ChanBeDu/relevant_section_length · Datasets at Hugging Face

41,897

184,266

45075

Discharge summary

report

Admission Date: [**2141-1-26**] Discharge Date: [**2141-1-31**] Date of Birth: [**2071-9-8**] Sex: M Service: CARDIOTHORACIC Allergies: Penicillins Attending:[**First Name3 (LF) 1505**] Chief Complaint: patient being evaluated for renal transplant found to have 3 vessel disease and referred to cardiac surgery for bypass grafting. Major Surgical or Invasive Procedure: s/p Coronary Artery Bypass Grafting x4(Left internal mammary-Left anterior descending artery, saphenous vein graft-Diagonal, saphenous vein graft-Obtuse marginal, saphenous vein graft- posterior descending artery)Left Ventricular Outflow Tract mass excision([**1-27**]) History of Present Illness: 69yo man with Lithium induced end stage renal disease on hemodialysis, being evaluated for renal transplant. Persantine MIBI was positive and echocardiogram showed Left ventricular outflow tract mass. Scheduled for cardiac catheterization which revealed 3 vessel disease. Then referred to cardiac surgery for bypass grafting prior to renal transplant. Past Medical History: - ESRD [**2-20**] lithium exposure and chronic interstitial nephritis on HD (recently initiated) - Left upper extremity AV fistula placed [**2139-9-23**] - Normal pressure hydrocephalus s/p drain at [**Hospital1 112**] in [**2138**] (no shunt seen on imaging) - Hypertension - Bipolar illness - Anemia - h/o Endocarditis with bacteremia - Pulmonary lymphadenopathy - DI from Lithium toxicity - LVOT mass Social History: Used to work at MFA museum in [**Location (un) 86**]. He has been living at the [**Hospital3 2558**] since his last admission. Prior to that, he had been living alone in [**Location (un) 2030**]. Patient denies any alcohol use. Former cigar smoking (2 per day), quit several years ago. Patient is close to his niece and nephew in the area. Family History: Noncontributory Physical Exam: Admission VS T BP 160/80 HR 67 RR 20 O2sat 96%-RA Ht 5'8" Wt 60K Gen NAD- appears chronically ill Skin sabaceous cysts of posterior neck neck supple, no LA Chest CTA-bilat CV RRR with 3/6 SEM Abdm soft, NT/+BS Ext warm, well perfused. 2+ edema bilat. No varicosities Neuro nonfocal exam Discharge VS T 98. HR 66 SR BP 120/73 RR 18 O2sat 94%-RA Gen NAD Neuro nonfocal exam CV RRR, no M/R/G. Sternum stable, incision CDI Pulm CTA-bilat Abdm soft, NT/+BS Ext warm, 2+ bilat edema. SVG site L w/steri strips-CDI skin AV fistula site with thrill and bruit Pertinent Results: [**2141-1-26**] 12:53PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.007 [**2141-1-26**] 12:53PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-8.0 LEUK-NEG [**2141-1-26**] 12:53PM URINE RBC-0 WBC-0 BACTERIA-NONE YEAST-NONE EPI-0 [**2141-1-26**] 10:35AM GLUCOSE-105 UREA N-67* CREAT-5.7*# SODIUM-142 POTASSIUM-4.4 CHLORIDE-99 TOTAL CO2-33* ANION GAP-14 [**2141-1-26**] 10:35AM ALT(SGPT)-12 AST(SGOT)-16 LD(LDH)-191 ALK PHOS-73 TOT BILI-0.3 [**2141-1-26**] 10:35AM ALBUMIN-3.8 MAGNESIUM-2.9* [**2141-1-26**] 10:35AM %HbA1c-5.6 [**2141-1-26**] 10:35AM WBC-6.1 RBC-2.87* HGB-10.4* HCT-29.4* MCV-102* MCH-36.4* MCHC-35.5* RDW-15.1 [**2141-1-26**] 10:35AM PLT COUNT-254 [**2141-1-26**] 10:35AM PT-15.1* PTT-30.7 INR(PT)-1.3* [**2141-1-30**] 05:48AM BLOOD WBC-6.4 RBC-2.63* Hgb-9.3* Hct-26.7* MCV-102* MCH-35.5* MCHC-35.0 RDW-16.3* Plt Ct-222 [**2141-1-30**] 05:48AM BLOOD Plt Ct-222 [**2141-1-27**] 03:27PM BLOOD PT-16.8* PTT-37.6* INR(PT)-1.5* [**2141-1-30**] 05:48AM BLOOD Glucose-98 UreaN-51* Creat-5.7*# Na-134 K-5.4* Cl-98 HCO3-27 AnGap-14 [**2141-1-27**] 03:27PM BLOOD ALT-12 AST-21 LD(LDH)-170 AlkPhos-44 Amylase-111* TotBili-0.2 [**2141-1-27**] 03:27PM BLOOD TSH-1.2 [**2141-1-27**] 03:27PM BLOOD T4-4.9 T3-74* ================================================================ [**Known lastname **],[**Known firstname **] D. [**Medical Record Number 96332**] M 69 [**2071-9-8**] Radiology Report CHEST (PORTABLE AP) Study Date of [**2141-1-28**] 4:33 PM REASON FOR THIS EXAMINATION: s/p CT removal ?PTX Final Report HISTORY: Status post chest tube removal, question pneumothorax. chests, 1 vw Compared with [**2141-1-27**], the ET tube, NG tube, mediastinal drains. and chest tubes have been removed. The Swan-Ganz catheter has been converted to a sheath, tip overlying the proximal SVC. Cardiomediastinal silhouette is stable. There has been partial clearing of increased retrocardiac density, with some residual patchyopacity at the left base. Minimal atelectasis at right base. Equivocal minimal bilateral pleural fluid. No CHF, other focal opacity, or gross effusion. No pneumothorax is detected. Epicardial pacing leads noted. DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 4343**] Approved: SAT [**2141-1-28**] 6:54 PM [**Hospital1 18**] ECHOCARDIOGRAPHY REPORT [**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 96333**] (Complete) Done [**2141-1-27**] at 12:43:21 PM FINAL Referring Physician [**Name9 (PRE) **] Information [**Name9 (PRE) **], [**First Name3 (LF) **] R. [**Hospital1 18**], Division of Cardiothorac [**Hospital Unit Name 4081**] [**Location (un) 86**], [**Numeric Identifier 718**] [**Last Name (LF) **], [**First Name3 (LF) **] Division of Cardiothoracic [**Doctor First Name **] [**First Name (Titles) **] [**Last Name (Titles) **] [**Hospital Unit Name 4081**] [**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2071-9-8**] Age (years): 69 M Hgt (in): BP (mm Hg): / Wgt (lb): HR (bpm): BSA (m2): Indication: Abnormal ECG. Aortic valve disease. Coronary artery disease. Hypertension. ICD-9 Codes: 440.0, 424.1 Test Information Date/Time: [**2141-1-27**] at 12:43 Interpret MD: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5209**], MD Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 168**], MD Doppler: Full Doppler and color Doppler Test Location: Anesthesia West OR cardiac Contrast: None Tech Quality: Adequate Tape #: 2009AW-1: Machine: Siemens Echocardiographic Measurements Results Measurements Normal Range Left Ventricle - Inferolateral Thickness: *1.5 cm 0.6 - 1.1 cm Left Ventricle - Ejection Fraction: 50% to 55% >= 55% Aorta - Ascending: *3.6 cm <= 3.4 cm Aorta - Arch: 2.6 cm <= 3.0 cm Findings LEFT ATRIUM: Mild LA enlargement. Good (>20 cm/s) LAA ejection velocity. No thrombus in the LAA. RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. LEFT VENTRICLE: Mild symmetric LVH with normal cavity size. Moderate symmetric LVH. Normal LV cavity size. Mild regional LV systolic dysfunction. LV WALL MOTION: Regional left ventricular wall motion findings as shown below; remaining LV segments contract normally. RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Normal aortic diameter at the sinus level. Simple atheroma in aortic root. Mildly dilated ascending aorta. Normal aortic arch diameter. Normal descending aorta diameter. Simple atheroma in descending aorta. AORTIC VALVE: Normal aortic valve leaflets (3). Mildly thickened aortic valve leaflets. Mild (1+) AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild mitral annular calcification. Mild (1+) MR. TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen. PERICARDIUM: No pericardial effusion. GENERAL COMMENTS: A TEE was performed in the location listed above. I certify I was present in compliance with HCFA regulations. The patient was under general anesthesia throughout the procedure. The TEE probe was passed with assistance from the anesthesioology staff using a laryngoscope. No TEE related complications. Results were personally reviewed with the MD caring for the patient. REGIONAL LEFT VENTRICULAR WALL MOTION: N = Normal, H = Hypokinetic, A = Akinetic, D = Dyskinetic Conclusions Pre-CPB: 1. The left atrium is mildly dilated. No thrombus is seen in the left atrial appendage. 2. There is mild symmetric left ventricular hypertrophy with normal cavity size. There is moderate symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. There is mild regional left ventricular systolic dysfunction with EF 50%. The remaining left ventricular segments contract normally. 3. Right ventricular chamber size and free wall motion are normal. 4. There are simple atheroma in the aortic root. The ascending aorta is mildly dilated. There are simple atheroma in the descending thoracic aorta. 5. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion. The aortic valve leaflets are mildly thickened. Mild (1+) aortic regurgitation is seen. Mobile mass in the subaortic region adherent to the anterior wall of the LVOT. Tissue density consistent with myxoma or fibroelastoma. No gradient seen. 6. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. 7. There is no pericardial effusion. Dr. [**Last Name (STitle) **] was notified in person of the results. Post-CPB: Preserved [**Hospital1 **]-Ventricular Systolic Function. Mild MR and trace TR unchanged. No new VSD or ASD. Mobile mass now no longer seen. Ascending and descending aorta unchanged I certify that I was present for this procedure in compliance with HCFA regulations. Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5209**], MD, Interpreting physician [**Last Name (NamePattern4) **] [**2141-1-27**] 13:58 = = = = = = = = = = = ================================================================ Brief Hospital Course: Mr [**Known lastname **] was admitted to [**Hospital1 18**] on [**2141-1-27**] for dialysis prior to scheduled coronary bypass surgery. On [**1-28**] he was brought to the operating room where he had coronary bypass grafting x4 with left internal mammary to left anterior descending artery, saphenous vein graft to diagonal, saphenous vein graft to obtuse marginal and saphenous vein graft to posterior descending artery. Please see operative report for details. he tolerated the operation well and was transferred from the operating room to the cardiac surgery ICU in stable condition. He continued to do well in the immediate post-operative period but remained intubated so that he could be dialyzed prior to extubation. On POD1 he was dialyzed and extubated successfully however he stayed in the ICU for pulmonary toilet. On POD2 he was transferred to the stepdown floor for continued post-operative care. His tubes lines and drains were removed according to protocol once he was on the stepdown floor. He made slow progress in his activity tolerance and on POD4 it was decided he was stable and ready for transfer to rehabilitation at [**Location (un) 8220**] Rehabilitation Center. He will be dialyzed at [**Hospital **] in [**Location (un) **] every T-Th-Sat @3:30. Medications on Admission: Darbepoetine 100 Q2wks Sensipar 30' Nephrocaps 1' Depakote 500 QHS doxazosin 8' Effexor XR 75' Imdur 30' Metoprolol 50" Renegal 2400''' Lisinopril 5' Simvastatin 20' clonazepam 1 HS Discharge Medications: 1. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed for constipation. 2. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) as needed for constipation. 3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 4. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed. 5. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 7. Divalproex 500 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 8. Venlafaxine 75 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO DAILY (Daily). 9. Sevelamer HCl 800 mg Tablet Sig: Three (3) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 10. Cinacalcet 30 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 12. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day. 13. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 14. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. Discharge Disposition: Extended Care Facility: [**Location (un) **] Discharge Diagnosis: s/p Coronary Artery Bypass Grafting x4 (Left internal mammary-Left anterior descending artery, saphenous vein graft-Diagonal, saphenous vein graft-Obtuse marginal, saphenous vein graft- posterior descending artery/Left Ventricular Outflow Tract mass excision([**1-27**]) PMH: HTN ESRD on HD Bipolar disorder Psoriasis Normal pressure hydrocephalus Discharge Condition: stable Discharge Instructions: Keep wounds clean and dry. OK to shower, no bathing or swimming. Take all medications as prescribed. Call for any fever, redness or drainage from wounds. No powder, creqam or lotion to incision. Followup Instructions: Dr [**Last Name (STitle) **] in 4 weeks Dr [**Last Name (STitle) 4127**] 2-3 weeks after discharge from rehab patient to call for all appointments Completed by:[**2141-1-31**]

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icd9cm

[ [ [] ] ]

[ "39.61", "36.15", "36.13", "37.33", "39.95" ]

icd9pcs

[ [ [] ] ]

12513, 12560

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2484, 4023

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1861, 1878

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7931, 9703

1893, 2465

238, 368

4055, 7887

706, 1059

1081, 1486

1502, 1845

6,359

191,983

24380

Discharge summary

report

Admission Date: [**2119-4-20**] Discharge Date: [**2119-5-1**] Service: CARDIOTHORACIC Allergies: Penicillins / Heparin Agents Attending:[**First Name3 (LF) 1505**] Chief Complaint: 83 year old white male with increasing DOE for 3 weeks. Major Surgical or Invasive Procedure: Redo sternotomy/AVR(#21 CE) [**2119-4-20**] History of Present Illness: This 83 year old white male has a history of CAD and is s/p CABGx4 in [**2109**]. He also has a PMH significant for aortic stenosis, HTN, chronic anemia, COPD, CRI, and hypercholesteremia. He had increased DOE for the past 3 weeks and an echo showed and increased AV gradient of 67 and [**First Name8 (NamePattern2) **] [**Location (un) 109**] of 0.6 cm2. He underwent cardiac cath on [**4-12**] which revealed: LVEF: 35-40% with [**Location (un) 109**] of 0.7 cm2, gradient of 55mmHg, 60% [**First Name9 (NamePattern2) **] [**Last Name (un) 2435**]., diffuse placquing of LAD and LCX with a 60% RCA [**Last Name (un) 2435**]. His 3 SVGs were patent and the LIMA->LAD had a distal fold to 70% stenosis. He is now admitted for redo sternotomy/AVR. Past Medical History: CAD - s/p CABGX4(LIMA->LAD, SVG->D1, OM, and PDA) [**2109**] Aortic stenosis HTN Chronic anemia Osteoarthritis Gout Hypothyroidism ^chol. BPH Asbestosis COPD CRI Social History: Lives alone, wife is in nursing home. Cigs: long history and now smokes [**1-20**] cigarettes/day ETOH: 2-3 beers/day Family History: unremarkable Physical Exam: Gen: Elderly white male in NAD AVSS HEENT: NC/AT, PERLA, EOMI Neck: supple, FROM, no lymphadenopathy or thyromegaly, carotids 2+= bilaterally without bruits. Lungs: Clear to A+P CV: RRR without R/G, 3/6 systolic ejection murmur Abd.: +BS, soft, nontender, without masses or hepatosplenomegaly Ext: without C/C/E, well-healed R saphenectomy incision Neuro: nonfocal Pertinent Results: Hct: 30.9 WBC: 11.8 Plt: 226 Na: 138 K: 5.1 Cl: 101 CO2: 28 BUN: 74 Cr: 2.8 Glu: 82 CHEST (PA & LAT) [**2119-4-29**] 12:16 PM CHEST (PA & LAT) Reason: r/o effusion [**Hospital 93**] MEDICAL CONDITION: 83 year old man with AS REASON FOR THIS EXAMINATION: r/o effusion CHEST TWO VIEWS. INDICATION: 83-year-old man with effusion. COMMENTS: PA and lateral radiographs of the chest are reviewed, and compared with the previous study of [**2119-4-25**]. The patient is status post CABG and median sternotomy and aortic valve replacement. There is continued prominence of the pulmonary vasculature with cardiomegaly indicating mild congestive heart failure, which is associated with small bilateral pleural effusion and bibasilar patchy atelectasis. IMPRESSION: Mild congestive heart failure with cardiomegaly and small bilateral pleural effusion. DR. [**First Name (STitle) 7204**] [**Name (STitle) 7205**] Approved: SUN [**2119-4-30**] 8:41 AM Brief Hospital Course: The patient was admitted on [**2119-4-20**] and had a redo sternotomy/AVR(21mmm CE pericardial. He tolerated the procedure well and was transferred to the CSRU on Epi, Neo, and Propofol. He was started on Natracor and remained intubated until POD#3. His chest tubes were d/c'd on POD#2. He was gradually weaned off his drips and had a peak creatinine of 3.3. He required aggressive respiratory therapy and was eventually transferred to the floor on POD#8. He continued to diurese and progress and was discharged to rehab on POD#11. Medications on Admission: Terasozin 3 mg daily Lipitor 40 mg daily Lopressor 25 mg [**Hospital1 **] Synthroid 175 mcg daily Plavix 75 mg daily Allopurinol 100 mg daily Combivent 2 puffs TID Lexapro 10 mg daily Procrit 14,000 U q week ASA 81 daily Colace 100 [**Hospital1 **] Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 3. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 3 days. 4. Brimonidine Tartrate 0.15 % Drops Sig: One (1) Drop Ophthalmic Q8H (every 8 hours). 5. Propoxyphene N-Acetaminophen 100-650 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. 6. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. Atorvastatin Calcium 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Terazosin HCl 1 mg Capsule Sig: Three (3) Capsule PO HS (at bedtime). 9. Levothyroxine Sodium 175 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Escitalopram Oxalate 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Lasix 40 mg Tablet Sig: One (1) Tablet PO twice a day for 7 days. 13. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 7 days. 14. Combivent 103-18 mcg/Actuation Aerosol Sig: [**11-20**] Inhalation three times a day. 15. Procrit 10,000 unit/mL Solution Sig: 14,000 units Injection once a week. 16. Plavix 75 mg PO daily. Discharge Disposition: Extended Care Facility: [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] Discharge Diagnosis: Aortic stenosis HTN ^chol. CAD - s/p CABG Hypothyroidism COPD/Asbestosis +smoker CRI Gout Depression Discharge Condition: Good. Discharge Instructions: Follow medications on discharge instructions. You may not drive for 4 weeks. You may not lift more than 10 lbs. for 3 months. You should shower, let water flow over wounds, pat dry with a towel. Do not use creams, lotions, or powders on wounds. Call for sternal drainage, temp. >101.5 D/C foley @ MN on [**5-1**] for voiding trial. Followup Instructions: Make an appointment with Dr. [**Last Name (STitle) 61740**] for 1-2 weeks. Make an appointment with Dr. [**Last Name (STitle) **] for 4 weeks. Make an appointment with Dr. [**Last Name (STitle) 8098**] for 2-3 weeks. Completed by:[**2119-5-1**]

[ "244.9", "V45.81", "401.9", "428.0", "272.0", "584.9", "496", "414.00", "424.1" ]

icd9cm

[ [ [] ] ]

[ "39.61", "00.13", "38.93", "35.21" ]

icd9pcs

[ [ [] ] ]

5027, 5119

2852, 3389

297, 343

5264, 5271

1874, 2044

5651, 5898

1460, 1474

3689, 5004

2081, 2105

5140, 5243

3415, 3666

5295, 5628

1489, 1855

202, 259

2134, 2829

371, 1123

1145, 1309

1325, 1444

1,651

133,003

23718

Discharge summary

report

Admission Date: [**2194-3-28**] Discharge Date: [**2194-4-12**] Date of Birth: [**2120-10-29**] Sex: F Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1505**] Chief Complaint: SOB/L Atrial myxoma Major Surgical or Invasive Procedure: s/p resection of left atrial myxoma and dacron patch closure of intraatrial septum History of Present Illness: 73 yo woman who presented to OSH ([**Hospital1 1474**]) on [**2194-3-27**] with increased shortness of breath over the past 2 to 3 months. Denied any chest discomfort, n, v, diaphoresis. Did note occasional PND. She had seen her PCP [**Name Initial (PRE) 13835**] 2 weeks pta c/o orthopnea and pnd without lower extr edema. She was started then on lasix and levaquin with significant improvement in her symptoms. At [**Hospital1 1474**], cxr showed chf and she improved with lasix, morphine, nitrates, and oxygen. On echo, pt was found to have a L atrial myxoma that is attached to the intraatrial septum and prolapsing (over 60% of the entire structure) into the left ventricle, causing obstruction. She will need surgery and was trasferred to [**Hospital1 **] for cath and surgical consult. Past Medical History: 1. hypertension 2. anxiety Social History: nonsmoker, nondrinker, married, lives at home with her husband of 56 years, retired retail store worker, six children Family History: myocardial infarction in her mother at age 73, no family history of cancer or sudden cardiac death Physical Exam: Vital Signs: 98.0, 127/61, 72, 18, 95% on 2L Gen: pleasant, lying in bed flat, nad HEENT: perrl, eomi, mmmm, o/p clear Neck: Supple, -JVD, -carotid bruits CV: rrr, nl S1 and S2, hyperdynamic pmi, [**3-9**] diastolic murmur at apex Lungs: crackles lll Abd: soft NT/ND, +BS Extr: no c/c/e, Nl DP/PT, moderate varicosites Neuro: AAOx3, non-focal Pertinent Results: Pre-Op EKG [**3-28**]: Sinus rhythm 80. Normal ECG Cath results 2/25:1. no significant CAD 2. mild elevation of right heart pressures 3. CT surgery evaluation for [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 16564**] CXR from OSH: CHF pattern with bilateral moderate sized pleural effusions, greater on the left. TEE [**3-29**]: A large/3.6x4.6cm spherical mass is seen attached to the mid-interatrial septum with herniation throught the mitral orifice during diastole most c/w with a myxoma is seen in the body of the left atrium. [**2194-3-29**] 06:05AM BLOOD WBC-8.0 RBC-4.12* Hgb-12.0 Hct-35.5* MCV-86 MCH-29.2 MCHC-33.9 RDW-13.9 Plt Ct-353 [**2194-4-12**] 06:20AM BLOOD WBC-10.2 RBC-3.21* Hgb-9.1* Hct-27.9* MCV-87 MCH-28.2 MCHC-32.5 RDW-15.2 Plt Ct-645* [**2194-3-29**] 06:05AM BLOOD PT-13.2 PTT-27.4 INR(PT)-1.1 [**2194-3-29**] 06:05AM BLOOD Plt Ct-353 [**2194-4-7**] 06:45AM BLOOD PT-16.1* PTT-38.1* INR(PT)-1.6 [**2194-4-12**] 06:20AM BLOOD Plt Ct-645* [**2194-3-29**] 06:05AM BLOOD Glucose-90 UreaN-15 Creat-0.7 Na-140 K-3.9 Cl-104 HCO3-27 AnGap-13 [**2194-4-10**] 11:30AM BLOOD Glucose-181* UreaN-10 Creat-0.8 Na-139 K-4.5 Cl-101 HCO3-33* AnGap-10 [**2194-4-12**] 06:20AM BLOOD UreaN-11 Creat-0.8 K-4.7 [**2194-3-29**] 06:05AM BLOOD ALT-9 AST-14 AlkPhos-69 Amylase-45 TotBili-0.3 [**2194-3-29**] 06:05AM BLOOD Albumin-3.5 Calcium-9.1 Phos-4.2 Mg-2.1 [**2194-3-29**] 12:26PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.020 [**2194-3-29**] 12:26PM URINE Blood-SM Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG [**2194-4-1**] 05:30AM URINE Color-Amber Appear-Hazy Sp [**Last Name (un) **]-1.025 [**2194-4-1**] 05:30AM URINE Blood-NEG Nitrite-NEG Protein-TR Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG [**2194-3-29**] 12:26PM URINE RBC-2 WBC-2 Bacteri-MOD Yeast-NONE Epi-8 [**2194-4-1**] 05:30AM URINE RBC-0-2 WBC-0-2 Bacteri-OCC Yeast-NONE Epi-0-2 [**2194-3-31**] 06:28PM PLEURAL TotProt-2.9 LD(LDH)-89 Albumin-1.8 [**2194-3-31**] 06:28PM PLEURAL WBC-535* RBC-2975* Polys-7* Lymphs-55* Monos-37* Meso-1* [**2194-3-31**] 06:15AM BLOOD WBC-16.9* RBC-3.83* Hgb-11.2* Hct-32.9* MCV-86 MCH-29.3 MCHC-34.2 RDW-14.1 Plt Ct-307 [**2194-4-2**] 05:40AM BLOOD WBC-13.2* RBC-3.70* Hgb-10.4* Hct-31.9* MCV-86 MCH-28.2 MCHC-32.7 RDW-14.2 Plt Ct-306 Brief Hospital Course: 73 yo female w/ pmhx sig for anxiety and hypertension who p/w atrial myxoma for removal. Pt had Cardiac Cath on [**2194-3-28**] with clean coronaries followed by a TEE on [**2194-3-29**] (see pertinent results). Pt. had dental consult on [**3-30**] secondary to poor dentition (see consult note). Pt was scheduled for surgery on [**3-31**], but had to be cancelled due to elevated temperature (101) and WBC (16.9). Pt started on clindamycin for periodontitis and cont. on admission ABX. Blood, urine, stool, sputum, and pleural fluid were obtained for cultures (see lab results). On [**4-1**], pt. again had increased fever and WBC. ID consulted, dental extraction recommended but OM FS felt it was unlikely to be source of infection. Pt. also had neuro consult secondary to possible Horner's syndrome/CVA due to left eye droop and unequal pupils. MRI/MRA was negative for acute ischemia and they then recommenced ophthalmology consult, chest CT, and check ACh-R ab. On [**4-2**], pt's WBC decreased to 13 (18 yesterday) and was afebrile, therefore she was brought to the operating room. Pt. underwent a resection of left atrial myxoma with a Dacron patch closure of intra atrial septum. Pt. tolerated the procedure well with a CPB time of 82 minutes and XCT time of 55 minutes. Pt. was brought to CSRU in stable condition with a HR of 92 A-Paced, MAP 76, CVP 14, PAD 25, [**Doctor First Name 1052**] 37 and being titrated on Neo and propofol. Later that day, propofol was weaned, NMB reversed and pt. became awake. Pt was moving all extremities, following commands, and then extubated without incidence. He was alert, awake, and neurologically intact. POD #1 - Pt. stable, Neo weaned. Chest tubes removed. ABX cont., cont. to check cultures, and pt. transferred to telemetry floor. POD #2 Pt. hemodynamically stable. WBC 12.8. Cont. ABX until ID further recommendation. Pacing wires removed. Pt. went into rapid A. Fib (190) overnight and was converted to SR in 80's following Lopressor and to Amio bolus x 2. Amio drip then started along with Mg given. POD #3 - Pt. still in SR (77). Right arm had non-tender palpable cord. Heat pack applied and check after pack comes off. POD #4 - Coumadin and heparin started. RUE likely to be phlebitis. POD #5 - Vanco started for phlebitis and pt. still receiving 7 day course of Levo/Clinda. Vascular consulted for RUE. POD #6 - Pt. had pruritis with Vanco. D/C vanco and Benadryl given. Heparin and Coumadin d/c'd. Pt. hemodynamically stable and encouraged to get OOB and ambulate. POD #7 - RUE erythema reducing. Blood cultures obtained today. VS stable. POD #[**9-10**] - RUE phlebitis improving/almost resolved. Ace wrap and warm compress continued. ABX changed to PO prior to D/C on [**4-12**]. All labs and vs were stable and cultures negative. Pt. was d/c'd home with VNA services. Medications on Admission: 1. lisinopril 20 mg daily 2. atenolol 50 daily 3. lasix 20 mg daily 3. ativan 0.5 mg q4-6 hrs prn 4. tylenol 350 q 4-6 hrs prn 5. colace 100 mg po bid 6. asa 325 mg po daily 7. azithromycin 250 mg po daily (ending [**4-2**]) 8. ceftriaxone 1 g IV q 24 hrs (ending [**4-2**]) Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*50 Tablet(s)* Refills:*0* 4. Lopressor 50 mg Tablet Sig: 1.5 Tablets PO twice a day. Disp:*90 Tablet(s)* Refills:*2* 5. Amiodarone HCl 200 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily) for 7 days: Then decrease to 200 mg PO daily. Disp:*40 Tablet(s)* Refills:*0* 6. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 7 days. Disp:*14 Tablet(s)* Refills:*0* 7. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO BID (2 times a day) for 7 days. Disp:*14 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0* 8. Augmentin 500-125 mg Tablet Sig: One (1) Tablet PO twice a day for 10 days. Disp:*20 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital1 1474**] VNA Discharge Diagnosis: Left Atrial Myxoma s/p resection of left atrial myxoma and dacron patch closure of intraatrial septum HTN Anxiety Discharge Condition: Good. Discharge Instructions: Follow medications on discahrge instructions. You may not drive for 4 weeks. You may not lift more than 10 lbs. for 3 months You should shower, let water flow over wounds, pat dry with a towel. Followup Instructions: Make an appointment with Dr. [**Last Name (STitle) 17025**] for 1-2 weeks. Make an appointment with Dr. [**Last Name (STitle) **] [**Last Name (STitle) **] 2-3 weeks. Make an appointment with Dr. [**Last Name (STitle) **] for 4 weeks. Completed by:[**2194-5-13**]

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icd9cm

[ [ [] ] ]

[ "37.23", "39.61", "88.72", "37.33", "34.91", "88.56" ]

icd9pcs

[ [ [] ] ]

8530, 8585

4279, 7110

342, 426

8742, 8749

1928, 4256

8991, 9256

1449, 1549

7435, 8507

8606, 8721

7136, 7412

8773, 8968

1564, 1909

283, 304

454, 1248

1270, 1298

1314, 1433

14,269

134,590

1826

Discharge summary

report

Admission Date: [**2156-2-29**] Discharge Date: [**2156-3-9**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 10223**] Chief Complaint: Cough, fever, increased sputum production Major Surgical or Invasive Procedure: Right Internal Jugular Venous Catheter Cosyntropin Stimulation Test History of Present Illness: HPI: [**Age over 90 **] yo female w/ [**Hospital 10224**] medical problems presents with hypercarbic resp failure requiring intubation in the ED. Pt presented w/ 3 day h/o SOB then acute worsening on day of admission. Unclear if she had any recent fevers. She did complain of a productive cough productive cough. Denied any orthopnea, PND. * Pt was recently admitted to [**Hospital1 18**] in [**2156-1-6**] for Influenza A PNA and sepsis requiring intubation and pressors and complicated by malignant HTN, hyponatremia, CHF exacerbation. Also had amarosis fugax but with CT with no acute changes, felt to be high risk, but didn't start coumadin because of known history of falls. * In the ED [**2-29**], he went into hypercarbic respiratory failure and was intubated. Chest xray showed retrocardiac density, and so she was started on cefepime/ vancomycin for presumed ventilator-associated pneumonia given recent hopitalization for Influenza. Started on dopamine for hypotension which was changed to levophed. Was extubated morning of [**3-2**] and ocntinued on levophed for support of hypotension. Transferred from [**Hospital Ward Name **] ICU to West ICU given bed availability. Past Medical History: -CHF- ECHO [**12-12**] EF 50-55% with mild MR [**First Name (Titles) **] [**Last Name (Titles) 10225**] -Coronary Artery Disease- s/p atheterization [**2153**]: Left dominant system; PCI LCx, LPDA, 50% RCA -Paroxysmal Atrial Fibrillation- treated w/ amiodarone, off coumadin due to risk of falls -Asthma -s/p thyroid sx -Diverticulitis -Hypercholesterolemia -Right Hip Fracture -History of [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] tears -Chronic Renal Insufficiency- baseline creatinine low 2's *** MEDS on Transfer [**3-2**]: Norepinephrine 0.1 mcg/kg/min Vancomycin HCl 1000 mg IV Q48H Cefepime 1 gm IV Q24H Albuterol-Ipratropium 8 PUFF IH Q6H Albuterol 0.083% Neb Soln 1 NEB IH Q6H Amiodarone HCl 200 mg PO DAILY Lansoprazole Oral Suspension 30 mg NG DAILY Aspirin 325 mg PO Levothyroxine Sodium 75 mcg PO DAILY Bisacodyl 10 mg PO DAILY: Calcium Carbonate 500 mg PO TID W/MEALS Miconazole Powder 2% 1 Appl TP TID Primidone 50 mg PO QOD Docusate Sodium (Liquid) 100 mg PO BID Promethazine HCl 25 mg IV Q6H:PRN Dolasetron Mesylate 12.5 mg IV Q8H:PRN Senna 1 TAB PO BID:PRN Simvastatin 20 mg PO DAILY Ferrous Sulfate 300 mg NG DAILY Social History: Lives alone; home health aid helps with acitivites of daily living. Tobacco: Quit in [**2109**] EtOH: Rare Family History: Non-contributory Physical Exam: PE on day of transfer: T 98.0 Tm 98.9 HR 72 (62-91) 121/37 (80-133/27-51) Face tent 12L RR 20 O2 sats 100% Ins/Outs 1000/1200 [**Location 10226**]2000L GENWell appearing elderly female in NAD HEENT CHEST Diffuse wheezes, no crackles, good aeration CV RR, nl S1, S2, no murmurs ABD soft, NT/ND/ NABS EXT 1+ pitting edema bilateral lower extermities NEURO Pertinent Results: Labs on Admission: [**2156-2-29**] 08:51AM WBC-19.4*# RBC-3.26* HGB-9.5* HCT-31.9* MCV-98 MCH-29.1 MCHC-29.7* RDW-16.1* [**2156-2-29**] 08:51AM GLUCOSE-325* UREA N-27* CREAT-2.1* SODIUM-138 CHLORIDE-106 TOTAL CO2-21* CALCIUM-8.4 PHOSPHATE-7.0*# MAGNESIUM-2.3 [**3-1**]: Cosyntropin Stimulation Test: negative Labs on Day of Transfer: [**2156-3-2**] 03:55AM BLOOD WBC-11.5* RBC-2.69* Hgb-7.7* Hct-25.3* MCV-94 MCH-28.7 MCHC-30.5* RDW-15.8* Plt Ct-386 [**2156-3-2**] 03:55AM BLOOD Glucose-122* UreaN-26* Creat-2.1* Na-141 K-3.6 Cl-109* HCO3-21* AnGap-15 [**2156-3-2**] 07:20AM BLOOD LD(LDH)-241 [**2156-3-2**] 07:20AM BLOOD Albumin-2.9* Phos-7.0* Iron-13* [**2156-3-2**] 07:20AM BLOOD calTIBC-233* Hapto-239* Ferritn-168* TRF-179* Radiology: [**3-5**]: Portable chest Xray 1) Persistent congestive failure. 2) Persistent opacity at the left base as described. 3) Possible pneumomediastinum. Per discussion with the resident caring for the patient, the patient has not undergone a procedure since the prior exam. Microbiology: [**2156-2-29**]: Blood Culture: No Growth to Date (as of [**3-2**]) SPUTUM GRAM STAIN (Final [**2156-3-2**]): >25 PMNs and <10 epithelial cells/100X field. 2+ (1-5 per 1000X FIELD): GRAM NEGATIVE ROD(S). ECHO: [**2156-3-3**] The left atrium is moderately dilated. The right atrium is moderately dilated. The left ventricular cavity is mildly dilated. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets are moderately thickened. There is mild aortic valve stenosis. Mild to moderate ([**1-11**]+) 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 moderate pulmonary artery systolic hypertension. Compared with the prior study (tape reviewed) of [**2156-1-7**], significant aortic valve gradient was not detected in the prior study (probably due to suboptimal Doppler study). CXR: ([**2156-3-3**]): SLight increase in CHF Labs on transfer from MICU to floor on [**3-4**]: [**2156-3-4**] 02:48AM BLOOD WBC-3.9* RBC-3.07* Hgb-9.1* Hct-28.1* MCV-92 MCH-29.5 MCHC-32.2 RDW-16.4* Plt Ct-355 [**2156-3-4**] 02:48AM BLOOD Plt Ct-355 [**2156-3-4**] 02:48AM BLOOD Glucose-149* UreaN-28* Creat-2.0* Na-142 K-4.1 Cl-109* HCO3-24 AnGap-13 [**2156-3-4**] 02:48AM BLOOD Calcium-7.8* Phos-3.4# Mg-2.0 Brief Hospital Course: A/P [**Age over 90 **] yo with nosocomial pneumonia/CHF leading to respiratory failure and resulting sepsis, resolved s/p extubation. * 1. Sepsis. On admission, pt intubated in ED, started on dopamine for hypotension and sent to MICU on levophed. Felt that patient likely developed bronchopneumonia with resulting CHF in setting of tachycardia - resulting in hypercarbic respiratory fl. Dopamine was changed to levophed given persistent tachycardia. Patient diuresed while in unit and she was successfully extubated on [**3-2**] but remained on pressors transiently given hypotension - which resolved s/p blood transfusion on [**3-3**]. Patient stablized in MICU and transferred to floor on [**3-4**]. On floor, held off on aggresive IVF given that she is extubated and presented with CHF, but will also held off on diuresis as already diuresed well. No other clear etiology of hypotension. SBP up to 140's and metoprolol restarted [**3-8**]. Pt had negative [**Last Name (un) 104**] stim test so no role for steroids during admission. Of note, ECHO [**12-12**] with LVEF 55%, mildly dilated LV, mod dilation of bilateral atria, Mild As and [**1-11**]+AR, 1+MR, moderate pulm HTN * 2. Nosocomial [**Name (NI) 10227**] Pt presented w/ fevers, increasing sputum production. CXR w/ retrocardiac density. Was intially on levo/vanc, but given GNR in sputum gram stain, she was originally continued on cefepime for Gram negative coverage. Rpt CXR w/ slight increase in CHF. Sputum cx from [**3-2**] growing MRSA, therefore pt abx were again changed to vancomycin and levoquin - levoquin was used given initial concern for GNR in sputum. Given severity of respiratory failure/sepsis and possibility of vent associated pna, will cont full course of levoquin. Unclear etiology of MRSA, however pt with recent hospitalization with INFLUENZA A and PNA and was d/ced at that time to [**Hospital3 4419**]. WIll cont both abx for 14 day course with last dose on [**3-18**]. Will dose vanc 1gm q24hrs as troughs were <5 initially. HER LAST DOSE OF VANCOMYCIN WAS at 6pm ON [**3-8**]. GIVEN THAT VANC LEVEL on [**3-9**] is 11, PLEASE GIVE ANOTHER DOSE OF VANC TONIGHT. Given that am vanc levels are persistently low, consider daily dosing (with daily trough level checks) although creatinine clearance would suggest less dosing needed - or may dose according to level by getting daily trough checks and dosing for level <15. Last dose of levoquin also [**3-18**]. Patient started on prednisone 60mg on admission. Will cont slow taper. Received 50mg prednisone PO this am. Will decrease dose to 40mg daily tomorrow ([**3-10**]) and decrease by 10mg every three days until course complete. Supplmental O2 needed prn after extubation, but sating mid 90's RA by time of discharge without need for supplemental O2. Chest PT and nebs prn wheezes. Will cont home nebs on discharge. Of note, PICC line was placed on [**3-9**] as initially planning on home abx administration. * 3. CHF- Most recent ECHO w/ EF 50-55%. Likely has diastolic dysfunction as well. Had been diuresed in MICU prior to transfer to floor. Cause of resp failure likely mixed PNA and CHF. Continue ASA and statin. Beta blocker held given concern for sepsis, but restarted on [**3-8**] at outpt dose of 12.5mg [**Hospital1 **]. TOelrated this dose well with SBP in 130-140s. * 4. CAD- S/p PCI of LCx and LPDA, 50% lesion in the RCA. No ECG changes during admission, however pt with baseline LBBB. Ruled out for MI on admission with troponin leak felt secondary to renal insufficiency. Continued statin and ASA during admission and on d/c. * 5. [**Name (NI) 10228**] Pt in NSR on admission. Continue amiodarone. No coumadin given falls risk. Beta blocker cont on transfer to rehab at outpt dose. * 6. Chronic Renal Insufficency- At baseline creatinine of 2.1. High phosphate at 7.0 and known elevated PTH. Pt has secondary hyperparathyroidism due to CRI, however, now that GFR is ~25, she is unable to exrete phosphate thus levels slowly increasing. Levels also likely high [**2-11**] calcitriol that she had been taking prior to admission. calcitriol d/c'ed. Continue TUMS with meals. Renally dosing medications. Continue low phosphate diet. Creatinine 1.6 on discharge. * 7. Anemia. Iron studies show mixed pciture with MCV 96 with anemia of chronic disease given low fe and low TIBC. Folate and B12 were checked given macrocytosis. B12 wnl, but folate less than 20. Pt started on 1gm folic acid per day during admit. Pt had hct drop to 25 on [**3-2**]. She was transfused 2 units of PRBCs with app bump. Hct stable throughout remainder of admission. However,stools GUIAIC positive. Given hct is stable, will hold off on w/u while inpt but will need GI eval in future. * 8. Hypothyroid- Cont levothyroxine at outpt dose during admit and on d/c. * 9. ? Conjunctivitis: Clinically improving. coag - seen on culture - like skin flora contaminant. Currently on erythromycin eye drops. Day [**7-22**] at time of discharge. 10. FEN- After extubation, pt had speech/swallow eval which she passed. Tolerated PO diet. Continue heart healthy diet. * 11. PPx- PPI, heparin SC, cont primidone for h/o tremors. 12. Code- FULL 13. Contact- [**First Name4 (NamePattern1) **] [**Known lastname **] (daughter) [**Telephone/Fax (1) 10229**] Medications on Admission: Meds on transfer from MICU to floor: Albuterol 0.083% Neb Soln 2 NEB IH Q3H Ipratropium Bromide Neb 1 NEB IH Q6H Amiodarone HCl 200 mg PO DAILY Levothyroxine Sodium 75 mcg PO DAILY Aspirin 325 mg PO DAILY Miconazole Powder 2% 1 Appl TP TID Apply to area under left breast Bisacodyl 10 mg PO DAILY:PRN Pantoprazole 40 mg PO Q24H Calcium Carbonate 500 mg PO TID W/MEALS Polysaccharide Iron Complex 150 mg PO DAILY Cefepime 1 gm IV Q24H Primidone 50 mg PO QOD Dolasetron Mesylate 12.5 mg IV Q8H:PRN Promethazine HCl 25 mg IV Q6H:PRN Docusate Sodium (Liquid) 100 mg PO BID Prednisone 60 mg PO DAILY Duration: 2 Doses Order date: [**3-3**] @ 1009 Erythromycin 0.5% Ophth Oint 0.5 in OU QID Senna 1 TAB PO BID:PRN Guaifenesin 15 ml PO Q4H Simvastatin 20 mg PO DAILY Heparin 5000 UNIT SC TID Discharge Medications: 1. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Amiodarone HCl 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 4. Levothyroxine Sodium 75 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. 6. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 7. Polysaccharide Iron Complex 150 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). Disp:*30 Capsule(s)* Refills:*2* 8. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 9. Guaifenesin 100 mg/5 mL Syrup Sig: Fifteen (15) ML PO Q4H (every 4 hours) as needed for cough. 10. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 9 days. Disp:*9 Tablet(s)* Refills:*0* 11. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation Q6H (every 6 hours). 12. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 13. Primidone 50 mg Tablet Sig: One (1) Tablet PO QOD (). 14. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 15. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 16. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID (3 times a day). 17. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) PO BID (2 times a day) as needed for constipation. 18. Erythromycin 5 mg/g Ointment Sig: One (1) drop Ophthalmic QID (4 times a day) for 7 days: please d/c on [**2156-3-16**]. 19. Menthol-Cetylpyridinium Cl 2 mg Lozenge Sig: One (1) Lozenge Mucous membrane PRN (as needed) as needed for cough. 20. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed for pain. 21. Prednisone 20 mg Tablet Sig: Two (2) Tablet PO once a day: please continue steroid taper by giving 40mg for three days ([**Date range (1) 10230**]) and then decreasing by 10mg every three days. Tablet(s) 22. Zolpidem Tartrate 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed. 23. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 24. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 25. vancomycin Please continue to dose vancomycin according to trough level. [**3-9**] vanc level was 11 so she Mrs. [**Known lastname **] is due for 1mg vanc tonight, [**3-9**]. thanks. Discharge Disposition: Extended Care Facility: [**Hospital6 **] - TCU Discharge Diagnosis: Primary Diagnosis: 1. Respiratory failure requiring intubation 2. MRSA PNA 3. Guiaic positive stool with stable hct 4. Asthma exacerbation Secondary Diagnosis: 1. Recent admission [**1-14**] for respiratory distress 2. Recent epsiode of malignant hypertension 3. Recent admission for INFLUENZA A 4. Paroxysmal Atrial Fibrillation. 5. Asthma. 6. Diverticulitis. 7. Hypercholesteremia. 8. Chronic Renal Insufficiency. 9. Systolic Heart Failure. 10. Mitral and Aortic Insufficiency. 11. S/P Left Hip Fracture. 12. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] Tear. 13. Hypothyroidism. 14. Left Bundle Branch Block. 15. Two vessel coronary artery disease s/p stenting of the mid LCX and origin LPDA. Discharge Condition: stable Discharge Instructions: Please call your PCP and schedule [**Name Initial (PRE) **]/u appointment within [**1-11**] weeks of discharge. Please discuss further GI work up for blood in stool at that time. Please take all medications as prescribed. You are being discharged to [**Hospital3 **] Rehabilitation Center to complete course of IV antibiotics. Followup Instructions: Provider: [**First Name11 (Name Pattern1) 177**] [**Last Name (NamePattern4) 720**], M.D. Where: [**Hospital6 29**] MEDICAL SPECIALTIES Phone:[**Telephone/Fax (1) 435**] Date/Time:[**2156-5-13**] 10:00 Please call Dr. [**Last Name (STitle) **] at [**Telephone/Fax (1) 10231**] to make a follow up appointment within 1-2 weeks of discharge.

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icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

14642, 14691

5827, 11112

304, 373

15452, 15460

3322, 3327

15835, 16178

2907, 2925

11948, 14619

14712, 14712

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223, 266

401, 1585

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14731, 14851

3341, 5804

1607, 2767

2783, 2891

27,472

130,371

8794

Discharge summary

report

Admission Date: [**2124-9-27**] Discharge Date: [**2124-10-11**] Date of Birth: [**2066-4-27**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2485**] Chief Complaint: dyspnea Major Surgical or Invasive Procedure: None History of Present Illness: The pt is a 58 yo male with CML s/p BMT in [**2121**], on lovenox for PEs, has chronic GVHD and was recently discharged after hypoxia and intubation in the ICU who presents today with hypoxia. In the emergency department vs were 97.9 BP 113/64 HR 74 RR 28 sat 89% 5L NC. He was placed on a NRB with sats in the 90s. He was then weaned to a NC satting 94% on 6L. CXR showed ? of new RLL PNA vs atelectasis. Exam was notable for gurgling and course breath sounds through out and for increased LE edema. He was given cefepime 2 g IV x1, levoquin 750mg po x1, vancomycin 1g IV x1, and tamiflu 75mg po x1. A flu swab was sent and blood cx were drawn. 2 18 gauge IVs were placed. VS were stable while in the ED. Vitals prior to transfer to the floor were T97.8 HR 73 BP 121/74 RR16 02 sat 94% on 6L NC. On arrival to the floor pt satting 94% on 100% face tent. Past Medical History: # CML s/p allogeneic stem cell transplant [**2121**] c/b GVHD # chronic GVH on immunosuppressants -has had chronic abdominal discomfort since transplant that is thought to be associated with GVHD. -bronchiectasis and bronchiolitis obliterans related to GVHD of the lung # Per d/c summaries: h/o resistant pseudomonas ([**2124-6-8**]), ESBL E coli ([**2124-5-21**]), stenotrophomonas ([**2123-12-23**])in sputum # course of linezolid for VRE bacteremia ([**2124-4-24**]) which he contracted during a hospitalization for cellulitis (see d/c summary [**2124-5-4**]) # Chronic RUQ pain since [**2113**] (?in addition to GVH-related pain) - work up unrevealing - on narcotics # Chronic RUQ pain since [**2113**] (?in addition to GVH-related pain) - work up unrevealing - on narcotics # GERD w/ Barrett's esophagus # Hypertension # h/o pulmonary embolism in [**5-8**]; DVT [**12-27**] # four compression fractures since the beginning of [**2122**] at T8, T9, T11, L1, and L3 Social History: Lives with his sister and her husband. Previously worked as a manufacturing manager, is now on disability. Tob: quit >x12yrs; 1ppd 10yrs pack-year history. EtoH: none. Illicits: none. Family History: Father with diabetes mellitus, BPH, alive at 85yrs Mother with h/o breast cancer; d. TIAs and CVD at 75yrs Sister with h/o breast cancer in her 50s, atrial fibrillation Two brothers with h/o melanoma Physical Exam: Exam on Admission: GENERAL: ill appearing male, talking in full sentence HEENT: Normocephalic, atraumatic. No conjunctival pallor. No scleral icterus. PERRLA/EOMI. dry MM. OP clear. Neck Supple, No LAD. CARDIAC: very difficult to hear given breath sounds LUNGS: gurgling and course rales throughout lungs posteriorly, no increased work of breathing of respiratory muscles ABDOMEN: +BS. distended. Tender throughout lower abd. No rebound. EXTREMITIES: LE equal bilaterally to sacrum. Unable to palpate DP pulses secondary to edema. 2+ radial pulses. Chronic venous stasis of lower extremities. SKIN: + chronic venous stasis of lower extremities. blood blisters on left hand. NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact. Preserved sensation throughout grossly. 5/5 strength UE And LE. 2+ reflexes in UE. PSYCH: Listens and responds to questions appropriately, pleasant Pertinent Results: Labs on Admission: [**2124-9-27**] 08:15PM BLOOD WBC-4.5 RBC-3.01* Hgb-9.6* Hct-29.8* MCV-99* MCH-31.9 MCHC-32.3 RDW-17.7* Plt Ct-189 [**2124-9-27**] 08:15PM BLOOD Neuts-91* Bands-1 Lymphs-0 Monos-7 Eos-1 Baso-0 Atyps-0 Metas-0 Myelos-0 [**2124-9-27**] 08:15PM BLOOD PT-11.1 PTT-27.8 INR(PT)-0.9 [**2124-9-27**] 08:15PM BLOOD Glucose-192* UreaN-28* Creat-0.8 Na-138 K-5.1 Cl-98 HCO3-34* AnGap-11 [**2124-9-27**] 08:15PM BLOOD ALT-48* AST-43* LD(LDH)-417* CK(CPK)-27* AlkPhos-541* TotBili-0.2 [**2124-9-28**] 04:01AM BLOOD Calcium-8.8 Phos-2.8 Mg-2.0 [**2124-9-28**] 04:56AM ABG pO2-62* pCO2-66* pH-7.35 calTCO2-38* Base XS-7 Cardiac Enzymes: [**2124-9-27**] 08:15PM BLOOD cTropnT-0.16* [**2124-9-28**] 04:01AM BLOOD CK-MB-5 cTropnT-0.12* [**2124-9-28**] 04:34PM BLOOD CK-MB-4 cTropnT-0.14* [**2124-9-28**] 07:59PM BLOOD CK-MB-4 cTropnT-0.14* [**2124-9-27**] 08:15PM CK(CPK)-27* [**2124-9-28**] 04:01AM BLOOD CK(CPK)-17* [**2124-9-28**] 07:59PM BLOOD CK(CPK)-18* Sputum ([**2124-9-28**]): ESCHERICHIA COLI (ESBL). MODERATE GROWTH. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI | AMPICILLIN------------ =>32 R AMPICILLIN/SULBACTAM-- 16 I CEFAZOLIN------------- =>64 R CEFEPIME-------------- =>64 R CEFTAZIDIME----------- R CEFTRIAXONE----------- =>64 R CEFUROXIME------------ =>64 R CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S PIPERACILLIN---------- =>128 R PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- =>16 R Blood Culture ([**2124-9-27**]): negative x2 Influenza DFA ([**2124-9-28**], [**2124-10-2**]): Negative for Influenza A and B Legionella ([**2124-9-29**]): negative C. diff A and B ([**2124-10-5**]): negative EKG ([**2124-9-27**]): Sinus rhythm with baseline artifact. Left axis deviation. Probable left anterior fascicular block. Leftward precordial R wave transition point. Non-diagnostic repolarization abnormalities. Compared to the previous tracing of [**2124-8-30**] multiple abnormalities persist without major change. CXR ([**2124-9-27**]): Portable AP upright chest radiograph is obtained. Evaluation is quite limited given the low lung volumes. The left-sided PICC line has been removed. Vague increased opacities at the lung bases may reflect small areas of pleural effusions. Bibasilar atelectasis is likely present. Cannot exclude underlying pneumonia. Heart size cannot be assessed. Mediastinal contour is difficult to assess as well, but grossly stable. No large pneumothorax is seen. Bones are demineralized. Brief Hospital Course: 58 year old male w past medical history of CML s/p BMT in [**2121**] on chronic immunosuppression with recent hospitalizations for his bronchiolitis obliterans, resistant pseudomonal infections, and recent intubation who presents with respiratory distress and hypoxia: . 1. Respiratory Failure/Pneumonia: On admission, the patient's respiratory failure was believed to be likely seconday to PNA. The patient was pan-cultured and started on Antibiotic regimen with Cefepime, Levofloxacin, Vancomycin for HCAP. WBC was 4.5 with one band. Flu swab was performed and the patient was started on prophylactic Tamiflu. He remained stable on face tent 100%, was transiently on non-invasive ventilation, but did not require intubation. The patient was initially started on stress dose steriods, but was eventually switch to PO prenisone. The patient was subsequently evaluated by ID and antibiotic regimen was switched to Tobramycin, Linezolid, Zosyn and therapeutic-dose Bactrim based on prior sensitivities. Azithromycin was transiently continued for antimicrobial and antiinflammatory effects in bronchiolitis obliterans but subsequently stopped. Inhaled Tobramycin and monthly IVIG were continued initially, but inhaled Tobramycin was eventually stopped during IV Abx course and was re-started prior to discharge. The patient was maintained on standing nebs. The patient was continued on Bactrim, acyclovir, and voriconazole for prophylaxis. Sputum culture eventually grew out ESBL E.coli and antibiotic regimen was shortned to Vancomycin alone for an 8 day total course. Patient's secretions were aggressively cleared with exsuffilator. Over the next several days, the patient's respiratory status has slowly improved and he had reduced oxygen requirements. He was comfortable on 4 liters NC and was able to get out of bed to chair. The patient may have been exposed to a possible H1N1 virus during his stay in the ICU. Because of that, repeat nasal swab was performed (which was negative), and the patient was maintained on droplet precautions for 7 days and received a total of 7 days of prophylactic Tamiflu. . 2. Chronic myelogenous leukemia s/p bone marrow transplantations, complicated by chronic graft-versus-host disease: We continued the patient on CellCept. Because of the concern that GVHD may be contributing to respiratory failure in this patient, the patient was started on an slow steroid taper starting at 60mg of PO Prednisone daily. The patient will eventually taper to a base dose of 20mg daily, which will be maintained indefinitely. . 3. Troponin Leak: This patient was noted to have stably evelated Troponins, which were also noted on prior admission. ACS was ruled out by three sets of stable enzymes. EKG with no obvious ischemic changes. . 4. Hx of PE, DVT: multiple PEs in [**2122**] and DVT in early [**2123**].- We continued home dose of lovenox 40mg [**Hospital1 **]. . 5. Multiple Vertebral Fractures: The patient was evaluated by pain consult. Pain control was achieved with Fentanyl patches, Methadone, Lidocaine patches, and morphine PRN. Medications on Admission: acetaminophen 650 mg PO Q4H PRN pain or fever milk of magnesia 30 mL PO daily PRN constipation bisacodyl suppository 10 mg PR daily PRN constipation Fleet enema PR daily PRN constipation pregabalin 150 mg PO QID mycophenolate 500 mg PO QAM mycophenolate mofetil 250mg po qpm prednisone 10 mg PO BID fentanyl 100 mcg/hr, apply 2 patches Q72H tobramycin 300 mg/5mL 5 mL via neb [**Hospital1 **] x 4 weeks starting [**2124-9-28**], then hold for 4 weeks azithromycin 500 mg PO daily x 2 days ([**2124-9-21**] + [**2124-9-22**]) azithromycin 250 mg PO daily x 6 days ([**Date range (3) 30715**]) azithromycin 250 mg PO every other day starting [**2124-9-29**] combivent 18/103 mcg 1 puff Q4H PRN SOB/wheezing morphine sulfate IR 60 mg PO Q4H PRN pain Ativan 0.5 mg PO Q4H PRN anxiety Ativan 1 mg PO Q4H PRN severe anxiety metoprolol 50 mg PO BID House supplement 4 oz. PO TID with meal Natural tears gtt to both eyes [**Hospital1 **] Methadone 15 mg PO BID Methadone 20 mg PO QHS Protonix 40 mg PO daily Pancrease MT10 30,000 units 2 caps PO TID with meals MVI wth minerals daily vit D3 400units 2 tabs daily budesonide 3mg caps po q8hrs senna 1 tab po bid colace 100mg po bid acyclovir 400mg po bid lidocaine patch 5% to R and L back daily voriconazole 200mg po q12 lovenox 40mg sc q12 hrs bactrim ss po daily miralax po daily calcium carbonate 1000mg po tid Discharge Medications: 1. Enoxaparin 40 mg/0.4 mL Syringe Sig: Forty (40) mg Subcutaneous Q12H (every 12 hours). 2. Fentanyl 100 mcg/hr Patch 72 hr Sig: Two (2) patches Transdermal every seventy-two (72) hours. 3. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily): Apply to left side of back for 12 hours daily, then remove for 12 hours. 4. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily): Apply to right side of back for 12 hours daily, then remove for 12 hours. 5. Methadone 5 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). 6. Methadone 10 mg Tablet Sig: Two (2) Tablet PO QHS (once a day (at bedtime)). 7. Pregabalin 75 mg Capsule Sig: Two (2) Capsule PO QID (4 times a day). 8. Morphine 30 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for pain. 9. Lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for anxiety. 10. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 11. Amylase-Lipase-Protease 30,000-10,000- 30,000 unit Capsule, Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed Release(E.C.) PO three times a day: with meals. 12. Multi-Vitamin W/Minerals Capsule Sig: One (1) Capsule PO once a day. 13. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). 14. Acyclovir 200 mg Capsule Sig: Two (2) Capsule PO Q12H (every 12 hours). 15. Voriconazole 200 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). 16. Calcium Carbonate 500 mg Tablet, Chewable Sig: Two (2) Tablet, Chewable PO three times a day. 17. Budesonide 3 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO Q 8H (Every 8 Hours). 18. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 19. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 20. Polyethylene Glycol 3350 17 gram/dose Powder Sig: Seventeen (17) grams PO DAILY (Daily) as needed for constipation. 21. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 22. Mycophenolate Mofetil 500 mg Tablet Sig: One (1) Tablet PO QAM (once a day (in the morning)). 23. Mycophenolate Mofetil 250 mg Capsule Sig: One (1) Capsule PO QPM (once a day (in the evening)). 24. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO every six (6) hours as needed for fever or pain. 25. Combivent 18-103 mcg/Actuation Aerosol Sig: Two (2) puffs Inhalation every 4-6 hours as needed for shortness of breath or wheezing. 26. Tobramycin 300 mg/5 mL Solution for Nebulization Sig: Five (5) ml Inhalation [**Hospital1 **] (2 times a day): 4 weeks on, 4 weeks off: started on [**10-7**] to end [**11-4**], to restart on [**12-3**]. 27. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: Three (3) ml Inhalation Q2H (every 2 hours) as needed for wheeze. 28. Ondansetron 4 mg IV Q8H:PRN nausea 29. 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. 30. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 31. oxygen Oxygen 2-4 liters/min by nasal cannula at all times. 32. Cough assist please dispense on mechanical insufflator-exsufflator cough assist use: at least twice daily settings: inspiratory pressure 26, expiratory rpessure 32, pause dialt at 2, AUTO mode, pressures depend on seal of mask which is small 33. Respiratory Therapy Requires frequent deep suctioning at least twice a day; [**Hospital1 **] use of acapella PEP device (at bedside); hourly use of incentive spirometer (at bedside); at lease twice daily use of insuffllator/exsufflator 34. Diphenhydramine HCl 50 mg/mL Solution Sig: 12.5 mg Injection x1 PRN as needed for prior to Gammagard. 35. Tylenol 325 mg Tablet Sig: Two (2) Tablet PO x1 PRN as needed for prior to Gammagard. 36. Gammagard S/D 10 gram Recon Soln Sig: as directed Intravenous once a month: next dose [**2124-10-17**]; premdicate with Tylenol 650mg PO and Benadryl 12.5mg IV. 37. Prednisone 10 mg Tablets, Dose Pack Sig: Four (4) Tablets, Dose Pack PO once a day: Until [**10-11**], switch to 30mg daily until [**10-19**]. Cont. Then, prednisone at 20mg daily until told otherwise by your doctor. . Tablets, Dose Pack(s) Discharge Disposition: Extended Care Facility: [**Hospital6 1293**] - [**Location (un) 1294**] Discharge Diagnosis: Primary: ESBL Echerichia coli Pneumonia, Chronic Graft vs. Host Disease, CML, Brochiolitis obliterans. Secondary: Vertebral Fractures Discharge Condition: Vitals stable, satting 95% on 4L nasal canula Discharge Instructions: You were admitted to the hospital because of difficulty breathing. You were treated with antibiotics for pneumonia. Because you may have been exposed to the flu, you were also treated with an antiviral medication called Tamiflu. You were also treated with steroids for graft-versus-host disease. You received respiratory therapy here. You are being discharged to a facility where respiratory therapy will be continued. We made the following changes to your medication regimen: - We increased your dose of Prednisone to 40mg daily. You should continue to take 40mg of Prednisone daily until [**10-11**], [**2123**] , at which time you should switch to 30mg daily until [**2124-10-19**]. At that time you should continue Prednisone at 20mg daily until told otherwise by your doctor. Followup Instructions: You have follow-up appointment with your Pulmonologist Dr. [**Last Name (STitle) **] as follows: Provider: [**Name10 (NameIs) 1571**] FUNCTION LAB Phone:[**Telephone/Fax (1) 609**] Date/Time:[**2124-11-2**] 2:40 Provider: [**Last Name (NamePattern4) **]. [**First Name (STitle) 1112**]/DR. [**Last Name (STitle) **] Phone:[**Telephone/Fax (1) 612**] Date/Time:[**2124-11-2**] 3:00

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icd9cm

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icd9pcs

[ [ [] ] ]

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358, 1217

3563, 4170

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30,213

133,682

334

Discharge summary

report

Admission Date: [**2129-6-12**] Discharge Date: [**2129-6-14**] Date of Birth: [**2050-1-17**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2704**] Chief Complaint: Planned Left internal carotid angio/stent Major Surgical or Invasive Procedure: Catheterization with left internal carotid stent placement. History of Present Illness: Pt is a 79 yo male CAD s/p CABG, PVD, R Coronary artery stenting, systolic CHF (EF 45%), CRF (creat 1.9), and HTN who is now s/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3098**] stenting. In [**Month (only) 958**] and [**Name (NI) **] pt had episodes x1 of LOC. In [**Month (only) 958**], his wife walked into the room to find him hunched over in his chair with + LOC and urinary incontinence. She believed that he may have experienced some sort of prodrome that caused him to sit down as the pt had been up out of the seat prior to the episode. It is unclear how long the episode lasted but it was more than a few seconds as she called EMS. During [**Month (only) **] the pt had another episode in which he was slumped over in his chair + for LOC and urinary incontinence. He regained consciousnes in about 5 seconds. The wife denies [**Name2 (NI) 3099**] movements, bowel incontinence, and states that the patient was not confused after the episode. . Review of systems + for exertional buttock and calf pain that resolves with rest. + for SOB after walking 7-10 minutes. . On review of symptoms, he denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, 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 chest pain, paroxysmal nocturnal dyspnea, orthopnea, ankle edema. Past Medical History: Hypertension Hyperlipidemia Peripheral vascular disease status post left iliac stenting in preparation for a fem-fem bypass for right iliac occlusion. Status post bilateral renal artery stenting under the care of Dr. [**First Name8 (NamePattern2) 487**] [**Last Name (NamePattern1) **] in [**2123-11-24**] Status post left common iliac artery stent for restenosis under the care of Dr. [**First Name8 (NamePattern2) 487**] [**Last Name (NamePattern1) **] Known left SFA total occlusion. CAD status post CABG in [**2113**]. Chronic systolic and diastolic heart failure with EF of 35%-40%. Status post coronary artery intervention under the care of Dr. [**Last Name (STitle) **] Chronic renal insufficiency, creatinine 1.9. Peripheral vascular disease, carotid artery stenosis, right greater than left . PSurgH: Colon CA s/p colectomy (last year) CABG ([**2113**]) Social History: +tob 65 pack-year history. Currently smokes [**11-24**] ppd. Occ EtOH. Lives independently with his wife on a [**Location (un) 470**] walk-up. Family History: Father died in WWII at 32 y.o., Mother died of alzheimers at 56 y.o. His brother had a CABG at 56. Physical Exam: Gen: WDWN middle aged male in NAD, resp or otherwise. Mood, affect appropriate. Pleasant. HEENT: NCAT. Sclera anicteric. PERRL. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. Neck: Supple with no JVD. CV: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. No S4, no S3. Chest: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. No crackles, wheeze, rhonchi anteriorly. Abd: +bs, soft, NTND. Ext: No c/c/e. Skin: No stasis dermatitis, ulcers, scars, or xanthomas. Pulses: Right: + R femoral bruit, Carotid 2+ without bruit; 2+ DP Left: + L femoral bruit, Carotid 2+ without bruit; 2+ DP Neuro: PERRL, CN II-XII intact, UE reflexes +2, strength 5/5 UE and LE, sensation intact bilaterally Pertinent Results: Lab results [**2129-6-13**] 05:50AM BLOOD WBC-4.7 RBC-4.11* Hgb-10.4* Hct-32.5* MCV-79* MCH-25.2* MCHC-31.9 RDW-15.8* Plt Ct-199 [**2129-6-13**] 05:50AM BLOOD Glucose-90 UreaN-30* Creat-2.0* Na-142 K-4.9 Cl-110* HCO3-24 AnGap-13 [**2129-6-14**] 04:49AM BLOOD UreaN-23* Creat-1.8* K-4.0 [**2129-6-14**] 12:02AM BLOOD CK(CPK)-69 [**2129-6-14**] 04:49AM BLOOD CK(CPK)-68 [**2129-6-13**] 05:50AM BLOOD Mg-2.2 . Echo [**2129-6-14**]: Mild regional left ventricular systolic dysfunction with focal hypokinesis of the basal to mid inferolateral wall and hypokinesis of the mid to distal septum. The remaining segments contract normally (LVEF = 45-50 %). Grade I (mild) LV diastolic dysfunction. The ascending aorta is mildly dilated. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is trivial mitral regurgitation. The tricuspid valve leaflets are mildly thickened. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. IMPRESSION: Regional left ventricular systolic dysfunction c/w multivessel coronary disease. Mild diastolic dysfunction. . ECG [**2129-6-14**]: Sinus bradycardia. First degree A-V delay. Prior inferior myocardial infarction. Lateral ST-T wave changes may be due to myocardial ischemia or left ventricular hypertrophy. . Cardiac Cath [**2129-6-13**]: 1. Severe 80% stenosis of left ICA. 2. Patent right ICA stent. 3. Successful PTA/stent of left ICA with bare metal stent. . Carotid series [**2129-6-1**]: LEFT: B-mode images of the left carotid bifurcation show an echolucent, heterogeneous plaque at the origin of the internal carotid artery. The common carotid artery waveforms are within normal limits and have velocities of 58 cm/sec. The internal carotid artery waveform has spectral broadening and velocities of 307/134 cm/sec. The ICA/CCA ratio is 5.2. By velocity criteria, this would correlate with an 80-99% stenosis. There has been progression from the previous exam of [**2128-11-23**]. Brief Hospital Course: The patient is a 79 yo male with previous right Coronary artery stenting who is s/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3098**] stenting at this admission. [**Doctor First Name 3098**] stenting: The patient had previous stenting to his [**Country **]. The patient had a carotid series on [**2129-6-1**] showing a carotid artery waveform with spectral broadening, velocities of 307/134 cm/sec, an ICA/CCA ratio of 5.2, and 80-99% stenosis. The patient received [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3098**] stent. He was monitored overnight in the ICU. His normal BP medications were held and his SBP was maintained between 100-160 without the need for pressors. His neurological function was monitored and remained normal. He received ASA and Plavix and was discharged on both medications. . # CAD/Ischemia: The pt is s/p CABG in [**2113**], LIMA to LAD, SVG to rPDA and rPLV, SVG to OM. He is s/p DES to SVG > OM2 in [**2124**]. While in the hospital his ASA, plavix, and lipitor were continued. His CKs were normal. . # Pump: The patient recieved an echo that showed left ventricular systolic dysfunction c/w multivessel coronary disease, mild diastolic dysfunction, and EF of 45-50%. He was euvolemic while in the hospital, had a normal pulmonary exam, and had normal oxygen sat. The patient was not on his home ACE or afterload reducers because of the possibility of decreased BP secondary to the vagal effects of stent placement. He should restart these medications after a BP check two days after discharge. . # Rhythm: The patient should receive a halter monitor as an outpatient to ensure that his previous two episodes of LOC were not secondary to an abnormal rhythm. . # HTN: The patient's normal home BP medications were held during the hospitalization because of the possibility of decreased BP secondary to the vagal effects of stent placement. He should restart these medications after a BP check two days after discharge. The patient's normal home BP meds are Norvasc 5mg PO daily, Lisinopril 5mg PO daily, Toprol 100mg daily, and Isosorbide Dinitrate 20mg TID . #CRI: The patient has chronic renal insufficiency. His baseline creatinine is 1.9 and was 1.8 on this admission. . # Prophylaxis: -The patient received Heparin 5000 units SQ TID during his hospitalization Medications on Admission: Amlodipine 10 mg PO daily Isosorbide Dinitrate 20 mg PO TID Lipitor 40 mg PO daily Lisinopril 5mg PO daily Nitroglycerin 400 MCG (1/150 GR) TABLET PRN CP Plavix 75mg PO daily ASA 325mg PO daily Toprol XL 100MG PO daily Omeprazole 20mg PO daily Discharge Medications: 1. Atorvastatin 40 mg PO DAILY 2. Omeprazole 20 mg Capsule PO DAILY 3. Aspirin 325 mg PO DAILY 4. Plavix 75 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: Primary: Carotid Artery Stenosis Secondary: Peripheral vascular disease. Coronary artery disease. Chronic systolic and diastolic CHF Discharge Condition: Stable. Discharge Instructions: You were admitted for carotid angiography with placement of a left carotid stent. . Your should continue to take Atorvastatin, Aspirin, Omeprazole and Plavix. . On Thursday you will have an appointment with [**First Name8 (NamePattern2) 402**] [**Last Name (NamePattern1) 3100**], Dr.[**Name (NI) 3101**] [**Name (STitle) **] Practicioner at which time they will assess which of your old blood pressure medications you should resume. . Please adhere to your follow-up appointments. They are important for managing your long-term health. . Please return to the hospital or call your doctor if you have temperature greater than 101, shortness of breath, worsening difficulty with swallowing, chest pain, abdominal pain, diarrhea, or any other symptoms that you are concerned about. Followup Instructions: Cardiovascular follow-up: Please follow up with [**First Name8 (NamePattern2) 402**] [**Last Name (NamePattern1) 3100**] in Dr.[**Name (NI) 3101**] office on [**Last Name (un) **]. [**6-16**] at 2pm. The office can be reached at [**Telephone/Fax (1) 3102**]. Provider: [**Name10 (NameIs) 3103**] LAB Phone:[**Telephone/Fax (1) 3104**] Date/Time: [**2129-6-28**] 1:00pm Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D. Phone:[**Telephone/Fax (1) 62**] on [**2129-7-11**] at 3:20pm. Completed by:[**2129-6-15**]

[ "V10.05", "428.0", "433.10", "272.4", "428.42", "V45.81", "403.90", "585.9" ]

icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

8788, 8794

6008, 8347

357, 419

8971, 8980

3906, 5985

9808, 10357

2993, 3094

8643, 8765

8815, 8950

8373, 8620

9004, 9785

3109, 3887

276, 319

447, 1929

1951, 2815

2831, 2977

67,661

110,215

39490

Discharge summary

report

Admission Date: [**2182-9-3**] Discharge Date: [**2182-9-10**] Date of Birth: [**2101-11-23**] Sex: M Service: NEUROSURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1271**] Chief Complaint: ataxia and dizziness Major Surgical or Invasive Procedure: Right Craniotomy for SDH evacuation ([**2182-9-4**]), no complications History of Present Illness: Patient is a very poor historian and largely uncooperative and slightly demented. Patient c/o long standing dizzyness, but reportidly has been increasingly ataxic with falls [**Name6 (MD) **] home RN. Past Medical History: DM (full PMH not known, and patient is unable to relate) Social History: Patient reports he lives alone, visiting nurse: [**Doctor First Name **] [**Telephone/Fax (1) 87229**] *HCP is a nephew who lives in [**State 8842**]. (photocopied HCP form is in chart)[**Name (NI) 3065**] [**Name (NI) 43672**] [**Telephone/Fax (3) 87230**] *Mr. W's friend [**Name (NI) 3979**] [**Name (NI) **] and his wife have visited him several times here in the hospital. They live nearby [**Telephone/Fax (1) 87231**], very helpful, concerned. Family History: NC Physical Exam: Gen: WD/WN, comfortable, NAD. HEENT: Pupils:3 to 2 EOMs: intact Neck: Supple. Extrem: Warm and well-perfused. Neuro: Mental status: Awake and alert, agitated at times. Orientation: Oriented to person, place, and date. Language: Speech fluent with good comprehension and repetition. Naming intact. No dysarthria or paraphasic errors. Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light, 3to2 mm bilaterally. Visual fields are full to confrontation. III, IV, VI: Extraocular movements intact bilaterally without nystagmus. V, VII: Facial strength and sensation intact and symmetric. VIII: Hearing intact to voice. IX, X: Palatal elevation symmetrical. [**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally. XII: Tongue midline without fasciculations. Motor: Normal bulk and tone bilaterally. No abnormal movements, tremors. Strength full power [**6-5**] throughout. No pronator drift Sensation: Intact to light touch Toes downgoing bilaterally Coordination: Left FTN dysmetria Pertinent Results: *** Initial CT Head on presentation [**2182-9-2**]: FINDINGS: There is a large mixed-density loculated collection layering over the right frontoparietal convexity measuring up to 20 mm in greatest thickness. Mass effect on the subjacent sulci is noted. In addition, there is 9 mm of leftward shift of the normally midline structures. Along the inferior aspect of the right frontal convexity, there is a hyperdense component (67 [**Doctor Last Name **]) measuring 4 mm which likely represents a superimposed more acute hemorrhage. Overall, this collection is unchanged over the roughly six hour interval, and no new hemorrhage is identified. There is no evidence of entrapment of the left ventricle. Basilar cisterns are preserved and the fourth ventricle is patent. No major vascular territorial infarction. Prominent hypodense foci in the right parieto-occipital region and occipital pole likely represent established encephalomalacia related to previous infarcts, perhaps embolic. In the left cerebral hemisphere, there is diffuse prominence of the sulci consistent with parenchymal volume loss, age-appropriate. Mild mucosal thickening in the left maxillary sinus. The remainder of visualized paranasal sinuses and mastoid air cells are well aerated. No osseous abnormality is identified. Dense calcification of the vertebral and cavernous carotid arteries is noted. IMPRESSION: No overall short-interval change in large mixed-density collection overlying the right frontoparietal convexity, compatible with acute superimposed on subacute-to-predominantly chronic subdural hematoma causing subfalcine herniation. No new hemorrhage compared to study performed six hours earlier. *** POST-operative NCHCT [**2182-9-5**] (after SDH evacuation [**9-4**]): FIDNINGS: There has been interval right frontal craniotomy and evacuation of a mixed density subdural collection. There is a large amount of expected post-surgical pneumocephalus with mass effect on the frontal lobes. There is a linear hyperdensity in the right frontal extra-axial space measuring 4 mm in greatest width and consistent with acute blood products in the surgical bed. Bifrontal extra-axial isodense collections remain measuring up to 11 mm on the right, compatible with chronic subdural or CSF hygromas. There is interval decreased shift of the normally midline structures leftward which now measures 5 mm compared to 9 mm previously. Basilar cisterns are preserved. Mucosal thickening in the left maxillary sinus and bilateral ethmoid sinuses is noted. Remainder of the visualized paranasal sinuses and mastoid air cells are well aerated. Calcification of the vertebral and cavernous carotid arteries is again noted. IMPRESSION: Interval right frontal craniotomy with expected post-surgical change. 4 mm linear rim of hyperdensity in the surgical bed consistent with acute blood products. Decreased shift of the normally midline structures leftward now measuring 5 mm compared to 9 mm previously. NOTE ON ATTENDING REVIEW: Right parietal and occipital hypodense areas with fluid attenuation representing evolution of the previously noted infarct/insult is again visualized and unchanged.( se 2, im13). Moderate amount of pneumocephalus with some mass effect on the frontal lobes. Attention on close follow up to exclude tension pneumocephalus. Atherosclerotic vascular calcifications are noted in the distal vertebral and internal carotid arteries. *** ECG [**2182-9-6**]: Probable ectopic atrial rhythm. Left axis deviation, likely due to left anterior fascicular block. Compared to the previous tracing of [**2182-9-4**] the rhythm appears to be coming from a non-sinus origin on the current tracing. The other findings are similar. Rate Intervals: PR QRS QT/QTc axes:P QRS T 74 110 114 394/[**Telephone/Fax (2) 87232**] *** CXR (pre-op [**2182-9-4**]): Small left retrocardiac atelectasis. Mild cardiomegaly. Brief Hospital Course: Pt was admitted after c/o dizzyness and ataxia. CT imaging revealed right sided SDH. The pt was unable to consent for himself and family was contact[**Name (NI) **]. [**Name2 (NI) **] was brought to the OR on [**2182-9-5**]. His post operative imaging was stable. His postoperative course was uneventful except for occassional sundowning that responded well to seroquel. Geriatrics was consulted for assistance with aggitation and polypharmacy. Their recommendations were followed. They recommended also that the pt is not to drive unless cleared by the DriveWise program. He advanced in his diet and activity. Social work and PT were consulted. He was deemed appropriate for subacute rehab. Medications on Admission: Antivert, metformin, Glucophage Discharge Medications: 1. Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 2. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 3. Oxycodone 5 mg Tablet Sig: .5 tab Tablet PO Q4H (every 4 hours) as needed for pain. 4. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q 8H (Every 8 Hours): taper to off as clinically indicated. 5. Cyanocobalamin (Vitamin B-12) 1,000 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Metformin 500 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Disposition: Extended Care Facility: Life Care Center of [**Location 15289**] Discharge Diagnosis: Right Subdural hematoma Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: ?????? Have a friend/family member check your incision daily for signs of infection. ?????? Take your pain medicine as prescribed. ?????? Exercise should be limited to walking; no lifting, straining, or excessive bending. ?????? You may wash your hair only after sutures and/or staples have been removed. If your wound closure uses dissolvable sutures, you must keep that area dry for 10 days. ?????? You may shower before this time using a shower cap to cover your head. ?????? Increase your intake of fluids and fiber, as narcotic pain medicine can cause constipation. We generally recommend taking an over the counter stool softener, such as Docusate (Colace) while taking narcotic pain medication. ?????? Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, Aspirin, Advil, and Ibuprofen etc. you have been discharged on Keppra (Levetiracetam), you will not require blood work monitoring. ?????? Clearance to drive and return to work will be addressed at your post-operative office visit. / YOU NEED TO BE [**Street Address(1) 87233**] WISE / IT IS RECOMMENDED THAT YOU DO NOT DRIVE UNLESS YOU ARE CLEARED TO DO SO. CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING ?????? New onset of tremors or seizures. ?????? Any confusion or change in mental status. ?????? Any numbness, tingling, weakness in your extremities. ?????? Pain or headache that is continually increasing, or not relieved by pain medication. ?????? Any signs of infection at the wound site: redness, swelling, tenderness, or drainage. ?????? Fever greater than or equal to 101?????? F. Followup Instructions: ??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr. [**Last Name (STitle) 739**], to be seen in 4 weeks. Provider: [**Name10 (NameIs) **] SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2182-10-9**] 1:15 Provider: [**Name10 (NameIs) **] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 1669**] Date/Time:[**2182-10-9**] 1:30 PLEASE SEE YOUR PRIMARY CARE PHYSICIAN AND UPDATE HIM/HER REGARDING YOUR HOSPITALIZATION. IT HAS BEEN ADVISED BY THE GERIATRIC SERVICE THAT YOU DO NOT DRIVE UNLESS YOU ARE CLEARED TO DO SO. YOU CAN [**Street Address(1) 87234**] WISE PROGRAM AT [**Telephone/Fax (1) **] [**Name6 (MD) 742**] [**Name8 (MD) **] MD [**MD Number(2) 1273**] Completed by:[**2182-9-10**]

[ "250.00", "372.72", "348.4", "432.1", "293.0", "780.4", "294.8", "401.9", "V15.88" ]

icd9cm

[ [ [] ] ]

[ "01.31" ]

icd9pcs

[ [ [] ] ]

7552, 7619

6225, 6927

340, 413

7687, 7687

2292, 6202

9515, 10277

1209, 1213

7009, 7529

7640, 7666

6953, 6986

7872, 9492

1228, 1354

280, 302

441, 643

1589, 2273

7702, 7848

665, 724

740, 1193

27,942

145,725

46600

Discharge summary

report

Admission Date: [**2123-7-16**] Discharge Date: [**2123-7-22**] Date of Birth: [**2046-1-8**] Sex: F Service: MEDICINE Allergies: Penicillins / Sulfonamides / Ciprofloxacin Attending:[**First Name3 (LF) 689**] Chief Complaint: Confusion, tachypnea and subjective fever Major Surgical or Invasive Procedure: None History of Present Illness: This is a 77 y.o. female with history of hypertension, hyperthyroidism who initially presented to the ED with confusion, exertional dyspnea, and subjective fevers. Upon initial evaluation in the ED, she was found to have positive urinalysis, treated empirically for UTI, and also had troponin elevated to 0.26 and was initially admitted to the [**Hospital1 1516**] service for cardiac evaluation. Patient had been started on heparin gtt given the troponin elevation. Upon arriving to the floor, she became increasingly agitated, somnolent, and tachypneic, her blood pressure rising to 190/110. In this setting, a blood gas was obtained, 7.22/62/141 on 2 litres nasal cannula. She was also febrile to 101.3. Given the above, decision was made to transfer patient to MICU. . Review of systems: No current chest pain, shortness of breath. + subjective fevers, occasional nausea, no vomitting, diarrhea, constipation, dysuria, urinary frequency, urgency, headaches, or focal weakness. . Past Medical History: - COPD - Hypertension - Urinary tract infections; hx of ESBL klebsiella UTI, - Hypothyroidism - ? Central arterial thrombosis of retinal vein surgically corrected - Venous thrombosis involving her left eye status post cataract removal Social History: - Lives at home with husband. [**Name (NI) **] 3 children. - She smoked up through 25 years ago (few cigarettes a day only). She drinks alcohol on a daily basis but only 1 or 2 drinks a day. - Husband is on the board of directors here at [**Hospital1 18**]. Family History: . Positive for hypertension, CAD, hyperlipidemia. Daughter had breast cancer 5 yrs ago (now ok) and 1 son has [**Name (NI) 4522**] disease. . Physical Exam: . Physical Exam: Vitals: 99.7, 96, 142/70, 98% 2 litres nasal cannula GEN: NAD, breathing comfortably HEENT: EOMI, Sclera anicteric, dry mucous membranes, OP clear NECK: Supple, no JVD, no carotid bruits COR: RRR, no M/G/R, normal S1 & S2, peripheral pulses intact PULM: Lungs CTAB, no W/R/R, no accessory muscle use ABD: Soft, NT, ND, +BS, no HSM, no palpable masses EXT: Warm, well-perfused, no C/C/E NEURO: A&O x 3, CN II-XII grossly intact, moves all 4 extremities SKIN: No rashes or ecchymoses . Pertinent Results: . Labs: Notable for Troponin 0.26=>0.23=>0.77=>0.21 . [**2123-7-16**] EKG Sinus rhythm and occasional ventricular ectopy. Compared to the prior tracing of [**2123-7-16**] there is variation in precordial lead placement. There is delayed precordial R wave transition and ST segment depression in leads V5-V6. Rate PR QRS QT/QTc P QRS T 84 144 84 384/424.85 67 58 42 . Chest x-ray on [**2123-7-16**]: IMPRESSION: No acute cardiopulmonary process. Interval resolution of previously noted pulmonary edema. . Persantine MIBI [**2123-7-22**] - Normal study; LVEF57% - No anginal type symptoms or ischemic ECG changes . Brief Hospital Course: 77 yo with hypertension, hypothyroidism and hx of ESBL klebsiella urosepsis in the past was admitted with mental status changes and subjective fevers. . # Urosepsis: Admitted with mental status changes which were most likely attribute to presence of fevers; transferred to the MICU after development of dyspnea. She was found to have a urinary tract infection as well as bacteremia with E.coli. E.coli was sensitive to multiple drugs including Levofloxacin, Ciprofloxacin, Gentamicin, Meropenem, Ceftriaxone and Ceftazidime, however due to pt's many allergies she was started on Gentamicin. She did not require intubation, and improved on Gentamicin. She was transferred to the floor where Gentamicin was discontinued and Levaquin was started. Pt. tolerated Levaquin without any difficulty and remained stable without any changes in mental status. Repeat blood and urine cultures after initial ones were negative. She is to continue Levaquin for 8 more days for a total of 14days of antibiotic therapy. . # NSTEMI: She was evaluated by cardiology upon admission and started on a heparin infusion. She did not have any new changes to her EKG and the lateral ST depression noted were old. After stabilization in MICU for mental status changes and respiratory distress, heparin infusion was d/c'ed and she was transferred to the floor. She did not have any events on telemetry or experience any symptoms of chestpain or shortness of breath while on the floor. Pt did have an elevation in her troponin level which peaked at 0.77 and was trending down, 0.21 at discharge. Cardiology felt demand ischemia vs. NSTEMI was causing the troponin leak. She was followed by cardiology during her stay in the hospital. An echo done revealed nml EF, however inferior wall hypokinesis. P-MIBI done prior to discharge did not show any defects. She was continued on ASA and Metoprolol while in house. Pt is to follow up with PCP; Would consider d/c of HRT due to NSTEMI. . #. Altered mental status: Confusion, most likely related to fevers and urinary tract infection. Pt's mental status improved on Gentamicin. Her UTI and bacteremia was treated with Levaquin. She did not have any more episodes while on admission. . # Hypertension: Pt was maintained on home dose Atenolol 75mg daily. She also is on a home regimen of HCTZ. To be continued upon discharge home. . # Anemia: She has had episodes of anemia in the past as evidence by OMR. She remained hemodynamically stable without evidence of active bleeding. Did not require any blood transfusions while in the hospital. . # COPD: History of COPD, had PFT's done while in house. Will need to be followed up by primary care provider. . # Hypothyroidism: Continued her home regimen of Armour Thyroid . # Thrombocytopenia: Plts were trending down after admission, had been on Heparin infusion at the same time. There was the question of HIT, however low suspicion, no evidence of thrombosis and Heparin drip was discontinued. Plt level remained stable. . Code: FULL . PCP: [**First Name8 (NamePattern2) 1312**] [**Last Name (NamePattern1) 1313**] [**Telephone/Fax (1) 7318**] . Contact: [**Name (NI) 5045**] [**Name (NI) 11907**] (husband) [**Telephone/Fax (1) 98961**] . Pt has reached maximal hospital benefit and is ready for discharge home. Medications on Admission: Medications on Admission: 1. Hydrochlorothiazide 12.5mg PO daily 2. Atenolol 75mg qdaily 3. Premarin 0.625 qdaily 4. Medroxyprogesterone 19mg qdaily 5. Timoptic 0.5%; one drop in each eye . Discharge Medications: 1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 2. Thyroid 120 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 4. Atenolol 25 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 5. Vitamin D 400 unit Capsule Sig: One (1) Capsule PO DAILY (Daily). Disp:*30 Capsule(s)* Refills:*2* 6. Conjugated Estrogens 0.625 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Medroxyprogesterone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours): Please do not take within 2 hours of taking calcium tablets. Disp:*8 Tablet(s)* Refills:*0* 9. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times a day). Disp:*90 Tablet, Chewable(s)* Refills:*2* 10. Hydrochlorothiazide 12.5 mg Tablet Sig: One (1) Tablet PO once a day. 11. Timoptic 0.5 % Drops Sig: One (1) drop Ophthalmic once a day. Discharge Disposition: Home Discharge Diagnosis: Urosepsis NSTEMI Discharge Condition: Good Discharge Instructions: You have been diagnosed with urinary tract infection which led to an infection of your blood. You may have had a mild heart attack (NSTEMI). . Please follow up with your primary care physician as scheduled below. You have had a few urinary tract infections in the past few months. We have made you an appointment with a Urologist Dr. [**Last Name (STitle) 86790**] [**Name (STitle) **] [**Telephone/Fax (1) 921**]. If unable to make this appointment please call and cancel or reschedule. . We have made some changes and added some new medications to your regimen. We have added Calcium & Vitamin D. Please take Levaquin(antibiotic) for 8 more days. Please discuss these changes with your primary care physician. . Please discuss with your primary care physician the possibility of discontinuing your hormone replacement therapy given your recent event of a heart attack. . You do not have to follow up with cardiology. Please discuss this with your primary physician. . Please call your primary physician or come to the emergency room if you develop chest pain, shortness of breath or any other worrisome signs. . Please eat a heart healthy, low sodium diet. Followup Instructions: Please follow up with Dr. [**First Name8 (NamePattern2) 1312**] [**Last Name (NamePattern1) 1313**] [**Telephone/Fax (1) 7318**] within 2 weeks of your discharge. . Urology: You have been scheduled an appointment with Dr. [**Last Name (STitle) 86790**] [**Name (STitle) **] [**Telephone/Fax (1) 921**] on [**2123-9-27**] at 1:30pm in the afternoon. Location: [**Location (un) 470**] of the [**Hospital Ward Name 23**] building.

[ "585.2", "276.2", "038.42", "403.90", "410.71", "276.51", "599.0", "287.5", "244.9", "496" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

7822, 7828

3249, 5215

343, 349

7889, 7896

2602, 3226

9103, 9534

1923, 2066

6771, 7799

7849, 7868

6578, 6748

7920, 9080

2098, 2583

1175, 1368

262, 305

377, 1156

5230, 6526

1390, 1629

1645, 1907

82,498

198,003

38834

Discharge summary

report

Admission Date: [**2116-5-4**] Discharge Date: [**2116-5-6**] Date of Birth: [**2086-12-22**] Sex: F Service: NEUROSURGERY Allergies: Penicillins Attending:[**First Name3 (LF) 78**] Chief Complaint: Headache Major Surgical or Invasive Procedure: cerebral angiogram History of Present Illness: HPI: The pt is a 29 year-old right-handed female with history of neck pain and spasm who presents with sudden onset of severe headache two times in the last 5 days. The patient first had a headache (which is unusual for her) on Wednesday. She was leading a group activity with her students (she is a special ED teacher) and was reportedly very active when she had the sudden onset of a severe headache, one of the worst she has ever experienced. She described it as throbbing, bifrontal and temporal, exacerbated by moving but non-positional, with some mild photophobia and worse phonophobia. It was worst at the onset and then slowly improved over the next two days, and was resolved by Friday. On Saturday she again experienced the sudden onset of a worse headache. She had just engaged in intercourse and post-intercourse had the sudden onset of a severe bifrontal headache. The headache had similar characteristics as the prior headache. It was worse when she changed elevations (from sitting to standing, or standing to sitting) but did not appear to have a distinct positional component. This time is was very severe and caused her to become both nauseous and she vomited multiple times. She noted that she could not even keep water down. She again had phono/photophobia. There was no hearing loss or vision change with the headache. No focal weakness or strange sensations. No sustained visual phenomena (although she did have a brief sensation of flashing lights on movement). This headache was again worse at the onset and the nausea and vomiting have improved, however she still was experiencing severe pain, and was not relieved with ~3g of Tylenol on Saturday. She came into the ED for further workup. She does not have a history of migraines, and she does not usually get headaches. She has been on Celexa for a long time but her dose increased from 10 to 20mg about 3 weeks prior. Before she was seen by neurology in the ED she already had a CT/CTA/MRI/A/V and LP. While the imaging, which was detailed below was normal, the LP was grossly blood and it is not clear if it was secondary to a traumatic tap. Per note the opening pressure was 17cm H20. Her headache has improved while she is in the ED, and now had worse neck muscle spasm then headache. On neuro ROS, the pt denies loss of vision, blurred vision, diplopia, dysarthria, dysphagia, lightheadedness, vertigo, tinnitus or hearing difficulty. Denies difficulties producing or comprehending speech. Denies focal weakness, numbness, parasthesiae. No bowel or bladder incontinence or retention. Denies difficulty with gait. On general review of systems, the pt denies recent fever or chills. No night sweats or recent weight loss or gain. Denies cough, shortness of breath. Denies chest pain or tightness, palpitations. Denies diarrhea, constipation or abdominal pain. No recent change in bowel or bladder habits. No dysuria. Denies arthralgias or myalgias. Denies rash. Past Medical History: - Chronic neck pain, on Flexeril, is scheduled to get PT in [**Month (only) 547**] - Anxiety - PUD (resolved with medication) - left foot injured in scooter accident many years prior Social History: Patient lives with 3 roommates. Is a teacher in a special ED class and reports her job is very strenuous. She smokes marijuana 3-4 times a week for relaxation, no tob, no other drugs, occ etoh. Family History: No family history of migraine or headaches. Family members with breast CA and stomach CA. No history of aneurysm or intracranial bleed. Grandmother with unspecified heart disease. Physical Exam: Vitals: T:97.1 P:93 R: 16 BP:133/80 SaO2:100 General: Awake, cooperative, NAD. HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in oropharynx Neck: Cervical muscle tenderness L> R. Supple, no carotid bruits appreciated. No nuchal rigidity, no meningismus Pulmonary: Lungs CTA bilaterally without R/R/W Cardiac: RRR, nl. S1S2, no M/R/G noted Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or organomegaly noted. Extremities: No C/C/E bilaterally, 2+ radial, DP pulses bilaterally. Skin: no rashes or lesions noted. Neurologic: -Mental Status: Alert, oriented x 3. Able to relate history without difficulty. Attentive, able to name [**Doctor Last Name 1841**] backward without difficulty. Language is fluent with intact repetition and comprehension. Normal prosody. There were no paraphasic 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. Pt. was able to register 3 objects and recall [**4-8**] at 5 minutes. The pt. had good knowledge of current events. There was no evidence of apraxia or neglect. -Cranial Nerves: I: Olfaction not tested. II: PERRL 3 to 2mm and brisk. VFF to confrontation. Funduscopic exam revealed no papilledema, exudates, or hemorrhages. III, IV, VI: EOMI without nystagmus. Normal saccades. V: Facial sensation intact to light touch. VII: No facial droop, facial musculature symmetric. VIII: Hearing intact to finger-rub bilaterally. IX, X: Palate elevates symmetrically. [**Doctor First Name 81**]: 5/5 strength in trapezii and SCM bilaterally. XII: Tongue protrudes in midline. -Motor: Normal bulk, tone throughout. No pronator drift bilaterally. No adventitious movements, such as tremor, noted. No asterixis noted. Delt Bic Tri WrE FFl FE IO IP Quad Ham TA [**First Name9 (NamePattern2) 2339**] [**Last Name (un) 938**] EDB L 5 5 5 5 5 5 5 5 5 5 5 5 5 5 R 5 5 5 5 5 5 5 5 5 5 5 5 5 5 -Sensory: No deficits to light touch, pinprick, cold sensation, vibratory sense, proprioception throughout. No extinction to DSS. With exception of slight decreased sensation on left foot to LT apparently since scooter accident involving the left foot. -DTRs: [**Name2 (NI) **] Tri [**Last Name (un) 1035**] Pat Ach L 2 2 2 2 1 R 2 2 2 2 1 Plantar response was flexor bilaterally. -Coordination: No intention tremor, no dysdiadochokinesia noted. No dysmetria on FNF or HKS bilaterally. -Gait: Good initiation. Narrow-based, normal stride and arm swing. Able to walk in tandem without difficulty. Romberg absent. on discharge: Non focal Pertinent Results: Admission Labs: [**2116-5-3**] 04:49PM BLOOD WBC-6.7 RBC-4.65 Hgb-14.2 Hct-41.8 MCV-90 MCH-30.5 MCHC-33.9 RDW-13.0 Plt Ct-281 [**2116-5-3**] 04:49PM BLOOD Neuts-54.3 Lymphs-37.7 Monos-6.0 Eos-1.0 Baso-1.1 [**2116-5-3**] 04:49PM BLOOD PT-11.8 PTT-29.7 INR(PT)-1.0 [**2116-5-3**] 04:49PM BLOOD Glucose-92 UreaN-10 Creat-0.8 Na-140 K-3.6 Cl-104 HCO3-29 AnGap-11 [**2116-5-3**] 04:49PM BLOOD ASA-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2116-5-4**] 08:55AM BLOOD Calcium-9.3 Phos-4.3 Mg-2.1 [**2116-5-3**] 10:00PM CEREBROSPINAL FLUID (CSF) WBC-10 HCT,Fl-2.5* Polys-46 Lymphs-40 Monos-0 Eos-1 Macroph-13 [**2116-5-3**] 10:00PM CEREBROSPINAL FLUID (CSF) WBC-19 HCT,Fl-2.5* Polys-29 Lymphs-60 Monos-0 Eos-1 Macroph-10 [**2116-5-3**] 10:00PM CEREBROSPINAL FLUID (CSF) TotProt-105* Glucose-45 Imaging: NCHCT ([**5-3**]) FINDINGS: There is asymmetric hyperdensity in the right transverse sinus. There is no evidence of acute hemorrhage or shift of normally midline structures. The ventricles and sulci are normal in appearance. There is normal [**Doctor Last Name 352**]-white matter differentiation. The basilar cisterns are preserved. The visualized paranasal sinuses are clear. IMPRESSION: Right transverse sinus hyperdensity concerning for sinus thrombosis. Further evaluation with MRV is recommended. CTA ([**5-3**]): [**Known lastname **],[**Known firstname 86193**] [**Medical Record Number 86194**] F [**2023-1-4**] Radiology Report CTA HEAD W&W/O C & RECONS Study Date of [**2116-5-3**] 10:56 PM [**Last Name (LF) 10902**],[**First Name3 (LF) **] EU [**2116-5-3**] 10:56 PM CTA HEAD W&W/O C & RECONS Clip # [**Clip Number (Radiology) 86195**] Reason: SEVERE HA Contrast: OPTIRAY Amt: 90 [**Hospital 93**] MEDICAL CONDITION: 29 year old woman with severe headache, sudden onset yesterday afternoon. Similar episode several days ago. LP with bloody fluid tubes [**2-10**]. REASON FOR THIS EXAMINATION: ? eval for aneurysm CONTRAINDICATIONS FOR IV CONTRAST: None. Wet Read: RSRc MON [**2116-5-4**] 12:13 AM No aneurysm or vascular occlusion. [**Doctor Last Name **] [**2116-5-4**] 12a Final Report EXAMINATION: CT angiogram of the head. HISTORY: A 29-year-old female presents with severe headache. COMPARISON: Brain MRI/MRA on this date. Also, non-contrast CT scan on this date. TECHNIQUE: Angiographic phase images through the head were obtained following administration of intravenous contrast. FINDINGS: The high cervical and intracranial internal carotid arteries are asymmetric, with the left side being smaller than the right, likely secondary to the hypoplastic left A1 segment. The internal carotid arteries are otherwise normal. The middle cerebral arteries are normal. There is a 3 x 5-mm inferolaterally oriented aneurysm arising from the anterior communicating artery. The more distal anterior cerebral artery branches are normal. The posterior circulation is normal. The intracranial veins are patent with no evidence for venous thrombosis. Again noted is a well-defined 18 mm mass within the right parotid gland, better visualized on the preceding MRI. There is mucus retention cyst within the posterior nasopharynx. There is no territorial hemorrhage or evidence for intracranial hemorrhage. IMPRESSION: 1. 3 x 5 mm inferiorly oriented anterior communicating artery aneurysm. 2. 18 mm right parotid mass, which was better visualized on the recent MRI, most likely representing pleomorphic adenoma, with a variety of less likely differential considerations. The findings were discussed with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 86196**] at the time of dictation, 10:15 on [**2116-5-4**], also additionally with the managing clinical team, Dr. [**Last Name (STitle) 7594**]. The study and the report were reviewed by the staff radiologist. DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] DR. [**First Name (STitle) **] [**Name (STitle) 12563**] Approved: MON [**2116-5-4**] 11:38 PM Imaging Lab MRI/MRV ([**5-3**]):[**Known lastname **],[**Known firstname 86193**] [**Medical Record Number 86194**] F [**2023-1-4**] FINDINGS: MRI: There is no structural or parenchymal signal abnormality. The ventricles are normal. There is no acute infarct. There is no abnormal intracranial enhancement, though there does appear to be a 5 mm inferiorly oriented anterior communicating artery aneurysm. The dural venous sinuses enhance normally. There is a small mucus retention cyst within the nasopharynx. There is an 18 x 13 mm mass within the right parotid gland which is T1 hypointense, T2 hyperintense and homogeneously enhancing. The mass is well encapsulated with no infiltrate of margins. The left parotid gland is normal. There is a tiny 2-mm T1 hypointense and T2 hyperintense nonenhancing lesion within the pars intermedia, most likely representing a pars intermedia cyst. The infundibulum and remaining pituitary tissue is normal. MRV: There is preferential drainage of the superior sagittal sinus into the right transverse sinus, with a relatively hypoplastic left transverse sinus, normal variant. There is no evidence for venous thrombosis. IMPRESSION: 1. Findings suggesting an inferiorly oriented anterior communicating artery aneurysm, better evaluated as a 3 x 5 mm on the followup CTA. 2. No evidence of venous thrombosis. 3. 18 mm right parotid mass with imaging findings most compatible with a pleomorphic adenoma, with a variety of less likely differential considerations. ENT consultation is recommended for further management. 4. Sella findings most likely representing a 2 mm pars intermedia cyst. If there are any clinical findings concerning for a pituitary lesion, dedicated MRI of the sella could be obtained in further evaluation. The findings were discussed with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 86196**] at the time of dictation, 10:15 on [**2116-5-4**], also additionally with the managing clinical team, Dr. [**Last Name (STitle) 7594**]. Brief Hospital Course: Ms. [**Known firstname **] [**Known lastname **] is a 29 year-old right-handed female with history of neck pain and spasm who presents with sudden onset of severe headache two times in the last 5 days. The headache is throbbing, sudden-onset, with nausea and vomiting and photo/phonophobia, not clearly positional, and in both case occurred after an emotionally excitable event. The patient exam is notable for some cervical muscles tenderness and otherwise has a normal neurological exam. # Neuro: She had a CT and MRI/MRV which were normal. She underwent an LP which was grossly bloody (although there was some question as to whether this was traumatic). She had a CTA which showed a 5x3mm ACA aneurysm. She underwent angiography on [**5-5**] which showed an acomm aneurysm which was coiled without incident. She was maintained on a heparin drip overnight. Her post procedure exam was stable. She was deemed safe for d/c to home. In addition to the above complaints, she does note neck pain related to her work, and was given a soft cervical collar to be worn while sleeping. # ENT: She was incidentally noted to have a right parotid mass on MRI, for which she should undergo evaluation by ENT as an outpatient. Medications on Admission: - Celexa 20mg - Flexaril 5mg TID Discharge Medications: 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): do not stop taking this medication on your own . Disp:*30 Tablet(s)* Refills:*2* 2. Percocet 5-325 mg Tablet Sig: 1-2 Tablets PO every four (4) hours as needed for pain. Disp:*40 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Acomm Aneurysm Discharge Condition: neurologically intact Discharge Instructions: Angiogram with Embolization and/or Stent placement Medications: ?????? Take Aspirin 325mg (enteric coated) once daily. ?????? Continue all other medications you were taking before surgery, unless otherwise directed ?????? You make take Tylenol or prescribed pain medications for any post procedure pain or discomfort. What 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 What to report to office: ?????? Changes in vision (loss of vision, blurring, double vision, half vision) ?????? Slurring of speech or difficulty finding correct words to use ?????? Severe headache or worsening headache not controlled by pain medication ?????? A sudden change in the ability to move or use your arm or leg or the ability to feel your arm or leg ?????? Trouble swallowing, breathing, or talking ?????? 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 our office. If bleeding does not stop, call 911 for transfer to closest Emergency Room! Followup Instructions: please call the office to be seen by Dr. [**First Name (STitle) **] in 4 weeks at [**Telephone/Fax (1) **] - you will NOT need any imaging of the brain at that time. For your parotid gland mass - you need to call the [**Hospital **] clinic at [**Telephone/Fax (1) **] to be seen in 2- 4weeks by Dr. [**Last Name (STitle) **] Completed by:[**2116-5-6**]

[ "300.00", "723.1", "210.2", "338.29", "437.3" ]

icd9cm

[ [ [] ] ]

[ "39.72", "88.41", "03.31" ]

icd9pcs

[ [ [] ] ]

14358, 14364

12758, 13984

282, 303

14423, 14447

6669, 6669

16433, 16790

3738, 3923

14068, 14335

8425, 8575

14385, 14402

14010, 14045

14471, 15491

15517, 16410

5126, 6625

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234, 244

8607, 12735

331, 3302

6686, 8385

4510, 5109

3324, 3509

3525, 3722

47,941

102,453

43097

Discharge summary

report

Admission Date: [**2187-5-30**] Discharge Date: [**2187-6-3**] Date of Birth: [**2129-7-12**] Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 12174**] Chief Complaint: hyponatremia spontaneous bacterial peritonitis Major Surgical or Invasive Procedure: Paracentesis [**6-2**] History of Present Illness: 57 yo F with Etoh/HCV cirrhosis, who was seen in routine liver follow up care and noted to have a sodium of 115 and sent to the ED. PAtient reports feeling weak and tired since Sunday but denies fever, chills, nausea, vomiting, diarrhea. She denies headache, confusion, vision change, slurred speech or gait ataxia. She reports no change in her diet and she has been strictly following a 1.5g fluid restriction and remained on her diuretics. She notes she feels very thirsty and he mouth always feels dry. Reported no change in abdominal girth. Clinic note indicates that she has had a 10lb weight loss in the last month but had no bleeding or encephalopathy. . Of note, she lost almost 20lbs after her last admission and was briefly (1 week) on a lower dose of diuretics, has been back at full dose for the last month or so. Her last recorded sodium was 128 on [**2187-4-6**]. . In the ED initial vital signs were 98.6 101 99/60 16 100% RA. Exam notable for: no asterixis, mildly distended abdomen. Labs were notable for: Sodium of 113 and chloride of 81. WBC 20.9, U/A negative. T. Bili 12.2. Paracentesis done and showed 2550 WBC with polys pending. Patient was given one dose of ceftriaxone and 1L NS with 50g albumin and admitted to the ICU for hyponatremia. CXR PA and Lat was unremarkable. Vs on transfer: 99.6 86 108/68 16 100% RA. . Review of Systems: (+) Per HPI (-) Review of Systems: GEN: No fever, chills, night sweats, HEENT: No headache, sinus tenderness, rhinorrhea or congestion. CV: No chest pain or tightness, palpitations. PULM: No cough, shortness of breath, or wheezing. GI: No nausea, vomiting, diarrhea, constipation. No recent change in bowel habits, no hematochezia or melena. GUI: No dysuria or change in bladder habits. DERM: No bruising. NEURO: No numbness/tingling in extremities. Past Medical History: -Alcoholic and hepatitis C cirrhosis. She has decompensation with jaundice and ascites. She has no esophageal varices and no history of encephalopathy. - Hepatitis C virus, genotype 1, viral load 70,000. - Alcohol abuse. - Severe esophagitis. - Portal hypertensive gastropathy. - Klebsiella Bacteremia in the setting of acute hepatic decompensation Social History: Previously lived in VT, recently moved to St. [**Doctor Last Name **]. Family in [**State 350**]. Patient reports cocaine use >20 years ago. She denies tobacco. Per report she was drinking 1-2 drinks 4 times a week up until 3 months ago and has been sober since then Family History: Renal failure [**3-7**] NSAIDS in mother, HTN in multiple family members; no liver disease Physical Exam: VS: T:afebrile P: 90 BP:112/63 R: 18 100% on RA on room air GEN: cachetic, jaundiced woman, AOx3, NAD HEENT: MM dry, no JVD, no cervical, supraclavicular, or axillary LAD Cards: RR no murmurs/gallops/rubs Pulm: CTAB except decreased BS at base. Abd: Distended but soft, NT, no rebound/guarding, Limbs: No LE edema, no tremors or asterixis Skin: No rashes, mild bruising on arms appear old Neuro: CNs II-XII intact. 5/5 strength in U/L extremities. sensation intact to LT, cerebellar fxn intact (FTN, HTS). Pertinent Results: [**2187-5-30**] 12:00PM BLOOD WBC-20.9*# RBC-2.38* Hgb-9.4* Hct-25.8* MCV-109* MCH-39.4* MCHC-36.3* RDW-14.9 Plt Ct-101*# [**2187-6-2**] 05:10AM BLOOD WBC-6.8 RBC-2.16* Hgb-8.2* Hct-22.0* MCV-102* MCH-37.9* MCHC-37.2* RDW-16.9* Plt Ct-72* [**2187-5-30**] 12:00PM BLOOD Neuts-85* Bands-1 Lymphs-9* Monos-5 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 [**2187-5-30**] 05:43PM BLOOD Neuts-85.7* Lymphs-8.9* Monos-4.7 Eos-0.6 Baso-0.2 [**2187-5-30**] 12:00PM BLOOD PT-19.7* PTT-32.7 INR(PT)-1.8* [**2187-6-2**] 05:10AM BLOOD PT-21.9* PTT-107.3* INR(PT)-2.0* [**2187-5-29**] 03:35PM BLOOD UreaN-15 Creat-0.8 Na-115* K-4.4 Cl-78* HCO3-22 AnGap-19 [**2187-6-2**] 05:10AM BLOOD Glucose-83 UreaN-9 Creat-0.5 Na-120* K-4.2 Cl-90* HCO3-25 AnGap-9 [**2187-5-30**] 12:00PM BLOOD ALT-45* AST-116* LD(LDH)-691* AlkPhos-116* TotBili-12.4* [**2187-6-2**] 05:10AM BLOOD ALT-27 AST-42* LD(LDH)-179 AlkPhos-94 TotBili-7.1* [**2187-5-30**] 12:00PM BLOOD Albumin-3.1* Calcium-8.8 Phos-3.8 Mg-1.9 [**2187-6-2**] 05:10AM BLOOD Albumin-3.6 Calcium-8.5 Phos-2.2* Mg-1.9 [**2187-5-29**] 03:35PM BLOOD AFP-8.5 [**2187-5-30**] 12:00PM BLOOD ASA-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2187-5-30**] 05:43PM BLOOD Ethanol-NEG [**2187-5-30**] 12:02PM BLOOD Glucose-149* Na-115* K-4.7 Cl-81* calHCO3-39* . [**2187-5-30**] 02:09PM ASCITES WBC-2550* RBC-250* Polys-82* Lymphs-2* Monos-13* Mesothe-1* Other-2* [**2187-6-2**] 02:28PM ASCITES WBC-80* RBC-365* Polys-9* Lymphs-11* Monos-0 Mesothe-2* Macroph-78* [**2187-5-30**] 02:09PM ASCITES TotPro-1.8 Glucose-148 LD(LDH)-99 Albumin-0.8 [**2187-6-2**] 02:28PM ASCITES TotPro-2.6 Glucose-156 Creat-0.3 LD(LDH)-119 Amylase-34 TotBili-3.8 Albumin-1.6 Brief Hospital Course: Ms. [**Known lastname **] was a 57 year-old woman with HCV and alcoholic cirrhosis who was admitted from home after being found to have profound hyponatremia. On admission she was found to have spontaneous bacterial peritonitis and received appropriate therapy with resolution. Hyponatremia: It is likely that her SBP and dietary indiscretions contributed to her worsened hyponatremia. She initially received fluid resuscitation and suspension of her diuretics with some improvement from 113 to 118. Subsequently she was placed on a 1L fluid restriction with continued resolution of her serum sodium to 123. It is also likely that treatment of her SBP further contributed to improved serum sodium. She was discharged on a 1L fluid restriction and a reduced dose of her diuretic regimen. She will have her sodium level checked on [**2187-6-5**]. . # SBP: She presented with no abdominal pain, but met criteria for SBP by paracentesis with >250 PMNs. She was treated for 5 days with IV Ceftriaxone with appropriate albumin given on day 1 and 3 ([**5-30**] and [**6-1**]). She also received a therapeutic paracentesis of 4.5 on [**6-2**] and received appropriate albumin protection following paracentesis. Analysis of peritoneal fluid revealed resolution of SBP with 8 PMNs. She was discharged on cipro daily for SBP prophylaxis . # Anemia: She has a known baseline Hct of 22-24 and presented with a Hct of 20. She received 1 unit of PRBC and subsequently remained with a stable Hct of 22 throughout her hospitalization. . # Alcoholic/Hep Cirrhosis: It was likely that her SBP causing decompensation of her LFTs which were subsequently observed to improve following SBP treatment. Medications on Admission: MVI daily Vitamin D on Sundays Lasix 80 Spironolactone 200 Discharge Medications: 1. Vitamin D Oral 2. multivitamin Oral 3. spironolactone 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 4. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 5. Cipro 250 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Hyponatremia Spontaneous Bacterial Peritonitis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Ms. [**Known lastname **], You were admitted to the hospital for low sodium. You were evaluated and treated by the medicine service. You were found to have an infection in your belly fluid and your received antibiotics. You also received removal of this fluid from your belly, which showed that the infection had been treated. By limiting your liquid intake your sodium level improved. Please continue to observe a 1 liter liquid intake restriction. Please take your medications as prescribed and keep your outpatient appointments. . The following changes have been made to your home medication: 1. Your Lasix has been DECREASED to 20 mg daily 2. Your Spronolactone has been DECREASED to 100 mg daily 3. You were STARTED on Cipro 250 mg daily . No other changes have been made to your home medications. Followup Instructions: Please come to the [**Hospital1 18**] lab on Tuesday for a blood draw. Please call [**Telephone/Fax (1) 2422**] to set up an appointment with Dr. [**Last Name (STitle) **] for within the next 2 weeks. Your current appointment is as follows: Department: LIVER CENTER When: FRIDAY [**2187-8-31**] at 11:40 AM With: [**First Name11 (Name Pattern1) 640**] [**Last Name (NamePattern4) **], MD [**Telephone/Fax (1) 2422**] Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) 858**] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage Please follow up with your primary care doctor, Dr. [**Last Name (STitle) 92938**], as previously scheduled. Phone: [**Telephone/Fax (1) 92939**].

[ "789.59", "567.23", "285.9", "782.4", "571.5", "537.89", "276.1", "572.3", "305.03", "571.2", "070.54" ]

icd9cm

[ [ [] ] ]

[ "54.91" ]

icd9pcs

[ [ [] ] ]

7384, 7390

5239, 6920

351, 376

7481, 7481

3545, 5216

8460, 9196

2904, 2996

7029, 7361

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3011, 3526

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265, 313

405, 1756

7496, 7608

2248, 2601

2617, 2888

75,655

116,866

50276

Discharge summary

report

Admission Date: [**2142-1-13**] Discharge Date: [**2142-1-15**] Date of Birth: [**2067-3-17**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 4760**] Chief Complaint: Bleeding from mouth/nose Major Surgical or Invasive Procedure: Nasal packing placement NGT placement Transfusion of blood products History of Present Illness: Mr. [**Known lastname 21006**] is a Spanish-speaking 74 yoM (son is translating in the [**Name (NI) **]) with a h/o CAD (s/p stent [**12-18**]), CVA, GERD and asthma who presented to the ED from home with 2+ hours of "spitting up" blood. Per patient and family, this was not [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 104845**] or hemoptysis, but rather blood in the OP. He denied emesis, cough, ENT pain, abd/chest pain, melena/brbpr and SOB. . In the ED, VS were T 99.2, P 79, BP 176/76, RR 14, 99% RA. NG tube was attempted to be placed twice w/o success; thus, NG lavage was not performed. He was noted to have bleeding from his NP and the right nares was packed (around 5 pm pm on [**2142-1-13**]). By 8 pm, the packing had been soaked through; the patient was then given affrin and a balloon was put in place to tamponade the bleed. Hct was 32.9 on admission with a baseline in low 40's as of [**10-18**] (MCV unchanged). Given he was not tachycardic or orthostatic, he did not receive an RBC transfusion in the ED. . Of note, the patient is on warfarin for stroke/TIA (?); ED notes say had a DVT in RLE one month ago and has been on Coumadin since that time, though has older rxn in OMR. His INR was noted to be 14.1 on admission. He was given 10 mg IV Vit K; two units of FFP have been ordered but not yet administered. The ED staff also spoke with the cards fellow given the recent stent placement (in right ? LE artery for PVD); they advised to keep on ASA and plavix currently. . ENT saw him in the ED and did a flex scope and standard anterior rhinoscopy. They noted several areas of oozing along the septum bilaterally w/o a clear single, brisk source. Gauze soaked in bacitracin was placed in the right nares. Left nares was packed with gelfoam and surgicell packing. Oral cavity clear. . The ED staff spoke with the GI fellow, who is deferring EGD tonight and is recommending IV PPI overnight. Low suspicion for UGIB. Past Medical History: TIA, on Coumadin Asthma Hyperlipidemia Hypertension Diabetes GERD H/O prostate cancer CAD, s/p MI with LV dysfunction, EF 45-50% PVD s/p CABG x2 in [**2132**] with SVG-PDA occluded s/p RCA stent x 2 (in [**2137**] (?[**2138**]), [**2139**]); with Cypher [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **]/p bilateral renal artery stenting followed by redo left renal artery stent for in-stent restenosis in [**2138-7-11**] H/O right occipital infarct with residual lest sided visual impairment H/O cataract of left eye Macular hole in left eye S/P phacoemulsificatiion, posterior chamber intraocular lens placement, pars plana vitrectomy, membrane peel of left eye Social History: -- He lives with his signficant other [**First Name8 (NamePattern2) 46975**] [**Last Name (NamePattern1) 3234**] ([**Telephone/Fax (1) 104846**]). -- He does not smoke or drink. -- He is retired from maintenance and previously worked as a bricklayer in [**Male First Name (un) 1056**]. -- He emmigrated to the US 35 years ago. Family History: - not contributory Physical Exam: General: well appearing; somewhat restless in bed HEENT: nose packed in ED (did not remove to examine); OP clear w/o evidence of bleeding Lungs: CTA b/l Cardio: III/VI ?SEM, loudest at LUSB; no m.r.g. Abd: soft, NTND, no suprapubic tenderness EXTREMITIES: no edema SKIN: no rashes, no cyanosis NEURO: AA, OX3; CN II - XII in tact Pertinent Results: [**2142-1-13**] 05:15PM BLOOD WBC-14.8*# RBC-4.22* Hgb-11.3* Hct-32.9* MCV-78* MCH-26.8* MCHC-34.4 RDW-14.7 Plt Ct-186 [**2142-1-13**] 05:15PM BLOOD Neuts-87.6* Lymphs-8.9* Monos-2.9 Eos-0.4 Baso-0.2 [**2142-1-13**] 05:15PM BLOOD PT-105.1* PTT-96.9* INR(PT)-14.1* [**2142-1-13**] 05:15PM BLOOD Glucose-221* UreaN-34* Creat-1.5* Na-139 K-4.8 Cl-101 HCO3-32 AnGap-11 [**2142-1-13**] 05:15PM BLOOD ALT-27 AST-28 AlkPhos-141* TotBili-0.4 [**2142-1-14**] 05:02AM BLOOD CK-MB-3 cTropnT-<0.01 [**2142-1-14**] 12:45PM BLOOD CK-MB-3 cTropnT-<0.01 [**2142-1-14**] 05:02AM BLOOD Calcium-8.8 Phos-2.4* Mg-1.9 . ECG: NSR 78, nml axis, first degree AVB, no new ST changes Brief Hospital Course: ASSESSMENT/PLAN: 74 y/o spanish speaking M with h/o PVD s/p stenting of RLE in [**12-18**], CVA, GERD and asthma who presented to the ED with gross epistaxis and hct drop in setting of elevated INR. . #) Epistaxis/Bleed: Initially unknown source, however ENT scoped the patient and visualized bleeding. There were several areas of oozing along the septum bilaterally w/o a clear single, brisk source. Gauze soaked in bacitracin was placed in the right nares. Left nares was packed with gelfoam and surgicell packing. Pt was reversed with Vitamin K and FFP, treated with Keflex and monitored overnight in the ICU. Bleeding was felt to be secondary to extremely supratherapeutic INR. Patient reported taking his coumadin twice a day which likely led to increased levels. Hct decreased from 38 to 29, however it remained stable after packing. He was called out to the floor on the 2nd hospital day and Hct remained stable. His coumadin was held and on the day of discharge INR was 1.2. He will continue Keflex while packing in place and this will remain in for 5 days. He will follow up with Dr. [**Last Name (STitle) **] (ENT) for packing removal. Given recent stent placement he was continued on ASA and plavix. . #) ARF: BUN 34, Cr 1.5 on admission; baseline Cr 1.0-1.1. BUN:Cr ratio suggested pre-renal etiology. Cr returned to baseline with IVF. . #) LEUKOCYTOSIS: WBC was 14 on admission. Patient was afebrile. Felt to be stress response given no localized signs of infection. He was treated with Keflex prophylactically and WBC normalized on day of discharge. . #) CAD/recent stent: The ED staff spoke with the cardiology service given the recent stent placement in RLE; they advised to keep on ASA and plavix. . #) GERD: Initially on protonix [**Hospital1 **] given concern for possible GI source of bleed. This was then stopped and patient was discharged on his usual outpatient ranitidine. . #) DIABETES: Patient is on metformin and NPH as outpatient. His metformin was held while in house. He was placed on a insulin SS while inpatient. He will resume his outpatient regimen on discharge. . #) HYPERLIPIDEMIA: Continued statin. . #) ASTHMA: Continued albuterol and advair. . #) HTN: On amlodipine and lisinopril at home. Antihypertensives were initially held given bleeding. These were restarted at discharge. . #) CODE: full (confirmed with son) . #) COMMUNICATION: son [**Name (NI) **] [**Name (NI) 1071**] [**Telephone/Fax (1) 104847**]; PCP [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 608**] Medications on Admission: Nitroglycerin 0.3 SL prn Aspirin 325mg daily Albuterol IH 2 puff Q6H prn ALbuterol 4mg tab PO Q12 Amlodipine 5mg po daily Albuterol 100mg Daily Atorvastatin 80mg Daily Clonidine 0.1 mg PO BID Advair 100-50 IH [**Hospital1 **] Lisinopril 20mg PO daily Singulair 10mg po Daily Ranitidine 150mg PO daily Iron 325 po Daily Fexofenadine 60mg PO daily Plavix 75 mg Daily Warfarin 5mg PO Daily Insulin NPH 35 units QAM Loratadine 10mg PO daily Discharge Medications: 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) puffs Inhalation every six (6) hours as needed for shortness of breath or wheezing. 3. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO once a day. 4. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Clonidine 0.1 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. Fluticasone-Salmeterol 100-50 mcg/Dose Disk with Device Sig: One (1) puff Inhalation [**Hospital1 **] (2 times a day). 7. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO once a day. 8. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO once a day. 10. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Fexofenadine 60 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Thirty Five (35) units Subcutaneous once a day: please resume your home dose of insulin. 14. Loratadine 10 mg Tablet Sig: One (1) Tablet PO once a day. 15. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q8H (every 8 hours) for 4 days. Disp:*12 Capsule(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: Primary: Epistaxis s/p nasal packing Elevated INR Secondary: Coronary artery disease CVA GERD Asthma Hypertension Diabetes Discharge Condition: Stable, no further bleeding, INR normalized Discharge Instructions: You were admitted to the hospital for bleeding from your nose. This was felt to be due to your coumadin level being too high. You should NOT take your coumadin until your nasal packing is removed and you follow up with Dr. [**Last Name (STitle) **]. Please stop your coumadin. You will need to complete a course of antibiotics to prevent infection at the packing site. You can continue your other medications as prescribed. You should keep your follow up appointments as below. Please avoid straining and bending over to prevent recurrent bleeding. Please call your doctor if you have recurrent bleeding, chest pain, difficulty breathing, high fevers or other concerning symptoms. Followup Instructions: Provider: [**Name10 (NameIs) **] STUDY Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2142-1-25**] 10:30 Provider: [**Name10 (NameIs) **] STUDY Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2142-1-25**] 11:00 Provider: [**Last Name (NamePattern5) 7224**], [**MD Number(3) 1240**]:[**Telephone/Fax (1) 62**] Date/Time:[**2142-1-25**] 1:30 . Please follow up with Dr. [**Last Name (STitle) **] on Thursday, [**1-18**] at 9am to have your packing removed. His office is located at [**Last Name (NamePattern1) 10357**]. ([**Hospital **] medical building) on the [**Location (un) **], suite E. Call [**Telephone/Fax (1) 41**] if you have any questions. . Please follow up with Dr. [**Last Name (STitle) **] in one week.

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icd9cm

[ [ [] ] ]

[ "99.05", "21.01", "99.04", "96.34" ]

icd9pcs

[ [ [] ] ]

8891, 8948

4518, 7116

340, 410

9116, 9162

3836, 4495

9896, 10616

3449, 3470

7604, 8868

8969, 9095

7142, 7581

9186, 9873

3485, 3817

276, 302

438, 2392

2414, 3088

3104, 3433

43,552

186,475

34655

Discharge summary

report

Admission Date: [**2142-8-7**] Discharge Date: [**2142-8-7**] Date of Birth: [**2090-9-5**] Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 5893**] Chief Complaint: Common bile duct stricture Major Surgical or Invasive Procedure: ERCP with biliary stent exchange [**2142-8-7**] History of Present Illness: 51F with h/o CBD stenosis s/p stent placement transferred from OSH for ERCP. Pt initally presented to OSH [**2142-7-15**] c/o 3 weeks of progressive weakness, intermittent vomiting and diarrhea. Labs notable for electrolyte abnormalities, normal, AST/ALT 47/19, elevated alk phos 250, Tbili 1.3, Alb 1.4, lipase 58, amylase 70. Admitted for presumed acute on chronic pancreatitis. Abdominal CT showed diffuse colonic thickening thought secondary to anasarca. Intubated for acute respiratory failure thought secondary to aspiration vs volume overload vs ARDS. Course also complicated by alcohol withdrawal seizures. Acute pancreatitis resolved but LFTs continued to fluctuate, concerning for biliary obstruction. Pt has CBD stent changed q3 months, last 3/[**2141**]. Transferred to [**Hospital1 18**] on vent for ERCP exchange of biliary stent. On arrival to the MICU, patient's VS remained stable. Past Medical History: -Alcoholism -chronic pain syndrome, on Dilaudid -chronic pancreatitis -severe protein calorie malnutrition previously on TPN via Hickman catheter dc/d in [**2140**] due to candidemia -anxiety/depression -DM secondary to pancreatic insufficiency, h/o HONK [**1-/2142**] -LUE DVT [**7-14**] in setting of PICC line -thrombosis of pancreatic SMV and splenic veins -CBD stricture s/p stent placement [**2140**]; stents changed q3 months Social History: Per previous admissions and OSH report: smokes 1ppd. History of etohism with 5-6 rum drinks daily. H/o rehab stay. Lives with husband and two children. Family History: Unable to obtain (pt intubated) Physical Exam: Vitals: 97.7 100/67 P88 R24 General: Intubated, opens eyes to voice HEENT: Sclera anicteric, MMM, small amount of dried blood noted on lips, 1cm laceration noted below lower lip on left side, PERRL Neck: supple, JVP not elevated CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi Abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly, no rebound or guarding GU: foley in place Ext: Warm, well perfused, 2+ pulses Pertinent Results: [**2142-8-7**] 05:26PM TYPE-MIX PO2-41* PCO2-51* PH-7.43 TOTAL CO2-35* BASE XS-7 [**2142-8-7**] 02:30PM GLUCOSE-157* UREA N-24* CREAT-0.2* SODIUM-141 POTASSIUM-3.6 CHLORIDE-99 TOTAL CO2-35* ANION GAP-11 [**2142-8-7**] 02:30PM ALT(SGPT)-212* AST(SGOT)-108* LD(LDH)-218 ALK PHOS-1339* AMYLASE-28 TOT BILI-1.6* [**2142-8-7**] 02:30PM ALBUMIN-4.2 CALCIUM-9.3 PHOSPHATE-3.3 MAGNESIUM-2.1 [**2142-8-7**] 02:30PM WBC-8.8 RBC-2.95*# HGB-9.6*# HCT-28.8*# MCV-98 MCH-32.4* MCHC-33.2 RDW-19.5* [**2142-8-7**] 02:30PM PT-11.1 PTT-31.7 INR(PT)-1.0 Brief Hospital Course: 51F with h/o CBD stenosis s/p stent placement recently admitted to OSH with acute on chronic pancreatitis c/b respiratory failure, transferred to [**Hospital1 18**] for ERCP exchange of biliary stent. Active Issues: #Respiratory failure: Intubated at OSH for acute respiratory failure thought to be due to aspiration vs volume overload vs ARDS in setting of pancreatitis. Ventilator settings on admission were: mode CMV, FiO2 60%, rate 14, tidal volume 400mL and were unchanged at time of transfer. O2 saturation 98-100%. CXR on admission showed appropriate ET tube placement, no signs of infiltrate, effusion or volume overload. Patient remained on ventilator for ERCP. #Biliary obstruction: Pt has h/o severe CBD stenosis with biliary stent; overdue for stent exchange (last changed 3/[**2141**]). LFTs intermittently elevated at OSH this admission. Concern for biliary obstruction given alk phos elevation to 1339. ERCP was performed, during which sludge was extracted from the CBD, the pervious stent was removed and two new biliary stents were placed. Esophageal candidiasis was incidentally noted during the procedure. Patient tolerated the procedure well. A small amount of blood oozing from site of stent placement was noted during ERCP and patient was given 15mcg DDAVP. Patient tolerated procedure well and vital signs remained stable. Pt was transferred back to [**Hospital 1562**] Hospital for continued care. Inactive Issues: #Acute on chronic pancreatitis: Likely secondary to alcohol abuse. Resolved per OSH report. #Abnormal CT abdomen: 'Diffuse intestinal thickening' on OSH CT thought to be likely secondary to anasarca. #DM: Likely secondary to pancreatic insufficiency in the setting of chronic pancreatitis, on glimepiride at home. Admission glucose 157. Sliding scale insulin ordered, none administered prior to transfer. #Cachexia/Malnutrition: Initial albumin 1.4 at OSH, 4.2 on admission after 2 weeks daily albumin at OSH. Initially on TPN, then tube feeds at OSH. Patient was kept NPO for ERCP. Medications on Admission: -Duonebs q6 hours -Ativan 0.25mg IV BID -Insulin Sliding Scale -Lasix 40mg IV BID -Aldactone 50mg PO daily -Lovenox 30mg SC daily -Bacid 1 PO daily Discharge Medications: -Ativan 0.25mg IV BID -Insulin Sliding Scale -Heparin 5000 UNIT SC TID Discharge Disposition: Extended Care Discharge Diagnosis: Common bile duct stricture Esophageal Candidiasis Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Lethargic but arousable. Activity Status: Bedbound. Discharge Instructions: Dear Mrs. [**Known lastname **], You were sent to [**Hospital1 69**] for a procedure called endoscopic retrograde colangiopancreatography (ERCP). During the ERCP, your common bile duct was drained and your biliary stent was replaced with two new stents. You will return to [**Hospital 1562**] Hospital for continuation of your care. Followup Instructions: Follow-up with Gastroenterology for repeat endoscopic retrograde colangiopancreatography (ERCP) in 3 months for biliary stent removal and possible revision. Completed by:[**2142-8-15**]

[ "112.84", "518.81", "576.2", "263.9", "305.1", "577.8", "782.3", "249.00", "799.4", "303.90", "V12.51", "300.4", "287.5" ]

icd9cm

[ [ [] ] ]

[ "97.05", "51.10", "96.71" ]

icd9pcs

[ [ [] ] ]

5444, 5459

3119, 3321

328, 377

5552, 5552

2548, 3096

6050, 6238

1950, 1983

5348, 5421

5480, 5531

5175, 5325

5691, 6027

1998, 2529

262, 290

3336, 4544

405, 1307

4561, 5149

5567, 5667

1329, 1764

1780, 1934

73,118

148,726

51882

Discharge summary

report

Admission Date: [**2197-4-2**] Discharge Date: [**2197-4-11**] Date of Birth: [**2131-7-11**] Sex: M Service: ORTHOPAEDICS Allergies: naproxen / ibuprofen Attending:[**First Name3 (LF) 3190**] Chief Complaint: Lower extremity weakness Major Surgical or Invasive Procedure: Lumbar laminectomy L2-5 History of Present Illness: 65 year old man with a multi year history of chronic back pain. He has been seen recently at [**Hospital1 18**] [**Location (un) 620**] and the [**Hospital1 18**] Spine Program as recently as [**2197-3-30**] where he obtained an MRI of his lumbar spine showing L2-3 lumbar disc herniation causing protrusion into the canal and compressing the Cauda. He had felt relatively well over the subsequent 2 days but awoke this morning with severe right sided lumbar pain. No parasthesias or radiation of the pain. He presented to [**Hospital1 18**] for further evaluation. Of note Patient denies chest pain, shortness of breath, nausea, vomiting. He does endorse new onset urinary retention. Past Medical History: Barretts Esophagus Depression Hypertension Paroxysmal atrial fibrillation Type II Diabetes Mellitus Social History: Activity Level: Community ambulator Mobility Devices: none Occupation: retired Tobacco: denies EtOH: denies Family History: N/C Physical Exam: A&O X 3; NAD RRR CTA B Abd soft NT/ND Vascular Radial DP PT R 2 2 2 L 2 2 2 Sensory UE C5 (Ax) C6 (MC) C7 (Mid finger) C8 (MACN) T1 (MBCN) T2-L2 Trunk R intact intact intact intact intact intact L intact intact intact intact intact intact Sensory LE L2 (Groin) L3 (Leg) L4 (Knee) L5 (Grt Toe) S1 (Sm toe) S2 (Post Thigh) R intact intact intact intact intact intact L intact intact intact intact intact intact Motor UE Deltoid (C5)Ax Biceps (C6)MC WE (C6)R Triceps (C7)R WF (C7)M FF (C8)AIN Fing Abd (T1)U R 5 5 5 5 5 5 5 L 5 5 5 5 5 5 5 Motor LE Add (L2) IP (L3) Quad (L3) Ham (L4) Ant Tib (L4/DP) [**Last Name (un) 938**]/GM (L5/SG) Peroneal (S1/SP) GS (S1-2/T) R 5 5 5 5 5 5 5 5 L 5 5 5 5 5 5 5 5 Reflexes Biceps (C4-5) BR (C5-6) Triceps (C6-7) Patellar (L3-4) Achilles (L5-S1) R 2 2 2 2 2 L 2 2 2 2 2 Straight Leg Raise Test: no pain with elevation of either leg Babinski:down going toes bilaterally Clonus:none Perianal sensation: intact Rectal tone:normal Pertinent Results: [**2197-4-10**] 09:00AM BLOOD WBC-3.9* RBC-3.40* Hgb-10.1* Hct-31.1* MCV-92 MCH-29.8 MCHC-32.6 RDW-13.1 Plt Ct-319 [**2197-4-8**] 06:55AM BLOOD WBC-5.2 RBC-3.04* Hgb-9.1* Hct-27.3* MCV-90 MCH-29.9 MCHC-33.3 RDW-13.0 Plt Ct-260 [**2197-4-6**] 11:49AM BLOOD WBC-6.1 RBC-3.18* Hgb-9.6* Hct-29.2* MCV-92 MCH-30.2 MCHC-32.8 RDW-13.2 Plt Ct-167 [**2197-4-5**] 04:57PM BLOOD WBC-8.1 RBC-3.47* Hgb-10.2* Hct-31.6* MCV-91 MCH-29.5 MCHC-32.5 RDW-13.0 Plt Ct-181 [**2197-4-11**] 05:35AM BLOOD PT-28.5* PTT-39.7* INR(PT)-2.7* [**2197-4-10**] 09:00AM BLOOD PT-26.9* PTT-101.6* INR(PT)-2.6* [**2197-4-10**] 05:20AM BLOOD PT-29.2* PTT-78.1* INR(PT)-2.8* [**2197-4-9**] 03:20PM BLOOD PT-40.3* INR(PT)-4.0* [**2197-4-10**] 05:20AM BLOOD Glucose-107* UreaN-12 Creat-0.9 Na-143 K-3.3 Cl-106 HCO3-26 AnGap-14 [**2197-4-6**] 04:58AM BLOOD Glucose-127* UreaN-11 Creat-1.0 Na-138 K-3.6 Cl-107 HCO3-26 AnGap-9 [**2197-4-5**] 04:57PM BLOOD Glucose-130* UreaN-15 Creat-1.5* Na-140 K-4.2 Cl-108 HCO3-25 AnGap-11 [**2197-4-2**] 07:35PM BLOOD Glucose-134* UreaN-17 Creat-0.9 Na-142 K-3.6 Cl-107 HCO3-24 AnGap-15 [**2197-4-10**] 05:20AM BLOOD Calcium-8.3* Phos-2.3* Mg-2.0 [**2197-4-6**] 12:11AM BLOOD Calcium-7.9* Phos-1.8* Mg-1.8 [**2197-4-4**] 07:13PM BLOOD Calcium-8.5 Phos-3.5 Mg-1.9 Brief Hospital Course: Mr. [**Known lastname **] was admitted to the service of Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 363**] for a lumbar laminectomy. He was informed and consented and elected to proceed. Please see Operative Note for procedure in detail. Post-operatively he was given antibiotics and pain medication. A hemovac drain was placed intra-operatively and this was removed POD 3. On the floor the patient was receiving pain control with epidural through [**4-5**] and was transitioned to PO meds then. He reportedly got 10mg of oxycodone and 0.5mg dilaudid at noon. At approximately 3pm he was sitting in the bedside chair sleeping when a BP check revealed SBP of 60. He was also hypoxic with sats in the low 80s. HR was mid 80s. Per the responding team he was not tachypnic. Temp was 100.9. He was layed supine and bolused 2LNS which improved his BP to 104/80 and a 100% NRB increased his sats to 94%. He was unable to be weaned off the NRB and transferred to the TICU for further care. Spiral CT revealed: 1. Bilateral segmental pulmonary emboli. 2. Mild-to-moderate bibasilar atelectasis with probable superimposed mild consolidation suggestive of infection or aspiration. 3. Probable cholelithiasis. 4. Heterogeneous appearance of the prostate. This could be a normal variant if there are no clinical symptoms for prostatitis. However, if there is a concern for infection in this region, an ultrasound examination can be performed to assess for fluid collections. 5. Post-L2 through L5 laminectomies, with expected neighboring postoperative change. He was started on a heparin drip and subsequently transitioned to coumadin with an every other day dosing of 2.5mg. His bladder catheter was removed POD 3 and his diet was advanced without difficulty. He was able to work with physical therapy for strength and balance. He was discharged in good condition and will follow up in the Orthopaedic Spine clinic. Medications on Admission: Lamotrigine 100 mg tid Seroquel XR 200 mg qd Clonazepam 1 mg [**Hospital1 **] Amlodipine 5 mg qd Lisinopril 30 mg qd Atorvastain 20 mg qd Omeprazole 20 mg [**Hospital1 **] Sumatriptan 25 mg qd 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. quetiapine 200 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily). 4. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. lisinopril 10 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 6. atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. diazepam 5 mg Tablet Sig: 1-2 Tablets PO Q8H (every 8 hours) as needed for muscle spasm. 8. oxycodone 5 mg Capsule Sig: [**12-20**] Capsules PO Q4H (every 4 hours) as needed for pain. 9. clonazepam 1 mg Tablet Sig: 1.5 Tablets PO QHS (once a day (at bedtime)). 10. lamotrigine 100 mg Tablet Sig: Two (2) Tablet PO QAM (once a day (in the morning)). 11. lamotrigine 100 mg Tablet Sig: One (1) Tablet PO QPM (once a day (in the evening)). 12. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1) Capsule, Ext Release 24 hr PO HS (at bedtime). 13. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO BID (2 times a day). 14. warfarin 2.5 mg Tablet Sig: One (1) Tablet PO every other day for 6 months: Last given [**4-10**]. Please skip [**4-11**]. Giving 2.5mg every other day X 6 months. Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2204**] following future dosing. Please draw INR each day for the next week to confirm goal INR 2.0-3.0. Discharge Disposition: Extended Care Facility: [**Hospital3 4103**] on the [**Doctor Last Name **] Discharge Diagnosis: Lumbar stenosis Post-op pulmonary embolis Post-op hypoxia and hypotension Discharge Condition: Good Discharge Instructions: You have undergone the following operation: POSTERIOR Lumbar Decompression Immediately after the operation: -Activity: You should not lift anything greater than 10 lbs for 2 weeks. You will be more comfortable if you do not sit or stand more than ~45 minutes without getting up and walking around. -Rehabilitation/ Physical Therapy: o2-3 times a day you should go for a walk for 15-30 minutes as part of your recovery. You can walk as much as you can tolerate. oLimit any kind of lifting. -Diet: Eat a normal healthy diet. You may have some constipation after surgery. You have been given medication to help with this issue. -Brace: You have been given a brace. This brace is to be worn for comfort when you are walking. You may take it off when sitting in a chair or while lying in bed. -Wound Care: Remove the dressing in 2 days. If the incision is draining cover it with a new sterile dressing. If it is dry then you can leave the incision open to the air. Once the incision is completely dry (usually 2-3 days after the operation) you may take a shower. Do not soak the incision in a bath or pool. If the incision starts draining at anytime after surgery, do not get the incision wet. Cover it with a sterile dressing. Call the office. -You should resume taking your normal home medications. No NSAIDs. -You have also been given Additional Medications to control your pain. Please allow 72 hours for refill of narcotic prescriptions, so please plan ahead. You can either have them mailed to your home or pick them up at the clinic located on [**Hospital Ward Name 23**] 2. We are not allowed to call in or fax narcotic prescriptions (oxycontin, oxycodone, percocet) to your pharmacy. In addition, we are only allowed to write for pain medications for 90 days from the date of surgery. Please call the office if you have a fever>101.5 degrees Fahrenheit and/or drainage from your wound. Physical Therapy: Activity: Out of bed w/ assist LSO for ambulation<br> Treatment Frequency: Please continue to change the dressing daily. Evaulate INR daily. Followup Instructions: With Dr. [**Last Name (STitle) 363**] in 10 days Completed by:[**2197-4-11**]

[ "250.00", "344.60", "584.9", "600.01", "276.51", "401.9", "E878.8", "272.4", "722.73", "530.81", "415.11", "424.0", "427.31", "788.20", "756.12", "530.85", "721.42", "458.29", "311" ]

icd9cm

[ [ [] ] ]

[ "03.90", "80.51", "03.09", "38.91" ]

icd9pcs

[ [ [] ] ]

7344, 7422

3601, 5536

309, 334

7539, 7546

2318, 3578

9677, 9756

1315, 1320

5780, 7321

7443, 7518

5562, 5757

7570, 7647

1335, 2299

9509, 9566

7683, 7876

245, 271

7912, 8379

8391, 9491

362, 1049

9587, 9654

1071, 1173

1189, 1299

8,695

120,293

21566

Discharge summary

report

Admission Date: [**2179-11-16**] Discharge Date: [**2179-11-26**] Date of Birth: [**2105-3-12**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 613**] Chief Complaint: Transfer from [**Hospital6 17032**] for management of sepsis Major Surgical or Invasive Procedure: cardiac catheterization History of Present Illness: The patient is a 74 year old female with a past medical history significant for CAD, CHF (EF 45%), COPD, and who was recently hospitalized at [**Hospital1 18**] from [**2179-10-24**] until [**2179-10-30**] for multiple problems, including MRSA bacteremia complicated by mitral valve endocarditis, right upper lobe pneumonia, and ST elevation myocardial infarction. During her last hospitalization, initial plans for cardiac intervention were deferred due to sepsis, hypotension, and the discovery of high grade MRSA bacteremia. The patient was discharged on [**10-30**] to [**Location (un) **] House rehabilitation facility so that she could complete her six week course of Vancomycin. On [**11-15**], the patient developed shaking chills, fever to 102, and hives while being administered Vancomycin. She also had loose stools for a period of days, and anorexia. She presented to [**Hospital6 17032**] on [**11-15**] for further evaluation. Her hospital course was notable for periods of hypotension (SBP 70-80s), requiring IVF and low dose neosynephrine. The patient was given empiric treatment with Flagyl for C. difficile colitis. She was administered Linezolid instead of Vancomycin for coverage of her MRSA bacteremia. Repeat blood cultures from the outside hospital have grown [**4-18**] gram positive cocci in pairs/clusters, with preliminary ID consistent with Staphylococci. The patient was transferred to the [**Hospital1 18**] MICU for further management of her hypotension and infectious issues. Past Medical History: CAD (anterior-inferior defects noted on previous stress tests), s/p STEMI on [**2179-10-24**]. Plans for cardiac intervention during recent hospitalization were deferred due to sepsis, hypotension, and the discovery of high grade MRSA bacteremia. ECHO disclosed EF 40-45%, and possible RV free wall depression. Peak CK=580, Trop 1.55. Patient is followed by Dr. [**Last Name (STitle) 11493**]. Staph aureus bacteremia, [**10-18**], complicated by mitral valve endocarditis. Patient started on Vancomycin [**2179-10-26**]. Source of MRSA bacteremia not identified, although may have been secondary to MRSA pneumonia (see below). RUL multifocal pneumonia, associated with parapneumonic right pleural effusion, noted on CT chest on [**2179-10-27**]. Attempts to sample this fluid collection were unsuccessful due to its relatively small size. Right hilar lymphadenopathy (2.3 x 2.3 cm right hilar lymph node) noted on [**10-27**] CT chest. 1.6 cm left breast mass Left upper lip basal cell carcinoma CHF (EF=40-45%, 1+ MR [**First Name (Titles) **] [**Last Name (Titles) **] [**2179-10-28**]), COPD Venous thromboembolism- PE. Patient takes Coumadin daily. Hyperthyroidism Hyperlipidemia Obesity Diverticulosis (noted on CT abdomen in [**10-18**]) Social History: The patient lives alone, but was discharged from [**Hospital1 18**] on [**10-30**] to [**Location (un) **] House rehabilatation facility. The patient has two children. The patient has a 20 pack year history of tobacco use. She has a history of occasional ETOH use. No history of illicit drugs. Family History: Non-contributory Physical Exam: Gen: Pleasant elderly female in NAD. VS: T: 99.1 BP: 103/37 HR: 96 RR: 30 O2 Sat: 96% RA HEENT: NC/AT. PERRL. EOMI. Lower teeth absent. No abscesses visualized in oropharynx. MMM. 1 cm raised lesion over L upper lip. Neck: Supple. No cervical LAD. No JVD. No thyromegaly. CVS: II/VI systolic murmur at LLSB. No S3/S4. No rub. Breasts: 1.5 cm mass in L upper breast. No skin lesions or nipple discharge. Lungs: Decreased BS R base. Diffuse expiratory wheezes. Abd: Obese, NT, ND, +BS. Extr: No LE edema. Warm, well-perfused. PICC site in L forearm shows no evidence of erythema or tenderness. No joint tenderness/swelling. No peripheral stigmata of endocarditis. Neuro: AxOx3. CN II-XII grossly intact. Strength 5/5 in upper and lower extremities. No focal neurologic deficits. Pertinent Results: Notable labs from [**Hospital6 17032**]: Blood cultures ([**11-15**]): 4/4 bottles MRSA Urine culture ([**11-15**]): negative to date C diff ([**11-15**]): neg x 1 Chemistries notable for BUN/Cr 38/2.5 ([**11-16**]), Cr 0.7 on [**10-30**] CK=35, Trop=0.25 ([**11-16**]) WBC on ([**11-15**]) elevated at 17.6, with 8 bands, 85 polys INR ([**11-15**]) elevated at 7.5 [**2179-11-16**] 09:40PM WBC-14.2* RBC-3.44* HGB-9.7* HCT-27.5* MCV-80* MCH-28.3 MCHC-35.5* RDW-13.8 [**2179-11-16**] 09:40PM NEUTS-94.7* BANDS-0 LYMPHS-2.8* MONOS-2.4 EOS-0.1 BASOS-0 [**2179-11-16**] 09:40PM PLT COUNT-172 [**2179-11-16**] 09:40PM PT-26.1* PTT-42.3* INR(PT)-4.3 [**2179-11-16**] 09:40PM GLUCOSE-170* UREA N-38* CREAT-1.5* SODIUM-139 POTASSIUM-4.0 CHLORIDE-108 TOTAL CO2-22 ANION GAP-13 [**2179-11-16**] 09:40PM ALT(SGPT)-33 AST(SGOT)-21 CK(CPK)-22* ALK PHOS-89 TOT BILI-0.6 [**2179-11-16**] 09:40PM CK-MB-4 cTropnT-0.06* [**2179-11-16**] 09:40PM ALBUMIN-3.1* CALCIUM-8.3* PHOSPHATE-2.4* MAGNESIUM-1.5* [**2179-11-16**] 11:15PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.020 [**2179-11-16**] 11:15PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-SM [**2179-11-16**] 11:15PM URINE RBC-12* WBC-11* BACTERIA-MANY YEAST-NONE EPI-<1 [**2179-11-16**] 11:15PM URINE EOS-NEGATIVE Blood cx ([**11-16**]) 4/4 bottles w/ MRSA Subsequent blood cx were negative Brief Hospital Course: A/P: 74 year old female with multiple medical problems, including CAD, CHF (EF 45%), and COPD, s/p recent [**Hospital1 18**] hospitalization for MRSA bacteremia complicated by mitral valve endocarditis, right upper lobe pneumonia, and ST elevation myocardial infarction. Patient now transferred from OSH for further evaluation of leukocytosis, acute renal failure, and hypotension requiring neosynephrine/IVF. 1. Sepsis: Pt had been recently discharged from [**Hospital1 18**] with MRSA endocarditis and bacteremia, and prior to this admission it was discovered at the OSH that she continued to have MRSA bacteremia. The day of her transfer to [**Hospital1 18**] she had [**4-18**] blood culture bottles positive for MRSA at the OSH and was started on Linezolid at that institution. Upon arrival to [**Hospital1 18**], the patient was continued on Linezolid, Infectious Disease was consulted and other possible infectious etiologies such as C diff were ruled out. Blood cultures drawn here were also [**4-18**] positive on the day of admit. She was started empirically on Flagyl for a brief course until 3 C diff toxin tests were negative. Her PICC line was thought to be a likely nidus for her continued bacteremia and was d/c'd and cultured, but failed to grow an organism. Her BP was maintained with IVF and Levophed initially, though pressors were quickly weaned off in the first night. ID felt that her continued bacteremia was much more likely due to an absces than to resistance to Vancomycin, and recommended that we search for such a collection. [**Month/Day (4) **] was chosen as the first study, given the pt's h/o endocarditis. The [**Month/Day (4) **] revealed worsening endocarditis as well as a new abscess near the mitral valve. 2. MRSA endocarditis/abscess: [**Month/Day (4) **] revealed MV abscess and worse endocarditis of MV as well as possible involvement of the AV. ID recommended changing from the linezolid back to vanc, but adding daptomycin as well and initially gentamycin. They also recommended getting a head CT to r/o emboli prior to her likely needed surgery for abscess drainage. CT [**Doctor First Name **] was initially recommended cath in prep for surgery given recent STEMI, but then after further review was not convinced that the pt had a true abscess requiring surgery. Eventually they decided to offer the patient the option of surgical repair. The patient initially agreed, but then changed her mind and despite the best efforts of the entire team to explain the situation and the risks of both the surgery and of not having surgery the patient remained adamant that she did not want the surgery. ID recommended 4 weeks of abx to be continued as an outpatient, though it was explained to the patient that this would be unlikely to cure her disease. 2. CAD, s/p STEMI: In prep for her operation, the patient underwent a cardiac cath that revealed 90% stenosis of her LAD. She was intended to have a CABG performed during her MVR and abscess drainage. The cath was complicated by a post-cath R groin hematoma that resolved on its own but required the transfusion of one unit of PRBCs. The patient was started on beta blockers and aspirin once able to tolerate. 3. Acute renal failure: on admission the patient was in ARF, which was determined to be prerenal in origin and which resolved with hydration. 4. Respiratory distress: on the first night of admit, the patient become acutely SOB with RR to the 40s and hypoxic to the 80s. She refused to be intubated, so a BIPAP was placed on to improve her oxygenation, which helped. However, she could not tolerate the mask and refused to wear it thereafter. It was felt that a large part of her distress was secondary to CHF in the setting of her worsening MR [**First Name (Titles) **] [**Last Name (Titles) **]. She responded well to Lasix diuresis, though became SOB on occassion throughout her stay. Each time she did, it was in the setting of either too much fluid or a elevated heart rate and blood pressure. Cardiology recommended beta-blockade and ACEI to reduce afterload, which improved her resp status. 5. Microembolic strokes: in prep for surgery, the pt underwent a head CT to r/o CVAs. She was found to have many small microemboli in her cerebrum and cerebellum, c/w showering from her endocarditis. Given the risk of bleed from these lesions will anticoagulated from heparin on CP bypass, CT [**Doctor First Name **] was reluctant to take her to the OR but eventually agreed. However, as mentioned above, the patient refused [**2-15**] "fear of dying". 5. Supratherapeutic INR: pt had been on coumadin as an outpatient for a h/o PEs, but had not had a recent INR check. Her INR slowly came down as we held her coumadin in house. 6. L breast mass: Patient has never undergone mammography. Will recommend evaluation as outpatient. 7. L upper lip basal cell carcinoma: Patient is followed by Dermatology, and it has been recommended that she have lesion removed. She has cancelled numerous appointments to have the lesion addressed. 8. Code status: Patient was DNR/DNI on arrival, then was made FULL code for Surgery, then back to DNR/DNI after she decided that she no longer wanted to have the surgery. On the final day of hospitalization, the issue of percutaneous intervention of the LAD stenosis was addressed with patient and again, patient refused any further intervention, surgery, catheterization, or otherwise. Following numerous discussions, patient clearly understood the consequences of her decision. She was transferred from the MICU to the medical floor on [**11-25**], transferred to rehab the following day. Medications on Admission: Meds on transfer from OSH: Neosynephrine @ 20 mcg/min Tapazole 10 mg PO qd Vitamin C 500 mg PO qd Zinc Sulfate 220 mg PO qd Flagyl 500 mg PO TID (started [**11-16**]) Linezolid 600 mg PO BID (started [**11-16**]) ASA 325 mg PO qd Plavix 75 mg PO qd Atrovent inh 1 puff q6hrs MVI with Fe 1 tab PO qd Protonix 40 mg PO qd Vitamin K 2 mg administered [**11-15**] Outpatient meds Lisinopril 5 mg PO qd, Atenolol 50 mg PO qd, Coumadin, and Lipitor 80 mg PO qd were held Discharge Medications: 1. Methimazole 10 mg Tablet Sig: One (1) Tablet PO QD (). 2. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Zinc Sulfate 220 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 4. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily). 5. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation QID (4 times a day) as needed for shortness of breath or wheezing. 6. Insulin Regular Human 100 unit/mL Solution Sig: Sliding Scale Injection ASDIR (AS DIRECTED). 7. Ipratropium Bromide 0.02 % Solution Sig: One (1) dose Inhalation Q6H (every 6 hours). 8. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical TID (3 times a day) as needed. 9. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed for fever. 10. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 11. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. 12. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 13. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO TID (3 times a day): Hold for systolic blood pressure less than 100, heart rate less than 60. Disp:*135 Tablet(s)* Refills:*2* 14. Captopril 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day): Hold for systolic blood pressure less than 100. Disp:*90 Tablet(s)* Refills:*2* 15. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): Hold for systolic blood pressure less than 100. Disp:*30 Tablet(s)* Refills:*2* 16. Daptomycin 500 mg Recon Soln Sig: One (1) Recon Soln Intravenous Q24H (every 24 hours). Disp:*28 Recon Soln(s)* Refills:*0* 17. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig: Thirty (30) mg PO once a day. Disp:*900 mg* Refills:*2* Discharge Disposition: Extended Care Facility: [**Hospital3 11496**] - [**Location (un) **] Discharge Diagnosis: Methicillin-resistant Staphylococcus aureus Endocarditis, with 3+ mitral regurgitation Congestive heart failure Coronary artery disease, left anterior descending coronary artery lesion 90% occluded Acute on Chronic renal failure Discharge Condition: Fair - continued episodes of mild pulmonary edema due to valve defect as well as chronic congestive heart failure. Furthermore, non-intervened 90% stenosis of left anterior descending coronary artery per patient's request. Requires 3 liters O2 by nasal cannula. Discharge Instructions: 1. Patient will require IV Daptomycin for four weeks following discharge. This is only temporizing therapy. She needs a f/u echocardiogram in appx 4 weeks to re-evaluate her valves. As she declined surgery, the definitive treatment for her extensive endocarditis, she will likely remain on lifelong antibiotics. - Please be vigilant for the develpment of muscle aches or weakness. - Please check CK once a week. - If renal function declines, please check creatinine clearance for re-adjustment for daptomycin dosing. 2. Continue taking medications as directed. - In addition, hold Lasix for systolic blood pressure <100. - Hold metoprolol for systolic blood pressure <100, or heart rate <60. Followup Instructions: For MRSA endocarditis, patient will require daptomycin therapy for four weeks following discharge. Please follow chemistries and CK weekly while on daptomycin. Dose of daptomycin may require adjustment per renal function. Patient has declined cardiac surgery or percutaneous intervention (and given embolic cerebral infarctions is not a candidate for thrombolysis or anticaogulation) for severe endocarditis and coronary artery disease, therefore fever and unstable angina are to be expected. Please draw cultures should patient become febrile and consider broadening antibiotic coverage. Provider: [**First Name4 (NamePattern1) 8694**] [**Last Name (NamePattern1) 8695**], MD Where: [**Hospital6 29**] Date/Time:[**2179-12-3**] 9:00 [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]

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Discharge summary

report

Admission Date: [**2125-2-20**] Discharge Date: [**2125-3-22**] Date of Birth: [**2042-5-26**] Sex: F Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2836**] Chief Complaint: Respiratory distress Major Surgical or Invasive Procedure: Thoracentesis History of Present Illness: 82 year-old woman with hypothyroidism, obesity, recent admission last month for pneumonia (treated with Vanco and Zosyn), admitted with SOB and hypoxia to 88%. She reports increased new lower extremity edema over the past few days. She denies cough, lightheadeness, nausea, vomiting, fevers, chills, or abdominal pain. Of note, patient was discharged from the [**Hospital1 882**] on [**1-30**] for pneumonia. At this time, her BUN was 11 and Cr 1.1. She completed a course of Vanco and Zosyn on [**2-2**]. While at rehab, she was continued on Lasix 40 mg daily and her Creatinine was noted to steadily rise. On [**2-5**], she was found to be coughing so was started on Avelox (completed [**2-13**]) for empiric PNA treatment. On [**2-8**], Her BUN was 34 and Cr 2.5 and so her lasix was lowered to 20 mg daily. Her lasix was ultimately stopped on [**2-13**] when she was found to have a BUN of 43 and Cr of 3.2. Her WBC was found to be rising on [**2-16**]. At that time, she was noted to have a rash on her back and worsening LE edema. Upon arrival to the ED, her vitals were T 98.1, HR 97, RR 22, 98% on 3LNC (88% on RA), BP 111/79. In the ED, she was hypotensive to the 80s transiently, but responded to IVF boluses. Her CXR was difficult to interpret but showed LLL opacity with effusion and she was treated for PNA with Vanco and Cefepime. Given her elevated LFTs, A RUQ was performed which demonstrated gallstones but could not rule out cholectysitis. She was seen by surgery who felt her presentation was not consistent with cholectysitis (no abdominal pain, fevers) and therefor did not recommend surgical intervention. Past Medical History: - Hypothyroidism - Obesity - Iron deficiency anemia - Thoracic aorta aneurysms - H/o gallstones - H/o pancreatic pseudocysts and radiographic evidence of pancreatitis without clinical symptoms (noted [**2125-1-26**]) - Recent LLL CAP with planned Vanco/Zosyn course to end [**2125-2-2**] - H/o renal failure in [**Month (only) **] due to "accidentally taking too much lasix" Social History: Patient currently residing at rehab facility after hospitalization for PNA. She is married. She denies alcohol or tobacco use. Family History: History of pancreatic cancer in family Physical Exam: Vitals: BP: 135/52 P: 93 R: 20 O2: 98% on 2LNC General: Alert, oriented x 2.5 (knows she is in a hospital, but not the name), not speaking in full sentences but not using accessory muscles HEENT: Sclera anicteric, dry mucous membranes Neck: Supple, JVP not elevated, no LAD Lungs: Diminished breath sounds at the left base, no crackles or wheezes CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: Soft, non-tender, no guarding, bowel sounds present, no rebound tenderness, no organomegaly GU: No foley Ext: Warm, well perfused, 2+ pitting edema bilaterally with increased erythema of left lower leg Skin: Diffuse maculopapular (non-pruritic rash of the trunk and proximal extremities Pertinent Results: [**2125-2-19**] WBC-10.4 RBC-3.19* Hgb-8.4* Hct-26.9* MCV-84 Plt Ct-348 Neuts-81.4* Lymphs-11.4* Monos-3.3 Eos-3.5 Baso-0.4 PT-14.7* PTT-30.8 INR(PT)-1.3* Glucose-112* UreaN-52* Creat-3.0* Na-144 K-3.9 Cl-110* HCO3-21* AnGap-17 ALT-81* AST-88* AlkPhos-139* TotBili-0.4 Lipase-571* proBNP-1308* cTropnT-0.04* Albumin-1.9* Calcium-6.9* Phos-4.7* Mg-2.0 Vanco-22.1* Lactate-0.9 [**2125-2-20**]: UPEP abnormal [**2125-2-21**]: PLEURAL FLUID CYTOLOGY: No malignant cells [**2125-2-23**]: BONE MARROW BIOPSY: PENDING IMAGING: CXR [**2125-2-19**]: 1. Large left lung base opacification, combination of consolidation and large left effusion. 2. Likely small right effusion. 3. Central venous congestion. ABDOMINAL ULTRASOUND [**2125-2-19**]: IMPRESSION: The constellation of cholelithiasis, peri-pancreatic fluid, and lab evidence of pancreatitis is consistent with gallstone pancreatitis. CT ABDOMEN AND PELVIS [**2125-2-20**]: 1. Diffuse enlargement of the pancreas with areas of hypodensity that could represent pseudocysts, although these are not well delineated given lack of IV contrast. Note that a pancreatic mass cannot be excluded. There are several focal fluid collections, likely representing pseudocysts, including within the gastrohepatic ligament, left upper quadrant, and likely splenic subcapsular. There is small abdominal and moderate pelvic ascites. There is apparent thickening of the distal stomach/proximal duodenum, with apparent mass effect from the pancreatic head enlargement. 2. Cholelithiasis. 3. Cecal and proximal ascending colonic thickening, which may be infectious or inflammatory, but ischemia cannot be excluded. 4. Large left pleural effusion and left lower lobe collapse. Small right pleural effusion and compressive atelectasis. ECHO [**2125-2-21**]: No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thickness, cavity size, and global systolic function are normal (LVEF>55%). Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The aortic root is mildly dilated at the sinus level. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. BILATERAL LOWER EXTREMITY DOPPLERS [**2125-2-22**]: 1. Left distal popliteal vein DVT. Left posterior tibial vein showed decreased flow consistent with thrombus. 2. Right and left calf veins not clearly evaluated. Brief Hospital Course: 82 year-old woman presents with gallstone pancreatitis with peripancreatic fluid with concomitant pleural effusion which is likely an extension of abdominal cavity fluid. Other active issues that the patient presented with are acute renal failure, LLE DVT, and abnormal UPEP. hospital course: The patient arrived in respiratory distress and hypoxic [**12-26**] CHF and pleural effusion. A thoracentesis was performed on [**2125-2-21**] and one liter of transudative fluid was aspirated. She was placed on Vanco, Cefepime, and Flagyl to cover both pneumonia and cholangitis. ERCP consult was obtained and deferred EUS or ERCP until clinical status improved. Pancreatitis was treated conservatively. CT scan performed and noted that her CBD was dilated, question if this is post-obstructive changes. Patient also had truncal rash that was non pruritic, drug rash-like, but there is not a clear offending medication. This was followed conservatively. Acute renal failure did not resolve after hydration, renal was consulted and followed noted that this is ATN with uric acid crystals. SPEP noted to have possible polyclonal hypergammaglobulinemia. UPEP showed heavy chain bands, so heme-onc was consulted. LLE DVT found and heparin gtt started. Post-pyloric feeding tube was placed because of pancreatitis. The patient was stable for transfer to the floor. After being transferred to the floor, she became tachypneic, tachycardic with mild hypotension and thus was transferred to the trauma ICU. This was thought to be due to PE for which she was treated with a heparin gtt. She was intubated on [**3-7**] and cardioverted for rapid afib and started on pressors. She remained in the TSICU for the remainder of her stay. She was intubated and sedated. She required pressors for hypotension and amiodarone for paroxysmal afib. She continued to have a significant vent requirement with high peep due to pulmonary edema. She receieved a trach on [**3-15**]. She had a dobhoff tube placed and was fed enterally. She had CVVH until [**3-13**] due to continued renal failure. She was maintained on a heparin gtt for DVT. She got an IVC filter placed on [**3-14**]. She was maintained on multiple abx: aztreonam for pna, flagyl for empiric cdiff, and fluconazole. The patient was relatively stable at the end of her hospitalization, but due to her significant illness and vent dependence and poor prognosis, she made the decision to come off of ventilator support on [**2125-3-21**]. She later died of respiratory arrest early on the morning of [**2125-3-22**]. PROBLEM LIST: #. Gallstone pancreatitis without abdominal pain: Post-pyloric feeding tube removed when patient demonstrated that she could eat orally without problem. ERCP service considered EUS to evaluate the pancreas parenchyma or ERCP to evaluate for retained gallstones but the patient was not clinically stable enough to undergo these procedures. The patient underwent IR placement of pseudocyst drain on [**3-8**] which returned approx 1800cc of fluid. This fluid was sent for culture though nothing grew. #. Shortness of breath [**12-26**] CHF, pleural effusion, and possible pneumonia. On antibiotics for pneumonia. As needed lasix for CHF. S/p 1 liter aspiration of pleural effusion on [**2125-2-21**]. Pleural effusion likely to reaccumulate since thoracentesis. Therapeutic thoracentesis as indicated. Cytology on pleural fluid was negative for malignancy. Patient reintubated on [**3-7**] and ultimately underwent bedside tracheostomy. She was unable to be weaned from the vent. The patient persistently indicated and stated her desire to not be on the vent, even if it meant that she would die from respiratory failure. The patient was deamed competent to make that decision, and the vent was turned off on the night of [**3-21**]. The patient passed away from respiratory failure at 1:40 am on [**3-22**]. #. Acute kidney injury [**12-26**] non-oliguric ATN, likely secondary to pancreatitis. Renal service was consulted. She was started on CVVH in the TSICU due to uremia and acidosis. #. Abnormal UPEP: Heme-onc performed bone marrow biopsy on [**2125-2-23**]. #. LLE DVT: Heparin gtt #. Hypothyroidism: Levothyroxine #. DNR/DNI: Confirmed with the patient and healthcare proxy, [**Name (NI) **] (pt's daughter). After the patient underwent a tracheostomy and was able to communicate, it became apparent that the patient did not wish to continue her life on a ventilator in the ICU. Multiple family meetings were held during which it was decided that the patient was competent to make her own decisions regarding what interventions she wanted. The patient decided that she did not want to be on a ventilator, even if to be off the ventilator would lead to imminent respiratory arrest. On [**2125-3-21**] the patient was made CMO based on her own wishes, and the family was present and agreed. The ventilator was detached on the night of [**2125-3-21**] and the patient soon passed away due to respiratory failure on [**2125-3-22**] at 1:40am. #. Communication: Patient, HCP is [**Name (NI) 122**] [**Name (NI) 86298**] (husband) [**Telephone/Fax (1) 86299**] Daughter: [**Telephone/Fax (1) 86300**] (home) [**Telephone/Fax (1) 86301**] (work) [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]. Family declined autopsy. The surgical team took over patient's care [**2125-3-4**] for further managment of her gallstone pancreatitis. [**3-4**]: She as started on flagyl and continued on vancomycin. Due to a significant luekocytosis stool camples were sent for C difficile. Hepain was continued with a goal of 60-80. Patient's UOP were poor, and she was admist active work up by the nephrology team. [**3-5**] TPN was started, PT was consulted. Patient was noted to be in ATN with nephrology activley following along. Diet was advance to low fat regular diet. [**3-6**] In the Pm of [**3-6**] Patient had preogresive work of breathing. Ecg was performed, ABG, and she was ruled out for MI, CXR. Due to increasing respiratory distress she was transferred to the ICU. A family discussion was had with the decision to possibly recinf patient's DNR order. Foley to gravity, Contineud on heparin. She as made NPO. Patient was intermittantly bolused overnight. [**3-7**]: Patient continued to have worsening acidosis.hypotension responding to volume. New onset rapid afib - became more hypotensive with lopressor. Loaded with amio x 2 to no effect. Worsening hypercarbia (39-55). Family discussion and agreed to allow intubation. Hypotensive post intubation, requiring dual pressors. Post film showing white out of the L lung. Bronchoscopy performed and mucus plugs suctioned. L svc CVL placed. With worsening acidosis and elevated Cr, temp HD line placed in case dialysis. L central aline placed and put on [**Last Name (un) **] monitor. As per renal team held off on on cvvh. Shocked for unstable afib - improved rate control. Patient transiently required dual pressors but levophed was weaned off and she remained on neosynephrine. Improved acidosis while intubated and on bicarb gtt. Resumed hep gtt. [**3-8**]: 600cc fluid from thoracentesis, CT with large pseudocyst surrounding liver, IR placed perc drain, returned 1800 cc fluid. Family informed about the progress. Remains on pressors [**3-10**]: Maintained CVVH and kept I/O even during AM. Transient hypotension SBP 80's, MAP < 60, responding to IVF and albumin. Transfused 1u pRBC for Hct 22. Lactate clearing to 2.2 from 2.6. Able to remove 1L o/n from CVVH and decrease neo requirement overnight. [**3-11**]: Transient hypotension on CVVH, minimal improvement after albumin. Given 1 UpRBC for HC of 23.3. TF held for high residuals despite reglan. KUB obtained with dilated loops-continues to stool, primary team aware. Pt with small amount TF suctioned from mouth, but no further episodes after manual drainage. PICC discontinued and cultured [**3-13**]: Stopped CVVH. Repeat CT scan showing loculated pseudocyst collection to liver and increased in size. Plan for drain in AM. Post-pyloric dobhoff placed. Continued tube feeds and resumed coumadin. [**3-14**]: Perihepatic Perc drain placed by IR-1400 drained, cultures sent. IVC filter placed by IR. Family meeting held-agree to trach [**3-15**]: Percutaenous trachesotomy placed. Right HD catheter removed secondary to contamination, tip sent and blood sent from site, left subclavian discontinued secondary to erthyema. Tip sent and blood culture. Right TLC subclavian resited. Cultures form peritoneal fluid negative, as well as thoracentesis. Luekocystosis presumed to be secondary to h/o PNA during hospitalization, persistent leukocytosis likely from pancreatic and splenic artery compression, also Positive for MM in UPEP/SPEP with s/p bone marrow biopsy indicative of reactive (not malignant) bone marrow [**3-17**]: Petechial rash on forearms-heparin stopped in AM. Started topical hydrocortisone and benadryl. Anticoagulation stopped. [**3-18**]: Derm to eval for skin lesions - biopsied. No recs. Refusing care and frustrated. Ethics cs obtained - family meeting in AM. Pressor dependent, when off, MAP's to 60's. Improving Cr and still making urine. [**3-19**]- alb + lasix. [**3-20**]- rash back from path = leukocytophilic vasculitis, sending vasculitis labs, family mtg held with ethics, no conclusion reached. Back on AC overnight for tachypnea [**Date range (1) 72705**] Significant family discussions RE withdrawal of care. On [**3-21**] patient was made CMO and expired shortly thereafter. Medications on Admission: Levothyroxine 175 mg daily Albuterol/Atrovent PRN Lactobacillus 1 tab [**Hospital1 **] Lovenox 30 mg daily Tylenol prn Milk of magnesia 30 mg PO prn Anatic gel prn GI upset Bisacodyl 10 mg prn Lasix 40 mg daily (stopped [**2125-2-8**]) Discharge Medications: None Discharge Disposition: Expired Discharge Diagnosis: pancreatitis with multiorgan failure respiratory arrest Discharge Condition: na Discharge Instructions: na Followup Instructions: na Completed by:[**2125-3-29**]

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icd9cm

[ [ [] ] ]

[ "96.04", "54.91", "38.95", "33.24", "34.91", "38.7", "99.15", "86.11", "38.93", "96.6", "31.1", "41.31", "39.95", "52.01", "96.72" ]

icd9pcs

[ [ [] ] ]

16037, 16046

6161, 6438

335, 350

16146, 16151

3371, 6138

16202, 16236

2582, 2622

16008, 16014

16067, 16125

15748, 15985

6455, 8735

16175, 16179

2637, 3352

275, 297

378, 2022

8749, 15722

2044, 2420

2436, 2566

46,411

114,901

40234

Discharge summary

report

Admission Date: [**2156-12-20**] Discharge Date: [**2156-12-23**] Date of Birth: [**2108-3-22**] Sex: M Service: MEDICINE Allergies: All allergies / adverse drug reactions previously recorded have been deleted Attending:[**First Name3 (LF) 3984**] Chief Complaint: Hypoxemia. Major Surgical or Invasive Procedure: Thoracentesis. History of Present Illness: Mr. [**Known lastname 88321**] is a 48 year old gentleman with a PMH significant for HCV cirrhosis and a recent admission for a traumatic fall with multiple IPH requiring bolt placement, multiple orthopedic fractures s/p surgeries, trach/PEG with hospital course complicated by Serratia pneumonia treated with pip/tazo now admitted for hypoxemia. The patient was admitted to [**Hospital1 18**] from [**Date range (1) 88322**] after a 30 foot fall from height with multiple IPH s/p intracranial bolt placement for elevated ICP, multiple orthopedic fractures requiring surgical intervention, splenectomy, and trach/PEG. He was noted to develop a VAP that speciated as pan-sensitive Serratia and he completed a course of pip/tazo, and also had a right-sided pneumothorax requiring chest tube placement. Per report, the patient was noted at rehab to have been progressively hypoxemic over the past 2 days with a outpatient CXR concerning for right-sided pneumonia. He did not have increased sputum production or fevers. He was then sent to the [**Hospital1 18**] ED for further evaluation. In the [**Hospital1 18**] ED, initial VS 98.1 62 92/54 18 95% 40% FM. CXR notable for right-sided complete opacification, for which the patient received vanco and pip/tazo. He was placed on volume cycled assist control, and was sent for a CT chest to rule out diaphragmatic rupture. While at CT, he received 5 haldol iv and 2 iv ativan for agitation, after which he was arousable to stimulation. He was then transferred to the [**Hospital Unit Name 153**] for further management. Currently, the patient is on mechanical ventilation, minimally responsive to verbal stimuli. ROS: Limited given somnolence. Past Medical History: Admitted [**Date range (1) 88323**] for 30 foot fall from roof. Multiple IPH(multiple intraparenchymal petechial, hemorrhages at [**Doctor Last Name 352**]-white matter junction, as well as involving the right mid brain, consistent with diffuse axonal injury), facial fractures, bilateral arm fractures as well as right knee fracture. Underwent splenectomy, multiple orthopedic surgeries. - Surgeries [**11-18**] -> ex-lap with splenectomy - Bolt placed on [**11-19**] - Trach/PEG on [**11-24**] - Facial ORIF on [**12-1**] - IVC filter placed [**12-7**] - HCAP treated with vanco and pip/tazo, speciated as pan-sensitive Serratia. - No evidence of seizure activity during admission, EEG demonstrating encephalopathy. Arousable to voice and stimulation with opening of eyes and localization to voice. Intermitently follows commands. - Discharged on 35% trach collar. - Received all appropriate vaccinations Social History: Worked as a roofer. Drinks 6-12 pack of beer daily, quit smoking recently. Family History: Non-contributory. Physical Exam: VS: 97.5 62 97/66 14 95% AC 550x14, 5, 50%. Gen: Vented. HEENT: Pupils 2->1 mm bilaterally. Sclerae anicteric. MM dry. CV: Nl S1+S2 Pulm: Bronchial breath sounds on right, rhonchorous on left anteriorly. Abd: Midline incision healing, no signs of surrounding erythema. G-tube in place. +bs. Ext: Right arm, right knee/RLE, LLE in braces. No c/c/e. Neuro: Opens eyes to verbal stimuli, not following commands. Pertinent Results: Labs at Admission: [**2156-12-20**] 03:30PM BLOOD WBC-15.8* RBC-3.46* Hgb-11.4* Hct-35.7* MCV-103* MCH-33.0* MCHC-32.0 RDW-15.8* Plt Ct-278 [**2156-12-20**] 03:30PM BLOOD Neuts-56.4 Lymphs-28.2 Monos-5.9 Eos-8.6* Baso-0.9 [**2156-12-20**] 03:30PM BLOOD PT-13.4 PTT-35.9* INR(PT)-1.1 [**2156-12-20**] 03:30PM BLOOD Glucose-93 UreaN-17 Creat-0.6 Na-132* K-7.8* Cl-100 HCO3-26 AnGap-14 [**2156-12-20**] 03:30PM BLOOD ALT-51* AST-139* LD(LDH)-646* AlkPhos-174* TotBili-0.4 [**2156-12-20**] 10:16PM BLOOD Calcium-8.6 Phos-3.9 Mg-2.0 [**2156-12-20**] 03:30PM BLOOD Albumin-2.7* [**2156-12-20**] 10:16PM BLOOD VitB12-1546* Folate-GREATER TH [**2156-12-20**] 03:40PM BLOOD Glucose-92 Lactate-1.3 Na-134* K-7.7* Cl-96* calHCO3-30 [**2156-12-20**] 09:57PM BLOOD Lactate-1.2 Labs at Discharge: [**2156-12-23**] 06:04AM BLOOD WBC-14.3* RBC-3.66* Hgb-11.7* Hct-37.6* MCV-103* MCH-32.1* MCHC-31.3 RDW-15.0 Plt Ct-316 [**2156-12-23**] 06:04AM BLOOD Neuts-51.9 Lymphs-29.0 Monos-8.5 Eos-9.8* Baso-0.8 [**2156-12-23**] 06:04AM BLOOD Glucose-122* UreaN-11 Creat-0.7 Na-141 K-4.1 Cl-104 HCO3-29 AnGap-12 [**2156-12-22**] 04:40AM BLOOD ALT-53* AST-100* LD(LDH)-242 AlkPhos-198* TotBili-0.5 [**2156-12-23**] 06:04AM BLOOD Calcium-8.9 Phos-2.7# Mg-2.0 Pleural Fluid Analysis: [**2156-12-21**] 5:37 pm PLEURAL FLUID GRAM STAIN (Final [**2156-12-21**]): NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. FLUID CULTURE (Preliminary): NO GROWTH. ANAEROBIC CULTURE (Preliminary): NO GROWTH. ACID FAST SMEAR (Final [**2156-12-22**]): NO ACID FAST BACILLI SEEN ON DIRECT SMEAR. ACID FAST CULTURE (Preliminary): PLEURAL ANALYSIS WBC RBC Polys Lymphs Monos Eos Meso Macro [**2156-12-21**] 17:37 850* [**Numeric Identifier 3652**]* 21* 17* 3* 56* 2* 1* PLEURAL CHEMISTRY TotProt Glucose LD(LDH) Cholest Triglyc [**2156-12-21**] 17:37 4.6 82 272 61 39 OTHER BODY FLUID pH [**2156-12-21**] 18:04 7.39 Pleural Fluid: NEGATIVE FOR MALIGNANT CELLS. Mesothelial cells, histiocytes, lymphocytes, and neutrophils. Imaging Studies: Chest CT without contrast ([**2156-12-20**]): 1. No evidence of diaphragmatic hernia. 2. Large right and moderate left simple pleural effusions. Consolidation and volume loss in the lower lobes bilaterally, right greater than left, may represent atelectasis however, aspiration or superimposed infection cannot entirely be excluded. 3. Healing rib and clavicle fractures, as described above. 4. No pneumothorax. Chest x-ray ([**2156-12-21**]): In comparison with the earlier study of this date, there has been removal of a substantial amount of right pleural effusion with a small residual. No evidence of pneumothorax. Tracheostomy tube remains in place and there is again evidence of volume loss at the left base. Transthoracic echocardiogram ([**2156-12-21**]: The left atrium and right atrium are normal in cavity size. There is mild symmetric left ventricular hypertrophy with normal cavity size and global systolic function (LVEF>55%). Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Right ventricular chamber size and free wall motion are normal. The aortic root is mildly dilated at the sinus level. The ascending aorta is mildly dilated. The aortic valve appears bicuspid with mildly thickened leaflets, eccentric closure point and fused right and left raphe. A gradient could not be assessed, but there does not appear to be significant aortic valve stenosis. No aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. The estimated pulmonary artery systolic pressure is normal. There is an anterior space which most likely represents a prominent fat pad. IMPRESSION: Probable bicuspid aortic valve with fused right/left raphe and no significant stenosis or regurgitation. Dilated ascending aorta. Mild symmetric left ventricular hypertrophy with preserved global biventricular systolic function. If there is a clinical suspicion for an aortic dissection - a thoracic CT/MRI or TEE are suggested. Brief Hospital Course: Mr. [**Known lastname 88321**] is a 48 year old gentleman with a PMH significant for HCV cirrhosis and a recent admission for a traumatic fall with multiple IPH requiring bolt placement, multiple orthopedic fractures s/p surgeries, trach/PEG with hospital course complicated by Serratia pneumonia treated with pip/tazo now admitted for hypoxemia. # Hypoxemia/leukocytosis: CTAP demonstrates a new right-sided pleural effusion with RLL collapse and volume loss throughout right side. Compressive atelectasis was considered, although could not rule out HCAP. With regard to new pleural effusion, LFTs were largely unchanged from prior, making hepatic hydrothorax unlikely. This may be a parapneumonic effusion with underlying pneumonia, or could also be from new heart failure. Would also consider chylothorax given history of trauma. The patient underwent thoracentesis on the first hospital day and 1.2 liters of exudative fluid were removed from the right pleural space. Cultures from the fluid came back negative, and the antibiotics were stopped. Trauma surgery was consulted who felt that the pleural fluid might be secondary to trauma. They recommended for repeat imaging in [**2-4**] days to see if the fluid was reaccumulating. Also, they recommended for repeat imaging if the patient develops any new respiratory symptoms. Interestingly, the fluid from the thoracentesis had an eosinophilic predominance (56% eosinophils). At the same time, the patient was noted to have a peripheral blood eosinophilia. This was all felt to be secondary to Depakote, which had been recently started. The divalproex was therefore stopped. Notably, after the thoracentesis, the patient's respiratory status improved markedly and he was able to be weaned back to the trach mask. With regard to work-up for other causes of pleural effusion, a transthoracic echocardiogram did not show any cardiac dysfunction, and infectious studies, as above, all returned negative. Cytologic analysis showed no malignant cells. Antibiotics were stopped after the first hospital day. Due to the calficifications noted on CT scan, a tuberculin skin test was placed to the right forearm on [**12-22**]. This should be interpreted on [**12-24**] or [**12-25**]. The spot of the PPD placement is marked with a bandaid. # Mental status: His mental status remained at baseline, per family members and rehab facility notes. He was agitated and minimally interactive. He required prn doses of Haldol and Ativan for agitation. With regard to the history of traumatic brain injury, neurosurgery was consulted during this admission and did not feel there was any need for intervention. Head CT was deferred. He was continued on Keppra for seizure prophylaxis. Divalproex, as above, was stopped due to peripheral blood and pleural fluid eosinophilia. # Anemia: Hematocrit was 35.8 on admission, baseline during last admission 27-33 with macrocytosis. His hematocrit remained stable. # Orthopedics: Orthopedics was contact[**Name (NI) **] during this admission. Follow-up plans are outlined in the discharge orders. # HCV cirrhosis: LFTs were at baseline. # Depression: Continue home psychotropic regimen. # Ulcerative colitis: Not currently treated. # Nutrition: pnt recieved TF's FEN: TF. . # PPx: recieved Heparin SQ. . # Access: Double lumen PICC in LAC; this was removed during the admission as patient was no longer needing antibiotics or continuous intravenous medicines. . # Code: Confirmed FULL [**Telephone/Fax (1) 88324**]. . # Contact: [**Name (NI) **] [**Name (NI) 88325**] (Sister). # Dispo: ICU level of care, transferred back to rehab after the thoracentesis and improvement in respiratory status. Medications on Admission: Albuterol nebs Dulcolax Chlorhexidine QID citalopram 20 mg qam Clonidine 0.1 mg Q12H. Clotrimazole topical tid divalproex sprinkles 250 Q8H Erythromycin eye ointment QID Famotidine 20 mg [**Hospital1 **] Ferrous sulfate 300 mg QAM Folate Heparin SQ Levetiracetam 1000 mg Q12H Methadone 5 mg Q8H MVI Quetiapine 25 mg QAM, 50 mg QPM Thiamine Trazodone 50 mg qhs APAP prn Ativan 0.5 mg prn quetiapine 25 mg Q6H prn Discharge Medications: 1. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for Constipation. Tablet, Delayed Release (E.C.)(s) 2. senna 8.6 mg Tablet Sig: 1-2 Tablets 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 90 mcg/Actuation HFA Aerosol Inhaler Sig: Four (4) Puff Inhalation Q6H (every 6 hours) as needed for wheezing. 5. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. levetiracetam 100 mg/mL Solution Sig: Ten (10) PO BID (2 times a day): 1000 mg PO BID. 8. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain or fever. 10. quetiapine 25 mg Tablet Sig: Two (2) Tablet PO QHS (once a day (at bedtime)). 11. quetiapine 25 mg Tablet Sig: One (1) Tablet PO QAM (once a day (in the morning)). 12. quetiapine 25 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for Agitation. 13. trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 14. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 15. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for anxiety or agitaiton. 16. methadone 5 mg Tablet Sig: One (1) Tablet PO every eight (8) hours: Hold for sedation/ RR<10. 17. ferrous sulfate 300 mg (60 mg Iron) Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Extended Care Facility: [**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**] Discharge Diagnosis: Primary: Drug induced pulmonary infusion Secondary: Traumatic brain injury secondary to mechanical fall Mutliple skeletal fractures secondary to mechanical fall Hepatitis C Virus Cirrhosis Depression Alcoholic Cirrhosis with history of withdrawal Ulcerative colitis Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Lethargic but arousable. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: You were admitted to the hospital due to worsening shortness of breath. You came to the hospital and had a chest xray which showed an accumulation of fluid around the right lung. The fluid around your lung was drained, and your shortness of breath improved. We felt the fluid accumulation was due to the new medication you started called "Depakaote". As a result, we discontinued this medication. You should follow up with your psychiatrist to make sure your medications are appropriately controlling your agitation. CHANGES TO YOUR MEDICATIONS: DEPAKOTE---> STOP TAKING THIS MEDICATION Followup Instructions: Please follow up at the [**Hospital1 18**] orthopedic hand clinic within 2 weeks by Tuesday [**2157-1-4**]. Please call to confimr appointment. Hand Clinic - Dr. [**First Name8 (NamePattern2) 951**] [**Last Name (NamePattern1) **] Department: Orthopedics Location: [**Hospital Ward Name 23**] 2 [**Hospital1 18**] Phone: ([**Telephone/Fax (1) 32269**] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**] MD [**MD Number(1) 2438**] Completed by:[**2156-12-23**]

[ "E929.3", "307.9", "780.09", "V54.19", "070.70", "571.2", "799.02", "511.89", "303.91", "V54.16", "V44.1", "288.3", "348.30", "V55.0", "304.81", "907.0", "V15.82", "V54.10", "518.83", "E936.3", "571.5" ]

icd9cm

[ [ [] ] ]

[ "96.71", "34.91", "96.6" ]

icd9pcs

[ [ [] ] ]

13439, 13536

7697, 9990

350, 366

13847, 13847

3589, 4355

14648, 15160

3126, 3145

11843, 13416

13557, 13826

11407, 11820

14031, 14553

3160, 3570

5233, 5645

14582, 14625

300, 312

4375, 5006

394, 2088

5089, 5199

13862, 14007

2110, 3018

3034, 3110

5038, 5053

5663, 7674

25,256

179,672

12437

Discharge summary

report

Admission Date: [**2162-5-25**] Discharge Date: [**2162-6-3**] Date of Birth: [**2123-3-28**] Sex: M Service: EMERGENCY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2565**] Chief Complaint: Fevers Major Surgical or Invasive Procedure: [**Last Name (un) 1372**]-intestinal feeding tube placement History of Present Illness: Mr. [**Known lastname 38598**] is a 39 year old patient with NHL s/p alloSCT [**2155**] and DLI [**2156**], in remission but with GVHD-associated bronchiolitis obliterans and severe restrictive lung disease who was recently admitted with fever, hypoxia and respiratory distress and discharged to [**Hospital1 **] on [**2162-5-19**]. He is now being readmitted from [**Hospital1 **] with low grade fevers for the past three days and a fever today to 101.2 in the setting of missing IV Colistin. . The patient had a prolonged hospital admission last month for pneumonia with multiple strains of highly resistant, elevated LFTs, and Left brachial DVT (for which systemic anticoagulation was not given for concern of recent GI bleed). His prednisone was increased during this admission for concern of GVHD but then subsequently tapered back to his prior dosage of 15mg QD. ID started him on both inhaled and intravenous colistin in addition to amikacin and he became afebrile with improved WBC count on this regimen. He was supposed to continue this until [**5-26**]. He was discharged to [**Hospital3 **] on [**2162-5-19**]. Over the last week at his rehab facility he was not continued on the IV Colistin for unclear reasons. He did receive INH Colistin, Amikacin, and Trimethoprim/Sulfamethoxazole. . He was noted to develop daily low grade fevers starting [**5-22**] to 100.2. This morning his temp wa 101.2. Otherwise there were no changes in his exam, no altered mental status, no increased coughing or production in sputum, no diarrhea, no urinary incontinence. Over the past week his BP has been 90s to low 100s, RR high 20s to low 30s, HR 95 - 117. The patient's family reportedly were also not happy with his current care at rehab and were wanting him to be admitted. . He went to his previously scheduled clinic visit, where he was evaluated and it was decided he should be admitted for his fevers. Upon arrival to the [**Hospital Unit Name 153**], he was hypertensive and had sinus tachycardia to the 160s. He was agitated with copious green/yellow secretions being suctioned out of his trach. He denied shortness of breath or pain, but was requesting morphine to releive his work of breathing. Past Medical History: Past Oncologic History: - [**4-/2154**] p/w fevers, night sweats, and weight loss in the setting of a left inguinal lymph node. - CT scan: 15x14x10cm mass in the LUQ. - Bx grade II/III follicular lymphoma. - Treated with six cycles of CHOP/Rituxan with good response, but showed evidence for relapse in [**12/2154**] and was treated with MINE chemotherapy for two cycles. - [**3-/2155**]: Underwent stem cell mobilization with Cytoxan followed by autologous stem cell transplant in - [**7-/2155**]: Noted for disease recurrence. He was initially treated with a course of Rituxan without response followed by Zevalin with - [**3-/2156**]: Noted progression of his disease. He was treated with one cycle of [**Hospital1 **] followed by one cycle of ESHAP. - [**2156-7-29**]: Nonmyeloablative allogeneic stem cell transplant with a [**5-30**] HLA-matched unrelated donor with Campath conditioning - Six-month follow-up CT noted for disease progression. - [**1-/2157**]: Received donor lymphocyte infusion in , complicated by acute liver/GI GVHD grade IV, for which [**Known firstname **] required a prolonged hospitalization in the summer of [**2156**]. - Multiple GI bleeds requiring ICU admissions and multiple transfusions and embolization of his bleeding. - Noted to have CNS lesions felt consistent with PTLD and this was treated with a course of Rituxan. No evidence for recurrence of the PTLD. - Acute liver GVHD, on CellCept, prednisone, and photophoresis. - [**2157-12-28**] Photophoresis was d/c'd due to episodes of bacteremia and eventual removal of his apheresis catheter. - [**2158-6-13**] restarted photopheresis on a weekly basis on , but then discontinued this again on [**2158-9-7**] as this was felt not to be making any impact on his liver function tests. - undergone phlebotomy due to iron overload with corresponding drop in his ferritin. He has continued with transient rises in his transaminases and bilirubin and has remained on varying doses of CellCept and prednisone which has been slowly tapered over the time. - [**2160-1-10**] CellCept discontinued. - [**2159-1-19**] admission due to increasing right hip pain. MRI revealed edema and infiltrating process in the psoas muscle bilaterally. After extensive workup, this was felt related to an infection and required several admissions with completion of antibiotics in 03/[**2158**]. - [**7-/2160**]: Last scans showed no evidence for lymphom and he has remained in remission. - [**2160-10-20**]: URI and treatment with course of Levaquin. - [**2160-11-13**] completed a 4 week course of Rituxan to treat his GVHD. -In [**5-/2161**], noted to have tiny echogenic nodule on abdominal [**Year (4 digits) 950**]. MRI of the liver also showed this nodule but was not as concerning on review and he is due to have a repeat MRI imaging in early [**Month (only) **]. -- GI varices and attempts at banding have been unsuccessful due to difficulty with passing the necessary instruments. He has been on a low dose beta blocker as well as simvastatin, which was started on [**2161-7-7**] to help with medical management of his varices. -On [**2161-8-3**], worsening cough and was noted to have a small new pneumothorax in the left apical area. This has essentially resolved over time - Issues with weight loss (followed by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]); multiple tests done with no etiology found; question malabsorption related to GVHD - Has on and off respiratory infections and has been treated with antibiotics (now colistin inhaled and IV) for resistant pseudomonas. Question underlying exacerbations of pulmonary GVHD in setting of his URIs. - Currently receives IVIG every month. . Other Past Medical History: 1. Non-Hodgkin's lymphoma s/p allo SCT 2. Grade 4 Acute GVHD of GI/liver following DLI with GI bleed, chronic transaminitis, portal HTN with esophageal varices (not able to band) 3. History of intracranial lesions felt consistent with PTLD. 4. Extensinve chronic GVHD of lung, liver, skin, mucous membranes. 5. Grade II esophageal varices, intollerant to beta blockade. 6. HSV in nasal washing [**11/2159**](completed course of Valtrex) 7. Hypothyroidism 8. hx of Psoas muscle infection Social History: Smoke: never EtOH: none currently; occassional use prior to NHL dx Drugs: never Born in [**Country **] and moved to the U.S. for college ([**Hospital1 **]). Married in [**2160-8-25**] and lives in [**Location **]. No children. Stays at home and writes (currently writing a book on being diagnosed with cancer at young age). Family History: No lymphoma or other cancers in the family. Father had CAD s/p PCI. Physical Exam: 99.9 157 169/120 96% on ventilator Gen: Cachectic male (appears less so since last admission), +Trach present, + NGT small caliber, distressed due to suctioning of airway HEENT: sclera anicteric CV: Tachycardic, no m/r/g Pulm: coarse breath sounds bilaterally, no wheezes, crackles Abd: soft, NT, ND, bowel sounds present Ext: no peripheral edema Pertinent Results: Microbiology [**2162-5-27**] URINE URINE CULTURE- negative [**2162-5-27**] BLOOD CULTURE Blood Culture, Routine-PENDING [**2162-5-27**] BLOOD CULTURE Blood Culture, Routine-PENDING [**2162-5-27**] STOOL CLOSTRIDIUM DIFFICILE TOXIN A & B TEST- negative [**2162-5-25**] MRSA SCREEN MRSA SCREEN-FINAL INPATIENT [**2162-5-25**] URINE URINE CULTURE-FINAL INPATIENT [**2162-5-25**] BLOOD CULTURE Blood Culture, Routine- negative [**2162-5-25**] 3:56 pm SPUTUM Source: Endotracheal. GRAM STAIN (Final [**2162-5-25**]): >25 PMNs and <10 epithelial cells/100X field. NO MICROORGANISMS SEEN. RESPIRATORY CULTURE (Preliminary): RARE GROWTH Commensal Respiratory Flora. PSEUDOMONAS AERUGINOSA. SPARSE GROWTH. OF TWO COLONIAL MORPHOLOGIES. Colistin SENSITIVITY TESTING REQUESTED BY AMI [**Doctor Last Name **] #[**Numeric Identifier 38652**] [**2162-5-28**]. SENT TO [**Hospital3 **] FOR COLISTIN SENSITIVITY [**2162-5-31**]. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ PSEUDOMONAS AERUGINOSA | AMIKACIN-------------- 16 S CEFEPIME-------------- 8 S CEFTAZIDIME----------- 8 S CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ =>16 R MEROPENEM------------- 4 S PIPERACILLIN/TAZO----- =>128 R TOBRAMYCIN------------ =>16 R . Imaging [**2162-5-25**] ECG Probable sinus tachycardia given patient's age but very rapid rate raises consideration of possible atrial tachycardia. Slight ST-T wave changes are non-specific. Since the previous tracing of [**2162-4-17**] tachycardic rate is faster. Otherwise, probably no significant change . [**2162-5-25**] Chest Xray IMPRESSION: Persistent pulmonary abnormalities with some more prominent patchy infiltrates in the right upper lobe area. Lateral pleural effusion also progressing slightly since next preceding study of [**2162-5-10**]. . [**2162-5-26**] Abdominal [**Month/Day/Year **] IMPRESSION: 1. Collapsed gallbladder with slight wall thickening may be due to third spacing. No stones identified within the gallbladder. No biliary ductal dilatation. 2. Slight increased area of echogenicity within the left lobe of the liver, incompletely characterized. CT could be performed for further evaluation. 3. Small amount of intra-abdominal ascites. 4. Increased echogenicity to the spleen, which appears small . [**2162-5-26**] [**First Name9 (NamePattern2) **] [**Last Name (un) 1372**]-intestinal Tube placement IMPRESSION: Post-pyloric tube placement. . [**2162-5-28**] Lower Extremity Doppler CONCLUSION: There is no [**Month/Day/Year 950**] evidence of deep venous thrombosis of the right lower extremity . [**2162-5-30**] Chest Xray Tracheostomy tube is in standard position. Feeding tube tip is either in the antrum or first portion of the duodenum. Cardiomediastinal contours are normal. Small to moderate bilateral pleural effusions, larger on the left side, are stable. Right upper lobe patchy opacities are unchanged as does bibasilar opacities, greater on the left side. In the bases, the opacities could be a combination of pleural effusion and atelectasis. . [**2162-5-31**] Abdominal [**Month/Day/Year **] IMPRESSION: 1. Stable 1.1 cm hyperechoic focus. This is most consistent with a hemangioma. Differential diagnosis includes focal fatty infiltration. 2. Small amount of ascites and small right pleural effusion unchanged. . [**2162-5-31**] Upper Extremity Doppler IMPRESSION: DVT involving one of the left brachial veins. The extent is unchanged compared to [**2162-5-15**]. . Brief Hospital Course: Mr. [**Known lastname 38598**] is a 39 year old man with NHL, s/p allo [**Known lastname 3242**] complicated by multi-organ GVHD and bronchiolitis obliterans. He is s/p trach and recent hospitalization for multi-drug resistant pseudomonas pneumonia. He presented from [**Hospital3 **] with fever x 3 days. He remains ventilator dependent. # Fever: On admission Mr. [**Known lastname 38598**] had low grade temperatures. He was restarted on the antibiotics that he was discharged on. This included both IV and inhaled colistin. ID was consulted on arrival. He was also continued on acyclovir, Bactrim, voriconazole, and meropenem. He was initially placed on vancomycin, but this was stopped shortly after arrival as there was no evidence of a gram positive infection. His amikacin was stopped on [**2162-5-29**]. Sputum grew pseudomonas strain that was less resistant than his prior pseudomonas. His IV colistin and meropenem were stopped on [**2162-5-31**] and he remained afebrile until discharge. His new antibiotic regimen which should be continued indefinitely includes Colistin 75 mg (inhaled) [**Hospital1 **] MWF, voriconazole 200 mg PO Q 12, acyclovir 400 mg PO Q 12, Bactrim DS 1 tab MWF. He will follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 724**] in [**Last Name (NamePattern1) 3242**]/infectious disease on [**6-29**], at 2 pm([**Hospital Ward Name 23**] 7 [**Hospital Ward Name 3242**]). # Ventilator dependent: Mr. [**Known lastname 38598**] initially had difficulty weaning off of the ventilator for even short periods of time. He was initially kept on pressure support, but then was able to tolerate trach collar for small periods of time a day (up to 2 hours). He should continue to have daily face mask trials off the vent. . # Acute renal failure: Had ARF with creatinine bump from 0.6 to 0.8. He was hydrated with IVF boluses and improved. A twelve hour creatine urine collection revealed a creatinine clearance of 52. Pharmacy was contact[**Name (NI) **] and all of his medications were appropriately renally dosed. . # Elevated LFTs: Likely from GVHD of the liver. RUQ on [**5-26**] showed no biliary obstruction, however did show area of hypoechoic liver that would be best characterized by CT, but due to fear of damaging kidneys with contrast he had a repeat [**Month/Year (2) 950**] that showed a stable lesion. . # Anemia: Hct stable. No evidence of blood loss. . # Leukocytosis: Chronically elevated white count. Currently at baseline. # Clogged feeding tube: Mr. [**Known lastname 38598**] received creon through his feeding tube shortly after admission. This resulted in clogging his feeding tube. He had a new one placed under fluoroscopic guidance. Creon was stopped. He had no further issues with his feeding tube. . # Tachycardia: EKG's showed a sinus tachycardia on admission. This gradually improved. He was given morphine for dyspnea/pain and normal saline boluses on admission. . # NHL s/p allo [**Known lastname 3242**] c/b GVHD ?????? GVHD is underlying cause for patient??????s liver dysfunction and bronchiolitis obliterans. During this admission we continued prednisone and mycophenolate. We also continued Bactrim, voriconazole, and acyclovir for prophylaxis. LFT's were trended and [**Known lastname 3242**] followed daily. He has a follow up appointment with Dr. [**Last Name (STitle) **] in [**Last Name (STitle) 3242**] on [**Last Name (LF) 766**], [**6-7**] at 11 am. . # Hypothyroidism: Continued levothyroxine at his normal dose. . # Upper extremity DVT: Mr. [**Known lastname 38598**] was diagnosed with an upper extermity DVT on his previous admission ([**5-15**]). The decision was made not to treat the DVT given his previous history of a significant GI bleed ([**2156**]). He had a repeat [**Year (4 digits) 950**] which showed a stable thrombus. The decision to anticoagulate was discussed with [**Year (4 digits) 3242**], primary oncology, and MICU team. It was decided to change him to once daily Fondaparinux 2.5 mg SubQ which is the lowest dose available given his low body weight. FEN/GI: Tube feeds were continued at the regular rate. . Access: PICC line was in place from a previous hospitalization. It was not removed. # Prophylaxis: Mr. [**Known lastname 38598**] was continued on prophylactic doses of subcutaneous heparin until discharge when the decision was made to change his anticoagulation to fondaparinux as above. . # Code: Mr. [**Known lastname 38598**] was a full code. This was confirmed on admission. . # Dispo: Mr. [**Known lastname 38598**] was discharged to rehab. Medications on Admission: Current Medications at [**Hospital1 **]: Colistin 75 mg INH [**Hospital1 **] Amikacin 700 mg IV Q day morphine 2 mg Q2 PRN levothyroxine 125 mcg M, T, W,R tylenol 650 mg Q6 PRN simethicone 80 mg TID PRN senna 5 ml [**Hospital1 **] PRN ondansetron 8 mg Q8 PRN lorazepam 0.5 mg Q4 PRN Ascorbic acid 500 mg Q day Zinc 220 mg Q day Lansoprazole 30 mg Qam Amylase/Lipase/Protease 1 Q day Guaifenesin 200 mg Q 6 PRN Ferrous sulfate 300 mg Q day Fluticasone 1 spray Q day Prednisone 15 mg Q am Trazodone 25 mg HS PRN heparin 500 Units SQ Acyclovir 400 mg [**Hospital1 **] Voriconazole 200 mg [**Hospital1 **] Acetylcysteine Q 12 Albuterol 4 puffs Q2 PRN Mycophenolate Mofetil 250 mg [**Hospital1 **] Bactrim 20 ml MWF Colistin 125 mg [**Hospital1 **] (started [**5-23**]) Ergocalciferol 5000 units Qwed **Note changes between actual meds given and meds on previous discharge: . Pt did not get Colisimethate sodium 150 mg IV BID (it was ordered 125 mg [**Hospital1 **]) [**2162-5-23**] Patient did not get Colisimethate sodium 75 mg INH [**Hospital1 **] until [**2162-5-23**] Pt received 250 mg [**Hospital1 **] of Mycophenolate Mofetil instead of 500 mg [**Hospital1 **] Pt received 400 mg [**Hospital1 **] Acyclovir instead of 500 mg [**Hospital1 **] Pt was given 700 mg Amikacin a day (dosage not clear on D/C summary) . Discharge Medications: 1. Morphine Sulfate 2 mg IV Q2H:PRN pain 2. Levothyroxine 125 mcg Tablet [**Hospital1 **]: One (1) Tablet PO 6X/WEEK (MO,TU,WE,TH,FR,SA). 3. Acetaminophen 650 mg/20.3 mL Solution [**Hospital1 **]: One (1) PO Q6H (every 6 hours) as needed for pain/fever. 4. Simethicone 80 mg Tablet, Chewable [**Hospital1 **]: One (1) Tablet, Chewable PO TID (3 times a day) as needed for indigestion. 5. Senna 8.6 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times a day) as needed for constipation. 6. Ondansetron 8 mg Tablet, Rapid Dissolve [**Hospital1 **]: One (1) Tablet, Rapid Dissolve PO Q8H (every 8 hours) as needed for nausea. 7. Lorazepam 0.5-2 mg IV Q4H:PRN anxiety 8. Ascorbic Acid 500 mg/5 mL Syrup [**Hospital1 **]: One (1) PO DAILY (Daily). 9. Zinc Sulfate 220 mg Capsule [**Hospital1 **]: One (1) Capsule PO DAILY (Daily). 10. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily). 11. Dextromethorphan-Guaifenesin 10-100 mg/5 mL Syrup [**Last Name (STitle) **]: Ten (10) ML PO Q6H (every 6 hours) as needed for cough. 12. Ferrous Sulfate 300 mg (60 mg Iron)/5 mL Liquid [**Last Name (STitle) **]: One (1) PO DAILY (Daily). 13. Fluticasone 50 mcg/Actuation Spray, Suspension [**Last Name (STitle) **]: One (1) Spray Nasal DAILY (Daily). 14. Prednisone 10 mg Tablet [**Last Name (STitle) **]: 1.5 Tablets PO DAILY (Daily). 15. Trazodone 50 mg Tablet [**Last Name (STitle) **]: 0.5 Tablet PO HS (at bedtime) as needed for insomnia. 16. Fondaparinux 2.5 mg/0.5 mL Syringe [**Last Name (STitle) **]: One (1) Subcutaneous DAILY (Daily). 17. Acyclovir 400 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO Q12H (every 12 hours). 18. Voriconazole 200 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO twice a day. 19. Acetylcysteine 20 % (200 mg/mL) Solution [**Last Name (STitle) **]: One (1) ML Miscellaneous Q2H (every 2 hours) as needed for thick secretions. 20. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler [**Last Name (STitle) **]: Six (6) Puff Inhalation Q2H (every 2 hours) as needed for SOB. 21. Mycophenolate Mofetil 250 mg IV BID 22. Sulfamethoxazole-Trimethoprim 800-160 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO 3X/WEEK (MO,WE,FR). 23. Ergocalciferol (Vitamin D2) 50,000 unit Capsule [**Last Name (STitle) **]: One (1) Capsule PO 1X/WEEK (SA). 24. Colistimethate Sodium 150 mg Recon Soln [**Last Name (STitle) **]: Seventy Five (75) mg Injection Please give [**Last Name (STitle) 766**], Wednesday, and Friday twice a day.: Do NOT give injection. Please give this formulation inhaled. Give via nebulizer twice a day on [**Last Name (STitle) 766**], Wednesday, and Friday. Discharge Disposition: Extended Care Facility: [**Hospital **] Hospital - [**Hospital1 8**] Discharge Diagnosis: Primary Diagnosis: Graft versus Host Disease Bronchiolitis Obliterans Upper Extremity DVT Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Lethargic but arousable. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Thank you for allowing us to take part in your care. You were admitted to the hospital with fevers. While you were in the hospital, we made several adjustments to your antibiotics. We also started treating you for a blood clot in your arm. These are the following changes to your medications: **STOP "IV" Colistin (However, you will remain on the "inhaled" colistin twice a day on [**Hospital1 766**], Wednesday, and Friday). ** Stop Amikacin ** STOP Heparin injections ** START Fondaparinux Followup Instructions: Please go to the following appointments: ID/[**Hospital1 3242**] [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4861**], MD Phone:[**Telephone/Fax (1) 3241**] Date/Time:[**2162-6-29**] 2:00 pm [**Month/Day/Year 3242**] Dr. [**Last Name (STitle) **], MD. Date/Time: [**6-7**] at 11:00 am You also have the following appointment already scheduled: Provider: [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 13645**], M.D. Phone:[**Telephone/Fax (1) 1803**] Date/Time:[**2162-9-23**] 2:30

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icd9cm

[ [ [] ] ]

[ "96.6", "96.72" ]

icd9pcs

[ [ [] ] ]

20056, 20127

11349, 15948

322, 384

20261, 20261

7666, 8273

20956, 21512

7213, 7282

17315, 20033

20148, 20148

15974, 17292

20439, 20704

7298, 7647

8314, 11326

20733, 20933

276, 284

412, 2617

20167, 20240

20276, 20415

6366, 6855

6871, 7197

29,609

127,784

27566

Discharge summary

report

Admission Date: [**2143-7-9**] Discharge Date: [**2143-7-13**] Date of Birth: [**2084-8-16**] Sex: M Service: CARDIOTHORACIC Allergies: Penicillins Attending:[**First Name3 (LF) 1283**] Chief Complaint: Asymptomatic with severe mitral valve regurgitation Major Surgical or Invasive Procedure: [**2143-7-9**] Mitral valve repair with posterior P2 quadrangular resection and placement of a 34 mm [**Doctor Last Name **] annuloplasty band. History of Present Illness: 58 y/o asymptomatic male with h/o mitral regurgitation. He has undergone serial echocardiograms which now reveal servere mitral regurgitation with enlarged left atrium. Past Medical History: Mitral Regurgitation, Hypertension, Hypercholesterolemia, h/o CLL, Mastocytosis, Depression Social History: Disabled. Quit smoking tobacco (pipe) 15 yrs ago. ETOH [**4-26**] drinks/week Family History: Non-contributory Physical Exam: VS: 68 20 140/88 5'[**46**]" 222@ Gen: Well-appearing male in NAD Skin: Unremarkable HEENT: EOMI, PERRL, NC/AT Neck: Supple, FROM, -JVD, -carotid bruit Chest: CTAB -w/r/r Heart: RRR +holosystolic murmur Ext: Warm, well-perfused, -edema, -varicosities Neuro: A&O x 3, non-focal Pertinent Results: [**7-9**] Echo: PRE-BYPASS: 1.No atrial septal defect is seen by 2D or color Doppler. 2.Left ventricular wall thicknesses and cavity size are normal. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is normal (LVEF>55%). 3.Right ventricular chamber size and free wall motion are normal. 4.The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. 5.The mitral valve leaflets are mildly thickened. The mitral valve leaflets are myxomatous. An eccentric jet of Severe (4+) mitral regurgitation is seen. 6. There is a trivial/physiologic pericardial effusion. POST-BYPASS: 1 .A well-seated mitral annuloplasty ring is seen with normal leaflet motion and gradients (mean gradient = 4 mmHg). There is no valvular systolic anterior motion ([**Male First Name (un) **]). Trivial (normal for prosthesis) mitral regurgitation is seen. 2. Biventricular systolic functions is preserved. 3. Aorta intact post decannulation [**2143-7-9**] 11:44AM BLOOD WBC-16.6*# RBC-2.95*# Hgb-9.3*# Hct-26.7*# MCV-91 MCH-31.6 MCHC-34.9 RDW-13.8 Plt Ct-128* [**2143-7-12**] 07:30AM BLOOD WBC-12.8* RBC-2.50* Hgb-7.7* Hct-23.7* MCV-95 MCH-30.6 MCHC-32.3 RDW-13.5 Plt Ct-160 [**2143-7-9**] 11:44AM BLOOD PT-13.7* PTT-33.7 INR(PT)-1.2* [**2143-7-9**] 02:40PM BLOOD PT-13.5* PTT-26.6 INR(PT)-1.2* [**2143-7-9**] 12:43PM BLOOD UreaN-17 Creat-1.0 Cl-109* HCO3-25 [**2143-7-12**] 07:30AM BLOOD Glucose-104 UreaN-12 Creat-0.9 Na-135 K-3.8 Cl-101 HCO3-31 AnGap-7* Brief Hospital Course: Mr. [**Known lastname 56289**] was a same-day admit after undergoing all pre-operative work-up as an outpatient. On day of admission he was brought to the operating room where he underwent a mitral valve repair via sternotomy. Please see operative note for surgical details. Minimal invasive approach was abandoned following difficulty advancing necessary catheters. Following surgery he was transferred to the CSRU for invasive monitoring in stable condition. Later on op day he was weaned from sedation, awoke neurologically intact and extubated. On post-op day one he was started on beta blockers and diuretics. He was gently diuresed towards his pre-op weight. On post-op day one he was transferred to the SDU for further care. His chest tubes and epicardial pacing wires were removed per protocol. He has remained stable & is ready for discharge home. Medications on Admission: Benicar 40mg qd, Zocor 40mg qd, Celexa 60mg qd, Wellbutrin 150mg [**Hospital1 **], Risperidone qhs, Benadryl prn Discharge Medications: 1. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*30 Tablet(s)* Refills:*0* 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*0* 3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*40 Tablet(s)* Refills:*0* 5. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 6. Citalopram 20 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 7. Bupropion 75 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Disp:*120 Tablet(s)* Refills:*0* 8. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 10 days. Disp:*20 Tablet(s)* Refills:*0* 9. Potassium Chloride 20 mEq Packet Sig: One (1) Packet PO Q12H (every 12 hours) for 10 days. Disp:*20 Packet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital3 **] Home Health & Hospice Discharge Diagnosis: Mitral Regurgitation s/p Mitral Valve Repair PMH: Hypertension, Hypercholesterolemia, h/o CLL, Mastocytosis, Depression Discharge Condition: Good Discharge Instructions: Patient should shower daily, no baths. No creams, lotions or ointments to incisions. No driving for at least one month. No lifting more than 10 lbs for at least 10 weeks from the date of surgery. Monitor wounds for signs of infection. Please call cardiac surgeon if start to experience fevers, sternal drainage and/or wound erythema. [**Last Name (NamePattern4) 2138**]p Instructions: Dr. [**Last Name (Prefixes) **] in 4 weeks Dr. [**Last Name (STitle) 67378**] in [**2-23**] weeks Dr. [**Last Name (STitle) 5448**] in [**1-22**] weeks [**Hospital Ward Name 121**] 2 for Wound Check in 2 weeks Completed by:[**2143-7-13**]

[ "V10.61", "272.0", "458.29", "424.0", "311", "401.9", "998.11" ]

icd9cm

[ [ [] ] ]

[ "39.61", "99.05", "35.33", "89.60" ]

icd9pcs

[ [ [] ] ]

4893, 4962

2779, 3637

329, 474

5125, 5131

1228, 2756

898, 916

3800, 4870

4983, 5104

3663, 3777

5155, 5490

5541, 5781

931, 1209

238, 291

502, 672

694, 787

803, 882

5,727

171,130

51964

Discharge summary

report

Admission Date: [**2159-4-20**] Discharge Date: [**2159-4-27**] Date of Birth: [**2096-11-3**] Sex: M Service: MEDICINE Allergies: Morphine Attending:[**First Name3 (LF) 2006**] Chief Complaint: Shortness of Breath Major Surgical or Invasive Procedure: None History of Present Illness: This is a 62yo M PMHx HTN, ESRD on HD, CHF (EF 28%), afib, non-compliance with HD, crack cocaine, recent admission to [**Hospital1 18**] (most recent [**Date range (1) 27746**]) for volume overload and SOB in setting of missing HD session, now p/w 1 day SOB. Patient reports that 1 day prior to admission, he had an episode of NB diarrhea, causing him to miss HD (normally scheduled for Tues/Thurs/Saturday). He subsequently noted development of shortness of breath and L-sided pleuritic CP. He describes pain as fleeting, lasting seconds at a time, non-exertional non-radiating, not related to eating, and without associated palpitations or diaphoresis. He also reported chills and subjective fevers. Of note, patient also reports using crack cocaine on the morning prior to his admission. . Patient was BIBEMS for further evaluation. In ED initial vital signs were 100.8 130 152/88 28 100%NRB. Exam was notable for tachypnea, dyspnea, desatting to 88% during transfer. Patient immediately initiated on Bipap. CXR demonstrated bilateral opacities c/w moderate to severe pulm edema. Labs were significant for WBC 7.8(N81), Hct 32.6, BNP48k, Trop 0.37. EKG was not sent with patient. Patient was given [**Date range (1) **], tylenol, levofloxacin, vancomycin, 1mg IV dilaudid. Was able to be weaned off bipap, and patient was admitted to MICU for further management. Vital signs prior to transfer were 104 133/79 24 96% 6LNC. . On arrival to the MICU patient was coughing, producing thick yellow mucus, but sitting up and talkative. Vital signs were 99.0 92 134/72 22 90%6LNC Past Medical History: 1. ESRD on HD T/Th/Sa at [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 9449**] [**Last Name (NamePattern1) **], [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 669**], [**Telephone/Fax (1) 69669**] 2. Type 2 diabetes mellitus c/b peripheral neuropathy 3. Chronic systolic CHF with EF 30% ([**10/2156**] TTE) 4. Atrial fibrillation/AFlutter - s/p ablation [**2153**]; s/p ablation x 2 in [**2155**] - not on coumadin due to history of GIBs. 5. Hypertension 6. Dyslipidemia 7. History of GI bleeds: Duodenal, jejunal, and gastric AVMs s/p thermal therapy; diverticulosis throughout colon 8. Chronic pancreatitis 9. ? HCV: HCV Ab + [**10/2150**], but neg [**2154**] 10. GERD 11. Gout: s/p arthroscopy with medial meniscectomy [**5-/2149**] 12. Depression with multiple hospitalizations due to SI 13. Polysubstance abuse: crack cocaine, EtOH, tobacco 14. recurrent chest pain following crack/cocaine use - no evidence CAD on cath [**2155**] 15. Erectile dysfunction s/p inflatable penile prosthesis [**5-/2148**] 16. H/o C diff in [**2156-8-14**] 17.thyrotoxicosis Social History: He lives with his [**Year (4 digits) 18933**]. He is on diability, but had worked previously for [**Company 31653**]. He smokes [**2-16**] cig/day. Denies recent alcohol use. Using cocaine, lasted used last week. Family History: Mother died of MI; per OMR multiple sibs with T2DM Physical Exam: Vitals: 99.0 92 134/72 22 90%6LNC ADMISSION EXAM: General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MM dry, PERRL Neck: supple, 8cm JVD, L-sided HD line in place c/d/i CV: irreg irreg, no murmurs, rubs, gallops Lungs: Diffuse crackles throughout w scattered ronchi bilaterally Abdomen: soft, mildly distended, nontender, naBS GU: no foley Ext: WWP, 1+ radial equal bilaterlly, DP dopplerable bilaterally, 1+ edema to mid-shin, no cyanosis Neuro: AOx3, moving all extremities DISCHARGE EXAM: afebrile, SBP 130s, HR 80-90s, 95% RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, PERRL CHEST: HD line removed, no erythema, pus or induration at site CV: irreg irreg, no murmurs, rubs, gallops Lungs: CTAB Abdomen: soft, mildly distended, nontender, naBS EXT: no edema Pertinent Results: ADMISSION LABS [**2159-4-20**] 08:10PM WBC-7.8 RBC-3.66* HGB-10.1* HCT-32.6* MCV-89 MCH-27.7 MCHC-31.0 RDW-15.7* [**2159-4-20**] 08:10PM NEUTS-81.7* LYMPHS-10.6* MONOS-5.1 EOS-1.7 BASOS-0.9 [**2159-4-20**] 08:10PM PLT COUNT-247 [**2159-4-20**] 07:28PM GLUCOSE-243* UREA N-71* CREAT-11.5*# SODIUM-135 POTASSIUM-8.3* CHLORIDE-93* TOTAL CO2-23 ANION GAP-27* [**2159-4-20**] 07:28PM estGFR-Using this [**2159-4-20**] 07:28PM ALT(SGPT)-38 AST(SGOT)-60* CK(CPK)-163 ALK PHOS-201* TOT BILI-0.6 [**2159-4-20**] 07:28PM LIPASE-23 [**2159-4-20**] 07:28PM CK-MB-8 cTropnT-0.37* proBNP-[**Numeric Identifier 107564**]* [**2159-4-20**] 07:28PM ALBUMIN-3.7 CALCIUM-10.1 PHOSPHATE-4.5 MAGNESIUM-2.8* [**2159-4-20**] 07:28PM DIGOXIN-0.9 [**2159-4-20**] 07:28PM [**Year/Month/Day **]-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2159-4-20**] 07:28PM TYPE-[**Last Name (un) **] PO2-91 PCO2-37 PH-7.50* TOTAL CO2-30 BASE XS-4 COMMENTS-GREEN-TOP [**2159-4-20**] 07:28PM LACTATE-2.0 K+-6.9* [**2159-4-20**] 07:28PM PT-12.6* PTT-33.1 INR(PT)-1.2* . EKG [**4-20**] Atrial flutter with a rapid ventricular response. Indeterminate axis with low QRS voltages in the limb leads. Non-specific ST-T wave changes. Compared to the previous tracing of [**2159-3-21**] there is no significant change. . IMAGING CXR [**4-20**] AP PORTABLE UPRIGHT CHEST RADIOGRAPH: The hilar and mediastinal contours are stable, with a mildly tortuous thoracic aorta. Again, seen is a moderate-sized right pleural effusion with mild right basal atelectasis. Bilateral perihilar and pulmonary alveolar opacities are most suggestive of moderate-to-severe pulmonary edema. Left IJ approach central venous [**Month/Day (4) 2286**] catheter ends in the right atrium. There is no pneumothorax. IMPRESSION: Moderate-sized right pleural effusion with moderate pulmonary edema. . ECHO [**4-21**] The left atrium is mildly dilated. The right atrium is moderately dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size. There is mild to moderate global left ventricular hypokinesis (LVEF = 35-40%). The right ventricular cavity is moderately dilated with mild global free wall hypokinesis. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. There is mild mitral regurgitation. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Mild LVH with mild to moderate global systolic dysfunction. Mild right ventricular systolic function. Mild mitral regurgitation. Moderate pulmonary hypertension. . CXR [**4-23**] FINDINGS: Dual-lumen left central line catheter tip lies at right upper atrium. The [**2159-4-21**] severe pulmonary edema is unchanged in severity but has redistributed, with interval improvement in the left lung and worsening on the right side. Normal heart size, mediastinal and hilar contours are stable. No pneumothorax. Small right pleural effusion is unchanged. IMPRESSION: Since [**2159-4-21**] severe pulmonary edema is unchanged in severity but has distribution with interval worsening in the right lung and improved on the left side. CXR [**4-25**]: In comparison with study of [**4-24**], there are lower lung volumes, which may account for some of the increased prominence of the transverse diameter of the heart. Again, there is moderately severe pulmonary edema. DISCHARGE LABS: [**2159-4-26**] 07:02AM BLOOD WBC-7.1 RBC-3.70* Hgb-10.3* Hct-34.0* MCV-92 MCH-27.9 MCHC-30.3* RDW-15.7* Plt Ct-313 [**2159-4-26**] 07:02AM BLOOD Glucose-170* UreaN-50* Creat-7.3*# Na-136 K-4.9 Cl-94* HCO3-29 AnGap-18 [**2159-4-26**] 07:02AM BLOOD Calcium-10.5* Phos-6.7* Mg-2.7* Brief Hospital Course: 62yo M PMHx DM, HTN, ESRD on HD Tu/Th/Sat, CHF (EF 28%), afib, h/o crack cocaine use, non-compliance with HD p/w hypoxia in setting of missed HD appointment, crack cocaine use # Hypoxia: He presented with hypoxia in the setting of missed [**Year/Month/Day 2286**] session and active crack cocaine smoking. His CXR showed pulmonary edema but PNA could not be ruled out so he was treated for possible co-existing health-care associated pneumonia with broad spectrum antibiotics. Echo showed stable to mildy depressed EF though unlikley to be cause of his pulmonary edema. He underwent multiple sessions of [**Year/Month/Day 2286**] and his respiratory status significantly improved. His antibiotics were stopped and he was transferred to the floor where he remained afebrile and was weaned off room air. He was satting 95% on RA at the time of discharge and denied SOB. # Left-sided Chest Pain: The patient has been admitted multiple times for chest pain thought to be musckuloskeletal chest pain. He again had chest pain here without associated EKG abonormalities that was not relieved with nitroglycerin. He did have elevated troponins though he has elevated troponins at baseline. The pain was easily reproducible on palpation and improved with removal of his tunneled [**Year/Month/Day 2286**] catheter. He was treated with percocet with good response. On the floor, he had recurrence of chest pain. On review of records, it was noted that his chest pain tended to occur in conjunction with RVR during previous admissions. This was found to be the case here as well, as CP occurred when rate began to run over 120-130s. RVR was managed as below and symptomatic relief for CP was otherwise provided with small doses of IV dilaudid to good effect (0.25mg IV q6h prn). Pt denied CP at the time of discharge and rate was well-controlled as below. # Atrial fibrillation/Flutter: He is chronically in afib/flutter. He has been well rate controlled here on Diltiazem and digoxin. Of note he is not on metoprolol because of his active cocaine use. During his admission his digoxin level was high on his home dose so his schedule was changed so that he would received Digoxin after HD with trough levels drawn pre-[**Year/Month/Day 2286**]. He is on full dose aspirin but not warfarin because of history of GI bleeding. He had two episodes of RVR on the floor with rates into the 160-170s. This was managed with diltiazem IV push 10mg on both occasions and his daily diltiazem dose was increased to 420mg from 360mg daily. It was noted that holding his diltiazem until after HD led to RVR so plan was made to take diltiazem every day at 12pm instead of in the morning. rate well-controlled in 80-90s on this dose. # ESRD: He receives HD T/Th/S as an oupatient. He has had multiple admission in the setting of missed [**Year/Month/Day 2286**]. He underwent multiple [**Year/Month/Day 2286**] sessions with improvement in his symptoms as above. He was transitioned back to his three times weekly schedule. His tunneled [**Year/Month/Day 2286**] catheter was removed because he has a functional fistula. We continued nephrocaps, cinacalcet, sevelamer carbonate. # DMII. Lantus and sliding scale insulin were continued. He did have mild hypoglycemia so his sliding scale was adjusted. # Diabetic Neuropathy: Continued gabapentin 100mg TID TRANSITIONAL ISSUES -Should check digoxin troughs pre-[**Year/Month/Day 2286**] -Take digoxin post [**Year/Month/Day 2286**] - follow up rate control on 420mg po diltiazem daily taken at noon - encourage cocaine cessation Medications on Admission: - albuterol sulfate prn - Nephrocaps 1mg daily - cinacalcet 90mg daily - digoxin 125mcg daily - diltiazem HCl 360mg Extended Release daily - gabapentin 100mg TID - hydroxyzine HCl 25mg prn - glargine 14 units [**Year/Month/Day 5910**] - Humalog sliding scale - Percocet 5-325mg before/after HD prn pain - Sevelamer carbonate 3200mg TID w meals - Ambien 5mg [**Year/Month/Day 5910**] - Docusate sodium 100mg [**Hospital1 **] - [**Hospital1 **] 325mg daily Discharge Medications: 1. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler Sig: Two (2) puffs Inhalation every four (4) hours as needed for shortness of breath or wheezing. 2. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 3. cinacalcet 30 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 4. diltiazem HCl 420 mg Capsule, Extended Release Sig: One (1) Capsule, Extended Release PO At lunch, or 2 PM. Disp:*30 Capsule, Extended Release(s)* Refills:*0* 5. gabapentin 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 6. hydroxyzine HCl 25 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pruritis. 7. sevelamer carbonate 800 mg Tablet Sig: Four (4) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 8. Ambien 5 mg Tablet Sig: One (1) Tablet PO at bedtime. 9. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 10. aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day. 11. digoxin 125 mcg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY (Every Other Day). 12. oxycodone-acetaminophen 5-325 mg Tablet Sig: One (1) Tablet PO twice a day as needed for pain: You should take this medication before and after [**Hospital1 2286**] session as needed for pain. Please do not drive, drink alcohol or operate heavy machinery while on this medication. . 13. Lantus 100 unit/mL Solution Sig: Fourteen (14) units Subcutaneous at bedtime. 14. Humalog 100 unit/mL Solution Sig: One (1) injection Subcutaneous as directed: Please follow usual sliding scale as outlined by your outpatient doctors with regards to this medication. Discharge Disposition: Home Discharge Diagnosis: Primary diagnosis: Fluid overload Atypical chest pain Atrial fibrillation with rapid ventricular response Secondary diagnosis: End-stage renal disease Diabetes mellitus type 2 Insomnia 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 107485**], It was a pleasure caring for you at [**Hospital1 18**]. You came for further evaluation of chest pain. Further evaluation showed that you had fluid on your lungs likely due to missing your [**Hospital1 2286**] session. Your heart rate was also fast, from your atrial fibrillation, at numerous times during this admission, and we adjusted your medications to deal with this. It is very important that you take this medication, diltiazem, on a daily basis. It is also VERY IMPORTANT that you stop using cocaine, as it is likely the reason for most of your hospitalizations, and is extremely bad for your health. It is important that you go to your [**Hospital1 2286**] sessions, as scheduled, and don't miss sessions, and follow up with the appointments listed below. your weight goes up by more than 3 lbs. The following changes have been made to your medications: We INCREASED your dose of diltiazem, which you should take on a daily basis. Please do not miss doses of these medications. We CHANGED the dose of your digoxin, in that you will now take this medication every other day instead of every day Followup Instructions: Department: [**Hospital3 249**] When: WEDNESDAY [**2159-5-2**] at 3:00 PM With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 2010**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: PODIATRY When: MONDAY [**2159-5-21**] at 8:30 AM With: [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 542**], DPM [**Telephone/Fax (1) 543**] Building: Ba [**Hospital Unit Name 723**] ([**Hospital Ward Name 121**] Complex) [**Location (un) **] Campus: WEST Best Parking: [**Street Address(1) 592**] Garage Department: [**Hospital3 249**] When: MONDAY [**2159-5-21**] at 10:30 AM With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 2010**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: HEMODIALYSIS When: SATURDAY [**2159-4-28**] at 7:30 AM

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icd9cm

[ [ [] ] ]

[ "39.95", "97.49" ]

icd9pcs

[ [ [] ] ]

13798, 13804

8129, 11687

289, 295

14036, 14036

4167, 7809

15396, 16417

3270, 3322

12193, 13775

13825, 13825

11713, 12170

14219, 15373

7825, 8106

3337, 3832

3848, 4148

230, 251

323, 1910

13955, 14015

13845, 13933

14051, 14195

1932, 3023

3039, 3254

70,516

199,605

53492

Discharge summary

report

Admission Date: [**2189-2-12**] Discharge Date: [**2189-3-27**] Date of Birth: [**2147-1-22**] Sex: F Service: MEDICINE Allergies: Aspirin / Penicillins / Sulfonamides / Biaxin / Levaquin / Cefzil / Motrin / Erythromycin Base Attending:[**First Name3 (LF) 3561**] Chief Complaint: Abdominal pain Major Surgical or Invasive Procedure: Intubation & mechanical ventilation Central venous line placement x 2 PICC line placement Hemodialysis catheter placement CVVH Radial a-line placement Paracentesis Tracheostomy Bronchoscopy History of Present Illness: 42 y/o lady with CVID, HepC, Type 1 DM, distant IBD > 20 yrs ago last flare, recent cryptospordial infection presented to OSH with worsening abdominal pain, nausea and vomitting. She was recently discharged on [**2189-2-11**] after admission with severe pancolitis and small ileocolic intussiception wihtout evidence of obstruction. The surgical service was consulted but saw no acute indication for surgery and followed the patient with serial abdominal exams. Initially she was placed on vancomycin, cefepime and flagyl which was then changed to flagyl only to complete a two week course. She was also found to have strep pneumo in her BCx on [**2189-2-2**], unclear source. She was asked to be on IV ceftriaxone for a 14 day course per ID recommendation. Her peritoneal tap showed 1500 wbc, 850 rbc, 27% poly and 70% macro. Gram stain and culture were negative. Acid fast smear was negative but culture is pending. Her stool studies have been negative. Patient went to OSH with abdominal pain, nausea and vomitting. Patient received Vancomycin there per verbal signout. In [**Hospital1 18**] ED her vitals were T 101.8 (R), HR 113 BP 85/52 RR 38 97% RA. Her SBP improved to ? 150s with IVF. She received 6.5 L of NS in total in ED. Patient was agitated and not oriented. She was intubated so that further workup could be done. She received fentanyl, etomidate, succinyl choline, and versed in ED. She also received 2 gram of cetriaxone, 2 gram of ampicillin and 4.5 gram of zosyn. patient also received acetaminophen and lactulose in ED. Past Medical History: 1) Type 1 Diabetes: followed by [**Last Name (un) **], difficult to control. Frequent admissions for AMS from hypoglycemia. 2) Common Variable Immuno-Deficiency: treated with IVIG q2 weeks, last [**10-14**] ?? at [**Hospital1 882**]. Assoc w/ recurrent infections - multiple pneumonias, recurrent UTIs. 3) h/o aseptic meningitis 4) Asthma 5) CBP ?? 6) Chronic HCV: Dx 11/[**2186**]. Most recent VL [**8-1**] 7,980,000 IU/mL. Bx [**8-/2188**] showed significant fibrosis but no cirrhosis. Followed by Dr. [**Last Name (STitle) 497**]. Also w/ portal hypertension, SBP on last admission. 7) Cryptosporidium: followed by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in ID. Dx [**9-/2188**], started on Nitazoxanide until [**11/2188**], then changed to Flagyl. 8) ? Inflammatory Bowel Disease (UC): Dx [**2162**], tx w/ prednisone x3 years, then stopped. Only other episode ~[**2172**], not currently on any treatment. 9) Migraine headaches 10) Anxiety / Depression 11) h/o Cocaine abuse, reported tox screen positive in [**12/2188**] 12) s/p CCY 13) s/p lap appy [**2180**] 14) s/p C-section 15) Carpal tunnel syndrome s/p surgery on right hand Social History: lives with fiancee and daughter, smokes [**12-26**] pack per day, denies any alcohol since [**7-1**], formerly used IV drugs but none since [**2184**]. Family History: No family history of diabetes. Multiple family members with [**Name2 (NI) 109976**] anemia. Mother has hypercholesterolemia and diverticular disease, father has peripheral vascular disease. Physical Exam: Gen: Intubated and sedated HEENT: PERRL, MMM, OT tube in place Heart: S1S2 RRR, II/VI midpeaking systolic murmur in RUSB>LUSB Lungs: CTAB in anterior lung fields Abdomen: hypoactive BS, soft, mildly distended Ext: Warm, [**1-27**]+ BLE pitting edema Neuro: Limited by sedation Pertinent Results: [**2189-2-11**] 06:31AM PLT COUNT-173 [**2189-2-11**] 06:31AM CALCIUM-7.9* PHOSPHATE-2.4* MAGNESIUM-1.5* [**2189-2-11**] 06:31AM ALT(SGPT)-111* AST(SGOT)-260* LD(LDH)-299* ALK PHOS-229* TOT BILI-2.7* [**2189-2-11**] 12:43PM PTT-106.3* [**2189-2-11**] 06:31AM WBC-8.9 RBC-2.96* HGB-9.6* HCT-28.5* MCV-96 MCH-32.5* MCHC-33.7 RDW-18.5* [**2189-2-11**] 06:31AM WBC-8.9 RBC-2.96* HGB-9.6* HCT-28.5* MCV-96 MCH-32.5* MCHC-33.7 RDW-18.5* [**2189-2-12**] 09:15PM PLT COUNT-184 [**2189-2-11**] 12:43PM PTT-106.3* [**2189-2-11**] 06:31AM ALT(SGPT)-111* AST(SGOT)-260* LD(LDH)-299* ALK PHOS-229* TOT BILI-2.7* [**2189-2-11**] 06:31AM CALCIUM-7.9* PHOSPHATE-2.4* MAGNESIUM-1.5* Brief Hospital Course: 42 y/o lady with CVID, HepC, Type 1 DM who presented with abdominal pain, nausea and vomitting. # Sepsis: Upon arrival to the MICU, she was hypotensive and required three pressors. In the setting of severe sepsis, she was given Xigris. It was discontinued after 24 hours due to a prolonged PTT > 150. ID was consulted. She was given IgG in the setting of her known CVID. She was initally treated with Vancomycin and Meropenem as broad-spectrum coverage. Vancomycin was changed to Linezolid given history of VRE, but then discontinued a few days later after cultures negative. She received IgG given her underlying CVID. Patient gradually improved and pressors were weaned to Levophed and Vasopressin. She was treated with a 7-day course of Meropenem for a ? of RLL pneumonia. She was treated for c. diff with PO and PR vancomycin as well as IV flagyl. All micro data at our institution remained NGTD, but positive c. diff toxin was reported by OSH. pressors were weaned off. Repeated imaging of the abdomen revealed stable bowel wall thickening, no pneumotosis. Tube feeds were attempted on multiple occasions but failed due to high residuals. # Respiratory failure: Patient was intubated in the setting of sepsis and subsequently developed ARDS. She initially required paralysis to maintain ventilator synchrony, as well as frequent recruitment maneuvers. An esophageal balloon was placed due to high PEEP requirement. A tracheostomy was performed at bedside on intubation day #4. Patient was eventually transitioned to pressure support with gradual reduction of fentanyl and versed. # Acute renal failure: Patient developed a metabolic acidosis with worsening renal function, rising creatinine, and oliguria on ~[**2-18**]. Etiology of ARF was felt to be ATN in the setting of sepsis and hypotension. Renal was consulted for urgent initiation of CVVH. Acidemia was corrected with CVVH, and urine output eventually resumed. CVVH was continued, with vasopressin, to remove ~ 20 liters of fluid which patient retained following her resuscitation. HD catheter was successfully removed on [**2-26**] with stable urine output and creatinine back to patient's baseline ~0.8. Pt resumed CVVH on [**3-21**] for rising BUN and concern for uremia. # Thrombocytopenia: Platelets nadired to ~ 20K. Hematology was consulted. Low fibrinogen, elevated INR, and thrombocytopenia were suggestive of DIC in the setting of sepsis vs. underlying liver disease. Fibrinogen 173 at time of admission; thus fibrinogen nadir at ~100 represented a drop from baseline. HIT antibody negative. Drug-induced thrombocytopenia is also a consideration with possible offending agents including Linezolid, PPI, Caspofungin. TTP-HUS less likely given lack of microangiopathic findings on the peripheral blood smear. Patient was transfused 2 units platelets in preparation for a procedure and subsequently platelet count remained > 100K and upward trending. . # Anemia: Patient received multple blood transfusions periodically to maintain hematocrit > 25. Hemolysis labs reflected a low haptoglobin, elevated LDH, though no schistocytes are apparent on peripheral blood smear, making TTP unlikely. Blood loss was associated with mucosal oozing as above, given probable DIC. Direct coombs antibody negative. # Type I diabetes: Patient initially presented with DKA in the setting of sepsis. She was treated with an insulin gtt. The insulin gtt was then discontinued and anion gap reopened at the same time patient developed a metabolic acidosis. Insulin gtt was then restarted with D10 infusion as glucoses were in the target 100-150 range. Eventually insulin infusion was transitioned to continuous infusion in TPN. Glucoses were noted to be labile. # Line infection: On [**2-26**], patient developed fevers, hypotension, and tachycardia. Her CVL, PICC, and HD catheter were all discontinued and patient was pan-cultured. HD catheter tip culture grew VRE, although this organism was never isolated from blood cultures. Patient was treated with a 14-day course of Daptomycin (day 1 = [**2-28**]). . After extensive discussions with the family patient and no improvement in mental status alongside multi organ failure the decision wa made to transition care to comfort measures and the patient subsequently expired. Medications on Admission: cholestyramine-aspartame 4g TID clotrimazole troches Lantus Discharge Medications: none Discharge Disposition: Expired Discharge Diagnosis: Clostridium difficile sepsis Acute renal failure Diabetic ketoacidosis Thrombocytopenia Anemia Cirrhosis Discharge Condition: expired Discharge Instructions: expired Followup Instructions: expired

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icd9cm

[ [ [] ] ]

[ "99.14", "38.93", "31.1", "54.91", "33.24", "38.91", "00.11", "96.72", "39.95", "38.95", "96.04", "99.15" ]

icd9pcs

[ [ [] ] ]

9217, 9226

4746, 9078

370, 561

9375, 9384

4036, 4723

9440, 9450

3526, 3719

9188, 9194

9247, 9354

9104, 9165

9408, 9417

3734, 4017

316, 332

589, 2150

2172, 3340

3356, 3510

62,693

188,327

7568+55844

Discharge summary

report+addendum

Admission Date: [**2153-6-20**] Discharge Date: [**2153-7-6**] Date of Birth: [**2100-5-27**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 165**] Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: 1.cardiac catheterization 2.Coronary artery bypass graft x5 with left internal mammary artery to left anterior descending artery and saphenous vein grafts to obtuse marginal 1 and 2 as a sequential and saphenous vein grafts to diagonal and right coronary arteries. 3. Endoscopic harvesting of the long saphenous vein. 4. PICC line placement History of Present Illness: 53 yo Caucasan male with Type 1 DM, HTN, and HLD with no previous cardiac surgery/procedure presents after about 2 days of dyspnea on exertion and 1 episode of substernal chest pressure one day prior to admission. Patient reported that he has been feeling feverish but only had 1x elevated temperature of 101.7 over the weekend which was resolved with Tylenol. He was concerned for viral upper respiratory infection more than his right foot infection which has been chronic for the last 5 years. His foot was recently evaluated by podiatry who thought his foot was doing better. Patient also noticed increased cough. The sputum is clear without blood. He denied any pleuritic chest pain, but does have chronic swelling of his right lower leg due to the infection. Yesterday, he noted a [**6-7**] non-radiating pressure in the middle of his chest while he carried a bag. It soon resolved after he unloaded the bag. However, he's never had this experience before. Of note, he reported decreased activity tolerance from being able to walk ~300 yards to ~[**Age over 90 **] yards before getting out of breath over the last few days. Cardiac workup revealed multivessel coronary artery disease and cardiac surgery was consulted for revascularizatin. Past Medical History: - HTN - HLD -Diastolic CHF - echo [**9-5**] with preserved EF left ventricular but no hypertrophy, left atrial enlargement, elevated E to E' ratio, or pulmonary hypertension CRF - Type 1 Diabetes on insulin pump - Diabetic Foot Ulcers - Charcot Foot - Anemia - s/p removal of antibiotic beads right foot. [**2152-2-10**] - Leg cramps - Hearing loss - Chronic cough - abnormal LFT Social History: - accountant - married with 4 children - ex-smoker. Quit in [**2133**] after 2ppd x 15-16 years. Quit cigar about 6-7 years ago. - EtOH on weekends - no recreational drug use Family History: - Factor V Leiden in one brother and one sister Significant for father passing away from MI, one brother with DM type I with MI x 2, and another brother passing away from MI at age 41. Physical Exam: Physical Exam on Admission - VS - T 98.0, HR 80, BP 124/58, RR20, 100% RA - Gen: middle aged male in NAD. Oriented x3. Mood, affect appropriate. - HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. - Neck: Supple. Could not appreciate any JVP. - CV: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. - Chest: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. - Abd: Soft, NTND. No HSM or tenderness. No abdominial bruits. insulin pump site at LUQ. site is c/d/i, no drainage or erythema. - Ext: no pitting edema bilaterally but right lower leg appears to be more swollen than the left. no pain on palpation. His feet are deformed bilaterally. Noted mile erythema on the sole of his right foot. area of debridement on right sole healing well. - Skin: No stasis dermatitis, ulcers, scars, or xanthomas. - Pulses: Right: DP 2+ PT 2+; Left: DP 2+ PT 2+ Physical Exam on Discharge Pertinent Results: Cardiac Markers [**2153-6-20**] 07:15PM CK(CPK)-76 [**2153-6-20**] 07:15PM CK-MB-4 cTropnT-0.15* [**2153-6-20**] 02:11PM proBNP-4655* [**2153-6-20**] 12:30PM CK(CPK)-90 [**2153-6-20**] 12:30PM cTropnT-0.14* [**2153-6-20**] 12:30PM CK-MB-5 . CBC [**2153-6-20**] 12:30PM WBC-15.9*# RBC-3.14* HGB-9.9* HCT-28.9* MCV-92 [**2153-6-20**] 12:30PM NEUTS-81.2* . Electrolytes [**2153-6-20**] 12:30PM GLUCOSE-188* UREA N-37* CREAT-1.8* SODIUM-131* POTASSIUM-4.3 CHLORIDE-92* TOTAL CO2-28 ANION GAP-15 . [**2153-6-21**] FOOT X-RAY: Soft tissue indentation is seen at the plantar aspect of the foot, compatible with a soft tissue defect or ulcer. There are postoperative changes at the hindfoot with evidence of prior destruction or debridement at the region of the anterior subtalar joint with an ovoid methyl methacrylate presumably antibiotic impregnated spacer in this region. A similar spacer is also visualized in the region of the fifth tarsometatarsal joint. Extensive chronic arthropathy is seen involving the intertarsal and tarsometatarsal joints in addition to the first metatarsophalangeal joint. There is vascular calcification. IMPRESSION: The overall appearance is similar to prior examination and while osteomyelitis is not excluded, no clear new area of bone destruction is seen. [**2153-6-22**] CAROTID US: Right ICA stenosis <40%; Left ICA stenosis <40% [**2153-7-4**] 04:06AM BLOOD WBC-8.3 RBC-2.71* Hgb-8.3* Hct-24.6* MCV-91 MCH-30.5 MCHC-33.7 RDW-15.1 Plt Ct-589* [**2153-6-20**] 12:30PM BLOOD WBC-15.9*# RBC-3.14* Hgb-9.9* Hct-28.9* MCV-92 MCH-31.6 MCHC-34.4 RDW-12.8 Plt Ct-512*# [**2153-7-1**] 02:01AM BLOOD PT-14.8* PTT-29.2 INR(PT)-1.3* [**2153-7-4**] 04:06AM BLOOD Glucose-63* UreaN-19 Creat-1.0 Na-134 K-4.3 Cl-93* HCO3-32 AnGap-13 [**2153-6-20**] 12:30PM BLOOD Glucose-188* UreaN-37* Creat-1.8* Na-131* K-4.3 Cl-92* HCO3-28 AnGap-15 [**2153-6-22**] 05:45AM BLOOD ALT-24 AST-45* LD(LDH)-186 CK(CPK)-150 AlkPhos-244* TotBili-0.4 Conclusions PREBYPASS No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thicknesses and cavity size are normal. The left ventricular cavity size is normal. There is moderate regional left ventricular systolic dysfunction with akinesis of the mid to distal infero and mid to distal antero septal wall, akinesis of the mid to distal inferior wall, distal anterior and distal lateral walls . Overall left ventricular systolic function is moderately depressed (LVEF= 30 %). The remaining left ventricular segments contract normally. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. POSTBYPASS LV function may be slightly improved with improvement of the mid to distal inferior wall. Previous WMA's described persist. LVEF~35%. RV systolic function remains normal. MR remains mild. I certify that I was present for this procedure in compliance with HCFA regulations. Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 168**], MD, Interpreting physician [**Last Name (NamePattern4) **] [**2153-6-28**] 10:59 Brief Hospital Course: Mr. [**Known lastname **] is a 53 yoM with Type 1 Diabetes Mellitus, Hypertension and NSTEMI with 3Vessel disease on recent cath. He is also being treated for Staph aureus bacteremia from an uncertain source that may be his chronic right foot osteomyelitis. . #. CAD. Patient was worked up for NSTEMI and r/o venous thrombosis. He was optimized with heparin drip, ASA/Metoprolol/statin. Diuretic and valsartan were held given elevated renal function (Crt 1.8) and cardiac catheterization. He subsequently underwent catheterization ([**2153-6-21**]) which demonstrated 3 vessel disease. Cardiac surgery was consulted for surgical intervention. Meanwhile, patient was cleared from venous thrombosis in the lower extremity. His cardiac enzymes continue to increase, and Integrillin adjusted to renal function was started. His BP gradually decreased to SBP ~ 100 with borderline tachycardia. Later, he began to have chest pain and SOB at rest. After discussion with the cardiology fellow and the CCU, patient was transferred to CCU for requiring escalation of care. In the CCU, heparin drip, integrillin, ASA/Metoprolol continued. Plavix was held for anticipated CABG during admission. Integrillin was d/c [**6-23**] when CKs began trending downwards. CK peaked at 274, and MB peaked at 14. CABG was delayed because of blood culture drawn in the ED that was positive for staph aureus. Subsequent survaillence blood culture were negative, and after 8 days of antibiotics he went for CABG [**2153-6-28**]. He was taken to the operating room and underwent Coronary artery bypass graft x5 with left internal mammary artery to left anterior descending artery and saphenous vein grafts to obtuse marginal 1 and 2 as a sequential and saphenous vein grafts to diagonal and right coronary arteries. Please refer to Dr[**Doctor First Name **] operative report for further details. He tolerated the procedure well and was transferred to the CVICU in critical but stable condition. He awoke neurologically intact and was extubated without incident. He was weaned off drips, hemodynamically stable. Beta-blocker/ASA/Statin and diuresis resumed. Postoperatively [**Last Name (un) **] and ID were consulted for follow up recommendations regarding Mr.[**Known lastname **] IDDM management and right lower extremity osteomyelitis. Vancomycin was continued per ID recommendations x 6 weeks from operative date. #. Type 1 Diabetes. This is a long standing issue, and patient continued to use home insulin pump preoperatively, but sugar remained in the 300s. The patient follows with [**Last Name (un) **] as an outpatient, and he was switched to Lantus qHS with a humalog sliding scale. He was changed to an insulin drip [**6-27**] perioperatively. HgA1C was found to be 6.9 during admission. [**Last Name (un) **] followed postoperatively as well. Mr.[**Known lastname **] remained off of his Insulin pump postop per patient request. . # Leukocytosis. Patient had leukocytosis, as result of bacteremia and ACS Also had recent fever, suggestive of underlying inflammatory response or possible infection. No localized infection except for the chronic right foot infection. ESR and CRP are also found to be elevated. Blood cx was positive for coag + staph aureus 1x. No evidence of active osteomyeltis on foot xray. Fever resolved and white count was normal by day 5 of admission. ID was consulted. They recommended a 6 week course of IV therapy given known chronic osteomyelitis. Blood Cx grew MSSA, but ID recommended continuing vanco given Hx of MRSA in the foot. The patient was on doxycycline as chronic supressive therapy as an outpatient, but the organism isolated was resistant to tetracyclines. Vanco troughs were checked regularly and pharmacy doses were adjusted to trough and renal function. TEE was performed intraoperatively and did not show any evidence of endocarditis. . #. Chronic right foot infection, which was recently evaluated by podiatry [**2153-6-11**]. At the time, podiatry thought the wound was healing well. Foot X ray was neg for osteomyelitis. Vascular surgery did not think amputation was not necessary although the foot appears to be the source of bacteremia. Dr.[**Last Name (STitle) **] to follow up with pt 2-3 weeks out from rehab. . #. Anemia. Patient's previous lab testing showed chronic microcytic anemia. 2 units pRBCs were given [**6-22**], after which patient was at basline Hct of about 30 until [**6-27**] when Hct was 26; he recieved one unit pRBCs. Iron was resumed. Stable anemia. He continued to progress and was cleared by Dr.[**First Name (STitle) **] for discharge to home on POD #8. All follow up appointments were advised.[**First Name8 (NamePattern2) **] [**Last Name (un) **], he will not be using his insulin pump at this time, to be re-evaluated at f/u visit with them. Fixed dose and SSI will be used at discharge. Medications on Admission: - Metoprolol succinate 200 mg qHS - Simvastatin 40 mg, QD - Valsartan (Diovan) 160 mg, QD - ASA 81 mg QD - Doxycycline 100 mg, [**Hospital1 **] - Furosemide 40 mg, 2 tabs, [**Hospital1 **] - Glucagon PRN - Insulin Aspart pump (0.5 u/hr basal + bolus with 1:15 carb ratio) - omeprazol 20 mg EC, [**Hospital1 **] - Cialis 20 mg - Ferrous Sulfate EC 324 mg QD - MVI Discharge Medications: 1. Vancomycin 500 mg Recon Soln Sig: 1250mg Recon Solns Intravenous Q 24H (Every 24 Hours) for 6 weeks ( through mid-[**Month (only) 216**]) Disp:*qs Recon Soln(s)* Refills:*6* 2. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for fever, pain. 3. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) as needed for constipation. 4. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3 hours) as needed for pain. Disp:*50 Tablet(s)* Refills:*0* 5. Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2* 6. Furosemide 40 mg Tablet Sig: Two (2) Tablet PO twice a day. Disp:*120 Tablet(s)* Refills:*1* 7. 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* 8. Metoprolol Tartrate 100 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:*60 Tablet(s)* Refills:*2* 9. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 10. Simvastatin 80 mg Tablet Sig: One (1) Tablet PO at bedtime. Disp:*30 Tablet(s)* Refills:*2* 11. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: Five (5) ML Intravenous once a day as needed for line flush. Disp:*50 ML(s)* Refills:*2* 12. Outpatient Lab Work vanco trough, BUN,creatinine,CBC w diff,ESR,CRP weekly and FAX to ID RNs at [**Telephone/Fax (1) 1419**] 13. durable goods Wheelchair with leg elevation extensions and hospital bed 14. Lantus 100 unit/mL Solution Sig: Twenty (20) units Subcutaneous at bedtime. Disp:*10 bottles* Refills:*2* 15. insulin fixed dose ( above) and sliding scale (copy attached) Discharge Disposition: Home With Service Facility: [**Hospital 2255**] [**Name (NI) 2256**] Discharge Diagnosis: Non-ST elevation myocardial infarction CAD, s/p Coronary artery bypass graft x5 **h/o MRSA Hypertension Hyperlipidemia Type I Diabetes on insulin pump Peripheral Neuropathy Chronic Right foot ulcers s/p debridement [**2153-6-11**] by Dr. [**Last Name (STitle) **] from podiatry Right Charcot foot Chronic Renal Insufficiency (baseline creat 1.1-1.6) Congestive Heart failure Anemia GERD abnormal LFTs Chronic cough leg cramps s/p tonsillectomy s/p Right foot surgeries for osteomyelitis in [**2150**] (took out piece of bone and ligament) s/p removal of antibiotic beads in Right foot [**2152-2-10**] s/p Open reduction and internal fixation of comminuted right fifth metacarpal fracture, Closed reduction and internal fixation of right fourth metacarpal fracture [**2144**] s/p Exploration of right fifth metacarpal phalangeal joint with tenolysis of EDC tendon to five and EDQ tendon, Removal of hardware, MP joint dorsal capsulotomy [**2146-6-20**] s/p Incision and drainage of right foot, Debridement of fifth metatarsal with bone biopsy [**2148-3-14**] s/p mult I&Ds of right foot from [**2145**]-[**2152**] (Op notes in OMR 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 for a heart attack. 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. 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 cardiac surgery office with any questions or concerns ([**Telephone/Fax (1) 170**]). Answering service will contact on call person during off hours.** Prescribed Antibiotic Information Vancomycin 1 gram IV q 24 hours, goal trough 15-20 laboratory monitoring required: Weekly CBC with diff, BUN, Cr, vancomycin trough, ESR, CRP All laboratory results should be faxed to Infectious disease R.Ns. at ([**Telephone/Fax (1) 1353**] All questions regarding outpatient antibiotics should be directed to the infectious disease R.Ns. at ([**Telephone/Fax (1) 1354**] or to on [**Name8 (MD) 138**] MD in when clinic is closed. Followup Instructions: Surgeon: Dr.[**First Name (STitle) **] # [**Telephone/Fax (1) 170**] appointment arranged for Monday [**8-16**] at 1:45 pm Podiatry: Dr.[**Last Name (STitle) **] #[**Telephone/Fax (1) 543**] please call for follow up appointment in [**1-31**] weeks after rehab Cardiologist:[**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) 437**], follow up in [**12-30**] weeks after discharge PCP:[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] follow up in [**12-30**] weeks after discharge **Prescribed Antibiotic Information Vancomycin 1 gram IV q 24 hours, goal trough 15-20 ( 6 week course through mid [**Month (only) 216**]) laboratory monitoring required: Weekly CBC with diff, BUN, Cr, vancomycin trough, ESR, CRP All laboratory results should be faxed to Infectious disease R.Ns. at ([**Telephone/Fax (1) 1353**] All questions regarding outpatient antibiotics should be directed to the infectious disease R.Ns. at ([**Telephone/Fax (1) 1354**] or to on [**Name8 (MD) 138**] MD in when clinic is closed. [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**] Completed by:[**2153-7-6**] Name: [**Known lastname 4755**],[**Known firstname 33**] J. Unit No: [**Numeric Identifier 4756**] Admission Date: [**2153-6-20**] Discharge Date: [**2153-7-6**] Date of Birth: [**2100-5-27**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 265**] Addendum: Per infectious disease - Dose of vanco changed to 750mg IV q12hrs. Home solutions called and new script faxed. Also the [**Known lastname 4757**] called and notified. Discharge Disposition: Home With Service Facility: [**Hospital 197**] [**Name (NI) 198**] [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 266**] Completed by:[**2153-7-6**]

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icd9cm

[ [ [] ] ]

[ "88.72", "37.22", "36.14", "38.93", "39.61", "88.56", "36.15", "99.20" ]

icd9pcs

[ [ [] ] ]

18612, 18800

7181, 12054

339, 698

15529, 15529

3931, 7158

16876, 18589

2595, 2782

12467, 14260

14375, 15508

12080, 12444

15712, 16853

2797, 3912

280, 301

726, 1982

15544, 15688

2004, 2385

2401, 2579

27,759

108,077

13229

Discharge summary

report

Admission Date: [**2198-10-31**] Discharge Date: [**2198-11-7**] Date of Birth: [**2120-8-18**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2234**] Chief Complaint: rectal bleeding Major Surgical or Invasive Procedure: 1. Colonoscopy x 2 History of Present Illness: This is a 78-year-old woman who presents with two days of rectal bleeding. She had a colonoscopy with polypectomy on [**2198-10-25**]. The polyp was a 4 cm distal transverse [**Date Range 499**] polyp on a stalk that was completely removed using a single-piece polypectomy with a hot snare (path = adenoma, completely excised). She was also noted to have mild diverticulosis of the transverse [**Date Range 499**] as well as small internal hemorrhoids. She has actually had small amounts of red blood following straining and passage of firm stool over the past few months. Following her colonoscopy six days ago, she noticed again a small amount of red blood passing with each loose stool ([**12-24**] BMs/day, small volume, painless). She has not had any melena, fevers, chills, abdominal pain, nausea, or vomiting. She has not had any lightheadedness, or syncope. Over the past two days, she has had two episodes of larger amounts of hematochezia that turn the toilet bowel red. She has not used any aspirin or non-steroidal anti-inflammatory medications. In the Emergency Department, she was hemodynamically stable with a HR of 78 and a BP of 140/77. Her rectal exam was notable for red blood. Past Medical History: Diverticulosis History of [**Month/Day (3) 499**] adenomas Grade I internal hemorrhoids Adrenal insufficiency S/p adrenal tumor resection 30 years ago ? Social History: She lives alone. She does not smoke or drink alcohol. Family History: Her brother had [**Name2 (NI) 499**] cancer diagnosed in his 70's. Physical Exam: VITALS: T 96.6, HR 75, BP 159/92, RR 18, O2 sat 98 RA GEN: Well-appearing, thin female. No acute distress. HEENT: Anicteric sclera. Supple neck. No cervical or supraclavicular lymphadenopathy. Clear oropharynx. CV: RRR. ? Faint systolic murmur at the apex. LUNGS: CTAB. ABD: Soft. Normal bowel sounds. Nontender. Nondistended. ? CCY scar. Very little abdominal wall fat. Mildly protuberant abdomen that protrudes slightly to the left. Easily palpable aortic impulse which does not feel enlarged or diffuse. EXT: Trace bilateral pedal edema R>L. SKIN: No rashes and no jaundice. NEURO: Alert & oriented. Grossly non-focal exam. Pertinent Results: Admit labs: [**2198-10-31**] 04:00PM WBC-6.2 RBC-3.08* HGB-10.0* HCT-28.8* MCV-93 MCH-32.4* MCHC-34.7 RDW-14.4 [**2198-10-31**] 04:00PM NEUTS-77.7* LYMPHS-18.1 MONOS-3.2 EOS-0.8 BASOS-0.2 [**2198-10-31**] 04:00PM PLT COUNT-349 [**2198-10-31**] 04:00PM PT-12.3 PTT-30.0 INR(PT)-1.0 [**2198-10-31**] 04:00PM GLUCOSE-113* UREA N-22* CREAT-0.7 SODIUM-134 POTASSIUM-4.4 CHLORIDE-97 TOTAL CO2-30 ANION GAP-11 [**2198-10-31**] 04:00PM ALT(SGPT)-21 AST(SGOT)-24 ALK PHOS-53 AMYLASE-128* TOT BILI-0.4 . Dishcarge labs: [**2198-11-7**] 10:30AM BLOOD WBC-8.2 RBC-3.65* Hgb-11.4* Hct-34.0* MCV-93 MCH-31.2 MCHC-33.5 RDW-16.2* Plt Ct-369 [**2198-11-7**] 10:30AM BLOOD Plt Ct-369 [**2198-11-7**] 07:45AM BLOOD Glucose-86 UreaN-8 Creat-0.6 Na-137 K-3.9 Cl-100 HCO3-29 AnGap-12 [**2198-11-7**] 07:45AM BLOOD Mg-1.9 Please see OMR for details of multiple colonoscopies, angio, bleeding studies Brief Hospital Course: This is a 78-year-old woman who presents with hematochezia six days after colonoscopy with a polypectomy(done [**10-25**]). GI bleed: Patient admitted to floor transiently on [**10-31**]. Patient had syncopal episode with crit drop and transferred to ICU. Given 3 units pRBC's and colonoscopy on [**11-1**]. Demonstrated significant clots, no clear bleeding source. Angio done [**11-1**] negative. Patient transferred to floor [**11-2**] evening with stable crits. Began having recurrent hematochezia [**Date range (1) 18319**] with stable CBC. Bleeding scan [**11-5**] negative. REpeat colonoscopy on [**11-6**] with clipping to polypectomy site, stigmata of recent bleeding. Patient discharged on [**11-7**]-tolerated full diet, no further hematochezia, crit stable, hemodynamically stable. Patient instructed to follow up with her PCP for crit check late this week. Endocrine: Patient with history of pheo s/p resection, adrenal insufficiency and hypothyroidism. Patient on stress dose steroids in ICU in setting GI bleed. Transitioned back to outpatient PO regimen of hydrocortisone and fludrocortisone with stabilization of hematocrit. Maintained on levothyroxine outpatient dosing Hypertension: On labetelol as outpatient. Held in setting of GI bleeding. BP gradually increased to systolics in 160's-170's by [**11-5**] but very labile and on [**2203-11-8**] generally 130's to 140's. Labetelol not re-started. Patient will see her primary care doctor before re-starting labetelol Hypokalemia: Repleted throughout. 3.9 on day of discharge. Social: Paitent expressed decision to transition to [**Hospital 4382**]. Provided resources by case management and social work to assist with this. Medications on Admission: Florinef 0.1 mg daily Cortisone 12.5 mg [**Hospital1 **] Synthroid 100 mcg daily Labetolol 200 mg [**Hospital1 **] Discharge Medications: 1. Hydrocortisone 5 mg Tablet Sig: 2.5 Tablets PO BID (2 times a day). 2. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Fludrocortisone 0.1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). 5. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times a day). 6. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily). 7. Outpatient Lab Work CBC to be checked [**11-8**]. Results to Dr. [**Last Name (STitle) 40323**] at [**Hospital1 **]. Hematocrit 34 on [**11-6**]. Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: 1. Gi bleeding 2.Acute blood loss anemia Secondary: 1. Adrenal insufficiency 2. Hypothyroidism 3. Hypertension Discharge Condition: Stable, HD stable, hematocrit stable, tolerating PO's, ambulating Discharge Instructions: follow up as below all medications as prescribed. you should take all the medications you were taken before admission except for your labetolol for blood pressure. Hold this medication until you are seen by Dr. [**Last Name (STitle) 40323**]. Followup Instructions: Follow up with Dr. [**Last Name (STitle) 40323**] on Friday as scheduled. You should have a 'CBC' checked when you see Dr. [**Last Name (STitle) 40323**]. This is to make sure you are not still bleeding. I have given you a prescription for this. Your hmatocrit is 34 on discharge. You alos have the following previously scheduled appointment:Provider: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Last Name (NamePattern1) **], M.D. Phone:[**Telephone/Fax (1) 463**] Date/Time:[**2199-8-1**] 2:45

[ "V12.72", "E878.8", "244.9", "401.9", "276.8", "285.1", "998.11", "455.0", "255.41", "562.10", "458.0" ]

icd9cm

[ [ [] ] ]

[ "99.04", "45.23", "88.47" ]

icd9pcs

[ [ [] ] ]

6016, 6074

3502, 5216

332, 352

6228, 6295

2586, 3479

6589, 7113

1852, 1920

5382, 5993

6095, 6207

5242, 5359

6319, 6566

1935, 2567

277, 294

380, 1588

1610, 1764

1780, 1836

30,142

185,067

47802

Discharge summary

report

Admission Date: [**2162-3-23**] Discharge Date: [**2162-5-12**] Date of Birth: [**2099-6-29**] Sex: M Service: CARDIOTHORACIC Allergies: Penicillins / Heparin Agents Attending:[**First Name3 (LF) 1267**] Chief Complaint: STEMI EtOH withdrawal Major Surgical or Invasive Procedure: Cardiac catherization with stent placement pre-op Intubation/ Ventilation AVR ([**Street Address(2) 11688**]. [**Male First Name (un) 923**] Epic porcine valve) [**2162-4-22**] History of Present Illness: 62 year old male with PMH of asthma, OSA on CPAP, HTN and hyperlipidemia who presented to his PCP this morning after experiencing sudden onset right jaw pain. He states he felt unwell this morning. He went downstairs to have breakfast and experienced the right jaw pain. He then experienced substernal, non-radiating chest pain which did not improve. He endorses diaphoresis, denies nausea or vomiting. He had never experienced this in the past. The paramedics gave the patient 324 mg of aspirin, 5 of metoprolol, 4 mg of morphine. In the ED he received [**Month/Day/Year **] 600 mg, heparin, and eptifibatide. On review of systems, he denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, 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 paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. The patient endorses dyspnea on exertion. Past Medical History: Asthma Sleep Apnea on CPAP Renal stone removal Left patellectomy Hypertension Hypercholesterolemia pre-op delirium/confusion Social History: Social history is significant for the absence of current tobacco use. The patient quit smoking 7 years ago after smoking 1PPD for many years. He drinks several glasses of vodka/day. Family History: There is family history of heart disease in his mother (age unknown). His father had emphysema. Physical Exam: ON ADMISSION: ============== Gen: WDWN middle aged male in NAD. Oriented x 3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. Neck: Supple, unable to assess JVP CV: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. Chest: Resp were unlabored, no accessory muscle use. Limited anterior exam as patient is currently on bedrest, clear anteriorly. Abd: Obese, soft, NTND. Normoactive bowel sounds. Ext: +1 bilateral edema, both feet cool to touch Skin: Bilateral stasis dermatitis Groin site: pressure bandage in place with +ooze, no bruit, small hematoma Pulses: Right: Carotid 2+ DP 2+ PT 1+ Left: Carotid 2+ DP 2+ PT 1+ ON TRANSFER TO MICU: ===================== Vital Signs: T- 97.1 BP- 100/64 HR- 117 RR- 24 O2- 98% on RA . General: Patient is a middle aged male, disheveled, combative with slurring speech. Oriented to name, not place or year. Patient does not follow commands HEENT: NCAT, EOM appear intact, does not follow command to follow. Sclera anicteric. OP: MMM, no lesions Neck: Obese, no JVP Chest: Uncooperative with exam. Fair airmovement, relatively clear to auscultation anterior and posterior bilaterally with few course expiratory breath sounds Cor: Tachycardic. No obvious murmurs, rubs, gallops Abd: Obese, moderately distended. Firm but not rigid, hypoactive bowel sounds. Ext: hyperpigmented skin over LE, 1+ pitting edema bilaterally at level of ankles Neuro: Difficult to fully assess, patient combative and uncooperative CN: No facial droop, appears to move eyes in all directions. Pupils equally reactive Motor: Moves all extremities, attempts to get out of chair and requires fair amount of strength to keep from getting up Sensory: Unable to test Cerebellum: Unable to test Gait: Unable to test Pertinent Results: Cardic cath (prelim): COMMENTS: 1. Selective coronary angiography of this right dominant system demonstrated single (1) vessel coronary artery disease. The left main demonstrated no angiographically apparent atherosclerotic disease. The left anterior descending artery was calcified but demonstrated no angiographically obstructive disease. The left circumflex demonstrated no significant atherosclerotic disease. The right coronary artery demonstrated a 60% calcified ostial lesion along with a totally occluded right posterior lateral branch. 2. Limited hemodynamics demonstrated elevated right (RVEDP 17 mm Hg) and left (mean PCWP of 23 mm Hg) heart filling pressures. The cardiac index was preserved at 2.75 L/min/m2 via the Fick. 3. LV ventriculography was deferred. 4. Successful PTCA and stenting of the right posterior lateral branch with a Micro Driver (2.25x12mm) bare metal stent. Final angiography demonstrated no angiographically apparent dissection, no residual stenosis and TIMI III flow throughout the vessel (See PTCA comments). FINAL DIAGNOSIS: 1. One vessel coronary artery disease. 2. Normal ventricular function. 3. Acute inferior ST elevation myocardial infarction, managed by acute PTCA and stenting with a bare metal stent to the right posterior lateral branch. Renal US: FINDINGS: The right kidney measures 11.0 cm and the left kidney measures 11.6 cm. Both kidneys have a normal echogenicity, without hydronephrosis or calculi. The bladder is decompressed. IMPRESSIONS: 1. Interval resolution of right hydronephrosis. [**2162-5-10**] 05:42AM BLOOD WBC-6.2 RBC-3.19* Hgb-10.0* Hct-29.8* MCV-93 MCH-31.3 MCHC-33.6 RDW-16.0* Plt Ct-250 [**2162-5-10**] 05:42AM BLOOD Glucose-140* UreaN-9 Creat-1.2 Na-142 K-3.5 Cl-106 HCO3-24 AnGap-16 [**2162-5-7**] 05:20AM BLOOD ALT-18 AST-19 LD(LDH)-242 AlkPhos-115 Amylase-50 TotBili-0.9 [**2162-5-1**] 03:34AM BLOOD PT-15.1* PTT-25.5 INR(PT)-1.3* Conclusions 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. A bioprosthetic aortic valve prosthesis is present. The transaortic gradient is higher than expected for this type of prosthesis. No aortic regurgitation is seen. Trivial mitral regurgitation is seen. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. IMPRESSION: Normal global biventricular systolic function. Aortic valve bioprosthesis with higher-than-expected gradients. No aortic regurgitation. Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 171**], MD, Interpreting physician [**Last Name (NamePattern4) **] [**2162-5-6**] 16:58 [**2162-5-10**] 05:42AM BLOOD WBC-6.2 RBC-3.19* Hgb-10.0* Hct-29.8* MCV-93 MCH-31.3 MCHC-33.6 RDW-16.0* Plt Ct-250 [**2162-5-7**] 05:20AM BLOOD Neuts-69.7 Lymphs-18.3 Monos-7.2 Eos-4.6* Baso-0.2 [**2162-5-10**] 05:42AM BLOOD Plt Ct-250 [**2162-5-10**] 05:42AM BLOOD Glucose-140* UreaN-9 Creat-1.2 Na-142 K-3.5 Cl-106 HCO3-24 AnGap-16 [**2162-5-7**] 05:20AM BLOOD ALT-18 AST-19 LD(LDH)-242 AlkPhos-115 Amylase-50 TotBili-0.9 [**2162-5-7**] 05:20AM BLOOD Lipase-45 [**2162-4-20**] 02:15PM BLOOD proBNP-6148* [**2162-5-10**] 05:42AM BLOOD Calcium-9.7 Phos-3.9 Mg-1.6 [**2162-4-20**] 03:45AM BLOOD HEPARIN DEPENDENT ANTIBODIES- Brief Hospital Course: He presented with inferior STEMI for which he was loaded with [**Last Name (LF) **], [**First Name3 (LF) **], Heparin, Integrillin and taken to the cath lab where he had a BMS placed to the right posterior lateral branch. He was started on [**First Name3 (LF) **]. The patient initally had acute renal failure, which resolved with hydration. One day post-catherization the patient appeared to go into early DTs treated with ativan and valium. He was transferred to the MICU. On [**3-26**] he was intubated after aspirating for airway protection. He spiked a temp, blood cultures grew gram + cocci and he was started on vancomycin and gentamicin for urosepsis. His HCT fell, he was transfused, CT was negative for RP bleed. TEE showed aortic valve vegetation. He was seen by cardiac surgery and infectious diseases and cardiology. He was extubated on [**3-31**]. He was reintubated on [**4-1**] for respiratory distress. He was desensitized to and switched to ampicillin. Gentamicin was held for progressive renal failure. He was taken to the operating room on [**4-6**] where he underwent incision and debridement of deep abscess of the posterior lumbosacral spine which grew coag neg staph. Ecoli grew in his sputum and he was treated with a 7 day course of ceftriaxone. He was extubated on [**4-11**] and was subsequently reintubated for inability to protect his airway and decreasing sats. Repeat echocardiogram showed worsening vegetation and aortic root abscess. HIT antibody was very weakly positive, heme consult was called to confirm that low likelihood of HIT. He was taken to the operating room on [**4-22**] where he underwent an AVR (23mm St. [**Male First Name (un) 923**] tissue valve). He was transferred to the ICU in critical but stable condition on levophed and propofol. He had a right pneumothorax for which a chest tube was placed. He remained on mechanical ventilation, and was ultimately extubated on POD # 3, and pressors & inotropes were weaned off. He again developed a right pneumothorax, had a thoracic surgery consult, and had a tube placed with resolution. He was disoriented, and agitated, and remained in the ICU for the next week due to the need for observation, and was transferred to the telemetry floor on [**2162-5-4**] (POD # 12). Mental status has continued to improve over the next few days. He had numerous episodes of pauses and was re-evaluated by EP for further management. He has remained hemodynamically stable, and is ready to be discharged to rehab to progress with physical therapy/mobility. He is to remain on his Gentamicin until [**5-13**], and Ampicillin until [**6-2**] per the ID service. He should have labs as ordered twice weekly, faxed to the [**Hospital **] clinic ( Dr. [**Last Name (STitle) 976**]. Additional pauses noted on evening of [**5-10**], and EP re-evaluated him to determine that he did not need a pacemaker. His evening pauses appear to be consistent with vasovagal events and may be related to his sleep apnea. Cleared for discharge to rehab on POD #20. Pt. is to make all followup appts. as per discharge instructions. Medications on Admission: Advair 500 Spiriva 18 mvc Albuterol 17 g Singulair 10 mg Avapro 300 mg Hctz 300 mg Lipitor 20 mg Allopurinol 300 mg Folic Acid 600 mcg L-theqnine 100 mg Aspirin 81 mg Vicodin IC 5-500mg [**1-6**] tab q 6 hours PRN Gabapentin tid Discharge Medications: 1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 2. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed. 3. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush Mid-line, non-heparin dependent: Flush with 10 mL Normal Saline daily and PRN per lumen. 8. Ampicillin Sodium 2 gram Recon Soln Sig: Two (2) Grams Injection Q4H (every 4 hours) for until 5/28 days. 9. Gentamicin in Saline (Iso-osm) 80 mg/50 mL Piggyback Sig: Eighty (80) mg Intravenous Q24H (every 24 hours): Until [**2162-5-13**]. 10. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day for 10 days: for 10 days; may continue prn after 10 days. Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - MACU Discharge Diagnosis: endocarditis s/p AVR on [**4-22**] Dyslipidemia,Hypertension,CAD s/p PCI,Asthma,Sleep Apnea on CPAP, Renal stone removal,Left patellectomy, pre-op delirium Discharge Condition: good Discharge Instructions: Call with fever, redness or drainage from incision or weight gain more than 2 pounds in one day or five in one week. Shower, no baths, no lotions, creams or powders to incisions. No lifting more than 10 pounds for 10 weeks. No driving until follow up with surgeon or at least one month. Followup Instructions: Ortho spine follow Dr [**Last Name (STitle) 1007**] 2-4 weeks [**Telephone/Fax (1) 1228**] With Dr. [**Last Name (STitle) **] upon discharge for rehab, or in [**3-9**] weeks. With Dr. [**Last Name (STitle) 311**] in [**2-7**] weeks With Dr. [**Last Name (STitle) 911**] in 2 weeks Already scheduled apppointments: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 7380**],MD MPH[**MD Number(3) 708**]:[**Telephone/Fax (1) 457**] Date/Time:[**2162-6-1**] 9:30 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D. Phone:[**Telephone/Fax (1) 10464**] Date/Time:[**2162-7-22**] 8:00 Completed by:[**2162-5-12**]

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icd9cm

[ [ [] ] ]

[ "83.21", "99.04", "36.06", "37.23", "34.04", "00.45", "39.61", "88.56", "89.60", "38.93", "00.40", "99.07", "99.05", "96.6", "77.49", "00.66", "88.72", "35.21", "96.72", "33.24", "77.69", "96.04" ]

icd9pcs

[ [ [] ] ]

11806, 11872

7423, 10531

317, 495

12072, 12079

3994, 5051

12414, 13079

1979, 2077

10811, 11783

11893, 12051

10557, 10788

5068, 7400

12103, 12391

2092, 2092

256, 279

523, 1615

2106, 3975

1637, 1764

1780, 1963

1,594

127,894

11834

Discharge summary

report

Admission Date: [**2118-11-23**] Discharge Date: [**2118-11-25**] Date of Birth: [**2060-2-14**] Sex: M Service: NEUROLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 618**] Chief Complaint: Dizziness, arm tingling, weakness, and LLE weakness Major Surgical or Invasive Procedure: Head CT History of Present Illness: 58 yo man with h/o DMII, HTN, and metastatic rectal cancer with metastases to the lung, liver, and cerebellum presents with worsened unsteadiness and 2 episodes of left sided tingling, and possible dysarthria. He initially had his cerebellar mets diagnosed due to headache on a CT in [**2118-10-20**] and had a VP shunt placed by neurosurgery. He was started on decadron as well to taper at home. He had continued unsteadiness, but walked around with a cane okay. He reports that for the last 2 weeks, he has had worsened unsteadiness and has been very tired, sleeping a lot. He says he thinks this is due to his XRT treatments which finished 6 days prior to admission. He has not fallen. Then, the day of presentation, he was at home and had the gradual onset of tingling in his RUE with no [**Month (only) **] that lasted 1.5 hours. This came on slowly over 20-25 minutes. When it was present he also felt his arm was very weak and he could not lift it. He also had pain in that arm and felt as if a snake was wrapped around his arm and squeezing it. It was not moving clonically. It is unclear if it was tonic at times. At about the same time, his LLE was also weak, but this apparently started after his arm weakness and only lasted ~25 minutes before resolving. With all of this, he describes significant dysarthria. He is unclear about the timing of all of this. He then normalized, but came to the ED. While here, he had another episode where his arm felt squeezed and weak again for ~25 minutes. His LLE was not as affected this time. This resolved and he is currently at baseline. On admission, he has a mild global headache and feels unsteady as he has for the last 2 weeks. He has no other issues at this time. ROS: Patient denies any fever, chills, nausea, vomiting, dysphagia, neck pain, visual changes, hearing changes, chest pain, shortness of breath, or vertigo. Past Medical History: 1. carcinoma of the rectosigmoid junction and rectum - s/p low anterior resection in [**2115**] - Neo adjuvant chemo radiation ([**2115**]) - Six cycles of CPT-11, 5-FU and leucovorin ([**2116**]) - Ostomy reversal ([**2116**]) - seven cycles of the [**Doctor Last Name **] regimen with Avastin ([**2116**]) - 6 week cycles of FLOX chemotherapy ([**2118**]) - VP shunt placed by neurosurgery ([**9-/2118**]) 2. hypertension 3. diabetes Social History: He is from the DR [**Last Name (STitle) **] came here 40 years ago. No smoking or EtOH. Family History: Noncontributory; no cancer. Physical Exam: On admission: Vitals:98, 84, 121/54, 18, 94% on RA Gen:NAD. HEENT:MMM. Sclera clear. OP clear Neck: No Carotid bruits CV: RRR, Nl S1 and S2, no murmurs/gallops/rubs Lung: Clear to auscultation bilaterally Ext:No cyanosis/edema Neurologic examination: Mental status: Awake and alert, cooperative with exam, normal affect Orientation: Oriented to person, place, and date Attention: Able to do MOYB Language: Fluent with good comprehension and repetition. Naming intact. No dysarthria or paraphasic errors No apraxia, no neglect. No ext to DSS. Calculation intact Cranial Nerves: I: not tested II: Pupils equally round and reactive to light, 4 to 3mm bilaterally. Visual fields are full to finger movement. Fundi normal bilaterally. III, IV, VI: Extraocular movements intact bilaterally without nystagmus. V, VII: Facial sensation intact and symmetric. Left NLF flattening, but apparent normal excursion. VIII: Hearing intact to finger rub bilaterally. IX, X: Palatal elevation symmetrical [**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally. XII: Tongue midline without fasciculations, intact movements Motor: Normal bulk and tone bilaterally No tremor Full strength except for 5-/5 strength in IPs bilaterally. Left pronation but no drift. Sensation: Intact to light touch, pinprick, temperature (cold), vibration throughout all extremities. [**Month (only) **] proprioception in [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 6816**]. Reflexes: B T Br Pa Ankle Right 3 1 1 1 1 Left 3 1 1 2 1 Toes were downgoing bilaterally Coordination: Normal on finger-nose-finger, but slightly ataxic. FFM and [**Doctor First Name **] slow but not overly clumsy bilaterally. Gait: Very unsteady, even with his cane. He had to reach for objects to steady himself when he tried to walk. Pertinent Results: Admission labs: CBC: WBC-8.9 RBC-4.50* Hgb-13.5* Hct-41.4 MCV-92 MCH-30.0 MCHC-32.6 RDW-14.7 Plt Ct-274 Diff: Neuts-87.1* Lymphs-9.3* Monos-3.2 Eos-0.4 Baso-0.1 Coags: PT-12.5 PTT-22.0 INR(PT)-1.1 Chem10: Glucose-816* UreaN-25* Creat-1.1 Na-129* K-5.9* Cl-93* HCO3-27 Calcium-9.1 Phos-2.3* Mg-2.0 cardiac enzymes negative x 2 Imaging: CXR ([**11-22**]): Unchanged appearance of advanced metastatic disease, without discrete foci of consolidation. No radiographic evidence of congestive heart failure. HCT ([**11-22**]): A ventriculoperitoneal shunt is seen entering the right frontal region and terminating in the right frontal [**Doctor Last Name 534**]. Again seen is the large left cerebellar mass measuring 22 mm, similar in appearance to the previous study. It has a smaller amount of adjacent vasogenic edema. Also seen is the right cerebellar mass, similar in size, with new high density foci suggesting interval hemorrhage. Additionally, there is interval prominence of the extra- axial space outlining the right lateral frontal cerebral convexity, measuring 5 mm in thickness and exerting mild mass effect, though there is no shift of the normally midline structures. The volume of the lateral ventricles has decreased since the last examination. No evidence of acute major vascular territorial infarct is identified. Ethmoid air cells and other sinuses are clear. No fractures are seen. Burr hole for the right VP shunt noted. IMPRESSION: 1. Interval appearance of high-density material within the right cerebellar known metastasis representing hemorrhage. Similar appearance of left cerebellar metastasis to last exam. 2. New 5-mm crescentic subdural fluid collection along the right frontal lateral cerebral convexity, exerting very mild mass effect. NOTE ADDED IN ATTENDING REVIEW: The right transfrontal VP shunt is unchanged in position, terminating in the frontal [**Doctor Last Name 534**] of the right lateral ventricle, region of foramen of [**Last Name (un) 2044**]. However, there has been a marked change in the appearance of the lateral ventricular bodies since the [**2118-10-26**] study, which now appear more slit-like. In additon, there is a moderate-sized subdural collection layering over the right cerebral convexity, new, which may be seen with "intracranial hypotension." These findings, in the clinical context, are suggestive of "over-shunting". MRI ([**11-23**]): A right frontal approach ventriculostomy drainage catheter remains unchanged in position. Three cerebellar enhancing metastatic lesions are identified, two in the left cerebellar hemisphere and one in the right. These were present on the prior examination. The right cerebellar hemisphere lesion measures 2.7 x 2.4 cm and is largely unchanged. The larger of the two left cerebellar hemisphere lesions measures 2.6 x 2.7 cm and is slightly increased in size compared to the prior examination where it measured approximately 2.6 x 2.2 cm. The right cerebellar hemispheric lesion has an area of susceptibility artifact which corresponds to increased attenuation seen on the recent CT scan. Increased attenuation in the left cerebellar hemispheric lesion demonstrates decreased signal intensity on T2-weighted images. No susceptibility artifact is noted in this left cerebellar hemispheric lesion. There is a small amount of subdural fluid seen extending over the entire right cerebral convexity. Post-contrast images demonstrate dural enhancement over the right cerebral convexity. The ventricles as seen on the prior recent CT scan are much smaller in size compared to the CT from [**2118-9-30**]. There is no change in the position of cerebellar tonsils on the sagittal image. The suprasellar cistern is normal in appearance. IMPRESSION: 1. Increased right subdural fluid and enhancement of the dura with decrease in size of the ventricles suggest intracranial hypotension. This may be due to over shunting from the ventricular drainage catheter. 2. Multiple cerebellar metastatic lesions. The right cerebellar hemispheric lesion has an area of susceptibility artifact and corresponding to increased attenuation on the CT suggestive of intratumoral hemorrhage. The left hemispheric lesion has decreased T2 signal intensity corresponding to increased attenuation on the CT and likely represents calcification in a mucinous metastasis. MRI c-spine: wet read: No evidence of metastatic bone disease to the C-spine. No cervical cord compression or major cervical canal stenosis. Mild multilevel degenerative disk changes. EEG: official read pending, wet read no abnormalities. Brief Hospital Course: 58yo man with metastatic rectal ca and known cerebellar metastases and hemorrhage into mets, presents with two discrete episodes of left arm "tingling" or "twisting" into extension, no LOC, lasting 30mins, followed immediately by left leg weakness. This is most consistent with seizure, possibly from the right-sided subdural fluid collection seen on MRI. Other etiologies include hyperglycemia, direct effect from the bleed in the cerebellum, though this should not cause arm extension, TIA, though this is less likely, or compression of brainstem/c-spine, in which he would be expected to have more cranial nerve findings. He was initially admitted to the ICU for closer neurologic monitoring given the abnormalities of his posterior fossa. He was started on keppra 500mg [**Hospital1 **] and continued on decadron, with a slightly higher dose of 4mg q8h (after a 10mg bolus given in the ED). An MRI brain showed three cerebellar metastases with new hemorrhage into one of these metastases, as well as a new right-sided subdural fluid collection and small ventricles. MRI of the cervical spine was also performed, which showed no evidence of brainstem compression or cervical canal stenosis. The radiologists raised the question of overshunting, but this was discussed with the neurosurgical team and determined to be of no concern and requiring no change in management. In addition, he was severely hyperglycemic on arrival in the ED. He was treated with IVF and an insulin gtt, then started on NPH with resulting improvement of BS control. [**Last Name (un) **] was consulted for better glycemic control, and he was started on glargine and sliding scale insulin per their recommendations. He was discharged to [**Last Name (un) **] for an appointment with diabetic teaching. His hypertension was treated with metoprolol as with his home regimen. Medications on Admission: Metoprolol 25 tid Percocet Protonix Decadron 4 [**Hospital1 **] Discharge Medications: 1. Dexamethasone 4 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours). Disp:*90 Tablet(s)* Refills:*0* 2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 3. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. Insulin Glargine 100 unit/mL Solution Sig: Sixty (60) units Subcutaneous at bedtime. Disp:*QS 1 month units* Refills:*2* 5. Keppra 250 mg Tablet Sig: Two (2) Tablet PO twice a day: Please take 3tabs QAM and 2 tabs QPM x 3 days, then 3 tabs [**Hospital1 **] x 3 days, then 4 tabs QAM and 3 tabs QPM x 3 days, then 4 tabs PO BID. Disp:*240 Tablet(s)* Refills:*2* 6. Humalog 100 unit/mL Solution Sig: As directed units Subcutaneous QAC and QHS: For breakfast, lunch, and dinner, check your blood sugar and give the following insulin: For 80 to 120, give 20 units. For 121 to 160, give 23 units. For 161 to 200. For 201 to 240, give 29 units. For 241 to 280, give 32 units. For 282 to 320, give 35 units. For nighttime- check your blood sugar at 9PM. If it is 80 to 160, don't give any additional insulin. If 161 to 200, give 6 units. If 201 to 240, give 9 units. If 241 to 280, give 12 units. If 281 to 320, give 15 units. Disp:*QS 1 month QS 1 month* Refills:*2* 7. One Touch Basic System Kit Sig: One (1) Miscell. QAC and QHS. Disp:*1 * Refills:*2* 8. Diabetic Lancets and Test Strips Please dispense one month supply using the One Touch system. Patient checking sugars 4 times per day. 9. Insulin syringes Please dispense one month supply of syringes for insulin delivery. Insulin 5 times per day. Discharge Disposition: Home Discharge Diagnosis: Subdural fluid collection Seizure Other diagnoses: DMII, HTN, and metastatic rectal CA with metastases to the lung, liver, and cerebellum s/p VP shunt. Recently getting XRT and decadron taper Discharge Condition: Stable; some mild cerebellar signs on exam, no further episodes of left arm movements. Discharge Instructions: Please take all your medications as directed. Please attend all your follow up appointments. Call your doctor or return to the emergency room for any more left arm movement abnormalities, loss of consciousness, difficulty walking, headaches, dizziness, or any new, worsening, or concerning symptoms. Followup Instructions: Go immediately upon discharge to the [**Hospital **] Clinic for your 2:30pm appointment. Please follow up with these appointments: Provider: [**Name10 (NameIs) 706**] MRI Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2118-12-5**] 2:30 Provider: [**First Name11 (Name Pattern1) 640**] [**Last Name (NamePattern4) 4861**], MD Phone:[**Telephone/Fax (1) 1844**] Date/Time:[**2118-12-5**] 4:00 Neurosurgery will call you for a follow up appointment that should be in one to two weeks. If you do not hear [**Last Name (un) **] the, please call [**Telephone/Fax (1) **]. You will also need a repeat Head CT prior to the appointment. [**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 632**]

[ "V15.3", "V10.06", "431", "E932.0", "198.3", "781.2", "251.8", "197.7", "780.39", "197.0", "V45.2", "401.9" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

13036, 13042

9366, 11219

369, 378

13280, 13369

4766, 4766

13719, 14446

2873, 2902

11333, 13013

13063, 13259

11245, 11310

13393, 13696

2917, 2917

278, 331

406, 2292

3496, 4747

4782, 9343

2931, 3145

3184, 3480

3169, 3169

2314, 2751

2767, 2857

72,487

100,759

37779

Discharge summary

report

Admission Date: [**2154-8-30**] Discharge Date: [**2154-9-1**] Date of Birth: [**2081-12-11**] Sex: F Service: MEDICINE Allergies: Optiray 320 Attending:[**First Name3 (LF) 2290**] Chief Complaint: Post-operative hypoxia Major Surgical or Invasive Procedure: Debridement of tracheal nodule with interventional pulmonology History of Present Illness: 72 yo F with poorly differentiated squamous cell carcinoma of the lung who underwent rigid bronch [**2154-8-30**] (Friday) in the CDC for debridement of a nodule partially occluding the trachea (CT 09/[**2153**]). Patient was apneic post-operatively attributed to paralytics, for which she was intubated and placed on AC until the paralytic wore off. She was then weaned to CPAP and extubated to high flow facemask without difficulty. She was later switched to high flow face tent and then nasal canula 4L->2L and was comfortable sating 92%. On the floor, the patient was comfortable on 2L nasal cannula, sating 94%. Complains of coughing when taking deep breaths, but otherwise stable. She denies CP, N/V/D/C, dysuria, HA, vision changes, or depressed mood. Past Medical History: Poorly differentiated SCC of lung: - s/p right upper lobectomy and chemotherapy [**2148**] - left lower lobe nodule 1.4cm, non-diagnostic CT-guided biopsy, s/p CyberKnife CAD s/p Coronary angioplasty [**2139**], [**2151**], CABG x 3v [**2151**] H/o Infectious colitis [**2152**] HTN IDDM Hypercholesterolemia Bladder surgery [**2123**] Hernia repair [**2147**], S/p Cholecystectomy [**2147**] Social History: Former smoker, 80 pack year history. No EtOH or drugs. Married. Family History: Father with lung/bone cancer, mother relatively healthy until later yrs. Physical Exam: VS: 97.9 96.9 102/60 20 96%2LNC GEN: Pleasant, comfortable, NAD HEENT: PERRL, EOMI, anicteric, dry MM RESP: Wheezing throughout with Rhonchorous breath sounds CV: RR, S1 and S2 wnl, no m/r/g ABD: Soft, NT, ND, +BS, no masses or hepatosplenomegaly EXT: Trace edema in bilateral lower extremities SKIN: No rashes, fairly dry skin, surfaces intact NEURO: AOx3. CNII-XII, sensory, and motor grossly intact. Pertinent Results: [**2154-9-1**] 07:10AM BLOOD WBC-5.9 RBC-4.15* Hgb-12.1 Hct-35.8* MCV-86 MCH-29.1 MCHC-33.7 RDW-15.4 Plt Ct-170 [**2154-8-30**] 11:05AM BLOOD WBC-8.8 RBC-5.04 Hgb-14.4 Hct-44.7 MCV-89 MCH-28.5 MCHC-32.2 RDW-15.2 Plt Ct-230 [**2154-9-1**] 07:10AM BLOOD Plt Ct-170 [**2154-8-30**] 11:05AM BLOOD Plt Ct-230 [**2154-8-30**] 11:05AM BLOOD Glucose-269* UreaN-14 Creat-0.7 Na-142 K-4.3 Cl-104 HCO3-33* AnGap-9 [**2154-8-31**] 04:08AM BLOOD Glucose-136* UreaN-10 Creat-0.6 Na-141 K-3.7 Cl-105 HCO3-29 AnGap-11 [**2154-8-31**] 04:08AM BLOOD Calcium-8.2* Phos-3.0 Mg-1.8 [**2154-8-30**] 11:05AM BLOOD Calcium-8.5 Phos-4.1 Mg-2.1 [**2154-8-30**] 02:09PM BLOOD Type-ART pO2-97 pCO2-49* pH-7.37 calTCO2-29 Base XS-1 [**2154-8-30**] 10:26AM BLOOD Type-ART pO2-66* pCO2-55* pH-7.33* calTCO2-30 Base XS-0 Intubat-INTUBATED [**2154-8-30**] 10:26AM BLOOD Glucose-239* Lactate-2.2* Na-141 K-4.4 Cl-102 [**2154-8-30**] 10:26AM BLOOD Hgb-14.4 calcHCT-43 O2 Sat-89 COHgb-2.0 MetHgb-0 [**2154-8-30**] 10:26AM BLOOD freeCa-1.13 [**2154-8-30**] MRSA SCREEN MRSA SCREEN-PENDING [**2154-8-31**] Radiology CHEST (PORTABLE AP) Right upper, right perihilar, right lower lobe opacities consistent with improving hemorrhage or aspiration are unchanged. A left lung is grossly clear. There is no evident pneumothorax. Right lung peripheral opacities better evaluated in prior CT [**8-5**] and are unchanged. [**2154-8-31**] Radiology CHEST (PORTABLE AP) There has been markedly improved in right upper, right perihilar and right lower lobe opacities consistent with improving hemorrhage or aspiration. Cardiomediastinal contours are unchanged with mild-to-moderate cardiomegaly. There is no evident pneumothorax. Of note, the lateral aspect of the left hemithorax was not included on the film. There are no increasing right pleural effusions. Sternal wires are aligned with fracture of the first wire. [**2154-8-30**] Radiology CHEST (PORTABLE AP) FINDINGS: In comparison with the earlier study of this date, the endotracheal tube has been removed. The diffuse area of opacification involving the perihilar region extending into both the apical and lower zone on the right is again seen. Again, this could well represent post-procedure hemorrhage, though supervening pneumonia cannot be excluded. [**2154-8-30**] Radiology CHEST (PORTABLE AP) IMPRESSIONS: Extensive right central and upper lung airspace opacity, which may reflect hemorrhage from the recent procedure, or asymmetric pulmonary edema. [**2154-8-30**] Pathology Tissue: Tracheal tumor Distal , [**2154-8-30**] [**Last Name (LF) 829**],[**First Name3 (LF) 828**] C. Not Finalized Brief Hospital Course: # Apnea/Hypoxia: The patient experienced apnea in the immediate post-operative period following debridement of a tracheal nodule. The apnea was thought to be attributed to paralytics, which warranted intubation. When the paralytic agents wore off, the patient was extubated, but remained hypoxia. The prolonged hypoxia post-operatively was attributed to aspiration pneumonitis likely with an element of post-operative inflammation from the procedure itself. The patient remained rhoncorous with course upper airway breath sounds throughout the hospitalization. CXR ruled out PNA as a potentialy source of hypoxia, and the patient did not produce significant volumes of concentration of blood in the sputum concerning for tracheal bleed. Other possibilities include worsening of underlying lung cancer which is unlikely to explain acute hypoxia. The patient was eventually transitioned to high flow face mask, followed by high-flow face tent, followed by nasal cannular on 4L. The patient was weaned without event from 4L to 2L nasal cannula and transferred to the inpatient medical floor, where she continued sat'ing ~94% on 2L. Nebs were administered on an as needed basis throughout the duration of hospitalization, and were found to be helpful in terms of coughing up phlegm. The patient was taken off supplemental oxygen the following day and sat'ed within her normal baseline range 88-92% on room air without any problems at rest. However, patient desaturated with physical therapy during activity. They recommended home oxygen (2L with activity)when ambulating with a walker. The patient will be discharged with home oxygen as well as VNA services. . # Hct Drop: The patient presented with a Hct 44.7 and found to have a Hct of 33.1 post-operatively. The low Hct is most likely attributable to fluids received during procedure and minimal blood loss, however given the 12 point drop, her lab values were followed and the Hct level was stable and began to rise without event or concern for chonic blood loss. Hct 34.0->35.8 this AM. . # Non-Small Cell Lung CA: A new tracheal mass identified on CT in [**Month (only) **] was highly concerning for metastasis and likely to grow to occlude airway the airway, so surgical debridement was warranted with interventional pulmonology without intraoperative complications outside of apnea/hypoxia as elaborated on above. The patient is now POD#2 s/p debridment by IP. Biopsy results are pending. She is followed by interventional pulmonology for continued management. . # Goals of Care: Discussed code status with patient, daughter and sons. [**Name (NI) **] quite clearly does not desire intubation or heroic measures. Daughter is having a difficult time with this but understands and respects her mother's wishes. The DNR/DNI status was confirmed with the patient and her health care proxy. . # IDDM: Continued home glargine and home meds. . # HTN: Continued amlodipine, lopressor and ASA. . # Hyperlipidemia: Continued home statin. Medications on Admission: AMLODIPINE 5 mg daily ESOMEPRAZOLE 40mg qd GLARGINE 8 units daily @ night LORAZEPAM 1mg [**Hospital1 **] METOPROLOL 150 mg [**Hospital1 **] REPAGLINIDE 0.5 mg tid SIMVASTATIN 40 mg qd ASPIRIN 81 mg daily FAMOTIDINE qd Discharge Medications: 1. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Tablet(s) 2. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 3. insulin glargine 100 unit/mL Solution Sig: Eight (8) units Subcutaneous at bedtime. 4. lorazepam 0.5 mg Tablet Sig: Two (2) Tablet PO twice a day as needed for insomnia. 5. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. repaglinide 0.5 mg Tablet Sig: One (1) Tablet PO three times a day. 8. Aspirin Low Dose 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 9. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain. 10. ipratropium-albuterol 18-103 mcg/Actuation Aerosol Sig: [**11-24**] puffs Inhalation every 4-6 hours as needed for shortness of breath or wheezing. Disp:*1 IH* Refills:*2* 11. Oxygen 2L nasal canula with ambulation 12. famotidine 20 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home With Service Facility: [**Location (un) 932**] Area VNA Discharge Diagnosis: Primary: Aspiration-induced hypoxia Secondary: Poorly differentiated SCC of lung: - right upper lobectomy and chemotherapy [**2148**] - left lower lobe nodule 1.4cm, non-diagnostic CT-guided biopsy, s/p CyberKnife Coronary artery disease: Coronary angioplasty [**2139**], [**2151**], CABG x 3v [**2151**] Infectious colitis [**2152**] Hypertension Insulin-dependent diabetes mellitus Hypercholesterolemia Bladder surgery [**2123**] Hernia repair [**2147**] Cholecystectomy [**2147**] Tracheal nodule debridement [**8-/2154**] Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane) and supplemental oxygen. Discharge Instructions: You were admitted to the [**Hospital 18**] hospital for surgical debridement of a tracheal nodule that was contributing to your difficulty breathing. You underwent this procedure with the interventional pulmonologists. After surgery you were found to have difficulty breathing and decreased oxygen levels that were thought to be a result of both the paralytic [**Doctor Last Name 360**] used during surgery as well as the possibility that you aspirated fluids into your trachea/lungs during surgery. As such, you were intubated and transferred to the medical intensive care unit (MICU) for respiratory care and support. In the MICU, your blood oxygen levels improved over the course of a day on supplemental oxygen and you were transitioned from a face-mask to a face-tent to a nasal cannula on supplementary oxygen. When your oxygen levels stabilized, you were transferred to the inpatient floor, where you were eventually weaned off of supplementary oxygen. You were breathing stable at your baseline blood oxygen levels on the inpatient floor at rest, but were found to be significantly short of breath with activity. As such, physical therapy has recommended home oxygen, as well as instructed you to walk with a walker. We have set up visiting nursing to assist you with your home oxygen, as well as evaluating you for home safety and continued physical therapy. The following changes were made to your at-home medications: 1) Added Home oxygen. 2) Added Albuterol-Ipratropium inhaler. Please take 1-2 PUFFs every 4-6 hours as needed for shortness of breath or wheezing. No other changes were made to your at-home medications. Please continue taking them as instructed. 3) Decreased your metoprolol to 50 mg twice a day from 150 mg Followup Instructions: Please follow-up with your primary care physician 7-10 days following discharge. Completed by:[**2154-9-1**]

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Discharge summary

report+addendum+addendum

Admission Date: [**2106-12-6**] Discharge Date: [**2106-12-15**] Date of Birth: [**2045-5-19**] Sex: F Service: CT Surgery HISTORY OF PRESENT ILLNESS: The patient is a 61 year old female with a long history of mitral valve prolapse. Over the last several months, she has experienced increased shortness of breath and fatigue. Echocardiogram had shown progression of her mitral regurgitation at 3+ to 4+ with a left ventricular ejection fraction of approximately 25%. Cardiac catheterization revealed nonobstructive coronary artery disease. Elevated filling pressures with a prominent V wave are consistent with severe mitral regurgitation as seen by cardiac catheterization. The patient was counseled on the risks and benefits and, therefore, agreed to have her mitral valve repaired with a bioprosthetic mitral valve. PAST MEDICAL HISTORY: 1. Pyelonephritis. 2. Degenerative joint disease. 3. Hypertension. 4. Fibromyalgia. 5. Chronic renal insufficiency. 6. Hiatal hernia. PAST SURGICAL HISTORY: 1. Breast biopsy. 2. Elbow surgery. 3. Total abdominal hysterectomy and bilateral salpingo-oophorectomy in the past. MEDICATIONS ON ADMISSION: Hydralazine, Plaquenil, Premarin, desipramine, multivitamins, Darvocet, Zantac and Ativan. LABORATORY DATA: Admission chest x-ray was notable for bilateral pleural effusions. Admission white blood cell count was 6, hematocrit 39 and platelet count 279,000. Urinalysis was unremarkable. Admission sodium was 141, potassium 3.9, chloride 99, bicarbonate 23, BUN 27, creatinine 1.7, prothrombin time 12.8, and partial thromboplastin time 25.3. HO[**Last Name (STitle) **] COURSE: The patient was taken to the Operating Room by Dr. [**Last Name (Prefixes) **] on [**2106-12-6**], where she underwent a thoracic approach with a mitral valve repair using an annuloplasty band prosthesis, serial number [**Serial Number 104594**], model number 4600, [**Doctor Last Name **] Life Sciences valve. Postoperatively, the patient remained intubated and was sent to the CSRU, where she was being maintained on Levophed, milrinone and propofol secondary to her labile intraoperative pressures and labile postoperative pressures. The patient remained intubated overnight. The next morning she was transfused three units to keep her hematocrit above 26 postoperatively. Her hematocrit was 35 on postoperative day number one. She was noted to have pulmonary artery pressures of 33/29 and cardiac output of 2.66 and index of 1.8. She was still being maintained with Levophed and milrinone and Neo-Synephrine as well as a propofol drip for sedation. The plan on postoperative day number one was to wean support as long as she was hemodynamically stable. The patient's hematocrit was followed serial and she was transfused to maintain a hematocrit greater than 30. Her milrinone was weaned as tolerated. Given her labile pressures postoperatively, she did receive an echocardiogram on [**2106-12-7**], which showed right ventricular failure and anterior wall hypokinesis. She was maintained with an intra-aortic balloon pump from [**2106-12-7**] into [**2106-12-8**], as well as pressors. Her increasing pressor requirement and balloon pump requirement was concerning, however, the patient did not sour clinically. Tube feeds were started because the patient was unable to be extubated and did not tolerate this hemodynamically. Her platelet count was noted to drop down to 94,000 on postoperative day number two. Her BUN and creatinine were 19 and 1.2, down from the admission of 1.7. Her coagulation profile had a prothrombin time and INR of 14 and 1.4 and partial thromboplastin time of 34 with an ionized calcium of 1.3. The patient failed to wean to extubate until [**2106-12-9**]. Her follow-up platelet count was noted to be 52,000 and it was thought that a medication such as Zantac or heparin or the balloon-pump, etc, or an indwelling catheter, such as the Swan-Ganz catheter, may be contributing to her thrombocytopenia. Therefore, all of the potentially inciting medications were discontinued. Her balloon-pump was discontinued after five packs of platelets were transfused. A HIT panel was sent for analysis that ultimately returned as positive. By postoperative day number three, the patient was neurologically stable and alert. She was on Percocet for pain. A chest x-ray showed large bilateral effusions. Her milrinone and hydralazine were discontinued and she was started on Lopressor. Nipride was weaned as tolerated. She was given albumin and Lasix as well. She was started on a diet with supplements. By postoperative day number four, the patient was noted to be somewhat confused and agitated. It was felt to be secondary to mild Intensive Care Unit psychosis. She was not hypoxic or severely volume depleted in any way or over-medicated. The patient was discharged to the floor with a sitter. She was started on hydralazine 10 mg every six hours as well as aspirin. Her Swan-Ganz catheter was moved to central venous pressure. On postoperative day number five, the Cordis was removed and the patient had a peripheral intravenous line placed. Her pacing wires were removed. Physical therapy and rehabilitation screening began. The patient was tolerating a diet and ambulating in the hallway. Her pain was being controlled. She was voiding spontaneously and reported a bowel movement. The chest tube, however, continued to have moderate to high output and was therefore maintained until postoperative day number eight, when it was discontinued. A follow-up chest x-ray showed bilateral pleural effusions with no pneumothorax. The effusions were stable, if not improved. Ultimately, the patient was slated for discharge to a rehabilitation facility the following day, on postoperative day number nine. She is stable and doing well. Her discharge examination is noted for a stable sternum with clean, dry and intact wound with Steri-Strips. She has a dressing over the superior abdomen, the site of her previous wire and chest tube insertion sites, which can be removed two days after discharge. The patient's heart is regular. She has decreased breath sounds at the bases bilaterally, no crackles. Abdomen is benign. Extremities are warm and well perfused with normal pulses. CONDITION ON DISCHARGE: Stable. DISCHARGE STATUS: The patient is being discharged to a cardiac rehabilitation facility. DISCHARGE DIAGNOSIS: History of mitral valve prolapse with severe mitral regurgitation and left ventricular ejection fraction of 30%, status post mitral valve repair #26 CE rim, complicated by postoperative right ventricular failure and anterior wall hypokinesis requiring intra-aortic balloon pump resuscitation; currently, patient is stable, afebrile and appropriate for discharge to a rehabilitation facility. [**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**] Dictated By:[**Last Name (NamePattern4) 3204**] MEDQUIST36 D: [**2106-12-14**] 11:46 T: [**2106-12-14**] 12:13 JOB#: [**Job Number **] Name: [**Known lastname 16968**], [**Known firstname **] Unit No: [**Numeric Identifier 16969**] Admission Date: [**2106-12-6**] Discharge Date: [**2106-12-15**] Date of Birth: [**2045-5-19**] Sex: F Service: CA/TH [**Doctor First Name 1379**] DISCHARGE MEDICATIONS: Includes Plaquenil 200 mg po bid, Premarin 0.625 mg po q day, desipramine 25 mg po q HS, Ativan 1.0 mg po q day, Hydralazine 10 mg po q six hours, Protonix 40 mg po q day, Neurontin 300 mg po q day, Percocet 5.0 mg, oxycodone 325 mg, Tylenol one to two tablets po q four to six hours prn, Colace 100 mg po bid, as well as aspirin 325 mg po q day, clonidine patch 0.3 mg po q week, and recommendations to take Boost supplements, one can po tid with meals. [**Doctor Last Name **] [**Last Name (Prefixes) **], M.D. [**MD Number(1) 681**] Dictated By:[**Last Name (NamePattern4) 935**] MEDQUIST36 D: [**2106-12-14**] 12:05 T: [**2106-12-17**] 09:06 JOB#: [**Job Number 16970**] Name: [**Known lastname 16968**], [**Known firstname **] Unit No: [**Numeric Identifier 16969**] Admission Date: [**2106-12-6**] Discharge Date: [**2106-12-18**] Date of Birth: [**2045-5-19**] Sex: F Service: Cardiothoracic Surgery ADDENDUM: This is an addendum to the Discharge Summary that was dictated on [**2106-12-14**]; as follows: On [**12-14**] the patient's chest tubes were discontinued. Her pacing wires were out already. Discharge Summary up through the [**12-14**] was dictated already. Discharge planning continued with a rehabilitation scan and continuing physical therapy. Laboratories did show the patient had heparin-induced thrombocytopenia. She had no complaints on [**12-15**]. Her shortness of breath was improved. She had a temperature maximum of 96, blood pressure 110/50, heart rate of 62, satting 96% on room air. Her sternum was stable. She had no drainage. She did have a sternal click. Her heart was regular in rate and rhythm with no murmur. She had decreased breath sounds at the apices bilaterally. She had trace peripheral edema. Chest x-ray showed bilateral apical pneumothoraces, but the patient was clinically asymptomatic. Discharge continued. The patient continued to be out of bed and moving with Physical Therapy, and a repeat chest x-ray was ordered. The patient was seen by the Electrophysiology Service also on [**12-15**], and the prior evening she was noted to have a 7-beat run of wide complex. She was asymptomatic. Then she had another 4-beat episode, also asymptomatic, shortly thereafter. She was having no chest pain at that time, and other than her intermittent shortness of breath she has been stable after surgery. The patient did describe brief palpitations every few days. On [**12-15**], her laboratories were white blood cell count of 10.8, hematocrit 34.8, platelet count of 175,000. A potassium of 3.3, blood urea nitrogen 39, creatinine 1.3. Calcium 8.5, magnesium 1.1, and PO4 of 4. Electrophysiology said from their standpoint it was not entirely clear whether it was truly ventricular tachycardia, probably supraventricular tachycardia with aberrancy. Regardless of this, she has no underlying coronary artery disease, and there was no reason to pursue this. They rather favored medical optimization by continuing her beta blocker for congestive heart failure, continuing to diuresis her with Lasix, and getting her going with improved afterload reduction. Since the patient did not tolerate ACE inhibitors in the past, different drugs would be tried to replace the hydralazine she was on, and it was recommended that she follow up with Dr. [**Last Name (STitle) 16971**] as an outpatient after her discharge. The patient was also seen by Case Management again on [**12-15**]. Electrophysiology, Dr. [**Last Name (STitle) **], also recommended possibly repeating her echocardiogram and adding digoxin, discontinuing her clonidine, and considering angiotensin receptor blocker. On [**12-16**], she had no complaints and again was followed by the Electrophysiology Service. She was seen again by the Electrophysiology Service who noted no new laboratories. Dr. [**Last Name (STitle) **] noted that the supraventricular tachycardia strips in her heart and recommended using digoxin and a beta blocker and continuing to replete her electrolytes and nutrition. She continued to be followed by Rehabilitation Service and Physical Therapy. On postoperative day 11, she had no complaints. She was ambulating with Physical Therapy without any dizziness or lightheadedness. She did have some occasional shortness of breath. She had a temperature maximum of 98. Her blood pressure was 95/51. She was satting 96% on room air. She had decreased breath sounds at both bases bilaterally, but no crackles. Her heart was regular in rate and rhythm with no murmur. Her abdominal examination was negative. She had trace pretibial edema, but her extremities were warm. A chest x-ray was ordered. Laboratories were to be repeated. She continued to ambulate with an assist, and her blood pressure medications continued to be titrated. Dr. [**Last Name (STitle) **] also made a couple of other suggestions as to her blood pressure regimen of medications to optimize affects, and on [**12-18**], on postoperative day 12, her blood pressure remained in the 90s. She had no orthostatic symptoms. Her shortness of breath was improved. She was feeling well. Her sternum was clean, dry, and intact. Her lungs were clear bilaterally. There was no sternal drainage. She had some trace edema of her extremities. She had instructions to follow up with Dr. [**First Name (STitle) **] on Monday, [**12-20**], and adjustments would be made in her medications, to continue with antihypertensives as well as adjusting her Lasix and digoxin as needed. MEDICATIONS ON DISCHARGE: (Her discharge medications which were listed on [**12-15**] were as follows) 1. Plaquenil 200 mg p.o. b.i.d. 2. Premarin 0.625 mg p.o. q.d. 3. Desipramine 25 mg p.o. q.h.s. 4. Ativan 1 mg p.o. q.d. 5. Protonix 40 mg p.o. q.d. 6. Neurontin 300 mg p.o. q.d. 7. Percocet 5/325. 8. Oxycodone. 9. Tylenol one to two tablets p.o. p.r.n. q.4-6h. 10. Colace 100 mg p.o. b.i.d. 11. Aspirin 325 mg p.o. q.d. 12. Boost supplements as needed, one can p.o. t.i.d. with meals. 13. Digoxin 0.125 mg p.o. q.o.d. It was unclear as to what her final dose of Lasix was at discharge, but it appears it might be Lasix 10 mg p.o. q.d. with K-Dur 20 mEq p.o. q.d. The patient was also slated to be discharged on Cozaar 50 mg p.o. q.d., but doses were being held for her relative hypotension as well as Lopressor 12.5 mg p.o. b.i.d. which was also being held for her low blood pressure. DI[**Last Name (STitle) 1390**]E INSTRUCTIONS: The patient was given instructions to follow up with her cardiac surgeon, Dr. [**Last Name (Prefixes) **], as well as with Dr. [**First Name (STitle) **] on Monday, [**12-20**] for adjustments in her medications. DISCHARGE STATUS: Again the patient was discharged to rehabilitation on [**2106-12-18**]. [**Doctor Last Name **] [**Last Name (Prefixes) **], M.D. [**MD Number(1) 681**] Dictated By:[**Last Name (NamePattern1) 981**] MEDQUIST36 D: [**2107-2-15**] 10:27 T: [**2107-2-17**] 12:47 JOB#: [**Job Number **]

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icd9cm

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Discharge summary

report

Admission Date: [**2149-9-25**] Discharge Date: [**2149-9-29**] Date of Birth: [**2088-9-16**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 898**] Chief Complaint: Fever, Dysuria Major Surgical or Invasive Procedure: Right Internal Jugular Central Line History of Present Illness: 61 yo with hx of Multiple Myeloma with amyloidosis that has been in remission presented to ED today with few days of urinary symptoms, including increased frequency, hesitancy, dysuria and flank pain. Initially she wasn't having temps and was trying to get an appt with covering PCP, [**Name10 (NameIs) **] today was spiking temps to T 102-103 and came in to the ED for evaluation. On arrival here was normotensive with tachycardia BP 139/65 HR 110 then started spiking to T 103.9 and BP [**Last Name (un) 19262**] to 80/50 with leukocytosis, bandemia and positive UA. Initially she was given levoflox 500mg IV x1 and then after starting sepsis protocol rec'd Ceftriaxone 1gm x1 and Vanc 1gm x1 and 4LNS. She had a renal ultrasound to r/o hydro. . She overall feels better here in [**Hospital Unit Name 153**], notes also vague abd pain in suprapubic region, but no n/v/d, +decreased appeitite for a few days. No other localizing symptoms including cough, SOB, CP or sick contacts. [**Name (NI) **] recent steroid or abx use. . Past Medical History: PMHx: - Osteopenia s/p zometa infusions - HTN - bladder/tongue amyloid - DVT [**2142**] L IJ, L sup femoral, L popliteal - s/p tonsillectomy - Epiglottitis x 2 - Hx of disseminated herpes in [**2146**] - Urge incontinence - +flu shot, +pneumovax . Onc Hx: Multiple myeloma stage III with amyloidosis dx'd in [**2142**], s/p melphalan, vincristine, adria and prednisone and then vincristine, doxorubicin and dexa, with recurrence followed by auto BMT and then mini-allo-BMT in 99 and again with recurrence had donor lymphocyte infusion from brother in [**2145**] Social History: Married and lives in [**Location 3786**], 2 children, one grandson, no etoh/tobacco, retired law office manager Family History: Hyertension, no malignancies Physical Exam: VS: T 97.2 P75 BP 90/36 RR20 Sat 98%on 4L NC SvO2 of 68% GEN aao, nad, pleasant woman, comfortable appearing HEENT PERRL, dry MM, +scleral icterus, Rij in place CHEST CTAB no wheezes, bibasilar crackles CV RRR, no murmurs, +scar on left chest from adrio extravasation ABD soft, +BS, +suprapubic tenderness EXT no edema, 2+DP bilaterally Pertinent Results: GLUCOSE-128* UREA N-47* CREAT-1.9* SODIUM-138 POTASSIUM-4.0 CHLORIDE-95* TOTAL CO2-27 LACTATE-1.2 FIBRINOGE-1050*# D-DIMER-1624* FDP-0-10 CORTISOL-53.0* CK-MB-2 cTropnT-<0.01 UA: RBC-[**3-29**]* WBC->50 BACTERIA-MANY YEAST-NONE EPI-0 BLOOD-LG NITRITE-NEG PROTEIN->300 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-0.2 PH-6.5 LEUK-MOD Renal USG: No hydronephrosis. Echogenic kidneys consistent with medicorenal disease. . CXR: mild cardiomegaly, large hiatal hernia, no infiltrates, RIJ in SVC . Echo [**2149-9-27**]: Left atrium is mildly dilated. There is severe global left ventricular hypokinesis with apical and anterior akinesis. Overall left ventricular systolic function is severely depressed (20%). Moderate [2+] tricuspid regurgitation is seen. There is borderline pulmonary artery systolic hypertension. LUE U/S negative for DVT. Stool culture negative for C diff. Brief Hospital Course: 61 yo woman with h/o MM admitted with urosepsis. . 1. Urosepsis: Urine and blood cultures grew out E.coli pansensitive except resistant to Bactrim. Renal ultrasound was negative for hydronephrosis. The patient was initially treated with Ceftriaxone and Vancomycin x 1 in the ED and Levaquin. Ms. [**Known lastname **] was continued on Levaquin and later Ceftriaxone was added for gram negative coverage. The sepsis protocol was intiated in the ED and continued in the ICU with set goals of SvO2 >70, CVP 8-12, MAP >65. The patient's condition improved overnight with fluids and antibiotics. The patient was transferred to the medical floor where she was afebrile with stable vital signs and continued to receive ceftriaxone and levofloxacin until final sensitivites returned, at which time she was changed to PO levofloxacin only. She was sent home with PO levo to complete a 14 day course of therapy. . 2. Acute SOB: In the ICU, the patient became acutely hypoxic and tachy to 126 on the day after admission, and was put on a non-rebreather with improvement. She was net positive 4L in the unit, and CXR showed fluid overload. She improved with IV Lasix as well as verapamil. Bedside echo at that time showed EF of 20% and severe global LV hypokinesis. We have no echos for comparison so it is unknown whether this is a new decrease in EF in setting of sepsis or whether this is secondary to some past insult, for example the patient's past doxorubicin treatment. Her fluid status was monitored on the floor and she received Lasix once prn SOB with improvement and good output of urine. On the day prior to admission the patient no longer required oxygen supplementation and retainedgood O2 sats. Per cardiology recommendation, the patient should be followed with an outpatient echo in [**1-26**] weeks and an outpatient cards follow up. . 3. ARF: On admission the patient's Cr was 1.9, up from baseline 0.9. This likely represents prerenal failure, as the patient appeared dry and responded to fluids by normalizing her creatinine. After large diuresis in the unit, urine lytes were ordered, and patient did not have nephrotic-range proteinuria. 4. Multiple myeloma: Ms. [**Known lastname **] has had extensive treatment in past w/ multiple recurrences - currently in remission, recent SPEP/UPEP wnl, beta2microglobulin has been stable. There was a question of atypical cells seen on a blood smear here. We held off on repeat SPEP, UPEP given recent normal. The patient has a follow up appointment with her oncologist at [**Hospital3 2576**] Hospital in 2 weeks. . 5. L arm swelling: On the day prior to discharge it was noted that the patient's L arm was larger than the right. It was nontender, however given the patient's history of DVTs and the prior placement of IVs and blood draws in this arm during her stay, [**Doctor Last Name **] u/s was ordered and was negative for DVT. 6. Diarrhea: on the day prior to discharge the patient experienced several episode of "green" diarrhea, which was sent for culture and was negative for C diff toxin. 7. The patient was full code and she expressed that her husband should be her health care proxy should it become necessary. Medications on Admission: - Hctz 25 mg daily - Verapamil 180 mg daily - Ditropan XL 5 mg [**Hospital1 **] - Protonix 40 mg daily - Calcium 1500mg daily Discharge Medications: 1. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once a day. 2. Verapamil 240 mg Cap, 24HR Sust Release Pellets Sig: One (1) Cap, 24HR Sust Release Pellets PO once a day. Disp:*30 Cap, 24HR Sust Release Pellets(s)* Refills:*2* 3. Oxybutynin Chloride 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 5. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times a day). 6. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 11 days. Disp:*11 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: 1) Urosepsis 2) Bacteremia 3) Cardiomyopathy Discharge Condition: Stable Discharge Instructions: Please call your doctor or return to the ER if you experience fever, chills, back pain or pain with urination, difficulty breathing, or chest pain. Take your medications as prescribed and follow up as scheduled below. Followup Instructions: Please call Dr. [**Last Name (STitle) **] ([**Telephone/Fax (1) 7477**]) for a follow up appointment after discharge from the hosptial. . 1. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 3919**], [**Last Name (NamePattern1) 280**] Where: [**Hospital6 29**] HEMATOLOGY/BMT Phone:[**Telephone/Fax (1) 3237**] Date/Time:[**2149-10-8**] 11:00 2. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4380**], MD Where: [**Hospital6 29**] HEMATOLOGY/BMT Phone:[**Telephone/Fax (1) 3237**] Date/Time:[**2149-10-8**] 11:00 3. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 3920**], RN Where: [**Hospital6 29**] HEMATOLOGY/ONCOLOGY Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2149-10-8**] 11:30 Completed by:[**2149-9-29**]

[ "203.01", "V42.81", "038.42", "599.0", "782.4", "425.4", "287.5", "401.9", "428.0", "787.91", "584.9", "995.92", "277.3", "518.81" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

7533, 7539

3477, 6666

329, 366

7628, 7637

2569, 3454

7904, 8667

2160, 2190

6842, 7510

7560, 7607

6692, 6819

7661, 7881

2205, 2550

275, 291

394, 1429

1451, 2014

2030, 2144

40,576

155,431

21932+57270

Discharge summary

report+addendum

Admission Date: [**2188-11-4**] Discharge Date: [**2188-11-17**] Date of Birth: [**2108-9-8**] Sex: M Service: CARDIOTHORACIC Allergies: Percocet Attending:[**First Name3 (LF) 5790**] Chief Complaint: 1. Right sided empyema. 2. Retroperitoneal bleed. Major Surgical or Invasive Procedure: [**2188-11-7**] Right VATS total pulmonary decortication. History of Present Illness: Mr. [**Known lastname 35028**] is an 80 year-old male who presented to [**Hospital 1562**] Hospital with right flank pain on [**2188-10-2**], sent home and represented on [**2188-10-6**] with persistent right flank pain. CT scan showed a multiloculated mass in the right retroperitoneum below the liver, displacing the peritoneal envelope laterally. [**2188-10-16**] CT scan direct biopsy showed inflammatory cell and grew a heavy pantoea species which is an Enterobacter-like bacteria. Resistent to cefazolin and ampicillin. He was started on Levaquin. Two pigtails were placed. The patient had a thoracentesis for a large right pleural effusion, which drained 50-60 mL of turbid fluid which grew Pantoea. A pigtail was placed. On [**2188-10-31**] 2 Flank and 1 pleural drain fell out. The patient returned to [**Hospital 1562**] Hospital. Repeat imaging studies showed a right pleural effusion had reaccumalated with multiple locules and webs. 50 cc of cloudy fluid was drained and the pigtail was replaced. 25 cc of bloody, non-purulent fluid drained was drained from the right flank, and 2 pigtails were placed. Cultures revealed no growth in both anerobic and aerobic. Gram stain showed neutrophils. He was seen by cardiology on [**2188-11-1**] for new lower extemity edema who increased his lasix 40/20. His coumadin was restarted. Labs on transfer: [**2188-11-4**] WBC 5.7, HCT 31, Hgb 10.3 Plts 191 INR 2.6 PT 26.3 Na+ 129 K 4.8 Chl 88 Co3 34 BUN 0.9 Cre 0.7 Glucose 100 Ca+ 8.1 The patient was transfered to [**Hospital1 18**] for evaluation and management. Past Medical History: CABG '[**80**] Atrial fibrillation s/p pacemaker placement '[**83**] (on chronic Coumadin) Hernia repair Bilateral knee repair Chronic back pain Social History: The patient is a retired tool and dye maker; he worked around chemicals but no asbestos. He has never smoked, and occasionally drinks alcohol. He lives on [**Location (un) **] with his wife for the past 20 years. Family History: Both parents died of coronary artery disease. One brother died at 72 of heart disease. Physical Exam: VS: T: 97.3, HR 73 and reg BP 116/58, 24, O2 sats on RA 98% Physical Exam: Gen: pt is pleasant in NAD Lungs: Diminished in RLL, clear otherwise CV: RRR, S1, S2, no MRG or JVD. Median sternotomy site healed from [**2180**], however sternal wires are apparent under the skin; not eroding through the skin Right Chest: right retroperitoneal drain intact. Old Chest tube site with suture. Abd: soft, NT, ND Ext: warm with 1+ BLE. Pertinent Results: [**2188-11-17**] 07:00AM BLOOD WBC-6.7 RBC-3.13* Hgb-9.2* Hct-28.9* MCV-92 MCH-29.3 MCHC-31.7 RDW-18.3* Plt Ct-218 [**2188-11-17**] 07:00AM BLOOD Glucose-105 UreaN-29* Creat-0.7 Na-140 K-4.7 Cl-105 HCO3-33* AnGap-7* [**2188-11-14**] PA and lateral CXR impression: The two right chest tubes have been removed in the interim. No apparent pneumothorax is seen. Right pleural effusion with adjacent atelectasis has slightly decreased in the interim with improved aeration of the right lung base. The left lung is unchanged. Cardiomediastinal silhouette and pacemaker leads are unchanged. The feeding tube tip is in the very proximal stomach, unchanged as well. Brief Hospital Course: Mr. [**Known lastname 35028**] was transfered from [**Hospital 1562**] Medical Center to [**Hospital1 18**] on [**2188-11-4**] for management of right empyema and retroperitoneal bleed. The patient underwent right VATS total pulmonary decortication by Dr. [**Last Name (STitle) **] on [**2188-11-7**] after being worked up for his empyema, and seen by cardiology given his cardiac history. The patient went to the PACU postoperatively and was extubated, however required reintubation shortly thereafter for resuscitation for acute blood loss. He was transferred to the SICU. He was tranfused blood, and remained intubated until [**2188-11-11**]. He transfered to the floor on [**2188-11-12**]. He initially failed swallow, however passed a thick nectar and soft solids diet on [**2188-11-13**]. PT/OT was working with the patient and recommended rehab on discharge. On [**2188-11-14**] the patient's right chest tubes were removed and chest xray did not reveal any pneumothorax. His right retroperitoneal drain remained intact, with daily flushing, however minimal output. Dr. [**Last Name (STitle) **] with general surgery is recommending follow up CT scan in one week from discharge and follow up to determine when the drain can be removed. At rehab the drain does not need flushing. The patient was confused during the night hours and pulled out his dobhoff, and presumably on his foley, although not witnessed, and had hematuria [**2188-11-13**] requiring urology consultation and continuous bladder irrigation. The three way catheter was discontinued on [**2188-11-17**] 10am and the patient has voided well since without hematuria. Geriatrics was consulted for delirium and placed the patient on nightly trazadone 25 mg, and on Monday [**2188-11-17**] the patient appears to have improved. Geriatrics recommends reevaluation at rehab prior to the patient actually going home. He should continue on trazadone 25 mg po qhs at rehab with fall precautions. It is also noted the patient had cardiology management for his ischemic cardiomyopathy. Last LVEF was 50-55% on [**2188-11-8**]. He has been optimized on his medications. Regarding anticoagulation for his PAF, the patient is being discharge without, given his risk of bleeding, and his retroperitoneal drain. Reinitiation will need to be explored as an outpatient by his primary medical doctors. He was even on his fluid balance during his inpatient stay and off lasix. Given his history of heart failure, and the fact that he's been on lasix, with new findings of leg edema, the patient is being reinitiated on lasix 20 mg po daily and KCl 10 meq po daily starting the day of discharge to rehab. He will need lyte follow up tomorrow or Wednesday. The patient should have daily weights at rehab to fine tune his diuretic regimine. The patient should also have his lytes closely followed, as he is on an ace inhibitor and may not need potassium replacement with the lasix. The patient passed a swallow evaluation [**2188-11-13**] for nectar thick liquids and soft solids, however his intake is poor, and the Registered Dietician recommended nocturnal tube feedings via dobhoff. The patient was evaluated by PT who recommended rehab, which the patient has a bed awaiting him on [**2188-11-17**] at Rehab Hospital of [**Location (un) **] in the Islands. The patient has been deemed safe for transfer by attending Dr. [**Last Name (STitle) **]. The patient and his wife are aware. All questions from the patient and family have been answered. Discharge Medications: 1. Pravastatin 20 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). 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: Ten (10) mL PO BID (2 times a day) as needed for constipation. 4. Acetaminophen 650 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours). 5. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day. 9. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO once a day. 10. Trazodone 50 mg Tablet Sig: half Tablet PO at bedtime: reeval need for at end of rehab before pt goes home. 11. Protonix 40 mg po daily Discharge Disposition: Extended Care Facility: [**Hospital **] Hospital of [**Location (un) **] & Islands - [**Location (un) 6251**] Discharge Diagnosis: 1. Right empyema. 2. Retroperitoneal bleed. Discharge Condition: stable. Discharge Instructions: 1. Check and record daily weight. Call if wt up 2 lbs in one day or 4 lbs in one week, as you will need diuretics adjusted. 2. Sit upright during all meals. 3. Ambulate three times a day with assistance. 4. Use incentive spirometer. 5. Record daily retroperitoneal drainage amount. 6. Flush Tube feeding with 100 ml of water before and after tube feeds. Followup Instructions: 1. Follow up with Dr. [**Last Name (STitle) **] on [**2188-12-2**] at 11 am, on [**Hospital Ward Name 517**] [**Hospital1 **] 116 ([**Location (un) **]). Prior to this appointment please get CXR at 10:30 am in the Clinical Center which is on the [**Hospital Ward Name 517**] as well. Call [**Telephone/Fax (1) 2348**] for any questions or directions. 2. Follow up with Dr. [**Last Name (STitle) **] of urology ([**Telephone/Fax (1) 277**]) on [**2188-12-2**] at 1:30 pm on [**Hospital Ward Name 516**] [**Hospital Ward Name 23**] Cneter [**Location (un) 470**] Surgical Specialties. 3. Follow up with Dr. [**Last Name (STitle) **] on Fri [**2188-11-21**]- First you will go to the [**Location (un) **] at 12:30am for a CT scan of your abdomen/pelvis to look at the retroperitoneal area, and to look at the drain. Then follow up with Dr. [**Last Name (STitle) **] [**Location (un) **] [**Hospital Ward Name 23**] Center at 2 pm. ([**Hospital Ward Name 516**]) 4. Once the patient is home he will need oupt follow up with his cardiologist and primary care physician. Completed by:[**2188-11-17**] Name: [**Known lastname **],[**Known firstname **] J Unit No: [**Numeric Identifier 10684**] Admission Date: [**2188-11-4**] Discharge Date: [**2188-11-17**] Date of Birth: [**2108-9-8**] Sex: M Service: CARDIOTHORACIC Allergies: Percocet Attending:[**First Name3 (LF) 3454**] Addendum: On discharge we will add aspirin 81 mg po daily, and instead of lasix 20 mg po daily, we will go to patients home dose of 40 mg po daily. Discharge Disposition: Extended Care Facility: [**Hospital **] Hospital of [**Location (un) 776**] & Islands - [**Location (un) 777**] [**Name6 (MD) **] [**Last Name (NamePattern4) 3455**] MD [**MD Number(2) 3456**] Completed by:[**2188-11-17**]

[ "V45.81", "599.71", "511.9", "V13.01", "428.21", "510.9", "E928.9", "285.1", "518.5", "530.81", "V43.65", "567.38", "272.4", "185", "V53.31", "867.0", "401.9", "244.9", "414.8", "293.0", "V58.61", "276.1" ]

icd9cm

[ [ [] ] ]

[ "34.20", "96.72", "96.6", "34.52" ]

icd9pcs

[ [ [] ] ]

10284, 10538

3646, 7155

325, 385

8267, 8277

2963, 3623

8680, 10261

2413, 2501

7178, 8044

8200, 8246

8301, 8657

2591, 2944

236, 287

413, 1998

2020, 2166

2182, 2397

69,295

134,331

8095

Discharge summary

report

Admission Date: [**2126-10-1**] Discharge Date: [**2126-11-17**] Date of Birth: [**2068-5-23**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 338**] Chief Complaint: lower GI bleeding, fever and hypotension Major Surgical or Invasive Procedure: CENTRAL VENOUS LINE PLACEMENT History of Present Illness: 58 year old woman with cryptogenic cirrhosis, followed by Dr [**First Name8 (NamePattern2) 2943**] [**Name (STitle) 696**], admitted on [**10-1**] with lower GI bleeding, fever and hypotension. MICU course was complicated by intubation from [**10-2**] to [**10-16**], bouts of hypotension and oliguria in the setting of profuse bleeding requiring a total of 7U PRBC and 16U FFP. Source of bleeding was identified as 1) Rectal varices and 2) Vaginal bleeding, felt to be in setting of flexiseal and very elevated INR. . Patient has undergone extensive workup for liver transplantation, given her very elevated MELD score (32 today). Patient is being transferred to our service for further treatment of liver decompensation and transplant evaluation. Past Medical History: 1)Cryptogenic cirrhosis 2)Cholelithiasis 3)Chronic lympedema of the right lower extremity 4)Right knee replacement [**2121**] 5)Recurrent cellulitis of the right lower extremity. 6)Group B streptococcal infection and ARF in [**2124**]. 7)Hypertension 8)Osteoarthritis 9)Left [**Hospital Ward Name 4675**] cyst 10)Tubal ligation Social History: She is married and lives with her husband and daughter. She has eight children. She does not use tobacco or alcohol. No smoking, no alcohol, no iv drug use. Pt. speaks [**Location 7972**] Portuguese, a little English, and understands some Spanish as well. Family History: No history of liver disease or autoimmune disease Physical Exam: VITAL SIGNS: T = 98.2 Tc = 97 HR 89 BP 150/71 RR: 22 . PHYSICAL EXAM GENERAL: Ill appearing woman, appears older than stated age, icteric, sitting in ICU chair. HEENT: Normocephalic, atraumatic. Significant scleral icterus. PERRLA/EOMI. Dry. OP clear. Neck Supple, No LAD, No thyromegaly. CARDIAC: Regular rhythm, normal rate. Normal S1, S2. No murmurs, rubs or [**Last Name (un) 549**]. LUNGS: CTAB, good air movement biaterally. ABDOMEN: Obese, distended, normoactive bowel sounds EXTREMITIES: 3+ Pittind edema in lower extremities, 2+ dorsalis pedis/ posterior tibial pulses. Left knee ulcer. SKIN: No rashes/lesions, ecchymoses. NEURO: Responds to stimuli, no interpreter available at this time Pertinent Results: Admission labs: [**2126-9-30**] 07:35PM BLOOD WBC-2.3* RBC-3.66* Hgb-12.5 Hct-37.6 MCV-103* MCH-34.1* MCHC-33.2 RDW-16.2* Plt Ct-107* [**2126-9-30**] 07:35PM BLOOD Neuts-73.3* Lymphs-20.1 Monos-5.8 Eos-0.6 Baso-0.3 [**2126-9-30**] 09:16PM BLOOD PT-23.1* PTT-35.5* INR(PT)-2.2* [**2126-9-30**] 07:35PM BLOOD Glucose-88 UreaN-11 Creat-0.8 Na-132* K-4.2 Cl-101 HCO3-24 AnGap-11 [**2126-9-30**] 07:35PM BLOOD ALT-38 AST-88* AlkPhos-157* TotBili-4.0* [**2126-9-30**] 07:35PM BLOOD Lipase-29 [**2126-9-30**] 07:53PM BLOOD Lactate-2.7* [**2126-9-30**] 07:53PM BLOOD Hgb-13.8 calcHCT-41 [**2126-10-25**] 01:25PM BLOOD ACA IgG-19.4* ACA IgM-11.6 [**2126-10-25**] 08:43AM BLOOD Smooth-POSITIVE * [**2126-10-25**] 08:43AM BLOOD [**Doctor First Name **]-NEGATIVE [**2126-10-15**] 03:19AM BLOOD CEA-2.0 AFP-2.1 [**2126-10-28**] 08:15AM BLOOD IgG-2157* [**2126-10-31**] 06:07AM BLOOD IgG-2044* [**2126-10-16**] 08:00AM BLOOD HIV Ab-NEGATIVE HEPATITIS ([**2126-10-15**]) Hepatitis C Virus Antibody NEGATIVE Hepatitis B Surface Antigen NEGATIVE Hepatitis B Surface Antibody POSITIVE Hepatitis B Virus Core Antibody POSITIVE Hepatitis A Virus Antibody POSITIVE HIV Antibody NEGATIVE . IMMUNOLOGY Carcinoembyronic Antigen (CEA) 2.0 ng/mL Alpha-Fetoprotein 2.1 ng/mL . HERPES-1 (IGG) ANTIBODY 4.31 H 0.00-0.89 INDEX HERPES-2 (IGG) ANTIBODY < 0.9 0.00-0.89 INDEX CERULOPLASMIN 13 L 18-53 MG/DL COPPER, 24-HOUR URINE 80.0 H 2-30 MCG/L . . . STUDIES: . [**2126-10-20**] PELVIC US: 1. Limited examination demonstrates an endometrial stripe measuring 1.4 cm. If the patient is postmenopausal, this is an abnormal finding, and differential diagnosis includes endometrial hyperplasia, endometrial polyp, or endometrial carcinoma and clinical correlation with biopsy is recommended. 2. Extensive ascites. 3. Ovaries not visualized on this limited examination. . ECHO ([**2126-10-16**]) The left atrium is mildly dilated. Left ventricular wall thicknesses are normal. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets are mildly thickened (?#). No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Physiologic mitral regurgitation is seen (within normal limits). The tricuspid valve leaflets are mildly thickened. There is a trivial/physiologic pericardial effusion. There is probably at least mild pulmonary artery systolic hypertension (although tricuspid regurgitation jet is now technically subopitmal). . Compared with the prior study (images reviewed) of [**2126-10-3**], probably at least mild pulmonary artery systolic pressures is now detected. . ABDOMINAL ULTRASOUND ([**2126-10-17**]) 1. Cirrhosis. 2. Bidirectional low velocity flow in a patent portal vein. 3. Mild-to-moderate ascites. 4. Cholelithiasis. . SIGMOIDOSCOPY [**2126-10-18**] Findings: Clotted blood was seen in the colon extending from the rectum to transverse colon. Other Three to four cords of rectal varices were identified. Mostly likely cause of rectal bleeding. Varices were injected with a 1:1 mixture of dermabond and ethiodol. Impression: Blood in the colon Three to four cords of rectal varices were identified. Mostly likely cause of rectal bleeding. Varices were injected with a 1:1 mixture of dermabond and ethiodol. Otherwise normal sigmoidoscopy to transverse colon -[**2126-11-2**] Abd U/S (Initial read): 1. Moderate ascites. 2. Reversed flow in the main portal vein. 3. Normal waveforms in the hepatic veins -[**2126-11-1**] Fluoro: Successful repositioning of the [**Last Name (un) 28075**]-[**Doctor First Name 1557**] tube beyond the pylorus in the ascending duodenum and additional placement of a NG tube in the gastric antrum. -[**2126-11-1**] KUB: Unchanged bowel gas pattern consistent with nonobstructive ileus. Feeding tube is now localized in the stomach. . Endometrial biopsy: Blood and very scant strips of surface endometrium with focal tubal metaplasia. Pap: NEGATIVE FOR INTRAEPITHELIAL LESION OR MALIGNANCY . Blood culture: negative HBV DNA: Not detected Urine culture ([**10-22**]): > 100K yeast Urine culture ([**10-24**]): 10K-100K yeast Right lower extremity wound/Catheter tip culture: Negative C Diff: Negative ([**10-25**] and [**10-31**]). Brief Hospital Course: Floor Course: #. CIRRHOSIS/TRANSPLANT EVAL: The patient's MELD was consistently in the high 30's, including total bilirubin levels in the high 30's. ALT/AST/AP were generally stable. The etiology of cirrhosis was not entirely clear, as her past workup included a mildly positive anti-smooth muscle antibody, and an isolated positive HBcAb, in the absence of surface antigen positivity. Repeat anti-[**Last Name (un) 15412**] was weakly positive at 1:40. IgG levels were elevated at >[**2116**]. She was empirically started on prednisone and broad-spectrum antibiotics, to cover possible autoimmune hepatitis as well as low-grade undetected infection. Prednisone was subsequently stopped several days later, as the patient had not demonstrated any improvement in her LFT's, and she experienced small amounts of blood in her stool. Culture data was generally negative, except for urine cultures revealing yeast. Pre-transplant evaluation included an endometrial biopsy and pap smear that was negative for malignancy. On [**11-2**], a donor liver was believed to be available, and the patient was taken to the pre-operative holding area. The donor was found to have a soft tissue infection, however, and the surgery was cancelled. The patient remained on the medical floor for several more days, during which her MELD increased into the 40's, with persistently high bilirubin, and worsening INR/creatinine. Her temperature slowly decreased into the 95-96 range. She did not tolerate a bear hugger. Her ABx coverage was expanded to vancomycin, cefepime, metronidazole, and micafungin. She became oliguric, and she received high amounts of crystalloid and colloid. On [**11-7**], she was found to have blood in her oropharynx. ENT was consulted, and performed rhinoscopy, showing likely epistaxis. She was transferred to the MICU, but did not require upper endoscopy. . #. HYPERVOLEMIA: The patient was massively volume overloaded upon transfer to the floor, given her aggressive IV fluid repletion. She was started on furosemide and spironolactone, and the spironolactone was subsequently increased to 200 mg daily. This was continued until [**11-2**], when the patient's creatinine was first noted to rise. She also developed hyperkalemia and hypermagnesemia, which were attributed to her acute kidney injury. Her weights were not recorded on the floor, despite repeated requests to nursing to measure any weights, including bed weights. Her recorded I/Os were initially consistent with net negative fluid balances, but the patient's urine output progressively worsened. . # LEUKOCYTOSIS: The patient developed a leukocytosis up to 16 in the setting of prednisone therapy. As mentioned above, her culture data was negative and she was consistently afebrile. She had been on broad-spectrum antibiotics prior to this leukocytosis. Her temperature and blood pressure slowly trended down, and her antibiotic coverage was broadened to vancomycin, cefepime, metronidazole, and micafungin. Culture data remained unrevealing, other than consistently growing yeast in her urine. Fungal blood and urine cultures were sent, revealing no growth. . # ODYNOPHAGIA/NECK PAIN: The patient complained of a sore throat in the setting of having had an NG tube in place. She was written for magic mouthwash, but did not require it once the NG tube was removed. The medication was discontinued after she was found to be hypermagnesemic, given magnesium component to maalox. She also complained of pain over her left neck, where her central line had been placed. CTA of the neck revealed no thrombosis, abscess or fluid collection, and there was no fluctuance to exam. # ACUTE KIDNEY INJURY: On [**11-7**], the patient's creatinine increased abruptly from 0.8 to 1.7. She had had underlying electrolyte abnormalities (hyperkalemia, hypermagnesemia, hyperphosphatemia) leading up to this. Urinalysis showed [**2-28**] granular casts. Her urine output also decreased significant, and she was olguric at time of transfer to MICU on [**11-7**]. . #. GI BLEEDING: Her initial reason for admission was GI bleed [**1-28**] portal hypertension and rectal varices. She had grade 3 internal hemmrhoids on C-scope. She was treated with injection of 1:1 mixture of dermabond and ethiodol on sigmoidoscopy. She was kept on daily PPI and vitamin K. She remained on propanolol for several days, but this was discontinued on [**11-6**] for systolic BP in the 90's and also to not mask a potential tachycardic response. She had small amounts of hematochezia several days prior to transfer to MICU, but hematocrit was generally stable at the time. However, her hematocrit trended down slowly at time of transfer to MICU, and she was transfused. . #. VAGINAL BLEEDING: TVUS concerning for thickened endometrial cancer. Path c/w tubal metaplasia, non-malignant condition. Pap negative for intraepithelial lesion or malignancy. Not actively bleeding . ======================================================= On transfer to MICU GREEN, pt was continued on broad spectrum antibiotics (vanoc, cefepime, flagyl). Micafungin was added for empiric antifungal coverage in the setting of continued decline (hypothermia, bradycardia) with braod anti-bacterial agents. Ganciclovir was also added for a borderline positive CMV viral load. . Ove the course of her first week in the MICU, the patient made progress, her BP improved to the point where she was having 300cc/hr of fluid removed by CVVH. She tolerated her first HD session, but soon thereafter had worsening hypotension with an increasing pressor requirement. Mental status declined further. . On sunday [**11-17**], the pt's lactate (arterial) was 7 and then 8. She went into AFIB/RVR and further dropped her BPs. She did not convert to sinus rhythm s/p amiodarone IV bolus x2. Prior to attempting cardioversion, a family mtg was held with HCPs present. Hepatology and Transplant were in agreement that [**Month (only) 3225**] status was not inappropriate. HCPs chose [**Name (NI) 3225**]. Pt was started on a morphine drip, pressors were discontinued and she passed several hours later. Medications on Admission: Albuterol INH Aluminum Hydroxide suspension 5-10ml PO/NG [**Hospital1 **] x 2 days Albumin 100gm IV x 1 Cefepime 2gm IV q24h Chloraseptic Throat Spray Senna [**Hospital1 **] Docusate [**Hospital1 **] Lactulose 30mg PO/NG q6h PRN goal [**5-1**] stools per day Lidocaine 5% ointment TP daily Flagyl 500mg q8h Micafungin 100mg IV q24h Octreotide IV 80mcg/hr Pantoprazole IV 8mg/hr Phytonadione 5mg PO daily Rifaximin 400mg PO TID Discharge Medications: n/a Discharge Disposition: Expired Discharge Diagnosis: END STAGE LIVER DISEASE DECOMPENSATED CRYPTOGENIC CIRRHOSIS Discharge Condition: DECEASED Discharge Instructions: N/A Followup Instructions: N/A Completed by:[**2126-11-17**]

[ "715.90", "572.3", "041.04", "275.2", "276.8", "112.2", "707.10", "995.92", "518.81", "785.52", "427.31", "457.1", "276.0", "571.5", "780.65", "584.5", "276.2", "286.9", "427.89", "E932.0", "276.7", "723.1", "287.4", "288.60", "251.2", "078.5", "275.3", "455.2", "348.31", "038.42", "401.9", "599.0", "787.20", "428.0", "789.59", "560.1", "784.7", "623.8", "280.0" ]

icd9cm

[ [ [] ] ]

[ "45.25", "68.16", "38.93", "39.98", "45.23", "21.01", "38.95", "96.6", "48.23", "45.13", "88.76", "21.21", "96.04", "54.91", "99.15", "38.91", "39.95", "96.72" ]

icd9pcs

[ [ [] ] ]

13589, 13598

6985, 13083

356, 388

13702, 13713

2597, 2597

13765, 13801

1807, 1858

13561, 13566

13619, 13681

13109, 13538

13737, 13742

1873, 2578

276, 318

416, 1166

2614, 6962

1188, 1517

1533, 1791

16,399

143,367

15447

Discharge summary

report

Admission Date: [**2179-9-4**] Discharge Date: [**2179-9-13**] Date of Birth: [**2117-6-21**] Sex: M Service: HISTORY OF PRESENT ILLNESS: The patient is a 62-year-old mental retarded gentleman seen at [**Hospital 1474**] Hospital for gait unsteadiness, found to have cerebellar bleed on head CT and transferred to [**Hospital6 256**] for further management. PAST MEDICAL HISTORY: 1. Hypertension ALLERGIES: PENICILLIN AND HALDOL SOCIAL HISTORY: Lives with his sister. ADMISSION LABS: White count was 6.8, hematocrit 44, platelets 140. Sodium 139, potassium 3.9, chloride 105, CO2 26, BUN 15, creatinine 0.9, glucose 202. Head CT shows a 3 x 3 x 4 cm right cerebellar vermis. PHYSICAL EXAM: The patient was awake and alert, responding to questions. Eyes opened spontaneously, moving all four extremities to commands. Pupils were 5 mm and minimally reactive, had positive doll's eyes, but poor cooperation with EOM exam. No nystagmus. Dysmetria, finger to nose right greater than left. Able to stand, but gait very unsteady. HOSPITAL COURSE: He was admitted to the Surgical Intensive Care Unit for monitoring. Remained in the Surgical Intensive Care Unit for close monitoring and blood pressure control. Repeat head CT showed no changes. The patient was eventually transferred into the regular floor. The patient went to the floor on [**2179-9-7**]. He was in stable condition on transfer. His vital signs were stable. He was afebrile. He did have an episode of rapid atrial fibrillation. He was seen by the cardiology service who recommended discontinuing digoxin and starting him on amiodarone. The patient converted to sinus rhythm on his own, has been in sinus rhythm and stable throughout the weekend. He did have an echocardiogram which was within normal limits on Friday. His vital signs have been stable. He has been afebrile and neurologically at his baseline, awake, alert and oriented x1, moving everything strongly and ready for transfer to rehabilitation. DISCHARGE MEDICATIONS: 1. Amiodarone 400 mg po q day 2. Levofloxacin 500 mg po q 24 hours for urinary tract infection 3. Atenolol 75 mg po bid, hold for systolic less than 100, heart rate less than 60 4. Lisinopril 30 mg po qd, hold for systolic blood pressure less than 100 5. Erythromycin 0.5 ophthalmic ointment both eyes qid 6. Hydralazine 20 mg po q6h prn for systolic blood pressure over 150 7. Colace 100 mg po bid 8. Tylenol 650 po q4h prn CONDITION: The patient was in stable condition at the time of discharge and will follow up with Dr. [**Last Name (STitle) 1327**] in three weeks' time with repeat head CT. [**Name6 (MD) 1339**] [**Last Name (NamePattern4) 1340**], M.D. [**MD Number(1) 1341**] Dictated By:[**Last Name (NamePattern1) 344**] MEDQUIST36 D: [**2179-9-13**] 09:27 T: [**2179-9-13**] 09:52 JOB#: [**Job Number 44816**]

[ "599.0", "372.30", "431", "401.9", "319", "427.31" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

2041, 2913

1080, 2018

723, 1062

159, 380

513, 707

402, 455

472, 496

7,054

123,181

26630

Discharge summary

report

Admission Date: [**2144-4-9**] Discharge Date: [**2144-4-17**] Date of Birth: [**2064-2-20**] Sex: M Service: SURGERY Allergies: Nitrofurantoin Attending:[**First Name3 (LF) 473**] Chief Complaint: pancreatic ca Major Surgical or Invasive Procedure: Whipple procedure History of Present Illness: 80y/o M pancreatic head and neck tumor Past Medical History: dysrhythmia, sick sinus syndrome, DM-II, Reflux, CBD obstruction, HTN Social History: ex-smoker Physical Exam: NAD RRR CTA b/l Abdomen soft nontender, transverse incision clean, dry and intact Right j-Tube intact Pertinent Results: [**2144-4-9**] 03:30PM CK(CPK)-132 [**2144-4-9**] 03:30PM CK-MB-3 cTropnT-<0.01 [**2144-4-9**] 02:31PM GLUCOSE-136* UREA N-19 CREAT-1.1 SODIUM-138 POTASSIUM-4.3 CHLORIDE-107 TOTAL CO2-22 ANION GAP-13 [**2144-4-9**] 02:31PM WBC-13.1*# RBC-3.54* HGB-12.5* HCT-33.9* MCV-96 MCH-35.4* MCHC-37.0*# RDW-14.4 [**2144-4-9**] 02:31PM PLT COUNT-218 [**2144-4-9**] 02:31PM PT-12.6 INR(PT)-1.1 [**2144-4-9**] 12:38PM TYPE-ART TIDAL VOL-700 O2-50 PO2-236* PCO2-39 PH-7.40 TOTAL CO2-25 BASE XS-0 INTUBATED-INTUBATED VENT-CONTROLLED [**2144-4-9**] 12:38PM GLUCOSE-97 LACTATE-2.0 NA+-138 K+-4.1 CL--106 [**2144-4-9**] 12:38PM HGB-12.3* calcHCT-37 O2 SAT-99 [**2144-4-9**] 12:38PM freeCa-1.18 [**2144-4-9**] 11:22AM TYPE-ART TIDAL VOL-700 O2-50 PO2-221* PCO2-45 PH-7.37 TOTAL CO2-27 BASE XS-0 INTUBATED-INTUBATED VENT-CONTROLLED [**2144-4-9**] 11:22AM freeCa-1.14 [**2144-4-9**] 09:58AM TYPE-ART PO2-220* PCO2-41 PH-7.38 TOTAL CO2-25 BASE XS-0 INTUBATED-INTUBATED [**2144-4-9**] 09:58AM GLUCOSE-163* LACTATE-1.3 NA+-138 K+-4.1 CL--106 [**2144-4-9**] 09:58AM HGB-11.5* calcHCT-35 [**2144-4-9**] 09:58AM freeCa-1.12 [**2144-4-9**] 08:44AM TYPE-ART RATES-/10 TIDAL VOL-700 O2-50 PO2-238* PCO2-38 PH-7.41 TOTAL CO2-25 BASE XS-0 INTUBATED-INTUBATED VENT-CONTROLLED [**2144-4-9**] 08:44AM GLUCOSE-133* LACTATE-1.4 NA+-139 K+-4.0 CL--106 [**2144-4-9**] 08:44AM freeCa-1.16 Brief Hospital Course: Patient was brought to the OR for elective Whipple procedure [**2144-4-9**]. Patient tolerated the procedure well, recovered in PACU and was transfered to floor for further. POD 1 was complicated ny episode of hypotnesion and atrial fibrillation requiring ICU care and cardiology consult. POD3 patient was remain stable and was transferred to floor for further care. Remainder of hospital course was uneventful. Patient acheive all postoperative goals such, tolerating PO diet, pain control via PO pain meds, return of bowel/bladder function and ambulating without distress. Patient was cleared for d/c to rehab with appropiate followup with Dr. [**Last Name (STitle) 468**]> Discharge Medications: 1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. Disp:*25 Tablet(s)* Refills:*0* 2. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QID (4 times a day). Disp:*120 Tablet(s)* Refills:*0* 3. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 4. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*0* 5. Tramadol 50 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 6. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*25 Tablet(s)* Refills:*0* Discharge Disposition: Extended Care Facility: [**Location (un) **] hills Discharge Diagnosis: Pancreatic cancer Discharge Condition: stable Discharge Instructions: Resume your regular medications. Take all new medications as directed. Do not drive while taking narcotics. You may shower. Allow water to run over the wound, and do not scrub. Pat the wound dry. Do not take a bath or swim until after follow-up appointment. No heavy lifting (> 10 lbs) for 6 weeks. Please call your doctor or return to the ER if you experience: -Fever (> 101.4) -Inability to eat/drink or persistant vomiting -Increased pain -Redness or discharge from your wound -Other symptoms concerning to you Followup Instructions: Please call Dr.[**Name (NI) 9886**] clinic to arrange appointment call ([**Telephone/Fax (1) 9058**] Please call [**Last Name (LF) 65688**],[**First Name3 (LF) **] [**Telephone/Fax (1) 65689**] to arange followup appoint for management of Coumadin & INR Completed by:[**2144-4-17**]

[ "285.1", "157.0", "V45.01", "311", "V10.51", "V10.11", "250.00", "530.81", "414.01", "427.31", "997.1", "401.9" ]

icd9cm

[ [ [] ] ]

[ "52.7", "46.32", "38.91" ]

icd9pcs

[ [ [] ] ]

3422, 3475

2042, 2719

286, 306

3537, 3546

631, 2019

4115, 4401

2742, 3399

3496, 3516

3570, 4092

509, 612

233, 248

334, 374

396, 467

483, 494

24,995

167,081

46138

Discharge summary

report

Admission Date: [**2173-1-23**] Discharge Date: [**2173-1-31**] Date of Birth: [**2107-9-11**] Sex: F Service: MEDICINE Allergies: Gantrisin / Lactose Attending:[**First Name3 (LF) 1973**] Chief Complaint: DKA, altered mental status Major Surgical or Invasive Procedure: Tunneled HD Catheter Placement Temporary HD Catheter Placement History of Present Illness: 65 F c hx Type I DM c/b peripheral neuropathy, proliferative retinopathy, ESRD on HD who developed UTI symptoms [**3-21**] d PTA. Followed by progressive weakness and over day prior to admission developed nausea, vomiting. Son spoke with patient day of admission and reported pt. slurring words and speaking in manner typical of her presentations with hyperglycemia. Pt. also reported no insulin use over several days [**2-19**] feeling unwell. Instructed patient to call EMS. EMS measured FSG in field in the high 400 range. Brought to ED where she was afebrile, slightly hypertensive, and tachycardic to low 100s. Received 2 L NS and 6 u insulin IV and started on insulin gtt at 6 u/hr. Underwent multiple attempts at access (PIVs, 2 EJs, SC line, IJ line, femoral line); eventually required use of dialysis catheter for hydration and insulin administration. Past Medical History: 1. DM type 1 x 35 years. Previous admissions for DKA and hypoglycemic episodes. Her DM is complicated by peripheral neuropathy, proliferative retinopathy (left eye blindness), and nephropathy. Followed at [**Last Name (un) **]. 2. Chronic renal failure: Appears [**2-19**] to DM and Cr has been 5 over past few months. On hemodialysis. 3. CAD - NSTEMI [**10-23**] in the setting of hospitalization for DKA, Nuclear stress test [**8-23**]: P-MIBI, without fixed or reversible defects, normal wall motion. EF 72%. 4. Hypertension 5. History of osteomyelitis, status post left transmetatarsal amputation. 6. History of herpes zoster of left chest in [**2163**]. 7. Bezoar, disclosed on UGI series [**7-/2166**]. 8. Achalasia 9. Carpal Tunnel Syndrome Social History: She lives at home with her son, who is mentally retarded. Past history of EtOH use. Ex-smoker, quit in [**2154**]. Previously smoked for 8yrs. No history of illicit drug use. Family History: Mother - DM Sister - breast ca, DM Brother - HTN [**Name (NI) 2957**] - SLE, d. renal failure Physical Exam: VS- Tc 96.8, 100, 160/59, 13, 100% RA HEENT- flat neck veins, poor skin turgor over sternum. scarred, whitish appearing [**Doctor First Name 2281**] over left eye. no LAD. tongue fissured and parched appearing LUNGS- CTA HEART- RRR, S1, S2, + [**3-23**] SM at LUSB/RUSB, non radiating. ? flow ABD- soft, ND, NT, BS+ EXT- wwp, s/p L toe amputation. Skin dry. no edema NEURO- alert and oriented * 2; can name objects, can move all extremities. Pertinent Results: ekg- ED - hyperacute T waves, lateral ST seg depressions, prominent J point elevations V1-V3 [**Hospital Unit Name 153**] - T waves appear less acute, [**Street Address(2) 4793**] depressions persist in V4-V6. J point elevations at baseline in V1-V3. Brief Hospital Course: In [**Name (NI) 153**], pt. noted to be alert and oriented * 2; slurring words and difficult to arouse. EKG reviewed and thought concerning for changes compatible with hyperkalemia. Given 1 amp calcium gluconate and 1 amp bicarb for hyperkalemia. Started on ciprofloxacin IV for suspected UTI. Given 15 u * 3 insulin IV boluses (over 3 hrs) and started on insulin gtt 10 u/hr. Given NS at 500cc hour. Anion gap initially 35. venous pH 7.15. Bicarb 7. In the ED, she received 4 L NS and 6 units of insulin and was started on insulin gtt @ 6 units/hr. On the floor, she was continued on NS and insulin gtt was uptitrated to 30 units/hr. She also received an additional 75 units of insulin in boluses of 15 units. She was started on IV Cipro for UTI. Electrolytes were checked Q3 hours and BGs were checked every hour. The following morning her anion gap had decreased to 4 and her glucose had dropped to less than 150. Her insulin drip was then decreased to 2 units/hr. Her potassium was initially elevated but dropped substantially with insulin and fluids. Her fluids were then changed to 1/2NS with 40 mEq KCl. The following morning her sugars had declined but her AG still slightly persisted. Her potassium had normalized. Given her underlying renal disease, her 1/2 NS w/ KCl was stopped and she was changed to D5 1/2NS to be continued with her insulin drip. Her potassium was greatly elevated on admission but was likely falsely elevated from extracellular movement due to insulin deficiency. In the ED, EKG showed peaked TWs. Upon arrival to the floor, she was given Calcium gluconate and sodium bicarb with resolution of her peaked TWs. As above, her hyperkalemia corrected rapidly with insulin and fluid administration. patient has a h/o NSTEMI in 10/[**2172**]. Negative pMIBI in 8/[**2172**]. Has baseline ST elevation in V1-V3. EKG in ED showed worsening ST elevations in V1-V3 as well as ST depressions in 1, aVL, V4-V6. CKs and troponins were intially negative in the ED. Patient denied chest pain/pressure, SOB, but she is diabetic so is at risk for silent MI. Repeat EKG on the floor showed resolution of ST elevations back to baseline and improvement in ST depressions. Believed to be most likely demand mediated. She was started on 325 mg daily aspirin and cardiac enzymes were cycled. She was also given IV metoprolol to replace her po metoprolol while she had altered mental status. Her enzymes remained flat but she had evolution of her EKG changes with development of TW inversions in her lateral precordial leads. However, as her cardiac enzymes were negative, these were considered nonspecific changes and no further interventions were pursued. [**Last Name (un) **] was consulted for glucose management, which required alterations to her lantus, with moderate control of her glucose. on HD QT/Th/Sat. Patient's line became infected due to emergent access in the ICU, so it was removed and a temporary HD cath with VIP port was placed in IR. Vancomycin given by level. After 2 days of antibiotics the catheter was replaced with a permanent tunneled catheter. Pt will continue on vancomycin as an outpatient with [**Doctor First Name **]. She is awaiting graft placement by transplant surgery. Patient should have an outpatient cardiac stress test as a repeat due to the demand ischemia demonstrated on admission. son - [**Name (NI) **] home: [**Telephone/Fax (1) 97825**], cell: [**Telephone/Fax (1) 97822**] Medications on Admission: Lisinopril 20 qd ASA 325 qd Atorvastatin 80 qd Metoprolol 50 tid B complex-vitamin C-folic acid 1 qd Sevelamer 800 tid Glargine 8 u SC qhs Discharge Medications: 1. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day). 4. Ciprofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 5 days. Disp:*5 Tablet(s)* Refills:*0* 5. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1) gram Intravenous ASDIR (AS DIRECTED) for 10 days: To be given at [**Doctor First Name 12074**]. 6. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: Diabetic Ketoacidosis Type 1 Diabetes Urinary Tract Infection Coronary Artery Disease Discharge Condition: Good Discharge Instructions: Return to the hospital if you have fever, chills, nausea/vomitting You will be getting antibiotics with your dialysis Followup Instructions: Provider: [**Name10 (NameIs) **] SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2173-2-5**] 11:00 Provider: [**First Name8 (NamePattern2) 278**] [**Last Name (NamePattern1) 279**], [**Name12 (NameIs) 280**] Date/Time:[**2173-3-24**] 11:20 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2173-3-29**] 1:00

[ "996.64", "362.01", "250.53", "276.7", "599.0", "250.43", "250.13", "585.6", "412", "276.1", "414.01", "996.62", "357.2", "250.63" ]

icd9cm

[ [ [] ] ]

[ "38.95", "39.95" ]

icd9pcs

[ [ [] ] ]

7352, 7409

3102, 6557

307, 372

7539, 7546

2826, 3079

7713, 8111

2248, 2343

6746, 7329

7430, 7518

6583, 6723

7570, 7690

2358, 2807

241, 269

400, 1268

1290, 2040

2056, 2232

54,305

142,295

42884

Discharge summary

report

Admission Date: [**2143-6-21**] Discharge Date: [**2143-6-28**] Date of Birth: [**2073-4-12**] Sex: M Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 1481**] Chief Complaint: esophageal cancer Major Surgical or Invasive Procedure: minimally invasive esophagectomy converted to open ( abdominal portion) History of Present Illness: 70-year-old man who had an upper GI bleed. An endoscopy showed some antral ulceration, which was controlled endoscopically and he was given proton pump inhibitors. These then were shown to improve and to be healing at the time of a followup endoscopy, where a small ridge of tissue was seen at the esophagogastric junction. Biopsy showed an adenocarcinoma. At this stage, it is a T1b lesion by endoscopic ultrasound. Some small lymph nodes were seen by endoscopic ultrasound, which were negative for cancer on fine needle aspiration. At the time of his staging, he also had a CT scan of the chest and abdomen, which showed a small pulmonary embolism, for which he was started on Lovenox. He has had a PET scan, which does not show the tumor and shows no evidence of metastatic disease. Past Medical History: PMH: hypertension, obesity, small CVA([**2129**]), h/o GI bleed, dvts, recent dx of PE, adenocarcinoma of the esophagus PSH: splenectomy Social History: The patient is a retired [**Doctor Last Name 3456**]. He drinks socially. He quit smoking over 15 years ago. Family History: Family history is negative for cancer or heart disease. Physical Exam: On physical examination, he is a well-developed gentleman who is 6 feet tall and weighs 232 pounds. Head, eyes, ears, nose and throat are normal. The neck is supple, without mass, nodes or thyromegaly. The chest is clear to percussion and auscultation. Heart sounds are regular without murmurs or gallops. The abdomen is soft with a long midline abdominal laparotomy scar without evidence of hernia or mass. The extremities are without cyanosis, clubbing or edema. He is neurologically intact. Pertinent Results: [**2143-6-21**] 08:20PM TYPE-ART TEMP-36.9 O2 FLOW-6 PO2-99 PCO2-53* PH-7.23* TOTAL CO2-23 BASE XS--5 INTUBATED-NOT INTUBA COMMENTS-VENTIMASK [**2143-6-21**] 08:20PM LACTATE-1.8 [**2143-6-21**] 07:38PM TYPE-ART O2 FLOW-6 PO2-106* PCO2-65* PH-7.17* TOTAL CO2-25 BASE XS--5 INTUBATED-NOT INTUBA COMMENTS-VENTIMASK [**2143-6-21**] 07:38PM GLUCOSE-137* LACTATE-2.0 K+-4.7 [**2143-6-21**] 07:38PM freeCa-1.10* [**2143-6-21**] 06:54PM TYPE-ART PO2-102 PCO2-76* PH-7.13* TOTAL CO2-27 BASE XS--5 [**2143-6-21**] 06:54PM LACTATE-2.3* [**2143-6-21**] 04:30PM GLUCOSE-139* UREA N-20 CREAT-1.3* SODIUM-140 POTASSIUM-5.2* CHLORIDE-108 TOTAL CO2-25 ANION GAP-12 [**2143-6-21**] 04:30PM estGFR-Using this [**2143-6-21**] 04:30PM CALCIUM-7.9* PHOSPHATE-4.5 MAGNESIUM-1.4* [**2143-6-21**] 04:30PM WBC-10.7 RBC-3.97* HGB-11.5* HCT-36.4* MCV-92 MCH-29.0 MCHC-31.6 RDW-15.0 [**2143-6-21**] 04:30PM PLT COUNT-242 [**2143-6-21**] 03:44PM TYPE-ART RATES-/12 TIDAL VOL-600 PEEP-5 O2-50 PO2-165* PCO2-46* PH-7.33* TOTAL CO2-25 BASE XS--1 INTUBATED-INTUBATED VENT-CONTROLLED [**2143-6-21**] 03:44PM GLUCOSE-138* LACTATE-3.4* NA+-137 K+-4.6 CL--106 [**2143-6-21**] 03:44PM HGB-11.4* calcHCT-34 [**2143-6-21**] 03:44PM freeCa-1.14 [**2143-6-21**] 03:06PM PT-11.6 PTT-28.5 INR(PT)-1.1 [**2143-6-21**] 03:06PM FIBRINOGE-348 [**2143-6-21**] 01:40PM TYPE-ART RATES-/14 TIDAL VOL-600 O2-55 PO2-92 PCO2-48* PH-7.32* TOTAL CO2-26 BASE XS--1 INTUBATED-INTUBATED VENT-CONTROLLED [**2143-6-21**] 01:40PM GLUCOSE-140* LACTATE-2.2* NA+-138 K+-4.2 CL--105 [**2143-6-21**] 01:40PM HGB-12.4* calcHCT-37 [**2143-6-21**] 01:40PM freeCa-1.17 [**2143-6-21**] 09:34AM TYPE-ART RATES-/14 TIDAL VOL-600 PEEP-5 O2-100 PO2-71* PCO2-37 PH-7.43 TOTAL CO2-25 BASE XS-0 AADO2-604 REQ O2-99 INTUBATED-INTUBATED VENT-CONTROLLED [**2143-6-21**] 09:34AM GLUCOSE-149* LACTATE-1.1 NA+-137 K+-4.0 CL--105 [**2143-6-21**] 09:34AM HGB-12.9* calcHCT-39 [**2143-6-21**] 09:34AM freeCa-1.17 CXR [**2143-6-27**] IMPRESSION: 1. Persistent left basilar opacification suggesting pleural effusion with associated atelectasis. Infection is difficult to exclude, however. 2. Small area of lucency along the course of the prior chest tube near its entry site into the right lower lateral chest, suggesting a very small loculated pneumothorax. CXR [**2143-6-28**] UGI barium swallow [**2143-6-26**] IMPRESSION: No evidence of leak or obstruction . BIOPSY (surgical) : see report for details - in summary - adenocarcinoma. Brief Hospital Course: The patient presented to the hospital for laparoscopic esophagectomy after being worked up in the outpatient setting. The abdominal portion was converted to open edue to intense adhesions from his proir splenectomy. The patient tolerated the procedure well, but required some pressors to maintain his blood pressure post-operatively. He was admitted to the ICU for monitoring. On POD 2, the patient was taken of pressors and his blood pressure was stable. On POD 3, the patient's Arterial line and his foley catheter were removed. On the same day, his NG tube was accidentally displaced and was discontinued. He voided on his own and did not experience any nausea despite removal of NGT. On POD 5, the patient had an upper GI barium study, which showed no leaks. His diet was slowly advanced and he tolerated. On POD 6, his chest tube was removed. A CXR showed a small pneumothorax. We performed the CXR again the following day, which showed a small left pleral effusion. His JP, which was discontinued on POD 7 and the patient was deemed stable for discharge. Physical therapy evaluated the patient, and they felt that home physical therapy would be beneficial for the patient. THe patient is to follow up with the surgeons in 2 weeks. Medications on Admission: 1. atenolol 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 2. clonazepam 1 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 3. diltiazem HCl 120 mg Capsule, Extended Release Sig: One (1) Capsule, Extended Release PO DAILY (Daily). 4. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 5. enoxaparin 100 mg/mL Syringe Sig: One (1) Subcutaneous [**Hospital1 **] (2 times a day). 6. pravastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. ferrous sulfate 325 mg (65 mg iron) Tablet Sig: One (1) Tablet PO once a day. 8. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 9. lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day. 10. triamterene-hydrochlorothiazid 37.5-25 mg Tablet Sig: One (1) Tablet PO once a day. 11. senna 8.6 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:*60 Tablet(s)* Refills:*2* 12. OxyContin 40 mg Tablet Extended Release 12 hr Sig: One (1) Tablet Extended Release 12 hr PO twice a day. 13. oxycodone 10 mg Tablet Sig: One (1) Tablet PO four times a day. Disp:*40 Tablet(s)* Refills:*0* Discharge Medications: 1. atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. clonazepam 1 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for agitation. 3. diltiazem HCl 120 mg Capsule, Extended Release Sig: One (1) Capsule, Extended Release PO DAILY (Daily). 4. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 5. enoxaparin 120 mg/0.8 mL Syringe Sig: One (1) Subcutaneous Q12H (every 12 hours). 6. pravastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 8. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 9. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 11. triamterene-hydrochlorothiazid 37.5-25 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 12. oxycodone 5 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8 hours) as needed for pain. 13. oxycodone 40 mg Tablet Extended Release 12 hr Sig: One (1) Tablet Extended Release 12 hr PO Q12H (every 12 hours). Discharge Disposition: Home With Service Facility: All Care VNA of Greater [**Location (un) **] Discharge Diagnosis: esophageal cancer Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: DISCHARGE INSTRUCTIONS: You were admitted to the west 3 surgery service for open esophagectomy. General Discharge Instructions: Please resume all regular home medications, unless specifically advised not to take a particular medication. Please take any new medications as prescribed. Please take the prescribed analgesic medications as needed. You may not drive or operate heavy machinery while taking narcotic analgesic medications. You may also take acetaminophen (Tylenol) as directed, but do not exceed 4000 mg in one day. Please get plenty of rest, continue to walk several times per day, and drink adequate amounts of fluids. Avoid strenuous physical activity and refrain from heavy lifting greater than 10 lbs., until you follow-up with your surgeon, who will instruct you further regarding activity restrictions. Please also follow-up with your primary care physician. [**Name10 (NameIs) 17779**] [**Name11 (NameIs) **]: *Please call your surgeon or go to the emergency department if you have increased pain, swelling, redness, or drainage from the [**Name11 (NameIs) **] site. *Avoid swimming and baths until cleared by your surgeon. *You may shower and wash incisions with a mild soap and warm water. Gently pat the area dry. *If you have staples, they will be removed at your follow-up appointment. *If you have steri-strips, they will fall off on their own. Please remove any remaining strips 7-10 days after surgery. Followup Instructions: Please call ([**Telephone/Fax (1) 1483**] upon discharge to schedule an appointment in the office of Dr. [**First Name8 (NamePattern2) 333**] [**Last Name (NamePattern1) **] in 2 weeks, or with any questions/concerns. Clinic is located in the [**Hospital **] Medical Office Building, [**Location (un) **], [**Hospital1 18**]. You have an appointment set with DR. [**Last Name (STitle) **] for [**2143-7-11**] at 10am. Completed by:[**2143-6-28**]

[ "458.29", "V12.51", "V64.41", "272.4", "E915", "278.00", "V12.55", "150.5", "V45.79", "568.0", "511.9", "401.9", "V58.61", "V15.82", "276.2", "719.46", "V12.54", "276.7", "933.1" ]

icd9cm

[ [ [] ] ]

[ "96.6", "42.52", "54.51", "54.59", "46.39", "42.42" ]

icd9pcs

[ [ [] ] ]

8292, 8367

4649, 5889

321, 395

8428, 8428

2119, 4626

10038, 10488

1524, 1582

7107, 8269

8388, 8407

5915, 7084

8602, 8674

1597, 2100

8706, 10015

264, 283

423, 1218

8443, 8554

1240, 1379

1395, 1508

48,059

101,819

50504

Discharge summary

report

Admission Date: [**2161-11-29**] Discharge Date: [**2161-12-2**] Date of Birth: [**2087-11-5**] Sex: F Service: MEDICINE Allergies: Penicillins / Sulfa (Sulfonamide Antibiotics) Attending:[**Last Name (NamePattern4) 290**] Chief Complaint: SOB, HYPOXIA, Major Surgical or Invasive Procedure: Pt was intubated History of Present Illness: . History of Present Illness: 74F with DM, chronic bronchiectasis c/b recurrent pseudomonal PNA, COPD on home O2, lung abscess s/p L lower lobectomy admitted to [**Hospital1 **]-[**Location (un) 620**] [**11-14**] with 2 days of fever, dyspnea, and chest heaviness. Noted to be hypoxic to 55% per transfer summary. CXR showed R-sided PNA. Initially managed on the floor and treated with zosyn and steroids. Zosyn switched to tobramycin & imipenem [**11-22**] when sputum Cx returned MDR pseudomonas. Eventually transferred to ICU for Afib with RVR, treated with diltiazem and digoxin. Bronch/BAL [**11-23**] also grew 2 strains of MDR pseudomonas and [**Female First Name (un) **]. Intubated [**11-24**] with 7.5 ETT for hypercapnic resp failure, at which time ABG 7.34/89/82/48. She remained hemodynamically stable. However, WBC# rose from 14.3 on [**11-27**] to 28.1 today. ABG this AM 7.50/52/144/41 on 400/12/5/0.4. Transferred to [**Hospital1 18**] for further evaluation and treatment. . On the floor, patient denies pain or difficulty breathing. . Past Medical History: DM Chronic bronchiectasis c/b recurrent pseudomonal PNA COPD on home O2 Lung abscess s/p L lower lobectomy +PPD with remote TB exposure Diverticulitis Osteoporosis Social History: Social History (per med records): Lives at home. Independent. Drinks [**1-24**] glasses of wine per day. Former smoker, quit smoking ~50 years ago. Family History: Family History: Not assessed. Physical Exam: Vitals: T 98.4 BP 116/56 P 84 RR 17 O2sat 95% on 400/12/5/0.35 General: Awake, opens eyes, appears comfortable, no access muscle use Neck: No JVD Lungs: diffuse rhonchi bilat no wheeze/rales CV: reg rate nl S1S2 no m/r/g Abdomen: soft NTND hypoactive BS Ext: warm, dry +PP 1+ pitting edema of all distal ext Pertinent Results: [**2161-11-29**] 02:25PM BLOOD WBC-29.2*# RBC-3.56* Hgb-10.8* Hct-34.0* MCV-95 MCH-30.4 MCHC-31.8 RDW-12.1 Plt Ct-262 [**2161-11-30**] 04:06AM BLOOD WBC-27.7* RBC-3.46* Hgb-11.0* Hct-33.6* MCV-97 MCH-31.8 MCHC-32.8 RDW-12.5 Plt Ct-279 [**2161-12-1**] 05:35AM BLOOD WBC-30.0* RBC-2.56*# Hgb-8.1*# Hct-24.9* MCV-97 MCH-31.4 MCHC-32.4 RDW-12.8 Plt Ct-279 [**2161-11-29**] 02:25PM BLOOD Neuts-94.6* Lymphs-1.8* Monos-3.4 Eos-0.1 Baso-0.1 [**2161-11-30**] 04:06AM BLOOD Neuts-95.4* Lymphs-1.5* Monos-2.5 Eos-0.5 Baso-0.1 [**2161-12-1**] 05:35AM BLOOD PT-13.9* PTT-150* INR(PT)-1.2* [**2161-11-29**] 02:25PM BLOOD Glucose-263* UreaN-61* Creat-0.3* Na-150* K-4.3 Cl-110* HCO3-36* AnGap-8 [**2161-12-1**] 05:35AM BLOOD Glucose-286* UreaN-76* Creat-0.4 Na-140 K-5.0 Cl-102 HCO3-35* AnGap-8 [**2161-11-29**] 02:25PM BLOOD ALT-20 AST-16 LD(LDH)-197 AlkPhos-52 TotBili-0.2 [**2161-11-29**] 02:25PM BLOOD Albumin-2.3* Calcium-7.4* Phos-3.0 Mg-2.7* [**2161-11-30**] 04:06AM BLOOD Calcium-7.8* Phos-3.6 Mg-2.5 [**2161-11-30**] 04:06AM BLOOD TSH-2.1 [**2161-11-29**] 02:25PM BLOOD Tobra-2.0* [**2161-11-30**] 05:30PM BLOOD Tobra-1.0* [**2161-11-29**] 02:44PM BLOOD Type-ART Temp-36.9 Rates-[**12-26**] Tidal V-420 PEEP-5 FiO2-35 pO2-113* pCO2-52* pH-7.48* calTCO2-40* Base XS-13 -ASSIST/CON Intubat-INTUBATED [**2161-11-30**] 06:20AM BLOOD Type-ART pO2-128* pCO2-60* pH-7.42 calTCO2-40* Base XS-12 [**2161-12-1**] 05:48AM BLOOD Type-ART pO2-129* pCO2-63* pH-7.40 calTCO2-40* Base XS-11 [**2161-11-29**] 02:44PM BLOOD Lactate-1.6 [**2161-11-30**] 03:49PM BLOOD Lactate-1.2 [**2161-12-1**] 05:48AM BLOOD Lactate-1.3 [**2161-12-1**] 05:48AM BLOOD freeCa-1.09* [**2161-11-29**] 03:30PM BLOOD B-GLUCAN-Test [**2161-11-29**] 03:30PM BLOOD ASPERGILLUS GALACTOMANNAN ANTIGEN-Test IMAGING : [**2161-12-1**] ABDOMINAL ULTRASOUND: The liver is diffusely heterogeneous in echotexture, but without focal lesions. There is no intrahepatic biliary ductal dilation. Common bile duct appears mildly dilated in the suprapancreatic portion, measuring 9-10 mm. The pancreatic duct tapers entering the pancreas but is not well seen distally There is normal antegrade flow in the main portal vein. The gallbladder is not distended, though there is marked gallbladder wall edema, which may reflect underlying liver disease or other causes of third spacing. There is no cholelithiasis identified. The spleen is normal in size, measuring 7 cm. Small amount of free fluid is identified in the left upper quadrant. The kidneys are symmetric in size, measuring 10.4 cm on the right and 10.9 cm on the left. There is no renal mass lesion, and no nephrolithiasis or hydronephrosis. The midline structures including the aorta, IVC, and pancreas, are obscured by overlying bowel gas. IMPRESSION: 1. Heterogeneous, coarse liver echotexture suggesting liver disease such as hepatitis or fibrosis. No focal liver lesions are identified. If further evaluation is desired, MRI could be considered when clinically feasible. 2. Mild dilation of suprapancreatic common bile duct, measuring 9-10 mm, without intrahepatic biliary ductal dilation. This is of dubious significance. MRCP could be performed if there is further concern. 3. Gallbladder wall edema, without associated distention or cholelithiasis to suggest acute cholecystitis. This may reflect third spacing, secondary to a number of causes, or may be from underlying liver disease. 4. Small amount of free fluid in the left upper quadrant adjacent to the spleen. 5. Obscuration of midline structures including the pancreas, aorta and IVC by overlying bowel gas. The study and the report were reviewed by the staff radiologist. Brief Hospital Course: Assessment and Plan: 74F with DM, chronic bronchiectasis c/b recurrent pseudomonal PNA, COPD on home O2, lung abscess s/p L lower lobectomy transferred for further management of hypercapnic respiratory failure due to MDR pseudomonal PNA. . #Hypercapnic respiratory failure/Pneumonia - pt respiratory status detiorated after presentation to the ED and she was intubated. Pt was diagnosed with MDR pseudomonal PNA and was being treated with Abx. She had an acute episode on a-fib with RVR and was medically managed. Ultimately it was planned for her to have DC cardioversion and so she was placed on Heparin drip in preparation for TEE and cardioversion. The morning after starting the drip, it was noticed that the patient had a large melenic stool and an acute drop in her hemoglobin and hematocrit. GI was consulted and an EGD showed bleeding around the ampulla. It was unclear whether the bleeding was coming from around the ampulla or within the ampulla. A RUQ U/S was done to rule out hemobilia or hemorrhagic mass. The family was contact[**Name (NI) **] at this time as goals of care have been a constant discussion. In addition, the patient was intubated, but clear and alert and she was aslo actively involved in the discussion of her care. The RUQ U/S was negative and IR and Surgery were notified for possible angiogram and intervention. As these events were developing, the family and pt were in active discussion with the medical team. The patient and family decided not to go ahead with the angiogram. The patient decided she wanted to be made CMO and be extubated. The patient was terminally extubated on [**2161-10-31**]. The patient died on [**2161-12-2**]. Medications on Admission: Vitals: T 98.4 BP 116/56 P 84 RR 17 O2sat 95% on 400/12/5/0.35 General: Awake, opens eyes, appears comfortable, no access muscle use Neck: No JVD Lungs: diffuse rhonchi bilat no wheeze/rales CV: reg rate nl S1S2 no m/r/g Abdomen: soft NTND hypoactive BS Ext: warm, dry +PP 1+ pitting edema of all distal ext Discharge Medications: N/A Discharge Disposition: Expired Discharge Diagnosis: N/A Discharge Condition: N/A Discharge Instructions: N/A Followup Instructions: N/A [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]

[ "427.32", "578.0", "518.81", "V46.2", "V66.7", "276.0", "578.1", "V58.67", "795.5", "V01.1", "427.31", "482.1", "494.0", "276.4", "250.00", "733.00" ]

icd9cm

[ [ [] ] ]

[ "96.71", "45.13", "96.04", "38.93", "33.29", "38.91", "33.22" ]

icd9pcs

[ [ [] ] ]

7921, 7930

5846, 7535

328, 346

7977, 7982

2172, 5823

8034, 8176

1814, 1829

7893, 7898

7951, 7956

7561, 7870

8006, 8011

1844, 2153

275, 290

404, 1430

1452, 1617

1633, 1782

53,804

193,457

38928

Discharge summary

report

Admission Date: [**2123-4-17**] Discharge Date: [**2123-4-27**] Date of Birth: [**2071-9-27**] Sex: M Service: MEDICINE Allergies: Peanut / Sulfur Attending:[**First Name3 (LF) 1515**] Chief Complaint: VF arrest s/p STEMI Major Surgical or Invasive Procedure: Cardiac catheterization with placement of DES in LAD. History of Present Illness: 51 yo man no known medical history was noticed to be driving erratically earlier this morning in NH and ultimately suffered an unrestrained MVA crashing his car into a tree. Did not appear to EMS to be traumatic arrest. Found apneic and pulseless in VF, with downtime of minutes before CPR initiated with EMS. Shocked 3x, epinephrine x2,atropine x1, lidocaine 2g IV then taken to [**Hospital3 25148**] Center in NH, then to [**University/College **]. On arrival to the [**Hospital1 18**] ED he had a GCS of 7, unconscious. Initial CE were CK: 1694 Trop-T: 4.11 and have EKG changes consistent with STEMI. He was loaded with amio, ASA, integrillin, and started on heparin drip. Within 3 hours of his arrest he hit the cath lab and was found to have total occlusion of the LAD proximally with BMS placed to the ostium of the LAD. There was also 30% distal RCA lesion, minimal Lcx disease. He underwent LHC with L ventriculograpy and coronary angiography which noted proximal TO of LAD. A BMS was placed. On leaving the cath lab he was found to be hypertensive and was started on nitro gtt, and NGT was placed, and transferred to the CCU. On arrival to the CCU he was hemodynamically stable. A repeat EKG at that time showed improvement in his ST elevation post revascularization. He was weaned off nitro GTT, continued on amnio and heparin GTT. . Past Medical History: eczema cholecystectomy Social History: works as an accountant, lives in [**Location **] alone. Has sister who lives in NY state who he is close to and considers his major support. Owns accounting firm with other employees. Occassional EtOH. Quit smoking several years ago Family History: father died of massive MI at age 47. Mother with ?mitral valve prolapse died at age 79 (about three months ago). Physical Exam: Wt: 250 pounds,height 73 Vitals: T , BP 139/101, HR 109 General:comatose prior to sedation, intubated HEENT: Pupils sluggish, equal round, sluggish but react to light, constricting from 6mm to 3mm, reflexes mute, babinski's flat, does not withdraw from painful stimuli,or respond to voice or sound. Neck:neck brace in place, unable to assess JVP Chest: ventilated breath sounds, clear anteriorly Heart: Distant heart sounds, RRR, no MRG, s1/s2 clear Abdomen:+bs, soft, nt, nd, no masses Extremities:R groin cath access site c/d/i/no bruit, no hematoma Ext: mottled/purplish extremities, slow cap refill, DP/PT pulses dopplerable Pertinent Results: ECG Study Date of [**2123-4-17**] 12:07:50 PM Sinus tachycardia. Left axis deviation. Acute ST segment elevation in the early precordial leads. Consider acute anteroseptal myocardial infarction. There are inferior changes which are likely reciprocal. Clinical correlation is suggested. No previous tracing available for comparison. Cardiac Cath Date of [**2123-4-17**] COMMENTS: 1. Selective coronary angiography in this right dominant system demonstrated single vessel CAD. The LMCA was normal. The proximal LAD had a total occlusion. The LCx had minimal disease. The RCA had a 30% distal stenosis. 2. Limited resting hemodynamics revealed normal blood pressures with SBP of 122 mm Hg and DBP of 93 mm Hg. 3. Successful PTCA and stenting of the ostial LAD with a 3.0 x 23mm Vision bare metal stent. Final angiography revealed no residual stenosis, no angiographically apparent dissection, and TIMI 3 flow. (see PTCA comments for details) FINAL DIAGNOSIS: 1. One vessel coronary artery disease. 2. Successful PTCA and stenting of the ostial LAD. Lab results [**2123-4-17**] 09:20PM URINE COLOR-Amber APPEAR-Hazy SP [**Last Name (un) 155**]->1.030 [**2123-4-17**] 09:20PM URINE BLOOD-LG NITRITE-NEG PROTEIN-75 GLUCOSE-1000 KETONE-NEG BILIRUBIN-NEG UROBILNGN-4* PH-6.5 LEUK-NEG [**2123-4-17**] 09:20PM URINE RBC->50 WBC->50 BACTERIA-MANY YEAST-NONE EPI-0-2 [**2123-4-17**] 09:20PM URINE GRANULAR-[**7-8**]* [**2123-4-17**] 08:41PM TYPE-ART TEMP-33.4 RATES-28/ TIDAL VOL-480 O2-100 PO2-125* PCO2-33* PH-7.22* TOTAL CO2-14* BASE XS--13 AADO2-556 REQ O2-92 -ASSIST/CON INTUBATED-INTUBATED [**2123-4-17**] 08:41PM LACTATE-5.4* [**2123-4-17**] 07:21PM GLUCOSE-390* UREA N-24* CREAT-1.7* SODIUM-135 POTASSIUM-4.8 CHLORIDE-100 TOTAL CO2-18* ANION GAP-22* [**2123-4-17**] 07:21PM CK(CPK)-7595* [**2123-4-17**] 07:21PM CALCIUM-8.3* PHOSPHATE-5.0* MAGNESIUM-2.4 [**2123-4-17**] 07:21PM WBC-26.6* RBC-5.51 HGB-15.5 HCT-50.3 MCV-91 MCH-28.1 MCHC-30.8* RDW-13.5 [**2123-4-17**] 07:21PM PLT COUNT-286 [**2123-4-17**] 05:30PM TYPE-ART TEMP-35.0 RATES-/16 TIDAL VOL-500 PEEP-8 O2-100 PO2-81 PCO2-50* PH-7.13* TOTAL CO2-18* BASE XS--12 AADO2-583 REQ O2-96 -ASSIST/CON INTUBATED-INTUBATED [**2123-4-17**] 05:30PM LACTATE-4.8* [**2123-4-17**] 05:30PM O2 SAT-94 [**2123-4-17**] 01:50PM GLUCOSE-256* UREA N-18 CREAT-1.2 SODIUM-132* POTASSIUM-5.5* CHLORIDE-104 TOTAL CO2-20* ANION GAP-14 [**2123-4-17**] 01:50PM CK(CPK)-1694* [**2123-4-17**] 01:50PM cTropnT-4.11* [**2123-4-17**] 12:24PM VoidSpec-SPECIMEN R [**2123-4-17**] 12:24PM URINE bnzodzpn-NEG barbitrt-NEG opiates-POS cocaine-NEG amphetmn-POS mthdone-NEG [**2123-4-17**] 12:24PM WBC-23.6* RBC-6.04 HGB-16.7 HCT-53.7* MCV-89 MCH-27.7 MCHC-31.2 RDW-13.7 [**2123-4-17**] 12:24PM PLT COUNT-289 [**2123-4-17**] 12:24PM PT-12.8 PTT-27.4 INR(PT)-1.1 [**2123-4-17**] 12:24PM URINE COLOR-Yellow APPEAR-Cloudy SP [**Last Name (un) 155**]-1.023 [**2123-4-17**] 12:24PM URINE BLOOD-LG NITRITE-NEG PROTEIN-500 GLUCOSE-250 KETONE-NEG BILIRUBIN-NEG UROBILNGN-1 PH-6.0 LEUK-TR [**2123-4-17**] 12:24PM URINE RBC-[**12-18**]* WBC->50 BACTERIA-MANY YEAST-NONE EPI-[**7-8**] [**2123-4-17**] 12:24PM URINE GRANULAR-[**7-8**]* HYALINE-[**7-8**]* [**2123-4-17**] 12:24PM URINE SPERM-MANY [**2123-4-17**] 12:23PM COMMENTS-GREEN TOP [**2123-4-17**] 12:23PM GLUCOSE-215* LACTATE-5.1* NA+-139 K+-6.5* CL--105 TCO2-17* . CXR [**2123-4-18**] FINDINGS: On today's radiograph, an endotracheal tube is seen. The tip of the tube projects 6 cm above the carina. A nasogastric tube shows a normal course, the tip of the tube projects over the middle parts of the stomach. The tip of a right internal jugular venous central access line projects over the mid-to-lower SVC. Otherwise, there is no relevant change. Increased lung volumes, subtotal left lower lobe atelectasis, mild-to-moderate cardiomegaly. No larger pleural effusions. No focal parenchymal opacities have newly appeared in the interval. . cxr: [**2123-4-19**] FINDINGS: Single bedside AP examination, presumably supine, with much of the lateral aspect of left hemithorax excluded. There has been a dramatic interval change since the bedside study obtained (for line placement) the preceding day. There is now diffuse airspace opacity involving both lungs, more confluent on the right, with numerous air-bronchograms. Allowing for this (and the positioning), there has been no significant change in heart size, pulmonary vascular congestion or significant pleural effusion. The right IJ central venous catheter is unchanged with tip at the superior vena cavo-atrial junction, and no pneumothorax (in this position). Since the previous study, the endotracheal and endogastric tubes have been removed. IMPRESSION: Extensive diffuse and confluent airspace process involving both lungs, new since the examination day before. While this may represent while massive aspiration event, as questioned clinically, pulmonary edema -either cardiogenic or noncardiogenic - as well as diffuse pulmonary hemorrhage are also diagnostic considerations, and should be closely correlated with clinical data (of which none is available, on review of OMR). . [**2123-4-19**] -TTE The left atrium is normal in size. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity is moderately dilated. Overall left ventricular systolic function is severely depressed (LVEF= 20-25 %) with global hypokinesis. No masses or thrombi are seen in the left ventricle. There is no ventricular septal defect. There is no aortic valve stenosis. No aortic regurgitation is seen. Trivial mitral regurgitation is seen. The pulmonary artery systolic pressure could not be determined. There is a trivial/physiologic pericardial effusion. . Bedside Echo [**2123-4-18**] The left atrium and right atrium are normal in cavity size. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. There is severe regional left ventricular systolic dysfunction with severe septal and anterior wall hypokinesis to akinesis and hypokinesis of the remaining segments (LVEF = [**11-12**] %). Right ventricular chamber size and free wall motion are normal. There is no mitral valve prolapse. Trivial mitral regurgitation is seen. The pulmonic valve prosthesis is not well seen. There is no pericardial effusion. PRELIMINARY REPORT developed by a Cardiology Fellow. Not reviewed/approved by the Attending Echo Physician. [**Name10 (NameIs) **] [**Name11 (NameIs) 64202**] caring for the patient were notified in person of the results on [**2123-4-18**] 9:45 a.m. . [**2123-4-17**] CT torso: Wet Read No acute cervical fracture or malalignment. Moderate multilevel degenerative disease with osteophytes may increase risk of spinal cord injury. Aspiration in the bilateral lung apices. . [**2123-4-17**] CT head Wet Read. FINDINGS: There is no acute intracranial hemorrhage, mass effect, edema, or major vascular territorial infarct. The ventricles and sulci are normal in size and symmetrical in configuration. There is good preservation of the [**Doctor Last Name 352**]-white matter differentiation. The visualized paranasal sinuses and mastoid air cells are clear. There is no acute osseous fracture. IMPRESSION: No acute intracranial injury [**2123-4-18**] 11:40 pm SPUTUM Site: ENDOTRACHEAL Source: Endotracheal. DUE TO LABORATORY ERROR, CULTURE PROCESSING HAS BEEN DELAYED. **FINAL REPORT [**2123-4-22**]** GRAM STAIN (Final [**2123-4-19**]): THIS IS A CORRECTED REPORT ([**2123-4-20**]). [**11-22**] PMNs and <10 epithelial cells/100X field. 4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS, CHAINS, AND CLUSTERS. 3+ (5-10 per 1000X FIELD): MULTIPLE ORGANISMS CONSISTENT WITH OROPHARYNGEAL FLORA. . PREVIOUSLY REPORTED AS. [**11-22**] PMNs and >10 epithelial cells/100X field. 4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS, CHAINS, AND CLUSTERS. 3+ (5-10 per 1000X FIELD): MULTIPLE ORGANISMS CONSISTENT WITH OROPHARYNGEAL FLORA ([**2123-4-19**]). RESPIRATORY CULTURE (Final [**2123-4-22**]): MODERATE GROWTH Commensal Respiratory Flora. STAPH AUREUS COAG +. MODERATE GROWTH. Staphylococcus species may develop resistance during prolonged therapy with quinolones. Therefore, isolates that are initially susceptible may become resistant within three to four days after initiation of therapy. Testing of repeat isolates may be warranted. GRAM NEGATIVE ROD(S). SPARSE GROWTH. BACILLUS SPECIES; NOT ANTHRACIS. SPARSE GROWTH. IN THIS QUANTITY, IT IS CONSIDERED PART OF Commensal Respiratory Flora. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPH AUREUS COAG + | CLINDAMYCIN-----------<=0.25 S ERYTHROMYCIN----------<=0.25 S GENTAMICIN------------ <=0.5 S LEVOFLOXACIN----------<=0.12 S OXACILLIN------------- 0.5 S TRIMETHOPRIM/SULFA---- <=0.5 S . INR 4.1 WBC: Hct: Brief Hospital Course: 51 y/o male with hx cholecystectomy/eczema who suffered a STEMI in the field with VF arrest, with CPR performed within minutes, found to have total occlusion of the LAD s/p reperfusion with BMS to LAD. He is s/p 24 hour Arctic Sun protocol. His hospital course has been complicated by anterograde amnesia and respiratory distress secondary to pneumonia. He had radiographic evidence of ARDS which was managed by treating his pneumonia initially with vanc, cefepime and flagyl and now with cefepime alone. He did have coag +ve staph and GNR in sputum but these were felt to be contaminants. He intermittently required oxygen therapy with BIPAP, non rebreather and high flow mask. He now has O2 sats of 96% on RA and has PRN ATrovent nebulizers to use for wheezing. He initially suffered anterograde amnesia but is now able to form new memories. . # STEMI s/p VF arrest: The patient had received CPR within minutes of his car crash and he was catheterized within three hours of his crash. He had been in Ventricular fibrillation in the field, was shocked into a perfusable rhythm, and was in sinus on arrival to our emergency room. His EKG was consistent with an anterior STEMI and his cardiac enzymes were highly elevated (TropT 4.11), peak CK's 1694. He was loaded with amiodarone and plavix, heparinized, and started on integrillin. On cardiac catheterization, he was found to have total occlusion of the LAD proximally. A bare metal stent was placed. He was briefly hypertensive following his procedure, was placed on a nitroglycerin drip and was subsequently weaned off and was mostly hypertensive. He underwent the artic sun cooling protocol to preserve neurologic function post arrest. The morning following his revascularization he acutely became hypotensive. He was volume resuscitated, started on dobutamine for pressor support which was eventually weaned off. A bedside echo revealed LVEF 25-30% with global hypokinesis. He was subsequently rewarmed per protocol. An echocardiogram performed 48 hours post revascularization showed mild symmetric LVH with moderately dilated LV cavity and LVEF of 20-25% with global hypokinesis. His cardiac enzymes trended downwards. An EEG performed during rewarming was suggestive of mild to moderate encephalopathy. He did suffer anterograde amnesia as a consequence of his arrest which improved gradually over the stay. He will follow up with neurology as an outpatient with Dr [**Last Name (STitle) **]. He underwent physical therapy per the STEMI protocol and will undergo cardiac rehabilitation to be coordinated by his outpatient cardiologist. He was discharged on high dose aspirin, plavix, atorvastatin, metoprolol, and an ace inhibitor. Anterior wall was found to be akinetic on Echo, and was anticoagulated accordingly with coumadin. A repeat echo will be done in ~ 1-2 months. He will need to have his INR followed as an outpatient. . # Respiratory distress: His hospital stay was complicated by acute respiratory distress on the 3rd day of admission. CXR showed extensive diffuse and confluent airspace process involving both lungs. He was treated with lasix, nitroglycerin, oxygen with BiPAP and positioning. He appeared to respond to the treatment with improvement in oxygen saturation and CXR until the next day when he deteriorated again with respiratory distress with low grade fever and elevated WBC. CXR showed worsening diffuse opacities. Sputum gram stain revealed gram positive cocci and multiple organisms consistent with oropharyngeal flora. A presumtive diagnosis of aspiration pneumonia was made and he was started on vancomycin/cefepime/flagyl. Sputum culture eventually revealed moderate growth of coagulase positive S.aureus and gram negative rod species and he was treated by cefepime alone eventually according to sensitivity. His CXR was concerning for ARDS given the presence of diffuse alveolar infiltrates however it improved with 02 treatment and antibiotics. . # Hypotension: He became hypotensive during the stay presumably due to diuresis that he received for pulmonary edema, on top of blood pressure medications. He briefly required pressors. His pulmonary edema improved with antibiotics after diagnosis of aspiration pneumonia, and it was decided to stop diuresis. His blood pressure eventually stayed in the normotensive range without pressors. . # Agitation: He has had several episodes of agitation in which he was managed by ativan, morphine or haldol PRN. It is thought that his respiratory distress played a role in his agitation and declined mental status following VF arrest. With gradual recovery in his respiratory function and mental status, he became stable without any further episodes and fully alert and oriented at the time of discharge. He can become easily frustrated with care. . # Altered MS: Initially he was poorly oriented with time and place and appeared to have anterograde amnesia. Over the hospital stay, however, his mental status gradually improved and eventually he became oriented in person, time and place and was able to form a new memories. He has been seen by neuro team during the stay and is going to have follow-up appointment with Dr [**Last Name (STitle) **] as outpatient. . # Metabolic Dyscrasias: He had metabolic dyscrasias on arrival to the CCU. His toxicology screen was positive for opiates and amphetamines which may have been partly due to the medications given in the field in managing his arrest. He was found to have a metabolic acidosis with an elevated lactate presumed to be [**3-2**] to his prolonged hypoxemia in the setting of his total occlusion of the LAD. He was also noted to be persistently hyperglycemic despite insulin injections and was started on an insulin drip with effect. He had elevated CK's secondary to both myocardial muscle death and rhabdomylosis. His metabolic acidosis and hyperlactatemia and elevated CK's corrected with IVF. Subsequently he developed metabolic alkalosis in the setting of respiratory distress which eventually improved with respiratory support. . # Leukocytosis: On admission he was found to have an elevated white count and was known to have aspirated in the field. During the arctic sun cooling protocol he had temperatures higher than the set temperatures and was thought to be spiking fevers. He was subsequently pan cultured and the sputum culture revealed coagulase positive S.aureus and gram negative rod species but these were felt to be contaminants. He received a clinical diagnosis of pneumonia and was initially treated with broad spectrum antibiotics with cefepime, vancomycin,metronidazole, and finally narrowed to cefepime alone. He was noted to have an e.coli UTI which was treated with the same antibiotic coverage. . # s/p trauma: He had a CT head/torso and C spine which was negative except for evidence of aspiration. He was evaluated by trauma surgery who initially placed a neck brace, which was removed once his c-spine had been cleared. . # Elevated LFTs: He was found to have mildly elevated LFTs. No evidence of hemolysis, lipase wnl, no ultrasound, continued to trend. LFTs eventually improved. Medications on Admission: hydrocortisone creams for eczema Discharge Medications: 1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): Do not stop or miss [**First Name (Titles) 691**] [**Last Name (Titles) 4319**] for at least one month. 3. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Nicotine 21 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr Transdermal DAILY (Daily) for 2 weeks. 5. Ipratropium Bromide 0.02 % Solution Sig: One (1) vial Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. 6. Betamethasone Dipropionate 0.05 % Ointment Sig: One (1) Appl Topical QID (4 times a day) as needed for eczema . 7. 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. 8. Cefepime 2 gram Recon Soln Sig: One (1) Recon Soln Injection Q12H (every 12 hours) for 3 days: to complete 10 day course. 9. Valsartan 40 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily): Hold SBP < 100. 10. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as needed for insomnia. 11. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): Please change to Metoprolol Succinate 50 mg when pt stable on this dose. Hold HR < 55, SBP <100. 12. Potassium & Sodium Phosphates 280-160-250 mg Powder in Packet Sig: One (1) Powder in Packet PO BID (2 times a day). 13. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO twice a day: Give while pt on Plavix and coumadin, then d/c. . Discharge Disposition: Extended Care Facility: [**Hospital3 7665**] Discharge Diagnosis: Primary ST Elevation Myocardial Infarction with Ventricular Fibrillation. Acute Systolic dysfunction, EF 25% . Secondary Eczema 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 because you had a heart attack. You had a stent placed in one of the main blood vessels in your heart which had been found to be occluded. You had some difficulty breathing which was likely due to a pneumonia. You received antibiotics for this. Your memory was initially impaired after the heart attack but you recovered over the course of your hospitalization. The following changes were made to your medications We added: Atorvastatin 80mg daily metoprolol 25 mg twice daily Valsartan 20 mg daily plavix 75mg daily aspirin 325mg daily Ipratropium Bromide nebulizers for wheezing or trouble breathing. Betamethasone Dipropionate 0.05 % Ointment for exzema Cefepime 2 gram One (1) Recon Soln Injection Q12H (every 12 hours) for 3 days to treat pneumonia Potassium & Sodium Phosphates 280-160-250 mg Powder in Packet to treat low phosphate levels Ranitidine to prevent stomach upset while you are on the Plavix and Warfarin. You were started on Coumadin (Warfarin) to prevent blood clots from developing in your heart. We hope you will be on this temporarily as your heart function improves. Your Warfarin is being held now because your INR is too high. We will follow it daily and restart when indicated. . You cannot drive until after you see Dr. [**Last Name (STitle) 86363**] and you have discussed this issue with him. He will make the final decision about when you will be safe driving. . Weigh yourself every day in the morning. Call Dr. [**Last Name (STitle) 86364**] if your weight increases more than 3 pounds in 1 day or 6 pounds in 3 days. Followup Instructions: Primary Care: Dr. [**First Name4 (NamePattern1) 2491**] [**Last Name (NamePattern1) 86365**] [**Street Address(2) 86366**] [**Location (un) 5450**], [**Numeric Identifier 86367**] ([**Telephone/Fax (1) 86368**] Fax: [**Telephone/Fax (1) 86369**] Date/time: [**5-14**] at 1:00pm. . Cardiology: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Location (un) 511**] Heart Institute [**Location (un) 86370**], [**Numeric Identifier 86371**] Fax: [**Telephone/Fax (1) 86372**] Phone: ([**Telephone/Fax (1) 86373**] Date/time: Tuesday [**6-1**] at 3:00pm. . Neurology: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] Phone: [**Telephone/Fax (1) 1690**] Date/Time:[**2123-6-18**] 10:30 [**Hospital1 69**], [**Location (un) 86**]. Please call the office for directions. Completed by:[**2123-4-29**]

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icd9pcs

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6005

Discharge summary

report

Admission Date: [**2188-6-12**] Discharge Date: [**2188-6-26**] Date of Birth: [**2126-4-8**] Sex: M Service: MEDICINE Allergies: Iodine; Iodine Containing / Shellfish Attending:[**First Name3 (LF) 2181**] Chief Complaint: CC: Abdominal pain Major Surgical or Invasive Procedure: Surgical debridement of Stage IV sacral ulcer History of Present Illness: 63 yo male, PMH of paraplegia s/p GSW, Stage IV sacral ulcers, presented with abdominal pain, SOB, cough, hypotension (92/48) in ER on [**2188-6-12**]. Pt has had moderate, periumbilical, constant abdominal pain for 1 week, not progressively worsening, and not worse after meals. Pt has had mild nausea but no vomiting, and poor PO intake. Pt has cough with whitish phlegm. Pt's SOB has been worsening for the past few days, to the point where now the pt gets SOB merely upon speaking. Pt had a temp spike of 101.2 one week ago. Pt has experienced no CP, no palpitations, no PND, no BRBPR. . In the [**Name (NI) **], pt was hypotensive to 80/60 which improved to 110/80 with 6L IVF. Pt was transfused with 2 U pRBCs, and given Levo/Flagyl/Vanco for wound. The pt has NOT been documented with MRSA nor with VRE. Pt was found to be guaiac negative in the ED. . In [**11-23**], the pt was admitted for worsening R sacral ulcer and foul-smelling discharge. A bone biopsy revealed Proteus and Enterococcus, and pt was placed on Amp/Levo/Gent. Further flaps were thought not to be useful. At this point, the pt were s/p 8 flaps, numerous debridements, L hip osteo ([**12-26**]), and R girdlestone debridement. At this time, the pt also had AG acidosis and anemia of chronic disease. . Since that time, pt was brought to ED in [**3-25**] because of abnormal wound drainage. A L posterior abscess cavity was found, and bilateral wound vacs were placed, which drained 150 ml/day of serosanguinous fluid/wound. No abx were prescribed, but debridements were performed. Past Medical History: 1. T10 paraplegic, s/p GSW at age 19 - now with colostomy, urostomy, and long history of sacral ulcers 2. Stage IV ischial pressure ulcers - s/p 11 flaps and multiple debridements 3. HTN 4. Cocaine abuse with narcotics contract 5. Osteomyelitis of L hip Social History: Pt lives alone, has home health nurse visits (VNA). Drinks alcohol occasionally, 3 cigs/day, used cocaine 3 weeks ago but denies other drug use. Family History: Noncontributory. Physical Exam: ON ADMISSION: Vitals: 97.7 / 111 / 18 / 120/80 (92/48 in ER) / 100% 2L Gen: A&Ox3 HEENT: Dry mucous membranes, no JVD Lungs: CTA anteriorly Cardiac: Normal S1/S2, no m/r/g Abdomen: Mild periumbilical tenderness, +BS, soft, ND, colostomy/urostomy in place Extr: No edema, no cyanosis, atrophied calves, guaiac neg Sacrum: L and R buttock wounds, approximately 10x10 cm and severe Stage IV with bone showing . ON DISCHARGE: Vitals: 99.5 / 100 / 18 / 130/70 / 100% RA I/O: 1050/3600 Gen: NAD, A&Ox3 HEENT: PERRL, no LAD, no JVD, nl thyroid size Lungs: CTAB Heart: RRR, no m/r/g Abd: No tenderness to palpation, urostomy, colostomy Extr: Stage IV sacral ulcers encompassing almost entire right and left buttocks, T10 paraplegic, sensory loss in [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 6816**], 1+ edema in LEs Pertinent Results: [**2188-6-23**] 04:09AM BLOOD WBC-9.9 RBC-4.04* Hgb-12.0* Hct-34.6* MCV-86 MCH-29.8 MCHC-34.7 RDW-15.2 Plt Ct-371 [**2188-6-23**] 04:09AM BLOOD Plt Ct-371 [**2188-6-23**] 04:09AM BLOOD PT-12.5 PTT-34.5 INR(PT)-1.0 [**2188-6-23**] 04:09AM BLOOD Glucose-78 UreaN-9 Creat-0.5 Na-135 K-4.4 Cl-106 HCO3-24 AnGap-9 [**2188-6-12**] 01:10PM BLOOD Glucose-109* UreaN-75* Creat-1.5* Na-132* K-6.1* Cl-108 HCO3-11* AnGap-19 [**2188-6-12**] 01:10PM BLOOD ALT-37 AST-37 CK(CPK)-23* AlkPhos-494* Amylase-69 TotBili-0.2 [**2188-6-12**] 01:10PM BLOOD CK-MB-NotDone cTropnT-0.07* [**2188-6-23**] 04:09AM BLOOD Calcium-7.9* Phos-2.4* Mg-1.6 [**2188-6-12**] 01:10PM BLOOD Albumin-2.6* Calcium-9.9 Phos-4.3 Mg-2.1 [**2188-6-12**] 09:57PM BLOOD Type-ART pO2-158* pCO2-21* pH-7.26* calHCO3-10* Base XS--15 Intubat-NOT INTUBA [**2188-6-17**] 01:36PM BLOOD Type-ART pO2-212* pCO2-41 pH-7.35 calHCO3-24 Base XS--2 CT ABDOMEN W/O CONTRAST [**2188-6-12**] 3:29 PM: COMPARISONS: MRA of the pelvis [**2188-4-23**] and CT view without contrast [**2187-11-28**]. CT OF THE ABDOMEN WITHOUT CONTRAST: There is minimal atelectasis at the right lung base. There is a rounded calcified nodule at the left lung base, which is unchanged and likely represents granuloma. At the left lung base is a linear high-density structure, which may represent a bullet fragment. The visualized heart and pericardium are unremarkable. The noncontrast enhanced liver, pancreas, spleen, adrenal glands, and left kidney are unremarkable. The right kidney contains a rounded low-density focus, which likely represents a simple renal cyst. The stomach, and intraabdominal loops of small and large bowel are unremarkable. The patient is status ureteroileostomy and colostomy, and these loops of bowel are unremarkable. There is no evidence of bowel wall edema, or bowel obstruction. Just inferior to the right kidney is a high- density metallic fragment, likely a bullet. There is no pathologically enlarged mesenteric or retroperitoneal lymphadenopathy. There is no free air or free fluid within the abdomen. Note is made of markedly atrophic back musculature. CT OF THE PELVIS WITHOUT CONTRAST: The rectum and intrapelvic loops of small and large bowel are unremarkable. The patient is status post cystectomy. There is no pathologically enlarged inguinal or pelvic lymphadenopathy, and there is no free fluid within the pelvis. Again, a high-density metallic fragment is noted within the right lower pelvis, likely a bullet. There are bilateral decubitus ulcers posterior to the lower pelvis and left and right hip joints. There is increased soft tissue density and air tracking from these decubitus ulcers into both hip joints. The patient is status post left femoral head resection in [**4-24**], however, there are marked irregularity and fragmentation about both hips which is concerning for chronic osteomyelitis in this region. BONE WINDOWS: As described above, irregularity and fragmentation of both femurs and hip joints, some of which may be related on the left to the patient's recent left femoral head resection. There are no suspicious lytic or blastic osseous lesions. IMPRESSION: Marked irregularity and fragmentation of both femurs and hip joints with air and fluid tracking into these joints from the patient's bilateral sacral decubitus ulcers. While on the left some of these changes could potentially be post operative secondary to the recent left femoral head resection, the severity of the joint and bone destruction is concerning for osteomyelitis bilaterally. LIVER OR GALLBLADDER US (SINGLE ORGAN) [**2188-6-13**] 2:59 PM: COMPARISON: CT of the abdomen dated [**2188-6-12**]. ABDOMEN ULTRASOUND: The liver echo texture is normal. There is a tiny calcification within the right lobe of the liver that likely represents a granuloma. There is no intrahepatic biliary ductal dilatation or focal liver mass. The main portal vein is patent with the appropriate direction of flow. The gallbladder contains 2 shadowing gallstones. There is no gallbladder wall thickening, edema or pericholecystic fluid. Common duct measures 5 mm. Limited views of the pancreas are normal. CONCLUSION: Cholelithiasis, without evidence of cholecystitis. MR HIP W&W/O CONTRAST LEFT [**2188-6-14**] 4:43 PM: HIP WITHOUT & WITH GADOLINIUM: The patient is post-girdlestone procedures bilaterally. There are soft tissue defects in the buttocks bilaterally packed with surgical gauze. There is abnormal enhancing soft tissue within the left gluteal soft tissues extending into the left iliac bone. The abnormal soft tissue extends to the medial aspect of the iliac bone but does not appear to extend into the pelvic cavity. The degree of abnormal soft tissue has increased compared with the prior study dated [**2188-4-23**]. Within the posterior right buttock, there is soft tissue loss extending down to the right iliac bone which is new when compared with the prior study. Abnormal enhancement is seen in this region as well. Signal changes in the adjacent right illiac bone are non-specific, but are typical for osteomyelitis. There is diffuse edema within the gluteal soft tissues. A focal area of susceptibility is noted along the left perineum likely due to metallic susceptibility artifact. IMPRESSION: Post-Girdlestone procedures bilaterally. Interval worsening of the degree of soft tissue loss overlying the posterior right hip which extends down to and involves the right iliac bone. Abnormal enhancing soft tissue extending into the left iliac bone, unchanged. The areas about both hips are concerning for osteomyelitis. Pathology Examination SPECIMEN SUBMITTED: ACETABULAR BONE,ILEUM Procedure date Tissue received Report Date Diagnosed by [**2188-6-17**] [**2188-6-17**] [**2188-6-20**] DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]/cwg FEMUR INCLUDING [**Numeric Identifier 23641**] LT PROXIMAL FEMUR. [**-3/4420**] LT: PELVIC BONE & SOFT TISSUE SACRUM. [**-2/3135**] LEFT PRESSURE SORE, RIGHT PRESSURE SORE. DIAGNOSIS: 1. Acetabulum: A. Acute and chronic osteomyelitis with osteonecrosis. B. Necrotic fibrocartilage and soft tissue. 2. Bone ileum: A. Acute and chronic osteomyelitis with osteonecrosis. B. Necrotic fibrocartilage. Brief Hospital Course: A/P: 63 yo male, PMH of paraplegia s/p GSW, Stage IV sacral ulcers, s/p many flaps and debridements, presented with abdominal pain, SOB, cough, hypotension (92/48) in ER on [**2188-6-12**]. . Pt was admitted to the MICU, where he was initially treated with cefepime, vanco, flagyl based on previous cultures, but was switched to Meropenem. His hypotension, SOB, cough, mild diarrhea, and non-gap acidosis resolved. His ARF and hyperkalemia were addressed. His abdominal pain was resolving, and he was transferred to the floor. . On the floor, the pt was maintained on Meropenem and underwent an I&D of the L hip and the R hip in 2 separate procedures. MRI of both hips showed After the second procedure, the pt became hypotensive on the floor and had an episode of syncope. He was transferred to the MICU again, where he was hemodynamically stabilized. The pt returned to the floor again, where his Meropenem was d/ced and replaced with Unasyn. . . 1. STAGE IV ISCHIAL PRESSURE ULCERS: Foul-smelling discharge upon admission, but clean, clear serosanguinous drainage, no erythema upon discharge. The primary issue addressed was to decide between dramatic surgery measures and long-term antibiotics. Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 1022**], Orthopedics ([**2188**]) discussed surgery options with the patient. A Picc line was placed in the pt's L UE for longterm Unasyn. . 2. ANEMIA: This is likely anemia of chronic disease given previous iron studies, and was stable throughout admission. . 3. COCAINE HISTORY (with narcotics contract): Pt has a history of cocaine use, and states that he has not used cocaine for the past few weeks. . 5. FEN: No IVF because PO diet. . 6. PROPHYLAXIS: - SC Heparin, PPI . 7. CODE: - FULL . 8. COMMUNICATION: - Friend: [**Name (NI) 23642**] [**Name (NI) 23643**] [**Telephone/Fax (1) 23644**] Medications on Admission: Lisinopril 5 mg PO QD Norvasc 2.5 mg PO QD Oxycodone 5 mg PO Q4H prn Actonel 35 mg PO Qweek Protonix 40 mg PO QD Zinc sulfate 220 mg PO QD MVI Ferrous sulfate 325 mg PO QD Mg oxide 400 mg PO QD Vitamin C 500 mg PO BID Calcium carbonate 500 mg [**Hospital1 **] with meals Trazodone 100 mg PO QHS Bactroban topical HCTZ 25 mg PO QD Ibuprofen PRN pain Amlodipine 10 mg PO QD MS Contin 15 mg PO QD ALL: shellfish causes anaphylaxis Discharge Medications: Neutra-Phos 2 PKT PO BID Duration: 1 Days Unasyn 1.5 gm IV Q8H Acetaminophen 500 mg PO Q4H Prochlorperazine 5-10 mg IV Q6H:PRN nausea Morphine Sulfate 2-4 mg IV Q4-6H:PRN Oxycodone 10 mg PO Q4H:PRN pain Senna 1 TAB PO BID:PRN Docusate Sodium 100 mg PO BID Pantoprazole 40 mg PO Q24H Discharge Disposition: Extended Care Facility: [**Hospital 23645**] Hospital and rehab center Discharge Diagnosis: Stage IV ischial pressure ulcers Discharge Condition: Stable. Pt has been hemodynamically stable, Hct has been stable. Completed by:[**2188-6-26**]

[ "V44.3", "995.91", "730.15", "584.9", "276.5", "730.05", "998.11", "E969", "458.29", "276.7", "285.29", "038.0", "305.60", "112.2", "344.1", "V44.6", "707.03", "401.9" ]

icd9cm

[ [ [] ] ]

[ "77.69", "86.28", "99.04", "38.93", "77.65" ]

icd9pcs

[ [ [] ] ]

12227, 12300

9580, 11441

316, 363

12376, 12472

3318, 9557

2428, 2446

11920, 12204

12321, 12355

11467, 11897

2461, 2461

2891, 3299

258, 278

391, 1965

2475, 2877

1987, 2248

2264, 2412

44,084

174,828

47486

Discharge summary

report

Admission Date: [**2115-7-25**] Discharge Date: [**2115-7-30**] Date of Birth: [**2057-7-18**] Sex: F Service: CARDIOTHORACIC Allergies: lisinopril Attending:[**First Name3 (LF) 165**] Chief Complaint: Substernal chest pain and throat tightness with exertion Major Surgical or Invasive Procedure: [**2115-7-25**] 1. Off pump coronary artery bypass graft x3, left internal mammary artery to left anterior descending artery and saphenous vein grafts to diagonal, and obtuse marginal arteries. 2. Endoscopic harvesting of the long saphenous vein. History of Present Illness: This is a 57-year-old patient with extensive coronary artery disease history with previous stenting presented again with symptoms and was investigated and found to have a significant lesion in the left anterior descending artery diagonal and the obtuse marginal arteries. Left ventricular function is well preserved and she was electively admitted for off pump coronary artery bypass grafting. Past Medical History: Coronary artery disease(s/p MI [**2104**]), BMS to proximal LAD [**2104**], DES to mid LAD [**2112**], DES to edge ISR of mid LAD DES and stenosis distal to stent [**2112**], DES to OM1, [**2115-1-31**]). diastolic congestive heart failure Hypertension Dyslipidemia Morbid obesity COPD GERD Rt rotator cuff injury/bursitis(outpt PT-2x/wk, Migraines, Depression/Anxiety DJD Hemorrhoids Rosacea Left foot tendion repair Social History: Lives in [**Location **] with her grandchildren. She quit smoking 11 years ago. She does not drink or use drugs. Family History: She was a [**Hospital1 **] of the state and does not know her family. Physical Exam: Physical Exam Pulse: 86 Resp:20 O2 sat:98% B/P Right: 132/68 Left: Height: 5'2 Weight:210 General: AAOx3, NAD Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur [] grade ______ Abdomen: Soft [x]non-distended [x]non-tender [x]bowel sounds +[x] Extremities: Warm [x], well-perfused [x] Edema [] _____ Varicosities: None [x] Neuro: Grossly intact [x] Pulses: Femoral Right: +2 Left:+2 DP Right:+2 Left:+2 PT [**Name (NI) 167**]:+2 Left:+2 Radial Right:cath site Left:+2 Carotid Bruit: None Pertinent Results: Echocargiogram [**2115-7-25**] LEFT ATRIUM: Normal LA size. RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. A catheter or pacing wire is seen in the RA and extending into the RV. Left-to-right shunt across the interatrial septum at rest. LEFT VENTRICLE: Wall thickness and cavity dimensions were obtained from 2D images. Normal regional LV systolic function. Overall normal LVEF (>55%). RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Normal diameter of aorta at the sinus, ascending and arch levels. Simple atheroma in ascending aorta. Normal descending aorta diameter. Simple atheroma in descending aorta. AORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR. MITRAL VALVE: Normal mitral valve leaflets with trivial MR. TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS. Physiologic PR. PERICARDIUM: No pericardial effusion. Conclusions Pre operative: The left atrium is normal in size. There is a small PFO with a left-to-right shunt across the interatrial septum. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The diameters of aorta at the sinus, ascending and arch levels are normal. There are simple atheroma in the ascending aorta. There are simple atheroma in the descending thoracic aorta. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no pericardial effusion. Chest X-Ray [**2115-7-28**]; There is mild-to-moderate cardiomegaly. Bilateral pleural effusions are small. Aside from atelectasis in the left lower lobe, the lungs are grossly clear. Almost complete resolution of atelectasis in the left upper lobe. Sternal wires are aligned. Widened mediastinum has improved. A small air-fluid level in the retrosternal region suggests the presence of a tiny pneumothorax and small effusion. These are most likely located in the left side. [**2115-7-30**] 06:05AM BLOOD WBC-11.7* RBC-3.06* Hgb-10.4* Hct-30.5* MCV-100* MCH-33.9* MCHC-34.0 RDW-13.5 Plt Ct-253 [**2115-7-29**] 06:15AM BLOOD WBC-11.1* RBC-3.23* Hgb-11.1* Hct-32.1* MCV-99* MCH-34.4* MCHC-34.6 RDW-13.3 Plt Ct-230 [**2115-7-27**] 08:20AM BLOOD WBC-14.0* RBC-3.26* Hgb-10.8* Hct-32.3* MCV-99* MCH-33.2* MCHC-33.4 RDW-13.3 Plt Ct-192 [**2115-7-30**] 06:05AM BLOOD Na-137 K-4.1 Cl-97 [**2115-7-29**] 06:15AM BLOOD Glucose-161* UreaN-19 Creat-1.1 Na-136 K-4.0 Cl-97 HCO3-29 AnGap-14 [**2115-7-28**] 08:00AM BLOOD Glucose-230* UreaN-14 Creat-0.9 Na-136 K-4.1 Cl-98 HCO3-26 AnGap-16 [**2115-7-27**] 08:20AM BLOOD Glucose-238* UreaN-16 Creat-1.0 Na-134 K-4.6 Cl-100 HCO3-22 AnGap-17 [**2115-7-26**] 04:00AM BLOOD Glucose-98 UreaN-13 Creat-0.9 Na-136 K-4.7 Cl-106 HCO3-23 AnGap-12 Brief Hospital Course: The patient was brought to the Operating Room on [**2115-7-25**] where the patient underwent Off pump coronary artery bypass graft x3, left internal mammary artery to left anterior descending artery and saphenous vein grafts to diagonal, and obtuse marginal arteries. Endoscopic harvesting of the long saphenous vein. Overall the patient tolerated the procedure well and post-operatively was transferred to the CVICU in stable condition for recovery and invasive monitoring. She required Nitroglycerin for hypertension her first night post op but was transitioned to oral betablocker and diuretics. POD 1 found the patient extubated, alert and oriented and breathing comfortably. The patient was neurologically intact and hemodynamically stable. The patient was transferred to the telemetry floor for further recovery. Chest tubes and pacing wires were discontinued without complication. She was started on plavix due to being done off pump and will it need to be continued for six months. Blood sugars were closely monitored and she was restarted on her home regime which have slowly improved. The patient was evaluated by the physical therapy service for assistance with strength and mobility. By the time of discharge on POD 5 the patient was ambulating freely, the wound was healing and pain was controlled with oral analgesics. The patient was discharged home with visiting nurse services in good condition with appropriate follow up instructions. Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from webOMR. 1. Atorvastatin 40 mg PO DAILY 2. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheezing 3. Benzonatate 100 mg PO TID:PRN tos 4. Clopidogrel 75 mg PO DAILY 5. Fluticasone Propionate 110mcg 2 PUFF IH [**Hospital1 **] 6. Glargine 80 Units Bedtime Insulin SC Sliding Scale using HUM Insulin 7. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY 8. Metoprolol Succinate XL 100 mg PO DAILY 9. Metronidazole Gel 0.75%-Vaginal 1 Appl VG HS 10. Naproxen 500 mg PO Q8H:PRN pain 11. Nitroglycerin SL 0.4 mg SL PRN cp 12. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO Q6H:PRN pain 13. Pantoprazole 40 mg PO Q12H 14. Ropinirole 0.25 mg PO QPM 15. Valsartan 80 mg PO DAILY 16. Aspirin 325 mg PO DAILY 17. Vitamin D 400 UNIT PO DAILY Discharge Medications: 1. Aspirin EC 81 mg PO DAILY 2. Atorvastatin 40 mg PO DAILY RX *atorvastatin 40 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 3. Clopidogrel 75 mg PO DAILY RX *clopidogrel 75 mg 1 tablet(s) by mouth daily Disp #*90 Tablet Refills:*1 4. Fluticasone Propionate 110mcg 2 PUFF IH [**Hospital1 **] RX *fluticasone [Flovent HFA] 220 mcg 2 puffs twice a day Disp #*1 Inhaler Refills:*0 5. Glargine 50 Units Bedtime Insulin SC Sliding Scale using HUM Insulin 6. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO Q6H:PRN pain RX *oxycodone-acetaminophen 5 mg-325 mg 1 tablet(s) by mouth Q 4 hrs Disp #*30 Tablet Refills:*0 7. Pantoprazole 40 mg PO Q24H RX *pantoprazole 40 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 8. Ropinirole 0.25 mg PO QPM 9. Furosemide 40 mg PO DAILY Duration: 7 Days RX *furosemide [Lasix] 40 mg 1 tablet(s) by mouth daily Disp #*7 Tablet Refills:*0 10. Ibuprofen 600 mg PO Q6H:PRN pain take with food RX *ibuprofen 600 mg 1 tablet(s) by mouth three times a day Disp #*90 Tablet Refills:*0 11. Metoprolol Tartrate 25 mg PO TID Hold for HR < 55 or SBP < 90 and call medical provider. [**Last Name (NamePattern4) 9641**] *metoprolol tartrate 25 mg 1 tablet(s) by mouth three times a day Disp #*90 Tablet Refills:*1 12. Potassium Chloride 20 mEq PO DAILY RX *potassium chloride 20 mEq 1 tablet by mouth daily Disp #*7 Tablet Refills:*0 13. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheezing RX *albuterol 2 puffs PRN Q 4 hrs Disp #*1 Inhaler Refills:*0 14. Vitamin D 400 UNIT PO DAILY Discharge Disposition: Home With Service Facility: All Care VNA of Greater [**Location (un) **] Discharge Diagnosis: Coronary artery disease(s/p MI [**2104**]), BMS to proximal LAD [**2104**], DES to mid LAD [**2112**], DES to edge ISR of mid LAD DES and stenosis distal to stent [**2112**], DES to OM1, [**2115-1-31**]). diastolic congestive heart failure Hypertension Dyslipidemia Morbid obesity COPD GERD Rt rotator cuff injury/bursitis(outpt PT-2x/wk, Migraines, Depression/Anxiety DJD Hemorrhoids Rosacea Left foot tendion repair Discharge Condition: Alert and oriented x3 nonfocal Ambulating, gait steady Sternal pain managed with oral analgesics Sternal Incision - healing well, no erythema or drainage Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming, and look at your incisions Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Females: Please wear bra to reduce pulling on incision, avoid rubbing on lower edge Followup Instructions: You are scheduled for the following appointments: Wound Check at Cardiac Surgery Office [**Telephone/Fax (1) 170**] on [**2115-8-8**] at 10:45a Surgeon Dr. [**First Name (STitle) **] on [**2115-8-27**] at 2:15p Cardiologist: [**Doctor First Name **] Fish [**2115-8-12**] at 2:20pm ([**Location (un) **] office) Please call to schedule the following: Primary Care Dr [**Last Name (STitle) 410**] in [**3-7**] weeks [**Telephone/Fax (1) 6662**] **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**] Completed by:[**2115-7-30**]

[ "272.4", "428.32", "401.9", "518.0", "346.90", "278.01", "250.62", "414.01", "715.90", "496", "412", "357.2", "726.10", "428.0", "440.0", "V45.82", "300.00", "311", "530.81", "V15.82", "V85.38", "413.9" ]

icd9cm

[ [ [] ] ]

[ "36.12", "36.15" ]

icd9pcs

[ [ [] ] ]

9201, 9276

5342, 6800

334, 583

9738, 9895

2344, 5319

10697, 11426

1596, 1668

7662, 9178

9297, 9717

6826, 7639

9919, 10674

1683, 2325

237, 296

611, 1008

1030, 1449

1465, 1580

12,567

144,162

3869

Discharge summary

report

Admission Date: [**2204-8-28**] Discharge Date: [**2204-9-12**] Date of Birth: [**2143-6-19**] Sex: F Service: MEDICINE Allergies: Tetracyclines Attending:[**First Name3 (LF) 2145**] Chief Complaint: SOB, wheezing Major Surgical or Invasive Procedure: intubation History of Present Illness: Ms. [**Known lastname 17327**] is a 60 y/o woman with severe COPD, with frequent flares but no prior intubation for COPD flare. Presented with approximately one week dyspnea, wheezing, productive cough of green sputum. Saw her PCP 1 wk ago [**8-20**] and treated with bactrim, as past data had shown respiratory pathogen Moraxella. Pt took her antibiotics but presented with unresolved symptoms of severe dyspnea and wheezing. + chills but with no fever. . ROS: cough, congestion, chills, x 3 weeks worse over one day. Abdominal pain given chronic constipation. Pleuritic pain. Denied chest pain. Past Medical History: 1. COPD, last PFTs [**2202-7-22**] with FVC 2.03 and FEV1 0.94 (62 and 39% predicted respectively) 2. IgA deficiency, on IV gamma globulin with Dr. [**Last Name (STitle) 2148**] but apparently no longer receiving; per PCP IV gamma globulin did not seem to make measurable impact on her frequency of COPD flares 3. CAD s/p MIs in [**2186**] (flu symptoms), [**2192**] (jaw pain), NSTEMI in [**2197**] (chest pain with left arm discomfort). Cath in [**2197**] with single vessel CAD s/p PTCA/stent to LCx. Cath in [**4-/2202**] with stent placement to RCA and LCx. 4. Hypertension 5. Hyperlipidemia 6. Gastritis, on PPI 7. Osteoporosis, with history of multiple compression and rib fractures from coughing 8. History of thrush/[**Female First Name (un) **] esophagitis [**12-30**] steroid therapy, on Diflucan prn 9. Depression 10. Tremor Social History: She lives with her daughter, son-in-law and 3 grand-children. She is a widow. She is an ex-smoker, with about a 30-pack-year smoking history, quit in [**2201-10-28**] (had previously stopped, then restarted, then stopped again). No EtOH. Family History: Mother with DM, father with pancreatic cancer. Physical Exam: T 97.8, HR 94, BP 152/91, RR 20. Sat97% on 6L GENERAL: flushed appearing female using accessory muscles for breathing with mask on face HEENT: OP clear, non elevated JVP. HEART: tachycardic, regular rhythm. LUNGS: decreased breath sounds bilaterally. Bilaterally expiratory wheeze. Sparse crackles. ABDOMEN: distended. + BS. EXTREMETIES: trace pre-tibial edema SKIN: Warm well perfused. No mottling. Pertinent Results: pH 7.40 pCO2 49 PCO2 78 PO2 . [**2204-8-28**] 09:00PM GLUCOSE-114* UREA N-12 CREAT-0.8 SODIUM-134 POTASSIUM-4.7 CHLORIDE-94* TOTAL CO2-32 ANION GAP-13 [**2204-8-28**] 09:00PM WBC-12.3* RBC-4.81 HGB-13.8 HCT-41.0 MCV-85 MCH-28.7 MCHC-33.7 RDW-14.6 Lactate:1.5 Trop-T: <0.01 . PT: 10.4 PTT: 22.6 INR: 0.9 . CXR: no pleural effusions, no consolidation . Chest CT 1. No pulmonary embolism or aortic dissection. Atherosclerosis is present in the coronary arteries, abdominal aorta and the proximal renal arteries. 2. Consolidation/atelectasis is present at the right lower lobe. 3. Multiple bilateral rib fractures and compression collapse of multiple vertebral bodies in the thoracic spine as described above. Brief Hospital Course: A/P: 60 y/o woman with severe COPD presenting with SOB, cough likely COPD exacerbation, requiring intubation for respiratory muscle fatigue. . 1) COPD, acute exacerbation In ED T 97.8, HR 94, BP 152/91, RR 20. Sat975 6L. Lung exam diffuse expiratory wheeze and crackles. Given nebulizer treatment continuous. Solumedrol 125 IV x 1. Mag 2 gram IV x 1. Ceftriaxone 1 gram. Azithromycin given. EKG with NSR no acute changes. CTA with no evidence of PE. She was subsequently admitted to [**Hospital Unit Name 153**] given need for continuous nebs, continuous wheezing with need for face mask at 100%. By the patient's history, she has had multiple COPD flares in the past but none requiring intubation. She initially tolerated BiPAP, however, experienced worsening distress and required intubation [**8-30**], extubated [**9-6**] but then developed acute onset of worsening respiratory distress. She was also hypertensive to SBPs 190s-200s, possible flash pulmonary edema She was given lasix with good diuresis, and started on labetolol & nitro drips for BP control. At that point she underwent a trial of BiPAP which after a short time she asked to discontinue the BiPAP and made clear at that point that she did not want to go through another intubation. Her family was contact[**Name (NI) **] and were in agreement with patient's wishes not to pursue either noninvasive or intubation and the decision was made to optimize medical therapy including steroids, nebulizer treatments, and provide morphine and ativan for symptomatic control of respiratory distress. She was on fentanyl patch as [**Name (NI) 3782**] for chronic ?rib pain and this was titrated to 50 mcg/hr patch to help dyspnea as well. She and her daughters met with the palliative care NP when she was tenuous in the ICU and they discussed various options including hospice. The pt has made it clear that being at home is a priority, though at this time her daughters have work obligations that make it difficult for someone to be home with her. Fortunately, the pt's respiratory status has improved significantly and she is to go to rehab. She has completed a 7 day course of Cefepime and Vancomycin ([**9-4**]) for empiric coverage of pneumonia. Her chest X-ray showed no evidence of no new infiltrate on CXR or evidence of pneumonia. At this time she is stable on [**12-31**] liters NC and breathing quite comfortably. She is to continue her nebs, inhalers, and will complete a steroid taper. 2) Leukocytosis: believed probably secondary to steroids. Culture data shows no active infection. One sputum showed sparse aspergillus but she has improved clinically without antifungal treatment and thus this was believed to be a colonizer rather than pathogen. . 3) CAD: no active symptoms. SHe is to continue ASA, Plavix, b-blocker statin, ACEi 4) HTN: episode elevated BP but now stable on the floor. She is on metoprolol, lisinopril. . 5) Osteoporosis: - Continue bisphosphonate. Her calcium has been temporarily held due to a few low phosphorous readings, but if this resolved in future she can resume Ca supplements . 6) Depression: continue Nortriptyline 7) Urinary retention: pt experienced several episodes of urinary retention on the floor after her ICU foley was removed. Possibly secondary to having recent foley vs. opioid. She was straight cathed intermittently but was able to urinate the day of discharge. We would like to avoid foley if necessary. UOP should be followed carefully at rehab. 8) Prophylaxis: she was initially on Hep SQ but this was discontinued due to her tendency to have prolonged ooze/bleed from injection sites (pt on ASA, Plavix). She was changed to sequential compression devices She was given influenza vaccine this admission. She reports she received the pneumovax within the last 1-2 years. . Code status: Do not resuscitate (DNR/DNI), discussed with Ms. [**Known lastname 17327**] and daughters, decided on [**2204-9-6**]. Confirmed again when transferred to the floor. . . # Communication: Daughter [**Name (NI) **] Phone number: [**Telephone/Fax (1) 17340**] Medications on Admission: Albuterol nebs/INH Simvastatin 20mg po qam Clopidogrel 75 mg po daily Omeprazole 20 mg po daily Alendronate 70 mg PO QSUN Fentanyl 25 mcg/hr Patch 72HR Oxycodone-Acetaminophen 5-325 mg 1-2 Tabs po Q4-6H Nortriptyline 25 mg po qhs Fluticasone-Salmeterol 500-50 mcg [**Hospital1 **] Atenolol 25 mg po daily Calcium 500 mg po daily Senna 8.6 mg po bid prn Docusate Sodium 100 mg po bid prn Prednisone 10 mg daily Insulin Lispro (Human): per SSI U subQ four times a day. Discharge Medications: 1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): hold for loose stools. 3. Nortriptyline 25 mg Capsule Sig: One (1) Capsule PO HS (at bedtime). 4. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain/fever. 5. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 6. Ergocalciferol (Vitamin D2) 50,000 unit Capsule Sig: One (1) Capsule PO 2X/WEEK ([**Doctor First Name **],WE). 7. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed for constipation. 8. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q8H (every 8 hours) as needed for Constipation. 9. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 10. Prednisone 10 mg Tablet Sig: Three (3) Tablet PO once a day for 3 days: start [**9-12**]. 11. Prednisone 10 mg Tablet Sig: Two (2) Tablet PO once a day for 3 days: start [**2204-9-15**]. 12. Prednisone 10 mg Tablet Sig: One (1) Tablet PO once a day for 3 days: start [**9-18**] and take last dose on [**9-20**]. 13. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 14. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day): hold for loose stools. 15. Fentanyl 50 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr Transdermal Q72H (every 72 hours). 16. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 17. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 18. Lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for agitation or dyspnea. 19. Morphine 10 mg/5 mL Solution Sig: 5-15 mg PO Q3H (every 3 hours) as needed for dyspnea, pain. 20. Advair Diskus 500-50 mcg/Dose Disk with Device Sig: One (1) puff Inhalation twice a day. 21. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation every four (4) hours as needed for shortness of breath or wheezing. 22. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: One (1) Inhalation every four (4) hours as needed for wheezing/shortness of breath. Discharge Disposition: Extended Care Facility: [**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**] Discharge Diagnosis: Primary: Chronic Obstructive Pulmonary Disease, Acute exacerbation Secondary: Coronary artery disease Hypertension Hyperlipidemia Hx gastritis Osteoporosis Depression Discharge Condition: stable Discharge Instructions: Please call your PCP with any worsening symptoms of shortness of breath, fever, chills, new cough. During this hospital stay you have expressed your desire not to be reintubated and not be on ventilator support in the future. Please continue to communicate with your family and physicians regarding your medical wishes. Followup Instructions: Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**Name Initial (NameIs) **].D. Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2204-9-18**] 10:20 Provider: [**Name10 (NameIs) 1571**] BREATHING TESTS Phone:[**Telephone/Fax (1) 612**] Date/Time:[**2204-12-18**] 10:40 Provider: [**First Name11 (Name Pattern1) 1569**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. Phone:[**Telephone/Fax (1) 612**] Date/Time:[**2204-12-18**] 11:00 [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 2158**] Completed by:[**2204-9-12**]

[ "288.60", "577.0", "428.0", "733.00", "491.21", "401.9", "414.01", "428.30", "272.4", "518.84", "486", "311", "285.9", "788.29" ]

icd9cm

[ [ [] ] ]

[ "96.04", "96.72", "38.93" ]

icd9pcs

[ [ [] ] ]

10081, 10178

3297, 7387

288, 300

10390, 10399

2551, 3274

10768, 11374

2067, 2115

7905, 10058

10199, 10369

7413, 7882

10423, 10745

2130, 2532

235, 250

328, 931

953, 1794

1810, 2051

60,432

174,164

54708

Discharge summary

report

Admission Date: [**2141-7-9**] Discharge Date: [**2141-7-28**] Date of Birth: [**2095-10-11**] Sex: M Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 1390**] Chief Complaint: s/p trauma Major Surgical or Invasive Procedure: [**2141-7-14**]: Inferior vena cava filter placement; Closed treatment, pelvic ring fracture with manipulation, axis application of uniplanar external fixator to the pelvis. [**2141-7-19**]: Placement of tracheostomy tube [**2141-7-20**]: 1. Removal of external fixator. 2. Open reduction of the anterior symphyseal disruption. 3. Open reduction internal fixation right sacroiliac joint. [**2141-7-27**]: Percutaneous gastrostomy History of Present Illness: This patient is a 45 year old male who was transferred from OSH s/p MCC. From outside hospital after a high-speed motorcycle accident where he was struck by a motor vehicle, reportedly thrown approximately 40 feet. He was found with a GCS of 3 intubated on the scene, hypotensive on arrival to outside hospital, given blood and found to have a open book pelvic fracture. Reportedly, his blood pressure improved with pelvic binding, but according to med flight, his blood pressure was in the 60s to 70s en route Past Medical History: Hyperlipidemia Social History: Lives with spouse and has 3 children Family History: non-contributory Physical Exam: On admission: Constitutional: Intubated, critically ill HEENT: Pupils equal, round and reactive to light C. collar in place Chest: No crepitus Cardiovascular: Regular Rate and Rhythm Abdominal: Soft, positive fast exam GU/Flank: No costovertebral angle tenderness Extr/Back: No gross long [**Doctor Last Name 534**] deformity Skin: Multiple abrasions throughout Neuro: Revised sedated On discharge: Vitals: T: 99.0 P: 94 BP: 118/70 R: 18 O2sat: 99% trach mask GEN: Alert, interactive. NAD. Follows commands. HEENT: Atraumatic, PERRLA. Tongue appearance consistent with thrush infection. Tracheostomy tube in place. CV: RRR PULM: CTAB ABD: Soft, nontender, nondistended. PEG tube in place. Skin: Multiple well-healed abrasions Pertinent Results: [**2141-7-9**] 03:30AM WBC-15.7* RBC-4.70 HGB-14.9 HCT-43.9 MCV-93 MCH-31.7 MCHC-33.9 RDW-14.4 [**2141-7-9**] 03:30AM PLT COUNT-178 [**2141-7-9**] 03:30AM PT-13.7* PTT-40.1* INR(PT)-1.3* [**2141-7-9**] 03:30AM FIBRINOGE-82* [**2141-7-9**] 03:30AM ASA-NEG ETHANOL-163* ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2141-7-9**] 03:30AM LIPASE-177* [**2141-7-9**] 03:30AM UREA N-15 CREAT-1.5* [**2141-7-9**] 03:34AM GLUCOSE-156* LACTATE-4.5* NA+-141 K+-3.6 CL--111* TCO2-20* [**2141-7-9**] 04:32AM TYPE-ART PO2-201* PCO2-38 PH-7.22* TOTAL CO2-16* BASE XS--11 [**2141-7-9**] 05:45AM GLUCOSE-138* UREA N-15 CREAT-1.2 SODIUM-143 POTASSIUM-4.1 CHLORIDE-109* TOTAL CO2-15* ANION GAP-23* [**2141-7-9**] 05:45AM CALCIUM-6.6* PHOSPHATE-5.2* MAGNESIUM-1.8 [**2141-7-9**] 05:45AM CK-MB-22* MB INDX-2.1 [**2141-7-9**] 05:45AM CK(CPK)-1046* CT HEAD W/O CONTRAST Study Date of [**2141-7-9**] 3:37 AM No acute intracranial hemorrhage or mass effect CT ABD & PELVIS/CHEST WITH CONTRAST Study Date of [**2141-7-9**] 3:38 AM IMPRESSION: 1. Grade 3 liver laceration with active extravasation resulting in intraperitoneal hematoma. As a result, the IVC is collapsed and the adrenals are hyperenhancing consistent with hypovolemia/hypoperfusion. 2. Stranding of the small bowel mesentery, with fluid seen between leaves of a mesentery and small foci of active extravasation concerning for mesenteric injury. Enteric injury is not excluded, though no free air is seen. 3. Diastasis of the pubic symphysis, disruption of the right sacroiliac joint and right sacral fracture, with multiple foci of active extravasation within the pelvis resulting in a large pelvic hematoma. 4. Non-displaced posterior rib fractures of the first and second ribs and left third rib, without mediastinal hematoma or evidence of great vessel injury. 5. Left L2 and L3 spinous process fractures and T4 and T5 spinous process avulsion fractures. 6. Partially visualized right acromion and scapular fractures. CT C-SPINE W/O CONTRAST Study Date of [**2141-7-9**] 3:38 AM There is levoscoliosis with reversal of cervical lordosis. There is asymmetry in the atlanto-occipital joints, right being slightly wider than the left. there is also mild widening of the lateral atlanto-axial joints on both sides; however, symmetric. [**2141-7-10**] TTE: IMPRESSION: Right ventricular cavity enlargement with free wall hypokinesis c/w possible RV contusion or other primary RV process. Normal left ventricular cavity size with preserved global and regional systolic function. Normal ascending aortic diameter. [**2141-7-28**] 05:46AM BLOOD WBC-6.7 RBC-3.34* Hgb-10.5* Hct-31.8* MCV-95 MCH-31.3 MCHC-32.9 RDW-15.5 Plt Ct-388 [**2141-7-28**] 05:46AM BLOOD Glucose-112* UreaN-16 Creat-0.8 Na-140 K-4.0 Cl-103 HCO3-30 AnGap-11 [**2141-7-28**] 05:46AM BLOOD Calcium-8.4 Phos-3.8 Mg-2.2 [**2141-7-23**] 12:17 pm SPUTUM Source: Endotracheal. **FINAL REPORT [**2141-7-26**]** GRAM STAIN (Final [**2141-7-23**]): >25 PMNs and <10 epithelial cells/100X field. 4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS AND CLUSTERS. 1+ (<1 per 1000X FIELD): BUDDING YEAST. RESPIRATORY CULTURE (Final [**2141-7-25**]): THIS IS A CORRECTED REPORT ([**2141-7-26**]). STAPH AUREUS COAG +. MODERATE GROWTH. This isolate is presumed to be resistant to clindamycin based on the detection of inducible resistance . Staphylococcus species may develop resistance during prolonged therapy with quinolones. Therefore, isolates that are initially susceptible may become resistant within three to four days after initiation of therapy. Testing of repeat isolates may be warranted. ERYTHROMYCIN PREVIOUSLY REPORTED WITH AN MIC OF 0.5 MCG/ML ([**2141-7-25**]). YEAST. SPARSE GROWTH. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPH AUREUS COAG + | CLINDAMYCIN----------- R ERYTHROMYCIN---------- R GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- 0.25 S OXACILLIN------------- 0.5 S TRIMETHOPRIM/SULFA---- <=0.5 S Brief Hospital Course: The patient was transferred to the trauma ICU under the Acute Care Surgery service for close monitoring. He remained in the ICU until [**2141-7-26**] when he was stable both hemodynamically and from a respiratory standpoint, at which time he was transferred to the surgical floor. He is medically stable and ready for discharge on [**2141-7-28**]. His hospital course is summarized by systems below: Neuro: He was intubated and sedated. He was intermittently paralyzed in order to optimize vent synchronization. Once his sedation was weaned, he slowly became more responsive mental-status wise. He responded appropriately to his family and eventually to nursing. He was started on standing serquel which was changed to prn as his agitation improved. At the time of discharge he is alert, interactive and following commands. On his admission c-spine CT scan, widening at the atlanto-occipital joint was noted. He remained in c-collar and neurosurgery was consulted, who recommended that he remain in the hard c-collar for 1 month. Pulm: He was intubated and mechanically ventilated. He had increasing vent requirements and a CT scan showed ARDS. He was started on ARDS protocol for vent settings and his oxygenation improved. He was also treated for a VAP, with cultures initially growing MSSA & proteus. Repeat sputum culture also showed MSSA. He continued on a high PEEP due to his ARDS and he was started on a lasix gtt in order to improve oxygenation. He continued to diurese well. He was weaned off of the vent until he tolerated trach mask for almost 24 hours starting on [**7-24**]. On transfer to the floor his oxygenation was stable on trach mask. His MSSA pneumonia is being treated with levofloxacin with the course to be completed on [**2141-8-3**]. He remains afebrile with a normal WBC count. CV: He was on pressors initially when he was hypotensive in the ICU. There was concern for continuing abdominal bleed or occult bowel injury but CT torso did not show evidence of active bleed. He was eventually weaned off pressors and remained stable. Echo on [**7-10**] showed EF >55%, RV cavitary enlargement w/ wall hypokinesis. He remained off pressors since [**7-14**]. His vital signs are currently stable at the time of discharge. GI: He was kept NPO/IVFs. A dobhoff was placed and he received nutrition through tube feeds. On [**2141-7-27**] he had a PEG placed and he was started on TF the next day. Given his improved mental status a speech and swallow evaluation was performed on [**7-28**] and he was cleared for a ground solid and thin liquid diet. GU: His UOP was monitored. He received multiple boluses of fluids for resuscitation. His foley catheter remained in place with adequate urine output. It was removed on [**7-28**] prior to transfer to rehab. Heme: He was transfused pRBCs as needed for a dropping hct. He received 10u pRBC on arrival for active extravasation in his abdomen. He went to IR for embolization of his abdominal bleeds, no extravasation was seen in the pelvis but liver bleed was embolized. His hematocrit continue to trend downward and a repeat CTA revealed no active bleed. He received a total of 16u of pRBCs while in the ICU. On the floor he remained without active signs of bleeding a stable hematocrit. MSK: His pelvis was wrapped for stabilization, initially. He had an ex-fix on [**7-14**] and ORIF on [**7-20**]. Physical therapy worked with him during his ICU course and did passive range of motion exercises. He was eventually allowed to have LLE full weight bearing and RLE touchdown weight bearing after his ORIF. ID: He had severe ARDS as well as a VAP with cultures growing MSSA and proteus. He was on an 7 day course of vanc/cipro/cefepime (stopped on [**7-18**]). He was restarted on vanc on [**7-23**] for GPCs growing in sputum. The vanc was changed to PO levofloxacin on [**7-25**] in order to transition the patient to PO medications. He was noted to have thush infection when on the ventilator in the ICU and was started on nystatin at that time. Prophylaxis: He had a IVC filter placed on [**7-14**]. He received subQ heparin as well once his hematocrit remained stable. His anticoagulation was later changed to lovenox 40 mg daily per orthopedics recommendations. On [**7-28**] he is afebrile with stable vital signs. His mental status continues to improve. His respiratory status is stable. He has no active signs of bleeding. He is being discharged to rehab with follow up in [**Hospital 2536**] clinic, ortho clinic, and neurosurgery clinic. Medications on Admission: ? cholesterol medication, unknown Discharge Medications: 1. Acetaminophen (Liquid) 650 mg PO Q6H fever, pain 2. Albuterol-Ipratropium [**4-7**] PUFF IH Q4H:PRN wheezing 3. Artificial Tear Ointment 1 Appl BOTH EYES PRN dry eyes 4. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation 5. Docusate Sodium (Liquid) 100 mg PO BID 6. Metoprolol Tartrate 25 mg PO BID 7. Senna 1 TAB PO BID Constipation 8. Levofloxacin 750 mg PO DAILY Duration: 7 Days last dose [**2141-8-3**] 9. Enoxaparin Sodium 40 mg SC DAILY 10. Nystatin 500,000 UNIT PO Q8H thrush 11. OxycoDONE Liquid 10-20 mg NG Q4H:PRN pain 12. Quetiapine Fumarate 25 mg PO BID:PRN agitation 13. traZODONE 25 mg PO HS:PRN insomnia Discharge Disposition: Extended Care Facility: [**Hospital3 7665**] Discharge Diagnosis: Trauma s/p motorcycle crash: - Open book pelvic fracture with active extravasation - Posterior 1st, bilateral 2nd, Left 3rd rib fractures - Segment VI liver laceration with active extravasation - Subcapsular splenic laceration - Right colic perivascular hematoma - Atlanto-occipital joint widening - L2-L3, T4-T5 spinous process fractures - Right acromium fracture - Acute Respiratory Distress Syndrome - Sepsis - Ventilator-associated pneumonia - Acute blood loss anemia Discharge Condition: Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Mental Status: Clear and coherent. Discharge Instructions: You were admitted to the hospital after a motorcycle crash. You sustained multiple injuries from your accident. You required a stay in the intensive care unit. You are now being discharged to rehab to continue your recovery. Followup Instructions: Department: GENERAL SURGERY/[**Hospital Unit Name 2193**] When: TUESDAY [**2141-8-15**] at 4:30 PM With: Dr. [**Last Name (STitle) **] [**Name (STitle) **] in the ACUTE CARE CLINIC Phone: [**Telephone/Fax (1) 600**] Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage Department: NEUROSURGERY When: WEDNESDAY [**2141-8-16**] at 11:45 AM With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 1669**] Building: LM [**Hospital Unit Name **] [**Location (un) **] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage Department: ORTHOPEDICS When: TUESDAY [**2141-8-8**] at 8:00 AM With: [**First Name11 (Name Pattern1) 2191**] [**Last Name (NamePattern4) 2192**], NP [**Telephone/Fax (1) 1228**] Building: [**Hospital6 29**] [**Location (un) 551**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: ORTHOPEDICS When: TUESDAY [**2141-8-8**] at 7:40 AM With: ORTHO XRAY (SCC 2) [**Telephone/Fax (1) 1228**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 551**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Completed by:[**2141-7-28**]

[ "902.22", "785.52", "805.4", "276.0", "805.2", "811.01", "864.03", "518.51", "276.3", "785.0", "997.31", "401.9", "038.9", "V49.87", "112.0", "E935.2", "285.1", "V46.11", "482.41", "E879.8", "560.1", "305.00", "865.02", "807.04", "E813.2", "995.92", "272.0", "276.69", "810.00", "808.43" ]

icd9cm

[ [ [] ] ]

[ "38.93", "33.23", "39.79", "96.6", "78.19", "33.24", "38.7", "43.11", "78.69", "79.89", "31.1", "88.49", "84.71", "38.97", "79.09", "88.47", "96.72", "38.91" ]

icd9pcs

[ [ [] ] ]

11810, 11857

6556, 11084

314, 749

12374, 12489

2179, 6533

12799, 14040

1397, 1415

11168, 11787

11878, 12353

11110, 11145

12550, 12776

1430, 1430

1832, 2160

264, 276

777, 1289

1445, 1817

12504, 12526

1311, 1327

1343, 1381

30,621

186,496

45995

Discharge summary

report

Admission Date: [**2162-3-6**] Discharge Date: [**2162-3-10**] Date of Birth: [**2082-7-23**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2840**] Chief Complaint: fever, altered mental status Major Surgical or Invasive Procedure: arterial line History of Present Illness: This is a 79 yo M with a h/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 309**] body dementia, atrial fibrillation, h/o BPH and UTIs, presenting from [**Hospital3 537**] with altered mental status and fever. Of note, a urine culture was sent several days ago from [**Hospital3 537**], and the pt was started on bactrim. Apparently that culture was not diagnostic but is growing 10,000-30,000 gram positive organisms. Per the son, after taking a nap he was more agitated and having difficulty walking. . In the ED, the pts vitals were: Tm 100.4, BP 83-118/41-69, HR 83-107, R 18, 98-100% on 4L NC. He was found to have a WBC of 11.1 with 30% bands, and a lactate of 3.2. His UA showed 21-50 WBC and moderate LE. CXR was unremarkable. He received 3L NS, CTX 1 gm IV x1, Cefepime 2 gm IV x1, azithromycin 500 mg IV x1, and tylenol 650 mg PR x1. His SBP dropped into the 70s, and he was started on a peripheral levophed gtt. Past Medical History: -h/o prostatitis -atrial fibrillation -h/o urinary tract infection -h/o BPH/Bladder outlet obstruction -h/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 309**] body dementia--followed by behavioral neurology, Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], -? sleep apnea -h/o psychosis -h/o RLL PNA in [**12-17**] with dysphagia by swallowing study -h/o delerium in setting of fevers Social History: Pt lives in [**Hospital3 537**] NH in [**Location (un) **] since [**12-17**], previously was in [**Hospital3 **] there. Pt retired in [**Month (only) 404**] ??????05. Widowed for 15 yrs. His son, [**Name (NI) **] lives in [**Name (NI) **]. He has a daughter in CA. He smoked 1 pack per day for 15 years, stopping over thirty years ago. He also had [**6-15**] drinks/night for 10 years, also stopping thirty years ago. Family History: Father committed suicide at the age of 53. His mother passed away at 64, DM, died apparently from hydrocephalus. no siblings Physical Exam: Physical Exam on admission to MICU: VS: Temp: 98.2 BP 135/46 P 83 R 16 Sat 98% on 2 L NC GEN: sleeping, not following commands, withdraws to pain, does not talk, will not open eyes but purposely will squeeze eye closed HEENT: constricted but equal and reactive, anicteric, dry MM, op without lesions NECK: no supraclavicular or cervical lymphadenopathy, no jvd, no carotid bruits RESP: CTA b/l but difficult to assess as pt will not cooperate with taking deep breaths CV: irreg irreg, S1 and S2 wnl, no m/r/g ABD: nd, +b/s, soft, nt, no masses or hepatosplenomegaly EXT: 1+ pitting edema at the ankles, warm, good pulses SKIN: no rashes/no jaundice NEURO: withdraws all extremities to pain Pertinent Results: CXR: FINDINGS: Compared to the previous examination there has been interval resolution of right lower lobe airspace opacification. There are no new areas of opacification. The cardiomediastinal silhouette is stable. Several clips project over the left neck. There is no pleural effusion. Soft tissues and osseous structures are otherwise unremarkable. IMPRESSION: No acute cardiopulmonary process. . CT Head: FINDINGS: There is no acute intracranial hemorrhage, shift of normally midline structures, hydrocephalus or major vascular territorial infarction. Prominence of the lateral ventricles and sulci is unchanged compared to the previous examination and likely related to atropy. Density values of the brain parenchyma are maintained. Mild hypodensities in the periventricular white matter are most consistent with chronic small vessel ischemia. The visualized paranasal sinuses and mastoid air cells are well aerated. IMPRESSION: No acute intracranial hemorrhage. . Brief Hospital Course: Upon presentation, the patient showed signs of possible sepsis with hypotension, tachycardia, and fevers, in the setting of a positive urinalysis. He responded rapidly to fluid boluses and initiation of intravenous antibiotics- initially vancomycin and zosyn followed by more narrowed coverage with vancomycin and ceftriaxone. Upon stabilization, he was moved to a general medical floor where IV antibiotics were continued for a presumed urinary tract infection. Culture data from our institution as well as from the [**Hospital3 **] were negative. However, given his co-morbidities of bladder outlet obstruction and frequent urinary tract infections, we continued treatment with an oral regimen of ciprofloxacin, after reviewing his past sensitivities. We clarified his baseline mental status with his caregivers at the [**Hospital3 **] to confirm that he was not delirious. He was discharged with a seven day course of ciprofloxacin. . His INR was found to be supratherapeutic on this admission. He will have this re-checked daily at his nursing home until it returns to a therapeutic range, at which point his coumadin will be restarted. Medications on Admission: -Carbidopa-Levodopa (25-100) 1 TAB PO BID Start: In am 8AM AND 4PM -Donepezil 10 mg daily -Finasteride 5 mg PO HS 8PM -Quetiapine Fumarate 12.5 mg PO DAILY 1 PM -Quetiapine Fumarate 25 mg PO QPM 8PM -Tamsulosin 0.4 mg PO HS 8PM -coumadin 6 mg 6 days per week and 2 mg 1 day per week -bactrim started [**3-5**] . Allergies: NKDA Discharge Medications: 1. Carbidopa-Levodopa 25-100 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 2. Donepezil 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 3. Finasteride 5 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)). 4. Quetiapine 25 mg Tablet Sig: 0.5 Tablet PO DAILY AT 1300HRS (). 5. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO DAILY AT 2000HRS (). 6. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO HS (at bedtime). 7. Ciprofloxacin 250 mg Tablet Sig: One (1) Tablet PO every twelve (12) hours for 6 days. Tablet(s) 8. Lab work Please check INR daily, and restart coumadin at 6mg daily six days per week and 2mg one day per week. Discharge Disposition: Extended Care Facility: [**Doctor First Name 533**] Centre for extended care Discharge Diagnosis: Urinary tract infection Discharge Condition: Stable, afebrile, normotensive. Discharge Instructions: You were admitted with a urinary tract infection. Your vital signs were initially unstable and you required intensive care for the first day of your admission. You improved with intravenous fluids and antibiotics. We will be discharging you with a seven day course of antibiotics. . Your INR was too high during this admission, this was likely due to your antibiotics. You will need to have this checked daily until your INR is within range at 2-3, at which time you should restart your coumadin. . If you develop unstable vital signs such as hypotension, dizziness, palpitations, or fevers, please return to the emergency department. . Please take all of your medications as indicated . Please follow up as indicated below. Followup Instructions: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3940**], MD Phone:[**Telephone/Fax (1) 719**] Date/Time:[**2162-3-18**] 1:30 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 658**], M.D. Phone:[**Telephone/Fax (1) 1690**] Date/Time:[**2162-7-6**] 2:30

[ "285.9", "599.0", "294.10", "427.31", "600.01", "V13.02", "331.82", "287.5", "V15.82", "V58.61" ]

icd9cm

[ [ [] ] ]

[ "38.93" ]

icd9pcs

[ [ [] ] ]

6307, 6386

4061, 5210

343, 358

6454, 6488

3067, 3467

7265, 7571

2215, 2342

5588, 6284

6407, 6433

5236, 5565

6512, 7242

2357, 3048

275, 305

386, 1321

3476, 4038

1343, 1764

1780, 2199

25,318

171,940

4260

Discharge summary

report

Admission Date: [**2123-8-6**] Discharge Date: [**2123-8-12**] Date of Birth: [**2047-5-14**] Sex: F Service: MED Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1377**] Chief Complaint: coffee ground emesis Major Surgical or Invasive Procedure: EGD History of Present Illness: 76 yo F with met hepatoma, ascites, DM2, h/o grade 2 esoph varices s/p banding, presents with 3-4 episodes of coffee ground emesis. Denies hematuria, BRBPR, abd pain, melena, diarrhea, CP, SOB, syncope, light-headedness. No LE swelling or inc abd girth. Past Medical History: HCC w/ metastases DM2 on insulin Ascites Esophageal varices, grade II s/p banding after upper GI bleed Chronic pancreatic insufficiency Breast cancer s/p lumpectomy and treated w/ tamoxifen hypothyroidism Social History: Lives at home w/ husband and uses walker, has one daughter Family History: not obtained Physical Exam: 91.2, 85/48, 90, 18, 100%4Lnc laying in bed, cachetic appearing dry MMM supple neck Chest CTAB in ant lung fields CV RRR, no m/r/g abd soft, no ascites, nt/nd, pos caput medusae ext no edema/ cyanosis, numerous petechiae Pertinent Results: [**2123-8-6**] 02:00PM WBC-14.7* RBC-2.40*# HGB-7.6* HCT-26.0* MCV-108*# MCH-31.5 MCHC-29.1* RDW-26.2* [**2123-8-6**] 02:00PM PT-13.6 PTT-36.5* INR(PT)-1.2 [**2123-8-6**] 02:00PM GLUCOSE-226* UREA N-60* CREAT-2.8* SODIUM-132* POTASSIUM-6.3* CHLORIDE-101 TOTAL CO2-8* ANION GAP-29* [**2123-8-6**] 03:45PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-0.2 PH-5.0 LEUK-NEG [**2123-8-6**] 04:45PM WBC-12.0* RBC-1.76*# HGB-5.5*# HCT-18.7*# MCV-107* MCH-31.2 MCHC-29.2* RDW-26.8* [**2123-8-6**] 11:55PM WBC-9.5 RBC-2.58*# HGB-7.9*# HCT-23.3* MCV-90# MCH-30.6 MCHC-34.0# RDW-21.7* [**2123-8-6**] 11:55PM GLUCOSE-292* UREA N-52* CREAT-2.1* SODIUM-138 POTASSIUM-3.9 CHLORIDE-103 TOTAL CO2-22 ANION GAP-17 [**2123-8-9**] 04:55AM BLOOD WBC-10.0 RBC-3.65* Hgb-11.2* Hct-33.5* MCV-92 MCH-30.6 MCHC-33.3 RDW-23.6* Plt Ct-107* [**2123-8-6**] 04:45PM BLOOD Neuts-93.5* Bands-0 Lymphs-4.9* Monos-1.0* Eos-0.6 Baso-0 [**2123-8-8**] 06:14PM BLOOD Plt Ct-72* [**2123-8-9**] 04:55AM BLOOD Plt Ct-107* [**2123-8-8**] 12:44AM BLOOD Glucose-116* UreaN-50* Creat-2.0* Na-141 K-4.4 Cl-109* HCO3-20* AnGap-16 [**2123-8-6**] 02:00PM BLOOD ALT-55* AST-108* AlkPhos-579* Amylase-33 TotBili-2.9* [**2123-8-7**] 05:39AM BLOOD ALT-72* AST-213* AlkPhos-332* TotBili-4.9* ----- CXR Bibasilar atelectases left greater than right. No new abnormalities. ---- LE Doppler Left deep venous thrombosis within the common femoral vein and superficial femoral vein Brief Hospital Course: Mrs [**Known lastname 16968**] was admitted for a presumed GI bleed. Pt was transfered to the MICU for evaluation of her GIB, ARF on CRF, ascites/cirrhosis/portal htn/hcc, LLE DVT. GIB-- In the ER she was given 2 Units FFP and IV protonix. BP ranged from 85-114/40s-90s. She was given 3 units prbcs and 3 units platelets over the next 2 days in the MICU. Also treated with octreoide initially. She had an EGD which showed gastropathy and esophagitis likely [**1-4**] portal hypertension. Her Hct stabilized, but her platelets were still variable. She was having small tarry stools only. She was not having bright red blood per rectum. Ascites-- There was a question of SBP. Patient and family declined a paracentesis. No antibiotics were used to treat possible infection. DVT-- A Large left femoral DVT was seen in the ED. The patient was not felt to be a candidate for [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 260**] filter, and family/patient did not want this intervention. This was not a problem while she was hospitalized. ARF--She had a high creatinine of 2.8, with a normal baseline. She was put on midodrine and octreotide temporarily with an improvement in her creatinine. This was stopped several days later. She was made CMO, but her last labs showed Cr=2.0. Hypotension-- She had some hypotensive episodes. Improved with midodrine. This was stopped, and her last vitals showed SBP in the 100s. Her vitals weren't checked for the last few days of her hospitalization. Met Acidosis-- Initially treated with bicarbonate and she had a good improvement. Again, after being made CMO, she did not have this monitored. DM-- Initially covered with RISS. While CMO, her blood sugar was not checked and her RISS was stopped. Hypothyroidism-- Initially treated with her home dose of levothyroxine. D/Ced after CMO status. After several days in the MICU, the prognosis was discussed with the pateint and her family by hepatologist, MICU team. The thought was that she was possibly in hepatorenal failure, had a dangerous DVT, and may have another GIB. The decision was made to make her CMO and withdrawl all medications except for morphine and olanzapine wafers. No paracentesis, no filter, no further transfusions. She got no more lab draws, blood glucose checks. The patient was transferred to the floor at this point. The palliative care team here talked with the family and they wanted to have the pt go home with home hospice. A hospice service was arranged. They talked with the family and arranged to provide services in their home. On discharge, the patient was stable and sleeping much of the day. She was able to wake up and answer questions appropriately though. Her vitals were not monitored here, but her last set 1-2 days before discharge showed SBP in 100s. She was sent home with morphine elixir, levsin, and olanzapine wafers. Her hospice requested lorazepam, but she gets more agitated with [**Last Name (LF) 18496**], [**First Name3 (LF) **] I did not write for this. Discharge Medications: 1. Levothyroxine Sodium 112 mcg Tablet Sig: One (1) Tablet PO M, W, F (). 2. Levothyroxine Sodium 75 mcg Tablet Sig: One (1) Tablet PO T/T/S/S (). 3. Artificial Saliva 0.15-0.15 % Solution Sig: One (1) ML Mucous membrane three times a day. Disp:*90 ML(s)* Refills:*2* 4. Olanzapine 5 mg Tablet, Rapid Dissolve Sig: 0.5 Tablet, Rapid Dissolve PO BID (2 times a day). Disp:*50 Tablet, Rapid Dissolve(s)* Refills:*2* 5. Morphine Sulfate 20 mg/5 mL Solution Sig: 5-20 mg PO q3-4 hours as needed for pain. Disp:*300 ml* Refills:*0* Discharge Disposition: Home With Service Facility: healthcare dimensions hospice Discharge Diagnosis: gastrointestinal bleed metastatic hepatoma Diabetes Melitis type 2 ascites, h/o varices grade 2 s/p banding chronic pancreatic insufficiency breast CA s/p lumpectomy and tamoxifen hypothyroidism h/o PBC Discharge Condition: Pt was comfortable. She was not in pain. She was not agitated. She did wake up on and off during the day and was able to answer questions appropriately, but spent much of the day sleeping/somnolent. Discharge Instructions: Please call your hospice nurse or Dr [**Last Name (STitle) 141**] at [**Telephone/Fax (1) 142**] or Dr [**First Name (STitle) 679**] at [**Telephone/Fax (1) 682**] if you have any problems or questions at home. Followup Instructions: Provider: [**Name10 (NameIs) **] WEST,ROOM FOUR GI ROOMS Where: GI ROOMS Date/Time:[**2123-9-13**] 9:00 Provider: [**Name10 (NameIs) 454**],NINE DAY CARE [**Hospital Ward Name **] 8 Where: DAY CARE [**Hospital Ward Name **] 8 Date/Time:[**2123-8-16**] 10:00 Provider: [**Name10 (NameIs) 454**],ELEVEN DAY CARE [**Hospital Ward Name **] 8 Where: DAY CARE [**Hospital Ward Name **] 8 Date/Time:[**2123-8-10**] 11:30 [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(1) 1379**]

[ "571.5", "584.9", "112.0", "453.8", "530.10", "V10.3", "530.82", "789.5", "197.7" ]

icd9cm

[ [ [] ] ]

[ "38.93", "45.13" ]

icd9pcs

[ [ [] ] ]

6328, 6388

2716, 5752

330, 336

6635, 6836

1211, 2693

7095, 7634

940, 955

5775, 6305

6409, 6614

6860, 7072

970, 1192

270, 292

364, 620

642, 848

864, 924

875

160,790

18603

Discharge summary

report

Admission Date: [**2156-7-7**] Discharge Date: [**2156-7-13**] Date of Birth: [**2133-11-23**] Sex: F Service: CHIEF COMPLAINT: Delerium tremens. HISTORY OF PRESENT ILLNESS: The patient is a 22 year-old female brought into the Emergency Room by EMS after [**Location (un) **] police entered her apartment after someone called for disorderly conduct. She was found by police intoxicated with multiple bruises. In the Emergency Room the patient was at first lucent with complaints of back pain and claims that she fell a lot while she was drinking. She admitted to drinking large amounts of alcohol with vomiting. In the Emergency Room the patient soon became agitated with delirium and reported hallucinations. She was very tremulous. She was given Ativan 5 mg intravenous times four and Valium 5 mg as well as a banana bag with vitamins. PAST MEDICAL HISTORY: Alcohol use. MEDICATIONS: None. SOCIAL HISTORY: The patient lives with her boyfriend. She drinks daily. She denies abuse. PHYSICAL EXAMINATION: Afebrile. Blood pressure 131/80. Pulse 104. Respirations 18. 99% on room air. General 22 year-old female sitting looking at ceiling. HEENT multiple bruises. Neck supple. Lungs clear to auscultation. Cardiovascular tachycardia, S1 and S2. Abdomen soft, nontender. Extremities multiple ecchymoses on left shoulder, left thigh, right thigh. Neurological confused, moving all four extremities. Skin diffuse ecchymoses and bruises on back. There were no obvious bony deformities. LABORATORY: White blood cell count 5.6, hematocrit 31.1, platelets 135, sodium 134, potassium 2.3, chloride 90, bicarbonate 25, BUN 6, creatinine 0.5, glucose 75. Coag studies PT 12.7, PTT 25.1, INR 1.1. Serum alcohol level 17. Serum tox negative. CT of head showed no acute intracranial hemorrhage. HOSPITAL COURSE: The patient was initially admitted to the Intensive Care Unit for treatment of delirium tremens. She was started on admission with a CIWA scale. She did not have any evidence of seizures. She was continued on Diazepam intravenous per CIWA with continuous monitoring of her vital signs. The patient was found to have acute pancreatitis likely due to alcohol use. Lipase was 2422, amylase 505, CK 141. The patient was also found to have a transaminitis. ALT 158, AST 408, alkaline phosphatase 356. The patient was kept NPO and received an abdominal ultrasound, which showed an echogenic liver consistent with fatty infiltration. The patient also found to be anemic with a macrocytic anemia likely due to alcohol use. Iron studies were normal as well as B-12 and folate. The patient was seen by social work to discus domestic violence issues. A psychiatric consult was also ordered to evaluate the patient's mental status and capacity to make decisions. Psychiatry pronounced the patient with impaired judgement secondary to delirium and declared her unable to demonstrate that she understands the risk to her health. As a result when the patient wanted to leave AMA she was not allowed. A one to one sitter was established for the patient. Social work continued to follow with the patient throughout her admission. The patient continued to deny domestic violence in her home and stated she felt very safe there. The patient expressed interest in alcohol rehab program, however, did not wish to enter one in the hospital while an inpatient. The patient wished to receive information about outpatient programs so she could return to school. The patient continued to do well and was transferred to the regular medicine floor [**Hospital1 139**] firm on [**2156-7-10**]. She had begun eating while in Intensive Care Unit, had decreased her Ativan requirement greatly. Her pancreatic enzymes and liver function tests continued to improve. Discussions were continued on the floor about the patient's discharge plans. She was then with capacity to make decisions per psychiatry. The patient decided she would go home and look into programs from there. CONDITION ON DISCHARGE: Stable. DISCHARGE DIAGNOSES: 1. Delirium tremens. 2. Alcohol use. 3. Pancreatitis. 4. Transaminitis. 5. Anemia. DISCHARGE MEDICATIONS: None. FOLLOW UP PLANS: The patient does not have a current primary care physician. [**Name10 (NameIs) **] will see me [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3315**] in the [**Hospital 191**] Clinic for follow up on [**8-9**]. The patient was encouraged to go to her appointment with me to establish care. I told her the social workers would meet her at the appointment and we would discuss treatment options again. The patient was discharged to home with her aunt. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3090**], M.D. [**MD Number(1) 3091**] Dictated By:[**Last Name (NamePattern1) 51084**] MEDQUIST36 D: [**2156-7-13**] 05:16 T: [**2156-7-18**] 08:47 JOB#: [**Job Number 51085**]

[ "291.0", "305.00", "281.9", "577.0" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

4071, 4160

4184, 4959

1850, 4016

1039, 1832

145, 164

193, 864

887, 922

939, 1016

4041, 4050

130

113,323

21549

Discharge summary

report

Unit No: [**Numeric Identifier 56787**] Admission Date: [**2119-11-14**] Discharge Date: [**2119-12-1**] Date of Birth: [**2058-6-3**] Sex: M Service: CSU HISTORY OF PRESENT ILLNESS: Father [**Name (NI) **] is a 61-year-old man, with known CAD, status post coronary artery bypass graft on [**2119-10-31**] with a LIMA to the LAD, saphenous vein graft to OM1, saphenous vein graft to D1, and saphenous vein graft to PDA. The patient was discharged home on [**11-5**], and returns on the day of admission complaining of sternal drainage x several days with increasing amounts on the day of admission. The patient denies fever, chills, nausea, vomiting, or malaise. PAST MEDICAL HISTORY: CAD, status post CABG with an EF of 20 percent. Diabetes mellitus, currently insulin dependent. Hypercholesterolemia. GERD. ALLERGIES: None. MEDS ON ADMISSION: 1. Colace 100 mg [**Hospital1 **]. 2. Aspirin 81 mg once daily. 3. Plavix 75 mg once daily. 4. Carvedilol 6.25 mg [**Hospital1 **]. 5. Simvastatin 40 mg once daily. 6. Lasix 40 mg [**Hospital1 **]. 7. Lantus insulin 45 units q pm. 8. Percocet 5/325, 1-2 tabs q 4 h prn. LABS ON ADMISSION: White count 18.6, hematocrit 33.9, platelets 893, PT 17.5, PTT 24, INR 1.1, sodium 139, potassium 4.2, chloride 101, CO2 25, BUN 14, creatinine 0.9, glucose 246. Chest x-ray shows cardiomegaly with left-sided effusion with atelectasis, multiple displaced wires. EKG: Sinus rhythm with a rate of 100, Q's in III and AVF, nonspecific ST changes with poor R wave progression. PHYSICAL EXAM: Temperature 103, heart rate 116--sinus tachycardia, blood pressure 100/47, respiratory rate 30, O2 sat 97 percent on 2 liters nasal prongs. Neuro: Alert and oriented x 3, moves all extremities, follows commands, nonfocal exam. Respiratory: Clear to auscultation with a sucking chest wound. Cardiovascular: Regular rate and rhythm. Sternum with surrounding erythema of about 10 cm, with a positive click. Small draining hole in midincision with milky serous drainage. Staples remain in place. Abdomen is soft, nontender, nondistended with normoactive bowel sounds. Extremities are warm and well-perfused with no edema. Right calf with a healing wound and minimal erythema. Left knee with an endoscopic site that is healing, open to air, clean and dry. HOSPITAL COURSE: The patient was admitted to the Cardiothoracic Intensive Care Unit. He was begun on vancomycin 1 gm q 12 h, as well as levofloxacin 500 mg once daily. He was typed and screened and kept NPO for mediastinal exploration plus/minus a flap closure. On hospital day 2, the patient was brought to the operating room. Please see the OR report for full details. In summary, the patient had a sternal exploration and debridement. He tolerated the operation well and was returned to the Cardiothoracic Intensive Care Unit intubated and sedated with an open chest wound. Plastic surgery was also following the patient. The patient did well in the immediate postoperative period. His anesthesia was reversed. He was weaned from the ventilator and successfully extubated. Several hours following extubation, the patient was found to be in acute respiratory distress and was emergently reintubated. From that point forward, he was kept sedated and ventilated awaiting plastics follow-up for flap closure. On the [**11-19**], the patient returned to the operating room. Please see the OR report for full details. In summary, the patient was brought to the operating room by the plastic surgery service for pectoral advancement with an omentum flap. He tolerated the operation well and was returned to the Cardiothoracic Intensive Care Unit. The patient remained intubated following his surgery. However, his sedation was minimized to allow the patient to overbreathe the ventilator. During that period, the patient had several episodes of coughing which led to a dehiscence of his abdominal incision, and on the [**11-20**] the patient again returned to the operating room for re-exploration and closure of the fascia of his abdominal wound. He tolerated this surgery well also and following that returned to the Cardiothoracic Intensive Care Unit, again ventilated and sedated. The patient remained ventilated and sedated for the next several days in an attempt to give the wound a chance to heal. Ultimately, the patient was successfully extubated on the [**11-24**]. However, he stayed in the Cardiothoracic Intensive Care Unit following extubation for close pulmonary monitoring. It should be noted that during the patient's ICU course, he had several intermittent episodes of atrial fibrillation for which he was begun on amiodarone, as well as heparin and ultimately Coumadin for anticoagulation. The patient did well over the next several days, and ultimately was transferred to the floor on [**11-28**], hospital day 15, postoperative day 13. At that point, a PICC line was placed for long-term antibiotic coverage. Over the next several days, the patient's activity level was increased with the assistance of the nursing and the physical therapy staff. His antibiotic coverage was continued. His anticoagulation was transitioned from intravenous to oral. Finally, on the [**12-1**], the patient's final [**Location (un) 1661**]- [**Location (un) 1662**] drain was removed from his chest, and it was decided that he was stable and ready to be transferred to rehabilitation for long-term antibiotic coverage, as well as glucose control. At that time, the patient's physical exam was as follows: Vital signs: Temperature 98.4, heart rate 82--sinus rhythm, blood pressure 113/66, respiratory rate 18, O2 sat 95 percent on room air, weight day of dictation 106.6 kg, preoperatively 100 kg. Lab data: PT 17.1, INR 1.9, sodium 139, potassium 3.7, chloride 100, bicarb 27, BUN 11, creatinine 0.9, glucose 149, white count 9.1, hematocrit 28.4, platelets 830. Physical exam - Neurologically: Alert and oriented x 3, nonfocal exam. Pulmonary: Clear to auscultation bilaterally. Cardiac: Regular rate and rhythm, S1, S2. Sternum: Incision with staples, clean and dry. No erythema or drainage. Abdomen was soft, nontender, nondistended with normoactive bowel sounds. Abdominal incision with staples, also clean and dry. Extremities were warm with no edema. Right saphenous vein graft harvest site was healing well, open to air, clean and dry. CONDITION ON DISCHARGE: Good. DISCHARGE DIAGNOSES: Coronary artery disease, status post coronary artery bypass grafting complicated by sternal infection requiring sternal debridement and flap closure. Diabetes mellitus. Hypercholesterolemia. Gastroesophageal reflux disease. FOLLOW UP: Follow-up with Dr. [**Last Name (STitle) 13797**] with plastic surgery service in 1 week. He is to call for an appointment at [**Telephone/Fax (1) 56789**]. He is also to have follow-up with Dr. [**Last Name (STitle) **] in 4 weeks. The patient is also to call for that appointment; the number is [**Telephone/Fax (1) 170**]. DISCHARGE MEDICATIONS: 1. Ranitidine 150 mg [**Hospital1 **]. 2. Simvastatin 40 mg once daily. 3. Ferrous sulfate 325 mg once daily. 4. Ascorbic acid 500 mg [**Hospital1 **]. 5. Zinc sulfate 220 mg once daily. 6. Aspirin 81 mg once daily. 7. Erythromycin ophthalmic ointment [**Hospital1 **]. 8. Colace 100 mg [**Hospital1 **]. 9. Metoprolol XL 100 mg once daily. 10.Glargine 24 units q at bedtime. 11.Humalog insulin sliding scale q ac and at bedtime. 12.Lasix 20 mg once daily. 13.Potassium chloride 20 mEq once daily. 14.Amiodarone 400 mg [**Hospital1 **] x 1 week, then 400 mg once daily x 1 week, then 200 mg once daily. 15.Oxacillin 2 grams q 4 h through [**12-28**]. 16.Warfarin as directed to maintain a target INR of 2 to 2.5. The patient's warfarin doses starting with 4 days ago - 3 mg, 5 mg, 5 mg, 5 mg. The patient is to receive 4 mg on the [**2032-11-29**].Albuterol 2 puffs qid prn. DISPOSITION: The patient is to be discharged to rehabilitation. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 1714**], [**MD Number(1) 1715**] Dictated By:[**Last Name (NamePattern4) 1718**] MEDQUIST36 D: [**2119-12-1**] 13:31:57 T: [**2119-12-1**] 14:15:12 Job#: [**Job Number 56790**]

[ "250.00", "518.5", "998.31", "730.28", "427.31", "998.59", "414.00", "V45.81", "530.81", "997.1" ]

icd9cm

[ [ [] ] ]

[ "96.6", "34.3", "96.72", "38.93", "86.22", "77.81", "83.82", "34.79", "78.41", "96.04" ]

icd9pcs

[ [ [] ] ]

6448, 6676

7041, 8258

2326, 6394

1545, 2308

6688, 7018

190, 672

1153, 1529

695, 847

6419, 6426

24,190

137,329

19970+57109

Discharge summary

report+addendum

Admission Date: [**2144-6-8**] Discharge Date: [**2144-6-30**] Date of Birth: [**2066-1-14**] Sex: M Service: MEDICINE Allergies: Sulfa (Sulfonamides) / Shellfish / Levaquin Attending:[**First Name3 (LF) 2160**] Chief Complaint: Weakness, s/p fall Major Surgical or Invasive Procedure: arterial line placement R IJ central venous line placement R wrist washout x 2 R shoulder and wrist washout Chest tube placement Bronchoscopy TEE History of Present Illness: This is a 78 year-old Cantonese speaking man with a history of coronary artery disease s/p CABG, s/pICD/pacer, atrial fibrillation, diabetes mellitus, hyperlipidemia, hypertension, chornic renal insufficiency who presents with 2 days of leg pain followed by whole body weakness. Says had been scratching his left leg in the past few days and then two days ago developed extreme pain in his left leg. Over the course of the last two days also developed extreme weakness first in his legs and then in his arms. Patient initially using his arms to prop himself up but had increasing upper extremity weakness and had fall Sunday night and was down until Monday morning when found by his son. Now reports severe weakness in both upper and lower extremities. Extreme pain in right shoulder and less severe pain in lower extremities and lower back. Has been taking all his meds including colchicine. . In the emergency department, fever to 100.8, initial blood pressure in the 70's, tachypneic to 24 with oxygen saturation of 100% on 2 liters. 2 liters normal saline given, levaquin, flagyl, vancomycin. ? of local reaction to levaquin. BP to 100's. RIJ placed. CXR, bilateral LENI's unremarkable. . On arrival to floor, patient afebrile, initally conversant and appropriate. Then patient acutely tachycardic, tachypneic, rigoring, remained afebrile. BP stable in 90's to 100's. Placed on NRB, given 1 additional liter of NS. Patient had complained of severe right shoulder and back pain, morphine given along with demerol for rigors. ABG obtained and revealed 7/41/22/284. With interventions, patient more somnolent, less tachypneic and cessation of rigors. Past Medical History: 1. Coronary artery disease s/p CABG [**3-5**] NYU, MI in [**12-8**] at OSH 2. hyperlipidemia 3. hypertension 4. Chronic Renal Insufficiency 5. Diabetes Mellitus 6. Gout 7. hypothyroidism 8. GERD 9. atrial fibrillation on coumadin Social History: +tobacco history x 25years, quit in '[**38**] No ETOH Lives with son Family History: non-contributory Physical Exam: VS: T 99.8 BP 118/70 HR 94 RR 18 O2sats 95% RA Gen: Frail, elderly, conversant. Moderate discomfort with movement of right arm HEENT: PERLLA, EOMI, anicteric, dry mm, op without lesions Neck: No LAD Lungs: Diminished breath sounds at the bases bilaterally, poor insp effort. Faint crackles bilaterally Heart: RRR no murmurs, rubs or gallops appreciated Abd: Soft, NT, ND, +BS no masses or hepatosplenomegaly Ext: Left leg with erythema, increased warmth, tenderness over lower extremity from ankle to knee [**2-8**]+ pitting edema. Right leg with pneumoboot, 2+ pitting edema. Faint DP's Right shoulder with increased warmth and pain on passive motion. No redness. Right arm is red and edematous 2+ pitting edema. Left arm no edema, redness, warmth, pain. . Pertinent Results: [**2144-6-30**] 05:19AM BLOOD WBC-6.9 RBC-3.00* Hgb-9.5* Hct-29.0* MCV-97 MCH-31.5 MCHC-32.6 RDW-16.3* Plt Ct-413 [**2144-6-25**] 07:30AM BLOOD WBC-7.2 RBC-3.31* Hgb-10.6* Hct-31.9* MCV-96 MCH-32.0 MCHC-33.2 RDW-16.5* Plt Ct-395 [**2144-6-8**] 12:20AM BLOOD WBC-3.7* RBC-4.19* Hgb-13.9* Hct-40.1 MCV-96 MCH-33.3* MCHC-34.7 RDW-16.5* Plt Ct-115* [**2144-6-29**] 07:55AM BLOOD Neuts-64.0 Lymphs-22.5 Monos-9.4 Eos-3.5 Baso-0.7 [**2144-6-30**] 05:19AM BLOOD PT-21.9* INR(PT)-2.1* [**2144-6-9**] 12:20PM BLOOD Fibrino-577* D-Dimer-6147* [**2144-6-10**] 12:09PM BLOOD Fibrino-675* [**2144-6-15**] 06:55AM BLOOD ESR-56* [**2144-6-30**] 05:19AM BLOOD Glucose-110* UreaN-37* Creat-1.5* Na-131* K-4.4 Cl-98 HCO3-28 AnGap-9 [**2144-6-29**] 07:55AM BLOOD ALT-23 AST-37 AlkPhos-113 TotBili-0.4 [**2144-6-23**] 07:40AM BLOOD proBNP-8111* [**2144-6-9**] 07:08AM BLOOD CK-MB-10 MB Indx-0.4 cTropnT-0.14* [**2144-6-8**] 06:28PM BLOOD CK-MB-10 cTropnT-0.12* [**2144-6-8**] 07:32AM BLOOD CK-MB-10 MB Indx-0.2 cTropnT-0.08* [**2144-6-8**] 12:20AM BLOOD CK-MB-7 cTropnT-0.06* [**2144-6-28**] 07:35AM BLOOD Calcium-8.1* Phos-3.1 Mg-2.0 [**2144-6-30**] 05:19AM BLOOD Mg-1.8 [**2144-6-21**] 07:20AM BLOOD Osmolal-273* [**2144-6-18**] 07:45AM BLOOD Osmolal-277 [**2144-6-15**] 06:55AM BLOOD CRP-200.7* [**2144-6-9**] 05:00AM BLOOD PEP-NO SPECIFI IgG-840 IgA-128 IgM-126 IFE-NO MONOCLO [**2144-6-10**] 07:19AM BLOOD Vanco-25.1* [**2144-6-25**] 07:30AM BLOOD Digoxin-1.7 [**2144-6-10**] 04:40AM BLOOD Acetmnp-7.8 [**2144-6-8**] 04:33PM BLOOD Type-ART Temp-36.8 Rates-/30 FiO2-100 pO2-214* pCO2-22* pH-7.37 calTCO2-13* Base XS--10 AADO2-487 REQ O2-81 Intubat-NOT INTUBA [**2144-6-8**] 12:26AM BLOOD Glucose-158* Lactate-3.5* [**2144-6-8**] 12:40AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.017 [**2144-6-8**] 12:40AM URINE Blood-LGE Nitrite-NEG Protein-30 Glucose-250 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG [**2144-6-8**] 12:40AM URINE RBC-[**3-9**]* WBC-0-2 Bacteri-MOD Yeast-NONE Epi-1 [**2144-6-21**] 04:54PM URINE Hours-RANDOM Creat-116 Na-45 [**2144-6-8**] 06:10PM URINE bnzodzp-NEG barbitr-NEG opiates-[**Known firstname **]S cocaine-NEG amphetm-NEG mthdone-NEG [**2144-6-24**] 02:32PM PLEURAL WBC-33* RBC-216* Polys-61* Lymphs-6* Monos-29* Meso-3* Macro-1* [**2144-6-24**] 02:32PM PLEURAL TotProt-2.2 Glucose-137 Creat-1.3 LD(LDH)-230 Amylase-14 Albumin-LESS THAN Cholest-18 [**2144-6-25**] 02:27PM JOINT FLUID WBC-[**Numeric Identifier **]* RBC-[**Numeric Identifier 27684**]* Polys-82* Lymphs-8 Monos-10 [**2144-6-25**] 02:16PM JOINT FLUID WBC-530* RBC-[**Numeric Identifier **]* Polys-7 Lymphs-17 Monos-14 Mesothe-1* Macro-61 [**2144-6-12**] 01:08PM JOINT FLUID WBC-[**Numeric Identifier 53838**]* RBC-[**Numeric Identifier 53839**]* Polys-99* Lymphs-1 Monos-0 Date 6 Specimen Tests Ordered By All [**2144-6-8**] [**2144-6-9**] [**2144-6-10**] [**2144-6-12**] [**2144-6-15**] [**2144-6-18**] [**2144-6-19**] [**2144-6-20**] [**2144-6-21**] [**2144-6-22**] [**2144-6-24**] [**2144-6-25**] All BLOOD CULTURE BRONCHIAL BRUSH BRONCHOALVEOLAR LAVAGE FLUID RECEIVED IN BLOOD CULTURE BOTTLES FLUID,OTHER JOINT FLUID PLEURAL FLUID SPUTUM SWAB TISSUE All INPATIENT [**2144-6-25**] JOINT FLUID GRAM STAIN-FINAL; FLUID CULTURE-FINAL; ANAEROBIC CULTURE-PENDING INPATIENT [**2144-6-25**] FLUID,OTHER GRAM STAIN-FINAL; FLUID CULTURE-FINAL; ANAEROBIC CULTURE-PENDING INPATIENT [**2144-6-25**] JOINT FLUID GRAM STAIN-FINAL INPATIENT [**2144-6-25**] JOINT FLUID GRAM STAIN-FINAL INPATIENT [**2144-6-24**] BRONCHOALVEOLAR LAVAGE GRAM STAIN-FINAL; RESPIRATORY CULTURE-FINAL; POTASSIUM HYDROXIDE PREPARATION-FINAL; IMMUNOFLUORESCENT TEST FOR PNEUMOCYSTIS CARINII-FINAL; FUNGAL CULTURE-PRELIMINARY {YEAST}; ACID FAST SMEAR-FINAL; ACID FAST CULTURE-PENDING; VIRAL CULTURE-PRELIMINARY INPATIENT [**2144-6-24**] TISSUE POTASSIUM HYDROXIDE PREPARATION-FINAL; IMMUNOFLUORESCENT TEST FOR PNEUMOCYSTIS CARINII-FINAL; FUNGAL CULTURE-PRELIMINARY; ACID FAST SMEAR-FINAL; ACID FAST CULTURE-PENDING; VIRAL CULTURE-PRELIMINARY INPATIENT [**2144-6-24**] BRONCHIAL BRUSH RESPIRATORY CULTURE-FINAL {STAPHYLOCOCCUS, COAGULASE NEGATIVE}; FUNGAL CULTURE-PRELIMINARY {YEAST}; ACID FAST SMEAR-FINAL; ACID FAST CULTURE-PENDING; VIRAL CULTURE-PRELIMINARY INPATIENT [**2144-6-24**] PLEURAL FLUID GRAM STAIN-FINAL; FLUID CULTURE-FINAL; ANAEROBIC CULTURE-PENDING; FUNGAL CULTURE-PRELIMINARY; ACID FAST SMEAR-FINAL; ACID FAST CULTURE-PENDING INPATIENT [**2144-6-22**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY CULTURE-FINAL {PSEUDOMONAS AERUGINOSA} INPATIENT [**2144-6-22**] SPUTUM ACID FAST SMEAR-FINAL; ACID FAST CULTURE-PENDING INPATIENT [**2144-6-21**] SPUTUM ACID FAST SMEAR-FINAL; ACID FAST CULTURE-PENDING INPATIENT [**2144-6-20**] SPUTUM ACID FAST SMEAR-FINAL; ACID FAST CULTURE-FINAL INPATIENT [**2144-6-19**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY CULTURE-FINAL; ACID FAST SMEAR-FINAL INPATIENT [**2144-6-18**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY CULTURE-FINAL INPATIENT [**2144-6-15**] SWAB GRAM STAIN-FINAL; FLUID CULTURE-FINAL; ANAEROBIC CULTURE-FINAL INPATIENT [**2144-6-15**] SWAB GRAM STAIN-FINAL; WOUND CULTURE-FINAL; ANAEROBIC CULTURE-FINAL INPATIENT [**2144-6-12**] FLUID RECEIVED IN BLOOD CULTURE BOTTLES AEROBIC BOTTLE-FINAL; ANAEROBIC BOTTLE-FINAL INPATIENT [**2144-6-10**] BLOOD CULTURE AEROBIC BOTTLE-FINAL; ANAEROBIC BOTTLE-FINAL INPATIENT [**2144-6-10**] BLOOD CULTURE AEROBIC BOTTLE-FINAL; ANAEROBIC BOTTLE-FINAL INPATIENT [**2144-6-9**] BLOOD CULTURE AEROBIC BOTTLE-FINAL; ANAEROBIC BOTTLE-FINAL INPATIENT [**2144-6-9**] BLOOD CULTURE AEROBIC BOTTLE-FINAL; ANAEROBIC BOTTLE-FINAL INPATIENT [**2144-6-8**] BLOOD CULTURE AEROBIC BOTTLE-FINAL {BETA STREPTOCOCCUS GROUP A}; ANAEROBIC BOTTLE-FINAL {BETA STREPTOCOCCUS GROUP A} INPATIENT [**2144-6-8**] BLOOD CULTURE AEROBIC BOTTLE-FINAL {BETA STREPTOCOCCUS GROUP A}; ANAEROBIC BOTTLE-FINAL {BETA STREPTOCOCCUS GROUP A} INPATIENT [**2144-6-8**] BLOOD CULTURE AEROBIC BOTTLE-FINAL; ANAEROBIC BOTTLE-FINAL CXR PORTABLE CHEST [**2144-6-29**]: COMPARISON: [**2144-6-27**] INDICATION: Diuresis. ICD remains in standard position. Cardiac silhouette is mildly enlarged, and there is new vascular engorgement, perihilar haziness and scattered septal thickening consistent with pulmonary edema from either fluid overload or CHF. Round nodule in right upper lobe is again demonstrated and corresponds to a suspicious nodule on recent chest CT dated [**2144-6-19**]. Small left pleural effusion is without change but a new right effusion is present. [**Numeric Identifier **] PICC W/O PORT [**2144-6-29**] 1:44 PM Reason: Please pace a L sided PICC line, but insert line only as so [**Hospital 93**] MEDICAL CONDITION: 78 year old man with GAS sepsis, L sided pacemaker, and R arm septic arthritis REASON FOR THIS EXAMINATION: Please pace a L sided PICC line, but insert line only as so far as the distal subclavian/proximal braciocephalic, ie AWAY FROM THE PACEMAKER INDICATION: IV access needed for antibiotics. The procedure was explained to the patient. A timeout was performed. RADIOLOGIST: Drs. [**Last Name (STitle) 9441**] and [**Name5 (PTitle) 380**] performed the procedure. Dr. [**Last Name (STitle) 380**], the Attending Radiologist, was present and supervised the entire procedure. TECHNIQUE: Using sterile technique and local anesthesia, the left brachial vein was punctured under direct ultrasound guidance using a micropuncture set. Hard copies of ultrasound images were obtained before and immediately after establishing intravenous access. A peel-away sheath was placed over a guidewire and a single lumen PICC line measuring 23 cm in length was then placed through the peel-away sheath with its tip positioned in the left subclavian vein under fluoroscopic guidance. Position of the catheter was confirmed by a fluoroscopic spot film of the chest. The peel-away sheath and the guidewire were then removed. The catheter was secured to the skin, flushed, and a sterile dressing applied. The patient tolerated the procedure well. There were no immediate complications. IMPRESSION: Uncomplicated ultrasound and fluoroscopically guided single lumen PICC line placement via the left brachial vein. Final length is 23 cm with the tip positioned in the left subclavian vein. The line is ready to use. INDICATIONS: 78-year-old man with pneumothorax status post chest tube removal. CHEST, AP UPRIGHT PORTABLE: Comparison is made to earlier in the same day. A chest tube has been removed from the right hemithorax. A small residual pneumothorax up to 4 mm in thickness remains. Otherwise, there has been no significant change. IMPRESSION: Small persistent pneumothorax. Cytology Report BRONCHIAL WASHINGS Procedure Date of [**2144-6-24**] REPORT APPROVED DATE: [**2144-6-25**] SPECIMEN RECEIVED: [**2144-6-24**] [**-7/2379**] BRONCHIAL WASHINGS SPECIMEN DESCRIPTION: Received 10 ml of cloudy brown fluid. Prepared 1 ThinPrep slide. CLINICAL DATA: Patient is 78 y/o from [**Country 651**] with RUL nodule. PREVIOUS BIOPSIES: [**2144-6-24**] [**-7/2379**] BRONCHIAL BRUSHINGS [**2141-10-4**] [**-4/3727**] RIHT SHOULDER REPORT TO: DR. [**First Name8 (NamePattern2) **] [**Name (STitle) **] DIAGNOSIS: Bronchoalveolar lavage: NEGATIVE FOR MALIGNANT CELLS. Bronchial epithelial cells, pulmonary macrophages and squamous cells. DIAGNOSED BY: [**First Name8 (NamePattern2) 803**] [**Last Name (NamePattern1) 10220**], CT(ASCP) [**First Name8 (NamePattern2) 32953**] [**First Name8 (NamePattern2) 32954**] [**Last Name (NamePattern1) 10165**], M.D. Lung, right upper lobe, transbronchial biopsy: Lung parenchymal, and fibrous tissue with anthracotic pigment. No malignancy identified. CT CHEST WITHOUT IV CONTRAST: A 16 x 19 mm lobulated solid solitary soft tissue nodule is seen in the right upper lobe posterior segment, abutting the major fissure. It corresponds with the recent chest radiograph findings and has no cavitation. No other lung nodules are identified. In the right upper lobe, there is scarring, with scattered micronodules and mild bronchiectasis, probably representing sequela of previous granulomatous exposure. Bilateral small nonhemorrhagic layering pleural effusions are present, with associated compressive atelectasis of the left lower lobe; consolidation in the right lower lobe is also present, more than would be expected for atelectasis. Several borderline lymph nodes are seen in the mediastinum, none larger than an 8 mm precarinal node (2:24). No definite hilar or axillary lymphadenopathy is present. The heart is enlarged; there are extensive coronary vascular calcifications, evidence of previous CABG, and dual-lead AICD, with wires following the expected course to a left pectoral generator. Staples overlying the right pectoralis muscle and subcutaneous air are consistent with the patient's recent shoulder procedure. This study is not designed to examine the abdomen, however, non-contrast images show layering radiopaque gallstones and several kidney cysts that are similar in appearance to the previous exam including CT scan of [**2141**]. Calcified splenic granuloma and hiatal hernia are also noted. No mass lesions are seen in the imaged portion of liver, adrenals, kidneys, or spleen. Bone windows show midline sternotomy wires and mild degenerative changes of the spine. T11 wedge configuration is unchanged. IMPRESSION: 1. 1.9-cm nodule in right upper lobe. Findings are most consistent with a lung neoplasm; septic embolus is much less likely, as the lesion is solitary, without cavitation. PET-CT may be useful for further characterization. 2. Scarring and multiple micronodules in the right upper lobe with very mild bronchiectasis, probably representing sequelae of granulomatous exposure but activity of disease is indeterminate without older studies for comparison; correlation with current infectious status or previous films is recommended to help determine chronicity of these findings. 3. Consolidation in right lower lobe may represent a pneumonia or atelectasis. 4. Bilateral small pleural effusions and associated compressive atelectasis in the left lower lobe. 5. Radiopaque gallstones. 6. Multiple bilateral renal cysts as previously documented. TEE - Conclusions: Mild spontaneous echo contrast is seen in the body of the left atrium. No mass/thrombus is seen in the left atrium or left atrial appendage. Mild spontaneous echo contrast is present in the left atrial appendage. No thrombus is seen in the right atrial appendage No atrial septal defect is seen by 2D or color Doppler. Right ventricular chamber size is normal. There are complex (>4mm) atheroma in the aortic arch. There are simple atheroma in the descending thoracic aorta. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No masses or vegetations are seen on the aortic valve. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. No mass or vegetation is seen on the mitral valve. Mild to moderate ([**1-7**]+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. The tricuspid regurgitation jet is eccentric and may be underestimated. There is at least mild pulmonary artery systolic hypertension. There is no pericardial effusion. No vegetation or abscess seen. Pacer leads seen with no definte associated vegetation (cannot definitively exclude). TTE - Conclusions: The left atrium is mildly dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size. There is moderate regional left ventricular systolic dysfunction with thinning/akinesis of the basal halves of the inferior and inferolateral walls and distal inferior and distal anterior walls. The apex is mildly dyskinetic. No masses or thrombi are seen in the left ventricle. The remaining left ventricular segments contract normally. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve leaflets are mildly thickened. Moderate (2+) mitral regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is a trivial/physiologic pericardial effusion. Compared with the prior study (images reviewed) of [**2144-4-29**], the estimated pulmonary artery systolic pressure is slightly higher. Regional left ventricular systolic function and valvular morphology are similar. The severity of tricuspid regurgitation is slightly lower and no aortic regurgitation is now seen. CLINICAL IMPLICATIONS: Based on [**2144**] AHA endocarditis prophylaxis recommendations, the echo findings indicate prophylaxis is NOT recommended. Clinical decisions regarding the need for prophylaxis should be based on clinical and echocardiographic data. CT spine- CONCLUSION: Acute T11 compression fracture with a small retropulsed fragment encroaching on the spinal canal. Relationship to the spinal cord cannot be determined on a CT scan. If this is a clinical concern, an MR may be indicated. Left renal mass, further evaluation may be indicated. IMPRESSION: 1. No cervical lymphadenopathy, abnormal soft tissue mass, or abnormal fluid collection to suggest paraspinal abscess. Please note non contrast CT has limited sensitivity for detection abscesses. 2. Multilevel degenerative changes of the spine as described above. 3. Low-attenuation area noted within the right maxilla likely represent periodontal disease. Please correlate clinically. IMPRESSION: Multilevel degenerative changes as described above. No definite paraspinal fluid collections; however, CT has low sensitivity for evaluation of spinal abscesses. US kidney - IMPRESSION: 1. No hydronephrosis. 2. 1.5 cm right kidney complex cyst, and 3 cm left kidney simple cyst. Followup Kidney MRI is recommended in [**4-10**] months for the complex cyst in the right kidney. 3. Cholelithiasis and mild gallbladder wall thickening. Brief Hospital Course: Given the prolonged complicated course - course described by problems - # Sepsis from strept bacteremia - source is left leg cellulitis. HE was treated withceftriaxone and clida initially and then only high dose ceftriaxone. ID followed pt in hosp. Plan to complete the course of six weeks from [**2144-6-25**] (last surgery). Dr [**Last Name (STitle) 9404**] in ID will follow him on [**2144-8-5**]. Weekly labs CBC, bun/creatinine, AST, ALT, alk phos, bilirubin should be faxed over to Dr [**Last Name (STitle) 9404**] at [**Telephone/Fax (1) 3382**]. At discharge, he was afebrile, WBC normal. Surveillance cultures remain neg so far since [**2144-6-9**]. TTE, TEE neg for IE/pacer involvement.PICC placed in left arm - terminating more prox than SVC (as also has a pacer) and pointing away from pacer. # Septic shoulder and wrist - s/p wash-out by ortho on [**2144-6-15**] and [**2144-6-25**]. Drains removed [**6-18**]. Continue Abx as above. PT for rehab. Pain controlled. Ortho follow up after dc - Dr [**Last Name (STitle) 1005**] /[**Doctor Last Name **]. # Pulmonary nodules/ Abnormal CT chest - concern for malignany. But bronchoscopic biopsy non-specific. Plan for follow up with CT surgery in clinic for further imaging, PET scan etc for diag of lung mass. AFB sputums neg to date. PPD was negative. FInal culture results to be followed up with PCP. . # Pneumothorax s/p bronchoscopy - pt developed a pneumothorax after bronchoscopy. CT placed by CT surgery and pulled out after resolution. Last CXR - tiny residual focus of air. Follow up as above. . # Hyponatremia - resolved with diuresis. Likely hypervolemic. Dose of lasix increased to 20 mg [**Known firstname **] daily. Monitor weekly at rehab. Also on 1 lit fluid restriction. # Gout, acute - rt big toe. Resolved on colchicine. It is advised that allopurinol be restarted after acute phase - per PCP/ MD at rehab. . # Thoracic fracture - cause could be traumatic vs osteomyelitis. Cannot get MRI due to pacemaker. Neurosurgery recommended a TLSO brace per neurosurg; logroll precautions. He was deemed not a candidate for vertebroplasty at this time by neuroradiology. PT/OT at rehab. Plan to F/u with neurosurg [**Telephone/Fax (1) 2731**] - Dr [**Last Name (STitle) **]. Please call to make appointment (recommended by them) for 1st week in [**Month (only) 216**]. Patient will need a CT sca nof T spine prior to the appointment. The clinic will arrange for both the scan and follow up with Dr [**Last Name (STitle) **]. . # Left kidney mass - as above - US showed - 1.5 cm right kidney complex cyst, and 3 cm left kidney simple cyst. Followup Kidney MRI is recommended in [**4-10**] months for the complex cyst in the right kidney. Will defer to PCP for follow up. # ARF - from ATN/sepsis - resolved. Creatinine at baseline (1.5) . # CHF systolic - EF 35-40%. ECHO suspicious of 3 vessel CAD. Had post-op hypoxia due to mild pulmonary edema on [**2144-6-15**]. Resolved on diuresis. Beta [**Last Name (LF) 7005**], [**First Name3 (LF) **], statin, lasix continued. Further w/u per PCP. . # Parox AFIB - Warfarin - Restarted after all procedures. Carvedilol, digoxin for HR control. INR follow up with PCP. . # Anemia - Hct at baseline. . # Thrombocytopenia - resolved. Likely related to sepsis. . # Type 2 DM - on insulin slid scale. . # Hypothyroidism - on levothyroxine. . # DVT prophylaxis - on warfarin. Discharged to [**Hospital3 **]. Plan communicated with patient's daughter at discharge. Medications on Admission: 1. omeprazole 20 mg 2. leevothyroxine 88 mcg daily 3. colchicine 0.6 mg QOD 4. lipitor 10 mg daily 5. coreg 12.5 [**Hospital1 **] 6. digitek 125 mcg daily 7. hyzaar 12.5/50 mg daily 8. aspirin 325 mg daily 9. coumadin 2.5mg daily 10. allopurinol 250 mg daily 11. imdur 60 mg daily 12. NPH and humalog sliding scales . Discharge Medications: 1. Digoxin 125 mcg Tablet Sig: One (1) Tablet [**Known firstname **] DAILY (Daily). Tablet(s) 2. Atorvastatin 10 mg Tablet Sig: One (1) Tablet [**Known firstname **] DAILY (Daily). 3. Aspirin 325 mg Tablet Sig: One (1) Tablet [**Known firstname **] DAILY (Daily). 4. Carvedilol 12.5 mg Tablet Sig: One (1) Tablet [**Hospital1 **] (2 times a day). 5. Sodium Chloride 0.9% Flush 3 ml IV DAILY:PRN Peripheral IV - Inspect site every shift 6. Levothyroxine 88 mcg Tablet Sig: One (1) Tablet [**Known firstname **] DAILY (Daily). 7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) [**Known firstname **] Q24H (every 24 hours). 8. Oxycodone 10 mg Tablet Sustained Release 12 hr Sig: One (1) Tablet Sustained Release 12 hr [**Known firstname **] Q12H (every 12 hours). 9. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical KEEP ON FOR 12 HOURS AND OFF FOR 12 HOURS (): to the right arm and forearm. 10. Oxycodone 5 mg Tablet Sig: One (1) Tablet [**Known firstname **] Q4-6H (every 4 to 6 hours) as needed for pain: hold for sedation. . Tablet(s) 11. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule [**Hospital1 **] (2 times a day). 12. Senna 8.6 mg Tablet Sig: One (1) Tablet [**Hospital1 **] (2 times a day). 13. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) [**Known firstname **] DAILY (Daily) as needed for constipation. 14. Furosemide 20 mg Tablet Sig: 1 Tablet [**Known firstname **] DAILY (Daily). 15. Warfarin 2.5 mg Tablet Sig: One (1) Tablet [**Known firstname **] at bedtime. 16. Colchicine 0.6 mg Tablet Sig: One (1) Tablet [**Known firstname **] EVERY OTHER DAY (Every Other Day). 17. Heparin Flush PICC (100 units/ml) 2 ml IV DAILY:PRN 10 ml NS followed by 2 ml of 100 Units/ml heparin (200 units heparin) each lumen Daily and PRN. Inspect site every shift. Discharge Disposition: Extended Care Facility: [**Hospital6 85**] - [**Location (un) 86**] Discharge Diagnosis: Sepsis from group A strept bacteremia, from left leg cellulitis Septic joints Thoracic compression fracture Congestive heart failure, systolic CAD Acute gout Renal mass Lung mass s/p bronchoscopy Iatrogenic pneumothorax s/p chest tube Thrombocytopenia Hyponatremia Discharge Condition: Stable Discharge Instructions: Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs. Adhere to 2 gm sodium diet. Fluid Restriction: 1 lit daily. Keep your appointments. Please take your medicines as prescribed. You will have to complete the IV antibiotics for another 4-6 weeks and the further course will be determined by infectious disease doctors. Call your doctor if you notice new chest pain, worsening arm pain, fevers, chills or any othet symptoms of concern to you. Weekly labs CBC, bun/creatinine, AST, ALT, alk phos, bilirubin should be faxed over to Dr [**Last Name (STitle) 9404**] at [**Telephone/Fax (1) 3382**]. Followup Instructions: Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] Phone:[**Telephone/Fax (1) 1228**] Date/Time:[**2144-7-6**] 9:30 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 53840**], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2144-8-5**] 10:30. Weekly labs CBC, bun/creatinine, AST, ALT, alk phos, bilirubin should be faxed over to Dr [**Last Name (STitle) 9404**] at [**Telephone/Fax (1) 3382**]. CT surgery - Dr [**Last Name (STitle) **] -- [**Hospital1 18**] [**Hospital Ward Name 23**] 9. [**0-0-**] -- at [**2144-7-16**] at 10 AM Orthopedic surgery - Dr [**Last Name (STitle) 1005**] -([**Telephone/Fax (1) 2007**] - [**2144-7-28**] at 1540 hrs. PCP [**Name Initial (PRE) **] [**Name10 (NameIs) **] [**First Name8 (NamePattern2) 4457**] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 8236**] -- [**2144-7-21**] at 9-30am Spine surgery - Dr [**Last Name (STitle) **] - Plan to F/u with neurosurg [**Telephone/Fax (1) 2731**] - Dr [**Last Name (STitle) **]. Please call to make appointment (recommended by them) for 1st week in [**Month (only) 216**]. Patient will need a CT scan of T spine prior to the appointment. The clinic will arrange for both the scan and follow up with Dr [**Last Name (STitle) **]. Name: [**Known lastname **],[**Known firstname **] [**Doctor Last Name **] Unit No: [**Numeric Identifier 10023**] Admission Date: [**2144-6-8**] Discharge Date: [**2144-6-30**] Date of Birth: [**2066-1-14**] Sex: M Service: MEDICINE Allergies: Sulfa (Sulfonamides) / Shellfish / Levaquin Attending:[**First Name3 (LF) 1455**] Addendum: The patient was discharged on ceftriaxone 2 grams IV q24 hours to complete a course of 6 weeks total. This medicine is missing in the discharge summary - discharge medication section by error. I have called [**Hospital3 **] today and talked with the patient's nurse, [**Female First Name (un) 10024**] who confirmed that the patient is getting ceftriaxone 2 grams IV q24 hours and the last day is [**2144-8-13**]. This was communicated to the patient's PCP as well. Discharge Disposition: Extended Care Facility: [**Hospital6 41**] - [**Location (un) 42**] [**Name6 (MD) **] [**Last Name (NamePattern4) 1456**] MD [**MD Number(2) 1457**] Completed by:[**2144-7-1**]

[ "711.09", "V45.81", "518.89", "428.0", "276.1", "038.0", "512.1", "287.5", "584.9", "428.20", "250.00", "682.6", "995.92", "585.9", "V45.02", "414.00", "274.0", "733.13" ]

icd9cm

[ [ [] ] ]

[ "80.11", "33.27", "80.81", "81.91", "80.73", "80.83", "88.72", "33.24", "80.13", "38.93" ]

icd9pcs

[ [ [] ] ]

28308, 28516

19302, 22786

322, 469

25470, 25479

3322, 9944

26145, 28285

2509, 2527

23155, 25068

9981, 10060

25182, 25449

22812, 23132

25503, 26122

2543, 3303

17892, 19279

264, 284

10089, 17869

497, 2151

2173, 2406

2422, 2493

6,962

185,719

537

Discharge summary

report

Admission Date: [**2180-5-24**] Discharge Date: [**2180-6-2**] Date of Birth: [**2112-4-25**] Sex: F Service: FENARD INTENSIVE CARE UNIT CHIEF COMPLAINT: Hypoxia. HISTORY OF PRESENT ILLNESS: This is a 68-year-old woman with a history of chronic obstructive pulmonary disease, history of right upper lobe pneumonia, status post prolonged intubation with trache and PEG placements from [**2177-11-24**] to [**2178-12-25**], full exercise tolerance at baseline, chronic productive cough with thick-clear sputum, but otherwise not on home O2 or po prednisone, who has been in her usual state of health until about a week prior to admission when she started to experience increased fatigue, and shortness of breath, and productive cough. But otherwise no fevers, chills, no overt upper respiratory infection, urinary tract infection, or abdominal symptoms. Two days prior to admission, her family noticed a dramatic worsening of shortness of breath and increased sputum production, but otherwise no change in the color or blood in the sputum. She also had significant worsening of appetite for two days. She fell at home the day prior to admission due to extreme weakness. She was on the floor for about 15 minutes, but no loss of consciousness. She was brought into the Emergency Room by her family. Her head CT scan was negative for hemorrhage. Her shortness of breath was much better with nebulizers and IV steroids. However, the next day while she was still in the Emergency Room, she was noticed to have increased lethargy, and was electively intubated for an arterial blood gas of pH 7.24, pCO2 84, and pO2 of 73. She became significantly hypotensive after intubation and required 10 liter normal saline resuscitation. She was started on Neo-Synephrine for blood pressure support. She was given a dose of levofloxacin and Vancomycin for empiric coverage of possible sepsis. Her chest x-ray and chest CT scan in the Emergency Department suggested right upper lobe pneumonia or other processes. PAST MEDICAL HISTORY: 1. Chronic obstructive pulmonary disease. 2. Severe emphysema and bronchitis. Pulmonary function tests in [**2178-6-24**] showed a FVC of 1.85 liters, FEV1 0.73 liters, and a FEV1/FVC ratio 39%. 3. Hypertension. 4. Vitamin B12 deficiency. 5. Alcohol and benzodiazepine dependency. 6. History of tuberculosis exposure versus infection. 7. Osteoporosis. 8. Status post right upper lobe pneumonia in [**2178-10-24**] to [**2178-12-25**] with prolonged intubation with trache and PEG placement. ALLERGIES: 1. Bactrim with nausea. 2. Orajel with benzocaine with dermatitis. MEDICATIONS ON ADMISSION: 1. Combivent two puffs [**Hospital1 **]. 2. Serevent two puffs [**Hospital1 **]. 3. Vitamin B12 250 mcg po q day. 4. Flovent two puffs [**Hospital1 **]. 5. Klonopin 1 mg po bid. 6. Atrovent. 7. Remeron 30 mg q hs. 8. Diltiazem 120 mg po bid. 9. Multivitamins one tablet po q day. 10. Stool softeners. 11. Oxycodone 5 mg prn for pain. SOCIAL HISTORY: Two packs per day until last year after the pneumonia. Still smokes now and then. Regular alcohol use. Lives with her son and grandson. EXAM ON ADMISSION: Temperature 97.0, heart rate 74, blood pressure 85/35, respiratory rate 16, O2 saturation 100% on FIO2 100% with vent setting of tidal volume 350, rate of 16, PEEP of 5, FIO2 1.0. General: She is intubated, but easily arousable, thin, chronically sick appearing, but otherwise in no acute distress. Head and neck examination is anicteric. Oropharynx is clear. Cardiovascular: Regular, rate, and rhythm. Lungs: Equal breath sounds bilaterally, significantly prolonged expiratory phases. Abdomen is soft, normal bowel sounds. Extremities no edema. Neurologic: Moves all extremities. Lines with Foley and ET tube. LABORATORIES UPON ADMISSION: Arterial blood gas 7.24, 84, 73 preintubation. After intubation, 7.07, 25, 459. Complete blood count: White count of 34.3, hematocrit of 43.5, platelets 474. PT of 16.0, PTT 53.4, INR of 1.7. Sodium 135, potassium 4.6, chloride 96, bicarb 31, BUN 9, creatinine 0.5, glucose of 133. Urinalysis is negative. Chest x-ray showed increased capacity and pleural thickening at the right upper lobe concerning for infection, TB versus aspergillosis, versus actinomycosis, versus mucomycosis, and also need to rule out neoplasts. Chest CT scan: Diffuse emphysematous changes with bullae, right apical thick walled cavity suggesting semi-invasive aspergillus, versus TB, versus actinomycosis, versus mucomycosis, versus neoplasts, multilobular pneumonia, versus aspiration, multiple liver lesions. Head CT scan: No evidence of intracranial hemorrhage. Sputum Gram stain showed [**11-25**]+ gram-positive cocci. Culture was essentially negative. Had some oral flora. Urine culture negative. Blood cultures were negative. HOSPITAL COURSE: Patient had remained relatively stable through her hospital stay. She finished a 10 day course of Vancomycin for a possible MRSA pneumonia. She continued to have low grade temperatures, but her white counts came down significantly to her baseline around 16. Since her initial hypertension was thought most likely secondary to intubation instead of sepsis, she was aggressively diuresed through her hospital stay, and she received 10 liters normal saline initially in the Emergency Room. Although her respiratory status continued to improve significantly, she was not able to be weaned off vent at this time. She had a trache and PEG placed so she can be discharged to rehab for slow weaning of ventilation. Decision was made to discharge her to rehab with Lasix drip in order to diurese her about 1 liter negative everyday until her weight is down back to her baseline or her BUN or creatinine start to increase. DISCHARGE CONDITION: Stable. DISCHARGE STATUS: [**Hospital **] Rehab. DISCHARGE DIAGNOSES: 1. Respiratory failure. 2. Right upper lobe pneumonia. 3. Chronic obstructive pulmonary disease. 4. Possible aspergillosis. 5. Hypertension. DISCHARGE MEDICATIONS: 1. Vitamin B12 250 mcg po q day. 2. Flovent two puffs [**Hospital1 **]. 3. Klonopin 1 mg po bid. 4. Senna one tablet po bid. 5. SubQ Heparin 5,000 units subQ [**Hospital1 **]. 6. Atrovent four puffs qid. 7. Albuterol four puffs qid. 8. Prevacid 30 mg po q day. 9. Multivitamins 5 cc po q day. 10. Colace 150 mg po bid. 11. Nystatin swish and swallow qid prn. 12. Ritalin 2.5 mg po q am. 13. Remeron 30 mg po q hs. 14. Dulcolax 10 mg po q day prn. 15. Milk of magnesia 30 cc po qid prn. 16. Lactulose 30 cc po qid prn. 17. Tylenol prn. 18. Lasix drip 0.25 mg/hour titrate to in and out's negative a liter per day until BUN and creatinine start to increase for weight back to baseline. 19. Insulin NPH 6 units [**Hospital1 **]. 20. Regular insulin-sliding scale qid. DISCHARGE FOLLOWUP: The patient will continue her outpatient followup with her primary care physician. [**Name10 (NameIs) **] will also need to be seen in the Pulmonary Clinic to followup the right upper lobe lesion. CT-guided aspiration versus biopsy might be considered. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**Name8 (MD) **], M.D. [**MD Number(1) 292**] Dictated By:[**Last Name (NamePattern1) 4432**] MEDQUIST36 D: [**2180-6-2**] 13:03 T: [**2180-6-2**] 13:19 JOB#: [**Job Number 4433**]

[ "401.9", "518.81", "117.3", "733.00", "492.8", "458.9", "482.41", "484.6", "266.2" ]

icd9cm

[ [ [] ] ]

[ "43.11", "31.1", "33.22" ]

icd9pcs

[ [ [] ] ]

5800, 5852

5873, 6015

6038, 6804

2651, 2986

4859, 5778

176, 186

6825, 7367

215, 2031

3815, 4841

2053, 2625

3003, 3147

55,896

160,135

4700+55598

Discharge summary

report+addendum

Admission Date: [**2153-12-21**] Discharge Date: [**2153-12-28**] Date of Birth: [**2080-3-14**] Sex: F Service: NEUROLOGY Allergies: Aspirin / Nsaids Attending:[**First Name3 (LF) 5378**] Chief Complaint: new onset seizure Major Surgical or Invasive Procedure: none History of Present Illness: 73 year old female with h/o ETOH abuse and depression, no prior history of seizure, presents with seizures. Today while she was playing Bingo at her living center, bystanders noticed right arm weakness and then shaking, followed by left leg shaking and then generalized shaking for one minute. After the episode she was confused but moving all extremities. She had no incontinence. No h/o head trauma. On EMS arrival, d-stick was 122. She was brought to [**Hospital1 **] [**Location (un) 620**], where she had another episode of "tonic movements, right gaze deviation, and increased somnnolence" concerning for seizure. She also had a small vomiting episode which raised concern for aspiration. She was intubated for airway protection. CT head was negative. She received versed 12mg total, levetiracetam 1g, and etomidate, lidocaine, succinylcholine, and magnesium (Mg level had been 1.4 on arrival). She was transferred to [**Hospital1 18**] for further evaluation and treatment. Past Medical History: ETOH abuse Cirrhosis Osteoporosis Depression S/p bilateral hip fractures, right total hip replacement ?prior CVA (history unclear) Social History: Lives at [**Location 583**] gardens. Currently drinks 2 glasses of alcohol daily. Quit smoking 5 years ago. Uses a walker at baseline. Physical Exam: BP 116/70, O2 sat 100% (intubated) Gen: Lying in bed, intubated. Initially on propofol; proprofol stopped prior to exam. HEENT: Normocephalic, atraumatic. Mucous membranes moist. Neck: Supple, but limited by ETT in place. CV: RRR, Nl S1 and S2, no murmurs/gallops/rubs Lung: Intubated. Clear to auscultation bilaterally Abd: +BS soft, nontender Skin: No rash Ext: No edema Neurologic examination: Mental status: Eyes open, eyes roving, some purposeful movements in reaching for ET tube, does not follow commands. Cranial Nerves: II: Pupils equally round and reactive to light, 3 to 2 mm bilaterally. III, IV, VI: Extraocular movements intact to Doll's maneuver. V1-3: Sensation intact V1-V3. VII: Face symmetric at rest. [**Doctor First Name 81**]: Sternocleidomastoid and trapezius full strength bilaterally. XII: Good bulk. No fasciculations. Tongue midline, movements intact. . Motor: Tone normal. Small spontaneous movements in all extremities; moves left arm slightly more than right. Deep tendon Reflexes: Biceps: Tric: Brachial: Patellar: Achilles Toes: Right 2 2 2 0 0 UPGOING Left 2 2 2 0 0 UPGOING . Sensation: Withdraws to noxious in all extremities. Pertinent Results: [**2153-12-21**] 07:30PM BLOOD WBC-20.5* RBC-4.14* Hgb-13.9 Hct-41.2 MCV-100* MCH-33.6* MCHC-33.8 RDW-13.1 Plt Ct-195 [**2153-12-25**] 08:50AM BLOOD WBC-9.4 RBC-3.19* Hgb-10.8* Hct-32.6* MCV-102* MCH-34.0* MCHC-33.3 RDW-13.1 Plt Ct-187 [**2153-12-21**] 07:30PM BLOOD Neuts-86* Bands-2 Lymphs-6* Monos-6 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 [**2153-12-25**] 02:33AM BLOOD PT-13.7* PTT-33.5 INR(PT)-1.2* [**2153-12-25**] 02:33AM BLOOD Fibrino-595* [**2153-12-25**] 08:50AM BLOOD Glucose-88 UreaN-10 Creat-0.5 Na-141 K-3.8 Cl-109* HCO3-23 AnGap-13 [**2153-12-25**] 02:33AM BLOOD ALT-18 AST-39 AlkPhos-100 Amylase-75 TotBili-1.4 [**2153-12-25**] 08:50AM BLOOD Calcium-8.5 Phos-2.9 Mg-1.8 [**2153-12-21**] 10:50PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2153-12-21**] 10:50PM BLOOD TSH-0.81 [**2153-12-21**] 10:50PM BLOOD Triglyc-74 HDL-66 CHOL/HD-2.4 LDLcalc-78 [**2153-12-25**] 09:01AM BLOOD %HbA1c-5.4 eAG-108 [**2153-12-22**] 04:07PM BLOOD Type-ART PEEP-5 pO2-190* pCO2-35 pH-7.43 calTCO2-24 Base XS-0 Intubat-INTUBATED [**2153-12-21**] 08:02PM BLOOD Type-ART Temp-36.1 Rates-16/1 Tidal V-550 FiO2-100 pO2-292* pCO2-33* pH-7.40 calTCO2-21 Base XS--2 AADO2-402 REQ O2-69 -ASSIST/CON Intubat-INTUBATED Brief Hospital Course: Ms. [**Known lastname 2987**] is a 73 year old woman with a history of alcohol abuse, depression, osteoarthritis and no prior history of seizures who was admitted to [**Hospital1 18**] on [**2153-12-21**] after experiencing a secondarily generalized seizure while playing bingo at her group home. #.New onset seizure: On arrival to [**Hospital1 **] [**Location (un) 620**], she experienced another episode of tonic movements, right gaze deviation, and increased somnnolence concerning for seizure (per report). She was intubated for airway protection and arrived to [**Hospital1 18**] sedated post-intubation and was admitted to the ICU. On her initial exam (off propofol but intubated), she did not follow commands, had intact extraocular movements with Doll's maneuver and had small spontaneous movements in all extremities, but moved the left arm slightly more than the right, and toes were upgoing bilaterally. Her exam improved over two days and she was transferred to the neurology floor. She received a keppra 1gm load. Repeat CT head demonstrated no evidence of acute hemorrhage but was notable for a hypodensity in the left temporo-occipital region that suggested an ischemic infarct. MRI head supported this finding, and suggested old ischemic infarct in the same Left temporo-occipital region. With evidence of old stroke, it is most likely that new onset of seizure occurred secondary to an old stroke. Patient has remained seizure free in house on LeVETiracetam 750 mg [**Hospital1 **]. She was evaluated with TTE, which showed mild to moderate systolic dysfunction and increased pulmonary artery pressure with mild MR, but had no evidence of emboli. She was prescribed low dose Aspirin and statin in setting of s/p CVA. . At the time of discharge, her examination was notable for impairments in attention and concentration as well minor motor strength deficits on the left side (including flattening of left nasolabial fold and weakness of L sternocleidomastoid) but was otherwise unremarkable. Physical therapy evaluated her and considered her a good candidate for rehab, remarking that she would not be considered safe to go home alone. . #. Hip Pain: Found to have 7 out of 10 hip pain upon passive or active movement of the thigh, worse in left hip than right hip. Bilateral hip xrays in three views (AP, lateral, oblique) showed no evidence of acute pathology and were notable for s/p Right total hip replacement and bilateral degenerative osteoarthritis. Physical therapy stood her up and noted that she was able to bear weight bilaterally. Ms. [**Known lastname 2987**] stated that her pain was tolerable while walking, commenting only that she felt dizzy and unsteady on her feet. In house, her pain was controlled with percocet Q6H and acetaminophen for breakthrough. . #. Headache: Ms. [**Known lastname 2987**] experienced a headache while in house when she was walked with Physical Therapy. After eating lunch and receiving some IV fluids, her headache had resolved. . #. Leukocytosis: On her first day of admission, her WBC increased from 11.4 to 20.5, but continued to trend downwards throughout her course. She remained afebrile in house and blood and urine cultures have been negative. Therefore, with suspicion for infection low, no LP was done. . #. History of EtOH abuse: Ms. [**Known lastname 2987**] was started on a CIWA scale in the ICU and given thiamine, folic acid, mg, and MVI. She had no symptoms of EtOH withdrawal during her admission. . #. FEN: Patient was initially NPO while intubated and then switched over to a regular diet after bedside swallow evaluation. #. Oxygen requirement: Ms. [**Known lastname 2987**] was initially transferred to the [**Hospital1 **] intubated because of concern about airway protection. She was extubated by HD#2 and was weaned from 4L to room air over the course of days. Of note, Chest X-Ray on [**12-25**] was notable for a large hiatal hernia that was likely responsible for a left mediastinal shift and atelectasis of the left lung. However, she has had no difficulty breathing and she has otherwise been well. #. Rash: Ms. [**Known lastname 2987**] developed an erythematous papular rash on her arms, back and the back of her legs. This rash is not present on her trunk or other areas of her body covered by clothing. We do not believe this is due to any new medications, specifically Keppra. It is more likely that this is due to a contact dermatitis and indeed, she does have a history of eczema. . CODE status: Full code Niece [**Name (NI) 19821**] [**Name (NI) 19822**] is HCP ([**Telephone/Fax (1) 19823**]) Medications on Admission: Metoprolol 50mg PO daily Magnesium oxide 400mg PO TID Zoloft 12.5mg PO daily MVI q tab PO daily KCl 20mEq PO daily Folate 1mg Po daily Thiamine 100mg PO daily Omeprazole 20mg PO daily Vitamin D 400 units PO daily Ferrous sulfate 325mg PO daily donepezil 5 mg qhs Percocet 5/325 q4h PRN pain Discharge Medications: 1. cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. sertraline 25 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 3. docusate sodium 50 mg/5 mL Liquid Sig: Ten (10) mL PO BID (2 times a day). 4. magnesium oxide 400 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 5. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for fever, pain. 6. metoprolol succinate 50 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 7. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 11. levetiracetam 750 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 12. camphor-menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical QID (4 times a day) as needed for rash. 13. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 14. donepezil 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 15. ferrous sulfate 300 mg (60 mg Iron) Tablet Sig: One (1) Tablet PO BID (2 times a day). 16. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 17. diphenhydramine HCl 12.5 mg/5 mL Elixir Sig: One (1) mL PO Q6H (every 6 hours) as needed for itching. 18. oxycodone-acetaminophen 5-325 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for pain. 19. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 20. omega-3 fatty acids Capsule Sig: One (1) Capsule PO BID (2 times a day). Discharge Disposition: Extended Care Facility: Newbridge on the [**Doctor Last Name **] - [**Location (un) 1411**] Discharge Diagnosis: New onset seizure after old stroke Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: It was a pleasure to take part in your care, Ms. [**Known lastname 2987**]. You were admitted to the hospital after you had a seizure while playing a game of Bingo. While in the hospital, we found that you had an old stroke that would explain the cause of your seizure. While you were here, we made the following changes to your medications: 1. We started you on a medication to prevent seizures called Keppra, which you will continue taking at home. 2. We started you on a low dose Aspirin (81mg) and simvastatin 40mg a day. We also recommend that you start fish oil in order to help prevent a stroke in the future Followup Instructions: You should keep your scheduled follow-up appointment with your PCP [**Last Name (NamePattern4) **] [**2154-1-11**] at 1pm. At this appointment you should discuss with your doctor [**First Name (Titles) **] [**Last Name (Titles) 19824**] and benefits of you taking aspirin. You will follow up in neurology with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 19825**] on Feburary 15, [**2154**] at 1pm in the neurology clinic in [**Hospital Ward Name 860**] 406. If you have questions, please call [**Telephone/Fax (1) 19826**]. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5379**] MD, [**MD Number(3) 5380**] Name: [**Known lastname 3271**],[**Known firstname 194**] A Unit No: [**Numeric Identifier 3272**] Admission Date: [**2153-12-21**] Discharge Date: [**2153-12-28**] Date of Birth: [**2080-3-14**] Sex: F Service: NEUROLOGY Allergies: Aspirin / Nsaids Attending:[**First Name3 (LF) 3273**] Addendum: Ms. [**Known lastname **] was held overnight on [**2153-12-27**], because of a concern about her rash. Dermatology was consulted and it was determined that the rash on her arms and legs were eczematous lesions and the rash on her back was miliaria. We prescribed triamcinolone ointment for 14 days for her arms and legs and were instructed to keep her back dry which will resolve that rash. On the AM of [**2153-12-28**], we consulted orthopedics about her worsening left hip pain especially because the hip x-ray was concerning for possible loosening of her prosthesis. However, orthopedics thought that it was unlikely that it was an acute issue and felt comfortable having her follow-up with her primary orthopedic surgeon for this issue. Her PCP's office (Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3274**]) is aware and will arrange follow-up. In regards to her neurological issues: her vessel imaging was significant for some mild intracranial stenosis of some vessels, but the quality was suboptimal due to motion. At this time, we do not think repeat imaging is necessary but may be considered as an outpatient. Discharge Medications: Addition: triamcinolone acetonide 0.1 % Ointment Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day) for 14 days. All other meds per previous d/c summary except for simvastatin and fatty acids, which will be discontinued. Discharge Disposition: Extended Care Facility: Newbridge on the [**Doctor Last Name **] - [**Location (un) 1502**] [**First Name11 (Name Pattern1) 77**] [**Last Name (NamePattern4) 3275**] MD, [**MD Number(3) 3276**] Completed by:[**2154-1-2**]

[ "438.89", "288.60", "553.3", "780.39", "303.91", "518.81", "692.9", "784.0", "571.2", "V43.64", "V15.82", "311" ]

icd9cm

[ [ [] ] ]

[ "96.71", "96.04" ]

icd9pcs

[ [ [] ] ]

14321, 14574

4194, 8807

298, 304

11044, 11044

2933, 4171

11861, 14044

14067, 14298

10986, 11023

8833, 9126

11220, 11838

1651, 2029

241, 260

332, 1326

2186, 2914

11059, 11196

2053, 2053

1348, 1480

1496, 1636

69,943

179,154

42634

Discharge summary

report

Admission Date: [**2113-2-22**] Discharge Date: [**2113-2-28**] Date of Birth: [**2070-10-31**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 8263**] Chief Complaint: transfer for liver disease Major Surgical or Invasive Procedure: -patient was intubated prior to arrival -arterial line placement History of Present Illness: 42yo M with h/o cryptogenic cirrhosis, refractory ascites requiring large volume paracenteses (most recently [**2-17**]), and portal HTN who present to OSH [**2-20**] with generalized weakness and SOB. He noted progressive dyspnea and decreased PO intake but denied CP, orthopnea, and PND. He reported generalized abdominal pain but denied hemetemesis, nausea, melanotic stools and dysuria. he reported regular bowel movements, medication compliance, and dietary adhearance. . In the ED at OSH, pt was afebrile with HR in 70s (beta blocked), hypotensive to 70s systolic, and satting well on RA. He received 3L NS, 50g albumin, Zosyn 3.375g and was started on peripheral dopamine before a right IJ was placed and converted to levophed. A diagnostic paracentesis was done with no evidence of SBP. The pt was transferred to the MICU where he was treated for septic shock of unclear etiology He remianed on levophed, rec'd additional 100g albulin and was treated with vanc/zosyn for ? HCAP vs UTI. He had oliguric ARF with FEUrea 6% and UNa<10, c/w either pre-renal azotemia vs HRS. Nephrology was consulted and he was started on midodrine and octreotide. Pt was also seen by GI who recommended transplant evaluation. The pt developed worsening dyspnea and work of breathing and was inubated on [**2-21**]. Transferred to [**Hospital1 18**] on levophed and propofol gtt w/intermittent sedation. . On arrival to the MICU, pt is intubated and sedated and hypothermic. An A line was placed in left radial artery. Past Medical History: -Cryptogenic cirrhosis c/b encephalopathy, refractory ascites, SBP, portal hypertension and edema. His current MELD score is 14, Child's class C Social History: - Lives with his sister in east [**Hospital1 **] - Smokes 1 pack per day for many years: pre-contemplative - No current alcohol use. Last EtOH use 24 yo - Occasional MJA Family History: - Uncle with Liver disease [**2-23**] alcohol Physical Exam: ADMISSION EXAM Vitals: T:95 BP:92/39 P:70 R: 18 O2: 100% on vent General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: supple, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi Abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CNII-XII intact, 5/5 strength upper/lower extremities, grossly normal sensation, 2+ reflexes bilaterally, gait deferred, finger-to-nose intact Pertinent Results: ADMISSION LABS [**2113-2-22**] 01:10AM BLOOD WBC-12.0*# RBC-2.22*# Hgb-7.1*# Hct-21.7*# MCV-98 MCH-31.9 MCHC-32.7 RDW-16.4* Plt Ct-89* [**2113-2-22**] 01:10AM BLOOD Neuts-83.4* Lymphs-8.5* Monos-7.3 Eos-0.7 Baso-0.1 [**2113-2-22**] 01:10AM BLOOD PT-32.0* PTT-79.6* INR(PT)-3.1* [**2113-2-22**] 01:10AM BLOOD Glucose-122* UreaN-102* Creat-4.8*# Na-126* K-5.5* Cl-95* HCO3-15* AnGap-22* [**2113-2-22**] 01:10AM BLOOD ALT-58* AST-128* LD(LDH)-187 CK(CPK)-131 AlkPhos-217* Amylase-23 TotBili-7.0* [**2113-2-22**] 01:10AM BLOOD Albumin-4.0 Calcium-8.6 Phos-6.9*# Mg-2.6 TTE [**2113-2-22**] At least moderate-severe mitral and tricuspid regurgitation. No vegetations visualized. Moderate pulmonary artery systolic hypertension. If clinically indicated, a TEE would better assess the etiology of the mitral regurgitation and the presence of vegetations. LEFT ANKLE X-RAY [**2113-2-22**] 1. Marked soft tissue swelling. 2. No radiographic evidence for osteomyelitis. If there is continued concern, recommend further evaluation with MRI. Brief Hospital Course: Mr. [**Known lastname 14800**] is a 42y/o gentleman with cryptogenic cirrhosis complicated by encephalopathy, refractory ascites, SBP, portal hypertension and edema who was transferred from an OSH for transplant evaluation. He was initially admitted to the OSH with dyspnea and abdominal pain, and was found to be hypotensive requiring pressors. He had severe acute renal failure that was concerning for hepatorenal syndrome so he was transferred to [**Hospital1 18**]. Here, his hypotension was worked up; he was felt to be in septic shock and was treated with broad-spectrum antibiotics with no clear source (team considered gall bladder source, SBP, pneumonia, UTI, left heel infection). His course was marked by severe encephalopathy; he was minimally responsive off all sedation for days despite the use of Lactulose and Rifaximin. In addition, he had severe kidney injury despite HRS treatment, for which dialysis was recommended. He was evaluated by the Hepatology team, who felt that he was not a candidate for liver transplant. Family meetings were held, and it was felt that the patient would not want hemodialysis, especially if there was no hope of reversing his underlying liver disease. On [**2113-2-25**], the decision was made to transition to comfort-focused care. He was extubated and pressors/antibiotics/non-comfort meds were stopped. A morphine drip was started. A scopolamine patch was placed. He was transferred to the general medical floor where he expired. Medications on Admission: ALBUTEROL SULFATE - (Prescribed upon d/c ) - 90 mcg HFA Aerosol Inhaler - 2 HFA(s) inhaled every 4-6 hours as needed for shortness of breath or wheezing CIPROFLOXACIN - 250 mg Tablet - 1 Tablet(s) by mouth once a day EPLERENONE - (Prescirbed upon d/c) - 25 mg Tablet - 1 Tablet(s) by mouth DAILY (Daily) FUROSEMIDE - (Prescibed upon d/c ) - 20 mg Tablet - 2 Tablet(s) by mouth twice a day LACTULOSE - (Prescibed upon d/c ) - 10 gram/15 mL Solution - 30 ml by mouth PANTOPRAZOLE - (Prescibed upon ) - 40 mg Tablet, Delayed Release (E.C.) - 1 Tablet(s) by mouth every twenty-four(24) hours RIFAXIMIN [XIFAXAN] - 550 mg Tablet - 1 Tablet(s) by mouth twice a day SILDENAFIL [VIAGRA] - (Prescibed upon d/c) - 100 mg Tablet - 1 Tablet(s) by mouth as directed Discharge Medications: patient expired Discharge Disposition: Expired Discharge Diagnosis: patient expired Discharge Condition: patient expired Discharge Instructions: patient expired Followup Instructions: patient expired

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Discharge summary

report

Admission Date: [**2138-11-25**] Discharge Date: [**2138-11-27**] Date of Birth: [**2094-4-16**] Sex: M Service: MEDICINE Allergies: IV Dye, Iodine Containing Attending:[**First Name3 (LF) 2297**] Chief Complaint: Hypotension requiring pressor & elevated BG Major Surgical or Invasive Procedure: Central venous line placement (femoral) History of Present Illness: 44 y/o male, with type I DM, resident of [**State 3914**], transferred from JP VA for hypotension, on peripheral dopamine. Per patient, he was in his USOH until this AM, when he noticed that his insulin pump was not working. He reported emesis x 5 minutes and a BG of 570. He changed his infusion set and gave himself an injection of 35 units of regular insulin. He subsequently travelled to his JP VA optho appointment. His BG was 350 at the eye clinic, for which he took 25 units of regular insulin. He then set his basal insulin pump rate at 1.4 units/hour. At 1 pm, he reported stomach cramps, nausea, diaphoresis. His muscle cramps were epigastric, non-radiating, and were intermittent. He did not take any medications for his pain. He drank some ginger-ale and ate a donut which alleviated his abdominal cramps. No modifying factors for his cramps. He was sent from [**Hospital 2081**] clinic to the JP VA ED for dizziness and diaphoresis. He recalls his BG being 170-180 there (not-treated). He was reportedly hypotensive to SBP 60/45, HR of 70, O2 sats 92%. He was given 0.5 liters of IVF, given a 0.5 mg atropine x 1, and transferred to [**Hospital1 18**] on peripheral dopamine. In the ED, initial vs were: T 97.6, P 100, BP 104/66, R 20, O2 sat 92% RA. He remained afebrile. His insulin pump was turned off and removed. ROS only notable for nausea, malaise, and suprapubic discomfort. He reports that he has been eating and drinking well, except for today. He denied CP, SOB, urinary symptoms. Exam was non-focal with exception of distended abdomen. He was guaiac negative. His testicular exam and prostate exam were felt to be normal. He was felt to be under-resuscitated. A femoral CVL was placed as his right and left IJ were felt to be "completely flat" with ultrasound, in addition to the fact that his carotid was felt to be directly posterior to his IJ. Subclavian CVL was not attempted given altered anatomy with his sternotomy and prior surgery. Patient was given 1 gram vancomycin, zosyn, zofran, and 4L IVF in the ED. He was continued on dopamine, as they were unable to wean despite IVF (SBP in the 80s with weaning attempt, baseline BP unknown). Labs notable for lactate of 1.5, Cr of 1.7 (unknown baseline), bicarb of 18, negative CE's. EKG reported as NSR at 62, nl axis, nl intervals, nl voltage, isolated Q wave in III, no ischemic changes. CT torso performed, which was largely unremarkable. Bedside US of pericardium without large effusion. U/A with few bacteria, 0-2 WBC, neg nitrites, neg leuk esterase. Blood and urine cultures pending. On transfer, BP 110/80 and HR 60. Access - femoral CVL and 22G PIV. On the floor, patient denies recent fevers, cough, diarrhea, dysuria, or flu-like illness. Past Medical History: - type 1 DM (followed by [**First Name8 (NamePattern2) 2048**] [**Last Name (NamePattern1) 57712**] at VA White River Junction in VT) - MI with CABG x 3v in [**2137-5-31**] - infected sternotomy (MRSA), s/p sternum removal (chest wall without cartilage with muscle flap) - "word finding difficulty" (previously on aricept, now off) - appendectomy - arthroscopy - HTN - HLD - macular edema - non-proliferative retinopathy Social History: - lives in [**State 3914**] - prior veteran - prior 1 ppd x 20 years, quit smoking in [**2136**] - rare EtOH - denies illicits Family History: HTN in mother, otherwise negative for early CAD or cancer. Physical Exam: Physical Exam on [**Hospital Unit Name 153**] Admission: Vitals: T: 98.1, HR 85, BP 105-132/64-69, RR 15, 96% on 2L NC General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MM dry, oropharynx clear Neck: supple, JVP difficult to assess, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate and rhythm, prominent S1 + S2, no murmurs, rubs, gallops, sternotomy with muscle flap c/d/i Abdomen: obese, soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Rectal: old, healed pressure ulcer, at coccyx Pertinent Results: Labs: [**2138-11-25**] 07:00PM BLOOD WBC-10.8 RBC-4.64 Hgb-14.2 Hct-40.4 MCV-87 MCH-30.7 MCHC-35.2* RDW-13.4 Plt Ct-376 Neuts-78.4* Lymphs-16.4* Monos-3.5 Eos-0.7 Baso-0.9 [**2138-11-26**] 03:44AM BLOOD WBC-10.9 RBC-3.71* Hgb-11.2* Hct-32.8* MCV-88 MCH-30.1 MCHC-34.0 RDW-13.1 Plt Ct-327 Neuts-69.8 Lymphs-23.5 Monos-5.2 Eos-1.1 Baso-0.4 [**2138-11-25**] 07:00PM BLOOD Glucose-181* UreaN-36* Creat-1.7* Na-135 K-4.8 Cl-101 HCO3-18* [**2138-11-26**] 03:44AM BLOOD Glucose-195* UreaN-26* Creat-1.2 Na-140 K-4.0 Cl-107 HCO3-23 [**2138-11-25**] 07:00PM BLOOD ALT-31 AST-32 LD(LDH)-383* AlkPhos-182* Amylase-40 TotBili-0.2 [**2138-11-26**] 03:44AM BLOOD ALT-20 AST-18 LD(LDH)-175 CK(CPK)-75 AlkPhos-140* TotBili-0.2 [**2138-11-25**] 07:00PM BLOOD Lipase-16 GGT-20 [**2138-11-25**] 07:00PM BLOOD cTropnT-<0.01 [**2138-11-26**] 03:44AM BLOOD CK-MB-3 cTropnT-<0.01 [**2138-11-25**] 07:00PM BLOOD TotProt-8.5* Albumin-5.0 Globuln-3.5 Calcium-10.1 Phos-4.0 Mg-2.3 [**2138-11-25**] 07:00PM BLOOD %HbA1c-12.4* eAG-309* [**2138-11-25**] 07:00PM BLOOD TSH-2.6 . Labs upon discharge: [**2138-11-27**] 06:13AM BLOOD WBC-7.3 RBC-3.70* Hgb-11.0* Hct-33.0* MCV-89 MCH-29.8 MCHC-33.4 RDW-12.7 Plt Ct-266 [**2138-11-27**] 06:13AM BLOOD PT-10.9 PTT-21.9* INR(PT)-0.9 [**2138-11-27**] 06:13AM BLOOD Glucose-297* UreaN-14 Creat-0.8 Na-134 K-4.5 Cl-103 HCO3-20* AnGap-16 [**2138-11-27**] 06:13AM BLOOD ALT-17 AST-19 LD(LDH)-201 AlkPhos-141* Amylase-28 TotBili-0.2 [**2138-11-27**] 06:13AM BLOOD Lipase-11 [**2138-11-26**] 03:44AM BLOOD CK-MB-3 cTropnT-<0.01 [**2138-11-27**] 06:13AM BLOOD Albumin-3.9 Calcium-8.8 Phos-3.2 Mg-1.9 [**2138-11-25**] 07:00PM BLOOD Cortsol-44.0* [**2138-11-26**] 04:10AM BLOOD Lactate-1.2 . Imaging: - CT chest/abdomen/pelvis [**2138-11-25**]: bibasilar atelectasis, no nodules, consolidations, or effusions in the lungs. s/p CABG to the left-sided vessels and large sternal defect 35 mm in the transverse dimension which is post-operative. No abdominal free fluid or free air. There is a repaired abdominal wall hernia on the right a minimal fat and bowel containing hernia. Small and large bowels are unremarkable. The rectum, sigmoid colon bladder, prostate, ureters, and seminal vesicles are normal. There is a left sided femoral venous catheter. No pelvic free fluid or free air. No acute pathology was seen to account for hypotension. . - CXR [**2138-11-26**]: AP chest compared to [**11-25**]: Interval widening of the upper mediastinum and left hilus suggests interval volume administration. Moderate-to-severe cardiomegaly is larger, but there is no pulmonary edema and, as yet, no pleural effusion. . ECHO [**2138-11-26**]: The left atrium is normal in size. Left ventricular wall thicknesses and cavity size are normal. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Overall left ventricular systolic function is normal (LVEF>55%). The aortic valve leaflets (?#) appear structurally normal with good leaflet excursion. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. The pulmonary artery systolic pressure could not be determined. The main pulmonary artery is dilated. There is no pericardial effusion. IMPRESSION: Suboptimal image quality. Preserved left ventricular function. Cannot accurately assess right ventricular size or function. Brief Hospital Course: Mr. [**Known lastname 88113**] is a 44 y/o male transferred from JP VA for hypotension with evidence of AGMA, [**Last Name (un) **], and elevated BG suggestive of DKA. # Hypotension: Believed to be most likely secondary to hypovolemia due to volume loss secondary to diabetic ketoacidosis. He had an ECHO completed which did not reveal RV dilitation concerning for a PE and there was no evidence of endocarditis. In the ED he had an extensive workup to rule out infection that might have been predisposing him to hypotension (although WBC was normal and he was afebrile), including a CT chest/abd/pelvis which did not reveal any nidus of infection. Antibiotics were stopped the morning after admission given the low suspicion for infection. He was managed with treatment for DKA using insulin drip. He was given several liters of NS IVF, his BP improved and he was able to be weaned off of dopamine. Blood cultures & urine cultures have been no growth to date. His home metoprolol and lisinopril were held during admission and upon discharge and can be started if needed as as outpatient. # DKA: Had elevated BG, AG metabolic acidosis and ketonuria on admission. Treated with insulin drip with successful closure of the anion gap. Tox screen was negative. He received IVF and insulin gtt, restarted a PO diet, and was transitioned to sliding scale insulin followed by restarting insulin drip. He was seen by [**Last Name (un) **] who made recommendations for his insulin pump. He will follow up with his outpt endocrinologist in VT and was educated on warning signs of rising glucose and DKA and instructed to seek emergency care if he was unable to manage his glucose goal <200 at home. # [**Last Name (un) **]: Likely pre-renal azotemia secondary to hypovolemia. Creatinine normalized with IV hydration. # Type 1 DM: followed by [**First Name8 (NamePattern2) 2048**] [**Last Name (NamePattern1) 57712**] at VA White River Junction in VT. He has associated non-proliferative retinopathy. His HgbA1C is 12.4 showing poorly controlled T1DM. He likely needs further education regarding adequeate insulin dosing through his pump and frequent follow up appointments with his physicians in order to maintain better glucose control. # CAD. Non-active. He continued with home aspirin and statin. BB and ACE inhibitors were held given initial hypotension on pressor. His home metoprolol and lisinopril were held secondary to hypotension during admission and upon discharge and can be started if needed as as outpatient. # HLD. His was continued on simvastatin during his admission. He was restarted on gemfibrozil upon discharge. We recommend a trial of lowering his simvastatin dose to 40mg due to risk of rhabdomyolysis on 80mg daily, if unsuccessful, atorvastatin should be considered. # Elevated alkaline phosphatase: Unclear etiology. GGT was normal indicating the source of alkaline phosphatase is likely not the biliary tree, instead may be coming from the bone or other sources. Recommend rechecking in 2 weeks at outpatient and continue work up if clinically indicated. The patient was full code for this admission. Medications on Admission: - insulin pump with ~ 29.9 units of basal insulin/day - lisinopril 5 mg qday - metoprolol 50 mg [**Hospital1 **] - simvastatin 80 mg daily - aspirin 81 mg daily - mirtazapine 30 mg qhs - gemfibrozil 300mgBID - omeprazole 20 mg [**Hospital1 **] Discharge Medications: 1. simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 2. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 3. mirtazapine 15 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 4. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO BID (2 times a day). 5. gemfibrozil 600 mg Tablet Sig: 0.5 Tablet PO twice a day. 6. insulin pump please continue your insulin pump per your usual home settings Discharge Disposition: Home Discharge Diagnosis: Primary Diagnoses: Diabetic ketoacidosis Hypotension Acute kidney injury Secondary Diagnoses: Type 1 diabetes mellitus Coronary artery disease Hyperlipidemia Hypertension Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to the hospital for diabetic ketoacidosis, a condition with high blood sugars, dehydration, and low blood pressures. You were given insulin and fluids and medication to keep your blood pressure sufficiently high through an IV and eventually all of your labs normalized and these medications were stopped. You were transitioned to subcutaneous insulin and then to your insulin pump. You were seen by one of the diabetes doctors from the [**Name5 (PTitle) **] Clinic to help us with these transitions. The following changes were made to your medications: Please stop taking lisinopril and metoprolol until your follow-up with your primary care physician Please talk with your physician about taking simvastatin and gemfibrozil together. Followup Instructions: Please follow-up with your primary care physician within the next 1-2 weeks. Completed by:[**2138-11-27**]

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icd9cm

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Discharge summary

report

Admission Date: [**2133-9-30**] Discharge Date: [**2133-10-2**] Date of Birth: [**2083-11-5**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2534**] Chief Complaint: s/p Motorcycle crash Major Surgical or Invasive Procedure: None History of Present Illness: 49 yo Left handed man with a PMH significant for A-fib (on warfarin), embolic stroke (seemingly R ant div MCA), CAD s/p stents and HTN. He was reportedly riding his motorcycle today (after having 2-3 beers) and states that a car swerved into his [**Male First Name (un) **] causing him to swerve and "lay his bike down." He is not sure how he hit his head. He states having a memory for the entire event and denies any loss of consciousness or anything resembling ictal activity. He was taken to [**Hospital **] hospital where he was noted to have a Right frontal and Right anterior temporal pole SDH. He was also noted to have a Left C5 facet fracture; he received 5mg of Vitamin K and 2 units of FFP and was then transferred to [**Hospital1 18**] for further management. Past Medical History: Afib, CAD s/p 5 stents PSH: 5 stents Family History: Noncontributory Physical Exam: Upon presentation: 97 BP 157/94 HR 83 R 23 General: In hard collar. Mental Status Examination: Oriented to [**Hospital3 **] hospital, [**Location (un) 86**]. Oriented to [**2133-9-30**]. Fluent and prosodic speech. Repetition intact. Follows three step commands briskly. MOYB done briskly and correctly. Registers 4 objects immediately and recalls all 4 at 5 min. Cranial nerves: PEERL 4->2mm, VFF. EOM full. V1-V3 intact to PP, LT and temp. Face symmetric. Tongue and palate midline. No dysarthria or dysphonia. Motor examination: No cogwheeling or tremor. No drift. Finger and toe tapping symmetric. No pronator drift. [**5-20**] in all extremities with exception of some pain limitation at left shoulder. Coordination: FNF without dysmetria. Reflexes: 2+ and symmetric with downgoing toes. Pertinent Results: [**2133-9-30**]: CXR: No acute traumatic process. CT C-spine: Anterior posteriorly oriented lucencies through the C4 left lateral facet that is suspicious for possible fracture. The thyroid gland demonstrates small punctate calcifications on the right, correlation with thyroid ultrasound is advised if clinically warranted in a non emergent basis. CT head: 4 mm in transverse dimension acute subdural hemorrhage layering along the right frontal lobe, with subjacent mass effect of the right frontal sulci. In addition, a 6-mm focus of extra-axial hemorrhage seen adjacent to the right temporal lobe. Continued followup is recommended. CT torso: 1. No evidence of traumatic injury to abdomen or pelvis. 2. Bilateral inferior renal scarring from prior infection or infarction. Repeat head CT: 1. Extra-axial hemorrhage layering along the right frontotemporal convexity, with appearance most compatible with acute subdural hemorrhage. 2. Interval increase in thickness with greatest transverse dimension now 7 mm, increased from 4 mm, without significant change in overall extent. 3. No new hemorrhage. Repeat head CT #2: Slight interval decrease in the size of the right subdural hemorrhage without evidence of new bleeding. MRI C-spine: possible fracture seen on CT not present. No malalignment. No fracture on MRI C-spine. Brief Hospital Course: He was admitted to the hospital to the Trauma Surgical ICU for close hemodynamic and neurological monitoring.His hospital course is summarized below by system: Neuro: Serial head CTs showed, at first, growth of his SDH from 4 to 7 mm, however this began to decrease in size as noted on a third head CT. His neurologic exam remained non-focal. He was loaded with dilantin for seizure prophylaxis, Dilaudid for pain. Because he had stabilized he was then transferred to the floor with q4h neuro checks. He will continue on the Dilantin for 7 days and will follow up as an outpatient in [**Hospital 4695**] clinic for repeat head imaging. Cardiovascular: in afib. Coumadin held secondary to his subdural hemorrhage. His blood pressure was intermittently high; his home medications were restarted and he has been instructed to follow up with his cardiologist after discharge. Pulmonary: No active issues. Gastrointestinal/Abdomen: was initially NPO, diet was advanced for which he was able to tolerate. Renal: Foley, urine output remained sufficient. His Foley was removed and he is voiding without difficulty. Hematology: Hct trended daily. Neurosurgery recommendation to decrease INR to 1.4, but given placement of cardiac stents no vitamin K given. His cardiologist, Dr. [**Last Name (STitle) 87368**] was contact[**Name (NI) **] re: his Coumadin being recommended to remain on hold for at least 1 month. Per his cardiologist he does not require Plavix as his stents were placed in [**2129**]; he would prefer that he be started on a Baby aspirin. Neurosurgery was contact[**Name (NI) **] and it was recommended to begin the baby ASA 7 days from the injury date. This information was provided on his discharge instructions. Medications on Admission: Lisinopril/Metoprolol/Colchicine/Simvastatin/Coumadin 10mg daily Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain. 2. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. Metoprolol Tartrate 50 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). 4. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 5. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. Dilantin Extended 100 mg Capsule Sig: Three (3) Capsule PO once a day for 4 days. Disp:*12 Capsule(s)* Refills:*0* 7. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for pain. Disp:*40 Tablet(s)* Refills:*0* 8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. 9. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day) as needed for constipation. 10. Milk of Magnesia 400 mg/5 mL Suspension Sig: Thirty (30) ML's PO twice a day as needed for constipation. 11. Baby Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO once a day: *DO NOT START UNTIL [**2133-10-7**]. Discharge Disposition: Home Discharge Diagnosis: s/p Motorcycle crash Subdural hematoma C5 facet fracture (subacute) 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 following a motorcycle crash where you sustained a bleeding injury to your brain. Your injury did not require any operations; your neurolgic status was followed closely and you were given Dilantin which is an anti-seizure medications to prevent convulsions or seizures; this medication will continue for a total of 7 days. Your Coumadin, which is a blood thinner is being recommended to be held for at least 1 month, this has been discussed with your cardiologist. He is recommending a Baby Aspirin until your Coumadin can be restarted. If at anytime in th next month you develop palpitations of feel as if your heart rate is irregular please contact your cardiologist to be seen immediatley. Followup Instructions: Follow up in 4 weeks with Dr. [**Last Name (STitle) 739**], Neurosurgery, call [**Telephone/Fax (1) 1669**] for an appointment. You will need a non-contrast head CT for this appointment. Follow up with your cardiologist, Dr. [**Last Name (STitle) 87368**] @ [**Hospital2 **] [**Hospital3 6783**] Hospital [**Telephone/Fax (1) 87369**] in the next 1-2 weeks re: monitoring while off of your usual blood thinner regimen. Completed by:[**2133-10-2**]

[ "V58.61", "414.01", "852.21", "V45.82", "305.00", "E818.2", "427.31", "805.05", "V12.54", "401.9" ]

icd9cm

[ [ [] ] ]

[ "99.07" ]

icd9pcs

[ [ [] ] ]

6347, 6353

3430, 5155

335, 341

6464, 6466

2076, 2427

7368, 7819

1224, 1241

5271, 6324

6374, 6443

5181, 5248

6616, 7345

1256, 1623

275, 297

369, 1147

1639, 2057

2436, 2863

2872, 3407

6481, 6592

1169, 1208

28,200

186,216

48038

Discharge summary

report

Admission Date: [**2105-4-25**] Discharge Date: [**2105-5-1**] Date of Birth: [**2047-1-29**] Sex: M Service: MEDICINE Allergies: Clonidine / Methyldopa, Methyldopate Attending:[**First Name3 (LF) 613**] Chief Complaint: Hematemesis, melena Major Surgical or Invasive Procedure: EGD History of Present Illness: 58M PMH ESRD on HD, HTN, CAD p/w two day history of melena and coffee ground emesis. These symptoms started the morning prior to admission, resolved during the day, and then restarted at 0200, one hour prior to presentation to the ED. He denies associated abdominal pain. Complains of SOB, LH. Denies chest pain. Chronic ASA use; no NSAIDs. Rare EtOH use; last one beer the night prior to symptoms. Never had these symptoms prior; no prior EGD. . In the ED, VS T: 97.5 BP: 191/95 HR: 87 RR: 16 SaO2: 100%RA. - Given 1L NS - NG lavage - coffee grounds, no bright red blood - Guaiac positive - Hematocrit 16 - sent type and screen (last hematocrit in system 38.9 [**8-/2104**]) - GI consulted Past Medical History: 1. CAD: Cardiac catheterization in [**2101**] showed 90% mid-RCA, 100% LCx, 60% OM1 s/p stent to RCA. 2. CHF: TTE [**2-19**] showed EF of 65-70% and severe diastolic dysfunction. 3. ESRD on HD: Presumably due to HTN. Initiated dialysis in [**2-18**]. on transplant list. 4. HTN: Long-standing HTN followed at [**Hospital1 112**], where secondary causes were ruled out per report. End-organ damage includes CRI, LVH and retinopathy. 5. S/p CVA [**2095**]: Current symptoms include occasional problems with fine motor use of the right hand and occasional drooling from the right side of his mouth. 6. OSA: Has used CPAP in the past but not currently. 7. Obesity: Currently improved. Social History: Lives in [**Location 669**]; sister lives in same house. Currently disabled. ~10 year smoking history, quit in [**2096**]. Social EtOH use. No other drug use. Family History: DM2, HTN. Sister with ESRD on HD. No h/o GIB. Physical Exam: VS: T: 97.3 BP: 150/98 HR: 81 RR: 14 Sa)2: 100% 2L GEN: NAD HEENT: AT, NC, PERRLA, EOMI, no conjuctival injection, anicteric, OP with coffee grounds, MM dry NECK: Supple, no LAD CV: RRR, nl s1, s2, systolic murmur PULM: CTAB, no w/r/r with good air movement throughout ABD: Soft, NT, ND, + BS, no HSM RECTAL: In ED, melena EXT: Warm, dry, palpable distal pulses BL NEURO: Alert & oriented, CN II-XII grossly intact, 5/5 strength throughout Brief Hospital Course: Assessment: 58M PMH ESRD on HD, HTN, CAD p/w UGIB, hematocrit 16 on admission. Admitted to the MICU, where EGD on [**4-25**] showed PUD with actively bleeding vessel (clipped). . # UGIB: Initial MICU admission where EGD [**4-25**] showed PUD with actively bleeding vessel - clipped. Likely due to chronic ASA use. Patient was transfused total of 10 units PRBC during this admission and one unit FFP for INR 1.4. Hematocrit remained stable ~30 since intervention during EGD. He was called out to floor where hct remained stable. ASA was held. He was initially treated with [**Hospital1 **] IV PPI, transitioned to PO on discharge. Serum H. pylori Ab: negative. Pt will need repeat EGD in [**5-24**] weeks as an outpatient (scheduled). . # HTN: Patient hypertensive when off anti-hypertensives (held in setting of GIB); per patient baseline systolic blood pressure 190. Home regimen was restarted and BP stabilized. . # Thrombocytopenia: Stable, trneding up at time of D/C. In setting of ten units PRBC, likely dilutional. No heparin sc, but did received heparin flushes so considered HIT (hep dep Ab negative). . # ESRD on HD: MWF schedule. Did have one extra session of dialysis Sunday for SOB after multiple transfusions. Restarted Cinacalcet, Renagel, Nephrocaps once taking POs. . # Chronic diastolic CHF: Euvolemic after additional session of HD on Sunday. Continued BBlocker and ACE-I once GIB stabilized. . # CAD: No active issues; last intervention RCA stent in [**2101**]. EKG unchanged. Troponin elevated from baseline in the setting of CKD, CK WNL. Helding ASA on discharge. [**Month (only) 116**] need dose reduction to 81 mg daily when restarted. Restarted B Blocker, stain, and ACE-I. . Medications on Admission: Lipitor 80 mg DAILY Renagel 2400 mg TID with meals Aspirin 325 mg DAILY Lisinopril 40 mg DAILY Nifedipine SR 90 mg DAILY Toprol XL 200 mg DAILY Cinacalcet 60 mg DAILY Renagel 1 capsule DAILY Discharge Medications: 1. Acetaminophen 160 mg/5 mL Solution Sig: Six [**Age over 90 1230**]y (650) mg PO Q6H (every 6 hours) as needed. 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 4. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr Sig: Four (4) Tablet Sustained Release 24 hr PO DAILY (Daily). 5. Nifedipine 30 mg Tablet Sustained Release Sig: Three (3) Tablet Sustained Release PO DAILY (Daily). 6. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 7. Atorvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 8. Sevelamer HCl 800 mg Tablet Sig: Three (3) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 9. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 10. Cinacalcet 30 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 11. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO twice a day. Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Bleeding Duodenal Ulcer Discharge Condition: Vital signs stable, ambulating, hematocrit stable. Discharge Instructions: You were admitted to the hospital with a bleed from your gastrointestinal tract. You were given blood transfusions, and the gastroenterologists looked at your stomach and found and ulcer that was bleeding. The bleeding was stopped and you were monitored to ensure that you blood level remained stable. It remained stable, and you were discharged. You are to folow up in the [**Hospital **] clinic. They will want to repeat the scope in [**5-24**] weeks to make sure the ulcer is healing. . Please take all medications as prescribed below. You are to stop taking aspirin until you are told to restart by your doctor. . Please keep all of your appointments as written below. An appointment with a new PCP was made with Dr. [**Last Name (STitle) **], as well as an appointment with gastroenterology. . If you have any symptoms of dizziness, chest pain, shortness of breath, dark stools, blood in stools, vomitting of dark material, or any other concerning symptoms you should go to the ER immediately. Followup Instructions: Provider [**First Name8 (NamePattern2) 2878**] [**First Name8 (NamePattern2) 26**] [**Last Name (NamePattern1) 2879**], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2105-5-15**] 11:00 Provider GI [**Apartment Address(1) 3921**] (ST-3) GI ROOMS Date/Time:[**2105-6-12**] 12:30 Provider [**First Name8 (NamePattern2) **] [**Name9 (PRE) **], MD Phone:[**Telephone/Fax (1) 463**] Date/Time:[**2105-6-12**] 12:30 [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]

[ "786.06", "285.1", "285.21", "V12.54", "585.6", "532.40", "403.91", "287.5", "428.32", "414.00", "428.0" ]

icd9cm

[ [ [] ] ]

[ "99.04", "38.95", "45.13", "39.95" ]

icd9pcs

[ [ [] ] ]

5496, 5502

2465, 4187

315, 320

5570, 5623

6677, 7216

1938, 1985

4429, 5473

5523, 5549

4213, 4406

5647, 6654

2000, 2442

256, 277

348, 1041

1063, 1746

1762, 1922

60,020

191,081

20467

Discharge summary

report

Admission Date: [**2165-12-29**] Discharge Date: [**2166-1-4**] Date of Birth: [**2114-7-6**] Sex: M Service: SURGERY Allergies: Sulfa (Sulfonamides) Attending:[**First Name3 (LF) 695**] Chief Complaint: confusion Major Surgical or Invasive Procedure: Lumbar puncture [**2166-1-2**] History of Present Illness: Mr. [**Known lastname **] is a 51 year old male s/p orthotopic liver transplant for HCV/HCC on [**2165-12-18**] was discharged home [**2165-12-24**]. He was seen in the clinic by Dr. [**Last Name (STitle) **] on [**2165-12-27**] and reportedly was doing well. Later that evening, he developed confusion. This escalated over the next two days to the point the patient was defacating throughout the house, claiming to be God, he also wrote odd emails, made bazaar phone calls to friends, and took naked pictures of himself. He was brought in by his family for further evaluation. He has not had any fever, chills, shortness of breath, urinary symptoms, rash, chest pain, or abdominal pain. The patient was admitted to [**Hospital Ward Name 121**] 10 and underwent a CT head scan. Following his CT scan, the patient was noticed to experience a seizure. A code blue was called. The patient never lost an airway, he was given a total of 5 mg IV ativan and he settled down. He maintained his airway throughout and he was transferred to the TSICU for further monitoring. Past Medical History: HCV, HCC with portal hypertension s/p liver transplant [**2165-12-18**], Osteomyelitis s/p leg fracture [**2137**], s/p multiple lithotripsies for kidney stones Social History: Past ETOH use, now quit, no tobacco or IVDU. Lives with wife and has two grown sons. Family History: Mother with [**Name (NI) 2320**], no family history of liver disease. Physical Exam: VS: Tmax 99.1 Tcurr 99.0 HR74 BP 132/94 RR 20 O2Sat 96 GA: alert and oriented x 3, no acute distress HEENT: normal EOM, PERL, no lymphadenopathy CVS: normal S1, S2, no murmurs Resp: clear to auscultation bilaterally [**Last Name (un) **]: +BS, soft, non-tender, non-distended, staples removed from incision prior to discharge, steri-strips placed, incision clean, dry and intact. Ext: no peripheral edema, normal sensation, normal motor strength 5/5 Pertinent Results: [**2165-12-29**] 07:00PM GLUCOSE-154* UREA N-10 CREAT-0.7 SODIUM-139 POTASSIUM-4.6 CHLORIDE-103 TOTAL CO2-24 ANION GAP-17 [**2165-12-29**] 07:00PM ALT(SGPT)-113* AST(SGOT)-35 ALK PHOS-111 TOT BILI-0.8 [**2165-12-29**] 07:00PM ALBUMIN-3.3* CALCIUM-8.4 PHOSPHATE-4.1 MAGNESIUM-1.4* [**2165-12-29**] 07:00PM WBC-13.0*# RBC-3.33* HGB-11.0* HCT-32.4* MCV-97 MCH-33.1* MCHC-34.1 RDW-19.5* [**2165-12-29**] 07:00PM PLT COUNT-228# [**2165-12-29**] 07:00PM tacroFK-21.9* [**2165-12-29**] 09:13PM CK(CPK)-152 [**2165-12-29**] 10:53PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-15 BILIRUBIN-NEG UROBILNGN-0.2 PH-7.0 LEUK-NEG Brief Hospital Course: Mr. [**Known lastname **] was admitted to hospital for evaluation of mental status changes. He underwent a CT head that was negative for a stroke and hemorrhage. Shortly after his CT scan Mr. [**Known lastname **] had a witnessed seizure which stopped with ativan administration on the floor. He was transferred to T/SICU for further monitoring and work-up [**2165-12-29**]. Neurology and Psychiatry were consulted. During his stay in the ICU patient had episodes of tachycardia and aggitation which were managed with lopressor and haldol. Psychiatry recommended the use of haldol rather than ativan as benzodiazepines had a paradoxical effect on his aggitation. No further seizures were witnessed or recorded. Neurology recommeded MRI, 24-hr EEG and lumbar puncture to determine the etiology of the seizures. MRI was negative. Patient was transferred to the floor on [**2165-12-31**] and he underwent 24 hour EEG following transfer. The differential diagnosis of Mr. [**Known lastname **] seizures was steroid psychosis versus tacrolimus toxicity. 24-EEG revealed some bicentral seizure activity. A sitter was arranged to monitor patient during the 24-hr EEG to determine if he became more confused or aggitated with his seizure activity. Mr. [**Known lastname **] was started on Levetiracetam for seizure prophylaxis. No clinical correlate was found with the seizure activity using video recordings. Lumbar puncture was performed to rule out a infectious source of the seizure activity and was found to be negative. On [**2166-1-1**], blood cultures taken [**2165-12-29**] returned positive for methicillin sensitive staphylococcus aureus and patient's antibiotic coverage was changed from vancomycin to dicloxacillin for 10 days. Mr. [**Known lastname **] had no further seizure events and was discharged home [**2166-1-4**] in good condition on levetriacetam for continued seizure prophylaxis and dicloxacillin to finish antibiotic treatment of the positive blood cultures. He was given instructions for outpatient labs and follow-up in transplant clinic and with neurology. Medications on Admission: Famotidine 20mg po BID, Fluconazole 400mg PO qday, Metoprolol 25mg PO TID, MMF 1000mg PO BID, Prednisone 20 mg PO qday, Tacrolimus 6mg po BID, Valcyte 900 mg PO qd, Colace 100 mg PO BID Discharge Medications: 1. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Disp:*120 Tablet(s)* Refills:*2* 2. Dicloxacillin 250 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours) for 10 days. Disp:*40 Capsule(s)* Refills:*0* 3. Fluconazole 200 mg Tablet Sig: Two (2) Tablet PO Q24H (every 24 hours). 4. Prednisone 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). 6. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). 7. Mycophenolate Mofetil 500 mg Tablet Sig: One (1) Tablet PO four times a day. 8. Valganciclovir 450 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 9. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 10. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. 11. Tacrolimus 1 mg Capsule Sig: Five (5) Capsule PO Q12H (every 12 hours). 12. Outpatient Lab Work Please have CBC, Liver function tests, Coagulation tests, tacrolimus level drawn. Discharge Disposition: Home Discharge Diagnosis: mental status changes seizures Discharge Condition: alert/oriented tolerating a regular diet ambulating independently Discharge Instructions: Please continue Keppra as ordered You will need to make a neurology follow up appointment with Dr. [**First Name (STitle) **] [**Name (STitle) 557**]. Call for appointment [**Telephone/Fax (1) 558**]. Follow prednisone taper. Labs every Monday and Thursday at [**Last Name (NamePattern1) 439**] Lab Continue to check blood sugar prior to breakfast and supper. Keep a record of blood sugars. Followup Instructions: Provider: [**First Name11 (Name Pattern1) 819**] [**Last Name (NamePattern4) 820**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2166-1-9**] 10:00 Provider: [**First Name11 (Name Pattern1) 674**] [**Last Name (NamePattern4) 675**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2166-1-15**] 10:40 Provider: [**First Name11 (Name Pattern1) 674**] [**Last Name (NamePattern4) 675**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2166-1-23**] 1:00 You will need to make a neurology follow up appointment with Dr. [**First Name (STitle) **] [**Name (STitle) 557**]. Call for appointment [**Telephone/Fax (1) 558**]. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**] MD, [**MD Number(3) 709**]

[ "285.9", "041.12", "V10.07", "V12.09", "780.39", "780.09", "V42.7" ]

icd9cm

[ [ [] ] ]

[ "89.19", "03.31" ]

icd9pcs

[ [ [] ] ]

6352, 6358

2951, 5048

288, 321

6433, 6501

2283, 2928

6941, 7699

1726, 1798

5285, 6329

6379, 6412

5074, 5262

6525, 6918

1813, 2264

239, 250

349, 1423

1445, 1608

1624, 1710

54,203

184,900

36380

Discharge summary

report

Admission Date: [**2153-4-16**] Discharge Date: [**2153-4-19**] Date of Birth: [**2124-12-16**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2641**] Chief Complaint: Found Down Major Surgical or Invasive Procedure: Extubation Lumbar puncture History of Present Illness: The patient is a 28 year old female with a history of untreated [**Doctor Last Name **] diesease who was found down the afternoon of presentation with the question of seizure like activity. The patient was originally diganosed in [**2148**] with Grave's disease, and had been managed in the past on antithyroid medication. She had never been compliant with the medication, feeling uncomfortable when her hormone levels were reduced. She recently carried a child to term without complication. Six months prior, the patient has a marked difficulty swallowing, and went to the ED of a local hospital. This was attributed to an enlarging goiter, and she was prescribed medication (unclear what) which she did not take. She is not followed by an endocrinologist. Over the last 6 months the family reports noticing a worsening of her baseline tremor, increased heat intolerance, and a marked increased in her "shakiness" the last couple of days prior to presentation. The night prior to presentation, the patinent worked as a bartended. The afternoon of presentation the patient was at [**Company 25282**] picking up some tampons for her period. She was reportedly found in the aisle of the store, unresponsive, with a question of upper extremity shaking. No reports of [**First Name9 (NamePattern2) 27386**] [**Last Name (un) 20694**] or micturition. EMS was activated at 1643, and on arrial, she had a HR of 145, BP 156/94, and BG of 112. She was combative, and non-sensical, saying "I want my mommy." She was given haldol and valium en route with good effect. She was taken to an OSH in NH, wwhere admission EKG showed ST at 153. TSH was <0.01, T4 14.6, T3 275, and a NCHCT was reportatdly unremarkable. She was intubated for airway protection, started on an esmolol gtt for control of her HR, wand was given 10mg of methimazole, 10mg of decadron, ativan, lopressor, and was transfered to [**Hospital1 18**] via medivac. On arrival to [**Hospital1 18**], the patient spiked a temp of 102.4, HR 112/ BP 113/79, and 100% on the vent. A chest XR now showed a right middle and possible lower lobe infiltrate, and the patient was given 2gm of CTX and 1g of vanc to empirically treat meningitis and cover for PNA. Esmolol gtt was continuned and up titrated, methimazole was redosed at 20mg, and propfol was continued for sedation. A diagnositc LP, with results given below. The patient was admitted to the MICU for further management. Per the patients family, the patient has not had any recent fevers/chills or diaphoresis. She had not noted any worsening shortness of breath or productive cough. No complaints of abdominal pain, n/v/d, and no signifificant weight loss. No recent change in her skin color. She has a history of cociane use in her childhood, but know known active drug use. She has had worsening lower back pain that has developed over the last couple of weeks and was recently prescribed pain medications/muscle relaxants. She has no history of seizures. . Past Medical History: [**Doctor Last Name 933**] disease, untreated Pre-eclampsia Social History: The patient is from [**Location (un) 8641**], NH. She lives with her mother and sister, and mother of an 11 [**Last Name (un) **] hold child. She works as a bartender at night. Smokes 1 ppd, history of cociane use, social drinker Family History: No family history of thyroid disorders or autoimmune disease. No history of seizure disorders or neuroglogic disease. Physical Exam: Vitals: T: 102.4 BP: 106/74 P: 106 O2: 100% on AC 400/14/5 General: Intubated and sedated HEENT: Sclera anicteric, PERRL, dry with excoriation on tongue, ET tube in place, thyroid enlarged w/o palpable nodules. No bruit. No LAD. Lungs: Mechanical breath sounds, no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis. Trace edema in UE. Has sparse pettechial rash on UE. Tattooos on fingers and toes. . Pertinent Results: [**2153-4-15**] 10:25PM URINE URIC ACID-RARE RBC-[**2-1**]* WBC-0-2 BACTERIA-RARE YEAST-NONE EPI-0-2 BLOOD-LG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.014 bnzodzpn-POS barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG [**2153-4-15**] 10:25PM PLT COUNT-309 NEUTS-94.9* LYMPHS-3.8* MONOS-0.7* EOS-0.4 BASOS-0.1 WBC-16.1* RBC-4.37 HGB-12.6 HCT-35.7* MCV-82 MCH-29.0 MCHC-35.5* RDW-13.5 [**2153-4-15**] 10:25PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG ANTI-TG-92* THYROGLB-UNABLE TO ANTITPO-989* T4-14.7* T3-242* calcTBG-0.66* TUptake-1.52* T4Index-22.3* TSH-LESS THAN CALCIUM-9.0 PHOSPHATE-3.1 MAGNESIUM-1.8 LIPASE-14 ALT(SGPT)-15 AST(SGOT)-28 ALK PHOS-112 TOT BILI-1.0 GLUCOSE-106* UREA N-11 CREAT-0.6 SODIUM-140 POTASSIUM-4.3 CHLORIDE-109* TOTAL CO2-21* ANION GAP-14 [**2153-4-15**] 11:20PM CEREBROSPINAL FLUID (CSF) WBC-1 RBC-98* POLYS-9 LYMPHS-59 MONOS-32 PROTEIN-46* GLUCOSE-66 [**2153-4-15**] 11:57PM TYPE-ART PO2-201* PCO2-40 PH-7.29* TOTAL CO2-20* BASE XS--6 [**2153-4-16**] 12:56AM LACTATE-1.1 [**2153-4-16**] 04:33AM PT-13.9* PTT-27.0 INR(PT)-1.2* PLT COUNT-329 WBC-9.5 RBC-4.24 HGB-12.1 HCT-34.2* MCV-81* MCH-28.7 MCHC-35.5* RDW-13.6 ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG CALCIUM-8.6 PHOSPHATE-3.7 MAGNESIUM-1.7 GLUCOSE-141* UREA N-13 CREAT-0.5 SODIUM-138 POTASSIUM-4.8 CHLORIDE-110* TOTAL CO2-17* ANION GAP-16 [**2153-4-16**] 04:48AM T3-113 FREE T4-3.0* TSH-<0.02* ECG Study Date of [**2153-4-15**] 10:18:08 PM Sinus tachycardia Nonspecific T wave changes in leads l, and aVL No previous tracing available for comparison Rate PR QRS QT/QTc P QRS T 110 152 84 316/403 52 48 73 CHEST (PORTABLE AP) Study Date of [**2153-4-15**] 10:25 PM IMPRESSION: Endotracheal tube in satisfactory position as above. There is a focal infiltrate in the lateral segment of the right middle lobe which may be indicative of aspiration or other underlying pneumonia. MRV HEAD W/O CONTRAST Study Date of [**2153-4-16**] 8:56 AM IMPRESSION: 1. High FLAIR signal in the sulci is likely related to recent lumbar pucture. 2. Normal appearance of the brain. If clinically indicated, high resolution imaging of the temporal lobes, per seizure protocol, could be performed at no additional charge. 3. Normal head MRI and MRV MRV HEAD W/O CONTRAST Study Date of [**2153-4-16**] 8:56 AM In comparison with the study of [**4-17**], the nasogastric tube has been removed. Low lung volumes, but no evidence of acute focal pneumonia. CHEST (PA & LAT) Study Date of [**2153-4-18**] 2:49 PM FINDINGS: In comparison with the study of [**4-17**], the nasogastric tube has been removed. Low lung volumes, but no evidence of acute focal pneumonia. Brief Hospital Course: The patient is a 28 year old female with a history of untreated [**Doctor Last Name **] disease who was found down the afternoon of presentation with the question of seizure like activity. She was transferred to [**Hospital1 18**] via medivac. . # Altered Mental Status: On arrival to [**Hospital1 18**], the patient was intubated and sedated. Vitals were notable for a temp of 102.4, HR 112/ BP 113/79, and 100% on the vent. A chest XR now showed a right middle and possible lower lobe infiltrate, and the patient was given 2gm of CTX and 1g of vancomycin to empirically treat meningitis and cover for PNA. Esmolol gtt was continued and up titrated, methimazole was redosed at 20mg, and propofol was continued for sedation. The patient was admitted to the MICU for further management. In the ICU, Pt remained febrile and was felt to have a right lower lobe process consistent with an aspiration pneumonia/pneumonitis. The patient was seen by neurology who felt that her story was possibly seizure related, however An EEG was performed that showed global slowing without evidence of focal seizure activity. MRI/MRV/MRA and LP were normal. The endocrine service was contact[**Name (NI) **] and felt that although the patient was clearly extremely hyperthyroid, her free thyroid hormone levels were not consistent with thyroid storm induced seizures. While her mentation remained slow, the patient was stable and transferred to the medicine service. While on the medicine service, the patient continued to improve and by the day of discharge was fully alert and oriented. There were no active signs of infection and it was felt that her initial presentation may have been a possible seizure or vasovagal episode. No anti-epileptics were recommended. The patient was instructed to follow-up with her primary care clinic to discuss further work-up. It was recommended that the patient not drive for 6 months to ensure no further syncopal episodes/seizures occur. # Hyperthyroidism: It was felt that the patient's level of thyroid hormone at OSH were not felt to be consistent with severe thyrotoxicosis. The patient was initially treated with PTU 200mg q8h, however the patient expressed her dissatisfaction on this medication at which point she was transitioned to Methimazole. She was treated with propanolol for tremor and tachycardia with good results. The importance of medication compliance was stressed and the patient was discharged with plans for follow-up in the endocrine clinic. # Pneumonia: While there was initial concern for pneumonia on transfer, the patient had no infectious symptoms leading up to her presentation event except complaints of malaise. She was treated with 3 days of antibiotics and fevers resolved. Sputum cultures were unremarkable. Repeat chest x-ray was also clear suggesting the original findings were more likely to represent aspiration pneumonia from LOC /intubation. Antibiotics were discontinued prior to discharge and the patient was sating well on room. # Tobacco Abuse: The patient was treated with a nicotine patch and educated on the importance of smoking cessation. Medications on Admission: Phenergan 25mg q6h PRN Vicodin 1 tab q6 PRN Carisoporodol 350mg q6PRN Labetolol 200mg [**Hospital1 **] Discharge Medications: 1. Methimazole 20 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 2. Propranolol 10 mg Tablet Sig: Two (2) Tablet PO once a day. Disp:*60 Tablet(s)* Refills:*2* 3. Outpatient Lab Work Please draw CBC, liver function tests (AST/ALT/Alk phos/LDH/Total Bili), TSH, total T3, total T4, T3 resin uptake. Please fax results to Dr. [**Last Name (STitle) **] ([**Telephone/Fax (1) 3541**] Discharge Disposition: Home Discharge Diagnosis: Grave's Disease/Hyperthyroidism Syncope Pneumonia Discharge Condition: The patient was hemodynamically stable, afebrile and without pain at the time of discharge. Discharge Instructions: You were admitted after an episode of unexplained unconciousness. It is not clear what caused your initial symptoms. Regardless of the cause, it we are required by law to recommend that you not drive for the next 6 months. If you do not have any additional events after that time, you may resume driving. We have started you on new treatment for your thyroid. It is stongly recommended that you continue these treatments as an outpatient. Untreated thyroid disease can have many long-term complications. We have arranged for you to follow-up with an endocrinologist here as an outpatient. You are being discharged on the following medications: Methimazole (Thyroid medication) Propranolol (To treat thyroid related tremor/fast heart rate/blood pressure) You should establish care with a primary care physician in your area. Please seek medical attention if you have any further episodes of loss of consciousness or fainting, chest pain, shortness of breath, changes in vision/headache or any other symptom of concern. Followup Instructions: Please follow up with: Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] Wednesday [**5-9**] at 2:30pm [**Hospital Ward Name 23**] Building [**Hospital1 **] [**Last Name (Titles) 516**] [**Location (un) **] You will need to have blood tests drawn 1 week prior to that visit Completed by:[**2153-5-2**]

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icd9cm

[ [ [] ] ]

[ "96.71", "03.31" ]

icd9pcs

[ [ [] ] ]

11048, 11054

7332, 7589

327, 356

11147, 11240

4472, 7309

12310, 12624

3699, 3818

10613, 11025

11075, 11126

10486, 10590

11264, 12287

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277, 289

384, 3353

7604, 10460

3375, 3436

3452, 3683

10,692

130,008

30822

Discharge summary

report

Admission Date: [**2111-5-26**] Discharge Date: [**2111-6-4**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 9240**] Chief Complaint: Stroke Major Surgical or Invasive Procedure: intubation [**2111-5-31**] History of Present Illness: 89 yo man with afib (not on coumadin), HTN, high chol, CAD, and worsening renal function in past few months who is recently s/p ureteral stent [**2111-5-18**], who presents as "CODE STROKE" at noon after last known well time of 3AM, with severe dysarthria and L arm>face>leg severe weakness after being found by his wife on the floor (presumably fell out of bed). Pt returned from driving trip to [**State 108**] 1 wk ago - had been hospitalized in [**State 108**] for renal failure; en route to [**Location (un) **], pt fell in a hotel room. Upon arrival, wife took him to [**Hospital3 **] where he had renal w/u, ureteral stent [**5-18**], and cardiac w/u for ? of ekg changes. Pt returned home and had been doing well in general with no f/c/card sx/resp/gi/gu/neuro sx until last night when he was "acting strangely" per wife - was very disappointed that TV was broken and pt could not watch [**First Name4 (NamePattern1) 892**] [**Last Name (NamePattern1) 41519**]. Went to bed at 10PM; pt recalls waking up feeling "normal" around 3AM (checked watch), and used urinal at side of bed, which has been instituted since return from [**State **] for urinary sx and to prevent falling oob. Wife thinks this "normal" period may have occurred later than 3AM but she did not check her watch. At 7AM wife woke up and pt continued to sleep. At 7:45 she called to him from next room. She thinks she heard a "thump" - when she walked to the room, she found her husband on the floor, pressed up against the cabinet on L side, and when he tried to speak he was slurring his speech. She called EMS and he was brought to [**Hospital3 **] Hosp, whereupon [**Hospital1 18**] stroke fellow contact[**Name (NI) **] for further w/u and consideration of intervention, and transfer arranged. Pt arrived at [**Hospital1 18**] ER at 12:00 and CODE STROKE called; stroke fellow and R3 present at bedside within 4 minutes, and initial NIHSS score was 17, for: level of consciousness (keeps eyes closed), partial gaze palsy (cannot bury sclera on L), visual field cut and neglect on L, L facial palsy, L arm with extension to nox stim only, and L leg with triple-flexion to stimulation, L body sensory loss, severe dysarthria, and extinction on the left to double simultaneous stimulation (though significant sensory loss as well). Pt could tell some details of story above, but is markedly dysarthric and slightly inattentive. IV TPA, IA TPA, and MERCI retrieval system not indicated for pt presenting out of time window for each. Past Medical History: Worsening CRI - creat 8.2 in [**5-4**], s/p emergency cystoscopy and ureteral stent in [**2111-5-18**] for R hydronephrosis; wife tells me that after discussion with renal, family has opted not to pursue dialysis Afib s/p PPM/AICD HTN High chol GI bleed [**Date Range 1686**] ago "peripheral neuropathy" since lumbar back surgery [**15**]-15yrs ago CAD, with "EKG changes in [**5-4**]" - per cards note, not acutally a change from prior ([**5-15**]: afib, v-pacing, rbbb pattern with L ant hemiblock, some nonspecific ST changes) - had cardiology w/u at [**Hospital3 **] [**5-18**] and echo [**5-19**] showed EF of 60% with no wall motion abnl (no clot), mod MR [**First Name (Titles) **] [**Last Name (Titles) **] Social History: Lives with wife; smoked from age 18-59 "never a lot" per wife, quit 30 [**Name2 (NI) 1686**] ago; drinks [**12-30**] glasses of scotch/night; formerly worked in sales, now retired Family History: mother had stroke at older age Physical Exam: T pending; HR 70 BP 156/90 RR 20 sats pending General appearance: L face abrasions, bruises and abrasions over L body; white male HEENT: moist mucus membranes, clear oropharynx Neck: in hard collar Heart: irreg irreg Lungs: clear to auscultation anteriorly Abdomen: soft, nontender +bs Extremities: warm, well-perfused Mental Status: The patient is alert and awake but keeps eyes closed and appears fatigued - DOW backwards is slightly slow; did not read sentences, but could repeat well; language is fluent and comprehension intact. No obvious hand agnosia. Could name objects; field cut impaired interpretation of cookie picture. Cranial Nerves: L field cut appears dense (vs severe neglect) - no blink to threat on L. The optic discs could not be visualized. Eye movements sig. for inability voluntarily to move both eyes much past midline to L (cannot bury sclera); could not perform OCR due to hard collar. Pupils react equally to light, both directly and consensually. Sensation on the face is decreased to LT over LUE>face>LLE. Facial movements are notable for L facial droop. Hearing is intact to voice. The palate appears to elevate in the midline, though very difficult to visualize. The tongue protrudes in the midline and is of normal appearance; speech markedly dysarthric. Motor System: Elev tone bilat LE; low tone in LUE RUE with poor effort on strength exam, shows mild weakness of triceps ([**4-2**]) and deltoid, though ?limited by pain, full at biceps and finger/wrist flex and finger ext RLE with full strength at IP, ham, quad, foot dorsi/plantarflex LUE with extension posturing to nox stim only, o/w no spont mvmt LLE with triple-flexion to gentle nox stim, vs purposeful w/d R arm/hand is tremulous with mvmt, no drift on R. Reflexes: The tendon reflexes are diminished on LUE, trace at knees, absent at ankles, 2+ at RUE. L toe is up, R down. Sensory: Sensation is nl to LT, pp on L, cannot feel LT on L arm, leg, slt on face. +EXT to dss over entire L side but sensory loss. Coordination: There is no ataxia of R hand, cannot move L hand voluntarily. Gait: cannot be performed Pertinent Results: [**2111-5-26**] 12:14PM PT-13.4* PTT-29.1 INR(PT)-1.2* [**2111-5-26**] 12:14PM WBC-10.1 RBC-3.59* HGB-10.8* HCT-32.5* MCV-91 MCH-30.2 MCHC-33.4 RDW-15.6* [**2111-5-26**] 12:14PM PLT COUNT-299 [**2111-5-26**] 12:14PM CK-MB-20* MB INDX-6.3* [**2111-5-26**] 12:14PM cTropnT-0.09* [**2111-5-26**] 08:25PM CK-MB-24* MB INDX-5.6 cTropnT-0.09* proBNP-[**Numeric Identifier 72957**]* [**2111-5-26**] 08:25PM CK(CPK)-425* [**2111-5-26**] 12:14PM ALT(SGPT)-32 AST(SGOT)-34 LD(LDH)-303* CK(CPK)-315* TOT BILI-0.3 CT head [**2111-5-26**]: IMPRESSION: 1. Study is limited due to motion artifacts. 2. No acute intracranial abnormality noted on the CT head. 3. Multilevel degenerative changes in the cervical spine, most prominent at C5-6 with moderate-to-severe spinal canal narrowing at that level. 4. 1-cm hypodense lesion in the right lobe of the thyroid, which could represent a complex cyst or a mass. This can be better evaluated with ultrasound of the thyroid. 5. Moderate left maxillary sinusitis with air-fluid level. CT head [**2111-5-27**]: FINDINGS: There has been interval development of a large region of hypodensity involving the right middle cerebral artery territory. There is no significant shift of normally midline structures. There is no hydrocephalus. No intra- or extra-axial hemorrhage is identified. None of the visualized vessels appear hyperdense on the current study. There is opacification of the left maxillary sinus, and partial opacification of the left mastoid air cells. Intracavernous internal carotid artery calcifications are noted. IMPRESSION: Evolving acute right middle cerebral artery infarct. No evidence of herniation. No evidence of hemorrhagic transformation. Carotid u/s [**2111-5-26**]: There is a less than 40% right ICA stenosis and a 60-69% left ICA stenosis. There is antegrade flow in the right vertebral artery and the left vertebral artery is unable to be visualized. . [**2111-6-3**] 06:55AM BLOOD WBC-7.3 RBC-3.32* Hgb-10.2* Hct-31.0* MCV-93 MCH-30.7 MCHC-32.9 RDW-15.9* Plt Ct-251 [**2111-6-2**] 03:07AM BLOOD PT-14.6* PTT-30.4 INR(PT)-1.3* [**2111-6-3**] 06:55AM BLOOD ALT-29 AST-40 LD(LDH)-342* AlkPhos-83 Amylase-98 TotBili-0.4 [**2111-6-3**] 06:55AM BLOOD Glucose-88 UreaN-77* Creat-5.1* Na-146* K-4.5 Cl-115* HCO3-19* AnGap-17 [**2111-5-31**] 06:23PM BLOOD CK-MB-7 cTropnT-0.08* Brief Hospital Course: 89 yo m w/ h/o CAD, afib (not on coumadin), s/p pacer/ICD, HTN, elev chol, and CRF who presented to [**Hospital1 18**] on [**5-26**] with L sided weakness after being found down by his wife. A R MCA stroke was confirmed by CT and the patient has perpetual left sided weakness. His initial presentation was outside of the recommended window and did not undergo thrombolysis. After hospitalization, he was found to be aspirating and developed an aspiration pneumonia and was started on levo/flagyl. However, he was then found to be in respiratory distress and a code blue was called on [**5-31**]. He was intubated and taken to the MICU. There he was started on Vancomycin and Pip/tazo. His respiratory status improved and he was extubated after 24 h. He required aggressive suctioning overnight during day 2 in the ICU, with improvment the next day. On transfer, orotracheal suctioning had only been performed on two occasions during the day. On presentation the patient was noted to have elevated Tns with negative CKi. Cardiology was consulted and felt [**1-30**] combination of large stroke and new ARF. Recommended ongoing B-blockade. Nephrology was also consulted to comment on the patient's renal deterioration and volume status (cxr c/w pulmonary edema and elev BNP on presentation). Impression in initial assessment was that etiology was post-renal obstruction (nephrolithiasis) following R uretral stenting in [**5-4**]. Patient was then transferred out of the MICU after extubation. His overall status did not significantly improve despite antibiotic and fluid support. Therefore, after an extensive discussion with the family, the decision was made to make the patient CMO. The patient was kept comfortable by removing NG tube and give prn morphine, scopolamine. The patient expired the following day. Communication was primarily with his wife:[**Telephone/Fax (1) 72958**] Medications on Admission: Meds obtained from last note/[**Hospital3 **], wife does not remember where she left med list: Clonidine 0.2mg tid Digoxin 0.12mg qod Micardis unknown dose Lopressor 15 mg qd Silos cavil (??) Zocor Vit C ASA 81 mg Discharge Medications: expired Discharge Disposition: Expired Discharge Diagnosis: Cerebral vascular accident Renal failure aspiration pneumonia Discharge Condition: expired

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icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

10558, 10567

8367, 10261

268, 296

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10287, 10503

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222, 230

324, 2842

4498, 5970

4181, 4482

2864, 3581

3597, 3779

26,291

105,585

17200

Discharge summary

report

Admission Date: [**2183-1-7**] Discharge Date: [**2183-1-10**] Date of Birth: [**2105-3-17**] Sex: M Service: MEDICINE Allergies: Ace Inhibitors Attending:[**First Name3 (LF) 633**] Chief Complaint: lightheadiness Major Surgical or Invasive Procedure: none History of Present Illness: 77 yo M with CHF, afib and HTN presented to the ED from [**Hospital **] clinic for hypotension. He was found on INR check today to have a blood pressure about 40s on palp. In the ED, found to have a blood pressure in the 80s. Inital vitals were 97.2 56 86/63 16 100% 4L. Received 250cc of fluid with increase to 110s. Hypotensive again to the 80s, received 500cc with return to 110s. He reports feeling fatigued and lightheaded over the last couple days. He reports drinking a glass or two of wine daily over the weekend. His son reports that he sounded drunk on Sunday. He denies any sick symptoms or contacts. On arrival to the ICU, patient feels well and has no complaints. 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: congestive heart failure CAD atrial fibrillation stroke in [**2162**] hypertension hyperlipidemia dysphagia Social History: He was born in [**Country 3587**] and then lived in [**Country 48229**]. Living in [**Hospital3 400**] in [**Location (un) 686**]. - Tobacco: None - Alcohol: [**11-18**] glass wine/day - Illicits: None Family History: Non contributory. Physical Exam: Admission Physical Exam: VS: 97.3 83 90/70 97% 16 General: Alert, oriented, no acute distress HEENT: MMM Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: Irreg irreg, 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: Admission Labs: [**2183-1-7**] 11:50AM BLOOD WBC-7.7 RBC-4.83 Hgb-14.8 Hct-43.5 MCV-90# MCH-30.6 MCHC-33.9 RDW-12.9 Plt Ct-302 [**2183-1-7**] 11:50AM BLOOD Neuts-71.2* Lymphs-18.9 Monos-8.5 Eos-0.9 Baso-0.5 [**2183-1-7**] 11:50AM BLOOD PT-31.9* PTT-36.8* INR(PT)-3.1* [**2183-1-7**] 11:50AM BLOOD Glucose-77 UreaN-59* Creat-2.6* Na-130* K-4.0 Cl-88* HCO3-31 AnGap-15 [**2183-1-7**] 11:50AM BLOOD cTropnT-< 0.01 [**2183-1-7**] 11:50AM BLOOD proBNP-949* [**2183-1-7**] 11:50AM BLOOD Calcium-8.9 Phos-3.8 Mg-2.3 [**2183-1-7**] 11:57AM BLOOD Lactate-1.4 [**2183-1-7**] 01:30PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.010 [**2183-1-7**] 01:30PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-0.2 pH-6.0 Leuks-NEG [**2183-1-7**] 01:30PM URINE Hours-RANDOM Creat-52 Na-40 K-17 Cl-32 [**2183-1-7**] 01:30PM URINE Osmolal-248 Micro: Blood cultures pending x2 CHEST (PORTABLE AP): IMPRESSION: No acute cardiopulmonary process. Stable cardiomegaly. . [**1-7**] EKG: Atrial fibrillation with controlled ventricular response rate. Intraventricular conduction delay of left bundle-branch block morphology. Probable prior inferior myocardial infarction. T wave inversions in the lateral and high lateral leads consistent with possible ischemia. Clinical correlation is suggested. Compared to the previous tracing of [**2183-1-7**] the findings are similar. . EKG [**1-7**]: Atrial fibrillation with slow ventricular response. Left axis deviation. Intraventricular conduction delay of left bundle-branch block type. Since the previous tracing of [**2176-6-6**] the rate is slower. QRS voltage is more prominent in the limb leads. ST-T wave abnormalities may be more prominent. Clinical correlation is suggested. . CT HEAD W/O CONTRAST Study Date of [**2183-1-7**] 1:41 PM There is no evidence of acute hemorrhage, edema, mass, mass effect, or new infarction. There is slit-like encephalomalacia in the region of the right basal ganglia suggesting prior hemorrhage with ex vacuo dilitation of the rigth lateral ventricle. Prominent periventricular white matter hypodensities are seen, most commonly due to chronic small vessel ischemic disease. The basal cisterns appear patent and there is preservation of [**Doctor Last Name 352**]-white differentiation elsewhere. No fracture is identified. The paranasal sinuses, mastoid air cells and middle ear cavities are clear. No facial or cranial soft tissue abnormalities are present. IMPRESSION: 1. No evidence of acute intracranial process. 2. Slit-like encephalomalacia in the area of the right basal ganglia is suggestive of prior hemorrhage. 3. White matter hypodensities most commonly due to chronic small vessel ischemic disease. . ECHO [**1-8**]: The left atrium is mildly dilated. Left ventricular wall thicknesses are normal. The left ventricular cavity is mildly dilated. There is severe global left ventricular hypokinesis (LVEF = 20-25%). Overall left ventricular systolic function is severely depressed (LVEF= 20-25%). No masses or thrombi are seen in the left ventricle. Right ventricular chamber size is normal with mild global free wall hypokinesis. The ascending aorta is mildly dilated. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. IMPRESSION: Suboptimal image quality. Severe global left ventricular hypokinesis with severely depressed systolic function (EF 20-25%). Normal right ventricular size with mild right ventricular hypokinesis. Mildly dilated ascending aorta. Mild mitral regurgitation . [**2183-1-10**] 06:30AM BLOOD WBC-6.8 RBC-4.71 Hgb-14.7 Hct-42.5 MCV-90 MCH-31.2 MCHC-34.5 RDW-12.7 Plt Ct-304 [**2183-1-9**] 05:45AM BLOOD WBC-7.2 RBC-4.54* Hgb-14.3 Hct-41.1 MCV-91 MCH-31.5 MCHC-34.8 RDW-12.8 Plt Ct-318 [**2183-1-7**] 11:50AM BLOOD WBC-7.7 RBC-4.83 Hgb-14.8 Hct-43.5 MCV-90# MCH-30.6 MCHC-33.9 RDW-12.9 Plt Ct-302 [**2183-1-7**] 11:50AM BLOOD Neuts-71.2* Lymphs-18.9 Monos-8.5 Eos-0.9 Baso-0.5 [**2183-1-10**] 06:30AM BLOOD Plt Ct-304 [**2183-1-10**] 06:30AM BLOOD PT-23.1* PTT-31.8 INR(PT)-2.2* [**2183-1-9**] 05:45AM BLOOD Plt Ct-318 [**2183-1-9**] 05:45AM BLOOD PT-26.6* PTT-35.6 INR(PT)-2.6* [**2183-1-8**] 09:05AM BLOOD PT-30.5* INR(PT)-3.0* [**2183-1-7**] 11:50AM BLOOD Plt Ct-302 [**2183-1-7**] 11:50AM BLOOD PT-31.9* PTT-36.8* INR(PT)-3.1* [**2183-1-10**] 06:30AM BLOOD Glucose-82 UreaN-28* Creat-1.3* Na-134 K-4.3 Cl-98 HCO3-29 AnGap-11 [**2183-1-9**] 05:45AM BLOOD Glucose-90 UreaN-34* Creat-1.4* Na-136 K-4.6 Cl-99 HCO3-31 AnGap-11 [**2183-1-8**] 05:38AM BLOOD Glucose-90 UreaN-42* Creat-1.6* Na-134 K-4.1 Cl-99 HCO3-27 AnGap-12 [**2183-1-9**] 05:45AM BLOOD CK(CPK)-190 [**2183-1-9**] 05:45AM BLOOD CK-MB-3 cTropnT-<0.01 [**2183-1-7**] 11:50AM BLOOD cTropnT-< 0.01 [**2183-1-7**] 11:50AM BLOOD proBNP-949* [**2183-1-7**] 11:57AM BLOOD Lactate-1.4 [**2183-1-10**] 06:30AM BLOOD Calcium-8.9 Phos-2.8 Mg-1.8 Brief Hospital Course: A/P: 77-year-old male with a history of systolic CHF with EF of 20%, atrial fibrillation on Coumadin, COPD, CAD who was admitted to the MICU [**1-7**] with hypotension thought to be due to hypovolemia now resolved after iv hydration. . #Hypotension: likely hypovolemia due to dehydration from diuretic use and drinking of ETOH at home. Pt did not have any infectious symptoms such as fever, leukocytosis or other localizing symptoms. Hypotension resolved with 2L IVF. EKG not suggestive of ischemia and cardiac enzymes were negative. TSH and cortisol not pursued as pt's symptoms resolved after IV fluids. However, BP still ranged at times from high 90's-110's and pt was asymptomatic and ambulating without dizziness or difficulty. Orthostatics were negative after IV hydration. Pt's lasix, spironolactone, HCTZ, and [**Last Name (un) **] were held during admission as well as tamsulosin. He was advised to continue to hold these medications upon discharge. Carvedilol was restarted. ECHO was repeated to ensure that cardiac function had not worsened and was found to be similiar to prior with EF 20-25%. Pt will be discharged on half dose of his valsartan 80mg daily. ++could have been due to increased ETOH prior to admit. Pt did not have any suggestion of ETOH withdrawal during admission and it did not appear that drinking ETOH is the norm for the patient, but that he had more drinks than normal weekend prior to admission. However, he should be continually advised to refrain from excess ETOH given his CHF. Pt did not display signs of clinical CHF during admission. . #acute on chronic renal failure-Presented with Cr 2.6. Baseline 1.2-1.5. Thought to be due to hypovolemia in the setting of diuretic use. Improved during admission to baseline of 1.3 with IVF and holding diuretics. Will continue to hold lasix, HCTZ, spironolactone upon DC. Resumed valsartan at 80mg (1/2home dose) upon DC. Pt should have repeat labs at his PCP appointment on [**2183-1-16**] to ensure stability of renal function. . #Systolic heart failure: EF 20%. Pt did not appear to have acute heart failure during admission. Repeat ECHO was unchanged from prior. Carvedilol was restarted. Pt was given an rx for valsartan 80mg daily ([**11-18**] home dose) upon discharge. His lasix, spironolactone, and HCTZ were not restarted during admission. He was set up with VNA services upon discharge to help monitor for signs of clinical heart failure in this setting of medication adjustment. BP range high 90's-110s during admission off these agents. Pt should follow up with PCP and cardiology (appointments listed below) in order to continue further titration of these medications prn. Pt should have repeat chemistry panel at upcoming PCP [**Name Initial (PRE) 648**]. Daily weights. . #Afib: rate controlled. Continued Carvedilol. INR initially slightly supratherapeutic, but then starting [**1-8**] his home regimen of 4mg alternating with 2mg daily was started. Started with 4mg daily on [**1-8**]. INR can be rechecked at PCP's appointment on [**2183-1-16**]. INR 3.1, 2, 2.6, 2.2 on day of DC. . #HLD: continued pravastatin . #BPH: held tamsulosin for now. Continued finasteride . #Reactive airways, ?COPD- continued inhalers, no sign of acute exacerbation. . #FEN: cardiac diet . #PPX: --therapeutic INR . FULL CODE Emergency contact: [**Name (NI) **] (son) [**Telephone/Fax (1) 48232**] . Transitional issues -close monitoring of volume status with lasix, HCTZ, and spironolactone being held. Restart prn -monitoring of chemistries, INR on [**2183-1-16**] PCP appointment [**Name9 (PRE) 48233**] further discussion about ETOH intake -consider TSH, cortisol should low grade hypotension continue to be an issue Medications on Admission: Albuterol 2 puffs q4 hours SOB Carvedilol 3.125mg [**Hospital1 **] Finasteride 5mg daily Fluticasone 50mcg per nostril [**Hospital1 **] runny nose Fluticaseone 110mcg 2 puffs [**Hospital1 **] Furosemide 20mg daily Combivent 2 puffs PRB dyspnea Pravastatin 40mg daily Sildenafil 25mg 1/2-1 tab PRN Spironolactone-HCTZ 25-25mg daily Tamsulosin 0.4mg qHS Valsartan 320mg tab, [**11-18**] tab daily Warfarin 4mg QOD, 2mg QOD Acetaminophen 650mg TID Discharge Medications: 1. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler Sig: 1-2 Puffs Inhalation Q4H (every 4 hours) as needed for dyspnea. 2. carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. fluticasone 110 mcg/actuation Aerosol Sig: One (1) Puff Inhalation [**Hospital1 **] (2 times a day). 5. fluticasone 110 mcg/actuation Aerosol Sig: One (1) Inhalation twice a day. 6. Combivent 18-103 mcg/actuation Aerosol Sig: [**11-18**] Inhalation every 4-6 hours as needed for shortness of breath or wheezing. 7. pravastatin 40 mg Tablet Sig: One (1) Tablet PO once a day. 8. valsartan 80 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*0* 9. warfarin 2 mg Tablet Sig: One (1) Tablet PO QOD (). 10. warfarin 4 mg Tablet Sig: One (1) Tablet PO every other day. 11. acetaminophen 650 mg Tablet Sig: One (1) Tablet PO every eight (8) hours as needed for pain. Discharge Disposition: Home With Service Facility: Laboure Center VNS Discharge Diagnosis: hypotension acute renal failure chronic systolic heart failure atrial fibrillation Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted with low blood pressure, fatigue, and kidney injury. Your symptoms were thought to be due to dehydration along with taking your medications for your heart. Your symptoms improved with IV fluids and stopping some of your heart medications. You did not have any signs of infection. Some of your heart medications will continue to be held upon discharge. However, it will be very important that you follow up with your PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 8499**] and your cardiologist to determine when you may resume these medications. . Medication changes: 1.stop lasix for now 2.stop HCTZ for now 3.stop spironolactone for now 4.DECREASE VALSARTAN TO 80MG DAILY, stop your 160mg dose 5.stop tamsulosin for now -please be sure to keep your PCP appointment below. You may need to restart some of these medications. . Please take all of your medications as prescribed and follow up with the appointments below. Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more than 3 lbs. Followup Instructions: Department: [**Hospital1 7975**] ST HLTH CTR-KCSS When: THURSDAY [**2183-1-16**] at 11:00 AM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 10134**], MD [**Telephone/Fax (1) 7980**] Building: [**Hospital1 7977**] ([**Location (un) 686**], MA) [**Location (un) **] Campus: OFF CAMPUS Best Parking: Free Parking on Site Department: CARDIAC SERVICES When: THURSDAY [**2183-1-23**] at 3:20 PM With: [**Doctor First Name 900**] [**Name8 (MD) 901**], M.D. [**Telephone/Fax (1) 62**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: [**Hospital1 7975**] ST HLTH CTR-KCSS When: FRIDAY [**2183-2-28**] at 9:00 AM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 10134**], MD [**Telephone/Fax (1) 7980**] Building: [**Hospital1 7977**] ([**Location (un) 686**], MA) [**Location (un) **] Campus: OFF CAMPUS Best Parking: Free Parking on Site

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icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

12690, 12739

7510, 11212

288, 295

12866, 12866

2364, 2364

14080, 15072

1841, 1860

11707, 12667

12760, 12845

11238, 11684

13017, 13594

1900, 2345

1022, 1469

13614, 14057

234, 250

323, 1003

2380, 7487

12881, 12993

1491, 1601

1617, 1825

11,517

119,266

20149

Discharge summary

report

Admission Date: [**2194-10-24**] Discharge Date: [**2194-10-29**] Service: Trauma HISTORY OF PRESENT ILLNESS: The patient is an 83-year-old pedestrian female struck by a car. The patient fell to the street. She had no loss of consciousness. The patient has a visible deformity in the left lower extremity and a laceration to the back of the head. Her vital signs were stable throughout. PAST MEDICAL HISTORY: (Past medical history is significant for) 1. Transient ischemic attack and cerebrovascular accident times two in [**2189**]. 2. Glutin intolerance. ALLERGIES: No known drug allergies. MEDICATIONS ON ADMISSION: 1. Fosamax. 2. Coumadin. 3. Calcitrate. SOCIAL HISTORY: No tobacco, alcohol, smoking, or drugs. PHYSICAL EXAMINATION ON PRESENTATION: On physical examination, the patient's temperature was 99.1 degrees Fahrenheit, her blood pressure was 150/95, her heart rate was 80, her respiratory rate was 18, and her oxygen saturation was 100% on 2 liters via nasal cannula. In general, the patient was alert and oriented. In no acute distress. The patient had a 2-cm laceration on the back of the scalp. Otherwise, the head examination was atraumatic. Pupils were equal, round, and reactive to light bilaterally. The trachea was midline. Cardiovascular examination revealed a regular rate and rhythm. The lungs were clear to auscultation bilaterally. The abdomen was soft, nontender, and nondistended. Extremity examination revealed a deformity on the left lower extremity. The pelvis was stable. Ecchymosis noted on the right knee. There was a hematoma on the left leg. The patient was moving all extremities well. The patient was following commands. Strength was [**4-7**] throughout. PERTINENT LABORATORY VALUES ON PRESENTATION: Laboratories on admission revealed the patient's white blood cell count was 7.2 and her hematocrit was 37. Her prothrombin time was 25.9, her partial thromboplastin time was 42.5, and her INR was 4.4. Her fibrinogen was 188. Urinalysis showed large blood; otherwise was negative. Serum toxicology screen and urine toxicology screen were negative. PERTINENT RADIOLOGY/IMAGING: A chest x-ray showed no pneumothorax. The pelvis showed a left superoinferior pubic rami fracture. A head computed tomography showed no intracranial bleed. A computed tomography of her cervical spine showed chronic osteoporotic changes. A computed tomography of the abdomen and pelvis showed a left six rib fracture. An x-ray of the left hip showed a proximal tibia/fibula fracture. A thoracolumbosacral x-ray showed anterolisthesis of L5-S1 and T10-T11 with unknown chronicity. CONCISE SUMMARY OF HOSPITAL COURSE: The patient was seen by the Orthopaedic Service. They reduced and splinted the left tibia/fibula in the Trauma Bay on conscious sedation using propofol. The patient was to be sent to the floor upstairs when she became transiently hypotensive with a systolic blood pressure to the 70s and with a heart rate in the 70s. The patient was alert and oriented. The patient's hematocrit level was repeated at that time and was stable. The patient's hypotension responded to fluids. Her blood pressure returned to a systolic blood pressure in the 120s. Several minutes later, the patient became hypotensive once again with a systolic blood pressure in the 60s and with bradycardia into the 40s. At this time, the patient had a chest x-ray done which was negative. An electrocardiogram was also done which was also negative. The patient was then admitted to the Trauma Surgical Intensive Care Unit for close blood pressure monitoring. The patient received 2 units of fresh frozen plasma, 1 mg of intravenous vitamin K, and her hematocrit and coagulations were followed. Staples were placed into the patient's scalp wound as well. The patient's hematocrit remained stable, and her INR had decreased to 1.9 and then subsequently to 1.1. The patient was to the operating room on post trauma day one for an open reduction/internal fixation of the left tibia/fibula. The patient was also seen by Neurosurgery. A computed tomography of the lumbosacral spine with thin cuts through L5 and S1 was done which showed no acute fracture. The patient had flexion and extension views with a computed tomography of the cervical spine as well which showed no acute fracture but did show some possible anterolisthesis of C3-C4 and C4-C5. Neurosurgery recommended that the patient remain in the hard collar for two weeks and follow up with them in two weeks for repeat evaluation. After the operation, the patient's Coumadin was restarted. Her INR at the time of discharge was 1.3. The patient was to continue Coumadin and heparin for six weeks. After six weeks, the heparin can be discontinued for deep venous thrombosis prophylaxis. The patient was to be nonweightbearing on the left lower extremity and ambulate with crutches and a walker. The patient's goal INR is 1.5 to 2. The patient was seen by the Physical Therapy Service and Occupational Therapy Service here and determined to be in need of rehabilitation after this acute hospitalization. CONDITION AT DISCHARGE: The patient's condition on discharge was good. DISCHARGE DISPOSITION: The patient was to be discharged to a rehabilitation facility. DISCHARGE DIAGNOSES: 1. Pedestrian struck by car. 2. Left rib fracture. 3. Proximal left tibia/fibula fracture. 4. Left superoinferior pubic rami fractures. 5. Stop wound. MEDICATIONS ON DISCHARGE: (Discharge medications included) 1. Coumadin 2.5 mg by mouth once per day. 2. Heparin 5000 units subcutaneously q.12h. (for six weeks). 3. Percocet one to two tablets by mouth q.4-6h. as needed (for pain). 4. Acetaminophen one tablet by mouth q.4-6h. as needed (for pain). 5. Fosamax. 6. Coumadin. 7. Calcitrate. DISCHARGE INSTRUCTIONS/FOLLOWUP: 1. The patient was instructed to follow up with Dr. [**First Name (STitle) **] (of Orthopaedic Service) in two weeks; (telephone number [**Telephone/Fax (1) 1113**]). 2. The patient was instructed to follow up with Dr. [**Last Name (STitle) 1327**] (of Neurosurgery Service) in two weeks; (telephone number [**Telephone/Fax (1) 1669**]). 3. The patient was instructed to follow up in the Trauma Clinic next week for staple removal (telephone number [**Telephone/Fax (1) 2359**]). 4. The patient was also instructed to follow up with her primary care physician. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 11889**] Dictated By:[**MD Number(1) 54165**] MEDQUIST36 D: [**2194-10-28**] 14:15 T: [**2194-10-28**] 14:17 JOB#: [**Job Number 54166**]

[ "579.0", "E818.7", "807.02", "796.3", "823.02", "715.98", "873.0", "733.00", "808.2" ]

icd9cm

[ [ [] ] ]

[ "99.04", "86.59", "79.56", "99.07" ]

icd9pcs

[ [ [] ] ]

5240, 5304

5325, 5482

5509, 5830

643, 687

5863, 6697

2696, 5153

5168, 5216

123, 405

428, 617

704, 2667

16,139

116,476

25570

Discharge summary

report

Admission Date: [**2179-11-16**] Discharge Date: [**2179-11-26**] Date of Birth: [**2098-10-25**] Sex: F Service: MEDICINE Allergies: Penicillins / Quinidine;Quinine Analogues Attending:[**First Name3 (LF) 2901**] Chief Complaint: Vomiting, malaise, increasing LE edema Major Surgical or Invasive Procedure: Pacemaker placement History of Present Illness: Mrs. [**Known lastname 63845**] is a 80 year-old female with a history of chronic AF, diastolic CHF, DM, hyperlipidemia, CRI, who presents with increasing LE edema and erythema, x 10days. In addition to the erythema, the pt had blisters that burst b/l. Pt was started on Levo 10 days ago for LE cellulitis. Pt also had vomiting, decreased PO intake. + fatigue, malaise, and abd distention. Some MS changes over past few days along with some LLE thigh ache/stiffness. Some DOE and lightheadedness. + baseline orthopnea. No PND. No CP. Pt denies fevers, palpitations, diarrhea, hemetemesis. During an admission for N/V/D on [**10-20**], pt was also found to have prolonged QT 700ms and her Amiodarone was d/c. She was started on Atenolol 12.5 [**Hospital1 **]. In the ER the patient was found to be in acute on chronic RF with Cr from baseline 1.6-1.9 to 4.4, Bun 130, mild CHF, K of 6.5. bradycardic to 20s with stable BP,w/ relative [**Name (NI) 63846**] SBP 80s. INR 3.0. Pt got atropine, glucagon, kayexalate. Temporary transvenous pacer was placed. Past Medical History: 1. Diabetes mellitus 2. CHF (diastolic) 3. Hypothyroidism 4. Gout 5. Hyperlipidemia 6. H/O bilateral DVT 7. Atrial fibrillatin 8. B12 deficiency 9. OP 10.Carotid artery stenosis: CEA on left (2-3 years prior) 11. CRI (baseline SCr of 1.6) Social History: Lives with daughter; former fish packer Tobacco: quit >20 years ago EtOH: denies Family History: NC Physical Exam: vital signs: T 97.5, BP 114/40, HR 60, RR 13, O2 sat 100% 3L GEN: obese female lying in bed HEENT: PERRL, MM very dry, poor dentition, no OP lesions, no LAD CV: brady; distant heart sounds; II/VI systolic murmur PULM: diffuse crackles b/l, no rhonchi or wheezes. ABD: soft, non-tender, obese, ventral hernia on exam; reducible, superficial epidermal abrasion under pannus on R. EXT: warm, + erythema bilaterally to knees, and evidence of previous ulcerations; no current ulcers noted Neuro: oriented x 2. No focal deficits. Pertinent Results: Laboratory Results: [**2179-11-16**] 09:00AM BLOOD WBC-9.9# RBC-4.19* Hgb-12.4 Hct-36.5 MCV-87 MCH-29.5 MCHC-33.9 RDW-15.3 Plt Ct-197 [**2179-11-17**] 05:49PM BLOOD WBC-9.2 RBC-3.65* Hgb-11.2* Hct-31.2* MCV-86 MCH-30.6 MCHC-35.8* RDW-15.5 Plt Ct-149* [**2179-11-22**] 04:41AM BLOOD WBC-9.7 RBC-3.25* Hgb-9.9* Hct-28.1* MCV-86 MCH-30.6 MCHC-35.4* RDW-15.7* Plt Ct-125* [**2179-11-25**] 06:15AM BLOOD WBC-8.6 RBC-3.22* Hgb-9.7* Hct-29.3* MCV-91 MCH-30.2 MCHC-33.2 RDW-16.4* Plt Ct-162 [**2179-11-16**] 09:00AM BLOOD Glucose-167* UreaN-132* Creat-4.4*# Na-119* K-8.8* Cl-86* HCO3-23 AnGap-19 [**2179-11-16**] 09:30PM BLOOD Glucose-129* UreaN-135* Creat-4.3* Na-125* K-5.4* Cl-90* HCO3-22 AnGap-18 [**2179-11-18**] 08:00AM BLOOD Glucose-142* UreaN-126* Creat-3.8* Na-132* K-3.6 Cl-96 HCO3-21* AnGap-19 [**2179-11-21**] 05:24AM BLOOD Glucose-129* UreaN-120* Creat-2.9* Na-134 K-4.5 Cl-102 HCO3-22 AnGap-15 [**2179-11-23**] 06:12AM BLOOD Glucose-107* UreaN-102* Creat-2.0* Na-140 K-4.0 Cl-106 HCO3-24 AnGap-14 [**2179-11-25**] 06:15AM BLOOD Glucose-120* UreaN-85* Creat-1.5* Na-145 K-4.3 Cl-111* HCO3-26 AnGap-12 [**2179-11-16**] 09:00AM BLOOD PT-28.7* PTT-37.1* INR(PT)-3.0* [**2179-11-16**] 09:30PM BLOOD PT-22.5* PTT-35.5* INR(PT)-2.2* [**2179-11-18**] 08:00AM BLOOD PT-26.7* PTT-36.8* INR(PT)-2.7* [**2179-11-25**] 06:15AM BLOOD PT-15.6* PTT-40.4* INR(PT)-1.4* [**2179-11-16**] 09:00AM BLOOD ALT-37 AST-94* CK(CPK)-155* AlkPhos-80 Amylase-84 TotBili-0.7 [**2179-11-16**] 10:50AM BLOOD ALT-31 AST-43* CK(CPK)-121 AlkPhos-92 Amylase-88 TotBili-0.7 [**2179-11-16**] 09:00AM BLOOD CK-MB-4 cTropnT-0.04* proBNP-5442* [**2179-11-17**] 06:19AM BLOOD CK-MB-8 cTropnT-0.09* [**2179-11-16**] 09:00AM BLOOD Calcium-8.9 Phos-6.0* Mg-5.4* [**2179-11-20**] 05:29AM BLOOD Calcium-8.5 Phos-5.0* Mg-4.5* [**2179-11-25**] 06:15AM BLOOD Calcium-8.8 Phos-3.2 Mg-3.6* [**2179-11-18**] 08:00AM BLOOD Free T4-1.7 [**2179-11-21**] 05:24AM BLOOD Cortsol-28.0* EKG: ventricular escape rhthm at 45. RBBB. TWI III, AVF (new). Relevant Imaging: 1)Cxray ([**11-16**]): Limited study. No obvious pneumonia, pneumothorax, or pleural effusion detected in these conditions. Apical redistribution of pulmonary blood flow. A repeat chest radiograph in a true AP projection is recommended for better delineation, as well as to better assess heart size. 2)Lower extremity U/S ([**11-16**]): No evidence of bilateral lower extremity deep venous thrombosis. 3)ECHO ([**11-17**]):The left atrium is moderately dilated. Left ventricular wall thickness, cavity size, and systolic function are normal (LVEF>55%). Regional left ventricular wall motion is normal. The right ventricular cavity is mildly dilated. Right ventricular systolic function is normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No masses or vegetations are seen on the aortic valve. No aortic regurgitation is seen. The mitral valve leaflets are moderately thickened. There is no mitral valve prolapse. Moderate (2+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. Severe [4+] tricuspid regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. 4)RUE U/S ([**11-20**]): Limited study of the right upper extremity, without intraluminal thrombus is identified. The right internal jugular and medial right subclavian veins were not examined as described. 5)Cxray ([**11-23**]):There was considerable rotation of the patient to the right, thereby making difficult comparisons of heart size with prior films. The left-sided pacemaker with its single ventricular lead seems unchanged in position. There has been interval placement of a right-sided PICC line, with its tip at the level of the mid or central portion of the superior vena cava. Bibasilar small pleural effusions are present, left worse than right. Brief Hospital Course: Ms. [**Known lastname 63845**] is a 80 yo female with a history of CRI, chronic AF on Coumadin, diastolic CHF who presents in ARF, bradycardia, hyperkalemia, uremic symptoms, and possible LE cellulitis. Hyperkalemia resolved and renal failure improving slowly with IVFs. Had been 100% transvenous paced, now s/p permanent pacemaker placement. 1) Rhythm: Patient has history of Chronic AF and became bradycardic in the setting of severe renal failure and hyperkalemia. Patient was discharged on Atenolol on her last admission, which is renally excreted, and became bradycardic as her creatinine increased. In the ED, she was given Atropine with a minimal response and a temporary pacer was placed in the EP lab. Her anti-hypertensives, diuretics, and Coumadin were held. Her pacer rate was initially set at 60 but slowly increased to 80, which she tolerated. Heparin gtt was started for anti-coagulation but was held because she had significant epistaxis and hematuria. She was followed closely by EP and a permanent single chamber pacemaker was placed with no complications. She was treated with 3 days of Vancomycin, per EP. She will need follow-up with EP and the device clinic. Would recommend no atenolol given h/o renal dysfunction, instead give metoprolol if requires restart of beta-blocker. 2) Pump: Patient has EF >55%, severe tricuspid regurgitation, likely diastolic dysfunction. She takes Lasix and Spironolactone at home, both of which were stopped given her renal failure and dehydration. She is extremely edematous on exam but is likely intravascularly depleted given her elevated BUN and dry mucous membranes on clinical exam. Patient was started on maintenance fluids several times during her hospital stay given her poor intake. She also required multiple fluid boluses to maintain her blood pressure. Would recommend to continue holding all diuretics for now despite peripheral edema given intravascularly deplete and extremely poor PO intake. 3) Acute-on-chronic renal failure: Patient initially came in with a creatinine of 4.4 and a potassium of 8.8, secondary to decreased PO intake, nausea, vomiting, and diuretics. Baseline creatinine is 1.6. Her BUN was elevated at 132 from dehydration. She did not require dialysis. In the ED she was given Kayexalate and glucagon. She was followed closely by renal during her stay. Her creatinine slowly improved to 1.5 on discharge. Her potassium quickly resolved as well. Recommend IV NS 1L @ 75cc/hr qod while PO intake poor to maintain intravascular volume. 4) Diabetes: Patient on Avandia and Glyburide at home. These were stopped given her renal failure and she was placed on a insulin sliding scale with sugars checked QID. Discontinued glyburide and avandia given h/o renal dysfunction, started on glipizide prior to discharge. 5) Lower extremity edema: Patient presented with skin changes, initially thought to be cellulitis. As her swelling improving it was thought that she had extensive venous stasis instead. Daily pressure dressings were done. The patient was started on Vancomycin for presumed MRSA cellulitis but was d/c'ed given that this was not the case. Completed 10 day course. 6) Elevated INR: Patient initially presented with an INR 3.0 on admission. Unlikely related to her dose of Coumadin. Secondary to poor PO intake. She was given several doses of Vitamin K to decrease her INR in preparation for her pacemaker placement. 7) Hyperlipidemia: Continue outpatient regimen of Lipitor. 8) Yeast infection: Miconazole cream to vaginal area. 9) Hypothyroidism: TSH initially elevated but now normalized. Started Synthroid. Medications on Admission: 1. Warfarin 2/3 mg PO QAM QOD 2. Docusate Sodium 100 mg Capsule PO BID 3. Montelukast 10 mg PO DAILY 4. Aspirin 81 mg Tablet, Chewable PO DAILY 5. Atorvastatin 10 mg PO DAILY 6. Donepezil 5 mg Tablet PO HS 7. Fluticasone 50 mcg/Actuation Aerosol, Spray Nasal DAILY 8. Levothyroxine 112 mcg Tablet PO DAILY 9. Nitroglycerin 0.4 mg Tablet, 10. Atenolol 12.5 mg Tablet PO once a day. 11. Alendronate 70 mg PO QFRI 12. glyburide 5mg Qpm 13. Furosemide 160 mg PO DAILY 14. Spironolactone 25 mg PO DAILY 15. Metolazone 2.5 mg PO once a week. 16. Avandia 2mg [**Hospital1 **] Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 4. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Donepezil 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 6. Fluticasone 50 mcg/Actuation Aerosol, Spray Sig: One (1) Spray Nasal DAILY (Daily). 7. Levothyroxine 112 mcg Tablet Sig: One (1) Tablet PO once a day. 8. Nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) Tablet, Sublingual Sublingual PRN (as needed) as needed for chest pain. 9. Insulin Lispro (Human) 100 unit/mL Solution Sig: One (1) Subcutaneous ASDIR (AS DIRECTED): sliding scale. 10. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed for pain. 11. Calcium Acetate 667 mg Capsule Sig: Two (2) Capsule PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 12. Miconazole Nitrate 2 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day). 13. Miconazole Nitrate 2 % Cream Sig: One (1) Appl Vaginal HS (at bedtime) for 3 days. 14. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000) units Injection TID (3 times a day). 15. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed for pain. 16. Warfarin 1 mg Tablet Sig: Three (3) Tablet PO HS (at bedtime). 17. Dextromethorphan-Guaifenesin 10-100 mg/5 mL Syrup Sig: Five (5) ML PO Q6H (every 6 hours) as needed for cough. 18. Megestrol 40 mg/mL Suspension Sig: Ten (10) ml PO DAILY (Daily). 19. Heparin Flush PICC (100 units/ml) 2 ml IV DAILY:PRN 10 ml NS followed by 2 ml of 100 Units/ml heparin (200 units heparin) each lumen Daily and PRN. Inspect site every shift. 20. Dolasetron Mesylate 12.5 mg IV Q8H:PRN nausea Discharge Disposition: Extended Care Facility: [**Hospital **] - [**Location (un) **] Discharge Diagnosis: bradycardia congestive heart failure exacerbation hyperkalemia hyponatremia acute renal failure uremia Discharge Condition: good Discharge Instructions: 1. Please take all medications as prescribed. 2. Please adhere to a 2gm sodium diet and 1.5L fluid restriction. 3. Please measure your weight daily and call your doctor if your wt increases > 3 pounds as you may need to restart some of your diuretics. 4. You have been started on several new medications: calcium acetate, megesterol, insulin, miconazole, percocet, anzemet, robitussin. 5. We have discontinued several medications including atenolol, spironolactone, metolazone, glyburide, avandia. 6. Call your doctor or return to the ED immediately if you experience worsening chest pain, shortness of breath, nausea, vomiting, sweating, fevers, chills, bleeding, or other concerning symptoms. Followup Instructions: You are scheduled for the following appointments. Please contact the [**Name2 (NI) 11686**] provider with any questions or if you need to reschedule. Provider: [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2179-11-29**] 2:00 Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1239**], [**Name Initial (NameIs) **].O. Phone:[**Telephone/Fax (1) 719**] Date/Time:[**2179-12-6**] 11:30 Provider: [**Name10 (NameIs) 1037**] [**Name8 (MD) 5647**], MD Phone:[**Telephone/Fax (1) 1971**] Date/Time:[**2180-1-13**] 1:30 [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2908**] MD, [**MD Number(3) 2909**]

[ "427.31", "276.52", "599.7", "991.6", "276.7", "250.00", "427.89", "784.7", "584.9", "426.0", "458.9", "112.1", "593.9", "276.1", "787.2", "428.30", "272.4", "397.0", "428.0", "244.9", "459.81", "112.3" ]

icd9cm

[ [ [] ] ]

[ "37.78", "99.04", "99.15", "38.93", "37.71", "37.81", "38.91" ]

icd9pcs

[ [ [] ] ]

12372, 12437

6288, 9904

344, 365

12584, 12591

2391, 4389

13339, 14041

1827, 1831

10524, 12349

12458, 12563

9930, 10501

12615, 13316

1846, 2372

266, 306

4407, 6265

393, 1449

1471, 1711

1727, 1811

59,828

157,244

42131

Discharge summary

report

Admission Date: [**2148-1-6**] Discharge Date: [**2148-1-14**] Date of Birth: [**2082-1-7**] Sex: M Service: ORTHOPAEDICS Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 3190**] Chief Complaint: Numbness and lower extremity weakness Major Surgical or Invasive Procedure: 1. Anterior cervical diskectomy C5-C6. 2. Fusion C5-C6. 3. Instrumentation C5-C6. 4. Total laminectomy of T10. 5. Multiple thoracic laminotomies from T6 to T10. 6. Fusion T6 to T11 for kyphosis. 7. Removal of previous instrumentation T10. 8. Application new instrumentation T6-T11. History of Present Illness: 65M who is 3 weeks post-op from T10-L3 fusion for L1 burst fx ([**12-11**]) with subsequent T12-L1 resvision ([**12-25**]), subsequent development of paraplegia due to spinal cord infact at T10. The patient was previously able to feel sensation around his T10 level, but over the past 2 days at rehab has developed numbness up to the level of approximately T4. Otherwise no new upper extremity weakness, but he has complained of incresing shortness of breath. He denies any recent fever, chills, chest pain, pleuritic pain, cough, abdominal pain. His foley has been in place since development of paraplegia. . In the ED, Initial vitals were 98.2 72 103/44 17 96% 6LNC. Noncontrast CT spine was concerning for new fracture above the level of instrumentation. He became hypotensive with SBP in low 90's for which he was given 5L of NS then started on norepinephrine. He subsequently developed hypoxia despite 6L N/C, and complained of increasing shortness of breath. Throughout his course he continued to mentate normally, no decreased in urine output, and did not become tachycardic. He was started on ciprofloxacin for UTI and vacnomycin and flagyl. He was admitted to the ICU for hypoxia and hypotension. . On transfer to the MICU he denied any shortness of breath, chest pain, pleuritic pain. He did have mild neck pain consistent with his chronic pain. He was initially weaned off the norepinephrine drip, but his SBP decreased to the upper 80's w/ MAP in mid 50's. He was restarted on phenylephrine to maintain MAP >65. . Imaging studies were obtained that were concerning for a T10 fracture. Past Medical History: PMH: - Obesity, 300 lbs, 66 inches tall - Chronic pain in neck, per patient [**2-22**] to arthritis - Burst fracture of L1, s/p transpedicular decompression of L1, laminectomies of T11 and 12, and L2 and L3, fusion of T10-L3, instrumentation T10-L3, and autograft on [**12-11**] - Renal cancer, s/p unilateral nephrectomy, - IDDM, poorly controlled per patient - HTN, poorly controlled per patient - R knee replacement in [**5-21**] DJD - S/p thyroid surgery for goiter 10 years ago Social History: Married with 2 kids, lives in [**Location 7658**] with his wife. [**Name (NI) 1403**] in tech support. Denies tobacco or drug use with occasional EtOH. Family History: Dad - CAD [**Name (NI) 21206**] - CAD, CVA from DVT that left her comatose for several years Physical Exam: Vitals: P 83 BP 87/43 RR 14 O2 Sat 96% 5L N/C Gen: no acute distress HEENT: MMM, PERRL, EOMI Resp: no resp distress, CTAB, mildly diminished RLL CVS: regular rate, no m/r/g Abd: protuberant, soft, nondistended Ext: 2+ pulses all extremities, warm LE bilaterally Neuro: CNIII-XII intact bilaterally, 0/5 LE strength, [**4-25**] upper extremity strength, complete loss of sensation below T4 level, otherwise intact, no dysmetria, gait not tested Pertinent Results: [**2148-1-7**] 09:29PM BLOOD WBC-9.8 RBC-2.86* Hgb-8.3* Hct-25.1* MCV-88 MCH-29.1 MCHC-33.1 RDW-14.4 Plt Ct-416 [**2148-1-7**] 04:52AM BLOOD WBC-10.8 RBC-2.85* Hgb-7.9* Hct-25.1* MCV-88 MCH-27.9 MCHC-31.6 RDW-14.4 Plt Ct-524* [**2148-1-6**] 12:00PM BLOOD WBC-8.7 RBC-2.94* Hgb-8.2* Hct-25.8* MCV-88 MCH-27.8 MCHC-31.7 RDW-14.3 Plt Ct-450* [**2148-1-7**] 09:40PM BLOOD PT-14.8* PTT-28.1 INR(PT)-1.4* [**2148-1-7**] 04:52AM BLOOD PT-13.2* PTT-29.1 INR(PT)-1.2* [**2148-1-6**] 12:00PM BLOOD PT-13.0* PTT-33.7 INR(PT)-1.2* [**2148-1-7**] 09:29PM BLOOD Glucose-137* UreaN-22* Creat-0.9 Na-139 K-3.9 Cl-103 HCO3-30 AnGap-10 [**2148-1-7**] 04:52AM BLOOD Glucose-115* UreaN-25* Creat-1.0 Na-138 K-5.0 Cl-99 HCO3-34* AnGap-10 [**2148-1-7**] 09:29PM BLOOD Calcium-8.3* Phos-3.4 Mg-1.7 [**2148-1-7**] 04:52AM BLOOD Calcium-8.5 Phos-3.9 Mg-2.0 [**2148-1-8**] 02:14AM BLOOD freeCa-1.23 CTA chest: 1. Within limits of motion artifact, no evidence of pulmonary embolus to the segmental level. 2. Large multiloculated pleural effusion on the right with near complete collapse of the right lower lobe. 3. Enlarged main pulmonary artery suggests pulmonary hypertension. 4. 13 mm LUL nodule may be slightly larger, although technique and motion artifact limit comparison. PET-CT is recommended if not previously performed given the history of malignancy. MRI OF THE CERVICAL SPINE. Again in comparison with the prior examination of the cervical spine dated [**2147-12-13**], there is extensive soft tissue swelling posteriorly from C3 through C6 level involving the inter-and supraspinous ligaments, and again extending dorsally to the nuchal ligament. The alignment of the cervical spine demonstrates anterior angulation at C5/C6, the prior examination demonstrates straightening of the cervical lordosis, therefore the possibility of anterior widening in this patient with history of ankylosing spondylitis is a consideration. Again there is severe spinal canal narrowing, more significant at C5/C6 level with bilateral neural foraminal narrowing. There is no evidence of abnormal enhancement within the spinal cord, however there is mild epidural enhancement with no definite fluid collection or epidural hematoma. Increase in the pattern of edema is identified throughout the thoracic spinal cord extending from the lower cervical spine at C6/C7 throughout the T10 vertebral level, new since the most recent study, suggesting edema and possible ischemic changes. Slight cord expansion is noted at C7/T1, no definite hematoma is identified at this level. MRI OF THE THORACIC SPINE. The alignment and configuration of the thoracic vertebral bodies from T1 through T9 appears unchanged. High signal intensity is noted throughout the thoracic spinal cord, new since the prior study, suggesting ischemic changes. Fracture at T10 vertebral body is re-demonstrated. The images throughout the lower thoracic spine are limited due to hardware artifact, however, are grossly unchanged since the prior study. MRI OF THE LUMBAR SPINE. Again multilevel degenerative changes are re-demonstrated, more significant at L2/L3 and L4/L5 levels with mild posterior disc bulging, there is no evidence of abnormal enhancement throughout the lumbar spine. IMPRESSION: 1. In comparison with the most recent MRI examination, there is new pattern of edema along the lower cervical and the thoracic spinal cord, suggesting edema and ischemic changes with mild pattern of enhancement and no definite fluid collection, the possibility of a new infarct is a consideration. 2. In the cervical spine, there is anterior widening of the intervertebral disc space at C5/C6, apparently new since the prior study, with persistent edema from C3 through C6 levels posteriorly and extending at the ligamentum nuchae, with significant spinal canal stenosis at C5/C6. 3. The fixation hardware appears grossly unchanged since the prior studies and obscures the anatomical detail in the lower thoracic spine. Unchanged multilevel degenerative changes throughout the lumbar spine as described above. Brief Hospital Course: 65M now 3 weeks post-op from T10-L3 fusion for L1 burst fx with subsequent T12-L1 resvision, subsequent development of paraplegia due to spinal cord infact at T10, now with new development of numbness to the level of T4. Found to be hypotensive w/ development of hypoxia in ED after 5L fluid bolus. [**Hospital **] transfered to MICU for stabilization and further management. In the MICU a noncontrast CT spine wasobtained and was concerning for new fracture above the level of instrumentation. He was admitted to the MICU for hypoxia and hypotension in the ED. He was started on levophed and had 5L fluid resuscitation in the ED. Was started on abx for a positive UA. In the MICU patient had persistent pressor requirements, worsening hypoxia for which a CTA was performed with no evidence of PE, but a a large multiloculated right pleural effusion with RLL collapse. He was started on broad spectrum abx for possible sepsis and PNA coverdage. His neuro exam progressed with worsening weakness in upper extremities, so he was taken back to the OR by ortho spine for a T6 to T11 extension of posterior fusion for the T10 fracture and a C5-6 anterior discectomy and fusion for severe central stenosis. Post-operatively, his lower extremity neurological exam did not improve. He had difficult weaning from the ventilator and a PEG and tracheostomy was considered. Mr. [**Known lastname 91386**] [**Last Name (Titles) **] this intervention. A Paliative Care consult was obtained in addition to an Ethics Support Service evaluation. Mr. [**Known lastname 91386**] on [**2148-1-13**] requested a cessation of life-prolonging interventions, and TSICU staff called Ethics Support Service for assistance in ensuring an appropriate patient-centered plan of care. After meeting with TSICU staff, and then in room with the staff and the patient, his wife [**Name (NI) 501**], brother, and two adult children, it was unequivocally clear that the patient understands his current situation, choices, and almost certain likelihood of death (most likely in hours to days) if ventilator support is discontinued. He wants life support discontinued at this time. His wishes were granted and he expired. Medications on Admission: 1. atorvastatin 10 mg PO HS 2. allopurinol 100 mg PO DAILY 3. aspirin 325 mg PO DAILY 4. acetaminophen 1000 mg PO Q6H 5. gabapentin 300 mg PO Q8H 6. oxycodone 40 mg Extended Release PO Q12H 7. oxycodone 5 mg PO Q3H prn pain 8. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Topical 9. bisacodyl 10 mg PO DAILY 10. docusate sodium 100 mg PO BID 11. pantoprazole 40 mg PO Q24H 12. gemfibrozil 600 mg Tablet PO DAILY 13. senna 8.6 mg PO BID 14. polyethylene glycol 3350 17 gram/dose PO 15. Fleet Enema 19-7 gram/118 mL 1 Rectal DAILY (Daily) prn for No BM in 48 hr. 16. sodium chloride 0.65 % Aerosol, Spray Sig: [**1-22**] Sprays Nasal TID prn congestion/dryness 17. insulin glargine 12 units sc bid: With breakfast and dinner. 18. insulin aspart per sliding scale qid 19. heparin (porcine) 5,000 unit/mL sc tid Discharge Medications: None Discharge Disposition: Expired Discharge Diagnosis: T10 fracture T10 spinal cord infarct UTI Cervical stenosis Discharge Condition: Expired Discharge Instructions: N/A Followup Instructions: N/A Completed by:[**2148-2-8**]

[ "V45.73", "806.29", "599.0", "839.05", "250.01", "V10.52", "518.52", "737.10", "V43.65", "V58.67", "276.4", "511.9", "720.0", "278.00", "401.9", "E885.9", "721.1" ]

icd9cm

[ [ [] ] ]

[ "81.63", "38.97", "81.05", "38.93", "96.71", "96.04", "80.51", "77.79", "81.02", "03.53", "33.24" ]

icd9pcs

[ [ [] ] ]

10695, 10704

7600, 9794

345, 629

10806, 10815

3523, 7577

10867, 10900

2949, 3043

10666, 10672

10725, 10785

9820, 10643

10839, 10844

3058, 3504

267, 307

657, 2256

2278, 2763

2779, 2933

18,419

113,847

12406+56361

Discharge summary

report+addendum

Admission Date: [**2154-1-4**] Discharge Date: [**2154-1-9**] Date of Birth: [**2081-7-17**] Sex: F Service: HISTORY OF PRESENT ILLNESS: The patient is a 72 year old female status post emergent coronary artery bypass graft times two secondary to catheterization complicated by asystole and hypotension, who was transferred recently from rehabilitation for management of a pericardial effusion. The patient was admitted in [**2153-11-20**] for an elective catheterization at which time the procedure was complicated by a perforation with subsequent ST elevations, asystole, and placement of an intra-aortic balloon pump and emergent coronary artery bypass graft times two. The patient was managed at [**Hospital1 69**] and then discharged to [**Hospital6 310**] on [**2153-12-19**]. At rehabilitation, the patient has progressed very poorly with persistent fatigue, dyspnea on exertion, tachypnea, as well as persistent pleural effusion. As part of her work-up, an echocardiogram was obtained on [**1-3**], which revealed a significant pericardial effusion as well as a reported right atrial compression and the patient was subsequently transferred to [**Hospital1 69**] for further management. Upon admission to the hospital, the patient was taken immediately to catheterization. Tamponade was suggested by equalization of the RA, right ventricular end diastolic pressure, and wedge pressures of approximately 15; 400 cc of serosanguinous fluid was drained from the pericardial space with resolution of normal pressures. Following the procedure, the patient was admitted to the Cardiac Care Unit, for observation. On arrival to the Cardiac Care Unit, the patient was without any complaints of shortness of breath and did not report any significant chest discomfort. PAST MEDICAL HISTORY: 1. Hypercholesterolemia. 2. Emergent coronary artery bypass graft times two in [**11/2153**], secondary to catheterization complicated by perforation after diagnosis of 99% left anterior descending, normal circumflex, non-critical right coronary artery. Course was complicated by ST elevations and subsequent asystole during the catheterization, placement of an intra-aortic balloon pump and subsequent emergent coronary artery bypass graft times two (SVG to the left anterior descending and obtuse marginal). ALLERGIES: The patient has no known drug allergies. MEDICATIONS: 1. Lopressor 50 mg p.o. twice a day. 2. Aspirin 325 mg p.o. q. day. 3. Plavix 75 mg p.o. q. day. 4. Protonix 40 mg p.o. q. day. 5. Lasix 60 mg p.o. q. day. 6. Lisinopril 2.5 mg p.o. q. day. 7. Fentanyl patch 25 micrograms applied to skin and change q. 72 hours. 8. Percocet, one tablet p.o. q. four to six hours p.r.n. break through pain. SOCIAL HISTORY: The patient is a Cantonese speaking female with a very involved family who lives locally. She denies any past history of smoking or alcohol use. She was transferred from [**Hospital **] Rehabilitation. PHYSICAL EXAMINATION: Vital signs were temperature 99.5 F.; heart rate 102; blood pressure 108/56; respiratory rate 20; saturating 94% on room air. Weight 46.9 kilograms. In general, awake, in no acute distress. HEENT: Pupils equally round and reactive to light. Moist mucous membranes. Neck: Jugular venous pressure at 10 cm. Cardiovascular: Regular rate and rhythm; no murmurs, rubs or gallops. Chest wall: Thoracotomy scar clean, dry and intact. Pigtail catheter intact without erythema. Pulmonary: Clear to auscultation bilaterally with scant crackles and decreased breath sounds at bilateral bases, left greater than right. Abdomen: Positive bowel sounds, soft, nontender, nondistended. Extremities: One plus pitting edema bilaterally. LABORATORY: White blood cell count 6.8, hematocrit 32.5, platelets 327. Sodium 135, potassium 3.9, chloride 97, bicarb 30, BUN 15, creatinine 1.3. PT 12.8, PTT 26.2, INR 1.1. Arterial blood gases: 7.44/40/60. Chest x-ray: Left pleural effusion, pneumopericardium, no obvious infiltrates. Mild congestive heart failure. HOSPITAL COURSE: The patient is a 72 year old female status post coronary artery bypass graft times two in [**2153-11-20**], who was admitted for pericardial effusion with evidence of cardiac tamponade on catheterization status post drainage of the effusion and placement of a pigtail catheter. 1. Cardiovascular: The patient recently underwent a coronary artery bypass graft times two approximately two and a half weeks prior to the time of admission. She was continued on her aspirin therapy, however, her Plavix was held given the serosanguinous fluid that was removed from the pericardial space. In addition, her beta blocker and ACE inhibitor were also held as the patient was mildly hypotensive at the time of admission, and these were titrated back as tolerated. The patient had no complaints of chest pain and no suggestion of anginal symptoms over the course of the hospital stay. The patient had her pericardial sac effectively drained during the catheterization and secondary to placement of pigtail catheter. Over the first two hospital days, the drainage from the catheter slowly decreased in quantity. An echocardiogram was obtained on Hospital day number four, which demonstrated near complete resolution of the pericardial effusion with fibrin formation, suggestive of early consolidation. Since the drain put out less than 50 cc in the 24 hours prior to this time, the pigtail catheter was removed without difficulty and the patient subsequently felt subjectively less short of breath and complained of less pain. The patient's blood pressure remained stable over the remainder of the hospital stay. Her beta blocker and ACE inhibitor were added back to her medication regimen and titrated up as tolerated. An echocardiogram was obtained on [**2154-1-7**], for evaluation of the pericardial effusion which, in addition, demonstrated a normal left atrium and left ventricle, small remnant of a pericardial effusion and ejection fraction of 70%. The patient's Lasix and Aldactone were held at time of admission secondary to feeling that the patient was likely on the dry side. Her fluid status was monitored closely over the hospital stay. As the patient begins to take more p.o. input, she will likely need titration of her Lasix back to her usual outpatient dose. In addition, the patient was maintained in Telemetry and demonstrated normal sinus rhythm with only occasional PCV's on Telemetry throughout the hospital stay. 2. Pulmonary: The patient was noted to have persistent pleural effusions, which are likely secondary to her coronary artery bypass graft performed approximately two weeks prior to the time of admission. Consideration was given to a thoracentesis, however, the patient maintained excellent oxygen saturations, a normal arterial blood gas and had no complaints of shortness of breath or respiratory discomfort once the pigtail catheter was removed. Since the fluid surrounding the lung space is likely similar to the fluid surrounding the pericardial space, it was not felt warranted to perform a thoracentesis for diagnostic purposes since Chemistry and Culture data were to be obtained from the pericardial fluid. Therefore, since the patient was asymmetric with her pleural effusions, it was felt that to monitor them closely and to hold off on aggressive therapeutic measures at this time. 3. Renal: The patient had a normal creatinine at time of admission which was followed closely over the hospital stay. She maintained excellent urine output and her creatinine remained within normal limits. 4. Infectious Disease: The patient had a normal white blood cell count and was afebrile at the time of admission. She did not demonstrate any signs or symptoms of infection throughout the course of the hospital stay. 5. Hematological: The patient's hematocrit was watched closely status post catheterization and pericardial drainage, however, her hematocrit remained stable and she had no bleeding issues during the hospital stay. 6. Musculoskeletal: The patient complained of significant arthritic back pain which she reported being chronic in nature. She was provided with a Fentanyl patch as well as Percocet p.r.n. breakthrough pain. These medications appeared to adequately control the patient's discomfort and she had no further complaints of pain. CONDITION AT DISCHARGE: The patient was discharged to home in stable condition. DISCHARGE INSTRUCTIONS: 1. She is to follow-up with Dr. [**Last Name (STitle) **] in Clinic at the end of [**Month (only) 956**]. DISPOSITION: The patient will be discharged to rehabilitation for further Physical Therapy and rehabilitation status post coronary artery bypass graft. MEDICATIONS AT TIME OF DISCHARGE: 1. Aspirin 325 mg p.o. q. day. 2. Lopressor 25 mg p.o. twice a day. 3. Heparin 5000 units subcutaneously twice a day. 4. Colace 100 mg p.o. twice a day. 5. Fentanyl patch 25 micrograms per hour to be changed q. 72 hours. 6. Zestril 2.5 mg p.o. q. day. 7. Percocet 1 tablet p.o. q. six hours p.r.n. breakthrough pain. 8. Tylenol 650 mg p.o. q. four hours p.r.n. fever or pain. 9. Dulcolax suppositories one tablet p.r. q. day p.r.n. [**Name6 (MD) **] [**Name8 (MD) **], MD [**MD Number(1) 21980**] Dictated By:[**Name8 (MD) 8860**] MEDQUIST36 D: [**2154-1-8**] 14:15 T: [**2154-1-8**] 14:19 JOB#: [**Job Number 38594**] Name: [**Known lastname **], [**Known firstname 6979**] Unit No: [**Numeric Identifier 6980**] Admission Date: [**2154-1-4**] Discharge Date: [**2154-1-12**] Date of Birth: [**2081-7-17**] Sex: F Service: ADDENDUM: 1. CARDIOVASCULAR: As the patient's p.o. status improved over the course of the hospital stay, she began to have some reaccumulation of fluid in her left extremities. She was therefore started back on a daily dose of Lasix at 10 mg p.o. q.d. which can be monitored and titrated up as needed as an outpatient. The patient had no further cardiovascular issues. 2. PULMONARY: Over the last few hospital days, after persistent questioning of the patient by various staff members regarding any residual shortness of breath, the patient finally admitted to some shortness of breath which did not completely resolve after removal of the pigtail catheter from the pericardial space. Therefore, given the patient's right-sided pleural effusion, it was felt that she might be experiencing some subjective shortness of breath secondary to this effusion. It was therefore determined to perform a thoracentesis for both diagnostic and therapeutic purposes. Proper consent was obtained from the patient's daughter (as a translator for the patient), and a right-sided thoracentesis was performed with removal of approximately 700 cc to 800 cc of serosanguineous fluid. Samples of the pleural fluid were sent for Gram stain and culture which were negative, as well as acid-fast bacillus stain and culture which were negative as well. On the day following the right-sided thoracentesis, the patient was questioned by the primary team as to whether she felt any improvement in her shortness of breath. The patient denied any significant improvement. However, later that day, upon questioning by other members of the team, she did admit to some improvement in her shortness of breath. Therefore, a Pulmonary consultation was obtained, who suggested that given the patient's equivocal answers she might benefit from thoracentesis of her left-sided pleural effusion as well. Therefore, consent was once again obtained (via the patient's daughter as translator), and a left-sided thoracentesis was performed with removal of approximately 500 cc of serosanguineous fluid without any complication. The patient was watched carefully over the following hospital day and had no further complaints of difficulties. She was therefore discharged to rehabilitation on [**1-12**] and was to follow up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 274**] in clinic as needed. MEDICATIONS ON DISCHARGE: Additional medications at the time of discharge included Lasix 10 mg p.o. q.d. [**Name6 (MD) **] [**Name8 (MD) **], MD [**MD Number(1) 285**] Dictated By:[**Name8 (MD) 6288**] MEDQUIST36 D: [**2154-2-11**] 10:26 T: [**2154-2-12**] 08:27 JOB#: [**Job Number 6981**]

[ "414.01", "272.0", "511.9", "423.9", "997.1", "V45.81" ]

icd9cm

[ [ [] ] ]

[ "37.21", "37.0", "34.91" ]

icd9pcs

[ [ [] ] ]

12123, 12427

4074, 8400

8497, 12096

2994, 4056

8416, 8473

159, 1797

1819, 2748

2765, 2970

5,696

117,399

19048+57013

Discharge summary

report+addendum

Admission Date: [**2164-11-29**] Discharge Date: [**2165-1-19**] Service: SURGERY Allergies: Tramadol / Advil / Nsaids / Hydrocodone Attending:[**First Name3 (LF) 3223**] Chief Complaint: Gi bleeding Major Surgical or Invasive Procedure: EGD on [**11-29**] and [**11-30**] Angiography on [**2164-11-30**] IVC Filter placement [**11-30**] ex-lap, duodenotomy, oversowing of ulcer, J-tube placement and liver biopsy History of Present Illness: This is an 86 year old gentleman with multiple medical problems who was found unresponsive at his nursing home and surrounded by bloody stools. he had recently been discharged on coumadin status-post a right hip repair. He has a history of black tarry stools in [**2164-8-13**] diagnosed as peptic ulcer disease. Past Medical History: 1. Hypertension 2. Chronic obstructive pulmonary disease 3. Osteoarthritis 4. Osteopenia 5. Dementia 6. Depression 7. Status post bilateral inguinal hernia repair 8. Status post bilateral cataract surgery 9. Status post right total hip replacement Social History: 1. No smoking 2. Occasional alcohol 3. No drug use Family History: non contributory Physical Exam: vital signs: BP 80/50 at [**Last Name (LF) **] , [**First Name3 (LF) **] 110-137/48-53. HR 96. Gen: responds to stimuli, non-conversant, not awake or alert HEENT: head NC/AT, pale conjunctivae CV: sinus tachycardia Pulm: CTAB Abd: soft, non-distended Rectal: guaic positive, bloody output Extr: pale Pertinent Results: [**2164-11-29**] 09:00AM BLOOD WBC-13.1*# RBC-1.66*# Hgb-4.6*# Hct-14.7*# MCV-89 MCH-27.9 MCHC-31.4 RDW-16.5* Plt Ct-530*# [**2164-12-3**] 04:14AM BLOOD WBC-9.5 RBC-2.82* Hgb-9.0* Hct-24.8* MCV-88 MCH-31.8 MCHC-36.2* RDW-15.7* Plt Ct-130* [**2164-12-8**] 01:56PM BLOOD WBC-12.1* RBC-3.37* Hgb-10.5* Hct-31.7* MCV-94 MCH-31.1 MCHC-33.0 RDW-14.9 Plt Ct-386 [**2164-12-25**] 05:30AM BLOOD WBC-10.8 RBC-2.94* Hgb-8.5* Hct-26.2* MCV-89 MCH-29.0 MCHC-32.5 RDW-16.6* Plt Ct-493* [**2165-1-9**] 06:30AM BLOOD WBC-8.5 RBC-3.03* Hgb-8.6* Hct-25.7* MCV-85 MCH-28.4 MCHC-33.4 RDW-17.7* Plt Ct-455* [**2164-11-29**] 09:00AM BLOOD Neuts-79.7* Bands-0 Lymphs-16.0* Monos-3.9 Eos-0.2 Baso-0.2 [**2165-1-8**] 03:30PM BLOOD Neuts-76.8* Lymphs-15.1* Monos-5.7 Eos-1.8 Baso-0.6 [**2164-11-29**] 09:00AM BLOOD PT-30.3* PTT-36.2* INR(PT)-6.9 [**2164-11-29**] 11:15AM BLOOD PT-16.8* PTT-30.7 INR(PT)-2.0 [**2164-11-29**] 03:06PM BLOOD PT-15.3* PTT-29.2 INR(PT)-1.6 [**2164-11-30**] 09:15AM BLOOD PT-16.1* PTT-42.5* INR(PT)-1.8 [**2164-12-3**] 04:14AM BLOOD PT-13.5* PTT-28.2 INR(PT)-1.2 [**2165-1-9**] 06:30AM BLOOD Plt Ct-455* [**2164-11-30**] 09:15AM BLOOD Fibrino-181 [**2164-11-29**] 09:00AM BLOOD Glucose-229* UreaN-38* Creat-1.1 Na-143 K-5.1 Cl-110* HCO3-21* AnGap-17 [**2164-11-30**] 01:46AM BLOOD Glucose-126* UreaN-23* Creat-0.8 Na-147* K-3.8 Cl-118* HCO3-23 AnGap-10 [**2165-1-10**] 09:30AM BLOOD Glucose-97 UreaN-23* Creat-0.7 Na-140 K-4.6 Cl-103 HCO3-26 AnGap-16 [**2164-11-29**] 09:00AM BLOOD CK(CPK)-20* [**2164-12-1**] 02:55AM BLOOD ALT-34 AST-46* CK(CPK)-148 AlkPhos-48 TotBili-0.7 [**2164-12-18**] 04:00PM BLOOD ALT-29 AST-32 LD(LDH)-280* AlkPhos-206* Amylase-63 TotBili-0.5 [**2164-11-29**] 07:02PM BLOOD CK-MB-28* MB Indx-12.1* cTropnT-0.63* [**2164-11-30**] 05:13AM BLOOD CK-MB-10 MB Indx-7.9* cTropnT-0.70* [**2164-12-1**] 02:55AM BLOOD CK-MB-4 cTropnT-0.49* [**2164-12-13**] 01:24AM BLOOD CK-MB-NotDone cTropnT-0.02* [**2164-11-30**] 01:46AM BLOOD Calcium-6.4* Phos-3.3# Mg-1.6 [**2164-12-1**] 02:55AM BLOOD Albumin-2.1* Calcium-7.1* Phos-2.9 Mg-1.8 [**2164-12-18**] 04:00PM BLOOD Albumin-2.5* [**2165-1-7**] 10:50AM BLOOD Albumin-2.5* Iron-8* [**2165-1-7**] 10:50AM BLOOD calTIBC-187* Ferritn-434* TRF-144* [**2164-12-18**] 04:00PM BLOOD Ammonia-29 [**2164-12-18**] 04:00PM BLOOD TSH-1.2 Microbiology: [**11-19**] urine cx: negative [**12-4**] sputum cx: MRSA [**12-10**] rectal swab: VRE [**12-24**] blood cx: pseudomonas [**12-24**] urine cx: pseudomonas and serratia [**1-6**] blood cx: negative [**1-6**] urine cx: negative [**1-8**] peri-j-tube swab: MRSA [**1-14**] stool: negative for c. diff RADIOLOGY: [**11-30**] Angiography:The procedure is performed by Drs. [**Last Name (STitle) **] and [**Doctor Last Name **] the attending physician, [**Name10 (NameIs) 1023**] was present and supervising throughout. Informed consent was obtained with the patient's sons. The patient was placed supine on the angiography table and his right groin was prepped and draped in standard sterile fashion. After infusion of 1% lidocaine, the right common femoral artery was accessed with a 19-gauge needle. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 7648**] wire was advanced into the abdominal aorta and the puncture needle was exchanged for a 5-French sheath which was attached to a continuous flush throughout the procedure. Using a C2 Cobra Glide catheter, selective access into the superior mesenteric artery was obtained and arteriogram was performed. This demonstrated a patent superior mesenteric. There was equivocal extravasation of contrast from the region of the gastroduodenal artery; however, this determination was difficult due to the overlying transverse colon. Next, selective access into the common hepatic artery was obtained with a C2 Cobra Glide catheter and angled Glidewire. Hepatic arteriogram demonstrated active extravasation of contrast from the region of the gastroduodenal- gastroepiploic junction as well as a branch of the superior pancreaticoduodenal artery. Superselective access was obtained into the gastroduodenal artery. Arteriogram performed at this position demonstrated active extravasation. Superselective access was obtained into the gastroepiploic artery. Arteriogram performed at this position demonstrated a patent gastroepiploic and confirmed that the catheter was distal to the site of extravasation in ideal location for snadwich technique of exclusion of the beeding source. Based on the diagnostic arteriograms, it was decided that the patient was a good candidate for and would benefit from embolization. With gradual withdrawal of the catheter four 3 mm x 5 cm coils were deployed across the area of active extravasation in the gastroduodenal- gastroepiploic junction. Superselective arteriogram of the proximal gastroduodenal artery demonstrated cessation of flow through this vessel. However, continued active extravasation was observed from a proximal branch of the superior pancreaticoduodenal artery. Superselective catheter access was obtained into the superior pancreaticoduodenal artery towards the superior mesenteric artery and an arteriogram was done. It showed patent vessel and good catheter position distal to the bleeding site. Three coils were deployed in the superior pancreaticoduodenal artery with gradual withdrawal of the catheter. A small amount of residual flow was observed on post- embolization arteriogram from the gastroduodenal artery. Subsequently, three additional 3 mm x 5 cm coils were deployed across the proximal gastroduodenal artery. Post- coiling arteriogram from the common hepatic artery demonstrated cessation of flow through the gastroduodenal artery and its branches including the gastroepiploic and superior pancreaticoduodenal. No further extravasation of contrast was observed. The catheter was subsequently removed. The sheath was secured with 0 silk suture. The patient was taken back to the intensive care unit in stable condition. There were no immediate post-procedure complications. IMPRESSION: 1. Active extravasation into the duodenum from the gastroduodenal- gastroepiploic junction and a branch of the superior pancreaticoduodenal artery. 2. Successful coiling of the gastroepiploic, gastroduodenal, and superior pancreaticoduodenal arteries. Post-embolization arteriogram demonstrated no further evidence of active extravasation [**1-6**] Abdominal CT: 1. Wedge-shaped low density spleen lesion, somewhat improved since the last examination, representing an infarct. 2. Low density lesion in the adrenal gland. A non-contrast CT scan of this region should be obtained on a nonemergent basis to ensure its benignity. 3. Otherwise, no significant interval change. [**1-10**] Video Swallow Eval: Weak oral phase with delayed swallow. Silent aspiration of thin liquids, nectar thickened liquids, and purees. Pharyngeal residue seen within the valleculae. [**12-24**] Chest CT: 1. Wedge-shaped low-density area in the spleen, probably representing infarction. No evidence of abscess formation. 2. Status post coiling of gastroduodenal arteries, with nonspecific fat stranding surrounding the coils. 3. Small left pleural effusion. 4. Gallstone. [**12-24**] IVC placement: Successful placement of a recovery IVC filter in the inferior vena cava. A retrievable filter had to be used since teh patient is potentially infected and superinfection of the filter without ability to remove it may have serious consequences. [**12-22**] CTA Chest: No pulmonary embolus. Bibasilar atelectasis and small bilateral pleural effusions. [**12-12**] Heat CT: No evidence of intracranial hemorrhage or mass effect. Please note that MRI is more sensitive than CT in the detection of acute ischemia if this is the clinical concern. See above report for additional findings. ENDOSCOPY: [**11-29**] EGD: Small hiatal hernia There was no evidence of blood in the stomach. There was stigmata of NG trauma. There was no evidence of post bulbar bleeding. Ulcer in the distal bulb Otherwise normal egd to second part of the duodenum [**11-30**] EGD: A large blood clot starting in the distal portion of the duodenal bulb and extending past the duodenal sweep was noted. There was active oozing around the clot. Despite multiple washings and use of polypectomy snare the clot could not be fully dislodged to visualize the source of bleeding. Bright red blood was noted distal to the clot site. Epinephrine was not used due to lack of visualization and ongoing myocardial infarction. Cardiology [**1-9**] Transthoracic Echo: The left atrium is elongated. The right atrium is moderately dilated. The left ventricular cavity size is normal. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The aortic valve is not well seen. There is a minimally increased gradient consistent with minimal aortic valve stenosis. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. No mitral regurgitation is seen. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. No vegetation seen (cannot exclude). Brief Hospital Course: This is an 86 year old gentleman who presented as a transfer from his nursing home with bloody stools. He had a prolonged hospital course as summarized below: GI: The patient was admitted with hematemesis. His hematocrit was 14 in the ER on presentation and NGT was bloody; he was intubated for aspiration precautions and immediately transfused with blood and FFP. Endoscopy was performed with findings of bleeding duodenal ulcerations. This could not be controlled endoscopically and the patient was taken for angiography with embolization on the day after admission, with resolution of his bleeding. After further bleeding on [**11-30**] he was taken to the operating room and underwent exp lap, duodenotomy, oversewn ulcer, j-tube placement and biopsy of liver mass. He was continued on a proton pump inhibitor. He failed various swallow evaluations and was fed through his J-tube. He had some diarrhea which improved with elemental formula. Pulm: The patient remained intubated in the intensive care unit for several days. During this time he was found to have MRSA positive sputum which was treated. He was successfully extubated and had normal pulmonary functions through the majority of his hospital course. He had some CHF that was effectively treated with daily Lasix diuresis. Neurology: During the [**Hospital 228**] hospital course he demonstrated periods of aphasia and dysarthria/dysphagia. He was evaluated by neurology and it was felt that this was consistent with his baseline dementia, with some component of overlying delirium. He remained stable throughout his hospital course and workup with Head CT and EEG was consistent with encephalopathy but no acute process. Heme: The patient was found to have superficial femoral vein clots. Given the patient's need for anticoagulation from his prior hip surgery, and his risk for further GI bleeding, an IVC filter was placed for prophylaxis. His coagulation studies remained normal throughout his hospital course after reversal upon his admission. He was started on iron and folate supplementation for anemia. ID: During the patient's prolonged ICU and hospital course, he developed several infectious processes which were treated. He had pseudomonas in his urine and blood which was treated with a course of Zosyn and follow-up studies were negative. He developed profound fevers during mid-late [**Month (only) 1096**] which were evaluated with serial cultures and echo studies with no positive cultures; these fevers eventually resolved. Please see the listing of his culture date under "Results" section. Ortho: The patient worked with physical therapy but was essentially bed-ridden given his recent right hip surgery and dementia. Dispo: Per consultation with the patient's family and social work services, a rehabiliation bed was found for the patient. He was discharged with planned interval follow-up with Dr. [**Last Name (STitle) 519**]. Discharge Medications: 1. Ferrous Sulfate 300 mg/5 mL Liquid Sig: One (1) PO DAILY (Daily). 2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Oxycodone 5 mg/5 mL Solution Sig: Two (2) ml PO Q8H (every 8 hours) as needed. 4. Fluconazole 150 mg Tablet Sig: One (1) Tablet PO QWEEK (). 5. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day). 6. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) ml Injection [**Hospital1 **] (2 times a day). 7. Tamsulosin 0.4 mg Capsule, Sust. Release 24HR Sig: One (1) Capsule, Sust. Release 24HR PO HS (at bedtime). 8. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**1-14**] Sprays Nasal TID (3 times a day). 9. Beclomethasone Diprop Monohyd 0.042 % Aerosol, Spray Sig: One (1) Spray Nasal [**Hospital1 **] (2 times a day). 10. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 11. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal HS (at bedtime) as needed. 12. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig: One (1) suspension PO BID (2 times a day). 13. Albuterol Sulfate 0.083 % Solution Sig: One (1) INH Inhalation Q6H (every 6 hours) as needed. 14. Zinc Oxide-Cod Liver Oil 40 % Ointment Sig: One (1) Appl Topical PRN (as needed). 15. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 16. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 17. Loperamide 1 mg/5 mL Liquid Sig: Two (2) mg PO QID (4 times a day). Tubefeeding: Probalance Full strength; Additives: Banana flakes, 3 packets per day Starting rate: 75 ml/hr; Do not advance rate Goal rate: 75 ml/hr Residual Check: q4h Hold feeding for residual >= : 100 ml Flush w/ 30 ml water Before and after each feeding Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - [**Location (un) 550**] Discharge Diagnosis: Primary: Duodenal Ulcer Bleed Secondary: Dementia, Pneumonia, Urinary Tract infections, tube-feeding dependence, COPD, hypertension, depression, s/p R total hip replacement Discharge Condition: stable Discharge Instructions: Please take medications as prescribed and read warning labels carefully. Please follow intructions as previously discussed by Dr. [**Last Name (STitle) 519**]. If symptoms worsen, such as bloody vomitus, bloody or black stool, or fainting, please call or go to the emergency room. Followup Instructions: Please Follow up with Dr. [**Last Name (STitle) 519**] within 1-2 weeks. Please call ahead of time to confirm appointment. ([**Telephone/Fax (1) 2007**]. Please follow-up with Dr. [**Last Name (STitle) **] in orthopaedics at [**Telephone/Fax (1) 9118**] [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 520**] MD, [**MD Number(3) 3226**] Completed by:[**2165-1-15**] Name: [**Known lastname 3624**],[**Known firstname **] Unit No: [**Numeric Identifier 9680**] Admission Date: [**2164-11-29**] Discharge Date: [**2165-1-19**] Date of Birth: [**2078-8-29**] Sex: M Service: SURGERY Allergies: Tramadol / Advil / Nsaids / Hydrocodone Attending:[**First Name3 (LF) 5964**] Addendum: In addendum to previously dictated discharge summary from [**2164-1-16**], rehab placement for the patient was found on [**2165-1-19**]. in the interval, he had a video swallow evaluation which he passed, and he was started on a purreed soft diet, with cycling of his tube feeds. His Zosyn was discontinued as was his fluconazole. All questions were answered to the satisfaction of him and his family upon discharge. Discharge Medications: 1. Ferrous Sulfate 300 mg/5 mL Liquid Sig: One (1) PO DAILY (Daily). 2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Oxycodone 5 mg/5 mL Solution Sig: Two (2) ml PO Q8H (every 8 hours) as needed. 4. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day). 5. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) ml Injection [**Hospital1 **] (2 times a day). 6. Tamsulosin 0.4 mg Capsule, Sust. Release 24HR Sig: One (1) Capsule, Sust. Release 24HR PO HS (at bedtime). 7. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**1-14**] Sprays Nasal TID (3 times a day). 8. Beclomethasone Diprop Monohyd 0.042 % Aerosol, Spray Sig: One (1) Spray Nasal [**Hospital1 **] (2 times a day). 9. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 10. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal HS (at bedtime) as needed. 11. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig: One (1) suspension PO BID (2 times a day). 12. Albuterol Sulfate 0.083 % Solution Sig: One (1) INH Inhalation Q6H (every 6 hours) as needed. 13. Zinc Oxide-Cod Liver Oil 40 % Ointment Sig: One (1) Appl Topical PRN (as needed). 14. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 15. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 16. Loperamide 1 mg/5 mL Liquid Sig: Two (2) mg PO QID (4 times a day). Discharge Disposition: Extended Care Facility: [**Hospital6 609**] for the Aged - [**Location (un) 1409**] Discharge Diagnosis: Primary: Duodenal Ulcer Bleed Secondary: Dementia, Pneumonia, Urinary Tract infections, tube-feeding dependence, COPD, hypertension, depression, s/p R total hip replacement Discharge Condition: stable Discharge Instructions: Pt should take all medications as prescribed. Calorie counts should be checked with goal of a slow ween off of tube feeding. He should be kept upright to prevent from aspiration precautions. If symptoms worsen, such as bloody vomitus, bloody or black stool, or fainting, please call or go to the emergency room. Followup Instructions: Please Follow up with Dr. [**Last Name (STitle) 1180**] within 1-2 weeks. Please call ahead of time to confirm appointment. ([**Telephone/Fax (1) 7848**]. [**First Name11 (Name Pattern1) 1080**] [**Last Name (NamePattern4) 3711**] MD, [**MD Number(3) 5966**] Completed by:[**2165-1-18**]

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46628

Discharge summary

report

Admission Date: [**2120-2-19**] Discharge Date: [**2120-2-28**] Date of Birth: [**2082-6-19**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 4765**] Chief Complaint: DOE, chest pressure Major Surgical or Invasive Procedure: None History of Present Illness: Pt is a 35 year-old man who has a h/o palpitations/SVT for over 10 years s/p ablation of two left sided accessory pathways in [**2117-9-20**] who now presents with SVT with chest pressure and SOB. . Per Dr.[**Name (NI) 1565**] last OMR note in [**4-19**], "these were documented to be a long RP tachycardia, which turned out to be in a left-sided accessory pathway. (From [**2117-1-6**] to [**2117-1-28**] the pt underwent a Pt Activated [**Name (NI) 99007**] Recorder that made note of episodes of Afib that occurred right after runs of rapid SVT with brief conversion to sinus. Prominent ST depressions were noted during these episodes also. The majority of the episodes were a long RP tachycardia that occasionally degenerated into atrial fibrillation.) He underwent a mapping and ablation of his pathway in [**2117-9-13**], localized to two locations on the left side of the mitral annulus. These were ablated. For the following seven months, he was free of symptoms whatsoever. He then began to develop a recurrence of palpitations, however, these were distinctly different than his supraventricular tachycardia. They were less intense and shorter in duration. In retrospect, he felt a similar feeling after some of his more typical SVT episodes prior to his ablation. Further monitoring ([**4-19**]) found that he is having runs of paroxysmal atrial fibrillation. He occasionally has a narrow complex tachycardia preceding this, which looks like an atrial tachycardia, perhaps the pulmonary vein etiology. In general, he is doing quite well with these and only has enduring periods of heightened stress. When relaxed, he seems to be very quiescent from any arrhythmia standpoint." . Pt. had been in his usual state of health until last night before admission when he couldn't sleep, feeling subjectively hot and cold. He developed chest pressure when lying on left chest starting roughly around MN. He also notes DOE, feeling winded when climbing one flight of stairs. He took atenolol 50 mg PRN (he takes PRN); however, symptoms persisted until he saw his PCP [**Last Name (NamePattern4) **] 6PM, who noted SVT with rate of 170, and sent him to ED. Possible triggers recently include several stressors in his life, URI symptoms (earache), recent etOH on Saturday, 2 cups of coffee daily chronically. . In ED, had unsuccessful cardioversion attempted with ibutilide, successfully converted with 200J without complication. CXR showed mild pulmonary edema. EP consulted and recommended atenolol 50 mg qd and observation. During obs, his HR increased to 150s with oxygen sats in 90-93% on room air. This rhythm was noted to be aflutter. He received propafenone 600 mg X1 and was cardioverted again (200J) to sinus rhythm. His CXR is suggestive of mild pulmonary edema and resting sats 92% on 8L NC. Per EP, he will continue propafenone 150mg q8hours and possible ablation in am. . In CCU, he reports feeling slightly better. he is still c/o mild left chest pressure only when he leans on L side. +mild SOB with talking. No sensation of palpitattions, LHD, dizzyness. he does feel very tired as he has not slept in 48 hrs. . On review of symptoms, 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 exertional buttock or calf pain. All of the other review of systems were negative. . Cardiac review of systems is notable for absence of paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. Past Medical History: SVT PAF Right inguinal hernia at age of 1 Social History: Patient is married and works as a sales engineer. Social history is significant for the absence of current tobacco use. There is no history of alcohol abuse. There is no family history of premature coronary artery disease or sudden death. Family History: Father: hx premature atrial fibrillation Mother: MVP Physical Exam: VS: T 99 , BP 131/95 , HR 104, RR 18, O2 92% on 5LNC Gen: WDWN young male in mild resp distress. Oriented x3. Mood, affect appropriate. Pleasant. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. MM dry. Neck: Supple with JVP at 10 cm (under jaw) CV: tachycardic, regular, normal S1, S2. No S4, no S3. No murmurs Chest: No chest wall deformities, scoliosis or kyphosis. Scarce crackles L>R 1/3 up bilaterally Abd: soft, NTND, No HSM or tenderness. No abdominial bruits. Ext: No c/c/e. Skin: No stasis dermatitis, ulcers, scars, or xanthomas. Pulses: Right: Carotid 2+ without bruit; 2+ DP Left: Carotid 2+ without bruit; 2+ DP Pertinent Results: TRANSESOPHAGEAL ECHOCARDIOGRAM: No spontaneous echo contrast or thrombus is seen in the body of the left atrium/left atrial appendage or the body of the right atrium/right atrial appendage. No atrial septal defect or patent foramen ovale is seen by 2D, color Doppler or saline contrast with maneuvers. The ascending, transverse and descending thoracic aorta are normal in diameter and free of atherosclerotic plaque to 45 cm from the incisors. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion. No masses or vegetations are seen on the aortic valve. No aortic regurgitation is seen. The mitral valve leaflets are structurally normal. No mass or vegetation is seen on the mitral valve. Mild (1+) mitral regurgitation is seen. IMPRESSION: No thrombus, masses, or vegetations identified. No PFO/ASD. Mild mitral regurgitation. . . TRANSTHORACIC ECHOCARDIOGRAM The left atrium is mildly dilated. The right atrium is moderately dilated. The estimated right atrial pressure is 0-10mmHg. Left ventricular wall thicknesses are normal. 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 pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. . . MRI/MRI HEAD AND NECK 1. Acute infarct of the medial right posterior temporal and occipital lobes. Small acute infarct of the right thalamus. 2. Acute thromboembolism of the P2 segment of the right posterior cerebral artery. 3. Normal MRA of the neck. . . CT ANGIOGRAM OF THE CHEST 1. No evidence of pulmonary embolism or pulmonary edema. 2. Bilateral pleural effusions with associated atelectasis. 3. Patchy areas of airspace disease involving both upper lobes suspicious for pneumonia. 4. The tip of the endotracheal tube is seen at the superior edge of the clavicles. Brief Hospital Course: The following issues were dealt with on this admission: . # Rhythm: On the evening of [**2-20**] the patient went into rapid atrial flutter with a rate in the 150's. He did not respond to a diltiazem drip, so he was started on procainamide following cardioversion, and then propafenone. He continued to have tachyarrhythmias on this regimen, and was started on amiodarone and esmolol drips on [**11-25**]. He did quite well on this regimen, and converted to sinus rhythm, with intermittent bouts of atrial fibrillation that were not sustained. He was transitioned to a po regimen of amiodarone and metoprolol on [**2-25**], which he tolerated well. . # Pump: Patient presented with signs and symptoms of pulmonary edema, confirmed on CXR and CT, which was thought to be secondary to a tachycardia-induced cardiomyopathy in the setting of his arrhythmia. An echocardiogram was ordered, and was wnl, and this was followed up with a cardiac MR (read pending on discharge). The edema was severe enough to require a brief period of intubation electively on [**2-20**]. The patient was extubated without any complications on the morning of [**2-22**]. . # CVA: Patient was found to have an acute right posterior cerebral infarction on CT head. MRI following showed an acute thromboembolism of the P2 segment of the right posterior cerebral artery, and acute infarction of the medial posterior temporal and occipital lobes, and a small acute infarct of the right thalamus. A TEE was negative for thrombus or ASD/PFO. Neurology was consulted, and recommeded anticoagulation with warfarin, with a heparin bridge to an INR of 2.5, and lipitor. He was discharged with follow up in coumadin clinic. . # PNA: The patient was found to have sputum cultures postive staph aureus, pan-sensitive, and resistant to penicillin. He was initially managed with vancomycin, and was transitioned to po dicloxacillin once his sensitivities confirmed the absence of MRSA. Medications on Admission: Atenolol Discharge Medications: 1. Warfarin 2.5 mg Tablet Sig: As directed by your coumadin clinic at Dr.[**Name (NI) 99008**] office Tablet PO once a day: Until your follow up with Dr. [**Last Name (STitle) **], continue to take 5mg each day, which is two 2.5mg tablets. Disp:*60 Tablet(s)* Refills:*2* 2. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). Disp:*180 Tablet(s)* Refills:*2* 3. Dicloxacillin 500 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours) for 3 days. Disp:*12 Capsule(s)* Refills:*0* 4. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO every twelve (12) hours. Disp:*60 Tablet(s)* Refills:*2* 5. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Atrial fibrillation Stroke Discharge Condition: Stable Discharge Instructions: You were admitted because you had an irregular heart rhythm. We controlled this with intravenous medications, and eventually transitioned you to oral medications called metoprolol and amiodarone. We will be discharging you with a monitor for your heart rhythm. This will be followed up by Dr. [**Last Name (STitle) 2357**]. . You also suffered a stroke during this admission, which required us to thin your blood with an IV medication called heparin. We transitioned you to an oral blood thinner called coumadin. You are also on a cholesterol drug called lipitor for stroke prevention. . You will need to follow up with your primary care physician [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] to monitor your coumadin. When you are on coumadin, we closely monitor a level in your blood called your INR, which measures how thin your blood is. This will be more frequent initially. Please see below for your follow up information. . You also need to follow up with Dr. [**Last Name (STitle) 2357**] for management of your abnormal heart rhythm. Please see below for follow up information. . . Please take all of your medications as indicated below. . . If you experience any concerning symptoms, please return to the emergency department. Followup Instructions: 1. Dr.[**Name (NI) 99008**] office will be in touch regarding follow-up for your coumadin 2. Dr.[**Name (NI) 7719**] nurse practitioner will contact you regarding follow up for your rhythm.

[ "458.29", "434.11", "V15.82", "427.89", "272.4", "482.41", "428.0", "425.9", "427.32", "434.01", "427.31" ]

icd9cm

[ [ [] ] ]

[ "96.71", "96.04", "38.93", "88.72", "99.62" ]

icd9pcs

[ [ [] ] ]

9936, 9942

7180, 9139

335, 342

10013, 10022

5067, 7157

11330, 11523

4290, 4345

9198, 9913

9963, 9992

9165, 9175

10046, 11307

4360, 5048

276, 297

370, 3951

3973, 4017

4033, 4274

47,683

173,366

50223

Discharge summary

report

Admission Date: [**2159-3-28**] Discharge Date: [**2159-4-1**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 7651**] Chief Complaint: Dyspnea Major Surgical or Invasive Procedure: None History of Present Illness: 84yo male with a history of congestive heart failure and multiple recent admissions was admitted from home with increased light-headedness and found to have acute renal failure. . He reports feeling light-headed with exertion with an episode the morning of admission of presyncope where he lowered himself to the ground hurting his back. He reports no LOC or hitting his head. He reports sensation of knees buckling. He had a second episode today when he walked in to get his blood drawn at clinic. He was asymptomatic at rest. According to his daughter, his systolic blood pressure was in the 60-70s over the previous few days and was in the 80s on the day of admission. Also of note, weight up from 201-205 over 2 days. . Review of systems. The patient denies any chest pain or pressure, new exertional dyspnea, orthopnea, PND or leg edema, palpitations, claudication-type symptoms, melena, rectal bleeding, or transient neurologic deficits. No change in weight, bowel habit or urinary symptoms. No cough, fever, night sweats, arthralgias, myalgias, headache or rash. All other review of systems negative. Of note, patient was recently admitted to [**Hospital1 18**] from [**Date range (1) 104757**]/09 for dyspnea and CHF exacerbation. He was initially requiring noninvasive ventilation in the ED. His [**Date range (1) 113**] on admission demonstrated worsening MR. [**Name13 (STitle) **] was diuresed initially with a lasix gtt and was then transitioned to torsemide 80mg [**Hospital1 **] and metolazone. Given a rise in his creatinine on the 48 hours prior to discharge, he was ultimately discharged on a regimen of torsemide 60mg [**Hospital1 **] without metolazone. His weight on admission was 106kg and on the day of discharge was 92kg. Regarding his MR, he was continued with medical management given that he was not interested in surgical repair. . Upon arrival to the ED, vital signs were 97.6, HR 55, BP 75/44, and 100% on 2L. His exam was notable for clear lungs, no peripheral edema. His labs were notable for mild hyponatremia at 130, acute renal failure with a creatinine of 4.3. He was given ibuprofen 600mg PO x 1. He received 1L NS with some improvement in his blood pressure. 62 / 78/47 / 20 / 98% on 2L. . Past Medical History: 1. Multiple Myeloma - treated at DF currently, on dexamethasone 2. DVT x 2, on coumadin 4. Valvular heart disease (MODERATE MR) 5. Hyperlipidemia 6. BPH 7. Constipation 8. Hypertension 9. Plantar fasciitis 10. Severe leg pain PAST SURGICAL HISTORY: 1. Appendectomy and tonsillectomy as a child 2. Nephrolithiasis s/p stone removal by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 986**] in [**2146**] 3. cholecystectomy by Dr. [**Last Name (STitle) **] in [**2153-9-17**] Social History: He does not smoke nor drink. Smoked < 1 year when young. He is married, has a son and a daughter. [**Name (NI) **] used to run a sportswear factory. Family History: His father died at 90 of cancer in the brain and his mother at 52 of breast cancer. Physical Exam: VS: T 97 HR 63 BP 73/47 RR 18 96%2L down to RA at discharge GEN:The patient is in no distress and appears comfortable SKIN:No rashes or skin changes noted HEENT: Flat JVD neck supple, No lymphadenopathy in cervical, posterior, or supraclavicular chains noted. CHEST:Lungs are clear without wheeze, rales, or rhonchi. CARDIAC: Regular rhythm; [**2-23**] Holosystemic murmurs best heard in LLSB, no rubs, or gallops. ABDOMEN: No apparent scars. Obese, Non-distended, and soft without tenderness EXTREMITIES:trace peripheral edema B/L, warm without cyanosis NEUROLOGIC: Alert and appropriate. CN II-XII grossly intact. BUE [**5-22**], and BLE [**5-22**] both proximally and distally. No pronator drift. Reflexes were symmetric. [**Last Name (un) **] going toes. Pulses: Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 1+ PT 1+ Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 1+ PT 1+ Pertinent Results: [**2159-3-28**] 03:30PM GLUCOSE-102 UREA N-71* CREAT-4.3*# SODIUM-130* POTASSIUM-3.5 CHLORIDE-81* TOTAL CO2-37* ANION GAP-16 [**2159-3-28**] 03:30PM estGFR-Using this [**2159-3-28**] 03:30PM LD(LDH)-271* CK(CPK)-132 [**2159-3-28**] 03:30PM cTropnT-0.10* [**2159-3-28**] 03:30PM CK-MB-3 [**2159-3-28**] 03:30PM WBC-10.1 RBC-3.49* HGB-11.3* HCT-33.5* MCV-96 MCH-32.3* MCHC-33.7 RDW-14.4 [**2159-3-28**] 03:30PM NEUTS-74.9* LYMPHS-14.2* MONOS-8.4 EOS-1.9 BASOS-0.6 [**2159-3-28**] 03:30PM PLT COUNT-284 [**2159-3-28**] 02:00PM UREA N-70* CREAT-4.1*# SODIUM-134 POTASSIUM-3.7 CHLORIDE-81* TOTAL CO2-38* ANION GAP-19 [**2159-3-28**] 02:00PM estGFR-Using this [**2159-3-28**] 02:00PM PT-22.7* INR(PT)-2.2* [**2159-3-28**] CXR IMPRESSION: Residual bibasilar atelectasis/effusion. Improved overall aeration and resolving CHF. Brief Hospital Course: 84yo male with a history of diastolic CHF, hypertension, and severe mitral regurgitation was admitted with acute on chronic diastolic heart failure, acute on chronic renal insufficiency, and hyponatremia. . 1. Acute on Chronic Kidney Injury-Etiology of his acute kidney injury is likely related to pre-renal causes such as aggressive diuresis, starting an ACEI, and a fluid restricted PO intake. Patient received 1L normal saline in the ED and received another 1.5L in CCU. Additional possibilities include allergic interstitial nephritis secondary to metolazone as this was a new medication for him during his previous admission. Post-renal causes are also possible given his BPH, although he has been draining urine without problem. [**Name (NI) **] consistent with prerenal azotemia. Creatinine improved to baseline with conservative care and holding diureses and AceI. . 2. Acute on Chronic Diastolic Congestive Heart Failure-Patient has had very difficult to manage heart failure in the past, resulting in multiple frequent admissions and aggressive diuresis. Patient's discharge regimen was torsemide 60mg [**Hospital1 **] which was a marked increase from his previous regimen of furosemide 80mg daily. Dry weight is ~97kg. Held torsemide on admission bc of ARF but restarted 20mg PO BID upon discharge when renal function returned to baseline. Resumed ACEI in the setting of acute renal failure. Held off on resuming BB because of borderline low BP. . 3. Hypotension- He was asymptomatic at rest and mentating well. Patient's discharge SBP was in the 80s so low baseline to start. That coupled with reinstiution of antihypertensives for needed for CHF and volume depletion in the setting of overdiuresis were likely. Received 2L fluids and BP improved along with UO. . 4. Mitral Regurgitation- Patient had a history of mitral regurgitation and on a recent [**Hospital1 113**], this was noted to be worsened over the last 2-3 months. Patient has been undergoing medical therapy as he does not want surgery. Restarted torsemide 20mg PO bid and lisinopril 2.5mg PO daily to keep patient I/O even. . 5. h/o DVTs-Patient was supratherapeutic upon discharge and INR therapeutic now. Continue coumadin 4mg daily if within INR [**2-20**]. . 6. Multiple Myeloma-Patient is followed at [**Company 2860**] and has been maintained on dexamethasone. Continue to hold dexamethasone secondary to fluid overload. . 7. BPH -Patient has a history of BPH and bladder spasms. Held finasteride for hypotension but consider restarting as outpatient. . 8. Obstructive Sleep Apnea-Patient has known sleep apnea, although he does not use CPAP at home. Will continue oxygen at night for comfort. # Back PAin -Patient felt like his fall prior to admission exacerbated old back injury. No neurologic deficits nor TTP. Improved with standing tylenol and monitor for improvement . # General Care cardiac - low sodium diet; replete electrolytes prn, Access: 2 PIVs, CODE: DNR/DNI, confirmed on admission, PPx: DVT ppx - anticoagulated on coumadin; Bowel regimen - senna and docusate, Disp: to rehab Medications on Admission: 1. Finasteride 5 mg daily 2. ASA 81mg PO daily 3. Calcitrate-Vitamin D 315-200 mg-unit [**Hospital1 **] 4. Multivitamins 5. Folic Acid 400mcg daily 6. Citalopram 40mg PO daily 7. Famotidine 20mg daily 8. Senna [**1-19**] tab qhs prn 9. Gabapentin 300 mg daily 10. Potassium Chloride 20mEq daily 11. Lisinopril 5mg PO daily 12. Metoprolol 12.5mg PO bid 13. Torsemide 60mg PO bid 14. Warfarin 4mg daily Discharge Medications: 1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 2. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 5. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours). 6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 8. Warfarin 2 mg Tablet Sig: Two (2) Tablet PO Once Daily at 4 PM. 9. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 10. Torsemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 11. Outpatient Lab Work Daily electrolytes, specifically potassium, and renal function Discharge Disposition: Extended Care Facility: [**Hospital6 4657**] - [**Location 1268**] Discharge Diagnosis: Primary: Acute Renal Failure Mitral Regurgitation Hypotension . Secondary: Diastolic Congestive Heart Failure Discharge Condition: Stable, satting well on room air. Discharge Instructions: You were admitted because of low blood pressures causing you to feel lightheaded. We also found you to have acute renal failure which we thought was due to too much diuretic. We gave you fluids which held your blood pressure medications and diuretics which both improved your renal failure and low blood pressure. . We changed your torsemide dose to 20mg by mouth twice a day. The rest of your medication regimen remains unchanged. Please note that your dry weight is about 97 kgs. . You should follow up with Dr.[**Name (NI) 17483**] in 1-2weeks. Please call his office to schedule an appointment ([**Telephone/Fax (1) 2037**]. . If you experience any of the following, chest pain, shortness of breath at rest or with exertion, cough, fever, chills, swelling in your legs, nausea, vomiting, or dizziness please call your doctor or go to your local emergency room. . Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs. Adhere to 2 gm sodium diet. Fluid Restriction:1.5L/day Followup Instructions: You should follow up with Dr.[**Name (NI) 17483**] in 1-2weeks. Please call his office to schedule an appointment ([**Telephone/Fax (1) 2037**]. Provider: [**First Name8 (NamePattern2) 1903**] [**Last Name (NamePattern1) 1904**], [**MD Number(3) 1240**]:[**Telephone/Fax (1) 62**] Date/Time:[**2159-4-17**] 2:30 Provider: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 719**] Date/Time:[**2159-4-12**] 9:00 Completed by:[**2159-4-1**]

[ "428.33", "584.9", "424.0", "V15.88", "V13.01", "724.5", "203.00", "327.23", "V12.51", "428.0", "458.9" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

9453, 9522

5101, 8183

269, 276

9676, 9712

4235, 5078

10758, 11236

3238, 3324

8635, 9430

9543, 9655

8209, 8612

9736, 10735

2811, 3056

3339, 4216

222, 231

304, 2538

2560, 2788

3072, 3222

69,761

133,673

10094

Discharge summary

report

Admission Date: [**2152-4-12**] Discharge Date: [**2152-4-16**] Date of Birth: [**2081-2-11**] Sex: M Service: NEUROSURGERY Allergies: Lipitor / Niacin Attending:[**First Name3 (LF) 1835**] Chief Complaint: Sphenoid [**Doctor First Name 362**] mass Major Surgical or Invasive Procedure: [**2152-4-12**]: Angiogram w/embolization [**2152-4-13**]: Left craniotomy for meningioma History of Present Illness: 71M seen [**2152-4-4**] in consultation for a newly diagnosed left sphenoid [**Doctor First Name 362**] meningioma. On [**3-16**], he awoke and was found to be very confused by his wife, and amnestic to recent events. She called the PCP, [**Name10 (NameIs) 1023**] recommended they go to the ER. While at [**Hospital6 204**], a MRI of the head was done and a left sphenoid [**Doctor First Name 362**] meningioma was discovered. Past Medical History: Atrial Fibrillation(on coumadin) Osteoarthritis s/p hemithyroidectomy for multinodular thyroid Dyslipidemia Hypertension s/p hernia repair s/p APPY Social History: Patient lives with Wife and has 7 grown kids. He denies ETOH, tobacco, or h/o IVDU. He worked for the power company for 40 years. Family History: Non contributory Physical Exam: Exam on Discharge: AOx3, face is symmetric. Tongue is midline. EOMI. Full strength and sensation in all exremities. Wound is clean dry and intact. Pertinent Results: Labs on Admission: [**2152-4-12**] 11:38AM BLOOD PT-16.4* PTT-26.6 INR(PT)-1.5* [**2152-4-13**] 03:07AM BLOOD Glucose-114* UreaN-14 Creat-1.1 Na-139 K-4.1 Cl-106 HCO3-26 AnGap-11 [**2152-4-13**] 03:07AM BLOOD WBC-12.9* RBC-4.36* Hgb-13.9* Hct-40.9 MCV-94 MCH-31.8 MCHC-33.9 RDW-14.1 Plt Ct-243 Labs on Discharge: [**2152-4-15**] 06:30AM BLOOD WBC-23.6* RBC-3.90* Hgb-12.3* Hct-36.8* MCV-94 MCH-31.6 MCHC-33.5 RDW-13.4 Plt Ct-263 [**2152-4-15**] 06:30AM BLOOD PT-12.4 PTT-22.1 INR(PT)-1.0 [**2152-4-15**] 06:30AM BLOOD Glucose-129* UreaN-19 Creat-1.0 Na-138 K-3.9 Cl-104 HCO3-25 AnGap-13 --------------- IMAGING: --------------- CT HEAD [**3-14**](POST-OP): No concerning postoperative hemorrhage. Expected postoperative changes including pneumocephalus, edema, soft tissue swelling and subcutaneous emphysema MRI HEAD [**3-15**](POST-OP):Status post resection of left-sided meningioma with no large area of residual enhancement identified. For residual subtle enhancement in the region of left cavernous carotid artery and adjacent left clinoid process, followup examination would be helpful for better assessment. No acute infarct or hydrocephalus seen. Brief Hospital Course: Patient was electively admitted on [**4-12**] for staged procedures to address his sphenoid [**Doctor First Name 362**] meningioma. On [**4-12**], his warfarin therapy was reversed and angiogram with embolization of feeding vessels. He was then recovered in the PACU pending craniotomy the following morning. Overnight [**4-12**], there was some bleeding from the right groin puncture site. Pressure was held over the right going for approx 30min, and bleeding stopped. His distal pulses remained intact. Additionally, overnight a WAND MRI study was performed for surgical planning. On [**4-13**], he was taken to the OR for left craniotomy for sphenoid [**Doctor First Name 362**] mass resection. Post-operatively, he was taken to the ICU for frequent neurologic monitoring. A post-operative CT of the head was done, showing expected post-operative findings, as well as post-operative MRI head to evalaute the extent of resection. On [**4-14**], steroid taper began(plan to taper every other day to "off"). He was trasnferred to the floor on [**4-14**]. He was seen and evaluate by PT and OT therapies, who determined he would be appropriate for disposition to home without the need for services. Follow up instructions were given for follow up in the Brain [**Hospital 341**] Clinic. Medications on Admission: AMLODIPINE - 5 mg Tablet - 1 Tablet(s) by mouth qam COLESEVELAM [WELCHOL] - 625 mg Tablet - 3 Tablet(s) by mouth twice a day DIGOXIN - 125 mcg Tablet - 1 Tablet(s) by mouth once a day EZETIMIBE [ZETIA] - 10 mg Tablet - 1 Tablet(s) by mouth once a day LEVETIRACETAM [KEPPRA] - (Prescribed by Other Provider) - 500 mg Tablet - 1 (One) Tablet(s) by mouth every twelve (12) hours METOPROLOL SUCCINATE - 200 mg Tablet Sustained Release 24 hr - 1 Tablet(s) by mouth once a day NIACIN [NIASPAN] - 500 mg Tablet Sustained Release - 1 Tablets(s) by mouth twice a day WARFARIN - 5 mg Tablet - 2 Tablet(s) by mouth once a day Medications - OTC FISH OIL-DHA-EPA - 1,200 mg-144 mg Capsule - 2 Capsule(s) by mouth once a day FOLIC ACID Discharge Medications: 1. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*50 Tablet(s)* Refills:*0* 2. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr Sig: Two (2) Tablet Sustained Release 24 hr PO DAILY (Daily). 5. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day): continue to take while you require narcotics. Disp:*30 Capsule(s)* Refills:*0* 8. Acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for Pain. 9. Colesevelam 625 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). 10. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Niacin 500 mg Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO BID (2 times a day). 12. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Disp:*120 Tablet(s)* Refills:*0* 13. Dexamethasone 1.5 mg Tablet Sig: Two (2) Tablet PO q6 () for 2 days: 3mg po q6 Duration: 2 Days . Disp:*10 Tablet(s)* Refills:*0* 14. Dexamethasone 2 mg Tablet Sig: One (1) Tablet PO every six (6) hours for 2 days: 2 mg po q6hx 2 Days Start: After 3 mg tapered dose. . Disp:*12 Tablet(s)* Refills:*0* 15. Dexamethasone 0.5 mg Tablet Sig: Two (2) Tablet PO every six (6) hours for 2 days: 1 mg po q6H x2 Days Start: After 2 mg tapered dose. Disp:*16 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Sphenoid [**Doctor First Name 362**] meningioma Discharge Condition: Neurologically Stable Discharge Instructions: GENERAL INSTRUCTIONS WOUND CARE: ?????? You or a family member should inspect your wound every day and report any of the following problems to your physician. ?????? Keep your incision clean and dry. ?????? You may wash your hair with a mild shampoo 24 hours after your sutures are removed. ?????? Do NOT apply any lotions, ointments or other products to your incision. ?????? DO NOT DRIVE until you are seen at the first follow up appointment. ?????? Do not lift objects over 10 pounds until approved by your physician. DIET Usually no special diet is prescribed after a craniotomy. A normal well balanced diet is recommended for recovery, and you should resume any specially prescribed diet you were eating before your surgery. Be sure however, to remain well hydrated, and increase your consumption of fiber, as pain medications may cause constipation. MEDICATIONS: ?????? Take all of your medications as ordered. You do not have to take pain medication unless it is needed. It is important that you are able to cough, breathe deeply, and is comfortable enough to walk. ?????? Do not use alcohol while taking pain medication. ?????? Medications that may be prescribed include: -Narcotic pain medication such as Dilaudid (hydromorphone). -An over the counter stool softener for constipation (Colace or Docusate). If you become constipated, try products such as Dulcolax, Milk of Magnesia, first, and then Magnesium Citrate or Fleets enema if needed). Often times, pain medication and anesthesia can cause constipation. ?????? You have been discharged on Keppra (Levetiracetam), you will not require blood work monitoring. ?????? Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, Aspirin, Advil, and Ibuprofen etc, as this can increase your chances of bleeding. ?????? You are being sent home on steroid medication(taper to off), make sure you are taking a medication to protect your stomach (Prilosec, Protonix, or Pepcid), as these medications can cause stomach irritation. Make sure to take your steroid medication with meals, or a glass of milk. ACTIVITY: The first few weeks after you are discharged you may feel tired or fatigued. This is normal. You should become a little stronger every day. Activity is the most important measure you can take to prevent complications and to begin to feel like yourself again. In general: ?????? Follow the activity instructions given to you by your doctor and therapist. ?????? Increase your activity slowly; do not do too much because you are feeling good. ?????? You may resume sexual activity as your tolerance allows. ?????? If you feel light headed or fatigued after increasing activity, rest, decrease the amount of activity that you do, and begin building your tolerance to activity more slowly. ?????? DO NOT DRIVE until you speak with your physician. ?????? Do not lift objects over 10 pounds until approved by your physician. ?????? Avoid any activity that causes you to hold your breath and push, for example weight lifting, lifting or moving heavy objects, or straining at stool. ?????? Do your breathing exercises every two hours. ?????? Use your incentive spirometer 10 times every hour, that you are awake. WHEN TO CALL YOUR SURGEON: With any surgery there are risks of complications. Although your surgery is over, there is the possibility of some of these complications developing. These complications include: infection, blood clots, or neurological changes. Call your Physician Immediately if you Experience: ?????? Confusion, fainting, blacking out, extreme fatigue, memory loss, or difficulty speaking. ?????? Double, or blurred vision. Loss of vision, either partial or total. ?????? Hallucinations ?????? Numbness, tingling, or weakness in your extremities or face. ?????? Stiff neck, and/or a fever of 101.5F or more. ?????? Severe sensitivity to light. (Photophobia) ?????? Severe headache or change in headache. ?????? Seizure ?????? Problems controlling your bowels or bladder. ?????? Productive cough with yellow or green sputum. ?????? Swelling, redness, or tenderness in your calf or thigh. Call 911 or go to the Nearest Emergency Room if you Experience: ?????? Sudden difficulty in breathing. ?????? New onset of seizure or change in seizure, or seizure from which you wake up confused. ?????? A seizure that lasts more than 5 minutes. Important Instructions Regarding Emergencies and After-Hour Calls ?????? If you have what you feel is a true emergency at any time, please present immediately to your local emergency room, where a doctor there will evaluate you and contact us if needed. Due to the complexity of neurosurgical procedures and treatment of neurosurgical problems, effective advice regarding emergency situations cannot be given over the telephone. ?????? Should you have a situation which is not life-threatening, but you feel needs addressing before normal office hours or on the weekend, please present to the local emergency room, where the physician there will evaluate you and contact us if needed. Followup Instructions: FOLLOW UP APPOINTMENT INSTRUCTIONS ??????Please return to the office in [**9-7**] days (from your date of surgery) for removal of your sutures and a wound check. This appointment can be made with the Nurse Practitioner. Please make this appointment by calling [**Telephone/Fax (1) 1669**]. If you live quite a distance from our office, please make arrangements for the same, with your PCP. ??????Please call the Brain [**Hospital 341**] Clinic Monday morning to schedule an appointment to be seen in approximatley 4 weeks time. The Brain [**Hospital 341**] Clinic is located on the [**Hospital Ward Name 516**] of [**Hospital1 18**], in the [**Hospital Ward Name 23**] Building, [**Location (un) **]. Their phone number is [**Telephone/Fax (1) 1844**]. ??????You will not need an MRI of the brain as this was done during your hospitalization. Completed by:[**2152-4-16**]

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Discharge summary

report

Admission Date: [**2134-5-26**] Discharge Date: [**2134-6-11**] Date of Birth: [**2060-8-31**] Sex: M Service: NEUROLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**Last Name (NamePattern1) 11784**] Chief Complaint: abnormal head CT Major Surgical or Invasive Procedure: 1. Stereotaxic right-frontal brain biopsy (Dr. [**First Name (STitle) **], nsgy) 2. Right-frontal Craniectomy for open brain biopsy (Dr. [**First Name (STitle) **], nsgy) History of Present Illness: Mr. [**Known lastname **] is a 73 yo M with hx traumatic fall in [**2127**] resulting in skull base fracture, bilateral IPH and SDH, partial R MCA infarct, prolonged ICU stay and PEG tube at that time, also hx afib, CAD, HLD, HTN, and [**Hospital 8466**] transferred from [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] based on CT head findings. He and his wife are rather vague historians. He says he just "didn't feel good" this morning. He reported mild abdominal pain but was able to eat breakfast without difficulty. His wife states he has seemed unwell for the past several days to weeks but cannot elaborate on this. Records indicate he was recently hospitalized at [**Hospital1 **] [**5-21**] for GI bleed. He underwent colonoscopy and it was thought bleed was possibly due to hemorrhoids. He denies headache, visual changes, weakness, sensory changes, bowel or bladder changes. No dysarthria, dysphagia, speech changes, cognitive changes, dizziness, fevers, chills, sweats, weight changes, vomiting, or diarrhea. He and his wife state they live alone and are independent with ADLs. He ambulates independently at baseline and per report has been doing well since his accident in [**2127**]. He has been on keppra since the accident but patient denies any seizure history. He received decadron 10 mg x1 in the ED. Past Medical History: -CAD s/p CABG -CHF -HLD -GERD -hx afib -traumatic fall in [**2127**] resulting in skull base fracture, bilateral temporal lobe IPH and SDH, partial R MCA infarct, prolonged ICU stay and PEG tube at that time Social History: -lives with wife. [**Name (NI) **] tobacco, etoh, or drug history. Family History: patient was unsure Physical Exam: ADMISSION PHYSICAL EXAM: Physical Examination; VS; T 98.6 P 74 BP 129/80 RR 16 100% RA Gen; lying in bed, NAD HEENT; NC/AT CV; RRR Pulm; CTA anteriorly Abd; soft, nt, nd Extr; no edema Neuro; MS; Awake, alert, friendly, and cooperative with exam. Speech is slow but fluent and at baseline as per wife. [**Name (NI) **] is a vague historian and has difficulty saying why he went to the ED today. He is oriented to [**Hospital1 18**] and year but cannot guess date or month. Able to do DOY forwards, but can only do one DOY backwards then stops, saying "this is tough." Can name pen but not knuckles. [**Last Name (un) 46566**] a watch a "telephone" but then self-corrects. Registers [**2-4**] words and recalls [**12-7**] at 5 minutes. Difficulty with Luria sequencing. b/l grasps. CN; PERRL 4mm-->3mm, horizontal eye movements intact, decreased upgaze. visual fields somewhat difficult to assess due to cooperation but appears to blink to threat. Left facial droop. Palate symmetric, tongue midline. Motor; normal bulk, paratonia throughout and increased tone in legs. Difficulty cooperating to assess drift but appears to have mild proximal LUE weakness (4+/5 deltoid, [**3-9**] tricep) and strength appears full in RUE. Distal strength limited by cooperation but handgrips strong. Uncooperative with LE testing but able to lift both legs symmetrically antigravity. Sensory; intact to light touch and pinprick throughout. Reflexes; 2+ at biceps, brachioradialis, patellars, 1+ achilles, toes upgoing b/l Coordination; FNF intact. RAMs slow b/l. Gait; deferred DISCHARGE PHYSICAL EXAM: VS: 97.5, BP 119/88, HR 60, RR 16, 100%RA GEN: AAOx1, cooperative, NAD HEENT: non-fixed R gaze preference, [**Month/Day (1) 3899**], OP clear, MM mildly dry, bandage over R frontal area, c/d/i CV: RRR no m/r/g PULM: CTA-B ABD: soft, very mildly distended, non-tender EXT: no peripheral edema. . NEUROLOGICAL EXAM: MS: AAOx1, cooperative. Speech is fluent but slow. Can do DOW forwards but not backwards. Recalls 0/3 words at 3 mins and [**1-7**] with cues. Moderate L-sided neglect noted throughout exam. . CN: PERRL 3->2mm; [**Name (NI) 3899**], pt blinks to threat. Mild left facial droop. Palate is symmetrical and tongue is midline. Shoulder shrug [**4-8**] bilaterally. . MOTOR: normal bulk, paratonia in UE's bilaterally and increased tone in LE's bilaterally. No drift. . [**Doctor First Name **] Tri [**Hospital1 **] WE FE FF IP R 5 5 5 5 5 5 5 L 4+ 5 5 5 5 5 5 . Patient unable to cooperate with LE exam, but was able to elevate both of his legs above the bed spontaneously . Sensation: Intact to light touch throughout. . Reflexes: 2+ and symmetric throughout, except 1+ bilaterally at achilles. Toes upgoing bilaterally. . Coordination: FNF, finger-to-nose, heel-knee-shin, and [**Doctor First Name **] normal. . Gait: Deferred. Pertinent Results: ADMISSION LABS: [**2134-5-26**] 01:30PM BLOOD WBC-6.2 RBC-4.90# Hgb-14.3# Hct-42.8# MCV-87 MCH-29.1 MCHC-33.3 RDW-15.7* Plt Ct-172# [**2134-5-26**] 01:30PM BLOOD Neuts-70.8* Lymphs-20.9 Monos-6.3 Eos-1.5 Baso-0.5 [**2134-5-26**] 01:30PM BLOOD PT-12.9 PTT-23.0 INR(PT)-1.1 [**2134-5-26**] 01:30PM BLOOD Glucose-85 UreaN-17 Creat-1.2 Na-141 K-4.3 Cl-104 HCO3-32 AnGap-9 [**2134-5-27**] 05:10AM BLOOD ALT-13 AST-14 LD(LDH)-178 AlkPhos-67 TotBili-0.7 [**2134-5-27**] 05:10AM BLOOD Albumin-3.8 Calcium-9.3 Phos-2.9 Mg-2.1 [**2134-5-26**] 01:36PM BLOOD Lactate-1.0 DISCHARGE LABS: [**2134-6-11**] 05:40AM BLOOD WBC-11.0 RBC-4.74 Hgb-14.1 Hct-41.6 MCV-88 MCH-29.8 MCHC-33.9 RDW-15.8* Plt Ct-232 [**2134-6-10**] 05:50AM BLOOD Glucose-105* UreaN-37* Creat-0.8 Na-137 K-4.4 Cl-102 HCO3-29 AnGap-10 IMAGING: CXR [**2134-5-26**]: IMPRESSION: No acute pulmonary process. No definite pulmonary nodule or mass identified. HEAD CT [**2134-5-26**]: IMPRESSION: 1. New vasogenic edema involving the right frontal lobe, with hypodense parenchymal lesion concerning for primary malignancy. MRI is recommended to further evaluate. 2. Encephalomalacia in the left temporal lobe and right temporo-occipital lobes likely reflects chronic infarction MR HEAD [**2134-5-27**]: IMPRESSION: New mass lesions in the right frontal, periventricular and temporal regions with some adjacent dural enhancement. The appearances are suggestive of primary brain neoplasm with appearances concerning for lymphoma or less likely glioma. The appearance would be unusual for metastatic disease; however, a it is [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] likely consideration. The nature of enhancement in the right parietal area of encephalomalacia is unclear. Multiple chronic infarcts are identified. CT ABD/PELVIS [**2134-5-27**]: IMPRESSION: 1. No definite evidence for primary or metastatic neoplasm. 2. Abdominal aortic aneurysm (33 mm) and iliac aneurysm, both increased somewhat since [**2127**]. Follow-up ultrasound surveillance is recommended in one year. 3. Mild small bowel prominence suggestive of a mild ileus. 4. Prior coronary bypass surgery. 5. Cholelithiasis. 6. Mild esophageal wall thickening, probably inflammatory in nature. MR HEAD [**2134-5-30**]: IMPRESSION: 1. Redemonstration of necrotic lesions in the right frontal lobe, right periventricular and right temporal lobe and right-sided dural enhancement. 2. Stable ventricular dimensions since the recent MR [**First Name8 (NamePattern2) **] [**5-27**],[**2133**] CT HEAD [**2134-5-31**]: IMPRESSION: Expected small amount of bleeding and pneumocephalus in the right frontal region related to a right-sided biopsy. CT HEAD [**2134-6-1**]: IMPRESSION: 1. In comparison to [**2134-2-28**] exam, there is no significant change in right frontal hemorrhage and small pneumocephalus related to recent biopsy. No evidence of new intracranial hemorrhage, shift of normal midline structures or hydrocephalus. 2. A 3.6 x 3 cm right frontal hypodense lesion, presumably a malignant focus, is unchanged in appearance with surrounding vasogenic edema and effacement of sulci. 3. Confluent hypodensities of left temporal and right temporal/occipital region, represents encephalomalacia, most likely due to remote infarction. Ex vacuo dilatation of the temporal [**Doctor Last Name 534**] of the left lateral ventricle is stable. 4. Sinus disease, as detailed above. MR HEAD [**2134-6-3**]: IMPRESSION: Enhancing right hemispheric brain lesions are identified for surgical planning. Surface markers were placed for planning purposes. CT HEAD [**2134-6-4**]: IMPRESSION: 1. Status post biopsy from right frontal approach with a small amount of subarachnoid blood; stable appearance of intraparenchymal blood from a prior biopsy site. Slight increase in pneumocephalus. 2. Stable appearance of bilateral temporo-occipital encephalomalacia. 3. Unchanged right maxillary sinus disease. VIDEO SWALLOW [**2134-6-9**]: IMPRESSION: Penetration and likely aspiration of nectar-thick barium with definite aspiration of thin barium Brief Hospital Course: 73 yo M with hx traumatic fall in [**2127**] resulting in skull base fracture, bilateral IPH and SDH, partial R MCA infarct, prolonged ICU stay and PEG tube at that time, also hx afib, CAD, HLD, HTN, and [**Hospital 8466**] transferred from [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] after he was found to have an abnormal CT head concerning for malignancy, now w/ frozen tissue pathology c/w GBM. . # Neuro: Mr. [**Known lastname **] was transferred to [**Hospital1 18**] Neurology with a Right-frontal brain mass. Although he had poorly-localizing "frontal" findings on his mental status exam, these were apparently not new (per family and patient), and overall his exam was not suggestive of a new brain lesion; this was more or less incidentally discovered on OSH ED NCHCT. MRI here did not make a definitive diagnosis (high-grade glioma versus lymphoma versus other), and the dexamethasone he had been started on was stopped due to the possibility of lymphoma. His prophylactic Keppra was continued. The first of two brain biopsies was stereotaxic, and was non-diagnostic (reactive gliosis and lymphocytes). The second biopsy (done on [**6-4**]) was diagnostic for glioblastoma multiforme. Patient's neuro exam has improved s/p biopsy, but has now stabilized. Family meeting on [**6-10**] with palliative care determined pt will be DNR/DNI with placement ideally at a [**Hospital1 1501**] with [**Hospital1 **] care. The family decided that they did not want treatment. Neuro-oncology had previously been consulted, but based on the family decision, no neuro-onc follow-up was arranged. As pt is demented at baseline and his wife has some mild dementia, pt's brother [**Name (NI) 3979**] is the main decision-maker. We sent patient out on 1gm keppra [**Hospital1 **] as well as dexamethasone PO, which will be a taper as follows: [**6-11**]: 2/2/2 [**6-12**]: 2/2/2 [**6-13**]: [**1-6**] (2mg [**Hospital1 **], and then pt is to be kept on this dose) Patient will need his sutures removed, so we made an appointment for him on [**6-17**] at 9am in the [**Hospital Unit Name **] [**Location (un) 470**] suite B. # Cardiology: patient with hx of afib, so we continued his amiodarone 200g QD, atorvastatin 2mg QD and metoprolol 12.5mg [**Hospital1 **] # CODE/CONTACT: DNR/[**Name2 (NI) 835**] (confirmed with family), brother [**Name (NI) **] (next of [**Doctor First Name **]) and nephew [**Name (NI) 4049**] [**Telephone/Fax (1) 46567**] Medications on Admission: -amidarone 200 mg daily -prevacid 30 mg EC daily -keppra 500 mg [**Hospital1 **] -metoprolol 12.5 mg [**Hospital1 **] -lipitor 20 mg daily Discharge Medications: 1. amiodarone 200 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily). 2. lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily). 3. atorvastatin 20 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily). 4. metoprolol tartrate 25 mg Tablet [**Last Name (STitle) **]: 0.5 Tablet PO BID (2 times a day). 5. levetiracetam 500 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO BID (2 times a day). 6. acetaminophen 325 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain/fever. 7. docusate sodium 50 mg/5 mL Liquid [**Last Name (STitle) **]: One Hundred (100) mg PO BID (2 times a day) as needed for constipation. 8. senna 8.6 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID (2 times a day) as needed for constipation. 9. bisacodyl 10 mg Suppository [**Last Name (STitle) **]: One (1) Suppository Rectal HS (at bedtime) as needed for Constipation. 10. dexamethasone 2 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO Q8H (every 8 hours): BUT DECREASE TO 2mg [**Hospital1 **] on [**6-13**] . Discharge Disposition: Extended Care Facility: [**Hospital1 700**] - [**Location (un) 701**] Discharge Diagnosis: Glioblastoma multiforme. Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). NEURO EXAM: notable for L-sided neglect, L facial droop, some L deltoid weakness and inability to cooperate with LE exam. Discharge Instructions: You were transferred to our [**Hospital1 18**] Neurology service due to the finding at [**Hospital3 4107**] of a large mass lesion on the right side of your brain (beneath your forehead). This lesion was biopsied with a needle, but the results were not diagnostic, so a larger biopsy was obtained on [**6-4**] and the final pathology showed glioblastoma multiforme (brain tumor). Your family decided not to treat you and to instead try to get you [**Month/Day (4) **] care for your cancer. We made the following changes to your medications: 1) We INCREASED your KEPPRA to 1 gram twice a day 2) We STARTED you on DEXAMETHASONE Q8H, then decreasing to 2mg [**Hospital1 **] on [**6-13**]. 3) We STARTED you on DOCUSATE 100mg twice a day as needed for constipation. 4) We STARTED you on SENNA 8.6mg twice a day as needed for constipation. 5) We STARTED you on BISACODYL 10mg per rectum at night as needed for constipation. 6) We STARTED you on TYLENOL 650mg every 6 hours as needed for pain or fever. DO NOT EXCEED 4GM in a given 24 hour period. Please continue to take your other medications as previously prescribed. If you experience any of the below listed Danger Signs please call your doctor [**First Name (Titles) **] [**Last Name (Titles) **] team. It was a pleasure taking care of you on this hospitalization. Followup Instructions: Please call your [**Last Name (Titles) **] team if you need assistance.

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28932

Discharge summary

report

Admission Date: [**2123-5-22**] Discharge Date: [**2123-5-31**] Date of Birth: [**2074-9-8**] Sex: M Service: MEDICINE Allergies: Penicillins / Terbutaline / Epinephrine / Glucocorticoids / Alupent / Iodine / Prednisone Attending:[**First Name3 (LF) 9853**] Chief Complaint: CHEST PAIN, SOB Major Surgical or Invasive Procedure: Intubation, Mechanical ventillation Femoral Central line placement PICC Placement History of Present Illness: 48 yo male with h/o severe COPD (requiring multiple intubations), diastolic CHF (EF 60% from [**2-/2122**]), CAD with reported prior MI, and hx of non-compliance, presented to ED today with shortness of breath and 3 hours of pleuritic substernal chest pain. On arrival to the ED, he was in acute distress with peripheral sat of 74% on room air, breathing 30-40 times per minute, with SBP=120, and having difficulty speaking. He improved to 100% on a NRB mask and was A&OX3 and able to relate part of his medical hx. EKG showing non-specific T-wave changes. The initial impression of the ED staff was that this pt was in heart failure given his hx and a CXR which they felt was c/w pulm edema. Lung exam was notable for diffuse wheezes. He was given lasix, 325 ASA, nitro (SL + drip) and nebs. He was switched from NRB to non-invasive BiPAP for concern over increasing effort to breathe, 15 minutes later, pt was intubated and sent for CTA of the Chest. This was negative for PE but showed extensive atelectasis of right lung, which ED interpreted as infectious. Given this finding, a low BNP, and his deteriorating condition (possible hypothermia), ED favored sepsis over CHF and fluid rescucitated him. A RIJ central line was placed which entered the right subclavian; this was removed and replaced with a right femoral line. A repeat chest x-ray was markedly different from his first CXR hours before showing new mediastinal shift to the right and new diffuse right sided opacities. He was given vanco/zosyn and admitted to the [**Hospital Unit Name 153**] with MAP=67 on levophed, HR=67, T=94.6 axillary. On arrival to the [**Hospital Unit Name 153**], T=97.0, BP= 106/63, HR=75, Peripheral Sat= 100% on AC 550, r=15, peep=5, FiO2=50%. On 0.06 of levophed, intubated and sedated with fentanyl/midazolam. Past Medical History: COPD with multiple intubations - h/o refusal to use steroids or BIPAP. Not on home O2 due to insurance issues. Diastolic CHF, followed at Sea Coast Cardiology in [**Location (un) 3844**] CAD s/p "multiple" MI's Multiple sclerosis per patient - stated was diagnosed 2 years ago followed by Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 12838**] ([**Telephone/Fax (1) 69783**]. However, when called this Dr. [**Last Name (STitle) 12838**], there was no record of patient. Diverticulosis Diabetes Mellitus GERD Social History: He is married, but his wife resides in a state psychiatric facility. He currently lives alone in CT. He is on disability. History of smoking with unknown # of pk years, currently denies smoking, ETOH, or recreational drug use. Family History: Father had emphysema, died of an MI at age 56. Mother died of an MI at age 70. Otherwise non-contributory. Physical Exam: VITALS: T99.1 BP124/86 HR80 RR24 SpO296/4l\L GENERAL: Appears uncomfortable, unable to finish complete sentences, frequent coughing CARD: RRR, difficult to appreciate due to lung sounds RESP: diffuse inspiratory and expiratory wheezes, but good air movement throughout ABD: obese, firm, nontender, nondistended EXT: no lower extremity edema NEURO: alert and oriented PSYCH: Talkative and insightful about his past, but unwilling to discuss details of personal life or current situation Pertinent Results: LABS: [**2123-5-26**] Na 142 K 3.3 Cl 102 CO2 30 BUN 11 Cr 0.8 Glu 77 Ca 8.9 Mg 1.9 P 2.6 ALT 6 AST 8 AP 61 TB 0.5 Alb 3.6 LDH 155 WBC 5.6 Hct 30.9 Plt 272 STUDIES: ECHO: LAST ECHO: [**2-/2122**] The left atrium is mildly dilated. Left ventricular wall thickness, cavity size, and global systolic function are normal (LVEF 60%). Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve leaflets are mildly thickened. There is mild mitral valve prolapse. There is no pericardial effusion. ECG: [**5-21**]: Baseline artifact. Sinus tachycardia. Diffuse ST-T wave changes which are non-specific. [**5-22**]: Sinus rhythm. Compared to tracing #1 no significant diagnostic change [**5-23**]: Marked sinus bradycardia Prolonged QT interval Since previous tracing of [**2123-5-22**], the heart rate is slower, the QT interval is longer IMAGING: [**5-22**] CTA: IMPRESSIONS: 1. No pulmonary embolism seen. 2. Atelectasis of the right upper and lower lobes and also partially the right middle lobe. 3. Mosaic appearance of the left lung likely due to air trapping rather than a perfusion abnormality. 4. OT tube terminates in the distal esophagus and needs to be advanced. Mildly dilated stomach. [**5-24**]: Portable CXR Right upper lobe middle atelectasis has increased as it did atelectasis in the right mid lung at the periphery. Right perihilar right lower lobe medially and left lower lobe medial atelectases are unchanged. There are no increasing pleural effusions. ET tube is high. The tip is 9 cm above the carina; it should be advanced for standard position. NG tube tip is in the stomach MICROBIOLOGY: [**5-22**]: blood cultures neg to date [**5-22**]: BAL, no microorganisms, no Legionella [**5-22**]: viral panel neg [**5-24**]: ET sputum, neg Brief Hospital Course: This is a 48 yo male with an unclear medical history including COPD previously requiring intubation, alleged CAD s/p MI, and diastolic CHF presenting with chest pain and in respiratory distress with progressive opacification and volume loss of the right lung field likely secondary to aspiration vs. mucus plugging which evolved while in the ED (likely during intubation). #) COPD: Mr. [**Known lastname **] was admitted from the ED already intubated for COPD/Asthma and peri-intubational hypotension. He was mechanically ventilated for 3 days, with extubation delayed due to difficulties in sedation and mental status while on the vent. He was started on Corticosteroids, MDIs, Levofloxacin->Azithromycin while intubated. He developed asymptomatic sinus bradycardia which was attributed variously to his sedation, intubation and steroid course. On the morning of day 3, the patient self-extubated and was started on a NRB. He was transitioned to Nasal cannula as his sensorium cleared throughout the day. Almost within minutes of self-extubation he requested to leave AMA. The following day the patient cleared and was transferred to the medical floor for further work up. When arriving to the floor, the patient remained in notable respiratory distress with increased work of breathing and unable to complete sentences. However, he was able to maintain his O2 saturation with supplemental nasal cannula oxygen. It was recommended to the patient to treat his COPD flare with prednisone, ipratroprium and albuterol nebulizers. However, the patient refused prednisone because it reportedly makes him crazy and refused ipratropium as he was reportedly told it is bad for his heart. The patient used albuterol nebulizers and inhalers and levalbuterol. He gradually improved with decreased work of breathing and tolerated being weaned down on supplemental oxygen. He attempted to leave the evening of [**5-30**] and was evaluated by psychiatry who deemed him to have the capacity to leave AMA, but he decided to stay until the morning. The following morning, he demanded to leave AMA and left the floor walking with a cane under his own power with no supplemental oxygen in no apparent distress. He refused to sign an AMA form but acknowledged understanding the risks of leaving against medical advice including permanent physical impairment and death. #) Chest Pain: Mr. [**Known lastname **] has history of CAD per OMR. It seems that pt has claimed other diagnoses which he does not carry i.e. Multiple Scelrosis. Echo from last year showed no focal wall motion abnml suggestive of prior MI. His EKG showed no findings of old or new ischemia. He was ruled out for MI with cardiac enzymes neg x3 and his chest pain resolved while inpatient. It was likely due to his COPD flare. He complained of some sternal chest pain and tightness on [**2123-5-30**], with a negative EKG. #) Hypotension: Per ED account, the patient had an episode of hypotension that may have been temporally related to initiation of sedation and intubation. Auto-peep may have been contributing given obstructive physiology, although currently not auto-peeping. He initially required levophed briefly, but he was quickly weaned off of levophed and his blood pressure stabilized within normal range. #) Hypertension: After several days of stable blood pressure, Mr. [**Known lastname **] was restarted on his home medications of lisinopril and lasix. #) Anxiety: We initially held on home clonazepam in the setting of respiratory distress and worry about respiratory depression. When the patient improved his respiration, we resarted his home clonazepam dose. Medications on Admission: Furosemide 40 mg QD Clonazepam 2 mg TID Aspirin 325 mg QD Ipratropium Q6H Oxycodone 10 mg Q12H Fluticasone 110 mcg/Actuation Aerosol [**Hospital1 **] Lispro sliding scale Montelukast 10 mg qd Lisinopril 20 mg qd Pantoprazole 40 mg q24 Albuterol Sulfate Q4H Discharge Medications: 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) Puff Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. 3. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Furosemide 40 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 Q24H (every 24 hours). 6. Clonazepam 1 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 7. Levalbuterol HCl 0.63 mg/3 mL Solution for Nebulization Sig: One (1) ML Inhalation q4H (). Discharge Disposition: Home Discharge Diagnosis: COPD exacerbation Secondary diagnosis Diastolic heart failure Coronary Artery Disease Diabetes Mellitus Discharge Condition: Patient left against medical advice Discharge Instructions: Patient left against medical advice Followup Instructions: Patient left against medical advice

[ "428.32", "414.01", "426.82", "518.81", "412", "401.9", "250.00", "300.00", "530.81", "458.29", "V58.66", "518.0", "428.0", "786.59", "493.22" ]

icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

10390, 10396

5777, 9421

365, 449

10545, 10582

3721, 5754

10666, 10704

3091, 3199

9729, 10367

10417, 10524

9447, 9706

10606, 10643

3214, 3702

310, 327

477, 2289

2311, 2830

2846, 3075

15,194

126,081

6806

Discharge summary

report

Admission Date: [**2144-11-18**] Discharge Date: [**2144-12-5**] Date of Birth: [**2067-9-1**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 905**] Chief Complaint: CHF exacerbation Major Surgical or Invasive Procedure: Central Line placment Hemodialysis History of Present Illness: 77-year-old male with history of DM Type II, CHF (last echo [**7-/2143**] with EF 20-30%, 1+ MR, 1+ AR, LAH), CAD s/p CABG [**2129**]/[**2132**] (unclear anatomy, not on file here), chronic LE edema, LE superficial ulcers, who presented with worsening dyspnea, increased abdominal girth x 2 days (baseline wt ~ 172 lbs => 176 on last check this week). Of note, has not re-filled his HF meds (bumex, digoxin, hydralazine, imdur) x 1-2 weeks. He describes progressive dyspnea on exertion x past two months, with cough productive of yellow-white sputum. His shortness of breath is worse on exertion, now to NYHA class II level (not on rest or ADLs, but on moderate exertion). No associated chest pain (his past MI prior to revascularization in [**2129**] was without chest pain), but does describe episodes of lightheadness/dizziness (not vertigo) on exertion. No fevers, chills, night sweats, n/v, abdominal pain, HA, vision changes, diarrhea, BRBPR, melena, joint pain, rash, dysuria. Of note, had episode of unheralded syncope on Monday; no aura or neurologic, cardiac prodrome; did not remember falling to ground, woke up on ground later after undetermined period, no bowel/bladder incontinence, post-ictal confusion, tongue biting. Recent office visit [**2144-10-20**] with ambulatory O2 sat 93 => 95-96% with exertion, but w/ + dyspnea symptoms requiring him to stop; had increase in girth prompting increase in bumex to 4 mg qd. Per past notes, it has been difficult to achieve a balance between his Cr and fluid management (baseline Cr 3.0). Of note, MIBI in [**3-/2143**] with ** reversible inferior defect **; never had LHC since CABG in [**2129**]/[**2132**]. With regard to LE cellulitis/chronic venous stasis, patient's venous stasis ulcers were worse, possibly infected. He experiences daytime somonlence per PCP, [**Name10 (NameIs) **] there is some concern about his ability to take care of himself. . Past Medical History: 1. Hypertension 2. Elevated cholesterol 3. Diabetes type 2 4. CAD s/p CABG in [**2129**] and [**2132**]. p-MIBI in [**3-/2143**] Partially reversible, moderate-severe myocardial perfusion defect involving the entire inferior wall and the inferior portion of the lateral wall. This perfusion defect is slightly less severe and shows slight increase in reversibility as compared to [**2142-3-29**]. LV enlargement and global hypokinesis with EF of 21%. 5. Congestive Heart Failure: ECHO [**2-21**]: Lventricular systolic function is severely depressed (ejection fraction 20-30 percent) secondary to akinesis of the inferior and posterior walls and severe hypokinesis of the inferior septum. Mild (1+) aortic regurgitation. Mild (1+) mitral regurgitation. 5. History of GI bleed in [**2139**] 6. Chronic renal insufficiency (2.3-2.7) 7. Benign prostatic hypertrophy s/p TURP 8. History of urinary incontinence 9. History of right shoulder surgery [**49**]. Anemia 11. Sleep Apnea Social History: No tobacco. Rare social EtOH. No IVDA Lives alone. No kids Sister lives in [**Name (NI) 86**] Retired. Former teacher Family History: History of coronary artery disease. Physical Exam: T: 96.5 BP: 118/64 HR: 61 RR: 18 O2sats: 98% RA Gen: NAD HEENT: NC/AT; MMM; OP clear without lesions or exudate; PERRLA ; EOMI NECK: Supple, No LAD, Thyroid smooth and not enlarged, JVP not distended Lungs: CTA bilaterally without wheezes, rhonchi or rales Heart: RRR, nl S1 and S2, no murmurs rubs or gallops Abd: Soft, NT, ND, NABS, no masses palpated Ext: No C/C/E; 2+DP/PT pulses bilaterally Skin: Warm and Dry Rectal: Normal rectal tone; brown guaiac negative stool Neuro: A&O x 3; CN II - XII individually tested and intact; strength 5/5 upper and lower extremities; sensation grossly intact in upper and lower extremities; 2+ reflexes in patella Pertinent Results: ECHO [**2144-11-20**] Conclusions: The left atrium is moderately dilated. The left ventricular cavity is moderately dilated. Overall left ventricular systolic function is severely depressed. Tissue velocity imaging E/e' is elevated (>15) suggesting increased left ventricular filling pressure (PCWP>18mmHg). Resting regional wall motion abnormalities include inferolateral, inferior and inferoseptal akinesis with severe hypokinesis elsewhere. The right ventricular cavity is mildly dilated. Right ventricular systolic function appears depressed. The ascending aorta is mildly dilated. The aortic valve leaflets are moderately thickened. There is probably at least mild to moderate aortic valve stenosis (however aortic valve area difficult to estimate given poor left ventricular stroke volume). Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. Compared with the prior report (tape unavailable) of [**2143-3-1**], left ventricular systolic function is probably worse. The right ventricle now appears mildly dilated with free wall hypokinesis. Significant aortic stenosis is now detected. . EKG - NSR at 100, left axis deviation, 1' AVB, delayed RWP (new), non-specific IVCD/LBBB likely lead placement (had been LBBB on prior EKG, likely lead placement) . LABS on discharge: WBC 12.1 (improving), HCT 28.4 (received one unit of blood in dialysis after this lab value), PLT 356 Na 135, k 4.2, Cl 98, HCO3 25, BUN 51, Cr 4.6 INR 1.8 . CHEST CT WITHOUT IV CONTRAST ([**2144-12-3**]): Mosaic pattern of pulmonary perfusion is unchanged from [**2143-12-30**]. There is new bibasilar atelectasis and a moderate-sized right pleural effusion. Small mediastinal lymph nodes are present, the largest of which measures 8 mm in short axis dimension. There are extensive coronary artery calcifications. Calcifications are also seen in the region of the mitral apparatus and along the posterior wall of the left ventricle, indicating prior infarction. A subcentimeter calcified nodule is present at the left lung base and there is a subcentimeter ill- defined nodule in the right middle lobe. These were both seen on the prior study and are not changed in the interval. Several other nodules seen on the prior study are not seen in the current study, either resolved of subsumed in the atelectasis in the right lung. Calcification of the right adrenal gland is stable. IMPRESSION: 1. Mosaic pulmonary perfusion unchanged since [**2143-12-18**], likely due to small airways obstruction. 2. New moderate size, nonhemmorhagic, layering, right pleural effusion and basal atelectasis. 3. Several small pulmonary nodules, unchanged from the prior study, others resolved or hidden in new atelectasis. Followup non- contrast chest CT is recommended after treatment to confirm stability of these nodules. Brief Hospital Course: Initial impression: Given slowly progressive nature of progressive exertional dyspnea, the patient's symptoms were felt to be most consistent with acute exacerbation of chronic systolic heart failure. In addition, given his persistently low EF, advanced (class III+) heart failure symptoms, his unheralded syncope was felt to be most likely progressive AS versus malignant ventricular arrhythmia. Initial management was directed toward lowering his wedge pressure and further afterload reduction for resolution of his systolic heart failure. In brief, his hospital admission involved unsuccessful diuresis on the general medical floor with bumex and zaroxolyn with nesiritide, with transfer to the coronary care unit for ultrafiltration. Hospital course below. FLOOR COURSE: Initially was restarted on digoxin and anti-hypertensives for afterload reduction in setting of acute decompensated heart failure. Lower extremity ulcerations initially appeared infected, prompting initiation of oxacillin, which was stopped 2 days into course given normal white count and reassessment of lower extremities (at that point, changes were felt to be more chronic). Myocardial infarction was ruled out by serial cardiac enzymes. Bumex 4 mg IV (his outpatient dose) was started, with poor diuresis, prompting addition of zaroxolyn for synergy. Serum creatinine increased to mid-3 (3.3) from 2.8 baseline on admission. He was transferred to the cardiology floor service for further management and addition of nesiritide, lasix drip, and diuril for maximal non-tailored catheter therapy. Creatinine continued to increased on nesritide, and per nephrology service, nesiritide was discontinued, in favor of bumex and hydrochlorothiazide. He was noted to have paroxysmal episodes of NSVT and AT; given the heart failure, he was started on PO amiodarone for rhythm control. Digoxin was restarted, with lopressor and nitrate held for further blood pressure room for fluid removal and amiodarone. Renal function continued to decline, with diuretic refractoriness, and he was transferred to the CCU on [**11-26**] for tailored therapy or CVVHF. CCU COURSE: In the CCU, he received an IR-guided temporary femoral line for CVVHF, which was continued until [**11-29**], when the line clotted. Lasix and zaroxolyn trial was attempted without success. A HD line was placed in the right internal jugular vein on [**12-1**], and dialysis was initiated on [**12-2**], on transfer back to the floor. Given concern for conduction delay, tissue doppler imaging echo was obtained, which disclosed a septal-to-posterior wall motion delay od 306 ms; however, biventricular pacing was deferred given his pituitary adenoma (and likely reimaging) and active lower extremity ulcerations. Transthoracic echocardiogram on [**11-20**] disclosed new aortic stenosis (valve area 1.0, though calculated in setting of low-flow, low-gradient), 1+ MR, global LV hypokinesis, with ejection fraction 21%. FLOOR COURSE: On the floor, he was continued on hemodialysis for goal removal 1-2 liters per run. Chest CT was obtained for evaluation of right pleural effusion, and it was felt that by imaging and ultrasound, the right pleural effusion was too small to tap. Digoxin was increased per renal (who discussed with his primary cardiologist, who felt that his digoxin level should be [**1-19**] for goal effect, per his past history). He was transfused 2 units packed red blood cells, and re-started on lisinopril. Given his low ejection fraction, he was started on coumadin for a goal INR [**2-20**], and should have a repeat INR check within 3 days of discharge. Ceftriaxone (initially started in CCU for presumed UTI) was converted to ciprofloxacin given persistently positive urinalysis, and repeat urine culture was sent (pending on dischage); patient will complete ciprofloxacin 3 day course and, on INR check, should have a repeat urinalysis. Spironolactone, lisinopril, amiodarone were continued, and he was started on renagel and nephrocaps as he initiated hemodialysis. PTH and iron studies (requested by renal) pending on discharge. Medications on Admission: ASA Digoxin 0.125 mg qd Imdur 60 mg qd Lipitor 40 mg qd Iron Toprol XL 50 mg qd Colace Senna Reglan Lantus RISS Hydralazine 25 mg qid Humalog Discharge Medications: 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 2. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 3. Lactulose 10 g/15 mL Syrup Sig: Fifteen (15) ML PO DAILY (Daily) as needed for constipation. 4. Coumadin 2 mg Tablet Sig: One (1) Tablet PO at bedtime: Please recheck INR on [**2144-12-6**] and adjust his dose as needed. Goal INR = [**2-20**]. 5. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed for SOB. 6. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily): This dose should be reduced to 200 mg daily on [**2144-12-17**]. 7. Digoxin 125 mcg Tablet Sig: 0.5 Tablet PO Every other day. 8. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 10. Sevelamer 800 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 11. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 12. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 13. Metoprolol Succinate 25 mg Tablet Sustained Release 24HR Sig: 0.5 Tablet Sustained Release 24HR PO DAILY (Daily). 14. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day): apply to groin. 15. Spironolactone 25 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 16. Tolterodine 1 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)). 17. Hydralazine 25 mg Tablet Sig: One (1) Tablet PO four times a day. 18. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 19. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 20. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 2 days: for UTI. 21. Lantus 100 unit/mL Solution Sig: Twenty (20) units SQ Subcutaneous QAM. 22. Regular insulin PLease use a regular insulin sliding scale QID. Discharge Disposition: Extended Care Facility: [**Hospital6 979**] - [**Location (un) 246**] Discharge Diagnosis: Congestive Heart Failure Exacerbation urinary tract infection Right-sided pleural effusion End-stage renal disease requiring hemodialysis for fluid management Hypertension Elevated cholesterol Diabetes type 2 CAD s/p CABG in [**2129**] and [**2132**]. positive p-MIBI in [**3-/2143**] CHF with an EF here 21%, LV global HK Benign prostatic hypertrophy s/p TURP Sleep Apnea Discharge Condition: Stable, on hemodialysis Discharge Instructions: Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs. Adhere to 2 gm sodium diet Fluid Restriction: 1.5 liter per day . You are to return to the hospital immediately if you should experienc any chest pain, shortness of breath or any other worrisome symptom. . Please take your medications as prescribed. Continue hemodialysis on Tuesdays, Thursdays and Saturdays. Followup Instructions: You are to follow up with your primary care physician [**Name Initial (PRE) 176**] 1 - 2 weeks of discharge. . You are to follow up with your PCP [**Name Initial (PRE) 176**] 4-6 weeks of discharge. Continue hemodialysis on Tuesdays, Thursdays and Saturdays. Provider: [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Doctor Last Name **] Phone:[**Telephone/Fax (1) 3512**] Date/Time:[**2144-12-28**] 10:00 Provider: [**Name10 (NameIs) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] SURGERY (NHB) Date/Time:[**2145-1-14**] 11:30 Provider: [**Name10 (NameIs) 1571**] BREATHING TEST Phone:[**Telephone/Fax (1) 612**] Date/Time:[**2145-3-9**] 10:55 [**Name6 (MD) 251**] [**Name8 (MD) **] MD [**MD Number(1) 910**]

[ "V45.81", "227.3", "398.91", "V58.67", "707.10", "427.1", "780.57", "459.81", "V15.81", "276.7", "396.2", "511.9", "250.40", "584.9", "403.91", "599.0" ]

icd9cm

[ [ [] ] ]

[ "38.95", "00.13", "99.04", "39.95", "38.93" ]

icd9pcs

[ [ [] ] ]

13520, 13592

7217, 11314

331, 368

14009, 14035

4192, 5666

14467, 15288

3466, 3503

11506, 13497

13613, 13988

11340, 11483

14059, 14444

3518, 4173

275, 293

5685, 7194

396, 2313

2335, 3314

3330, 3450

59,841

183,492

50895

Discharge summary

report

Admission Date: [**2200-7-15**] Discharge Date: [**2200-7-19**] Date of Birth: [**2119-7-19**] Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 613**] Chief Complaint: maroon-colored stools Major Surgical or Invasive Procedure: [**2200-7-18**] - Colonoscopy History of Present Illness: This is an 80 year-old Female with a history of Atrial fibrillation (on Dabigatran), h/o AVR for aortic stenosis (removal of left atrial appendage, [**2200-5-28**]) who was recently admitted for C.diff colitis with colonoscopy and polypectomy, now presenting with bloody bowel movements x 3-days. . Her most recent admission was on [**2200-7-4**] for C.diff colitis that was treated with PO Vancomycin and Flagyl, and was found to have a cecal mass on CT imaging of the abdomen, which led to colonoscopy that admission with ascending colon polypectomy; she was also noted to have non-bleeding internal hemorrhoids. She was discharged on [**2200-7-11**]. The day following her discharge, she developed maroon-colored stools that have occurred 1-2 times daily, initially without clotting or frank blood, appearing dark-maroon. Since the polypectomy, she notes 4 bloody bowel movements. Last bowel movement was a day prior to admission, large volume per the patient. . In the ED, VS 98.3 85 130/81 18 100% RA. Her HCT was 28% (recent baseline high 28 to 33%), rectal exam showed red blood, type/screen and crossmatch were sent. Prior to transfer, VS 86 121/59 24 100% RA. The patient was given 1L NS and remained HD stable. She was evaluated by GI who recommended holding anticoagulation, an nasogastric tube was placed for bowel prep with plan to perform colonoscopy in the AM. . Upon arrival to the floor, she denied N/V or abdominal pain. An NGT was placed and she received 2L of Moviprep. Her bloody bowel movements have increased, she notes 7 since starting the prep with some evidence of clotting and frank bleeding mixed with brown stool. She denies lightheadedness or dizziness, although she has been in bed. She denies fevers or chills. She has no nausea or vomiting. She notes some mild weakness in her lower extremities related to her prior surgery. She denies abdominal pain Past Medical History: PAST MEDICAL HISTORY: 1. Atrial fibrillation (diagnosed in [**2179**], on Dabigatran) 2. Aortic stenosis (s/p bioprosthetic AVR and resection of LAA, [**2200-5-28**]) 3. Tachy-brady syndrome (s/p ablation of atrial tachycardia and single-chamber pacemaker implant ([**Company 1543**] Sigma) in [**2-/2191**]) 4. Hypertension 5. Hyperlipidemia 6. Hypothyroidism 7. Vascular disease including right carotid stenosis and left subclavian stenosis 8. Right cerebellar embolic stroke in [**7-/2190**] (no residual deficits) 9. Diverticulitis 10. Colon Cancer s/p partial colectomy (roughly 15 yrs ago) 11. Multiple small bowel obstructions . PAST SURGICAL HISTORY: 1. s/p Aortic valve replacement (aortic valve bioprosthesis), removal of left atrial appendage 2. s/p Right shoulder arthroscopic subacromial decompression, debridement ([**2199-2-20**]) 3. s/p Laparoscopic cholecystectomy ([**2192-9-14**]) 4. s/p Right shoulder subacromial decompression ([**2189-1-14**]) 5. s/p Ex-lap, LOA, reanastomosis of proximal sigmoid colostomy to the rectum ([**2184-1-6**]) 6. Fistulotomy and anal sphincteroplasty ([**2182-2-18**]) Social History: Lives alone in senior housing, remains active. Denies tobacco or alcohol use; no recreational substance use. Using a walker since surgery. Family History: Father died of cancer at 60 yeard ols; Mother died at 83 with diabetes and gangrene. Sisters and brother with emphysema brother died of renal failure Physical Exam: VITALS: 97.3/96.7 91 122/90 18 100%RA I/O: NPO/600 | BM x 7 GENERAL: NAD, comfortable, appropriate. NGT in place. HEENT: PERRLA, EOMI, MMM, OP clear. NECK: Supple, no LAD HEART: irregularly irregular, RR, no M/R/G, Nl S1, slightly loud S2, midline sternotomy incision C/D/I, well-approximted and healing. AICD pocket noted. LUNGS: CTA bilaterally, no R/C/W ABDOMEN: soft/NT/ND, no masses or HSM, no rebound/guarding RECTAL: internal hemorrhoids palpated, small specks of red blood, no stool in vault; clotting, frank blood on pad. EXTR: trace bilateral LE edema; warm, well perfused, 2+ peripheral pulses. NEURO: A&Ox3, CNs II-XII grossly intact, muscle strength 5/5 throughout, sensation grossly intact throughout. Pertinent Results: ADMISSION LABS [**2200-7-15**] 08:25PM BLOOD WBC-6.0 RBC-3.27* Hgb-9.4* Hct-28.0* MCV-86 MCH-28.8 MCHC-33.6 RDW-17.5* Plt Ct-340 [**2200-7-15**] 08:25PM BLOOD PT-16.8* PTT-41.9* INR(PT)-1.5* [**2200-7-15**] 08:25PM BLOOD Glucose-112* UreaN-20 Creat-0.9 Na-136 K-6.8* Cl-105 HCO3-25 AnGap-13 [**2200-7-15**] 08:25PM BLOOD Calcium-9.1 Phos-3.9 Mg-2.0 . PERTINENT LABS [**2200-7-15**] 08:25PM BLOOD Hct-28.0* [**2200-7-16**] 05:04AM BLOOD Hct-25.9* [**2200-7-16**] 11:35AM BLOOD Hct-24.8* [**2200-7-16**] 02:04PM BLOOD Hct-26.7* [**2200-7-17**] 12:00AM BLOOD * Hct-24.6* [**2200-7-17**] 05:44AM BLOOD Hct-28.5* [**2200-7-17**] 02:33PM BLOOD Hct-25.8* [**2200-7-18**] 07:10AM BLOOD Hct-27.5* [**2200-7-19**] 03:10PM BLOOD Hct-31.7* [**2200-7-15**] 08:25PM BLOOD cTropnT-<0.01 [**2200-7-15**] 09:01PM BLOOD Lactate-1.4 . DISCHARGE LABS [**2200-7-19**] 03:10PM BLOOD WBC-7.1# RBC-3.72* Hgb-11.0* Hct-31.7* MCV-85 MCH-29.5 MCHC-34.7 RDW-17.7* Plt Ct-334 [**2200-7-18**] 07:10AM BLOOD PT-12.0 PTT-27.4 INR(PT)-1.0 [**2200-7-18**] 07:10AM BLOOD Glucose-90 UreaN-5* Creat-0.5 Na-143 K-3.6 Cl-110* HCO3-25 AnGap-12 [**2200-7-18**] 07:10AM BLOOD Phos-2.8 Mg-2.0 . IMAGING/PROCEDURES: [**2200-7-15**] CHEST (PORTABLE AP) - sternotomy wires, AICD in place; bilateral layering suggestive of small effusions, no consolidation, costophrenic angles blunted. See radiology report. . [**2200-7-10**] COLONOSCOPY - Polyp in the proximal ascending colon (polypectomy, endoclip). Grade 1 internal hemorrhoids. Otherwise normal colonoscopy to cecum. . [**2200-7-17**] COLONOSCOPY-Diverticulosis of the sigmoid colon. Normal mucosa in the colon. Unable to locate previous polypectomy site. Procedure was not completed after multiple attempts to pass into the ascending colon continued to fail. Otherwise normal colonoscopy to cecum. . [**2200-7-18**] COLONOSCOPY -The previously noted polypectomy site with a single clip was identified. There was an ulcer with oozing adjacent to the site. Two endoclips were successfully applied for the purpose of hemostasis. Brief Hospital Course: The patient is an 80yo woman with a history of A.fib (on Dabigatran), h/o AVR for aortic stenosis (removal of left atrial appendage, [**2200-5-28**]) who was recently admitted for C.diff colitis with colonoscopy and polypectomy ([**2200-7-10**]), who presented with hematochezia in the setting of hemodynamic stability. . # GI BLEEDING MICU COURSE: Given the patient's recent h/o colonoscopy with ascending colon polypectomy and endoclip placement, this site was the likely etiology of a lower GI bleed. The patient was transferred to the MICU on [**7-16**] for urgent colonoscopy in setting of on-going blood loss. Unfortunately the patient needed MAC sedation in order to complete colonoscopy. She was thus observed overnight and remained hemodynamically stable. Records revealed HCT baseline of 28-33%. She presented with a HCT of 25.9%. While she remained hemodynamically stable without tachycardia or hypotension, she receieved a total of 1 unit of pRBCs while in the unit. Colonoscopy in the MICU on [**2200-7-17**] failed to locate previous polypectomy site as multiple attempts to pass into the ascending colon were unscucessful. The patient was transferred to the medicine floor in stable condition for further evaluation. MEDICINE FLOOR COURSE: Upon arrival to the floor, the patient's HCT was 24.6. Again, she remained asymptomatic but given her h/o AS and ongoing bleed, she was transfused 1 unit pRBCs. In addition, we continued to hold her anticoagulation. A colonoscopy was again performed on [**2200-7-18**]. The previous polypectomy site with a single clip was identified. There was an ulcer with oozing adjacent to the site. Two endoclips were successfully applied for the purpose of hemostasis. The remainder of the [**Hospital 228**] hospital [**Last Name (un) 10128**] was uncomplicated. She had no recurrences of frank blood per rectum, her HCT remained stable, and was 31.7 prior to discharge. . # ATRIAL FIBRILLATION The patient was taking dabigatran 150 [**Hospital1 **] for anticoagulation and rate controlled with Metoprolol 75 TID. The dabigatran was held at the time of admission. Her metoprolol dose was initially reduced so as not to completely mask a compensatory tachycardia secondary to volume loss. It was then uptitrtated, and she was discharged on metoprolol succinate 150mg daily. The patient's cardiologist, Dr. [**Last Name (STitle) **], was consulted regarding recommendations for anticoagulation. The patient does have a prior h/o TIA, but was now felt to be at a reduced risk for embolic stroke given recent resection of atrial appendage. Given risk of ongoing GI bleed, he recommended re-initiation of anticoagulation with Coumadin five days following colonoscopy with no need for bridging. Therapeutic INR goal will be 1.8-2.5. . **TRANSITION OF CARE ISSUES -Please note medication error in discharge paperwork. The patient was actually discharged on metoprolol succinate 150mg daily. -The patient will need monitoring of INR and adjustment of coumadin dose. -The patient will also need to follow up with Gastroenterology within two weeks and with Cardiology within two months. Medications on Admission: HOME MEDICATIONS: 1. Vancomycin 125 mg PO Q6H (end date [**2200-7-17**]) 2. Dabigatran etexilate 150 mg PO BID 3. Simvastatin 40 mg PO daily 4. Aspirin 81 mg PO daily 5. Omeprazole 20 mg PO daily 6. Metoprolol tartrate 75 mg PO Q8H 7. Levothyroxine 50 mcg PO daily Discharge Medications: 1. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. levothyroxine 50 mcg 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. metoprolol succinate 50 mg Tablet Extended Release 24 hr Sig: 1.5 Tablet Extended Release 24 hrs PO three times a day. Disp:*135 Tablet Extended Release 24 hr(s)* Refills:*2*] NOTE: This is an error, the patient was actually discharged with a prescription for metoprolol succinate 150mg daily. *** 5. Coumadin 4 mg Tablet Sig: One (1) Tablet PO once a day: Change dose as directed by coumadin clinic on Friday when you show up. Disp:*30 Tablet(s)* Refills:*0* 6. Outpatient [**Name (NI) **] Work PT/INR for Friday [**7-25**] Discharge Disposition: Home With Service Facility: [**Company 1519**] Discharge Diagnosis: Primary Diagnoses: 1. lower gastrointestinal bleeding secondary to recent polypectomy 2. acute blood loss anemia . Secondary Diagnoses: 1. Atrial fibrillation 2. Aortic stenosis 3. Hypertension 4. Hyperlipidemia 5. Hypothyroidism Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms [**Known lastname 25288**], You were admitted to the hospital for rectal bleeding. You were given blood because your blood counts were found to be low. A colonoscopy was done and showed that there was an ulcer in the area where they removed the polyp during the first colonoscopy. They put two clips in that area to stop the bleeding. Please follow up with your gastroenterologist in two to three weeks. You can call [**Telephone/Fax (1) 463**] to make an appointment with Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 105803**] who saw you while you were here. One of the reasons you were bleeding was because of the blood thinner, pradaxa. Your cardiologist recommends stopping the pradaxa, and starting coumadin in five days (Wednesday). Please follow up in coumadin clinic once you start the coumadin to have your INR checked. (The goal for your INR will be 1.8-2.5). Please call your PCP to make an appointment to be seen Monday-Wednesday of next week. . MEDICATION CHANGES STOP pradaxa (dabigatran) START coumadin 4mg daily on wednesday, you will need an INR check on Friday [**7-25**]. CHANGE metoprolol to metoprolol 75mg three times daily It was a pleasure taking care of you. Followup Instructions: Department: CARDIAC SURGERY When: TUESDAY [**2200-7-22**] at 2:30 PM With: [**First Name8 (NamePattern2) 177**] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 170**] Building: LM [**Hospital Unit Name **] [**Location (un) 551**] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage Please call Dr [**Last Name (STitle) 8505**],[**First Name3 (LF) **] [**Telephone/Fax (1) 8506**] to make an appointment between monday and wednesday of next week Please call [**Telephone/Fax (1) 463**] to make an appointment with Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 105803**], Gastroenterologist, within 2-3 weeks Please call Dr [**Last Name (STitle) **] [**Telephone/Fax (1) 62**] to make an appointment within the next 1-2 months [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]

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icd9cm

[ [ [] ] ]

[ "45.23", "45.43" ]

icd9pcs

[ [ [] ] ]

10811, 10860

6564, 9692

326, 358

11134, 11134

4496, 6541

12529, 13422

3588, 3739

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264, 288

386, 2271

11149, 11261

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3432, 3572

28,684

183,188

7381

Discharge summary

report

Admission Date: [**2106-3-12**] Discharge Date: [**2106-3-16**] Service: MEDICINE Allergies: Levofloxacin / Seroquel Attending:[**First Name3 (LF) 134**] Chief Complaint: bradycardia Major Surgical or Invasive Procedure: none History of Present Illness: [**Age over 90 **] year old gentleman with atrial fibrillation, Mobitz II block, chronic kidney disease (Cr 1.3), COPD, hypertension, and dementia. He presented from the [**Hospital1 **] dementia unit. Per the daughter, he apparently felt dizzy with "waves coming at his head". Staff attempted to have pt eat breakfast but he vomited. Couldn't tolerate taking medications either. The facility performed stat labs reportedly consistent with dehydration with K 6.3 and ARF. HR 30 on Digoxin. [**2106-1-22**] dig level was 1.2 On presentation to the ED, the patient was bradycardic to HR 20's to 30's, sBP in 120's. EKG revealed complete Laboratories notable for K of 6.3 with BUN of 65 and creatinine of 2.2. Digoxin 3.5. Patient given calcium gluconate/bicarbonate/dextrose along with Kayexelate. K to 4.5 two hours later. Heart rate to 80's with EKG now with rates in 80's with Mobitz II. Chest X-ray read as R pleural effusion. Lactate rose from 1.2 to 3.5. Pt given levofloxacin which was stopped mid-infusion when it was realized he had a known allergy to this medication. Later patient passed a large stool and heart rate fell to 40's, SBP unchanged; however, pt also seemed cyanotic and became hypoxic to 80's. Given atropine and monoclonal antibody to digoxin. Pt placed on non-rebreather with normalization of oxygen. Given benadryl, high dose steroids and continous combivent. Per daughter, he is currently at his normal baseline with respect to his baseline. He responds to simple questions, but is unable to respond to commands. Review of symptoms: Pt unable to provide. Cardiac review of systems is notable for absence of chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. Past Medical History: 1) COPD 2) Asthma 3) Dementia 4) Psoriasis 5) Glaucoma 6) Mobitz Type 2 7) Atrial fibrillation/flutter 8) CRI, baseline creatinine around 1.3 . Cardiac Risk Factors: , Hypertension Social History: Used to live alone in [**State 108**] with assistance from son. Sent up here by same son and then told daughter that he could not return. Sister is now the legal guardian. [**Name (NI) **] recently has been living at rehab. (From d/c summary of Dr. [**Last Name (STitle) 2455**] Smoked a pipe approximately 70 years ago. Used to drink [**12-2**] [**Doctor Last Name **] [**Doctor Last Name **]/day but none in 3 months. No illicits. Family History: Family history is unknown. Physical Exam: VS: T 98.8 , BP 105/78 , HR 88, RR 28, O2 100 % on 200% NRB Gen: Elderly, ill appearing gentleman. Uncomfortable appearing. Sterotyped facial movements but no accessory muscles use. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Mouth: MM dry. Neck: Supple with JVP of <6 cm. CV: Irregularly irregular, normal S1, S2. No S4, no S3. Chest: Scatter rales, decreased air movement both bases anteriorly. Abd: NTND, Ext: N Skin: Brown rash in L groin Pulses: Right: 1+ DP Left: 1+ DP Neurol: AO x1 (recognizes daugther) spontaneously moves all extremities. Pertinent Results: [**2106-3-12**] 09:09PM LACTATE-3.5* K+-4.4 [**2106-3-12**] 07:52PM PH-7.41 [**2106-3-12**] 07:52PM GLUCOSE-91 LACTATE-3.4* NA+-146 K+-4.1 CL--106 TCO2-25 [**2106-3-12**] 07:52PM freeCa-1.09* [**2106-3-12**] 07:45PM GLUCOSE-99 UREA N-64* CREAT-2.1* SODIUM-144 POTASSIUM-4.5 CHLORIDE-108 TOTAL CO2-25 ANION GAP-16 [**2106-3-12**] 07:45PM CALCIUM-9.3 PHOSPHATE-3.1 MAGNESIUM-3.0* [**2106-3-12**] 05:52PM GLUCOSE-110* LACTATE-1.2 NA+-140 K+-5.9* CL--102 TCO2-28 [**2106-3-12**] 05:52PM HGB-11.8* calcHCT-35 O2 SAT-61 [**2106-3-12**] 05:30PM GLUCOSE-119* UREA N-65* CREAT-2.2* SODIUM-139 POTASSIUM-6.3* CHLORIDE-105 TOTAL CO2-28 ANION GAP-12 [**2106-3-12**] 05:30PM estGFR-Using this [**2106-3-12**] 05:30PM CK(CPK)-85 [**2106-3-12**] 05:30PM CK-MB-NotDone cTropnT-0.15* [**2106-3-12**] 05:30PM ALBUMIN-3.9 CALCIUM-9.4 PHOSPHATE-4.0 MAGNESIUM-3.1* [**2106-3-12**] 05:30PM DIGOXIN-3.5* [**2106-3-12**] 05:30PM WBC-11.0 RBC-4.22* HGB-11.9* HCT-37.3* MCV-88 MCH-28.2 MCHC-31.9 RDW-15.2 [**2106-3-12**] 05:30PM NEUTS-75.8* LYMPHS-16.7* MONOS-5.3 EOS-2.0 BASOS-0.2 [**2106-3-12**] 05:30PM PLT COUNT-788* [**2106-3-12**] 05:30PM PT-13.8* PTT-27.7 INR(PT)-1.2* [**2106-3-16**] 07:05AM BLOOD WBC-10.5 RBC-3.75* Hgb-10.7* Hct-34.0* MCV-91 MCH-28.7 MCHC-31.6 RDW-14.8 Plt Ct-544* [**2106-3-15**] 08:20AM BLOOD PT-13.3 PTT-25.8 INR(PT)-1.1 [**2106-3-16**] 07:05AM BLOOD Glucose-103 UreaN-44* Creat-1.6* Na-145 K-5.0 Cl-109* HCO3-24 AnGap-17 [**2106-3-16**] 07:05AM BLOOD Calcium-9.0 Phos-3.4 Mg-2.5 [**2106-3-15**] 08:20AM BLOOD Digoxin-1.4 [**2106-3-13**] 06:18AM URINE Blood-SM Nitrite-NEG Protein-TR Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG [**2106-3-13**] 06:18AM URINE RBC-[**2-3**]* WBC-[**2-3**] Bacteri-OCC Yeast-NONE Epi-0-2 TransE-0-2 [**2106-3-13**] 06:18AM URINE CastHy-0-2 [**2106-3-13**] 06:18AM URINE AmorphX-FEW [**2106-3-13**] 06:18AM URINE Hours-RANDOM Creat-119 Na-25 . Micro: UCx [**3-13**]: Negative BCx [**3-12**]: Negative to date . Reports: CHEST (PORTABLE AP) [**2106-3-12**] 10:25 PM FINDINGS: This examination is markedly limited by patient motion during image acquisition. Since the earlier examination of [**3-12**], a right-sided pleural effusion is probably little changed. Slight blunting of the left costophrenic sulcus could represent a tiny pleural effusion. The heart size and mediastinal contours are grossly within normal limits. The appearance of increased density at the right lung base could partially relate to patient motion as it is less apparent on a repeated radiograph of [**3-13**], [**2105**], at 8:20 a.m. No definite pneumothorax is seen, although evaluation is limited on this examination. IMPRESSION: Technically limited study. No significant interval change in bilateral pleural effusions, right greater than left, and probable no significant change in right lower lung consolidation or atelectasis. . CHEST (PORTABLE AP) [**2106-3-12**] 5:56 PM FINDINGS: Low lung volumes. Large right-sided pleural effusion is seen with subjacent atelectasis. Left basilar ateleactasis also noted. The cardiac silhouette cannot be completely evaluated, but appears grossly unchanged. There is no pneumothorax. The aorta is mildly tortuous with calcifications. The pulmonary vasculature is normal. The osseous structures demonstrate degenerative changes of the thoracic spine. IMPRESSION: Large right-sided pleural effusion, bibasilar atelectasis. Cannot exclude pneumonia at the right lung base. No evidence of CHF. . ECG Study Date of [**2106-3-12**] 5:36:38 PM Atrial fibrillation with slow ventricular response. Underlying right bundle-branch block. Compared to the previous tracing of [**2105-11-26**] the ventricular rate is markedly diminished. TRACING #1 . ECG Study Date of [**2106-3-12**] 5:52:34 PM Sinus bradycardia with 2:1 block. Right bundle-branch block with secondary ST-T wave abnormalities. Compared to tracing #1 normal sinus rhythm has returned. TRACING #2 . ECG Study Date of [**2106-3-12**] 6:00:12 PM Normal sinus rhythm with variable block. Right bundle-branch block. P waves are best appreciated in leads V1-V2. No diagnostic change from tracing #2. TRACING #3. . ECG Study Date of [**2106-3-12**] 7:42:14 PM Normal sinus rhythm with right bundle-branch block and secondary ST-T wave abnormalities. Compared to tracing #3 the variable block is no longer present. TRACING #4 . ECG Study Date of [**2106-3-12**] 9:59:54 PM Sinus bradycardia with variable block and underlying right bundle-branch block with 2:1 block. Compared to tracing #4 the 2:1 block is new. Clinical correlation is suggested. TRACING #5 . CHEST (PORTABLE AP) [**2106-3-13**] 7:41 AM FINDINGS: Since the examination of several hours earlier, which was limited by motion, as well as the examination of earlier on [**3-12**], a right-sided pleural effusion is probably little changed allowing for differences in technique and positioning. Slight blunting of the left costophrenic sulcus could represent a tiny effusion but is little changed. Right basilar atelectasis appears minimally improved from the earlier examination on [**3-12**]. There are bilateral low lung volumes. Heart size and mediastinal contours are unchanged. No pneumothorax. IMPRESSION: 1. Little change in right pleural effusion and right basilar atelectasis/consolidation. 2. Probable tiny left pleural effusion. . CHEST (PORTABLE AP) [**2106-3-14**] 7:38 AM CHEST, SINGLE AP PORTABLE VIEW. Rotated positioning. Allowing for this, I doubt significant interval change compared with [**2106-3-13**]. Again seen are bilateral right greater than left effusions and underlying collapse and/or consolidation. The degree of pulmonary vascular plethora seen in the right upper zone is however greater than on [**2106-3-12**] -- ? asymmetric CHF or cephalization of vessels due to changes at the right base. . CHEST (PORTABLE AP) [**2106-3-15**] 8:13 PM FINDINGS: In comparison with the study of [**3-14**], there is little overall change. Again, there is a large right pleural effusion and a much smaller effusion on the left. Underlying atelectasis bilaterally. The pulmonary vascularity is essentially within normal limits at this time. . CHEST (PORTABLE AP) [**2106-3-16**] 8:31 AM FINDINGS: In comparison with the study of [**3-15**], there is little change in the extensive opacification involving the lower half of the right hemithorax with a smaller opacification at the left base. Again, this is consistent with pleural effusion and underlying atelectatic change, though the possibility of supervening pneumonia can certainly not be excluded. Brief Hospital Course: [**Age over 90 **] year old gentleman with CKD, COPD, atrial fibrillation, h/o Mobitz type II, and dementia who presents with bradycardia, hyperkalemia, and acute renal failure with elevated digoxin level. Also history of vomiting with evidence of aspiration pneumonia on CXR. Hemodynamically stable and able to oxygenate normally on 2L. Lactate elevated, mentation at baseline per daughter in law. They do not want aggressive measures. . #) Bradycardia, likely from digoxin toxicity, esp given hyperkalemia. Status post digimab, Ca/gluc/bicarb. Ca could also have worsened toxicity. His rate improved during his stay, although he was intermittently bradycardic below 45 bpm during sleep. He was monitored on telemetry and had no events. His bradycardia was asymptomatic. His verapamil was held during his stay. His potassium should be closely monitored. His verapamil and digoxin should be held until he has follow-up with Dr. [**Last Name (STitle) **] on [**2106-4-1**]. The patient's renal failure and potassium will need to be follow closely. In the future, if the patient develops infection, dehydration or renal failure, his digoxin level will need to monitored closely and will likely need to be decreased. Please check his chem 10 on [**2106-3-19**] to ensure that his creatine is at baseline and electrolytes are appropriate. Please give results to facility physician and fax to Dr. [**Last Name (STitle) **] (PCP). Dr. [**Last Name (STitle) **] office phone number is: [**0-0-**]. . #)Fluid Status: He was dry upon admission. He was givem fluid resuscitation and maintenance fluid. . #) Atrial fibrillation, Mobitz II, family does not wish for pacemaker or temp wire. He was monitored on tele as above and his verapamil was d/c'd as above. He was continued on aspirin. . #) Aspiration pneumonia. Likely given CXR findings, brief hypoxia and h/o vomiting. He was treated broadly given residence in a nursing home with clindamycin, vancomycin, and ceftriaxone. He has been discharge on clindamycin and ceftriaxone as per orders for a total 10 day course to be completed on [**2106-3-24**]. He also had a pleural effusion, but with discussions with family, it was thought that he probably won't be able to cooperate with thoracentesis and decided against this for now. He should be followed up as an outpatient for his pleural effusion. . #) Renal failure: baseline roughly 1.3. His creatinine was elevated upon admission and improved to 1.6 upon discharge. He will need his renal failure monitored closely as an outpatient. Please check his chem 10 on [**2106-3-19**] to ensure that his creatine is at baseline and electrolytes are appropriate. Please give results to facility physician and fax to Dr. [**Last Name (STitle) **] (PCP). Dr. [**Last Name (STitle) **] office phone number is: [**0-0-**]. . #) COPD: he did not appear to he having a COPD flair upon admission and during his stay. He was continued on advair and given albuterol/atrovent prn. . #) Dementia, h/o sundowning: Significant confusion at night. Responds well to zyprexa. Please avoid seroquel. . #) Glaucoma, maintain latanoprost . #) FEN: dysphagia diet . #) Prophylaxis: Hep SC . #) Code: DNR/DNI Medications on Admission: Aspirin 325 daily Verapamil SR 300 daily Digoxin 0.125 mg daily Advair 250/50 twice a day Depakote 250 twice a day Atrovent nebulizers q 6 hours Calcium Carbonate (Tums) 500 TID Seroquel 12.5 daily Latanoprost 0.005% both eyes hs Discharge Medications: 1. Ipratropium Bromide 0.02 % Solution Sig: [**12-2**] Inhalation Q6H (every 6 hours). 2. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at bedtime). 3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 4. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) puff Inhalation [**Hospital1 **] (2 times a day). 5. Olanzapine 5 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO QHS (once a day (at bedtime)) as needed for agitation. 6. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization Sig: One (1) nebs Inhalation Q4H (every 4 hours) as needed for SOB, wheezing. 8. Ceftriaxone-Dextrose (Iso-osm) 1 gram/50 mL Piggyback Sig: One (1) Intravenous Q24H (every 24 hours) for 8 days: Started on [**3-15**] for a 10 day course to end on [**2106-3-24**]. 9. Clindamycin in D5W 600 mg/50 mL Piggyback Sig: One (1) Intravenous every eight (8) hours for 8 days: Started on [**2106-3-15**] for a 10 day course to end on [**2106-3-24**]. 10. Dextromethorphan-Guaifenesin 10-100 mg/5 mL Syrup Sig: [**4-10**] MLs PO Q4H (every 4 hours) as needed for cough. 11. Depakote 250 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO twice a day. Discharge Disposition: Extended Care Facility: [**Hospital1 599**] of [**Location (un) 55**] Discharge Diagnosis: Digoxin toxicity with bradycardia Acute Renal Failure Pneumonia Discharge Condition: improved, stable Discharge Instructions: This patient was admitted with dehydration, renal failure, bradycardia and digoxin toxicity. He was also diagnosed with pneumonia and started on antibiotics. After treatment of digoxin toxicity, his bradycardia resolved and he had no further adverse events. . The following medication changes have been made: 1. Verapamil was held is the setting of profound bradycardia. This medication should be held until this has been discussed his cardiologist, Dr. [**Last Name (STitle) **]. 2. Dixogin was held in the setting of bradycardia and dixogin toxicity. This medication should be held until this has been discussed his cardiologist, Dr. [**Last Name (STitle) **]. 3. Seroquel should not be given anymore. If the patient has agitation, Zyprexa should be used judiciously. 4. He has been started on antibiotics for aspiration pneumonia. He should complete a 10 day course to end on [**2106-3-24**]. 5. He is being sent out on 2 liters O2 by nasal cannula. . The patient's renal failure and potassium will need to be follow closely. In the future, if the patient develops infection, dehydration or renal failure, his digoxin level will need to monitored closely and will likely need to be decreased. . Please call primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **], with any questions/concerns, or return to emergency department. Followup Instructions: Please follow up with Dr. [**Last Name (STitle) **] on [**4-1**] at 3:15pm. Appointment has been set up for you already. Phone: [**0-0-**].

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icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

14749, 14821

9945, 13146

242, 249

14929, 14948

3321, 9922

16354, 16498

2708, 2736

13426, 14726

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13172, 13403

14972, 16331

2751, 3302

191, 204

277, 2036

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26,017

113,862

28652

Discharge summary

report

Admission Date: [**2157-9-22**] Discharge Date: [**2157-9-24**] Date of Birth: [**2082-10-25**] Sex: M Service: MEDICINE Allergies: Penicillins Attending:[**Last Name (NamePattern4) 290**] Chief Complaint: Respiratory distress Major Surgical or Invasive Procedure: Cervical lymph node biopsy in OR History of Present Illness: . Mr [**Known lastname 66103**] is a 74yo morbidly obese male with hx significant for HTN, stroke, cor pulmonale [**3-17**] COPD, DM, and stroke, transfered from OSH with LLE DVT, PE, and lympadenopathy on CT. . Course at OSH: In brief, patient was admitted to [**Hospital3 18201**] on [**2157-9-12**], with productive cough, SOB, increased O2 requirement(2->4L) and treated for a COPD flare with levaquin, solumedrol IV, and advair. He showed improvement in his leukocytosis and respiratory status. After a few days, however, there was a gradual rise in WBC up to 19, and he began to deteriorate again. His CXR was negative for new infiltrates and his Ucx was clear, but his blood grew MRSA and he was placed on IV vancomycin. He showed an elevated d-dimer, and was subsequently found to have R popliteal DVT on LE Dopplers. His respiratory status continued to worsen, but his VQ scan showed low probability for pulmonary embolism. Given patient's obesity and immobility, he was placed on lovenox and warfarin. His Chest CT at the time demonstrated extensive LAD in his cervical and supraclavicular nodes bilaterally with extension down into the anterior mediastium and to the level of the AP window. Previous CT on [**2157-6-27**], had in fact commented on chest mass/infiltrate. Significant LAD was not noted in the abdomen, and the liver and spleen to be uninvolved. Because of the rapid progression of the LAD, patient was transferred to [**Hospital1 **] for further evaluation, tissue biopsy, and treatment. . On presentation to the Medicine Service at [**Hospital1 **], patient complains of having pain and discomfort in his shoulder and neck for many months. He describes feeling so weak at one point that he was unable to remain standing long enough to take a shower. He believes that his respiratory status has declined and that he has had trouble breathing for the last few weeks. It became worse around the time he was diagnosed with a DVT at the OSH hospital. He denies chest pain with inspiration or pain in his legs. . He denies any recent travel, chills, or sick contacts. [**Name (NI) **] denies CP and palpitations. Patient admits to SOB on lying down. He admits to abdomenal discomfort, bloating and diarrhea for the last few weeks, perhaps for months. Denies blood per rectum or melena. No dysuria, hematuria. He also denies denies pain in his leg. He admits to sweats and weight loss >10lbs in last 6 mo but no fevers. Past exposures include [**Doctor Last Name 360**] [**Location (un) 2452**] when he was stationed in [**Country 10181**]. His brother died of an aucte leukemea at age 74. . Past Medical History: COPD-requires supplemental O2: Pulmonologist Dr. [**Last Name (STitle) 28583**]. Sleep apnea? Stroke-lacunar infarct Meniere's disease: Right ear deafness. +Vertigo GERD Sick sinus syndrome s/p Permanent pacemaker Diabetes Hypertension Morbid Obesity Chronic renal insufficiency with baseline creatinine of 1.6-1.8 Cor pulmonale: EF50%, per cardiologist Social History: No history of smoking Family History: Brother died at age 74 of leukemia Physical Exam: . T96.9 BP140/72 HR72 RR28 O2sat94%on2L Gen: obese male. NAD, uncomfortable. Unable to finish full sentences. HEENT:PERRL, EOMI, tongue/buccal mucosa/pharyx with ulcers. Neck: bilateral supracalvicular and cervical LAD- nontender, mobile Pulm: distant breath sounds, inspiratory wheeze, no crackles Cor: Regular, nls1s2 no gallops, no murmurs appreciated abdomen: +BS, distended, mildly tender diffusely, most tender in epigastric area, Skin: Large ecchymoses on left thigh (~20cmx8cm), lower back(~15cmx6cm). Nontender, nonpulsating. Ext: Mild tenderness to palpation of popliteal fossa. No edema in extremity. Assymetry in LE not notable Neuro: AxOx3, CNII-XII intact. Sensation intact in UE to light touch. Pertinent Results: OSH: CXR [**2157-9-16**]: no acute infilatrates or effusions. No cardiomegaly. . CT [**2157-6-27**]: Infiltrate/mass on chest CT, recommended follow-up . U/S [**2157-9-16**]: DVT R LE . VQ: Low probablity for PE . UA:yellow, clear, Glucose negative, bili negative, ketone negative, SG1.015, blood moderat, pH 5.0, proetin, negative, urobili neg, nitrite neg, leuko esterase neg. . Bld cx [**2157-9-13**]: MRSA . Stool [**9-16**]: neg for C-diff stool Toxin A, WBC, salmonella, shigella, campylobacter and ecoli 0157:H7. . 141 106 77 / 92 AGap=13 3.5 26 1.9 \ Ca: 8.3 Mg: 3.0 P: 4.4 ALT: 51 AP: 100 Tbili: 0.6 Alb: 3.4 AST: 44 LDH: 644 Dbili: TProt: [**Doctor First Name **]: Lip: UricA:12.5 . 85 15.9 \ 12.3 / 159 / 35.3 \ N:90 Band:2 L:2 M:3 E:1 Bas:0 Metas: 2 Anisocy: 1+ Microcy: 1+ Plt-Est: Normal . PT: 30.0 PTT: 31.1 INR: 3.2 Brief Hospital Course: Assessment and Plan: . Mr [**Known lastname 66103**] is a 74yo morbidly obese male with hx significant for HTN, stroke, cor pulmonale [**3-17**] COPD, CRI, DM, and stroke, transfered from OSH with LLE DVT, PE, and lympadenopathy on CT. . #Enlarged lymph nodes on CT: Patients clinical presentation was most concerning for lymphoma, especially given his family history of leukemia and exposure to [**Doctor Last Name 360**] [**Location (un) 2452**]. The nontender superficial, LAD located in the cervical, supraclavicular, and mediastinal areas is typical of Hodgkin's disease. This orderly, anatomic spread to adjacent nodes, is most c/w the contigous spread of HD. However, sensation of abdominal fullness and bone pain, reported as pain in his back and neck, may be indicative of the nontender diffuse LAD of NHL. Patient has remained febrile, even during infection with MRSA per records; however, he has had the other constitutional or B symptoms of weight loss and sweats. The rapid progression of his LAD may suggest an aggressive lymphoma such as mantle cell. However, it appears a past CT in [**6-18**] commented on the mediastinal infiltrate/mass, which could be referring to the earlier stage of this condition. If this is HD lymphoma, this patient clearly has greater than a single LN region affected, making this [**Hospital1 69333**] stage II or higher. We need abdomenal and pelvic imaging for further staging. HD Limited disease has 80% long-term survival, whereas advanced disease has a considerably less survial time. If this is HD, it is most beneficial to treat it early. Patient's recent respiratory decline may be [**3-17**] mediastinal mass obstructing the airway. SVC syndrome is another complication. It is also important to rule out infectious causes of enlarged lymph nodes: CMV, EBV, TB. -surgery was consulted to identify best surgical procedure for excisional lymph node biopsy . CRI: Patient has a history of chronic renal insufficiency. He currently has a BUN77 and Cr1.9, which is in the range he has remained in the last week. It is important to realize that renal involvement with lymphoma is seen in 2 to 14 percent of all patients, and an elevated serum creatinine is reported in 26 to 56 percent. Patient is euvolemic on exam. -determine baseline bun/creatinine levels from PCP [**Name10 (NameIs) 15282**] to hold lasix -no contrast during imaging . cor pulmonale/COPD: -supplemental oxygen -nebs -advair -spiriva -continue steroid taper . GERD: denies any current symptoms -protonix . HTN: appears to be well-controlled -Beta blocker . CAD: -cont plavix, aspirin -d/c nitropatch . Diabetes -insulin sliding scale . MICU Course: -Patient was transferred to the MICU for desaturations. He was fiberoptically intubated and stabilized on pressors. Biopsy was performed in the OR after INR correction with FFP. Preliminary pathology results showed poorly-differentiated large cell carcinoma with focal glandular and focal clear cell features. After diagnosis was made, it was discussed with the family the few options for therapy and the generally poor prognosis. He was made comfort measures only and expired subsequently after extubation. Medications on Admission: Zopinex and Atrovent, 1.25/0.5 nebulizers every 6 hours while awake Glyburide 2.5 mg po qday Vyvox 600mg po q12h Guaifenisin 1200mg po bid Vitamin B complex, t tablet qday Toprol XL 25mg po qday Protonix 40mg po qday Nitropatch 0.2mg po qday Diltiazem XT 120mg po qdaily Aspirin 325mg po qday Advair 250/50 one puff [**Hospital1 **] Spiriva 18micrograms, one puff daily Plavix 75mg po daily MVI one tablet po qday Prednisone 20mg po daily for 2 days, then prednisone 10mg po qday for 2 days, then d/c Requip one tablet po daily Accu-cheks with regular insulin coverage as per sliding scale Coumadin ALLERGY: PENICILLIN 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**]

[ "V58.61", "V09.0", "453.40", "162.8", "V15.89", "196.0", "250.00", "438.9", "790.7", "491.21", "327.23", "278.01", "709.09", "425.4", "428.0", "V45.01", "403.91", "530.81", "V16.6", "518.81", "196.1", "196.3" ]

icd9cm

[ [ [] ] ]

[ "40.11", "99.21", "96.04", "40.21", "38.93", "99.07", "33.22", "96.71", "99.19" ]

icd9pcs

[ [ [] ] ]

8931, 8940

5083, 8261

301, 335

8991, 9000

4193, 5060

9056, 9202

3409, 3445

8961, 8970

8287, 8908

9024, 9033

3460, 4174

241, 263

363, 2977

2999, 3354

3370, 3393

8,233

169,832

2485

Discharge summary

report

Admission Date: [**2165-4-6**] Discharge Date: [**2165-4-9**] Date of Birth: [**2115-8-3**] Sex: M Service: MEDICINE Allergies: Codeine / Flexeril / Lipitor Attending:[**First Name3 (LF) 134**] Chief Complaint: Chest pain Major Surgical or Invasive Procedure: Cardiac catheterization [**2165-4-6**]: Cypher stent to proximal LAD History of Present Illness: The patient is a 49 year old male with a history of heavy EtOH use 17 years ago, DMII x 3 years (diet-controlled), HTN, HL, a 30 pack year smoking history, with a history of negative MIBI x 2 who presents with the chief complaint of substernal chest pressure. The patient had just gotten out of his car and was walking from his car when he experienced [**2170-6-7**] substernal chest pressure associated with shortness of breath, diaphoresis, no nausea/vomiting or radiating pain to jaw/left arm or back. The patient felt he was suffering a heart attack and drove himself to the [**Hospital1 18**] ED where it was discovered he had large 3-[**Street Address(2) 5366**] elevation V1-V6 with peaked T waves V2-V5 with inverted T waves in III and ST depressions in II, III and avF. The patient did not become pain free until he had a stent placed in the cath lab. In the ED, he received 5 mg IV Lopressor x2, heparin and integrillin, nitro gtt, morphine 2 and 4 mg IV, plavix 300 mg. His troponin was <0.01 in the ED. In the cath lab, the following were found: Right dominant system with EF 50% with normal filling pressures and mild systemic hypotension LMCA normal 100% LAD after D1 without collaterals 50% OM1 80% mid vessel RCA Cypher Stent to LAD In the cath lab, the patient had vfib arrest and was shocked with 200 J x 1 and returned to NSR. The patient at baseline denies physical activity but denies any difficulty going up 2-3 flights of stairs. He denies any orthopnea, paroxysmal nocturnal dyspnea, or increased swelling in his extremities. He sleeps with 2 pillows for comfort only. The patient states he usually gets sharp, substernal chest pain once a week at rest that is different in nature than the pressure he experienced on presentation. He relates his usual pain to his esophageal hernia. Past Medical History: DMII x 3 years HTN HL h/o EtOH use - drank [**2-3**] quarts vodka, scotch/day 17 years ago Esophageal hernia 2 herniated discs in lower back h/o narcotic addiction h/o IV drug use and cocaine use Social History: The patient currently works for [**Female First Name (un) 12745**] Health. He smokes 1 ppd x 36 years. He denies current EtOH use but admits to heavy EtOH use 17 years ago with 1-2 quarts of vodka, scotch a day. He denies a history of DTs, seizures. He also admits to a remote history of cocaine and IV drug use. He also has had a narcotic addiction which required methadone. Family History: Father deceased at age 65 from DMII, no history of CAD Mother deceased at age 68 from lung cancer Has 2 siblings HTN, no other medical issues Physical Exam: Tc=97.3 P=69 BP=116/71 RR=18 100% on RA Gen - NAD, AOX3, breath smelling of EtOH HEENT - no JVD, no carotid bruits Heart - RRR, no M/R/G Lungs - CTAB (anteriorly) Abdomen - Soft, NT, ND, + BS Ext - Right groin small hematoma, soft, no bruit, +2 d. pedis bilaterally, no C/C/E, sheath in place Pertinent Results: CXR [**2165-4-6**]: No cardiomegaly, no pleural effusions/pulmonary edema. No acute disease. [**2165-4-9**] 07:10AM BLOOD WBC-9.2 RBC-5.16 Hgb-16.0 Hct-45.0 MCV-87 MCH-31.0 MCHC-35.6* RDW-13.0 Plt Ct-236 [**2165-4-8**] 07:10AM BLOOD WBC-8.0 RBC-5.74 Hgb-17.2 Hct-50.5 MCV-88 MCH-29.9 MCHC-34.1 RDW-13.0 Plt Ct-228 [**2165-4-7**] 06:04AM BLOOD WBC-10.5 RBC-5.23 Hgb-15.7 Hct-46.2 MCV-88 MCH-30.1 MCHC-34.0 RDW-13.2 Plt Ct-224 [**2165-4-6**] 11:35PM BLOOD Hct-42.9 Plt Ct-243 [**2165-4-6**] 05:14PM BLOOD WBC-13.4* RBC-5.01 Hgb-15.1 Hct-43.6 MCV-87 MCH-30.1 MCHC-34.6 RDW-13.1 Plt Ct-237 [**2165-4-6**] 02:15PM BLOOD WBC-9.3 RBC-5.63 Hgb-17.1 Hct-49.2 MCV-87 MCH-30.4 MCHC-34.9 RDW-13.2 Plt Ct-316 [**2165-4-8**] 07:10AM BLOOD PT-13.0 PTT-25.6 INR(PT)-1.1 [**2165-4-9**] 07:10AM BLOOD Glucose-117* UreaN-14 Creat-0.9 Na-138 K-4.4 Cl-107 HCO3-22 AnGap-13 [**2165-4-6**] 02:15PM BLOOD UreaN-20 Creat-1.1 Na-139 K-3.2* Cl-104 HCO3-23 AnGap-15 [**2165-4-9**] 07:10AM BLOOD CK(CPK)-179* [**2165-4-9**] 12:00AM BLOOD CK(CPK)-201* [**2165-4-7**] 06:04AM BLOOD CK(CPK)-741* [**2165-4-6**] 11:35PM BLOOD CK(CPK)-763* [**2165-4-6**] 05:14PM BLOOD ALT-22 AST-28 LD(LDH)-171 CK(CPK)-319* AlkPhos-59 Amylase-61 TotBili-0.5 [**2165-4-7**] 06:04AM BLOOD CK-MB-58* MB Indx-7.8* cTropnT-1.73* [**2165-4-6**] 11:35PM BLOOD CK-MB-60* MB Indx-7.9* [**2165-4-6**] 05:14PM BLOOD CK-MB-23* MB Indx-7.2* [**2165-4-6**] 05:14PM BLOOD %HbA1c-6.1* [**2165-4-6**] 05:14PM BLOOD Triglyc-33 HDL-42 CHOL/HD-3.9 LDLcalc-116 Cath Study Date of [**2165-4-8**] COMMENTS: 1. Coronary angiography demonstrated a right dominant system with single vessel coronary artery disease. The LMCA had no angiographically apparent, flow-limiting disease. The LAD had no angiographically apparent, flow-limiting disease with a widely patent LAD stent. The LCx had an OM1 with a 50% lesion. The RCA had a midvessel 70% lesion. 2. Limited resting hemodynamics revealed normal central blood pressures of 131/81 mmHg. 3. Successful placement of 3.5 x 13 mm Cypher drug-eluting stent in RCA postdilated with a 3.75 mm balloon. Final angiography demonstrated minimal residual stenosis, no angiographically apparent dissection, and normal flow (See PTCA Comments). FINAL DIAGNOSIS: 1. Single vessel coronary artery disease. 2. Normal central blood pressure. 3. Successful placement of drug-eluting stent in RCA. C.CATH Study Date of [**2165-4-6**] COMMENTS: 1. Selective coronary angiography revealed a right dominant system with two vessel coronary artery disease and abrupt occlusion of the LAD. The LMCA did not have any angiographic evidence of coronary artery disease. The LAD had a total occlusion just after the take-off of the first diagonal branch, which was large. This was the infarct vessel and was stented (see below). The LCX had a 50% stenosis of its first OM branch. The RCA had a discrete 80% stenosis in the mid-vessel and was dominant. 2. Hemodynamics performed after the coronary intervention demonstrated normal filling pressures and a reduced cardiac output and index. There was mild systemic hypotension. There was no evidence of a gradient between the LV and the aorta on pullback of the catheter. 3. Left ventriculography revealed an EF of 50% with apical hypokinesis. There was no mitral regurgitation. 4. Successful primary PTCA and stenting of the mid LAD with a 3.5 x 23 mm Cypher DES. Final angiography revealed no residual stenosis, no apparent dissection, and normal flow (see PTCA comments). FINAL DIAGNOSIS: 1. Three vessel coronary artery disease. 2. Preserved ventricular function. 3. Acute anterior myocardial infarction managed by primary PTCA and placement of a drug-eluting stent in the LAD. CHEST (PORTABLE AP) [**2165-4-6**] 2:23 PM CHEST, ONE VIEW: Comparison with [**2163-1-3**]. The cardiac and mediastinal contours are stable and within normal limits. No pleural effusions, although the right costophrenic angle is incompletely imaged. No pulmonary edema, pneumothorax, or infiltrate. IMPRESSION: No acute cardiopulmonary process. Brief Hospital Course: The patient is a 49 year old male with a history of remote heavy EtOH and drug use, DMII, 30 pack year tobacco history, HL and HTN who presented with large anterior STEMI s/p Cypher stent to the proximal LAD complicated by Vfib arrest 1. CAD - The patient underwent initial catheterization in the setting of his STEMI which showed a totally occluded LAD after the take-off of the first diagonal branch which was subsequently stented with a Cypher stent. His cardiac cath was complicated by ventricular fibrillation arrest to which he resumed NSR after one shock of 300 joules. He was taken back to the cath lab on [**2165-4-8**] to address a 70% RCA lesion which was stented with a Cypher stent as well without further events. - The patient was continued on Plavix and aspirin. - We held off on a B-blocker initially given his relative low BP in the cath lab but he was able to tolerate up to Toprol XL 50 mg prior to discharge. In addition, we managed to titrate up to 5 mg of Lisinopril. - The patient states that he did not tolerate lipitor in the past secondary to myalgias and elevated liver enzymes. We started the patient on Crestor to see if he had an indiosyncratic effect with lipitor. Crestor was started at a low dose which the patient tolerated well. 2. DMII - The patient does not check his blood sugars at home and although he has been seen in [**Last Name (un) **], he says he only went to one appointment. We checked a HbA1C which was 6.1. He was maintained on a sliding scale insulin during his stay with blood sugars in the mid 100 range. The patient was given an appointment to follow up with [**Last Name (un) **] as an outpatient for a tailored outpatient regimen. 3. HTN - The patient took Felodipine 5 mg QD and Diovan/HCTZ 160/12.5 QD at home. We discharged the patient on Toprol XL 50 mg and Lisinopril 5 mg for cardioprotective effects. Medications on Admission: Plendil 5 mg PO QD Diovan/HCTZ 160/12.5 PO QD Paxil 25 mg PO QD ASA 81 mg PO QD Nexium [**Hospital1 **] Discharge Medications: 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Nexium 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO twice a day. 3. Rosuvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 4. Paroxetine HCl 25 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily). 5. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 6. Metoprolol Succinate 50 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily). Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2* 7. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 8. Nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) Sublingual up to 3 as needed: Please place one tablet under the tongue if you experience any chest pain for up to three doses. If your pain is not relieved, please call 911 immediately. Disp:*30 30* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Anterior ST elevation myocardial infarction Diet-controlled Type II Diabetes Discharge Condition: Stable. Discharge Instructions: Please call 911 or report to the ER if you experience any chest pain. DO NOT drive yourself to the ER if you experience more chest pain. It is important for your health to stop smoking as you just had a heart attack. Smoking raises your risk of heart disease and another heart attack. You MUST take your aspirin every day and plavix every day for the next 9 months. Failure to do so may result in another heart attack or even death. Followup Instructions: Please schedule an appointment to see your primary care physician [**Last Name (NamePattern4) **] 2 weeks. Please call [**Telephone/Fax (1) 4022**] to schedule an appointment with your cardiologist, Dr. [**First Name8 (NamePattern2) 122**] [**Last Name (NamePattern1) 3302**], in 4 weeks. You are scheduled to see the [**Last Name (un) **] Diabetes Center on Friday, [**4-26**] at 9:00 am with Dr. [**Last Name (STitle) 12746**]. You may go to the [**Last Name (un) **] Center, [**Location (un) **]. Please call [**Telephone/Fax (1) 12747**] should you have questions. It is important that you have diabetic follow up after your heart attack.

[ "724.2", "427.41", "305.1", "530.81", "250.00", "414.01", "272.4", "410.71", "V70.7", "997.1", "401.9" ]

icd9cm

[ [ [] ] ]

[ "36.07", "37.23", "37.22", "99.62", "88.56", "99.20", "88.53", "36.01" ]

icd9pcs

[ [ [] ] ]

10458, 10464

7368, 9239

296, 366

10585, 10594

3314, 5526

11078, 11726

2838, 2981

9394, 10435

10485, 10564

9265, 9371

6806, 7345

10618, 11055

2996, 3295

246, 258

394, 2209

2231, 2429

2445, 2822

46,473

117,015

54711

Discharge summary

report

Admission Date: [**2125-5-29**] Discharge Date: [**2125-6-6**] Date of Birth: [**2091-12-13**] Sex: F Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 1390**] Chief Complaint: Unresponsiveness s/p assault. Major Surgical or Invasive Procedure: Intubated for altered mental status on admission, [**2125-5-29**]. History of Present Illness: This patient is a 33 year old female who presents to [**Hospital1 18**] via med flight s/p assault. She was found in her bathroom down, bleeding from her head and a nearby bathroom scale covered in blood. Questionable assault. She was unresponsive and her head was covered in blood. She was intubated on scene and transferred to [**Hospital1 18**] for evaluation by [**Location (un) **]. Per EMS she is known to be in an abusive relationship. Past Medical History: PMHx: EtOH abuse, h/o seizures w/ DTs, bipolar disorder. PSHx: Unknown. Social History: History of alchoholism, abusive relationship. Physical Exam: On admission: Temp: afebrile HR: 106 BP: 170/72 Resp: 20 O(2)Sat: 100% vent Constitutional: intubated, sedated HEENT: + facial trauma, orbital edema ETT in place; c-collar in place Chest: Clear to auscultation Cardiovascular: Regular Rate and Rhythm, Normal first and second heart sounds Abdominal: Soft, Nondistended Pelvic: No obvious GU trauma Extr/Back: No cyanosis, clubbing or edema Skin: No rash, Warm and dry Heme/[**Last Name (un) **]/[**Last Name (un) **]: No petechiae On discharge: VS Temp 97.8, BP 109/56, HR 80, RR 16, sat 96% on room air. Neuro: AAO x person, place, needed reorientation to date. EENT: Periorbital swelling and resolving ecchymosis. Pulm: Clear bilaterally in full lung fields. Abdomen: Soft, non-tender, non-distended. Hypoactive BS. Extremities: Warm, well-perfused. Pertinent Results: [**2125-5-29**] 05:15PM BLOOD ASA-NEG Ethanol-98* Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2125-5-29**] 05:15PM BLOOD WBC-16.0* RBC-3.90* Hgb-10.3* Hct-32.4* MCV-83 MCH-26.3* MCHC-31.7 RDW-18.1* Plt Ct-364 [**2125-5-29**] 05:15PM BLOOD PT-13.9* PTT-27.4 INR(PT)-1.3* [**2125-5-29**] 05:15PM BLOOD Plt Ct-364 [**2125-5-29**] 05:15PM BLOOD Fibrino-171* [**2125-5-29**] 05:15PM BLOOD UreaN-14 Creat-0.6 [**2125-5-30**] 12:23AM BLOOD Calcium-8.6 Phos-3.9 Mg-1.7 [**2125-5-30**] 12:23AM BLOOD HBsAb-NEGATIVE [**2125-5-29**] 05:24PM BLOOD Glucose-107* Na-140 K-3.4 Cl-105 calHCO3-15* [**2125-6-4**] 06:06AM BLOOD WBC-6.3 RBC-3.49* Hgb-9.0* Hct-28.6* MCV-82 MCH-25.9* MCHC-31.5 RDW-19.5* Plt Ct-386 [**2125-6-4**] 06:06AM BLOOD Plt Ct-386 [**2125-6-4**] 06:06AM BLOOD Glucose-93 UreaN-13 Creat-0.5 Na-142 K-3.7 Cl-102 HCO3-27 AnGap-17 [**2125-6-4**] 06:06AM BLOOD Calcium-8.9 Phos-4.1 Mg-1.9 [**2125-5-29**] CT of sinus/mandible/maxilla 1. Bilateral nasal bone, frontal processes of the maxilla and anterior nasal spine fractures. 2. Diffuse soft tissue swelling of the scalp and face. [**2125-5-29**] CT of head without contrast 1. Bilateral nasal bone and frontal process of the maxilla fractures. 2. Diffuse facial and scalp subcutaneous edema and subgaleal hematoma noted towards the left posterior vertex. Brief Hospital Course: 33F who presents to [**Hospital1 18**] s/p assault. She was found in her bathroom down, bleeding from her head. Questionable assault. She was unresponsive and her head was covered in blood. She was intubated on the scene and transferred to [**Hospital1 18**] for further management. She was pan-scanned in the ED (see results section above). FAST scan was negative and the patient was hemodynamically stable. Due to the question of sexual assault, [**Name Initial (MD) **] SANE RN was contact[**Name (NI) **]. She was evaluated by that individual and evidence was collected for processing. The patient was admitted to trauma SICU for continued care on [**2125-5-29**]. ICU course ([**2125-5-29**] - [**2125-6-3**]): Pt was admitted to TSICU intubated, sedated on [**5-29**]. CT spine shows acute fractures. CT maxillary sinus show bilateral nasal bone, frontal process of the maxilla and anterior nasal spine fractures. Diffuse facial and scalp subcutaneous edema. CT head show bilateral nasal bone fractures. And CT abd/pelvis shows no acute abnormality. On [**5-30**], the chin lac was repaired and T+L spine cleared. Pt was bolused 500 LR x1 for low UOP, and IVF increased to 125 with improvment. We were unable to extubate pt due to severe agitation and inability to follow commands. Pt also spiked temperature of 101, blood culture was sent. Home depakote was also restarted at this time. Pt was extubated with improvement in mental status on [**5-31**]. On [**6-1**], pt has altered mental status that requiring repeat doses of valium and haldol for agitation. On [**6-2**], we have to repeat multiple doses of valium and haldol throughout the day, we restarted psych meds in the afternoon, which resulted in great improvement in her mental status. On [**6-3**], pt's diet was advanced to regular, she was stable to transfer to regular floor. Her [**Hospital **] hospital course per organs system are detailed below: Neurologic: -pain: oxycodone PO, dilaudid iv prn breakthrough, tylenol PO -hx heavy ETOH: decrease valium dosing to 20 q2, restart home depakote Cardiovascular: Tachycardia: Withdrawal vs. pain: continue ciwa and pain control Pulmonary: NAI Gastrointestinal: No acute issues Nutrition: advance as tolerates Renal: NAI Hematology: cont to monitor HCT, her anemia likely [**12-21**] ETOH use, and acute dilutional Endocrine: RISS Infectious Disease: augmentin MSK: facial fractures/lacerations: augmentin, sinus precautions, PRS f/u outpt, HOB elevation Ophthal: b/l orbital edema, ecchymosis, continue ointment. Optho f/u in 1 week Social: SANE nursing was involved for possible sexual assault - testing per protocol, privacy protection, check ID of all male visitors Psych: restarted home meds Consults: ACS, opthalomology, PRS, social work Prophylaxis: - DVT: boots, SQH Mrs. [**Known lastname 111871**] was transferred from trauma SICU to the surgical floor on [**2125-6-3**]. At that time, she was hemodynamically stable. Neurologically, the patient was agitated at times and uncooperative. A CIWA scale was initiated due to the patient's history of alcohol use. Unasyn was continued for facial fractures and later transitioned to PO augmentin. The total course of antibiotics was completed. The patient's foley was discontinued and she later voided without issue. Mrs. [**Known lastname 111871**] was being followed by the plastic surgery group for her nasal bone fractures, as well as physical and occupational therapy. The patient's mental status slowly returned and she required occupational therapy to assist with cognitive recovery. Physical therapy had assisted Mrs. [**Known lastname 111871**] with rehabilitation of her right arm, leg and ankle. It was their recommendation that she continue with outpatient OT and PT, as well as neuro-cognitive evaluation. The patient was discharged hemodynamically stable and afebrile. Social work has evaluated the patient during her stay. The patient felt that she was safe being discharged with her fiance. He will be taking time off to care for her full-time until her cognitive status improves. Discharge teaching was provided by myself and the bedside RN. Medications on Admission: Gabapentin 800''', trazodone 200 qhs, buspirone 10''', baclofen 20''' PRN, depakote 250 qAM, 500 qPM, hydroxyzine 25 q6h, celexa 40'. Discharge Medications: 1. Acetaminophen 650 mg PO Q6H pain 2. Senna 2 TAB PO HS 3. Docusate Sodium 100 mg PO BID 4. BusPIRone 10 mg PO TID PRN anxiety 5. Gabapentin 800 mg PO TID 6. Baclofen 20 mg PO TID 7. Divalproex (DELayed Release) 250 mg PO QAM 8. Divalproex (DELayed Release) 500 mg PO QPM 9. Citalopram 40 mg PO DAILY 10. HydrOXYzine 25 mg PO QID 11. Nicotine Patch 14 mg TD DAILY agitation 12. traZODONE 200 mg PO HS:PRN insomnia hold for sedation 13. OxycoDONE (Immediate Release) 10 mg PO Q4H:PRN pain RX *oxycodone 5 mg [**11-20**] tablet(s) by mouth every four (4) hours Disp #*40 Tablet Refills:*0 14. Ibuprofen 600 mg PO Q8H:PRN pain RX *ibuprofen 600 mg 1 tablet(s) by mouth every six (6) hours Disp #*30 Tablet Refills:*0 15. Artificial Tears Preserv. Free 1-2 DROP BOTH EYES PRN irritation 16. Outpatient Physical Therapy Outpatient PT to address R knee, R ankle, and R shoulder impairments/pain. 17. Outpatient Occupational Therapy OT evaluation to maximize safety secondary to cognitive deficits. Treatment Plan: cognition, ADLs, mobility, balance, patient and family education Frequency: 1-2x wk Duration: one week Discharge Disposition: Home Discharge Diagnosis: Bilateral nasal bone and frontal process of the maxilla fractures Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to [**Hospital1 **] Hospital after you were assaulted. Your injuries include bilateral (both sides) nasal bone fractures, frontal process maxillary fracture and a subgaleal hematoma. You have also experienced pain to your right arm, knee and ankle. MEDICATIONS: o Resume all your home medications as you were prior to being admitted to the hospital. o In regards to your pain, you have been prescribed narcotic (oxycodone) and non-narcotic (ibuprofen) medications. They often work well when taken together. Follow the directions on the prescription bottles and take them when needed. o Do not drive or operate machinery when taking narcotics. The medicine can make you drowsy and impair your thinking. o Narcotics may cause constipation. You may take over the counter colace and senna if you experience this symptom. Drink plenty of water and get exercise, as tolerated, to reduce the risk of constipation. SINUS PRECAUTIONS: Regarding your nasal bone and sinus fractures: Certain precautions will assist healing and we ask that you faithfully follow these instructions: 1. Take the prescribed medications as directed. 2. Do not forcefully spit for several days. 3. Do not smoke for several days. 4. Do not use straws for several days. 5. Do not forcefully blow your nose for at least 2 weeks, even though your sinus may feel ??????stuffy?????? or there may be some nasal drainage. 6. Try not to sneeze; it will cause undesired sinus pressure. If you must sneeze, keep your mouth open. 7. Do not rinse vigorously for several days. GENTLE salt water swishes may be used. Slight bleeding from the nose is not uncommon for several days after the surgery. Please keep our office advised of any changes in your condition, especially if drainage or pain increases. It is important that you keep all future appointments until this condition has resolved. You will require 24 hour assistance at home while you recover from your injuries. Physical and occupational therapy have been ordered to assist you in regaining bothing cognitive and physical abilities as you were prior to your injuries. Also, follow-up appointments have been made for you as noted below. Followup Instructions: Department: DIV OF PLASTIC SURGERY When: FRIDAY [**2125-6-15**] at 1:30 PM With: [**First Name11 (Name Pattern1) 2053**] [**Last Name (NamePattern1) 6751**], MD [**Telephone/Fax (1) 6742**] Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage Department: COGNITIVE NEUROLOGY UNIT When: THURSDAY [**2125-6-21**] at 11:00 AM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 6403**], MD [**Telephone/Fax (1) 1690**] Building: Ks [**Hospital Ward Name 860**] Building ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) **] Campus: EAST Best Parking: Main Garage Completed by:[**2125-6-7**]

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icd9cm

[ [ [] ] ]

[ "96.71", "86.59", "08.81" ]

icd9pcs

[ [ [] ] ]

8703, 8709

3226, 7380

333, 402

8819, 8819

1883, 3203

11185, 11945

7565, 8680

8730, 8798

7406, 7542

8970, 11162

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1550, 1864

264, 295

430, 876

1067, 1535

8834, 8946

898, 974

990, 1037

27,383

163,023

34615

Discharge summary

report

Admission Date: [**2160-7-9**] Discharge Date: [**2160-8-6**] Date of Birth: [**2089-10-9**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 165**] Chief Complaint: confusion and slurred speech Major Surgical or Invasive Procedure: CABGx6 [**2160-7-11**] sternal debridement [**2160-7-21**] Bilateral pectoralis flap closure sternal wound [**7-24**] History of Present Illness: 70 yo male presented to OSH with confusion and slurred speech. His glucose was 29 and this responded to treatment. EKG showed inferior Q waves with ST elev. in III, AVF, and ST depression laterally. Troponin elevated to 0.46 and CK 1016. Head CT revealed no acute process. Past Medical History: CAD htn hyperlipidemia diabetes mellitus neuropathy PAD carotid stenosis Social History: retired computer operator rare ETOH quit [**2132**] , 40 pack-year hx Family History: NC Physical Exam: 5'8" 80.7 kg HR 99 RR 25 130/66 NAD bilat. thighs healed from skin graft removal EOMI pupils 2mm non-reactive neck supple, full ROM, no lymphadenopathy CTAB RRR no m/r/g soft , NT, ND+ BS warm, well-perfused, no edema or varicosities noted alert and orientated x3 , nonfocal exam right fem closure device, left 2+ 1+ bil. DP/PT 2+ bil. radials no carotid bruits appreciated Pertinent Results: [**2160-7-9**] 09:49PM CK-MB-25* MB INDX-2.6 cTropnT-1.24* [**2160-7-9**] 06:51PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.025 [**2160-7-9**] 02:16PM GLUCOSE-96 UREA N-13 CREAT-0.7 SODIUM-139 POTASSIUM-4.0 CHLORIDE-100 TOTAL CO2-28 ANION GAP-15 [**2160-7-9**] 02:16PM ALT(SGPT)-38 AST(SGOT)-104* LD(LDH)-504* CK(CPK)-1224* ALK PHOS-92 AMYLASE-36 TOT BILI-0.7 [**2160-7-9**] 02:16PM LIPASE-13 [**2160-7-9**] 02:16PM ALBUMIN-4.1 [**2160-7-9**] 02:16PM TSH-1.4 [**2160-7-9**] 02:16PM WBC-13.1* RBC-4.71 HGB-14.4 HCT-42.2 MCV-90 MCH-30.6 MCHC-34.1 RDW-13.5 [**2160-7-9**] 02:16PM PLT COUNT-290 [**2160-7-9**] 02:16PM PT-13.3 PTT-23.4 INR(PT)-1.1 [**2160-8-6**] 02:37AM BLOOD WBC-13.0* RBC-2.96* Hgb-9.2* Hct-26.8* MCV-90 MCH-31.1 MCHC-34.4 RDW-14.3 Plt Ct-485* [**2160-8-6**] 02:37AM BLOOD Plt Ct-485* [**2160-8-5**] 02:30AM BLOOD PT-15.0* PTT-34.4 INR(PT)-1.3* [**2160-8-6**] 02:37AM BLOOD Glucose-165* UreaN-31* Creat-1.2 Na-137 K-4.5 Cl-101 HCO3-31 AnGap-10 [**2160-7-31**] 05:12PM BLOOD ALT-26 AST-32 AlkPhos-160* TotBili-0.4 [**2160-7-10**] 03:51AM BLOOD %HbA1c-7.6* [**2160-8-5**] 09:17PM BLOOD Vanco-17.4Conclusions PRE-BYPASS: 1. The left atrium is normal in size. No atrial septal defect is seen by 2D or color Doppler. 2. Left ventricular wall thicknesses are normal. The left ventricular cavity is mildly dilated. There is severe regional left ventricular systolic dysfunction with apical, mid-inferior, infero-lateral, infero-septal hypokinesis.. Overall left ventricular systolic function is severely depressed (LVEF= 25-30%). 3. Right ventricular chamber size is normal. with focal hypokinesis of the apical free wall. 4. There are simple atheroma in the aortic arch. There are simple atheroma in the descending thoracic aorta. 5. There are three aortic valve leaflets. There is no aortic valve stenosis. Trace aortic regurgitation is seen. 6. Mild (1+) mitral regurgitation is seen. 7. There is a small pericardial effusion. Dr. [**First Name (STitle) **] was notified in person of the results. POST-BYPASS: For the post-bypass study, the patient was receiving vasoactive infusions including milrinone and norepinephrine and is being AV paced. 1. Initially RV function and inferior wall severly hypokinetic, large air pocket in LV. After venting and infusion of inotropes, function significantly improved. 2. Aorta is intact post decannulation. 3. Other findings are unchanged. I certify that I was present for this procedure in compliance with HCFA regulations. Electronically signed by [**Name6 (MD) 928**] [**Name8 (MD) 929**], MD, MD, Interpreting physician [**Last Name (NamePattern4) **] [**2160-7-11**] 14:03 [**Known lastname 79422**],[**Known firstname 1775**] M [**Medical Record Number 79423**] M 70 [**2089-10-9**] Radiology Report CHEST (PORTABLE AP) Study Date of [**2160-8-4**] 1:11 PM [**Last Name (LF) **],[**First Name3 (LF) **] CSURG CSRU [**2160-8-4**] SCHED CHEST (PORTABLE AP) Clip # [**Clip Number (Radiology) 79424**] Reason: assess left effusion [**Hospital 93**] MEDICAL CONDITION: 70 year old man s/p cabg/pec flap closure REASON FOR THIS EXAMINATION: assess left effusion Final Report HISTORY: Status post CABG with pectoral flap closure, to assess left effusion. FINDINGS: In comparison with the study of [**8-1**], there is little overall change in the degree of left pleural effusion. Underlying atelectasis is also seen. The Dobbhoff tube is coiled within the upper stomach. The nasogastric tube appears to extend at least to the second portion of the duodenum. The right lung is clear. DR. [**First Name8 (NamePattern2) 1569**] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 11006**] Approved: MON [**2160-8-4**] 3:30 PM Brief Hospital Course: Admitted [**7-9**] and completed preop workup which revealed a 70-70% left carotid stenosis. Underwent surgery with Dr. [**First Name (STitle) **] on [**7-11**]. Transferred to the CVICU in fair condition. Extubated the following afternoon. Drips weaned over the course of the next several days. Went into Afib on POD #3 and amiodarone started, in addition to beta blockade titration. Had some lingering confusion/agitation and this was treated with haldol and then zyprexa. Mild aspiration lead to a bedside swallowing eval. Ultimately, he was treated for PNA with AV abx. Left pleural effusion tapped on POD #3. Coumadin started for Afib/ flutter. PICC line placed POD #7. Tube feeds started. Developed an unstable sternum on POD #9. Coumadin held and Vit. K given. Went to OR on POD #10 for sternal debridement, washout and VAC placement. ID and clinical nutrtion consulted. Evaluated by plastic surgery and returned to the OR on POD #13 with Dr. [**Last Name (STitle) 23606**] for debridement/ bilat. pec flap closure of chest. Extubated again on POD # 18. Repeat swallowing eval done [**7-31**] for aspiration risk. Dobhoff tube placed [**8-1**] for tube feeds and two more swallowing evals done prior to being cleared for discharge to rehab on POD # 26. Pt. continued to improve slowly. Pt. is to make all followup appts as per discharge instructions. Medications on Admission: atenolol 50 mg daily lantus 48 units QHS ASA 325 mg daily lisinopril 20 mg daily elavil 50 mg daily ( neuropathy) humalog SS ( 18 units with each meal) tylenol prn/advil prn Discharge Medications: 1. Acetaminophen 325 mg Tablet [**Month/Day (1) **]: 1-2 Tablets PO Q4H (every 4 hours) as needed for temperature >38.0. 2. Atorvastatin 80 mg Tablet [**Month/Day (1) **]: One (1) Tablet PO DAILY (Daily). 3. Aspirin 81 mg Tablet, Chewable [**Month/Day (1) **]: One (1) Tablet, Chewable PO DAILY (Daily). 4. Heparin (Porcine) 5,000 unit/mL Solution [**Month/Day (1) **]: 5000 (5000) units Injection TID (3 times a day). 5. Lisinopril 20 mg Tablet [**Month/Day (1) **]: Two (2) Tablet PO DAILY (Daily). 6. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization [**Month/Day (1) **]: Three (3) ml Inhalation Q4H (every 4 hours). 7. Ipratropium Bromide 0.02 % Solution [**Month/Day (1) **]: One (1) ml Inhalation Q6H (every 6 hours). 8. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily). 9. Carvedilol 12.5 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO BID (2 times a day). 10. Olanzapine 5 mg Tablet, Rapid Dissolve [**Last Name (STitle) **]: One (1) Tablet, Rapid Dissolve PO QHS (once a day (at bedtime)). 11. Insulin Glargine 100 unit/mL Solution [**Last Name (STitle) **]: Forty (40) units Subcutaneous once a day. 12. Clopidogrel 75 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily). 13. Humalog 100 unit/mL Solution [**Last Name (STitle) **]: sliding scale Subcutaneous QAC&HS. 14. Polysaccharide Iron Complex 150 mg Capsule [**Last Name (STitle) **]: One (1) Capsule PO DAILY (Daily). 15. Ascorbic Acid 500 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID (2 times a day). 16. Heparin, Porcine (PF) 10 unit/mL Syringe [**Last Name (STitle) **]: as directed below ML Intravenous PRN (as needed) as needed for line flush: 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. . 17. Cefepime 2 gram Recon Soln [**Last Name (STitle) **]: Two (2) gms Injection Q12H (every 12 hours): through [**9-15**]. 18. Vancomycin in Dextrose 1 gram/200 mL Piggyback [**Month (only) **]: One (1) gm Intravenous Q 24H (Every 24 Hours): through [**9-15**]. Discharge Disposition: Extended Care Facility: [**Hospital6 1293**] - [**Location (un) 1294**] Discharge Diagnosis: CAD, s/p CABGx6 [**2160-7-11**] sternal wound infection s/p debridements and bil. pec. flap closure htn hyperlipidemia diabetes mellitus neuropathy PAD carotid stenosis postop A Fib 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 report any wound drainage or temperature greater than 101.5 No creams, lotions, powders, or ointments to incisions No driving for one month and until off all narcotics No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] Followup Instructions: Dr. [**First Name (STitle) **] in 4 weeks ([**Telephone/Fax (1) 170**]) please call for appointment Dr.[**First Name (STitle) 1075**] in [**12-30**] weeks please call for appointment Dr.[**First Name (STitle) **],[**First Name3 (LF) 412**] A. [**Telephone/Fax (1) 20221**] in [**11-28**] weeks please call for appointment Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 7447**], MD Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2160-8-27**] 11:00 Dr [**First Name (STitle) **]: PLastic surgery clinic @[**Telephone/Fax (1) 26412**] one week from discharge-please call to schedule appt [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**] Completed by:[**2160-8-6**]

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icd9cm

[ [ [] ] ]

[ "34.1", "39.61", "88.72", "34.91", "83.82", "36.15", "86.74", "38.93", "36.14", "96.6" ]

icd9pcs

[ [ [] ] ]

8962, 9036

5157, 6517

347, 468

9262, 9269

1386, 4424

9856, 10589

969, 973

6741, 8939

4464, 4506

9057, 9241

6543, 6718

9293, 9833

988, 1367

279, 309

4538, 5134

496, 770

792, 866

882, 953

52,816

193,689

8622

Discharge summary

report

Admission Date: [**2153-5-31**] Discharge Date: [**2153-6-7**] Date of Birth: [**2072-1-10**] Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 2610**] Chief Complaint: Hyperkalemia, Altered Mental Status Major Surgical or Invasive Procedure: None History of Present Illness: This is an 81 year old female with a history atrial fibrillation and diabetes mellitus II who was transferred to the MICU from the ED for management of hyperkalemia. She presented to the ED on [**5-31**] directly from Dr. [**Last Name (STitle) 30218**] office, where she was noted to be fatigued, delirius, and with questionable oxygen saturations (poor curve, 80% at one point). After being discharged on [**2153-5-23**], she had done well at rehab. She was walking around. Three days prior to admission here, she became more delirius and fatigued. She was diagnosed with a UTI yesterday and was given a dose of levofloxacin. . She had a recent admission from [**2153-5-13**] to [**2153-5-23**] when she presented with metformin related lactic acidosis, SIRS, [**Last Name (un) **] and hyperkalemia. She was dialyzed for three days. She developed a left sided pneumothorax as a complication of HD line placement; this was treated with pigtail placement and later chest tube placement. . In the ED, her vitals were T97.9 HR 33 BP 125/45 and sat 98% 4L Nasal Cannula. She was found to have a K of 8, NA 130, CO2 15, glucose 232, and lactate 1.6. She was treated with a total of 4g of calcium gluconate, 14 units of insulin, 2 amp D50, 5 albuterol nebulizers, and aspirin 325mg. Her heart rate increased with these interventions. An EKG revealed wider than usual qrs in addition to peaked t waves. . Upon arrival to the ICU, she had no acute complaints. She was not short of breath. Past Medical History: - Atrial fibrillation - HTN - Hypercholesterolemia - Hypothyroidism - DM type II - Systolic CHF - COPD - Bipolar affective disorder with psychotic features - Osteoarthritis - S/p thyroid removal for polyps - S/p cholecystectomy Social History: She is divorced. She has three children who are quite involved. The patient currently lives alone in a senior housing apartment. She no longer has services, but her daughter reports that Mrs. [**Known lastname 30215**] is doing well, caring for herself since her lithium dose was adjusted. She does go to the senior center for lunch. No alcohol. She has been smoking for approximately 35 years and is trying to cut down. Key relationships: daughter and son. Family History: mother had rheumatic fever and bipolar disorder. Her father had pernicious anemia. Both sisters have thyroid disorders and one had ovarian cancer. Physical Exam: ADMISSION EXAM: General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema . DISCHARGE EXAM: VS: Tm:98.7 Tc: 98.1 Bp: 134/96 (120-134/47-96) P:66 (64-77) RR: 18 02: 98%RA Glucose:190 General: Awake, alert, no apparent distress, oriented to self, place and president HEENT: Sclera anicteric, PERRL, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, mild atelectasis at bases CV: Regular rate and rhythm, normal S1 + S2,III/VI systolic murmur over Ao Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CNs2-12 intact . Pertinent Results: ADMISSION LABS: [**2153-5-31**] 09:15AM BLOOD WBC-10.8 RBC-3.33* Hgb-9.7* Hct-29.5* MCV-89 MCH-29.2 MCHC-33.0 RDW-18.6* Plt Ct-247 [**2153-5-31**] 09:15AM BLOOD PT-13.0 PTT-20.1* INR(PT)-1.1 [**2153-5-31**] 09:15AM BLOOD Glucose-252* UreaN-53* Creat-3.6*# Na-126* K-9.4* Cl-99 HCO3-15* AnGap-21* [**2153-5-31**] 09:15AM BLOOD Calcium-11.1* Phos-6.0*# Mg-2.3 [**2153-5-31**] 09:15AM BLOOD ALT-22 AST-48* AlkPhos-83 TotBili-0.3 [**2153-5-31**] 09:15AM BLOOD Lipase-41 [**2153-5-31**] 09:15AM BLOOD cTropnT-0.01 [**2153-5-31**] 09:27AM BLOOD Lactate-1.6 [**2153-5-31**] 05:50PM BLOOD Lithium-1.0 [**2153-6-1**] 04:10PM BLOOD TSH-1.5 [**2153-6-1**] 04:10PM BLOOD Free T4-1.9* . URINE: [**2153-5-31**] 02:47PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.006 [**2153-5-31**] 02:47PM URINE Blood-NEG Nitrite-NEG Protein-30 Glucose-TR Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-MOD [**2153-5-31**] 02:47PM URINE RBC-<1 WBC-76* Bacteri-FEW Yeast-NONE Epi-0 [**2153-5-31**] 02:47PM URINE CastHy-3* [**2153-5-31**] 05:50PM URINE Eos-POSITIVE [**2153-5-31**] 05:50PM URINE Hours-RANDOM UreaN-291 Creat-39 Na-59 K-48 Cl-62 [**2153-5-31**] 05:50PM URINE Osmolal-315 . DISCHARGE LABS: . MICRO: [**2153-5-31**] Blood Cx: no growth to date [**2153-5-31**] Urine Cx: no growth . IMAGING: [**2153-5-31**] Portable CXR: The patient is rotated slightly to the left. The previously noted tiny left pneumothorax is no longer well appreciated. There is mild bibasilar atelectasis. Cardiac and mediastinal silhouettes are stable, as are the hilar contours. No overt pulmonary edema is seen. Degenerative change is noted at the right acromioclavicular joint. IMPRESSION: No acute cardiopulmonary process. Brief Hospital Course: 81 year old woman with a history of AFib, CHF, DM, with recent hospitalization for [**Last Name (un) **] due to metformin-induced lactic acidosis, who presented with delirium, dyspnea, [**Last Name (un) **], and hyperkalemia. . # Acute kidney injury: FeNa 3.5% suggesting a intrinsic renal etiology, likely from UTI leading to poor PO intake, decreased renal perfusion and ATN. Supported by observation of muddy brown casts on urine sediment. Lithium may also have been contributing. We held the lithium and hydrated with IVF and renally dosed medications and renal function improved. Lithium was restarted at a reduced dose of 75mg daily upon discharge. . # Hyperkalemia: Likely due to [**Last Name (un) **]. She was given 1L NS with 1 amp of HCO3, lasix 80mg IV for forced diuresis, and kayexalate 30mg. Her urine output improved and her potassium normalized. . # Delirium: Patient was delirious on admission, likely due to infection and hyperkalemia. No new meds or exposures to cause delirium. Patient was frequently reoriented and received haldol 0.25mg PO as needed for agitation and sleep at night. Will continue on standing haldol 0.25mg PO QHS for help with anxiety and agitation at night. . # UTI: Complicated given recent hospitalization with foley and recent antibiotic use. Urine culture in hospital negative after 2 days of Abx. Culture from rehab growing klebsiella and pseudomonas both sensitive to ciprofloxacin. Will continue ciprofloxacin 500mg for a 10-day course ([**Date range (1) 30219**]). . # Anemia: Normocytic normochromic anemia, likely combination of iron deficiency and anemia of chronic disease. Hematocrit was stable throughout stay. . # Atrial fibrillation: Chads2 score is 4 correlating with a high risk of embolic phenomena, though the patient is currently only anticoagulated with ASA 81mg. The patient was started on 1mg coumadin daily on discharge after discussion of goals of care with Dr. [**Last Name (STitle) **]. . # CHF: EF of 35%. Patient is euvolemic on exam and no evidence of pulmonary edema on CXR. Patient continued on aspirin through stay, and given metoprolol for rate control after episode of tachycardia. Will continue home carvidelol 3.125 mg by mouth twice daily on discharge. . # HTN: Patient was hypotensive through much of her stay. Carvidelol held on admission and metoprolol given for rate control. Will continue home carvidelol 3.125 mg by mouth twice daily on discharge . # Diabetes: Patient was treated with humalog sliding scale while in the hospital. She was restarted on glibizide 2.5mg by mouth daily on discharge. . # Bipolar Disorder: We initially held lithium and continued perphenazine 2mg in AM, 4mg in PM. Lithium was restarted at a reduced dose of 75mg upon discharge. . # Hyperlipidemia: Decreased simvastatin dose to 40mg daily. . # Hypothyroidism: TSH wnl but free T4 slightly elevated, though difficult to interpret in the setting of acute illness. We continued home dose of levothyroxine and recommend outpatient follow up. . # COPD: Asymptomatic. Continued tiotropium. Medications on Admission: 1. carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 2. levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. lithium carbonate 150 mg Capsule Sig: One (1) Capsule PO QAM (once a day (in the morning)). 4. perphenazine 2 mg Tablet Sig: One (1) Tablet PO QAM (once a day (in the morning)). 5. perphenazine 2 mg Tablet Sig: Two (2) Tablet PO QPM (once a day (in the evening)). 6. simvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day. 7. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 8. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO once a day. 9. calcium carbonate-vitamin D3 600 mg(1,500mg) -400 unit Tablet Sig: One (1) Tablet PO twice a day. 10. glipizide 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 11. amiloride 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 12. ferrous sulfate 325 mg (65 mg iron) Tablet Sig: One (1) Tablet PO once a day. Discharge Medications: 1. levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 3. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 4. perphenazine 2 mg Tablet Sig: One (1) Tablet PO QAM (once a day (in the morning)). 5. perphenazine 2 mg Tablet Sig: Two (2) Tablet PO QHS (once a day (at bedtime)). 6. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for Pain. 7. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours): last dose is [**6-9**]. 8. carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO twice a day. 9. Calcium 600 + D(3) 600 mg(1,500mg) -400 unit Tablet Sig: One (1) Tablet PO twice a day: hold medication until Cipro course complete. 10. simvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day. 11. Coumadin 1 mg Tablet Sig: One (1) Tablet PO once a day. 12. glipizide 5 mg Tablet Sig: [**12-17**] Tablet PO once a day. 13. ferrous sulfate 325 mg (65 mg iron) Tablet Sig: One (1) Tablet PO once a day: start after finish course of Cipro. 14. lithium carbonate 300 mg Tablet Sig: [**12-19**] Tablet PO once a day: One quarter tablet for a total of 75mg PO daily. Discharge Disposition: Extended Care Facility: [**Location (un) 10140**] Nursing Center - [**Location (un) 10059**] Discharge Diagnosis: Primary: urinary tract infection, acute kidney injury, hyperkalemia Secondary: bipolar disorder, atrial fibrillation Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Ms. [**Known lastname 30215**], It was a pleasure caring for you. You were admitted with altered mental status, worsening kidney function, and electrolyte abnormalities, and were found to have a UTI. We gave you fluids and antibiotics, and this resolved. . We made the following changes to your medications: - DECREASE lithium to 75mg daily - DECREASE simvastatin to 40mg daily - START ciprofloxacin to be taken through [**2153-6-9**] (two more doses after discharge from hospital) - STOP amiloride - START Glipizide 2.5mg by mouth daily - START Coumadin 1mg by mouth daily -START Haldol 0.25mg by mouth nightly Followup Instructions: **You are scheduled to see your PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] on [**2153-7-23**], however we would like for you to be seen sooner. Please call her office to schedule a follow up appointment within one week of leaving rehab. [**Telephone/Fax (1) 719**] . **You were already scheduled for the following appointments: Department: WEST [**Hospital 2002**] CLINIC When: TUESDAY [**2153-6-12**] at 10:30 AM With: [**Name6 (MD) 1532**] [**Last Name (NamePattern4) 8786**], MD [**Telephone/Fax (1) 3020**] Building: De [**Hospital1 **] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **] Campus: EAST Best Parking: [**Street Address(1) 592**] Garage . Department: GERONTOLOGY When: MONDAY [**2153-7-23**] at 10:00 AM With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 719**] Building: LM [**Hospital Unit Name **] [**Location (un) **] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage . Department: CARDIAC SERVICES When: THURSDAY [**2153-8-2**] at 10:00 AM With: ECHOCARDIOGRAM [**Telephone/Fax (1) 62**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage

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icd9cm

[ [ [] ] ]

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icd9pcs

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21091

Discharge summary

report

Admission Date: [**2152-11-21**] Discharge Date: [**2152-11-24**] Date of Birth: [**2101-11-17**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 7055**] Chief Complaint: NSTEMI Major Surgical or Invasive Procedure: Cardiac catheterization, no intervention History of Present Illness: 51 yo male with history of CAD s/p CABG X3 in [**2145**] (LIMA to LAD, SVG to Diag and OM), HTN, HLD, tobacco use, ITP presents from [**Hospital3 3583**]. He woke up from sleep at 6am with severe substernal chest pain, radiating to both arms (L>R), with some tingling. HE took one nitroglycerin which helped with the pain initially, but it returned in 15 minutes, he felt as if an "elephant was sitting on his chest." He also complained of some diaphoresis during those episodes, but denied N/V. The patient presented to [**Hospital1 3325**] this AM with this chest pain. He was found to have elevated BP to 206/126. EKG showed ST depressions. Initial trop was 1.03. He was given SL nitro, total of 8mg IV morphine, 600mg plavix, 325mg aspirin, 50mg metoprolol PO. He was admitted to their CCU where he had recurrent chest pain at 4pm. He was then started on heparin and nitro drips. Most recent troponin prior to transfer was 9.10, CPK > 1000. On transfer, he has no chest pain. He was transferred here for emergent Cath. . On review of systems, he denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. He denies recent fevers, chills or rigors. He denies exertional buttock or calf pain. All of the other review of systems were negative. . Past Medical History: 1. CARDIAC RISK FACTORS:(-)Diabetes,(+)Dyslipidemia,(+)Hypertension 2. CARDIAC HISTORY: -CABG: [**2145**] X3 LIMA to LAD, SVG to Diag, SVG to OM 3. OTHER PAST MEDICAL HISTORY: ITP - was worked up at OSH, no splenectomy. Appendectomy at age 10 Social History: Lives with his girlfriend named [**Name (NI) 53564**]. [**Name2 (NI) 12694**] of water well. Divorced 4 years ago. 3 Children. He states that he quit smoking on and off, but most recently a month ago, but had a few cigarettes while in [**Last Name (un) **] last week. Routine EtOH intake [**2-10**] beers daily. company in [**Location (un) 3320**] -Tobacco history: (+) -ETOH: (+) -Illicit drugs: none. Family History: Brother CAD with angioplasty, Father -lung CA at 61, Mother - [**Name (NI) **]. Physical Exam: On Admission: VS: T=100PM BP= 137/85 HR= 85 RR= 18 O2 sat=98% on GENERAL: WDWN in NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple CARDIAC: RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. EXTREMITIES: No c/c/e. No femoral bruits. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ . On discharge: VSS. Pertinent Results: [**2152-11-21**] 09:30PM PLT COUNT-158 [**2152-11-21**] 09:30PM WBC-12.7* RBC-4.73 HGB-14.3# HCT-41.4 MCV-88 MCH-30.3 MCHC-34.6 RDW-13.9 [**2152-11-21**] 09:30PM CK-MB-129* MB INDX-8.8* cTropnT-2.44* [**2152-11-21**] 09:30PM CK(CPK)-1472* [**2152-11-21**] 09:30PM estGFR-Using this [**2152-11-21**] 09:30PM GLUCOSE-151* UREA N-17 CREAT-1.2 SODIUM-136 POTASSIUM-4.0 CHLORIDE-101 TOTAL CO2-25 ANION GAP-14 ECHO: The left atrium is mildly dilated. The left atrium is elongated. The right atrium is moderately dilated. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. There is mild regional left ventricular systolic dysfunction with hypokinesis of the basal to mid-inferior and inferolateral walls. The right ventricular cavity is mildly dilated with low-normal free wall contractility. The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (3) are mildly thickened. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. The pulmonary artery systolic pressure could not be determined. There is a trivial/physiologic pericardial effusion. IMPRESSION: Regional LV systolic dysfunction consistent with CAD. Mildly dilated RV with borderline normal function. No pathologic valvular abnormality seen. Cardiac Cath: Report not available at time of discharge. Brief Hospital Course: 51M with CAD s/p CABG X3 in [**2145**] (LIMA to LAD, SVG to Diag and OM), HTN, HLD, tobacco use, ITP presents from [**Hospital3 3583**] with chest pain. He was transported to the cath lab for emergent cath and then was admitted to the CCU for post-cath care. . # NSTEMI: Based on Cath from [**2145**], which showed Left main and two vessel coronary artery disease, mild global systolic left ventricular dysfunction, Normal left ventricular diastolic function; patient undergone CABG X3 LIMA to LAD, SVG to Diag, SVG to OM. At OSH EKG showed ST depressions in Lateral leads (I, AvL, V2-3). Patient s/p cath (which demonstrated SVG to OM was occluded, LIMA to LAD was patent, severe LV diastolic heart failur ) with no stenting, with deferred PCI due to likely completed NSTEMI. Also, CK: 1472 MB: 129 MBI: 8.8 Trop-T: 2.44. HE received 160 ml of contrast total. He was started on Aspirin 325 Daily, Eptifibatide 2 mcg/kg/min IV DRIP INFUSION Duration: 18, - Continue Heparin drip 6 hours s/p arterial hemostasis until chest-pain free, with no bolusing. This was stopped on HD#2. Plavix 75mg Daily (was loaded at OSH) for 1 month post MI. Atorvastatin 80mg Daily. Metoprolol titrated to HR of 60-70, as BP tolerates. We maintained O2 saturation above 90% with nasal cannula as needed. His Cardiac Enzymes peaked. Post cath checks without any complications. Echo was done and showed Regional LV systolic dysfunction consistent with CAD. Mildly dilated RV with borderline normal function. No pathologic valvular abnormality was seen. This patient would greatly benefit from total smoking cessation, and this was discussed with him. . . # Hypertensive Emergency/HTN - patient's BP was in 200's at OSH. Patient received Lasix 20, and was on nitro Drip while in cath. While in the CCU his blood pressure was not in the hypertensive. We monitored his blood pressure while in hospital. We stopped his home lisinopril, but he should resume it later if his blood pressure is increased. . # Elevated WBC count - likely post Cath but with low grade fever. This improved prior to discharge, and he was afebrile while in hospital. . #PROPHYLAXIS: Patient was prophylaxed with subcutaneous heparin and pneumoboots while inpatient. Medications on Admission: MEDICATIONS on TRANSFER: Metoprolol 50mg daily Heparin 1500units/hr Nitro 90mcg/min . HOME MEDICATIONS: Aspirin 325 daily Crestor 40mg Daily Lisinopril 20 Daily Multivitamin Cod liver oil Discharge Medications: 1. aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 2. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*11* 3. metoprolol succinate 50 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* 4. Crestor 40 mg Tablet Sig: One (1) Tablet PO once a day. 5. lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet, Sublingual Sublingual PRN (as needed) as needed for chest pain. Disp:*25 Tablets* Refills:*0* 7. isosorbide mononitrate 30 mg Tablet Sustained Release 24 hr Sig: 0.5 Tablet Sustained Release 24 hr PO DAILY (Daily). Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Non ST Elevation Myocardial Infarction Coronary Artery Disease Hypertension Dyslipidemia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You had chest pain and a heart attack at [**Hospital3 3583**] and was transferred here for a cardiac catheterization. We found a blockage in one of the bypassed veins. We did not try to fix this artery as it appeared that the heart attack was over. You have done very well after the heart attack and an echocardiogram showed that your heart function is still OK but not quite as strong as before. You will have another echocardiogram at your new cardiologists office. Please follow the instructions of the physical therapist regarding activity until you see Dr. [**Last Name (STitle) 5310**]. We have made the following changes to your medicines: 1. Start taking Plavix every day to prevent any further blockages in your heart arteries 2. Start taking Imdur to prevent any chest pain and help lower your blood pressure. 3. Start taking Metoprolol to help your heart recover from the heart attack. 4. Continue to take a full (325mg) aspirin, Lisinopril and Crestor as before. 5. Take the nitroglycerin as directed for any chest pain or pressure. Please call Dr. [**Last Name (STitle) 5310**] if you have chest pain. Call 911 if the nitroglycerin does not relieve the chest pain. . Please talk to Dr. [**Last Name (STitle) 5310**] about returning to physical activity . You will need to stop smoking entirely to prevent further heart attacks. Smoking is a major contributor to your heart disease. Smoking cessation strategies have been discussed with you. Followup Instructions: Name: [**Last Name (LF) **],[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] Specialty: Internal Medicine Address: 3 VILLAGE GREEN NORTH, STE. 321, [**Location (un) **],[**Numeric Identifier 40624**] Phone: [**Telephone/Fax (1) 55984**] Appointment: Thursday [**11-30**] at 11:00AM Name: [**Last Name (LF) 5310**], [**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] Specialist: Cardiology Address: [**Doctor Last Name 37166**],LOWER LEVEL, [**Location (un) **],[**Numeric Identifier **] Phone: [**Telephone/Fax (1) 5315**] Appointment: Tuesday [**12-13**] at 2:20PM Completed by:[**2152-11-24**]

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icd9cm

[ [ [] ] ]

[ "88.56", "37.22" ]

icd9pcs

[ [ [] ] ]

8222, 8228

4887, 7113

315, 358

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27,332

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31940+57771

Discharge summary

report+addendum

Admission Date: [**2101-1-10**] Discharge Date: [**2101-1-22**] Date of Birth: [**2045-1-10**] Sex: M Service: CARDIOTHORACIC Allergies: Demerol / Shellfish / Chlorpromazine / Dilaudid Attending:[**First Name3 (LF) 2969**] Chief Complaint: Esophageal cancer Major Surgical or Invasive Procedure: Tri-incisional esophagectomy, [**2101-1-10**] History of Present Illness: 55-year-old male who was recently diagnosed with T3 N1 adenocarcinoma of the esophagus. He began to have dysphagia with solid food in approximately [**2100-1-28**], which progressed over the next 6 months. EGD and biopsy on [**2100-9-22**] revealed adenocarcinoma arising at the GE junction without Barrett's metaplasia seen, and possible adenocarcinoma versus contamination at 25 cm. Chest CAT scan on [**2100-9-27**] revealed mild fullness of the distal esophagus, scattered nonspecific small lymph nodes, and a punctate nonspecific right lung nodule. Hepatic steatosis and diverticulosis were also noted. PET CT scan on [**2100-9-30**] revealed a small focal hypermetabolic area in the distal third of the esophagus, without CT correlation with the biopsy of the area of concern for malignancy. There is reported GE junction carcinoma, which does not display FDG hypermetabolism. There was no definite evidence of extra esophageal FDG-avid metastatic disease. He then underwent another EGD with ultrasound on [**2100-10-6**] here at [**Hospital1 69**]. Pathology revealed adenocarcinoma at the GE junction, infiltrating the muscularis propria, however, the esophagus at 25 cm was consistent with a squamous epithelium only. Ultrasound revealed N1 status. A J tube and port were placed. He began concurrent chemoradiation with cisplatin and 5-FU delivered via 96 hour pump on [**2100-10-25**]. He received 2 chemo cycles and radiation therapy and now presents for surgical resection. Past Medical History: - Barrett's esophagus, esophageal ca s/p chemo/radiation. See HPI. -Recent PE on coumadin - s/p recent Left lower extremity cellulitis, likely etiology from his leg brace. - Left lower extremity injury in [**2062**] with resultant left lower extremity foot drop with a brace. He has undergone four operations on his left lower extremity in [**2062**]. He had a bypass at the femoral artery and a bone graft. He also had an ankle surgery in [**2078**]. - Benign [**Year (4 digits) 499**] polyps, last colonscopy q3-4 yrs. - GERD - Hemorrhoids. Social History: The patient lives in [**Male First Name (un) 1056**]. He was originally from [**Country 5976**] and moved to [**Male First Name (un) 1056**] in [**2052**]. He is married with one daughter age 25 and one granddaughter age 7. The patient's brother lives in [**Name (NI) 3494**] and the patient will be staying with him during the duration of his treatment. The patient is this ex-smoker having quit in [**2070**] after approximately 24 pack years. He drinks alcohol very rarely. He owns his own business with his wife. [**Name (NI) **] manufactures mop heads Family History: - M: diagnosed with GI polyps and ultimately died at the age of 57 from a brain tumor. - A paternal grandmother had [**Name2 (NI) 499**] cancer at the age of 70, but ultimately passed away of a heart attack. - F: CAD s/p MI & CABG, currently in good health in his 90s. Physical Exam: GENERAL: The patient is a well-appearing male in no acute distress. He is alert and oriented x3. Head: AT,NC. Eyes: Extraocular movements intact. Pupils equal, round, reactive to light. Sclerae anicteric, conjunctiva pink. ENT: Mucous membranes moist. Pharynx with small scattered ulcerations. Neck: Supple. Well healing neck incision. Lymphatics: There is no appreciable cervical, supraclavicular, Heart: Regular rate and rhythm, normal S1, S2, no murmurs, rubs, or gallops. Lungs: Clear to auscultation bilaterally. Abdomen: Normal bowel sounds, soft, nontender, nondistended. There is no hepatosplenomegaly appreciated. VAC in place midline, holding suction. Wet-to-dry dressing lateral abdominal incision. Minimal erythema without purulent drainage. Neuro: There are no focal abnormalities. Pertinent Results: [**2101-1-22**] 05:05AM BLOOD WBC-15.5* RBC-2.87* Hgb-9.2* Hct-26.5* MCV-92 MCH-32.0 MCHC-34.7 RDW-14.6 Plt Ct-517* [**2101-1-21**] 05:40AM BLOOD WBC-16.7* RBC-2.91* Hgb-9.3* Hct-26.9* MCV-92 MCH-32.1* MCHC-34.7 RDW-14.6 Plt Ct-516* [**2101-1-11**] 02:32AM BLOOD WBC-16.7* RBC-3.59* Hgb-11.7* Hct-32.5* MCV-91 MCH-32.4* MCHC-35.8* RDW-15.1 Plt Ct-347 [**2101-1-10**] 05:36PM BLOOD WBC-16.0*# RBC-3.58* Hgb-12.1* Hct-33.7* MCV-94 MCH-34.0* MCHC-36.0* RDW-15.5 Plt Ct-401 [**2101-1-21**] 05:40AM BLOOD Neuts-84* Bands-0 Lymphs-8* Monos-4 Eos-1 Baso-0 Atyps-0 Metas-2* Myelos-1* [**2101-1-22**] 05:05AM BLOOD Plt Ct-517* [**2101-1-22**] 05:05AM BLOOD PT-12.9 PTT-25.1 INR(PT)-1.1 [**2101-1-21**] 05:40AM BLOOD Glucose-99 UreaN-10 Creat-0.5 Na-136 K-4.0 Cl-102 HCO3-26 AnGap-12 [**2101-1-20**] 07:11AM BLOOD Glucose-97 UreaN-10 Creat-0.5 Na-136 K-4.3 Cl-101 HCO3-26 AnGap-13 [**2101-1-10**] 05:36PM BLOOD Glucose-152* UreaN-7 Creat-0.8 Na-136 K-4.6 Cl-104 HCO3-21* AnGap-16 [**2101-1-12**] 05:57AM BLOOD CK(CPK)-1159* [**2101-1-11**] 03:37PM BLOOD CK(CPK)-1225* [**2101-1-21**] 05:40AM BLOOD Calcium-8.0* Phos-4.0 Mg-1.8 [**2101-1-20**] 07:11AM BLOOD Calcium-8.0* Phos-4.0 Mg-1.8 [**2101-1-11**] 02:32AM BLOOD Calcium-8.6 Phos-4.7* Mg-2.0 [**2101-1-10**] 05:36PM BLOOD Calcium-9.2 Phos-4.8* Mg-1.3* [**2101-1-11**] 10:10PM BLOOD Lactate-1.1 K-3.7 [**2101-1-10**] 06:06PM BLOOD Glucose-131* [**2101-1-10**] 11:18AM BLOOD Glucose-120* Lactate-1.2 Na-136 K-3.7 Cl-104 [**2101-1-10**] 08:59AM BLOOD Glucose-95 Lactate-1.1 Na-138 K-3.6 Cl-103 RADIOLOGY Final Report CHEST (PORTABLE AP) [**2101-1-10**] 5:09 PM CHEST (PORTABLE AP) Reason: Please assess for pneumo, effusion, etc [**Hospital 93**] MEDICAL CONDITION: 55 year old man with bilateral chest tubes, s/p esophagectomy REASON FOR THIS EXAMINATION: Please assess for pneumo, effusion, etc REASON FOR EXAMINATION: Follow-up of a patient after esophagectomy. Portable AP chest radiograph was compared to preoperative study from [**2101-1-6**]. The ETT tube tip is 6 cm above the carina. The NG tube tip terminates at the regular location of the gastroesophageal junction. The right subclavian line tip is at the cavoatrial junction. The bilateral chest tubes are shown, the right one terminating in the right apex and the left tip being located in the left posterior pleural space. The post-surgical drain is in the left upper mediastinum. The cardiomediastinal silhouette is unremarkable for post- surgical stage. The bibasilar lower retrocardiac atelectasis are noted, most likely explained by relatively low lung volumes. Small left apical and lateral pneumothorax is demonstrated with possible basal component. Small amount of left subcutaneous emphysema is noted. Findings were discussed with Dr. [**First Name (STitle) **] at the time of dictation over phone by Dr. [**Last Name (STitle) **]. The study and the report were reviewed by the staff radiologist. DR. [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 16277**] DR. [**First Name4 (NamePattern1) 2618**] [**Last Name (NamePattern1) 2619**] DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 5785**] Approved: WED [**2101-1-12**] 8:36 AM RADIOLOGY Final Report CHEST (PA & LAT) [**2101-1-19**] 8:40 AM CHEST (PA & LAT) Reason: assess for effusion, pneumothorax, hemothorax, consolidation [**Hospital 93**] MEDICAL CONDITION: 56 year old man s/p esophagogastrectomy now w shortness of breath REASON FOR THIS EXAMINATION: assess for effusion, pneumothorax, hemothorax, consolidation PA AND LATERAL VIEWS OF THE CHEST REASON FOR EXAM: Esophagogastrectomy with shortness of breath. Left lower lobe retrocardiac opacity is new, could be due to atelectasis. Pneumonia cannot be excluded. Moderate right and small left pleural effusions are unchanged. Distal atelectasis in the left base is stable. There is no pneumothorax. Cardiomediastinal contour is unchanged. Right subclavian catheter remains in place with the tip in the right atrium. IMPRESSION: New left lower lobe retrocardiac opacity. Compared to prior study of [**2101-1-15**], this could be due to atelectasis, but pneumonia cannot be excluded. RADIOLOGY Final Report ABDOMEN (SUPINE & ERECT) [**2101-1-18**] 11:36 AM ABDOMEN (SUPINE & ERECT) Reason: eval for abn gas patterns. pt s/p esophagectomy with hypoact [**Hospital 93**] MEDICAL CONDITION: 56 year old man with REASON FOR THIS EXAMINATION: eval for abn gas patterns. pt s/p esophagectomy with hypoactive bs and no return of bowel function. also with inc burping INDICATION: 56-year-old man status post esophagectomy with hypoactive bowel sounds and no return of bowel function, evaluate for abnormal gas patterns. COMPARISON: Scout film of CT from [**2101-1-3**]. SUPINE AND UPRIGHT ABDOMINAL RADIOGRAPHS: Dilated gas-filled large bowel to the level of the mid descending [**Year (4 digits) 499**]. Air is seen in the rectum. Multiple air-fluid levels are seen. IMPRESSION: Dilated large bowel consistent with ileus; if clinical situation worsens recommend a followup radiograph to evaluate for possibility of obstruction. The study and the report were reviewed by the staff radiologist. DR. [**First Name8 (NamePattern2) 5206**] [**Name (STitle) **] DR. [**First Name (STitle) 5432**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] Brief Hospital Course: Patient underwent an esophagectomy, pyloroplasty, and reduction of incisional hernia with primary repair on [**2101-1-10**] as planned (for operative details, please see dictated report). He tolerated the procedure well and was transferred to the ICU for observation, was extubated on POD 1 and was transferred to a nursing floor on POD 2. Neuro: Patient was extubated on POD 1 and epidural catheter was placed with good pain control. He was subsequently transitioned to PCA Dilaudid and eventually transitioned to PO meds once he was able to take POs. Cardiovascular: Hear rate/rhythm was controlled postoperatively with Lopressor. He did not have any adverse cardiac events during his hospitalization. He did complain of chest pain after extubation. EKG was normal without acute changes and he had negative cardiac enzymes x3. This pain subsequently improved and was thought to be [**1-29**] surgery. Pulmonary: Extubated on POD 1. He had bilateral chest tubes postoperatively. CXR was stable and showed no pneumothorax. Left chest tube was removed on POD4 without complications. Right chest tube was removed on POD 5. He had good lung re-expansion. Ambulation and incentive spirometry was aggressively encouraged. He was re-started on coumadin with bridging lovenox for his recent history of PE. GI: Post-operative course was complicated by post op ileus and slow return of bowel function. He was kept NPO. Tube feeds were started on POD4 through J tube. With the return of bowel function and flatus, his J-tube feedings were advanced to goal. He had a bedside grape-juice swallow on POD 7 that did not show leak into neck JP drain. His oral diet was advanced to clears and subsequently to include full liquids. JP drain was removed on POD 9. He is discharged to rehab facility on tube feeds and a full liquid diet ID: Patient developed erythema with purulent drainage from midline wound. Wound was opened and he was started on antibiotics. Cultures revealed ENTEROBACTER CLOACAE that was pan sensitive. He received a 7 day course of levofloxacin. He remained afebrile. After 3 days of wet to dry dressing changes a VAC dressing was applied. Subsequent examinations revealed erythema overlying the hernia repair left of midline. U/S examination showed a thick-walled fluid collection within the subcutaneous tissues measuring 7x3 cm. This wound was opened and revealed old hematoma with no obvious purulence. Wet to dry dressings were started. His leukocytosis began to trend down. Heme: DVT prophylaxis was achieved with SC Heparin. He was subsequently started on Coumadin/Lovenox with therapeutic goal INR [**1-30**] and Lovenox for bridging anticoagulation. Patient is being discharged to rehabilitation facility. He will follow up with Dr. [**Last Name (STitle) **] at [**Hospital1 18**] on Thursday, [**1-27**] with a barium swallow evaluation. Discharge Medications: 1. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2 times a day). Disp:*50 * Refills:*2* 2. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs PO Q6H (every 6 hours) as needed for pain. Disp:*50 ML(s)* Refills:*0* 3. Enoxaparin 40 mg/0.4 mL Syringe Sig: One (1) Subcutaneous [**Hospital1 **] (2 times a day). Disp:*60 * Refills:*2* 4. Warfarin 5 mg Tablet Sig: One (1) Tablet PO DAILY16 (Once Daily at 16). Disp:*40 Tablet(s)* Refills:*2* 5. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 6. Pantoprazole 40 mg Recon Soln Sig: One (1) Recon Soln Intravenous Q24H (every 24 hours). Disp:*30 Recon Soln(s)* Refills:*2* 7. Heparin Lock Flush (Porcine) 10 unit/mL Solution Sig: One (1) ML Intravenous DAILY (Daily) as needed. Disp:*50 ML(s)* Refills:*0* 8. Levofloxacin 750 mg Tablet Sig: One (1) Tablet PO once a day for 2 weeks. Disp:*14 Tablet(s)* Refills:*0* Discharge Disposition: Extended Care Facility: [**Hospital3 7**] & Rehab Center - [**Hospital1 8**] Discharge Diagnosis: Esophageal cancer Discharge Condition: Satisfactory Discharge Instructions: Full liquid diet No heavy lifting or strenuous activity for 6 weeks Wound vac to midline incision, change every 2 days Change LLQ wound with wet-->dry packing; change TID Followup Instructions: F/U on Thursday, [**2101-1-27**] in clinic with Dr. [**Last Name (STitle) **]; F/U with barium swallow on same day before clinic visit Completed by:[**2101-1-22**] Name: [**Known lastname **] [**Last Name (LF) 12334**],[**Known firstname 837**] Unit No: [**Numeric Identifier 12335**] Admission Date: [**2101-1-10**] Discharge Date: [**2101-1-22**] Date of Birth: [**2045-1-10**] Sex: M Service: CARDIOTHORACIC Allergies: Demerol / Shellfish / Chlorpromazine / Dilaudid Attending:[**First Name3 (LF) 9814**] Addendum: Correction to discharge summary: Patient is being discharged on a 14 day course of levofloxacin (not 7 days as stated in previous discharge summary). Rehab will follow daily INRs and adjust coumadin until therapeutic at 2-3. Discharge Disposition: Extended Care Facility: [**Hospital3 14**] & Rehab Center - [**Hospital1 15**] [**First Name11 (Name Pattern1) 3549**] [**Last Name (NamePattern1) 9816**] MD [**MD Number(2) 9817**] Completed by:[**2101-1-22**]

[ "560.1", "998.59", "530.85", "553.21", "150.3", "997.4", "V44.4", "196.1", "041.85", "530.81", "E878.6", "998.12", "V58.61", "V12.51", "151.0" ]

icd9cm

[ [ [] ] ]

[ "43.5", "42.42", "53.51", "96.6", "40.3", "44.29" ]

icd9pcs

[ [ [] ] ]

14624, 14866

9575, 12439

332, 380

13569, 13584

4178, 5855

13803, 14601

3060, 3332

12462, 13405

8585, 8606

13528, 13548

13608, 13780

3347, 4159

275, 294

8635, 9552

408, 1901

1924, 2469

2485, 3044

21,274

175,983

5664

Discharge summary

report

Admission Date: [**2181-12-6**] Discharge Date: [**2181-12-13**] Date of Birth: Sex: M Service: [**Hospital1 **] CHIEF COMPLAINT: Diabetic ketoacidosis and pancreatitis. HISTORY OF PRESENT ILLNESS: This is a 53-year-old male with a history of human immunodeficiency virus, not on any antiretrovirals secondary to belief that they caused his diabetes. He has a history of hepatitis C also secondary to intravenous drug abuse, and insulin-dependent diabetes mellitus, who presents to the Emergency Department on [**12-6**] with diabetic ketoacidosis with a pH of 7.09, and fingerstick blood sugar of 400. The patient had complained of polydipsia, polyuria times four days, along with blurry vision and weight loss. He also complained of left lower quadrant and left flank pain over the same period of time which was relieved by urinating. The patient denied fever. He had some chills, though, while he was in the Emergency Department. He denied a cough, denied dysuria, denied diarrhea or changes in bowel habits. PAST MEDICAL HISTORY: (Significant for) 1. Human immunodeficiency virus. The patient is not on any antiretrovirals secondary to his belief that they caused his diabetes. 2. Hepatitis C, again from intravenous drug abuse. 3. Diabetes, but refuses to take insulin. 4. He has bipolar disorder. 5. Hypertension. MEDICATIONS ON ADMISSION: Bactrim, clonidine, azithromycin, Klonopin, Zyprexa, Percocet, Neurontin. SOCIAL HISTORY: He is married times 26 years. His son died, reportedly fell off the [**Name (NI) 22639**] bridge. He denies smoking, denies drinking. He had intravenous drug abuse for 35 years. He use to work as an animal research technician. He intravenous drugs in [**2170**]. PHYSICAL EXAMINATION ON ADMISSION: His pulse was 110. His blood pressure was 140/60, and his respiratory rate was 20, with 100% saturation on room air. In general, a thin, chronically ill-appearing male in no apparent distress. HEENT was normocephalic, anicteric. Pupils were equal, round, and reactive to light and accommodation. Chest was clear to auscultation bilaterally. Cardiovascular was tachycardic, but no murmurs, rubs or gallops were appreciated. Abdomen had positive bowel sounds. There was tenderness in the left upper quadrant. No rebound. No guarding. Extremities were thin without edema. His skin revealed diffuse reticular rash which was not pruritic. LABORATORY ON ADMISSION: On admission, a white blood cell count of 7.5, hematocrit 45, and platelets of 108. Sodium of 134, potassium of 4.5, chloride of 99, bicarbonate of 7, BUN of 17, creatinine of 1.3,, and glucose on admission of 434. HOSPITAL COURSE: The patient was admitted to the Medical Intensive Care Unit and started on an insulin drip. He did well over the course of two days and was subsequently transferred to the floor. When he was transferred to the floor he was tolerating a clear liquid diet with no obvious source for the abdominal pain which was thought to be pancreatitis, but no source of pancreatitis was found. There was no alcohol history, no gallstones on an imaging study, but he did have increase in enzymes. The patient did well. His diabetic ketoacidosis was resolved. He underwent some teaching as far as the need to take his insulin. He was restarted on the psychiatric medications; he had apparently not been taking them. For his human immunodeficiency virus, no antiretrovirals were taken at present. We did continue the Pneumocystis carinii pneumonia prophylaxis, and he was to be followed by his primary care physician upon discharge. CONDITION AT DISCHARGE: He was discharged in good condition on [**2181-12-13**]. [**Name6 (MD) 2415**] [**Last Name (NamePattern4) 3474**], M.D. [**MD Number(1) 3475**] Dictated By:[**Last Name (NamePattern1) 22640**] MEDQUIST36 D: [**2182-6-18**] 13:32 T: [**2182-6-20**] 05:16 JOB#: [**Job Number 22641**]

[ "276.5", "042", "296.7", "401.9", "250.10", "577.0", "305.00", "V02.62" ]

icd9cm

[ [ [] ] ]

[ "38.93", "89.61" ]

icd9pcs

[ [ [] ] ]

1392, 1467

2696, 3631

3646, 3968

159, 200

229, 1049

2460, 2677

1072, 1365

1484, 1773

16,761

110,575

29633+57649

Discharge summary

report+addendum

Admission Date: [**2126-5-16**] Discharge Date: [**2126-6-12**] Date of Birth: [**2065-5-4**] Sex: F Service: CARDIOTHORACIC Allergies: Codeine / Phenergan Attending:[**First Name3 (LF) 165**] Chief Complaint: Chest Pain Major Surgical or Invasive Procedure: Cardiac Catheterization PICC Line placement History of Present Illness: 61 year old spanish-speaking female with CAD s/p recent RCA bare metal stent [**1-2**], DM, HTN presented to OSH with chest pain. By report, the chest pain has been intermittent for at least a month, but she did not tell her family about it until this week. She presented to [**Hospital6 3105**] On [**5-15**] for increased severity of this pain. She describes the pain as a "sharp" pain starting in left shoulder blade and radiating around to left anterior chest associated with some shortness of breath. Pain is worse with exertion and improves w/ rest. By report, she also has been having left shoulder pain and started on percocet at [**Hospital6 5016**]. At [**Hospital3 **], she had nausea with emesis x 3 (non-bloody). She initially received sl NTG. First set two sets of cardiac enzymes were negative; on eve of [**5-16**], however, by report new TW in precordial leads and + TnT --> started on heparin gtt and transfered to [**Hospital1 18**]. . Currently denying active chest pain or shortness of breath, though endorses mild nausea. . ROS: On review of symptoms, denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, hemoptysis, black stools or red stools. 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. Reports worsened ability to do stairs (stops frequently), but unable to quantify it exactly. . Past Medical History: PAST MEDICAL HISTORY: CAD cath in [**2119**] at OSH with 70% LAD stenosis, 60% LCX stenosis Cath in [**1-2**] with stent to RCA ETT in [**2123**] at OSH with no ischemia and 60% LVEF DM2 with retinopathy adn nephropathy HTN Hypercholesterolemia obesity OA depression SEVERE NONCOMPLIANCE GERD with hiatal hernia anxiety tension HA CRI 1.0-1.3 baseline Cr PAD h/o cholecystectomy Social History: Has lived in U.S. since [**2098**] from [**Male First Name (un) 1056**]. She lives with granddaughter. She quit smoking 15 years ago and denies alcohol or drug use. Family History: mother with diabetes and CAD and an aunt with the same. Physical Exam: Vitals: 97.4F HR 87 BP 137/65 20 100% 3L Gen: obese, fatigued, NAD. HEENT: anicteric, EOMI, MMM. JVD unable to assess. CV: regular, 80s, normal s1 and S2. No murmurs or rubs. ?mild exacerbation of pain on palpation of shoulder Resp: CTAB Abd: obese, soft, NT/ND. Ext: no LE edema, 2+ DP pulses Skin: no jaundice, no rash Pertinent Results: [**2126-5-16**] 11:02PM BLOOD WBC-14.4* RBC-4.05* Hgb-12.2 Hct-36.5 MCV-90 MCH-30.1 MCHC-33.4 RDW-13.8 Plt Ct-364 [**2126-5-16**] 11:02PM BLOOD Glucose-345* UreaN-46* Creat-1.3* Na-136 K-6.3* Cl-104 HCO3-20* AnGap-18 [**2126-5-16**] 11:02PM BLOOD CK(CPK)-289* CK-MB-33* MB Indx-11.4* cTropnT-0.80* [**2126-5-17**] 05:30AM BLOOD CK(CPK)-466* CK-MB-50* MB Indx-10.7* cTropnT-1.01* [**2126-5-17**] 12:45PM BLOOD CK(CPK)-502* CK-MB-49* MB Indx-9.8* cTropnT-1.47* [**2126-5-17**] 07:40PM BLOOD CK(CPK)-468* CK-MB-40* MB Indx-8.5* cTropnT-1.82* [**2126-5-18**] 07:15AM BLOOD CK(CPK)-318* CK-MB-25* MB Indx-7.9* cTropnT-1.67* [**2126-5-19**] 07:05AM BLOOD CK(CPK)-141* CK-MB-12* MB Indx-8.5* cTropnT-1.73* [**2126-5-20**] 06:55AM BLOOD CK(CPK)-84 CK-MB-NotDone cTropnT-1.81* . [**2126-5-17**] 05:30AM BLOOD ALT-22 AST-53* CK(CPK)-466* AlkPhos-113 TotBili-0.3 [**2126-5-20**] 06:55AM BLOOD ALT-121* AST-62* LD(LDH)-409* CK(CPK)-84 AlkPhos-158* . [**2128-5-24**] %HbA1c: 7.6 . ECHOCARDIOGRAM [**2126-5-18**] Mild left ventrical apical aneurysm with severe global systolic dysfunction c/w multivessel CAD or other diffuse process. Right ventricular free wall hypokinesis. Mild mitral regurgitation. Mild pulmonary artery systolic hypertension. . LIVER OR GALLBLADDER US (SINGLE ORGAN) [**2126-5-19**] 12:35 PM Very mildly echogenic liver consistent with questionable fatty infiltration. Portal vein is patent and gallbladder has been removed. . [**2126-5-20**] Cardiac Catheterization: 1. Coronary angiography showed severe three vessel coronary artery disease. The left main coronary artery had moderate calcification but no angiographically apparent flow limiting stenoses. The LAD was diffusely calcified with a proximal stenosis of 90% followed by another 90% stenosis in mid segment. The LCX was nondominant vessel with modest calcification. The RCA was a large dominant vessel with severe instent restenosis proximally. 2. Arterial conduit angiography revealed a robust patent LIMA with no lesions. 3. Limited resting hemodynamics revealed severely elevated left sided filling pressures (LVEDP was 32 mm Hg). Systemic arterial pressures were severely elevated (aortic pressure was 179/83 mm Hg). There was no significant gradient across the aortic valve upon pullback of the catheter from the left ventricle to the ascending aorta. FINAL DIAGNOSIS: 1. Two vessel coronary artery disease. 2. Severely elevated left sided filling pressures. 3. Severely elevated systemic arterial pressure. . [**2126-5-21**] Myocardial Viability Study: 1. Severe resting perfusion defects of the apex, distal inferior wall and the mid and basal inferoseptal walls. This is consistent with poor probability of recovery of function after revascularization. 2. Mild resting perfusion defects of the inferior wall and distal ventricle and normal perfusion of the mid and basal anterior and anterolateral walls, consistent with high probability of recovery of function after revascularization. 3. Inreased right ventricular uptake, consistent with global reduction in left ventricular perfusion. 4. Increased left ventricular cavity size. Brief Hospital Course: Ms. [**Known lastname **] was taken to the OR on [**2126-5-29**] for CABG X 4 (LIMA>LAD, SVG>OM, SVG>Diag, SVG>PDA) and ASD closure. Post-op, she was taken to the CSRU on epinephrine, milrinone, norepinephrine drips. She remained on mechanical ventilation for the first few post-operative days, while improving hemodynamically and weaning off vasopressors and inotropes. She was extubated on POD # 3. She went in to rapid atrial fibrillation, which was treated with metoprolol and amiodarone. The electrophysiology service was consulted, and followed her for this. For the next few days, her rhythm varied from bradycardia (junctional and sinus) in the 30's to rapid AFib. She remained in the ICU due to continued need for pacing (via her epicardial wires). For this reason, she underwent permanent pacmaker palcement on [**2126-6-6**]. Her epicardial wires were removed. Anticoagulation for AFib was initiated with warfarin, with a target INR 2.0-2.5. This will be dosed by the pt's PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] once discharged from rehab. She has remained stable hemodynamically, and is ready to be discharged to rehab on [**2126-6-12**]. She has progressed slowly from a mobility standpoint, and should continue with physical therapy. Medications on Admission: CAD cath in [**2119**] at OSH with 70% LAD stenosis, 60% LCX stenosis Cath in [**1-2**] with stent to RCA ETT in [**2123**] at OSH with no ischemia and 60% LVEF DM2 with retinopathy adn nephropathy HTN Hypercholesterolemia obesity OA depression SEVERE NONCOMPLIANCE GERD with hiatal hernia anxiety tension HA CRI 1.0-1.3 baseline Cr PAD h/o cholecystectomy Discharge Disposition: Extended Care Facility: tba Discharge Diagnosis: CAD DM HTN OA depression GERD AF Tachy/brady syndrome Discharge Condition: good Followup Instructions: with [**Hospital **] clinic on Friday, [**6-14**] at 1pm ([**Telephone/Fax (1) 2361**] With Dr. [**Last Name (STitle) **] in [**3-31**] weeks ([**Telephone/Fax (1) 1504**] with PCP, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in [**3-2**] weeks [**Telephone/Fax (1) 66039**] with Dr. [**Last Name (STitle) **] in 1 month, please call for appt. ([**Telephone/Fax (1) 5425**] For your diabetes, please follow-up in the [**Hospital **] [**Hospital 32231**] Clinic - please call [**Telephone/Fax (1) 14404**] to make an appointment. [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**] Completed by:[**2126-6-12**] Name: [**Known lastname 11973**],[**Known firstname 2499**] M Unit No: [**Numeric Identifier 11974**] Admission Date: [**2126-5-16**] Discharge Date: [**2126-6-12**] Date of Birth: [**2065-5-4**] Sex: F Service: CARDIOTHORACIC Allergies: Codeine / Phenergan Attending:[**First Name3 (LF) 265**] Addendum: This is an addendum to the discharge summary of [**Known firstname **] [**Known lastname **] from [**2126-6-12**]. Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 4. Paroxetine HCl 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* 5. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 6. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet PO every 4-6 hours as needed for pain. Disp:*40 Tablet(s)* Refills:*0* 7. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO every eight (8) hours for 4 days: then decrease to 200 mg twice daily for 1 week, then 200 mg daily for 1 month, then discontinue. Disp:*60 Tablet(s)* Refills:*0* 8. Plavix 75 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 9. Insulin Lisp & Lisp Prot (Hum) 100 unit/mL (75-25) Suspension Sig: as directed Units Subcutaneous twice a day: 15 Units before breakfast, 10 Units before dinner. Disp:*1 vial* Refills:*2* 10. Insulin Regular Human 100 unit/mL Solution Sig: as directed Units Injection four times a day: sliding scale as directed. Disp:*1 vial* Refills:*2* 11. Furosemide 40 mg Tablet Sig: One (1) Tablet PO twice a day for 2 weeks: then decrease to daily. Disp:*60 Tablet(s)* Refills:*2* 12. Toprol XL 50 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* 13. Potassium Chloride 20 mEq Packet Sig: One (1) Packet PO once a day. Disp:*30 Packet(s)* Refills:*2* 14. Warfarin 1 mg Tablet Sig: Three (3) Tablet PO ONCE (Once) for 2 days: 2mg today, [**6-10**] & tomorrow, [**6-11**], then INR to be checked and called to Dr. [**Last Name (STitle) **] for continued dosing, for target INR 2.0-2.5. Disp:*60 Tablet(s)* Refills:*0* Discharge Disposition: Extended Care Facility: [**Hospital 7571**] Health Care Center [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 266**] Completed by:[**2126-6-13**]

[ "362.01", "553.3", "427.81", "790.4", "V15.81", "428.0", "410.71", "276.7", "585.9", "530.81", "997.1", "300.00", "250.42", "311", "272.0", "V45.82", "715.90", "403.90", "583.81", "599.0", "250.52", "276.1", "414.01", "745.5", "427.31", "250.12" ]

icd9cm

[ [ [] ] ]

[ "37.72", "35.71", "96.6", "37.83", "39.61", "96.71", "38.93", "36.13", "88.56", "37.22", "89.45", "36.15" ]

icd9pcs

[ [ [] ] ]

11301, 11486

6116, 7399

295, 340

7935, 7942

2959, 5306

7965, 9149

2545, 2602

9172, 11278

7858, 7914

7425, 7784

5323, 6093

2617, 2940

245, 257

368, 1942

1986, 2346

2362, 2529

66,717

169,165

54667+59622

Discharge summary

report+addendum

Admission Date: [**2129-7-31**] Discharge Date: [**2129-8-14**] Date of Birth: [**2049-11-27**] Sex: M Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 165**] Chief Complaint: decline in activity tolerance Major Surgical or Invasive Procedure: [**2129-8-1**] 1. Aortic valve replacement with a size 25 mm [**Doctor Last Name **] Magna Ease tissue valve. 2. Coronary artery bypass graft x1, saphenous vein graft to diagonal artery. 3. Endoscopic harvesting of the long saphenous vein. 4. Left atrial appendage ligation. History of Present Illness: 79 year old male who has been followed for aortic stenosis and his recent echo has shown severe aortic stenosis with a valve area estimated at 0.4cm2. He reports an obvious decline in his activity tolerance as compared to a year ago. This has been slowly progressing and is now limiting his ability to do the things he enjoys including playing golf. In addition, he describes new mild dyspnea on exertion. He notes palpitations when he lies down at night. He was referred for right and left heart catheterization and surgical consultation for an aortic valve replacement. Past Medical History: Coronary Artery Disease Hypertension Hyperlipidemia Aortic stenosis Chronic Atrial Fibrillation on Coumadin [**5-/2127**]: Prior CVA in the setting of a subtheraputic INR (no residual) Non insulin dependent diabetes Peripheral neuropathy involving his feet Right shoulder bursitis Past Surgical History: Cholecystectomy Social History: Lives with:wife Contact:[**Last Name (NamePattern4) **] [**Name (NI) 111795**] (daughter) Phone #[**Telephone/Fax (1) 111796**] Occupation: Retired attorney Cigarettes: Smoked no [x] yes [] Other Tobacco use:denies ETOH: < 1 drink/week [x] [**2-22**] drinks/week [] >8 drinks/week [] Illicit drug use: denies Family History: non-contributory Physical Exam: Pulse:79 Resp:16 O2 sat:94/RA B/P Right:151/64 Left:143/65 Height:5'[**28**]" Weight:162 lbs General: Skin: Dry [X] intact [X] HEENT: PERRLA [X] EOMI [X] Neck: Supple [X] Full ROM [X] Chest: Lungs clear bilaterally [X] Heart: RRR [] Irregular [X] Murmur [X] grade __3/6_SEM___ Abdomen: Soft [X] non-distended [X] non-tender [X] bowel sounds + [X] Extremities: Warm X[], well-perfused [X] Edema [] _____ Varicosities: b/l LE varicosities noted Neuro: Grossly intact [X] Pulses: Femoral Right: P Left: P DP Right: P Left: P PT [**Name (NI) 167**]: P Left: Non-palp Radial Right: P Left: P Carotid Bruit None heard Pertinent Results: Intra-op TEE: Conclusions Prebypass: The left atrium is normal in size. No mass/thrombus is seen in the left atrium or left atrial appendage. The right atrium is moderately dilated. Left ventricular wall thicknesses and cavity size are normal. There is hypokinesis of inferior wall of left ventricle and the remaining left ventricular segments contract normally. Right ventricular chamber size and free wall motion are normal. There are simple atheroma in the ascending aorta. There are simple atheroma in the descending thoracic aorta. There are three aortic valve leaflets. The aortic valve leaflets are severely thickened/deformed. There is critical aortic valve stenosis (valve area <0.8cm2). Mild (1+) aortic regurgitation is seen. Moderate (2+) mitral regurgitation is seen. No evidence of systolic flow reversal in pulmonary veins. Vena contracta of mitral valve is 0.57 cm. Dr.[**Last Name (STitle) **] was notified in person of the results in the operating room. Postbypass: Well seated Aortic Valve, no perivalvular leak. Mean gradient 7 mm Hg. Left atrial appendage stump visualized. No sign of aortic dissection. Preserved unchanged left ventricular systolic function. Mitral Regurgitation improved to mild (1+) following CABG, AVR. Dr [**Last Name (STitle) **] notified in person of findings. [**2129-8-10**] 08:50AM BLOOD WBC-12.4* RBC-3.53* Hgb-10.7* Hct-33.3* MCV-94 MCH-30.2 MCHC-32.0 RDW-15.2 Plt Ct-200 [**2129-8-9**] 05:30AM BLOOD WBC-13.3* RBC-3.36* Hgb-10.2* Hct-31.5* MCV-94 MCH-30.3 MCHC-32.3 RDW-15.2 Plt Ct-165 [**2129-8-7**] 12:53AM BLOOD WBC-13.0* RBC-3.15* Hgb-9.6* Hct-29.0* MCV-92 MCH-30.5 MCHC-33.2 RDW-15.1 Plt Ct-182 [**2129-8-6**] 04:21AM BLOOD WBC-15.1* RBC-3.24* Hgb-9.9* Hct-29.7* MCV-92 MCH-30.5 MCHC-33.2 RDW-15.2 Plt Ct-199 [**2129-8-11**] 09:00AM BLOOD PT-26.3* PTT-43.1* INR(PT)-2.5* [**2129-8-10**] 08:50AM BLOOD PT-26.6* INR(PT)-2.6* [**2129-8-9**] 09:10AM BLOOD PT-28.4* INR(PT)-2.7* [**2129-8-11**] 06:25AM BLOOD Glucose-93 UreaN-22* Creat-1.1 Na-141 K-4.3 Cl-100 HCO3-35* AnGap-10 [**2129-8-10**] 08:50AM BLOOD Glucose-62* UreaN-27* Creat-1.1 Na-140 K-4.1 Cl-98 HCO3-31 AnGap-15 [**2129-8-9**] 08:45PM BLOOD Na-136 K-4.2 Cl-97 [**2129-8-9**] 05:30AM BLOOD Glucose-68* UreaN-33* Creat-1.1 Na-136 K-3.7 Cl-96 HCO3-31 AnGap-13 [**2129-8-11**] 09:00AM BLOOD PT-26.3* PTT-43.1* INR(PT)-2.5* [**2129-8-11**] 11:00AM BLOOD WBC-12.1* RBC-3.45* Hgb-10.3* Hct-32.3* MCV-94 MCH-29.8 MCHC-31.8 RDW-14.9 Plt Ct-259 Brief Hospital Course: The patient was brought to the Operating Room on [**2129-8-1**] where the patient underwent CABG x 1, AVR, LAA ligation with Dr. [**First Name (STitle) **]. Overall the patient tolerated the procedure well and post-operatively was transferred to the CVICU in stable condition for recovery and invasive monitoring. POD 1 found the patient extubated, alert and oriented and breathing comfortably. The patient was neurologically intact and hemodynamically stable, weaned from inotropic and vasopressor support. Beta blocker was initiated and the patient was gently diuresed toward the preoperative weight. Coumadin was resumed on POD 1 for atrial fibrillation. The patient was transferred to the telemetry floor for further recovery. Chest tubes were discontinued without complication. ACE Inhibitor was added for hypertension but was stopped due to an elevated creatinine to 2.7. Lasix was decreased and creatinine was 1.1 at the time of discharge. He developed heart block and was evaluated by the EP service. He was transferred back to CVICU. Rhythm began to recover, and the patient progressed to junctional rhythm. He was transferred back to the telemetry floor and pacing wires discontinued. He began to have increased ectopy on POD 9 and Lopressor was introduced at 12.5 mg [**Hospital1 **], which the patient tolerated well. This was titrated up to 25 mg [**Hospital1 **] per EP recommendation. He was hemdynamically stable and asymptomatic with his rhythm and ectopy. He will follow up with EP in the next 1-2 weeks. He did have a small amount of serous drainage from his upper sternal pole. He was afebrile, WBC was stable at 12.1, and he had a stable sternum at the time of discharge. He will be brought back for a wound check in 5 days and instructed to call with any fever, chills, or increased drainage. The patient was evaluated by the physical therapy service for assistance with strength and mobility. By the time of discharge on POD 10 the patient was ambulating with assistance and pain was controlled with oral analgesics. The patient was discharged home with physical therapy and visiting nurse services in good condition with appropriate follow up instructions. *Of note, mediastinal lymphadenopathy was noted on pre-op Chest CT. Repeat chest CT is recommended in 3 months.* Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from webOMR. 1. Digoxin 0.25 mg PO DAILY 2. Gabapentin 300 mg PO BID 3. Gemfibrozil 600 mg PO BID 4. GlipiZIDE 2.5 mg PO BID 5. Lorazepam 0.5 mg PO HS:PRN insomnia 6. MetFORMIN (Glucophage) 500 mg PO BID 7. Potassium Chloride 20 mEq PO BID 8. Pravastatin 40 mg PO DAILY 9. Verapamil 240 mg PO Q24H 10. Warfarin 5 mg PO DAILY16 11. Ascorbic Acid 500 mg PO DAILY 12. Aspirin 81 mg PO DAILY 13. ZYRtec *NF* 10 mg Oral daily 14. Vitamin D 1000 UNIT PO DAILY 15. Centrum Complete *NF* (multivitamin-iron-folic acid) 18-400 mg-mcg Oral daily 16. Super B Complex + C *NF* (vitamin B comp & C no.4) 150 mg Oral daily 17. Vitamin E 400 UNIT PO DAILY Discharge Medications: 1. Aspirin 81 mg PO DAILY 2. Gabapentin 300 mg PO BID 3. Gemfibrozil 600 mg PO BID 4. GlipiZIDE 2.5 mg PO BID 5. Potassium Chloride 20 mEq PO DAILY 6. Pravastatin 40 mg PO DAILY 7. Ascorbic Acid 500 mg PO DAILY 8. Vitamin E 400 UNIT PO DAILY 9. Warfarin 5 mg PO ONCE Duration: 1 Doses RX *Coumadin 2.5 mg [**1-17**] tablet(s) by mouth daily Disp #*60 Tablet Refills:*0 10. Docusate Sodium 100 mg PO BID 11. Furosemide 20 mg PO DAILY RX *Lasix 40 mg 1 tablet(s) by mouth daily Disp #*7 Tablet Refills:*0 12. Metoprolol Tartrate 25 mg PO BID Hold for HR <55 or SBP <95 RX *metoprolol tartrate 25 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*0 13. Pantoprazole 40 mg PO Q24H RX *pantoprazole 40 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 14. Centrum Complete *NF* (multivitamin-iron-folic acid) 18-400 mg-mcg Oral daily 15. Lorazepam 0.5 mg PO HS:PRN insomnia 16. MetFORMIN (Glucophage) 500 mg PO BID 17. Super B Complex + C *NF* (vitamin B comp & C no.4) 150 mg Oral daily 18. Vitamin D 1000 UNIT PO DAILY 19. ZYRtec *NF* 10 mg Oral daily Discharge Disposition: Extended Care Facility: tba Discharge Diagnosis: Coronary Artery Disease Hypertension Hyperlipidemia Aortic stenosis Chronic Atrial Fibrillation on Coumadin [**5-/2127**]: Prior CVA in the setting of a subtheraputic INR (no residual) Non insulin dependent diabetes Peripheral neuropathy involving his feet Right shoulder bursitis Past Surgical History: Cholecystectomy Discharge Condition: Alert and oriented x3 nonfocal Ambulating with steady gait Sternal pain managed with oral analgesics Sternal Incision - healing well, no erythema or drainage Edema: Trace lower extremity edema Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming, and look at your incisions Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Followup Instructions: You are scheduled for the following appointments: Wound Check at Cardiac Surgery Office [**Telephone/Fax (1) 170**] [**2129-8-6**] 10:30 in the [**Hospital **] medical office building, [**Doctor First Name **], Suite2A Surgeon: Dr. [**First Name (STitle) **] [**Telephone/Fax (1) 170**] [**2129-9-6**] at 2:00p in the [**Hospital **] medical office building, [**Doctor First Name **], Suite2A Cardiogolist: Dr. [**Last Name (STitle) **] at [**Hospital1 18**] [**Hospital1 **] [**2129-8-23**] at 9:20 AM Please call to schedule the following: Primary Care Dr. [**Last Name (STitle) **],[**Doctor Last Name **] [**Telephone/Fax (1) 31188**] in [**4-21**] weeks **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** *****Chest CT in 3 months to follow-up mediastinal lymph node enlargement on pre-op CT***** [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**] Completed by:[**2129-8-11**] Name: [**Known lastname **],[**Known firstname 133**] J Unit No: [**Numeric Identifier 18359**] Admission Date: [**2129-7-31**] Discharge Date: [**2129-8-14**] Date of Birth: [**2049-11-27**] Sex: M Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 265**] Addendum: Mr. [**Known lastname **] discharge on [**2129-8-11**] was post poned due to runs of asymptomatic, afib w/ RVR which were initially thought to be non-sustained VT. EP continued to follow Mr. [**Known lastname **] closely. On POD# 13 Mr. [**Name14 (STitle) 18360**] was cleared for discharge to home with VNA and it was arranged for him to have [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] of Hearts Monitor upon discharge. All follow up appointments and instructions were advised. Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from webOMR. 1. Digoxin 0.25 mg PO DAILY 2. Gabapentin 300 mg PO BID 3. Gemfibrozil 600 mg PO BID 4. GlipiZIDE 2.5 mg PO BID 5. Lorazepam 0.5 mg PO HS:PRN insomnia 6. MetFORMIN (Glucophage) 500 mg PO BID 7. Potassium Chloride 20 mEq PO BID 8. Pravastatin 40 mg PO DAILY 9. Verapamil 240 mg PO Q24H 10. Warfarin 5 mg PO DAILY16 11. Ascorbic Acid 500 mg PO DAILY 12. Aspirin 81 mg PO DAILY 13. ZYRtec *NF* 10 mg Oral daily 14. Vitamin D 1000 UNIT PO DAILY 15. Centrum Complete *NF* (multivitamin-iron-folic acid) 18-400 mg-mcg Oral daily 16. Super B Complex + C *NF* (vitamin B comp & C no.4) 150 mg Oral daily 17. Vitamin E 400 UNIT PO DAILY Discharge Medications: 1. Aspirin 81 mg PO DAILY RX *Adult Low Dose Aspirin 81 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*0 2. Gabapentin 300 mg PO BID 3. Gemfibrozil 600 mg PO BID 4. GlipiZIDE 2.5 mg PO DAILY RX *glipizide 5 mg 0.5 (One half) tablet(s) by mouth once a day Disp #*30 Tablet Refills:*0 5. Potassium Chloride 20 mEq PO DAILY RX *potassium chloride 20 mEq 1 mEq(s) by mouth once a day Disp #*30 Tablet Refills:*0 6. Pravastatin 40 mg PO DAILY 7. Ascorbic Acid 500 mg PO DAILY 8. Vitamin E 400 UNIT PO DAILY 9. Docusate Sodium 100 mg PO BID 10. Furosemide 20 mg PO DAILY RX *Lasix 40 mg 1 tablet(s) by mouth daily Disp #*7 Tablet Refills:*0 RX *furosemide 20 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*0 11. Metoprolol Tartrate 25 mg PO BID Hold for HR <55 or SBP <95 RX *metoprolol tartrate 25 mg 0.5 (One half) tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*0 12. Pantoprazole 40 mg PO Q24H RX *pantoprazole 40 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 13. Centrum Complete *NF* (multivitamin-iron-folic acid) 18-400 mg-mcg Oral daily 14. Lorazepam 0.5 mg PO HS:PRN insomnia 15. MetFORMIN (Glucophage) 500 mg PO BID 16. Super B Complex + C *NF* (vitamin B comp & C no.4) 150 mg Oral daily 17. Vitamin D 1000 UNIT PO DAILY 18. ZYRtec *NF* 10 mg Oral daily 19. [**Hospital 18361**] Hospital Bed Patient has a medical condition which requires positioning of the body not feasible in an ordinary bed to alleviate pain. Diagnosis CAD s/p CABG/AVR [**37**]. Warfarin 2.5 mg PO DAILY16 dose to be determined by INR Discharge Disposition: Extended Care Facility: tba Discharge Instructions: you will not be able to shower until your heart monitor is removed. until then please wash daily including washing incisions gently with mild soap, no baths or swimming, and look at your incisions Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 1477**] **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 1477**]. Answering service will contact on call person during off hours** Labs: PT/INR for Coumadin ?????? indication afib Goal INR 2.0-3.0 First draw [**2129-8-15**] Results to phone fax Dr.[**Last Name (STitle) 18362**] [**Name (STitle) 17844**] [**Telephone/Fax (1) 18363**] Followup Instructions: You are scheduled for the following appointments: Surgeon: Dr. [**First Name (STitle) **] [**Telephone/Fax (1) 1477**] [**2129-9-6**] at 2:00p in the [**Hospital **] medical office building, [**Doctor First Name **], Suite2A Cardiogolist: Dr. [**Last Name (STitle) 86**] at [**Hospital1 8**] [**Hospital1 **] [**2129-8-23**] at 9:20 AM Please call to schedule the following: Primary Care Dr. [**Last Name (STitle) 17844**],[**Doctor Last Name 18362**] [**Telephone/Fax (1) 18363**] in [**4-21**] weeks Labs: PT/INR for Coumadin ?????? indication afib Goal INR 2.0-3.0 First draw [**2129-8-15**] Results to phone fax Dr.[**Last Name (STitle) 18362**] [**Name (STitle) 17844**] [**Telephone/Fax (1) 18363**] **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 1477**]. Answering service will contact on call person during off hours** *****Chest CT in 3 months to follow-up mediastinal lymph node enlargement on pre-op CT***** [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 266**] Completed by:[**2129-8-14**]

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icd9cm

[ [ [] ] ]

[ "39.61", "36.11", "37.99", "35.21" ]

icd9pcs

[ [ [] ] ]

14945, 14975

5113, 7417

341, 626

9680, 9875

2637, 5090

16047, 17135

1915, 1934

13358, 14922

9337, 9618

12609, 13335

14999, 16024

9641, 9659

1949, 2618

271, 303

654, 1227

1249, 1530

1587, 1899

14,633

168,775

7314

Discharge summary

report

Admission Date: [**2110-1-23**] Discharge Date: [**2110-2-12**] Service: VASCULAR HISTORY OF PRESENT ILLNESS: The patient was initiay seen in Dr.[**Name (NI) 27017**] office in [**2109-12-21**]. Her chief complaint was progressive claudication of the lower extremities the right worse then the left. She also noted to have buttocks, thigh and calf radiation of the pain. It is aggravated by walking up hills. She is able to walk less then a half a block before she has to stop. She does admit to some numbness and tingling in her feet and also tingling in her right anterior thigh. She is a smoker. She has insulin dependent diabetes and she has had a transient neurologic event in the remote past. PAST MEDICAL HISTORY: Diabetes type 2 insulin dependent, hypertension, coronary artery disease, prior myocardial infarction. PAST SURGICAL HISTORY: Pelvic surgery remote for ovarian cyst, but was actually a walled off appendicitis. She has had cardiac catheterization in [**2109-8-21**] at the [**Hospital1 1444**], which demonstrated an occluded right coronary artery, which was collateralized. The left anterior descending coronary artery was without lesion and the circumflex had diffuse disease. She is a former smoker. She has not smoked for twenty years. She has a history of transient ischemic attacks, remote. No reoccurrence. PHYSICAL EXAMINATION: The patient is an obese elderly female with a right carotid bruit. Her pulse examination, extremities show 2+ femoral pulses with bruits of both femoral arteries and absent pulses below the femoral level bilaterally. Remaining examination is unremarkable. Angiography showed diffuse aortoiliac disease left greater then the right with bilateral femoral arteriole occlusions. MEDICATIONS: Lasix 40 mg b.i.d., Tiazac 300 mg q.d., Cardura 200 mg b.i.d., Metoprolol 50 mg b.i.d., Hydrochlorothiazide 25 mg q.d., aspirin 81 mg q.d., multi vitamin tablets, Tums b.i.d., insulin is Lente 20 units q.a.m. with 6 to 10 of regular with 0 to 3 units of regular insulin at noon and presupper 6 to 10 units of regular insulin, h.s. Lente is 8 units. PREOPERATIVE LABORATORIES: CBC with a white blood cell count of 12.0, hematocrit 30.0, platelets 213, PT/INR/PTT were normal. BUN 29, creatinine 1.2, K 3.4. Chest x-ray was unremarkable. Electrocardiogram showed normal sinus rhythm. HOSPITAL COURSE: The patient was admitted to the preoperative holding area on [**2110-1-23**]. She underwent aortobifemoral bypass graft. She tolerated the procedure well and was transferred to the PACU in stable condition. Immediately postoperatively, she remained hemodynamically stable. Her CVP was 14. Her PA pressure 60/30. Wedge 19. Cardiac index 3.1. SVR 642. She received 2 units of packed red blood cells intraoperatively and 250 cc cell [**Doctor Last Name 10105**]. She had a dopplerable posterior tibial pulse and dorsalis pedis pulse bilaterally. Her postoperative hematocrit was 30. She continued to do well and was transferred to the VICU for continued monitoring and care. On postoperative day one overnight events included low urinary output. The patient's FENA was 0.2%. She was given fluid boluses. Her creatinine was 1.4, hematocrit 31. Blood gas 7.23, 43, 136, 19 and -9. Her physical examination was unremarkable and her pulse examination was unchanged. Her epidural was in adequate place and decreased was needed. She required increase fluid resuscitation to maintain her systolic pressure. She remained in the VICU. [**Last Name (un) **] Service followed the patient during her postoperative period and managed her glucose management. She did intermittently require intravenous insulin drip. Renal was consulted, because of increase creatinine and potassium postoperatively. Her baseline creatinine was 1.2. She bumped postoperatively to 1.7 with a potassium to 6.8 to 5.5 post treatment. Renal felt that the renal insult was secondary to hypotension hypoperfusion syndrome and to maintain a systolic blood pressure greater then 110, send off a urine for C&S. Her epidural was discontinued and she was converted to morphine for analgesic control. On postoperative day three her white count was up 13.6 from 12.5. Her hematocrit remained stable at 30. Her BUN was 35, creatinine 1.7 and K 5.1. She remained in the VICU. She required intravenous fluid maintenance and change in her beta blockade for her tachycardia. Her renal function continued to improve. Her pulse examinations remained unchanged. Her urinary output improved. Postoperative day number four her nasogastric tube was discontinued and she was begun on sips. Her hematocrit was 28.5, creatinine continued to improve at 1.3. She continued to improve on her urinary output. She remained in the VICU. A Swan-Ganz catheter was changed on postoperative day four to a triple lumen catheter. Post change chest x-ray was unremarkable. Postoperative day five her diet was advanced as tolerated. She was delined. Her preoperative medications were instituted. Her hematocrit remained stable at 30 and her creatinine returned to baseline of 1.2. Her potassium was 3.9. She was continued to be followed by the [**Last Name (un) **] Service. The patient complained of nausea and an electrocardiogram was obtained, which was negative for any acute ischemic event. The patient had a KUB done, which showed an ileus on KUB and the nasogastric tube was replaced and the patient was made NPO. Nasogastric was continued and her electrolytes were monitored and supplemented accordingly. She began complaining of some right lower and upper quadrant tenderness. The next 24 to 48 hours a trail of nasogastric tube clamping was tried, but the patient was with nausea at clamping. Nasogastric remained in place. Reglan was begun to improve gastric motility. Physical therapy saw the patient and felt the patient would require physical therapy at rehab to improve her ambulation independently. The patient developed low urinary output on postoperative day two. She was returned to the VICU for monitoring. The patient's white count continued to show persistent elevation to a maximum of 22.1. Renal was requested to see the patient and they felt that her acute renal failure was prerenal due to biliary sepsis. She was restarted on an insulin drip. CT of the abdomen was obtained, which showed gallbladder changes. An ultrasound guided percutaneous cholecystotomy was done with an #8 French catheter. 250 cc of purulent material was withdrawn. This was sent for culture. The patient had a new triple lumen placed on [**2110-2-3**] without event. She had been begun on Ampicillin, Levofloxacin and Flagyl for broad spectrum antibiotics coverage. Her white count began to show diminishing trend after onset of antibiotics and drainage. Her renal function improved. Culture grew gram negative rods, gram positive cocci and gram positive rods. She was continued on her intravenous fluids and remained in the VICU. The patient was evaluated by the General Surgical Service Dr.[**Name (NI) 1745**] [**Name (STitle) 4869**] and they felt at this time elective cholecystectomy would be done at a later date. They would continue antibiotics post discharge and percutaneous drainage and follow up within two to three weeks post discharge. Her nasogastric was removed on postoperative day number eleven. She was begun on clears and as tolerated diet was advanced. Her white count continued to show a downward trend and her creatinine remained stable. She was restarted on her preoperative medications and diet was advanced as tolerated. The patient was transferred to the floor on postoperative day thirteen. Physical therapy revaluated the patient and felt she would require short term rehab. Calorie counts were begun. The patient began ambulation. She had a total course of Ampicillin, Levofloxacin and Flagyl, which were discontinue on [**2-11**]. Stool was sent for C-diff, which was negative. Glucoses became under control. She had adequate caloric intake. She had an episode of nausea, which was related to medications, which resolved. Electrocardiogram was unremarkable. We also continued to adjust her insulin dosing according to her glucoses. The patient was discharged in stable condition to rehab. She is taking 84% of her calories by food and 70% protein needs were met. At the time of discharge abdominal wounds were clean, dry and intact. Her heel pulses were dopplerable bilaterally. Her feet were warm. The patient should follow up with Dr. [**Last Name (STitle) 1476**] in two weeks time. She should also follow up with Dr. [**Last Name (STitle) 519**] on the General Surgical Service at the same time. Appointment can be called by calling [**Telephone/Fax (1) 6554**]. The patient was ambulating with assistance to essential distances only at the time of discharge. DISCHARGE MEDICATIONS: Lente insulin 22 units q.a.m. and 12 units at h.s. with a regular sliding scale before meals and at bedtime as follows, breakfast glucoses less then 100 no insulin, 101 to 150 5 units, 151 to 200 6 units, 201 to 250 8 units, 251 to 300 9 units, 301 to 350 10 units, greater then 351 12 and call HO. Lunch sliding scale glucoses less then 150 no insulin, 151 to 200 2 units, 201 to 250 3 units, 251 to 300 4 units, 301 to 350 6 units, greater then 351 8 units. Dinner sliding scale is as follows, glucoses less then 50 no insulin, 51 to 100 2 units, 101 to 150 6 units, 151 to 200 8 units, 201 to 250 10 units, 251 to 300 12 units, 301 to 350 14 units, greater then 351 16 units. H.s. sliding scale, glucoses less then 200 no insulin, 201 to 250 2 units, 251 to 300 3 units, 301 to 350 4 units, greater then 351 6 units. Reglan 10 mg a.c. and h.s., Tiazac 300 mg q.d., Cardura 2 mg q.d., Hydrochlorothiazide 25 mg daily, Protonix 40 mg q.d., Percocet tablets 5/325 one to two q 4 to 6 hours prn, Lasix 40 mg b.i.d. DISCHARGE DIAGNOSES: 1. Bilateral calf claudication status post aortobifemoral bypass. 2. Acute renal failure secondary to hypovolemia and sepsis. 3. Infected gallbladder status post cystotomy. 4. Postoperative ileus resolved. 5. Blood loss anemia corrected. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1477**], M.D. [**MD Number(1) 1478**] Dictated By:[**Last Name (NamePattern1) 1479**] MEDQUIST36 D: [**2110-2-11**] 14:26 T: [**2110-2-11**] 14:45 JOB#: [**Job Number 27018**]

[ "997.5", "584.9", "276.5", "E878.2", "575.0", "998.59", "038.49", "440.21", "285.1" ]

icd9cm

[ [ [] ] ]

[ "38.93", "99.04", "39.25", "89.64", "51.01" ]

icd9pcs

[ [ [] ] ]

9956, 10481

8917, 9935

2384, 8893

870, 1363

1386, 2366

123, 719

742, 846

45,893

164,711

6546

Discharge summary

report

Admission Date: [**2127-2-20**] Discharge Date: [**2127-2-28**] Date of Birth: [**2056-7-13**] Sex: M Service: SURGERY Allergies: Lipitor Attending:[**First Name3 (LF) 4748**] Chief Complaint: Left Lower Extremity Ischemia Major Surgical or Invasive Procedure: left fem-[**Doctor Last Name **] bypass, resection of L fem aneurysm History of Present Illness: Patient presented to pre-op holding for fem-[**Doctor Last Name **] bypass (left). At that time, patient denied nausea, vomiting, fever, or chills. Past Medical History: HTN, Dysrhythmia, Mitral Valve Prolapse, CHF, Bil CEA Social History: No tobacco Family History: N/C Physical Exam: At discharge: VSS Gen: AAO x 3 Cardio: Irregular rhythm, no murmurs appreciated Lungs: CTAB Abdomen: S/NT/ND Extremities: Left extremity incision site clean, dry, and intact. Palpable DP pulse, dopplarable PT. Pertinent Results: [**2127-2-24**] 04:00AM BLOOD WBC-8.3 RBC-3.05* Hgb-9.8* Hct-29.3* MCV-96 MCH-32.1* MCHC-33.3 RDW-16.9* Plt Ct-152 [**2127-2-23**] 01:59AM BLOOD WBC-12.0* RBC-3.06* Hgb-9.9* Hct-28.9* MCV-95 MCH-32.2* MCHC-34.1 RDW-16.4* Plt Ct-122* [**2127-2-22**] 02:21AM BLOOD WBC-13.6* RBC-3.17* Hgb-10.1* Hct-29.6* MCV-93 MCH-31.7 MCHC-34.0 RDW-16.3* Plt Ct-101* [**2127-2-21**] 02:13PM BLOOD WBC-12.1* RBC-3.04* Hgb-10.0* Hct-28.0* MCV-92 MCH-33.0* MCHC-35.8* RDW-16.4* Plt Ct-111* [**2127-2-21**] 12:20AM BLOOD WBC-13.5*# RBC-3.61* Hgb-11.7* Hct-33.6* MCV-93 MCH-32.5* MCHC-35.0 RDW-16.5* Plt Ct-120* [**2127-2-24**] 08:24AM BLOOD PT-15.0* PTT-38.4* INR(PT)-1.3* [**2127-2-23**] 01:59AM BLOOD PT-18.4* PTT-47.6* INR(PT)-1.7* [**2127-2-22**] 02:21AM BLOOD PT-19.0* PTT-39.2* INR(PT)-1.7* [**2127-2-21**] 12:20AM BLOOD PT-17.8* PTT-34.2 INR(PT)-1.6* [**2127-2-20**] 02:00PM BLOOD PT-18.9* PTT-40.7* INR(PT)-1.7* [**2127-2-24**] 04:00AM BLOOD Glucose-111* UreaN-16 Creat-0.8 Na-134 K-4.2 Cl-102 HCO3-26 AnGap-10 [**2127-2-23**] 12:07PM BLOOD Glucose-139* Na-133 K-4.5 Cl-101 [**2127-2-22**] 09:25PM BLOOD Glucose-116* K-4.1 [**2127-2-22**] 02:21AM BLOOD Glucose-114* UreaN-10 Creat-0.8 Na-136 K-3.7 Cl-104 HCO3-25 AnGap-11 [**2127-2-21**] 02:13PM BLOOD Glucose-167* UreaN-9 Creat-0.8 Na-136 K-3.2* Cl-104 HCO3-23 AnGap-12 [**2127-2-21**] 12:20AM BLOOD Glucose-92 UreaN-10 Creat-0.9 Na-134 K-4.3 Cl-104 HCO3-23 AnGap-11 [**2127-2-20**] 02:00PM BLOOD Glucose-131* UreaN-8 Creat-0.6 Na-134 K-4.3 Cl-108 HCO3-23 AnGap-7* [**2127-2-22**] 02:21AM BLOOD ALT-22 AST-40 LD(LDH)-178 AlkPhos-61 Amylase-62 TotBili-2.0* [**2127-2-24**] 04:00AM BLOOD Calcium-8.0* Phos-3.5 Mg-2.0 [**2127-2-23**] 01:59AM BLOOD Calcium-8.5 Phos-2.9 Mg-1.6 [**2127-2-22**] 09:25PM BLOOD Calcium-7.7* Mg-1.7 [**2127-2-22**] 02:21AM BLOOD Albumin-3.0* Calcium-8.1* Phos-2.8 Mg-2.1 [**2127-2-21**] 02:13PM BLOOD Calcium-7.9* Phos-3.1 Mg-1.9 [**2127-2-21**] 12:20AM BLOOD Calcium-7.8* Phos-3.1 Mg-1.6 [**2127-2-20**] 02:00PM BLOOD Calcium-8.1* Phos-3.7 Mg-1.3* Brief Hospital Course: Mr. [**Name13 (STitle) 9700**] is a 70 y.o. male that had left lower extremity ischemia and arrived at the pre-op holding on [**2127-2-20**] for a fem-[**Doctor Last Name **] bypass. The patient's operating had a large amount of blood loss (roughly 2L). He was taken to the PACU where the patient had continued hypotension. He was given two units of blood, and was started on albumin and crystalloid. He was started on pressors. He was then transferred to the ICU where the patient had continued hypotension. He was given another unit of blood, more crystlloid, and albumin. The patient was continued on pressors until [**2127-2-22**]. He was transferred to the floor on [**2127-2-23**]. The patient continued to require fluid boluses for resucitation purposes for hypotension. On [**2127-2-24**], the patient triggered for hypotension that did not respond to a fluid bolus. The patient's BP was systolic of 70s non-responsive to fluid bolus. He continued to have adequate urine output, and he continued to mentate well. He was given one unit of PRBCs. His blood pressure continued in the mid-80s, low 90s. His ACE inhibitor and HCTZ continued to be held. On [**2-25**], physical therapy worked with the patient, and he was found to be tachycardic (140s) when walking. His ACE inhibitor and HCTZ continued to be held. On [**2-26**], the patient's foley and JP drained were pulled. He continued to be tachycardic with physical therapy, and the patient was given a bolus of albumin followed by IV lasix as he was still above his admission weight. On [**2-27**], the patient's HCTZ was restarted. Physical therapy cleared the patient to go home. On [**2-28**], the patient was discharged to home with services, with vital signs stable. The upper pole of the incision is draining serous fluid, to have dressing changes [**Hospital1 **] and as needed. Will FU w/ Dr. [**Last Name (STitle) 1391**] and Dr. [**First Name (STitle) 3236**] as planned. Medications on Admission: Hctz 25 mg qdaily; ASA 325 mg qdaily; Omeprazole 20 mg qdaily; Lisinopril 40 mg qdaily; Nifedical 60 mg qdaily; Metoprolol 100 mg qdaily; Warfarin 7.5 mg x 5 days, and 5 mg x 1 day Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 2. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Nifedipine 60 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO DAILY (Daily). 5. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical QID (4 times a day) as needed for itching. 6. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO BID (2 times a day) as needed for constipation. 7. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 8. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 9. Warfarin 5 mg Tablet Sig: One (1) Tablet PO once a week: Saturday. 10. Hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 11. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 12. Outpatient Lab Work INR three times per week Goal INR [**2-12**] Call/ Fax results to Dr. [**First Name (STitle) 3236**] Phone: [**Telephone/Fax (1) 25076**] Fax: [**Telephone/Fax (1) 25077**] 13. Warfarin 2.5 mg Tablet Sig: Three (3) Tablet PO Once Daily at 4 PM. Discharge Disposition: Home With Service Facility: [**Location (un) **] VNA Discharge Diagnosis: Left lower extremity ischemia Acute anemia secondary to blood loss and hemodilution, with resultant hemodynamic instability, required multiple blood transfusions. HCT now stable, VSS Secondary diagnosis: HTN Dysrhythmia Mitral Valve Prolapse CHF Bil CEA Discharge Condition: Mental Status:Clear and coherent Level of Consciousness:Alert and interactive Activity Status:Ambulatory - Independent short distances Discharge Instructions: Division of Vascular and Endovascular Surgery Lower Extremity Bypass Discharge Instructions ACTIVITIES: - ambulate essential distances until FU with Dr. [**Last Name (STitle) 1391**] - Ace wrap leg from foot-knee when ambulating, to prevent swelling - Your operated leg is expected to have some swelling and will resolve over time - Elevate leg when sitting - no driving till FU - may shower, pat dry your incisions, no tub baths WOUND: - Keep wound dry and clean, call if noted to have redness, draining, swelling, or if temp is greater than 101.5 - Your staples will be removed on your FU with Dr. [**Last Name (STitle) 1391**] DIET: - Diet as tolerated eat a well balanced meal - Your appetite will take time to normalize - Prevent constipation by drinking adequate fluid and eat foods [**Doctor First Name **] in fiber, take stool softener while on pain medications MEDICATIONS: - Continue all medications as directed - Take your pain medications conservatively - Your pain will get better over time Followup Instructions: Call Dr.[**Name (NI) 1392**] office for FU appointment. Phone [**Telephone/Fax (1) 1393**] FU w/ Dr. [**First Name (STitle) 3236**] in the next 2 weeks regarding Coumadin therapy Completed by:[**2127-2-28**]

[ "442.3", "458.29", "998.11", "427.31", "424.0", "427.89", "285.1", "V58.61", "E878.2", "401.9", "440.21", "428.0" ]

icd9cm

[ [ [] ] ]

[ "39.29", "38.48" ]

icd9pcs

[ [ [] ] ]

6505, 6560

2958, 4925

297, 368

6858, 6858

922, 2935

8055, 8266

666, 671

5156, 6482

6581, 6764

4951, 5133

7019, 8032

686, 686

700, 903

228, 259

396, 545

6785, 6837

6872, 6995

567, 622

638, 650

73,608

162,231

39399

Discharge summary

report

Admission Date: [**2118-9-30**] Discharge Date: [**2118-10-6**] Date of Birth: [**2068-5-25**] Sex: M Service: SURGERY Allergies: Cephalosporins / Sulfa (Sulfonamide Antibiotics) Attending:[**First Name3 (LF) 5569**] Chief Complaint: ESLD Major Surgical or Invasive Procedure: liver [**First Name3 (LF) **] [**2118-10-1**] History of Present Illness: 50M with hepatitis C cirrhosis and hepatocellular carcinoma s/p RFA ablation. His cirrhosis had been complicated by gastric variceal bleeding in [**9-/2116**], lower extremity edema, and hepatic encephalopathy. In terms of his hepatocellular carcinoma, he has had three lesions, one is 2.4 cm, one is 2.1, the third is 1.7 cm. They were ablated with radiofrequency and repeat CAT scans did not show any recurrence. His last surveillance CAT scan was on [**2118-9-16**]. There were stable lesions without evidence of recurrence. He does have evidence of portal hypertension and cholelithiasis. His recent bone scan was negative. Today Mr. [**Known lastname **] presents pre-operatively for liver [**Known lastname **]. He denies fevers, dysuria or signs of recent infection though he does note a blister on his right second toe. He otherwise feels well. He does not have ascites requiring paracentesis and notes that lower extremity edema has improved with recent diuretics. Review of Systems: (+) per HPI (-) denies headache, numbness, tingling, fevers, chills, fatigue, malaise, significant weight loss, weight gain, changes in hearing or vision, chest pain, shortness of breath, DOE, hemoptysis, cough, wheeze, palpitations, abdominal pain, nausea, vomiting, diarrhea, constipation, denies dysuria, rash, pruritis, joint pain, heat intolerance, cold intolerance, easy bruising, bleeding, mood changes Past Medical History: Alcohol abuse Alcoholic Cirrhosis c/w esophogeal and gastric varices with bleeding x1, encephalopathy (per pt, unable to confirm in chart). Hepatitis C HCC [**2118-9-30**] Orthotopic deceased donor (brain dead donor) liver [**Month/Day/Year **] (piggyback) portal vein-to-portal vein anastomosis, common bile duct-to-common bile duct anastomosis without T tube, common hepatic artery of the donor to branch patch of the recipient hepatic artery anastomosis. ORIF R elbow L shoulder, pelvis, BL PTX after [**2081**] fall. Social History: He quit smoking cigarettes five years ago after 20 years of smoking. He quit drinking alcohol on [**2116-9-20**]. Prior to quitting, he drank moderate alcohol daily. He has a remote history of recreational drug use. He is married and had worked in shipping and receiving but is not working any more as he is unable to climb ladders. Family History: Mother died at age 62; she had hypertension and diabetes. Father is alive in his 70's with hypertension. He has three sisters in good health. No family history of liver disease or liver cancer. Physical Exam: T: 98.6 P: 61 BP: 134/67 RR: 18 O2sat: 99 RA Weight: 137.6 Kg General: awake, alert, NAD HEENT: NCAT, EOMI, anicteric Heart: RRR, NMRG Lungs: CTAB, normal excursion, no respiratory distress Back: no vertebral tenderness, no CVAT Abdomen: soft, obese, NT, ND, reducible umbilical hernia, no appreciable ascites Extremities: WWP, no CCE, no tenderness, 2+ B radial/DP/PT, small blister over right second toe Pyschiatric: normal judgment/insight, normal memory, normal mood/affect Labs: 137 / 106 / 21 6.4 >------< 61 ---------------< 73 31.8 4.0 / 28 / 1.0 AST: 102 ALT: 46 Tbili: 1.8 Alk Phos: 191 Fibrinogen: 152 PT: 16.3 PTT: 35.1 INR: 1.4 U/A: negative Imaging CXR: no evidence of consolidation or focal process EKG: SR, no evidence of ischemia Bone Scan [**2118-9-16**]: no evidence of bone metastasis Pertinent Results: [**2118-10-4**] 10:00AM BLOOD WBC-14.6* RBC-4.28* Hgb-14.4 Hct-40.5 MCV-95 MCH-33.7* MCHC-35.6* RDW-15.6* Plt Ct-111* [**2118-10-3**] 05:20AM BLOOD PT-12.1 PTT-25.9 INR(PT)-1.0 [**2118-10-2**] 02:10AM BLOOD Fibrino-215 [**2118-10-4**] 10:00AM BLOOD Glucose-92 UreaN-40* Creat-1.2 Na-135 K-4.5 Cl-101 HCO3-26 AnGap-13 [**2118-10-4**] 10:00AM BLOOD ALT-259* AST-84* AlkPhos-65 TotBili-1.2 [**2118-10-4**] 10:00AM BLOOD Albumin-2.7* Calcium-8.1* Phos-4.1 Mg-2.0 [**2118-10-4**] 10:00AM BLOOD tacroFK-7.6 [**2118-9-30**] 8:38 pm SWAB Source: Rectal swab. **FINAL REPORT [**2118-10-3**]** R/O VANCOMYCIN RESISTANT ENTEROCOCCUS (Final [**2118-10-3**]): No VRE isolated. [**2118-9-30**] 9:23 pm URINE Source: CVS. **FINAL REPORT [**2118-10-1**]** URINE CULTURE (Final [**2118-10-1**]): NO GROWTH. Brief Hospital Course: On [**2118-9-30**], he underwent Orthotopic deceased donor (brain dead donor) liver [**Date Range **] (piggyback) portal vein-to-portal vein anastomosis, common bile duct-to-common bile duct anastomosis without T tube, common hepatic artery of the donor to branch patch of the recipient hepatic artery anastomosis for HCV/ETOH cirrhosis and HCC. Surgeon was Dr. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]. Two JP drains were placed, one at the hilum and one posterior to the liver. Please see operative note for details. Immediately postop, he was sent to the SICU intubated and remained hemodynamically stable. LFTs initially increased as expected. Hepatic duplex on postop day 1 demonstrated patent vasculature with notation of slightly higher arterial resistive indices than normal. JP drainage was non-bilious. He was extubated on postop day 1. Sips were started and diet was advanced over the subsequent days. He was transferred out of the SICU on postop day 1. IV pain medication was switched to oxycodone. Pain was well controlled. Chevron incision was intact with staples without redness or drainage. LFTs decreased daily. Immunosuppression consisted of Cellcept which was well tolerated. Tapering steroid per protocol. Prograf was started on day 0 and doses were up titrated to 6mg [**Hospital1 **] per trough levels that increased to 7.6. On [**10-6**], trough was 11.8. Dose was decreased to 5mg [**Hospital1 **]. Pentamidine inhalation treatment was given on [**10-5**] for PCP prophylaxis given allergy to sulfa. He required intermittent IV Lasix for generalized edema then Lasix 80mg [**Hospital1 **] was ordered as scheduled on [**10-5**]. Weight was 138.4 down from 168.6. Foley was removed and he was able to urinate. Blood glucoses were mildly elevated with max in 170s. Minimal regular sliding scale insulin was used. [**Last Name (un) **] was consulted and followed. Insulin was not indicated for home as glucoses were in the low 100s by postop day 4 and it was expected that control would improve with decreasing steroids. Physical therapy cleared him for home as he was ambulating independently. Medication teaching went well. He felt well and was discharged to home on [**10-6**]. Twice weekly labs were to be drawn at outpatient Quest lab starting on Tuesday [**10-12**]. Medications on Admission: lasix 80', spironolactone 150', clotrimazole 10', lactulose 15 ml titrate to two bm's daily, nadolol 20'', omeprazole 40', rifaximin 550'', trazodone 100 hs Discharge Medications: 1. prednisone 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): start [**10-7**]. follow taper. 2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. pentamidine 300 mg Recon Soln Sig: One (1) Recon Soln Inhalation once a month: given [**10-5**]. 4. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 5. mycophenolate mofetil 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 6. fluconazole 200 mg Tablet Sig: Two (2) Tablet PO Q24H (every 24 hours). 7. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*60 Tablet(s)* Refills:*0* 8. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily) as needed for HTN. 9. valganciclovir 450 mg Tablet Sig: Two (2) Tablet PO Q24H (every 24 hours). 10. tacrolimus 5 mg Capsule Sig: One (1) Capsule PO Q12H (every 12 hours). 11. furosemide 80 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*30 Tablet(s)* Refills:*0* 12. One Touch Ultra Test Strip Sig: One (1) Miscellaneous three times a day. Disp:*1 box* Refills:*2* 13. One Touch Ultra System Kit Kit Sig: One (1) kit Miscellaneous once a day. Disp:*1 kit* Refills:*0* 14. One Touch UltraSoft Lancets Misc Sig: One (1) Miscellaneous three times a day. Disp:*1 box* Refills:*2* Discharge Disposition: Home With Service Facility: [**Company 1519**] Discharge Diagnosis: HCV cirrhosis/HCC elevated glucoses secondary to steroids Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Please call Dr.[**Name (NI) 1369**] office [**Telephone/Fax (1) 673**] if you experience the following: fever (temperature of 101 or greater), shaking chills, nausea, vomiting, inability to take any of your medications, abdominal distension, increased incision pain, incision or old drain site redness/bleeding/drainage, dizziness, excess thirst, leg swelling improves or constipation/diarrhea You will need to have blood drawn at Quest every Monday and Thursday for labs. You may shower,use soap/water, pat dry. Do not apply powder/lotion/ointment to incisions. No tub baths or swimming No driving while taking pain medications No heavy lifting/straining Followup Instructions: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**], MD, PHD[**MD Number(3) 708**]:[**Telephone/Fax (1) 673**] Date/Time:[**2118-10-12**] 9:00 Provider: [**Name10 (NameIs) **] SOCIAL WORKER Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2118-10-19**] 2:20 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**], MD, PHD[**MD Number(3) 708**]:[**Telephone/Fax (1) 673**] Date/Time:[**2118-10-19**] 3:20 Completed by:[**2118-10-6**]

[ "572.3", "790.29", "456.8", "303.93", "456.21", "070.70", "155.0", "E932.0", "571.2" ]

icd9cm

[ [ [] ] ]

[ "00.93", "50.59" ]

icd9pcs

[ [ [] ] ]

8628, 8677

4707, 7064

313, 361

8779, 8779

3806, 4684

9610, 10098

2714, 2911

7272, 8605

8698, 8758

7090, 7249

8930, 9587

2926, 3787

1390, 1802

269, 275

389, 1371

8794, 8906

1824, 2347

2363, 2698

67,653

161,341

4272

Discharge summary

report

Admission Date: [**2146-7-21**] Discharge Date: [**2146-8-2**] Date of Birth: [**2072-10-16**] Sex: M Service: CARDIOTHORACIC Allergies: Ticlid / Morphine / Percocet / Codeine Attending:[**First Name3 (LF) 1505**] Chief Complaint: Shortness of breath. Major Surgical or Invasive Procedure: [**2146-7-27**] 1. Aortic valve replacement with a 25-mm Biocor Epic tissue heart valve. 2. Mitral valve repair with a mitral valve annuloplasty with a 30-mm [**Doctor Last Name 405**] band. 3. Coronary artery bypass grafting x2; with left internal mammary artery graft to left anterior descending, and lesser saphenous vein graft to the posterior descending artery. History of Present Illness: 73M w/ hx of critical AS, CAD, PAD and recent NSTEMI with CHF exacerbation last week ([**2146-7-10**] - [**2146-7-13**]) discharged on medical management now returns with complaint of increased SOB. He reports doing well for the first few days after discharge, however he began to experience significant SOB and fatigue with minimal activity. He reports eating Italian sausages and fast food yesterday prior to the development of these symptoms during the day. When going to bed last night, he had difficulty sleeping due to SOB and had to sit up to catch his breath. He ended up spending much of the night sitting up in a chair. At the urging of his wife, he came to the [**Name (NI) **] today for further evaluation and management. On arrival to the [**Last Name (LF) **], [**First Name3 (LF) **] EKG was performed which noted the presence of LBBB. This is a stable finding in this patient, however a code STEMI was called and he was rushed to the cath lab. On arrival to the cath lab, his EKG was again reviewed and the stable LBBB was noted. He therefore did not undergo catheterization. He is now sent to the floor for a presumed CHF exacerbation and probable consultation with cardiac surgery for expedition of his planned AVR and CABG. He denies any associated chest pain, nausea, vomiting, abdominal discomfort, increased edema, headache, fevers, vision changes, or other comlaints. Past Medical History: CAD MR [**First Name (Titles) **] [**Last Name (Titles) **] NSTEMI [**11-13**] Hypertension Atrial Fibrillation on Coumadin Diabetes Chronic renal insufficiency Congestive heart failure- acute exacerbation [**12-13**] Peripheral vascular disease Venous stasis Chronic RLE cellulitis - resolved [**2142**] Perirectal Abscess drainage x 2 s/p fistulectomy Obesity Mild GERD Psoriasis Tonsillectomy MRSA Bilateral carpal tunnel syndrome Gout Social History: He lives in [**Location 5110**] with his wife. [**Name (NI) **] is a retired [**Hospital1 8**] police officer, currently works part-time as a driver for Enterprise rental cars. He has four adult children. He uses a cane occasionally. He was previously given a walker but had difficulty using it. - Tobacco: quit smoking 45 years ago, rare cigar. - ETOH: social, last drink over 2 years - Illicit Drugs: none Family History: 5 brothers, 2 sisters; only one sister still alive (age 85); two sons, three daughters, 7 grandchildren. Mother: died age 86; Arthritis Father: died age 81; MI No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death. Physical Exam: ADMISSION: 96.2 HR: 46 BP: 128/67 Resp: 20 O(2)Sat: 96 Constitutional: Overweight male appearing stated age lying in bed. Speaking sentences interrupted by mild-moderate dyspnea. No acute distress HEENT: Normocephalic, atraumatic. JVP assessed but unable to identify - possibly intracranial but unable to confirm due to body habitus despite holding inspirations and sitting up Chest: lungs clear to auscultation bilaterally, no wheezes, rhonchi or rales appreciated Cardiovascular: normal rate, irregular rhythm. III/VI systolic murmur at right second intercostal space. no rubs or gallops Abdominal: Soft, obese, Nontender, NABS Extr: [**2-4**]+ pitting edema. warm and well-perfused Skin: No rashes noted Neuro: CNII-XII intact. MAEE. Speech fluent. Mood/affect appropriate. Pertinent Results: ADMISSON: [**2146-7-21**] 01:28PM BLOOD WBC-8.7 RBC-3.85* Hgb-11.1* Hct-34.1* MCV-88 MCH-28.8 MCHC-32.6 RDW-16.3* Plt Ct-247 [**2146-7-21**] 01:28PM BLOOD Neuts-81.5* Lymphs-14.7* Monos-2.7 Eos-0.8 Baso-0.3 [**2146-7-21**] 01:28PM BLOOD PT-26.3* PTT-43.1* INR(PT)-2.5* [**2146-7-21**] 01:28PM BLOOD Glucose-125* UreaN-57* Creat-1.9* Na-141 K-4.2 Cl-103 HCO3-27 AnGap-15 [**2146-7-21**] 01:28PM BLOOD Calcium-9.0 Phos-4.0 Mg-2.2 CARDIAC ENZYMES: [**2146-7-21**] 01:28PM BLOOD CK-MB-8 [**2146-7-21**] 01:28PM BLOOD cTropnT-0.11* [**2146-7-21**] 08:50PM BLOOD CK-MB-10 MB Indx-4.3 cTropnT-0.18* [**2146-7-22**] 07:10AM BLOOD CK-MB-8 cTropnT-0.18* [**2146-7-23**] 06:30AM BLOOD CK-MB-5 cTropnT-0.12* [**2146-7-21**] EKG: Atrial fibrillation with moderate ventricular response. Compared to tracing #1 there is no significant diagnostic change. TRACING #2 Read by: [**Last Name (LF) **],[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] Intervals Axes Rate PR QRS QT/QTc P QRS T 61 0 106 490/491 0 21 42 [**2146-7-21**] EKG: Atrial fibrillation with slow ventricular response. Occasional multifocal ventricular premature beats. Inferolateral ST-T wave abnormalities which are non-specific. Compared to the previous tracing of [**2146-7-12**] there is no significant diagnostic change. TRACING #1 Read by: [**Last Name (LF) **],[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] Intervals Axes Rate PR QRS QT/QTc P QRS T 56 0 122 486/479 0 18 175 [**2146-7-21**] CXR AP PORTABLE: REASON FOR EXAM: Recent NSTEMI, shortness of breath, CHF exacerbation. Comparison is made with prior study, [**7-10**]. Mild-to-moderate cardiomegaly is stable. There has been improvement in now mild-to-moderate pulmonary edema. There is no pneumothorax or enlarging pleural effusions. [**2146-7-26**] EKG: Atrial fibrillation with a controlled ventricular response. Left bundle-branch block. Compared to the previous tracing of [**2146-7-21**] there is no significant change. Read by: [**Last Name (LF) 2194**],[**First Name3 (LF) **] H. Intervals Axes Rate PR QRS QT/QTc P QRS T 82 0 166 426/464 0 -13 138 . Intra-op TEE [**2146-7-27**] Conclusions PRE-CPB: The left atrium is markedly dilated. No atrial septal defect is seen by 2D or color Doppler. There is moderate symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. There is mild global left ventricular hypokinesis (LVEF = 45 %). The right ventricular cavity is moderately dilated with normal free wall contractility. There are simple atheroma in the ascending aorta. There are simple atheroma in the aortic arch. There are simple 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. There is critical aortic valve stenosis (valve area <0.8cm2). Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. The mitral valve leaflets do not fully coapt. Severe (4+) central mitral regurgitation is seen. Dr [**Last Name (STitle) **] was notified of findings at time of study. POST-CPB: There is a bioprosthetic valve in the aortic position. The valve is well seated with normally mobile leaflets. There are no apparent paravalvular leaks. There is no AI. The peak gradient across the aortic valve is 14mmHg, the mean gradient is 6mmHg. A mitral annuloplasty ring is seen, consistent with mitral valve repair. There is no residual mitral regurgitation. The left ventricular systolic function remains mildly depressed, estimated EF=45%. The right ventricular systolic function is preserved. Other valvular function is unchanged. There is no evidence of dissection. I certify that I was present for this procedure in compliance with HCFA regulations. Electronically signed by [**First Name8 (NamePattern2) **] [**Name8 (MD) 17792**], MD, Interpreting physician [**Last Name (NamePattern4) **] [**2146-7-27**] 17:12 . [**2146-8-2**] 08:00AM BLOOD WBC-8.3 RBC-3.36* Hgb-9.6* Hct-30.7* MCV-91 MCH-28.6 MCHC-31.4 RDW-15.9* Plt Ct-243# [**2146-8-1**] 12:42PM BLOOD Hct-29.0* [**2146-8-2**] 08:00AM BLOOD PT-26.4* INR(PT)-2.5* [**2146-8-1**] 03:06AM BLOOD PT-17.6* INR(PT)-1.7* [**2146-7-31**] 01:20AM BLOOD PT-14.5* INR(PT)-1.4* [**2146-7-30**] 08:13AM BLOOD PT-13.9* PTT-30.7 INR(PT)-1.3* [**2146-7-29**] 12:19AM BLOOD PT-13.7* PTT-29.2 INR(PT)-1.3* [**2146-8-2**] 08:00AM BLOOD Glucose-143* UreaN-66* Creat-1.7* Na-139 K-4.6 Cl-102 HCO3-27 AnGap-15 [**2146-8-1**] 12:42PM BLOOD Glucose-126* UreaN-65* Creat-1.7* Na-140 K-4.1 Cl-102 HCO3-28 AnGap-14 [**2146-8-1**] 03:06AM BLOOD Glucose-125* UreaN-71* Creat-1.8* Na-142 K-3.7 Cl-103 HCO3-28 AnGap-15 Brief Hospital Course: MEDICINE COURSE: 73 y/o M with history of critical AS, CAD, a-fib with recent admission for NSTEMI and acute on chronic systolic heart failure now presents with SOB likely due to CHF exacerbation. ACUTE ISSUES: # Acute on Chronic Systolic Congestive Heart Failure: Given the patient's history of recent acute on chronic sCHF, his worsening SOB in the setting of dietary non-compliance, and significant lower extremity edema, the most likely cause of his SOB is another exacerbation of his sCHF. His lungs were CTAB, however his increased lower extremity edema and clinical picture is otherwise consistent with fluid overload. Additionally during his recent admission, his lungs remained clear despite volume overload. He remained stable though with a constant O2 requirement, satting in the mid-09s on 2L NC. While his consumption of fast food and Italian sausages and subsequent fluid overload is the most likely cause of this exacerbation, it was also important to rule out an acute ischemic event as a factor in his CHF exacerbation. He has denied any chest pain, and his EKG is unchanged compared to prior, and interpretation of troponins and ck-mb consistent with demand ischemia as well as resolving elevation from recent NSTEMI. He received IV furosemide ranging from 40-80 mg mostly [**Hospital1 **] and had some improvement in his fluid status. However, his SOB had only mild improvement, and when the decision for surgery was made he was maintained on his home po torsemide for even fluid goals. He was continued on medical management for optimization of fluid status and plan for C-[**Doctor First Name **] to go ahead with CABG, AVR, MV repair which initially had been planned for [**Month (only) 216**]. For now, we will continue medical management and mild diuresis. ACE-I was held given his upcoming surgery. # h/o NSTEMI and Critical aortic stenosis: During his last hospitalization, he was managed medically with aspirin, heparin gtt, beta-blockers, statin therapy, and was diuresed with torsemide and IV lasix. He was not felt to be a candidate for PCI during that visit. He had resolution of his chest discomfort as well as his shortness of breath at that time. He has undergone an evaluation for aortic valve replacement and was seen by the C-[**Doctor First Name **] team during that time, now with plans for CABG/AVR this visit. CHRONIC ISSUES: # ATRIAL FIBRILLATION: During his last hospital course, he remained in atrial fibrillation with slow ventricular rate. He was continued on metoprolol, but coumadin was held and replaced with heparin gtt given his upcoming surgery. # DM: Maintained on sliding scale insulin with basal doses . # CKD: No acute issues during last admission. Creatinine remained stable during the medical management portion of this hospitalization. SURGICAL COURSE: The patient was brought to the Operating Room on [**2146-7-27**] where the patient underwent CABG x 2, AVR (tissue), MV repair with Dr. [**Last Name (STitle) **]. Overall the patient tolerated the procedure well and post-operatively was transferred to the CVICU in stable condition for recovery and invasive monitoring. The patient weaned off of inotropic/vasopressor support on POD 1. He required aggressive diuresis with a Lasix drip. He was extubated on POD 3. Beta blocker was initiated and the patient was gently diuresed toward the preoperative weight. He did experience some delirium and was started on Seroquel. Chest tubes and pacing wires were discontinued without complication. The patient was transferred to the telemetry floor for further recovery. The patient was evaluated by the physical therapy service for assistance with strength and mobility. By the time of discharge on POD 6 the patient required maximum assistance with ambulation, the wound was healing and pain was controlled with oral analgesics. The patient was discharged to [**Hospital 38**] Rehab in good condition with appropriate follow up instructions. Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from PatientwebOMR. 1. Aspirin 81 mg PO DAILY 2. Atorvastatin 40 mg PO DAILY 3. Insulin SC Sliding Scale Insulin SC Sliding Scale using HUM Insulin 4. Victoza *NF* (liraglutide) 0.6 mg/0.1 mL (18 mg/3 mL) Subcutaneous daily 5. Torsemide 40 mg PO DAILY 6. Metoprolol Succinate XL 25 mg PO DAILY 7. Warfarin 4 mg PO DAYS ([**Doctor First Name **],MO,TU,WE,TH,FR,SA) 8. Levothyroxine Sodium 25 mcg PO DAILY 9. Nitroglycerin SL 0.4 mg SL PRN chest pain Discharge Medications: 1. Aspirin 81 mg PO DAILY 2. Atorvastatin 80 mg PO DAILY 3. 70/30 40 Units Breakfast 70/30 40 Units Dinner Insulin SC Sliding Scale using REG Insulin 4. Levothyroxine Sodium 25 mcg PO DAILY 5. Warfarin 4 mg PO DAYS ([**Doctor First Name **],MO,TU,WE,TH,FR,SA) dose may change daily for goal INR [**2-4**], dx: AFib 6. Albuterol Inhaler 4 PUFF IH Q4H:PRN bronchospasm 7. Bisacodyl 10 mg PR DAILY:PRN constipation 8. Docusate Sodium 100 mg PO BID 9. Heparin 5000 UNIT SC TID 10. Metoprolol Tartrate 12.5 mg PO BID Hold for HR < 55 or SBP < 90 and call medical provider. 11. Milk of Magnesia 30 ml PO HS:PRN constipation 12. Ranitidine 150 mg PO DAILY 13. TraMADOL (Ultram) 50 mg PO Q4H:PRN pain RX *tramadol 50 mg 1 tablet(s) by mouth every four (4) hours Disp #*40 Tablet Refills:*0 14. Zolpidem Tartrate 10 mg PO HS 15. Nitroglycerin SL 0.4 mg SL PRN chest pain 16. Victoza *NF* (liraglutide) 0.6 mg/0.1 mL (18 mg/3 mL) Subcutaneous daily 17. Torsemide 40 mg PO DAILY Discharge Disposition: Extended Care Facility: [**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**] Discharge Diagnosis: CAD MR [**First Name (Titles) **] [**Last Name (Titles) **] NSTEMI [**11-13**] Hypertension Atrial Fibrillation on Coumadin Diabetes Chronic renal insufficiency Congestive heart failure- acute exacerbation [**12-13**] Peripheral vascular disease Venous stasis Chronic RLE cellulitis - resolved [**2142**] Perirectal Abscess drainage x 2 s/p fistulectomy Obesity Mild GERD Psoriasis Tonsillectomy MRSA Bilateral carpal tunnel syndrome Gout Past Surgical History: S/p Left CEA [**4-13**], s/p Right CE [**12-7**] -known occluded s/p bilateral CFA-PT bypass with SVG 03 and 04 S/p right 5th metatarsal head resection s/p Perirectal Abscess drainage x 2 s/p fistulectomy s/p Right knee arthroscopic surgery s/p bilateral cataracts Discharge Condition: Alert and oriented x3 nonfocal Deconditioned, Max Assist Sternal pain managed with oral analgesics Sternal Incision - healing well, no erythema or drainage 2+ LE edema Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming, and look at your incisions Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Followup Instructions: You are scheduled for the following appointments: Surgeon Dr. [**Last Name (STitle) **], [**2146-9-7**] 2:15, [**Telephone/Fax (1) 170**] The Cardiac Surgery office will call rehab with the following appointment PCP/Cardiologist Dr. [**Last Name (STitle) **],[**First Name3 (LF) 1730**] [**0-0-**] **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:[**2146-8-2**]

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icd9cm

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50734

Discharge summary

report

Admission Date: [**2114-3-13**] Discharge Date: [**2114-3-22**] Date of Birth: [**2067-3-6**] Sex: F Service: MEDICINE Allergies: Latex / Penicillins / Glucocorticoids (Corticosteroids) Attending:[**First Name3 (LF) 2248**] Chief Complaint: Shortness of Breath Major Surgical or Invasive Procedure: cardiac catheterization transesophageal echo attempted mitral valvuloplasty History of Present Illness: Ms. [**Known lastname 60258**] is a 46 year-old woman with history of advanced interstitial lung disease, likely NSIP, chronic diastolic CHF, DM, and chronic pain s/p MVA who initially presented to [**Hospital 6451**] on [**2114-3-12**] with worsening shortness of breath. Of note, she was recently admitted to [**Hospital1 18**] with respiratory failure from [**2114-2-14**]- [**2114-2-23**]. During that admission, her respiratory failure was felt to be secondary to diastolic CHF, HCAP and possibly an ILD flare. She was treated with steroids, diuresis and antibiotics. In follow up conversation with her pulmonologist, he seemed to think that her respiratory failure was more related to her mitral stenosis and recommended tapering off steroids in the next 2 weeks as well as a follow up TEE and heart cath. . Per the patient, since d/c from [**Hospital1 18**], she has had worsening shortness of breath and "bloating." She also had been experiencing high fevers at home, up to 105. She attributes some of these symptoms to the steroids and reports that she had some improvement after tapering off of the steroids. However, she did continue to feel bad and ultimately presented to [**Hospital3 **] yesterday for evaluation. She also endorses exertional chest pain, which she describes as electric-shocklike, located in the central and left chest. She also bas been having panic attacks, with shortness of breath and heart palpitations. She also has had a dry cough recently, which improves with albuterol. . While at [**Hospital3 417**], she was seen by the cardiology and pulmonary consult services. Labs were significant for a WBC of 12.4 which improved to 6.6. She underwent a CXR, which shoed pulmonary congestion with confluent densities (greater on R), ? infiltrates vs. edema. CT chest was also performed, which showed "complex scan with acute and chronic lung disease, increased infiltration could be due to infection and CHF mediastinal hilar adenopathy." ABG was performed on [**2114-3-12**] on 15LPM NRB and showed pO2 65, pCO2 41, pH 7.42. She was treated with levofloxacin, nebs, and IV lasix. She requested transfer to [**Hospital1 18**] given that her providers are primarily located here. . On arrival to the floor, patient's VS were T=99.5 BP=110/73 HR=90 RR=20 O2 sat=95%/5L. . Review of systems was generally pan-positive. She endorsed chornic back pain as well as the above symptoms listed in the HPI. She denied any N/V/D/C or urinary symptoms. Past Medical History: # Non-specific interstitial pneumonitis (possibly idiopathic pulmonary hemosiderosis?) - s/p lung biopsy by VATS [**2109**] at [**Hospital1 **], lost to follow-up until [**2112**] - followed by [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] - Home O2 requirement of ~4-8L - [**2114-1-2**] PFTs: DLCO 40% predicted, TLC 58% predicted, FEV1 54% - Overall consistent with restrictive lung disease # CHF, chronic diastolic # Mitral stenosis, mild, area 1.5-2.0cm2, appearance of valve consistent with Rheumatic heart disease # Diabetes Mellitus, on insulin # Depression # Chronic pain status post MVA # ?Cardiomegaly # TTE with ?rheumatic MV disease # CAD s/p MI (normal MIBI in [**2109**]) # Cervical dysplasia # Colonic polyps s/p multiple polypectomies # Hiatal hernia # Migraines . PAST SURGICAL HISTORY: # TAH-BSO # Cervical cone bx # Mediastinoscopy & L VATS [**2109**] Social History: She lives in [**Location **]. She is currently widowed. She has been disabled after a motor vehicle accident which happened several years ago. - Tobacco: ~25 pack year history, quit 9 months ago - Alcohol: denies - Illicits: h/o illicit drug use in youth Family History: (per OMR): She has two children. She has several relatives who have had lung problems and has died from complications related lung disease. Her mother had COPD, died of respiratory failure, father with cardiovascular disease. She had a sister who died after a lung biopsy was performed. She states that several of her family members may have had asbestos exposure including the patient. Physical Exam: VS: T=99.5 BP=110/73 HR=90 RR=20 O2 sat=95%/5L GENERAL: WDWN 47 y/o F in NAD. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple with no JVD noted. CARDIAC: RRR, normal S1, S2. No m/r/g. 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: Obese. Soft, ND. Some mild TTP in the lower abdomen bilaterally. No rebound or guarding. BS present. EXTREMITIES: No c/c/e. No calf tenderness. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. BACK: TTP diffusely throughout the entire back, particularly over the upper paraspinal regions bilaterally and the right lower back. No pinpoint tenderness or spinal tenderness. NEURO: Non focal. Limited strength exam [**1-24**] pain. PULSES: Right: PT 2+ Left: PT 2+ VS: 98.1 afebrile, 93/55 (93-121/55-72) 76 (65-77) 18 100% 4L wgt: 98.8, yest 99.4 24hr I=700/O= 2600 General: resting but easily rousable, NAD, appropriate, cooperative. HEENT: NCAT, PERRL, EOMI, no scleral icterus, MMM Neck: supple, no significant JVD (but limited by body habitus) or carotid bruits appreciated Pulmonary: CTAB, no wheezes, rhonchi or rales Cardiac: RRR, nl S1 S2, no murmurs, rubs or gallops appreciated Abdomen: soft, NT, ND, normoactive bowel sounds Extremities: No edema, no cyanosis Skin: no rashes or lesions noted. Neurologic: Alert, oriented x 3. Able to relate history without difficulty. Cranial nerves II-XII intact. No focal deficits noted Pertinent Results: Admission Labs: [**2114-3-14**] 01:00AM BLOOD WBC-8.0 RBC-3.28* Hgb-9.3* Hct-26.3* MCV-80* MCH-28.4 MCHC-35.3* RDW-15.0 Plt Ct-319 [**2114-3-14**] 01:00AM BLOOD Neuts-78.8* Lymphs-14.3* Monos-2.7 Eos-3.7 Baso-0.4 [**2114-3-14**] 01:00AM BLOOD PT-15.2* PTT-29.4 INR(PT)-1.3* [**2114-3-14**] 01:00AM BLOOD Glucose-235* UreaN-7 Creat-0.7 Na-137 K-3.8 Cl-101 HCO3-25 AnGap-15 [**2114-3-14**] 01:00AM BLOOD CK-MB-1 cTropnT-<0.01 [**2114-3-14**] 01:00AM BLOOD Calcium-8.9 Phos-2.3*# Mg-1.8 . C-cath [**2114-3-14**] 1. Selective coronary angiography in this right dominant system revealed no significant coronary artery disease. The LMCA, LAD, LCx, and RCA were all normal without angiographically apparent flow limited disease. The LCx had a large ramus branch. 2. Limited resting hemodynamics revealed elevated left and right sided filling pressures with mean PCWP 29mmHg and RVEDP 15mmHg. There was severe pulmonary arterial hypertension with PASP 69 mmHg. Central aortic pressures were normal at 137/80 with a mean of 97 mmHg. 3. The mean mitral valve gradient was 13.5 mmHg and calculated MVA 1.23 cm2 with excellent hemodynamic tracings, oxygen saturation confirmed PCWP and reversed transducers. FINAL DIAGNOSIS: 1. No angiographically apparent coronary artery disease. 2. Moderate mitral stenosis with valve area 1.23 cm2, mean transmitral pressure gradient 13.4 mmHg. 3. Biventricular diastolic dysfunction. 4. Severe pulmonary arterial hypertension. . TTE [**2114-3-15**] The left atrium is mildly dilated. The right atrium is moderately dilated. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thickness, cavity size, and global systolic function are normal (LVEF>55%). Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are moderately thickened. The mitral valve shows characteristic rheumatic deformity. There is moderate thickening of the mitral valve chordae. Mild (1+) mitral regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is a trivial/physiologic pericardial effusion. IMPRESSION: Suboptimal image quality (body habitus). Characteristic rheumatic deformity of the mitral valve with elevated transvalvular gradient suggestive of moderate mitral stenosis. However, visually the mitral valve appears more pliable. This elevated gradient may be due to an underestimate of the severity of mitral regurgitation in the setting of moderately thickened mitral valve leaflets and chordal structures. Alternatively, it may be that the subvalvular structures are more thickened/deformed and adversely affecting the effective mitral valve orifice than is able to be appreciated on transthoracic imaging. Given the internal inconsistencies on the current study, a transesophageal echo for further characterization of the mitral valve apparatus is recommended. Compared with the prior study (images reviewed) of [**2114-2-20**], the severity of mitral stenosis is qualitatively similar but the mitral valve area has decreased from 1.8 cm2 to 1.3 cm2 on the current study. The severity of pulmonary artery systolic hypertension has markedly decreased and the right ventricular function has improved. . TEE [**2114-3-16**] (preliminary) No spontaneous echo contrast or thrombus is seen in the body of the left atrium or left atrial appendage. No atrial septal defect is seen by 2D or color Doppler. Overall left ventricular systolic function is normal (LVEF>55%). The ascending, transverse and descending thoracic aorta are normal in diameter and free of atherosclerotic plaque to 33 cm from the incisors (the probe was not advanced past the GE junction due to hiatal hernia). The aortic valve leaflets (3) appear structurally normal with good leaflet excursion. No masses or vegetations are seen on the aortic valve. No aortic regurgitation is seen. The mitral valve leaflets are moderately thickened.The mitral valve shows characteristic rheumatic deformity with bowing of the anterior leaflet and tethering of the posterior leaflet motion. No mass or vegetation is seen on the mitral valve. There is severe valvular mitral stenosis (mean gradient 15mm Hg). Mild to moderate ([**12-24**]+) mitral regurgitation is seen. There is no pericardial effusion. IMPRESSION: Rheumatic deformity of the mitral valve with severe mitral stenosis. Mild ot moderate mitral regurgitation. Preserved global LV systolic function. . TTE [**2114-3-16**] Limited and focused imaging. Left ventricular wall thickness, cavity size, and global systolic function are normal (LVEF>55%). Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. There is no pericardial effusion. . TTE [**2114-3-17**] 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 mitral valve leaflets are mildly thickened. The mitral valve shows characteristic rheumatic deformity. There is severe valvular mitral stenosis. Mild (1+) mitral regurgitation is seen. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] There is no pericardial effusion. IMPRESSION: No pericardial effusion. Severe rheumatic mitral stenosis. Grossly-preserved biventricular systolic function. Compared with the prior study (images reviewed) of [**2114-3-16**], findings are similar. Both studies were focused on excluding pericardial effusion. TTE (Complete) Done [**2114-3-21**] at 11:06:59 AM FINAL The left atrium is elongated. A small atrial septal defect is suggested (clip [**Clip Number (Radiology) **]) but could not be confirmed. Left ventricular wall thickness, cavity size, and global systolic function are normal (LVEF>55%). Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. The estimated cardiac index is normal (>=2.5L/min/m2). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are moderately thickened. There is no mitral valve prolapse. There is mild valvular mitral stenosis (area 1.9cm2). An eccentric jet of mild to moderate ([**12-24**]+) mitral regurgitation is seen. The pulmonary artery systolic pressure could not be determined. There is a trivial/physiologic pericardial effusion. Compared with the prior study (images reviewed) of [**2114-3-15**] (pervalvuloplasty), the severity of mitral stenosis is markedly reduced and the mitral leaflets are more mobile. Brief Hospital Course: Ms. [**Known lastname 60258**] was admitted to the cardiology service. Her CXR on admission showed likely worsening pulmonary edema on a background of ILD. Given lack of focal infiltrate, leucocytosis, and fever, abx were stopped. Steroids or other immunsupression were held at the recommendation of her primary pulmonologist. She was diuresed with IV lasix. Right and left heart cath was done and showed no obstructive CAD, elevated PCWP, and MVA 1.23cm2. Repeat TTE showed normal EF and moderate mitral stenosis, but was a limited study given body habitus. It was felt that she may benefit from mitral valuloplasty as mitral stenosis was the best explanation for her recurrent CHF and elevated wedge pressures. During her time on the cardiology floor, she was satting high 90s on 5-6L, which the patient uses at home, and appeared to be breathing comfortably. TEE was done to look for evidence of thrombus. In the cath lab on [**2114-3-16**] while attepmting valvuloplasty, when crossing the wire transeptally, there was entry into the aorta. The case was aborted, and the patient was transferred to the CCU for closer monitoring. . The patient had a TTE post-procedure that showed no pericardial effusion or changes in the aorta. She remained hemodynamically stable overnight in the CCU. She continued to be diuresed with lasix. Her insulin sliding scale was uptitrated for hyperglycemia. The arterial and venous sheaths were removed from her groin the following day. Repeat TTE demonstrated no interval changes with no pericardial effusions. She was called back out to the cardiology floor. CXR Pa/Lat was ordered for AM after call-out both to assess fluid status and to better evaluate possibility of underlying infectious process. Repeat CXR was much improved without pulmonary edema. Decision was made to take pt back for valvuloplasty on Tuesday. Procedure was successful and without complication; gradient improved (see ECHO and procedure report for full details). Pt's clinical status was monitored for an additional day and lasix was titrated. She was d/c'ed home with VNA and planned outpt follow-up with cardiology and pulm. Medications on Admission: (Per last d/c summary) 1. sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. prednisone 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily): Continue until you see Dr. [**Last Name (STitle) **]. 3. valsartan 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 5. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) Puff Inhalation every 4-6 hours as needed for wheeze. 6. sulfamethoxazole-trimethoprim 400-80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. dextromethorphan-guaifenesin 10-100 mg/5 mL Liquid Sig: Five (5) ML PO Q6H (every 6 hours) as needed for cough. 8. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig: 0.5 Tablet Extended Release 24 hr PO DAILY (Daily). 9. morphine 30 mg Tablet Extended Release Sig: Two (2) Tablet Extended Release PO Q12H (every 12 hours) as needed for neck/shoulder pain. 10. oxycodone 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for pain. 11. morphine 30 mg Tablet Extended Release Sig: One (1) Tablet Extended Release PO NOON (At Noon). 12. diazepam 5 mg Tablet Sig: One (1) Tablet PO every 6-8 hours as needed for anxiety. 14. insulin glargine 100 unit/mL Solution Sig: Twenty Four (24) Subcutaneous at bedtime. 15. insulin Novolog Sig: One (1) four times a day: Follow Sliding Scale. 16. Insulin Syringe MicroFine 0.3 mL 28 x [**12-24**] Syringe Sig: One (1) Miscellaneous four times a day. 17. Lasix 40 mg Tablet Sig: 1 and [**12-24**] Tablet PO once a day: take total of 60mg (1.5 tablets) a day. Discharge Medications: 1. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO once a day. 2. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) puffs Inhalation every four (4) hours as needed for shortness of breath or wheezing. 3. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 4. dextromethorphan-guaifenesin 10-100 mg/5 mL Liquid Sig: Five (5) mL PO every six (6) hours as needed for cough. 5. morphine 30 mg Tablet Extended Release Sig: Two (2) Tablet Extended Release PO twice a day as needed for pain: Please take 60 mg in the am, 30 mg at noon, and 60 mg in the evening as you were before admission. . 6. oxycodone 5 mg Tablet Sig: One (1) Tablet PO twice a day as needed for pain. 7. diazepam 5 mg Tablet Sig: One (1) Tablet PO three times a day as needed for anxiety. 8. Lantus 100 unit/mL Solution Sig: Twenty Four (24) units Subcutaneous at bedtime. 9. Novolog 100 unit/mL Solution Sig: One (1) unit Subcutaneous four times a day: Please resume your sliding scale as previously prescribed. 10. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 11. losartan 25 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 12. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 13. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 14. aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day. 15. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical TID (3 times a day) as needed for itching, redness. Disp:*1 bottle* Refills:*0* 16. fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1) Spray Nasal DAILY (Daily). Disp:*1 bottle* Refills:*2* 17. sodium chloride 0.65 % Aerosol, Spray Sig: [**12-24**] Sprays Nasal QID (4 times a day) as needed for nose dryness. 18. morphine 30 mg Tablet Extended Release Sig: One (1) Tablet Extended Release PO at noon: Please take 60 mg in the am, 30 mg at noon, and 60 mg in the evening as you were before admission. . Discharge Disposition: Home With Service Facility: [**Company 1519**]/[**Hospital1 8**] VNA Discharge Diagnosis: primary: mitral stenosis acute on chronic diastolic heart failure . secondary: interstitial lung disease Type II diabetes Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Ms. [**Known lastname 60258**], Thank you for coming to [**Hospital1 69**] for your care. You were transferred here from [**Hospital3 417**], where ypu were admitted with shortness of breath. Your symptoms were felt to be due to fluid in the lungs. We gave you a medicine called Lasix (furosamide) to help get rid of the fluid. We thought the cause for the fluid was your tight mitral valve. We did a few tests to better asses the tightness of your valve, and we thought you would benefit from a procedure called valuloplasty or ballooning to open up the valve more. The first attempt was complicated by [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] in the aorta and was unsuccessful; the second attempt was successful and your valve was successfully dilated. You were able to be discharged home with follow-up planned as an outpatient. . We made the following changes to your medications: - Please DECREASE your lasix dose to 40mg daily - Please INCREASE your Metoprolol XL dose from 12.5 daily to 25 mg daily - Please STOP taking valsartan. Instead, please START taking losartan 25mg daily. Please speak to your doctor regarding this change. - You reported that you were no longer taking Sertraline (Zoloft) so we have taken this off your medication list; we encourage you to speak with your doctor(s) if you experience any symptoms of depression. - We also STOPPED/did NOT continue the Prednisone and Sulfamethoxazole-trimethoprim (Bactrim) that is listed on your medication list as this was not thought to be helping your [**Last Name **] problem - Please use saline nasal spray and fluticasone spray for your nose as needed - Please use miconazole nitrate poweder for red itchy skin as needed - We are leaving Lantus at 24 units as we discussed because you felt this was safer for your sugars; but as we also discussed, you will need to closely monitor your sugars. Please be sure to take all medication as prescribed. . Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more than 3 lbs. . Please be sure to keep all follow-up appointments with your PCP, [**Name10 (NameIs) 2085**] and other health care providers. . It was a pleasure taking care of you and we wish you a speedy recovery. Followup Instructions: Please be sure to keep all follow-up appointments with your PCP, [**Name10 (NameIs) 2085**] and other health care providers. Please note that we have arranged follow-up with Dr. [**First Name (STitle) **] but this is at his [**Location (un) 2277**] office. Please see address and office number provided below. Name: [**Last Name (LF) **],[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] Location: [**Location (un) 2274**]-[**Location (un) **] Address: 111 [**Doctor Last Name **] DR, [**Location (un) **],[**Numeric Identifier 17464**] Phone: [**Telephone/Fax (1) 105541**] Appointment: Monday [**2114-3-26**] 2:00pm Name: [**Last Name (LF) **], [**Name8 (MD) **] MD Location: [**Hospital1 641**]- Cardiology Address: [**Location (un) **], [**Location (un) **],[**Numeric Identifier 6425**] Phone: [**Telephone/Fax (1) 2258**] Appointment: Tuesday [**2114-3-27**] 2:10pm Department: PULMONARY FUNCTION LAB When: MONDAY [**2114-4-2**] at 1:10 PM With: PULMONARY FUNCTION LAB [**Telephone/Fax (1) 609**] Building: [**Hospital6 29**] [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: MEDICAL SPECIALTIES When: MONDAY [**2114-4-2**] at 1:30 PM With: [**Name6 (MD) **] [**Name8 (MD) 611**], M.D. [**Telephone/Fax (1) 612**] Building: [**Hospital6 29**] [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 2264**] Completed by:[**2114-3-24**]

[ "276.3", "E870.6", "428.0", "515", "998.2", "250.00", "424.0", "416.8", "428.33", "V58.67", "311" ]

icd9cm

[ [ [] ] ]

[ "37.21", "35.96", "88.54", "37.23", "88.72" ]

icd9pcs

[ [ [] ] ]

19131, 19202

13168, 15314

335, 413

19367, 19367

6139, 6139

21776, 23305

4117, 4505

16996, 19108

19223, 19346

15340, 16973

7354, 13145

19517, 20395

3760, 3829

4520, 6120

20424, 21753

276, 297

441, 2913

6155, 7337

19382, 19493

2935, 3737

3845, 4101

27,581

175,864

27981

Discharge summary

report

Admission Date: [**2111-7-27**] Discharge Date: [**2111-7-29**] Date of Birth: [**2044-10-15**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 348**] Chief Complaint: Blood in stool Major Surgical or Invasive Procedure: Colonoscopy History of Present Illness: Mr [**Known lastname 68135**] is a 66 year old man, originally from [**Country 3396**], with history of hypertension, hyperlipidemia and diverticulosis, presenting with bloody bowel movements for 5 days PTA. Patient reports he was in his otherwise good state of health when he began having diarrhea. Shortly thereafter, he noted his stool turned dark colored and the toilet water began turning red. He did not see any blood clots. Patient denies any recent travel, but does report recently trying cambodian food. Patient denies any nausea, vomiting, chest pain, but does report some dyspnea with exertion (going up the stairs) that has conincided with the above complaints. Denies feeling dizzy when he gets up, but does report some palpitations. In the ED, vital signs T 97.4, HR 75, BP 84/64, RR 16, O2 Sat 100% RA. Rectal vault with bright red blood. Two large bore IV placed on Bilateral UE, patient given 1L NS bolus and 1 unit of PRBC, with ipmrovement in SBP to 102/64. NG lavage performed; negative for blood. Patient admitted to MICU for further monitoring. Past Medical History: 1. Hypertension 2. Hyperlipidemia 3. Diverticulosis 4. Inguinal hernia s/p repair 5. Colonic adenomas s/p resection Social History: Patient originally from [**Country 3396**], lives with wife. [**Name (NI) **] etoh or cigarette use. Family History: No familial history of colon cancer, no chronic medical conditions. Physical Exam: Vitals Temp: HR: 77 BP: 126/68 RR: 20 O2 Sat: 100% RA GEN: Well appearing man in no distress HEENT: PERRL, sclera anicteric, pale conjunctiva CV: Regular rate, soft systolic flow murmur at apex, no rubs/gallops. Normal S1/S2 Lungs: Clear to auscultation bilaterally, no rales/rhonchi/wheezes Abdomen: Soft, non tender non distended, normoactive bowel sounds. No guarding, no hepato/spleno megaly Extremities: Cold, 2+ pulses, no clubbing cyanosis or edema. Pertinent Results: CT ABDOMEN AND PELVIS . There is no pericardial or pleural effusion. The lung bases are clear. There are several subcentimeter hepatic hypodensities, likely a combination of cysts and hemangiomas. There is a subcentimeter right renal hypodensity, too small to characterise. The spleen, adrenal glands, pancreas, and left kidney appear unremarkable. There is no upper abdominal lymphadenopathy. . There is no pelvic lymphadenopathy. There is no free fluid in the pelvis. There is colonic diverticulosis without evidence of diverticulitis. The appendix is visualized and appears unremarkable. MUSCULOSKELETAL: There are minor degenerative changes present in the lumbar spine. CONCLUSION: 1. No evidence of diverticulitis or appendicitis. Scattered diverticulosis is seen throughout the colon. 2. Scattered hepatic hypodensities, likely a combination of cysts and hemangiomas. . --------------- CHEST X-RAY --------------- Portable view of the chest in upright position demonstrates the cardiomediastinal silhouette to be within normal limits. There is no pneumothorax, consolidation, or pleural effusion. The pulmonary vasculature is normal. The osseous structures are unremarkable. . Colonoscopy Diverticulosis of the colon Grade 2 internal hemorrhoids Brief Hospital Course: 66 year old male with history of diverticulitis and colon adenomas who presented with hematochezia. 1. Hematochezia: The patient was initially admitted for hematochezia the night prior to admission. He was also symptomatic with dizziness, chills, and dyspnea on exertion. He was [**Hospital 1801**] transferred to the MICU, where he received 2 units of PRBC. Upon transfer to the floor, he was hemodynamically stable with resolution of sypmtoms, and remained this way throughout the rest of his admission. CT abdomen and pelvis did not demonstrate diverticulitis or appendicitis, but did demonstrate diverticulosis throughout the colon. A colonoscopy was performed which demonstrated diverticulosis throughout the colon and grade 2 internal hemorrhoids, but no source of acute bleeding. At this point, both diverticulosis and internal hemorrhoids may be the source of the patient's painless bleeding. He was recommended by GI to have a repeat colonoscopy performed in 5 years and to follow-up in [**Hospital **] clinic for a possible capsule study if symptoms persist. 2. Liver hypodensities: Incidentally found on CT abdomen and pelvis. Per radiology report, likely to represent cysts or hemangiomas. 3. Hypertension: On admission, the patient's anti-hypertensive medications were held given intravascular volume status. He was normotensive throughout his admission, and on discharge was instructed to resume his home medication regimen. 4. Diabetes: The patient's home glucophage regimen was help on admission, and he was controlled with ISS during his hospital course. On discharge, he was instructed to resume his home diabetic regimen including glucophage. 5. Hyperlipidemia: The patient was continued on home statin therapy while admitted. Medications on Admission: Lipitor 10mg Glucophage 500mg daily? Monopril 10mg daily Atenolol 50mg daily Lisinopril 20mg daily Vicodin 5/500mg PRN Colace 100mg daily Discharge Medications: 1. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Glucophage 500 mg Tablet Sig: One (1) Tablet PO once a day. 3. Monopril 10 mg Tablet Sig: One (1) Tablet PO once a day. 4. Atenolol 50 mg Tablet Sig: One (1) Tablet PO once a day. 5. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home Discharge Diagnosis: Primary - Hematochezia Secondary Diverticulosis Internal hemorrhoids Hypertension Hyperlipidemia Inguinal hernia s/p repair Colonic adenomas s/p resection Discharge Condition: Patient was discharged in stable condition. Discharge Instructions: 1. You were admitted for bloody stools. You were also complaining of new shortness of breath, chills, and dizziness since you started bleeding, which was likely due to blood loss. You had a colonosocpy performed while admitted that demonstrated diverticulosis and internal hemorrhoids, but no source of obvious bleeding. You were also transfused with red blood cells while hospitalized. You will need to follow-up with gastroenterology in [**2-9**] weeks as listed below. 2. Please resume all of your home medications as taken prior to admission. It is very important that you take all of your medications as prescribed. 3. It is very important that you make all of your doctors [**Name5 (PTitle) 4314**]. 4. If you have another episode of large amounts of bright red blood with stools, chest pain, shortness of breath, fever, or other concerning symptoms, please call your PCP or go to your local Emergency Department immediately Followup Instructions: Please follow-up wiht gastroenterology in [**2-9**] weeks. You can make an appointment by calling ([**Telephone/Fax (1) 2233**]. Please follow-up with your PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 16365**], in 2 weeks. You can make an appointment by calling ([**Telephone/Fax (1) 43017**] Completed by:[**2111-7-31**]

[ "455.0", "250.00", "573.8", "578.1", "427.89", "562.10", "285.1", "276.52", "228.04", "272.4", "401.9" ]

icd9cm

[ [ [] ] ]

[ "96.33", "96.07", "45.23", "99.04" ]

icd9pcs

[ [ [] ] ]

5856, 5862

3570, 5330

330, 344

6062, 6108

2289, 3547

7094, 7435

1717, 1787

5519, 5833

5883, 6041

5356, 5496

6132, 7071

1802, 2270

276, 292

372, 1442

1464, 1582

1598, 1701

4,485

182,432

53591

Discharge summary

report

Admission Date: [**2122-8-14**] Discharge Date: [**2122-8-25**] Service: MEDICINE Allergies: Aspirin / Adalat Cc / Univasc / Rhinocort Aqua / Celebrex / Remeron Attending:[**First Name3 (LF) 2186**] Chief Complaint: chest pain Major Surgical or Invasive Procedure: Cardiac catheterization History of Present Illness: Pt is an 84 year old woman with a PMH of HTN, Chronic back and knee pain (s/p diskectomy), depression and OA found down at home and brought to the hospital [**8-14**]. According to her son, who translated for her today, she had a 10 day history of burning chest, back and shoulder pain. This pain was not associated with exertion and was worse with inspiration but not positional. It was also associated with SOB and diaphoresis. She has been nauseated and vomioted an unknown amount of times. Pt attributes this to narcotic regimen which was recently adjusted by PCP. . This am, pt states that around 7:30 am she fell in her bathroom and was found by a home aid at 10:30am. She remembers falling and feeling lightheaded prior to falling. She is unsure if she lost consciousness or hit her head. She denies CP, palpitations, N/V around the time of the fall. She also states that she defecated during this time and denies urination. . She was found at [**Hospital1 18**] ED to have an EKG with diffuse ST elevations in 2,3, AvF, V2-6 and Qs in 2,3,F. CK was 819, MB 61 and Trop 2.3. She was sent to cath where she was found to have 3VD with LMCA 50%, LAD diffuse dz 60-70% and LCx 90%, RCA 80% diffuse with mildly elevated filling pressures (PCW 17, RA 10), LVgram with EF 30%, 2+ MR. [**Name13 (STitle) **] intervention was performed. . ROS: (Difficult history given son as translator) As above and DOE, Presyncope, No changes in vision, hearing. No changes in bowel or urinary habits. Past Medical History: PMH: Depression, Reflex Sympathetic Dystrophy (R foot), OA, Meniscal dz, LBP s/p L3-4 diskectomy and L4-5 stenosis, occipital neuralgia, GERD Physical Exam: PE: T 98.4 BP 114/72 96 18 98% 2L N/C HEENT: MMM, No Exudates, PERRLA, EOMI Neck: Supple, Midline trachea, anodular thyroid Chest: clear, anteriorly c/v: RRR, [**1-4**] HSM parasternal abd: Soft, NT, ND Obese, No HSM, No masses ext: no edema, cyanosis or clubbing Pertinent Results: Data: Cardiac Cath [**8-14**]: 1. Selective coronary angiography revealed a right dominant system with three vessel calcific disease. The LMCA had a distal tapering 50% lesion. The LAD wsa diffusely diseased and calcified with serial 70% lesions. it was a lrage vessel that wrapped aorund the apex and supplied the distal half of the inferior septum. The LCX had an ostial 90% stenosis. The RCA was small and diffusely diseased with 80% serial lesions in the diastal AV groove. 2. Left ventriculography showed apical balooning with akinesis of anteroapical and inferoapical wall and EF of 30-40% on Vgram. 3. Hemodynamic assessmnet showed mildly elevated to high normal left and right sided filling pressures. CO/CI 4.54/2.62 EF >55% . Echo [**2119-6-9**] The left 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 leaflets (3) are mildly thickened. There is no significant aortic valve stenosis. Trace aortic regurgitation is seen. The mitral leaflets are mildly thickened. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. There is minimal pulmonic stenosis Brief Hospital Course: 1) Chest pain: Patient was admitted and underwent cardiac catheterization on [**8-14**]. She was found to have three-vessel disease with LMCA 50%, LAD diffuse dz 60-70% and LCx 90%, RCA 80% diffuse with mildly elevated filling pressures (PCW 17, RA 10), LVgram with EF 30%, 2+ MR. [**Name13 (STitle) **] intervention was performed. Patient was managed medically, with ASA, Atorvastatin,Mteoprolol, Plavix, and nitroglycerin as needed. Metoprolol was later discontinued as it may have been contributing to the patient's dizziness and Plavix was discontinued when the patient developed thrombocytopenia. Plan is for the patient to re-start Plavix as outpatient, once platelets have recovered. . 2) Pain. Patient has chronic burning total body pain for which she was seen by the pain service. which is treated with oxycontin, gabapentin, and ativan with some relief. Patient was transitioned to xanax for discharge. . 3) Dizziness: Patient complained of a sensation of dizziness which may have contributed to her fall at home. Patient was seen by neurology an an MRI was obtained, which was normal. It seemed that the likely etiology of her dizziness was oxycontin, which the patient takes to treat her chronic pain. The dose which had been increased during this admission was decreased and changed to more frequent dosing. Patient was evaluated by PT and by the RN and she was able to able to ambulate by herself to a bedside commode without difficulty. Since her medications were decreased she has not complained about dizziness and she will receive physical therapy at rehab. For safety, she will remain on fall precautions at rehab. . 4) Dispo: The patient's son was initially very resistant to the idea of sending his mother to a rehabilitation/skilled nursing facility. He spoke to Dr. [**Last Name (STitle) **] who explained that his mother required more consistent care than the son was able to provide at home. Son agreed and patient was discharged to rehab. Medications on Admission: Neurontin 60 TID Diovan 80 Daily oxycontin 40 [**Hospital1 **] Ativan PRN HCTZ 25 Daily Demerol Colace Lactulose Meclizine KCL 10meq/day compazine 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. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. Disp:*60 Tablet(s)* Refills:*0* 3. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 4. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet, Sublingual Sublingual PRN (as needed) as needed for chest pain. Disp:*1 small bottle* Refills:*1* 5. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 6. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. Disp:*90 Tablet(s)* Refills:*0* 7. Aluminum-Magnesium Hydroxide 225-200 mg/5 mL Suspension Sig: 15-30 MLs PO QID (4 times a day) as needed. 8. Alprazolam 0.5 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 9. Gabapentin 300 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day). 10. Oxycodone 20 mg Tablet Sustained Release 12HR Sig: One (1) Tablet Sustained Release 12HR PO Q8H (every 8 hours). Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - [**Location (un) 550**] Discharge Diagnosis: ST Elevation Myocardial Infarction Thrombocytopenia Anemia Chronic low back pain Chronic knee pain Discharge Condition: Stable Discharge Instructions: If you experience fevers, chills, nausea, vomiting, chest pain, shortness of breath, or any other concerning symptoms, contact your physician or return to the emergency room. . You are currently not taking Plavix, which is a type of anti-platelet [**Doctor Last Name 360**], because you have low platelets. You should speak to your physician about restarting this medication once your platelet level has returned to [**Location 213**]. Followup Instructions: Please contact your physician [**Last Name (NamePattern4) **] [**Telephone/Fax (1) 250**] for an appointment in the next 2-4 weeks. Your other scheduled appointments are as indicated below: . Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 6730**], MD Where: [**Hospital6 29**] DERMATOLOGY Phone:[**Telephone/Fax (1) 1971**] Date/Time:[**2122-9-2**] 11:00 Provider: [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] Where: FD [**Hospital Ward Name **] BUILDING ([**Hospital Ward Name **]/[**Hospital Ward Name **] COMPLEX) PAIN MANAGEMENT CENTER Phone:[**Telephone/Fax (1) 1091**] Date/Time:[**2122-9-24**] 10:20 Provider: [**First Name11 (Name Pattern1) 198**] [**Last Name (NamePattern4) 199**], M.D. Where: [**Hospital6 29**] [**Hospital3 249**] Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2122-10-28**] 10:00

[ "285.9", "424.0", "414.01", "401.9", "311", "337.22", "287.5", "584.9", "410.71", "253.6", "428.0", "599.0", "423.9" ]

icd9cm

[ [ [] ] ]

[ "37.23", "99.05", "88.56", "88.53" ]

icd9pcs

[ [ [] ] ]

6939, 7024

3659, 5636

286, 312

7167, 7176

2313, 3636

7661, 8558

5833, 6916

7045, 7146

5662, 5810

7200, 7638

2020, 2294

236, 248

340, 1840

1862, 2005

70,944

157,798

17401

Discharge summary

report

Admission Date: [**2193-11-5**] Discharge Date: [**2193-11-12**] Date of Birth: [**2131-8-27**] Sex: F Service: MEDICINE Allergies: Penicillins / Aspirin / Heparin Agents Attending:[**Doctor First Name 2080**] Chief Complaint: Hypotension, lower abdominal cellulitis Major Surgical or Invasive Procedure: Multiple, serial debridements by general surgery of necrotic abdominal cellulitis PICC placement History of Present Illness: HISTORY OF PRESENT ILLNESS: 62 yo female with morbid obesity (BMI 67), hyperlipidemia, chronic kidney disease (baseline creatinine 1), and DM II who was transferred from [**Hospital3 7569**] (MD there was [**First Name8 (NamePattern2) **] [**Doctor Last Name **]) for further evaluation of black necrotic tissue on her abdomen and hypotension. . The pt presented to [**Hospital3 7569**] on [**2193-11-4**] due to increased abdominal pain and swelling, along with edema of the left breast. On presentation, she was found to have extensive abdominal wall erythema, with areas of necrosis and ulceration. She was also noted to be hypoglycemic to 64, for which she received [**12-21**] amp of D50. Blood and wound cultures were performed, and the patient was treated with IV vancomycin. That evening, the patient became hypotensive to the 80s, responding to fluid boluses and dopamine. Labs were notable for an increase in WBC from 8.3 to 21.7. The patient was seen by the surgical service, who recommended transfer to [**Hospital1 18**] for further management given need for extensive debridement. Vitals at the time of transfer were BP 116/38 96% on 2L (not on oxygen at home). . Of note, the patient was recently admitted to [**Hospital3 **] from [**2193-9-29**] to [**2193-10-9**] for urosepsis. She was treated with Levoquin and discharged on Augmentin. During that hospitalization the patient had a creatinine of 2.1 which returned to 1 prior to discharge. At the time of discharge her abd was notable for weeping abdominal wounds. At rehab, she developed c diff and was started on po vanco with no diarrhea since [**2193-11-3**]. . MEDICATIONS ON TRANSFER: silvadene cream to ulcerated area [**Hospital1 **] IV vancomycin 1 gm Q12H omeprazole 20 mg PO daily vancomycin 250 mg PO 4 times daily zosyn 3.375mg IV q6hrs insulin sliding scale . On arrival to the [**Hospital Unit Name 153**], the patient was complaining of mild lower abdominal pain. She was briefly weaned off of dopamine but dropped her blood pressure to the 80s, requiring dopamine to be restarted. IV vancomycin and piperacillin/tazobactam, PO vancomycin for C difficile were all continued. General surgery (and plastics) were consulted and performed serial debridements and subsequently signed off. Of note, IV vancomycin was changed to daptomycin due to thrombocytopenia (and all heparin products were stopped). Meropenem was changed to ceftazidime per wound culture sensitivities. The pt was weaned from the dopamine drip and remained hemodynamically stable for 24 hours prior to transfer to floor on evening of [**2193-11-8**]. The pt's renal function returned to her baseline. Past Medical History: Hyperlipidemia DM II Rheumatoid Arthritis Hypertension Social History: The pt lives with her sister, [**Name (NI) 1743**]. She has many siblings and no children. She quit smoking in [**2180**] and denies ethanol or drug abuse. Family History: Her brother died in his 30s from an MI. Her two sisters are diabetic. Physical Exam: VS: T=96.8, BP=140/62, HR=96 RR=20 O2=95%/4L GENERAL: Morbidly obese woman in NAD. NEURO: A & O x 4. Appropriate. CN II-XII intact. Strength 5/5 in upper extremities. Dorsiflexion/plantarflexion [**4-23**] bilaterally. Proximal lower extremity strength testing limited by edema. Sensation intact distally to light touch. HEENT: Normocephalic, atraumatic. No scleral icterus. Poor dentition. OP clear. CARDIAC: Regular rhythm, normal rate. Normal S1, S2. LUNGS: Quiet lungs sounds [**1-21**] body habitus. BREASTS: Edematous bilaterally, especially on left. ABDOMEN: Very obese, with peau-d'orange skin changes. Large area of erythema and warmth in left lower abdomen extending into intertrigous area under pannus, with areas of ulceration and skin necrosis. EXTREMITIES: Anasarca. Unable to palpate pulses [**1-21**] edema, but extremities are warm and well-perfused. SKIN: Ulceration of bilateral knees, right heel, and right elbow, with black eschar over ulcers. Cellulitis of left leg. Abdominal cellulitis as noted above. Sacral decubitus ulcer. Pertinent Results: [**2193-11-5**] 05:42PM GLUCOSE-117* UREA N-37* CREAT-1.2* SODIUM-136 POTASSIUM-5.0 CHLORIDE-107 TOTAL CO2-27 ANION GAP-7* [**2193-11-5**] 05:42PM CALCIUM-7.7* PHOSPHATE-3.3 MAGNESIUM-1.8 [**2193-11-5**] 05:42PM WBC-19.2* RBC-2.20* HGB-7.7* HCT-24.2* MCV-110* MCH-35.0* MCHC-31.9 RDW-18.1* [**2193-11-5**] 05:42PM NEUTS-78* BANDS-10* LYMPHS-8* MONOS-4 EOS-0 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 [**2193-11-5**] 05:42PM PLT SMR-VERY LOW PLT COUNT-71* [**2193-11-5**] 05:42PM PT-15.6* PTT-33.8 INR(PT)-1.4* . Studies ([**Hospital1 18**]): . CXR Portable AP [**2193-11-5**]: Limited radiograph. Patient rotated. Left lung difficult to evaluate. Right lung opacities more seen at lung bases, could be atelectasis at the lung base, cannot r/o pneumonia (overlap with mediastinal silhouette due to rotation of the patient). Heart silhouette apperas enlarged, but due to rotation has opverlap with breast tissue, and hard to evaluate. Overall, significantly limited radiograph. If concern, could be repeated. . Lower Extremity Ultrasound [**2193-11-5**]: Nondiagnostic limited study due to patient body habitus; unable to penetrate to see the veins. If continuos concern, CTV can be done (if clinically determined that patient can receive contrast, since patient has h/o chronic renal failure). . EKG [**2193-11-5**]: Sinus tachycardia at 100. Normal axis and intervals. Low QRS voltages. No ST changes. TWI in aVR, V1. . STUDIES ([**Hospital3 **]): . Echocardiogram [**2193-9-30**]: 1. Technically limited study. Left ventricular dilatation, preserved left ventricular function. Ejection fraction of 60%. 2. Mitral annular calcification with mild mitral regurgitation with left atrial enlargement. . Bilateral LE Ultrasound [**2193-10-5**]: Extremely limited study. Only the popliteal veins were visualized. No overt DVT is seen in the popliteal veins. . Abdominal U/S [**2193-11-9**]: FINDINGS: Grayscale and color ultrasound was performed and targeted to the extensive area of ulceration of the lower abdomen. There is extensive soft tissue edema. No focal drainable collections are identified. A prominent vessel is noted 2 cm below the skin surface. IMPRESSION: Extensive edema without focal collection identified. . Discharge Labs: [**2193-11-12**] 04:45AM BLOOD WBC-11.1* RBC-1.88* Hgb-6.2* Hct-21.0* MCV-112* MCH-32.9* MCHC-29.4* RDW-19.3* Plt Ct-110* [**2193-11-12**] 04:45AM BLOOD Glucose-108* UreaN-57* Creat-1.0 Na-140 K-4.8 Cl-109* HCO3-28 AnGap-8 [**2193-11-8**] 03:39AM BLOOD ALT-24 AST-22 LD(LDH)-191 AlkPhos-156* TotBili-0.4 [**2193-11-12**] 04:45AM BLOOD Calcium-7.9* Phos-4.1 Mg-2.3 [**2193-11-9**] 10:02AM BLOOD calTIBC-165* Ferritn-560* TRF-127* [**2193-11-9**] 11:17AM BLOOD Type-ART pO2-79* pCO2-69* pH-7.22* calTCO2-30 Base XS--1 [**2193-11-10**] 06:40AM BLOOD SEROTONIN RELEASE ANTIBODY-PND Brief Hospital Course: ASSESSMENT AND PLAN: 62 yo F obesity, HTN, RA presenting with sepsis from abdominal paniculitis and ulceration; lower extremity; thrombocytopenia/anemia, and CO2 retention. Hospital course is as follows: . 1. Sepsis/leukocytosis: The patient was transferred from [**Hospital 11373**] on dopamine and continued to require dopamine for about 24 hours. Pulmonary embolism was considered in the differential diagnosis given morbid obesity, immobility, and left lower extremity edema. However, lower extremity ultrasound was non-diagnostic secondary to the patient's body habitus, and the [**Hospital Unit Name 153**] team decided not to pursue CTA given the patient's risk of contrast nephropathy and the team's low suspicion for PE. During the second hospital day, the patient was weaned off of dopamine, and she did not require pressors after that. Blood, urine, and wound cultures were sent, and the patient's abdominal wound infection was treated as below. . 2. Panniculitis/Ulceration: The patient was seen by the plastic surgery service, who performed debridement at the bedside. She was also seen by general surgery, who signed off because the patient refused operative debridement under general anesthesia. The patient was initially treated with empirically with vancomycin/Zosyn, which was changed to daptomycin/meropenem on [**2193-11-7**] due to concern about possible vancomycin-induced thrombocytopenia. Wound cultures from [**Hospital3 **] grew pseudomonas, S. aureaus, coag-negative Staph, and two species of gram negative rods. The pseudomonas was sensitive to ceftazidime, so the patient's antibiotics were changed to vancomycin/ceftazidime on [**2193-11-8**]. ID/heme was consulted and was changed back to vanco/ceftaz given low concern for vanco induced thrombocytopenia. Her antibiotics were subsequently narrowed to ceftazidime alone. Would care followed closely, and Plastics surgery deferred any additional debridement. - patient will need aggressive [**Hospital1 **] wound care with chemical debridement over time, and plastic surgery eval going forward to consider more aggressive debridement - Continue ceftazidime 2g IV q8 for 14 days total (through [**2193-11-17**]) . 3. Thrombocytopenia: On admission, the patient had platelet count 71 (down from approximately 250 in 10/[**2192**]). A heparin-dependent antibody test was sent and was equivocal. The patient was initially treated with Lovenox, which was changed to fondaparinux on [**2193-11-6**]. Fondaparinux was discontinud on [**2193-11-7**]. Aside from heparin-induced thrombocytopenia, the differential diagnosis also included vancomycin-induced thrombocytopenia, and thrombocytopenia related to the patient's rheumatoid arthritis or her immunosuppressive medications. Oral vancomycin was continued, but IV vancomycin was stopped. Hematology was consulted. SRA was sent and smear reviewed. Her platelet count improved spontaneously to low 100s and was thought to be multifactorial by heme, not HIT. Fondaparinux was restarted for DVT prophylaxis and heparin products should be avoided until SRA returns - Will need TIW CBCs to monitor platelet. - follow up SRA from [**Hospital1 18**] - Will need to see [**Hospital1 18**] Hematology within 4 weeks . 4. Hypoglycemia/Diabetes Mellitis, type 2: The patient had an episodes of hypoglycemia (with blood glucose in 60s) at [**Hospital 11373**]. At [**Hospital1 18**], the patient's blood sugar was elevated to the 200s for her first two hospital days. She was put on glargine 80 units daily with humalog SS. On the floor, she was not taking good POs and was intermittently hypoglycemic to 60s, responsive to D5. Her glargine was stopped and her sliding scale decreased. - Will need QID fingersticks and humalog sliding scale. Would avoid standing insuling until taking good POs and has elevated blood sugars. Her metformin was held during admission. . 5. Clostridium difficile: Continued home PO vancomycin. The patient was diagnosed with C. diff just prior to admission. C. diff toxin was checked during this admission and was negative. She must complete 5 days of PO vanco after completing course of ceftazidime for her panniculitis. . 6. Rheumatoid arthritis: Was on methotrexate 7.5mg daily and cytotec 200mg QID as an outpatient, as well as weekly enbrel. These were held during admission in the setting of her infection. They will be held at discharge. . 7. Hypercarbia/Somnolence: On admission out of the [**Hospital Unit Name 153**], patient was noted to be somnolent but easily arousable with a nonfocal exam, worse in the mornings. ABG suggested respiratory acidosis (see results). Respiratory evaluated the patient. Her supplemental 02 was held with improvement in her somnolence. She likely retains CO2 when her resp drive is suppressed, confounded by likely obesity hypoventilation and OSA at night as her somnolence is worse in the morning. She was also given morphine for pain on [**11-11**] as well as seroquel for mild agitation. Additionally, she did not sleep well at night, leading to sleepiness during the daytime hourse. - Patient may be sleepy but arousable in the mornings, but should improve during the day. Please limit supplemental 02 as this suppresses her respiratory drive and can cause retention. Allow lower 02 sats. Please use her ear for 02 sat readings as her fingers are unreliable. - Please limit psychoactive medications - Consider evaluation for sleep apnea - Frequent stimulation, incentive spirometry . 8. Anemia of chronic disease/?underlying MDS: The patient's iron studies confirmed inflammation. Hematology also considered underlying bone marrow dysfunction base on review of her blood smear. Her Hct trended down in the setting of inflammation and phlebotomy. She was transfused 1 unit PRBCs on [**2193-11-10**] and again on [**2193-11-12**]. There was no evidence of bleeding or hemolysis. She will need to follow up with hematology closely. - TIW CBC to monitor Hct. Consider xfusion if <21. - Follow up with hematology at [**Hospital1 18**] within 1 month to evaluate for underlying bone marrow dysfunction . 9. Peripheral edema: Likely in the setting of IVF and dependent edema for immobility. - Started lasix 20mg daily to diurese and put out well to this. . 10. Skin breakdown: In addition to pannus ulcers, has skin breakdown over knees, flanks, and ankles. Aggressive wound care and turning will be required . 11: Social: Patient was found to scream out from time to time. She was not delirious but sad and in "pain all over." With social support this can be controlled. Would limit psychoactive medications as this may exacerbate this. . 12 Hypertension, benign: held her atenolol, HCTZ, lisinopril as her BP remained stable . 13. Hyperlipidemia: Held her lovastatin during admission . Contacts: Sister [**Name (NI) 6480**] [**Name (NI) 37063**] [**Telephone/Fax (1) 48654**], sister [**Name (NI) 1743**] [**Telephone/Fax (1) 48655**] . Has disussion with patient regarding goals of care. She was not desiring intubation, though she "just wanted to be kept alive." She was not able to articulate specifically what that meant, or what her goals for quaility of life were. This should be addressed going forward given her underlying comorbidities. Medications on Admission: home: atenolol 25mg daily HCTZ 25mg daily NPH 80mg [**Hospital1 **], HISS lisinopril 40mg daily lovastatin 40mg daily metformin 1g [**Hospital1 **] methotrexate 7.5mg daily cytotec 200mg QID Nabumetone 750mg daily Enbrel weekly . transfer: CefTAZidime 2 g IV Q12H MetRONIDAZOLE (FLagyl) 500 mg IV Q8H Daptomycin 1000 mg IV Q24H Vancomycin Oral Liquid 250 mg PO/NG Q6H Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol Discharge Medications: 1. Vancomycin 125 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours): continue 5 days after finishing ceftazidime. 2. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain, fever. 3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 4. Fondaparinux 2.5 mg/0.5 mL Syringe Sig: One (1) injection Subcutaneous DAILY (Daily). 5. Ceftazidime 2 gram Recon Soln Sig: One (1) Recon Soln Injection Q8H (every 8 hours): through [**2193-11-17**] for 14 day course. 6. Insulin Lispro 100 unit/mL Solution Sig: 1-10 units Subcutaneous ASDIR (AS DIRECTED): per protocol. 7. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) nebulizer Inhalation every six (6) hours as needed for shortness of breath or wheezing. Discharge Disposition: Extended Care Facility: [**Hospital6 1293**] - [**Location (un) 1294**] Discharge Diagnosis: Panniculitis, infected ulcers Sepsis Thrombocytopenia Anemia of chronic disease Chronic Kidney Disease Hypertension, benign Obesity Hypercarbia, retention Presumed obstructive sleep apnea Rheumatoid arthritis Hyperlipidemia Discharge Condition: Good Discharge Instructions: Patient was admitted with panniculitis and infected ulcers, requiring a brief MICU stay and intravenous antibiotics. She was also found to have anemia and thrombocytopenia, most likely from multifactorial causes and inflammation. She will need to complete a course of antibiotics for her infection, as well as aggressive wound care. She will also need to follow up with hematology and have her counts closely monitored. She should also be seen by plastic surgery/wound care going forward to monitor the progress of her ulceration . Take all medications as prescribed. Have patient return to the hospital with fevers, recurrence of wound infection, bleeding, or any other concerning symptoms Followup Instructions: PCP: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**0-0-**] in [**1-23**] weeks . Hematology at [**Hospital1 18**] within 4 weeks: ([**Telephone/Fax (1) 14703**] . Plastic Surgery clinic within 4 weeks: ([**Telephone/Fax (1) 2868**]

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Discharge summary

report

Admission Date: [**2132-11-20**] Discharge Date: [**2132-12-9**] Date of Birth: [**2051-9-27**] Sex: M Service: CARDIOTHORACIC Allergies: Lipitor Attending:[**First Name3 (LF) 922**] Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: [**2132-12-2**] LV Apico-Aortic Valved Conduit via Left Thoracotomy(16mm LV Apical Connector with a 18mm Porcine Valved Conduit) History of Present Illness: Mr. [**Known lastname 40134**] is an 81 year-old gentleman with an extensive history of coronary artery disease, s/p AMI at age 37, CABG in [**2115**] (LIMA-LAD, SVG-PDA, SVG-OM1) with redo in [**2121**] (occuded LIMA-LAD and SVG-PDA, RIMA-LAD,SVG-PDA, SVG-OM2). He had a [**2129**] catheterization for NSTEMI and underwent PCI of 90% lesion in the OM1 with a 3 x 8 mm Cypher DES. His RIMA-LAD, SVG-PDA and SVG-OM2 were all patent. History also significant for CHF with an an EF of 25% s/p cardiac resynchronization and biventricular pacemaker placement, hypertension and hyperlipidemia. At his baseline (a few months back), the patient was able to work in the yard for 10 minutes+ after which time he would become SOB. After resting for 10-15 minutes he would again be okay to work. Over the last few weeks, he has noticed SOB at rest. Some of these episodes are associated with "chest tightness". The tightness was across his chest with no radiation. He would occasionally have nausea with it but no diapheresis. Usually lasted a few minutes and would be relieved, at times, with burping or walking. He did not note any of the tightness with exertion. He notes that the pain is not like that of his MI, which was back pain and much more severe. Over the last week he has noticed that the symptoms are increasing in frequency (now occuring daily). On the day of admission, he awoke at 6am and felt SOB. This did not abate and given the duration of symptoms, he went to his PCP who then referred him to an OSH. His symptoms improved with intravenous Lasix and he was eventually transferred to the [**Hospital1 18**] for cardiac surgical evaluation. Past Medical History: Systolic Congestive Heart Failure Coronary Artery Disease - Prior CABG [**2115**], [**2121**] Anterior MI at age 37 Biventricular Pacemaker and Cardiac Resynchronization Hypertension Hyperlipidemia History of Abscess Excision Cholecystectomy History of Remote MVA Social History: Retired sales officer. Lives alone in [**Location (un) 11790**]. History of remote tobacco, and admits to occasional ETOH Family History: No premature coronary artery disease Physical Exam: Vitals: 98.2, 113/66, 73, 18, 93% on 3L General: Elderly male in no acute distress HEENT: Oropharynx benign, EOMI Neck: Supple, no JVD Lungs: CTA bilaterally Heart: Iregular rate and rhythm, 3/6 systolic murmur Abdomen: Soft, nontender with normoactive bowel sounds Ext: Warm, no edema. Well healed bilateral scars Pulses: 1+ distally Neuro: Alert and oriented, CN 2- 12 grossly intact, no focal deficits noted Pertinent Results: [**2132-11-20**] 11:05PM BLOOD WBC-7.8 RBC-3.90* Hgb-11.9*# Hct-35.5* MCV-91 MCH-30.4 MCHC-33.4 RDW-15.6* Plt Ct-212 [**2132-11-20**] 11:05PM BLOOD PT-17.3* PTT-39.2* INR(PT)-1.6* [**2132-11-20**] 11:05PM BLOOD Glucose-178* UreaN-25* Creat-1.4* Na-140 K-4.1 Cl-98 HCO3-31 AnGap-15 [**2132-11-20**] 11:05PM BLOOD CK-MB-NotDone cTropnT-0.02* [**2132-11-22**] 09:30AM BLOOD Triglyc-78 HDL-33 CHOL/HD-5.3 LDLcalc-125 LDLmeas-129 [**2132-11-21**] 06:00AM BLOOD TSH-2.2 [**2132-11-20**] 11:05PM BLOOD Digoxin-2.0 [**2132-11-21**] Echocardiogram: The left atrium is markedly dilated. The right atrium is moderately dilated. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity is moderately dilated. There is severe regional left ventricular systolic dysfunction with severe hypokinesis/akinesis of the inferolateral, lateral, anteroseptal and apical segments. There is hypokinesis of the remaining segments, with relative preservation of only the basal and mid-inferior segments and basal anterior segment (LVEF = 25%). No masses or thrombi are seen in the left ventricle. Right ventricular chamber size and free wall motion are normal. The ascending aorta is mildly dilated. The aortic arch is mildly dilated. There are three severely thickened aortic valve leaflets. There is severe aortic valve stenosis (area <0.8cm2). Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Moderate (2+) mitral regurgitation is seen. The left ventricular inflow pattern suggests a restrictive filling abnormality, with elevated left atrial pressure. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. [**2132-11-24**] Cardiac Catheterization: 1. Selective coronary angiography of this right dominant system demonstrates severe native vessel disease. The LMCA has a patent stent into the ramus. The pLAD is 100 occluded. The AV groove LCx is a small vessel- OM1 is 90% occluded and beyond OM1 there is a subtotal occlusion. OM2 fills via the patent SVG graft. The RCA is known occluded and is not engaged. 2. Arterial conduit angiography of the RIMA to LAD showed the graft to be widely patent. Of note, the rigth subclavian artery originates distal to the origin of the left subclavian artery. The RIMA graft travels in front of the heart, directly behind the sternum to anastomose with the LAD. 3. Bypass graft angiography shows that the SVG to PDA that was patent in [**2129**] is now proximally occluded. The SVG to OM2 remains patent and fills the OM2 distally. [**2132-11-25**] Chest CT Scan: 1. Widespread ground-glass opacities with upper lung distribution. Radiological pattern is consistent with respiratory bronchiolitis (in a smoker), hypersensitivity pneumonitis, or acute viral infection such as viral, less likely pulmonary hemorrhage. 2. Extensive atherosclerotic coronary and aortic calcifications. 3. Severe aortic valve calcifications consistent with known aortic stenosis. 4. Hypodense liver lesions, some of them too small to be precisely characterized. Evaluation with ultrasound is recommended . Status post cholecystectomy. 5. Bilateral left more than right pleural effusions. 6. Cardiomegaly. Possible left ventricular aneurysm [**2132-11-25**] Carotid Ultrasound: Minimal plaque with bilateral less than 40% carotid stenosis. [**2132-12-8**] WBC 9.3, HCT 29.9, PLT 229 [**2132-12-9**] INR 2.2 [**2132-12-8**] INR 2.7 [**2132-12-7**] INR 1.8 [**2132-12-6**] INR 1.3 [**2132-12-9**] Na 134, K 4.7, Cl 92, HCO3 36, BUN 29, Cr 1.0 [**2132-12-9**] Mg 3.1 Brief Hospital Course: Mr. [**Known lastname 40134**] was admitted to cardiology service. He was noted to be in atrial fibrillation and started on intravenous Heparin. Cardiac surgery was consulted and extensive preoperative evaluation was performed. An echocardiogram revealed substantial increase in aortic stenosis and pulmonary pressures, while left ventricular function and the severity of mitral regurgitation appeared similar in comparison to [**2129**] - see result section for additional details. Cardiac catheterization was performed which showed patent RIMA to LAD and patent vein graft to obtuse marginal. The vein graft to the PDA was occluded. (See result section for additional cath results.) Additional preoperative workup included chest CT scan and carotid non invasive studies - see result section. He was also cleared by the dental service after clinical and radiographic examinations showed no obvious infection. Given the location of the RIMA and extensive aortic calcifications, it was decided to proceed with LV apico-aortic valved conduit approach via thoracotmy rather than median sternotomy. His preoperative course was otherwise uneventful and he remained pain free on medical therapy. On [**12-2**], Dr. [**Last Name (STitle) 914**] performed an LV Apico-Aortic Valved Conduit operation via left thoractomy. Please see seperate dictated operative note for details. Following the operation, he was brought to the CVICU for invasive monitoring. Within 24 hours, he awoke neurologically intact and was extubated. He was initially maintained on Amiodarone for ventricular ectopy while Warfarin anticoagulation was initiated for atrial fibrillation. Due to persistent postop hypotension, it took several days to wean from inotropic support. Once his hemodynamics stablized, he eventually transferred to the SDU for further care and recovery. He remained in atrial fibrillation with improvement in ventricular ectopy. Amiodarone was eventually discontinued while beta blockade was advanced as tolerated. Warfarin was dosed for a goal INR between 2.0 - 2.5. Over several days, he continued to make clinical improvements with diuresis and made steady progress with physical therapy. By postperative day seven, he was medically cleared for discharge to rehab. At discharge, his BP was 96/50 with a HR of 71. His oxygen saturations were 95% on room air and the discharge chest x-ray showing a slight element of fluid overload. At discharge, he will continue to require diuresis. If there is improvement in blood pressure, an ACE inhibitor should be resumed given his congestive heart failure. Medications on Admission: Aspirin 325 qd, Lopressor 50 qam and 25 qpm, Lasix 40 qd, Fosinopril 20 qd, Digoxin 0.25 qd, Zetia 10 qd, Prilosec, Fish Oil, Xanax 0.25 qhs Discharge Medications: 1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Warfarin 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): goal INR 2-2.5 please check INR mon-wed-fri. 5. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 6. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two (2) Capsule, Sustained Release PO BID (2 times a day): twice a day for 1 week then decrease to daily . 7. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 9. Furosemide 20 mg Tablet Sig: One (1) Tablet PO twice a day: twice a day for 1 week then decrease to daily . Discharge Disposition: Extended Care Facility: Watch [**Doctor Last Name **] Manor Discharge Diagnosis: Aortic Stenosis - s/p LV Apico-Aortic Valved Conduit Systolic Congestive Heart Failure Coronary Artery Disease - Prior CABG [**2115**], [**2121**] Biventricular Pacemaker Hypertension Hyperlipidemia Atrial Fibrillation Discharge Condition: Good Discharge Instructions: 1)Please shower daily. No baths. Pat dry incisions, do not rub. 2)Avoid creams and lotions to surgical incisions. 3)Call cardiac surgeon if there is concern for wound infection. 4)No lifting more than 10 lbs for at least 10 weeks from surgical date. 5)No driving for at least one month 6)Warfarin should be adjusted for goal INR between 2.0 - 2.5. Please monitor INR every Monday, Wed, Friday. Please arrange Warfarin follow up with PCP or cardiologist prior to discharge from rehab. Followup Instructions: Dr. [**Last Name (STitle) 914**] in [**5-15**] weeks, call for appt Dr. [**Last Name (STitle) 24717**] in [**3-15**] weeks, call for appt Dr. [**Last Name (STitle) 120**] in [**3-15**] weeks, call for appt Completed by:[**2132-12-9**]

[ "272.4", "427.31", "458.29", "428.23", "V53.39", "401.9", "V45.82", "511.0", "414.01", "414.02", "424.1", "466.19", "423.1", "413.9" ]

icd9cm

[ [ [] ] ]

[ "35.21", "37.12", "37.22", "88.72", "35.93", "88.56", "39.61", "99.04", "99.05" ]

icd9pcs

[ [ [] ] ]

10430, 10492

6633, 9222

294, 425

10755, 10762

3034, 6610

11294, 11531

2550, 2588

9413, 10407

10513, 10734

9248, 9390

10786, 11271

2603, 3015

235, 256

453, 2106

2128, 2394

2410, 2534

29,760

166,173

33165

Discharge summary

report

Admission Date: [**2193-12-17**] Discharge Date: [**2193-12-27**] Date of Birth: [**2124-6-16**] Sex: F Service: OBSTETRICS/GYNECOLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 6743**] Chief Complaint: ovarian cancer Major Surgical or Invasive Procedure: Debulking surgery including colectomy with end ileostomy, cholecystectomy, R oopherectomy, placement of bilateral J-P drains, placement of GJ tube. History of Present Illness: Ms [**Known lastname 77072**] is a 69 year old woman with advanced ovarian cancer who underwent debulking surgery today. This ultimately involved a total colectomy with end ileostomy; R oopherectomy; placement of a G-J tube; and a cholecystectomy. The uterus and ovaries could not be removed because of tumor encasing the uterus, ovaries, and bladder; there was large omental caking; and thus, significant amounts of tumor had to be left in the abdomen. There were no major complications of the surgery, but given the extent of the surgery and the possibility of post-operative difficulties, the ob/gyn and general surgery services (both working on the case) agreed that she would be best cared for in an intensive care unit tonight. . Over the last six months, Ms [**Known lastname 77072**] has lost approximately 20 pounds, and has had a number of exacerbations of her anxiety, increased vegetative symptoms, and a significant fear of falling; she was admitted to the [**Hospital3 2568**] psychiatric unit from [**Date range (1) 77073**] for these symptoms. She was noted to have a distended abdomen; a CT revealed omental cake, adnexal masses, and massive ascites. A CA-125 level was 548. Colonoscopy revealed strictures, and a barium enema confirmed them; peritoneal cytology revealed malignant cells consistent with ovarian cancer. After consultation with a gynecological oncology specialist she elected to proceed with the surgery undertaken today. . Post-operatively she is somewhat groggy and does not want to open her eyes, and does not want to hear about her surgery. She is complaining of pain in the lower abdomen as well as her chronic lower back pain (for which she uses a fentanyl patch as an outpatient). She is also complaining of nausea. She denies any discomfort or pain other than these three problems. Specifically, she denies any difficulty with breathing or chest pain or dyspnea. . Past Medical History: Stage IIIC ovarian cancer, hypertension, depression, anxiety, chronic low back pain, osteoarthritis, IBS, anemia, glaucoma. Past surgical hx: D&C for spontaneous abortion, many years ago. Social History: Lives alone; has three children who accompanied her to her gyn onc visit earlier this month; is widowed. In the outpatient setting she denied any drug or alcohol use. Family History: Patient reports her mother had "liver cancer" in her 80s; no other history of malignancy. Physical Exam: (Post-operative exam, in [**Hospital Ward Name 332**] ICU) . VS: Temp: 98.6 BP: 111/59 HR: 79 RR: 14 O2sat: 100 GEN: lying still w eyes closed, non-toxic appearing, breathing without difficulty, in evident discomfort by facial expression HEENT: MMM, OP w slight blood at posterior aspect c/w intubation injury; refuses to open eyes NECK: no carotid bruits RESP: CTA b/l with good air movement throughout on anterior exam CV: RR, S1 and S2 wnl, no m/r/g ABD: drains and [**Hospital Ward Name 9341**] in place, dressed, draining. J-P drains draining copious serosanguinous fluid. Some tenderness to palpation; extensive palpation deferred given pain. EXT: no c/c/e, cool, good pulses SKIN: no rashes/no jaundice NEURO: AAO. [**3-7**]+/5 strength at grip, dorsi/plantarflexion, biceps; symmetrical. No sensory deficits to light touch appreciated at extremities. For cold glove test, feels cold sensation to approx T8 from below. Pertinent Results: [**2193-12-17**] 07:11PM WBC-17.6*# RBC-4.98 HGB-14.4# HCT-43.4 MCV-87 MCH-28.9 MCHC-33.2 RDW-14.4 [**2193-12-17**] 07:11PM PLT COUNT-326 [**2193-12-17**] 07:11PM GLUCOSE-160* UREA N-10 CREAT-0.5 SODIUM-144 POTASSIUM-4.4 CHLORIDE-110* TOTAL CO2-21* ANION GAP-17 [**2193-12-17**] 07:11PM CALCIUM-8.0* PHOSPHATE-4.7* MAGNESIUM-1.6 [**2193-12-17**] 05:07PM GLUCOSE-168* LACTATE-1.9 NA+-135 K+-4.3 CL--106 [**2193-12-17**] 05:07PM HGB-13.3 calcHCT-40 [**2193-12-17**] 05:07PM freeCa-1.03* [**2193-12-17**] 05:07PM TYPE-ART RATES-/10 TIDAL VOL-400 O2-33 O2 FLOW-0.5 PO2-134* PCO2-40 PH-7.38 TOTAL CO2-25 BASE XS-0 INTUBATED-INTUBATED VENT-CONTROLLED [**2193-12-26**] 05:59AM BLOOD WBC-5.7 RBC-2.83* Hgb-7.8* Hct-24.6* MCV-87 MCH-27.5 MCHC-31.6 RDW-15.3 Plt Ct-387 [**2193-12-18**] 02:46AM BLOOD Neuts-88.3* Bands-0 Lymphs-6.2* Monos-5.2 Eos-0.2 Baso-0.1 [**2193-12-20**] 04:23PM BLOOD PT-14.4* PTT-28.9 INR(PT)-1.3* [**2193-12-26**] 05:59AM BLOOD Glucose-154* UreaN-6 Creat-0.5 Na-140 K-4.4 Cl-105 HCO3-30 AnGap-9 [**2193-12-20**] 04:23PM BLOOD ALT-6 AST-13 AlkPhos-73 TotBili-0.3 [**2193-12-20**] 04:23PM BLOOD VitB12-509 Folate-6.7 [**2193-12-20**] 04:23PM BLOOD TSH-6.3* [**2193-12-21**] 05:23AM BLOOD Free T4-0.95 Brief Hospital Course: This is a 69 year old woman with advanced ovarian cancer with widespread abdominal involvement, who was admitted [**2193-12-7**] status post colectomy w end ileostomy, cholecystectomy, R oopherectomy, and debulking, with placement of a G-J tube, two [**Location (un) 1661**]-[**Location (un) 1662**] drains, a GJ tube. . # Intraoperative course: On [**2193-12-7**] the pt underwent exam under anesthesia, exploratory laparotomy, right salpingo-oophorectomy, and drainage of 4 liters ascites by Dr [**Last Name (STitle) 2028**]. This was followed by lysis of adhesions, abdominal colectomy, end ileostomy with Hartmann's pouch of rectum, gastrojejunostomy feeding tube, and open cholecystectomy by Dr [**First Name (STitle) 2819**]. The surgery was uncomplicated. Estimated blood loss was 800 cc. She developed hypotension intraoperatively and was transfused 2 units of packed RBCs. Intraoperative findings were significant for studding of all peritoneal surfaces, a solid cake of tumor from the top of the bladder back to the sacral promontory with indistinct tissue plains, tumor infiltration into retroperitoneal spaces, tumor compression of ileocecal portion of the bowel, complete replacement of the infracolic omentum with 15 cm tumor, tumor extension along the infragastric omentum and lesser sac, studding of diaphragmatic surfaces bilaterally. Upon completion of surgery, the colon had been removed to the level of the sacral promontory, tumor remained within the pelvis, and approximatedly 70% of tumor was removed. Please see dictated operative reports for full details. . #. Cardiovascular: Pt developed fluid responsive hypotension on POD#0, due to post-operative fluid shifts and medication effects of the epidural. Blood pressure rose to normal levels within the ICU admission; fluid boluses were used to maintain pressure and hydration during the post-operative course. As pt's blood pressure reached high normal, her outpatient medication regimen of amlodipine and lisinopril were restarted. Her blood pressure remained stable within normal limits for the remainder of the hospitalization. . #. GU: The pt had borderline urine output on POD#0 that resolved with IV fluid hydration. Her urine output remained adequate for the duration of hospitalization. Her foley was discontinued on POD#6. She voided without difficulty during the day, but experienced urinary incontinence thoughout that night. This was thought to be a combination of timely ambulation and discontinuation of her home imipramine per psych recommendations. UA and Ucx were neg for UTI. Incontinence resolved. . #. Heme: The pt received 2 units of packed RBCs intraoperatively. Hematocrit fluxes were most consistent with fluid shifts; she did not appear to have major post-operative blood loss. She remained asymptomatic from her anemia for the duration of her hospitalization and her Hct was stable 22-24. . #. Neuro: Post-operative pain was initially managed with an epidural, but the epidural fell out and a fentanyl PCA was started for control of pain. She was transitioned to dilaudid pca, then dilaudid po with adequate pain control. Fentanyl Patch 50 mcg/hr TP Q72H was continued throughout hospitalization. . # GI. Continued zofran and prochlorperazine initially; however, discontinued the latter with delirium (below). Ativan discontinued per psych recs, and prn zyprexa added for nausea. The stoma nurse [**First Name (Titles) 77074**] [**Last Name (Titles) 9341**] teaching as in inpt and will continue to follow as an outpt. . # Infectious disease. Surgery recommended 4 days ceftazidime and flagyl for ppx against intrabdominal infection. Pt had 2 isolated low grade fevers. Work ups were negative for infection. Pt was not restarted on further antibiotics. These temperatures were attributed to atelectasis and insentive spirometry and ambulation were encouraged. . # Depression/anxiety. During MICU course the patient had some delirium and confusion. The psychiatry service was consulted. Per their recs, we obtained MRI head, which was read as no metastatic disease; TSH, folate, B12; and discontinued her ativan, imipramine and prochlorperazine, while adding olanzapine for nausea and anxiety. We continued her home mirtazapine and sertraline. Confusion resolved and pt was restarted on home ativan dose without recurrance of symptoms. Pt will need outpt psychiatry follow up. . # HEENT. Continue home timolol for glaucoma. . # FEN. Tube feeds through the GJ tube were started on [**12-20**] and advanced to 60cc/hr for 10 hrs a day. Pt was tolerating solids po at the time of discharge. However, calorie counts remained inadequate and pt was discharged with tube feeds. Electrolytes were checked daily and repleted prn. . #. Ovarian Ca, s/p debulking. Pt will follow up as outpt with Dr [**Last Name (STitle) 2244**] for discussion of chemotherapeutic options. . # PPX. Pneumoboots. Heparin SC. PPI . # CODE. DNI/DNR . # COMMUNICATION. With patient. Medications on Admission: Lorazepam 0.5 mg [**Hospital1 **] Colace 100 mg [**Hospital1 **] Fentanyl patch 50 mcg/hr q72 hrs Imipramine 50 mg nightly Lisinopril 30 mg q AM Amlodipine 5 mg q AM Pantoprazole 40 mg daily Mirtazapine 15 mg nightly Timolol (opthalmic) 0.25% one drop each eye once daily Sertraline 100 mg Discharge Medications: 1. Cyanocobalamin 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 2. Sertraline 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 3. Timolol Maleate 0.25 % Drops Sig: One (1) Drop Ophthalmic DAILY (Daily). Disp:*5 mL* Refills:*2* 4. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). Disp:*30 Tablet(s)* Refills:*2* 5. Fentanyl 50 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr Transdermal Q72H (every 72 hours). Disp:*10 Patch 72 hr(s)* Refills:*2* 6. Lisinopril 10 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* 7. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day). Disp:*120 Tablet, Chewable(s)* Refills:*2* 8. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3 hours) as needed for pain. Disp:*90 Tablet(s)* Refills:*0* 9. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID PRN () as needed for anxiety. Disp:*60 Tablet(s)* Refills:*0* 10. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Extended Care Facility: [**Hospital1 6930**] Skilled Nursing and Rehabilitation Discharge Diagnosis: advanced ovarian cancer depression anxiety glaucoma Discharge Condition: stable Discharge Instructions: Please call your doctor for increased abdominal pain, fevers, chills, chest pain, shortness of breath, leg pain/swelling, any concerns. No heavy lifting x 6 wks. Followup Instructions: Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 7614**] Date/Time:[**2194-1-6**] 11:00 Please call Dr [**First Name (STitle) 2819**] at ([**Telephone/Fax (1) 6347**] to schedule a follow up appointment for your [**Telephone/Fax (1) 9341**], GJ tube and tube feeds. Please call ([**Telephone/Fax (1) 62850**] to set up outpt follow up or your stoma. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 6753**] Completed by:[**2193-12-27**]

[ "183.0", "401.9", "789.51", "197.8", "197.4", "198.82", "293.0", "198.89", "458.29", "198.1", "518.0", "197.5", "560.9", "276.50", "300.4", "574.10", "197.6" ]

icd9cm

[ [ [] ] ]

[ "45.8", "44.39", "99.04", "65.49", "51.22", "96.6", "46.23", "38.93" ]

icd9pcs

[ [ [] ] ]

11607, 11689

5147, 10134

345, 494

11785, 11794

3894, 5124

12005, 12569

2840, 2931

10475, 11584

11710, 11764

10160, 10452

11818, 11982

2946, 3875

291, 307

522, 2429

2451, 2640

2656, 2824

43,501

139,163

45112

Discharge summary

report

Admission Date: [**2129-7-28**] Discharge Date: [**2129-8-2**] Service: MEDICINE Allergies: [**Doctor First Name **] Attending:[**First Name3 (LF) 1943**] Chief Complaint: Hypoxia Major Surgical or Invasive Procedure: None History of Present Illness: The patient is an 84 y.o. F with h/o HTN, TIA, dementia, vitamin B12 deficiency recently discharged from [**Hospital1 18**] where she was diagnosed wth a massive PE with HD instability requiring CCU stay. Echo demonstrated RV dilatation and R heart overload. Treated with IV heparin-> lovenox -> coumadin. She now presents with hypoxia from her NH. CXR in ED demonstrated CHF. Given lasix 40 mg IV with improvement in symptoms. She is admitted for a CHF exacerbation. Past Medical History: (per nursing facility records and OMR): HTN TIA Dementia Hypothyroidism, hx [**Doctor Last Name 933**] dz, s/p RAI therapy Anemia Urge Incontinence Osteopenia Vitamin B12 Deficiency Symptomatic Bradycardia h/o asthma/allergic rhinitis/chronic bronchitis Social History: Patient currently resides at [**First Name4 (NamePattern1) 3504**] [**Last Name (NamePattern1) **] Nursing center ([**Telephone/Fax (1) 6014**]) in [**Location (un) 538**] after being hospitalized at [**Hospital1 18**] for burns she sustained on her legs 2/[**2127**]. At that time she was found to be living in sub-optimal conditions with her daughter in a run-down house which was poorly insulated therefore needing a lot of space heaters that led to pts burns. Pt was also appointed a healthcare proxy, [**Name (NI) **] ([**Telephone/Fax (1) 96422**]). [**Name2 (NI) **] current tobacco, alcohol, or IVDA. (Per OMR) Family History: Per daughter: Brother with [**Name2 (NI) 499**] cancer in his 60s or 70s. Sister with breast cancer in her 70s. Another sister with thyroid cancer, ?kidney/pancreas mass. Per OMR: Her mother "dropped dead" in her 40s/50s in front of her (sudden death). Her sister "dropped dead" at age 23 in front of her (sudden death). Her father died in his 50s of unknown cause, and had a history of arthritis. She has 11 siblings who have died, none suddenly or from known cardiac causes. Physical Exam: VS: T = 99.6 GENERAL: Thin elderly female with contracted upper extremities Nourishment: at risk Grooming: Fair Mentation: Drowsy, opens eyes very briefly, repeatedly asks us to leave her alone Eyes:NC/AT, could not asses pupils since pt refused to really open her eyes, EOMI without nystagmus, no scleral icterus noted Ears/Nose/Mouth/Throat:- could not assess, pt refused to open her mouth Neck: supple, Respiratory: Decreased BS througout with poor inspiratory effort Cardiovascular: RRR, nl. S1S2, no M/R/G noted Gastrointestinal: soft, mildly distended abdomen but non-tender, normoactive bowel sounds, no masses or organomegaly noted. Genitourinary: deferred Rectal: Vault empty of stool Skin: Well healing venous ulcer on RLE. No pressure ulcer Extremities: No C/C/E bilaterally, 2+ radial, 1 + DP pulses b/l. Neurologic: -mental status: Alert, oriented x 1. [**Location (un) 669**]. Unable to answer any other questions. Not cooperative with care and refusing to obey simple commands. -cranial nerves: II-XII intact- no obvious facial droop. -motor: contracted upper extremities. Would not relax them. Unable to assess strength. Appears to move all extremities appropriately. No foley catheter/tracheostomy/PEG/ventilator support/chest tube/colostomy Psychiatric: Refusing care. Pertinent Results: Admission CXR ([**2129-7-28**]): Bilateral pleural effusions with cardiomegaly. There is hazy indistinctness of the pulmonary vasculature likely due to diffuse mild edema. Early developing pneumonia in the right lung base is difficult to entirely exclude. Chest CT ([**2129-7-29**]): No signs of pulmonary infarction. New loculated right pleural effusion and adjacent atelectasis. Near-complete resolution of lingular consolidation. Hypodense area in the superior pole of the left kidney cannot be further evaluated. If evaluation is required, ultrasound of the abdomen can be obtained. Large simple cyst of the superior pole of right kidney. Unchanged severe pulmonary arterial hypertension. ECHO ([**2129-8-2**]): Mild symmetric LVH with normal cavity size. Overall LV systolic function is normal (LVEF>55%). RV cavity is markedly dilated with moderate global free wall hypokinesis. Abnormal septal motion/position consistent with RV pressure/volume overload. The aortic valve leaflets (3) are mildly thickened but AS is not present. Mild (1+) AR is seen. The mitral valve leaflets are mildly thickened. Mild (1+) MR is seen. Moderate [2+] TR is seen. There is moderate PA artery systolic hypertension. Significant pulmonic regurgitation is seen. The main PA is dilated. There is a small pericardial effusion. The effusion appears circumferential. Compared with the prior study (images reviewed) of [**2129-7-19**], estimated PA pressures are higher. The severity of TR has increased. The other previously described abnormalities are still present. Brief Hospital Course: 84-year old female recently discharged from the [**Hospital1 18**] for hypoxia and hypotension [**12-27**] large main pulmonary artery PE on Coumadin presenting with hypoxia. 1. Hypoxia [**12-27**] Acute CHF (combination of systolic and diastolic): The patient presented with hypoxia with O2 sats in the 80s likely from an exacerbation of CHF. Gentle diuresis improved her O2 sats to the 90s on room air. The patient did have a brief stay in the ICU. Antibiotics were initially started for empiric treatment of pneumonia, but discontinued [**12-27**] low likelihood of having an infection given good clinical condition, absence of fever, and no leukocytosis. Patient's euvolemic weight in the hospital is 70.6 kg (155 lbs.) 2. UTI: Patient denied dysuria. Equivocal UA on [**7-29**] with increased WBC's on [**7-30**], but negative ucx. Treated with Cipro for total of 3 days. She ramains asymptomtic. She is incontinent of urine, but has known baseline urge incontinence. 3. Dementia/Delirium: Chronic dementia. The patient was at baseline with regard to dementia at the time of discharge. She is at baseline only oriented to self. 4. Prior PE: The patient is on anti-coagulation for prior massive pulmonary artery pulmonary embolism. Coumadin dose was titrated with goal INR between 2 and 3. 5. Hypothyroidism: Stable. Continued home levothyroxine. 6. Hypercholesterolemia: Stable. Continued home zocor. 7. Vitamin B12 Deficiency: Stable. Continued home supplementation. 8. Code Status: A family meeting was held with [**Doctor First Name **], the patient's daughter, and the legal [**Name (NI) **] [**Name (NI) **] [**Name (NI) 96423**], along with the medical and the palliative care team. The recent decline of the patient along with her multiple medical problems with anticipation of worsening prognosis over time was discussed. A plan to alter diuretic doses in case of wt gain or breathing difficulties was discussed in order to prevent re-hospitalization. The poor prognosis of Mr [**Name13 (STitle) 19862**] in a code setting was discussed. Given this information the family felt strongly that the patient remain full code. Medications on Admission: Mechanical soft diet Colace 100 mg po bid Lasix 20 mg po qd Tylenol 325 mg po qd Coumadin 2.5 mg po qd MOM 30 cc Dulcolax Fleets Senna Zocor 40 mg po qd Levothyroxine 125 mcg qd ASA 81 mg po qd Vitamin B12 500 mcg qd Discharge Medications: 1. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day. 2. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for PAIN. 4. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM. 5. Milk of Magnesia 400 mg/5 mL Suspension Sig: Thirty (30) ml PO once a day as needed for constipation. 6. Dulcolax 5 mg Tablet, Delayed Release (E.C.) Sig: [**11-26**] Tablet, Delayed Release (E.C.)s PO at bedtime as needed for constipation. 7. Fleet Laxative 5 mg Tablet, Delayed Release (E.C.) Sig: [**11-26**] Tablet, Delayed Release (E.C.)s PO once a day as needed for constipation. 8. Senna 8.6 mg Capsule Sig: One (1) Capsule PO twice a day as needed for constipation. 9. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 12. Cyanocobalamin 500 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Disposition: Extended Care Facility: [**First Name4 (NamePattern1) 3504**] [**Last Name (NamePattern1) **] Rehabilitation & Nursing Center - [**Location (un) 538**] Discharge Diagnosis: Primary Diagnoses: Acute systolic right heart failure Pulmonary Embolism Urinary tract infection Secondary diagnoses: Hypertension Dementia Hypothyroidism due to [**Doctor Last Name **] disease s/p RAI Urinary urge incontinence Bradycardia Anemia Vitamin b12 deficiency Discharge Condition: Stable. Discharge Instructions: You were admitted to the hospital for having blood in your urine and low blood oxygen levels. The blood in your urine was likely caused by an infection which was treated with antibiotics. Your low oxygen levels were caused by heart failure and fluid around your lungs which was seen on chest x-ray and chest CT. On admission, it seemed possible that you had an infection so you were given IV antibiotics until infection was ruled out. You were treated with lasix, a diuretic, to removed the fluid from around your lungs. You responded well to the treatment with improvement in your blood's oxygen level. You had an echocardiogram which showed worsening of your heart function. You will need to follow-up with your physician at your nursing home regarding titration of your diuretic. You should also be weighed every morning, and call you doctor if your weight increases by more than 3 pounds. You should adhere to 2 gm sodium diet. ------- The following changes were made to your medications: Your lasix dose was increased from 20 mg by mouth daily to 40 mg daily ------- You should seek medical attention at your facility if you experience any of the following symptoms: increased confusion, fevers, shortness of breath, chest pain, increased swelling in your legs, blood in your urine or burning upon urination, light-headedness to the point of feeling like you may pass out. ------------- Please check daily weights. Patient's euvolemic weight in the hospital is 70.6 kg (155 lbs.). If her weight increases by 2 pounds, please give a second 40 mg dose of lasix that evening and continue 40 mg of lasix twice daily by mouth until she returns to her goal weight of 155 lbs. If the patient becomes short of breath or drop her oxygen saturation, please give a dose of 40 mg of lasix by mouth and monitor for improvement. As high doses of lasix can drop her blood pressure, please monitor it closely. Followup Instructions: PCP: [**Name Initial (NameIs) 2169**]: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 94291**], M.D. Date/Time:[**2129-8-30**] 12:20 Completed by:[**2129-8-2**]

[ "272.0", "415.19", "788.33", "293.0", "599.70", "427.89", "294.8", "428.43", "428.0", "285.9", "599.0", "266.2", "244.9" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

8572, 8726

5065, 7223

239, 246

9040, 9050

3481, 5042

11010, 11190

1675, 2155

7490, 8549

8747, 8845

7249, 7467

9074, 10987

3184, 3462

2170, 3004

8866, 9019

192, 201

274, 745

3019, 3167

767, 1022

1038, 1659

64,232

130,639

32996

Discharge summary

report

Admission Date: [**2190-3-27**] Discharge Date: [**2190-3-30**] Date of Birth: [**2158-8-6**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 545**] Chief Complaint: dyspnea Major Surgical or Invasive Procedure: None History of Present Illness: 31yM 3 days ago presented to [**Hospital1 18**] [**Location (un) 620**] for planned pilonidal cyst excision. By report, pt difficult intubation, blood noted in ETT at the time of intubation. Procedure aborted, pt kept intubated in ICU overnight, underwent bronch which did not show abnormalities. Extubated the next day, discharged home. Since then, patient with persistent throat pain as well as progressive SOB. No fevers. No voice change. Went to BIN ED, imaging per report in the ED c/w R pneumonia. Pat hypoxic to 92%, was given CTX, LEVO, and transferred to [**Hospital1 **] given concern for airway obstruction. In [**Hospital1 **] ED, seen by ENT, underwent scope that showed erythema and very mild edema likely consistent with his h/o traumatic intubation. No lacerations or focal injuries to the glottis. Airway widely patent with no signs of impending upper airway obstruction. Labs notable for WBC 15K, lactate 1.9, nl Chem 7 and coags, CK 262 w/ MB 4, TnT 0.05. UA was negative. Patient underwent CTA that per prelim report was negative for PE, but showed b/l lower lobe patchy opacities, c/w aspiration. Flagyl was added. Given the patient's low O2 Sats, he was transferred to ICU for monitoring. Of note, finished 10-day [**Last Name (un) 10128**] of amoxicillin, bactrim, and flagyl for buttock abscess drainage starting [**2190-3-10**]. ROS: +SOB, sore throat, dysphagia, myalgias. Past Medical History: Asthma Obesity Probably OSA (being evaluated) NKDA Social History: currently not working. He has a 14 pack-year smoking history. Family History: (+) diabetes and heart disease. Physical Exam: VS 97.4, 109, 137/89, 20, 97%NC Gen:morbidly obese gentleman, mild tachypnea and increased WOB HEENT: no stridor , no facial swelling, slightly dry MM, PERRL, OP clear CV: tachy, RR, no murmurs Chest: few crackles at bases, some wheezing, overall good air movement Abd: very obese, S, NT, +BS Ext: 3+ edema b/l Neuro: AOx3, no focal deficits Skin: warm, no rashes Back: midline over sacrum ca. 1cm incision site w/o drainage, no erythema or fluctuance Pertinent Results: ABG at BIN after extubation on RA: 7.43/41/56 ECG: SR, tachy, no acute ST-TW changes Imaging: CTA [**2190-3-27**]: 1. No central pulmonary embolism. 2. Bilateral lower lobe patchy opacities, which are most consistent with aspiration. . Admit labs: ----------- [**2190-3-27**] 12:51AM WBC-15.0* RBC-4.26* HGB-12.6* HCT-36.4* MCV-85 MCH-29.6 MCHC-34.6 RDW-12.6 [**2190-3-27**] 12:51AM NEUTS-75.4* LYMPHS-18.6 MONOS-4.2 EOS-1.2 BASOS-0.5 [**2190-3-27**] 12:51AM PT-11.5 PTT-21.3* INR(PT)-1.0 [**2190-3-27**] 12:51AM GLUCOSE-146* UREA N-18 CREAT-0.8 SODIUM-143 POTASSIUM-3.5 CHLORIDE-104 TOTAL CO2-30 ANION GAP-13 [**2190-3-27**] 12:51AM CK(CPK)-262* [**2190-3-27**] 12:51AM cTropnT-0.05* [**2190-3-27**] 03:40AM URINE BLOOD-MOD NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [**2190-3-27**] 03:40AM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.015 [**2190-3-27**] 03:40AM URINE RBC-[**4-14**]* WBC-0-2 BACTERIA-OCC YEAST-NONE EPI-0-2 . Other Labs: ----------- [**2190-3-27**] 05:10PM TSH-0.48 [**2190-3-27**] 05:10PM CK-MB-3 cTropnT-0.03* [**2190-3-27**] 05:10PM CK(CPK)-115 [**2190-3-30**] 06:30AM BLOOD WBC-11.0 RBC-4.25* Hgb-12.6* Hct-37.5* MCV-88 MCH-29.7 MCHC-33.6 RDW-12.0 Plt Ct-344 [**2190-3-29**] 05:21PM BLOOD %HbA1c-5.9 [**2190-3-29**] 07:15AM BLOOD Triglyc-295* HDL-34 CHOL/HD-5.5 LDLcalc-95 [**2190-3-27**] 6:07 am Influenza A/B by DFA Source: Nasopharyngeal aspirate. **FINAL REPORT [**2190-3-27**]** DIRECT INFLUENZA A ANTIGEN TEST (Final [**2190-3-27**]): Negative for Influenza A viral antigen. DIRECT INFLUENZA B ANTIGEN TEST (Final [**2190-3-27**]): NEGATIVE FOR INFLUENZA B VIRAL ANTIGEN. . Other Studies: -------------- TTE ([**3-30**]): The left atrium is mildly dilated. Left ventricular wall thicknesses and cavity size are normal. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Overall left ventricular systolic function is low normal (LVEF 50-55%). The number of aortic valve leaflets cannot be determined. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are structurally normal. Trivial mitral regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Suboptimal image quality. At least moderate pulmonary hypertension. Low normal left ventricular systolic function. Right ventricle not well visualized. Brief Hospital Course: 31yo obese man with h/o asthma admitted with respiratory distress and possible aspiration pneumonia. # Respiratory distress/Pneumonia, possibly aspiration/asthma/likely OSA: Respiratory distress multifactorial in setting of underlying asthma, likely OSA, and restrictive lung disease from obesity with superimposed aspiration pneumonia. continued ceftriaxone (day 1 = [**3-26**]), which was changed to Cefpodoxime on discharge. He will complete a 10-day course of this. Changed levo to azithromycin (day 1 = [**3-27**]) and he will complete a 5-day course of this. Treated asthma exacerbation with PO steroids for five days total. Administered albuterol and atrovent nebulizers. Initiated BiPAP for patient, which seemed to improve his overall energy level. Per ENT, provided pt with humidified air and gave PPI TID with meals to protect larynx from reflux. Sent a DFA for flu, which was negative. Pt has an outpatient sleep study for OSA in order to obtain BiPAP at home. # Elevated cardiac enzymes/Lymphedema: Symptoms of dyspnea could be from acute cardiac ischemia. Alternatively, he could have had subclinical cardiac ischemia that has resulted in poor cardiac function, thus developing LE edema over the last 2 months. EKG shows sinus tachycardia without ischemic changes. Trended cardiac enzymes which were decreased with flat CK MB. Continued ASA. A TTE was as above, which was notable for elevated PA pressures, which could be c/w an undiagnosed OSA. The EF was 50-55%. # Tachycardia: Per patient??????s fianc??????, he is tachycardic at baseline. TSH was normal. patient was given IV fluids with marginal repsonse. Prior to discharge HR was in 90s. # Pilonidal cyst: deferred excision given acute illness. He will follow up for a local excision. Medications on Admission: Albuterol Discharge Medications: 1. Cefpodoxime 200 mg Tablet Sig: One (1) Tablet PO twice a day for 6 days. Disp:*12 Tablet(s)* Refills:*0* 2. Azithromycin 250 mg Tablet Sig: Two (2) Tablet PO Q24H (every 24 hours) for 1 days. Disp:*2 Tablet(s)* Refills:*0* 3. Prednisone 20 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily) for 1 days. Disp:*3 Tablet(s)* Refills:*0* 4. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) Inhalation four times a day as needed for shortness of breath or wheezing. Disp:*1 MDI* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Pneumonia, likely aspiration Obstructive Sleep Apnea (likely) Pulmonary Hypertension Elevated cardiac enzymes Pilonidal cyst Asthma, acute on chronic Hypoxemic respiratory failure Discharge Condition: Afebrile, vital signs stable, ambulating without difficulty. Discharge Instructions: You will need to complete your course of antibiotics. You will need to take cefpodoxime for 6 more days (10-day total course) and azithromycin for one more day (5 day total course). You will need to take prednisone for one more day (complete 5-day course). You can use an albuterol inhaler as needed. . You will need to have your outpatient sleep study as schedule so that you can be started on the BiPAP machine. While in the hospital, your settings were 12 IPAP/8 EPAP with 2L oxygen. . Call your doctor or return to the emergency room if you should have shortness of breath or chest pain. Followup Instructions: Primary Care: [**First Name4 (NamePattern1) 488**] [**Last Name (NamePattern1) 6401**], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2190-3-31**] 1:30 Surgery: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3000**], MD Phone:[**Telephone/Fax (1) 2998**] Date/Time:[**2190-4-2**] 11:15

[ "E879.8", "327.23", "493.92", "685.1", "997.3", "278.01", "518.81", "416.0", "507.0" ]

icd9cm

[ [ [] ] ]

[ "31.42" ]

icd9pcs

[ [ [] ] ]

7345, 7351

5008, 6773

321, 327

7574, 7636

2450, 3463

8280, 8590

1930, 1963

6833, 7322

7372, 7553

6799, 6810

7660, 8257

1978, 2431

274, 283

355, 1759

1781, 1834

1850, 1914

3475, 4985

5,692

193,147

54072

Discharge summary

report

Admission Date: [**2147-12-15**] Discharge Date: [**2147-12-27**] Date of Birth: [**2099-9-1**] Sex: M Service: MEDICINE Allergies: Nafcillin / Clindamycin Attending:[**Doctor First Name 1402**] Chief Complaint: ICD shock Major Surgical or Invasive Procedure: Internal and Epicardial Ablation History of Present Illness: 48yo male with a history of arrhythmogenic right ventricular dysplasia s/p multiple ICD [**Hospital 110840**] transferred from NH for managment of sustained VT despite multiple ICD discharges. Pt was in his usual state of health until Sunday while walkingand acrrying a 25lb load up [**Doctor Last Name **] went into VT and was shocked 5 times. He transmitted his event to Ep who felt he had had an appropriate ICD discharge to exertional VT. This evening he was hunting and was startled by a moose when he again went into VT. He was shocked three times and had his wife come and bring the magnet to turn of his ICD. His VT persisted and he went to [**Location (un) 59322**] [**Hospital **] Hospital in [**Location (un) **] for treatment. While there he was loaded with amiodarone 150mg over 10 min and his VT persisted and received 2g of Magnesium. He was shocked twice by ED personell and eventually cardioverted. He was transferred to [**Hospital1 18**] via ambulance on an Amiodarone drip. . He denies any signs or symptoms of ischemia or other illness in the days to weeks leading up to these events. He did experience marked SOB and mild abdominal pain during his episode however does not endorse any black or bloody stools or any chest pain. Past Medical History: 1. CARDIAC RISK FACTORS: 2. CARDIAC HISTORY: -CABG: -PERCUTANEOUS CORONARY INTERVENTIONS: -PACING/ICD: Right ventricular ICD 3. OTHER PAST MEDICAL HISTORY: 1. Arrhythmogenic right ventricular cardiomyopathy. 2. Exertional syncope at the age of 16, treated chronically with quinidine. 3. Inducible VT by EP study on [**2135-5-10**]. 4. Dual chamber ICD implant (left pectoral) on [**2135-5-11**], with a pacesetter atrial lead and a CPI ventricular lead. 5. New right-sided ICD in [**2139**], at an outside hospital following lead fracture. 6. Endocarditis involving the right-sided ICD in [**2143-11-3**]. 7. Hemi-sternotomy and lead extraction on [**2143-11-6**]. 8. Implant of a [**Company 1543**] 6949 RV lead on [**2144-1-23**], following venoplasty of an occluded right axillary subclavian vein. 9. Right ventricular 6949 lead extraction on [**2145-8-2**], due to high impedance and lead recall with implant of a St. [**First Name5 (NamePattern1) 923**] [**Last Name (NamePattern1) 110841**] right ventricular dual coil defibrillation lead following right subclavian venoplasty. 10. Subclavian stenosis bilaterally with positional SVC syndrome. Social History: Works as a real estate [**Doctor Last Name 360**]. He is married with 2 children from a previous marriage, they have several pets including a dog and cats. Of note he hunts deer and wild [**Country 1073**], and guts his own game. He last did this when he was feeling well in [**6-8**] when he hunted [**Country 1073**]. . Family History: The Family Medical History is notable for his mother who is 72 and is in good health. His father died of esophageal cancer at the age of 58. He has four siblings, who are alive and in good health. No history of cardiac disorders in the family Physical Exam: VS: T=96.4...BP= 90/60, HR 60s...O2 sat= 98% RA GENERAL: WDWN [**Male First Name (un) 4746**] in NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple CARDIAC: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. Pacer pocket is without erythema or warmth. LUNGS: CTA BL ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. EXTREMITIES: No c/c/e. No femoral bruits. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: Radial 2+ DP 2+ Left: Radial 2+ DP 2+ Pertinent Results: Echo [**2147-12-19**]: The left atrium is dilated. Left ventricular wall thicknesses and cavity size are normal. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Overall left ventricular systolic function is normal (LVEF>55%). There is no ventricular septal defect. The right ventricular cavity is mildly dilated The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are structurally normal. An eccentric, posteriorly directed jet of Mild to moderate ([**2-4**]+) 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. Compared with the prior study (images reviewed) of [**2143-10-18**], there does not appear to be a mass on the RA/RV wire (cannot exclude). LV systolic function appears normal on the current study. The right ventricle continues to appear dilated and depressed. Mild to moderate posteriorly directed mitral regurgitation is seen (increased since prior). Trace aortic regurgitation is present on the current study. . Echo [**2147-12-26**]: There is a small pericardial effusion around the distal right ventricle. There are no echocardiographic signs of tamponade. Pacemaker lead tip seen embedded in the right ventricular free wall. . Echo [**2147-12-27**]: The right atrial pressure is indeterminate. Left ventricular wall thickness, cavity size, and global systolic function are normal (LVEF>55%). The right ventricular cavity is dilated with severe global free wall hypokinesis. No aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. The estimated pulmonary artery systolic pressure is normal. There is a small circumferential pericardial effusion without echocardiographic signs of tamponade. Compared with the prior study (images reviewed), the pericardial effusion now appears more circumferential, but likely similar in absolute volume of fluid. . CT coronary: IMPRESSION: 1. Mild nonobstructive noncalcified plaque within LAD, LCX, and RCA, causing up to 30% luminal narrowing. 2. Borderline mediastinal and hilar lymph nodes, that might be consistent with the diagnosis of sarcoisdosis. No evidence of pulmonary sarcoidosis. No definite evidence of abnormal myocardial perfusion/thickening to suggest cardiac sarcoidosis. 3. Partially visualized left upper lobe pulmonary nodule, stable since at least [**2145-6-4**]. 4. Retained cardiac pacer wire within proximal left brachiocephalic vein, unchanged since [**2145**]. 5. Small hiatal hernia. . Brief Hospital Course: 48 YOM with history of ARVD and multiple ICD placements transferred from OSH for evaluation of sustained VT refractory to multiple ICD shocks and quinidine therapy. . # Arrythmogenic Right Ventricular Dysplasia: EP followed patient. Echo showed EF>55% with LV depressed and dilated. Chest CT with coronaries revealed nonobstructive noncalcified plaque within LAD, LCX, and RCA, causing up to 30% luminal narrowing. CT also showed borderline mediastinal and hilar lymph nodes. No definite evidence of abnormal myocardial perfusion/thickening to suggest cardiac sarcoidosis. The patient's venogram showed signifcant scarring. The patient was scheduled for epicardial ablation, but during the procedure, the EP team was not able to perform ablation because the ICD lead was stenosed to LV and not functioning. The ICD lead could not be removed in EP lab. The patient was discharged home on Lifevest and scheduled to return for open chest procedure that includes ablation and replacement of ICD on right side in [**2-4**] weeks. . # Ventricular Tachycardia: Admitted for episodes of V tach. EP followed pt closely. He was continued on home quinidine. Pt had EP examination that did not allow for ablation, as mentioned above. He was discharged home with a plan to return for open chest procedure that includes ablation and replacement of ICD on right side in [**2-4**] weeks. Medications on Admission: - atenolol 50mg daily - quinidine 648mg TID - Coumadin 2.5mg daily Discharge Medications: 1. quinidine gluconate 324 mg Tablet Sustained Release Sig: Two (2) Tablet Sustained Release PO Q8H (every 8 hours). Disp:*240 Tablet Sustained Release(s)* Refills:*2* 2. acetaminophen 500 mg Capsule Sig: [**2-4**] Capsules PO Q6H (every 6 hours) as needed for pain. 3. lorazepam 1 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for anxiety. Disp:*40 Tablet(s)* Refills:*0* 4. cortisone 1 % Cream Sig: One (1) Appl Topical QID (4 times a day) as needed for rash on chest. 5. warfarin 2.5 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 6. atenolol 100 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Ventricular Tachycardia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted because your ICD fired and we performed many tests to see if we could ascertain the cause and control the ventricular tachycardia. We found that the ICD lead was not working so you will go home with a Lifevest to shock you out of ventricular tachycardia if needed. You have not had any episodes of VT here and we increased the Atenolol to prevent more VT. You will return here in [**2-4**] weeks to get an ablation and get the ICD replaced. Dr.[**Name (NI) 7914**] office will be in touch with you to arrange this. . Medication changes: 1. Increase Atenolol to 100 mg daily 2. Start taking Ativan as needed to control any anxiety. Do not drink alcohol or drive while taking this medicine. 4. Continue Quinidine to control the VT. 5. Restart coumadin at your previous dose, please get your INR checked on Monday [**1-1**]. 6. You can eat high potassium foods such as bananas and [**Location (un) 2452**] juice and take a over the counter magnesium supplement if you want at the recommended dose. Followup Instructions: Department: CARDIAC SERVICES When: FRIDAY [**2148-4-26**] at 11:30 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 [**2148-4-26**] at 1 PM With: ECHOCARDIOGRAM [**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 [**2148-4-26**] at 2:00 PM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1008**], M.D. [**Telephone/Fax (1) 62**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage

[ "996.04", "E879.8", "425.4", "V58.61", "423.1", "427.1" ]

icd9cm

[ [ [] ] ]

[ "37.26", "37.27", "37.34", "37.12" ]

icd9pcs

[ [ [] ] ]

9082, 9088

6891, 8265

296, 331

9156, 9156

4127, 6868

10344, 11184

3147, 3392

8383, 9059

9109, 9135

8291, 8360

9307, 9842

3407, 4108

1677, 1757

9862, 10321

247, 258

359, 1610

9171, 9283

1788, 2788

1632, 1657

2804, 3131

11,702

137,963

49700

Discharge summary

report

Admission Date: [**2153-6-6**] Discharge Date: [**2153-6-11**] Date of Birth: [**2079-7-7**] Sex: M Service: MEDICINE Allergies: Nsaids Attending:[**First Name3 (LF) 5552**] Chief Complaint: N/V Major Surgical or Invasive Procedure: EGD History of Present Illness: HPI (per [**Hospital Unit Name 153**] admission note): 73 yo M h/o MDS x 10 yrs, TURP [**2141**], with Grade I T3N1b pancreatic adenocarcinoma discovered incidentally on CT scan in early [**2153**] now s/p partial pancreatectomy and total splenectomy on [**2153-3-13**] who was sent in from clinic [**6-6**] for anemia. Had been feeling well recently - since partial pancreatectomy in late [**Month (only) 956**] he has gained 7 lbs, still working as a tax attorney. For 6 weeks he has been receiving XRT and xeloda, both of which have been well tolerated without N/V/D/constipation, skin changes, mucositis. He does report some mild fatigue since initiating the XRT. This has not been particularly worse recently. He notes no change in his bowel habits - he generally has 2 BM per day that are dark brown. On [**6-5**] he vomited stomach contents (no blood/bile) while walking outside - he did feel nauseated prior to vomiting. He vomited again on the morning of admission -again, no blood/bile/coffee grounds. He has been receiving Procrit weekly since [**Month (only) 462**] and went in for his weekly shot on the day of admission when he was found to have a HCT of 16. He was sent to the ED where a rectal exam revealed melanotic guaiac positive stool and repeat HCT ~16. There, he was transfused with one unit pRBC with a second unit initiated on arrival to the ICU. NGL in ED showed coffee grounds and flecks of red, no clots, no fresh blood. ROS: some fatigue since initiating XRT 6 weeks ago. He has gained wt since surgery. 2 BM per day, dark brown, no vomiting except the day PTA as noted above. No dysphagia, no skin changes with XRT, no abd pain s/p surgery nor with XRT. No f/c at home. No NS/cough/hemoptysis. No focal weakness. No CP, palpitations. No [**Location (un) **]. Past Medical History: ONC HISTORY: He has had MDS x 10 years - managed by Dr. [**Last Name (STitle) 2539**], his PCP. [**Name10 (NameIs) 2772**], almost 1 yr PTA he visited Dr. [**Last Name (STitle) 410**] for further management. In [**Month (only) 462**] he began getting Procrit with good response. In [**Month (only) **] he developed DM and treated with oral antihyperglycemics. CT scan in early [**2152**] that demonstrated a mass in the pancreas - f/u MRI redemonstrated this. On [**2153-3-13**], he was taken to the OR for a partial pancreatectomy and splenectomy; path revealed pancreatic adenocarcinoma Grade I with margins that were not clear, T3N1b ([**3-11**] nodes positive). The surgery was uncomplicated and the pt did well therafter. He has been treated with a 6 week course of Xeloda and XRT. Last dose of xeloda was on the morning of admission. Last XRT is planned for [**2153-6-7**]. He has a CT scan for restaging scheduled for [**6-12**]. . PMH: 1. Dm dx'd [**11/2152**] 2. Ring sideroblastic anemia/ MDS diagnosed in the early [**2137**] by bone marrow biopsy: The patient had been treated only with vitamin B-6, was never transfused and had no complications. He is treated by Dr. [**Last Name (STitle) 410**]. Procrit at 60,000 units approximately every week. 3. Status post transurethral resection of prostate in [**2141**] for benign prostatic hypertrophy. 4. Gout: The patient had one flare in [**2147-4-15**] to the right ankle, which was his only episode and he was then on allopurinol for quite some time. 5. Status post back surgery in [**2127**]. 6. Scarlet fever as a child. 7. Midbody Pancreatic Mass s/p subtotal pancreatectomy in [**2153-3-13**] - presently receiving Xeloda and radiation therapy under the direction of Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] 8. Splenectomy in [**2153-3-13**] for massive splenomegaly 9. Aseptic meningitis [**2149**] ([**2-15**] NSAID's) Social History: The patient was married, had three children and quit tobacco in [**2122**]. Prior to that, he had a 30 pack year history. He used alcohol rarely. He worked as a tax attorney in [**Location (un) 86**]. He lived in [**Location (un) 745**]. Family History: His sister died of congestive heart failure. Physical Exam: Vitals: Tm 99.2 Tc 97.2 BP 118/45 HR 70 O2sat 97% RA Gen: NAD, [**Location (un) 1131**] the newspaper HEENT: OP clear CV: RRR, nl S1S2, [**2-19**] holosystolic murmur throughout the precordium Lung: bibasilar crackles Abd: Soft, NT, ND, +BS. Midline scar with large peri-umbilical scab. Ext: No clubbing, cyanosis, or edema. Neuro: grossly non-focal Pertinent Results: REPORTS: . CHEST (PORTABLE AP) [**2153-6-6**] 7:33 PM IMPRESSION: No acute cardiopulmonary process. . EGD [**2153-6-7**] Findings: Esophagus: Normal esophagus. Stomach: Excavated Lesions There was a single cratered non-bleeding 4mm ulcer was found at the pylorus; it was well-head and nonbleeding. Duodenum: Excavated Lesions A single acute cratered 1cm ulcer was found in the duodenal bulb. A red-to-maroon colored clot was situated within it. After this clot was washed off with saline, a visible vessel was seen within it, suggesting recent bleeding. Four cc of epinephrine at a concentration of 1:10,000 was injected around the vessel with good hemostasis. [**Hospital1 **]-CAP Electrocautery was applied for hemostasis successfully. Another ulcer in the duodenal bulb, more distally was seen. It was about 0.5 cm, and had an adherent red-to-maroon colored clot. The clot was washed off with normal saline, revealing a visible vessel, which appeared to have recently bled. Six cc of epinephrine at a concentration of 1:10,000 was injected for hemostasis with success. Then a single endoclip was successfully deployed around the vessel, achieving good hemostasis. Impression: Ulcer in the duodenal bulb (injection, thermal therapy) Ulcer in the pylorus Gastric ulcer . LABS: . [**2153-6-6**] 03:40PM BLOOD WBC-25.6* RBC-1.66*# Hgb-5.5*# Hct-16.5*# MCV-100* MCH-33.4* MCHC-33.4 RDW-29.6* Plt Ct-270 [**2153-6-6**] 06:41PM BLOOD WBC-22.3* RBC-1.63* Hgb-5.3* Hct-16.7* MCV-103* MCH-32.4* MCHC-31.6 RDW-30.2* [**2153-6-7**] 01:10AM BLOOD Hct-16.0* [**2153-6-7**] 04:45AM BLOOD WBC-16.7* RBC-1.94* Hgb-6.6* Hct-17.8* MCV-92# MCH-34.2* MCHC-37.2*# RDW-27.2* Plt Ct-211 [**2153-6-7**] 10:40AM BLOOD Hct-21.0* [**2153-6-7**] 03:30PM BLOOD Hct-19.8* [**2153-6-7**] 10:32PM BLOOD Hct-25.3*# [**2153-6-8**] 03:27AM BLOOD WBC-24.8* RBC-2.71*# Hgb-8.7*# Hct-25.6* MCV-95 MCH-32.0 MCHC-33.8 RDW-23.3* Plt Ct-222 [**2153-6-8**] 08:51AM BLOOD WBC-31.5* RBC-2.85* Hgb-9.1* Hct-27.1* MCV-95 MCH-32.0 MCHC-33.6 RDW-23.2* Plt Ct-256 [**2153-6-8**] 06:30PM BLOOD Hct-25.8* [**2153-6-8**] 11:45PM BLOOD Hct-24.9* [**2153-6-9**] 07:23AM BLOOD WBC-26.6* RBC-2.85* Hgb-9.1* Hct-27.3* MCV-96 MCH-31.8 MCHC-33.3 RDW-23.8* Plt Ct-288 [**2153-6-9**] 03:00PM BLOOD Hct-27.5* [**2153-6-10**] 12:05AM BLOOD Hct-24.9* [**2153-6-10**] 07:15AM BLOOD WBC-27.0* RBC-2.77* Hgb-8.8* Hct-26.6* MCV-96 MCH-31.9 MCHC-33.2 RDW-23.2* Plt Ct-242 [**2153-6-10**] 11:30AM BLOOD Hct-25.0* [**2153-6-10**] 07:00PM BLOOD Hct-25.3* [**2153-6-11**] 06:35AM BLOOD WBC-26.3* RBC-2.81* Hgb-8.8* Hct-26.0* MCV-93 MCH-31.3 MCHC-33.8 RDW-23.2* Plt Ct-249 [**2153-6-9**] 07:23AM BLOOD Neuts-80* Bands-7* Lymphs-1* Monos-4 Eos-6* Baso-0 Atyps-0 Metas-1* Myelos-1* NRBC-71* [**2153-6-6**] 06:41PM BLOOD Neuts-72* Bands-8* Lymphs-6* Monos-7 Eos-6* Baso-0 Atyps-1* Metas-0 Myelos-0 NRBC-50* [**2153-6-11**] 06:35AM BLOOD Plt Ct-249 LPlt-3+ [**2153-6-7**] 04:45AM BLOOD PT-12.6 PTT-26.5 INR(PT)-1.1 [**2153-6-6**] 06:41PM BLOOD PT-13.1 PTT-26.0 INR(PT)-1.1 [**2153-6-6**] 03:40PM BLOOD Gran Ct-[**Numeric Identifier **]* [**2153-6-11**] 06:35AM BLOOD Glucose-141* UreaN-13 Creat-0.6 Na-137 K-4.2 Cl-103 HCO3-26 AnGap-12 [**2153-6-6**] 06:41PM BLOOD Glucose-264* UreaN-64* Creat-0.9 Na-138 K-4.8 Cl-101 HCO3-25 AnGap-17 [**2153-6-6**] 06:41PM BLOOD ALT-20 AST-21 LD(LDH)-361* CK(CPK)-18* AlkPhos-150* TotBili-0.4 [**2153-6-6**] 06:41PM BLOOD Lipase-15 [**2153-6-6**] 06:41PM BLOOD CK-MB-NotDone cTropnT-<0.01 [**2153-6-11**] 06:35AM BLOOD Calcium-8.0* Phos-2.0* Mg-2.1 [**2153-6-8**] 03:27AM BLOOD Calcium-8.0* Phos-3.0 Mg-2.0 [**2153-6-6**] 06:41PM BLOOD Albumin-3.6 UricAcd-5.2 [**2153-6-7**] 05:24PM BLOOD CA [**66**]-9: 10 [**2153-6-7**] 12:37AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.030 [**2153-6-7**] 12:37AM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG . MICRO: . [**2153-6-7**] 5:24 pm SEROLOGY/BLOOD **FINAL REPORT [**2153-6-8**]** HELICOBACTER PYLORI ANTIBODY TEST (Final [**2153-6-8**]): NEGATIVE BY EIA. Reference Range: Negative. Brief Hospital Course: 73 yo M h/o MDS, s/p recent partial pancreatectomy for mass and splenectomy for splenomegaly, who was admitted for melanotic stools and decreased HCT. Found to have gastric and duodenal ulcers. . #) UGIB: likely due to gastric/duodenal ulcers as seen by EGD. Pt was admitted to the ICU initially, then underwent injection and thermal therapy during the EGD. Pt was then transferred to the floor once his hct stabilized. - pt required 6 U PRBC's during the admission - hct stabilized prior to discharge, although pt continued to have guaiac + stools - pt was mande NPO initially, then tolerated regular diet prior to discharge - H. pylori Ab was negative - Pt should not have NSAIDs due to high risk of lesions rebleeding - pt was placed initially on IV protonix [**Hospital1 **], then swithced to PO protonix [**Hospital1 **]. Pt should continue protonix 40 mg PO twice a day for 8 weeks, and then daily thereafter. . #) DM - recently diagnosed, presumably due to carcinoma. Managed with oral meds at home, but these were held while in the hospital. FS were in high 200's here, so pt was started on low-dose NPH as well as ISS. - pt was restarted on oral hypoglycemic on discharge . #) Pancreatic Cancer: Pt was 2.5 months out from pancreatic surgery for Grade I, T3 N1b adenocarcinoma resection. - pt will continue on xeloda as an outpatient - pt had final session of XRT to the pancreas during this admission on [**6-8**] (this had been scheduled prior to admission for GI bleed) - pt's abdominal incision from recent surgery was found to have small wound draining brownish fluid. Pt's surgeon (Dr. [**Last Name (STitle) 468**] was notified, and recommended starting zinc and Vit C to assist healing. Pt was continued on zinc and Vit C on discharge. . #) MDS: pt has hx of MDS x 10 years. - transfusions were given as above - continued iron - continued vitamin B6, folic acid - pt to receive procrit as an outpatient . #) Gout: stable. continued allopurinol. . #) Leukocytosis: Pt was at baseline. Likely secondary to MDS. . #) Ppx: held hep sq given GI bleed. pneumoboots, PPI [**Hospital1 **] . #) Code: FULL . #) Communication: WIFE [**Name (NI) 382**] . #) Dispo: home Medications on Admission: Meds (From Discharge in [**3-19**]): ASA 81 qd folic acid 1 tid vit B6 100 tid iron qd allopurinol 300mg qd glipizide 10mg [**Hospital1 **] metformin 500 [**Hospital1 **] Discharge Medications: 1. Outpatient Lab Work Please have a CBC checked on [**2153-6-12**] and have the results faxed to your PCP and your oncologist. 2. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO twice a day: take 1 tablet [**Hospital1 **] for 8 weeks, then 1 tablet QD thereafter. Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*3* 3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:*90 Tablet(s)* Refills:*2* 4. Pyridoxine 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* 5. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 6. Allopurinol 300 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 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. Glipizide 10 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:*60 Tablet(s)* Refills:*2* 10. Metformin 500 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:*60 Tablet(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Upper GI bleed secondary to gastric and duodenal ulcers Blood loss anemia pancreatic CA MDS Discharge Condition: Vitals stable. Hct stable. Discharge Instructions: Please seek medical attention immediately if you experience blood in your stool, dark or tarry stools, coughing up blood, chest [**Last Name (un) 2187**], shortness of breath, nausea, vomiting, fevers, chills, or dizziness. Please take all medications as prescribed. Do not take aspirin unless your PCP or oncologist instructs you to re-start this medication. Please attend all follow-up appointments. Followup Instructions: Please have your hematocrit checked tomorrow. You have an oncology clinic appointment scheduled for Wednesday, but you can call to change this appointment to tomorrow. Provider: [**Name10 (NameIs) **] SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2153-6-12**] 1:30 Provider: [**Name10 (NameIs) 13145**],[**Name11 (NameIs) **] HEMATOLOGY/ONCOLOGY-CC9 Date/Time:[**2153-6-13**] 9:30 Provider: [**Name10 (NameIs) 4618**],[**Name11 (NameIs) 4617**] HEMATOLOGY/ONCOLOGY-CC9 Date/Time:[**2153-6-13**] 9:30 Please follow up with your radiation oncologist in 4 weeks. Please follow-up in [**Hospital **] clinic in [**1-15**] weeks; call ([**Telephone/Fax (1) 8892**] to make an appointment. Completed by:[**2153-6-26**]

[ "238.7", "532.40", "274.9", "280.0", "250.00", "157.8" ]

icd9cm

[ [ [] ] ]

[ "99.04", "44.43", "92.29" ]

icd9pcs

[ [ [] ] ]

12467, 12473

8870, 11048

269, 275

12609, 12638

4736, 8847

13090, 13816

4304, 4350

11270, 12444

12494, 12588

11074, 11247

12662, 13067

4365, 4717

226, 231

303, 2094

2116, 4033

4049, 4288

20,172

129,844

47121

Discharge summary

report

Admission Date: [**2183-10-7**] Discharge Date: [**2183-10-9**] Date of Birth: [**2115-8-6**] Sex: F Service: CCU CHIEF COMPLAINT: Decreased blood pressure and decreased hematocrit, post renal artery stent. HISTORY OF PRESENT ILLNESS: The patient is a 68-year-old female with a history of coronary artery disease and peripheral vascular disease, status post left artery stent, here for nausea and lightheadedness which began the morning after the stent was placed when the patient got up out of bed to go to the bathroom. She experienced no chest pain or shortness of breath. Her hematocrit was found to be 28.5 on [**2183-10-2**] and her hematocrit on [**2183-10-8**] was 22. Her creatinine at this time was 1.6 which was down from 1.9. The patient had received verapamil 120 mg the morning of her lightheadedness, but had received no other blood pressure medication. With dopamine drip begun at 15 mcg/kg, the patient had a heart rate of 78 and blood pressure of 94/31. One unit of blood was given to her on the floor and another unit was subsequently transfused in the CCU to raise her blood pressure and improve her hematocrit. The patient also received iron shots every week secondary to a history of anemia. Her last transfusion was approximately one year ago with an unknown source of bleeding. PAST MEDICAL HISTORY: Significant for coronary artery disease. In [**2170**], the patient had a right coronary artery PTCA with a right dominant system. In [**2178**], she had a right coronary artery stent with a PTCA of D1. In [**2180**], she had a mid-RCA ISR treated with PTCA. On [**2183-4-3**], she had an 80% mid-RCA which was PTCA'd and stented. On [**2183-8-12**], she had catheterization for dyspnea and CHF which showed left main disease 30% ostial, LAD 30-40% lesion proximally, a D1 ostial 40%, circumflex proximally occluded, right CA with mildly patent stents, moderate pulmonary artery hypertension, and an ejection fraction of 75% with trace MR, and severe LV diastolic dysfunction. On [**2183-9-17**], she had an MRA which showed reduction of size and perfusion of the left kidney and evidence of right artery stenosis. Her echo showed LVEF of 50-80% with normal wall motion and normal mitral and aortic valves. The patient also has a history of peripheral vascular disease, hypertension, hyperlipidemia, COPD, anemia, history of GI bleed with sigmoid colectomy, coronary artery disease, status post left carotid stenosis, history of depression, history of renal artery stenosis and chronic renal insufficiency. MEDICATIONS PRIOR TO ADMISSION: Aspirin 81 mg po qd, tamoxifen 10 mg po qd, lasix 20 mg po qd, hydrochlorothiazide 12.5 mg po qd, Protonix 40 mg po qd, lisinopril 20 mg po qd, Paxil 25 mg po qd, Singulair 10 mg po qd, Imdur 60 mg po [**Last Name (LF) **], [**First Name3 (LF) **]-Dur 300 mg po bid, [**Doctor First Name **] 60 mg po bid, verapamil 120 mg po bid, Neurontin 100 mg po q hs, lorazepam 0.5 mg po prn, colace 100 mg po bid, senokot 1-2 tablets po q hs, lactulose 2 tbsp po bid, iron shots q week, Flovent 2 puffs [**Hospital1 **], Serevent 2 puffs [**Hospital1 **], albuterol 2 puffs IH q 4-6. ALLERGIES: Include aspirin at a higher dose of 325, codeine, percocet, beta blockers which lead to bronchospasm, shellfish and dye. SOCIAL HISTORY: The patient is a widow who lives alone. She has several children in the area and is followed by [**Hospital3 **] VNA multiple times per week. She used to smoke two packs per day for approximately 50 years and quit in [**Month (only) 216**] of this year. She drinks socially for six to seven years and stopped a few years ago. PHYSICAL EXAM ON ADMISSION: Vital signs included a blood pressure of 104/50 not on any drips and a heart rate of 72 upon admission to the CCU. General appearance - well-appearing, pale, obese female, talking and alert. HEENT - moist mucous membranes. Neck exam - no JVD, some obesity. In the right carotid there was a scar present but no bruits. Cardiac - regular rate and rhythm without murmurs, rubs or gallops. Pulmonary - bilaterally clear to auscultation. Abdomen - positive bowel sounds, soft, nontender, obese, no periumbilical bruising, no flank ecchymoses. Extremities - no cyanosis, clubbing or edema, warm extremities, palpable DP and PT bilaterally. Bilateral femoral bruits, right greater than left with no hematoma and twitching of both lower extremities given history of restless leg syndrome. LABS: That morning she ruled out x 3 for an MI. She also had a hematocrit of 22.1, K 4.4, BUN 48, creatinine 1.6. She had an EKG done which showed normal sinus rhythm at [**Street Address(2) 99881**] elevations in I and AVL, left axis deviation, but no criteria for LVH and no other changes. The patient had a CT of the abdomen and pelvis done to rule out an acute bleed which showed minimal atelectasis and no pulmonary nodules, normal liver, pancreas, spleen, kidney. There was a renal stone in the right kidney pelvis, but otherwise no signs of retroperitoneal bleeding. No signs of hydronephrosis. No pelvic free air or fluid, and otherwise unremarkable CT of abdomen and pelvis. HOSPITAL COURSE: Given the above, the patient was hydrated and her hypotension was thought to be secondary to the verapamil she received the morning she was transferred to the CCU. She was given two units of blood with improvement in her hematocrit. A rectal exam was performed which showed that she was guaiac negative, and with this chronic history of anemia which subsequently stabilized, the patient was deemed stable for discharge. She was discharged to home and will follow-up with Dr. [**First Name (STitle) **] in one week's time, and follow-up with her PCP. [**Name10 (NameIs) **] was given copies of her catheterization report, and she was continued all of her previous medications except lasix, hydrochlorothiazide, lisinopril, and her Imdur dose was halved to 30 mg po qd. The other medications would be restarted by her PCP as her blood pressure was monitored. The patient was discharged in stable condition. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3184**], M.D. [**MD Number(1) 5211**] Dictated By:[**MD Number(1) 99882**] MEDQUIST36 D: [**2183-10-14**] 21:00 T: [**2183-10-22**] 09:29 JOB#: [**Job Number **]

[ "496", "440.20", "440.1", "458.2", "285.9", "401.9", "414.01", "790.01", "272.0" ]

icd9cm

[ [ [] ] ]

[ "88.45", "88.42", "39.50", "39.90" ]

icd9pcs

[ [ [] ] ]

5185, 6358

2602, 3311

149, 226

255, 1330

3687, 5167

1353, 2569

3328, 3672

29,772

147,175

46047

Discharge summary

report

Admission Date: [**2169-6-28**] Discharge Date: [**2169-6-30**] Date of Birth: [**2109-10-17**] Sex: M Service: NEUROSURGERY Allergies: Iodine; Iodine Containing Attending:[**First Name3 (LF) 1854**] Chief Complaint: Headaches Major Surgical or Invasive Procedure: N/A History of Present Illness: 59-year-old right-handed man, with a history of metastatic renal cell carcinoma, who was referred by Dr [**Last Name (STitle) 724**] for a craniotomy. His oncological problem started in [**2160**] with right flank pain. A mass in the right kidney was found and he underwent a right nephrectomy. His treatment was followed by PTK787 at [**Company 2860**] for 1-2 years, followed by CCI-779 and interferon. In [**2166**] he started sorafenib and then in [**2167-1-25**] he was started on Sutent. He stopped Sutent on [**2169-5-25**] due to progressive lung disease. His neurological problem started on [**2169-6-20**] when he woke up with extensive holocranial headache and confusion. He supposed to have radiation to his lung that day but he forgot. He went to [**Hospital **]??????s Hospital and his wife noted that he was neglecting his left side. He had difficulty lifting the left side as well. He did not have nausea, vomiting, seizure, or fall. He was placed on dexamethasone 6 mg in a.m. and Keppra 500 mg po twice daily. He was discharged home on [**2169-6-22**]. Past Medical History: PMH: 1. Metastatic renal cell CA: s/p right nephrectomy, PTK-787, high-dose IL2, CCI-779/interferon 2. R bronchus intermedius obstruction [**2-25**] metastasis: s/p rigid bronch [**2166-10-8**] w/ tumor debridement, stent not placed 2. Right DVT - on lovenox for treatment Social History: No Tob/EtOH/IVDU. Lives with wife. Originally from [**Country 5976**]. Family History: Non-contributory Physical Exam: Exam upon admission: Temperature 98.8 F. His blood pressure is 130/85. Heart rate is 60. Respiratory rate is 16. His skin has full turgor. HEENT is unremarkable. Neck is supple and there is no bruit. There is no lymphadenopathy. Cardiac examination reveals regular rate and rhythms. His lungs are clear. His abdomen is soft with good bowel sounds. His extremities do not show clubbing, cyanosis, or edema. Neurological Examination: His Karnofsky Performance Score is 90. He is awake, alert, and oriented times 3. There is no right/left confusion or finger agnosia. His calculation is intact. His language is fluent with good comprehension, naming, and repetition. Short-term recall is intact. Cranial Nerve Examination: His pupils are equal and reactive to light, 5 mm to 2 mm bilaterally. Extraocular movements are full; there is no nystagmus. Visual fields are full to confrontation. Funduscopic examination reveals sharp disks margins bilaterally. His face is symmetric. Facial sensation is intact bilaterally. His hearing is intact bilaterally. His tongue is midline. Palate goes up in the midline. Sternocleidomastoids and upper trapezius are strong. Motor Examination: He does not have a drift. His muscle strengths are [**5-29**] at all muscle groups. His muscle tone is normal. His reflexes are 2- bilaterally. His ankle jerks are absent. His toes are downgoing. Sensory examination is intact to touch and proprioception. Coordination examination does not reveal dysmetria. His gait is normal. He does not have a Romberg. Pertinent Results: [**2169-6-30**] 06:22AM BLOOD WBC-17.5* RBC-3.50* Hgb-11.6* Hct-37.4* MCV-107* MCH-33.1* MCHC-31.0 RDW-16.1* Plt Ct-295 [**2169-6-30**] 06:22AM BLOOD Plt Ct-295 [**2169-6-30**] 06:22AM BLOOD Glucose-207* UreaN-31* Creat-0.9 Na-140 K-4.8 Cl-107 HCO3-22 AnGap-16 [**2169-6-30**] 06:22AM BLOOD Calcium-9.1 Phos-3.6# Mg-2.4 [**2169-6-30**] 10:38AM BLOOD Type-ART pO2-63* pCO2-49* pH-7.25* calTCO2-23 Base XS--5 [**2169-6-30**] 10:38AM BLOOD Lactate-3.0* [**2169-6-30**] 07:44AM BLOOD Hgb-11.9* calcHCT-36 O2 Sat-99 [**2169-6-30**] 07:44AM BLOOD freeCa-1.12 Brief Hospital Course: Mr [**Known lastname 84191**] was admitted to the Neurosurgery service on [**6-28**] and underwent a right temporoparietal craniotomy for removal of renal cell met. Post operatively he went to the TSICU for Q1 VS and monitoring, his BP was kept less than 140. Neurologically he was oriented x 3 but with more complex questioning he was slightly confused. He was able to converse with his wife and was able to ambulate in his room. His stength and sensation were full. PT saw him and felt that he would be able to be discharged home and would not require rehab. His post-op CT and MRI were reviewed by Dr. [**Last Name (STitle) **] and it was determined that it was safe to restart his lovenox that he was on for a DVT. He was transferred to the step-down unit at 11pm on [**2169-6-29**] and his neuro exam was stable. Overnight, he complained of a headache, but remained oriented, was conversant, and was moving all extremities. At about 6:25 am on [**2169-6-30**] the nurse called the covering physician to come to the bedside because the patient was having rapid and shallow respirations. The patient became unresponsive but had an O2Sat of 98%, BP was 188/95, HR 48-54. The physician took the patient emergently to CT scan which revealed massive interventricular hemorrhage. He was then brought down the [**Doctor Last Name **] to the ER and was emergently intubated. The patient was then taken emergently to the OR for bilateral placement of EVDs. After the surgery Dr. [**Last Name (STitle) **] found him to have bilateral dilated, unreactive pupils. He was taken to CT scan which showed good placement of the EVDs. Then he went to the TSICU. Shortly after arrival, the patient was made DNR by his wife. [**Name (NI) **] no longer had a blood pressure and then he was made CMO by his wife. The patient passed away at 11:23am. The patient's wife was present and she had family and friends with her at the hospital to support her and help contact additional family members. Medications on Admission: Acetaminophen Metoprolol Tartrate 75 mg PO BID Albuterol MDI [**1-25**] PUFF IH Q4H:PRN SOB/Wheeze LeVETiracetam 500 mg PO Q12H Pantoprazole 40 mg PO Q24H Levothyroxine Sodium 125 mcg PO DAILY Dexamethasone 4 mg PO Q6H OxycoDONE (Immediate Release) 5-10 mg PO Q4H:PRN Docusate Sodium 100 mg PO BID Enoxaparin Sodium 90 mg SC Q12H Discharge Medications: none Discharge Disposition: Expired Discharge Diagnosis: N/A Discharge Condition: N/A Discharge Instructions: N/A Completed by:[**2169-6-30**]

[ "V58.61", "189.0", "V12.51", "427.31", "530.81", "401.9", "431", "198.3", "244.9", "197.0" ]

icd9cm

[ [ [] ] ]

[ "96.04", "96.07", "02.39", "96.71", "01.59" ]

icd9pcs

[ [ [] ] ]

6370, 6379

3980, 5959

301, 307

6427, 6433

3403, 3957

1814, 1832

6341, 6347

6400, 6406

5985, 6318

6457, 6491

1847, 1854

252, 263

335, 1412

1868, 3384

1434, 1709

1725, 1798

63,947

169,320

47637

Discharge summary

report

Admission Date: [**2128-4-28**] Discharge Date: [**2128-5-5**] Date of Birth: [**2045-10-9**] Sex: M Service: CARDIOTHORACIC Allergies: lisinopril / Quinapril / Diovan Attending:[**First Name3 (LF) 1505**] Chief Complaint: DOE Major Surgical or Invasive Procedure: Coronary Artery Bypass x 4 (LIMA-LAD, SVG-Diag, SVG-OM, SVG-PDA) [**2128-4-28**] History of Present Illness: 82M with history of hyperlipidemia and htn who has recently experienced exertional dyspnea. Workup included exercise MIBI which was abnormal. Cardiac cath revealed 3 vessel CAD. Surgical evaluation is requested for CABG. Past Medical History: CAD HTN Hypercholesterolemia Social History: Lives with: wife Occupation: Chairman of local life insurance company Tobacco: denies ETOH: denies Family History: non-contributory Physical Exam: Pulse: 54SB Resp: 16 O2 sat: 95%RA B/P Right: Left: 146/85 Height: 5'7" Weight: 84kg General: NAD, WGWN, appears slightly younger than stated age Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x] Neck: Supple [] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Extremities: Warm [x], well-perfused [x] Edema Varicosities: 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: no bruits Pertinent Results: [**2128-5-5**] 04:50AM BLOOD WBC-8.8 RBC-4.20* Hgb-12.7* Hct-38.1* MCV-91 MCH-30.2 MCHC-33.3 RDW-14.2 Plt Ct-254 [**2128-5-4**] 04:20AM BLOOD WBC-8.1 RBC-4.03* Hgb-12.6* Hct-36.4* MCV-90 MCH-31.2 MCHC-34.6 RDW-14.2 Plt Ct-262 [**2128-5-5**] 04:50AM BLOOD Na-140 K-4.2 Cl-108 [**2128-5-4**] 04:20AM BLOOD Glucose-124* UreaN-30* Creat-0.8 Na-142 K-3.6 Cl-107 HCO3-24 AnGap-15 Intra-op TEE, [**2128-4-28**] Conclusions PREBYPASS: Pt for CABG. Left ventricular wall thickness, cavity size, and global systolic function are normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The ascending, transverse and descending thoracic aorta are normal in diameter and free of significant atherosclerotic plaque. The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. The TV and PV are normal. There is no pericardial effusion. The left attrium is normal in size. A patent foramen ovale is present with left to right flow. There is no clot in the left atrial appendage. Diastolic funciton is impaired with E'<6 cm/sec. Transmitral inflow is consistent with psuedonormal diastolic function. POSTBYPASS: no change. Good systolic funciton with LVEF >55, and no segmental wall motion abnormalities. No dissection seen following removal of the aortic cannula. No wall motion changes following chest closure. Brief Hospital Course: The patient was brought to the operating room on [**2128-4-28**] where the patient underwent CABG x 4 with Dr. [**Last Name (STitle) **]. Overall the patient tolerated the procedure well and post-operatively was transferred to the CVICU in stable condition for recovery and invasive monitoring. The patient remained agitated early on POD 1 and extubation was delayed until late on POD 1. He initially had some post-op confusion which was treated with haldol found the patient extubated, alert and oriented and breathing comfortably. Neurology consulted and determined the patient to have post-op delerium. This cleared and the patient's mental status returned to his baseline. Blood pressure was labile in the initial post-op period, but would stabilize. Beta blocker was initiated and the patient was gently diuresed toward the preoperative weight. The patient was transferred to the telemetry floor for further recovery. Chest tubes and pacing wires were discontinued without complication. The patient was evaluated by the physical therapy service for assistance with strength and mobility. By the time of discharge on POD 7, the patient was ambulating freely, the wound was healing and pain was controlled with oral analgesics. The patient was discharged to home in good condition with appropriate follow up instructions. Medications on Admission: QUINAPRIL - (Prescribed by Other Provider) - 40 mg Tablet - 1 (One) Tablet(s) by mouth once a day SIMVASTATIN - (Prescribed by Other Provider) - 20 mg Tablet - 1 (One) Tablet(s) by mouth once a day Medications - OTC ASPIRIN [[**Doctor Last Name **] ASPIRIN] - (Prescribed by Other Provider) - 325 mg Tablet - 1 (One) Tablet(s) by mouth once a day CHOLECALCIFEROL (VITAMIN D3) [VITAMIN D-3] - (OTC) - 2,000 unit Capsule - 1 (One) Capsule(s) by mouth once a day OMEGA 3-DHA-EPA-FISH OIL - (OTC) - 1,000 mg (120 mg-180 mg) Capsule - 1 (One) Capsule(s) by mouth once a day Discharge Medications: 1. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*0* 2. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 4. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:*90 Tablet(s)* Refills:*2* 5. lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* 6. furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day for 1 weeks. Disp:*7 Tablet(s)* Refills:*0* 7. potassium chloride 10 mEq Tablet Extended Release Sig: Two (2) Tablet Extended Release PO once a day for 1 weeks. Disp:*14 Tablet Extended Release(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: CAD HTN Hypercholesterolemia Discharge Condition: Alert and oriented x3 nonfocal Ambulating, gait steady Sternal pain managed with oral analgesics Sternal Incision - healing well, no erythema or drainage 1+ edema bilateral LEs Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming, and look at your incisions Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Followup Instructions: You are scheduled for the following appointments: Surgeon Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 170**], [**2128-5-27**] 1:15 Cardiologist Dr. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 62**], [**2128-5-14**] 9:00 Please call to schedule the following: Primary Care Dr. [**First Name (STitle) **],[**First Name3 (LF) **] S. [**Telephone/Fax (1) 7318**] in [**5-18**] 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:[**2128-5-6**]

[ "401.9", "292.81", "293.0", "272.4", "414.01", "E947.9" ]

icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

5873, 5930

3133, 4468

302, 385

6003, 6182

1555, 3110

6970, 7634

824, 842

5094, 5850

5951, 5982

4494, 5071

6206, 6947

857, 1536

258, 264

413, 638

660, 691

707, 808

28,019

131,821

7613

Discharge summary

report

Admission Date: [**2138-11-28**] Discharge Date: [**2138-12-3**] Date of Birth: [**2081-1-1**] Sex: F Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1267**] Chief Complaint: chest tightness with exertion Major Surgical or Invasive Procedure: CABGx4(LIMA-LAD,SVG-Diag,SVG-OM,SVG-PDA)[**11-29**] History of Present Illness: 57 y/o Cantonese speaking F with known 3V CAD, medically managed with recent 2 day episode of exertional angina. Underwent cardiac cath which again revealed severe three vessel coronary artery disease. Referred for surgical revascularization. Past Medical History: Coronary Artery Disease s/p Myocardial Infarction [**8-9**], Hypertension, Hypercholesterolemia, Diabetes, melodysplastic syndrome, Peripheral Vawscular Disease s/p R com Fem to [**Doctor Last Name **] BPG, Retinopathy, GERD, Chronic Renal Insufficiency(1.3-1.8) Social History: no alcohol non smoker Family History: n/c Physical Exam: HR 66 RR 16 BP 177/92 WDWN Asian F in NAD Lungs CTAB Heart RRR no Murmur Abdomen benign Extrem warm, no edema Pertinent Results: [**2138-11-28**] Echo: PRE-BYPASS: The left atrium is normal in size. No spontaneous echo contrast or thrombus is seen in the body of the left atrium/left atrial appendage or the body of the right atrium/right atrial appendage. No atrial septal defect is seen by 2D or color Doppler. 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. There are focal calcifications in the aortic arch. There are simple atheroma in the descending thoracic aorta. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no pericardial effusion. Post_Bypass: Preserved biventricular systolic function. LVEF 55%. Thoracic aortic contour is intact. Trivial MR< TR Brief Hospital Course: Ms. [**Known lastname **] was a same day admit and on the day of admission she was brought directly to the operating room where she underwent a coronary artery bypass graft x 4. Please see operative report for surgical details. Following surgery she was transferred to the CVICU for invasive monitoring in stable condition. On post-op day one she was weaned from sedation, awoke neurologically intact and extubated. Chest tubes were removed and she was started on beta blockers and diuretics. She was gently diuresed towards her pre-op weight. On post-op day two she was transferred to the telemetry floor for further care and her pre-op medications were restarted. On post-op day three her epicardial pacing wires were removed. Over the next several days her medications were titrated and she worked with physical therapy for strength and mobility. On post-op day 5 she was discharged to home with VNA services and the appropriate follow-up appointments. Medications on Admission: Aspirin 81mg qd, Norvasc 5mg qd, Lipitor 80mg qd, Plavix 75mg qd, Iron, Folic Acid, Glyburide 5mg [**Hospital1 **], Lisinopril 10mg, MVI, Pyridoxine25mg qd, Zantac 150mg qd, Toprol XL 100mg qd, Lantus Discharge Medications: 1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 2. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*0* 5. Furosemide 20 mg Tablet Sig: Two (2) Tablet PO once a day for 5 days. Disp:*10 Tablet(s)* Refills:*0* 6. Glyburide 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*0* 7. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 8. Pyridoxine 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*0* 9. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 10. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12 hours) for 5 days. Disp:*20 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0* 11. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed. Disp:*30 Tablet(s)* Refills:*0* 12. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 13. Toprol XL 100 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*0* 14. Norvasc 5 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Coronary Artery Disease s/p Coronary Artery Bypass Graft x 4 PMH: Hypertension, Hypercholesterolemia, Diabetes, melodysplastic syndrome, Peripheral Vawscular Disease s/p R com Fem to [**Doctor Last Name **] BPG, Retinopathy, GERD, Chronic Renal Insufficiency(1.3-1.8) Discharge Condition: Good Discharge Instructions: Call with fever, redness or drainage from incision or weight gain more than 2 pounds in one day or five in one week. Shower, no baths, no lotions, creams or powders to incisions. No lifting more than 10 pounds or driving until follow up with surgeon. Followup Instructions: Dr. [**First Name (STitle) **] 2 weeks Dr. [**Last Name (STitle) **] 4 weeks Dr. [**Last Name (STitle) 1016**] 2 weeks Already scheduled apppointments: Provider: [**Name10 (NameIs) 26**] [**Name8 (MD) 28**], RN Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2138-12-4**] 2:00 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 647**], MD Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2139-1-1**] 1:30 Provider: [**Name10 (NameIs) 26**] [**Name8 (MD) 28**], RN Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2139-1-1**] 2:30 Completed by:[**2138-12-3**]

[ "440.21", "414.01", "285.29", "585.9", "238.75", "250.50", "362.01", "403.90", "272.0", "530.81", "411.1" ]

icd9cm

[ [ [] ] ]

[ "36.15", "36.13", "99.04", "38.93", "39.61" ]

icd9pcs

[ [ [] ] ]

5027, 5085

2127, 3084

351, 404

5396, 5402

1167, 2104

5701, 6276

1017, 1022

3335, 5004

5106, 5375

3110, 3312

5426, 5678

1037, 1148

282, 313

432, 676

698, 962

978, 1001

16,594

167,099

5034

Discharge summary

report

Admission Date: [**2113-9-20**] Discharge Date: [**2113-9-27**] Date of Birth: [**2043-2-4**] Sex: F Service: MED Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 898**] Chief Complaint: Abdominal discomfort, nausea Major Surgical or Invasive Procedure: Lumbar puncture thoracentesis History of Present Illness: 70 yo caucasian female w/ PMHx significant for HTN, MGUS, SBO w/ bowel resection who was initially admitted [**9-20**] for N/V malaise one week after surgery to remove basal cell carcinoma from her nose. Also complained of abdominal discomfort. Has long history of constipation and needs dulcolax +/- enemas every few days to have bowel movements. Passed flatus/BM on day prior to admission and review of systems was negative for fever/chills/chest pain/dyspnea/sick contacts/strange foods/hematochezia/melena/hematuria. Upon presentation, Pt was found to have acute renal failure, and a dilated colon and distal small bowel on KUB. Past Medical History: 1. Monoclonal gammopathy of unknown significance, IgG type. Followed by Dr [**Last Name (STitle) **], at the [**Hospital1 18**] 2. Hypertension. 3. Shingles. 4. Total abdominal hysterectomy with bilateral salpingo-oophorectomy secondary to uterine fibroids and appendectomy. 5. SBO w/ lysis of adhesions and bowel resection 6. Basal cell carcinoma w/ flap reconstruction 7. GERD 8. Rectal polyp 9. arthritis 10. cholesystectomy Social History: Married, lives with husband who is a lawyer. Occasional ETOH and nonsmoker. Family History: non-contributory Physical Exam: VS -temp 97.2 BP 106/54 HR 104 RR 20 O2sat 96% on Room air GEN: elderly female in no acute distress, poor historian HEENT: slight erythema at the surgical site, no tenderness or warmth NECK: supple CV: regular rate and rhythm, no murmurs appreciated RESP: clear to auscultation bilaterally ABD: well-healed old midline scar, distended and tympanitic, mostly nontender, normoactive bowel sounds, no hepatomegaly, no peritoneal signs GUIAIC: trace positive on admission x 1, negative at discharge x 1 EXT: no clubbing, cyanosis, edema. 2+ DP pulses bilaterally, warm extremities NEURO: Alert & Oriented x3, slight anxiety over feeling ill. Poor historian Pertinent Results: [**9-21**] CSF - WBC 0 RBC 0 TP 45 GLU 39 CSF & Blood cx NGTD [**9-21**] Barium enema - dilated large bowel with no obstructing lesion from rectum to midtransverse colon. [**9-20**] CXR - EKG - NSR w/ freaquent PACs [**2113-9-20**] 07:59PM GLUCOSE-71 UREA N-62* CREAT-1.1 SODIUM-140 POTASSIUM-3.1* CHLORIDE-103 TOTAL CO2-26 ANION GAP-14 [**2113-9-20**] 07:59PM ALT(SGPT)-20 AST(SGOT)-22 ALK PHOS-92 TOT BILI-0.3 [**2113-9-20**] 07:59PM CALCIUM-8.4 PHOSPHATE-2.2*# MAGNESIUM-2.2 [**2113-9-20**] 07:59PM WBC-10.1 RBC-3.51* HGB-10.6* HCT-30.6* MCV-87 MCH-30.1 MCHC-34.6 RDW-13.2 [**2113-9-20**] 07:59PM NEUTS-84* BANDS-2 LYMPHS-8* MONOS-6 EOS-0 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 Brief Hospital Course: Upon admission, patient was seen by the surgical service. She was noted to have a strange affect with some confusion. She had a gastrograffin study to r/o obstruction. Based on negative study, it was thought that patient had a colonic obstruction secondary to opiate use. She was made NPO and treated w/ IVF. Her acute renal failure resolved with intravenous fluids. On [**9-21**], Ms. [**Known lastname 20789**] was found to be more lethargic, anxious and agitated with a slight bandemia. Given her mental status change, a lumbar puncture was performed, which was negative for any infection. She was ruled out for myocardial infarction by enzymes due to complaint of chest pain. She was also started on Keflex for cellulitis of the surgical site of her facial basal cell ca resection. Later that night, she was also found to have a blood glucose in the 40's and was transferred to the [**Hospital Unit Name 153**]. Her [**Hospital Unit Name 153**] course significant for resolution of hypoglycemia and ileus and also for a temperature spike and leukocytosis noted on [**2113-9-23**]. Fever work-up included urine culture, chest x-ray, blood cultures. Cultures all negative, but CXR revealed LLL infiltrate with effusion. Started on Ceftriaxone and Azithromycin for pneumonia. Pleural fluid tapped showing transudative effusion. All cultures remain negative to date. Work-up of her hypoglycemia included cortisol (12.8), [**Doctor First Name **] (negative), anti-centromere antibody (negative), rheumatoid factor (10; in normal range), scleroderma antibody (pending), complement levels (case report of pseudohypoglycemia in Raynaud's) C3 and C4 (normal levels), insulin level (6) (in normal range), c-peptide (4.4 =slightly higher than normal range), beta-hydroxybutyrate (<0.1) (in normal range), sulfonyurea level (pending). Patient was called out to the floor on [**9-25**], but remained in the ICU until [**9-26**], awaiting bed placement. She was transferred in stable condition. Her hospital course also significant for a slowly decreasing hematocrit. She presented on [**2113-9-20**] with a hematocrit of 35, but appeared dehydrated at the time. With IV hydration, her hematocrit decreased to 30. Over the last [**3-30**] days, it has trended down to 26.3, then 27, then 24.4 on day of discharge. Her anemia is thought to be secondary to frequent blood draws and IVF resusitation, and a preliminary work up shows anemia of chronic disease with low iron and tibc. A reticulocyte count was sent and was low at 0.9. Her GUAIAC was noted to be both trace positive and negative during her admission. She was completely asymtomatic of this hematocrit drop and did not wish to be transfused prior to discharge. Patient has a baseline hct in the 34-35 range, we believe, which may be attributed to her diagnosis of MGUS. This new decline should be closely monitored and patient was told to have her counts checked within a few days of discharge. She will need an outpatient colonoscopy. Patient's white blood cell count increased to 19.9 on day of planned discharge ([**9-26**]). A manual differential was added and showed increasing bands to 14. During this time, patient remained afebrile and continued to feel well. Her CSF and pleural fluid cultures remained negative. Urine and blood cultures were also negative. At this time, a repeat urinalysis was obtained and was negative for any signs of infection. A c dif toxin was sent (pt c/o mild bloating, no diarrhea) but did not reach the lab for some reason. Her only known infectious source remains her Left lower lobe infiltrate seen on xray, for which she continued to be treated with azithromycin/ceftriaxone until discharge, when she was changed to levofloxacin to complete a 10 day course. On [**9-27**], patient continued to feel better. She remained afebrile, had a normal BM, which relieved her bloating, and her wbc decreased to 16.5 with decreased bands of 5. Patient was told to follow up with her wbc's as well upon discharge. It is of note that her LDH was in the normal range during her hospitalization. She has close follow up with Dr [**Last Name (STitle) **], scheduled for 2 weeks from her discharge to follow up on these heme issues. Medications on Admission: Medications at home triam/hctz 25/50mg QD celexa 20mg QD Toprol 50mg QD Tums suppositories/enemas Medications on transfer from [**Hospital Unit Name 153**]: Reglan 10mg PO TID calcium carbonate PRN Lorazepam PRN Aluminum-Magnesium Hydrox.-Simethicone 15-30 ml PO QID:PRN Zolpidem Tartrate 5 mg PO HS Famotidine 20 mg PO BID Azithromycin 250 mg PO Q24H Ceftriaxone 1 gm IV Q24H Thiamine HCl 100 mg IV QD Acetaminophen 325-650 mg PO Q4-6H:PRN Bisacodyl 10 mg PR HS:PRN Mupirocin Cream 2% 1 Appl TP [**Hospital1 **] to nose wound Discharge Medications: 1. Mupirocin Calcium 2 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day). Disp:*qs 2 weeks tube* Refills:*2* 2. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed. Tablet, Chewable(s) 3. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 4. Celexa 20 mg Tablet Sig: One (1) Tablet PO once a day: as before . 5. Nifedipine ER 60 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO once a day: as before. 6. Toprol XL 50 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO once a day: as before. 7. Levaquin 500 mg Tablet Sig: One (1) Tablet PO once a day for 6 days. Disp:*6 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Post operative, narcotic Ileus Left lower lobe Pneumonia hypertension Monoclonal gammopathy of unknown significance Gastroesophageal Reflux Disease h/o bowel obstuction and resection Recent excision of basal cell carcinoma of nose Discharge Condition: stable Discharge Instructions: **Please take all medications as prescribed. New medications include levaquin (for 5 more days to complete pneumonia treatment) and protonix (for heartburn). You may stop or decrease the dose of protonix as your symptoms improve. Please bring your medication list with you to Dr[**Name (NI) 2935**] office so he can make adjustments as necessary. **If you develop fevers, chills, nausea, worsening abdominal pain, confusion, please return to the nearest emergency room. **Please follow up with your physicians as stated below. Followup Instructions: Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2204**] [**Telephone/Fax (3) 20790**] on [**2113-10-23**] at 2:40 pm. This was his earliest appointment, but the office will call you with an appointment sooner within the next few days. He should recheck your blood counts to make sure your white blood cells are decreasing and your red blood cells are increasing towards normal levels. You also have pending labs that were sent out that need to be followed up with such as sulfonylurea levels and the scleroderma antibody that were checked as a work up for your symptoms and low blood surgars. Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 647**], MD Where: [**Hospital6 29**] HEMATOLOGY/ONCOLOGY Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2113-10-17**] 4:00 Completed by:[**2113-9-27**]

[ "998.59", "511.9", "251.1", "507.0", "276.5", "682.0", "584.9", "560.1", "E935.2" ]

icd9cm

[ [ [] ] ]

[ "96.07", "34.91", "03.31" ]

icd9pcs

[ [ [] ] ]

8712, 8718

3035, 7262

337, 369

8993, 9001

2315, 3012

9576, 10415

1603, 1622

7842, 8689

8739, 8972

7288, 7819

9025, 9553

1637, 2296

269, 299

397, 1033

1055, 1493

1509, 1587

67,446

156,485

9041

Discharge summary

report

Admission Date: [**2193-7-12**] Discharge Date: [**2193-7-18**] Date of Birth: [**2108-6-1**] Sex: F Service: MEDICINE Allergies: Bacitracin Attending:[**First Name3 (LF) 2763**] Chief Complaint: fell Major Surgical or Invasive Procedure: none History of Present Illness: Reason for MICU transfer: hypoxia History of Present Illness: 85 yo F w/ poor pulmonary function on 5L NC at baseline (up to 9 L if exercising). The patient reports that she went to her PCP yesterday morning for routine f/u. She was c/o feeling weak/low energy and he wanted to check U/A, but she was unable to urinate. He did check routine labs and told her she was anemic and to increase her Fe supplement. They also discussed stopping her coumadin, but wanted to speak with her pulmonologist Dr. [**Last Name (STitle) 575**] first. She went home and was generally feeling weak with low energy. She then had a bout of loose stool, nonbloody but high volume in the afternoon. Denies any associated n/v/f/c/abd pain. States has had periodic diarrhea, last episode Monday, but prior to that had been several weeks. She then had a poor appetite for the rest of the day and maybe ate one [**Location (un) 6002**] all day. In the early morning around 4 am she got up to go the the bathroom and on the way back to her bed felt her legs give out and fell to the floor. No preceeding dizziness, n, chest pain, palps. No LOC. Possible head strike but remembers the whole thing. Does feel some pain in back of neck and right arm as a result. Regarding her breathing, she feels it has been gradually worsening lately. Her only recent medication changes here a decrease in her prednisone from 20 to 15 mg in [**Month (only) 547**]. She also had a UTI about 1 month ago. Initially treated with Cipro, but came back as a resistant organism and was changed to another abx - ? macrobid per her daughter. On Arrival to the ED, VS were 88 148/80 16 87% 6L. She triggered for hypoxia, had a negative trauma fast. She was put on a non-rebreather with sats in the 90s, she was then transitioned off and was 87% on 6L NC. A CXR showed severe pulmonary fibrosis, but no clear infiltrate or edema. NCHCT unremarkable and CT C spine showed multilevel DJD. ECG not changed from baseline, reportedly guaiac neg. VBG was 7.32/65/35/35. Labs showed baseline anemia at 29, [**Last Name (un) **] with Cr 1.4 from baseline of 1.0, [**Last Name (un) 263**] 2.3, neg trop. She was given 500 CC NS. She was admitted to the MICU for further evaluation of her hypoxia. Vitals on transfer were 82, 98% on 6L NC. Drops to 60s on 5L. On arrival to the MICU, patient reports she is feeling slightly better, but her breathing not quite at baseline. She also feels some discomfort from skin tears on her arms and right chest wall. Past Medical History: Past Medical History: - Severe idiopathic pulmonary fibrosis, on high flow oxygen, Last FEV1 and vital capacity 0.72 and 0.87 (37 and 30% predicted respectively)[**4-25**] - pulmonary hypertension with biventricular dilatation. - DMII - HTN - HL - severe lower back pain - depression - hiatal hernia - small left upper lobe nodule - thyroid nodule - h/o pontine stroke ([**2186**]) - residual mild left hemiparesis - submassive PE and DVT [**12-24**], on anticoagulation with IVC filter placed at that time --> plan to stop soon. - History of GI bleed, likely due to prior nonsteroidal anti-inflammatory drug therapy. -CAD. Social History: She lives in [**Hospital1 392**] with her daughter [**Name (NI) **]. She has been a widow since [**2159**]. She has two daughters, one who lives in [**State 350**], and another who lives in [**State 5887**]. She has a son who lives in [**Name (NI) 12000**]. She smoked only for 10 years and quit 40 years ago. She reports [**2-15**] glasses of wine per week Family History: No family history of blood clots or strokes. She reports a cousin has [**Name2 (NI) 500**] cancer but denies other cancer in the family. She also notes several family members have heart disease. Physical Exam: Vitals: T: 98.4 BP: 107/64 P: 83 R:20 -30s when talking O2:NRB to 92% on 5L General: tired appearing elderly female, NAD, resting in bed [**Name2 (NI) 4459**]: Sclera anicteric, mildly dry MM, oropharynx clear, EOMI, PERRL Neck: supple CV: Regular rate and rhythm, prominent S2, no murmurs appreciated Lungs: dry crackles b/l, halfway up b/l Abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, 1+ edema b/l L>R. No calf ttp or cords, neg homans sign b/l SKin: diffuse ecchymoses and skin tears over arms Discharge exam unchanged exam, bandages in place over skin Pertinent Results: [**2193-7-12**] 11:43AM URINE BLOOD-SM NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-SM [**2193-7-12**] 05:30AM GLUCOSE-112* UREA N-36* CREAT-1.4* SODIUM-144 POTASSIUM-4.5 CHLORIDE-100 TOTAL CO2-32 ANION GAP-17 [**2193-7-12**] 05:30AM cTropnT-<0.01 [**2193-7-12**] 05:30AM WBC-7.1 RBC-2.97* HGB-9.1* HCT-29.0* MCV-98 MCH-30.8 MCHC-31.5 RDW-15.8* [**2193-7-12**] 05:30AM NEUTS-71.5* LYMPHS-21.0 MONOS-4.6 EOS-2.3 BASOS-0.5 [**2193-7-12**] 05:30AM PLT COUNT-218 [**2193-7-12**] 05:30AM PT-23.7* PTT-31.2 [**Month/Day/Year 263**](PT)-2.3* Brief Hospital Course: 85 yo F with severe pulmonary fibrosis on 5 L O2 at home who presents with presyncope and increased hypoxia, likely related to dehydration in setting of diarrhea # mechanical fall/dehydration: patient was brought into the hospital with presyncope and a mechanical fall after diarrhea, fall was likely related to dehydration and presyncope. She was treated with IV fluids and given high flow oxygen per her usual requirements due to IPF. She was found to have E. Coli UTI with frequency and urgency that was treated with PO antibiotics which may have also contributed to weakness that led to her mechanical fall. She was evaluated by physical therapy and found to be in need of wheelchair for mobility and of 24 hour care. The patient was discharged to rehab. # Interstitial pulmonary disease/Hypoxia: She was kept in the ICU because of her desaturations into the 80s and high 70s while speaking due to her underlying and progressive pulmonary fibrosis. She was kept on her home O2 and occasionally required increasing amounts of O2 by nasal cannula and high flow oxygen for symptom control. She stayed in the ICU throughout her admission due to desaturations with eating, talking and other activity however the patient remained awake and conversant throughout and other vital signs were stable. Prednisone continued at 15 mg daily during admission and weaned to 10 mg daily on discharge, bactrim continued for PCP [**Name Initial (PRE) **]. # UTI: Ucx grew E. coli sensitive to ceftriaxone. Patient transitioned to PO cefpodoxime for 7 day course, to finish on [**2193-7-21**]. # [**Last Name (un) **]: Most like prerenal in setting of dehydration from poor PO intake and diarrhea. Improved with IV fluids. Cr returned to baseline on discharge. # anemia: Currently at baseline. no s/s of bleeding. Fe supplementation continued and pt was started on B12 supplementation as well. # Hx PE/DVT on coumadin: Now 6 months out from diagnosis of PE, discussed with Dr. [**Last Name (STitle) 575**] (pulmonary) and agreed with discontinuing coumadin. # DM2: Metformin held while in house with sliding scale insulin for blood sugar controlled. Restarted metformin on discharge. # CAD: continued ASA, metoprolol, simvastatin # depression: continued lexapro, mirtazepine Transitional Issues: # Code status: patient was DNR/DNI during this admission # Patient requires 4-5 liters of oxygen at baseline and desaturates with activity including eating, working with physical therapy and talking related to her interstitial pulmonary disease. Other vital signs remain stable when this occurs and there are no further interventions for her pulmonary disease. # Cefpodoxime course ends on [**2193-7-21**] for UTI treatment Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from PatientwebOMR. 1. Sulfameth/Trimethoprim Suspension 10 mL PO DAILY 2. Escitalopram Oxalate 40 mg PO QAM 3. Escitalopram Oxalate 20 mg PO QPM 4. Fluticasone Propionate NASAL 2 SPRY NU DAILY 5. MetFORMIN (Glucophage) 1000 mg PO DAILY 6. MetFORMIN (Glucophage) 500 mg PO QHS 7. Metoprolol Tartrate 12.5 mg PO BID 8. Mirtazapine 30 mg PO HS 9. Pantoprazole 20 mg PO Q12H 10. PredniSONE 15 mg PO DAILY 11. Simvastatin 20 mg PO DAILY 12. Warfarin 2 mg PO 4X/WEEK ([**Doctor First Name **],MO,WE,TH,FR) 13. Aspirin 81 mg PO DAILY 14. Calcium 600 with Vitamin D3 *NF* (calcium carbonate-vitamin D3) 600 mg(1,500mg) -400 unit Oral daily 15. Ferrous Sulfate 325 mg PO DAILY Discharge Medications: 1. Aspirin 81 mg PO DAILY 2. Escitalopram Oxalate 40 mg PO QAM 3. Escitalopram Oxalate 20 mg PO QPM 4. Ferrous Sulfate 325 mg PO DAILY 5. Fluticasone Propionate NASAL 2 SPRY NU DAILY 6. Metoprolol Tartrate 12.5 mg PO BID 7. Mirtazapine 30 mg PO HS 8. Pantoprazole 20 mg PO Q12H 9. PredniSONE 15 mg PO DAILY 10. Simvastatin 20 mg PO DAILY 11. Cefpodoxime Proxetil 200 mg PO Q12H Duration: 7 Days 12. Calcium 600 with Vitamin D3 *NF* (calcium carbonate-vitamin D3) 600 mg(1,500mg) -400 unit Oral daily 13. MetFORMIN (Glucophage) 1000 mg PO DAILY 14. MetFORMIN (Glucophage) 500 mg PO QHS 15. Sulfameth/Trimethoprim Suspension 10 mL PO DAILY 16. Loperamide 2 mg PO QAM:PRN diarrhea Please do not take if having fevers. Discharge Disposition: Extended Care Facility: Newbridge on the [**Doctor Last Name **] - [**Location (un) 1411**] Discharge Diagnosis: Dehydration Interstitial pulmonary fibrosis 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 10113**], It was our pleasure to care for you at [**Hospital1 18**]. You were seen in the hospital for weakness and shortness of breath, most likely related to your lung disease and being dehydrated. You were monitored in the ICU and your symptoms improved with IV fluids. Changes to your medications: Please STOP taking warfarin Please START taking cefpodoxime 200 mg twice a day until [**2193-7-21**] Please START taking loperamide every morning as needed for diarrhea. Do not take if you are having fevers. Followup Instructions: Please call your PCP, [**Last Name (NamePattern4) **]. [**First Name (STitle) **] to set up an appointment in the next 1-2 weeks. Tel:[**Telephone/Fax (1) 8324**] Department: PULMONARY FUNCTION LAB When: FRIDAY [**2193-8-16**] at 9:10 AM With: PULMONARY FUNCTION LAB [**Telephone/Fax (1) 609**] Building: [**Hospital6 29**] [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: MEDICAL SPECIALTIES When: FRIDAY [**2193-8-16**] at 9:30 AM With: [**First Name11 (Name Pattern1) 1569**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**Telephone/Fax (1) 612**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: PFT When: FRIDAY [**2193-8-16**] at 9:30 AM [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 2764**] Completed by:[**2193-7-18**]

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icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

9635, 9729

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275, 281

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185,686

22743

Discharge summary

report

Admission Date: [**2195-7-24**] Discharge Date: [**2195-8-1**] Date of Birth: [**2133-11-11**] Sex: M Service: NEUROLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2569**] Chief Complaint: Poorly responsive with decreased speech output Major Surgical or Invasive Procedure: G-tube placement History of Present Illness: History obtained from records from [**Hospital3 **] Hospital HPI: 61 M w/ hx Aortic St. [**Male First Name (un) 923**] mechanical valve, on coumadin, (though found subtherapeutic), prior stroke sympotmatic of vertigo, HTN, HLD, CAD, s/p CABG x 1, COPD, anemia, last spoke with his daughter the morning of [**7-22**]. He did not answer phone calls later in the day, and eventually daughter [**Name (NI) 653**] a family friend who is a police officer to check on him. He was found down, w/ abrasions on his face, and aphasic. He was taken to OSH where NCHCT revealed large L-MCA infarct, started on mannitol and transferred to [**Hospital1 18**]. Past Medical History: AoVR (St. [**Male First Name (un) 923**] mechanical), chroncially anticoagulated prior stroke sympotmatic of vertigo HTN HLD CAD, s/p CABG x 1 COPD anemia Social History: Patient is married with two daughters. [**Name (NI) **] works as the vice president for a food processing company. Smoking history: smoked 1-2 packs a day for the past 40 years, quit [**2190-9-20**]. Admits to only social ETOH. Denies recreational drug use. Family History: Father had several strokes in his 60's, dying of an MI at age 65. Physical Exam: T- 98.1 F BP- 133/89 HR- 91 RR- 23 O2Sat 96% 2 L NC Gen: Lying in bed, NAD HEENT: NC/AT, dry mucosa, abrasion on R face. R eye scleral hematoma Neck: No tenderness to palpation, no carotid or vertebral bruit (though can appreciate transmitted S1 and S2) CV: RRR, Nl S1 and S2, no murmurs/gallops/rubs (of note, does not have the classic mechanical valve sound) Lung: scattered ronchi bilaterally aBd: +BS soft, nontender ext: no c/c/e; equal radial and pedal pulses B/L. Neurologic examination: Mental status: Awake and alert, tracks examiner R to L. Makes grunting noises but to other vocalizations. Does not follow any verbal commands, but will occassionally mimic e.g. holding up arm. Cranial Nerves: Pupils equally round and reactive to light, 4 to 1 mm bilaterally. Visual fields: BTT present, but diminished on R, intact on L. Extraocular movements cross midline bilaterally, no nystagmus. Facial movement with mild R weakness - though appears to move well when yawns. (+) cough. Motor: Normal bulk bilaterally. Mildly increased tone in RUE. No observed myoclonus or tremor Does not cooperate with motor testing fully, but moves LUE and LLE spont against gravity and able to provide some resistance. Appears to have some spont mvmt of RUE (attempting to fix sheets). Both RUE and RLE flex to noxious stim against gravity. Sensation: withdraws to noxious in all 4 ext. Reflexes: +2 and symmetric throughout, except Achilles which were 1 B/L. Toes downgoing L, upgoing on R Pertinent Results: Radiology Report CT HEAD W/O CONTRAST Study Date of [**2195-7-27**] 9:05 AM HISTORY: 61-year-old male with large stroke, evaluate for bleeding. COMPARISON: [**7-25**] and [**2195-7-24**]. TECHNIQUE: Contiguous axial images of the head were obtained without IV contrast. FINDINGS: A large left MCA territorial infarct is similar in appearance to the prior study, without evidence of hemorrhagic transformation. No significant mass effect is identified, without shift of normally midline structures. Periventricular white matter hypodensities are most compatible with chronic small vessel ischmemic changes. A more confluent hypodensity within the right parietal lobe is unchanged, and likely reflects a more chronic infarct with encephalomalacia and some volume loss with ex vacuo dilatation of the ipsilateral lateral ventricle. The ventricular system is stable in size and configuration, without evidence of new hydrocephalus. The paranasal sinuses and mastoid air cells are normally aerated. Atherosclerotic calcifications of the cavernous carotid and vertebral arteries are seen bilaterally. Osseous structures are unremarkable. IMPRESSION: Stable appearance of large left MCA territorial infarct, without evidence of hemorrhagic transformation. Brief Hospital Course: Mr. [**Known lastname **] is a 61 M w/ hx St. [**Male First Name (un) 923**] mechanical Ao valve, on coumadin, (though found subtherapeutic), recently found down at home R hemiparetic and aphasic, taken to OSH where NCHCT revealed large L-MCA infarct, started on mannitol and transferred to [**Hospital1 18**]. 1. Left MCA infarct: Mr. [**Known lastname **] was found to have a large L MCA infarct, suspected to be secondary to having a mechanical aortic valve, and being subtherapeutic on Coumadin. He was started on mannitol prior to transfer to [**Hospital1 18**]. He had serial head CTs which showed a stable large infarct, and the mannitol was tapered off, discontinued on [**7-29**]. With his stable head CTs, without signs of hemorrhagic conversion, he was started on Coumadin on [**7-29**], which he should continue with a goal INR of 2.0-2.5. He had an A1C of 5.4% and an LDL of 82. Exam on discharge was notable for a fluent aphasia. He is able to state high frequency phrases, but also will say non-sensical words, and is perseverative, with inability to reliably follow commands. He is able to move all extremities, but does not cooperate with full strength testing. 2. Hypertension. After allowing autoregulation of BPs, Mr. [**Known lastname **] was restarted on lisinopril, with a goal SBP of <140. 3. Bradycardia. Mr. [**Known lastname **] is consistently in sinus bradycardia, generally from 40-50 bpms. His 12-lead EKG is normal, and this may simply be a consequence of his stroke. 4. FEN: The patient was evaluated by speech and swallow, with a video swallow, which raised concern for possible silent aspiration. He had a G-tube placed on [**7-29**], but should continue to work with speech and swallow to work on improvement of his abilities. Code status: Full, confirmed with wife [**Name (NI) 382**] Medications on Admission: coumadin 3 mg Qday Lasix 20 mg Qday Clonidine 0.1 mg [**Hospital1 **] Lisinopril 20 mg Qday Ranitidine, dose unknown Zocor 40 mg Qday Norvasc, dose unknown Coreg 25 mg [**Hospital1 **] Wellbutrin 150 mg Qday Buproprion dose unknown Discharge Medications: 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for Constipation. 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 5. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day) as needed for thrush. 6. Lisinopril 10 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 7. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000) U Injection TID (3 times a day). 8. Warfarin 1 mg Tablet Sig: Three (3) Tablet PO Once Daily at 4 PM. Discharge Disposition: Extended Care Facility: [**Hospital **] Hospital of [**Location (un) **] and Islands Discharge Diagnosis: Primary: Left MCA stroke Secondary: Mechanical aortic valve Discharge Condition: Fluent aphasia. Frequent use of high frequency phrases, and occasional non-sensical words, however exihibits poor comprehension, unable to follow commands. Able to lift all extremities anti-gravity Discharge Instructions: You were admitted for right sided weakness and speech difficulties. You were found to have a large left sided stroke. This was likely secondary to not being therapeutic on your Coumadin. The Coumadin can now be restarted, with a goal INR of [**12-22**].5. If you notice new headache, worsening weakness, or other concerning symptoms, please return to the nearest ED for further evaluation. Followup Instructions: You have the following follow-up appointment: Provider: [**Name10 (NameIs) **] [**Name11 (NameIs) **], [**Name Initial (NameIs) **].D. Phone:[**Telephone/Fax (1) 2574**] Date/Time:[**2195-9-8**] 1:00 [**First Name8 (NamePattern2) **] [**Name8 (MD) 162**] MD [**MD Number(2) 2575**]

[ "401.9", "V43.3", "V58.61", "787.20", "434.11", "414.00", "496", "285.9", "V45.81", "427.89" ]

icd9cm

[ [ [] ] ]

[ "96.6", "43.11" ]

icd9pcs

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7177, 7264

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363, 381

7369, 7571

3118, 4373

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7285, 7348

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2318, 3099

2123, 2302

2108, 2108

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1252, 1512

31,442

168,138

30847

Discharge summary

report

Admission Date: [**2118-5-20**] Discharge Date: [**2118-5-26**] Date of Birth: [**2036-2-26**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 6578**] Chief Complaint: dyspnea Major Surgical or Invasive Procedure: Temporary Hemodialysis line placement by interventional radiology History of Present Illness: 82 yo male with ESRD on HD, Afib, s/p PPM/ICD, CAD, HTN, PVD presented with 2 day history of dyspnea. He was recently discharged on [**5-13**] from the vascular service after undergoing angioplasty of his LLE for chronic ulcers. He was doing well at home, then per his wife, patient started having increased dyspnea for the last 2 days. She didn't think he had fevers at home, and the cough was non-productive at home. She states he also seemed more lethargic at home, but mental status was normal. She also reports that he did complain of some abdominal bloating, but no significant pain. . In the ED, initial vitals were 99.7, 149/80, 100, 18, 76% on NRB. He was started on BiPAP 10/5 with improvement of O2 sat to 100%. He was given vanco, zosyn, and levoflox for treatment of HAP, though no acute infiltrate was noted on CXR. Nephrology was called in the ER, and plan is for HD once admitted to MICU. He was noted to have hyperkalemia to 6.5, but no ECG changes. [**Name (NI) **] wife and patient both confirmed DNR/DNI status. During his stay in ER, he had a temperature to 102. Patient was then transferred to MICU on BiPAP. Past Medical History: 1. Atrial fibrillation- the patient's Coumadin was [**Name (NI) 8910**] in [**2-/2116**], not restarted due to fall risk. -CHF, TTE [**12-26**] EF 20-30% LAE, [**Last Name (un) **], LV/RV hypokinesis, mod TR 2. Status post pacemaker placement in [**2089**]- This was placed on the right side after an episode of cardiac arrhythmia resulting in cardiac arrest. The patient reports that this pacemaker is no longer functional. 3. Status post pacemaker with defibrillator placement- [**2102**] 4. Status post cardiac arrest- This occurred in [**2089**] and was due to an arrhythmia. 5. Coronary artery disease status post CABG- [**2102**] 6. Hypertension 7. End-stage renal disease- hemodialysis M,W,F in [**Location (un) **]. His nephrologist is Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. 8. Anemia- The patient is on Darbopoitin. 9. Fall- The patient had a fall on Mother's Day [**2115**]. He fell again on [**2116-5-14**] with resultant subdural hematoma. 10. Umbilical hernia 11. Hypercholesterolemia 12. Hypothyroidism 13. Melanoma 14. Cirrhosis? Social History: Pt lives at home with his wife. [**Name (NI) **] has home health aid during the nights and early mornings. Family History: Non-contributory. Physical Exam: GEN: WDWN elderly male, NAD, somnolent but arousable to voice; on NIPPV HEENT: mask on, oropharynx dry CV: irregularly irregular, 2/6 systolic murmur at base LUNGS: bibasilar crackles, few scattered wheezes ABDOMEN: soft, distenended, positive BS. + fluid wave. non tender EXT: no edema SKIN: no rash NEURO: A/O x 3. moves all extremities without difficulty Pertinent Results: Admission Labs: [**2118-5-20**] 09:00AM BLOOD WBC-17.7*# RBC-3.54* Hgb-11.9* Hct-39.0* MCV-110* MCH-33.6* MCHC-30.4* RDW-17.6* Plt Ct-258 [**2118-5-20**] 09:00AM BLOOD Neuts-94* Bands-0 Lymphs-3* Monos-3 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 [**2118-5-20**] 09:00AM BLOOD Hypochr-2+ Anisocy-2+ Poiklo-NORMAL Macrocy-2+ Microcy-NORMAL Polychr-OCCASIONAL [**2118-5-20**] 09:00AM BLOOD PT-16.6* PTT-31.2 INR(PT)-1.5* [**2118-5-20**] 09:00AM BLOOD Glucose-92 UreaN-32* Creat-4.5* Na-138 K-6.2* Cl-98 HCO3-24 AnGap-22* [**2118-5-20**] 09:00AM BLOOD ALT-28 AST-55* CK(CPK)-42 AlkPhos-207* TotBili-2.0* [**2118-5-20**] 09:00AM BLOOD cTropnT-0.35* [**2118-5-20**] 09:00AM BLOOD Digoxin-1.0 Microbiology: BLOOD CULTURE ([**2118-5-20**]) Postive x2: Aerobic Bottle Gram Stain (Final [**2118-5-20**]): GRAM POSITIVE COCCI. IN PAIRS AND CLUSTERS. SENSITIVITIES: STAPH AUREUS COAG + | CLINDAMYCIN-----------<=0.25 S ERYTHROMYCIN----------<=0.25 S GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- 0.25 S OXACILLIN------------- 0.5 S TRIMETHOPRIM/SULFA---- <=0.5 S MRSA SCREEN (Final [**2118-5-22**]): No MRSA isolated. WOUND CULTURE (Final [**2118-5-24**]): Source: Dialysis Catheter Tip STAPH AUREUS COAG +. >15 colonies. SENSITIVITIES: MIC expressed in MCG/ML STAPH AUREUS COAG + | CLINDAMYCIN-----------<=0.25 S ERYTHROMYCIN----------<=0.25 S GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- 0.25 S OXACILLIN------------- 0.5 S TRIMETHOPRIM/SULFA---- <=0.5 S Blood Cultures negative on [**2118-5-21**] x2, [**2118-5-22**], [**2118-5-24**]. Pending on [**2118-5-26**]. Discharge Labs: [**2118-5-26**] 07:55AM BLOOD WBC-9.1 RBC-3.01* Hgb-9.9* Hct-32.6* MCV-108* MCH-32.9* MCHC-30.5* RDW-16.3* Plt Ct-215 [**2118-5-20**] 09:00AM BLOOD Neuts-94* Bands-0 Lymphs-3* Monos-3 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 [**2118-5-26**] 07:55AM BLOOD Plt Ct-215 [**2118-5-26**] 07:55AM BLOOD Glucose-80 UreaN-18 Creat-3.6* Na-142 K-4.1 Cl-99 HCO3-28 AnGap-19 [**2118-5-22**] 03:33AM BLOOD ALT-18 AST-25 LD(LDH)-206 AlkPhos-160* TotBili-1.0 [**2118-5-26**] 07:55AM BLOOD Calcium-9.0 Phos-4.2 Mg-1.6 [**2118-5-26**] 07:55AM BLOOD Vanco-17.6 [**2118-5-22**] 03:33AM BLOOD Digoxin-0.9 PROCEDURE: Placement of non-tunneled hemodialysis catheter in the right internal jugular vein. ([**2118-5-23**]) IMPRESSION: Successful placement of non-tunneled temporary hemodialysis catheter via the right internal jugular vein with tip of the catheter terminating in the right atrium,with ultrasound and fluoroscopic guidance. Catheter is ready to use. CHEST X-RAYS PORTABLE CXR ([**2118-5-20**]) IMPRESSION: Somewhat limited study due to patient position and respiratory motion. Persitent right pleural effusion and right basilar opacity, possibly representing atelectasis, but pneumonia is not excluded. Small left pleural effusion. No CHF. PORTABLE CXR ([**2118-5-21**]) IMPRESSION: No significant change from [**2118-5-20**]. Bilateral pleural effusions, moderate and partially loculated on the right and small on the left are stable. Stable cardiomegaly. PORTABLE CHEST X-RAY ([**2118-5-22**]) Comparison is made to the prior study from [**2118-5-21**]. The heart is markedly enlarged. Mediastinum is within normal limits but demonstrates post-surgical changes consistent with sternotomy. The right IJ large-bore catheter has been removed. Bilateral pacemakers are present with single leads each terminating in the right ventricle. There are bilateral pleural effusions. The one on the right is loculated and unchanged from the prior study. There is bibasilar atelectasis. ECHO TTE ([**2118-5-21**]): IMPRESSION: No echocardiographic evidence of endocarditis. Moderate global left ventricular hypokinesis with severe diastolic dysfunction and elevated filling pressures. Dilated right ventricle. Moderate pulmonary hypertension. Severe aortic stenosis. Moderate to severe tricuspid regurgitation. Moderate sized loculated pericardial effusion located posterior to the inferior wall. If clinically suggested, the absence of a vegetation by 2D echocardiography does not exclude endocarditis. Compared with the prior study (images reviewed) of [**2117-1-5**], the severity of aortic stenosis and tricuspid regurgitation have increased. Left ventricular ejection fraction appears more vigorous. The pericardial effusion is new. No aortic regurgitation is seen. EKG Atrial fibrillation. Right bundle-branch block. Left anterior hemiblock. Compared to the previous tracing of [**2118-5-11**] no change. Intervals Axes Rate PR QRS QT/QTc P QRS T 93 0 142 344/401 0 -100 75 URINE Brief Hospital Course: 82 yo male with ESRD on HD, HTN, PVD, CAD s/p CABG, s/p PPM/ICD placement, afib who presented with 2 days onset of dyspnea, lethargy. in ED found to be hypoxic to 76% on NRB. The patient was admitted to MICU, started on Vancomycin, Zosyn and Levaquin for presumed sepsis. Oxygen saturation has improved to 100% on room air on BiPAP. BiPAP was discontiniued after several hours and the patient was placed on 4L NC with oxygen saturation above 90%. Blood cultures from the day of admission grew out GPCs. Hemodialysis catheter was promptly removed. HD catheter tip cultures yielded Gram positive rods (Staph aureus -- see sensitivities in report). Zosyn and Levaquin were subsequently [**Date Range 8910**], but the patient was continued on Vancomycin. Vancomycin troughs were obtained daily and Vancomycin dose was adjusted accordingly. The patient was hypotensive on several occasions while in MICU, but always responded well to small fluid boluses of 250cc, and never required pressors. We were careful to avoid large boluses of fluid as the patient is on dialysis. The patient was initially febrile, but defervesed by HD#3. Echocardiogram (TTE) reveraled on evidence of endocarditis, but showed a small pericardial effusion that was not tappable and did not show tamponade physiology. The patient was subsequently transferred to a medicine floor. He experienced gradual improvement of oxygenation to his baseline over the course of hospitalization (currently over 95% on room air). Thus we concluded that hypoxia was secondary to patient's underlying sepsis. Nebulizer treatments with Ipratropium and Albuterol were continue throughout hospitalization. A new hemodialysis catheter was placed on [**2118-5-23**] by IR. The patient continued to receive dialysis on schedule throughout this hospitalization. We continued nephrocaps. At the time of discharge, the patient is afebrile with stable blood pressures and oxygenation above 95% on room air. We continued to obtain daily blood cultures. Blood cultures have not yielded any organisms since [**2118-5-21**]. The patient will need to complete a 14 day total course of Vancomycin since the time of last positive blood cultures to be completed on [**2118-6-3**]. He is being discharged to a rehabilitation facility. There are a few additional issues that have been stable during this hospitalization, but are discussed below: Peripheral Vascular Disease: the patient is s/p angioplasty in [**4-26**]. Wound care consult done for care of his LE ulcers. Dressings were changed regularly. We continued outpatient management with clopidogrel and aspirin. We continue to monitor distal pulses. Coronary Artery Disease - the patient is s/p CABG. We continued outpatient management with aspirin, plavix, and beta blocker Cirrhosis: The patient's mental status has returned to [**Location 213**] once underlying infection was treated. He was continued on rifaximin for prophylaxis. The patient had an coagulopathy (INR 1.3-1.4), but no evidence of active bleeding throughout hospitalization. Pruritis: Pt. with pruritus on his back, likely uremic in nature during this hospitalization. Treated with Hydrocerin, Sarna lotion and Capsaicin PRN with improved symptoms. Diet: The patient received Heart Healthy diet supplemented with Boost. Prophylaxis: The patient received SQ Heparin for DVT Prophylaxis and PPI for GI prophylaxis. Communication: with patient and wife; wife [**Name (NI) **] [**Telephone/Fax (1) 72992**] (cell), [**Telephone/Fax (1) 72991**] (home). Code status: Confirmed DNR / DNI during this hospitalization. Medications on Admission: ASA 81 mg daily Nephrocaps Clopidogrel 75 mg daily Digoxin 125 mcg every other day Lactulose TID Latanoprost QHS Levothyroxine 100 mcg daily Nadolol 10 mg daily Oxycodone 5 mg Q6H PRN Pantoprazole 40 mg daily Rifaximin 400 mg TID Zolpidem 5 mg QHS Discharge Medications: 1. Vancomycin in Dextrose 1 gram/200 mL Piggyback Sig: One (1) gram Intravenous HD PROTOCOL (HD Protochol) for 8 days: Please continue per HD protocol until [**2118-6-3**]. 2. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO Q SUNDAY, TUESDAY, FRIDAY (). 3. Rifaximin 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 5. Nadolol 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 6. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at bedtime). 9. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 10. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb inh Inhalation Q6H (every 6 hours) as needed for wheezing. 11. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 12. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) neb inh Inhalation Q4H (every 4 hours) as needed for wheezing. 13. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3 times a day). 14. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 15. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 16. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for insomnia. 17. White Petrolatum-Mineral Oil Cream Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day). 18. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day). 19. Capsaicin 0.025 % Cream Sig: One (1) Appl Topical TID (3 times a day) as needed for pruritis. 20. Acetaminophen 500 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - [**Location (un) 550**] Discharge Diagnosis: Primary: Sepsis secondary to hemodialysis line infection. Secondary: Peripheral vascular Disease, End Stage Renal Disease. Hypertension, Coronary Artery Disease, atrial fibrillation. Discharge Condition: Vital signs stable, afebrile, Systolic Blood Pressure 110s-120s, setting over 95% on room air. Discharge Instructions: You were admitted to the hospital with worsening shorness of breath, fevers and increasing confusion for a few days. In the Emergency Department, it was determined that your oxygenation was very poor and you were transferred to the ICU. You were started on broad spectrum antibiotics (Vanco, Zosyn, Levaquin). Your blood cultures grew bacteria (Gram Positive Cocci), which likely came from your Hemodialysis Line. Your antibiotic regimen was shortned to just Vancomycin, since we now knew the specific organism that was causing your infecion. Your old Hemodialysis line was replaced with a new one. Your fevers have resolved and your oxygenation got progressively better back to your baseline. Your mental status has returned to [**Location 213**]. You need to continue to take Vancomycin until [**2118-6-3**], for a total of 14 days since your positive blood culture. You also need to continue on your nebulizers. You need to follow up with your primary doctor Dr. [**Last Name (STitle) **], your Cardiologist Dr. [**Last Name (STitle) 73**], your Podiatrist, and your Vascular Surgeon Dr. [**Last Name (STitle) **] (see appointments below). Please call your primary doctor or return to the Emergency Department right away should you develop fevers, chills, difficulty breathing, shortness of breath, extreme fatigue, worsening cough or confusion. Followup Instructions: We made you an appointment with your primary doctor as follows: MD: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] Specialty: Internal Medicine Date and time: Monday [**2118-6-6**] at 9 AM Location: [**Hospital1 18**] [**Last Name (NamePattern1) 439**] [**Hospital **] Medical Office Building [**Hospital Unit Name **] Phone number: ([**Telephone/Fax (1) 6846**] You are also scheduled to follow up with your cardiologist Dr. [**Last Name (STitle) 73**] on Tuesday, [**2118-5-31**] at 11:00 am as shown below. Additionally, you have appointments with your Podiatrist and Vascular Surgeon as shown below: [**2118-6-16**] 03:20p Dr. [**First Name11 (Name Pattern1) 1112**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 1111**] LM [**Hospital Unit Name **], [**Location (un) **] VASCULAR SURGERY (SB) [**2118-6-16**] 02:30p VASCULAR [**Apartment Address(1) **] ([**Doctor First Name **]) LM [**Hospital Unit Name **], [**Location (un) **] VASCULAR LMOB (NHB) [**2118-6-7**] 03:40p PODIATRY,[**Doctor Last Name 722**] BA [**Hospital Unit Name **] ([**Hospital Ward Name **] COMPLEX), [**Location (un) **] [**Hospital 1947**] CLINIC (SB) [**2118-5-31**] 11:40a [**Doctor Last Name **]-CC7 SC [**Hospital Ward Name **] CLINICAL CTR, [**Location (un) **] CC7 CARDIOLOGY (SB) [**2118-5-31**] 11:00a DEVICE CLINIC (SB) SC [**Hospital Ward Name **] CLINICAL CTR, [**Location (un) **] DEVICE CLINIC (SB) Completed by:[**2118-8-2**]

[ "038.9", "585.6", "V45.81", "995.92", "518.81", "414.00", "996.62", "276.7", "V45.01", "403.91", "427.31", "285.9" ]

icd9cm

[ [ [] ] ]

[ "38.95", "39.95" ]

icd9pcs

[ [ [] ] ]

13682, 13767

7876, 11482

323, 391

13995, 14092

3212, 3212

15500, 16999

2799, 2818

11780, 13659

13788, 13974

11508, 11757

14116, 15477

4876, 7853

2833, 3193

276, 285

419, 1558

3229, 4859

1580, 2658

2674, 2783

10,375

134,572

50790

Discharge summary

report

Admission Date: [**2178-5-17**] Discharge Date: [**2178-6-18**] Date of Birth: [**2103-8-7**] Sex: F Service: SURGERY Allergies: Hydrochlorothiazide Attending:[**First Name3 (LF) 148**] Chief Complaint: Abdominal pain Major Surgical or Invasive Procedure: PICC line [**6-12**] ERCP w/ sphincterotomy [**5-18**] TEE [**6-9**] Tracheostomy [**6-11**] History of Present Illness: 74y female with hypertension and a recent stroke affecting her speech, who presents with 2 days of abdominal pain. She states it is constant, and radiates to her back. It started after eating a double cheese pizza and hard lemonade. There is no prior history of such an episode. She had multiple bouts of nausea and vomiting, with chills and decreased flatus. Past Medical History: 1. Colon cancer dx'd in [**2159**], tx'd with hemicolectomy, XRT, chemo. Last colonoscopy showed: Last CEA was in the 8 range (down from 9) 2. Lymphedema from XRT, takes a diuretic 3. Cataracts 4. Hypertension 5. heart murmur - TTE in [**2172**] showed LA mod dilated, LV mildly hypertrophied, aortic sclerosis, mild AI, mild MR. 6. Anxiety 7. CAD 8. Left corona radiata stroke with right facial droop and dysathria [**1-/2178**] 9. gallstones 10. scoliosis 11. rectus sheath hematoma 12. history of sacral ulcer status post z-plasty 13. ectopic pregnancy x2 Social History: Married, former secretary, waitress. + tobacco x 40 years at 4ppd, quit 30 yrs ago. No alcohol or drug use. Family History: Mother with stroke at age 82. no early deaths. 2 daughters- healthy Physical Exam: VS: temp 101.5, HR 114, BP 213/98, RR 20, 97%RA Ill appearing, no distress Sclera mildly icteric, mucous membranes dry Lungs clear to auscultation bilaterally Abdomen distended, soft, diffusely tender, especially in the epigastrum and right upper quandrant Rectal tone normal with no masses, guaiac negative Extremities warm, well perfused, 3+ edema Pertinent Results: [**2178-5-17**] 09:10PM BLOOD WBC-19.2*# RBC-4.81 Hgb-15.5 Hct-44.0 MCV-92 MCH-32.3* MCHC-35.2* RDW-13.3 Plt Ct-230 [**2178-5-17**] 09:10PM BLOOD Neuts-87* Bands-10* Lymphs-3* Monos-0 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 [**2178-5-17**] 09:10PM BLOOD PT-13.1 PTT-23.2 INR(PT)-1.1 [**2178-5-17**] 09:10PM BLOOD Glucose-189* UreaN-29* Creat-1.2* Na-143 K-3.5 Cl-104 HCO3-24 AnGap-19 [**2178-5-17**] 09:10PM BLOOD ALT-345* AST-388* AlkPhos-246* Amylase-1235* TotBili-8.4* [**2178-5-17**] 09:10PM BLOOD Lipase-2443* [**2178-5-17**] 09:10PM BLOOD Albumin-4.2 Calcium-9.3 Mg-1.2* [**2178-6-18**] 03:01AM BLOOD WBC-7.5 RBC-2.95* Hgb-8.8* Hct-27.7* MCV-94 MCH-29.9 MCHC-31.8 RDW-17.1* Plt Ct-213 [**2178-6-18**] 03:01AM BLOOD Plt Ct-213 [**2178-6-18**] 03:01AM BLOOD Glucose-100 UreaN-25* Creat-1.2* Na-141 K-3.5 Cl-102 HCO3-31* AnGap-12 [**2178-6-16**] 12:45AM BLOOD ALT-22 AST-14 AlkPhos-159* Amylase-37 TotBili-0.7 [**2178-6-16**] 12:45AM BLOOD Lipase-37 [**2178-6-18**] 03:01AM BLOOD Calcium-8.4 Phos-3.0 Mg-1.8 [**2178-6-18**] 05:25AM BLOOD Vanco-17.8* Ultrasound [**5-17**]: IMPRESSION: 1. Dilated common bile duct with mild intrahepatic biliary ductal dilatation and dilataion of the pancreatic duct. 2. Edematous gallbladder wall. ERCP [**5-18**]: There was bulging of the major pailla suggestive of an impacted stone. A stone causing partial obstruction was seen in the distal CBD. There was dilation of the CBD above the stone however accurate radiographic evaluation could not be obtained due to the use of the C-arm in the ICU. A sphincterotomy was performed in the 12 o'clock position using a sphincterotome over an existing guidewire. A 15mm balloon was used to sweep the duct multiple times wich successfully extracted stones, sludge and a large amount of purulent material. Brief Hospital Course: Ms. [**Known lastname 105630**] was admitted on [**2178-5-17**]. Ultrasound at the time of admission demonstrated pancreatic duct dilitation and an edematous gallbladder. She was admitted to the ICU. [**5-18**] she underwent ERCP w/ sphincterotomy, an impacted stone was removed. She has had a prolonged ICU course. Review of hospital course by system includes. Neuro: Neurology was consutled on [**5-29**] for mental status changes. The team believed the patient's MS [**First Name (Titles) 4245**] [**Last Name (Titles) 105631**] from her overall metabolic and infectious conditions. A head CT was performed which was negative. A lumbar puncture was also done which too was negative. Cardiovascular: The cardiology team was consulted on [**5-19**] and a TTE was obtained showing decreased biventricular systolic dysfunction representing a diffuse process. On [**6-1**] a repeat TTE followed by a TEE was done to rule out endocarditis; no vegatation or abscess was seen. A TEE was again performed on [**6-9**] there was no significant change from the prior study. The patient was treated with amiodarone to control her atrial fibrillation. Pulmonary: Patient was intubated on admission and transferred to the ICU. Patient was initially extubated on hospital day six. The patient was re-intubated on [**5-30**] for hypercarbic respiratory failure and airway protection. The patient was extubated again on [**6-5**] and re-intubated on [**6-6**] for respiratory decompensation. The patient ultimately underwent a tracheostomy on [**6-11**]. The patient tolerated a trach mask on [**6-12**]. Bronchoscopy on [**6-13**] with suctioning of bronchial plugs. CT chest on [**6-14**] showed collapse of the left lung with left sided pleural effusion. Left sided thoracentesis was done on [**6-14**] to remove fluid with hope of re-expanding left lung. GI: Patient was admitted with a diagnosis of gallstone pancreatitis, she underwent ERCP w/ sphincterotomy on [**5-18**]. Her tube feeds were started due anticipation of a prolonged period without orally based enteral nutrition. [**5-27**] patient had a CT scan of the abdomen,it showed no gallstones or abscess. A post-pyloric dobhoff was placed on [**6-1**]. The patient's caloric intake was maintained by a combination of TPN and tube feeds. Each nutritional replacment was employed at different times independently of the other based on the patient's tolerance for tube feeds or TPN. FEN: Patient was dehydrated, with hypovolemia and treated with aggressive fluid hydration upon admission to the hospital. Tube feeds were held on [**6-17**] due to high residuals. Currently the patient is not on TPN, while nutrition more recently has been maintained with tube feeds. Renal: Foley in place to monitor urine output. Heme: Blood loss and anemia in the unit requiring multiple transfusions. Currently, hematocrit is stable. ID: Consult was obtained on [**5-30**] the ID team continued to follow the patient throughout her entire hospital stay. The patient had multiple episodes of fever and cultures which were positive for the following organisms. [**6-13**] Blood: MRSA // [**6-10**] Sputum: MRSA, Klebsiella // [**6-9**] Sputum: MRSA, Klebsiella // 23: Bld/Tip- pend // [**6-6**] Blood: [**Female First Name (un) 564**] // [**6-6**]: urine - neg // [**6-5**] Blood: [**Female First Name (un) 564**] // [**6-3**] Blood: [**Female First Name (un) 564**] // [**6-1**] Blood: [**Female First Name (un) 564**] // [**5-31**] Blood: [**Female First Name (un) 564**] // [**5-30**] Bladder swab: Enterococcus, [**Female First Name (un) 564**], Staph coag Pos, GNR, Staph Coag Neg // [**5-30**] Blood: [**Female First Name (un) 564**] // [**5-29**] Cath tip: [**Female First Name (un) 564**] // [**5-29**] Blood: [**Female First Name (un) 564**] // [**5-29**] Urine: Enterococcus, Yeast // [**5-27**] Cath tip: [**Female First Name (un) **] // Urine [**5-17**] KLEBSIELLA PNEUMONIAE, Viridans // Blood 5/01 KLEBSIELLA PNEUMONIAE, Corynybacterium Additionally the patient had multiple line changes secondary to spiking temperatures and positive cultures.The patient was treated with multiple antibiotics during her hospital course and at the time of discharge he was being treated with Ambisome, Caspofungin and Vancomycin. Please continue Ambisome and caspofungin until [**6-23**], Vancomycin should be continued until [**6-29**]. Endo: The patient has been maintained on an insulin sliding scale through the duration of her hospital course. Consults: The team orderd a pysch consult on the patient on [**5-25**] becuse the patient appeared to be confused. An opthomology consult was ordered to rule out fungally related eye infection. The patient was seen and evaluated by optho; they deemed that there was no eye infection. Hospital Procedures while in the SICU PICC line [**6-12**] Mulitple bronchoscopies Left thoracocentesis [**6-14**] Transesophageal echo [**6-9**]: normal ERCP with sphincterotomy [**5-18**] Tracheostomy [**6-11**] Medications on Admission: ASA 325mg daily buspirone 5mg TID colace 100mg [**Hospital1 **] lasix 20mg daily lipitor 10mg daily lisinopril 20mg daily neurontin 100mg [**Hospital1 **] omeprazole 20mg daily roxicet prn zinc 220mg daily vit C Discharge Medications: 1. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day) as needed. 2. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 3. Acetaminophen 160 mg/5 mL Elixir Sig: One (1) PO Q4-6H (every 4 to 6 hours) as needed. 4. Terbinafine HCl 1 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day). 5. Insulin Regular Human 100 unit/mL Solution Sig: One (1) Injection ASDIR (AS DIRECTED). 6. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [**1-18**] Puffs Inhalation Q6H (every 6 hours) as needed. 7. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 8. Metoprolol Tartrate 50 mg Tablet Sig: 1.5 Tablets PO TID (3 times a day). 9. Sertraline HCl 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Amiodarone HCl 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 11. Hydralazine HCl 10 mg IV Q6 PRN 12. Fentanyl Citrate 25-50 mcg IV Q2H:PRN 13. Caspofungin 50 mg IV Q24H 14. Ambisome 300 mg IV Q24H 15. Furosemide 40 mg IV BID 16. Vancomycin HCl 1000 mg IV Q24H vanco level 17 17. Dolasetron Mesylate 12.5 mg IV Q4H:PRN Discharge Disposition: Extended Care Facility: [**Hospital3 7**] & Rehab Center - [**Hospital1 8**] Discharge Diagnosis: Atrial Fibrillation Pancreatitis HTN hyperlipidemia h/o aspiration respiratory distress bacteremia ([**Female First Name (un) **]) UTI (klebsiella) Discharge Condition: Good Discharge Instructions: Patient may shower. Please call your surgeon or return to the emergency room if you experience fever >101.5, nausea, vomiting, abdominal pain, shortness of breath, abdominal pain or any significant change in your medical condition. Ambisome and caspofungin should be continued til [**6-23**] while vanco should be continued til [**6-29**]. Followup Instructions: Please follow up with Dr. [**Last Name (STitle) **] in 2 weeks. Upon discharge please call Dr.[**Initials (NamePattern4) 2829**] [**Last Name (NamePattern4) 105632**] in order to schedule your follow up appointment.([**Telephone/Fax (1) 2363**] Provider: [**Name10 (NameIs) 251**] [**Last Name (NamePattern4) 252**], M.D. Where: [**Hospital6 29**] [**Hospital3 1935**] CENTER Phone:[**Telephone/Fax (1) 253**] Date/Time:[**2178-11-11**] 9:15 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2038**], MD Where: [**Hospital6 29**] HEMATOLOGY/ONCOLOGY Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2179-4-28**] 10:00

[ "599.0", "427.31", "401.9", "518.81", "996.62", "V10.05", "280.0", "112.5", "574.91", "041.00", "577.0", "511.9", "276.5" ]

icd9cm

[ [ [] ] ]

[ "03.31", "96.6", "99.15", "51.88", "96.04", "00.14", "33.23", "31.1", "34.91", "96.72", "38.93", "88.72", "51.85" ]

icd9pcs

[ [ [] ] ]

10230, 10309

3769, 8760

292, 387

10501, 10507

1958, 3746

10896, 11543

1504, 1573

9022, 10207

10330, 10480

8786, 8999

10531, 10873

1588, 1939

238, 254

415, 780

802, 1363

1379, 1488