ChanBeDu/relevant_section_length · Datasets at Hugging Face

40,189

125,646

42918

Discharge summary

report

Admission Date: [**2173-9-21**] Discharge Date: [**2173-9-24**] Date of Birth: [**2104-8-24**] Sex: F Service: SURGERY Allergies: Flagyl / Keflex / Codeine Attending:[**First Name3 (LF) 301**] Chief Complaint: 69 year old female admitted for weight reduction surgery. Major Surgical or Invasive Procedure: Status Post Lap nissen fundoplication with hiatal hernia repair complicated by external jugular infiltration, neck swelling and hypotension. History of Present Illness: The patient is a 69-year-old woman referred from the GI service with severe reflux symptoms. She has been treated with maximum medical therapy and on endoscopy was noted to have a gaping lower esophageal sphincter and hiatal hernia. She was referred for surgical options and was highly motivated for laparoscopic repair if possible. Past Medical History: Gerd, hyperlipidemia, sinusitis, allergies and anxiety. Social History: She is a nondrinker, nonsmoker. She drinks occasional alcohol. Family History: No significant past family medical history. Physical Exam: Physical Exam: In general, she is alert and oriented x3 with normal mood and affect. Normal judgment and insight. Normal memory. Eyes/vision. Pupils are equal, round and reactive to light and accommodation. Conjunctivae are pink, Sclerae anicteric. Ears, nose, mouth, and throat: Normal hearing. She has a class 3 airway. Tongue is midline. Mucosa is pink. Neck supple. No masses. Respiratory: Breath sounds clear to auscultation. Cardiovascular: Regular rate and rhythm, S1 and S2 are normal. Abdomen: Soft, nontender, nondistended, well-healed incisions. Extremities: No clubbing, cyanosis, or edema. Neurologically, cranial nerves II-XII are grossly intact. Musculoskeletal: Full range of motion in the upper extremities and lower extremities, head, neck, spine, ribs, and pelvis, normal gait. Skin: No rashes are identified. Pertinent Results: [**2173-9-21**] 01:15PM BLOOD WBC-13.5*# RBC-4.24 Hgb-13.0 Hct-38.7 MCV-91 MCH-30.7 MCHC-33.6 RDW-13.1 Plt Ct-190 [**2173-9-24**] 05:50AM BLOOD WBC-6.4# RBC-3.92* Hgb-12.0 Hct-35.5* MCV-91 MCH-30.7 MCHC-33.9 RDW-13.0 Plt Ct-190 [**2173-9-22**] 03:13AM BLOOD Glucose-122* UreaN-10 Creat-0.6 Na-141 K-3.7 Cl-109* HCO3-23 AnGap-13 [**2173-9-24**] 05:50AM BLOOD Glucose-85 UreaN-16 Creat-0.6 Na-143 K-3.4 Cl-108 HCO3-27 AnGap-11 [**2173-9-21**] 03:56PM BLOOD Type-ART pO2-101 pCO2-48* pH-7.32* calTCO2-26 Base XS--1 [**2173-9-22**] 12:32AM BLOOD Type-ART Rates-12/ PEEP-5 FiO2-50 pO2-89 pCO2-45 pH-7.40 calTCO2-29 Base XS-1 Intubat-INTUBATED [**2173-9-21**] 03:56PM BLOOD freeCa-1.09* [**2173-9-22**] 12:32AM BLOOD freeCa-1.16 [**2173-9-22**] Upper GI study No evidence of leak or obstruction. Brief Hospital Course: Patient underwent a Lap nissen fundoplication with hiatal hernia repair complicated by external jugular infiltration with hypotension. She was transferred to the surgical intensive care unit for 12 hours of intubation and close monitoring. She was extubated on postoperative day one and transferred to floor. She had an upper gi study which confirmed no leak or extravasation. She was started on clears and advanced to mechanical soft diet. Pain medication was given and adjusted as she is sensitive to narcotics. She was encouraged to use her incentive spiromenter and deep breathe and cough. On postoperative day 3 she is tolerating a mechanical soft diet without nausea or vomiting. She has an oxygen saturation of 94-99% on room air. We will discharge her home today with her sister with return appointment with Dr. [**Last Name (STitle) **] in one week. Medications on Admission: Nexium, pravastatin, Effexor, fexofenadine Discharge Medications: 1. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 2.5-5 MLs PO Q4H (every 4 hours) as needed. Disp:*250 ML(s)* Refills:*0* 2. Venlafaxine 37.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Pravastatin 20 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 4. Colace 50 mg/5 mL Liquid Sig: Ten (10) ml PO twice a day. Disp:*500 ml* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: Severe Gerd Discharge Condition: Stable Discharge Instructions: You are being discharged on medications to treat the pain from your operation. These medications will make you drowsy and impair your ability to drive a motor vehicle or operate machinery safely. You MUST refrain from such activities while taking these medications. Please call your doctor or return to the emergency room if you have any of the following: * You experience new chest pain, pressure, squeezing or tightness. * New or worsening cough or wheezing. * If you are vomiting and cannot keep in fluids or your medications. * You are getting dehydrated due to continued vomiting, diarrhea or other reasons. Signs of dehydration include dry mouth, rapid heartbeat or feeling dizzy or faint when standing. * You see blood or dark/black material when you vomit or have a bowel movement. * You have shaking chills, or a fever greater than 101.5 (F) degrees or 38(C) degrees. * Any serious change in your symptoms, or any new symptoms that concern you. * Please resume all regular home medications and take any new meds as ordered. Activity: No heavy lifting of items [**9-15**] pounds for 6 weeks. You may resume moderate exercise at your discretion, no abdominal exercises. Wound Care: You may shower, no tub baths or swimming. If there is clear drainage from your incisions, cover with clean, dry gauze. Your steri-strips will fall off on their own. Please remove any remaining strips 7-10 days after surgery. Please call the doctor if you have increased pain, swelling, redness, or drainage from the incision sites. Followup Instructions: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 304**], MD Phone:[**Telephone/Fax (1) 274**] Date/Time:[**2173-10-1**] 1:45 Completed by:[**2173-9-24**]

[ "300.00", "276.52", "999.9", "553.3", "272.4", "473.9", "458.29", "530.81", "E879.8", "784.2" ]

icd9cm

[ [ [] ] ]

[ "38.93", "93.90", "44.67", "53.71", "96.71", "88.72" ]

icd9pcs

[ [ [] ] ]

4108, 4114

2777, 3639

342, 485

4189, 4198

1961, 2754

5790, 5971

1024, 1070

3732, 4085

4135, 4135

3665, 3709

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1101, 1942

245, 304

5433, 5767

513, 847

4154, 4168

869, 926

942, 1008

18,436

162,493

29621

Discharge summary

report

Admission Date: [**2113-1-30**] Discharge Date: [**2113-3-6**] Date of Birth: [**2054-1-9**] Sex: M Service: CARDIOTHORACIC Allergies: Heparin Agents Attending:[**First Name3 (LF) 922**] Chief Complaint: Aortic Valve Abscess s/p CABG/AVR [**12/2111**] Major Surgical or Invasive Procedure: [**2113-2-27**] - Right Thoracentesis [**2113-2-21**] - PICC line in interventional radiology [**2113-2-13**] - Placement of permenant pacemaker ([**Company 1543**] Sigma dual chamber) [**2113-2-9**] - Cardiac surgery 1. Redo sternotomy. 2. Redo coronary artery bypass grafting x4 with a reverse saphenous vein graft to the distal left anterior descending coronary artery; reverse saphenous vein double sequential graft from aorta to the first diagonal and first obtuse marginal coronary artery; as well as reverse saphenous vein single graft from the aorta to the posterior descending coronary artery. 3. Aortic root replacement with a 25 mm homograft with left coronary button re-implantation and oversewing of the right native coronary ostia. 4. Mitral valve replacement with a 27 mm [**Company 1543**] Mosaic bioprosthetic valve. 5. Endoscopic greater saphenous vein harvesting. [**2113-1-31**] - Cardiac Catheterization History of Present Illness: The patient is a 65-year-old gentleman who approximately a year ago underwent four-vessel coronary bypass grafting and aortic valve replacement with a St. [**Male First Name (un) 923**] mechanical prosthesis at [**Hospital3 45967**] in [**Doctor Last Name 792**]by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 27598**]. The patient did well for many months but was noted to have fevers, chills and was diagnosed with staph epidermidis prosthetic aortic valve endocarditis with acute vegetation below the aortic valve and partial dehiscence of the valve, as well as severe mitral regurgitation and involvement of the mitral valve with aortic root abscess. Cardiac cath here demonstrated that all of his vein grafts were totally occluded and his mammary to LAD anastomosis had a 60%stenosis within it. The patient was admitted for preoperative work-up and management for possible redo cardiac surgery. Past Medical History: 1. Hodgkin lymphoma (L preauricular per pt) - S/P XRT and splenectomy in [**2080**] 2. Thyroid cancer - S/P thyroidectomy in [**2102**] 3. Left CEA [**2110**] 4. Hypercholesterolemia 5. PCI RCA [**2110**] 6. CABG/AVR (St. [**Male First Name (un) 1525**] metal valve) [**2111**] Social History: Married, 2 kids, works at a toy company, occasional EtOH, quit tobacco in [**2084**]. Family History: Mom alive at 84 - well; dad died at 80 with prostate cancer; 2 brothers - well. Physical Exam: Admit PE VS: 96.4 HR 58 with second degree AVB BP 86/56 94% RA sats NEURO: A+Ox3, MAE, CN II-XII intact. NECK: Supple, no JVD LUNGS: CTA HEART: RRR, Nl s1-s2, III.VI systolic murmur ABD: Benign SKIN: Warm, dry EXT: 2+ pulses Discharge PE VS: 97.8 102 106/57 20 100% RA 83.3kg NEURO: A+Ox3, MAE LUNGS: CTAB w/ decreased BS Right base HEART: RRR, -murmur ABD: Soft, NT/ND, +BS EXT: L EVH c/d/i, calf site w/ mild erythema, -warmth. Right four toes and left three toes blackend/purplish color. As well as left fingers with purplish discoloration. Pulses present throughout. Discoloration d/t thrombus believed to be from thrombocytopenia. Pertinent Results: [**2113-1-30**] ECHO There is mild symmetric left ventricular hypertrophy with normal cavity size. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Overall left ventricular systolic function is mildly depressed. A mechanical aortic valve prosthesis is present. The aortic prosthesis cannot be fully assessed but a 1cm somewhat mobile echodensity is seen on the LV side of the prosthesis in the subcostal views (clip#[**Clip Number (Radiology) **]) c/w a vegetatiaon. The aortic valve gradient was not assessed. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. No discrete vegetation is seen (does not exclude). Mild to moderate ([**1-3**]+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. Moderate [2+] tricuspid regurgitation is seen. No discrete vegetation is seen (does not exclude). There is no pericardial effusion. [**2113-1-31**] Cardiac Catheterization 1. Selective coronary angiography revealed a right dominant system with severe three vessel disease and occluded SVG grafts. LMCAhad a mid vessle 30% stenosis. The LAD had a 50% lesion at S1 and an 80% lesion at D2. The dital vessel filled via LIMA. LCX was proximally occluded and the distal OM filled via collaterals. RCA was occluded in the mid-vessel. SVG to RCA, diagonal and OM were all occluded. LIMA to LAD was patent but there was a 60% lesion just proximal to the anastomosis. 2. Aortography showed 3+ AI. 3. Left ventriculography was deferred given endocarditis on the prosthetic valve. 4. Limited hemodynamic assessment showed normal systemic aortic pressures. 5. Fluoroscopy showed excessive motion of the prosthetic aortic valve. [**2113-2-1**] Head CTA 1. No acute hemorrhage or mass effect. 2. Mild chronic microvascular infarction, as noted above. 3. No evidence of central or peripheral arterial aneurysms. Please note that CTA has limited sensitivity for peripheral mycotic aneurysms, for which conventional angiography may still be required for detection. 4. No significant arterial stenoses. [**2113-2-1**] Chest/Abdomen CT 1. Single small solitary pulmonary nodule, for which 12- and 24-month followup CT chest examinations are recommended to ensure stability and/or resolution, in the absence of known malignancy. 2. Transvenous pacer wire terminating in the right ventricle. 3. Status post aortic valve replacement. 4. No definite evidence of septic emboli or abscesses. However, there are small bilateral perfusion defects in the kidneys which could relate to non- occlusive emboli. A similar appearance can also be seen in pyelonephritis. Correlation with urinalysis is recommended. [**2113-2-3**] Renal Ultrasound The right kidney measures 12.5 cm and the left kidney 11.2 cm. Both kidneys are morphologically normal without stones, hydronephrosis or solid mass. There are normal waveforms in the right lower, mid, and upper interlobar arteries and main renal artery. Color Doppler shows uniform perfusion of the right kidney. Doppler evaluation of the left kidney was not possible due to the patient's difficulty with breath holding maneuvers. [**2113-2-3**] Carotid Duplex Ultrasound Less than 40% right carotid stenosis. No stenosis of the left carotid. [**2113-2-27**] LE U/S 1. No DVT on the right. The basilic vein on the right is not visualized secondary to a PICC line with overlying dressings which preclude assessment for the basilic vein. 2. Residual left internal jugular vein non-occlusive thrombus. Patent subclavian, axillary and basilic veins without thrombus. [**2113-3-6**] Chest X-ray Right PICC line and permanent pacemaker remain in place. There has been prior median sternotomy and coronary artery bypass surgery. Lung volumes are low, accentuating the cardiac silhouette and bronchovascular structures. There is persistent interstitial edema. More confluent opacities are again demonstrated at the lung bases, right greater than left adjacent to moderate right and small left pleural effusions. Appearance of the base is slightly worse that could be accentuated by the lower lung volumes. [**2113-1-30**] 06:28PM GLUCOSE-121* UREA N-24* CREAT-0.8 SODIUM-132* POTASSIUM-3.9 CHLORIDE-97 TOTAL CO2-25 ANION GAP-14 [**2113-1-30**] 06:28PM WBC-18.9* RBC-4.12* HGB-11.7* HCT-34.1* MCV-83 MCH-28.4 MCHC-34.3 RDW-17.5* [**2113-1-30**] 06:28PM PT-24.2* PTT-34.7 INR(PT)-2.4* [**2113-3-6**] WBC-14.9 RBC-3.59 Hgb-10.2 Hct-32.6 MCV-91 MCH-28.4 MCHC-31.3 RDW-17.5 Plt Ct-392 [**2113-3-6**] 05:33AM PT-20.3*PTT-36.0*INR-2.0*PLT-392 RENAL&GLUCOSE Glucose-103 UreaN-21 Creat-1.1 Na134 K-[**4-5**] Cl-97 HCO3-32 AnGap-9 Brief Hospital Course: Mr. [**Known lastname 71002**] was admitted to the [**Hospital1 18**] on [**2113-1-30**] via transfer from [**Hospital3 35813**] Center for further management of his endocarditis. He was transferred to the intensive care unit over the weekend for diuresis and management of his congestive heart failure. A transvenous pacer was placed for heart block. Vancomycin was continued. As his platelets dropped to 52,000, a heparin induced thrombocytopenia (HIT) assay was sent which was negative. As his conditioned worsened with increasing need for inotropes, it was decided to proceed more urgently with surgery. Ciprofloxacin was started for a urinary tract infection. A cardiac catheterization was performed which revealed three vessel coronary artery disease with occluded vein grafts and a patent internal mammary to the left anterior descending. An echocardiogram was significant for 3+ aortic regurgitation 3+ mitral regurgitation and 2+ tricuspid valve regurgitation. His ejection fraction was noted to be 45%. On [**2113-2-9**], Mr. [**Known lastname 71002**] was taken to the operating room where he underwent a redo sternotomy, four vessel coronary artery bypass grafting, a Bentall procedure, a mitral valve replacement with a 27mm [**Company 1543**] mosaic valve, an left ventricular outflow tract repair and removal of a temporary pacer lead. Please see operative report for details. Postoperatively he was taken to the intensive care unit for monitoring. Pressors were slowly weaned off. On [**2113-2-11**], Mr. [**Known lastname 71002**] [**Last Name (Titles) 5058**] neurologically intact and was extubated. Gentle diuresis was initiated. On [**2113-2-13**], Mr. [**Known lastname 71002**] was taken to the electrophysiology lab where a dual chamber pacemaker was placed. Coumadin was started for anticoagulation as he developed a left internal jugular and subclavian thrombosis. A repeat HIT was sent which was again negative. The hematology service was consulted who felt that despite being negative for HIT, he clinically had HIT (Heparin should not be used). It was also noted that his liver function studies were elevated which were then followed closely. His pacemaker was interrogated by the electrophysiology service which showed it to be functioning normally. On postoperative day five, Mr. [**Known lastname 71002**] was transferred to the step down unit for further recovery. The physical therapy was consulted for assistance with his postoperative strength and mobility. Zosyn was started for a right lower lobe consolidation. As he was slow to become therapeutic on Coumadin, lepirudin was started as a bridge. The [**Known lastname 1106**] surgery service was consulted for ischemic toes due to thrombocytopenia. These were watched closely with the presumption that amputation would likely be necessary at some point. He was returned to the intensive care unit for lack of access and placement of a groin line. He developed some mild sternal drainage which slowly improved without evidence of infection. Nystatin was started for thrush with good results. A PICC line was placed under fluoroscopy for access in his right arm. Repeat venous ultrasound continued to show thrombus in his left jugular, subclavian, axillary and basilic vein. An ankle-brachial index study was performed which was normal. Anticoagulation was continued with a slow INR response. Ultimately his INR became therapeutic on Coumadin and lepirudin was discontinued. On post-op day seventeen he required a right thoracentesis in which 2600 cc of serosanguinous fluid was removed. Later on this day he was transferred back to the CSRU d/t increasing somnolence and required closer monitoring. The following day he was transferred back to the SDU more alert and orientated. Mr. [**Known lastname 71002**] continued to make steady progress and was discharged to rehabilitation on post-op day twenty-four. He will follow-up with Dr. [**Last Name (STitle) 914**], cardiologist, primary care physician, [**Name10 (NameIs) 1106**] surgeon, pacer device clinic, and infectious disease as an outpatient. Coumadin will be continued for HIT for 6 months. Medications on Admission: Home Meds: Coumadin, Lipitor, Flovent, Atrovent, Aspirin, Protonix Meds at transfer: Synthroid, Lipitor, Flovent, Atrovent, Aspirin, Vancomycin, Rocephin, Protonix, Ativan Discharge Medications: 1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 2. Cilostazol 100 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 5. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Levothyroxine 175 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [**Hospital1 **] (2 times a day). 8. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [**1-3**] Puffs Inhalation Q6H (every 6 hours) as needed. 9. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO three times a day. 10. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID (3 times a day). 11. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 13. Vancomycin 500 mg Recon Soln Sig: One (1) Recon Soln Intravenous Q 12H (Every 12 Hours): check trough weekly. 14. Gabapentin 400 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 15. Furosemide 40 mg Tablet Sig: 1.5 Tablets PO twice a day. 16. Warfarin 3 mg Tablet Sig: One (1) Tablet PO ONCE (Once): please check INR [**3-8**] goal INR 2-2.5 for DVT . 17. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two (2) Capsule, Sustained Release PO BID (2 times a day). 18. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr Sig: 4.5 Tablet Sustained Release 24 hrs PO BID (2 times a day). Discharge Disposition: Extended Care Facility: On [**Location (un) **] - [**Location (un) **] Discharge Diagnosis: Aortic Abscess/Coronary Artery Disease/Mitral Regurgitation s/p Bentall procedure, Coronary Artery Bypass Graft x 4, Aortic and Mitral Valve Replacement Complete Heart Block s/p Placement of permenant pacemaker Thrombocytopenia/Clinically had HIT (lab panel was HIT antibody negative) PMH: Mobitz Type I AV Block, Hypercholesterolemia, Thyroid Cancer w/ thyroidectomy, s/p CABGx4/AVR [**2113-12-29**], Splenectomy in [**2080**], Left Carotid Endarterectomy in [**2110**], Hodgkins Lymphoma with radiation in [**2080**] Discharge Condition: Good Discharge Instructions: 1) Monitor wounds for signs of infection. These include redness, drainage or increased pain. 2) Report any fever greater then 100.5. 3) Report any weight gain of 2 pounds in 24 hours or 5 pounds in 1 week. 4) No lotions, creams or powders to incision until it has healed. You may shower and wash incision. No bathing or swimming for 1 month. Use sunscreen on incision if exposed to sun. 5)No lifting greater then 10 pounds for 10 weeks. 6)No driving for 1 month. Followup Instructions: Follow-up with Dr. [**Last Name (STitle) 914**] in 1 month. ([**Telephone/Fax (1) 1504**] Follow-up with PCP [**Last Name (NamePattern4) **]. [**Location (un) 71003**] in 2 weeks. [**Telephone/Fax (1) 71004**] Follow-up with local cardiologist, Dr. [**Last Name (STitle) 36812**] for pacemaker check in [**3-9**] or [**3-10**] Dr. [**Last Name (STitle) 36812**] office has been called and will call you to schedule the appointment. Follow up with Dr. [**Last Name (STitle) **] ([**Last Name (STitle) **] surgeon) in 1 week. Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5866**], MD Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2113-3-17**] 10:00 Labs: q weekly (wednesday) Vancomycin trough, CBC w/ diff, LFT, Cr fax results to [**Telephone/Fax (1) 432**] please first draw [**2113-3-9**] PICC line needs to be removed under fluoro please schedule, and pacemaker checked after PICC line removed. PT/INR for DVT goal INR 2-2.5 first draw [**3-8**] Call all providers for appointments. Completed by:[**2113-3-6**]

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icd9cm

[ [ [] ] ]

[ "99.05", "35.21", "37.83", "99.07", "88.72", "00.17", "37.72", "39.61", "37.78", "38.45", "89.64", "88.57", "34.91", "36.99", "35.23", "35.39", "88.56", "36.14", "37.22", "38.93", "88.42", "88.67", "99.04" ]

icd9pcs

[ [ [] ] ]

14104, 14177

8052, 12192

326, 1257

14739, 14745

3383, 8029

15256, 16299

2627, 2708

12414, 14081

14198, 14718

12218, 12391

14769, 15233

2723, 3364

239, 288

1285, 2207

2229, 2508

2524, 2611

28,692

188,845

32940

Discharge summary

report

Admission Date: [**2129-1-6**] Discharge Date: [**2129-1-10**] Date of Birth: [**2051-10-29**] Sex: M Service: CARDIOTHORACIC Allergies: Codeine / Erythromycin Base / Penicillins / Imdur Attending:[**First Name3 (LF) 922**] Chief Complaint: Chest heaviness Major Surgical or Invasive Procedure: Coronary artery bypass graft x3 (Left internal mammary artery>left anterior descending, saphenous vein graft > RAMUS, saphenous vein graft > obtuse marginal, Aortic Valve replacement (25mm [**Company **] Mosaic Ultra Porcine valve) [**2129-1-6**] History of Present Illness: 77 year old male with chest heaviness, abnormal stress test referred for cardiac catherization that revealed coronary artery disease. Referred to cardiac surgery for evaluation and work up. Past Medical History: Hypertension Aortic Stenosis Elevated cholesterol Diabetes Mellitus type 2 Peripheral vascular disease Spinal Stenosis Arthritis Depression Benign prostatic hypertrophy Sleep Apnea s/p rt hip repair - hip fx d/t fall Cerebral vascualar accident [**2098**] [**2102**] Social History: Retired police officer Lives with spouse Denies tobacco [**Name (NI) **] glass of wine Family History: mother deceased age 58 heart disease Physical Exam: General well appearing Skin unremarkable HEENT unremarkable Neck supple, Full ROM Chest CTA bilat Heart RRR Abd soft, NT, ND, +BS Ext warm, well perfused no edema no varicosities Neuro grossly intact Pertinent Results: [**2129-1-10**] 09:30AM BLOOD WBC-7.7 RBC-2.50* Hgb-7.5* Hct-23.3* MCV-93 MCH-29.9 MCHC-32.1 RDW-13.6 Plt Ct-198 [**2129-1-6**] 01:27PM BLOOD WBC-11.3*# RBC-2.71* Hgb-8.4* Hct-25.6* MCV-94 MCH-31.0 MCHC-32.8 RDW-14.2 Plt Ct-149* [**2129-1-10**] 09:30AM BLOOD Plt Ct-198 [**2129-1-10**] 09:30AM BLOOD PT-11.9 PTT-23.2 INR(PT)-1.0 [**2129-1-6**] 01:27PM BLOOD Plt Ct-149* [**2129-1-6**] 01:27PM BLOOD PT-15.8* PTT-33.1 INR(PT)-1.4* [**2129-1-6**] 01:27PM BLOOD Fibrino-170 [**2129-1-10**] 09:30AM BLOOD Glucose-207* UreaN-31* Creat-1.1 Na-140 K-4.8 Cl-105 HCO3-27 AnGap-13 [**2129-1-6**] 03:01PM BLOOD UreaN-22* Creat-1.1 Cl-116* HCO3-21* [**2129-1-10**] 09:30AM BLOOD Calcium-8.4 Phos-2.6* Mg-2.5 RADIOLOGY Final Report CHEST (PA & LAT) [**2129-1-9**] 10:38 AM CHEST (PA & LAT) Reason: pneumo post chest tube pull [**Hospital 93**] MEDICAL CONDITION: 77 year old man with s/p chest pull REASON FOR THIS EXAMINATION: pneumo post chest tube pull HISTORY: Chest tube removal. Three radiographs of the chest demonstrate interval removal of the support lines seen on [**2129-1-6**]. There is bibasilar atelectasis, much worse on the left than the right. No pneumothorax is identified. There is a small left-sided pleural effusion. Patient is status post median sternotomy. Trachea is midline. IMPRESSION: Interval removal of support lines. Left basilar atelectasis and pleural effusion. DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 6892**] Approved: MON [**2129-1-10**] 9:14 AM [**Hospital1 18**] ECHOCARDIOGRAPHY REPORT [**Known lastname **], [**Known firstname 4075**] [**Hospital1 18**] [**Numeric Identifier 76639**] (Complete) Done [**2129-1-6**] at 9:48:00 AM FINAL Referring Physician [**Name9 (PRE) **] Information [**Name9 (PRE) **], [**First Name3 (LF) 177**] [**Hospital Unit Name 927**] [**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2051-10-29**] Age (years): 77 M Hgt (in): 71 BP (mm Hg): 100/60 Wgt (lb): 226 HR (bpm): 55 BSA (m2): 2.22 m2 Indication: Intraoperative TEE for CABG Abnormal ECG. Aortic valve disease. Chest pain. Hypertension. Ventricular ectopy. ICD-9 Codes: 410.91, 424.1, 440.0, 424.0, 427.89 Test Information Date/Time: [**2129-1-6**] at 09:48 Interpret MD: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5209**], MD Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 5740**], MD Doppler: Full Doppler and color Doppler Test Location: Anesthesia West OR cardiac Contrast: None Tech Quality: Adequate Tape #: 2008AW2-: Machine: 2 Echocardiographic Measurements Results Measurements Normal Range Left Ventricle - Septal Wall Thickness: *1.3 cm 0.6 - 1.1 cm Left Ventricle - Diastolic Dimension: 5.2 cm <= 5.6 cm Left Ventricle - Ejection Fraction: <= 60% >= 55% Aorta - Annulus: 2.2 cm <= 3.0 cm Aorta - Sinus Level: 3.4 cm <= 3.6 cm Aorta - Sinotubular Ridge: 2.5 cm <= 3.0 cm Aorta - Ascending: 3.3 cm <= 3.4 cm Aorta - Descending Thoracic: 2.2 cm <= 2.5 cm Aortic Valve - Peak Velocity: *2.7 m/sec <= 2.0 m/sec Aortic Valve - LVOT diam: 2.1 cm Aortic Valve - Valve Area: *0.8 cm2 >= 3.0 cm2 Findings LEFT ATRIUM: Good (>20 cm/s) LAA ejection velocity. RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is seen in the RA and extending into the RV. Normal interatrial septum. No ASD by 2D or color Doppler. LEFT VENTRICLE: Moderate symmetric LVH. Normal LV cavity size. Overall normal LVEF (>55%). RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Normal aortic diameter at the sinus level. Normal ascending aorta diameter. Normal descending aorta diameter. Complex (>4mm) atheroma in the descending thoracic aorta. AORTIC VALVE: Three aortic valve leaflets. Moderately thickened aortic valve leaflets. Severe AS (AoVA <0.8cm2). Trace AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. Trivial MR. TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with physiologic PR. PERICARDIUM: Trivial/physiologic pericardial effusion. GENERAL COMMENTS: A TEE was performed in the location listed above. I certify I was present in compliance with HCFA regulations. The patient was under general anesthesia throughout the procedure. The patient received antibiotic prophylaxis. The TEE probe was passed with assistance from the anesthesioology staff using a laryngoscope. No TEE related complications. Resting bradycardia (HR<60bpm). Results were personally reviewed with the MD caring for the patient. Conclusions PRE-BYPASS: 1. No atrial septal defect is seen by 2D or color Doppler. 2. There is moderate to severe symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF>55%). 3. Right ventricular chamber size and free wall motion are normal. 4. There are complex (>4mm) atheroma in the descending thoracic aorta. 5. There are three aortic valve leaflets. The aortic valve leaflets are moderately thickened, and the leaftlet mobility is restricted. There is severe aortic valve stenosis (area <0.8cm2). Trace aortic regurgitation is seen. 6. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. 7. There is a trivial/physiologic pericardial effusion. POST-BYPASS: Pt removed from cardiopulmonary bypass AV paced on a phenylephrine infusion. 1. There is a bioprosthetic valve in the aortic postion. The valve is well seated, the leaflets move well, and there is no evidence of paravalvular leak. There is trace aortic regurgitation centrally. 2. Biventricular function is well preserved. 3. Aortic contours are intact post-decannulation. 4. Mitral, tricuspid and pulmonic valve anatomy are unchanged from pre-bypass. I certify that I was present for this procedure in compliance with HCFA regulations. Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5209**], MD, Interpreting physician [**Last Name (NamePattern4) **] [**2129-1-6**] 13:59 Cardiology Report ECG Study Date of [**2129-1-6**] 7:17:54 PM Supravantricular rhythm of unclear mechanism, possibly atrial fibrillation. Ventricular premature depolarizations. Right bundle-branch block. Compared to previous tracing of [**2128-12-30**] cardiac rhythm is no longer sinus mechanism, although actual rhythm is unclear. Read by: [**Last Name (LF) **],[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 975**] Intervals Axes Rate PR QRS QT/QTc P QRS T 63 86 134 [**Telephone/Fax (2) 76640**] -2 Brief Hospital Course: Admitted to same day surgery and went to the operating room for aortic valve replacement and coronary artery bypass graft surgery. Please see operative report for further details. He was transferred to the CVICU for hemodynamic monitoring. During the first 24 hours he was weaned from sedation, awoke neurologically intact, and was extubated without difficulty. On post operative day 1 he was transferred to the floor. Physical therapy worked with him for strength and mobility. He continued to progress and was ready for discharge to rehab on post operative day 4. Medications on Admission: plavix 75mg daily ASA 81 mg daily Glucophage 1000mg [**Hospital1 **] Glyburide 2.5mg daily Actos 30mg daily Lipitor 40mg daily Zestril 40mg daily Lopressor 50mg daily Cymbalta 60mg daily Flomax 0.4mg daily Proscar 5mg daily Fish oil Colace/senna Vitamin b 12 Vitamin C Discharge Medications: 1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 3. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 5. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 7. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. Pioglitazone 15 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 9. Glyburide 2.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Metformin 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 11. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. 12. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 13. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO HS (at bedtime). 15. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day for 2 weeks. 16. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 2 weeks. 17. Ferrous Gluconate 325 mg (37.5 mg Iron) Tablet Sig: One (1) Tablet PO once a day. 18. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO twice a day. Discharge Disposition: Extended Care Facility: [**Hospital3 **] TCU - [**Location (un) 2498**] Discharge Diagnosis: Coronary artery disease s/p cabg Aortic Stenosis s/p AVR Hypertension Diabetes mellitus CVA Spinal Stenosis Arthritis Depression BPH Sleep Apnea (CPAP) PVD Discharge Condition: Good Discharge Instructions: Please shower daily including washing incisions, no baths or swimming Monitor wounds for infection - redness, drainage, or increased pain Report any fever greater than 101 Report any weight gain of greater than 2 pounds in 24 hours or 5 pounds in a week No creams, lotions, powders, or ointments to incisions No driving for approximately one month No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] Followup Instructions: Dr [**Last Name (STitle) 914**] in 4 weeks ([**Telephone/Fax (1) 170**]) please call for appointment Dr [**Last Name (STitle) 6700**] in 1 week ([**Telephone/Fax (1) 76641**]) please call for appointment Dr [**Last Name (STitle) 7047**] in [**2-6**] weeks - please call for appointment Completed by:[**2129-1-10**]

[ "276.2", "V45.81", "311", "413.9", "424.1", "414.01", "V10.82", "401.9", "327.23", "250.00" ]

icd9cm

[ [ [] ] ]

[ "39.61", "36.12", "35.21", "36.15" ]

icd9pcs

[ [ [] ] ]

10599, 10673

8196, 8769

331, 580

10873, 10880

1483, 2303

11392, 11710

1210, 1248

9089, 10576

2340, 2376

10694, 10852

8795, 9066

10904, 11369

1263, 1464

276, 293

2405, 8173

608, 800

822, 1090

1106, 1194

30,163

107,032

10287

Discharge summary

report

Admission Date: [**2111-4-9**] Discharge Date: [**2111-4-12**] Date of Birth: [**2057-12-17**] Sex: F Service: CARDIOTHORACIC Allergies: Adhesive Tape Attending:[**First Name3 (LF) 5790**] Chief Complaint: subglottic stenosis Major Surgical or Invasive Procedure: Microsuspension laryngoscopy dilatation of subglottis, flexible bronchoscopy, chest tube placement History of Present Illness: 53 F s/p baloon dilation and jet ventillation for subglottic stenosis today, complicated by desaturations, s/p left pneumothorax, s/p chest tube placed by general surgery emergently in the OR. The sequence of events is as follows: she was saturating well on a face mask, then she was intubated with a 4 Fr ETT, then extubated, then dilated from 4-5 mm to 6-7 mm just below the vocal cords. She desaturated during this dilation. She was then jet ventillated using the laryngoscope and then a cook catheter was placed and she was further jet ventillated for about 5- 10 minutes. The cook catheter was then removed and she was further dilated to about 8-9 mm. She continued to desaturate to the 40's. She was then re-intubated with a 4 Fr ETT and she continuted to desaturate. Importantly, per her ENT surgeon, her airway looked fine and there was no bleeding or evidence of injury. At this time, she had absent breath sounds on the left. Bilateral needle thoracosomy was attempted, but due to her obesity and body habitus they were unable to get any return of air. At that point, general surgery was called and a chest tube was placed without any return of air or blood. Her saturations improved and she was successfully extubated. She is s/p multiple dilations, CO2 laser lysis, and sterios injections by Dr. [**First Name (STitle) **] (ENT) since [**2102**]. She has had SOB for 5 years, initally thought to be caused by asthma, but did not respond to appropriate therapy. Past Medical History: HTN, polychondritis, Nissen fundoplication, transient tracheotomy with an anterior cricoid split with rib cartilage graft, iron deficiency anemia Social History: n/c Family History: n/c Physical Exam: NAD, AxOx3 RRR, S1S2 CTA b/l obese, soft, NT/ND Pertinent Results: [**2111-4-9**] 10:16AM BLOOD WBC-10.3 RBC-4.17* Hgb-12.8 Hct-37.5 MCV-90 MCH-30.7 MCHC-34.1 RDW-14.7 Plt Ct-368 [**2111-4-11**] 07:45AM BLOOD WBC-7.7 RBC-3.87* Hgb-11.8* Hct-33.6* MCV-87 MCH-30.4 MCHC-35.0 RDW-14.9 Plt Ct-309 [**2111-4-9**] 10:16AM BLOOD PT-12.3 PTT-30.0 INR(PT)-1.0 [**2111-4-9**] 10:16AM BLOOD Glucose-140* UreaN-13 Creat-0.7 Na-139 K-4.0 Cl-102 HCO3-28 AnGap-13 [**2111-4-11**] 07:45AM BLOOD Glucose-89 UreaN-11 Creat-0.6 Na-142 K-3.8 Cl-102 HCO3-28 AnGap-16 Brief Hospital Course: The patient was admitted [**2111-4-19**] for a scheduled microsuspension laryngoscopy dilatation of subglottis. During the operation she desaturated and had a left chest tube placed, as described in the HPI. She was transferred to the ICU. Bronchoscopy was performed at the bedside. Please see operative note for details. A small, healing tracheal tear was found. Antibiotics (Zosyn and Fluconazole) were started prophylactially. She was perfectly stable on an oxygen face mask and did not require intubation. A barium swallow was performed to look for esophageal injury. This was negative. On HD 2, she was transferred from the ICU to the floor. She was stable on an oxygen face mask. Repeat bronchoscopy was performed and was stable. On HD 4, her chest tube was removed. Repeat CXR looked ok. She was weaned off oxygen and sent home. Medications on Admission: [**Doctor First Name **] 180', Fe, MVI, lisinopril/HCTZ 20/25', methotrexate 10 q Fri, Nexium 40', Singulair 10', Astelin ", Nasocort', Mucinex" Discharge Medications: 1. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Guaifenesin 600 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO BID (2 times a day). 3. Fexofenadine 60 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 4. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily). 5. Methotrexate Sodium 2.5 mg Tablet Sig: Four (4) Tablet PO 1X/WEEK (SA). 6. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q3H (every 3 hours) as needed. Disp:*30 Tablet(s)* Refills:*0* 7. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours). 8. Fluconazole 200 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 5 days. Disp:*5 Tablet(s)* Refills:*0* 9. Amoxicillin-Pot Clavulanate 875-125 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 10 days. Disp:*20 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: subglotic stenosis, tracheal injury Discharge Condition: good Discharge Instructions: Please call or come to the ED with any fevers > 101, cough, shortness of breath, wheezing, abdominal pain, or any other worrisome issues. Please continue your antibiotics as directed. Please continue on all of your home medications Followup Instructions: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 14465**], MD Phone:[**Telephone/Fax (1) 2226**] Date/Time:[**2111-4-28**] 8:45 Please follow up with Dr. [**First Name (STitle) 34209**] please call his office Please follow-up with Dr. [**Last Name (STitle) 3450**] of GI to proceed with GERD work-up Completed by:[**2111-4-12**]

[ "E878.8", "512.1", "568.89", "401.9", "998.81", "478.74", "733.99", "998.2" ]

icd9cm

[ [ [] ] ]

[ "33.22", "34.04", "31.98" ]

icd9pcs

[ [ [] ] ]

4611, 4617

2714, 3567

300, 401

4697, 4704

2211, 2691

4985, 5342

2123, 2128

3762, 4588

4638, 4676

3593, 3739

4728, 4962

2143, 2192

241, 262

429, 1916

1938, 2086

2102, 2107

30,399

146,398

32094

Discharge summary

report

Admission Date: [**2125-11-14**] Discharge Date: [**2125-12-4**] Date of Birth: [**2069-11-21**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 4691**] Chief Complaint: pedestrian struck Major Surgical or Invasive Procedure: 1. Exploratory laparotomy. 2. Liver biopsy. 3. Dorsal slit of penile foreskin. 1. T3-L3 fusion. 2. Multiple thoracic laminotomies. 3. Multiple lumbar laminotomies. 4. Instrumentation T3-L3. 5. Autograft. 1. Partial vertebrectomy L1 2. Fusion T12-L2 3: Spacer L1-L2 4. Instrumentation L1-L2 5. Autograft 6. Open reduction internal fixation of left periprosthetic femur fracture using percutaneous technique 1. Tracheostomy. 2. Percutaneous endoscopic gastrostomy (PEG). PICC line placement History of Present Illness: 56 yo M who was a pedestrian struck by a car. He was brought to [**Hospital1 18**] by helicopter rescue from another hospital. The patient was hypotensive and transiently fluid responsive, requiring O negative blood in the ER. Chest x-ray and pelvic x-ray were negative for sources of blood loss. There was no external blood loss. FAST ultrasound exam performed by ED staff was thought by ED staff to be positive for hemoperitoneum. The patient was therefore brought emergently to the OR for exploratory laparotomy. Past Medical History: DM2 HTN GERD s/p L hip ORIF Social History: h/o EtOH abuse Family History: noncontributory Physical Exam: On discharge Afebrile Awake, responsive, cooperative RRR CTA, tolerating trach mask soft nontender, nondistended wounds well healed LE 1+ edema, warm Pertinent Results: [**2125-12-4**] 12:45AM BLOOD WBC-11.2* RBC-2.94* Hgb-8.9* Hct-27.5* MCV-94 MCH-30.5 MCHC-32.5 RDW-16.3* Plt Ct-572* [**2125-12-4**] 12:45AM BLOOD Plt Ct-572* [**2125-12-3**] 02:01AM BLOOD Plt Ct-562* [**2125-12-4**] 12:45AM BLOOD Glucose-149* UreaN-10 Creat-0.4* Na-134 K-4.2 Cl-103 HCO3-22 AnGap-13 [**2125-12-3**] 02:01AM BLOOD Glucose-141* UreaN-10 Creat-0.4* Na-136 K-4.4 Cl-103 HCO3-25 AnGap-12 [**2125-12-2**] 02:16AM BLOOD Glucose-148* UreaN-9 Creat-0.4* Na-133 K-4.4 Cl-103 HCO3-23 AnGap-11 [**2125-12-4**] 08:40AM BLOOD Vanco-4.2* [**2125-11-14**] 06:10PM BLOOD ASA-NEG Ethanol-326* Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG CT chest/abdomen/pelvis ([**11-14**]): IMPRESSION: 1. Bilateral dependent consolidation versus atelectasis and adjacent pleural effusion. 2. Postoperative changes related to laparotomy. 3. Diffuse low attenuation of the liver consistent with fatty infiltration. 4. Right adrenal nodule which is incompletely characterized and can be further evaluated on a non-emergent basis. 5. Tiny low-density lesions within bilateral kidneys, too small to characterize. 6. High density fluid in the retroperitoneum, adajacent to the psoas, right greater than left, most suggestive of hemorrhage. 7. Fracture of T9 vertebral body, and right posterior 11th and probably 12th rib. CT Cspine ([**11-14**]): IMPRESSION: No fracture or malalignment. CT head ([**11-14**]): IMPRESSION: No hemorrhage. LLE plain films ([**11-14**]): FINDINGS: There is a fracture just below the inferior tip of the left total hip prosthesis. There is displacement of the distal shaft laterally in relation to the proximal femur. There is also a small non-displaced fracture involving the proximal shaft laterally approximately 10 cm from the inferior prosthesis tip. The visualized portions of the left hip prosthesis is intact. The tibia and fibula are within normal limits. Vascular calcifications are seen. There are degenerative changes seen of the foot. Brief Hospital Course: Pt was taken urgently to the OR as described. Post operatively the patient was taken to the TSICU intubated. He was kept on Logroll percautions until the spine was repaired. He was taken to the OR with Orthopedics for ORIF of the LLE peri-prosthetic fracture. He tolerated the procedure well and was taken back to the TSICU intubated. On [**11-16**] the patient developed Afib w/ RVR. He became hypotensive and amiodarone drip was started. His rate was controlled, and Cardiology was consulted. A CTA was obtained and showed: No evidence of pulmonary embolism within the central pulmonary arteries. The more distal arteries cannot be accurately assessed. A large R pleural effusion was noted and a chest tube was placed. An MI was ruled out. He converted to a normal sinus rythm on [**11-21**] spontaneously. Tube feeds via doboff tube were started on [**11-20**]. Aggressive diuresis with lasix gtt was started. An IVC filter was placed [**11-21**]. The patient was noted to have an elevated PTT. He was seen by Hem/Onc, "noted to have an isolated rise in his PTT from nml yesterday to 150 across 3 measurements today. No evidence of DIC. He was receiving heparin flushes though his last lab draw was from a peripheral source. He has no known autoimmune, neoplastic, d/o." All studies were normal and the PTT normalized on its own. On [**11-20**] pt was taken to the OR for the first of a planned 2 stage procedure. He underwent Anterior Fusion T12-L2(EBL 1.5L) via Left thoracotomy, a Left chest tube was placed. He tolerated the procedure well and was kept intubated as the T9 fracture was unstable and the posterior repair was planned. On [**11-24**] he underwent Posterior Fusion T3-L3. Both chest tubes were removed when outputs were minimal. He was then extubated and diuresed. On [**11-27**] he was re-intubated for resp distress and inablity to control secretions. A bronchoscopy was performed with no mechanical cause for failure seen. On [**11-28**] he went to OR for tracheostomy and PEG. He tolerated the procedure well. He did well and was weaned to trach mask by [**11-29**]. Tube feeds were continued at a goal rate. On [**12-2**] Vanco/Zosyn for increased sputum, worsening RLL infiltrate. He remianed afebrile with a normal WBC and on trach mask. There was concern for a H. flu. Cultures are pending at this time. Medications on Admission: Diltiazem, Lisinopril, Protonix, Albuterol, Metformin 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. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 4. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2 times a day). 5. Therapeutic Multivitamin Liquid Sig: Five (5) ML PO DAILY (Daily). 6. Albuterol 90 mcg/Actuation Aerosol Sig: Six (6) Puff Inhalation Q4H (every 4 hours). 7. Acetaminophen 650 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. 8. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 9. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). 10. Oxycodone 5 mg/5 mL Solution Sig: One (1) PO Q4H (every 4 hours) as needed for pain. 11. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID (3 times a day) as needed. 12. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO Q6H (every 6 hours) as needed. 13. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [**Hospital1 **] (2 times a day). 14. Diltiazem HCl 30 mg Tablet Sig: One (1) Tablet PO QID (4 times a day). 15. Fluconazole 400 mg IV Q24H 16. Vancomycin 1000 mg IV Q 12H started [**2125-12-2**] 17. Piperacillin-Tazobactam Na 4.5 gm IV Q8H started [**2125-12-2**] Discharge Disposition: Extended Care Facility: [**Hospital6 1293**] - [**Location (un) **] Discharge Diagnosis: 1. Left periprosthetic femur fracture 2. L1 fracture, L1-2 Disc Disruption 3. Multiple trauma with prolonged vent dependency and nutritional dependency. 4. Phimosis 5. HTN 6. GERD 6. Afib with RVR 7. Retroperitoneal hematoma with IR intervention Discharge Condition: Stable Discharge Instructions: Please continue all medications as directed. Please call or return if you have: - Fever (>101 F) - Increased pain - Foul discharge from your wound - Other symptoms concerning to you or your care providers Antibiotics may be stopped on [**12-15**]. Followup Instructions: Trauma: Please follow up with Dr. [**Last Name (STitle) **] in 2 weeks. Call his office, ([**Telephone/Fax (1) 22750**], to arrange the appointment. Ortho: Dr. [**Last Name (STitle) 1005**] ([**Telephone/Fax (1) 1228**]) in 2 weeks. Spine: Dr. [**Last Name (STitle) 363**] ([**Telephone/Fax (1) 61627**] in 2 weeks. Urology: Dr. [**Last Name (STitle) **] ([**Telephone/Fax (1) 10797**] in 2 weeks.

[ "998.11", "996.44", "285.1", "958.4", "805.4", "868.04", "511.9", "E814.7", "250.00", "805.2", "V46.11", "605", "427.31", "401.9", "839.20" ]

icd9cm

[ [ [] ] ]

[ "80.51", "81.05", "81.62", "79.35", "50.11", "64.91", "38.7", "54.11", "39.79", "81.04", "84.51", "77.89", "81.64", "38.93", "77.79", "31.1", "43.11", "34.04", "96.6" ]

icd9pcs

[ [ [] ] ]

7597, 7667

3669, 6035

334, 831

7965, 7974

1678, 3646

8273, 8683

1476, 1493

6139, 7574

7688, 7944

6061, 6116

7998, 8250

1508, 1659

277, 296

859, 1377

1399, 1428

1444, 1460

70,753

114,913

41320

Discharge summary

report

Admission Date: [**2163-2-22**] Discharge Date: [**2163-2-24**] Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**Last Name (NamePattern4) 290**] Chief Complaint: CC:[**CC Contact Info 89949**] Major Surgical or Invasive Procedure: None History of Present Illness: [**Age over 90 **] yo F PMH dementia presented to OSH following evaluation at nursing home for cough, decreased appetite that demonstrated creatinine increase to 3.6. Patient describes recent cough (per HCP 1 week duration) but denies fever or chills. Denies abdominal pain, nausea, vomiting. Denies chest pain or shortness of breath. Per HCP patient has not been eating well last several months. . Patient presented to OSH found to have T 94.5, creatinine 3.6, WBC 8.6 (N80%), bilirubin of 8 and an ALP of almost 1400. Her ultrasound showed some thickening of the GB wall, and did not comment on her CBD. There were stones and sludge reported. CXR demonstrated increased opacity right lung base medially and left retrocardiac region. She was transferred to [**Hospital1 18**] for further management. . On arrival to our ED VS T 97.7, BP 96/54, HR 90, O2Sat 95% 2L. SBP dropped to 60 which improved to SBP 90s with 3 L of NS. Labs notable for lactate 2.1, creatinine 3.5 (from baseline of 1.1), ALT 58, AST 120, AP 1061, Tbili 6.1, Alb 2.9, lipase 13, WBC 7.1 (N 79, L 14), INR 1.3. Gallbladder ultrasound demonstrated markedly distended GB with sludge/stones but no thickening or definite [**Doctor Last Name 515**] sign. CBD irregular in appearance measuring up to 1 cm in diameter. Moderate to large amount of ascites. Patent main portal vein. Blood and urine cultures sent. Patient given Levofloxacin (received Unasyn at OSH). Surgery was consulted - patient's HCP declined surgery but will consider ERCP. Consequently patient is being admitted to the MICU. . On arrival to the ICU, patient overall looks well and is conversant. . ROS: The patient denies any fevers, chills, weight change, nausea, vomiting, abdominal pain, diarrhea, constipation, melena, hematochezia, chest pain, shortness of breath. Patient has chronic edema. Describes increase in urinary frequency but no dysur Past Medical History: Dementia Glaucoma HTN Cholelithiasis GERD Osteopenia Spinal stenosis Lymphedema Right hip replacement Social History: Patient lives in long-term care facility Blueberry [**Doctor Last Name **]. Son is HCP. [**Name (NI) **] history of tobacco abuse Family History: Non-contributory Physical Exam: GEN: elderly female, no acute distress HEENT: Dry mucosa, EOMI, PERRL, sclera icteric, no epistaxis or rhinorrhea, OP Clear. NECK: No JVD COR: RRR, no M/G/R, normal S1 S2, radial pulses +2 PULM: Decreased breath sounds throughout ABD: Soft, moderately distended, non-tender to light and deep palpation. No fluid wave. No rebound or gaurding. + BS. EXT: 3+ pitting edema b/l, no palpable cords NEURO: alert, oriented to place and season. CN II ?????? XII grossly intact. Moves all 4 extremities. SKIN: + jaundice. Pertinent Results: [**2163-2-22**] 06:30PM WBC-7.1 RBC-3.82* HGB-11.5* HCT-35.5* MCV-93 MCH-30.0 MCHC-32.3 RDW-16.0* [**2163-2-22**] 06:30PM PLT COUNT-202 [**2163-2-22**] 06:30PM NEUTS-79.6* LYMPHS-14.1* MONOS-5.4 EOS-0.6 BASOS-0.3 [**2163-2-22**] 06:30PM PT-14.8* PTT-24.6 INR(PT)-1.3* [**2163-2-22**] 06:30PM GLUCOSE-110* UREA N-110* CREAT-3.5* SODIUM-141 POTASSIUM-5.0 CHLORIDE-99 TOTAL CO2-26 ANION GAP-21* [**2163-2-22**] 06:30PM ALT(SGPT)-58* AST(SGOT)-120* CK(CPK)-51 ALK PHOS-1061* TOT BILI-6.1* DIR BILI-5.2* INDIR BIL-0.9 [**2163-2-22**] 06:30PM LIPASE-13 [**2163-2-22**] 06:30PM cTropnT-0.09* [**2163-2-22**] 06:30PM CK-MB-5 [**2163-2-22**] 06:31PM LACTATE-2.1* [**2163-2-22**] 07:00PM URINE RBC-0-2 WBC-0-2 BACTERIA-OCC YEAST-NONE EPI-0-2 [**2163-2-22**] 07:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-SM UROBILNGN-NEG PH-5.0 LEUK-TR [**2163-2-22**] 07:00PM URINE COLOR-Amber APPEAR-Clear SP [**Last Name (un) 155**]-1.011 [**2163-2-22**] 09:54PM URINE HOURS-RANDOM CREAT-71 SODIUM-61 POTASSIUM-33 CHLORIDE-54 . Renal US: The right kidney measures 9.2 cm and shows cortical thinning but no hydronephrosis. The left kidney is only partially seen but it too shows no evidence of hydronephrosis. The spleen is not enlarged. The bowel is predominantly pulled posteriorly suggesting that the cause of the ascites is intra-abdominal spread of malignancy.Neither pancreas or aorta could be seen. IMPRESSION: Pancreas and aorta not seen. Extensive ascites that is probably malignant. . EXAM: Right upper quadrant ultrasound. COMPARISONS: None available. FINDINGS: There is a large amount of intra-abdominal ascites. The liver demonstrates no focal or textural abnormalities. There is irregularity of the common bile duct which measures up to 10 mm. The gallbladder is distended containing layering stones and sludge. There is no appreciable gallbladder wall thickening. There was a negative son[**Name (NI) 493**] [**Name (NI) **] sign. The main portal vein is patent with appropriate hepatopetal flow. The pancreas is not well visualized. IMPRESSION: 1. Markedly distended gallbladder containing stones and sludge. No gallbladder wall thickening or pericholecystic fluid. However, in the appropriate clinical setting, acute cholecystitis would be of concern and further evaluation with HIDA scan could be obtained. 2. Large amount of intra-abdominal ascites. 3. Irregularity of the common bile duct, which measures up to 10mm. The study and the report were reviewed by the staff radiologist . CXR: HISTORY: [**Age over 90 **]-year-old woman with cough and hypotension. IMPRESSION: AP chest reviewed in the absence of any prior chest imaging: Pulmonary edema is at least mild in severity. Large region of opacification in the left lower lobe, seen through the cardiac silhouette, obscures the left diaphragmatic pleural surface and could be pneumonia or left lower lobe collapse, but could also be mediastinal abnormality such as a thoracic aortic aneurysm or large hiatus hernia. Lateral view would be very helpful. Small bilateral pleural effusions are presumed. Heart is at least moderately enlarged if not severely. Elevation of the left main bronchus suggests substantial left atrial dilatation, and a ring-like calcification could be in the mitral annulus. Once again, lateral view would be very helpful. Dr. [**First Name (STitle) 89950**] and I discussed these findings by telephone. Brief Hospital Course: [**Age over 90 **] year-old female with a history of dementia trasnferred from OSH for obstructive jaundice. . # Jaundice: Initial concern for choledocholithiasis and patient covered with antibiotics. After review, growing concern for malignant etiology: cholangiocarcinoma vs pancreatic malignancy. Discussion held with family regarding goals of care. Central venous line, ERCP and surgery declined. Palliative care consulted. Decision made to return to [**Hospital3 **] facility with hospice. Interventions were miniminalized prior to discharge. Antibiotics were discontinued, pressors were weaned off. # Goals of care. Palliative care consulted shortly after admission. Referral made to Hospice [**Location (un) 1121**] for palliative care at Blueberry [**Doctor Last Name **]. Family counseled and prepared regarding likely upcoming events such as continued anorexia secondary to the natural consequence of aging, cancer, dying process as well as further inability to ambulate. Palliative care recommended: trial of pain medication of low dose morphine 2.5 mg prn. Tylenol avoiding in setting of abnormal liver function tests. Patient was without complaints of pain at time of discharge. . # Hypotension. On admission patient with asymptomatic hypotension in the 70s. Started on low dose pressor support. After discussion regarding goals of care decision made to wean pressors unless symptomatic. All anti-hypertensives medications held. Patient hemodynamically stable at time of transfer. . # Renal failure: Most likely pre-renal versus ATN from shock. Renal US without hydronephrosis. Creatinine improved with trial of fluids. Renal function was not trended after goals of care discussion took place. . # Glaucoma: Continue Lumigan. . # GERD: Continue prilosec. . #. CAD. Continued Aspirin. Held ACE in setting of hypotension and renal failure. Medications on Admission: ASA 81 Colace 100 mg [**Hospital1 **] Lisinopril 10 mg qd Prilosec 20 mg daily Lasix 40 mg daily Lumigan 0.03% one drop each at bedtime Robitussin Discharge Medications: 1. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for Constipation. 2. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for Constipation. 3. docusate sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2 times a day). 4. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as needed for SOB. 5. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed for SOB. 6. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 7. latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at bedtime). 8. codeine-guaifenesin 10-100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6 hours) as needed for cough. 9. morphine 10 mg/5 mL Solution Sig: 2.5 mg PO Q4H (every 4 hours) as needed for pain: Please use if tylenol ineffective. 10. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). Discharge Disposition: Extended Care Facility: Blueberry [**Doctor Last Name **] Healthcare - [**Hospital1 **] Discharge Diagnosis: Primary Obstructive Jaundice . Secondary Dementia Congestive Heart Failure Lymphedema Discharge Condition: Mental status: confused at times Unable to ambulate Discharge Instructions: Dear Ms [**Known lastname 89951**], you were admitted to [**Hospital3 **] Hospital for further evaluation of your distended belly. . Shortly after arrival to the ICU decisions were made to avoid invasive intervention and refocus goals of care on continued comfort. The palliative care team was consulted. The plan is for you to return to Blue [**Doctor Last Name 3646**] [**Doctor Last Name **] with additional supports in place. . CHANGES TO YOUR MEDICATIONS: Stop take Lisinopril Hold Lasix given low blood pressure. Start taking low dose Morphine as needed for pain Start taking cough suppressants for comfort Followup Instructions: Plan to return to Blue [**Doctor Last Name 3646**] [**Doctor Last Name **] with hospice [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**] Completed by:[**2163-2-24**]

[ "576.1", "199.1", "401.9", "789.59", "785.50", "584.5", "V66.7", "530.81", "414.01", "294.8", "576.2" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

9654, 9744

6537, 8392

288, 294

9874, 9874

3065, 6514

10589, 10844

2498, 2516

8590, 9631

9765, 9853

8418, 8567

9952, 10384

2531, 3046

10413, 10566

219, 250

322, 2210

9889, 9928

2232, 2335

2351, 2482

44,851

154,901

21867

Discharge summary

report

Admission Date: [**2193-12-4**] Discharge Date: [**2193-12-25**] Date of Birth: [**2156-8-16**] Sex: F Service: MEDICINE Allergies: Compazine Attending:[**Last Name (NamePattern4) 290**] Chief Complaint: cough and dyspnea Major Surgical or Invasive Procedure: [**2193-12-4**]- intubation, mechanical ventilation History of Present Illness: 37 year-old Ethiopian female with metastatic colon CA to brain, lung (s/p whole brain radiation and XRT to chest, diagnosed in [**2188**]), who presented to the ED with 3 weeks of increased cough which has worsened significally in the past 3 days. She was seen as an outpatient 2 days ago and started on levofloxacin. She was found to be flu swab negative at that time. . In the emergency department vs on arrival were 100.4 132 102/75 O2 sat 85%. She stated her O2 sat was 85% on RA at home. She had dyspnea and tachypnea. CXR showed markedly worsened bilateral opacities. Lactate was 1.2. She was placed on a NRB. ABG showed ABG 7.44/43/41 and she was later intubated after an extensive discussion with patient and HCP (see code status below). Blood and urine cultures were drawn and she received cefepime and vancomycin. She also received stress dose steroids with 100mg hydrocortisone as she was on home dexamethasone. Total of 1L IVF given in ED. Most recent VS: 138/96 117 100% on AC 400/15/5/100%. . Currently, she is intubated and sedated and unable to provide any further history. Past Medical History: ONCOLOGIC HISTORY: [**Known firstname 57315**] Bezabhe was diagnosed with T3, N2, stage IIIC colon cancer in [**11/2188**] by colonoscopy. She underwent right hemicolectomy on [**2188-11-25**] with resection of a 4.5cm poorly differentiated adenocarcinoma with lymphovascular invasion. Seven of thirteen nodes were involved. MRI of the abdomen at the time of diagnosis showed two hepatic hemangiomas; no metastasis. She then completed six months of adjuvant chemotherapy with 5-FU/Leucovorin after having failed oxaliplatin due to severe nausea. Cancer recurred with Krukenberg tumor resected by left salpingoophorectomy and right salpingectomy in [**11/2189**], and again in right ovary status post right salpingoophorectomy in 8/[**2190**]. CEA rose and she was found to have pulmonary metastasis and then treated with irinotecan/Erbitux, completed in 4/[**2191**]. . CEA noted 95->276 in [**1-24**], CT TORSO on [**2191-2-13**] shows disease progression in the thorax and pelvis. She started first cycle of cpt-11 and erbitux on [**2-27**]. . . PMH: - colon cancer as above - bilateral oophorectomies - now on HRT Social History: Originally from [**Country 4812**], now living with her siblings in [**Location (un) 3146**], MA, denies etoh, tobacco, or ivdu. Has a 9 year old daughter (father of daughter lives in [**Country 4812**]) Family History: Unaware of incidence of colorectal, gastric, uterine, ovarian Ca in [**Country 4812**]. Physical Exam: T= 99.9 BP= 108/67 HR= 132 RR= 24 O2= 94% GENERAL: intubated, sedated HEENT: alopecia. well healed craniotomy scar. No conjunctival pallor. No scleral icterus. PERRLA/EOMI. MMM. OP clear. Neck: LIJ in place. No LAD, No thyromegaly. CARDIAC: tachycardic regular rhythm. Normal S1, S2. No murmurs, rubs or [**Last Name (un) 549**]. CHEST: Port in place. Bronchial breath sounds at LUL with coarsened breath sounds throughout. ABDOMEN: Well healed surgical scar. NABS. Soft, NT, ND. No HSM EXTREMITIES: No edema or calf pain, 2+ dorsalis pedis/ posterior tibial pulses. SKIN: No rashes/lesions, ecchymoses. Pertinent Results: Labs on Admission: [**2193-12-4**] 09:40AM BLOOD WBC-9.4 RBC-3.78* Hgb-10.0* Hct-31.7* MCV-84 MCH-26.5* MCHC-31.6 RDW-15.3 Plt Ct-353 [**2193-12-4**] 09:40AM BLOOD Neuts-87.9* Lymphs-8.9* Monos-2.3 Eos-0.6 Baso-0.2 [**2193-12-7**] 03:26AM BLOOD PT-15.4* PTT-32.1 INR(PT)-1.3* [**2193-12-4**] 09:40AM BLOOD Glucose-90 UreaN-11 Creat-0.3* Na-137 K-4.1 Cl-100 HCO3-26 AnGap-15 [**2193-12-5**] 05:37AM BLOOD Albumin-2.2* Calcium-7.4* Phos-3.3 Mg-1.8 Cardiac Enzymes: [**2193-12-4**] 09:40AM BLOOD CK(CPK)-28 [**2193-12-12**] 03:44PM BLOOD CK(CPK)-37 [**2193-12-4**] 09:40AM BLOOD cTropnT-<0.01 [**2193-12-6**] 10:02PM BLOOD CK-MB-1 cTropnT-<0.01 [**2193-12-12**] 03:44PM BLOOD CK-MB-2 cTropnT-<0.01 [**12-4**] CXR (multiple) extensive metatatic disease especially in LUL. IJ in good place. ETT in good position. No PTX or effusions. . [**11-27**] CT CHEST IMPRESSION: Marked interval progression of extensive pulmonary and left hilar nodal metastases with new bronchial compromise, left upper lobe. . [**11-20**] MRI HEAD IMPRESSION: 1. Mild increase in the left frontal enhancing lesion, which now measures 1.0 x 1.0 x 1.3 cm in the transverse, AP, and CC dimensions compared to the prior of 0.8 x 0.9 x 1.0 cm in similar dimensions. 2. Post-surgical changes noted in the left posterior fossa, with enhancement of the dura and mild enhancement in the surgical bed, with the area of blood products, in the surgical bed being smaller compared to the prior study. Thrombosis/post-surgical changes in the left transverse sinus, unchanged. 3. New FLAIR hyperintense focus in the left side of the splenium of the corpus callosum without enhancement and questionable decreased diffusion raising the possibility of subacute infarct or cystic change. Attention can be paid to this on followup scans. 4. Mildly low-lying cerebellar tonsils 0.8 cm below the margins of the foramen magnum, not significantly changed allowing for the technical differences. Brief Hospital Course: Ms. [**Known lastname 57314**] is a 37-year old Ethiopian lady with widely metastatic colon cancer to the brain and lungs who was admitted from the emergency department, where she was intubated for respiratory distress. Her [**Hospital Unit Name 153**] course was complicated by hypotension/sepsis and sustained polymorphic ventricular tachycardia. She died on [**2193-12-25**] at 2:25pm. Each of the problems addressed during this hospitalization are described in detail below: 1. RESPIRATORY DISTRESS- The patient was intubated for respiratory distress in the ED. Prior to intubation, the patient understood that there is a high chance that she may not be able to get extubated if her respiratory failure is largely secondary to metastatic disease. She that she would not want to remain intubated indefinitely should extubation attempts fail. On presentation, the patient was maintained on mechanical ventilation. Despite a course of empiric treatment for HAP with Vancomycin, Cefepime, Levaquin and Flagyl for 10 days, the patient's lung compliance remained extremely poor. All attempts to wean her off ventilation were unsuccessful. Decrease in PEEP resulted to volume loss and collapse. Bronchoscopy was performed which revealed no mucous plugging, but showed extensive extrinsic compression by the tumor. There was no further evidence of infecion, as the patient was afebrile, normotensive, with normal WBC count. A discussion with the family about the patient's goals of care are ongoing. Patient was made CMO on [**12-23**] and remained intubated until [**12-25**] until health care proxy elected to withdraw respiratory support. Patient expired on [**2193-12-25**] at 2:25pm. 2. METASTATIC COLON CANCER- The patient was seen by Oncology, who concluded that there are no further pallaiative treatments available at this point. Drs. [**Last Name (STitle) 57364**] and [**Name5 (PTitle) 1852**] [**Name5 (PTitle) 37653**] in ongoing discussions with the family. Rad Onc commented to family on lack of options on [**12-18**]. 3. HYPOTENSION/SEPSIS- On presentation, the patient was hypotensive likely secondary to sepsis and was maintained on Levophed in order to keep MAPs>65. The patient was pan-cultured and immediate empiric treatment with Vancomycin and Zosyn was initiated. After the initial dose, Zosyn was switched to Cefepime, and Levaquin and Flagyl were added. Over the next several days, hypotension has resolved and the patient remained afebrile with normal WBC counts. The patient completed a 10 day course of antibiotics. All cultures were negative. Sputum culture was negative for PCP. 4. SUSTAINED POLYMORPHIC VT- On [**2193-12-13**], the patient had sustained 41-beat run of polymorphic VT. Etiology was believed to be likely metabolic. Amiodarone gtt was initiated and the patient was transitioned to PO Amiodarone 400 [**Hospital1 **] the following day. Dosing was decreased on [**12-21**] and stopped on [**12-23**] when was made CMO. Medications on Admission: 1. Dexamethasone 4 mg q.a.m., 2 mg q.p.m. 2. Keppra 500 mg b.i.d. 3. Lorazepam p.r.n. 4. Morphine elixir p.r.n. calf pain. 5. Omeprazole 20 mg daily. 6. Zofran 48 mg p.r.n. nausea, vomiting Discharge Disposition: Expired Discharge Diagnosis: respiratory failure secondary to metastatic colon cancer to the lungs Discharge Condition: Discharge Instructions: Followup Instructions: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]

[ "198.89", "276.8", "518.84", "228.09", "197.0", "285.9", "198.3", "288.60", "276.52", "995.91", "V10.05", "427.1", "038.9", "564.00" ]

icd9cm

[ [ [] ] ]

[ "96.6", "96.04", "96.72", "38.91", "88.72", "38.93", "33.23" ]

icd9pcs

[ [ [] ] ]

8783, 8792

5553, 8537

296, 349

8909, 8909

3583, 3588

8991, 9099

2855, 2944

8813, 8885

8563, 8760

8936, 8936

2959, 3564

4049, 5530

239, 258

377, 1470

3603, 4031

1492, 2617

2633, 2839

32,348

146,380

3520

Discharge summary

report

Admission Date: [**2145-7-25**] Discharge Date: [**2145-7-26**] Date of Birth: [**2068-1-28**] Sex: M Service: MEDICINE Allergies: Clonidine Attending:[**First Name3 (LF) 2901**] Chief Complaint: Weakness, hypotension Major Surgical or Invasive Procedure: VT code with shock, CPR Intubation Right femoral CVL placement Right axillary a line placement History of Present Illness: The patient is a 77M with [**Hospital 10224**] medical problems including systolic CHF, 3V CAD s/p multiple BMS, ESRD on HD, atrial fibrillation on coumadin, CVA with residual R-sided deficits, recent hospitalization with nausea, vomitting, diarrhea and thrombosed AV fistula who presented to the ED with worsening diarrhea and lethargy. He was admitted to the hospital for similar symptoms twice in the past 2 weeks, recently discharged on [**7-23**]. At home, he had stool incontinence, which is chronic dating back to radiation, with worsening diarrhea up to 5 times per day of non-bloody, non-mucuus brown liquid diarrhea. In the ED, he denied abdominal pain, nausea, vomiting, fever or chills. No CP, no SOB. He has been feeling extremely weak at home for past day, his last HD was yesterday with limited making of urine. . In the [**Name (NI) **], pt had hypotension without anything focal on presentation. 76/34. He had a line in for HD and received fluids for sepsis and hypotension with SBP rising to low 90s. A femoral line was placed due to difficult access and preferred because of unkown INR. Pressures stayed in the 80s. Baseline was 100-110 per ED. He was subsequently started on dopa. After the line was placed, BP dropped to 65 and pt VT arrested (HR was 140s prior to this). He was shocked once, developed pulseless electrical activity and started on CPR. Epi x 2 and bicarb was given. Pt was in PEA for 4-5 minutes and then had return of spontaneous circulation. Pt was given succinylcholine and itnubated. Of note, pt had vomited right before the arrest. He was given levo and BP went to 90-100 and HR to 130. He got vanco, zosyn and rectal zosyn for presumed sepsis. Post cardiac arrest team was consulted regarding cooling protocol, but pt's mental status returned when he came to CCU (could follow commands) so cooling was not done. Pt received a total of 4.5L IVF in ED and an additional 1L in CCU. Trop 0.6 which is nl for him but MB is up. Past Medical History: - ESRD (CKD stage 5) on dialysis (Tues, Thurs, Sat) with left arm AV fistula placed in [**2143**] requiring multiple revisions, with attempted placement of PD catheter failed due to inguinal and pleural hernias. Renal failure caused by phospho-soda. - systolic CHF - last echo [**12/2144**] with EF 30%, severe hypokinesis of the interventricular septum (anterior and inferior) and anterior free wall, and extensive apical hypokinesis with focal dyskinesis. 2+ MR, 2+ TR, severe PA hypertension - Diabetes mellitus, insulin-dependent - Known CAD, s/p PCI with BMS to RCA for NSTEMI in [**5-/2142**]; 3VD on last cath in [**7-/2144**] - Atrial fibrillation: on coumadin for since ~[**2137**], with history of embolic CVA - Hypertension - Hyperlipidemia - CVA: Embolic in nature, over 15 years ago, with residual weakness in his right leg and arm - Prostate cancer status-post radiation therapy in [**2135**] - Radiation proctitis with bleed in [**2142**] requiring PRBC transfusion - radiation cystitis, requiring hospitalization - History of colon polyps - Diverticulosis - Hematuria requiring previous transfusions and cauterizations - Concern for Factor V Leiden - Hernias, inguinal and pleural Social History: - Lives in multilevel home w/ son and HCP [**Name (NI) **] [**Name (NI) **] in [**Name (NI) 3494**]. - walks using walker in house, cane outside house - Tobacco: Denies - Alcohol: Denies current use - Illicits: Denies Family History: -History of cardiac disease in family Physical Exam: Tmax: 37.3 ??????C (99.2 ??????F) Tcurrent: 37.3 ??????C (99.2 ??????F) HR: 103 (91 - 158) bpm BP: 81/69(72) {42/28(32) - 118/104(107)} mmHg RR: 17 (14 - 24) insp/min SpO2: 98% Heart rhythm: AF (Atrial Fibrillation) Mixed Venous O2% Sat: 54 - 54 Respiratory O2 Delivery Device: Endotracheal tube Ventilator mode: CMV/ASSIST/AutoFlow Vt (Set): 550 (550 - 550) mL RR (Set): 16 RR (Spontaneous): 0 PEEP: 10 cmH2O FiO2: 100% PIP: 28 cmH2O Plateau: 22 cmH2O SpO2: 98% Ve: 9.5 L/min PaO2 / FiO2: 94 General Appearance: No(t) Well nourished Eyes / Conjunctiva: PERRL Head, Ears, Nose, Throat: Endotracheal tube Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal), HR irregular Peripheral Vascular: (Right radial pulse: Absent), (Left radial pulse: Diminished), (Right DP pulse: Diminished), (Left DP pulse: Diminished) Abdominal: Soft, No(t) Non-tender, Bowel sounds present Extremities: Right lower extremity edema: Absent, Left lower extremity edema: Absent Skin: Not assessed Neurologic: Responds to: Noxious stimuli, Movement: Not assessed, Tone: Not assessed Pertinent Results: Admission labs: [**2145-7-25**] 01:40PM BLOOD WBC-8.4 RBC-3.08* Hgb-10.6* Hct-32.4* MCV-105* MCH-34.4* MCHC-32.7 RDW-16.1* Plt Ct-301 [**2145-7-25**] 01:40PM BLOOD Neuts-78* Bands-0 Lymphs-10* Monos-8 Eos-3 Baso-0 Atyps-0 Metas-1* Myelos-0 [**2145-7-25**] 04:00PM BLOOD PT-19.0* PTT-56.9* INR(PT)-1.7* [**2145-7-25**] 01:40PM BLOOD Plt Smr-NORMAL Plt Ct-301 [**2145-7-25**] 07:57PM BLOOD Glucose-183* UreaN-43* Creat-3.8* Na-137 K-6.2* Cl-101 HCO3-23 AnGap-19 [**2145-7-25**] 01:40PM BLOOD CK(CPK)-77 [**2145-7-25**] 01:40PM BLOOD CK-MB-14* MB Indx-18.2* cTropnT-0.60* [**2145-7-25**] 07:57PM BLOOD Calcium-9.6 Phos-6.6*# Mg-2.3 [**2145-7-25**] 01:40PM BLOOD Digoxin-1.3 [**2145-7-25**] 01:42PM BLOOD Glucose-234* Lactate-3.0* Na-135 K-4.9 Cl-94* calHCO3-27 [**2145-7-25**] 08:04PM BLOOD Type-ART Temp-37.2 pO2-79* pCO2-41 pH-7.38 calTCO2-25 Base XS-0 [**2145-7-25**] 06:42PM BLOOD O2 Sat-49 Brief Hospital Course: Mr. [**Known lastname 16149**] is 77 y/o M with a complicated PMH incl including systolic CHF, 3V CAD s/p multiple BMS, ESRD on HD, a fib on coumadin, CVA, recent hospitalizations with N/V/D and thrombosed AV fistula who presented with lethargy, diarrhea, and hypotension to ED. After femoral CVL was placed in the ED, he had a VT then PEA arrest, with return of spontaneous circulation with shock and CPR. He was transferred to the CCU in the evenng on [**7-25**] on levophed and dopamine for pressure support. He was noted to be responsive to commands so cooling protocol was not initiated. Family mtg with the pt's 2 sons and HCP (friend [**Name (NI) **] [**Name (NI) **]) but the CCU resident revealed that they thought the pt had been DNR. Unfortunately, this was never noted in his past [**Hospital1 **] records and he was ordered for full code status on his last admission. He was made DNR with no shocks or CPR in the evening of [**7-25**]. . Right axillary A line was placed by cardiac fellow and pt was maintained on pressors levo/dopa/vasopressin overnight. He was treated for arrhythmia with amiodarone, sepsis with vanco/zosyn. . Pts HCP, [**Name (NI) **] [**Name (NI) **] approached CCU resident at 8am stating he had talked to the pt's sons and they had agreed to make the pt [**Name (NI) 3225**]. The CCU team then rounded on the pt and attg Dr. [**Last Name (STitle) 911**] and fellow Dr. [**Last Name (STitle) 16157**] agreed that this was a reasonable decision as the pt was being maintained on 3 pressors and the etiology of his shock was still unclear. Pt's outpt cardiologist, Dr. [**Last Name (STitle) **] and NEOB were notified. Pressors and mechanical ventilation were weaned. Pt went asystolic on tele and was pronounced at 905am after physical exam. Son and HCP refused autopsy. Medical examiner was notified as this was a death w/i 24 hrs of admission and waived the case. Causes of death were: Cardiogenic/septic shock, ESRD on HD, CAD. Medications on Admission: Discharge Medications from [**2145-7-23**]: 1. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO once a day. 2. Carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO twice a day. 3. Sevelamer Carbonate 800 mg Tablet Sig: Two (2) Tablet PO three times a day. 4. Lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO once a day. 5. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO Sunday, Wednesday, Friday. 6. Coumadin 1 mg Tablet Sig: 1.5 Tablets PO once a day: please hold [**7-23**] and restart on [**7-24**]. . 7. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Capsule PO once a day. 8. Sevelamer Carbonate 800 mg Tablet Sig: One (1) Tablet PO once a day as needed for snack. 9. NPH Insulin Human Recomb 100 unit/mL Suspension Sig: One (1) 15 Subcutaneous qam. 10. Insulin Lispro 100 unit/mL Solution Sig: One (1) Subcutaneous Per sliding scale subcutaneous as directed. 11. Isosorbide Dinitrate 40 mg Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO twice a day. Discharge Medications: Pt deceased Discharge Disposition: Expired Discharge Diagnosis: Primary diagnosis: Cardiogenic and Septic shock Secondary diagnoses: VF arrest Respiratory failure ESRD on HD CAD A fib DM Systolic CHF EF 30-35% Discharge Condition: Deceased Discharge Instructions: Deceased Followup Instructions: Deceased [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2908**] MD, [**MD Number(3) 2909**] Completed by:[**2145-7-26**]

[ "285.9", "V45.11", "403.91", "V58.61", "428.22", "427.31", "428.0", "427.5", "438.89", "785.51", "414.01", "038.9", "995.92", "427.1", "V45.82", "607.89", "785.52", "585.6", "250.00" ]

icd9cm

[ [ [] ] ]

[ "96.71", "38.93", "38.91", "96.04", "99.60" ]

icd9pcs

[ [ [] ] ]

8974, 8983

5929, 7900

292, 388

9174, 9184

5012, 5012

9241, 9409

3870, 3909

8938, 8951

9004, 9004

7926, 8915

9208, 9218

3924, 4993

9074, 9153

231, 254

416, 2395

5029, 5906

9023, 9053

2417, 3618

3634, 3854

24,697

142,161

26873

Discharge summary

report

Admission Date: [**2133-11-10**] Discharge Date: [**2133-11-20**] Date of Birth: [**2088-7-24**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2297**] Chief Complaint: Acute alcohol intoxication/liver failure/bleeding gastric varices. Major Surgical or Invasive Procedure: Trans-jugular intrahepatic porto-systemic shunt (TIPS). Esophagogastroduodenoscopy (EGD). Bronchoscopy. History of Present Illness: 45M with history of alcoholism presented to OSH with hematemesis and now transferred to [**Hospital1 18**] for actively bleeding gastric varices. . The patient was in his USOH until the night prior to admission, when after drinking approximately a pint of hard liquor, his wife found him "about to pass out" and she lowered him onto the bed. His eyes subsequently rolled back and she called 911, but patient refused transport. EMTs were called once this happened again. The wife was later contact[**Name (NI) **] by the police who were contact[**Name (NI) **] by someone who witnessed the patient pull to the side of the road in his truck and discard his clothing, which were soaked in blood. The patien later admitted to vomiting a "bucket-full" of blood on his clothes in his truck. . At OSH, pt vomited 1800cc of blood. BP 87/54, HR 139. His hct was 28 and his INR 2.3 and he received 2U PRBC and 2U FFP. He was started on octreotide and levofloxacin and underwent an EGD which showed 4cm gastric fundic varices with active bleeding. Stomach was full of old and new blood. No noted esophageal bleeding lesions. Nothing was treated endoscopically and the patient was transferred to [**Hospital1 18**] for octreotide and for TIPS procedure. . In [**Hospital1 18**] [**Name (NI) **], pt noted to be tachycardic in 120s-140s with BP 120/80 and hct 32.1. He was given 10mg IV Valium x 3, banana bag, calcium gluconate 2g, Octreotide 50mcg/hr and pantoprazole 40mg IV x 1. Denies N/V, abdominal pain, CP, SOB. Reports tremulousness. He had an NG lavage which showed dark red blood which did not clear with 500cc. He was given 2U FFP in the ED. Past Medical History: 1. Alcohol abuse, drinks 1 pint/day, last sobriety ~2 yrs ago, no hx of withdrawl sz, previously admitted 2 yrs ago for detox 2. Anxiety 3. Depression 4. Admitted [**5-31**] for "dehydration", wife thought he was "yellow" Social History: Lives with his wife and two children (age 20 and 21). Works in road construction. Drinks one pint of hard liquor per night, last drink the evening of [**11-8**]. Smokes 1/2-1 ppd for thirty years. Family History: Father alcoholic and died at age 65 of complications of alcoholism. Sister also alcoholic. Mother alive with asthma. Physical Exam: Vitals: T 98.9 BP 146/74 HR 141 RR 21 97%RA Gen: ill-appearing man in NAD, breath smells of alcohol HEENT: PERRL, EOMI, sclerae icteric, dry mucous membranes, crusted blood on lips Neck: no JVD or LAD Lung: CTA bilaterally Chest: telangiectasias Cor: tachycardic, regular rhythm, nml S1S2 Abd: NABS, soft NTND Ext: slight palmar erythema, no edema Pertinent Results: Admission Labs: [**2133-11-10**] 01:31AM BLOOD WBC-9.5 RBC-3.25* Hgb-11.0* Hct-32.1* MCV-99* MCH-33.7* MCHC-34.1 RDW-14.5 Plt Ct-57* [**2133-11-10**] 01:31AM BLOOD Neuts-89.5* Lymphs-6.6* Monos-3.6 Eos-0.3 Baso-0.1 [**2133-11-10**] 01:31AM BLOOD PT-19.1* PTT-33.9 INR(PT)-2.6 [**2133-11-10**] 01:31AM BLOOD Plt Smr-VERY LOW Plt Ct-57* [**2133-11-10**] 10:10AM BLOOD Fibrino-144* [**2133-11-10**] 01:31AM BLOOD Glucose-138* UreaN-30* Creat-1.3* Na-144 K-5.5* Cl-102 HCO3-15* AnGap-33* [**2133-11-10**] 01:31AM BLOOD ALT-994* AST-2371* AlkPhos-80 TotBili-8.6* [**2133-11-10**] 01:31AM BLOOD Lipase-72* [**2133-11-10**] 01:31AM BLOOD Albumin-3.1* Calcium-7.1* Phos-3.9 Mg-1.6 [**2133-11-11**] 02:35AM BLOOD Ammonia-195* [**2133-11-10**] 04:30AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE HBcAb-NEGATIVE HAV Ab-POSITIVE [**2133-11-10**] 01:31AM BLOOD ASA-NEG Ethanol-136* Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2133-11-10**] 07:24AM BLOOD Type-ART pO2-78* pCO2-30* pH-7.51* calHCO3-25 Base XS-1 [**2133-11-10**] 06:52AM BLOOD Lactate-9.7* [**2133-11-10**] 10:15AM BLOOD Glucose-113* Lactate-5.7* Na-149* K-4.0 Cl-111 [**2133-11-10**] 10:15AM BLOOD Hgb-10.5* calcHCT-32 [**2133-11-10**] 04:44AM BLOOD freeCa-0.81* . CXR [**2133-11-10**]: 1. Confluent airspace opacities within the right and left lower lung zones, suggestive of multifocal pneumonia or aspiration. 2. Right IJ catheter is seen, with a kink in the proximal most portion. . TIPS [**2133-11-10**]: 1) Portal hypertension with pressure gradient between the portal vein and hepatic vein measured 14 mmHg prior to formation of the portosystemic shunt. Large gastric varices were demonstrated. 2) Transjugular intrahepatic portosystemic shunt placement and alcohol embolization of two large gastric varices with good angiographic results was performed. The post-TIPS portosystemic pressure gradient was reduced to 9 mmHg. 3) Placement of a 9-French 11 cm triple-lumen central venous catheter via the right internal jugular vein with the tip in the SVC, ready for use. . ECG [**2133-11-10**]: Sinus tachycardia; Modest diffuse nonspecific ST-T wave changes. . CXR [**2133-11-11**]: Increased opacification at the left lung base likely represents worsening pneumonia or aspiration. Improved aeration of the right lung base probably represents improving atelectasis. . RUQ u/s [**2133-11-11**]: The left portal vein is not visualized. There is hepatopetal flow within the main portal vein with velocities of approximately 15 cm/sec. The TIPS is poorly visualized. There appears to be wall-to-wall flow velocities of approximately 37, 60, and 76 cm/sec returned from the proximal, mid, and distal TIPS respectively. The IVC is patent. There is no evidence of intra or perihepatic hematoma. . CT head [**2133-11-12**]: There is no intracranial hemorrhage, abnormal extra-axial fluid collection, mass effect or midline shift. The ventricles and basal cisterns are unremarkable. The slightly lower attenuation of the left temporal lobe is thought to be artifactual given the slightly asymmetric positioning of the patient's head. There is no definite focal effacement in this area. Fluid in the ethmoid, sphenoid, and maxillary sinuses is probably secondary to endotracheal intubation. . CXR [**2133-11-12**]: Heterogeneous opacification at the right lung base, which cleared between [**11-10**] and 16, has recurred. Although I cannot exclude pneumonia, the sequence of events more likely reflects asymmetric edema accompanied by small bilateral pleural effusions. Left lower lobe atelectasis persists. The heart is normal size. There is no pneumothorax. Tip of endotracheal tube at the thoracic inlet is more than 8 cm from the carina, 4 cm above optimal placement. Tip of the right jugular sheath projects over the SVC. No pneumothorax or mediastinal widening. . ECG [**2133-11-12**]: Sinus rhythm. Non-diagnostic repolarization abnormalities. Compared to the previous tracing of [**2133-11-10**] heart rate is slower. Otherwise, no major change. . CXR [**2133-11-13**]: Consolidation in the lungs, particularly the left has increased substantially since [**10-11**], having improved between 15 and 16. Some of this may be due to pulmonary edema but worsening pneumonia, particularly in the left lung is presumed. Tip of the endotracheal tube is above the upper margin of the clavicles, more than 8 cm from the carina and 4 cm above optimal placement. Nasogastric tube passes into the stomach and out of view. Right internal jugular sheath projects over the expected course of the right internal jugular vein, but is sharply folded proximally. There is at least a small left pleural effusion. The heart is top normal size and unchanged. There is no pneumothorax. . Brief Hospital Course: A 45yoM with history of alcoholism presented with large amount of hematemesis and was transferred to [**Hospital1 18**] for actively bleeding gastric varices seen on EGD. . 1. GI bleed: The Pt. was admitted with a history and LFT pattern consistent with alcoholic liver failure/cirrhosis. The Pt. was transfused with pRBCs for goal Hct>30. The patient was started on octreotide gtt, levofloxacin (per data showing benefit with esophageal varices) for 10 days, and IV protonix. The patient was evaluated by the liver/gi service and underwent the TIPS procedure. Following the TIPS procedure, the Pt's hematocrit remained stable, and transaminases and NH3 trended down toward normal levels, although bilirubin levels increased. The patient had an NG tube placed, and was treated with lactulose and rifaximin, and tube feeds were started on hospital day 4. . 2. Fever: The Pt. had persistent fevers upon admission. Initially Pt. had no signs of infection, and neuro exam (pupils, extremity tone) was unchanged. A head CT was negative. Due to liver disease, Pt. was not treated with acetaminophen; instead a cooling blanket was used. Due to concern for an aspiration pneumonia, the Pt. was started on levofloxacin and clindamycin on admission. Fluid from a bronchoalveolar lavage (BAL) grew 4+ gram positive cocci in pairs and clusters. Vancomycin was added to the regimen for improved gram positive coverage. . 3. Respiratory failure: The patient was intubated upon admission for airway protection, and maintained on assist control ventilation with propofol sedation. The Pt's pCO2 was allowed to run around 55, and CPAP + pressure support trials were initiated, which the Pt. seemed to tolerate. By hospital day 4, the Pt. was off sedation, but still remained asleep and essentially unresponsive. Fentanyl gtt was titrated to Pt. comfort while ETT tube was in place. . 4. Hepatitis: Pt. was admitted with elevated LFTs, likely a result of alcoholic cirrhosis, especially given transaminase ratio AST:ALT > 2:1. Presence of gastric varices points to cirrhosis. The patient underwent the TIPS procedure and was treated with rifaximin as above. Viral and autoimmune serologies were negative for Hep B and Hep C but positive for Hep A, and a ceruloplasmin level was found to be 16 (low). Following the TIPS procedure, the Pt's LFTs normalized, however, the bilirubin increased from 9.9 up to 25.4. The etiology of this was thought to be either TIPS-induced liver dysfunction vs. post-op jaundice and sepsis. On hospital day 7 the pt began to show signs of acute renal failure, and hepatorenal syndrome was considered likely, with the normalizing LFTs actually representing loss of synthetic liver function. . 5. Alcoholism: Pt's last alcoholic drink was [**11-8**]. Tremulousness and tachycardia on admission were likely related to alcohol withdrawal. The patient was treated with valium 5-10mg Q1H:PRN dosed according to a CIWA Scale. . #. Psych: The Pt. has a history of depression, anxiety and substance abuse. Urine toxicology on admission was positive for cocaine, though wife did not know about a history of drug abuse. Social Work and substance abuse were consulted and met with the Pt. after he woke up. He was also treated with a nicotine patch. . #. Tachycardia: Likely related to both active GI bleed and hypovolemia as well as alcohol withdrawal given concomitant tremulousness. Initial management addressed hemodynamic stability and fluid resuscitation, and then the Pt. was treated with nadolol, which has non-specific beta 1&2 blocking activity. . 6. ARF: Creatinine normalized initially. Pt. was initially prerenal related to blood loss. Cr normalized following fluid/blood product resuscitation, and Is/Os were monitored throughout hospitalization. On hospital day 7, the Cr began to rise dramatically, and hepatorenal syndrome was considered likely. The renal service was involved to monitor his requirements for hemodialysis. . 7. Metabolic acidosis: Anion gap initially 27, likely related to alcoholic ketoacidosis, closed following TIPS procedure and resolution of transaminitis. Electrolytes were monitored and aggresively repleted. . 8. FEN: The patient was initially given thiamine, folate, D5, MVI, and electrolytes were monitored and repleted. After placement of an NG-tube, tube feeds were started with free water boluses via NG tube for hypernatremia 250cc Q4H + 1L D5 today (free water deficit was ~7L). Erythromycin IV was used to encourage forward gi motility. . 9. Prophylaxis: The patient wore pneumoboots and was treated with IV protonix during the time he was sedated/intubated. . As the hepatorenal syndrome worsened, the liver and renal services felt that the patient's prognosis was extremely poor and thus recommended against hemodialysis given that the patient was unlikely to recover. After several family discussions, the family decided to withdraw care. The patient expired on [**2133-11-20**]. Medications on Admission: (Pt is non-compliant) Buspirone Disulfuram Discharge Medications: none Discharge Disposition: Expired Discharge Diagnosis: bleeding gastric varices alcoholism hepatorenal syndrome Discharge Condition: expired Discharge Instructions: n/a Followup Instructions: n/a

[ "V09.0", "571.2", "276.52", "303.01", "482.41", "571.1", "305.60", "995.92", "572.3", "286.7", "507.0", "038.9", "518.81", "584.9", "305.1", "572.2", "285.1", "578.0", "570", "572.4", "276.2", "291.81", "456.8" ]

icd9cm

[ [ [] ] ]

[ "99.05", "99.06", "99.07", "96.72", "44.44", "96.07", "96.04", "33.24", "99.04", "96.6", "39.1" ]

icd9pcs

[ [ [] ] ]

12979, 12988

7895, 12856

384, 490

13089, 13098

3148, 3148

13150, 13156

2646, 2765

12950, 12956

13009, 13068

12882, 12927

13122, 13127

2780, 3129

278, 346

518, 2167

3164, 7872

2189, 2413

2429, 2630

15,278

107,592

28679

Discharge summary

report

Admission Date: [**2143-8-5**] Discharge Date: [**2143-8-24**] Date of Birth: [**2092-8-15**] Sex: M Service: MEDICINE Allergies: Sulfa (Sulfonamides) Attending:[**First Name3 (LF) 9240**] Chief Complaint: hypotension, jaundice Major Surgical or Invasive Procedure: US guided placement of cholecystostomy tube CT guided placement of biloma drain History of Present Illness: 51 y/o m with h/o PVD p/w 2 weeks of decreased appetite and 3 day hx RUQ pain and increasing jaundice at OSH on admission last week. He also p/w 20-30 pound weight loss. . Of note, on the day of admission, the pt was initially sent to the ERCP suite for procedure from [**Hospital 8**] Hospital with plan of returning him post-procedure. However, on arrival, he was reportedly obtunded, hypoglycemic and hypotensive to 70/40. He was given D5W and sent back to [**Hospital 8**] Hospital. He was reportedly fluid responsive there but was sent back to [**Hospital1 **] for further management. . ROS: Unable to fully obtain, pt denied SOB/CP, had severe abd pain and little appetite. Past Medical History: Etoh abuse (confirmed by father) [**Name (NI) 7792**] Rheumatoid Arthritis PVD c/b amputations Social History: No sig other or children, father lives in [**Name (NI) **]. Did not answer questions re: EtoH or smoking Family History: Brother with adv esophageal ca Physical Exam: Vitals: T 99.4// BP 71/47// HR 94// rr 32// O2 sat 100%2L Gen: cachetic, jaundiced agitated man, appears older than stated age HEENT: Adentulous, mm dry, scleral icterus Neck: Supple, no LAD, scars midline Heart: RR no m/g/r Lungs: Diffusely rhonchorous a/l ABd: Distended, tender esp in RUQ with guarding no rebound, hypoactive but present BS Ext: Warm well-perfused, b/l TMAs, 2+ DPs Psych: A&O to self, year, [**Location (un) **]Hospital Pertinent Results: [**2143-8-5**] 08:05PM GLUCOSE-86 UREA N-4* CREAT-0.3* SODIUM-134 POTASSIUM-3.1* CHLORIDE-106 TOTAL CO2-22 ANION GAP-9 [**2143-8-5**] 08:05PM ALT(SGPT)-162* AST(SGOT)-443* LD(LDH)-223 ALK PHOS-1501* AMYLASE-26 TOT BILI-13.3* [**2143-8-5**] 08:05PM LIPASE-32 [**2143-8-5**] 08:05PM ALBUMIN-1.6* CALCIUM-6.3* PHOSPHATE-2.3* MAGNESIUM-1.5* [**2143-8-5**] 08:05PM HBsAg-NEGATIVE HBs Ab-NEGATIVE HBc Ab-NEGATIVE HAV Ab-NEGATIVE [**2143-8-5**] 08:05PM HCV Ab-NEGATIVE [**2143-8-5**] 08:05PM WBC-9.1 RBC-2.87* HGB-8.8* HCT-26.8* MCV-94 MCH-30.6 MCHC-32.7 RDW-23.2* [**2143-8-5**] 08:05PM NEUTS-92* BANDS-0 LYMPHS-1* MONOS-3 EOS-0 BASOS-2 ATYPS-1* METAS-0 MYELOS-1* [**2143-8-5**] 08:05PM HYPOCHROM-3+ ANISOCYT-2+ POIKILOCY-OCCASIONAL MACROCYT-OCCASIONAL MICROCYT-OCCASIONAL POLYCHROM-NORMAL TARGET-OCCASIONAL TEARDROP-OCCASIONAL HOW-JOL-OCCASIONAL BITE-OCCASIONAL FRAGMENT-OCCASIONAL [**2143-8-5**] 08:05PM PLT SMR-VERY LOW PLT COUNT-55* [**2143-8-5**] 08:05PM PT-14.9* PTT-60.8* INR(PT)-1.3* [**2143-8-5**] 08:05PM FDP-0-10 [**2143-8-5**] 08:05PM FIBRINOGE-380 D-DIMER-1115* [**2143-8-5**] 07:33PM URINE HOURS-RANDOM CREAT-108 SODIUM-90 [**2143-8-5**] 07:33PM URINE COLOR-Brown APPEAR-Cloudy SP [**Last Name (un) 155**]-1.010 [**2143-8-5**] 07:33PM URINE BLOOD-LGE NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-50 BILIRUBIN-LG UROBILNGN-4* PH-7.0 LEUK-SM [**2143-8-5**] 07:33PM URINE RBC-880* WBC-15* BACTERIA-MOD YEAST-NONE EPI-2 [**2143-8-5**] 07:33PM URINE MUCOUS-RARE COMMENT-DUE TO ABNORMAL URINE COLOR INTERPRET DIPSTICK WITH CAUTION [**2143-8-5**] GB US: 1. Distended gallbladder with edematous wall which, in the correct setting, may represent acute acalculous cholecystitis. Correlation with patient's clinical status and lab values recommended. Alternatively, HIDA scan could be obtained. 2. Diffusely echogenic liver, compatible with patient's known history of hepatitis C. No ascites or evidence of portal venous hypertension. More serious forms of liver disease cannot be excluded on the basis of this study. [**2143-8-6**] CT Abd: Successful readjustment of percutaneous cholecystotomy tube with the pigtail well formed within the gallbladder. [**2143-8-6**] Abd US: A limited ultrasound examination was performed of the right upper quadrant. The cholecystostomy tube was seen entering the gallbladder, although its course within the gallbladder and extension through the posterior wall was not well visualized on ultrasound despite multiple attempts. Heterogeneously echoic material was identified within the gallbladder consistent with hemorrhage/clot. It was decided that due to the lack of visualization of the catheter that readjustment of the catheter would be better performed using CT guidance. Therefore, ultrasound-guided adjustment of the catheter was aborted. [**2143-8-6**] CT Abd: 1. Errant course of cholecystostomy tube as described. Repositioning is suggested. Small collection of blood both within the gallbladder and moderate- sized around the liver. 2. Heterogeneous pelvic presacral retroperitoneal masses with adjacent lymphadenopathy. Areas of low attenuation consistent with fat narrows the differential to include liposarcoma or teratoma. Extramedullary hematopoiesis would also be a possibility in the appropriate clinical setting 3. Heavily calcified internal and external iliac vessels consistent with underlying atherosclerotic disease. 4. Degenerative changes of lower thoracic and lumbar spine. 5. Bilateral pleural effusions and associated atelectasis. 6. Free fluid within both the pelvis and abdomen. [**2143-8-6**] GB Drainage US: ULTRASOUND-GUIDED CHOLECYSTOSTOMY TUBE PLACEMENT: Written informed consent was obtained by the ICU/surgical house staff. The procedure was performed emergently at bedside in the Intensive Care Unit. Ultrasound was used to select an appropriate spot for percutaneous cholecystostomy tube placement. The area was prepped and draped in sterile fashion. The skin and subcutaneous tissues were anesthetized using 7 cc of 1% lidocaine. Using continuous son[**Name (NI) 493**] guidance, a 8 French [**Last Name (un) 2823**] catheter was advanced into the gallbladder. Aspiration yielded clear dark brown fluid. The needle and stiffener were then removed. The pigtail was deployed. Approximately 100 cc of additional bilious fluid was then aspirated and removed to bag drainage. Post-procedure imaging showed the catheter within a nearly collapsed gallbladder. Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1968**], the attending radiologist, performed the procedure. The patient tolerated the procedure well without immediate complication. ICU nursing provided sedation throughout the procedure, during which the patient was under continuous hemodynamic monitoring. A total of 75 mcg of fentanyl and 1 mg of Versed were administered. IMPRESSION: Bedside placement of percutaneous cholecystostomy tube. pCXR: Cardiac silhouette is enlarged. There is a left retrocardiac opacity with obscuration of the left medial hemidiaphragm. There is also some atelectasis seen in the right mid lung field. No focal consolidation is seen. The patient has a right IJ central line with distal tip at the mid SVC. There is fixation plate in the lower cervical spine. A left humeral prosthesis is seen. [**2143-8-9**] MRCP Within the lesser sac, there is a 7.3 x 10.5 X 10.8 cm, loculated fluid collection with thin septations and a thickened enhancing wall, which is slightly increased in size compared to the prior CT study of [**2143-8-6**]. A separate component extends through the esophageal hiatus into the left chest, unchanged from the [**2143-8-6**] CECT. A portion of the collection surrounds the caudate lobe of the liver. The stomach is draped over this collection superiorly and anteriorly, and its inferior aspect is bounded by the transverse colon. As such, an accessible window for drainage by cross sectional imaging is limited. A CT study after decompression of the stomach with an NG tube to evaluate for a possible accessible percutaneous drainage window could be attempted. Alternatively, an endoscopic approach could be performed. Previously placed cholecystostomy catheter is seen through the liver to the gallbladder wall, it's tip is not well identified, though some images suggest it is within the gallbladder. There is a tiny 2-cm collection within segment V of the liver and the gallbladder, unchanged (series 200, image 20). Small-to-moderate amount of ascites has slightly increased in the interval. No focal liver lesions are seen. The spleen, adrenal glands, and kidneys are normal in appearance. Findings were discussed with Dr. [**Last Name (STitle) **]. [**Doctor Last Name **] on [**2143-8-13**] at 3:30 p.m. IMPRESSION: Mildly complex organized fluid collection in the lesser sac, likely representing a biloma, which has slightly increased in size from the CT study of one week prior. No definite percutaneous accessible drainage window is readily identified. [**2143-8-14**] CT Hepatic Drainage: 1. Successful placement of abdominal fluid collection drainage catheter. 2. Multiple presacral heterogeneous masses suggestive of liposarcoma, teratoma, nerve sheath tumors or possibly extramedullary hematopoiesis as previously indicated. Given profound osteopenia, extraosseous myeloma is considered. MR would be helpful in further evaluation.Biopsy could be performed when the patients acute condition allows 3. Dense atherosclerotic calcification and marked degenerative osseous changes as described above. 4. Bilateral pleural effusions and associated atelectasis. [**2143-8-20**] CT OF THE ABDOMEN WITH IV CONTRAST: The lung bases reveal bilateral improvement in pleural effusions with small fluid collections within the pleurae persisting bilaterally. No nodules, opacities, or infiltrates are noted at the lung bases bilaterally. The visualized heart and pericardium are unremarkable. No focal lesions are identified within the liver. The cholecystostomy tube is again identified and is coiled within the gallbladder. The pancreas, spleen, adrenal glands, and kidneys are unremarkable. Fluid collection within the lesser sac is again identified and measures approximately 8 x 5.5 cm. This is smaller than on the previous study where it measured 11 x 7 cm. A draining catheter is noted in the anterior aspect of the collection. Visualized loops of small and large bowel are unremarkable. No free air is identified. Another small fluid collection is seen in series 2, image 44 in the right side of the abdomen measuring approximately 22 x 26 mm. Of note, fluid is seen tracking into the esophageal hiatus and is stable when compared to previous study. Also noted multiple soft tissue densities likely representing lymph nodes were identified near the left crux of the diaphragm retroperitoneally. These are best seen in series 2, images 5 through 12. Again note is made of dense atherosclerotic calcification of the aorta and its branches. CT OF THE PELVIS WITH CONTRAST: Again the pelvis is poorly visualized secondary to artifact from bilateral femoral prostheses. Again identified are two heterogeneous retroperitoneal masses located presacrally with a third smaller similar-appearing heterogeneous mass noted superiorly lateral to the iliac vessels. These are unchanged in appearance compared to previous exam. Surgical clips are again identified in the right pelvis. Small amount of pelvic fluid is again identified. BONE WINDOWS: Osseous structures are significant for bilateral hip prostheses and diffuse osteopenia. Multiple compression deformities of the thoracic and lumbar spine are noted on sagittal images. Multiple previous healed pelvic fractures are also again noted. IMPRESSION: 1. Interval successful partial drainage of abdominal fluid collection. Catheter is located in more anterior aspect of remaining fluid, which seems to be located more posteriorly. Since the anterior and posterior aspects of this fluid collection seem to communicate adjusting patient position may assist in further drainageI(ie prone position) . If this is unsuccessful, advancement of the catheter is an option. This was discussed with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] at the time of this dictation. 2. Previously defined multiple presacral heterogeneous masses with the differential including liposarcoma, teratoma, extramedullary hematopoiesis, and nerve sheath tumors. Recommend biopsy as patient's condition allows. Soft tissue masses likely representing lymphadenopathy also noted in the retroperitoneum near the left diaphragmatic crux. . 3. Improvement in bilateral pleural effusions. 4. Marked osteopenia and degenerative changes of lumbar and thoracic spine including compression deformities. Brief Hospital Course: 1. Hypotension: Presented as high CO state and low SVR, consistent with sepsis. Given transaminitis, found to have acalculous cholecystitis. An US guided cholecystostomy tube was placed. He continued to have severe abdominal pain and a CT was checked which showed the cholecytostomy tube went all the way through the gallbladder. The tube was then pulled back under guidance, and follow up CT showed correct placement. Gallbladder aspirate grew pansensitive Klebsiella. Pt. was treated with levofloxacin and flagyl and will continue this for a total of 2 weeks. On the floor pt. improved initially but then developed persistent abdominal pain/nausea, f/u CT showed interval development of extracholecystic biloma. A drainage tube was inserted under CT guidance. The patient then improved greatly with improved abdominal pain and began tolerating a regular diet. Pt. then accidentally pulled out the cholecystostomy tube, but his abdominal pain remained improved. A follow up CT showed interval decrease in size of his biloma. Pt. will need to have a follow up CT in 2 weeks ([**9-6**]) after discharge to evaluate his biloma, if this is improved and the drain is putting out less than 10cc/d his drain will be pulled by CT radiology. . 2. Bilateral heterogenous retroperitoneal masses: Discovered incidentally on CT abdomen. Appearance c/w either teratomas or lipomyosarcomas. Oncology consulted and HCG and AFP levels checked and found to be normal, rec f/u as outpatient for CT guided biopsy when acute illness resolved. . 3. Adrenal Insufficiency: Found to be persisitently hypotensive to 70-80/40-50, but asymptomatic. [**Last Name (un) **] stim test showed inappropriate response, with baseline low cortisol. Seen by endocrine service and started on prednisone 10 mg daily. They felt it may be difficult to ever take him off this given his long h/o steroid use. His aldosterone levels were appropriate and he was felt not to need florinef. . 4. EtOH dependence: Initially put on CIWA scale in ICU but never required much benzodiazepine. No clear signs of EtOH withdrawl. . 5. [**Last Name (un) 7792**]: Rec'd heparin gtt, BB, ASA at OSH for CE elevation. CE's positive there. Trop I elevated here and trending up, despite normal CK. Likely [**1-17**] to hypovolemia and sepsis picture. Not C/W ACS. CE trended down eventually. . 6. Bowel movements: Loose stool. ? infection vs. obstruction C diff negative but given empiric course of flagyl. . 7. Thrombocytopenia: DDx incl hypersplenism (though no portal htn on u/s), marrow suppression [**1-17**] EtOH. HIT neg. Platelets improved on discharge. . 8. Anemia: Likely in part dilutional, may be related to BM suppression. Phlebotomy, as well as chronic oozing. Not c/w acute DIC. Iron studies c/w anemia of chronic disease. B12/folate wnl. Given 1 unit PRBCs on [**8-7**], subsequently hct remained stable. . 10) PPX: Pneumoboots, PPI . 12) Code: Full . 13) Comm: Pt and father [**Name (NI) **] [**Known lastname 69375**] [**Telephone/Fax (1) 69376**] cell Medications on Admission: 1. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 2. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 3. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q6H (every 6 hours) as needed. Disp:*qs 1 month* Refills:*2* 4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 7. Oxycodone 5 mg Tablet Sig: Two (2) Tablet PO Q3H (every 3 hours) as needed. Disp:*30 Tablet(s)* Refills:*0* 8. Gabapentin 300 mg Capsule Sig: Two (2) Capsule PO Q8H (every 8 hours). Disp:*qs 1 month* Refills:*2* Discharge Medications: 1. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 2. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 3. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q6H (every 6 hours) as needed. Disp:*qs 1 month* Refills:*2* 4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 5. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 10 days. Disp:*10 Tablet(s)* Refills:*0* 6. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 10 days. Disp:*30 Tablet(s)* Refills:*0* 7. Oxycodone 5 mg Tablet Sig: Two (2) Tablet PO Q3H (every 3 hours) as needed. Disp:*30 Tablet(s)* Refills:*0* 8. Gabapentin 300 mg Capsule Sig: Two (2) Capsule PO Q8H (every 8 hours). Disp:*qs 1 month* Refills:*2* 9. Prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Acalculous Cholecystitis Intrabdominal Biloma Bilateral Retroperiteal Masses Discharge Condition: stable Discharge Instructions: Please continue your regular medications. Please follow up with your PCP in the next week. Please follow up for your CT scan of your abdomen on the 22nd. The radiologists will tell you at that time if your tube can come out. Please change your drain dressing daily and empty your bag daily. Followup Instructions: 1. Please have your follow up CT scan of your abdomen on [**2143-9-6**] at 9am in the [**Hospital Unit Name 1825**], [**Location (un) 470**]. You can call [**Telephone/Fax (1) 327**] if you have questions. Make sure you have nothing to eat/drink 3 hours prior to exam. They will use this scan to determine if your biloma drain can be removed. 2. Please follow up with your PCP in the next week. You will need to have your bilateral retroperitoneal masses followed up with either CT guided biopsy or serial imaging.

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Discharge summary

report

Admission Date: [**2204-4-8**] Discharge Date: [**2204-4-13**] Date of Birth: [**2137-7-10**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 2387**] Chief Complaint: feeling unwell Major Surgical or Invasive Procedure: Right Internal Jugular Line placement History of Present Illness: 66 yo m with DM, h/o CAD s/p CABG with PCI in '[**99**], severe PVD, CKD, and s/p Vfib arrest who presents with 1 day of vague symptoms. He reports that he started feeling unwell yesterday afternoon with nausea, lightheadedness, and some shortness of breath. He denies chest pain or pressure, palpitations, vomiting, sweating. He was noted to be altered by his wife with concern re: difficulty speaking, perhaps a left sided facial droop and possible left hemianopsia, but limited evidence for this. The patient denies having any difficultly speaking or visual changes, but says that he was confused and seeing things that weren't there. His wife reported to the neurologist that he never had a facial droop. . He reports chronic DOE, no CP at rest or with exercise, + claudication (calf pain) with ambulating 2 blocks, denies orthopnea, sleeps on 4 pillows at night. + PND. He reports LE edema at baseline. He lost 10 lbs over past 3 months, which he attributes to diet and exercise. He initially went to an OSH, where CT head was negative. He was found to have new [**Last Name (un) **] and elevated cardiac enzymes. He was hypotensive at OSH to SBP 80s, started on peripheral dopamine and sent to the ED. In the ED, initial vs were: 98.9 86 94/45 on dopamine 20 95%. He was also reporting worsening of chronic low back pain. His exam was notable for [**3-11**] murmur, benign abdomen, rectal was guaiac neg. A bedside U/S in the ED was neg for pericardial effusion. Cardiology consult was requested for stat ECHO in ED, to look for new WMA, but was not performed. EKG was not felt to be markedly changed from baseline. There was some concern for aortic aneurysm given back pain so he had a CT torso w/o contrast, which was negative for aneurysm. Vascular was consulted and felt aortic dissection was unlikely. Neurology was consulted for concern re: TIA and they did not feel he had a primary neurologic process. Due to persistent hypotension, a RIJ was placed and he was started on levofed. He was not given any antibiotics as he was afebrile without e/o infection. VS prior to transfer were 79 93/36 on levofed 0.12mcg, 18 99% on 3L. Past Medical History: Diabetes Dyslipidemia Hypertension Severe CAD s/p CABG in [**2196**] and PCI in [**2199**] CKD (Baseline Cr = 2.6) S/p VF arrest on a treadmill test in [**2196**] Bilateral SFA stenting with re-stenosis and arthectomy (+) ABI and claudication (worse on L) [**4-11**] - left common femoral to below-knee popliteal artery bypass with non reversed right saphenous vein Social History: Lives with wife, immigrated from Caribbean approximately 40 years ago. Retired construction worker. -Tobacco history: Denies -ETOH: Denies -Illicit drugs: Denies Family History: Mother died of stroke at age 45. Father with diabetes and hypertension and died at age 70. Two brothers with coronary artery disease, one died [**2200**] at age 59 from MI. Physical Exam: Admission Exam: Vitals: 79 93/36 on levofed 0.12mcg, 18 99% on 3L General: Alert, oriented x3, no acute distress HEENT: Sclera anicteric, EOMI, MMM, oropharynx clear Neck: CVL in right IJ (CVP 21), supple, difficult to assess JVP on left, no LAD Lungs: bilat rales at bases. CV: Regular rate and rhythm, distant heart sounds, normal S1 + S2, 2/6 SEM at RUSB, no rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: foley in place Ext: cool extremities, unable to palpate DP or PT pulses, trace non-pitting edema. NEURO: CN 2-12 intact, MAE, sensation grossly intact. Disharge Exam: General: Alert, oriented x3, answering questions appropriately, no acute distress HEENT: Sclera anicteric, EOMI, MMM, oropharynx clear Neck: CVL in right IJ (CVP 21), supple, difficult to assess JVP on left, no LAD Lungs: bilat rales at bases. CV: Regular rate and rhythm, distant heart sounds, normal S1 + S2, 2/6 SEM at RUSB, no rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: foley in place Ext: cool extremities, unable to palpate DP or PT pulses, trace non-pitting edema. NEURO: CN 2-12 intact, MAE, sensation grossly intact. Pertinent Results: Admission Labs: [**2204-4-8**] 04:00AM BLOOD WBC-8.3 RBC-4.82 Hgb-12.6* Hct-38.4* MCV-80* MCH-26.1* MCHC-32.7 RDW-14.9 Plt Ct-271# [**2204-4-8**] 04:00AM BLOOD PT-22.5* PTT-27.2 INR(PT)-2.1* [**2204-4-8**] 04:00AM BLOOD Glucose-135* UreaN-66* Creat-5.0*# Na-137 K-4.0 Cl-107 HCO3-20* AnGap-14 [**2204-4-8**] 04:00AM BLOOD ALT-150* AST-59* LD(LDH)-250 AlkPhos-109 TotBili-0.2 Cardiac Markers: [**2204-4-8**] 04:00AM BLOOD cTropnT-0.39* [**2204-4-8**] 07:15AM BLOOD CK-MB-16* MB Indx-6.6* [**2204-4-8**] 07:15AM BLOOD cTropnT-0.44* [**2204-4-8**] 04:34PM BLOOD CK-MB-19* MB Indx-6.7* cTropnT-0.56* [**2204-4-9**] 01:34AM BLOOD CK-MB-14* MB Indx-5.5 cTropnT-0.50* [**2204-4-9**] 06:19AM BLOOD CK-MB-12* MB Indx-5.0 cTropnT-0.53* [**2204-4-9**] 05:30PM BLOOD CK-MB-9 cTropnT-0.71* [**2204-4-8**] 04:59AM BLOOD Lactate-1.3 K-4.0 [**2204-4-8**] 07:32AM BLOOD Lactate-1.0 Imaging: carotid series: [**2204-4-9**] 1. Less than 40% stenosis of the right internal carotid artery. 2. 40-59% stenosis of the left internal carotid artery. 3. Reversal of flow in the right vertebral artery, suggestive of subclavian steal. Echo: [**2204-4-9**] Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Overall left ventricular systolic function is severely depressed (LVEF= 25-30 %) with global hypokinesis and apical akinesis. A left ventricular mass/thrombus cannot be excluded. There is no ventricular septal defect. with severe global free wall hypokinesis. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are structurally normal. No mitral regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion CT abdomen/ pelvis: [**2204-4-8**] 1. normal caliber thoracic and abdominal aorta. no hematoma detected. Dissection cannot be detected due to lack of IV contrast. 2. Unusually large appendix (12 mm diameter) but no secondary signs of appendicitis. This may represent a mucocele, and elective resection should be considered. 3. Hyperdense right renal mass may represent a hemorrhagic cyst, but this is incompletely evaluated with this technique. This can be further assesed with ultrasound. 4. No acute intrathoracic, intraabdominal, or intrapelvic process seen. 5. Enlarged pretracheal lymph node. Discharge Labs: CBC: WBC-7.8 RBC-5.01 Hgb-12.7* Hct-38.0* MCV-76* MCH-25.4* MCHC-33.4 RDW-14.4 Plt Ct-221 PT-19.4* PTT-72.0* INR(PT)-1.8* Glucose-140* UreaN-102* Creat-3.8*# Na-140 K-3.7 Cl-103 HCO3-24 AnGap-17 ALT-50* AST-21 AlkPhos-94 TotBili-0.2 Calcium-8.8 Phos-3.7 Mg-2.2 Brief Hospital Course: 66 yo m with DM, h/o CAD s/p CABG with PCI in '[**99**], severe PVD, CKD, and s/p Vfib arrest who presents with 1 day of vague symptoms found to have hypotension, [**Last Name (un) **] and elevated CE. # Shock/Hypotension: On arrival to the ED, patient's exam was most consistent with cardiogenic shock, with a prior known EF 25-30%. He had no evidence of sepsis or hypovolemia on exam. His hypotension was likely triggered by new administration of minoxidil causing hypotension and stress leading to stress and demand ischemia. Home BP medications were held, and he was started on levophed with a goal MAP of 55-60. On admission to the MICU, an a-line was placed for monitoring of his blood pressures. Overnight in the MICU he required increasing doses of levophed to maintain blood pressure. His CE were trended, showing elevation of troponin and mild elevation in CK in setting of acute kidney injury and demand ischemia. Repeat Echo showed stable EF of 25-30%, RV free wall hypokinesis and apical akinesis. The patient was transferred to the CCU for further management of cardiogenic shock. Levophed was transitioned to dopamine and patient was started on lasix gtt for diuresis with good result. Dopamine was weaned off on [**2204-4-11**]. Throughout hospitalization, patient was maintained on therapeutic INR with coumadin or with therapeutic PTT with heparin gtt given history of recently diagnosed LV thrombus. In setting of renal failure, patient was started on carvedilol on [**2204-4-11**] and was not restarted on atenolol. As an outpatient, the patient should be restarted on [**Last Name (un) **] and spironolactone as tolerated by BP and recovery of kidney function. Of note, noninvasive blood pressures were difficult to monitor on patient secondary to severe PVD. Carotid dopplers showed possible subclavian steal on right, so BP should be monitored on left. # Coronaries: Upon admission serial EKG showed nonspecific ST changes in the lateral leads, that were initially concerning for ACS. Cardiac enzymes were trended, showing elevation of troponin to 0.95 with only mild CK elevation in the setting of worsened renal failure (see below) and cardiogenic shock. Patient continued on ASA, plavix and atorvostatin through duration of hospitalization. Atenolol was held secondary to renal failure and hypotension, and was later transitioned to carvedilol once cardiogenic shock had resolved. Carvedilol dose uptitrated to 25mg [**Hospital1 **] by time of discharge but other anti-hypertensives were held since BP had been so low at presentation and had not yet rebounded to previously elevated levels. # Acute Kidney Injury on chronic kidney disease: Patient admitted with oliguric renal failure with Cr elevated to 5.0 from baseline of 2.6. Likely etiology secondary to ATN in the setting of his ongoing hypotension and poor forward flow. Renal was consulted for help with management given his possible need for catheterization and severe renal dysfunction. Kidney function improved with initiation of dopamine and lasix gtt. Home [**Last Name (un) **] and atenolol were held given worsened renal function. Renal function was trended daily with creatinine peaking at 6.5. On discharge had improved to 3.8 and was trending in the right direction but will be rechecked on Monday at Dr.[**Name (NI) 5452**] office. # Altered mental status/reported neurologic changes: Presented with vague neurologic complaints of confusion, dysarthria, and facial droop which had resolved by presentation to the ED. Initially the patient was noted to have some waxing - [**Doctor Last Name 688**] mental status thought to be secondary to toxic metabolic encephalopathy from azotemia and cerbral hypoperfusion from hypotension. Neurologic exam was nonfocal and mental status improved through hospital course. Neurology was consulted and felt that initial presentation was consistent with a TIA. For secondary prevention, risk factor management was optimized and patient constinued on strict control of hypercholesterolemia, hypertension, and on antiplatelet agents. HA1C was found to be 10.6. Patient contined on coumadin to prevent embolic stroke from known LV thrombus although this was held for a couple days during hospitalization while there was concern that proceedure might be needed as below. # Known LV thrombus: Pt with history of LV thrombus documented on prior TTE. Had been on warfarin as an outpatient but this was held for a couple days as inpatient as concern that patient would need additional invasive proceedures. Placed on heparin gtt to cover while INR subtherapeutic. Warfarin was restarted 2 days prior to D/c and INR climbing but only up to 1.8 on day of D/c so pt administered one sub-cutaneous dose of 80mg enoxaparin on day of discharge and given script for one additional dose of 80mg enoxaparin the next day. Pharmacy was contact[**Name (NI) **] to confirm that dosing should be 80mg daily for therapeutic anti-coagulation in setting of improving renal failure. # Transaminitis: New this admission, likely secondary to poor forward flow given his presentation of hypotension. Trended through hospital course and noted to be downtrending. # Diabetes: Type II on insulin, on 75/25 [**Hospital1 **] [**First Name8 (NamePattern2) **] [**Last Name (un) 387**] recommendations. Home regimen was held upon admission given poor PO intake and patient transitioned to glargine + ISS. Insulin regimen was adjusted to maintain blood sugars in 100-200. Ultimately put on NPH (70/30) regimen of 15 units in AM and 15 units in PM with ISS to cover. Discharged on this regimen. # Incidental CT findings - noted incidentally on CT A/p. Large appendix (12 mm diameter) but no secondary signs of appendicitis, enlarged pretracheal lymph node and hyperdense right renal mass that may represent a hemorrhagic cyst requires outpatient surgical follow-up. Medications on Admission: -hydralazine?? Minoxidil Coumadin -Lipitor 80 mg Tab 1 Tablet(s) by mouth DAILY (Daily) -Plavix 75 mg Tab 1 Tablet(s) by mouth DAILY (Daily) # Humalog Mix 75-25 100 unit/mL (75-25) Susp, Sub-Q Inj 1 Insulin(s) once a day As [**First Name8 (NamePattern2) **] [**Last Name (un) 387**] DM -Benicar 20 mg Tab 2 Tablet(s) by mouth qd () -Aspirin 325 mg Tab 1 Tablet(s) by mouth DAILY (Daily) -Atenolol 100 mg Tab 1 Tablet(s) by mouth once a day -Isosorbide Mononitrate SR 30 mg 24 hr Tab 2 Tablet(s) by mouth DAILY (Daily) -Spironolactone 25 mg Tab 2 Tablet(s) by mouth three times a day -Folic Acid 1 mg Tab 1 Tablet(s) by mouth DAILY (Daily) -hydralazine 50 mg Tab Oral 1 Tablet(s) Three times daily -Coumadin 5 mg Tab Oral 1 Tablet(s) Once Daily -gabapentin 100 mg Tab Oral 1 Tablet(s) Three times daily -minoxidil 10 mg Tab Oral 1 Tablet(s) Once Daily -started few days ago by Dr. [**Last Name (STitle) **] [**Name (STitle) 46090**] 20 mg Tab Oral 1 Tablet(s) Once Daily -Pletal 100 mg Tab Oral 1 Tablet(s) Twice Daily cilostazol -aldactone 50mg TID Discharge Medications: 1. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM. 5. insulin NPH & regular human 100 unit/mL (70-30) Suspension Sig: Fifteen (15) Units Subcutaneous twice a day. Disp:*900 Units* Refills:*2* 6. furosemide 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 7. carvedilol 12.5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Disp:*120 Tablet(s)* Refills:*0* 8. enoxaparin 80 mg/0.8 mL Syringe Sig: One (1) syringe Subcutaneous DAILY (Daily) for 1 doses: Please take dose at 3pm on Sat, [**4-14**]. Disp:*1 syringe* Refills:*0* 9. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. insulin aspart 100 unit/mL Solution Sig: One (1) syringe Subcutaneous four times a day: Take your blood sugars before each meal and administer additional insulin according to attached sliding scale:. Disp:*900 units* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: 1) Hypotension 2) Acute renal failure Secondary Diagnosis: 1) Diabetes 2) Systolic Heart Failure 3) Hypertension Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Mr. [**Known lastname **], you were admitted to the hospital with low blood pressure and worsened kidney function. You initially were sent to the cardiac ICU where medications were used to support your blood pressure. You had a cat-scan of your abdomen to see if there was something obstructing your kidenys. You received contrast with this CT and medications after the CT to protect your kineys from the contrast. Your warfarin was stopped for a couple days because we thought you might need additional proceedures with high risk of bleeding. We also stopped many of your blood pressure medications because you had such a low blood pressure initially. Your kidney function has improved and should continue to improve and your blood pressure has come back up so we have restarted some blood pressure medications. Your INR is currently slightly less than 2 even though we have restarted your warfarin so you will get a shot of lovenox today and give yourself 1 shot of lovenox tomorrow to make sure your blood is thin enough until you are seen in clinic on Monday. While you were in the hospital there was also initially some concern that you had a stroke. The neurologic service came to see you and said you did not have a stroke but may have experienced what we call a TIA with no residual symptoms. You will follow up with Dr. [**Last Name (STitle) **] in clinic on Monday where you will have your INR and electrolytes checked. The following changes were made to your medications: - Start carvedilol 25mg by mouth twice each day for blood pressure - Increase home furosemide to 80mg by mouth once each day for fluid - Start enoxaparin 80mg sub-cutaneously for 1 day (only take this medication on Saturday, then stop) - Your insulin coverage was changed to NPH 70/30 taking 15 units in the morning and 15 units in the evening with a sliding scale to cover your meal time insulin (see attached sheet) - Continue your home Atorvastatin, warfarin, plavix, aspirin, folic acid - Stop all your other home medications for now until further instructed by Dr. [**Last Name (STitle) **]: stop minoxidil, hydralazine, isosorbide mononitrate, spironolactone, cilostazol, atenolol, benicar, your former sliding scale. Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more than 3 lbs. Please give yourself your enoxaparin shot on Saturday as mentioned above. Please make sure to check your blood sugars before each meal and give yourself the additional insulin as instructed by the attached insulin slidding scale. Followup Instructions: You have a follow-up appointment scheduled on Monday [**2204-4-16**] with Dr. [**Last Name (STitle) **]. You will have your INR and electrolytes checked at this visit. You also have a follow-up appointment scheduled with your PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 11139**] on Thursday [**4-26**] at 12:30pm. At this appointment you should discuss the findings of your CT scan described below. ** While you were hospitalized, you received a CT scan of your abdomen and pelvis to make sure there was no damage to your kidneys. While your kidneys looked fine there were the following findings which should be discussed with your PCP at next visit. 1. Unusually large appendix (12 mm diameter) but no secondary signs of appendicitis. This may represent a mucocele, and elective resection should be considered. 2. Hyperdense right renal mass may represent a hemorrhagic cyst, but this is incompletely evaluated with this technique. This can be further assesed with ultrasound. 3. Enlarged pretracheal lymph node.

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icd9cm

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icd9pcs

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7545

Discharge summary

report

Admission Date: [**2143-4-16**] Discharge Date: [**2143-4-23**] Date of Birth: [**2071-5-31**] Sex: F Service: SURGERY Allergies: Iodine; Iodine Containing / Gadolinium-Containing Agents Attending:[**First Name3 (LF) 2597**] Chief Complaint: Severe disabling claudication with malfunctioning of left axillary bifemoral graft with bilateral femoral artery stenoses and partial thrombosis of femoral-femoral crossover graft. Major Surgical or Invasive Procedure: [**4-17**] OR: L ax-fem revision with 6mm PTFE, fem-fem with 6mm PTFE History of Present Illness: 71 year old f s/p RT CIA-bifem bypass with Dacron in [**2137**] complicated by thrombus. Then has LT axillary to fem/fem bypass in [**2137**]. Restenosis noted during follow up duplex/MRA. Diagnostic angiogram on [**2143-3-27**] revealed patent distal axillofemoral bypass with moderate stenosis in the midportion of graft and high grade stenosis at the proximal anastamosis. Required surgical revision. Patient admitted for planned surgery in am. Past Medical History: PMH: rheumatoid arthritis, cad, mi, osteoarthritis, lung ca with rul resection s/p chem and xrt. gerd, HTN, PSH: ballon angioplasty x 2 rle [**2129**], rul resection with xrt / chemo, TAH with b/l saplingoopherectomy, Appy, carpal tunnel release x 2 b/l, lipoma removal, [**Hospital Ward Name **] cyst b/l hands, RCIA to bifemoral BPG with 6mm dacron PTFE [**2137**] / complicated by thrombus then had Left axillary to fem - fem BPG [**2137**], benign growth removal colon Social History: lives at home, uses wheel chair Family History: n/c Physical Exam: VS: 97.3, 101/38, 16 RA 96%RA Neuro A+OX3 Lungs: CTA CARDS: RRR ABD: soft, NT Pulses: B/L DP/PT doppler Pertinent Results: [**2143-4-22**] 05:08AM BLOOD WBC-6.4 RBC-3.01* Hgb-9.6* Hct-27.0* MCV-90 MCH-31.8 MCHC-35.5* RDW-14.6 Plt Ct-230 [**2143-4-22**] 05:08AM BLOOD Plt Ct-230 [**2143-4-22**] 05:08AM BLOOD PT-13.0 INR(PT)-1.1 [**2143-4-22**] 05:08AM BLOOD Glucose-97 UreaN-14 Creat-1.5* Na-137 K-3.7 Cl-99 HCO3-34* AnGap-8 [**2143-4-22**] 05:08AM BLOOD Calcium-8.5 Phos-3.2 Mg-2.3 Brief Hospital Course: Admitted preop for fem-fem revision. Preop labs, ECG obtained. patient has had all PAT as outpatient. Home medications resumed. [**2143-4-17**]: No overnight events. Underwent Revision of left axillary-femoral graft with jump graft, a 6 mm PTFE and left to right femoral-femoral bypass with 6 mm PTFE graft. Extubated and transfered to PACU. VSS. Pain controlled. Transfered to VICU when bed was available. [**2143-4-18**] VSS. Transfused 1uPRBCs for HCT 25. Diet advanced. B/L DP/PT pulses dopplerable. IVF heplocked. Patient kept on bedrest today. [**2143-4-19**] Stroke team called to evaluate patient secondary to confusion. Her exam is notable for inattention and bilateral asterixis, in addition to signs of peripheral neuropathy that is chronic. She is not a candidate for tPA for several reasons; chiefly, her event is not consistent by history with stroke, she has no acute neurologic deficits and her recent surgery. All signs point to encephalopathy, likely infectious or toxic/metabolic in origin. Impression: encephalopathy. Pain medications held. Chest x-ray showing stable examination with no acute pulmonary process. [**2143-4-20**] Temp of 101.8- cultures sent. Urine Cx negative, blood cx negative to date (at discharge). WBC WNL. all lines discontinued [**2143-4-21**]: Temp of 101.8- encourage OOB, incentive spirometry. Transfused with 1uPRBCs. IV lasix given. [**2143-4-22**]: No overnight events. T 99.3- 97.3. Patient OOB with nursing staff. Physical therapy consult obtained for home safery vs rehab evaluation . Continued on ASA, Coumadin and SQ heparin. Medications on Admission: Doxepin 25 ", dIGITEK 0.25, TENORMIN 12.5 ", LIPITOR 40, FOLGARD RX, ASA 81, PRILOSEC 20 ", DULCOLAX 20 ", MECLIZINE 12.5 NOON, LORAZEPAM 0.5 QHS, COUMADIN 3, ALDACTAZIDE 25 MG m/w/f, FYNTNAL PATCH Q 72 HOURS, LIDODERM PATCH Q 12 ON / OFF, VIT B-6 50,0000 IU, Discharge Medications: 1. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Atenolol 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 4. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 5. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO HS (at bedtime). 6. Meclizine 12.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Doxepin 25 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 9. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO MWF (Monday-Wednesday-Friday). 10. Fentanyl 75 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr Transdermal Q72H (every 72 hours). 11. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical 12 HRS ON /12 HRS OFF (): 1 PTCH TD 12 HRS ON /12 HRS OFF. 12. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. Disp:*30 Tablet(s)* Refills:*0* 13. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 14. Warfarin 1 mg Tablet Sig: Three (3) Tablet PO HS (at bedtime): Continue anticaogulation by primary care MD [**Last Name (LF) **],[**First Name3 (LF) 198**] B. [**Telephone/Fax (1) 8363**]. Discharge Disposition: Home With Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: 71F s/p RCIA to bifemoral BPG with 6mm dacron PTFE [**2137**] / complicated by thrombus then had Left axillary to fem - fem BPG [**2137**]. [**4-17**] OR: L ax-fem revision with 6mm PTFE, fem-fem with 6mm PTFE . PMH: rheumatoid arthritis, cad, mi, osteoarthritis, lung ca with rul resection s/p chem and xrt. gerd, HTN, PSH: ballon angioplasty x 2 rle [**2129**], rul resection with xrt / chemo, TAH with b/l saplingoopherectomy, Appy, carpal tunnel release x 2 b/l, lipoma removal, [**Hospital Ward Name **] cyst b/l hands, RCIA to bifemoral BPG with 6mm dacron PTFE [**2137**] / complicated by thrombus then had Left axillary to fem - fem BPG [**2137**], benign growth removal colon Discharge Condition: Good. Discharge Instructions: Division of Vascular and Endovascular Surgery Lower Extremity Bypass Surgery Discharge Instructions What to expect when you go home: 1. It is normal to feel tired, this will last for 4-6 weeks ?????? You should get up out of bed every day and gradually increase your activity each day ?????? Unless you were told not to bear any weight on operative foot: you may walk and you may go up and down stairs ?????? Increase your activities as you can tolerate- do not do too much right away! 2. It is normal to have swelling of the leg you were operated on: ?????? Elevate your leg above the level of your heart (use [**1-19**] pillows or a recliner) every 2-3 hours throughout the day and at night ?????? Avoid prolonged periods of standing or sitting without your legs elevated 3. It is normal to have a decreased appetite, your appetite will return with time ?????? You will probably lose your taste for food and lose some weight ?????? Eat small frequent meals ?????? It is important to eat nutritious food options (high fiber, lean meats, vegetables/fruits, low fat, low cholesterol) to maintain your strength and assist in wound healing ?????? To avoid constipation: eat a high fiber diet and use stool softener while taking pain medication What activities you can and cannot do: ?????? No driving until post-op visit and you are no longer taking pain medications ?????? Unless you were told not to bear any weight on operative foot: ?????? You should get up every day, get dressed and walk ?????? You should gradually increase your activity ?????? You may up and down stairs, go outside and/or ride in a car ?????? Increase your activities as you can tolerate- do not do too much right away! ?????? No heavy lifting, pushing or pulling (greater than 5 pounds) until your post op visit ?????? You may shower (unless you have stitches or foot incisions) no direct spray on incision, let the soapy water run over incision, rinse and pat dry ?????? Your incision may be left uncovered, unless you have small amounts of drainage from the wound, then place a dry dressing over the area that is draining, as needed ?????? Take all the medications you were taking before surgery, unless otherwise directed ?????? Take one full strength (325mg) enteric coated aspirin daily, unless otherwise directed ?????? Call and schedule an appointment to be seen in 2 weeks for staple/suture removal What to report to office: ?????? Redness that extends away from your incision ?????? A sudden increase in pain that is not controlled with pain medication ?????? A sudden change in the ability to move or use your leg or the ability to feel your leg ?????? Temperature greater than 100.5F for 24 hours ?????? Bleeding, new or increased drainage from incision or white, yellow or green drainage from incisions Followup Instructions: Call Dr.[**Name (NI) 5695**] office to schedule a post op visit to be seen in [**9-29**] days. [**Telephone/Fax (1) 3121**] Completed by:[**2143-4-23**]

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icd9cm

[ [ [] ] ]

[ "39.29" ]

icd9pcs

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41130

Discharge summary

report

Admission Date: [**2154-7-5**] Discharge Date: [**2154-7-12**] Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 1505**] Chief Complaint: Weakness and fatigue Major Surgical or Invasive Procedure: [**2154-7-5**] - 1. Aortic valve replacement (21-mm St. [**Hospital 923**] Medical Biocor tissue valve). 2. Coronary artery bypass grafting x3 -- left internal mammary artery graft to left anterior descending and reversed saphenous vein graft to the marginal branch and the terminal circumflex coronary artery. History of Present Illness: 86 year old male with history of atrial fibrillation and aortic stenosis ([**Location (un) 109**] 1 on Cardiac catheterization). Over the past 24 hours he presented to outside hospital with complaint of chest pain, fatique, weakness and mild upper back pain. EKG with chronic ST segment changes,inferior infarct, anterior ST changes, troponin 0.4. His hematocrit was found to be 17 and he was transfused with 2 units PRBC. Additionally INR was elevated 5.7 related to coumadin for atrial fibrillation and was treated 2 units FFP and Vitamin K 10mg po. Due to recurrent chest pain he was transferred for further evaluation due to known coronary artery disease and aortic stenosis. He was seen by cardiac surgery in [**Month (only) **] in evaluation for cardiac surgery however declined surgery. Past Medical History: Hard of hearing Rate Controlled Atrial fibrillation- on Coumadin previously Coumadin discontinued due to GI bleed Aortic valve disorder ([**Location (un) 109**] 1) Arthritis Anemia recieves IV Iron Gastroesophageal reflux disease Colon cancer s/p colon resection Prostate cancer s/p radioactive seed implant Social History: Lives with: widowed, lives with daughter, [**Name (NI) 5627**] Occupation:Retired Tobacco: none- quit [**2113**] ETOH: [**2-10**]+ beers/day Family History: None Physical Exam: Pulse:80's irreg, Resp: 14 O2 sat: 2l 98% B/P Right: 108/52 Left: 109/54 Height: 5'[**52**]" Weight: 80.4kg General: Hard of hearing, sitting up in chair no acute distress denies any pain Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [] Irregular [x] Murmur [**2-10**] syst. Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] well healed mid-line scar s/p partial colectomy Extremities: Warm [x], well-perfused [x] Edema- none Varicosities- minimal Neuro: alert and oriented x3 nonfocal Pulses: Femoral Right: 2+ Left:2+ DP Right: 1+ Left:1+ PT [**Name (NI) 167**]: Doppler Left:doppler Radial Right: 2+ Left:2+ Carotid Bruit Right: None Left:None Pertinent Results: [**2154-7-5**] ECHO PRE-CPB: The left atrium is mildly dilated. Mild spontaneous echo contrast is present in the left atrial appendage. The left atrial appendage emptying velocity is depressed (<0.2m/s). A left atrial appendage thrombus cannot be excluded. A patent foramen ovale is present. A left-to-right shunt across the interatrial septum is seen at rest. Left ventricular wall thicknesses are normal. The left ventricular cavity is moderately dilated. Overall left ventricular systolic function is moderately depressed (LVEF= 35 %). Hypokinesis is most notable in the inferior and inferoseptal segments. The mid-inferior wall segment also appears thinned. Right ventricular chamber size and free wall motion are normal. There are complex (>4mm) atheroma in the descending thoracic aorta. No thoracic aortic dissection is seen. There are three aortic valve leaflets. The aortic valve leaflets are severely thickened/deformed. The left coronary cusp appears to be the only one with good mobility. There is severe aortic valve stenosis (valve area 0.8-1.0cm2). Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. [**Month/Day/Year **] (2+) mitral regurgitation is seen. There is a central and an eccentric component. Due to the eccentric nature of the regurgitant jet, its severity may be significantly underestimated (Coanda effect). [**Month/Day/Year **] [2+] tricuspid regurgitation is seen. POST-CPB: A bioprosthetic valve is seen in the aortic position. The valve appears well-seated with normal leaflet mobility. No paravalvular leaks are seen. There is no AI. The peak gradient across the aortic valve is 25mmHg, the mean gradient is 14mmHg with CO of 4. The MR [**First Name (Titles) 19947**] [**Last Name (Titles) 1192**] with an eccentric component. The TR appears mild to [**Last Name (Titles) 1192**]. The LV systolic function appears similar to pre-op with estimated EF = 35% on phenylephrine infusion only. Same regional wall motion pattern is noted as preop. There is no evidence of aortic dissection. [**2154-7-12**] 04:23AM BLOOD WBC-11.8* RBC-3.30* Hgb-10.3* Hct-29.4* MCV-89 MCH-31.4 MCHC-35.1* RDW-16.3* Plt Ct-234 [**2154-7-12**] 04:23AM BLOOD UreaN-32* Creat-1.0 Na-135 K-3.5 Cl-101 [**2154-7-11**] 04:30AM BLOOD Glucose-95 UreaN-34* Creat-0.9 Na-133 K-3.3 Cl-99 HCO3-23 AnGap-14 Brief Hospital Course: Mr. [**Known lastname 5239**] was admitted to the [**Hospital1 18**] on [**2154-7-5**] for surgical management of his cardiac disease. He was taken directly to the operating room where he underwent coronary artery bypass grafting to three vessels and an aortic valve replacement. Please see operative note for details. Postoperatively he was taken to the intensive care unit for monitoring. Within 48 hours, he awoke neurologically intact and was extubated. He was a little slow to wake, however cleared by postoperative day two. He was transfused for postoperative anemia. He remained in atrial fibrillation however given his significant past GI bleed, coumadin was not resumed. He was gently diuresed towards his preoperative weight. The physical therapy service was consulted for assistance with his care. On postoperative day five, he was transferred to the step down unit for further recovery. He continued to make steady progress and was discharged to [**Hospital 88766**] rehab on [**2154-7-12**]. All follow-up appoinments were arranged. Medications on Admission: Doxazosin 8 mg daily Lasix 80 mg daily Hydroxyurea 1000 mg wednesday and saturday Prilosec 20 mg daily Coumadin 5 mg mon-wed-fri-sun, 2.5 mg tues-thrus-sat - last dose Vitamin C 500mg daily Leutin 1 tab in am and 1 tab in PM Tylenol 650 mg twice a day Ascorbic acid Aspirin 81 mg daily Ferrous sulfate 325 mg TID Multivitamin Discharge Medications: 1. metoprolol tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 2. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 3. hydroxyurea 500 mg Capsule Sig: Two (2) Capsule PO 2X/WEEK (WE,SA). 4. atorvastatin 10 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) for 1 months. 6. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 7. doxazosin 4 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 8. lutein 10 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 9. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day. 12. ascorbic acid 500 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. potassium chloride 20 mEq Tablet, ER Particles/Crystals Sig: One (1) Tablet, ER Particles/Crystals PO once a day. 14. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for pain. 15. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as needed for wheezes. 16. potassium chloride 10 mEq Tablet Extended Release Sig: Two (2) Tablet Extended Release PO once a day. 17. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed for constipation. Discharge Disposition: Extended Care Facility: [**Hospital3 30191**] Rehabilitation & Nursing Center - [**Location (un) 22287**] Discharge Diagnosis: Aortic stenosis/Coronary artery disease Hard of hearing Atrial fibrillation- on Coumadin Aortic valve disorder ([**Location (un) 109**] 1) Arthritis Anemia recieves IV Iron Gastroesophageal reflux disease Colon cancer s/p colon resection Prostate cancer s/p radioactive seed implant Discharge Condition: Alert and oriented x3 nonfocal Ambulating with steady gait Incisional pain managed with Incisions: Sternal - healing well, no erythema or drainage Leg Left - healing well, no erythema or drainage. 1+ Edema Discharge Instructions: 1) Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage. 2) Please NO lotions, cream, powder, or ointments to incisions. 3) Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart provided. 4) No driving for approximately one month and while taking narcotics. Driving will be discussed at follow up appointment with surgeon when you will likely be cleared to drive. 5) No lifting more than 10 pounds for 10 weeks 6) Please call with any questions or concerns [**Telephone/Fax (1) 170**] **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: Surgeon: [**Name6 (MD) **] [**Name8 (MD) 6144**], MD Phone:[**Telephone/Fax (1) 170**], [**2154-8-14**] 1:00 Cardiologist: [**Month/Day/Year 5310**] on [**8-2**] at 2:20pm Please call to schedule appointments with your Primary Care Dr. [**Last Name (STitle) **],PIOTR [**Telephone/Fax (1) 20264**] in [**3-12**] 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:[**2154-7-12**]

[ "V58.61", "530.81", "V10.46", "E878.2", "V10.05", "424.1", "427.31", "285.1", "414.01" ]

icd9cm

[ [ [] ] ]

[ "39.61", "35.21", "36.15", "36.12" ]

icd9pcs

[ [ [] ] ]

8103, 8211

5144, 6191

277, 590

8538, 8746

2769, 5121

9634, 10147

1922, 1928

6569, 8080

8232, 8517

6217, 6546

8770, 9611

1943, 2750

217, 239

618, 1416

1438, 1747

1763, 1906

18,193

143,236

24315

Discharge summary

report

Admission Date: [**2153-4-29**] Discharge Date: [**2153-5-4**] Date of Birth: [**2132-10-27**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 348**] Chief Complaint: Tylenol overdose Major Surgical or Invasive Procedure: Thoracentesis History of Present Illness: 20 y.o. male with h/o polysubstance abuse and depression presents s/p tylenol O.D. on [**2153-4-27**]. He was in his USOH until the evening of [**4-27**] when he felt depressed and drank a 6-pack of beer. He then began superficially cutting his left wrist and then took #20 tabs of 500 mg tylenol. He passed out and awoke at 10 AM on [**4-28**] with mild ABD pain, nausea, vomiting (brown material) and had mild ataxia. He continued to vomit and then presented to [**Hospital3 **] Hospital. There he was noted to have transaminitis, coagulopathy and thrombocytopenia and was transferred to [**Hospital1 18**] [**Hospital Unit Name 153**]. During ICU stay, patient was started on mucomyst for elevated INR (peak 14.1 [**2153-4-30**] and transaminitis (ALT [**Numeric Identifier **], AST 7208) and ARF. Received 4 days of NAC. Hepatology and transplant surgery following for possible OLT. On HD#4, LFTs peaked and both coagulopathy and ARF resolved. Was seen by psyched and 1:1 sitter was d/c'd by HD#4. Now transfered to medical [**Hospital1 **] team for monitoring and transition to outpatient psych facility. Past Medical History: -Childhood heart murmur -Polysubstance abuse (cocaine, marijuana, EtOH with h/o rehab) Social History: SH: Lives with girlfriend. Unemployed-worked as roofer. 1 pack cig/week. 2 beers/day. Family History: FH: Grandfather with EtOH abuse. Physical Exam: T 98.6 HR 100 BP 127/54 RR 26 O2Sat 98%ra GEN: pale, diaphoretic, many tatoos HEENT: PERRL, EOMI CV: regular, no mrg LUNGS: clear ABD: RUQ tenderness, no rebound, +BS EXT: no edema NEURO: mild asterixis PSYCH: denies SI Pertinent Results: CT Abd [**2153-4-30**]: 1) Markedly fatty infiltrated liver, with no focal lesions. 2) No variant hepatic arterial, portal venous, or hepatic venous anatomy. CT Chest [**2153-4-30**]: There is a large pleural effusion on the right, with right lower lobe collapse and consolidation ECHO: 1. The left ventricular cavity size is normal. Regional left ventricular wall motion is normal. Left ventricular systolic function is hyperdynamic (EF>75%). CXR IMPRESSION: New bilateral pleural effusions (right>left), Given the clinical history, underlying pneumonia at the right base and/or aspiration not excluded; correlate clinically. Post Thoracentesis CXR IMPRESSION: Status post thoracentesis with resolution of right-sided pleural effusion; no pneumothorax identified. Admission Labs CBC [**2153-4-28**] 09:25PM BLOOD WBC-14.1* RBC-5.43 Hgb-16.4 Hct-46.5 MCV-86 MCH-30.2 MCHC-35.3* RDW-12.4 Plt Ct-42* [**2153-4-28**] 09:25PM BLOOD Neuts-73* Bands-12* Lymphs-11* Monos-0 Eos-0 Baso-0 Atyps-4* Metas-0 Myelos-0 [**2153-4-28**] 09:25PM BLOOD Plt Smr-VERY LOW Plt Ct-42* Hemolysis Labs [**2153-4-28**] 09:40PM BLOOD Fibrino-117* [**2153-4-28**] 09:25PM BLOOD Hapto-<20* Chemistries [**2153-4-28**] 09:25PM BLOOD Glucose-208* UreaN-18 Creat-1.0 Na-137 K-5.5* Cl-103 HCO3-16* AnGap-24* LFTs [**2153-4-29**] 04:14AM BLOOD Lipase-29 [**2153-4-28**] 09:25PM BLOOD Albumin-4.1 Calcium-8.3* Phos-2.2* Mg-1.6 [**2153-4-29**] 07:53PM BLOOD Ammonia-78* Toxicology [**2153-4-29**] 04:14AM BLOOD Acetone-NEGATIVE Osmolal-291 [**2153-4-28**] 09:25PM BLOOD Ethanol-NEG Acetmnp-11.8 Hepatitis Serologies [**2153-4-28**] 09:25PM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE HBcAb-NEGATIVE HAV Ab-NEGATIVE IgM HBc-NEGATIVE IgM HAV-NEGATIVE [**2153-4-28**] 09:25PM BLOOD HCV Ab-POSITIVE HCV VIRAL LOAD (Pending) HIV Testing [**2153-4-29**] 12:18PM BLOOD HIV Ab-NEGATIVE Other testing [**2153-4-29**] 12:21PM BLOOD FacVIII-147 Angiotensin converting enzyme 105 H ([**7-/2115**] U/L) HERPES I (IGG) ANTIBODY 4.61 A NEGATIVE HSV (IGG) INTERPRETATION ANTIBODY TO HSV TYPE 1 DETECTED. Pleural Fluid Analysis [**2153-5-3**] 12:52PM PLEURAL WBC-1225* RBC-1000* Polys-61* Lymphs-8* Monos-14* Meso-3* Macro-14* [**2153-5-3**] 12:52PM PLEURAL TotProt-2.5 Glucose-125 LD(LDH)-230 [**2153-5-3**] 12:52 pm PLEURAL FLUID GRAM STAIN (Final [**2153-5-3**]): 2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. FLUID CULTURE (Preliminary): NO GROWTH. ANAEROBIC CULTURE (Pending) Other Microbiology: EBV/CMV neg. Neg MRSA and VRE screens [**2153-4-29**]: [**12-4**] (aerobic bottle) GRAM POSITIVE RODS. CONSISTENT WITH CORYNEBACTERIUM ANDPROPIONIBACTERIUM SPECIES. FURTHER IDENTIFICATION TO FOLLOW Brief Hospital Course: Tylenol Overdose The patient was admitted after ingesting a significant amount of tylenol in a suicide gesture with grossly abnormal liver function tests and coagulation profile. He was hospitalized and supported for acute liver failure. Transplant surgery was following but in light of improving clinical picture and labs during hospitalization, there was ultimately no indication for liver transplant. He was followed by the transplant service, the liver service, and the toxicology service. The patient was aggressively hydrated and received a course of mucomyst. His labs improved on this regimen. His pain was controlled with morphine as needed. Depression/Suicide attempt The psychiatry service followed the patient while admitted and he expressed regret over the suicide attempt and no suicidal ideation; he reported multiple stressors at home including the deaths of friends. [**Name (NI) **] was felt to be stable for non-inpatient psychiatry treatment for his depression, and will follow up with his local crisis team. Acute Renal Failure The patient had mild transient renal failure (peak Cr 1.0) that resolved during hospitalization. Coagulopathy [**12-27**] acute liver injury. These values normalized over the course of his hospitalization. Hematology followed the patient. Hepatitis C Incidentally, the patient was found to be hepatitis C antibody positive. He reported that he had been HCV negative two years ago and since that time had not had unprotected sex or injected drugs, but had had tatoos done since then. A HCV viral load was pending on discharge. A U/A showed only trace protein. He was given the Hepatitis A vaccine while hospitalized. He will follow up with the liver service on discharge. SW provided support for this new diagnosis. ?Pneumonia The patient was found to have a right lower lobe infiltrate on imaging and was mildly hypoxic on transfer to the medicine service. He had developed a mild leukocytosis and had been started on levofloxacin and flagyl for a question of aspiration pneumonia (the patient initially had an NGT in place though he was never intubated). He had an associated right-sided pleural effusion for which he underwent a thoracentesis which showed an exudative effusion without evidence of empyema and with a negative culture. His hypoxia resolved and his CXR post procedure showed no evidence of a pneumothorax and showed impressive resolution of the opacification in the right lower lobe. His leukocytosis resolved and he was discharged to finish a 7 day course of antibiotics. EtOH abuse The patient also has a history of alcohol abuse and was kept on thiamine and folate. This issue was also addressed by the social work and psychiatric teams. Thrombocytopenia Nadir of 26 and likely multifactorial: EtOH abuse, poor nutritional status and acute liver failure. No spontaneous bleeding. Platelets on discharge were 175. Hypophosphatemia The patient was aggressively repleted. ?GIB Patient had a history of coffee ground emesis. An NG lavage showed coffee grounds with clearing. His HCT dropped with hydration but remained thereafter stable and he had no further episodes of coffee ground emesis, BRBPR, melena or any other symptoms concerning for GI bleed. The patient was discharged home to follow up with the crisis team in his area for possible placement. Medications on Admission: None Discharge Medications: 1. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 2. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily). Disp:*30 Cap(s)* Refills:*2* 3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 4. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 3 days. Disp:*3 Tablet(s)* Refills:*0* 5. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 3 days. Disp:*9 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Acute liver failure secondary to alcohol and tylenol overdose Hepatitis C Depression, suicide attempt Discharge Condition: Stable, tolerating an oral diet, afebrile, no suicidal ideation Discharge Instructions: 1. Please take your medications as prescribed. You were admitted for acute liver faiure and are improving. Avoid alcohol. You should follow up in the liver clinic (see below) to follow up for hepatitis C. 2. Please call the "crisis team" tomorrow ([**Telephone/Fax (1) 61614**]) and they will help arrange further follow up. Followup Instructions: Provider: [**Last Name (NamePattern4) **]. [**First Name (STitle) **] [**Name (STitle) **] Where: LM [**Hospital Unit Name 7129**] CENTER Phone:[**Telephone/Fax (1) 2422**] Date/Time:[**2153-5-21**] 10:20 Call the crisis team at [**Telephone/Fax (1) 61614**] tomorrow.

[ "276.2", "507.0", "305.00", "286.6", "570", "511.9", "287.5", "311", "E950.0", "965.4", "070.70" ]

icd9cm

[ [ [] ] ]

[ "34.91" ]

icd9pcs

[ [ [] ] ]

8748, 8754

4790, 8145

331, 346

8900, 8965

2009, 4473

9344, 9616

1718, 1752

8200, 8725

8775, 8879

8171, 8177

8989, 9321

1767, 1990

275, 293

374, 1486

1508, 1597

1613, 1702

4505, 4767

4,454

143,382

10301

Discharge summary

report

Admission Date: [**2185-3-15**] Discharge Date: [**2185-3-17**] Date of Birth: [**2111-6-23**] Sex: M Service: HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname **] is a 73-year-old male with a past history of multi-infarct dementia, multiple admissions for aspiration pneumonias, and diabetes mellitus, who was admitted for a likely aspiration event. On the day of admission, the patient was found by the nursing home staff to be tachycardic and tachypneic with a respiratory rate of 32. He also had decreased oxygen saturation and was put on five liters by face mask with an oxygen saturation of 90-93%. The patient was brought to [**Hospital1 188**] for further evaluation and treatment. He is nonverbal at baseline and is totally dependent for all care. In the Emergency Department, the patient was afebrile with a heart rate of 120, blood pressure 180/86, respiratory rate 30 and oxygen saturation of 99% on a 100% nonrebreather mask. He was given a dose of vancomycin, ceftriaxone, and Flagyl for likely aspiration pneumonia and transferred to the medical intensive care unit for further management. PAST MEDICAL HISTORY: 1. Multi-infarct dementia, nonverbal at baseline. 2. Hypertension. 3. Diabetes mellitus. 4. Benign prostatic hypertrophy, status post chronic suprapubic catheter placement. 5. History of multiple urinary tract infections with VRE, MRSA, and Pseudomonas. 6. Multiple hospitalizations for aspiration pneumonia. 7. Status post gastrojejunostomy tube. 8. Sacral decubitus ulcers. ALLERGIES: The patient has no known drug allergies. MEDICATIONS: 1. Aspirin 81 mg per G-tube q. day. 2. Novolin insulin 8 units subcutaneously q.a.m. 3. Pepcid 40 mg per G-tube q. day. 4. Zinc 220 mg per G-tube q. day. 5. Vitamin C 500 mg per G-tube b.i.d. 6. Multivitamin per G-tube q. day. 7. Scopolamine patch p.r.n. 8. Peravite tube feeds at 85 cc per hour. 9. Free water boluses 300 cc q. 6 hours per G-tube. SOCIAL HISTORY: The patient lives at [**Hospital3 6560**] Home. He is a full code. PHYSICAL EXAMINATION: The patient was afebrile with a temperature of 99.0, heart rate 103, blood pressure 129/84, respiratory rate 25, oxygen saturation 97% on a 100% nonrebreather. In general, the patient was a chronically ill-appearing male in mild respiratory distress. Head and neck examination was significant for dry mucous membranes, no lymphadenopathy and flat neck veins. Lungs had rhonchorous breath sounds bilaterally throughout with no wheezes. Cardiac examination revealed a regular rhythm with no murmurs. Abdomen had positive bowel sounds, was soft, nontender, clean J-tube site with no erythema or exudate. No hepatosplenomegaly was noted. Extremities had no edema. Neurologically, the patient was awake but not vocal. He responded to voice as well as pain. LABORATORY DATA: Complete blood count was significant for a white count of 10.6, hematocrit of 43 and no left shift on differential. Chem-7 was significant for a sodium of 141, BUN 30, creatinine 0.9. ABGs showed a pH of 7.41, PCO2 of 42, PO2 of 186. Urinalysis showed a specific gravity greater than 1.030, with 3-5 white cells and no bacteria. EKG showed sinus tachycardia, normal axis intervals, early R wave progression and no acute ST-T wave changes. There was no change compared to prior EKG. Chest x-ray showed possible left perihilar opacity consistent with prior x-ray and no definite pneumonia. HOSPITAL COURSE: 1. Pneumonia: The patient was treated with levofloxacin for a likely aspiration pneumonia. Blood and urine cultures were drawn, urine culture was negative, and blood cultures were pending at the time of discharge. The patient had decreased secretions, with decreased suctioning requirement, and was evaluated by physical therapy and determined not to require any further chest physical therapy. He also had a decreasing oxygen requirement and was saturating 96% on two liters by nasal cannula at the time of discharge. He received three days of levofloxacin and will be continued on ceftriaxone for a full ten-day course. 2. Cardiovascular: The patient was hypertensive during his first 24 hours of admission, and was treated with metoprolol to decrease his blood pressure. This was likely secondary to stress response and infection. His blood pressure was normal at the time of discharge. 3. Fluids, electrolytes and nutrition: The patient was hypernatremic at the time of admission, and he was administered hypotonic fluids to replace his free water deficit. At the time of discharge, his hypernatremia had resolved. Initially, tube feeds were withheld but he was at goal at the time of discharge. To decrease on the likelihood of aspiration, the patient's free water boluses should be limited to a total volume of 150 cc per bolus. 4. Diabetes mellitus: The patient was restarted on half dose insulin as his tube feeds were restarted and to continue on his outpatient regimen at the time of discharge. DISPOSITION: The patient was discharged in stable condition back to his nursing home, the Bostonian. DISCHARGE DIAGNOSES: 1. Aspiration pneumonia. 2. All prior diagnoses. DISCHARGE MEDICATIONS: 1. Ceftriaxone 1 gram intravenous q. day x nine days. 2. All prior medications. DISCHARGE PLAN: 1. The patient will be discharged to the [**Hospital3 6560**] Home for further treatment there by his primary care [**Provider Number 34259**]. He should continue for a full 10-day course of antibiotics for aspiration pneumonia. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. Dictated By:[**Last Name (NamePattern1) 6916**] MEDQUIST36 D: [**2185-3-17**] 10:30 T: [**2185-3-17**] 10:50 JOB#: [**Job Number **]

[ "250.00", "707.0", "401.9", "276.0", "600.0", "507.0", "290.40", "276.5" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

5110, 5160

5183, 5264

3465, 5089

2073, 3447

160, 1132

5280, 5754

1155, 1965

1982, 2050

61,802

182,959

13157+56432

Discharge summary

report+addendum

Admission Date: [**2159-9-20**] Discharge Date: [**2159-10-4**] Date of Birth: [**2089-6-9**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1505**] Chief Complaint: not feeling well and hypotension Major Surgical or Invasive Procedure: [**2159-9-27**] Sternotomy wound superficial abscess drainage History of Present Illness: Mr. [**Known lastname 40143**] is s/p AVR/ascending aorta replacement on [**9-14**] and was discharged home on [**9-18**] after an [**Hospital 40145**] hospital course. He was feeling well until this am when he reports he woke up not feeling well. Denies lightheadedness, dizziness, chest pain, nausea, vomiting. When the visiting nurse evaluated him, he was found to have a blood pressure of 60/40. He was sent to [**Hospital3 417**] hospital where he was hemodynamicaly stable w/systolic bood pressures 90s to 100s. He had a non-contrast CT scan which showed "ill-defined fluid collection/induration containing a dot of air inferiorly; mild pericardial effusion mostly in the pericardial recess of the superior mediastinum, containing air with slightly complicated appearance. Infectedpericardial effusion cannot be ruled out." He was transfered to [**Hospital1 18**] for further evaluation. Past Medical History: Past Medical History: neuroblastoma [**2139**] (chemo/radiation left eye, subsequent enucleation) hypertension skin CA hypercholesterolemia pterygium right eye ? thyroid disorder ( being evaluated) Past Surgical History: enucleation left eye [**2150**] LN bx left neck Social History: Race:Caucasian Last Dental Exam:6 months ago Lives with:wife Occupation:part-time clothing sales Tobacco:never ETOH:occ. glass of wine Family History: non-contributory Physical Exam: Pulse:89 SR Resp:16 O2 sat:98 on RA B/P Right:100/62 Left: General: Skin: Dry [x] intact [x] HEENT: R PRRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur no rub/murmur Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Extremities: Warm [x], well-perfused [x] Edema 1+ , no calf erythema or tenderness Neuro: Grossly intact[x] Pulses: DP Right:2+ Left:2+ PT [**Name (NI) 167**]:2+ Left:2+ Radial Right:2+ Left:2+ sternum: sternum stable, incision clean, dry, area of mild erythema on superior portion to the R side of sternal incision, +blanchable Pertinent Results: [**2159-9-28**] Echo Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Overall left ventricular systolic function is normal (LVEF>55%). with normal free wall contractility. The appearance of the ascending aorta is consistent with a normal tube graft. A bioprosthetic aortic valve prosthesis is present. The transaortic gradient is normal for this prosthesis. A paravalvular aortic valve leak is probably 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. No masses or vegetations are seen on the mitral valve, but cannot be fully excluded due to suboptimal image quality. Trivial mitral regurgitation is seen. There is a small pericardial effusion. IMPRESSION: No valvular vegetations seen. Normally-functioning aortic valve bioprosthesis. Compared with the prior study (images reviewed) of [**2159-9-21**], the findings are similar. Admission [**2159-9-20**] 09:25PM PT-14.0* PTT-28.0 INR(PT)-1.2* [**2159-9-20**] 09:25PM PLT COUNT-357# [**2159-9-20**] 09:25PM NEUTS-84.1* LYMPHS-8.8* MONOS-4.2 EOS-2.0 BASOS-0.9 [**2159-9-20**] 09:25PM WBC-17.5*# RBC-3.58* HGB-10.7* HCT-31.6* MCV-88 MCH-29.8 MCHC-33.7 RDW-13.8 [**2159-9-20**] 09:25PM LIPASE-25 [**2159-9-20**] 09:25PM ALT(SGPT)-110* AST(SGOT)-87* ALK PHOS-84 AMYLASE-26 TOT BILI-1.0 [**2159-9-20**] 09:25PM UREA N-25* CREAT-1.2 [**2159-9-20**] 09:32PM GLUCOSE-115* LACTATE-1.4 NA+-130* K+-4.3 CL--94* TCO2-27 Discharge [**2159-10-4**] 04:58AM BLOOD WBC-8.8 RBC-3.30* Hgb-9.9* Hct-28.8* MCV-87 MCH-30.1 MCHC-34.6 RDW-14.0 Plt Ct-414 [**2159-10-4**] 04:58AM BLOOD Plt Ct-414 [**2159-10-4**] 04:58AM BLOOD ESR-83* [**2159-10-4**] 04:58AM BLOOD Glucose-81 UreaN-34* Creat-2.1* Na-131* K-4.8 Cl-98 HCO3-28 AnGap-10 [**2159-10-4**] 04:58AM BLOOD Glucose-81 UreaN-34* Creat-2.1* Na-131* K-4.8 Cl-98 HCO3-28 AnGap-10 [**2159-10-3**] 05:01AM BLOOD ALT-10 AST-74* AlkPhos-101 Amylase-37 TotBili-0.2 [**2159-9-25**] 04:40AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE IgM HAV-NEGATIVE Radiology Report CT CHEST W/O CONTRAST Study Date of [**2159-10-3**] 10:44 AM [**Hospital 93**] MEDICAL CONDITION: 70 year old man superficial sternal wound REASON FOR THIS EXAMINATION: eval for sternal infection Final Report CT CHEST WITHOUT IV CONTRAST: The patient has undergone prior graft placement in the ascending aorta and aortic valve replacement, with a median sternotomy. Since the prior exam, there has been further decrease in size of multiple collections. The retrosternal collection centered behind the manubrium and upper sternum has decreased in size and density, which suggests an evolving hematoma. The periaortic collection is likely comprised of two regions, including an intrapericardial component of pericardial effusion containing locules of air, and an extrapericardial component extending cranially along the aorta. Both collections have decreased in size, and there is much less air within the pericardial space. Overall, this collection has improved greatly from the prior exam of [**2159-9-21**]. Additionally, inflammatory changes and stranding in the retrosternal space has also improved. Additional pericardial fluid layering dependently, moderate in size, is unchanged. A defect in the subcutaneous tissues overlying the sternum is compatible with recent debridement. However, the sternum itself demonstrates new lucency on either side of the sternotomy line, concerning for developing dehiscence or osteomyelitis. The sternal closure wires remain intact and in unchanged position at this time. Aortic graft material, aortic valve prosthesis and a right PICC remain in place. Dense atherosclerotic calcifications are noted of the coronary arteries and the aortic arch. There is no new hilar or mediastinal lymphadenopathy by size criteria. The largest lymph node measures 9 mm in the precarinal space. There is no axillary lymphadenopathy by size criteria. Lungs again demonstrate small bilateral pleural effusions with rounded atelectasis at the left lung base, in an unchanged configuration. Small calcified granulomas in the right lung are unchanged. There is no new lesion. The tracheobronchial tree is patent to subsegmental levels. The esophagus remains patulous, containing aerosolized material in the upper esophagus, placing the patient at increased risk for aspiration. While this exam is not optimized for assessment of the abdomen, a right hepatic cyst is unchanged, and there are no acute abnormalities in the upper abdomen. OSSEOUS STRUCTURES: For discussion of the sternal changes, see above. No additional worrisome bony abnormalities are seen. Multilevel degenerative changes are present in the spine. IMPRESSION: 1. Interval improvement in the retrosternal and periaortic collections. The retrosternal collection likely represents evolving hematoma. The paraaortic collection likely reflect both intrapericardial fluid and extrapericardial collection, both improved. 2. New sternal lucencies on either side of the sternotomy line, concerning for developing dehiscence or osteomyelitis. Sternal wires remain intact. Followup imaging recommended as needed. 3. Unchanged bilateral pleural effusions with rounded atelectasis at the left lung base. Moderate pericardial effusion, also unchanged. 4. Patulous esophagus containing aerosolized material, placing the patient at increased risk for aspiration. Brief Hospital Course: 70 year old man s/p aortic valve replacement/ascending aprta replacement on [**9-14**] discharged home on [**9-18**]. Readmitted with fevers and hypotension on [**9-20**]. The sternal wound was noted to be erythematous on admission. He was pan cutured and started on broad spectrum antibiotics, initially Vancomycina nd Cipro which were changed to Nafcillin after cultures revealed STAPH AUREUS COAG +. Infectious disease service was consulted. The patient had developed acute renal failure with a BUN/Cr that peaked at 46/2.8. He also became hyponatremic durung this period and was placed on a free water restriction. The renal service was consulted and they felt the renal dysfunction was an interstitial nephritis likely from the Nafcilin. The antibiotics were changed and his renal function gradually improved. The wound continued to be erythematous and the pateint continued to have leukocytosis, on [**9-27**] he was brought to the operating room for: Sternotomy wound superficial abscess drainage. The wound was left open and a VAC dressing was placed. After the wound was opened the erythema began to resolve and the leukocytosis also resolved. He remained in the hospital for several days after debridement for subsequent VAC changes and antibiotic review. On POD 7 he was discharged home with a VAC dressing in place, visiting nurses and home infusion therapy. He is to continue antibiotics through [**11-8**]. He is to follow-up with Dr [**Last Name (STitle) **] in 1 week and with Infectious diseases on [**10-18**]. Medications on Admission: colace 100mg by mouth twice daily ranitidine 150mg by mouth twice daily aspirin 81 mg by mouth daily simvastatin 80 mg by mouth daily percocet 5/325 1 tab by mout every 4 hours as needed ferrous sulfate 300mg by mouth daily losartan 100mg by mouth daily folic acid 1mg by mouth daily lopressor 100mg by mouth twice daily multivitamin 1 tab my mouth daily omega 3 fatty acids 1 cap by mouth daily furosimide 40mg by mouth daily x 7 days potassium chloride 20mEq by mouth daily x 7 days Discharge Medications: 1. Outpatient Lab Work Weekly Safety Labs: CBC, K, Bun/Cr, LFTs results to ID fax: [**Telephone/Fax (1) 1419**] 2. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 4. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 5. simvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 6. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain. Disp:*50 Tablet(s)* Refills:*0* 7. zinc sulfate 220 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). Disp:*30 Capsule(s)* Refills:*2* 8. ascorbic acid 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 9. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 10. cefazolin 1 gram Recon Soln Sig: One (1) gm Injection every eight (8) hours for 5 weeks: end date [**11-8**]. Discharge Disposition: Home With Service Facility: [**Hospital1 1474**] VNA Discharge Diagnosis: superficial sternal infection PMH: Aortic stenosis s/p AVR Dilated aorta s/p replacement of ascending aorta hypertension skin cancer hypercholesterolemia pterygium right eye neuroblastoma [**2139**] Discharge Condition: Alert and oriented x3 nonfocal Ambulating with steady gait Incisional pain managed with tylenol Incisions: Sternal - wound vac Discharge Instructions: 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 one month or 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: Provider: [**Name10 (NameIs) **] [**Name8 (MD) 6144**], MD Phone:[**Telephone/Fax (1) 170**] Date/Time:[**2159-10-11**] 1:00 Provider: [**Name10 (NameIs) 1412**] [**Name Initial (NameIs) **] [**Name12 (NameIs) 1413**], M.D. Date/Time:[**2159-10-18**] 2:10 [**Hospital **] clinic, LMOB basement Provider: [**Name10 (NameIs) 2323**] [**Name11 (NameIs) 2324**], MD Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2159-11-2**] 11:00, [**Hospital **] clinic, LMOB basement weekly safety labs: CBC, K, Bun/Cr, LFTs faxed to ID [**Telephone/Fax (1) 1419**] Cardiologist: Dr [**Last Name (STitle) **] [**10-18**] at 4pm Please call to schedule appointments with your Primary Care Dr [**First Name8 (NamePattern2) 122**] [**Last Name (NamePattern1) 10740**] in [**3-26**] weeks [**Telephone/Fax (1) 40144**] Chest CT on [**10-18**] @11AM-[**Location (un) 470**]. [**Hospital Ward Name 40146**] Completed by:[**2159-10-4**] Name: [**Known lastname 7230**],[**Known firstname 326**] Unit No: [**Numeric Identifier 7231**] Admission Date: [**2159-9-20**] Discharge Date: [**2159-10-4**] Date of Birth: [**2089-6-9**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 741**] Addendum: Per ID recommendations Cefazolin was increased to 2 gm IV q 8 hrs. Discharge Disposition: Home With Service Facility: [**Hospital1 328**] VNA [**Name6 (MD) **] [**Name8 (MD) 747**] MD [**MD Number(2) 748**] Completed by:[**2159-10-4**]

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Discharge summary

report

Admission Date: [**2163-12-15**] Discharge Date: [**2163-12-22**] Date of Birth: [**2095-9-16**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 1145**] Chief Complaint: s/p VF arrest and cardiogenic shock Major Surgical or Invasive Procedure: cardiac catheterization with no intervention Cardioversion Pulmonary Intubation History of Present Illness: 68 yo M with history of CAD s/p PCI (DES) to LAD at [**Hospital 12017**] Hospital in [**2156**], HTN, HL, PVD s/p aorto-femoral bypass (?[**2152**] at [**Hospital3 **]) and COPD currently smoking who is being transferred from [**Hospital6 19155**] with cardiogenic shock after VF arrest and suspected cardiogenic shock. Patient stopped his ASA and clopidogrel on [**Hospital6 2974**] (6 days ago) as he was instructed for rectal sphincterectomy/fissure repair which he underwent on [**2163-12-14**]. While in the day surgery recovery room he began having burning CP, EKG done at the time showed inverted T waves (per report, no EKG evidence). The pt hospitalist/intensivist was called and while evaluating the patient went into Vfib arrest and was pulseless for 20 minutes, defibrillated x5, given epi and amiodarone with ROSC. After this he was reported to have regained intermittent conciousness and was transferred to the ICU where he was given amiodarone (with bolus), heparin gtt, clopidogrel, ASA, lidocaine gtt (with bolus) and intubated. EKG then showed Q waves in leads V1 and V2 and 1-[**Street Address(2) 1766**] elevations in V1 and V2, hyperacute T waves in V3-V6 and ~[**Street Address(2) 4793**] depressions in I and II, and cardiac enzymes showed CK of 4270, CKMB of 610 and Tn-XX of 136. He was stabilized overninght and EKG on [**2162-12-15**] showed Q waves in V1-V5. Labs at that time showed: CKMB >306 [**12-15**], ABG on vent - 7.32/45/148/23, CK 4270 CKmb 610, tropI 136, WBC of 15.1 with 83% PMNs. UA suggested possible UTI. At this point the decision was made to transfer to [**Hospital1 18**] for further management. cxr showed that the ET tube may be into right mainstem bronchus, there is whiteout of the left side per report. There are conflicting stories regarding neurologic function - OSH states he did not recover any function but flight med techs state he was gagging on the tube and did reach his hand up at one point. Of note, pt's last echo in [**2161**] showed normal LV function and mild tricuspid regurg. . 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, joint pains, cough, hemoptysis, black stools or red stools. S/he denies recent fevers, chills or rigors. S/he denies exertional buttock or calf pain. All of the other review of systems were negative. . Cardiac review of systems is notable for absence of chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. Social History: - Tobacco history: Current smoker - ETOH: 8-10 beers per week retired demolition work for power company divorced lives in [**Location 4693**] - Illicit drugs: none Family History: father died at 98 mother died from complications from stroke in her early 70s brother with multiple sclerosis, another brother had a stroke, sister with pancreatic cancer Physical Exam: ON ADMISSION VS: T= AF BP=122/71 HR=88 RR=14 O2 sat=95% GENERAL: intubated and sedated, unresponsive. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK:difficult to assess [**1-5**] intubation. 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. Legs are warm with pulses, 1+ pitting edema SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ . ON DISCHARGE: Vitals - Tm/Tc: 98.4/96 HR: 81-84 BP: 93-113/50-55 O2 sat 96% RA. In/Out: Last 24H: 1388/2450 Last 8H: 360/455 Weight: 101.9 GENERAL: 68 yo M in no acute distress, sitting in chair HEENT: mucous membs dry, no lymphadenopathy, JVP non elevated CHEST: CTABL, no crackles, NO wheezes CV: S1 S2 Normal in quality and intensity RRR no murmurs rubs or gallops, distant EXT: wwp, [**12-5**]+ edema bilat to knees. DPs, PTs 1+. NEURO: CNs II-XII intact. 5/5 strength in U/L extremities. gait WNL. exam otherwise unchanged. Pertinent Results: CBC [**2163-12-15**] 12:30PM BLOOD WBC-12.9* RBC-3.95* Hgb-13.5* Hct-38.4* MCV-97 MCH-34.3* MCHC-35.2* RDW-12.9 Plt Ct-211 [**2163-12-17**] 06:39AM BLOOD WBC-8.6 RBC-3.14* Hgb-10.8* Hct-30.7* MCV-98 MCH-34.6* MCHC-35.3* RDW-13.1 Plt Ct-150 [**2163-12-22**] 07:05AM BLOOD WBC-7.9 RBC-3.32* Hgb-11.3* Hct-31.7* MCV-96 MCH-34.0* MCHC-35.5* RDW-13.0 Plt Ct-272 . DIFF [**2163-12-15**] 12:30PM BLOOD Neuts-86.0* Lymphs-7.4* Monos-6.2 Eos-0.1 Baso-0.2 [**2163-12-20**] 06:45AM BLOOD Neuts-71.3* Lymphs-18.4 Monos-6.4 Eos-3.3 Baso-0.5 COAGS [**2163-12-15**] 12:30PM BLOOD PT-12.2 PTT-67.5* INR(PT)-1.1 [**2163-12-22**] 07:05AM BLOOD PT-15.4* INR(PT)-1.4* . ELECTROLYTES [**2163-12-15**] 12:30PM BLOOD Glucose-175* UreaN-28* Creat-1.5* Na-133 K-4.1 Cl-99 HCO3-23 AnGap-15 [**2163-12-22**] 07:05AM BLOOD Glucose-94 UreaN-28* Creat-1.1 Na-138 K-3.9 Cl-99 HCO3-29 AnGap-14 . LFTs [**2163-12-15**] 12:30PM BLOOD ALT-131* AST-565* LD(LDH)-1381* CK(CPK)-5726* AlkPhos-57 TotBili-0.4 [**2163-12-17**] 06:39AM BLOOD ALT-64* AST-150* . CARDIAC ENZYMES [**2163-12-15**] 12:30PM BLOOD CK-MB->500 cTropnT-11.21* [**2163-12-15**] 08:17PM BLOOD CK-MB-296* cTropnT-7.97* [**2163-12-16**] 04:36AM BLOOD CK-MB-144* MB Indx-4.7 cTropnT-6.69* [**2163-12-17**] 06:39AM BLOOD CK-MB-13* cTropnT-4.71* [**2163-12-15**] 05:23PM BLOOD Type-ART Temp-37.4 pO2-85 pCO2-38 pH-7.43 calTCO2-26 Base XS-0 . UA [**2163-12-15**] 12:47PM URINE Blood-MOD Nitrite-NEG Protein-TR Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG [**2163-12-15**] 12:47PM URINE RBC-15* WBC-7* Bacteri-FEW Yeast-NONE Epi-0 . ECG [**2163-12-15**] Sinus rhythm. Anteroseptal myocardial infarction of indeterminate age. No previous tracing available for comparison . TTE: [**2163-12-15**] 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 akinesis of the anteroseptal segments, apical walls (with relative preservation of the apical inferior segment), and true apex (?near-aneurysmal). Hypokinesis of the basal and mid inferoseptal, anterior and anterolateral walls. No masses or thrombi are seen in the left ventricle. Right ventricular chamber size is normal with depressed free wall contractility. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Severely depresssed left ventricular systolic function with regional wall motion abnormalities as described above. Moderate pulmonary artery systolic hypertension. EF > 15-20% . CXR [**2163-12-15**] IMPRESSION: 1. Endotracheal tube is too low and at the level of the carina pointing towards the main stem bronchus. 2. Right internal jugular catheter ends in the mid SVC. No pneumothorax. 3. Left basilar hazy opacification is likely atelectasis, although early pneumonia cannot be excluded. . [**2163-12-16**] CXR FINDINGS: In comparison with the study of [**12-15**], the endotracheal tube has been removed. The patient has taken a much better inspiration. Mild enlargement of the cardiac silhouette with probable worsening of pulmonary vascular congestion. Left hemidiaphragm is not well seen, consistent with small effusion and atelectasis. Right IJ catheter tip remains in the upper portion of the SVC. . CARDIAC CATH [**2163-12-20**] COMMENTS: 1. Vascular access obtained via the right common femoral artery with placement of a 6 Fr sheath. Selective right and left coronary angiograms obtained using 5 Fr JR 4 and JL 4 diagnostic catheters. The JR 4 catheter was also used to perform left heart catheterization. In the end, a 6 Fr Mynx device was deployed over the right common femoral artery arteriotomy site for hemostasis. Patient tolerated the procedure well without any complications. 2. Selective coronary angiography:Selective coronary angiography of the left coronary arterial system revealed a circumflex coronary artery and its branches having no significant disease. The left anterior descending coronary artery had a stent in mid-LAD astride the origin of a second diagonal. The LAD had a 50% stenosis in the distal segment of the stent. The diagonal had a 60% ostial stenosis. The appearence of the LAD stent was that of recanalized stent thrombosis. The right coronary and its branches were free of any significant luminal stenosis. FINAL DIAGNOSIS: 1. Single vessel CAD involving LAD 2. Possible stent thrombosis followed by recanalization in the stent in mid-LAD. There is a 50% in-stent restenosis in the distal segment of the stent. 3. Severely elevated LVEDP (35 mm Hg) 4. Successful deployment of a 6 Fr Mynx device to right CFA. Brief Hospital Course: #vfib arrest - Pt developed post-operative anterior Q wave myocardial infarction on [**2163-12-14**] in setting of stopping aspirin followed by ventricular fibrillation arrest. He was defibrillated x5. Pt was pulseless for 20 minutes then got pulse back. Received 5 shocks first of which for vfib at 5:30 pm got 150j then got 1mg of epi for bradycardia 39-42, second shock at 5:39 with BP 102/63, received 300g amiodarone then in VF, shocks at 5:48, 5:49, 5:50 with pulse back at 120 with BP of 90/60 got 150 g lidocaine. His EKG (anterior Q waves)and TTE (akinesis of the anteroseptal segments, apical walls) were consistent with proximal LAD territory infarction [**1-5**] stent thrombosis after stopping aspirin. Pt arrived at [**Hospital1 18**] 18 hours after the event and was therefore out of the window for cooling or thrombolytics. Pt was started on a heparin drip and a lidocaine drip as his vfib arrest was in the setting of acute ischemia. Lidocaine was stopped on [**2163-12-16**]. Lactate was only 1.2 on transfer. EP was consulted and and pt was sent home with a lifevest per their recommendations with plan for repeat echo in roughly 1 month for re-assessment of EF and consideration of AICD. Pt had full return of neurologic function and was found to be an alert/oriented lively conversationalist. Also without any focal neurologic deficits on neuro exam. . #[**Date Range **] - In the PACU [**2163-12-14**] at [**Location (un) **] following sphincterotomy pt c/o chest pain was found to have hyperacute T waves in V3-V6 and ~[**Street Address(2) 4793**] depressions in I and II, and cardiac enzymes showed CK of 4270, CKMB of 610 and Tn-XX of 136. Pt then experienced Vfib arrest, see above, and was intubated/stabilized overnight and EKG on [**2162-12-15**] showed Q waves in V1-V5. Pt was transferred to [**Hospital1 18**] where MB on presentation was >500 and troponin 11.21, enzymes subsequently trended down. Pt had been started on plavix at [**Location (un) **], which was continued along with aspirin, heparin gtt and atorvastatin 80. Pt's last documented cath was from [**2-6**] and showed: left main: normal no disease. LAD: 85% proximal stenosis along with mild long mid area of disease, post stenosis. large diag branch noted within the ostia of 60% stenosis. Lcirc: normal vessel without disease. results of PCI: reduction of the initial 85% severe proximal/LAD stenosis to 0% and a reduction of the initial 60% ostial diagonal branch stenosis to less than 20%. Cath was performed at [**Hospital1 18**] on [**2163-12-20**] which showed: 50% flow through stent, (likely thrombus that migrated distally) TIMI 3 flow, no intervention, no other lesions. Pt was sent home on crestor as he stated atorvastatin "did not work for him" in the past (likely was referring to myalgias). Also home with metoprolol, aspirin/plavix, lisinopril, and spironolactone. . #CHF - ECHO after vfib arrest/[**Date Range **] showed: severely depresssed left ventricular systolic function with regional wall motion abnormalities. Moderate pulmonary artery systolic hypertension. EF 15-20%. prior to admission pts last TTEwas at [**Hospital **] hospital [**1-/2161**], showed: compared to study of [**6-/2158**] no significant changes. left atrium borderline enlarge, normal LV fn, normal wall motion. Trace AI, trace MR, trace TR. LVEF 55%. Pt had been taking lasix 40 daily and metolazone 5mg m/w/f at home. On admission, pt was persistently tachycardic, likely as compensation for impaired contractility. Pt was aggressively diuresed with good resolution in respiratory status and cxr findings of improvement in pulmonary edema. Given his marked apical akinesis of LV with EF of 15-20% pt was sent home with warfarin lifelong anticoagulation, and bridged with enoxaparin. . #respiratory status - pt was intubated [**2163-12-14**] in setting of vib arrest, extubated on [**2163-12-16**] at [**Hospital1 18**] without issues. Remained with O2 requirement (NC sufficient to maintain appropriate sats). Evidence of pulmonary edema on CXR secondary to [**Hospital1 **], Vfib arrest responsible for decreased EF to 15-20%. hypoxia/dyspnea resolved with aggressive diuresis, see CHF above. . #hypotension - transferred on levophed for low blood pressures, likely [**1-5**] cardiac injury s/p stent thrombosis. Pt was also on propofol for sedation while on ventilator and this was likely contributingg. Levophed was quickly weaned without issue. Propofol was changed to fentanyl/midazolam which were also weaned the day after transfer. . #fever/leukocytosis - on transfer pt was found to have dark cloudy urine. He had received 1g CTX on [**2163-12-14**] at OSH for WBC of 15 and concern for UTI. UA at OSH was cloudy, trace ketones, large blood, neg nit and leuks WBC [**2-6**] RBC [**5-13**] 4+ bacteria. Although cultures and UA were negative at [**Hospital1 18**], CTX was continued for 7 day course as these studies had been done after pt had received his first dose. WBC trended down to normal limits. It was also felt that [**Hospital1 **]/vfib arrest was contributing somewhat to leukocytosis. . #Atrial fibrillation - pt was newly with atrial fibrillation s/p Vfib arrest/[**Hospital1 **]. He was successfully cardioverted on [**2163-12-18**] . #[**Last Name (un) **] (Cr of 1 --> 1.5): in setting of vfib arrest/[**Name (NI) **] pt had an elevated creatinine to 1.5 on transfer from baseline 1.0. With extubation, pressor weaning, and diuresis creatinine quickly went back to baseline. . #transaminitis - LFTs considerably elevated with ALT of 131 AST 565 LD 1381 (alkphos 57, tbili 0.4). These elevations were felt to be [**1-5**] poor perfusion during vfib arrest. LFTs trended down and on discharge ALT was 64 and AST was down to 150. Pt without jaundice,n/v/abd pain. . #tobacco use - pt longtime and current smoker. Was extensively counseled on the risks of smoking and was maintained on a nicotene patch throughout hospital stay. . #s/p sphincterotomy - contact[**Name (NI) **] [**Name2 (NI) 5059**] at OSH who did the procedure to get recs for dressing. Pt was monitored closely as he was being anticoagulation but no signs of significant bleeding and remained hemodynamically stable. Medications on Admission: lisinopril 20 mg po daily atenolol 25 mg crestor 20 mg lasix 40 mg daily metolazone 5mg m/w/f plavix 75 mg po daily . Medications on transfer: heparin gtt levophed gtt propofol gtt lidocain gtt ceftriaxone 1g D#1 [**2163-12-15**] tylenol Discharge Medications: 1. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 2. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*11* 3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1) packet PO DAILY (Daily) as needed for constipation. 5. lisinopril 5 mg Tablet Sig: 0.5 Tablet PO at bedtime. Disp:*15 Tablet(s)* Refills:*2* 6. warfarin 2 mg Tablet Sig: 2.5 Tablets PO once a day. Disp:*75 Tablet(s)* Refills:*2* 7. enoxaparin 100 mg/mL Syringe Sig: One (1) syringe Subcutaneous [**Hospital1 **] (2 times a day). Disp:*60 syringe* Refills:*2* 8. metoprolol succinate 25 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* 9. rosuvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 10. spironolactone 25 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). Disp:*15 Tablet(s)* Refills:*2* 11. torsemide 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* 12. nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr Transdermal DAILY (Daily). Disp:*30 Patch 24 hr(s)* Refills:*2* 13. nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) tablet Sublingual as directed. Disp:*25 tablets* Refills:*0* Discharge Disposition: Home With Service Facility: All Care VNA of Greater [**Location (un) **] Discharge Diagnosis: ST Elevation Myocardial Infarction New Atrial flutter Coronary artery disease Ventricular fibrillation arrest Acute Systolic Congestive heart failure 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 at [**Hospital1 18**]. You were found to be having a heart attack after your surgery and had a cradiac arrest dur to a heart rhythm called ventricular fibrillation that was treated with medicines and an electrical shock. You required a breathing tube to help you breathe while you were so sick. You were transferred to [**Hospital1 18**] and a cardiac catheterization showed that you likely had a clot in your previous stent that has not cleared somewhat and you have good blood flow through the stent. You are now back on your aspirin and plavix and need to take these medicines every day without fail. Do not stop taking aspirin and plavix or miss [**First Name (Titles) 691**] [**Last Name (Titles) 11014**]s unless Dr. [**Last Name (STitle) 41007**] tells you it is OK. You are being sent home with a lifevest that will administer an electrical shock if your heart develops ventricular fibrillation again. You will need to wear this vest until you see Dr. [**Last Name (STitle) **] [**Last Name (STitle) **] [**Hospital1 18**]. Your weight at discharge is 224 pounds. Weigh yourself every morning, call Dr. [**Last Name (STitle) 41007**] if weight goes up more than 3 lbs in 1 day or 5 pounds in 3 days. Please check your legs and your breathing daily for signs that you are retaining more fluid. You had another heart rhythm problem called atrial flutter. You were cardioverted into a normal sinus rhythm and it has not returned. However, because of this rhythm and the fact that your heart is weak, you are at an increased risk of a stroke from a blood clot. You have been started on . WE made the following changes to your medicines: 1. STOP taking furosemide and metolazone. 2. START taking torsemide instead to get rid of extra fluid 3. START taking spironolactone to help your diuretics work better 4. STOP taking Atenolol 5. START taking metoprolol intead to lower your heart rate and help your heart pump better 6. DECREASE your Lisinopril because your blood pressure is lower now. You can take this at night. 7. INCREASE the Crestor to help lower your cholesterol further. 8. Take nitroglycerin for chest pain. Take one tablet, wait 5 minutes, then take one more tablet. Call 911 if your chest pain does not go away after 2 nitroglycerin tablets, call Dr. [**Last Name (STitle) 41007**] for any chest pain. 9. START taking docusate and miralax to prevent constipation Followup Instructions: . Department: CARDIAC SERVICES: Electrophysiology When: [**Last Name (STitle) **] [**2164-1-20**] at 9:00 AM With: [**Name6 (MD) **] [**Name8 (MD) 163**], 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: Primary Care Name: [**Last Name (LF) **],[**First Name8 (NamePattern2) **] [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 2974**] [**12-23**] at 11:30 Location: [**Hospital **] MEDICAL ASSOCIATES Address: [**Street Address(2) 75551**] [**Apartment Address(1) **], [**Location (un) **],[**Numeric Identifier 87435**] Phone: [**Telephone/Fax (1) 65542**] Fax: [**Telephone/Fax (1) 87436**] Please check Chem-7, CBC and INR . Department: General Surgery Name: Dr. [**First Name8 (NamePattern2) 12395**] [**Last Name (NamePattern1) 75549**] When: Dr. [**Last Name (STitle) 91983**] office is working on a hospital follow up appointment for you in [**8-18**] days after your hospital discharge. If you have not heard from the office in 2 business days please call the office number listed below. Location: [**Hospital3 **]Surgical Specialties Building: [**Apartment Address(1) 91984**] Phone: ([**Telephone/Fax (1) 91985**] . Department: Cardiology Name: Dr. [**First Name8 (NamePattern2) 39489**] [**Name (STitle) 41007**] When: Wednesday [**2164-1-18**] at 2:00 PM Location: [**Hospital 46644**] MEDICAL ASSOCIATES Address: [**Street Address(1) **] WAY, [**Location (un) **],[**Numeric Identifier 75553**] Phone: [**Telephone/Fax (1) 86181**]

[ "410.11", "428.21", "401.9", "416.8", "427.32", "V12.53", "427.41", "414.01", "428.0", "496", "272.4", "584.9", "V45.82", "410.91", "427.31", "443.9", "599.0", "305.1", "785.51" ]

icd9cm

[ [ [] ] ]

[ "99.62", "96.71", "88.56", "37.22" ]

icd9pcs

[ [ [] ] ]

17666, 17741

9741, 15945

342, 424

17935, 17935

4884, 9413

20528, 22126

3239, 3412

16234, 17643

17762, 17914

15971, 16089

9430, 9718

18086, 20505

3427, 4334

4348, 4865

267, 304

452, 3037

17950, 18062

16114, 16211

3053, 3223

22,057

112,022

24120

Discharge summary

report

Unit No: [**Numeric Identifier 61305**] Admission Date: [**2144-4-18**] Discharge Date: [**2144-4-18**] Date of Birth: Sex: Service: [**Last Name (un) **] HISTORY OF PRESENT ILLNESS: This is an 82-year-old gentleman with multiple comorbidities who presents with abdominal pain, fever, and shock. There was a question of a history of Crohn disease in the past, but in retrospect the patient probably had intestinal ischemia. At rehabilitation center with a fever to 101.8 and hypotension. He was transferred to [**Hospital3 11531**] where he required vasopressors, intubated, and transferred. PAST MEDICAL HISTORY: Notable for multiple comorbidities including coronary artery disease, peripheral vascular disease, chronic renal insufficiency. He has had multiple bypasses and coronary artery bypass as well as above-the-knee amputations and below-the-knee amputations. PHYSICAL EXAMINATION: The patient was intubated and sedated and in extremist, with a blood pressure of 80/40 which was raised to 115/50 with vasopressors. The abdomen was distended without masses. The extremities were cool status post the above-mentioned amputations. LABORATORY DATA: Evaluation included a white blood cell count of 3500 with a left shift. INR was 1.7. Bicarbonate was 16. CPK was 449 with a MB fraction of 9. Creatinine was 1.8. Blood gasses revealed a significant base deficit. STUDIES: A CT scan was performed which showed pneumatosis of the left colon. HOSPITAL COURSE: The patient was admitted with a diagnosis of colonic ischemia and infarction. This was thought to be most likely an unsurvivable injury in this elderly man. A long discussion was held with the family who wished aggressive treatment on the basis of past wishes expressed by the patient himself and understood the very low likelihood of survival even with operation. The patient was then to the operating room where there was an extensive infarction throughout the majority of the intestinal tract. This was not a survivable injury. The patient was closed. He was sent back to the intensive care unit. After family members were able to be assembled the patient had withdrawal of support. The patient then expired shortly thereafter. FINAL DIAGNOSES: 1. Intestinal infarction. 2. Coronary artery disease. 3. Chronic renal insufficiency. 4. Peripheral vascular disease. 5. Diabetes mellitus. 6. Status post multiple amputations. SURGICAL PROCEDURE: Exploratory laparotomy. DISPOSITION: Post was declined by the family. [**First Name11 (Name Pattern1) 333**] [**Last Name (NamePattern4) 366**], [**MD Number(1) 367**] Dictated By:[**Last Name (NamePattern4) 24987**] MEDQUIST36 D: [**2144-7-10**] 14:14:44 T: [**2144-7-11**] 14:12:16 Job#: [**Job Number **]

[ "V45.81", "V49.76", "785.52", "555.9", "038.9", "427.31", "995.94", "250.00", "276.2", "557.0" ]

icd9cm

[ [ [] ] ]

[ "00.17", "99.04", "54.11", "96.04", "38.93", "96.71" ]

icd9pcs

[ [ [] ] ]

1474, 2206

2223, 2767

899, 1456

188, 598

621, 876

1,819

116,360

10862

Discharge summary

report

Admission Date: [**2187-5-8**] Discharge Date: [**2187-5-10**] Date of Birth: [**2101-6-24**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 2880**] Chief Complaint: Fatigue Major Surgical or Invasive Procedure: DDD pacemaker implantation History of Present Illness: Mr [**Known lastname 4020**] is an 85 year old male with history of CAD s/p CABG x2 and s/p AVR with bioprosthetic valve (not on anticoagulation), transferred from [**Hospital1 **] [**Location (un) 620**] with complete heart block. He has been experiencing recurrent episodes of lightheadedness upon standing and falls for the past two weeks. He has been generally asymptomatic when lying still, but repeatedly feels lightheaded when standing. Has not had any nausea, diaphoresis, or chest pain. Hit head softly one week ago, but denies loss of consciousness. . On presentation to [**Hospital1 **] [**Location (un) 620**], initial VS were 97.3, 152/73, 37, 16, 100% 2l NC. Labs there showed hct 39.3, BUN/creat 54/1.4, INR 1.1, Alk phos 234, AST 147 (ALT 51), and normal CK/MB/trop. ECG showed complete heart block with wide-QRS complex escape beats. CXR showed no acute processes. He was seen by cardiology who recommended transfer to [**Hospital1 18**]. . In the ED, initial VS were 98.0, 132/63 22 100% 2L NC. Ventricular rate was consistently in the 30s. ECG showed complete heart block, with ventricular escape beats, rate in the 30s. Labs revealed hct 34.7 (baseline high 20s-low 30s), elevated BUN/creat 56/1.2, negative troponin, and normal potassium, magnesium, and other electrolytes. Pacer pads were placed on his chest but were not employed. . Upon arrival to the CCU, the patient is without significant complaints. He is awake, alert, and appears comfortable. He is persistently bradycardic to the 30s, with occasional runs of hemodynamically insignificant NSVT. . On review of systems, he endorses only chronic polyarticular arthralgias. He denies any prior history of 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 chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, or ankle edema. Past Medical History: 1. CARDIAC RISK FACTORS: -Diabetes, +Dyslipidemia, +Hypertension 2. CARDIAC HISTORY: [**2177-8-19**]: CABG x4: -in-situ LIMA to diagonal -reversed SVG to distal LAD -reversed SVG to OM1 -reversed SVG to PDA [**2184-1-15**]: -Redo CABG x2: SVG to LAD, SVG to PDA -AVR with 23 mm Biocor porcine valve. -Endoscopic vein harvesting -c/b post-operative atrial fibrillation requiring amiodarone . OTHER PAST MEDICAL HISTORY: - Unresponsive episode in [**2187-3-6**] believed [**2-7**] TIA vs seizure - L3-L4 spinal stenosis - L basilic vein thrombosis [**8-6**] - Parkinson's disease - BPH - diverticulosis - arthritis - s/p cataract surgery - s/p tonsillectomy Social History: Retired engineer. Denies any tobacco history or significant alcohol intake. Wife passed away in [**2179**]. Lives home alone, but has several children and friends visit him daily. Family History: - No family history of arrhythmia, cardiomyopathies, or sudden cardiac death - Mother: [**Name (NI) 5895**] disease - Father: Alcoholism, ?MI at age 40 - Son: tourette's disease Physical Exam: VS: T=97.1 BP=132/108 HR=43 RR=16 O2 sat=99% 4L NC GENERAL: Elderly caucasian gentleman with Parkinsonian features. NAD. Oriented x3. Mood, affect appropriate. HEENT: Masked facies. NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. NECK: Supple with JVP of 7 cm H20. CARDIAC: PMI located in 5th intercostal space, midclavicular line. Regular rhythm, bradycardic. Absent S1, prominent S2. +Holosystolic murmur most prominent at LUSB. No rubs or lifts. LUNGS: CTAB, no W/R/R. No accessory muscle use ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. EXTREMITIES: +High frequency, low amplitude upper extremity tremor, which decreases with purposeful movements. No c/c/e. No femoral bruits. SKIN: No rashes PULSES: Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ . VS: T=97.1 BP=128/88 HR=56 RR=16 O2 sat=98%2L GENERAL: Elderly caucasian gentleman with Parkinsonian features. NAD. Oriented x3. Mood, affect appropriate. HEENT: Masked facies. NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. NECK: Supple with JVP of 7 cm H20. CHEST: Pacemaker site without tenderness or erythema CARDIAC: PMI located in 5th intercostal space, midclavicular line. Regular rhythm, bradycardic. Absent S1, prominent S2. +Holosystolic murmur most prominent at LUSB. No rubs or lifts. LUNGS: CTAB, no W/R/R. No accessory muscle use ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. EXTREMITIES: +High frequency, low amplitude upper extremity tremor, which decreases with purposeful movements. No c/c/e. No femoral bruits. SKIN: No rashes 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: Lab Trends: . CBC: [**2187-5-8**] 06:00PM BLOOD WBC-7.4 RBC-3.57* Hgb-11.8*# Hct-34.7*# MCV-97 MCH-33.2* MCHC-34.2 RDW-13.4 Plt Ct-161# [**2187-5-9**] 02:24AM BLOOD WBC-7.6 RBC-3.51* Hgb-11.5* Hct-34.0* MCV-97 MCH-32.9* MCHC-34.0 RDW-13.2 Plt Ct-143* [**2187-5-10**] 12:40AM BLOOD WBC-8.0 RBC-3.60* Hgb-11.8* Hct-34.2* MCV-95 MCH-32.8* MCHC-34.5 RDW-13.3 Plt Ct-163 . INR [**2187-5-8**] 06:00PM BLOOD PT-13.8* PTT-27.7 INR(PT)-1.2* . Chemistry: [**2187-5-8**] 06:00PM BLOOD Glucose-93 UreaN-56* Creat-1.2 Na-141 K-4.5 Cl-107 HCO3-27 AnGap-12 [**2187-5-9**] 02:24AM BLOOD Glucose-105* UreaN-54* Creat-1.3* Na-140 K-4.7 Cl-107 HCO3-26 AnGap-12 [**2187-5-10**] 12:40AM BLOOD Glucose-91 UreaN-38* Creat-1.2 Na-139 K-4.7 Cl-107 HCO3-26 AnGap-11 . LFTs: [**2187-5-8**] 06:00PM BLOOD ALT-60* AST-125* CK(CPK)-90 AlkPhos-171* TotBili-0.4 [**2187-5-9**] 02:24AM BLOOD ALT-34 AST-105* AlkPhos-160* TotBili-0.6 [**2187-5-10**] 12:40AM BLOOD ALT-22 AST-66* AlkPhos-146* TotBili-0.5 . CXR [**5-10**] FINDINGS: Sternotomy wires are midline. The first sternotomy wire is fractured, but unchanged since [**2184-2-6**]. A left pacemaker device is noted with leads terminating appropriately in the right atrium and right ventricle. Mediastinal surgical clips are noted. Bilateral lungs show changes consistent with chronic lung disease; however, no focal consolidation, pleural effusion, or pneumothorax is noted. The cardiac, mediastinal and hilar contours are within normal limits. IMPRESSION: No consolidation, pleural effusion, or pneumothorax. . ECG [**5-8**]: Sinus rhythm with complete heart block and ventricular escape rhythm. Compared to the previous tracing of [**2184-2-4**] complete heart block is new. TRACING #1 - Prior ECG ([**2184-2-4**]): Sinus rhythm. Left bundle-branch block. Baseline artifact. Compared to the previous tracing of [**2184-1-20**] the lateral T waves are upright. The inferior T waves are still inverted. These changes may be non-specific but clinical correlation is suggested . ECG [**5-9**]: Ventricular paced rhythm. Compared to the previous tracing pacing is now present. TRACING #2 Brief Hospital Course: 85 y/o M with hx CAD s/p CABG x2, AS s/p AVR, LBBB, Htn, HL, presenting with several episodes of presyncope and syncope over the past several weeks, found to be in complete heart block now s/p successful pacemaker placement . ACTIVE ISSUES: . # Complete heart block/syncope: Presenting EKG showed complete heart block. The patient underwent placement of PPM without complication. The etiology of the patient's heartblock was thought to be sick-sinus syndrome; CEs were serially negative and there were no ischemic changes on serial EKGs although a missed ischemic event was considered; TSH was within normal limits; lyme serologies were negative. BB was initially held in the acute setting then restarted after PPM placement when the patient became hypertensive. The patient was discharged on 12.5mg daily metoprolol succinate at his home dose and follow-up with the device clinic as well as antibiotics for 48h. . # HTN: Became hypertensive after placement of PPM in the setting of holding BB. Became normotensive after restarting home dose metoprolol as above. . # Elevated LFTs: LFTs were found to be mildly elevated from baseline, in particular the patient's AP. Further work-up was deferred for the outpatient setting. . # Delirium: The patient had an episode of delirium after placement of PPM attributed to medical stressors and environmental change in the setting of low cognitive reserve due to Parkinson's and advanced age. The episode resolved with Trazodone. There was no clear toxic-metabolic etiology of the delirium; he remained hemodynamically stable. . INACTIVE ISSUES: . # CAD s/p CABG: Presented with symptoms of ACS. Continued outpatient regimen. Became hypertensive off of BB, which was then restarted at home dose. . # Parkinsons disease: Continued on sinemet, ropinorole . # Spinal stenosis: Presented with chronic paresthesias and tingling in lower extremities; no changes were made to home regimen. . # BPH: Remained stable. No changes were made to home regimen. . TRANSITIONAL ISSUES: . # PPM: Follow-up with device clinic as detailed below. . # Elevated LFTs: Patient will require further work-up after discharge, starting with a RUQ ultrasound. Medications on Admission: -metoprolol 12.5 mg PO daily -simvastatin 20 mg PO daily -aspirin 325 mg PO daily -docusate 100 mg PO BID -ropinorole 1 mg PO QID -carbidopa-levodopa 25-100 PO 5x/day -vitamin C, E, B12, D, Calcium Discharge Medications: 1. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig: 0.5 Tablet Extended Release 24 hr PO DAILY (Daily). 2. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. docusate sodium 100 mg Tablet Sig: One (1) Tablet PO twice a day. 4. ropinirole 1 mg Tablet Sig: One (1) Tablet PO QID (4 times a day). 5. simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day. 6. carbidopa-levodopa 25-100 mg Tablet Sig: One (1) Tablet PO 5X/DAY (5 Times a Day). 7. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q8H (every 8 hours) as needed for post-pacemaker for 2 days. Disp:*6 Capsule(s)* Refills:*0* Discharge Disposition: Extended Care Facility: [**Hospital 38**] Rehab Hospital at [**Hospital1 **] Discharge Diagnosis: Third degree AV block Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Mr [**Known lastname 4020**] it was a pleasure taking care of you. . You were admitted due to weakness and repeated episodes of fainting in recent weeks. You were found to have very slow heart rate. A pacemaker was implanted in your chest in order to help your heart beat at a normal rate. . You are discharged with the following new medication: . Cephalexin 500 mg Capsule, take One (1) Capsule PO Q8H (every 8 hours) for 2 days to prevent infection. . No other changes were made to your medications, please continue to take your regular medications as prescribed. . For the next week please avoid lifting or other strenous activity involving your left arm. Also avoid raising your left arm about above the level of the shoulder. Followup Instructions: please keep the following appointments: . Name: [**Last Name (LF) **],[**First Name3 (LF) 35386**] I. MD Location: [**Location (un) **] [**University/College **] FAMILY MEDICINE Address: [**Street Address(2) **], [**Apartment Address(1) 35387**], [**Location (un) 35388**],[**Numeric Identifier **] Phone: [**Telephone/Fax (1) 17203**] Appointment: Wednesday [**2187-5-16**] 10:30am Department: CARDIAC SERVICES When: THURSDAY [**2187-5-17**] at 10:00 AM With: DEVICE CLINIC [**Telephone/Fax (1) 62**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage [**First Name11 (Name Pattern1) 900**] [**Last Name (NamePattern1) 2882**] MD, [**MD Number(3) 2883**]

[ "332.0", "724.02", "V45.81", "293.0", "V12.04", "V12.72", "600.00", "V45.01", "426.0", "426.3", "790.6", "V12.51", "V42.2", "562.10" ]

icd9cm

[ [ [] ] ]

[ "37.83", "38.93", "37.72" ]

icd9pcs

[ [ [] ] ]

10734, 10813

7607, 7833

311, 340

10879, 10879

5475, 7584

11823, 12603

3361, 3543

10029, 10711

10834, 10858

9807, 10006

11062, 11800

3558, 5456

2575, 2887

9618, 9781

264, 273

7848, 9177

368, 2467

9194, 9597

10894, 11038

2909, 3148

3164, 3345

69,225

183,477

28300

Discharge summary

report

Admission Date: [**2149-6-26**] Discharge Date: [**2149-6-29**] Date of Birth: [**2068-4-9**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 2290**] Chief Complaint: GI Bleed Major Surgical or Invasive Procedure: Balloon enteroscopy History of Present Illness: 81yo M w/ PMHx of CHF (EF <45% on [**5-17**] ECHO), recent DVT in left arm [**1-8**] PICC on heparin SQ and Fe-deficiency anemia w/ recent GI bleed last month who presents to the ED after capsule endoscopy showed active bleeding in small bowel. With this report from capsule endoscopy, the patient was referred by GI to the ED for admission and further evaluation/treamtent for possible balloon enteroscopy. . Of note, the patient previously had a colonoscopy and endoscopy when he initially presented with GI bleed; neither of which were able to identify a source of bleeding, leading to capsule endoscopy. The patient reports that since his first episode of bloody stool, he has not had any other bowel movements with frank blood. He does endorse black tarry stools. He denies abdominal pain, nausea, vomitting, and hematemesis. He endorses some constipation. Today, he reports feeling some dizziness, particularly when he moves from a sitting position to standing or sometimes when walking. He endorses poor appetite but has not had weight loss. He does not use Ibuprofen and has stopped taking his daily ASA (although he is unsure when he stopped this medication). The patient continues to be on heparin SQ for treatment of his DVT. . In the ED, initial VS were: T 97.8 P 81 BP 102/52 R 16 O2 sat 97%RA. Patient was type and screened. He was given 1L NS and 1 unit of pRBCs in the ED. . In the unit, when the patient arrived, initial VS were T 96.7 HR 88 BP 103/90 RR 17 O2 Sat 97% RA. He was conversant and answering questions appropriately. Transfusion of 1 unit of pRBCs was finishing when the patient arrived to the unit. . 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: Past Medical History: -CHF, EF <35% (ECHO report [**5-17**]) with BiV pacemaker -h/o MV Enterococcus endocarditis, one ventricular pacemaker lead with some vegetation -CAD -HTN -HLD -T2DM, diet-controlled. -h/o erosive gastritis -diverticulosis/itis -OSA -Cataracts -Glaucoma bilaterally -Pulmonary nodule LLL . Past Surgical History: -CABG complicated by Mitral Valve endocarditis(Eneterococcus) -Bioprosthetic MVR [**2148-2-7**] -Tricuspid annuloplasty Social History: He lives with his wife and sister in law usually but has been in rehab since his last discharge. Occupation: retired electrical engineer; designed the radio transmitter that was responsible for communication between the NASA lunar module and orbiting capsule during the space race of the [**2097**] Tobacco: quit 25 years ago; 40-60 PYHx ETOH: rare occ. Recreational Drugs: denies use Family History: Son with MI requiring CABG at age 50. Brother had an MI at age 63. Mother died 65 believed to have lung dz otherwise unspecified Physical Exam: ADMITTING PHYSICAL EXAM: Vitals: T: 96.7 BP: 103/90 P: 88 R: 17 O2: 97% on RA General: Pleasant patient alert and oriented lying in bed in NAD HEENT: Sclera anicteric. MMM. OP without erythema/exudate. Neck: Supple. JVP not elevated. Lungs: Clear to auscultation bilaterally. No crackles or wheezes. CV: RRR. No murmurs, rubs, gallops Abdomen: Normal, active bowel sounds present. Midline, healed surgical scar appreciated. Soft. NT/ND. No HSM. No rebound/guarding. GU: No foley Ext: WWP, 2+ DPs. No clubbing, cyanosis, or pitting edema b/l. Skin: Ecchymoses appreciated. No ulcerations or rashes. DISCHARGE PHYSICAL EXAM: unchanged from above Pertinent Results: ADMITTING LABS: [**2149-6-25**] 10:55PM PT-14.6* PTT-33.4 INR(PT)-1.3* [**2149-6-25**] 10:55PM PLT SMR-LOW PLT COUNT-133*# [**2149-6-25**] 10:55PM HYPOCHROM-2+ ANISOCYT-2+ POIKILOCY-OCCASIONAL MACROCYT-OCCASIONAL MICROCYT-2+ POLYCHROM-NORMAL OVALOCYT-OCCASIONAL [**2149-6-25**] 10:55PM NEUTS-67 BANDS-0 LYMPHS-22 MONOS-10 EOS-1 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 [**2149-6-25**] 10:55PM WBC-4.3 RBC-2.80* HGB-7.1* HCT-22.3* MCV-80* MCH-25.5* MCHC-32.0 RDW-18.3* [**2149-6-25**] 10:55PM estGFR-Using this [**2149-6-25**] 10:55PM GLUCOSE-101* UREA N-25* CREAT-1.0 SODIUM-139 POTASSIUM-4.3 CHLORIDE-103 TOTAL CO2-28 ANION GAP-12 DISCHARGE LABS: [**2149-6-29**] 07:15AM BLOOD WBC-6.4 RBC-3.54* Hgb-9.7* Hct-28.5* MCV-80* MCH-27.4 MCHC-34.1 RDW-16.1* Plt Ct-130* [**2149-6-28**] 07:35AM BLOOD PT-14.6* PTT-35.4* INR(PT)-1.3* [**2149-6-29**] 07:15AM BLOOD Glucose-85 UreaN-22* Creat-0.8 Na-140 K-4.1 Cl-105 HCO3-25 AnGap-14 [**2149-6-27**] 04:01AM BLOOD ALT-13 AST-13 AlkPhos-53 TotBili-0.6 [**2149-6-29**] 07:15AM BLOOD Calcium-8.3* Mg-2.0 *** Left upper extremity Ultrasound: IMPRESSION: Non-occlusive clot in one branch of the left brachial vein without extension into the axillary vein. *** Small Bowel Enteroscopy: Findings: Esophagus: Normal esophagus. Stomach: Normal stomach. Duodenum: Normal duodenum. Jejunum: A circumferential friable mass of about 4-5 cm in length with luminal narrowing and areas of ulceration was noted in mid/distal jejunum. However the scope was able to pass the area of narrowing. A retained capsule was noted in that area. Retrieval of the capsule was not possible due to the angulation of the scope and the resultant difficulty in passing instruments down the scope channel. The area was tattooed with 2 cc.[**Country 11150**] ink with success. Cold forceps biopsies were performed for histology at the mid/distal jejunum at the site of the mass. Impression: A circumferential friable mass of about 4-5 cm in length with luminal narrowing and areas of ulceration was noted in mid/distal jejunum. However the scope was able to pass the area of narrowing. A retained capsule was noted in that area. Retrieval of the capsule was not possible due to the angulation of the scope and the resultant difficulty in passing instruments down the scope channel. These findings are compatible with a small bowel tumor. (injection, biopsy) Otherwise normal small bowel enteroscopy to mid/distal jejunum Recommendations: Await biopsy results. Clear liquids today and advance diet as tolerated tomorrow. Brief Hospital Course: 81yo M w/ PMHx of CHF (EF <35% on [**5-17**] ECHO), recent DVT in left arm [**1-8**] PICC on heparin SQ and Fe-deficiency anemia w/ recent GI bleed last month who presents to the ED after capsule endoscopy showed active bleeding in small bowel for further management. . #GI Bleed/ Acute blood loss anemia: Capsule endoscopy showing active bleeding in the small bowel. Of note, patient recently had a CT abdomen/pelvis that showed a segment of abnormal bowel wall thickening involving the midline small bowel, which has a dilated appearance and is adjacent to several prominent mesenteric lymph nodes. This appearance of aneurysmal dilation of small bowel is concerning for small bowel lymphoma. He was taken for small bowel endoscopy but the study was unrevealing, perhaps not reaching the area noted on the CT to be abnormal. Patient reports dark, tarry stools, but has not had frank blood in his stools. He reports some dizziness when sitting up and when standing/walking. On admission, he was made NPO in anticipation for procedure by GI and continued on protonix 40mg IV q24hrs. GI was consulted and recommended balloon enteroscopy. The procedure revealed a friable tissue mass consistent with distal small bowel tumor. Biopsies were performed. Final pathology report of the biopsy is pending, however preliminary report is suggestive of malignancy, most likely lymphoma. Surgery was consulted and discussed with the patient the possiblity of going to surgery for resection of the area. Currently, the patient is not interested in going to surgery. The fact that this surgery would be palliative was explained to the patiend and his wife. However, they wish to defer surgery at this time. They have been told that the patient is at risk of further bleeding and/or obstruction without this surgery and that surgery would, in many ways, be palliative. Palliative care was called to discuss his decision regarding treatment options. At this point, his plan is to wait for final pathology results and to think about his options and then make a final decision. He received 3 units of PRBCs during this admission. His hematocrit was 28 at the time of discharge and had been stable for 24 hours. He is expected, however, to have continued slow oozing from this mass. He should have his hematocrit checked at least twice weekly and should receive blood transfusions to maintain a goal hematocrit of 28 (unless he opts for hospice). He was also seen by oncology who recommended surgery and noted that it was consistent with a palliative approach. The plan is for him to follow-up with oncology once final pathology is back. . #CHF: Patient with last EF 35% on [**5-17**] ECHO. s/p biventricular pacer with EKG showing ventricular pacing. Patient appeared euvolemic on exam without LE edema, crackles, or elevated JVD. At home, patient is on, lisinopril, metoprolol and torsemide. These medications were initially held given his NPO status for procedure. Metoprolol was restarted and titrated back up to his home dose prior to discharge (12.5 mg twice daily). Lisinopril and torsemide were held as he appeared euvolemic and his blood pressure was normal in the 100's-110's systolic. . #HTN: As above, his home lisinopril and torsemide were held. His metoprolol was restarted. . #h/o UE DVT: When discharged from hospitalization when he developed UE DVT, the patient was started on [**Hospital1 **] heparin injections for prophylaxis per Heme-Onc consult from last admission. It is possible that hypercoagulable state may be due to a possible malignancy (suspecting small intestinal lymphoma). Appears that GI bleeding became an issue with the initiation of heparin therapy. Per rehabilitation records, the patient has still been taking heparin SQ [**Hospital1 **]. On presentation to the ED, coag studies show PTT 33.4. Heparin was stopped in the setting of GI bleeding. This was discussed in detail with the hematology/oncology team. They recommended continuing SC heparin at 5,000 units twice daily until he makes further decisions about pursuing care versus pursuing comfort based approach. This was discussed with the patient and with his wife. The risk of holding heparin and resulting DVT and pulmonary embolism, potentially resulting in death, was explained to the patient. The risk of giving heparin and likely continued oozing from his mass was also explained to the patient. Bleeding could be treated, however, with blood transfusions, whereas pulmonary embolism is less treatable and could be deadly. He opted to continue SC heparin for now. His wife was supportive of this decision. This should be readdressed once he makes a decision about his future care. If he chooses to pursue surgery, then it makes sense to continue. If he chooses to be CMO and hospice care, then it might make sense to discontinue. . #thrombocytopenia: Platelets have steadily decreased since early [**Month (only) 205**] when patient was last discharged from the hospital. Patient was started on heparin as an outpatient at 5000 units [**Hospital1 **]. Differential included HIT versus medications. Patient also started Linezolid and then was transitioned to Doxycycline, both of which can cause thrombocytopenia. Doxycycline was continued for treatment of cardiac device vegetation. Platelets were trended; HIT antibody was not sent off. . #h/o CoNS Blood stream infection, K. pneumo bloodstream infection, Cardiac device vegetation: Followed by ID as an outpatient. Cardiac device vegetation present on ventricular lead. During his previous admission, the decision was made to try to salvage the ventricular device. Patient recently transitioned from Linezolid to doxycycline for treatment. The patient should be continued on doxycycline. . #HLD: Patient's home statin was held. . For the purposes of coordination of care, continued discussion with consulting teams, and close monitoring of his tenuous status, he was offered the opportunity to stay in house. However, he strongly desired transfer to a skilled nursing facility for continued rehabilitation and to be closer to his family. He is hoping to get home as soon as possible. Medications on Admission: Medications: per ALF note Doxycycline 100mg po BID Lisinopril 5mg; one half tablet by mouth daily at night Metoprolol succinate 12.5mg twice a day Pantoprazole 40mg, 1 tablet once a day Simvastatin 40mg table 1 tablet by mouth Torsemide 10mg every day Ascorbic acid 250mg tablet [**Hospital1 **] Ferrous gluconate 325mg tablet [**Hospital1 **] Psyllium husk: uncertain dosage Discharge Medications: 1. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for Constipation. 2. senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day) as needed for Constipation. 3. nystatin 100,000 unit/g Cream Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day). 4. doxycycline hyclate 100 mg Capsule Sig: One (1) Capsule PO Q12H (every 12 hours). 5. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) injection Injection [**Hospital1 **] (2 times a day). 6. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 7. guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6 hours) as needed for cough. Discharge Disposition: Extended Care Facility: [**Location (un) 39857**] - [**Location 9583**] Discharge Diagnosis: Jejunal mass, likely lymphoma GIB Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: You were admitted to the hospital with bleeding from your small bowel. You underwent an endoscopy and had a mass that was biopsied. The biopsy showed a cancer, likely a lymphoma. You were seen by surgery and oncology -- both recommended surgery. However, you did not want to have surgery at this time and wanted to think about it more. You were also seen by palliative care to discuss your options. The oncologists will get in touch with you with follow-up. ... Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more than 3 lbs. Followup Instructions: You should follow-up with your primary care doctor within 1-week of being discharged from the skilled nursing facility. You should follow-up with oncology. They will contact you with an appointment date and time. Department: INFECTIOUS DISEASE When: WEDNESDAY [**2149-7-16**] at 11:00 AM With: [**First Name11 (Name Pattern1) 1037**] [**Last Name (NamePattern4) 2335**], MD [**Telephone/Fax (1) 457**] Building: LM [**Hospital Unit Name **] [**Hospital 1422**] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage Department: CARDIAC SERVICES When: FRIDAY [**2149-8-8**] at 11:00 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: FRIDAY [**2149-8-8**] at 12:00 PM With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**Telephone/Fax (1) 62**] Building: [**Hospital6 29**] [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage

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icd9cm

[ [ [] ] ]

[ "45.13", "45.16" ]

icd9pcs

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312, 333

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12,313

188,607

1798

Discharge summary

report

Admission Date: [**2151-7-28**] Discharge Date: Service: VASCULAR CHIEF COMPLAINT: Abdominal aortic aneurysm. HISTORY OF PRESENT ILLNESS: The patient was initially seen in [**Month (only) 547**] of this year by Dr. [**Last Name (STitle) 1476**]. He is an 82-year-old male who was seen in the Emergency Room with a history of hematuria which subsided. During the course of the evaluation, he underwent a CT of the abdomen which noted a 4.0 x 2.6 filling defect, rather illy defined. A low attenuation in the right posterior liver lobe was also noted at that time. He had a 6.3 cm infrarenal abdominal aortic aneurysm with right iliac aneurysmal changes of 2.2 cm and left iliac changes of 1.6 cm. He denied any symptoms in relationship to his aneurysm. The patient was referred to Dr. [**Last Name (STitle) 1476**] for evaluation and treatment. PAST MEDICAL HISTORY: Coronary artery disease. Myocardial infarction times two. Coronary artery bypass grafting in [**2144**]. History of atrial fibrillation, chronic, diagnosed since [**2144**]. Mitral valve prolapse with prophylaxis with procedures. Diabetes type 2, not on medication. Benign prostatic hypertrophy. Peptic ulcer disease. Liver hemangioma by CT. Hepatitis A positive. PAST SURGICAL HISTORY: Coronary artery bypass grafting times six in [**2144**]. Prostate surgery, reoperative times four. Cataract surgery. Nasal polypectomy. SOCIAL HISTORY: Positive for a 20 pack-year history of smoking; he discontinued in [**2124**]. He denied alcohol or drugs. ALLERGIES: NO KNOWN DRUG ALLERGIES. MEDICATIONS: Fosamax 70 mg q.week, Hyzaar 1 q.d., Lipitor 80 mg q.d., Lotensin Hydrochloride 20/25 q.d., Coreg 25 mg daily. Other medications include Ranitidine 150 mg b.i.d., Folic Acid 1 mg q.d., Multivitamin tab q.d. PHYSICAL EXAMINATION: General: The patient was a well-built, well-nourished, elderly male in no acute distress. Vitals signs: Blood pressure 112/64, pulse 42, respirations 12. HEENT: Unremarkable. There were no carotid bruits. No thyromegaly. The carotid pulses were palpable. Chest: Minimal crackles at the right base, otherwise clear. Heart: Regular, rate and rhythm. Normal S1 and S2. Normal murmurs, rubs or gallops. Occasional extrasystole. Abdomen: Soft and nontender. There was a pulsatile mass at midline that was nontender. Right renal artery bruits. Extremities: No edema. His femorals were palpable. Pedal pulses palpable bilaterally. PREOPERATIVE LABS: Electrocardiogram was normal sinus rhythm with a V-rate of 64 with multiple ventricular premature complexes. There was early transition. There was left atrial enlargement. There was inferior wall infarct changes noted. There were nonspecific anterolateral T-wave abnormalities which could not exclude ischemia. Chest x-ray showed no acute cardiopulmonary disease. White count 11.5, hematocrit 34.1, platelet count 129,000; BUN 20, creatinine 1.1, potassium 3.7, calcium 1.18, magnesium 1.6, phosphorus 4.1. HOSPITAL COURSE: The patient was admitted to the Preoperative Holding Area. He underwent a transabdominal abdomino-aortic repair. He tolerated the procedure well. He was transferred to the PACU in stable condition with palpable dorsalis pedis and posterior tibial pulses bilaterally. During his PACU stay, he was noted to have episodes of hypotension in the mid 90s to mid 80s. The patient was bolused with lactated Ringer's multiple times to maintain a systolic blood pressure greater than 95-100. He remained intubated. His cardiac index showed improvement when systolic blood pressure improved to 130/135 with an index of 3.44. He received 2 U of packed red cells intraoperatively and 3 U of cell [**Doctor Last Name 10105**] intraoperatively. He was transferred to the SICU for continued monitoring and ventilatory support. His pressures in the SICU were reported as 134/64, PAP was 32/14, CBP 8, wedge 16, index 3.44. His exam was unremarkable. On postoperative day #1 there were no overnight events. He remained intubated overnight. He remained hemodynamically stable with a blood pressure of 142/69. CBP 8, pulmonary pressure 29/12, index 2.87, blood gases were 7.41, 38, 190, 25, 98% on 40% pressure support. Postoperative hematocrit was 35, BUN and creatinine were 19 and 1.3. PT and INR were normal. Recommendations were to wean to extubate, keep systolic blood pressure less than 160 with the use of Nitroglycerin or Lopressor if heart rate is greater than 60. Perioperative Kefzol was continued. He remained in the SICU. The patient continued to do well on postoperative day #2. Overnight the epidural was discontinued, and the patient was extubated. He remained hemodynamically stable. He remained NPO. His Swan-Ganz was changed to a triple-lumen catheter without incident. The patient continued to do well and transferred to the regular nursing floor on postoperative day #3. He required gentle diuresis over this period of time and received repletion of electrolytes as indicated. Physical Therapy began to work with the patient. After discussions with the patient, we felt that he would benefit from a skilled nursing facility and continued rehabilitation for independent mobility. He was given Dulcolax on hospital day #4 with results of flatus and multiple semi-liquid bowel movements. His diet was begun on clear liquids which he tolerated, and this was progressed as tolerated to regular diet. The patient's Foley was discontinued. His potassium was 3.1, and this was repleted. The remaining hospital course was unremarkable. His wounds were clean, dry and intact. DISCHARGE MEDICATIONS: Percocet tab [**12-22**] q.3-4 hours p.r.n. pain, Zantac 150 mg q.d., Dulcolax suppository 1 p.r. p.r.n., Hydrochlorothiazide 25 mg q.d., Miconazole powder 2 affected areas p.r.n., Lopressor 50 mg q.d., hold for systolic blood pressure less than 120, Lotensin 10 mg q.d., hold for systolic blood pressure less than 130, Coreg 25 mg q.d., hold for systolic blood pressure less than 100, heart rate less than 60, Timolol eye drops 0.5% O.U. 1 drop b.i.d., Pilocarpine 1 drop O.U. q.i.d., Lipitor 80 mg q.d. DISCHARGE DIAGNOSIS: 1. Abdominal aortic aneurysm status post repair. 2. Hyperkalemia secondary to diuresis, corrected. 3. Hypertension, controlled. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1477**], M.D. [**MD Number(1) 1478**] Dictated By:[**Last Name (NamePattern1) 1479**] MEDQUIST36 D: [**2151-8-2**] 10:49 T: [**2151-8-2**] 11:48 JOB#: [**Job Number 10106**]

[ "V45.81", "401.9", "414.01", "412", "276.7", "441.4", "250.00" ]

icd9cm

[ [ [] ] ]

[ "38.44" ]

icd9pcs

[ [ [] ] ]

5663, 6169

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3035, 5639

1286, 1425

1835, 3017

95, 123

152, 865

888, 1262

1442, 1812

64,885

147,577

34813

Discharge summary

report

Admission Date: [**2150-11-11**] Discharge Date: [**2150-11-22**] Service: CARDIOTHORACIC Allergies: Lisinopril Attending:[**First Name3 (LF) 1505**] Chief Complaint: Chest pain Major Surgical or Invasive Procedure: [**2150-11-11**] Cardiac Catheterization [**2150-11-17**] Two Vessel Coronary Artery Bypass Grafting utilizing the LIMA to LAD, and vein graft to the diagonal artery. History of Present Illness: Mr. [**Known lastname 79731**] is a 85 y/o M with history of coronary artery disease who underwent cardiac catheterization in [**2146**] where he was found to have a moderate lesion in the proximal LAD and was medically managed. He underwent another cardiac catheterization in [**Month (only) 116**] [**2150**] for worsening chest pain. He was found to have 60%, 70% and 80% lesions in the proximal LAD, a 70% lesion in the mid LAD, and an 80% lesion of the moderatedly sized ostial D3. In addition he reportedly had a 30% stenosis of the proximal OM3 and a 40% mid-RCA lesion. He subsequently underwent stenting of the proximal and mid LAD lesions with a 2.5 x 16 m Taxus stent and overlapping 2.5 mm Taxus stents (24 mm distally and 12 mm more proximally). His LVEF was not reported but his resting left heart filling pressures were elevated at 18 mmHg. On the day prior to this admission, he was seen in cardiology follow up with Dr. [**First Name (STitle) 1075**] for complaints of chest tightnees. He has been going to cardiac rehab, working out three times per week. Last Friday he developed chest tightness while on the treadmill. It resolved after approximately 5 minutes. The following day he had a recurrence which also resolved spontaneously. On Sunday he once again had another episode but at rest watching TV for which he took an ASA and after a period of time the discomfort subsided. On Monday while shopping, at the grocery store he had yet another episode for which he took a nitroglycerin. He was subsequently admitted for repeat cardiac catheterization. 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. All of the other review of systems were negative. Cardiac review of systems is notable for absence of paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. Past Medical History: CAD, s/p stenting to LAD in [**6-11**] Dysphagia, Shatzki??????s ring Type II Diabetes Mellitus Hyperlipidemia Hypertension Gout Neuropathy Glaucoma Polypectomy S/P arthroscopic surgery of the Left knee BPH, s/p TURP Social History: He is married with 2 grown children. He no longer smokes but has 1 glass of wine per day. He is a retired research chemist. Family History: Denies premature CAD Physical Exam: Preop Exam VS -T:m/c 98.3 HR 40s-50s BP 120s-140s/60s RR 18 O2sat 98% RA Gen: WDWN older gentleman in NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. Neck: Supple with JVD 2 cm above clavicle. CV: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2, S3. No m/r. Chest: Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. Abd: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. Ext: No c/c/e. No femoral bruits. Cath site with surrounding ecchymoses. No bruit. No hematoma. Pulses: Right: DP 2+ Left: DP 2+ Pertinent Results: [**2150-11-11**] Cardiac Cath: 1. Selective coronary angiography of this right dominant system revealed extensive single vessel disease. The LMCA was patent. The LAD had severe, diffuse in-stent stenosis (90-95%) in all three stents. The LCx had a 30% proximal lesion and a 40% stenosis in a large OM3 branch. The RCA had a 30% eccentric stenosis in the mid-vessel. 2. Limited resting hemodynamics revealed elevated left heart filling pressures with an LVEDP of 32mmHg. There was moderate systemic arterial hypertension with a central aortic SBP of 160mmHg. 3. Left ventriculography demonstrated no mitral regurgitation. The calculated LVEF was 45% with anterior wall hypokinesis. 4. Supravalvular aortography demonstrated a normal aortic root and ascending aorta with no regurgitation. [**2150-11-12**] Echocardiogram: The left atrium is mildly dilated. The right atrial pressure is indeterminate. There is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (LVEF>55%). The right ventricular cavity is mildly dilated with normal free wall contractility. The aortic root is mildly dilated at the sinus level. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Trace aortic regurgitation is seen. The mitral valve leaflets are structurally normal. There is no mitral valve prolapse. Mild to moderate ([**2-4**]+) mitral regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. [**2150-11-13**] Carotid Ultrasound: 1. A 40-59% right ICA stenosis, graded closer to 40%. 2. No significant left ICA stenosis (graded as less than 40%). [**2150-11-13**] 06:45AM BLOOD WBC-5.1 RBC-3.51* Hgb-11.2* Hct-32.4* MCV-92 MCH-31.8 MCHC-34.5 RDW-13.8 Plt Ct-247 [**2150-11-12**] 09:50AM BLOOD PT-13.1 PTT-44.5* INR(PT)-1.1 [**2150-11-12**] 06:35AM BLOOD UreaN-17 Creat-1.4* K-3.8 [**2150-11-13**] 06:45AM BLOOD ALT-15 AST-16 AlkPhos-66 TotBili-0.3 [**2150-11-13**] 06:45AM BLOOD %HbA1c-6.6* [**2150-11-13**] 06:45AM BLOOD Triglyc-169* HDL-49 CHOL/HD-3.3 LDLcalc-78 Brief Hospital Course: Mr. [**Known lastname 79731**] was admitted under cardiology and underwent repeat cardiac catheterization. Findings were notable for severe single vessel coronary artery disease(multiple in-stent restenosis of the LAD) with moderate systolic and diastolic ventricular dysfunction - see result section for further detail. Based upon the above results, cardiac surgery was consulted and further evaluation was performed. Additional preoperative workup included transthoracic echocardiogram and carotid ultrasound. The ECHO showed an LVEF of 55-60% with only [**2-4**]+MR while carotid ultrasound found only mild disease of the right internal carotid artery - please see result section for further detail. Mr. [**Known lastname 79732**]' preoperative course was otherwise uneventul. He remained pain free on medical therapy and intravenous Heparin. On [**11-17**], Dr. [**Last Name (STitle) **] performed coronary artery bypass grafting surgery - see operative note for further detail. Following the operation, he was brought to the CVICU for invasive monitoring. Within 24 hours, he awoke neurologically intact and was extubated without incident. The patient was transferred to the step down unit where he made excellent progress with physical therapy, showing good strength and balance prior to discharge. He does have a history of benign prostatic hyperplasia, and did have urinary retention. This was managed with a foley catheter, with which the patient was discharged and given instructions to follow up with his urologist, Dr. [**Last Name (STitle) 59777**]. Additionally, he was started on Flomax. The patient was transfused two units of packed red blood cells for a hematocrit of 21. Hematocrit rose appropriately. By the time of discharge on POD 5, the patient was ambulating freely, the wound was healing, and pain was controlled with oral analgesics. Medications on Admission: Metformin 500 mg 1 tab [**Hospital1 **] Omeprazole 20 mg 1 tab daily Plavix 75 mg 1 tab daily Atenolol 25 mg 1 tab daily Niacin 500 mg 1 tab [**Hospital1 **] Gabapentin 100 mg 1 tab [**Hospital1 **] Alphagan 0.02% 1 drip OU [**Hospital1 **] Simvastatin 40 mg 1 tab daily Doxazosin 1 mg ?????? tab daily Finesteride 5 mg 1 tab daily ASA 325 mg 1 tab daily Allopurinol 100 mg 1 tab daily Vitamin D 400 IU 1 tab [**Hospital1 **] . Discharge Medications: 1. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 2. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12 hours). Disp:*60 Tab Sust.Rel. Particle/Crystal(s)* Refills:*2* 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 5. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 6. Metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*0* 7. 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* 8. Niacin 100 mg Tablet Sig: Five (5) Tablet PO BID (2 times a day). Disp:*300 Tablet(s)* Refills:*0* 9. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*0* 10. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 11. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 12. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). Disp:*15 Tablet(s)* Refills:*0* 13. Brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2 times a day). Disp:*qs * Refills:*0* 14. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO HS (at bedtime). Disp:*30 Capsule, Sust. Release 24 hr(s)* Refills:*0* 15. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for pain. Disp:*60 Tablet(s)* Refills:*0* 16. Propoxyphene N-Acetaminophen 100-650 mg Tablet Sig: [**2-4**] Tablets PO Q6H (every 6 hours) as needed. Disp:*60 Tablet(s)* Refills:*0* 17. Furosemide 20 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:*60 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Location (un) 1110**] VNA Discharge Diagnosis: Coronary Artery Disease - s/p CABG Prior PCI/stening to LAD Hypertension Dyslipidemia Type II Diabetes Mellitus Shatzki Ring s/p Esophogeal Dilitation Urinary Retention Discharge Condition: Good Discharge Instructions: No driving for at least one month No lifting more than 10 lbs for at least 10weeks from surgery date Shower daily, no baths. No creams, lotions or ointments to surgical incisions. Clean wounds with soap and water. Pat dry wounds only, no rubbing. Call if there is any concern for wound infection. Followup Instructions: Dr. [**Last Name (STitle) **] in [**5-9**] weeks, call for appt Dr. [**First Name (STitle) 1075**] in [**3-8**] weeks, call for appt Dr. [**Last Name (STitle) **] in [**3-8**] weeks, call for appt Dr. [**Last Name (STitle) 79733**] this week. Completed by:[**2150-11-22**]

[ "433.10", "429.3", "V04.81", "427.89", "530.3", "274.9", "788.20", "355.9", "600.01", "V45.89", "V45.82", "V15.82", "E879.0", "272.4", "440.0", "996.72", "250.00", "E942.9", "458.29", "365.9", "276.6", "414.01", "411.1", "285.9", "585.3", "403.90", "564.00" ]

icd9cm

[ [ [] ] ]

[ "37.22", "99.52", "39.64", "99.04", "36.11", "88.56", "39.61", "88.42", "88.53", "36.15" ]

icd9pcs

[ [ [] ] ]

10211, 10270

5749, 7617

237, 406

10483, 10490

3631, 5726

10835, 11110

2874, 2896

8095, 10188

10291, 10462

7643, 8072

10514, 10812

2911, 3612

187, 199

434, 2474

2496, 2715

2731, 2858

66,256

166,051

13111

Discharge summary

report

Admission Date: [**2169-11-23**] Discharge Date: [**2169-11-28**] Date of Birth: [**2105-9-19**] Sex: F Service: CARDIOTHORACIC Allergies: Aspirin / Ciprofloxacin / Procardia / Niacin / Biaxin / Niaspan / Ibuprofen / Crestor / Quinolones / Neosporin / Adhesive Tape Attending:[**First Name3 (LF) 3948**] Chief Complaint: Cough s/p bronchoscopy Major Surgical or Invasive Procedure: [**2169-11-24**] : Rigid bronchoscopy with black Dumon bronchoscope. Cryotherapy for debridement of granulation tissue, distal left main-stem. Balloon dilatation to 10 mm, distal left main-stem. Mechanical debridement of granulation tissue, left main-stem. [**2169-11-24**]: Flexible bronchoscopy [**2169-11-23**]: Rigid bronchoscopy. Foreign body removal (Y-stent). History of Present Illness: 64F with PMH of morbid obesity, OSA, severe COPD, and TBM s/p placement of Y-stent on [**2169-11-6**], who presented today for scheduled removal of her Y-stent. She states that since having the stent in place she has suffered from increased shortness of breath and coughing, with increased sputum and mucus production. The procedure itself was uncomplicated, but in the PACU she had nearly 2 hours of prolonged coughing which developed into pleuritic CP. She received albuterol nebs, lidocaine nebs, IV codeine, and 125mg IV solumedrol. A CXR revealed diffuse left lung collapse from mucus plugging and probable aspiration. She was placed on CPAP in the PACU with some improvement in respiratory stauts. ABG was 7.41/47/65/31. EKG was not concerning for ischemia. Cardiac enzymes were negative. The decision was made to to perform bronchoscopy at that time, but to admit to MICU for repsiraotry monitoring and possible bronch in AM if plug had not cleared by then. . Currently she endorses shortness of breath above her baseline. She has diffuse pleuritic chest pain that is non-radiating. She occasionally has spasms of uncontrollable coughing. Past Medical History: 1. Obesity. 2. History of pericarditis/tamponade secondary to polyserositis. She has been on steroids for this for the past 17 years. 3. History of pleural effusion. 4. Sarcoidosis. 5. GERD. 6. History of lung nodule status post thoracotomy with left lower lobe wedge resection and ([**Hospital1 2025**] [**2160**]). 7. Asthma. 8. Hiatal hernia. 9. OSA on nocturnal CPAP (plus 12) 10. Hypertension. 11. Lactose intolerance. 12. Tracheobronchomalacia Social History: The patient is divorced. She lives alone in [**Location (un) **], [**State 350**]. She has one son who lives close by. She has been on disability since [**2149**]. Prior to that, she worked as a financial analyst. She has a rare glass of wine. She quit smoking in [**2160**]. Prior to that she smoked a pack a day for 40 years. She has never used any illicit drugs. She denies asbestos exposure and reports no known TB exposures. She had a negative PPD test last year prior to starting Enbrel therapy. Family History: There is no family history of lung disease or sarcoid. Her mother died secondary to rectal cancer 82 years old. Notably she did have lupus. Her father died secondary to an MI at 72 years old. Her son is healthy. Physical Exam: VS: 99.6 94 113/51 24 90% 2L NC Gen: obese middle aged female, frequently coughing, but not in acute resp distress, speaking in full sentences HEENT: NC/AT, MMM Neck: obese Cor: RRR, 2/6 systolic murmur at LSB Resp: Scattered wheezes bilateral Abd: obese, s/nt/nd +BS Ext: WWP. 2+ b/l pitting edema to knee. + digital clubbing Pertinent Results: [**2169-11-26**] WBC-17.5* RBC-4.55 Hgb-12.1 Hct-35.6* Plt Ct-755* [**2169-11-25**] WBC-20.0* RBC-4.08* Hgb-10.7* Hct-31.9* Plt Ct-684* [**2169-11-24**] WBC-15.7* RBC-3.93* Hgb-10.6* Hct-30.3* Plt Ct-603* [**2169-11-23**] WBC-19.6*# RBC-4.12* Hgb-10.9* Hct-32.0* Plt Ct-624* [**2169-11-23**] Neuts-91.9* Lymphs-6.2* Monos-1.4* Eos-0.5 Baso-0.1 [**2169-11-27**] Glucose-80 UreaN-25* Creat-0.8 Na-137 K-4.1 Cl-97 HCO3-33* [**2169-11-27**] 02:35AM BLOOD K-4.0 [**2169-11-25**] Glucose-129* UreaN-21* Creat-0.6 Na-139 K-3.8 Cl-96 HCO3-32 [**2169-11-23**] Glucose-126* UreaN-8 Na-136 K-4.1 Cl-94* HCO3-31 [**2169-11-26**] CK(CPK)-36 [**2169-11-24**] CK(CPK)-29 [**2169-11-23**] CK(CPK)-40 [**2169-11-27**] BLOOD cTropnT-<0.01 [**2169-11-26**] CK-MB-NotDone cTropnT-<0.01 [**2169-11-27**] BLOOD Calcium-9.2 Phos-3.9 Mg-2.0 CXR: [**2169-11-24**] In comparison with study of [**11-23**], there has been substantial re-expansion of the left lung, presumably from expectoration of a mucus plug. Atelectatic changes persist at the left base and there is continued elevation of the left hemidiaphragmatic contour. [**2169-11-23**] In comparison with the study of [**11-17**], there has been substantial volume loss in the left lung with opacification of most of the left hemithorax following stent removal. Some patchy quality of the opacification raises the possibility of supervening aspiration or hemorrhage from recent bronchoscopy. Chest CT: [**2169-11-27**] 1. Negative examination for pulmonary embolism. 2. Long-term stability of noncalcified pulmonary nodules, consistent with a benign etiology. 3. Stable appearance of the left lower lobe post-surgical changes with scarring. 4. Coronary calcifications. 5. Mucoid impactation in bronchi of left lower lobe. Brief Hospital Course: 64F with OSA, severe COPD, and TBP s/p removal of Y-stent [**11-23**] who is admitted to the MICU post-procedurally with left lung collapse and evidence of mucus plugging and aspiration and respiratory failure. She was placed on CPAP with aggressive pulmonary toileting, chest PT and mucolytics. Intravenous steroids were started for COPD excerbation. Cardiac enzymes were negative. On [**2168-11-23**] she had Flexible bronchoscopy which showed granulation tissue distal to LMS occluding 75% of lunar. Distal airway was patent. She then procedued to the operating room for Rigid bronchoscopy, Cryotherapy for debridement of granulation tissue, distal left main-stem. Balloon dilatation to 10 mm, distal left main-stem. Mechanical debridement of granulation tissue, left main-stem. She tolerated the procedure her saturations were monitored in the ICU prior to transfer to the floor. The post procedure chest film showed some residual atelectasis and possibly effusion at the left base with elevation of the left hemidiaphragmatic contour, no recurrence of the substantial volume loss seen previously and no evidence of pneumothorax. Her oxygenation improved Sats were 91% on 2L nasal cannula. She transferred to the floor on a steroid taper, home CPAP settings, aggressive pulmonary toileting and chest PT. On [**2169-11-25**] her pain was managed with PO pain medicaiton, the foley was removed and she voided. Her diet was advanced and she ambulated in the halls. On [**2169-11-26**] she had an episode of atrial fibrillation in the 150's. She was given IV lopressor with spontaneous conversion to sinus rhythm. She was started on a standing dose of low dose beta-blocker, her lytes were repleted. On [**2169-11-27**] Chest CT was negative for pulmonary embolism. On [**2169-11-28**] her respiratory status was at baseline, she continued on a steroid taper, and was discharged to home with VNA. She will follow-up as an outpatient. Medications on Admission: # Micardis/HCTZ 40/12.5 one tablet daily # Nexium 40 mg t.i.d. # Flexeril 10 mg b.i.d. # Medrol 4 mg daily, # Zyrtec 10 mg daily # Singulair 10 mg daily # cyproheptadine 4 mg b.i.d. # Lasix 20 mg daily p.r.n. edema # Enbrel injections 50 mg every week (has not taken in the past two weeks) # Advair 250/50 one puff twice daily # Rhinocort 32 mcg two sprays per nostril daily # vitamin E # calcium # vitamin C # vitamin B12 # multivitamin # vitamin D # Imodium p.r.n. # Benadryl p.r.n # Tylenol p.r.n. Discharge Medications: 1. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 2. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 4. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Calcium Carbonate 500 mg Tablet, Chewable Sig: Two (2) Tablet, Chewable PO BID (2 times a day). 6. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 8. Cyclobenzaprine 10 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 9. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: Two (2) Spray Nasal DAILY (Daily). 10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed. 11. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed. Disp:*50 Tablet(s)* Refills:*0* 12. Prednisone 10 mg Tablet Sig: Four (4) Tablet PO once a day for 2 days. Disp:*25 Tablet(s)* Refills:*0* 13. Prednisone 10 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily) for 3 days. 14. Prednisone 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily) for 3 days: then 1 x days, then [**11-17**] tablet (5mg) x 3 days. 15. Saline Solution Sig: Three (3) ML Miscellaneous three times a day: Nebulizers . Disp:*300 * Refills:*2* 16. Micardis HCT 40-12.5 mg Tablet Sig: One (1) Tablet PO once a day. 17. Nexium 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO three times a day. 18. Zyrtec 10 mg Tablet Sig: One (1) Tablet PO once a day. 19. Cyproheptadine 4 mg Tablet Sig: One (1) Tablet PO twice a day. 20. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day as needed. 21. Toprol XL 25 mg Tablet Sustained Release 24 hr Sig: 0.5 Tablet Sustained Release 24 hr PO once a day. Disp:*15 Tablet Sustained Release 24 hr(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Hospital6 486**] Discharge Diagnosis: Obesity. History of pericarditis/tamponade secondary to polyserositis, steroids x 17 yrs History of pleural effusion. Sarcoidosis. GERD. History of lung nodule status post thoracotomy with left lower lobe wedge resection and ([**Hospital1 2025**] [**2160**]). Asthma. Hiatal hernia. OSA on nocturnal CPAP (plus 12) Hypertension. Lactose intolerance. Discharge Condition: stable Discharge Instructions: Call Dr.[**Name (NI) 14679**] office [**Telephone/Fax (1) 7769**] if develops: -Fever > 101 or chills -Increased shortness of breath, cough or sputum production Prednisone taper 40 x 2 days, 30 x 3 days, 20 x 3 days, 10 x 3 days then 5 mg day. Please contact your rheumatologist regarding your medrol 4 mg daily. (when to start) Followup Instructions: Follow-up with Dr. [**Last Name (STitle) **] [**12-12**] @10:00am in the [**Hospital Ward Name 121**] Building [**Hospital1 **] I Chest Disease Center, [**Location (un) **] Follow-up with Dr. [**Last Name (STitle) **] [**12-12**] at 10:30 am Chest Disease Center Please follow-up with your rheumatologist regarding steroids Completed by:[**2169-11-29**]

[ "507.0", "553.3", "530.81", "786.59", "427.31", "V15.82", "518.0", "518.5", "278.01", "401.9", "338.29", "V58.65", "517.8", "519.19", "327.23", "493.22", "V44.8", "135", "511.89" ]

icd9cm

[ [ [] ] ]

[ "33.22", "33.78", "32.01", "33.91" ]

icd9pcs

[ [ [] ] ]

9807, 9857

5335, 7282

418, 787

10251, 10260

3549, 5312

10638, 10994

2973, 3186

7834, 9784

9878, 10230

7308, 7811

10284, 10615

3201, 3530

356, 380

815, 1963

1985, 2438

2454, 2957

51,059

120,418

45600

Discharge summary

report

Admission Date: [**2100-8-12**] Discharge Date: [**2100-8-17**] Date of Birth: [**2014-11-26**] Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 1115**] Chief Complaint: Right leg laceration Major Surgical or Invasive Procedure: none Placement of Wound Vac Placement of PICC Line History of Present Illness: 85 year old wheelchair-bound woman with a history of transverse myelitis, theapeutic on coumadin for prior DVTs, admitted for a laceration to the right anterior thigh after being hit by her wheelchair. On fall, patient did not have a head strike. She presented to the ED with profuse right calf bleeding. In the ED, patient had a syncopal event in the context of hypotension to SBP 50. HGB stable, Trop x 1 negative. EKG without changes. She was given 3L of fluid. She underwent X-ray of the right femur and right knee. Patient was seen by surgery. Primary closure of her wound was attempted, but was unable to be approximated due to edema. The patient was found to have dopplerable pulses on the right. A wet to dry bandage was placed on the wound. She was given morphine 2mg IV x 1 for pain and was transferred to the floor. . On the floor, the patient triggered immediately on admission for 78/palp, and altered mental status in the setting of profuse blood loss. Bleeding was controlled. Access with 1 20-gauge IV was obtained. Multiple attempts were made to establish a second IV site, without success. The patient was type and crossed, and transferred to the ICU. . On admission to the ICU, VS: 96 110/85 89 15 100% RA. The patient complained of pain in her leg and mild dizziness, but was otherwise stable. She was alert and oriented x 3. Past Medical History: - Collagenous colitis - Transverse myelitis, wheelchair bound - TIA - Bilateral DVTs ([**2092**]) on coumadin - Osteoarthritis - Glaucoma - MRSA discitis in [**2090**] - Carpal tunnel syndrome s/p right decompression 2 years ago - Maxillary cancer s/p resection & reconstruction - ? Seizure - History of C. Diff Social History: - Lives at home, has VNA for chronic indwelling Foley - Previously employed as a lawyer (graduated from [**Name (NI) **] Law) - Tobacco: Denies. Quit 40 years ago. - EtOH: occasional - Recreational drugs: Never Family History: Non-Contributory Physical Exam: Admission Physical Exam: VS: 96 110/85 89 15 100% RA HEENT: MM dry; No Lymphadenopathy or thyromegaly; no JVD Card: Normal S1, S2, no murmurs, rubs or gallops Lungs: CTA bilaterally Abdomen: Soft, non-tender, non-distended Ext: Large, profusely bleeding contusion on leg with surrounding expanding hematoma. Hematoma tender to palpation; Right DP and PT with biphasic doppler signals Neuro: A&Ox3; CN II- XII grossly intact; Strength 5/5 bilaterally; Sensation grossly intact Skin: Scattered ecchymosis on upper and lower extremities bilaterally Discharge physical exam: O: VS T97.4 BP 122/62 P 72 96% RA HEENT: MMM, EOMI Card: Normal S1, S2, no murmurs, rubs or gallops Lungs: CTA bilaterally, no wheezing or rhonchi Abdomen: Soft, non-tender, non-distended Ext: Irregular lac to R thigh, wound vac running. Leg grossly swollen but improved and softer. Left arm swollen and red. Denies pain. Neuro: A&Ox3; CN II- XII grossly intact; No sensation in lower extremities with limited [**1-30**] stregnth. 4+/5 bilaterally in upper extremities. Skin: Scattered ecchymosis on upper and lower extremities bilaterally Pertinent Results: [**2100-8-12**] 10:25AM BLOOD WBC-10.4 RBC-4.13* Hgb-12.2 Hct-37.5 MCV-91 MCH-29.5 MCHC-32.5 RDW-15.0 Plt Ct-356# [**2100-8-12**] 09:40PM BLOOD WBC-11.6* RBC-1.96*# Hgb-5.8*# Hct-17.3*# MCV-88 MCH-29.5 MCHC-33.4 RDW-14.9 Plt Ct-243 [**2100-8-13**] 03:29AM BLOOD WBC-9.6 RBC-2.68*# Hgb-8.2*# Hct-23.9*# MCV-89 MCH-30.8 MCHC-34.5 RDW-14.5 Plt Ct-181 [**2100-8-12**] 10:25AM BLOOD Plt Ct-356# [**2100-8-12**] 11:40AM BLOOD PT-36.1* PTT-30.0 INR(PT)-3.6* [**2100-8-12**] 09:40PM BLOOD PT-42.6* PTT-32.5 INR(PT)-4.4* [**2100-8-13**] 08:54AM BLOOD PT-13.1 PTT-24.1 INR(PT)-1.1 [**2100-8-12**] 10:25AM BLOOD Glucose-95 UreaN-14 Creat-0.4 Na-140 K-3.3 Cl-104 HCO3-28 AnGap-11 [**2100-8-12**] 09:40PM BLOOD Glucose-137* UreaN-12 Creat-0.2* Na-143 K-2.8* Cl-117* HCO3-21* AnGap-8 [**2100-8-13**] 03:29AM BLOOD Glucose-104* UreaN-11 Creat-0.3* Na-142 K-3.7 Cl-113* HCO3-24 AnGap-9 [**2100-8-12**] 10:25AM BLOOD cTropnT-<0.01 [**2100-8-13**] 03:29AM BLOOD CK-MB-5 cTropnT-0.10* [**2100-8-13**] 08:52AM BLOOD CK-MB-5 cTropnT-0.07* [**2100-8-12**] 09:40PM BLOOD Calcium-6.8* Phos-2.9 Mg-1.4* [**2100-8-13**] 03:29AM BLOOD Calcium-8.3* Phos-3.9 Mg-3.8* [**2100-8-12**] 09:47PM BLOOD Lactate-0.6 . Relevant Labs: [**2100-8-13**] 03:29AM BLOOD CK-MB-5 cTropnT-0.10* [**2100-8-13**] 08:52AM BLOOD CK-MB-5 cTropnT-0.07* [**2100-8-13**] 03:25PM BLOOD CK-MB-4 cTropnT-0.05* . Discharge Labs: [**2100-8-17**] 05:20AM BLOOD WBC-9.2 RBC-3.05* Hgb-9.3* Hct-27.1* MCV-89 MCH-30.4 MCHC-34.3 RDW-14.9 Plt Ct-180 [**2100-8-17**] 05:20AM BLOOD Glucose-100 UreaN-14 Creat-0.3* Na-143 K-3.9 Cl-108 HCO3-29 AnGap-10 . Imaging: Femur AP/Lat: 1. Increased callus formation about a right intertrochanteric hip fracture. No evidence of new fractures. 2. Chronic remodeling changes in the right femoral head and acetabulum consistent with congenital hip dysplasia. . Ultrasound left arm Final Report INDICATION: 85-year-old woman with worsening redness in the left upper arm. Patient has a peripherally inserted line in the left brachial vein. COMPARISON: None. FINDINGS: A small amount of thrombus coats the PICC line as it courses through the left subclavian. The thrombus does not adhere to the vessel wall. It is nonocclusive with preserved flow. There is normal [**Doctor Last Name 352**]-scale appearance, compressibility and color flow of the left IJ, axillary and brachial veins. There is normal flow and compressibility of the basilic and cephalic veins. IMPRESSION: Minimal amount of thrombus coating the PICC line in the left subclavian vein. Vein is patent with color flow. . Brief Hospital Course: 85 year old wheelchair-bound woman with a history of transverse myelitis, theapeutic on coumadin for prior DVTs, admitted to MICU for hypotension in the setting of acute laceration with supra-therapuetic INR. #Acute blood loss anemia / Hemorrhage / Hypovolemic Hypotension - Patient admitted with hypotension thought to be both hypovolemic due to acute blood loss and distributive secondary to administration of IV morphine. Over the first hours of her admission, she developed a rapidly expanding hematoma surrounding her laceration associated with a hematocrit drop from 37.5 to 17.3 in the setting of a supratherapeutic INR to 4.4. She was transfused 3 units of PRBCs, 3 units of FFP and 10 mg of vitamin K. Her bleeding stabilized and her hypotension resolved. Warfarin was held throughout admission. Morphine was also held out of concern for hypotension. #Coagulopathy - Patient was admitted with a supratheraputic INR due to coumadin use and consumption of coagulation factors due to bleeding. Warfarin was held throughout admission. Patient was given 10 mg Vitamin K and 3 units of FFP. Warfarin held at discharge; defer to outpatient providers whether to restart in outpatient setting (takes for history of bilateral DVT in [**2092**]). #Laceration/Hematoma - Patient admitted with laceration from fall, assoiciated with rapidly enlarging hematoma. Patient seen by surgery in ED, who attempted primary closure of the wound but wound was unable to be closed due to edema and felt that stiches would not be effective because of her very thin fragile skin. She was placed on wound vac running at 75 mmHg continuous with follow up with surgery. The patient's pulses remained stable throughout admission. She is discharged to rehab for wound care. #Chest pain - Patient had a short episode of chest pain on admission in the context of a hematocrit of 17 and hypotension. She had no associated EKG changes. Troponin rose from 0.01 to 0.1, but swiftly decreased to baseline over the course of the following day. Chest pain likely due to demand ischemia from hypotension and profound anemia. The patient did not have any further episodes of chest pain or EKG changes. Consider outpatient cardiac workup if clinically indicated. #History DVTs - On chronic coumadin. Coumadin held throughout admission due to acute bleed. Upon normalization of INR and stabilization of bleed, the patient was resumed on Heparin 5000 units SC TID. At this time, it was felt that anticoagulation could be held until the laceration and hematoma improved and then resumed at the primary care physician's discretion. Ultrasound in [**Month (only) **] of this year revealed chronic DVTs, which have not progressed from previous ultrasound imaging in mid [**2088**]. # LUE edema: The patient developed mild LUE edema around her PICC site. Ultrasound showed a small amount of thrombus coating the picc line only. PICC was removed. #GERD - Chronic. Home Pantoprazole EC 20 mg daily continued on admission. #Hyperlipidemia - Chronic. Simvastatin 10 mg QD continued on admission. #Collagenous colitis - Budesonide continued on admission. #Glaucoma - Brimonide 0.2% OT [**Hospital1 **] to right eye continued on admission. Dorzolamide-timolol 2-0.5 % OT [**Hospital1 **] held as non-formulary. #Constipation - Chronic. Docusate 100 mg [**Hospital1 **] continued. #Code- DNR/Ok to intubate Transitional Issues: No outstanding tests or incidental findings. There is the issue of anticoagulation which will need close follow up. As the patient became hypotensive and had severe bleed requiring multiple units of PRBC to correct, it was thought that restarting her anticoagulation for chronic DVTs was be too risky at this time. We will leave the decision of whether to restart anticoagulation following improvement of wound to outpatient doctors. Medications on Admission: - Acetaminophen 325 mg TID - Pantoprazole EC 20 mg QBREAKFAST - Simvastatin 10 mg QD - Budesonide ER 9 mg QD - Dorzolamide-timolol 2-0.5 % OT [**Hospital1 **] - Lidocaine 5 %(700 mg/patch) TOP DAILY - Oxycodone 5 mg PO Q4H PRN - Docusate 100 mg [**Hospital1 **] - Senna [**Hospital1 **] with narcotics - Warfarin 3-4 mg QD - Brimonide 0.2% OT [**Hospital1 **] to right eye Discharge Medications: 1. pantoprazole 20 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Qam. 2. simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. budesonide 3 mg Capsule, Delayed & Ext.Release Sig: Three (3) Capsule, Delayed & Ext.Release PO DAILY (Daily). 4. dorzolamide-timolol 2-0.5 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2 times a day). 5. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Topical once a day: 12 hours on and 12 hours off. 6. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. 7. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 8. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 9. brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2 times a day). 10. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO three times a day. Discharge Disposition: Extended Care Facility: [**Hospital3 2558**] - [**Location (un) **] Discharge Diagnosis: PRIMARY: Right thigh laceration, Chronic Deep vein thrombosis, Transverse myelitis SECONDARY: GERD, hyperlipidemia, collagenous colitis, glaucoma Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Dear MS. [**Known lastname **] [**Known lastname **], It was a pleasure taking care of you at [**Hospital1 18**]. You were found to have a severe laceration of your right thigh after transferring yourself from your toilet to wheelchair. You had a large bleed which was corrected by reversing your anticoagulation from warfarin and you were given red blood cells. Surgery felt that in order for your wound to heal properly, you would need to go home with a Wound Vac to help the blood drain. They felt that suturing your wound would not be possible, because your skin is very sensitive from your steroid medication. Please discuss anticoagulation with your primary care physician. [**Name10 (NameIs) 227**] the degree of your bleeding from your leg, the surgeons have recommended at least one week without anticoagulation from the time of your injury. Please discuss whether or not you need to resume anticoagulation as an outpatient. The following changes were made to your medication regimen: INCREASE acetaminophen three times daily for pain STOP Warfarin Followup Instructions: Please attend the following appointments: Department: GENERAL SURGERY/[**Hospital Unit Name 2193**] When: TUESDAY [**2100-8-31**] at 1 PM With: ACUTE CARE CLINIC [**Telephone/Fax (1) 600**] Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage Completed by:[**2100-8-17**]

[ "285.1", "558.9", "V46.3", "V58.61", "323.82", "894.0", "E917.9", "272.4", "V12.51", "790.92" ]

icd9cm

[ [ [] ] ]

[ "38.93" ]

icd9pcs

[ [ [] ] ]

11348, 11418

6113, 9508

326, 379

11608, 11608

3535, 4890

12876, 13261

2355, 2373

10391, 11325

11439, 11587

9994, 10368

11784, 12853

4906, 6090

2413, 2947

9529, 9968

266, 288

407, 1773

11623, 11760

1795, 2109

2125, 2339

2972, 3516

74,627

126,036

37696

Discharge summary

report

Admission Date: [**2131-12-10**] Discharge Date: [**2131-12-15**] Date of Birth: [**2105-10-28**] Sex: M Service: ORTHOPAEDICS Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 14197**] Chief Complaint: Right distal femur osteosarcoma status-post neoadjuvant chemotherapy. Major Surgical or Invasive Procedure: Radical resection of osteosarcoma right distal femur and endoprosthesis reconstruction. [**2131-12-10**] Dr. [**Last Name (STitle) **], Dr. [**First Name (STitle) 4223**], Dr. [**Last Name (STitle) **]. Assistants: Dr. [**First Name (STitle) **], Dr. [**First Name (STitle) 3636**], Dr. [**Last Name (STitle) 933**]. History of Present Illness: The patient is a 26-year-old gentleman who presented with a huge osteosarcoma of his femur. It had an extensive soft tissue mass and was extremely painful at diagnosis. It extended from 7 cm below the lesser trochanter and probably extended into the knee joint. He also had metastatic disease. He was started on preoperative chemotherapy with some improvement of his pain, although the size of the mass did not change. We talked to him extensively with an interpreter about a recommendation for an amputation but he strongly preferred an attempt at limb salvage and given the fact that his prognosis was poor with his metastatic disease, it was elected to proceed with that. Social History: Denies history of tobacco, alcohol, or drug use. Lives with his wife, no children. Not currently working, but had previously worked in a restaurant. Family History: non-contributory Physical Exam: Afebrile with stable vital signs. Voiding spontaneously. Incision benign (clean, dry, intact). Light touch sensation intact distally in superficial peroneal, deep peroneal, tibial distribution. 2+ DP and PT pulses. Motor intact distally to extensor hallucis, tibialis anterior, and gastrocsoleus complex. Pertinent Results: [**2131-12-14**] 09:05AM BLOOD WBC-4.4 RBC-3.44* Hgb-9.4* Hct-28.6* MCV-83 MCH-27.3 MCHC-32.8 RDW-16.1* Plt Ct-1324* [**2131-12-10**] 09:15PM BLOOD WBC-3.4* RBC-2.66* Hgb-7.5* Hct-21.2* MCV-80* MCH-28.4 MCHC-35.5* RDW-17.5* Plt Ct-417# [**2131-12-14**] 09:05AM BLOOD Glucose-115* UreaN-4* Creat-0.3* Na-133 K-4.6 Cl-99 HCO3-30 AnGap-9 Final pathology pending Brief Hospital Course: Mr. [**Known lastname 84495**] was admitted as noted above. He underwent the above procedure without complication. Due to the vascular dissection required, Dr. [**Last Name (STitle) **] of vascular surgery assisted with the case. Dr. [**First Name (STitle) 4223**] assisted with the reconstructive portions of the case. His intra-operative blood loss was 1100cc and he received 5 units of packed red blood cells intra-operatively. He was extubated and taken to the ICU at the conclusion of the case. He received an additional two units over the night following his surgery. On the morning of post-op day one he was deemed stable for transfer to the floor. He was initially tachycardic and febrile as high as 102.3, but this improved throughout his hospitalization. The anesthesia pain service assisted with his post-operative pain control while he had an epidural in place. He mobilized with PT non-weight bearing on his right lower extremity. He was converted from a posterior splint to [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 6587**] locked at 30 degrees except for CPM and range of motion from 0-30 degrees on post-op day 2. His drain was discontinued and prophylactic Ancef stopped 48 hours after surgery. On [**12-15**] he was mobilizing well, had stable vital signs, was tolerating a regular diet, voiding spontaneously, had had a bowel movement and was deemed stable for discharge. Medications on Admission: -Lovenox 50mg [**Hospital1 **] (last dose 12/13 at 0500) -Morphine 15-45mg po q2h prn -Methadone 5mg po tid -Gabapentin 200mg q8h -Ativan 0.5mg q6h prn -Reglan -Phenergan -Protonix -valcyclovir -Thorazine prn for hiccoughs Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 2. Methadone 5 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day) as needed for Pain: Do not take if somnalent/altered mental status. . Disp:*100 Tablet(s)* Refills:*0* 3. Enoxaparin 30 mg/0.3 mL Syringe Sig: One (1) Subcutaneous Q12H (every 12 hours) for 4 weeks. Disp:*56 syringes* Refills:*0* 4. Hydromorphone 4 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3 hours) as needed for pain. Disp:*100 Tablet(s)* Refills:*0* 5. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q 8H (Every 8 Hours) as needed for fever. 6. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q8H (every 8 hours). Disp:*60 Capsule(s)* Refills:*2* 7. Lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for spasm, pain. Disp:*50 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Osteosarcoma right distal femur Discharge Condition: Good. Afebrile, with stable vital signs. Awake, alert, appropriate. Mobilizing with assitance. Voiding spontaneously. Incision benign, Light touch sensation intact in superficial peroneal, deep peroneal, and tibial distributions. Motor intact [**Last Name (un) 938**], TA, GSC. Discharge Instructions: Keep Right leg elevated. Non-weight bearing right lower extremity Physical Therapy: Non-weight bearing right lower extremity x6 weeks. Keep [**Doctor Last Name 6587**] locked at 30 degrees except for range of motion. CPM 0-30 degrees for 30 minutes a day, three times per day. Quad sets OK. Treatments Frequency: Change incision with dry, sterile gauze. Please wear TEDs at all times as much as possible and overwrap with ABD and ace wrap to keep swelling down. Allow steristrips to fall off on their own. Sutures will dissolve on their own. Keep right leg elevated while resting. Followup Instructions: Follow-up with Dr. [**Last Name (STitle) **] in 2 weeks with a repeat ultrasound in the morning prior to your appointment.

[ "V58.61", "170.7", "780.60", "427.89", "280.0", "V15.3", "197.0", "V87.41", "338.18", "V12.51" ]

icd9cm

[ [ [] ] ]

[ "77.87", "03.90", "77.85", "80.96", "84.48" ]

icd9pcs

[ [ [] ] ]

4933, 4939

2350, 3772

393, 714

5015, 5301

1964, 2327

5937, 6063

1601, 1619

4045, 4910

4960, 4994

3798, 4022

5325, 5392

1634, 1945

5410, 5620

5642, 5914

284, 355

742, 1418

1434, 1585

14,101

144,927

15989+15990+56719

Discharge summary

report+report+addendum

Admission Date: [**2200-3-2**] Discharge Date: [**2200-3-5**] Date of Birth: [**2122-10-15**] Sex: M Service: CARDIOLOGY REASON FOR ADMISSION: Shortness of breath and hypoglycemia. HISTORY OF PRESENT ILLNESS: This is a 76 year old male with past medical history of coronary artery disease, status post coronary artery bypass graft in [**2188**], and [**2196**], atrial flutter, status post ablation, congestive heart failure with ejection fraction of 20 to 25%, status post AICD placement, multiple myeloma, diabetes mellitus, who presented to an outside hospital on [**2200-3-2**], with the chief complaint of shortness of breath times three days. He states that for the past month prior to admission he noted anergia and increasing dyspnea. Six months prior to admission, he was able to walk twelve steps without difficulty. For the past few weeks, however, he has noted difficulty breathing, i.e., difficulty getting air in, especially with exertion, specifically with walking the twelve steps into his house. He also notes increasing orthopnea from two pillows to three pillows over the past month as well as paroxysmal nocturnal dyspnea. In late [**Month (only) 956**], he was seen in the Electrophysiology Device Clinic and begun on Lasix 20 mg once daily for congestive heart failure. On [**2200-2-27**], his Lasix dose was increased to 40 mg per day when he was seen in clinic after an episode of feeling a sensation of chills that awoke him from sleep accompanied by shortness of breath. On [**2200-2-28**], he noticed that he was "washed out" with increasing shortness of breath and decreasing p.o. intake. On [**2200-3-1**], he awoke in the middle of the night short of breath, sitting at the edge of the bed. He then became diaphoretic, light-headed, put his head between his knees and fell over into his bed without any head trauma. When he awoke after an unknown period of time, he was not lethargic, had no postictal signs. He was still markedly short of breath. He called EMS and was taken to an outside hospital. Of note, he had no sensation of palpitations or chest discomfort throughout this episode. At the outside hospital Emergency Department, fasting blood sugar was noted to be 31. The patient was saturating at 92% in room air. He was found to have bilateral rales on examination and was given 40 mg intravenous Lasix, Aspirin, one amp of D50 and one half Nitroglycerin paste and transferred to [**Hospital1 69**] for further evaluation given that his prior cardiologist is Dr. [**Last Name (STitle) **]. At the [**Hospital1 69**] Emergency Department, he was started on a D10W drip and transferred to the floor with q2hour fingerstick glucose checks. PAST MEDICAL HISTORY: 1. Prolonged PR interval. 2. Left bundle branch block. 3. Nonsustained ventricular tachycardia, status post AICD placement in [**2199-8-26**]. 4. Atrial flutter, status post ablation in [**2199-10-26**]. 5. Multiple myeloma diagnosed by bone marrow biopsy in [**2199-1-26**], with aspirate smears demonstrating a MTE ratio of 3:1, less than 1% blasts, 3% promyelocytes, 5% myelocytes, 7% metamyelocytes, 31% bands/neutrophils, 30% plasma cells, 8% lymphocytes, 16% erythroid cells. The plasma cells appear to be dysplastic with prominent nucleoli and there were multinucleated plasma cells seen as well. He had been treated for multiple myeloma prior to this biopsy with Thalidomide as well as Methylprednisone in the past. The patient also received one cycle of Melphalan. The initial IgG level was 4520 with IgA and IgM at less than 7 and 28, respectively. 6. Status post cholecystectomy, date unknown. 7. Coronary artery disease, status post coronary artery bypass graft in [**2178**], and [**2196**], with an episode of mediastinitis complicating one of the bypass surgeries. His last coronary catheterization was on [**2199-10-9**], which demonstrated patent left internal mammary artery to left anterior descending, and saphenous vein graft to R1/OM1 and right posterior descending artery, as well as severe three vessel coronary disease of a right dominant system, moderate diastolic ventricular function, left ventriculogram was not performed secondary to renal insufficiency. The pressures were as follows; right ventricular end diastolic pressure 18, wedge pressure 24, left ventricular end diastolic pressure 20 and the cardiac index was preserved at 2.5 liters per minute per meter square. 8. Prostate cancer, status post radiation therapy. 9. Bladder cancer, status post BCG instillation. 10. Congestive heart failure, left and right sided, with an ejection fraction of 20 to 25%. Severe global left ventricular hypokinesis to akinesis, 2+ mitral regurgitation, left atrial moderate dilation, left ventricular moderate dilation, mild pulmonary hypertension by echocardiogram performed on [**2199-10-9**]. 11. Diabetes mellitus type 2 diagnosed in [**2198**]. It is unclear how the patient got this diagnosis, however, he has been on Glipizide and Metformin for approximately one year with no episodes of hypoglycemia in the past. 12. Status post tonsillectomy. SOCIAL HISTORY: The patient lives with his wife. His son works at [**Hospital1 69**] in the information technology division. The patient denies alcohol or smoking. He is a former business executive. FAMILY HISTORY: Father with laryngeal cancer, history of depression and history of gynecologic cancer in two or more relatives. MEDICATIONS ON ADMISSION: 1. Coumadin 5 mg p.o. once daily. 2. Aspirin 81 mg p.o. once daily. 3. Lipitor 40 mg p.o. once daily. 4. Lopressor 50 mg p.o. twice a day. 5. Amiodarone 200 mg p.o. once daily. 6. Hydrochlorothiazide 25 mg p.o. once daily. 7. Lisinopril 20 mg p.o. once daily. 8. Tricor 160 mg p.o. once daily. 9. Metformin 500 mg p.o. twice a day. 10. Glipizide 10 mg p.o. once daily. 11. Multivitamin one p.o. once daily. 12. Lasix 40 mg p.o. once daily. PHYSICAL EXAMINATION: At the time of admission, temperature 97.9, blood pressure 165/65, heart rate 76 and paced and regular, respiratory rate 20, oxygen saturation 98% on two liters. In general, the patient is lying in bed, speaking four to five words at a time secondary to shortness of breath. The patient is alert and oriented times three, apparent use of accessory muscles of respiration. Head, eyes, ears, nose and throat - The pupils are equal, round, and reactive to light and accommodation. Extraocular movements are intact. Visual fields are intact bilaterally. Cardiovascular is regular rate and rhythm, II/VI systolic murmur best auscultated at the apex, heard throughout the precordium, nondisplaced point of maximal impulse. Jugular venous distention at nine centimeters. The lungs revealed crackles one half up bilaterally, no wheezes. The abdomen is soft, nontender, nondistended, positive bowel sounds. Extremities showed trace to 1+ sacral edema, cool feet, 2+ dorsalis pedis and radial pulses bilaterally. LABORATORY DATA: White blood cell count 3.1, hematocrit 30.0, platelet count 135,000. Chem7 showed sodium 138, potassium 4.0, chloride 98, bicarbonate 31, blood urea nitrogen 32, creatinine 2.2. INR 1.8. CK 91, troponin less than 0.01. Glucose 96. Chest x-ray showed findings consistent with congestive heart failure, more confluent opacity in the right infrahilar region, may reflect asymmetric edema or underlying pneumonia, read by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]. HOSPITAL COURSE: 1. Congestive heart failure - The patient was initially continued on 40 mg of Lasix per day, given the findings on lung examination and the peripheral edema. He was continued on ace inhibitor, beta blocker, with a less than two gram sodium diet, one liter fluid restriction. Enzymes were cycled and were negative times three. Blood pressure was initially controlled with a Nitroglycerin drip. A repeat echocardiogram was performed once the patient was transferred to the Intensive Care Unit and demonstrated diffuse segments of akinesis/hypokinesis in the apex, septal region, inferolateral region and inferior region, as well as moderate right ventricular systolic depression and an unchanged ejection fraction, unchanged mitral regurgitation at 2+. Once in the Intensive Care Unit, Natrecor drip was started with good effect on diuresis. We used Lasix with caution given the patient's rising creatinine. At the time of transfer to the floor, the patient had oxygen saturation of 99% on two liters nasal cannula. 2. Hypoglycemia - The patient was initially treated with an insulin sliding scale. The Glipizide and Metformin were held and one amp of D50 was given for isolated low glucose levels. However, on the evening of [**2200-3-3**], the patient had persistent episodes of hypoglycemia despite 9 amps of D50 and 1 mg of Glucagon on the floor. He was transferred to the Medical Intensive Care Unit where a D10W drip was initiated. Nevertheless, the patient still required D50 pushes for two glucose levels below 50. Fingerstick glucose levels were checked q1hour. Beta 2 Hydroxybutyrate was checked. C-PEP was checked. Insulin and proinsulin was checked. They are all pending at the time of dictation. TSH, T4 and cortisol were checked and were all within normal limits. An endocrine consultation was obtained which suggested that most likely the hypoglycemia was secondary to decreased excretion of Sulfonylureas in Metformin in the setting of acute renal failure, as well as possible contribution to Hydrochlorothiazide induced insulin resistant. Liver function tests were checked and were within normal limits. The D10W drip was eventually titrated down to D5W drip and then after the patient developed hyponatremia was changed to D5 normal saline and was then weaned off on the morning of [**2200-3-2**], at which time fingerstick glucose remained within normal limits and fingerstick glucose checks were changed to q4hours and then to q6hours. Of note, the patient did have one episode of hyperglycemia in the 400s during this period of time and was covered with six units of regular insulin before transfer to the medical floor. 3. Coronary artery disease - The patient was continued on his outpatient regimen of Aspirin, beta blocker, statin and ace inhibitor. 4. Nonsustained ventricular tachycardia - The patient had two episodes of nonsustained ventricular tachycardia during his hospitalization. Electrophysiology consultation was obtained and recommended continuing Amiodarone and beta blockers as he had been on previously. The Amiodarone was increased to 400 mg once daily. The pacemaker was interrogated and reprogrammed to increase the bradycardia setting to 60 beats per minute on [**2200-3-5**]. The ventricular tachycardia zone was changed to track at lower rates of 143 (420 milliseconds) to 188, 370 milliseconds. The AV delay was increased from 240 milliseconds to 250 milliseconds to allow for more intrinsic conduction. The patient had an episode of symptomatic nonsustained ventricular tachycardia on the morning of [**2200-3-5**], while being examined by the Medical Intensive Care Unit team. He had some presyncope with light-headedness, was found to have a fingerstick glucose of 184. This was in the setting of bradycardia to 50 beats per minute on telemetry, which resolved after ten seconds. This occurred prior to the interrogation of the pacemaker by the Electrophysiology service. 5. Acute on chronic renal failure - This was felt to be secondary to an increase in the Lasix dose five days prior to admission as well as the use of Levofloxacin, see below, as well as the use of ace inhibitors as well as decreased p.o. intake in the days prior to admission. The patient's creatinine rose from 2.2 on admission to 2.5 on [**2200-3-4**], and was at 2.2 on the day of transfer to the floor. 6. Urinary tract infection - The patient was felt to have urinary tract infection by urinalysis on admission and was started on Levofloxacin which was subsequently renally dosed. Culture results were negative at the time of dictation and the patient will be given a total of five days of Levofloxacin at 250 mg p.o. once daily. 7. Atrial fibrillation - The patient was continued on Coumadin with INR goal of 2.0. 8. Apical akinesis - The patient was continued on Coumadin. 9. Nutrition - The patient was started back on [**First Name8 (NamePattern2) **] [**Doctor First Name **] diet with less than two grams sodium, less than one liter of fluid per day. This discharge summary covers the dates from [**2200-3-2**], through [**2200-3-5**]. An additional discharge addendum will be dictated at a later time. DR.[**First Name (STitle) **],[**First Name3 (LF) **] 12-981 Dictated By:[**Last Name (NamePattern1) 1811**] MEDQUIST36 D: [**2200-3-5**] 17:69 T: [**2200-3-5**] 19:45 JOB#: [**Job Number 45784**] Admission Date: [**2200-3-2**] Discharge Date: [**2200-3-7**] Date of Birth: [**2122-10-15**] Sex: M Service: [**Location (un) 259**] MEDICINE HISTORY OF THE PRESENT ILLNESS: The patient is a 76-year-old male with a past medical history of coronary artery disease, status post CABG in [**2178**] and [**2196**] also with A flutter, CHF with ejection fraction of 20-25%, status post ICD, multiple myeloma who presented to an outside hospital on [**2200-3-2**] with a chief complaint of shortness of breath for three days. He states that for the past month he has noticed decreased energy and increasing shortness of breath. Six months ago, he was able to walk up 12 steps without difficulty and lately he has noticed heavy breathing with 12 steps. He also notes increasing orthopnea from two to three pillows over the past month. Late last month, he was seen in the Electrophysiology Device Clinic and was started on Lasix 20 mg p.o. q.d. Just prior to admission, he noticed chills and awoke from sleep short of breath. Two days prior to admission, he reports feeling "washed out" with increasing shortness of breath and decreased p.o. intake. On the day of admission, he awoke feeling short of breath. He was sitting at the edge of the bed and then fell to the floor feeling very dizzy, diaphoretic, and short of breath and called 9-1-1. He reports no chest pain throughout all of these episodes, although he does report decreased p.o. intake, denied nausea, vomiting, or diarrhea. At the outside hospital, the patient was found to have a blood sugar of 31. His 02 saturation was 92% on room air. He was also found to have bilateral crackles and was given 40 mg of IV Lasix and aspirin, an amp of D50 and a half an inch of nitroglycerin paste and was transferred to [**Hospital1 18**] for further care. PAST MEDICAL HISTORY: 1. Prolonged PR interval. 2. Left bundle branch block. 3. NSVT status post ICD placement. 4. Atrial flutter, status post ablation in [**2199-10-26**]. 5. Multiple myeloma treated with thalidomide in the past, methyl prednisolone. 6. Status post cholecystectomy. 7. CAD, status post CABG in [**2178**] and [**2196**], last catheterization in [**2199-9-25**] showed three vessel coronary artery disease, moderate diastolic ventricular dysfunction, patent LIMA to LAD, and SVG to RI/OM and PDA. 8. Prostate cancer, status post XRT. 9. Bladder cancer. 10. CHF with ejection fraction of 20-25%, 2+ MR, [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 5660**] dilated, severe global LV hypokinesis to akinesis, overall LV systolic function severely depressed. SOCIAL HISTORY: The patient lives with his wife. His son works at [**Hospital1 18**]. Denied alcohol or smoking. He is a former business executive. Stopped working after his heart attack. ALLERGIES: The patient is allergic to penicillin, causes knee swelling. ADMISSION MEDICATIONS: 1. Coumadin 5 mg p.o. q.d. 2. Aspirin 81 mg q.d. 3. Lipitor 40 q.d. 4. Lopressor 50 b.i.d. 5. Amiodarone 200 q.d. 6. Hydrochlorothiazide 25 q.d. 7. Lisinopril 20 q.d. 8. Tri-Cor 160 q.d. 9. Metformin 500 b.i.d. 10. Glipizide 10 p.o. q.d. 11. Multivitamin 1 q.d. 12. Lasix 20 q.d. PHYSICAL EXAMINATION ON ADMISSION: Vital signs: Temperature 97.9, blood pressure 165/65, pulse 76, respirations 20, saturating 98% on 2 liters. General: This is an elderly gentleman lying in bed, speaking four to five words at a time with breaths in between. He was alert and oriented times three. Cardiovascular: Regular rate. No murmurs were appreciated. Chest had crackles half way up bilaterally. No wheezes. Abdomen: Soft, nontender, nondistended, with normoactive bowel sounds. Extremities: Sacral edema, cool feet, 2+ dorsalis pedis pulses bilaterally. LABORATORY/RADIOLOGIC DATA: On admission, white count 3.1, hematocrit 30.4, platelets 167,000. INR 2.1. Chem-7 significant for a BUN of 27, creatinine 2.3. The urinalysis was significant for 21-50 white cells. HOSPITAL COURSE: 1. HYPOGLYCEMIA: The patient was found to be hypoglycemic to 31. He was originally given amps of D50 with difficult control. He was sent to the ICU shortly after admission for closer glucose monitoring and was started on a D10 drip due to very difficult to control blood sugars. The patient's hypoglycemia was felt likely due to the use of oral hypoglycemic agents in the setting of acute renal failure. These medications may have longer half life in the setting of acute renal failure and, therefore, the patient's blood sugar was difficult to control. The patient was weaned from his D10 drip and remained stable during the ICU stay. The patient was transitioned to regular insulin sliding scale and then restarted on Glipizide only. The patient will follow-up with his primary care physician for further monitoring of his blood sugars and titration of oral hypoglycemics. The Metformin was held and will not be restarted due to the patient's chronic renal insufficiency on acute renal failure at this admission. 2. CARDIOVASCULAR, CORONARY ARTERY DISEASE: The patient is status post CABG with significant coronary artery disease. The patient had enzymes cycled times two, first set being at the outside hospital and one set here, both of which were negative as a cause for congestive heart failure. The patient was continued on aspirin, statin, beta blocker, and ACE inhibitor during this admission. 3. HEART PUMP: The patient was with CHF with an ejection fraction of 20-25%. He reported increasing shortness of breath in the weeks prior to admission. The patient was diuresed with Lasix. Originally upon admission to the ICU, the patient was given both Lasix IV and started on nisiritide drip for diuresis. The patient diuresed well with improvement in his oxygen saturation and pulmonary examination. The patient's diuretics were transiently held when his creatinine bumped from his admission of 2.3 to 2.4. At the time of discharge, the patient was restarted on his Lasix 20 mg p.o. q.d. with good effect. 4. RHYTHM: The patient is with a history of A flutter. He did have evidence of an SVT on telemetry this admission. The electrophysiologist made adjustments to his pacemaker and ICD. He will follow-up with them as an outpatient. In addition, the patient was continued on his Coumadin for A flutter. The patient's Amiodarone was also increased to 400 mg p.o. q.d. given the evidence of NSVT. 5. ACUTE RENAL FAILURE: The patient is with a baseline creatinine of 1.8 to 2. The patient's acute renal failure may be due to the addition of Lasix, 20 mg as an outpatient. The patient's renal function was monitored and was normalized during this admission and should be followed closely as an outpatient. 6. MULTIPLE MYELOMA: The patient is cared for by Dr. [**Last Name (STitle) **]. There was no further treatment for this pursued at the time of this admission. He will follow-up with Dr. [**Last Name (STitle) **] after discharge. 7. FLUIDS, ELECTROLYTES, AND NUTRITION: The patient was continued on a low-sodium diet. His electrolytes were monitored and maintained. 8. INFECTIOUS DISEASE: The patient was with a urinary tract infection. He was given five days of levofloxacin for treatment of an uncomplicated urinary tract infection. He remained afebrile without further evidence of infection. DISPOSITION: The patient was with increased weakness after the episode of hypoglycemia and also due to his shortness of breath which he had been experiencing for the week prior to discharge, the patient preferred rehabilitation for physical therapy to improve his strength prior to discharge to home. CONDITION ON DISCHARGE: Stable with good oxygen saturation and good glycemic control. DISCHARGE STATUS: To rehabilitation facility. DISCHARGE DIAGNOSIS: 1. Hypoglycemia. 2. Acute on chronic renal failure. 3. Congestive heart failure. 4. Urinary tract infection. 5. S/P ICD. DISCHARGE MEDICATIONS: 1. Aspirin 81 q.d. 2. Atorvostatin 40 q.d. 3. Lisinopril 20 q.d. 4. Multivitamin q.d. 5. Amiodarone 400 q.d. 6. Metoprolol 50 b.i.d. 7. Coumadin 1 mg p.o. q.h.s. to be adjusted by primary care physician. 8. Glipizide 5 mg p.o. b.i.d. also to be adjusted by primary care physician. 9. Lasix 20 mg p.o. q.d. FOLLOW-UP: The patient will follow-up with his primary care physician within the week following discharge to home. In addition to this, the patient will follow-up with Dr. [**Last Name (STitle) **] in the Electrophysiology Clinic on [**2200-3-26**] as well as Dr. [**Last Name (STitle) **] for his multiple myeloma on [**2200-3-26**]. [**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) **] Dictated By:[**Name8 (MD) 12502**] MEDQUIST36 D: [**2200-3-6**] 05:43 T: [**2200-3-6**] 17:55 JOB#: [**Job Number 45785**] Name: [**Known lastname 8420**], [**Known firstname **] Unit No: [**Numeric Identifier 8421**] Admission Date: [**2200-3-2**] Discharge Date: [**2200-3-10**] Date of Birth: [**2122-10-15**] Sex: M Service: [**Location (un) 571**] MEDICINE ADDENDUM: This is a Discharge Summary Addendum to cover dates [**3-7**] through [**3-10**]. Please see prior discharge summary for further details. 1. RESPIRATORY: The patient had stable respiratory status after diuresis in the Medical Intensive Care Unit and Intensive Care Unit. He was restarted on his prior dose of Lasix 20 mg p.o. q. day. Although there were crackles at the bases to auscultation, this likely represents atelectasis and not heart failure. The patient was clinically stable and ready for discharge. 2. DIABETES MELLITUS: The patient experienced elevated blood sugars in the afternoons and therefore his dose of Glipizide was increased from 5 mg in the morning to 15 mg p.o. q. a.m. At Rehabilitation, he will have four times a day fingersticks and the dose further adjusted. The Regular insulin sliding scale will be discontinued prior to his discharge to home. The patient will follow-up with his primary care physician as an outpatient for further monitoring of his blood sugar. He has been instructed to take his blood sugar at least twice daily and call his primary care physician if he should have values of less than 70 or greater than 275. 3. RENAL: The patient's renal function improved as diuretics were held. Lasix was restarted and the creatinine remained stable. The patient was not restarted on his Hydrochlorothiazide. The patient's renal function will be checked at rehabilitation and by his primary care physician. 4. CARDIAC: The patient had no further events on Telemetry. He was continued on his amiodarone at the increased dose of 400 mg p.o. q. day. He will follow-up with Dr. [**Last Name (STitle) **] for further pacemaker care. His INR should also be checked and Coumadin dose adjusted for INR 2.0 to 2.5. The patient is stable for discharge to [**Hospital 8422**] [**Hospital **] Medical Center in [**Hospital1 2314**] on [**2200-3-10**]. CONDITION ON DISCHARGE: Stable. DISCHARGE STATUS: To rehabilitation. DISCHARGE DIAGNOSES: 1. Hypoglycemia. 2. Acute on chronic renal failure. 3. Congestive heart failure. 4. Urinary tract infection. 5. S/P ICD. DISCHARGE MEDICATIONS: 1. Aspirin 81 q. day. 2. Atorvastatin 40 q. day. 3. Lisinopril 20 q. day. 4. Multivitamin q. day. 5. Amiodarone 400 q. day. 6. Colace 100 twice a day. 7. Metoprolol SR 59 mg p.o. q. day. 8. Coumadin 2.5 mg p.o. q. day. 9. Lasix 20 p.o. q. day. 10. Glipizide 15 mg q. a.m. and 5 mg q. p.m. DISCHARGE INSTRUCTIONS: 1. The patient was instructed to follow-up with his primary care physician within [**Name Initial (PRE) **] week following discharge. He will have his blood checked for monitoring of his INR as well as his renal function. 2. In addition to this, the patient will monitor his blood sugars at home and follow-up with his primary care physician for further monitoring of his diabetes mellitus regimen. 3. The patient will also follow-up with Cardiology and he has an appointment with Dr. [**Last Name (STitle) **] on [**2200-3-26**]. [**Name6 (MD) 2292**] [**Name8 (MD) 2293**], M.D. [**MD Number(1) 2294**] Dictated By:[**Name8 (MD) 2450**] MEDQUIST36 D: [**2200-3-10**] 19:38 T: [**2200-3-10**] 19:58 JOB#: [**Job Number 8423**]

[ "250.80", "584.9", "414.01", "427.1", "428.0", "427.31", "585", "599.0", "427.32" ]

icd9cm

[ [ [] ] ]

[ "00.13" ]

icd9pcs

[ [ [] ] ]

5353, 5466

24092, 24219

24242, 24541

20740, 20867

5492, 5942

16928, 20583

24565, 25340

15830, 16141

5965, 7489

233, 2718

16156, 16910

14769, 15538

15555, 15807

24022, 24071

16,112

139,553

50606

Discharge summary

report

Admission Date: [**2171-4-16**] Discharge Date: [**2171-4-24**] Date of Birth: [**2093-12-30**] Sex: M Service: MEDICINE Allergies: Ace Inhibitors Attending:[**First Name3 (LF) 10223**] Chief Complaint: fever and hypotension Major Surgical or Invasive Procedure: thoracentesis tunneled cath placement History of Present Illness: 77 yo man with CAD, CHF (EF 20%), DM 2, CRI recently started HD (4 sessions per patient), s/p UTI by dipstick [**2171-3-22**] (? if treated), was at [**Hospital3 **] center when noted to have temp to 102.5 and hypotension SBP 70s around 5 am --> given ampicillin 2 g IV, Bactrim DS po, 500 cc IVF bolus without response. Sent to [**Hospital1 18**] ED where SBP as low as 40s. Started on levophed with good results (SBP 80s-90s). In ED given, Vanco 1 g, Levofloxacin, and Flagyl. Of note, at 2 am BP was 160/79. Patient did not know why he was in the hospital but denied CP, SOB, cough, dysuria, diarrhea, or any pain. . Of note, patient was hospitalized early [**Month (only) 547**] (D/Ced [**3-28**]) for PNA, C. diff colitis, funguria and CHF exacerbation. Patient has had worsening renal failure since [**2-23**] (creat [**2-22**] whereas was previously 2.2-2.4). He eventually agreed to HD and tunnel cath placed by IR in R SC on [**2171-4-4**]. Past Medical History: 1. Type 2 DM with neuropathy 2. 3 vessel CAD s/p cath [**4-24**] and [**12-26**]: PTCA LAD and LCX, course complicated by ischemic CM with EF 20%, 3. s/p Right Femoral-popliteal bypass 4. CHF: [**1-23**] ischemic cardiomyopathy w/ EF <20% 5. CRI: [**1-23**] diabetic nephropathy, baseline CR 2.2-2.4 6. Anemia of chronic disease, baseline HCT 30 7. h/o VF arrest [**4-/2170**] 8. Hypertension 9. stroke: Left posterior deep white matter CVA [**7-25**], right sided weakness, resolved aphasia 10. Seizures in the setting of sepsis: [**4-24**] on dilantin 11. Urinary retention 12. s/p OS catract, s/p OD catract [**2166**] 13. s/p thoroscopic, parietal decrotication for hemothorax [**4-24**] 14. s/p tracheostomy [**4-24**] 15. s/p EGD with percutaneous gastrostomy [**4-24**] 16. s/p cholecystectomy [**7-25**] 17. s/p appendectomy 18. Bell's Palsy 19. h/o MRSA bacteremia 20. h/o lower extremity dvt, [**9-/2170**], [**12/2170**] on coumadin Social History: Patient is married. He has been between hospital and [**Hospital1 **] since [**4-24**]. He is a retired court officer and state representative. Denies any history of tobacco, alcohol, or illicit drug use. Family History: mother died at 92, had diabetes and breast cancer sisters ages 70 and 80 - one has CAD and had MI, other with MR, thyroid problems brother died at 52 of cancer of unknown type Physical Exam: (On transfer to floor from MICU) Tm 102.5 on admission. Tc 98.4 BP 118/70 HR 86 R26 98% 4LNC Gen: No acute distress HEENT: MMM, OP clear CV: RRR nl s1s2 Lungs: dull with crackles left base Abd: noft NTND +BS Ext: bilateral heel skin changes, no edema Neuro: alert and oriented to person, place, time Skin: Stage II decub ulcer Pertinent Results: Admission Labs Chemistries: [**2171-4-16**] 01:50PM GLUCOSE-228* UREA N-27* CREAT-2.2* SODIUM-132* POTASSIUM-4.9 CHLORIDE-101 TOTAL CO2-20* ANION GAP-16 [**2171-4-16**] 11:58PM LACTATE-1.8 [**2171-4-16**] 06:10PM PT-18.9* INR(PT)-2.2 CBC: [**2171-4-16**] 04:20PM WBC-27.7* RBC-3.65* HGB-11.3* HCT-34.1* MCV-93 MCH-31.0 MCHC-33.2 RDW-18.9* [**2171-4-16**] 04:20PM PLT COUNT-171 [**Last Name (un) **] Stim: [**2171-4-16**] 10:55AM CORTISOL-57.5* [**2171-4-16**] 11:30AM CORTISOL-63.2* Cultures: ANAEROBIC BOTTLE (Final [**2171-4-18**]): REPORTED BY PHONE TO [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] CC7B [**Numeric Identifier 67857**] [**2171-4-17**] @ 12:20AM. STAPH AUREUS COAG +. FINAL SENSITIVITIES. Oxacillin RESISTANT Staphylococci MUST be reported as also RESISTANT to other penicillins, cephalosporins, carbacephems, carbapenems, and beta-lactamase inhibitor combinations. Rifampin should not be used alone for therapy. SENSITIVITIES: MIC expressed in MCG/ML STAPH AUREUS COAG + | CLINDAMYCIN----------- =>8 R ERYTHROMYCIN---------- =>8 R GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- =>8 R OXACILLIN------------- =>4 R PENICILLIN------------ =>0.5 R RIFAMPIN-------------- <=0.5 S TETRACYCLINE---------- 2 S VANCOMYCIN------------ <=1 S [**2171-4-16**] 6:00 am URINE Site: CATHETER URINE CULTURE (Final [**2171-4-17**]): YEAST. 10,000-100,000 ORGANISMS/ML.. CHEST (PORTABLE AP) [**2171-4-16**] 5:55 AM: There is stable cardiomegaly. The aorta is tortuous. Mediastinal and hilar contours are stable. Pulmonary vasculature is prominent. There is peribronchial cuffing and increased bilateral interstitial markings. The moderate left pleural effusion appears increased compared to prior exam as does the small right pleural effusion. There appears to be a minimally displaced lower left rib fracture. It is unclear if this was present previously. Osseous structures are otherwise stable. Right IJ tunneled dialysis catheter is again noted. IMPRESSION: CHF. Increase in bilateral pleural effusions, larger on the left. Left lower rib fracture, age indeterminant. CTA CHEST W&W/O C &RECONS [**2171-4-17**] 4:21 PM: 1 Gynecomastia. 2. Bilateral pleural effusions, greater on the left than right. 3. Adjacent atelectasis or consolidation of much of the left lower lobe, with patchy atelectasis at the right base. 4 No evidence of pulmonary embolism. 5 Congestive heart failure. TTE [**2171-4-17**]: The left atrium is mildly dilated. Left ventricular wall thicknesses and cavity size are normal. There is severe global left ventricular hypokinesis. The basal inferolateral wall contracts best. The remaining segments are near akinetic with mild apical dyskinesis. No masses or thrombi are seen in the left ventricle. Right ventricular chamber size is normal with mild global free wall hypokinesis. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. There is a very prominent left pleural effusion. Compared with the prior study (tape reviewed) of [**2170-8-10**], the anterior septum is now severely hypokinetic and global systolic function is more depressed. No 2D echo evidence of endocarditis identified. Discharge labs: WBC 9.2 Hb 10.3* Hct 31.5* Mcv 93 Plt 203 Chemistries: Glu 127* Bun 41* Cr 3.4* Na 135 k 4.1 Cl 100 CO2 25 Coags: PT 15.0* PTT 30.9 INR 1.5 Brief Hospital Course: 1) Fever, hypotension: He was felt to have an infection given the fever and hypotension at presetation. The most likely source was the recently placed line versus a urinary tract infection. In the MICU he got multiple antibiotics and was put on levophed which was weaned to off on [**4-17**]. Three sets of blood cultures were positive for MRSA. His urine culture grew only yeast with 10-100k cfu consistent with previous, fungal colonization. His dialysis line was pulled and he was afebrile after that point in the MICU. He was transferred to the medical floor for antibiotic therapy. New HD access was placed [**2171-4-23**] without complication. Vancomycin IV should be continued for a total of 14 days until [**2171-4-30**]. 2) Pleural effusion: He was noted to be hypoxic and have bilateral pleural effusions. A CTA showed no pulmonary embolus but did reveal the extent of the effusions and some atelectasis on the left side. The left sided pleural effusion was tapped. Chemistries, cytology currently pending. The cell count could not be done due to a lab error. 3) Funguria - The patient had persistent urine contamination with yeast. ID was curbsided and sugested that fluconazole likely would not treat the combination of C glabrata and albicans, but could be attempted if the UA were positive for LE and WBC's. They said they would recommend against treating if there appeared to be no inflammatory response. 4) CHF - The patient has a history of CHF and an echocardiogram performed on [**4-17**] showed an EF of <20%. He was kept on fluid restricted low salt diet and ACE and beta blockers were titrated as tolerated. 5) DVT since [**9-24**], [**12/2170**]- The patient's coumadin was held as he needed line placement during admission, and he was covered with heparin while hospitalized. His previous coumadin dose was 2mg and this was restarted prior to discharge. 6) Ulcers - Dressing changes were used for the skin changes on his heels and for his sacral stage II ulcer. A therapeutic mattress should be considered at rehab. 7) End stage renal disease - The patient had recently been started on hemodialysis and receives HD M/W/F. Dialysis was continued while hospitalized through a temporary catheter. New access was placed via IR guidance on [**2171-4-23**]. He tolerated dialysis treatment on [**2171-4-24**]. Medications on Admission: 1. Zinc Sulfate 220 mg QD 2. simvastatin 40mg QD 3. Plavix 75 mg QD 4. Epoetin Alfa 4,000 unit QMOWEFR 5. Bisacodyl 6. Calcitriol 0.25 mcg QD 7. Vitamin A 20,000 QD 8. Aspirin 325 mg QD 9. Pantoprazole 40 mg Q12 10. Metoprolol 12.5mg [**Hospital1 **] 11. Hydralazine HCl 5mg Q8 12. B Complex-Vitamin C-Folic Acid 1 mg Capsule QD 13. Sevelamer HCl 800 mg TID 14. Ascorbic Acid 500 mg QD 15. Simethicone 80 mg Tablet 16. Docusate Sodium 100 mg [**Hospital1 **] 17. Trazodone HCl 25 QHS 18. Sodium Citrate-Citric Acid 500-334 mg/5 mL 30ml QD 19. Insulin Glargine 24u QAM 20. Ipratropium Bromide 1puff Q6H 22. Albuterol Sulfate 1 neb Q6H 23. Coumadin 2 mg QHS Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 3. Prochlorperazine Edisylate 5 mg/mL Solution Sig: One (1) Injection Q6H (every 6 hours) as needed. 4. Vancomycin HCl in Dextrose 1 g/200 mL Piggyback Sig: One (1) gram Intravenous Q48H (every 48 hours) for 14 days: started [**4-16**], end [**4-30**]. 5. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 6. Lorazepam 2 mg/mL Syringe Sig: 0.5 mg Injection Q4H (every 4 hours) as needed for anxiety. 7. Simethicone 80 mg Tablet, Chewable Sig: 0.5-1 Tablet, Chewable PO QID (4 times a day) as needed. 8. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 10. Quetiapine Fumarate 25 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)). 11. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 12. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. Vitamin A 10,000 unit Capsule Sig: Two (2) Capsule PO DAILY (Daily). 15. B-Complex with Vitamin C Tablet Sig: One (1) Tablet PO DAILY (Daily). 16. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 17. Zinc Sulfate 220 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 18. Ipratropium Bromide 0.02 % Solution Sig: One (1) ampule neb Inhalation Q6H (every 6 hours) as needed. 19. Albuterol Sulfate 0.083 % Solution Sig: One (1) ampule neb Inhalation Q6H (every 6 hours) as needed. 20. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 21. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). Tablet(s) 22. Insulin Glargine 100 unit/mL Solution Sig: Twenty Four (24) units Subcutaneous qAM. 23. Coumadin 2 mg Tablet Sig: One (1) Tablet PO once a day. Tablet(s) 24. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID (3 times a day) as needed for intertrigo. Discharge Disposition: Extended Care Facility: [**Hospital6 85**] - [**Location (un) 86**] Discharge Diagnosis: Primary: MRSA bacteremia from catheter infection Secondary: end stage renal disease pleural effusion funguria congestive heart failure decubitis ulcer diabetic foot ulcer left bells palsy Discharge Condition: patient was stable for discharge. Discharge Instructions: Weigh yourself every morning, consult with your physician if your weight changes by more than 3 lbs. Adhere to 2 gm sodium diet Fluid Restriction: [**2165**] ml daily If you have fevers greater than 101.4, chills, shortness of breath, or other concerns, please return to the emergency department or call your doctor. Followup Instructions: 1)Provider: [**First Name11 (Name Pattern1) 610**] [**Initial (NamePattern1) **] [**Last Name (NamePattern1) **], MD Where: [**Hospital6 29**] CARDIAC SERVICES Phone:[**Telephone/Fax (1) 285**] Date/Time:[**2171-4-29**] 10:30

[ "707.07", "357.2", "250.40", "250.60", "V58.67", "707.03", "427.31", "995.92", "038.11", "785.52", "511.9", "403.91", "285.29", "780.39", "V58.61", "428.0", "414.8", "996.62" ]

icd9cm

[ [ [] ] ]

[ "38.95", "34.91", "39.95", "99.07" ]

icd9pcs

[ [ [] ] ]

12090, 12160

6829, 9170

299, 339

12392, 12427

3068, 6648

12795, 13024

2529, 2706

9877, 12067

12181, 12371

9196, 9854

12451, 12772

6664, 6806

2721, 3049

238, 261

367, 1319

1341, 2287

2303, 2513

17,836

174,709

27403

Discharge summary

report

Admission Date: [**2157-6-15**] Discharge Date: [**2157-6-24**] Date of Birth: [**2084-7-22**] Sex: F Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 281**] Chief Complaint: PNA d/t severe TBM resulting in resp distress. transferred from [**Doctor Last Name 15594**] [**Hospital 107**] hosp to [**Hospital1 18**] for surgical eval Major Surgical or Invasive Procedure: Flexible and Rigid Bronchoscopies dobhoff feeding tube History of Present Illness: 72yo F transferred for tracheobronchomalacia , aspiration PNA and large goiter. Past Medical History: diabetes, cerebral palsy, MR, UTI, Depression, OA, psoriasis Social History: lives in group home. Brother [**Name (NI) 487**] is spokes person [**Telephone/Fax (1) 67101**] (cell) Family History: non-contributory Physical Exam: Physical exam on admission: General: Arrived intubated. MAE purposefully. HEENT: PERRLA, Neck+ goiter. Resp: #8 ETT in place. breath sounds course throughout. COR: RRR S1, S2 ABD: Obese, round, NT, ND, +BS. Extrem: No C/C/trace edema. Pertinent Results: CXR: INDICATION: Large goiter, respiratory failure. FINDINGS: Left subclavian central venous catheter is unchanged. Mediastinal widening secondary to a large left goiter again noted. Pulmonary vasculature is normal indicating resolving pulmonary edema. Small/moderate left pleural effusion is enlarging. Marked scoliosis is unchanged. IMPRESSION: Resolving pulmonary edema. Enlarging small left pleural effusion. 8.3 3.87* 11.2* 34.1* 88 28.8 32.7 14.7 290 RECEIVED AT 6:50AM Chemistry RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap [**2157-6-21**] 05:31AM 129* 9 0.7 143 4.0 108 20* 19 PITUITARY TSH [**2157-6-16**] 03:17AM 0.93 THYROID T4 Free T4 [**2157-6-16**] 03:17AM 6.6 1.1 IMMUNOLOGY Anti-Tg Thyrogl [**2157-6-16**] 03:17AM LESS THAN 1 324*2 1 LESS THAN 20 [**Last Name (un) **]-INTESTINAL TUBE PLACEMENT (W/FLUORO) [**2157-6-22**] 4:08 PM Reason: Placement of postpyloris feeding tube [**Hospital 93**] MEDICAL CONDITION: 72 year old woman with severe tracheobronchomalacia Placement of postpyloris feeding tube CT NECK CLINICAL INFORMATION: Airway obstruction. Goiter. TECHNIQUE: Post-contrast MDCT from skull base to thoracic inlet. FINDINGS: The thyroid gland is grossly enlarged, containing multiple hypodense nodules and foci of calcification. The enlargement involves particularly the thyroidal isthmus in the left hemithyroid, which has a large retrosternal component, extending well into the anterior mediastinum, displacing the thoracic trachea towards the right (series 2, image 129). As a result, there are post-brachiocephalic veins bilaterally. Endotracheal tube and nasogastric tube are in place at the time of scanning. Opacification of the nasal cavities bilaterally, and the right maxillary sinus is probably secondary to the endotracheal intubation. No abnormally enlarged cervical lymph nodes can be identified. Soft tissue planes are preserved within the neck. Review of bone windows demonstrates no focal lytic or sclerotic bony abnormalities. There are bilateral pleural effusions, more on the left, with underlying atelectasis. CONCLUSION: Gross retrosternal goiter on the left, displacing the thoracic trachea, endotracheal tube. No abnormally enlarged cervical lymph nodes. Bilateral pleural effusions with atelectasis at the dependent portions of the lungs. Bilat upper extrem US done on [**2157-6-23**] and found to have thrombus at left cephalic vein @ ACF to 2cm above. Left brachial patent w/o thrombus. CONCLUSION: Gross retrosternal goiter on the left, displacing the thoracic trachea, endotracheal tube. No abnormally enlarged cervical lymph nodes. Bilateral pleural effusions with atelectasis at the dependent portions of the lungs. Brief Hospital Course: Pt was accepted from [**Doctor Last Name 15594**] [**Hospital **] Hospital to [**Hospital1 18**] on [**2157-6-15**] for eval of TBM after aspiration of po's at group home where she resides which required intubation d/t hypoxia. CT scan at OSH revealed large goiter possibly contributing to narrowing of trachea. Arrived to [**Hospital1 18**] intubated and admitted to the ICU. Flex Bronch was performed and pt was found to have severe right and left main stem Tracheobronchial Malacia (TBM). CT scan of neck done and goiter did not appear to be compressing airway. Evaluated by thoracic surgery (Dr. [**First Name4 (NamePattern1) 951**] [**Last Name (NamePattern1) 952**]) and felt not be a candidiate for surgical resection and conservative treatment was recommended. [**2157-6-17**] Rigid Bronch was performed for controlled extubation in OR setting for possible stent placement if extubation failed. Extubation was successful. Remained in ICU for pul toilet. [**2157-6-18**] Noted to be coughing w/ po's. Kept NPO and swallow eval performed ar bedside w/ no obious aspiration. Video swallow done - no aspiration but had great difficulty coordinating breathing and swallowing efforts. Desat and tacycardic during swallow. Suggest keep NPO and place post pyloric feeding tube for now and repeat swallow eval in future (approx one week). Continued on ceftriaxone and flagyl which was initiated at [**Hospital3 36606**] for aspiration PNA. These ABX were d/c'd and started on po augmentin x 7 days on [**2157-6-23**]- thru [**2157-6-30**]. Central line was d/c'd on [**2157-6-23**] after left upper swelling and erythema was noted. Upper extrem ultrasound was done which revealed left cephalic thrombus at ACF to 2cm above. No need for IV anticoagulation- maintained on SQ heparin and pneumoboots. Presently oob via [**Doctor Last Name **]- debilitated requiring rehab and ongoing swallow eval and therapy. requires [**Doctor Last Name **] OOB Medications on Admission: Meds on transfer: zyprexa 10', paxil 40', lovenox 40', pepcid 20", flagyl 500''', rocephin, ativan, morphine. Discharge Medications: 1. Olanzapine 10 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO HS (at bedtime). 2. Paroxetine HCl 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 3. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID (3 times a day) as needed. 4. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation Q4-6H (every 4 to 6 hours) as needed for dyspnea. 5. Hydralazine 20 mg/mL Solution Sig: Ten (10) mg Injection Q6H (every 6 hours). 6. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection three times a day. 7. Amoxicillin-Pot Clavulanate 250-62.5 mg/5 mL Suspension for Reconstitution Sig: Five Hundred (500) mg PO TID (3 times a day) for 7 days. 8. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 9. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig: One (1) PO DAILY (Daily). 10. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 11. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours). Discharge Disposition: Extended Care Facility: [**Hospital3 7**] & Rehab Center - [**Hospital1 8**] Discharge Diagnosis: PNA d/t severe TBM-not candidate for sugical resection pulmonary edema goiter Discharge Condition: fair Discharge Instructions: Continue pulmonary hygiene, antibiotics, Occupational and Physical therapy,tube feeds until f/u swallow eval. elevate left upper extrem -thrombus at left cephalic vein @ACF about 2cm above- no need for IV heparin. Followup Instructions: Contact Dr. [**First Name (STitle) **] [**Name (STitle) **] (interventional pulmonary) for questions [**Telephone/Fax (1) 3020**]. [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 286**] Completed by:[**2157-6-24**]

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icd9cm

[ [ [] ] ]

[ "96.04", "98.15", "38.93", "96.71", "96.6", "33.23", "33.22" ]

icd9pcs

[ [ [] ] ]

7030, 7109

3885, 5830

477, 534

7230, 7236

1152, 2073

7498, 7751

864, 882

5990, 7007

2110, 3862

7130, 7209

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281, 439

562, 643

925, 1133

666, 728

744, 848

5874, 5967

46,228

156,714

54406

Discharge summary

report

Admission Date: [**2183-11-26**] Discharge Date: [**2183-12-2**] Date of Birth: [**2124-6-6**] Sex: M Service: MEDICINE Allergies: Oxycodone Attending:[**First Name3 (LF) 2009**] Chief Complaint: Pt found unconscious by EMS Major Surgical or Invasive Procedure: Endotracheal Intubation. History of Present Illness: Chief Complaint: Found unconscious, seizure . Breify Summary of HPI and Hospital Course: History and Physical per night float. After recieiving Diazepam/Olanzipine/Haldol last night surronding Code [**Name (NI) 50119**] (pt tried to leave hospital) pt is extremely sedated this AM and is unable to answer historical questions. . Per nightfloat note [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]. This is a 59 year old man who was found unconscious by EMS. Upon arrival in the ED he was responsive and combative. At that time, he made comments about having been attacked by someone with a baseball bat. Shortly thereafter, he had a generalized tonic clonic seizure in the ED. He was intubated for airway protection and stabilized with lorazepam and propofol. A serum and urine tox screens were positive for alcohol, benzodiazepine, cocaine, and opiates. He became diaphoretic and hypertensive after intubation, but this resolved with additional lorazepam. A CT head and neck showed no fractures on wet read. He was given folic acid, thiamine, saline, and transfered to the MICU for further management. . On arrival to the ICU, patient cleared by trauma surgery, but complained of c-spine tenderness. As a result, was maintained in a c-collar and spine curbsided regarding MRI to r/o c-spine injury. Ultimately cleared for MRI which showed no major concerning findings and c-collar was discontinued. Patient was continued intuabated during most of this time, and was only extubated after c-spine cleared. Course complicated by fever in ICU and evolving RLL infiltrate that manifested on hospital day 1. Impression was for aspiration pneumonia. Patient was covered with vanco/ctx/flagyl initially and narrowed to CTX/flagyl after sputum cultures grew moraxella. Patient extubated on [**2183-11-28**] with extended intubation generally atributable to need to obtain cervical MRI rather than respiratory distress. Patient's course further complicated by etoh withdrawal requiring q1 valium after extubation. Has been tolerating q4H valium for the past 12 hours. Received a total of 105mg valium from midnight [**11-30**] to time of call out and a total of 175mg on [**2183-11-29**]. Total valium for last three days is approximately: 350mg. Ultimately, patient's identify was confirmed by nursing staff, as [**Known firstname **] [**Known lastname 30258**] who reportedly is frequently admitted with etoh intoxication although medical record information not available currently. Patient is now called out to the medical floor for management. Review of previous medical records reveals multiple admissions for etoh inoxication, seizures, and discharges AMA on times from ICU. . This AM patient is extremely sedated. He opens eyes to sternal rub but will not speak or answer questions. 97, 113/84, 109, 18, 98% RA. Past Medical History: Alcoholism, chronic - (active drinker) Polysubstance abuse Intravenous drug abuse. Chronic HCV infection Remote history of vertebral osteomyelitis Low Back Pain / Degenerative disease Vertebral compression fractures. Diabetes mellitus type II Pseudo-seizures Hypertension Depression Left parietal bone lesion NOS - ?atypical hemangioma Calf injury [**2175**] with left gluteal transplant to left calf Social History: (per OMR, patient uncooperative with confirming) He drinks 1/2-1 pint of vodka per day. Also uses cocaine. Positive tobacco with one half of a pack per week. He used intravenous heroin 30 years ago. He is unemployed, on disability. Emigrated from [**Male First Name (un) 1056**] in [**2132**]. Pt is a veteran, homeless. He has a sister in [**Name (NI) 392**] but does not know where she lives. Also one sister in [**Name2 (NI) **] [**Name (NI) **]. Not in contact with his family. No friends. Wife died last spring. Family History: (per OMR) Positive for diabetes Physical Exam: T 97, HR 109, BP 113/84, RR18, O2 98% on RA, 18 GEN: Pt sedated, breathing without respiratory distress, opens eye with sternal rub, no vocalization. HEENT: MMM, NCAT, poor dentition, o/p clear, Small pupils 2mm Bilaterally, reactive to light. Neck: reasonably supple, no C-spine ttp CV: RRR, no MRG PULM: Coarse BS decreased at bases, no wheezes or crackles, cough with white sputum. ABD: BS+, + scars present, no masses or HSM LIMBS: No tremor or edema SKIN: No rashes noted NEURO: Pt sedated. Arousable to sternal rub. Will assess after sedation lifts. Pertinent Results: Labs on Admission: [**2183-11-26**] 02:10AM BLOOD WBC-10.8 RBC-4.94 Hgb-13.8* Hct-42.0 MCV-85 MCH-28.0 MCHC-32.9 RDW-17.2* Plt Ct-251 [**2183-11-26**] 02:10AM BLOOD Plt Ct-251 [**2183-11-26**] 05:58AM BLOOD Glucose-74 UreaN-10 Creat-0.6 Na-144 K-3.7 Cl-107 HCO3-24 AnGap-17 [**2183-11-27**] 01:35AM BLOOD ALT-120* AST-130* AlkPhos-73 TotBili-0.6 [**2183-11-27**] 01:35AM BLOOD Calcium-8.5 Phos-3.3 Mg-1.9 [**2183-11-26**] 05:58AM BLOOD Triglyc-218* [**2183-11-30**] 07:05PM BLOOD Phenyto-<0.6 [**2183-11-26**] 02:10AM BLOOD ASA-NEG Ethanol-146* Acetmnp-NEG Bnzodzp-POS Barbitr-NEG Tricycl-NEG [**2183-11-26**] 02:11AM BLOOD Glucose-80 Lactate-3.4* Na-146 K-5.1 Cl-102 calHCO3-26 Labs morning prior to leaving AMA: [**2183-12-2**] 07:45AM BLOOD WBC-7.9 RBC-4.57* Hgb-12.9* Hct-39.3* MCV-86 MCH-28.2 MCHC-32.8 RDW-16.5* Plt Ct-312 [**2183-12-2**] 07:45AM BLOOD Plt Ct-312 [**2183-12-2**] 07:45AM BLOOD Glucose-93 UreaN-17 Creat-0.8 Na-140 K-4.3 Cl-105 HCO3-26 AnGap-13 [**2183-11-30**] 01:39AM BLOOD ALT-57* AST-36 LD(LDH)-176 AlkPhos-69 TotBili-0.3 [**2183-12-2**] 07:45AM BLOOD Calcium-9.4 Phos-4.1 Mg-1.8 Studies: CXR ([**11-27**]): New subtle opacity within the right lower lobe may represent an early infiltrative process. CXR ([**11-30**])In comparison with the study of [**11-29**], there is a decrease in the right basilar consolidation, consistent with resolving aspiration pneumonia. The left base now is essentially clear. CT Cspine([**2183-11-26**]): 1. No acute fracture or traumatic malalignment. 2. Exuberant ossification of the ALL, from C5/6 through C7/1, likely related to underlying DISH (based on limited single AP radiograph of the chest); though this is interrupted, there is no evidence of acute fracture. CT Head ([**2183-11-26**]): 1. No acute intracranial abnormality. 2. Chronic microvascular and lacunar infarction. 3. Chronic sinus inflammatory disease. CT T/L spine ([**2183-11-26**]): 1. No evidence of acute vertebral compression fracture or other injury involving the thoracolumbar spine. 2. Prominent Schmorl nodes in the L1 and L2 superior endplates, with associated chronic-appearing compression and anterior wedge deformity, but no spinal canal compromise. 3. L4-5: Multifactorial severe spinal canal and left more than right neural foraminal stenosis, with significant compression of the thecal sac and likely impingement upon the exiting left L4 nerve root. 4. Likely forme fruste DISH involving the thoracolumbar spine, with evident fusion at the L5-S1 level, incompletely imaged. 5. Paraseptal emphysema at the left lung apex and evident bibasilar dependent atelectasis, chronic bronchiectasis and scarring, which may relate to prior aspiration episodes, and apparent interlobular septal thickening, of unclear significance; these findings are incompletely imaged. MRI Cspine ([**11-28**]): Ossification of the anterior longitudinal ligaments with associated degenerative chagnes, but without evidence of ligamentous injury or an acute fracture or dislocation. There is no evidence of spinal cord compromise. Brief Hospital Course: 59 y/o M w/ h/o hep c, polysubstance abuse multiple previous admissions for etoh abuse/seizure p/w grand-mal seizure and etoh withdrawal requiring ICU stay. . # Encephalopathy, due to benzodiazepine toxicity: On the morning of transfer to the general medical floor, patient was found to be extremely sedated. Given the large amount of diazepam patient received over the past few days, it was thought to be secondary to benzo toxicity. Patient is protecting airway and ABG shows adequate ventilation. This sedation improved throughout the course of the day and on the day patient left AMA level of sedation was greatly improved however patient continued to be disoriented to time. Pt able to state name/place. . # Etoh Abuse: In the ICU patient recieved diazepam per CIWA protocal. Continued on CIWA while on floor. After developing benzo toxicity diazepam was held and CIWA continued to be monitored. Overnight prior to leaving AMA pt showed improvement on CIWA scale with a high score of 10. During stay patient was given Thiamine/Folate/Multivitamin. . # Suicidal Ideation: After transfer out of the ICU. Pt vocalized suicidal ideation to the night float resident during a period of agitation. Pt had no plan. Psychiatry was consulted and evaluated prior to DC. Pt on morning left AMA denied suicidal ideation to the primary team. Further psych evaluated and patient denied suicial ideation. Psychiatry felt that he should not be restrained from leaving. . # Seizure: Likely EtOH withdrawl. Phenytoin level <0.6. No known seizure history. Head CT without acute process. No seizure acitivity after transfer to the floor. At discharge patient asked to follow up with PCP regarding medical regimen at home. . # Pneumonia, likely aspiration. Culture positive for moraxella. Patient continued on antibiotics with flagyl and ceftriaxone during hospitalization ([**11-27**] -[**12-1**]). At discharge patient afebrile with CXR showing resolution in pneumonia ([**11-30**]). Pt asked to follow up with PCP regarding pneumonia or return to the hospital if symptoms recur. . # Trauma: C spine cleared by MRI. No other acute fractures identified. . # Hep C: Stable, no prior EGD's to suggest varices. No portal HTN by USD [**2175**] . # Nutrition: Ensure TID with meals. Medications on Admission: Home Medications: (1,2 per OMR. 3-7 per rx found on patient dated "[**10-19**]") 1. Verapamil 180 mg daily 2. Citalopram 20 mg daily 3. Dilantin 50mg daily 4. Dilantin XL 400mg daily 5. Lisinopril 10mg [**Hospital1 **] 6. Thiamine 100mg daily 7. Metoprolol 50mg [**Hospital1 **] Discharge Medications: Pt stated that he does not take any medication as an outpatient. Pt has been given prescriptions in the past however does not appear to be taking. Pt asked to follow up with his primary care physician to discuss outpatient medical regimen and to continue medications as previously prescribed. No additions to the patients outpatient medication regimen were made. PCP [**Last Name (LF) **],[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 111372**] JR. [**Name (NI) **] CORNER HEALTH CENTER [**University/College 17629**], [**Location (un) **],[**Numeric Identifier 58270**] Phone: [**Telephone/Fax (1) 7538**] Fax: [**Telephone/Fax (1) 111373**] Discharge Disposition: Home Discharge Diagnosis: Primary: EtOH Withdrawl Seizure Discharge Condition: Hemodynamically stable. Oriented to person, place, difficulty with time. Pt left AMA despite our concern. Evaluated by psychiatry who felt patient had no continued suicidal ideation and did not need to be restrained. Discharge Instructions: Patient asked to follow up with his primary care physician at his earliest convienence. He was warned that we did not feel that he was ready to be discharged and that leaving AMA would put him at risk for further EtOH withdrawal symptoms. He was reminded that he could always return to the ED if he developed chest pain, shortness of breath, fever, nausea, vomiting, diarrhea, seizures, or any other concerning symptom. Followup Instructions: Patient asked to follow up with his primary care physician this week or at his earliest convenience. Name: [**Last Name (LF) **],[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 111372**] JR. Location: [**Name2 (NI) **] CORNER HEALTH CENTER Address: [**University/College 17629**], [**Location (un) **],[**Numeric Identifier 58270**] Phone: [**Telephone/Fax (1) 7538**] Fax: [**Telephone/Fax (1) 111373**]

[ "305.60", "291.81", "518.81", "305.40", "228.09", "V62.84", "311", "492.8", "780.39", "E939.4", "507.0", "494.0", "401.9", "305.50", "292.81", "250.00", "070.54", "722.52", "482.83", "305.1" ]

icd9cm

[ [ [] ] ]

[ "96.04", "96.71" ]

icd9pcs

[ [ [] ] ]

11143, 11149

7864, 10130

298, 324

11224, 11442

4783, 4788

11910, 12333

4157, 4190

10459, 11120

11170, 11203

10156, 10156

442, 3182

11466, 11887

4205, 4764

10174, 10436

369, 424

352, 352

4802, 7841

3204, 3606

3622, 4141

10,861

176,108

50847

Discharge summary

report

Admission Date: [**2145-3-18**] Discharge Date: [**2145-3-23**] Service: NEUROLOGY CHIEF COMPLAINT: Right-sided weakness and inability to speak. HISTORY OF PRESENT ILLNESS: The patient is an 84-year-old, right-handed man, with a history of atrial fibrillation, hypertension, and history of Barrett's esophagitis in [**2142**], who came home late from work today and was with his wife eating supper when at 7:15 p.m., he suddenly stood up and stumbled. She noted that his right face was drooping. He was unable to talk and had a right-sided weakness. She immediately called 911, and he was brought to the [**Hospital6 1760**] Emergency Department. PAST MEDICAL HISTORY: 1. Atrial fibrillation on Coumadin. 2. Hypertension. 3. Barrett's esophagitis in [**2142**]. 4. Right hemicolectomy in [**2141**] for a large edematous polyp. 5. Hemorrhoids with guaiac positive stool. 6. Prostate cancer status post radiation therapy 5-7 years ago. REVIEW OF SYSTEMS: There were no recent illnesses per family. ALLERGIES: NO KNOWN DRUG ALLERGIES. MEDICATIONS ON ADMISSION: Norvasc, Atenolol, Protonix, Cozaar. SOCIAL HISTORY: The patient's smokes four cigars a week. He does not drink alcohol or use drugs. He is married and owns a construction firm. FAMILY HISTORY: Brother with atrial fibrillation. PHYSICAL EXAMINATION: Vital signs: The patient was afebrile, blood pressure 161/97, pulse 70-80. General: He was an aphasic man with right hemiplegia. Neck: Supple. Without carotid bruits. Cardiovascular: Irregular, irregular rhythm. Lungs: Clear to auscultation bilaterally. Abdomen: Soft, nontender, nondistended. Normoactive bowel sounds. Extremities: No edema or rashes. Neurological: He was awake and alert. He was globally aphasic with no verbal output. He has a right hemifacial neglect. He localized with pain on the left but not on the right. He followed no commands. On cranial nerve exam his disk were flat and sharp. There were no hemorrhages on funduscopic exam. He blinked to threat bilaterally. Pupils equal, round and reactive to light. He had a fixed left gaze. He was unable to bring the eyes past midline. He had a right upper motor neuron pattern facial droop. Tongue was symmetric. Palate elevated symmetrically. On motor exam he moved the left side with good strength but followed no commands. His right side was completely immobile, but the tone was elevated in the right leg. On sensory exam he localized to pain on the left. With nail bed pressure on the right, he winces and then looked for a source on his left. On reflex exam, he was 2 out of 4 in the triceps, biceps, and patellar reflexes bilaterally. He was 1 out of 4 in the brachial, radialis and Achilles reflex bilaterally. Toes were upgoing on the left, downgoing on the right. Coordination and gait exam could not be tested. LABORATORY DATA: On admission stool was guaiac positive. Sodium 140, potassium 4.1, chloride 105, bicarb 27, BUN 23, creatinine 1.3, glucose 178, CK 154, MB 8, troponin less than 0.01, calcium 10.2, magnesium 1.9, phosphate 2.7; ALT 34, alkaline phosphatase 145, total bilirubin 0.9, albumin 4.3, AST 30, LDH 261, amylase 68, lipase 41, osmolality 300; white count 5.7, hematocrit 42.6, platelet count 185; INR 1.2, PTT 28.1, PT 13.7. Noncontrast head CT showed no hemorrhage or mass affect. There was a left MCA hyperdense sign with a bright spot that may represent initial emboli. HOSPITAL COURSE: 1. Neurology: Right MCA CVA status post TPA: The patient received intra-arterial TPA and was then admitted to the Intensive Care Unit for monitoring. After administration of TPA, he regained full strength on the right side of his body; however, he remained globally aphasic with minimal comprehension to things such as, "what is your name." He was had decreased verbal output and was able to write one-word lines. He also regained the ability to have full extraocular eye movements with more attention to his right side. He was then put on Heparin and Coumadin for an INR of [**1-12**]. Although his lipid panel was normal with a cholesterol of 163, triglyceride of 117, and HDL of 61, and LDL of 79, he was started on low-dose statin. Echocardiogram of the heart was done showing no evidence of clot or PFO, but there was a mildly dilated left atrium. Carotid ultrasounds were done showing no stenosis in the carotid arteries bilaterally. During the hospital course, he was also put on a regular Insulin sliding scale to prevent any hyperglycemia that may be toxic to injured neurons. 2. Cardiovascular/atrial fibrillation: Given his atrial fibrillation, he was put on low-dose beta-blocker to control his rate. He was also then anticoagulated given his history of atrial fibrillation and now a stroke. 3. Rheumatology/gout: He had some pain of the right first metatarsal and right ankle. The family reported that he has a history of gout and has taken Colchicine in the past. Uric acid was checked and found to be elevated at 8.8, so he was started on Colchicine for pain. DISCHARGE DIAGNOSIS: 1. Right MCA cerebrovascular infarction, status post TPA administration. 2. Atrial fibrillation. 3. Gout. DISCHARGE MEDICATIONS: Heparin drip to be discontinued after INR reaches 2, Coumadin 2.5 mg p.o. q.h.s., Lipitor 10 mg p.o. q.d., Lopressor 25 mg p.o. t.i.d., Colchicine 0.6 mg p.o. b.i.d. x 3 days, Prevacid 30 mg p.o. q.d. CONDITION ON DISCHARGE: Stable. DISCHARGE STATUS: To a rehabilitation center. [**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 12114**] Dictated By:[**Last Name (NamePattern1) 4270**] MEDQUIST36 D: [**2145-3-22**] 20:15 T: [**2145-3-22**] 20:19 JOB#: [**Job Number 105726**]

[ "V10.05", "434.91", "401.9", "427.31" ]

icd9cm

[ [ [] ] ]

[ "88.41", "99.10" ]

icd9pcs

[ [ [] ] ]

1293, 1328

5230, 5432

5096, 5206

1093, 1131

3481, 5075

1351, 3463

984, 1066

113, 159

188, 666

689, 964

1148, 1276

5457, 5765

57,989

103,129

37065

Discharge summary

report

Admission Date: [**2123-3-9**] Discharge Date: [**2123-3-15**] Date of Birth: [**2042-11-1**] Sex: F Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1505**] Chief Complaint: Dyspnea on exertion Major Surgical or Invasive Procedure: [**2123-3-10**] - AVR (23mm [**Company 1543**] Mosaic Porcine) History of Present Illness: 80 year old female with history of hypertension and hyperlipidemia with known aortic stenosis for 6 months who presents for evaluation for aortic valve replacment. The patient is limited by dyspnea on exertion that has affected her daily activities. Past Medical History: Past Medical History: Hypertension Hyperlipidemia Aortic Stenosis History of falls Osteoporosis Past Surgical History: s/p Right hip replacement S/p left hip plate and screw s/p THS and BSO 30 years ago s/p Tonsillectomy Social History: Family History:NC Race: Causasian Last Dental Exam: Full dentures Lives with: Senior living center (estranged from husband; has 2 grown sons) Occupation: none Tobacco: denies ETOH: denies Family History: None Physical Exam: Pulse: 89 Resp: 16 O2 sat: 97 B/P Right: 136/75 Left: 128/66 Height:5'0" Weight:138 lbs General: well-developed elderly female in no acute distress Skin: Dry [X] intact [X] HEENT: PERRLA [X] EOMI [X] Neck: Supple [X] Full ROM [X] Chest: Lungs clear bilaterally [X] Heart: RRR [X] Irregular [] Murmur 4/6 systolic Abdomen: Soft [X] non-distended [] non-tender [X] bowel sounds + [X] Extremities: Warm [X], well-perfused [X] Edema Varicosities: None [X] Neuro: Grossly intact [X] Pulses: Femoral Right: 2+ Left: 2+ DP Right: 2+ Left: 2+ PT [**Name (NI) 167**]: 2+ Left: 2+ Radial Right: 2+ Left: 2+ Carotid Bruit Right/Left: transmitted murmur Pertinent Results: [**2123-3-10**] ECHO Pre Bypass: The left atrium is mildly dilated and elongated. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Regional left ventricular wall motion is normal. Right ventricular chamber size and free wall motion are normal. There are complex (>4mm) atheroma in the aortic root, aortic arch, and the descending thoracic aorta. There are three aortic valve leaflets. The aortic valve leaflets are severely thickened/deformed. There is moderate aortic valve stenosis (valve area 1.0-1.2cm2). Trace aortic regurgitation is seen. The mitral valve leaflets are moderately thickened. No mitral regurgitation is seen. Post Bypass: Patient is in sinus rhythm with pac's on phenylepherine infusion. Preserved biventricular function LVEF >55%. There is a bioprosthetic valve in the aortic position (#23 mosaic per surgeons) without AI or perivalvular leaks. Peak gradient 7 mm Hg, mean 6 mm Hg on aortic valve. Aortic contours intact. Remaining exam is unchanged. All findings discussed with surgeons at the time of the exam. [**2123-3-9**] Cardiac Catheterization Clean coronaries Brief Hospital Course: Ms. [**Known lastname **] was admitted to the [**Hospital1 18**] on [**2123-3-9**] for a cardiac catheterization in preparation for an aortic valve replacement. Her cardiac catheterization revealed clean coronaries and severe aortic stenosis. She was worked-up in the usual preoperative manner. On [**2123-3-10**] she was talken to the operating room where she underwent an aortic valve replacement with a bioprosthesis. Please see operative note for details. Postoperatively she wastaken to the intensive care unit for invasive hemodynamic monitoring. Over the next 24 hours, she awoke neurologically intact and was extubated. She was transferred to the stepdown unit on POD#2. She was started on betablockade and diuresed toward her pre-operative weight. Her chest tubes and temporary pacing wires were removed per protocol. She was evaluated by physical therapy for strength and conditioning and rehab was recommended. She was cleared for discharge on POD#5 by Dr. [**Last Name (STitle) **]. Medications on Admission: Fosamax Lipitor 10mg qd Lisinopril 2mg qd Discharge Medications: 1. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): Until at pre-op weight of 59kg. Then chnage to home diuretic HCTZ. 2. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO DAILY (Daily): while on lasix. 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 5. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours). 6. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed for constipation. 7. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 9. Alendronate 70 mg Tablet Sig: One (1) Tablet PO once a week. Discharge Disposition: Extended Care Facility: [**Hospital3 13990**] Health Care Center Discharge Diagnosis: AS s/p AVR Hypertension Hyperlipidemia History of falls Osteoporosis 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) **] in 4 weeks [**Telephone/Fax (1) 170**] Primary Care Dr.[**Last Name (STitle) 15942**] in [**1-30**] weeks Cardiologist Dr. [**Last Name (STitle) 10543**] in [**1-30**] weeks Completed by:[**2123-3-15**]

[ "733.00", "272.4", "458.29", "298.9", "V43.64", "424.1", "V15.88", "287.5", "401.9", "V45.89" ]

icd9cm

[ [ [] ] ]

[ "39.64", "88.56", "35.21", "39.61", "88.72", "37.23" ]

icd9pcs

[ [ [] ] ]

5023, 5090

3058, 4054

340, 405

5203, 5299

1892, 3035

5924, 6204

1152, 1158

4147, 5000

5111, 5182

4080, 4124

5323, 5901

826, 930

1173, 1873

281, 302

433, 685

729, 803

946, 946

52,647

113,731

7695

Discharge summary

report

Admission Date: [**2123-5-11**] Discharge Date: [**2123-5-18**] Date of Birth: [**2041-2-23**] Sex: F Service: SURGERY Allergies: Levofloxacin Attending:[**First Name3 (LF) 2597**] Chief Complaint: Ischemic ulcer and rest pain of the left foot. Major Surgical or Invasive Procedure: [**2123-5-12**] Thrombectomy L iliac stent w/ restenting x 2, L CFA/Profunda endarterectomy w/ SFA patch/venous patch angioplasty History of Present Illness: This 82-year-old lady with severe peripheral [**Month/Day/Year 1106**] disease and end-stage kidney disease (on hemodialysis) has rest pain of her left foot with a small ulceration. She has previously undergone a left external iliac artery angioplasty and stent via a percutaneous approach. Recent CT angiography showed the stent to be occluded with complete thrombosis of her common femoral artery. Her superficial femoral artery is chronically occluded, and the profunda femoris artery is patent. We are attempting to reopen the previously placed covered stent graft in the iliac and then revise the problem. Past Medical History: -ESRD on HD, had renal artery stenosis, s/p stent -Afib -Controversial dx of SCLCA -Hypothyroid -Hx GI bleed in the past -Hx old foot drop (presumed left based on exam) -s/p bilateral cataract surgeries Social History: She formerly worked for Gilette in financial controls department; divorced; smoked 1ppd x 50 yrs, quit in [**2116**] at time of ca dx. She does not drink or use drugs. Family History: The patient's father died secondary to coronary artery disease at the age 66. The patient's sister died at age 51 secondary to myocardial infarction. The patient's mother has diabetes mellitus. Physical Exam: PHYSICAL EXAMINATION Vitals: BP: 109/70 mmHg supine, HR 132 bpm, RR 25 bpm, O2: 93 % on 2LNC. CONSTITUTIONAL: No acute distress, mildly sedated. EYES: No conjunctival pallor. No icterus. ENT/Mouth: MMM. OP clear. THYROID: No thyromegaly or thyroid nodules. CV: Nondisplaced PMI. Normal rate. irregular rhythm. nl S1, S2. No extra heart sounds. No appreciable murmurs (limited by loud rhonchi, [**Year (4 digits) 13042**] noise) LUNGS: Coarse rhonchorous breath sounds bilaterally. No crackles, wheezes. GI: NABS. Soft, NT, ND. No HSM. MUSCULO: Supple neck. Normal muscle tone. Full strength grossly. HEME/LYMPH: No palpable LAD. Trace peripheral edema. Dopplerable distal pulses bilaterally. SKIN: Cool extremities. NEURO: A&Ox3, although mildly lethargic. Grossly normal without any significant focal deficits PSYCH: Mood and affect were appropriate. Pertinent Results: [**2123-5-17**] 07:40AM BLOOD WBC-6.4 RBC-3.43* Hgb-10.6* Hct-32.0* MCV-93 MCH-30.9 MCHC-33.1 RDW-16.3* Plt Ct-150 [**2123-5-17**] 07:40AM BLOOD Calcium-9.4 Phos-3.4 Mg-1.8 CT SCAN IMPRESSION: 1. No evidence of hematoma. 2. Renal cysts. 3. Small pleural effusions with atelectasis and right lower lobe infiltrate. Brief Hospital Course: Mrs. [**Known lastname 27974**],[**Known firstname 27975**] [**Last Name (NamePattern1) 27976**] admitted on [**5-11**] with Ischemic ulcer and rest pain of theleft foot. She agreed to have an elective surgery. Pre-operatively, she was consented. A CXR, EKG, UA, CBC, Electrolytes, T/S - were obtained, all other preperations were made. It was decided that she would undergo a: Left external iliac thrombectomy with common and deep femoral artery endarterectomy and patch angioplasty using endarterectomized superficial femoral artery and saphenous vein with selective left iliac angiography, stenting of proximal common/external iliac and distal external iliac/common femoral arteries, and completion arteriography. She was prepped, and brought down to the operating room for surgery. Intra-operatively, he was closely monitored and remained hemodynamically stable. He tolerated the procedure well without any difficulty or complication. Post-operatively, she was extubated and transferred to the [**Month/Year (2) 13042**] for further stabilization and monitoring. While in the [**Name (NI) 13042**] pt went into Atrial fibrillation. A cardiology consult was obtained. They recommended to hold amiodaron, Give IV lopressor and fluid resusitation. To note pt did have history of tachybrady syndrome and has a PPM in place. A renal consult was alos obtained. for HD. She did recieve HD on her scheduled days while here. Pt was also noted to have a HCT of 19. She did recieve blood products. A stat cat scan was obtained. She did not have a retroperitoneal bleed. Her HCT was stable post operative period. She was admitted to the CVICU for further care. A EP consult was also obtained. They agreed with cardiology plans. They also recommended to hold amiodarone and to titrated BB as needed. She was then transferred to the VICU for further recovery. While in the VICU she recieved monitered care. When stable she was delined including her aline. Her diet was advanced. A PT consult was obtained. To note her troponins were followed, she plateued. EP and cardiology signed off. They recommended no amiodarone and to titrate the BB as necessary. When she was stabalized from the acute setting of post operative care, she was transfered to floor status On the floor, she remained hemodynamically stable with his pain controlled. She progressed with physical therapy to improve her strength and mobility. Also on the floor her abdomen became distended. KUB demonstarted an ileus. Her pain meds were held. Made NPO. Reglan and erthromycin were started. She also had a coughing episode where the expectorant was purulent. This was sent for gram stain. Antibiotics were then started. CXR revealed atelectasis vs PNA. GRAM STAIN (Final [**2123-5-14**]): [**12-6**] PMNs and <10 epithelial cells/100X field. 1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS AND CLUSTERS. 1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S). RESPIRATORY CULTURE (Final [**2123-5-16**]): SPARSE GROWTH Commensal Respiratory Flora. Pt afebrile, no WBC. After sputum cx showed Commensal Respiratory Flora, her antibiotics where then stopped. Her ileus resolved with conservative treatment. She is taking PO without difficulty. She continues to make steady progress without any incidents. She was discharged to a rehabilitation facility in stable condition. Medications on Admission: levothyroxine 88', oxezepam 15 qhs, plavix, amiodarone 200', asa 81' Discharge Medications: 1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 2. Levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 4. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 5. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO TID (3 times a day). Discharge Disposition: Extended Care Facility: [**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**] Discharge Diagnosis: PMH: tachybrady syndrome s/p PPM placed [**11-20**] PVD CHF Afib ESRD on HD Renal artery stenosis Hypothyroidism GI bleed PSH: -[**11-20**] stenting of the left external iliac artery and Balloon angioplasty of the left profunda femoris artery. -[**5-22**] Left external iliac thrombectomy with common and deep femoral artery endarterectomy and patch angioplasty, stenting of proximal common/external iliac and distal external iliac/common femoral arteries, -renal artery stent - bilateral cataracts 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: Division of [**Month/Year (2) **] and Endovascular Surgery Lower Extremity Angioplasty/Stent Discharge Instructions Medications: ?????? Take Aspirin 325mg (enteric coated) once daily ?????? Plavix (Clopidogrel) 75mg once daily ?????? Continue all other medications you were taking before surgery, except amiodarone ?????? You make take Tylenol or prescribed pain medications for any post procedure pain or discomfort What to expect when you go home/rehab: It is normal to have slight swelling of the legs: ?????? Elevate your leg above the level of your heart (use [**3-17**] pillows or a recliner) every 2-3 hours throughout the day and at night ?????? Avoid prolonged periods of standing or sitting without your legs elevated ?????? It is normal to feel tired and have a decreased appetite, your appetite will return with time ?????? Drink plenty of fluids and eat small frequent meals ?????? It is important to eat nutritious food options (high fiber, lean meats, vegetables/fruits, low fat, low cholesterol) to maintain your strength and assist in wound healing ?????? To avoid constipation: eat a high fiber diet and use stool softener while taking pain medication What activities you can and cannot do: ?????? When you go home, you may walk and go up and down stairs ?????? You may shower (let the soapy water run over groin incision, rinse and pat dry) ?????? Your incision may be left uncovered, unless you have small amounts of drainage from the wound, then place a dry dressing or band aid over the area that is draining, as needed ?????? No heavy lifting, pushing or pulling (greater than 5 lbs) for 1 week (to allow groin puncture to heal) ?????? After 1 week, you may resume sexual activity ?????? After 1 week, gradually increase your activities and distance walked as you can tolerate ?????? No driving until you are no longer taking pain medications ?????? Call and schedule an appointment to be seen in [**4-15**] 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 [**Date Range 1106**] office [**Telephone/Fax (1) 1237**]. If bleeding does not stop, call 911 for transfer to closest Emergency Room. Followup Instructions: Provider: [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2604**], MD Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2123-6-7**] 1:00 Completed by:[**2123-5-18**]

[ "327.23", "427.81", "440.1", "440.8", "585.6", "428.0", "285.21", "496", "V45.01", "427.31", "996.74", "707.14", "440.23", "997.4", "560.1", "244.9", "444.22", "424.0" ]

icd9cm

[ [ [] ] ]

[ "00.43", "39.50", "39.95", "38.18", "00.46", "88.47", "39.90" ]

icd9pcs

[ [ [] ] ]

6912, 7009

2959, 6320

320, 452

7553, 7553

2615, 2936

10324, 10510

1527, 1725

6439, 6889

7030, 7532

6346, 6416

7734, 9715

9741, 10301

1740, 2596

233, 282

480, 1097

7568, 7710

1119, 1324

1340, 1511

26,313

105,755

18335

Discharge summary

report

Admission Date: [**2128-3-11**] Discharge Date: [**2128-3-21**] Date of Birth: [**2098-8-12**] Sex: M Service: GU Surgery BRIEF CLINICAL HISTORY: Patient is a 29-year-old white male first seen by Dr. [**Last Name (STitle) **] in late [**Month (only) **] for irritated bladder symptoms which had been developing for several months. At that time he had been working in the Middle East as a computer consultant, and his thinking was that perhaps he had prostatitis and/or ureteral stone. Workup however, eventually led to a TURB revealing an 18/18 positive cores for signet ring adenocarcinoma including 2+ seminal vesicle biopsies. Subsequent workup to find the primary source for the cancer included colonoscopy and gastroscopy were negative in addition to body CT, MR of the pelvis indicated involvement of a probable rectal duplicator cyst with the entire posterior bladder and possible rectal wall involvement. After careful consideration and treatment, plan was setup whereby the patient wound undergo neoadjuvant 5FU and x-ray therapy to the pelvis. This was completed by [**2128-1-19**], and followed by plan for pelvic exeneration with reconstruction depending on the intraoperative findings. The surgery would be conducted in conjunction with Dr. [**Last Name (STitle) 1888**] of the General Surgery team. PAST MEDICAL HISTORY: Irritable bowel history. PAST SURGICAL HISTORY: Surgery for fracture of the right foot in [**2119**], multiple teeth extractions, no other. MEDICATIONS: None. ALLERGIES: None. EXAMINATION: Examination on presentation on day of his surgery finds the patient afebrile, vital signs stable. He is 5 foot 11 inches, weighed 270 pounds. Pulse 78, blood pressure 112/80, saturating 98% on room air. In general, patient is a healthy-appearing gentleman of Middle Eastern decent in no acute distress. He is alert and oriented times three. HEENT examination shows cranial nerves II through XII intact. Pupils are equal, round, and reactive to light. Anterior and posterior lymph node chains show no evidence of any tenderness or swelling. Cardiac examination is unremarkable with regular rate and rhythm. Pulmonary examination: Unremarkable with lungs are clear to auscultation bilaterally. Abdomen is soft and nontender with no evidence of any herniation. OPERATIVE COURSE: On [**2128-3-24**], patient underwent surgery jointly between the GU Surgical team and Dr.[**Name (NI) 4999**] [**Name (STitle) **] Surgery team. Procedure included pelvic exeneration, appendectomy, radical cystectomy, prostatectomy, creation of colostomy and creation of a diverting urostomy. Procedures reported to have undergone without complications, however, involvement of the cancer was far more extensive than originally had been thought, and procedure was changed mid course from a potentially curative one to palliative procedure. The intraoperative findings were immediately communicated with both the patient's family and then later with the patient himself. Following the surgery, the patient was transferred to the Surgical Intensive Care Unit still extubated. He had a colostomy with appliance in place, urostomy with appliance in place, and stents present. First postoperative night was uneventful. The following morning he was extubated again without problems. [**Name (NI) 1194**] control was adequate with a Morphine PCA. On hospital day two, postoperative day one, patient was transferred to a normal surgical floor in stable condition. On hospital day three, the patient began enterostomal training with the enterostomy training nurse. On hospital day three, postoperative day two, the patient had the first of several temperatures to 102.2. These would ultimately choose to become refractory to treatment. Over the next several days, the fevers would peak to 104.2. As part of the workup, the patient had a total of eight sets of blood cultures drawn, none of which were shown to grow out confirmed organisms. Likewise, patient's indwelling catheters including a right internal jugular catheter and a left Port-A-Cath, which had been placed several months earlier were also removed. None of these effected the fevers. At no time, however, did the patient's white blood cell count increase to reflect an active infection. A potential course for the fevers were never found. Potential source of the fevers were not pursued any further. On postoperative day four, output from the patient's J-P drains was sent for creatinine level confirming that this was less than 1. Both J-Ps were pulled that same day. On postoperative day five, patient had an appearance of diffuse maculopapular rash across his back. Based on the distribution of this rash, it appeared to be a contact dermatitis, but nevertheless, a Dermatology consult was requested given the patient's persistent fevers low-grade tachycardia. Dermatology consult confirmed the presence that this indeed was contact dermatitis. [**Name2 (NI) **] was started on topical cortisone, which appeared to help. On [**2128-3-16**], patient had another spike of fevers to 104.1, and it was decided that his Permacath should indeed be removed. After consulting with Dr. [**Last Name (STitle) **] of the General Surgery service, this was organized for the following morning and proceeded without complication. However, fevers did not dissipate with this, and the patient continued to have fevers albeit at lower peaks. On postoperative day six, patient had first episode of flatus. His p.o. intake was then advanced from sips through clears, ultimate fulls and solids, which he tolerated extremely well. On postoperative day nine, patient had a final fever peak. It was thought that it was necessary to work this up and patient was sent for an abdomen CT with p.o. and IV contrast. This showed no evidence of any fluid collections, abscesses, or obvious causes for the fever spikes. Thereafter, the [**Hospital 228**] hospital course was unremarkable. He was discharged on [**2128-3-21**]. DISPOSITION: Patient is discharged to home. He will have home nursing association followup with him to confirm that he is able to care of his ostomy effectively. DISCHARGE MEDICATIONS: 1. Percocet 1-2 tablets p.o. q.4-6h. prn pain. 2. Keflex for total of five more days. FOLLOWUP: Patient will follow up with Dr. [**Last Name (STitle) **] in [**1-9**] weeks and Dr. [**Last Name (STitle) 1888**] in [**1-9**] weeks. DIAGNOSES: 1. Patient is status post cystectomy, prostatectomy, distal colectomy, creation of diverting colostomy, creation of diverting urostomy. 2. Fevers of unknown origin. 3. Postoperative anemia. [**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 276**], M.D. [**MD Number(1) 19331**] Dictated By:[**Last Name (NamePattern1) 6825**] MEDQUIST36 D: [**2128-3-25**] 10:59 T: [**2128-3-25**] 11:57 JOB#: [**Job Number 50516**] (cclist)

[ "198.1", "285.9", "511.9", "153.5", "198.82", "198.89", "780.6", "197.5", "197.6" ]

icd9cm

[ [ [] ] ]

[ "47.09", "86.09", "96.71", "99.04", "56.51", "57.71", "45.26", "48.62" ]

icd9pcs

[ [ [] ] ]

6221, 6948

1410, 6198

1360, 1386

64,929

167,483

40307

Discharge summary

report

Admission Date: [**2142-9-29**] Discharge Date: [**2142-10-31**] Date of Birth: [**2102-5-23**] Sex: M Service: NEUROSURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 78**] Chief Complaint: found down Major Surgical or Invasive Procedure: [**9-29**]: Left Craniectomy & SDH evacuation [**10-1**]: Arch Bar placement wtih OMFS [**10-10**]: Tracheostomy with PEG placement [**10-31**]: Left Cranioplasty History of Present Illness: 40 yo M unknown PMHx found down on the roadside, brought to outside hospital and airlifted to [**Hospital1 18**] after CTH revealed L frontal SDH with midline shift. Past Medical History: bipolar depression Social History: lives with common law wife Remote hx of depression that resolved. No longer on meds +ETOH No smoking coccaine + on tox Family History: non-contributory Physical Exam: PHYSICAL EXAM (on admission): Gen: intubated HEENT: Pupils: L 5mm nonreactive, R 4mm nonreactive Neck: C-collar in place Lungs: CTA bilaterally. Cardiac: RRR. S1/S2. Abd: Soft, NT, BS+ Extrem: Cool Neuro: Mental status: Intubated, GCS 5T, left pupil 5mm nonreactive, right pupil 4mm nonreactive, no corneals bilaterally, no oculocephalic bilaterally, + cough, + gag, trace flexion LUE, twitches RUE, no movement BLE Pertinent Results: [**2142-9-29**] 05:10AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2142-9-29**] 05:10AM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-POS amphetmn-NEG mthdone-NEG [**2142-9-29**] Initial HEad CT: IMPRESSION: 1. Left subdural hematoma, with additional inferior left frontal hemorrhagic contusion, and extensive subarachnoid blood throughout the basal cisterns, left sylvian fissure, and left frontal regions. 2. 11 mm rightward midline shift, as well as complete effacement of the basal cisterns, reflecting downward herniation secondary to extensive supratentorial edema. 3. Effacement of the left occipital and temporal horns, with minimal dilation of the right temporal [**Doctor Last Name 534**], compatible with trapping. 4. Left temporal bone transverse fracture, extending through the carotid canal. If evaluation of carotid patency is clinically warranted, CTA should be performed. 5. Right occipital fracture extending to the foramen magnum. [**9-29**] Repeat Head CT: slight increase in SDH size from previous CT. [**2142-9-29**] 5:25 AM SUPINE TRAUMA CHEST RADIOGRAPH: There is an underlying trauma board and a buckle over the right apex, which obscures fine detail. There is no focal consolidation within the lungs, and there is no large effusion or pneumothorax. Apparent superior mediastinal widening likely reflects rotation, given no evidence of mediastinal injury on subsequent CT. There is no pulmonary consolidation. There are no displaced rib fractures identified. Nasogastric tube passes into the stomach, though the stomach remains distended. An endotracheal tube terminates at the thoracic inlet, 6 cm above the carina. IMPRESSION: No definite traumatic injury in the chest. Apparent superior mediastinal widening likely reflects rotation. Endotracheal tube should be slightly advanced for optimal positioning. TRAUMA TORSO: There is dependent atelectasis in the lungs, without evidence of pulmonary contusion or laceration. There is no pneumothorax. There is no effusion. There is no evidence of pneumonia. The heart and mediastinal structures are unremarkable. There is no evidence of acute aortic injury. The great vessels of the arch are unremarkable. The endotracheal tube is well positioned within the trachea at the thoracic inlet. The airways are patent to the subsegmental level. The esophagus is unremarkable, containing an orogastric tube. There is no mediastinal or hilar adenopathy, and there is no mediastinal hematoma. The thyroid enhances normally. CT ABDOMEN: Liver is normal in size and attenuation. There is no evidence for traumatic injury. The hepatic vasculature is widely patent. The IVC is distended. Spleen enhances heterogeneously given the phase of contrast timing. The pancreas is normal in size and attenuation. There is no pancreatic ductal dilation. There is no fluid identified in the retroperitoneum. There are no adrenal nodules or masses. There is symmetric renal parenchymal enhancement and contrast excretion. There is no perinephric hematoma. The stomach is distended, though an NG tube is seen passing within. Intra-abdominal loops of small and large bowel are unremarkable. There is no bowel distention or bowel wall thickening. Evaluation is limited by lack of oral contrast and paucity of mesenteric fat. There is no apparent mesenteric or retroperitoneal adenopathy. There is no free fluid or free air. The aorta is normal in caliber. Mesenteric vessels are patent, into the superior mesenteric and portal veins. CT PELVIS: There is no free fluid in the pelvis. Bladder contains a Foley catheter, with a moderate amount of excreted contrast material. A small amount of air present as well, compatible with a recent catheter placement. The rectum and sigmoid colon are unremarkable. Prostate is normal. There is no pelvic or inguinal adenopathy. BONE WINDOWS: There are no fractures identified. IMPRESSION: No evidence of traumatic injury in the chest, abdomen, or pelvis. CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST [**2142-9-29**] FINDINGS: There is a fracture through the left temporal bone which appears near to the ossicles on the left, however does not appear to involve these or the left jugular foramen. A fracture of the right occipital bone is partially imaged on this examination. A fracture of the left occipital bone is also seen (2:95). There is a minimally displaced fracture of the alveolar process of the left maxilla (2:68). At the level of the nasal bone and lateral walls of the orbits there is motion artifact such that a nasal bone fracture or lateral orbital wall fracture is not entirely excluded, particularly on the left. A fluid level is seen within the sphenoid sinus. Mucosal thickening within the maxillary sinuses and ethmoid air cells is also seen. A nasogastric tube and endotracheal tube are in place. Hemorrhage within the left frontal lobe and contusions in the bilateral frontal lobes, inferiorly are better assessed on accompanying head CT of the same date. The patient is status post left craniectomy with postoperative changes from evacuation of a left subdural hematoma. Again these are better assessed on the accompanying head CT of the same date. IMPRESSION: 1. Fracture of the left temporal bone, bilateral occipital bones and alveolar process of the left maxilla. Motion artifact limits evaluation of the nasal bone and lateral orbital walls. 2. Intracranial hemorrhage and postoperative changes, better assessed on accompanying head CT of the same date. CTA HEAD NECK [**2142-9-30**] IMPRESSION: There is no evidence of critical stenosis or flow stenotic lesions in the head or neck vessels. Unchanged right frontal lobe hematoma with associated trans-galeal herniation, apparently stable and unchanged since the prior study. Mild residual pneumocephalus is redemonstrated. PORTABLE ABDOMEN Study Date of [**2142-10-13**] REASON FOR EXAM: High gastric residual despite tube feeding off. Comparison is made with chest x-ray from the day earlier. The patient has known pneumoperitoneum. The small bowel loops appear fluid filled all throughout the abdomen. They do not have air within. Gastrostomy tube is in place. CT HEAD W/O CONTRAST Study Date of [**2142-10-13**] 1:13 PM Final Report CT HEAD: Axial imaging was performed through the brain without IV contrast.COMPARISON: Head CT [**2142-10-10**], most recent study. FINDINGS: Patient is status post left frontal craniectomy. There is stable appearance to herniation of the left frontal lobe. There is extensive vasogenic edema with stable appearance to intraparenchymal hemorrhage in the left frontal lobe. This intraparenchymal hemorrhage and edema causes mass effect causing subfalcine herniation which appears stable compared to the previous study. No new areas of hemorrhage are present. The overall size and configuration of ventricles appear similar to the previous study. No new areas concerning for acute infarct. Basilar cisterns remain patent. Extra-axial fluid, possibly hygroma appears stable. The visualized sinuses are clear. There is trace fluid within bilateral mastoid air cells. Again redemonstrated is a skull base fracture. IMPRESSION: Overall stable appearance to extensive left frontal intraparenchymal hemorrhage causing mass effect with subfalcine herniation. Stable edema and appearance of the herniated left frontal lobe through a craniectomy defect. No new acute findings. Unchanged skull base fracture. The study and the report were reviewed by the staff radiologist. Head CT [**2142-10-13**]: IMPRESSION: Overall stable appearance to extensive left frontal intraparenchymal hemorrhage causing mass effect with subfalcine herniation. Stable edema and appearance of the herniated left frontal lobe through a craniectomy defect. No new acute findings. Unchanged skull base fracture. HEAD CT [**2142-10-30**]: Evolving left frontal intraparenchymal hemorrhage with decrease vasogenic edema and mass effect on adjacent left cerebral sulci. Stable appearance of the herniated left frontal lobe through the craniectomy defect. No new hemorrhage or acute vascular infarction. Unchanged skull base fractures. Brief Hospital Course: Pt taken to the operating room directly from the trauma bay for emergent craniectomy and SDH evacuation. Surgery was without complication. He was taken to the TSICU for admission. Post operative head CT revealed a slight interval increase in left frontal hemorrhage. He was continued on dilantin and SBP goal <160. Trauma & OMFS were consulted for spine clearance and facial trauma. On [**9-29**], he became febile with Tm 101.4. BAL was later performed and grew HAEMOPHILUS INFLUENZAE, BETA-LACTAMASE POSITIVE, KLEBSIELLA OXYTOCA, KLEBSIELLA PNEUMONIAE. He was started on vanco and pip tazo for VAP; this was later swithced to vanco and cirpo. He has since been seen by ID and is currently on Vanco and Ceftazadime for VAP; the vanco is to be completed on [**10-26**] and the ceftaz on [**11-1**]. On [**10-1**], his C-collar was removed; OMF wired his upper jaw. During the next few days, repeat head CTs were stable. On [**10-7**], he was switched to CPAP On [**10-9**], he was found to have bilat UE Clots, but decision wasm made for no treatment. There was no evidence of LE DVTs. On [**10-11**], Metoprolol was started for worsening diastolic HTN. There was pneumoperitnoenum noted on KUB; the trauma team was aware and did not believe any intervention was necessary. On [**10-13**], on exam the patient was not moving his left upper extremity to noxious stimuli. A Stat Head Ct was ordered and was found to be stable. The patients exam continued to improve throughout the day. In the morning the tube feedings were held for gastric residual of 200 cc and greater. A KUB was ordered which was consistent with pneumoperitoneum. Tube feedings were stopped and IVF was initiated at 75cc/hr. On [**10-14**], general surgery who placed the percutaneous endoscopic gastrostomy was called to discuss the high residuals and significance of the pneumoperitoneum noted on the KUB the day prior. The general surgery team recommended that the patient begin Reglan 10 mg TID. This was initiated and the tube feedings were restarted at 10cc/hr. On exam, the patient pupils were equal and reactive. The patient was able to localize pain with his left upper extremity, he was intermittently moving his his left lower extremity to command. He exhibited right hemiplegia. On [**10-17**], his staples and trach sutures were removed. On [**10-18**], he had mild erythema superior to trach site; there was no crepitus. On exam, he opens his eyes to voice, his pupils are equally round and reactive to light, he has spontaneous movement of his left upper and lower extremities with interim response to commands on this side, he also spontaneously moves his right lower extremity. He was seen by Speech to evaluate for PMV but was able to tolerate. During the week of [**10-22**] his exam improved, he was awake and following commands appeared to nod appropriately, he established medical decision makers with social work. His respiratory status improved, he received a power PICC on [**10-26**] for continued antibiotics. He was seen by speech and swallow and was found not to be ready to have diet advanced so he continues on tube feeds. From [**10-27**] to [**10-31**] patient was awaiting rehab bed placement. On [**2142-10-31**] patient underwent left cranioplasty with bone flap reconstruction without complication. Patient is neurologically much improved, alert and oriented, follows complex commands, moves upper extremities, lower extremities remain atrophic and weak. Patient is being discharged stable to [**Hospital 38**] Rehab facility on [**2142-10-31**]. Medications on Admission: unknown Discharge Medications: 1. acetaminophen 650 mg Suppository Sig: One (1) Suppository Rectal Q6H (every 6 hours) as needed for fever. 2. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day) as needed for dvt prophy. 3. oxycodone-acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs PO Q4H (every 4 hours) as needed for pain. 4. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO Q6H (every 6 hours) as needed for constipation. 5. famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). 6. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical QID (4 times a day) as needed for rash. 7. nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day) as needed for thrush. 8. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 9. senna 8.6 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) as needed for constipation. 10. vancomycin in D5W 1 gram/200 mL Piggyback Sig: One (1) Intravenous Q 8H (Every 8 Hours) for 7 days: To be completed [**10-26**]. 11. ceftazidime 1 gram Recon Soln Sig: One (1) Intravenous every eight (8) hours for 2 weeks: Last dose to be completed on [**11-1**]. 12. Metoclopramide 10 mg IV Q6H 13. HydrALAzine 10-20 mg IV Q6H:PRN sbp>160 14. Heparin Flush (10 units/ml) 2 mL IV PRN line flush PICC, heparin dependent: Flush with 10mL Normal Saline followed by Heparin as above daily and PRN per lumen. Discharge Disposition: Extended Care Facility: [**Hospital6 2222**] - [**Location (un) 538**] Discharge Diagnosis: Traumatic Brain Injury Subdural Hematoma with intraparenchymal contusion facial fracture Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Alert and interactive. Activity Status: Bedbound. Discharge Instructions: General Instructions ?????? Have a friend/family member check your incision daily for signs of infection. ?????? Take your pain medicine as prescribed. ?????? Exercise should be limited to walking; no lifting, straining, or excessive bending. ?????? 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 were on a medication such as Coumadin (Warfarin), or Plavix (clopidogrel), or Aspirin, prior to your injury, you may safely resume taking this on after your follow up appointment ?????? 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**]. **** Please wear your helmet when out of bed **** Followup Instructions: Follow-Up Appointment Instructions ??????Please call ([**Telephone/Fax (1) 2102**] 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.

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icd9cm

[ [ [] ] ]

[ "01.25", "38.93", "76.73", "43.11", "02.04", "96.71", "38.97", "33.24", "33.29", "02.06", "93.55", "96.72", "31.1" ]

icd9pcs

[ [ [] ] ]

14613, 14686

9560, 13133

329, 494

14819, 14819

1355, 1587

16104, 16339

885, 903

13192, 14590

14707, 14798

13159, 13168

14953, 16081

918, 1123

279, 291

522, 690

7639, 9537

2382, 7630

14834, 14929

712, 732

748, 869

23,895

188,467

47031+58967

Discharge summary

report+addendum

Admission Date: [**2116-4-11**] Discharge Date: [**2116-4-15**] Date of Birth: [**2054-2-16**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 443**] Chief Complaint: Dyspnea, chest pain Major Surgical or Invasive Procedure: Percutaneous intervention with bare-metal stent to Left Anterior Descending Artery History of Present Illness: In brief, patient is a 62yo male w/ h/o anxiety, EtOH abuse, HTN, HLD, stage III CKD and HCV admitted on [**2116-4-11**] with chest pain and SOB in the setting of alcohol withdrawal. Patient has had multiple social stressors including loss his job 1 year ago, recent loss of unemployment benefits, threat of eviction. For the 3 days prior to admission, he has been having intermittent, worsening dull chest pain that then became constant. The pain was substernal, radiated to his left arm and was accompanied by diaphoresis, nausea, tachypnea, lightheadedness and a feeling of impending doom. He has had similar symptoms in the setting of anxiety attacks in the past. He was drinking heavily to try to control the pain. . In the ED, initial vs were: T 97.3 P 120 BP 151/77 R 22 O2 sat 97% RA. Patient was given a SL nitroglycerin, a banana bag, IV fluids and Valium 10mg IVx2. Chest pain did not improve with SL nitro. Thought to be in alcohol withdrawal, and with valium his BP and symptoms improved. Complained of headache after SL nitro. He was admitted to medicine wards for alcohol withdrawal. . On hospital day 2, patient developed chest pain relieved by sublingal nitro. His EKG showed continued J point ST elevations in II,III, AVF, old T wave inversion in AVl and new T wave inversions in V1-V3. His were elevated and peaked at a CK-Mb of 19 and a uptrending troponin of 0.16 in the setting of chronically elevated creatinine of 1.4-1.7. He was started on a heparin drip. Today at 4 am, he developed 1 hour of chest pressure. His BPs have dropped to the 90s with SL nitro. and was transferred to the CCU for nitro drip. He also developed a worsening hypoxia and briefly required a non-rebreather which was weaned quickly and he was transferred on nasal cannula. Review of systems was positive for sweats and chills, but no documented fevers. Denies recent weight loss or gain. Denies sinus tenderness, rhinorrhea or congestion. Denied cough. Denied vomiting, diarrhea, constipation or abdominal pain. No recent change in bowel or bladder habits. No dysuria. Denied arthralgias or myalgias. Past Medical History: - HTN - HLD - HCV - genotype 2; last VL [**2116-1-10**] was 3,230,000 - Anxiety - recent admit to [**Hospital1 **] psych unit; sees Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 62317**] at [**Hospital1 **] ([**Last Name (un) 99725**]) - CKD stage III - mild COPD - s/p hernia repair - longstanding alcoholism - tobacco use - diastolic dysfunction on Echo in '[**13**] - normal stress test in [**8-/2115**] - hyperparathyroidism - persistently elevated PTH - has not undergone further work-up Social History: Substance Abuse History: adapted from OMR Heavy drinker since his 20s. Most recently has been drinking 1 quart of vodka per day x 3 days. Before that was drinking about 1 pint vodka per day. Has smoked cigarettes/cigars since his 20s; currently smoking [**2-27**] cigars per day. - h/o blackouts, DTs, hallucinations during withdrawal, unsure about seizure but thinks so - Multiple detox treatments, including Addiction Treatment Center ([**Location (un) 583**]), [**Location (un) 86**] City, [**Hospital1 882**], [**Last Name (un) 5112**], [**Hospital1 10551**] - Past heroin abuse x 30 years, stopped 10 years ago (used to shoot [**1-26**] bags/day) and went to methadone clinic. - Experimented with LSD, MJ, crack cocaine in past - Smoked 1.5ppd, smoked for 20 [**Month/Day (2) 1686**] . Social History: adapted from OMR - Born and raised in [**Location (un) 86**], one younger brother with whom he has occasional contact ([**Name (NI) **]) and who lives with their mother (who is 90+ years old and recently given 6 mos to live) - Divorced for [**11-3**] [**Month/Year (2) 1686**], keeps in touch with 30 y/o daughter and is on good terms with ex-wife. - Lives in rooming house in [**Location (un) **] for last 3-4 years; lives alone - Denies h/o physical/sexual abuse - Educated through 3 years college - Employment: Worked as mechanical engineer until fired for alcoholism in [**2099**]. Later worked as a magician, lost job when store closed in [**2112-2-5**]. Laid off from work for [**Location (un) 86**] Trolley on [**Holiday 1451**] [**2114**]. - Never worked for the military -No current legal issues, denies having served jail time. - states that he is served meals on wheels at home Family History: Mother is alive, has DM, father died of HF and kidney disease at 86 age. Denies psychiatric family history Physical Exam: Admission Exam ([**2116-4-11**]) VS: 96.4, P: 79, BP: 127/82, RR: 19, 95% 3L NC GEN: anxious, slightly despondent male in NAD HEENT: PERRL, EOMI, no LAD, sl dry MM, yellowish tongue, prominent papillae CV: no JVD, RRR, no m/r/g PULM: CTAB, no wheezes, rales, rhonchi ABD: overweight, central adiposity, BS+, soft, ND, NT EXT: no edema, 2+ DP, PT, radial pulses bilaterally NEURO: CN II-XII intact, 5/5 strength throughout Pertinent Results: Admission Labs ([**4-11**]): WBC-10.3# RBC-4.59* Hgb-13.8* Hct-41.9 MCV-91 MCH-30.1 MCHC-32.9 RDW-17.3* Plt Ct-283 Neuts-87.3* Lymphs-8.0* Monos-4.3 Eos-0.1 Baso-0.4 PT-11.0 PTT-20.8* INR(PT)-0.9 Glucose-105* UreaN-35* Creat-1.9* Na-136 K-5.6* Cl-97 HCO3-9* AnGap-36* ALT-34 AST-34 CK(CPK)-72 AlkPhos-74 TotBili-0.6 . Cardiac Markers: [**2116-4-11**] 09:20PM BLOOD CK-MB-19* MB Indx-17.0* cTropnT-0.14* [**2116-4-12**] 12:41AM BLOOD CK-MB-16* MB Indx-17.8* cTropnT-0.14* [**2116-4-12**] 06:50AM BLOOD CK-MB-13* MB Indx-20.6* cTropnT-0.11* [**2116-4-12**] 05:00PM BLOOD CK-MB-11* MB Indx-5.3 cTropnT-0.10* [**2116-4-12**] 11:45PM BLOOD CK-MB-8 cTropnT-0.14* [**2116-4-13**] 07:33AM BLOOD CK-MB-6 cTropnT-0.16* [**2116-4-13**] 03:53PM BLOOD CK-MB-4 cTropnT-0.18* [**2116-4-14**] 04:29PM BLOOD CK-MB-2 . Other Labs: Drug Screen [**2116-4-11**] 11:20AM BLOOD ASA-7.7 Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG Acetone-SMALL Osmolal-301 Iron Studies: calTIBC-209* Ferritn-394 TRF-161* Iron-26* . Imaging: Cardiac Cath ([**4-14**]) - Prelim report COMMENTS: 1. Selective coronary angiography of this right dominant system demonstrated two vessel coronary artery disease. The LMCA had no angiographically apparent flow-limiting coronary artery disease. The LAD had a calcified, 70-80% lesion after D1. The high first diagonal had diffuse disease a mid vessel total oclusion with collaterals. The LCx had mild diffuse diease. The RCA had a 60% proximal and distal lesions. 2. Limited resting hemodyanamics revealed normal systemic blood pressure, with a central aortic pressure of 131/86 mmHg. FINAL DIAGNOSIS: 1. Two vessel coronary artery disease. . ECHO ([**4-14**]) Conclusions The left atrium is mildly dilated. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF 70%). Right ventricular chamber size and free wall motion are normal. The ascending aorta is mildly dilated. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. There is an anterior space which most likely represents a prominent fat pad. Compared with the findings of the prior study (images reviewed) of [**2113-7-21**], the findings are similar. . Discharge Labs ([**4-15**]): WBC-7.6 RBC-3.50* Hgb-10.8* Hct-32.0* MCV-92 MCH-30.9 MCHC-33.7 RDW-17.3* Plt Ct-150 Glucose-112* UreaN-24* Creat-1.6* Na-136 K-4.6 Cl-104 HCO3-26 AnGap-11 Brief Hospital Course: Mr. [**Known lastname **] is a 62 year-old man with a history of anxiety, alcohol abuse, hypertension, hyperlipidemia, stage III CKD and HCV admitted with chest pain in the setting of alcholol withdrawal with signs and symptoms of [**Hospital 7792**] transferred to CCU for worsened hypoxia and chest pain requiring nitro drip with subsequent cardiac catheterization with placement of bare metal stent to his proximal LAD. . # Coronaries: He had no known CAD but did have multiple risk factors including HTN, HLD, current tobacco use, and significant recent stress. He reported a history of chest pressure that radiated to his left arm in addition to SOB. On arrival to he the CCU he was experiencing chest pain that required a nitroglycerin drip to keep him pain free. He had EKG changes in an LAD distribution and cardiac biomarker elevations that were consistent with NSTEMI. He had not had a catheterization in the past because of his history of medication non-compliance, therefore it was determined that if intervention was required balloon angioplasty or bare metal stent would be preferable to DES. On [**4-14**], he was taken to cardiac catheterization with identification of proximal LAD disease with placement of bare-metal stent to proximal LAD. He was continued on metoprolol (uptitrated to 50mg QID), amlodipine, valsartan, atorvastatin 80 mg daily, aspirin 325 mg po daily, and plavix 75 mg po daily. Due to coronary stent, pt should not receive electroconvlusive therapy (ETC) as part of any depression treatment, for 30 days post stent. At this point in time, pt is medically stable and appropriate for transfer to a psychiatric floor. . #Pump: Patient has no known history of CHF. He appeared euvolemic on exam. He did not require diuresis during CCU stay. . #Rhythm: His alcohol withdrawl placed him at increased risk for arrhythmia. He remained in sinus rhythm throughout his hospitalization. . #Hypertension: He has known hypertension as an outpatient. His blood pressure was well controlled throughout his admission. He was continued on his home dose of amlodipine and valsartan with metoprolol uptitrated 50mg QID. . # Depression: He was very despondent on admission with significant hopeless and anxiety. He has known severe depression and will likely need inpatient psychiatric admission after medical stabilization. Pyschiatry continued to follow patient during admission and guided treatment of depression. He received his home dose of quietpine, fluoxetine and trazodone. At time of stabilization for cardiac issues pt was transfered to the psychiatry service for further management of EtOH withdrawal/depression as he was appropriate for transfer to a psych floor in relation to his other medical issues. Due to coronary stent, pt should not receive electroconvlusive therapy (ETC) as part of any depression treatment, for 30 days post stent. . # EtOH withdrawal: He has a history of DTs in the setting of alcohol withdrawl. He did endorse tremors and visual hallucinations on the day of admission and he was maintained on a diazepam CIWA scale without further evidence of tremulousness. He was maintaned on thiamine, folate, and daily multivitamin. . #CKD: He has known stage III CKD. His creatinine on admission was 1.4, which is slightly better than prior baseline of 1.6-2.0. His renal status was carefully monitored and remained stable. He received appropriate pre-cath and post-cath hydration and Cr was stabile through admission. . #Anemia: He has a anemia at baseline with HCT in the high 30s. This was appropriately montiored and and remained stable throghout hospitalization. . # Hep C: His most recent viral load was very elevated and he has no history of cirrhosis. His coags were normal and his LFTs were WNL. . #Tobacco: He currently smokes tobacco typically [**2-27**] cigars daily. He declined desire to use a nicotine patch while admitted in the hospital. Medications on Admission: 1. albuterol sulfate 90 mcg/Actuation HFA 2 puffs QQ6H PRN 2. pravastatin 80 mg QHS 3. trazodone 50 mg QHS PRN insomnia 4. aspirin 325 mg daily 5. multivitamin one tab daily (has not been taking) 6. thiamine HCl 100 mg daily (has not been taking) 7. folic acid 1 mg Tablet daily 8. quetiapine 50 mg [**Hospital1 **] 9. quetiapine 100 mg QHS 10. fluoxetine 40mg daily 11. gabapentin 100 mg TID 12. Toprol XL 150mg daily 13. Diovan 160mg daily 14. Amlodipine 10mg daily Discharge Medications: 1. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 2. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: 1-2 puffs Inhalation every four (4) hours as needed for shortness of breath or wheezing. Disp:*1 inhaler* Refills:*1* 3. pravastatin 80 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 4. trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for insomnia. Disp:*30 Tablet(s)* Refills:*2* 5. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 7. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 8. quetiapine 25 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Disp:*120 Tablet(s)* Refills:*2* 9. quetiapine 100 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)). Disp:*30 Tablet(s)* Refills:*2* 10. fluoxetine 40 mg Capsule Sig: One (1) Capsule PO once a day. Disp:*30 Capsule(s)* Refills:*2* 11. gabapentin 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). Disp:*90 Capsule(s)* Refills:*2* 12. metoprolol succinate 200 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO once a day. Disp:*30 Tablet Extended Release 24 hr(s)* Refills:*2* 13. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 14. valsartan 160 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 15. amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 16. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): Do not stop taking or miss [**First Name (Titles) 691**] [**Last Name (Titles) 4319**] unless Dr. [**Last Name (STitle) 99727**] tells you to. Disp:*30 Tablet(s)* Refills:*2* 17. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) injection Injection TID (3 times a day): Continue until pt is ambulatory. 18. diazepam 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for CIWA>10. Discharge Disposition: Extended Care Facility: [**Hospital1 69**] - [**Location (un) 86**] Discharge Diagnosis: Non ST Elevation myocardial infarction Hypertension Stage 3 Chronic Kidney Disease Hepatitis C Virus Chronic Obstructive Pulmonary Disease Active Alcohol abuse Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You had a heart attack and needed to have a cardiac catheterization and a bare metal stent was placed in your left anterior coronary artery to open the artery. You will need to take aspirin and plavix (clopidogrel) every day for at least one month to keep the stent open and prevent the artery from clotting off again and causing another heart attack. Do not stop taking aspirin or plavix or miss [**First Name (Titles) 691**] [**Last Name (Titles) 4319**] unless Dr. [**Last Name (STitle) 171**] tells you it is OK. Due to coronary stent, pt should not receive electroconvlusive therapy (ETC) as part of any depression treatment, for 30 days post stent. . WE made the following changes to your medicines: 1. Increase Metoprolol to 200 mg daily 2. Start taking Plavix (clopidogrel) with your aspirin daily. Do not stop taking or miss [**First Name (Titles) 691**] [**Last Name (Titles) 4319**] for one month unless Dr. [**Last Name (STitle) 171**] tells you to. 3. Start Valium for alcohol withdrawal 4. STart heparin injections to prevent blood clots in your legs 5. STart colace to soften stools and prevent straining Followup Instructions: Please make appt with Dr. [**First Name4 (NamePattern1) 2398**] [**Last Name (NamePattern1) **] ([**Doctor Last Name **] is attending) on discharge from psychiatric facility . Cardiology: You will follow-up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 171**] in cardiology clinic. The extact date of this appointment is still to be determined. Name: [**Known lastname 299**],[**Known firstname **] Unit No: [**Numeric Identifier 15968**] Admission Date: [**2116-4-11**] Discharge Date: [**2116-4-15**] Date of Birth: [**2054-2-16**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 3780**] Addendum: MRSA screening swab from [**2116-4-13**] was still pending but had not positive growth to date as of [**2116-4-15**]. Discharge Disposition: Extended Care Facility: [**Hospital1 536**] - [**Location (un) 42**] [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3782**] MD [**MD Number(2) 3783**] Completed by:[**2116-4-15**]

[ "276.51", "781.2", "300.00", "070.54", "296.20", "496", "414.01", "291.81", "410.71", "585.3", "276.2", "303.91" ]

icd9cm

[ [ [] ] ]

[ "88.56", "00.40", "00.45", "37.22", "00.66", "36.06" ]

icd9pcs

[ [ [] ] ]

17094, 17322

8090, 11993

323, 407

14902, 14902

5369, 6170

16199, 17071

4803, 4911

12512, 14605

14719, 14881

12019, 12489

6986, 8067

15053, 16176

4926, 5350

264, 285

435, 2536

14917, 15029

2558, 3073

3896, 4787

6182, 6969

6,911

161,710

27851

Discharge summary

report

Admission Date: [**2172-5-28**] Discharge Date: [**2172-6-5**] Date of Birth: [**2108-12-31**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 398**] Chief Complaint: Reason for ICU: hypotension requiring pressors, intubated for hypercarbic respiratory arrest Major Surgical or Invasive Procedure: intubation History of Present Illness: 63 yo M with hx of schizophrenia and anxiety, s/p splenectomy who presented on [**5-26**] to [**Hospital3 934**] Hospital with complaints of 3.5 weeks of left sided chest and abdominal pain x several days. He described the pain to the OSH MDs as associated with SOB, no rhinorrhea/chills, constant, no associated N/V. No change with position or food, mild dysuria and frequency. He reported black BMs x few days. He reported to the GI MDs that he continues to drink 2 beers per day and 4 ounces of gin. He denied any tylenol use recently but takes bufferin for pain. . At the OSH, his initial vitals were 97.4, HR 178, RR 36, BP 136/100, 98% on RA. His EKG was read as SVT. He was given dilt 10 mg IV x 2, lopressor 25 mg IV x 1 and unasyn 3g IV x 1 for a question of diverticulitis. His Cr was notable to be 1.6 and AST 510 and ALT 338. He was hydrated, ruled out for MI, and was seen by cardiology, GI, and surgery and ID. Had an ultrasound with gallstones and negative HIDA scan. Abd CT with minimal ascites and diverticulosis but no evidence of infection. Chest CTA was also done given widened mediastinum which was reportedly negative. Over the course of the next 2 days, developed increasing LFTs to the [**2166**] range and INR increased to 3.0. His hepatitis A/B/C work-up was negative and he had a tylenol lvl <10 on arrival to the OSH. He slowly became more confused and lethargic. Slipped and fell without hitting his head, Pulled out his foley. His lactate on 24th was noted to be 3.0. He then earlier today developed increasing RR into the 30s with sats low 80s and was intubated for hypercarbic resp arrest. He was started on levophed for unclear BPs (supposedly low) and was maintained on a beta-blocker for tachycardia. He was noted to have minimal urine output. He was transferred here for further evaluation. Past Medical History: 1. Schizophrenia 2. Anxiety 3. s/p splenectomy after truama, MVA in [**2138**] (unaware of pneumococcal vaccination status) Social History: disabled and divorced, quit smoking in '[**38**], drinks 2 beers/day. lives alone. has been on SSI x 20 years. Family History: father with CVA Physical Exam: 99.7, 111, 94/50, 25, 94% on AC 600/16/5/60% Gen - obese male, intubated and sedated HEENT- pupils minimally reactive bilaterally 2-> 1.5mm Neck - thick; R. IJ with C/D/I dressings CV - tachycardic, regular, nl S1/S2, no murmurs appreciated Chest - decreased breath sounds anteriorly, too large to listen posteriorly as cannot move pt Abd - soft, distended, ?NT, +BS Ext - pneumoboots on, no edema appreciated, warm extremities Neuro - unable to assess as sedated Pertinent Results: [**2172-5-28**] 09:00PM URINE WBCCLUMP-MOD MUCOUS-FEW [**2172-5-28**] 09:00PM URINE HYALINE-0-2 [**2172-5-28**] 09:00PM URINE RBC-21-50* WBC->50 BACTERIA-MANY YEAST-NONE EPI-0 [**2172-5-28**] 09:00PM URINE BLOOD-LG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-TR [**2172-5-28**] 09:00PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.040* [**2172-5-28**] 09:00PM URINE OSMOLAL-538 [**2172-5-28**] 09:00PM URINE HOURS-RANDOM CREAT-103 SODIUM-23 [**2172-5-28**] 09:01PM PT-30.1* PTT-35.7* INR(PT)-3.2* [**2172-5-28**] 09:01PM PLT COUNT-225 [**2172-5-28**] 09:01PM WBC-23.5* RBC-4.72 HGB-14.7 HCT-44.7 MCV-95 MCH-31.2 MCHC-33.0 RDW-15.9* [**2172-5-28**] 09:01PM CORTISOL-23.1* [**2172-5-28**] 09:01PM ALBUMIN-3.1* CALCIUM-7.8* PHOSPHATE-5.0* MAGNESIUM-2.6 [**2172-5-28**] 09:01PM LIPASE-48 [**2172-5-28**] 09:01PM ALT(SGPT)-4123* AST(SGOT)-6069* LD(LDH)-4662* ALK PHOS-100 AMYLASE-42 TOT BILI-2.0* [**2172-5-28**] 09:01PM GLUCOSE-175* UREA N-70* CREAT-2.9* SODIUM-136 POTASSIUM-4.6 CHLORIDE-97 TOTAL CO2-25 ANION GAP-19 [**2172-5-28**] 10:17PM HCV Ab-NEGATIVE [**2172-5-28**] 10:17PM [**Doctor First Name **]-POSITIVE TITER-1:80 [**Last Name (un) **] [**2172-5-28**] 10:17PM HBsAg-NEGATIVE HBs Ab-NEGATIVE IgM HBc-NEGATIVE IgM HAV-NEGATIVE [**2172-5-28**] 11:00PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2172-5-28**] 11:00PM CORTISOL-22.1* [**2172-5-28**] 11:42PM O2 SAT-77 [**2172-5-28**] 11:42PM TYPE-MIX [**2172-5-28**] 11:52PM freeCa-1.05* [**2172-5-28**] 11:52PM LACTATE-2.7* [**2172-5-28**] 11:52PM TYPE-ART TEMP-37.4 RATES-/16 TIDAL VOL-600 PEEP-10 O2-60 PO2-100 PCO2-41 PH-7.37 TOTAL CO2-25 BASE XS--1 -ASSIST/CON INTUBATED-INTUBATED . ([**2172-5-28**]) RIGHT UPPER QUADRANT ULTRASOUND: The liver is diffusely echogenic consistent with fatty infiltration. No focal hepatic lesion is identified. There are a few small shadowing gallstones in the gallbladder but no wall thickening or pericholecystic fluid. The common duct is not dilated measuring 5 mm. There is no intrahepatic biliary ductal dilatation. There is a small amount of perihepatic and lower quadrant ascites. Doppler evaluation demonstrates absence of color flow in the main portal vein consistent with thrombosis. The hepatic veins are patent. Arterial waveform is demonstrated in the main hepatic artery but due to technical scanning difficulties, the left and right hepatic arteries are not identified. IMPRESSION: 1. Absence of Doppler flow in the portal vein consistent with portal vein thrombosis. 2. Cholelithiasis without evidence of cholecystitis. 3. Fatty infiltration of the liver. More significant disease such as cirrhosis or fibrosis or underlying mass cannot be excluded. 4. Small amount of perihepatic and lower quadrant ascites. . . CXR [**2172-5-28**]. The ET tube is 5.5 cm above the carina in good position. A right internal jugular central catheter tip is in mid SVC. The NG tube tip is in the stomach. The severe widening of the mediastinum and the enlarged cardiac silhouette are unchanged. The concern is about possible aortic pathology or pericardial effusion. The lungs are clear except for left lower lobe consolidation. There is bilateral small pleural effusion, unchanged. . Brief Hospital Course: A/P: 63 yo M w/ hx of schizophrenia and anxiety s/p remote splenectomy who presented from OSH with fulminant hepatic failure, acute renal failure, hypercarbic respiratory arrest s/p intubation, hypotension on pressors who presents here for further evaluation. . # Sepsis - the patient was started on an empiric course of zosyn, levofloxacin for broad antibacterial coverage. Sepsis physiology resolved and pressors were weaned off. No source of infection was identified despite multiple blood, urine cx's, CXR without evidence of pneumonia. Pt scheduled to complete a 14 day course of the antibiotics. # Resp failure - initially intubated in setting of sepsis, airway protection. He received significant amount of fluids for volume resuscitation in setting of sepsis, was about 10L positive initially. Oxygenation and ventilation were maintained, and he was extubated on [**6-4**]. Initially he was noted to have elevated pCO2 to the 50's, although no baseline is available. Suspect that he may have a component of OSA and obesity hypoventilation syndrome. Ventilation improved on lower amounts of FIO2, able to weane to nasal cannula. Initiated BIPAP for overnight support, will need outpatient sleep study to evaluate for OSA. . # Liver failure: noted to have markedly elevated LFTs, thought to be shock liver from hypotension. Tylenol level noted to be <10, and he did received 14 doses of NAC, although low suspicion for tylenol toxicity. Viral hepatitis serologies were negative. LFTs trended down with hemodynamic support. He was given lactulose while liver function was poor to prevent encephalopathy. His lipase and amylase were noted to be slightly increase, however, nl alk phos and bilirubin as well as benign abdominal exam did not suggest any concominant biliary process. . # ARF: Cr elevated to 2.9 at admission, no baseline known. FeNa was 0.5%. This improved with hemodynamic support. Once diuresis was initiated, his Cr initially increased again, and this was thought to be related to poor forward flow from impaired systolic function. He was started on hydralazine for afterload reduction, his Cr improved and urine ouput increased. His Cr once again trended down and stabilized around 1.7. Hydralazine was changed to captopril for afterload reduction. . # systolic CHF - EF 20% by echo at admission, significantly fluid overloaded after fluid resusctitation. He was slowly diuresed. Impaired EF thought to be related to myocardial stunting in setting of hypotension. It is expected to improve, will need repeat echo in future. Ischemic baseline disease cannot be ruled out. . # Tachycardia - pt was noted to be tachycardic to 130's throughout much of his stay. Electrophysiology was consulted for EKGs that were thought to be A-flutter with 2:1 conductin, in addition he was noted to have WPW. EP recommended using beta blocker for rate control, consider ablation in the future. Beta blockers were tirated up to metoprolol 25mg po tid. Other EKGs were also noted to be c/w accelerated junctional rhythm. Patient had 8 beat run of NSVT just prior to discharge. His electrolytes were normal at this time, and he had just been started on a B-blocker. This should be titrated up as needed at rehab. He should have a repeat ECHO in 1 month and follow up with cardiology. ECGs will be monitored to look for QT interval prolongation. . #Ventricular Tachycardia: Pt had several occasions of non-sustained ventricular tachycardia, he was asymptomatic during this time. Given his depressed cardiac ejection fraction, he will need an echo in one month and if still with a depressed ejection fraction will need to be considered for an ICD. Please monitor his electrolytes closely, titrate up his beta blocker as allowed by his pressure, monitor his QT interval and if prolonged reconsider using beta blocker. . # FEN: pt had a speech and swallow evaluation after extubation, no signs or symptoms of aspiration, advanced diet as tolerated. He required significant K repletin with diuresis, approximately 40mEq daily. . # PPX - IV protonix [**Hospital1 **] initially, then changed to once daily protonix, pneumoboots, SC heparin . # Contacts: [**First Name4 (NamePattern1) **] [**Known lastname 45074**] - [**Telephone/Fax (1) 67875**]; attg at OSH: Gowda [**Telephone/Fax (1) 54268**]; PCP [**First Name8 (NamePattern2) 402**] [**Last Name (NamePattern1) 67876**] [**Telephone/Fax (1) 54268**] . # Discussion was held with the family when he was in septic shock with multi-organ system failure and he was intubated. Decision was made that he would be DNR, but intubated if needed. Medications on Admission: seroquel 20 mg po qd Discharge Medications: 1. Fludrocortisone 0.1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 1 doses. Disp:*1 Tablet(s)* Refills:*0* 2. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 3. Insulin NPH Human Recomb 100 unit/mL Cartridge Sig: Forty (40) units Subcutaneous twice a day. Disp:*30 cartridges* Refills:*4* 4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 5. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily). Disp:*30 Cap(s)* Refills:*2* 6. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 7. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 8. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 9. Captopril 12.5 mg Tablet Sig: 0.5 Tablet PO TID (3 times a day). Disp:*45 Tablet(s)* Refills:*2* 10. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1) gram Intravenous Q 24H (Every 24 Hours): Please finish a 14 day course (stop after dose [**2172-6-10**]). Disp:*5 grams* Refills:*0* 11. Piperacillin-Tazobactam 2.25 g Recon Soln Sig: 2.25 g Intravenous Q6H (every 6 hours): Please finish a 14 day course (stop after dose [**2172-6-10**]). Disp:*QS QS* Refills:*0* 12. Furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day: Titrate to adequate urine ouput (>30cc/hr). Please monitor K+ until stable on regimen. . Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Extended Care Facility: [**Hospital3 105**] Northeast -[**Location (un) 701**] Discharge Diagnosis: Primary: Hepatic Failure Acute Renal failure Congestive Heart Failure Hypercarbic Respiratory Failure Atrial fibrillation/[**Doctor Last Name 79**]-Parkinson-White Syndrome . Secondary: Schizophrenia Anxiety s/p Splenectomy Discharge Condition: Extubated, with renal function improving, liver function tests resolving, respiratory status improved, and vital signs stable. Discharge Instructions: Take your medications as prescribed. You have been prescribed some new medications. You will need to have some blood tests monitored while you are at rehab. These results will be followed by the MD at your facility, or should be called to Dr. [**Last Name (STitle) 67876**] ([**Telephone/Fax (1) 54268**]). Call your doctor or return to the ER for worsening breathing, chest pain, fevers/chills, confusion or feeling very tired, palpitations or your heart racing, any other symptom which concerns you. Followup Instructions: You will need cardiology follow up in 1 month. This can be arranged through your rehab facility. You will need a repeat ECHOcardiogram at this time. . Follow up with Dr. [**Last Name (STitle) 67876**] upon discharge from acute rehab. Completed by:[**2172-7-10**]

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icd9cm

[ [ [] ] ]

[ "38.91", "00.17", "96.6", "96.72" ]

icd9pcs

[ [ [] ] ]

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172,833

45226

Discharge summary

report

Admission Date: [**2137-3-19**] [**Year/Month/Day **] Date: [**2137-3-26**] Date of Birth: [**2063-3-11**] Sex: M Service: SURGERY Allergies: Penicillins Attending:[**Last Name (NamePattern1) 15344**] Chief Complaint: Abdominal pain Major Surgical or Invasive Procedure: Placement of percutaneous cholecystostomy tube History of Present Illness: 74M h/o HTN, IDDM, CAD, GERD, presents from rehab with complaint of abdominal pain, constipation, and low-grade fevers. Pt has also reportedly had copious bilious output from his J-tube. He describes the pain as sharp and confined to the left lower quadrant. He denies nausea/vomiting and chills. Past Medical History: 1. Proximal basilar artery stenosis, on coumadin, followed by Dr. [**First Name (STitle) **] [**Name (STitle) **] here. On MRI, also has evidence of old left cerebellar, right thalamus/basal ganglia and right parietal infarcts in addition to small vessel disease. 2. CAD, s/p CABG [**2126**] 3. HTN 4. DM type II, followed by [**Last Name (un) **] 5. GERD 6. Hypothyroidism 7. s/p CCK Social History: Lives with wife, retired teacher. No tobacco, EtOH Family History: +DM, sister with [**Name2 (NI) 500**] cancer Physical Exam: Physical exam on [**Name2 (NI) **]: Gen: Tired, elderly-appearing man lying comfortably in bed. CV: Regular rate and rhythm, no murmurs appreciated. Pulm: Clear bilaterally, without rales or crackles. Abd: Mildly distended, diffusely tender to palpation, limited guarding in LLQ. Rectal: normal tone, guaiac negative Pertinent Results: [**2137-3-24**] 05:20AM BLOOD WBC-7.3 RBC-3.35* Hgb-10.3* Hct-31.2* MCV-93 MCH-30.9 MCHC-33.1 RDW-15.1 Plt Ct-195 [**2137-3-21**] 04:04AM BLOOD ALT-24 AST-20 LD(LDH)-138 CK(CPK)-31* AlkPhos-66 Amylase-44 TotBili-1.1 Brief Hospital Course: Pt admitted through the ER for slurred speech, abd pain, and nausea/vomiting. CT showed inflamed gallbladder, with sludge and small stones, inflammatory changes in pericolic fat. Pt admitted to SICU, placed on a diltiazem drip to treat his rapid atrial fibrillation, with a plan to place a percutaneous cholecystostomy tube. After this was placed, he was restarted on trophic tube feeds. The opinion of the neurology service was that his neurologic symptoms (slurred speech, occasional disorientation), were manifestations of his prior neurovascular event, and not a new concern. He stabilized from his acute cholangitis and was transferred to the floor in good condition on [**2137-3-22**]. His tube feeds were gradually increased to goal. His pain gradually diminished, and the t-tube put out only dark, clear bilious fluid. By [**2137-3-25**], he was doing very well. He continued to do well on [**2137-3-26**], and was discharged to his rehab facility in good condition. Medications on Admission: 1. Amiodarone HCl 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Amlodipine Besylate 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Brimonidine Tartrate 0.2 % Drops Sig: One (1) Drop Ophthalmic Q8H (every 8 hours). 4. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at bedtime). 5. Valproate Sodium 250 mg/5 mL Syrup Sig: Three (3) mL PO Q8H (every 8 hours). 6. Albuterol Sulfate 0.083 % Solution Sig: One (1) inh Inhalation Q6H (every 6 hours) as needed. 7. Diltiazem HCl 90 mg Tablet Sig: One (1) Tablet PO QID (4 times a day). 8. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily). 9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 10. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 11. Levothyroxine Sodium 25 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 13. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). [**Date Range **] Medications: 1. Amiodarone HCl 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Amlodipine Besylate 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Brimonidine Tartrate 0.2 % Drops Sig: One (1) Drop Ophthalmic Q8H (every 8 hours). 4. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at bedtime). 5. Valproate Sodium 250 mg/5 mL Syrup Sig: Three (3) mL PO Q8H (every 8 hours). 6. Albuterol Sulfate 0.083 % Solution Sig: One (1) inh Inhalation Q6H (every 6 hours) as needed. 7. Diltiazem HCl 90 mg Tablet Sig: One (1) Tablet PO QID (4 times a day). 8. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily). 9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 10. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 11. Levothyroxine Sodium 25 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 13. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). [**Date Range **] Disposition: Extended Care Facility: [**Hospital1 700**] - [**Location (un) 701**] [**Location (un) **] Diagnosis: Cholangitis/Cholecystitis [**Location (un) **] Condition: Good. [**Location (un) **] Instructions: Please take all medications as prescribed. Please have T-tube capped, and flush once per day. If you develop abdominal pain, you may place the drain to bag drainage. If you develop fevers, chills, nausea/vomiting, severe abdominal pain, or other concerning symptoms please contact our office or a local emergency room. Please return to see Dr [**Last Name (STitle) **] in 3 weeks. Followup Instructions: Please see Dr [**Last Name (STitle) **] in 3 weeks.

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icd9cm

[ [ [] ] ]

[ "51.01" ]

icd9pcs

[ [ [] ] ]

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253, 269

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180,321

5415

Discharge summary

report

Admission Date: [**2146-1-26**] Discharge Date: [**2146-1-30**] Date of Birth: [**2078-9-26**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**Last Name (NamePattern4) 290**] Chief Complaint: Rigors Major Surgical or Invasive Procedure: Intubation and Mechanical Ventilation Central Venous Line Placement Arterial Line Placement History of Present Illness: 68yo male with Downs Syndrome, [**Last Name (NamePattern4) 862**] disorder (last [**Last Name (NamePattern4) 862**] [**4-/2145**]), urinary retention c/b CKD III due to urethral stricture and neurogenic bladder, recurrent UTIs and HOCM (LVOT gradient 100mmHg) who is presenting after being seen in urology clinic today, where [**Known lastname **] placement was unsuccessfully attempted for PVR >1L. In clinic he was noted to have a UTI, and was sent home with Cipro with plan for urethrotomy in the OR [**2146-1-28**]. However, he never filled his prescription and was noted to be febrile and rigoring at his group home. He was initially taken to [**Hospital1 3278**], where he received a dose of Vanc, but his HCP requested transfer to [**Hospital1 18**]. The patient's baseline state of function is very low; but sister accompanied him to [**Hospital1 18**]. He cannot walk due to b/l hip replacements and L hip osteomyelitis. . In the ED, initial VS were: T 100.2 HR 93 BP 106/89 RR 16 O2 Sat 99% 4L Nasal Cannula His BP was re-checked and found to be 88/49-->BP 58/66-->78/50. IV NS was started with open, a L IJ was placed and Levophed gtt was started. Blood and urine cultures were drawn (Vanc given at [**Hospital1 3278**]) and the pt was started on Vanc/Zosyn. His BPs continued to be low (65/35) and Dopamine was added, though he was not maxed out on Levophed. Urology was consulted and placed a suprapubic cathetar. Labs were notable for + UA, WBC 5.4 (20% bands), INR 1.8, Cr 2.3 (baseline 1.3-1.8), HCT 29 (baseline in low 30s) and Lactate 8.3. CXR showed no focal consolidation, EKG showed new ST depressions II, V4-V6 as well LVH, which is chronic. He received a total of 4L NS in the ED and was admitted to the MICU. . On arrival to the MICU, initial VS were: T 99.6 BP 104/34 HR 98 RR 21 O2 Sat 93% NC He was making urine (500cc in bag) and mentating near his baseline per sister, who accompanied him. An arterial line was placed and Dopamine, Levophed, Neosynephrine and Vasopression were required to keep MAP 65. SVO2 was 58, CVP was 5. NS was given wide open. VBG was 7.15/46/40. Past Medical History: 1. Down syndrome 2. Mental retardation 3. NSETMI - recent DC on [**12-5**] 4. Hypercholesterolemia 5. s/p R hip replacement and no L hip 6. Osteoporosis 7. Seizures - generalized seizures 8. BPH 9. Hypothyroidism Social History: Lives in a group home - wheelchair bound. [**First Name4 (NamePattern1) **] [**Known lastname 8389**] is the HCP ([**Telephone/Fax (1) 21968**]). No tobacco, EtOH or drug hx. Family History: There is no family history of premature coronary artery disease or sudden death. Physical Exam: Admission Exam: T 99.6 BP 104/34 HR 98 RR 21 O2 Sat 93% NC General: Alert, anxious appearing, moderate distress HEENT: Sclera anicteric, oropharynx clear, EOMI, PERRL Neck: JVP below the clavicle CV: Tachycardic, II/VI systolic murmur heard best at the apex, no rubs or gallops Lungs: Faint expiratory wheeze, otherwise CTAB, no increased WOB Abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly GU: suprapubic cathetar Ext: cool, 1+ distal pulses Skin: Mottling on the BLEs, BUEs and chest Neuro: Alert, responds to yes/no questions, follows commands, non verbal . Discharge Exam: Expired Pertinent Results: Admission Labs: [**2146-1-26**] 09:15PM BLOOD WBC-5.4 RBC-2.88* Hgb-9.8* Hct-29.2* MCV-101* MCH-34.1* MCHC-33.6 RDW-14.7 Plt Ct-71* [**2146-1-26**] 09:15PM BLOOD Neuts-76* Bands-20* Lymphs-2* Monos-1* Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-1* NRBC-2* [**2146-1-26**] 09:15PM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-OCCASIONAL Macrocy-1+ Microcy-NORMAL Polychr-OCCASIONAL Ovalocy-OCCASIONAL Burr-OCCASIONAL [**2146-1-26**] 09:47PM BLOOD PT-19.2* PTT-46.8* INR(PT)-1.8* [**2146-1-27**] 12:50AM BLOOD Fibrino-115* [**2146-1-26**] 09:15PM BLOOD Glucose-109* UreaN-37* Creat-2.3* Na-139 K-3.7 Cl-105 HCO3-18* AnGap-20 [**2146-1-27**] 12:50AM BLOOD ALT-47* AST-71* LD(LDH)-418* CK(CPK)-655* AlkPhos-68 TotBili-0.8 [**2146-1-27**] 12:50AM BLOOD CK-MB-23* MB Indx-3.5 cTropnT-0.34* [**2146-1-27**] 12:50AM BLOOD Albumin-2.3* Calcium-6.1* Phos-2.6* Mg-1.3* [**2146-1-27**] 01:54PM BLOOD D-Dimer->[**Numeric Identifier 3652**] [**2146-1-27**] 12:50AM BLOOD Cortsol-27.0* [**2146-1-27**] 06:36AM BLOOD Phenyto-6.0* Phenyfr-PND [**2146-1-27**] 01:06AM BLOOD Type-[**Last Name (un) **] Temp-37.6 pO2-40* pCO2-46* pH-7.15* calTCO2-17* Base XS--13 Intubat-NOT INTUBA [**2146-1-26**] 09:44PM BLOOD Lactate-8.3* [**2146-1-27**] 01:06AM BLOOD freeCa-0.96* . TTE ([**2146-1-27**]): The left atrium is mildly dilated. There is moderate symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is normal (LVEF>55%). There is a moderate resting left ventricular outflow tract obstruction (40 mmHg). The findings are consistent with hypertrophic obstructive cardiomyopathy (HOCM). Right ventricular chamber size and free wall motion are normal. The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are structurally normal. There is no mitral valve prolapse. There is systolic anterior motion of the mitral valve leaflets. A late systolic jet of eccentric, moderate to severe (3+) mitral regurgitation is seen. Moderate [2+] tricuspid regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Hypertrophic obstructive cardiomyopathy with moderate resting LVOT obstruction. Moderate to severe late systolic functional mitral regurgitation. Moderate tricuspid regurgitation. Mild pulmonary hypertension. . CXR ([**2146-1-27**]): 1. Left internal jugular catheter with tip in the region of the junction of the left brachiocephalic vein and high superior vena cava with possible hematoma along the medial left brachiocephalic vein. Close clinical observation is recommended. 2. Mild to moderate pulmonary edema. . CXR ([**2146-1-27**]): 1. ET tube is 3.6 cm above the carina. 2. Increased atelectasis in the right upper lobe compared to the prior examination. 3. Stable consolidation in the right perihilar region, unchanged from the prior examination. 4. Mild-to-moderate pulmonary edema is unchanged from the prior examination. . Abd Ultrasound ([**2146-1-28**]): 1. Small amount of ascites. 2. Partially imaged left pleural effusion. 3. Resolution of previously seen bilateral hydronephrosis. 4. No evidence of intra-abdominal abscess or renal stone. . Discharge Labs: Pt made CMO, expired Brief Hospital Course: Primary Reason for Admission: 67 y/o man with fever, rigors, positive UA and hypotension concerning for urosepsis admitted to the MICU for hypotension. . Active Problems: . # Hypotension: Likely septic shock given elevated lactate, rigors, fever and likely urinary source. On admission to the MICU, Levophed, Vasopressin, Dopamine and Phenyleprine were required to maintain MAP >65. The pt received aggressive IVF recussittaion with NS; a total of 16L in the first 24 hours. He also received 100mg IV Hydrocortisone x1 on admission for refractory hypotension in the setting of septic shock. A random cortisol was checked and was normal, and stress steroids were discontinued. His urine cultures grew [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] and Proteus Mirabilis, both sensitive to Meropenem, which he had been on for 3 days at the time of culture/sensitivity results. He contined to require [**1-23**] pressors despite appropriate antibiotic therapy and correction of acidosis. He was made CMO on [**2146-1-30**] and died withing minutes of extubation and cessation of pressors. . # Respiratory Failure: Six hours after admission, the pt became increaasingly acidotic and had increased WOB. He was unable to mount a respiratory response to his metabolic acidosis and was therefore intubated. He was started on ARDSNET protocol given his pulmonary edema. He was terminally extubated on [**2146-1-30**] with family at the bedside. . # NSTEMI: Troponinemia and ST depressions in V4-V6 are most likely due to demand ischemia in the setting of hypotension and known structural heart disease. His troponins and CKMB were trended and contiunued to increase throughout the first 24 hours of his hospital course (MB peak 42, Trop peak 2.06). TTE on HD 1 showed normal LV regional wall motion, severe MR, moderate TR and mild pulmonary HTN. His home ASA was continued, no Heparin or Plavix given. . # DIC: Thrombocytopenia likely consumptive in the setting of septic shock. Given his elevated PT/PTT/INR, concern was for DIC. Fibrinogen was low and fibrin degredation products were high, consistent with DIC. He had intermittent bleeding from his suprapubic cathetar, but otherwise had no bleeding; HCTs remained stable. Hematology was asked to comment on Cryoprecipitate tranfusion threshold and recommended giving Cryoprecipitate for Fibrinogen <100. His fibrinogen was trended and normalized. No blood/plasma products were given. . # Metabolic Acidosis: On admission, pt had an anion gap acidosis, likely due to elevated lactate in the setting of severe septic shock. Given aggressive IVF recussitation with NS, pt also developed a non-gap hyperchloremic metabolic acidosis. Mr [**Known lastname 8389**] was unable to mount an appropriate compensatory respiratory response and was intubated for worsening acidosis. He was also started on a NaHCO3 gtt and received intermittent HCO3 ampules to stabilize his pH. By HD 3, his pH had normalized. . # Fever: Pt was noted to be febrile in the ED and was started on Vanc/Zosyn. Presumed source was GU tract given known UTI and instrumentation of his urethra in [**Hospital 159**] clinic the day of admission. Pt has grown Vanc sensitive Enterococcus in the past. No clear pulmonary source, no other localizing complaints. Antibiotics were broadened to Dapto/Meroprnem given his clinical deterioration and increasing WBC count. Urine cultures grew E coli and Proteus, both susceptible to Meropenem. Renal ultrasound was negative for renal abscess. He defervesced by HD #1 and his Dapto/[**Last Name (un) **] were continued until he was made CMO on [**2146-1-30**]. . # Acute on Chronic Renal Failure: Likely related to hypoperfusion and septic shock. His UOP was marginal throughout his course and renal was consulted. Perparations were made for CVVH, which was never initiated, as the pt was made CMO. . Chronic Problems: . # HOCM: Pt with known HOCM and significant LOVT gradient of 100mm Hg. As such, he is preload dependent, making aggressive IVF recussitation all the more important to maintain adequate perfusion. . # [**Date Range **] Disorder: No recent seizures (last [**4-/2145**]); there was question of [**Year (4 digits) 862**] today at [**Hospital3 **] facility, but per sister, was more likely rigors and not typical of his seizures. - cont Dilantin 260mg po qday - cont Levetiracetam 2000mg po qday . Transitional Issues: Pt expited at 12:20 with family at the bedside within minutes of being made CMO. Family declined autopsy. Medications on Admission: ATORVASTATIN [LIPITOR] - 80 mg Tablet - 1 Tablet(s) by mouth HS (at bedtime) BISMUTH TRIBROM-PETROLATUM,WH [XEROFORM PETROLATUM DRESSING] - 2" X 2" Bandage - use as directed in affected area every 24 hours and as needed Dx: decubitus ulcer CICLOPIROX - 0.77 % Cream - Apply affected areas both feet twice a day as directed. CIPROFLOXACIN - 500 mg Tablet - 500 Tablet(s) by mouth twice a day DOUGHNUT CUSHION - - use as directed once a day FINASTERIDE - 5 mg Tablet - 1 Tablet(s) by mouth once a day LEVETIRACETAM - 500 mg Tablet - 2 Tablet(s) by mouth twice a day LEVOTHYROXINE - 137 mcg Tablet - 1 Tablet(s) by mouth qam NYSTATIN - 100,000 unit/gram Powder - apply to left foot twice a day NYSTATIN - 100,000 unit/gram Cream - apply to affected area on toes twice a day OVERLAY FOR MATTRESS - - use as directed once a day DX: Downs' syndrome, wheel chair bound and decubitui. PHENYTOIN SODIUM EXTENDED [DILANTIN KAPSEAL] - 100 mg Capsule - take 1 Capsule(s) by mouth twice a day Brand name only- medically necessary - No Substitution PHENYTOIN SODIUM EXTENDED [DILANTIN KAPSEAL] - 30 mg Capsule - take 1 Capsule(s) by mouth twice a day Brand name only- medically necessary - No Substitution TAMSULOSIN [FLOMAX] - 0.4 mg Capsule, Ext Release 24 hr - 1 (One) Capsule(s) by mouth at bedtime . Medications - OTC ACETAMINOPHEN - (Dose adjustment - no new Rx) - 325 mg Tablet - 2 Tablet(s) by mouth every 4 hours as needed for mild pain ALUM-MAG HYDROXIDE-SIMETH [MYLANTA] - (Prescribed by Other Provider) - Dosage uncertain ASPIRIN [ENTERIC COATED ASPIRIN] - 81 mg Tablet, Delayed Release (E.C.) - take 1 Tablet(s) by mouth once a day CALCIUM CARBONATE [CALCIUM 500] - 500 mg (1,250 mg) Tablet - 2 tablets by mouth daily at 4 pm; do not provide at the same time as his dilantin CHOLECALCIFEROL (VITAMIN D3) - 1,000 unit Capsule - 1 Capsule(s) by mouth daily (at 4 pm) MENTHOL-ZINC OXIDE [MEDICATED BODY POWDER] - 0.15 %-1 % Powder - apply topically once a day to mid thighs, and other irritated skin MULTIVITAMIN - Tablet - 1 (One) Tablet(s) by mouth once a day ; Multivitamin without calcium. Replaces rx dated [**2145-11-19**] NEOMYCIN-BACITRACNZN-POLYMYXIN [NEOSPORIN] - 3.5 mg-400 unit-[**Unit Number **],000 unit/gram Ointment - as directed PETROLATUM, WHITE-LANOLIN [VITAMIN A & D DIAPER RASH] - Ointment - apply to affected area on buttocks twice a day and as needed for moisture barrier protection Discharge Medications: Expired Discharge Disposition: Expired Discharge Diagnosis: Expired Discharge Condition: Expired Discharge Instructions: Expired Followup Instructions: Expired [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]

[ "425.11", "410.71", "276.2", "584.5", "244.9", "345.90", "785.52", "038.9", "600.01", "585.3", "518.81", "758.0", "788.20", "599.0", "995.92", "286.6", "596.54", "733.00", "598.9", "287.5", "V43.64" ]

icd9cm

[ [ [] ] ]

[ "96.04", "57.18", "38.97", "38.91", "96.71" ]

icd9pcs

[ [ [] ] ]

14166, 14175

7165, 11541

318, 411

14226, 14235

3725, 3725

14291, 14437

2990, 3072

14134, 14143

14196, 14205

11696, 14111

14259, 14268

7120, 7142

3087, 3680

3696, 3706

11562, 11670

272, 280

439, 2541

3742, 7104

2563, 2779

2795, 2974

55,013

183,882

54590

Discharge summary

report

Admission Date: [**2109-6-5**] Discharge Date: [**2109-6-12**] Date of Birth: [**2047-11-5**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 8115**] Chief Complaint: Altered Mental Status Major Surgical or Invasive Procedure: None History of Present Illness: 61 yo woman h/o breast cancer s/p resection, metastatic poorly differentiated sarcoma went for Right pneumonectomy for mets ([**Doctor Last Name **] [**2-/2109**]), now presents with several weeks of intermittent AMS/confusion/occasional speech difficulty, worsen today. For the past few weeks she has developed some confusion and aphasia according to the family. Pt herself states that she does notice that she can't find correct words. Denies any respiratory sx, headaches, changes in the vision or balance. She recently had PET which did not show any activity. Family called Dr [**First Name (STitle) **] who referred her to ED for evaluation. When she arrived, CXR found to have loculated L pleural fluids, UA is unimpressive, Head CT showed spherical lesions, c/w metastatic disease - widespread. Neurosurg report no emergent surgical therapy likely, did not recommend steroids now given infection of unclear type (ie. elevated WBC). Heme-onc aware of the patient. She was noted to be persistently tachycardic after 2 L. . Initial vitals, pain [**8-25**] temp 100.4 hr 123 bp 143/93 rr18 sat 98 on 2L. Given Acetaminophen, Piperacillin-Tazob, Vancomycin, Morphine Sulfate in ED. Pain controlled. prior to transfer vitals were: 98.5 114 119/78 22-26 98% NC. UA unimpressive, Ucx sent. EKG TWI in V3. . On the floor, 98 104/66 rr 10 sat 100. comfortable, able to answer questions appropriately. Past Medical History: Past Medical History: breast cancer felt to be due to a variant BRCA2 mutation HTN endometriosis depression PSH: b/l oophorectomy, lumpectomy x3, b/l mastectomy Social History: The patient is married and lives with her husband in [**Name (NI) 4047**]. She works as a bookkeeper for a construction company, but is not currently working due to her illness. She smoked tobacco socially in the past, but has not smoked regularly. She has two daughters. She drinks alcohol socially. Family History: The patient has no Ashkenazi [**Hospital1 **] heritage in her family. Her mother had pancreatic cancer in her 60s. Her first cousin, her maternal uncle's daughter, had breast cancer in her 60s and died of an MI at 67. The patient's paternal grandmother had breast cancer in her 70s. Physical Exam: General: Alert, oriented, mild distress, cachetic HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: abscent lung sounds on right, left no wheezes, rales, ronchi CV: tachy, 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: [**2109-6-5**] 09:00PM BLOOD WBC-28.3*# RBC-4.11* Hgb-9.8* Hct-32.4* MCV-79* MCH-23.9* MCHC-30.3* RDW-16.6* Plt Ct-913* [**2109-6-6**] 03:16AM BLOOD WBC-21.0* RBC-3.41* Hgb-8.4* Hct-26.6* MCV-78* MCH-24.6* MCHC-31.5 RDW-16.1* Plt Ct-719* [**2109-6-6**] 03:00PM BLOOD Hct-28.2* Brief Hospital Course: Mrs. [**Known lastname **] is a 61 yo woman with a h/o breast cancer s/p resection that is metastatic and poorly differentiated sarcoma s/p Right pneumonectomy for mets ([**Doctor Last Name **] 4/[**2108**]). She now presents with several weeks of intermittent AMS, confusion and occasional speech difficulty that had worsened on presentation. . AMS: On admission, the patient had difficulty with speech and was confused to the point where she couldn't remember her daughter's names. She had a CT scan and MRI of the head that showed multiple brain mets (~14 spherical lesions). Her acute mental status change was secondary to brain metastasis from her sarcoma. The patient was followed by Radiation Oncology during her hospitalization. They recommended whole brain radiation. She completed brain mapping and completed 4 radiation treatments. Her mental status improved and she was able to communicate clearly by the day of discharge. . Leukocytosis/infection: The elevated WBC count with fever was suggestive of infectious etiology, however we believe this is a paraneoplastic phenomemnon. Blood cultures and urine cultures were sent and there was no growth. No antibiotics were used at this time. The patient continued to have persistent leukocytosis on the day of discharge. We suspect that the leukocytosis is related to her tumor burden. . Thrombocytosis, anemia: Appears to be presistent after diagnosis of her sarcoma. There was no need for transfusions during her hospitalization. . Pain Medication: No complaints about pain. We continued her on the following regimen throughout her hospitalization: - Continue Morphine Sulfate 2-4 mg IV q4h:prn pain and Morphine Sulfate IR 15 mg PO/NG Q4H:PRN pain. - Continue Lidocaine 5% Patch 1 PTCH TD daily 12 hrs. . Palliative Care had a meeting with the family and patient today. The family is very protective of the mother. They were all aware of her prognosis, but they want to limit discussion about end of life issues around the patient. The family would like many of the services offered by hospice, but were not willing to agree to accept these services at this time. The family was comfortable with accepting [**Year (4 digits) 269**] services. Medications on Admission: GABAPENTIN 600 mg PO TID LISINOPRIL 5 mg PO Daily LORAZEPAM 0.5 mg Tablet [**11-17**] Tablet(s)PO Q4-6 hours as needed MORPHINE 15 mg Tablet PO q 4-6 hours as needed for Pain ASCORBIC ACID [VITAMIN C] n ASPIRIN [[**Doctor Last Name **] [**Hospital1 **] ASPIRIN] 81 mg Tablet daily. Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Gabapentin 300 mg Capsule Sig: Two (2) Capsule PO TID (3 times a day) for 1 weeks. Disp:*42 Capsule(s)* Refills:*1* 4. Morphine 15 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO Q12H (every 12 hours) for 2 weeks. Disp:*28 Tablet Sustained Release(s)* Refills:*1* 5. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 6. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily) for 1 weeks. Disp:*7 Adhesive Patch, Medicated(s)* Refills:*0* 7. Morphine 15 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain for 1 weeks. Disp:*84 Tablet(s)* Refills:*0* 8. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for fever. 9. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 1 weeks. Disp:*14 Tablet(s)* Refills:*2* 10. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO Q6H (every 6 hours) as needed for constipation. 11. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 12. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal HS (at bedtime) as needed for constipation. 13. Polyethylene Glycol 3350 17 gram/dose Powder Sig: One (1) PO DAILY (Daily) as needed for constipation. 14. Dexamethasone 4 mg Tablet Sig: One (1) Tablet PO as directed for 17 doses: Please take 4mg three times a day for three days, then taper down to 4mg two times a day for three days. Disp:*17 Tablet(s)* Refills:*0* 15. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for anxiety/insomnia for 1 weeks. Disp:*28 Tablet(s)* Refills:*1* 16. Dexamethasone 2 mg Tablet Sig: One (1) Tablet PO as directed for 9 doses: Please take 2mg [**Hospital1 **] for three days and then taper down to 2mg daily for three days. Disp:*9 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital 2255**] [**Name (NI) 2256**] Discharge Diagnosis: Lung Sarcoma Brain metastases Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: It was a pleasure working with you during your hospital admisssion. You were admitted for confusion and mental status changes. We found two metstatic lesions in the brain that explain your symptoms. During your hospital admission, you were started on radiation therapy. You received your first dose on Friday morning and you completed 3 treatments this week. We encourage you to continue your home medications on discharge. In addition, we recommend that you continue your steroid, Dexamethasone. Over the next few days, you will need to taper your steroid dose. The instructions will be included in your discharge paperwork and can be given to your visiting nurses. Please follow-up with your primary oncologist in the next few weeks. Followup Instructions: Provider: [**Name10 (NameIs) **] SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2109-6-10**] 11:15 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3000**], MD Phone:[**0-0-**] Date/Time:[**2109-6-13**] 10:00 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 23908**], MD Phone:[**Telephone/Fax (1) 1387**] Date/Time:[**2109-6-19**] 9:40 [**Name6 (MD) **] [**Name8 (MD) 4908**] MD [**MD Number(2) 8116**]

[ "197.0", "V10.89", "198.3", "511.9", "311", "401.9", "V10.3", "238.71", "285.22" ]

icd9cm

[ [ [] ] ]

[ "92.29" ]

icd9pcs

[ [ [] ] ]

7963, 8034

3362, 5568

336, 342

8108, 8108

3061, 3339

9019, 9510

2289, 2573

5901, 7940

8055, 8087

5594, 5878

8259, 8996

2588, 3042

275, 298

370, 1770

8123, 8235

1814, 1955

1971, 2273

21,982

169,966

14651

Discharge summary

report

Admission Date: [**2196-8-19**] Discharge Date: [**2196-8-23**] Service: CCU HISTORY OF PRESENT ILLNESS: The patient is a [**Age over 90 **]-year-old woman with a history of hypertension who developed 10/10 chest pain with diaphoresis and nausea at 6 p.m. on the day of admission. The patient first went to [**Hospital3 1280**] Hospital Emergency Department. Initial electrocardiogram revealed ST elevations in V2 through V3. The patient became pain free with nitroglycerin with some improvement in ST segment but without total return to baseline. Because of her history of cerebrovascular accident of unknown etiology back in [**2195-12-10**], the decision was made not to give the patient t-PA, and the patient was transferred to [**Hospital1 69**] for catheterization. PAST MEDICAL HISTORY: (Past Medical History includes) 1. Hypertension. 2. Cerebrovascular accident in [**2195-12-10**]. 3. Stomach cancer. 4. Hypothyroidism. MEDICATIONS ON ADMISSION: Outpatient medications included Ativan (unknown dose), atenolol (unknown dose), Synthroid (unknown dose), and aspirin 81 mg p.o. q.d. ALLERGIES: The patient has no known drug allergies. MEDICATIONS ON TRANSFER: Medications on transfer from [**Hospital3 6454**] Hospital included aspirin, nitroglycerin times four, morphine, heparin, and Integrilin. SOCIAL HISTORY: The patient denies smoking and alcohol. She is widowed. She has no children. She lives with her sister who does much of her activities of daily living. FAMILY HISTORY: Family history was noncontributory. PHYSICAL EXAMINATION ON PRESENTATION: On physical examination, her blood pressure was 117/44, heart rate was 46, in a normal sinus rhythm, respiratory rate was 16, pulse oximetry was 99% on 2 liters. The patient was an elderly woman, lying in bed, alert, and cooperative. In no acute distress. Head, eyes, ears, nose, and throat examination revealed pupils were equal, round, and reactive to light. Extraocular movements were intact. Sclerae were anicteric. Mucous membranes were moist. The oropharynx was clear. The neck was supple. No jugular venous distention. No carotid bruits. Cardiovascular examination revealed a slow rate, regular. Normal first heart sound and second heart sound. No murmurs, rubs, or gallops were appreciated. The lungs were clear to auscultation bilaterally. The abdomen was soft, nontender, and nondistended. Positive bowel sounds. The patient had a right femoral line sheath in the right groin region. No bruit or hematoma were present. No bleeding. The patient's distal pulses were 2+. The patient had no rash. The patient was alert and oriented times three. Cranial nerves were grossly intact. Motor was [**6-12**] in all extremities. No significant differences were perceived in the right or left extremities. PERTINENT LABORATORY DATA ON PRESENTATION: Laboratories on transfer revealed white blood cell count was 13.3 and hematocrit was 39.4. Chemistries were significant for a blood urea nitrogen of 50 and a creatinine of 3.1. Her cardiac enzymes were 90. AST was 11 and AST was 18. RADIOLOGY/IMAGING: Electrocardiogram from the outside hospital revealed 1-mm ST elevations in V2 through V3. This decreased after nitroglycerin was given. At [**Hospital1 69**] she was noted to still be in sinus bradycardia with ST elevations of 1 mm in V2 with V3 back to baseline. HOSPITAL COURSE: At catheterization, the patient was found to have a mid left anterior descending artery 90% distal stenosis with TIMI-III flow. Also, the left circumflex with 80% stenosis at the first obtuse marginal and 60% at second obtuse marginal. The right coronary artery had mild luminal irregularities. Stents were placed in the left anterior descending artery. Hemodynamics revealed a right atrial pressure of 7, right ventricle of 30/3, pulmonary artery pressure of 26/9, and a wedge pressure of 10. Cardiac output was 3.5. The patient was admitted to the Coronary Care Unit for observation, status post cardiac catheterization. She was maintained on aspirin, Plavix, and Integrilin was continued for 18 hours. She was started on Lipitor. An ACE inhibitor was withheld initially secondary to elevated blood urea nitrogen and creatinine; however, it was then started after her creatinine had fallen from admission to 3, and it was found that her baseline was elevated; as per her primary care physician. [**Name10 (NameIs) **] baseline is around 2.5. However, after starting low-dose ACE inhibitor, her creatinine began to rise again. The ACE inhibitor was discontinued, and she was switched to hydralazine. The benefits of an ACE inhibitor were discussed with her primary care physician who will follow her renal function as an outpatient, and the patient may be started on an ACE inhibitor at that point. The patient had an echocardiogram which revealed an ejection fraction of 35%, moderate left ventricular systolic dysfunction, medial to distal anteroseptal hypokinesis/akinesis, apical akinesis, and trivial pericardial effusion. Despite her low ejection fraction, anticoagulation was initially held secondary to the risk and benefits of bleeding and compliance in this patient. However, in the future, it may be considered beneficial starting anticoagulation. Initially, the patient was in sinus bradycardia. Beta blockers were held. However, her bradycardia dissipated. She became normal rate, and she was started on low-dose beta blocker at initially 12.5 mg p.o. b.i.d. On discharge, the patient was discharged on Isordil 10 mg p.o. t.i.d., hydralazine 25 mg p.o. t.i.d., Lopressor 25 mg p.o. b.i.d., and Lipitor. Her creatinine, which initially rose, fell after admission. It crept up causing discontinuation of the ACE inhibitor and starting on hydralazine and Isordil; however, her creatinine then stabilized around 3.6. The patient was to follow up with her primary care physician, [**Name10 (NameIs) **] which time a decision can be made whether to start an ACE inhibitor. The patient developed a urinary tract infection during her hospital course. She was started on a 7-day course of ciprofloxacin for complicated urinary tract infection secondary to indwelling Foley catheter. CONDITION AT DISCHARGE: The patient was in stable condition at the time of discharge. DISCHARGE STATUS: Discharge status was to home with [**Hospital6 407**]. DISCHARGE DIAGNOSES: 1. ST-elevation myocardial infarction. 2. Status post cardiac catheterization of the left anterior descending artery. MEDICATIONS ON DISCHARGE: (Discharge medications included) 1. Isordil 10 mg p.o. t.i.d. 2. Hydralazine 25 mg p.o. t.i.d. 3. Metoprolol 25 mg p.o. b.i.d. 4. Lipitor 10 mg p.o. q.d. 5. Ciprofloxacin 500 mg p.o. q.d. (for a 7-day course). 6. Synthroid 25 mcg p.o. q.d. 7. Aspirin 325 mg p.o. q.d. 8. Plavix 75 mg p.o. q.d. DISCHARGE INSTRUCTIONS/FOLLOWUP: The patient was to follow up in the Cardiology Clinic. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3184**], M.D. [**MD Number(1) 5211**] Dictated By:[**Name8 (MD) 43155**] MEDQUIST36 D: [**2197-1-11**] 12:06 T: [**2197-1-13**] 09:41 JOB#: [**Job Number 43156**]

[ "593.9", "438.89", "414.01", "V10.04", "410.11", "401.9", "244.9", "427.9", "599.0" ]

icd9cm

[ [ [] ] ]

[ "37.23", "36.06", "99.20", "88.55", "36.01" ]

icd9pcs

[ [ [] ] ]

1525, 3398

6412, 6533

6560, 6863

979, 1168

3416, 6237

6898, 7219

6252, 6391

116, 788

1195, 1334

811, 952

1351, 1507

22,963

123,169

9154

Discharge summary

report

Admission Date: [**2184-6-29**] Discharge Date: [**2184-7-7**] Date of Birth: [**2133-7-20**] Sex: M Service: MEDICINE Allergies: Penicillins / Bactrim Attending:[**First Name3 (LF) 2297**] Chief Complaint: bright red blood per rectum Major Surgical or Invasive Procedure: colonoscopy femoral central venous catheter History of Present Illness: This is a 50 y/o male with a history of HIV/AIDS and Hep C with cirrhosis/variceal bleeds/portal gastropathy/portal vein thromboses who was recently hospitalized from [**Date range (1) 31501**] for a massive GI (rectal bleed), who now presents today with BRBPR. Per patient, he has not had any rectal bleeding since his last admission until 6pm this evening. Patient reports increasing firmness to his stools recently and began haveing BRBPR while having a BM this evening. Unable to estimate amount of bleeding. No n/v/hematemesis/abdominal pain. No melena. No f/c/s. Reports baseline LH/dizziness. No CP/SOB/palpitations. Per patient's girlfriend, patient began using cocaine recently again, last use yesterday. He presented to the ED tonight for further management. Of note, the patient was due for injection of the rectal varices this Thursday ([**2184-7-2**]) with Dr. [**Last Name (STitle) 497**]. . During his last admission from [**5-23**] - [**6-18**] for a massive GI bleed (over 8 L in the first 24 hours) he required over 20 units of blood and >12 L NS. Patient was also intubated during that time for airway protection. Endoscopy revealed large rectal varices but TIPS was unsuccessful due to his portal vein thromboses. He received an embolization with dermabond injection on [**2184-6-10**] of his large rectal varices and his bleeding stopped. Of note, this admission was preceded by a relapse of his drug use, particularly cocaine. He also developed bilateral DVTs despite his massive bleed and an IVC filter was placed on [**6-14**] as the risk of anticoagulation was too high. TIPS was again attempted but was unsuccessful. . In the ED tonight, VS T 97.4, BP 81-95/50-62, HR 80, RR 14, SaO2 99%/2L NC. He was given 3 L NS and 2 U PRBCs. Exam was significant for large amount of BRBPR. GI was called to see the patient and bleeding had resolved at that time. Patient was admitted to the MICU for further management. . ROS - Otherwise negative. Of note, pt had a fall 5 days ago and resulting abrasion on forehead. Denies any h/a. Past Medical History: # HIV/AIDS dx in [**2163**], CD4 nadir 47 in [**9-6**] [**5-7**] - CD-4 119,viral load 175 copies [**10-7**] - CD-4 47, viral load >100K copies. [**12-7**] - CD -4 104, 4%, PVL 100 [**1-6**] CD-4 144,14%, PVL 80. [**2-8**] CD-4 83, 14%, PVL UD on Kaletra, Epzicom, and Viread which had previously controlled his viral load. # Hepatitis C, s/p varices, portal gastropathy, splenomegaly AFP of 1.7 in 11/[**2183**]. +portal vein thromboses, rectal varices s/p embolization procedure [**6-7**]. Hepatitis C RNA of 504,000 IU. His Hep C genotype is 4a. esophageal varices that have been banded multiple times; receives regular EGD through Dr. [**Last Name (STitle) 497**]. # IVC filter placed [**6-14**] for bilateral DVTs # Leukopenia believed secondary to splenic sequetration (PET scan negative [**11-6**]) # Renal insufficiency thought related to GI bleeds and possibly tenofovir. # H/o zoster # Esophageal candidiasis (seen on EGD most recently [**10-13**]) # H/o positive toxo IgG in [**2180**] # H/o positive CMV IgG in [**2180**] # H/o positive Hep A ab in [**2183**] # H/o positive Hep B core AB in [**2183**] (with neg sAB, neg antigen) # H/o negative RPR in [**2183**] # Negative PPD in [**2183**] # Osteomyelitis L knee 10 years ago [**3-5**] IVDA # Portal vein thrombosis seen on CT in [**2183**] # Gout (dx age 18; hx of tophi removal; on allopurinol in the past. Was seen in [**Hospital **] Clinic [**2182-3-5**].) # Substance abuse (mostly IV heroin, benzos, cocaine) Social History: Lives with girlfriend, on [**Name (NI) 31500**]. Smoked 2ppd x 20-30 yrs, no EtOH. H/o IVDA. Recent cocaine use (last use yesterday), with frequent [**5-6**] d "binges." Occasional bzd abuse. Denies any EtOh use. Family History: NC Physical Exam: VS: Tc 96.3, BP 112/78, HR 77, RR 18, SaO2 100%/2 L NC General: Cachectic-appearing male, slightly lethargic in NAD HEENT: NC/AT, PERRL, EOMI. No icterus. MM dry, OP clear. Small abrasion on forehead. Neck: supple, no LAD or JVD Chest: CTA-B anteriorly CV: RRR s1 s2 normal, no m/g/r Abd: soft, NT/ND, NABS. +Hepatosplenomegaly Ext: no c/c/e, scars on left foot; right femoral line in place, c/d/i Neuro: AO x 3, lethargic but arousable. No asterixis on exam. Pertinent Results: [**2184-6-29**] 07:17PM BLOOD WBC-1.5* RBC-3.73* Hgb-11.1* Hct-33.4* MCV-90 MCH-29.7 MCHC-33.2 RDW-16.7* Plt Ct-73* [**2184-6-30**] 03:24AM BLOOD WBC-0.8* RBC-2.60*# Hgb-7.9*# Hct-23.3* MCV-89 MCH-30.4 MCHC-34.1 RDW-16.4* Plt Ct-68* Gran Ct-490* [**2184-6-30**] 01:03PM BLOOD Hct-26.5* [**2184-6-30**] 09:36AM BLOOD PT-14.7* PTT-28.0 INR(PT)-1.3* [**2184-6-29**] 07:17PM BLOOD Fibrino-163 [**2184-6-30**] 03:24AM BLOOD Glucose-126* UreaN-7 Creat-0.9 Na-140 K-3.6 Cl-107 HCO3-25 AnGap-12 [**2184-6-30**] 12:22AM BLOOD Hct-25.4* Plt Ct-50* [**2184-6-30**] 12:46AM BLOOD Hct-26.2* Plt Ct-51* [**2184-6-30**] 03:24AM BLOOD WBC-0.8* RBC-2.60*# Hgb-7.9*# Hct-23.3* MCV-89 MCH-30.4 MCHC-34.1 RDW-16.4* Plt Ct-68* [**2184-6-30**] 09:36AM BLOOD Hct-26.5* Plt Ct-62* [**2184-6-30**] 01:03PM BLOOD Hct-26.5* [**2184-6-30**] 05:06PM BLOOD Hct-28.4* [**2184-6-30**] 09:23PM BLOOD Hct-29.5* Plt Ct-67* [**2184-7-1**] 02:34AM BLOOD WBC-1.1* RBC-3.24* Hgb-9.9*# Hct-28.6* MCV-88 MCH-30.5 MCHC-34.6 RDW-16.6* Plt Ct-61* [**2184-7-1**] 11:18AM BLOOD Hct-28.2* [**2184-7-1**] 06:47PM BLOOD Hct-28.2* [**2184-7-1**] 11:02PM BLOOD Hct-30.2* [**2184-7-2**] 05:33AM BLOOD WBC-0.9* RBC-3.30* Hgb-10.0* Hct-29.6* MCV-90 MCH-30.2 MCHC-33.7 RDW-16.5* Plt Ct-66* [**2184-7-2**] 09:18PM BLOOD Hct-28.9* Plt Ct-62* [**2184-7-3**] 03:21AM BLOOD WBC-0.7* RBC-3.06* Hgb-9.2* Hct-27.9* MCV-91 MCH-30.1 MCHC-33.0 RDW-16.2* Plt Ct-66* [**2184-7-3**] 10:01PM BLOOD WBC-1.9* RBC-2.51* Hgb-7.7* Hct-21.9* MCV-87 MCH-30.6 MCHC-35.1* RDW-16.4* Plt Ct-59* [**2184-7-4**] 05:28AM BLOOD Hct-18.5* [**2184-7-6**] 09:26AM BLOOD Hct-22.5* [**2184-7-6**] 06:07PM BLOOD Hct-25.0* [**2184-7-7**] 05:00AM BLOOD WBC-1.2* RBC-2.57* Hgb-7.9* Hct-23.0* MCV-89 MCH-30.8 MCHC-34.4 RDW-16.9* Plt Ct-40* [**2184-7-4**] 03:16AM BLOOD Glucose-130* UreaN-8 Creat-0.8 Na-135 K-3.7 Cl-108 HCO3-23 AnGap-8 [**2184-7-1**] 02:34AM BLOOD ALT-10 AST-21 LD(LDH)-142 AlkPhos-79 TotBili-0.5 [**2184-6-30**] flex sig: Findings: Contents: Clotted blood was seen in the colon. There was stool in the colon. Other A large varix with central ulceration and stigmata of recent bleeding was seen in the rectum at approximately 5 cm. One, 2 cc. dermabond mixed 7:3 dermabond:ethadiol injection was applied for hemostasis with success. Impression: Stool in the colon Blood in the colon A large varix with central ulceration and stigmata of recent bleeding was seen in the rectum at approximately 5 cm. (injection) Recommendations: Monitor in ICU overnight Clear liquid diet, may advance in AM Miralax PRN titrated to 3 loose stools per day follow up sigmoidoscopy in 2 weeks. Additional notes: The attending was present during the entire procedure. Rectal varix was apparent source of bleeding, non-bleeding at time of procedure but with stigmata, injected with good hemostasis. [**2184-7-2**] flex sig: Findings: Contents: There was brown stool in the colon, no blood was seen Other Varix appeared improved with erythema and friability, no clot seen. Area appeared firm. Impression: Stool in the colon Varix appeared improved with erythema and friability, no clot seen. Area appeared firm. [**2184-7-6**] flex sig: Findings: Mucosa: Diffuse erythema was noted in the rectum. Protruding Lesions A single large external hemorrhoid was noted. Other Two strands of grade 1 rectal varices present. Impression: A single large external hemorrhoid Two strands of grade 1 rectal varices present. Erythema in the rectum Otherwise normal sigmoidoscopy to splenic flexure Additional notes: The rectal varices have responded well to the glue therapy. Brief Hospital Course: 50 y/o male with Hep C cirrhosis, [**Month/Day/Year 13808**], HIV, recent massive rectal bleed, re-representing with BRBPR . Rectal bleeding - From rectal varices initially. Received pRBCs to keep hct>25, PLTs >50, FFP, cryo and started on an octreotide drip. Continued to have brisk bleed. Rectal foley placed and ballon inflated with 40cc H2O and bleeding tamponaded. Colonoscopy showed a large varix with central ulceration and stigmata of recent bleeding and with dermabond:ethadiol injection with good hemostasis was achieved. His hct stayed stable after the procedure and was started on Miralax prn to titrate stools to 3 per day. Pt was called out to the floor on [**7-1**] after stable hct for 24 hours. However, as soon as as pt arrived on the floor, he had BRBPR after having a soft bowel movement which stopped spontaneously. Pt was hemodynamically stable with stable hct, but was transferred back to the unit for further close monitor. Liver team again put a foley and tamponaded the rectum. The following morning he again underwent another sigmoidoscopy which did not show any active bleeding. However, soon after flex sig, he rebled requiring more transfusion. Bleeding stopped spontaneously. At this point, Liver didn't think Dermabond or any other therapy would help. He later rebled on the night of [**7-3**] massively requiring more PRBC, vasopressin gtt and dopamine gtt. Hemostasis was not successful with a foley catheter, [**First Name8 (NamePattern2) **] [**Last Name (un) **] was placed to tamponade which achieved hemostasis. Given his poor prognosis and no good medical options, multiple discussions regarding goals of care were made and even palliative consult was involved. However, given his clinical stability off pressors and no further rectal bleeding, comfort care was reversed on [**2184-7-6**]. He again underwent another flex sig on [**7-6**] which only showed no active bleeding but large external hemorrhoids. Pt was observed for 24 hours in the ICU and then was discharged to home with services. His hct at d/c was 23 (transfusion >25 increases risk of rebleeding per liver, so pt was not transfused given no active bleeding). He'll follow up with his PCP 2 days after discharge from the ICU and also with Dr. [**Last Name (STitle) 497**] in 2 weeks after d/c. . # [**Last Name (STitle) 13808**] - c/b encephalopathy, varices, portal gastropathy, splenomegaly, +portal vein thromboses, rectal varices s/p embolization. Held lasix/propranolol/aldactone for now given low BP. . # HIV - Followed by outpatient ID/[**Hospital3 6616**]. Recently was restarted on his HAART medications but given his illness, HAART was held. Last CD4 count [**6-7**] 24, VL pending. Dapsone was held for neutropenia. Azithromycin was continued for MAC [**Month/Year (2) **]. . # Leukopenia/thrombocytopenia/anemia - thought to be [**3-5**] splenic sequestration and HIV. Pt was kept on neutropenic precaution. Held dapsone for neutropenia. Platelets were transfused for plt<50 during active bleeding. . # Addiction history - recent cocaine use, h/o heroin use. On methadone chronically. Initially held methadone given his altered mental status but later was restarted. Pt was on morphine gtt while he was heading towards CMO, but later was discontinued when comfort care was reversed. . # Hyperglycemia - pt without previous history of diabetes, though he has been placed in insulin sliding scale over multiple admissions. Recent Hgb A1C [**6-7**] <5. Hyperglycemia was thought to be [**3-5**] stress. Pt was continued on insuling sliding scale. . # Altered mental status: CT head was negative for bleed. His mental status returned to his baseline with resuscitation. # F/E/N - NPO while massive bleeding. Restarted neutropenic diet. . # [**Month/Day (2) 5**] - IV PPI, octreotide gtt, IVC (no pneumoboots given recent DVTs, no anticoagulation) . # Access - Right femoral cordis [**2184-6-29**] --d/ced in ICU, Right radial A-line [**2184-6-29**]--d/ced in ICU. RIJ d/ced on the day of discharge. . # Code - DNR/DNI (confirmed) . # Communication - girlfriend, [**Name (NI) 698**] [**Telephone/Fax (1) 31502**]; son [**Name (NI) 382**] [**Name (NI) **] [**Name (NI) **] [**Telephone/Fax (1) 31503**] Medications on Admission: Kaletra Epizcom Viread Allopurinol 300 mg qd Dapsone 100 mg qd Azithromycin 1200 mg q week (on Sundays) Omeprazole 20 mg qd Spironolactone 50 mg qd Lasix 20 mg qd Rifaximin 200 mg tid Propranolol 10 mg tid Methadone 60 mg, Oxycodone 30 PRN breakthrough. Discharge Medications: 1. Clonazepam 1 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 2. Polyethylene Glycol 3350 17 g (100%) Powder in Packet Sig: One (1) Powder in Packet PO TID (3 times a day). Disp:*90 Powder in Packet(s)* Refills:*2* 3. Methadone 10 mg Tablet Sig: Six (6) Tablet PO DAILY (Daily). 4. Azithromycin 600 mg Tablet Sig: Two (2) Tablet PO QSUN (every Sunday). Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Primary diagnoses: Rectal variceal bleeding Secondary diagnoses: HIV/AIDS Hepatitis C cirrhosis Discharge Condition: Stable. No active rectal bleeding. Discharge Instructions: Return to emergency room if you develop profuse rectal bleeding, chest pain, shortness of breath, abdominal pain, fevers, chills, or any other worrisome symptoms. Please take medications as instructed and keep your follow up appointments. Followup Instructions: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5866**], MD Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2184-7-9**] 11:45 Provider: [**Name10 (NameIs) **], [**Name11 (NameIs) **], MD. Phone: ([**Telephone/Fax (1) 1582**] Date/Time: [**2184-7-23**] 11:20

[ "304.01", "070.54", "284.1", "789.5", "274.9", "455.2", "042", "571.5" ]

icd9cm

[ [ [] ] ]

[ "49.42", "45.24", "99.04" ]

icd9pcs

[ [ [] ] ]

13207, 13265

8275, 11869

309, 354

13406, 13443

4685, 8252

13731, 14018

4185, 4189

12820, 13184

13286, 13331

12541, 12797

13467, 13708

4204, 4666

13352, 13385

242, 271

382, 2432

11884, 12515

2454, 3938

3954, 4169

32,013

194,219

1493

Discharge summary

report

Admission Date: [**2188-5-10**] Discharge Date: [**2188-5-16**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**Known firstname 2745**] Chief Complaint: Fever, hematuria, hypotension Major Surgical or Invasive Procedure: EGD History of Present Illness: 87 y/o male w/ multiple medical problems including untreated colon cancer (found on colonoscopy [**2184**], declined surgery at the time), BPH, afib, diastolic heart failure and chronic right sided pleural effusion who presents with fevers/chills and urinary retention from [**Hospital 100**] Rehab. Patient was without specific symptoms except for continued complications with urinary catheter that again stopped draining on [**5-9**] but improved with manipulation. Also with worsening dysuria over the past couple of days, but has had dysuria/suprapubic discomfort over the last 2 months ever since a traumatic foley placement. Had fever to 101 day prior to presentation with chills, as well as more fatigue than usual. Also relates black stools for the last 10-11 days, multiple times per day, no BRBPR, no LH or dizziness. Also was started on iron recently. Social ETOH, no NSAID, no nausea/emesis/hematemesis or abdominal pain. No URI sxs, cough, shortness of breath, chest pain, rashes or new skin lesions. Per patient reason for transfer was SBP around 89 in the setting of fever. In ED vitals 100.1, 71, 90/50, 18, 90% RA, 93% on 4-5L. Foley not draining well and when flushed had some blood clots. Coudet #20 inserted and 375cc of dark red urine noted. Received 1L IVFs and BP responded in high 90's. HCT 25 from baseline around 30 and given 1 unit PRBCs. Rectal exam guaiac positive. Total ins 1075, total outs 500. Tylenol 1gm PO, levoquin 750mg IV, ceftriazone 2gm IV. Past Medical History: Colonoscopy [**2184-3-25**]: >Polyp in the transverse colon (polypectomy) - adenoma >Polyps in the sigmoid colon (polypectomy)- Colonic mucosa with focal hyperplastic features >Polypoid, ulcerated mass in the hepatic flexure (biopsy) - Superficial fragments of colonic mucosa with ulceration, marked acute inflammation, and highly atypical glands, suspicious for carcinoma. Past history: # Colon mass during colonoscopy for guaiac positive stools in [**2184**]. Pathology was worrisome for carcinoma. Although the patient was offered resection by Dr. [**Last Name (STitle) **], he declined # hematuria/BPH - traumatic foley insertion and manipulation [**3-16**] lead to urosepsis and subsequent urinary retention # sick sinus syndrome and bifascicular block s/p pacemaker [**2184**] # PAF - on amiodarone, not on coumadin d/t concern for malignancy # H/O SVT # Atrial flutter status post ablation [**2-/2186**] - not on anticoagulation d/t concern for malignancy # Anemia - on arenesp and iron # Echo [**2186**]: mild-to-moderate mitral regurgitation, RA and LA # BPH s/p TURMP [**2187**] # b/l edema with skin changes # hard of hearing # hx of guiaic positive stools/GI bleeding # osteoarthritis # osteoporosis # subclinical hypothyroid state as per record # renal insufficiency # right pleural effusion - Found on CT on [**2188-2-25**] for increasing DOE. [**3-6**] and [**3-18**] thoracentesis c/w transudative. Workup during last admission revealed RV diastolic dysfunction. Concern was for PE as etiology, but unable to get CTA d/w ARF and V/Q not helpful. Not anticoagulated due to h/o GIB, pleurodesis not an option d/t transudative. # Tibial talar dislocation with comminuted distal tib fib fracture status post surgery [**2181**] # hx syncope in [**2181**], unclear etiology Social History: Was living alone, now at [**Hospital1 100**] Rebab. Former smoker with 35-pk-yrs, quit 50-55 yrs ago. Social ETOH. Family History: brother had [**Name2 (NI) 500**] marrow stem cell transplant at age 82 Sister died from heart attack. Also had an unknown cancer. Mother died from an unknown cancer. Neice has unknown cancer. Physical Exam: Tmax: 36.3 ??????C (97.3 ??????F) Tcurrent: 36.3 ??????C (97.3 ??????F) HR: 70 (70 - 72) bpm BP: 89/53(62) {89/53(62) - 100/57(68)} mmHg RR: 15 (13 - 15) insp/min SpO2: 93% Heart rhythm: SR (Sinus Rhythm) Height: 72 Inch Awake, alert and oriented HEENT: no jaundice Lungs: CTA CVS: regular Abd: soft, NT, BS+, no HSM Ext: trace edema Brief Hospital Course: The patient is an 87 y.o.m. with multiple medical problems including untreated colon cancer, BPH, chronic foley, afib, diastolic heart failure and chronic right sided pleural effusion who presents with fevers/chills, hypotension, and urinary retention from [**Hospital 100**] Rehab. # Hypotension - Believed by ICU team to be secondary to preseptic physiology secondary to UTI and melena. Resolved after volume resuscitation and treatment of UTI. # GIB -Patient with melena on presentation. EGD [**5-12**] revealed a single non-bleeding erosion in the antrum of the stomach. # Urinary retention - Etiology from traumatic foley placement during admission in [**2-29**], followed by urology and Dr. [**Last Name (STitle) 3748**] as an outpatient. Foley currently draining well without clots after manipulation overnight. Continue BPH meds. Outpatient urology f/u. #UTI) [**5-10**] urine culture no growth but patient with symptoms of UTI and equivocal u/a in setting of hypotension with indwelling foley and thus was presumptively started on abx by ED and ICU. Will complete 7 day course of abx. C. Difficile Colitis) Patient developed during his hospitalization. Flagyl po for 14 days total. # CKD - Currently at baseline. Cr 1.1 #Colon CA) Patient underwent colonoscopy on [**5-15**] that revealed pseudomembranous colitis, two polyps and his earlier colonic mass at the hepatic flexure. Per GI, there is concern for future risk of obstruction from mass. Patient now appears more interested in discussing surgical options. Patient to f/u in Dr.[**Name (NI) 8788**] clinic. Oncology service noted no role for solitary chemo given size of mass. Medications on Admission: Amiodarone 200 mg daily Aspirin 81 mg daily Toprol-XL 25 mg daily Terazosin (hytrin) 10 mg daily Lasix 40 mg daily Keflex 500 Q12H Proscar 5 mg daily Discharge Medications: 1. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Furosemide 10 mg/mL Solution Sig: Two (2) mL Injection DAILY (Daily). 3. Toprol XL 25 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. 4. Terazosin 10 mg Capsule Sig: One (1) Capsule PO once a day. 5. Proscar 5 mg Tablet Sig: One (1) Tablet PO once a day. 6. Cefpodoxime 100 mg po bid for 2 more days (d/c on am of [**5-19**]) 7. Flagyl 500 mg po tid for 12 more days. 8. medication change Note: Given recent melena, holding patient's prior asa 81 mg EC po qd. Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - MACU Discharge Diagnosis: UTI Clostridium Difficile Diarrhea and Colitis Heart Failure, Diastolic Discharge Condition: Vital Signs Stable Discharge Instructions: Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs. Adhere to 2 gm sodium diet Fluid Restriction: 2000cc/day Return to ED if having bleeding from rectum, fevers, difficulty breathing. Followup Instructions: Patient to f/u with Dr. [**Last Name (STitle) **], Colorectal surgery clinic, [**Last Name (NamePattern1) **]., [**Hospital Unit Name **]. [**Telephone/Fax (1) 2981**]. Dr.[**Name (NI) 1482**] office called, message left for his administative assistant. Patient to schedule f/u with PCP [**Last Name (NamePattern4) **] 2 weeks.

[ "428.0", "427.31", "285.1", "788.20", "428.32", "578.9", "511.9", "599.0", "733.00", "600.00", "038.9", "560.9", "211.3", "996.64", "008.45", "244.9", "995.91", "153.0", "585.9" ]

icd9cm

[ [ [] ] ]

[ "45.13", "45.23", "99.04" ]

icd9pcs

[ [ [] ] ]

6801, 6867

4337, 6000

291, 296

6982, 7002

7255, 7586

3768, 3962

6201, 6778

6888, 6961

6026, 6178

7026, 7232

3977, 4314

222, 253

324, 1809

1831, 3620

3636, 3752

25,111

178,755

14986

Discharge summary

report

Admission Date: [**2147-1-2**] Discharge Date: [**2147-1-14**] Date of Birth: [**2092-8-16**] Sex: M Service: VASCULAR CHIEF COMPLAINT: Ischemic left foot rest pain. HISTORY OF PRESENT ILLNESS: Obtained from the patient's wife and computer records. She was a reliable historian. The patient is a 54 year-old white male with known coronary artery disease, angioplasty and stent placement in [**Month (only) 216**] of this year with diabetes, hypertension and history of SIADH. He has known peripheral vascular disease and underwent a right femoral AT bypass with flap in [**Month (only) **] of this year who returns now with increasing left calf claudication and rest pain times one week. The patient was seen by Dr. [**Last Name (STitle) 1391**] and Dr. [**Last Name (STitle) **] podiatry on [**2146-12-30**]. The patient is scheduled for an outpatient arteriogram on [**2147-1-3**], but because of increasing symptoms the patient is now admitted for further evaluation and treatment. ALLERGIES: No known drug allergies. MEDICATIONS ON ADMISSION: Lantus 6 units q.h.s., Prandin 2 mg t.i.d. with meals, Humalog sliding scale at lunch, Atenolol 25 mg q.d., aspirin 325 mg q.d. last dose was stopped prior to his arteriogram. PAST MEDICAL HISTORY: Coronary artery disease. He had a stress test done in [**Month (only) 216**] of this year, which was positive. He underwent angioplasty with stent placement times two to the left anterior descending coronary artery and angioplasty with stent to the right coronary artery in [**Month (only) 216**] of this year. He was recatheterized on [**2146-9-20**] for elevated cardiac enzymes. He had patent stents at that time. He has been a diabetic since the age of 32 with triopathy. Hypertension, history of hip fractures secondary to motor vehicle accident in [**2140**], osteomyelitis of the right fifth metatarsal head in [**Month (only) **] of this year. Hyponatremia, SIADH in [**Month (only) **] of this year treated. Peripheral vascular disease. PAST SURGICAL HISTORY: Open reduction and internal fixation of hip in [**2140**], right superficial femoral artery to posterior tibial with right saphenous vein graft in [**Month (only) **] of this year. Right fifth metatarsal head resection in [**Month (only) **] of this year. Right foot primary closure with advancement flap in [**Month (only) **] of this year. SOCIAL HISTORY: He is a fisherman, lobsterman. He has had transfusions in the past. He has never smoked. Occasional beer. He is married and lives with his wife. PHYSICAL EXAMINATION: Temperature 100.7. Pulse 90. Respirations 16. Blood pressure 140/90. O2 sat 97% on room air. General appearence, alert, cooperative male in no acute distress. HEENT examination is unremarkable. Pulse examination shows intact carotids bilaterally. The right radial pulse is palpable. The left is palpable, but diminished in intensity. The abdominal aorta is nonprominent. The femoral pulses are palpable bilaterally. There are no carotid or femoral bruits. Popliteals are absent. The dorsalis pedis and posterior tibial on the right have dopplerable signal. On the left absent signal. Chest examination lungs are clear to auscultation. Heart is a regular rate and rhythm without murmur. Abdominal examination is unremarkable. Bone joint examination shows no ankle edema. The right foot is warm, pink with a yield fifth metatarsal head incision. The left foot is significantly cooler from ankle distally with multiple red skin discolorations on the dorsum of the foot. There is severe dependent ruber. There is a dry gangrenous lesion on the medial aspect of the first metatarsal head. HOSPITAL COURSE: The patient was prehydrated and Mucomyst protocol was begun. He underwent arteriogram on [**2147-1-3**], which demonstrated normal aorta, iliac without significant disease on the left, mild diffuse disease of the superficial femoral artery and PFA. The superficial femoral artery occludes at the adductor canal, reconstitutes as AK popliteal with moderate disease, BK popliteal has moderate disease with significant proximal AT disease. There is no proximal PT or peroneal. The AT occludes at the calf. The PT reconstructs above the ankle and continues at the arch. Pulmonary consult was placed prior to surgery to assess pulmonary risks with chest x-ray findings of left lower lobe pneumonia. They felt that he had appropriate coverage with Levofloxacin and Flagyl and there was a low suspicion for pulmonary embolus and there was an effusion that should be tapped and cultured otherwise was to proceed with planned surgery. [**Last Name (un) **] was consulted to follow the patient for his diabetic management during his perioperative period. The Prandin was discontinued and his Lantus insulin was increased to 6 to 8 units at h.s. and sliding scale premeals and at supper time were written for. The patient's admitting sodium was 127, which was stabilized, but he was covered perioperatively with Dexamethasone 4 mg pre 2 mg post surgical procedure. His insulin requirements continued to require adjustment. The patient underwent on [**2147-1-6**] a right common femoral artery to posterior tibial bypass graft in situ saphenous vein and angioscopy. He underwent an intraoperative TE, which showed global right ventricular and left ventricular hypokinesis, moderate MR to severe MR [**First Name (Titles) 151**] [**Last Name (Titles) 13223**]. The patient was transferred to the PACU with a monophasic dorsalis pedis pulse in stable condition. His immediate postoperative electrocardiogram was without changes, but cycled CKs were obtained. The patient's total CK peaked at 271 and defervesced in the next 48 hours to 123. His MB fractions were flat and were not done, but his troponin levels peaked at 45 and defervesced 48 hours later to 20.4. During this period of time the patient required inotropic support and nitroglycerin for after load reduction. Cardiology was consulted regarding elevated enzymes and diminished cardiac index. Their recommendations were to diurese to keep the pulmonary wedge pressure less then equal to 18. Titrate dobutamine to maintain an adequate cardiac output and index, hold beta blockers while on Dobutamine, aspirin, continue intravenous heparin, cycle electrocardiograms and CPK MBs. Postoperative hematocrit was 37.2, BUN 47, creatinine 1.4, K 4.2. The patient was transferred to the CICU for continued hemodynamic inotropic support. He required 2 units of packed cells perioperatively. He maintained his hematocrit above 30. He is continued on perioperative Vancomycin, Levo and Flagyl. He remained in the CICU. He was extubated on postoperative day two. His blood gas was 7.4, 42, 83, 27 and 0. Hematocrit remained stable at 36.3 after transfusion. BUN and creatinine remained stable. The patient was transferred to the regular nursing floor on [**2147-1-11**], antibiotics were discontinued. He was slow with ambulation limited for weight bear. He required adjustment in his heparin dosing and Lopressor for adequate blood pressure control and anticoagulation. Prednisone was instituted 10 mg q.a.m. and 5 q.p.m. Anticoagulation was continued. Coumadinization was begun on [**2147-1-11**]. The patient required 3 to 6 months of anticoagulation secondary to his myocardial events. He will require an echocardiogram in three months. He was started on Lisinopril 2.5 mg q.d. for after load reduction. Physical therapy saw the patient. At the time of discharge the patient was in stable condition. Wounds were clean, dry and intact. The patient is to follow up with Dr. [**Last Name (STitle) 1391**] in two weeks time. He should follow up with his endocrinologist for continued management of his adrenal insufficiency and his cardiologist regarding his cardiac follow up. Echocardiogram was done on [**1-10**], which demonstrated ejection fraction of 20 to 25%. Left atrium was elongated, the right atrium and intraatrial septum was moderately dilated. The left ventricle was mild, symmetric left ventricular hypertrophy, overall left ventricular systolic function is severely depressed. There is a large thrombus seen in the left ventricle. The resting regional left ventricular wall motion abnormalities are seen in the basilar anterior, which is hypokinetic, mid anterior, which is hypokinetic. Basal anteroseptal, which is hypokinetic. Mid anteroseptal, which is hypokinetic. Basal inferior septal, which is hypokinetic. Mid inferior septal, which is hypokinetic. Basal inferior, which is akinetic. Mid inferior was akinetic. Basal infralateral, which is akinetic. Mid infralateral, which is akinetic. Septal apex is akinetic, inferior apex is akinetic, lateral apex is akinetic and apex is dyskinetic. Right ventricle shows severe global right ventricular free wall hypokinesis. DISCHARGE MEDICATIONS: Lisinopril 2.5 mg q.d., Miconazole powder 2% to peri area b.i.d. and prn. Prednisone 5 mg po q.p.m. 10 mg q.a.m., Propofol 50 mg b.i.d., insulin sliding scale and fixed insulin please see enclosed flow sheet. Slugrocortisone acetate 0.1 mg b.i.d., Darvocet N 100 one q 6 hours prn for pain, acetominophen 325 to 650 mg q 4 to 6 hours prn for pain, aspirin 325 mg q.d., Warfarin dose will be adjusted and maintain an INR between 2.5 and 3.5. DISCHARGE DIAGNOSES: 1. Ischemic left foot status post left common femoral to posterior tibial bypass in situ saphenous vein. 2. Perioperative myocardial infarction treated, ejection fraction 20 to 25%. 3. Adrenal insufficiency treated on maintenance minimal corticosteroids. 4. Diabetes insulin dependent, stable. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 4417**] Dictated By:[**Last Name (NamePattern1) 1479**] MEDQUIST36 D: [**2147-1-13**] 08:55 T: [**2147-1-13**] 09:06 JOB#: [**Job Number 43866**]

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32,008

181,524

32938

Discharge summary

report

Admission Date: [**2163-1-17**] Discharge Date: [**2163-1-21**] Date of Birth: [**2107-1-3**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 3556**] Chief Complaint: Lethargy, generalized weakness, worsening jaundice Major Surgical or Invasive Procedure: paracentesis ERCP History of Present Illness: 56 yo woman with stage IV cholangiocarcinoma metastatic to liver diagnosed during ex lap in [**11-13**], who presents with lethargy, generalized weakness and increasing jaundice. Pt had been feeling relatively well until [**2163-1-14**], when she started her second cycle of chemo (Gemzar and cisplatin). Following chemo, she noted feeling gradually more fatigued. Her family reports she was more slow w/ responses to questions & seemed more tired. The pt notes no specific complaints except for ongoing hemorrhoidal pain and occasional, transient knee pain. She denies n/v/d, f/c, abd pain. No sob/cp. No dysuria. Her appetite has also become quite poor, and she not been eating or drinking much. She has been taking ibuprofen (about 800-1200mg daily per pt over last wk). She notes decreased UOP. . In the ED, rectal temp 99.6, 89, SBP 80s, 97 on 2L. She was given 1L of NS w/ improvement in SBP to 90s-100s. Her primary onc reports that her baseline SBP is 90s-100s. Her labs were notable for Tbili 7.2 (was reportedly ~4 last week per primary onc). Crt was elevated at 1.2 (BL 0.5). U/S liver showed new ascites, stable CBD & e/o GB CA w/ stones in GB as well. Seen by surgery, who felt she did was not operative candidate & recommended ERCP c/s. A diagnostic paracenteisis was performed & peritoneal fluid sent for cx. . ROS: As above, plus b/l LE edema. Pt took lasix 10mg PO day prior to admission b/c of this. Otherwise, ROS negative. Past Medical History: - Cholangiocarcinoma diagnosed during aborted cholecystectomy, undergoing chemotherapy. Was initially getting Gemzar w/ irinotecan. However, b/c of elevated bili, cisplatin substituted for irinotecan. Now day 1 of 2nd cycle was [**2163-1-14**]. Oncologist is Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] at [**Hospital3 **] - DM2 - HTN Social History: From [**Location (un) 3156**] originally, denies tobacco or drugs Family History: NC Physical Exam: VS: T 98.6, BP 114/69, HR 88, RR 16, 96%RA Gen: ill appearing, jaundiced HEENT: EOMI, icteric sclera, MM dry Neck: supple, no LAD, R IJ intact Chest: porta-cath side C/D/I Lung: CTAB Heart: RRR no m/r/g Abd: obese with slight epigastric/RUQ firmness in the area, laparoscopic scars noted, healing well Ext: 1+ pitting edema, ext warm Skin, jaundiced Neuro: no asterixis Pertinent Results: Admission Labs: [**2163-1-17**] WBC-16.8* RBC-3.09* Hgb-8.6* Hct-28.5* MCV-92# MCH-27.9 MCHC-30.3* RDW-23.3* Plt Ct-129* Neuts-82.8* Bands-0 Lymphs-16.3* Monos-0.4* Eos-0.4 Baso-0.2 Hypochr-1+ Anisocy-2+ Poiklo-2+ Macrocy-2+ Microcy-1+ Polychr-1+ Target-1+ Schisto-1+ Tear Dr[**Last Name (STitle) 833**] [**2163-1-18**] PT-16.7* INR(PT)-1.5* [**2163-1-17**] Glucose-157* UreaN-38* Creat-1.4* Na-128* K-5.5* Cl-100 HCO3-20* AnGap-14 [**2163-1-17**] ALT-51* AST-141* AlkPhos-586* TotBili-7.2* DirBili-5.7* IndBili-1.5 [**2163-1-17**] Albumin-1.4* Calcium-7.5* Phos-3.7# Mg-1.6 Ammonia-124* EKG: Sinus rhythm, LAD, RBBB with LAFB, peaked T waves, unchanged from [**2163-1-1**] . IMAGING: [**2162-12-3**] ABD CT: IMPRESSION: 1. Findings most consistent with gallbladder carcinoma with direct invasion of the liver. There is tumor infiltration into the mesenteric fat with small tumor nodules and concern for infiltration of the duodenum as described above. 2. A gallstone is seen relatively [**Name2 (NI) 76638**] to the remainder of the gallbladder and is likely located in a displaced cystic duct. Less likey it has erroded through the gallbladder wall and is located outside the lumen of the gallbladder. 2. Compression of the left portal vein by large liver lesion without portal vein thrombosis. 3. Multiple liver metastasis. 4. Lymphnode metastases in the porta hepatis. 5. Multiple tiny 1-2 mm hypoattenuating lesions within the right kidney, too small to characterize, but likely representing cysts. 6. Moderate bilateral lower lobe atelectasis and small bilateral pleural effusions. 7. Small amount of free intraperitoneal air from recent surgical procedure. . [**2163-1-17**] ABD US: Again seen is abnormal gallbladder wall thickening, with multiple gallstones and soft tissue in the region of the neck, consistent with known tumor. Also again seen is abnormal liver architecture adjacent to the gallbladder, consistent with metastases. The common duct again measures approximately 5 mm. Normal direction of flow again seen within the portal vein, which again appears diminutive. There is new small-to-moderate amount of ascites. Right pleural effusion is also seen. IMPRESSION: 1. Findings again suggestive of cholangiocarcinoma with hepatic metastases, not significantly changed in appearance from prior study. Common duct appears relatively stable compared to prior at 5 mm in diameter. 2. New small-to-moderate amount of ascites. 3. Right pleural effusion. [**2163-1-17**] 7:00 pm PERITONEAL FLUID PERITONEAL FLUID. GRAM STAIN (Final [**2163-1-17**]): NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. FLUID CULTURE (Final [**2163-1-20**]): NO GROWTH. ANAEROBIC CULTURE (Preliminary): NO GROWTH. Brief Hospital Course: 55F with recently diagnosed stage IV cholangiocarcinoma, DM2, and HTN, who presents with lethargy, weakness, worsening jaundice after cycle of chemotherapy was found to be hypotensive w/ new ARF and worsening hyperbilirubinemia with persistent fluid responsive hypotension. After surgery declined any operative intervention, GI was consulted for possible palliative ERCP. The procedure was scheduled for [**1-18**] but was postponed as the patient was felt to be too unstable to undergo the procedure. Eventually, went to ERCP on [**1-20**] and developed respiratory distress with hypoxia requiring intubation in the PACU. Was admitted to the ICU where initial ABG significant for pH 7.08, worsening AG, and lactate of 8.2. Was started on pressors, broad spectrum antibiotics, and stress dose steroids. She received IV albumin to support her intravascular volume given her extensive ascites. Despite these interventions, she developed worsening renal failure and MODS with persistent hypoperfusion and elevated lactate. Her coags were consistent with low grade DIC. She was switched to levophed with no improvement. After discussion with her family, HCP, and oncologist on the night of ICU admission, she was made DNR with a plan to continue aggressive treatment for approximately 24 hours. After this timeframe had past and the patient exhibited no improvement in her severe septic shock with multi-organ dysfunction, and in consultation with her family, the transistion was made to comfort measures. She expired on Friday, [**1-21**]. . Medications on Admission: 1. Loperamide 2 mg PO QID as needed for diahrrea. 2. Zolpidem 5 mg PO HS as needed. 3. Percocet 5-325 mg PO q6h:prn. 4. Metoprolol Succinate 200 mg Tablet Sustained Release 24 hr 5. Nystatin 100,000 unit/mL Suspension (5) ML PO QID 6. Hydrocortisone Acetate 1 % [**Hospital1 **] as needed for Hemorhoid Pain. 7. Acetaminophen 500 mg Tablet PO Q6H as needed. 8. Prilosec 20 mg Capsule, Delayed Release(E.C.) PO once a day. 9. Insulin Glargine 100 unit/mL Solution Sig: Fourteen (14) units Subcutaneous at bedtime. 10. Insulin Lispro 100 unit/mL Solution Sig: 2-10 units according to the sliding scale 11. lasix 10mg po prn 12. ibuprofen prn 13. serax prn Discharge Medications: n/a Discharge Disposition: Expired Discharge Diagnosis: n/a Discharge Condition: expired Discharge Instructions: n/a Followup Instructions: n/a [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3559**] MD, [**MD Number(3) 3560**]

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icd9cm

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Discharge summary

report+addendum

Admission Date: [**2146-4-10**] Discharge Date: [**2146-4-14**] Service: [**Location (un) 259**] I NOTE: Date of Discharge is expected to be [**2146-4-15**]. CHIEF COMPLAINT: Fevers and increased white blood cell count. HISTORY OF PRESENT ILLNESS: This is an 85 year old female with multiple medical problems who was sent in to the [**Hospital1 1444**] Emergency Room from her nursing home for fevers and an increased white blood cell count. The patient was recently admitted to [**Hospital1 346**] from [**2146-3-17**] until [**2146-4-6**] initially for shortness of breath and then had a prolonged hospital course which included respiratory distress thought secondary to a chronic obstructive pulmonary disease flare from Pseudomonal pneumonia. Other etiologies were entertained including allergic bronchopulmonary aspergillosis versus Turk-[**Doctor Last Name 3532**]. During the patient's last admission she had intermittent shortness of breath episodes that were treated with Lasix for pulmonary edema. She had also ruled out for an myocardial infarction at that time. Her hospital course at that time was also complicated by a steroid induced myopathy, incidental thyroid nodule with biochemically sick euthyroid, acute T12 compression fracture, ataxia attributed to steroid myopathy, pancytopenia attributed to medication, and a PEG placement. Upon evaluation for the current admission, the patient's daughter stated that since her discharge, the patient's mental status has been at baseline until the day prior to admission when she became slightly more depressed. She had been calling out for her deceased mother. The patient also appeared confused and agitated. At the nursing home, her temperature was 101.1 F.; heart rate was 106 and respiratory rate was 14. She was saturating 94% on two liters and had been placed on a nonrebreather by the EMS. At the nursing home she had been given Ciprofloxacin, Azithromycin and ceftazidime for one day. Per the patient's daughter, the patient had not had any headache, chest pain, change in her vision, diarrhea. She complained of mild abdominal diffuse pain. PAST MEDICAL HISTORY: 1. Status post pseudomonal pneumonia. 2. Chronic obstructive pulmonary disease. 3. Diverticulitis. 4. Pancreatitis complicated by pseudocyst. 5. Asthma. 6. Gastroesophageal reflux disease. 7. History of eosinophilia. 8. Hypercholesterolemia. 9. Atrial fibrillation, rate controlled. 10. Alzheimer's dementia. 11. Degenerative joint disease. 12. Coronary artery disease with a history of anterior myocardial infarction and an ejection fraction of greater than 55%. 13. T12 compression fracture. 14. Bronchiectasis. 15. Pancytopenia. 16. Sick euthyroid. 17. Steroid myopathy. 18. Status post PEG placement. MEDICATIONS: 1. Albuterol nebulizers q. six hours. 2. Calcitriol 0.25 micrograms q. day. 3. Salmeterol 50 micrograms q. 12 hours. 4. Guaifenesin q. six hours p.r.n. 5. Multivitamin. 6. Tylenol p.r.n. 7. Dulcolax suppositories p.r.n. 8. Colace 100 mg p.o. twice a day. 9. Flovent 110 micrograms, six puffs twice a day. 10. Alendronate 5 mg p.o. q. day. 11. Lidocaine patch p.r.n. 12. Calcium carbonate 1500 mg twice a day. 13. Prednisone 15 mg p.o. q. day. 14. Atrovent nebulizers q. six hours. 15. Nystatin swish and swallow. 16. Paxil 10 mg p.o. q. day. 17. Risperdal 0.5 mg p.o. twice a day p.r.n. 18. Zithromax 250 mg q. day. 19. Ciprofloxacin 500 mg q. day. 20. Ceftazidine one gram intravenously q. eight hours. 21. Lasix 20 mg p.o. q. day. 22. Diltiazem. SOCIAL HISTORY: The patient has a significant history of tobacco use. She resides at the [**Hospital3 2732**] home for the past week since her discharge from the hospital. PHYSICAL EXAMINATION: On evaluation in the Emergency Room, the patient was febrile with a temperature of 101.8 F.; blood pressure 145/66; heart rate 110; respiratory rate 22; 99% on a non-rebreather, 93% on room air at rest. The patient appeared sedated and was becoming agitated and combative at times. Her Pupils equally round and reactive to light. Her neck was supple without any lymphadenopathy or bruits. Her oropharynx was dry and her mucous membranes were moist without exudates. She had fine crackles half way up bilaterally on her lung examination and had occasional expiratory wheezes. She had no accessory muscle use. Her heart was regular rate and rhythm with S1, S2. Her abdomen was soft, nontender to deep palpation. She had normoactive bowel sounds and no guarding. Her PEG site was clean, dry and intact without erythema or drainage. Her legs were in lambs wool boots. She had trace edema to the ankles. There were no cords or erythema present. On neurologic examination, she responded to commands by opening her eyes, but appeared sedated. She had no point tenderness over her spine. She had no sacral decubitus ulcers and no skin ulcers. LABORATORY: Her labs were as follows on admission, white blood cell count 19.8, hematocrit 29.7, platelets 671. She had 70% neutrophils and 7% bands. Her electrolytes were as follows: Sodium 139, potassium 3.8, chloride 99, bicarbonate 29, BUN 18, creatinine 0.5, glucose 143. Her lactate was 0.9. Her first set of cardiac enzymes revealed the following: A CK of 30, MB of 3, troponin of 0.13. Her second troponin was 0.15. Her INR was 1.2. Two sets of blood cultures and a urine culture were drawn. Her ALT was 25, alkaline phosphatase 82, total bilirubin 0.2, lipase 78, amylase 83. On urinalysis she had moderate leukocytes and moderate blood. She had a white blood cell count of greater than 50 in her urine and many bacteria. There were three to five epithelial cells. Chest x-ray showed increasing rounded but ill defined opacity in the left upper lobe, same as in [**2146-2-17**]. There was a question of cavitary worsening left upper lobe opacity. An EKG was done which showed sinus tachycardia at 108 with normal intervals and left axis deviation. HOSPITAL COURSE BY PROBLEM: 1. FEVERS: Initially, the patient's fevers were thought to be due to a urinary tract infection as seen on her urinalysis upon admission. She had been placed on Levaquin to treat for the urinary tract infection, however, when the cultures came back showing methicillin resistant Staphylococcus aureus, the patient was switched to Vancomycin. Also, blood cultures had been drawn upon admission. The first set of blood cultures ended up growth enterococcus which was resistant to Vancomycin; thus, the patient's Vancomycin was discontinued and the Levaquin was discontinued as well. She was then started on Linezolid. An Infectious Disease consultation was obtained. They recommended that the patient undergo possible transesophageal echocardiogram; however, given the patient's agitated state, this test was not done. She was kept on the Linezolid and she was also started on clindamycin. Per Infectious Disease recommendations, the patient was to be kept on the Linezolid for a total of three or four weeks. The patient continued to have occasional spikes in her temperature. Surveillance blood cultures were drawn daily. The patient daily did not complain of any sort of symptoms; however, it was difficult to obtain a history daily given that the patient has a baseline dementia. 2. PULMONARY NODULE: Given the presence of this pulmonary nodule on chest x-ray upon admission, a CT scan was recommended by a pulmonary consultation that had been obtained in the early part of the [**Hospital 228**] hospital course. CT scan showed that the nodule had been present on a prior CT scan but had slightly grown in size. They were unable to rule out whether this was TB versus aspergillosis. Thus, the patient was placed in isolation in order to have her ruled out for tuberculosis. Sputum was induced on multiple occasions. The first two sets of sputum cultures had no acid fast bacilli on smear. Cultures were pending. The third set at the time of this dictation has not been induced yet. The patient had initially been placed on ceftazidime and Ciprofloxacin in case this had been a recurrence of her Pseudomonal pneumonia. However, after an Infectious Disease consultation had been obtained, they thought that this was low suspicion and decided to place the patient on Clindamycin. The Pulmonary Team followed the patient throughout her hospital course. 3. ELEVATED TROPONIN: Given that the patient's CK and MBs were within normal limits, it was thought that the patient's slightly elevated troponins were likely from demand ischemia. She had no new EKG changes and the patient continued to be asymptomatic. She denied any chest pain or shortness of breath throughout her hospital course. She was placed on Telemetry throughout her hospital course. There were no events up to the time of this dictation. 4. DECREASED HEMATOCRIT: The patient had a slightly decreased hematocrit upon admission. On hospital day two, she was transfused one unit of blood. Her hematocrit remained stable throughout the remainder of her hospital course. 5. MENTAL STATUS: The patient has baseline Alzheimer's Disease dementia. Initially she appeared improved since her last admission, although at times she had periods of agitation and depression. She was placed on Risperdal twice a day p.r.n. for agitation. 6. NUTRITION: The patient was continued on her tube feeds for her PEG that had been placed at her prior admission. A swallow consultation was obtained to see if the patient was at high risk for aspiration. The patient refused to have this test done, and given that she clearly had some risk of aspiration, she was made NPO as her diet throughout her hospital course. 7. CODE STATUS; The patient was a full code during her hospital stay up until the point of this discharge summary. 8. PROPHYLAXIS: The patient was placed on Colace, Dulcolax, heparin subcutaneously for deep venous thrombosis prophylaxis, fall precautions, aspiration precautions. 9. DIABETES MELLITUS: The patient had her fingersticks checked four times a day. She was placed on a regular insulin sliding scale due to the diabetes mellitus that had developed from her long chronic use of Prednisone. Her blood sugars remained well controlled during her hospital stay. The plan is for the patient to be discharged to a rehabilitation facility after she is ruled out for tuberculosis. At the rehabilitation facility she will receive the antibiotics, Linezolid and clindamycin up to a total of three weeks. DISCHARGE STATUS: Discharged to a rehabilitation facility. CONDITION AT DISCHARGE: Stable. DISCHARGE DIAGNOSES: 1. VRE bacteremia. 2. Methicillin resistant Staphylococcus aureus urinary tract infection. 3. Severe chronic obstructive pulmonary disease. 4. Pulmonary nodule. 5. Rule out tuberculosis. 6. Asthma. 7. Gastroesophageal reflux disease. 8. Alzheimer's Disease dementia. 9. T12 compression fracture. 10. Bronchiectasis. 11. Pancytopenia. 12. Steroid myopathy. DISCHARGE INSTRUCTIONS: 1. The patient was instructed to call her doctor or return to the Emergency Room if she experienced any further chest pain, increased shortness of breath, abdominal pain, fevers, change in mental status, or other worrisome symptoms. 2. She was also told to follow-up with the Infectious Disease Clinic. 3. She is to follow-up with her primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **]. 4. In addition, the patient had been scheduled for certain appointments during her prior hospital stay which were still pending such as her appointment with Neurology and Pulmonary. If there are any further events in the [**Hospital 228**] hospital course, they will be dictated at a later time. [**Name6 (MD) **] [**Name8 (MD) **], MD [**MD Number(1) 21980**] Dictated By:[**Name8 (MD) 4955**] MEDQUIST36 D: [**2146-4-14**] 14:44 T: [**2146-4-14**] 17:38 JOB#: [**Job Number 99483**] cc:[**Last Name (NamePattern1) 99484**] Name: [**Known lastname 15941**],[**Known firstname 6532**] V Unit No: [**Numeric Identifier 15942**] Admission Date: [**2146-4-10**] Discharge Date: [**2146-4-21**] Date of Birth: [**2060-7-9**] Sex: F Service: MED Allergies: Compazine / Tetracyclines / Aspirin / Sulfa (Sulfonamides) / Darvocet-N 100 / Ultram / Flagyl / Clindamycin Attending:[**First Name3 (LF) 8956**] Chief Complaint: Dyspnea, Respiratory Failure Major Surgical or Invasive Procedure: Non-invasive ventilation Brief Hospital Course: The patient was transferred to the [**Hospital Unit Name 1863**] with increasing O2 requirements and worsening respiratory status. Over the course of the next several days, neither the patient's mental status nor respiratory status improved despite continued antibiotics, agressive pulmonary toilet. She continued to appear uncomfortable and received prn pain medications. After discussion with the family, the patient was made DNR/DNI but continued to require non-invasive ventilation. After several more days without any improvement, another family meeting was held. The patient's son and daughter communicated that the patient would have opted for comfort measures at this point. The patient was made CMO and started on a morphine drip titrated to the patient's comfort. Within 24 hours, the patient had expired. The patient's son was present at the time of her death. Family members requested a partial autopsy to investigate the patient's dementia. The patient's primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 274**] continued to be in contact with the family and to follow the patient in the ICU. Discharge Disposition: Extended Care Discharge Diagnosis: VRE bacteremia MRSA uti severe copd pulmonary nodule r/o TB delirium Discharge Condition: deceased [**First Name11 (Name Pattern1) 77**] [**Last Name (NamePattern4) 8958**] MD [**MD Number(1) 8825**] Completed by:[**2146-8-27**]

[ "041.04", "493.22", "038.11", "518.89", "995.92", "518.81", "599.0", "263.9", "V44.1" ]

icd9cm

[ [ [] ] ]

[ "00.14", "93.90", "96.6", "38.91", "99.04" ]

icd9pcs

[ [ [] ] ]

13740, 13755

12577, 13717

12528, 12554

13868, 14037

10637, 11003

13776, 13847

11027, 12443

3749, 5976

10607, 10616

12460, 12490

6004, 9073

265, 2143

9089, 10591

2165, 3551

3568, 3726

16,362

128,677

47119

Discharge summary

report

Admission Date: [**2101-9-25**] Discharge Date: [**2101-10-8**] Service: MED Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 99**] Chief Complaint: Increasing shortness of breath, orthopnea Major Surgical or Invasive Procedure: None. History of Present Illness: 87 y/o male with MMP including CAD s/p CABG '[**88**], carotid stenosis s/p CEA '[**92**], Parkinson's dz, Anemia, PUD presenting with worsening DOE x 2 weeks. Pt was recently d/ced on [**9-14**] with hematuria, UTI, anemia requiring PRBC transfusion (discharge Hct 31), ARF (creat on discharge 1.3),and CHF. Discharged on Lasix 20 mg PO QD for CHF and Levofloxacin 250 PO QD for total 2 week course. Now c/o 2 wk increasing DOE and sob at rest, +worsening orthopnea from 2 pillows to 3 pillows over last 2 wks, +worsening LE edema R>L, +PND, +productive cough. Wife states that sob has been worsening especially over the last 2 days and wife called PCP this [**Name Initial (PRE) **].m. concerned about pt's status at home. 2 days ago, pt's wife was told to increase Lasix dose to 40 mg QD. Pt states that he cannot walk more than a few feet before feeling sob (unclear how different this is from baseline). Denies f/c, no calf pain, no CP, no n/v/abd pain, no BRBPR, no melena, no hematemesis, no palpitation, no dizziness/lightheadedness/fatigue, no dysuria, no change in bowel/bladder habits. Of note, pt's wife has also been sick with ?bronchitis vs PNA over the last week treated with Erythromycin. On transfer to [**Hospital1 18**], given 40 IV lasix, nebs, O2. Also given 1 dose Ceftriaxone and Clindamycin in ED. Past Medical History: -CAD s/p CABG in [**2088**] -carotid stenosis s/p CEA in [**2092**] -GERD -inguinal hernia -s/p AAA removal -cervical spondylosis -myelopathy -restless legs syndrome -Parkinson's disease -MGUS, recent nl. SPEP -anemia: felt to be multifactorial in nature (Fe def.and MGUS) -spinal stenosis -hemorrhoids -L hiatal hernia repair -PUD, S/P billroth II and vagotomy Social History: Pt. is married and lives with his wife. [**Name (NI) **] quit smoking cigarettes in [**2079**]. He does not use EtOH. Family History: Significant for diabetes mellitus and cardiac disease. Physical Exam: T 96 BP 142/70 P 76 R 20 Sat 97% RA Gen: frail,elderly male lying comfortably, NAD HEENT: PERRL, EOMI, OP clear with MMM, no exudates, conjunctiva pink Chest: decreased breath sounds at left base, coarse rhonchi at R lung [**2-4**] way up, +egophany R>L CV: RRR, no m/r/g Abd: s/nt/nd +BS Ext: 1+ pitting edema R>L, no calf tenderness, neg Homans sign Pertinent Results: [**2101-9-25**] 08:55AM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.018 [**2101-9-25**] 08:55AM URINE BLOOD-MOD NITRITE-NEG PROTEIN-500 GLUCOSE-NEG KETONE-15 BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG [**2101-9-25**] 08:55AM URINE RBC-0-2 WBC-0-2 BACTERIA-MANY YEAST-NONE EPI-0 RENAL EPI-[**4-8**] [**2101-9-25**] 08:50AM GLUCOSE-156* UREA N-61* CREAT-2.3* SODIUM-138 POTASSIUM-3.7 CHLORIDE-107 TOTAL CO2-19* ANION GAP-16 [**2101-9-25**] 08:50AM CK(CPK)-101 [**2101-9-25**] 08:50AM cTropnT-0.12* [**2101-9-25**] 08:50AM CK-MB-5 [**2101-9-25**] 08:50AM WBC-8.6 RBC-2.89* HGB-9.5* HCT-27.9* MCV-97 MCH-33.0* MCHC-34.1 RDW-13.8 [**2101-9-25**] 08:50AM NEUTS-87.5* BANDS-0 LYMPHS-5.7* MONOS-2.7 EOS-3.8 BASOS-0.3 CXR [**9-25**]: now more extensive involvement of R lung with reticular opacities, abnormality now involving entire R lung; R chest wall pleural thickening; +reticular opacities at L base; impression: concerning for infectious etiology EKG: NSR at bpm, nl intervals and axis, ?0.[**Street Address(2) 1755**] elev in V1,J point elev V2, no other sig ST changes U/S RLE: neg for DVT Brief Hospital Course: A/P: 87 y/o male with MMP including Parkinson's Disease, prev ARF, CHF, CAD s/p CABG [**2088**], carotid stenosis s/p CEA '[**92**], restless leg syndrome, MGUS, anemia, PUD with recent discharge for anemia/CHF/PNA now admitted with worsening DOE x 2 wks, LE edema R>L, worsening orthopnea and PND. Shortness of breath thought to be due to PNA so pt was continued on his outpatient levofloxacin and azithromycin. Pt went into acute respiratory failure on [**9-28**] requiring intubation. Chest xray revealed diffuse bilat patchy opacities so antibiotic coverage was broadened to Azithromycin/Vancomycin and Zosyn. on [**9-30**] pt went into acure on chronic renal failure though due to being prerenal and ATN, and required hemodialysis. Pt continued to require ventilatory support without much improvement and brochoscopy was performed but unhelpful. Chest CT revealed fibrotic changes consistent with a chronic fibrotic process, unlikely to resolve in the near future. After 9 days of hemodialysis treatment the Renal team felt that his chances for renal recovery was unlikely. On [**2101-10-3**] a family meeting was held with the pt's wife, his PCP [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1007**], MICU attending Dr. [**Last Name (STitle) 99878**], and the renal team to discuss prognosis. The family decided to make the pt DNR/DNI but to see how he progressed over the next few days. The pt showed no improvement in his respiratory failure or renal recovery so a second family meeting was held on [**2101-10-7**] with the same parties present except for the Renal team and it was decided to make the pt comfort measures only with morphine for respiratory distress. The pt was pronounced on [**2101-10-8**] at 3am. Family requested that no post-mortem be performed. Medications on Admission: 1.Flomax 0.4 mg PO QD 2. Celexa 20 mg PO QD 3. Ranitidine 150 mg PO QD 4. Sinemet 25/100 mg SR 1 tab PO TID 5. Sinemet 50/200 SR 1 tab PO qpm 6. Levofloxacin 250 mg PO QD 7. Mirapex 0.125 mg PO TID 8. Lasix 20 mg PO QD Discharge Disposition: Home with Service Facility: Pt died Discharge Diagnosis: Pneumonia Discharge Condition: dead

[ "428.0", "518.84", "446.4", "486", "332.0", "584.5", "585", "263.9", "515" ]

icd9cm

[ [ [] ] ]

[ "96.72", "89.64", "39.95", "99.04", "38.93", "96.04", "99.15", "96.6", "38.95", "33.24" ]

icd9pcs

[ [ [] ] ]

5894, 5932

3799, 5624

297, 304

5985, 5992

2646, 3776

2199, 2255

5953, 5964

5650, 5871

2270, 2627

216, 259

332, 1661

1683, 2046

2062, 2183

1,982

133,155

20284

Discharge summary

report

Admission Date: [**2166-2-15**] Discharge Date: [**2166-2-21**] Date of Birth: [**2106-6-11**] Sex: M Service: MEDICINE Allergies: Iodine; Iodine Containing / Betadine / Shellfish Attending:[**First Name3 (LF) 54453**] Chief Complaint: S/P fall- Pt presenting from OSH after fall with acute renal failure, GI bleed, and aspiration pneumonia. Major Surgical or Invasive Procedure: 1. Intubation on [**2166-2-16**] 2. EGDs on [**2166-2-16**] and [**2166-2-17**] History of Present Illness: HPI: 59 y/o man with PMH significant for melanoma and esophageal cancern s/p resetion admitted to [**Hospital1 18**] on [**2166-2-16**] with hypotension, renal failure, and a GI bleed. Initially, the pt presented to an OSH s/p a fall onto his right hand onto the ice. Pt denies hitting head and no LOC. At the OSH, he was found to have a creatinine of 11.1, BUN 119, and Hct of 32.5. Head CT was reported as negative. It was noted that ETOH was "smelled" on the pt's breath after the fall although he denies that he was drinking. Of note, he has been maintained on a CIWA scale throughout admission but has not required any ativan per this. On arrival in the [**Hospital1 18**] ED, the pt's VS were 98.8 100 75/47. He was started on dopamine and later propofol for he hyptension. As pt had an episode of BRBPR, NG lavage was done which was positive. Pt was given 1 unit of PRBC, FFP, and DDAVP. He was started on an IV PPI. Pt was found to have striderous breathing and was electively intubated. AT that time, his oxygen saturation is noted as 100% but it is unclear how much oxygen he was on (? 2L NC). He was started on levofloxacin and vancomycin for concern of a aspiration PNA on CXR. Pt was then transferred to the MICU for further care. GI saw the pt on the night of admission. They preformed an upper endoscopy which showed evidence of the previous esophago-gastric anastomosis 15 cm from the incisors in the upper third of the esophagus. There was esophagitis with stigmata of recent bleeding in the upper third of the esophagus. The stomach contained partially digested food. A single nonbleeding 6 mm ulcer could be visualized in the distal stomach. Pt was continued on [**Hospital1 **] IV PPI. The pt's hypotension was initially treated as sepsis. The pt was covered broadly with levo, vanco, and flagyl. It was felt that his infection was secondary to asipraion. Renal was also consulted given the pt's severe acute renal failure. He was felt to be very dry in setting of low Hct. Surgery was also consulted for recommendations on dressing of the pt's neck wound. On [**2-17**], pt was much more stable from a respiratory standpoint. He was kept intubated initially so a repeat EGD could be done. This showed multiple superficial and cratered ulcers in the stomach ranging in size from 3 mm to 12 mm in the body, antrum, and pylorus. A clot suggested recent bleeding on the 2 ulcers near the pylorus. On had a clot adherent and the other was oozing. [**Hospital1 **]-CAP electrocautery was applied with successful hemostasis. The duodenum was normal. Pt's Hct has been stable since this time. He was intubated without problem. The pt did fail [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 104**] stim test done in the unit so he was started on a seven day course of hydrocortisone and fludrocortisone. On [**2-18**], the MICU called the pt out to the floor. He was hemodynamically stable at that time. He had had no further bleeding and Hct was stable. Creatinine was trending down as below. Past Medical History: 1. Amelonotic melanoma of the left shoulder s/p excision [**2-14**]. The sentinal lymph node was negative for metastatic disease. 2. SCC of the left ankle s/p excision. Was metastatic for which the pt received radiation. 3. Esophagela cancer s/p resection 2 months prior to admission. 4. HTN 5. Gout 6. H/O ATN 7. H/O multiple nonmelanoma skin cancers Social History: Pt lives alone at home. He drinks approximately 2 alcoholic drinks per day. No drugs or tobacco. Family History: NC Physical Exam: 98.0 116/80 90 12 95% RA Gen- Alert and oriented. NAD. HEENT- NC AT. EOMI. Anicteric sclera. Mildly dry mucous membranes. No lesions in the oropharynx. Cardiac- RRR. No m,r,g. Pulm- CTAB. No wheezes, rales, or rhonchi. Abdomen- Soft. NT. ND. Positive bowel sounds. Extremities- No c/c/e. 2+ DP pulse on right and 1+ DP pulse on left. Neuro- CN II-SII intact. 5/5 strength in upper and lower extremities bilaterally. Pertinent Results: [**2166-2-15**] 08:10PM BLOOD WBC-7.0 RBC-3.08*# Hgb-8.8*# Hct-27.2*# MCV-88 MCH-28.4 MCHC-32.2 RDW-15.4 Plt Ct-241 [**2166-2-15**] 08:10PM BLOOD Neuts-80* Bands-10* Lymphs-5* Monos-3 Eos-1 Baso-0 Atyps-1* Metas-0 Myelos-0 [**2166-2-15**] 08:10PM BLOOD Hypochr-1+ Anisocy-1+ Poiklo-2+ Macrocy-1+ Microcy-1+ Polychr-NORMAL Ovalocy-1+ Burr-2+ [**2166-2-15**] 08:10PM BLOOD Plt Ct-241 [**2166-2-15**] 08:10PM BLOOD PT-15.9* PTT-33.4 INR(PT)-1.6 [**2166-2-15**] 08:10PM BLOOD Glucose-96 UreaN-113* Creat-9.4*# Na-143 K-5.3* Cl-110* HCO3-16* AnGap-22* [**2166-2-15**] 08:10PM BLOOD ALT-8 AST-15 LD(LDH)-191 CK(CPK)-81 AlkPhos-109 Amylase-56 TotBili-0.3 [**2166-2-15**] 08:10PM BLOOD Lipase-245* [**2166-2-15**] 08:10PM BLOOD CK-MB-NotDone cTropnT-0.04* [**2166-2-15**] 08:10PM BLOOD Albumin-2.7* Calcium-8.5 Phos-7.8*# Mg-1.4* [**2166-2-15**] 08:10PM BLOOD Hapto-290* [**2166-2-16**] 12:31PM BLOOD Cortsol-12.0 [**2166-2-16**] 01:42PM BLOOD Cortsol-15.5 [**2166-2-15**] 08:10PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2166-2-15**] 08:28PM BLOOD Lactate-1.7 [**2166-2-21**] 04:59AM BLOOD WBC-8.9 RBC-3.34* Hgb-9.6* Hct-28.0* MCV-84 MCH-28.8 MCHC-34.2 RDW-15.3 Plt Ct-142* [**2166-2-21**] 04:59AM BLOOD Plt Ct-142* [**2166-2-21**] 04:59AM BLOOD Glucose-112* UreaN-45* Creat-2.1* Na-145 K-3.4 Cl-109* HCO3-30* AnGap-9 [**2166-2-21**] 04:59AM BLOOD Calcium-8.1* Phos-2.9 Mg-1.8 Chest x-ray ([**2-15**]): FINDINGS: There has been interval placement of an endotracheal tube, with tip terminating approximately 2.7-cm above the carina. The heart size and mediastinal contours are unchanged, with gas containing structure and density along the right mediastinal border consistent with a a esophagectomy and pull- through. Heterogeneous contrast is seen within the right lung consistent with aspirated barium. There is new linear opacity at the left base consistent with atelectasis. No pleural effusions or pneumothorax. Osseous structures are unremarkable. IMPRESSION: S/P endotracheal intubation. New plate-like atelectasis at the left base. Otherwise, stable radiograph appearance of the chest. Renal US ([**2-16**]): PORTABLE RENAL ULTRASOUND: The right kidney measures 10 cm in length, and the left kidney measures 10.6 cm in length. No renal masses, stones, or hydronephrosis is seen. No perinephric fluid collections are seen. The bladder was not evaluated. IMPRESSION: No hydronephrosis or renal calculi. CT scan ([**2-20**]): CT OF THE ABDOMEN WITHOUT CONTRAST: There are bilateral pleural effusions, as well as bibasilar atelectasis. A gastric pull-up is seen in the right chest. There are surgical sutures adjacent to this region. On this unenhanced scan, the liver, gallbladder, kidneys, spleen, pancreas, ureters, and adrenal glands are unremarkable. There is a small amount of free fluid in the pericolic gutters, right greater than left. There are calcifications of the descending aorta. There is no evidence of a retroperitoneal hematoma. There are no identified pathologically enlarged lymph nodes in the abdomen. There is a small area of diastasis of the anterior abdominal wall. There is evidence of fluid in the soft tissues consistent with anasarca. No free air in the abdomen. The large and small bowel are unremarkable. CT OF THE PELVIS WITHOUT CONTRAST: There is stranding in the left inguinal soft tissue, which could be post-op as there was prior lymph node dissection in this region. There are multiple air fluid levels in the rectum and distal large bowel, consistent with the recent history of hematochezia. The bladder contains a Foley catheter. There is a small amount of free fluid in the pelvis. There are no pathologically enlarged inguinal lymph nodes. Adjacent to the left iliac bone, medially is a 5.5 x 4.5 cm fluid filled collection, measuring approximately 10 Houndsfield units. This is new from the prior study. According to the referring surgeon, this is consistent with the region of the recent post-surgical procedure in this region. There are bilateral fat containing inguinal hernias. BONE WINDOWS: No suspicious osteolytic or sclerotic lesions. REFORMATTED IMAGES: These show no definite bowel dilatation. IMPRESSION: 1) Although the colon is not distended with contrast, there are no detected mass lesions. The air fluid levels are consistent with the history of hematochezia. 2) Left pelvic mass medial to the left iliac bone, consistent with a post-op seroma. The less likely possibilities include a new mass, or sequella of an old hematoma. 3) Left inguinal stranding, likely post-surgical, although a small hematoma in this region is not excluded. Clinical correlation recommended. 4) Bilateral pleural effusion. KUB ([**2-20**]): Distribution of bowel gas is unremarkable with gas present throughout the colon and in the rectum and no evidence for intestinal obstruction. Surgical clips are present in the left upper quadrant. Multiple irregular radiodensities overlie the right lower hemithorax location undetermined but seen in both films possibly aspirated barium. Brief Hospital Course: 59 y/o man with PMH significant for melanoma and esophageal cancern s/p resetion admitted to [**Hospital1 18**] on [**2166-2-16**] with hypotension, renal failure, and a GI bleed. Initially was cared for in the MICU but was transferred to the floor on [**2-18**] as was clinically stable. Floor course was complicated by a small amount of BRBPR and increased abdominal pain. Now with decreased pain. Will transfer to [**Hospital6 **] for further care by his surgery team and oncologist. 1. GI bleed- Appreciate GI input. Pt had an episode of BRBPR in the ED on arrival at [**Hospital1 18**]. At that time, his NG lavage was pink tinged. His Hct was slightly below baseline and the pt recieved 2 units of PRBC. GI was consulted and the pt had EGDs on [**2-16**] and [**2-17**]. The first test was limited as the stomach was filled with food. On the second EGD, multiple ulcers were visualized in the stomach. Two were actively bleeding and these were cauterized. Please see copies of the complete reports in the transfer paperwork. Following the second EGC, the pt's Hct remained stable and he had no further bleeding until [**2-19**]. At that time, he had a small amount of BRBPR associated with abdominal pain. NG lavage at that time was negative. However, the pt's Hct remained stable and he was hemodynamically stable. He had no further bleeding during the rest of the hospitalization and this was felt to be most likely due to a hemorrhoid. He subsequently had two formed, nonbloody stools. Serial Hcts were followed throughout admission. Pt was maintained on a [**Hospital1 **] PPI. 2. Abdominal pain- Pt developed abdominal pain and nausea on the morning of [**2-19**]. At that time, his abdomen was soft without rebound or gaurding. He had normal bowel sounds. However, that evening, the pt's pain became more severe and he vomiting a large amount of nondigested food and bile. Pt had mild rebound and decreased bowel sounds. A KUB was obtained that did not show obstruction or free air. The following day, the pt recieved a CT of his abdomen following IV fluids and mucomyst given his acute renal failure. Results are as above. They are significant for surgical changes but did not show a clear etiology of his abdominal sympoms. Pt was followed by GI and surgery. GI did not feel that further scopes were indicated. Surgery talked to the pt's surgery team at [**Hospital1 2177**] and plans were made to further asses him at that institution. By [**2-21**], the pt's abdominal pain was much improved. 2. Renal failure- Pt presented to the hospital with acute renal failure with an initial creatinine of 9.4. This was thought to be secondary to volume depletion secondary to dehydration and bleeding. Renal followed thorughout the pt's hospitalizaion. The pt improved dramatically early in the admission with IV fluids and his creatinine has continued to trend down since that time. Renal US on [**2-16**] showed no renal calculi, obstruction, or hydronephrosis. Creatinine at this time has trended down to 2.1. Of note, the pt's bicarb was low on [**2-18**] at 14. He received a total of three liters of D5W with 2 amps of bicarb. His HCO3 corrected with this and has been stable since. 3. [**Name (NI) **] Pt was hypotensive and febrile on admission. He had a CXR which showed aspiration of barium in the right lung. At that time, pt was started on treatment for probable aspiration PNA with levo, flagyl, and vanco. His sputum culture from [**2-16**] and [**2-17**] grew methicillin resistant coag positive staph aureus. Blood cultures are pending no growth to date. The pt remained afebrile and his WBC count trended down during admission. Given this, the pt's vancomycin was discontinued on [**2-20**] as it was felt that the MRSA was conlinizaion. Pt was continued on levo and flagyl with plans for a 10 day course. The pt is currently day 7 of 10. 4. HTN- Holding all BP meds at this time given recent hypotension in setting of infection and GI bleed. They most likely can be restarted in the near future depending on what type of surgery intervention the pt has at [**Hospital1 2177**]. 5. [**Name (NI) 53769**] Pt with history of multiple skin cancers and esophageal s/p excision two months ago. His oncologist is Dr. [**Last Name (STitle) **] at [**Hospital1 2177**]. In addition, all of his oncologic surgeries have occurred there. He is not getting any chemo or radiation at this time. Pt will be transferred to [**Hospital1 2177**] at this time for further care. 6. Relative [**Name (NI) 104**] insufficient- Pt'[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 104**] stem test showed a relative insufficiency on admission. At that time, he was started on a 7 day course of hydrocortisone and flornef. Pt is currently day 5 of 7. 7. FEN- Speech and swallow evaluated the pt on [**2-18**]. His recommended diet is thin liquids and ground solids. Pt should set bolt upright for all POs, should not use straws, should use chin tuck method, and should not have mixed consistencies. All meds should be broken in puree. However, he has been NPO since [**2-19**]. Agressive electrolyte replacement throughout admission. 8. Proph- PPI; pneumoboots; bowel regimen. Of note, pt was initially on a CIWA scale for possible ETOH withdrawal but did not requird any medicaion. 9. [**Name (NI) 54454**] PT, OT, and social work (question ETOH abuse) ordered today.. 10. [**Name (NI) 11053**] Pt will be transferred to [**Hospital6 **] for further surgery and oncology care. Medications on Admission: Medications on Transfer: 1. Metronidazole 500 mg IV Q12H 2. Levofloxacin 250 mg IV Q48H 3. Hydrocortisone 50 mg IV Q6H for 7 day total course 4. Fludrocortisone 0.05 mg daily 5. Ativan PRN 6. Pantoprazole 40 mg PO Q12H 7. Vancomycin by level- last dose was on morning of [**2-18**] Discharge Medications: 1. Fludrocortisone Acetate 0.1 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily) for 2 days. 2. Trazodone HCl 50 mg Tablet Sig: 0.25 Tablet PO HS (at bedtime) as needed. 3. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 5. Metronidazole in NaCl (Iso-os) 500 mg/100 mL Piggyback Sig: Five Hundred (500) mg Intravenous Q12H (every 12 hours) for 3 days. Disp:*3000 mg* Refills:*0* 6. Hydrocortisone Sod Succinate 100 mg/2 mL Recon Soln Sig: Fifty (50) mg Injection Q6H (every 6 hours) for 2 days. 7. Levofloxacin in D5W 250 mg/50 mL Piggyback Sig: Two Hundred Fifty (250) mg Intravenous Q24H (every 24 hours) for 3 days. 8. Pantoprazole 40 mg IV Q12H Discharge Disposition: Extended Care Facility: [**Hospital6 **] TCU - [**Location (un) 86**] Discharge Diagnosis: Primary diagnosis: Acute renal failure Secondary diagnosis: Aspiration pneumonia GI bleed S/P fall Esophageal cancer s/p resection Hypertension Discharge Condition: Stable. Pt with oxygen saturation in the mid to high 90s on room air. Hct stable. Discharge Instructions: 1. Please take all medications as prescribed. 2. Please keep all follow up appointments. 3. Seek medical attention for fevers, chills, chest pain, shortness of breath, decreased urine output, blood in your stools, or any other concerning symptoms. Followup Instructions: Pt is being transferred to [**Hospital6 **] for further care as this is where his oncologist and surgeon are located. 1. Follow up with your primary care physician [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] within two weeks of discharge from [**Hospital1 2177**]. 2. Follow up with the surgery service and oncology at [**Hospital 2082**] per their directions.

[ "038.9", "V10.82", "V10.03", "507.0", "518.81", "531.40", "995.92", "401.9", "584.9", "785.52", "274.9", "285.1", "276.5" ]

icd9cm

[ [ [] ] ]

[ "96.71", "00.17", "96.04", "99.07", "38.93", "99.04", "45.13", "44.43" ]

icd9pcs

[ [ [] ] ]

16218, 16290

9601, 15100

416, 499

16479, 16562

4515, 9578

16860, 17241

4056, 4060

15432, 16195

16311, 16311

15126, 15126

16586, 16837

4075, 4496

271, 378

527, 3551

16372, 16458

16330, 16351

15151, 15409

3573, 3926

3942, 4040

5,392

115,425

25471

Discharge summary

report

Admission Date: [**2109-8-23**] Discharge Date: [**2109-9-5**] Date of Birth: [**2028-12-14**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 5547**] Chief Complaint: Abdominal pain Major Surgical or Invasive Procedure: Open cholecystectomy and intraoperative cholangiogram History of Present Illness: This is a 80 year old who presented to the ED with abdominal pain. He complains of nausea and vomiting and diarrhea. Th pain is worse in the RUQ. He can only eat small amounts. He denies chest pain, has no SOB. He reports falling 2 days ago and being unable to get up. It is unclear if he had LOC. He does not have headaches or weakness. He also reports no dysuria, but discolored urine. Past Medical History: Afib HTN Deaf/mute Falls Social History: Independent with ADLs. Brother and other family members nearby and available. Family History: NC Physical Exam: VS: 99.2, 126, 122/72, 16, 98% RA Gen: NAD, alert, awake, responsive, able to answer questions, read statements and follow commands. He is a poor historian despite sign language services. Head: PERRLA, EOMI, + scleral icterus, obvious jaundice. Right eye with bruising laterally CV: irregular, irregular tachy rhythm Chest: clear to auscultation bilat. Abd: soft, nontender, nondistended, no hepatosplenomegaly, old healed scars at midline and right inguinal hernia. Pertinent Results: CHEST (PA & LAT) [**2109-8-23**] 2:06 PM CHEST (PA & LAT) Reason: rib fracture? pneumo? [**Hospital 93**] MEDICAL CONDITION: 80 year old man with fall REASON FOR THIS EXAMINATION: rib fracture? pneumo? INDICATION: Assessment for rib fracture or pneumonia in a patient with fall. TECHNIQUE: PA and lateral view of the chest. Comparison available from [**2108-8-20**]. FINDINGS: Heart, mediastinal, and hilar contours are normal. Right lung is clear. Left lung has basilar atelectasis and pleural thickening. There is no pleural effusion. The remainder of left lung is clear. IMPRESSION: Atelectasis and pleural thickening in basilar portion of left lung. Otherwise, normal study. ABDOMEN U.S. (COMPLETE STUDY) Reason: cholecystitis? cholelithiasis? [**Hospital 93**] MEDICAL CONDITION: 80 year old man with jaundice and RUQ pain REASON FOR THIS EXAMINATION: cholecystitis? cholelithiasis? INDICATION: Jaundice and right upper quadrant pain. Question cholecystitis. COMPARISON: [**2109-2-20**]. FINDINGS: There is marked edema, hyperemia, and a ragged appearance of the gallbladder wall. The gallbladder is mildly/moderately distended with multiple gallstones. There is trace pericholecystic fluid. There is no intrahepatic ductal dilation, and the proximal common bile duct measures 6 mm. Extrahepatically, the common bile duct dilates to 12 mm. The common bile duct is not visualized adequately throughout its course, and the evaluation for stones is not reliable. The pancreatic duct measures 3 mm. The proximal pancreas appears normal. There is a focal area of gallbladder wall thickening measuring 14 x 8 mm. This likely represents an area of adenomyoma (malignancy is less likely, but also a diagnostic consideration). The right kidney measures 10.7 cm and contains a 7-mm echogenic focus in the lower pole of the right kidney. Shadowing indicates this to be a nonobstructing stone. Previously described 5-mm angiomyolipoma in the lower pole is not clearly seen. The left kidney measures 10.6 cm. The spleen is not enlarged. IMPRESSION: 1. Acute cholecystitis with gallbladder stones, thickened and edematous gallbladder wall. 2. A focal area of gallbladder wall thickening is most likely adenomyoma, but malignancy is a diagnostic consideration. 3. Right lower pole nonobstructing stone. CT HEAD W/O CONTRAST [**2109-8-23**] 3:27 PM CT HEAD W/O CONTRAST Reason: bleed? [**Hospital 93**] MEDICAL CONDITION: 80 year old man with fall REASON FOR THIS EXAMINATION: bleed? CONTRAINDICATIONS for IV CONTRAST: None. INDICATION: Fall. COMPARISON: None. TECHNIQUE: Non-contrast axial head CT. FINDINGS: There is no evidence for intracranial hemorrhage. There is no mass effect or shift of normally midline structures. The ventricles, cisterns, and sulci maintain a normal configuration. There is atherosclerotic calcification of the cavernous carotids. The osseous structures are unremarkable without evidence for fracture. The visualized paranasal sinuses are clear. The mastoid air cells are clear. The patient is edentulous. Note is made of a left phthisis bulbi. IMPRESSION: No intracranial hemorrhage. CT ABDOMEN W/CONTRAST [**2109-8-23**] 3:28 PM CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Reason: divertic? soild organ damage? free fluid? Field of view: 36 Contrast: OPTIRAY [**Hospital 93**] MEDICAL CONDITION: 80 year old man with abd pain s/p fall REASON FOR THIS EXAMINATION: divertic? soild organ damage? free fluid? CONTRAINDICATIONS for IV CONTRAST: None. INDICATION: Abdominal pain, status post fall. COMPARISON: [**2109-1-10**]. TECHNIQUE: Contrast-enhanced axial CT imaging of the abdomen and pelvis was reviewed. CT ABDOMEN WITH CONTRAST: There is a small left pleural effusion and associated atelectasis. The liver enhances without suspicious lesions. The gallbladder is distended with gallbladder wall thickening and multiple stones. Please see ultrasound report from the same day for further details. The pancreas, spleen, stomach, small bowel loops are unremarkable, and there is no free air, free fluid, or pathologic adenopathy. CT PELVIS WITH CONTRAST: There is a very mild bowel wall thickening of the colon that is nonspecific, and may be related to its collapsed state. There is diverticulosis of the sigmoid colon. There is a 4-mm thin rectangular metallic object in the deep pelvis, unchanged. The kidneys enhance and excrete normally. Bilateral inguinal hernias, the left containing small bowel loops, and the right containing a small amount of free fluid is unchanged. Note is made of a giant sigmoid diverticulum. BONE WINDOWS: No suspicious lesions are identified. IMPRESSION: 1. Moderately distended gallbladder with gallbladder wall thickening and multiple gallstones, most consistent with acute cholecystitis. For further information, please see the ultrasound report from same day. 2. No evidence for bowel obstruction or traumatic injury. 3. Bilateral inguinal hernias containing free fluid and small bowel loops. 4. Small left pleural effusion. Atrial fibrillation with slow ventricular response Read by: [**Last Name (LF) 2889**],[**First Name3 (LF) 2890**] K. Intervals Axes Rate PR QRS QT/QTc P QRS T 59 0 90 444/441.72 0 26 21 PATIENT/TEST INFORMATION: Indication: r/o Myocardial infarction. Weight (lb): 150 BP (mm Hg): 120/80 Status: Inpatient Date/Time: [**2109-8-29**] at 14:18 Test: TTE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Tape Number: 2006W030-0:00 Test Location: West Echo Lab Technical Quality: Adequate REFERRING DOCTOR: DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] MEASUREMENTS: Left Atrium - Long Axis Dimension: *4.5 cm (nl <= 4.0 cm) Left Atrium - Four Chamber Length: *5.8 cm (nl <= 5.2 cm) Right Atrium - Four Chamber Length: *6.5 cm (nl <= 5.0 cm) Left Ventricle - Septal Wall Thickness: 1.1 cm (nl 0.6 - 1.1 cm) Left Ventricle - Inferolateral Thickness: 1.0 cm (nl 0.6 - 1.1 cm) Left Ventricle - Diastolic Dimension: 4.1 cm (nl <= 5.6 cm) Left Ventricle - Systolic Dimension: 2.6 cm Left Ventricle - Fractional Shortening: 0.37 (nl >= 0.29) Left Ventricle - Ejection Fraction: >= 60% (nl >=55%) Aorta - Valve Level: 3.4 cm (nl <= 3.6 cm) Aorta - Ascending: 3.0 cm (nl <= 3.4 cm) Aortic Valve - Peak Velocity: 1.6 m/sec (nl <= 2.0 m/sec) Mitral Valve - E Wave: 1.1 m/sec TR Gradient (+ RA = PASP): *20 to 28 mm Hg (nl <= 25 mm Hg) INTERPRETATION: Findings: LEFT ATRIUM: Mild LA enlargement. RIGHT ATRIUM/INTERATRIAL SEPTUM: Moderately dilated RA. LEFT VENTRICLE: Mild (non-obstructive) focal hypertrophy of the basal septum. Normal LV cavity size. Overall normal LVEF (>55%). RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Normal aortic root diameter. Normal ascending aorta diameter. AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild (1+) MR. TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Physiologic TR. Borderline PA systolic hypertension. PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with physiologic PR. PERICARDIUM: No pericardial effusion. Conclusions: The left atrium is mildly dilated. The right atrium is moderately dilated. There is mild (non-obstructive) focal hypertrophy of the basal septum. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is borderline pulmonary artery systolic hypertension. There is no pericardial effusion. CHEST (PORTABLE AP) [**2109-8-30**] 8:45 PM CHEST (PORTABLE AP) Reason: eval for change [**Hospital 93**] MEDICAL CONDITION: 80 year old man s/p open CCY w/ acute desaturation. REASON FOR THIS EXAMINATION: eval for change INDICATION: Status post cholecystectomy with acute desaturation. TECHNIQUE: AP radiograph of the chest, compared with examination of [**2109-8-23**]. FINDINGS: Cardiac and mediastinal silhouettes remain unchanged. There is increase in retrocardiac opacity since the prior examination. There is persistence of pleural thickening and atelectasis at the left base. Pulmonary vascularity is slightly more prominent than the prior examination, more so on the left than right. Linear tubular lucency seen inferior to the heart is compatible with postoperative intraabdominal free air, status post open cholecystectomy. IMPRESSION: 1. Retrocardiac opacity and slight left lobe opacity, possibly representing atelectasis/volume loss in a postoperative patient. 2. Left-sided pleural effusion and pleural thickening. RADIOLOGY Preliminary Report CHOLANGIOGRAM,IN OR W FILMS [**2109-8-30**] 4:35 PM CHOLANGIOGRAM,IN OR W FILMS Reason: CHOLANGIGRAM-CHECK DUCTS INDICATION: Intraoperative cholangiogram. COMPARISONS: None. FINDINGS: A single fluoroscopic spot image obtained during recent intraoperative cholangiogram obtained without a radiologist present is submitted for review. This image demonstrates opacification of the cystic duct and common bile duct with no evidence of stones, other filling defects, extrinsic compression or structural ductal abnormalities. Contrast is seen draining into the duodenum. RADIOLOGY Final Report CHEST (PORTABLE AP) [**2109-8-31**] 6:21 AM CHEST (PORTABLE AP) Reason: eval for aspiration/pneumonia [**Hospital 93**] MEDICAL CONDITION: 80 year old man s/p open CCY w/ acute desaturation, now s/p intubation. REASON FOR THIS EXAMINATION: eval for aspiration/pneumonia INDICATION: Cholecystectomy, acute desaturation, evaluate for aspiration or pneumonia. SINGLE AP RADIOGRAPH: Compared with examination performed 22:49 on [**2109-8-30**]. FINDINGS: Tip of the endotracheal tube remains approximately 3 cm above the carina. Abdominal free air remains evident. The cardiac and mediastinal silhouettes remain unchanged. The aeration of the left and right lungs is essentially unchanged when compared with the prior examination. There is persistent blunting of the left costophrenic angle, similar in morphology to the preoperative examination of [**2109-8-23**], and likely representing pleural thickening. Persistent mild increase in opacity at the left lung base may represent a mild effusion versus atelectasis. No new opacities are present to suggest aspiration. [**2109-8-23**] 1:40 pm BLOOD CULTURE **FINAL REPORT [**2109-8-26**]** AEROBIC BOTTLE (Final [**2109-8-26**]): [**2109-8-24**] REPORTED BY PHONE TO [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 63655**] AT 7:15 AM. ESCHERICHIA COLI. IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE # [**Numeric Identifier 63656**] [**2109-9-2**]. ANAEROBIC BOTTLE (Final [**2109-8-26**]): ESCHERICHIA COLI. IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE # [**Numeric Identifier 63656**] [**2109-8-23**]. [**2109-8-25**] 1:42 am BLOOD CULTURE Site: ARM 1 OF 2. **FINAL REPORT [**2109-8-31**]** AEROBIC BOTTLE (Final [**2109-8-31**]): NO GROWTH. ANAEROBIC BOTTLE (Final [**2109-8-31**]): NO GROWTH. Brief Hospital Course: He was admitted to [**Hospital1 18**] on [**2109-8-23**]. An US showed acute cholecystitis with gallbladder stones and a CT confirmed a moderately distended gallbladder with gallbladder wall thickening and multiple gallstones, most consistent with acute cholecystitis. A head CT was performed due to his fall injury and was negative. GI: An ERCP on [**2109-8-24**] showed the major papilla appeared patulous suggesting recent stone passage. Cannulation of the biliary duct was successful and deep with a sphincterotome using a free-hand technique. He was placed on intravenous antibiotics and bowel rest. The patient was monitored expectantly until his pancreatic enzymes normalized. A cholecystectomy was next performed. He did well from a surgical standpoint and his diet was slowly advanced over the next few days. He was tolerating a diet and had +flatus and +BM prior to discharge. Resp: s/p open cholecystectomy on [**2109-8-30**], he was difficult to arouse and dropped his Os sats to the 50s. He was reintubated at the bedside. The next day he was extubated and doing well. Abd: His abdomen remained soft, slightly tender along the incision line and non-distended. His staples remained in place and will be D/C'd at his follow-up appointment. Pain: He was started on a PCA and his pain was well controlled. Once tolerating a PO diet, he was started on Percocet. ID: A blood culture on [**2109-8-23**] was positive for ESCHERICHIA COLI and he was started on Levo and Flagyl. A repeat blood culture on [**2109-8-25**] showed no growth. CV: A-fib. He received Lopressor and Diltiazem for rate control. His INR was 2.0 and he received 6 units of fresh frozen plasma prior to surgery. His Coumadin was held and he was on a heparin drip for anticoagulation prior to surgery. Coumadin was restarted POD 3. A trigger was called for A-fib with a rate of 157 POD 4. He was given his Toprol XL 200 mg and started back on Diltiazem 240 mg. His rate stabilized in the 80's. Physical Therapy: PT recommended home with physical therapy and VNA was arranged. Medications on Admission: coumadin 1', Atorvastatin 40', Diltiazem SR 240', Toprol XL 200' Discharge Medications: 1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed for 4 weeks. Disp:*40 Tablet(s)* Refills:*0* 2. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Metoprolol Succinate 100 mg Tablet Sustained Release 24HR Sig: Two (2) Tablet Sustained Release 24HR PO DAILY (Daily). 4. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QIDACHS (4 times a day (before meals and at bedtime)). Disp:*qs Tablet(s)* Refills:*2* 5. Diltiazem HCl 240 mg Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO DAILY (Daily). 6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 7. Warfarin 5 mg Tablet Sig: One (1) Tablet PO once a day for 2 weeks: Please have your blood drawn and monitor your INR. Follow-up with Dr. [**Last Name (STitle) 5351**] for your Warfarin dose. Disp:*14 Tablet(s)* Refills:*0* 8. Outpatient Lab Work VNA - please check INR on Friday and inform Dr. [**Last Name (STitle) 5351**] [**Telephone/Fax (1) 608**] of the results. 9. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: Acute cholecystitis and gallstone pancreatitis Discharge Condition: Good Discharge Instructions: You may resume your regular medications. Take all new medications as directed. You may resume your regular diet. You may shower. Allow water to run over the wound and pat dry. No baths for 2 weeeks. * Increasing pain * Fever (>101.5 F) * Inability to eat or persistent vomiting * Inability to pass gas or stool * Other symptoms concerning to you Followup Instructions: Please follow-up with Dr. [**Last Name (STitle) 1924**]. Provider: [**Last Name (NamePattern4) **]. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] Phone:[**Telephone/Fax (1) 1927**] Date/Time:[**2109-9-10**] 11:00 Completed by:[**2109-9-5**]

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38204

Discharge summary

report

Admission Date: [**2102-7-9**] Discharge Date: [**2102-7-14**] Date of Birth: [**2026-3-27**] Sex: M Service: MEDICINE Allergies: Keflex Attending:[**First Name3 (LF) 2751**] Chief Complaint: petechiae Major Surgical or Invasive Procedure: None History of Present Illness: 76 yo man with DM, HTN, PVD s/p left toe amputation and L iliac stent in [**4-/2102**] c/b large RP bleed, prostate cancer s/p prostatectomy, hx of prior DVT ([**3-/2102**] [**Name8 (MD) **] MD report) on coumadin and chronic left foot wound who presented to [**Hospital1 18**] with petechia/bruising x 1 day in setting of starting keflex at rehab and was found to have profound TP and anemia. . He was admitted to the floor o/n, with normal BPs and HR in 100s, and was found to have continuing dropping HCT 29 on admission -> 23 -> 1UPRBC -> 19.9 in setting of severe thrombocytopenia. Initial evaluation in the ED for DIC was negative (see hematology note) and he was felt to have either drug induced TP, ITP or HIT (no evidence of thromboses). He was started on Prednisone 50mg given 4U FFP and 5mg Vit K to reverse the INR (3.7->2.0). This morning, HCT continued to drop as above despite PRBC transfusions, he is thus being transferred to MICU for further care. Of note, he has had guaiac positive stools but no melena or hematochezia. Per discussion with patient and Admission notes, he was in USOH at rehab until AM of admission, when he noticed small red dots all over his legs, which proliferated through the day. He also noted slight bleeding from his mouth/lips. He was initially taken [**Hospital 8125**] Hospital, then transferred to [**Hospital1 18**] for further evaluation. . "Recent medication changes include recent initiation of Keflex (for leg ulcer) which was started on [**7-7**]. Further, heparin was DCd on [**6-23**]. Otherwise he denies any recent sick contacts. [**Name (NI) **] exposure to ticks or recent bug bites." . At time of MICU resident evaluation, he had no complaints, other than wanting to go home. Denied pain, blood stools, hemoptysis, abodminal distension. He did not feel he was confused, but could not perform calculations or attention tasks. He has no HA, vision changes, numbness, but states that Right leg has had different sensation over the past few weeks. Per ROS on admission: refer to admission note. . "In the ED initial vitals, Temp: Not recorded, 91 120/74 18 94. Heme/Onc and vascular consults were obtained. Vascular was asked to evalute the lower extremity ulcer for possible osteomyeleitis and intervention - found pulses palpable with doppler, recommended non invasive lower extremity studies and antibiotics (Vanc, Cipro, Flagyl). Heme reviewed peripheral smear which did not reveal schistocytes and thought this to be secondary to drug reaction or ITP and advised to wait on transfusing plt, reverse INR, and start prednisone 50mg Daily." Past Medical History: -DM: diet-controlled, not insulin-dependent -chronic L foot ulcer (per OSH records, cx'ed Pseudomonas and MRSA on [**6-30**]: PA sensitive to cefepime and amikacin; MRSA sensitive to Bactrim, gent, vanc, rifampin) -HTN -CAD: [**3-/2102**] MIBI from OSH showed 53% EF, small inferior scar w/ minimal peri-infarct ischemia -PVD sp left toe ([**1-3**]) amputation ([**2102-4-29**] - [**Hospital3 **]), s/p L -iliac stent c/b RP bleed while on AC. -Prostate cancer sp prostatectomy ([**2056**]) - ? Hx of prior DVT, ? on coumadin for this though no documentation of DVT at OSH records. -Chronic Left Foot Wound -AAA < 3cm, intra-abdominal -ischemic colitis [**2095**] -HL -carries a diagnosis of mild dementia (per son no dementia, since starting dilaudid has seen the changes). Social History: Was at rehab. Used to work as a photographer. Widowed last [**Month (only) **]. - Tobacco: 10 cigs/day - Alcohol: denies. - Illicits: denies. Family History: NC. Physical Exam: General: Alert, oriented, inattentive. HEENT: Sclera anicteric, dMM, palatal petechiae, tobacco stain on mustache Neck: supple, no JVD. no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: RR, normal S1 + S2, [**2-4**] SM at 2RICS. Abdomen: soft, non-tender, non-distended, bowel sounds present, no splenomegaly Ext: warm, dry, well perfused on R. Left foot dressed. Petechiae throughout, predominantly in LEs, but also on abdomen, chest arms and face. Pertinent Results: Admission lab results: [**2102-7-9**] 08:20PM RET AUT-1.4 [**2102-7-9**] 08:20PM FIBRINOGE-481* [**2102-7-9**] 08:20PM PT-35.6* PTT-31.5 INR(PT)-3.7* [**2102-7-9**] 08:20PM PLT SMR-RARE PLT COUNT-<5* [**2102-7-9**] 08:20PM HYPOCHROM-1+ ANISOCYT-NORMAL POIKILOCY-1+ MACROCYT-NORMAL MICROCYT-1+ POLYCHROM-NORMAL SPHEROCYT-OCCASIONAL OVALOCYT-OCCASIONAL SCHISTOCY-OCCASIONAL BITE-OCCASIONAL [**2102-7-9**] 08:20PM NEUTS-76.1* LYMPHS-16.7* MONOS-4.9 EOS-1.6 BASOS-0.6 [**2102-7-9**] 08:20PM WBC-13.1* RBC-3.22* HGB-9.9* HCT-28.9* MCV-90 MCH-30.9 MCHC-34.4 RDW-14.2 [**2102-7-9**] 08:20PM HAPTOGLOB-214* [**2102-7-9**] 10:54PM D-DIMER-550* Platelet levels: [**2102-7-9**] 08:20PM BLOOD Plt Smr-RARE Plt Ct-<5* [**2102-7-10**] 11:21AM BLOOD Plt Smr-RARE Plt Ct-5* [**2102-7-10**] 01:35PM BLOOD Plt Ct-99*# [**2102-7-10**] 03:19PM BLOOD Plt Ct-78* [**2102-7-10**] 08:28PM BLOOD Plt Ct-81* [**2102-7-11**] 01:27AM BLOOD Plt Ct-62* [**2102-7-11**] 09:30PM BLOOD Plt Ct-49* [**2102-7-12**] 12:16AM BLOOD Plt Ct-90*# [**2102-7-12**] 08:27AM BLOOD Plt Ct-110* [**2102-7-12**] 10:25PM BLOOD Plt Ct-86* [**2102-7-13**] 06:04AM BLOOD Plt Ct-97* [**2102-7-14**] 01:15AM BLOOD Plt Ct-159# [**2102-7-14**] 05:43AM BLOOD Plt Ct-223 Lab results at discharge: [**2102-7-14**] 05:43AM BLOOD WBC-13.9* RBC-3.61* Hgb-10.8* Hct-31.6* MCV-88 MCH-29.8 MCHC-34.0 RDW-16.1* Plt Ct-223 [**2102-7-14**] 05:43AM BLOOD Glucose-107* UreaN-22* Creat-0.8 Na-142 K-3.9 Cl-107 HCO3-30 AnGap-9 [**2102-7-14**] 05:43AM BLOOD Calcium-9.6 Phos-3.0 Mg-2.1 CT Abdomen and Pelvis from [**2102-7-9**]: IMPRESSION 1. Moderate sized retroperitoneal hematoma involving the right psoas and iliopsoas muscle. An additional fluid collection within the retroperitoneum abutting the transversalis muscle on the right also likely represents a separate site of hematoma given the clinical history. 2. 3-cm infrarenal abdominal aortic aneurysm. No evidence of active bleeding. 3. Small right pleural effusion. Scattered centrilobular nodules, tree-in-[**Male First Name (un) 239**] opacities, and mild bronchial wall thickening all suggestive of underlying infectious bronchiolitis, possibly aspiration related. Given size and appearance a followup CT in three to six months can be obtained to document resolution after appropriate treatment. 4. Prominent pancreatic duct and common bile duct with no obstructive mass lesions seen. While this may reflect underlying ampullary stenosis, differential diagnostic considerations for the dilated pancreatic duct includes main branch IPMT. If alteration in care will occur, can consider correlation with MRCP or ERCP. 5. Left adrenal adenoma. Moderate-to-severe sigmoid diverticulosis with no findings of acute diverticulitis. 6. Probable Paget's disease of left iliac [**Doctor First Name 362**]. [**2102-7-14**] 05:43AM BLOOD WBC-13.9* RBC-3.61* Hgb-10.8* Hct-31.6* MCV-88 MCH-29.8 MCHC-34.0 RDW-16.1* Plt Ct-223 [**2102-7-14**] 01:15AM BLOOD WBC-15.2* RBC-3.56* Hgb-10.9* Hct-30.7* MCV-86 MCH-30.7 MCHC-35.6* RDW-16.1* Plt Ct-159# [**2102-7-13**] 06:04AM BLOOD WBC-13.5* RBC-3.41* Hgb-10.5* Hct-29.5* MCV-86 MCH-30.8 MCHC-35.6* RDW-15.9* Plt Ct-97* [**2102-7-14**] 05:43AM BLOOD Glucose-107* UreaN-22* Creat-0.8 Na-142 K-3.9 Cl-107 HCO3-30 AnGap-9 Brief Hospital Course: # RETROPERITONEAL BLEED (RP BLEED), SPONTANEOUS The patient came in with a low hematocrit around 30, from a previous level of 41. Upon admission to the floor, the patient's Hct dropped from 28.9 to 23.3 on [**2102-7-10**]. The patient was noted to have a severe, normocytic anemia. There was no evidence of hemolysis: per Heme, no sign of hemolysis on smear, labs not suggestive of hemolysis. Aspirin and coumadin were held and the patient was given vitamin K and fresh frozen plasma. A CT scan on [**2102-7-10**] showed a large fluid collection in the right transversalis muscle measuring 6.9 cm (AP) x 3.4 cm (transverse) x 13.1 cm (CC), most consistent with a retroperitoneal hematoma. He was seen by vascular surgery, who given his hemodynamic stability, felt that he should be managed conservatively. His retic was 1.4, an inappropriately low response in setting of a severe anemia, implicating involvement of the BM. The patient was transfused 2 units of pRBC on [**2102-7-11**] with an appropriate bump in Hct to 28.2. The patient's Hct remained stable subsequently without need for further transfusion. # THROMBOCYTOPENIA, ACUTE: The patient arrived with severe thrombocytopenia, with a plt count less than 5K. There was no evidence of DIC. The differential included ITP and drug-induced thrombocytopenia. The patient was started on prednisone 100 MG daily. A Coomb's test was negative. The HIT Ab came out as being mildly positive (patient had Hx of hep on [**6-27**] at rehab), but the likelihood of having HIT was deemdd low. Per consult with hematology, the picture was inconsistent with HIT, as platelet levels hardly ever go below 20-30K. The patient was transfused with a goal plt count of > 50. He received one unit of platelets on [**7-11**] with a bump in platelet levels to 91K. His platelet response afterwards was robust, with his platelets increasing to 226K on discharge. It is unclear whether he had ITP or drug-induced thrombocytopenia. He should avoid Keflex, other cephalosporins and, likely, other beta-lactams unless he is in a highly supervised setting, in case this is a drug reaction. He should taper off prednisone slowly under the care of a hematologist (being set-up at this time), with 60mg of prednisone daily for 2 weeks and decreasing slowly afterwards, in case this is ITP. He recevied the pneumovax and meningococcal vaccines. An HIV test was negative. # Coagulopathy: The patient was found to have an elevated INR to 3.7 upon admission. Per history from an outside surgeon, the patient was on coumadin for a presumed, acute occlusion of the left foot that led to ulcerations. The coumadin was held in the ED, and the patient was given 4 units of FFP and was reversed with vitamin K (5MG). The INR drifted downwards during admission, and eventually reached 1.1 by the time he was called out to the floor. Per discussion with outside surgeon, the coumadin was to be held until further evaluation for the need of anticoagulation. This discussion should be re-evaluated by his primary care doctor or his surgeons at [**Hospital6 33**]. # PERIPHERAL VASCULAR DISEASE (PVD) WITH CRITICAL LIMB ISCHEMIA remity Ulcer: S/p amputation of toes [**1-3**]. Pulses dopplerable as noted by Vascular. Vascular surgery saw patient and said there was no operative management necessary. There was no evidence of osteo on XR. Clinically does not appear to have osteo. Foot ulcer grew Pseudomonas and MRSA on [**6-30**]. Podiatry also followed the patient and started the patient on wet to dry dressings. Pain was the most pressing issue regarding his condition, and was addressed with fentanyl patch, gabapentin, and prn dilaudid. The patient's fentanyl was increased from 50 mcg Q72 hours to 75 mcg. Dilaudid prn was also required for dressing changes (PO 4mg Q4hrs PRN). Coumadin was discontinued. Aspirin was restarted prior to discharge. # CAD/HTN. The patient has been normotensive throughout hospital stay. EF 50-55% at OSH ~ 2mo ago. Has hypokinesis of basal inferolateral flow on echo in [**Month (only) 547**]. Betablockade and aspirin are continued. Zocor was continued. #. DM: at home, diet-controlled and on Metformin. Holding Metformin while in the unit. Fingersticks from 100-200. On a diabetic diet. Metformin restarted on discharge. Medications on Admission: Liquid Antacid 30ml PO q4H PRN Dyspepsia Bisacodyl 10mg Suppository PR PRN constipation Milk of Magnesia 30ml PO daily PRN Constipation Dilaudid 8 mg PO Q3H PRN pain Imodium 2mg PO Q6H PRN loose stool Miralax 17 grams mixed with 8 ounces fluid PO dialy Fentanyl Patch (50 mcg) apply one patch Q 72hours Alprazolam PO four times daily Acetaminophen 325 2 tabs PO prn pain or increased temperature Keflex 500mg 4 times daily - started [**7-7**] Heparin 5000U TID - stopped [**6-24**] Metformin 500 mg PO daily Lasix 40mg Daily Omeprazole 20mg Daily Zocor 20mg one tab daily at bedtime ASA 81mg Daily Multivitamin one tab daily Neurontin 300mg TID Atenolol 50mg Daily Coumadin 5mg Daily Discharge Medications: 1. Liquid Antacid 200-200-20 mg/5 mL Suspension Sig: Thirty (30) mL PO every four (4) hours as needed for heartburn. 2. Bisacodyl 5 mg Tablet Sig: Two (2) Tablet PO once a day as needed for constipation. 3. Milk of Magnesia 400 mg/5 mL Suspension Sig: Thirty (30) mL PO once a day as needed for constipation. 4. Dilaudid 8 mg Tablet Sig: One (1) Tablet PO q3 as needed for pain. Disp:*100 Tablet(s)* Refills:*0* 5. Imodium A-D 2 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for loose stool. 6. Miralax 17 gram Powder in Packet Sig: One (1) packet PO once a day. 7. Fentanyl 50 mcg/hr Patch 72 hr Sig: One (1) patch Transdermal every seventy-two (72) hours. Disp:*10 patches* Refills:*0* 8. Alprazolam 1 mg Tablet Sig: One (1) Tablet PO twice a day as needed for anxiety: Dosage unclear on transfer to [**Hospital1 18**]. Not given in hospital. 9. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO PRN as needed for fever or pain. 10. Metformin 500 mg Tablet Sig: One (1) Tablet PO once a day. 11. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day. 12. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 13. Zocor 20 mg Tablet Sig: One (1) Tablet PO at bedtime. 14. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day. 15. Multivitamin Capsule Sig: One (1) Capsule PO once a day. 16. Neurontin 300 mg Capsule Sig: One (1) Capsule PO three times a day. 17. Atenolol 50 mg Tablet Sig: One (1) Tablet PO once a day. 18. Prednisone 50 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Extended Care Facility: [**Hospital6 31006**] of [**Location (un) **] Discharge Diagnosis: Primary: Thrombocytopenia, retroperitoneal bleed, anemia, left foot wound Secondary: Diabetes mellitus, hypertension, peripheral vascular disease Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Mr. [**Known lastname **], It was a pleasure taking care of you during your hospitalizaton. You were admitted with very low platelets and a low blood count. It was determined that you were bleeding into your back. You were transferred to the Medical Intensive Care Unit and treated by getting blood and platelet transfusions. Your blood count stabilized and your platelet count returned to a normal level, and you were transferred back to the regular floor. It was thought that the low platelets were related either to an antibiotic you received, Keflex, or to a condition called ITP, where the immune system attacks its own platelets. We stopped the Keflex and you were started on steroids, which can help treat ITP. We discharged you on a steroid taper. It is very important that you follow up with your doctors at rehab and the Hematologist as you need to have your blood counts followed. You were also found to have blood in your stool, so you should have a colonoscopy as an outpatient. You should follow up with your primary care doctor regarding this. We stopped on of your blood thinners, Coumadin, because you had a large bleed. Please talk to your surgeon and primary care doctor about whether you should restart the Coumadin. Followup Instructions: You will be seen by the doctors at rehab Department: Hematology Physician: [**Last Name (NamePattern4) **]. [**Last Name (STitle) 58397**] Time: Friday, [**7-21**] at 8:30am Location: [**Hospital3 328**], [**Location (un) 936**], MA Phone: [**Telephone/Fax (1) 85183**] Completed by:[**2102-7-16**]

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icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

14329, 14401

7693, 12011

276, 282

14592, 14592

4408, 5653

16053, 16355

3888, 3893

12746, 14306

14422, 14571

12037, 12723

14775, 16030

3908, 4389

5667, 7670

227, 238

310, 2324

2338, 2912

14607, 14751

2934, 3711

3727, 3872

76,196

108,756

41724

Discharge summary

report

Admission Date: [**2113-1-29**] Discharge Date: [**2113-1-30**] Date of Birth: [**2027-5-4**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 106**] Chief Complaint: hypotension Major Surgical or Invasive Procedure: none History of Present Illness: 85 yo male with a history of severe AS, 3VD CAD, CHF, s/p recent admission to [**Hospital1 18**] ([**2113-1-11**] to [**2113-1-21**]) for acute on chronic systolic CHF, with multiple recent admissions to [**Hospital1 1516**] for severe AS and acute on chronic systolic CHF. He has been evaluated for AVR/CABG, but his multiple recent admissions have delayed his surgery. . Prior to this, the patient has had multiple hospitalisations at [**Hospital1 **] in [**Month (only) **]-[**2112-12-29**]. He was admitted in [**Month (only) **] s/p LOC w/ left orbital fracture thoguht to be secondary to AVNRT s/p ablation, was found to have aortic stenosis and 3 vessel CAD on Cath. He was d/ced with eval for surgery, but developed GI bleeding from a gastric ulcer. Upon discharge he developed aCHF exacerbation, and readmitted to [**Hospital1 18**] where his course was complicated by C. diff colitis. . Patient had been at [**Location (un) 1121**] [**Hospital3 **] where he was noted to have low blood pressures(SBP 80s, baseline 90s), was agitated and had loose stools for 3 days. Patient also reported some difficulty breathing for the past well. He denied any fever, cough, abdominal pain, chest pain, palpitations. Rehab hospitalists and family requested transfer to [**Hospital1 18**], but he was noted to be hypotensive to SBP 65, so transported to nearest ED at [**Hospital3 7362**]. He was thought to be septic with leukocytosis and left shift, with question of pneumonia on CXR, anasarca and pleural effusions. Also noted to be in ARF this morning with empty bladder, minimal urine output, difficulty with foley catheterisation. His labs were: WBC 13 on presentation, 15.6 today with 24% bands, H/H 12.2/36.1, Platelets: 210. Chem7 notable for BUN 79, Creatinne 4.7 (4.1 on [**1-29**]), up from a baseline of around 2.8. CK 1118->1557; Troponin 2.12->3.13; BNP 3211, up from a baseline of 1750. INR 3.5, lactate 1.7. Urinalysis negative. Urine lytes: K: 59.7, Creatinine: 98.4, BUN 479. At [**Hospital3 **], he reports that he has not passed stool or gas for the last 2 days, his urine output has dropped. Today, he also had an episode of vomiting brown fluid. . He was given 3+L fluids, started on vasopressin, dopamine, levophed, now weaned down to dopamine 10 and levophed 10, PO Vanc, IV Vanc and IV Zosyn. Minutes prior to scheduled transfer to [**Hospital1 18**], the patient developed chest pain and was given sublingual nitroglycerin. However, he became hypotensive and transfer was temporarily suspended. He was then placed on dopamine 15 + levophed 28 mcg/kg/min and transferred to [**Hospital1 18**]. Past Medical History: Past Medical History: - DMII - HTN - CVA (2 yrs ago, started on warfarin afterwards) - CAD - atrial fibrillation - hx DVT [**2102**] - severe aortic stenosis - systolic CHF (EF 40-45% with global hypokinesis) - syncope w/ left orbital fracture, thought to be [**3-2**] AVNRT, now s/p ablation Past Surgical History: - s/p hip surgery - s/p knee surgery - s/p carpal tunnel syndrome Social History: Pt lives in rehab following recent d/c from [**Hospital1 18**] ([**2113-1-21**]). Previosly lived in [**Location 13011**] w/ his wife. [**Name (NI) **] lives approximately 5 minutes away. Pt denies EtOH, has a distant history of EtOH use. Non-smoker. No illicit drugs. Family History: Pt denies family history of CAD, cancers or DMII. Physical Exam: ADMISSION EXAM VS: T= 98.2 BP=85/42HR=69 RR=30 O2 sat=84% 2L GENERAL: NAD. Sleepy but rousable, speech slurred, left facial droop. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. Slow reacting pupils, pupils not constricting fully to bright light. NECK: Supple. 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: Rhonchorous. ABDOMEN: Distended, fluid thrill+ve, shfting dullnes +ve, tender to deep palpation, but no rebound, no guarding, no flank bruising. Not peritonitic. No masses or organomegaly. EXTREMITIES: No c/c/e. No femoral bruits. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Barely palpable. All pulses dopplerable. Pertinent Results: ADMISSION LABS [**2113-1-29**] 07:58PM BLOOD WBC-20.5*# RBC-3.82* Hgb-11.5* Hct-36.0* MCV-94 MCH-30.1 MCHC-32.0 RDW-17.8* Plt Ct-249 [**2113-1-29**] 07:58PM BLOOD Neuts-86.1* Lymphs-11.3* Monos-2.2 Eos-0.1 Baso-0.2 [**2113-1-29**] 07:58PM BLOOD PT-48.8* PTT-44.3* INR(PT)-4.8* [**2113-1-29**] 07:58PM BLOOD Glucose-175* UreaN-85* Creat-5.0*# Na-129* K-5.5* Cl-93* HCO3-11* AnGap-31* [**2113-1-29**] 07:58PM BLOOD ALT-25 AST-102* LD(LDH)-476* CK(CPK)-1711* AlkPhos-102 Amylase-81 TotBili-1.4 [**2113-1-29**] 07:58PM BLOOD Albumin-2.6* Calcium-6.7* Phos-9.5*# Mg-2.6 [**2113-1-29**] 08:15PM BLOOD Lactate-6.9* [**2113-1-29**] 09:34PM BLOOD Lactate-7.2* . PERTINENT STUDIES ECHO [**2113-1-29**] Conclusions There is moderate symmetric left ventricular hypertrophy. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. There is moderate to severe global left ventricular hypokinesis (LVEF =25-30 %). The aortic valve leaflets are severely thickened/deformed. The mitral valve leaflets are mildly thickened. Moderate to severe (3+) mitral regurgitation is seen. There is moderate pulmonary artery systolic hypertension. IMPRESSION: Moderate to severe global hypokinesis. Moderate to severe mitral regurgitation. Moderate pulmonary hypertension. Compared with the prior study (images reviewed) of [**2113-1-14**], LV function has decreased. . CXR [**2113-1-29**] Although not labeled, this film is probably obtained supine. The cardiac silhouette is prominent, but similar to [**2113-1-11**]. There is hazy opacity diffusely through both lungs -- I suspect the presence of bilateral layering effusions. There is probably underlying collapse and/or consolidation, with suggestion of air bronchograms in the right infrahilar region. . Clinical correlation to confirm that the film was obtained supine is recommended as it is difficult to assess the degree of aerated lung on this film. If clinically indicated, an upright, lateral and/or decubitus films could help to further assess the underlying lung. . KUB [**2113-1-29**] Brief Hospital Course: 85 yo male with history of critical AS, 3VD CAD, paroxysmal atrial fibrillation on coumadin readmitted from rehab to OSH with sepsis, colitis, acute on chronic renal failure, exacerbation of congestive heart failure, and possible NSTEMI. . ACTIVE ISSUES # Hypotension/Shock: Pt presented with shock, likely combined septic and cardiogenic shock, with multisystem failure and lactic acidosis. The septic component is likely secondary to GI source given the recent C.diff infection. Surgery consult was obtained shortly after admission to CCU. Pt's abdominal exam worsened rapidly with distension and rebound tenderness. KUB showed dilitation of bowel. Given his unstable hemodynamics, surgery was deferred. Pt was treated with iv flagyl. The cardiogenic component of his shock is based on elevation of troponin to 3 at OSH. Given his known critical AS and three vessel coronary artery disease (including left main), he has little reserve for cardiac output. It is also possible that the GI symptoms were secondary to ischemic bowel in the setting of NSTEMI. Pt was transferred on pressors. He was treated with maximum dose of levophed, dopamine and vassopressin while he was at CCU. His blood pressure was maintained at 80s/40s with reasonable mental status. . # End of life: [**Name (NI) 1094**] son came to the hospital and was notified of the critical situation. The decision was made to withdraw care and focus on comfort measures. Pressor was weaned, and morphine gtt was started. Chaplain was called and service was provided at the bedside. At 2AM on [**2113-1-30**], pt became unresponsive with asystole on telemetry. There were no evidence of radial/carotid pulses, pupilary reflex, or heart/lung sounds on exam. Pt was declared dead. His sons [**Name (NI) **] and [**Name (NI) 25368**] came and saw pt after his expiration. Family declined autopsy. Medical examiner was called given the death occured within 24 hours of transfer, but the case was waived. His PCP was notified. Medications on Admission: 1. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 2. rosuvastatin 40 mg po qd 3. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 4. amiodarone 200 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. lopressor 12.5 mg [**Hospital1 **] 6. Lidoderm 1 patch daily 7. Seroquel qhs 8. Zinc Sulfate 220 mg qd 9. Multivitamin 1 tablet qd 10. insulin humulin subq sliding scale 11. aldactone 12.5mg po 12. saliva substitute0.15-0.15% MM qd 13. warfarin O qd 14. Potassium chloride 40meq qd 15. vancomycin 250 mg PO qd 16. ascorbic acid 500mg PO 17. Lantus 2 untis subq qd Discharge Medications: none Discharge Disposition: Expired Discharge Diagnosis: septic shock cardiogenic shock Discharge Condition: expired Discharge Instructions: none Followup Instructions: none

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icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

9418, 9427

6657, 8665

314, 320

9501, 9510

4572, 6634

9563, 9570

3674, 3725

9389, 9395

9448, 9480

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9534, 9540

3303, 3371

3740, 4553

263, 276

348, 2964

3008, 3280

3387, 3658

51,698

137,588

23244

Discharge summary

report

Admission Date: [**2142-2-13**] Discharge Date: [**2142-2-19**] Date of Birth: [**2072-4-9**] Sex: M Service: NEUROSURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 3227**] Chief Complaint: Headaches, emesis, altered mental status, right hemiparesis Major Surgical or Invasive Procedure: [**2142-2-13**]: Left Craniotomy for subdural Hematoma with Dr. [**First Name (STitle) **] History of Present Illness: This is a 69 year old male who has been on Coumadin for a history of multiple DVTs and a PE. He had complained of a headache for several days and had multiple episodes of vomiting. His son found him confused after family members reported a stuporous "drunken" state. He was brought to the OSH. He reportedly wasmoving all extremities and was able to answer some questions. His head CT revealed a large left SDH. He was given 10 mg SC of vitamin K and FFP as well as a dilantin load. He was transferred to [**Hospital1 18**] for a neurosurgical evaluation. Upon arrival to [**Hospital1 18**], he was still moving spontaneously but unable to answer questions per the ER. He was given profiline and a second dose of FFP. Past Medical History: varicose vein stripping DVT L superfical femoral L4-5, L5-S1 stenosis HTN hyperlipidemia PE IVC filter hip replacement Social History: warehouse worker forced to quit 1 [**1-13**] yrs ago due to L hip pain. no tobacco, no ETOH Family History: NC Physical Exam: On admission: T:98.3 BP:147/89 HR:89 RR:17 O2Sats:98% 4L NC Gen: Lethargic, agitated HEENT: Pupils: PERRL EOMs-unable to test Neck: Supple. Lungs: CTA bilaterally. Cardiac: RRR. S1/S2. Abd: Obese, Soft, NT, BS+ Extrem: Warm and well-perfused. Neuro: Mental status: Lethargic, follows some commands. Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light, 3 to 2 mm bilaterally. Visual fields are full to confrontation. III, IV, VI: unable to test V, VII: Facial strength and sensation intact and symmetric. VIII: Hearing intact to voice. IX-XII: Tongue midline without fasciculations. Motor: Normal bulk and tone bilaterally. No abnormal movements, tremors. Moving left side spontaneously. Moving RUE spontaneously but less than left. Briskly withdraws RLE to minimal noxious stimuli. Unable to assess pronator drift. Sensation: Appears intact to light touch bilaterally and patient opens eyes and says "Ai" to noxious stimuli. On Discharge: A&Ox3 PERRL 3-2mm bilaterally EOMs: intact Face symmetrical Tongue midline Motor: D B T IP Q H [**Last Name (un) **] AT [**Last Name (un) 938**] R 5 5 5 5 5 5 5 5 5 L 5 5 5 5 5 5 5 5 5 Incision: clean, dry and intact- anterior aspect of wound has an area of white- appears to be dressing that was stuck to incisional glue. Pertinent Results: CT Head [**2142-2-13**]: Left subdural hematoma with a hyperdense focus in the left frontoparietal region consistent with acute hemorrhage. 1.4 cm rightward subfalcine herniation and compression of the left lateral ventricle without ventricular entrapment. Overall, unchanged since outside hospital study performed two hours ago. CT Head [**2142-2-14**]: Newly apparent 5-mm in transverse dimension posteriorly centered right subdural hemorrhage. The patient is status post left craniotomy with interval evacuation of previously noted left subdural hemorrhage. Improvement in mass effect with now 4 mm rightward midline shift decreased from 9 using comparable measurements. Improvement in compression of the left lateral ventricle. LENIS [**2142-2-15**]: 1. Incomplete compressibility of the left mid-to-lower superficial femoral vein which may represent partially occlusive or chronic DVT. 2. No evidence of right lower extremity DVT. CT Head [**2142-2-19**]: Stable CT scan Brief Hospital Course: Mr. [**Known lastname 1794**] was admitted to [**Hospital1 18**] under the CAre of Dr [**First Name (STitle) **]. He was taken to the OR on the evening of [**2142-2-13**] for Left craniotomy for SDH evacuation. He was left intubated and transported to the ICU. He was extubated aorund noon on [**2142-2-14**]. He was MAE with right sided weakness but not following commands. HE became febrile to 101.8 early am on [**2142-2-15**]. Sputum cultures were positive for Gram + cocci in pairs. LENS showed a Left superficial femoral DVT that was either chronic or a new partially occlusive DVT. His PCP [**Last Name (NamePattern4) **].[**Last Name (STitle) 1057**] was contact[**Name (NI) **] at his new office [**Telephone/Fax (1) 14331**]. His office had records dating from [**2139**]. The patient has been on Coumdain since then without a new diagnosis of DVT. Therefore we determined that his origical DVT was prior to [**2139**] and this finding was consistant with new L DVT. Venodynes were removed form the LLE. Hematology was consulted with regards to whether anticoagulation is warranted. In the context of a recent evacuation of the SDH and the small size of the DVT, it was felt that the patient can be initiated on subcutaneous heparin at prophylactic dose since the patient has an IVC filter in place. The joint decision between neurosurgery and hematology was to initiate anti-coagulation approxiamtely 2 weeks after the SDH evacuation. He was seen by the Speach/Swallow service. They recommended a pureed diet. His neruologic status was improved on 2.4 and transfer to the SDU was initiated. On [**2142-2-16**] he was neurologically stable in the SDU. Levofloxacin was started in the setting of low grade fever and sputum with gram + cocci. CT head showed a L PCA infarct. Stroke Neurology was consulted. Work up revealed no evidence of embolic or thrombotic lesions. The patient will f/u with the neurology clinic for work up of hypercoagulability. Also on [**2142-2-16**], his foley was discontiued for a voiding trial. His bowel regimen was increased. PT and OT were consulted. KUB showed a decrease in air in small bowel and repeat head CT was stable. Pt was cleared to go to rehab on [**2142-2-19**] Medications on Admission: Coumadin 6 mg daily Verapamin ER 180 mg daily Simvastatin 20 mg daily Ibuprofen 600 mg PRN - arthritic pain Aspirin 81 mg daily Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain, temp. 2. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 3. Verapamil 120 mg Tablet Sig: 0.5 Tablet PO Q8H (every 8 hours). 4. Levetiracetam 750 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 6. Insulin Lispro 100 unit/mL Solution Sig: One (1) Subcutaneous ASDIR (AS DIRECTED). 7. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO Q6H (every 6 hours). 9. Hydrocortisone Acetate 1 % Ointment Sig: One (1) Appl Rectal TID (3 times a day) as needed for PRN. 10. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO BID (2 times a day). 11. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q6H (every 6 hours) as needed for Constipation. 12. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO Q6H (every 6 hours) as needed for Constipation. 13. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 14. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO TID (3 times a day). 15. Polyethylene Glycol 3350 17 gram/dose Powder Sig: One (1) PO DAILY (Daily). 16. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 17. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 4 days. Tablet(s) 18. 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. 19. Ondansetron 4 mg IV Q8H:PRN nausea 20. Dilaudid 2 mg Tablet Sig: 1-2 Tablets PO every six (6) hours as needed for pain. Discharge Disposition: Extended Care Facility: [**Hospital **] [**Hospital **] Hospital Discharge Diagnosis: Left Subdural Hematoma Left Superficial Femeral Deep Vein Thrombosis Left PCA infarct 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: General Instructions ?????? Have a friend/family member check your incision daily for signs of infection. ?????? Take your pain medicine as prescribed. ?????? Exercise should be limited to walking; no lifting, straining, or excessive bending. ?????? You may wash your hair but do not scrub surgical wound. 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. ?????? Coumadin may be restarted on [**2142-2-26**] ?????? You have been prescribed an anti-seizure medicine, Keppra, take it as prescribed. ?????? Clearance to drive and return to work will be addressed at your post-operative office visit. ?????? You need to continue a strict bowel regimen. 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. **** SUTURES ARE DISSOLVEABLE**** Please keep dry x 7days post-op. NO COUMADIN UNTIL [**2142-2-26**] Followup Instructions: Follow-Up Appointment Instructions ??????Please call ([**Telephone/Fax (1) 9403**] to schedule an appointment with Dr. [**First Name (STitle) **], to be seen on [**2142-3-8**] (this is one week post Coumadin). ??????You will need a CT scan of the brain without contrast. ??????You will need to follow up with Dr. [**Last Name (STitle) **] from Stroke Neurology please call ([**Telephone/Fax (1) 7394**] for an appointment. Your TTE was done inpatient prior to discharge. Completed by:[**2142-2-19**]

[ "V43.64", "272.4", "342.90", "V12.51", "278.00", "432.1", "348.4", "434.91", "V58.61", "453.41", "401.9", "486" ]

icd9cm

[ [ [] ] ]

[ "01.31" ]

icd9pcs

[ [ [] ] ]

8031, 8098

3893, 6115

378, 471

8228, 8228

2888, 3870

9806, 10310

1488, 1492

6294, 8008

8119, 8207

6141, 6271

8398, 9783

1507, 1507

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279, 340

499, 1220

1844, 2482

1521, 1778

8242, 8374

1242, 1362

1378, 1472

66,706

147,794

24016

Discharge summary

report

Admission Date: [**2118-10-15**] Discharge Date: [**2118-10-19**] Date of Birth: [**2090-1-21**] Sex: M Service: MEDICINE Allergies: Haldol Attending:[**First Name3 (LF) 1115**] Chief Complaint: Somnolence Major Surgical or Invasive Procedure: none. History of Present Illness: Mr. [**Known lastname **] is a 28 y/o M with PMH of bipolar disorder, anxiety, and depression who was found slumped over a car earlier today and BIBA to [**Hospital1 18**]. The patient was very somnolent when found although was able to state that he had taken Seroquel and Xanax in doses "more than usual." A suboxone tablet and a Flexeril tablet were found in his pocket. On interview here the patient reports taking 1200mg Seroquel, 16mg Klonipin and 13 shots of EtOH on Thursday. No recollection of events between Thursday and arriving in ED today. The patient recently underwent treatment for 30 days at MasAC and was released Wednesday. . In the ED the patient was found to be lethargic. ECG was remarkable for sinus tach. Utox was negative. Labs otherwise notable for a lactate of 3.6. Given Narcan with slight improvement in MS. 2L of IV fluids given with improvement in lactate to 0.8. Was initially admitted to OBS in the ED although spiked a fever to 102.4. A CXR showed a righ sided opacity in the RML. Given vanc, levaquin and an additional 3L of NS. Swithced abx to vanc/ceftriaxone/azithro due to rash with levaquin. Transferred to the MICU for further monitoring given high risk of EtOH withdrawal and respiratory depression with Seroquel overdose. . On arrival to the [**Hospital Unit Name 153**] initial vitals are 100.3 168/94 144 94%RA. Patient appears manic with pressured speech. Easily agitated. . ROS: (+) as per HPI. Also endorses cough productive of green sputum over the past week. Otherwise denies CP, palp, SOB, fever/chills, N/V/D, changes in bowel/bladder habits, recent weight loss, HA or vision changes. Past Medical History: Depression Anxiety Bipolar disorder Umbilical hernia Asthma Right foot fracture ADD Social History: Smokes 1.5 PPD, drinks 4-6 shots every ohter day (no h/o withdrawal or DTs), occasional marijuana, h/o cocaine use Family History: Mother - alcoholism Physical Exam: Admission PEx: Vitals- 100.3 168/94 144 94%RA General- Patient appears agitated, pressured speech, easily distracted HEENT- PERRLA, EOMI, anicteric, MMM, OP clear Neck- Supple, no JVP CV- Tachycardic, S1 and S2 appreciated, no m/r/g Chest- Good air entry b/l. Diffuse wheezes. Abdomen- Soft, ND. Umbilical hernia that could not be reduced secondary to pain. Extremity- Well ehaled surgical scar over right lateral heel. TTP. Neuro- Awake, alert and oriented. Moving all extremities. Discharge Exam: Vitals- 98.3, 116/69, 74, 95% RA General- Patient appears agitated, pressured speech, easily distracted HEENT- PERRLA, EOMI, anicteric, MMM, OP clear Neck- Supple, no JVP CV- Tachycardic, S1 and S2 appreciated, no m/r/g Chest- Good air entry b/l. Diffuse wheezes. Abdomen- Soft, ND. Umbilical hernia that could not be reduced secondary to pain. Extremity- Well ehaled surgical scar over right lateral heel. TTP. Neuro- Awake, alert and oriented. Moving all extremities. Pertinent Results: ADMISSION LABS: [**2118-10-15**] 02:30PM BLOOD WBC-6.2 RBC-4.04* Hgb-11.0* Hct-33.4* MCV-83 MCH-27.2 MCHC-32.8 RDW-14.6 Plt Ct-260 [**2118-10-15**] 02:30PM BLOOD Neuts-51.2 Lymphs-35.3 Monos-5.7 Eos-7.2* Baso-0.7 [**2118-10-15**] 02:30PM BLOOD PT-13.9* PTT-32.8 INR(PT)-1.2* [**2118-10-15**] 02:30PM BLOOD UreaN-17 Creat-0.8 [**2118-10-16**] 12:47AM BLOOD ALT-18 AST-22 CK(CPK)-150 AlkPhos-57 TotBili-0.4 [**2118-10-16**] 12:47AM BLOOD Albumin-3.9 Calcium-8.5 Phos-2.7 Mg-2.0 [**2118-10-15**] 02:30PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2118-10-15**] 03:03PM BLOOD Glucose-98 Lactate-3.6* Na-143 K-3.5 Cl-101 calHCO3-27 [**2118-10-15**] 03:03PM BLOOD freeCa-1.17 IMAGING: CXR: As compared to the previous radiograph, the extensive multifocal opacities have substantially decreased. However, a right upper lobe opacity with air bronchograms is still clearly visible and likely to correspond to pneumonia. No evidence of pleural effusions. No pulmonary edema. Borderline size of the cardiac silhouette. Brief Hospital Course: 28 y/o M with h/o psychiatric d/os and substance abuse who presents after being found somnolent on the street likely due to Seroquel overdose. Now with new fever concerning for PNA vs. early EtOH withdrawal. # Drug overdose: The patient was found slumped over a car and was somnolent on arrival to the ED. He endorsed using large amounts of Seroquel, EtOH, and Xanax. Urine tox was (-); patient reports his last drink being >1 day prior. Recieved naloxone in the ED with minimal response. Admitted to ICU for close monitoring of resp status given long Seroquel wash-out period. EKG unremarkable, no QTc prolongation. Pt was alert by the time he reached [**Hospital Unit Name 153**] floor, where he became agitated and verbally abusive. Pt became more calm with ativan and pain medication (has h/o chronic pain and drug abuse, so concern was for withdrawal). He was monitored on CIWA but did not score. His respiratory status was stable throughout [**Hospital Unit Name 153**] stay so he was transferred to the floor where he did not show any signs of continued withdrawl and was given 0.5 mg PO ativan PRN for aggiation. Patient was not discharged on any anxiolytic medicaitons. . # Fever: While being obs'ed in the ED, the patient developed a fever to 102.4. A CXR showed a RML consolidation which was new since a prior film in [**11/2117**], though lung volumes were decreased. Blood, urine, and sputum cultures were obtained. Pt was started on vanc/azithro/CTX for empiric treatment of CAP. Pt was placed on CIWA for possible EtOH withdrawal but did not score. Vanc was given in ED but discontinued on the floor because there was no indication for MRSA coverage. Repeat CXR confirmed likely presence of PNA but in RUL. Pt was doing well so was continued on azithro/CTX and was transferred to the floor. Sputum cultures grew pan-sensitive S. aureus and the patient was treated with IV vancomycin while inpaitent and discharged to complete a 14 day course of PO clindamycin 600 mg Q8H. . # EtOH abuse: pt has a h/o EtOH abuse. Reports last drink was Thursday. Recently detoxed at MasAC making withdrawal at this time less likely. Kept on CIWA in [**Hospital Unit Name 153**] but did not score. Given MVI, folate, thiamine. SW was consulted as well as psych. Pt expressed desire to be treated by inpatient psych facility once medically stable. Patient will follow up with pshyciatric providers and an appointment was made for him at [**Location 61127**]Multi-Service Agency - [**Location (un) 3146**] Counseling Center - Day Treatment for [**Location (un) **] [**10-24**] at 4 pm. # Asthma: gave albuterol and ipratropium nebs as well as montelukast. Stopped salmeterol because pt was not on a steroid, which should be combined with [**Last Name (un) **] to reduce cardiovascular side effects. Would recommend fluticasone or advair as a replacement, to be outpatient PCP. # Chronic pain: patient c/o chronic pain in right foot, neck, and umbilical hernia site. Had prior surgery on right foot for unknown reason. Held home gabapentin given somnolence. Added tylenol for pain and oxycodone 15mg po q6h prn, which pt said worked well in managing pain. Patient was discharged on 750 mg Robaxin Q6H PRN for pain per psychiatry, patient was not discharged with any opiates. # Psych (Bipolar D/o, depression): Continued Clozaril and cymbalta at home dosing. Psych consulted. Pt reports having psych meds discontinued in detox facility, which he did not like. Pt expressed desire to be treated by inpatient psych facility once medically stable. Psych agreed to make arrangements for this once pt was medically cleared. Psych rec'd restarting seroquel at 100mg po q6h prn while in house, but declined to send patient on out on standing antipsychotics given his abuse history and need to establish long term pshyciatric care. Patient will follow up with pshyciatric providers and an appointment was made for him at [**Location 61127**]Multi-Service Agency - [**Location (un) 3146**] Counseling Center - Day Treatment for [**Location (un) **] [**10-24**] at 4 pm. # Anemia: The patient has had mild normocytic anemia since 1/[**2116**]. Hgb on admission was 11.0. Most likely due to chronic malnutrition and marrow supression due to EtOH/substance abuse. Also considered GI bleeding given recent h/o ?UGI bleed and continued NSAID use. GI consulted and recommended outpatient EGD and colonoscopy. TRANSITIONAL ISSUES: Patient will require an outpatient workup for his anemia as above. Medications on Admission: Presently no home medications. Reports all home medications were stopped during his stay at MasAC last month. Discharge Medications: 1. Combivent 18-103 mcg/Actuation Aerosol Sig: Two (2) puffs Inhalation three times a day. 2. montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 4. salmeterol 50 mcg/dose Disk with Device Sig: One (1) puff Inhalation twice a day. 5. ibuprofen 800 mg Tablet Sig: One (1) Tablet PO three times a day. 6. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*qs Tablet(s)* Refills:*0* 7. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*qs Tablet(s)* Refills:*0* 8. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*qs Tablet(s)* Refills:*0* 9. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*qs Tablet(s)* Refills:*0* 10. clindamycin HCl 300 mg Capsule Sig: Two (2) Capsule PO every eight (8) hours for 14 days. Disp:*84 Capsule(s)* Refills:*0* 11. Robaxin-750 750 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for pain. Disp:*20 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: overdose/intoxication of medications RML pneumonia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Mr. [**Known lastname **], You have been admitted to the hospital for an overdose of several non-prescribed medications. You were also found to have a pneumonia and are on antibiotics for this. You will be on clindamycin 600 mg every 8 hours for 14 days. . You were also given a prescription for a pain medication called Robaxin. You should take this every 6 hours as needed for your muscle pains. . You will leave here with with close follow up with outpatient psychiatry, who will evaluate you and prescribe you a regimen for your psychiatric illnesses. Followup Instructions: You have the following appointments: Department: [**Hospital3 249**] When: FRIDAY [**2118-10-28**] at 1:45 PM With: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 250**] Address: [**Location (un) 830**] [**Location (un) 86**], [**Numeric Identifier 718**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**] South [**Hospital **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 6982**] is your new physician in [**Name9 (PRE) 191**] and Dr. [**Last Name (STitle) 6982**] works closely with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 438**], [**First Name3 (LF) **] both will be involved in your care. For insurance purposes please indicate Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 438**] as your Primary Care Physician Department: DIV. OF GASTROENTEROLOGY When: WEDNESDAY [**2118-10-19**] at 1 PM With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 9864**], MD [**Telephone/Fax (1) 463**] Building: Ra [**Hospital Unit Name 1825**] ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) **] Campus: EAST Best Parking: Main Garage [**Location **]Multi-Service Agency with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Last Name (NamePattern1) 766**] [**2118-10-24**] 4 pm [**First Name4 (NamePattern1) 61128**] [**Last Name (NamePattern1) **]

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icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

10089, 10095

4309, 8732

281, 289

10190, 10190

3241, 3241

10923, 12448

2212, 2233

8981, 10066

10116, 10169

8847, 8958

10341, 10900

2248, 2733

2750, 3222

8753, 8821

230, 243

317, 1956

3257, 4286

10205, 10317

1978, 2063

2079, 2196

64,752

103,766

14885

Discharge summary

report

Admission Date: [**2162-6-23**] Discharge Date: [**2162-6-28**] Service: MEDICINE Allergies: Penicillins / Bactrim Attending:[**First Name3 (LF) 2782**] Chief Complaint: Fever Abdominal pain Major Surgical or Invasive Procedure: None History of Present Illness: [**Age over 90 **] yo female with history of dementia presented with altered mental status, fever, vomiting and lethargy. In the ED, initial vitals were 101 95 192/65 18 98% 3L. -PE: loud diffuse systolic ejection murmur. AAOX self and location. Follows commands selectively. Non focal neurological exam. -Labs notable for leukocytosis w/ left shift, Transaminitis w/ bilirubinemia. -CXR was done -CT a/p was done for elevated LFTs/tbili -She was given flagyl, vanco, and levaquin -Full Code per graddaughter. She will bring living will in AM Most Recent Vitals: 98.4 94 18 118/46 97% 2l. Spoke to patient's daughter who reports patient's memory is poor but she can hold a conversation. She recognizes most people unless she hasn't seen family memebers in a long time. She feeds herself, is mobile and goes down to dining room herself. On arrival to the MICU, she is comfortable and reports achy bilateral hip pain. She reports chronic abdominal and back pain unchanged from prior. Past Medical History: - Dementia - Arthritis - Sjogrens - Cataracts - Bleeding ulcer - Narrow complex tachycardia: [**1-29**], reverted to sinus, on toprol. - L2-L3 compression fractures - Anterior abdominal wall fat-containing hernia and right inguinal hernia Social History: Lives in [**Hospital3 **] [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] facility and ambulates with walker. All of her cooking and cleaning are done for her. She has help in shower three times per week. Previously interior decorator, has 3 children, widowed, family very involved. Drinks alcohol only on holidays, no smoking. Family History: Mother/Father with CAD. Physical Exam: Admission: Vitals: 98.2 76 100/34 17 97% on 2L General: Alert, oriented to self and hospital, no acute distress HEENT: Sclera anicteric, MM dry, oropharynx clear, EOMI, PERRL Neck: supple, JVP not elevated, no LAD CV: RRR, normal S1 + S2, 3/6 SEM best heard over RUWB Lungs: CTAB, no wheezes, rales, ronchi Abdomen: +BS, soft, non-distended, tender over epigastrium and umbilicus, pain with attempt at reduction of umbilical hernia, no peritoneal signs GU: +foley Ext: wwp, 2+ pulses, no clubbing, cyanosis or edema Neuro: CNII-XII intact, 5/5 strength upper/lower extremities, grossly normal sensation Discharge: Vitals: T: 97.7 BP: 144/70 P: 70 R: 18 O2: 97% on RA General: Alert, oriented to self, comfortable, no acute distress, sleeping HEENT: Sclera anicteric, MMM Neck: Supple. No LAD. Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2, 2/6 systolic ejection murmur heard best at RUSB, no rubs, gallops Abdomen: Soft, protuberant, non-distended, nontender, bowel sounds present Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Pertinent Results: ADMISSION LABS: [**2162-6-23**] 10:30PM BLOOD WBC-18.6*# RBC-4.54 Hgb-11.8* Hct-36.2 MCV-80* MCH-25.9* MCHC-32.5 RDW-16.8* Plt Ct-461* [**2162-6-23**] 10:30PM BLOOD Neuts-93.7* Lymphs-2.9* Monos-3.1 Eos-0.2 Baso-0.1 [**2162-6-24**] 05:49AM BLOOD PT-14.3* PTT-31.3 INR(PT)-1.3* [**2162-6-23**] 09:15PM BLOOD Glucose-124* UreaN-13 Creat-0.6 Na-133 K-3.7 Cl-96 HCO3-22 AnGap-19 [**2162-6-23**] 09:15PM BLOOD ALT-599* AST-788* AlkPhos-209* TotBili-2.6* [**2162-6-23**] 10:30PM BLOOD DirBili-1.1* [**2162-6-23**] 09:15PM BLOOD Lipase-3582* [**2162-6-24**] 05:49AM BLOOD Lipase-1236* [**2162-6-23**] 09:15PM BLOOD proBNP-1234* [**2162-6-23**] 09:15PM BLOOD Albumin-4.0 Calcium-9.5 Phos-3.2 Mg-2.0 [**2162-6-24**] 05:49AM BLOOD Triglyc-65 HDL-51 CHOL/HD-2.7 LDLcalc-72 [**2162-6-23**] 10:30PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2162-6-23**] 08:15PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.007 [**2162-6-23**] 08:15PM URINE Blood-NEG Nitrite-NEG Protein-30 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-TR [**2162-6-23**] 08:15PM URINE RBC-3* WBC-2 Bacteri-MOD Yeast-NONE Epi-0 [**2162-6-23**] 08:15PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG cocaine-NEG amphetm-NEG mthdone-NEG DISCHARGE LABS: [**2162-6-28**] 05:55AM BLOOD WBC-12.3* RBC-4.65 Hgb-12.0 Hct-36.7 MCV-79* MCH-25.9* MCHC-32.8 RDW-17.2* Plt Ct-500* [**2162-6-28**] 05:55AM BLOOD Neuts-68.8 Lymphs-17.4* Monos-9.9 Eos-3.6 Baso-0.2 [**2162-6-28**] 05:55AM BLOOD Plt Ct-500* [**2162-6-25**] 04:14AM BLOOD PT-14.3* PTT-48.6* INR(PT)-1.3* [**2162-6-28**] 05:55AM BLOOD Glucose-130* UreaN-9 Creat-0.4 Na-135 K-3.9 Cl-101 HCO3-24 AnGap-14 [**2162-6-28**] 05:55AM BLOOD ALT-92* AST-26 AlkPhos-108* TotBili-0.5 [**2162-6-28**] 05:55AM BLOOD Lipase-425* [**2162-6-28**] 05:55AM BLOOD Calcium-9.0 Phos-3.7 Mg-1.8 [**2162-6-24**] 05:49AM BLOOD Triglyc-65 HDL-51 CHOL/HD-2.7 LDLcalc-72 MICRO: [**2162-6-23**] 8:15 pm URINE **FINAL REPORT [**2162-6-25**]** URINE CULTURE (Final [**2162-6-25**]): KLEBSIELLA PNEUMONIAE. >100,000 ORGANISMS/ML.. Piperacillin/tazobactam sensitivity testing available on request. Cefazolin interpretative criteria are based on a dosage regimen of 2g every 8h. GRAM POSITIVE BACTERIA. >100,000 ORGANISMS/ML.. Alpha hemolytic colonies consistent with alpha streptococcus or Lactobacillus sp. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ KLEBSIELLA PNEUMONIAE | AMPICILLIN/SULBACTAM-- 8 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- <=16 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S [**2162-6-23**] 9:00 pm BLOOD CULTURE #1. **FINAL REPORT [**2162-6-27**]** Blood Culture, Routine (Final [**2162-6-26**]): ESCHERICHIA COLI. FINAL SENSITIVITIES. Cefazolin interpretative criteria are based on a dosage regimen of 2g every 8h. Piperacillin/Tazobactam sensitivity testing performed by [**First Name8 (NamePattern2) 3077**] [**Last Name (NamePattern1) 3060**]. ESCHERICHIA COLI. SECOND STRAIN. FINAL SENSITIVITIES. Cefazolin interpretative criteria are based on a dosage regimen of 2g every 8h. Piperacillin/Tazobactam sensitivity testing performed by [**First Name8 (NamePattern2) 3077**] [**Last Name (NamePattern1) 3060**]. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI | ESCHERICHIA COLI | | AMPICILLIN------------ 8 S 8 S AMPICILLIN/SULBACTAM-- 4 S 4 S CEFAZOLIN------------- <=4 S <=4 S CEFEPIME-------------- <=1 S <=1 S CEFTAZIDIME----------- <=1 S <=1 S CEFTRIAXONE----------- <=1 S <=1 S CIPROFLOXACIN---------<=0.25 S <=0.25 S GENTAMICIN------------ <=1 S <=1 S MEROPENEM-------------<=0.25 S <=0.25 S PIPERACILLIN/TAZO----- S S TOBRAMYCIN------------ <=1 S <=1 S TRIMETHOPRIM/SULFA---- <=1 S <=1 S Aerobic Bottle Gram Stain (Final [**2162-6-24**]): GRAM NEGATIVE ROD(S). Reported to and read back by [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 43649**] [**2162-6-24**] 9:30AM. Anaerobic Bottle Gram Stain (Final [**2162-6-24**]): GRAM NEGATIVE ROD(S). [**2162-6-23**] 9:15 pm BLOOD CULTURE #2. **FINAL REPORT [**2162-6-26**]** Blood Culture, Routine (Final [**2162-6-26**]): ESCHERICHIA COLI. IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE # 350-1181H [**2162-6-23**]. Aerobic Bottle Gram Stain (Final [**2162-6-24**]): GRAM NEGATIVE ROD(S). Anaerobic Bottle Gram Stain (Final [**2162-6-24**]): GRAM NEGATIVE ROD(S). Blood cultures [**2162-6-25**] and [**2162-6-26**]: Pending (NGTD). MRSA SCREEN (Final [**2162-6-26**]): No MRSA isolated. CT A/P: 1. Prominent common bile duct measuring up to 1 cm, similar from prior. Mildly increased intrahepatic biliary ductal dilatation. No clear distal obstructing lesion is identified. 2. No intra-abdominal fluid collection to suggest abscess formation. No ascites. 3. Appendix not clearly visualized; however, no secondary signs of acute appendicitis. 4. Sigmoid diverticulosis without signs of acute diverticulitis. 5. Cecum containing right inguinal hernia without evidence of obstruction, unchanged from prior. 6. Stable severe compression deformities of the L2 and L3 vertebral bodies. CXR: 1. Bibasilar opacities concerning for pneumonia in this patient with fever and altered mental status, though atelectasis is also possible. 2. Probable small left pleural effusion. RUQ u/s [**2162-6-27**]: FINDINGS: There are no focal hepatic lesions. There is no intra- or extra-hepatic biliary dilation with the common bile duct measuring between 6 and 8 mm. There is no evidence of obstruction, stones or masses in the CBD. Gallbladder is normal without stones. Spleen is normal in size measuring 7 cm. The left kidney measures 10.3, the right kidney measures 10.2 cm without evidence of hydronephrosis, stones, or masses. The portal vein is patent with normal hepatopetal flow. The abdominal aorta and IVC are normal. IMPRESSION: Normal CBD and no evidence of gallstones. Brief Hospital Course: [**Age over 90 **] yo female with history of dementia who reportedly had fever and altered mental status at her nursing home found to have pan sensitive E. Coli septicemia likely from a biliary source. # E. Coli Septicemia likely secondary to Cholangitis: Patient noted on initial blood cultures to have pan-sensitive E coli. She was initially started on Unasyn to cover likely biliary source, transitioned to ceftriaxone and then PO cefpodoxime with plan for total 14 day course (on day 5 of 14 on day of discharge). Likely biliary source of bacteria; initial concern for urinary source given GNR in urine, but later grew out pan-sensitive Klebsiella in urine. Most likely source of septicemia is cholangitis given initial intrahepatic ductal dilitation and CBD dilitation on CT; resolved by day prior to discharge per RUQ ultrasound. No evidence of stones in the gallbladder on day prior to discharge; no evidence of obstructive mass on imaging, and given the resolution of the symptoms, she likely had a transient obstruction from a stone that has since passed. The patient improved clinically and her LFTs and white count trended down, with WBC 12 on day of discharge. . # Pancreatitis: Patient with abdominal pain, elevated lipase, and dusky stranding around pancreas on CT scan on admission. Bisap score was 3 given age, SIRS criteria (fever and leukocytosis), and pleural effusion. She was mildly hemoconcentrated with elevated hct and dry on exam. Most likely cause of pancreatitis is gallstones given prominent CBD (although size normal for age) and intrahepatic ductal dilatation, though CBD diameter stable from previous imaging and resolved on RUQ u/s on day prior to discharge. No clear inciting medications, normal TG, and no EtOH. No evidence of malignancy causing obstruction based on CT scan, and symptoms resolved without intervention making persistant obstruction unlikely. Considered ERCP but felt risk outweighed potential benefit given rapid improvement with antibiotics and conservative management. She was initially managed conservatively with NPO, IVF, and diet was advanced which she tolerated. On day of discharge, abdominal pain resolved and all labs trending towards normal. . # HTN: The patient's SBP was quite labile, ranging from 100 on admission to 190 on the floor. Had been on metoprolol succinate 12.5 mg daily which was held in the ICU given septicemia. Restarted on metoprolol succinate 25 mg daily on discharge. . # Bacteruria: Patient's urine grew pan-sensitive Klebsiella. No urinary symptoms. Likely asymptomatic bacturia, not source of septicemia; covered by cefpodoxime. . # Umbilical hernia: Mildly tender but reducible. No signs of obstruction, strangulation, or incarceration. Initially elevated lactate, now trended down and within normal limits on discharge. . # Dementia: Granddaughters report she is at her baseline. Initially held donepizil, then later restarted. . # Sjogrens: Stable. Continued artificial tears. . # Code status: Per extensive discussion with granddaughter, patient now DNR/DNI. # Transitions: 1) Blood cultures pending from [**2162-6-25**] and [**2162-6-26**] 2) Finish 14-day course of cefpodoxime 400 mg [**Hospital1 **], to be completed [**2162-7-7**] 3) Monitor blood pressure, may benefit from different antihypertensive medications given labile blood pressure 4) Consider RUQ ultrasound or MRCP as outpatient if develops abdominal pain in the future Medications on Admission: 1. Vitamin D 1,000 unit Capsule daily 2. Donepezil 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 3. Omeprazole 20 mg Capsule, Delayed Release(E.C.) daily 4. Metoprolol succinate 25 mg Tablet Sig: 0.5 Tablet PO daily 5. Multivitamin Capsule Sig: One (1) Capsule PO once a day. 6. Oxycodone 5 mg Capsule Sig: 2 Capsules PO BID 7. Calcium carbonate-vit D3-min 600 mg calcium- 400 unit Tablet [**Hospital1 **] 8. Glucosamine-chondroitin 500-400 mg Tablet (2) Tablet [**Hospital1 **] 10. Alendronate 70 mg Tablet Sig: One (1) Tablet PO every Monday 11. Miralax 17 gram/dose Powder Sig: One (1) packet PO tid 12. Artificial Tears Drops Sig: 1-2 drop Ophthalmic tid prn 13. Cranberry 1 tab daily Discharge Medications: 1. Artificial Tears 1-2 DROP BOTH EYES PRN irritation 2. Donepezil 10 mg PO HS 3. Metoprolol Succinate XL 25 mg PO DAILY 4. Multivitamins 1 TAB PO DAILY 5. Omeprazole 20 mg PO DAILY 6. Polyethylene Glycol 17 g PO TID:PRN constipation 7. Vitamin D 1000 UNIT PO DAILY 8. Cefpodoxime Proxetil 400 mg PO Q12H Duration: 9 Days Last Day [**2162-7-7**] RX *cefpodoxime 200 mg 2 Tablet(s) by mouth twice a day Disp #*36 Tablet Refills:*0 9. Miconazole Powder 2% 1 Appl TP PRN rash RX *Anti-Fungal 2 % Please apply to rash Four times a day Disp #*1 Bottle Refills:*0 10. Alendronate Sodium 70 mg PO QMON 11. calcium carbonate-vitamin D3 *NF* 600 mg calcium- 200 unit Oral [**Hospital1 **] 12. glucosamine-chondroitin *NF* 500-400 mg Oral [**Hospital1 **] 13. OxycoDONE (Immediate Release) 5-10 mg PO BID:PRN pain This medication was held during hospitalization 14. Acetaminophen 650 mg PO Q6H:PRN pain Discharge Disposition: Extended Care Facility: [**First Name4 (NamePattern1) 8463**] [**Last Name (NamePattern1) **] Place Discharge Diagnosis: Acute Cholangitis Septicemia (blood stream infection) Pancreatitis Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Ms. [**Known lastname **], It was a pleasure participating in your care at [**Hospital1 18**]. You were admitted for abdominal pain and fever. You were found to have a bacteria called E. coli in your blood, originally from an infection of your gall bladder and bile ducts. You will continue an antibiotic called cefpodoxime for a total duration of 14 days. See attached for any medication changes. Followup Instructions: You will have a follow-up appointment scheduled with your rehab.

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icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

15017, 15119

9919, 13351

250, 256

15230, 15230

3096, 3096

15844, 15912

1918, 1944

14098, 14994

15140, 15209

13377, 14075

15415, 15821

4360, 9896

1959, 3077

190, 212

284, 1274

3112, 4344

15245, 15391

1296, 1536

1552, 1902

76,844

102,087

36856

Discharge summary

report

Admission Date: [**2116-7-19**] Discharge Date: [**2116-7-22**] Service: NEUROLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 5018**] Chief Complaint: bleed tranferred from OSH Major Surgical or Invasive Procedure: None History of Present Illness: Ms. [**Known lastname 83237**] is an 88 yo RH woman with a pMH remarkable for HTN, CHF and LBD on coumadin (parox AF) p/w a fall 24h prior to admission at [**Hospital1 18**]. She fell from her rocking chair and struck the LEFT side of her head and LEFT hand yesterday at noon. She did not loose her consciousness (as per nurse who saw her in her chair 1 minute prior to falling). She is usually having falls when attempting to walk with her walker. She did have a bilateral hip replacement and a subsequent LEFT femoral fracture (with residual internal hip rotation) that impairs her gait (for 2 years). She remained in the [**Hospital3 **] facility, but started to become confused. She was taken to [**Hospital3 4107**] today at around 11:00 am, where she received a CT scan that showed a small (1. 3cm) left frontal intraparenchimal bleed without a midline shift, not open to the ventricles, no data of hydrocephalus. At [**Hospital1 **] her VS were stable. At the time she was confused. She had an INR of 2.97 and received vitamin K 10 mg iv without complications. Once at [**Hospital1 18**] ED, her VS were 98.6F, 70 bpm, 161/ 71, 16RR, So2 100% in RA. She was alert and oriented *3. Pleasant and cooperative with the ED team. She received FFP and a new CT CNS and C-spine scan w/o contrast that showed. The family denies any previous episodes with focal deficits eventually resolving. Sh ehas been having viual hallucinations for 24 months. Those are well formed (people). She talks to them, but they do not reply. She has been seeing her husband lately (he passed the way 6 months ago). Past Medical History: PMH: PCP:[**Telephone/Fax (1) 83238**] HTN Paroximal CHF (unknown EF and diastolic function) LBD Depression?? Urinary incontinence No previous strokes or spontaneous bleeds/ coagulopathy or brain tumors. No Hx of seizure Social History: Lives in [**Location 10549**] living facility Family History: no hx of early strokes, or spontaneous bleeds/ coagulopathy, brain tumors. No Hx of seizures. Physical Exam: VS: 98.6F, 70 bpm, 161/ 71, 16RR, So2 100% in RA. Gen: Lying in bed, NAD. HEENT: NC/AT, moist oral mucosa Neck: supple, no carotid or vertebral bruit Back: No point tenderness or erythema CV: Nl S1 and S2, no murmurs/gallops/rubs Lung: Clear to auscultation bilaterally Abd: Soft, nontender, non-distended. No masses or megalies.Percussion within normal limits. +BS. Ext: no edema, no DVT data. Pulses ++ and symmetric. Neurologic examination: No meningismus. No photophobia. MS:General: alert, awake, normal affect Orientation: oriented to person, place, date, situation Attention: 20 to 1 backwards +. Follows simple/complex commands. Speech/Language: fluent w/o paraphasic errors; comprehension,repetition, naming: normal. Prosody: normal. Memory: Registers [**3-24**] and Recalls [**2-25**] when given choices at 5 min Praxis/ agnosia: Able to brush teeth. No field cuts. CN:I: not tested II,III: VFF to confrontation, PERRL 3mm to 2mm, fundus w/o papilledema. III,IV,VI: EOMI, no ptosis. No nystagmus V: sensation intact V1-V3 to LT VII: Facial strength intact/symmetrical VIII: hears finger rub bilaterally IX,X: palate elevates symmetrically, uvula midlineXI: SCM/trapezeii [**5-26**] bilaterally XII: tongue protrudes midline, no dysarthria Rinne: R ear: AC>BC, LEFT ear AC> BC [**Doctor Last Name 15716**]: central. Motor: Normal bulk. Tone: Coughweeling in both arms. No tremor, no asterixis or myoclonus. No pronator drift: Delt;C5 bic:C6 Tri:C7 Wr ext:C6 Fing ext:C7 Left 5 5 5 5 5 Right 5 5 5 5 5 IP: Quad: Hamst: Dorsiflex: [**Last Name (un) 938**]:Pl.flex Left internal rotation and antigravity (not new). Right 5 5 5 5 5 Deep tendon Reflexes: Bicip:C5 Tric:C7 Brachial:C6 Patellar:L4 Toes: Right 1 1 1 1 DOWNGOING Left 1 1 1 1 DOWNGOING Sensation: Intact to light touch, vibration, and temperature.Propioception: normal. Coordination: *Finger-nose-finger normal. *Rapid Arm Movements bl clumsy *Fine finger tapping: no decrement Pertinent Results: [**2116-7-19**] 05:35PM GLUCOSE-85 UREA N-19 CREAT-1.0 SODIUM-141 POTASSIUM-4.3 CHLORIDE-103 TOTAL CO2-31 ANION GAP-11 [**2116-7-19**] 05:10PM WBC-6.1 RBC-3.67* HGB-10.6* HCT-31.5* MCV-86 MCH-28.9 MCHC-33.6 RDW-15.0 [**2116-7-19**] 05:10PM NEUTS-71.9* LYMPHS-20.7 MONOS-5.3 EOS-1.9 BASOS-0.3 [**2116-7-19**] 05:10PM PT-27.9* PTT-38.3* INR(PT)-2.7* [**2116-7-20**] 02:32AM BLOOD CK-MB-3 cTropnT-0.04* [**2116-7-20**] 08:35AM BLOOD CK-MB-5 cTropnT-0.05* [**2116-7-20**] 02:32AM BLOOD Triglyc-80 HDL-51 CHOL/HD-4.0 LDLcalc-135* [**2116-7-20**] 02:32AM BLOOD TSH-1.6 Wrist x ray: No acute fracture. Old distal radious and ulnar styloid fractures. CNS scan without contrast: LEF frontal bleed. no mas effect, not open to ventricles. Brief Hospital Course: Mrs.[**Last Name (un) 83239**] INR was corrected with vitamin K at OSH and Profilnine and FFP here. Ms [**Known lastname 83237**] was admitted to the neurologic ICU service overnight for observation for her left frontal intraparechymal hemorrhage. Her ICH was thought to represent a traumatic contusion. She remained stable and her neurologic exam was normal other than a slight right facial droop. No repeat imaging or further work up was felt to be necessary. Fasting lipid panel w/ LDL 135, total Chol 202. Discharged on ASA 81 qd with plans to re-start coumadin in [**7-31**] days. When therapeutic on coumadin, ASA will be discontinued. Cards: Telemetry unremarkable No ID, Endo, GI, Resp issues this admission Medications on Admission: Coumadin 5mg qhs, but Tuesday and Friday 7 mg qhs ASA 81 mg qd. Metoprolol 25 mg [**Hospital1 **], verapamil 240 qd, lisinopril 20 qd. Furosemide 20 mg qd Sinemet/ carbidopa: 25/ 100 tid Aricept 5 mh qd. Celexa 20 qd. Bactrim SS 100/ 80, Tolterodine (antimuscarinic) 7.5 qd MVI Discharge Medications: 1. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 2. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Carbidopa-Levodopa 25-100 mg Tablet Sustained Release Sig: One (1) Tablet PO TID (3 times a day). 5. Donepezil 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 6. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Tolterodine 1 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 9. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 10. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily): This medication is to be stopped when coumadin reaches therapeutic dose. Coumadin to be started [**7-27**]. 11. Verapamil 240 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO once a day. Discharge Disposition: Extended Care Facility: [**First Name8 (NamePattern2) **] [**Hospital **] Nursing Home - [**Location (un) 5087**] Discharge Diagnosis: Primary: traumatic left frontal intaparychymal hemorrhage (contusion) Secondary: Paroxysmal atrial fibrilation treated with coumadin CHF Hypertension [**Last Name (un) 309**] Body Dementia Discharge Condition: She is at her baseline. Still mild rigth sidede droop. Otherwise her neurological examination is normal. Discharge Instructions: You were admitted to the ICU with bleeding in the front left part of your brain after a fall. The bleeding has stabilized and your coumadin was reversed . Please take all medications as perscribed. If you have concerns about the medications, please call your PCP before changing the doses. . Please call your PCP or return to the emergency room if you experience any worsening in your symptoms or have other concerns Please note that coumadin was reversed and stopped because of hemorrhage. Aspirin has been started in meantime. Coumadin should be resumed at prior dose on [**7-27**], and titrate to goal INR [**2-25**]. Aspirin to be discontinued once INR therapeutic. Followup Instructions: Provider: [**Name10 (NameIs) 4267**] [**Last Name (NamePattern4) 4268**], MD, PHD[**MD Number(3) 708**]:[**Telephone/Fax (1) 657**] Date/Time:[**2116-9-8**] 1:00 PCP: [**Name10 (NameIs) 9529**],[**Name11 (NameIs) **] [**Telephone/Fax (1) 17503**] [**Name6 (MD) 4267**] [**Last Name (NamePattern4) 4268**] MD, [**MD Number(3) 5023**]

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icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

7343, 7459

5296, 6023

290, 297

7693, 7800

4534, 5273

8523, 8889

2250, 2346

6352, 7320

7480, 7672

6049, 6329

7824, 8500

2361, 2783

224, 252

325, 1926

2807, 4515

1948, 2171

2187, 2234

27,172

129,356

49078

Discharge summary

report

Admission Date: [**2109-6-6**] Discharge Date: [**2109-7-9**] Date of Birth: [**2055-11-20**] Sex: M Service: SURGERY Allergies: Penicillins / Aspirin / Ibuprofen / Ciprofloxacin Attending:[**First Name3 (LF) 668**] Chief Complaint: ESLD (alcoholic cirrhosis)/ Hepatorenal syndrome here for orthotopic liver [**First Name3 (LF) **] Major Surgical or Invasive Procedure: [**2109-6-6**]: orthotopic liver [**Month/Day/Year **] [**2109-6-20**]: EGD [**2109-6-23**]: Exploratory laparotomy, evacuation of hematoma, liver biopsy [**2109-6-27**]: EGD History of Present Illness: 53 y/o male with alcoholic cirrhosis and known grade II esophageal varices, portal gastropathy, hepatorenal syndrome and non occlusive portal vein thrombus who presents for orthotopic liver [**Month/Day/Year **]. He had a recent admission at [**Hospital1 18**] in [**Month (only) **], and has undergone paracentesis, and GI bleeds. He currently denies fever, chills, nausea, vomiting, abdominal pain, diarrhea or dysuria. No recent sickness. Past Medical History: alcoholic cirrhosis, listed for [**Month (only) **] - prior ascites - prior hepatorenal syndrome requiring several sessions of hemodialysis - known grade II esophageal varices and portal gastropathy by EGD [**2109-4-9**] - history of candidal and bacterial (SBP) peritonitis - colorectal cancer (stage unknown) s/p colectomy in [**11/2108**] - cervical stenosis - hyperlipidemia - hypertension - history of C Diff colitis - anemia with baseline Hct 27-30 - history of Torsades while on ciprofloxacin - depression - history of positive PF4 antibody - BPH Social History: Home: Lived with wife and daughter in [**Name2 (NI) **] prior to hospitalization in [**Month (only) 958**]. Has since been at [**Hospital1 100**]/[**Hospital 8218**] rehab Occupation: used to work as construction worker. EtOH: denies ETOH for past 5 years, extensive in the past Drugs: denies h/o IVDA Tobacco: Tobacco: [**Date range (1) 61126**] PPD x 30 years; quit in 2/[**2108**]. Family History: Denies fhx of early MI, stroke, cancer. Physical Exam: VS:: 97.8, 65, 121/84, 22, 98%RA Gen: NAD HEENT: icteric sclera, moist mucous membranes, oropharynx clear Neck: supple, no LAD, no JVD CV: RR normal S1S2, no M/R/G Lungs: decreased BS at bases bilaterally, diffuse wheezes, no crackles Abd: well healed midline abdominal incision, distended, tympanic Extr: No edema, 2+ pedal pulses Neuro A+Ox3, CN II-XII grossly intact, no asterixis Pertinent Results: On Admission: [**2109-6-6**] WBC-6.5 RBC-2.69* Hgb-9.3* Hct-27.5* MCV-102* MCH-34.5* MCHC-33.7 RDW-18.6* Plt Ct-104* PT-19.8* PTT-40.1* INR(PT)-1.8* Glucose-138* UreaN-69* Creat-1.8* Na-136 K-4.5 Cl-109* HCO3-19* AnGap-13 ALT-25 AST-65* AlkPhos-170* TotBili-3.0* Albumin-2.3* Calcium-8.3* Phos-4.0# Mg-1.9 On Discharge: [**2109-7-9**] WBC-10.7 RBC-3.06* Hgb-9.4* Hct-28.7* MCV-94 MCH-30.8 MCHC-32.8 RDW-16.4* Plt Ct-186 Glucose-140* UreaN-80* Creat-1.5* Na-136 K-5.8* Cl-107 HCO3-18* AnGap-17 ALT-18 AST-13 AlkPhos-178* TotBili-0.4 Albumin-2.5* Calcium-8.6 Phos-4.6* Mg-2.0 tacroFK-15.0 (Dose dropped to 1 mg [**Hospital1 **] Brief Hospital Course: 53 y/o male admitted for orthoptopic liver [**Hospital1 **]. He was taken to the OR by Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] and Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]. The liver resection to remove his native liver was difficult. During the surgery he received 16 units RBCs, 22 units FFP, 5 units platelets and had an EBL of 9 liters. Once the portal anastomosis was secured, the liver pinked up and was making bile. He has an end-to-end anastomosis of the common hepatic artery to a branch patch of the gastroduodenal and the proper hepatic artery, duct to duct anastomosis. Two [**Doctor Last Name 406**] drains were placed and the patient was transferred intubated to the SICU. Please see the operative note for further surgical detail. He was extubated on POD 1. He was reintubated on POD 2, due to acute desaturation, BAL performed with thick secretions obtained, normal flora on culture. In addition on POD 2 he underwent a bedside thoracentesis for a large left pleural effusion with drainage of 750 cc serosanguinous fluid. Pleural fluid had no growth. He was able to be extubated [**Last Name (un) 7162**] on POD 4. A feeding tube was placed on [**6-10**] and tube feeds initiated. He was seen daily by physical therapy. Transferred to the regular surgical floor on POD 8. Despite several placements with subsequent "pull outs" the patient did not have a Dobhoff in place for nutritional supplementation despite encouragement by all teams and nutrition of the importance of the tube feeds. A psych consult was called on [**6-14**] due to reported significant changes from patients baseline, especially as reported by wife. [**Name (NI) 15110**] to concerns for prolonged QTc and risk for Torsades, many medications were ruled out in this patient. Assess ment per psych is mild delirium with steroid induced hypomania. His remeron was discontinued. As behavior is reported as irritable but not grossly agitated, no medications were added. He remained without the Dobhoff, calorie counts were initiated, supplements written. Continued work with PT shows minimal ability to achieve ADL's, and requiring maximum assist with mobility. He had a bridled Dobhoff placed on [**2109-6-20**], tube feeds were started. In the meantime he had been maintained on TPN via a PICC line. He was having decreasing hematocrits around POD 17, and despite receiving transfusions, he was not having appropriate Hct increases. CT of abdomen revealed - Slight interval increase in the intraabdomial/pelvic and subcapsular fluid collection, part of which is still high attenuation consistent with continued bleeding. The location of the fluid has also redistributed somewhat, with a little bit less inferior to the tip of the liver. And so he underwent Exploratory laparotomy, evacuation of hematoma, liver biopsy with Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] on [**6-23**]. Per op report there was a moderate amount of blood posterior to the hilum and around the right lobe of the liver, which was evacuated. There was also a sizable hematoma along the left side of the vena cava between the vena cava and the crus of the diaphragm and this was also removed and evacuated. there was a moderate amount of bleeding from the gallbladder fossa itself but this responded to argon beam coagulation. He was returned to the surgical floor following his PACU recovery, and his Hct has remained stable since that time. On [**6-27**] an EGD revealed friability, erythemamatous ulcerations and congestion in the middle third of the esophagus and lower third of the esophagus compatible with esophagitis, a biopsy was sent which revealed "Severe acute (neurophilic) esophagitis; stain for fungus is negative. Iron stain is negative." The stomach mucosa was normal and to the second part of the duodenum. He had not been on Fluconazole due to QTc prolongation concerns. He was started on Ambisome x 10 days. He was then started on PO Fluconazole, QTc interval has been normal. The ND tube remained out and he was maintained nutritionally on TPN via PICC line. On [**7-2**] he again was sent for bridled Dobhoff feeding tube, and Nutren 2.0 was started. Initially he had some diarrhea and distention. Due to concerns for increased potassium and kidney function slightly decreased he was switched to nutren renal for tube feeds. Needs bowel regimen in place. He was still being followed by OT/PT who recommended D/C to a rehab facility. He remains a maximum assist. Labs to be drawn every Monday and Thursday. PLease have patient follow up with outpatient clinic visits per schedule. Medications on Admission: Midodrine 10mg po TId, Rifaximin 200mg po TId, Remeron 7.5mg po HS Oxycodone 10mg po q6 prn Discharge Medications: 1. Metoprolol Tartrate 25 mg Tablet [**Month/Day (1) **]: One (1) Tablet PO BID (2 times a day). 2. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr [**Month/Day (1) **]: One (1) Capsule, Sust. Release 24 hr PO DAILY (Daily). 3. Sodium Chloride 0.65 % Aerosol, Spray [**Month/Day (1) **]: [**11-28**] Sprays Nasal PRN (as needed) as needed for dry nose. 4. Camphor-Menthol 0.5-0.5 % Lotion [**Month/Day (2) **]: One (1) Appl Topical PRN (as needed). 5. Mycophenolate Mofetil 500 mg Tablet [**Month/Day (2) **]: Two (2) Tablet PO BID (2 times a day). 6. Valganciclovir 450 mg Tablet [**Month/Day (2) **]: Two (2) Tablet PO DAILY (Daily). 7. Oxycodone 5 mg Tablet [**Month/Day (2) **]: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. 8. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR PO BID (2 times a day). 9. Insulin Regular Human 100 unit/mL Solution [**Last Name (STitle) **]: Per sliding scale Injection ASDIR (AS DIRECTED). 10. Fluconazole 200 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO Q24H (every 24 hours). 11. Prednisone 5 mg Tablet [**Last Name (STitle) **]: Three (3) Tablet PO DAILY (Daily): Per [**Last Name (STitle) **] taper. 12. Docusate Sodium 50 mg/5 mL Liquid [**Last Name (STitle) **]: 10 ml PO BID (2 times a day). 13. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily). 14. Dulcolax 10 mg Suppository [**Last Name (STitle) **]: One (1) Rectal once a day as needed for constipation. 15. Nystatin 100,000 unit/mL Suspension [**Last Name (STitle) **]: Five (5) ML PO QID (4 times a day). 16. Tacrolimus 1 mg Capsule [**Last Name (STitle) **]: One (1) Capsule PO twice a day: Trough Prograf Thurs [**7-11**] in addition to regular labs. Fax to [**Telephone/Fax (1) 697**]. 17. Medication Maalox/Diphenhydramine/Lidocaine 30 mL PO TID 18. PICC line Care Sodium Chloride 0.9% Flush 10 mL IV PRN line flush PICC, non-heparin dependent: Flush with 10 mL Normal Saline daily and PRN per lumen Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - MACU Discharge Diagnosis: ETOH Cirrhosis, ascites, hepatorenal syndrome, esophageal varices, portal gastropathy, partial portal vein thrombosis now s/p Orthotopic Liver [**Hospital6 **] [**2109-6-6**] Discharge Condition: Stable, fair Discharge Instructions: Please call the [**Month/Day/Year **] clinic at [**Telephone/Fax (1) 673**] for fever > 101, chills, nausea, vomiting, diarrhea, inability to take or keep down medications. Tube feeds via bridled [**Last Name (un) **] duodenal tube. NO MEDS to be flushed down ND tube [**Last Name (un) 1326**] Labwork per [**Last Name (un) **] clinic guidelines: CBC, Chem 10, AST, ALT, Alk phos, Albumin, T Bili, Trough Prograf level. Fax results to [**Telephone/Fax (1) 697**]. Labs q Monday and Thursday. Patient may shower Weekly EKG to assess QTc interval remaining normal Followup Instructions: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2109-7-11**] 2:40 [**Last Name (LF) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] CENTER (NHB) Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2109-7-11**] 2:15 [**First Name11 (Name Pattern1) 819**] [**Last Name (NamePattern4) 820**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2109-7-18**] 9:30 Completed by:[**2109-7-9**]

[ "263.9", "303.93", "600.00", "293.0", "571.2", "486", "285.9", "707.03", "518.0", "518.5", "511.9", "998.12", "456.21", "530.10", "537.89", "V10.05", "530.20", "560.1", "572.4", "272.4", "V15.82", "452", "401.9" ]

icd9cm

[ [ [] ] ]

[ "45.16", "99.07", "99.15", "99.05", "96.04", "34.04", "33.24", "38.93", "34.91", "99.00", "96.6", "54.19", "50.59", "99.04", "33.22", "46.32", "00.93", "96.71" ]

icd9pcs

[ [ [] ] ]

10017, 10083

3162, 7810

406, 583

10302, 10317

2512, 2512

10927, 11437

2052, 2093

7953, 9994

10104, 10281

7836, 7930

10341, 10904

2108, 2493

2832, 3139

268, 368

611, 1054

2526, 2818

1077, 1633

1649, 2036

58,562

195,904

35774

Discharge summary

report

Admission Date: [**2183-4-8**] Discharge Date: [**2183-4-15**] Date of Birth: [**2116-1-10**] Sex: M Service: CARDIOTHORACIC Allergies: Penicillins Attending:[**First Name3 (LF) 165**] Chief Complaint: Chest pain Major Surgical or Invasive Procedure: [**2183-4-10**] - Coronary artery bypass grafting to three vessels. (Left internal mammary artery->Left anterior descending artery, saphenous vein graft(SVG)->Diagonal artery, SVG->Obtuse marginal artery). History of Present Illness: Mr. [**Known lastname **] was admitted to the [**Hospital1 18**] on [**2183-4-8**] for further management of his coronary artery disease. He originallty presented to his primary care physician with dyspnea with minimal exertion. An echo was performed which showed concentric left ventricular hypertrophy. An exercise stress test was performed which was positive for ischemia. A cardiac catheterization was then obtained which revealed severe left main and two vessel disease. He is now admitted for preoperative work-up for coronary artery bypass grafting. Past Medical History: Coronary artery disease s/p three vessel bypass grafting Hypertension Hyperlipidemia Obesity Prostate Cancer Glaucoma Nephrolithiasis Arthritis Social History: Works part-time in post office. Lives with sister and her husband. [**Name (NI) 4084**] smoked. Family History: Mother with heart failure. Physical Exam: 80 SR 18 137/76 64" 119kg\ GEN: No acute distress HEART: Regular rate and rhythm. No murmur LUNGS: Clear Abdomen: Benign, obese Extremities: Pulses intact, no varicosities. No edema Pertinent Results: [**2183-4-8**] 09:16PM WBC-11.0 RBC-4.83 HGB-15.1 HCT-42.4 MCV-88 MCH-31.2 MCHC-35.5* RDW-13.2 [**2183-4-8**] 09:16PM PT-16.0* PTT-27.0 INR(PT)-1.4* [**2183-4-8**] 09:16PM %HbA1c-6.2* [**2183-4-8**] 09:16PM ALT(SGPT)-21 AST(SGOT)-16 LD(LDH)-140 ALK PHOS-66 TOT BILI-0.5 [**2183-4-8**] 09:16PM GLUCOSE-114* UREA N-21* CREAT-1.1 SODIUM-140 POTASSIUM-3.8 CHLORIDE-106 TOTAL CO2-26 ANION GAP-12 [**2183-4-8**] 11:14PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [**2183-4-15**] 10:33AM BLOOD WBC-11.8* RBC-3.77* Hgb-11.4* Hct-34.2* MCV-91 MCH-30.3 MCHC-33.4 RDW-13.3 Plt Ct-308 [**2183-4-15**] 10:33AM BLOOD Plt Ct-308 [**2183-4-15**] 06:55AM BLOOD PT-14.9* INR(PT)-1.3* [**2183-4-14**] 09:05AM BLOOD Glucose-199* UreaN-19 Creat-1.1 Na-135 K-4.3 Cl-97 HCO3-33* AnGap-9 [**2183-4-10**] ECHO PRE-BYPASS: No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). Right ventricular chamber size and free wall motion are normal. There are simple atheroma in the descending thoracic aorta. There are three aortic valve leaflets. There is no aortic valve stenosis. Trace aortic regurgitation is seen. Trivial mitral regurgitation is seen. There is no pericardial effusion. POST-BYPASS: The patient is in sinus rhythm and on an infusion of phenylephrine. Biventricular function is preserved. The aorta is intact. Pulmonary artery catheter is in the right pulmonary artery. The examination is unchanged. Radiology Report CHEST (PA & LAT) Study Date of [**2183-4-14**] 2:35 PM CHEST (PA & LAT) Clip # [**Clip Number (Radiology) 81358**] Reason: evaluate for effusion Final Report HISTORY: 67-year-old man, status post CABG, evaluate for pleural effusion. COMPARISON: [**2183-4-12**]. PA AND LATERAL CHEST RADIOGRAPH: There are unchanged midline sternotomy wires and also small clips along the cardiac border compatible with CABG. The cardiac silhouette is essentially unchanged. There are small bilateral pleural effusions. There is appearance of increased lucency in the left lower lung, compatible with improved aeration and decreased atelectasis. There is minimal subcutaneous air in the anterior chest wall, compatible with recent surgery. IMPRESSION: 1. Small bilateral pleural effusions. 2. Improving atelectasis. 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 (NamePattern4) 5785**] Brief Hospital Course: Mr. [**Known lastname **] was admitted to the [**Hospital1 18**] on [**2183-4-8**] for surgical management of his coronary artery disease. He was placed on heparin given his left main disease. Mr. [**Known lastname **] was worked-up in the usual preoperative manner and found to be ready for surgery. On [**2183-4-10**], Mr. [**Known lastname **] was taken to the operating room where he underwent coronary artery bypass grafting to three vessels. Please see operative note for details. Postoperatively he was taken to the intensive care unit for monitoring. Over the next several hours, he awoke neurologically intact and was extubated. Chest tubes were removed on POD#1 and he was transferred from the ICU to the floor. On POD#2 Mr. [**Known lastname **]' renal function was noted to be worsening, lasix was decreased and on POD#3 renal function had improved. Mr. [**Known lastname **]' pacing wires were removed per protocol. Over the next several days his activity level progressed with assistance from physical therapy. On POD5 he was ready for discharge home with visiting nurses. Medications on Admission: Glyburide 2.5', ASA 81', Betaxolol 2 gtts [**Hospital1 **], Zocor 20', Atenolol 25', Allopurinol 100' Discharge Medications: 1. Potassium Chloride 10 mEq Tablet Sustained Release Sig: Two (2) Tablet Sustained Release PO once a day for 2 weeks. Disp:*28 Tablet Sustained Release(s)* Refills:*0* 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 3. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 5. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 6. Betaxolol 0.25 % Drops, Suspension Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2 times a day). 7. Glyburide 2.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day for 2 weeks. Disp:*14 Tablet(s)* Refills:*0* 9. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO once a day: 400mg QD x 1 week then 200mg QD. Disp:*40 Tablet(s)* Refills:*2* 10. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 11. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours) as needed for left arm phlebitis for 5 days. Disp:*20 Capsule(s)* Refills:*0* 12. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain. 13. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO every four (4) hours as needed. Disp:*50 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Location (un) 1110**] VNA Discharge Diagnosis: Coronary Artery Disease status post Coronary Artery Bypass Graft x 3 Hypertension Hyperlipidemia Obesity Prostate Cancer Glaucoma Nephrolithiasis Arthritis Discharge Condition: Good Discharge Instructions: 1)Monitor wounds for signs of infection. These include redness, drainage or increased pain. In the event that you have drainage from your sternal wound, please contact the [**Name2 (NI) 5059**] at ([**Telephone/Fax (1) 4044**]. 2)Report any fever greater then 100.5. 3)Report any weight gain of 2 pounds in 24 hours or 5 pounds in 1 week. 4)No lotions, creams or powders to incision until it has healed. You may shower and wash incision. Gently pat the wound dry. Please shower daily. No bathing or swimming for 1 month. Use sunscreen on incision if exposed to sun. 5)No lifting greater then 10 pounds for 10 weeks from date of surgery. 6)No driving for 1 month or while taking narcotics for pain. 7) Call with any questions or concerns. Followup Instructions: Please follow-up with Dr. [**First Name (STitle) **] in 1 month. ([**Telephone/Fax (1) 1504**] Please follow-up with Dr. [**Last Name (STitle) 8051**] in 2 weeks. Please follow-up with Dr. [**Last Name (STitle) 11427**] in 1 week. [**Telephone/Fax (1) 8058**] Please call all providers for appointments. [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**] Completed by:[**2183-4-15**]

[ "592.0", "401.9", "518.0", "511.9", "250.00", "427.31", "365.9", "V10.46", "V85.4", "278.00", "414.01", "411.1" ]

icd9cm

[ [ [] ] ]

[ "36.12", "39.61", "36.15", "33.23" ]

icd9pcs

[ [ [] ] ]

7034, 7093

4284, 5372

287, 495

7293, 7300

1628, 4261

8087, 8513

1378, 1406

5524, 7011

7114, 7272

5398, 5501

7324, 8064

1421, 1609

237, 249

523, 1081

1103, 1249

1265, 1362

13,006

174,170

9423

Discharge summary

report

Admission Date: [**2176-1-29**] Discharge Date: [**2176-2-7**] Date of Birth: [**2116-5-13**] Sex: M Service: UROLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 6157**] Chief Complaint: Prostate Ca Major Surgical or Invasive Procedure: Radical prostatectomy History of Present Illness: Mr [**Known lastname **] is a 59-year-old gentleman with a history of abnormal digital rectal exam. He had a prostate needle biopsy approximately seven months ago which demonstrated high grade PIN. A followup prostate biopsy demonstrated a [**Doctor Last Name **] 3 plus 3 involving 40 percent of the core on the right side. He presented to the hospital for a radical retropubic prostatectomy with Dr. [**Last Name (STitle) 4229**]. Past Medical History: HTN Afib hyperchol. Social History: He does not smoke. He works as a maintenance worker. Family History: Significant for stroke of father at the age of 92 and of mother who [**Name2 (NI) **] at the age of 53. Pertinent Results: [**2176-1-29**] 08:21AM HGB-12.2* calcHCT-37 [**2176-1-29**] 08:21AM GLUCOSE-105 NA+-140 K+-3.8 CL--103 TCO2-26 [**2176-1-29**] 01:15PM WBC-14.8*# RBC-3.37*# HGB-10.5*# HCT-30.9*# MCV-92 MCH-31.2 MCHC-34.0 RDW-13.7 [**2176-1-29**] 01:15PM PLT COUNT-204 Brief Hospital Course: Patient tolerated procedure well and was transferred to 12R. On POD2, on [**2176-1-31**], he started becoming short of breath and his oxygen sats dropped to low 90s with a temp of 102.1. He had a chest x-ray that showed bilateral consolidations and he was treated with antibiotics for pneumonia. On POD3, [**2-1**], patient experienced O2 desaturation to mid-80s and he had a CTA that showed bilateral PEs. He desaturated down to 72% on 3 liters and he was transferred to the ICU. Hematology was consulted and recommendations were followed. He was started on heparin IV. He was transfused 2 units of blood. He had lower extremity Dopplers that showed no clot. On POD4, He was hemodynamically stable and transferred back to floor. Warfarin was initiated. On POD6, INR was 2.2, and Heparin was discontinued. On POD7, INR was elevated and Warfarin was held. On POD8, INR remained elevated and he was given a low dose of Warfarin. On POD9, patient was deemed stable and suitable for discharge. At discharge, he had 96% O2 sat on room air and lungs sounded clear. His INR was 2.2. Hct was stable. Discharge Medications: 1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. Disp:*30 Tablet(s)* Refills:*0* 2. Atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Amlodipine Besylate 5 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). Disp:*60 Capsule(s)* Refills:*2* 5. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO once a day for 3 days: Please take first day on the day prior to appointment with Dr. [**Last Name (STitle) 4229**]. Disp:*3 Tablet(s)* Refills:*0* 6. Warfarin Sodium 2.5 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*0* 7. Metoprolol Tartrate 50 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 8. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 9. Oxazepam 15 mg Capsule Sig: One (1) Capsule PO at bedtime as needed for insomnia. Disp:*30 Capsule(s)* Refills:*1* Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Prostate Ca Discharge Condition: Good Discharge Instructions: Go to an Emergency Room if you experience symptoms including, but not necessarily limited to: new and continuing nausea, vomiting, fevers (>101.5 F), chills, or shortness of breath. Proceed to the ER/EW/ED if your wound becomes red, swollen, warm, or produces pus. Leave the steri strips on until they begin to peel, then you may remove them. Staples and stitches will remain until your follow-up appointment. 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. You may resume your regular diet as tolerated. You may take showers (no baths) after your dressings have been removed from your wounds. Continue taking your home medications unless otherwise contraindicated and follow up with PCP. [**Name10 (NameIs) **] will go home with a leg bag for at least one week. Start Levaquin on day prior to clinic appt with [**Doctor Last Name 4229**]. Continue anticoagulation for 6mo to 1 year. Thereafter prophylactic anticoagulation when in high risk situation (prolonged immobilization, plane ride, etc). Followup Instructions: Follow up in 1 weeks with Dr. [**Last Name (STitle) 4229**] for catheter removal. Please restart taking Levoquin starting one day prior to this clinic appointment. See Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] tomorrow for 1st blood draw. Continue blood draws per schedule listed on Page 1. After completion of his anticoagulation treatment and after you have been off anticoagulation for a month, need to see a hematologist in order to have his antithrombin III, protein C, and protein S checked and perhaps a D-dimer. Completed by:[**2176-2-7**]

[ "427.31", "E878.6", "185", "272.0", "415.11", "401.9" ]

icd9cm

[ [ [] ] ]

[ "99.04", "40.3", "99.02", "60.5" ]

icd9pcs

[ [ [] ] ]

3490, 3548

1354, 2451

325, 349

3604, 3610

1069, 1331

5027, 5605

945, 1050

2474, 3467

3569, 3583

3634, 5004

274, 287

377, 814

836, 857

873, 929

8,921

187,121

9289

Discharge summary

report

Admission Date: [**2129-8-4**] Discharge Date: [**2129-8-8**] Date of Birth: [**2051-9-14**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 783**] Chief Complaint: Abd pain AMS Major Surgical or Invasive Procedure: None History of Present Illness: 77 y.o. male with h/o rheumatic heart disease s/p mechanical mvr/avr (elev Ao gradient at 45mmHg, 2+MR), PAF on coumadin, VVI PPM, CAD w/ known 3VD, diastolic HF with preserved EF 55%, who presented to PMD's office today for check up. Reports that over the last three weeks has been having post-prandial RUQ pain, which occurs approx xx minutes follow eating. Daughter noted that the patient was increasingly fatigued today and seemed confused. Denies f/chills/rashes. +c/o frequent urination. . Presented to PMD who, by report, checked labs and noted that patient had significantly elevated Cr and was sent to ED. In ED, 95.8/60/96/44, 97% 2L confused on presentation. Given elevated WBCC 15.5, and mild hypotension patient started on MUST protocol. RIJ placed and patient levofloxacin and metronidazole. . Past Medical History: 1. CAD - s/p cath [**2128-10-20**] with 3VD: 99% distal LAD, 60% LCx at origin of prior PTCA, RCA 50% distal with 70% RPL. Prior LAD and RCA stents widely patent. [**2128-7-30**]:stenting of the RCA with 3 overlapping cypher [**Name Prefix (Prefixes) **] -[**Last Name (Prefixes) **] [**2128-8-11**]: rotational atherectomy, PTCA and stenting of the LAD/LCX. Last stress [**9-27**]--> moderate to severe, fixed perfusion defect of all three segments of the inferior and inferolateral walls extending into the apex (fixed compared to partially reversible in [**7-28**]). 2. MVR/AVR - complicated by [**Date Range 31820**] 2+MR [**Last Name (Titles) 3564**] 3. CHF - EF >55% 2+MR [**Last Name (Titles) 31820**], RV dysfunction, moderate pulmonary HTN 4. PAF s/p VVI pacemaker [**7-28**] 5. CRI baseline Cr 1.5-1.7 6. MDS 7. Chronic mechanical hemolysis 8. Hx. of perirectal abscess s/p surgery 9. Gout 10. Hemorrhoidal bleeding 11. PPM [**11-27**] VVI Social History: No EtOH or tobacco. Was living alone at home (widower) prior to recent hospitalizations. Two daughters heavily involved in care. Family History: Noncontributory Physical Exam: 97.7, 64, 109/43, 19, 99% ra Ill appearing male comfortable, lying flat, in NAD. PERRL, anicteric OP clr, no sublingual jaundice JVP not appreciable [**1-26**] RIJ PMI laterally displaced. Regular prominent S1,S2. No m/r/g. b/l basilar crackles. +bs. soft. minimal RUQ tenderness. no [**Doctor Last Name **] sign. minimal epigasric tenderness. no hepatosplenomegaly. no le edema. skin: multiple eccymosis of b/l upper ext . Pertinent Results: Labs: [**2129-8-8**] 06:00AM BLOOD WBC-8.7 RBC-3.21* Hgb-10.0* Hct-28.9* MCV-90 MCH-31.1 MCHC-34.5 RDW-23.5* Plt Ct-93* [**2129-8-4**] 11:00AM BLOOD WBC-15.5*# RBC-3.48* Hgb-10.8* Hct-30.8* MCV-89# MCH-31.0 MCHC-35.0# RDW-25.2* Plt Ct-213 [**2129-8-4**] 11:00AM BLOOD Neuts-91* Bands-1 Lymphs-3* Monos-5 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 [**2129-8-7**] 06:00AM BLOOD Neuts-94.7* Bands-0 Lymphs-2.9* Monos-1.9* Eos-0.4 Baso-0.1 [**2129-8-4**] 11:00AM BLOOD Hypochr-NORMAL Anisocy-NORMAL Poiklo-2+ Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL Ovalocy-1+ Schisto-2+ Burr-OCCASIONAL Tear Dr[**Last Name (STitle) 833**] [**Name (STitle) 15924**] [**2129-8-8**] 06:00AM BLOOD Plt Smr-LOW Plt Ct-93* [**2129-8-8**] 06:00AM BLOOD PT-14.7* PTT-78.5* INR(PT)-1.4 [**2129-8-4**] 03:40PM BLOOD PT-14.9* PTT-36.0* INR(PT)-1.5 [**2129-8-8**] 06:00AM BLOOD Glucose-106* UreaN-87* Creat-1.8* Na-136 K-3.3 Cl-103 HCO3-22 AnGap-14 [**2129-8-4**] 11:00AM BLOOD Glucose-104 UreaN-248* Creat-3.2*# Na-123* K-5.1 Cl-77* HCO3-20* AnGap-31* [**2129-8-7**] 06:00AM BLOOD ALT-16 AST-51* LD(LDH)-1275* AlkPhos-43 Amylase-122* TotBili-1.9* [**2129-8-4**] 11:00AM BLOOD ALT-19 AST-72* AlkPhos-51 Amylase-270* TotBili-1.5 [**2129-8-7**] 06:00AM BLOOD Lipase-46 [**2129-8-4**] 11:00AM BLOOD Lipase-193* [**2129-8-8**] 06:00AM BLOOD Calcium-8.2* Phos-4.1 Mg-2.2 [**2129-8-7**] 06:00AM BLOOD Albumin-3.2* Calcium-8.1* Phos-4.1# Mg-2.4 [**2129-8-4**] 03:40PM BLOOD TotProt-5.3* [**2129-8-4**] 11:00AM BLOOD Albumin-4.5 Calcium-8.7 Phos-10.1*# Mg-3.7* [**2129-8-4**] 03:40PM BLOOD Cortsol-15.3 [**2129-8-5**] 05:24AM BLOOD Digoxin-1.6 [**2129-8-4**] 11:59PM BLOOD Type-ART pO2-120* pCO2-30* pH-7.49* calHCO3-23 Base XS-1 [**2129-8-5**] 05:31AM BLOOD Lactate-1.9 [**2129-8-4**] 03:54PM BLOOD Lactate-2.0 [**2129-8-4**] 11:00AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.009 [**2129-8-4**] 11:00AM URINE Blood-TR Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG [**2129-8-4**] 11:00AM URINE RBC-0-2 WBC-0-2 Bacteri-MOD Yeast-NONE Epi-0-2 [**2129-8-4**] 11:00AM URINE CastGr-0-2 CastHy-0-2 [**2129-8-4**] 11:00AM URINE Hours-RANDOM Creat-34 Na-41 K-36 Cl-53 Micro: [**2129-8-7**] STOOL INPATIENT C diff tox negative [**2129-8-4**] BLOOD CULTURE EMERGENCY [**Hospital1 **] Pending [**2129-8-4**] BLOOD CULTURE EMERGENCY [**Hospital1 **] Pending [**2129-8-4**] URINE EMERGENCY [**Hospital1 **] no growth Reports: [**2129-8-4**] Cardiology ECG Ventricular paced rhythm Since previous tracing of [**2128-2-16**], 100% paced rhythm at 60bpm [**2129-8-4**] Radiology CHEST (PORTABLE AP) IMPRESSION: Reduced right pleural effusion. No acute abnormality. [**2129-8-4**] Radiology ABDOMEN (SUPINE & ERECT) IMPRESSION: 1. Pacing device in the left upper quadrant, which probably corresponds to the palpable subcutaneous foreign body. 2. Cholelithiasis. 3. Right pleural effusion. [**2129-8-4**] Radiology LIVER OR GALLBLADDER US CONCLUSION: 1.Cholelithiasis. 2.Moderately distended sludge filled gallbladder with gallstones with suggestion of gallbladder wall edema. In the appropriate clinical setting, this appearance could represent acute cholecystitis. Clinical correlation advised. If clinically required, a HIDA scan could help clarify. [**2129-8-4**] Radiology CHEST PORT. LINE PLACEMENT IMPRESSION: 1. Satisfactory placement of right internal jugular line. 2. No pneumothorax. [**2129-8-4**] Radiology RENAL U.S. IMPRESSION: No evidence of hydronephrosis bilaterally. Brief Hospital Course: 77 yo m with h/o cad, diastolic HF, who p/w 3 wk h/o post-prandial RUQ pain, confusion. Hypotension: felt to likely be [**1-26**] hypovolemia given history of aggressive diuresis and exam findings consistent with dehydration. Outpt bp's noted to be 80-110 systolic. No evid of cardiogenic shock. Admitted to MICU with MUST protocol, though there was no evidence of sepsis. Held diuretics, beta blocker, dig. Cultures remained without growth. BP improved quickly with rehydration. Was given stress dose steroids as had been on 10mg [**Hospital1 **] prednisone on admit for gout. Starting prednisone taper on discharge, taper to off. If gout flares, could do local injection, avoid NSAIDs given renal failure. . ARF on chronic renal failure: likely prerenal from dehydration. Resolved rapidly with hydration. Urine lytes/osms consistent with prerenal state. No evid of hydronephrosis on renal u/s. Renally dosed meds, checked dig level which was not supratherapeutic, though stopped this medication in favor of beta blockade for rate control once indicated (has not had need for beta blockade yet as still paced at 60bpm on discharge). . RUQ pain: presentation was concerning for cholecystitis, and though he did have stones in his GB there was no indication on imaging that he had cholecystitis. Felt that he may have had a mild gallstone pancreatitis given his transient pancreatic enzyme elevation, possibly from a passing gallstone. There was no evidence of ischemic bowel (neg thumbprinting on KUB, no h/o BRB, benign abdomen). His abd exam improved and remained benign throughout the rest of his stay. He was on levo/flagyl for coverage of possible cholecystitis, though this was d/c'd on Day#5, the day of his discharge, as he had no indication for antibiotics. . Hyponatremia: felt to be hypovolemic in origin, resolved quickly with IVF; was on HCTZ, this was discontinued and he should not be restarted on it. . Afib: inr was low [**1-26**] holding coumadin; had GI bleed during this admission in the setting of PTT>150, likely from hemorrhoids (negative Cspy 1y prior). Restarted coumadin, bridging with heparin gtt given mechanical valve (cannot use Lovenox). Has had no recurrent GI bleed and hct has remained stable. . GI bleed: in setting of supratherapeutic PTT > 150 and after straining to have a bowel movement, the patient developed BRBPR. In this setting, he also had epistaxis and oozing from his central line. Given his neg cspy 1y PTA and known hemorrhoids, this was felt to be the cause of his BRBPR. His hct remained stable and all evid of bleeding stopped after his PTT was brought down below 100. He remained HD stable throughout his stay on the medical floor. Medications on Admission: xopenex .63 q6h prn plavix 75mg qday digoxin .0625 alternating w/ .125 qod hctz 25mg qday aldactone 25mg [**Hospital1 **] lasix 80mg [**Hospital1 **] zantac 150mg qday mvi prednisone 10mg [**Hospital1 **] coumadin 7.5 mg qday epogen 60K units qwk ferrous sulfate 300mg folic acid 1mg qday milk of magnesia prn toprol 12.5 qday Discharge Medications: 1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 3. Levalbuterol HCl 0.63 mg/3 mL Solution Sig: Three (3) ML Inhalation q6h () as needed. 4. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 5. Fludrocortisone 0.1 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 6. Epoetin Alfa 20,000 unit/mL Solution Sig: 20,000 units Injection QMOWEFR (Monday -Wednesday-Friday). 7. Zolpidem Tartrate 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for sleep. 8. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Insulin Lispro (Human) 100 unit/mL Solution Sig: One (1) injection Subcutaneous ASDIR (AS DIRECTED): per sliding scale. 10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 11. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 12. Warfarin Sodium 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime): please titrate to INR 2.5-3.5. 13. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 14. Heparin Flush CVL (100 units/ml) 1 ml IV DAILY:PRN 10ml NS followed by 1ml of 100 units/ml heparin (100 units heparin) each lumen QD and PRN. Inspect site every shift 15. Heparin Sod (Porcine) in D5W 100 unit/mL Parenteral Solution Sig: One (1) drip Intravenous ASDIR (AS DIRECTED): target PTT 60-100; continue until INR 2.5-3.5. 16. Prednisone 20 mg Tablet Sig: Three (3) Tablet PO once a day for 10 days: please give 60mg x 2d, 40mg x 2d, 20mg x 2d, 10mg x 2d, 5mg x2d, then stop. Discharge Disposition: Extended Care Facility: [**Hospital1 700**] - [**Location (un) 701**] Discharge Diagnosis: Dehydration Hypovolemic shock Acute renal failure Cholecystitis Hyponatremia Atrial fibrillation Discharge Condition: Hemodynamically stable, hematocrit stable at baseline, no confusion Discharge Instructions: Please continue to take all medications as prescribed and to follow up with your doctors. For your congestive heart failure, please weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs. Adhere to 2 gm sodium diet. Fluid Restriction: 2L per day Followup Instructions: Please keep the following previously scheduled appointments: Provider: [**Name10 (NameIs) 676**] CLINIC Where: [**Hospital6 29**] CARDIAC SERVICES Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2129-9-21**] 9:30 Provider: [**Name10 (NameIs) 900**] [**Name8 (MD) 901**], M.D. Where: [**Hospital6 29**] CARDIAC SERVICES Phone:[**Telephone/Fax (1) 902**] Date/Time:[**2129-9-21**] 10:00 Dr. [**Last Name (STitle) 73**] may want to perform a repeat echocardiogram to re-evaluate your heart's ability to pump given your recent exacerbation of congestive heart failure. You had many of your blood pressure medications held in the setting of your low blood pressure. Dr. [**Last Name (STitle) 73**] will likely need to adjust these at your next appointment. In addition to these appointments, you should schedule an appointment with your PCP at the earliest convenient time to be followed up after this hospitalization. You will also need an outpatient colonoscopy to follow up your GI bleeding during this admission. [**First Name11 (Name Pattern1) 734**] [**Last Name (NamePattern1) 735**] MD, [**MD Number(3) 799**]

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icd9cm

[ [ [] ] ]

[ "99.02" ]

icd9pcs

[ [ [] ] ]

11084, 11156

6321, 9011

325, 332

11297, 11366

2797, 6298

11678, 12824

2318, 2335

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2350, 2778

273, 287

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2171, 2302

43,509

142,968

39398

Discharge summary

report

Admission Date: [**2104-6-19**] Discharge Date: [**2104-6-29**] Date of Birth: [**2020-5-13**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 613**] Chief Complaint: SDH Major Surgical or Invasive Procedure: None History of Present Illness: 84 y.o. female with PMH significant for atrial fibrillation and mechanical aortic valve on coumadin presents from an OSH with left sided SDH. Patient was at home yesterday, felt off balance, and fell forwards in the bathroom. She is unsure of LOC during the fall. She was helped up by her daughter, with whom she lives, and contined with her regular activities. She felt well for the remainder of the day and this morning she felt more "wobbly." Her daughter felt that she was "off" and when she noticed the patient was febrile she took her to an OSH. A head CT was performed that detected a left sided SDH. She was found to be febrile to 102 and subsequently received 1 dose of rocephin. She also received 10mg of vitamin K and was transferred to [**Hospital1 18**]. In our ED, her INR was found to be 3.5 and she was also found to be febrile to 103.4. She has no specific complaints and denies headache, blurry vision, dizziness, and nausea/vomiting. UA and CXR in ED negative. She received 10mg SQ Vit K and 3 units FFP with repeat INR now 1.7. She became mildly dsypneic after so much volume, but this resolved with her home lasix and additional 20mg IV lasix. Repeat head CT showed expected evolution of SDH but no enlargement or increase in shift (already 5mm). No herniation. Currently reactive pupils and intact neuro exam except slight L facial droop. On PO and IV pain meds. Concern for worsening neuro exam this AM, stat HCT, possible OR. Past Medical History: PMH: (1) A-Fib (s/p cardioversion 1 year ago, now in NSR) (2) CAD s/p stent (3) Hypertension (4) Anxiety (5) GERD (6) CHF (7) Hyponatremia PSH: (1) Aortic stenosis, s/p Aortic Valve Replacement Social History: Soc: Patient is widowed and currently lives with her daughter and son-in-law. Enjoys [**Location (un) 1131**] the newspaper and watching TV. No smoking or ETOH history. Family History: Noncontributory. Physical Exam: VS: Tm 99.6 Tc97.9 HR 68 BP 155/62 RR 18 SaO2 97% on 2LNC . (exam on admission to Neuro ICU currently unavailable) Pertinent Results: ADMISSION LABS: [**2104-6-19**] 03:35PM BLOOD WBC-13.5* RBC-3.39* Hgb-11.0* Hct-32.7* MCV-96 MCH-32.4* MCHC-33.6 RDW-13.8 Plt Ct-184 [**2104-6-19**] 03:35PM BLOOD Neuts-86.4* Lymphs-7.7* Monos-5.0 Eos-0.6 Baso-0.2 [**2104-6-19**] 03:35PM BLOOD PT-34.3* PTT-31.1 INR(PT)-3.5* [**2104-6-19**] 03:35PM BLOOD Glucose-126* UreaN-19 Creat-1.0 Na-138 K-4.0 Cl-101 HCO3-28 AnGap-13 [**2104-6-19**] 03:35PM BLOOD Calcium-8.3* Phos-3.9 Mg-2.0 [**2104-6-19**] 03:35PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-13 Bnzodzp-NEG Barbitr-NEG Tricycl-NEG IMAGING: CT HEAD [**2104-6-19**] - IMPRESSION: 1. Stable appearance of left acute subdural hematoma resulting in 6 mm of left to right midline shift. 2. Periventricular white matter change consistent with chronic small vessel ischemia. CT HEAD [**2104-6-20**] - IMPRESSION: Stable left frontoparietal subdural hematoma with redistribution of blood products. New left frontal lobe intraparenchymal hemorrhage. Increased mass effect with increased effacement of sulci, cisterns, and the lateral and third ventricles, increased shift of midline structures. Brief Hospital Course: 84 yo f with PMHx of CHF, Aortic stenosis, CAD and Afib on coumadin who presented to ED on [**6-19**] after a fall. It was unknown if she had LOC. She was admitted to the NSURG ICU because of a left-sided 8 mm subdural hematoma. Her INR was elevated to 3.5 which was reversed on admission. The patient and the family declined operative interventions for the SDH, which NSURG felt was reasonable. She was discharged to floor on NSURG service and was noted to have worsening lethargy on [**6-20**]; a repeat Head CT showed a new intraparenchymal hemorrhage and stable subdural hematoma. The patient developed hypoxia and was felt to be in acute diastolic heart failure with an NSTEMI. Anticoagulation was not indicated given her ICH and so she was treated with aggressive blood pressure and heart rate control. The patient was also diuresed with improvement in her oxygenation. She was treated empirically for a hospital acquired pneumonia given her fevers and hypoxia. Her mental status continued to decline with at first right sided and then left sided paralysis. Neurology was consulted and felt that these changes were most likely due to her ICH and surrounding edema. She was treated with high dose decadaron without much change in her symptoms. She was maintained on seizure prophylaxis and the neurology team did not feel that the patient was having seizures as an explanation of her somnolence. The patient's status continued to decline she developed guaiac positive stools and likely had a stress ulcerations from the ICH and steroids. The family felt that given the patient's poor prognosis and her very low likelihood of meaningful recovery that she would want to have comfort focused care. She passed away comfortably on [**2104-6-29**] at 7:00pm. Medications on Admission: 1. Amiodarone 200mg Daily 2. Celexa 20mg Daily 3. Ferrous Sulfate 325mg Twice Daily 4. Isosorbide 30mg PO Daily 5. K-Dur Daily 6. Lasix 20mg HS 7. Laxis 40mg Daily 8. Metoprolol 50mg Daily 9. Nitro PRN 10. Prilosec 20mg Daily 11. Xanax 0.25mg Daily Discharge Medications: NONE Discharge Disposition: Expired Discharge Diagnosis: Subdural Hematoma Intraparenchymal Hemorrhage Non-ST Elevation Myocardial Infarction Acute Diastolic Heart Failure Hospital Acquired Pneumonia Gastrointestinal Bleeding Discharge Condition: Expired Discharge Instructions: N/A Followup Instructions: N/A [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**] Completed by:[**2104-6-30**]

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icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

5611, 5620

3514, 5283

318, 324

5832, 5841

2402, 2402

5893, 6048

2223, 2241

5582, 5588

5641, 5811

5309, 5559

5865, 5870

2256, 2383

275, 280

352, 1803

2418, 3491

1825, 2021

2037, 2207

49,341

139,145

36101

Discharge summary

report

Admission Date: [**2187-10-24**] Discharge Date: [**2187-10-27**] Date of Birth: [**2139-8-30**] Sex: F Service: MEDICINE Allergies: No Drug Allergy Information on File Attending:[**First Name3 (LF) 7651**] Chief Complaint: Panic Attack Major Surgical or Invasive Procedure: Cardiac catherization with stent placement History of Present Illness: 48 F with h/o anxiety disorder, tobacco use, and family history of MI presented following 5 days of chest pain. Saturday afternoon at 5:30 PM she developed bilateral buring across chest radiating to both arms. She had drenching diaphoresis that was controlled with ice pack. 4 days PTA woke up with vomiting, felt sick, bones aching. Felt better Monday and Tuesday. Wednesday had "panic attack" at grocery store with chest pain and shortness of breath, triggered by thinking about Today show episode on heart attacks. She presented to [**Hospital3 **] ED for uncontrollable anxiety. At OSH ED, EKG showing 2-3 mm STE in inferior leads with reciprocal depressions. She received ASA 325, lopressor 5mg, plavix 600 mg, heparin bolus+gtt, integralin bolus+gtt. Patient was transferred to [**Hospital1 18**] for urgent cardiac catheterization. Past Medical History: - Panic attacks and anxiety disorder, seen by a psychiatrist and learned CBT. Never medicated. Anxiety started 9 years ago with sudden cardiac death of oldest sister. - GERD Social History: -Tobacco history: 1 PPD for 30 years -ETOH: Occasional -Illicit drugs: Denies Family History: Sister died 9 years ago at 46 from sudden cardiac death in sleep. Brother with CAD s/p stenting at 52 years Mon with heart attack at 53 Physical Exam: VS: T=97.7 BP= 117/81 HR=87 O2 sat= 99 GENERAL: NAD A&Ox3 HEENT: Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. NECK: JVP not distended 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: Anterior breath sounds CTAB, without crackles, wheezes or rhonchi. ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. EXTREMITIES: Right-side cath site with small old blood. No hematoma or bruit. No c/c/e. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: Carotid 2+ DP 2+ PT 2+ Left: Carotid 2+ DP 2+ PT 2+ Pertinent Results: [**2187-10-27**] 06:40AM BLOOD WBC-8.2 RBC-3.58* Hgb-10.7* Hct-31.1* MCV-87 MCH-29.9 MCHC-34.4 RDW-12.6 Plt Ct-333 [**2187-10-25**] 05:00AM BLOOD PT-13.0 PTT-26.0 INR(PT)-1.1 [**2187-10-27**] 06:40AM BLOOD Glucose-92 UreaN-9 Creat-0.6 Na-140 K-4.5 Cl-105 HCO3-26 AnGap-14 [**2187-10-25**] 05:00AM BLOOD ALT-46* AST-37 LD(LDH)-470* CK(CPK)-134 [**2187-10-24**] 08:00PM BLOOD cTropnT-2.62* [**2187-10-25**] 05:00AM BLOOD CK-MB-7 cTropnT-2.43* [**2187-10-27**] 06:40AM BLOOD Calcium-8.7 Phos-3.5 Mg-2.2 [**2187-10-25**] 05:00AM BLOOD Triglyc-87 HDL-28 CHOL/HD-6.0 LDLcalc-124 LDLmeas-118 TTE [**10-25**]: Mild regional left ventricular systolic dysfunction, c/w CAD. EF 40-45% CXR [**10-25**]: Mild fluid overload but no overt pulmonary edema. No pleural effusions. No pneumonia. CARDIAC CATH: She was found to have right dominant system, with LMCA 50% ostium with ventriculairzation with every injection LAD 30% mid LCX no sig disease RCA 50% ostium, 100% mid with left-to-right collaterals. Xience 2.5x28 DES placed to mid RCA. HEMODYNAMICS: RA 19 AO 120/75 (92) RV 57/11, end 19 PCW 31 PA 40/21 (31) CI: 3.09 [**MD Number(3) **]: 73.8 % EKG: [**2187-10-24**] 18:09-> Sinus tach @ 120, Nl axis/intervals. Q-wave and 2-3mm STE in II,III, aVF. STD in I, aVL, V2. Brief Hospital Course: 48 F with anxiety, tobacco and (+) FH p/w 5 days of chest pain, s/p stenting of RCA mid TO. * STEMI - On presentation to OSH, pt had EKG with ST elevations in inferior leads with reciprocal depressions and was thus transferred for urgent catheterization after receiving ASA, beta-blocker, Plavix loading dose, heparin bolus and drip and integrilin bolus and drip. Her cardiac enzymes at that time were at their peak CPK of 167 and Troponin I of 17.02. She was later found to have peaked in her Trop T as well at 2.62. In the cath lab, patient was HD stable with CI 3.09, mean RA pressure 18, PCWP 31, PA mean 31. She was found to have right dominant system, with LMCA 50% ostium, LAD 30% mid, LCX normal, RCA 50% ostium, 100% mid with left-to-right collaterals. DES placed to mid RCA. Hemodynamics were consistent with RV ischemia/infarction physiology. She was transferred to CCU for HD monitoring were she continued to be comfortable, denying chest pain, shortness or breath or nausea. She did occasionally report some anxiety relieved by anxiolytics and not associated with any EKG changes. Given the fact that pt had reported 5 days of chest pain, troponin>CK elevation, and Q-waves on presentation, pt's STEMI was thought to be presenting late in the course of her ischemia and thus was predicted to recover function of the right ventricle but not likely substantial function of the inferior left ventricular wall. Cath lab and echocardiogram findings confirmed RV failure. In spite of previous reported negative stress test, collaterals were thought to suggest longstanding angina, which may have been attributed to panic attacks in the past. Pt was treated with ASA, metoprolol, plavix, high dose statin, and eventual addition of ACE inhibitor. She also received 18 hr integralin which she tolerated well. She had no furthur complications including mechanical, arrhythmic or pain related. * ANXIETY DISORDER - Pt had appropriate level of anxiety in context of longstanding personal and family history. She was treated with minimal PRN ativan. * TOBACCO USE - Pt and pt's husband were counseled on the importance of smoking cessation. * GASTROESOPHAGEAL REFLUX DISEASE - Pt was continued on home omeprazole. - continue omeprazole Medications on Admission: Prilosec daily Discharge Medications: 1. Toprol XL 100 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2* 2. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 3. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 4. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 5. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*11* 6. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Primary: ST-Elevation Myocardial Infarction Tobacco Abuse Systolic Heart Failure, new onset Secondary: Anxiety Hyperlipidemia Discharge Condition: The patient was discharged hemodynamically stable, afebrile with appropriate follow up. Discharge Instructions: You were admitted to the hospital after you had a heart attack. You had a stent placed in your heart to help the blockage. You must take aspirin and Plavix as directed until you are instructed to stop them. The following are your new medications: Toprol XL, aspirin, Plavix, Lipitor, and lisinopril. Please take them as directed. They are very important for your heart. Please stop smoking. Information was given to you on admission regarding smoking cessation. Please follow up with a mental health profession for treatment of your anxiety. Please keep all follow up appointments. They are listed below. Please call your PCP or seek medical attention in the emergency room if you experience any chest pain, shortness of breath, fevers, chills, nausea, vomiting, abdominal pain, or any other concerning symptom. You have some evidence of heart failure. Please weigh yourself daily and avoid excessive salt in your diet. If your weight goes up by more than 6 pounds in [**1-14**] days, call your PCP. Followup Instructions: Please follow up with your PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] in [**12-13**] weeks by calling [**Telephone/Fax (1) 26408**] for an appointment. Please follow up with your cardiologist, Dr. [**Last Name (STitle) 120**], in [**12-13**] weeks by calling [**Telephone/Fax (1) 62**] for an appointment. Completed by:[**2187-10-30**]

[ "530.81", "272.4", "428.20", "428.0", "300.00", "410.71", "414.01" ]

icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

6737, 6743

3713, 5963

311, 356

6914, 7004

2419, 3690

8060, 8419

1543, 1680

6028, 6714

6764, 6893

5989, 6005

7028, 8037

1695, 2400

259, 273

384, 1233

1255, 1432

1448, 1527

73,816

159,209

46111

Discharge summary

report

Admission Date: [**2160-2-22**] Discharge Date: [**2160-3-11**] Date of Birth: [**2101-8-15**] Sex: F Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 17197**] Chief Complaint: Open left posterior knee dislocation Major Surgical or Invasive Procedure: [**2160-2-23**]: left popliteal artery exploration with left above-knee to below-knee popliteal artery bypass using right greater saphenous vein, left lower extremity four compartment fasciotomies, open reduction internal fixation of patella dislocation History of Present Illness: 58F presents to the [**Hospital1 18**] ER with a left posterior knee dislocation after suffering a fall onto her knees. Patient was found to have open popliteal fossa laceration with bone protruding. She was evaluated by ortho who performed a bedside reduction and was subsequently found to have a pulseless left leg requiring emergent exploration in the operating room. Past Medical History: Past Medical History: Anxiety Hypertension Past Surgical History: Right total knee replacement [**2151**] Social History: non-contributory to trauma Family History: non-contributory to trauma Physical Exam: Alert and oriented x 3 VS: BP 120s/60 HR 80s Resp: Lungs clear Abd: Soft, non tender Ext: Pulses: Left: Femoral palp, DP palp ,PT dop Right: Femoral palp, DP palp ,PT palp Feet warm, well perfused. No open areas Incisions: Left medial thigh and right groin stapled, clean and dry. Open to air. Wounds: Left medial and lateral fasciotomy sites clean and granulating. Pertinent Results: CTA aorta/bifem/iliac with runoff [**2160-2-22**]: 1. Abrupt cut off of the left popliteal artery at the level of the distal femoral metaphysis concerning for avulsion injury and thrombosis secondary to recent dislocation. 2. Distal reconstitution of the left anterior tibial and posterior tibial arteries at the level of the proximal tibia, though no flow seen in the left peroneal artery throughout its course. 3. Laceration of the posterior soft tissues in the left popliteal fossa. Small intramuscular hematoma posterior to the distal femur though no evidence of active extravasation. 4. No joint effusion or definite fracture. CT torso with contrast [**2160-2-23**]: 1. No post-traumatic sequelae in the chest, abdomen or pelvis. 2. Small bilateral pleural effusions with adjacent compressive atelectasis. 3. Left axillary lymph node measuring up to 1.7 cm and left inguinal lymph node measuring 1 cm. Although these may be reactive, underlying malignancy cannot be excluded. Please correlate clinically and if persistent, they may warrant further workup. 4. Sclerotic T4 pedicle on the left. Bone scan is recommended to exclude osseous metastatic disease. BLE duplex venous US [**2160-3-3**]: 1. Limited examination of the left lower extremity from the level of the popliteal vein and inferior within the calf due to hardware; however, no evidence of deep venous thrombosis in the common femoral or superficial femoral veins. 2. No evidence of deep venous thrombosis in the right lower extremity. XR L knee [**2160-3-7**]: Skin irregularity, likely from prior open dislocation. Skin staples are present. Multiple surgical clips are seen within the soft tissues. No fracture identified. No dislocation. External fixator present and unchanged. [**2160-3-8**] 05:27AM BLOOD WBC-11.1* RBC-3.48* Hgb-10.5* Hct-30.3* MCV-87 MCH-30.2 MCHC-34.7 RDW-14.8 Plt Ct-387 [**2160-3-7**] 05:04AM BLOOD Glucose-117* UreaN-23* Creat-0.7 Na-136 K-4.0 Cl-101 HCO3-27 AnGap-12 Brief Hospital Course: On [**2160-2-23**], the patient underwent emergent external fixation of the open dislocation of her left knee as well as above-knee to below-knee popliteal artery bypass secondary to traumatic injury. She was hemodynamically stable during the surgery but required aggressive fluid resuscitation and 13 units of packed red blood cells. She was initially monitored in the ICU and was extubated on POD #2. She was transferred out of the ICU on POD #3. The left popliteal wound and lower leg fasciotomies were intially packed with wet-to-dry dressings. The fasciotomies sites were changed to VAC suction dressings on POD #5. The wounds remained clean throughout the admission and showed healthy granulation. Her VAC is due to be changed on [**2160-3-12**]. Her staples are due to be taken out on [**2160-3-23**]. Due to the trauma of her injury, she also has evidence of tibial and peroneal nerve injury resulting in left foot drop and partial loss of sensation in the foot. She worked with physical therapy to regain partial mobility. She remained non-weight bearing on the left lower extremity but is able pivot on her right leg. Due to poor venous access, a PICC line was placed on POD #12. She had a urinary tract infection during her stay which was treated with ciprofloxacin. She has remained afebrile and hemodynamically stable throughout the admission. She was discharged to rehab on POD 17 in stable condition with follow up arranged with orthopedics, neurology, plastic surgery and vascular surgery. Medications on Admission: hctz neurontin lorazepam Discharge Medications: 1. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 2. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 3. gabapentin 400 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 4. hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 5. lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for anxiety. 6. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for pain. 8. HYDROmorphone (Dilaudid) 0.25 mg IV PRN dressing changes 9. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q3H (every 3 hours) as needed for pain . 10. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain. 11. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 12. Heparin Flush (10 units/ml) 2 mL IV PRN line flush PICC, heparin dependent: Flush with 10mL Normal Saline followed by Heparin as above daily and PRN per lumen. Discharge Disposition: Extended Care Facility: [**Hospital1 **] Nursing & Therapy Center - [**Location 1268**] ([**Location (un) 86**] Center for Rehabilitation and Sub-Acute Care) Discharge Diagnosis: Left patella dislocation with left popliteal artery thrombus Discharge Condition: Level of Consciousness: Alert and interactive. Mental Status: Clear and coherent. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: You were admitted to the hospital after a fall which dislocated your left knee cap. You needed surgery to realign and stablize the knee cap and restore the circulation to your foot. You are to but no weight on your left foot. You have staples in your left thigh and right groin which should be removed on [**2160-3-23**]. The VAC dressing on your faciotomy sites is changed every 3 days and is due to be changed on [**2160-3-12**]. Followup Instructions: Department: PLASTIC SURGERY When: WEDNESDAY [**2160-3-26**] at 9:30 AM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2477**], MD [**Telephone/Fax (1) 31444**] Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage Department: ORTHOPEDICS When: THURSDAY [**2160-4-3**] at 8:50 AM With: [**Name6 (MD) 13978**] [**Name8 (MD) **], MD [**Telephone/Fax (1) 1228**] Building: [**Hospital6 29**] [**Location (un) 551**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: NEUROLOGY When: THURSDAY [**2160-4-3**] at 10:00 AM With: DRS. [**Name5 (PTitle) **] & [**Doctor Last Name 37664**] [**Telephone/Fax (1) 2846**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 858**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: VASCULAR SURGERY When: [**2160-4-7**] at 10:30 AM With: VASCULAR LAB FOLLOWED BY APPOINTMENT WITH DR. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] AT 11:15AM IN THE SAME SUITE. Completed by:[**2160-3-11**]

[ "836.4", "956.3", "999.9", "300.00", "453.41", "401.9", "956.2", "041.49", "276.2", "V49.87", "728.88", "278.01", "V43.65", "V70.7", "736.79", "458.9", "599.0", "041.04", "904.41", "E879.8", "E885.9" ]

icd9cm

[ [ [] ] ]

[ "38.97", "39.29", "96.6", "96.71", "78.17", "83.14", "79.76" ]

icd9pcs

[ [ [] ] ]

6312, 6472

3637, 5155

341, 596

6577, 6624

1647, 3614

7213, 8369

1187, 1215

5230, 6289

6493, 6556

5181, 5207

6753, 7190

1085, 1127

1230, 1628

265, 303

624, 996

6639, 6729

1040, 1062

1143, 1171

59,845

112,573

6366

Discharge summary

report

Admission Date: [**2174-11-18**] Discharge Date: [**2174-11-26**] Date of Birth: [**2113-11-21**] Sex: F Service: CARDIOTHORACIC Allergies: Ativan / Erythromycin Base / Statins-Hmg-Coa Reductase Inhibitors / [**Female First Name (un) 504**] Type Anesthetics / Bactrim / Lidoderm / cleaning chemicals / strog perfume and scents Attending:[**First Name3 (LF) 5790**] Chief Complaint: Cervical tracheomalacia Major Surgical or Invasive Procedure: [**2174-11-18**] 1. Cervical tracheal resection and reconstruction. 2. Bronchoscopy with bronchoalveolar lavage. History of Present Illness: 60 year old female with h/o tracheobronchomalcia s/p trachobronchoplasty in [**6-/2173**] with recent admittion to the medicine service for observation s/p an elective bronchoscopy with stent placement in cervial trachea. She was taken off of Heliox and did well for about 25 min. then developed severe dyspnea requiring IV Medrol and Heliox. She completed a Prednisone taper last week along with a 10 day course of Levoquin for tracheobronchitis. Currently she still has a cough productive of yellow sputum but denies SOB, fevers, chills. She presents now for evaluation for resection of her cervical tracheomalasia. Past Medical History: Trachael bronchomalacia s/p right thoracotomy with tracheobronchoplasty on [**2173-7-2**] GERD s/p lap Toupee fundoplication [**2174-1-21**] Coronaray Artery Disease LAD w/< 30% stenosis Migraines Colonvaginal fistula Vaginitis PSH: Cesarean section x 3 Left Breast Lumpectomy Social History: Denies tobacco, ethanol and drug use. Has exposure to cleaning agents. Works for an electrical company. She is married and lives with family Family History: Mother pancreas ca Father Siblings ovarian ca Offspring Other lung ca Physical Exam: On Discharge: VS: 98.2 82 109/68 18 97% on RA GEN: NAD, AOx3 CV: RRR PULM: No respiratory distress. ABD: Soft, NT, ND EXT: No c/c/e. Pertinent Results: [**2174-11-26**] 10:40AM BLOOD WBC-8.4 RBC-4.11* Hgb-11.7* Hct-35.5* MCV-86 MCH-28.5 MCHC-33.0 RDW-14.4 Plt Ct-274 [**2174-11-25**] 09:20AM BLOOD WBC-12.7* RBC-4.07* Hgb-12.0 Hct-34.5* MCV-85 MCH-29.5 MCHC-34.8 RDW-14.2 Plt Ct-264 [**2174-11-24**] 10:00PM BLOOD WBC-11.7*# RBC-4.57 Hgb-13.0 Hct-37.9 MCV-83 MCH-28.5 MCHC-34.4 RDW-14.1 Plt Ct-289 [**2174-11-24**] 07:20AM BLOOD WBC-7.1 RBC-3.91* Hgb-11.2* Hct-33.1* MCV-85 MCH-28.7 MCHC-33.9 RDW-14.3 Plt Ct-253 [**2174-11-19**] 06:13AM BLOOD WBC-9.8 RBC-4.28 Hgb-12.2 Hct-36.7 MCV-86 MCH-28.5 MCHC-33.2 RDW-13.5 Plt Ct-282 [**2174-11-18**] 09:26PM BLOOD WBC-8.9 RBC-4.35 Hgb-12.2 Hct-37.6 MCV-86 MCH-28.1 MCHC-32.5 RDW-13.7 Plt Ct-264 [**2174-11-24**] 07:20AM BLOOD Neuts-64.4 Lymphs-27.8 Monos-3.3 Eos-3.9 Baso-0.5 [**2174-11-24**] 10:00PM BLOOD Glucose-176* UreaN-5* Creat-0.5 Na-137 K-3.4 Cl-106 HCO3-20* AnGap-14 [**2174-11-24**] 07:20AM BLOOD Glucose-106* UreaN-5* Creat-0.6 Na-145 K-3.5 Cl-110* HCO3-26 AnGap-13 [**2174-11-19**] 06:13AM BLOOD Glucose-118* UreaN-15 Creat-0.5 Na-143 K-4.0 Cl-110* HCO3-25 AnGap-12 [**2174-11-18**] 09:26PM BLOOD Glucose-123* UreaN-16 Creat-0.7 Na-142 K-3.8 Cl-111* [**2174-11-24**] 10:00PM BLOOD Calcium-9.0 Phos-1.8*# Mg-1.9 [**2174-11-24**] 07:20AM BLOOD Calcium-8.9 Phos-3.5 Mg-1.8 [**2174-11-19**] 06:13AM BLOOD Calcium-8.7 Phos-4.3# Mg-2.0 [**2174-11-18**] 09:26PM BLOOD Calcium-8.7 Mg-1.8 [**2174-11-24**] 10:16PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.5 Leuks-NEG [**2174-11-24**] 10:16PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.007 URINE CULTURE (Final [**2174-11-26**]): MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. [**2174-11-18**] CXR: IMPRESSION: 1. The cardiac and mediastinal contours are stable with the heart remaining enlarged with a left ventricular prominence. Low volumes remain low, although there are increased linear opacities in both lungs, which may reflect a component of interstitial edema superimposed upon areas of scarring. No pleural effusions. A curvilinear radiopaque opacity is seen overlying the left apex and the mid trachea. It is unclear whether this is extrinsic to the patient or is related to the patient's recent surgery. Clinical correlation is advised. [**2174-11-24**] EKG: Sinus tachycardia. Vertical axis. Q waves in leads III and VF with ST-T wave abnormalities. Probable inferior myocardial infarction. RSR' pattern in lead V1 with late R wave progression. Early precordial T wave inversions of uncertain significance. Low voltage, particularly in the precordial leads. Since the previous tracing of [**2174-10-6**] the rate is faster. ST-T wave abnormalities are more prominent. QRS voltage is also more prominent.Clinical correlation is suggested. [**2174-11-24**] CXR: IMPRESSION: No acute cardiopulmonary process. [**2174-11-24**] CXR: IMPRESSION: AP chest compared to [**11-24**], 9:40 a.m.: I see no focal consolidation to suggest pneumonia, though the left lower lobe is obscured by the cardiac silhouette. There has been a mild increase in pulmonary vascular recruitment but no edema or appreciable effusion and no pneumothorax. Heart size normal. [**2174-11-25**] CXR: IMPRESSION: No pneumonia/aspiration. Brief Hospital Course: [**Known firstname **] [**Known lastname 24621**] was admitted to the Thoracic Surgery Service following cervical tracheal resection and reconstruction with Bronchoscopy with bronchoalveolar lavage on [**2174-11-18**] (Reader referred to operative report for complete details). Patient was initially brought to the ICU for close monitoring of respiratory status and was transferred to the floor on POD 1 and diet was advanced to sips. Retention was left in place to prevent hyperextension of the neck. On POD 3 diet was advanced to soft regular diet and JP drain was discontinued. On POD 5 diet was advanced to a regular diet. On POD 6 flexible bronchoscopy was performed which showed a well healing anastomosis and retention suture was discontinued. That evening she spiked a fever to 104.5 which was attributed to the after effects of the bronchoscopy and fever resolved with tylenol. Thereafter the patient remained afebrile and was able to be discharged on POD 8. Neuro: Immediately postoperatively the patient had pain control issue due to retention sutures causing muscular discomfort and spasm which was relieved with muscle relaxants. Thereafter pain was well controlled on PO pain medications with good effect and adequate pain control. CV: The patient remained stable from a cardiovascular standpoint; vital signs were routinely monitored. Pulmonary: The patient remained stable from a pulmonary standpoint; vital signs were routinely monitored. Good pulmonary toilet, early ambulation and incentive spirrometry were encouraged throughout hospitalization. GI/GU/FEN: Post-operatively, the patient was made NPO with IV fluids. Diet was advanced when appropriate, which was well tolerated. Patient's intake and output were closely monitored, and IV fluid was adjusted when necessary. Electrolytes were routinely followed, and repleted when necessary. ID: The patient's white blood count and fever curves were closely watched for signs of infection. After spiking a fever on POD6 fever curves were trended and patient remained afebrile. Endocrine: The patient's blood sugar was monitored throughout his stay; insulin dosing was adjusted accordingly. Hematology: The patient's complete blood count was examined routinely; no transfusions were required. Prophylaxis: The patient received subcutaneous heparin and venodyne boots were used during this stay; was encouraged to get up and ambulate as early as possible. At the time of discharge, the patient was doing well, afebrile with stable vital signs. The patient was tolerating a regular diet, ambulating, voiding without assistance, and pain was well controlled. The patient received discharge teaching and follow-up instructions with understanding verbalized and agreement with the discharge plan. Medications on Admission: Tylenol w/ codein 300/30 mg prn migraine, Albuterol MDI 2 puffs q 4 hrs prn, Amitriptyline 10 mg qhs, Gabapentin 600 TID, Heliox 80%/20% O2 via NRB @ 10L TID prn, Morphine ER 30 mg qhs, Racemic epi prn, oxycodone 15 mg, Percocet 5/325 mg, Protonix 40 [**Hospital1 **], Ropinirole 0.25 mg qhs, Topiramate100 mgBID, Zolpidem5 mg [**12-19**] qhs prn, ASA 81 mg qd Discharge Medications: 1. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 2. amitriptyline 10 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 3. topiramate 100 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. ropinirole 0.25 mg Tablet Sig: One (1) Tablet PO QPM (once a day (in the evening)). 5. gabapentin 300 mg Capsule Sig: Two (2) Capsule PO TID (3 times a day). 6. ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for headache. 7. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. Disp:*50 Capsule(s)* Refills:*2* 8. methocarbamol 500 mg Tablet Sig: Two (2) Tablet PO QID (4 times a day). Disp:*240 Tablet(s)* Refills:*2* 9. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*50 Tablet(s)* Refills:*0* 10. acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO Q 8H (Every 8 Hours) as needed for pain. Discharge Disposition: Home Discharge Diagnosis: Cervical tracheomalacia (dynamic tracheal obstruction). 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 for tracheoplasty and you have recovered well despite some initial problems with pain control. You are now ready for discharge. * Continue to take adequate pain medication so that you are able to cough and deep breath and use your incentive spirometer. Call Dr.[**Name (NI) 2347**] office [**Telephone/Fax (1) 2348**] if you experience: -Fevers > 101 or chills -Increased shortness of breath, cough (it is normal to cough up blood tinge sputum for a few days) or chest pain -No driving while taking narcotics -Take stool softners with narcotics Activity -Shower daily. -Walk 4-5 times a day for 10-15 minutes increase to a Goal of 30 minutes daily Followup Instructions: Please call Dr.[**Name (NI) 2347**] Office Phone: ([**Telephone/Fax (1) 17398**] to schedule your follow up appointment in 2 weeks.

[ "414.01", "616.10", "338.18", "530.81", "V45.89", "619.1", "519.19", "V87.2", "780.62", "346.90" ]

icd9cm

[ [ [] ] ]

[ "96.56", "33.22", "31.79", "97.38", "31.5" ]

icd9pcs

[ [ [] ] ]

9473, 9479

5285, 8060

480, 595

9579, 9579

1965, 5262

10441, 10576

1725, 1797

8471, 9450

9500, 9558

8086, 8448

9730, 10418

1812, 1812

1826, 1946

417, 442

623, 1245

9594, 9706

1267, 1547

1563, 1709

41,014

172,717

20582

Discharge summary

report

Admission Date: [**2193-11-10**] Discharge Date: [**2193-11-19**] Date of Birth: [**2133-4-7**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 3913**] Chief Complaint: hypoxia, tachycardia Major Surgical or Invasive Procedure: None History of Present Illness: 60 M with history of multiple myeloma s/p transplant in [**2189**] as well as a history of recent aortic aneurysm rupture requiring prolonged OSH ICU stay, c/b asystolic arrest, trach (now reversed) presents with 1 day of sore throat as well as increasing pain and redness in his neck at the site of the prior trach. He feels like there is something "expanding in his neck". He also reports subjective fevers and chills x 1 day, as well as nonproductive cough x 3 days. he also reports a "stiff neck on the left" x 1 day. . Of note, he was seen by Dr [**Last Name (STitle) 12375**] in clinic last week, and was given Dexamethasone 20 mg x 2 days for increasing IgG. . In the ED: Contrast CT of neck/chest was done; no evidence of abscess. ENT consulted, fiberoptic exam wnl. Given cefepime and clinda. Given 8 mg morphine for pain, BP fell from 115-->80s systolic. Given 4L NS, BP improved to 95 systolic. He is admitted to the BMT service for further treatment. . On arrival to the floor, he states he feels "remarkably better". Still w/ sore throat. Tired. . ROS: The patient denies any fevers, chills, weight change, nausea, vomiting, abdominal pain, diarrhea, constipation, melena, hematochezia, chest pain, shortness of breath, orthopnea, PND, lower extremity oedema, cough, urinary frequency, urgency, dysuria, lightheadedness, gait unsteadiness, focal weakness, vision changes, headache, rash or skin changes. Past Medical History: Past onc history: -Biclonal multiple myeloma: history of IgA and IgG multiple myeloma, who was originally treated with thalidomide and Decadron before moving to an autologous stem-cell transplant in 10/[**2189**]. He has been doing well since transplant, with his main complaint being some peripheral neuropathy in both his upper and lower extremities that began while on thalidomide. In [**3-/2192**], IgG was noted to be mildly increased, but no therapy was recommended at that time. IgG is again slightly elevated from previously today and SPEP/IFE were sent. . 1.Malignant melanoma spring, [**2192**], treated with wide local excision, negative margins, sentinal nodes biopsied (negative per pt. report) -Aortic aneurysm, last imaged 1.5 years ago, 4.7cm at that time per pt. -h/o DVT in [**2189**] s/p IVC filter -neuropathy secondary to chemo treatment 2.History of sleep apnea, not on CPAP. -s/p radial keratotomy [**2181**]. 3.-s/p ENT surgery for deviated nasal septum ~ 17 yrs ago. 4.-s/p multiple bone fractures secondary to accidents. 5.-s/p inguinal hernia repair in childhood. -s/p penile surgery [**02**] yrs. ago. 6.-s/p appendectomy in childhood 7.-h/o hospitalization for pneumonia 12-17 years ago. 8.-Childhood asthma with hospitalizations. 9.Right forearm compartment syndrome 10.-hepatitis B core antibody positive -Migraine headaches . Social History: Mr. [**Known lastname 55036**] is married, lives with his wife. [**Name (NI) **] has 2 adult children. His 28 yr old daughter has bipolar disorder. His 25 yr old son is healthy and a [**Name (NI) **]. He is a medical insurance salesperson for the past 30 years. He served in the Navy in [**Country 3992**] for 2 years. Smoked cigarrettes x 10 yrs until 25 yrs ago. Does not drink alcohol since [**10**] yrs ago. He denied history of hepatitis or blood transfusions however he has had multiple surgeries and was found on recent blood tests to be hepatitis B core antibody positive. Family History: Father had HTN Physical Exam: Vitals: T: 103 BP: 118/72 HR: 129 RR: 18 O2Sat: 98% NRB GEN: tired-appearing elderly man, comfortably conversational HEENT: EOMI, PERRL, sclera anicteric, no epistaxis or rhinorrhea, MMM, OP Clear NECK: No erythema or swelling. Trach site well healed. No JVD, carotid pulses brisk, no bruits, no cervical lymphadenopathy, trachea midline COR: Tachy, nl S1/S2, no M/G/R, radial pulses +2 PULM: Crackles at R base 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. Pertinent Results: 128 98 26 -------------<124 3.9 23 1.1 . WBC 10.8 N:71.3 L:20.6 M:7.7 E:0.2 Bas:0.2 Hgb: 9.2 Plt: 152 Hct: 26.1 (baseline 34, most recent 28) . Lactate:2.0 Trop-T: <0.01, MB: 2 PT: 15.4 PTT: 30.1 INR: 1.4 . Micro: Blood Culture (4/4 bottles on [**11-10**]): STREPTOCOCCUS PNEUMONIAE. FINAL SENSITIVITIES. For treatment with oral penicillin, the MIC break points are <=0.06 ug/ml (S), 0.12-1.0 (I) and >=2 ug/ml (R). MEROPENEM 0.047 MCG/ML Sensitivity testing performed by Etest. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STREPTOCOCCUS PNEUMONIAE | CEFTRIAXONE-----------<=0.06 S LEVOFLOXACIN---------- <=0.5 S MEROPENEM------------- S PENICILLIN G---------- 0.25 I TETRACYCLINE---------- =>16 R TRIMETHOPRIM/SULFA---- <=0.5 S VANCOMYCIN------------ <=1 S . UA negative . CT-Head and Neck ([**11-10**]): 1. No evidence of aortic dissection or central/segmental pulmonary embolism 2. No focal fluid collections or abscess. Soft tissue thickening and stranding within the lower anterior neck adjacent to tracheostomy site suggesting underlying cellulitis with possible early phlegmon. 3. Slight bowing of the posterior membrane involving the distal trachea and the left mainstem bronchus likely related to underlying tracheobrochomalacia. A dedicated CT trachea protocol may be helpful for a more definitive assessment. 4. Stable appearance to slightly dilated fluid-filled esophagus suggestive of underlying dysmotility. Please correlate with patient's clinical symptoms. . CT CHEST ([**11-15**]): As compared to the previous examination from [**2193-11-10**], there is a newly occurred bilateral pleural effusions with subsequent atelectasis and newly appeared middle lobe opacities suggestive of either infection or pneumonia. The CT appearance of the mediastinum and notably the aorta is unchanged. . MRI L-Spine: 1. No evidence of discitis, osteomyelitis or epidural abscess. 2. No evidence of cauda equina compression or distal spinal cord compression near the conus. 3. Degenerative changes as seen previously with severe left foraminal narrowing at L4-5 secondary to disc protrusion and scoliosis with deformity of the exiting left L4 nerve root. 4. Resolution of previously seen disc herniation within the spinal canal. 5. Unchanged multilevel degenerative disease. Brief Hospital Course: 60 M with h/o MM s/p transplant, recent prolonged hospitalization for ruptured aortic aneurysm presentes with neck cellulitis at site of prior trach. . CELLULITIS: ENT evaluated pt in ED; Fiberoptic laryngoscopy was normal. He receieved Clinda and cefapime in the ED, felt better on arrival to the floor. Blood cultures were positive for Pneumococcus. ID was consulted and recommended vancomycin, ceftazidime, and clindamycin initially. This was tapered to vancomycin and ceftazidime on [**11-12**], and then changed to ceftriaxone on [**11-13**]. By [**11-13**], erythema and tenderness was essentially resolved. He was started on levo and flagyl on [**11-17**]. ** He will complete a seven day course from date of discharge of levoquin + flagyl for pneumococcal cellulitis and bacteremia in the setting of aspiration. ** Follow up with ENT scheduled [**11-26**] at 5:45 PM. . PNEUMOCOCCAL BACTEREMIA: Blood cultures from [**11-10**] grew pneumococcus in [**5-3**] bottles. The source of this was felt to be the cellulitis. He was continued on vancomycin and then switched to levofloxacin on [**11-17**]. He was discharged antibiotics as above . ASPIRATION PNEUMONITIS & MICU COURSE: On the morning of [**2193-11-15**], he was nauseaus and vomited. Shortly afterwards, he was found to have tachycardia with HR in the 130s, desating to the 80s on room air, with O2 sat up to low 90s on NRB. EKG showed sinus tach. CXR showed right basilar consolidation and right pleural effusion. Patient was given solumedrol by the BMT moonlighter. Vanco and pip-tazo were ordered. Patient was transferred to the [**Hospital Unit Name 153**] for further management. There, a CT-scan showed b/l pleural effusions and R middle lobe consolidation consistant with possible aspiration PNA. A chest U/S showed effusions not large enough to tap. Over the evening of [**11-15**], the patient became hypotensive (SBP 70's) and diaphoretic. He improved following 250cc of IVF with SBP in the 100's, EKG no change. Zosyn was stopped morning of [**11-16**], he was started on levoquin. Given humoral immunodeficiency from multiple myeloma in the setting of active infection, IVIG was given on [**11-16**]. He was subsequently stable and called out the evening on [**11-16**]. . CHEST PAIN: On [**11-18**], he complained of some right-sided chest pain with arm motion, unlike anything he had with aortic dissection. He was tender to palpation midline in the 6th intracostal space. An EKG was unchanged. A chest x-ray showed no evidence of effusion and resolving pneumonia under the area of tenderness. This pain was felt to be musculoskelital. He was evaluated by Cardiac surgery who said there were no signs or symptoms that would be concerning for an aortic aneurysm problem, but that a [**Name (NI) 55037**] would be necessary to rule it out. The risks and benefits of a CT with contrast were discussed and the patient deferred. ** Consider follow-up CT-angiogram . BACK PAIN : Developed back pain on morning of [**11-13**]. This is chronic per patient's report, secondary to a herniated L4 disk. Exam revealed tenderness in left pelvic bone. MRI on [**11-13**] showed no abscess, and chonic narrowing of the L4 root foramin. His hip pain resolved over a few days and he was without pain on discharge. . HYPONATREMIA: He had hypovolemic hyponatremia in the ED that resolved overnight with 4 L IVF. . LEFT SHOULDER PAIN: He had pain on admission that appeared musculoskeletal by exam, with tenderness over L trapezius muscle. Cardiac etiology was ruled out with EKG and enzymes. Aspirin 325 mg was given during rule out. No evidence of pneumonia. Pain improved with resolving cellulitis. . ELEVATED INR: INR was 1.4 on admission, likely nutritional in setting of recent prolonged hospital course. This improved over the course of his admission. DIC labs were negative. Elevation was likely nutritional. . MULTIPLE MYELOMA : Followed by Dr [**Last Name (STitle) **]. Evidence of worsening anemia. IgG was found to be elevated but not as high as in the past. Treatment options were discussed. ** further treatment as per primary oncologist. . #. PERIPHERAL NEUROPATHY: He was continued on Lyrica and Neurontin . #. HYPERTENSION: He had previously been taking medications to control his blood pressure (Lisinopril, Norvasc, Lopressor), but blood pressures were normal without these medications in the hospital. These were discontinued on discharge. ** Follow pressures and consider [**Last Name (STitle) 9533**] antihypertensives as needed. . PIVs Regular diet bowel regimen, SC heparin comm: wife - [**Name (NI) 5627**] - [**Telephone/Fax (1) 55038**] Medications on Admission: Lyrica 75 1 TID Neurontin 600 mg TID with meals Neurotin 900 mg QHS Ritalin 5 mg QAM Lopressor 25 mg [**Hospital1 **] Norvasc 2.5 mg QAM Lisinopril 2.5 Q daily Protonix 40 mg daily Requip 0.5 mg TID (for RLS) Nortriptaline 100 mg QHS (for RLS) Seroquil 25 mg QHS Spireva 1 puff daily Vitamin B 100 mg tabs daily Discharge Medications: 1. Pregabalin 75 mg Capsule Sig: One (1) Capsule PO three times a day. 2. Gabapentin 300 mg Capsule Sig: Two (2) Capsule PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 3. Gabapentin 300 mg Capsule Sig: Three (3) Capsule PO HS (at bedtime). 4. Methylphenidate 5 mg Tablet Sig: One (1) Tablet PO QAM (once a day (in the morning)). 5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 6. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 7 days. Disp:*7 Tablet(s)* Refills:*0* 7. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 7 days. Disp:*21 Tablet(s)* Refills:*0* 8. Ropinirole 0.25 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 9. Nortriptyline 25 mg Capsule Sig: Four (4) Capsule PO HS (at bedtime). 10. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)). 11. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 12. Cyanocobalamin 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Disposition: Home Discharge Diagnosis: CELLULITIS PNEUMOCOCCAL BACTEREMIA ASPIRATION PNEUMONITIS BACK PAIN HYPONATREMIA LEFT SHOULDER PAIN ELEVATED INR MULTIPLE MYELOMA HYPERTENSION Discharge Condition: Stable, cellulitis resolved, pain free. T 97 HR 82 BP 123/69 HR 82 RR 20 Sat 97/RA Discharge Instructions: You were admitted for cellulitis, a skin infection, on your neck. You also had Streptococcus pneumoniae bacteria in your blood, that may have been related to this cellulitis. You had a transient episode of shortness of breath that was likely related to stomach acid going into the lung. Finally, you had back pain. An MRI showed a narrowed canal for the L4 nerve that may have been causing this pain. You had previously been taking medications to control your blood pressure (Lisinopril, Norvasc, Lopressor). Your pressures were normal without these medications in the hospital and you should discuss with your doctor [**First Name (Titles) 5001**] [**Last Name (Titles) 9533**] them. You should follow up with [**First Name8 (NamePattern2) 714**] [**Last Name (NamePattern1) 3236**], [**MD Number(3) 7967**] BMT service at 3:30 on [**11-26**], as well as with ENT on at 5:45 PM that same day. Followup Instructions: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 9574**], [**MD Number(3) 1240**]:[**Telephone/Fax (1) 3241**] Date/Time:[**2193-11-26**] 3:30 Provider: [**First Name4 (NamePattern1) 177**] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 41**] Date/Time:[**2193-11-26**] 5:45 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 7779**], MD Phone:[**Telephone/Fax (1) 3241**] Date/Time:[**2194-1-2**] 11:00 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 9574**], [**MD Number(3) 1240**]:[**Telephone/Fax (1) 3241**] Date/Time:[**2194-1-2**] 12:00 Completed by:[**2193-11-19**]

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icd9cm

[ [ [] ] ]

[ "99.14", "31.42" ]

icd9pcs

[ [ [] ] ]

13087, 13093

6994, 11621

337, 344

13280, 13370

4640, 6971

14317, 14984

3790, 3806

11984, 13064

13114, 13259

11647, 11961

13394, 14294

3821, 4621

277, 299

373, 1793

1815, 3175

3191, 3774

59,448

104,933

18602

Discharge summary

report

Admission Date: [**2185-8-10**] Discharge Date: [**2185-9-1**] Date of Birth: [**2122-7-2**] Sex: M Service: MEDICINE Allergies: Adhesive Tape Attending:[**First Name3 (LF) 3918**] Chief Complaint: headaches Major Surgical or Invasive Procedure: -R IJ dialysis line placement -CVVHD -Lumbar puncture History of Present Illness: 62 y/o M with hx of renal transplant and diagnosis of diffuse Large B Cell Lymphoma s/p [**Hospital1 **] chmotherapy and recent intrathecal chemotherapy presents with headache. pt has been apparently getting worsening headache since 15th with some photophobia and some confusion at times. no focal neurological complaints. no fever/chill/rigor. no neck stiffness or photophobia. no visual disturbances or nausea. pt subsequently saw Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] on [**8-8**] and underwent MRI of brain for evaluation. This apparently demonstrated extensive lesion in both hemispheres but restricted to white matter only, he was therefore referred to the ED for evaluation. In [**Name (NI) **] pt was seen by neurology consult, onc consult and renal consult. his only current complaint is mild headache which responded to po tylenol. he underwent LP per neuro recommendation and is admitted for further evaluations. . In the hospital pt was LP'd and had brain bx which confirmed B lymphoma. He subsequently underwent high dose MTX therapy via CVVH which completed. His course was complicated by enterococcus UTI treated with amoxicillin and C. Diff treated with Flagyl. Of note pt is on atovaqon for PCP prophylaxis and is getting lekovorin for rescue. He was just switched from [**Last Name (un) **] to FK due to falling counts. today he under went LUE uss for possible dvt which was negative. . Past Medical History: # Chronic renal failure secondary to diabetic nephropathy s/p Kidney transplant [**4-/2180**] # Brittle DM on insulin w/ multiple episodes of hypoglycemia # Right lenticulostriate/basal ganglia stroke found on [**2185-2-28**] # CAD s/p CABG [**2173**] # HTN # Hyperlipidemia # s/p aortoilliac bybass # s/p AKA amputation during [**Country 3992**] after gunshot with phantom limb pain # Osteomylitis of L hip # h/o kidney stone # MVA s/p splenectomy [**6-/2181**] # Diabetic retinopathy # Bilateral carotid stenosis # s/p cervical fusion # Anxiety with PTSD # h/o colitis in [**2183**] s/p colonoscopy w/ ileitis/colitis, ? crohns vs microscopic colitis Social History: Lives with his wife and son. Worked as a counselor at the VA. Remote 15-20 pack/yr smoking history. No alcohol use. No illicit drug use. Family History: Mother: Died with ovarian cancer Father: Diabetes, "brain tumor" Oldest of 9 children, several with DM, CHF. No history of blood disorders, leukemia or lymphoma. No history of strokes. Physical Exam: temp 98.6, hr 70/min, rr 16/min, sats 96% on 3L neck supple, no jvd rrr, nl s1+s2, no m/r/g bilateral wheeze worse on right [**Last Name (un) 103**] soft, non tender, nl bs ext warm, leg amputation, good pulse in other leg cns [**3-24**] intact Pertinent Results: [**2185-8-10**] 06:14AM BLOOD WBC-3.8*# RBC-3.23* Hgb-10.7* Hct-33.0* MCV-102* MCH-33.1* MCHC-32.3 RDW-19.1* Plt Ct-97* [**2185-8-29**] 12:00AM BLOOD WBC-3.5*# RBC-2.72* Hgb-8.8* Hct-26.8* MCV-99* MCH-32.3* MCHC-32.8 RDW-18.9* Plt Ct-79* [**2185-8-27**] 12:00AM BLOOD Gran Ct-1305* [**2185-8-29**] 12:00AM BLOOD Plt Smr-VERY LOW Plt Ct-79* [**2185-8-29**] 12:00AM BLOOD Glucose-190* UreaN-67* Creat-1.8* Na-144 K-5.0 Cl-114* HCO3-20* AnGap-15 [**2185-8-29**] 12:00AM BLOOD ALT-11 AST-15 LD(LDH)-368* AlkPhos-82 TotBili-0.6 [**2185-8-29**] 12:00AM BLOOD Albumin-3.3* Calcium-9.0 Phos-3.2 Mg-2.0 [**2185-8-28**] 05:29AM BLOOD tacroFK-5.8 TEST RESULT ---- ------ HEPARIN DEPENDENT ANTIBODIES NEGATIVE COMMENT: NEGATIVE PF4 HEPARIN ANTIBODY BY [**Doctor First Name **] MRI OF THE HEAD WITH AND WITHOUT CONTRAST CLINICAL INDICATION: 63-year-old man with history of CNS lymphoma, status post high dose of chemotherapy, now with worsening mental status change, MRI to evaluate progression of CNS lymphoma. COMPARISON: Multiple prior examinations of the head, the most recent consistent with CT of the head without contrast dated [**2185-8-25**] at 1034 hours, prior MRI of the head dated [**2185-8-12**] and [**2185-8-9**]. TECHNIQUE: Pre-contrast axial and sagittal T1-weighted images were obtained,axial FLAIR, axial T2, axial magnetic susceptibility and axial diffusion-weighted sequences. After the administration of gadolinium contrast, the T1-weighted images were repeated in axial T1, sagittal MP-RAGE and multiplanar reconstructions. FINDINGS: In comparison with the most recent MRI dated [**2185-8-10**], there is evidence of larger pattern of vasogenic edema, involving the right temporal lobe, apparently extending at the right parahippocampal formation (4:10), the pattern of abnormal enhancement on the right temporal lobe lesion remains similar, extending at the head of the caudate nucleus on the right. The pattern of abnormal enhancement involving the left occipitoparietal region remains stable with a new area of enhancement tracking the biopsy site, post-surgical changes are identified on the left parietal convexity consistent with a burr hole. On the diffusion-weighted sequence, there is evidence of a heterogeneous area of high signal at the head of the caudate nucleus, which is not clearly identified on the corresponding ADC map, however, the possibility of small areas with subacute ischemia cannot be completely excluded (702:16). Normal flow void signal is identified in the major vascular structures. There are no new areas with abnormal enhancement. The area of abnormal enhancement on the right temporal lobe measures approximately 18.6 x 22.7 mm in size. The area of abnormal enhancement on the head of the caudate nucleus measures approximately 9.9 x 15.3 mm and the area of abnormal enhancement on the left parietooccipital region measures approximately 32.8 x 32.5 mm in maximum dimensions. Persistent mucosal thickening is identified on the left maxillary sinus, presumably a small mucous retention cyst. IMPRESSION: Larger area of vasogenic edema and effacement of the sulci involving the right temporal lobe as described above, apparently extending at the right hippocampal formation, no definite uncal herniation is identified, the perimesencephalic cisterns are patent. The pattern of enhancement in the different lesions located at the right temporal lobe, right head of the caudate nucleus and left parietooccipital regions remain stable with similar pattern of enhancement and vasogenic edema, new track of abnormal enhancement is identified in the surgical site with associated surgical changes consistent with a left parietal burr hole. Questionable area of restricted diffusion identified on the diffusion-weighted sequence of the head of the caudate nucleus (702:16), which is not clearly identified on the corresponding ADC map, however, ischemic changes cannot be completely excluded, please correlate clinically. Brief Hospital Course: 63-year-old male with DM-II, HTN, CAD, CKD, non-Hodgkin B-cell lymphoma s/p chemotherapy (no radiation therapy), s/p kidney transplant (on Rapamune & Prednisone) who presented with worsening HTN urgency and 2 weeks of throbbing headaches and found to have extensive bihemispheric white matter lesions on MRI (R temporal and L parieto-occipital). . #HEME/Oncology: The patient was diagnosed with B-cell lymphoma diagnosed [**1-/2185**] and is s/p 6 cycles of chemotherapy (R-[**Hospital1 **] x5, R-CHOP x1) and 2 cycles of IT ara-C with last dose given on [**2185-7-13**] per OMR. The had an LP and imaging which showed significant mets to the brain. He was treated with methotrexate. The patient also recieved leucovorin, bicarb and CVVHD to aid in renal protection. The patient developed an acutely worsening mental status. He was given steroids and had repeat imaging which showed worsening of mets in increased brain edema. The decision was made to start whole brain radiation as treatment. After two treatments with whole brain radiation, and worsening of clinical condition, the family decided to make the patient comfort measures only. The whole family was present for the decision and the patient's death. Dr. [**First Name (STitle) **] and Dr. [**Last Name (STitle) **] were informed of the decision. He was started on a morphine drip and standing ativan. . #Headaches: While presentation was initially concerning for hypertensive urgency, multiple lesions were found on brain MRI and thought to be the cause of his pain. Pt was sent for brain biopsy which was highly suggestive of lymphoma. Patient was treated initially with tylenol for pain, however required IV pain medications for severe headaches. . #Hypertension: Prior to admission, pts SBPs have been intermittently in the 170s over last month per OMR notes and his usual lisinopril and lasix have been discontinued for unclear reasons (likely related to his chemotherapies). On admission he was hypertensive to the 180s-200s. He was treated with PO labetalol and clonidine while in the ICU; pt also required labetalol gtt to achieve post-surgical BP goals of 130-160. Pt was transitioned to home regimen of carvedilol 12.5 mg [**Hospital1 **] and clonidine 0.1 mg [**Hospital1 **]. . #Renal transplant: His was improved from his usual baseline of 1.6-1.7 for most of his ICU stay. He is on sirolimus and prednisone for immunosuppression which were continued in the ICU. He underwent CVVHD following methotrexate therapy to preserve remaining renal function. CVVHD therapy was complicated by filter clotting but was continued to achieve a methotrexate level of <0.05. Due to concern of worsening thrombocytopenia, sirolimus (switched to tacrolimus), bactrim and acyclovir were discontinued. . # Thrombocytopenia: HIT ab negative, concern for chemotherapy-induced thrombocytopenia. [**Month (only) 116**] also be a result of sirolimus treatment so switched to prograft on [**8-18**] for immunosuppression. Also d/ced bactrim (switched to atovoquone) and acyclovir. . # UTI: Pt was cultured on [**8-15**] for fevers. Urine grew enterococci susceptible to ampcillin. Empiric therapy with vancomycin was switched to ampcillin. . # Diabetes mellitus II: Etiology of his renal failure per OMR. Usually on home Lantus with humalog sliding scale. Followed by [**Hospital **] Clinic. Lantus dose was decreased while inpatient for hypoglycemia and was supplemented by ISS. . # Coronary artery disease: status-post 3V CABG in [**2173**]. No chest pain, EKG with no ischemic changes on admission. He remained asymptomatic currently in [**Hospital Unit Name 153**]. Aspirin on hold due to IT chemotherapy per OMR. Anti-hypertensives continued. . #Phantom limb pain: continue tylenol as needed, recently stopped taking Vicodin. . Medications on Admission: Acyclovir 400 mg PO TID Carvedilol 12.5 mg PO BID Clonazepam 1 mg PO QHS Clonidine 0.1 mg PO BID Clotrimazole 1 TROC PO QID Fluconazole 100 mg PO Daily Hydrocodone-Acetaminophen 5 mg-500 mg 1-2 Tabs PO Q12 hours PRN Pain Novolog Sliding Scale SC QID Insulin Glargine 24 Units SC QHS Lidocaine Viscous 20 mg/mL Solution 1 mL PO TID PRN Pain Lorazepam 0.5 mg 1-2 Tabs PO Q4Hours PRN Nausea Ondansetron 8mg PO Q8hours PRN Nausea Pantoprazole 40 mg PO BID Prednisone 2.5 mg PO Daily Prochlorperazine 10 mg PO Q6h PRN Nausea Caphosol QID Sirolimus 2mg and 3mg alt days Docusate Sodium 100 mg PO BID Senna 1 Tab PO BID:PRN Constipation Discharge Medications: n/a Discharge Disposition: Expired Discharge Diagnosis: patient expired Discharge Condition: n/a Discharge Instructions: n/a Followup Instructions: n/a [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 3922**]

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icd9cm

[ [ [] ] ]

[ "03.31", "99.25", "92.29", "01.13", "38.93" ]

icd9pcs

[ [ [] ] ]

11689, 11698

7184, 10981

282, 337

11757, 11762

3121, 7161

11814, 11912

2652, 2840

11661, 11666

11719, 11736

11007, 11638

11786, 11791

2855, 3102

233, 244

365, 1804

1826, 2481

2497, 2636

44,770

131,309

40218

Discharge summary

report

Admission Date: [**2193-1-1**] Discharge Date: [**2193-1-22**] Date of Birth: [**2131-2-1**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 5134**] Chief Complaint: Weakness and fall Major Surgical or Invasive Procedure: None History of Present Illness: Pt is a 61 yo F with undifferentiated carcinoma in lung and liver who presents from an OSH after a fall at home. Of note, patient was recently admitted to [**Hospital1 18**] from [**12-18**] -[**12-25**] with nausea and vomiting, thought to be due to his underlying malignancy. His hospital course was complicated by a code STEMI which was due to a moderate size pericardial effusion requiring a brief stay in the CCU. Pleural effusion was never tapped. Patient was set up to see outpatient oncologist Dr. [**Last Name (STitle) 1852**] after discharge to discuss outpatient chemotherapy, but has not been to his appointment yet because he states he overslept that day. . Patient reports that he has been feeling more weak and tired at home. he has not been eating and drinking well due to anorexia and lack of appetitite, and reports eating on average about 1 meal a day, usually only a [**Location (un) 6002**]. He was at home when he felt he 'lost his balance' and fell to his knees the day of admission. No head strike. Denies any chest pain, palpitation, SOB, LH, or syncope prior to, during, or after the episode. Did not loose his bowels or bladder. No seizure activity. Pt was not getting any PT at home. He states due to his fatigue he does not walk around very much and mostly lies in bed or sits in a chair all day. Pt also with some nausea and vomiting, but fairly well controlled with his prochlorperazine, and last episode was a few days ago. He presented to an OSH ([**Hospital3 417**]) where a CXR demonstrated a new pleural effusion. Given 1 gram of Vancomycin and 1 gram of CFTX at OSH. He was transferred to the [**Hospital1 18**] ED for further management. . In the ED, VS were: 100.9 100 102/61 22 96% 3L. Labs sig for WBC of 48.3 (43.1 on discharge on [**12-25**]), Hct of 22.5, lactate of 2.6, INR of 1.4. Received no IVFs, Flagyl 500 mg IV x1, and 60 mEQ of PO K in the Ed. While there, pt had one episode of AF with RVR to the 180s with associated hypotension with systolics down to 80s. RVR broke with 10 of IV diltiazem and he was given 30 mg PO diltiazem immediately afterwards. Pulsus measured as [**7-24**]. Bedside TTE done by ED showed moderate sized pericardial effusion with no evidence of tamponade physiology. CCU fellow was consulted for possible CCU admission, but did not think the current pericardial effusion was large enough to warrant CCU admission for pericardiocentesis or STAT TTE and declined the admission. Heme-onc fellow was also consulted and declined OMED admission given recent medicine admit and that the patient had not yet established care with his new oncologist, and that chemotherapy would be unlikely at this time. . REVIEW OF SYSTEMS: (+)ve: (-)ve: fever, chills, night sweats, loss of appetite, fatigue, chest pain, palpitations, rhinorrhea, nasal congestion, cough, sputum production, hemoptysis, dyspnea, orthopnea, paroxysmal nocturnal dyspnea, nausea, vomiting, diarrhea, constipation, hematochezia, melena, dysuria, urinary frequency, urinary urgency, focal numbness, focal weakness, myalgias, arthralgias Past Medical History: Hospitalized in [**2150**] for severe gastroenteritis Ventral hernia R scrotal cyst s/p removal in [**2170**] Poorly differentiated carcinoma on liver and pleural biopsies Social History: Per report, lifelong smoker, previously 1 PPD, currently [**12-16**] PPD; Also in documentation was history of heavy EtOH use ([**2-15**] hard shots/per day) until quit 2 years ago. Discussion with family denies any history of heavy alcohol or smoking use. Denies IVDU or other illicits. Lives with wife in [**Name (NI) **], MA. No children, retired from armed services in [**2187**]; has service around the world including [**Country 3992**]. Family History: Father died at age 57 with liver cirrhosis. Mother died from lung cancer in 80s. Physical Exam: Exam on Admission: VS: afebrile. HR 116 BP 92/60 RR 25 92% on 4 L NC GEN: cachectic male, appears exhausted, pale HEENT: neck supple, MM tachy and dry. no oral lesions. Anicteric sclera. PERRLA. EOMI. NECK: JVD ~10 cm at 45' angle. JVD collapses with inspirations. PULM: decreased BS up to mid lung bases on R with dullness to percussion. Egophony present on R>L. Decreased BS on L. CARD: muffled HS; rub present throughout cardiac cycle. Tachycardic. S1/S2 present. no m/g; pulsus ~10mmHg. ABD: NBS. Distended abdomen. Ill defined nodular mass left of umbilicus approximately 3cm in diamter. NT no g/rt. EXT: wwp 2+ pitting edema to mid shins. NEURO: AOx3, answers in yes/no, paucity of speech. Pertinent Results: STUDIES: EKG: SR, 98 BPM, normal axis, normal intervals, TWF in III, AVF, AVL, V5, V6 EKG [**1-7**]: Atrial fibrillation with rapid ventricular response. ST-T wave abnormalities. Since the previous tracing of [**2193-1-3**] there is atrial fibrillation with rapid ventricular response. ST-T wave abnormalities are new. Clinical correlation is suggested. EKG [**1-16**]: Sinus tachycardia with atrial premature beats and ventricular premature beat. Modest low amplitude T wave changes are non-specific. Since the previous tracing of [**2193-1-7**] ectopy is now present. Imaging: CXR - [**2193-1-1**] - Large R sided pleural effusion, appear slightly worsened compared to [**2192-12-22**] CXR. CXR [**1-16**]: 1. Persistent right basilar opacification and increased extent of lobulated pleural opacities suggesting enlarging pleural-based fluid collections and possibly burden of metastatic disease. 2. Generalized but somewhat heterogeneous mild new opacification of the right lung in conjunction with increasing pleural opacities, which may represent atelectasis, the result of lymphatic obstruction, although pneumonia is not excluded. [**2192-12-18**] CT ABD W CONTRAST: 1. Progression of large complex hepatic lesion which now occupies greater than 60% of the hepatic parenchyma. Findings are concordant with recent biopsy results of poorly differentiated carcinoma. At this point, there are no imaging features suggestive of abscess. 2. Increase in size and of numerous pulmonary nodules seen on limited views of the lung bases. 3. New appearance of multiple mesenteric implants suggestive of metastatic disease. TTE ([**2191-12-23**]): Left ventricular wall thickness, cavity size, and global systolic function are normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. No aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. There is mild pulmonary artery systolic hypertension. There is a small to moderate sized pericardial effusion, primarily anterior to the right ventricle. There are no echocardiographic signs of tamponade. IMPRESSION: Small to moderate-sized pericardial effusion without echocardiographic signs of tamponade. Normal global and regional biventricular systolic function TTE ([**2192-1-4**]) Left ventricular wall thicknesses are normal. The left ventricular cavity is small. Overall left ventricular systolic function is normal (LVEF>55%). There is a moderate to large sized pericardial effusion. The effusion appears circumferential. There is brief right atrial diastolic collapse and brief diastolic invagination of the right ventricular free wall. IMPRESSION: findings are consistent with early cardiac tamponade CT ([**2192-1-3**]) FINDINGS: The aorta opacifies normally without evidence of dissection. The pulmonary arteries opacify normally without intraluminal filling defects to suggest pulmonary embolism. The heart is normal in size. A new pericardial effusion is moderate in severity, causing straightening of the ventricular septum and distortion and attenuation of the right atrium, concerning for tamponade physiology. No pericardial nodularity is identified. Multiple mediastinal lymph nodes are new or enlarged including a 14-mm lower right paratracheal lymph node which is new. Numerous non-pathologically enlarged upper paratracheal and thoracic inlet lymph nodes are new. A right hilar lymph node is mildly enlarged measuring 11 mm, previously measuring 9 mm. Previously identified pleural thickening and nodularity have rapidly progressed within the right hemithorax with numerous new pleural metastases identified and involving both the minor and major fissure. Several areas of loculated pleural fluid are noted, most prominent along the paramediastinal pleural surface and within the major and minor fissures. A new left pleural effusion is moderate in severity. No pleural thickening or nodularity is noted within the left hemithorax. Right lower lobe airspace consolidation is attributed to atelectasis. Multiple new pulmonary nodules are identified including a 6-mm left lower lobe nodule (400B:36), a 3-mm right lower lobe nodule (3:52), a ground glass 9-mm nodule in the right upper lobe (3:39), a 4-mm right upper lobe nodule (3:34) and a 4-mm right upper lobe nodule, consistent with pulmonary metastases. There are no bony lesions suspicious for malignancy. Multilevel degenerative changes noted throughout the spine. Although the study was not designed for subdiaphragmatic evaluation, numerous low-density lesions within the liver have increased in size, most consistent with worsening hepatic metastases. Findings are better characterized on prior CT abdomen dated [**2192-12-18**]. IMPRESSION: 1. No evidence of pulmonary embolism. 2. Moderate pericardial fluid causing attenuation and distortion of the right atrium, concerning for tamponade physiology. Clinical correlation is essential, as reported in preliminary [**Location (un) 1131**] on [**1-4**] and discussed with Dr. [**Last Name (STitle) 17316**] at 12:10 a.m. by Dr. [**Last Name (STitle) **]. 3. Marked interval progression of extensive pleural metastases in the right hemithorax, bilateral pulmonary nodules and mediastinal and hilar lymphadenopathy, all of which is consistent with worsening metastatic disease. 4. Moderate left pleural effusion; no pleural nodules. 5. Partially imaged numerous low-density lesions in the liver, demonstrating interval increase in size. LABORATORY DATA [**1-1**] Blood Cultures x 2: no growth [**2193-1-1**] 08:00AM GLUCOSE-70 UREA N-14 CREAT-0.4* SODIUM-138 POTASSIUM-3.5 CHLORIDE-100 TOTAL CO2-27 ANION GAP-15 [**2193-1-1**] 08:00AM CK(CPK)-11* [**2193-1-1**] 08:00AM CK-MB-1 cTropnT-<0.01 [**2193-1-1**] 08:00AM CALCIUM-7.7* PHOSPHATE-3.3 MAGNESIUM-2.0 [**2193-1-1**] 08:00AM TSH-4.2 [**2193-1-1**] 08:00AM WBC-50.8* RBC-2.56* HGB-7.2* HCT-23.5* MCV-92 MCH-28.2 MCHC-30.7* RDW-19.6* [**2193-1-1**] 08:00AM PLT COUNT-413 [**2193-1-1**] 03:45AM URINE HOURS-RANDOM [**2193-1-1**] 03:45AM URINE GR HOLD-HOLD [**2193-1-1**] 03:45AM URINE COLOR-Amber APPEAR-Clear SP [**Last Name (un) 155**]-1.026 [**2193-1-1**] 03:45AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-25 GLUCOSE-NEG KETONE-TR BILIRUBIN-SM UROBILNGN-4* PH-5.0 LEUK-NEG [**2193-1-1**] 03:45AM URINE RBC-0-2 WBC-0-2 BACTERIA-FEW YEAST-NONE EPI-0 [**2193-1-1**] 03:45AM URINE MUCOUS-FEW [**2193-1-1**] 12:20AM LACTATE-2.6* [**2193-1-1**] 12:10AM GLUCOSE-102* UREA N-14 CREAT-0.4* SODIUM-131* POTASSIUM-3.0* CHLORIDE-96 TOTAL CO2-26 ANION GAP-12 [**2193-1-1**] 12:10AM estGFR-Using this [**2193-1-1**] 12:10AM cTropnT-<0.01 [**2193-1-1**] 12:10AM WBC-48.3* RBC-2.47* HGB-6.9* HCT-22.5* MCV-91 MCH-27.9 MCHC-30.7* RDW-19.2* [**2193-1-1**] 12:10AM NEUTS-96* BANDS-0 LYMPHS-3* MONOS-1* EOS-0 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 [**2193-1-1**] 12:10AM HYPOCHROM-2+ ANISOCYT-1+ POIKILOCY-OCCASIONAL MACROCYT-1+ MICROCYT-NORMAL POLYCHROM-OCCASIONAL OVALOCYT-OCCASIONAL TEARDROP-OCCASIONAL [**2193-1-1**] 12:10AM PLT SMR-NORMAL PLT COUNT-391 [**2193-1-1**] 12:10AM PT-15.7* PTT-29.1 INR(PT)-1.4* [**2193-1-3**] 06:40AM BLOOD ALT-49* AST-103* LD(LDH)-427* AlkPhos-338* TotBili-0.8 Brief Hospital Course: 61yo man with metastatic poorly differentiated carcinoma who presented after a fall at home. Poorly differentiated carcinoma: Noted on liver and pleural biopsies. Presumed HCC with sarcomatoid growth. Cancer occupying more than 60% of liver, with metastatic disease to the pleural space. Family meeting held on [**2193-1-4**] as well as [**2193-1-8**] to discuss goals of care. Medical professional team included oncology, palliative care specialists, general medicine physicians, and social workers. A discussion with pt and family outlined patient had a terminal disease, and further surgical or medical interventions would yield little benefit. Thus, he and his HCP decided that a long term care facility with hospice care was in his best interest, with goals of care focused on comfort. Placement was delayed and on [**1-21**] the patient was noted to be less alert and less responsive. Through a discussion with the [**Hospital 228**] health care proxy, the patient was made [**Name (NI) 3225**]. The patient expired shortly thereafter with his family at the bedside. Cause of death was likely congestive heart failure related to malignant pericardial effusion secondary to advanced likely hepatocellular carcinoma. The family declined autopsy. Palliative Care: the patient received anti-emetics, anxiolytics and narcotics for relief of symptoms prescribed with the guidance of the palliative care team. Pleural effusion: Noted new pleural effusion on admission. Had bedside ultrasound by pulmonary team which illustrated metastatic disease in the pleural space, with no tapable effussion. No intervention was performed, as aspiration of fluid would not relieve symptomatology. Pericardial effusion: Most likely malignant effusion in setting of known oncologic disease. TTE's were concerning for early tamponade physiology. Considering effusion was most likely from a malignant etiology, tapping the effusion was declined by cardiology, as they felt a pericardial window was the most necessary intervention for relieving the fluid accumulation. Family meeting held, and pursuit of a pericardial window was deemed very aggressive, and would not change patient's overall prognosis given metastaic disease, and would contribute more morbidity than benefit. Thus, pericardial window was declined by the patient and HCP. [**Name (NI) **] intervention was performed. The patient was monitored for worsening fluid accumulation or signs of tamponade. Atrial fibrillation: Patient had episode of AF w/ RVR associated with hypotension in the ED on presentation. Inciting etiology was unclear, but presumed to be due to irritation from pericardial effusion or fluid shifts in setting of persistent nausea and vomiting. Had multiple episodes of atrial fibrillation with rapid ventricular rate while on the medical floors. Treated with 25 mg of metoprolol [**Hospital1 **]. For breakthrough RVR, responded well to 10 mg IV diltiazem push over 2 minutes. Hemodynamically stable for approximately 10 days prior to death with no known episodes of atrial fibrillation, although blood pressures consistently low with SBP's in the 80s-90's and DBP's in the 40-60's. Fall: Likely mechanical in the setting of deconditioning/weakness from his malignancy versus dehydration from nausea/vomiting. No history of any pre-heralding symptoms concernign for vasovagal, or neurologic etiology of his fall. EKG unremarkable, troponin negative x3. IVF was given. During hospitalization, decreased mobility secondary to deconditioning, anasarca, and weakness. Required assistance from bed to chair. Medications on Admission: 1. prochlorperazine maleate 5 mg Tablet Sig: 1-2 Tablets PO every six (6) hours as needed for nausea. Disp:*30 Tablet(s)* Refills:*0* 2. furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day for 3 days. Disp:*3 Tablet(s)* Refills:*0* 3. potassium chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 3 days: Please take while taking lasix. Disp:*3 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0* Discharge Medications: N/A Discharge Disposition: Expired Discharge Diagnosis: PRIMARY: Metastatic cancer of undetermined primary (presumably hepatocellular carcinoma) . SECONDARY (sequela of metastatic disease) Pleural Effussion Pericardial Effussion Discharge Condition: Deceased Discharge Instructions: N/A Followup Instructions: N/A

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Discharge summary

report

Admission Date: [**2128-10-4**] Discharge Date: [**2128-10-30**] Date of Birth: [**2051-1-14**] Sex: F Service: NEUROLOGY Allergies: Indocin / Fosamax / Diltiazem / Norvasc / Motrin / Actonel Attending:[**First Name3 (LF) 4583**] Chief Complaint: Left sided weakness (face, arm, leg) Major Surgical or Invasive Procedure: Intubation x2 Stereotactic brain biopsy Stereotactic brain aspiration IVIG x5 days History of Present Illness: This is a 77 year old woman with hx MG for >7 yrs on Mestinon only, post-polio syndrome, who presents with several weeks (and possibly months) of progressive generalized weakness. She reports that she began to feel unwell when her husband died in [**6-29**] of a stroke - she felt depressed. In [**7-29**], she developed a GI virus and had profuse vomiting, diarrhea and abdominal pain as well as chills and worsening weakness over several weeks, unable to keep her mestinon down at times. She had a headache with this and was prescribed percocet and told to sleep in a soft collar at night to help with neck muscle contraction. The GI virus cleared three weeks ago, but she still felt weak all over, as if her myasthenia was getting worse. Two weeks ago she had fevers and chills at home for about a week, which have since resolved (one week ago). She feels that her speech has become softer and she feels out of breath, particularly when she talks or does any amount of exercise. She doesn't even want to walk, because it makes her feel markedly weak. When she swallows, the liquid comes out her nose. She continues to take pills and has not complained of choking on foods or liquids. Her daughter noticed a left facial droop about 4-5 days ago. She c/o no new numbness, tingling, diplopia or new visual changes, trouble with hearing or headaches except as aforementioned. She did fall several weeks ago and struck the right side of her head, but has not had pain at that site since then. She has had no cp, cough, dysuria, or recent GI sx. Past Medical History: -Myasthenia [**Last Name (un) **] - dx'ed before [**2121**], followed by Dr. [**Last Name (STitle) **], on Mestinon only with no hx use of immunomodulatory agents (steroids, cellcept), no hx intubation or hospitalizations for her MG, in general under "very good control." She has baseline fatiguable weakness of delt at times, has not had recent ptosis. -Post-polio syndrome, with bulbar features - soft speech, occasional trouble with swallowing -HTN -Raynaud's phenomenon -s/p TAH -MVP Social History: Lives alone; husband died in [**6-29**] of stroke at [**Hospital1 112**], daughter involved with care. No tob, etoh, drugs. Family History: No strokes, no MG or neurological d/o's in family. Physical [**Hospital1 **]: NIF -12, FVC 1.05 T 98.4 HR 55 BP 142/73 RR 14 100%RA General appearance: fatigued appearance, elderly white female HEENT: moist mucus membranes, clear oropharynx Neck: supple, no bruits Heart: regular rate and rhythm Lungs: diminished breath sounds at R>L base Abdomen: soft, nontender +bs Extremities: warm, well-perfused Skull & Spine: Neck movements are full and not painful to palpation in the paraspinal soft tissues Mental Status: The patient is alert and attentive, +DOW backwards, registered three objects at 30 seconds and recalled 3 out of 3 items at 3 minutes. Good knowledge for current events. Language is [**Hospital1 5235**] with no errors. There is no apraxia or agnosia. Cranial Nerves: There is mild ptosis after upgaze for 45 seconds. The visual fields are full. The optic discs are normal in appearance. Eye movements are normal, with no nystagmus. Pupils react equally to light, both directly and consensually - though there is <1mm anisocoria with R eye slightly bigger than L. Sensation on the face is [**Hospital1 5235**] to light touch, pin prick. There is a L UMN facial droop. Hearing is [**Hospital1 5235**] to finger rub. The palate elevates in the midline. The tongue protrudes in the midline and is of normal appearance. Motor System: Decreased bulk symmetrically throughout, normal tone throughout. There is 4+/5 weakness of neck extensors, and 4+/5 weakness of R deltoid, 4/5 weakness L deltoid. The R deltoid has fatiguable weakness after 30 seconds of abd/adduction exercises is 4-/5. R bicep 4+/5, R tricep 4+/5, full at R wrist ext, full R finger ext/flex. L bicep 4+/5, L tricep [**4-28**], 4+/5 wrist ext, 5-/5 finger ext, [**5-28**] finger flex. In lower ext, R IP is 5-/5, R ham is 5-/5, R quad is full, R foot dorsi- and plantarflexion is full. L IP [**4-28**], L ham 4+/5, L quad [**5-28**], L foot dorsiflex 4+/5, L foot plantarflex [**5-28**]. There is L pronator drift. Reflexes: The tendon reflexes brisk throughout, symmetric R=L. The plantar reflexes are flexor. Sensory: Sensation is [**Month/Day (1) 5235**] to pin prick, light touch, vibration sense, and position sense in all extremities and trunk, but there is ext to DSS over the L trunk, limbs and face. Coordination: There is no ataxia. The finger/nose test and finger and foot tapping are performed normally, as are rapid alternating hand movements. Gait: pt declines, feels too weak to walk Pertinent Results: Labs on admission: pH 7.47 pCO2 37 pO2 113 *air bubble in tube HCO3 28 Lactate:0.9 [**2128-10-4**] 2:46p 141 103 24 137 -------------< 4.2 29 1.6 card [**Last Name (un) **] pending Ca: 9.6 Mg: 2.1 P: 3.4 MCV 91 WBC 6.6 H/H 10.5/30.1 PLT 221 Imaging: "CT: IMPRESSION: Large mass lesion of low attenuation involving the right temporal lobe surrounded by significant vasogenic edema and resulting in mass effect and 10 mm midline shift to the left with early changes of subfalcine herniation of the brain. The findings were conveyed to Dr. [**Last Name (STitle) 43932**] to the eemergency room at the time of the examination. Neurosurgical consultation is recommended with followup." CXR: no pneumonia Video Swallow: Poor bolus control, including aspiration of thin liquids without spontaneous cough. Please see the report of the speech and swallow pathologist for further information. Pathology: R Temporoparietal mass Note: The tumor infiltrates predominately white matter. The neoplastic cells are small and round with a small amount of cytoplasm. Scattered tumor cells are elongated with coarse eosinophilic processes. Immunohistochemistry is being performed on the formalin-fixed paraffin-embedded tissue and the results will be performed in an addendum. Glial tumor subtyping and grading will be included in the addendum. ADDENDUM: Immunohistochemistry was performed and reveals a high proliferation rate MIB-1 (Ki67) with nuclear staining in >25% of tumor nuclei (block B,D). HMB45 is negative. The tumor cells infiltrate brain and some areas are seen floating in a loose matrix. These latter regions show strong GFAP positive staining of fibrillary processes (blocks B, D). Scattered CD68 and LCA positive cells are also present blocks (B, D). The results are consistent with the diagnosis of high grade malignant glioma. Tumor necrosis and microvascular proliferation are not detected in the small sample. Based solely on the biopsy specimen, the diagnosis is ANAPLASTIC ASTROCYTOMA (WHO grade III). Radiologic studies indicate a ring-enhancing cystic mass suggesting the possibility of higher grade tumor in unsampled parts of the tumor. MRI head [**2128-10-28**]: The large heterogeneous lesion with necrotic center and irregularly nodular-enhancing periphery in the left temporal region is again demonstrated. There is no change in the perilesional edema and the mild shift of the midline structures. No new lesions are noted. There is compression of the right lateral ventricle from the mass effect. Post-biopsy changes are noted in the right frontal region. IMPRESSION: Large right temporal lobe necrotic GBM demonstrated for CyberKnife procedure. Brief Hospital Course: Briefly, 77 year old woman with history of post-polio syndrome (bulbar weakness) and overlying myasthenia [**Last Name (un) 2902**] on mestinon at home with no past complications, who presents with a combination of fatiguable weakness and myasthenic reaction on [**Last Name (un) **], poor NIF/FVC consistent with myasthenic crisis, as well as overlying cortical sensory signs on the left with motor weakness in UMN pattern, suggesting a focal lesion in the brain R hemisphere. She was admitted to the neurology ICU with myasthenic crisis and new R temporo-parietal mass on head CT. NEURO: She was subsequently begun on decadron to decrease the cerebral edema associated with the mass and continued intubation given possible worsening of myasthenia crisis. No know primary tumor and torso CT was negative. MRI brain with gadolinium showed the right temporal lobe mass being solitary suggestive of a primary malignant glioma or an isolated metastatic lesion. Neurosurgery was contact[**Name (NI) **] and stereotactic brain biopsy was performed on [**10-12**]. Mestinon was resumed post-procedure. Pathology showed infiltrating glioma which was confirmed by immunophenotyping to be anaplastic astrocytoma. Post-operative course was complicated by a Serratia Marcescens pneumonia by BAL that was treated with Ceftazidine x 14 days. Patient was also initiated on 5 day course of IVIG to treat her myasthenia. Patient was successfully extubated on [**10-21**]. After discussion with the patient and her family, patient was again taken to OR for palliative aspiration of the brain mass in the attempt to decompress the R temporal region on [**10-28**]. Patient will follow-up with Dr. [**Last Name (STitle) **] in [**Hospital 878**] clinic as an outpatient. She will continue taking mestinon and decadron at discharge. CV: During pre-operative workup, patient was found to have had a NSTEMI with peak enzymes of 0.53 and CK 146. ECHO showed EF 35%. Cardiology was consulted and recommended beta blockade peri-operatively. Aspirin 325mg was started and held peri-operatively; and patient was started on Metoprolol as tolerated. Patient tolerated both brain surgeries with flat cardiac enzymes. Patient was without chest pain throughout hospital course. ID/PULM: Patient spiked a temperature and on [**10-13**], patient underwent bronchoscopy which showed thick secretions. Lavage culture grew Serratia marcescens. Patient completed 14 day course of Ceftazidime for likely pneumonia. Medications on Admission: Lisinopril 40 mg HCTZ 12.5 mg qod Mestinon 30 mg tid Valium 2 mg qhs Discharge Medications: 1. Acetaminophen 650 mg Suppository Sig: One (1) Suppository Rectal Q4-6H (every 4 to 6 hours) as needed. 2. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6 hours) as needed. 3. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal HS (at bedtime) as needed. 4. Docusate Sodium 100 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs PO Q4-6H (every 4 to 6 hours) as needed. 6. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times a day). 8. Insulin Regular Human 100 unit/mL Solution Sig: PER SLIDING SCALE UNITS Injection ASDIR (AS DIRECTED). 9. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig: Thirty (30) mg PO DAILY (Daily). 10. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 11. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000) UNIT Injection TID (3 times a day). 12. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: One (1) ML Intravenous DAILY (Daily) as needed: 10ml NS followed by 1ml of 100 units/ml heparin (100 units heparin) each lumen QD and PRN. Inspect site every shift . 13. Sodium Chloride 0.9 % Syringe Sig: Three (3) ML Injection DAILY (Daily) as needed: Peripheral IV - Inspect site every shift. 14. Pyridostigmine Bromide 5 mg/mL Solution Sig: One (1) mg Injection Q8H (every 8 hours). 15. Dexamethasone Sodium Phosphate 4 mg/mL Solution Sig: Four (4) mg Injection Q8H (every 8 hours). 16. Phenytoin Sodium 50 mg/mL Solution Sig: One Hundred (100) mg Intravenous Q8H (every 8 hours). Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - MACU Discharge Diagnosis: Primary diagnosis: Anaplastic astrocytoma (right temporo-parietal mass) Myasthenia [**Last Name (un) 2902**] Secondary diagnosis: Post-polio syndrome - soft speech, occas trouble swallowing Hypertension Raynaud's phenomenon S/p total abdominal hysterectomy Mitral valve prolapse Discharge Condition: Neurologically stable. MS [**First Name (Titles) **] [**Last Name (Titles) 5235**]. No ptosis on sustained upgaze. Slight left facial droop. Left arm and leg weakness 4-/5 and right side 4+/5. 2+ DTRs throughout. Discharge Instructions: Please take medications as prescribed. Please keep follow-up appointments. If you have any worsening shortness of breath, weakness in your arms or legs, increased confusion or any other worrying symptoms, please call your outpatient neurologist [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 43**], MD or return to the emergency room. Followup Instructions: [ ] Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 43**], [**Name Initial (NameIs) **].D. Phone:[**Telephone/Fax (1) 541**] Date/Time:[**2128-12-6**] 12:30 [ ] Please follow-up with Dr. [**Last Name (STitle) **]. Pines. Phone: [**Telephone/Fax (1) 37171**]. Please call on Monday and schedule an appointment to be seen within 1-2 weeks of discharge. [ ] Please follow-up with your Cardiologist, Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 87575**]. Phone: [**Telephone/Fax (1) 99135**]. Please call on Monday and schedule an appointment to be seen within 1-2 months of discharge. Completed by:[**2128-10-30**]

[ "358.01", "285.22", "191.2", "482.83", "401.9", "424.0", "443.0", "138", "342.92", "410.71", "518.81" ]

icd9cm

[ [ [] ] ]

[ "96.07", "02.39", "01.13", "96.04", "96.6", "99.14", "33.24", "96.72", "38.93" ]

icd9pcs

[ [ [] ] ]

12231, 12297

7942, 10426

359, 444

12621, 12836

5227, 5232

13236, 13900

2701, 3210

10546, 12208

12318, 12318

10452, 10523

12860, 13213

282, 321

472, 2029

3493, 5208

12449, 12600

12337, 12428

5246, 7919

3225, 3477

2051, 2542

2558, 2685

47,721

194,505

54213

Discharge summary

report

Admission Date: [**2108-3-13**] Discharge Date: [**2108-3-15**] Date of Birth: [**2031-11-8**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 3326**] Chief Complaint: fever, hypotension Major Surgical or Invasive Procedure: ERCP with Stent Placement [**3-14**] History of Present Illness: 76 year old man with PMH of paroxysmal afib, MDS on azacytidine with pancytopenia - platelet and PRBC transfusion dependent, recent hx of perforated diverticulitis s/p colectomy/ostomy ([**12-1**]), s/p biliary stent placement on [**2108-2-24**] for a distal biliary stricture without sphincterotomy due to low plts (passed 5 stones and had 7 day course of augmentin), who was admitted to [**Hospital **] hospital with fever, hypotension, and elevated LFTs. Of note, he was at [**Location (un) **] from [**Date range (1) 111096**] for a similar presentation and was given IV zosyn and neupogen, cultures were negative and was discharged on ciprofloxacin after becoming afebrile for 24 hours. Then a day later, on [**2108-3-12**], he represented to [**Location (un) **] with current complaints. He had a CXR that was negative for cardiopulmonary issues. He was given IVF, zosyn, neupogen and metoprolol xl. His labs were notable for BiliT 2.3, AST 73, ALT 102. Cultures were pending. He was transferred to [**Hospital1 18**] for repeat ERCP with sphincterotomy/stent. . On arrival to the MICU, patient's VS were stable. He reported mild abdominal pain but otherwise no current complaints such as nausea, diarrhea, or constipation. Past Medical History: MDS, plt and PRBC transfusion dependent, treated with azacitidine (just started, received 2 doses, on [**2-20**] and [**2-21**]) Perforated diverticulitis, s/p colectomy/ostomy ([**11/2107**]) CKD h/o Afib L4 radiculopathy beta thalassemia Epistaxis choledocholithiasis Social History: Lives with wife, retired mechanical engineer. Social EtOH (1 beer per week) Denies tobacco, illicits/recreational drug use Family History: no family history of pancreatic cancer Physical Exam: ADMISSION PHYSICAL EXAM: General: Jaundiced. Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: supple, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi Abdomen: Colostomy bag draining brown stool. Tender in right mid abdomen. Negative [**Doctor Last Name **] sign. GU: no foley Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CNII-XII intact, 5/5 strength upper/lower extremities, grossly normal sensation, 2+ reflexes bilaterally, gait deferred. . DISCHARGE PHYSICAL EXAM: Tmax: 98.5 ??????F HR: 88 BP: 114/62 RR: 21 SpO2: 96% General: mildly jaundiced. Alert, oriented, no acute distress HEENT: Sclera mildly icteric, MMM, oropharynx clear, EOMI, PERRL Neck: supple, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi Abdomen: Colostomy bag draining thin brown stool. Tender in right mid abdomen. Negative [**Doctor Last Name **] sign. GU: no foley Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CNII-XII intact, 5/5 strength upper/lower extremities, grossly normal sensation, 2+ reflexes bilaterally, gait deferred. Pertinent Results: Admission labs [**2108-3-13**]: WBC-0.5*# RBC-2.56* Hgb-7.5* Hct-22.8* MCV-89 MCH-29.2 MCHC-32.9 RDW-15.5 Plt Ct-11* Neuts-8* Bands-0 Lymphs-90* Monos-1* Eos-0 Baso-0 Atyps-1* Metas-0 Myelos-0 PT-17.0* PTT-31.7 INR(PT)-1.6* Glucose-104* UreaN-25* Creat-1.1 Na-128* K-3.7 Cl-98 HCO3-20* AnGap-14 ALT-176* AST-63* LD(LDH)-94 AlkPhos-102 Amylase-23 TotBili-2.7* Albumin-1.8* Calcium-7.7* Phos-3.4 Mg-1.8 Lactate-0.8 . Discharge Labs [**2108-3-15**]: WBC-0.7* RBC-2.42* Hgb-7.2* Hct-21.7* MCV-90 MCH-29.6 MCHC-33.0 RDW-15.8* Plt Ct-15* Neuts-10* Bands-1 Lymphs-88* Monos-1* Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 PT-16.5* PTT-29.2 INR(PT)-1.6* Glucose-106* UreaN-21* Creat-1.2 Na-133 K-3.6 Cl-100 HCO3-23 AnGap-14 ALT-102* AST-35 LD(LDH)-97 AlkPhos-85 TotBili-2.8* . Imaging: CXR [**2108-3-13**]: Lungs are clear. Heart is mildly enlarged. Thoracic aorta is generally large and tortuous but not focally aneurysmal in the either the arch or descending portion. The ascending thoracic aorta cannot be assessed on a single frontal conventional chest radiograph. There is no pleural abnormality or evidence of central adenopathy. . CTA abdomen/pancreas protocol [**2108-3-13**]: 1. Ill-defined fluid in the hepatic hilum without a discrete mass along the biliary ducts, pancreas, or hepatic hilum, although it is difficult to exclude subtle mass or tumor infiltration. It is also hard to exclude the possibility that increased attenuation in the hepatic hilum may partly reflect tumor infiltration. Correlation with cytology is recommended. If there is a concern for malignancy, it is possible that MR might be more sensitive to detect a subtle soft tissue mass along the extrahepatic biliary ducts or within the pancreas. 2. Irregular gallbladder wall thickening which may be a chronic process, although a recent or acute or chronic inflammatory process is not excluded by this examination. Brief Hospital Course: Mr. [**Known lastname 111097**] is a 76 year old man with a history of MDS with pancytopenia, s/p recent biliary stent placement on [**2108-2-24**] for a distal biliary stricture who presented to OSH hospital with fever, hypotension, and elevated LFTs; transferred to [**Hospital1 18**] MICU for ERCP for colangitis. . # Cholangitis (s/p ERCP with stent replacement): Patient admitted to the MICU with fevers, hypotension, jaundice, RUQ pain, elevated LFTs. On admission, he underwent ERCP with replacement of a 9cm stent for stricture. He then underwent CT scan of the pancreas, that did not reveal any defined mass to explain the stricture. CT scan did show a hyperemic gallbladder with pericholecystic stranding, consistent with cholangitis. The patient was seen by infectious disease, who recommended an antibiotic course of two weeks of zoysn (start date [**2108-3-13**]), with transition to augmentin until the patient undergoes repeat ERCP. Inflammation and fever curve improved with stent placement and antibiotics. The patient will undergo repeat ERCP with Dr. [**Last Name (STitle) **] in [**1-22**] weeks. Appointment scheduled by the biliary team at [**Hospital1 18**] in coordination with the patient's outpatient oncologist given ongoing chemotherapy. . # Febrile Neutropenia: The patient presented to [**Location (un) **] with fever, jaundice, abdominal pain, and hypotension. In combination, and given his biliary history, these are likely due to cholangitis as above. The differential of febrile neutropenia is very broad, but the patient had no other localizing signs throughout admission. CXR and urinalysis without evidence of infection. Fever curve trended down with continued zosyn. Patient should remain on zosyn for 2 weeks, per infectious disease. He should then transition to PO augmentin. Blood and urine cultures pending at the time of discharge. . # Myelodysplastic syndrome: On chemotherapy with Pancytopenia, now transfusion dependent. He is receiving outpatient chemotherapy with azacytidine (not given during hospital admission to [**Hospital1 18**]). The patient received 2 units of PRBCs for HCT of 21 during admission. He received 2 units of platelets prior to his ERCP. The patient was continued on home neupogen. NOTE: The patient was given 1U prbc for hct of 21.7 on day of dicharge. No post-transfusion hematocrit checked prior to transfer to [**Location (un) **]. . # Paroxysmal Afib: According to the documentation available the patient had new paroxysmal afib during his recent [**Location (un) **] hospitalization and was started on metoprolol 25mg [**Hospital1 **]. Metoprolol was first held on admission out of concern for sepsis. It was resumed on transfer back to [**Hospital **] hospital. The patient experienced no episodes of Afib with RVR during admission. He did have [**11-21**] runs of short, non-sustained, asymptomatic SVT recorded on telemetry. . # DVT Prophylaxis: none, given severe thrombocytopenia . # Access: PIV . # Code: Full Code . # Disposition: Patient was transferred back to [**Hospital **] Hospital for continuity of care . TRANSITIONAL ISSUES: - blood and urine cultures pending at time of discharge - Patient will need repeat ERCP in [**1-22**] weeks (scheduled) - Patient to complete two week course of zosyn for cholangitis (start date [**2108-3-13**]). He should then transition to augmentin PO until follow up with ERCP. - NOTE: The patient was given 1U prbc for hct of 21.7 on day of dicharge. No post-transfusion hematocrit checked prior to transfer to [**Location (un) **]. Medications on Admission: Toprolol XL 25 [**Hospital1 **] Neupogen 480 sq daily Reglan IV PRN Zosyn 3.375g IV Q6H Discharge Medications: 1. Piperacillin-Tazobactam 4.5 g IV Q8H x 2 weeks (start date [**2108-3-13**]) 2. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for fever. 3. filgrastim 480 mcg/1.6 mL Solution Sig: One (1) Injection Q24H (every 24 hours). 4. Toprol XL 25 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO once a day. Discharge Disposition: Extended Care Discharge Diagnosis: Primary: --Cholangitis --Biliary Stricture NOS --Myelodysplastic Syndrome --Pancytopenia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Mr. [**Known lastname 111097**], . You were transferred to [**Hospital1 18**] from [**Hospital **] Hospital for further evaluation of fevers, abdominal pain, low blood pressure. You were found to have an obstruction in the common bile duct. The duct was opened with a stent in a procedure called ERCP. You were continued on antibiotics to treat an infection of the bile ducts. . You were also given two blood and two platelet transfusions. . You were transferred back to [**Hospital **] hospital. Your medication list will be updated prior to you leaving the [**Hospital **] Hospital. . It was a pleasure caring for you during your stay at [**Hospital 18**] medical center. Followup Instructions: Department: ENDO SUITES When: FRIDAY [**2108-4-6**] at 8:30 AM . Department: DIGESTIVE DISEASE CENTER When: FRIDAY [**2108-4-6**] at 8:30 AM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2839**], MD [**Telephone/Fax (1) 463**] Building: [**First Name8 (NamePattern2) **] [**Hospital Ward Name 1950**] Building ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) 1951**] Campus: EAST Best Parking: Main Garage

[ "276.1", "V44.3", "576.2", "427.31", "458.9", "576.1", "780.61", "585.9", "238.75", "288.00", "276.2", "282.44" ]

icd9cm

[ [ [] ] ]

[ "51.10", "97.55", "97.05" ]

icd9pcs

[ [ [] ] ]

9528, 9543

5420, 8535

324, 363

9676, 9676

3512, 5397

10526, 11001

2079, 2120

9137, 9505

9564, 9655

9024, 9114

9827, 10503

2160, 2777

8556, 8998

265, 286

391, 1629

9691, 9803

1651, 1922

1938, 2063

2802, 3493

12,448

164,086

19433

Discharge summary

report

Admission Date: [**2109-12-16**] Discharge Date: [**2109-12-23**] Date of Birth: [**2042-8-30**] Sex: M Service: Cardiac Surgery Service HISTORY OF PRESENT ILLNESS: This is a 67 year old patient of Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 40143**] who was referred to operating table cardiac catheterization due to complaints of exertional chest discomfort and abnormal exercise tolerance test. This gentleman is very active, participating in tennis, kayaking and swimming and since [**Month (only) 216**] the patient had noted several episodes of chest tightness and pressure that occurred while playing tennis. The patient has also noticed that in the afternoon the patient was walking approximately [**11-24**] mile with his dog and the patient felt tightness and pressure in his chest. The patient's symptoms had been variable at times and he was able to exercise without any discomfort at all and the patient has not had symptoms at rest. The patient's exercise tolerance test on [**2109-12-2**] showed 5 minutes of [**Doctor First Name **] protocol with maximum heart rate of 153 beats/minute and chest heaviness with exercise. Electrocardiogram showed premature atrial contractions and premature ventricular contractions with [**Street Address(2) 1766**] depression. The patient denied claudication, orthopnea, edema, or lightheadedness. PAST MEDICAL HISTORY: The patient had no past medical history. PAST SURGICAL HISTORY: Broken nose, dislocated finger. ALLERGIES: No known drug allergies. MEDICATIONS: Aspirin 325 mg q. day, Imdur 30 mg p.o. q. day. HOSPITAL COURSE: The patient had an transesophageal echocardiogram which showed a normal left ventricular function and no significant reperpitation and no effusion. Right ventricular function was okay with question of hypertrophy of the right ventricular free wall. The patient was admitted to the hospital. The patient had angio which showed left ventricular ejection fraction of 60% and MCA with distal 60% stenosis, left anterior descending with subtotal occlusion at the ostium and then long 80% proximal stenosis followed by 80% stenosis at the D1. A chest x-ray showed ostial 40% lesion, ramus showed large vessels subtotally occluded at the ostium and the right coronary artery showed 40% mid vessel lesion. With these findings the patient was emergently taken to the Operating Room for coronary artery bypass graft times three. The patient had a left internal mammary artery to the left anterior descending bypass, saphenous vein graft to ramus and saphenous vein graft to obtuse marginal bypass. The patient was transferred to the Cardiac Surgery Recovery Unit. The patient was put on Vancomycin and insulin drip and was treated with Morphine Sulfate for pain. Postoperatively the patient's heart rate, however, climbed to 100 and since blood pressure required Neo to keep the blood pressure up, the patient was felt to have bleeding and was taken back to the Operating Room emergently with approximately 120 mm of sanguinous drainage with an incident we felt was turning. The patient received Protamine. Hematocrit was 28.8, therefore the patient received 3 units of packed red blood cells and 2 units of fresh frozen plasma and one pack of platelets. After returning from the Operating Room the patient was transferred back to the Cardiac Surgery Recovery Unit and the patient continued to be intubated and was monitored closely. On postoperative day #1, the patient was continued to be weaned from the ventilator. The patient had no complaints of pain. The patient was out of bed and to chair. On postoperative day #2, we obtained a physical therapy consult who recommended to work on goals of ambulation and to plan to discharge home. On postoperative day #3, the patient continued to remain afebrile with stable vital signs. The patient was alert and oriented and was following commands. The patient's lungs were clear, and examination of the abdomen showed soft abdomen, nontender, nondistended. The patient was denying nausea and vomiting. The patient continued to have voiding, and the patient was encouraged to be out of bed and walk. On postoperative day #3, the mediastinal chest tubes were removed and the wicks were removed and Foley catheter was removed. He continued physical therapy and we increased the Lopressor to 25 b.i.d. to control his heart rate and blood pressure. On postoperative day #4, the patient had temperature maximum of 100.3, otherwise had good pressure and good heart rate, and with good p.o. and good urine output. The patient had a chest x-ray. The x-rays showed an unchanged appearance in the small left apical pneumothorax and basilar pleural effusion associated with atelectasis consistent with post coronary artery bypass graft. On postoperative day #6, the patient remained afebrile with stable vital signs. The patient was clear by physical therapy to be discharged home. The patient's Metoprolol was increased to 75 b.i.d. The patient had a Clostridium difficile which was negative and had a repeat chest x-ray which showed pneumothorax has decreased in size with persistent minimal bibasilar subsegmental atelectasis, small bilateral pleural effusion. On postoperative day #7, the patient continued to be afebrile with stable vital signs. He was taking good p.o. and making good urine. The patient was not in any distress. Examination of the heart revealed regular rate and rhythm. There was no erythema along the incision. The chest was clear to auscultation and the abdomen was soft, nontender, nondistended. The patient was discharged home. CONDITION ON DISCHARGE: Good. DISCHARGE STATUS: Home. DISCHARGE DIAGNOSIS: Coronary artery disease status post coronary artery bypass graft. DISCHARGE MEDICATIONS: 1. Lasix 20 mg p.o. b.i.d. for seven days 2. Potassium 10 mEq p.o. b.i.d. for seven days 3. Colace 100 mg p.o. b.i.d. 4. Aspirin 325 mg p.o. q. day 5. Lopressor 50 mg p.o. b.i.d. [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 75**] Dictated By:[**Last Name (NamePattern1) 3118**] MEDQUIST36 D: [**2109-12-23**] 11:06 T: [**2109-12-23**] 11:19 JOB#: [**Job Number 52820**]

[ "E878.2", "424.0", "512.1", "414.01", "411.1", "E849.7", "998.11" ]

icd9cm

[ [ [] ] ]

[ "37.61", "34.03", "99.04", "39.61", "36.15", "37.22", "36.12", "88.72", "88.56" ]

icd9pcs

[ [ [] ] ]

5822, 6312

5732, 5799

1640, 5652

1488, 1622

187, 1399

1422, 1464

5677, 5710

27,121

176,772

34637

Discharge summary

report

Admission Date: [**2127-2-23**] Discharge Date: [**2127-4-25**] Date of Birth: [**2065-12-24**] Sex: M Service: MEDICINE Allergies: Ativan Attending:[**First Name3 (LF) 3918**] Chief Complaint: syncope Major Surgical or Invasive Procedure: CT guided liver biopsy PICC line placement, removed IVC filter placed R IJ triple lumen catheter History of Present Illness: This is a 61-year-old man with a history of diffuse large B-cell lymphoma status post six cycles of R-CHOP between [**6-/2126**] and [**10/2126**] and also status post five cycles of high-dose methotrexate and one dose of intrathecal methotrexate, who presents with symptoms cough, shortness of breath, mild chest discomfort, generalized weakness, and possible syncopal episode at his rehab facility today. The patient is a somewhat poor historian, but per notes from [**Hospital1 **], the patient was found by the staff at rehab to be hypotensive (SBP 60's)and minimally unresponsive after having had a bowel movement earlier this morning. Given that he had recently been admitted to [**Hospital1 18**] for similar symptoms, the rehab staff was concerned that he had again experience a syncopal episode, and sent him to [**Hospital1 **] ED for further evaluation. The patient states that he does not recall losing consciousness earlier today, but cannot elaborate any further and cannot say if he forgot any of the events which occurred earlier this morning. He does describe that he had mild chest discomfort and left thigh pain that made him feel short of breath and unable to talk, but that he is currently pain free. He also states that he has had symptoms of a cough and shortness of breath for a few days, but that his shortness of breath today was worse. While at [**Hospital1 **], the patient was found to tachycardic to the 120's, afebrile, with a BP of 96/64. He had radiographic evidence concerning for a RUL PNA on CXR. He was also noted to be coughing with thick secretions that improved with humidified air. A head CT was unremarkable. EKG showed non specific lateral T wave changes, as well a troponin level of 0.26, however, upon arrival there, the patient denied having any symptoms of chest discomfort earlier in the day. His tachycardia improved to the 90's after receiving 2L of IVF. The patient was given 2gm of IV Ceftazidime for his pneumonia and transferred to [**Hospital1 18**] for further care per the request of his family. In arrival to [**Hospital1 18**] ED, initial vitals: T- 98.5, BP 115's/70's, HR 110's, O2 99% RA. Troponin was found again to be slightly elevated (0.39), but lower than when he was recently discharged. 1L IVF given and the patient's HR improved to 100. In the [**Name (NI) **], pt remained afebrile, with stable BP (135-94), RR 18, O2 97% RA, upon transfer to the floor. Of note, the patient was recently admitted to the [**Name (NI) 3242**] service on [**2127-2-11**] for nausea and abdominal pain. He underwent a work up which included a CT of the abdomen and pelvis which showed colitis involving the distal portion of the transverse colon, descending colon, and proximal sigmoid colon. A new 2cm right hepatic lesion concerning for lymphoma was also identified on that scan. The patient also underwent an EGD that was unremarkable, Sigmoidoscopy which confirmed pseudomembranous colitis, and an upper GI study which showed dysmotility in the lower third of esophagus, but no evidence of stricture or mass. During that admission, the patient was ultimately found to be [**Date Range **] positive, treated with PO vancomycin, and discharged back to his [**Hospital1 1501**] on [**2127-2-17**] with improvement in his symptoms. Shortly after discharge, the patient returned to the ED after being found by EMS to have altered mental status, junctional bradycardia with HR 20-30's, and hypotension with systolic BP's in the 80's. The patient was observed on the [**Hospital Unit Name 196**] service, underwent a TTE which showed a normal LVEF, mild MR but otherwise no significant valvular abnormalities, and no overall interval change from previous TTE in [**2126-12-19**]. The patient was evaluated by EP and determined to have had experienced a vasovagal episode. Troponins during that admission were mildy elevated, but were determined to be secondary to demand ischemia, with flat CKs as well. . Past Medical History: Past Oncologic History: Mr. [**Known lastname **] initially presented to an outside hospital in [**6-25**] with a 30-pound weight loss over the prior 6 months. He was worked up and found to have a soft tissue mass in the cardiac ventricles involving the myocardium and extending into the interatrial septum. He was also noted to have multiple pulmonary nodules, bilateral pleural effusions, a pericardial effusion, large bilateral adrenal masses, and diffuse soft tissue masses involving both kidneys. The [**Hospital 228**] hospital course was complicated by the development of tamponade physiology, and the patient ultimately underwent a pericardial window. A renal biopsy on [**2127-7-23**] confirmed diffuse large B-cell lymphoma (Stage 4B), and a pericardial biopsy on [**2127-7-25**] also was consistent with large B-cell lymphoma. He was diffusely immunoreactive for CD20 and co-expressed Bcl-2 and Bcl-6. CD43, CD5, TdT, Bcl-1, S100 were negative. LMP for EBV was negative. CD10 and CD30 were weekly expressed. In addition, a bone marrow biopsy demonstrated bone marrow involvement by lymphoma. The patient was initiated on R-CHOP on [**2126-7-26**] and received six cycles between [**7-/2126**] and [**10/2126**] and is also status post five cycles of high-dose methotrexate and one dose of intrathecal methotrexate. Past Medical History: # Large B Cell lymphma as above # Recent C Diff Colitis # DVTs, on Lovenox # Strep viridans bacteremia (1 bottle; PICC-associated? treated w/ ceftriaxone/PCN/ceftriaxone x4 weeks total) # Erythema nodosum, right forearm ([**8-/2126**]) # Nephrolithiasis # Anemia # Gerd . Past Surgical History: # Amputation of right 2nd digit after electrical accident 45 years ago Social History: Social History: (Per OMR) The patient is married and has one son. [**Name (NI) **] is a retired engineer. + 60 pk year history of tobacco, but quit in [**Month (only) 205**] of [**2125**], just prior to his diagnosis of lymphoma due to symptoms of profound weakness. Drinks socially, ~ 2 drinks per month. No illicit drug use. One son is alive and healthy, and is also a physician. [**Name10 (NameIs) **] has been able to accomplish basic ADLs with minimal assistance, but is dependent on advanced ADLs. Family History: FHx: Family History: (per OMR) Father - died of [**Name (NI) **] Mother - SLE, DM, CAD; died age 75 Brother - cardiac arrythmias Brother - prostate CA Son - healthy Physical Exam: Physical Exam on Admission: V/S: T- 97.8, BP 142/77, P 103. R 20, O2 99% RA GEN: Thin, cachetic appearing, pale, and sleepy but easily arousable, in NAD HEENT: PERRL, EOMI, mucous membranes dry, oropharynx clear NECK: No lymphadenopathy PULM: No evidence of respiratory distrses, lungs clear to auscultation without wheezes, rhonchi or rales CV: Tachycardic, nl s1, s2, no murmurs or extra heart sounds appreciated ABD: soft, flat, non-tender, non distended, hyperactive bowel sounds, no hepatosmplenolmegaly EXT: Warm, well perfused without lower extremity edema. Non-tender calves, 2+ distal pulses bilaterally NEURO: Follows commands, oriented x 3. . Physical Exam on Discharge: VS: T 97.2 BP 104/64, HR 92, RR 18, 99% RA GEN: thin man, cachetic, NAD HEENT: PERRLA, EOMI, MMM, OP clear NECK: R IJ in place supple PULM: CTA B/L CV: regular rate and rhythm, no murmurs, rubs and gallops ABD: soft, non-tender, non-distended, no HSM EXT: diffuse peripheral edema, 3+ pitting edema of bilateral lower extremities, RUE > LUE swelling NEURO: alert and oriented X 3, cranial nerves II-XII intact, [**4-22**] muslce strenth Pertinent Results: CXR on admission: FINDINGS: In comparison with the study of [**1-3**], the left subclavian catheter has been removed. Little change in the appearance of the heart and lungs. Right apical pleural thickening and scarring persists. No definite acute focal pneumonia. [**2127-2-27**] BILATERAL LOWER EXTREMITY ULTRASOUND: Grayscale and Doppler son[**Name (NI) 867**] of the right and left common femoral, superficial femoral and popliteal veinswere performed. On the right, there is a small amount of intraluminal material in the right mid superficial femoral vein where the vein does not compress completely, consistent with a very small amount of residual thrombus. The distal portion of the right SFV and both popliteal veins are now compressible (previously were not compressible). Aside from the focal abnormality in the mid right superficial femoral vein, deep veins of the right and left lower extremities are patent and compressible, with normal waveforms and augmentation. IMPRESSION: Mild residual thrombus is present in the mid right superficial femoral vein, which is not fully compressible at this time. Elsewhere, the veins are patent and compressible. Unilateral Extremity Ultrasound (L leg): IMPRESSION: Occlusive DVT involving the left common femoral vein and superficial femoral vein in its proximal and mid portions. CT Scan: [**3-16**] IMPRESSION: 1. Marked bowel wall thickening and edema involving the cecum and ascending colon, consistent with typhlitis. Additionally, inflammatory changes surround the transverse, descending and sigmoid colon, and rectum, but to a lesser degree than the cecum and ascending colon. No evidence of perforation. 2. Cholelithiasis with unchanged prominent CBD measuring 11 mm and proximal pancreatic duct measuring 5 mm. 3. Heterogeneous hypodensities of the inferior poles of the right kidney, adjacent to the inflamed bowel and mesentery, likely reactive inflammation. 4. Unchanged atherosclerotic disease with stable mild aneurysmal dilatation of the right common iliac artery. 5. Previously noted right hepatic lesion not well visualized. CT Scan: [**3-21**] IMPRESSION: 1. Near-complete interval resolution of left chest wall mass, with decreased cardiac masses, consistent with improvement in lymphoma. 2. Circumferential wall thickening and inflammatory change involving the proximal ascending colon, suspicious for colitis which may be infectious or inflammatory in nature. 3. Stable right upper lobe consolidation with central cavitation, with multiple additional nodular opacities which are stable to minimally decreased in size, as described. 4. Multiple peripheral renal hypodensities bilaterally, which may reflect infection, small regions of infarct, or may be related to the patient's known lymphoma. Multiple regions of scarring are also present within the left kidney. Recommend clinical correlation. 5. Cholelithiasis. 6. Fullness of the adrenal glands bilaterally. This is slightly more prominent at the lateral aspect of the left adrenal gland, but no definite focal adrenal lesion is seen. 7. Extensive atherosclerotic disease of the distal aorta with bilateral common iliac artery aneurysms measuring up to 2.5 cm in size on the right. CT Scan [**2127-4-1**]: 1. Unchanged colonic wall thickening particularly of the cecum, and ascending colon. The transverse, descending, and sigmoid colonic wall is also thickened, although to a lesser degree. These findings may be consistent with typhlitis, a diffuse colitis, or Clostridium difficile colitis. 2. Patent abdominal arterial vasculature including the arterial and venous systems. 3. Sigmoid diverticulosis without diverticulitis. 4. New abdominal and pelvic ascites. 5. Dilation of the left femoral vein compared to the right raising concern for a thrombus within the left femoral vein and would recommend further evaluation with ultrasound. 5. Stable aneurysmal dilation of the right and left iliac arteries. Echo [**2127-3-27**]: The left atrium is normal in size. Left ventricular wall thickness, cavity size, and global systolic function are normal (LVEF>55%). There is mild regional left ventricular systolic dysfunction with mild hypokinesis of the basal inferior wall. Right ventricular chamber size and free wall motion are normal. The aortic root is mildly dilated at the sinus level. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. 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 pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. Compared with the prior study (images reviewed) of [**2127-3-10**], the heart rate is much lower. Overall ejection fraction has improved with now only very mild hypokinesis of the basal inferior wall. The other findings are similar. Head MRI [**2127-4-16**]: 1. No acute intracranial abnormalities. No evidence of intracranial neoplastic disease. No significant change compared to [**Month (only) 958**] [**2126**]. 2. Stable appearance of remote left basal ganglia lacunar infarcts and chronic small vessel ischemic disease U/S RUE [**2127-4-22**]: IMPRESSION: Expansile right extremity DVT extending through the majority of the right subclavian, as well as the entire axillary and brachial veins. There is also a probable thrombus in the basilic vein, although examination was technically difficult. The cephalic vein was not identified. Lab Results on Discharge [**2127-4-25**]: WBC 9.1 98% N, 2%L, 0%M, 0%E ANC 8918 HCT 23.5 (received 1 unit PRBCs after this result) Platelets 63 . Na 141 K 3.5 Cl 108 CO2 28 BUN 23 Creat 0.5 Glucose 81 Calcium 7.4 Mg 1.5 Phos 2.4 ALT 17 AST 20 LDH 220 Alk Phos 60 T. Bili 0.5 Brief Hospital Course: 61 y/o M with hx of DLBCL who presents with second syncopal episode in one week, with continued elevated troponins and unclear etiology of syncope. Transferred from [**Hospital1 **] for concern of RUL pneumonia. Received 3 courses of ESHAP and intrathecal chemotherapy during this hospitalization. Hospital course complicated by fever and neutropenia secondary to clostridium difficile infection, typhlitis, and atrial fibrillation with rapid ventricular rate. Hospital course by problem list: # RUL PNA: On admission, patient with symptoms cough and shortness of breath, and noted to have thickened sputum production at [**Hospital **] hospital with portable CXR concerning for pneumonia. Was covered with zosyn initially here. Repeat PA and lat CXR here did not show a pneumonia and the zosyn was stopped after two days because he did not clinically appear infected. Was not neutropenic. Then had an episode of aspiartion while in the CCU and found to have aspiration pneumonitis v. aspiration pneumonia on CXR. Was treated with a 8 day course of flagyl/levo and stopped. His cough and symptoms improved. # Pre-syncope: Episode very similar to previous episode of syncope, occuring after pt had BM, with associated transient hypotension and bradycardia. By time of admission, the patient was normotensive, without bradycardia, and alert. Calcium channel blocker discontinued last admission, which was initially started for achlasia. During admission he was asymptomatic and monitored on telemetry for four days. He had no alarms. He had orthostatic hypotension with daily vitals. We did try a bolus challenge and after 500 cc NS, his orthostatics improved slightly but quickly returned on recheck several hours later. His syncope was thought to be either secondary to vaso-vagal syncope associated with BMs or orthostasis. We did not start beta blocker because of orthostasis. We started captopril for hypertension while lying down and wanted to optimize his cardiac standpoint. Then on [**2-28**] at 11am, pt had an episode of syncope. He stood up, walked to the chair, sat down for a few minutes then felt dizzy and became unresponsive. His BP was 60s/30s, responsive to IVFs, HR btw 70s and 120s. EKG showed new T wave inversions. He was incontinent of stool during this episode. He regained responsiveness after only two to three minutes and was A+Ox3 but lethargic. He complained of SOB and O2 was 98% on RA. He said it felt similar to his other episodes. Cards was reconsulted and he was transferred to CCU for possible EP study as arrhythmia as possible cause of syncope. CCU Course: Pt did not have any further episodes of syncope or arrhythmia while monitored on telemetry on the cardiology floor. No EP study was performed since pt did not have any further episodes despite having several BMs on the floor. He was later found to have lymphoma involvement of the heart based on CT scan, which was likely the cause of the syncope. We started chemo as outlined below. He had no more syncopal episodes. # Diffuse Large B-Cell Lymphoma: Patient is s/p 6 cycles R-CHOP + Methotrexate, completed in [**10-26**]. However, recent CT abdomen showed evidence of new liver lesion concerning for disease recurrence. Had CT guided liver biopsy on [**2127-2-26**]. The biopsy was positive and on workup of other disease, was found to have involvement in his heart, chest wall and retropharyngeal space. He also was assumed to have it in his CSF, even though the first LP had only one aytpical cell. He received a total of 3 cycles of ESHAP chemotherapy and two doses of intra-thecal ARA-C. His last cycle of ESHAP was [**Date range (1) 79455**]. No discrete hepatic lesions noted on CT abdomen on [**3-21**]. Flow cytometry showed indefinite evidence of lymphomatous involvement of the CSF. He was followed by neuro-oncology in-house who recommended no further IT ARA-C and to follow his neurologic symptoms clinically, and to re-refer him back to his outpatient neuro-oncologist (Dr. [**Last Name (STitle) 79456**] if he had any worsening confusion or neurologic symptoms. # Febrile neutropenia - Patient had fever and neutropenia, and was treated with IV and oral vancomcyin, cefepime, flagyl, ciprofloxacin and micafungin. Likely source was C. difficile infection (see below). # h/o C Diff colitis: Pt with episode of diarrhea at rehab, and with loose stool here. Last stool sample on [**2127-2-20**] negative for [**Name (NI) **], pt has been on PO vanc for positive stool culture on [**2-12**]. Had continued diarrhea while inpatient and was started on PO flagyl. It seemed to improve slightly, but still was present. Eventually two more c.diff samples were negative and the meds were stopped. When he became neutropenic, his diarrhea started to be more severe and he had abdominal cramping and a positive c.diff again on [**2127-3-12**]. He was treated with PO vancomycin and IV/PO flagyl. He did not tolerate PO Vancomycin and was continued on IV Flagyl on discharge. Diarrhea has slowed down dramatically and C. difficile toxin assay was negative x3 on discharge. His IV Flagyl should continue until [**2127-5-8**] to complete a 14 day course after all other antibiotics were stopped. # Typhlitis: Noted in the setting of chemotherapy. Treated with IV/PO Vancomycin, Cefepime, and IV/PO Flagyl. Noted to have stable cecal and ascending colon thickening on serial CTs. PO Vancomycin discontinued due to nausea. These antibiotics were discontinued at the time of discharge and he was discharged on IV Flagyl for his C. Diff. # DVTs - was initially on lovenox for DVT diagnosed in [**Month (only) **]. Lovenox was held for liver biopsy and repeat B leni's showed no further DVT, so it was decided to not continue lovenox. Then his L leg swelled again and he had another DVT in his left common femoral vein diagnosed on [**2127-3-10**]. An IVC filter was placed in lieu of anticoagulation because of his low platelets from chemotherapy. On [**2127-4-22**], swelling of the right upper extremity was noted. This was the site of his PICC line. An ultrasound showed extensive clot in the subclavian and axillary veins. He was started on Lovenox, 1mg/kg [**Hospital1 **] (60mg SC BID). His platelets should be transfused > 50 while on Lovenox. # Elevated Troponin / likely CAD: Troponin found to be slightly elevated during last admission and determined to be from demand ischemia, as patient was asymptommatic. Earlier today, pt complained of mild chest discomfort, and troponins still slightly elevated, but trending down from last admission. Plan was for stress test as outpatient and started aspirin. No statin because of liver lesion. # Atrial fibrillation with rapid ventricular rate: Patient had a history of this, then multiple episodes of AF w/ RVR while inpatient. Patient was transferred to the MICU twice for AF w/ RVR and hemodynamic instability. During both admissions, he converted to sinus rhythm with either IV metoprolol or IV diltiazem. He had 2 episodes of AF w/ RVR in the setting of being diuresed, one requiring ICU transfer for hemodynamic instability. He was converted with diltiazem again and returned to the floor on an increased dose of metoprolol. He was followed by cardiology who recommended aggressive electrolyte repletion (K > 4, Mg > 2 at all times), no further diuresis with lasix as he was intravascularly dry, (leg elevation and [**Male First Name (un) **] stockings for his lower extremity edema) and rate control with Toprol XL PO daily. He has had intermittent atrial fibrillation with hemodynamic stability, blood pressures in the 100s-110s systolic. His Toprol XL dose was increased to 200mg PO daily. He was stable in normal sinus rhythm but had another episode of afib on [**2127-4-25**] in the morning, lasting for 4 hours. This broke with his Toprol XL dose. He should be given an extra dose of Metoprolol Tartrate 50mg PO at midnight to prevent atrial fibrillation in the morning. #) VRE urosepsis: Noted to have VRE urosepsis on [**2127-4-8**] with positive blood and urine cultures. Remained hemodynamically stable. Started on Daptomycin on [**2127-4-10**]. Surveillence blood cultures were drawn and were negative on [**2127-4-11**] and [**2127-4-12**]. He remained afebrile. TTE showed no evidence of endocarditis. He completed a 14 day course of daptomycin which ended on [**2127-4-24**]. Weekly CKs were checked and were stable. He had no other evidence of blood infection, fevers or hemodynamic instability after Daptomycin was stopped. #) Platelet refractoriness: Was noted to not be adequately increasing platelet count after transfusions during neutropenic nadir. HLA typing (panel reactive antibody) typing was negative. Recovered and began responding to platelet transfusions once out of neutropenic nadir. # Back pain- Patient complained of chronic backpain and had decreased rectal tone on exam so L-S MRI ordered but pt refused. L-S plain films showed no evidence of fracture, no evidence of lytic or sclerotic lesions. Minimal dextroscoliosis with no otherwise gross abnormality. The sacroiliac joints are unremarkable. Calcified aorta is noted on the lateral view. There are dense areas in the right upper abdomen most likely representing diverticula. We had the pain service see him and he was switched to methadone 5 mg TID and morphine for breakthrough pain. # Double vision: Seen by opthalmology, has 6th cranial nerve palsy. No evidence of lymphomatous involvement causing palsty. Wear eye patch over L eye. Should be seen in outpatient clinic to be fitted for prizm glasses. _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ________________________________________________________________ Instructions for Rehab: Please pretreat with Tylenol 650 mg PO x1 and Benadryl 50 mg PO x1 prior to all blood transfusions. 1. Pt should be monitored on telemetry for atrial fibrillation. If having frequent episodes, Toprol XL can be increased or Metoprolol Tartrate given to help keep pt in sinus rhythm. 2. Pt should have CBC checked daily for the next 7-10 days or until stable. Transfusion parameters are as follows: HCT< 25, transfuse 1 unit PRBCs HCT< 21, transfsue 2 untis PRBCs Platelets <50, transfuse 1 bag platlets, recheck in 1 hour This patient should have platlets maintained over 50 while on Lovenox. 3. Electrolyte Parameters. The patient should have magnesium and potassium repletion on a daily basis. His magnesium and potassium levels should be checked every day and given repletion on the follow scale: Mg < 2.0, give 2gm IV Magnesium Mg < 1.4, give 4gm IV Magnesium K < 4.0, give 40meq Potassium (PO or IV) K < 3.6, give 60meq Potassium (PO or IV) K < 3.2, give 80meq Potassium (PO or IV) 4. Wound Care: Patient has a pressure ulcer on sacrum: Turn patient side to side while in bed off back. If OOB, limit sit time to 1 hr and sit on a ROHO cushion. Please apply a thin layer of DuoDerm Gel to the coccyx ulcer and apply Mepilex sacral border dressing over the area. (Do not use a small Mepilex dressing) Change every 3 days or prn. 5. Triple Lumen catheter: x-ray on [**2127-4-23**] confirms R IJ triple lumen catheter in SVC. Please provide line care. 6. Neupogen: The patient was started on Neupogen on [**2127-4-24**] in anticipation of WBC count dropping due to ESHAP. His WBC was 9.1 with ANC of 8918 on [**2127-4-25**] (after 1 dose). He was given a dose of Neupogen on [**2127-4-25**]. He should have his WBC and absolute neutrophil count (ANC) checked on [**2127-4-26**]. If ANC is > [**2117**] for 2 days, neupogen can be stopped. 7. Antibiotics: IV Flagyl should continue until [**2127-5-8**] which is 14 days after other antibiotics stopped to treat C. Diff infection. 8. Lasix: IV LASIX WILL CAUSE THIS PATIENT TO GO INTO ATRIAL FIBRILLATION. Swelling should be treated with leg elevation and [**Male First Name (un) **] stockings. If Lasix is clinically indicated, small doses of PO Lasix can be used with caution. Medications on Admission: Enoxaparin 60mg Subcutaneous Q12H Fentanyl Patch 100 mcg/hr Q72H Vancomycin 250 mg PO Q6H through [**2-28**] Metoclopramide 10 mg PO QID Protonix 40 mg PO once a day. Multivitamin one capsule PO daily. Hydromorphone 4 mg - 8mg PO Q6H prn pain Acetaminophen 325 mg PO Q6H prn Simethicone 80 mg PO Q8 PRN Gas pain. Compazine 10 mg PO Q8 PRN nausea. Colace 100 mg PO twice a day PRN constipation. Zolpidem 5mg po QHS prn Discharge Medications: 1. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily): apply near back. 2. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2 times a day) as needed. 3. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day) as needed: On aspiration pre-cautions, please brush onto tongue. 4. Olanzapine 5 mg Tablet, Rapid Dissolve Sig: 0.5 Tablet, Rapid Dissolve PO every six (6) hours as needed for nausea: ONLY GIVE IF PATIENT COMPLAINS OF NAUSEA. 5. Methadone 5 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 6. Filgrastim 300 mcg/mL Solution Sig: One (1) Injection Q24H (every 24 hours): give until ANC > [**2117**] for 2 consecutive days. 7. Morphine 2 mg/mL Syringe Sig: 1-2 mg Injection Q4H (every 4 hours) as needed for pain: hold for RR < 9, sedation. 8. Ondansetron HCl (PF) 4 mg/2 mL Solution Sig: Eight (8) mg Injection Q6H (every 6 hours) as needed for nausea. 9. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed. 10. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed for heartburn. 11. Magnesium Sulfate 4 % Solution Sig: [**1-22**] grams Injection once a day as needed for as directed: Per sliding scale below: Magnesium <1.2: 4 gm and [**Name8 (MD) 138**] MD Magnesium 1.2-1.5: 4 gm Magnesium 1.6-1.7: 2 gm Magnesium 1.7-2.0: 2 gm . 12. Multivitamin Tablet Sig: One (1) Tablet PO once a day. 13. Potassium Chloride 20 mEq/50 mL Piggyback Sig: 40-60 mEQ Intravenous once a day as needed for per sliding scale: Sliding Scale: Potassium 4.0 - 3.6: 40 mEq Potassium 3.5 - 3.3: 60 mEq Potassium 3.2 - 3.0: 80 mEq Potassium < 3.0: Notify HO . 14. Potassium Phosphate Dibasic 3 mMole/mL Parenteral Solution Sig: Fifteen (15) mMole Intravenous PRN (as needed) as needed for per sliding scale: Sliding Scale: Phosphate >= 1.5 < 2.4: 15 mmol Phosphate < 1.5: Notify HO . 15. Metoclopramide 10 mg Tablet Sig: 0.5 Tablet PO QIDACHS (4 times a day (before meals and at bedtime)). 16. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 17. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr Sig: Two (2) Tablet Sustained Release 24 hr PO DAILY (Daily). 18. Enoxaparin 60 mg/0.6 mL Syringe Sig: One (1) syringe Subcutaneous Q12H (every 12 hours). 19. Acyclovir 200 mg Capsule Sig: Two (2) Capsule PO Q8H (every 8 hours). 20. Fluconazole 200 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours). 21. Metoclopramide 10 mg IV BID:PRN nausea, dry heaving 22. Chlorpromazine 25 mg/mL Solution Sig: Ten (10) mg Injection Q4H (every 4 hours) as needed for wretching, dry heaves. 23. Metronidazole in NaCl (Iso-os) 500 mg/100 mL Piggyback Sig: Five Hundred (500) mg Intravenous Q8H (every 8 hours) for 14 days: last dose on [**2127-5-8**]. 24. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: Ten (10) ML Intravenous PRN (as needed) as needed for line flush. 25. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Disposition: Extended Care Facility: [**Hospital3 105**] Northeast - [**Location (un) 1110**] Discharge Diagnosis: Primary Diagnosis: 1. Diffuse Large B-cell Lymphoma 2. Deep Vein Thrombosis in lower and upper extremities 3. Atrial Fibrillation with Rapid Ventricular Rate, intermittent 4. Cardiogenic Syncope 5. Clostridium difficile infection 6. Febrile neutropenia 7. Typhlitis 8. VRE Urosepsis Discharge Condition: afebrile, hemodynamically stable, in normal sinus rhythm Discharge Instructions: You were admitted for fainting, it was likely due to the lymphoma in your heart. We monitored you closely, and then started chemotherapy. You received 2 doses of ESHAP chemotherapy and intrathecal ara-C as well. Your cancer showed some improvement with this chemotherapy. You had a rapid heart rate known as atrial fibrillation with rapid ventricular rate. This was controlled with medications and you are currently on oral metoprolol to control this heart rate. You had fevers while your counts were low. You also had clostridium difficile infection again, and an infection of the colon known as typhlitis. Both of these conditions, we treated with antibiotics. You remain on Flagyl IV on discharge. The following changes were made to your home medications. 1. Your enoxaparin, fentanyl patch, hydromorphone, tylenol, compazine, and zolpidem were stopped. 2. You were started on methadone 5 mg by mouth three times a day, morphine, and lidocaine patch for pain control. 3. You should continue on flagyl IV for 14 days, last day 4. Zyprexa was added as needed for nausea only. 5. Metoprolol 150 mg XL daily was added for control of your heart rate. It is extremely important that you do not miss taking this medication. 6. Please take neupogen until directed by your outpatient oncologist to discontinue this medication. 7. Your as needed compazine for nausea was switched to zofran. 8. You were started on acyclovir and fluconazole for prophylaxis against viral and fungal infections during your neutropenic phase. 9. Phosphate, Potassium, and Magnesium Sliding Scales as directed. Please return to the hospital or call your primary oncologist if you experience fevers greater than 100.4, chills, night sweats, worsening abdominal pain, worsening diarrhea, inability to tolerate good oral intake of food and fluids, loss of consciousness, or any other symptoms not listed here concerning enough to warrant physician [**Name Initial (PRE) 2742**]. Followup Instructions: Hematology/Oncology: Dr. [**Last Name (STitle) **] and [**First Name8 (NamePattern2) 3742**] [**Last Name (NamePattern1) 41684**], NP on [**2127-5-2**] at 3:30pm. Please call optholmology at ([**Telephone/Fax (1) 253**]) to arrange an outpatient appointment to get fitted for prizm glasses at your convenience. [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 3922**]

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icd9cm

[ [ [] ] ]

[ "99.04", "03.31", "38.93", "99.05", "38.7", "99.25", "50.11", "99.15" ]

icd9pcs

[ [ [] ] ]

29345, 29428

13773, 14255

276, 374

29755, 29814

7963, 7967

31818, 32225

6662, 6808

26214, 29322

29449, 29449

25771, 26191

29838, 31795

6030, 6103

6823, 6837

7505, 7944

229, 238

24512, 25745

402, 4361

14270, 24500

29468, 29734

7981, 13750

5735, 6007

6135, 6625

15,544

168,278

12000

Discharge summary

report

Admission Date: [**2150-10-26**] Discharge Date: [**2150-10-30**] Date of Birth: [**2092-5-10**] Sex: M Service: Vascular HISTORY OF PRESENT ILLNESS: Mr. [**Known firstname **] [**Known lastname 37712**] is a 58-year-old male who, prior to admission, had a carotid noninvasive study that revealed greater than 90% stenosis of his left carotid artery; thus, a left carotid endarterectomy was indicated. HOSPITAL COURSE: On [**10-26**], the patient was admitted to [**Hospital1 69**] and underwent a left carotid endarterectomy without shunt, as well as endarterectomy of the external carotid artery via a second arteriotomy with Dacron patch. The patient was unable to be aroused in the operating room at the end of the operation. At this time, he was found to have bilateral upgoing toes. The patient was moving in response to pain in the left arm and the bilateral lower extremities. Because the patient could not be extubated, the patient underwent another procedure with the preoperative diagnosis being a left internal carotid artery occasional with postoperative diagnosis actually being an open internal carotid artery on the left. The procedure, at that point in time, was a re-exploration of the neck on the left side, and on the table arteriography which showed a patent internal carotid artery. It was presumed at this time that the patient had suffered an intraoperative stroke. Thus, the stroke team was involved in the patient's management as well as the Surgical Intensive Care Unit team. On examination by the stroke team, the patient was intubated and still withdrawing to pain with the left arm. The eyes were oriented toward the left side, and there seemed to be a right hemiplegia of the arm and bilateral Babinski signs. At this time, they felt that this was most likely a left middle cerebral artery region stroke and recommended a magnetic resonance imaging of the head. This magnetic resonance imaging revealed a large left middle cerebral artery, a left anterior cerebral artery, and a right anterior cerebral artery infarct. It was felt that the right anterior cerebral artery infarct was likely secondary to a hypoplastic right A1 segment of the Circle of [**Location (un) 431**] with perfusion of the right anterior cerebral artery from the left anterior circulation. On [**10-28**], the patient's neurologic examination appeared to deteriorate further. The patient was found to have decerebrate posturing and continued to have bilateral Babinski signs. At this time, Neurosurgery was consulted. They felt that there was no surgical options that could improve the patient's situation. Later that evening, at 6:30 p.m., the patient was found to have pupils that were fixed at 4 mm. The Intensive Care Unit attending was made aware of this. Neurology was reconsulted. They suggested Decadron and hyperventilation therapy. Because the patient's clinical examination suggested the possibility of brain death at this time, on [**10-29**], an apnea test was performed over 10 minutes, and no respiratory effect was detected. PCO2 increased from 44 to 72. The oxygen saturation was greater than 94% throughout. This result was consistent with brain death. This was done by the Intensive Care Unit staff. On [**10-30**], a SPEC scan was done to confirm brain death, and this scan showed no brain uptake. On examination, the patient continued to have no brain stem reflexes. On [**10-30**], at 12:40 a.m., the patient again had a clinical examination as well as an apnea test that showed that the patient was brain dead. The Intensive Care Unit attending and Dr. [**Last Name (STitle) 1391**] discussed this with the patient's wife. The medical examiner was informed of the patient's brain death, and the case was declined by Dr. [**Last Name (STitle) 7324**]. The patient's wife wished that her husband's internal organs be donated. At this time, the Organ Bank took over the care of the deceased patient and harvested the patient's organs. DISCHARGE DIAGNOSES: Final diagnosis was stroke and brain death, status post left carotid endarterectomy. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 4417**] Dictated By:[**Last Name (NamePattern1) 4039**] MEDQUIST36 D: [**2151-2-8**] 14:17 T: [**2151-2-9**] 11:38 JOB#: [**Job Number **]

[ "412", "425.5", "433.10", "250.00", "276.0", "507.0", "997.02", "278.01", "997.3" ]

icd9cm

[ [ [] ] ]

[ "38.12", "96.6", "88.41", "96.71" ]

icd9pcs

[ [ [] ] ]

4032, 4385

440, 4010

168, 421

57,599

193,195

38123

Discharge summary

report

Admission Date: [**2109-5-22**] Discharge Date: [**2109-5-30**] Date of Birth: [**2059-8-24**] Sex: F Service: CARDIOTHORACIC Allergies: Topamax / Percocet / Tizanidine / Lyrica / Tramadol / Methocarbamol / Naproxen / Gabapentin / Sulfa (Sulfonamide Antibiotics) / Cefazolin / Albuterol Attending:[**First Name3 (LF) 5790**] Chief Complaint: Cervical tracheomalacia. Major Surgical or Invasive Procedure: [**2109-5-22**]: Cervical tracheal resection and reconstruction, bronchoscopy with bronchoalveolar lavage. History of Present Illness: The patient is a 49-year-old woman with severe diffuse tracheobronchomalacia. She had previously undergone a thoracic tracheobronchoplasty and now has residual severe malacia at the site of her tracheostomy stoma in the cervical trachea. She presents for correction of this obstructive an extremely symptomatic abnormality. Past Medical History: -Severe TBL at both mainstem bronchi and bronchus intermedius, s/p both metal and silicone stents (unsuccessful [**1-2**] inflammation requiring intubation during stent removal [**6-9**]), s/p Trach/PEG [**6-9**]. - Recent MSSA VAP and PNA x3 in recent years -Osteopenia/osteoarthritis -Chronic pain -Type II DM -Diabetic neuropathy -Depression -Fibromyalgia -Herpes -Hiatal hernia -Hypertension -Hypothyroidism -IBS -GI bleed -nephrolithiasis -Irregular heart rhythm -NASH (w/up Hepatitis serologies, Fe studies, alpha-1-antitrypsin neg). -PTSD -Agoraphobia -GERD -Latent TB - INH course stopped (with ID input) [**1-2**] - transaminitis -Carpal tunnel -S/P appendectomy -S/P C-section -S/P cholecystectomy -S/P hysterectomy -S/P R oophorectomy -S/P L ovarian cystectomy -S/P shoulder surgery x4 -S/P L breast ductal excision -S/P liver biopsy x2 Social History: - Lives in VT w/ husband and mom. - Tobacco history: none, has used medical marijuana in the past. - ETOH: allergic (hives) - Illicit drugs: none Family History: noncontributory Physical Exam: VS: T: 97.0 HR 68 SR BP: 140/88 Sats: 95 RA General: 49 year-old female in no apparent distress HEENT: normocephalic, mucus membranes moist NEck: supple, no lymphadenopathy Card:RRR Resp: clear breath sounds occasional rhonchus GI: benign Extr: warm Incision: neck clean dry intact, no erythema, margins well approximated Neuro: awake, alert oriented Pertinent Results: [**2109-5-30**] WBC-7.4 RBC-4.23 Hgb-11.4* Hct-35.2 Plt Ct-235 [**2109-5-22**] WBC-13.6* RBC-4.29 Hgb-11.7* Hct-35.6 Plt Ct-251 [**2109-5-27**] Glucose-134* UreaN-6 Creat-0.5 Na-142 K-3.9 Cl-101 HCO3-32 [**2109-5-22**] Glucose-152* UreaN-9 Creat-0.6 Na-139 K-4.1 Cl-103 HCO3-23 [**2109-5-27**] Calcium-9.3 Phos-4.1 Mg-1.8 CXR: [**2109-5-29**]: CHEST, PA AND LATERAL VIEWS: Compared to the prior exam, there is improved aeration of the lungs bilaterally with minimal bibasilar atelectasis. There is no effusion or pneumothorax. Cardiomediastinal silhouette, hilar contours and pulmonary vasculature are normal with improved hemodynamics and no residual evidence of volume overload. IMPRESSION: No pleural effusion. Video-swallow: [**2109-5-29**] Intermittent penetration with thin and nectar thick barium only. No aspiration. Brief Hospital Course: Mrs. [**Known lastname 85068**] was admitted [**2109-5-22**] for Cervical tracheal resection and reconstruction, bronchoscopy with bronchoalveolar lavage. She was extubated in the operating from, transfer to the SICU. in stable condition. Upon admission to SICU her voice initially raspy with concern for recurrent laryngeal. Over the next 24 hours her voice returned to baseline. She complained of chest tightness/TBM symptoms which improvement with nebs. On [**2109-5-23**] she become confused. An ABG revealed hypoxemia/hypercarbia likely secondary to sedation/narcotics. Her narcotics were tapered and she improved. She transfer to the floor on [**2109-5-26**]. Respiratory: aggressive saline, Xopenex and Atrovent nebs her respiratory status improved. Flexible bronchoscopy was done [**2109-5-28**]. The anastomosis site is healing nicely. The guard suture was removed. Her overall respiratory status has improved. She is able to speak in complete sentences. Swallow: [**2109-5-24**] a bedside swallow was cleared for puree diet with thin liquids. A video-swallow was done [**2109-5-29**] Intermittent penetration with thin and nectar thick barium only. No aspiration. Recommendations: PO diet: thin liquids, regular consistency solids. Meds whole with water. good oral care. Card: hemodynamically stable sinus rhythm without ectopy. Blood pressure 140's amlodipine was restarted. GI: PPI and bowel regime. She tolerated a diabetic diet. Renal: normal renal function with good urine output. Electrolytes were replete as needed Endocrine: Insulin sliding scale and lantus was titrated to keep glucose level < 150. Pain/anxiety: her home dose Xanax was restarted at 1/2 her dose. Her pain was well controlled with PO Dilaudid. Disposition: she continued to make steady progress and was discharged to home on [**2109-5-30**]. She will follow-up with Dr. [**Last Name (STitle) **] as an outpatient. Medications on Admission: Acyclovir 400 mg daily, Alprazolam 1 mg tid, Amitryptiline 100 mg hs, Fluoxetine 80 mg daily, Dilaudid 8mg prn, Lantus/Lispro, Ipratropium, Kapidex 60 mg daily, Mucomyst prn, Ranitidine 150 mg [**Hospital1 **], Colace, Viactiv, Mucinex, MVI, Senna Discharge Medications: 1. levalbuterol HCl 0.63 mg/3 mL Solution for Nebulization Sig: Three (3) ML Inhalation q6h () as needed for wheezing. 2. ipratropium bromide 0.02 % Solution Sig: Three (3) mL Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. 3. alprazolam 1 mg Tablet Sig: 0.5-1.0 Tablet PO every eight (8) hours as needed for anxiety. 4. senna 8.8 mg/5 mL Syrup Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 5. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 6. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO every 6-8 hours as needed for pain. Disp:*70 Tablet(s)* Refills:*0* 7. amitriptyline 100 mg Tablet Sig: One (1) Tablet PO at bedtime. 8. fluoxetine 40 mg Capsule Sig: Two (2) Capsule PO once a day. 9. ranitidine HCl 150 mg Capsule Sig: One (1) Capsule PO twice a day. 10. Mucinex 1,200 mg Tablet, ER Multiphase 12 hr Sig: One (1) Tablet, ER Multiphase 12 hr PO twice a day. 11. amlodipine 5 mg Tablet Sig: One (1) Tablet PO once a day. 12. kapidex Sig: One (1) 60 mg at bedtime. 13. acyclovir 400 mg Tablet Sig: One (1) Tablet PO once a day. 14. insulin glargine 100 unit/mL Solution Sig: Thirty Two (32) units Subcutaneous at bedtime. 15. Lispro Sliding Scale continue previous insulin sliding scale 16. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO twice a day. 17. multivitamin-min-calcium-FA 200-0.4 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO once a day. Discharge Disposition: Home With Service Facility: Central [**Hospital 3914**] Home Health and Hospice Discharge Diagnosis: Cervical tracheomalacia. Tracheobronchomalacia Recent MSSA VAP and PNA x3 Diabetic Mellitus Type 2 (neuropathy) Osteopenia/Osteoarthritis Depression Fibromyalgia Herpes Hiatal hernia Hypertension Hypothyroidism Irritable bowel syndrome, GI bleed Nephrolithiasis, Irregular heart rhythm, NASH, PTSD, Agoraphobia, GERD, Latent TB, Carpal tunnel PSH: appendectomy, C-section, cholecystectomy, hysterectomy, R oophorectomy, L ovarian cystectomy, shoulder surgery x4, L breast ductal excision, liver biopsy x2 Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Call Dr.[**Name (NI) 2347**] office [**Telephone/Fax (1) 2348**] if you experience: -Fevers > 101 or chills -Increased shortness of breath, cough or chest pain -Neck incision develops drainage -Continue saline nebs as previous Pain -Acetaminophen 650 every 8 hours as needed for pain -Hydromorphone 2-6 mg for pain Activity -Shower daily. Wash incision with mild soap & water, rinse, pat dry -No tub bathing swimming or hot tubs until incision healed -Walk frequently Followup Instructions: Follow-up with Dr. [**Last Name (STitle) **] for flexible bronchoscopy on [**2109-6-19**]. Please arrive at 10:00 am in the [**Hospital Ward Name 517**] Clinical Center [**Hospital1 85069**] check in [**Location (un) **] Information Desk for your 11:30 appointment Nothing to Eat or Drink after midnight [**2109-6-19**] Completed by:[**2109-5-30**]

[ "E878.3", "338.29", "309.81", "250.60", "519.19", "357.2", "244.9", "729.1", "401.9", "571.8", "311", "519.09", "733.90", "599.72", "300.22" ]

icd9cm

[ [ [] ] ]

[ "31.79", "96.56", "31.5", "33.23" ]

icd9pcs

[ [ [] ] ]

6957, 7039

3217, 5134

442, 551

7588, 7588

2363, 3194

8233, 8586

1959, 1976

5433, 6934

7060, 7567

5160, 5410

7739, 8210

1991, 2344

377, 404

579, 907

7603, 7715

929, 1778

1794, 1943

3,649

139,020

23861

Discharge summary

report

Admission Date: [**2135-6-28**] Discharge Date: [**2135-9-1**] Date of Birth: [**2083-11-22**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 943**] Chief Complaint: Abdominal Pain Major Surgical or Invasive Procedure: Incarcerated Incisional Hernia repair with small bowel resection; large volume paracentesis; endotracheal intubation and ventilation for airway management History of Present Illness: 51 yo m w/ h/o alcholic and hcv cirrhosis, CRI, traumatic splenic rupture, R tib-fib fx following MVA, and has a prior history of incisional hernias with incarceration. He now presents with small-bowel obstruction and a tender incarcerated hernia in his previous midline incision. He is brought urgently to the operating room. Past Medical History: 1. HepC cirrhosis: decompensated with ascites on diuretics, encephalopathy on lactulose/[**First Name3 (LF) 8005**], gr I varices seen on [**8-13**] EGD 2. s/p splenectomy [**2-10**] trauma, fall from height 3. s/p appendectomy 4. incisional hernia 5. R tib/fib fx s/p vehicular trauma [**2108**]. Repaired w/ pin and mult screws. Also injury to R elbow, pt does not believe there is hardware in place. Social History: lives alone, niece [**Name (NI) **] organizes medications and helps with shopping/transportation, active in all ADLs; + tobacco (7 cig/d); h/o EtOH abuse, quit 6y ago, in AA; h/o cocaine use, last use 11 mos. ago. Family History: father with emphysema, mother with cancer of unknown primary, brothers died of cirrhosis, no renal disease Physical Exam: Physical Exam on admission: t 98.1, bp 124/69, p 93, r 20 98% ra Middle aged male in NAD. Alert and oriented x3 PERRL, anicteric. No hemorrhages noted. OP clr. Regular S1, soft S2 w/ III/VI SEM @LUSB LCA b/l Protuberant abdomen w/ incisional hernia. decreased bowel sounds. nt. +shifting dullness. +fluid wave. +caput. 2+ LE edema on R. midline scar. 1+ edema on the R w/o tenderness R elbow scar. No erythema/swelling/tenderness. No splinter hemorrhages, [**Last Name (un) **] lesions, osler nodes. No asterixis Pertinent Results: [**2135-6-27**] 09:20PM PT-16.4* PTT-38.3* INR(PT)-1.5* [**2135-6-27**] 09:20PM PLT COUNT-150 [**2135-6-27**] 09:20PM WBC-10.9 RBC-2.73* HGB-9.5* HCT-28.8* MCV-105* MCH-34.7* MCHC-32.9 RDW-18.5* [**2135-6-27**] 09:20PM ALBUMIN-2.5* CALCIUM-8.5 PHOSPHATE-4.9* MAGNESIUM-1.6 [**2135-6-27**] 09:20PM LIPASE-38 [**2135-6-27**] 09:20PM ALT(SGPT)-33 AST(SGOT)-144* ALK PHOS-238* [**2135-6-27**] 09:20PM GLUCOSE-129* UREA N-28* CREAT-1.9* SODIUM-134 POTASSIUM-7.0* CHLORIDE-106 TOTAL CO2-19* ANION GAP-16 [**2135-6-27**] 10:35PM ALBUMIN-2.2* [**2135-6-27**] 10:35PM LIPASE-25 [**2135-6-27**] 10:35PM ALT(SGPT)-32 AST(SGOT)-100* ALK PHOS-223* AMYLASE-38 TOT BILI-2.0* [**2135-6-27**] 10:44PM LACTATE-2.4* K+-5.8* [**2135-8-29**] 03:56AM BLOOD WBC-14.3* RBC-3.10* Hgb-10.0* Hct-28.7* MCV-93 MCH-32.4* MCHC-34.9 RDW-23.9* Plt Ct-48* [**2135-8-29**] 03:56AM BLOOD PT-41.4* PTT-83.2* INR(PT)-4.7* [**2135-8-29**] 03:56AM BLOOD Fibrino-59* [**2135-8-29**] 03:56AM BLOOD Glucose-153* UreaN-80* Creat-3.4* Na-144 K-4.4 Cl-112* HCO3-15* AnGap-21* [**2135-8-27**] 04:44AM BLOOD ALT-11 AST-27 LD(LDH)-118 AlkPhos-68 TotBili-7.7* [**2135-8-29**] 03:56AM BLOOD ALT-9 AST-27 AlkPhos-81 TotBili-10.3* [**2135-8-29**] 03:56AM BLOOD Calcium-9.4 Phos-7.0* Mg-2.2 [**2135-8-26**] 04:22AM BLOOD TotProt-5.5* Albumin-3.5 Globuln-2.0 Calcium-9.1 Phos-5.2* Mg-1.9 [**2135-8-27**] 05:34PM BLOOD Cortsol-8.7 [**2135-8-27**] 05:34PM BLOOD Cortsol-9.0 [**2135-8-27**] 03:49PM BLOOD Cortsol-7.5 [**2135-8-19**] 04:39AM BLOOD HIV Ab-NEGATIVE [**2135-8-29**] 03:56AM BLOOD Vanco-30.0 [**2135-8-29**] 04:07AM BLOOD Type-ART Temp-37.1 Rates-22/0 Tidal V-600 PEEP-8 FiO2-40 pO2-130* pCO2-29* pH-7.34* calTCO2-16* Base XS--8 -ASSIST/CON Intubat-INTUBATED [**2135-8-29**] 04:07AM BLOOD Lactate-3.4* MICROBIOLOGY DATA: [**2135-6-27**] BLOOD CULTURE AEROBIC BOTTLE-FINAL; ANAEROBIC BOTTLE-FINAL {ENTEROCOCCUS FAECIUM} [**2135-7-10**] FLUID RECEIVED IN BLOOD CULTURE BOTTLES (PERITONEAL FLUID) AEROBIC BOTTLE-FINAL {[**Female First Name (un) **] ALBICANS}; ANAEROBIC BOTTLE-FINAL {[**Female First Name (un) **] ALBICANS, [**Female First Name (un) **] (TORULOPSIS) [**Female First Name (un) **]} [**2135-7-11**] PERITONEAL FLUID GRAM STAIN-FINAL; FLUID CULTURE-FINAL {[**Female First Name (un) **] (TORULOPSIS) [**Female First Name (un) **]}; ANAEROBIC CULTURE-FINAL [**2135-8-3**] FLUID RECEIVED IN BLOOD CULTURE BOTTLES BLOOD/FUNGAL CULTURE-FINAL {[**Female First Name (un) **] ALBICANS}; BLOOD/AFB CULTURE-FINAL [**2135-8-23**] PLEURAL FLUID GRAM STAIN-FINAL; FLUID CULTURE-FINAL {STAPH AUREUS COAG +}; ANAEROBIC CULTURE-FINAL; ACID FAST CULTURE-PENDING; ACID FAST SMEAR-FINAL [**2135-8-23**] FLUID RECEIVED IN BLOOD CULTURE BOTTLES (PERITONEAL FLUID)AEROBIC BOTTLE-FINAL {STAPH AUREUS COAG +}; ANAEROBIC BOTTLE-FINAL {STAPH AUREUS COAG +} [**2135-8-24**] BLOOD CULTURE AEROBIC BOTTLE-FINAL {STAPH AUREUS COAG +}; ANAEROBIC BOTTLE-FINAL {STAPH AUREUS COAG +} CT PELVIS W/O CONTRAST [**2135-6-28**] 3:15 PM CT ABDOMEN W/O CONTRAST; -59 DISTINCT PROCEDURAL SERVIC Reason: already received contrast but ileus present, reimage with co [**Hospital 93**] MEDICAL CONDITION: 51 year old man with hepC cirrhosis with varices, ascites, with 2d N/V/abd pain, REASON FOR THIS EXAMINATION: already received contrast but ileus present, reimage with contrast movemetn CONTRAINDICATIONS for IV CONTRAST: renal failure INDICATION: 51-year-old man with hepatitis C cirrhosis, varices, ascites with previous abdominal CT questioning strangulated bowel loop. COMPARISON: [**2135-6-28**] at 3:14 a.m. TECHNIQUE: MDCT axial non-contrast images of the abdomen and pelvis were obtained with sagittal and coronal reformatted images. CT ABDOMEN WITHOUT IV CONTRAST: Again seen is a large right-sided pleural effusion with associated atelectasis. There is no pericardial effusion. There is a diffusely nodular liver consistent with the patient's history of cirrhosis. The gallbladder is enlarged but there is no evidence of cholecystitis. There is perihepatic ascites and free fluid seen within the abdomen consistent with the prior study. Allowing for the lack of IV contrast, the adrenal glands, pancreas, and kidneys are unremarkable. Again seen are multiple varices in the anterior abdominal wall. Contrast is seen within the stomach and within loops of small bowel. Compared to the prior examination the contrast has progressed. There is an apparent transition point at a complex anterior abdominal wall defect. Several loops of bowel are seen to pass through this defect and one loop in particular has an appearance worrisome for strangulation with fluid seen surrounding it. Far superiorly there is a suggestion of extraluminal air. No contrast is seen in distally collapsed loops of small bowel. CT PELVIS WITHOUT IV CONTRAST: The rectum, sigmoid colon, and bladder are unremarkable. Again seen is a small amount of free fluid within the pelvis consistent with ascites. BONE WINDOWS: Demonstrate no suspicious lytic or sclerotic foci. Multiplanar reformatted images confirm the above findings. IMPRESSION: Limited examination secondary to lack of IV contrast. There are multiple dilated loops of small bowel consistent with SBO and an apparent transition point at an anterior wall defect. A single loop of bowel which has passed through this defect is concerning for incarcerated bowel. The findings were discussed with the surgical house staff officer at 8:15 p.m. on [**2135-6-28**]. CHEST (PA & LAT) [**2135-6-28**] 6:47 AM CHEST (PA & LAT) Reason: r/o pleural effusion. [**Hospital 93**] MEDICAL CONDITION: 51 year old man with SOB and ascites REASON FOR THIS EXAMINATION: r/o pleural effusion. INDICATION: Shortness of breath and ascites. Evaluate for effusion. COMPARISON: [**2135-2-14**]. PA AND LATERAL CHEST RADIOGRAPHS Cardiac and mediastinal, hilar contours appear unchanged. There is a moderate-to-large right-sided pleural effusion. No focal consolidation is seen within lungs. IMPRESSION: Again seen is a moderate-to-large right-sided pleural effusion, slightly increased compared to [**2135-2-14**]. Pathology Examination Name Birthdate Age Sex Pathology # [**Hospital1 18**] [**Known lastname 60866**],[**Known firstname **] [**2083-11-22**] 51 Male [**-6/2432**] [**Numeric Identifier 60867**] Report to: DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) 1345**] Gross Description by: DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) 60868**]/dif SPECIMEN SUBMITTED: INCARCERATED SMALL BOWEL Procedure date Tissue received Report Date Diagnosed by [**2135-6-28**] [**2135-6-29**] [**2135-7-1**] DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]/nbh Previous biopsies: [**-5/4681**] UMBILICAL HERNIA SAC. DIAGNOSIS: Small bowel, segmental resection: Small bowel with transmural ischemic necrosis. Resection margins appear viable. Clinical: Hernia. Gross: The specimen is received fresh labeled with "[**Known firstname **] [**Known lastname 47097**]" and the medical record number and "incarcerated small bowel" and consists of a segment of small bowel measuring 10.0 cm x 5.5 x 1.0 cm. There are two stapled resection margins, one measuring 4.0 cm and the second measuring 4.8 cm. The serosa is deeply erythematous. The specimen is opened to reveal a hemorrhagic and ischemic appearing small bowel mucosa. There is blood present within the lumen. No masses or lesions are identified. The specimen is sectioned and represented as follows: A-B = resection margin, C = sections of small bowel mucosa. CHEST (PORTABLE AP) [**2135-6-29**] 8:06 AM CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN Reason: ? NGt tip ? effusion vs consolidation** please do portable U [**Hospital 93**] MEDICAL CONDITION: 51 year old man with s/p ex-lap, has R whiteout ** please do portable UPRIGHT ** REASON FOR THIS EXAMINATION: ? NGt tip ? effusion vs consolidation** please do portable UPRIGHT ** CHEST ONE VIEW PORTABLE INDICATION: 51-year-old man with effusion and consolidation. COMMENTS: Portable semi-erect AP radiograph of the chest is reviewed, and compared with the previous study at 3:27 a.m. The tip of the endotracheal tube is identified at the thoracic inlet. A nasogastric tube courses towards the stomach. The right jugular IV catheter terminates in the superior vena cava. No pneumothorax is identified. There is continued mild congestive heart failure with cardiomegaly associated with large right pleural effusion. Atelectasis is seen in the right lung base. RENAL U.S. [**2135-7-2**] 9:35 AM RENAL U.S. Reason: Please assess for renal pathology [**Hospital 93**] MEDICAL CONDITION: 51 year old man with renal failure REASON FOR THIS EXAMINATION: Please assess for renal pathology INDICATION: 51-year-old male with renal failure. Assess for renal pathology. COMPARISON: CT abdomen and pelvis [**2135-6-28**], [**Year (4 digits) 950**] paracentesis [**2135-5-26**]. RENAL [**Year (4 digits) **]: This exam is limited secondary to limited patient positioning. The right kidney measures 10.5 cm. The left kidney measures 12.3 cm. There is no evidence of hydronephrosis. No evidence of stones. Marked ascites is present. The liver is small and nodular consistent with cirrhosis. IMPRESSION: No evidence of hydronephrosis or stones. Marked ascites. Cirrhosis. UNILAT UP EXT VEINS US LEFT [**2135-7-8**] 1:32 PM UNILAT UP EXT VEINS US LEFT Reason: swelling in arm following PICC placement 2 days ago [**Hospital 93**] MEDICAL CONDITION: 51 year old man s/p hernia reduction, POD 10 REASON FOR THIS EXAMINATION: swelling in arm following PICC placement 2 days ago STUDY: Duplex [**Hospital 950**] of left upper extremity. INDICATION: The patient is status post PICC line insertion. Rule out DVT. TECHNIQUE: Grayscale, color flow and pulse wave Doppler insonation of the deep veins of the left upper extremity were performed using dynamic compression maneuvers where appropriate to assess for vessel patency. COMPARISON: There was a previous left sided duplex [**Hospital 950**] performed in [**2134-10-9**]. REPORT: There is normal compressibility, augmentation, and respiratory variation where appropriate of the deep veins of left upper extremity. The PICC line is identified within the left basilic vein extending proximally into the left subclavian vein. No thrombus is identified in either of these veins and no thrombus or adherent thrombus is identified adjacent to the PICC line. CONCLUSION: Normal examination. No evidence of DVT. CT PELVIS W/O CONTRAST [**2135-7-10**] 10:29 PM CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Reason: assess for perf w/PO contrast only. no IV contrast Field of view: 50 [**Hospital 93**] MEDICAL CONDITION: 51 year old man with hepC cirrhosis with varices, ascites, s/p ventral hernia repair, now s/p paracentesis today w/WBC 1110, likely SBP though question of possible leak/perf REASON FOR THIS EXAMINATION: assess for perf w/PO contrast only. no IV contrast CONTRAINDICATIONS for IV CONTRAST: elevated Cr 51-year-old male with hepatitis C, cirrhosis and ascites, now with concern for bowel perforation versus spontaneous bacterial peritonitis. COMPARISON: [**2135-6-28**]. TECHNIQUE: MDCT continuously acquired axial images of the abdomen and pelvis were obtained with oral but no IV contrast at the ordering physician's request. Coronal and sagittal reformatted images were also obtained. CT OF THE ABDOMEN WITHOUT IV CONTRAST: The visualized lung bases demonstrate a moderate-to-large right pleural effusion with associated atelectasis of the right lower lobe. The left lung base is grossly clear. There are coronary artery calcifications. Evaluation of the abdomen is limited by the noncontrast technique. The liver is shrunken and nodular consistent with cirrhosis. The gallbladder is not well visualized. The patient is status post splenectomy. The pancreas, adrenal glands and right kidney are unremarkable. There are at least two round hypodense lesions of the left kidney which are consistent with simple cysts. There is a large amount of intra-abdominal ascites. Evaluation of the bowel is somewhat limited by ascites. The stomach is nondistended. There are a few loops of mildly dilated small bowel measuring up to 4.6 cm but no evidence of obstruction with oral contrast passing freely through normal caliber large bowel to the rectum. Patient is status post interval ventral hernia repair. There is generalized wall edema throughout the colon probably secondary to liver failure. No inflammatory stranding or mural gas is identified. There is no free intra-abdominal air. CT OF THE PELVIS WITHOUT IV CONTRAST: Oral contrast extends freely through to the rectum. The prostate, seminal vesicles, and urinary bladder are unremarkable. The pelvic loops of bowel are of normal caliber. Ascites tracks into the pelvis. BONE WINDOWS: No suspicious lytic or sclerotic osseous lesions are identified. IMPRESSION: 1. No free intra-abdominal air or other evidence of bowel perforation. 2. A few loops of mildly dilated small bowel up to 4.8 cm, however no evidence of obstruction with free passage of oral contrast through to the rectum. 3. Cirrhotic liver with a large amount of intra-abdominal ascites. 4. Status post interval ventral hernia repair. UNILAT LOWER EXT VEINS RIGHT [**2135-7-18**] 1:50 PM UNILAT LOWER EXT VEINS RIGHT Reason: PLEASE ASSES FOR DVT IN RLE, R>L [**Hospital 93**] MEDICAL CONDITION: 51 year old man s/p incisional hernia repair, small bowel resection POD 20 REASON FOR THIS EXAMINATION: please assess for DVT in RLE EXAMINATION: Right lower extremity venous Doppler, [**2135-7-18**]. COMPARISON: None. INDICATION: Status post incisional hernia repair and small bowel resection, evaluate for DVT in right lower extremity. FINDINGS: [**Doctor Last Name **] scale, color Doppler, and spectral waveform imaging of the right lower extremity deep venous system was performed. There is no evidence of intraluminal thrombus within the right common femoral, superficial femoral and popliteal veins. These veins demonstrate normal color flow and augmentation. Incidental note is made of ill-defined complex fluid collection in the popliteal region which most likely represents a ruptured [**Hospital Ward Name **] cyst. IMPRESSION: 1. No evidence of deep venous thrombosis in the right lower extremity. 2. Ruptured [**Hospital Ward Name **] cyst. CHEST (PA & LAT) [**2135-7-27**] 1:53 PM CHEST (PA & LAT) Reason: Please eval for infiltrate/pneumonia [**Hospital 93**] MEDICAL CONDITION: 51 year old man with cirrhosis, s/p bacteremia and fungemia, now with increasing WBC again. REASON FOR THIS EXAMINATION: Please eval for infiltrate/pneumonia CLINICAL HISTORY: 51-year-old man with cirrhosis status post bacteremia and fungemia, now with increasing white cell count. CHEST, AP AND LATERAL: Extensive opacification is seen within the right lower lung posteriorly. This is associated with right pleural effusion also. The lower lobe opacifications are new and probably represent pneumonic consolidation. Elsewhere, the lung fields appear clear. IMPRESSION: Persistent right effusion. New right lower lobe infiltrate. CT ABDOMEN W/CONTRAST [**2135-7-29**] 10:25 AM CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Reason: Please eval for intraabdominal source of infection Field of view: 38 Contrast: OPTIRAY [**Hospital 93**] MEDICAL CONDITION: 51 year old man with cirrhosis, s/p incarcerated hernia repair and small bowel resection. Now with hospital-acquired pna, but WBC still increasing. (+) diffuse abdominal pain, no SBP. REASON FOR THIS EXAMINATION: Please eval for intraabdominal source of infection CONTRAINDICATIONS for IV CONTRAST: None. EXAMINATION: CT of the abdomen and pelvis dated [**2135-7-29**] COMPARISON: CT of the abdomen and pelvis dated [**2135-7-13**]. INDICATION: 51-year-old male with cirrhosis status post incarcerated hernia repair and small bowel resection, now with hospital-acquired pneumonia with increasing white count, diffuse abdominal pain, but no SBP. Please evaluate for intra-abdominal source of infection. TECHNIQUE: MDCT axial images are obtained through the abdomen and pelvis after the administration of IV and oral contrast. The clinical team was aware of the patient's creatinine of 1.7 and used hydration and bicarbonate solution before and after the exam to help prevent contrast nephropathy. FINDINGS FOR CT OF THE ABDOMEN WITH CONTRAST: There is a large right pleural effusion and right lower lobe atelectasis, unchanged. There has been interval development of a tiny left pleural effusion and left basilar atelectasis. Again seen is a shrunken liver with nodular contour consistent with cirrhosis. The gallbladder is present. The patient is status post splenectomy. The pancreas, adrenal glands, and right kidney are unremarkable. Again seen are two low density lesions involving the left kidney, the interpolar region and at the lower pole, consistent with renal cysts. There has been slight interval increase in quantity of ascites within the abdomen since the prior exam. Multiple fluid collections are demonstrated within the subcutaneous tissues in region of prior hernia repair, the largest of which measures 5.7 cm x 2.3 cm, unchanged. Multiple dilated loops of small bowel are seen, which have thickened wall, there is no evidence for obstruction since contrast is seen within colon. The bowel wall thickening is thickening is likely secondary to hypoalbuminemia. There has been interval resolution of the diffuse colonic thickening seen on the prior examination. Numerous porta splenic collateral vessels are demonstrated. The bones demonstrate no suspicious lesions. FINDINGS FOR CT OF THE PELVIS: There has been slight increase in amount of intrapelvic ascites. There has been interval resolution of the colonic wall thickening. There is no lymphadenopathy or free intraperitoneal gas. BONE WINDOWS: Multiple old left lower rib fractures are demonstrated. There is evidence of old trauma to the left ilium. IMPRESSION: 1) Cirrhosis with slight increase in intra-abdominal and intrapelvic ascites. Stable large right pleural effusion and right basilar atelectasis. New tiny left pleural effusion and left lower lobe atelectasis. 2) Dilated loops of small bowel without evidence of bowel obstruction. Small bowel wall thickening, likely secondary to low protein state. 3) Interval resolution of the diffuse colonic thickening. [**Year (4 digits) **], [**2135-8-1**] Conclusions: The left atrium is mildly dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size and systolic function (LVEF>55%). Regional left ventricular wall motion is normal. Right ventricular chamber size and free wall motion are normal. The aortic root is moderately dilated. The aortic valve leaflets (3) are mildly thickened. There is a minimally increased gradient consistent with minimal aortic valve stenosis. Significant aortic regurgitation is present, but cannot be quantified - ?mild. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. Compared with the prior study (images reviewed) of [**2135-6-20**], the findings are similar. The aortic valve is better defined on the current study and appears to be trileaflet. The morphology and severity of aortic regurgitation appear similar. Based on [**2126**] AHA endocarditis prophylaxis recommendations, the echo findings indicate a moderate risk (prophylaxis recommended). Clinical decisions regarding the need for prophylaxis should be based on clinical and echocardiographic data. BILAT LOWER EXT VEINS [**2135-8-2**] 6:02 PM BILAT LOWER EXT VEINS Reason: INCR WBC PLEASE EVAL FOR DVT'S [**Hospital 93**] MEDICAL CONDITION: 51 year old man w/ HepC/EtOH cirrhosis, recent fungemia and bacteremia now with incr WBC without definite source. REASON FOR THIS EXAMINATION: Please eval for DVTs INDICATION: 51-year-old man with hepatitis C and cirrhosis with recent fungemia and bacteremia, now with increasing white blood cell count. Evaluate for DVT. COMPARISON: Study from [**2135-7-18**]. BILATERAL LOWER EXTREMITY [**Month/Day/Year **]: [**Doctor Last Name **]-scale and color Doppler son[**Name (NI) 867**] was performed of the right and left common femoral, superficial femoral, and popliteal veins. Normal flow, compressibility, augmentation, and waveforms are demonstrated. No intraluminal thrombus is identified. IMPRESSION: No DVT. CHEST (PA & LAT) [**2135-8-11**] 3:17 PM CHEST (PA & LAT) Reason: r/u pna [**Hospital 93**] MEDICAL CONDITION: 51 year old man with cirrhosis, candidal peritonitis, now with increasing WBC again. REASON FOR THIS EXAMINATION: r/u pna REASON FOR EXAMINATION: Increased white blood cell in patient with known [**Female First Name (un) 564**] peritonitis. PA and lateral upright chest radiograph compared to the previous film from [**2135-7-27**], and [**2135-7-30**]. The left PICC line was inserted in the meantime interval with its tip projecting over the inferior portion of superior vena cava. The heart size is normal. There is no mediastinal widening or shifting. The right lower lobe consolidation is grossly unchanged with some increase in pleural effusion better demonstrated on the lateral exam. The rest of the lungs are unremarkable. The healed fractures on the left are again demonstrated. IMPRESSION: Grossly unchanged right lower lobe consolidation with some increase in pleural effusion. MR 3D RENDERING W/POST PROCESSING ON INDEPENDENT WS [**2135-8-13**] 2:08 PM MRI PELVIS W/O & W/CONTRAST; MR CONTRAST GADOLIN Reason: ? intraabdominal abcessPLEASE PERFORM BOTH ABDOMEN AND PELVI Contrast: MAGNEVIST [**Hospital 93**] MEDICAL CONDITION: 51 year old man with cirrhosis, h/o VRE bactermiea, , candidemia, perirectal abscess on exam, increasing white counts REASON FOR THIS EXAMINATION: ? intraabdominal abcessPLEASE PERFORM BOTH ABDOMEN AND PELVIS STUDY to look for abcess CLINICAL HISTORY: 51-year-old gentleman with cirrhosis, VRE bacteremia, candidemia, and perirectal abscess on exam. TECHNIQUE: Multiplanar T1- and T2-weighted images were acquired on a 1.5 Tesla magnet. Dynamic volumetric images were acquired before, during, and following intravenous administration of 0.1 mmol/kg of gadolinium-DTPA. Subtraction images and reformatted images were created on an independent workstation. FINDINGS: A linear tract emerges from the anal verge at approximately the 6 o'clock position. At the anal verge, there is an associated adjacent 13 x 9 mm region of enhancement. T2-weighted images show hypointensity in the region of enhancement on T1-weighted images; therefore, this may represent fibrosis or early organization. No supralevator collections. Note is made of marked free fluid within the pelvis and edema within the subcutaneous fat. Fat-containing inguinal hernias are identified bilaterally. Subtraction images and 2- and 3-dimensional reformatted images were helpful in delineating pathology. IMPRESSIONS: 1. Linear tract with associated area of enhancement adjacent to the anal verge, at approximately the 6 o'clock position. No drainable fluid collection is present. Signal characteristics may represent early organization of inflammation. 2. Ascites and anasarca. CT ABDOMEN W/O CONTRAST [**2135-8-14**] 10:57 PM CT CHEST W/O CONTRAST; CT ABDOMEN W/O CONTRAST Reason: ?occult abcess/assess pneumonia and effusion seen on cxrayCa Field of view: 46 [**Hospital 93**] MEDICAL CONDITION: 51 year old man with hep c/alcoholic cirrhosis, unexplained leukocytosis REASON FOR THIS EXAMINATION: ?occult abcess/assess pneumonia and effusion seen on cxrayCannot get contrast due to renal failure. CONTRAINDICATIONS for IV CONTRAST: None. INDICATION: Alcoholic cirrhosis with unexplained leukocytosis. COMPARISON: [**2135-7-29**]. TECHNIQUE: Non-contrast axial CT imaging of the chest, abdomen and pelvis without contrast was reviewed. Coronal and sagittal reformats were obtained and reviewed. CT CHEST WITHOUT CONTRAST: There is a moderate/large right pleural effusion with presumed associated atelectasis that is relatively unchanged from [**7-29**]. Bullous changes are present in the apices, and there is minimal left basilar atelectasis. Left subclavian central venous catheter tip terminates in the right atrium. Calcification is present within the mitral annulus. No pathologic adenopathy identified. Note of gynecomastia. A few small lymph nodes are present in the pericardial fat. CT ABDOMEN WITHOUT CONTRAST: The liver is shrunken and nodular, consistent with cirrhosis. Attenuation is decreased within the left hepatic lobe of unclear etiology. There is abundant ascites in the abdomen and pelvis, increased from [**2135-7-29**]. There is a small anterior wall defect containing ascites. Multiple collaterals are presentThe gallbladder, pancreas, adrenal glands, and right kidney are unremarkable. The patient is status post splenectomy. Low- density lesions in the left kidney are unchanged. There are a few mildly dilated small bowel loops, but unchanged if not slightly improved from [**2135-7-29**]. Bowel wall thickening is likely secondary to ascites. Numerous collaterals are present throughout the abdomen. CT PELVIS WITH CONTRAST: The rectum, sigmoid is unchanged. Note of bilateral fat-containing inguinal hernias. The distal ureters and bladder are normal. Ascites is present in the pelvis. Though evaluation for focal fluid collections is limited per non-contrast CT, no suspicious areas are identified. BONE WINDOWS: No suspicious lesions are identified. Note of multiple poorly healed previous left posterior rib fractures. There is a prior left iliac fracture. IMPRESSION: No marked interval change from [**7-29**] with a large right pleural effusion and associated atelectasis, marked ascites, and hallmarks of advanced cirrhosis. Mildly dilated small bowel loops are unchanged. ANKLE/FOOT (AP, LAT & OBL) RIGHT [**2135-8-17**] 3:57 PM ANKLE/FOOT (AP, LAT & OBL) RIG Reason: rule out osteomyelitis of prosthetic hardware [**Hospital 93**] MEDICAL CONDITION: 51 year old man with cirrhosis, history of VRE bacteremia, persistent WBC, suspect osteo of tibia hardware REASON FOR THIS EXAMINATION: rule out osteomyelitis of prosthetic hardware HISTORY: Bacteremia and previous tibial hardware. Assess osteomyelitis. These two exams consist of three views of the right ankle and distal tibia/fibula as well as three views of the right foot. There is marked generalized soft tissue swelling particularly on the dorsum of the foot. There are healed fracture deformities in the distal diaphysis of both the tibia and fibula with lateral tibial plate and screws. There is relatively smooth bridging cortical new bone present with slight irregularity posterior to the fibular fracture of doubtful significance and unchanged from [**2135-6-16**]. There is no evidence of loosening of the plate or screws. Ankle mortise congruent with the talus. The bones of the foot are intact. IMPRESSION: Soft tissue swelling. Sequelae of previous fractures. No evidence of osteomyelitis. DUPLEX DOPP ABD/PEL [**2135-8-19**] 5:58 PM LIVER OR GALLBLADDER US (SINGL; -59 DISTINCT PROCEDURAL SERVIC Reason: WITH DUPLEX PLEASE-ASSESS for PV thrombosis [**Hospital 93**] MEDICAL CONDITION: 51 year old man with ESLD/cirrhosis for [**Hospital **], ascites with acute rise in t. bili. REASON FOR THIS EXAMINATION: WITH DUPLEX PLEASE-ASSESS for PV thrombosis 51-year-old male with end-stage liver disease, cirrhosis, awaiting [**Hospital **] with acute rise in bilirubin, and concern for portal vein thrombosis. LIVER [**Hospital **] WITH DOPPLER: The liver is shrunken and nodular with coarsened echogenicity consistent with cirrhosis. No definite focal hepatic lesion is identified. No intra- or extra-hepatic biliary ductal dilatation is identified. There is moderate amount of ascites around the liver. Doppler evaluation demonstrates appropriate directionality and waveform of the main, left and right portal veins as well as main, left and right hepatic arteries and main and right hepatic veins. The left hepatic vein is not identified, due to technical factors. The IVC is patent. IMPRESSION: No evidence of portal vein thrombosis. Severe cirrhosis with moderate ascites. Left hepatic vein not visualized due to technical factors, but all other vessels are accounted for with appropriate directionality and waveform. IN-111 WHITE BLOOD CELL STUDY [**2135-8-24**] IN-111 WHITE BLOOD CELL STUDY Reason: KNOWN CIRROHSIS, CANDIDIAL PERITONITIS, PERSISTENT WBC = 20 DESPITE ANTIFUNGAL THERAPY RADIOPHARMECEUTICAL DATA: 455.0 uCi In-111 WBCs; History: 51yo many with candidial peritonitis ? occult infection / abscess REPORT: Following the injection of autologous white blood cells labeled with In-111, images of the whole body were obtained. These images show abnormal, heterogeneous, intense lung uptake with highest uptake in the left lower lobe and right lower lobe. Compared with the prior study of [**2135-6-23**] the lung uptake is new. Also the patient's liver is smaller and there is haziness in the abdomen consistent with cirrhosis and ascites. IMPRESSION: Abnormal, intense lung uptake worst in LLL and RLL. CHEST (PORTABLE AP) [**2135-8-27**] 1:27 PM CHEST (PORTABLE AP) Reason: pls check ETT position after advancement [**Hospital 93**] MEDICAL CONDITION: 51 yo male w/cirrhosis, candidemia, MRSA sepsis s/p malposition ET tube REASON FOR THIS EXAMINATION: pls check ETT position after advancement HISTORY: Cirrhosis, candidemia MRSA sepsis, status post ET tube malposition, check ET tube position after advancement. CHEST, SINGLE AP VIEW. Lines and tubes are unchanged. The ET tube lies approximately 7 cm above the carina at the level of mid clavicle, overall similar to its appearance on the film from one day earlier. Radiographically, it is somewhat high but in overall satisfactory position. If clinically indicated, it could be advanced by 1-3 cm. The right IJ central line tip overlies the distal SVC unchanged. Of note, the NG tube is coiled in left upper quadrant and overlies the hemidiaphragm itself. I suspect this is within the gastric fundus, but this is difficult to confirm on these views. The pleural and parenchymal findings are unchanged. There is evidence of CHF, with bibasilar atelectasis and a small right pleural effusion. The left costophrenic angle is excluded from the film. No pneumothorax is detected. IMPRESSION: 1. ET tube position essentially unchanged compared with [**2135-8-26**]. See comment. 2. Right lung base chest tube, with small effusion, unchanged. Brief Hospital Course: Patient was admitted to the ICU after surgical resection of small bowel obstruction and repair of incisional hernia. Patient was found to be bacteremic with VRE and treatment started with Linezolid after surgery on [**6-27**]. Patient was admitted to the ICU and progressed without incidence, was extubated and transferred to the floor with exception of poor nutritional intake and continued bactermia treatment. Nutrition was consulted and has followed patient throughout course. He has been on TPN on/off since [**2135-7-4**]. Once on floor, patient became more encephalopathic and restraints were used prudently to control outbursts. Patient had resistant ascites which has been one of the hallmarks of his stay. Patient did hallucinate at times, had slurred speech, and patient was treated with rifaximen and lactulose. Patient care was supportive with concern for patient's resistant ascites and poor general nutritional status. Patient had PICC placed on [**7-5**] for antibiotics. Patient has been seen by PT throughout stay. On [**7-10**], one of multiple paracentesis grew out [**Female First Name (un) 564**] albicans and eventually [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 563**]. He also had 1110 WBCs, 58% polys. Patient also found to have fungemia. Patient had been treated with Fluconazole but was switched to Caspofungin then eventually to Micafungin 100 qd secondary to pharmacy/ID recs due to better metabolism by liver and need for higher Caspo dose. Zosyn started for SBP treatment. Paracentesis on [**7-13**] to 3200 WBC with 86% polys. Meropenam was started per ID in case of ESBL organisms and linezolid continued for VRE. Rifaxamin was d/c at this time. CXR showed Right sided pleural effusion as patient complaining of difficulty breathing. US-guided thoracentesis was going to be attempted but did not occur as patient did not allow procedure. Secondary to thrombocytopenia to 14, pt. was switched from linezolid to Daptomycin for VRE coverage and platelets have risen slowly and completed a full course of antibiotics with resolution of the VRE bacteremia. Mr. [**Known lastname 47097**] was transferred to the hepatorenal medicine service on [**2135-7-22**] for continued management of his medical problems. [**Name (NI) **] was continued on iv Micafungin per the ID team for a 15 day course until [**7-26**] at which point he had another paracentesis, this time with no evidence of bacterial or fungal peritonitis (330 WBCs, 28% neutrophils). The next day, however, his peripheral white blood cell count began rising and his PICC line was pulled (and TPN discontinued) due to concern for a line infection, but the line tip culture showed no infection. He remained without any localizing signs/symptoms of infection, though his WBC continued rising. A CXR on [**2135-7-27**] showed a new RLL consolidation and he was started empirically on Zosyn for a nosocomial pneumonia, though his WBC continued rising. A thoracentesis of his parapneumonic effusion showed no empyema and he was switched to po levofloxacin and metronidazole, still with no improvement in his WBC. A perianal cyst (which had not been previously noted) ruptured on [**8-3**], though his WBC didn't drop with drainage of this cyst. On [**2135-8-3**], his ascites was again tapped and he was noted to have >4000 WBCs (39% neutrophils). He was resumed on the Micafungin per ID recs. Cultures of this fluid grew [**Female First Name (un) 564**] albicans and C. [**Female First Name (un) 563**]. He was taken off the [**Female First Name (un) **] waiting list due to this fungal peritonitis, although it was planned to re-list him after the infection was cleared. He was therefore maintained on micafungin IV. In [**Month (only) 205**], his creatinine began to rise above his baseline of 1.2 and eventually as high as 2.7. He had not previously carried a diagnosis of hepatorenal syndrome but renal ultrasounds and urine electrolytes did not point to any other renal pathology. His creatinine did gradually respond to empiric therapy with octreotide and midodrine for hepatorenal syndrome. His malnutrition had become a growing concern leading to the initiation of TPN. Although his TPN was d/c'ed on [**7-27**] due to a concern for a line infection, his appetite began to improve and he ws steadily consuming [**2-11**] Boost supplements daily through mid-[**Month (only) 216**], when his mental status began to deteriorate due to a worsening of hepatic encephalopathy and poor oxygenation due to recurrent/enlarging pleural effusions and tense ascites and he could not protect his airway well enough to take a po diet. No source could be found for his persistent leukocytosis, however. Repeated imaging of the abdomen did not reveal any abscesses; imaging of the orthopaedic hardware in the R tibia did not suggest osteomyelitis. In mid-[**Month (only) 216**] his encephalopathy became worse, making him confused and disoriented, and the abdomen was again imaged without diagnostic findings other than worsening ascites. A diagnostic paracentesis was performed with findings consistent with bacterial peritonitis on [**8-23**]; cultures of the peritoneal fluid grew Staph aureus. The next day blood cultures also grew Staph aureus and vancomycin was started but the patient became increasingly disoriented and lethargic. Arterial blood gases showed hypoxia and hypercapnia. A radio-labeled white blood cell scan was also performed at the time of the diagnostic paracentesis, since the patient??????s renal function contraindicated IV contrast dye, to look for abscesses; the only intensities on WBC scanning were in the lungs. He was transferred to the ICU for intubation and ventilatory support. The recurrent right pleural effusion was again tapped and culture of the fluid grew Staph aureus; a chest tube was placed to drain the infected fluid. Pressors were started to maintain his blood pressure. Despite these interventions to address his overwhelming Staph infection, his mental status did not improve; sedatives were stopped and there was no return of cognitive function. The family was advised of his poor prognosis and multisystem organ failure and they decided to pursue comfort measures only, since further interventions seemed only to prolong his suffering. He was extubated and transferred out of the ICU and back to the hepatorenal service on [**8-30**]. His pain was controlled with narcotics as needed. He expired on [**9-1**]. Medications on Admission: 1. Multivitamin 2. Folic Acid 1 mg 3. Pantoprazole 40 mg Tablet, 1 tab QD 4. Aspirin 81 mg Tablet, 1 tab QD 5. Lactulose 10 g/15 mL Thirty (30) ML PO TID (3 times a day). 6. [**Month/Year (2) **] 400 mg tid 7. Oxycodone 5 mg Tablet 2 tab [**Hospital1 **] 8. Furosemide 40 mg 1 Tablet PO 9. Spironolactone 50 mg [**Hospital1 **] :*2* 11. Levofloxacin 250 mg qd Discharge Medications: not applicable Discharge Disposition: Home with Service Discharge Diagnosis: Incarcerated Incisional Hernia repair with small bowel resection; subsequent [**Female First Name (un) 564**] albicans and C [**Female First Name (un) 563**] peritonitis; Staphylococcus aureus superinfection with dissemination of infection and multisystem organ failure; HCV/Alcoholic Cirrhosis Discharge Condition: Deceased. Discharge Instructions: not applicable Followup Instructions: none

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icd9cm

[ [ [] ] ]

[ "34.91", "96.04", "45.62", "00.14", "96.72", "38.93", "53.61", "54.91", "99.04", "99.07", "99.15", "96.07", "34.04", "46.75" ]

icd9pcs

[ [ [] ] ]

39974, 39993

33030, 39524

329, 486

40332, 40343

2178, 5295

40406, 40413

1519, 1627

39935, 39951

31763, 31835

40014, 40311

39550, 39912

40367, 40383

1642, 1656

275, 291

31864, 33007

514, 843

1670, 2159

865, 1271

1287, 1503

28,206

157,774

11856+56292

Discharge summary

report+addendum

Admission Date: [**2197-5-19**] Discharge Date: [**2197-5-26**] Date of Birth: [**2132-10-15**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1481**] Chief Complaint: Esophageal Cancer Major Surgical or Invasive Procedure: [**2197-5-19**] - Minimally invasive esophagectomy and tube jejunostomy. History of Present Illness: Mr. [**Known lastname **] is a gentleman with the diagnosis of esophageal carcinoma. As you know, he was noted to have a mass at his esophagogastric junction. This is in the setting of some dysphagia. The mass did not seem to be particularly large but was biopsied and has adenocarcinoma. He has been staged including an endoscopic ultrasound, which was done at my request, which shows this to be a T3 lesion. He had some suspicious lymph nodes which were in the periesophageal region. He has been seen by Dr. [**Last Name (STitle) 3274**] and I have discussed his care with him and it was thought best that he be offered chemoradiation. There has been some difficulty in getting things done due to his language difficulties. He has had a PET scan which shows the tumor itself but no evidence of metastatic disease. He has not had any significant weight loss. He has completed his chemoradiation. He has had a followup scan, which still shows some activity in the area of the tumor. He does have two local nodes which take up FDG, but these may be inflammatory. There is no evidence of metastatic disease. Past Medical History: 1. Esophageal Cancer Patient was initially diagnosed in [**2197-1-4**] at which time he developed problems swallowing with solid food getting stuck in his mid-chest. EGD on [**2197-1-4**] demonstrated a 3cm malignant, nodular mass at the GE junction with biopsy consistent with adenocarcinoma, extending beneath squamous epithelium. Endoscopic ultrasound was performed on [**2197-1-16**] with staging consistent with T3N1. He is being treated with 5FU and radiation. He had his first dose of 5-FU on [**2197-2-25**] which he tolerated well. Given his renal insufficiency he is not a candidate for cisplatin therapy, however his primary oncologist is considering adding a second [**Doctor Last Name 360**] depending on how he responds to 5-FU 2. Anemia 3. Asthma 4. Hypertension 5. Hypothyroidism 6. Gout, chronic smoldering, polyarticular 7. Chronic Renal Insufficiency - baseline cr 1.4 8. Clostridium difficile colitis and treated with PO vanco 9. Strongyloides infection, dx in [**2194**] with eosinophilia and anemia s/p Ivermectin therapy Social History: Home: Pt is from [**Male First Name (un) 1056**] originally, immigrated here > 12 years ago. Lives alone. Not able to read. Spanish-speaking alone. Separated from wife and has 4 children who do not live locally. Occupation: previously employed in farm work EtOH: previously used to binge drink but quit drinking Drugs: Denies Tobacco: quit 15-20 years ago Family History: No hx of CAD, CVA, DM, Cancer. Physical Exam: On discharge: 97.9, 91, 115/98, 20, 95RA A&Ox3 RRR Lungs clear to auscultation with decreased breath sounds in the RLL. Abdomen soft, nontender, incisions intact, no erythema, staples in good position. R chest wall with dressing in place. Ext no edema Pertinent Results: [**2197-5-22**] 02:35PM BLOOD WBC-10.8 RBC-3.15* Hgb-9.9* Hct-29.0* MCV-92 MCH-31.4 MCHC-34.1 RDW-17.7* Plt Ct-137* [**2197-5-25**] 06:41AM BLOOD WBC-8.7 RBC-3.45* Hgb-10.9* Hct-32.4* MCV-94 MCH-31.6 MCHC-33.7 RDW-17.4* Plt Ct-171 [**2197-5-19**] 04:30PM BLOOD Plt Ct-114*# [**2197-5-25**] 06:41AM BLOOD Plt Ct-171 [**2197-5-19**] 04:30PM BLOOD Glucose-128* UreaN-18 Creat-1.4* Na-138 K-4.3 Cl-109* HCO3-23 AnGap-10 [**2197-5-25**] 06:41AM BLOOD Glucose-151* UreaN-38* Creat-1.3* Na-139 K-3.8 Cl-102 HCO3-23 AnGap-18 [**2197-5-19**] 04:30PM BLOOD ALT-18 AST-37 AlkPhos-80 TotBili-0.8 [**2197-5-23**] 05:26AM BLOOD CK(CPK)-285* [**2197-5-22**] 02:35PM BLOOD CK-MB-5 cTropnT-<0.01 [**2197-5-22**] 11:20PM BLOOD CK-MB-4 cTropnT-<0.01 [**2197-5-23**] 05:26AM BLOOD CK-MB-3 cTropnT-<0.01 [**2197-5-19**] 04:30PM BLOOD Albumin-3.1* Calcium-8.5 Phos-3.6 Mg-1.4* [**2197-5-25**] 06:41AM BLOOD Calcium-8.2* Phos-3.3 Mg-2.0 [**2197-5-19**] 09:02AM BLOOD Glucose-142* Lactate-1.1 Na-136 K-4.1 Cl-107 [**2197-5-21**] 09:16AM BLOOD Lactate-0.80 [**2197-5-19**] CXR IMPRESSION: 1. Status post esophagectomy with a feeding tube in the neoesophagus, terminating above the hemidiaphragm. 2. Cardiomegaly and mediastinal enlargment superiorly indicative of mediastinal post-surgical changes or hematoma. 3. Right chest wall subcutaneous emphysema. 4. A right-sided PICC line and central line terminate in the SVC at various levels. 5. New left retrocardiac atelectasis and/or aspiration and a left mid lung infiltrate that could be a focus of atelectasis and small left pleural effusion are new on today's examination. Continuous followup is recommended. [**2197-5-19**] Pathology DIAGNOSIS: 1. Esophagus, esophagogastrectomy (A-X): a. No residual carcinoma seen; see note. b. Twenty-one lymph nodes, no malignancy identified (0/21). c. Two lymph nodes with partial scarring, consistent with treatment effect. 2. Lymph node, left gastric (Y): One lymph node, no malignancy identified (0/1). Note: An ulcerated area up to 3 cm is present in the distal esophagus. The area is focally re-epithelialized with gastric cardiac-type, and fundic-type epithelium. A few isolated glands with atypical epithelial cells are seen with other benign-appearing glands in muscularis mucosae, probably representing treatment effect. No definite carcinoma is seen. Dr. [**Last Name (STitle) **]. Brown reviewed slide D and concurred. [**2197-5-20**] EKG Sinus rhythm Aberrantly conducted supraventricular extrasystoles versus ventricular premature complex Trigeminal pattern Early R wave progression Since previous tracing of [**2197-5-11**], premature beats are new, ST-T wave abnormalities are less [**2197-5-22**] ECHO The left atrium is normal in size. Left ventricular wall thicknesses are 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 root is mildly dilated at the sinus level. The aortic valve is not well seen. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] The tricuspid valve leaflets are mildly thickened. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. IMPRESSION: poor technical quality. Left ventricular function is probably normal, a focal wall motion abnormality cannot be fully excluded. The right ventricle is not well seen but is probably normal. Mild mitral regurgitation. Compared with the report of the prior study (images unavailable for review) of [**2193-2-7**], the degree of mitral regurgitation may have increased. The other findings appear similar. [**2197-5-24**] UGI swallow study IMPRESSION: Limited study, but no sign of leak or holdup of contrast. [**2197-5-25**] CXR IMPRESSION: No pneumothorax status post chest tube removal. Micro: [**5-22**] UA neg [**5-22**] Bcx pending [**5-22**] Spcx, Ucx: neg MRSA screen x 4: all negative Brief Hospital Course: Patient was taken to the OR and tolerated the procedure well. He was transferred to the ICU intubated and remained intubated for a few days because he could not pass his RSBI although he was on minimal vent settings of CPAP and PS of [**4-24**] with excellent oxygenation and ventilation. On POD 1 he had new onset of afib and was rate controlled on diltiazem. Tube feeds were started. He was diuresed with lasix gtt and kept intubated. An ECHO was done - see results section. POD 3 he was extubated and tube feeds were increased. He was transitioned to amiodarone gtt and lopressor through J tube. POD 4 he converted back to normal sinus rhythm. His amiodarone drip was transitioned to J tube amiodarone. POD 5 he had a negative swallow study and was transferred to the floor. He was stable on the floor and on POD 6 his JP drain and Chest tube were removed. His post pull CXR was negative for ptx. His diet was advanced to soft regular and he tolerated it well. He was having bowel movements. Physical therapy felt he would need additional assistance to work with balance and gait training and as a team we felt he could benefit from rehab since he lives alone. He was afebrile and hemodynamically stable at discharge. Wounds look excellent and he is tolerating a soft solid diet well. He is urinating and having bowel movments. Medications on Admission: albuterol prn, advair 500/50 [**Hospital1 **], Lipitor 10', lactulose 15', Prevacid 30'', Synthroid 25', Singulair 10', nifedipine SR 30', nystatin S&S prn, senna, darvocet Discharge Medications: 1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) mL Injection [**Hospital1 **] (2 times a day). 2. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed: do not exceed 4 grams per day. 3. Levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 5. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours). 6. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day): okay to take it orally. 7. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs PO Q4H (every 4 hours) as needed: okay to take orally and transition to tablet when tolerating. 8. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 9. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day) as needed. 10. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours). 11. Colace 50 mg/5 mL Liquid Sig: Two (2) mL PO twice a day: while using narcotics. Discharge Disposition: Extended Care Facility: Roscommon Discharge Diagnosis: Esophageal Cancer Atrial Fibrillation Discharge Condition: Good Discharge Instructions: Call or come back if you have any fevers, chills, nausea, vomiting, increasing redness around incisions or any other concerns. You should eat a soft regular diet. Do not eat any chips, crackers, fishbones, bread, or any other sharp/hard foods. Take pain medications as needed. Take a stool softener to prevent constipation. You should resume your home medication. You should be out of bed and walking multiple times per day Your staples should be removed on post operative day 14. This can be done at rehab or at your appointment with Dr. [**Last Name (STitle) **]. You should use your incentive spirometer 10x every hour and have chest physical therapy done every day Followup Instructions: You should follow up with Dr. [**Last Name (STitle) **] in [**6-29**] days. Please call ([**Telephone/Fax (1) 1483**] to set up an appointment. Name: [**Known lastname 5020**],[**Known firstname **] Unit No: [**Numeric Identifier 6707**] Admission Date: [**2197-5-19**] Discharge Date: [**2197-5-26**] Date of Birth: [**2132-10-15**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 203**] Addendum: Mr. [**Known lastname **] was discharged on his home meds, except for nifedipine and darvocet since he was started on metoprolol and percocet here. He is instructed to wean off of his amiodarone in 5 days which will be [**2197-5-31**]. Discharge Disposition: Extended Care Facility: Roscommon [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 206**] MD [**MD Number(1) 207**] Completed by:[**2197-5-26**]

[ "403.90", "530.81", "427.31", "274.9", "244.9", "427.32", "511.9", "585.9", "493.90", "250.00", "272.4", "355.9", "530.5", "151.0", "362.10" ]

icd9cm

[ [ [] ] ]

[ "43.99", "54.21", "96.6", "46.39" ]

icd9pcs

[ [ [] ] ]

11889, 12080

7595, 8942

333, 408

10361, 10368

3336, 7572

11093, 11866

3016, 3048

9165, 10221

10301, 10340

8968, 9142

10392, 11070

3063, 3063

3077, 3317

276, 295

436, 1556

1578, 2626

2642, 3000

17,758

101,569

46248+58889

Discharge summary

report+addendum

Admission Date: [**2116-12-4**] Discharge Date: [**2117-1-14**] Date of Birth: [**2058-5-20**] Sex: F Service: VASCULAR CHIEF COMPLAINT: Left thigh swelling. HISTORY OF PRESENT ILLNESS: This is a 58-year-old black female, with a past medical history significant for severe peripheral vascular disease, who has had multiple MIs and CVAs. The patient has end-stage renal disease on hemodialysis. She has previously had a left fem-[**Doctor Last Name **] bypass with [**Doctor Last Name 4726**]-Tex in [**2108**], which occluded and was later revised to a composite graft, one-third [**Doctor Last Name 4726**]-Tex and two-thirds greater saphenous vein fem-[**Doctor Last Name **] on the left. She also underwent a left axillofem-fem bypass and thrombectomy later. In [**2116-1-5**], she was noted to have a left lower quadrant mass. A CT scan at that time defined a 4x5 cm collection around the graft. This was treated conservatively. Subsequently, in [**Month (only) 359**] of this year she became febrile with abdominal pain and presented to an outside hospital. A CT demonstrated increasing perigraft fluid, but was noncontrast study. Blood cultures were positive for GPCs. She was given a dose of vanco and gent, and this was given at her last hemodialysis. Her hemodialysis schedule is Tuesday, Thursday and Saturday. The patient is now admitted for further evaluation and treatment. PAST MEDICAL HISTORY: 1. History of coronary artery disease, status post MI. 2. History of CVA. 3. History of peripheral vascular disease. 4. Type 2 diabetes, noninsulin dependent. 5. Hyperlipidemia. PAST SURGICAL HISTORY: 1. Axillofemoral-fem bypass. 2. Left fem-[**Doctor Last Name **] with revision x 2. 3. Left AV graft fistula. 4. Right carotid endarterectomy. ALLERGIES: No known drug allergies. MEDICATIONS ON ADMISSION: 1. Glyburide 5 mg [**Hospital1 **]. 2. Isosorbide dinitrate 20 mg tid. 3. Lisinopril 10 mg qd. 4. Lasix 80 mg qd. 5. Lipitor 10 mg hs. 6. Prevacid 30 mg qd. 7. Labetalol 100 mg tid. SOCIAL HISTORY: The patient is a smoker currently. Quantitation of smoking unknown. She does have a history of alcohol and drug abuse, but has abstained from alcohol or drug use. PHYSICAL EXAM: 99.6, 84, 20, 100% on room air. GENERAL APPEARANCE: This is a well-appearing female, oriented x 3, diminished recall. HEENT EXAM: Unremarkable. There is a Hickman catheter and a right IJ. PULSE EXAM: Shows palpable carotids bilaterally with a right carotid bruit. Brachial and radial pulses are palpable at 4+. On the right 3+ femoral, 2+ popliteal, dopplerable DP, and 3+ PT. On the left, the femoral is 2+, popliteal 2+, DP dopplerable, PT 3+ palpable. CHEST EXAM: Shows left an axillary incision well-healed. A catheter for hemodialysis in the right subclavian area. Her chest is clear to auscultation bilaterally. HEART: Regular rate and rhythm without murmur, gallop or rub. ABDOMINAL EXAM: Soft, nontender. There is in the left lower quadrant a multilobular mass which extends to the left groin. It is nonpulsatile. HOSPITAL COURSE: The patient was admitted to the vascular service. Infectious disease was consulted. This is a patient with known MRSA. Recommendations were blood cultures, wound cultures. Gent and vanco should be continued. Gent should be dosed when level less than 2.0 and this should be a singular dose and then discontinued. The vancomycin should be dosed when random level less than 15. They felt that the Flagyl could be discontinued. The patient underwent on [**2116-12-15**] I&D of the left thigh abscess with drainage. I&D was done after undergoing an ultrasound localized needle aspiration of the left groin site. The Gram stain of the fluid demonstrated gram-positive cocci in pairs and clusters. This was identified as staph coag positive, heavy growth. Anaerobes and fungal cultures were negative. The patient was MRSA from the flank abscess fluid cultures. The patient was continued on vancomycin and dosed at a random level. The renal service followed the patient and managed her hemodialysis needs. The patient continued to be followed by infectious disease, and a diagnosis of MRSA bacteremia and perigraft infection was determined by cultures. The patient required multiple blood cultures for recurrent high fevers. She was placed empirically on Flagyl for anaerobic coverage. Stool cultures were sent, and the patient was positive for C. diff. She was empirically begun on Flagyl. After a 2-week course of Flagyl, the patient's most recent stool culture from [**1-10**] was negative for C. diff. On [**2116-12-21**], the patient underwent a redo right axillobifemoral bypass with removal of the infected left bypass graft, and a right #15 Quinton catheter was changed over a wire. There was noted to be purulent collection of fluid on the distal aspect of the left axillofemoral bypass. There was extensive fibrinous changes on the prior sartorius muscle area. The patient did require 4 units of packed red blood cells and 2 units of FFP intraoperatively. PTFE was used for the right axillobifemoral bypass. The patient tolerated the procedure well and was transferred to the PACU in stable condition. She was placed on an Insulin drip for glycemic control. The patient was reintubated on postoperative day #1. Blood gases were 7.31, 31, 184, 16-9 on an FIO2 of 40%. She was transferred to the SICU for continued monitoring and care. She had been placed on Levofloxacin and dopamine for vasopressor support, inotropic support, and this was slowly begun to be weaned on postoperative day #2. Her postoperative hematocrit after 5 units of packed red blood cells was 34, white 18.0, BUN 29, creatinine 4.4, K 4.5. Her CK was 57, MB 4, troponin 1.10. The patient did have a metabolic acidosis on postoperative day #1, and she was treated with bicarbonate IV infusion. The patient was followed by the cardiology service. They did not feel that the troponin levels were true myocardial infarction. With the broadening of her antibiotics and drainage of the wound, there was improvement in her white count. She received a unit of packed cells x 2. Her post-transfusion crit was 32.9. Blood cultures, as of date, from [**12-9**] through [**12-16**] were no growth. The [**12-8**] cultures grew staph coag positive. The [**12-19**] C. diff was negative. The catheter tip on [**12-12**] was staph epi. The wound culture continued to grow MRSA. The patient remained intubated with JPs in place. She required an additional 2 units of packed red blood cells. Post-transfusion crit was 32.9. Nutritional services was requested to see the patient. They felt that she had caloric nutritional needs of 1,588-1,900 cal, 25-30 cal/kg. Protein needs were 1.3-1.5 gm/kg. A multivitamin and mineral supplement was reinstituted. On postoperative day #3, the patient required a unit of packed red blood cells for a hematocrit of 28.6. She was continued on Levophed and dopamine for inotropic and vasopressor support. Her IV fluids were discontinued. The patient was begun on tube feeds, and she remained in the SICU. She was placed on CPAP with pressure support of 5 which she tolerated well. Her post-transfusion crit was 28.5. The white count continued to show improvement at 17.6. The cultures were no growth. Urine was no growth. She remained in SICU. The JPs were removed on a graduating basis. Line cath was changed on [**12-12**]. This tip grew staph epi, oxacillin resistant. The patient was weaned off her Levophed by postoperative day #4. She continued on CPAP with an FIO2 of 40%, blood gas 7.44, 34, 179, 24 and 0, 98% O2 sat. On [**2116-12-25**], the right internal jugular Quinton line was changed over a guide wire without difficulty. Post-transfusion crit was 30.9. A white count showed some increase to 20.1. The patient continued to run low-grade temperatures. The patient was transfused on postoperative day #6 for a hematocrit of 27.9. Post-transfusion crit was 29.9. White count remained persistently elevated at 20.6. The patient was extubated on postoperative day #7. Tube feeds were held, and TPN was instituted secondary to an acute episode of respiratory decompensation. Stool for C. diff was sent and this was positive. The patient was placed on Flagyl on [**2116-12-28**]. A Swan-Ganz catheter was placed on postoperative day #7 without difficulty. Chest x-ray was unremarkable. A new arterial line was also placed at the same time without any difficulty. The patient underwent LENIs of the pelvic veins which were negative; this was on postoperative day #8. White count remained stable at 20.2, hematocrit 28.4. The patient's dopamine was finally weaned off by postoperative day #9. Her post-transfusion crit was 32.9. Epogen was instituted. The patient did require Haldol dosing for an episode of confusion with improvement with the Haldol. The patient was transferred from the SICU to the VICU on [**2116-12-31**]. Calcium acetate 667 mg tablets tid were instituted. Repeat blood cultures were sent. The patient's central line was discontinued on postoperative day #12, and a PICC line was placed. Her white count showed improvement from 28.3 to 22.7. She was continued on her vancomycin and Flagyl. Because of the patient's persistent white count elevation, the patient was pancultured, and urinalysis was requested which was positive for bacteria, and RBC greater than 50, and WBC. The right thigh incision was I&D on postoperative day #3, and cultures were sent. Normal saline wet-to-dry dressings were begun. There was an improvement in her confusion. Her white count remained elevated at 24.7, but the patient was afebrile. She was continued on TPN. The patient remained in the VICU. The patient underwent a swallow evaluation on [**2117-1-4**]. It noted that the patient presented with functional speech, language and swallowing despite confusion and disorientation. She just has some oral candidiasis. There were no overt signs or symptoms of aspiration. They recommended that we could continue a regular diet with liquids, regular and soft solids, and treatment of the oral thrush. TPN was weaned on [**2117-1-4**]. Vancomycin was discontinued on [**2117-1-5**]. The patient was begun on Linezolid 75 mg q 12 h for VRE. The [**Last Name (un) **] service was consulted on [**1-5**] for management of her diabetes. Adjustments in her Insulin regime were made secondary to persistent hyperglycemia. Last JP was discontinued on [**2117-1-6**]. Blood cultures 11/28 grew VRE. Urine culture grew VRE. C. diff was positive. With Insulin adjusting, there was significant improvement in her glucose control. With the start of Linezolid there was improvement in the patient's total white count, and blood cultures were no growth. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 4417**] Dictated By:[**Last Name (NamePattern1) 1479**] MEDQUIST36 D: [**2117-1-13**] 12:59 T: [**2117-1-13**] 14:08 JOB#: [**Job Number 98315**] Name: [**Known lastname **], [**Known firstname **] Unit No: [**Numeric Identifier 15685**] Admission Date: [**2116-12-4**] Discharge Date: [**2117-1-16**] Date of Birth: [**2058-5-20**] Sex: F Service: VASCULAR ADDENDUM TO DISCHARGE SUMMARY The patient stayed an additional two days for disposition reasons only. The patient continued to remain clinically stable. Her wounds continued to granulate and demonstrate healing process. The patient remained afebrile. Further cultures were obtained and remained negative. The patient continued on dialysis three times a week as scheduled. By [**2117-1-16**], a position at [**Hospital3 4287**] became available and it was felt that the patient should be ready for discharge to this rehabilitation facility. There is only one change to discharge medications and that is a Nephrophos which should be taken q. day; otherwise, the patient should follow-up with Dr. [**Last Name (STitle) **] within two weeks of discharge. The patient should schedule an appointment with his office. DISCHARGE STATUS: To rehabilitation. CONDITION AT DISCHARGE: Good. [**First Name11 (Name Pattern1) 77**] [**Last Name (NamePattern1) 237**], M.D. [**MD Number(1) 238**] Dictated By:[**Name8 (MD) 4548**] MEDQUIST36 D: [**2117-1-16**] 12:01 T: [**2117-1-16**] 12:45 JOB#: [**Job Number 15686**]

[ "E878.2", "038.19", "584.9", "518.81", "112.0", "008.45", "E879.1", "403.91", "996.62" ]

icd9cm

[ [ [] ] ]

[ "38.93", "89.64", "39.95", "38.91", "38.95", "97.49", "39.49", "96.04", "54.0", "99.15", "39.29", "88.72", "99.04" ]

icd9pcs

[ [ [] ] ]

1855, 2038

3090, 12233

1647, 1829

2236, 3072

12249, 12519

159, 181

210, 1423

1445, 1624

2055, 2220

10,112

188,574

52258

Discharge summary

report

Admission Date: [**2148-1-13**] Discharge Date: [**2148-1-19**] Service: MICU HISTORY OF PRESENT ILLNESS: The patient is a 78 year-old white female with a long psychiatric history, [**Hospital 108071**] transferred from an outside hospital status post a V fibrillation arrest. By report the patient was found unresponsive slumped over a toilet at her [**Hospital3 **] facility without pulse or respirations. Upon EMS arrival food was removed from the back of the patient's throat. The patient was emergently intubated. On the cardiac monitor the patient was found to be in asystole for which she was given epinephrine intravenous times three and Atropine times two in an alternating fashion according to ACLs protocol. The patient did develop ventricular fibrillation on the cardiac monitor for which she received a cardioversion times one restoring normal sinus rhythm. The patient was started on a Lidocaine drip, which was later changed to an Amiodarone load of 150 mg. The patient was first evaluated at [**Hospital 11694**] [**Hospital 107**] Hospital where an emergent femoral central venous line was placed. The arterial blood gas at the outside hospital was 7.07, PCO2 47, oxygen 563 with repeat gas. Following intubation 7.29, PCO2 32, PO2 173. Because of the lack of bed availability the patient was transferred to [**Hospital1 1444**] for further evaluation and management. The patient had previously signed a DNR verification, but had subsequently crossed out the words "do not" and added a signed and dated addendum stating "please resuscitate me and all my body parts" on the form. By report the patient had a colonoscopy, which was unremarkable on [**1-12**]. PAST MEDICAL HISTORY: 1. Bipolar disorder. The patient had been admitted multiple times to a psychiatric facility and had been on multiple medications. 2 . Hypothyroidism. 3. Osteoporosis. 4. Migraines. 5. Degenerative joint disease. 6. Status post right hip replacement in [**2132**]. 7. Gastroesophageal reflux disease. 8. History of sick sinus syndrome with prolonged PR interval presumed secondary to lithium toxicity. 9. Parkinsonism. 10. In [**2145-5-13**] the patient had a normal echocardiogram with normal left ventricular and right ventricular function. FAMILY HISTORY: The patient has multiple relatives with psychiatric medical history. She has an uncle that committed suicide. SOCIAL HISTORY: The patient lived in an [**Hospital3 **] facility. She is divorced and is currently estranged from her family members. ALLERGIES: Tetanus and horse serum. MEDICATIONS ON ADMISSION: Fosamax 70 mg po q week, Synthroid 112 micrograms po q day. Vitamin C, multivitamin, enteric coated aspirin, vitamin B, caltrate, Sinemet 25/100 one tab po q day, Colace 100 mg po b.i.d., Tums b.i.d., Zantac 150 mg po b.i.d., Zyprexa 2.5 mg po q day, Effexor 37.5 mg po q day, Vioxx 12.5 mg po q day. Purinol prn and Cafergot prn. ADMISSION LABORATORY DATA FROM THE OUTSIDE HOSPITAL: White blood cell count 6.1, hematocrit 38.2, platelets 169, sodium 141, potassium 3.6, chloride 101, bicarb 20, creatinine 1.1, glucose 334, INR 1.2, PTT 29, creatine kinase 437 with an MB of 7.2, troponin I less then .3. Chest x-ray per the outside Emergency Department eating and tracheal tube in good position. No congestive heart failure or infiltrate. Electrocardiogram at the outside hospital sinus tachycardia at 111. Normal axis, normal intervals, borderline QT prolongation with [**Street Address(2) 4793**] depression in V3 through V5. At [**Hospital1 69**] the patient was in normal sinus rhythm at 60 with normal axis, intervals, T wave inversions in 1 and L with normalization of V5 and V6 with slight STT changes in [**2146-8-13**]. HOSPITAL COURSE: 1. Neurology: Upon arrival to the [**Hospital1 1444**] the patient was having myoclonic jerks in her upper extremities and face. She underwent an emergent head CT, which was negative for cerebrovascular accident or acute bleed. Throughout her stay the patient remained unresponsive to any stimuli including painful and noxious stimuli. The patient was determined to have intact brain stem by evaluation of the Intensive Care Unit team and the neurology consult service. The day following admission the patient underwent an MRI, which is also negative for acute pathology as well as an electroencephalogram, which was consistent with encephalopathy secondary to anoxic brain injury. In the opinion of the neurology service she was felt to suffer a anoxic brain injury. Over the course of the next several days the patient remained unresponsive to any stimuli at all. It was felt that following three to four days in this state her chance of any recovery of any high cognitive function was very remote. 2. Respiratory: The patient remained intubated and ventilated on minimal ventilator settings. She was initially managed on AC setting and then changed to pressure support, but then required change back to SIMV. 3. Cardiovascular: Throughout her stay at [**Hospital1 346**] the patient remained hemodynamically stable. She was initially given an Amiodarone load by intravenous infusion. The patient ruled out for myocardial infarction with enzymes times three. Her slight elevation in cardiac enzymes were felt to be secondary to the CPR from her cardiac arrest. 4. Infectious disease: Throughout her stay the patient continued to be intermittently febrile. However, her white blood cell count remained normal. In addition, her chest x-ray and urinalyses were also unremarkable. All blood cultures drawn remained negative. Given the patient's anoxic insult to her brain these fevers were felt most likely to be secondary to her anoxic insult. 5. Fluids, electrolytes and nutrition: The patient was initially maintained on intravenous fluid and then tube feeds. 6. Communication/disposition: Following the patient's admission multiple attempts were made to contact the patient's next of [**Doctor First Name **] and family members. Apparently she had been estranged from her multiple family members for some time and they do not keep in touch regularly. The patient's next of [**Doctor First Name **] who was [**Doctor First Name 653**] was Mrs. [**Last Name (STitle) 108072**] [**Name (STitle) 108073**], [**Telephone/Fax (1) 108074**]. After multiple discussions with her regarding the patient's overall very grim prognosis and meaningful chance for recovery, the patient felt that if her sister were able to make decisions for herself she would not like to continue living in this persistent vegetative state and stated that she would prefer (the patient to have all life support systems removed). The patient's sons Mr. [**First Name4 (NamePattern1) 8516**] [**Known lastname 105561**] and Mr. [**First Name4 (NamePattern1) **] [**Known lastname 105561**] were also [**Known lastname 653**] by phone, both of whom agreed that their mother would not want to live in this state and agreed to the withdraw of life support. The patient's primary care physician [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 7790**] was also [**Last Name (NamePattern1) 653**] who concurred with the patient's family members thoughts and deliberations . The legal service department was [**Name (NI) 653**] at [**Hospital1 188**] who felt that this course of action given the patient's grim prognosis was appropriate. On [**2148-1-18**] all care was withdrawn from the patient and that the patient was extubated and started on morphine and Ativan drips. The patient's family members were [**Name (NI) 653**] regarding whether the withdraw of care should be withheld until they could come to [**Location (un) 86**] to pay their final respects. However, all family members including both her sons and the patient's sister declined this offer and stated that it would be appropriate to withdraw care at this time. As stated above the care was withdrawn on [**1-18**]. At 2:13 p.m. on [**1-19**], the patient was found unresponsive without spontaneous respirations or palpable pulse. The patient had fixed and dilated pupils bilaterally without response to painful or noxious stimuli. The time of death was 2:13 p.m. on [**1-19**]. DISCHARGE DIAGNOSES: 1. Cardiac arrest. 2. Respiratory failure. 3. Noxious brain injury. 4. Failure. [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 5587**] Dictated By:[**Last Name (NamePattern1) 9280**] MEDQUIST36 D: [**2148-1-19**] 03:37 T: [**2148-1-23**] 11:46 JOB#: [**Job Number 108075**]

[ "780.03", "296.7", "530.81", "427.41", "244.9", "562.10", "332.0", "518.81", "348.1" ]

icd9cm

[ [ [] ] ]

[ "45.24", "45.42" ]

icd9pcs

[ [ [] ] ]

2290, 2402

8288, 8681

2605, 3745

3763, 8267

117, 1698

1720, 2273

2419, 2578

23,233

161,597

11220

Discharge summary

report

Admission Date: [**2116-7-13**] Discharge Date: [**2116-7-14**] Date of Birth: [**2052-8-11**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**Last Name (NamePattern4) 290**] Chief Complaint: slurred speech/facial droop Major Surgical or Invasive Procedure: Arterial line placement History of Present Illness: 63 yo man with history of recently diagnosed amioderone induced thyroidtoxicosis, AF on coumadin, right-sided heart failure, COPD, and DM2 who presents from [**Hospital1 **] [**Hospital1 **] with slurred speech and facial droop. He was recently treated for MRSA endocarditis at [**Hospital1 **]. Patient arrived to the ED with confusion, minimally interactive, was rapidly intubated due to poor airway protection. He subsequently went into seizure. CT scan showed small left sulcal hyperdensity, over the left parietal lobe, suspicious for subarachnoid hemorrhage. He was sedated on fentanyl and versed. neuro/neurosurg evaluated noted that the small subarachnoid hemorrhage not amenable to surgical intervention. Question if there is stroke with possible hemorrhagic conversion. . Patient had very varible SBP 70-140, on levo and neo, 4L fluid, foley. He was given profilnine, and vit K and FFP to reverse INR. Femoral line in groin. Abbroviat in chest wall. Patient underwent a CTA/CTV of the head (though suboptimal in quality due to lack of peripheral access) and CT of torsal. . In the ED, initial vs were: T P BP R O2 sat. Patient was given Patient was given Naloxone, Phenylephrine, Levophed, Midazolam, Fentanyl, Phenytoin, Phytonadione, Piperacillin-Tazob, Vancomycin, 4L of fluids. . On the floor, patient was intubated, sedated. . Review of systems: (+) Per HPI Past Medical History: 1. Obesity s/p gastric bypass surgery 2. Type 2 Diabetes Mellitus, on NPH insulin 3. Atrial fibrillation on warfarin and amiodarone 4. CHF with RV dysfunction [**1-14**] to OSA 5. HTN 6. GERD 7. Obstructive sleep apnea--has not tolerated CPAP 8. Amiodarone induced thyrotoxicosis--was treated with steroids, however stopped due to weight gain, psychosis, and hyperglycemia, now on methimazole 9. Moderate pulmonary HTN Social History: Home: He lives in [**Location 4288**] with his wife and teenage son. [**Name (NI) **] has another son living in the [**Name (NI) 86**] area. Occupation: He is a retired school teacher and currently works as a rental car salesman EtOH: Occasional glass of wine Drugs: Denies Tobacco: Denies Family History: Family history of obesity and stroke. No family history of CAD. Physical Exam: VS: T92.7, HR 93, BP 96/60, 100% on vent General: sedated, intubated HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: coarse breath sounds, without wheezes, rales, ronchi CV: tachy, regular rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, 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 [**2116-7-13**] 06:10PM BLOOD WBC-11.2* RBC-3.66* Hgb-9.6* Hct-30.2* MCV-83 MCH-26.2* MCHC-31.7 RDW-20.1* Plt Ct-125* [**2116-7-13**] 11:32PM BLOOD WBC-6.7 RBC-3.27* Hgb-8.9* Hct-27.1* MCV-83 MCH-27.2 MCHC-32.7 RDW-20.2* Plt Ct-115* [**2116-7-13**] 11:32PM BLOOD Plt Ct-115* [**2116-7-13**] 11:32PM BLOOD Plt Ct-115* [**2116-7-13**] 11:32PM BLOOD PT-19.9* PTT-35.0 INR(PT)-1.8* [**2116-7-13**] 07:49PM BLOOD PT-39.0* PTT-150.0* INR(PT)-4.1* [**2116-7-13**] 06:10PM BLOOD PT-49.1* PTT-46.8* INR(PT)-5.3* [**2116-7-13**] 06:10PM BLOOD Plt Smr-LOW Plt Ct-125* [**2116-7-13**] 11:32PM BLOOD Fibrino-433* [**2116-7-13**] 11:32PM BLOOD Glucose-138* UreaN-15 Creat-1.1 Na-130* K-4.4 Cl-94* HCO3-18* AnGap-22* [**2116-7-13**] 06:10PM BLOOD Glucose-132* UreaN-15 Creat-1.0 Na-130* K-4.8 Cl-92* HCO3-22 AnGap-21* [**2116-7-13**] 11:32PM BLOOD ALT-36 AST-38 [**2116-7-13**] 06:10PM BLOOD cTropnT-0.02* [**2116-7-13**] 11:32PM BLOOD Calcium-7.9* Phos-3.5 Mg-1.8 [**2116-7-13**] 06:10PM BLOOD Calcium-7.9* Phos-2.9 Mg-1.8 [**2116-7-13**] 11:32PM BLOOD TSH-0.61 [**2116-7-13**] 06:10PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2116-7-13**] 07:49PM BLOOD RedHold-HOLD [**2116-7-13**] 11:46PM BLOOD Type-CENTRAL VE pH-7.32* [**2116-7-13**] 07:53PM BLOOD Lactate-6.6* [**2116-7-13**] 11:46PM BLOOD O2 Sat-97 [**2116-7-13**] 11:46PM BLOOD freeCa-0.88* ECHO on [**7-14**] The left atrium is moderately dilated. The right atrium is moderately dilated. No atrial septal defect is seen by 2D or color Doppler. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF 70%). There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Moderate (2+) mitral regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is a small pericardial effusion. There are no echocardiographic signs of tamponade. Compared with the findings of the prior study (images reviewed) of [**2116-4-24**], the findings are similar. CT HEAD on [**7-13**] 1. Stable appearance of left parietal subarachnoid hemorrhage. 2. No new foci of hemorrhage identified (allowing for limitation, above). 3. Opacification of the ethmoidal air cells and fluid layering within the nasal cavity, bilaterally, and the right maxillary sinus and sphenoid air cell. CTA/CTV was not performed due to lack of IV access. CT TORSO on [**7-13**] 1. Suboptimal evaluation due to hand injection of IV contrast. 2. Bilateral pleural effusions, right greater than left with associated compressive atelectasis and non-specific ground-glass opacity in the lungs could represent inflamation or infection. 3. Hypodensity in the right kidney is incompletely evaluated and could represent a cyst or other lesion, but infarct cannot be excluded. 4. Umbilical and right-sided inguinal bowel-containing hernias without evidence of obstruction/incarceraction. The study and the report were reviewed by the staff radiologist. Brief Hospital Course: HYPOTENSION/SHOCK: multifactorial - thought secondary to possibly septic picture (given known source of VISA endocarditis) and possible cardiogenic factor. An echo was done and the patient required 4 pressors in order to keep MAPs in the 60s. He received 1 upRBCs which helped transiently. He was bolused a total of 9L NS as well between the ED and the floor. The patient was started on stress dose steroids given his long standing h/o steroid use. His home medications for HTN and Afib were held in the setting of hypotension, and cultures were taken for the possible infectious cause. His abx coverage was expanded to linezolid, cefepime, and flagyl while on the floor to cover broadly. An ID consult was called, and an SvO2 was checked in an effort to differentiate between the possible septic/cardiac etiologies. Ultimately, after much of the workup could be completed, the patient's wife opted for comfort care, and he was taken off of the four pressors and made comfortable. He expired shortly thereafter. . ► ENDOCARDITIS (VISA): was on synercid at OSH due to Lsided lesion, and as above, his coverage was increased to broad spectrum abx. Also, he was put in the for the ECHO to evaluate his valves and overall CV status. As previously mentioned, when he was transitioned to CMO, his abx were stopped. . ► ACIDOSIS, METABOLIC: likely due to hypoperfusion of the end organs given elevated lactate. We continued to trend his lactate, however it continued to rise from 6.6 in the ED to >12 before his death. Bicarb was given given the increasing trend, and IV hydration was maintained for perfusion pressures. . ► SEIZURE vs STROKE: imaging suggest subarachnoid hemorrhage, not for surgical intervention. The patient was continued on the phenytoin on the floor as he was loaded with dilantin in the ED. A neuro and neurosurgery c/s were called in the ED, and the patient was not a surgical candidate. An EEG was ordered, however this study could not be completed after he was made CMO. . # Ventilation: The patient was kept sedated while mechanical ventilation was used. His CT chest notable for b/l pleural effusions with RLL segmental collapse. He was extubated when he was made CMO. . ► ATRIAL FIBRILLATION (AFIB) on Coumadin with high INR - given subarachnoid bleed, he was reversed with profilnine, vitamin K, and FFP. We held any anticoagulation and decided to trend INR. . ► ANEMIA, CHRONIC - currently at baseline, we continued to trend his Hct. He did receive one u PRBC in an effort to increase end organ perfusion. . #) Wounds/ulcers ?????? wound care c/s was called . #) Code: Pt was DNR/DNI after a conversation with his wife on [**2116-7-14**]. [**Name2 (NI) **] was made CMO after this conversation and expired shortly thereafter. Medications on Admission: Zolpidem 10mg daily digoxin 0.25mg po daily metoprolol tartrate 25mg PO bid Lisinopril 5mg PO daily warfarin 1.5mg po dialy furosemide 60mg PO daily prednisone 20mg PO dialy Epo [**Numeric Identifier 389**] SQ 1/wk (wednesday) Synercid 750mg IV Q8H Daptomycin 650mg x1 insulin ss Neutrophos 2 PO TID Alumina/Mag/simethicone PO Q6H prn KCl 40mEq PO x1 petrolatum white 1 app topical Q2H prn and QHS miconazole powder 1 app topical q shift multivitamin 1 tab po daily ferrous sulfate 325 po bid pantoprazole 40 mg PO bid morphine sulfate 2mg IV push q6h prn nepro full strenght daily ibuprofen prn acetaminophen prn Discharge Medications: none Discharge Disposition: Expired Discharge Diagnosis: deceased Discharge Condition: deceased Discharge Instructions: N/A as pt is deceased Followup Instructions: none [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**] Completed by:[**2116-7-15**]

[ "780.39", "995.92", "287.5", "496", "286.9", "E942.0", "785.52", "427.31", "421.0", "401.9", "518.81", "242.80", "V45.86", "276.2", "428.0", "530.81", "327.23", "V58.67", "038.9", "430", "250.00", "416.8" ]

icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

9937, 9946

6418, 9221

350, 375

9998, 10008

3119, 6395

10078, 10249

2545, 2610

9908, 9914

9967, 9977

9247, 9885

10032, 10055

2625, 3100

1764, 1778

283, 312

403, 1745

1800, 2221

2237, 2529

3,191

188,863

51368

Discharge summary

report

Admission Date: [**2161-3-21**] Discharge Date: [**2161-3-24**] Date of Birth: [**2098-9-22**] Sex: F Service: CARDIOTHORACIC Allergies: Penicillins / Iodine; Iodine Containing Attending:[**First Name3 (LF) 1283**] Chief Complaint: Syncope Major Surgical or Invasive Procedure: None History of Present Illness: 62 year old female with known Aortic Stenosis, [**Location (un) 109**] 0.6cm2, peak gradient 73, scheduled for AVR later this month with Dr. [**Last Name (STitle) 1290**]. Patient was taken to [**Hospital6 **] ED after three syncopal episodes, one with loc of 5-10min. She was also complaining of cough productive of green sputum, chills x3 days. She further complained of chest pressure and shortness of breath. Past Medical History: NIDDM Hypertension Asthma Critical Aortic stenosis Lupus - off steroids since 5 years ago Congestive Heart Failure Gout Hypercholesteremia Social History: Smoked ~3 cigs/day X 15 years, quit 30 years ago. Family History: NC Physical Exam: HEENT: conjunctiva erythematous left>right, no jvd, transmitted murmur Bilateral carotids, trachea midline Chest:B/C CTAB anteriorly, RRR SEM II/VI loudest RSB 2ICS ABD: S/NT/protuberant/BS + EXT:trace edema, distal pulses 2+ Neuro:nonfocal Pertinent Results: Cardiology Report ECHO Study Date of [**2161-3-23**] PATIENT/TEST INFORMATION: Indication: Aortic valve disease. Left ventricular function. Preoperative assessment. Height: (in) 68 Weight (lb): 230 BSA (m2): 2.17 m2 BP (mm Hg): 85/40 HR (bpm): 90 Status: Inpatient Date/Time: [**2161-3-23**] at 11:03 Test: Portable TTE (Focused views) Doppler: Full Doppler and color Doppler Contrast: Definity Tape Number: 2006W000-0:00 Test Location: West MICU Technical Quality: Suboptimal REFERRING DOCTOR: DR. [**First Name (STitle) 412**] [**Last Name (Prefixes) 413**] MEASUREMENTS: Left Atrium - Four Chamber Length: *6.1 cm (nl <= 5.2 cm) Right Atrium - Four Chamber Length: 4.4 cm (nl <= 5.0 cm) Left Ventricle - Ejection Fraction: 55% to 60% (nl >=55%) Aortic Valve - Peak Velocity: *5.3 m/sec (nl <= 2.0 m/sec) Aortic Valve - Peak Gradient: 113 mm Hg Aortic Valve - Mean Gradient: 78 mm Hg Aortic Valve - LVOT Peak Vel: 1.00 m/sec Aortic Valve - LVOT Diam: 2.0 cm Aortic Valve - Valve Area: *0.6 cm2 (nl >= 3.0 cm2) Mitral Valve - E Wave: 1.0 m/sec Mitral Valve - A Wave: 1.2 m/sec Mitral Valve - E/A Ratio: 0.83 Mitral Valve - E Wave Deceleration Time: 259 msec TR Gradient (+ RA = PASP): *47 mm Hg (nl <= 25 mm Hg) INTERPRETATION: Findings: LEFT ATRIUM: Elongated LA. RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. LEFT VENTRICLE: Normal LV wall thickness, cavity size, and systolic function (LVEF>55%). Suboptimal technical quality, a focal LV wall motion abnormality cannot be fully excluded. No LV mass/thrombus. RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTIC VALVE: ?# aortic valve leaflets. Severely thickened/deformed aortic valve leaflets. Severe AS. No AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild mitral annular calcification. Mild thickening of mitral valve chordae. Mild (1+) MR. LV inflow pattern c/w impaired relaxation. TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Mild [1+] TR. Moderate PA systolic hypertension. PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with physiologic PR. PERICARDIUM: No pericardial effusion. GENERAL COMMENTS: Suboptimal image quality - poor echo windows. Suboptimal image quality - body habitus. Conclusions: The left atrium is elongated. There is an echodensity within the posterior [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] that likely represents the ridge betweeen the left atrial appendage and the [**Doctor Last Name **] pulmonary vein (warfarin ridge). 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. No masses or thrombi are seen in the left ventricle. Right ventricular chamber size and free wall motion are normal. The number of aortic valve leaflets cannot be determined. The aortic valve leaflets are severely thickened/deformed. There is severe aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. The left ventricular inflow pattern suggests impaired relaxation. The tricuspid valve leaflets are mildly thickened. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Severe aortic stenosis. Moderate pulmonary hypertension. Normal LVEF. Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD on [**2161-3-23**] 14:34. [**Location (un) **] PHYSICIAN: [**Name10 (NameIs) **],[**First Name3 (LF) **] RADIOLOGY Preliminary Report CAROTID SERIES COMPLETE PORT [**2161-3-23**] 3:15 PM CAROTID SERIES COMPLETE PORT Reason: syncope [**Hospital 93**] MEDICAL CONDITION: 62 year old woman with AS, syncope, preop REASON FOR THIS EXAMINATION: syncope CAROTID SERIES COMPLETE. REASON: Aortic stenosis. FINDINGS: Duplex evaluation was performed of both carotid arteries. Minimal plaque was identified. On the right, peak systolic velocities are 51, 64, 37 in the ICA, CCA, ECA respectively. The ICA to CCA ratio is 0.8. This is consistent with no stenosis. On the left, peak systolic velocities are 60, 75, 51 in the ICA, CCA, ECA respectively. The ICA to CCA ratio is 0.8. This is consistent with no stenosis. There is antegrade flow in both vertebral arteries. IMPRESSION: No evidence of stenosis in either carotid artery. DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] RADIOLOGY Final Report CHEST (PORTABLE AP) [**2161-3-22**] 7:31 AM CHEST (PORTABLE AP) Reason: r/o effusion [**Hospital 93**] MEDICAL CONDITION: 62 year old woman with AS REASON FOR THIS EXAMINATION: r/o effusion CHEST ONE VIEW PORTABLE. INDICATION: 62-year-old woman with AS. COMMENTS: Portable erect AP radiograph of the chest is reviewed. No previous study is available for comparison. There is mild congestive heart failure with cardiomegaly. There is marked tortuosity of the thoracic aorta, which is consistent with patient's history of aortic stenosis. No evidence of pneumothorax is identified. IMPRESSION: Mild congestive heart failure. DR. [**First Name (STitle) 7204**] [**Name (STitle) 7205**] Approved: SUN [**2161-3-22**] 11:34 AM Cardiology Report ECG Study Date of [**2161-3-21**] 11:51:56 PM Sinus rhythm Early transition Since previous tracing, no significant change Read by: [**Last Name (LF) **],[**First Name3 (LF) **] J. Intervals Axes Rate PR QRS QT/QTc P QRS T 86 164 100 398/441.28 41 6 93 [**2161-3-21**] 08:55PM GLUCOSE-180* UREA N-50* CREAT-2.0* SODIUM-136 POTASSIUM-4.3 CHLORIDE-104 TOTAL CO2-20* ANION GAP-16 [**2161-3-21**] 08:55PM ALT(SGPT)-12 AST(SGOT)-19 LD(LDH)-143 ALK PHOS-119* TOT BILI-0.2 [**2161-3-21**] 08:55PM WBC-14.9* RBC-3.15* HGB-8.9* HCT-27.2* MCV-86 MCH-28.1 MCHC-32.6 RDW-16.0* [**2161-3-21**] 07:40PM URINE BLOOD-TR NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-SM [**2161-3-21**] 07:40PM URINE RBC-0-2 WBC-0-2 BACTERIA-MOD YEAST-NONE EPI-<1 Brief Hospital Course: Mrs. [**Known lastname 106519**] was admitted after presentation to OSH ED for syncopal episodes associated with a loss of consciousness and CHF. She was admitted for diuresis and cardiac monitoring. Cardiology was consulted for management of CHF in the setting of Aortic stenosis. She was empirically placed on levaquin for possible pneumonia. Blood Cultures were negative after 72hours. She was gently diuresed toward her baseline weight. Urine culture showed a E. Coli UTI, sensitivities pending. On hospital day 4 Mrs. [**Known lastname 106519**] was 1.5kg below her baseline weight, able to walk up two flights of stairs without distress, denying any chest discomfort or shortness of breath at rest. She has dental follow up scheduled with her dentist as an outpatient for filling of two dental carries prior to AVR on [**2161-4-10**] with Dr. [**Last Name (STitle) 1290**]. She was instructed to minimize her trips out of her apartment (3 story walk up) and to call 911 and come to [**Hospital1 18**] if she has further episodes of CP, DOE, SOB, or syncope. She is to keep her PAT appointment on [**2161-4-1**] for her AVR. Medications on Admission: Atrovent 12.5 Albuterol Allopurinol 300' Plaquenil 200' Prozac 20' Lasix 20' Glyburide 25/Metformin 500'' Lantus 24hs ASA 81' Benicar 20' Lipitor 10' Humalog [**3-29**] SSI Neurontin 400 tid Maxair prn Discharge Medications: 1. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 2. Hydroxychloroquine 200 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 3. Fluoxetine 20 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). Disp:*30 Capsule(s)* Refills:*2* 4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 5. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 6. Erythromycin 5 mg/g Ointment Sig: One (1) Ophthalmic QID (4 times a day). Disp:*qs qs* Refills:*2* 7. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 3 days. Disp:*3 Tablet(s)* Refills:*0* 8. Glyburide 2.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 9. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: One (1) Inhalation four times a day. Disp:*qs qs* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Aortic stenosis, Asthma, DM, HTN, Lupus, Gout, Hypercholesteremia Discharge Condition: Good Discharge Instructions: Resume your previous medications. Limit your physical exertion, as tolerated. If you experience persistent shortness of breath, chest pain, or further fainting episodes, call 911 and come to [**Hospital1 18**] ED. Call [**Telephone/Fax (1) 170**] with any routine questions regarding your upcoming surgery Followup Instructions: Follow up with your dentist regarding treatment for two dental carries prior to your surgery on [**2161-4-10**]. You will be admitted to [**Hospital1 18**] on [**2161-4-10**] the AM of your surgery Completed by:[**2161-3-24**]

[ "424.1", "041.4", "710.0", "250.00", "274.9", "493.90", "428.0", "428.30", "416.0", "272.0", "V15.82", "599.0" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

9832, 9838

7400, 8540

314, 321

9948, 9955

1291, 1347

10312, 10542

1011, 1015

8793, 9809

5965, 5991

9859, 9927

8566, 8770

9979, 10289

1373, 4796

1030, 1272

267, 276

6020, 7377

349, 764

4828, 5013

786, 927

943, 995

68,674

100,610

32493

Discharge summary

report

Admission Date: [**2136-12-19**] Discharge Date: [**2136-12-26**] Date of Birth: [**2055-10-16**] Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 633**] Chief Complaint: Chronic Blood Loss Anemia, respiratory distress Major Surgical or Invasive Procedure: EGD with banding blood transfusion History of Present Illness: Ms. [**Known lastname 75806**] is an 81 y/o F with a history of dCHF (EF 50-65% in [**2133**]), afib, and chronic blood loss from GAVE syndrome who presented today for elective EGD under MAC anesthesia. Per endoscopy report, the findings were consistent with known diagnosis of nodular gastric antral vascular ectasia. Mild sponaneous oozing was noted. Band ligation was performed for homeostasis. After the procedure the patient was complaining of shortness of breath. She reports that she has been chronically short of breath for 11 years, however she does not require any oxygen at home. Of note the patient had not taken her lasix the morning of the procedure and received 800cc of lactated ringers during the endoscopy. She denies chest pain, cough, wheeze, or leg pain. No known history of COPD or asthma. She reports that her bilateral leg swelling is no worse than baseline (documented to be 3+ edema in recent PCP [**Name Initial (PRE) 626**]). . On arrival to the medicine floor she was desatting to the low 80s on nasal cannula and was placed on 5liter facemask. Her blood pressures were in the 90s systolic which is slightly below baseline according to outpatient records of 100s-110s systolic. Heart rates 90s in afib. Diuresis was not initiated on the floor because of concern for low blood pressures. The patient was therefore transfered to the [**Hospital Unit Name 153**] for further management. VS prior to transfer were 87/57 87 20 99% on 5liter facemask. EKG showed Atrial fibrillation with rate of 96, NA/NI no majors change compared to prior. . On arrival to the ICU, patient denies any chest pain. She reports shortness of breath is improved while wearing the oxygen. . Review of systems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies cough, or wheezing. Denies chest pain, chest pressure, palpitations, or weakness. Denies nausea, vomiting, diarrhea, constipation, abdominal pain, or changes in bowel habits. Denies dysuria, frequency, or urgency. Denies arthralgias or myalgias. Denies rashes or skin changes. Past Medical History: Gastric Antral Vascular Ectasia [GAVE] Anemia requiring transfusion related to GI bleed Right heart failure (EF 50-65% in [**2133**]), 3+ Tricuspid regurgitation Atrial fibrillation, not on Coumadin or ASA due to chronic blood loss Hypertension Hyperlipidemia Type 2 Diabetes Mellitus Hypothyroidism Chronic Kidney Disease Stage II (Recent Creatinine 1.3) Social History: Lives at home with husband - [**Name (NI) 1139**]: none - Alcohol: [**1-25**] drinks/month - Illicits: none Family History: 3 siblings had lung cancer Physical Exam: Physical Exam: General: Alert, oriented with face mask in place HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP elevated 5cm above sternal angle Lungs: Diminished breath sounds diffusely. No wheezes, rales, or rhonchi. No accessory muscle use. CV: Irregular. 4/6 systolic murmur heard throughout. 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, 2+ pitting edema bilaterally at baseline per patient. No tenderness or erythema. . Pertinent Results: . [**Location (un) **] hosp records: - Echo [**2130**]: EF 60%, RV enlarged with preserved systolic function, biatrial enlargement, mild AS with valve area 2.2, moderate MR, severe TR, mildly elevated pulm artery systolic pressure 29 plus estimated right atrial pressure. -On [**10/2136**] admitted to [**Hospital **] hosp seen for SOB and pedal edema, given lasix diuresed from weight 73->70 Kg . On initial presentation during that admission, she was satting 96% on 2L. BP 125/65. HR 48.Cr 1.4, D-dimer 0.4. They transfused her 1 U PRBC on [**11-12**], discharge HCT 31. Sent out on lasix 40mg PO daily. (of note, in past: Was on amiodarone 200mg daily in [**2130**].) . [**Hospital1 18**] REPORTS/LABS- [**12-20**] EKG- Atrial fibrillation. Low voltage throughout. Non-specific T wave abnormality in the lateral leads. Abnormal tracing. No previous tracing available for comparison. . CXR [**12-20**]: FINDINGS: Cardiac silhouette is enlarged. Prominence of right cardiac border could reflect enlarged right-sided cardiac [**Doctor Last Name 1754**] or adjacent pericardial abnormality such as a pericardial cyst or prominent fat pad. Attention to this on standard PA and lateral chest radiograph is recommended when the patient's condition permits. No focal areas of consolidation are present within the lungs. Questionable small pleural effusions, which could also be more fully address by standard PA and lateral chest radiographs. . EKG [**12-21**]: Atrial fibrillation. Low voltage throughout. Abnormal tracing. Compared to the previous tracing ST segment abnormalities are resolved. TRACING #2 . ECHO [**Hospital1 18**] [**2136-12-20**] The left atrium is moderately dilated. The right atrium is markedly dilated. A patent foramen ovale is present. There is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (LVEF>55%). The right ventricular cavity is moderately dilated with mild global free wall hypokinesis. The ascending aorta is mildly dilated. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. An eccentric jet of moderate to severe (3+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. Severe [4+] tricuspid regurgitation is seen. There is mild pulmonary artery systolic hypertension. [In the setting of at least moderate to severe tricuspid regurgitation, the estimated pulmonary artery systolic pressure may be underestimated due to a very high right atrial pressure.] There is no pericardial effusion. . IMPRESSION: Moderately dilated right ventricle with mild systolic dysfunction. Normal global and regional left ventricular systolic function. Severe tricuspid regurgitation. Moderate to severe mitral regurgitation. At least mild pulmonary hypertension. . CXR [**2136-12-20**]: IMPRESSION: No acute intrathoracic process. . [**12-21**] LENI: IMPRESSION: No evidence of DVT in the right or left lower extremities. . VQ SCAN [**2136-12-21**] INTERPRETATION: Ventilation images obtained with Tc-[**Age over 90 **]m aerosol in 8 views demonstrate some accumulation of tracer in the large airways. Matched defects in the right lung base, is likely due to pleural effusion. Perfusion images in the same 8 views show >2 mismatched segmental defects in the right upper lobe and superior segment of the right lower lobe. Chest x-ray shows a small right pleural effusion and cardiomegaly. The above findings are consistent with a high likelihood ratio for pulmonary embolism. IMPRESSION: High likelihood ratio of pulmonary embolism in the right upper lobe. . Renal u/s [**12-22**]: 1. Limited study showing no evidence of hydronephrosis and no direct evidence of venous clot. 2. Suggested reversal of diastaolic flow in the left renal artery. The significance of this is unclear given the limitations noted, and may be related to a high-resistance system including acute tubular necrosis, or might be artifactual. If vascular thrombus is still of concern, noncontrast MRV of the renal veins may be of use to confirm patency. 3. Small bilateral kidneys, consistent with chronic medical renal disease. . EKG [**12-22**]- Significant baseline artifact precludes an accurate interpretation of the rhythm. No clear P waves are seen suggesting possible atrial fibrillation. Poor R wave progression in leads V1-V3 of unclear significance. No other interpretation is possible based on this tracing. Compared to the previous tracing of [**2136-12-20**] atrial fibrillation is likely still present. . EKG [**12-22**]: FINDINGS: Since [**2136-12-20**], mild right pleural effusion and mild to moderate right basilar atelectasis is worse. Mildly enlarged heart size is stable and a suspicion for pericardial effusion was raised. Findings were discussed with Dr.[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] who mentioned regarding recent echocardiogrpaphy which revealed sever cardiomegaly secondary to multivalvular involvement, but no pericardial effusion. Aorta is generally larger, however, there is no evidence of a focal aneurysm. There is no evidence of pulmonary edema. . CXR [**2136-12-25**]: FINDINGS: In comparison with the study of [**12-22**], there is further accumulation of fluid within the right pleural space with compressive atelectasis. The upper right lung and the entire left lung are clear with no evidence of pulmonary vascular congestion . BCX-negative . labs: [**2136-12-26**] 08:30AM BLOOD WBC-8.0 RBC-3.25* Hgb-8.9* Hct-28.0* MCV-86 MCH-27.4 MCHC-31.9 RDW-18.0* Plt Ct-361 [**2136-12-25**] 04:20AM BLOOD WBC-7.1 RBC-3.17* Hgb-8.6* Hct-27.2* MCV-86 MCH-27.2 MCHC-31.8 RDW-17.7* Plt Ct-352 [**2136-12-24**] 06:33AM BLOOD WBC-5.3 RBC-3.07* Hgb-8.3* Hct-26.7* MCV-87 MCH-27.0 MCHC-31.0 RDW-17.8* Plt Ct-336 [**2136-12-23**] 07:15AM BLOOD WBC-6.4 RBC-2.63* Hgb-7.0* Hct-23.6* MCV-90 MCH-26.8* MCHC-29.9* RDW-17.0* Plt Ct-340 [**2136-12-22**] 12:50PM BLOOD WBC-7.2 RBC-2.80* Hgb-7.7* Hct-25.1* MCV-90 MCH-27.4 MCHC-30.6* RDW-17.1* Plt Ct-379 [**2136-12-22**] 07:00AM BLOOD WBC-6.9 RBC-2.68* Hgb-7.4* Hct-24.1* MCV-90 MCH-27.8 MCHC-30.9* RDW-17.0* Plt Ct-339 [**2136-12-21**] 03:43PM BLOOD WBC-6.5 RBC-2.81* Hgb-7.8* Hct-25.4* MCV-91 MCH-27.7 MCHC-30.6* RDW-17.1* Plt Ct-368 [**2136-12-21**] 03:02AM BLOOD WBC-8.6 RBC-2.81* Hgb-7.8* Hct-25.7* MCV-91 MCH-27.9 MCHC-30.5* RDW-17.4* Plt Ct-328 [**2136-12-20**] 05:08AM BLOOD WBC-7.6 RBC-2.93* Hgb-8.1* Hct-26.3* MCV-90 MCH-27.6 MCHC-30.7* RDW-17.2* Plt Ct-367 [**2136-12-19**] 07:46PM BLOOD WBC-5.7 RBC-3.22* Hgb-9.0* Hct-29.7* MCV-92 MCH-28.1 MCHC-30.4* RDW-17.4* Plt Ct-387 [**2136-12-20**] 05:08AM BLOOD Neuts-86* Bands-0 Lymphs-4* Monos-10 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 [**2136-12-19**] 07:46PM BLOOD Neuts-82* Bands-0 Lymphs-7* Monos-10 Eos-1 Baso-0 Atyps-0 Metas-0 Myelos-0 [**2136-12-20**] 05:08AM BLOOD Hypochr-1+ Anisocy-1+ Poiklo-1+ Macrocy-1+ Microcy-OCCASIONAL Polychr-OCCASIONAL Ovalocy-1+ Fragmen-OCCASIONAL [**2136-12-19**] 07:46PM BLOOD Hypochr-OCCASIONAL Anisocy-1+ Poiklo-NORMAL Macrocy-1+ Microcy-NORMAL Polychr-OCCASIONAL [**2136-12-22**] 07:00AM BLOOD PT-13.8* PTT-26.6 INR(PT)-1.3* [**2136-12-26**] 08:30AM BLOOD Glucose-170* UreaN-23* Creat-1.1 Na-138 K-3.6 Cl-103 HCO3-29 AnGap-10 [**2136-12-25**] 04:20AM BLOOD Glucose-94 UreaN-32* Creat-1.0 Na-139 K-3.7 Cl-104 HCO3-27 AnGap-12 [**2136-12-24**] 06:33AM BLOOD Glucose-91 UreaN-39* Creat-1.2* Na-138 K-3.7 Cl-103 HCO3-30 AnGap-9 [**2136-12-23**] 07:15AM BLOOD Glucose-109* UreaN-47* Creat-1.3* Na-140 K-4.1 Cl-105 HCO3-29 AnGap-10 [**2136-12-22**] 07:00AM BLOOD Glucose-149* UreaN-58* Creat-1.6* Na-139 K-4.0 Cl-104 HCO3-28 AnGap-11 [**2136-12-21**] 03:43PM BLOOD Glucose-187* UreaN-60* Creat-1.7* Na-139 K-4.4 Cl-103 HCO3-27 AnGap-13 [**2136-12-21**] 03:02AM BLOOD Glucose-151* UreaN-62* Creat-1.8* Na-138 K-4.1 Cl-102 HCO3-26 AnGap-14 [**2136-12-20**] 05:08AM BLOOD Glucose-146* UreaN-63* Creat-1.7* Na-139 K-4.8 Cl-102 HCO3-28 AnGap-14 [**2136-12-19**] 07:46PM BLOOD Glucose-108* UreaN-62* Creat-1.6* Na-141 K-4.6 Cl-103 HCO3-29 AnGap-14 [**2136-12-21**] 03:02AM BLOOD CK(CPK)-37 [**2136-12-20**] 03:52PM BLOOD CK(CPK)-24* [**2136-12-20**] 05:08AM BLOOD CK(CPK)-27* [**2136-12-19**] 07:46PM BLOOD CK(CPK)-31 [**2136-12-21**] 03:02AM BLOOD CK-MB-2 cTropnT-0.02* [**2136-12-20**] 03:52PM BLOOD CK-MB-2 cTropnT-0.02* [**2136-12-20**] 05:08AM BLOOD CK-MB-3 cTropnT-0.02* proBNP-4777* [**2136-12-19**] 07:46PM BLOOD CK-MB-3 cTropnT-<0.01 [**2136-12-26**] 08:30AM BLOOD Calcium-8.4 Phos-1.8* Mg-1.7 [**2136-12-22**] 07:00AM BLOOD Calcium-8.4 Phos-3.2 Mg-2.8* [**2136-12-21**] 03:02AM BLOOD Calcium-8.3* Phos-4.3 Mg-2.8* [**2136-12-20**] 05:08AM BLOOD Calcium-8.6 Phos-5.4* Mg-3.1* [**2136-12-19**] 07:46PM BLOOD Calcium-9.3 Phos-5.4* Mg-3.1* [**2136-12-21**] 03:43PM BLOOD TSH-3.9 [**2136-12-20**] 05:34AM BLOOD Lactate-1.5 [**2136-12-20**] 12:49AM BLOOD Lactate-3.0* [**2136-12-20**] 12:49AM BLOOD Type-ART pO2-82* pCO2-43 pH-7.36 calTCO2-25 Base XS--1 Brief Hospital Course: 81 y/o female with a history of chronic diastolic CHF (EF 50-65% in [**2133**]), atrial fibrillation, not on Coumadin, and chronic blood loss anemia from gasric antral vascular ectasias admitted with hypoxemia following endoscopic banding of her gastric AVMs. #Hypoxemia/Acute vs. chronic pulmonary embolism/Chronic diastolic heart failure with secondary pulmonary hypertension: Etiology of acute onset worsening hypoxemia on admission was initially not obvious. Physical exam was consistent with volume overload but exam was complicated by tricuspid regurgitation and v-waves to the jaw. Aspiration was considered but absence of significant lung pathology on exam or chest X-ray made this less likely. A V/Q scan was performed and was read as having high probability for PE in the right upper lobe. Additionally, an echocardiogram was notable for preserved EF, but with mod-severe mitral regurgitation, right ventricular dilatation and reduced systolic function with severe tricuspid regurgitation and the presence of a PFO (No valsalva or agitated saline contrast maneuvers were performed). These echo findings were similar to echo in [**2130**]. . Given her multiple contraindications for anticoagulation, including history of requiring blood transfusions every 10 days for her gastric AVMs transfusion dependance and recurrent GI bleeds, anticoagulation was not pursued. Additionally, bilateral lower extremity ultrasounds were negative for DVT, so an IVC filter was not placed. Despite lack of intervention, the patient improved slowly with reduced oxygen requirement with re-initiation of diuretic regimen. The risks and benefits of anticoagulation and the current clinical dilemma were discussed with the patient and the patient's PCP [**Last Name (NamePattern4) **] [**2136-12-25**] and pt's son [**Name (NI) **] [**Name (NI) 75806**] on [**2136-12-25**]. In addition, pt was given 1 unit of PRBCs during admission. However, should the patient get to a place where she may only require monthly transfusion or should she develop chest pain, hypotension, tachycardia, increasing hypoxia, etc, the risk/benefit ratio of anticoagulation for PE may change to favor anticoagulation. In addition, the patient also did not show signs of a hemodynamically significant PE. She did have periods of relative hypotension during times of afib with RVR. Pt carries a diagnosis of afib prior to admission and her BP was improved predictably with better HR control. In addition, there was question of the acute vs. chronic PE. The echo findings appear to be present in [**2130**] and could be explained by her valvular disease. Pt had sats of ~94-96% on RA, ambulatory sats 92-93% on RA. However, pt did experience occasional noctural hypoxia to 84% on RA and was therefore sent home with home oxygen at 1-2L nightly for now. Troponins 0.02 x3, BNP ~4000 during admission. Oxygenation much improved during admission. VNA can also help with monitoring for hypoxia. Pt has a scheduled appointment with her cardiologist and PCP after DC to continue this discussion. Can discuss whether patient may benefit from an IVC filter in the future. # Atrial Fibrillation: Not on coumadin or aspirin due to chronic GI bleeding. The patient is on rate control with atenolol at home (25mg TID?). She was restarted on metoprolol given her renal failure and CKD and this was uptitrated to 25mg TID by day of discharge. Pt tolerated this well and seemed to have better BP's with appropriate rate control. BP range 90's-110's during admission. She did have periods of afib with RVR prior to uptitration of meds. She was discharged with VNA for cardiopulmonary monitoring. . #Chronic blood loss anemia/Gastric Antral Vascular Ectasia [GAVE] s/p banding on the day of admission: She requires transfusion ~every 2 weeks at the present time. Work up to date has included multiple EGDs with argon plasma coagulation which has been unsuccessful thus far and therefore patient had scheduled EGD on admission for banding. The patient did have drop in her hematocrit during her admission and was transfused 1 unit PRBCs. A repeat EGD with banding was recommended in 1 month follow-up with GI. HCT on discharge was 28. She was instructed to have repeat HCT at PCP follow up. . #Chronic diastolic heart failure: continued outpt regimen of lasix, BB . # LE edema: She reports chronic worsening bilateral LE edema over the last 5-6 weeks. LENIs were negative for PE. Pt was continued on lasix therapy . #Hypertension: Home anti-hypertensives were initially held upon admission and then restarted. She was discharged on metoprolol 25mg TID . # Hyperlipidemia: She was continued on home simvastatin. . # Type 2 Diabetes Mellitus: Home oral medications including glipizide were held on admission. She was treated with an insulin sliding scale. She was instructed to resume glipizide upon discharge. . # Hypothyroidism: She was continued on levothyroxine. . #Acute-on-Chronic renal failure, stage II-III: Her renal function on admission was 1.6 and rose to 1.8, but improved during admission. Cr on discharge was 1.1. Pt should also have repeat Cr at PCP f/u to ensure continued improvement. . TRANSITIONAL ISSUES: Code: DNR/I Follow-up: Repeat EGD and banding with GI in 1 month Should have PCP and Cardiology follow up given chronic diastolic heart failure, pulmonary hypertension and now PE with minimal therapeutic options. Should discuss whether there may be benefit to IVC filter in the future. Medications on Admission: From MICU admit note: Simvastatin 10mg qhs Levothyroxine 112mcg daily Glipizide 5mg daily MVI 1 tab daily Loratadine 10mg daily Iron 160mg slow realease PO BID Omperazole 20mg PO BID Ascorbic Acid 250mg PO BID Atenolol 25mg PO TID Furosemide 40mg PO daily Discharge Medications: 1. simvastatin 10 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 2. levothyroxine 112 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. multivitamin Tablet Sig: One (1) Tablet PO once a day. 4. loratadine 10 mg Tablet Sig: One (1) Tablet PO once a day. 5. iron 160 mg (50 mg iron) Tablet Extended Release Sig: One (1) Tablet Extended Release PO twice a day. 6. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO twice a day. 7. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. dm glipizide 5mg daily 9. ascorbic acid 250 mg Tablet Sig: One (1) Tablet PO twice a day. 10. home oxygen therapy 2 liters continuous oxygen therapy at night. DX: pulmonary embolism, pulmonary hypertension saturation 84% on RA at night 11. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:*90 Tablet(s)* Refills:*1* Discharge Disposition: Home With Service Facility: Steward VNA Discharge Diagnosis: GI bleed secondary to GAVE Probable pulmonary embolism Chronic diastolic heart failure atrial fibrilliation with RVR . chronic -diabetes -CKD -hypothyroidism Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were initially admitted to the hospital after an elective endoscopic banding procedure for the abnormal blood vessels in your stomach causing gastrointestinal bleeding and chronic anemia. After the procedure, you were noted to have low blood pressure and low oxygen levels, due most likely to a combination of an aspiration event(inhaling some of your mouth secretions) and also to a blood clot (pulmonary embolism) in the lungs. However, after discussion with the GI specialists, given the risk of bleeding, especially in the GI tract, we have decided not to put you on blood thinning medication for the lung clot. You initially required a significant amount of oxygen, however, your oxygen levels improved and you will only need oxygen at night time for now. You will be continuing this discussion with your PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] and cardiologist Dr. [**Last Name (STitle) **] after discharge. . Also, your kidney function was slightly impaired during admission. This improved, but should be followed up after discharge. . Medication changes: 1.your atenolol was changed to metoprolol given your kidney function. Your discharge dose will be 25mg of metoprolol three times a day. Stop taking atenolol. Followup Instructions: Name: [**Last Name (LF) **],[**First Name3 (LF) 177**] A./ PCP [**Name Initial (PRE) **]: [**Street Address(2) 75807**], [**Location (un) **],[**Numeric Identifier 8538**] Phone: [**Telephone/Fax (1) 61040**] When: [**Last Name (LF) 766**], [**2136-1-1**]:00 AM Name: [**Last Name (LF) **], [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD/ CARDIOLOGY Address: [**Street Address(2) 75807**],STE 2C, [**Location (un) **],[**Numeric Identifier 23881**] Phone: [**Telephone/Fax (1) 44655**] When: [**Last Name (LF) 766**], [**2137-1-14**]:00 PM Name: [**Last Name (LF) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] Location: S. W. GASTROENTEROLOGICAL ASSOCIATES Address: 886 [**State **] [**Last Name (LF) **], [**First Name3 (LF) **],[**Numeric Identifier 23881**] Phone: [**Telephone/Fax (1) 25843**] *It is recommended that you see Dr. [**Last Name (STitle) 1437**] within 2 weeks. His office staff will contact you to schedule an appointment.

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Discharge summary

report

Admission Date: [**2138-3-24**] Discharge Date: [**2138-3-30**] Date of Birth: [**2077-12-30**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 4232**] Chief Complaint: leg pain Major Surgical or Invasive Procedure: none History of Present Illness: Mr. [**Known lastname 44065**] is a 60 year old man with a history of cerebral palsy, atrial flutter, PE not on anticoagulation, urinary incontinence, and recurrent LE cellulitis who presents with symptoms of bilateral LE infection. Pt reports that his legs started to appear "infected" three days ago, though he cannot describe any specific changes from baseline. He did not visit his PCP but instead came to the ED last night at 6pm. He denies fevers/chills/sweats but does report nausea and decreased PO intake yesterday. Otherwise, health has been at baseline, which for the patient includes episodic self-resolving dyspnea at rest, non-productive cough, urinary incontinence w/o dysuria, alternating constipation and diarrhea, chronic low back pain (unchanged). No headache, chest pain, abdominal pain. Appetite unchanged until yesterday. Last BM yesterday. No diarrhea this week. No recent abx use or bladder instrumentation. Did not take Lasix on day of admission, otherwise has been taking it [**Hospital1 **] as prescribed. . In the ED, initial vital signs were: T 97.7 P80 BP109/84 R18 O2sat 96% RA. Patient was given 2LNS, 4mg IV Morphine for chronic low back pain, 1g Cefazolin, & was noted to develop an SVT to the 230's requiring Adenosine 12mg x 2 and 2 doses of Diltiazem. An EKG in the ED demonstrated atrial flutter with 2:1 AV block. At the time of tranfer, the patient's vital signs were: P102 BP135/74 R14 O2Sat94% 2LNC on a diltiazem gtt. . In the ICU: pt remained hemodynamically stable. We maintained him on his dilt drip and gave a 1L NS bolus. . Review of sytems: (+) Per HPI. Also endorses occasional PND. +Weight gain since becoming wheel-chair bound in [**2130**]. (-) Per HPI Past Medical History: Cerebral palsy History of Bilateral PEs ([**12/2134**]) not on anti-coagulation Aflutter Moderate Pulmonary hypertension, 2+ TR on TTE h/o recurrent MRSA cellulitis Incontinence Cervical spondylosis Chronic back pain Obesity Hyperlipidemia Chronic venous insufficiency Depression Open heart surgery at age 12, unknown type of repair (patent foramen ovale or ventricular septal defect?) Social History: The patient lives alone in [**Location (un) 44064**]. He has a personal care assistant, PT, and VNA to assist him. Had prior admission for abuse from previous caregiver, he reports being currently well-cared for. Uses cane and electric wheel chair to ambulate. Tobacco: Smoked 1ppd x 10yrs, quit [**2128**] EOTH: Social alcohol use Illicts: None Family History: Mother: Died at 48 from brain tumor Sister died at 42 from breast cancer Physical Exam: Vitals: T:99.4 BP:103/71 P:103 R:30 O2:96% on RA . General: Alert, oriented, mildly tachypneic but in no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: Supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: Soft, non-tender, obesely distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: +Foley Ext: Bilateral LE erythema, spreading to thighs on R, with edema, induration, warmth, and scabbing; no open wounds; R DP palpable; all distal pulses present by Doppler Neuro: L-sided hemiparesis; L fist clenched at baseline Pertinent Results: WBC 23.4 Hgb 15.4 Hct 45.9 PLT 335 84N 5B 1L 10M Lactate 3.1 Chem 7: 138 94 20 156 3.7 26 1.0 U/A: Blood Nitrite Protein Glucose Ketone Bilirub Urobiln pH Leuks MOD POS 25 NEG NEG NEG NEG 5.0 SM RBC WBC Bacteri Yeast Epi RenalEp [**6-12**] [**11-22**] MOD NONE 0-2 0-2 Images: Abd/Pelvic CT [**3-25**] - Preliminary Report: No hydronephrosis or hydroureter. Right and probable left nonobstructive renal calculi measuring up to 1 cm on the right side. Bilateral renal tiny hypodensities, statistically represent cysts. Distended rectum containing stool. Mildly distended gallbladder, otherwise unremarkable on CT. In case of clinical concern for acute cholecystitis, an ultrasound can be obtained. Bilateral LE Veins [**3-25**] - IMPRESSION: Severely limited study due to [**Hospital 228**] medical condition and severe pain and lack of cooperation due to severe pain. A repeat study can be obtained when patient is able to tolerate this study. No definite deep venous thrombosis within the common femoral veins. This exam is also limited due to patient's subcutaneous edema. . EKG: AFL with 2:1 block; normal axis; no LVH; diffuse ST-segment depressions across precordial leads compared with prior AFL EKG from [**9-11**]. Labs on discharge: [**2138-3-30**] 05:35AM BLOOD WBC-7.3 RBC-5.67 Hgb-14.9 Hct-45.6 MCV-80* MCH-26.3* MCHC-32.7 RDW-14.6 Plt Ct-301 [**2138-3-30**] 05:35AM BLOOD Glucose-109* UreaN-17 Creat-0.9 Na-137 K-4.3 Cl-101 HCO3-26 AnGap-14 [**2138-3-30**] 05:35AM BLOOD Calcium-9.1 Phos-3.4 Mg-2.4 [**2138-3-29**] 05:50AM BLOOD TSH-11* [**2138-3-24**] 07:40AM BLOOD %HbA1c-6.7* eAG-146* Brief Hospital Course: 60 year old man with h/o cerebral palsy, atrial flutter, chronic venous stasis, bilateral PE, and recurrent MRSA cellulitis, presenting with LE cellulits, possible UTI and SVT. He was started on a diltiazem drip for aflutter. In the ICU his metoprolol was uptitrated which controlled his heart rate reasonably well. He was also transitioned oral antibiotics for celulitis and UTI (Bactrim and Cipro). At the time of dishcarge to the floor he was still in aflutter, HR ~ 100. On the floor he was continued on Bactrim, Ciprofloxacin was discontinued given questionable diagnosis of UTI (lack of symptoms) and given Bactrim is typically sufficient treatment of UTI. Diuresis was also resumed for treatment of his lower extremity edema. Prior to his discharge as his infection was improving patient triggered for delirium. It lasted for one day. The following morning delirium had resolved but he was kept overnight for observation. He was discharged at baseline mental status to complete a 14 day course of antibiotics. To F/U by PCP: -recheck thyroid levels, levothyroxine increased -consider ablation for aflutter Medications on Admission: (confirmed with PCP) Baclofen 20mg PO TID Lovastatin 40mg tid Zoloft 200mg qhs Lasix 40mg [**Hospital1 **] Lopressor 100mg [**Hospital1 **] Klonopin 1 mg qhs Viagra 50mg prn Levothyroxine 50mcg daily Discharge Medications: 1. Baclofen 20 mg Tablet Sig: One (1) Tablet PO three times a day. 2. Lovastatin 40 mg Tablet Sig: One (1) Tablet PO once a day. 3. Sertraline 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 4. Furosemide 20 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). 5. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 6. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day. 7. Sulfamethoxazole-Trimethoprim 800-160 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*18 Tablet(s)* Refills:*0* 8. Ammonium Lactate 12 % Lotion Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day). Disp:*1 tube* Refills:*0* 9. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical TID (3 times a day) as needed for pruritus. Disp:*1 tube* Refills:*0* 10. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). Disp:*10 Tablet(s)* Refills:*0* 11. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: Uphams Corner Home Care Discharge Diagnosis: primary: cellulitis urinary tract infection atrial flutter Discharge Condition: Stable, alert, oriented, heart rate well controlled Discharge Instructions: Dear Mr. [**Known lastname 44065**] - It was a pleasure to care for you during your hospitalizaiton. You were admitted for a skin infection of your lower legs. You were also found to have a urinary tract infection. And your heart rate was very fast. You were admitted to the ICU to treat your fast heart rate. When it was controlled with medications you were transferred to the floor where your medications were adjusted, you were treated with antibiotics, and evaluated by physical therapy. You home services, including twice daily visits with your home aide, will continue. Medications changed during this hospitalization: Increase Lasix to 60 mg twice daily Increase Lopressor (metoprolol) to 100 mg three times a day Increase levothyroxine to 75 daily Please take bactrim DS twice daily for 9 days after discharge Please take ciprofloxacin 500 mg every 12 hrs for 5 more days after discharge You were started on Aspirin 81 mg every day Lactic acid cream and Sarna cream can be used for itch as needed There are no other changes to your medications. Please continue to take the rest of your home medications as directed. Followup Instructions: Appointment #1 MD: Dr. [**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) 2392**] Specialty: Internal Medicine-Primary Care Date/ Time: [**2138-4-3**] 10:00am Location: [**Street Address(2) 6421**], [**Location (un) 86**] MA Phone number: [**Telephone/Fax (1) 5723**] [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(1) 4236**] Completed by:[**2138-4-2**]

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icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

7730, 7784

5336, 6462

325, 332

7887, 7941

3667, 4934

9120, 9526

2856, 2930

6712, 7707

7805, 7866

6488, 6689

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2945, 3648

277, 287

4953, 5313

1950, 2068

360, 1932

2090, 2477

2493, 2840

3,425

158,813

13832

Discharge summary

report

Admission Date: [**2143-12-25**] Discharge Date: [**2144-1-6**] Date of Birth: [**2094-5-22**] Sex: M Service: SURGERY Allergies: Morphine Sulfate / Adhesive Tape Attending:[**First Name3 (LF) 974**] Chief Complaint: Enterocutaneous fistula Major Surgical or Invasive Procedure: 1. Resection of ileoanal pouch and enterocutaneous fistula. 2. Segmental small bowel resection. 3. Take down and reconstruction end-ileostomy. 4. Extensive enterolysis, approximately four hours. 5. Cystoscopy and insertion of ureteral stents (per urology). History of Present Illness: This 49-year-old male with longstanding Crohn's disease is well-known to me as I had taken care of him for several years ago because of a chronic pouchitis. He originally had an ileoanal pouch because he was diagnosed as ulcerative colitis. However, this was a misdiagnosis and, in fact, the patient has regional enteritis. He has had multiple problems with this. He transferred his care to Dr. [**Last Name (STitle) **] in [**2136**] and has had multiple dilatations, most recently requiring a diversion away from the pouch. After Dr.[**Name (NI) 37605**] retirement, the patient developed a fistula from the distal segment and pouch into the abdominal wall and was hospitalized for several days with a rather severe cellulitis. Although he had previously refused removal of the pouch at this point-in-time having lived with his end-ileostomy which he had been given in a previous operation by Dr. [**Last Name (STitle) **], he has elected at this point-in-time removal of this bowel and resection of the fistula was appropriate. Because he has had previous problems with malnutrition and immunosuppression, it was elected to admit him in the preoperative setting for evaluation of his wound management postoperatively as well as evaluation by enterostomal therapy and additionally consultation with colorectal surgery as planned surgical intervention which is to occur, is to be coordinated with Dr. [**Last Name (STitle) 1120**]. The patient was to have a CT scan to characterize any changes in the abdominal cavity pending this resection. Nutritional status is also to be evaluated. Additionally, he was seen at this point-in-time by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 572**], who actually feels he is a very confident in and, therefore, Dr. [**First Name (STitle) 572**] will be additionally advised of this admission and asked to participate in care as appropriate. Past Medical History: *PE *IVC filter *Severe Crohn's disease *s/p proctocolectomy and ileoanal pouch formation [**2125**] *Exploratory laparotomy and lysis of adhesions [**2137**]. *Recurrent small bowel and pouch strictures requiring dilitations. Colonoscopy and balloon dilation (last [**2-8**], [**4-9**] and [**5-10**]) *SB resection, end ileostomy [**2142-10-2**] *Gout *Depression *Anxiety Social History: Lives at home with family; they are very involved and supportive. Pt has a remote 10 pack-year smoking history, but quit approximately twenty-five yrs ago. Occasional ETOH. Denies illicit drugs. Family History: No family history of inflammatory bowel disease or colon cancer. Positive for diabetes and coronary artery disease. Physical Exam: Today on admission to the medical center, his blood pressure was good at 120/80. His heart rate was 80 and his temperature was normal. The nursing admitting records also recognize a pulse oximetry at 99% on room air. On physical examination, he was generally alert and oriented, comfortable. He was somewhat obese. His lungs were clear to auscultation and percussion. Heart sounds were crisp and he had a regular rhythm. Additionally, he had good inflow into both his upper and lower extremities with palpable pedal pulses. His abdomen was soft. He the fistula noted on the right hemi-abdomen. The stoma was well-situated in the upper abdomen and actually was quite robust almost as though prolapsed but really this had not changed over several months. There was minimal, if any, peristomal herniation. Consideration of re-siting the stoma remained a concern if the adhesive disease was as bad as had been reported. Therefore, although we will mark the abdomen for re-siting, this may not occur. The abdominal wall had no current marked erythema or induration indicating any cellulitis. His extremities were without cyanosis, clubbing or edema and his skin was generally unremarkable. The patient overall was quite cheerful and was anticipating this next procedure in an effort to control this fistula which had been very problem[**Name (NI) 115**] as far as recurrent infections and drainage which had also been impacting his work. Pertinent Results: [**2143-12-25**] 03:30PM BLOOD WBC-7.1 RBC-5.57 Hgb-15.3 Hct-46.5 MCV-84 MCH-27.5 MCHC-32.9 RDW-16.3* Plt Ct-311 [**2143-12-25**] 03:30PM BLOOD Neuts-76.0* Lymphs-12.7* Monos-5.1 Eos-5.2* Baso-0.9 [**2143-12-25**] 03:30PM BLOOD PT-20.1* PTT-32.3 INR(PT)-1.9* [**2143-12-25**] 03:30PM BLOOD Glucose-95 UreaN-23* Creat-1.7* Na-136 K-3.7 Cl-102 HCO3-20* AnGap-18 [**2143-12-25**] 03:30PM BLOOD ALT-39 AST-29 LD(LDH)-162 AlkPhos-128* TotBili-0.3 [**2143-12-25**] 03:30PM BLOOD Albumin-4.5 Calcium-9.3 Phos-2.7 Mg-1.9 [**2143-12-27**] 05:42PM BLOOD WBC-14.5*# RBC-3.14*# Hgb-9.0*# Hct-26.0*# MCV-83 MCH-28.5 MCHC-34.4 RDW-16.3* Plt Ct-298 [**2143-12-28**] 02:50AM BLOOD WBC-9.6 RBC-2.60* Hgb-7.5* Hct-21.4* MCV-82 MCH-28.9 MCHC-35.1* RDW-16.8* Plt Ct-256 [**2143-12-28**] 12:30PM BLOOD Hct-25.6* [**2143-12-28**] 11:18PM BLOOD Hct-22.4* [**2143-12-29**] 05:13AM BLOOD WBC-9.5 RBC-2.89* Hgb-8.6* Hct-24.8* MCV-86 MCH-29.7 MCHC-34.6 RDW-16.2* Plt Ct-220 [**2143-12-30**] 06:50AM BLOOD WBC-9.7 RBC-2.69* Hgb-8.0* Hct-23.5* MCV-88 MCH-29.8 MCHC-34.1 RDW-16.5* Plt Ct-261 [**2143-12-31**] 05:10AM BLOOD WBC-9.8 RBC-2.72* Hgb-8.1* Hct-23.6* MCV-87 MCH-29.9 MCHC-34.5 RDW-16.9* Plt Ct-313 [**2144-1-1**] 05:06AM BLOOD WBC-7.7 RBC-2.62* Hgb-7.8* Hct-22.8* MCV-87 MCH-29.9 MCHC-34.3 RDW-16.7* Plt Ct-303 [**2144-1-2**] 04:32AM BLOOD WBC-10.4 RBC-2.73* Hgb-8.3* Hct-24.1* MCV-89 MCH-30.4 MCHC-34.4 RDW-16.5* Plt Ct-290 [**2143-12-27**] 04:29AM BLOOD PT-14.9* PTT-29.0 INR(PT)-1.3* [**2143-12-27**] 05:42PM BLOOD PT-16.0* PTT-26.5 INR(PT)-1.4* [**2143-12-28**] 02:50AM BLOOD PT-14.0* PTT-28.0 INR(PT)-1.2* [**2143-12-27**] 11:06AM BLOOD Glucose-122* Lactate-3.9* Na-132* K-5.2 Cl-104 [**2143-12-27**] 12:53PM BLOOD Glucose-113* Lactate-4.0* Na-133* K-5.4* Cl-109 [**2143-12-27**] 02:01PM BLOOD Glucose-143* Lactate-4.9* Na-133* K-5.7* Cl-106 [**2143-12-27**] 03:05PM BLOOD Glucose-111* Lactate-4.7* Na-137 K-4.8 Cl-108 [**2143-12-27**] 05:49PM BLOOD Lactate-3.8* [**2143-12-27**] 10:44PM BLOOD Lactate-2.8* K-4.9 [**2143-12-28**] 08:43AM BLOOD Glucose-136* Lactate-2.0 K-4.5 [**2143-12-28**] 03:05PM BLOOD Lactate-1.1 [**2143-12-30**] 02:47PM URINE Blood-LG Nitrite-NEG Protein-500 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-TR [**2143-12-30**] 02:47PM URINE RBC->50 WBC-0-2 Bacteri-FEW Yeast-NONE Epi-0-2 . Radiographic Studies: Microbiology: [**2143-12-27**] 8:50 am ABSCESS Site: ABDOMEN #1. **FINAL REPORT [**2144-1-2**]** GRAM STAIN (Final [**2143-12-27**]): 2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. WOUND CULTURE (Final [**2143-12-30**]): NO GROWTH. ANAEROBIC CULTURE (Final [**2144-1-2**]): NO GROWTH. [**2143-12-27**] 8:43 pm MRSA SCREEN Source: Nasal swab. **FINAL REPORT [**2143-12-29**]** MRSA SCREEN (Final [**2143-12-29**]): POSITIVE FOR METHICILLIN RESISTANT STAPH AUREUS. Brief Hospital Course: The patient was admitted to the hospital and his pain was controlled and he was kept NPO for 3days. He had his surgery and did well post-operatively, spending the first 3 days in the ICU because of the length of the surgery performed. On POD#3 Mr [**Known lastname 41454**] was stable enough to be transferred to the floor. While on the floor he was found to have a bladder rupture and was seen by urology who recommended treating the patient with ciprofloxacin, to have the patient keep the foley in for continual bladder decompression, and to give oxybutinin. Mr [**Known lastname 41454**] was given a "leg bag" for convenient urine collection while at home and taught how to use it. He also had a VAC dressing applied to his semi-closed abdominal wound and had home-VNA set up for dressing changes and for INR draws. Medications on Admission: coumadin 2 5x/ 4 2x per week, allopurinol 300, lipram 4500?, paroxetine, promethazine, protonix 40, ambien; VitC 1000 Discharge Medications: 1. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation Q6H (every 6 hours) as needed. 2. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 2 weeks. Disp:*28 Tablet(s)* Refills:*0* 3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 4. Paroxetine HCl 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 5. Allopurinol 100 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily). 6. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO every four (4) hours as needed for pain for 2 weeks. Disp:*60 Tablet(s)* Refills:*0* 7. Oxybutynin Chloride 5 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 1 months. Disp:*90 Tablet(s)* Refills:*0* 8. Prednisone 5 mg Tablet Sig: One (1) Tablet PO once a day for 4 days: after 4 days, take [**12-6**] tab per day for 4 days. Disp:*6 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: All Care VNA of Greater [**Location (un) **] Discharge Diagnosis: 1. Enterocutaneous fistula. 2. Abdominal abscess. 3. Chronic Crohn's disease. 4. Defunctionalized and inflamed ileoanal pouch. 5. Closed small bowel loop with a resultant abscess. 6. Bladder rupture Discharge Condition: Stable. Afebrile. Vital signs stable. Pain controlled. Discharge Instructions: Please eat a low residue diet and make sure to get up and out of bed as much as possible. Please use your incentive spirometer 10x an hour when you are awake. Take your antibiotics and other medicines as prescribed. We have shown you how to empty your catheter bag, please do so as needed. We have arranged for visiting nursing to help with your wound care. Avoid lifting objects > 5lbs until your follow-up appointment with the surgeon. Avoid driving or operating heavy machinery while taking pain medications. . 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, increased ostomy output 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 in your ostomy. * You have blood in your urine * Your pain is getting worse or is changing location or moving to your chest or back. * You have shaking chills, or a fever greater than 101.5 (F) degrees or 38(C) degrees. * You see pus draining from your wound or increasing redness around the wound. * Any serious change in your symptoms, or any new symptoms that concern you. * You experience new chest pain, pressure, squeezing or tightness. * New or worsening cough or wheezing. . Followup Instructions: Please follow up with Dr [**Last Name (STitle) 365**] in Urology in one week. Call ([**Telephone/Fax (1) 18591**] for an appointment. Please follow up with Dr [**Last Name (STitle) **] in one week as well. Call ([**Telephone/Fax (1) 4336**] for an appointment. Please follow up with Dr [**First Name (STitle) 572**] in one week as well. Call ([**Telephone/Fax (1) 26817**] for an appointment.

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icd9cm

[ [ [] ] ]

[ "38.93", "99.15", "45.62", "59.8", "46.41", "46.74", "88.14", "57.32", "99.04", "54.59" ]

icd9pcs

[ [ [] ] ]

9628, 9703

7719, 8543

315, 578

9946, 10002

4750, 7696

11443, 11841

3148, 3267

8712, 9605

9724, 9925

8569, 8689

10026, 11420

3282, 4731

252, 277

606, 2520

2542, 2919

2935, 3132

7,809

117,262

48892

Discharge summary

report

Admission Date: [**2136-8-20**] Discharge Date: [**2136-8-29**] Date of Birth: [**2078-12-5**] Sex: F Service: MEDICINE Allergies: Penicillins Attending:[**First Name3 (LF) 832**] Chief Complaint: Hyperglycemia / DKA Major Surgical or Invasive Procedure: central line placement (right internal jugular, [**8-20**]) History of Present Illness: 57 year old female with type 1 diabetes mellitus with multiple recents hospitalization and considerable complications of her disease, hypertension, and [**Doctor Last Name 933**] disease with 3 days of nausea, [**Doctor Last Name **] (~4 times a day), diarrhea, and epigastric pain ([**10-29**]). She reports that she has been taking her Lantus, but had not continued with her Humalog dosing. Most recent FSBGs for her were in the 300s-400s, but she did not inform any of her doctors about this. She has had markedly decreased PO intake over the past 3 days as well. She also acknowledges that her allergies have been a bit less controlled as of late. She initially stated that her loose stools were bright red in color, but then explained that she was not sure. When her vomitous started to become darker, she was finally worried enough to come to the hospital. Upon transfer to [**Hospital1 18**] [**Last Name (LF) **], [**First Name3 (LF) **] EMS report, emesis was black/brown. She was very drowsy, but responsive and arousable. She was actively complaining of epigastric pain to palpation, without rebound or guarding. She was most recently admitted on [**2136-6-16**], initially to the [**Hospital Unit Name 153**] on insulin gtt for DKA, likely precipitated by a recent URI or "toe-nail trauma" but was without fevers or signs of infection. She continued to have difficulty with glucose control throughout this admission, but was transferred to the floor once her DKA had resolved and discharged once glucose better controlled. [**Last Name (un) **] has been involved with her insulin regimen and she sees an endocrinologist regularly. Routine colonoscopy was also done during this admission and was normal. Of note, she has been admitted 3 other times this year with 2 episodes of DKA and 1 episode of hypoglycemia. Prior to that, she had not been admitted since [**2135-7-21**]. In the ED, initial VS were: 100.8 112 75/49 20 98%on 3L. She was initially triggered for AMS, hypotension, and nursing concern. She was started on an insulin gtt at 7 units/hr with a 10 units IV dose up front. She was given a total of 4g calcium gluconate for hyperkalemia and peaked T waves on EKG. A right IJ was placed and she was given 3L NS IVF, then switched to [**1-22**] NS with KCl. Broad antibiotic coverage with Vanc/Cipro/Flagyl was started. NG lavage showed greenish-brownish output and NG was left in place, followed by Foley placement. Hct stable at 38.4. U/A showed glucosuria and ketonuria. CT abd/pelvis was unremarkable. . In the ICU, she is quite tired and complaining of some abdominal pain. She is much less nauseated. Past Medical History: ---Type I DM: diagnosed at age 5, multiple hospitalizations for DKA and hyperglycemia. Complicated by retinopathy, severe peripheral neuropathy, and gastroparesis with marked constipation. --Had a stroke in setting of past episode of DKA w/foot drop --Diabetic polyneuropathy --Hypertension --Grave's disease, on MMI --Reactive airway disease --Seronegative arthritis, followed in rheumatology --Hepatitis C, genotype 1A, biopsy with grade 1 inflammation, no on antiviral therapy; acquired from a blood transfusion in [**2110**]. Had previous liver biopsy without significant fibrosis. Never been treated with antivirals. --GERD --Status post bilateral knee arthroscopies --Migraine headaches -Asthma -s/p TAH -Depression -Mouth surgery for removal of tumors Social History: Patient lives in an apt building. She has a son, daughter and another brother who live on another floor. She is a never smoker and does not use alcohol or drugs. She has not worked for many years. She uses a wheelchair at baseline. Family History: Mother died of colon cancer. There are multiple family members with DM. Physical Exam: Admission Physical Exam: Vitals: T: 96.6 BP: 143/64 P: 115 RR: 14 SpO2: 100% on 3L General: sleepy, but alert and oriented x3, no acute distress, mild abdominal pain [**Year (4 digits) 4459**]: [**Year (4 digits) 2994**], EOMI, sclera anicteric, dry MM, oropharynx could not be visualized; ?acanthosis nigricans around right eye with hyperpigmentation Neck: supple, JVP unable to assess due to CVL, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: Regular rate and rhythm, normal S1/S2, soft II/VII holosystolic murmur to carotids, no rubs or gallops Abdomen: soft, diffusely tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: foley in place with clear urine Rectal: guaiac neg Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Skin: no other hyperpigmented areas or evidence of breakdown Pertinent Results: Admission Labs: [**2136-8-20**] 06:30AM GLUCOSE-1192* UREA N-68* CREAT-3.0* SODIUM-126* POTASSIUM-6.6* CHLORIDE-78* TOTAL CO2-7* ANION GAP-48* [**2136-8-20**] 06:30AM ALT(SGPT)-28 AST(SGOT)-39 ALK PHOS-82 TOT BILI-0.4 [**2136-8-20**] 06:30AM LIPASE-95* [**2136-8-20**] 06:30AM ALBUMIN-3.8 CALCIUM-8.9 PHOSPHATE-9.5* MAGNESIUM-2.1 [**2136-8-20**] 06:30AM WBC-15.1* RBC-3.91* HGB-11.9* HCT-38.4 MCV-98 MCH-30.5 MCHC-31.0 RDW-13.7 [**2136-8-20**] 06:30AM NEUTS-89.3* LYMPHS-7.5* MONOS-2.9 EOS-0.2 BASOS-0.1 [**2136-8-20**] 06:30AM PT-12.9 PTT-29.4 INR(PT)-1.1 [**2136-8-20**] 06:47AM freeCa-0.94* [**2136-8-20**] 06:47AM HGB-11.4* calcHCT-34 [**2136-8-20**] 06:47AM PH-7.27* COMMENTS-GREEN TOP [**2136-8-20**] 06:47AM GLUCOSE-GREATER TH LACTATE-5.3* NA+-128* K+-6.4* CL--89* TCO2-8* . Microbiology: [**2136-8-24**] SEROLOGY/BLOOD RAPID PLASMA REAGIN TEST- Non-reactive [**2136-8-23**] BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT [**2136-8-23**] URINE URINE CULTURE-FINAL INPATIENT [**2136-8-23**] BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT [**2136-8-23**] BLOOD CULTURE NOT PROCESSED INPATIENT [**2136-8-20**] MRSA SCREEN MRSA SCREEN-FINAL INPATIENT [**2136-8-20**] BLOOD CULTURE Blood Culture, Routine-PENDING EMERGENCY [**Hospital1 **] [**2136-8-20**] URINE URINE CULTURE-FINAL EMERGENCY [**Hospital1 **] [**2136-8-20**] BLOOD CULTURE Blood Culture, Routine-PENDING EMERGENCY [**Hospital1 **] . EKG [**8-20**]-Sinus tachycardia. Intraventricular conduction delay. Slightly prolonged Q-T interval for rate. Consider electrolyte abnormalities/acidosis. Compared to the previous tracing T wave morphology and QRS width changes would suggest a metabolic derangement. Clinical correlation is advised. . CT IMPRESSION: 1. No acute intra-abdominal process. 2. Fatty liver. 3. Soft tissue gas in the groin bilaterally. Correlation with history of attempted line placement is recommended. 4. 7 mm left perirectal lymph node. Correlation with history is recommended and evaluation by colonoscopy can be performed if indicated. . CXR [**8-21**]-The NG tube tip is in the stomach. The right internal jugular line tip is at the cavoatrial junction. The heart size and mediastinal contours are unremarkable. Lungs are essentially clear. There is no pleural effusion or pneumothorax. . ECHO-Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF 65%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. The left ventricular inflow pattern suggests impaired relaxation. The estimated pulmonary artery systolic pressure is normal. There is a trivial/physiologic pericardial effusion. . [**8-23**]-CT-IMPRESSION: No acute intracranial hemorrhage or mass effect. A hypodense area in the left inferior frontal lobe can eb artifactual- followup/work up as clinically indicated. . [**8-23**] CT abd-pelvis-IMPRESSION: 1. No retroperitoneal bleed. 2. Stable 7-mm left perirectal lymph node and right perirectal calcification. 3. Hypodense lesion in the left kidney, incompletely evaluated, but likely simple cyst. . EEG-IMPRESSION: This is an abnormal portable EEG due to attenuation and slowing of the background consistent with a mild to moderate encephalopathy. The patient appeared to be drowsy or asleep for most of the record. NOTE: Multiple lead artifacts throughout the study obscured the underlying rhythm. No frank epileptiform discharges, areas of focal slowing or electrographic seizures were seen during this recording. . CTA chest-IMPRESSION: No pulmonary embolism or aortic dissection. . MR [**First Name (Titles) 430**] [**Last Name (Titles) 102671**]: No acute infarction or focus of hemorrhage. No abnormality noted in the left inferior frontal lobe corresponding to the lesion seen on prior CT Head, which probably was artifactual. Brief Hospital Course: 57 year old female with uncontrolled type 1 diabetes mellitus with multiple admission over the past year, now presenting with diabetic ketoacidosis in setting of poor PO intake and medication noncompliance. . Diabetic ketoacidosis: She is followed closely by [**Last Name (un) **], but her blood glucose has been extremely difficult to control as of late, with her last admission about 1.5 months ago for DKA. In the ED, her initial glucose was 1192 with an AG of 41. Insulin gtt and IVFs started with mild narrowing of her AG, improving lactate, and improving renal failure. Her respiratory alkalosis was initially not compensating fully for her severe acidosis, with pH of 7.27 on recent ABG. With better control of her ketoacidosis, her respiratory status improved. On the evening of [**8-20**], the insulin drip was stopped and she was restarted on both long- and short-acting SC insulin. [**Last Name (un) **] was contact[**Name (NI) **] to ensure their expertise was contibuting to her care both as an inpatient and on discharge. [**Last Name (un) **] recommended increasing her lantus from 18U to 24U and adjusted the sliding scale. Patient had a volume deficit of approximately 5L on arrival to the floor and was aggressively fluid resuscitated with D5W 1/2NS. On [**8-21**], her anion gap closed and glucose levels improved. On [**8-22**], glucose levels were in the high 100s and low 200s. [**Last Name (un) **] continued to follow the patient on the medical floor with daily titration of her regimen. Her regimen was titrated to lantus 24units in the evening, 75/25 13 units in the morning and a humalog sliding scale. In the 24 hours prior to discharge, her blood sugard was in the range of 180-280. . Unresponsiveness/metabolic encephalopathy-unclear etiology. Per report, pt found unresponsive at 1:30am on [**8-23**]. BP 86/40, HR 89 at the time, 12RR sat 97% on RA. ABG ok, FS 350, pt had not received any narcotics recently (last dose noon) she was given narcan without effect. Head CT neg, CT abd neg. CXR neg. Stox/utox ordered and returned positive for benzodiazepines which pt has not been receiving this admission. Pt prescribed valium as an outpt. Doubt seizure from [**Month/Day (4) **] withdrawal as pt with [**Month/Day (4) **] in tox screen and is not showing any other signs of withdrawal. Pt's room was searched and no substances were found. Labs showed slight Hct drop, but CT abdomen did not show acute findings. EKG did not show ischemia, and cardiac enzymes were negative. Overall, could have been from seizure vs. medication effect. EEG did showed encephalopathy. ECHO was normal. TFTs were normal. B12 normal. CTA chest did not show PE. ABG normal. RPR was nonreactive. MRI of the brain showed no acute abnormality. Her dose of gabapentin and opioids were decreased and slowly her mental status improved back to baseline. The patient was seen by psychiatry who felt that pt had cognitive impairments, delerium, and psychosocial pathology. She would benefit from outpatient neurology evaluation and neuro-cognitive testing. . Question of GI bleed. There was initial concern for GI bleeding with EMS reports of black emesis. However, NG lavage was performed and showed green-brown output, Guaiac negative. Rectal exam is Guaiac negative as well. Prior colonoscopy (given family history) was negative during previous admission. . Gastroparesis-Pt continued on reglan, antiemetics for symptoms. Pt was given judicious percocet as she stated that this helps her pain. See below, as she was advised that this could actually worsen her symptoms. . Chest pain. The patient complained of some chest pain. EKGs unchanged and serial enzymes negative. Echo normal. Unclear etiology if GI from gastritis/esophagitis due to [**Month/Day (4) **]/gastroparesis vs. MSK. CTA of chest does not show pulmonary cause. Stress in [**2131**] normal. Pt continued on PPI. Lipids were at goal. . Headache-pt reports [**10-29**] constant headache similar to prior to admission. Pt states due to "personal reasons". No neurologic symtoms or other red flags. Head CT negative, except showed a Left inferior frontal area hypodensity that could be artifact. MRI showed no acute process and confirmed that left inferior frontal hypodensity was an artifact on wet read. Her headaches improved over several days. . Prior diabetic complications: Previous poorly controlled t1DM has left her with polyneuropathy with foot drop, nephropathy, and autonomic dysfunction (gastroparesis), and retinopathy. Her gabapentin dose was changed given acute renal failure and episode of unresponsiveness . Acute kidney injury: Most likely secondary to hypovolemia from her volume-depleted ketoacidotic state. Aggressive IVF corrected her Cr to 1.1. Her medications were renally dosed, and her [**Last Name (un) **] was re-started at a reduced dose once Cr returned to baseline. . [**Doctor Last Name 933**] disease: Currently taking methimazole for therapy. TFTs were checked during admission and were found to be normal. . HTN and hypotension. The patient had wide fluctuation in blood pressures from HTN with SBP 180 to "asymptomatic hypotension" SPB 80's. Unclear etiology but likely due to autonomic neuropathy. She had a negative infectious work-up. Echo was normal. CTA neg for PE. Initially she had been on both [**First Name8 (NamePattern2) **] [**Last Name (un) **] and was started on a beta-blocker for sinus tachycardia. This beta-blocker was subsequently discontinued due to recurrent episodes of asymptomatic hypotension. Her blood pressure improved was in the range of 116-124 in the 18 hours prior to discharge. Pt should have an outpatient neurology consultation with an autonomic specialist. . Sinus tachycardia-likely due to volume depletion from recent DKA. Pt was given aggressive IVF and monitored closely for signs of infection and/or PE (not hypoxic and without pulmonary symptoms). CTA negative. She did have episodic persistent asymptomatic sinus tachycardia. . Chronic pain-continue oxycodone althougth this is not the best [**Doctor Last Name 360**] for gastroparesis or a patient with cognitive benefits. Advised pt that she should not take this medication or should take at low doses. She states that this med works very well to control her pain. For now she continues on it. . Depression/social situation- continued amitriptyline. SW consulted as pt appeared somewhat depressed and is frequently admitted. ?event [**8-23**] related? Pt reports anxiety and depression and this is likely contributing to pt's frequent admissions and difficulty managing chronic illness at home. Pt with social stressors-housing etc as well. Psychiatry consulted and does not feel that pt has major depression or anxiety. Believes that pt has cognitive impairment possible from chronic medical illness/repeat DKAs, slight encephalopathy (that will be c/b opioids and [**Month/Day (4) **] use in outpt setting-rec'd to decrease or stop) and difficult current psychosocial situation. Psychiatry talked to PCP who will be arranging for outpt psychiatric follow up and eval. Depression could be contibuting to reports of all over [**10-29**] pain. . Incidental radiographic findings: - CT abdomen-Stable 7-mm left perirectal lymph node and right perirectal calcification. Hypodense lesion in the left kidney, incompletely evaluated, but likely simple cyst. . Hypercholesterolemia: continued simvastatin . Seronegative arthritis: continued sulfasalazine . Asthma: continued fluticasone-salmeterol 250-50 [**Hospital1 **], with albuterol PRN. Medications on Admission: 1. amitriptyline 50 mg qhs 2. fluticasone-salmeterol 250-50 mcg [**Hospital1 **] 3. hyoscyamine sulfate 0.375 mg [**Hospital1 **] 4. losartan 50 mg daily 5. methimazole 10 mg TID 6. montelukast 10 mg daily 7. pantoprazole 40 mg daily 8. polyethylene glycol 3350 17 gram/dose daily 9. simvastatin 20 mg daily 10. sulfasalazine 1000 mg [**Hospital1 **] 11. prochlorperazine maleate 10 mg [**Hospital1 **] 12. docusate sodium 100 mg [**Hospital1 **] 13. gabapentin 900 mg TID 14. metoclopramide 10 mg QIDACHS 15. calcium carbonate 200 mg calcium (500 mg) TID 16. cholecalciferol (vitamin D3) 800 unit daily 17. ferrous sulfate 300 mg (60 mg iron) daily 18. oxycodone-acetaminophen 5-325 mg [**Hospital1 **] PRN pain 19. insulin glargine 18 units qAM, 24 units qPM 20. Humalog 2 - 10 Units TID per scale (up to 67 units a day, per sliding scale) Discharge Medications: 1. amitriptyline 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). Tablet(s) 2. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 3. methimazole 10 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 4. montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 6. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1) PO DAILY (Daily). 7. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 8. sulfasalazine 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 9. prochlorperazine maleate 10 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 10. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 11. gabapentin 300 mg Capsule Sig: One (1) Capsule PO twice a day. 12. metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QIDACHS (4 times a day (before meals and at bedtime)). 13. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable Sig: One (1) Tablet, Chewable PO three times a day. 14. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* 15. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 16. hyoscyamine sulfate 0.375 mg Tablet Extended Release 12 hr Sig: One (1) Tablet Extended Release 12 hr PO twice a day. 17. oxycodone-acetaminophen 5-325 mg Tablet Sig: One (1) Tablet PO twice a day as needed for pain. 18. losartan 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* 19. alcohol swabs Pads, Medicated Sig: One (1) Box Topical four times a day. Disp:*1 Box* Refills:*2* 20. lancets Misc Sig: One (1) Box Miscellaneous four times a day. Disp:*1 Box* Refills:*2* 21. Ultra Touch 2 Glucometer Test Strips Please dispense 1 box of test strips for QID fingerstick checks with the Ultra Touch 2 Glucometer. Refills: 2. 22. Lantus 100 unit/mL Solution Sig: Twenty Four (24) units Subcutaneous at bedtime. Disp:*1 month supply* Refills:*5* 23. Lantus Solostar 100 unit/mL (3 mL) Insulin Pen Sig: Twenty Four (24) units Subcutaneous at bedtime: Per patient request. To be used only when unable to use insulin vial/syringes. Disp:*1 month supply* Refills:*5* 24. Humalog Mix 75-25 100 unit/mL (75-25) Suspension Sig: Thirteen (13) units Subcutaneous once a day. Disp:*1 month supply* Refills:*5* 25. Humalog Mix 75-25 KwikPen 100 unit/mL (75-25) Insulin Pen Sig: Thirteen (13) unit Subcutaneous once a day: Per patient request. To be used only when unable to use insulin vial/syringes. Disp:*1 month supply* Refills:*5* 26. Humalog 100 unit/mL Solution Sig: Per sliding scale Subcutaneous four times a day. Disp:*10 ml* Refills:*5* 27. Humalog KwikPen 100 unit/mL Insulin Pen Sig: Per sliding scale Subcutaneous four times a day: Per patient request. To be used only when unable to use insulin vial/syringes. Disp:*10 ml* Refills:*5* 28. Syringe Please provide Fixed Needle Insulin Syringe 0.5mL 29gx1/2" for injection of insulin. Dispense: 1 month supply for 6 times daily administration. Refills: 5 Discharge Disposition: Home With Service Facility: Uphams Corner Home Care Discharge Diagnosis: Primary: Diabetic ketoacidosis DM I uncontrolled with complications autonomic neuropathy (tachycardia, hyper/hypotension) depression gastroparesis Seconday: Asthma Graves' disease Chronic pain Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You came into the hospital with another episode of DKA. It is very important that you continue to follow your insulin regimen at home even when you are not feeling well. Take all insulin as prescribed and follow-up at the [**Hospital **] clinic for ongoing care. Home nurses will continue to help you at home with insulin dosing. . You had an episode of unresponsiveness. It is possible that this episode was related to your medications. You should not take valium or percocet because this may cloud your ability to think. You should work with your PCP to decrease these doses or change to different medications for pain. . In addition, you were also evaluated by psychiatry who thought that you would benefit from following up with a psychiatrist after discharge. Your primary care doctor, will be working to arrange this for you. . You showed episodes of intermittent fast heart rates and high and low blood pressures. This is likely due to diabetes affecting the nerves that control these organs. Please discuss this further with your primary care doctor. . We reduced your dose of losartan. Please take the new prescribed dose rather than the old one. Followup Instructions: Department: Primary Care Name: Dr. [**First Name8 (NamePattern2) 58216**] [**Name (STitle) 7537**] When: We were unable to reach Dr. [**Last Name (STitle) 102672**] office to make your appointment 4-8 days after your hospital discharge. You should be hearing from the office regarding your follow up appointment. If you have not heard from the office in 2 business days please call the number listed below. Location: UPHAMS CORNER HEALTH CENTER Address: [**University/College 17629**], [**Location (un) **],[**Numeric Identifier 17630**] Phone: [**Telephone/Fax (1) 7538**] Department: Endocrinology- [**Last Name (un) **] Diabetes Center Name: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] When: Wednesday [**2136-9-12**] at 11 AM Location: [**Last Name (un) **] DIABETES CENTER Address: ONE [**Last Name (un) **] PLACE, [**Location (un) **],[**Numeric Identifier 718**] Phone: [**Telephone/Fax (1) 2378**] Department: RHEUMATOLOGY When: TUESDAY [**2136-8-28**] at 1:30 PM With: [**Name6 (MD) 3712**] [**Name8 (MD) **], MD [**Telephone/Fax (1) 2226**] Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) 861**] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage Department: LIVER CENTER When: TUESDAY [**2136-12-11**] at 11:15 AM With: [**Name6 (MD) **] [**Last Name (NamePattern4) 2424**], MD [**Telephone/Fax (1) 2422**] Building: LM [**Hospital Unit Name **] [**Location (un) 858**] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage

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Discharge summary

report+addendum

Admission Date: [**2192-3-26**] Discharge Date: [**2192-4-5**] Service: MEDICINE Allergies: Dyazide / Prempro / Nsaids / Percocet / Voltaren Attending:[**First Name3 (LF) 30**] Chief Complaint: left hip fracture s/p mechanical fall Major Surgical or Invasive Procedure: Left Hip ORIF History of Present Illness: 83 yo female with a past medical history of coronary artery disease, congestive heart failure, arthritis, and a AAA was admitted to medicine s/p a mechanical fall one day ago. Pt reports that she tripped on her rug one day ago, landing on her left side. She remained on her left side overnight because she could not get to her phone and was found on the morning of admission by her neighbor. When found by her neighbor, she was unable to walk but was awake, alert, and oriented x 3. Patient denies chest pain, shortness of breath, palpitations, loss of consciousness, numbness or tingling. Review of systems notable for left hip pain, which patient reports is only present with movement of any kind and not present at rest. Additional review of systems is notable for the following: hearing loss - has been evaluated by audiology and found to have mild to moderately sensorineural hearing loss; nausea and vomiting two weeks ago which has now resolved; and loss of vision in right eye. Patient denies fevers, chills, abdominal pain, dysuria, diarrhea. . Patient has had multiple falls in the past, usually related to decreased vision. According to her daughter-in-law, she had a fall down stairs four years ago when she fractured her left shoulder and had another fall down stairs 15 years ago. She has been on Fosamax and Vitamin D with Dr. [**Last Name (STitle) **]. . When seen in the ED, patient's vital signs were temp 98,3 . HR 104 / BP 138/71 / RR 18 / 94% on 4L. She received Morphine 2mg IV x 2. . PCP: [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] ([**Telephone/Fax (1) 109779**] Past Medical History: (For details, please see OMR) ATRIAL FIBRILLATION CORONARY ARTERY DISEASE: ADULT ONSET DIABETES MELLITUS THORACIC DISSECTION s/p repair ABDOMINAL AORTIC ANEURYSM ("6cm", "inoperable") CHRONIC RENAL FAILURE (Cr: 1.2-1.5) GLAUCOMA LEG EDEMA KNEE PAIN CHRONIC URINARY TRACT INFECTION ALLERGIC RHINITIS NIGHT SWEATS LEFT SHOULDER PAIN GLAUCOMA LOW BACK PAIN OSTEOPOROSIS PSORIASIS ELEVATED CHOLESTEROL NECK PAIN HYPERTENSION S/P SUBTOTAL THYROIDECTOMY Social History: Home: lives alone at [**Location (un) 109780**]; walks around at home with walker and has assistance for housework and other activities of daily living Denies drugs, EtOH, tobacco Russian-speaking primarily Walks with walker and requires home oxygen Family History: noncontributory Physical Exam: T 98.1 / HR 115 / BP 130/80 / RR 22 / Pulse ox 96% 4L Gen: lying still on right side, no acute distress, nontoxic appearing HEENT: Clear OP, MMM NECK: Supple, thick neck, could not assess JVD due to thick neck CV: tachycardic, irregularly irregular with 3/6 systolic murmur heard best at LUSB LUNGS: CTA, BS BL, No W/R/C ABD: Soft, NT, ND. NL BS. No HSM EXT: No edema. 2+ DP pulses BL SKIN: No lesions NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact. Preserved sensation throughout. 5/5 strength in upper extremities. Normal coordination. Gait assessment deferred PSYCH: Listens and responds to questions appropriately, pleasant Pertinent Results: [**2192-3-26**] 11:15AM URINE HYALINE-[**6-10**]* [**2192-3-26**] 11:15AM URINE RBC-0-2 WBC-[**3-5**] BACTERIA-MANY YEAST-RARE EPI-<1 [**2192-3-26**] 11:15AM URINE BLOOD-SM NITRITE-POS PROTEIN-30 GLUCOSE-NEG KETONE-50 BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [**2192-3-26**] 11:15AM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.022 [**2192-3-26**] 11:30AM URINE RBC-0-2 WBC-0-2 BACTERIA-MANY YEAST-NONE EPI-0-2 [**2192-3-26**] 11:30AM URINE BLOOD-SM NITRITE-POS PROTEIN-30 GLUCOSE-NEG KETONE-50 BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [**2192-3-26**] 11:30AM PT-32.0* PTT-31.3 INR(PT)-3.4* [**2192-3-26**] 11:30AM WBC-8.9# RBC-4.33 HGB-13.1 HCT-41.3 MCV-95 MCH-30.3 MCHC-31.8 RDW-13.9 [**2192-3-26**] 11:30AM NEUTS-90.2* BANDS-0 LYMPHS-6.7* MONOS-2.6 EOS-0.1 BASOS-0.3 [**2192-3-26**] 11:30AM HYPOCHROM-NORMAL ANISOCYT-NORMAL POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL [**2192-3-26**] 11:30AM CK-MB-13* MB INDX-2.0 cTropnT-<0.01 [**2192-3-26**] 11:30AM CK(CPK)-642* [**2192-3-26**] 11:30AM GLUCOSE-194* UREA N-37* CREAT-1.2* SODIUM-143 POTASSIUM-4.1 CHLORIDE-104 TOTAL CO2-26 ANION GAP-17 - [**2192-3-26**] CT C spine - IMPRESSION: No fracture or malalignment within the cervical spine. - [**2192-3-26**] CT Head - 1. No intracranial hemorrhage or mass effect. 2. Focal parenchymal calcification in the cortex of the left parasagittal frontal lobe. Differential diagnosis for this lesion includes a small aneurysm, low-grade tumor, arteriovenous malformation, or prior infection. MRI with gadolinium could be performed for further evaluation if indicated. - [**2192-3-26**] Left Hip XR - IMPRESSION: Acute left intertrochanteric femoral fracture, with likely extension of the fracture line into into the basicervical portion of the femoral neck. Slight medial displacement and varus angulation of the distal femoral shaft. - [**2192-3-27**] CXR - IMPRESSION: Stable appearance to the mediastinum and cardiomegaly, with the patient's known history of ascending and descending aortic aneurysm. No acute cardiopulmonary abnormalities are identified. - [**2192-3-29**] Echo - The left atrium is markedly dilated. The right atrium is markedly dilated; moderate symmetric left ventricular hypertrophy; left ventricular cavity is unusually small. Overall left ventricular systolic function is normal (LVEF 70%); no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The aortic root is moderately dilated athe sinus level. The aortic arch is mildly dilated. There are focal calcifications in the aortic arch. The descending thoracic aorta is mildly dilated. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. Moderate [2+] tricuspid regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. There are linear echodensities in the aortic arch and descending aorta (at the level of the left atrium) that may be acoustic reverberation artifact secondary to arterial wall calcification but a dissection flap cannot be excluded with certainty. A CT angiographic study or cardiac MR or transesophageal echocardiogram could help elucidate the nature of this finding if clinically indicated. - [**2192-4-1**] CT Pelvis - 1. No evidence hemorrhage or new hematoma. 2. Stable appearance of the distal abdominal dissection and aneurysm. Brief Hospital Course: 83 yo female with past medical history significant for congestive heart failure, arthritis, hypertension, and stable abdominal aortic aneurysm, who presented from home with left hip fracture. Patient underwent left hip ORIF with orthopedic surgery. Her post-operative course was complicated by an episode of hypotension requiring MICU care and pressors. Her hypotension was thought likely secondary to blood loss into her hip post-op and had resolved within 1-2 days. Upon discharge, her blood pressure improved and she remained stable on 2L oxygen (consistent with home). . 1. Left Hip Fracture Patient had mechanical fall resulting in left hip fracture. Patient underwent left hip ORIF by orthopedic surgery without immediate complications. Patient was maintained on lovenox for DVT prophylaxis and upon discharge, patient's lovenox was increased to therapeutic doses while awaiting therapeutic INR. Patient was started on vitamin D while as an inpatient and was continued on her outpatient calcium. Pt to follow-up as an outpatient with Dr. [**Last Name (STitle) **]. . 2. Atrial Fibrillation and Supratherapeutic INR Patient maintained on rate control and anticoagulation for her afib. On admission, patient's INR was supratherapeutic for unclear reason. Upon discharge, patient's INR was still subtherapeutic and she was started on therapeutic doses of lovenox until her INR becomes therapeutic. Patient was maintained on metoprolol as an inpatient and was discharged back on her home regimen of atenolol. . 3. Hypotension Patient had an episode of hypotension on post-operative day #2 requiring transfer to the ICU for BP support with pressors. Patient's blood pressure slowly improved with fluid resuscitation and blood transfusions and was transferred back to the floor where her blood pressure has been stable. 4. Hypoxia Patient with persistent hypoxia which improves with 2-3L oxygen. Per chart review, patient requires home oxygen as she was 88-90% on 2L. Patient has been seen by Dr. [**Last Name (STitle) **] in pulmonary who has recommended that she be on home O2. Patient has been resistant to home O2 in the past. Differential diagnosis of patient's hypoxia includes more acutely atelectasis and deconditioning. More chronic causes of her hypoxia include sleep apnea, obesity hypoventilation syndrome, and pulmonary hypertension. Patient was continued on oxygen, CPAP at night, and was using the incentive spirometer with mild improvement in her breathing. . 5. Urinary Tract Infection Patient had a urinary tract infection with Klebsiella that was sensitive to ciprofloxacin. . 6. Type 2 Diabetes Mellitus Patient was maintained on her home regimen of glipizide with sliding scale insulin. . 7. Hypothyroidism Stable. Patient was continued on her outpatient regimen of 50mcg levothyroxine . 10. Congestive Heart Failure Patient was slightly overloaded on exam, although CXR not suggestive of CHF. Patient was diuresed and then maintained on her outpatient regimen. . 12. Osteoporosis Stable. Patient continued her fosamax and calcium carbonate. She was also started on Vitamin D. # CODE: FULL CODE # COMM: patient, son and daughter-in-law [**Name (NI) 3535**] and [**Name (NI) 109781**] [**Name (NI) 109782**] - Home number [**Telephone/Fax (1) 109783**]; Son's cell phone [**Telephone/Fax (1) 109784**]; Daughter-in-law's work number [**Telephone/Fax (1) 109785**] Discharge Medications: 1. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Calcium Carbonate 500 mg Tablet, Chewable Sig: Three (3) Tablet, Chewable PO Q 24H (Every 24 Hours). 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Timolol Maleate 0.25 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2 times a day). 6. Alendronate 70 mg Tablet Sig: One (1) Tablet PO QSAT (every Saturday). 7. Brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic QAM (once a day (in the morning)). 8. Dorzolamide-Timolol 2-0.5 % Drops Sig: One (1) Drop Ophthalmic QAM (once a day (in the morning)). 9. Artificial Tear with Lanolin 0.1-0.1 % Ointment Sig: One (1) Appl Ophthalmic PRN (as needed). 10. Bimatoprost 0.03 % Drops Sig: One (1) Ophthalmic qhs (). 11. Cromolyn 4 % Drops Sig: One (1) Drop Ophthalmic DAILY (Daily). 12. Donepezil 5 mg Tablet Sig: One (1) Cap PO DAILY (Daily). 13. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 14. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed. 15. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day) as needed. 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. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO Q6H (every 6 hours) as needed. 19. Warfarin 3 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 20. Furosemide 40 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily). 21. Enoxaparin 100 mg/mL Syringe Sig: One (1) Subcutaneous Q12H (every 12 hours). 22. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours). 23. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 24. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 25. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO once a day. 26. Atenolol 25 mg Tablet Sig: [**1-3**] tablet Tablet PO once a day. 27. Glipizide 2.5 mg Tab,Sust Rel Osmotic Push 24hr Sig: [**1-3**] tab Tab,Sust Rel Osmotic Push 24hr PO once a day. 28. Ergocalciferol (Vitamin D2) 400 unit Tablet Sig: Two (2) Tablet PO once a day. Discharge Disposition: Extended Care Facility: [**Hospital3 2558**] - [**Location (un) **] Discharge Diagnosis: PRIMARY DIAGNOSIS: 1. Left Hip Fracture 2. Hypotension secondary to blood loss . SECONDARY DIAGNOSIS: -Atrial Fibrillation -Congestive Heart Failure--Echo [**2190**], EF 50% with diastolic dysfunction -Arthritis -Stable Infrarenal Aortic Aneurysm ([**11-6**] 7.8 x 6.8 cm) -Arthritis -Type 2 Diabetes Mellitus -Coronary Artery Disease s/p CABG in [**2173**] -Aortic Dissection s/p repair in [**2181**] Discharge Condition: Stable - Patient is moving with assistance, resting and ambulating with oxygen, and tolerating oral intake. Discharge Instructions: - While you were here, you were diagnosed with a left hip fracture for which you underwent a left hip repair. Your procedure was relatively uncomplicated but shortly after the procedure your blood pressure was very low. This required blood transfusions and medications to maintain your blood pressure. However, since then your blood pressure has been stable and you have progressed well. We have been slowly adding back your medications for your blood pressure. - When you left the hospital, you had two blood cultures still pending. Please have Dr. [**Last Name (STitle) **] follow these blood cultures. - Please take all your medications as prescribed. - While you were here, we have added the following medications: --- lovenox for prophylaxis against blood clots, please keep this medication until your coumadin level becomes therapeutic --- Vitamin D2 to protect your bones - If you have any symptoms of fevers, chills, night sweats, chest pain, shortness of breath, nausea, vomiting, or leg pain, please seek medical attention. Followup Instructions: - Please follow-up with your orthopedic surgeon Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] on [**2192-4-12**] 11:30. His office phone number is [**Telephone/Fax (1) 1228**]. - Please also follow-up with your primary care physician [**First Name11 (Name Pattern1) 198**] [**Last Name (NamePattern4) 199**], M.D. on [**2192-5-2**] 11:40. When you follow-up with Dr. [**Last Name (STitle) **], - Please also follow-up with your cardiologist DR. [**First Name (STitle) **]/DR. [**First Name (STitle) **] on [**2192-5-17**] 10:00. If you need to reschedule, please call his office at [**Telephone/Fax (1) 612**]. - Please also follow-up with your pulmonologist. You have an appointment with Dr. [**Last Name (STitle) **] on [**2192-5-18**] at 9:10am. - When you follow-up with Dr. [**Last Name (STitle) **], please follow-up with him regarding possibly doing a head MRI. When you were here, you had a head CT, which demonstrated a mild abnormality in calcification in the left parasagittal frontal lobe. Please follow-up with him regarding doing an MRI to follow this up. - When you meet with Dr. [**Last Name (STitle) **], please have him follow-up your blood cultures that were still pending upon your discharge from the hospital. Name: [**Known lastname 17999**],[**Known firstname 11404**] Unit No: [**Numeric Identifier 18000**] Admission Date: [**2192-3-26**] Discharge Date: [**2192-4-5**] Date of Birth: [**2108-12-20**] Sex: F Service: MEDICINE Allergies: Dyazide / Prempro / Nsaids / Percocet / Voltaren Attending:[**First Name3 (LF) 175**] Addendum: Please see admission medications. Medications on Admission: ASA 81mg PO daily Atenolol 12.5mg PO daily Atorvastatin 10mg PO daily Atrovent 2 sprays [**Hospital1 **] Calcium Carbonate 1500mg PO daily Colace 100mg PO bid Fosamax 70mg qSaturday Furosemide 60mg PO daily Glipizide 1.25mg PO daily Levothyrxoine 50mcg Po daily Lisinopril 5mg PO daily Home O2 Spironolactone 12.5mg PO daily Timolol eye drops Warfarin 3mg PO daily Discharge Disposition: Extended Care Facility: [**Hospital3 901**] - [**Location (un) 382**] [**First Name11 (Name Pattern1) 77**] [**Last Name (NamePattern1) 181**] MD [**MD Number(1) 182**] Completed by:[**2192-4-5**]

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icd9cm

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icd9pcs

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Discharge summary

report

Admission Date: [**2116-12-22**] Discharge Date: [**2116-12-25**] Service: MEDICINE Allergies: Percocet / Lisinopril / Zetia / [**Year/Month/Day **] / Lovastatin / Doxepin / Boniva / Gleevec Attending:[**First Name3 (LF) 3531**] Chief Complaint: Chief Complaint: Weakness, dizziness Reason for MICU Admission: Hyperglycemia Major Surgical or Invasive Procedure: None History of Present Illness: Patient is an 87 yo F with CML recently discontinued from [**First Name3 (LF) 99026**], DM2, HTN, CKD, CAD, CHF, afib who presents with increasing fatigue, generalized weakness, and dizziness for the past 2 weeks. She had a PCP [**Name Initial (PRE) 648**] 2 weeks ago, was noted to have a HgbA1c of 9.9%, and started on glipizide 2.5 mg daily. During this time, she also noted a 10 lb weight loss due to anorexia and some nausea. She denies any fever, chills. She had a dry cough for one day, which has since resolved. Her DOE is at baseline. She has [**Name Initial (PRE) **] angina at rest. Her last episode was in the ambulance, where she described a fleeting substernal pain, rating [**1-20**] without radiation, and resolved prior to any intervention. She does not consistently get chest pain with exertion, usually at rest. She also reports mild dysuria x 2 days. . In the ED, initial vs were: T 97.4, P74, BP 121/57, R 16, O2 sat 100% on RA. Labs were sig. for K 5.9, Cr 1.9, BUN 56, glu 543, Na 130. WBC is [**10-18**] wtih 80% pmns. EKG showed no ischemic changes or peaked T waves. U/A had tr leuk, neg nitr, neg ketones. UCx is pending. CXR showed no acute pulmonary process. Patient was given 5 units of insulin IV and started on insulin gtt. Pt received 500 cc NS. During her ED stay, she developed dizziness. EKG was repeated and was sig. for STE in leads III and AVF. Cardiology said no intervention at this time. . On the floor, she denies any chest pain. Only complains of fatigue. . Review of sytems: As above. Past Medical History: 1. Hypertension / CAD / CHF, [**2094**] IWMI cardiogenic shock. Cath: LVEF 0.40, INFERIOR AKINESIS, 1+ MR, LMCA, LAD AND LCX -- NO SIGNIFICANT DISEASE, RCA -- 100% PROX. [**2110-1-6**] ETT modified [**Doctor Last Name 4001**], 3.5 min, 55% age pred max heart rate, MIBI LVEF 48%, large inf fixed defect. Echocard [**5-/2113**]: mild sym LVH, EF only 30%, 2+ MR. s/p mi [**2094**], cath [**2103**] one vessel dz RCA, LVEF 40%; [**4-13**] ETT fixed defect inf/lat and apical EF 42%, [**12-17**] new septal moderate, parially reversible defect 2. Type 2 diabetes, diet controlled. 3. Atrial fib / flutter and wide complex tachycardia, rx pacemaker / defibrillator [**2108**], anticoag, followed by Dr. [**Last Name (STitle) **]. 4. CML, stable on Gleevec despite side effects incl eye discomfort and occasional gassiness, dry heaves 5. Hyperlipidemia, discontinued pravachol due to myalgias which then promptly resolved. Had liver problems on [**Name2 (NI) 17339**], zocor so intolerant to multiple statins. 6. COPD, FEV1 1.13 [**2112**]. Stopped smoking in [**2094**], pulmonary eval [**2112**]: deconditioning and wt is contributing to dyspnea. 7. Depression, 8. Eczema / psoriasis, pruritis improved with Sarna. 9. GERD, ? asymptomatic. 10. Gout, treated. 11. Hypothyroidism. 12. Mesenteric ischemia, without abdominal sx after eating. Positive angiogram 13. Osteporosis. stopped Fosamax due to heartburn. 14. Renal insufficiency, creat 1.4. Social History: Social History: Pt lives alone in her own apartment. She has a homemaker and someone who helps buy her groceries. She ambulates with a walker. She was a previously smoker, 2ppd x 40 years, quit in [**2094**]. No ETOH or recreational drugs. Family History: Family History: Mother, brother, and [**Name2 (NI) 802**] with DM. Sister, brother with heart disease. Sister with breast cancer, who has now passed. Physical Exam: General: Alert, oriented x3, no acute distress HEENT: PERRL, EOMI, no nystagmus, sclera anicteric, MM slightly dry, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally except for a few crackles in the LLL 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 CVAT GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Pertinent Results: [**2116-12-22**] 12:00PM BLOOD WBC-12.6* RBC-3.96* Hgb-12.7 Hct-39.7 MCV-100* MCH-32.1* MCHC-32.1 RDW-15.4 Plt Ct-154 [**2116-12-22**] 12:00PM BLOOD Neuts-79.6* Lymphs-10.4* Monos-4.1 Eos-5.1* Baso-0.8 [**2116-12-23**] 02:34AM BLOOD WBC-11.3* RBC-3.38* Hgb-11.5* Hct-33.8* MCV-100* MCH-34.0* MCHC-34.0 RDW-14.9 Plt Ct-133* [**2116-12-24**] 05:55AM BLOOD WBC-9.9 RBC-3.39* Hgb-11.8* Hct-34.4* MCV-102* MCH-34.8* MCHC-34.3 RDW-14.6 Plt Ct-135* [**2116-12-25**] 06:45AM BLOOD WBC-11.6* RBC-3.59* Hgb-11.9* Hct-35.9* MCV-100* MCH-33.2* MCHC-33.2 RDW-14.8 Plt Ct-162 [**2116-12-22**] 12:00PM BLOOD PT-35.5* PTT-31.6 INR(PT)-3.6* [**2116-12-23**] 02:34AM BLOOD PT-33.6* PTT-32.9 INR(PT)-3.4* [**2116-12-24**] 10:45AM BLOOD PT-26.7* PTT-28.8 INR(PT)-2.6* [**2116-12-25**] 06:45AM BLOOD PT-25.4* PTT-28.5 INR(PT)-2.5* [**2116-12-22**] 12:00PM BLOOD Glucose-543* UreaN-56* Creat-1.9* Na-130* K-5.9* Cl-96 HCO3-22 AnGap-18 [**2116-12-23**] 02:34AM BLOOD Glucose-227* UreaN-43* Creat-1.5* Na-140 K-4.7 Cl-107 HCO3-24 AnGap-14 [**2116-12-24**] 05:55AM BLOOD Glucose-242* UreaN-41* Creat-1.5* Na-141 K-4.1 Cl-108 HCO3-23 AnGap-14 [**2116-12-25**] 06:45AM BLOOD Glucose-205* UreaN-44* Creat-1.7* Na-142 K-3.9 Cl-108 HCO3-24 AnGap-14 [**2116-12-22**] 12:00PM BLOOD Calcium-9.8 Phos-3.8 Mg-2.5 [**2116-12-22**] 07:22PM BLOOD Calcium-9.1 Phos-3.0 Mg-2.5 [**2116-12-23**] 02:34AM BLOOD Calcium-8.8 Phos-3.2 Mg-2.3 [**2116-12-24**] 05:55AM BLOOD Calcium-9.0 Phos-3.6 Mg-2.4 [**2116-12-22**] 07:22PM BLOOD ALT-43* AST-31 CK(CPK)-25* AlkPhos-78 Amylase-31 TotBili-0.6 [**2116-12-22**] 07:22PM BLOOD Lipase-76* [**2116-12-22**] 12:00PM BLOOD CK-MB-3 [**2116-12-22**] 12:00PM BLOOD cTropnT-0.02* [**2116-12-22**] 07:22PM BLOOD CK-MB-4 cTropnT-0.02* [**2116-12-23**] 02:34AM BLOOD CK-MB-4 cTropnT-0.02* [**2116-12-22**] 12:00PM BLOOD CK(CPK)-58 [**2116-12-22**] 04:06PM BLOOD CK(CPK)-26* [**2116-12-23**] 02:34AM BLOOD CK(CPK)-37 [**2116-12-22**] 07:22PM BLOOD Osmolal-298 [**2116-12-22**] 12:00PM BLOOD Digoxin-1.2 URINE CULTURE (Preliminary): GRAM NEGATIVE ROD(S). 10,000-100,000 ORGANISMS/ML.. PROTEUS SPECIES. 10,000-100,000 ORGANISMS/ML.. FINDINGS: Similar to the prior exam, a left chest wall pacemaker/AICD with dual contiguous leads remains stable in position and course. The lungs are clear without consolidation or edema. Aortic tortuosity with calcification of the arch is again noted. The cardiac silhouette remains enlarged but stable. No effusion or pneumothorax is noted. A gradual S-shaped scoliosis of the thoracolumbar spine including prior vertebroplasty in the upper lumbar spine is again noted and likewise stable. IMPRESSION: No acute pulmonary process. Brief Hospital Course: Assessment and Plan: 87 yo F with h/o DM type 2, CML, HTN, HL, CAD s/p MI in [**2094**] (treated medically), ventricular tachycardia s/p AICD, and PAF who presents with hyperglycemia. hyperglycemia/DM2: The patient was admitted with a blood sugar of 543 and recent HbA1c of 9.9% ([**2116-12-9**]), up significantly from a previous value of 6.2% ([**2116-7-8**]). She had been previously diet-controlled until two weeks prior to admission, when her PCP started her on glipizide 2.5 mg for her increased HbA1c. The Ddx for her spike in blood sugars was natural progression, change in diet, nonadherence to medication, infection (UTI), or cardiac ischemia. In the ED, she was treated with 5U insulin IV and started on insulin drip. EKG showed no ischemic changes or peaked T waves, and CXR showed no acute pulmonary process. Troponins were <0.02 x3. One day after admission, she was transitioned off insulin drip onto insulin sliding scale and Lantus 10U at bedtime. On [**2116-12-24**], [**First Name8 (NamePattern2) **] [**Last Name (un) **] consult was called, and her evening Lantus was eventually increased to 22U and her sliding scale titrated up as well. In addition, she was started on PO glipizide 2.5 mg [**Hospital1 **]. The worsening of her glucose control may have been secondary to discontinuing [**Hospital1 **]. Some evidence exists implying increased insulin sensitivity with [**Last Name (LF) **], [**First Name3 (LF) **] it is possible that her discontinuation of [**First Name3 (LF) **] several weeks ago worsened her glucose control. Her discharge medications for diabetes were as follows: Lantus 20U qhs, glipizide 5 mg [**Hospital1 **]. She was scheduled for outpatient f/u at [**Last Name (un) **], as well as with her PCP within the week after discharge. ##UTI On admission, the patient complained of dysuria, and her UA showed many bacteria and [**4-22**] WBC's. Subsequent urine culture grew Proteus mirabilis, and Klebsiella pneumoniae. On [**12-22**], the patient was started on a 5 day course of ciprofloxacin 250 qday. She remained afebrile throughout her hospital admission. #Coronary artery disease s/p MI [**2094**] (RCA occlusion, managed medically): The patient's admission EKG showed mild STE's in the inferior leads, which resolved on subsequent EKGs throughout the admission. Troponin levels were <0.02 x3. For her known CAD, we continued ASA 325 mg daily, as well as atenolol 12.5 mg in am, 25 mg in pm daily. Statin was not initiated because of the patient's reported prior allergy to atorvastatin and her history of elevated LFT's. #Systolic CHF ECHO in [**8-21**] showed LVEF of 40%. The patient's Lasix was held until [**12-24**], at which point Lasix 40 mg PO was given. The patient's remained on room air through her admission, and her shortness of breath was at baseline. #Ventricular tachyarrhythmia s/p AICD in [**2107**] The patient remained on her home dofetilide 500 mcg q12h and digoxin 0.125 mg po daily. Her digoxin level was 0.7 on [**2116-12-23**]. #Paroxysmal atrial fibrillation: INR on admission was 3.4, and coumadin was held. On [**12-24**], INR was 2.6, and coumadin was restarted on the patient's home regimen (4 mg/day on [**Doctor First Name **], M, W, F, Sa and 5 mg/day on T, Th). #HTN: The patient remained stable (100-120s/50-60s) on her home irbesartan 75 mg daily and atenolol. #CML: The patient was previously on [**Doctor First Name 99026**] from [**2110**] until 3 weeks prior to admission, at which point her oncologist changed her to dasatinib. On admission, she was not taking any medication for her CML. She has been scheduled for outpatient f/u with her oncologist, Dr. [**Last Name (STitle) 2539**]. #CKD: The patient's baseline Cr was 2.0 and her Cr remained 1.5-1.9 over her admission. #Hypothyroidism: The patient was stable on her home levothyroxine 88 mcg/day. #Gout: The patient was stable on her home allopurinol. #Osteoporosis: The patient was given daily calcium carbonate supplements. #Nutrition/prophylaxis The patient was placed on a low sodium, cardiac healthy, diabetic diet. Medications on Admission: ALLOPURINOL - 100 mg Tablet - 2 Tablet(s) by mouth every day ATENOLOL - 25 mg Tablet - [**11-14**] Tablet(s) by mouth in AM and 1 tab in PM per Dr.[**Name (NI) 71235**] note - prevent heart attack, blood pressure DIGOXIN - (Prescribed by Other Provider) - 125 mcg Tablet - 1 Tablet(s) by mouth once a day DOFETILIDE [TIKOSYN] - 500 mcg Capsule - one Capsule(s) by mouth twice a day FUROSEMIDE - 40 mg Tablet - 1 Tablet(s) by mouth once a day - diuretic GLIPIZIDE - 2.5 mg Tablet Extended Rel 24 hr - 1 Tablet(s) by mouth once a day before breakfast - diabetes IRBESARTAN [AVAPRO] - 75 mg Tablet - 1 Tablet(s) by mouth 1 po qd LEVOTHYROXINE - 88 mcg Tablet - 1 Tablet(s) by mouth once a day, take separately from calcium - thyroid POTASSIUM CHLORIDE [K-DUR] - 20 mEq Tab Sust.Rel. Particle/Crystal - 1 Tab(s) by mouth twice a day WARFARIN - 2 mg Tablet - 2 - 3 Tablet(s) by mouth once a day as directed ASPIRIN [ENTERIC COATED ASPIRIN] - (OTC) - 81 mg Tablet, Delayed Release (E.C.) - 1 Tablet(s) by mouth once a day with food - heart protection Discharge Medications: 1. Allopurinol 100 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 2. Atenolol 25 mg Tablet Sig: 0.5 Tablet PO QAM (once a day (in the morning)). 3. Atenolol 25 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)). 4. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Dofetilide 500 mcg Capsule Sig: One (1) Capsule PO Q12H (every 12 hours). 6. Levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Ciprofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 1 days. Disp:*1 Tablet(s)* Refills:*0* 8. Irbesartan 150 mg Tablet Sig: 0.5 Tablet PO daily (). 9. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Glipizide 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 11. Warfarin 2 mg Tablet Sig: Two (2) Tablet PO ASDIR ([**Doctor First Name **],MO,WE,FR,SA). 12. Warfarin 2 mg Tablet Sig: 2.5 Tablets PO ASDIR(Tues, Thurs). Tablet(s) 13. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day. 14. K-Dur 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO twice a day. 15. Lantus Solostar 300 unit/3 mL Insulin Pen Sig: Twenty (20) Units Subcutaneous at bedtime. Disp:*2 Pens* Refills:*2* 16. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day. 17. Calcium 500 mg Tablet Sig: Two (2) Tablet PO twice a day. Discharge Disposition: Home With Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: Hyperglycemia from uncontrolled diabetes mellitus type II UTI Discharge Condition: Stable, ambulatory, tolerating oral diet Discharge Instructions: Dear Ms. [**Known lastname 1617**], You were admitted for acutely increased blood sugar levels (>500) from your diabetes. You were treated with IV insulin, and we performed multiple finger sticks each day to monitor your blood glucose. You were also given an oral medication (glipizide) to help with your diabetes. Your other [**Known lastname **] medical conditions (coronary heart disease, hypertension, congestive heart failure, hypothyroidism, gout, osteoporosis) were treated with your home medications. Please take all medications as directed. The following changes were made to your medications: 1) Lantus 20U by injection once before bedtime each day 2) Glipizide 5 mg tablet twice a day (one in morning, one at night) each day Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more than 3 lbs. Followup Instructions: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 9052**], MD Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2117-1-1**] 9:30 Provider: [**Name10 (NameIs) **],[**First Name8 (NamePattern2) 2352**] [**Last Name (NamePattern1) 2352**] - ADULT MEDICINE (SB) Phone:[**Telephone/Fax (1) 1144**] Date/Time:[**2117-1-1**] 11:00 Dr. [**First Name (STitle) **] [**Name (STitle) 9835**] (endocrinologist) on Tuesday [**12-29**] at 11:30 am: [**Last Name (un) 3911**] [**Location (un) 86**], MA [**Location (un) **] Completed by:[**2116-12-27**]

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icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

13671, 13728

7102, 11186

384, 390

13834, 13877

4407, 6409

14754, 15316

3727, 3862

12287, 13648

13749, 13813

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283, 346

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23,034

141,018

18048

Discharge summary

report

Admission Date: [**2160-3-24**] Discharge Date: [**2160-4-1**] Service: CHIEF COMPLAINT: Stage 4 decubitus ulcer; surgical wound dehiscence. HISTORY OF PRESENT ILLNESS: This is an 83-year-old female with a history of inferior wall myocardial infarction, obesity, and chronic renal insufficiency who presented to [**Hospital 1474**] Hospital Emergency Room on [**2160-1-20**] with abdominal pain. An abdominal computed tomography at that time revealed free air, and the patient was taken emergently to the operating room. An exploratory laparotomy revealed a perforated duodenal ulcer and cholecystitis. An open cholecystectomy, lysis of adhesions, and oversewing the duodenal ulcer was performed. A jejunostomy tube was placed at that time. A right lower extremity ulcer was evaluated by Surgery but not intervened upon. The patient was transferred to the Intensive Care Unit, and on [**1-27**] had a tracheostomy placed due to difficulty weaning secondary to numerous episodes of mucus plugging. The sputum was positive for Pseudomonas, and the surgical wound was positive for methicillin-resistant Staphylococcus aureus and Pseudomonas at that time. The patient was treated with intravenous ceftazidime and vancomycin for a full course. Her postoperative course was complicated by anemia requiring several transfusions and self-terminating runs of supraventricular tachycardia (treated with as needed beta blockers), and an echocardiogram revealing an ejection fraction of 55% and mild left ventricular hypertrophy. The patient's renal failure improved when started on a ACE inhibitor. Tube feeds were started for malnutrition. Epogen iron for treatment of anemia of chronic disease, and the patient was discharged to rehabilitation for further care. Today, the patient was transferred from rehabilitation when it was discovered that she had feculent material in her stage 4 decubitus ulcer. The patient was taken to the Emergency Department where a white blood cell count was noted to be 24 at [**Hospital 1474**] Hospital. The patient was monitored on telemetry and was hemodynamically stable. The Emergency Department attending discussed the case with the surgical attending who felt that the patient would need debridement of skin graft by Vascular Surgery. Tube feeds were stopped this a.m. since there was a question of jejunostomy tube dysfunction. The patient was transferred to [**Hospital1 188**] Medical Intensive Care Unit for further medical management and surgical evaluation. PAST MEDICAL HISTORY: 1. Supraventricular tachycardia. 2. Myocardial infarction. 3. Hypertension. 4. Cellulitis. 5. Obesity. 6. Total abdominal hysterectomy. 7. Large ventral hernia. 8. Renal cysts bilaterally (by computed tomography). 9. Coronary artery disease; status post inferior wall myocardial infarction, with a past ejection fraction of 55%, and mild left ventricular hypertrophy. 10. Respiratory failure; status post tracheostomy on [**2160-1-31**]. 11. Chronic renal failure (with a baseline creatinine of 2.7). 12. Perforated duodenal ulcer. 13. Cholecystitis; status post cholecystectomy. 14. Status post appendectomy. 15. Bowel perforation; required colostomy which was eventually reversed. 16. Methicillin-resistant Staphylococcus aureus and Pseudomonas pneumonia. MEDICATIONS ON ADMISSION: 1. Digoxin 0.125 mg per nasogastric tube q.d. 2. Diltiazem 90 mg p.o. q.i.d. 3. Docusate 100 mg p.o. b.i.d. 4. Morphine sulfate 5 mg prior to dressing changes. 5. Doxycycline 100 mg. 6. Epogen 10,000 units on Monday, Wednesday, and Friday. 7. Iron 300 mg p.o. b.i.d. 8. Lasix 60 mg p.o. q.d. 9. Prevacid 30 mg p.o. q.d. 10. Zinc 220 mg p.o. q.a.m. 11. Ambien 5 mg p.o. q.h.s. as needed. 12. Protein powder two scoops p.o. b.i.d. 13. Tylenol 650 mg p.o. q.4h. as needed (for pain). 14. Bisacodyl 10 mg p.r. q.d. as needed. 15. Fleet enemas per rectum q.d. as needed 16. Ativan 0.5 mg p.o. b.i.d. as needed. ALLERGIES: CODEINE (produces a rash), NONSTEROIDAL ANTIINFLAMMATORY DRUGS (peptic ulcer disease), and 'PYRAZOLES' ANALGESICS. SOCIAL HISTORY: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 49937**] is power of attorney. Her husband is alive and active in her management. PERTINENT LABORATORY VALUES ON PRESENTATION: Laboratories upon admission revealed white blood cell count was 24.2, hematocrit was 29.6, and platelets were 379. Differential with 93.1 neutrophils, 3.6 lymphocytes, and 2.4 monocytes). Electrolytes revealed sodium was 138, potassium was 4.4, chloride was 96, bicarbonate was 37, blood urea nitrogen was 69, creatinine was 1.2, and blood glucose was 100. Calcium was 8.9. PHYSICAL EXAMINATION ON PRESENTATION: Physical examination revealed temperature was 98.8, heart rate was 109 (atrial fibrillation), blood pressure was 137/69, respiratory rate was 17, and synchronized intermittent mandatory ventilation was 600 X 11, FIO2 was 0.5%, positive end-expiratory pressure was 10, positive end-airway pressure was 36, flat 17, 98%. Head, eyes, ears, nose, and throat examination revealed mucous membranes were dry. Cardiovascular examination revealed normal first heart sounds and second heart sounds. No murmurs, rubs, or gallops. The lungs were clear to auscultation bilaterally. The abdomen revealed large wound dehiscence in the ventral region. Extremity examination revealed a large necrotic stage 4 decubitus ulcer foul odor. HOSPITAL COURSE: The patient was admitted to the Medical Intensive Care Unit Service and was followed very closely by Plastic Surgery, General Surgery, and Vascular Surgery. 1. DECUBITUS ULCER ISSUES: The patient had her stage 4 decubitus ulcer debrided times three by the vascular surgeons. The patient had Decon solution applied to the area times four times, and these dressings were changed over to wet-to-dry dressings t.i.d. The patient was started on empiric antibiotics, since it was thought that she also had osteomyelitis. Erythrocyte sedimentation rate was notably very high. A sacral x-ray was unrevealing, because it was a poor study due to her body habitus. The patient was started on vancomycin for presumed osteomyelitis which was to be continued for eight weeks; according to the plastic surgeons. The patient would need aggressive wound care to this region; including an air mattress, frequent turnings, and evaluation by the Plastic Service in eight weeks to insure that this decubitus ulcer was improving. She also required morphine prior to her dressing changes. 2. VENTRAL HERNIA ISSUES: As far as the patient's ventral hernia defect, the jejunostomy tube was evaluated by Radiology, and it was noted that the jejunostomy tube was functional, and there was no extravasation of dye around the jejunostomy tube insertion site. The patient tolerated the procedure well, and feeding tubes were started once again. 3. VENOUS STASIS ULCER ISSUES: As far as the patient's right lower extremity venous stasis ulcer, this was evaluated by Vascular Surgery who felt that dressing changes were appropriate at this time and that she should follow up with Vascular Surgery at [**Hospital 1474**] Hospital for an eventual split-thickness skin graft, but that no intervention at this time was necessary. The ventral surgical wound dehiscence was also evaluated by General Surgery who cleaned the wound by debriding it and continued wet-to-dry dressing changes, and it was thought that there would be no need to correct the defect any other way, and that this wound should heal by secondary intention. Blood cultures were taken at the time of admission, and they rapidly grew out 4/4 bottles of gram-negative organisms which were later identified as Klebsiella. The patient was started on Zosyn for this, and subsequent blood cultures times three were negative. The patient's temperature and white blood cell count came down from an initial of 24.2 to 13 at the time of discharge. The sensitivities on the blood cultures revealed pan-sensitive organisms, and it was thought that a 2-week treatment with Zosyn should be sufficient to clear the Klebsiella bacteremia; which most probably came from her sputum. Zosyn was chosen since the patient had a history of Pseudomonas pneumonia, and this was thought to be an effect [**Doctor Last Name 360**]. 4. HEMATOLOGIC ISSUES: From a hematologic standpoint, the patient's hematocrit tended to be on the low side. Given her history of coronary artery disease and inferior wall myocardial infarction, she was transfused 2 units of packed red blood cells initially and transfused 1 more unit two days prior to discharge. It was noted that (per pathology) that the patient did develop some minor antibodies status post these transfusions. She developed anti-C antibody and anti-CW antibody, but her TAT was negative, and a full hemolysis panel revealed no active hemolysis, and her hematocrit stay stable throughout this admission. 5. CARDIOVASCULAR SYSTEM: As far as the patient's cardiovascular standpoint, the patient was noted to have frequent pauses throughout her telemetry monitoring here. Her digoxin level was measured and was within normal limits. Her diltiazem level was decreased from an initial dosage of 90 mg q.i.d. to 30 mg q.i.d. at the time of discharge. The patient never had any hemodynamic compromise, and her blood pressure remained in the 90s to 110s systolically; and usually these pauses occurred while she was sleeping, and it was thought that this was just due to increased vagal tone at that time. 6. PULMONARY ISSUES: As far as the patient failure to wean, it was thought that the patient would not be able to come off the tracheostomy onto a tracheal mask during her time here, but her requirement for pressure support decreased steadily throughout her stay as her pneumonia (which was visualized on x-ray) continued to improve and the thick secretions she made continued to get better. The patient was evaluated for a Passy-Muir valve, but it was thought that due to the type of tracheostomy that she had that this was not possible. Of note, the patient also had episodic apneic episodes, and this was not correlated with the morphine administration which she had for her dressing changes. They usually occurred at night but lasted 20 seconds and spontaneously resolved on their own. The patient was continued throughout this admission on pressure support of 15, positive end-expiratory pressure of 5, FIO2 of 40%. On these settings, she pulled tidal volumes of 420 cc. A recent arterial blood gas revealed the following numbers; 7.40/59/104 which was thought to be her baseline level of function. It was thought that either pressure supports or synchronized intermittent mandatory ventilation would be reasonable methods of ventilation in this patient. 7. NUTRITIONAL ISSUES: As far as the patient's malnutrition, it was thought that a Nutrition consultation would be appropriate given the patient's severe need for nutritional supplementation. The patient was seen and evaluated by a Nutrition consultation who recommended placing the patient on Promote with fiber at full strength with ProMod added at 75 g per day with a goal rate of 75 mL per hour. Residuals were checked q.4h., and the patient had free water flushes of 100 mL of water q.8h. The patient tolerated this feeding regimen very well, and there were no further problems. 8. PAIN ISSUES: As far as the patient's pain, the patient was continued on 5 mg of intravenous morphine prior to dressing changes with good effect. It was thought that at the time of discharge, the patient was ready to be discharged back to her home institution for further followup with Plastic Surgery, Vascular Surgery, and the Medicine team there. The patient would have to continue an 8-week course of her vancomycin and Zosyn for her decubitus ulcer since there was a history of methicillin-resistant Staphylococcus aureus and Pseudomonas which grew out of that wound, as well as the fact that she has osteomyelitis. The patient would have to continue the Zosyn as well for her pneumonia which seemed to be greatly improving throughout this stay. The patient's blood cultures were negative, and her white blood cell count was trending toward normal. The patient did have episodic hypothermic episodes throughout her stay here, but these were axillary temperatures and not core temperatures, and her temperature at the time of discharge was 95.7. The patient would need periodic vancomycin level checks due to her chronic renal insufficiency and digoxin level checks. MEDICATIONS ON DISCHARGE: 1. Diltiazem 30 mg p.o. q.i.d. (hold for a spontaneous bacterial peritonitis of less than 100 or a heart rate of less than 55). 2. Vancomycin 1 g intravenously q.24h. (times seven more weeks). 3. Digoxin 0.125 mg per nasogastric tube 4. Zosyn 4.5 g intravenously q.8h. (times seven more weeks). 5. Oxycodone 5 mg p.o./nasogastric tube q.8h. as needed. 6. Tylenol 325 mg to 650 mg p.r. q.4-6h. as needed. 7. Bisacodyl 10 mg p.o./p.r. q.d. as needed. 8. Heparin 5000 units subcutaneously q.8h. 9. Lorazepam 0.5 mg intravenously q.12h. as needed. 10. Ambien 5 mg to 10 mg p.o. q.h.s. as needed. 11. Morphine sulfate 5 mg intravenously q.4h. as needed (prior to dressing changes). DISCHARGE INSTRUCTIONS/FOLLOWUP: 1. The patient was to be seen by Plastics within one to two weeks of return to her institution. 2. The patient was to be seen by Vascular Surgery for eventual need of a split-thickness skin graft. 3. The patient's ventral wound was to have re-evaluated by Surgery and debrided once gain if necessary. 4. The patient needs rigorous nursing care to her sacral decubitus ulcer. She needs t.i.d. dressing changes, frequent turnings, and air mattress to prevent worsening of the decubitus ulcer and to provide good granulation tissue return to that region. 5. The patient was to receive aggressive wound care to her right lower extremity wound. She was to receive wound changes b.i.d., circumferentially, around her lower extremity ulcer and Kerlix and an ACE wrap up to the knee at that region. 6. The patient was to receive vancomycin and digoxin level checks. 7. The patient was to be on contact methicillin-resistant Staphylococcus aureus precautions. 8. The patient needs aggressive nutrition for her adequate would healing. DR.[**Last Name (STitle) **],[**First Name3 (LF) **] 12-697 Dictated By:[**Name8 (MD) 4712**] MEDQUIST36 D: [**2160-4-1**] 09:09 T: [**2160-4-1**] 09:26 JOB#: [**Job Number 49938**]

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icd9cm

[ [ [] ] ]

[ "86.22", "38.93", "96.6", "86.28", "96.72" ]

icd9pcs

[ [ [] ] ]

12643, 13340

3359, 4118

5486, 12616

13373, 14624

101, 154

183, 2526

2549, 3332

4135, 5467

75,591

168,936

47357

Discharge summary

report

Admission Date: [**2160-11-16**] Discharge Date: [**2160-11-19**] Date of Birth: [**2085-8-22**] Sex: M Service: MEDICINE Allergies: Aspirin / Indomethacin / Ciprofloxacin / Probenecid / Allopurinol And Derivatives / Phenytoin / Keflex Attending:[**First Name3 (LF) 2024**] Chief Complaint: Hypotension Major Surgical or Invasive Procedure: None History of Present Illness: 75 year old gentleman with a PMH significant for HCV cirrhosis c/b HCC s/p lobe resection in [**2156**], POD 12 from craniotomy for SDH now admitted to the [**Hospital Unit Name 153**] for fever, rash, and hypotension. The patient was noted at rehab to be febrile to 103 today, and was also complaining of a "total body itchiness" and was noted both at rehab and by the ED attending to have trunk and arm erythema. He was started on keflex yesterday for possible superficial phlebitis at an old PIV site, and denies any localizing symptoms including HA, menigismus, cough, shortness of breath, dysuria, n/v/d. . Of note, the patient was admitted to [**Hospital1 18**] under the Neurosurgical service from [**Date range (1) 30844**] after a fall with bilateral SDH, and underwent right craniotomy on [**11-5**], and ultimately was discharged to rehab on dilantin for seizure prophylaxis. In addition, he was started on keflex the day prior to admission for question of cellulitis on his left forearm at the location of a prior PIV site. . In the [**Hospital1 18**] ED, initial VS 99 68 78/60 18 94%RA. The patient had a negative CXR and UA, an I+/- CTH that was read as unchanged from most recent post-operative study, and Neurosurgery was consulted with low suspicion for CNS infection. The patient received 10 mg IV dexamethasone, 5 L IVF, vancomycin, and levofloxacin, and was admitted to the [**Hospital Unit Name 153**] for further management. . Currently, the patient is resting comfortably without complaints. Continues to deny any CP/SOB, f/c/s, n/v/d, abd pain, HA, palpitations, dysuria. Past Medical History: 1. Hypertension 2. Hypothyroidism 3. Gout 4. GERD 5. BPH 6. Hepatitis C 7. Hepatocellular carcinoma Social History: Single. No children. Cousin and friends are support system. Retired from [**Location (un) 6692**] Airport working for United on ramp service. Quit smoking and drinking in the [**2139**]. Family History: Mother: breast cancer, died at 69 Sister: bipolar disorder Aunt: breast cancer, died in 80s. Physical Exam: Admission Exam: . VS: T:98.5, HR:72, BP:106/69, RR:22, SO2:94%RA Gen: NAD HEENT: PERRL, eomi, sclerae anicteric. MM dry. OP clear without lesions, exudate, or erythema. CV: Nl S1+S2 Pulm: CTAB Abd: S/NT +bs, ? ascites on exam. Ext: No c/c/e. Neuro: AO x3, CN II-XII intact. Skin: Stapled surgical site on cranium without surround erythema . Physical Exam: VS: Tmax 97.7 Tc 96.0 HR 52 (52-73) BP 119/68 (106-130/60-82) RR 16 O2 sat 99% on RA I/O 24h 3120-975 . GEN: AOx3, NAD HEENT: PERRLA. EOMI. Bil Exophthalmus (this is a feature from childhood and runs in the family per patient). Surgical sight on cranium w/o erythea/swelling/tenderness. MMM. no LAD. no JVD. neck supple. Right thyroid fullness/nodule? Cards: RRR S1/S2 normal. no murmurs/gallops/rubs. Pulm: CTA Abd: soft, NT, distended, +BS. no rebound/guarding. Extremities: wwp, no edema. DPs, PTs 2+. Skin: no rashes. Neuro/Psych: CNs II-XII intact. no gross deficit Pertinent Results: Admission Results: . [**2160-11-16**] 01:08PM BLOOD WBC-6.9 RBC-3.43* Hgb-10.8* Hct-32.9* MCV-96 MCH-31.5 MCHC-32.8 RDW-16.1* Plt Ct-224# [**2160-11-16**] 01:08PM BLOOD Neuts-84.3* Lymphs-10.0* Monos-1.6* Eos-3.9 Baso-0.2 [**2160-11-16**] 01:08PM BLOOD PT-14.9* PTT-31.6 INR(PT)-1.3* [**2160-11-16**] 01:08PM BLOOD Glucose-154* UreaN-19 Creat-1.3* Na-133 K-4.6 Cl-103 HCO3-17* AnGap-18 [**2160-11-16**] 01:08PM BLOOD ALT-52* AST-110* AlkPhos-350* TotBili-2.2* DirBili-1.1* IndBili-1.1 [**2160-11-16**] 01:08PM BLOOD Calcium-8.0* Phos-2.9 Mg-1.6 [**2160-11-16**] 01:13PM BLOOD Lactate-3.1* K-4.4 . CXR ([**2160-11-16**]): No acute cardiopulmonary process. . CT Head With and Without Contrast ([**2160-11-16**]): Stable appearance of evolving bilateral subdural hematomas and interval resorption of postoperative pneumocephalus, with no concerning enhancement. . Interval Results: . Right Upper Quadrant Ultrasound ([**2160-11-17**]): **DICTATED, FINAL PENDING** 1. Heterogeneous liver with lesions consistent with multifocal hepatocellular carcinoma. 2. Patent portal veins. 3. Patent hepatic veins and artery. 4. Moderate amount of asciates. . . . Last Updated on [**2160-11-17**] Brief Hospital Course: 75 year old gentleman with a PMH significant for HCV cirrhosis complicated by HCC s/p lobe resection in [**2156**], who presented on post-operative day 12 from craniotomy for a subdural hematoma with fever, rash, and hypotension. . #. Hypotension and Fever: There was immediate concern for sepsis on presentation to the ED, although no apparent source was isolated and no significant fever was recorded in the hospital (had 100.4 on admission to the ED). Sepsis workup was negative including CXR, UA, Urine and Blood cultures. Final blood cutlure results are still pending. Given recent craniotomy the neurosurgery service was consulted and was not concerned for CNS infection. A RUQ ultraound was performed that confirmed a moderate amount of ascites and patency of the hepatic vessels, but the abdomen was not tender and the suspicion for SBP was low. Adrenal insuficiency was ruled out per cosyntropin test. The patient did receive a dose of Vancomycin and Levofloxacin in the ED but none were continued in the ICU as the patient remained afebrile and the ICU team's suspicion for infectious process was low. The patient recieved a dose of IV steroids in the ED and subsequently recieved a 3 day course of Prednisone 60mg. Dilantin was considered as a possible etiology for his presentation, especially given the acute renal failure and associated morbilliform rash, as a type IV drug reaction, including DRESS, though no eosinophilia was noted on differential. Adittionally patient had recently been started on Keflex so anaphylactic shock due to allergy to cephalosporins is another possibility. Both dilantin and Keflex were discontinued and should be avoided in the future. The patient remained afebrile and normotensive during his ICU stay and the day after admission was transferred to the oncology service. He remained stable on the oncology floor and is now discharged back to rehab facility. . #. Acute Renal Failure: Patient was admitted with a serum creatinine of 1.2, up from a known baseline of 0.9 to 1 likely pre-renal failure in the setting of hypotension. His Cr. on discharge was 0.9. Renal functions and electrolytes should be followed in the outpatient setting. . #. Elevated Liver Enzymes: 2/2o Hepatitis C Cirrhosis and Hepatocellular Carcinoma: Patient failed Interferon and Ribavirin in the past. Patient with known multifocal HCC recurrence re-confirmed per RUQ ultrasound on this admission. . # Metabolic Acidosis: initially normochloremic with slightly elevated AG, then hyperchloremic with normal anion gap. Likely initially [**1-15**] to tissue hypoperfusion given the elevated lactate on admission. Lactate was 3.1 on admission and decreased to 1.3. Also contributed to by renal failure. Bicarbonate trending up on discharge. . # Anemia: at baseline of 30-35. Had initial drop of Hct secondary to rehydration and resolution of Hemmoconcentration, Hct back to baseline at discharge. . #. Hypertension: Anti-hypertensives were held in the setting of hypotension. Tamsulosin 0.4 mg was restarted on discharge. Amlodipine continues to be held on discharge . #. Hypothyroid: Patient was continued on Levothyroxine without event. Of note patient found to have increased palpable right lower thyroid lobe. Further workup of this finding may be considered in the out patient setting. . # Code status during this admission: Full Medications on Admission: 1. Amlodipine 5 mg DAILY 2. Tamsulosin 0.4 mg HS 3. Oxycodone 5 mg Q4H as needed for pain. 4. Multivitamin 5. Cholecalciferol (vitamin D3) 400 Units DAILY 6. Vitamin E 400 Units DAILY 7. Levothyroxine 75 mcg DAILY 8. Docusate sodium 100 mg [**Hospital1 **] 9. Phenytoin sodium extended 100 mg TID 10. Keflex Discharge Medications: 1. tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO at bedtime. 2. oxycodone 5 mg Tablet Sig: One (1) Tablet PO every four (4) hours as needed for Pain. 3. multivitamin Tablet Oral 4. cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO once a day. 5. levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 7. vitamin E 400 unit Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Extended Care Facility: [**Location (un) 23095**] Discharge Diagnosis: Suspected Drug Reaction/Anaphylaxis CAVE PHENYTOIN CAVE CEPHALEXIN s/p craniotomy for bilateral acute on chronic sub dural hemmorahge Hepatitis C cirrhosis Hepatocelular Carcinoma Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: You were admitted because of rash and low blood pressure. You were treated with intravenous fluids and steroids and your condition quickly improved. We believe this event may have been due to reaction or allergy to medications you were taking either Dilantin (phenytoin) or Keflex (cephalexin). Please avoid these medications in the future. . The following changes were made to your medications: - STOP Dilantin - STOP Keflex - Amlodipin was stopped, please consult your treating physician about restarting this medication . Please continue to take your home medications without change. . Please discussed imaging of your thyroid gland with your primary care provider. Followup Instructions: please keep the following appointments: . Department: RADIOLOGY When: TUESDAY [**2160-12-9**] at 10:00 AM With: CAT SCAN [**Telephone/Fax (1) 327**] Building: CC CLINICAL CENTER [**Location (un) **] Campus: WEST Best Parking: [**Street Address(1) 592**] Garage Department: NEUROSURGERY When: TUESDAY [**2160-12-9**] at 10:30 AM With: [**Name6 (MD) **] [**Last Name (NamePattern4) 9151**], MD [**Telephone/Fax (1) 1669**] Building: LM [**Hospital Unit Name **] [**Location (un) **] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage Department: HEMATOLOGY/ONCOLOGY When: MONDAY [**2160-12-22**] at 3:30 PM With: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 2502**], 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:[**2160-11-20**]

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icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

8887, 8939

4625, 7980

377, 383

9163, 9163

3420, 4602

10039, 10945

2358, 2453

8338, 8864

8960, 9142

8006, 8315

9346, 10016

2824, 3401

326, 339

411, 2013

9178, 9322

2035, 2137

2153, 2342

24,958

170,094

45006+58775+58779

Discharge summary

report+addendum+addendum

Admission Date: [**2127-8-5**] Discharge Date: [**2127-8-20**] Service: CCU HISTORY OF PRESENT ILLNESS: The patient is a 77-year-old woman who came in for a diagnostic catheterization after admission for a congestive heart failure exacerbation one week earlier. MEDICATIONS ON ADMISSION: 1. Lisinopril 50 mg p.o. q.d. 2. Niacin 100 mg p.o. q.d. 3. Lipitor 20 mg p.o. q.d. 4. Multivitamin. 5. Enteric-coated aspirin 325 mg p.o. q.d. 6. Atenolol 25 mg p.o. q.d. 7. Imdur 30 mg p.o. q.d. 8. Plavix 75 mg p.o. q.d. 9. Insulin NPH 10 units q.a.m. ALLERGIES: PENICILLIN, TETRACYCLINE, AZATHIOPRINE, PROCARDIA. HOSPITAL COURSE: The catheterization showed diffuse 3-vessel coronary artery disease. The left main coronary artery had 40% distal stenosis. The left anterior descending artery was diffusely diseased with serial 50% lesions. The dominant left circumflex artery had a diffusely disease mid vessel, and the first posterior descending artery was normal. The origin of the bifurcating first obtuse marginal branch with a 60% stenosis, and there was a long diffuse 60% stenosis distal to the previously placed stent with a long 90% stenosis in the lower pole. The patient was awaiting coronary artery bypass graft on the floor when she went into flash pulmonary edema and was intubated. She was believed at that point not to be an appropriate surgical candidate and was sent back to the catheterization laboratory for a therapeutic catheterization. Successful percutaneous transluminal coronary angioplasty of the bifurcating obtuse marginal branch was performed proximal to the bifurcation but distal to the previously placed stent. The patient was transferred to the Coronary Care Unit where she experienced a prolonged intubation due to persistent sedation. Neurology was consulted, and a magnetic resonance imaging was done which was nondiagnostic secondary to motion defect. An electroencephalogram was done as well showing nonspecific flowing pattern. As no other organic causes were found, the patient's prolonged sedation was felt to be a result of a hypoxic brain injury. All sedatives were held, and one week after being unresponsive even to painful stimuli, the patient began to awaken. She was extubated successfully and had rapid improvement. During her intubation, the patient spiked a fever and was pan cultured. She was found to have sputum positive for levofloxacin-resistant Staphylococcus aureus. All other cultures, including blood and urine, were otherwise negative. The patient was initially started on vancomycin and levofloxacin. Vancomycin was discontinued after five days when sensitivities returned. The patient was to be continued on levofloxacin orally for a 14-day course. MEDICATIONS ON DISCHARGE: 1. Atorvastatin 20 mg p.o. q.d. 2. Aspirin 325 mg p.o. q.d. 3. Plavix 75 mg p.o. q.d. 4. Lisinopril 20 mg p.o. q.d. 5. Lasix 80 mg p.o. q.d. 6. Metoprolol-XL 100 mg p.o. q.d. 7. NPH 10 units q.a.m. 8. Levofloxacin 500 mg p.o. q.d. (started on [**2127-8-12**]; to be completed on [**2127-8-26**]). CONDITION AT DISCHARGE: Condition on discharge was stable. DISCHARGE STATUS: Discharged to a rehabilitation facility. CODE STATUS: Full code. DISCHARGE FOLLOWUP: The patient was to follow up with her primary care physician (Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]) within two weeks. [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 4786**] Dictated By:[**Last Name (NamePattern4) 8500**] MEDQUIST36 D: [**2127-8-20**] 16:01 T: [**2127-8-26**] 08:22 JOB#: [**Job Number **] Name: [**Known lastname 15272**], [**Known firstname 6758**] Unit No: [**Numeric Identifier 15273**] Admission Date: [**2127-8-5**] Discharge Date: [**2127-8-20**] Date of Birth: [**2049-11-14**] Sex: F Service: ADDENDUM: Patient's past medical history includes: 1. Coronary artery disease status post myocardial infarction on [**2-2**], [**6-20**]. 2. Congestive heart failure with an ejection fraction of 20% (resting regional wall motion abnormalities including mid to distal anterior, septal and apical akinesis with hypokinesis elsewhere). 3. Hypertension. 4. PVD status post bilateral lower extremity toe amputation. 5. Hip fracture times two, left shoulder fracture. 6. Degenerative joint disease. 7. Chronic obstructive pulmonary disease. DR.[**Last Name (STitle) **],[**First Name3 (LF) **] 12-255 Dictated By:[**Last Name (NamePattern4) 15275**] MEDQUIST36 D: [**2127-8-20**] 16:04 T: [**2127-8-21**] 12:13 JOB#: [**Job Number 15276**] Name: [**Known lastname 15272**], [**Known firstname 6758**] Unit No: [**Numeric Identifier 15273**] Admission Date: [**2127-8-5**] Discharge Date: [**2127-8-20**] Date of Birth: [**2049-11-14**] Sex: F Service: ADDENDUM: Patient's past medical history includes: 1. Coronary artery disease status post myocardial infarction on [**2-2**], [**6-20**]. 2. Congestive heart failure with an ejection fraction of 20% (resting regional wall motion abnormalities including mid to distal anterior, septal and apical akinesis with hypokinesis elsewhere). 3. Hypertension. 4. PVD status post bilateral lower extremity toe amputation. 5. Hip fracture times two, left shoulder fracture. 6. Degenerative joint disease. 7. Chronic obstructive pulmonary disease. DR.[**Last Name (STitle) **],[**First Name3 (LF) **] 12-255 Dictated By:[**Last Name (NamePattern4) 15275**] MEDQUIST36 D: [**2127-8-20**] 16:04 T: [**2127-8-21**] 12:13 JOB#: [**Job Number 15276**]

[ "428.0", "997.02", "038.11", "414.00", "411.1", "424.0", "496", "348.1", "518.5" ]

icd9cm

[ [ [] ] ]

[ "96.04", "88.56", "88.53", "36.01", "96.72", "37.22" ]

icd9pcs

[ [ [] ] ]

2771, 3087

300, 628

646, 2745

3102, 3225

3246, 5757

115, 274

49,840

128,177

50885

Discharge summary

report

Admission Date: [**2162-9-9**] Discharge Date: [**2162-9-12**] Date of Birth: [**2110-10-11**] Sex: M Service: MEDICINE Allergies: Adhesive Tape / Ibuprofen Attending:[**First Name3 (LF) 425**] Chief Complaint: Shortness of breath and palpitations. Major Surgical or Invasive Procedure: none History of Present Illness: 51 y/o gentleman with morbid obesity, HTN, lymphedema, who presents with new onset atrial fibrillation. The patient recently was hospitalized in late [**Month (only) **] after a fall and right lower extremity pain. He was discharged to [**Hospital1 **] and went home one week ago. He saw his PCP two days ago and found to have wheezing. That evening he developed shortness of breath. Yesterday he developed worsening shortness of breath at around 10 AM which limited his walking to approx [**10-7**] steps. He was able to walk 0.5 miles without limitation approx 3 days ago. Yesterday patient also experienced palpitations. His visiting nurse was concerned and recommended that patient comes to ED. . 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. Patient has experienced chills overnight. All of the other review of systems were negative. . Cardiac review of systems is notable for absence of chest pain, syncope or presyncope. . In the ED, initial vitals were T 96.5 BP 93/38 HR 144 RR 22 96% RA. Patient recieved 10 mg IV dilt, 3L NS, cipro 400 mg IV x1, flagyl 500 mg IV x 1, Zofran IV 4 mg x2, Kayaxelate 30 ml PO x 1. He also recieved Ipratropium neb x 1. His HR improved to 80-90s. He was also started on heparin gtt. Past Medical History: Hypertension Obesity, Gastric bypass [**2152**] c/b ventral hernia s/p multiple repairs Depression MVA - remote, with fracture right upper extremity, s/p ORIF Cellulitis Chronic right lower extremity cellulitis and lymphedema Social History: Non-smoker. Denies EtOH or drug use. Patient is on disability. Lives by himself in an apartment in [**Location (un) 86**]. Family History: Lung CA in mother and father, both were smokers, and both died of this, his mother at age 39. His sister has ovarian ca. His father also had gout. Physical Exam: VS: T=97.3 BP=121/92 HR=96 RR=14 O2 sat= 98% in 3LNC GENERAL: Pleasant gentleman in NAD. Oriented x3. Mood, affect appropriate. Morbidly obese. HEENT: NCAT. Sclera anicteric. EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple with JVP of 8 cm. CARDIAC: normal S1, S2 irregularly irregular. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. ABDOMEN: Soft, ND. Mild tenderness in periumblical area. EXTREMITIES: 2+ BLE pitting edema, darkened skin in RLE. Pertinent Results: [**2162-9-9**] 01:00PM BLOOD WBC-11.3*# RBC-4.15* Hgb-9.9* Hct-33.3* MCV-80* MCH-24.0* MCHC-29.9* RDW-17.4* Plt Ct-488*# [**2162-9-10**] 02:00AM BLOOD WBC-11.1* RBC-3.52* Hgb-8.8* Hct-27.6* MCV-78* MCH-25.0* MCHC-32.0 RDW-17.7* [**2162-9-11**] 05:40AM BLOOD WBC-9.7 RBC-3.88* Hgb-9.4* Hct-30.6* MCV-79* MCH-24.2* MCHC-30.7* RDW-17.9* [**2162-9-9**] 01:00PM BLOOD Neuts-80.3* Lymphs-13.3* Monos-4.9 Eos-0.9 Baso-0.5 [**2162-9-10**] 02:00AM BLOOD Neuts-77.5* Lymphs-13.4* Monos-7.4 Eos-1.3 Baso-0.4 [**2162-9-11**] 05:40AM BLOOD Neuts-76* Bands-5 Lymphs-10* Monos-6 Eos-3 Baso-0 Atyps-0 Metas-0 Myelos-0 [**2162-9-11**] 05:40AM BLOOD Hypochr-2+ Anisocy-NORMAL Poiklo-OCCASIONAL Macrocy-NORMAL Microcy-2+ Polychr-NORMAL [**2162-9-9**] 01:00PM BLOOD PT-15.3* PTT-26.2 INR(PT)-1.3* [**2162-9-10**] 02:00AM BLOOD PT-16.1* PTT-47.5* INR(PT)-1.4* [**2162-9-11**] 05:40AM BLOOD PT-16.1* PTT-69.5* INR(PT)-1.4* [**2162-9-12**] 05:23AM BLOOD PT-20.0* PTT-90.4* INR(PT)-1.8* [**2162-9-9**] 01:00PM BLOOD Glucose-121* UreaN-14 Creat-0.8 Na-138 K-5.6* Cl-102 HCO3-25 AnGap-17 [**2162-9-10**] 02:00AM BLOOD Glucose-107* UreaN-14 Creat-0.8 Na-143 K-5.0 Cl-108 HCO3-25 AnGap-15 [**2162-9-11**] 05:40AM BLOOD Glucose-104 UreaN-12 Creat-0.8 Na-141 K-3.9 Cl-105 HCO3-27 AnGap-13 [**2162-9-12**] 05:23AM BLOOD Glucose-101 UreaN-10 Creat-0.8 Na-140 K-3.6 Cl-103 HCO3-26 AnGap-15 [**2162-9-9**] 01:00PM BLOOD ALT-12 AST-14 CK(CPK)-24* AlkPhos-114 [**2162-9-10**] 02:00AM BLOOD CK(CPK)-31* [**2162-9-9**] 01:00PM BLOOD CK-MB-NotDone cTropnT-<0.01 [**2162-9-9**] 01:00PM BLOOD Calcium-9.2 Phos-3.5 Mg-2.2 [**2162-9-10**] 02:00AM BLOOD Calcium-8.6 Phos-4.0 Mg-2.1 [**2162-9-11**] 05:40AM BLOOD Calcium-8.6 Phos-3.4 Mg-2.0 [**2162-9-12**] 05:23AM BLOOD Calcium-8.7 Phos-3.2 Mg-1.9 [**2162-9-9**] 01:00PM BLOOD TSH-2.0 [**2162-9-9**] 01:00PM BLOOD ASA-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2162-9-9**] 01:07PM BLOOD Lactate-2.6* [**2162-9-9**] 11:45PM URINE bnzodzp-NEG barbitr-NEG opiates-POS cocaine-NEG amphetm-NEG mthdone-NEG [**2162-9-9**] 10:20PM URINE RBC-167* WBC-0 Bacteri-NONE Yeast-NONE Epi-0 [**2162-9-9**] 10:20PM URINE Blood-MOD Nitrite-NEG Protein-30 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-4* pH-6.5 Leuks-NEG [**2162-9-9**] 10:20PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]->1.050* . Urine culture [**9-9**] x2 - neg Blood culture [**9-9**] x3 - neg . CT abd/pelv and CTA chest [**2162-9-9**]: 1. No pulmonary embolism identified. 2. Large fluid collection surrounding a hernia mesh within the ventral abdominal wall. Though this could reflect a postoperative seroma, superinfection cannot be excluded. . CXR portable [**2162-9-9**]: The cardiomediastinal silhouette is unchanged. The widened superior mediastinum is compatible with the known mediastinal lipomatosis. There is linear atelectasis in the right middle lung field. No focal consolidation is noted. The pulmonary vasculature and hilar contours are otherwise unremarkable. The degenerative changes are noted in the underlying thoracolumbar spine. IMPRESSION: No acute intrathoracic process. . TTE [**2162-9-10**]: The left atrium is mildly dilated. 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 60%). There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The aortic root is moderately dilated at the sinus level. The aortic arch is moderately dilated. There are focal calcifications in the aortic arch. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. . Abd Xray supine and erect [**2162-9-11**]: A nonspecific bowel gas pattern is visualized. Surgical clips are present, consistent with recent surgery. . Labs upon discharge: Brief Hospital Course: Mr. [**Known lastname **] is a 51 year old gentleman with a past medical history of morbid obesity, hypertension, and lymphedema, who presents with symptomatic new onset atrial fibrillation. On [**9-12**], Mr. [**Known lastname **] was discharged from [**Hospital1 771**] in good condition, with stable vital signs, and with appropriate outpatient follow-up care arranged. Mr. [**Known lastname 105797**] hospital course was notable for: . # atrial fibrillation- The patient was seen and evaluated for new-onset atrial fibrillation. He was admitted to the hospital and monitored on telemetry. The precipitant of this episode was not clear. He was started on Metoprolol XL 200 mg daily and discharged on this medication. During his hospitalization Mr. [**Known lastname **] remained intermittently in this rhythm. During episodes when he was in this rhythm he was asymptomatic, denying chest pain, chest discomfort, palpitations, and shortness of breath. Cardioversion was discussed but was deferred since the patient was never symptomatic. . #Anticoagulation- Due to new onset atrial fibrillation, upon admission Mr. [**Known lastname **] was started on a Heparin drip, and oral coumadin. He was discharged with a prescription for Coumadin and with follow-up arranged at the [**Hospital1 **] [**Hospital3 **]. The patient also received 81 mg aspirin daily while in the hospital. . #Abdominal pain- While hospitalized, on a few occasions Mr. [**Known lastname **] complained of abdominal pain, focused around the area of his ventral hernia repair. A thorough evaluation, including consultation with gastrointestinal surgery, revealed that the patient had a seroma, which was stable and unlikely to be infected. He was briefly started on Ciprofloxacin and Flagyl for concern of possible infection, but these medications were discontinued shortly thereafter. His fever curve was trended carefully, as was his white blood cell count. The patient remained afebrile and his leukocytosis upon admission resolved spontaneously. . # Hyperkalemia: On admission the patient was noted to have a serum potassium of 5.6. He was given Kayexelate in the Emergency Department, and his hyperkalemia resolved. His serum potassium was checked daily during his hospitalization, and he was placed on telemetry, and the patient was normokalemic thereafter. . On [**9-12**], the patient's symptoms had resolved and he was discharged to his facility of residence, in good condition, with stable vital signs, and with appropriate outpatient follow-up care arranged. The following medication changes were made: START Metoprolol XL 200 mg daily STOP Atenolol START Warfarin (Coumadin) 5 mg daily Medications on Admission: -Cholecalciferol (Vitamin D3) 1,000 unit Tab 1 daily -Calcium Citrate twice a day -Multivitamins Chewable a day -Atenolol 25 mg once a day -lasix 40 mg once a day -Lisinopril 10 mg once a day -Omeprazole 20 mg once a day -Vitamin B-12 1,000 mcg once a day -tramadol 50 mg [**12-25**] Q6 hours PRN -Docusate Sodium 100 mg twice a day -Ferrous Sulfate 325 mg daily -Gabapentin 800 mg three times a day -lidocaine 5 % (700 mg/patch) Adhesive Patch every 12 hours . Discharge Medications: 1. Tramadol 50 mg Tablet Sig: 1-2 Tablets PO every six (6) hours as needed for pain. 2. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 3. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). Disp:*30 Tablet, Chewable(s)* Refills:*2* 6. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr Sig: Two (2) Tablet Sustained Release 24 hr PO DAILY (Daily). Disp:*60 Tablet Sustained Release 24 hr(s)* Refills:*2* 7. Cholecalciferol (Vitamin D3) 1,000 unit Tablet Sig: One (1) Tablet PO once a day. 8. Calcium Citrate 200 mg (950 mg) Tablet Sig: One (1) Tablet PO twice a day. 9. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day. 10. Vitamin B-12 1,000 mcg Tablet Sig: One (1) Tablet PO once a day. 11. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO twice a day. 12. Gabapentin 800 mg Tablet Sig: One (1) Tablet PO three times a day. 13. Outpatient Lab Work Please check INR on monday, [**2162-9-13**]. Please forward the results to Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], telephone [**Telephone/Fax (1) 1247**], fax [**Telephone/Fax (1) 3382**]. 14. Warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM. Disp:*30 Tablet(s)* Refills:*3* 15. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home With Service Facility: Art of care Discharge Diagnosis: Primary Diagnosis: New-onset atrial fibrillation Secondary Diagnoses: Hypertension Obesity Depression Chronic right lower extremity cellulitis and lymphedema Discharge Condition: stable and improved Discharge Instructions: You were admitted to the hospital with an abnormal heart rhythm called atrial fibrillation. You received medication to slow your heart rate down and a medication to prevent blood clots from forming in your heart. You were initially monitored in the ICU, you did well, and were transferred to the floor, and continued to do well. You are being discharged with the following medication changes: START Metoprolol XL 200 mg daily STOP Atenolol START Warfarin (Coumadin) 5 mg daily Warfarin thins your blood. Your VNA needs to draw INR (blood thinning level) on Monday and forward the result to Dr.[**Last Name (STitle) **]. He will make the necessary changes to the Wafarin dose. . If you experience any chest pain, worsening shortness of breath, dizziness or other concerning symptoms, please return to the hospital or call your PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] at [**Telephone/Fax (1) 250**]. . Followup Instructions: Dr.[**Doctor Last Name 35583**] office is arranging a follow-up appointment for you. You will be contact[**Name (NI) **] with the date and time of the appointment. If you do not hear from them within the next few days, please call his office at [**Telephone/Fax (1) 62**] to make an appointment. . Please call to make an appointment to see your PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] ([**Telephone/Fax (1) 250**]) within one week. He will specifically need to follow-up on your INR (which measures your coumadin levels) that will be drawn by VNA on monday. . [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2967**], RNC Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2162-10-8**] 9:10 [**Hospital 6800**] CLINIC Phone:[**Telephone/Fax (1) 253**] Date/Time:[**2162-10-27**] 9:00 [**First Name11 (Name Pattern1) 354**] [**Last Name (NamePattern4) 3013**], M.D. Phone:[**Telephone/Fax (1) 253**] Date/Time:[**2162-10-27**] 9:30

[ "427.32", "401.9", "311", "682.6", "427.31", "276.7", "278.01", "V45.86" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

11845, 11887

7140, 9811

323, 330

12090, 12112

2980, 7099

13088, 14060

2196, 2345

10323, 11822

11908, 11908

9837, 10300

12136, 12512

2360, 2961

11979, 12069

12532, 13065

246, 285

7117, 7117

358, 1790

11927, 11958

1812, 2039

2055, 2180

11,723

111,882

28441

Discharge summary

report

Admission Date: [**2180-10-15**] Discharge Date: [**2180-11-10**] Date of Birth: [**2145-7-4**] Sex: F Service: MEDICINE Allergies: Compazine / Zosyn Attending:[**Last Name (NamePattern1) 1167**] Chief Complaint: Nausea, labored breathing Major Surgical or Invasive Procedure: cardiac catheterization endocardial biopsy History of Present Illness: 35yF with multiple medical problems (including SLE, restrictive lung disease, global cardiomyopathy with severely depressed systolic function, nephrotic syndrome), with recent admission [**Date range (1) 68983**] for nausea, vomiting, and diarrhea, re-admitted with shortness of breath, tachycardia, and persistent nausea. Her symptoms began in [**Month (only) **] (after a recent hospitalization), when she developed diarrhea (which she relates to her metoprolol). The diarrhea (multiple times daily, non-bloody, brown in color) initially improved but then worsened again. She then developed nausea, vomiting, and dry heaves, without abdominal pain, and was admitted on [**10-10**]. She also reported worsening shortness of breath, 3 pillow orthopnea, and episodes of paroxysmal nocturnal dyspnea. She was felt to be intravascularly dry, so she was given IV fluids. She had a thorough workup for causes of her diarrhea (infectious, structural, medication related etc.) and was scheduled for GI follow up on [**10-16**]. During the admission, an echocardiogram was performed, demonstrating worsening systolic function (EF 15-20%), but she was felt to be intravascularly dry, so her Lasix was held. Given the patient's concern that her diarrhea started at the same time as metoprolol (75mg daily), this medication was also stopped (and switched to carvedilol 3.125mg [**Hospital1 **]). She was to have close follow up with her cardiologist. She had acute on chronic renal failure which returned to close to baseline (1.5) with IV fluids; she had a renal biopsy during that admission, the results of which are still pending. Her Imuran was initially held during the last hospitalization but was restarted after a conversation with her [**Hospital1 112**] rheumatologist. During that hospitalization, her nausea was not fully explained, but there was a possibility that restarting her Imuran may have contributed. Her presentation today is similar. She has nausea and dry heaves (non-bloody, non-bilious), along with worsening shortness of breath/PND/orthopnea. Her husband (who follows her vitals closely) has noted increased blood pressures and heart rates since she was discharged from the hospital. Given her worsened nausea and tachycardia to the 120's, he brought her to the hospital. She denies any history of blood clot (but had IUFD at 21wks recently). In the ED, triage vitals were T97.6F, HR 124, BP 126/109, RR 18, Sat 100%. She was given 4mg IV ondansteron x 2, in addition to ceftriaxone and azithromycin given an equivocal chest x-ray. She was transferred to the floor for further evaluation. Her respiratory rate was noted to be as high as 33. On review of systems, she reports nausea and vomiting, as well as shortness for breath and orthopnea as above. Diarrhea is unchanged. She denies fevers, chills, chest pain (but perhaps some chest "heaviness"), palpitations, pleuritic chest pain, cough, weakness, numbness, tingling, abdominal pain, constipation, hematemesis, hematochezia, urinary symptoms. Past Medical History: - SLE: diagnosed in [**2168**], manifested by kidney disease (membranous nephropathy by report of biopsy), facial rash, Sjogren's syndrome, Raynaud's phenomenon, and pleuritis - Gastritis - Restrictive lung disease: followed by Dr. [**Last Name (STitle) **], noted to be moderate to severe on PFTs completed 5/[**2179**]. - History of pancytopenia associated with varicella zoster infection - History of persistent thrombocytopenia - Baseline proteinuria (Cr 0.8-0.9 pre-pregnancy) - Intrauterine fetal demise [**7-/2180**] (at gestational age ~21wks) - Right- and left-sided cardiomyopathy (EF estimated 15-20% in [**9-/2180**]) Social History: Patient is a computer programer in [**Location (un) 745**] and married. She was accompanied at presentation by her husband [**Name (NI) **] and sister. She denies tobacco or EtOH. Family History: Adopted Physical Exam: Vitals: T94.5F (oral, repeat axillary temp was 95.4F), BP 120/94, HR 120, RR 40, Sat 95%RA General: Moon facies, chronically ill-appearing, tachypneic, in mild respiratory distress; malar rash present HEENT: EOMI, PERRL, anicteric, OP clear Heart: Tachycardic without murmurs Lungs: Clear to auscultation bilaterally, no crackles appreciated Back: No CVA tenderness, no spinal tenderness Abd: Soft, non-tender, non-distended, + bowel sounds, no hepatosplenomegaly Extremities: No clubbing, cyanosis; 1+ DP pulses bilaterally; 2+ pitting edema in feet to mid-shin bilaterally (L>R) Neuro: A&O x 3 Pertinent Results: Urine: Yellow, Hazy, SpecGr 1.022, pH 6.0, Sm leuk, Sm blood, 500 prot, [**1-20**] RBC, few bacteria, 0-2 epi Na 133 K 4.3 Cl 101 HCO3 18 BUN 33 Creat 1.4 Gluc 100 CK: 13 MB: Notdone Trop-T: 0.04 ALT: 29 AST: 34 AP: 121 Tbili: 0.3 Lip: 64 proBNP: [**Numeric Identifier 68984**] WBC 5.6 N:81.3 L:12.8 M:5.3 E:0.4 Bas:0.2 Hgb 12.1 Hct 37.5 Plt 137 MCV 96 PT: 11.7 PTT: 24.4 INR: 1.0 CXR [**10-15**] PA/Lat (prelim): Retrocardiac opacification which may represent atelectasis vs. pneumonia; bibasilar effusions and increased hilar infiltrates suggestive of volume overload; stable moderate cardiomegaly. ECG [**10-15**]: Sinus tachycardia. Leftward axis, normal intervals. TWF in I, II, V5-V6 (interpreted as pseudonormalization in ED, but unimpressive). [**Month/Year (2) **] [**10-11**]: The left atrium is elongated. No atrial septal defect is seen by 2D or color Doppler. The right atrial pressure is indeterminate. Left ventricular wall thicknesses are normal. The left ventricular cavity is mildly dilated. There is severe global left ventricular hypokinesis (LVEF = 15-20 %). No masses or thrombi are seen in the left ventricle. There is no ventricular septal defect. RV with severe global free wall hypokinesis. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are structurally normal. There is no mitral valve prolapse. Moderate (2+) mitral regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. Compared with the prior study (images reviewed) of [**2180-7-24**], the LV cavity size has increased and the LVEF is slightly lower (LVEF OVERestimated on prior study). RV dysfunction is now more prominent. . The left atrium is elongated. Left ventricular wall thicknesses and cavity size are normal. There is moderate global left ventricular hypokinesis. Quantitative (biplane) LVEF = 33 %. Right ventricular chamber size is normal with borderline normal free wall systolic function. 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 regurgitation. The mitral valve leaflets are structurally normal. There is no mitral valve prolapse. Moderate (2+) mitral regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. . [**Year (4 digits) **] [**2180-11-6**] Left ventricular wall thicknesses are normal. The left ventricular cavity is mildly dilated. There is moderate to severe global left ventricular hypokinesis (LVEF = 30 %). Right ventricular chamber size is normal. with borderline normal free wall function. 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. There is moderate thickening of the mitral valve chordae. Moderate to severe (3+) mitral regurgitation is seen. Moderate [2+] tricuspid regurgitation is seen. There is moderate pulmonary artery systolic hypertension. Significant pulmonic regurgitation is seen. There is no pericardial effusion. [**Month/Day/Year **] [**2180-11-9**] Compared with the prior study (images reviewed) of [**2180-11-6**], left ventricular cavity size is smaller, global systolic function is improved (quantitative biplane LVEF 30% on review of prior study), and the severity of mitral regurgitation and estimated pulmonary artery systolic pressure are reduced. Brief Hospital Course: 35yF with multiple medical problems (including SLE, restrictive lung disease, global cardiomyopathy with severely depressed systolic function, nephrotic syndrome), with recent admission [**Date range (1) 68983**] for nausea, vomiting, and diarrhea, admitted with shortness of breath, tachycardia, and persistent nausea. . #) Cardiomyopathy: Pt was initially admitted to the hospitalist service but transferred for cath and endocardial biopsy in the setting of worsening EF. Her cardiomyopathy was thought to be due to lupus. Peripartum cardiomyopathy was also considered however given the timing of onset and biopsy showing immune complexes seen on endocardial biopsy, lupus cardiomyopathy was thought to be more likely. She was treated with steroids, cytoxan, plasmaphoresis, IVIG and supportive care, and improved from an EF of 15 to 33%. It is unclear which therapy led to improvement. She did require temporary CCU transfer for milrinone given worsening EF, however was weaned after a few days and transferred back to the floor in stable condition. Her mitral regurgitation and hypertension also contributed to her poor forward flow, and htn improved with diuresis, hydralazine, lisinopril and amlodipine. . #) sCHF, volume overload: On admission, pt was clearly tachypneic but satting well on room air. Reported 3 pillow orthopnea and paroxysmal noctural dyspnea, in the setting of recent d/c Lasix and IVF resuscitation, LE edema also suggested fluid overload. BNP extremely elevated at 65,187. She also had non-specific sxs concerning for HF including throat tightness and GI sxs. Her sxs improved with diuresis and symptomatic management and she was discharged on oral torsemide. She was also treated with BP control and bblocker therapy. Given her SOB and LE edema R>L, a LE US was performed and showed no LE clot, therefore PE was thought to be unlikely. . #) SLE. Pt diagnosed in [**2168**], manifested by kidney disease previously membranous nephropathy, facial rash, Sjogren's syndrome, Raynaud's phenomenon, and pleuritis. Previously followed by Dr. [**Last Name (STitle) 68981**] at B&W, however has requested to transfer her care to [**Hospital1 18**] after this admission. Initially contined on Plaquenil and Imuran, as well as prednisone. Plaquenil dc'd per rheumatology recs. Cardiomyopathy and renal failure on current admission were felt to be manifestation of underlying lupus. Rheumatology was consulted and recommended aggressive therapy with steriods, cytoxan and plasmapheresis. Received solumedrol 1g daily x 3 followed by solumedrol 30mg IV q12hrs, which was uptitrated to 60 q 12 hrs and subseuquently tapered and she was ultimately discharged on prednisone 60mg orally daily. She was also placed on atovaquone PCP prophylaxis in the setting of immunosuppression. She recieved 1 dose of cytoxan 750mg on [**10-20**] with mesna, cell counts with nadir on [**11-5**]. Prior to cytoxan, she received 7.5mg Lupron for ovarian protection with plans to pursue egg harvesting for fertility as an outpatient. Received 5 cycles of plasmapheresis. 3 doses of IVIG was also administered given that pts HF continued to worsen during the hospital stay. Additional plasmaphoreis was considered but held due to her continued improvement. . #) Nausea/diarrhea. Initially thought secondary to restarting Imuran, however pt and husband attributed to bblocker therapy. Most likely due to gut edema in the setting of right HF. GI was consulted and agreed however recommended ruling out infectious etiology given her immunosuppression; w/u was negative. She improved with symptomatic tx and treatment of her HH. . #) thrombocytopenia: Pt bleeding from HD site [**10-21**], improved with Cryo, Platelets, and Surgicel. Patient developed thrombocytopenia with nadir of 68, likely multifactorial related to dilution, imunnosupression, and possibly pheresis. Heme consulted and recommended removing ASA, NSAIDs, all heparin products, f/u LFTs, fibrinogen. Platelet drop was too quick to be related to Cytoxan and likelihood of developping 4T score is 3. HIT ab negative. Fibrinogen nomralized. Thrombocytopenia quickly improved, however then fluctuated in the setting of cytoxan use. IgG and IgM ACA negative, so unlikely to have prothrombotic state. . #) Acute on chronic RF: Pt with h/o SLE Nephritis. Pt previously with membranous nephropathy on prior biopsy. She had repeat biopsy showing type 3,4,5 lupus nephritis. Worsening renal failure with creatinine increased to 3.7 up from 1.4 on admission. Urine lytes indicative of prerenal ischemia (FeUrea < 0.02%) +/- evolving ATN likely from poor cardiac output/ cardiorenal syndrome. renal U/S show's no obstruction. While her renal function showed some initial worsening with diuresis, diuresis was continued due to continued volume overload, and creatinine remained stable. . # HTN: BPs improved with uptitration of hydralazine and addition of lisinopril. Pt concerned that hydralazine may be causing joint pain. Given this and her improved renal function, lisinopril was uptitrated and hydralazine discontinued. Blood pressures stable . # Anemia: Likely due to acute renal disease, cytoxan therapy. Pt was given one unit of PRBCs while in patient and started on epo with good improvement in her crit. . # Joint pain: ? medication side effect (IVIG, hydralazine) vs lupus flare, however pt has never had joint pain with lupus flares in the past. Hydralazine was discontinued, symptomatic relief with tylenol, PT. Medications on Admission: Pantoprazole 40 mg po BID Prednisone 15 mg qam and 5 mg qpm Vitamin D 400 units daily Calcium 500 mg twice daily Ferrous sulfate 325 mg once daily (not continued last admission) Multivitamin one tablet once daily (not continued last admission) Cyanocobalamin 1000 mcg injection once a month (not listed at last admission) Folic acid 1mg daily Furosemide 40 mg by mouth once daily (held after admission) Plaquenil 200 mg by mouth once daily Metoprolol 75 mg XL by mouth daily at bedtime (changed to carvedilol) Carvedilol 3.125mg [**Hospital1 **] Imuran 50 mg daily Discharge Medications: 1. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO once a day. 2. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times a day). 3. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: 2.5 Tablets PO DAILY (Daily). 4. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain: please do not exceed 3000mg/day. 5. Atovaquone 750 mg/5 mL Suspension Sig: Two (2) 5ml teaspoons PO DAILY (Daily). Disp:*300 ml* Refills:*2* 6. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 7. Epoetin Alfa 4,000 unit/mL Solution Sig: One (1) injection Injection QMOWEFR ([**Hospital1 766**] -Wednesday-Friday). Disp:*12 injections* Refills:*2* 8. Carvedilol 12.5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Disp:*120 Tablet(s)* Refills:*2* 9. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO BID (2 times a day). Disp:*300 ML(s)* Refills:*2* 10. Amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 11. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 12. Prednisone 20 mg Tablet Sig: Three (3) Tablet PO once a day. Disp:*90 Tablet(s)* Refills:*0* 13. Hydrocortisone 2.5 % Cream Sig: One (1) Appl Rectal Q DAY (). Disp:*1 tube* Refills:*2* 14. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 15. Torsemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Primary Systemic Lupus Erythematosus Associated Cardiomyopathy. . Secondary Systemic Lupus Erythematosus Hypertension Persistent Thrombocytopenia Discharge Condition: stable, good, baseline ambulatory and mental status Discharge Instructions: You were admitted to the hospital because you were having nausea shortness of breath. You were found to have a lupus induced cardiomyopathy causing heart failure. You received immunosuppressive medications to control your immune system and your heart function improved as shown on serial echos. You received diuretics to remove the fluid that accumulated due to the heart failure, and medications to control your blood pressure. . The following changes were made to your medications. We STOPPED: plaquenil . We changed to: carvedilol 25mg twice a day vitamin D 1000mg daily . We added: lisinopril 20mg daily torsemide 20mg twice a day hydrocortisone 2.5% rectal cream 1 application per rectum daily with rectal pain spironolactone 25mg daily amlodipine 10mg daily ferrous sulphate 325mg daily erythropoeitin Alfa 4000 unit SC injection MWF atovaquone suspension 1500mg daily while on prednisone nyastatin 5ml p.o [**Hospital1 **] as needed for oral thrush . Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more than 3 lbs. Followup Instructions: 1.Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 4900**], MD Phone:[**Telephone/Fax (1) 2226**] Date/Time:[**2180-11-13**] 8:00 . 2.MD: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5700**] Specialty: PCP [**Name Initial (PRE) 2897**]/ Time: Thursday, [**11-24**] at 3:15pm Location: [**Apartment Address(1) 68985**], [**Location (un) 583**], MA Phone number: [**Telephone/Fax (1) 31923**] . 3.Cardiology [**Telephone/Fax (1) **] Lab Specialty: Cardiology Date/ Time: [**Last Name (LF) 766**], [**11-21**] at 3:00pm Location: [**Location (un) **], [**Hospital Ward Name 23**] Bldg [**Location (un) **], [**Location (un) 86**], MA Phone number: [**Telephone/Fax (1) 62**] . 4.MD: Dr. [**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) 437**] Specialty: Cardiology Date/ Time: [**Last Name (LF) 766**], [**11-21**] at 4:00pm Location: [**Location (un) **], [**Hospital Ward Name 23**] Bldg [**Location (un) **], [**Location (un) 86**], MA Phone number: [**Telephone/Fax (1) 62**]

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icd9cm

[ [ [] ] ]

[ "88.56", "38.93", "39.95", "99.71", "99.14", "37.23", "37.25", "38.95", "88.52" ]

icd9pcs

[ [ [] ] ]

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8502, 14013

313, 358

16399, 16453

4914, 8479

17549, 18591

4274, 4283

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16477, 17526

4298, 4895

248, 275

386, 3406

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4076, 4258

18,187

174,185

633

Discharge summary

report

Admission Date: [**2162-8-8**] Discharge Date: [**2162-8-12**] Date of Birth: [**2103-3-15**] Sex: F Service: MEDICINE Allergies: Tetracycline Attending:[**First Name3 (LF) 3624**] Chief Complaint: Epigastric Pain Major Surgical or Invasive Procedure: None History of Present Illness: This is a 59 year old woman with history of HTN, DM, s/p renal transplant in [**2150**], currently on cellcept and cyclosporine presents with one week of nausea and vomiting. One week prior to presentation she has acute onset of nausea, vomiting and abd pain. She did not notice any blood in the vomitus. Her pain was [**8-2**], epigastric and radiated to the back. She has not had pain like this before. She denies drinking alcohol. No recent spider bites. No change in her weight recently. No personal or family history of cancer. She was recently admitted at [**Hospital1 **] for dyspnea attributed to pulmonary edema/fluid overload. ECHO [**6-1**] shows mild LVH and EF 55%. Prior to this she was admited for E. coli pyelonephritis and was treated with Zosyn and ciprofloxacin. She has history of ESRD s/p cadaveric renal transplant in [**2150**]. She has a baseline cre of 2.5 (near her baseline). She has been mantained on immunosupression with prednisone, cellcept and cyclosporin (all of these were started more than one year ago without recent changes). She also takes EPO for anemia. . In the ED, initial vs were: 97.4 63 160/63 18 99. Patient was placed NPO and given morphine for pain and ondasentron. RUQ US showed a distened GB but without stones. No CBD dilatation. CXR without acute changes. While in the ED her urine output was 150 cc over a period of 5 hrs. She received 1 lt NS. Prior to transfer her vitals were 97.6 60 149/44 18 99RA. . Review of sytems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denied cough, shortness of [**Year (4 digits) 1440**]. Denied chest pain or tightness, palpitations. Denied nausea, vomiting, diarrhea, constipation or abdominal pain. No recent change in bowel or bladder habits. No dysuria. Denied arthralgias or myalgias Past Medical History: 1. Hypertension 2. Diabetes-45+ years, type I 3. Status post renal transplant in [**0-0-**] crt 1.3-1.6 4. Sciatica 5. Multinodular goiter 6. Cataract surgery. 7. Hyperlipidemia. 8. Depression. 9. History of vertigo. 10. History of nephrolithiasis. 11. s/p left eye vitreous hemorrhage Social History: The patient is divorced with two adult children. She lives alone in a one family house with stairs. Her two daughters and ex-husband see her regularly and lve near by. No tobacco, ETOH, illicit drug use. From [**Location (un) 4708**]. Family History: Father with CAD, died age 55yo 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, rhonchi CV: Regular rate and rhythm, normal S1 + S2, systolic murmur left sternal border [**2-26**], rubs, gallops Abdomen: diffusely ttp, more pronounced on epigastrium, no rebound tenderness or guarding, no organomegaly, no [**Doctor Last Name 4862**] or [**Last Name (un) 4863**] signs. GU: foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Pertinent Results: . ADMISSION LABS: [**2162-8-8**] 01:40PM BLOOD WBC-15.5* RBC-5.16 Hgb-12.4 Hct-41.3 MCV-80* MCH-24.0* MCHC-30.0* RDW-16.9* Plt Ct-272 [**2162-8-8**] 01:40PM BLOOD Neuts-83.3* Lymphs-12.0* Monos-3.5 Eos-1.0 Baso-0.1 [**2162-8-8**] 01:40PM BLOOD PT-12.2 PTT-27.1 INR(PT)-1.0 [**2162-8-8**] 01:40PM BLOOD Glucose-185* UreaN-113* Creat-2.5* Na-133 K-4.6 Cl-101 HCO3-17* AnGap-20 [**2162-8-8**] 01:40PM BLOOD ALT-8 AST-15 AlkPhos-163* TotBili-0.4 [**2162-8-8**] 09:15PM BLOOD LD(LDH)-828* TotBili-0.4 [**2162-8-8**] 10:57PM BLOOD LD(LDH)-260* TotBili-0.3 [**2162-8-8**] 01:40PM BLOOD Lipase-2812* [**2162-8-8**] 10:57PM BLOOD Lipase-1451* GGT-10 [**2162-8-8**] 09:15PM BLOOD TotProt-5.6* Albumin-3.1* Globuln-2.5 Calcium-8.2* Phos-6.8* Mg-2.0 [**2162-8-8**] 10:57PM BLOOD TotProt-4.8* Albumin-2.8* Globuln-2.0 Calcium-7.8* Phos-6.0* Mg-1.7 [**2162-8-8**] 09:15PM BLOOD Cyclspr-63* [**2162-8-8**] 10:57PM BLOOD Cyclspr-60* [**2162-8-9**] 09:21PM BLOOD Type-ART Temp-36.7 pO2-35* pCO2-46* pH-7.24* calTCO2-21 Base XS--8 [**2162-8-8**] 01:46PM BLOOD Lactate-1.7 [**2162-8-9**] 09:21PM BLOOD Glucose-134* Lactate-0.8 Na-132* K-4.7 Cl-103 [**2162-8-9**] 09:21PM BLOOD freeCa-1.21 . MICROBIOLOGY: MRSA SCREENING: NEG BLOOD CULTURE ON [**8-8**] X 2: NO GROWTH URINE CULTURE ON [**2162-8-8**]: NO GROWTH URINE CULTURE ON [**2162-8-10**]: [**2162-8-10**] 4:32 am URINE Source: Catheter. **FINAL REPORT [**2162-8-12**]** URINE CULTURE (Final [**2162-8-12**]): ESCHERICHIA COLI. >100,000 ORGANISMS/ML.. PRESUMPTIVE IDENTIFICATION. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI | AMPICILLIN------------ =>32 R AMPICILLIN/SULBACTAM-- 16 I CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CEFUROXIME------------ 4 S CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ =>16 R MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- <=16 S PIPERACILLIN---------- 32 I PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ 4 S TRIMETHOPRIM/SULFA---- =>16 R DISCHARGE LABS: [**2162-8-12**] 04:55AM BLOOD WBC-8.8 RBC-3.94* Hgb-9.4* Hct-32.5* MCV-83 MCH-23.9* MCHC-29.0* RDW-16.2* Plt Ct-198 [**2162-8-11**] 05:15AM BLOOD PT-13.1 PTT-32.5 INR(PT)-1.1 [**2162-8-12**] 04:55AM BLOOD Glucose-140* UreaN-89* Creat-2.2* Na-136 K-4.6 Cl-105 HCO3-20* AnGap-16 [**2162-8-10**] 05:40AM BLOOD ALT-7 AST-11 LD(LDH)-180 AlkPhos-142* TotBili-0.3 [**2162-8-12**] 04:55AM BLOOD Lipase-276* [**2162-8-12**] 04:55AM BLOOD Calcium-8.4 Phos-4.8* Mg-2.4 IMAGING: CXRAY ON [**2162-8-8**]: CHEST, AP AND LATERAL: There has been interval removal of a right PICC. The lung volumes are low, with accentuation of the cardiomediastinal contours. The heart is stable in size. Atherosclerotic calcifications of the aortic arch are noted. Aside from minimal discoid atelectasis in the left lower lung, the lungs are clear without consolidation or edema. There is no pleural effusion or pneumothorax. IMPRESSION: Low lung volumes and minimal left lower lung atelectasis. LIVER AND GALLBLADDER US ON [**2162-8-8**]: FINDINGS: No focal hepatic lesion is identified. The portal vein is patent with hepatopetal flow. There is no evidence of gallstones, gallbladder wall thickening, or pericholecystic fluid. There is no intra- or extra- hepatic biliary ductal dilatation with the CBD measuring 6 mm. Limited views of the pancreatic head and body are unremarkable, without a focal lesion. Limited views of the right kidney reveal an atrophic native right kidney. IMPRESSION: No evidence of gallstones or acute cholecystitis. ECHO [**6-1**] The left atrium is mildly dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion . EKG ON [**2162-8-8**]: Sinus bradycardia. Possible left atrial abnormality. Left bundle-branch block. Compared to the previous tracing of [**2162-6-8**] the heart rate is slower. Intervals Axes Rate PR QRS QT/QTc P QRS T 56 178 146 470/463 53 -23 122 Brief Hospital Course: 59 year old woman with history of HTN, DM, s/p renal transplant in [**2150**], currently on cellcept and cyclosporine presents with one week of nausea and vomiting, who was found to have an elevated lipase, AP and leukocytosis consistent with pancreatitis. . # Abdominal pain/Nausea and vomiting: Pt presented with one wk of nausea/vomiting and was found to have elevated lipase (2812 at admission) and Alk Phos (160) with leukocytosis (WBC at 15). She also complained of epigastric pain radiating to her back level [**8-2**]. These findings were consistent with pancreatitis. The etiologies of her acute pancreatitis was not clear. The differential diagnosis included biliary causes including gall stones, however this is less likely given that US of RUQ did not show gall stones. This still not completely excluded given that she could have passed the stone. This could also be due to gall bladder sludge. Another common cause is alcohol which the patient denies having any alcohol intake. She has a history of hyperlipilipidemia but this is well controlled as of [**5-1**] (total chol 158, HDL60, LDL 82, TG 80). She was on Immuno suppressant meds, so opportunist infections that can cause pancreatitis were also in the differential. These include cytomegalovirus, varicella-zoster virus, herpes simplex virus, and parasites (Toxoplasma, Cryptosporidium). This is however less likely and pt had negative blood cultures. Medications can also cause acute pancreatitis. Patient has been on tetracyclin for recurrent UTIs and on meridia which are likely culprits. GI was consulted and these meds were stopped. She was also started on ursodiol 600 mg [**Hospital1 **] for gallbladder sludge. There was also recommendation for MRCP if pt continued to be symptomatic. She was initially treated with supportive therapy with NPO, IV fluids and pain management. She was initially admitted to the ICU for close observation of SIRS and sent to the floor once stable. After stopping the tetracyclin and meridia her symptoms started to improved and pt had her diet advanced as tolerated. Her labs had also trended down with lipase quickly dropping to 246 and Alk phos to 140. Her epigastric and right upper quad pain had subsided and pt was able to tolerate small-mod amounts of solid food and appropriate amounts of fluids. . # CKI: Pt has a history of ESRD s/p cadaveric renal transplant in [**2150**]. She has a baseline cre of 2.5 (near her baseline). Her creatine trended down to the 2.2 by time of discharge. She has been maintained on immunosuppression with prednisone, cellcept and cyclosporin (all of these were started more than one year ago without recent changes). She initially had low UO in the ED and was given IV fluids which she responded to with appropriate UO. Her Cyclosporin levels were WNL at low 60s. She also takes EPO for anemia. She had prior admission for fluid overload which seen to be stable during this hospitalization. She was continued on her home meds. . # Recurrent UTIs: Pt had recurrent episodes of E.coli UTI for which she was taking tetracyclin for it. Tetracyclin was stopped since it was thought to be likely to be the cause of her pancreatitis. Her Urine culture grew E.coli resistant to: Ampicillin, cipro, gent, Bactrim, and zozyn. Pt was asymptomatic so no antibiotics were started. She had recent cystoscopy for evaluation of recurrent UTIs which showed apparently normal bladder by and normal bladder emptying. Pt will have close follow-up with ID to further decide antibiotic options for prophylaxis therapy. . # DM1 - She was diagnosed more than 45 years ago. Her last A1C=6.5% in [**Month (only) 116**] of 09. She was continued on her home Lantus and Humalog insulin sliding scale. Her glucose in the evening have been difficult to control and I attempted to get pt an appointment with [**Last Name (un) **] post discharge. [**Hospital **] clinic will call once they are able to arrange for appointment. . # HTN/diastolic CHF - Pt had recent admission for fluid overload. She has been stable during this admission. Continued her home dose of Losartan 100 mg Qday, Metoprolol 200 mg twice a day and lasix 80mg [**Hospital1 **]. . # Anemia: Pt on iron supplementation and on Epo injections weekly her Hct remained stable in the low 30s%. . # Hyperlipidemia - Continued home simvastatin . # Constipation - continue on colace and lactulose . # Gout - Her home renally dosed allopurinol was continued. . # Code - full code Medications on Admission: ACETAMINOPHEN-CODEINE [TYLENOL-CODEINE #3] - 300 mg-30 mg Tablet - one to two Tablet(s) by mouth twice a day ALBUTEROL - 90 mcg Aerosol - 2 puffs inh four times a day as needed for shortness of [**Hospital1 1440**] ALLOPURINOL - 100 mg Tablet - 1 Tablet(s) by mouth every other day CALCITRIOL - 0.25 mcg Capsule - one Capsule(s) by mouth daily CYCLOSPORINE - 25 mg Capsule - 1 Capsule(s) by mouth twice a day to be taken with 50mg tablet, for total 75mg twice daily CYCLOSPORINE MODIFIED - 50 mg Capsule - 1 Capsule(s) by mouth twice a day to be taken with 50mg tablet, for total 75mg twice daily EPOETIN ALFA [PROCRIT] - 20,000 unit/mL Solution - [**Numeric Identifier 389**] units weekly FLUTICASONE - 50 mcg/Actuation Spray, Suspension - one spray each nostril qd FUROSEMIDE - 40 mg Tablet - three Tablet(s) by mouth in the am, two tablets at night INSULIN ASPART [NOVOLOG] - 100 unit/mL Solution - 70 units 2-3 times a day INSULIN GLARGINE [LANTUS] - 100 unit/mL Solution - 25-30 units in am 25 u in the evening LACTULOSE - 10 gram/15 mL Solution - 30ml Solution(s) by mouth every 8 hours as needed LANCETS,THIN - - AS DIRECTED LOSARTAN [COZAAR] - 100 mg Tablet - 1 Tablet(s) by mouth once a day METOPROLOL TARTRATE - 100 mg Tablet - Two Tablet(s) by mouth twice a day MYCOPHENOLATE MOFETIL [CELLCEPT] - 500 mg Tablet - one Tablet(s) by mouth twice a day NIFEDIPINE - 60 mg Tablet Sustained Release - one Tablet(s) by mouth daily NYSTATIN - [**Numeric Identifier 4856**] U/G Cream - APPLY TO AFFECTED AREA TWICE A DAY OXYCODONE-ACETAMINOPHEN [ROXICET] - 5 mg-325 mg Tablet - [**12-25**] Tablet(s) by mouth q4-6 hrs as needed for as needed for pain PREDNISONE - (Prescribed by Other Provider) - 5 mg Tablet - 1 Tablet(s) by mouth once a day SEVELAMER CARBONATE [RENVELA] - 800 mg Tablet - 1 Tablet(s) by mouth three times a day SIBUTRAMINE [MERIDIA] - 10 mg Capsule - 1 Capsule(s) by mouth daily SIMVASTATIN - 5 mg Tablet - 1 (One) Tablet(s) by mouth once a day SYRINGE 1ML (INSULIN) - 1 ML SYRINGE - USE AS DIRECTED BLOOD SUGAR DIAGNOSTIC [ONE TOUCH ULTRA TEST] - Strip - as directed 3-4 times a day CALCIUM CARBONATE - (OTC) - 500 mg Tablet, Chewable - 2 Tablet(s) by mouth three times per day with meals CALCIUM CARBONATE [EXTRA-STRENGTH CHEW ANTACID] - 300 mg (750 mg) Tablet, Chewable - 2 Tablet(s) by mouth three times a day with meals FERROUS SULFATE - (Prescribed by Other Provider) - 325 mg (65 mg Iron) Tablet - 1 Tablet(s) by mouth per day Discharge Medications: 1. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Cyclosporine Modified 25 mg Capsule Sig: Three (3) Capsule PO Q12H (every 12 hours). 3. Mycophenolate Mofetil 250 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: 1-2 puffs Inhalation every six (6) hours as needed for shortness of [**Month/Day (2) 1440**] or wheezing. 5. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO DAILY (Daily). 6. Epogen 20,000 unit/mL Solution Sig: One (1) Injection once a week. 7. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1) Nasal once a day. 8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 9. Sevelamer Carbonate 800 mg Tablet Sig: One (1) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). Tablet(s) 10. Ursodiol 300 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 11. Insulin Glargine 100 unit/mL Solution Sig: Five (5) units Subcutaneous twice a day. 12. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO every other day. 13. Lasix 80 mg Tablet Sig: One (1) Tablet PO twice a day. 14. Simvastatin 5 mg Tablet Sig: One (1) Tablet PO once a day. 15. Losartan 100 mg Tablet Sig: One (1) Tablet PO once a day. 16. Metoprolol Tartrate 100 mg Tablet Sig: Two (2) Tablet PO twice a day. 17. Novolog 100 unit/mL Solution Sig: 1-10 units Subcutaneous four times a day: per sliding scale. 18. Lactulose Oral 19. Calcium 500 500 mg (1,250 mg) Tablet, Chewable Sig: [**12-25**] Tablet, Chewables PO once a day. 20. Ferrous Sulfate 325 mg (65 mg Iron) Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 21. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO every 4-6 hours as needed for pain for 7 days. Disp:*20 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Primary: Abdominal pain Pancreatitis . Secondary: ESRD s/p renal transplant in 98 Hypertension Hyperlipidemia Diabetes Discharge Condition: Stable, tolerating po, renal function at baseline Discharge Instructions: You were admitted with abdominal pain and found to have acute pancreatitis. This has been evaluated by the gastroenterologist the underlying cause is not entirely clear, though it may have been precipitated by the Tetracycline or Meridia. It is important that you avoid these medications and you will need follow up with ID with regards to alternative antibiotics for prophylaxis of UTIs. It is also important that you maintain adequate hydration while at home. Please note the following changes to your medications: - stop tetracycline - avoid Meridia - start Ursodiol you can discuss whether this will need to be restarted) If you develop any recurrent abdominal pain, nausea, vomiting, inability to take oral fluids, decrease urine output or any other general worsening of condition, please call your PCP or come directly to the ER. Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs. Adhere to 2 gm sodium diet Fluid Restriction: 1-2L per day Followup Instructions: Provider: [**Last Name (NamePattern4) **]. [**Last Name (STitle) 724**] Tuesday [**8-31**] at 10 am transplant clinic Provider: [**First Name11 (Name Pattern1) 1877**] [**Last Name (NamePattern1) 1878**], M.D. Phone:[**Telephone/Fax (1) 721**] Date/Time:[**2162-8-25**] 10:00 Provider: [**Name10 (NameIs) **] [**Name10 (NameIs) **], RNC Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2162-9-1**] 11:40 (Dr.[**Name (NI) 4864**] nurse) Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4853**], M.D. Phone:[**Telephone/Fax (1) 253**] Date/Time:[**2162-9-15**] 9:15 It is important for you to call the [**Last Name (un) **] at [**Telephone/Fax (1) 4865**] as they are trying to fit you in for a follow up in the next few weeks [**First Name4 (NamePattern1) 971**] [**Last Name (NamePattern1) 970**] MD [**MD Number(1) 3629**]

[ "V58.65", "585.6", "428.32", "276.1", "250.01", "577.0", "274.9", "V58.67", "241.1", "272.4", "V42.0", "428.0", "403.91", "276.52", "724.3" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

16858, 16916

8038, 12501

288, 295

17079, 17131

3409, 3411

18153, 19034

2781, 2813

15015, 16835

16937, 17058

12527, 14992

17155, 17647

5671, 8015

2828, 3390

17676, 18130

233, 250

1802, 2200

323, 1784

3427, 5655

2222, 2509

2525, 2765

79,100

105,591

30893

Discharge summary

report

Admission Date: [**2104-8-4**] Discharge Date: [**2104-8-9**] Date of Birth: [**2062-9-27**] Sex: F Service: PLASTIC Allergies: Penicillins / Vaccine/Toxoid Preps,Combo. Classifier / Morphine Attending:[**First Name3 (LF) 5883**] Chief Complaint: s/p Right Skin Sparing Mastectomy and Breast Reconstruction with bilateral [**Last Name (un) 5884**] Flap Major Surgical or Invasive Procedure: Right Skin Sparing Mastectomy and Breast Reconstruction with bilateral [**Last Name (un) 5884**] Flap History of Present Illness: 41-year-old female with stage II invassive ductal Ca, HER-2/neu positive s/p chemotherapy and radiation and left radical mastectomy who presents for right skin sparing mastectomy, breast reconstruction with bilateral [**Last Name (un) 5884**] flaps. Past Medical History: hypertension, cardiomyopathy secondary to chemotherapy, hypothyroidism, guillain-[**Location (un) **] syndrome at age 14 Social History: works as occupational therapist in the [**Location (un) 686**] Program for frail elders Family History: n/a Physical Exam: VS: Afebrile, VSS Constitutional: Well appearing, no acute distress Neck: No masses CV: RRR, no murmurs Resp: CTAB, no wheezes or crackles Breast: Flaps viable bilaterally with incisions c/d/i, JP drains x4 with serosanguinous fluid Abd: Soft, mildly TTP, nondistended, +BS, incisions c/d/i Ext: Warm, distal pulses palpable bilaterally Skin: Face, neck and chest is normal Musculoskeletal: Normal to gait and station Spine, Pelvis and Extremities: Stable Psychiatric: Normal to judgment, insight, memory, mood and affect Pertinent Results: [**2104-8-6**] 06:00AM BLOOD WBC-7.2 RBC-3.49* Hgb-10.3* Hct-30.9* MCV-89 MCH-29.5 MCHC-33.3 RDW-13.8 Plt Ct-249 [**2104-8-5**] 04:20AM BLOOD WBC-7.6# RBC-4.02* Hgb-11.4* Hct-34.9* MCV-87 MCH-28.3 MCHC-32.6 RDW-13.6 Plt Ct-235 [**2104-8-6**] 06:00AM BLOOD Plt Ct-249 [**2104-8-6**] 06:00AM BLOOD PT-12.2 PTT-27.0 INR(PT)-1.0 [**2104-8-5**] 04:20AM BLOOD Plt Ct-235 [**2104-8-6**] 06:00AM BLOOD Glucose-131* UreaN-7 Creat-0.6 Na-138 K-4.3 Cl-104 HCO3-27 AnGap-11 [**2104-8-6**] 06:00AM BLOOD Calcium-8.7 Phos-1.8*# Mg-1.8 Brief Hospital Course: The patient was admitted to the plastic surgery service on [**2104-8-4**] and had Right Skin Sparing Mastectomy and Breast Reconstruction with bilateral [**Last Name (un) 5884**] Flap. The patient tolerated the procedure well. Neuro: post-operatively the patient received Dilaudid IV/PCA with adequate pain control. When she tolerated oral intake, the patient was transitioned to an oral pain medication regimine. Cardiovascular: the patient remained stable throughout her admission. Her vital signs were routinely monitored. Pulmonary: the patient remained stable throughout her admission. Her vital signs were routinely monitored. GI/GI: post-operatively the patient was given IV fluids until tolerating PO intake. Her diet was advanced when appropriate. She was also started on a bowel regimine to prevent constipation in the setting of narcotic pain medications. Foley catheter was removed on hospital day 2 and intake/output were closely monitored. ID: post-operatively the patient was started on IV Clindamycin which was then switched to PO Clindamycin prior to discharge. The patient was closely watched for any signs or symptoms of infection. Prophylaxis: The patient received subcutaneous heparin for DVT prophylaxis and pneumoboots. She was also encourage to ambulate as much as possible. At the time of discharge on [**8-10**] the patient was doing well, ambulating, tolerating a regular diet with good pain control on oral regimine. Her vital signs were stable and her incisions looked healthy. Medications on Admission: lisinopril 40 mg daily, toprol XL 100 mg daily, simvastatin 20 mg daily, levothyroxine 137 mcg daily, fluconazole, sertraline, Zometa, calcium, vitamin D3, omeprazole, lorazepam prn, vicodin prn, ibuprofen prn, and exemestane Discharge Medications: 1. Aspirin 81 mg Tablet Sig: 1.5 Tablets PO once a day for 30 days. 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day): please take while on narcotic pain medications. Disp:*30 Capsule(s)* Refills:*0* 3. Percocet 5-325 mg Tablet Sig: One (1) Tablet PO every [**3-17**] hours as needed for pain. Disp:*30 Tablet(s)* Refills:*0* 4. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 5. Exemestane 25 mg Tablet Sig: One (1) Tablet PO QDay (). 6. Levothyroxine 137 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 8. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 9. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 10. Sertraline 50 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 11. Clindamycin HCl 300 mg Capsule Sig: One (1) Capsule PO three times a day for 2 weeks: Please take until instructed to stop at follow up. Disp:*42 Capsule(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: S/P Right Skin Sparing Mastectomy and Breast Reconstruction with [**Last Name (un) 5884**] Flap Bilateral Discharge Condition: Good Discharge Instructions: Return to the ER if: - you are vomiting and cannot keep in fluids or your medications - if you have shaking chills, fever > 101.5, increased redness + swelling or discharge from your incision, chest pain, shortness of breath or any other symptoms which concern you - any serious change in your symptoms - please resume all regular home medications and take new meds as ordered - do not rive or operate heavy machinery while taking narcotic pain medications. You may have constipation when taking narcotic pain medications. You should continued drinking fluids and taking stool softeners and high fiber foods. - avoid strenuous activity - avoid pressure to your chest or abdomen - you may shower but avoid soaking wounds prior to approval from your surgeon You are also being discharged with drains in place. Drain care is a clean procedure. wash your hands thoroughly with sopa and water before performing drain care. Perform drainage care twice a day. Try to empty the drain at the same time each day. Pull the stopper out of the drainage bottle and empty the drainage fluid into the measuring cup. Record the amount of drainage fluid on the record sheet. Reestablish drain suction. Followup Instructions: Please confirm your appointment with Dr. [**First Name (STitle) **] at the time and number listed below. Provider: [**First Name11 (Name Pattern1) 1216**] [**Last Name (NamePattern4) 2612**], MD Phone:[**Telephone/Fax (1) 6331**] Date/Time:[**2104-8-15**] 9:15

[ "V10.3", "V45.71", "244.9", "401.9", "E933.1", "425.4", "V15.3", "V50.41" ]

icd9cm

[ [ [] ] ]

[ "85.74", "85.34" ]

icd9pcs

[ [ [] ] ]

5099, 5157

2185, 3704

427, 531

5307, 5314

1640, 2162

6570, 6835

1077, 1082

3980, 5076

5178, 5286

3730, 3957

5338, 6547

1097, 1621

282, 389

559, 812

834, 956

972, 1061

14,623

118,322

25378

Discharge summary

report

Admission Date: [**2109-8-5**] Discharge Date: [**2109-8-8**] Date of Birth: [**2059-7-21**] Sex: F Service: NEUROLOGY Allergies: Latex / Hydrochlorothiazide / Temazepam Attending:[**First Name3 (LF) 618**] Chief Complaint: "Pins and needles sensation over right arm and leg" Major Surgical or Invasive Procedure: None. History of Present Illness: The patient is a 50 year old right-handed female with past medical history of TIA, peripheral vascular disease, HTN, hypercholesterolemia, tobacci use, left carotid stenosis 85% who presented as a transfer from OSH for Code Stroke. The patient reported that she was in her usual state of health until the morning of admission. She awoke at approximately 5am with a "pins and needles sensation" over her entire right arm and leg. She was able to get up, walk without difficulty at that time. The parasthesiae lasted for about 1.5 hours. The pt stated that between 8:30 and 9am, her right arm/leg went completely flaccid and the parasthesiae over the right side recurred. She also noted blurring of her vision. She denied ay areas of blindness/amarousis fugax. She also noted a dull frontal headache. She called her husband at work, who came home and called EMS. Per records, EMS arrived at 9:12am. Initial vitals HR: 68, BP 157/106. EMS took her to [**Hospital 8641**] Hospital. Vitals on arrival were 98.5, P 55, RR 16, BP 156/65, BS 128. Head CT there revealed no intracranial hemorrhage. She received 9mg bolus of tPA at 11:35 am. Per nursing notes at the OSH, the pt was able to move her right side somewhat after administration of tPA. She was transferred to the [**Hospital1 18**] for further care. Her symptoms were noted to worsen en route where she finished the tPA drip. On arrival to the [**Hospital1 18**], the pt reported numbness and parasthesiae over her entire right face, arm and leg and she could not move her right arm or leg. She also complained of having difficulty swallowing. Her blurry vision and headache had resolved. NIHSS on arrival to the [**Hospital1 18**] was 13 with: 2 partial paralysis lower face 3 right arm, no effort against gravity 3 right leg, no effort against gravity 2 limb ataxia in right arm and leg 2 severe sensory loss right hemibody 1 mild to moderate slurring of words 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. During her ICU course, her deficits steadily improved. Her work-up was completed. At the time of my encounter, the pt noted that her right-sided weakness has much improved over the time of her hospital stay. She had developed a tremor in the right hand which is also improved per the pt. She offered no comnplaints. Past Medical History: 1. TIAs in past, last [**2108-9-26**] with bilateral blurring of vision x 30 minutes. Other TIAs (she states [**4-30**] total) included blurry vision in either eye-->felt by her neurologist to be migraine related. 2. Bilateral common iliac artery stents [**1-30**] 3. Left carotid stenosis 85% 4. Right carotid stenosis 5. Hypertension 6. Left breast lumpectomy [**4-30**], benign 7. ?Multiple sclerosis (diagnosis given by her outpatient neurologist for muscle spasms from mid thorax down). 8. Lumbar degenerative disease with facet arthopathy 9. Lumbar gluteal myofascial pain syndrome 10. Bilateral carpal tunnel syndrome status post left release surgery [**15**]. Migraine headaches 12. Hypercholesterolemia Social History: The pt is married with 3 sons. Homemaker. Smoked 1.5 ppd x 15 years. No alcohol or drug use. Family History: Mother deceased from CAD at age 68. Father deceased from CAD at 72. Physical Exam: Vitals: T: 98.8F P: 64 R: 16 BP: 126/70 SaO2: 95% RA General: Awake, alert, NAD. HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in OP Neck: supple, no JVD or carotid bruits appreciated Pulmonary: Lungs CTA bilaterally without R/R/W Cardiac: RRR, nl. S1S2, no M/R/G noted Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or organomegaly noted. Extremities: No C/C/E bilaterally, 2+ radial, DP and PT pulses b/l. Skin: no rashes or lesions noted. Neurologic: -mental status: Alert, oriented x 3. Able to relate history without difficulty. Able to name [**Doctor Last Name 1841**] backward without difficulty. Language is fluent with intact repitition and comprehension. There were no paraphrasic errors. Pt. was able to name both high and low frequency objects. Able to read without difficulty. Speech was not dysarthric. Able to follow both midline and appendicular commands. -cranial nerves: Olfaction not tested. PERRL 3 to 2mm and brisk. VFF to confrontation. There is no ptosis bilaterally. Fundoscopic exam revealed no papilledema or hemorrhages; venous pulsations present. EOMI without nystagmus. Sensation intact to light touch over face. No facial droop, facial musculature symmetric. Hearing intact to finger-rub bilaterally. Palate elevates symmetrically in midline. 5/5 strength in trapezii and SCM bilaterally. Tongue protrudes in midline; no fasciculations. -motor: normal bulk throughout. Cogwheel rigidity noted in RUE. Subtle, 4 Hz resting tremor of RUE. Subtle pronator drift on right. Delt Bic Tri WrF WrE FFl FE IO IP Quad Ham TA [**First Name9 (NamePattern2) 2339**] [**Last Name (un) 938**] L 5 5 4+ 5 4+ 5 4 5 4+ 5 4+ 5 5 5 R 5 5 5 5 5 5 5 5 5 5 5 5 5 5 -sensory: No deficits to light touch, vibratory sense, proprioception throughout. -coordination: FNF and HKS WNL bilaterally. -DTRs: 3+ biceps, triceps, brachioradialis, patellar and 1+ ankle jerks bilaterally. + crossed adductor reflex. Plantar response was flexor bilaterally. -gait: Walks with assistance of cane, decreased arm swing on right. Pertinent Results: EKG: Sinus bradycardia at 53 bpm with TWI V1-V3. T wave flat V4. MRI/MRA head [**2109-8-5**]: 1. Evolving acute infarction in the left posterior limb of the internal capsule and adjacent corona radiata. 2. No visualized flow in the distal M1 segment of the left middle cerebral artery, just before the bifurcation with faint flow in the post-bifurcation branches, likely representing high-grade, but incomplete occlusion in the distal M1 segment. 3. Neck MRA is limited by patient motion. There may be some left internal carotid origin stenosis. Further evaluation is recommended by carotid ultrasound. Transthoracic echocardiogram [**2109-8-6**]: 1. 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. 2. Left ventricular wall thickness, cavity size, and systolic function are normal (LVEF>55%). Regional left ventricular wall motion is normal. Carotid Duplex Doppler Ultrasound [**2109-8-6**]: FINDINGS: Duplex evaluation was performed of both carotid and vertebral arteries. Moderate plaque was identified on the left. On the right, peak systolic velocities are 75, 62, and 82 in the ICA, CCA, and ECA respectively. The ICA to CCA ratio is 1.2. This is consistent with less than 40% stenosis. On the left, peak systolic velocities are 196, 57, and 109 in the ICA, CCA, and ECA respectively. The ICA to CCA ratio is 3.4. This is consistent with a 60-69% stenosis. There is antegrade flow in both vertebral arteries. IMPRESSION: Moderate left-sided plaque with a 60-69% carotid stenosis. On the right, there is less than 40% stenosis. CTA head [**2109-8-7**]: FINDINGS: Evaluation of the non-contrast head CT reveals an area of well-defined low density corresponding to the area of previously mentioned infarct. It is consistent with the previously described left posterior limb internal capsule and adjacent corona radiata infarct. No additional lesions are seen. There is no significant mass effect. No shift of the midline structures is noted. A [**Doctor Last Name 352**]-white matter differentiation is preserved. There are no extra-axial collections. Evaluation of the CTA reveals an area of high density within the mid left MCA (M1 segment). This is present on the pre-contrast images and represents calcium. Just immediately distal to this area, there is no flow seen. Just distal to this, area of no flow with normal appearing horizontal and vertical segments of the distal MCA. It is believed that the MCA is still patent due to the adequate visualization of the distal vessels. The right internal carotid artery and its branches appear normal. The posterior circulation is unremarkable with no evidence of aneurysm. There is a normal basilar and the PCA. IMPRESSION: Hyperdensity in the posterior lobe of the internal capsule and adjacent corona radiata consistent with previously identified infarct. Calcification within the mid left MCA (M1 segment). No flow is visualized just immediately distal to this calcification. However, there is almost immediate visualization of the distal horizontal and vertical MCA branches. Therefore, flow is still likely present. Brief Hospital Course: 1. Stroke: The pt received IV tPA at an OSH with improvement in her symptoms. MRI/MRA on admission was remarkable for infarction in left internal capsule (posterior limb) and corona radiata with no visualized flow in the distal M1 segment of the left middle cerebral artery, just before the bifurcation with faint flow in the post-bifurcation branches, likely representing high-grade, but incomplete occlusion in the distal M1 segment. Subsequent studies have revealed 60-69% stenosis in the left internal carotid artery. CTA of the head has demonstrated patent flow past a L MCA M1 segment calcification. Given her signficant, symptomatic left internal carotid artery stenosis on aspirin and plavix, the decision was made to begin anticoagulation with warfarin and continue 81mg of ASA daily. She was also maintained on statin for hyperlipidemia. She will follow-up in the neurology clinic for consideration of carotid stenting or carotid endarterectomy at a later date. From a symptomatic standpoint, the pt's deficits had much improved by the time of discharge. She did develop a mild, low-frequency tremor of her right hand on hospital day three which was felt to be secondary to peri-infarct irritation. This, in fact, also improved by the time of discharge (although was still observable). She requested home physical therapy to aid in gait and balance training. 2. HTN: The pt's antihypertensive medication was held while in-house to maximize cerbral perfusion. She was asked to resume her regimen on discharge. Medications on Admission: 1. ASA 325 mg po qd 2. Diazepam 3. Atenolol 4. Fluoxetine 5. Lipitor 6. Plavix 7. Estradiol 8. Skelaxin 9. Oxycodone 10. Gabapentin 11. Enalapril Discharge Medications: 1. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Enalapril Maleate 20 mg Tablet Sig: Two (2) Tablet PO once a day. 3. Atenolol Oral 4. Warfarin Sodium 5 mg Tablet Sig: One (1) Tablet PO once a day: Have INR checked by PCP who will adjust dose to goal INR [**2-28**]. [**Month/Day (3) **]:*30 Tablet(s)* Refills:*2* 5. Lovenox 80 mg/0.8 mL Syringe Sig: One (1) Subcutaneous twice a day: Inject [**Hospital1 **] until instructed to d/c according to PCP. [**Name Initial (NameIs) **]:*20 syringes* Refills:*2* 6. Fluoxetine Oral 7. Oxycodone Oral 8. Gabapentin Oral 9. ASA 81mg po daily (pt. was given a paper Rx) Discharge Disposition: Home With Service Facility: [**Location (un) 8300**] VNA and Hospice Discharge Diagnosis: 1. Left Capsular/lacunar Stroke 2. Left carotid stenosis 3. Right carotid stenosis 4. Hypertension 5. Hypercholesterolemia 6. Tobacco abuse Discharge Condition: Patient is much improved compared to admission. She has regained force in right upper extremity. She has complained of mild right hand tremor, cause might be related to reperfusion, it has since then decreased, but will still be evaluated as an outpatient. Discharge Instructions: Please continue with all medications as listed below. Please attend all follow-up appointments Call your Primary Care Physician or go to the Emergency Room if you develop any of the following symptoms: worsening headache, blurry or double vision, convulsions, dizziness, worsening nausea or vomiting, or any other concerning symptom. Followup Instructions: Please follow up at [**Hospital1 63458**], [**Location (un) 63459**], [**Last Name (un) 53428**], NH at 8:30am on [**2109-8-13**]. Please call Dr. [**First Name (STitle) **] [**Name (STitle) **] at [**Telephone/Fax (1) 2574**] (W/[**Location (un) **] 1)for Neurology/Stroke follow-up within the next 1-2 months. [**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 632**]

[ "443.9", "272.4", "342.90", "305.1", "278.00", "434.11", "401.9", "784.5", "V12.59", "333.1" ]

icd9cm

[ [ [] ] ]

[ "88.41" ]

icd9pcs

[ [ [] ] ]

11665, 11736

9274, 10799

350, 358

11919, 12177

6073, 9251

12560, 12968

3845, 3914

10995, 11642

11757, 11898

10825, 10972

12201, 12537

4854, 6054

3929, 4412

259, 312

386, 2982

4427, 4837

3004, 3717

3733, 3829

27,530

140,235

6211

Discharge summary

report

Admission Date: [**2115-1-17**] Discharge Date: [**2115-1-30**] Date of Birth: [**2051-12-5**] Sex: M Service: SURGERY Allergies: Codeine / Percocet Attending:[**First Name3 (LF) 6346**] Chief Complaint: Transverse Colon Mass Major Surgical or Invasive Procedure: transverse colectomy atrial fibrillation focus ablation History of Present Illness: The pt is a 63 y/o M with a history of kidney [**First Name3 (LF) **] who had a colon cancer removed 2years ago and on repeat colonoscopy had a mass just distal to his ileocolic anastomosis after a right colectomy. Biopsies were dysplastic in nature. He came to the [**Hospital1 18**] for a transverse colectomy for the same. Past Medical History: 1. polycystic kidney disease, s/p R-sided [**Hospital1 **] in [**2103**] 2. HTN 3. Anemia- prior to kidney [**Year (4 digits) **] 4. gout 5. previous MI >1 year ago, bare metal stents with 12mo on plavix Social History: Mr. [**Known lastname 24214**] is a prior smoker of 44 pack years. There is no history of alcohol abuse. Family History: There is no family history of premature coronary artery disease or sudden death. His mother died from brain cancer, and his father died from cirrhosis. Physical Exam: Gen: NAD, AOx3 HEENT: MMM, anicteric, EOM-I CVS: reg,no m/r/g Pulm: no resp distress,ctabl Abd: Soft,mildly distended ,mildly tender LE: no LLE wound:c/d/i,no erythema or ecchymosis,staples in place Pertinent Results: [**2115-1-30**] 10:50AM BLOOD WBC-5.5# RBC-3.20* Hgb-9.0* Hct-28.3* MCV-88 MCH-28.1 MCHC-31.9 RDW-17.5* Plt Ct-136* [**2115-1-29**] 06:55AM BLOOD WBC-11.8* RBC-3.13* Hgb-8.9* Hct-26.9* MCV-86 MCH-28.3 MCHC-32.9 RDW-17.7* Plt Ct-120* [**2115-1-28**] 06:20AM BLOOD WBC-17.1*# RBC-3.30* Hgb-9.4* Hct-28.2* MCV-86 MCH-28.5 MCHC-33.3 RDW-17.6* Plt Ct-123* [**2115-1-27**] 02:32AM BLOOD WBC-10.8 RBC-3.46* Hgb-9.7* Hct-31.0* MCV-90 MCH-28.2 MCHC-31.4 RDW-17.4* Plt Ct-188 [**2115-1-26**] 10:45AM BLOOD WBC-9.2 RBC-3.99* Hgb-11.3* Hct-35.2* MCV-88 MCH-28.4 MCHC-32.2 RDW-17.0* Plt Ct-245 [**2115-1-25**] 05:15AM BLOOD WBC-6.3 RBC-3.60* Hgb-10.0* Hct-30.8* MCV-86 MCH-27.7 MCHC-32.4 RDW-16.4* Plt Ct-185 [**2115-1-24**] 05:40AM BLOOD WBC-7.8 RBC-3.84* Hgb-10.5* Hct-33.1* MCV-86 MCH-27.4 MCHC-31.8 RDW-15.9* Plt Ct-218 [**2115-1-23**] 06:12AM BLOOD WBC-6.2 RBC-3.99* Hgb-11.2* Hct-34.4* MCV-86 MCH-27.9 MCHC-32.5 RDW-15.7* Plt Ct-220 [**2115-1-18**] 06:40AM BLOOD WBC-6.6 RBC-3.85* Hgb-10.5* Hct-33.1* MCV-86 MCH-27.3 MCHC-31.7 RDW-15.4 Plt Ct-163 [**2115-1-30**] 12:22PM BLOOD PT-19.7* PTT-29.7 INR(PT)-1.8* [**2115-1-29**] 06:55AM BLOOD PT-22.9* PTT-33.0 INR(PT)-2.2* [**2115-1-28**] 06:20AM BLOOD PT-25.9* PTT-35.5* INR(PT)-2.5* [**2115-1-27**] 02:32AM BLOOD PT-24.9* PTT-93.6* INR(PT)-2.4* [**2115-1-26**] 10:45AM BLOOD PT-20.5* PTT-75.4* INR(PT)-1.9* [**2115-1-25**] 05:15AM BLOOD PT-19.6* PTT-57.7* INR(PT)-1.8* [**2115-1-24**] 05:40AM BLOOD PT-17.4* PTT-56.2* INR(PT)-1.6* [**2115-1-23**] 06:12AM BLOOD PT-14.8* PTT-46.5* INR(PT)-1.3* [**2115-1-22**] 07:00AM BLOOD PT-14.2* PTT-44.6* INR(PT)-1.2* [**2115-1-21**] 01:05PM BLOOD PT-14.0* PTT-25.1 INR(PT)-1.2* [**2115-1-29**] 06:55AM BLOOD Glucose-463* UreaN-25* Creat-2.1* Na-133 K-3.8 Cl-107 HCO3-19* AnGap-11 [**2115-1-27**] 02:32AM BLOOD Glucose-353* UreaN-31* Creat-2.0* Na-136 K-4.0 Cl-111* HCO3-17* AnGap-12 [**2115-1-25**] 09:37PM BLOOD Glucose-116* UreaN-31* Creat-1.8* Na-141 K-4.3 Cl-113* HCO3-18* AnGap-14 [**2115-1-24**] 05:40AM BLOOD Glucose-110* UreaN-50* Creat-2.0* Na-146* K-3.9 Cl-116* HCO3-21* AnGap-13 [**2115-1-22**] 09:20PM BLOOD Glucose-122* UreaN-62* Creat-2.7* Na-142 K-4.5 Cl-112* HCO3-19* AnGap-16 [**2115-1-21**] 04:00AM BLOOD Glucose-111* UreaN-54* Creat-2.6* Na-138 K-4.7 Cl-109* HCO3-21* AnGap-13 [**2115-1-18**] 06:40AM BLOOD Glucose-112* UreaN-49* Creat-2.6* Na-137 K-4.6 Cl-102 HCO3-25 AnGap-15 [**2115-1-21**] 11:05AM BLOOD CK-MB-4 cTropnT-0.02* [**2115-1-21**] 04:00AM BLOOD CK-MB-4 cTropnT-0.02* [**2115-1-29**] 06:55AM BLOOD Calcium-7.6* Phos-2.1* Mg-2.3 [**2115-1-28**] 06:20AM BLOOD Calcium-8.1* Phos-3.1# Mg-2.2 [**2115-1-23**] 06:12AM BLOOD TSH-0.45 [**2115-1-29**] 03:10PM BLOOD Cyclspr-45* [**2115-1-27**] 02:32AM BLOOD Cyclspr-84* [**2115-1-26**] 10:45AM BLOOD Cyclspr-213 [**2115-1-25**] 05:15AM BLOOD Cyclspr-170 [**2115-1-23**] 06:12AM BLOOD Cyclspr-91* [**2115-1-22**] 07:00AM BLOOD Cyclspr-115 [**2115-1-21**] 04:00AM BLOOD Cyclspr-132 [**2115-1-18**] 06:40AM BLOOD Cyclspr-83* Brief Hospital Course: The patient was admitted to the [**Hospital1 18**] for colectomy for colon mass. Patient's PACU stay was unremarkable.On POD1 the patient underwent an USG which showed no hyronephrosis. The patient failed trial of void and foley was replaced. The patient's diet was slowly advanced which he tolerated well.On POD4 the paitent had A flutter and wascardioverted to sinus rhythm.On POD 5 the patient again had A fib to 150's and was transferred to ICU where he was cardioverted.The patient was started on warfarin and iv metprolol .A dobhoff was passed for po feeds.The patient spiked at temperature to 103 on [**2115-1-27**] and was pancultured.He had a CT scan which showed subcutaneous fluid collection.His dobhoff was d/ced and was started on clears and advanced to a regular diet.He was transferred out of the ICU.On [**2115-1-29**],the patient underwent aflutter ablation.He was started on amiodarone 200 mg [**Hospital1 **]. He had a fever 101.8 and was pan cultured again.His urine cultures were positive for E coli and was started on 14 day course of cefepime.On the day of discharge the patient was tolerating a regular diet,voiding normally and his pain was well controlled and would follow up with Dr [**First Name (STitle) 2819**] in 1 week. Medications on Admission: ALLOPURINOL 200',CYCLOSPORINE MODIFIED [GENGRAF]50'',FUROSEMIDE 40', LISINOPRIL 2.5',METOPROLOL SUCCINATE 25',CELLCEPT [**Pager number **] '',PREDNISONE 5 ',SIMVASTATIN 40',SIROLIMUS [RAPAMUNE] 4',ASPIRIN 81',CALCIUM CARBONATE-VIT D3 (600 mg/400 unit)'',FERROUS SULFATE 325 mg'' Discharge Medications: 1. prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. metoclopramide 10 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours). 3. mycophenolate mofetil 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. warfarin 2.5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM. Disp:*20 Tablet(s)* Refills:*2* 6. cyclosporine modified 25 mg Capsule Sig: Two (2) Capsule PO Q12H (every 12 hours). 7. amiodarone 200 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): Please convert to 200 once a day after 1 month. Disp:*60 Tablet(s)* Refills:*2* 8. famotidine 10 mg Tablet Sig: Two (2) Tablet PO twice a day. Disp:*120 Tablet(s)* Refills:*0* 9. Dilaudid 2 mg Tablet Sig: One (1) Tablet PO q4h prn as needed for pain. Disp:*20 Tablet(s)* Refills:*0* 10. ciprofloxacin 250 mg Tablet Sig: One (1) Tablet PO twice a day for 11 days. Disp:*22 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Colon carcinoma Atrial fibrillation Urinary Tract Infection Post operative ileus Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Please call Dr [**First Name (STitle) 2819**] if you have any of the followinng syptoms: Redness that is spreading,Pain not adequately relieved with medication,Drainage from wound,Opening of incision,Nausea and vomiting,Abdominal pain,Abdominal swelling,Nausea and vomiting,Vomiting blood,Difficulty swallowing,Diarrhea,Constipation,Blood in stool,Black stool Please call [**First Name (STitle) **] clinic if you have any of the following symptom fever greater that 101 F, burning urination or difficulty in urination. Please call Dr [**Last Name (STitle) **] or go to the ER if you have any of the following symptoms : palpitations,chest discomfort,chest pain,syncope. It is ok to take a shower.Please donot take a tub bath till your first clinic visit with Dr [**First Name (STitle) 2819**]. You are currently on pain meds,which cause drowsiness.Please donot drive or operate heavy machinery while you are on them. Your cyclosporine levels and INR need to checked. Please get them drawn at the [**First Name (STitle) **] clinic on [**2115-1-31**] and [**2115-2-4**]. Followup Instructions: Provider: [**First Name4 (NamePattern1) 971**] [**Last Name (NamePattern1) 970**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2115-2-11**] 3:20 Provider : [**Name10 (NameIs) **] [**First Name (STitle) 2819**] Office Phone: ([**Telephone/Fax (1) 6347**] .Ph:date :[**2-10**] weeks Provider:[**Name10 (NameIs) **] clinic Ph:[**Numeric Identifier 24220**].Please call in for appointment for cyclosporine levels on [**2115-1-31**] and [**2115-2-4**]. Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1523**], MD Phone:[**Telephone/Fax (1) 62**] Date:2 weeks Completed by:[**2115-2-3**]

[ "412", "788.20", "V42.0", "274.9", "753.12", "568.0", "414.01", "997.4", "V45.82", "E878.8", "427.32", "427.31", "997.1", "153.1", "560.1", "599.0" ]

icd9cm

[ [ [] ] ]

[ "99.62", "45.74", "54.59", "57.95", "37.34", "45.93", "37.26" ]

icd9pcs

[ [ [] ] ]

7031, 7037

4467, 5720

300, 358

7161, 7161

1468, 4444

8405, 9022

1079, 1232

6049, 7008

7058, 7140

5746, 6026

7312, 8382

1247, 1449

239, 262

386, 713

7176, 7288

735, 940

956, 1063

11,255

115,949

48023

Discharge summary

report

Admission Date: [**2201-1-2**] Discharge Date: [**2201-1-6**] Date of Birth: [**2139-12-17**] Sex: F Service: MEDICINE Allergies: Seroquel Attending:[**First Name3 (LF) 358**] Chief Complaint: Dyspnea Major Surgical or Invasive Procedure: Bronchoscopy History of Present Illness: 61F with PMH of schizophrenia, longstanding asthma/COPD, and tracheobronchomalacia s/p Y stenting on [**2200-12-13**], who now presents after being found at home after falling on the floor. She states she has been fee;ling generally weaker and weaker since her recent stenting. She endorses subjective fevers and chills and malaise. On the morning of admission, she slumped onto the floor from her bed "softly" and called lifeline herself. EMS found her with a sat in the mid-80's on room air. Her home O2 was twisted and non-functional. By report, there were pills scattered on the floor. She admits to taking 1 extra thorazine pill last night in an effort to sleep, but denies current SI. although she admits that a long time ago she did engage in self-injurious behavior. . In ED, VS were 100.4 88 107/41 17 86%RA, with labile O2 sats on [**4-5**] liters; Lungs were rhonchorous, with poor resp effort. ABG showed 7.33/56/99, lactate 0.8. On BiPAP ([**10-5**]), sats improved. She was transiently hypotensive to the 80's, which spontaneously improved to 100's; didn't get IVF b/c of spontaneous resolution. U/A was clean, but urine culture and blood cultures were sent. Labs revealed an elevated WBC count of 17.5. CXR was suspicious for aspiration or early PNA. She received vanco/zosyn/solumderol and was admitted to the ICU. . On admission to the ICU, she stated she feelt better than earlier today. She was easily transferred from a NRB to 5L NC without respiratory distress or subjective SOB. Past Medical History: Schizophrenia Anxiety/depression H/o sexual abuse Asthma COPD S/p ASD repair [**2151**] S/p L hip replacement [**2191**] S/p multiple R leg fractures [**2191**] Social History: Lives in group home in [**Location (un) **] ("[**Doctor First Name **] House"). Lives with a roommate. Mother lives nearby in family home; they are very close and see each other 1-2x/week. She has a h/o tobacco 3ppd x 10years, quit 10 years ago. Denies EtOH or other drug use. Has a h/o sexual abuse while in a hospital in the [**2161**]'s, and has been seeing the same psychiatrist ([**First Name8 (NamePattern2) 9485**] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 100807**]) for 30 years. Family History: GM died of lung ca, mother survivor of lung ca Physical Exam: VS: 97.6 89 129/54 13-20 90-94% on 4L NC GEN: appears ashen/blue, which is normal for her as a side effect of thorzine, obese, anxious but pleasant HEENT: NC/AT, dry MM, bluish coloration in face, EOMI, PERRL Neck: thick neck, unable to assess JVD, no LAD, no bruits, supple CV: difficult to auscultate given pulm exam, but RRR, no MRG appreciated Pulm: diffuse inspiratory and expiratory rhonchi anteriorly and posteriorly, with expiratory wheezes throughout Abd: +BS, obese, protuberant, tympanic throughout, soft, nt/nd, no HSM Ext: 1+ edema B/L, no c/c, 2+DP B/L Neuro: AAOX3, CN 2-12 grossly intact B/L, nonfocal Psych: no suicidal or homicidal ideations Pertinent Results: WBC 17 Hct 31 CEs negative ABG: 7.33 / 56 / 99 / 31 lactate 0.8 . MICRO: Sputum, UCx and BCx: NG . RADIOLOGY/STUDIES: [**2201-1-2**] CXR FINDINGS: Tracheal Y-stent is again noted in grossly stable position. Study is significantly limited by moderate rightward patient rotation. Bibasilar ill-defined opacities are poorly evaluated with differential including atelectasis, aspiration or early pneumonia. No supine evidence of pneumothorax is detected. . [**2201-1-5**] CXR: Bibasilar atelectasis with interval right-sided improvement since examination from [**2201-1-3**]. Brief Hospital Course: 61F with PMH of COPD, TBM s/p recent Y-stenting, now presenting with acute onset hypoxia, low grade temp, with CXR concerning for early PNA. . ICU COURSE: She was rapidly weaned off bipap in ICU and has been stable on [**3-4**] L O2. She is on home O2, 3-4 L. She had a bronchoscopy and stent was found to be in place. She was contd on vanc/zosyn for HCP and also on steroids for possible COPD exacerbation. She was transferred to the floor. . HYPOXIA: Her hypoxia was most likely secondary to inflammatory response to y-stenting that was exacerbated by her missing her medications during the holidays. She improved quickly with broad spectrum antibiotics, but did not likely have a hospital-acquired pneumonia. She was also treated with steroids for COPD initially. These were discontinued as she did not have significant evidence of COPD. She had a bronchoscopy in the ICU that showed the stent to be in good position. Repeat chest x-ray on [**1-5**] showed interval resolution of consolidations. She has been at her baseline O2 requirement since [**1-4**]. - She will complete a course for community-acquired pneumonia, as she has been stable on this regimen with cefpodoxime and azithromycin. No quinolone [**2-2**] QT. - She should continue her home nebs, singulair, and chest PT - possible repeat bronchoscopy in [**3-4**] weeks; will follow up with pulmonary . SCHITZOPHRENIA: She was continued on thorazine, gabapentin, clonazepam, buspirone . DISPO: Home oxygen and VNA were arranged for patient at moms house, where she will have someone around for assistance. Medications on Admission: Up to date in OMR. 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. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 puffs Inhalation every 4-6 hours as needed for shortness of breath or wheezing. 3. Buspirone 10 mg Tablet Sig: Three (3) Tablet PO twice a day. 4. Alendronate 70 mg Tablet Sig: One (1) Tablet PO QSAT (every Saturday). 5. Calcium 600 + D(3) 600-400 mg-unit Tablet Sig: Two (2) Tablet PO once a day. 6. Chlorpromazine 100 mg Tablet Sig: Twelve (12) Tablet PO HS (at bedtime). 7. Chlorpromazine 100 mg Tablet Sig: Four (4) Tablet PO once a day. 8. Clonazepam 1 mg Tablet Sig: Three (3) Tablet PO twice a day as needed for anxiety or insomnia. 9. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Gabapentin 400 mg Capsule Sig: Two (2) Capsule PO HS (at bedtime). 11. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO twice a day. 12. Levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 14. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 15. Darvocet A[**Telephone/Fax (3) **] mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for pain. 16. Acetylcysteine 20 % (200 mg/mL) Solution Sig: One (1) neb Miscellaneous twice a day. 17. Lactulose 10 gram/15 mL Syrup Sig: 30-60 MLs PO HS (at bedtime). 18. Ibuprofen 400 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8 hours) as needed for shoulder pain. 19. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 20. Cefpodoxime 100 mg Tablet Sig: Two (2) Tablet PO Q12H (every 12 hours) for 3 days. Disp:*7 Tablet(s)* Refills:*0* 21. Azithromycin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 3 days. Disp:*3 Tablet(s)* Refills:*0* 22. Benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day) as needed for cough. Discharge Disposition: Home With Service Facility: [**Company 1519**] Discharge Diagnosis: Primary: Tracheobronchomalacia, COPD, Pneumonia Secondary: Schizophrenia, Anxiety, Depression, Asthma Discharge Condition: Hemodynamically stable, afebrile and with appropriate oxygen saturation on baseline supplemental oxygen. Discharge Instructions: You were admitted after being found down in your home, with a low oxygen saturation (hypoxia). This was thought to be due to not taking some of your lung medications for several days. There was also concern that you may have an early pneumonia. Thus, you are being discharged with antibiotics and your regular home oxygen. Take all medications as prescribed. Your two new medications are Cefpodoxime and Azithromycin. You should complete the course of these mediations. Please keep all outpatient appointments. Seek medical advice if you notice increased difficulty breathing, chest pain, abdominal pain, fever > 101 degrees, chills or any other symptom which is concerning to you. Followup Instructions: Provider: [**Name10 (NameIs) 1571**] FUNCTION LAB Phone:[**Telephone/Fax (1) 609**] Date/Time:[**2201-1-22**] 2:40 Provider: [**Last Name (NamePattern4) **]. [**First Name (STitle) **] / DR. [**Last Name (STitle) **] Phone:[**Telephone/Fax (1) 612**] Date/Time:[**2201-1-22**] 3:00 Provider: [**Name10 (NameIs) 1570**],INTERPRET W/LAB NO CHECK-IN [**Name10 (NameIs) 1570**] INTEPRETATION BILLING Date/Time:[**2201-1-22**] 3:00 Completed by:[**2201-1-6**]

[ "244.9", "486", "309.81", "493.20", "748.3", "278.00", "934.1", "733.00", "E912", "530.81", "295.62" ]

icd9cm

[ [ [] ] ]

[ "96.05" ]

icd9pcs

[ [ [] ] ]

7502, 7551

3879, 5454

275, 289

7697, 7804

3281, 3856

8540, 8999

2536, 2584

5524, 7479

7572, 7676

5480, 5501

7828, 8517

2599, 3262

228, 237

317, 1819

1841, 2003

2019, 2520

15,964

150,968

44831

Discharge summary

report

Admission Date: [**2190-12-29**] Discharge Date: [**2191-1-11**] Service: MEDICINE Allergies: Penicillins Attending:[**First Name3 (LF) 898**] Chief Complaint: Tachycardia, hypotension, altered mental status Major Surgical or Invasive Procedure: Mediastinoscopy, lymph node biopsy History of Present Illness: 83 y/o man with PMH significant for type 2 DM, CHF, first degree AV block, and recent 2 month illness characterized by weight loss and failure to thrive who was admitted through the ED on sepsis protocol. Pt was recently admitted to [**Hospital1 18**] from [**12-13**] through [**12-23**] with failure to thrive. At that time, he was evaluated for a possible malignancy given the presence of widspread lymphadenopathy. Bone marrow biopsy was done which was consistent with a possible myeloproliferative disorder. Interventional pulmonary then did a BAL and TBNA on [**12-20**] which was nondiagnostic without malignant cells. Therefor, the pt was scheduled for a mediastinoscopy with thoracic surgery but has not yet received this procedure. During this admission, the pt was also treated for possible sepsis since he had hypotension with a SBP in the 80s and an elevated WBC count of 23 on admission. He was treated emperically with vancomycin and aztreonam. These were then discontinued as his WBC count decreased but he was continued on stress dose steroids. Pt was discharged to rehab on [**12-23**]. . Pt did fairly well at rehab until [**2190-12-28**] when per report he suffered a fall. Pt was apparently not injured but this morning he was unresponsive and wouldn't follow commands. The pt's wife reported that he hadn't had any new complaints over the past few days. It is unclear what occurred during the course of the day at the nursing home and further information will need to be obtained. However, at 6:00 PM he was noted to be pale and diaphoretic with a temperature of 102.8 and BP of 100/50. He was transported to the ED for further evaluation. . In the [**Name (NI) **], pt's VS were 104, tachycardia to the 140s, and hypotensive to the 90s/50s. He was intubated for altered mental status. Pt was then placed on the sepsis protocol. He received vancomycin, levofloxacin, and flagyl in addition to stress dose steroids. The pt also received three liters of normal saline. Pt was then admitted to the [**Hospital Unit Name 153**] for further care. Past Medical History: 1. Asymptomatic AV dissociation and bradycardia s/p [**Company 1543**] Sigma 300 DR [**Last Name (STitle) 4448**] placement [**5-18**]. First degree AV block. Last echo [**7-16**] w/ EF >55%, diastolic dysfunction. Holter [**2187**]: SR w/ moderate PR prolongation, AEA w/ runs of atrial tachycardia, 2 beat run of VT 2. Type 2 diabetes mellitus 3. Benign prostatic hypertrophy s/p TURP-- path w/ prostate ca [**Doctor Last Name **] 3+3 = 6 4. Status post left total knee replacement in [**2181**]. 5. Status post right total hip replacement in [**2183**]. 6. Diverticulosis with colonic polyp (c-scope [**2186**]). 7. Lower gastrointestinal bleed 8. Recent circumcision for balontitis 9. Rheumatoid arthritis on prednisone (received outpatient steroid injection 1 week prior to admission) 10. Psudogout on colchicine 11. (?) Cirrhosis (consistent findings on recent ultrasound, but not seen on CT abdomen [**11-24**]) Social History: The patient lives with his wife in [**Name (NI) **] Corner. Father of two children, one in the local area ([**Location (un) 745**]). Worked in auto mechanics for many years, now retired. Previous history of heavy smoking (quit 40 years ago). Drinks about 1 beer/week. No history of other drug use. Family History: Non-contributory Physical Exam: VS: Tm 98.5 p95 bp 100/40 (98-106/40-51) r 25 97-100 10L cool neb I/o 1800/2400 General: awake, alert NAD, elderly male. HEENT: perrl, eomi, mmm Chest: good air movement, no wheezes, crackles CV: RRR, systolic murmur LUSB abd: soft, NT/ND, no HSM ext: no c/c/e. distal pulses palpable Pertinent Results: [**12-29**] CXR: Cardiac and mediastinal contours are stable. Lung volumes are reduced. Pulmonary vascular markings are somewhat indistinct but without frank pulmonary edema. An endotracheal tube is seen with its tip just proximal to the carina. An NG tube is seen with its tip in the stomach. There is a right IJ central venous catheter with its tip in the distal SVC. No pneumothorax is seen on this supine radiograph. IMPRESSION: Low lung volumes. Lines and tubes in satisfactory position. [**12-29**] Non-contrast head CT: FINDINGS: There is no intra- or extra-axial hemorrhage, mass effect, or shift of normally midline structures. The [**Doctor Last Name 352**]-white matter differentiation is preserved. Low attenuation within the periventricular white matter is consistent with small vessel infarction. There is mild mucosal thickening within the left maxillary sinus. Remaining paranasal sinuses and mastoid air cells are appropriately aerated. There is no evidence of fracture. IMPRESSION: 1. No intra- or extra-axial hemorrhage. 2. No major vascular territorial infarction. [**1-1**] CXR: CHEST X-RAY, PORTABLE AP: Comparison made to prior study of one day earlier. A right internal jugular central venous line is unchanged in position with tip in the mid superior vena cava. The ET tube has been removed. The cardiomediastinal silhouette is stable. Increased interstitial markings are noted bilaterally. No infiltrates are present. IMPRESSION: Slighty increased interstial pulmonary edema. [**1-2**] Head CTA: FINDINGS: The early arterial enhancement phase of this CTA may be suboptimal for the detection of intracranial masses. The noncontrast images of the head are degraded by motion. As presented, there is no change from the prior day. There is no intracranial hemorrhage, abnormal extraaxial fluid collection, mass effect or midline shift. The ventricles are unchanged in configuration. Low attenuation in the periventricular white matter remains similar in appearance. The [**Doctor Last Name 352**]-white matter interface is preserved. No enhancing intracranial lesion is detected. The major tributaries of the circle of [**Location (un) 431**] appear patent, without significant stenosis or aneurysmal dilatation. No arteriovenous malformation is detected. IMPRESSION: No intracranial mass is identified. See note above re: CTA technique relating to mass lesion detection. [**1-5**] RUQ U/S: FINDINGS: The liver is markedly heterogenous, with predominantly increased echogenicity with multiple focal areas of decreased echogenicity, which appears to be increased in number and size compared to the prior study. Common bile duct is not dilated. There is no evidence of intrahepatic ductal dilatation. Gallbladder is mildly dilated, with sludges. Spleen measures 15 cm. The previously noted multiple nodules in the spleen could not be well demonstrated on the present study, in this patient who could not hold the breath. Note is made of ascites. IMPRESSION: 1. Markedly heterogenous echotexture of the liver, with multiple small hypodense areas, the largest one in the right lobe measuring 2.5 cm, which appears to be increased in size and number compared to the prior CT study. The findings probably represent microabscess, or hepatic involvement of malignancy such as lymphoma. Please correlate clinically. 2. Splenomegaly. Prior noted splenic lesions are not well demonstrated on the present study. 3. Ascites. Brief Hospital Course: In the [**Hospital Unit Name 153**], Mr. [**Known lastname **] was suspected of being septic, with fever to 104F, mental status changes, hypotension, and leukocytosis with left-shift. He was intubated and placed on the sepsis protocol, and was placed on vancomycin, flagyl, cefepime, and acyclovir. The latter was added due to HSV-like cytopathic effects seen on [**12-18**] BAL. Cefepime switched to ceftriaxone on ID recommendations on [**12-31**]. No evidence of PNA on CXR. UA normal with no growth on UCx. [**12-30**] blood cultures had no growth on bacterial cultures, and preliminarily no growth on fungal or mycobacterial cultures. LP was done [**12-30**], which showed no evidence of meningitis. CSF and serum cryptococcal Ag negative. CSF bacterial, fungal, and AFB cultures no growth. CSF HSV PCR was checked, which was ultimately negative. Abx d/c'ed once CSF bacterial cultures were negative. BAL with transbronchial biopsy was done on [**12-31**], and respiratory cultures eventually grew MRSA, and was negative to date for AFB or nocardia. Pt also found to be in ARF on admission to [**Hospital Unit Name 153**] with Cr 2.3 from baseline 0.8. This was thought to be mainly prerenal, +/- ATN. He was treated with IVF, and creatinine gradually decreased back to baseline over the next five days. Fibrinogen normal, no FDPs. It was observed that Mr. [**Known lastname **]' INR was elevated to 2.7, with tbili elevated to 2.7. Transaminases were high-normal, but also trended up slowly over course of hospitalization, with AST trending from 50 to 86, and ALT from 16 to 39. Hep C Ab found to be equivocal. HBVSAg neg, HBVSAb negative, HBVCAb negative. CMV IgG positive, IgM negative. EBV negative. HHV8 Ag, and Histoplasma Ag pending. A RUQ U/S was done on [**1-5**], which demonstrated multifocal areas of hypoattenuation, consistent with microabscesses or metastatic disease. Mr. [**Known lastname **] was extubated on [**12-31**], and sent to [**Company 191**] service on [**1-1**] for further management. On the floor, the family made their desire known that they would like Mr. [**Known lastname **] to have a biopsy that could explain his deteriorating condition. Thoracic surgery was consulted, who scheduled him tentatitvely for a mediastinoscopy and node biopsy for [**1-11**]. He was taken off ASA. During his course on the floor, his LFTs remained elevated, and the aforementioned RUQ U/S was done, which suggested microabscesses vs metastatic disease. At this point, the idea was entertained to attempt to obtain tissue through a liver core biopsy, which would be less invasive and stressful. In preparation for a possible lymph node biopsy and to better image the liver lesions, a CT was done. Mr. [**Known lastname **]' mediastinal LAD appeared unchanged; however, the liver lesions seen on U/S could not be visualized on CT. During his admission, Mr. [**Known lastname **] had a waxing and [**Doctor Last Name 688**], but ultimately deteriorating course in terms of his mental status, respiratory status, and hemodynamics. Post-extubation, he had a very raspy voice, and failed a speech and swallow test, leading team to suspect laryngeal nerve and/or vocal fold damage. He was made NPO. An NG tube was attempted, but Mr. [**Known lastname **] refused placement. His family did not want a PEG placed until a diagnosis was made that could give some hint of prognosis. Ultimately, TPN was started. He had a very low albumin (2.0), thought to be [**3-17**] poor nutritional status and his deteriorating hepatic function. He became severely edematous to the point of anasarca, and daily decsions were made regarding how to balance fluids and TPN, necessary for hemodynamic stability and nutrition, with diuresis for comfort. On [**1-3**], he was found to have an acute decline in mental status, unable or unwilling to open his eyes, and only responding to noxious stimuli. Neuro was consulted, who recommended a toxic/metabolic work-up, which was negative. An EEG was also done, which showed generalized theta slowing c/w toxic/metabolic etiology. Mr. [**Known lastname **] also had at least two likely aspiration events. CXR demonstrated LLL, RML, and RLL infiltrates. He was placed on broad spectrum antibiotics and stress dose steroids, due to Mr. [**Known lastname **]' long history of prednisone for RA, in context of hypotension and tachycardia associated with these episodes. Mutiple discussions were held with Mr. [**Known lastname **]' family regarding the goals of care. They made it clear that they would like to be able to obtain a biopsy in order to have a diagnosis. If he continued to be too unstable for biopsy, however, they would like to focus on comfort care. The reiterated that he should be DNR/DNI, and unneccesary invasive tests or interventions should be avoided. Unfortunately, Mr. [**Known lastname **]' status, while intermittently improving to the point where he could interact with his wife and son, ultimately deteriorated. On [**1-10**], he gradually became hypotensive to 80s/40s and tachycardic to 130s with SaO2 in 80s on NRB. IVF temporarily improved his BP, and respiratory therapy was called to perform deep suctioning, which improved his respiratory status. His condition, however, was tenuous throughout the day and night. At 5:45AM on [**1-11**], his BP was back to 75/40 and not responsive to IVF. His son was called and asked to come in. At 7:15AM, was called to bedside. Mr. [**Known lastname **] had no heartbeat or breath sounds after two minutes of auscultation. He had no corneal reflex and no pulse. He was pronounced dead at 7:21AM. His family and the attending were called. His son requested an autopsy. Medications on Admission: 1. Aspirin 325 mg daily 2. Multivitamin 1 tab daily 3. Colchicine 0.6 mg daily 4. Colace 100 mg [**Hospital1 **] PRN 5. Prednisone 5 mg daily 6. Calcium carbonate 500 mg TID 7. Fosamax 80 mg weekly 8. Prilosec 40 mg daily 9. Lantus 15 units daily 10. Spironolactone 50 mg daily 11. RISS 12. Compazine 5 mg Q6H PRN 13. Lasix 60 mg daily 14. Celexa 20 mg daily Discharge Disposition: Expired Discharge Diagnosis: Cardiopulmonary arrest [**3-17**] pneumonia Discharge Condition: Deceased Discharge Instructions: N/A Followup Instructions: N/A

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icd9cm

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icd9pcs

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32585+57814

Discharge summary

report+addendum

Admission Date: [**2152-10-11**] Discharge Date: [**2152-10-13**] Date of Birth: [**2084-2-24**] Sex: F Service: MEDICINE Allergies: Aspirin / Penicillins / Vancomycin / Iodine / Nsaids / Lyrica Attending:[**First Name3 (LF) 1436**] Chief Complaint: Aspirin Desensitization Major Surgical or Invasive Procedure: cardiac catheterization and stents to RCA. History of Present Illness: Patient is a 68 y/o W with history of CAD, w/ CABG in [**2143**] w/ LIMA to LAD and SVG from RIMA to Marginal branch of circumflex, DM (last A1c 8.9), recurrent CVA's in past w/o residual weakness, COPD (on 3L NC at baseline) who presented to [**Hospital 1514**] Hospital on [**2152-10-4**] c/o chest pain. Patient described the acute onset of sharp substernal chest pain with radiation to her left arm while getting up to use the bathroom at home. This episode was associated with dizzyness, some diaphoresis, nausea, mild shortness of breath but without syncope emesis or other complaints. She activated EMS and was brought to [**Hospital 1514**] Hospital where she was admitted as a ROMI. . Additionally, patient reports history of intermittent chest pain over several years with multiple hospitalizations in the past. Also reports increasing chest pain about once per month over the past year but increasing in severity and frequency. In addition, she describes requiring less exertion to precipitate her episodes. Patient reports orthopnea at baseline and sleeps upright in her recliner as a result. Reports baseline peripheral edema as well with occasional PND. Is wheelchair dependent at baseline. Cardiac review of systems is notable for absence of palpitations, syncope or presyncope. . At the OSH, patient's cardiac enzymes were negative, but repeat EKG's showed TWI's in V2-V5 stable over several EKG's. Cards consult recommended performing diagnostic cath which was performed [**10-9**] demonstrating: - Severe 3 vessel CAD - High Grade Stenosis (85%) of dominant RCA which is non-revascularized. - Diffuse narrowing of the distal RCA with 70% stenosis. - Proximal LAD w/ 30% stenosis and stent, and mid-LAD with 100% occluded stent, but distal LAD with supply from LIMA. - Circumflex with Mid 45% stenosis. . Impression at OSH was that the patient would benefit from stenting of the proximal RCA stenosis with a DES. Patient was then transferred to [**Hospital1 18**] for aspirin desensitization and stenting. . On review of symptoms, she denies any prior history of bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. He denies recent fevers, chills or rigors. She denies exertional buttock or calf pain. She does report occasional headaches. Past Medical History: Cardiac Risk Factors: - Diabetes Type II, last A1c 8.9 [**9-/2152**], complicated by diabetic gastroparesis and peripheral neuropathy - Dyslipidemia, on zocor 40mg qd - Hypertension, on metoprolol 50 [**Hospital1 **] . Cardiac History: CABG in [**2143**], w/ LIMA to LAD (patent [**2152-10-9**]), SVG to Marginal branch of circ (patent [**2152-10-9**]) - Prior stents to proximal and mid-LAD as evidenced by most recent Cath - dates/types not known. . Additional PMH: - Chronic Renal insufficiency, Cr at OSH 1.6 - DVT w/ PE, now s/p IVC filter, and on coumadin - Psoriasis - COPD on 3L NC at baseline - Hiatal Hernia - Hypothyroidism - Left subclavian stenosis [**2-/2150**] - Depression - Anemia, baseline Hct 27.8% Social History: Patient lives alone in [**Location (un) 1514**] NH. Has visiting nurse and home health aid who helps with medications. Has two daughters who she is involved with and does not mind if we discuss her care with them. She is a retired police officer. Smoked 1 ppd for nearly 40 years. Denies history of etoh use or IVDU. Family History: Family History notable for DM in father and mother. [**Name (NI) 6419**] with CAD first diagnosed in their 60's. No family history of SCD, aspirin allergy that she is aware of. Physical Exam: VS: T 97.6. , BP 130/50 LA, BP 150/60 RA , HR 59, RR 15, O2 99 % on 3L Gen: obese elederly woman in NAD, resp or otherwise. Oriented x3. Mood, affect appropriate but at times a bit odd. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Mild conjunctival pallor. Wears dentures at baseline. Neck: Supple, no significant JVD. CV: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. No S4, no S3. Systolic murmur II/VI at LUSB. Chest: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. No crackles, wheeze, rhonchi. Abd: Obese, soft, non-distended. Mild discomfort with palpation in RUQ, RLQ, LLQ, no rebound, no guarding, no masses. Skin: Mild dermatitis under breasts bilaterally. Pulses: Right: Carotid 2+ without bruit; Femoral 2+ without bruit; 1+ DP Left: Carotid 2+ without bruit; Femoral 2+ without hematoma or bruit; DP dopplerable, PT pulses dopplerable b/l. Neuro: AO, CN II - [**Doctor First Name 81**], tongue deviates to left with protrusion, speech is mildly dysarthric at baseline (without dentures in place on exam). No focal weakness on exam, extremities grossly 4+/5 upper and lower. Pertinent Results: [**2152-10-11**] 12:23PM PT-13.2* PTT-150* INR(PT)-1.2* [**2152-10-11**] 12:23PM PLT COUNT-301 [**2152-10-11**] 12:23PM WBC-7.3 RBC-2.65* HGB-8.9* HCT-26.3* MCV-100* MCH-33.7* MCHC-33.9 RDW-16.8* [**2152-10-11**] 12:23PM GLUCOSE-406* UREA N-21* CREAT-1.4* SODIUM-135 POTASSIUM-4.0 CHLORIDE-95* TOTAL CO2-31 ANION GAP-13 [**2152-10-11**] 12:23PM estGFR-Using this [**2152-10-11**] 12:23PM CALCIUM-8.9 PHOSPHATE-3.5 MAGNESIUM-2.1 [**2152-10-11**] 08:20PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-NEG [**2152-10-11**] 08:20PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.007 Brief Hospital Course: Patient was admitted to the CCU for management: . #1)ASA Desensitization was accomplished using the standard protocol without complication. . #2)CAD: Performed [**2152-10-12**] and 2 drug eluting stents were placed in the RCA. Pt. remains chest pain free. Lopressor, Zocor and Imdur were continued. She will need Plavix 76 mg daily, uninterrupted for 12 months. It may only be stopped under the direction of Dr. [**Last Name (STitle) **]. She will need to take aspirin lifelong. EKG shows Sinus rhythm and is without changes. #3)Diabetes: NPH dose was adjusted in [**Location (un) 1514**] Hopsital due to glucose elevations. Glucose remained elevated with NaHCo3 infusion during and after cardiac cathetherization. NPH dose now resembles home dose. Glucose values ranged from 133,265,335, 406 during this admission and she was given Regular insulin sliding scale as needed. She will require continued monitoring and treatment. Pt. continues with multiple medications for peripheral neiropathy. She is wheelchair bound. She declined Physical Therapy evaluation on [**2152-10-13**]. She has a history of falls. Most recent fall at home was 2 weeks ago. She will need further evaluation of this staus prior to returning home safely. She may benefit from rehabilitation, however she declines this option at this time. #4) HTN: Norvasc was added for improved blood pressure control. We recommend considering Ace inhibitor after settling from cardiac cath if creatinine is stable. Blood pressure range is from 109/52-209/73. She will need continue monitoring and treatment. #5) Chronic renal insufficiency: Creatinine was 1.4 on [**2152-10-12**]. She was prehydrated with NaHCo3 before and during catheterization procedure. Medications on Admission: metoprolol 50mg PO BID Heparin gtt at 1300 units/hr combivent 2 puff INH [**Hospital1 **] docusate Na 100mg [**Hospital1 **] duloxetine 60mg qd, 30mg qd advair 100ucg [**Hospital1 **] furosemide 20mg PO qd gabapentin 300mg qhs, 600mg [**Hospital1 **] gemfibrozil 600mg [**Hospital1 **] insulin lispro SS insulin NPH 37 units qhs insulin NPH 42 units qam imdur 30mg [**Hospital1 **] levothyroxine 75 ucg qd lidocaine patch 5% 2 patches each day (one each leg) metoclopramide 5mg PO qachs nortiptyline 25mg qhs nystatin top [**Hospital1 **] pantoprazole 40mg PO BID quetiapine 50mg qhs simvastatin 40mg PO qd . PRN butalbital/APAP/CAFF cyclobenzaprine fentanyl glucagon lactulose lorazepam 0.25mg q8 morphine nitroglycerin propoxyphene-APAP Discharge Medications: 1. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. Duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 4. Duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO QPM (once a day (in the evening)). 5. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation Q6H (every 6 hours) as needed. 6. Fluticasone-Salmeterol 100-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 8. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 10. Gabapentin 300 mg Capsule Sig: Two (2) Capsule PO HS (at bedtime). 11. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily). 13. Metoclopramide 10 mg Tablet Sig: 0.5 Tablet PO QIDACHS (4 times a day (before meals and at bedtime)). 14. Nortriptyline 25 mg Capsule Sig: One (1) Capsule PO HS (at bedtime). 15. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 16. Quetiapine 25 mg Tablet Sig: Two (2) Tablet PO QHS (once a day (at bedtime)). 17. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 18. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO BID (2 times a day). 19. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day). 20. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 21. Warfarin 2.5 mg Tablet Sig: Three (3) Tablet PO DAYS (TH,FR) for 2 days: INR on [**2152-10-14**] for further Coumadin dose. 22. Methadone 10 mg Tablet Sig: One (1) Tablet PO QID (4 times a day). 23. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*11* 24. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 25. Insulin NPH Human Recomb Subcutaneous 42 units in am, and 37 units in evening. Discharge Disposition: Home with Service Discharge Diagnosis: Coronary artery dsease. Hypertension Diabetes. Hyperlipidemia IVC filter and hx. of CVA-. on Coumadin therapy Left subclavian stenosis Chronic renal insufficiency Discharge Condition: VS; 97.6-[**Numeric Identifier 75961**] 168/78 Labs: groin: no hematoma or bruit Followup Instructions: Dr. [**Last Name (STitle) 75962**] in 1 week. Dr. [**Last Name (STitle) **] [**2152-10-18**] 10:45am. Completed by:[**2152-10-13**] Name: [**Known lastname **],[**Known firstname 194**] A Unit No: [**Numeric Identifier 12442**] Admission Date: [**2152-10-11**] Discharge Date: [**2152-10-13**] Date of Birth: [**2084-2-24**] Sex: F Service: MEDICINE Allergies: Aspirin / Penicillins / Vancomycin / Iodine / Nsaids / Lyrica Attending:[**First Name3 (LF) 12443**] Addendum: After speaking with patient's Primary Care Physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 12444**] ([**Telephone/Fax (1) 12445**]),pt. will be transferred to [**Hospital **] Hospital PCU unit for further monitoring and treatment of CAD, diabetes, hypertension, peripheral neuropathy, chronic renal insufficiency and mobility status. Major Surgical or Invasive Procedure: cardiac catheterization and stents to RCA. History of Present Illness: see discharge summary [**2152-10-13**] Past Medical History: Cardiac Risk Factors: - Diabetes Type II, last A1c 8.9 [**9-/2152**], complicated by diabetic gastroparesis and peripheral neuropathy - Dyslipidemia, on zocor 40mg qd - Hypertension, on metoprolol 50 [**Hospital1 **] . Cardiac History: CABG in [**2143**], w/ LIMA to LAD (patent [**2152-10-9**]), SVG to Marginal branch of circ (patent [**2152-10-9**]) - Prior stents to proximal and mid-LAD as evidenced by most recent Cath - dates/types not known. . Additional PMH: - Chronic Renal insufficiency, Cr at OSH 1.6 - DVT w/ PE, now s/p IVC filter, and on coumadin - Psoriasis - COPD on 3L NC at baseline - Hiatal Hernia - Hypothyroidism - Left subclavian stenosis [**2-/2150**] - Depression - Anemia, baseline Hct 27.8% Social History: Patient lives alone in [**Location (un) **] NH. Has visiting nurse and home health aid who helps with medications. Has two daughters who she is involved with and does not mind if we discuss her care with them. She is a retired police officer. Smoked 1 ppd for nearly 40 years. Denies history of etoh use or IVDU. Family History: Family History notable for DM in father and mother. [**Name (NI) 12378**] with CAD first diagnosed in their 60's. No family history of SCD, aspirin allergy that she is aware of. Physical Exam: see disharge summary [**2152-10-13**] Pertinent Results: see disharge summary [**2152-10-13**] Brief Hospital Course: see discharge summary [**2152-10-13**] Medications on Admission: see discharge summary [**2152-10-13**] Discharge Medications: 1. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. Duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 4. Duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO QPM (once a day (in the evening)). 5. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation Q6H (every 6 hours) as needed. 6. Fluticasone-Salmeterol 100-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 8. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 10. Gabapentin 300 mg Capsule Sig: Two (2) Capsule PO HS (at bedtime). 11. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily). 13. Metoclopramide 10 mg Tablet Sig: 0.5 Tablet PO QIDACHS (4 times a day (before meals and at bedtime)). 14. Nortriptyline 25 mg Capsule Sig: One (1) Capsule PO HS (at bedtime). 15. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 16. Quetiapine 25 mg Tablet Sig: Two (2) Tablet PO QHS (once a day (at bedtime)). 17. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 18. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO BID (2 times a day). 19. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day). 20. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 21. Warfarin 2.5 mg Tablet Sig: Three (3) Tablet PO DAYS (TH,FR) for 2 days: INR on [**2152-10-14**] for further Coumadin dose. 22. Methadone 10 mg Tablet Sig: One (1) Tablet PO QID (4 times a day). 23. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*11* 24. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 25. Insulin NPH Human Recomb Subcutaneous Discharge Disposition: Extended Care Discharge Diagnosis: Coronary artery dsease. Hypertension Diabetes. Hyperlipidemia IVC filter and hx. of CVA-. on Coumadin therapy Left subclavian stenosis Chronic renal insufficiency peripheral neuropathy Discharge Condition: VS; 97.6-[**Numeric Identifier 12446**] 168/78 Labs: p[ending groin: no hematoma or bruit Discharge Instructions: Post cardiac catheterization and stent wound and activity guidelines. Take Plavix uninterrupted for 12 months. Do not stop unless directed by Dr. [**Last Name (STitle) **]. Note Norvasc start. Followup Instructions: Dr. [**Last Name (STitle) **] in 1 week. Dr. [**Last Name (STitle) **] [**2152-10-18**] 10:45am. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1729**] MD [**MD Number(1) 6268**] Completed by:[**2152-10-13**]

[ "411.1", "585.9", "357.2", "536.3", "V45.81", "496", "250.60", "V58.61", "285.21", "414.01", "272.4", "403.90", "V14.6", "244.9" ]

icd9cm

[ [ [] ] ]

[ "00.40", "36.07", "88.55", "37.22", "00.46", "99.20", "00.66", "99.12", "88.52" ]

icd9pcs

[ [ [] ] ]

16046, 16061

13583, 13623

12045, 12090

16290, 16382

13521, 13560

16625, 16882

13267, 13448

13712, 16023

16082, 16269

13649, 13689

16406, 16602

13463, 13502

285, 310

12118, 12158

12180, 12913

12930, 13250

15,148

173,372

9300

Discharge summary

report

Admission Date: [**2124-11-21**] Discharge Date: [**2124-12-2**] Date of Birth: [**2063-10-22**] Sex: M Service: HISTORY OF PRESENT ILLNESS: The patient is a 61 year old male with a history of aortic valve replacement for infected endocarditis on [**2124-2-4**], thought to be secondary to lower extremity osteomyelitis, likely Streptococcus organism. He was admitted on [**2124-11-22**] to the Podiatry Service for left foot ulceration. During the stay on Podiatry Service he developed moderate to severe cardiovalvular leak/dehiscence. The patient also has diabetes whose course is complicated by end stage renal disease on hemodialysis and has been followed by the Renal Service here at [**Hospital6 256**] since [**2124-11-22**], getting dialysis Mondays, Wednesdays and Fridays. Renal notes have noted a I/VI systolic murmur and clear lungs over the hospital course, however, bibasilar crackles have developed and a systolic murmur was noted to have increase on [**11-28**] and a S3 was heard as well on that date. An echocardiogram was recommended, this echocardiogram on [**2124-11-30**] which was a transthoracic echocardiogram and showed left ventricular hypertrophy with an ejection fraction of 55% with moderate dilated aortic root, question of a partial dehiscence with 3 to 4+ aortic insufficiency ? abscess, 2+ mitral regurgitation and 2+ tricuspid regurgitation. A follow up transesophageal echocardiogram was performed on [**12-1**]. This showed partial dehiscence and echolucent cavity 2.4 times 3 cm. which is felt to be very suspicious for an abscess or an intravalvular fibrosing hematoma. The patient had blood cultures drawn on [**11-30**], two sets which have shown no growth to date as of [**12-1**]. He has also had swabs that were done from his left foot wound, one swab grew rare coagulase positive Staphylococcus, rare coagulase negative Staphylococcus and rare diphtheroids. Another one from [**11-21**] grew rare Methicillin-sensitive resistant Staphylococcus aureus, again out of the left foot. The patient was transferred to the [**Hospital6 2018**] Cardiac Care Unit Service on the evening of [**12-1**] secondary to his worsening echocardiogram and worsening lung and cardiac examination. The patient denied shortness of breath or any chest pain, feeling rundown fatigued or any fevers, chills or rigors. PAST MEDICAL HISTORY: Notable for aortic valve replacement mentioned [**2124-2-2**], diabetes, hypercholesterolemia, hypertension. He also has had the osteomyelitis complicated by left transmetatarsal amputation. He also has chronic venous stasis. SOCIAL HISTORY: He is on disability. He quit smoking in [**2089**]. He does not drink. He does not use drugs. He has a family history of coronary artery disease. MEDICATIONS: Medications on transfer from the Podiatry Service to the GCU Service included Metoclopramide, Synthroid 25 mcg q.d., Lipitor 10 q.d., Nephrocaps, sliding scale insulin, Levaquin 250 q.o.d., Flagyl 50 q.d. and Protonix and Aspirin. PHYSICAL EXAMINATION: Physical examination on [**12-1**] revealed temperature 99.1, blood pressure 102/70, 94% on 3 liters nasal cannula pulsed at 3 liters 90 q. shift, lying, nasal cannula. Jugulovenous distension slightly increased to 9 cm, roughly 4 to 5 cm above the angle of Luie. He has crackles roughly two-thirds the way up bilaterally. Chest shows a normal median sternotomy scar. Skin shows evidence of a lower extremity venous stasis changes. His heart examination revealed a regular rate and rhythm, S1 and S2, S3 is appreciated. There is no S4 appreciated. There is an early systolic II/VI murmur and a diastolic rumble II/VI. His carotids are palpable [**2-3**]. There are no bruits bilaterally. He has bilateral edema, roughly 1 to 2+ and he has vacuum dressing on his left lower extremity. LABORATORY DATA: Electrocardiogram on [**2124-11-22**], sinus at 89, leftward axis at roughly 50 degrees, PR 16, QTC 478, QRS 156, right bundle branch block with left anterior fascicular block with nonspecific ST-T wave changes. Echocardiogram as mentioned above. Laboratory data on [**12-1**], white count 8.2, hematocrit 29.8, hemoglobin 9.4, MCV 89, platelet count 372, INR 1.3 on [**11-24**]. PTT was 26. Urinalysis on [**11-22**], 8 white blood cells, a few bacteria, 2 red blood cells. Chem-7 on [**12-1**], sodium 134, potassium 5.3, chloride 99, bicarbonate 24, BUN 58, creatinine .5, glucose 91, magnesium 1.8, phosphorus 4.5, calcium 8 all predialysis, but will repeat. Blood cultures, two sets on [**11-30**] showed no growth to date, another set is being drawn on [**12-1**]. Swab of the left foot on [**11-23**], coagulase positive Staphylococcus rare, coagulase negative Staphylococcus rare, diphtheroids rare. Urine culture, no growth to date on [**11-22**]. On [**11-21**], wound Methicillin-sensitive resistant Staphylococcus aureus rare, left foot. The patient is a 60 year old male with osteomyelitis, status post debridement and left transmetatarsal amputation who has a history of endocarditis, chronic aortic valve replacement, bioprosthetic valve on [**2124-2-2**], also he has diabetes complicated by hemodialysis for end stage renal disease, now has a perivalvular leak, presence of abscess on a transesophageal echocardiogram, left with the assumption that this is endocarditis likely coming from the foot wound in terms of possible source that has lead to the vascular infection. HOSPITAL COURSE/PLAN: 1. Failure - The patient is anuric, will consult Renal Team, AMC if we can pick up some more volume via dialysis. 2. Adding ACE inhibitor for afterload reduction as blood pressure tolerates. 3. Addressing the infectious issues of the endocarditis, we will dose the patient's Vancomycin. Check Vancomycin level and dose the patient's Vancomycin bilevel for a level of 15 and give the patient a dose of Gentamicin 80 intravenously times one. Then we will dose the Gentamicin after dialysis. 4. The patient is already end stage renal disease and anuric, the Gentamicin is modified in terms of renal toxicity. 5. Check daily electrocardiograms, following Prolene suture. 6. Place the patient on Telemetry. 7. Continue Aspirin and Lipitor. 8. Cardiothoracic Surgery is following our patient and is going to follow him closely regarding the timing of surgery. Ideally we are trying to have the patient transfer back to [**Hospital1 2177**] for evaluation and treatment by Dr. [**Last Name (STitle) 23**] who performed the initial aortic valve replacement. 9. We are ultimately going to continue Levo and Flagyl for broad coverage, however, at the current time it is obvious that that is the source, most concerning is for Methicillin-sensitive resistant Staphylococcus aureus. 10. Per the diabetes, we are going to continue the patient on a sliding scale, tight glucose control if his sugars are very high we will continue the drip. At this point, the patient is hemodynamically stable, not requiring any pressure support. If it does become an issue, check Cortisol, to make sure the patient is not insufficient. 11. Transfer the patient to the TCU here for monitoring and attempts to transfer him to [**Hospital1 2177**] electively for evaluation for possible aortic valve replacement. DISCHARGE DIAGNOSIS: 1. Aortic insufficiency with valve dehiscence 2. Left foot osteomyelitis. 3. Diabetes mellitus complicated by end stage renal disease on hemodialysis. 4. Hypercholesterolemia. 5. Chronic venous stasis. DISCHARGE MEDICATIONS: Vancomycin 1 gm dosed intravenously for a level less than 15, Gentamicin 80 mg intravenously, getting first dose on [**2124-12-1**], to be dosed after hemodialysis for three to five days depending on blood cultures. Continue on Levaquin and Metronidazole for broad coverage until positive. Levaquin 250 p.o. q.o.d., Flagyl 500 p.o. t.i.d. for broad coverage until culture data becomes more available. Calcium acetate 667 mg p.o. t.i.d. with meals. Nephrocaps 1 p.o. q.d. Insulin sliding scale. Lipitor 10 q.d. Levothyroxine 25 mg p.o. q.h.s. Aspirin 325 q.d., Protonix 440 p.o. q.d., Benadryl prn, Acetaminophen prn, Colace 100 b.i.d., Captopril starting 6.25 p.o. t.i.d. titrate to 12.5 t.i.d. at tomorrow's dose. Reglan 10 p.o. b.i.d., Senna prn, Bisacodyl prn. DR [**First Name11 (Name Pattern1) 5445**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 5446**] 48.121 Dictated By:[**Last Name (NamePattern1) 1659**] MEDQUIST36 D: [**2124-12-1**] 21:53 T: [**2124-12-1**] 22:30 JOB#: [**Job Number 31843**]

[ "428.0", "730.07", "707.15", "996.61", "997.62", "E878.1", "041.19", "585", "996.02" ]

icd9cm

[ [ [] ] ]

[ "88.72", "84.3", "39.95" ]

icd9pcs

[ [ [] ] ]

7545, 8596

7313, 7521

3063, 7292

162, 2374

2397, 2626

2643, 3040

48,143

142,304

41491

Discharge summary

report

Admission Date: [**2162-8-10**] Discharge Date: [**2162-8-16**] Date of Birth: [**2078-12-15**] Sex: F Service: MEDICINE Allergies: Omega-3 Fish Oil Attending:[**First Name3 (LF) 5129**] Chief Complaint: shortness of [**First Name3 (LF) 1440**] Major Surgical or Invasive Procedure: none History of Present Illness: 83F with history of COPD on home O2, sCHF (EF 25%), squamous cell lung cancer and anemia, presented with one week worsening dyspnea on exertion with acute worsening this afternoon. Discharged from [**Hospital1 18**] on [**2162-8-6**] after treatment for acute on chronic diastolic heart failure exacerbation. She received IV lasix with improvement of her symptoms. During that admission, she had an echo that showed EF 25% (previously 40-45% in 3/[**2162**]). Additionally, due to hypoxia had work-up for DVT and PE which were negative. CT showed interval worsening of her known squamous cell carcinoma with associated left sided effusion. She was discharged [**Last Name (un) **] on no diuretics due to concern of impaired renal function. Sent home with home O2 and hospital bed with plan for outpatient discussion of care for carcinoma. Additionally, has not been taking BP meds as prescribed. This afternoon, woke up with acute shortness of [**Last Name (LF) 1440**], [**First Name3 (LF) **] called 911. + orthopnea, worsening peripheral edema, +PND. + chest tightness. + cough, dry, non-productive. no syncope or palpitations. No fever/chills, no N/V/D/constipation/dysuria. Poor Appetite. Previously active and independent in ADLs. . Due to symptoms, called 911, in ambulance noted to be tachypnic to 40's, hypoxic - placed on biPap and recieved SL: NTG for SBP 180's with improvement in symptoms. . In the ED, initial vs were: T 97.5 P 111 BP 133/82 R 25 O2 sat. 100% NRB. On exam, afebrile, HR 180-100, pressure in 140's, RR 20's on BiPAP with bilateral basilar crackles, JVD, pedal edema. Previous renal dysfunction improved, lactate WNL. CXR with worsening left pleural effusion. Stopped nitro gtt since > than goal 20% reduction. No troponin. Recieved abx for HCAP - vanco, cefepime, levo. Vitals prior to transfer 102 144/67 24 4L 02 NC 97% . On the floor, patient is mildly anxious, no acute respiratory distress. Past Medical History: # COPD -- not on home O2 # Diastolic CHF # Hypertension # Hyperlipidemia # PVD # Proteinuria # Monoclonal gammopathy # Osteoporosis # Glaucoma # Anemia (baseline hct 32) # Seizure History # Tobacco abuse Social History: She has 3 children, 2 sons and 1 daughter. She lives with one of her grandsons and her daughter is involved in her care. # Tobacco: Smokes [**1-31**] PPD for many years, has smoked more in past # Alcohol: Occasional social drinking # Drugs: None Family History: Glaucoma on mother's side of family. Physical Exam: Admission PE: Vitals: T: 98.6 BP: 145/91 P: 109 R: 20 O2: 96% 2L NC General: Alert, oriented, speaks comfortably, chronically ill appearing HEENT: sclera with chronic changes, MMM, oropharynx clear, no thrush Neck: supple, JVP elevated, no LAD Lungs: diminished BS bilateral lung bases with rhonchi and crackles appreciated more superior portions. occasional wheeze. CV: tachycardic, regular rhythm, normal S1 + S2, S3 present, no murmurs/rubs. Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: + foley Ext: pitting edema in bilateral lower extremities; warm, well perfused, 2+ pulses, no clubbing, cyanosis Discharge PE: VS: T 37, HR 108, BP 150/91, RR 24, SaO2 94% NC General: Very pleasant, NAD, breathing comfortably on NC. Cachectic. HEENT: MMM Neck: elevated JVP, supple, no LAD. Lungs: decreased [**Month/Day (2) 1440**] sounds at bases bilaterally, diffuse crackles Heart: tachycardic, regular rhythm, Nl S1/S2, +S3 appreciated at sternal border Abd: +BS, soft, NT/ND Extr: bipedal pitting edema, 2+ peripheral pulses. Pertinent Results: Admission labs: [**2162-8-10**] 08:15PM WBC-8.6 RBC-3.21* HGB-10.2* HCT-31.7* MCV-99* MCH-31.8 MCHC-32.2 RDW-15.5 [**2162-8-10**] 08:15PM GLUCOSE-137* UREA N-19 CREAT-1.1 SODIUM-141 POTASSIUM-5.1 CHLORIDE-103 TOTAL CO2-29 ANION GAP-14 [**2162-8-10**] 08:15PM cTropnT-0.02* [**2162-8-10**] 08:26PM LACTATE-1.6 [**2162-8-10**] 08:15PM PT-13.4 PTT-28.5 INR(PT)-1.1 [**2162-8-10**] 08:15PM NEUTS-73.8* LYMPHS-17.0* MONOS-4.0 EOS-4.5* BASOS-0.6 Discharge labs: [**2162-8-16**] 05:20AM BLOOD WBC-5.4 RBC-2.72* Hgb-8.6* Hct-26.1* MCV-96 MCH-31.6 MCHC-32.9 RDW-14.5 Plt Ct-405 [**2162-8-16**] 05:20AM BLOOD Glucose-111* UreaN-43* Creat-1.6* Na-136 K-4.5 Cl-98 HCO3-31 AnGap-12 [**2162-8-13**] 01:30PM PLEURAL WBC-395* RBC-225* Polys-21* Lymphs-52* Monos-0 Meso-5* Macro-19* Other-3* [**2162-8-13**] 01:30PM PLEURAL TotProt-2.8 Glucose-169 LD(LDH)-83 Microbiology: [**8-10**]: Blood cultures demonstrated no growth [**2162-8-13**] 1:30 pm PLEURAL FLUID PLEURAL FLUID. GRAM STAIN (Final [**2162-8-13**]): 2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. This is a concentrated smear made by cytospin method, please refer to hematology for a quantitative white blood cell count.. FLUID CULTURE (Final [**2162-8-16**]): NO GROWTH. ANAEROBIC CULTURE (Preliminary): NO GROWTH. FUNGAL CULTURE (Preliminary): Imaging: CXR [**8-11**]: Severe emphysematous changes are redemonstrated. Again noted is a moderate-sized left pleural effusion, which may be slightly larger when compared to the prior study. Worsening bibasilar air space opacities are noted which is concerning for infection or aspiration. Mild pulmonary vascular engorgement is also noted. There is no pneumothorax. Small right pleural effusion is increased when compared to the prior study. Extensive degenerative changes of the left glenohumeral joint are noted. There is no pneumothorax. Cardiac silhouette size is difficult to assess given the presence of bibasilar air space opacities and bilateral pleural effusions. Tortuosity of the thoracic aorta with atherosclerotic calcifications is again noted. IMPRESSION: 1. Worsening bibasilar air space opacities which is concerning for infection or aspiration. 2. Moderate-sized left and small right pleural effusions. 3. Mild pulmonary vascular congestion. 4. Severe emphysema. CXR ([**8-13**]): A pigtail catheter is seen near the left lung base with the tip towards the left cardiophrenic angle. There is no evidence of pneumothorax. Bilateral lungs are hyperinflated consistent with extensive emphysema changes. Left pleural effusion has significantly reduced and there is residual minimal pleural effusion with atelectasis of the underlying lung. Mild-to-moderate right pleural effusion is unchanged basal atelectasis. Mild interstitial thickening is seen in the left mid and bilateral lung bases suggestive of mild pulmonary edema. There is mild cardiomegaly. Brief Hospital Course: 83F with COPD oh home O2, severe systolic and diastolic CHF (EF=25%), squamous cell lung CA was admitted with dyspnea x 1 week that worsened acutely on the day of admission. She was admitted to the ICU from the ED. Her hospital course was significant for the following issues: . # Dyspnea - Patient's dyspnea was thought to be multifactorial but was consistent with flash pulmonary edema/acute on chronic systolic and diastolic heart failure. The patient was initially started on broad-spectrum antibiotics for possibility of pneumonia, but she remained afebrile and exhibited no signs of infection, so antibiotics were discontinued. Serial cardiac enzymes were negative for acute MI. Of note, no maintenance diuretic had been prescribed when she was discharged home on her last admission. Aggressive diuresis was pursued in the ICU. She was maintained on beta-blocker and [**Last Name (un) **]. Despite diuresis, she continued to have a large right pleural effusion of unclear etiology. Interventional pulmonary performed a thoracentesis and pigtail catheter placement and drained approximately 1 L of fluid, most suggestive of transudate BUT pleural fluid CYTOLOGY is still PENDING. After drainage, her oxygen requirement decreased to 1L NC and the pigtail catheter has been removed. She remains with sats in the mid-high 90s on 1.5l/min via NC. . #Acute Renal Failure: Upon admission, the creatinine was 1.1, but with the aggressive diuresis, the creatinine climbed to 1.6. Clearly, the titration of diuretics based on daily weights, O2 sats, pulmonary signs and symptoms, and renal function will be crucial to preventing re-hospitalization. . # COPD: Patient was placed on standing nebs and her home ADVAIR was continued. She had intermittent episodes of anxiety and was started on oral morphiine solution. . # Hypertension - She was quite hypertensive per report of the EMTs who arrived at her home. Her home meds were resumed at half the dose with plans to taper up as tolerated. She was maintained on metoprolol 50mg po BID and Irbesartan 150mg qDay, half her home doses. Currently, after aggressive diuresis she is running SBPs in the 100-110 range, and occasionally to the 90s so this will also have to be titrated at the [**Hospital 1501**] rehab. . # Squamous Cell Lung CA-She was diagnosed within 3 months of admission. Her Atrius oncologist followed her while in house. She is not a candidate for treatment (XRT/chemo)due to her multiple co-morbidities. # Anemia - She has been chronically anemic and her hematocrit remained stable. She had no signs of active bleed. # Urinary retention: Throughout her hospital course, she had a few episodes of urinary retention ("feeling that she had to urinate but couldn't go"). Bladder scans revealed up to 300 cc of urine. This was likely due to severe constipation. She had several enemas with large bowel movements. Agressive bowel regimen was started and her iron supplements were discontinued. She is now able to void without difficulty. A UA was negative for infection. # GERD- She was continued on home omeprazole. # Hyperlipidemia- She was continued on her rosuvastatin. # Glaucoma - She was continued on her eye drops (pilocarpine, brimonidine, timolol, latanprost). #Goals of Care: She is A&O x 3 on the day of discharge. I had a fairly long conversation today with her about what she would want us to do if she were to stop breathing and/or her hear were to stop. Her answer was "everything". I discussed in detail what we would do, the likely futility of the attempts given her severe heart failure, lung CA, and other medical problems, and the very low probability that whe would be able to come off the ventilator if she needed intubation. I checked her understanding by asking her to tell me back what I explained to her and it was clear to me that she understands the implications of her request to remain FULL CODE. Clearly this issue should be re-discussed with her and her daughter periodically given the very poor prognosis of her severe heart failure combined with severe emphysema, lung cancer, and renal failure as well as her age. #Risk of re-admission- very high in this fragile patient. She will need: -daily weights -daily physician or NP/PA review of her clinical status and medication regimen -monitoring of her renal function in the setting of diuresis -availability of chest X-Ray for evaluation of decreasing sats - DDX includes pulmonary edema, re-development of pleural effusion (lower likelyhood if she is maintained on the "dry" side as she is now), PNA. IF CXR negative emphysema exacerbation should be considered. -She is at high risk for DVT/PE given her CA, HF, immobility, and should remain on at least SQ heparin. However, her pulmonary reserve is so low that she is unlikely to survive aq PE of any significant size. -If her Hct drops (currently 25%), we would be very cautious about blood transfusion given her heart failure. Would transfuse only if she is symptomatic or if her Hct drops below 22%, though we leave this to the discretion of the [**Hospital1 1501**] physician. Medications on Admission: albuterol inhaler 2 puffs q6 prn amlodipine 10mg daily aspirin 81 mg daily bimatoprost eye gtt brimonidine eye gtt caltrate 600 [**Hospital1 **] ferrous gluconate fluticasone-salmeterol Discharge Medications: 1. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 2. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours). 3. fluticasone-salmeterol 100-50 mcg/dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 4. rosuvastatin 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 5. irbesartan 150 mg Tablet Sig: One (1) Tablet PO daily (). 6. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 8. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 9. timolol maleate 0.5 % Drops Sig: One (1) Drop Ophthalmic DAILY (Daily). 10. brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic Q 12H (Every 12 Hours). 11. pilocarpine HCl 4 % Drops Sig: One (1) Drop Ophthalmic HS (at bedtime). 12. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 13. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable Sig: One (1) Tablet, Chewable PO BID (2 times a day). 14. latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at bedtime). 15. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for insomnia. 16. metoprolol succinate 100 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily). 17. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1) PO DAILY (Daily) as needed for hold for diarrhea. 18. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 19. morphine 10 mg/5 mL Solution Sig: [**3-4**] ml PO Q8H (every 8 hours) as needed for pain. 20. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 21. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 22. camphor-menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical QID (4 times a day) as needed for itchiness to back. Discharge Disposition: Extended Care Facility: [**First Name4 (NamePattern1) 1188**] [**Last Name (NamePattern1) **] - [**Location (un) 538**] Discharge Diagnosis: Acute exacerbation of systolc heart failure Severe, O2-dependent COPD (emphysema) Squamous cell lung CA Acute renal failure in the setting of aggressive diuresis Acute on chronic anemia Hypertension 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: The patient should be weighed daily. She is currentlyu at or below her ideal "dry weight". If her weight continues to drop, and/or her creatinine continues to increase, would decrease the diuretic dose byt 25-50%. Weight gains of more than 3Lbs over one week should be reported to the physician and may represent a need for more diuretics. Blood pressures are currently on the low side. No recent changes have been made to her anti-hypertensive regimen, but should be considered if her BP continues to run low. Her hematocrit is 25%. Given her severe systolic heart failure, we would be very cautious about transfusing blood products due to concern about heart failure exacerbation. She is on chronic low flow O2 (1-2L by NC) for her severe emphysema. She needs to remain on DVT prophylaxis given her lung cancer, heart failure, and relative [**Name (NI) 90257**]. Followup Instructions: Department: WEST [**Hospital 2002**] CLINIC When: TUESDAY [**2162-9-14**] at 9:00 AM With: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 3020**] Building: De [**Hospital1 **] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **] Campus: WEST Best Parking: [**Street Address(1) 592**] Garage

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icd9cm

[ [ [] ] ]

[ "34.91" ]

icd9pcs

[ [ [] ] ]

14321, 14443

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319, 325

14686, 14686

4006, 4006

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353, 2307

4022, 4459

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14701, 14845

2329, 2535

2551, 2799

75,305

174,712

30470

Discharge summary

report

Admission Date: [**2149-3-7**] Discharge Date: [**2149-3-10**] Date of Birth: [**2095-9-11**] Sex: F Service: MEDICINE Allergies: Iodine-Iodine Containing / Optiray 350 / metformin Attending:[**First Name3 (LF) 2290**] Chief Complaint: abdominal pain, nausea, vomiting Major Surgical or Invasive Procedure: none History of Present Illness: 53 YO F w metastatic melanoma, adrenal insuff on chronic steroids p/w 3 days of persistant n, v, diarrhea and assoc chest and abd pain. The patient's husband was recently ill with a diarrheal illness but he improved and then the patient started to notice nausea, vomiting and profuse watery diarrhea with no blood. She has not been able to take any POs since the onset of her symptoms. She denies fever or chills. She came into the ED given the persistance of her symptoms. . Ypon arrival to the ED, her initial VS were: 98.2 140 115/69 18 98% RA. Exam was notable for a woman in distress actively vomiting with abdominal TTP R > L. Labs were notable for WBC 10.6, normal creatinine, and a gap of 21 with ketones and 10 WBCs in her urine. CT A/P non con (due to contrast allergy) was done and showed questionable tip appendicitis. She was resultantly seen by surgery who felt her presentation was not c/w appy but rather gastroenteritis. She was given 10u IV regular insulin, dexamethasone 10mg IV once, morphine, ativan, reglan, cipro for presumed UTI, tylenol and 4L NS to which she only put out 300ccs urine. 2 PIVs were placed. VS prior to transfer were: 126 115/77 24 95%2L. She was admitted to the ICU for her tachycardia. . Upon arrival to the ICU, the patient reports a severe [**8-30**] bilateral, temporal headache. She has phono and photophobia. She has not vomited for several hours and her last BM was this morning. She denies visual changes or neck stiffness. She does describe chest wall pain since vomiting several times. She notices this pain mostly when she swallows fluids. She also reports diffuse abdominal tenderness since shortly after the onset of her symptoms. Past Medical History: ONCOLOGIC HISTORY: [**2140**]: Diagnosed with malignant melanoma of right shoulder, negative sentinel lymph node biopsy [**2144**]: Diagnosed with met melanoma and underwent BCT [**5-27**] with cisplatin, dacarbazine, vinblastine and IL-2 with disease progression noted [**9-26**] - enrolled in MDX-010 trial [**11-26**]: Received last treatment [**5-28**]: CT-evidence of disease progression with enlarging right paratracheal and retrocaval nodes. [**2146-7-6**]: Restarted on therapy with MDX-010 (C2W1). CT on [**7-5**] showed slight increase in size of right paratracheal node. [**2146-9-7**]: Completed 3 treatments of MDX-010 [**11-27**]: CT showed minimal interval progression [**2147-3-8**]: CT showed interval disease progression in the form of retrocaval node enlargement in the upper abdomen. [**2147-5-24**]: Last dose of CTLA-4 Ab infusion. [**6-/2147**]: CT Torso -minimal change with no evidence of new metastatic focus. [**2147-10-11**]: Ipilimumab on the compassionate access trial, protocol 07-350, started. [**12/2147**]: Found to have autoimmune hypophysitis secondary to Ipilimumab (CTLA-4 antibody). Protocol discontinued. [**1-/2148**]: Signed consent for Plexxikon. However, was found not to have specific BRAF mutation. [**2148-3-27**]: Started the Phase I RAF 265 clinical trial with dose reduction x 2 for nausea and vomiting and neuropathy. Therapy was held on [**2149-2-5**] due to atrial flutter (unrelated to study drug) requiring cardiac ablation and could not be restarted after previous two dose reductions. . OTHER PAST MEDICAL HISTORY: metastatic melanoma aflutter s/p ablation HTN Lower extremity DVT initially on coumadin but recieved IVC filter with recurrent hemoptysis and subsequent PE despite lovenox and filter C-section x3 CCY tonsillectomy/adenoidectomy neuropathy Social History: Married w/ three children. She is a housewife. She quit smoking 29 years ago 1.5 ppd for 2 yrs and she reports no EtOH. Family History: Brother - melanoma in 20s. Mother with HTN, breast cancer @ 65 and has DMII. Father with MI in 60s. Physical Exam: ADMISSION EXAM: Vitals: 97.5 129/70 120 27 91% on RA General: Alert, oriented, in acute distress, almost in tears with severe headache-related pain HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, cushingoid, JVP not appreciated although difficult exam, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, few basilar rales CV: Regular, tachycardic, normal S1 + S2, no murmurs, rubs, gallops; reproducible sternal/sub-sternal chest wall pain; no subq emphysema Abdomen: soft, obese mild, diffuse tenderness, non-distended, bowel sounds present but decreased, no rebound tenderness or guarding GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Pertinent Results: ADMISSION LABS: [**2149-3-7**] 10:40AM BLOOD WBC-10.6 RBC-4.87 Hgb-15.8 Hct-45.1 MCV-93 MCH-32.6* MCHC-35.2* RDW-14.3 Plt Ct-221 [**2149-3-7**] 10:40AM BLOOD Neuts-72.3* Lymphs-21.5 Monos-4.4 Eos-0.7 Baso-1.2 [**2149-3-7**] 10:40AM BLOOD Glucose-290* UreaN-11 Creat-1.0 Na-134 K-3.0* Cl-95* HCO3-18* AnGap-24* [**2149-3-7**] 10:40AM BLOOD ALT-66* AST-52* AlkPhos-101 TotBili-1.1 . PERTINENT LABS: [**2149-3-7**] 10:40AM BLOOD cTropnT-<0.01 [**2149-3-7**] 09:09PM BLOOD CK-MB-2 cTropnT-<0.01 [**2149-3-7**] 10:59AM BLOOD Lactate-3.0* [**2149-3-7**] 03:35PM BLOOD Lactate-1.2 K-3.6 [**2149-3-7**] 09:22PM BLOOD Lactate-1.4 . DISCHARGE LABS: [**2149-3-10**] 06:08AM BLOOD WBC-6.1 RBC-3.80* Hgb-12.6 Hct-35.2* MCV-93 MCH-33.0* MCHC-35.7* RDW-14.2 Plt Ct-196 [**2149-3-10**] 06:08AM BLOOD Glucose-159* UreaN-14 Creat-0.8 Na-145 K-3.4 Cl-111* HCO3-24 AnGap-13 [**2149-3-9**] 07:25AM BLOOD ALT-42* AST-35 AlkPhos-75 TotBili-0.4 [**2149-3-10**] 06:08AM BLOOD Calcium-8.6 Phos-3.6 Mg-1.7 [**2149-3-7**] 09:47PM BLOOD %HbA1c-11.4* eAG-280* . EKG: Sinus tachycardia to 142. Nl axis, normal intervals. PRWP. Sub-mm ST depression in V5/V6. . MICROBIOLOGY: [**2149-3-7**] Blood Cx: pending [**2149-3-7**] Urine Cx: pending . IMAGING: [**2149-3-7**] CXR: Large right paratracheal and right perihilar masses compatible with known metastatic disease. No focal consolidations to suggest pneumonia. No free air under the diaphragms. . [**2149-3-7**] CT Abdomen/Pelvis w/o con: 1. The proximal appendix is air filled and normal in size. The distal appendix is borderline enlarged, measuring 7.5 mm, demonstrates no intraluminal air, and there is equivocal periappendiceal fat stranding. Early tip appendicitis cannot be entirely excluded and clinical correlation recommended. 2. Stable appearance of the right retrocaval node, as detailed above. 3. Hepatic steatosis. Brief Hospital Course: 53 year old woman with metastatic melanoma, adrenal insufficiency, and NIDDM presenting with 3d of nausea, vomiting and abdominal pain found to have sinus tachycardia and severe headache. . # Tachycardia: Review of recent outpatient vital signs suggests patient's baseline HR usually in the 90s-110s. With recent poor PO intake, her additional tachycardia is likely related to hypovolemia in the setting of her GI illness. History of nausea and vomiting suggests that she might not have been getting her metoprolol which is also likely contributing. Her HR has returned to the 90s with fluid resuscitation and her home metoprolol dosing. Although the patient does have an underlying malignancy and is thus at a higher risk for PE, there is no indication for CTA at this time since the tachycardia has resolved. . # Headache: Patient had a severe bilateral headache upon presentation which improved with rest, hydration, and small amounts of dilaudid. No indication for urgent head imaging at this time. Patient is scheduled for an upcoming outpatient head CT. . # Nausea/vomiting/diarrhea: Likely secondary to a viral gastroenteritis considering sick contacts and symptomatic improvement. No new meds. No clear food precipitants. CT abdomen/pelvis negative for appendicitis or other acute pathology. LFTs wnl. Symptomatic management with reglan and zofran. The patient's symptoms have resolved and she is tolerating a regular diet. . # Chest Discomfort: Notably worsened with food/drinking. Felt secondary to acute worsening of GERD due to significant vomiting worsening esophageal acidity and inability to keep down her H2 blocker. Cardiac enzymes negative and ekg w/o ischemic changes. Improved with improvement of vomiting and H2 blocker. . # U/A: Suggestive of UTI so patient was given a dose of ciprofloxacin in the ED. She is asymptomatic so further antibiotics held in the MICU. Urine culture grew 10,000 to 100,000 CFU of alpha-hemolytic strep. Since patient was not symptomatic, this was not treated further. . # Adrenal insufficiency: Continued home prednisone 6mg daily. . # HTN: Continued metoprolol. . # Diabetes type 2: A1c: 11.4%. Patient has never been treated for diabetes before. Monitored via insulin sliding scale initially, though blood sugars poorly controlled. Added Lantus with improvement in blood sugars. Provided extensive diabetic teaching and instruction on Lantus use as she was sent home on 18 units of lantus daily. She has close follow up with her [**Month/Day/Year 3390**] and [**Name9 (PRE) **] for further management. . # Neuropathy: Continued gabapentin. . # Code Status: Full Code. Medications on Admission: Prescription meds- GABAPENTIN - (Dose adjustment - no new Rx) - 300 mg Capsule - 3 Capsule(s) by mouth fhree times daily HYDROCODONE-ACETAMINOPHEN [VICODIN] - (Prescribed by Other Provider: [**Name Initial (NameIs) 3390**]) - 5 mg-500 mg Tablet - 1 Tablet(s) by mouth 4-6 hours as needed for pain METOCLOPRAMIDE - (Prescribed by Other Provider) - 10 mg Tablet - 1 Tablet(s) by mouth two times a day as needed for nausea METOPROLOL TARTRATE - 50 mg Tablet - 1 Tablet(s) by mouth three times a day MIRTAZAPINE - 45 mg Tablet - 1 Tablet(s) by mouth once a day POTASSIUM PHOSPHATE, MONOBASIC [K-PHOS ORIGINAL] - 500 mg Tablet, Soluble - 2 Tablet(s) by mouth twice a day PREDNISONE - 1 mg Tablet - 1 Tablet(s) by mouth daily PREDNISONE - 5 mg Tablet - 1 Tablet(s) by mouth once a day . Medications - OTC BLOOD SUGAR DIAGNOSTIC [ONE TOUCH TEST] - Strip - FOUR TIMES A DAY AS INSTRUCTED CALCIUM CARBONATE [CALCIUM 500] - (OTC) - 500 mg (1,250 mg) Tablet - 1 Tablet(s) by mouth daily Take separately from MVI CHOLECALCIFEROL (VITAMIN D3) - (Prescribed by Other Provider) - 1,000 unit Capsule - 1 Capsule(s) by mouth daily EUCERIN LOTION - (OTC) - - Apply to skin daily as needed for prn MULTIVITAMIN-CA-IRON-MINERALS - (Prescribed by Other Provider) - Tablet - 1 Tablet(s) by mouth once a day PYRIDOXINE - 50 mg Tablet - 1 Tablet(s) by mouth daily RANITIDINE HCL - (OTC) - 150 mg Capsule - 1 Capsule(s) by mouth twice daily Discharge Medications: 1. gabapentin 300 mg Capsule Sig: Three (3) Capsule PO three times a day. 2. metoclopramide 10 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for nausea. 3. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. mirtazapine 15 mg Tablet Sig: Three (3) Tablet PO HS (at bedtime). 5. prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. prednisone 1 mg Tablet Sig: One (1) Tablet PO once a day. 7. Lantus Solostar 100 unit/mL (3 mL) Insulin Pen Sig: Eighteen (18) units Subcutaneous at bedtime. Disp:*2 pens* Refills:*2* 8. Lantus Pen Needles Dispense one box To be used with Insulin Pen Refills: Two 9. hydrocodone-acetaminophen 5-500 mg Tablet Sig: One (1) Tablet PO every 4-6 hours as needed for pain: Do not exceed 4 grams of tylenol in 24 hours. 10. Calcium 500 500 mg (1,250 mg) Tablet Sig: One (1) Tablet PO once a day. 11. Vitamin D 1,000 unit Capsule Sig: One (1) Capsule PO once a day. 12. pyridoxine 50 mg Tablet Sig: One (1) Tablet PO once a day. 13. Multi-Vitamin W/Minerals Capsule Sig: One (1) Capsule PO once a day. 14. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 15. blood sugar diagnostic Strip Sig: One (1) Box Miscellaneous four times a day as needed for Glucose monitoring: To be used with ONE TOUCH TEST glucometer. Disp:*2 box* Refills:*2* 16. insulin glargine 100 unit/mL Solution Sig: Eighteen (18) Units Subcutaneous at bedtime: Please use this solution with syringe if you do not have access to the Lantus Pen. Disp:*1 Bottle* Refills:*2* 17. insulin syringe-[**Name Initial (NameIs) **] U-100 Syringe Sig: One (1) syringe Miscellaneous at bedtime: To be used to draw up Lantus solution from bottle. . Disp:*8 Syringes* Refills:*2* 18. potassium phosphate, monobasic 500 mg Tablet, Soluble Sig: One (1) Tablet, Soluble PO twice a day. Discharge Disposition: Home With Service Facility: [**First Name5 (NamePattern1) 392**] [**Last Name (NamePattern1) 269**] Discharge Diagnosis: Primary: Gastroenteritis Diabetes Secondary: Melanoma Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted due to vomiting and diarrhea which was felt to be gastroenteritis as this completely resolved prior to your discharge. You were monitored briefly in the ICU because your heart rate was very fast. This improved when you received fluids through your IV. Your blood sugars were very high during your hospital stay and you were started on insulin. You were taught how to give yourself insulin and you will have a visiting nurse help you further with monitoring of your blood sugars. It is important that you check your blood sugars in the morning and each time prior to your meals and document these blood sugars in a note book. It is very important that you keep your follow up appointments with your doctors as [**Name5 (PTitle) **] [**Name5 (PTitle) **] need very close monitoring of your insulin regimen. You should continue all of your medications with the following important changes: 1. START Lantus 18 units to be taken at night every day 2. OK to continue potassium supplementation as already prescribed as you were receiving a lot of extra potassium in the hospital. You should discuss with your doctor that you are taking this and have your potassium levels monitored closely. It is very important to make sure your sugar does not get too low, if your blood sugar is 51 to 70 mg/dL, eat 10 to 15 grams of fast-acting carbohydrate (eg, [**12-22**] cup fruit juice, 6 to 8 hard candies, 3 to 4 glucose tablets). If you are less than 50 mg/dL, eat 20 to 30 grams of fast-acting carbohydrates. (e.g. 1 cup of fruit juice, [**12-5**] hard candies, [**5-28**] glucose tablets) ***It is important that you keep all of your appointments that are listed below.*** ***I have provided you with information on diabetes care.*** Followup Instructions: Department: HEMATOLOGY/ONCOLOGY When: WEDNESDAY [**2149-3-12**] at 2:30 PM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 9402**], 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 Department: HEMATOLOGY/ONCOLOGY When: WEDNESDAY [**2149-3-12**] at 2:30 PM With: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 10837**], RN [**Telephone/Fax (1) 22**] Building: [**Hospital6 29**] [**Location (un) 24**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: HEMATOLOGY/ONCOLOGY When: WEDNESDAY [**2149-3-12**] at 2:30 PM With: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 6575**], 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 Name: [**Last Name (LF) 1924**], [**Name8 (MD) 10827**] NP Location: [**Hospital 20086**] MEDICAL GROUP Address: [**Street Address(2) 20087**], 2F, [**Hospital1 **],[**Numeric Identifier 20089**] Phone: [**Telephone/Fax (1) 7164**] Appointment: Tuesday [**3-18**] at 11AM Department: MEDICAL SPECIALTIES When: MONDAY [**2149-4-14**] at 1 PM With: [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 13645**], M.D. [**Telephone/Fax (1) 1803**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage ***You are currently on a wait list for an earlier appointment, as none are available presently. If an appointment opens up, the office will call you***

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icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

12744, 12846

6766, 9387

343, 349

12944, 12944

4892, 4892

14871, 16611

4055, 4157

10865, 12721

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271, 305

377, 2064

4908, 5273

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3662, 3902

3918, 4039

26,161

163,407

12671

Discharge summary

report

Admission Date: [**2113-7-4**] Discharge Date: [**2113-7-20**] Date of Birth: [**2060-1-14**] Sex: F Service: MEDICINE Allergies: Morphine / Norvasc Attending:[**First Name3 (LF) 3624**] Chief Complaint: altered mental status Major Surgical or Invasive Procedure: Inutbation PICC placement Lumbar Puncture History of Present Illness: 53 yo W w/ DM1 (brittle on insulin pump), s/p LURT [**2106**] (Baseline Cr 1.4-1.7), CAD (s/p multiple PCIs), [**Year (4 digits) 19874**] (EF 45%), HTN/HL who initially presented to [**Hospital3 **] with a left proximal humerus fracture now transfered to [**Hospital1 18**] for respiratory distress, septic shock, and renal failure. Patient initially went to [**Hospital3 **] on [**2113-7-3**] after trippering over a chair, falling, and sustaining a left proximal humerus fracture without dislocation. Orthopedics saw and advised conservative management and she was given dilaudid for pain as well as a muscle relaxant (unknown type). At 5am on [**2113-7-4**], patient noted to be lethargic with sats to 70s as well as febrile to 103.1. She was given 1 dose of Narcan with little change. Put on 100% NRB and trasfered to CCU where she was given Ceftazidime and Vancomycin. ABG at time showed pO2 of 60%. Some question if EKG changes inferiorly (reported as elevations). Cardiology saw and thought not a cardiac cause. ECHO showed EF 40%. Cards thought she was developing ARDS. ID consulted and recommended switching Ceftazidime to Zosyn for Asp PNA. Cr was 2.1 on admission and rose to 2.9 on [**7-4**]. Continued to be hypotensive despite fluids (unsure how much) and was started on phenylephrine gtt. Insulin pump (home med) was discontinued and ISS started. [**Last Name (un) **] and bactrim were held. Pts [**Hospital1 18**] renal transplant attending ([**Doctor Last Name **]) was contact[**Name (NI) **] and patient was transfered to [**Hospital1 18**] for further care. Immediately prior to transfer patient was intubated due to concerns Re transfer saftey with pt still on NRB and concerns by [**Hospital3 **] that she was developing ARDS. Pressures dropped significantly after intubation with Rocuronium and Propofol and had to go up on Phenylephrine. Patient was stable on ride over and EMTs were able to go down on her pressor requirement. She did well on the vent with relatively minimal sedation and remained responsive to voice on ride over. On arrival to the MICU, patient intubated and sedated, just got propofol bolus. However, able to respond to voice and follow simple commands. Reporting no pain. Seems to understand what I am saying. Review of systems: Unable to obtain as intubaed Past Medical History: - DM1 ([**2076**]), brittle, c/b nephropathy and retinopathy on insulin pump (last A1C at [**Last Name (un) **] in [**2110**] of 9.6%) - s/p LURT in [**2106**], c/b humoral rejection followed by multiple plasmapheresis, recent Cr baseline (1.4-1.7) - CAD, s/p "silent" inferior MI '[**07**], s/p LAD and LCX DES '[**07**]. - [**Last Name (LF) 19874**], [**First Name3 (LF) **] 40-50%. - Hypertension - HL - Obesity - s/p vitreous hemorrhage OD - L leg swelling [**3-16**] lymphocele in the pelvis - Charcot-foot deformity on Left - hx of RP bleed - IBS - Hypothyroidism Social History: Lives in [**Location 7661**] w/ husband who is her kidney donor. Has two adult children who are healthy. Retired from medical records. Tobacco - denies EtOH - denies Drug use - denies. Family History: [**Name (NI) 12237**] DM [**Name (NI) 12238**] [**Name (NI) 1932**] died at age 50's No h/o of kidney disease Physical Exam: Admission exam: General: Intubated and sedated, responsive to voice, comfortable on vent, seems to become drowsy after a few minutes and closes eyes HEENT: Sclera anicteric, PERRL, ET tube in place Neck: supple, no LAD, R IJ in place without surrounding erythema or induration CV: Regular rate and rhythm, normal S1 + S2, no m/r/g Lungs: Clear to auscultation anteriorly, no wheezes, rales, ronchi Abdomen: soft, non-tender, distended [**3-16**] to habitus, faint BS GU: foley in place Ext: warm, well perfused, 2+ pulses, no clubbing, charcot deformity on left with 2+ edema below ankle on left, trace edema on right Neuro: nods yes/no to simple questions, moves hands/feet on command, pupils equal and reactive, comfortable, drowsy and drifts off after a few seconds Discharge exam: General: AOx3, anxious but appropriate HEENT: anicteric, dry MM CV: RRR, no m/r/g Lungs: CTAB, no w/r/r Abd: soft, not tender, +BS Ext: warm, 2+ pulses, charcot deformity on left with 1+ edema below ankle on left, trace edema on right; left arm with limited mobility due to pain Neuro: grossly intact Pertinent Results: Admission labs: [**2113-7-4**] 07:19PM BLOOD WBC-17.2*# RBC-3.45* Hgb-8.6* Hct-28.4* MCV-82 MCH-24.9* MCHC-30.3* RDW-17.6* Plt Ct-276 [**2113-7-4**] 07:19PM BLOOD Neuts-66 Bands-25* Lymphs-5* Monos-1* Eos-1 Baso-0 Atyps-0 Metas-2* Myelos-0 [**2113-7-4**] 07:19PM BLOOD PT-11.6 PTT-27.5 INR(PT)-1.1 [**2113-7-4**] 07:19PM BLOOD Glucose-292* UreaN-57* Creat-3.1*# Na-129* K-5.1 Cl-93* HCO3-21* AnGap-20 [**2113-7-4**] 07:19PM BLOOD ALT-60* AST-129* LD(LDH)-343* CK(CPK)-1812* AlkPhos-117* TotBili-0.9 [**2113-7-4**] 07:19PM BLOOD Albumin-3.7 Calcium-7.9* Phos-5.7*# Mg-2.0 Other pertinent labs: [**2113-7-4**] 07:19PM BLOOD CK-MB-32* MB Indx-1.8 cTropnT-1.34* [**2113-7-5**] 03:27AM BLOOD CK-MB-24* MB Indx-1.4 cTropnT-1.15* [**2113-7-6**] 04:00AM BLOOD cTropnT-0.91* [**2113-7-12**] 03:20AM BLOOD Hapto-553* [**2113-7-5**] 03:27AM BLOOD %HbA1c-7.1* eAG-157* [**2113-7-6**] 04:00AM BLOOD TSH-0.75 [**2113-7-5**] 03:27AM BLOOD Cortsol-23.8* [**2113-7-8**] 07:14AM BLOOD IgG-524* IgM-13* Discharge labs: [**2113-7-20**] 05:30AM BLOOD WBC-10.3 RBC-3.06* Hgb-7.9* Hct-25.7* MCV-84 MCH-25.8* MCHC-30.7* RDW-17.8* Plt Ct-701* [**2113-7-20**] 05:30AM BLOOD Glucose-148* UreaN-22* Creat-1.1 Na-137 K-4.6 Cl-107 HCO3-20* AnGap-15 [**2113-7-20**] 05:30AM BLOOD Calcium-8.6 Phos-3.6 Mg-1.7 [**2113-7-19**] 05:20AM BLOOD calTIBC-189* Ferritn-750* TRF-145* [**2113-7-20**] 05:30AM BLOOD rapmycn-4.9* IMAGING [**2113-7-4**] CXR: Mild-to-moderate cardiomegaly is stable. ET tube tip is low, 1.5 cm above the carina, can be withdraw couple of centimeters for more standard position. NG tube tip is in the stomach, but the side hole is at the EG junction and should be advanced for more standard position. Right IJ catheter tip is at the cavoatrial junction. Left perihilar and lower lobe opacities are worrisome for aspiration given the clinical concern. There is mild vascular congestion. There is no pneumothorax. If any, there is a small left pleural effusion. [**2113-7-5**] Head CT: FINDINGS: There are no comparison studies on record. There is no significant abnormality of the extracalvarial soft tissues, and no underlying skull fracture is seen. There is no intra- or extra-axial hemorrhage, the midline structures are in the midline and the ventricles and cisterns are normal in size and configuration, with slight asymmetric prominence of all components of the right lateral ventricle, likely congenital/developmental. There is mucosal thickening involving scattered anterior ethmoidal air cells, bilaterally, which appears more marked since the sinus CT of [**2113-2-14**]. The remaining visualized paranasal sinuses, as well as the mastoid air cells and middle ear cavities are clear. IMPRESSION: No evidence of acute intracranial injury, and no skull fracture. [**2113-7-6**] Humerus XRay: IMPRESSION: Proximal left humerus comminuted fracture involving surgical neck with mild subluxation posteriorly of distal fracture fragment approximately two cortical widths with fracture line extension also extending towards greater tuberosity. Glenohumeral articulation is maintained. [**2113-7-6**] Abdominal x-ray: IMPRESSION: Air within small and large bowel is nonspecific. No evidence of obstruction. [**2113-7-6**] EEG: IMPRESSION: This is an abnormal continuous ICU monitoring study because of significantly abnormal background rhythms. At the beginning of the record, extremely frequent high voltage triphasic-appearing waves admixed with a few more paroxysmal epileptiform discharges were noted. Between the bursts, there was evidence of a severe encephalopathy with suppression of electrical activity. Later in the record, at that time noted above, there appeared to be a marked improvement in terms of the paroxysmal behavior in the record and an overall improvement in the background rhythms. No significant asymmetry or sustained seizure activity was identified. [**2113-7-7**] EEG: IMPRESSION: This is an abnormal continuous ICU monitoring study because of the diffuse encephalopathic features noted above which include background slowing in the slow theta bandwidth and superimposed paroxysmal high voltage sharp slow waves. These latter discharges were predominantly bilateral and synchronous but also showed right hemisphere predominance and periods of multifocality. There were, however, no sustained seizures recorded. [**2113-7-8**] EEG: IMPRESSION: This was a poor electrographic recording session. Throughout the session, the recording from the right hemisphere electrodes were non-functional. Late in the recording, the left hemisphere electrodes also became disconnected. Prior to the left hemisphere electrodes becoming non-functional, the EEG showed improvement in the diffuse encephalopathic features from the previous day and fewer paroxysmal bursts. No sustained seizure discharges in the left hemisphere were identified. [**2113-7-11**] MRI Head: IMPRESSION: No significant abnormalities on MRI of the brain with and without gadolinium with somewhat limited post-gadolinium images by motion. Fluid in both bilateral mastoid air cells. Microbiology: -[**2113-7-6**] 10:20 pm STOOL CONSISTENCY: NOT APPLICABLE Source: Stool. **FINAL REPORT [**2113-7-7**]** C. difficile DNA amplification assay (Final [**2113-7-7**]): CLOSTRIDIUM DIFFICILE. -Blood Cultures ([**7-9**]): no growth -CSF Studies: Cyptococcal antigen - not detected CMV DNA, QL PCR - NOT DETECTED VARICELLA ZOSTER VIRUS (VZV) - Not Detected Adenovirus DNA, Qn PCR - No DNA Detected Herpes Simplex Virus PCR - Negative BORRELIA BURGDORFERI ANTIBODY INDEX FOR CNS INFECTION: negative CSF EBV-PCR: negative CSF TOXOPLASMA GONDII BY PCR: negative -DFA negative Brief Hospital Course: 53 yo W w/ DM1, s/p LURT [**2106**] (on sirolimus/pred), CAD (s/p multiple PCIs), [**Year (4 digits) 19874**] (EF 45%) who presented to [**Hospital3 **] with a fall and L humerus fracture now transfered to [**Hospital1 18**] for management of [**Last Name (un) **], respiratory distress, and shock. Patient had complicated MICU course where she was treated for altered mental status, pneumonia, and c. diff. She stabilized and was sent to rehab from the floor. # Altered mental status: On arrival from outside hospital, patient had altered mental status. She was intermittently confused, agitated, and somnolent with definite waxing and [**Doctor Last Name 688**] components. In the setting of fevers and confusion, there was concern for encephalitis or meningitis. Patient had an LP which was significant for elevated opening pressure of 37 and elevated RBCs - WBC was 5 (lymph predominant). She was empirically treated for bacterial and viral meningitis until cultures negative and patient improved. HSV PCR from CSF negative. Numerous other viral tests from CSF were sent and were negative at time of discharge. Also, some concern for possible seizures so neuro consulted and EEG done. EEG initially was concerning for seizure-like activity so Keppra started. However, repeat EEG's without seizures and ultimately thought that seizures were highly unlikely so keppra was down-titrated and discontinued. A significant portion if not all of AMS may have been due to delirium and toxic-metabolic encephalopathy in patient with two significant infections and admitted to the ICU for a prolonged period. Mental status improved slowly over 10 days of ICU stay suggesting toxic-metabolic delerium as the reason for the alteration. At discharge, patient is alert and oriented x 3 and back to her baseline mental status. # Respiratory Failure/Pneumonia: Was transfered to [**Hospital1 18**] intubated after respiratory distress at an OSH which may have been triggered by aspiration event. Chest imaging showed prominent bilateral pneumonia. She was covered with broad spectrum coverage for HCAP. Was extubated shortly after arrival at [**Hospital1 18**] ICU, but had significant oxygen requirement for the next few days. Had another questionable aspiration even a day or two after arrival so was given very limited PO intake for first few days. Pneumonia ultimately improved and antibotics stopped after roughly 10 total days of HCAP coverage. She was discharged on lasix 60mg daily and she was on room air. # Severe Cdiff colitis: A couple days into hospitalization, developed diarrhea and worsening WBC. Stool sent for Cdiff toxin which was positive. Rectal tube placed and patient started on PO Vancomycin 500mg Q6hrs. Couple days later also started on IV metronidazole for both this and pneumonia. Never developed acute abdomen or significant ileus although did require an NGT for a few days due to vomiting. Plan to complete 14 days of PO Vanco/PO metronidazole after last day of other antibiotics. Last day of Cdiff treatment antibiotics should be [**2113-7-26**]. She was also started on cholestyramine to help reduce the amount of diarrhea she was having and this can be discontinued at the patient's discretion in a few days. # Acute on CKD: s/p LURT in [**2106**], c/b humoral rejection followed by multiple plasmapheresis, recent Cr baseline (1.4-1.7) on Sirolimus and prednisone. Cr up at presentation and presumed that [**Last Name (un) **] was due to septic shock. Cr improved initially with fluids and patient continued on home prednisone 4mg daily with reduction of Sirolimus to 0.5mg daily. Renal consult service followed and helped manage Sirolimus dosing, and she should continue this dose of 0.5mg daily until she follows-up in clinic. Valsartan held initially due to infection and [**Last Name (un) **] but was restarted at discharge. Continued on Bactrim prophylaxis. She requires a once weekly RAPAMYCIN level, CBC, Chem7, calcium, phosphate, AST, ALT, UA, urine protein/creatinine ratio checked every Tuesday and results faxed to [**Telephone/Fax (1) 697**]. # Anemia: Suspect secondary to renal failure and mild GI losses secondary to C.diff (trace guaiac positive) +/- some bone marrow stunning in setting of severe infection. No evidence of hemolysis or iron deficiency. HCT responded to 2units HCT 20 ->27 and stabilized. Patient receives Epo as an outpatient and should continue this on discharge. # DM1: Has history of brittle diabetes on home insulin pump (although somewhat unclear how much [**Name (NI) 39150**] she takes). Was placed on an insulin gtt while in the ICU and [**Last Name (un) **] consulted to help with management. Day before ICU callout was transitioned to lantus with humalog sliding scale. She was discharged on lantus [**Hospital1 **] with sliding scale insulin and should not resume her insulin pump until following up with her outpatient DM provider. # Left Humeral Fracture: Had gone to OSH initially with fall and found to have a proximal left humerus fracture. Ortho saw here and recommended conservative management with a sling. Due to mental status tried to limit narcotics (and some history that she is very sensative to narcotics), so given tylenol, lidocaine patch. Patient will have to call orthopedic clinic to schedule follow-up in four weeks and she was discharged with a cuff and collar sling. # Depression/Anxiety: High dose citalopram at home as well as busprione and clonazepam at home. Citalopram was decreased to 20mg in setting of multiple other meds and buspirone and clonazepam were initially held given AMS. The buspirone and clonazepam were restarted at home dose, and citalopram was reduced to 40mg at discharge. # CAD/NSTEMI: Had elevated cardiac markers at OSH thought to be demand ischemia in setting of septic shock. Cards saw here and said no need for heparin gtt. Continued on ASA, statin, metoprolol. Cardiac markers trended down. # [**Hospital1 19874**] (EF 40-50%): Baseline mild decreased EF. Clincally stable without evidence of exacerbation. Once infectious issues stabilized, restarted lasix with PRN doses in the ICU, and discharged on lasix 60mg PO daily. # Charcot-foot deformity on Left: Associated left sided LE swelling. # HYPERTENSION: Initially BP meds held in setting of infection. Ultimately restarted all home meds. # HLD: continued home atorvastatin # Hypothyroidism: continued home levothyroxine # FEN: Was NPO initially, then received tube feeds for a few days, ultimately advanced to diabetic diet # Code: Full # Disposition: She is very deconditioned and needs significant rehab. . TRANSITIONAL ISSUES 1. Please check RAPAMYCIN level, CBC, Chem7, calcium, phosphate, AST, ALT, UA, urine protein/creatinine ratio every Tuesday and results faxed to [**Telephone/Fax (1) 697**] 2. She needs to call her Diabetes provider and schedule an appointment to discuss restarting her insulin pump once she is on a stable diet 3. Rapamycin dose changed during this hospitalization, will have weekly level checked and follow up with renal regarding dose titration. 4. Can discontinue cholestyramine in a few days once diarrhea improves 5. Consider up-titrating patient's citalopram dose from 40mg back to baseline dose of 60mg for her anxiety/depression Medications on Admission: Medications on OSH Transfer: Acyclovir 750 mg IV Q12H ([**7-6**]) CefePIME 2 g IV Q12H ([**7-7**]) Vancomycin 1500 mg IV Q 24H ([**7-9**]) Vancomycin Oral Liquid 125 mg PO/NG Q6H ([**7-7**]) PredniSONE 4 mg PO/NG DAILY Sirolimus 1 mg PO DAILY Senna 1 TAB PO BID:PRN Constipation Docusate Sodium (Liquid) 100 mg PO BID Heparin 5000 UNIT SC TID Aspirin 81 mg PO/NG DAILY Start: In am Atorvastatin 80 mg PO/NG DAILY Start: In am Levothyroxine Sodium 50 mcg PO/NG DAILY Acetaminophen 650 mg PO/NG Q6H:PRN pain/fever Insulin 100 Units/100 ml NS @ [**3-28**] UNIT/HR IV DRIP Acetaminophen IV 1000 mg IV Q6H:PRN fever Ondansetron 4 mg IV Q8H:PRN nausea Promethazine 12.5 mg IV Q6H:PRN nausea/vomitting LeVETiracetam 750 mg IV Q12H Metoprolol Tartrate 37.5 mg PO/NG TID Furosemide 40 mg PO/NG DAILY Sulfameth/Trimethoprim SS 1 TAB PO/NG DAILY Quetiapine Fumarate 25 mg PO/NG [**Hospital1 **]: PRN agitation Valsartan 80 mg PO/NG DAILY Ipratropium Bromide Neb 1 NEB IH Q6H Albuterol 0.083% Neb Soln 1 NEB IH Q6H Albuterol 0.083% Neb Soln 1 NEB IH Q2H:PRN wheezing/sob Ipratropium Bromide Neb 1 NEB IH Q6H:PRN SOB/wheezing Discharge Medications: 1. Aspirin 81 mg PO DAILY 2. Atorvastatin 80 mg PO DAILY 3. BusPIRone 5 mg PO TID 4. Calcium Carbonate 500 mg PO TID 5. Clonazepam 0.5 mg PO BID:PRN anxiety 6. Fluticasone Propionate NASAL 1 SPRY NU [**Hospital1 **] 7. Levothyroxine Sodium 50 mcg PO DAILY 8. Omeprazole 40 mg PO DAILY 9. PredniSONE 4 mg PO DAILY 10. Sulfameth/Trimethoprim SS 1 TAB PO DAILY 11. Sirolimus 0.5 mg PO DAILY Start: In am Daily dose to be administered at 6am 12. Albuterol 0.083% Neb Soln 1 NEB IH Q2H:PRN wheezing/sob 13. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN SOB/wheezing 14. Lidocaine 5% Patch 1 PTCH TD DAILY apply to left arm in area of fracture 15. Metoprolol Succinate XL 100 mg PO DAILY 16. Glargine 40 Units Breakfast Glargine 18 Units Bedtime Insulin SC Sliding Scale using HUM Insulin 17. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H 18. Vancomycin Oral Liquid 125 mg PO Q6H 19. Citalopram 40 mg PO DAILY 20. Fish Oil (Omega 3) 1000 mg PO BID 21. Multivitamins 1 TAB PO DAILY 22. Nystatin Cream 1 Appl TP [**Hospital1 **] 23. Vitamin D 800 UNIT PO DAILY 24. Valsartan 80 mg PO BID 25. Cepacol (Menthol) 1 LOZ PO PRN sore throat 26. Cholestyramine 4 gm PO TID please space out 3-4 hours from vanco 27. Guaifenesin-Dextromethorphan 5 mL PO Q6H:PRN cough 28. traZODONE 25 mg PO HS:PRN insomnia 29. Furosemide 60 mg PO DAILY hold for sbp <100 30. Epoetin Alfa 10,000 UNIT SC QMOWEFR Start: HS 31. Outpatient Lab Work - Have Rapamycin level, CBC, Chem7, calcium, phosphate, AST, ALT, UA, urine protein/creatinine ratio checked every Tuesday and results faxed to [**Telephone/Fax (1) 697**] Discharge Disposition: Extended Care Facility: [**Location (un) **] House Nursing Home - [**Location 9583**] Discharge Diagnosis: Pneumonia Altered mental status 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 39143**], You were admitted to [**Hospital1 18**] after you developed a serious infection in your lungs requiring intubation, blood pressure support, and close monitoring in the intensive care unit. Your lung infection resolved with antibiotic treatment. You became very confused while in the ICU but this was not thought to be due to an infection in your spinal cord as a spinal tap was performed which was negative. There was some concern that you were having seizures so you were briefly started on seizure medications but the neurologists feel you do not actually require this medication so this was discontinued. You also developed a diarrheal infection in your colon called clostridium difficile for which you will continue to require antibiotics once you leave. Followup Instructions: 1. Dr. [**First Name (STitle) **] [**Name (STitle) **] Renal transplant medicine WHERE: [**Hospital Unit Name **], [**Location (un) **] TRANSPLANT MEDICINE (NHB) WHERE: [**Hospital1 69**], [**Hospital Ward Name 517**] WHEN: Thursday, [**8-3**] at 8:20AM 2. Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] Orthopedics WHERE: [**Hospital Ward Name 23**] building, [**Location (un) **] WHERE: [**Hospital1 69**], [**Hospital Ward Name **] WHEN: Tuesday, [**8-15**] at 8:30AM 3. Please call your diabetes doctor [**First Name (Titles) **] [**Hospital3 **] to arrange for a follow-up appointment in the next few weeks to discuss when it is safe for you to restart your insulin pump. [**First Name4 (NamePattern1) 971**] [**Last Name (NamePattern1) 970**] MD [**MD Number(1) 3629**]

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icd9cm

[ [ [] ] ]

[ "03.31", "96.6", "96.71", "38.97" ]

icd9pcs

[ [ [] ] ]

20449, 20537

10418, 10890

300, 344

20613, 20613

4728, 4728

21620, 22478

3495, 3606

18853, 20426

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3621, 4391

4407, 4709

2651, 2682

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4744, 5300

5322, 5714

20628, 20772

2704, 3276

3292, 3479

1,224

168,781

17857

Discharge summary

report

Admission Date: [**2187-6-11**] Discharge Date: [**2187-6-23**] Date of Birth: [**2112-9-3**] Sex: F Service: ADMISSION DIAGNOSIS: Empyema, right chest. DIAGNOSIS UPON DEATH: 1. Empyema, right chest. 2. Adult Respiratory Distress Syndrome. 3. Multisystem organ failure. 4. HIT positivity. 5. Intracerebral stroke. 6. Death. HOSPITAL COURSE: This is a 74-year-old female who was diagnosed with nonsmall cell cancer and had received six weeks of neoadjuvant chemotherapy and was taken to the Operating Room on [**2187-5-28**] where she underwent an intraoperative bronchoscopy and mediastinoscopy with an open thoracotomy and resection of right upper lobe. This operation went uneventfully and had a postoperative course significant for a prolonged air leak and the patient was ultimately discharged to home by postoperative day number nine. One week later, she was seen in the outpatient clinic where she was noted to have some chest pain, low-grade fever, lethargy, and was draining some seropurulent material from her thoracic wounds. A CT scan of the chest was obtained which showed a large right-sided hydropneumothorax. She was readmitted then on [**2187-6-11**] where she underwent a CT-guided pigtail aspiration and drainage of the cavity which revealed a large amount of purulence. The Gram's stain revealed gram-positive cocci. She was taken to the Operating Room on [**2187-6-12**] for exploration of her right pleural empyema. She received vancomycin and Zosyn perioperatively. Approximately 200 cc of purulent material was drained from the right lung and she was decorticated at that time. Three dependent chest tubes were placed intraoperatively as well as an apical irrigating [**Doctor Last Name 406**] drain. The patient postoperatively was extubated and sent to the PACU and irrigation of the [**Doctor Last Name 406**] drain was begun on postoperative day number one with clear serosanguinous effluence from the chest tube. Later on that day, she went into atrial fibrillation with rapid ventricular response and was beta blocked and placed on an Amiodarone drip. Later on that night, in the PACU, she went into progressive respiratory distress and required intubation with mechanical ventilation. The following day, she continued to manifest low-grade temperatures and mild hypotension with a systolic blood pressure in the 90s necessitating a Neo-Synephrine drip. Soon thereafter, she was transferred to the CRSU. Her chest x-ray showed initially low-grade ARDS predominantly unilaterally on the right hand side; however, she continued to require ventilation with ventilatory support, P02s in the mid 70s to 80s; however, her chest x-ray began to show bilateral diffuse interstitial infiltrates consistent with ARDS. This was confirmed by placement of a Swan-Ganz catheter and she was started on a Lasix drip in order to diurese her pulmonary parenchyma as much as possible. Her antibiotics were continued with vancomycin and Zosyn and per ID consult recommendations. However, she continued to require increasing doses of Neo-Synephrine and adjustments to her ventilation and she underwent an echocardiogram on [**2187-6-18**] which showed a normal ejection fraction of 55% with no evidence of cardiogenic etiology. She was noted to have a decrease in her platelets on [**2187-6-17**] from approximately 130 down to 84 and a HIT screen was ordered which came back positive. Her subcutaneous heparin prophylaxis was stopped and a Hematology consult was obtained. Hematology recommended holding off on platelets and Lepirudin for the time being and ID recommended that Zosyn be changed to Cipro due to its potential for causing thrombocytopenia. During this time, she was noted not to be following commands while her sedation was lightened but she was still moving all extremities. A CT of the head was obtained to evaluate for possible progression of her known stroke disease and this showed a large right new temporal occipital infarct and a new left-sided occipital infarct. Neurologic consultation was obtained and agreed that anticoagulation would be extremely high risk for this patient. She required pharmacologic paralysis with pancoronium in order to decrease her peak airway pressures on the ventilator and she was begun on tube feeds which she tolerated for approximately 24-48 hours but had to be stopped for increasing high residuals. A repeat echocardiogram on [**2187-6-20**] showed no evidence of cardiogenic etiology for her hemodynamic demise. By [**2187-6-21**], her condition continued to deteriorate requiring multiple pressors and increasing FI02 requirements despite having had tried several modes of ventilator therapy with the VSICU consulting services making recommendations as well. Empiric Flagyl coverage was started per ID. An extensive family meeting was held on [**2187-6-21**] and given the patient's worsening cardiopulmonary status as well as her progressive neurologic injury, the family decided to make the patient DNR with no increase in cardiopulmonary support at midnight on [**2187-6-21**]. The patient expired at 6:45 a.m. on [**2187-6-22**] the following morning. [**First Name11 (Name Pattern1) 177**] [**Last Name (NamePattern4) 178**], M.D. [**MD Number(1) 179**] Dictated By:[**Last Name (STitle) 49527**] MEDQUIST36 D: [**2187-6-26**] 07:48 T: [**2187-7-2**] 10:28 JOB#: [**Job Number 49528**]

[ "510.9", "482.41", "287.4", "518.5", "511.8", "286.6", "997.02", "038.9", "785.59" ]

icd9cm

[ [ [] ] ]

[ "96.04", "38.93", "33.22", "34.09", "96.6", "96.72", "34.51", "03.90" ]

icd9pcs

[ [ [] ] ]

368, 5454

149, 350