediastinal, and hilar contours are unchanged; right heart border obscuration again seen, as seen on previous examinations. Again identified is severe apical emphysema. This may accentuate the appearance of lower lobe vascular crowding. Linear atelectasis identified at the left lung base. No pleural effusion. No pneumothorax. Osseous structures appear unchanged. IMPRESSION: Similar appearance of severe apical emphysema and lower lobe vascular crowding, without significant change since [**2199-5-27**] examinations. . CHEST, PA AND LATERAL: The marked upper lobe bullous emphysema is unchanged. This accentuates the appearance of lower lobe vascular crowding. There is no focal consolidation. No pleural effusions are present. The cardiac size, mediastinal and hilar contours are unremarkable. IMPRESSION: Biapical bullous emphysema without pneumonia. Brief Hospital Course: # COPD exacerbation: Patient was treated with IV steroids, azithromycin, and [**Year (4 digits) 1988**] nebs with improvement back to her baseline. She was discharged home on a slow prednisone [**Year (4 digits) 15123**]. She is on continuous oxygen at home at baseline. . # Hemoptysis: Given patient reported no risk factors for PE and had no lower extremity swelling on exam, work-up for PE was deferred. Patient improved quickly to her baseline with treatment of her COPD flare and her hemoptysis resolved. Patient denies any history of weight loss, but CT chest without contrast (given poor renal function) could be considered to further investigate for evidence of malignancy. . # Acute renal failure: Patient's creatinine returned to her baseline off her ACE and with supportive IVF. She was discharged off her ACEI, given her potassium has been running high. She will follow-up with her primary care doctor to discuss restarting this medication if her creatinine and potassium remain stable. # Type 2 diabetes: Patient's sugars were difficult to control while patient was on steroids. [**Last Name (un) **] was consulted and recommended starting NPH, in addition to increasing the patient's home glipizide. The patient received teaching with a glucometer and was able to check her sugars confidently prior to [**Last Name (un) **]. She was given a schedule to wean her NPH as her steroid dose is decreased and she will have close follow-up at [**Last Name (un) **]. . # Somnolence/Pysch: Patient was noted to be intermittently somnolent. The concern in the ICU was for C02 retention; however, repeat ABGs were no different from her baseline. Patient's neuroleptics were held with improvement in sx. She remains on Depakote; risperidal held; and seroquel reduced to 50 mg po qhs. . # CHF: Repeat Echo actually demonstrated improvement in EF to normal. Blood pressure well controlled on her home diltiazem, in addition to newly started nifedipine in the setting of elevated bp's off her ACEI. . # EPS: During her hospitalization noted to be intermittently jittery. Initial concern was ?myoclonic jerks. Repeat ABGs without change in C02. Seen by Neuro/Psych who felt etiology likely secondary to EPS and steroids. Changes to neuroleptics as described above. . # Sinus tachycardia: On the floor, patient had rare bursts of a SVT which appears to be sinus tachycardia. Cardiology was consulted for telemetry and 12 ld concerning for possible afib/flutter but felt this was consistent with sinus tachycardia with background noise from her tremor. . # Bipolar disorder: Patient's psychiatric medications were adjusted, as above. Her mood remained stable on steroids, without evidence of mania. She denies any insomnia. . # Hyperkalemia: Patient had an episode of hyperkalemia while off her ACEI. Renal was consulted. FEK 23%, thus low suspicion for hyporeninemic hypoaldosterone state. CK was normal so no evidence of rhabdo. Renal suspects hyperK due to dietary noncompliance. Patient was put on a renal diet and received nutrition counseling on continuing on this diet at home. Her potassium remained stable and will be rechecked as an outpatient. Medications on Admission: ADVAIR DISKUS 250-50 mcg/Dose--1 puff inh twice a day ALBUTEROL NEBS/IH Q4-6H DILTIAZEM HCL 360mg QD DIVALPROEX SODIUM 250MG QAM/500 QPM GLIPIZIDE 5 mg QD IPRATROPIUM BROMIDE IH/NEB Q6h IRON 325 mg QD LIPITOR 20 mg QD LISINOPRIL 40MG QD MULTIVITAMIN QD RISPERIDONE 1MG QAM, 3MG QHS SEROQUEL 150mg QHS TIOTROPIUM BROMIDE 18 mcg QD TRAZODONE HCL 50MG QHS . [**Last Name (un) **] Medications: 1. Outpatient [**Last Name (un) **] Work Please draw sodium, potassium, chloride, bicarbonate, BUN, creatinine, glucose, calcium, and phosphorus on [**2200-2-11**]. Please notify Dr. [**First Name (STitle) 17137**] [**Name (STitle) **] of results: Phone [**Telephone/Fax (1) 250**]. 2. Insulin NPH Human Recomb 300 unit/3 mL Insulin Pen Sig: Fifteen (15) units Subcutaneous qam for 3 days: on [**2200-2-11**]. Disp:*3 prefilled syringes* Refills:*0* 3. Insulin NPH Human Recomb 300 unit/3 mL Insulin Pen Sig: Thirty (30) units Subcutaneous qam for 2 days: on [**1-14**]. Disp:*2 prefilled syringes* Refills:*0* 4. Insulin NPH Human Recomb 300 unit/3 mL Insulin Pen Sig: Seven (7) units Subcutaneous qam for 3 days: on [**2200-2-14**]. Disp:*3 prefilled syringes* Refills:*0* 5. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). Disp:*1 inhaler* Refills:*2* 6. Advair Diskus 500-50 mcg/Dose Disk with Device Sig: One (1) INH Inhalation twice a day. Disp:*1 inhaler* Refills:*2* 7. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 puffs Inhalation every 4-6 hours as needed for shortness of breath or wheezing: PLEASE USE YOUR SPACER WITH YOUR INHALER. Disp:*1 INHALER* Refills:*2* 8. Albuterol Sulfate 0.083 % Solution Sig: One (1) NEBULIZER TREATMENT Inhalation every 4-6 hours as needed for shortness of breath or wheezing. Disp:*20 VIALS* Refills:*2* 9. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 10. Valproic Acid 250 mg Capsule Sig: One (1) Capsule PO QAM (once a day (in the morning)). Disp:*30 Capsule(s)* Refills:*0* 11. Valproic Acid 250 mg Capsule Sig: Two (2) Capsule PO QHS (once a day (at bedtime)). Disp:*60 Capsule(s)* Refills:*0* 12. Prilosec OTC 20 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day for 8 days. Disp:*8 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 13. Diltiazem HCl 180 mg Capsule, Sustained Release Sig: Two (2) Capsule, Sustained Release PO DAILY (Daily). Disp:*60 Capsule, Sustained Release(s)* Refills:*2* 14. Glipizide 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 15. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 16. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 17. Quetiapine 25 mg Tablet Sig: Two (2) Tablet PO QHS (once a day (at bedtime)). Disp:*60 Tablet(s)* Refills:*0* 18. Prednisone 5 mg Tablet Sig: 1-4 Tablets PO once a day for 8 days. Disp:*17 Tablet(s)* Refills:*0* 19. Nifedipine 30 mg Tab,Sust Rel Osmotic Push 24HR Sig: One (1) Tab,Sust Rel Osmotic Push 24HR PO once a day. Disp:*30 Tab,Sust Rel Osmotic Push 24HR(s)* Refills:*0* [**Date range (3) **] Disposition: Home With Service Facility: [**Hospital 119**] Homecare [**Hospital **] Diagnosis: COPD exacerbation hyperkalemia chronic renal insufficiency type 2 diabetes, poorly controlled with complications bipolar disorder sinus tachycardia [**Hospital **] Condition: good: breathing at baseline, blood sugars well controlled, electrolytes stable [**Hospital **] Instructions: Please call your doctor or go to the emergency room if you experience worsening shortness of breath, temperature > 101, worsening cough, chest pain, heart racing, or other concerning symptoms. Please have labs drawn on [**Hospital 3816**] to check your electrolytes. Please follow the special kidney diet (low potassium, low phosphorus) you were provided. Please take your blood sugar before every meal and at bedtime. Record these numbers on a piece of paper and bring this with you to your [**Last Name (un) **] appointment. If you ever feel shaky, sweaty, or weak check your blood sugar. If it is < 70, drink some juice and recheck it in 30 minutes. If it is still < 70 call 911. If it improves to > 70, do not take any more insulin, regardless of your prescribed dose. If you are ever vomiting or otherwise unable to eat, do not take any insulin that day. Followup Instructions: Please follow-up with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1557**], nurse [**Last Name (NamePattern1) 3639**] [**First Name8 (NamePattern2) 767**] [**Last Name (Titles) **] Diabetes Center on [**2200-2-13**] at 12:30 PM to discuss management of your diabetes. Please bring your glucometer to this appointment. Phone: ([**Telephone/Fax (1) 17484**] Location: One [**Last Name (un) **] Place, [**Location (un) 86**], [**Numeric Identifier 718**] Please follow-up with nurse [**First Name8 (NamePattern2) 3639**] [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], who works with your primary care doctor [**First Name (Titles) **] [**Last Name (Titles) 3816**], [**2200-2-11**] at 12:40 PM to assess how your breathing is doing. Phone: [**Telephone/Fax (1) 250**]. Location: [**Hospital6 733**], [**Location (un) **], [**Hospital Ward Name 23**] 6, Central Suite Please follow-up with your primary care doctor, Dr. [**First Name (STitle) **], on [**2200-3-3**] at 2 PM for routine care. Phone: [**Telephone/Fax (1) 250**]. Location: [**Hospital6 733**], [**Location (un) **], [**Hospital Ward Name 23**] 6, North Suite Please follow-up with your psychiatrist, Dr. [**Last Name (STitle) **], on [**2-12**], [**2200**] at 10:00 AM. Phone: ([**Telephone/Fax (1) 24780**]

[ "584.9", "493.22", "518.81", "425.4", "564.00", "285.21", "296.80", "585.6", "790.92", "578.0", "427.89", "250.92", "403.91", "276.51", "272.0" ]

icd9cm

[ [ [] ] ]

[ "93.90", "38.91" ]

icd9pcs

[ [ [] ] ]

5769, 8952

389, 395

2921, 5746

13446, 14765

2240, 2382

8978, 13423

2397, 2902

318, 351

423, 1640

1662, 2102

2118, 2224

54,245

153,070

35746

Discharge summary

report

Admission Date: [**2146-1-31**] Discharge Date: [**2146-2-12**] Date of Birth: [**2101-8-31**] Sex: F Service: MEDICINE Allergies: Penicillins Attending:[**Male First Name (un) 5282**] Chief Complaint: transfer from outside hospital for worsening abdominal girth and somnolence. Major Surgical or Invasive Procedure: 1. diagnostic and symptomatic paracentesis 2. transjugular liver biopsy 3 ultrasound guided diagnostic paracentesis History of Present Illness: Pt is a 44 yo female with a history of hepatitis B and C, active IVDU, bipolar disorder who presented initially to [**Hospital 8**] Hospital with complaints of diffuse abdominal pain, increasing abdominal girth, yellow eyes and skin, diarrhea, nausea, vomiting, and decreased appetite. . At the OSH, an abdominal CT showed ascites and an unsuccessful paracentesis was performed. She completed an empiric 7 day course of IV cipro and flagyl for possible SBP. During her hospital stay, her abdominal girth worsened and she developed peripheral edema. Aldactone was started but stopped when her creatinine increased from 0.5 on admission to 1. In addition, she was noted to become more somnolent over the hospital course, and her INR, transaminases, and bilirubin continued to rise. Given her minimal improvement, a decision was made at the OSH to start IV NAC, and transfer her to [**Hospital1 18**] for further management. . On the floor, initial vs were: T 98.9 P 87 BP 118/77 R 18 O2 sat 96% RA. In general, the patient stated that she had been feeling tired recently. Also, earlier today prior to transfer, she admitted to having one episode of nausea and vomiting, without hematemesis. She complains that her abdomen feels tight and "compressing everything." She denies being SOB, but has difficulty taking deep breaths. She also reports gaining 15 pounds in the last several weeks. She now c/o dry heaving and acid reflux after eating. Review of sytems: (+) Feels congested. Recent antibiotic use: metronidazole x 14d for vaginal infection in early [**Month (only) 956**], now resolved. (-) Denies fever, chills, night sweats, headache, sinus tenderness, rhinorrhea. Denied chest pain or tightness, palpitations. Currently no diarrhea or loose stool. Denies dysuria, arthralgias or myalgias. Past Medical History: 1. hepatitis b due to sexual intercourse with her prior partner. Diagnosed 20 years ago, which she declined treatment. 2. hepatitis c, recent diagnosis, likely due to her recent IV drug use history per patient. 3. bipolar disorder. Denies recent hospitalizations for mania. Patient has been taking valproic acid for the last three years. 4. asthma. Has had ED visits, but no hospitalizations. Last steroid use was several years ago. 5. active IV drug user. She does endorse recent cocaine and heroin use via IV. Prior to recent drug use, she states that the last time she used illicit IV drugs was 20 years ago. Social History: Lives alone in [**Location (un) 2251**]. Has a daughter. Is unemployed and receives SSI financial support. Quit smoking 2 wks prior to admission, smoking [**11-19**] ppd for 14 years. Denies recent etoh use. Last alcohol use was senior prom she states. Also denied recent tylenol or narcotic use at home. She does endorse recent cocaine and heroin use via IV. Her reasoning was due to recent stressors in her home. Her stressors include a 23 year old daughter who recently went to college and her boyfriend who was just recently jailed. Another stressor is that she has to move out of her boyfriend's apartment and is now homeless. Prior notes report a history of domestic violence with a verbally abusive partner. Family History: Mother was an alcoholic. Father passed away at age 62 due to lung cancer. Her daughter is healthy and is currently in school. Physical Exam: Admission Physical Exam: . Vitals: T 98.5, 117/77, 110, 18, 94% RA General: thin appearing, awake, but tired appearing, mild jaundice, NAD HEENT: Sclera icteric, droopy eyelids bilaterraly, MMM, oropharynx clear Neck: supple, no LAD Chest: occasional spider angiomas. Lungs: decreased breath sounds at bases bilaterally, no wheezes or crackles, good respiratory effort CV: Tachycardic, normal S1 + S2, III/VI early systolic murmur at LLSB, no rubs, no gallops Abdomen: caput medusa, tense and distended, with diffuse tenderness to palpation, normal bowel sounds, no guarding Ext: Warm, well perfused, 2+ pulses, 2+ pitting edema bilaterally to the knees, mild palmar erythema. Neuro: oriented to person, place and time, without confusion, mild tremors in hands bilaterally, no flapping tremor. EOMI. ___________________________________ Physical Exam on [**2146-2-11**]: . General: very somnolent, but easily arousable, improved jaundice, NAD HEENT: Sclera icteric, MMM, oropharynx clear Lungs: decreased breath sounds at bases bilaterally, CV: Tachycardic, normal S1 + S2 Abdomen: less tense and distended, mild tenderness to palpation, tympanic, normal bowel sounds, no guarding, left flank petechiae is slightly tender to palpation and improving. Ext: Warm, well perfused, improved pitting edema to 1+ bilaterally to the knees Neuro: oriented to person and place, but not to time. very slow to respond to questions. She responds with short phrases. significantly worsened asterixis. Pertinent Results: OSH Initial Admission labs: INR of 2, Tbili 14.4, D bili 7.3, Alk phos 175, AST 630, ALT 239. Blood cultures finalized as negative. . OSH: hepatitis panel: Hep A ab reactive, Hep A IgM non-reactive Hep B viral load 110 Hep C ab positive, Hep C RNA <615 Hep D ab positive HIV 1&2 ab negative . OSH Tox screen [**1-23**] positive for benzos, opiates, cannabinoids salicyclates: 7 Acetaminophen: <10, ethyl alcohol, <10 urine ethyl alchol: negative . [**Hospital1 18**] Labs: HIV viral load negative CMB IgM and EBV IgM negative HBV viral load <40, HCV viral load not detected HDV viral RNA DETECTED . ___________________________________ Admission Labs: [**2146-1-31**] 09:25PM BLOOD WBC-9.9 RBC-3.00* Hgb-10.4* Hct-29.5* MCV-99* MCH-34.6* MCHC-35.1* RDW-18.6* Plt Ct-168 [**2146-1-31**] 09:25PM BLOOD PT-39.6* PTT-45.5* INR(PT)-4.3* [**2146-1-31**] 09:25PM BLOOD Glucose-113* UreaN-18 Creat-1.0 Na-127* K-3.8 Cl-96 HCO3-22 AnGap-13 [**2146-1-31**] 09:25PM BLOOD ALT-215* AST-699* LD(LDH)-328* AlkPhos-175* TotBili-19.1* [**2146-1-31**] 09:25PM BLOOD Albumin-2.6* Calcium-8.2* Phos-3.8 Mg-2.3 Iron-146 [**2146-1-31**] 09:25PM BLOOD calTIBC-151* Ferritn-GREATER TH TRF-116* [**2146-1-31**] 09:25PM BLOOD HBsAg-POSITIVE* HBsAb-POSITIVE HBcAb-POSITIVE IgM HAV-NEGATIVE [**2146-1-31**] 09:25PM BLOOD Smooth-NEGATIVE [**2146-1-31**] 09:25PM BLOOD [**Doctor First Name **]-POSITIVE Titer-1:320 PAT [**2146-1-31**] 09:25PM BLOOD IgG-3033* [**2146-2-2**] 05:40PM BLOOD HIV Ab-NEGATIVE [**2146-1-31**] 09:25PM BLOOD HCV Ab-POSITIVE* [**2146-2-1**] 12:41PM BLOOD HEPATITIS D VIRUS RNA, QUALITATIVE, RT-PCR-DETECTED [**2146-1-31**] 09:25PM BLOOD CERULOPLASMIN-negative [**2146-1-31**] 09:25PM BLOOD ALPHA-1-ANTITRYPSIN-negative ___________________________________ Last set of labs before making patient "Comfort measures only" . [**2146-2-7**] 05:10AM BLOOD WBC-7.1 RBC-2.77* Hgb-9.5* Hct-26.5* MCV-96 MCH-34.5* MCHC-36.0* RDW-21.0* Plt Ct-89* [**2146-2-7**] 05:10AM BLOOD PT-49.4* PTT-52.8* INR(PT)-5.6* [**2146-2-4**] 08:50AM BLOOD Ret Aut-5.6* [**2146-2-7**] 05:10AM BLOOD Fibrino-114* [**2146-2-7**] 05:10AM BLOOD Glucose-110* UreaN-20 Creat-0.7 Na-139 K-2.6* Cl-102 HCO3-30 AnGap-10 [**2146-2-7**] 05:10AM BLOOD ALT-58* AST-152* AlkPhos-93 TotBili-23.8* [**2146-2-7**] 05:10AM BLOOD Lipase-51 [**2146-2-7**] 05:10AM BLOOD Calcium-8.5 Phos-1.9*# Mg-2.5 [**2146-2-4**] 08:50AM BLOOD VitB12-GREATER TH Folate-15.5 Hapto-<20* . ______________________________________ Studies: . OSH Abdominal U/S: distended gallbladder, no obstruction of CBD, no wall thickening or pericholecystic fluid. . OSH Abd/Pelvis CT: + Ascites, distended gallbladder with no stones or obstruction . Abd U/S with dopplers: shruken, nodular, heterogenous liver, no focal lesions, no biliary dilatation, sludge gallbladder, spleen not enlarged, R/L kidneys without hydronephrosis, bilateral pleural effusions, moderate ascites, patent hepatic vasculature. . Abd CT: 1. Moderate ascites. 2. Bilateral small pleural effusions, with left greater than right basal consolidations, which may represent atelectasis, underlying pneumonia cannot be excluded. 3. Findings consistent with known liver cirrhosis. 4. Anasarca. . CXR: [**2-5**]: Bilateral basilar atelectasis and small pleural effusions, more marked on the left. No change from prior study. . Liver biopsy: 1. Fragmented, scant biopsy containing four definite portal tracts with moderate, portal and periportal, and mild lobular, predominantly mononuclear inflammation including occasional plasma cells and neutrophils. 2. Marked intracellular cholestasis with foci of balloon degeneration. 3. Trichrome stain shows increased portal fibrosis and separate large fibrous areas with bile duct proliferation, see note. 4. Iron stain shows mild iron deposition in hepatocytes and Kupffer cells. Note: Large fibrous areas with bile ducts can be seen adjacent to large hepatic veins. Given that this is a trans-jugular biopsy, it is difficult to determine whether this represents a septa seen in cirrhosis or fibrous tissue subjacent to a large hepatic vein. A fibrous septa of cirrhosis is favored because of the presence of areas of bile duct proliferation. There is no prominent plasma cell infiltrate seen in the biopsy. Dr. [**Last Name (STitle) **]. [**Doctor Last Name 497**] was informed of the findings on [**2146-2-4**]. Liver cytology: Poor sample. Not diagnostic. Brief Hospital Course: Ms. [**Known lastname 81294**] is a 44 yo woman with hepatitis a (IgG), b (HBsAg +, cAb +, sAb +), c (HCVab), and d (HDV RNA +), active IVDU, anxiety, and bipolar disorder admitted with decompensated liver injury s/p transjugular liver biopsy with worsening hepatic encephalopathy. Patient was changed to comfort measures only (CMO) and DNR-DNI after discussing results of our tests and poor prognosis with patient. . Comfort Measures only: Palliative care was consulted when patient made CMO on [**2-7**]. We changed all her medications to PO form. We discontinued her peripheral IV access. We gave her the option to refuse her medications. Since [**2-8**], she refused her supportive care medications: lactulose and rifaximin; rifaximin was discontinued on [**2-11**] but we continue to offer lactulose should she choose to take in to alleviate hepatic encephalopathy so that she can interact with her family. Hospice care personnel evaluated her for a proper location near where her mother lives but she passed away on Saturday, [**2-12**] before transfer. . Decompensated liver disease: Child-[**Doctor Last Name 14477**] class C at time of admission. Her chronic low replicating Hep B virus, hepatitis C, and new diagnosis of hepatitis D have likely led to her decompensated cirrhosis. We treated her with entecavir for HBsAg until she was made CMO. She was continued on lactulose and rifaximin during her stay until she was made CMO, at which point only lactulose was offered. The paracentesis on [**2-1**] removed 900 cc, and was negative for SBP. Patient received 4 units FFP for transjugular liver biopsy which was done on [**2-3**] which was poor quality sample demonstrating no plasma cells. Three diagnostic paracentesis were attempted on [**2-3**] given leukocytosis with left shift and worsening abdominal pain; however they were unsuccessful. She had another diagnostic paracentesis by IR on [**2-4**] after receiving 4 units of FFP which was negative for SBP. An 8 point Hct drop was noted on [**2-4**]. The drop may have been related to hemodilution vs. mild abdominal bleeding. As a result, patient received 2 units of pRBCs, followed by furosemide 40 mg IV x 2. Stool was guaiac negative. Pt was started on levofloxacin and metronidazole for concern for bowel perforation on [**2-7**]. She had a one day stay in the MICU for close observation because she became more encephalopathic with confusion, worsening asterixis, and somnolence on [**2-4**]. She was hemodynamically stable during her MICU stay; she was given lactulose, and her encephalopathy improved. She was then transferred back to the floor, where she remained hemodynamically stable. On [**2-7**], results showed that Hepatitis D RNA was detected. Given no treatment for Hepatitis D, and worsening liver function tests and encephalopathy, patient and family decided to be comfort measures only and code status was changed to DNR-DNI on [**2-7**]. She became progressively become more somnolent and was less responsive to questions. She has had chronic intermittent abdominal pain which resolved with morphine and we titrated it to make her comfortable. . # Partial SBO vs. Ileus / Epigastric discomfort : On the night of MICU transfer, an NGT tube was placed for concern that she would be unable to tolerate POs when she became more encephalopathic. On [**2-6**], her NG tube was putting out several hundred CC's per shift and KUB showed early/partial SBO vs ileus. It was removed when she was better able to tolerate clear diet on [**2-8**]. The patient was then advanced to regular diet on [**2-9**]. Her epigastric discomfort was likely due to acid reflux from her distended abdomen. It was unlikely to be due to cardiac ischemia given EKG on [**2-4**] was without signs of acute ischemia. Patient was given ranitidine and aluminum-magnesium-simethicone prn for epigastric discomfort and ondansetron and lorazepam prn for nausea. . # Anemia: Initial Hct on transfer from OSH was ~ 30. She had a low of 20.3 and got 2u pRBCs on [**2-4**]. Anemia could be due to repeat failed paracentesis on [**2-3**] vs. hemodilution from getting 4units FFP and albumin on [**2-3**]. Pt also received another 4u FFP on [**2-4**]. Stool was guaiac negative in the MICU. As patient wished to CMO, labs were no longer drawn. . # ARF: Cr: 0.7 on last lab draw from Cr: 0.9, with high of Cr 2.4 during hospital stay likely related to started her furosemide, spironolactone, entecavir, or/and poor PO intake. As patient wished to CMO, labs were no longer drawn. . # Anxiety/ Insomnia/ Bipolar disorder: Patient had much anxiety during hospital stay. She regularly took lorazepam 1 mg PO twice a day prior to admission. Her sleep cycles were noted to be switched as she had difficulty sleeping at night and she was sleeping during the daytime. This change in sleep cycles could potentially be due to her worsening encephalopathy. When she was made CMO, she was given lorazepam more frequently prn. During hospital stay, her bipolar disorder was stable without any manic episodes. She appeared more calm in the second week of her hospital stay. . # Hyponatremia: Improved and resolved on last blood draw. (Na: 128 on transfer from OSH). Her hyponatremia was likely due to be hypervolemic from her decompensated liver failure. As patient wished to CMO, labs were no longer drawn. . # FEN: Hypervolemic. We repleted her potassium once when K was 2.6. During her stay she was in a regular diet, then changed to clear liquids when NGT was placed as she became more encephalopathic. When she wished to CMO, NGT was removed and her diet changed back to regular diet as tolerated. She was unable to tolerate bread as she vomited it on [**2-10**]. . # Code: DNR-DNI, CMO. . # Contact: [**Name (NI) **] (mother)([**Location (un) **] care proxy) landline: [**Telephone/Fax (1) 81295**], cell: [**Telephone/Fax (1) 81296**]; [**First Name8 (NamePattern2) 81297**] [**Known lastname 81294**] (daugher) cell: [**Telephone/Fax (1) 81298**]. Family was at the bedside when patient expired on [**2-12**]. Medications on Admission: Medications at home: lorazepam 1 mg [**Hospital1 **] depakote 1000mg in AM, 250 mg in PM. albuterol neb PRN advair 100/50 [**Hospital1 **] OCP depot shot q3 months MVI 1 tab daily . Medications on transfer: senna 2 tabs qhs MCI qd colace 100 mg [**Hospital1 **] protonix 40 mg qd NAC IV lorazepam 1 mg [**Hospital1 **] prn zofran 4 mg IV q4 prn nausea oxycodone 5 mg po q6 hours prn Discharge Medications: none Discharge Disposition: Expired Discharge Diagnosis: Primary: decompensated liver failure secondary to hepatitis B and D, anemia, acute renal failure, partial small bowel obstruction, hyponatremia, hypokalemia, anxiety, insomnia Secondary: bipolar disorder Discharge Condition: Expired Discharge Instructions: n/a Followup Instructions: n/a Completed by:[**2146-2-14**]

[ "560.1", "070.49", "070.20", "296.89", "570", "571.5", "280.0", "789.59", "305.50", "305.60", "572.8", "276.1", "780.52" ]

icd9cm

[ [ [] ] ]

[ "50.13", "99.04", "88.64", "54.91", "96.07", "99.07" ]

icd9pcs

[ [ [] ] ]

16281, 16290

9753, 15819

353, 471

16538, 16547

5339, 5351

16599, 16633

3692, 3819

16252, 16258

16311, 16517

15845, 15845

16571, 16576

15866, 16027

3859, 5320

237, 315

1963, 2302

499, 1945

5991, 9730

16052, 16229

2324, 2941

2957, 3676

31,044

187,413

11180+56214

Discharge summary

report+addendum

Admission Date: [**2124-1-7**] Discharge Date: [**2124-1-12**] Date of Birth: [**2082-8-31**] Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 2290**] Chief Complaint: tylenol overdose Major Surgical or Invasive Procedure: Intubation ([**2124-1-7**]) Extubation ([**2124-1-8**]) History of Present Illness: 41F intubated and transferred from [**Hospital1 **] s/p Tylenol PM overdose. The patient was reported found down, unresponsive this afternoon with an empty bottle of Tylenol PM and an empty bottle of alcohol. She was last seen on the night prior. She has a long history of alcohol abuse, admissions for overdoses, including those requiring intubation. At OSH she was intubated for airway protection. Initial labs were notable for Tylenol level of >300 and ASA level of 1, LFTs unremarkable with AST 43 and ALT 37, coags unremarkable and renal function with Cr of 0.4 and ETOH level of 255. She was given a dose of activated charcoal via OG tube and started empirically on NAC. Additional workup at OSH included a CT head which showed questionable intraparenchymal bleed. She was transiently hypotensive but did not require pressors. . In the ED her initial ECG demonstrates QRS of 79 and QTC of 396 - she was loaded with 150 mg/kg of NAC at OSH and started on 12.5 mg/kg/hr. She was initially on propofol for sedation however was dropping her pressures and overbreathing the vent so was switched fentanyl/midazolam. Repeat head CT showed No acute intracranial process. . On the floor, the patient was intubated and sedated. T ? BP 129/87 HR 93 Sat 100%. . Review of systems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies cough, shortness of breath, or wheezing. Denies chest pain, chest pressure, palpitations, or weakness. Denies nausea, vomiting, diarrhea, constipation, abdominal pain, or changes in bowel habits. Denies dysuria, frequency, or urgency. Denies arthralgias or myalgias. Denies rashes or skin changes. Past Medical History: etoh abuse depression h/o suicide attempts h/o domestic abuse ? h/o eating disorder Social History: Patient lives with roomate. She is separated from her second husband and was divorced in [**2113**]. First husband was physically abusive. Long history of etoh abuse. Sober x 6 yrs. Started drinking last year before she got married. Husband cheating on her. Had restraining order against him but this may be removed now. ? whether there is phsyical abuse in this relationship as well but she denied to her family. Reportedly he was slipping her etoh. Multiple recent hosp for etoh intox and was court ordered to go to sobriety program but the judge who knows her excused her yesterday. H/O suicide attempts and has been making si comments to family members recently. [**Name2 (NI) **] tobacco or drug use. Pt is a public defender (attorney) in [**Location (un) 1110**]. Family History: NC Physical Exam: Vitals: 97.7 128/84 97 100% General: intubated, sedated, opens eyes to voice HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Pertinent Results: Admission Labs [**2124-1-7**] 06:25PM BLOOD WBC-5.9 RBC-3.07* Hgb-9.9* Hct-27.7* MCV-90 MCH-32.1* MCHC-35.5* RDW-14.2 Plt Ct-200 [**2124-1-7**] 06:25PM BLOOD Neuts-86.7* Lymphs-10.5* Monos-2.4 Eos-0.1 Baso-0.3 [**2124-1-7**] 06:25PM BLOOD Glucose-93 UreaN-9 Creat-0.5 Na-142 K-4.4 Cl-119* HCO3-15* AnGap-12 [**2124-1-7**] 06:25PM BLOOD ALT-32 AST-40 CK(CPK)-54 AlkPhos-48 TotBili-0.2 [**2124-1-7**] 06:25PM BLOOD Albumin-3.4* [**2124-1-7**] 06:25PM BLOOD ASA-NEG Ethanol-105* Acetmnp-360* Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2124-1-7**] 07:24PM BLOOD Lactate-0.9 . Pertinent Labs [**2124-1-9**] 05:43PM BLOOD WBC-5.9 RBC-3.52* Hgb-10.4* Hct-31.9* MCV-91 MCH-29.4 MCHC-32.5 RDW-15.0 Plt Ct-252 [**2124-1-8**] 06:57AM BLOOD PT-14.3* PTT-24.9 INR(PT)-1.2* [**2124-1-9**] 12:11AM BLOOD PT-16.1* PTT-35.6* INR(PT)-1.4* [**2124-1-9**] 05:43PM BLOOD PT-14.8* PTT-29.0 INR(PT)-1.3* [**2124-1-8**] 02:12PM BLOOD Glucose-93 UreaN-4* Creat-0.5 Na-130* K-3.3 Cl-101 HCO3-16* AnGap-16 [**2124-1-9**] 05:23AM BLOOD Glucose-103* UreaN-3* Creat-0.4 Na-128* K-3.6 Cl-102 HCO3-13* AnGap-17 [**2124-1-9**] 05:43PM BLOOD Glucose-113* UreaN-3* Creat-0.4 Na-133 K-3.8 Cl-109* HCO3-13* AnGap-15 [**2124-1-8**] 02:12PM BLOOD ALT-33 AST-37 LD(LDH)-216 AlkPhos-57 TotBili-0.9 [**2124-1-9**] 12:11AM BLOOD ALT-64* AST-106* LD(LDH)-263* AlkPhos-52 TotBili-0.8 [**2124-1-9**] 11:50AM BLOOD ALT-54* AST-56* LD(LDH)-203 AlkPhos-53 TotBili-0.6 [**2124-1-9**] 05:43PM BLOOD ALT-51* AST-50* LD(LDH)-193 AlkPhos-48 TotBili-0.7 [**2124-1-9**] 05:23AM BLOOD Osmolal-265* [**2124-1-9**] 05:23AM BLOOD TSH-1.3 [**2124-1-9**] 05:23AM BLOOD Cortsol-19.5 [**2124-1-8**] 12:17AM BLOOD ASA-NEG Acetmnp-169* [**2124-1-8**] 06:57AM BLOOD ASA-NEG Acetmnp-127* [**2124-1-8**] 02:12PM BLOOD Acetmnp-86* [**2124-1-9**] 12:11AM BLOOD Acetmnp-78* [**2124-1-9**] 05:23AM BLOOD Acetmnp-85* [**2124-1-9**] 11:50AM BLOOD Acetmnp-50* [**2124-1-9**] 05:43PM BLOOD Acetmnp-10 [**2124-1-11**] 05:25AM BLOOD PT-11.4 PTT-23.5 INR(PT)-0.9 [**2124-1-11**] 05:25AM BLOOD ALT-60* AST-64* LD(LDH)-169 AlkPhos-48 Amylase-85 TotBili-0.4 [**2124-1-11**] 05:25AM BLOOD Acetmnp-NEG IMAGING: [**2124-1-8**] LIVER OR GALLBLADDER US: No textural or focal hepatic abnormalities. Major intrahepatic vasculature patent with normal Doppler waveforms. . MICRO: [**2124-1-11**] URINE CULTURE-PENDING [**2124-1-10**] BLOOD CULTURE-PENDING [**2124-1-10**] BLOOD CULTURE-PENDING [**2124-1-8**] MRSA SCREEN-NEG [**2124-1-7**] 6:25 pm BLOOD CULTURE: STAPHYLOCOCCUS, COAGULASE NEGATIVE. Isolated from only one set in the previous five days. | CLINDAMYCIN-----------<=0.25 S ERYTHROMYCIN---------- =>8 R GENTAMICIN------------ <=0.5 S LEVOFLOXACIN----------<=0.12 S OXACILLIN-------------<=0.25 S TETRACYCLINE---------- <=1 S VANCOMYCIN------------ <=0.5 S . URINE: [**2124-1-7**] 06:25PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.009 [**2124-1-7**] 06:25PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-150 Bilirub-SM Urobiln-NEG pH-5.0 Leuks-NEG [**2124-1-7**] 06:25PM URINE RBC-0 WBC-0-2 Bacteri-OCC Yeast-NONE Epi-0 [**2124-1-7**] 06:25PM URINE UCG-NEGATIVE [**2124-1-7**] 06:25PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG cocaine-NEG amphetm-NEG mthdone-NEG [**2124-1-11**] 09:53PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.002 [**2124-1-11**] 09:53PM URINE Blood-LG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG [**2124-1-11**] 09:53PM URINE RBC-0-2 WBC-0-2 Bacteri-RARE Yeast-NONE Epi-0-2 Brief Hospital Course: *** OUTSTANDING ISSUE: *** - please recheck urine analysis as outpatient given hematuria on UA as an inpatient . 41 year old female admitted to medical intensive care unit status post likely overdose of Tylenol PM at unknown time and initial level of > 300 and normal liver enzymes and intact synthetic function. Her physical exam was suggestive of a mixed overdose with Tylenol as well as anticholinergic effects from benadryl. She also demonstrated significant clonus and hyperreflexia which would not be expected from a Tylenol PM overdose and may represent the influence of additional medications. # Acetaminophen toxicity: Patient was sedated due to altered mental status and briefly required endotracheal intubation. CT head on [**1-7**] without acute process. Initial tylenol level was > 300 with normal liver enzymes and function. Toxicology consulted and N-acetylcysteine drip was started. Over the next 24 hours, tylenol level continued to decline with peak of transaminases < 100 and intact synthetic function. N-acetylcyseteine drip was continued until tylenol level was undetectable on the afternoon of [**2124-1-10**]. # Hyponatremia: Resolved at time of discharge. Likely from malnutrition (tea and toast diet) with poor salt intake due to alcoholic intake. Improved with resuscitation with sodium chloride. Thyroid and adrenal function intact. # Suicidal Attempt: Patient with suspected attempted overdose. Psychology was consulted, BEST team consulted for placement due to lack of insurance. Due to concern for her safety, she was sectioned 12 and ultimately transferred to a psychiatric facility. She was maintained on 1:1 observation during her time at [**Hospital1 18**]. # Alcohol Abuse: Patient with longstanding history of alcohol abuse. CIWA scale was started on [**2124-1-9**], discontinued on [**2124-1-10**] after persistently [**Doctor Last Name **] 0. # Metabolic acidosis: Likely secondary to hyperchloremic fluid resuscitation and ketoacidosis from malnutrition, bicarb improved to 27 on [**2124-1-11**]. # Positive blood culture: Positive on [**1-7**] for coag negative Staph, felt to be contaminant given lack of clinical findings. Blood cultures were repeated on [**1-10**] and were negative. Medications on Admission: None Discharge Medications: 1. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. potassium & sodium phosphates 280-160-250 mg Powder in Packet Sig: One (1) Powder in Packet PO DAILY (Daily). Discharge Disposition: Extended Care Facility: [**Hospital **] [**Hospital 1281**] Hospital Discharge Diagnosis: Acetaminophen overdose, depression Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. [**Known lastname **], You were admitted for taking too much Tylenol; you also needed help with your breathing and were intubated for a short time. Your liver has recovered from the Tylenol, but it is very important to take medications only as directed. You are being discharged to a psychiatric facility for further care. . Please make the following changes to your medications: - Started daily vitamins and electrolytes as listed separately. . It was a pleasure to meet you and participate in your care. Followup Instructions: Please call your Primary care doctor, Dr. [**Last Name (STitle) 35984**] at [**Telephone/Fax (1) 35985**] to make an appointment in [**12-19**] weeks. Name: [**Known lastname 6408**],[**Known firstname **] Unit No: [**Numeric Identifier 6409**] Admission Date: [**2124-1-7**] Discharge Date: [**2124-1-12**] Date of Birth: [**2082-8-31**] Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 6410**] Addendum: #. Hematuria -- Ms. [**Known lastname **] complained of hematuria after her foley catheter was removed. This was likely due to trauma from the catheter. A UA was checked, which showed moderate blood on dip and 1 RBC per high power field. She reported that her hematuria had resolved. However, a repeat UA was not obtained prior to discharge. This should be done as an outpatient to ensure resolution of her hematuria. Discharge Disposition: Extended Care Facility: [**Hospital 2057**] [**Hospital **] Hospital [**First Name11 (Name Pattern1) 2162**] [**Last Name (NamePattern4) 6411**] MD [**MD Number(2) 6412**] Completed by:[**2124-1-18**]

[ "276.1", "787.01", "E928.9", "E950.4", "518.81", "E950.0", "311", "293.0", "263.9", "965.4", "276.2", "599.70", "303.90", "963.0" ]

icd9cm

[ [ [] ] ]

[ "96.71" ]

icd9pcs

[ [ [] ] ]

11581, 11813

7130, 9374

320, 377

9916, 9916

3572, 7107

10606, 11558

3038, 3042

9429, 9743

9858, 9895

9400, 9406

10067, 10427

3057, 3553

10456, 10583

1680, 2127

264, 282

405, 1661

9931, 10043

2149, 2234

2250, 3022

51,017

194,728

35204

Discharge summary

report

Admission Date: [**2194-1-17**] Discharge Date: [**2194-1-31**] Date of Birth: [**2110-8-10**] Sex: M Service: NEUROSURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 78**] Chief Complaint: Subdural hematoma Major Surgical or Invasive Procedure: Left frontal and parietal burr holes for evacuation of subdural hematoma History of Present Illness: 83 yo M transferred from OSH with left subdural hematoma. Pt has history of 1 month of decline in mental status and increase in gait abnormalities. Since Saturday, pt has developed R facial droop per family. Pt has no history of anticoagulation. Pt does report a history of a fall. Pt confused whether or not he hit his head at the time. The pt's family was not present. Past Medical History: Macular degeneration Iron deficiency anemia HTN GI bleed Emphysema Social History: Pt lives alone. Family visits frequently. Family History: non-contributory Physical Exam: On Admission PHYSICAL EXAM: O: T: 99.1 BP: 146/71 HR: 92 R 16 O2Sats 100%RA Gen: pinpoint, comfortable, NAD. HEENT: Pupils: 2->1 mm, reactive, EOMI Lungs: CTA bilaterally. Cardiac: RRR. S1/S2. Abd: Soft, NT, BS+ Extrem: Warm and well-perfused. Neuro: Mental status: Awake and alert, cooperative with exam, normal affect. Pt unable to count backwards from 20. Pt unable to follow complex commands. Orientation: Oriented to person, place, and date. Language: Speech fluent with good comprehension and repetition. Naming intact. No dysarthria or paraphasic errors. Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light, to mm bilaterally. Visual fields are full to confrontation. III, IV, VI: Extraocular movements intact bilaterally without nystagmus. V, VII: Right facial droop, facial sensation intact and symmetric. VIII: Hearing intact to voice. IX, X: Palatal elevation symmetrical. [**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally. XII: Tongue midline without fasciculations. Motor: Normal bulk and tone bilaterally. Pt with upper extremity with 3 jerks. Strength decreased to [**3-16**] on RUE. + pronator drift Sensation: Intact to light touch, propioception, and pinprick bilaterally. Reflexes: B T Br Pa Ac Right 2+ --------- Left 2+ --------- Toes downgoing bilaterally Coordination: normal on finger-nose-finger Upon d/c Pt is neurologically intact. A&Ox3, follows commands, MAE, full strength. Incisions well healed. Pertinent Results: [**2194-1-17**] 04:54PM BLOOD WBC-10.3 RBC-4.04* Hgb-10.4* Hct-30.7* MCV-76* MCH-25.6* MCHC-33.7 RDW-20.9* Plt Ct-585* [**2194-1-17**] 04:54PM BLOOD PT-15.8* PTT-27.9 INR(PT)-1.4* [**2194-1-18**] 03:31AM BLOOD Glucose-110* UreaN-39* Creat-1.7* Na-140 K-4.5 Cl-107 HCO3-22 AnGap-16 [**2194-1-18**] 10:27AM BLOOD ALT-6 AST-16 AlkPhos-78 TotBili-0.3 [**2194-1-18**] 03:31AM BLOOD Calcium-8.2* Phos-3.2 Mg-2.4 [**2194-1-24**] 01:47AM BLOOD WBC-5.7 RBC-3.03* Hgb-7.7* Hct-23.0* MCV-76* MCH-25.5* MCHC-33.5 RDW-19.7* Plt Ct-386 [**2194-1-24**] 08:26AM BLOOD PT-14.3* PTT-36.6* INR(PT)-1.2* [**2194-1-24**] 01:47AM BLOOD Glucose-90 UreaN-21* Creat-1.2 Na-137 K-3.6 Cl-103 HCO3-28 AnGap-10 [**1-17**] Head CT: Large acute-on-chronic left subdural hematoma, with approximately 1.1 cm rightward shift of the septum pellucidum. Significant mass effect demonstrated with effacement of sulci involving the entire left cerebral hemisphere with ipsilateral uncal herniation. [**1-21**] Head CT: The large left subdural collection is essentially stable in size. While it is predominantly chronic, there is evidence acute blood products posteriorly, denser since the previous study, which may be due to interim rebleeding or clot retraction. [**1-29**] Head CT IMPRESSION: No acute intracranial hemorrhage. No significant change in large complex left subdural collection allowing for differences in patient positioning. Brief Hospital Course: Pt was admitted to the ICU with subdural hematoma and new onset R facial droop. As the pt was symptomatic from his chronic subdural hematoma, pt underwent left frontal and parietal burr holes for evacuation of subdural hematoma on [**2194-1-18**]. He tolerated the procedure well however had new-onset rapid a-fib and was admitted to the ICU. He was loaded with amiodarone and then converted to PO however he then had another episode of rapid a-fib and re-started on IV amiodarone. He was also placed on Lopressor at this time. He then transitioned to POs and was in Sinus Rhythm. He then developed an upper extremity DVT in his R arm and was anti coagulated with Heparin and subsequently found to have Pulmonary emboli and will need 3-6months of systemic anticoagualtion. He was however clinically benign. He had LENIs of his lower extremities and they were negative. He was transitioned to coumadin however INR was supratherapeautic to 5.4 and coumadin held. Today it is 3.2 and is currently receiving 2mg daily. He had stable head CTs and neurologically non-focal exam. He worked well with PT/OT and transferred to rehab. He will follow-up with Neurosurgery, Cardiology and his PCP. Medications on Admission: Prednisone 10 mg Vitamin E Cod liver oil Ocuvite B12 injections Prilosec 40 mg Lisinopril HCTZ 5/12.5 mg q day Rhinocort 2 sprays [**Hospital1 **] Advair 500/50 1 puff q day Discharge Medications: 1. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 2. Prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: [**12-13**] Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. 4. Acetaminophen-Codeine 300-30 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. 5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. Levetiracetam 500 mg Tablet Sig: Two (2) 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 Q24H (every 24 hours). 9. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day): Please hold for SBP<100 or HR<60. 10. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Warfarin 2 mg Tablet Sig: One (1) Tablet PO once a day for 1 doses. 12. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed for GI Upset. Discharge Disposition: Extended Care Facility: [**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**] Discharge Diagnosis: Left Subdural Hematoma RUE DVT Multiple Pulmonary Emboli Discharge Condition: Neurologically stable Discharge Instructions: DISCHARGE INSTRUCTIONS FOR CRANIOTOMY/HEAD INJURY ?????? Have a family member check your incision daily for signs of infection ?????? Take your pain medicine as prescribed ?????? Exercise should be limited to walking; no lifting, straining, excessive bending ?????? You may wash your hair only after your staples have been removed ?????? You may shower before this time with assistance and use of a shower cap ?????? Increase your intake of fluids and fiber as pain medicine (narcotics) can cause constipation ?????? Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, aspirin, Advil, Ibuprofen etc. ?????? You have been prescribed an anti-seizure medicine, called Keppra. Take it as prescribed until your follow up appointment. ?????? Clearance to drive and return to work will be addressed at your post-operative office visit CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING: ?????? New onset of tremors or seizures ?????? Any confusion or change in mental status ?????? Any numbness, tingling, weakness in your extremities ?????? Pain or headache that is continually increasing or not relieved by pain medication ?????? Any signs of infection at the wound site: redness, swelling, tenderness, drainage ?????? Fever greater than or equal to 101?????? F Followup Instructions: PLEASE CALL [**Telephone/Fax (1) **] TO SCHEDULE AN APPOINTMENT WITH DR.[**First Name (STitle) **] TO BE SEEN IN 4 WEEKS. YOU WILL NEED A CAT SCAN OF THE BRAIN WITHOUT CONTRAST You have a Follow up with cardiology on [**3-3**]@1020 with Dr. [**Last Name (STitle) 73**] in the [**Hospital Ward Name 23**] Building [**Location (un) **] in the Cardiac Center. If you have any question re your Appt. please call ([**Telephone/Fax (1) 3942**]. Prior to your appt please call [**Telephone/Fax (1) 10676**] to make sure that your demographic information is up to date. Please also f/u with your PCP prior to your appt. Because it is recommended that you have out patient Pulmonary function tests, Diffusing Capacity of the Lung for Carbon Monoxide (DLCO), optho exam/serial thyroid function tests. You also had hypodensities on Chest CT which should be evaluated. This time frame to be determined by your PCP and an out pt colonoscopy as well Completed by:[**2194-1-31**]

[ "427.31", "280.9", "401.1", "599.0", "790.92", "496", "415.11", "331.0", "E879.9", "458.9", "585.9", "403.90", "997.1", "432.1" ]

icd9cm

[ [ [] ] ]

[ "99.04", "38.91", "01.31" ]

icd9pcs

[ [ [] ] ]

6605, 6702

3979, 5167

335, 409

6803, 6827

2548, 3242

8194, 9164

982, 1000

5391, 6582

6723, 6782

5193, 5368

6851, 8171

1043, 1276

278, 297

437, 815

1606, 2529

3530, 3956

1291, 1590

837, 906

922, 966

58,940

129,487

40447

Discharge summary

report

Admission Date: [**2198-1-11**] Discharge Date: [**2198-1-16**] Date of Birth: [**2150-3-15**] Sex: M Service: MEDICINE Allergies: lisinopril Attending:[**First Name3 (LF) 2901**] Chief Complaint: STEMI Major Surgical or Invasive Procedure: [**2198-1-11**] - Left heart catheterization with drug eluting stent in left anterior descending artery [**2198-1-15**] - Left heart cath with drug eluting stent to an obtuse marginal and posterolateral branch History of Present Illness: Mr. [**Known lastname **] is a 47yo male with past medical history of htn, hld and family history of CABG in his brother at age 38, who was found to have STEMI and is s/p LHC with intervention. The patient reports that he had had about 2 weeks of chest pain, which had been right sided and associated with right arm tingling. There was associated nausea. He had no associated dyspnea. He reports that he did note chest pain in his sternum once when he was running. He is able to walk up flights of stairs, limited by knee pain not SOB. He does endorse a dry cough, which has started since he began lisinopril (now discontinued). . His PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **], got biomarkers and found his troponin to be elevated to 0.66. Dr. [**Last Name (STitle) **] called Mr. [**Known lastname **] to advise that he report to the [**Hospital1 18**] ED. En route to the ED, the patient did experiencing acute chest pain, he received nitro which brought the pain to a [**2-20**] but ongoing chest pressure. In the ED, his EKG revealed STE in V2-V4 and Q's in III, aVF and V2-V3. He was loaded with Plavix 600mg, heparin bolus and aspirin. In the cath lab, the patient was found to have: LAD with 99% mid occlusion; diffuse 60% mid to distal occlusions; LCX 90% major OM; RCA 80% posterolateral. He received drug eluting stent of mid LAD with 2.75 x 28 Promus. Diffuse moderately severe disease in mid to distal LAD was not dilated. He was hemodynamically stable throughout the procedure. . 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 dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. Past Medical History: 1. CARDIAC RISK FACTORS: -Diabetes, +Dyslipidemia, +Hypertension 2. CARDIAC HISTORY: - CABG: none - PERCUTANEOUS CORONARY INTERVENTIONS: [**2198-1-11**] LHC with DES in LAD. - PACING/ICD: none 3. OTHER PAST MEDICAL HISTORY: - cervical dystonic tremor - Appendectomy at age 44, hospitalized due to perioperative complications at [**Hospital1 2025**] x 1 month. Social History: Marital Status: single Lives with: son Employment: [**Hospital6 **] Hospital, public safety, 40 hrs/wk Smoking hx: never EtOH hx: 5 beers/week but last drink was in the summer. Illicit drug use: former MJ, no other ILL, no IVDU STDs: neg, last HIV test 2 yrs ago Hails from: [**Male First Name (un) 1056**] Family History: Mother: 68yo DM2 on insulin, HTN Father: not involved, but had an AMI 10 yrs ago at age 60 Siblings: 1 brother with CABG at age 38. 1 sister - pt unaware of her health status Children: 1 son, 18yo, healthy Physical Exam: ADMISSION PHYSICAL EXAM: VS: T=98.5 BP=147/100 HR=90 RR= 16 O2 sat= 98% RA GENERAL: NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink. No xanthalesma. 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. No abdominial bruits. EXTREMITIES: No c/c/e. No femoral bruits. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ DISCHARGE PHYSICAL EXAM: GENERAL: NAD. Oriented x 3. Mood, affect appropriate. HEENT: no LAD or JVD CARDIAC: RR, normal S1, S2. No murmur, rub or gallop. No thrills, lifts. No S3 or S4. LUNGS: Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. ABDOMEN: soft, NT/ND. No HSM or tenderness. EXTREMITIES: No cyanosis, clubbing or edema. No femoral bruits. Right groin with mild ecchymosis and tenderness, no hematoma. SKIN: No stasis dermatitis, ulcers. PULSES: Right: DP 2+ PT 2+ Left: DP 2+ PT 2+ Pertinent Results: ADMISSION LABS: [**2198-1-11**] 09:00PM BLOOD WBC-7.6 RBC-5.06 Hgb-15.1 Hct-45.4 MCV-90 MCH-29.9 MCHC-33.3 RDW-12.9 Plt Ct-307 [**2198-1-11**] 09:00PM BLOOD Neuts-56.4 Lymphs-35.8 Monos-4.9 Eos-2.2 Baso-0.6 [**2198-1-11**] 09:00PM BLOOD PT-11.3 PTT-33.1 INR(PT)-1.0 [**2198-1-11**] 09:00PM BLOOD Plt Ct-307 [**2198-1-11**] 10:43AM BLOOD UreaN-18 Creat-0.9 Na-139 K-5.1 Cl-102 HCO3-30 AnGap-12 [**2198-1-11**] 09:00PM BLOOD Calcium-10.1 Phos-4.1 PERTINENT LABS AND STUDIES [**2198-1-11**] 10:43AM BLOOD CK-MB-7 cTropnT-0.66* [**2198-1-11**] 09:00PM BLOOD cTropnT-0.69* [**2198-1-11**] 10:43AM BLOOD CK(CPK)-238 - ECG [**2198-1-11**]: Qs in inferior leads; ST elevations in anterior leads, rate 95. . - CXR [**2198-1-11**]: No acute cardiopulmonary process. . - C SPINE NON TRAUMA [**2198-1-11**]: No acute abnormality. . - CARDIAC CATH [**2198-1-11**]: LAD with 99% mid occlusion; diffuse 60% mid to distal occlusions; LCX 90% major OM; RCA 80% posterolateral. He received drug eluting stent of mid LAD with 2.75 x 28 Promus. Diffuse moderately severe disease in mid to distal LAD was not dilated. -CARDIAC CATH [**2198-1-15**]: (full report not available at time of discharge summary) - DES placed in OM branch of LCx as well as in posterolateral branch Discharge labs: [**2198-1-16**] 07:25AM BLOOD WBC-6.9 RBC-5.27 Hgb-15.9 Hct-45.8 MCV-87 MCH-30.2 MCHC-34.8 RDW-13.4 Plt Ct-261 [**2198-1-16**] 07:25AM BLOOD Glucose-107* UreaN-11 Creat-0.9 Na-135 K-4.3 Cl-100 HCO3-26 AnGap-13 [**2198-1-16**] 07:25AM BLOOD Calcium-9.6 Phos-5.0* Mg-2.1 Brief Hospital Course: 47M with a PMH significant for HTN, HLD, tremor who presented with STEMI s/p LHC and placement of proximal LAD (single drug eluting Promus stent) noted to have three vessel disease; with LCx and RHC involvement. S/P DES x2 on [**1-15**] to OM and RPL . # CAD: Patient presented to [**Hospital1 18**] for management of STEMI. The patient was found to have three vessel disease on initial left heart cath and had intervention on the LAD, which was thought to be the culprit lesion. He was started on ASA 325 mg PO daily and initially received Prasugrel 10mg PO daily s/p load of clopidogrel 600 mg PO x1 for dual antiplatlet therapy. Received eptifibatide at 2 mcg/kg/min x 18 hours after the initial cardiac cath. Immediately after the first LHC, he was noted to have ongoing ST segment elevations. Started on losartan for afterload reduction (has cough to ACEi) and to decrease cardiac work. Home propranolol was changed to metoprolol at discharge. Plan to continue Plavix for 1 year for DES, also started on high dose statin (atorvastatin 80mg). A transthoracic echo performed after the intial cardiac catheterization and showed evidence of apical akinesis with an EF of 35%. He was discharged on warfarin to prevent thrombus formation. As mentioned below, he will need a repeat TTE in 6 weeks to evaluate whether he would benefit from ICD placement. . # HTN: Patient with history of hypertension. At discharge, his home antihypertensive regimen will be changed to metoprolol and losartan as above. . CHRONIC CARE: # HLD: lipids elevated in [**2197-9-11**], with LDL of 163 and total cholesterol of 256. High dose atorvastatin at discharge because he is s/p STEMI. . # Cervical dystonic tremor: the patient is following with neurology and may proceed with Botulism injections to treat his tremor in the outpatient setting. His home propranolol (which he took for tremor) has been stopped and changed to metoprolol as above. . ISSUES OF TRANSITIONS IN CARE: CODE: full code (Confirmed) COMM: [**Name (NI) 2013**] [**Name (NI) 1071**], mother, [**Telephone/Fax (1) 88626**] PENDING STUDIES: ISSUES TO ADDRESS AT FOLLOW UP: - Will need repeat echocardiogram in 1.5 months to evaluate heart function, if the EF is depressed, patient should be referred to EP for ICD placement. Repeat echo may also be indicated in 3 months as well. - Will need INR followed as an outpatient as he has been discharged on Coumadin Medications on Admission: - propanolol 10mg TID (started [**1-10**], not yet started Rx) - aspirin 81mg daily - On [**1-10**], discontinued from lisopril 10mg PO daily and simvastatin 20mg daily Discharge Medications: 1. metoprolol succinate 100 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily). Disp:*30 Tablet Extended Release 24 hr(s)* Refills:*2* 2. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 3. losartan 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 4. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 5. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 6. warfarin 2 mg Tablet Sig: 2.5 Tablets PO once a day. Disp:*75 Tablet(s)* Refills:*2* 7. Outpatient Lab Work Please check INR, chem-7 and CBC on Friday [**1-19**] before your appt with Dr. [**Last Name (STitle) **] Discharge Disposition: Home Discharge Diagnosis: primary: ST elevation myocardial infarction, hypertension secondary: hyperlipidemia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [**Known lastname **], You were admitted because you were found to have a heart attack. Two cardiac catherizations were done to clear blockages in your heart arteries that caused the heart attack. You had some drug eluting stents placed to keep these arteries open. You have been started on aspirin and clopidogrel (PLavix) to prevent the stents from clotting off and causing another heart attack. You will need to take these medicines every day without fail, do not miss [**First Name (Titles) 691**] [**Last Name (Titles) 4319**] or stop taking aspirin and plavix unless Dr. [**Last Name (STitle) **] tells you it is OK. Your heart is weak after the heart attack and you will need to avoid salt in your diet and watch for signs of swelling or trouble breathing. Make sure to weigh yourself every day in the morning before breakfast. Call Dr. [**Last Name (STitle) **] if your weight increases more than 3 pounds in 1 day or 5 pounds in 3 days. You were started on coumadin because of your weak heart. You will need to take this every day and get your coumadin blood level checked frequently. [**Doctor First Name **] from Dr.[**Name (NI) 84011**] office will contact you about your coumadin dose. . Please note the following changes to your medications: 1. STOP taking lisinopril and propanolol 2. START taking clopidogrel (plavix) and aspirin every day to keep the stents open 3. START taking atorvastatin (Lipitor) every day to lower your cholesterol 4. START taking Metoprolol to lower your heart rate and help your heart recover from the heart attack. 5. START taking losartan to lower your blood pressure and help your heart recover from the heart attack. 6. START taking coumadin to prevent blood clots and a stroke. You will need to get your INR checked on Friday [**1-19**] at Dr. [**Name (NI) 88627**] office. You have a prescription to take to the office. You will need a repeat echocardiogram in 1.5months. Followup Instructions: Department: [**Hospital1 18**] [**Location (un) 2352**]- ADULT MED When: [**1-19**] at 9:20am Building: [**Location (un) 2355**] ([**Location (un) **], MA) [**Location (un) 551**] Campus: OFF CAMPUS Best Parking: Free Parking on Site ***Please get your INR checked BEFORE Dr.[**Name (NI) 13892**] appt. . Department: [**Hospital1 18**] [**Location (un) 2352**]- ADULT MED When: THURSDAY [**2198-2-1**] at 6:30 PM With: [**First Name11 (Name Pattern1) 1569**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 4012**], MD [**Telephone/Fax (1) 1144**] Building: [**Location (un) 2355**] ([**Location (un) **], MA) [**Location (un) 551**] Campus: OFF CAMPUS Best Parking: Free Parking on Site [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2908**] MD, [**MD Number(3) 2909**]

[ "410.01", "429.9", "272.4", "333.1", "414.01", "401.9" ]

icd9cm

[ [ [] ] ]

[ "00.41", "00.66", "36.07", "37.22", "00.45", "00.40", "88.56", "00.46", "99.20" ]

icd9pcs

[ [ [] ] ]

9863, 9869

6403, 8524

277, 488

9996, 9996

4832, 4832

12103, 12942

3263, 3470

9042, 9840

9890, 9975

8849, 9019

10147, 11384

6110, 6380

3510, 4283

2643, 2754

8535, 8823

11413, 12080

232, 239

516, 2535

4849, 6094

10011, 10123

2785, 2923

2557, 2623

2939, 3247

4308, 4813

22,865

141,506

3531+55482

Discharge summary

report+addendum

Admission Date: [**2103-2-6**] Discharge Date: [**2103-2-14**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2297**] Chief Complaint: hypotension, nausea, vomitting Major Surgical or Invasive Procedure: none. History of Present Illness: This is a [**Age over 90 **] yo male with HTN, CHF, CAD, advanced dementia, who initially presented on [**2-6**] with a 2 day hx of diarrhea, vomiting, and cough while at [**Hospital 100**] Rehab. Pt is non-verbal thus history per records. Multiple others wsere sick at [**Hospital 100**] rehab. Pt was noted to be hypotensive 80/60 at [**Hospital1 100**] and transferred to [**Hospital1 18**]. . In the [**Name (NI) **], pt was febrile to 101.8, had BP of 80/60, HR 110's, and RR 40 on arrival. His BP improved after 4L NS. He was found to have dirty UA, possible infiltrate on CXR, and was given vanc/levo/flagyl. . In the MICU he was given fluids and continued on above antibiotics. He did not require intubation or pressors(He is DNR/DNI). Of note he was also found to have a creatinine of 4.6. He had a Hct drop from 37.5 to 21.8, but then on recheck was 31. However does have guaiac + brown stool. Past Medical History: Anemia (baseline hct 33 in '[**00**]) CHF (unkwnon EF) CAD h/o MRSA UTI h/o DVT LLE (was on coumadin, stopped [**11-14**]) advanced dementia (per son, pt opens eyes but mostly non-verbal) RA CRI (creat 2.0 on [**10-15**]) Psoriasis Social History: Lives at [**Hospital 100**] Rehab. No smoking or EtOH. Family very involved with care. Family History: NC Physical Exam: Vitals: T 99 BP 118/77 HR 86 RR 20 O2sat 99% 5L NC Gen: non-verbal, but responsive to painful stimuli, mouth open HEENT: PERRL. OP dry. Neck: No visible JVD Cardio: distant heart sounds, RRR Resp: decreased BS throughout, scattered rhonchi Abd: soft, nt, nd, +BS Ext: no edema. Severe contractures of bilateral upper ext. Neuro: non-verbal. Respons to painful stimuli. Does not open eyes to commands. Pertinent Results: [**2103-2-6**] 06:09AM PLT SMR-NORMAL PLT COUNT-319 [**2103-2-6**] 06:09AM HYPOCHROM-NORMAL ANISOCYT-1+ POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL ELLIPTOCY-1+ [**2103-2-6**] 06:09AM WBC-16.6*# RBC-4.38* HGB-12.1* HCT-37.5* MCV-86 MCH-27.6 MCHC-32.3 RDW-14.4 [**2103-2-6**] 06:09AM ALBUMIN-3.1* CALCIUM-8.7 PHOSPHATE-4.3 MAGNESIUM-2.5 [**2103-2-6**] 06:09AM CK-MB-5 cTropnT-0.26* [**2103-2-6**] 06:09AM LIPASE-14 [**2103-2-6**] 06:09AM ALT(SGPT)-14 AST(SGOT)-23 LD(LDH)-297* CK(CPK)-428* ALK PHOS-84 AMYLASE-301* TOT BILI-0.3 [**2103-2-6**] 06:09AM estGFR-Using this [**2103-2-6**] 06:09AM GLUCOSE-152* UREA N-84* CREAT-4.4*# SODIUM-150* POTASSIUM-5.7* CHLORIDE-114* TOTAL CO2-18* ANION GAP-24* [**2103-2-6**] 06:19AM LACTATE-2.4* [**2103-2-6**] 06:30AM URINE RBC-[**5-20**]* WBC->50 BACTERIA-MANY YEAST-NONE EPI-0-2 [**2103-2-6**] 06:30AM URINE BLOOD-MOD NITRITE-NEG PROTEIN-500 GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-MOD [**2103-2-6**] 06:30AM URINE COLOR-Yellow APPEAR-Cloudy SP [**Last Name (un) 155**]-1.015 [**2103-2-6**] 07:00PM PLT COUNT-163 [**2103-2-6**] 07:00PM WBC-7.1# RBC-2.51*# HGB-7.0*# HCT-21.8*# MCV-87 MCH-28.0 MCHC-32.2 RDW-14.5 [**2103-2-6**] 07:00PM CK-MB-5 cTropnT-0.13* [**2103-2-6**] 07:00PM LIPASE-8 [**2103-2-6**] 07:00PM ALT(SGPT)-8 AST(SGOT)-15 CK(CPK)-259* ALK PHOS-44 AMYLASE-183* TOT BILI-0.2 [**2103-2-6**] 08:08PM LACTATE-1.6 [**2103-2-6**] 09:24PM FIBRINOGE-598* [**2103-2-6**] 09:24PM PLT SMR-NORMAL PLT COUNT-193 [**2103-2-6**] 09:24PM PLT SMR-NORMAL PLT COUNT-202 [**2103-2-6**] 09:24PM HYPOCHROM-1+ ANISOCYT-NORMAL POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL OVALOCYT-1+ ELLIPTOCY-1+ [**2103-2-6**] 09:24PM HYPOCHROM-1+ ANISOCYT-NORMAL POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL [**2103-2-6**] 09:24PM NEUTS-64 BANDS-25* LYMPHS-8* MONOS-1* EOS-0 BASOS-0 ATYPS-0 METAS-2* MYELOS-0 [**2103-2-6**] 09:24PM WBC-10.0 RBC-3.66*# HGB-10.5*# HCT-31.0*# MCV-85 MCH-28.7 MCHC-33.9 RDW-14.4 [**2103-2-6**] 09:24PM WBC-8.8 RBC-3.49*# HGB-9.8*# HCT-30.1*# MCV-86 MCH-28.2 MCHC-32.6 RDW-14.5 [**2103-2-6**] 09:24PM URINE OSMOLAL-438 [**2103-2-6**] 09:24PM ALT(SGPT)-12 AST(SGOT)-20 LD(LDH)-243 CK(CPK)-559* ALK PHOS-67 AMYLASE-240* TOT BILI-0.2 [**2103-2-6**] 09:24PM GLUCOSE-115* UREA N-92* CREAT-4.3*# SODIUM-152* POTASSIUM-5.1 CHLORIDE-119* TOTAL CO2-18* ANION GAP-20 . CXR: 1. Possible early left lower lung zone infiltrate. 2. Cardiomegaly. [**2103-2-8**] 03:00AM BLOOD WBC-5.9 RBC-3.04* Hgb-8.6* Hct-25.8* MCV-85 MCH-28.1 MCHC-33.1 RDW-14.5 Plt Ct-189 [**2103-2-6**] 09:24PM BLOOD Neuts-57 Bands-31* Lymphs-11* Monos-0 Eos-0 Baso-0 Atyps-0 Metas-1* Myelos-0 [**2103-2-8**] 03:00AM BLOOD Glucose-177* UreaN-96* Creat-4.6* Na-150* K-3.9 Cl-118* HCO3-19* AnGap-17 [**2103-2-7**] 02:24AM BLOOD ALT-13 AST-24 LD(LDH)-228 AlkPhos-64 Amylase-187* TotBili-0.2 [**2103-2-7**] 02:24AM BLOOD Lipase-11 [**2103-2-8**] 03:00AM BLOOD Calcium-7.5* Phos-3.2 Mg-2.1 [**2103-2-6**] 09:24PM BLOOD calTIBC-157* Hapto-328* Ferritn-351 TRF-121* Brief Hospital Course: This is a [**Age over 90 **] yo m with HTN, CHF, CAD, p/w N/V/D found to be septic. . 1) Sepsis: The patient was admitted with leukoctyosis, lactate elevation to 2.4 and fever. Initially there was question of PNA, thought to be aspiration given his h/o vomiting and the patient had a dirty urine with > 50 leukocytes. The patient was found to be profoundly volume depleted and was resuscitated with IVF. He was empirically started on Vanc/levo/flagyl for broad coverage, including MRSA given pt's history, aspiration pneumonia, and likely UTI. Legionella antigen was negative. Blood, sputum, and urine cultures were sent. After the aforementioned interventions, the patient's BP normalized and the patient quicklyl defervesced. After 48 hrs, blood and sputum cultures were negative but urine culture grew out coag positive staph aureus. Sensitivities are pending. Given the patient has not spiked in house, and has no other clinical signs of PNA, coverage for asp PNA was stopped. We will continue the vancomycin for possible MRSA in his urine. This should be continued for ten days or until sensitivities suggest otherwise. C.diff is also pending upon discharge. This will also need to be followed up and flagyl restarted if positive. . 2) conjunctivitis: The patient was noted to have erythemetous conjunctiva L>R and was started on erythromycin eye drops. This should be continued for a seven day course. . 3) Anemia: The patient has a normocytic anemia with a HCT today of 25.8. The patient was found to have guaiac + stools. However, the family does not with to pursue any diagnostic procedures and would like to minimize any interventions. Therefore, we did not work the anemia up any further. . 4) CAD/CHF: After aggressive fluid resuscitation the patient briefly experienced pulmonary edema and was put on a NRB with sats in the mid 90's. He was given lasix and was taken of the NRB mask and transitioned to 6L 02 via NC with SaO2 100%. The patient's aspirin was discontinued as his stool was found to be guaiac positive and his HCT was 25.8 with a baseline crit in high 20s low 30s. . 5) HTN: Initially the pt's Toprol and amlodapine were stopped given his hypotension. However, the patient was given 5mg Toprol IV prn for hypertension as he was unable to take PO medications and the family did not want an NGT placed. The amlodapine was not continued. The patient was discharged on no BP meds. However, metoprolol IV may be needed in the future for blood pressure control as the patient continues to recover from his infections. . 6) Elevated trop: The patient's CK's and Trops were elevated upon admission, but MBs were negative. EKG did not show evidence of ischemia. Therefore, the elevated trops were likely secondary to increased demand in the setting of renal failure and severe hypotension. . 7) Acute on chronic renal failure: The patient's most recent Cr prior to admission was 1.3 in [**2092**]. He was initially thought to be pre-renal in setting of sepsis with FENa<1%. However, his cr did not improve s/p aggressive hydration. Renal USN neg for hydronephrosis. Therefore, it was thought that the pt may be at a new baseline. . 8) Hypernatremia: The patient came in with elevated Na level which was attributed to a free water deficit in the setting of N/V and diarrhea and decreased PO intake. He had a 3.9L water deficit on admission. He was volume resuscitated with normal saline and then started on D5W at 150cc/hr for about 12 hrs. The family refused an NGT to deliver free water boluses. Therefore, the patient was continued on D5W with the rate increased to 200cc/hr. . Code: DNR/DNI Medications on Admission: Acetaminophen 325-650 mg PO/PR Q4-6H:PRN Levofloxacin 250 mg IV DAILY Albuterol 0.083% Neb Q6H:PRN MetRONIDAZOLE (FLagyl) 500 mg IV Q8H Or Artificial Tears PRN Protonix 40mg qday Erythromycin 0.5% Ophth Oint OD QID Heparin 5000 UNIT SC TID Vanco 1gm IV Q48hrs Ipratropium Bromide Neb Q6H Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 2. Dulcolax 5 mg Tablet, Delayed Release (E.C.) Sig: [**12-12**] Tablet, Delayed Release (E.C.)s PO once a day as needed for constipation. 3. CALCIUM 500+D 500-125 mg-unit Tablet Sig: One (1) Tablet PO three times a day. 4. topical creams please take the following creams as previously prescribed: Sebulex topical lac-hydrin topical [**Hospital1 **] prn 5. Senna 8.6 mg Capsule Sig: [**12-12**] Capsules PO at bedtime. 6. Albuterol Sulfate 0.083 % Solution Sig: One (1) neb Inhalation every four (4) hours as needed for shortness of breath or wheezing. 7. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb Inhalation Q6H (every 6 hours). 8. Erythromycin 5 mg/g Ointment Sig: Two (2) drops Ophthalmic QID (4 times a day) for 7 days. 9. Vancomycin 1,000 mg Recon Soln Sig: 1000 (1000) mg Intravenous Q48hr for 7 days. 10. 5% dextrose in water Sig: 200 ml/hour continuous: continue for goal sodium <143, may adjust rate prn. Discharge Disposition: Extended Care Facility: [**Hospital3 **] Center Discharge Diagnosis: UTI gastroenteritis conjunctivitis severe dehydration secondary to gastroenteritis Discharge Condition: Good. Discharge Instructions: Please return to the ER if you experience increasing fevers, difficulty breathing or any symptoms that concern you. . Please follow up on blood and stool cultures and sensitivities of urine culture results. Followup Instructions: Please follow up with your PCP upon discharge. Please have him follow up on all culture data. Name: [**Known lastname 2549**],[**Known firstname **] Unit No: [**Numeric Identifier 2550**] Admission Date: [**2103-2-6**] Discharge Date: [**2103-2-14**] Date of Birth: [**2011-4-11**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2551**] Addendum: the pt. was transferred from the ICU to the floor for further treatment of hypernatremia and PNA. Pt. was treated with free water repletion, his sodium improved somewhat with free water. We continued vancomycin, flagyl, and levaquin. His fever and WBC count improved. Speech and swallow eval deemed pt. to be an aspiration risk, however, the family wanted the patient fed for comfort reasons. They understood and accepted the risks of aspiration. With feeding, the pt. did seem to aspirate and had copious secretions and cough. on [**2103-2-13**] he again became febrile. A subsequent CXR showed increased infiltrates in the LLL, probably [**1-12**] to aspiration. After discussions between the attending and family, it was determined that goals of care for the patient would be made comfort measures. The pt. was transferred back to [**Hospital **] rehab for continued care. The current levaquin treatment was to be continued per the families wishes. Discharge Disposition: Extended Care Facility: [**Hospital3 **] Center [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2552**] MD [**MD Number(2) 2553**] Completed by:[**2103-2-14**]

[ "038.9", "995.92", "584.9", "294.8", "410.71", "403.90", "372.30", "558.9", "707.03", "428.0", "276.0", "276.51", "585.9", "599.0", "507.0", "714.0", "428.23", "280.9" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

12067, 12274

5176, 8790

292, 299

10347, 10355

2050, 5153

10610, 12044

1609, 1613

9129, 10147

10241, 10326

8816, 9106

10379, 10587

1628, 2031

222, 254

327, 1232

1254, 1489

1505, 1593

30,518

110,185

31135

Discharge summary

report

Admission Date: [**2105-9-20**] Discharge Date: [**2105-10-12**] Date of Birth: [**2079-9-22**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2817**] Chief Complaint: Admit to MICU for Resp distress, Dyspnea and HCT of 11 Major Surgical or Invasive Procedure: 1)Intubation ([**9-20**]) 2)Right IJ central line (placed [**9-20**], removed [**9-21**] for HD catheter placement) 3)Double-lumen hemodialysis catheter (placed [**9-20**]) History of Present Illness: Mr. [**Known lastname **] is a 25yo male who presented with ARF and HCT 11 from OSH; pt has baseline muscular dystrophy and renal disease of unclear etiology, non-hemorrhagic anemia in [**2-/2105**] (s/p transfusion of 4 units pRBC) with poor follow-up. For the past week, the patient's per oral intake decreased secondary to new dysphagia, fatigue increased, and pt began gagging w/ nausea and emesis. The patient has chronic watery nonbloody diarrhea. Notably he had worsening dyspnea today. He lives with an aide who stopped his medications a week ago (toprol, paxil, norvasc) because they "make his stomach sick." The patient was brought to OSH in respiratory distress, at [**Location (un) **], he was found to have HCT 11, creatinine 12.1, HCO3 6. His ABG 7.03/ 13/157. He was intubated for severe respiratory distress, his bicarbonate stabilized, and transferred to [**Hospital1 18**] via [**Location (un) 7622**] for further workup and care, including a for presumed GI bleed. In ED, nasogastric lavage was negative and stool was guaiac negative X1, slightly positive the second time. CT of the abdomen and chest radiograph were unrevealing. He was also thrombocytopenic on admission. Renal was consulted in ED, bicarbonate deficit was 400 mEq and he received 150 mEq in ED. Renal recs ([**Telephone/Fax (1) 73499**]): monitor potassium during bicarbonate infusion, check lytes q2h during bicarb infusion, and replete with 20 mEq potassium. [**4-19**] g CaGluc was provided for transfusions. Renal U/S and spot urine prot/cr ratio were performed. When he was admitted to the ICU at [**Hospital1 18**] he had a Hgb of 5.1, WBC of 6.8 (83% neutrophils, no bands), Plt of 90, BUN/Cr of 202/12.6, bicarb of 6, glucose of 160, and anion gap of 37. Upon arrival at the MICU, the patient was given 3 amps bicarbonate in 1L D5W between units of blood. The patient was hyperventilated to blow off CO2. Of note, the patient had an admission beginning on [**2105-2-16**] at an outside hospital for a very similar clinical picture: metabolic acidosis, acute renal failure, and anemia. On admission at that time, his hemoglobin and hematocrit were 7.5 and 22. He received 2 units of PRBCs which increased his counts to 10.5/31.7 on [**2105-2-23**]. He did not receive close follow-up in the interval to the present day. Past Medical History: 1)Facioscapulohumeral dystrophy, diagnosed at age 5, (baseline in wheelchair) 2)Admission to [**Location (un) **] in [**2-/2105**] for ARF and metabolic acidosis 3)Hypertension 4)Chronic kidney disease, ?IgA nephropathy (hx of kidney bx, results unknown) 5)History of proteinuria 6)Chronic diarrhea (work-up in [**2-/2105**] unrevealing, results of endoscopic biopsies unknown at this time) 7)Anemia Social History: Single. No tobacco, no ETOH, no drugs. Family History: -Mother, and both siblings have facioscapulohumeral dystrophy (autosomal dominant inheritance) -No known history of cancer -No known history of bleeding or clotting disorders Physical Exam: VITALS: Temp 93, BP 186/104, HR 86, RR 28 GENERAL: obese male fatigued/malaised, hypothermic HEENT: Head normotraumatic, acephalicPEERLA, pale conjunctiva, nonedematous sclera, endotracheal tube in place; teeth and gums WNL, moist MM. CARDIOVASCULAR: RRR, no MRG RESPIRATORY: lung clear to ausculation bilaterally. Ventilated. ABDOMEN: absent bowel sounds, soft to palpation SKIN: cold periphery, warm core skin, nonmottled EXTREMITIES: 1+ peripheral edema, absent cyanosis, absent clubbing, MUSCULOSKELETAL: unable to assess secondary to patient's altered mental status NEUROLOGICAL: Unresponsive. No spontaneous movement. Sedated. Pertinent Results: Laboratory results: [**2105-9-20**] 07:40PM URINE AMORPH-FEW [**2105-9-20**] 07:40PM URINE RBC-0-2 WBC-[**7-26**]* BACTERIA-FEW YEAST-NONE EPI-<1 [**2105-9-20**] 07:40PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-500 GLUCOSE-100 KETONE-50 BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-TR [**2105-9-20**] 07:40PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.014 [**2105-9-20**] 07:40PM FIBRINOGE-455* D-DIMER-1522* [**2105-9-20**] 07:40PM PT-14.2* PTT-32.5 INR(PT)-1.3* [**2105-9-20**] 07:40PM PLT SMR-LOW PLT COUNT-90* [**2105-9-20**] 07:40PM HYPOCHROM-1+ ANISOCYT-1+ POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-1+ POLYCHROM-NORMAL SPHEROCYT-OCCASIONAL SCHISTOCY-OCCASIONAL BURR-OCCASIONAL FRAGMENT-OCCASIONAL [**2105-9-20**] 07:40PM NEUTS-82.3* BANDS-0 LYMPHS-12.4* MONOS-2.8 EOS-2.4 BASOS-0.1 [**2105-9-20**] 07:40PM WBC-6.8 RBC-1.73* HGB-5.1* HCT-14.6* MCV-84 MCH-29.3 MCHC-34.7 RDW-17.3* [**2105-9-20**] 07:40PM ALBUMIN-3.2* CALCIUM-7.4* MAGNESIUM-2.6 [**2105-9-20**] 07:40PM CK-MB-51* MB INDX-12.0* [**2105-9-20**] 07:40PM LIPASE-114* [**2105-9-20**] 07:40PM ALT(SGPT)-15 AST(SGOT)-10 CK(CPK)-425* ALK PHOS-80 [**2105-9-20**] 07:40PM LD(LDH)-347* TOT BILI-0.2 [**2105-9-20**] 07:40PM estGFR-Using this [**2105-9-20**] 07:40PM GLUCOSE-160* UREA N-202* CREAT-12.6* SODIUM-143 POTASSIUM-4.7 CHLORIDE-105 TOTAL CO2-6* ANION GAP-37* [**2105-9-20**] 08:20PM LACTATE-0.7 [**2105-9-20**] 08:38PM freeCa-1.0* [**2105-9-20**] 08:38PM HGB-5.1* calcHCT-15 O2 SAT-97 [**2105-9-20**] 08:38PM GLUCOSE-145* LACTATE-1.0 NA+-140 K+-4.7 CL--115* [**2105-9-20**] 08:38PM TYPE-ART RATES-/24 TIDAL VOL-500 O2-100 PO2-524* PCO2-18* PH-7.13* TOTAL CO2-6* BASE XS--21 AADO2-188 REQ O2-39 INTUBATED-INTUBATED VENT-CONTROLLED [**2105-9-20**] 11:39PM PT-13.6* PTT-31.9 INR(PT)-1.2* [**2105-9-20**] 07:40PM LIPASE-114* [**2105-9-20**] 07:40PM ALT(SGPT)-15 AST(SGOT)-10 CK(CPK)-425* ALK PHOS-80 [**2105-9-20**] 07:40PM LD(LDH)-347* TOT BILI-0.2 [**2105-9-20**] 07:40PM estGFR-Using this [**2105-9-20**] 07:40PM GLUCOSE-160* UREA N-202* CREAT-12.6* SODIUM-143 POTASSIUM-4.7 CHLORIDE-105 TOTAL CO2-6* ANION GAP-37* [**2105-9-20**] 08:20PM LACTATE-0.7 [**2105-9-20**] 08:38PM freeCa-1.0* [**2105-9-20**] 08:38PM HGB-5.1* calcHCT-15 O2 SAT-97 [**2105-9-20**] 08:38PM GLUCOSE-145* LACTATE-1.0 NA+-140 K+-4.7 CL--115* [**2105-9-20**] 08:38PM TYPE-ART RATES-/24 TIDAL VOL-500 O2-100 PO2-524* PCO2-18* PH-7.13* TOTAL CO2-6* BASE XS--21 AADO2-188 REQ O2-39 INTUBATED-INTUBATED VENT-CONTROLLED [**2105-9-20**] 11:39PM OSMOLAL-369* [**2105-9-20**] 11:39PM CALCIUM-7.2* PHOSPHATE-13.3* MAGNESIUM-2.4 [**2105-9-20**] 11:39PM LIPASE-107* [**2105-9-20**] 11:39PM CK(CPK)-375* AMYLASE-56 [**2105-9-20**] 11:39PM GLUCOSE-271* UREA N-186* CREAT-12.1* SODIUM-144 POTASSIUM-4.1 CHLORIDE-104 TOTAL CO2-8* ANION GAP-36* [**2105-9-20**] 11:40PM URINE HOURS-RANDOM UREA N-340 CREAT-28 SODIUM-76 TOTAL CO2-<5 MICROBIOLOGY: 8/5 BLOOD CULTURES x2: negative [**9-23**] AND [**9-25**] C. DIFFICLE EIA: negative [**9-24**] SPUTUM GRAM STAIN AND CULTURES: negative [**9-26**] AND [**9-27**] BLOOD CULTURES x4: pending U/A: (+) protein, (+) ketones Relevant Imaging: [**2105-9-20**] CT ABDOMEN AND PELVIS WITHOUT INTRAVENOUS CONTRAST: CT ABDOMEN WITHOUT INTRAVENOUS CONTRAST: 1. Limited study due to lack of intravenous or oral contrast. No radiographic findings to explain the patient's drop in hematocrit. No evidence for intraperitoneal hematoma. 2. Atrophic kidneys and trace ascites. 3. Marked lumbar scoliosis. 4. Nodular opacities at the lung bases may represent evolving infectious etiology. Recommend follow up imaging to ensure resolution after appropriate treatment. [**2105-9-20**] EKG: Sinus tachycardia. Cannot rule out old anterolateral myocardial infarction. Modest lateral ST-T wave changes which are non-specific. No previous tracing available for comparison. Intervals Axes Rate PR QRS QT/QTc P QRS T 102 150 96 370/428.85 48 -9 79 [**2105-9-21**]: NON-CONTRAST CT CHEST: Multiple ground glass foci and worsening bibasilar consolidation all worrisome for an infectious process. 2. Small pericardial and bilateral pleural effusions. 3. Heterogeneous-appearing thyroid with surrounding fluid density incompletely imaged. Correlate soft tissue edema clinically with symtpoms of infection versus fluid overload. The thyroid gland could be further evaluated with ultrasound as clinically warranted. [**2105-9-22**] CHEST XR: New right upper lobe collapse. 2. New mid left lung airspace opacity that could represent pneumonia. 3. New mild-to-moderate left pleural effusion. [**2105-9-22**] ECHOCARDIOGRAPHY: EF>55%. Mild symmetric left ventricular hypertrophy with preserved overall left ventricular systolic function (cannot exclude subtle focal regional dysfunction given subooptimal image quality). Small circumferential pericardial effusion without echocardiographic evidence of tamponade. [**2105-9-26**] CT HEAD WITHOUT CONTRAST: No intracranial hemorrhage, mass effect, or major vascular territorial infarction. MR is more sensitive for the evaluation of the brain ischemia in patients with seizures. Small amount of fluid in the sphenoid sinus. [**2105-9-28**] ELECTROENCEPHALOGRAM: This telemetry captured no pushbutton activations. Routine sampling and spike and seizure detection programs demonstrated a normal background rhythm during wakefulness with no focal, lateralized, or epileptiform features. There were no electrographic seizures recorded. [**9-30**] CHEST xray: No new infiltrates or CHF. Improving left basal densities. Gas distended bowel. [**2105-9-29**] ABDOMINAL XR, SUPINE ONE VIEW: Moderately dilated loops of small and large bowel, which is suggestive of an ileus. However, a more centered film including erect views may provide better evaluation for obstruction and the presence of free air. Brief Hospital Course: Mr. [**Known lastname **] is a 26yo male with fascioscapulohumeral muscular dystropy and renal failure secondary to end-stage IgA nephropathy, who presented with respiratory failure, profound anemia, and profound acidosis, now s/p tracheostomy and PEG. 1)End stage IgA nephropathy: Acute on chronic renal failure secondary to IgA nephropathy, likely complicated by hypertension. Of note, no renal biopsy done here; IgA diagnosis per renal team's communication with Mr. [**Known lastname 4675**] primary nephrologist. Full renal failure workup on presentation included: urine sediment analysis: granular casts, multiple red blood cells. Burr cells seen on peripheral smear c/w renal failure and uremia (BUN 186). Negative UDS. Normal urine lytes, except protein/creatinine ratio 24.6. Renal u/s in ED ruled out obstruction. BUN:Creatinine ratio <20 but patient with chronic diarrhea, therefore prerenal azotemia could contribute to renal failure. It was felt that most likely intrarenal pathology underlied the patient's current renal failure, as explained by prior diagnosis of IgA nephropathy. [**Hospital1 18**] renal team consulted and followed patient throughout stay. Patient's electrolyte and consequent clinical status much improved on HD and patient was maintained on a Tuesday, Thursday, Saturday HD schedule. PTH (1077 pg/mL) is increased which is consistent with renal osteodystrophy. Please continue cinacalcet as an outpatient to prevent further osteodystrophy. Patient will likely need vitamin D supplementation in future. Vitamin D deficient: 25-OH, total 7 NG/ML, D3 7 NG/ML, D2 <4 NG/ML. Continue HD on T Th Sa HD schedule. Next HD on Tuesday, will likely be at rehabiliation facility. Of note, renal used 30 bicarbonate (vs. 25) due to alkalemia (ABG 7.51/35/116), with improved blood gas s/p HD (7.45/39/179). Also, last weight prior to HD was 96.9 kg on [**2105-10-10**]. 2)Anemia: Profound anemia at presentation but much improved with epogen begun with HD. Multi-factorial and largely related to the anemia of chronic renal failure. At [**Hospital1 18**], he received 4 units of PRBCs on [**8-5**] which increased his HCT from 14.6 to 23.6; his HCT was 11 at his initial presentation on [**9-20**] at [**Hospital3 7569**]. Originally, differential diagnosis included: GI bleed vs. occult bleed vs. anemia of chronic disease. Trace guiac. Negative NGT lavage in ED. CT abdomen negative for RP bleed or pooled blood. Peripheral smear also significant for hypochromic, microcytic anemia . MCV=83 c/w normochromic anemia of chronic disease or mixed anemia (RDW elevated 16.9). No evidence of acute bleed on CT, rectal exam, or hemodynamically. Hematology was consulted to evaluate the patient for TTP-HUS in the setting of anemia and thrombocytopenia. Patient's peripheral blood smear showed no evidence of intravascular hemolysis, as only rare schistocytes and no bite cells were seen. Hematology thus felt it was very unlikely that patient has TTP-HUS. Additionally, the smear shows no evidence of microangiopathic pathology such as DIC. Furthermore, B12 and folate normals are normal. Iron studies do not show deficiency, but reflect chronic inflammatory state. The multifactoral causes of his anemia include: bilateral atrophic kidneys on imaging which do not appropriately secrete epogen. Fascioscapulohumeral dystrophy, which along with his chronic kidney disease, may also have contributed to an anemia of chronic inflammation/disease. His reticulocyte count indicated that his marrow is not producing an appropriate reactive reticulocytosis, likely reflecting some marrow suppression secondary to chronic inflammation. Workup for other chronic diseases included: negative HBV, HCV, HIV, UPEP, SPEP. Since [**9-29**], hematocrits have peaked at 34.5-->26.1 [**2105-10-7**])-->23 yesterday ([**2105-10-8**])-->24.4 ([**2105-10-11**]). He will need close follow-up as an outpatient and serial hematocrits to be monitored at rehabilitation; of note, transfusion threshold at [**Hospital1 18**] was HCT <21. Continue Epogen at 3000 units 3X/week at HD, increasing dose of epogen with HD as needed; renal recommendations include pRBCs with HD as well. 3)Respiratory distress with hypoxia and hypercarbia: Pneumonia on CXR. Repeat CT chest on [**9-21**] showed worsening bibasilar consolidation and multiple ground glass foci worrisome for an infectious process. Sputum cultures with 3+ GPC in pairs in clusters on sputum gram stain yesterday. Labile nature of hypoxia not consistent with pulmonary edema but respiratory status improved with fluid removal by HD. Patient was more consistently hypercarbic vs. hypoxic. Extubation goal achieved. Treated for 13 days with antibiotics for empiric PNA. Treatment included 6 days azithromycin/ceftriaxone; 4 days levofloxacin; 3 days vancomycin, cefepime, flagyl. The patient developed notably poor lung volumes secondary to ileus causing abdominal distension. Ileus was thought to be due to muscular dystrophy and ICU myopathy. Pt also with poor cough reflex which has caused intermittent mucous plugging with acute oxygen desaturations and partial lung collapses. Pt desaturated and became apneic with hypotension and was intubated ([**10-4**]) secondary to unresolving respiratory distress. The patient was intubated for apnea in setting of hypotension. The patient's respiratory muscles were thought to be severely deconditioned and the patient also had increased secretions. A percutaneous tracheostomy was placed by interventional pulmonology on [**2105-10-7**] to assist with secretion suctioning. Of note, metabolic alkalosis was thought to contribute to apnea. Renal adjusted bicarbonate in dialysate but recommended we consider further workup. Of note, pH normalized s/p HD with adjusted bicarb. At rehabilitation, continue to wean patient on pressure support ventilation. Awaiting speech consult for PMV. Continue Ipratropium nebulizers. Weaned midazalam and fentanyl drips. Bolus fentanyl as needed and continue fentanyl patch at 50 mg/hour. Passy muir valve placed by speech. Patient should be continued to be followed by speech at the rehab facility. 4)L eye injection: Likely conjunctivitis. Continue erythromycin drops to L eye planned course to be discontinued on [**10-13**]. 5)Hypertension: Blood pressures better controlled on current regimen, but the patient was in esmolol drip for a short time. Hypertension partly related to worsening renal failure as well as [**Name8 (MD) 73500**] MD related to hypertension. Upon discharge the patient's regimen included the following medications per PEG: Metoprolol 75 mg PO/NG QID and Amlodipine 10 mg PO/NG daily. HTN covered with metoprolol 5 mg IV if needed between metoprolol dosages. 6)Depression/anxiety: Patient has stated multiple times overnight "let me die", denies suicidal ideation, tearful, scared due to his situation. Patient was on Paxil as outpatient. Psychiatry service consulted. Olanzapine given PRN for agitation, max dose of 30mg/24hrs; now 5 mg q HD only. Once mental status returns fully to baseline, consider reinitiation of Zoloft for depression. Pt will require outpt psychiatric follow up and likely would benefit from partial hospital program/day program after done with rehab. [**Doctor Last Name **] Huppuch, the psychiatry case manager at [**Hospital3 **] will be in contact with the rehab facility regarding outpatient follow-up. 7)Mental status changes: Patient s/p seizure-like activity vs. agitation in setting of agitation preceded by psychoses (deity delusions). Pt stated he is god. EEG, CT head negative for seizure focus. Ammonia level 20. Discontinued flagyl and avoiding quinolones and sertraline as it lowers seizure threshold and C. dificle negative X2. Also, the patient has been waxing and [**Doctor Last Name 688**] and was yelling throughout the night. Neuro and psych consulted; psych believes patient is delirious. Delirium improved prior to intubation but was difficult to assess s/p reintubation on sedation. Reassessment of mental status upon discharge as weaning sedation (including a benzodiazepene) reveals baseline delirium. Olanzapine PRN for agitation/psychoses as above. Appears to be at baseline at time of discharge. 8)Thrombocytopenia (resolved)- Sequestration versus consumption. DIC panel: D-dimer 1522, fibrinogen 455, PT 14.2, INR 1.3. Haptoglobin Pending. Not likely DIC as patient not oozing from IV sites, mucous membranes, will continue to monitor thrombocytopenia closely. Even though platelets are low, Hematology felt they were they are relatively stable at 75-90 and fibrin degradation products are within normal limits. Consumptive platelet process could not be ruled out but there was no evidence of splenomegaly on exam, and peripheral blood smear does not have cell types indicative of hypersplenism. During hospital stay platelets slowly trended upward and upon discharge were within normal limits. 9)Acute acid base disorder (resolved)- At presentation, the patient p/w anion gap metabolic acidosis (AG approx. 32). He has chronic diarrhea and may have had a superimposed non-AG metabolic acidosis as well though delta, delta ratio approx. 1 and did not suggest this. Anion gap metabolic acidosis was likely secondary to profound uremia (BUN 202). In addition the patient compensated via respiratory alkalosis at presentation, with RR 32 at presentation; the patient's respiratory failure was likely related to tachypnea in setting of acid-base disorder. Calculated osmolar gap 7 (Osm measured 369, calculated 363) inconsistent with ingestions or other etiologies of metabolic acidosis. Bicarbonate infusion was given. Hyperventilation was begun with a ventilator (Goal pH>7.25). Until the patient's acid-base status stabilized, the lytes were followed serially and ABGs q 2 hours to adjust respiration on ventilator and/or bicarbonate infusion. The patient was resuscitated and the acute acid base imbalance resolved with the above interventions. 10)FEN: PEG tube placed prior to discharge. Tolerating tube feeds appropriately. Continue Nutren via PEG tube. Na stable at 138 today with free water decreased from 200 to 50 q6 hr. 11)Prophylaxis: Continue heparin SQ, PPI. 12)Full code. Medications on Admission: Paxil Norvasc Toprol Discharge Medications: 1. Zyprexa 2.5 mg Tablet Oral 2. Acetaminophen 160 mg/5 mL Solution Sig: Six [**Age over 90 1230**]y (650) milligrams PO Q6H (every 6 hours) as needed. 3. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 5. Senna 8.8 mg/5 mL Syrup Sig: One (1) Tablet PO BID (2 times a day). 6. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Six (6) Puff Inhalation Q4-6H (every 4 to 6 hours) as needed. 7. Fentanyl Citrate 25-100 mcg IV Q2H:PRN 8. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO QID (4 times a day). 9. Sodium Chloride 0.9% Flush 3 ml IV DAILY:PRN Peripheral IV - Inspect site every shift 10. Erythromycin 5 mg/g Ointment Sig: 0.5 inch Ophthalmic QID (4 times a day). 11. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000) units units Injection TID (3 times a day). 12. Artificial Tear with Lanolin 0.1-0.1 % Ointment Sig: One (1) Appl Ophthalmic TID (3 times a day). 13. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 14. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 15. Fentanyl 50 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr Transdermal Q72H (every 72 hours). 16. Albuterol 90 mcg/Actuation Aerosol Sig: Six (6) Puff Inhalation Q6H (every 6 hours) as needed. 17. Olanzapine 5 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO QHS (once a day (at bedtime)). 18. Docusate Sodium 50 mg/5 mL Liquid Sig: One Hundred (100) milligrams PO BID (2 times a day). Discharge Disposition: Extended Care Facility: [**Hospital6 1293**] - [**Location (un) 1294**] Discharge Diagnosis: Primary diagnoses: 1)Renal failure 2)Respiratory failure 3)metabolic acidosis 4)Anemia 5)Mental status changes 6)Hypertension Secondary diagnoses: 1. Fascioscapulohumeral muscular dystrophy Discharge Condition: Stable Discharge Instructions: 1)You were admitted to the intensive care unit with renal failure. You were placed on hemodialysis and subsequently improved. During your stay, a chest x-ray was concerning for pneumonia and you were treated with antibiotics. 2)Please take all medications as listed in your discharge instructions. 3)You were started on eye drops for an eye infection. You should stop using these drops on [**2105-10-13**]. 4)Please scheduled follow-up with your primary care physician after being discharged from the hospital. 5)If you experience any fevers, chills, chest pain, shortness of breath, fevers, chills, or any other concerning symptoms please return to the emergency department. Followup Instructions: Please follow up with your outpatient nephrologist and primary care doctor within several days of discharge from rehabilitation.

[ "583.9", "518.81", "276.2", "300.4", "403.91", "359.1", "585.6", "560.1", "372.30", "287.5", "276.51", "584.9", "285.21", "486" ]

icd9cm

[ [ [] ] ]

[ "38.95", "43.11", "39.95", "38.93", "96.71", "99.15", "99.04", "96.6", "31.1", "33.22", "96.04" ]

icd9pcs

[ [ [] ] ]

22059, 22133

10159, 20439

371, 546

22368, 22377

4246, 7414

23107, 23239

3397, 3574

20510, 22036

22154, 22281

20465, 20487

22401, 23084

3589, 4227

22302, 22347

277, 333

7432, 10136

574, 2902

2924, 3325

3341, 3381