ChanBeDu/relevant_section_length · Datasets at Hugging Face

82,599

158,752

38692

Discharge summary

report

Admission Date: [**2187-2-1**] Discharge Date: [**2187-3-22**] Date of Birth: [**2117-3-2**] Sex: F Service: MEDICINE Allergies: aspirin / NSAIDS Attending:[**First Name3 (LF) 10293**] Chief Complaint: shortness of breath Major Surgical or Invasive Procedure: thoracentesis, endoscopy TIPS failed x 3 History of Present Illness: 69F h/o primary biliary cirrhosis,chronic LE edema on chronic furosemide, remote h/o breast cancer s/p XRT, obesity, and depression who presented to an OSH ([**Hospital 4199**] Hospital) from rehab on [**2187-1-26**] with acute onset of shortness of breath and desaturation to 80% SpO2 on room air. CXR was notable for large right sided pleural effusion that was attibuted to hepatic hydrothorax given her history of liver disease. CT was negative for PE. There was initial concern for MI given the patients shortness of breath however troponins were negative x 2 and EKG did not exhibit ST segment changes. Diuresis was initiated with bolus doses of 80 mg IV lasix [**Hospital1 **] with good response ( patient was 1.5 L negative per day) however her symptoms failed to resolve and she ultimately underwent thoracentesis with removal of 1.5 L of fluid (cell count [**Pager number **] RBCs, 0 WBCs, pH 8.2, protein < 1 glucose 107) was consistent with a transudative process. Paracentesis was not performed. The patient was seen by GI who recommended transfer to a tertiary care center for referral for possible TIPS. Over the course of her hospitalization there was also concern for a GI bleed given hemoglobin drop from 12 to 8.9 in the setting of guaiac positive stools. She was transfused 2 units PRBCs with maintainence of stable HCTs. The patient was also noted to have a urine culure for which she was empirically started on ceftriaxone 1 gram daily on [**2186-2-1**]. Subsequently demonstrated proteus and citrobacter for which the patient was switched to zosyn. Vitals on transfer were 98, 64, 20, 95% 3L, 102/53. . Of note Patient had been discharged from [**Hospital1 18**] on [**2187-11-9**] after being admitted for c.diff and cellulitis. She was found to be living was found to be living in a filthy and unsafe home at that time. There was a question of her safety at home. Ultimately after a long discussion with the patient and social work her son was made her health care proxy. . On arrival patient was extremely confused with slowed speech. She was alert and oriented to person only. She was able to deny pain but was otherwise unable to participate in an interview. . ROS: patient was uable to participate in a review of systems Past Medical History: PER OMR/EPIC: PBC diagnosed 20 yrs ago HTN Breast Ca s/p XRT Obesity Hypothyroidism CREST GERD Depression Migraine headaches Social History: [**Hospital 8735**] medical [**Doctor Last Name **]/IT specialist, smoked PPD but quit >40 yrs ago, does not drink, no drug use. Family History: Mother colon cancer, father pancreatic cancer. Physical Exam: ADMISSION EXAM VS: 96.8 105/57 66 22 98% 3L NC GENERAL: ill appearing female only intermittently responding to questions, A+O to person only HEENT: Sclera anicteric. PERRL, EOMI. NECK: Supple with low JVP CARDIAC: PMI located in 5th intercostal space, midclavicular line. RRR, S1 S2 clear and of good quality without murmurs, rubs or gallops. No S3 or S4 appreciated. LUNGS: No chest wall deformities, scoliosis or kyphosis. Mildy tachypneic, no accessory muscle use, mild crackles bilaterally, BS decreased at bilteral bases R > L ABDOMEN: Distended but Soft, non-tender to palpation. Dullness to percussion. + Fluid wave, umbical hernia present, No HSM or tenderness. EXTREMITIES: Cool, no clubbing or cyanosis. 2+ peripheral edema bilaterally to the knees with assoicated erythem and dry flaking skin, no warmth. . DISCHARGE EXAM VS: T98.1, BP91-106/56-61, HR 64-76, RR 18, 97-100% on 2L [**Telephone/Fax (1) 85957**], 3BM Gen: Chronically ill appearing woman in no acute distress, AOx3, no asterixis HEENT: MMM, OP clear CARDIAC: RRR, no wheezing/rhonchi/rales LUNGS: Diffuse crackles b/l, decent air movement on left, dullness to percussion of right lung up 1/2 up the lung fields, no egophony ABDOMEN: Distended but Soft, non-tender to palpation, no hepatosplenomegaly EXTREMITIES: 2+ pitting edema to the knee b/l lower extremities Pertinent Results: ADMISSION LABS [**2187-2-1**] 07:15PM BLOOD WBC-8.4# RBC-3.95* Hgb-11.7* Hct-36.7 MCV-93 MCH-29.6 MCHC-31.9 RDW-16.0* Plt Ct-130*# [**2187-2-1**] 07:15PM BLOOD PT-14.2* PTT-33.6 INR(PT)-1.3* [**2187-2-1**] 07:15PM BLOOD Glucose-120* UreaN-23* Creat-0.6 Na-144 K-4.4 Cl-102 HCO3-36* AnGap-10 [**2187-2-1**] 07:15PM BLOOD ALT-32 AST-46* LD(LDH)-256* AlkPhos-105 TotBili-2.4* [**2187-2-1**] 09:29PM BLOOD Lactate-1.7 . DISCHARGE LABS [**2187-3-22**] 07:00AM BLOOD WBC-5.6 RBC-2.58* Hgb-8.1* Hct-24.9* MCV-97 MCH-31.4 MCHC-32.5 RDW-17.4* Plt Ct-64* [**2187-3-22**] 07:00AM BLOOD PT-13.1* PTT-33.1 INR(PT)-1.2* [**2187-3-22**] 07:00AM BLOOD Glucose-93 UreaN-74* Creat-1.3* Na-129* K-4.0 Cl-93* HCO3-25 AnGap-15 [**2187-3-20**] 05:40AM BLOOD ALT-36 AST-33 LD(LDH)-191 AlkPhos-133* TotBili-1.0 [**2187-3-22**] 07:00AM BLOOD Calcium-8.0* Phos-4.9* Mg-2.7* [**2187-3-3**] 05:01AM BLOOD calTIBC-222* Ferritn-179* TRF-171* [**2187-3-9**] 04:02PM BLOOD Glucose-91 Lactate-0.5 Na-128* K-4.2 Cl-92* . URINE STUDIES [**2187-2-1**] 08:20PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.006 [**2187-2-1**] 08:20PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.5 Leuks-TR [**2187-2-1**] 08:20PM URINE RBC-<1 WBC-3 Bacteri-NONE Yeast-NONE Epi-0 [**2187-2-1**] 08:20PM URINE CastHy-14* [**2187-2-1**] 08:20PM URINE Mucous-OCC . PERITONEAL FLUID STUDIES [**2187-2-3**] 04:45PM ASCITES WBC-145* RBC-[**Numeric Identifier 85958**]* Polys-40* Lymphs-26* Monos-7* Eos-2* Macroph-25* [**2187-2-3**] 04:45PM ASCITES TotPro-0.5 Glucose-163 LD(LDH)-46 Albumin-LESS THAN . MICROBIOLOGY URINE CULTURE (Final [**2187-2-3**]): MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH FECAL CONTAMINATION. . Blood Culture, Routine (Final [**2187-2-8**]): NO GROWTH. x 2 . [**2187-2-3**] 3:34 pm PERITONEAL FLUID PERITONEAL FLUID. GRAM STAIN (Final [**2187-2-3**]): 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. FLUID CULTURE (Final [**2187-2-6**]): NO GROWTH. ANAEROBIC CULTURE (Preliminary): NO GROWTH. . CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2187-2-5**]): Feces negative for C.difficile toxin A & B by EIA. (Reference Range-Negative). . STUDIES EKG [**2187-2-1**] Sinus rhythm. Borderline low voltage across the limb leads [**2187-2-2**] Sinus rhythm. Borderline low voltage across the limb leads. When compared to the tracing of [**2186-11-4**] no new changes are noted. [**2187-2-6**] Sinus bradycardia. No change compared to tracing #1. Repolarization ST-T wave changes persist. . CHEST XRAY [**2187-2-1**] Large right pleural effusion layering posteriorly in the presumably supine patient increased substantially since [**11-5**], shifting the mediastinum moderately to the left, where there is now a new small effusion. Prior chest radiographs showed a large uniformly opaque retrocardiac opacity which could have been either a hiatus hernia or saccular aneurysm of the aorta, now obscured by new left lower lobe atelectasis incidental to leftward mediastinal shift. There is probably no pulmonary edema. No pneumothorax. . [**2187-2-3**] Again seen is a large right-sided pleural effusion layering posteriorly with associated right-sided volume loss. There is dense retrocardiac opacity compatible with volume loss/effusion/infiltrate. The left upper lung is relatively spared and appears well aerated. Compared to the prior study there is no significant interval change. . [**2187-2-7**] In comparison with study of [**2-3**], there is still extensive right pleural effusion. The slight change in the appearance most likely reflects differences in patient position. Extensive opacification is seen in the retrocardiac region, silhouetting the left hemidiaphragm. This is consistent with substantial volume loss in the left lower lobe with small pleural effusion. However, in the appropriate clinical setting, supervening pneumonia would have to be considered. . Abdominal US 1. Findings compatible with cirrhosis and portal hypertension. Ascites and pleural effusion noted. 2. Normal liver Doppler without evidence of portal vein thrombosis. Limited assessment of the hepatic arteries, but a normal waveform was observed in the main hepatic artery. 3. Cholelithiasis. 4. Probable splenic hemangioma and cyst. . Endoscopy . CT Chest: 1. Either anterior mediastinal cystic lesion or paramediastinal pleural fluid collection. Additional imaging recommended with the patient in right decubitus. 2. Huge nonhemorrhagic right pleural effusion and small left pleural effusion are responsible for atelectasis, severe on the right, mild on the left. Ascites. 3. Mild right middle lobe pneumonia. 4. ET tube 3 cm, too low. . MRI Neck 1. Multilevel, multifactorial degenerative changes as described above, with small protrusions indenting the thecal sac; mild right-sided foraminal narrowing at C4/5 and C6/7 levels. Osseous details cna be assessed with PXR/CT if necessary. 2. No evidence of compression on the cervical cord. No large area of signal intensity abnormality in the cervical cord on the sagittal sequences, evaluation being limited on the axial sequences due to motion despite repetition. 3. Moderate amount of fluid in the nasopharynx and hypopharynx, which may relate to intubation. Correlate clinically. 4. Bilateral moderate/large pleural effusions can be correlated with plain radiograph of the chest. 5. Decreased visualization of the vertebral artery flow voids, in the mid/lower cervical spine can be correlated with color Doppler evaluation. The distal V2 and V3 and V4 segments are patent. Final Report INDICATION: 70 year old woman with PBC cirrhosis and refractory ascites/hepatic hydrothorax. For TIPS. PHYSICIANS: Dr [**First Name4 (NamePattern1) 440**] [**Last Name (NamePattern1) **] (fellow), Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] (resident) and Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] (attending radiologist). Dr [**Last Name (STitle) **] was present throughout total procedure. PROCEDURE: 1. Ultrasound-guided paracentesis. 2. Right internal jugular vein access. 3. Hepatic venography and CO2 portography. 4. Portal pressure gradient measurements. 5. US guided umbilical vein access and venogram MEDICATIONS: Patient was intubated and sedated prior to arriving from the MICU. The patient was monitored by anesthesia and trained radiology nurse. PROCEDURE: Prior to initiation of the procedure, informed consent was obtained. Patient was placed on the table, the right neck and abdomen was prepped and draped in a sterile manner. Initially,under ultrasound guidance, a 21 G needle was used to access the abdominal cavity adjacent to the liver, followed by placement .018 wire and exchanging needle for micropuncture sheath. The wire and inner stiffener were removed and [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] wire was placed followed by placement of a 5 French Omni flush catheter which was secured to the skin and then attached to a vacuum drainage bottle. ~ 700 cc of straw colored ascites was removed over the course of the whole ~ 5 hr procedure. Next, micropuncture access was used to access the right internal jugular vein, and after fascial dilatation, a 10 French sheath was placed down into the IVC over [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] wire. Eventually an Amplatz wire was extended into lower IVC and used to anchor the sheath in the upper IVC to allow for cannulation of the hepatic veins with a 5 French C2 catheter. Once the right hepatic vein was catheterized a right hepatic venogram was performed, which was unremarkable. This was followed by pressure measurements in the right atrium and wedged right hepatic vein measurements using occlusion balloon. Pressure measurements revealed a relatively small 8 mmHg portosystemic gradient. AP and lateral views confirmed posterior location. CO2 portography demonstrated poor filling of the portal venous system, with visualization of just two branches of what appeared to be the right portal vein. Next we cannulated the middle hepatic vein and performed CO2 portograms. This similarly yielded poor visualization of the portal system. It was then decided to try to opacify the portal system by directly accessing the umbilical vein. We did this with a 21 gauge needle and a .018 wire. We exchanged the needle for a the plastic inner stiffener of the Accustick sheath. We performed a venogram which demonstrated flow away from the liver in a large collateral vein up toward the chest. We used a Headliner and Transcend wire to try to navigate retrograde to flow into the main portal vein. However given an extensive ball-like focus of tortuosity in this patent umbilical vein, we could not navigate past this into the main portal vein. Using the limited portograms we stuck multiple times using a [**Last Name (un) 29723**] [**Last Name (un) 29724**] needle in both the middle hepatic (posterior passes) and right hepatic veins (anterior passes). At one point during a posterior pass from the middle hepatic vein we had good blood return from what was likely the right main portal vein, however a wire would not pass. The procedure was terminated when contrast extravasation into the peritoneum was noted after injecting contrast through blue catheter in [**Last Name (un) 29723**] [**Last Name (un) 29724**] needle set upon pulling back from final pass. Monitoring of ascites output never revealed a change in appearance from the straw colored ascites. The procedure was terminated at that point. All wires, catheters and sheaths were removed. Hemostasis was achieved with manual compression. IMPRESSION: 1. Ultrasound-guided paracentesis. 2. Unsuccessful TIPS placement as described above. 3. Postosystemic gradient is relatively low at 8 mmHg. Pleural fluid: NEGATIVE FOR MALIGNANT CELLS. [**2187-3-20**] 05:40AM BLOOD T4-2.1* T3-44* [**2187-3-19**] 03:31PM BLOOD TSH-64* Brief Hospital Course: 69 yo female with primary biliary cirrhosis with refractory ascites, chronic LE edema on chronic furosemide, remote h/o breast cancer s/p XRT, and depression who presented from and OSH after presenting with shortness of breath ultimately found to have significant ascites, and pleural effusions s/p thoracentesis who was transferred to [**Hospital1 18**] for evaluation for possible TIPS. TIPS was unable to be placed three times due to difficult anatomy, and ultimately Ms. [**Known lastname 34754**] respiratory status was maximized with diuretics. . ACTIVE ISSUES . # Shortness of Breath- Shortness of breath was felt to be due to pleural effusion related to the patients known liver disease (ie hepatic hydrothorax). The patient was afebrile without previous history of symptoms suggestive of pneumonia. Cardiac w/o including echo, and troponins at OSH was negative. CTA was negative for PE. Patient was diuresed with bolus doses of 80 mg IV lasix with improvement in her respiratory status. Patients oxygen was weaned and she was able to maintain saturations in the mid 90s on room air. Lower extremity edema and ascites also improved with aggressive diuresis. On HD#11 NG tube placement was attempted for esophageal impaction during which patient had an acute hypoxic episode with O2 sats dropping to the 50s. Event was felt to be due to flash pulmonary edema in the setting of hypertensive urgency with SBPs in the 170s. She was started on a non-rebreather with some improvement in oxygenation and transferred to the MICU. In the MICU, patient's blood pressures remained under good control and she was quickly weaned off the non-rebreather to a shovel mask. She was electively intubated on [**2-12**] for increased work of breathing and endoscopy the next day. The endoscopy showed no impaction, only a Schatzki ring. There was much difficulty weaning patient off the ventilator due to her muscle weakness (see below). Thoracentesis was undertaken on [**2-21**] to help remove the hepatic hydothorax in an effort to optimize her for extubation. As her RSBIs and NIFs continued to improve with diuresis and optimization of nutrition, patient was extubated successfully on [**2-24**]. . From [**Date range (1) 85959**] Ms. [**Known lastname 12130**] was diuresed initially on a lasix drip at 20-25 mg/hr and was diuresed approximately 30 liters on the floor. While on the floor, she also received 2 2.5L thoracenteses. By the week of [**2187-3-12**], Ms. [**Known lastname 12130**] was able to be weaned from IV diuretics without major fluid accumulation by physical exam. To definitively treat Ms. [**Known lastname 34754**] hydrothorax, a TIPS was seriously considered. However, due to technical failure secondary to Ms. [**Known lastname 34754**] diminutive hepatic vasculature TIPS failed 3 times. Other interventions such as pleurodesis and pleurex or peritoneal catheter were considered but were ultimately rejected due to the excessive pain infection risk involved. . # Chest Pain: Ms. [**Known lastname 12130**] complained of chest pain on [**2187-3-22**] in the morning during a period of time in which she was anxious about leaving the hospital. The chest pain improved with ativan. The pain was in the center of her chest, was not associated with exertion, and one other time resolved spontaneously after 2 minutes without ativan. There were no EKG changes from prior. This was thought unlikely to be ACS, but she was started on a daily aspirin 81mg due to her risk factors for ACS. She does have a history of bleeding while on aspirin, but it was felt that the risk reduction for MI outweighs the risk of bleed. Would have a low threshold to discontinue aspirin, however. . # Primary Biliary Cirrhosis- Patient was diagnosed 20 years ago. She is not a transplant candidate due to social issues at home, and Ms. [**Known lastname 12130**] does not wish to have a transplant. TIPS failed x3. She was aggressively diuresed initially with lasix drip and then transitioned to an oral dose. She was continued on her home ursodiol, and discharged on increased doses of spironolactone/lasix. . # Hypothyroidism- Patient was initially continued on her home levofloxacin dose of 25 mcg daily. Initial TSH was slightly elevated at 12 but was thought to be consistent with sick euthyroid. Due to persistent hyponatremia, a TSH was re-checked and was found to be elevated at 64. Ms. [**Known lastname 12130**] was started on an increased dose of levothyroxine (100 mcg daily) with improvement in hyponatremia, and symptomatic improvement. . # Hyponatremia: Hyponatremia progressively worsened from 130 to 121 during Ms. [**Known lastname 34754**] third week of admission in the setting of aggressive diuresis. Her urine sodium was < 10 consistent with decreased effective circulating volume, but urine osmolality was 426 consistent with failure to adequately concentrate the urine. Due to the lower than expected osmolality, Ms. [**Known lastname 12130**] was placed on a 1.5L oral fluid restriction, and TSH/coritsol were checked. AM cortisol was within normal limits, but (as above) TSH was highly elevated. Hyponatremia was initially symptomatic with "queasiness" when Ms. [**Known lastname 34754**] sodium was 121. Sodium improved to 129 with fluid restriction, increased levothyroxine, and minimal IV NS boluses 250cc NS x 2. Ms. [**Known lastname 34754**] queasiness improved. . # Muscle Weakness: While intubated and on the mechanical ventilator, there was difficult weaning patient off the vent due to profound muscle weakness with NIF in the low 20s. Neurology was consulted who noted profound myopathy on EMG, partly related to nutritional status and likely related to an underlying process of unclear etiology. CT Chest was undertaken to look for thymoma and MRI of the Neck was done to evaluate for possible coexistent neuropathy, both of which were largely unrevealing. Her NIFs improved daily with nutrition allowing for successful extubation on [**2-24**]. Weakness progressively improved on the floor. It is possible that some of her weakness is secondary to hypothyroidism given her TSH of 64. . # Altered Mental Status- The patient was noted to be extremely confused on admission to [**Hospital1 18**]. Patient was afebrile without signs of focal infection on exam. She did have erythematous lower extremities but this is likely reflective of chronic edema and not a cellulities. Chemistry panel was unremarkable. Diagnositic paracentesis was negative for SBP with a white blood cell count of 145, 40% PMNs, and [**Numeric Identifier 85958**] red blood cells. Ultimately it was felt that the patients confusion was reflective of toxic metabolic encepholopathy in the setting of a UTI which was diagnosed at the OSH. OSH culture data grew grew proteus and citrobacter > 100,000 CFU both sensitive to ciprofloxacin. She was started on ciprofloxacin in addition to lactulose in case there was a component of hepatic encepholopathy. The patient developed diarrhea and the lactulose was discontinued. C.diff was negative. Rifaximin was initiated instead. Patient's mental status improved and was at baseline at the time of discharge. . # Nutrition- Patient was noted to have poor oral intake over the course of her admission in the setting of a substantial amount of weight loss over the past several months. She was evaluated by speech and swallow specialists who noted food impaction in his esophagus. Patient became acutely hypoxic and hypertensive during NG tube placement so she as transferred to the MICU. There she underwent elective intubation for endoscopy which revealed no evidence of esophageal impaction. Dobhoff tube was placed during endoscopy and tube feeds were started. Later on in her course, when she and her son/HCP [**Name (NI) **] [**Name (NI) 12130**] decided to pursue more comfort focused care, the dobhoff was pulled so that she could return to [**Location (un) 6107**] house. STABLE ISSUES. # QT prolongation- Patient was noted to have a QT inteval of 500 at OSH. Celexa was discontinued with normalization of the QT interval. This medication was restarted at the time of discharge as her QTc was normal at 427. . TRANSITIONAL ISSUES - Patient will follow-up with Dr. [**First Name (STitle) 26390**] - Patient was discharged to a skilled nursing facility - Please re-check TSH in 1 month from discharge ([**2187-4-22**]), given her increased dose of levothyroxine. Medications on Admission: Home medications 1. levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for Pain. 3. multivitamin Tablet Sig: One (1) Cap PO DAILY (Daily). 4. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 5. ursodiol 300 mg Capsule Sig: Two (2) Capsule PO DAILY (Daily). 6. ursodiol 300 mg Capsule Sig: One (1) Capsule PO DINNER (Dinner). 7. metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours). 8. cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours). 9. nadolol 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 10. spironolactone 25 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 11. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). . medications on transfer IV lasix 80 mg [**Hospital1 **] ceftriaxone 1 gram q 24 first dose [**2187-1-31**] spironolactone 100 albuterol PRN levothyroxine 150 mcg daily nadolol 40 mg daily protonix 40 daily ursodiol 600 qam 300 qpm vitamin D 800 daily lorazepam 0.25 tid prn magnesium oxide 400 PO BID MVI Discharge Medications: 1. levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8 hours) as needed for pain. 3. multivitamin Tablet Sig: One (1) tablet PO DAILY (Daily). 4. ursodiol 300 mg Capsule Sig: Two (2) Capsule PO QAM (once a day (in the morning)). 5. ursodiol 300 mg Capsule Sig: One (1) Capsule PO QPM (once a day (in the evening)). 6. spironolactone 25 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 7. furosemide 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). 9. sodium chloride 0.65 % Aerosol, Spray Sig: [**1-1**] Sprays Nasal [**Hospital1 **] (2 times a day) as needed for dryness. 10. rifaximin 550 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 11. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO BID (2 times a day). 12. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) Injection [**Hospital1 **] (2 times a day). 13. pramoxine-mineral oil-zinc 1-12.5 % Ointment Sig: One (1) Appl Rectal QID (4 times a day). 14. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 15. docusate sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2 times a day) as needed for constipation. 16. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 17. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. 18. citalopram 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 19. metoclopramide 10 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 20. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for anxiety. 21. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 22. ipratropium bromide 17 mcg/actuation HFA Aerosol Inhaler Sig: 4-6 Puffs Inhalation Q6H (every 6 hours) as needed for wheezing. 23. Outpatient Lab Work Please obtain CBC, basic metabolic panel (especially BUN/Creatinine), and LFTs twice weekly (Friday and Tuesday) and fax results to Dr. [**First Name (STitle) 26390**] at [**Telephone/Fax (1) 85960**]. Discharge Disposition: Extended Care Facility: [**Hospital **] LivingCenter - [**First Name4 (NamePattern1) 6107**] [**Last Name (NamePattern1) **] - [**Location (un) 3786**] Discharge Diagnosis: Primary Diagnosis Primary Biliary Cirrhosis Hepatic Hydrothorax Hepatic Encephalopathy Hypothyroidism 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: Ms [**Known lastname 12130**], It was a pleasure participating in your care while you were admitted to [**Hospital1 69**]. As you know you were admitted to the hospital because you were having trouble breathing which was likely because you had a large amount of fluid on your lungs. You were given medications to help remove this fluid and your breathing improved. We tried a procedure called TIPS to reduce this fluid however we were unable to place it three times. We were able to keep the fluid off of your lungs with the diuretics lasix and spironolactone. You will need to have labs checked twice weekly to make sure your kidney function does not worsen with the diuretics. . Also while you were here we made the decision that overall our goals of care should be to make you comfortable and not necessarily engage in aggressive care. Therefore, we pulled the NG feeding tube, and avoided a procedure called pleurodesis. We also decided that in the event of an emergency, a breathing tube should not be placed, and CPR should not be performed. In other words, you and your son, [**Name (NI) **] [**Name (NI) 12130**], decided to make your code status: Do Not Resuscitate/Do Not Intubate. We Made the following changes to your medications Increase levothyroxine to 100mcg daily. Your thyroid level was very low this admission and was likely making you lethargic and reducing your sodium level Stop metronidazole/cephalexin as you no longer need antibiotics Stop nadolol due to low BP Increase spironolactone to 50mg daily and lasix to 80mg daily to help keep the fluid off of your lungs Stop omeprazole, and start protonix to prevent reflux symptoms Start vitamin D for your bone health Start nasal saline to help keep your nose comfortable while using oxygen Start lactulose/rifaximin to keep your mental status clear Start heparin to prevent clots Start Tucks for your hemorrhoids Start Senna and docusate as needed for constipation Start oxycodone as needed for pain Start citalopram for depression Start metoclopramide for reduced nausea Start lorazepam for anxiety Start aspirin to prevent a heart attack Start ipratropium as needed for shortness of breath Please continue to take all other medications as instructed. Followup Instructions: Name: [**Last Name (LF) 26390**], [**First Name7 (NamePattern1) 449**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] Location: [**Hospital1 641**] Address: [**Location (un) **], [**Location (un) **],[**Numeric Identifier 718**] Phone: [**Telephone/Fax (1) 2296**] *It is recommended that you see Dr. [**First Name (STitle) 26390**] within 2 weeks. His office staff are working on an appointment for you. If you dont hear from his office within a few days, please call to get your appointment information.

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[ "45.13", "00.69", "34.91", "54.91", "96.72", "88.64", "96.6" ]

icd9pcs

[ [ [] ] ]

26246, 26400

14428, 22848

296, 339

26546, 26546

4357, 6429

28985, 29509

2933, 2981

24043, 26223

26421, 26525

22874, 24020

26729, 28962

2996, 4338

237, 258

367, 2622

6465, 14405

26561, 26705

2644, 2770

2786, 2917

4,916

132,525

30318

Discharge summary

report

Admission Date: [**2182-10-15**] [**Month/Day/Year **] Date: [**2182-10-21**] Date of Birth: [**2109-11-29**] Sex: F Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2534**] Chief Complaint: colostomy Major Surgical or Invasive Procedure: [**2182-10-15**] Left colostomy closure with [**Doctor Last Name 3379**] procedure History of Present Illness: 75-year-old female who in [**2181-2-14**] underwent a Hartmann procedure with segmental resection of sigmoid colon for a perforated sigmoid diverticulitis with fecal peritonitis. She returns now for elective colostomy closure and resection of remaining diverticular disease in the left colon. Past Medical History: Type II DM CAD - s/p CABG Family History: Noncontributory Pertinent Results: [**2182-10-15**] 07:20PM GLUCOSE-183* UREA N-8 CREAT-0.6 SODIUM-137 POTASSIUM-4.1 CHLORIDE-104 TOTAL CO2-19* ANION GAP-18 [**2182-10-15**] 07:20PM CALCIUM-7.7* PHOSPHATE-3.5 MAGNESIUM-0.6* [**2182-10-15**] 07:20PM WBC-7.2 RBC-2.80* HGB-8.4*# HCT-25.7* MCV-92 MCH-29.9 MCHC-32.6 RDW-14.4 [**2182-10-15**] 07:20PM PLT COUNT-352 SPECIMEN SUBMITTED: Left colon. Procedure date Tissue received Report Date Diagnosed by [**2182-10-15**] [**2182-10-16**] [**2182-10-18**] DR. [**Last Name (STitle) **]. FU/mb???????????? Previous biopsies: [**Numeric Identifier 72161**] BOWEL. DIAGNOSIS: Colon, left, colectomy: 1. Diverticulosis. 2. Mild focal acute inflammation of ostomy site. Clinical: Peritonitis, status post sigmoid resection/colostomy. Gross: The specimen is received fresh labeled with the patient's name "[**Known lastname 7363**], [**Known firstname 40658**]" and the medical record number and "left colon." It consists of a segment of colon that measures 30 cm in length and up to 3.5 cm in diameter. A portion of mesocolon is attached that measures 30 x 5 x 3 cm. There is a proximal stapled margin that measures 4.5 cm in length. The distal end is remarkable for a colostomy site with a rim of skin that measures 0.4 cm in width. The colostomy site has a pink tan mucosa that is unremarkable. The serosa of the bowel is smooth and unremarkable. The specimen is opened along the anti mesocolonic surface to reveal fecal material within the lumen. The mucosa is tan with normal folds and is involved by diverticular disease in the distal portion of the specimen. No masses or polyps are identified. The bowel wall is involved by multiple diverticula that measure up to 1.2 cm in depth. The specimen is represented as follows: A = proximal stapled margin, B = ostomy site, C = normal colon, D-E = diverticula, F = mesocolon. Brief Hospital Course: She was admitted to the Surgery service and taken to the operating room on [**10-15**] for colostomy takedown. There were no intraoperative complications. Postoperatively she has done well; she is tolerating a diet and passing flatus. She was evaluated by Physical therapy and it is being recommended that she go to a rehab facility post acute hospital stay. Medications on Admission: ins 17U/d, metformin 500''', ASA 325', colace 100'', Cymbalta 20'', prilosec 20', risperdal 0.5'', simvastatin 40', toprol 100', tramadol 25'', zetia 10' . [**Month/Year (2) **] Medications: 1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) ML Injection TID (3 times a day). 2. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: One (1) neb rx Inhalation Q6H (every 6 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. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. 5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 6. Duloxetine 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO BID (2 times a day). 7. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 9. Insulin Regular Human 100 unit/mL Solution Sig: One (1) Injection every six (6) hours as needed for per sliding scale: See attached scale. [**Month/Year (2) **] Disposition: Extended Care Facility: [**Hospital1 599**] of [**Location (un) 55**] [**Location (un) **] Diagnosis: Colostomy take down Secondary diagnosis: [**Doctor Last Name 3379**] for Perforated Diverticulitis [**Doctor Last Name **] Condition: Good [**Doctor Last Name **] Instructions: please return to the hospital if you have any fevers, chills, drainage, nausea, vomiting, dizziness, bleeding, or other symptoms that worry you or your family. Followup Instructions: Appt with Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 3243**], MD Phone:[**Telephone/Fax (1) 600**] Date/Time:[**2182-10-24**] 1:00, located at [**Last Name (NamePattern1) **]. Suite 2G

[ "250.00", "294.0", "562.10", "V45.81", "614.6", "V55.3", "401.9" ]

icd9cm

[ [ [] ] ]

[ "45.75", "46.52", "99.04", "54.59" ]

icd9pcs

[ [ [] ] ]

2751, 3112

339, 423

847, 2728

4827, 5046

811, 828

3138, 4430

4462, 4482

290, 301

451, 746

4503, 4804

768, 795

9,132

102,937

29945

Discharge summary

report

Admission Date: [**2199-5-1**] Discharge Date: [**2199-5-8**] Date of Birth: [**2121-4-19**] Sex: M Service: SURGERY Allergies: Dilantin / Heparin Agents Attending:[**First Name3 (LF) 2777**] Chief Complaint: Juxta-renal abdominal aortic aneurysm. Major Surgical or Invasive Procedure: 1. Infrarenal tube graft repair of abdominal aortic aneurysm via retroperitoneal approach. History of Present Illness: Pt is a 78 year old man currently admitted for AAA repair who is recently s/p intraventricular hemorrhage Past Medical History: PMHx: * Seizure disorder (details not available at this time) * Abdominal aortic aneurysm * Atrial fibrillation * Hypertension * COPD * CHF * Pulmonary hypertension * Benign prostatic hypertrophy * T2 compression fracture found [**2199-1-7**] * s/p MRSA baceremia [**2199-1-7**] * s/p heparin induced thrombocytopenia * s/p cholecystectomy [**2198-1-7**] Social History: Retired from [**Company 2676**], lives in rehab, has son and daughter-in-law. Quit smoking 10 years ago, ?4 packs per day for 20 years. No EtOH. Family History: Family history: Mother - deceased, stroke. Father - deceased, MI. Physical Exam: Physical exam: T Afeb HR 88 BP 150/87 RR 14 Sat 96% on RA ) GEN sitting in chair, leaning to the right side, asleep HEENT NCAT, MMM, OP clear, +~1.5cm skin-colored fleshy, irregular lesion beneath right eye Chest CTAB CVS irregular rhythm, no m/r/g ABD soft, NT, ND, +BS EXT no rash, weak distal pulses Pertinent Results: [**2199-5-8**] INR 2.6 [**2199-5-7**] 02:20AM BLOOD WBC-6.2 RBC-3.15* Hgb-9.5* Hct-28.0* MCV-89 MCH-30.3 MCHC-34.1 RDW-16.1* Plt Ct-167 [**2199-5-7**] 02:20AM BLOOD PT-23.5* PTT-36.1* INR(PT)-2.3* [**2199-5-7**] 02:20AM BLOOD Glucose-136* UreaN-25* Creat-1.2 Na-138 K-4.3 Cl-108 HCO3-25 AnGap-9 [**2199-5-7**] 02:20AM BLOOD Calcium-8.0* Phos-2.0* Mg-2.0 [**2199-5-4**] 08:22AM BLOOD Lactate-1.0 [**2199-5-2**] 10:22PM BLOOD Glucose-100 Lactate-2.3* K-3.4* Cl-125* EVALUATION: The examination was performed while the patient was seated upright in the bed on VICU 11. Cognition, language, speech, voice: Awake, alert, but slow to respond, limited verbal output, appearing fatigued. He did follow one step commands, though inconsistently, with a delay and with visual cues/modeling. Pt's speech was intelligible and fluent, but responses were very limited. Vocal quality was breathy, though the pt could generate adequate voicing with effort. Teeth: Edentulous Secretions: Mild amount of thick, clear, sputum was stranding from the hard palate to the tongue. This was removed with the Yankauer catheter. ORAL MOTOR EXAM: WFL for labial and lingual symmetry and ROM. However, both labial/buccal tone and tongue strength were diminished. Palatal elevation was symmetrical. Gag was absent. SWALLOWING ASSESSMENT: PO swallowing assessment was completed at bedside with ice chips, thin liquids (tsp, cup), purees ( tsp x2), and nectar thick liquid (tsp, cup). Oral transit was minimally slowed though no residue was noted. Pt had a difficult time initiating taking any po's, so feeding was required however he would not open his mouth sufficiently to actually allow adequate boluses into his mouth. Laryngeal elevation appeared adequate to palpation, though he swallowed multiple times per bolus. He did c/o sensation of puree sticking in his throat. Overt coughing was noted with thin liquids and pt confirmed sensation of aspiration. No further po's could be assessed as pt refused any more boluses. SUMMARY / IMPRESSION: Pt is demonstrating overt signs of aspiration with thin liquids, but more significantly is refusing all po's, despite maximal encouragement. As such, beyond thin liquids the examination was limited by the pt's fatigue, delayed response time and refusal. Notes from discharge facility indicate poor po intake has been an issue, but the pt was on a full po diet so it appears that he was able to advance off of tube feedings. Unclear whether this decline is related to post op somnolence or possible toxic-metabolic issues noted per neurology. However, at this time, I would recommend the pt remain NPO with enteral nutrition and medications via the PEG. We will plan to re-evaluate pt later this week, either [**2199-5-8**] or [**2199-5-9**]. RECOMMENDATIONS: 1. Remain NPO with enteral nutrition and medications via the PEG. MR HEAD W/O CONTRAST [**2199-5-4**] 9:13 PM Interpretation: There are several areas of hyperintensity on the diffusion weighted images. These are located in the right frontal and left occipital lobes with questionable involvement of the left frontal lobe. These areas are hyperintense on FLAIR, raising the possibility that they may represent T2 shine through. However, these diffusion findings are new since the prior MR examination. Therefore, these likely reflect relatively new ischemia, although they may not be truly acute. There is no evidence of hemorrhage, edema, masses, or mass effect. The vessels appear unchanged, with a large right A1, and no detectable left A1 branch of the anterior cerebral artery. Impression: Several areas of diffusion abnormality suggesting recent infarction. No evidence of hemorrhage. CT HEAD W/O CONTRAST [**2199-5-4**] 2:36 PM FINDINGS: There is no evidence of hemorrhage, mass effect, or shift of normally midline structures. Chronic right frontal and parietal lobe infarctions are again noted. Marked periventricular white matter hypodensity is again seen most consistent with chronic microvascular infarctions. The ventricles are prominent and similar in size and symmetry. The paranasal sinuses and mastoid air cells are well aerated. IMPRESSION: No evidence of hemorrhage. Stable prominent ventricles. NOTE ADDED AT ATTENDING REVIEW: I agree with the above interpretation. However, I am concerned that the CTA may suggest an arteriovenous malformation. There were numerous prominent vessels, arterial and venous, and no explanation for the hemorrhage. I discussed this concern with Dr. [**Last Name (STitle) 71522**] at 9:25 pm on [**2199-5-4**]. [**2199-5-1**] EKG Atrial fibrillation, mean ventricular rate, 80. Compared to the previous tracing of [**2199-4-25**] no major change. Intervals Axes Rate PR QRS QT/QTc P QRS T 80 0 72 [**Telephone/Fax (2) 71523**]7 55 Brief Hospital Course: [**5-1**], Pt admitted had a Infrarenal tube graft repair of abdominal aortic aneurysm via retroperitoneal approach. Tolerated the procedure well. Had epidural placed for pain control .L renal cross clamp time 25 minutes. Argatroban was administered intra-operatively Prolong intubation in SICU / requiring pressure support / metabolic acidosis On [**5-2**], there was a period of hypotension to 90s/50s requiring pressor support, but this was transient. Pt was extubated on [**5-3**]. Pain is currently being managed with Dilaudid PCA and Bupivacaine epidural. The last morphine dose was at 4:50pm on [**5-2**]. Epidural DC by pain service Pt has been somewhat difficult to arouse with limited speech output and eye rolling during morning rounds [**5-4**], prompting consult for seizure evaluation from Neurology CT scan / MRI done - no acute process. Possible AVM. To be followed as an outpt. Medications adjusted. Final neurological - toxic-metabolic encephalopathy related to post-surgical state and sedative medications (Dilaudid) being used for pain control Pt received fundaperinox from transition to coumadin for Afib. Hx of HIT pos. When INR at goal, Fundaperinox was DC'd. Pt with difficulty swallowing / G tube / pt on TF. Speech and swallow consult obtained: BEDSIDE SWALLOWING EVALUATION: HISTORY: Thank you for referring this 78 year old male admitted from [**Hospital1 1501**] on [**2199-5-1**] for AAA repair. AAA was diagnosed when pt was admitted [**12-12**] s/p right parietal subacute infarction as well as right intraventricular hemorrhage. Post op, neurology was consulted as the pt was somnolent with decreased speech output. Neurology consult reported that the pt may have toxic-metabolic encephalopathy related to post-surgical state and sedative medications being used for pain control. PMH includes: s/p right parietal subacute infarction and right intraventricular hemorrhage, Seizure disorder, Abdominal aortic aneurysm, Atrial fibrillation, Hypertension, COPD, CHF, Pulmonary hypertension,Benign prostatic hypertrophy, T2 compression fracture found [**2199-1-7**], s/p MRSA bacteremia [**1-13**], s/p heparin induced thrombocytopenia, s/p cholecystectomy [**1-12**],(+) UTI. We were consulted this admission to evaluate whether pt was able to swallow safely. We evaluated the pt multiple times last admission with the last examination being a video swallow study completed on [**2199-2-7**]. That study revealed a mild-moderate oropharyngeal dysphagia that worsened over time. After fatigue, he demonstrated reduced A-P tongue movement, moderate oral cavity residue, moderately reduced hyolaryngeal excursion and laryngeal valve closure, moderate vallecular residue and mild pyriform sinus residue. Pt was observed to penetrate both thin and nectar thick liquids with eventual aspiration of residue of thin liquids. Because pt's oral and pharyngeal muscles fatigued so quickly, he was at risk to aspirate any texture of solid or liquid over the course of an entire meal. As such, we recommended that the pt remain primarily NPO at this time with nutrition, hydration, and medication via PEG. Per discharge summary from rehab facility, the pt participated in speech therapy, had a repeat video swallow study and progressed to a ground solid, thin liquid po diet while at rehab. However, his po intake remained poor despite stopping tube feedings and starting the pt on Megace. However, notes from rehab facility and extended care facility indicate the pt was solely on a po diet, not on tube feedings prior to admission here for AAA repair. EVALUATION: The examination was performed while the patient was seated upright in the bed on VICU 11. Cognition, language, speech, voice: Awake, alert, but slow to respond, limited verbal output, appearing fatigued. He did follow one step commands, though inconsistently, with a delay and with visual cues/modeling. Pt's speech was intelligible and fluent, but responses were very limited. Vocal quality was breathy, though the pt could generate adequate voicing with effort. Teeth: Edentulous Secretions: Mild amount of thick, clear, sputum was stranding from the hard palate to the tongue. This was removed with the Yankauer catheter. ORAL MOTOR EXAM: WFL for labial and lingual symmetry and ROM. However, both labial/buccal tone and tongue strength were diminished. Palatal elevation was symmetrical. Gag was absent. SWALLOWING ASSESSMENT: PO swallowing assessment was completed at bedside with ice chips, thin liquids (tsp, cup), purees ( tsp x2), and nectar thick liquid (tsp, cup). Oral transit was minimally slowed though no residue was noted. Pt had a difficult time initiating taking any po's, so feeding was required however he would not open his mouth sufficiently to actually allow adequate boluses into his mouth. Laryngeal elevation appeared adequate to palpation, though he swallowed multiple times per bolus. He did c/o sensation of puree sticking in his throat. Overt coughing was noted with thin liquids and pt confirmed sensation of aspiration. No further po's could be assessed as pt refused any more boluses. SUMMARY / IMPRESSION: Pt is demonstrating overt signs of aspiration with thin liquids, but more significantly is refusing all po's, despite maximal encouragement. As such, beyond thin liquids the examination was limited by the pt's fatigue, delayed response time and refusal. Notes from discharge facility indicate poor po intake has been an issue, but the pt was on a full po diet so it appears that he was able to advance off of tube feedings. Unclear whether this decline is related to post op somnolence or possible toxic-metabolic issues noted per neurology. However, at this time, I would recommend the pt remain NPO with enteral nutrition and medications via the PEG. RECOMMENDATIONS: 1. Remain NPO with enteral nutrition and medications via the PEG. [**2199-5-7**] No overnight events, neurology signed off- will see as outpatient. PT/OT continued. REhab screen in process. [**2199-5-8**]: VSS. No overnight events. Will discharge to rehab with tubefeeds via Gtube. Patient will follow up with Dr. [**Last Name (STitle) **] as scheduled. Remains on Coumadin for afib (goal INR 2.0-3.0) Medications on Admission: keppra 1000', toprol 75", albuterol, enalapril 5', megace 400', NTG prn, prevacid 30', ultram 50 prn, colace 100", senna 1", warfarin 3 to 5'(for AF) Discharge Medications: 1. Albuterol Sulfate 0.083 % Solution [**Last Name (STitle) **]: One (1) Inhalation Q6H (every 6 hours) as needed. 2. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution [**Last Name (STitle) **]: 5-10 MLs PO Q4-6H (every 4 to 6 hours) as needed. ML(s) 3. Metoprolol Tartrate 25 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID (2 times a day). 4. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily). 5. Aspirin 325 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily). 6. Simvastatin 10 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily). 7. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr [**Last Name (STitle) **]: One (1) Capsule, Sust. Release 24 hr PO DAILY (Daily). 8. Levetiracetam 100 mg/mL Solution [**Last Name (STitle) **]: One (1) PO BID (2 times a day). 9. Warfarin 3 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO HS (at bedtime): goal [**2-9**] / INR. 10. Tubefeeding orders Tubefeeding: Start After 12:01AM; Probalance Full strength; Starting rate: 10 ml/hr; Advance rate by 10 ml q4h Goal rate: 55 ml/hr Residual Check: q4h Hold feeding for residual >= : 150 ml Flush w/ 200 ml water q8h 11. Regular Insulin sliding scale Insulin SC Sliding Scale Breakfast Lunch Dinner Bedtime Regular Glucose Insulin Dose 0-65 mg/dL [**1-8**] amp D50 66-120 mg/dL 0 Units 0 Units 0 Units 0 Units 121-160 mg/dL 2 Units 2 Units 2 Units 2 Units 161-200 mg/dL 4 Units 4 Units 4 Units 4 Units Discharge Disposition: Extended Care Facility: [**Location (un) **] Manor - [**Location (un) **] Discharge Diagnosis: PRIMARY . AAA post operative pro long intubation - hypoxia hyotension requiring pressure support hyperchloremic metabolic acidosis 2nd to NS infusion guiac positive stools hypokalemia / hypomagnesium Heparin induced thrombocytopenia . SECONDARY . AF seizure disorder HTN R. intraventricular bleed emphysema T2 compression fx Post operative transfusion decrease platelets post op confusion Discharge Condition: stable Plt 167 Creat 1.2 INR(PT)-2.6 Discharge Instructions: Division of [**Location (un) **] and Endovascular Surgery Abdominal Aortic Aneurysm (AAA) Surgery Discharge Instructions What to expect when you go home: 1. It is normal to feel weak and tired, this will last for [**6-14**] weeks ?????? You should get up out of bed every day and gradually increase your activity each day ?????? You may walk and you may go up and down stairs ?????? Increase your activities as you can tolerate- do not do too much right away! 2. It is normal to have incisional and leg swelling: ?????? Wear loose fitting pants/clothing (this will be less irritating to incision) ?????? Elevate your legs above the level of your heart (use [**2-9**] pillows or a recliner) every 2-3 hours throughout the day and at night ?????? Avoid prolonged periods of standing or sitting without your legs elevated 3. It is normal to have a decreased appetite, your appetite will return with time ?????? You will probably lose your taste for food and lose some weight ?????? Eat small frequent meals ?????? It is important to eat nutritious food options (high fiber, lean meats, vegetables/fruits, low fat, low cholesterol) to maintain your strength and assist in wound healing ?????? To avoid constipation: eat a high fiber diet and use stool softener while taking pain medication What activities you can and cannot do: ?????? No driving until post-op visit and you are no longer taking pain medications ?????? You should get up every day, get dressed and walk, gradually increasing your activity ?????? You may up and down stairs, go outside and/or ride in a car ?????? Increase your activities as you can tolerate- do not do too much right away! ?????? No heavy lifting, pushing or pulling (greater than 5 pounds) until your post op visit ?????? You may shower (let the soapy water run over incision, rinse and pat dry) ?????? Your incision may be left uncovered, unless you have small amounts of drainage from the wound, then place a dry dressing over the area that is draining, as needed ?????? Take all the medications you were taking before surgery, unless otherwise directed ?????? Take one full strength (325mg) enteric coated aspirin daily, unless otherwise directed ?????? Call and schedule an appointment to be seen in 2 weeks for staple/suture removal What to report to office: ?????? Redness that extends away from your incision ?????? A sudden increase in pain that is not controlled with pain medication ?????? A sudden change in the ability to move or use your leg or the ability to feel your leg ?????? Temperature greater than 101.5F for 24 hours ?????? Bleeding from incision ?????? New or increased drainage from incision or white, yellow or green drainage from incisions Followup Instructions: Call Neurology and schedule an appointment, They can be reached at 617 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3469**], MD Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2199-5-23**] 11:15 Completed by:[**2199-5-8**]

[ "276.8", "349.82", "428.0", "E934.2", "427.31", "588.89", "416.8", "441.4", "792.1", "V12.59", "492.8", "287.4", "458.29", "401.9", "458.9", "276.2" ]

icd9cm

[ [ [] ] ]

[ "93.90", "96.71", "38.44", "96.6" ]

icd9pcs

[ [ [] ] ]

14351, 14427

6338, 12561

322, 415

14860, 14899

1525, 6315

17649, 17905

1125, 1176

12761, 14328

14448, 14839

12587, 12738

14923, 17197

17223, 17626

1206, 1506

244, 284

443, 550

572, 930

946, 1093

26,523

142,901

6063

Discharge summary

report

Admission Date: [**2193-2-11**] Discharge Date: [**2193-2-20**] Date of Birth: [**2130-7-8**] Sex: F Service: MEDICINE Allergies: Compazine / Pepcid / Nitroglycerin / Dicloxacillin / Neurontin / Tape / Detrol / Ambien / Methadone Attending:[**First Name3 (LF) 1973**] Chief Complaint: Altered Mental Status Major Surgical or Invasive Procedure: [**2193-2-18**] TEE PICC Placement Removal of Central Catheter History of Present Illness: 62 y/o female brought in from [**Hospital3 7**] with altered mental status for one week and six blood cultures growing [**First Name5 (NamePattern1) 564**] [**Last Name (NamePattern1) 23807**]. At [**Hospital1 **], initially received ertapenum for presumptive UTI. Urine cultures came back as yeast. Blood cultures positive for staph epi and yeast, and so started on fluconazole and vancomycin. Later placed on caspofungin for multiple blood cultures with yeast. Per patient's husband, for the last week she was hallucinating with visual and tactile hallucinations. Pain meds and psychotrophic meds were stopped, without resolution of mental status changes. . In ED, febrile to 101.4, given Vanco, Levo, Flagyl, and Ceftriaxone. LP was unsuccessful. . Past Medical History: 1. MRSA 2. Metastatic thyroid CA s/p iodine and XRT and now on synthroid 3. Right lower extremity cellulitis 4. Nuerogenic bladder: Pt self catheterizes 5. Chronic low back pain: Pt is on continuous morphine PCA. 6. Depression 7. Type 2 DM 8. Chronic arachnoiditis 9. Esophageal dysmotility 10. DVT and PE s/p placement of IVC filter. Felt to be hypercoagulable 11. Chronic UTIs with pseudomonas/Klebsiella 12. Obstructive Sleep Apnea 13. Osteoarthritis 14. CHF now recovered. LVEF of 60%. 15. HTN 16. Anemia of chronic disease 17. Right ankle graft 18. Seizure [**2190-8-14**] 19. s/p Klebsiella line infection [**12-31**] 20. s/p ERCP for retained stone [**12-31**] 21. Hospitalized at [**Hospital1 **] [**6-30**] with R thumb/forearm cellulitis s/p several courses of Vancomycin 22. Splenic cyst 23. Osteomyelitis of the right second toe with chronic ulceration s/p distal phalangectomy of the right second toe with ulcer excision 24. Peripheral vascular disease 25. Squamous Cell Carcinoma 26. s/p Cholecystectomy Social History: Married. Currently residing at [**Hospital1 **] after recent [**Hospital1 18**] hospitalization. Cared for by husband at home. Pt has one son. Worked as a research chemist. No ETOH or tobacco use. Family History: Father has CAD, Mother with CVA Physical Exam: Well appearing white female T 96.4, 156/64, 74, 18, 100 Pain: [**2196-5-2**] SKIN: No rashes. HEENT: PERRL. EOMI. Sclera anicteric. Mucous membranes dry. NECK: No LAD CHEST: No axillary LAD, non erythematous, no rashes. Lungs clear. HEART: Regular rhythm. Soft 2/6 systolic murmur at LUSB. BACK: No CVA tenderness. ABD: Scars from prior G tube and CCY. + BS. Soft, NT, ND, no suprapubic tenderness. EXT: - CCE. Abscent pulses. NEURO: Alert. CAOx3. CN 2-12 intact. Motor strength equal and [**3-30**] in both upper extremities. Pertinent Results: [**2193-2-19**] 05:39AM BLOOD WBC-5.8 RBC-3.53* Hgb-10.4* Hct-29.6* MCV-84 MCH-29.5 MCHC-35.2* RDW-17.1* Plt Ct-371 [**2193-2-19**] 05:39AM BLOOD Plt Ct-371 [**2193-2-19**] 05:39AM BLOOD UreaN-14 Creat-0.6 Na-140 K-4.1 HCO3-34* [**2193-2-18**] 05:01AM BLOOD Glucose-204* UreaN-15 Creat-0.7 Na-139 K-3.8 Cl-100 HCO3-33* AnGap-10 [**2193-2-19**] 05:39AM BLOOD Phos-3.5 Mg-1.4* [**2193-2-19**] 05:39AM BLOOD TSH-1.1 [**2193-2-19**] 05:39AM BLOOD T4-PND Free T4-2.2* . [**2193-2-14**] US GUID FOR VAS. ACCESS: 1. Successful placement of double-lumen PICC line, via a left brachial vein, terminating in the superior vena cava. Ready for use. 2. Limited venography by hand ejection showing significant narrowing of the left axillary and distal veins, with evidence of collateral circulation. . [**2193-2-15**] TTE ECHO: The left atrium is mildly dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size and systolic function (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 masses or vegetations are seen on the aortic valve. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. No mass or vegetation is seen on the mitral valve. Trivial mitral regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. . [**2193-2-18**] CXR: Tip of left-sided PICC catheter within distal SVC or upper cavoatrial junction. . [**2193-2-18**] TEE ECHO: No atrial septal defect is seen by 2D or color Doppler. There is symmetric left ventricular hypertrophy. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. There are complex (>4mm) atheroma in the aortic arch. There are simple atheroma in the descending thoracic aorta. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. No masses or vegetations are seen on the aortic valve. The mitral valve appears structurally normal with trivial mitral regurgitation. No mass or vegetation is seen on the mitral valve. The tricuspid valve leaflets are mildly thickened. There is no pericardial effusion. No vegetation seen. Catheter seen entering right atrium via the SVC. The catheter tip visibile in the right atrium near the tricuspid valve (contact with valve notclearly documented). Would consider pullback of catheter to RA/SVC junction if clinically indicated. Brief Hospital Course: A/P: 62 y/o female with h/o chronic pain with long-term Hickman now p/w UTI, fungemia, and altered mental status. Patient intitially presented to the MICU on the [**Hospital Ward Name **], and was transferred to the hospitalist service for further management. . #) Septicemia due to [**First Name4 (NamePattern1) 564**] [**Last Name (NamePattern1) **] Infection: Improved significantly. Likely due to underlying infection ([**Female First Name (un) 564**] Albicans fungemia) as she has had mental status changes in the past with infections that have resolved once her infection is treated with concern for brain lesions. Most metabolic derangements, including uremia and ARF, have resolved. Tox screen negative. No evidence of seizure. LFT's normal. Head CT negative x2 for acute processes or masses. LP was unsuccessful and unlikely to be successful given her significant scarring. Transiently on precedex with improvement. - Caspofungin x14 days, to end on [**2193-2-26**] - She currently has a Left arm picc. When IV medications are complete, this should be removed. It is strongly recommended by our ID consultants that she not have a new central line placed in the near future. In speaking with her PCP (Dr. [**Last Name (STitle) **] there is no likely immediate need for one. - surgery D/C'd line [**2-12**], tip culture NGTD - ophtho exam [**2-12**] showed no eye involvement - Chest CT showed multiple nodular paranchymal lesions with tiny cavitations concerning for fungal infection, inflammatory process, or metastatic thyroid CA - Pt will require repeat chest CT in 2 months time - TTE/TEE to eval for vegetation were negative . #) UTI - Bacterial: Neurogenic bladder with intermittent catheterizations. Had foley from [**Hospital1 **]. U/A on admission was notable for many bacteria, elevated WBCs and small esterase positivity. - changed foley on admission to ICU - Received Cefepime x 3 d given her history of UTIs with E coli and Pseudomonas that have been resistant to Bactrim and fluoroquinolones. - Urine culture here is negative, but grew yeast at OSH. - Cefepime D/C'd [**2-13**] - Patient initially also given vancomycin, which was discontinued due to no bacterial infection found . #) Skin lesion: Papular nodule on right shin. DDx folliculitis v. metastatic nodule v. skin seeding of fungemia. - Derm performed punch biopsy [**2-12**] - pathology: -Epidermal acanthosis with spongiosis and dyskeratosis (see comment). -No evidence of fungal organisms on PAS-D stain. -No evidence of metastatic carcinoma. -Multiple tissue levels examined. - Will need suture removal [**2-27**] . #) Thyroid Carcinoma: Metastatic papillary thyroid CA s/p thyroidectomy [**2165**] + XRT. Found to have elevated thyrotropin stimulated thyroglobulin and treated with radioactive iodine in [**2189-12-27**]. New lung lesions and rising TSH (was on suppression therapy). Endocrine consult believes lung nodules unlikely to be thyroid CA. History of poor absorption. - Followed by Dr. [**Last Name (STitle) 574**] - Endocrine consulted - Changed from levothyroxine to levoxyl 150mcg [**Hospital1 **] (goal is suppression therapy) - TSH and free T4 were rechecked to assess trend (will require 6-8 weeks on this new regimen to reach steady state) - Outpatient endocrine follow up with Dr. [**Last Name (STitle) 574**] . #) Acute Renal Failure: -resolved after IV hydration. Cr returned to baseline of 0.8-0.9. Was likely due to infection, AMS and decreased PO intake. . #) Hypertension - Benign: - BPs labile, likely due to pain, and narcotics - metoprolol, and clonidine. - The patient is normally on hydralazine, however she has gotten in trouble in the past with concurrent titration of her pain regimen and antihypertensives at the same time. In discussions with her PCP, [**Name10 (NameIs) **] concurs, and she should have a completely stable pain regimen prior to adding any hypertensives. She has been running in the 150 range when in mild pain - No other change in anti-hypertensives at this time [**12-28**] new pain med regimen . #) Diabetes, Type 2 uncontrolled: - insulin sliding scale - Metformin 850 [**Hospital1 **] . #) Anemia of chronic disease: - known h/o guaiac positive stools that have been evaluated by endoscopy without bleeding source identified (non-bleeding grade II internal hemorrhoids seen). Also with component of anemia of chronic disease. - Hct baseline of 30 - follow hct, transfuse 1 unit for syptomatic improvement; otherwise transfuse for Hct < 21 . #) H/O DVT/PE: - On warfarin at home for h/o hypercoaguability and h/o DVT and PE. Also has IVC filter in place. - warfarin at home dose, follow INR #) BACK PAIN - CHRONIC - We started fentanyl patch for our basal rate at 50mcg, then using morphine PCA have determined: 1. currently she requires the patch alone while sleeping (reports no pain, and used no PCA doses overnight). Do NOT increase the patch if at all possible, as in the past she has gotten in trouble with these increases 2. Given her all her breakthrough doses have been during the day, we are adding a low dose Sustained-release Morphine at 15mg 3. I would strongly recommend that you continue the PCA currently to capture further timing data, and that would make a very small increment in her daytime Morphine-SR doses (such as to 30 only). I would not add any nighttime meds 4. As she becomes more active she will likely require more daytime coverage, but the nighttime will remain at 50mcg of fentanyl. - I have discussed this regimen with the PCP (Dr. [**Last Name (STitle) **] who concurrs this is a good plan #) Access: LEFT ARM PICC line #) Code: Full code. #) Contact: [**Name (NI) 4906**] [**Name (NI) **] ([**Telephone/Fax (1) 23808**]. NOTE: PATIENT REQUESTED TO BE ON DR.[**Doctor Last Name 23809**] SERVICE AT [**Hospital1 **], AS HE WAS THE ORIGINAL ATTENDING ON THE CASE Medications on Admission: Caspofungin 50 mg IV QD Vanco 1 g (last [**2193-2-10**]- trough >20 on [**2193-2-11**]) ASA 324 mg DAILY Levothyroxine 200 mcg DAILY Ferrous Sulfate 325 mg DAILY Senna 8.6 mg [**Hospital1 **] Docusate Sodium 100 mg [**Hospital1 **] Dulcolax 10 mg DAILY Lactulose 30 gm DAILY Metformin 850 mg [**Hospital1 **] (being held) Quinine Sulfate 324 mg QHS Baclofen 20 mg TID Lisinopril 20 mg DAILY HCTZ 12.5 mg DAILY Pantoprazole 40 mg DAILY Tizanidine 2 mg DAILY Citalopram 40 mg DAILY (recently decreased to 20 mg DAILY) Seroquel 75 mg QHS Folic Acid 1 mg DAILY Amitriptyline 50 mg DAILY Trazodone 100 mg DAILY Morphine 15 mg Q6H Metoprolol Tartrate 50 mg TID HydrALAzine 50 mg Q6H Clonidine 0.2 mg Patch QWeekly(every Friday) Warfarin 7.5 mg QHS Discharge Medications: 1. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed. 3. Senna 8.6 mg Capsule Sig: One (1) Capsule PO twice a day as needed for constipation. 4. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO Q8H (every 8 hours) as needed. 6. Olanzapine 10 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO BID (2 times a day) as needed for agitation. 7. Clonidine 0.2 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QTHUR (every Thursday). 8. Levothyroxine 100 mcg Tablet Sig: 1.5 Tablets PO BID (2 times a day). 9. Warfarin 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 10. RISS RISS as per protocol QAC/HS 11. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 12. Caspofungin 70 mg Recon Soln Sig: Fifty (50) mg Intravenous Q24H (every 24 hours) for 9 days. 13. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed. 14. Baclofen 10 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 15. Fentanyl 50 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr Transdermal Q72H (every 72 hours). 16. Morphine 1 mg/mL Syringe Sig: 0.5 mg Injection Every 10 [**Hospital1 **]: PCA, No Basal rate. 17. Amitriptyline 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 18. Metformin 850 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 19. Morphine 15 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO QAM (once a day (in the morning)). 20. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: Two (2) ML Intravenous DAILY (Daily) as needed. Discharge Disposition: Extended Care Facility: [**Hospital3 7**] & Rehab Center - [**Hospital1 8**] Discharge Diagnosis: Candidemia [**12-28**] line infection Thyroid Ca Chronic back pain Type II DM, uncontrolled Hx DVT/PE HTN 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: Followup Instructions: - Will need suture removal from bx of shin lesion [**2-27**] - Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 6730**], MD Phone:[**Telephone/Fax (1) 1971**] Date/Time:[**2193-2-22**] 1:00 - Pt given information from SW on the Mind/Body Institute in [**Location (un) 55**], MA re: outpatient emotional support. Pt may benefit from SW support at ECF. - Provider: [**First Name11 (Name Pattern1) 312**] [**Last Name (NamePattern4) 3015**], M.D. Phone:[**Telephone/Fax (1) 1803**] Date/Time:[**2193-3-14**] 11:00, Endocrinology dept, [**Hospital Ward Name 23**] [**Location (un) 436**]. - Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 6730**], MD Phone:[**Telephone/Fax (1) 1971**] Date/Time:[**2193-4-12**] 3:15 **Pt requesting to be on Dr.[**Name (NI) **] service at ECF.

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Discharge summary

report

[** **] Date: [**2118-10-24**] Discharge Date: [**2118-11-2**] Service: MEDICINE Allergies: Codeine / Versed / Colchicine / Lipitor / Multaq / Statins-Hmg-Coa Reductase Inhibitors Attending:[**First Name3 (LF) 10842**] Chief Complaint: Chief Complaint: BRBPR, AMS Reason for MICU transfer: S/p Code Blue for PEA Major Surgical or Invasive Procedure: None History of Present Illness: History obtained from the medicine [**First Name3 (LF) **] note done the morning of her transfer to the MICU since patient has baseline dementia and is unable to give accurate hitory. This is a [**Age over 90 **]yoF with history of Alzheimer's Disease, Afib (not on anti-coag), CVA, recurrent GI bleeds, diverticulosis, recurrent and resistant UTIs who presents with altered mental status and dyspnea x2 days. Per HCP/nephew, patient had [**Name (NI) 19456**] symptoms for approximately 7 days however over the last 2-3 days, he noticed patient with increased fatigue, DOE and reduced PO intake. On day of presentation, she mentioned to him that she had BRB after having a bowel movement. He saw that there was blood tracking down her leg and onto her sock and decided to bring her to ED for evaluation. In the ED, initial VS were: 97.2 85 105/58 20 98% ra. Exam was significant for diffuse wheezing on lung exam and rectal exam w/ dark blood. Labs had several abnormalities including hyperkalemia to 6.1, WBC to 11.4 and Plt 127. Lactate was 1.5. CXR was showed pulmonary edema. UA was positive. EKG showed no peaked Ts and normal QRS. Pt received 2L IVF and 2g cefepime as well as calcium gluconate 2g. Patient was then admitted for further evaluation. VS prior to transfer were 98.2 107 118/83 17 98%RA She was admitted to the floor over night by night float and patient reported feeling better however complained of feeling thirsty. She had episodes of afib with RVR (to the 140s) which was controlled with unknown doses of beta blocker. Also recieved fluids for tachycardia in the low 100s. In addition, she was given Kayexelate for hyperkalemia (peaked Ts) over night. Started on Cefepime and Meropenem for her h/o reccurent/resistant UTIs. At 11am on [**2118-10-25**], she was found to be pulseless by ancillary staff, a code blue was announced. Initial MD exam showed PEA. Eventually patient was noted to have a HR in the 20s-30s and continued to be non-responsive. No blood pressure obtained. She received <30 seconds of compressions. She eventually had ROSC. There were also reports of a BM with brbpr prior to the code. VS after resusciatation were HR 110s, BP 140s/80s, RR 10, 100 on NRB. On arrival to the MICU, she is drowsy with baseline dementia. Does not endorse any complaints of pain, chest pain, abdominal pain, SOB, lightheadedness, dizziness. Denies any n/v. Poor historian. Review of systems: Negative, see HPI for pertinents Past Medical History: 1. Hypertension 2. Atrial fibrillation (diagnosed [**2108**], complicated right arm thrombus) 3. Cerebrovascular accident to left insula ([**12/2112**]) - mild right facial asymmetry deficit, some short-term memory issues 4. Mild cognitive impairment 5. Colonic gastrointestinal bleeding (4 episodes in [**2111**]-[**2114**]; previously on Coumadin, now Aspirin only) 6. Diastolic, systolic congestive heart failure 7. Moderate mitral regurgitation 8. Moderate aortic regurgitation 9. Diverticulosis 10. Gout 11. Amiodarone-induced hypothyroidism ([**11/2115**]) 12. Multi-drug resistant E.coli and MRSA, VRE UTIs (likely due to uterine/bladder prolapse) 13. Dyspepsia 14. s/p right cataract surgery ([**2114**]) 15. s/p right breast mass excision for atypical ductal hyperplasia ([**5-/2112**]) 16. s/p open appendectomy ([**2052**]) 17. Compression fracture of thoracic vertebrae ([**4-/2116**]) 18. s/p hip fracture repair ([**6-/2116**]) 19. small incidental aortic arch aneurysm ([**-1/2021**]) Social History: Patient lives at home alone with a nephew and has 2 daily caretakes. Previously employed as a seamstress. Denies tobacco use or alcohol use; no recreational substance use. Dependent on most ADLs. Uses [**Numeric Identifier **] at baseline. Family History: Mother with hypertension. Physical Exam: [**Numeric Identifier **] PHYSICAL EXAM: Vitals: T: 98.5 BP: 94/45 P: 104 R: 18 O2: 100%RA General: Alert, drowsy, oriented to person, place and month, NAD HEENT: Sclera anicteric, dry MM, oropharynx clear, EOMI, PERRL Neck: Supple, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Coarse breath sounds, decreased lung sounds at bases Abdomen: Soft, non-tender, non-distended, bowel sounds present, no organomegaly GU: Foley could not be placed, possible vaginal bleeding, uterine/bladder prolapse Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: Grossly nonfocal, unable to fully assess due to drowsiness DISCHARGE PHYSICAL EXAM: Patient passed away during this [**Numeric Identifier **] Pertinent Results: [**Numeric Identifier **] LABS: [**2118-10-24**] 08:42PM BLOOD WBC-11.4*# RBC-3.41* Hgb-9.3* Hct-29.0* MCV-85 MCH-27.2# MCHC-32.0 RDW-20.9* Plt Ct-127* [**2118-10-24**] 08:42PM BLOOD Neuts-83.0* Lymphs-11.2* Monos-5.3 Eos-0.4 Baso-0 [**2118-10-24**] 08:42PM BLOOD Plt Ct-127* [**2118-10-24**] 08:42PM BLOOD PT-15.5* PTT-27.5 INR(PT)-1.5* [**2118-10-25**] 03:20AM BLOOD Fibrino-374 [**2118-10-24**] 08:42PM BLOOD Glucose-98 UreaN-47* Creat-1.8* Na-132* K-6.1* Cl-103 HCO3-16* AnGap-19 [**2118-10-25**] 03:20AM BLOOD ALT-61* AST-216* AlkPhos-50 [**2118-10-25**] 03:20AM BLOOD Albumin-4.2 Calcium-8.7 Phos-3.8 Mg-2.0 [**2118-10-24**] 10:55PM BLOOD Lactate-1.5 [**2118-10-24**] 09:00PM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.020 [**2118-10-24**] 09:00PM URINE Blood-MOD Nitrite-NEG Protein-100 Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-2* pH-5.5 Leuks-LG [**2118-10-24**] 09:00PM URINE RBC-8* WBC->182* Bacteri-MANY Yeast-NONE Epi-0 [**2118-10-24**] 09:00PM URINE CastHy-9* [**2118-10-25**] 03:27AM URINE Hours-RANDOM UreaN-322 Creat-207 Na-23 K-71 Cl-12 [**2118-10-25**] 03:27AM URINE Osmolal-398 IMAGING: CXR [**2118-10-24**] IMPRESSION: Low lung volumes and mild pulmonary edema. Cardiomegaly. There appears to be blunting of the posterior left costophrenic angle which may be due to a pleural effusion. CXR [**2118-10-25**] FINDINGS: AP single view of the chest has been obtained with patient in supine position. Comparison is made to the most recent PA and lateral chest examination of [**2118-10-24**]. Cardiomegaly as before. Generally widened and somewhat elongated thoracic aorta with extensive wall calcifications, also unchanged. Moderate degree of perivascular haze is seen in the pulmonary circulation consistent with mild degree of pulmonary congestion. No evidence of pleural effusion in the lateral pleural sinuses, and no pneumothorax in the apical area. In comparison with the previous study, no new acute pulmonary infiltrate. Telephone contact with referring physician, [**Name (NI) **] [**Last Name (NamePattern1) **], was established at 1:50 p.m. using telephone [**Numeric Identifier 19457**]. Telephone contact with Dr. [**Last Name (STitle) **] revealed that the patient had a cardiac arrest during the latest examination interval, and CPR was performed. It can therefore be added on the portable chest examination, single view in supine position, there is no evidence of any rib fracture, pneumothorax, or other abnormalities. CXR [**2118-10-30**] IMPRESSION: 1. Slight interval reduction in lung volumes with appearance of patchy bibasilar opacities which likely reflect patchy atelectasis. In addition, there is an interstitial process bilaterally, likely reflecting interval appearance of mild interstitial edema. The heart remains enlarged which may reflect cardiomegaly, although pericardial effusion cannot be excluded. Mediastinal contours are likely stable given differences in patient positioning. No pneumothorax. Probable small bilateral effusions. CXR [**2118-10-31**]: FINDINGS: As compared to the previous radiograph, there is moderately increasing evidence of pulmonary edema and bilateral pleural effusions. Subsequent bilateral areas of atelectasis. Unchanged low lung volumes with moderate cardiomegaly. EKG [**2118-10-24**] Atrial fibrillation. Compared to the previous tracing of [**2117-9-1**] no change. MICRO [**2118-10-25**] 3:20 am BLOOD CULTURE **FINAL REPORT [**2118-10-31**]** Blood Culture, Routine (Final [**2118-10-31**]): NO GROWTH. [**2118-10-24**] 9:00 pm URINE CATHETER. **FINAL REPORT [**2118-10-26**]** URINE CULTURE (Final [**2118-10-26**]): KLEBSIELLA PNEUMONIAE. >100,000 ORGANISMS/ML.. Cefazolin interpretative criteria are based on a dosage regimen of 2g every 8h. Piperacillin/tazobactam sensitivity testing available on request. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ KLEBSIELLA PNEUMONIAE | AMPICILLIN/SULBACTAM-- 4 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- 64 I TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S Brief Hospital Course: [**Age over 90 **] y/o female with h/o recurrent resistant UTIs, recurrent GI bleeds (h/o diverticulosis), who was initially admitted to the hospital for BRBPR and altered mental status, went into PEA arrest on the floor and was resuscitated with <30sec of chest compressions and transferred to the MICU. After stabilization she was transferred back to the floor. HOSPITAL COURSE BY PROBLEM #Shock: Patient was hypotensive and tachycardic on arrival to MICU. In light of the patient's recent h/o BRBPR, her shock was most likley [**2-17**] hemorrhage/hypovolemia. Other considerations included urosepsis since the patient was currently being treated for a UTI (positive UA in ER). However, the patient was been afebrile in the MICU and had a normal WBC count on arrival. Could have also been cardiogenic (s/p cardiac event, ST depression on lateral inferior leads likely from demand), however, more likely due to LGIB/hypovolemia. Would have not been able to start heparin drip if ACS due to bleeding and thus held off on checking troponins. Another consideration is that the PEA event could have also been caused by a vasovagal reaction after a large bloody BM. After arriving at the MICU, patient received two units of blood and aggressive IVF. No [**Month/Day (2) 14938**] was placed since HCP (nephew) perferred not placing a [**Name (NI) 14938**] if possible. The patient had two dark maroon BMs with clots on [**2118-10-26**]. The hematocrit stabilized at above 30 during her stay in the MICU. After transfer to the floor the patient's BPs remained stable and she experienced no more BRBPR. On [**2118-11-2**] I was called for low BP and patient was triggered. She was pale in the face, but reported to be asymptomatic. EKG was unremarkable except for slow a-fib. O2 sat was 99% on room air and HR 80. Patient was slightly tachypneic. ALso had new WBC count to 14.9. IVF were given without improvement in BP (was bolusing fluid throughout event). Broad spectrum antibiotics were ordered, but before they came to the bedside patient became agonal and passed away. Unclear etiology, but PE is high on the differential given her underlying a-fib and we had been holding anticoagulation and only using pneumoboots given her GI bleed and risks for bleeding. #Pulmonary Edema: The patient developed pulmonary edema after resusciation with blood and IVF during her first 48 hours in the MICU. Likely multifactorial from her CKD, CHF, and afib. She was initially placed on a lasix gtt but was transitioned to IV metolazone and lasix. Goal I/Os was met at negative 1L. CXR at time of transfer to the floor showed improving pulmonary edema. After transfer to the floor, diuresis was continued for one more day. The patient's respiratory status improved. #GI bleed: Likely BRBPR is due to diverticulosis in light of PMH. Unlikely to be a brisk UGIB, however, should not be ruled out. The patient had two dark maroon BMs with clots on [**2118-10-26**]. Family did not want to pursue aggressive intervention and further work-up for the definite cause of her bleeding was not undertaken. She was transfused 2 units after transfer to the MICU. After transfer back to the floor, she had no more BRBPR. #Anemia: Likely [**2-17**] GI bleed. Baseline hct is 27-30. The patient was transfused 2 units of blood in the MICU and hct increased appropriately. #UTI: The patient's UA after [**Month/Day (2) **] was consistent with UTI, and she was started initially on meropenem given a h/o reccurent UTIs with resistant bacteria. Foley was placed by urology in the MICU due to h/o difficult Foley placements. Urine cx returned showing Klebsiella that was pan-sensitive (except to Nitrofurantoin). Meropenem was switched to ceftriaxone for a total treatment course of 10 days, which was completed in-hospital. #Hyperkalemia: Reportedly had peaked T waves in ED. Was monitored during her stay and normalized without intervention. #[**Last Name (un) **] on CKD: Likely due to LGIB/hypovolemia. Baseline Cr is 1.3-1.5. After initial resuscitation, Cr was 1.7. It continued to increase during her stay in the MICU. Renal was consulted who recommended optimization of diuresis in order to improve forward flow. #Afib: Report of episodes of RVR on the floor immediately after [**Last Name (un) **], for which the pt was given unknown dose of beta blocker. HR in the 100s on arrival to MICU. EKG done on the floor during the code blue showed afib. We continued Metoprolol Tartrate 25mg PO BID with BP holding parameters. Aspirin was also held in light of LGIB. Metoprolol was increased to 37.5mg PO TID for optomoization of forward cardiac flow with the goal HR of below 100. After transfer back to the floor the patient remained persistently tachycardic to the 100s-110s and her metoprolol was uptitrated again to 50mg PO TID. #Coagulopathy: Elevated INR (1.5) on [**Last Name (un) **], which rose during her hospitalization. Possibly secondary to nutritional deficiency vs. liver dysfunction. She was given vitamin K and her INR 1.5. #Hypothyroidism: Continued home levothyroxine while in-house. Patient passed away while in house. Family was notified, post mortem denied. Medications on [**Last Name (un) **]: Preadmission medications listed are correct and complete. Information was obtained from Family/Caregiver. 1. Alendronate Sodium 70 mg PO Frequency is Unknown 2. Doxazosin 4 mg PO DAILY hold for sbp < 100 3. Fosfomycin Tromethamine 3 g PO EVERY 10 DAYS Dissolve in [**3-20**] oz (90-120 mL) water and take immediately - Last dose was on [**10-21**] 4. Levothyroxine Sodium 100 mcg PO DAILY 5. Metoprolol Succinate XL 100 mg PO DAILY hold for sbp < 100 and hr < 60 6. Omeprazole 20 mg PO THREE TIMES PER WEEK 7. Aspirin 325 mg PO DAILY 8. Vitamin D 1000 UNIT PO DAILY 9. Cyanocobalamin 1000 mcg PO DAILY Discharge Medications: 1. Acetaminophen 500 mg PO Q6H:PRN pain 2. Cyanocobalamin 1000 mcg PO DAILY 3. Levothyroxine Sodium 100 mcg PO DAILY 4. Vitamin D 1000 UNIT PO DAILY 5. Metoprolol Succinate XL 100 mg PO DAILY hold for sbp < 100 and hr < 60 6. Multivitamins 1 TAB PO DAILY 7. Omeprazole 20 mg PO THREE TIMES PER WEEK 8. Fosfomycin Tromethamine 3 g PO EVERY 10 DAYS Dissolve in [**3-20**] oz (90-120 mL) water and take immediately - Last dose was on [**10-21**] 9. Doxazosin 4 mg PO DAILY hold for sbp < 100 10. Aspirin 81 mg PO DAILY 11. Alendronate Sodium 70 mg PO WEEKLY Discharge Disposition: Expired Discharge Diagnosis: Lower GI bleeding Blood loss anemia Acute decompensated diastolic CHF Urinary tract infection Acute kidney injury Discharge Condition: Passed away Discharge Instructions: Passed away Followup Instructions: Passed away

[ "790.4", "276.1", "569.1", "331.83", "331.0", "427.31", "518.81", "441.4", "438.83", "599.0", "396.3", "276.7", "438.89", "507.0", "285.1", "288.60", "287.5", "294.10", "780.93", "995.92", "785.59", "293.0", "V49.86", "427.5", "V15.51", "038.9", "244.9", "403.90", "276.2", "584.9", "428.0", "618.1", "041.3", "585.4", "286.7", "428.33", "274.9", "562.12" ]

icd9cm

[ [ [] ] ]

[ "38.97", "99.60" ]

icd9pcs

[ [ [] ] ]

15935, 15944

9518, 15332

373, 380

16102, 16115

4990, 9495

16175, 16189

4158, 4185

15355, 15912

15965, 16081

16139, 16152

4241, 4887

2828, 2862

273, 335

408, 2809

2884, 3885

3901, 4142

4912, 4971

64,988

191,663

30846

Discharge summary

report

Admission Date: [**2112-9-5**] Discharge Date: [**2112-9-7**] Date of Birth: [**2061-5-19**] Sex: M Service: CARDIOTHORACIC Allergies: Penicillins Attending:[**First Name3 (LF) 165**] Chief Complaint: fatigue Major Surgical or Invasive Procedure: Drainage of pericardial effusion and creation of pericardial window History of Present Illness: 51M with aortic aneurysm repaired in [**Month (only) 205**], was sent to the [**Hospital1 18**] ED by pcp for evaluation. Patient had dental procedure 5 days ago (took abx before) and developed low grade fevers to 100.5 at home. Also reports fatigue and decreased appetite. He also got a flu shot 5 days ago. Also reports chest pain that began while surfing, lasted 1 day associated with muscle spasm, and has since resolved. Has not had any chest pain since. Denies cough, SOB, N/V/D, abdominal pain, HA, neck pain. Past Medical History: Ascending Aortic Aneurysm Hypertension Osteoarthritis, neck Social History: Occupation: Captains a tug boat for the [**Company 16410**] Last Dental Exam: q4mos, Dr. [**Last Name (STitle) 72989**] in [**Hospital1 **] Lives with: Wife [**Name (NI) **]: Caucasian Tobacco: Non-smoker, 15 pack year history, quit [**2092**] ETOH: none x 10 years Family History: uncle died at 40yo MI aunt with "heart problems" both parents living and well 71yo Physical Exam: Physical Exam Pulse: 91 Resp: 16 O2 sat: 100% RA B/P Right: 109/76 Left: Height: 69" Weight: 76.2 kg General: Skin: Dry [x] [**Year (4 digits) 5235**] [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 [**Year (4 digits) 5235**] [x] Pulses: Femoral Right: 2+ Left: 2+ DP Right: 1+ Left: 1+ PT [**Name (NI) 167**]: 1+ Left: 1+ Radial Right: 2+ Left: 2+ Carotid Bruit Right: no Left: no Pertinent Results: [**Hospital1 18**] ECHOCARDIOGRAPHY REPORT [**Known lastname **], [**Known firstname 251**] [**Hospital1 18**] [**Numeric Identifier 72990**] (Complete) Done [**2112-9-6**] at 8:52:12 AM PRELIMINARY Referring Physician [**Name9 (PRE) **] Information [**Name9 (PRE) **], [**First Name3 (LF) **] Division of Cardiothoracic [**Doctor First Name **] [**First Name (Titles) **] [**Last Name (Titles) **] [**Hospital Unit Name 4081**] [**Location (un) 86**], [**Numeric Identifier 39593**] Status: Inpatient DOB: [**2061-5-19**] Age (years): 51 M Hgt (in): 69 BP (mm Hg): 121/56 Wgt (lb): 150 HR (bpm): 78 BSA (m2): 1.83 m2 Indication: Intraoperative TEE for pericardial window. Aortic valve disease. Left ventricular function. Pericardial effusion. Preoperative assessment. Prosthetic valve function. Right ventricular function. Shortness of breath. Valvular heart disease. ICD-9 Codes: 786.05, 423.3, 423.9 Test Information Date/Time: [**2112-9-6**] at 08:52 Interpret MD: [**Name6 (MD) 1509**] [**Name8 (MD) 1510**], MD Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 1510**], MD Doppler: Limited Doppler and color Doppler Test Location: Anesthesia West OR cardiac Contrast: None Tech Quality: Adequate Tape #: 2012AW3-: Machine: u/s 3 Echocardiographic Measurements Results Measurements Normal Range Left Ventricle - Ejection Fraction: 45% >= 55% Findings LEFT VENTRICLE: Mildly depressed LVEF. RIGHT VENTRICLE: Mild global RV free wall hypokinesis. AORTIC VALVE: Bioprosthetic aortic valve prosthesis (AVR). No AR. MITRAL VALVE: Mild (1+) MR. TRICUSPID VALVE: Mild [1+] TR. PERICARDIUM: Large pericardial effusion. Effusion circumferential. Sustained RA diastolic collapse, c/w low filling pressures or early tamponade. [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 7216**] collapse. GENERAL COMMENTS: Informed consent was obtained. The patient was under general anesthesia throughout the procedure. No TEE related complications. The patient appears to be in sinus the patient. Conclusions Pre pericardial window Overall left ventricular systolic function is mildly depressed (LVEF= 45 %). with mild global RV free wall hypokinesis. A bioprosthetic aortic valve prosthesis is present. No aortic regurgitation is seen. There is mild mitral regurgitation. There is a large pericardial effusion. The effusion appears circumferential that more to the left and posterior. There is sustained right atrial collapse, consistent with low filling pressures or early tamponade. There is left atrial diastolic collapse. Fibrinous material noted behind the left atrial wall. Dr. [**Last Name (STitle) **] was notified in person of the results on [**2112-9-6**] at 830 am . Post pericardial window There is trivial pericardial effusion. The fibrinous material behind the left atrium still exists. Rest of examination in unchanged. I certify that I was present for this procedure in compliance with HCFA regulations. Interpretation assigned to [**Name6 (MD) 1509**] [**Name8 (MD) 1510**], MD, Interpreting physician ?????? [**2102**] CareGroup IS. All rights reserved. [**2112-9-5**] 06:17PM PT-12.7* PTT-27.8 INR(PT)-1.2* [**2112-9-7**] 03:46AM BLOOD WBC-9.8 RBC-4.20* Hgb-11.7* Hct-34.7* MCV-83 MCH-27.7 MCHC-33.6 RDW-15.7* Plt Ct-325 [**2112-9-5**] 03:36PM BLOOD WBC-8.6 RBC-4.34* Hgb-12.3* Hct-36.7* MCV-85 MCH-28.3 MCHC-33.4 RDW-15.5 Plt Ct-323 [**2112-9-7**] 03:46AM BLOOD PT-13.8* PTT-27.0 INR(PT)-1.3* [**2112-9-5**] 06:17PM BLOOD PT-12.7* PTT-27.8 INR(PT)-1.2* [**2112-9-7**] 03:46AM BLOOD Glucose-103* UreaN-8 Creat-0.5 Na-138 K-3.8 Cl-106 HCO3-25 AnGap-11 [**2112-9-5**] 03:36PM BLOOD Glucose-106* UreaN-9 Creat-0.6 Na-134 K-4.5 Cl-97 HCO3-29 AnGap-13 Brief Hospital Course: 51 male status post Bentall in [**5-26**] who has a large pericardial effusion with early tamponade physiology. He was admitted to the CVICU. On [**9-6**] he was taken to the operating room and underwent Pericardial window with Dr. [**First Name (STitle) **]. Please see operative note for further surgical details. Clear serous fluid, about 1200 cc, was drained and sent for analysis. Transesophageal echocardiogram showed complete clearance of the fluid and relief of the tamponade. A pericardial window was created. He tolerated the procedure well and was transferred to the CVICU for monitoring. POD#1 the pericardial drain was discontinued per protocol. The pt was ready for discharge to home directly from CVICU per Dr.[**First Name (STitle) **]. Follow up appoinments were advised. Medications on Admission: ASCORBIC ACID - (Prescribed by Other Provider) - ascorbic acid 500 mg tablet 1 tablet(s) by mouth once a day ASPIRIN [ADULT LOW DOSE ASPIRIN] - (Prescribed by Other Provider) - Adult Low Dose Aspirin 81 mg tablet,delayed release 1 tablet(s) by mouth once a day CALCIUM CARBONATE-VITAMIN D3 [CALCIUM 600 + D(3)] - (OTC) - Calcium 600 + D(3) 600 mg (1,500 mg)-400 unit tablet 1 tablet(s) by mouth once a day DOCOSAHEXANOIC ACID-EPA [FISH OIL] - (Prescribed by Other Provider) - Fish Oil 120 mg-180 mg capsule 2 capsule(s) by mouth once a day GLUCOSAMINE-CHONDROITIN [COSAMIN DS] - (OTC) - Cosamin DS 500 mg-400 mg tablet 1 tablet(s) by mouth twice a day MULTIVITAMIN-IRON-FOLIC ACID [DAILY MULTIPLE] - (OTC) - Daily Multiple 18 mg-400 mcg tablet 1 tablet(s) by mouth once a day Discharge Medications: 1. Acetaminophen 650 mg PO/PR Q4H:PRN temperature >38.0 2. Aspirin EC 81 mg PO DAILY 3. Atorvastatin 10 mg PO HS 4. Carvedilol 3.125 mg PO BID 5. Docusate Sodium 100 mg PO BID 6. Oxycodone-Acetaminophen (5mg-325mg) [**11-16**] TAB PO Q4H:PRN pain 7. Ranitidine 150 mg PO BID Discharge Disposition: Home Discharge Diagnosis: pericardial effusion causing early signs of tamponade. Discharge Condition: Alert and oriented x3 nonfocal Ambulating with steady gait Incisional pain managed with oral analgesia Incisions: Subxiphoid - healing well, no erythema or drainage Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] Females: Please wear bra to reduce pulling on incision, avoid rubbing on lower edge **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Followup Instructions: You are scheduled for the following appointments Surgeon:Dr.[**First Name (STitle) **] #[**Telephone/Fax (1) 170**] Date/Time:[**2112-9-27**] 2:30 Cardiologist:ECHOCARDIOGRAM Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2112-12-26**] 9:00 Provider [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4450**], M.D. Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2112-12-26**] 10:00 Please call to schedule appointments with your Primary Care Dr.[**Last Name (STitle) **],[**First Name3 (LF) **] E. [**Telephone/Fax (1) 2205**] in [**11-16**] 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** [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**] Completed by:[**2112-9-7**]

[ "721.0", "401.9", "423.3", "423.9", "V42.2" ]

icd9cm

[ [ [] ] ]

[ "37.12" ]

icd9pcs

[ [ [] ] ]

7820, 7826

5894, 6687

284, 354

7925, 8092

2109, 5871

9016, 9860

1286, 1370

7520, 7797

7847, 7904

6713, 7497

8116, 8993

1385, 2089

236, 246

382, 902

924, 985

1001, 1270

81,997

174,338

8242

Discharge summary

report

Admission Date: [**2199-10-24**] Discharge Date: [**2199-10-29**] Date of Birth: [**2116-1-12**] Sex: F Service: OBSTETRICS/GYNECOLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 7141**] Chief Complaint: Pelvic mass Major Surgical or Invasive Procedure: Exploratory laparotomy, supracervical hysterectomy, bilateral salpingo-oophorectomy, pelvic and para-aortic lymph node dissection, omentectomy, appendectomy, repair of cystotomy. History of Present Illness: Ms. [**Known lastname 29257**] is an 83-year-old woman who initially presented to the emergency room at [**Hospital1 18**] [**Location (un) 620**] with one day of abdominal pain, nausea, and vomiting. She was found to have pre-renal acute renal failure and was admitted to the medical service for hydration. During this admission, a pelvic mass was found. A pelvic ultrasound and an abdominal CT revealed massive ascites and a 12-cm pelvic mass. A pelvic MRI revealed a heterogeneous pelvic mass suspicious for a neoplasm, thought to be arising from the uterus, or less likely from the ovary or from the rectum. There was a small-to-moderate amount of ascites with proteinaceous debris in the procedure cul-de-sac. Her CEA level was 212 and her CA-125 level was only elevated to 71. Ms. [**Known lastname 29257**] was transferred to [**Hospital1 1170**] on [**2199-9-13**], and discharged from the hospital after resoluation of her renal failure. She does have lower pelvic discomfort, but has been tolerating a regular diet since then. She has no gastrointestinal symptoms. Past Medical History: Past Medical History: - Osteoporosis. - DVT of the right leg in [**2190**], s/p Coumadin. - Frequent UTIs Past Surgical History: None. OB/GYN History: - Gravida 0 - Denies any history of pelvic infections or abnormal Pap smears. Social History: 30 pack year smoker. No ETOH or drugs. Widowed since [**2190**]. Lives alone in [**Location (un) 745**]. Retired factory worker. Family History: She denies any family history of breast, ovarian, or uterine cancer. Physical Exam: She appears her stated age, in no apparent distress. Lymphatics: Lymph node survey, negative cervical, supraclavicular, axillary, or inguinal adenopathy. Chest: Lungs clear bilaterally. Heart: Regular rate and rhythm. I appreciate no murmurs. Back: No spinal or CVA tenderness. Abdomen: Slightly distended without a dominant palpable mass. Extremities: There is no clubbing, cyanosis, or edema. Pelvic: Normal external genitalia. The inner labia minora is normal. The urethral meatus is normal. Speculum was placed. The cervix is normal in appearance. There is no cervical motion tenderness. Bimanual exam reveals a mobile uterus with mass without any posterior cul-de-sac nodularity. Rectal: Reveals no mass or lesion. There is good sphincter tone. Pertinent Results: [**2199-10-23**] 08:30AM BLOOD WBC-7.3 RBC-3.55* Hgb-10.4* Hct-31.8* MCV-90 MCH-29.4 MCHC-32.7 RDW-13.1 Plt Ct-252 [**2199-10-28**] 06:00AM BLOOD WBC-9.8 RBC-3.23* Hgb-9.9* Hct-29.1* MCV-90 MCH-30.7 MCHC-34.0 RDW-13.9 Plt Ct-251 [**2199-10-23**] 08:30AM BLOOD UreaN-15 Creat-0.9 Na-139 K-4.4 Cl-103 HCO3-30 AnGap-10 [**2199-10-25**] 03:29AM BLOOD Glucose-134* UreaN-19 Creat-1.1 Na-140 K-5.7* Cl-108 HCO3-23 AnGap-15 [**2199-10-29**] 05:55AM BLOOD K-4.5 . CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2199-10-29**]): REPORTED BY PHONE TO S. [**Doctor Last Name **], R.N. ON [**2199-10-29**] AT 0540. CLOSTRIDIUM DIFFICILE. FECES POSITIVE FOR C. DIFFICILE TOXIN BY EIA. Radiology Report CHEST (PORTABLE AP) Study Date of [**2199-10-24**] 10:36 PM FINDINGS: No previous images. The cardiac silhouette is at the upper limits of normal in size and there is mild tortuosity of the aorta. Specifically, no evidence of pulmonary edema, pleural effusion, or acute pneumonia. There may be minimal bibasilar atelectatic change. . Radiology Report RENAL U.S. Study Date of [**2199-10-25**] 10:04 AM IMPRESSION: 1. No evidence of hydronephrosis to explain low urine output. Decompressed bladder with Foley catheter in place. 2. Small amount of free intraperitoneal fluid. . PORTABLE CHEST, [**2199-10-25**] FINDINGS: The cardiac silhouette is mildly enlarged, but pulmonary vascularity is normal, and there is no evidence of pulmonary edema. The aorta remains tortuous. Minor areas of atelectasis are present, with linear opacities in the right infrahilar and left retrocardiac region. Possible very small left pleural effusion. . CT CHEST W/CONTRAST [**10-28**]: IMPRESSIONS: 1. No evidence of mediastinal or hilar adenopathy. Previously seen right hilar opacity likely corresponds to vascular structures. 2. Subpleural 2-3 mm lung nodules. For patient at high risk for intrathoracic malignancy, follow-up CT is recommended in 12 months to document stability. Otherwise, no follow up is necessary. 3. Dependent atelectatic changes. 4. Moderate ascites. Anasarca Brief Hospital Course: Pt is an 83 yo female admitted s/p ex-lap, SCH-BSO, pelvic and para-aortic LN dissection, omentectomy, appendectomy, repair of cystotomy for 15 cm right adnexal mass, likely mucinous ovarian ca on frozen. Intraoperative course was complicated only by cystotomy which was primarily repaired. Please see operative report for full details. . The patient's post operative course was complicated by the following issues: . *) Hypotension: - Initially low BPs immediately post op, improved with hydration and was normotensive upon discharge. . *) Hyperkalemia: - Post operatively had elevated K up to 5.7, which was not treated and improved spontaneously. K was normal upon discharge. . *) Cystotomy: - A cystotomy was primarily repaired intra-op. Plan was made to keep a foley catheter in until POD 10. Patient was discharged home with foley and VNA care. . *) Low urine output: - This was an isssue on POD 1 and 2. Thought to be due to third spacing of fluid and intravascular hypovolemia. Improved with fluid boluses. . *) Post op anemia: - Patient's pre-op hct was 32. Due to EBL of 1000 cc, she received 2U PRBC intra-operatively and 2U PRBC in the PACU. Her hematocrit had a nadir of 28 and remained stable at 29.1 on day of discharge. . *) Pulmonary nodules: - A post-op CXR showed possible hilar LAD. This was further evaluated with a chest CT which revealed no lymphadenopathy, but did show 2-3 mm subpleural nodules. F/u chest CT in 12 months was recommended. . *) C. Diff: - Patient had one day of loose stools on POD#5, and her stool tested positive for C. Diff. She was started on a 10 day course of Flagyl 500mg PO TID. Her diarrhea was not severe. She had no fever or dehydration or electrolyte abnormalities. . *) Disposition - Pt was discharged POD #6 in stable condition. VNA was arranged for foley care. She was asked to f/u in the office for staple removal and foley catheter removal. Medications on Admission: Boniva Discharge Medications: 1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed. Disp:*40 Tablet(s)* Refills:*0* 2. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. Disp:*40 Tablet(s)* Refills:*0* 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 4. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 10 days. Disp:*30 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Adnexal mass Discharge Condition: Good Discharge Instructions: No heavy lifting or strenuous activity for 6 weeks. Take pain medications as needed. No driving while taking the Percocet. Call if you have any fevers or chills, increasing pain, nausea or vomiting, increase in your diarrhea, redness or drainage from your incision, or any other problems. Followup Instructions: Please call Dr.[**Name (NI) 2989**] office ([**Telephone/Fax (1) 26840**] to nake an appointment early next week to have your staples and your foley removed. Provider: [**Name10 (NameIs) **] [**Last Name (NamePattern4) 7613**], MD Phone:[**Telephone/Fax (1) 5777**] Date/Time:[**2199-11-28**] 10:15 Completed by:[**2199-10-31**]

[ "799.02", "733.00", "285.1", "E870.0", "V12.51", "568.0", "458.29", "276.7", "789.59", "183.0", "998.2" ]

icd9cm

[ [ [] ] ]

[ "40.3", "56.82", "68.39", "99.04", "54.4", "54.11", "65.61", "54.59", "54.19", "47.19", "57.32" ]

icd9pcs

[ [ [] ] ]

7478, 7536

5008, 6926

342, 523

7593, 7600

2928, 4985

7937, 8269

2059, 2130

6983, 7455

7557, 7572

6952, 6960

7624, 7914

1790, 1894

2145, 2909

291, 304

551, 1634

1679, 1766

1910, 2043

53,600

180,367

35209

Discharge summary

report

Admission Date: [**2185-3-13**] Discharge Date: [**2185-3-18**] Date of Birth: [**2124-4-24**] Sex: M Service: MEDICINE Allergies: Penicillins / Ampicillin / Folic Acid Attending:[**First Name3 (LF) 4365**] Chief Complaint: Seizure Major Surgical or Invasive Procedure: Intubation/extubation History of Present Illness: Mr. [**Known lastname **] is 60 year old male with past medical history of alcohol abuse and withdrawal, diastolic congestive heart failure, seizures, COPD, intraparenchymal bleed, and atrial fibrillation who presented with seizures. Patient is intubated and cannot provide additional history, however per report from the ED staff, he presented after having a seizure at the home where he was staying, per report the seizure lasted 1-2 minutes. . Per report to ED staff, he stated his last drink was yesterday, and he has had been to several hospitals recently. His vitals on presentation were blood pressure 126/75, heart rate 74, respiratory rate of 18, and 100% on 15 liter non-rebreather mask. He was reported to be combative and agitated, however was alert and oriented times three. He denied any complaints or other difficulties at that time. He was given 10 mg of valium, then 2 mg of IM ativan. . He was noted to have a possible seizure while in the emergency room, and was intubated for airway protection and anticipated need for significant amount of sedating medications. There were not a lot of secretions noted at that time. He was given versed, fentanyl, 10 mg of haldol, thiamine, folic acid, multivitamin, and vancomycin for redness of his hand. He was noted to be initially tachycardic to the 150's, however this improved to 110's at time of transfer and after three liters of fluid including a banana bag. He underwent a head CT, which was negative for acute intracranial hemorrhage or fracture. A serum toxicology screen was negative for alcohol and other drugs. A phenytoin level was 3.6. He was transferred on a versed drip at 14 mg/hour and fentanyl 100 mcg/hour. . Upon arrival to the ICU, he is intubated but agitated, attempting to sit upright and remove his endotracheal tube. Past Medical History: Diastolic CHF Chronic Pleural Effusions s/p VATS and decortication [**10-29**] COPD EtOH abuse with history of withdrawal seizures Pulmonary HTN Chronic Atrial Fibrillation Adenocarcinoma of the Esophagus s/p chemotherapy and radiation Depression OSA GERD Social History: Pt is homeless and lives in a shelter in [**Hospital1 8**]. Drinks 1pt vodka daily Family History: Unable to obtain Physical Exam: GENERAL: Intubated, dishevled HEENT: NC, no obvious trauma. No scleral icterus. Moist mucous membranes NECK: 3 cm rubbery nodule on right side of neck LUNGS: CTA anteriorly, intubated on admission CARDIAC: RRR no m/g/r ABDOMEN: soft, NT ND EXTR: warm, no c/c/e NEURO: Intubated and sedated SKIN: No lesions Pertinent Results: Labs on admission: [**2185-3-13**] 01:15PM BLOOD WBC-8.9# RBC-3.67* Hgb-11.3* Hct-33.3* MCV-91 MCH-30.8 MCHC-34.0 RDW-17.4* Plt Ct-380 [**2185-3-13**] 01:15PM BLOOD Neuts-85.2* Lymphs-8.4* Monos-5.3 Eos-0.7 Baso-0.4 [**2185-3-14**] 04:09AM BLOOD Glucose-74 UreaN-11 Creat-0.5 Na-138 K-4.1 Cl-106 HCO3-23 AnGap-13 [**2185-3-13**] 01:15PM BLOOD ALT-15 AST-35 AlkPhos-111 TotBili-0.3 [**2185-3-13**] 01:15PM BLOOD Lipase-13 [**2185-3-13**] 01:15PM BLOOD Albumin-3.7 Calcium-8.6 Phos-2.4* Mg-1.2* Iron-54 [**2185-3-13**] 01:15PM BLOOD calTIBC-225* VitB12-333 Folate-9.1 Ferritn-104 TRF-173* [**2185-3-14**] 04:09AM BLOOD Phenyto-6.8* [**2185-3-13**] 01:15PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2185-3-14**] 08:09AM BLOOD freeCa-1.09* [**2185-3-13**] 06:02PM URINE Color-Yellow Appear-Cloudy Sp [**Last Name (un) **]-1.013 [**2185-3-13**] 06:02PM URINE Blood-NEG Nitrite-NEG Protein-TR Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG [**2185-3-13**] 06:02PM URINE RBC-8* WBC-2 Bacteri-FEW Yeast-NONE Epi-0 TransE-<1 . Labs on discharge: [**2185-3-18**] 07:55AM BLOOD WBC-6.7 RBC-3.13* Hgb-9.6* Hct-29.1* MCV-93 MCH-30.6 MCHC-32.9 RDW-17.0* Plt Ct-311 [**2185-3-18**] 07:55AM BLOOD Glucose-113* UreaN-11 Creat-0.7 Na-135 K-4.2 Cl-97 HCO3-33* AnGap-9 [**2185-3-18**] 07:55AM BLOOD Calcium-8.4 Phos-3.3 Mg-1.4* . Microbiology: [**3-13**] blood culture - no growth to date [**3-13**] urine culture - negative [**3-13**] MRSA screen - negative [**3-14**] Sputum culture - MORAXELLA CATARRHALIS . Imaging: [**3-13**] Chest x-ray: 1. Endotracheal tube with tip 5.0 cm from the carina. 2. OG tube with tip projecting below the diaphragm; the side hole is not well visualized but may be above the diaphragm, recommend advancement. 2. Bibasal pleural effusions and associated relaxation atelectasis. . [**3-13**] head CT: IMPRESSION: 1. No acute intracranial hemorrhage. 2. No acute fracture. Right occipital nondisplaced fracture is again noted. 3. Extensive encephalomalacia as above. 4. Slightly increased sinus thickening may be related to intubation or worsening sinus disease. . [**3-14**] ECHO: The left atrium is moderately dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size and global systolic function (LVEF>55%). Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. The aortic root is mildly dilated at the sinus level. 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. There is no mitral valve prolapse. Trivial mitral regurgitation is seen. Moderate [2+] tricuspid regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Mild pulmonary artery systolic hypertension. Mild symmetric left ventricular hypertrophy with normal cavity sizes and global biventricular systolic function. Dilated ascending aorta. Brief Hospital Course: Mr. [**Known lastname **] is a 60 year old male with past medical history of alcohol abuse, seizures, intracranial bleed, diastolic CHF, esophageal cancer and COPD who presented intubated after witnessed seizure in the emergency department. . # Respiratory distress: Patient was intubated on admission in setting of seizure, as below. Was extubated but required oxygen transiently since extubation, with occasional desaturations. Likely related to episodes of AFib with rapid heart rate (see below), as now that is resolved, O2 sats have stabilized. Patient was managed on COPD medications as below, discharged with stable saturation on ambient air. . # Atrial fibrillation: Developed atrial fibrillation with rapid heart rate during his hospital course. Metoprolol was titrated up to metoprolol 25mg PO q 6hr for added HR control. However, with this BP dropped, so therefore, started dig 0.125mg daily and decreased metoprolol to 12.5mg [**Hospital1 **]. With these measures, heart rate and blood pressure were stable on discharge. . # History of alcohol withdrawal and acute delirium: During this admission the patient initially received >200mg valium during the first 24 hr of admission. Head CT [**3-13**] only notable for encephalomalacia likely from contusion. On [**3-15**] the pt was noted to be agitated, trying to leave, dysarthric and combative. Psychiatry was asked to see the patient and the psychiatry service determined that the patient was likely intoxicated on benzodiazepines. They recommended standing Haldol 2.5mg po as well as a taper of valium. He completed this taper with improvement of mental status to baseline at time of discharge, haldol was discontinued on discharge. . # Seizure disorder: unclear if seizure on presentation was from his underlying seizure disorder or ETOH withdrawl. Patient reported his last drink a day prior to admission and his alcohol level was zero. Head CT was negative for intracranial hemorrhage. Continued on valium taper to completion, and adjusted dose of dilantin for appropriate level. . # COPD: Continued spiriva, inhalers. . # Esophageal adenocarcinoma: Patient is status-post treatment, unclear if this has been followed up regularly. Not an acute issue at this time. Will need outpatient oncology follow up. . On discharge, wanted to do physical therapy evaluation to see if patient required rehab, but he repeatedly refused. Therefore, once medically cleared for discharge, he was discharged to a shelter. Medications on Admission: (Per discharge summary from [**9-/2184**], unknown what patient was taking recently) - Simvastatin 40 mg daily - Metoprolol Tartrate 25 mg [**Hospital1 **] - Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q4H PRN - Fluticasone-Salmeterol 250-50 mcg/Dose Disk [**Hospital1 **] - Tiotropium Bromide 18 mcg Capsule daily - Prilosec OTC 20 mg [**Hospital1 **] - Phenytoin 125 mg/5 mL Suspension: Ten (10) cc PO Q12H (every 12 hours): = 250mg [**Hospital1 **] - Sodium Chloride 1 gram Tablet: Three (3) Tablet PO TID W/MEALS - Magnesium Oxide 400 mg Tablet [**Hospital1 **] - Multivitamin daily . Late in hospital course, were able to get true outpatient medications at time of admission: Lovenox 120 mg daily Iron 325 mg po daily mag oxide 400 mg [**Hospital1 **] metoprolol 25 mg daily prilosec 20 mg daily dilantin 200 mg qam and 300 qhs simvastatin 40 mg daily thiamine 100 mg daily spiriva 1 inh daily advair 250/50 [**Hospital1 **] albuterol prn MVI daily colace prn tylenol prn Discharge Medications: 1. Lovenox 120 mg/0.8 mL Syringe Sig: One (1) injection Subcutaneous once a day. Disp:*30 injections* Refills:*2* 2. Iron 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 3. Magnesium Oxide 400 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:*60 Tablet(s)* Refills:*2* 4. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). Disp:*30 Tablet(s)* Refills:*2* 5. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2* 6. Phenytoin Sodium Extended 200 mg Capsule Sig: 1.5 Capsules PO BID (2 times a day). Disp:*90 Capsule(s)* Refills:*2* 7. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 8. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 9. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). Disp:*30 Cap(s)* Refills:*2* 10. Advair Diskus 250-50 mcg/Dose Disk with Device Sig: One (1) INH Inhalation twice a day. Disp:*1 discus* Refills:*2* 11. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 puffs Inhalation every four (4) hours as needed for shortness of breath or wheezing. Disp:*1 cartridge* Refills:*2* 12. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 13. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day. Disp:*60 Capsule(s)* Refills:*2* 14. Tylenol 325 mg Tablet Sig: 1-2 Tablets PO three times a day as needed. 15. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Seizure Alcohol withdrawl Respiratory failure Atrial fibrillation COPD Esophageal cancer Discharge Condition: Stable. Respiratory status and cardiac status stable. Discharge Instructions: You were admitted to the hospital with a seizure and were transiently in the intensive care unit with a breathing tube. You were treated for your seizure as well as your elevated heart rate. Please take medications as directed. Please contact physician if develop fevers/chills, shortness of breath, chest pain/pressure, any other questions or concerns. Followup Instructions: Please follow up with your primary care physician in the next 1 week.

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icd9cm

[ [ [] ] ]

[ "96.04", "96.71" ]

icd9pcs

[ [ [] ] ]

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306, 330

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33945

Discharge summary

report

Admission Date: [**2149-11-10**] Discharge Date: [**2149-11-18**] Date of Birth: [**2089-8-22**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 348**] Chief Complaint: Primary hyperparathyroidism Major Surgical or Invasive Procedure: Parathyroidectomy with removal of right inferior parathyroid adenoma History of Present Illness: Mr. [**Known lastname 40317**] is a 60 year old male with a past medical history significant for CAD, CHF, CVA, HTN, recent diagnosis of prostate cancer, and primary hyperparathyroidism (ultrasound positive right lower pole, sestamibi negative) who was admitted for scheduled right parathyroidectomy which was performed on [**2149-11-10**]. His post op course was complicated by a wound infection with purulence draining from his neck wound which was explored at the bedside and showed frank pus with initial gram stain demonstrating GPC in clusters and was started on vancomycin. On POD 2 (day of transfer to MICU) he was also found to have progressively worsening hypoxia and fever with desaturations to 88-90% RA improved to 92-93% on 4L NC, and eventually progressed to needing a 40% shovel mask. He also developed fever to 101.1. Imaging showed evidence of RLL consolidation and he then had a CTA that did NOT show any PE but demonstrated right lung base consolidation. He also received 20 mg IV Lasix for pulmonary edema. He was then transferred to the [**Hospital Unit Name 153**] for further management. Past Medical History: 1. Hypertension. 2. CVA in [**2143**] status post TPA administration. 3. s/p MI in [**2143**] (no known intervention) with associated CHF, unclear [**Name2 (NI) **], never been on diuretuics 4. Chronic pancreatitis thought to be due to EtOH 5. Bilateral hip replacement. 6. Left knee arthroscopy times multiple. 7. Recently diagnosed with prostate cancer a few months ago; currently planned for external beam radiation therapy. 8. H/o RA since childhood 9. S/p right lower parathyroidectomy complicated by wound infection and right lower lung base consolidation Past Psych Hx: a)Prior dx- depression in past year, none prior to this b)Hospitalizations- denies c)Suicide- denies d)Aggression-denies e)Treaters- [**Last Name (un) **] [**Doctor Last Name 23509**]; No prior psychiatric treaters f)Prior treatments- Zoloft last fall, trazodone in past for sleep Social History: Lives at [**Hospital3 11148**] [**Hospital3 **] Facility in [**Location (un) 86**], [**State 350**]. He has had multiple personal traumas in the last five years, including the death of several family members and the loss of his job along with multiple hospital admissions for chronic pancreatitis that he denies is related to ETOH. He smokes five to six cigarettes per day and has done that for the past 30 years. He drinks ETOH socially. He has no drug abuse reported. Family History: 1. Brother with melanoma. 2. Father died at age 85, did not die of prostate cancer but had prostate cancer, received brachytherapy. 3. Uncle with cancer of unknown primary. 4. Both paternal grandparents with cancer of unknown primary site. Physical Exam: On [**2149-11-18**]: VS: 99.2; 74; 132/72; 12; 95% (RA). Gen: NAD HEENT: Neck dressing c/di/i CV: Nl S1+S2 Pulm: CTA bilat Abd: S/NT/ND +bs Ext: Trace edema bilaterally. Left arm in cast. Neuro: Oriented to person, place, and year. CN II-XII intact. R UE PICC line; RUE cord (antecubital) Pertinent Results: [**2149-11-13**] CTA chest: Likely aspiration pneumonia. Moderate in severity, further supported by the presence of debris in the trachea. . [**11-15**] wrist: FINDINGS: In comparison with study of [**10-21**], overlying cast somewhat obscures detail. The fracture lines in the distal ulna is again seen, as is the extensive dystrophic calcification between the lower shaft of the ulna and radius. There is approximately 7 mm distraction of the distal fracture fragment. Brief Hospital Course: Mr. [**Known lastname 40317**] is a 60 year old male with a past medical history significant for CAD, CHF, CVA, HTN, recent diagnosis of prostate cancer admitted for scheduled right parathyroidectomy complicated by neck wound purulent infection with GPC's in clusters, and progressively worsening hypoxia, fever, and evidence of RLL consolidation. 1. Hypoxia/sepsis: With WBC's, tachycardia, tachypnea, and fever was admitted to [**Hospital Unit Name 153**] with concern for sepsis. With A-a gradient and focal consolidation at right base with scattered ground glass opacities consistent with pneumonia. Neck wound infection which grew GPC's in clusters also considered potential source of sepsis. He was treated with as HCAP with Vanc/Zosyn/cipro. He will complete a ten day course of antibiotics, through [**2149-11-22**] . 2. Surgical site infection status post parathyroidectomy: Initially treated with vancomycin. Now with oozing at the surgical site but no evidence for infection per the surgical team. Will continue wound care. Will f/u with Dr. [**Last Name (STitle) **]. . 3. Neuro: Patient with delirium in the setting of hypoxia, now resolved. Depression: SSRI resumed; switched from standing ativan to standing klonopin, with ativan as needed. Will benefit from continued social work and psychopharmacology input. . 4. ARF: Resolved. . 5. Left arm fracture: Patient will follow-up with the orthopedics team in the next two weeks for cast removal. . 6. HTN: Anti-hypertensive regimen was held through [**Hospital Unit Name 153**] course given concern for sepsis. This was resumed on the medical service. . 7. Chronic pancreatitis: Pancreatic enzyme replacement was restarted when he resumed POs. 8. Prostate CA: Plan for external beam radiation; will need follow-up with Dr. [**Last Name (STitle) 656**]. . 9. RUE thrombus - will continue warm compresses; there was no DVT on ultrasound . 10. Access - RUE PICC line . 11. Disp - To [**Doctor First Name **] House for further care . Code: Full Medications on Admission: Medications at home: - amlodipine 10 mg Tablet 1 Tablet(s) by mouth once a day - celecoxib [Celebrex] 100 mg Capsule 1 Capsule(s) by mouth twice a day - citalopram 40 mg Tablet 1 Tablet(s) by mouth once a day - clonidine 0.3 mg Tablet 1 Tablet(s) by mouth twice a day - folic acid 1 mg Tablet 1 Tablet(s) by mouth once a day - hydrocodone-acetaminophen 5 mg-500 mg Tablet q6 hours PRN - labetalol 100 mg Tablet 1 Tablet(s) by mouth twice a day - lipase-protease-amylase [Pancrelipase 5000] 5,000 unit-[**Unit Number **],000 unit-[**Unit Number **],000 unit Capsule, Delayed Release(E.C.) 1 Capsule(s) by mouth three times a day - phenazopyridine 100 mg Tablet 1 Tablet(s) by mouth three times a day as needed for burning or discomfort with urination - aspirin [Adult Low Dose Aspirin] 81 mg Tablet, Delayed Release (E.C.) 1 Tablet(s) by mouth once a day - calcium carbonate - docusate sodium 100 mg Capsule 1 Capsule(s) by mouth twice a day as needed for constipation - ferrous sulfate 325 mg (65 mg Iron) Tablet - omega-3 fatty acids-fish oil 300 mg-1,000 mg Capsule 1 Capsule(s) by mouth twice a day Discharge Medications: Heparin 5000 UNIT SC TID Vancomycin 1000 mg IV Q 12H Through [**2149-11-22**] Piperacillin-Tazobactam 4.5 g IV Through [**2149-11-22**] Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheezing Ipratropium Bromide Neb 1 NEB IH Q6H:PRN wheezing Nicotine Patch 14 mg TD DAILY Ondansetron 4 mg IV Q8H:PRN nausea Acetaminophen 1000 mg PO/NG Q6H:PRN pain, fever Labetalol 100 mg PO/NG [**Hospital1 **] OxycoDONE (Immediate Release) 5 mg PO/NG Q6H:PRN pain not relieved by Tylenol Pancrelipase 5000 1 CAP PO TID W/MEALS Guaifenesin-Dextromethorphan 5 mL PO/NG Q6H:PRN cough Aspirin EC 81 mg PO DAILY 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. Amlodipine 10 mg PO/NG DAILY Citalopram 40 mg PO/NG DAILY Multivitamins 1 TAB PO/NG DAILY CloniDINE 0.3 mg PO BID hold for sbp<100 Docusate Sodium 100 mg PO BID Furosemide 20 mg PO/NG DAILY Senna 1 TAB PO/NG [**Hospital1 **] Simvastatin 20 mg PO/NG DAILY Mirtazapine 15 mg PO/NG HS Lorazepam 0.5 mg PO/NG Q8H:PRN anxiety Ciprofloxacin HCl 500 mg PO/NG Q12H Through [**2149-11-22**] Clonazepam 0.5 mg PO/NG TID Discharge Disposition: Extended Care Facility: [**Hospital **] Healthcare Center - [**Location (un) 1110**] Discharge Diagnosis: Status post parathyroidectomy Pneumonia Delirium Upper extremity thrombosis (not DVT) Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Take your antibiotics through [**2149-11-22**] Anticipated length of stay is less than 30 days Followup Instructions: Department: ORTHOPEDICS When: TUESDAY [**2149-11-25**] at 10:40 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 Department: ORTHOPEDICS When: TUESDAY [**2149-11-25**] at 11:00 AM With: HAND CLINIC [**Telephone/Fax (1) 3009**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 551**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Dr. [**Last Name (STitle) **] (surgery) [**Telephone/Fax (1) 9**] Monday, [**2149-12-1**] at 3:30 pm; [**Street Address(2) **], [**Location (un) **] [**Location (un) 895**] . Dr. [**Last Name (STitle) 656**] (radiation oncology) [**Telephone/Fax (1) 9710**] [**2149-12-3**] at 9am - [**Hospital Ward Name 23**] Building [**Location (un) 442**] - [**Hospital1 18**] . [**First Name8 (NamePattern2) 4457**] [**Last Name (NamePattern1) 10686**] (Primary care) - [**Telephone/Fax (1) 608**] One of her partners will see you at [**Name (NI) **] House.

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icd9cm

[ [ [] ] ]

[ "06.89" ]

icd9pcs

[ [ [] ] ]

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40216

Discharge summary

report

Admission Date: [**2117-6-8**] Discharge Date: [**2117-6-28**] Date of Birth: [**2030-12-30**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 9160**] Chief Complaint: Weakness and falls Major Surgical or Invasive Procedure: EGD History of Present Illness: The patient is an 86 year old male with multiple medical issues including previously treated follicular lymphoma, diastolic CHF, paroxysmal atrial fibrillation, COPD no longer on home O2, and CKD who was admitted to OSH on [**2117-6-6**] with weakness and falls at home. . On that admission, he was found to be in atrial fibrillation with labs notable for CK 500-600s, Calcium 12.5, PTH not elevated, Creatinine 1.4, and HCT 27 (baseline in mid 30s). His head CT head showed no acute process. He was given 1500 ml IV fluids with improvement in his calcium to 10.7. He converted to sinus rhythm at 70 bpm with vital signs stable. He was recently being evaluated here for possible Nissen fundoplication, and was transferred to [**Hospital1 18**] for further management of his anemia and hypercalcemia. . On reaching the floor, he reported some recent dyspnea on exertion and dizziness when standing. He denied any other acute complaints. He notes that his activiy level has been declining, and he no longer likes to walk around his home due to fatigue and dyspnea. he uses a walker when he does ambulate. He was previously on home oxygen for COPD, but no longer uses it. He lives alone with support from his neighbors for shopping. . REVIEW OF SYSTEMS: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea, or congestion. Denies cough. Denies chest pain, pressure, tightness, or palpitations. Denies nausea, vomiting, diarrhea, constipation, or abdominal pain. No recent change in bowel or bladder habits. No dysuria or hematuria. No rashes or concerning skin lesions. Denies arthralgias or myalgias. Review of systems was otherwise negative. Past Medical History: # Follicular Lymphoma -- advanced disease with pulmonary, pleural, kidney involvement -- s/p 1.5 cycles of Bendamustine/Rituxan, last [**2116-1-2**] -- complicated by acute CHF and rapid AFib during treatment -- treatment held since then, but clinically stable # Chronic diastolic CHF -- prior systolic CHF as well -- most recent LVEF 55% ([**2116-4-13**]), prior TTE with LVEF 15% ([**2115**]) # Paroxysmal Atrial Fibrillation -- during chemotherapy # Hypertension # Chronic pleural effusions # COPD -- previously on home oxygen # Chronic Kidney Disease # Renal Mass -- related to lymphoma # BPH # Hypothyroidism # Paraesophageal hernia -- present for 10 years # UGIB History # Chronic Anemia -- requiring transfusions # GERD # Spinal compression fractures # Right Inguinal Hernia Repair # Macular degeneration # Posterior vitrious detachment # Cataracts s/p surgery # compression fracutre T11, L1-L2 (s/p fall in [**Month (only) **]) Social History: # Home: Lives alone, does not ambulate much in home. Uses walker when he does. Neighbors help with shopping. Eats mostly premade meals, does not cook much. VNA 1x per week on tues. puts meds in boxes. 2 sons- [**Known firstname **], lawyer in [**Name2 (NI) **], hcp, full code. other son in NJ is Urologist. # Work: Retired # Tobacco: Smoked 3 PPD for 25 years, quit in [**2075**] # Alcohol: None # Drugs: None Family History: No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death. # Mother: Died from cancer, unsure of type. # Father: Tuberculosis # Sister: Unsure how she is doing. Physical Exam: ADMISSION VS: T 98.4, BP 150/76, HR 74, RR 22, SpO2 95% on RA Gen: Elderly male in NAD. Oriented x3. Mood, affect appropriate. Hard of hearing. HEENT: Sclera anicteric. Left pupil slightly smaller than right but both reactive to light. Slight left lid ptosis. EOMI. MMM, OP benign. Neck: JVP not elevated. No cervical lymphadenopathy. No carotid bruits noted. CV: RRR with normal S1, S2. No M/R/G. Chest: Respiration unlabored. Coarse breath sounds and few scattered crackles without focal findings. Abd: Bowel sounds present. Soft, NT, ND. No organomegaly or masses. Ext: WWP. Digital cap refill <2 sec. No C/C/E. Distal pulses intact radial 2+, DP 2+, PT 2+. Skin: No rashes, ulcers, or other lesions noted. Neuro: CN II-XII grossly intact. Strength 4/5 in left arm, [**5-22**] in other limbs. No pronator drift. Normal rapid alternating movements on right, slower on left. Performance of finger-to-nose worse on left than right. Normal speech. DISCHARGE: VS: RR 16 Gen: Elderly male in NAD. Oriented x3.Hard of hearing. appears comfortable HEENT: Sclera anicteric. Left sided Horner's syndrome. OP - moist w/ brownish plaque on tongue Neck: JVP not elevated. CV: RRR with normal S1, S2. soft systolic murmur across precordium. ?diastolic murmur + S3 gallop Abd: Bowel sounds present. Soft, NT, ND. No organomegaly or masses. Ext: WWP. No C/C/E. 2+ DP Pertinent Results: ADMISSION [**2117-6-9**] 01:58AM BLOOD WBC-6.2 RBC-3.44* Hgb-10.0* Hct-31.7* MCV-92# MCH-28.9 MCHC-31.4 RDW-13.1 Plt Ct-231 [**2117-6-9**] 01:58AM BLOOD Neuts-72.8* Lymphs-12.5* Monos-8.5 Eos-5.4* Baso-0.7 [**2117-6-9**] 01:58AM BLOOD Glucose-97 UreaN-17 Creat-1.3* Na-139 K-4.0 Cl-106 HCO3-20* AnGap-17 [**2117-6-9**] 01:58AM BLOOD ALT-19 AST-33 LD(LDH)-263* CK(CPK)-115 AlkPhos-67 TotBili-0.5 [**2117-6-9**] 01:58AM BLOOD Albumin-3.5 Calcium-10.7* Phos-3.2 Mg-1.4* . PERTINENT [**2117-6-9**] 01:58AM BLOOD ALT-19 AST-33 LD(LDH)-263* CK(CPK)-115 AlkPhos-67 TotBili-0.5 [**2117-6-10**] 07:50AM BLOOD LD(LDH)-222 [**2117-6-9**] 11:00AM BLOOD CK-MB-4 cTropnT-<0.01 [**2117-6-9**] 01:58AM BLOOD CK-MB-5 cTropnT-<0.01 [**2117-6-9**] 01:58AM BLOOD TSH-3.1 [**2117-6-9**] 04:10AM BLOOD PTH-<6* . CHEST (PA & LAT) Study Date of [**2117-6-9**] 9:14 PM As compared to the previous radiograph from [**2117-6-6**], there is no relevant change. The known left apical mass is obliterated by the soft tissues of the neck. Unchanged evidence of moderate cardiomegaly with moderate pulmonary edema and signs of interstitial fluid overload. Presence of a small left pleural effusion cannot be excluded. No newly appeared parenchymal opacities. . CT CHEST W/O CONTRAST Study Date of [**2117-6-10**] 1. Left apical mass, substantially progressed since [**2117-3-21**] and chest radiograph from [**2117-1-17**], progressing into the neck with multiple pulmonary metastases and liver hypodensities, highly concerning for metastatic disease. Findings are most likely representing Pancoast tumor, primary lung malignancy. Lymphoma will be substantially less likely. 2. Unusual appearance of the left kidney, partially imaged with this technique which is not tailored for evaluation of renal disease. If clinically warranted, correlation with ultrasound or dedicated CT or MR might be considered. Correlation with urine cytology might also be beneficial. Brief Hospital Course: PRIMARY REASON FOR HOSPITALIZATION: ==================================== Mr. [**Known lastname 88299**] is an 86 year old male with multiple medical issues including previously treated follicular lymphoma, paraesophageal hernia, diastolic CHF, afib, COPD who was admitted to OSH on [**2117-6-6**] with weakness and falls, during workup at [**Hospital1 18**] found to have new diagnosis of metastatic cancer likely from the lung. ACTIVE ISSUES: ================== # L upper lung malignancy (Pancoast tumor): Discovered on work-up of hypercalcemia with CT scan on [**6-13**]. Oncology consult thought likely primary lung cancer that has metastasized to liver and R lung, less likely lymphoma. Oncology gave a 6-month prognosis and recommended that pt would not be a good candidate for treatment as he is too weak, did not tolerate chemotherapy in the past, and biopsy would not be helpful as treatment would not change despite the type of cancer. Palliative care was consulted and contributed to his care. # Goals of care: Patient was made DNR/DNI during his stay. Multiple family meetings were held throughout the admission with patient's son [**Name (NI) **] (also healthcare proxy), Dr. [**Last Name (STitle) **] (palliative care), Dr. [**First Name (STitle) 3459**] (oncologist), and medical team. Given the patient's prognosis and after extensive discussion with the patient and his son, his code status was change to "comfort measures only." # Coffee ground emesis in setting of GERD with paraesophageal hernia: Pt began to experience symptoms during [**Date range (1) 88300**]. Differential included gastritis, GERD causing upper GI bleed, hiatal hernia (ulceration/gastritis/erosions), cancer metastasis invading into upper GI mucosa, gastric outlet obstruction, or tumor impinging on the emesis nerve tract (i.e. C3-5). NG tube was inserted, but pt pulled it out in the MICU and refused to have it replaced. Sucralfate and PPI were given to treat upper GI bleed. Aspirin was discontinued. Pt was recently undergoing evaluation by Thoracic Surgery for repair of a large paraesophageal hernia - Dr. [**First Name (STitle) **] was peripherally involved in goals of care discussions and decided not to operate in light of patient's current clinical status and risk of possibly reducing the patient's quality of life post-operatively and inability to wean off the ventilator. - Continue PPI and sucralfate for comfort - Standing tylenol and fentanyl patch for pain control. Hydromorphone PRN for breakthrough pain. - Anti-emetics as needed for comfort (promethazine and zofran) # Dyspnea in setting of aspiration pneumonitis: Complicated by untreated COPD, hiatal hernia, and pulmonary mass causing pulmonary compression from mass effect. He desaturated on [**6-13**] and required MICU transfer and non-rebreather. However his respiratory status improved rapidly suggesting aspiration. In the MICU there was concern for HCAP, for which he was treated with IV vancomycin and cefepime for 8 days. When vital signs were last checked he was saturating in the low-mid 90s on 3L nasal cannula. - Continue Oxygen as needed for comfort # Weakness and Falls: His recent weakness and falls are most likely multifactorial. His recent fall may have been related to atrial fibrillation, weakness from hypercalcemia or anemia, and mechanical fall from tripping. Orthostatics were negative. # Hypercalcemia: He was hypercalcemic at outside hospital with reportedly low PTH. His hypercalcemia is likely related to new malignancy given his known history of follicular lymphoma, ongoing anemia, and elevated LDH. Fluids were given for hypercalcemia, which improved during admission. Last checked Ca was 8.8 on [**6-16**]. No further interventions were done since hypercalcemia did not appear to be symptomatic. # Hiccups: Pt had recurrent hiccups making him extremely uncomfortable. He is currently asymptomatic. Most likely from hiatal hernia affecting diaphragm or mass pushing on vagus nerve. We treated him with chlorpromazine 5 mg PO TID, which improved his hiccups. - Continue chlorpromazine to reduce hiccups for comfort. Can stop if patient is over-sedated or hiccups resolve. # Anemia: His hematocrit was roughly stable 25-30 without receiving any transfusions during this admission. Transfusion was decided to not be in lines with goals of care and labs were not drawn as of [**2117-6-16**]. # Left Hand/Arm Pain: Most likely from brachial plexus compression from pancoast tumor. - Standing tylenol and fentanyl patch for pain control. Hydromorphone PRN for breakthrough pain. CHRONIC ISSUES: ================== # Chronic Diastolic CHF: Throughout his stay he appeared euvolemic with minimal LE edema or crackles. [**3-/2117**] EF of 50%. Sodium restriction was eased as consistent with goals of care. # Paroxysmal Atrial Fibrillation: He was initially in AFib at OSH, which may have precipitated his recent weakness and falls. He converted spontaneously at OSH and was in sinus rhythm on arrival. He had negative troponins. He is not currently on anticoagulation, and is likely not a good candidate given his recent falls, poor functional capacity, and goals of care. Aspirin was discontinued in setting of GI bleed. Telemetry was discontinued as consistent with goals of care but patient was in sinus rhythm prior to that. - His metoprolol was stopped since not contributing to comfort. If patient is having symptomatic palpitations, could consider restarting metoprolol in the future. # Hypertension: He was somewhat hypertensive on arrival, most likely due to his pain. His metoprolol was stopped since not contributing to hs comfort. # Hypothyroidism: We continued his home Levothyroxine 50 mcg PO DAILY. Can consider discontinuing this later if not contributing to comfort. TRANSITIONAL ISSUES: ===================== # Dispo: being discharged to inpatient hospice. # Contacts: hcp/son [**Known firstname **] [**Telephone/Fax (3) 88301**]; # Code Status: DNR/DNI, Comfort Measures Only. Medications on Admission: Aspirin 81 mg PO DAILY - on hold x months Metoprolol Tartrate 50 mg PO TID Hydralazine 20 mg PO TID Furosemide 40 mg PO DAILY - on hold x months Isosorbide Mononitrate ER 30 mg PO DAILY Levothyroxine (LEVOXYL) 50 mcg PO DAILY Omeprazole 20 mg PO BID -- unsure why two PPIs Sucralfate 1 gram PO Q6H Colace 100 mg PO BID PRN constipation Multivitamin 1 tab PO DAILY Discharge Medications: 1. hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q3H (every 3 hours) as needed for pain. 2. fentanyl 12 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr Transdermal Q72H (every 72 hours). 3. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 4. chlorpromazine 10 mg Tablet Sig: 0.5 Tablet PO TID (3 times a day). 5. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 6. promethazine 25 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for nausea. 7. ondansetron HCl 4 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8 hours) as needed for nausea. 8. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal HS (at bedtime) as needed for constipation. 9. sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times a day). 10. levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Disposition: Extended Care Facility: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] House - [**Location (un) 13588**] Discharge Diagnosis: Primary diagnosis: lung malignancy, hypercalcemia, fall Secondary diagnosis: diastolic heart failure, Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Dear Mr. [**Known lastname 88299**], You were admitted to the hospital for evaluation of falls, weakness, and high calcium levels. Unfortunately, we found that the underlying cause of this was a lung tumor. After much discussion, it was decided to focus on comfort and discharge you to hospice. Take care. Followup Instructions: N/A [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 9162**]

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icd9cm

[ [ [] ] ]

[ "38.97" ]

icd9pcs

[ [ [] ] ]

14362, 14488

7025, 7455

323, 329

14633, 14633

5058, 7002

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3478, 3667

13443, 14339

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14586, 14612

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14648, 14784

11623, 12814

2094, 3032

3048, 3462

27,726

130,328

27483

Discharge summary

report

Admission Date: [**2187-12-28**] Discharge Date: [**2187-12-30**] Date of Birth: [**2116-10-30**] Sex: F Service: MEDICINE Allergies: Proxy[**Name (NI) 67216**] / Caffeine / Butalbital / Barbiturates / Xanthines Attending:[**First Name3 (LF) 3561**] Chief Complaint: Displaced tunnelled HD catheter Major Surgical or Invasive Procedure: Replacement of tunnelled HD catheter History of Present Illness: 71F ventilator-dependent h/o COPD, ESRD on HD, HTN, and CHF (unknown EF) presented after her tunneled HD catheter was found displaced [**3-9**] pt's scratching the site. HD catheter was noted to be displaced at HD, and pt was sent to ED for evaluation. . ED course: # Meds: Ceftriaxone x1 dose, azithromycin x1 dose, IVF 500cc. # Studies: --CXR: Mild volume overload, displaced HD catheter. # Clinical course: IR-guided catheter replacement; admitted to MICU for further management. Past Medical History: --CV # PVD, s/p R CEA, s/p B iliac stents, B toe gangrene autoamputating # HTN # CHF no previous echo here, so unclear [**Name2 (NI) **] # Paroxysmal AF # Anemia # s/p multiple embolic CVA # h/o Cholesterol emboli syndrome --GU # ESRD on HD of unclear etiology. ? d/t chronic pyelo and uncontrolled HTN. Outpatient nephrologist: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1366**] --Pulmonary # Respiratory failure s/p trach in [**2-11**], vent-dependent with chronic PS at rehab, currently undergoing trach collar trials. # COPD # Recurrent aspiration PNA --GI # h/o GI bleeding # Adenocarcinoma of the colon s/p resection in [**2186**] # s/p PEG --Endocrine # Hypothyroidism --Neuro # Dementia --ID # h/o MRSA colonization # h/o VRE infection # h/o C.diff colitis Social History: # Personal: Lives at [**Hospital 100**] Rehab. Divorced. Three adult children. # Tobacco: Former smoker. 3 packs per day x 13 years. # Alcohol: Occasional past use. Family History: # Siblings: MI in 60s. Schizophrenia. Physical Exam: VS: T afebrile, BP 98/38, HR 64, RR 10, O2Sat 100% on current vent settings Vent Settings: SIMV+PS, PS 10, PEEP 5, TV 450, FiO2 50% Gen: NAD Heart: RRR, S1/S2, no m/r/g. Lungs: Rales throughout anterior lung fields. Abd: Soft, NTND, BS+. Ext: WWP Pertinent Results: Admission labs: [**2187-12-28**] 11:40AM WBC-9.7 RBC-3.12* HGB-10.6* HCT-31.3* MCV-100* MCH-33.8* MCHC-33.8 RDW-18.2* [**2187-12-28**] 11:40AM NEUTS-67 BANDS-0 LYMPHS-20 MONOS-4 EOS-6* BASOS-1 ATYPS-2* METAS-0 MYELOS-0 [**2187-12-28**] 11:40AM GLUCOSE-92 UREA N-88* CREAT-5.0*# SODIUM-136 POTASSIUM-4.9 CHLORIDE-93* TOTAL CO2-28 ANION GAP-20 [**2187-12-28**] 12:39PM LACTATE-1.6 [**2187-12-28**] 11:40AM PLT COUNT-371 [**2187-12-28**] 11:40AM PT-13.3 PTT-31.7 INR(PT)-1.1 . # CHEST (PORTABLE AP) [**2187-12-28**] 11:33 AM Evidence of fluid overload with malpositioned right-sided hemodialysis catheter. Brief Hospital Course: 71F vent-dependent, h/o ESRD on HD, h/o refractory C. diff infection, admitted for HD catheter replacement. . # ESRD on HD of unclear etiology: Upon admission, pt's tunneled catheter was removed and then replaced with a 15.5 French double-lumen hemodialysis catheter with 23 cm tip-to-cuff length via the left internal jugular vein with the tip in the right atrium. Pt underwent hemodialysis on [**12-29**] with approximately 1.6L removed, and tolerated hemodialysis without a BP drop. Calcium acetate was started TID with meals. . # Query line infection: Line site was found to be erythematous and tender to palpation, mildly indurated, but without purulence. Blood cultures drawn [**12-28**] with no growth at time of discharge. Pt was started on vancomycin 1 gm IV per HD protocol to cover skin flora in institutionalized pt, and discharge with plan to continue vancomycin for a total 7 day course, ending [**1-3**]. . # Possible PNA: Pt had copious green secretions upon admission; CXR revealed retrocardiac opacity and pneumonia could not be excluded. Pt was broadly covered for nosocomial and nursing home-acquired PNA with vancomycin as above, as well as piperacillin-tazobactam for a total of a 7 day course. Pt was therefore discharged with plan to continue piperacillin-tazobactam until [**1-3**]. . # Diarrhea possibly [**3-9**] C.Diff: Pt had h/o refractory C. diff, and had >10 episodes of diarrhea on day of admission. WBC was within normal limits and no abdominal tenderness was evident on clinical exam. C. diff A and B toxins were pending at time of discharge. She was continued on vancomycin 125 mg PO Q6H and metronidazole 500 mg PO TID, with plan to continue both for one week after discontinuing vancomycin IV and piperacillin-tazobactam IV (end [**2188-1-12**]). . # Chronic vent-dependent respiratory failure, s/p trach: Pt continued on pressure support per [**Hospital 100**] Rehab regimen. . # DNR Medications on Admission: Digoxin 0.125mg PO daily Aspirin 81mg daily Levothyroxine 125 mcg PO daily Vancomycin PO 125mg QID Diphenhydramine 25mg PO Q8H:PRN Omeprazole Lactobacillus Respiratory regimen: Tiotropium, ipratropium, albuterol Pain regimen: Lidocaine 5% patch daily, oxycodone 2.5mg PO Q6H:PRN, hydromorphone 0.75mg PO Q2H:PRN, acetaminophen PRN Discharge Medications: 1. Aspirin 81 mg Tablet, Chewable [**Hospital **]: One (1) Tablet, Chewable PO DAILY (Daily). 2. Levothyroxine 125 mcg Tablet [**Hospital **]: One (1) Tablet PO DAILY (Daily). 3. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated [**Hospital **]: One (1) Adhesive Patch, Medicated Topical DAILY (Daily): 12 hours on, then 12 hours off. 4. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily). 5. Acetaminophen 325 mg Tablet [**Last Name (STitle) **]: 1-2 Tablets PO Q6H (every 6 hours) as needed. 6. Diphenhydramine HCl 25 mg Capsule [**Last Name (STitle) **]: One (1) Capsule PO Q8H (every 8 hours) as needed. 7. Oxycodone 5 mg Tablet [**Last Name (STitle) **]: 0.5 Tablet PO Q6H (every 6 hours) as needed. 8. Heparin (Porcine) 5,000 unit/mL Solution [**Last Name (STitle) **]: One (1) injection Injection TID (3 times a day). 9. Albuterol 90 mcg/Actuation Aerosol [**Last Name (STitle) **]: 1-2 Puffs Inhalation Q2H (every 2 hours) as needed for wheezing. 10. Ipratropium Bromide 17 mcg/Actuation Aerosol [**Last Name (STitle) **]: Two (2) Puff Inhalation Q6H (every 6 hours). 11. Metronidazole 500 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO TID (3 times a day) for 14 days. Disp:*42 Tablet(s)* Refills:*0* 12. Chlorhexidine Gluconate 0.12 % Mouthwash [**Last Name (STitle) **]: Fifteen (15) ML Mucous membrane [**Hospital1 **] (2 times a day). 13. Digoxin 125 mcg Tablet [**Hospital1 **]: One (1) Tablet PO EVERY OTHER DAY (Every Other Day). 14. Hydromorphone 2 mg Tablet [**Hospital1 **]: 0.5 Tablet PO Q2H (every 2 hours) as needed. 15. Calcium Acetate 667 mg Capsule [**Hospital1 **]: Two (2) Capsule PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 16. Vancomycin 1,000 mg Recon Soln [**Hospital1 **]: One (1) injection Intravenous once a day for 7 days. Disp:*7 g* Refills:*0* 17. Piperacillin-Tazobactam 2.25 gram Recon Soln [**Hospital1 **]: One (1) injection Intravenous Q12H (every 12 hours) for 7 days: Please dispense 31.5 g (2.25 g per injection, for 14 injections). Disp:*QS g* Refills:*0* 18. Vancomycin 125 mg Capsule [**Hospital1 **]: One (1) Capsule PO once a day for 14 days: Please use vancomycin 125mg PO liquid. Disp:*14 Capsule(s)* Refills:*0* Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - MACU Discharge Diagnosis: Primary diagnosis: # Tunnelled hemodialysis catheter removal and replacement # Possible tunnelled catheter infection # Possible C. Difficile colitis # Hospital acquired PNA . Secondary diagnosis: # End stage renal disease on hemodialysis Discharge Condition: Afebrile, stable BP and HR Discharge Instructions: You were admitted to the hospital to replace your dialysis catheter. You were treated for a possible HD catheter infection with IV Vancomycin, which you should continue for 7 more days (you started this antibiotic on [**12-28**]). You also had increased discolored mucus and potential pneumonia on chest X-ray for which you should continue 7 days of another antibiotic called Zosyn. . Also, you had more than 10 episodes of diarrhea while you were in the hospital. You should therefore take oral vancomycin and oral metronidazole until [**1-12**]. . You should continue with your usual regimen of hemodialysis at your rehabilitation center. Followup Instructions: Please follow-up per your rehab physician's instructions. Completed by:[**2188-6-1**]

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icd9cm

[ [ [] ] ]

[ "96.71", "96.6", "39.95", "38.95" ]

icd9pcs

[ [ [] ] ]

7508, 7574

2898, 4831

373, 411

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439, 924

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171,462

11246

Discharge summary

report

Admission Date: [**2169-12-4**] Discharge Date: [**2170-5-18**] Date of Birth: [**2101-10-15**] Sex: F Service: MEDICINE Allergies: Zosyn / Cefepime Attending:[**Last Name (NamePattern1) 4377**] Chief Complaint: Fever Major Surgical or Invasive Procedure: Bone marrow biopsy ([**2169-12-21**] and [**2170-3-19**] and [**2170-5-18**]) PICC line placement J tube placement History of Present Illness: Mrs. [**Known lastname **] is a 68 year-old woman with a history of gastric DLBCL [**2158**] followed by autologous SCT [**2165**] and AML [**3-5**] secondary MDS. She is being admitted for hypotension on day +8 after underwent AraC/Idarubicin induction [**2169-8-30**]. She was subsequently admitted [**Date range (2) 36123**] for febrile neutropenia and pseudomonal sepsis. Bone marrow biopsy done at the time demonstrated recurrence of AML, so she was enrolled in a trial of AraC +/- clofarabine ([**Date range (1) 36125**]). She tolerated the medication well and was discharged on day +6. She was again admitted [**Date range (3) 36127**] with hypotension. Day 22 BM biopsy [**2169-11-30**] showed persistant disease. She was discharged to home with plan to follow-up in clinic. Since she was home, she was feeling well this past weekend. Today her visiting nurse found her to have a temperature of 102. She has an erythematous papular rash on her nose that she states is not new for her and is not pruritic or painful - feels this is irritation from tissues for runny nose. She denies any localizing symptoms such as headache, neck pain, chest pain, cough, shortness of breath, abdominal pain, nausea, diarrhea, or dysuria. Past Medical History: Past Oncologic History . She was first diagnosed with gastric diffuse large B-cell lymphoma in [**2158**]. She underwent partial gastrectomy, radiation therapy, and CHOP chemotherapy. She relapsed in [**2164**] and was found to have diffuse disease in the supraclavicular nodes and mediastinum. She underwent R-CHOP and two cycles of RICE. She subsequently relapsed and underwent autologous stem cell transplant in [**4-4**]. . After the transplant, she did well until [**2169-6-1**] when she was admitted to [**Hospital3 417**] Hospital with symptoms consistent with pneumonia. Her counts were significant for a white blood count of 2.6, hematocrit 31.1, and platelet count of 23,000. Bone marrow biopsy after resolution of the pneumonia showed myelodysplastic syndrome with increased blasts (5-10% with trilineage dysplasia), thought to be [**3-5**] her prior chemotherapy, radiation therapy, and stem cell transplant.Chromosomal studies revealed chromosome abnormalities of deletion 5, 7 and 20. . Mrs. [**Known lastname **] was readmitted for persistent fevers on [**2169-8-4**] and was noted to have increasing blasts in her peripheral blood. A bone marrow biopsy on [**2169-8-14**] was consistent with increasing blasts to 10% in the marrow. She underwent induction with Idarubicin and Ara-C on [**2169-8-30**]. Bone marrow biopsy [**10-26**] showed recurrence of leukemia. For this reason she elected to enroll in the randomized trial of AraC/clofarabine. . PAST MEDICAL HISTORY: 1. AML secondary to MDS, diagnosed in [**2169**] (see details above) 2. Gastric DLBCL (Diffuse Large B cell lymphoma) from supraclavicular L/N in [**2158**] with relapse in [**2165**], s/p adriamycin tx, 2 cycles of CHOP, 2 cycles of RICE tx, s/p autologous stem cell transplant in 3/[**2165**]. Relapsed gastric lymphoma s/p partial gastrectomy with chemotherapy. 3. GERD 4. Chronic systolic heart failure (EF 30-40%), recently evaluated by cardiology; thought to be secondary to a previous asymptomatic inferoposterior wall MI (distribution of injury not consistent with cardiomyopathy secondary to anthracycline toxicity). Had a P-Mibi for further evaluation which confirmed moderate perfusion defect of PDA territory and medium sized, severe perfusion defect of LAD territory as well as severe systolic dysfunction. The decision was made to defer cardiac catheterization until oncologic issues had been resolved. Cardiac medications including low-dose ACEI and beta-blocker were started. Repeat echo showed that EF was stable at 35-40%. Social History: The patient lives with her husband, and daughter's family. She quit smoking 4 months ago, but had smoked for 25 years. She denies alcohol use or drug use. She had previously worked as a waitress. She was born in [**Country 2784**] and moved to the United States at age 20. Family History: Father had heart failure and mother had diabetes. Physical Exam: VITAL SIGNS - T 99.3, BP 101/63, RR 20, HR 92, 100%RA GENERAL - Well-appearing female NAD, comfortable HEENT - NC/AT, PERRLA, [**Country 3899**], sclerae anicteric, MMM, OP clear NECK - Supple, no thyromegaly, no JVD, no carotid bruits LUNGS - CTA bilat, no r/rh/wh, good air movement, resp unlabored, no accessory muscle use HEART - RRR, no MRG, nl S1/S2 ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no rebound/guarding EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs) SKIN - Maculopapular rash on nose; several macules, dark red in color, on dorsal surface of feet bilaterally NEURO - Awake, A&Ox3, CNs II-XII grossly intact, muscle strength [**6-5**] throughout, sensation grossly intact throughout Pertinent Results: Chest radiograph, portable ([**2169-12-4**]): In comparison with study of [**11-16**], allowing for the portable technique, there is little change. Specifically, there is no evidence of acute pneumonia. Immunophenotyping ([**2169-12-6**]): Immunophenotypic findings consistent with peripheral blood CD34/CD33 positive myeloblasts. Ratio of mean fluorescent intensity of CD33 positive blast to mean fluorescent intensity of isotype control is 3.2. CT chest without contrast ([**2169-12-6**]): 1. Improvement of pulmonary interstitial edema and decrease in the size of pleural effusions from prior CT study. 2. Foci of ground-glass opacity in the left upper lobe are stable-to-slightly improved and probably are also part of the same process. 3. No evidence of pneumonia. Bone marrow biopsy ([**2169-12-21**]): HYPOCELLULAR BONE MARROW WITH EXTENSIVE FIBROSIS, MARROW REGENERATION AND INCREASED MYELOBLASTS. Though a significant population of maturing erythroid and myeloid precursors are present, immature, non-clustered cells consistent with blasts comprise at least 10% of marrow cellularity. By immunohistochemistry, CD34 highlights mononuclear cells which comprise approximately 10% of the cellularity. The findings are consistent with marrow regeneration with persistent involvement by acute leukemia. CD117 and MPO stain approximately 30% of cells. The remainder appear to correspond to maturing erythroid precursors. Chest radiograph, 2-view ([**2169-12-29**]): Minimal right perihilar atelectasis. No evidence for pneumonia. Brief Hospital Course: 68 yo F with AML admitted with fever and neutropenia, noted to have persistent leukemic involvement of bone marrow, who underwent allogeneic SCT during this hospitalization. She had a very complicated hospital course including fever and neutropenia, acute graft-versus-host disease, thalamic stroke, CMV Viremia, and multiple UTIs. Patient had repeat bone marrow biopsy on [**2170-5-8**] showing recurrent leukemia. Patient was made DNR/DNI/CMO at that time by her health care proxy. She passed away on [**2170-5-18**] after being hospitalized for 5 months. #. AML: The patient was admitted on [**2169-12-4**] with fever. She underwent immunophenotyping on admission and was found to have persistent AML. The patient underwent Azacytadine/gemtuzumab therapy from [**12-7**] to [**12-11**]. A bone marrow biopsy on [**2169-12-21**] again showed marrow regeneration with persistent involvement by acute leukemia. The patient was then started on Dacogen therapy. Another bone marror biopsy was performed on [**1-16**], which revealed a hypocellular bone marrow and <5% blasts. At this time, it was decided that the patient should undergo an allogeneic SCT. She underwent a pre-SCT Infectious Disease evaluation, and she increased her performance and nutritional status. The patient started conditioning therapy on [**2170-2-9**] and received a SCT on [**2170-2-16**]. She tolerated her graft well. On [**3-19**], her bone marrow biopsy showed no evidence of residual leukemia. She was maintained on Cyclosporine for GVHD prophylaxis. She was changed from inhailed pentamidine to atovaquone when her J-tube was placed. She was on Acyclovir. In [**Month (only) 958**], her platelets started dropping, but her CMV was positive. It was unclear whether it was disease related v. from CMV. She was treated with gancyclovir, but continued to have persistent CMV infection. Repeat bone marrow biopsy showed persistent blasts, (20-30%) consistent with recurrent leukemia. Care was withdrawn by Health care proxy and patient expired peacefully. #. Hemorrhagic Stroke: The patient had a hemorrhagic stroke on [**2-14**], in the setting of low platelets and conditioning chemotherapy. The patient was evaluated by neurosurgery and neurology, and it was determined that she is not an optimal surgical candidate. The patient received neurology checks every hour, and she had multiple CTs of her head, which did not show a progression of this hemorrhage. Her mental status was waxing and [**Doctor Last Name 688**]. Neurology performed a 24 hour EEG which did not show any evidence of seizure activity. They felt that her mental status was the natural progression of her thalamic stroke. She was seen by PT and OT and speach therapy in the hospital for stroke rehab. She eventually came to the point where she was nonresponsive and did not wake up for weeks. Then in mid-[**Month (only) **], she started opening her eyes and answering yes/no questions. Eventually she woke up and had a normal mental status. She was alert and oriented and having regular converstations. She had continued R side deficit, but was starting to regain some movement in her R leg. . #. Neutropenic fever/other infections - The patient presented to the hospital with a neutropenic fever. No infectious etiology was found, and the patient was restarted on her home regimen of Acyclovir and Ambosome. The fever persisted, and the patient was thus started on Vancomycin and Meropenem. The patient remained asymptommatic, and no etiology was found. In early [**Month (only) 1096**], the patient had a CT chest which revealed bilateral bronchopneumonia. A BAL was performed on [**1-3**], which did not show any evidence of PCP, [**Name10 (NameIs) **], Mycobacteria, or viral etiologies. The patient had two ICU admissions during this time for pulmonary edema. During her second admission, her antibiotics were increased to include Daptomycin, Meropenem, Tobramycin, Bactrim, Acyclovir, Posaconazole and PO Flagyl. The patient remained afebrile, and her antibiotics were gradually discontinued, with the exception of Micafungin (changed from Posaconazole secondary to rising LFTs), Acyclovir, and Vancomycin. On [**2-16**], the patient again became febrile to 100.8. She was restarted on Tobramycin, and she was pan-cultured. The Tobramycin was later discontinued and the patient has remained afebrile to date. Her antibiotics were slowly weaned back. She was doing well and then at the end of [**Month (only) **] was found to have UTI and treated with meropenem and CMV viremia and treated with gancyclovir. Eventually these were weaned off. She then started having fevers persistently, and was found to have a VRE UTI and was started on daptomycin. This was discontinued once patient was made CMO. . # Pulmonary Edema: From [**1-3**] through [**1-10**] the patients weight increased to 118lbs as she was placed on IVF for SBP as low as 70s. This lead to ICU admissions on two occassions. In the setting of BNPs 15 - 35K, pulmonary edema on CXR, the patient was placed on a lasix drip each time with subsequent improvements in her BP. The patient was mentating at all times. Did not reoccur after these ICU admissions. . #3. Hemodynamics - Patient was placed on a low-dose beta-blocker. During hospital course she experienced episodes of hypotension when maintenance fluids were stopped requiring continuation at low rate (75 cc/hour). In particular, she had three episodes of systolic BP in 70s; she remained asymptomatic in all episodes, and all episodes resolved with small fluid bolus (e.g. 250cc NC). Echo was found to have improvement to EF of 50%. In early [**Month (only) 1096**] the patient was found to be hypotensive to the 70s in the setting of fevers and subsequently was sent to the unit on each occasion. The patient was noted to have an elevated BNP ranging from 15K to 35K in the setting of increased 02 requirement to 4L NC, crackles on exam, pulmonary edema on CXR, and the patients weight at 118lbs up from 110lbs on admission. The patients mantenance fluids were d'c'd. The patient subsequently remained normotensive with pressures ranging systolically from 90s to 120s. . #. Chest Pain: The patient with known LAD and PDA defects. On [**1-27**] the patient developed [**9-10**] substernal chest pressure while ambulating. EKG unchanged. Cardiac Enzymes were flat. Cards was c/s and stated that the patient would not be a candidate for cardiac catheterization of POBA, as she is unable to take Plavix or ASA long-term. Has had no recurrent CP since that time. . # Elevated LFTs: Patient had a mild recurrent transaminitis. Posaconazole was changed to Micofungin as a possible source for elevated transaminases, and a RUQ U/S was performed which showed stones in the gallbladder and CBD. ERCP was contact[**Name (NI) **] but as the elevation in T. bili was minimal, given her current illness she would not be a good candidate for ERCP. She also had some rise in AP/bili in [**Month (only) 958**] and was started on treatment for GVHD for liver and gut involvement as she was having diarrhea. A steroid course was initiated and tapered off as diarrhea and LFTs improved. She continued on cyclosporine and was titrated to 3x/week levels. Did need to be increased at the end of [**Month (only) 958**]. . # Nutrition: Patient was initially on TPN following her stroke. A J-tube was placed by surgery on [**2170-3-22**]. A J-tube was placed as the patient had a past partial gastrectomy for a gastric cancer. After the J-tube placement she developed bilious emesis. A barium study revealed an obstruction above the site of the J-tube, but the J-tube itself and distal bowel was unobstructed. Her tube feeds were resumed with a forluma that did not require pancreatic enzymes or bile. As her Albumin was low Surgery said she was not a surgical candidate. An NG tube was placed to suction her gastric secretions and bile. Evenutally the NG tube fell out, but she had no more emesis and the SBO must have resolved on it's own. She continued on J tube feeds, but TPN was stopped. She then passed speech and swallow and is on a restricted diet and eating for pleasure. Once made CMO, IVFs were stopped and patient was given minimal tube feeds for comfort per family request until she expired. . # GI bleed - had coffee ground emesis in late [**Month (only) 116**], likely from a gastritis. GI did not think a scope was warranted as her hct was stable and her stools were guiac negative. We started her on [**Hospital1 **] protonix for now and she has no more episodes. Transfused to keep her plt above 50. Medications on Admission: 1. Omeprazole 20 mg Capsule, PO DAILY 2. Acyclovir 200 mg Capsule Sig: Two (2) Capsule PO Q8H 3. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H 4. Amphotericin B Liposome 50 mg Suspension for Reconstitution Sig: One [**Age over 90 1230**]y (150) mg Intravenous Q48H 5. Metoprolol Tartrate 25 mg Tablet Sig: [**2-4**] Tablet PO twice a day: dose is 6.25 mg by mouth twice daily. Discharge Medications: None-expired Discharge Disposition: Expired Facility: [**Hospital3 7**] & Rehab Center - [**Hospital1 8**] Discharge Diagnosis: Primary Diagnosis: 1. AML 2. Hemorrhagic thalamic stroke 3. Small bowel obstruction 4. Graft v. Host Disease 5. Hyperkalemia Discharge Condition: Expired Discharge Instructions: You were admitted to the hospital in Novemeber for AML. We were able to get you well enough to undergo a stem cell transplant. During prepartion for your stem cell transplant, you had a stroke which caused you to have some right side weakness and made you very somnulent for many many days. We placed a tube into your intestines to help you get enough nutrition. You also had a small bowel obstruction which resolved on its own. You passed speech and swallow test and can eat when you're hungry. Unfortunately, a repeat bone marrow biopsy showed recurrent leukemia. Your health care proxies (per your wishes) withdrew care and you passed away peacefully. Followup Instructions: None (expired) Completed by:[**2170-6-13**]

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icd9cm

[ [ [] ] ]

[ "99.25", "86.11", "41.31", "46.39", "41.05", "99.15", "33.24" ]

icd9pcs

[ [ [] ] ]

16010, 16083

6901, 15536

292, 408

16252, 16261

5336, 6878

16964, 17009

4530, 4581

15973, 15987

16104, 16104

15562, 15950

16285, 16941

4596, 5317

247, 254

436, 1671

16123, 16231

3180, 4224

4240, 4514

23,259

180,239

30059

Discharge summary

report

Admission Date: [**2129-3-30**] Discharge Date: [**2129-4-29**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 30**] Chief Complaint: Acute pancreatitis Major Surgical or Invasive Procedure: Paracentesis, [**2129-4-13**] History of Present Illness: 87M with h/o HTN, h/o bladder ca, who presented to the [**Hospital1 **] [**Location (un) 620**] ED on [**3-30**] with abdominal pain. He states the pain was located in the RLQ, acute in onset, constant, sharp, not crampy. It began at ~12:30pm this afternoon and has been steady since then. He has had some nausea and one episode of vomiting at the OSH. He denies diarrhea, and notes 1 small BM today. He denies fever and chills at home. He has had no recent illnesses and denies sick contacts. . In the [**Hospital1 **] [**Location (un) 620**] ED, his VS were T 97.5, BP 160/80, HR 78, RR 20, O2sat 96% RA. He had mild RLQ tenderness on palpation. His labs showed leukocytosis (13.2) and bandemia (14%), Hct 43.5, mildly elevated LFTs including total bili 1.1, amylase 2400, and lipase [**Numeric Identifier 2249**]. He was sent for a non-contrast CT abd/pelv which showed (per [**Hospital1 18**] Radiology review) thickened edematous gallbladder with surrounding fat stranding, stranding around the head of the pancreas, grossly normal-appearing biliary and pancreatic duct system, extensive fat stranding throughout the abdomen. RUQ US was also performed, unknown findings as no documentation and report is still pending. He was given toradol 15mg IV, morphine 2mg IV x1, morphine 4mg IV x2, levofloxacin 500mg IV, Flagyl 500mg IV, and 2L NS. He was transferred to the [**Hospital1 18**] MICU with a diagnosis of acute gallstone pancreatitis. . Currently, he continues to complain of [**11-9**] pain. He states the pain has now moved to a band-like distribution in the upper abdomen. He denies nausea, chills, chest pain, shortness of breath, headache, pain or weakness of extremities, lightheadedness. He denies biliary colic in the past and known history of cholelithiasis. He denies EtOH use. He has no history of pancreatitis in the past. ROS positive for some short-term memory loss and difficulty concentrating. Past Medical History: 1. Hypertension- patient does not know the names of his BP meds 2. Bladder cancer- diagnosed 7y ago, pt unclear of treatment (?intravesical chemo) 3. H/o pneumonia- [**11-5**], hospitalized x 7d in [**Location (un) 1110**] Social History: widower x 2y, lives alone, daughter lives nearby, reports independence in all ADLs (incl. cooking, cleaning, grocery shopping, driving) but states his daughter manages his money; + tobacco, >50 pk-yrs, quit 25y ago; very rare EtOH use; no drug use Family History: noncontributory Physical Exam: Vitals- T 98.1, HR 63, BP 142/56, RR 23, O2sat 94% on 2LNC, Wt 76.5kg General- elderly man lying in bed, NAD, appears comfortable, A&Ox3 HEENT- NCAT, sclerae anicteric, arcus senilis, OP clear, MMM Neck- supple, JVP ~7cm Pulm- CTAB, good air movement CV- RRR, nl S1/S2, no murmur Abd- + BS, distended but soft, mild LLQ and RUQ TTP with no rebound/guarding, no epigastric or RLQ TTP, ? rectus diastasis Extrem- trace LE edema to mid-calf, feet warm and well-perfused Neuro- A&Ox3, CN III-XII intact to challenge, UE/LE strength 5/5 b/l, sensation intact to LT throughout, bic/BR/pat/BR DTRs 2+ b/l, toes downgoing b/l, no pronator drift Pertinent Results: See OMR for complete results. Brief Hospital Course: initial unit stay: A/P: 87M with HTN, h/o bladder cancer, transferred from OSH with acute pancreatitis, likely secondary to obstructive cholelithiasis. Brief hospital course as below, by problems: . # Acute pancreatitis: Patient presented with abdominal pain with elevated pancreatic enzymes, consistent with acute pancreatitis. Radiographic imaging demonstrated a thickened gallbladder with pericholecystic fluid and stranding. Given his age and hematocrit on presentation, there was concern for a high risk of mortality by [**Last Name (un) **] criteria. He was made NPO and given aggressive intravenous fluid hydration. His pain and enzymes improved somewhat and a repeat RUQ US revealed no evidence of cholecystitis or ductal dilatation. The pt was started on tube feeds and discharged to the floor with plan for cholecystectomy in 2 weeks. Pain and enzymes now improving. Currently thinking that pancreatitis is secondary to choledolethiasis but with elevated LFTs returning to baseline no role for ERCP. Abdomen remains distended without stool since admission. Respiratory Distress: Mr. [**Known lastname **] had been developing worsening abdominal distention with increasing leukocytosis and increasing lethargy on the floor and was transferred back to the MICU. At the time of transfer to the ICU, his ABG was consistent with respiratory acidosis and he was intubated. After intubation he became hypotensive, not responding to 3L IVF and requiring levophed. This was initially weaned off, however during his course in the ICU he became repeatedly hypotensive requiring levophed and was difficult to wean. He had severe total body anasarca however given his low blood pressure he was unable to tolerate diuresis. Levophed was finally weaned about three days before he was called out of the unit and the patient's BP remained stable. The patient required prolonged intubation and had increased secretions. He was treated for presumed ventilator associated pneumonia. Overall he was treated with vanco/zosyn for a total 21day course. After failing two spontaneous breathing trials, the patient was suddenly improved in terms of his ventilation/oxygenation and passed spontaneous breathing trial. He was successfully extubated on [**4-26**] and was weaned to nasal cannula without event. He was then transferred to the floor and shortly after developed persistent respiratory distress. No intervention was made as the pt was CMO and he expired the next day. - ascites: Prior paracentesis had been consistent with SBP and he had been on vanco/zosyn antibiotics. Flagyl and fluconazole were added empirically onreturn to the unit, however these were stopped after about 4 days as no source was discovered. His ascites were tapped with ultrasound guidance, however only 60cc could be removed, thought likely due to loculation of the fluid. Cell count was negative for SBP and culture of the fluid was negative. - pancreatic pseudocyst: CT abdomen obtained at the time of unit transfer revealed large ascites and a new 6.6cmx6.7cm fluid collection in the gastrosplenic ligament extending towards the pancreas. Omental studding was not seen on this study. The peri-pancreatic fluid was not considered amenable to percutaneous drainage and surgery was consulted. They felt this imaging was consistent with pancreastic pseudocyst and did not suspect infection of this pseudocyst. They recommended repeat imaging in 6 weeks with outpatient surgical follow up for possible surgical drainage at that time if persistent fluid collection. GI was also consulted and they felt that this was possible not a pseudocyst but rather more loculated ascites. They recommended repeat CT in one week to assess for change in appearance. Repeat Ct abdomen was consistent with pancreatic pseudocyst and a slight decrease in the size of his ascites as well as the pseudocyst. - recurrent fevers: The patient developed recurrent fevers of unknown origin despite greater than two weeks of vanco/zosyn. Repeat paracentesis had been negative for SBP, blood, urine and sputum cultures were negative. CXR showed no new pneumonia. His PICC as well as central line were pulled. Despite the fevers, his white count actually steadily decreased and his hemodynamics improved. It was postulated that his fevers may have been drug fevers, and in fact after completing his 21 day course of vanco/zosyn his fevers decreased. He was afebrile x 3 days at the time of call out from the ICU. - Code Status: We had several discussions with the patient's family during his course. Initially the patient had walked in to the hospital on his own, having lived independently, and expressed a desire to return to an independent baseline. He agreed to "two weeks of intubation" but stated that he would not want heroic procedures beyond that period of time. The team became concerned that the patient's family's wishes to continue intubation and many procedures might be against his wishes. We spoke with his primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 931**], who had had several code status discussions with the patient before and believed that his wishes would be most consistent with being made comfortable at this point. After discussion with the patient's family, his code status was changed from full code to DNR/DNI, with thought that once he was extubated he would not be reintubated if needed. He did well with extubation, however it is very unlikely that the patient will reach his desired return to independent baseline. We recommended that the patient's family consider making him CMO. They decided to continue current care, however not to escalate care, meaning a turn for the worse would prompt CMO status. He is not to be reintubated or resuscitated, they do not want pressors nor ICU transfers at this time. The patient himself refused PICC prior to call out to the floor, and his family agreed with this decision. The patient acutely decompensated on the night of his transfer to the floor. His status was discussed with the attending MD, the family, and the in -house care team. He was made CMO and expired then next morning. Medications on Admission: ASA 81 mg qd [**2129-2-11**] [**Doctor First Name **] 180 mg qd [**2124**] Lisinopril 10 mg started [**2129-2-11**] "blood pressure pills" (unknown names and doses) Discharge Medications: None. Discharge Disposition: Expired Discharge Diagnosis: Respiratory Failure. Discharge Condition: Expired. Discharge Instructions: None. Followup Instructions: None.

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icd9cm

[ [ [] ] ]

[ "93.90", "38.93", "96.72", "96.6", "96.04", "99.15", "00.17", "38.91", "54.91" ]

icd9pcs

[ [ [] ] ]

9953, 9962

3545, 9708

279, 310

10026, 10036

3491, 3522

10090, 10098

2802, 2819

9923, 9930

9983, 10005

9734, 9900

10060, 10067

2834, 3472

221, 241

338, 2275

2297, 2521

2537, 2786

78,117

199,785

38079

Discharge summary

report

Admission Date: [**2136-6-12**] Discharge Date: [**2136-6-16**] Date of Birth: [**2076-8-20**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 443**] Chief Complaint: Fall Major Surgical or Invasive Procedure: Pacemaker placement History of Present Illness: 59yo F with epilepsy on Tegretol who initially presented with syncope s/p colonoscopy prep resulting in subdural hematoma now being transferred to CCU after intermittent complete heart block noted on telemetry. Ms [**Known lastname 85012**] initially presented to [**Hospital6 1109**] on [**2136-6-12**] following routine colonoscopy. She had not eaten in 30 hours. She got up from resting position to go to the kitchen and passed out. She has no memory of the hour preceeding the fall and several hours following the event. Apparently, in the horus prior to the event, she had told her husband she felt dizzy. Patient's daughter heard her fall and noted that she had lost consciousness for several seconds and had lump in the back of her head following fall. After waking up the patient developed nausea, vomiting, and dizziness w/ no visual changes, neck pain, chest pain, or shortness of breath. While in the OSH ED, she was noted initially to be in normal SR then became bradycardic to 34; she vomiting at this time, and then returned to rate of 80 thereafter. A Tegretol level drawn at that time was 6.6. A head CT was obtained which showed a subarachnoid, subdural and parenchymal hemorrhage largely on the left. She was transferred to [**Hospital1 18**] for further neurosurgical evaluation. Given her intracranial bleed, a decision was made to intubate her prior to transfer for airway protection. . At [**Hospital1 18**], she received propofol for sedation while intubated; on [**6-13**] in the morning she was extubated. Head CT and c-spine imaging was obtained; neurosurgery cleared her spine and felt no emergent intervention was needed for hemorrhages which appeared to be resolving compared to prior imaging. Around 1 PM and again around 230 PM on [**6-13**], she experienced complete heart block lasting at least 15 seconds; other than nausea, she had no other complaints over this period. Given her intermittent complete heart block and history of syncope, she was transferred to the CCU for further management. . Over the past several months, she denies any symptoms on review of her recent health. Denies fevers, chills, rigors, rashes, joint pains, vomiting, chest pain/pressure, abdominal pain, dysuria. No prior episodes of dizziness or falls. Her last seizure was about 10 years ago. No known tick bites. In the days prior to current episode she did admit to some URI symptoms. Past Medical History: epilepsy since age 4 - the patient has generalized convulsions only out of sleep and she has not had a seizure in greater than 10 years, hypercholesterolemia, hypertension, carpal tunnel surgery. Social History: Lives with husband and daughter. [**Name (NI) 1403**] as housekeeper. No ETOH, tobacco. Family History: n/c Physical Exam: Physical Exam: General: intubated on propofol HEENT: NCAT, moist mucous membranes Neck: supple Extremities: no c/c/e. Neurological Exam: Mental status: Does not open eyes to voice. Cranial Nerves: II: PERRL, 4-->2mm with light. optic discs sharp. VII: facial symmetric Motor/[**Last Name (un) **]: Withdraws symmetrically in all four extremities. Reflexes: 1+ symmetric Toes downgoing bilaterally. Pertinent Results: ADMISSION LABS: [**2136-6-12**] 05:45PM URINE RBC-0-2 WBC-0-2 BACTERIA-NONE YEAST-NONE EPI-0-2 [**2136-6-12**] 05:50PM PT-12.1 PTT-21.7* INR(PT)-1.0 [**2136-6-12**] 05:50PM WBC-13.7* RBC-4.39 HGB-13.5 HCT-38.5 MCV-88 MCH-30.6 MCHC-35.0 RDW-12.4 [**2136-6-12**] 05:50PM GLUCOSE-127* UREA N-6 CREAT-0.6 SODIUM-130* POTASSIUM-3.8 CHLORIDE-97 TOTAL CO2-22 ANION GAP-15 . Discharge labs: [**2136-6-16**] 06:30AM BLOOD WBC-10.0 RBC-4.25 Hgb-12.6 Hct-36.7 MCV-86 MCH-29.7 MCHC-34.4 RDW-12.3 Plt Ct-227 [**2136-6-16**] 06:30AM BLOOD PT-12.7 PTT-24.2 INR(PT)-1.1 [**2136-6-16**] 06:30AM BLOOD Glucose-98 UreaN-9 Creat-0.5 Na-133 K-3.6 Cl-99 HCO3-27 AnGap-11 [**2136-6-16**] 06:30AM BLOOD Calcium-8.4 Phos-2.9 Mg-2.0 . [**2136-6-13**] CT head: 1. Relatively thin subdural hematoma over the left convexity, layering on the tentorium. 2. Multiple foci of hemorrhagic contusion predominantly in the left frontal, temporal and parietal lobes, and small contusions in the right temporoparietal region. 3. Subarachnoid hemorrhage along the left convexity and focus of subarachnoid blood at the interpeduncular fossa, which appears new compared to prior scan. 4. No hydrocephalus, and no evidence of subfalcine or uncal herniation. . [**2136-6-13**] CT Cspine: IMPRESSION: 1. No cervical spine fracture or acute alignment abnormality. 2. Subtle lucent line in the left occipital bone on sagittal view, could be artifact; however, cannot exclude a subtle fracture. 3. Heterogeneous appearance to the thyroid gland; recommend thyroid ultrasound on an elective basis, if one has not been performed elsewhere. NOTE ADDED IN ATTENDING REVIEW: Comparing the sagittal reformations to the "source" axial images, as well as the coronal reformations (as well as the [**Hospital1 **] NECT of the head, 3:5), the "linear lucency" appears more tubular and well- corticated, and more likely represents a prominent vascular channel, than a true fracture line. . [**2136-6-14**] Echo: The left atrium is normal in size. The estimated right atrial pressure is 0-10mmHg. Left ventricular wall thicknesses and cavity size are normal. Regional left ventricular wall motion is normal. Left ventricular systolic function is hyperdynamic (EF>75%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are structurally normal. There is no mitral valve prolapse. Trivial mitral regurgitation is seen. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. IMPRESSION: Normal biventricular systolic function. . [**2136-6-14**] CT Head: 1. Similar appearance of left frontal and temporal hemorrhagic contusions, accounting for differences in slice selection. 2. Slight decrease in subdural hematoma layering over the tentorium. 3. Similar to slightly decreased conspicuity of subarachnoid hemorrhage predominantly along the left frontoparietal convexity. 4. No new hemorrhage. No evidence of hydrocephalus or mass effect. . [**2136-6-16**] CXR: Left transvenous pacemaker leads terminate in standard position in the right atrium and right ventricle. There is no evident pneumothorax or pleural effusion. The lungs are clear. Cardiomediastinal contours are normal. Brief Hospital Course: . 59 year old female with history of epilepsy controlled on Tegretol with new and now resolving subdural hematoma and intraparenchymal/subarachnoid hemorrhages following syncopal event secondary to dehydration from colonoscopy prep, now being transferred to CCU after intermittent complete heart block. . # Subdural hematoma/subarachnoid hemorrhages: The patient was admitted to the neurosurgery service in the Surgical ICU for Q1 neuro checks. She remained on her tegretol for seizure prophylaxis. She remained intubated until HD#2, when she was extubated without difficulty. A repeat Head CT showed a resolving SDH and contusions. She was neurologically intact. In the afternoon of HD #2, the patient went into complete heart block. Cardiology was consulted and she was sent to to Cardiac ICU, see below. . # Intermittent complete heart block - Patient had a temporary pacer placed and then had a permanent pacemaker felt. Troponins negative at OSH; no other EKG findings concerning for ischemia noted. An echo was also obtained to evaluate for structural abnormalities, wall motion abnormalities. . # Hyponatremia - In setting of recent hemorrhage, could be secondary to SIADH. Other possibilities include hypovolemic hyponatremia in setting of poor PO intake and diarrhea over past two days. This resolved prior to discharge. . # Seizure Disorder - Stable, on tegretol. Continue home regimen. . # Hypertension - Continue lisinopril. Currently normotensive. . # Hyperlipidemia - Continue pravastatin. . Medications on Admission: IC-Epitol (Tegretol) 200 mg [**Hospital1 **], Pravastatin 20 mg qhs, Lisinopril 5 mg daily, Vit D. Discharge Medications: 1. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Pravastatin 20 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 3. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). 4. Carbamazepine 200 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours). Disp:*3 Capsule(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: Subdural hematoma Complete heart block s/p pacemaker Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: You were admitted to the hospital with syncope. You had imaging of your head that showed some bleeding around your brain. Neurosurgeons evaluated you and felt that the bleed was stable and did not require intervention. We moved you to the cardiac intensive care unit for heart block. A pacemaker was placed. This should help prevent further syncope. There are several reasons why you may have experienced this heart rhythm; we ordered a lot of blood tests which will take some time to come back. . We made the following changes to your medications: -Continue the antibiotic cephelexin for another 3 doses. You should take this every 6 hours. You can stop taking this medicine after 3 doses. . You should follow up with cardiology. Your appointment is scheduled below. You should also follow up with neurosurgery. Please refer to the number below to make this appointment. Followup Instructions: Provider DEVICE CLINIC Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2136-6-26**] 1:30 . Neurosurgery: Please call [**Telephone/Fax (1) 22729**] to schedule this appointment. They would like to see you in 6 weeks at time, at which point you will also need a repeat head CT. Completed by:[**2136-6-17**]

[ "427.5", "272.0", "851.42", "276.1", "426.0", "E885.9", "780.2", "401.9", "345.10" ]

icd9cm

[ [ [] ] ]

[ "96.71", "37.83", "38.91", "38.93", "37.72" ]

icd9pcs

[ [ [] ] ]

9012, 9018

6923, 8437

319, 341

9134, 9134

3575, 3575

10211, 10517

3133, 3138

8587, 8989

9039, 9039

8463, 8564

9310, 9830

3965, 4307

3168, 3272

9859, 10188

3291, 3291

275, 281

369, 2789

3351, 3556

6271, 6900

3591, 3949

9058, 9113

9149, 9286

2811, 3009

3025, 3117

25,060

145,509

11459

Discharge summary

report

Admission Date: [**2114-10-23**] Discharge Date: [**2114-10-25**] Date of Birth: [**2065-7-29**] Sex: F Service: CCU HISTORY OF PRESENT ILLNESS: The patient is a 49 year-old woman with idiopathic cardiomyopathy diagnosed one to two months ago with an EF ranging from 25 to 40% on various echocardiograms, Hodgkin's lymphoma at age 18 treated with chemotherapy as well as radiation therapy to the mediastinum, history of left bundle branch block, hypertension, coronary artery disease, who presents from the outside hospital with presenting symptoms being nausea, vomiting, diarrhea, fatigue, dyspnea on exertion and weakness for two days. Although she has had dyspnea on exertion as well as weakness in the past and this is correlated with pulmonary edema, she has never had associated nausea and vomiting and diarrhea in the past. She had two days of these symptoms and then had near syncope on the two days prior to admission and on that day she was admitted to [**Hospital3 36606**] Hospital in [**Hospital1 189**]. There she ruled in for a nonST elevation myocardial infarction with a peak CK of 427 and an MB of 21 and a troponin of 5.82. She developed a junctional rhythm with a rate of 44 and a blood pressure of 90/48 at that time. However, this resolved. She was transferred to [**Hospital1 346**] for cardiac catheterization and possible PCI. PAST MEDICAL HISTORY: Hypertension, Hodgkin's disease at age 18 status post chemotherapy and radiation therapy to the mediastinum. Known coronary artery disease with workup to date as follows, cardiac catheterization on [**6-13**] showed a codominant system with a 50 to 60% lesion at the left circumflex and 80 to 90% right coronary artery osteal narrowing, normal left ventricular EF, moderate 2+ mitral regurgitation, wedge of 22 and pulmonary artery pressure 40/22. Cardiac output not measured at that time. Echocardiogram of [**6-18**] showed an EF of 40%, left atrial enlargement, normal left ventricular dimensions, 2 to 3+ mitral regurgitation and 2+ tricuspid regurgitation. ETT on [**9-10**] exercise nine minutes on [**Doctor First Name **] protocol, stopped for chest tightness and progressive dyspnea on exertion. Electrocardiogram not interpretable. Echocardiogram on [**9-6**] left atrial dilation, moderate global left ventricular hypokinesis with EF of 25%, 4+ mitral regurgitation and no pericardial effusion. Cardiac catheterization on [**8-18**], right coronary artery osteal lesion 80%, EF 41% and 2+ mitral regurgitation. An exercise MIBI in [**8-18**] showed a mild septal wall defect. Her cardiomyopathy appears to be manifest itself as paroxysmal pulmonary edema. This is often in the setting of hypertension. Apparently carcinoid and pheochromocytoma have already been ruled out on a prior admission. MEDICATIONS ON ADMISSION: Aspirin 325 mg po q.d., Enalapril 20 mg po b.i.d., Lasix 40 mg po q day, Lovenox 70 mg subQ b.i.d., Pepcid 20 mg po b.i.d., Coreg 12.5 mg po b.i.d., nitroglycerin 0.4 mg sublingually q 5 minutes with a maximum of three prn. ALLERGIES: No known drug allergies. FAMILY HISTORY: Mother has asthma. No diabetes mellitus, congestive heart failure, myocardial infarction or angina known in the family. SOCIAL HISTORY: No tobacco or ethanol. LABORATORY ON ADMISSION: White blood cell count 9.0, hematocrit 28.9, hemoglobin 10.3, platelets 371. Chem 7 sodium 131, potassium 4.1, chloride 97, bicarb 23, BUN 40, creatinine 1.9, glucose 120, calcium 8.4, magnesium 2.1, phosphate 5.1. She ruled in for myocardial infarction by enzymes at the outside hospital as described above. Upon admission to [**Hospital1 18**] her CK was 167 with an MB of 6. Electrocardiogram showed normal sinus rhythm at 78 with a left bundle branch block, which is old. Chest x-ray within normal limits. No pulmonary edema. No cardiomegaly. IMPRESSION: This is a 49 year-old female with a recent history of congestive heart failure in the setting of hypertension and one vessel coronary artery disease involving the osteal of the right coronary artery. She is transferred with recent GI complaints that were followed by shortness of breath and junctional rhythm, increased troponin and transient hypotension. HOSPITAL COURSE: 1. Cardiovascular: A: Coronary artery disease: The patient ruled in for a nonST elevation myocardial infarction at the outside hospital. Upon arrival at [**Hospital1 69**] she went to the cardiac catheterization laboratory where a left heart catheterization revealed 99% right coronary artery osteal stenosis with TIMI one flow. This was successfully stented. We continued her on aspirin and initiated a months course of Plavix. B: Ventricular function: Hemodynamics measured a cardiac catheterization revealed significantly elevated right and left sided filling pressures with RVEDP of 15, mean PAP of 22, mean wedge of 15 and LVEDP of 16. Left ventriculogram showed anterolateral wall hypokinesis and the LVEF was calculated at 50%. No significant mitral regurgitation was seen. Given the patient's systolic and diastolic ventricular dysfunction Lasix and ace inhibitor was continued. Final doses of these are listed under discharge medications. Once it was certain that the patient's blood pressure had remained stable on diuretic and ace inhibitor, we restarted the patient's Carvedilol. C: Rate and rhythm: There is no recurrence of the patient's junctional rhythm and in fact this had resolved by the time she was admitted to our hospital. Her left bundle branch block persisted throughout her hospital stay and her rate was within normal limits. 2. Renal: The patient was admitted with renal insufficiency, but this resolved with hydration. 3. Hematology: The patient's hematocrit dropped by six points over the first night of her admission, however, this was felt secondary to hemodilution. Recheck of the hematocrit revealed that the hematocrit was stable and no bleeding was suspected. 4. Fluids, electrolytes and nutrition: Electrolyte repletion was provided to maintain the patient's potassium above 4 and the her magnesium above 2. She followed a cardiac diet. CONDITION AT DISCHARGE: Good. DISCHARGE STATUS: She was discharged to home. DISCHARGE MEDICATIONS: 1. Enalapril 10 mg po b.i.d. 2. Coreg 12.5 mg po b.i.d. 3. Lasix 20 mg po q.d. 4. Aldactone 25 mg po q.d. 5. Aspirin 325 mg po q.d. 6. Plavix 75 mg po q.d. for one month. She was instructed to drink approximately 2 liters of fluid per day and follow up was arranged with her cardiologist Dr. [**Last Name (STitle) 13584**]. DISCHARGE DIAGNOSES: 1. NonST elevation myocardial infarction. 2. Successful stent to right coronary artery lesion. 3. Cardiomyopathy. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 2057**] Dictated By:[**Name8 (MD) 2734**] MEDQUIST36 D: [**2114-11-13**] 10:41 T: [**2114-11-16**] 08:55 JOB#: [**Job Number 36607**]

[ "424.0", "715.90", "593.9", "401.9", "414.01", "410.71", "428.0", "425.4" ]

icd9cm

[ [ [] ] ]

[ "88.56", "36.01", "37.23", "88.53", "36.06" ]

icd9pcs

[ [ [] ] ]

3121, 3243

6616, 6996

6261, 6595

2841, 3104

4253, 6167

6182, 6237

163, 1376

3310, 4235

1399, 2814

3260, 3295

2,945

124,671

24795

Discharge summary

report

Admission Date: [**2156-9-26**] Discharge Date: [**2156-9-29**] Date of Birth: [**2136-9-29**] Sex: F Service: MEDICINE Allergies: Penicillins Attending:[**First Name3 (LF) 348**] Chief Complaint: Acetaminophen and aspirin overdose Major Surgical or Invasive Procedure: None History of Present Illness: Patient is a 19 year old female with Hx of several past suicide attempts transferred from [**Hospital 1562**] Hospital with an aspirin and tylenol overdose after 24hours s/p ingestion with Tylenol level at that time was well within parameters for probable hepatic toxicity per the Rumack-[**Doctor First Name **] nomogram. Reportedly day prior to admission to OSH, at 1 pm, pt took 70 pills each of ASA and tylenol (around 30 g). She subsequently vomited, including pill fragments yesterday. She did have some tinnitus. Otherwise was doing well but decided to call 911 the subsequent morning and was brought to ED at the OSH. In the ED, the pt was asymptomatic. Pt. Was given her inital dose of PO Mucomyst 7 grams. About an hour and a half later she vomited the initial dose. She denies taking any other substances. Initial Tylenol level at approximately 24 H was 31 with initial AST/ALT 62/63 increase to 411/332. Pt was transferred from OSH for liver transplant evaluation if her liver function worsened. On admission to the MICU, the patient denied any Suicidal ideations/homocidal ideations. She denied any fever/chills, chest pain, shortness of breath, abdominal pain, BRBPR, hematemesis, diarrhea. She did report some nausea, but no emesis. The patient did report life stressors but did not wish to endorse further. . Patient was admitted with plan to give IV N-aceytlcysteine loading (150mg/kg over 15min, then 50mg/kg over 4 hours, then 100mg/kg over 16hours) and plans to monitor LFTs and INR. The liver team was consulted who recommended the patient finish the course of mucomyst 70mg/kg and recommended no vitamin K be given so as to trend the patient's INR as a marker of hepatic function. They also recommended continuing PPI and dolasteron for nausea associated with overdose. On admission, the patient's LFTs were AST = 543 and ALT = 648 with INR of 1.4. These peaked at 1076 and 1075 respictively, now trending downward with values of 374/830 today and INR of 1.2. The patient has no evidence of hepatic necrosis and will likely recover full hepatic function. She is currently awaiting placement for inpatient psychiatric hospitilization and is being admitted to the medical service for continued observation while awaiting placement. Past Medical History: 1. Suicide Attempts x4- using different methods. One last year, landed her in a coma in [**Hospital3 **] hospital x3 days. She has been intubated for those events in the past. 2. Psychiatric History: very complex including chart diagnoses of bipolar disorder, ADHD, schizoaffective disorder, and OCD. Currently not taking any meds except zyprexa, but has taken depakote and lithium in the past. Social History: Obtained her GED from High School. Currently single but sexually active. EtOH 1-3 beers ever couple nights. Denies cocaine, heroin, canabis, ecstasy. Currently lost her job a few weeks ago. Her boyfriend recently got out of jail. Family History: Adopted from [**Country 10181**] Physical Exam: 97.6 125/54 82 18 98%RA NAD, AAOx3, lying in bed, speaking in full sentences, has nail polish, sleeping with a pink [**Male First Name (un) **] bear. MMM, OP-clear, nose ring, neck FROM, PERRL, anicteric CTA-B RR without murmur soft, NT/ND, +BS, no HSM, keloid above belly button. No C/C/E, warm, no rashes No asterixis Pertinent Results: Admission Labs: [**2156-9-26**] CBC: WBC-8.9 RBC-4.12* HGB-12.8 HCT-36.8 MCV-90 MCH-31.1 MCHC-34.8 RDW-12.4 CHEM: GLUCOSE-127* UREA N-5* CREAT-0.7 SODIUM-141 POTASSIUM-3.9 CHLORIDE-109* TOTAL CO2-23 ANION GAP-13 LFTs: ALT(SGPT)-543* AST(SGOT)-648* LD(LDH)-589* ALK PHOS-74 TOT BILI-0.3 LIPASE-22 AMYLASE-35 Coags: PT-14.2* PTT-34.5 INR(PT)-1.4 Additional labs/studies . AST: 648 -> 1056 -> 1076 -> 825 -> 614 -> 374 -> 120 ALT: 543 -> 899 -> 1075 -> 1069 -> 979 -> 830 -> 588 INR: 1.4 -> 1.4 -> 1.3 -> 1.3 -> 1.4 -> 1.2 -> 1.1 . [**2156-9-27**]: ABG pO2-139* pCO2-28* pH-7.43 calHCO3-19* Base XS--3 [**2156-9-27**]: Lactate-1.5 Discharge Labs: [**2156-9-29**] CBC: WBC-4.5 RBC-3.88* Hgb-12.1 Hct-35.5* MCV-91 MCH-31.3 MCHC-34.2 RDW-12.8 Plt Ct-228 Chem: Glucose-89 UreaN-7 Creat-0.5 Na-140 K-3.7 Cl-106 HCO3-25 Calcium-9.3 Phos-3.3 Mg-2.0 LFTs: ALT-588* AST-120* AlkPhos-80 TotBili-0.4 DirBili-0.1 IndBili-0.3 Brief Hospital Course: A/P: Patient is a 19 year old female with multiple psyciatric diagnoses including bipolar disorder, Borderline personality disorder, schizoaffective disorder, ADHD admitted s/p suicide attempt by Tylenol and aspirin. . 1. Tylenol overdose - Patient was transferred from outside hospital with tylenol ingestion with levels in range of probable hepatotoxicity. She was started on IV mucomyst at OSH and transferred to [**Hospital1 18**] for further care and possible assesssment for transplant if need be. Upon admission to the intensive care unit, the patient was given a loading dose of mucomyst and additionally received remainded of acetylcysteine doses per protocol. The patient LFTS on admission were remarkable for AST = 648 and ALT = 543 which continued to rise initially on admission, peaking the day after admission at AST = 1076 and ALT = 1069. Since that time, the patient's LFTs have continued to resolve, msot recent upon discharge AST = 120 and ALT = 588. The patient's INR was mildly elevated on admission to 1.4. The patient did not receive Vitamin K as per GI's request so as to be able to chart the patient's hepatic function reliably. The patient's INR corrected spontaneously, now 1.1 on discharge without any events of bleeding during the patient's admission. The patient's synthetic function is currently completely restored and the patient is expected to recover fully from this insult. . 2. Psych - The psychiatry team was immediately part of the patient's care. Upon initial evaluation, given the patient's hepatotoxicity, the recommendation was made that all psych meds should be held. The patient carries multiple psychiatric diagnoses including Borderline PD, Bipolar, ADHD, and schizoaffective disorder with multiple suicide attempts. Given the patient's recent suicide attempt, she was kept with a 1:1 sitter while in the hospital. The patient was assessed daily for safety and endorsed to the team each day that she was not having and suicidal or homicidal ideation and denied throughout her hospital course any visual or auditory hallucinations. The patient is being discharged without any medications with expected assessment and appropriate treatment as necessary at the inpatient psych unit. The patient was discharged to the care of [**Hospital1 **] 4. . 3. FEN- The patient was on a house diet with repletion of electrolytes as needed Medications on Admission: Zyprexa but does not know the dose No herbals/vitamin supplements Discharge Medications: None Discharge Disposition: Extended Care Discharge Diagnosis: 1. Acetaminophen overdose 2. Suicide attempt 3. Bipolar disorder Discharge Condition: Good. Patient is with normal hepatic function, resolving transaminitis, without pain. Patient afebrile, hemodynamically stable Discharge Instructions: 1. Please take all medications as instructed 2. Please keep all outpatient appointments upon discharge 3. Please return to hospital for medical care if onset of severe abdominal pain, nausea/vomiting, bleeding or any other concerning symptoms. Followup Instructions: 1. Patient to be transferred to inpatient psychiatric facility 2. Please follow up with your psychiatrist upon discharge 3. Please follow up with your primary care physician upon discharge

[ "314.01", "965.4", "300.3", "E950.0", "295.70", "300.9", "296.7", "301.83", "573.3" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

7141, 7156

4622, 6996

306, 312

7265, 7394

3684, 3684

7688, 7882

3290, 3324

7112, 7118

7177, 7244

7022, 7089

7418, 7665

4329, 4599

3339, 3665

232, 268

340, 2602

3700, 4313

2624, 3023

3039, 3274

22,291

113,542

23270

Discharge summary

report

Admission Date: [**2131-4-2**] Discharge Date: [**2131-4-11**] Date of Birth: [**2065-10-1**] Sex: F Service: CARDIOTHORACIC Allergies: Amoxicillin / Valium / Darvon / Latex Attending:[**First Name3 (LF) 1283**] Chief Complaint: Chest and left lateral back pain Major Surgical or Invasive Procedure: Asc Ao Aneurysm repair [**Last Name (NamePattern4) 15255**] of Present Illness: Mrs. [**Known lastname **] is a delightful 65 year old woman who back in [**2130-12-27**] with a 6 month history of epigastric and left lateral chest and back pain. A CT scan showed an enlarged aorta. A cardiac catheterization was performed which showed no significant coronary artery disease. She was subseqquently referred to Dr. [**Last Name (Prefixes) **] for suirgical management. She is admitted to day for preoperative testing and surgery. Past Medical History: Ascending aortic aneurysm Hypertension Hypercholesterolemia Depression Anxiety Social History: Smoked 1 pack per day for 47 years. SHe does not drink alcohol. Lives with partner and has two daughters. Family History: Noncontributory Physical Exam: VITALS: 57 SB, BP: (L) 130/60, (R) 118/59 96% RA sat NEURO: Alert, no focal deficits CARDIAC: Regular rate and rhythm, No murmur LUNGS: Clear ABDOMEN: Soft, nontender, nondistened. Normoactive bowel sounds EXTEMITIES: No edema, no varicosities PULSES: 2+ femoral, 1+ dorsalis pedis and posterior tibial. Pertinent Results: [**2131-4-2**] 05:02PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-SM [**2131-4-2**] 05:02PM URINE RBC-0 WBC-[**7-6**]* BACTERIA-FEW YEAST-NONE EPI-0 [**2131-4-2**] 05:50PM PT-12.6 PTT-26.4 INR(PT)-1.0 [**2131-4-2**] 05:50PM WBC-5.8 RBC-3.98* HGB-12.2 HCT-35.0* MCV-88 MCH-30.6 MCHC-34.8 RDW-14.0 [**2131-4-2**] 05:50PM ALT(SGPT)-26 AST(SGOT)-37 ALK PHOS-85 AMYLASE-33 TOT BILI-0.4 [**2131-4-2**] 05:50PM GLUCOSE-99 UREA N-21* CREAT-0.7 SODIUM-141 POTASSIUM-3.6 CHLORIDE-100 TOTAL CO2-31* ANION GAP-14 [**2131-4-2**] CXR 1. No acute cardiopulmonary disease. 2. Stable tortuosity of the thoracic aorta consistent with an ascending aortic aneurysm. [**2131-4-10**] CXR Disappearance of tiny left apical pneumothorax. Persistent enlargement of the heart shadow and left lower lobe densities consistent with postoperative remaining pericardial effusion, left lower lobe atelectasis and pleural densities. Further followup to document embolization is recommended. [**Last Name (NamePattern4) 4125**]ospital Course: Ms. [**Known lastname **] was admitted to the [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1675**] [**Last Name (NamePattern1) **] Medical Center on [**2131-4-2**] for surgical management of her aortic aneurysm. She was worked-up in the usual preoperative manner. The psychiatry service was consulted for her anxiety. It was recommended that Ms. [**Known lastname **] continue her paxil and ativan as per her at home doses. Levofloxacin and flagyl were started for a urinary tract infection. The infectious disease service was consulted and it was felt that her initial urinalysis was a vaginal contaminant. Repeat urinalysis was performed and she was cleared for surgery by the infectious disease service. On [**2131-4-3**], Ms. [**Known lastname **] was taken to the operating room where she underwent an ascending aorta replacement utilizing a 26 mm gelweave graft. Postoperatively she was taken to the cardiac surgical intensive care unit for monitoring. On postoperative day one, Ms. [**Known lastname **] [**Last Name (Titles) 5058**] neurologically intact and was extubated. She was transfused with packed red blood cells for postoperative anemia. On postoperative day two, she was transferred to the cardiac surgical step down unit for further recovery. Ms. [**Known lastname **] was gently diuresed towards her preoperative weight. The physical therapy service was consulted for assistance with her postoperative strength and mobility. Her pacing wires and drains were removed per protocol. Beta blockade was titrated for optimal heart rate and blood pressure control. Her diuretic was switched to hydrochlorothiazide for fluid management. Ms. [**Known lastname **] developed wheezing with ambulation. A chest x-ray showed a moderate left pleural effusion. Thoracentesis was performed which drained 700 cc's of fluid with good effect. Ms. [**Known lastname **] continued to make steady progress and was discharged home on postoperative day eight. She will follow-up with Dr. [**Last Name (Prefixes) **], her cardiologist and her primary care physician as an outpatient. Medications on Admission: Lipitor 20mg daily Hydrochlorothiazide 50mg once daily Multivitamin daily Atenolol 50mg once daily 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. Paroxetine HCl 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 3. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 4. Hydrochlorothiazide 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. Disp:*50 Tablet(s)* Refills:*0* 6. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. Disp:*30 Tablet(s)* Refills:*0* 7. Lopressor 50 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:*60 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Location (un) 932**] Area VNA Discharge Diagnosis: s/p Asc Aortic Aneurysm repair (#26 Gelweave graft) PMH: HTN, ^chol, Depression, Anxiety Discharge Condition: good Discharge Instructions: keep wound clean and dry. OK to shower, no bathing or swimming. take all medications as prescribed. call for any fever, redness or drainage from wounds Followup Instructions: Dr [**Last Name (STitle) **] in [**3-30**] weeks Dr [**Last Name (STitle) **] in 4 weeks Completed by:[**2131-4-11**]

[ "441.2", "998.11", "285.1", "272.0", "401.9", "293.9", "511.9" ]

icd9cm

[ [ [] ] ]

[ "34.91", "39.61", "99.04", "35.11", "38.45" ]

icd9pcs

[ [ [] ] ]

5592, 5655

336, 866

5788, 5794

1468, 2499

5994, 6114

1109, 1126

4796, 5569

5676, 5767

4673, 4773

5818, 5971

1141, 1449

2550, 4647

264, 298

888, 969

985, 1093

50,407

133,457

10167+56115

Discharge summary

report+addendum

Admission Date: [**2190-5-16**] Discharge Date: [**2190-5-25**] Date of Birth: [**2108-5-1**] Sex: M Service: NEUROSURGERY Allergies: Penicillins Attending:[**First Name3 (LF) 78**] Chief Complaint: fall Major Surgical or Invasive Procedure: [**2190-5-16**]: right craniotomy for sub dural hematoma evacuation History of Present Illness: This is an 82 year old man who took a sleep aide for the first time last night. He rolled out of bed and hit his head around 4:30am. He was confused and disoriented and his family brought him to the ED. CT head showed a small right SDH. INR was 2.8 due to Coumadin use. Neurosurgery was consulted. Past Medical History: Afib, cardiac catheterization, HTN, gout, herniorrhaphy Social History: He does part time consulting for the Railway. He does not smoke. ETOH use is rare. He lives with wife and son. Family History: NC Physical Exam: on arrival PHYSICAL EXAM: O: BP: 131 /101 HR: 86 R 17 O2Sats 100% RA Gen: WD/WN, comfortable, NAD. HEENT: Pupils: 1.5 to 1.0 EOMs intact Extrem: Warm and well-perfused. Neuro: Mental status: Awake and alert, cooperative with exam, normal affect. Some tangential thinking. Orientation: Oriented to person, place, and date ([**5-15**]). Recall: [**12-7**] objects at 5 minutes. Language: Speech fluent with good comprehension and repetition. No dysarthria or paraphasic errors. Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light, 1.5 to 1.0 mm bilaterally. III, IV, VI: Extraocular movements intact bilaterally without nystagmus. V, VII: Facial strength and sensation intact and symmetric. VIII: Hearing intact to voice. IX, X: Palatal elevation symmetrical. XII: Tongue midline without fasciculations. Motor: Normal bulk and tone bilaterally. No abnormal movements, tremors. Strength full power [**4-8**] throughout. No pronator drift Sensation: Intact to light touch Coordination: normal on finger-nose-finger On Discharge: Patient is Alert, Oriented to date, Hosptial, and self CN 2-12 grossly intact No drift [**4-8**] motor strenght on isolated Muscle exam testing. Patient needs assistance with ambulation. Wound C/D/I, slight boggyness under skin flap. Staples removed [**2190-5-25**] Pertinent Results: [**2190-5-16**] CT Brain: FINDINGS: There is a right parietal/temporal subdural hematoma measuring 6 mm in maximum transverse diameter, with slight extension along the right tentorium and falx. There is minimal mass effect on the adjacent sulci. However, the sulci and ventricles are overall mildly enlarged due to mild cerebral atrophy. There is no shift of normally midline structures. No parenchymal edema is seen. There is a hematoma in the midline posterior scalp at the vertex. There is no fracture. The bilateral mastoid air cells and paranasal sinuses are well aerated. IMPRESSION: 1. Small right subdural hematoma. 2. Posterior scalp hematoma at the vertex. No fracture. [**2190-5-16**] CT BRAIN FINDINGS: There is marked interval expansion of the known right convexity subdural hematoma with acute blood products. There is new leftward shift of the normally midline structures by approximately 1.5 cm. There is effacement of the subjacent sulci and near-complete effacement of the right lateral ventricle. The third ventricle is compressed, and the left lateral ventricle is now dilated, indicating entrapment. New effacement of the perimesencephalic cistern suggests mild right uncal herniation. Small amount of subdural blood products is again seen along the right tentorium and falx. Bilateral carotid calcifications are present. Visualized paranasal sinuses and mastoid air cells are well aerated. No suspicious lytic or sclerotic osseous lesion is identified. A midline posterior scalp hematoma is again seen at the vertex. IMPRESSION: 1. Rapid interval enlargement of right subdural hematoma with new leftward shift of the normally midline structures by 1.5 cm, subfalcine herniation and likely mild right uncal herniation. 2. Effacement of the right lateral ventricle, compression of the third ventricle and entrapment of the left lateral ventricle. [**2190-5-16**] CXR FINDINGS: Comparison is made to the prior chest radiograph from [**2180-2-8**]. There is an endotracheal tube whose distal tip is almost 10 cm above the carina and high; this could be advanced approximately 2-3 cm for more optimal placement. There is a feeding tube whose distal tip is at the GE junction and the side port is in the lower esophagus. This could be advanced approximately 15-20 cm for more optimal placement. The cardiac silhouette is upper limits of normal. There is a left retrocardiac opacity and left-sided pleural effusion. [**2190-5-18**] CT BRAIN IMPRESSION: 1. Unchanged small extraaxial, likely subdural hematoma overlying the right temporal lobe. 2. New extraaxial, likely epidural fluid collection underlying the right frontal/parietal craniotomy. Increased effacement of right sulci, but unchanged compression of the right lateral ventricle and unchanged mild leftward shift of normally midline structures. 3. Unchanged two foci of right frontal intraparenchymal hemorrhage 4. New minimal intraventricular hemorrhage. [**2190-5-19**] CT Brain: 1. No evidence of acute intracranial hemorrhage. Small residual right temporal subdural hematoma and right frontal intraparenchymal hematoma are stable since first post-operative study. 2. Hypodense right frontoparietal extra-axial collection has steadily increased in size compared to first postoperative study of [**5-16**], [**2189**], as has an associated extracranial, subgaleal collection of similar attenuation. These findings raise concern for ongoing CSF leak. 3. Stable mass effect upon the right hemispheric sulci and right lateral ventricle, with associated 5 mm leftward shift of midline structures. No central herniation. 4. Unchanged left frontal hypodense lesion with hyperdense rim. [**2190-5-19**] CT Brain: Unchanged from previous CT. Brief Hospital Course: Mr. [**Known lastname 805**] was admitted to the neurosurgery service after initial evaluation in the Emergency room. During the course of the next few hours his mental status worsened, a repeat CT of the head showed interveral evolution of his subdural hematoma and the patient was taken to the operating room for evacuation. He underwent a right sided craniectomy for subdural hematoma evacuation. Post operatively he was transferred intubated to the Neurosurgical ICU. He was successfully extubated the following morning. On [**5-19**] there was concern for increased lethargy and he underwent a CT head which showed a slight increase in the collection under the crani site. He was kept in the ICU. Overnight, there was concern for increased lethargy and a CT was once again repeated without change. He remained in the ICU for observation and then was subsequently transferred to SDU on [**5-20**]. A speech and swallow eval was obtained which he passed and his diet was advanced. He remained stable and was ultimately transferred to floor status. Medications on Admission: Zolpidem 50 mg po QHS Amlodipine 5mg po QD HCTZ 25 po QD Doxazosin 40mg po QD Allopurinol 300 po QD Coumadin 2 mg poQD Trandolapril 4 mg po QD Discharge Medications: 1. therapeutic multivitamin Liquid Sig: One (1) Tablet PO DAILY (Daily). 2. senna 8.6 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 3. tramadol 50 mg Tablet Sig: 0.5 Tablet PO Q6H (every 6 hours) as needed for pain. 4. docusate sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2 times a day). 5. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 7. doxazosin 4 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 8. allopurinol 300 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. trandolapril 2 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 11. famotidine 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 13. phenytoin 125 mg/5 mL Suspension Sig: One (1) PO Q8H (every 8 hours). Discharge Disposition: Extended Care Facility: [**Hospital6 85**] - [**Location (un) 86**] Discharge Diagnosis: Right subdural hematoma, acute Brain Compression, requiring surgery Dysphagia Atrial Fibrillation 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: General Instructions ?????? Take your pain medicine as prescribed. ?????? Exercise should be limited to walking; no lifting, straining, or excessive bending. ?????? Increase your intake of fluids and fiber, as narcotic pain medicine can cause constipation. We generally recommend taking an over the counter stool softener, such as Docusate (Colace) while taking narcotic pain medication. ?????? Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, Aspirin, Advil, or Ibuprofen etc. ?????? If you were on a medication such as Coumadin (Warfarin), or Plavix (clopidogrel), or Aspirin prior to your injury, you may safely resume taking this on [**2190-5-30**]. ?????? you have been prescribed Dilantin (Phenytoin) for anti-seizure medicine, take it as prescribed and follow up with laboratory blood drawing in one week. This can be drawn at your PCP??????s office, but please have the results faxed to [**Telephone/Fax (1) 87**]. CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING ?????? New onset of tremors or seizures. ?????? Any confusion, lethargy or change in mental status. ?????? Any numbness, tingling, weakness in your extremities. ?????? Pain or headache that is continually increasing, or not relieved by pain medication. ?????? New onset of the loss of function, or decrease of function on one whole side of your body. Followup Instructions: Follow-Up Appointment Instructions ??????Please call ([**Telephone/Fax (1) 2102**] to schedule an appointment with Dr. [**First Name (STitle) **], to be seen in 4 weeks. ??????You will need a CT scan of the brain without contrast prior to your appointment. This can be scheduled when you call to make your office visit appointment. Completed by:[**2190-5-25**] Name: [**Known lastname 183**],[**Known firstname **] Unit No: [**Numeric Identifier 5954**] Admission Date: [**2190-5-16**] Discharge Date: [**2190-5-25**] Date of Birth: [**2108-5-1**] Sex: M Service: NEUROSURGERY Allergies: Penicillins Attending:[**First Name3 (LF) 40**] Addendum: This pt had a CXR on [**2190-5-23**] which showed pleural effusions and pulmonary edema. He had not interventions for this - repeat imaging today showed improvement per rediology. The pt was cleared for discharge. Brief Hospital Course: This pt had a CXR on [**2190-5-23**] which showed pleural effusions and pulmonary edema. He had not interventions for this - repeat imaging today showed improvement per rediology. The pt was cleared for discharge. Discharge Disposition: Extended Care Facility: [**Hospital6 41**] - [**Location (un) 42**] [**Name6 (MD) **] [**Last Name (NamePattern4) 43**] MD [**MD Number(2) 44**] Completed by:[**2190-5-25**]

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icd9cm

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19560+57064

Discharge summary

report+addendum

Admission Date: [**2102-2-3**] Discharge Date: [**2102-2-27**] Date of Birth: [**2055-5-5**] Sex: M Service: MICU-[**Location (un) **] REASON FOR ADMISSION: Syncope. HISTORY OF PRESENT ILLNESS: This is a 46 year old male with a history of alcoholic and hepatitis C cirrhosis who presented to the [**Hospital6 256**] after being found down covered in feces in an inebriated state. The patient was brought to the Emergency Room where he was found to have a hematocrit of 18. In the Emergency Room he was guaiac positive and nasogastric lavage was negative. He was transfused with 2 units of packed red cells and resuscitated with 4 liters of normal saline. His systolic blood pressure ranged from the 90s to 110s and he was noted to have a temperature of 100.6. A chest x-ray revealed a right middle lobe and right lower lobe pneumonia consistent with aspiration. He received Ceftriaxone and Clindamycin. Of note, the patient states that he felt unwell for two to three days prior to admission with some abdominal pain, nausea, vomiting and diarrhea. He denies hematemesis, coffee ground emesis, bright red blood per rectum, melena, urinary symptoms, abdominal pain, shortness of breath and chest pressure, palpitations, weight changes, or travel. He does admit to having a cough productive of clear sputum and some chills. The reason for his syncopal episode is unclear. [**Name2 (NI) **] does remember drinking quite a large amount of Vodka, feeling lightheaded and then does not remember what happened subsequently. He denies any head trauma. PAST MEDICAL HISTORY: 1. History of alcohol withdrawal with delirium tremens. 2. Alcohol abuse. 3. Right forearm fracture. 3. Status post assault in [**2101-9-7**]. 4. Hepatitis C. 5. Osteomyelitis of the right tibia, status post skin grafting, irrigation and debridement. 6. Status post fractures of the tibia and fibula on the left, Grade 3B open in [**2093**], status post irrigation and debridement and external fixation at [**Hospital 9301**] Hospital in [**Location (un) 86**]. 7. Osteopenia. 8. Scalp laceration on [**2101-3-22**], status post fall. 9. Schizophrenia, unknown. MEDICATIONS ON ADMISSION: None. ALLERGIES: Motrin leads to hives. SOCIAL HISTORY: Drinks approximately 2 pints of Vodka per day for the last 20 years. Tobacco half a pack per day for 30 years. No intravenous drug abuse. Lives with fiance, [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2412**]. Has family members in [**Name (NI) 4565**] and [**State 18250**]. Is homeless, has lived at [**First Name8 (NamePattern2) 2048**] [**Last Name (NamePattern1) **] House. FAMILY HISTORY: Non-contributory. PHYSICAL EXAMINATION ON ADMISSION: Temperature 100.6, heart rate 106, blood pressure 112/55, respirations 17, oxygenating 97% on 2 liters. General: Lying in bed in no apparent distress, asleep but easily arousable. Head, eyes, ears, nose and throat: Pale conjunctiva, mild scleral icterus. Pupils equal, round and reactive to light and accommodation. Extraocular movements intact. Horizontal nystagmus. Normal oropharynx. No evidence of lymphadenopathy. Jugular venous pulsations are flat. Cardiovascular: Tachycardiac, regular, no murmurs, rubs, clicks or gallops. Chest: Rhonchi at the right base, positive egophony. Abdomen: Mildly tender to palpation over the periumbilical area. Liver at 20 cm in the midclavicular line. No splenomegaly appreciated. No fluid wave. Positive bowel sounds, soft. Extremities, 2+ edema bilaterally. Right lower extremity with healed surgical scar. Dorsalis pedis pulses bilaterally palpable. Neurological examination: Cranial nerves II through XII grossly intact, [**4-12**] motor strength of biceps, triceps, hip flexors and extensors. Light touch intact bilaterally, 2+ patellar reflexes bilaterally. LABORATORY DATA: Initial data revealed white blood cell count 14.4, hematocrit 24.5, up from 18.8, platelets 140. Initial arterial blood gas was 7.47, 39, 81 with a lactate of 1.8. Serum alcohol level 409, serum toxicology screen negative. Urinalysis negative. Chem-7 128, 3.7, 85, 28, 20.9, 138, ALT 19, AST 130, amylase 64, alkaline phosphatase 329, total bilirubin 3.4, creatinine kinase 104, lipase 89, INR 1.3. Abdominal ultrasound demonstrates a fatty enlarged liver, small amount of ascites, normal gallbladder, no gallstone, no ductal dilatation. Iron 138, TIBC 155, haptoglobin 158, ferritin 1,026, CRF 119. Initial electrocardiogram shows a sinus rhythm at 130 beats/minute with a normal axis, decreased voltage throughout the precordial leads. Q waves in leads V1 through V3. HOSPITAL COURSE: 1. Gastrointestinal bleed - Most likely upper gastrointestinal bleed given the melena on examination, despite negative nasogastric lavage especially with a patient with a history of extensive history of alcoholic hepatitis with possible portal hypertension. The patient had two large bore intravenous lines placed. The patient was cross-matched for 4 units and transfused 2 units of packed red cells with a hematocrit goal greater than 26. Intravenous proton pump inhibitor was initiated. The patient was made NPO and a gastrointestinal consult was obtained, however, they decided that given the patient's mental status changes and stable hematocrit and hemodynamic stability that the upper and potentially lower gastrointestinal scope could be deferred. The question was again raised after the patient was in the Medical Intensive Care Unit and again the Gastrointestinal Service declined to perform a scope because the patient had mental status changes and wants him to be stable with no additional episodes of bleeding. 2. Infectious disease - From the time of the patient's admission it was suspected that he had a right lower lobe and right middle lobe pneumonia. This was confirmed with serial chest x-rays. A thoracentesis was performed on [**2102-2-21**] at which time 300 cc of serous fluid were drained from the left pleural space. This fluid was felt to be consistent with a transudate overall, despite one of Light's criteria, being positive for exudate, the LDH ratio greater than .6. The SAAG was greater than 1.2, consistent with a transudative fluid secondary to the patient's hypoalbuminemic state and likely portal hypertension. The ascites fluid was also drained on the same date and was also consistent with low protein fluid, consistent with a transudative state or portal hypertension. The patient was treated with a 14 day course of Ceftriaxone and Flagyl as well as a 14 day course of Vancomycin by level. The Vancomycin was added in the Medical Intensive Care Unit given the patient's central line and concern for skin source of infection. Of note, he had low-grade temperatures throughout the majority of his hospital course. Clostridium difficile toxin, A and B were sent and were negative times ten at the time of dictation. There was also concern initially for spontaneous bacterial peritonitis as a source of infection and an ultrasound-guided paracentesis was performed which was negative for evidence for spontaneous bacterial peritonitis with neutrophil count less than 250. Multiple blood cultures were sent, all of which were negative at the time of dictation with the exception of what was thought to be contamination with yeast. Of note, the Ceftriaxone was changed to Levofloxacin for better atypical coverage on [**2102-2-14**] and a full dose of Ceftriaxone was not received, however, a 14 day course of Levofloxacin was received. This antibiotic change was also performed, given that the patient had no evidence of spontaneous bacterial peritonitis. At the time of dictation a definitive source of infection was still not found, however, it was thought that the most likely source would be the lungs and serial chest x-rays showed resolving right lower lobe and right middle lobe pneumonia. Of note, a repeat paracentesis was performed which also was negative in both gram stain and both bacterial and fungal cultures at the time of dictation. 3. Respiratory failure - The patient had a waxing and [**Doctor Last Name 688**] mental status likely secondary to the use of Valium for alcohol withdrawal on the medical floor. He was admitted to the Medical Intensive Care Unit on [**2102-2-6**] with hypercarbic respiratory failure with an initial blood gas of 7.30, 48 and 60. Initially the patient was tried on a CPAP trial, however, this was not successful and the patient continued to be acidotic at 7.29 with a pCO2 persistently at 45 with concern for the patient's ability to protect his airway. To prevent aspiration the head of the bed was kept at greater than 30 degrees, all sedative and psychotropic medications were discontinued. The patient was intubated from [**2102-2-6**] through [**2102-2-24**]. The difficulty in weaning in him was felt to be most likely secondary to massive anasarca and pulmonary edema as indicated by the high levels of positive end-expiratory pressure required to oxygenate the patient as well as the high tidal volumes required to ventilate the patient. After diuresing the patient approximately 15 kg, compared with his initial admission weight, he was finally able to be extubated to first facemask and then on [**2102-2-25**] to 2 liters of nasal cannula, sating at 100%. Subsequent measures to improve oxygenation and ventilation included metered dose inhalers q. 4 hours, aggressive nasotracheal suctioning, initially q. 1 hour. 4. Septic shock - The patient's hemodynamic picture was felt to be consistent with distributive shock secondary to sepsis given that an echocardiogram was performed showing a normal ejection fraction and the patient had markedly improved blood pressure, status post treatment with broad spectrum antibiotics. A Cortisol stimulation test was performed and found that the patient's Cortisol did not rise by greater than 9 and as such she was started on Hydrocortisone, fluids with Cortisone per the recent studies suggesting the benefits of steroid therapy for septic shock. The patient was intermittently placed on Levophed with good effect at maintaining the blood pressure in addition to fluid boluses. 5. Alcohol withdrawal - On the medical floor the patient was placed on a CIWA scale and the day prior to transfer to the Medical Intensive Care Unit received a total of 90 mg of Valium, all additional doses of Valium were held and the patient was allowed to self-taper off of the benzodiazepines. Upon extubation on [**2102-2-24**] he was found to show evidence of Wernicke's encephalopathy with tangential garbled speech and poor cerebellar function. This was his baseline, according to his fiance. Albumin was attempted prior to aggressive diuresis with no effect. 6. Hepatitis - The patient tested positive for hepatitis A exposure and hepatitis C exposure. Hepatitis C viral load was below the lower limits of normal. An ultrasound of the abdomen was performed on [**2102-2-9**] which showed echogenic liver consistent with fatty infiltration, other forms of liver disease and Marfan's liver disease including significant hepatic fibrosis/cirrhosis can not be excluded on the study. Gallbladder wall edema consistent with hepatitis or wild human state, moderate to large amount of ascites most prominent in the left lower quadrant and stable in appearance. Slight echogenic kidneys which may be consistent with chronic parenchymal disease. No hydronephrosis or stones. Moderate ascites. A repeat ultrasound was performed on [**2102-2-20**] which showed an unchanged appearance of the gallbladder. A computerized axial tomography scan of the abdomen and pelvis was performed after extubation on [**2102-2-25**], given the patient's abdominal pain, sludge in the gallbladder, gallbladder wall edema and pericholecystic fluid. In addition, a surgery consult was obtained for concern for acute cholecystitis or cholangitis given the patient's persistently high bilirubins to greater than 10. Trental 4 mg p.o. t.i.d. was attempted and failed for alcoholic hepatitis, despite a discriminate function of less than 32. 7. Coagulopathy - The patient continued to have an INR ranging from 1.6 to 2.2 throughout his hospital stay. That was somewhat refractory to Vitamin K administration. Lupus anticoagulant was negative. Platelets were transfused to greater than 10. Hematocrit transfused to greater than 26. 8. Diarrhea - The patient had profuse diarrhea in the initial period of hospitalization. The Colace was discontinued. Clostridium difficile was checked greater than seven times and was negative. The Clostridium difficile toxin B is still pending at the time of dictation. All other cultures of stool were negative at the time of dictation. 9. Acute renal failure - On [**2102-2-9**] the patient's creatinine was begun to rise from 1.1 to two days later 2.5, to two days later 3.7, to greater than 4. Examination of the urine sediment revealed muddy brown casts consistent with acute tubular necrosis. This was felt to be delayed. Acute tubular necrosis resulting from a period of hypotension when the patient had had a syncopal episode prior to admission. It was not felt that it was prerenal despite the fact that the fractional excretion of sodium was less than 2% and that the patient was found to be fluid responsive when comparing the pulse pressure differential with inspiration and expiration (which is said to be a marker of fluid responsiveness and acute septic shock). A few days after the creatinine began to rise, the patient went into oliguric renal failure producing less than 10 cc of urine per hour, at some points producing less than 5 cc of urine per hour as his creatinine began to rise, while initially the treatment was to use Levophed to keep the mean arterial pressure greater than 70, the transfused hematocrit greater than 30, this was unsuccessful after three days and it was decided to do a Lasix trial, 80 mg t.i.d. of Lasix was initiated with good urine output. Subsequently the patient was placed on 12 mg/hr of Lasix with a resulting urine output of greater than 200 cc/hr. After seven days on the Lasix drip at this dosage, the patient diuresed greater than 12 liters of fluid and returned to his baseline weight of 85 kg after being a maximum of 99 kg, when he was in his state of maximum anasarca. 10. Skin breakdown - Status post being found down in a pile of his own feces, the patient had marked skin breakdown over the buttocks and sacral region. Wound care was provided per Intensive Care Unit protocol and the area was kept clean, dry and intact. The ability to prevent skin breakdown was aided by the massive diuresis and Miconazole powder was changed to Ketoconazole powder with good effect. Of note, the patient also had marked edema of his scrotum and sacrum which benefited form diuresis and ketoconazole powder. 11. Social situation - Given the patient's homeless status, social work consult was obtained. We managed to obtain records from [**Hospital6 1129**] where the patient had been an inpatient as well as from the [**First Name8 (NamePattern2) 2048**] [**Last Name (NamePattern1) **] House where the patient resided off and on. We were also put in touch with his fiance [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2412**], [**Telephone/Fax (1) 53057**] as well as his brother, [**Name (NI) **] [**Name (NI) 32872**], [**Telephone/Fax (1) 53058**] as well as his sister, [**Name (NI) **] [**Name (NI) **] [**Telephone/Fax (1) 53059**]. 12. Fluids, electrolytes and nutrition - An nasogastric tube was placed and a nutrition consult was obtained for nutrition during the patient's period of intubation. Tube feeds were concentrated to avoid volume overload. Nepro at 40 cc/hr was used with low residuals obtained. Of note, the patient did have hypernatremia and free water boluses, approximately 1.5 liters/day were given during the patient's period of aggressive diuresis. 13. Psychiatry - Note that after extubation, the patient had mumbled unintelligible speech given his history of schizophrenia. A psychiatry consult was obtained on [**2102-2-24**] which recommended using Haldol for agitation. The patient had attempted assault one of the physical therapists during a physical therapy session and had a history of attempted assault of various medical personnel. 14. Dysphagia - There was some concern for the patient's ability to protect his airway status post extubation. On [**2102-2-24**], a swallowing evaluation was performed which recommended initiating a p.o. diet, consisting of soft solids and thin liquids, and one to one assistance/supervision at meals with basic precautions, due to the patient's poor cognition. However, overall the patient did quite well in tolerating p.o. diet. 15. Glucose control - The patient was maintained euglycemic with the use of an insulin sliding scale. This completes hospital course covering the dates from [**2102-2-3**] through [**2102-2-25**]. An additional discharge addendum will be dictated at a later time. DR.[**First Name (STitle) **],[**First Name3 (LF) **] 12-AHZ Dictated By:[**Last Name (NamePattern1) 1811**] MEDQUIST36 D: [**2102-2-25**] 16:45 T: [**2102-2-25**] 18:14 JOB#: [**Job Number 53060**] Name: [**Known lastname 9858**], [**Known firstname 63**] Unit No: [**Numeric Identifier 9859**] Admission Date: [**2102-2-3**] Discharge Date: [**2102-3-8**] Date of Birth: [**2055-5-5**] Sex: M Service: MEDICINE ADDENDUM: This covers hospital days [**2102-2-27**] through [**2102-3-8**]. Please see previous interns discharge summary for past medical history and hospital course from admission through [**2-27**]. HOSPITAL COURSE: 1. Gastrointestinal bleed: The patient with melanotic stools at admission. He was followed by GI for this. Following resolution of his altered mental status he had an esophagogastroduodenoscopy. The esophagogastroduodenoscopy did show grade one gastric varices, however, was negative for any acute source of bleeding. The patient initially was prepped for a colonoscopy to further evaluate his gastrointestinal tract, however, he then refused colonoscopy. The patient has no further melena or bright red blood per rectum through his hospital stay and his hematocrits remained stable. 2. Infectious disease: The patient was transferred out of the unit on antibiotics specifically Levaquin for right lower lobe and right middle lobe pneumonia. He was continued on Levaquin for a total of three weeks of therapy. The patient developed a marked leukocytosis. He also had several episodes of hypothermia. He had multiple blood cultures, which were negative. His chest x-ray showed no changes. There was concern for possible SBP. He had previously had two negative taps, but a third tap was done on [**3-3**], which was negative for SBP. He also had an abdominal CT and right upper quadrant ultrasound, which was also negative for any source of infection. The patient continued to have perfuse diarrhea and there was concern for C-difficile colitis. He had multiple C-diff toxins times 11 sent all of which were negative. An additional C-diff sample was sent for a toxin B as opposed to a toxin A. This also was negative. Given the patient's clinical presentation in conjunction with his marked leukocytosis he was started empirically on po Flagyl with plans to treat him empirically for two weeks for question of C-diff colitis. Some component of leukocytosis was thought to be leukemoid reaction related to his severe hepatic disease. 3. Liver disease: The patient with alcoholic hepatitis. He also had serologies positive for hepatitis B and C. He was followed by the Hepatology team. Given his elevated liver function tests he was started on Trental for his alcoholic hepatitis. He was maintained on Trental for concerns for portal hypertension given his severe liver disease and his varices seen on esophagogastroduodenoscopy. He had received Octreotide earlier in the hospital stay. He was started on a low dose beta-blocker, which he tolerated well. The patient had an elevated INR throughout his hospital stay thought to be due to his liver disease. He was started on vitamin K with some improvement in his INR. He had no active bleeding with this. 4. Acute renal failure: Patient with acute renal failure thought to be due to ATN in the setting of hypotension. The patient had converted into a nonoliguric stages and ATN with excellent autodiuresis. His creatinine continued to trend down and he continued to diurese well on his own. His electrolytes were followed closely and did not exhibit any abnormalities. 5. Cardiovascular: The patient persistently tachycardic. Multiple electrocardiograms showed him to be in normal sinus rhythm. No clear source of pain, infection or other reversible etiology localized. Tachycardia was thought to be most likely due to his volume status, decreased intravascular volume. He did have a repeat cardiac echocardiogram, which showed no significant change from his previous echocardiogram and no evidence of tachycardia myopathy. 6. Diarrhea: The patient continued to have perfuse diarrhea. As mentioned above multiple C-diffs were sent, which were negative. He refused colonoscopy to better evaluate his gastrointestinal tract. He was started on Cholestyramine and also on a high fiber diet with prn cilium in the hope of bulking his stool. 7. Integument: Patient with extensive skin breakdown over his buttocks and sacral region with a stage one sacral decubitus ulcer. The patient received wound care evaluation with frequent dressing changes. Skin scar was complicated by his perfuse diarrhea, however, rectal tube was placed, which resulted in some improvement. DISCHARGE STATUS: The patient is discharged to acute rehab. DISCHARGE CONDITION: Stable. DISCHARGE DIAGNOSES: 1. Pneumonia. 2. Gastrointestinal bleed. 3. Septic shock. 4. Grade one gastric varices. 5. Portal hypertension. 6. Respiratory failure. 7. End stage liver disease. 8. Hepatitis C. 9. Hepatitis A. 10. Alcohol abuse. 11. Wernicke's encephalopathy. 12. Coagulopathy. 13. Acute renal failure/ATN. 14. Sacral decubitus ulcer. DISCHARGE MEDICATIONS: 1. Zinc oxide cod liver oil 40% ointment applied topical prn. 2. Cilium packets t.i.d. prn diarrhea. 3. Thiamine 100 mg q day. 4. Folic acid 1 mg q day. 5. Multivitamin q day. 6. Pantoprazole 40 mg q day. 7. Ketoconazole 2% cream b.i.d. prn. 8. Cholysteramine 4 gram packet one packet po t.i.d. 9. Subq heparin. 10. Aluminum magnesium hydroxide prn. 11. Flagyl 500 mg t.i.d. times 12 days. DISCHARGE FOLLOW UP: The patient is to follow up in the [**Hospital 5313**] Clinic in addition to his normal primary care physician follow up. [**First Name8 (NamePattern2) 46**] [**Doctor First Name 258**], M.D. [**MD Number(1) 259**] Dictated By:[**Last Name (NamePattern1) 9097**] MEDQUIST36 D: [**2102-3-8**] 08:13 T: [**2102-3-8**] 08:33 JOB#: [**Job Number 9860**]

[ "707.0", "070.54", "584.5", "507.0", "518.81", "285.1", "295.62", "571.2", "785.52" ]

icd9cm

[ [ [] ] ]

[ "34.91", "54.91", "96.6", "96.72", "96.04", "45.13" ]

icd9pcs

[ [ [] ] ]

21986, 21995

2688, 2728

22016, 22352

22375, 22787

2208, 2251

17836, 21964

22799, 23190

217, 1578

2743, 4666

1601, 2181

2268, 2671

23,476

132,921

28917

Discharge summary

report

Admission Date: [**2145-9-20**] Discharge Date: [**2145-9-30**] Date of Birth: [**2074-5-19**] Sex: F Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 371**] Chief Complaint: Pedestrian struck by a motor vehicle. Major Surgical or Invasive Procedure: PLASTIC SURGERY: 1. Right lower extremity debridement of skin, subcutaneous tissue and muscle. 2. Tibialis anterior fascial turnover flap. 3. Local advancement rotational flap. 4. Full-thickness skin graft 1200 cm2. 5. Vacuum-assisted closure dressing. 6. Complex wound closure of stellate lacerations of the scalp. ORTHOPEDIC SURGERY: 1. Irrigation and debridement of significantly contaminated and degloved wound. 2. Intramedullary nailing with a 8 x 240 mm Synthes nail. 3. Application of external fixation of the foot for supporting the extremity off the bed. 4. Fasciotomies, anterior and lateral compartment. History of Present Illness: 71 year old female pedestrian with mental retardation who was struck by a motor vehicle. She was taken to an area hospital where she was found to have a subarachnoid hemorrhage and open comminuted distal tib fib fracture. She was then transported to [**Hospital1 18**] via [**Location (un) 7622**] for continued trauma care. Past Medical History: Mental retardation Mandibular fx Family History: Noncontributory. Physical Exam: PE: Vitals: T97.8 HR88 BP 170/P HEENT: Lept parietal occipital laceration with currant oozing and underlying hematoma, no depression noted NECK: C-collar in place, unable to evaluate due to decreased mental status CHEST: breaht sounds bilaterally, no evidence of flail chest ABD: FAST negative, no gross eccymosis, guaiac negative, decreased rectal tone GU: Foley passed with urine (no gross blood) EXT: open, grossly degloved RLE tib/fib fracture by visualization with palpable distal pulses; muslce and bone exposed from knee to ankle, no other gross deformity noted NEURO: patient intuabted and unresponsive GCS: PTP Pertinent Results: AP CHEST, 2:14 P.M. [**9-20**] HISTORY: Trauma. Rule out pneumothorax. IMPRESSION: AP chest read in conjunction with a chest CT performed 20 minutes later and dictated separately. Mild mediastinal widening in the right lower paratracheal region, evaluated by CT scanning, is not pathologic. Dependent atelectasis seen on the CT scan is only suggested on this study. There is no pneumothorax or pleural effusion. The heart is normal size. Thoracic aorta is tortuous but not dilated. ET tube in standard placement. Nasogastric tube passes into the stomach and out of view. TECHNIQUE: Non-contrast head CT. HEAD CT WITHOUT INTRAVENOUS CONTRAST: Small amount of blood is demonstrated within the sulci of the right frontal lobe towards the vertex consistent with a tiny subarachnoid hemorrhage. No other intra- or extra-axial hemorrhage, mass effect, or shift of midline structures is demonstrated. Scattered areas of low attenuation are seen within the white matter of both cerebral hemispheres, likely representing chronic microvascular infarction. Differentiation of the [**Doctor Last Name 352**] and white matter is otherwise preserved. Prominence of the sulci and ventricles bilaterally consistent with age appropriate involutional change. The basal cisterns are unremarkable. A large left parietal scalp hematoma is present. No fractures noted. Polypoid mucosal thickening is seen involving the right-sided ethmoid air cells, and moderate circumferential mucosal thickening is present within the right maxillary sinus. There is complete opacification of the right frontal sinus. Remaining visualized paranasal sinuses and mastoid air cells are clear. IMPRESSION: 1. Small subarachnoid hemorrhage and large left parietal scalp hematoma. 2. Chronic microvascular infarction involving the subcortical white matter of both cerebral hemispheres. 3. Chronic sinus disease involving the right frontal, ethmoid, and maxillary sinuses. CT Abdomen/Pelvis INDICATION: Hematoma status post pedestrian versus automotive collision. Evaluate for intra-abdominal or thoracic pathology. COMPARISON: None. TECHNIQUE: Axial MDCT images were obtained from the lung apices to the pubic symphysis following the administration of 130 cc intravenous Optiray. Additionally, coronal and sagittal reformatted images are provided. CONTRAST: Intravenous non-ionic contrast was administered due to the rapid rate of bolus injection required for this examination. CT OF THE CHEST WITH INTRAVENOUS CONTRAST: The heart, pericardium, and great vessels appear within normal limits. There is no evidence of mediastinal hematoma. An endotracheal tube is in place. The central airways are patent. There is no pathologic appearing mediastinal, hilar, or axillary lymphadenopathy. There is bilateral dependent atelectasis predominantly involving the lower lobes. No pneumothorax or pleural effusion. A 2-mm nodule is seen within the right middle lobe (series 2, image 28). CT OF THE ABDOMEN WITH INTRAVENOUS CONTRAST: There is mild hypodensity within the periportal regions, consistent with periportal edema. The liver, spleen, gallbladder, pancreas, adrenal glands, and kidneys appear otherwise unremarkable without evidence of solid organ injury. The aorta is normal in caliber and contour. There is no free fluid and no free air within the abdomen. The large and small bowel loops are normal in caliber, and there is no abnormal bowel wall thickening. There is marked gastric distention, with nasogastric tube in place within the stomach. There is no mesenteric or retroperitoneal lymphadenopathy. CT OF THE PELVIS WITH INTRAVENOUS CONTRAST: The bladder contains a Foley catheter and air consistent with Foley catheter insertion. The uterus demonstrates a lobulated, heterogeneous contour, likely indicating uterine fibroids. There is sigmoid diverticulosis without evidence of surrounding inflammation. The rectum appears unremarkable. There is no free fluid and no free air within the pelvis. No pathologic-appearing pelvic or inguinal lymph nodes are identified. BONE WINDOWS: Bone windows demonstrate no evidence of fracture. MULTIPLANAR REFORMATS: Coronal and sagittal reformations demonstrate no evidence of solid organ injury or fracture. IMPRESSION: 1. No evidence of traumatic injury to the thorax or abdomen and pelvis. 2. Bilateral atelectasis. 3. Gastric distention with nasogastric tube in place. 4. 2-mm nodule within the right middle lobe. If there is no history of prior malignancy, one-year followup with CT is recommended to assess stability. If there is a history of prior malignancy, three-month CT followup is recommended. CT C-Spine No fracture or subluxation is present. Mild degenerative changes are noted at C5-6 with narrowing of the intervertebral disc space, endplate cystic changes, and osteophytic spurring. Visualized outline of thecal sac is unremarkable. The soft tissues appear unremarkable. An endotracheal tube is seen within the trachea, and an orogastric tube is present within the esophagus. Incidental note is made of small gas bubbles within both subclavian veins bilaterally. Visualized lung apices are clear. Periapical lucency is demonstrated around a right upper molar ([**Doctor First Name **] #2) with osseous erosion superiorly to involve the floor of the right maxillary sinus, as well as apparent defect within the bone medial to this molar which could represent focal thinning versus a possible fracture medial. IMPRESSION: 1) No fracture or subluxation. 2) Focal defect in the bone medial to a right upper molar ([**Doctor First Name **] #2) which may be secondary to focal thinning vs. a fracture. Periapical lucency may be secondary to periapical granuloma, cyst, or abscess. TECHNIQUE: Non-contrast head CT scan. COMPARISON STUDY: [**2145-9-20**]. Head CT scan, interpreted by Drs. [**Last Name (STitle) **] and [**Name5 (PTitle) **] as revealing "stable small subarachnoid hemorrhage near the right vertex; stable left frontoparietal subgaleal hematoma; high attenuation fluid within the right nasal cavity is consistent with blood." FINDINGS: In the twelve hour interval between CT scans, there is little change in the extent of the small right vertex subarachnoid hemorrhage. The subgaleal hematoma appears to have reduced slightly in size, with some decrease in the gas within it. Also, the opacification of the right nasal cavity is considerably less extensive. However, the right maxillary antral opacification still remains essentially complete. No other interval changes are appreciated. IMPRESSION: Mild interval improvement in some abnormalities, as noted above. [**2145-9-20**] 11:56PM LACTATE-3.1* [**2145-9-20**] 09:26PM GLUCOSE-225* UREA N-12 CREAT-0.5 SODIUM-137 POTASSIUM-4.0 CHLORIDE-107 TOTAL CO2-22 ANION GAP-12 [**2145-9-20**] 09:26PM WBC-9.4# RBC-3.24* HGB-9.7* HCT-26.5* MCV-82 MCH-29.9 MCHC-36.6* RDW-14.3 [**2145-9-20**] 09:26PM PLT COUNT-183 [**2145-9-20**] 09:26PM PT-14.7* PTT-33.9 INR(PT)-1.3* Blood Urine CSF Other Fluid Microbiology Recent Last Day Last Week Last 30 Days All Results Hide Comments From Date To Date Hematology COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct [**2145-9-29**] 04:54AM 11.4* 3.19* 9.3* 27.4* 86 29.2 34.0 14.3 615*# BASIC COAGULATION (PT, PTT, PLT, INR) PT PTT Plt Ct INR(PT) [**2145-9-29**] 04:54AM 615*# BASIC COAGULATION (FIBRINOGEN, DD, TT, REPTILASE, BT) Fibrino [**2145-9-21**] 02:04AM 185 Chemistry RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap [**2145-9-29**] 04:54AM 113* 11 0.6 137 4.4 102 28 11 ENZYMES & BILIRUBIN ALT AST LD(LDH) CK(CPK) AlkPhos Amylase TotBili DirBili [**2145-9-20**] 02:20PM 43 MODERATELY HEMOLYZED CHEMISTRY TotProt Albumin Globuln Calcium Phos Mg UricAcd Iron [**2145-9-29**] 04:54AM 8.6 2.4 NEUROPSYCHIATRIC Phenyto [**2145-9-23**] 04:43AM 12.3 Brief Hospital Course: Patient admitted to the Trauma service. She underwent a series of imaging, including a CT head with contrast, CT c-Spine, CT chest/abdomen/pelvis, Chest Xray, and lower extremity films (see Pertinent results section). Orthopedics, Plastics and Neurosurgery were consulted because of her injuries. She was taken to the operating room by Orthopedics for repair of her right leg injuries. An external fixator was placed; this was removed on HD #8. Plastic Surgery was involved because of the extent of the degloving injury to her right lower extremity; this was debrided and closed in the operating room during her IM nail by Orthopedics. Her weight bearing status was upgraded on HD #10 to WBAT, dependent position RLE 15 minutes at a time 4 times/day. Plastic surgery has recommended continuing po Keflex for at least 1 more week. Neurosurgery was consulted because of subarachnoid hemorrhage; she was loaded with Dilantin, serial head CT imaging was done and ICP bolt was not indicated. She will need to follow up with Neurosurgery in 4 weeks for repeat head imaging. She was started on Lopressor for elevated heart rate and blood pressure; she was not on any medication for her blood pressure prior to this hospitalization. Once at rehab and if she remains stable, it is likely that this can be discontinued. Vascular surgery was also consulted to assess for any vessel injury to her right lower extremity it was determined that her limb was not threatened. Physical and Occupational therapy were consulted and have recommended short rehab stay. Social work was closely involved with patient for coping and emotional support. Medications on Admission: ALL: NKDA Discharge Medications: 1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection [**Hospital1 **] (2 times a day). 2. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO twice a day: hold for loose stools. 4. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q 3-4 H PRN as needed for pain. 5. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain. 6. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 7. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times a day). 8. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO BID (2 times a day). 9. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO Q6H (every 6 hours) as needed for constipation. 10. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily). 13. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): hold for HR <60 &/or SBP 110. 14. Insulin Regular Human 100 unit/mL Solution Sig: One (1) Injection four times a day as needed for per sliding scale. 15. Keflex 500 mg Capsule Sig: One (1) Capsule PO four times a day for 7 days. Discharge Disposition: Extended Care Facility: [**Hospital 5503**] [**Hospital **] Hospital Discharge Diagnosis: s/p Pedestrian Struck Scalp laceration Subarachnoid hemorrhage Degloving injury right leg Right tibial fibula fracture Discharge Condition: Good Discharge Instructions: You may weight bear as tolerated on your right leg; only allowing your right leg to be in a dependent (down) position for 15 min at a time 4 times/day until you follow up with Plastics next Friday. Followup Instructions: Follow up with Plastic Surgery next Friday in clinic, call [**Telephone/Fax (1) 5343**] for an appointment. Follow up with Dr. [**Last Name (STitle) 1005**], Orthopedics, in 2 weeks. Call [**Telephone/Fax (1) 1228**] for an appointment. Follow up in Trauma clinic in 2 weeks, call [**Telephone/Fax (1) 6429**] for an appointment. Follow up with Dr. [**Last Name (STitle) **], Neurosurgery, in 4 weeks. Call [**Telephone/Fax (1) 1669**] for an appointment. Inform the office that you will need a repeat head CT scan for this appointment. Completed by:[**2145-9-30**]

[ "852.00", "424.0", "821.31", "319", "823.92", "911.0", "958.8", "873.0", "E814.7", "920", "891.2" ]

icd9cm

[ [ [] ] ]

[ "86.63", "83.45", "96.71", "99.04", "83.09", "79.66", "78.17", "79.36", "86.59", "86.74", "96.59", "78.67" ]

icd9pcs

[ [ [] ] ]

13215, 13286

10092, 11728

351, 995

13449, 13456

2097, 10069

13702, 14273

1423, 1441

11789, 13192

13307, 13428

11755, 11766

13480, 13679

1456, 2078

274, 313

1023, 1350

1372, 1407

31,603

107,403

32894

Discharge summary

report

Admission Date: [**2131-2-27**] Discharge Date: [**2131-3-1**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 4765**] Chief Complaint: chest pain Major Surgical or Invasive Procedure: none History of Present Illness: 89 yo W with PMH of HTN, dyslipidemia transferred from OSH after presenting with severe back pain and severe L-sided CP that woke her from sleep. Pt was at home with caretaker when she began complaining of sharp, pleuritic midscapular pain. EMS came, gave her ASA x 2, and SLNG x1 with resolution of pain. She initially went to Caritas [**Hospital6 5016**], had 1" nitropaste, more SLNG, 80po KCL, was found to be hypotensive to 80/46. EKG @ OSH was rate 100, nml axis, prolonged PR interval, small STE in III. . She had CTA at OSH that was notable for Type A aortic dissection. She was then transferred to [**Hospital1 18**] for further management. . In ED, VS: T:99 HR96 135/85 16 96RA. She was given 10mg x 1, 20mg x1 and 40mg x 1 of IV labetalol without decrease in systolic bp. Therefore patient was started on labetalol gtt with good effect. EKG showed prolonged PR intervals, new STE in II, aVF. Seen by CT surgery who felt patient was not surgical candidate due to age and multiple medical problems. . On review of symptoms, family 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. Does report hx of bleeding hemorrhoids. All of the other review of systems were negative. . *** Cardiac review of systems is notable for absence of chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. Past Medical History: HTN Hypercholesterolemia Dementia Afib . Cardiac Risk Factors: -Diabetes, +Dyslipidemia, +Hypertension Social History: NC Family History: NC Physical Exam: VS: T 99.9, BP 130/80, HR 92, RR 21, O2 97% on RA on labetalol 0.3mg/min gtt Gen: Elderly female in NAD, resp or otherwise. Oriented x1. Mood, affect appropriate. Pleasant. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. Neck: Supple with JVP of 8 cm. 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. + crackles at b/l bases; No wheezes, or rhonchi. Abd: Obese, soft, NTND, No HSM or tenderness. No abdominial bruits. Ext: No c/c/e. No femoral bruits. pulses equal in b/l arms Skin: No stasis dermatitis, ulcers, scars, or xanthomas. Pulses: Right: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP Left: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP Pertinent Results: CXR: IMPRESSION: 1. Tortuous aorta and widened mediastinum is consistent with type A aortic dissection as seen on outside chest CTA. 2. No evidence of CHF or pleural effusions. Brief Hospital Course: 89 yo W w PMH of HTN, hyperlipidemia transferred from OSH with Type A aortic dissection. . Mrs [**Last Name (STitle) 76563**] was found to have a Type A dissection confirmed on CTA at OSH. CXR here with widened mediastinum. CT surgery evaluated her; she was not a surgical candidate due to age and comorbidities. She opted for medical management in discussion with her family. Her code status was DNR/DNI. She was treated with IV labetalol. On the morning of [**3-1**] she awoke feeling well, however, she then developed hypotension and afib. She then became asystolic, and was pronounced dead shortly thereafter. Her family (daughters) were notified, and arrived shortly after her death. . # Communication: Patient and daughter [**Name (NI) **], cell ([**Telephone/Fax (1) 76564**] Medications on Admission: Atenolol 50' Imdur 30' Lexapro 20' Potassium 10' ASA 81' Megace 40' Zocor 10' Trazodone 50' Cyclobenzaprine 10' Senna daily Colace 100' MVI Discharge Medications: NA Discharge Disposition: Expired Discharge Diagnosis: Aortic Dissection Discharge Condition: Deceased Discharge Instructions: NA Followup Instructions: NA

[ "458.9", "426.10", "441.02", "401.9", "455.8", "294.8", "V64.1", "427.5", "427.31", "272.4" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

4191, 4200

3182, 3973

272, 278

4261, 4271

2981, 3159

4322, 4327

2058, 2062

4164, 4168

4221, 4240

3999, 4141

4295, 4299

2077, 2962

222, 234

306, 1895

1917, 2022

2038, 2042

48,676

196,921

35595

Discharge summary

report

Admission Date: [**2183-4-14**] Discharge Date: [**2183-4-28**] Date of Birth: [**2107-11-2**] Sex: M Service: MEDICINE Allergies: Aspirin / Coumadin / Iodine-Iodine Containing / Ciprofloxacin Attending:[**First Name3 (LF) 613**] Chief Complaint: Altered mental status Major Surgical or Invasive Procedure: none History of Present Illness: MR. [**Known lastname 13474**] is a 75 YOM with paraplegia, neurogenic bladder with chronic indwelling foley changed every month, ESRD on HD T/Th/S, CAD s/p stent, multiple decubs w/ skin flap recent hospitalization in [**Month (only) 1096**] for scrotal infection with subcutaneous tissue gas from traumatic foley that was not thought to be Fourniers who presents now from [**Hospital3 26615**] hospital with mental status changes. Per discussion with wife on the phone pt has been having HA off and on for the past year. However, he developed HA last night and thought he should go to the hospital. Wife said she didn't think he should go to the hospital for a HA. So he took a sleeping pill and tylenol and when he woke up (the day of admission) he said his HA was better. He stated he felt "so good." But then developed awful HA again and vomited. He then took a nap and when he woke he said he thought she should call an ambulance because of ambulance. She states he wasnt acting like himself, very "out of it." Usually very polite and clear. Per daughter there is also concern for vision loss. The patient was looking for the toilet paper and could not see it even though it was in front of him and thats why they took him to the hospital. . Per records from [**Hospital3 26615**], he was altered but intermittantly cooperative. He had a head CT that was negative for acute stroke. No infectious work up was started and he was given 1 Gm CTX empirically and sent to [**Hospital1 18**] for further management. He was also noted to have hypertension to 180s and his nephrologist was called who reports that this is normal for him prior to HD. He was given 10 mg IV labetolol. Prior to this he began having tremors and was given ativan and 1 gm dilantin for concern for seizures prior to transfer. . In the ED, initial VS: 97.2 76 114/64 16 96% 4L NC. The patient was noted to be somnolent with purulent urine coming from foley. Initially the Ed resident was going to do LP and pt was premedicated with 1 mg ativan. But the patient's mental status improved and given the foley findings UTI was presumed more likley thatn meningitis so LP was deferred. He was noted on labs to have K+ 5.9. EKG reportedly showed no pk T waves. He is due for HD tomorrow. He was given 1 amp Ca gluconate, D50 and 10 U insulin. He was given 1 L IVF. Vital signs prior to transfer were: 92 181/78 18 95% RA. . ROS: Per wife: [**Name (NI) **] has had some loose BM that are normal for him. Has chronic productive cough - white. Has not been complaining of hematuria or blood in BM. Not complaining of pain. No sensation from the waste down. Past Medical History: ESRD - initiated on HD [**3-7**] Sacral Decubitus Ulcer HTN CAD s/p stent Colostomy Chronic Renal Insufficiency anemia Skin flap for coccygeal decub ([**2179**]) Paraplegic x 35 years following fall from tree (cant feel past umbilicus) CVAs x 3 Renal Cancer s/p open left partial nephrectomy ([**2180**]) R renal artery stenosis s/p R renal artery stent in 08 Neurogenic bladder/bowel with chronic indwelling foley urethral stricture left ureteral stent placement ([**2181-4-13**]) Embolization of L renal vessel Social History: Pt lives at home with his wife. Was previously at [**Location (un) 5028**] for rehab 2 months ago, prior to that was living at [**Hospital 8612**] hospital. Denies smoking, etoh, other drugs. [**Name6 (MD) **] visiting RN once a day. Wife helps with other ADLs. Family History: Negative for kidney, bladder or prostate cancer. Physical Exam: Admission Physical Exam: VS: 97.6 167/79 107 20 97% RA GENERAL: aggitated, writhing in bed pulling at lines. Oriented x 0, repeating the same sentence (unable to understand words) HEENT: NC/AT, left pupil constricts, right pupil pt refused to open, MMM NECK: Supple, no thyromegaly, no JVD HEART: RRR, no obvious murmurs LUNGS: CTA bilat, resp unlabored, but difficult to get good posterior lung exam ABDOMEN: ostomy in place with formed brown stool. Soft/NT/ND, no rebound/guarding. EXTREMITIES: thin lower extremities. WWP, no c/c/e, 2+ peripheral pulses. SKIN: large ischeal decub ulcers bilat with exudate and erythema around borders, appear infected. sacral ulcer with intack skin ovrlying, erythematous, no exudate NEURO: Pt not cooperative with exam, grabbing and pulling, not following commands, A and O x 0. Moving upper extremities spontaneously Pertinent Results: [**2183-4-14**] 07:11PM BLOOD WBC-12.4* RBC-4.12* Hgb-12.7* Hct-40.0 MCV-97# MCH-30.9 MCHC-31.8 RDW-15.2 Plt Ct-388 [**2183-4-14**] 07:11PM BLOOD Neuts-93.5* Lymphs-3.1* Monos-2.0 Eos-0.1 Baso-1.3 [**2183-4-14**] 07:11PM BLOOD PT-12.0 PTT-21.9* INR(PT)-1.0 [**2183-4-14**] 07:11PM BLOOD Glucose-171* UreaN-69* Creat-5.5* Na-133 K-5.9* Cl-94* HCO3-21* AnGap-24* [**2183-4-14**] 07:11PM BLOOD ALT-10 AST-14 CK(CPK)-28* AlkPhos-94 TotBili-0.1 [**2183-4-14**] 07:11PM BLOOD Lipase-76* [**2183-4-14**] 07:11PM BLOOD CK-MB-3 [**2183-4-14**] 07:11PM BLOOD cTropnT-0.43* [**2183-4-14**] 07:11PM BLOOD Calcium-9.1 Phos-8.2*# Mg-2.7* [**2183-4-14**] 07:23PM BLOOD Lactate-2.8* [**2183-4-14**] 08:25PM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.015 [**2183-4-14**] 08:25PM URINE Blood-SM Nitrite-NEG Protein-600 Glucose-150 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-LG [**2183-4-14**] 08:25PM URINE RBC-13* WBC->182* Bacteri-FEW Yeast-NONE Epi-0 [**2183-4-14**] 08:25PM URINE WBC Clm-MANY Pertinent [**2183-4-15**] 08:20AM BLOOD CK(CPK)-766* [**2183-4-15**] 08:20AM BLOOD Lipase-29 [**2183-4-15**] 08:20AM BLOOD CK-MB-6 cTropnT-0.46* [**2183-4-15**] 08:20AM BLOOD Albumin-3.1* [**2183-4-15**] 08:20AM BLOOD CRP-128.3* [**2183-4-16**] 06:10AM BLOOD CK(CPK)-560* [**2183-4-16**] 06:10AM BLOOD CK-MB-5 cTropnT-0.68* [**2183-4-16**] 02:20PM CEREBROSPINAL FLUID (CSF) WBC-67 RBC-[**Numeric Identifier 81017**]* Polys-91 Lymphs-8 Monos-1 [**2183-4-16**] 02:20PM CEREBROSPINAL FLUID (CSF) WBC-33 RBC-8900* Polys-84 Lymphs-16 Monos-0 [**2183-4-16**] 02:20PM CEREBROSPINAL FLUID (CSF) TotProt-1730* Glucose-36 [**2183-4-17**] 08:20AM BLOOD VitB12-1746* [**2183-4-17**] 08:20AM BLOOD TSH-1.5 Microbiology: - Blood cultures 4/18 x2, [**4-15**] x1, [**4-16**] x2, [**4-21**] x2: negative [**2183-4-14**] - Urine culture [**4-14**]: URINE CULTURE (Final [**2183-4-15**]): MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH FECAL CONTAMINATION. - Urine culture [**4-15**]: URINE CULTURE (Final [**2183-4-16**]): MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. <10,000 organisms/ml. - CSF Cryptococcal antigen [**4-16**]: negative - CSF/LP culture [**4-16**]: GRAM STAIN (Final [**2183-4-16**]): 2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. This is a concentrated smear made by cytospin method, please refer to hematology for a quantitative white blood cell count. FLUID CULTURE (Final [**2183-4-22**]): NO GROWTH. FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. VIRAL CULTURE (Preliminary): NO VIRUS ISOLATED. - CSF HSV PCR [**4-16**]: not detected - RPR [**4-17**]: NR - Sputum expectorated [**4-20**]: GRAM STAIN (Final [**2183-4-20**]): <10 PMNs and <10 epithelial cells/100X field. 1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S). QUALITY OF SPECIMEN CANNOT BE ASSESSED. RESPIRATORY CULTURE (Final [**2183-4-22**]): SPARSE GROWTH Commensal Respiratory Flora - Sputum [**4-23**]: GRAM STAIN (Final [**2183-4-23**]): >25 PMNs and <10 epithelial cells/100X field. 3+ (5-10 per 1000X FIELD): MULTIPLE ORGANISMS CONSISTENT WITH OROPHARYNGEAL FLORA. RESPIRATORY CULTURE (Final [**2183-4-25**]): MODERATE GROWTH Commensal Respiratory Flora. Imaging: [**2183-4-15**] - CXR: Central venous catheter tip projected over SVC. No acute consolidation. [**2183-4-16**] - TTE: The left atrium and right atrium are normal in cavity size. There is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (LVEF>55%). There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The descending thoracic aorta is mildly dilated. 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 mildly thickened. Mild (1+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. The estimated pulmonary artery systolic pressure is normal. IMPRESSION: Mild symmetric left ventricular hypertrophy with preserved global and regional biventricular systolic function. Mild mitral regurgitation. [**2183-4-17**] - CT head w/o contrast: There is no evidence of intra- or extra-axial hemorrhage, mass effect or midline shift seen. Specifically, no evidence of acute subarachnoid hemorrhage seen. There is mild brain atrophy and small vessel disease. No evidence of mass effect seen. No large areas of brain edema identified. IMPRESSION: No evidence of acute hemorrhage. Specifically, no acute subarachnoid hemorrhage is seen. It should be noted that chronic hemorrhage may not be detected with CT and MRI may be more sensitive. No mass effect or hydrocephalus. [**2183-4-18**] - CXR: A right pleural effusion is small. The nasogastric tube tip is projected over the expected location of the body of the stomach, its side hole at the gastroesophageal junction. A wide-bore right-sided central venous catheter tip is obscured by spinal fixation rods. A right posterior lower rib fracture is healed. Mild cardiomegaly is stable. IMPRESSION: 1. Small right pleural effusion. 2. Nasogastric tube tip projected over the stomach, but its side hole is at the expected location of gastroesophageal junction. - EEG: ABNORMALITY #1: There were occasional bursts of medium-amplitude delta slowing seen over the left posterior quadrant. ABNORMALITY #2: The background is a poorly organized [**6-3**] Hz theta frequency rhythm during the most awake portions of the recording. BACKGROUND: The background is a poorly organized [**6-3**] Hz theta frequency rhythm during the most awake portions of the recording. HYPERVENTILATION: Was not performed due to the patient's lack of cooperation. INTERMITTENT PHOTIC STIMULATION: Did not produce activation of the record. SLEEP: The patient was awake and drowsy during this recording but did not attain stage II of sleep. CARDIAC MONITOR: Showed a generally regular rhythm between 70-80 bpm. IMPRESSION: This is an abnormal routine EEG in the awake and drowsy states due to the presence of occasional bursts of medium-amplitude delta slowing seen over the left posterior quadrant, consistent with a focal region of subcortical dysfunction. In addition, the poorly organized background of [**6-3**] Hz theta frequency is consistent with a diffuse mild encephalopathy, most commonly seen with medication effect, metabolic disturbance, or infection. There were no epileptiform features seen. [**2183-4-19**] - CXR: Patchy increased density consistent with atelectasis or consolidation is again demonstrated in the lower left lung. There is streaky density in the lower right lung consistent with subsegmental atelectasis as well. A small right pleural effusion persists. Mediastinal structures are stable, as well. Bilateral [**Location (un) 931**] rods remain in place. A nasogastric tube and double-lumen right internal jugular catheter remains in place. The sidehole of the nasogastric tube appears to have advanced slightly, below the level of the diaphragm. Compared with the previous study, parenchymal density in the lower left chest appears slightly worse. IMPRESSION: The nasogastric tube appears to have advanced slightly. Increased density in the left lung suggests developing pneumonia. [**2183-4-21**] - EEG: ROUTINE SAMPLING: Shows a mostly [**4-1**] Hz disorganized delta rhythm background with frequent bursts of anteriorly predominant triphasic waves. In addition, occasional multifocal sharp discharges seen over the bifrontal or bioccipital regions with shifting predominance. At times, these discharges had a generalized distribution. SPIKE DETECTION PROGRAMS: There were 897 entries in these files which again included multifocal sharp and sharp and slow wave discharges seen in a bifrontal, bioccipital region with shifting predominance, and also generalized discharges were seen. SEIZURE DETECTION PROGRAMS: There were six entries in these files which included frequent multifocal sharp and spike and slow wave discharges seen in a bifrontal, bioccipital, and generalized distribution occasionally with a shifting predominance. In addition, there were frequent anteriorly predominant triphasic waves. PUSHBUTTON ACTIVATIONS: There were no entries in these files. SLEEP: There were no definite features of sleep architecture. CARDIAC MONITOR: Showed a generally regular rhythm with an average rate of 80-90 bpm. IMPRESSION: This is an abnormal continuous EEG due to the presence of a [**4-1**] Hz disorganized delta background with frequent triphasic waves. This pattern is consistent with a moderate diffuse encephalopathy commonly seen with medication effect, metabolic disturbance, or infection. In addition, the presence of frequent multifocal sharp and sharp and slow wave discharges, seen in a bifrontal, bioccipital, and generalized distribution with shifting predominance, is indicative of a multifocal or generalized cortical irritability, with epileptogenic potential. There were no clear electrographic seizures seen. - CT head w/o contrast: No acute intracranial abnormality. No changes in comparison to prior study dated [**2183-4-17**]. [**2183-4-22**] - EEG: ROUTINE SAMPLING: Shows a [**4-1**] Hz generalized theta frequency background with frequent periods of additional superimposed [**1-30**] Hz delta slowing and brief one second bursts of generalized suppression. In addition, there are frequent frontally predominant triphasic waves and multifocal sharp and sharp and slow wave discharges in a generalized, bifrontal, and bioccipital distribution with a shifting predominance. Overall, the sharp interictal discharges are higher amplitude and not as frequent compared to the previous recording, however, they are occasionally rhythmic at 1-2 Hz lasting for one to two seconds. In addition, there are numerous electrographic seizures most frequently characterized by generalized [**12-29**] Hz rhythmic sharp and sharp and slow wave discharges lasting between 10 and 30 seconds and often obscured by significant muscle artifact seen broadly over the left hemisphere. These correlated with left facial grimacing, irregular leftward head jerking, and left arm and shoulder jerking seen on video which will be described in more detail in the pushbutton and seizure files below. However, the record does improve after 11am after which the seizures and discharges become less prominent. SPIKE DETECTION PROGRAMS: There were 778 entries in these files which included many high amplitude sharps in a generalized bifrontal and bioccipital distribution with shifting predominance. SEIZURE DETECTION PROGRAMS: There were 37 entries in these files which included a significant number of the pushbutton events described below. However, there were an additional eight electrographic and clinical seizures which were not caught by pushbutton which, again, were associated with left facial grimace, leftward head jerking, and left arm and shoulder posturing which were associated electrographically with 2-5 Hz generalized spike and wave rhythmic discharges lasting between five and ten seconds which were sometimes preceded by a period of generalized suppression of the background. These events occurred at 9:09 a.m., 9:25 a.m., 9:33 a.m., 9:58 a.m., 10 a.m., 16:40, 19:07, and 23:02. PUSHBUTTON ACTIVATIONS: There were 21 entries in these files. The majority of the pushbutton events were for clinical episodes of irregular left head jerking, left facial grimace, and left arm posturing with shoulder twitching which were most frequently associated with significant muscle artifact broadly across the left hemisphere and generalized rhythmic [**12-29**] Hz sharp discharges lasting between 10 and 30 seconds best represented by the pushbutton events occurring at 17:53 a.m., 8:55 a.m., 9:44 a.m., 10:03 a.m., 10:12 a.m., and 10:23 a.m. Overall, there were 22 similar leftsided focal motor seizures associated with this generalized rhythmic sharp activity seen in the pushbutton files. However, there was one example seen at 7:58 a.m. during which the patient appeared to be lying on his right side and had a rightward irregular head jerking motion which was associated electrographically with 1-2 Hz generalized discharges with a left hemispheric predominance. Overall, the seizures appear to become more brief and the focal motor twitching less prominent in the later pushbutton files. SLEEP: The patient demonstrated no normal features of sleep architecture. CARDIAC MONITOR: Showed a generally regular rhythm. However, it was notably tachycardic between 100-110 bpm. IMPRESSION: This is an abnormal continuous EEG due to the presence of 31 seizures which were mostly characterized by irregular head twitching to the left, left facial grimace, and left shoulder and arm jerking. They were associated electrographically with generalized rhythmic [**12-29**] Hz sharp discharges lasting between 10 and 30 seconds. Sometimes these electrographic seizures were preceded by brief periods of generalized suppression of the background with a leftsided predominance. Rarely, the seizures manifest with right-sided head jerking with the same electrographic features. In addition, overall, the background activity during the majority of the record is a disorganized [**4-1**] Hz delta rhythm with additional superimposed periods of [**12-29**] Hz delta slowing and brief periods of generalized suppression of the background with frequent anteriorly predominant triphasic waves suggestive of a moderate diffuse encephalopathy commonly seen with medication effect, metabolic disturbance, and infection. Interictally, there are also more frequent high amplitude interictal sharp discharges with a generalized bifrontal and bioccipital distribution with a shifting predominance. While the initial portion of the tracing appears to be significantly more epileptiform and more encephalopathic compared to the previous day's tracing, there is overall improvement of the background beginning at 11 a.m. with the frequency of the triphasic waves and epileptiform discharges significantly decreasing which is associated with a decreased frequency of seizures and briefer duration of seizures throughout the rest of the recording. Note is made of a regular but tachycardic EKG strip which may be further evaluated with a 12-lead EKG. [**2183-4-23**] - EEG: ROUTINE SAMPLING: Shows a mostly [**6-3**] Hz disorganized theta frequency background with occasional bursts of frontally predominant triphasic waves. In addition, there are occasional generalized and multifocal sharp discharges seen over the bifrontal or bioccipital region with shifting predominance. However, compared to the previous tracing, there are fewer bursts of triphasic waves and less frequent sharp discharges. During the routine sampling at 8:52 AM, there was a brief period during which the patient was observed to have an irregular jerking motion of his head to the left and leftsided facial grimace which was associated with significant muscle artifact and R>L generalized slowing seen on EEG lasting for six to eight seconds which likely represents a clinical focal motor seizure. SPIKE DETECTION PROGRAMS: There were 1,000 entries in these files which included occasional generalized frontally predominant triphasic waves, generalized and multifocal sharp waves in a bifrontal and bioccipital distribution with shifting predominance. SEIZURE DETECTION PROGRAMS: Included 10 automatic seizure detections which included one event occurring at 19:19 PM during which the patient had irregular movement of his head and irregular left arm jerking motions which was associated with significant muscle artifact on the EEG as well as R>L delta slowing lasting between eight and ten seconds which is suspicious for a clinical seizure, though slighlty different than his previous seizures. In addition, there were two other events occurring at 16:19 and 19:17 during which the patient was observed to have irregular side to side head movements which was not associated with any clear change on EEG which likely represents myoclonus. PUSHBUTTON ACTIVATIONS: There were no entries in these files. CONTINUOUS EEG: Shows frequent brief periods of [**12-29**] Hz rhythmic low-amplitude generalized sharp discharges lasting between five and ten seconds, occurring at 8:59, 9:01, 9:28, 10:05, and 10:21 AM. Because there was no video available for review, it is unclear whether or not there was any clinical change associated with these events. SLEEP: The patient did not demonstrate any clear features of normal sleep architecture. CARDIAC MONITOR: Showed a generally regular rhythm with an average rate of 80-90 bpm. IMPRESSION: This is an abnormal continuous EEG due to the presence of a single clinical seizure occurring at 8:52 AM during which the patient was observed to have leftward head jerking motions and left facial grimace which was associated with R>L generalized slowing on EEG which likely represents a clinical seizure. In addition, there were a few equivocal events, during which side to side head movements were seen in the Seizure Detection programs, which were less likely seizures and more likely myoclonus. Overall, compared to the previous day's tracing, the frequency of seizures is significantly decreased. In addition, the background activity of [**6-3**] Hz theta with occasional superimposed anteriorly predominant triphasic waves is consistent with a diffuse mild encephalopathy commonly seen with medication effect, metabolic disturbance, or infection. Furthermore, there are occasional multifocal interictal sharp discharges seen over the bifrontal and bioccipital region with shifting predominance as well as occasionally in a generalized distribution. Finally, as described above in the Continuous EEG section, there are occasional brief periods of rhythmic [**12-29**] Hz low amplitude generalized sharp activity which do not meet criteria for an electrographic seizure but are suggestive of generalized increased cortical irritability. Overall, compared to the previous day's tracing, there is significant improvement as the background has improved and the frequency of ictal and interictal activity has significantly decreased. Brief Hospital Course: Mr. [**Known lastname 13474**] is a 75 YOM with ESRD on HD, paraplegia with chronic indwelling foley catheter who presented from OSH with mental status changes, found to have seizure activity eventually made CMO on the floor expiring on [**2183-4-28**] #. Altered mental status, [**1-29**] delirium and post-ictal state. Delirium is likely [**1-29**] infectious etiology (see below). He was initially noted to be very agitated and combative, attmpting to pull out his HD line, colostomy bag and chronic indwelling Foley catheter, requiring restraints (pharmacologic and 2-point), on arrival. Initially patient was covered empirically for meningitis, infected decubitus ulcer, UTI, and ? osteomyelitis (but most likely chronic) upon arrival to the hospital although cultures were unrevealing. He was started on vancomycin, ceftriaxone, ampicillin, and acyclovir. He underwent LP with CSF that was negative but had gross blood. CT head without contrast did not show intracranial hemorrhage. He could not undergo MRI because of hardware. Ampicillin was discontinued as CSF bacterial culture was negative. Subsequently, he was switched to HAP/aspiration pneumonia coverage as his culture results return and developed more respiratory symptoms. Acyclovir was stopped as HSV PCR returned negative. His altered mental status only improved slightly but never back to baseline per his family members. [**Name (NI) **] was later noted to have seizure activities, which likely explain part of his somnolence toward the later part of his hospital course. Of note, his TSH, B12, and RPR were wnl. He was ultimately made CMO in the MICU, therefore, prompting discontinuation of all antibiotics as well as dialysis. A morphine drip was started on the floor on [**4-26**], and the patient expired on [**4-28**]. #. Seizure. New. ? metabolic/infectious vs. new intracranial lesions not detected by non-contrast CT head. There was initial question of seizure from the OSH. However, patient did well in the beginning of hospital course without signs of seizure, but did have an episode of right arm rigidity and decreased responsiveness, prompting neurology consult and initial EEG monitoring. Later on [**2183-4-21**], patient was noted to have left [**Hospital1 **] eye deviation with nystagmus with involuntary tonic clonic movement of his head and neck. He received IV Ativan with improvement. Neurology was called to the bedside, and patient was subsequently placed on continuous EEG monitoring and Dilantin loading. By [**2183-4-22**], additional seizure activities were witnessed by EEG as well as observation while he was in dialysis. Lacosemide was added to his antiepileptic regimen, and he was switched to fosphenytoin. His antiepileptic medications were switched to IV and were dosed renally. Per EEG report, after loading of the dilantin and lacosemide, seizure activities decreased. He was later transferred to the MICU for close monitoring given hypoxia, which could be [**1-29**] underlying seizure activities. Discussion was held with family with regarding to having patient undergo contrast CT given unclear etiology of his new seizure. However, the family deferred on CT head with contrast. He could not undergo MRI given hardware in his back. While in the MICU, despite familys decision to transition to CMO, patient was kept on antiepileptic medications for comfort. As above, he was started on a morphine drip on the floor and subsequently expired #. Hospital acquired pneumonia/Aspiration pneumonia. This was noted on [**2183-4-19**], a day after placement of the NGT. NGT was placed in the setting of patient's refusal to take any po meds, food, and uncontrolled HTN on IV antihypertensives. Previous CXR was not convincing for pneumonia in the setting of negative pulmonary symptoms and signs. Antibiotics were readjusted to vancomycine, cefepime, and Flagyl to cover fro HAP and aspiration pneumonia. He was later noted to be hypoxic on RA, leading to a trigger on [**4-22**]. He was placed on NRB, but was unable to be weaned. Family was informed. Patient was transferred to the MICU for more concern of hypoxia in the setting of pneumonia and seizure, requiring more intensive monitoring, but patient was DNR/DNI. He was suctioned, and copious amount of sputum was removed with improvement of his oxygenation. He was able to be weaned to 3L NC upon return to the floor, although by that time, the family has decided that he should be CMO. Therefore, antibiotics were discontinued upon his return to the floor on [**2183-4-25**]. #. Hypoxia. This was noted on [**2183-4-22**] during the trigger during which patient was trigger. It was concerning in the setting of HAP/Aspiration pneumonia in the setting of possible persistent seizure. Patient was transferred to the MICU with NRB. He was suctioned with improvement. He was weaned to 3L NC prior to transfer to the floor. Abx, however, were stopped given his CMO status upon return to the floor on [**2183-4-25**], and the patient subsequently expired as above. #. Upper GI bleeding. After patient was in MICU, he was noted to have + bloody secretion from the NGT. Aspiration showed blood. He did not receive any blood product while in the MICU. His Hct trended down but then stabilized. His ASA and Plavix were discontinued given persistent slow ooz. It is most likely this is [**1-29**] stress ulcer. He continued to have very small amount of melanic output from his ostomy bag. NGT was removed prior to return from the MICU given CMO status, and pt expired as abovee. #. Hypertension, [**1-29**] inadequate control with IV antihypertensives. His SBP was consistently in the 180s-200s during the initial part of his hospital course as he refused to take any oral medications in the setting of delirium. IV labetolol, IV hydralazine, and his routine dialysis could not control his HTN. Medical team was concern for his risk of intracranial bleeding in the setting of uncontrolled SBP, so an NGT was placed on [**2183-4-18**]. Once his regular oral antihypertensives were administered, his SBP improved to the 130s-140s, which per his PCP was his baseline. However, his antihypertensives were discontinued after his family transitioned him to CMO, and subsequently expired as above on [**4-28**]. #. Sinus tachycardia. Most likely [**1-29**] acute inflammatory process mentioned above and hyperactive delirium. He recieved IVF initially prior to the NGT placement for possible dehydration. See above for treatments #. Nutrition. He received D5 1/2 NS initially until NGT was placed. Then, he received a brief periods of tube feed, until seizure activities were noted. He was kept NPO after seizures were observed, to prevent further aspiration. #. Elevated troponin and CK. EKG showed peaked T wave but no ST changes other than prominent J points in precordial leads. CKMB flat. ? recent NSTEMI as he does have history of CAD with stent in RCA (per PCP [**Name9 (PRE) **] covering physician [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 42600**]). Possibly from ? seizure in OSH or straining against the restraints. Cardiology consult thought this is [**1-29**] ESRD and also in the setting of sinus tachycardia. He was initially kept on ASA, Plavix, home statin, and antihypertensives until UGIB and transition to CMO. #. Hyperkalemia. Noted on initial presentation. Likely in the setting of ESRD needing HD. #. ESRD on HD. T/Th/Sat. Newly initiated HD this year with tunneled catheter. He was followed closely by nephrology. 2-point restraints were placed to prevent self-removal of HD line. He was kept on home meds when with NGT in place as he had refused all po meds prior to NGT placements. During MICU stay, his HCPs decided to transition patient to CMO with discontinuation of his dialysis. #. Stage 3 decubitus ulcers. In bilateral ischial as well as tronchateric sites. Wound nurse [**First Name (Titles) **] [**Last Name (Titles) 4221**] and thought that these are chronic wounds without significant signs of infection, although wounds are deep enough to possibly cause osteomyelitis (could not be evaluated as he has + hard [**Location (un) **] for MRI, and bone scan was not pursued due to other more likely infectious sources). Pain medication was administered prior to dressing change each day. He continued to receive wound care for comfort. Medications on Admission: Venofer HD Vit C 500 mg [**Hospital1 **] Ambien 5 mg HS Tums PRN Tylenol 325 mg Q 4 PRN Amlodipine 10 mg Q day Bicitra 60 mg TID Lotrisone cream Doxazosin 1 mg HS Epogen with HD Ferrous sulfate 325 mg [**Hospital1 **] Hydralazine 50 mg TID Imdur 30 mg ER Q day Metoprolol 50 mg Q day nephrocaps Q day Nitroquick PRN SL Plavix 75 mg Q day Pravastatin 40 mg Q day Renvela 800 mg TIDAC Discharge Medications: Expired Discharge Disposition: Expired Discharge Diagnosis: expired Discharge Condition: expired Discharge Instructions: expired Followup Instructions: expired [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]

[ "707.03", "V45.82", "V10.52", "E879.6", "518.81", "414.01", "285.1", "780.39", "578.9", "585.6", "707.24", "599.0", "349.82", "403.91", "276.7", "V45.11", "996.64", "507.0", "596.54", "344.1" ]

icd9cm

[ [ [] ] ]

[ "39.95", "03.31", "96.6", "38.93" ]

icd9pcs

[ [ [] ] ]

32148, 32157

23218, 31683

343, 349

32208, 32217

4772, 7346

32273, 32404

3831, 3881

32116, 32125

32178, 32187

31709, 32093

32241, 32250

3921, 4753

7379, 23195

282, 305

377, 3000

3022, 3536

3552, 3815

24,163

179,718

4533

Discharge summary

report

Admission Date: [**2158-5-2**] Discharge Date: [**2158-5-17**] Date of Birth: [**2083-8-18**] Sex: F Service: NSU HISTORY OF PRESENT ILLNESS: The patient is a 74-year-old woman, with a complicated medical history which includes a meningioma resection in [**2143**], [**2152**], breast cancer with lumpectomy in [**2154**] and [**2136**] with metastasis to the liver, and an AV fistula that was embolized in [**2156-3-1**] and then again in [**2156**]. The patient is again admitted for repair of AV fistula. The patient has been complaining of increased occipital pain due to this AV fistula. PHYSICAL EXAM: She appears her stated age. She is awake, alert and oriented x 3. Cardiac is regular rate and rhythm. No murmur, rub or gallop. Her lungs are clear to auscultation. Abdomen soft, nontender, nondistended, with a midline scar. Extremities - no clubbing, cyanosis or edema. HOSPITAL COURSE: She is admitted status post craniotomy and resection of an AV fistula on [**2158-5-2**] by Dr. [**Last Name (STitle) 1132**]. She underwent suboccipital crani for repair of this AV fistula without intraop complication. Postop, her vital signs are stable. She is afebrile. She is awake, alert. EOMS are full. Face is symmetric. Her strength is [**4-5**] in all muscle groups. Her tongue is midline. Her dressing is clean, dry and intact. She was in the recovery room overnight. She remained neurologically stable and was transferred to the regular floor on postop day 1. She was awake, alert and oriented x 3. EOMS full. No drift. Her strength was full in all muscle groups. Her dressing was clean, dry and intact. On [**2158-5-5**], the patient's O2 requirements started to increase. She was 94 percent with a 50 percent face mask. Chest x-ray on [**2158-5-5**] showed worsening left lower lobe opacity which may relate to atelectasis or pneumonia. The patient also had increase in the left pleural effusion at the time. On [**5-6**], the patient continued to have increasing O2 requirements with shortness of breath. Her SAT's were 88 percent on room air. She was following commands and answering all questions. She did have bibasilar rales. She was given 10 mg of IV Lasix and had a repeat chest x-ray on [**5-6**] which showed increase in mild CHF with no pleural effusion. She was treated with Lasix with good diuresis. The patient's respiratory status continued to decline and; therefore, a pulmonary consult was obtained no [**2158-5-9**]. Pulmonary recommended antibiotic coverage for her pneumonia, and due to the patient's complicated allergy history to IV antibiotics, the patient was covered with aztreonam, and then linezolid was added due to risk of MRSA. The patient's O2 requirements continued to be high. She was still on the 50 percent face mask with SAT's 92 percent, and then 94 percent on 3 liters, 88 percent on room air. Chest x-ray continued to show worsening pneumonia, multilobar pneumonia, and pulmonary continued to follow the patient carefully. ID was also involved when on [**2158-5-13**], the patient developed a rash. ID recommended continuing aztreonam and linezolid for a 14-day course for this complicated pneumonia, and the patient was screened for MRSA. So far, the MRSA screen has come back negative. The patient also had a CTA to rule out pulmonary embolism which was negative. The patient's rash was kind of a papular that comes and goes, usually after her dose of antibiotics. The ID staff was aware of this, but recommended continuing the IV antibiotics at this time. The patient was treated with Benadryl for the rash, and ID recommended trying to finish the course of antibiotics for her pneumonia. Currently, she was weaned to 3 liters of nasal cannula oxygen with her SAT's 96-97 percent. DISCHARGE MEDICATIONS: She continued on aztreonam 2,000 mg IV q 8 h, linezolid 600 mg IV q 12 h, both day 10 of 14 days, so the patient has 4 more days of antibiotics for this pneumonia. 1. Metoprolol 12.5 mg po bid--hold for heart rate less than 60, SBP less than 120. 2. Oxycodone 5 mg po q 4 h prn. 3. Miconazole powder 2 percent 1 application tid prn. 4. Femara 2.5 mg po qd. 5. Keppra 500 mg po bid. 6. Colace 100 mg po bid. 7. Benadryl 25 po prn rash. 8. Hydralazine 20 mg po q 6 h prn SBP greater than 150. CONDITION ON DISCHARGE: Stable. FOLLOW UP: She will follow-up with Dr. [**Last Name (STitle) 1132**] in 2 week's time. [**Name6 (MD) **] [**Last Name (NamePattern4) 1359**], [**MD Number(1) 1360**] Dictated By:[**Last Name (NamePattern1) 6583**] MEDQUIST36 D: [**2158-5-17**] 10:40:54 T: [**2158-5-17**] 11:14:54 Job#: [**Job Number 19322**]

[ "997.3", "486", "197.7", "428.0", "V10.3", "437.3" ]

icd9cm

[ [ [] ] ]

[ "39.53", "88.41", "00.14" ]

icd9pcs

[ [ [] ] ]

3822, 4318

929, 3798

634, 911

4364, 4694

164, 618

4343, 4352

18,599

169,259

21170

Discharge summary

report

Admission Date: [**2197-5-24**] Discharge Date: [**2197-6-1**] Date of Birth: [**2129-3-18**] Sex: M Service: CSU HISTORY OF PRESENT ILLNESS: This is a 68-year-old gentleman with known aortic stenosis admitted to an outside hospital in early [**Month (only) 116**] with complaints of increasing shortness of breath and chest heaviness. The patient was found to be in CHF. The patient was transferred to the [**Hospital1 190**] for cardiac catheterization. At that time, cardiac catheterization showed an aortic valve area of 0.85 cm squared with a peak gradient of 40 mmHg and LVEDP of 22, ejection fraction of 40 percent, a 40 percent left circumflex stenosis, and diffuse plaque in the LAD. The patient was referred to Dr. [**Last Name (STitle) **] for an aortic valve replacement. PAST MEDICAL HISTORY: 1. Hypertension. 2. Hypercholesterolemia. 3. Type 2 diabetes. 4. Peripheral vascular disease. 5. History of osteomyelitis in the right foot. 6. Nocturnal leg cramps. 7. Neuropathy. 8. Status post bilateral cataract surgery. 9. Status post left rotator cuff surgery. SOCIAL HISTORY: The patient lives alt home with his wife. [**Name (NI) **] denied tobacco use. Denied ETOH use. ALLERGIES: The patient has no known drug allergies. MEDICATIONS: 1. Zestril 10 mg p.o. q.d. 2. Lipitor 40 mg p.o. q.d. 3. Lantus insulin 40 units q.a.m., 30 units q.p.m. 4. Humalog sliding scale. 5. Enteric coated aspirin 81 mg p.o. q.d. 6. Actos 30 mg p.o. q.d. 7. Quinine 260 mg p.o. q.d. 8. Lasix 40 mg p.o. q.d. HOSPITAL COURSE: The patient was admitted to the [**Hospital1 346**] on [**2197-5-24**], one day prior to going to the Operating Room for hemodynamic optimization. The patient was taken to the Operating Room on [**2197-5-25**] with Dr. [**Last Name (STitle) **] for an aortic valve replacement with a 21 mm [**Last Name (un) 3843**]-[**Doctor Last Name **] pericardial valve. Please see the operative note for full details. Total cardiopulmonary bypass time was 120 minutes, cross clamp time 81 minutes. The patient was transferred to the Intensive Care Unit in stable condition. At the end of the operation, the patient developed atrial arrhythmias. The patient was started on an Amiodarone drip. The patient required low-dose Levophed for maintaining adequate systolic blood pressure. The patient's hematic indices were good with good cardiac output. The patient was weaned and extubated from mechanical ventilation on his first postoperative day. The patient's pulmonary artery catheter was removed on postoperative day number one. On postoperative day number two, the patient was found to have a platelet count in the 70s. Heparin antibody was sent which was subsequently negative. The patient was started on Lopressor and continued on Amiodarone. The patient's hematocrit was 24. The patient was transfused 1 unit of packed red blood cells. The evening of postoperative day number two and postoperative day number three, the patient developed atrial fibrillation. The patient was given additional IV Lopressor and he converted to sinus rhythm. The patient continued on his Lasix and Lopressor, remained in sinus rhythm, started on a heparin drip for anticoagulation. [**Last Name (un) **] consulted on the patient due to his diabetes, recommended continuing the patient's Lantus. On postoperative day number four, the patient was transferred from the Intensive Care Unit to the regular part of the hospital where he began working with Physical Therapy. The patient's epicardial pacing wires were removed without incident. The patient was started on Coumadin. By postoperative day number six, the patient was able to ambulate 500 feet and climb one flight of stairs with Physical Therapy. Also, on postoperative day number six, in the early morning, the patient's left peripheral IV which the heparin infusion had been going had infiltrated. The patient was found to have an edematous arm. The IV was removed and the arm was elevated at that time. The patient had normal capillary refill with normal sensory and motor function, Over the course of the day, the edema decreased. The arm became ecchymotic. The heparin drip was discontinued. By postoperative day number seven, the patient was cleared for discharge to home. CONDITION ON DISCHARGE: The temperature max was 98.8, pulse 80, sinus rhythm, blood pressure 109/41, respiratory rate 16, room air, oxygen saturation 97 percent. The laboratory data revealed a white blood cell count 7.1, hematocrit 26.7, platelet count 226,000, potassium 4.5, BUN 18, creatinine 1.1. The patient's weight on [**2197-6-1**] was 112 kilograms. The patient was 107 kilograms preoperatively. Neurologically, the patient was awake, alert, and oriented times three. The heart revealed a regular rate and rhythm without rub or murmur. Breath sounds were clear bilaterally. The abdomen was obese, positive bowel sounds, soft, nontender, nondistended. Sternum incision revealed that the staples were intact, clean, and dry. There was no erythema or drainage. The sternum was stable. Bilateral lower extremities were warm and well perfuse. There was [**1-13**]+ pitting edema. The left upper extremity from the midforearm to the midupper arm was ecchymotic in the medial and posterior portion with three small blisters in the medial portion of the arm. The capillary refill was less than two seconds. The strength was equal to the right side and sensation was intact. The patient denied any pain. There was no warmth. DISCHARGE MEDICATIONS: 1. Lopressor 25 mg p.o. b.i.d. 2. Colace 100 mg p.o. b.i.d. 3. Enteric coated aspirin 325 mg p.o. q.d. 4. Percocet 5/325 one to two p.o. every four to six hours p.r.n. 5. Protonix 20 mg p.o. q.d. 6. Amiodarone 400 mg p.o. q.d. times one month. 7. Actos 30 mg p.o. q.d. 8. Lipitor 40 mg p.o. q.d. 9. Lasix 40 mg p.o. b.i.d. times ten days and then Lasix 40 mg p.o. q.d. 10. Potassium chloride 20 mEq p.o. b.i.d. times ten days. 11. Coumadin 2.5 mg p.o. on [**2197-6-1**]. The INR will be checked on [**2197-6-2**] by the visiting nurse and the results will be called to the patient's cardiologist, Dr.[**Name (NI) 56122**], office with further INR checks and Coumadin dosing per Dr. [**First Name (STitle) **]. 12. Lantus and Humalog insulin per the sliding scale. DISPOSITION: The patient is to be discharged to home in stable condition. DISCHARGE DIAGNOSIS: 1. Aortic stenosis. 2. Status post aortic valve replacement. 3. Postoperative atrial fibrillation. 4. Type 2 diabetes mellitus. 5. Neuropathy. 6. Hypercholesterolemia. 7. Hypertension. 8. Peripheral vascular disease. FOLLOW UP: The patient is to follow-up with his cardiologist, Dr. [**First Name (STitle) **], in one to two weeks in the office and by the phone on [**2197-6-2**] for his Coumadin dosing. The patient is to follow-up with his primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 12246**], in one to two weeks. The patient is to follow- up with Dr. [**Last Name (STitle) **] in two weeks with an appointment on [**Hospital Ward Name 121**] II prior to his appointment with Dr. [**Last Name (STitle) **] for staple removal. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 1714**], MD 2229 Dictated By:[**Doctor Last Name 56123**] MEDQUIST36 D: [**2197-6-1**] 14:44:05 T: [**2197-6-1**] 15:38:07 Job#: [**Job Number 56124**]

[ "357.2", "443.9", "427.31", "424.1", "E878.8", "997.1", "250.60", "424.0", "428.0" ]

icd9cm

[ [ [] ] ]

[ "89.64", "38.91", "35.21", "39.61", "38.93", "88.72", "99.04" ]

icd9pcs

[ [ [] ] ]

5553, 6432

6453, 6672

1553, 4289

6684, 7468

164, 810

832, 1100

1117, 1535

4314, 5530

23,706

174,249

46535

Discharge summary

report

Admission Date: [**2200-6-30**] Discharge Date: [**2200-7-4**] Date of Birth: [**2134-1-20**] Sex: F Service: MEDICINE Allergies: Codeine / Bactrim / Sulfa (Sulfonamides) Attending:[**First Name3 (LF) 2160**] Chief Complaint: dyspnea Major Surgical or Invasive Procedure: none History of Present Illness: 66 yoF w/ a h/o Severe COPD, OSA, and diastolic heart failure as well as HTN, DM II and alzhemiers dementia presents with acute dyspnea. She is unable to provide a full history. She does not know when her dyspnea started, she does not know if she is orthopneic. She denies cough currently or with any of her dyspneic episodes. She denies chest pain, lower extremity edema, abd pain, constipation / diarrhea or other symptoms. Good PO intake per patient. She states that she lives at home by herself and that her friend fills her pill box and helps her take her medications. She is not sure if she uses her inhalers but she states that she uses everything that her friend helps her take. In the ED, 97.0 ax 110 150/100 40 95% continuous nebulizer. She received Methylprednisone 125mg IV, levofloxacin 750mg IV and magnesium 2gms with IV NS 500cc. Past Medical History: Obstructive Sleep Apnea (on BiPAP at night) COPD (last spirometry [**2200-6-16**] FVC 0.82 (40%), FEV1 0.4 (28%), FEV1/FVC 49 (70%) Last intubation [**8-20**]. Multiple ICU admissions for BiPAP. On [**3-17**].5 L by NC at home and BiPAP at night (14/10).) diastolic HF (EF 75%) DM2 HTN GERD Hyperlipidemia Morbid Obesity (BMI 51) Schizophrenia Depression Alzheimer's Dementia s/p R ankle ORIF Social History: 40 pack-year history of smoking, quit 10 years ago, no alcohol, no drug use. Family History: non contributory Physical Exam: GEN: AOx 3. HEENT: JVP unable to assess, upper airway sounds- wheezes audible without stethescope, no stridor CARD: SEM [**2-19**] @ USB w/o radiation PULM: diffuse mild wheezes bilaterally, very poor air movement, paradoxial breathing, prolonged expiratory phase ABD: soft, obese, NT, ND, no masses or organomegaly EXT: WWP, [**1-15**]+ non pitting pedal edema Some baseline dementia Pertinent Results: [**2200-7-4**] 06:15AM BLOOD WBC-10.9 RBC-4.78 Hgb-11.0* Hct-36.1 MCV-76* MCH-23.0* MCHC-30.4* RDW-17.3* Plt Ct-313 [**2200-6-30**] 10:30PM BLOOD WBC-20.9* RBC-5.21 Hgb-11.8* Hct-41.1# MCV-79* MCH-22.6* MCHC-28.6* RDW-17.0* Plt Ct-355 [**2200-7-1**] 06:22AM BLOOD Neuts-97.1* Lymphs-1.0* Monos-0* Eos-0 Baso-0 Myelos-2.0* NRBC-1* [**2200-6-30**] 10:30PM BLOOD Neuts-90.9* Bands-0 Lymphs-5.4* Monos-2.5 Eos-1.0 Baso-0.2 [**2200-7-1**] 06:22AM BLOOD Hypochr-NORMAL Anisocy-2+ Poiklo-2+ Macrocy-NORMAL Microcy-2+ Polychr-1+ Ovalocy-1+ Ellipto-2+ [**2200-6-30**] 10:30PM BLOOD PT-11.5 PTT-20.7* INR(PT)-1.0 [**2200-7-4**] 06:15AM BLOOD Glucose-78 Creat-0.6 Na-142 K-3.9 Cl-99 HCO3-36* AnGap-11 [**2200-6-30**] 10:30PM BLOOD Glucose-186* UreaN-15 Creat-0.8 Na-139 K-5.8* Cl-99 HCO3-30 AnGap-16 [**2200-6-30**] 10:30PM BLOOD CK(CPK)-86 [**2200-6-30**] 10:30PM BLOOD CK-MB-NotDone cTropnT-<0.01 proBNP-376* [**2200-7-3**] 06:25AM BLOOD Mg-2.2 [**2200-7-2**] 05:55AM BLOOD Calcium-8.8 Phos-3.9 Mg-2.5 [**2200-7-1**] 06:22AM BLOOD Calcium-9.2 Phos-4.2 Mg-2.7* [**2200-7-3**] 10:02AM BLOOD Type-ART pO2-59* pCO2-65* pH-7.41 calTCO2-43* Base XS-12 [**2200-6-30**] 10:34PM BLOOD Type-ART pO2-84* pCO2-79* pH-7.27* calTCO2-38* Base XS-5 [**2200-6-30**] 10:27PM BLOOD Glucose-181* Lactate-1.0 Na-142 K-4.3 Cl-97* [**2200-6-30**] 10:27PM BLOOD Hgb-12.2 calcHCT-37 O2 Sat-95 [**2200-7-1**] 02:57AM URINE Color-Yellow Appear-SlHazy Sp [**Last Name (un) **]->1.030 [**2200-7-1**] 02:57AM URINE Blood-TR Nitrite-NEG Protein-100 Glucose-NEG Ketone-TR Bilirub-SM Urobiln-1 pH-5.5 Leuks-NEG [**2200-7-1**] 02:57AM URINE RBC-[**3-19**]* WBC-0-2 Bacteri-RARE Yeast-NONE Epi-0-2 RenalEp-0-2 [**2200-7-1**] 2:57 am URINE Site: CATHETER **FINAL REPORT [**2200-7-2**]** URINE CULTURE (Final [**2200-7-2**]): NO GROWTH. [**Known lastname **],[**Known firstname 247**] M [**Medical Record Number 98820**] F 66 [**2134-1-20**] Radiology Report CHEST (PORTABLE AP) Study Date of [**2200-6-30**] 10:01 PM [**Last Name (LF) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] [**2200-6-30**] SCHED CHEST (PORTABLE AP) Clip # [**Clip Number (Radiology) 98821**] Reason: please assess for pna [**Hospital 93**] MEDICAL CONDITION: 66 year old woman with sob REASON FOR THIS EXAMINATION: please assess for pna Final Report SINGLE VIEW OF THE CHEST DATED [**2200-6-30**] HISTORY: 66-year-old woman with shortness of breath; assess for pneumonia. FINDINGS: Single bedside AP examination labeled "erect" with excessive lordotic positioning, is compared with semi-upright study dated [**2200-4-27**]. There is more marked cardiomegaly with pulmonary vascular congestion and blurring, indicative of interstitial edema, as well as right greater than left pleural effusions. There is no overt alveolar edema or focal consolidation. Airspace opacity at the right lung base likely represents a combination of atelectasis and effusion; pneumonic consolidation at this site cannot be excluded. IMPRESSION: CHF with right effusion and right basilar atelectasis, significantly worse since [**2200-4-27**]. DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 7593**] Approved: WED [**2200-7-2**] 9:39 PM Imaging Lab [**Known lastname **],[**Known firstname 247**] M [**Medical Record Number 98820**] F 66 [**2134-1-20**] Cardiology Report ECG Study Date of [**2200-6-30**] 9:57:46 PM Sinus tachycardia Consider left atrial abnormality Low precordial lead QRS voltages Modest ST-T wave changes These findings are nonspecific but clinical correlation is suggested Since previous tracing of [**2200-4-27**], no significant change Read by: [**Last Name (LF) **],[**First Name3 (LF) 177**] W. Intervals Axes Rate PR QRS QT/QTc P QRS T 106 168 76 332/[**Telephone/Fax (2) 98822**] Brief Hospital Course: Ms [**Known lastname 35914**] was admitted to the ICU for respiratory distress and treated for a severe COPD flare and acute on chronic diastolic heart failure. She was treated with albuterol, atrovent, O2, Bipap, steroids. She rapidly improved after the inital 24 hours. Thereafter, advair and spiriva were restarted. Plan to complete 5 day course of levofloxacin. Patient is currently full code as discussed with her friend and health care proxy is her friend [**Name (NI) **] [**Name (NI) 1456**] ([**Telephone/Fax (1) 98823**]. Lasix dose was increased to 40 mg (20 mg is the home dose) wih good diuresis and improvement. She was transiently hypotensive in ER and responded to fluids. Slowly home meds were reintroduced. At discharge the dose of hydralazine is lower than the home dose with a normal BP. Her home regimen is lisinopril 40mg daily, hydral 50mg tid and norvasc 10mg daily. Leukocytosis: trended downward with treatment of COPD. Abnormal differential was noted. Please refer above. Defer to PCP to recheck and follow up. Schizophrenia/dementia: on resperidone, aricept. The dose of fluoxetine is conflicting. Refer below. There is a discrepancy between the dose of fluoxetine at home and that the pharmacy told us. she was given 40 mg here til the dose was confirmed with proxy. Discharge dose is 80 mg daily - which is the dose she was discharged on last time from our hospital and what [**Doctor First Name **] told us patient was on at home prior to this admission. Medications on Admission: Meds confirmed with health care proxy - [**Name (NI) **] [**Name (NI) 1456**] ([**Telephone/Fax (1) 98823**]: Amlodipine 10 mg daily Lisinopril 40 mg po daily Lasix 20mg daily Hydralazine 50mg po tid Risperidone 2 mg po daily Fluoxetine 40 mg tablet - 2 tabs daily (80mg/day)(confirmed with proxy [**Name (NI) **]) Aricept 5 mg po qhs Prilosec 20mg [**Hospital1 **] Singulair 10 mg daily Spiriva daily [**Hospital1 **] Advair 250-50 [**Hospital1 **] Albuterol nebs QID Trazodone 50mg at bedtime Prednisone 10 mg daily (has constantly been on prednisone since [**2200-3-15**] due to various tapers). Last dose if 10 mg daily. Home O2, 3lit / min (24 hours) *** I called [**Company 4916**] pharmacy at [**Telephone/Fax (1) 98824**] to confirm the fluoxetine dose. The dose they have is fluoxetine 40 mg tablets. Take 2 tabs [**Hospital1 **]. This dose is different from the dose that [**Doctor First Name **] tells us. Discharge Medications: 1. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q6H (every 6 hours). 2. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q2H (every 2 hours) as needed for shortness of breath or wheezing. 3. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 4. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 5. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Hydralazine 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 7. Risperidone 2 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Fluoxetine 20 mg Capsule Sig: Four (4) Capsule PO DAILY (Daily). 9. Donepezil 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 10. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO twice a day. 11. Montelukast 10 mg Tablet Sig: One (1) Tablet PO once a day. 12. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 13. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 14. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 15. Senna 8.6 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 16. insulin Insulin coverage for elevated sugars by sliding scale. 17. Prednisone 20 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily): To be tapered depending on patient's clinical state. . 18. Levofloxacin 500 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily) for 2 days: last day [**2200-7-6**]. Discharge Disposition: Extended Care Facility: [**Hospital3 105**] Northeast - [**Location (un) 38**] Discharge Diagnosis: Acute on chronic respitatory failure Chronic obstructive pulmonary disease exacerbation Obstructive sleep apnea Hypotension (history of hypertension) Acute on chronic diastolic heart failure Morbid obesity Alzheimer's dementia History of smoking Discharge Condition: stable Discharge Instructions: You were treated for a flare of the chronic obstructive lung disease. You are being dischrged to pulmonary rehabilitation. The steroids will need to be tapered based on your lung status by the doctors at the rehab. Followup Instructions: Provider: [**Last Name (NamePattern4) **]. [**Last Name (STitle) 20111**]/DR. [**Last Name (STitle) 3172**] Phone:[**Telephone/Fax (1) 612**] Date/Time:[**2200-7-23**] 11:00 PCP: [**Name10 (NameIs) **],[**First Name8 (NamePattern2) **] [**Doctor First Name **] [**Telephone/Fax (1) 693**] - follow up with your primary care doctor once you have been discharged from the rehab

[ "295.90", "428.33", "428.0", "278.01", "V45.89", "331.0", "530.81", "518.84", "401.9", "327.23", "796.3", "250.00", "491.21", "311", "294.10" ]

icd9cm

[ [ [] ] ]

[ "93.90" ]

icd9pcs

[ [ [] ] ]

10176, 10257

6092, 7583

308, 314

10547, 10556

2163, 4426

10820, 11200

1724, 1742

8552, 10153

4466, 4493

10278, 10526

7609, 8529

10580, 10797

1757, 2144

261, 270

4525, 6069

342, 1198

1220, 1614

1630, 1708

71,647

127,410

36121

Discharge summary

report

Admission Date: [**2184-12-28**] Discharge Date: [**2185-1-1**] Date of Birth: [**2116-11-22**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2597**] Chief Complaint: Left carotid stenosis Major Surgical or Invasive Procedure: Carotid Endarterectomy History of Present Illness: This 68-year-old male with multiple medical problems was recently found to have an asymptomatic left carotid stenosis in the 80-99% range Past Medical History: PMH: L carotid stenosis, cardiomyopathy, HLD, DM, PVD, gout, CRF no HD PSH: s/p AICD and pacemaker [**2183-7-30**] for symptomatic bradycardia. Social History: n/c Family History: n/c Physical Exam: PE: AFVSS NEURO: PERRL / EOMI MAE equally Answers simple commands Neg pronator drift Sensation intact to ST 2 plus DTR Neg Babinski HEENT: NCAT Neg lesions nares, oral pharnyx, auditory Supple / FAROM neg lyphandopathy, supra clavicular nodes LUNGS: CTA b/l CARDIAC: RRR without murmers ABDOMEN: Soft, NTTP, ND, pos BS, neg CVA tenderness EXT: rle - palp fem, [**Doctor Last Name **], pt, dp lle - palp fem, [**Doctor Last Name **], pt, dp Pertinent Results: [**2185-1-1**] 10:20AM BLOOD WBC-7.3 RBC-3.32* Hgb-10.0* Hct-28.8* MCV-87 MCH-30.0 MCHC-34.6 RDW-14.5 Plt Ct-134* [**2185-1-1**] 10:20AM BLOOD Neuts-70.4* Lymphs-13.8* Monos-9.5 Eos-6.0* Baso-0.5 [**2184-12-31**] 06:17AM BLOOD PT-13.8* PTT-30.7 INR(PT)-1.2* [**2185-1-1**] 10:20AM BLOOD Plt Ct-134* [**2185-1-1**] 08:20AM BLOOD Glucose-137* UreaN-56* Creat-4.4* Na-138 K-4.3 Cl-102 HCO3-26 AnGap-14 [**2184-12-31**] 06:17AM BLOOD Glucose-96 UreaN-60* Creat-4.4* Na-139 K-5.0 Cl-104 HCO3-25 AnGap-15 [**2184-12-30**] 04:27PM BLOOD Glucose-113* UreaN-56* Creat-4.2* Na-140 K-4.8 Cl-106 HCO3-24 AnGap-15 [**2184-12-31**] 06:17AM BLOOD Calcium-8.5 Phos-4.8* Mg-2.5 [**2184-12-30**] 09:40AM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.005 URINE Blood-SM Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG URINE RBC-0 WBC-0 Bacteri-OCC Yeast-NONE Epi-0 URINE Hours-RANDOM UreaN-246 Creat-38 Na-64 K-12 Cl-57 TotProt-17 HCO3-LESS THAN Prot/Cr-0.4* URINE Osmolal-248 [**2184-12-30**] 9:40 am URINE Source: Catheter. URINE CULTURE (Final [**2184-12-31**]): NO GROWTH Brief Hospital Course: Mr. [**Known lastname **],[**Known firstname **] was admitted on [**12-28**] with Carotid artery stenosis. He agreed to have an elective surgery. Pre-operatively, he was consented. A CXR, EKG, UA, CBC, Electrolytes, T/S - were obtained, all other preperations were made. He underwent a: PROCEDURE: Left carotid endarterectomy and Dacron patch angioplasty. He was prepped, and brought down to the operating room for surgery. Intra-operatively, he was closely monitored and remained hemodynamically stable. He tolerated the procedure well without any difficulty or complication. Post-operatively, he was extubated and transferred to the PACU for further stabilization and monitoring. He was then transferred to the VICU for further recovery. While in the VICU he recieved monitered care. When stable he was delined. His diet was advanced. A PT consult was obtained. When he was stabalized from the acute setting of post operative care, he was transfered to floor status On the floor, he remained hemodynamically stable with his pain controlled. He progressed with physical therapy to improve her strength and mobility.He continues to make steady progress without any incidents. He was discharged to a rehabilitation facility in stable condition. To note he has a history of CRI. He did have ARF on top of CRI. His creat was 4.4 x 2 days. He is makeiin good urine on DC. Medications on Admission: Meds: atorvastatin 10', Carvedilol 25", Digoxin 125', Glipizide 5", Hydralazine 25'", ASA 81 Discharge Medications: 1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). Disp:*100 Tablet, Chewable(s)* Refills:*2* 2. Glipizide 5 mg Tab,Sust Rel Osmotic Push 24hr Sig: One (1) Tab,Sust Rel Osmotic Push 24hr PO DAILY (Daily). 3. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Carvedilol 12.5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 5. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Hydralazine 25 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours). 7. Clonidine 0.1 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:*90 Tablet(s)* Refills:*2* 8. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* 9. Outpatient Lab Work Chem 10 10. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 11. Clonidine 0.1 mg Tablet Sig: One (1) Tablet PO three times a day. Disp:*90 Tablet(s)* Refills:*0* 12. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO once a day. Disp:*60 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: VNA Assoc. of [**Hospital3 **] Discharge Diagnosis: Carotid Stenosis ARF on top of CRI PMH: HTN, L carotid stenosis, cardiomyopathy, HLD, DM, PVD, gout, CRF no HD PSH: s/p AICD and pacemaker [**2183-7-30**] for symptomatic bradycardia. Discharge Condition: Good Discharge Instructions: Division of Vascular and Endovascular Surgery Carotid Endarterectomy Surgery Discharge Instructions What to expect when you go home: 1. Surgical Incision: ?????? It is normal to have some swelling and feel a firm ridge along the incision ?????? Your incision may be slightly red and raised, it may feel irritated from the staples 2. You may have a sore throat and/or mild hoarseness ?????? Try warm tea, throat lozenges or cool/cold beverages 3. You may have a mild headache, especially on the side of your surgery ?????? Try ibuprofen, acetaminophen, or your discharge pain medication ?????? If headache worsens, is associated with visual changes or lasts longer than 2 hours- call vascular surgeon??????s office 4. It is normal to feel tired, this will last for 4-6 weeks ?????? You should get up out of bed every day and gradually increase your activity each day ?????? You may walk and you may go up and down stairs ?????? Increase your activities as you can tolerate- do not do too much right away! 5. It is normal to have a decreased appetite, your appetite will return with time ?????? You will probably lose your taste for food and lose some weight ?????? Eat small frequent meals ?????? It is important to eat nutritious food options (high fiber, lean meats, vegetables/fruits, low fat, low cholesterol) to maintain your strength and assist in wound healing ?????? To avoid constipation: eat a high fiber diet and use stool softener while taking pain medication What activities you can and cannot do: ?????? No driving until post-op visit and you are no longer taking pain medications ?????? No excessive head turning, lifting, pushing or pulling (greater than 5 lbs) until your post op visit ?????? You may shower (no direct spray on incision, let the soapy water run over incision, rinse and pat dry) ?????? Your incision may be left uncovered, unless you have small amounts of drainage from the wound, then place a dry dressing over the area that is draining, as needed ?????? Take all the medications you were taking before surgery, unless otherwise directed ?????? Take one full strength (325mg) enteric coated aspirin daily, unless otherwise directed 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 ?????? Temperature greater than 101.5F for 24 hours ?????? Bleeding, new or increased drainage from incision or white, yellow or green drainage from incisions You should have your blood drawn (chem 10) Sunday or Monday by your PCP and the results faxed to Dr.[**Name (NI) 1720**] office at ([**Telephone/Fax (1) 74117**] Followup Instructions: 1. VASCULAR SURGERY (SB) [**2185-1-27**] 01:15p VASCULAR [**Apartment Address(1) **] ([**Doctor First Name **]) LM [**Hospital Unit Name **], [**Location (un) **] 2. VASCULAR LAB Phone:[**Telephone/Fax (1) 1237**] [**2185-1-31**] 01:40p [**Last Name (LF) 1111**],[**First Name3 (LF) 1112**] B. 3. Please follow up with you PCP and Nephrology doctor as soon as possible. You will need every other day blood draws to monitor you creatinine level. You should have your blood drawn (chem 10) Monday by your PCP and the results faxed to Dr. [**Last Name (STitle) **] at ([**Telephone/Fax (1) 25065**] (LM [**Hospital Unit Name **], [**Location (un) **] Phone:[**Telephone/Fax (1) 1237**]), your PCP, [**Name10 (NameIs) **] your Nephrologist. 4. You also need to get your blood pressure checked next week from your primary care doctor. Completed by:[**2185-1-4**]

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icd9cm

[ [ [] ] ]

[ "38.12", "00.40" ]

icd9pcs

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337, 362

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7,647

100,421

15353

Discharge summary

report

Admission Date: [**2138-7-25**] Discharge Date: [**2138-8-2**] Date of Birth: [**2078-12-25**] Sex: F Service: CARDIOTHORACIC Allergies: Latex / Cortisone / Iodine Attending:[**Last Name (NamePattern1) 1561**] Chief Complaint: Transferred form [**Hospital3 **] HOspital for evalulation and treatment for persistent Right pleural effusion with CT output 3L/day. Major Surgical or Invasive Procedure: chest tube placement--right History of Present Illness: 59F h/o advanced metastatic (poorly dif invasive ductal CA) with mets to bone who had recent managment of OSH for pericardial effusion that required s/p windows [**6-24**], [**6-30**] who had bilateral CT for effusions c/b persistent R pleural effusion with CT output >3L/day despite pleurodesis X2 that required transfer to CT surgical service at [**Hospital1 18**] on [**7-25**] for further management. Pt continues on aggressive IV fluids for replacement of fluid losses through chest tube. Pt received 25mg IV adriamycin on [**7-25**] prior to transfer. Her vitals on admission were as follows: 96.6 103 114/53 19 100% 4liters. Pt has had ongoing high output from CT which is being matched with IV fluids/albumin. She had CT torso and echo done with EF >55%. Cardiology was consulted for assistance in management. Right SC line was d/c and tip sent for culture after blood cx returned with CNS 2/2 bottles. She continues on vancomycin and levofloxacin. She was transferred to the CSRU last night after having ongoing CT output on floor and worsening clinical status. The CT was removed this AM despite high output. She has had worsening respiratory status through the day today. She became letharic and hypoxic. She was emregently intubated and chest tube was placed at bedside with 1L output initially. ABG now improving with ph going from 7.05 to 7.24 She has had falling cell counts since admission with WBC going from 5.1 to 1.7, Hct from 31.8 to 23.9, plat # 148 to 85. OSH events: -pericardial drainage with a partial pericardiectomy for presentation with cardiac tamponade -[**2138-6-30**] repeat pericardial drainage and drainage of right/left pleural space with resultant pericardial drain and bilateral -Right pleurodesis with doxycylcine on [**7-12**] and [**2138-7-17**] - PEG placement [**2138-7-10**] with [**Female First Name (un) **] esophagitis noted. Chemotherapy history: Pt received taxotere weekly 9 cycles (3weeks on 3weeks off) [**4-20**] -[**1-20**]. She progressed after this. She then received gemzar [**Date range (1) 44594**]. She then presented with pleural and pericardial fluid from OSH. She was started on weekly adriamycin 2 or 3 doses while at OSH. (outpatient Oncology RN- [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 44595**] X 2333 Past Medical History: [**Female First Name (un) 564**] esophagitis s/p PEG [**6-21**], metastatic BReast Cancer on Chemotherapy, s/p radiation therapy, port placement Right subclavian, Left mastectomy [**2-17**], Hypertension, chronic pain Social History: lives w/ husband in RI. Very supportive family. Family History: n/a Pertinent Results: Micro from OSH: BCx ([**7-1**]) 1/4 bottles + staph aureus, [**Last Name (un) 36**] to Levo UCx ([**7-1**]) negative Pericardial fluid: negative cytology Pericardial bx: negative for malignancy Pleural fluid: transudative CT scan ([**7-27**]): L pleural effusion, upper lobes consolidated (PNA vs lymphangitic tumor spread), small R PTX, diffuse bone mets, mediastinal & para-aortic retroperitoneal LAD, moderate ascites, 3 spleen lesions. MIcro culture data - negative [**Date range (1) 44596**]. [**2138-7-25**] 10:38PM GLUCOSE-314* UREA N-23* CREAT-0.5 SODIUM-118* POTASSIUM-6.6* CHLORIDE-98 TOTAL CO2-21* ANION GAP-6* [**2138-7-25**] 10:38PM ALT(SGPT)-39 AST(SGOT)-15 LD(LDH)-334* CK(CPK)-35 ALK PHOS-169* AMYLASE-14 TOT BILI-0.3 [**2138-7-25**] 10:38PM ALBUMIN-2.0* CALCIUM-6.5* PHOSPHATE-1.7* MAGNESIUM-2.1 IRON-24* CHOLEST-131 [**2138-7-25**] 10:38PM WBC-5.1 RBC-3.53* HGB-11.0* HCT-31.8* MCV-90 MCH-31.3 MCHC-34.7 RDW-17.5* Hematology COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct [**2138-7-31**] 03:41AM 2.5* 3.14* 9.6* 27.9* 89 30.7 34.5 17.4* 72* Source: Line-art DIFFERENTIAL Neuts Bands Lymphs Monos Eos Baso Atyps Metas [**2138-7-30**] 02:19AM 92.6* 0 4.8* 2.4 0.2 0.1 RED CELL MORPHOLOGY Hypochr Anisocy Poiklo Macrocy Microcy Polychr Spheroc Ovalocy Schisto Tear Dr [**2138-7-30**] 02:19AM NORMAL1 1+ 1+ 1+ 1+ NORMAL 1+ 1+ OCCASIONAL OCCASIONAL 1 NORMAL MANUALLY COUNTED BASIC COAGULATION (PT, PTT, PLT, INR) PT PTT Plt Smr Plt Ct INR(PT) [**2138-7-31**] 03:41AM 72* Source: Line-art BASIC COAGULATION (FIBRINOGEN, DD, TT, REPTILASE, BT) Fibrino [**2138-7-30**] 02:19AM 380 RADIOLOGY Final Report CHEST (PORTABLE AP) [**2138-7-30**] 9:05 PM Reason: r/o pulm edema, effusions. [**Hospital 93**] MEDICAL CONDITION: 59yo F with malignant pleural effusions from metastatic breast cancer. now extubated. REASON FOR THIS EXAMINATION: r/o pulm edema, effusions. REASON FOR EXAMINATION: Evaluation of pulmonary edema in patient with bilateral minor pleural effusion due to lung cancer. Portable AP chest radiograph compared to [**2138-7-29**]. The patient was extubated in the meantime interval. The right internal jugular line tip is 1 cm below the cavoatrial junction. The heart size and the mediastinal contours are unchanged. There is worsening of bilateral pulmonary edema as well as of left lower lobe consolidation. The bilateral pleural effusion is grossly unchanged. There is no evidence of pneumothorax with the technical limitation of this film. The tip of the right chest tube is unchanged. IMPRESSION: 1. Meanwhile extubation of the patient. 2. Worsening of the bilateral pulmonary edema. Brief Hospital Course: 59F h/o metastatic BRCA mets to bone on CTX, recurrent pericardial effusion s/p pericardial windows [**6-24**], [**6-30**] @ OSH, persistent R pleural effusion with CT output 3L/day tx'd from [**Hospital3 44597**]. Pt received 25mg IV adriamycin on [**7-25**] prior to transfer. Patient was admitted to floor and was treated aggressively w/ IV fluids/ albumin for replacement of fluid losses through chest tube. CT torso and echo done with EF >55%. Cardiology was consulted for assistance in management. Right SC line was d/c and tip sent for culture after blood cx returned with CNS [**3-20**] bottles. Vancomycin and levofloxacin started and continued until [**2138-7-31**]. HD#[**5-21**]-Overnight she was transferred to ICU for ongoing CT output on floor and worsening clinical status. The CT was removed this AM despite high output. She developed worsening resp status, letharic and hypoxia requiring emergent intubation and chest tube was placement at bedside with 1L output initially. ABG now improved, but w/ continued falling cell counts since admission with WBC going from 5.1 to 1.7, Hct from 31.8 to 23.9, plat # 148 to 85 and metabolic acidosis. HD6-Oncology consulted by Thoracic Surgery. Presentation of significant surgical risk and continued chemotherapy no indicated due to patient condition discussed w/ patient and husband as well as discussion of code status. Pt and husband in agreement of DNR/DNI status, and discussed w/ family and Attending Thoracic Surgeon. Social Worker support provided. HD 7- Patient decision to become comfort measures only and plan for discharge w/ Hospice Care. Family in agreement and w/ patient HD 8- Hospice plans made for discharge next day. Medical arrangements make, medication presriptions provided to Hospice. Pt to be discharged w/ chest tube, extra dressings and pleurovac provided to Hospice personel Medications on Admission: [**Female First Name (un) 564**] esophagitis s/p PEG [**6-21**], metastatic BReast Cancer on Chemotherapy, s/p radiation therapy, port placement Right subclavian, Left mastectomy [**2-17**], Hypertension, chronic pain Discharge Medications: 1. Morphine 10 mg/5 mL Solution Sig: Fifteen (15) cc PO Q4H (every 4 hours). Disp:*150 cc* Refills:*0* 2. Hydromorphone 2 mg Tablet Sig: 1-3 Tablets PO Q2H (every 2 hours) as needed for pain. Disp:*60 Tablet(s)* Refills:*0* 3. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) PO BID (2 times a day). 4. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 5. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q6H (every 6 hours) as needed. 6. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation QID (4 times a day). 7. Hyoscyamine Sulfate 0.125 mg Tablet, Sublingual Sig: One (1) Tablet, Sublingual Sublingual Q4H (every 4 hours) as needed for secretions. Disp:*30 Tablet, Sublingual(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**First Name9 (NamePattern2) 269**] [**Location 7188**] [**Location (un) 44598**]Hospice Discharge Diagnosis: [**Female First Name (un) 564**] esophagitis s/p PEG [**6-21**], metastatic BReast Cancer on Chemotherapy, s/p radiation therapy, port placement Right subclavian, Left mastectomy [**2-17**], Hypertension, chronic pain Discharge Condition: fair Discharge Instructions: Provide palliative care, comfort measures only for patient. Administer medications as needed and as directed as stated on discharge instructions. Completed by:[**2138-8-12**]

[ "518.81", "457.8", "197.2", "284.8", "V10.3", "276.1", "198.5", "276.7", "423.9" ]

icd9cm

[ [ [] ] ]

[ "96.6", "96.04", "34.04", "96.71" ]

icd9pcs

[ [ [] ] ]

8780, 8900

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436, 465

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3161, 4910

3137, 3142

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4947, 5033

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262, 398

5062, 5830

494, 2813

2836, 3056

3072, 3121

27,660

193,625

52041

Discharge summary

report

Admission Date: [**2111-12-14**] Discharge Date: [**2111-12-16**] Date of Birth: [**2033-11-9**] Sex: F Service: MEDICINE Allergies: Percocet / Codeine / Hydrochlorothiazide / Percodan / Cardizem Attending:[**First Name3 (LF) 21112**] Chief Complaint: rising creatinine Major Surgical or Invasive Procedure: Renal Biopsy History of Present Illness: HPI: 78 y/o female with HTN, DM2, CAD S/P CABG, Afib, ESRD S/P Renal Transplant, and RAS S/P Angioplasty who is referred in for workup of rising creatinine, latest value of 3.5 up from last in our system of 2.5 in mid [**Month (only) **]). She reports no complaints other than continued left arm and bilateral leg swelling which has been getting worse over the last month. She also has had some intching of her back, but denies thirst, nausea, vomiting, change in frequency/color/odor of urine. She denies headache, [**Month (only) **], chills, chest pain, dyspnea on exertion, orthopnea, PND, abdominal pain, graft tenderness, diarrhea, polyuria. She has not been using any NSAIDS. She did have her metolazone restarted one week ago and took a dose on thursday and saturday because of worsening leg edema. Her furosemide dose has been stable. Her potassium was changed from daily to [**Hospital1 **] last week as well. She was started back on allopurinol about a month ago. Otherwise on changes in her health and she has actually been feeling well. Past Medical History: # DM Type II --Renal allograft artery angioplasty [**2-27**] HTN --Renal transplant ([**2099**]): No information about donor # Atrial fibrillation, not currently anticoagulated s/p [**8-1**] hemicolectomy # Right hemicolectomy ([**7-/2111**]) # CAD s/p CABG ([**2098**]: LIMA to LAD, SVG to PDA, SVG to OM, SVG to diag) # Cholecystectomy # Zoster Social History: # Personal: Widowed, lives with son # Smoking: Never # Alcohol: Never # Also has VNS come to help weekly Family History: Mother died of ? htn in her 80s Physical Exam: General: AAOx3 in NAD, Elderly female wearing wig. VITALS: T 97.3 BP 129/66 (129-188) HR 62 (62-70) RR 20 100% RA HEENT: PERRL. EOMI, no scleral icterus, MMM. Neck: No LAD or masses, no JVD or carotid bruits Chest: CTABL. Cardiac: Regularly irregular; S3 or split S2 Abdomen: Soft, NT, ND, active bowel sounds, RLQ graft nontender and firm without a bruit. Extremities: LE pitting edema to the knee and over the sacrum. Left arm with blaiteral nonpatent AV fistula. Swelling of the left arm but not right. Weak left radial and distal LE pulses bilaterally. Neuro: AAOx3, CNII-XII intact Pertinent Results: [**2111-12-14**] 10:20PM PT-12.7 PTT-29.6 INR(PT)-1.1 [**2111-12-14**] 10:20PM PLT COUNT-239 [**2111-12-14**] 10:20PM WBC-5.5 RBC-3.81* HGB-11.3* HCT-33.9* MCV-89 MCH-29.6 MCHC-33.2 RDW-18.9* [**2111-12-14**] 10:20PM FREE T4-1.2 [**2111-12-14**] 10:20PM TSH-8.4* [**2111-12-14**] 10:20PM CALCIUM-6.4* PHOSPHATE-6.5*# MAGNESIUM-1.4* [**2111-12-14**] 10:20PM estGFR-Using this [**2111-12-14**] 10:20PM GLUCOSE-227* UREA N-72* CREAT-4.6*# SODIUM-139 POTASSIUM-3.1* CHLORIDE-103 TOTAL CO2-20* ANION GAP-19 [**2111-12-16**] 06:10AM BLOOD PTH-397* [**2111-12-14**] 10:20PM BLOOD TSH-8.4* [**2111-12-16**] 08:46AM BLOOD FK506-7.6 [**2111-12-15**] 05:50AM BLOOD FK506-6.0 [**2111-12-16**] 06:10AM BLOOD BK VIRUS BY PCR, BLOOD-PND [**2111-12-15**] 08:00AM URINE Hours-RANDOM UreaN-239 Creat-26 Na-98 TotProt-575 Prot/Cr-22.1* [**2111-12-15**] 08:00AM URINE Eos-NEGATIVE [**2111-12-15**] 08:00AM URINE Blood-NEG Nitrite-NEG Protein-500 Glucose-100 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG . RENAL ULTRASOUND: IMPRESSION: Unchanged overall appearance of renal transplant with marked upper pole cortical thinning and underlying focal hydronephrosis. Doppler examination demonstrates relatively normal venous flow and preserved systolic and diastolic arterial flow, though the latter is low in amplitude, as before. The renal artery shows slightly broadened spectral waveforms, with normal parenchymal resistive indices, ranging from 0.54 to 0.62 in the mid- and lower poles; these results are not significantly changed compared to prior exams. The preserved brisk arterial upstroke would militate against significant re-stenosis of the stented renal artery. However, though the Doppler evaluation of the upper pole parenchyma is limited, the elevated RIs, which appear new, in the setting of rising creatinine, raise the possibility of chronic rejection. This may need to be addressed directly, by renal biopsy. The study and the report were reviewed by the staff radiologist. Brief Hospital Course: A/P: 77 y/o Female with HTN, DM2, CAD S/P CABG, Afib, ESRD S/P Renal Transplant, and RAS S/P Angioplasty with rising creatinine and elevated blood pressure, but asymptomatic. . 1. Acute on Chronic Renal Failure: Likely etiology of rising creatinine is worsening of her chronic kidney disease due to hypertensive nephrosclerosis and diabetic nephropathy. Urine studies were consistent with an intrinsic cause of renal failure and patient had nephrotic range proteinuria. Renal transplant ultrasound with Dopplers was negative for RAS and showed normal venous flow. Serum protein and urine protein had been negative in [**Month (only) **]. The patient's diuretics were held for concern of renal hypoperfusion. Prograf levels were followed and were within therapeutic range, making renal failure secondary to prograf unlikely. - 2. Hypertension: Blood pressure was elevated while in hospital and patient's medications were changed to correct this. We increased her labetalol to 200mg, amlodipine was increased to 10mg and clonidine was increased to 0.2mg tid. - 3. Leg Edema: Has normal EF, so possibly diastolic failure vs. worsening renal disease. Etiology is most likely anasarca secondary to protein losing nephropathy. However, patient's diuretics were held. - 4. Right Basilar Decreased breath sounds: Likely pleural effusion. Doubt PNA given lack of cough, sputum, fevers. CXR unread but appears to have stable chronic R sided effusion. As appears stable otherwise, patient was not treated at this time. - 5. Irregular rate: Hx of Afib, not on coumadin. On ECG, NSR with PAC's, LVH and RBBB. - continue beta blocker as well rate controlled - coumadin has been held because of diverticular bleed requiring hemicolectomy - 6. DM Type II: - diabetic diet - regular insulin sliding scale - 7. CAD s/p CABG and stenting: No chest pain. - cont beta blocker and statin - not on aspirin or plavix, unclear when last stent was put in, but possibly stopped because of bleed. - 8. Diastolic Dysfunction: Pt was continued on antihypertensives with good effect. - 9. Secondary Hyperparathyroidism: Pt was continued on calcitriol. PTH level was checked and remained elevated. Calcium levels were within normal. - 10. Hypothyroidism: Continued on home regimen of levothyroxine; TSH elevated but free T4 normal - 11. Anemia: Likely ACD from renal disease. HCT was stable with no evidence of bleeding. - 12. h/o Gout: Allopurinol was held in house - Medications on Admission: nsulin 12 untis NPH and regular insulin sliding scale Prednisone 5 mg QAM Amiodarone 100 mg QOD Calcitriol 0.25 mcg DAILY Levothyroxine 100 mcg DAILY Pantoprazole 40 gm DAILY Labetolol 150 mg [**Hospital1 **] Tacrolimus (Prograf) 2 mg [**Hospital1 **] Furosemide 80 mg [**Hospital1 **] Amlodipine 5 mg DAILY Lipitor 10 mg DAILY Allipurinol 100 mg QHS Metolazone 2.5 mg QSAT and QTHURS Ferrous Sulfate 325 mg DAILY Sodium Bicarbonate 650 mg DAILY Potassium 20 mEQ [**Hospital1 **] Clonidine 0.1 mg [**Hospital1 **] Vitamin D Aranesp . Discharge Medications: 1. Amiodarone 200 mg Tablet Sig: 0.5 Tablet PO EVERY OTHER DAY (Every Other Day). 2. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 5. Tacrolimus 1 mg Capsule Sig: Two (2) Capsule PO Q12H (every 12 hours). 6. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Tablet(s) 7. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Sodium Bicarbonate 650 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 10. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO DAILY (Daily). 11. Outpatient Lab Work Please draw CBC, chem-10, FK 506 level. Please fax results to transplant center at [**Telephone/Fax (1) 697**] 12. Labetalol 200 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 13. Clonidine 0.1 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). Disp:*180 Tablet(s)* Refills:*2* 14. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Twelve (12) UNITS Subcutaneous q AM. 15. Calcium Acetate 667 mg Capsule Sig: One (1) Capsule PO TID W/MEALS (3 TIMES A DAY WITH MEALS). Disp:*90 Capsule(s)* Refills:*2* Discharge Disposition: Home With Service Facility: Community VNA, Attelboro Discharge Diagnosis: Primary: Acute on chronic renal insufficiency Hypertension Diabetes Type II Atrial fibrillation Secondary: CAD s/p CABG Diastolic Dysfunction End Stage Renal Failure S/P Renal Transplant Secondary Hyperparathyroidism Hypothyroidism Anemia Discharge Condition: Good Discharge Instructions: You were admitted to the hospital with worsening renal function. This is most likely due to chronic kidney disease. You underwent a kidney biopsy while you were in the hospital. You should follow up with Dr. [**Last Name (STitle) **] on [**12-22**]. . You should also have your blood drawn on THIS FRIDAY. We have given you a prescription for this. You can have them drawn at the transplant center. . If you develop any worrisome symptoms such as abdominal pain, pain at the site of biopsy, bleeding, blood in your urine, pain with urination, [**Month/Year (2) **], chest pain , shortness of breath, please contact your doctor or return to the emergency room. . Followup Instructions: You have the following appointment scheduled for you: Provider: [**Name10 (NameIs) **] [**Last Name (NamePattern4) 11082**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2111-12-22**] 8:00 Provider: [**Name10 (NameIs) **] [**Last Name (NamePattern4) 11082**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2112-2-2**] 10:30

[ "511.9", "588.81", "250.40", "403.91", "V58.67", "584.9", "V45.81", "285.21", "585.6", "V42.0", "427.31" ]

icd9cm

[ [ [] ] ]

[ "55.23" ]

icd9pcs

[ [ [] ] ]

8990, 9045

4623, 7065

344, 359

9329, 9336

2605, 4600

10048, 10384

1948, 1982

7650, 8967

9066, 9308

7091, 7627

9360, 10025

1997, 2586

287, 306

387, 1438

1460, 1809

1825, 1932

7,051

144,890

48506

Discharge summary

report

Admission Date: [**2160-8-2**] Discharge Date: [**2160-8-14**] Date of Birth: [**2104-1-10**] Sex: F Service: MED Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 759**] Chief Complaint: wheezing, sob Major Surgical or Invasive Procedure: Intubated [**8-6**], extubated [**8-8**] History of Present Illness: 56 y/o female with adult onset asthma (s/p 2 previous intubations and tracheostomies) and COPD (on chronic 2L home O2), OSA, admitted initially to [**Hospital Unit Name 153**] on [**8-2**] with shortness of breath and increased wheezing, chest tightness. Pt had reported that she had progressively worsening wheezing/sob x [**12-14**] wks and had been requiring more frequent alb nebs at home. Initially denied any f/c, n/v, abd pain,d/c or any other associated symptoms. Home peak flows are 200-300, initially in ED was as low as 130, improved only to 150 after albuterol neb. In [**Name (NI) **], pt was given combivent nebs x10, solumedrol 125 mg IV x 1, heliox therapy x 45 min. In [**Name (NI) 153**], pt was continued on Solumedrol 125 mg IV q8h, combivent nebs, had occasional desats to 70-80% while coughing/vomiting. Also started on course of azithromycin [**8-5**] x 5 days. On evening of [**8-5**], became more tachypneic and hypercarbic with PCO2 at 82 on ABG (7/28/82/127), intubated for resp distress and increased work in breathing. Pt was then extubated [**8-8**] without difficulty with RSBI 23. She still experienced occasional desats to 80% at night (last desat [**8-9**]), but since has improved with frequent nebs and continued high dose solumedrol. Pt transferred [**8-11**] to medicine floor for further management. Currently, feeling well, no complaints. Denies any shortness of breath, chest pain, nausea or vomiting/abd pain, dysuria, no f/c. +diarrhea yesterday (loose, watery) but no bms today. Also ROS + for cough productive with whitish/yellow sputum but pt states this is unchanged for the last week. Past Medical History: 1. Adult onset asthma, s/p 2 previous intubations and tracheostomies for prolonged weans 2. COPD, on chronic home O2 2L 3. OSA, not currently using CPAP at home 4. GERD 5. HTN 6. DM Social History: Denies EtOH use, former smoker 2 ppd x 30 yrs, quit [**2151**] No IVDA Currently on disability for asthma Family History: Noncontributory Physical Exam: T 98 BP 122/62 P 74 R 20 Sat 96% 4L NC Gen: pleasant obese female, A+O x3, lying comfortably, NAD HEENT: PERRL, EOMI, OP clear with MMM, no sinus tenderness Neck: supple, NT, no LAD Pulm: decreased BS throughout with prolonged exp phase, few scattered wheezes, no rales CV: RRR, no m/r/g Abd: s/nt/obese +BS Ext: 1+ edema nonpitting, +2DP pulses bilaterally Pertinent Results: [**2160-8-2**] 04:20PM PLT COUNT-314 [**2160-8-2**] 04:20PM NEUTS-46.8* LYMPHS-41.4 MONOS-4.5 EOS-6.9* BASOS-0.5 [**2160-8-2**] 04:20PM WBC-6.6 RBC-4.37 HGB-14.6 HCT-42.5 MCV-97 MCH-33.4* MCHC-34.3 RDW-12.5 [**2160-8-2**] 04:20PM GLUCOSE-98 UREA N-13 CREAT-0.7 SODIUM-141 POTASSIUM-4.5 CHLORIDE-103 TOTAL CO2-30* ANION GAP-13 Labs on transfer: Central line tip cx pending [**2160-8-11**] 04:31AM BLOOD WBC-17.3*# RBC-3.99* Hgb-13.1 Hct-39.2 MCV-98 MCH-32.8* MCHC-33.3 RDW-12.3 Plt Ct-226 [**2160-8-11**] 04:31AM BLOOD Glucose-139* UreaN-25* Creat-0.6 Na-138 K-3.8 Cl-100 HCO3-33* AnGap-9 [**2160-8-11**] 04:31AM BLOOD Calcium-8.8 Phos-3.4 Mg-2.5 [**2160-8-9**] 06:59AM BLOOD Type-ART pO2-76* pCO2-53* pH-7.41 calHCO3-35* Base XS-6 Brief Hospital Course: A/P: 56 y/o female with adult onset asthma and COPD on chronic home O2 admitted to [**Hospital Unit Name 153**] for status asthmaticus, s/p intubation [**8-6**] and extubated [**8-8**], now improved after steroids and nebs tx, transferred to medicine floor for further management. 1. Status asthmaticus: Now appears improved s/p extubation, satting in mid 90s on 4L NC. Still has been maintained on steroid taper since admission [**5-2**] with solumedrol 125 mg IV TID. MICU notes have mentioned "will wean steroids",but not weaned as of yet. PF per MICU resident checked last night and was 190, not far off pt's baseline. - Since pt has arrived so late to floor and already has received solumedrol dose for today, pt switched to PO steroids [**8-11**] 60 mg po prednisone (will give 3 week taper) - Cont with frequent alb/atrovent nebs q4 standing - Cont with flovent, salmeterol inhalers, [**Month/Year (2) 8895**] per outpt doses - Likely CO2 retainer given prev ABG, so will monitor O2 sats carefully, goal low 90s - Peak flow 260 - f/u with Dr.[**Last Name (STitle) 19419**] 2. Leukocytosis: wbc almost doubled, now decreasing, unclear etiology. Pt has remained afebrile. Central line pulled in [**Hospital Unit Name 153**] and sent for culture, now growth. - Will also check C diff given hospital stay, previous Azithromycin use, h/o recent diarrhea. Pt has now not had any diarrhea. - No other focal signs of infection - Will cx if spikes - Check CBC with diff [**Doctor First Name **] and follow fever curve - pt has not been febrile. No more diarrhea. Therefore, leukocytosis likely [**1-14**] stress of intubation/extubation and steroids. 3. DM2: qid FS, RISS and fixed doses, probably will have decreased insulin requirement with taper of steroids43. 4. HTN: titrate up lisinopril 5. GERD: cont. protonix 6. FEN: DM diet 7. Ppx: sc heparin, bowel regimen 8. Access: PIV 9. Code: Full, confirmed in [**Hospital Unit Name 153**]. 10. Dispo: to home. Will d/w CM re: potential for rehab. PT consult obtained and no home PT required. Clinic appts with Dr.[**Last Name (STitle) **] [**2160-8-21**] and in [**Hospital **] Clinic Medications on Admission: 1. Albuterol nebs prn 2. Advair 250/50 [**Hospital1 **] 3. Atrovent IH 2 puffs [**Hospital1 **] 4. Lisinopril 10 QD 5. Calcium supplements 6. [**Hospital1 **] 10 mg PO QD 7. Insulin 70/30 30 units qam, 20 units q pm 8. RISS 9. Protonix 40 mg PO QD Discharge Medications: 1. Salmeterol Xinafoate 50 mcg/DOSE Disk with Device Sig: One (1) Disk with Device Inhalation Q12H (every 12 hours). Disp:*60 Disk with Device(s)* Refills:*2* 2. Montelukast Sodium 10 mg Tablet Sig: One (1) Tablet PO QD (once a day). Disp:*30 Tablet(s)* Refills:*2* 3. Fluticasone Propionate 110 mcg/Actuation Aerosol Sig: Four (4) Puff Inhalation [**Hospital1 **] (2 times a day). Disp:*qs * Refills:*2* 4. 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:*0* 5. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours). Disp:*qs * Refills:*2* 6. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation Q4H (every 4 hours). Disp:*qs * Refills:*2* 7. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO QD (once a day). Disp:*30 Tablet(s)* Refills:*2* 8. Prednisone 20 mg Tablet Sig: Three (3) Tablet PO QD (once a day) for 7 days. Disp:*21 Tablet(s)* Refills:*0* 9. Prednisone 20 mg Tablet Sig: Two (2) Tablet PO once a day for 7 days. Disp:*14 Tablet(s)* Refills:*0* 10. Prednisone 20 mg Tablet Sig: One (1) Tablet PO once a day for 7 days. Disp:*7 Tablet(s)* Refills:*0* 11. Prednisone 5 mg Tablet Sig: One (1) Tablet PO once a day for 7 days. Disp:*7 Tablet(s)* Refills:*0* 12. Insulin 70/30 70-30 unit/mL Suspension Sig: Thirty (30) u Subcutaneous qAM for 3 months: 30 U 70/30 qAM. Disp:*qs * Refills:*0* 13. Insulin 70/30 70-30 unit/mL Suspension Sig: Twenty (20) U Subcutaneous at bedtime for 7 months: 20 U 70/30 qHS. Disp:*qs * Refills:*0* Discharge Disposition: Home with Service Discharge Diagnosis: Status Asthmaticus Discharge Condition: Good Discharge Instructions: Please monitor your respiratory status. If any increase work of breathing, cough or weakness, please call your doctor or go to the ER. Followup Instructions: Dr.[**Last Name (STitle) **] at [**2160-8-21**] at 11:am in [**Hospital Ward Name 23**] Bldg on [**Location (un) 1773**] in Rehab Services Dr.[**First Name4 (NamePattern1) 1123**] [**Last Name (NamePattern1) 27318**] at [**Hospital **] Clinic [**2160-8-19**] at 2:pm Completed by:[**2160-8-14**]

[ "401.9", "530.81", "V15.82", "780.57", "478.29", "787.01", "250.00", "493.21" ]

icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

7634, 7653

3563, 5709

322, 364

7716, 7722

2798, 3540

7906, 8204

2382, 2399

6007, 7611

7674, 7695

5735, 5984

7746, 7883

2414, 2779

269, 284

392, 2038

2060, 2243

2259, 2366

13,536

149,305

11217

Discharge summary

report

Admission Date: [**2125-5-17**] Discharge Date: [**2125-5-25**] Date of Birth: [**2067-10-28**] Sex: F Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 668**] Chief Complaint: intraabdominal mass Major Surgical or Invasive Procedure: Exploratory laparotomy, left lateral segmentectomy and splenectomy. History of Present Illness: 57F admitted last month for respiratory compensation, found to have abdominal mass incidentally on CT chest. She denied any abdominal pain, diarrhea, constipation, or recent weight loss. Work-up at that time showed no evidence of metastasis. The origin of the mass was questionable, with MRI suggestive of splenic origin and US suggestive of hepatic origin. It was decided that after her respiratory issues were resolved that she return to the hospital for exploratory laparotomy and resection of the mass. Past Medical History: DM, last a1c 7.7 in [**2123**] ESRD (2o2 IDDM and HTN), s/p renal transplant [**2122**] on immunosuppressants, episode of allograft nephropathy documented by biopsy HTN b/l thoracotomy for spontaneous PTX, [**2110**] Hyperlipidemia Lymphangiomeiomatosis (cystic dz) of lung Social History: Pt was raised in the Phillipines, immigrated to the US in [**2096**]. Married lives with husband. 2 kids. No tob/etoh/drugs. Family History: NC Physical Exam: NAD CTAB RRR soft, nontender, obese no edema Pertinent Results: [**2125-5-25**] 05:00AM BLOOD WBC-10.9 RBC-2.66* Hgb-7.7* Hct-23.9* MCV-90 MCH-29.1 MCHC-32.4 RDW-16.0* Plt Ct-354 [**2125-5-17**] 07:15PM BLOOD WBC-3.5* RBC-3.91* Hgb-10.3* Hct-33.6* MCV-86 MCH-26.4* MCHC-30.8* RDW-15.9* Plt Ct-140* [**2125-5-25**] 05:00AM BLOOD Plt Ct-354 [**2125-5-23**] 05:08AM BLOOD PT-11.4 PTT-30.1 INR(PT)-1.0 [**2125-5-17**] 07:15PM BLOOD PT-11.6 PTT-27.8 INR(PT)-1.0 [**2125-5-25**] 05:00AM BLOOD Glucose-140* UreaN-43* Creat-3.6* Na-143 K-3.4 Cl-109* HCO3-25 AnGap-12 [**2125-5-17**] 07:15PM BLOOD Glucose-206* UreaN-86* Creat-3.9* Na-141 K-4.8 Cl-111* HCO3-17* AnGap-18 [**2125-5-25**] 05:00AM BLOOD ALT-15 AST-7 AlkPhos-57 Amylase-28 TotBili-0.1 [**2125-5-17**] 07:15PM BLOOD ALT-12 AST-13 LD(LDH)-204 AlkPhos-83 Amylase-62 TotBili-0.1 [**2125-5-25**] 05:00AM BLOOD Albumin-2.6* Calcium-7.9* Phos-3.6 Mg-1.6 [**2125-5-17**] CXR: Overall unchanged appearance of the chest with cardiomegaly, increased interstitial markings with cystic changes, representing interstitial lung disease noted on the prior CT scan. Small bilateral pleural effusion in bilateral costophrenic angles. [**2125-5-21**] EKG: Sinus rhythm Nonspecific lateral ST-T wave abnormalities Late precordial QRS transition - is nonspecific Since previous tracing of [**2125-4-22**], modest sinus tachycardia and ST-T wave changes present [**2125-5-22**] RUE US: 1. No deep venous thrombosis in right internal jugular, subclavian, axillary, basilic, or brachial veins. 2. Unusual structure within the right antecubital fossa containing arterial waveform, possibly representing an AV malformation. Brief Hospital Course: 57F admitted for resection of intrabdominal mass. Pt underwent splenectomy and left lateral segmentectomy on [**2125-5-18**] (see operative report for details) and was extubated and transferred to the PACU in stable condition. She remained in the ICU overnight for monitoring. Pain was controlled with PCA and pt was started on sips and clears. SHe was transferred to the floor on POD1. She did have some respiratory issues post-operatively, requiring supplemental O2 via nasal cannula and face tent. CXR showed bilateral cystic disease consistent LAM and prominent interstitial markings. She was diuresed with IV lasix, given chest PT, frequent neb treatments, and encouraged to use incentive spirometry. Her diet was advanced on POD2. On POD4 pt had a fever of 101.9 and she was pan-cultured. She was also placed on vanc and levo for empiric coverage. She defervesced with improved respiratory status. She also became anemic with Hct of 24.5 and was transfused 1 unit of prbc. PT was consulted and after many days of therapy, pt was cleared for discharge home. Her JP amylase remained normal and her JP's were removed on POD5 and 6. By POD7, pt was tolerating a PO diet, pain was well-controlled with PO medication, and oxygen-requirements returnd to baseline. She was discharged on [**2125-5-25**] in stable condition. Her immunosuppression and renal function was followed throughout her hospital course by transplant nephrology. Medications on Admission: 1. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1) Tablet PO 3X/WEEK (MO,WE,FR). 3. Mycophenolate Mofetil 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 5. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 6. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 8. Sodium Citrate-Citric Acid 500-334 mg/5 mL Solution Sig: Thirty (30) ML PO BID (2 times a day). 9. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 10. Doxazosin 1 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 11. Calcitriol 0.5 mcg Capsule Sig: One (1) Capsule PO DAILY (Daily). 12. Rosuvastatin 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Discharge Medications: 1. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1) Tablet PO 3X/WEEK (MO,WE,FR). 3. Mycophenolate Mofetil 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. Disp:*40 Tablet(s)* Refills:*0* 5. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 6. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 8. Sodium Citrate-Citric Acid 500-334 mg/5 mL Solution Sig: Thirty (30) ML PO BID (2 times a day). 9. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 10. Doxazosin 1 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 11. Calcitriol 0.5 mcg Capsule Sig: One (1) Capsule PO DAILY (Daily). 12. Rosuvastatin 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 14. Outpatient Lab Work Biweekly Labs (Every Monday and Thursday): Chem7, CBC, Ca, PO4, AST, T Bili, U/A Discharge Disposition: Home with Service Discharge Diagnosis: Left upper quadrant mass. Discharge Condition: Good 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, but 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 persistent vomiting -Increased pain -Redness or discharge from your wound -Other symptoms concerning to you Followup Instructions: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2125-6-4**] 3:20 [**First Name4 (NamePattern1) 971**] [**Last Name (NamePattern1) 970**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2125-6-5**] 11:10 Completed by:[**2125-5-25**]

[ "155.0", "403.91", "V42.0", "780.57", "235.7", "250.00", "585.6" ]

icd9cm

[ [ [] ] ]

[ "41.5", "99.04", "50.22" ]

icd9pcs

[ [ [] ] ]

6789, 6808

3099, 4549

334, 404

6878, 6884

1484, 3076

7452, 7764

1399, 1403

5563, 6766

6829, 6857

4575, 5540

6908, 7429

1418, 1465

275, 296

432, 943

965, 1240

1256, 1383

6,687

178,447

1436

Discharge summary

report

Admission Date: [**2194-3-8**] Discharge Date: [**2194-3-18**] Date of Birth: [**2132-9-20**] Sex: F Service: CARDIOTHORACIC Allergies: Atropine / Zosyn Attending:[**First Name3 (LF) 165**] Chief Complaint: Dyspnea on exertion, transferred from OSH. Major Surgical or Invasive Procedure: [**2194-3-12**] - s/p CABGx4(LIMA->LAD, SV Grafts->[**Last Name (LF) **], [**First Name3 (LF) **], RCA) [**2194-3-8**] - Cardiac Catheterization History of Present Illness: Patient is a 61 yo F with a history of MI, and IDDM diabetes who presented to an outside hospital with the onset of worsening dyspnea on exertion. Apparently she was in her usual state of health (dyspnea with significant exertion) when she began feeling vague chest dull pain similar to her previous MI (approx Thursday AM). The pressure continued on and off until presentation. Notably the pressure again started night prior to admission approx at 5 PM and lasted "all night". When she noticed that she was more short of breath with walking to the mailbox this morning, she came to the ED. She has not had any dizziness, light headedness, presyncope/syncope, nausea, vomitng, fever, chills. She also noted last night feeling weak and took 4 glucose pills (did not check FS). This morning she found that she had a glucose of >400 and gave herself 2U insulin and repeat FS was 230s. . At the outside hospital she was found to have ECG changes c/w ST elevations in inferior leads and labs notable for Trop I > 50, CK > 1200 with MBI 7.6% started on aspirin 325 mg, Plavix 300 mg, Integrelin bolus +drip (1040AM), heparin bolus + drip (3000U, 600Ugtt). Additionally she was given levofloxacin 500 mg for suspicion of pneumonia on CXR as well as morphine and nitroglycerin for CP. . On arrival to the [**Hospital1 18**] ED, initial vitals were 76 114/54, 18, 98% RA. She was given Integrillin 2 mcg/kg/min (briefly), heparin 600 U/hr gtt, mucomyst 600 mg x 1, 1/2 NS with 1 amp Na HC03, 300 mg plavix. . On arrival to the CCU, she had no chest pain, no shortness of breath. Only had right shoulder pain after laying on the cath table. Past Medical History: CAD Hypertension. Insulin-dependent diabetes mellitus, dx at age 13, pump started [**2183-9-6**]. Status post bilateral laser surgery to eyes. Status post bilateral cataract surgery, corneal transplants Pacemaker placement: DDD [**Company 1543**] pacemaker, Prodigy DR S7860, last interrogated on [**2-24**] with 1.5-3.5 battery life, not pacer dependent. DM w/ Eye Manifestation, type 1, last HbA1C 7.4: [**3-1**] Hypercholesterolemia Anemia, unspecified Chronic kidney disease, stage 3 Social History: significant for the absence of current tobacco use. There is no history of alcohol abuse. Family History: There is no family history of premature coronary artery disease or sudden death. Physical Exam: VS: BP 117/71 HR 83 RR 18 O2 96% 4L 62" 131 # Gen: WDWN middle aged female in NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. eccentric pupil, reactive, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. Neck: Supple with JVP of 11 cm. CV: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 ?S4. Chest: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. Crackles at right base Abd: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. Ext: No edema, ?clubbing. No femoral bruits. Skin: No stasis dermatitis, ulcers, scars, or xanthomas. . Pulses: Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP [**11-26**]+ PT 2+ Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP [**11-26**]+ PT 2+ Pertinent Results: [**2194-3-8**] 01:50PM BLOOD WBC-9.4 RBC-3.55* Hgb-11.0* Hct-31.2* MCV-88 MCH-30.9 MCHC-35.2* RDW-14.8 Plt Ct-138* [**2194-3-9**] 05:10AM BLOOD WBC-8.2 RBC-3.19* Hgb-9.9* Hct-27.9* MCV-88 MCH-30.9 MCHC-35.3* RDW-14.7 Plt Ct-135* [**2194-3-9**] 06:44PM BLOOD Hct-32.1* [**2194-3-8**] 01:50PM BLOOD Neuts-74.2* Lymphs-21.3 Monos-4.4 Eos-0 Baso-0.2 [**2194-3-8**] 01:50PM BLOOD PT-14.7* PTT-121.6* INR(PT)-1.3* [**2194-3-8**] 01:50PM BLOOD Glucose-119* UreaN-64* Creat-1.9* Na-138 K-4.9 Cl-102 HCO3-24 AnGap-17 [**2194-3-8**] 01:50PM BLOOD CK(CPK)-1740* [**2194-3-8**] 06:15PM BLOOD ALT-436* AST-650* AlkPhos-64 Amylase-200* DirBili-0.2 [**2194-3-9**] 05:10AM BLOOD ALT-392* AST-460* CK(CPK)-1023* AlkPhos-63 TotBili-0.5 [**2194-3-9**] 06:44PM BLOOD CK(CPK)-577* [**2194-3-8**] 01:50PM BLOOD cTropnT-5.65* [**2194-3-8**] 11:58PM BLOOD CK-MB-66* MB Indx-4.9 cTropnT-4.43* [**2194-3-8**] 01:50PM BLOOD Calcium-9.5 Phos-4.7* Mg-3.4* [**2194-3-8**] 11:58PM BLOOD Calcium-8.3* Mg-3.0* Cholest-103 [**2194-3-8**] 06:15PM BLOOD %HbA1c-7.3* [Hgb]-DONE [A1c]-DONE [**2194-3-8**] 11:58PM BLOOD Triglyc-55 HDL-50 CHOL/HD-2.1 LDLcalc-42 . Admission CXR: FINDINGS: Portable upright chest radiograph is reviewed and compared to [**2187-5-20**]. Cardiac size is not enlarged. Mediastinal and hilar contours are unremarkable. Pulmonary vasculature is not enlarged. There is ill-defined airspace opacity, with air bronchograms within the right upper lobe, likely the posterior segment, and also probably in the right lower lung field. The left lung is clear. There is no pleural effusion or pneumothorax. Right- sided pacemaker and two leads overlying the heart are unchanged in position since prior exam. Osseous structures are unremarkable. IMPRESSION: Right upper lobe pneumonia. . ECHO [**3-11**]: INTERPRETATION: Findings: LEFT ATRIUM: Normal LA size. RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. LEFT VENTRICLE: Normal LV wall thickness. Normal LV cavity size. Mild regional LV systolic dysfunction. False LV tendon (normal variant). Mildly depressed LVEF. No resting LVOT gradient. LV WALL MOTION: Regional LV wall motion abnormalities include: basal inferior - akinetic; mid inferior - akinetic; mid inferolateral - hypo; inferior apex - akinetic; RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Normal aortic diameter at the sinus level. Normal ascending aorta diameter. Normal aortic arch diameter. AORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR. MITRAL VALVE: Normal mitral valve leaflets. Mild (1+) MR. TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Normal PA systolic pressure. PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with physiologic PR. PERICARDIUM: No pericardial effusion. Conclusions: The left atrium is normal in size. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. There is mild regional left ventricular systolic dysfunction with inferior akinesis and inferolateral hypokinesis. Overall left ventricular systolic function is mildly depressed. 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 structurally normal. Mild (1+) mitral regurgitation is seen. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. [**2194-3-8**] Cardiac Catheterization 1. Selective coronary angiography in this right dominant system revealed three vessel coronary artery disease. The LMCA had mild disease. The LAD had a 90% stenosis in the mid vessel and a 50% stenosis in the mid vessel. The LCx had a 90% ostial lesion and a 70% lesion in the mid vessel. The RCA had a 40% proximal stenosis, 60% mid vessel stenosis, and 60% distal stenosis. 2. Left ventriculography was deferred. 3. Resting hemodynamics demonstrated elevated left and right sided filling pressures with an LVEDP and RVEDP of 21 mmHg and 17 mmHg, respectively. There was pulmonary arterial hypertension with a PA pressure of 50/22 (systolic/diastolic in mmHg). Cardiac index was severely depressed at 1.5 l/min/m2. Cardiology Report ECHO Study Date of [**2194-3-12**] PATIENT/TEST INFORMATION: Indication: Aortic valve disease. Coronary artery disease. Left ventricular function. Mitral valve disease. Status: Inpatient Date/Time: [**2194-3-12**] at 12:02 Test: TEE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Tape Number: 2007AW210-0:00 Test Location: Anesthesia West OR cardiac Technical Quality: Adequate REFERRING DOCTOR: DR. [**First Name (STitle) **] [**Name (STitle) **] MEASUREMENTS: Left Ventricle - Ejection Fraction: 30% to 35% (nl >=55%) Aorta - Valve Level: 2.4 cm (nl <= 3.6 cm) Aorta - Ascending: 2.7 cm (nl <= 3.4 cm) INTERPRETATION: Findings: LEFT ATRIUM: Normal LA size. No spontaneous echo contrast or thrombus in the LA/LAA or the RA/RAA. RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. A catheter or pacing wire is seen in the RA. A mass/thrombus associated with a catheter/pacing wire in the RA or RV. No ASD by 2D or color Doppler. LEFT VENTRICLE: Normal LV cavity size. Severe regional LV systolic dysfunction. Moderately depressed LVEF. LV WALL MOTION: Regional LV wall motion abnormalities include: basal anterior - hypo; mid anterior - hypo; basal anteroseptal - hypo; mid anteroseptal - hypo; basal inferoseptal - hypo; mid inferoseptal - hypo; basal inferior - hypo; mid inferior - hypo; basal inferolateral - hypo; mid inferolateral - hypo; basal anterolateral - hypo; mid anterolateral - hypo; anterior apex - hypo; septal apex - hypo; inferior apex - hypo; lateral apex - hypo; apex - hypo; RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Normal aortic diameter at the sinus level. Normal ascending aorta diameter. Normal descending aorta diameter. Simple atheroma in descending aorta. AORTIC VALVE: Three aortic valve leaflets. Mildly thickened aortic valve leaflets. No AS. No AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild mitral annular calcification. Mild thickening of mitral valve chordae. No MS. Mild (1+) MR. TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with physiologic PR. PERICARDIUM: No pericardial effusion. GENERAL COMMENTS: A TEE was performed in the location listed above. I certify I was present in compliance with HCFA regulations. No TEE related complications. The patient was under general anesthesia throughout the procedure. Conclusions: 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. A mass/thrombus associated with a catheter/pacing wire is seen in the right atrium and/or right ventricle. No atrial septal defect is seen by 2D or color Doppler. The left ventricular cavity size is normal. Overall left ventricular systolic function is moderately depressed. Right ventricular chamber size and free wall motion are normal. There are simple atheroma in the descending thoracic aorta. There are three aortic valve leaflets. The aortic valve leaflets are mildly thickened. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. There is no pericardial effusion. Electronically signed by [**First Name8 (NamePattern2) 6506**] [**Name8 (MD) 6507**], MD on [**2194-3-12**] 14:35. [**Location (un) **] PHYSICIAN: (07-05674FRADIOLOGY Final Report CHEST (PA & LAT) [**2194-3-18**] 11:48 AM CHEST (PA & LAT) Reason: evaluation of pleural effusion [**Hospital 93**] MEDICAL CONDITION: 61 year old woman with acute CAD s/p CABG. Please page [**First Name8 (NamePattern2) **] [**Doctor Last Name **] at [**Numeric Identifier 8570**] with abnormalities. Pt still in the OR, please perform when in the CSRU. REASON FOR THIS EXAMINATION: evaluation of pleural effusion PA AND LATERAL CHEST INDICATION: Evaluate pleural effusion. FINDINGS: Compared with 4/23, the small right pleural effusion appears unchanged. There is now increased patchy atelectasis/infiltrate at the left lung base. Even allowing for lower lung volumes, the pulmonary vascularity appears mildly engorged, consistent with mild CHF. DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] Approved: TUE [**2194-3-18**] 10:58 PM Brief Hospital Course: Mrs. [**Known lastname 8571**] was admitted to the [**Hospital1 18**] on [**2194-3-8**] via transfer for further management Plavix, aspirin and heparin were continued. She underwent a cardiac catheterization which revealed severe three vessel disease. Given the severity of her disease, the cardiac surgical service was consulted for surgical revascularization. She ruled in for a myocardial infarction and heparin, plavix and aspirin were continued. Mrs. [**Known lastname 8571**] was worked-up in the usual preoperative manner including a carotid duplex ultrasound which showed normal internal carotid arteries. She was transfused with red blood cells for preoperative anemia. On [**2194-3-12**], Mrs. [**Known lastname 8571**] was taken to the operating room where she underwent coronary artery bypass grafting to four vessels. Postoperatively she was taken to the cardiac surgical intensive care unit for monitoring. On postoperative day one, she awoke neurologically intact and was extubated. The [**Last Name (un) **] diabetes service was consulted to assist with her postoperative hyperglycemia and elevated preoperative hemoglobbin A1c. They followed her throughout her postoperative course. Aspirin, beta blockade and a statin were resumed. On postoperative day two, she was transferred to the step down unit for further recovery. She was gently diuresed towaards her preoperative weight.Chest tubes and pacing wires removed. The physical therapy service was consulted for assistance with her postoperative strength and mobility. She developed a large left pleural effusion for which she underwent thoracentesis of 600cc on [**3-17**]. Insulin pump was managed by the [**Last Name (un) **] service with the pt. Cleared for discharge to home with VNA on POD #6. Pt. is to make all follow-up appts. as per discharge instructions. Medications on Admission: Altace 10 mg QDay Humalog 100 U/ml as directed Lasix 40 Qday Lipitor 40mg 1 once a day Glucagon 1mg prn Niferex 100mg/5ml 5 ml [**Hospital1 **] Humalog 300 U/3ml before meals Calcium 600mg twice a day Toprol Xl 50mg once a day Zetia 10mg 1 time per day Cosopt 0.5-2% 1 as directed both eyes qd Isosorbide Dinitrate 10mg three times a day One Touch Ultra - Lancets Lancet as directed Aspirin 81mg Pred Forte 1% once a day Folic Acid 0.4mg once a day Xalatan 0.005% once a day both eyes Coenzyme Q10 50mg 1 per day Vitamin C 500mg twice a day Plavix 75mg 1/2tab every other day Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*0* 2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for pain. Disp:*50 Tablet(s)* Refills:*0* 4. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 5. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 6. Prednisolone Acetate 1 % Drops, Suspension Sig: One (1) Drop Ophthalmic DAILY (Daily). Disp:*1 bottle* Refills:*2* 7. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at bedtime). Disp:*1 bottle* Refills:*2* 8. Dorzolamide-Timolol 2-0.5 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2 times a day). Disp:*1 bottle* Refills:*2* 9. Ferrous Gluconate 300 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 10. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*0* 11. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*0* 12. Altace 5 mg Capsule Sig: One (1) Capsule PO once a day. Disp:*30 Capsule(s)* Refills:*0* 13. insulin pump continue and follow up with [**Hospital **] Clinic 14. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): please take twice daily for 1 week and then decrease to once a day . Disp:*60 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Company 1519**] Discharge Diagnosis: Coronary artery disease s/p CABG X 4 IDDM Osteomyelitis Chronic renal insufficiency pacemaker HTN Discharge Condition: Good. Discharge Instructions: Follow medications on discharge instructions. Do not drive for 4 weeks. Do not lift more than 10 lbs. for 2 months. Shower daily, let water flow over wounds, pat dry with a towel. Do not use creams, lotions, or powders on wounds. Call our office for temp>101.5, sternal drainage. Followup Instructions: Make an appointment with Dr. [**Last Name (STitle) 634**] for 1-2 weeks. [**Telephone/Fax (1) 8572**] Make an appointment with Dr [**Last Name (STitle) 8573**] for 2 weeks [**Telephone/Fax (1) 8572**] Make an appointment with Dr. [**First Name (STitle) **] in 4 weeks.[**Telephone/Fax (1) 170**] Make an appointment with [**Last Name (un) **] follow-up. [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**] Completed by:[**2194-3-27**]

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Discharge summary

report+addendum

Admission Date: [**2131-8-1**] Discharge Date: [**2131-8-5**] Date of Birth: [**2070-1-3**] Sex: F Service: SURGERY Allergies: Lipitor / Pravachol / simvastatin Attending:[**First Name3 (LF) 32612**] Chief Complaint: Pancreatic body mass Major Surgical or Invasive Procedure: Robotic distal pancreatectomy and splenectomy History of Present Illness: Ms. [**Known lastname 32610**] is a 61-year-old woman with a cystic pancreatic body mass measuring 1.7 x 1.4 cm. The mass was an incidental finding seen on CT performed for emesis in [**2124**], and at that time measured 1.4 x 1.3 cm. The mass had been followed with no change up until [**2127**]. On her most recent imaging performed at [**Hospital1 **] [**Location (un) 620**], the mass had grown to 1.7 x 1.4cm with an increase in the degree of wall enhancement. Ms. [**Known lastname 32610**] [**Last Name (Titles) 15797**] fevers, chills, nausea, vomiting, diarrhea, flushing and shortness of breath. EUS performed [**2131-6-8**] revealed a 1.8 x 1.6 cm round lesion, complex cystic mass in the distal body of the pancreas. The mass was predominently solid with a cystic component. The findings were compatible with pancreatic neuroendocrine tumor. The pancreatic and bile ducts were normal. Past Medical History: 1. Papillary Thyroid Cancer s/p resection 2. Hyperparathyroidism 3. History of bleeding after dental resection at age 12. Never worked up for VWF. 4. B cell Lymphoma 4. HTN 5. Hypothyroidism 6. Hypercholesterolemia 7. Functional platelet disorder 8. Depression PSH: 1. Dental extractions - c/b excessive bleeding 2. Breast reduction surgery - no complications except extensive ecchymoses 3. Total thyroidectomy PGH: 1. Heavy Menses thought to be [**1-25**] Fibroids. Social History: She works as a technical writer. She lives alone with her parrot. She does not smoke or drink any alcohol. Family History: Cousin - [**Name (NI) **] [**Last Name (Prefixes) 4516**] Disease. No FH of thyroid/parathyroid disease but her brother had kidney stones. Her mother had breast cancer at age 48. Physical Exam: Upon discharge: Vitals - 99.5 98.9 68 147/76 16 92%RA Gen - AAOx3, NAD CV - RRR +S1/S2 Resp - CTAB, no crackles/wheezes/rhonchi Abd - soft, non-tender, non-distended, no rebound/rigidity/guarding, +BS, no palpable masses Inc - clean/dry/intact, small amount of purple bruising surrounding left-most and right-most incisions, no erythema/drainage/induration Ext - no edema/clubbing/cyanosis Pertinent Results: [**2131-8-4**] 07:15AM BLOOD WBC-19.3* RBC-3.78* Hgb-11.5* Hct-34.3* MCV-91 MCH-30.5 MCHC-33.6 RDW-13.2 Plt Ct-468* [**2131-8-4**] 07:15AM BLOOD Plt Ct-468* [**2131-8-5**] 05:25AM BLOOD Glucose-101* UreaN-14 Creat-0.5 Na-140 K-4.0 Cl-105 HCO3-26 AnGap-13 [**2131-8-5**] 05:25AM BLOOD Calcium-8.0* Phos-2.9 Mg-2.2 Operative Pathology: pending at time of discharge. Brief Hospital Course: The patient was admitted to the General Surgical Service for evaluation and treatment. On [**2131-8-1**], the patient underwent robotic distal pancreatectomy and splenectomy, which went well without complication (reader referred to the Operative Note for details). After a brief, uneventful stay in the PACU, the patient arrived on the floor NPO, on IV fluids and antibiotics, with a foley catheter, JP drain, dPCA for pain control, on amicar as specified by her consultant specialist, for history of functional platelet disorder. The patient was hemodynamically stable. On POD#1 ([**8-2**]): The patient continued to have good pain control with a dPCA. She was admitted to the ICU due to regulations for administration of Amicar. She continued to have a foley catheter, on IV fluids, and with her JP drain in place. She was advanced to clear liquids on this day, which she tolerated well. In the evening of this day, it was determined upon discussion with her hematology specialist, that Amicar was no longer required. This medication was discontinued, and the patient was moved to the general surgical floor for the remainder of her recovery. On POD#2 ([**8-3**]): The patient was continued on a dPCA for pain control, and toradol was added to her regimen for 3 days, which she tolerated well. She continued to take in clear liquids, and her IV fluids were discontinued upon sufficient oral intake. She continued to have a foley catheter and JP drain. She ambulated multiple times per day with nursing assistance. On POD#3 ([**8-4**]): The patient continued to have good pain control on the specified regimen. She took in good oral intake of clear liquids. Her foley catheter was discontinued, and she voided independently. Her JP drain was maintained. She ambulated regularly. On POD#4 ([**8-5**]): The patient was transitioned to oral pain medications, which she tolerated very well. Her diet was advanced to a low-fat regular diet. All her home medications were restarted. She ambulated multiple times on this day. She was administered the full set of post-splenectomy vaccines. She was provided JP drain teaching, and set up with VNA care. The patient remained stable from a cardiovascular standpoint; vital signs were routinely monitored. Good pulmonary toilet, early ambulation and incentive spirometry were encouraged throughout hospitalization. Electrolytes were routinely followed, and repleted when necessary. The patient's white blood count and fever curves were closely watched for signs of infection. Wound care was performed regularly and thoroughly. The patient's blood sugar was monitored throughout his stay; insulin dosing was adjusted accordingly. The patient received subcutaneous heparin and venodyne boots were used during this stay; was encouraged to get up and ambulate as early as possible. At the time of discharge, the patient was doing well, afebrile with stable vital signs. The patient was tolerating a regular diet, ambulating, voiding without assistance, and pain was well controlled. The patient received discharge teaching and follow-up instructions with understanding verbalized and agreement with the discharge plan. Medications on Admission: ERGOCALCIFEROL (VITAMIN D2) [VITAMIN D2] - 50,000 unit capsule - one Capsule(s) by mouth every week FLUOXETINE - 40 mg capsule - one Capsule(s) by mouth once a day - note new size HYDROCHLOROTHIAZIDE - 25 mg tablet - one Tablet(s) by mouth once a day LEVOTHYROXINE [LEVOXYL] - 150 mcg tablet - 1 Tablet(s) by mouth daily Take fasting with water only - No Substitution LISINOPRIL - 10 mg tablet - one Tablet(s) by mouth once a day Discharge Medications: 1. Fluoxetine 40 mg PO DAILY 2. Hydrochlorothiazide 25 mg PO DAILY 3. Lisinopril 10 mg PO DAILY 4. Omeprazole 20 mg PO DAILY 5. Vitamin D 50,000 UNIT PO 1X/WEEK (SA) 6. OxycoDONE (Immediate Release) 5-10 mg PO Q4H:PRN pain RX *oxycodone 5 mg [**12-25**] tablet(s) by mouth Q6H:PRN Disp #*50 Tablet Refills:*0 7. Levothyroxine Sodium 150 mcg PO DAILY Discharge Disposition: Home With Service Facility: Allcare VNA and Hospice Discharge Diagnosis: Pancreatic body mass Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to the surgery service at [**Hospital1 18**] for surgical resection of your pancreatic mass. You have done well in the post operative period and are now safe to return home to complete your recovery with the following instructions: Please resume all regular home medications , unless specifically advised not to take a particular medication. Also, please take any new medications as prescribed. Please get plenty of rest, continue to ambulate several times per day, and drink adequate amounts of fluids. Avoid lifting weights greater than [**5-3**] lbs until you follow-up with your surgeon, who will instruct you further regarding activity restrictions. Avoid driving or operating heavy machinery while taking pain medications. Please follow-up with your surgeon and Primary Care Provider (PCP) as advised. Incision Care: *Please call your doctor or nurse practitioner if you have increased pain, swelling, redness, or drainage from the incision site. *Avoid swimming and baths until your follow-up appointment. *You may shower, and wash surgical incisions with a mild soap and warm water. Gently pat the area dry. *If you have staples, they will be removed at your follow-up appointment. *If you have steri-strips, they will fall off on their own. Please remove any remaining strips 7-10 days after surgery. JP Drain Care: *Please look at the site every day for signs of infection (increased redness or pain, swelling, odor, yellow or bloody discharge, warm to touch, fever). *Maintain suction of the bulb. *Note color, consistency, and amount of fluid in the drain. Call the doctor, nurse practitioner, or VNA nurse if the amount increases significantly or changes in character. *Be sure to empty the drain frequently. Record the output, if instructed to do so. *You may shower; wash the area gently with warm, soapy water. *Keep the insertion site clean and dry otherwise. *Avoid swimming, baths, hot tubs; do not submerge yourself in water. *Make sure to keep the drain attached securely to your body to prevent pulling or dislocation. Please call your doctor or nurse practitioner if you experience the following: *You experience new chest pain, pressure, squeezing or tightness. *New or worsening cough, shortness of breath, or wheeze. *If you are vomiting and cannot keep down fluids or your medications. *You are getting dehydrated due to continued vomiting, diarrhea, or other reasons. Signs of dehydration include dry mouth, rapid heartbeat, or feeling dizzy or faint when standing. *You see blood or dark/black material when you vomit or have a bowel movement. *You experience burning when you urinate, have blood in your urine, or experience a discharge. *Your pain is not improving within 8-12 hours or is not gone within 24 hours. Call or return immediately if your pain is getting worse or changes location or moving to your chest or back. *You have shaking chills, or fever greater than 101.5 degrees Fahrenheit or 38 degrees Celsius. *Any change in your symptoms, or any new symptoms that concern you. Followup Instructions: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1207**], MD Phone:[**Telephone/Fax (1) 2789**] Date/Time:[**2131-9-10**] 10:30 Provider: [**First Name11 (Name Pattern1) 3972**] [**Last Name (NamePattern4) 3973**], MD Phone:[**Telephone/Fax (1) 1803**] Date/Time:[**2131-9-13**] 11:00 Please follow up with Dr. [**Last Name (STitle) **] in clinic Friday [**2131-8-10**]. Someone from Dr.[**Name (NI) 32613**] clinic will call you tomorrow ([**2131-8-6**]) to set up an appointment. Completed by:[**2131-8-5**] Name: [**Known lastname 5657**],[**Known firstname 4497**] Unit No: [**Numeric Identifier 5658**] Admission Date: [**2131-8-1**] Discharge Date: [**2131-8-5**] Date of Birth: [**2070-1-3**] Sex: F Service: SURGERY Allergies: Lipitor / Pravachol / simvastatin Attending:[**First Name3 (LF) 5659**] Addendum: This addendum is to clarify, as confirmed by the final Pathology report, the final tumor type/diagnosis. Operative Pathology (reported [**2131-8-6**]): DIAGNOSIS: I. Distal pancreas, distal pancreatectomy (A-N): Well differentiated pancreatic neuroendocrine tumor (1.3 cm), confined to the pancreas (pT1), without lymphovascular invasion, tumor necrosis, or increased mitotic activity; see synoptic report. Two regional lymph nodes without evidence of tumor (pN0). Resection margins are free of neuroendocrine tumor. II. Spleen and hilar fat, 320 grams (O-P): Spleen with expanded and congested red pulp; given the patient's history of a lymphoproliferative disorder, a review of these slides by hematopathology is in progress and the results will be issued in a separate addendum. MICROSCOPIC Functionality type: Pancreatic endocrine tumor, non-functional. WHO Classification: Well-differentiated endocrine tumor, benign behavior (Confined to pancreas. <2 cm, no angioinvasion or perineural invasion, <2 mitoses per 10 HPF). Mitotic activity: Less than 2 mitoses/10 High Power Fields. Tumor necrosis: Not identified. Margins: Uninvolved by tumor. Distance from closest margin: 1.5 cm. Specified margin: Pancreatic transection margin. Primary Tumor: Tumor confined to pancreas. Primary Tumor (pT): pT1: Tumor limited to pancreas, 2 cm or less in greatest dimension. Regional Lymph Nodes (pN): pN0: No regional lymph node metastasis. Lymph Nodes Number examined: 2. Number involved: 0. Distant metastasis (pM): pMX: Cannot be assessed. Lymphatic/vascular Invasion: Absent. Perineural invasion: Absent. Additional Pathologic Findings: None identified. Based on the above operative pathology report, the final tumor type is classified as: Benign islet cell tumor. Discharge Disposition: Home With Service Facility: Allcare VNA and Hospice [**First Name11 (Name Pattern1) 46**] [**Last Name (NamePattern4) 5660**] MD [**MD Number(2) 5661**] Completed by:[**2131-10-1**]

[ "244.0", "272.4", "287.1", "401.9", "V10.79", "211.7", "V10.87" ]

icd9cm

[ [ [] ] ]

[ "41.5", "52.52", "17.42" ]

icd9pcs

[ [ [] ] ]

13005, 13218

2923, 6090

312, 360

7065, 7065

2534, 2900

10290, 12982

1927, 2109

6570, 6923

7021, 7044

6116, 6547

7216, 8049

8064, 10267

2124, 2124

252, 274

2140, 2515

388, 1293

7080, 7192

1315, 1786

1802, 1911

58,947

100,037

13143

Discharge summary

report

Admission Date: [**2183-3-23**] Discharge Date: [**2183-5-9**] Date of Birth: [**2124-10-29**] Sex: M Service: MEDICINE Allergies: Penicillins Attending:[**First Name3 (LF) 7591**] Chief Complaint: Weakness Major Surgical or Invasive Procedure: Bone marrow biopsy History of Present Illness: 58 y/o M presented to [**Hospital1 **] [**Location (un) 620**] after a syncopal episode today where he sustained a facial hematoma. Pt remembers going to the bathroom in the early morning and then awoke on the floor approx 2hrs laterwith left sided facial bruising and incontinence. Pt reports severe nosebleeds that began 2 days prior to admission. On saturday, he was feeling lightheaded and developped severe right thigh pain. On Sunday, he noticed decreased appetite, left thigh pain and fevers/chills. On further review of symptoms, pt has been noticing increased bruising and general lethargy for the last week. Per report, his wife has been trying to get him to see [**Name8 (MD) **] MD for months as she has been concerned about his generalized weakness. . Pt initially presented to [**Hospital1 **] [**Location (un) **] and was febrile to 101.2 and received Vanc and Ceftazidime for neutropenic fever. He underwent head CT that revealed small foci of petechial hemorrhage within the left frontal lobe and small subarachnoid hemorrhage. Initial VS on arrival to the [**Hospital1 18**] ED: T 100.4 P 76 BP 110/55 R 18 O2 sat 99% RA. Pt was given Acyclovir for possible Zoster. He underwent CTA that was negative for PE and received 2L of NS IVF. Pt was being transfused with a second bag of plts prior to arrival to ICU. . On arrival, pt was complaining of right & left proximal thigh pain approx [**8-22**]. Otherwise, denying CP, SOB, HA, abd pain, nausea, visual changes. He was feeling exhausted and still mildly lightheaded. Past Medical History: Osteoarthritis (knees) Social History: Pt works as a headmaster in [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 1573**] school. He lives with his wife and has two healthy children, three grandchildren. He used to be a marathon runner. Denies smoking and illicit drug use. He reports consuming approx 1 drink per day. Family History: Father died of metastatic prostate cancer in his 80s, mother alive with HTN and insulin resistance. Physical Exam: Vitals: T: 98.6 BP: 137/73 P: 83 R: 20 O2: 975 on RA General: alert, oriented, large ecchymosis over left orbit, eye swollen shut HEENT: sclera anicteric, dry MM, oropharynx with dried blood Neck: supple, JVP not elevated, precervical lymphadenopathy Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: RRR, normal S1/S2, no m/r/g Abdomen: soft, NT, ND, NABS, no rebound tenderness or guarding, no appreciable hepatosplenomegaly Inguinal: no inguinal lymphadenopathy Ext: Warm, well perfused, 2+ pulses Neuro: CN 2-12 intact (except unable to assess left eye due to swelling & eccyhmoses). Strength 5/5 all four extremities distally. Unable to assess proximal muscle strength in lower extremities [**3-17**] pain. Sensation intact distally. Gait not assessed. No saddle anesthesia, no focal spinal tenderness. Pertinent Results: [**2183-3-23**] 08:46PM GLUCOSE-116* UREA N-14 CREAT-0.8 SODIUM-138 POTASSIUM-3.7 CHLORIDE-105 TOTAL CO2-24 ANION GAP-13 [**2183-3-23**] 08:46PM ALT(SGPT)-21 AST(SGOT)-20 LD(LDH)-286* CK(CPK)-126 ALK PHOS-65 TOT BILI-0.8 [**2183-3-23**] 08:46PM ALBUMIN-3.9 CALCIUM-8.5 PHOSPHATE-3.1 MAGNESIUM-2.0 URIC ACID-5.1 [**2183-3-23**] 08:46PM WBC-0.7* RBC-2.21* HGB-7.6* HCT-20.3* MCV-92 MCH-34.5* MCHC-37.5* RDW-17.5* [**2183-3-23**] 08:46PM I-HOS-AVAILABLE [**2183-3-23**] 08:46PM PLT COUNT-43* [**2183-3-23**] 08:46PM PT-17.0* PTT-29.8 INR(PT)-1.5* [**2183-3-23**] 08:46PM FDP-160-320* [**2183-3-23**] 08:46PM FIBRINOGE-303 [**2183-3-23**] 08:46PM GRAN CT-230* [**2183-3-23**] 06:55PM PLT COUNT-53*# [**2183-3-23**] 03:40PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]->1.050 [**2183-3-23**] 03:40PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG [**2183-3-23**] 03:40PM URINE RBC-[**4-17**]* WBC-[**4-17**] BACTERIA-RARE YEAST-NONE EPI-0-2 [**2183-3-23**] 03:40PM URINE MUCOUS-OCC [**2183-3-23**] 03:16PM LACTATE-2.0 [**2183-3-23**] 03:10PM GLUCOSE-123* UREA N-16 CREAT-0.9 SODIUM-137 POTASSIUM-3.9 CHLORIDE-102 TOTAL CO2-24 ANION GAP-15 [**2183-3-23**] 03:10PM estGFR-Using this [**2183-3-23**] 03:10PM CK(CPK)-147 [**2183-3-23**] 03:10PM CK-MB-1 cTropnT-<0.01 [**2183-3-23**] 03:10PM WBC-0.7* RBC-2.63* HGB-8.9* HCT-24.2* MCV-92 MCH-34.0* MCHC-37.0* RDW-17.8* [**2183-3-23**] 03:10PM NEUTS-8* BANDS-4 LYMPHS-76* MONOS-0 EOS-0 BASOS-0 ATYPS-0 METAS-4* MYELOS-2* NUC RBCS-2* OTHER-6* [**2183-3-23**] 03:10PM HYPOCHROM-NORMAL ANISOCYT-1+ POIKILOCY-OCCASIONAL MACROCYT-1+ MICROCYT-NORMAL POLYCHROM-OCCASIONAL OVALOCYT-OCCASIONAL TEARDROP-OCCASIONAL [**2183-3-23**] 03:10PM PLT SMR-VERY LOW PLT COUNT-29* [**2183-3-23**] 03:10PM PT-15.9* PTT-28.2 INR(PT)-1.4* [**2183-3-23**] 03:10PM GRAN CT-290* [**2183-3-24**] CT HEAD IMPRESSION: 1. Increased size of left frontal and right posterior cingulate gyrus intraparenchymal hemorrhages. 2. Increased size of right frontal, right temporal, and interhemispheric subarachnoid hemorrhage. 3. No midline shift. No evidence of acute infarction. [**2183-3-24**] MRI L/T-SPINE No evidence of acute spine injury within the cervical, thoracic or lumbar spine. Note is made of a fluid level within the lower lumbar spine, most consistent with layering subarachnoid blood. Pathology Examination Name Birthdate Age Sex Pathology # [**Hospital1 18**] [**Known lastname 40120**],[**Known firstname **] [**2124-10-29**] 58 Male [**Numeric Identifier 40121**] [**Numeric Identifier 40122**] Report to: DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **] Gross Description by: DR. [**Last Name (STitle) **]. MARIAPPAN SPECIMEN SUBMITTED: Immunophenotyping, Bone Marrow Procedure date Tissue received Report Date Diagnosed by [**2183-3-24**] [**2183-3-24**] [**2183-3-25**] DR. [**Last Name (STitle) **]. MARIAPPAN/ttl Previous biopsies: [**Numeric Identifier 40123**] BONE MARROW BIOPSY (1 JAR). INTERPRETATION Immunophenotypic findings consistent with involvement by: an immature population of cells consistent with acute myelogenous leukemia. Lack of CD34 and HLA-DR [**Last Name (STitle) 40124**] to be consistent with a diagnosis of acute promyelocytic leukemia. Correlation with morphologic and cytogenetic findings is recommended. Brief Hospital Course: 58 y/o M presenting after syncopal episode found to have multiple small ICH and new pancytopenia. Had complicated course of AMPL treatment # Leukemia: Patient found to have AMPL via bone marrow biopsy the day of admission to the MICU. He was started on ATRA and monitored closely for symptoms of DIC, TLS and ATRA syndrome. He was transfused as needed with PRBC, platlets and FFP. He did not develop overt signs of DIC. He was induced with Ara-c and daunurubicin. His counts responded appropriatly. A repeat BM biopsy showed remission and he will continue the ATRA for now and follow up with Dr. [**Last Name (STitle) 410**] for plans of stage two of his treatment. . # Fevers: He initially was on Vancomycin and cefepime when first starting treatment due to a hx of fevers at home, but as his culture data was negative and he remained afebrile his antibiotics were discontinued. He remained afebrile until [**4-14**] when he spiked a fever. He was cultured and his blood grew strep viridans. He was started on vanco/cefepime at that time. He also had a headache the day he spiked and a CT was done showing what appeared to be brain abscesses. His antibiotics were eventually broadened to vanco, meropenem, fluconzaole and flagyl for the brain abscesses. He continued to spike, though for approximately a week. He complained of some thigh pain and we did an ultrasound showing bilateral fluid collections. They were drained in IR and grew MSSA. He then developed a pneumonia during his febrile period and was transferred to the ICU for several days. He required O2 for a while after being discharged from the ICU. While in the ICU, his neutrophil count started to drop, and it was worried that he might be having a drug effect. His vanco was discontinued and his counts began to recover. Eventually he was on meropenem, voriconazole and acyclovir and stopped having fevers. A repeat CT scan showed resolution of his PNA. Serial repeat head CTs showed slow decrease in size of his abscesses. And an MRI of his thigh showed retained small fluid collections bilaterally. The plan is to complete 6 week course of the above antibiotics for his brain abscesses. We will reimage his thighs with an MRI as an outpatient and depending on those results, he will either need surgical drainage or still prolonged course of abx. He will follow up with ID. . # ICH: Pt with multiple small ICH sustained from fall with acute left sided head injury in the setting of profound thrombocytopenia. CT head revealed small foci of intraparenchymal hemorrhage and subarachnoid hemorrhage. (no hydrocephalus or shift). On [**3-24**] follow-up Head CT revealed interval increase in hemorrhage but without appreciable midline shift or infarction. The pt's neurologic exam remained stable. Neurosurgery followed closely. Platlet goal was > 75K. A repeat head CT one month after a fall showed the brain abscesses that were discussed above. Neuro onc was consulted and followed along. It was decided not to do a biopsy. He also required heparin and then lovenox for DVTs, and repeat head CTs while on these anticoaulants remained stable and without new bleeds. . # Thigh pain/weakness: Etiology unclear and unable to get good exam as limited by pain. This may be bone marrow pain. No evidence of hematoma or cellulitis. No bowel or bladder dysfunction, no saddle anesthesia, no focal spinal tenderness to indicate acute cord compression. MRI or the T/L-spine revealed no evidence of acute cord compression. There was evidence of layering fluid likely from the SAH. Although unlikely to be causing the pt's leg pain (nerve irritation secondary to blood) Neurosurgery recommended starting Decadron on [**2182-3-24**]. He was not kept on decadron because chemotherapy was initiated. Eventually he was found to have abscesses in his thighs, as discussed above. . # Afib - pt went into afib while in the ICU. His blood pressures remained stable and he was started on metoprolol. His high rates were 130s-140s; he contined to have afib on and off for about a week and then remained in NSR the week prior to discharge. His metoprolol was titrated to 25 mg tid for good rate control. . # [**Name (NI) 6059**] - pt had one episode of 16 b [**Name (NI) 6059**] v. afib with aberrancy. Cards was consulted and we did agressive electrolyte repletion and continued the metoprolol. He did not have any more occurrences. . # Vasovagal bradycardia - the day prior to admission, while the patient was having a bowel movement, he was noted on telemetry to brady to the 30s, he felt light headed and it resolved in 5 minutes. Appeared to be vaso-vagal and he did not have any more occurrences. Again, cards was consulted and they recommended leaving the metoprolol dose the same at 25 mg tid, as bb actually helps prevent vagal episodes. . # DVTs - while patient was in the ICU, he developed bilaterally pedal edema, thought initially to be due to large amount of IVFs. Because of his new afib, though, we did ultrasounds and found him to have DVTs in R leg, R arm (because he was edematous and had pain around a new PICC line). Heparin was started overnight, but because of his hx of ICHs, it was decided to stop the heparin and place an IVC filter. It was put in place without complications. Evenutally he was found to have bilaterally leg DVTs and then bilateral upper extremity DVTs. At that point, it was decided that he should be anticoagulated. Heparin was initially. Repeat head CT showed no bleed. And then he was converted to lovenox for outpatient treatment of the DVTs. He also had a VQ scan during these findings of DVT that showed low prob of PE. . # Access - pt initially had a subclavian line, then it was pulled while the patient was febrile in early [**Month (only) 958**]. He had PIVs until transfer to the ICU when a PICC line was placed. The PICC line was removed after a DVT was found in the arm. He again had PIVs for a while until a IR guided subclavian line was placed. For outpatient continuation of his 6 week course of antibiotics, a hickman was placed as PICCs could not be placed due to bilateraly UE DVTs. . # Pt was discharged walking around, passing PT and going up stairs. He respiratory status was much improved and he was not on O2 and had no SOB. He was advised not to start work yet and take it easy, although, he was ready to get back to work as soon as possible. Medications on Admission: None Discharge Medications: 1. Heparin Flush 10 unit/mL Kit Sig: One (1) flush Intravenous 6x/day. Disp:*180 flushes* Refills:*2* 2. Saline Flush 0.9 % Syringe Sig: One (1) flush Injection 10x/day. Disp:*300 flushes* Refills:*2* 3. Meropenem 1 gram Recon Soln Sig: One (1) recon soln Intravenous every eight (8) hours for 22 days: This will make end date on [**5-30**]; will be total of 6 week course. Disp:*66 recon soln* Refills:*0* 4. Vesanoid 10 mg Capsule Sig: Five (5) Capsule PO twice a day for 14 days: No substitutions please. Disp:*140 Capsule(s)* Refills:*0* 5. Acyclovir 200 mg Capsule Sig: Two (2) Capsule PO Q8H (every 8 hours). Disp:*180 Capsule(s)* Refills:*2* 6. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:*90 Tablet(s)* Refills:*2* 7. Voriconazole 200 mg Tablet Sig: 1.5 Tablets PO Q12H (every 12 hours). Disp:*90 Tablet(s)* Refills:*2* 8. Enoxaparin 100 mg/mL Syringe Sig: One (1) syringe Subcutaneous Q12H (every 12 hours). Disp:*60 syringe* Refills:*2* Discharge Disposition: Home With Service Facility: Critical Care Systems Discharge Diagnosis: APML Intracranial hemorrhage Syncope Discharge Condition: vital signs stable, walking around, on lovenox, normal neurological exam, afebrile Discharge Instructions: You were admitted to the hospital because you fell. You were found to have low blood counts and a bone marrow biospy showed that you have leukemia. You also had some small areas of bleeding in your head that were stable based on repeat CT scans. You received chemotherapy for your leukemia. . While you were here, you developed an infection both in your brain around the areas where the inital bleeds were found, as well as in your thighs. We treated you with antibiotics which you will need to continue after going home. . You also developed blood clots in your arms and legs. We place a filter in your inferior vena cave (a large vein in your abdomen) so the clots would not go to your lungs. We also anticoagulated you with heparin. You can go home on lovenox to stay anticoagulated. . Lastly, you developed a heart arrhythmia called atrial fibrillation. For that, you should continue taking the medicine metoprolol. . You will have a home nurse help you and your wife do antibiotics and the lovenox shots. You should make sure to start returning to work very slowly. It is probably best to not work or work from home the first week and see how you are feeling before starting to think about going back to the school. You can discuss your progress with Dr. [**Last Name (STitle) 410**] at your follow up appointments. . You should return to the hospital for any fainting, headaches, dizziness, chest pain, shortness of breath, swelling in your extremities, palpitiations or any other concerns. Followup Instructions: Please follow up with Dr. [**Last Name (STitle) 410**] on [**Hospital Ward Name 23**] 7 on Tuesday [**2183-5-13**] at 1:30 pm. Phone number [**Telephone/Fax (1) 3241**]. Please follow up with infectious disease and Dr. [**Last Name (STitle) **] on [**2183-5-19**] at 3:00 pm. Phone number ([**Telephone/Fax (1) 4170**]. You will need a repeat MRI prior to seeing Dr. [**Last Name (STitle) **]. We will give you the date and time at your next appointment. Completed by:[**2183-5-15**]

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icd9cm

[ [ [] ] ]

[ "33.23", "38.7", "03.31", "88.72", "41.31", "38.93", "99.04", "99.07", "99.06", "86.01", "99.05" ]

icd9pcs

[ [ [] ] ]

14163, 14215

6685, 13098

281, 301

14296, 14381

3217, 6662

15937, 16428

2249, 2350

13153, 14140

14236, 14275

13124, 13130

14405, 15914

2365, 3198

233, 243

329, 1876

1898, 1923

1939, 2233

82,359

128,232

7693

Discharge summary

report

Admission Date: [**2183-1-23**] Discharge Date: [**2183-1-26**] Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 1881**] Chief Complaint: shortness of breath Major Surgical or Invasive Procedure: none History of Present Illness: 83 yo male with history of CAD, DM with significant neuropathy, HTN, CHF with EF 40-45% in [**2176**] presenting with acute dyspnea. The patient was in his usual state of health until he started feeling fatigued on the day prior to admission on [**2183-1-23**]. Of note, he says he stopped taking his lasix 1 month ago because he was told by his PCP to do so, however, PCP's letter does not support this. He also reports some sodium indiscretions including occasional bacon and corned hash. Last night, he was awoken by the sensation of sudden severe dyspnea and tachypnea. He took oxazepam which gave him no relief and he promptly called EMS. Per EMS report, he was saturating in the 60s on room air and was given supplemental O2 and lasix 40mg IV ONCE. . In the ED, initial vs were: 97.7 110 152/96 30 85% RA (as low as 79% on RA). He was still hypoxic and tachypneic in the ED, and was therefore given another 40mg of lasix IV in the ED and was initiated on bipap. His saturations improved to 100% and he became more comfortable and less tachypneic. After 30 minutes, however, he became hypotensive to the 80s/50s and thereore bipap was discontinued. A nitro gtt was ordered but never given secondary to hypotension. His saturations and tachypnea improved however but he still remained on 4LNC as he was found to be 89% on RA. He refused a foley therefore it was difficult to discern how much urine output response he had. His last set of vitals were 97.4 102 137/88 18 94%4LNC. . Of note, he had a recent hospitalization for acute heart failure and new onset atrial fibrillation at [**Location (un) 745**]-Wellesly ICU [**11-22**]. He was incidentally noted to have left 5th and 6th rib fractures on CXR secondary to recent fall. He was given labetolol for RVR rate control but became hypotensive and given dopamine. His RVR worsened and was switched to neosynephrine. His troponins peaked to 1.97 but were thought to be [**1-15**] demand. He was diuresed with lasix and called out to the regular floor with continued improvement. He was not anticoaggulated [**1-15**] frequent falls, but started on ASA 325 daily and discharged to rehab. He continues to see PT. . On arrival to the MICU, he denied complaints but felt cold. . Review of systems: (+) Per HPI. Frequent falls [**1-15**] neuropathy, most recent 1 week ago with mild-moderate head trauma no LOC. (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies cough, or wheezing. Denies chest pain, chest pressure, palpitations, or weakness. Denies nausea, vomiting, diarrhea, constipation, abdominal pain, or changes in bowel habits. Denies dysuria, frequency, or urgency. Denies arthralgias or myalgias. Denies rashes or skin changes. Past Medical History: 1. CAD: PMIBI [**2-15**] with fixed apical/ant wall defect, no reversible defects 2. DM type 2, complicated by peripheral neuropathy 3. HTN 4. CHF: echo [**2-15**] with trivial MR, LVEF 40-45%, apical/ant/inf hypokinesis 5. h/o basal cell CA 6. h/o squamous cell CA of skin 7. Frequent falls 8. New onset a fib [**11-22**] not on coumadin [**1-15**] falls. Social History: Lives with his wife, still drives, walks with cane when he is out and a walker in his home. Has had about [**2-14**] mechanical falls per month over the past few months and this is concerning for him. He has been worried about having to need help at home or having to move to [**Hospital3 **] although he adamantly refuses to go to rehab. Drinks 3-4 high balls per day, former smoker, no drug use. Former OB/GYN, retired in late [**2151**]'s. Wife was a gyn pathologist. Family History: non-contributory Physical Exam: MICU ADMISSION PHYSICAL EXAM General: Alert, oriented, mild respiratory distress, delayed speech impediment noted since childhood HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP elevated midway up neck at 45 degrees, no LAD Lungs: Rales bilaterally 2/3 up, no wheezes, mild ronchi, no egophony CV: Tachycardic regular rhythm, [**2-16**] SM murmurs at RUSB with loss of S2, no rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: condom cath foley Ext: cool, well perfused, 1+ edema bilaterally, no clubbing, cyanosis Neuro: CN 2-12 intact. Left arm tricep weakness (states this is old), [**3-18**] bilateral hip and gastroc flex/ext, 1+ patellars, downgoing toes Pertinent Results: [**2183-1-23**] 07:34AM WBC-6.7 RBC-4.70 HGB-14.9 HCT-43.8 MCV-93 MCH-31.8 MCHC-34.1 RDW-14.3 NEUTS-84.9* LYMPHS-10.6* MONOS-2.3 EOS-1.7 BASOS-0.5 PLT COUNT-172 GLUCOSE-101* UREA N-25* CREAT-1.4* SODIUM-144 POTASSIUM-4.9 CHLORIDE-112* TOTAL CO2-17* ANION GAP-20 CALCIUM-8.5 PHOSPHATE-4.1 MAGNESIUM-2.3 PT-12.1 PTT-21.7* INR(PT)-1.0 cTropnT-0.01 proBNP-3067* LACTATE-2.8* TYPE-ART PO2-112* PCO2-35 PH-7.42 TOTAL CO2-23 BASE XS-0 TSH-0.88 [**2183-1-23**] 11:59AM LACTATE-1.6 CXR [**1-24**] FINDINGS: Compared to the film from earlier the same day, there continues to be moderate cardiomegaly, pulmonary vascular redistribution and hazy alveolar infiltrate. Left posterior rib fractures are again visualized. IMPRESSION: CHF, similar in appearance compared to the film from earlier the same day. EKG [**1-24**] Narrow complex regular supraventricular tachycardia. Possible prior inferior myocardial infarction. Poor R wave progression. Non-specific inferolateral ST-T wave changes. Cannot exclude myocardial ischemia. Compared to the previous tracing of [**2183-1-23**] irregular supraventricular tachycardia is present. ST-T wave changes are more pronounced and possibly rate-related. TTE [**1-23**] The left atrium is elongated. No atrial septal defect is seen by 2D or color Doppler. The estimated right atrial pressure is 0-5 mmHg. There is mild symmetric left ventricular hypertrophy with normal cavity size. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. There is mild regional left ventricular systolic dysfunction with akinesis of all distal segments and the apex. Overall left ventricular systolic function is mildly depressed (LVEF= 30-45 %). 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 are severely thickened/deformed. There is mild to moderate aortic valve stenosis (valve area 1.0-1.2cm2). No aortic regurgitation is seen. The mitral valve leaflets are moderately thickened. Trivial mitral regurgitation is seen. The pulmonary artery systolic pressure could not be determined. There is an anterior space which most likely represents a prominent fat pad. IMPRESSION: Mild symmetric left ventricular hypertrophy with normal cavity size and mildly reduced overall left ventricular systolic function with regional wall motion abnormalities as described above. Elevated left ventricular filling pressures. Mild to moderate aortic valve stenosis. No clinically signficant valvular regurgitation. Indeterminate pulmonary artery systolic pressures. Compared with the report of the prior study (images unavailable for review) of [**2177-2-17**], mild to moderate aortic stenosis is new. The overall left ventricular systolic function is similar although additional new wall motion abnormalities cannot be excluded given suboptimal image quality. Brief Hospital Course: 88 yo male with history of CAD, DM with significant neuropathy, HTN, CHF with EF 40-45% in [**2176**] who presented to the ED on [**2183-1-23**] with acute dyspnea in the setting of recent discontinuation of lasix and dietary indiscretions. #) Dyspnea: Most likely secondary to acute on chronic systolic congestive heart failure secondary to 1 month of lasix nonadherance from a misunderstanding of PCP [**Name Initial (PRE) 10700**]. Also contributing was sodium indiscretions. The patient was diuresed with excellent effect and was transitioned to room air over 48 hours. He was restarted on lasix 40mg as he was prescribed with good effect in the past. His BP meds were initially held but isosorbide and metoprolol were restarted prior to discharge. He was given the number for Dr[**Name (NI) 9388**] office to arrange cardiology consultation as an outpatient. His lisinopril was held and he was asked to discuss this with his PCP and cardiologist as an outpatient. . #) The [**Hospital 228**] hospital course was complicated by supraventricular tachycardia. He was given both metoprolol and diltiazem while in the MICU. His SVT was likely related to missing several doses of metoprolol as well as volume shifts with diuresis in the setting of an abnormal LA. After his SVT resolved the patient remained in sinus rhythm without event. Of note, he did receive a new diagnosis of AFib from [**Hospital3 **] but is not on coumadin due to many recent falls. He was continued on aspirin with cards evaluation planned as an outpatient as above. . #) The patient's home DM regimen should be restarted upon return home and his blood sugars were well controlled while in the hospital. #) The patient remained DNR/I throughout his hospitalization. . #) Healthy Disposition Plan was debated between the patient, his wife and several healthcare providers. Physical Therapy along with the patient's in house medical team felt the patient was unsafe to be discharged to home given his recent falls and recommended strongly that the patient go to rehab. He adamantly refused the idea of rehab and felt his wife and in home services could help take care of him in his home. He had the capacity to make this decision so he was discharged to home with his wife along with [**Name (NI) 269**], PT and OT services and home safety evaluation. Medications on Admission: PER OMR 1) Aspirin 325mg PO daily 2) Cilastazol 100mg PO BID 3) Lasix 40mg PO daily (again not taking per PCP instruction, however, PCP gave no instruction) 4) Lisinopril 20mg PO daily 5) Metoprolol 100mg PO BID 6) Provastatin 80mg PO daily 7) Isodril 10mg PO TID 8) Insulin humulin NPH 30 units SQ QAM, 10 units QPM 9) oxazepam 10) detrol Discharge Medications: 1. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. cilostazol 100 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 4. pravastatin 80 mg Tablet Sig: One (1) Tablet PO once a day. 5. isosorbide mononitrate 30 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO once a day. 6. Humulin N Subcutaneous 7. metoprolol tartrate 100 mg Tablet Sig: One (1) Tablet PO twice a day. 8. oxazepam 10 mg Capsule Sig: One (1) Capsule PO HS (at bedtime) as needed for Insomnia. 9. Detrol LA 4 mg Capsule, Ext Release 24 hr Sig: One (1) Capsule, Ext Release 24 hr PO at bedtime. Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Acute on Chronic Systolic CHF Atrial Fibrillation with rapid ventricular response Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: You were admitted to the hospital for shortness of breath. This was felt to be a result of heart failure. You were treated with diuretics which you should continue. You also had a fast, difficult to control heart rate likely related to volume shifts in the setting of heart failure and not receiving your regular medications (metoprolol) while in the ED and initially in the MICU. Your medication changes are listed below: 1. RESTART lasix 40mg daily. Weigh yourself daily. If your weight increases 3 pounds call Dr [**Last Name (STitle) **]. 2. STOP lisinopril until you follow up with Dr [**Last Name (STitle) **]. You should otherwise continue your medications as you were prior to this hospitalization. Your doctors feel strongly that you should go to in patient rehab to improve your strength and balance. You refused this and are at risk for more falls at home. Followup Instructions: Please call [**Hospital3 **] and Dr[**Name (NI) 9388**] office at the following numbers to arrange appointments as listed: [**Company 191**] - [**Telephone/Fax (1) 250**]; please see Dr [**Last Name (STitle) **] or another provider [**Name Initial (PRE) 176**] 1 week in follow up of this hospitalization. Dr [**Last Name (STitle) **] (Cardiology) - ([**Location 27973**]office OR ([**Telephone/Fax (1) 8937**] [**Location (un) 620**] Office Previously arranged appointment: Department: DERMATOLOGY AND LASER When: WEDNESDAY [**2183-1-29**] at 1 PM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 8157**], MD [**Telephone/Fax (1) 3965**] Building: [**Location (un) 3966**] ([**Location (un) 55**], MA) [**Location (un) **] Campus: OFF CAMPUS Best Parking: Free Parking on Site [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1882**] MD, [**MD Number(3) 1883**]

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icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

11200, 11258

7751, 10080

271, 277

11384, 11384

4779, 7728

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3999, 4760

2555, 3082

212, 233

305, 2536

11399, 11543

3104, 3462

3478, 3950

50,923

148,522

42553

Discharge summary

report

Admission Date: [**2138-3-22**] Discharge Date: [**2138-4-6**] Date of Birth: [**2109-8-3**] Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 896**] Chief Complaint: Back/Flank pain s/p renal biopsy Major Surgical or Invasive Procedure: None History of Present Illness: Ms [**Known lastname 92093**] is a 28 y/o female with hx of SLE, asthma, and hypertension, who is transferred to [**Hospital1 18**] from OSH due to large retroperitoneal hematoma and anemia refractory to blood transfusions. She underwent a right renal biopsy on [**3-13**], to evaluate etiology of rising creatinine and proteinuria. The following day, she was was evaluated for flank pain, and was found on imaging to have a 6x1 cm perinephric hematoma. She continued to have flank pain on [**3-18**], and underwent arteriography and thrombin injection by OSH IR, with successful thrombosis of R renal pseudoaneursym. She was subsequently discharged home. . She re-presented to OSH on [**3-20**], due to worsening R flank pain. U/s showed thrombosed pseudoaneursym. CT scan revealed large subcapsularhematoma (16 x 8 x 4cm), extending into retroperitoneum and pelvis. Her admission hgb was 7.4, which dropped to 6.3 over four hours. She was transfused 2u RBC and 2u FFP, along with one unit of platelets, with improvement in hgb to 7.2. She became mildly hypotensive to 90 systolic, and tachycardic to 148, with worsening flank and leg pain. She received two additional units of RBCs, with her hgb level unchanged at 7.2. Four hrs later, hgb was 6.7. Her labs have also been notable for rising leukocytosis (18 -> 21) and creatinine (1.66 -> 1.87), and thrombocytopenia (95 -> 72). Decision was made to transfer to tertiary care center for IR or surgical intervention to control bleeding. VS prior to transfer were 101.2, 122, 127/66, 92% room air. Urine output has been ~30 cc/hr. On transfer, pt was given two additional units (#5 and 6) of RBCs. . On arrival to the MICU, the patient is awake and interactive, but tearful and in significant distress from pain. She feels like she has "a [**Doctor Last Name **] inside of" her abdomen, and the pain radiates down her anterior and posterior thigh. She is asking to be put under general anesthesia if she needs to undergo another IR procedure. She denies chest pain, dyspnea, nausea, vomiting, constipation, diarrhea, dysuria, or rash. She is thirsty and is asking for water. . On transfer to medicine floor, pt is alert and oriented. Her vitals are stable and she has not been febrile. Pain is still limiting her ability to ambulate. Her crits have been stable, last crit was 25.8. She is eating and drinking adequately. . Past Medical History: SLE c/b lupus nephritis asthma hypertension hx bacterial pneumonia s/p appendectomy s/p cholecystectomy s/p colonoscopy Social History: Lives at home with husband and three children. Non smoker, denies etoh/illcits Family History: Maternal GM with diabetes, cancer. Maternal GM and paternal GF with CVD. Mother with lupus. Physical Exam: Admission Exam: Vitals: T:99.0 BP:166/90 P:111 R:21 O2:91% RA, 95 kg, 5'2" General: Awake, alert, oriented, tearful in distress from pain HEENT: MM dry. No conjunctival icterus, injection or pallor. OP clear. EOMI. Neck: supple, no JVD or LAD CV: Tachycardic, regular, normal S1/S2, no S3/S4/M/R Lungs: CTAB, no wheezes, rales, ronchi Abdomen: obese, non-distended, + significantly tender to palpation over left abdomen, +BS throughout Ext: +asymmetric swelling of upper right leg, but not tense. warm, symmetric 2+ DP/PT/radial pulses, no clubbing or cyanosis. No ecchymosis or rash. Neuro: CNII-XII intact, generally 4/5 strength throughout, limited due to pain, gait deferred . Discahrge Exam: discharge wt was 225lbs alert oriented x3 NecK: no JVD CV: systolic murmur, normal s1/s2 abdomen: tender on right side, anasarcic LE: 3+ pitting edema Pertinent Results: Admission Labs: [**2138-3-22**] 01:33AM BLOOD WBC-19.7* RBC-2.78* Hgb-8.6* Hct-23.1* MCV-83 MCH-30.8 MCHC-37.0* RDW-15.2 Plt Ct-90* [**2138-3-22**] 01:33AM BLOOD Neuts-93.9* Lymphs-3.8* Monos-2.0 Eos-0.2 Baso-0.2 [**2138-3-22**] 01:33AM BLOOD PT-16.0* PTT-26.8 INR(PT)-1.5* [**2138-3-22**] 01:33AM BLOOD Fibrino-370 [**2138-3-22**] 01:33AM BLOOD Lupus-NEG [**2138-3-22**] 01:33AM BLOOD Glucose-88 UreaN-37* Creat-1.9* Na-137 K-4.2 Cl-105 HCO3-25 AnGap-11 [**2138-3-22**] 01:33AM BLOOD ALT-667* AST-759* LD(LDH)-593* AlkPhos-198* TotBili-3.3* DirBili-2.0* IndBili-1.3 [**2138-3-22**] 01:33AM BLOOD cTropnT-0.07* [**2138-3-22**] 09:30AM BLOOD cTropnT-0.04* [**2138-3-22**] 02:47PM BLOOD cTropnT-0.04* [**2138-3-23**] 04:59AM BLOOD Lipase-12 [**2138-3-22**] 01:33AM BLOOD Albumin-2.5* Calcium-7.5* Phos-5.4* Mg-1.4* [**2138-3-22**] 01:33AM BLOOD Hapto-108 [**2138-3-22**] 01:33AM BLOOD Acetmnp-NEG [**2138-3-22**] 02:59AM BLOOD Lactate-0.8 . Discharge Labs: Abd Ultrasound w Duplex ([**2138-3-22**]): 1. Normal liver Doppler examination. 2. Splenomegaly with splenic calcifications, granulomatous disease. 3. No intra- or extra-hepatic biliary ductal dilation. 4. Perinephric hematoma, better seen on recent CT. . CXR ([**2138-3-22**]): New left IJ catheter tip is at the cavoatrial junction. There is no pneumothorax. Right IJ catheter tip is in the IVC. There are low lung volumes. There is mild-to-moderate cardiomegaly. There is mild vascular congestion. Small bilateral pleural effusions are larger on the right side. Bibasilar atelectases are larger on the right side. . CT Abd/Pelvis ([**2138-3-23**]): 1. Interval enlargement of the perinephric and retroperitoneal hematoma when compared to the [**2138-3-20**] examination. Correlation with serial hematocrits recommended. No evidence of liquified component or superimposed infection. 2. Approximately 1-cm area of enhancement within heterogeneous region in the lower pole of right kidney likely relates to residual pseudoaneurysm. 3. Marked anasarca. . MRI/MRA Neck/Head ([**2138-3-24**]): 1. No acute infarct or hemorrhage. 2. No evidence of focal flow-limiting stenosis, occlusion, dissection or aneurysm larger than 3 mm in the major arteries of head and neck. The MRA neck study is suboptimal due to poor timing of the bolus and significant venous contamintaion. . Micro [**2138-3-22**] 1:50 am URINE Source: Catheter. **FINAL REPORT [**2138-3-24**]** URINE CULTURE (Final [**2138-3-24**]): KLEBSIELLA PNEUMONIAE. >100,000 ORGANISMS/ML.. Piperacillin/tazobactam sensitivity testing available on request. Cefazolin interpretative criteria are based on a dosage regimen of 2g every 8h. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ KLEBSIELLA PNEUMONIAE | AMPICILLIN/SULBACTAM-- 4 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- 64 I TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S . [**2138-3-24**]: urine: 10-100K vre . Discharge [**2138-4-6**] 08:00AM BLOOD WBC-8.2 RBC-3.26* Hgb-9.8* Hct-31.3* MCV-96 MCH-30.1 MCHC-31.4 RDW-15.2 Plt Ct-184 [**2138-4-6**] 08:00AM BLOOD Glucose-105* UreaN-57* Creat-1.1 Na-140 K-4.9 Cl-106 HCO3-28 AnGap-11 [**2138-4-2**] 09:14AM BLOOD ALT-33 AST-25 LD(LDH)-500* AlkPhos-140* TotBili-0.5 [**2138-4-6**] 08:00AM BLOOD Calcium-8.3* Phos-4.5 Mg-1.6 Brief Hospital Course: Diagnoses: 1. SLE with lupus nephritis 2. Acute renal failure 3. Anemia, acute blood loss and chronic disease 4. Perinephric hematoma 4. Pain, complication of hematoma 6. Eosphageal candidiasis 7. Hypertension, severe 8. Thrombocytopenia 9. Nystagmus 10. Urinary tract infection (klebsiella) Primary Reason for Admission: 28 year-old woman with a history of lupus nephritis, nine days s/p renal biopsy performed for worsening creatinine/proteinuria, complicated by severe RP bleed. Active Problems: # RP Bleed/Perinephric Hematoma: On admission there was concern for ongoing blood loss given worsening pain and tachycardia/hypotension at OSH. IR and surgery were consulted and felt no intervention was indicated. Her HCTs were trended and remained stable s/p transfusion 2U pRBCs. Repeat CT scan was performed and showed interval increase in the size of the perinephric hematoma (see report). Her HCT remained stable for the remainder of her MICU course and she was observed s/p ambulation due to potential for dislodging the clot with activity - HCT remained stable and she was called out to the floor. On floor pt continued to have abdominal pain. Her crits remained stable. A repeat CT scan was performed that did not show any expansion of the bleed. # Leukocytosis/Bandemia/UTI: Likely multifactorial due to stress reaction from renal biopsy, chronic steroid use and Legionella UTI. Initially she was covered broadly with Vanc/Cefepime, which were narrowed to Ceftriaxone based on unrine culture and sensitivity data which revealed klebsiella. CT scan with contrast showed no e/o infected hematoma. Her WBC count trended down and she remained afebrile for >48 hours in the MICU. She was treated for a ten day course of ctx in house. # Acute renal failure/Lupus Nephritis: Unknown baseline but reason for biopsy on [**3-13**] was worsening renal function and proteinuria. Creatinine was 1.6 on admission to OSH; on transfer to [**Hospital1 18**] 1.9. She was given 2U pRBCs due to concern for developing hypovolemic shock and prerenal failure and continued on her home Prednisone 20mg po qday and Hydroxychloroquine 200 mg PO BID. Her OSH biopsy results were obtained and showed class IV/V diffuse proliferative membranous nephritis consistent with Lupis Nephritis. At the time of call out from the MICU, Cr was 1.3. Renal was consulted and recommended starting pt on pulse steroids. Once her u/a was clear, we started her on 500mg solumedrol x3 days and then transitioned her to MMF and 60 mg PO prednisone daily. Her protein:cr ratio significantly improved and her albumin improved to 3.1. She was discharged on MMF 1g [**Hospital1 **] and prednisone 60mg PO daily as well as bactrim ppx. In terms of her anasarca, she was diuresed on the floor with 40mg IV lasix for several days and her weight reached a nadir of 217. She was transitioned to PO lasix 60mg [**Hospital1 **] for one day but her cr bumped to 1.8. Diuresis was held for 2 days and her weight increased to 235lbs. Bumex was then started and she diuresed well with 2mg [**Hospital1 **]. At discharge her wt was 225lbs. Kidney function improved. # Hypertension: Pt's HTN was very difficult to control. On floor pt's lisinopril was transiently held during [**Last Name (un) **] and her blood pressure became extremely labile and would not come down below 170 systolic despite tripling her dose of labetolol. When lisinopril restarted her blood pressures improved to normal. given the compressive physiology of her perinephric hematoma it is likely that she is experiencing overstimulation of her RAAS. Medical management with an ACE is appropriate for now to control BP. # Candidal Esophagitis. While on the floor pt developed [**Female First Name (un) **] with severe odynophagia. An EGD was not performed and clinical diagnosis was made. she was started on fluconazole 200mg PO daily for 2 week course and her symptoms quickly resolved. Chronic Problems: # Elevated LFTs: Etiology not clear; labs were normal at OSH < 48 hours prior to transfer. Pt continues to have significant right sided abdominal pain, but not focused over RUQ. No jaundice or signs of portal hypertension. Potentially ischemic liver injury from combination of mild hypotension and severe anemia, although unusual for bili to rise concurrently with ALT/AST. Not on acetaminophen, percocet or other hepatotoxic medications at OSH. Unlikely to represent new acute viral hepatitis. LFTs trended down when on the floor. # Tachycardia: Sinus tach with lateral T wave changes and mild troponin leak. Likely due to pain, anxiety, and decreased O2 delivery in setting of severe anemia. Improved on the floor. # Asthma: No wheeze on exam, respiratory status stable. Transitional: establish care with PCP, [**Name10 (NameIs) 2225**] and Nephrology at [**Hospital1 **] likely increase MMF at next neph visit f/u crit, creatinine at f/u Medications on Admission: Home Meds: amlodipine 10 mg daily labetalol 400 mg daily lisinopril 10 mg daily MS contin 30 mg Q12H senna-docusate 8.5-50 mg 2 tabs [**Hospital1 **] percocet 5-325 mg, 1-2 tabs Q6H PRN prednisone taper (20 mg [**Hospital1 **] x3 days, then 20 mg daily x3 days, then 10 mg daily until seen by [**Hospital1 **]) pantoprazole 40 mg Q12 bisacodyl 10 mg daily albuterol HFA 2 puffs Q4H PRN hydroxychloroquine 200 mg [**Hospital1 **] . Transfer Meds: docusate 100 mg [**Hospital1 **] fentanyl 50 mcg IV Q1H PRN hydromorphone 1-2 mg Q1H PRN hydroxychloroquine 200 mg [**Hospital1 **] lorazepam 1 mg Q4H PRN prednisone 20 mg [**Hospital1 **] senna 17.2 mg [**Hospital1 **] Discharge Medications: 1. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. Disp:*30 Tablet(s)* Refills:*0* 2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(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). 4. sulfamethoxazole-trimethoprim 400-80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 6. prednisone 20 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 7. Calcium 500 + D 500 mg(1,250mg) -400 unit Tablet Sig: Two (2) Tablet PO once a day. Disp:*60 Tablet(s)* Refills:*2* 8. fluconazole 200 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 11 days. Disp:*11 Tablet(s)* Refills:*0* 9. hydromorphone 4 mg Tablet Sig: One (1) Tablet PO every [**4-18**] hours for 15 days. Disp:*90 Tablet(s)* Refills:*0* 10. mycophenolate mofetil 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Disp:*120 Tablet(s)* Refills:*2* 11. gabapentin 400 mg Capsule Sig: Two (2) Capsule PO TID (3 times a day). Disp:*180 Capsule(s)* Refills:*2* 12. lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 13. labetalol 200 mg Tablet Sig: Four (4) Tablet PO TID (3 times a day). Disp:*360 Tablet(s)* Refills:*2* 14. OxyContin 40 mg Tablet Extended Release 12 hr Sig: One (1) Tablet Extended Release 12 hr PO twice a day. Disp:*60 Tablet Extended Release 12 hr(s)* Refills:*0* 15. bumetanide 2 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Discharge Disposition: Home Discharge Diagnosis: perinephric hematoma lupus glomerulonephritis anasarca acute kidney injury hypertension complicated urinary tract infection Candidal esophagitis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to [**Hospital1 18**] for complications after a renal biopsy. You had a perinephric hematoma around your kidney, meaning that blood collected around your kidney after the procedure. We believe that the bleeding has stopped but there is still old blood around your kidney that your body should resorb over time. . The results of your biospy showed severe glomerulonephritis secondary to your lupus. We treated this with high dose steroids and a medication called mycophenolate. After three days of steroids we switched you over to prednisone 60mg daily. Both of these medications will help suppress your disease. . We have also started you on several medications to control your blood pressure and to protect your kidneys, a list has been provided below. Please take all of the medications we send you home with exactly as prescribed. . We also treated you with for ten days for a urinary tract infection with IV antibiotics . Finally, we treated you with a medication called fluconazole for candidal esophagitis. . We have made the following changes to your home medications. . 1. Start Bumex 2mg tab every 12hrs 2. Increase lisinopril 20mg by mouth every day 3. Increase labetolol 800mg by mouth every 8hrs 4. START Oxycontin 40mg by mouth twice daily 5. START dilaudid 4mg by mouth every 4-6 hrs as needed for pain 6. START Bactrim 400-80mg tab by mouth once daily 7. START Prednisone 60mg by mouth once daily 8. start fluconazole 200mg by mouth for 11 days 9. Start mycophenolate mofetil 1000mg tablet by mouth twice daily 10. START calcium and vitamin D supplements 11. STOP MS Contin and percocet 12. Continue the remainder of your home medications . Please weigh yourself every day. Call your doctor if you put on more than 3 lbs in one day Followup Instructions: You will receive a call for a follow up appointment with Dr. [**Last Name (STitle) 21173**] in [**Hospital3 **] on [**Hospital Ward Name 23**] [**Location (un) **]. . You will also receive a call for follow up in our renal clinic within the next week.

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icd9cm

[ [ [] ] ]

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icd9pcs

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Discharge summary

report

Admission Date: [**2108-6-8**] Discharge Date: [**2108-6-26**] Date of Birth: [**2026-12-30**] Sex: F Service: SURGERY Allergies: Sulfa (Sulfonamides) / Cefazolin / Aminophylline Attending:[**First Name3 (LF) 2597**] Chief Complaint: Left groin infection Major Surgical or Invasive Procedure: Excision of distal portion of left axillobifemoral graft and replacement with interposition left axillary profunda bypass and left axillary to mid cross-femoral bypass with 8-mm PTFE and debridement and closure of left groin wound. History of Present Illness: This elderly lady has a history of very severe peripheral vascular disease. She is status post a left axillary bifemoral graft and right femoral peroneal vein graft. She previously had a jump graft from the distal left axillary graft to the profunda femoris artery in [**2106**]. The entire graft occluded about a month and a half ago when she underwent a thrombectomy in the left groin. The left groin wound became infected and opened. The graft was exposed. She developed gram-negative Pseudomonas infection with bacteremia, is now having removal of the infected portion of the graft. Both her legs are entirely dependent on her axillary bifemoral graft and right femoral peroneal bypass so the graft must be replaced. Past Medical History: 1) Peripheral vascular disease 2) s/p right femoral peroneal bypass 3) s/p common femoral artery thrombectomy 4) status post left axillo bifemoral 5) status post profunda 6) status post left 7) ilioprofunda with PTFE 8) aortic insufficiency 9) HTN 10) DM2 diet controlled 11) coronary artery disease 12) status post myocardial infarction 13) status post CABG remote 14) hypothyroidism on no supplement at this time Social History: She denies alcohol, drug or tobacco use Family History: Noncontributory Physical Exam: a/o x 3 nad supple / farom neg lyphandopathy cts rrr abd - benign surgical incisions C/D/I all pulses palp distally right prosthetic left leg stroke right arm / cntracted Pertinent Results: ON ADMISSION: [**2108-6-8**] 04:45PM BLOOD WBC-13.8*# RBC-3.11* Hgb-9.8* Hct-28.8* MCV-93 MCH-31.6 MCHC-34.0 RDW-15.9* Plt Ct-261 [**2108-6-8**] 04:45PM BLOOD PT-61.8* PTT-42.2* INR(PT)-7.7* [**2108-6-8**] 04:45PM BLOOD Glucose-271* UreaN-4* Creat-1.1 Na-134 K-3.4 Cl-99 HCO3-19* AnGap-19 [**2108-6-8**] 04:45PM BLOOD CK(CPK)-47 [**2108-6-8**] 04:45PM BLOOD CK-MB-4 cTropnT-0.09* proBNP-[**Numeric Identifier 27206**]* [**2108-6-9**] 05:53AM BLOOD Calcium-8.2* Phos-3.7 Mg-2.4 . ON DISCHARGE: [**2108-6-26**] 05:08AM BLOOD WBC-4.7 RBC-3.28* Hgb-10.2* Hct-30.0* MCV-91 MCH-31.0 MCHC-33.9 RDW-15.9* Plt Ct-180 [**2108-6-26**] 05:08AM BLOOD PT-24.9* PTT-52.1* INR(PT)-2.5* [**2108-6-26**] 05:08AM BLOOD Glucose-72 UreaN-26* Creat-0.8 Na-138 K-4.1 Cl-100 HCO3-29 AnGap-13 [**2108-6-25**] 04:09PM BLOOD ALT-15 AST-25 AlkPhos-75 Amylase-57 TotBili-0.4 [**2108-6-25**] 04:09PM BLOOD Lipase-30 [**2108-6-20**] 03:21AM BLOOD CK-MB-NotDone cTropnT-0.06* [**2108-6-26**] 05:08AM BLOOD Calcium-8.4 Phos-3.0 Mg-2.6 . RADIOLOGY Final Report ABDOMEN (SUPINE & ERECT) [**2108-6-8**] 6:37 PM ABDOMEN (SUPINE & ERECT) Reason: assess for infection/obstruction/ileus [**Hospital 93**] MEDICAL CONDITION: 81 year old woman with episode of nausea and vomiting and SOB today; had infected hematoma at R groin vascular graft site [**4-26**], with wound vac there now REASON FOR THIS EXAMINATION: assess for infection/obstruction/ileus HISTORY: 81-year-old female with episode of nausea and vomiting and shortness of breath today. Known infected right groin hematoma. Evaluate for signs of obstruction or ileus. Comparison is made to prior abdominal radiographs dated [**2108-5-20**] and prior CT dated in [**2108-5-15**]. UPRIGHT AND SUPINE ABDOMINAL RADIOGRAPHS FINDINGS: Bowel gas pattern is unremarkable without evidence of dilated large or small bowel. Air is noted distally within the rectum. No evidence of pneumoperitoneum. Marked degenerative changes of the spine, calcified gallstones, dense vascular calcifications, and left common iliac vascular stent are all unchanged. Surgical clips are noted over the left femoral neck. IMPRESSION: No evidence of bowel obstruction or ileus. . RADIOLOGY Final Report CHEST (PA & LAT) [**2108-6-8**] 6:36 PM CHEST (PA & LAT) Reason: r/o PNA, effusion, pulm edema [**Hospital 93**] MEDICAL CONDITION: 81F with sudden onset SOB, crackles at R base, N/V REASON FOR THIS EXAMINATION: r/o PNA, effusion, pulm edema HISTORY: 81-year-old female with sudden onset shortness of breath and right basilar crackles. Evaluate for pneumonia, effusion, or pulmonary edema. Comparison is made to prior radiographs dated [**5-21**] and [**2108-5-28**]. PA AND LATERAL CHEST RADIOGRAPHS. FINDINGS: Mild interstitial edema persists and may be slightly improved from most recent radiograph as does small bilateral pleural effusions (right greater than left). No new focal parenchymal infiltrates are identified, and there is no evidence of pneumothorax. Cardiomediastinal silhouette remains mildly enlarged and there is stable appearance to median sternotomy wires and left- sided PICC catheter, which terminates in the upper SVC. Chronic changes involving the left glenohumeral joint are stable. IMPRESSION: Persistent mild bilateral interstitial pulmonary edema at the lung bases with small bilateral pleural effusions. . RADIOLOGY Final Report CHEST (PA & LAT) [**2108-6-9**] 8:16 AM CHEST (PA & LAT) Reason: eval chf [**Hospital 93**] MEDICAL CONDITION: 81F with sudden onset SOB, crackles at R base, N/V REASON FOR THIS EXAMINATION: eval chf INDICATION: 81-year-old female with sudden onset shortness of breath and crackles. COMPARISON: [**2108-6-8**]. FRONTAL AND LATERAL CHEST RADIOGRAPHS: A left-sided PICC line is seen with tip in the proximal SVC. The patient is status post CABG and median sternotomy wires are intact. Mild interstitial edema has slightly worsened and there are persistent small bilateral pleural effusions. No focal parenchymal infiltrate or pneumothorax is identified. Chronic left glenohumeral joint changes are stable. IMPRESSION: 1. Mild interstitial pulmonary edema and small bilateral pleural effusions. . RADIOLOGY Final Report CHEST (PA & LAT) [**2108-6-12**] 3:07 PM CHEST (PA & LAT) Reason: eval for low grade fever [**Hospital 93**] MEDICAL CONDITION: 81F p/w L groin exposed graft s/p thrombectomy of R fem-peroneal graft, fem-fem, patch angioplasty of L ax-fem, PTA/stent of R TP trunk and prox peroneal, c/b post-op MI; presents with FUO and acute CHF with low grade fevers REASON FOR THIS EXAMINATION: eval for low grade fever PA LATERAL CHEST [**6-12**] INDICATION: Extensive vascular surgical history as above. Evaluate for low-grade fever/CHF. FINDINGS: Compared with [**2108-6-9**], the pulmonary edema and bilateral pleural effusions have resolved except for a tiny posterior right effusion. No overt CHF or pneumonia. . RADIOLOGY Final Report CT PELVIS W&W/O C [**2108-6-12**] 10:37 AM CT ABD W&W/O C; CT PELVIS W&W/O C Reason: PLEASE GO DOWN TO ABOVE THE KNEE; eval for fluid collection [**Hospital 93**] MEDICAL CONDITION: 81F p/w L groin exposed graft s/p thrombectomy of R fem-peroneal graft, fem-fem, patch angioplasty of L ax-fem, PTA/stent of R TP trunk and prox peroneal, c/b post-op MI; presents with FUO and acute CHF with continued low grade fevers REASON FOR THIS EXAMINATION: PLEASE GO DOWN TO ABOVE THE KNEE; eval for fluid collection CONTRAINDICATIONS for IV CONTRAST: None. CT ABDOMEN, PELVIS AND THIGHS WITH AND WITHOUT CONTRAST, [**2108-6-12**] HISTORY: Peripheral vascular disease, status post recent thrombectomy of right fem/peroneal graft, fem/femoral graft and patch angioplasty of left ax/fem graft. Left groin wound left open to granulate. Also, status post PTA/stent of right tibioperoneal trunk and proximal peroneal. Complicated by postoperative MI. Now with fever of unknown margin and acute CHF. TECHNIQUE: Multidetector axial images were carried out through the abdomen, pelvis and thighs both before and after intravenous administration of 100 mL of Optiray nonionic contrast. Coronal and sagittal reformatted images were filmed. Comparison is made to prior CT of the abdomen and pelvis from [**2104-12-30**], and CTA from [**2108-4-13**]. FINDINGS: ABDOMEN: Upper images include the chest and show that there is no lung parenchymal edema or pleural fluid at the bases. A less than 2 mm nodular density seen at the right lung base peripherally is not seen on prior studies. Some pleural thickening and atelectasis or scar is seen at the right base posteromedially. Prominent coronary and mitral annular calcifications are seen. The lower chest and abdominal subcutaneous portion of the patient's left axillofemoral graft is patent. At the level of the left groin, the origin of the fem/fem component of the graft has significant filling defect, nearly occluding the lumen focally. There is, however, complete opacification of the femoral crossover portion of the graft, and the right-sided anastomosis appears widely pain as does the visualized portion of the right femoral/peroneal graft (distal anastomosis into peroneal not included in view of study). On the left, the femoral to profunda portion of the graft is seen to the level of the mid thigh, where it appears to be anastomosed with profundus femoris measuring only [**2-18**] millimeters. Immediately anterior and adjacent to the left Profunda femoris is a 5-6 mm nonenhancing rounded structure, probably the patient's old left iliac- profunda bypass. Dense calcification is seen in the patient's occluded native arteries. The open left groin wound shows some smooth induration consistent with granulation tissue, but no fluid collection or abnormal enhancement is seen. An inguinal lymph node just lateral to the open wound on the left measures 9 mm in short- axis dimension. On the right, a low-density fluid collection is seen anterior to and surrounding the region of the femoral to distal anastomosis. This measures almost 4 cm in greatest dimension, but is relatively homogeneous and low in density. There is a smaller, 16 x 10 mm ovoid collection, possibly in continuity with this, just superior to this, and a smaller ovoid density just inferomedial to this on the right representing an enhancing right inguinal lymph node. No findings suggestive of infected groin abscesses are seen on either side. The right common femoral vein appears non-acutely thrombosed (denser than left common femoral vein pre-contrast and unenhanced post- contrast, but not distended or showing any inflammatory change). The liver and spleen have an unchanged appearance compared to prior studies, with single small hypodensities unchanged compared to [**2104**]. Large heterogeneous calcified gallstone is seen without evidence of acute cholecystitis. The inflammatory change in the anterior pararenal space suggestive of acute pancreatitis on the [**Month (only) 958**] study has resolved; however, there is now a focal 9-10 mm hypodensity at the tail of the pancreas, which may be sequela from that inflammation. This does not have density measurements consistent with fluid, but is also rather small to accurately characterize. The native aorta shows dense atherosclerotic plaque including origins of the celiac axis and superior mesenteric artery which are stenosed. Calcified plaques are seen at the origin of both renal arteries. A large area of wedge- shaped hypodensity in the right kidney laterally appears to have decreased in volume, suggesting this was related to old infection or infarction. This had been noted since [**2104**], but it appears more contractive. New on today's study is a tiny wedge-shaped hypodensity in the left kidney anteriorly. There are calcifications seen on the pre-contrast view of the kidneys, probably vascular. There is a small amount of fluid around the right kidney superiorly which is new from the [**Month (only) 958**] study. This is low in density. Some fatty induration in the subcutaneous fat of the anterior abdominal wall is probably related to subcutaneous injections. PELVIS: See above for vascular bypass details. In addition, old occluded metallic stent is seen in the left iliac system. There is some free low- density intraperitoneal fluid seen, right greater than left, and this was also noted in [**Month (only) 958**], but no regional bowel inflammation is seen. As noted above, the right common femoral vein may be occluded (apparently non-acute). The urinary bladder is nearly empty at the time of scanning. Evaluation of bones shows severe diffuse osteopenia, mottled at the level of distal femora and probably at least partially secondary to disuse. Thoracic spine osteophytes are seen, and facet osteoarthritis is seen in the lower lumbar spine bilaterally. An anterior intrathecal calcification is seen at the level below the inferior body of L2, possibly arising from the vertebral body. Grade 1 spondylolisthesis of L4 on L5 is unchanged. Hypertrophic bone at the anterior superior iliac spine on the left may be enthesopathic related to previous healed fracture. CONCLUSION: 1. Incompletely occlusive filling defect consistent with thrombus or heaped neointima at left inguinal level of fem/fem crossover graft. 2. Right groin fluid collection surrounding femoral portion of graft, most consistent with seroma, with no definite infection seen in either groin region. Inguinal nodes seen bilaterally. 3. New 1-cm hypodensity in tail of pancreas, with inflammatory change seen in [**2108-3-15**] resolved. Recc f/u. 4. Free intraperitoneal fluid, most notable dependently in the right side of the pelvis, not significantly different compared to [**2108-3-15**], but with some new low-density fluid seen at the superior portion of the right kidney. 5. A 2-mm right base pulmonary nodule--recommend follow up in approximately 1 year's time, which can be coordinated with any other vascular follow up the patient has (pulmonary nodule follow up need not require contrast). 6. Severe native atherosclerotic disease with coronary artery calcification and calcified stenoses origins of visceral vessels, as described, with occlusion of native infrarenal aorta. 7. Cholelithiasis without evidence of cholecystitis. 8. Severe osteopenia, degenerative changes and disc disease in the lumbar spine, with unchanged spondylolisthesis. . RADIOLOGY Final Report CHEST (PORTABLE AP) [**2108-6-13**] 6:11 PM CHEST (PORTABLE AP) Reason: eval acute cardiopulmonary process [**Hospital 93**] MEDICAL CONDITION: 81F p/w L groin exposed graft s/p thrombectomy of R fem-peroneal graft, fem-fem, patch angioplasty of L ax-fem, PTA/stent of R TP trunk and prox peroneal, c/b post-op MI; presents with FUO and acute CHF now septic REASON FOR THIS EXAMINATION: eval acute cardiopulmonary process STUDY: AP portable chest x-ray. INDICATION: 81-year-old female post-op MI presenting with fever and acute CHF. Assess for acute cardiopulmonary process. COMPARISONS: [**2108-6-12**]. FINDINGS: Compared to the film from the previous day the right sided small pleural effusion appears slightly more prominent. A left pleural effusion may also be present. The cardiomediastinal contour is stable. A PICC remains unchanged in position. Multiple median sternotomy wires are unchanged. The lungs are overall clear. There severe loss of joint space of the left shoulder and bone on bone articulation consistent with end stage degenerative disease. IMPRESSION: No acute cardiopulmonary process. Persistent right pleural effusion. Possible small left pleural effusion. . RADIOLOGY Final Report PERSANTINE MIBI [**2108-6-13**] PERSANTINE MIBI Reason: PRE-OP EVAL RADIOPHARMECEUTICAL DATA: 9.6 mCi Tc-[**Age over 90 **]m Sestamibi Rest ([**2108-6-13**]); 29.2 mCi Tc-99m Sestamibi Stress ([**2108-6-13**]); HISTORY: CAD s/p CABG. SUMMARY OF DATA FROM THE EXERCISE LAB: Dipyridamole was infused intravenously for 4 minutes at a dose of 0.142 mg/kg/min. METHOD: Resting perfusion images were obtained with Tc-99m sestamibi. Tracer was injected approximately one hour prior to obtaining the resting images. Two minutes after the cessation of infusion of dipyridamole, approximately three times the resting dose of Tc99m sestamibi was administered IV. Stress images were obtained approximately one hour following tracer injection. Imaging protocol: Gated SPECT. This study was interpreted using the 17-segment myocardial perfusion model. INTERPRETATION: There is no prior study for comparison. There is soft tissue attenuation from the patient's arm. Left ventricular cavity size is moderately enlarged more on stress than on rest. Rest and stress perfusion images reveal severe, fixed defects involving the a apical, inferior, inferolateral, and anterolateral walls. Gated images reveal severe, global hypokinesis. The wall motion in the basal anterior wall appears the best. The calculated left ventricular ejection fraction is 17%. IMPRESSION: 1. No reversible myocardial perfusion defects. 2. Severe, fixed defects in the apical, inferior, inferolateral, and anterolateral walls. 3. Evidence of transient cavitary dilatation. 4. EF is 17%. The findings were discussed with Dr. [**Last Name (STitle) 20425**]. . Cardiology Report STRESS Study Date of [**2108-6-13**] RESTING DATA EKG: SINUS, LAFB, PRWP, NSSTTW HEART RATE: 78 BLOOD PRESSURE: 120/- PROTOCOL / STAGE TIME SPEED ELEVATION [**Doctor Last Name 10502**] HEART BLOOD RPP (MIN) (MPH) (%) RATE PRESSURE 1 0-4 0.142MG/ KG/MIN 88 [**Telephone/Fax (1) 27207**] TOTAL EXERCISE TIME: 4 % MAX HRT RATE ACHIEVED: 63 SYMPTOMS: NONE ST DEPRESSION: NONE INTERPRETATION: This 81 year old type 2 IDDM woman s/p CABG ~91 was referred to the lab for evaluation. The patient was infused with 0.142 mg/kg/min of dipyridamole over 4 minutes. No arm, neck, back or chest discomfort was reported by the patient throughout the study. There were no significant ST segment changes during the infusion or in recovery. The rhythm was sinus with occasional isolated apbs and vpbs. Appropriate hemodynamic response to the infusion. The patient noted a history of upset stomach with p.o. aminophylline use in the past. To reverse the dipyridamole she received 50 mg of aminophylline IV with no adverse events. IMPRESSION: No anginal type symptoms or ischemic EKG changes. Nuclear report sent separately. . RADIOLOGY Final Report GUIDANCE FOR ABSCESS ([**Numeric Identifier 10268**]) [**2108-6-14**] 1:45 PM US SIMPLE/SING ABSC/CYST DRAIN; US EXTREMITY NONVASCULAR RIGHT Reason: pt has fluid collection over PTFE graft in right groin by [**Hospital **] [**Hospital 93**] MEDICAL CONDITION: 81 year old woman with REASON FOR THIS EXAMINATION: pt has fluid collection over PTFE graft in right groin by ct scan / please aspirate and send for cx's and sensitivities EXAMINATION: Ultrasound-guided aspiration of fluid in right groin. INDICATION: Status post fem-fem bypass. Query infected. FINDINGS: Informed written consent was obtained. Timeout with double patient identifiers was performed. Using local anesthetic, aseptic technique and ultrasound guidance, 5 cc of serous fluid was aspirated from the right groin. The procedure was well tolerated with no complications. The attending, Dr. [**First Name (STitle) **], was present and actively participated throughout the procedure. Fluid was sent for culture and sensitivity. IMPRESSION: Status post successful diagnostic aspiration of fluid in the right groin. . RADIOLOGY Final Report CHEST PORT. LINE PLACEMENT [**2108-6-18**] 11:27 AM CHEST PORT. LINE PLACEMENT Reason: s/p swan insertion [**Hospital 93**] MEDICAL CONDITION: 81F p/w L groin exposed graft s/p thrombectomy of R fem-peroneal graft, fem-fem, patch angioplasty of L ax-fem, PTA/stent of R TP trunk and prox peroneal, c/b post-op MI; presents with FUO and acute CHF now septic REASON FOR THIS EXAMINATION: s/p swan insertion PORTABLE CHEST [**2108-6-18**]: COMPARISON: [**2108-6-13**]. INDICATION: Swan-Ganz catheter insertion. A Swan-Ganz catheter has been placed with distal tip terminating in the right interlobar pulmonary artery, with no pneumothorax evident. Left PICC line remains in standard position. Cardiac silhouette is upper limits of normal in size. Patchy bibasilar opacities have developed and are probably due to atelectasis, but aspiration is an additional consideration in the appropriate setting. There are also probable small bilateral pleural effusions. IMPRESSION: Swan-Ganz catheter terminates in interlobar portion of right pulmonary artery with no pneumothorax. . Cardiology Report ECHO Study Date of [**2108-6-19**] PATIENT/TEST INFORMATION: Indication: Hypertension. Left ventricular function. Valvular heart disease. Intraop monitoring. Height: (in) 60 Weight (lb): 122 BSA (m2): 1.51 m2 BP (mm Hg): 139/55 HR (bpm): 61 Status: Inpatient Date/Time: [**2108-6-19**] at 12:08 Test: TEE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Tape Number: 2007AW000-0:00 Test Location: Anesthesia West OR cardiac Technical Quality: Adequate REFERRING DOCTOR: DR. [**First Name11 (Name Pattern1) 1112**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 1111**] MEASUREMENTS: Left Ventricle - Septal Wall Thickness: *1.3 cm (nl 0.6 - 1.1 cm) Left Ventricle - Inferolateral Thickness: *1.3 cm (nl 0.6 - 1.1 cm) Left Ventricle - Ejection Fraction: 25% (nl >=55%) Aorta - Ascending: 2.9 cm (nl <= 3.4 cm) Aortic Valve - Peak Velocity: 1.6 m/sec (nl <= 2.0 m/sec) Aortic Valve - Peak Gradient: 11 mm Hg Aortic Valve - Mean Gradient: 5 mm Hg Aortic Valve - LVOT Peak Vel: 2.00 m/sec Aortic Valve - LVOT VTI: 12 Aortic Valve - LVOT Diam: 1.8 cm Aortic Valve - Valve Area: *1.0 cm2 (nl >= 3.0 cm2) Mitral Valve - E Wave: 1.4 m/sec Mitral Valve - A Wave: 0.7 m/sec Mitral Valve - E/A Ratio: 2.00 Mitral Valve - E Wave Deceleration Time: 126 msec TR Gradient (+ RA = PASP): *40 mm Hg (nl <= 25 mm Hg) INTERPRETATION: Findings: LEFT ATRIUM: Mild LA enlargement. Mild spontaneous echo contrast in the LAA. Good (>20 cm/s) LAA ejection velocity. All four pulmonary veins identified and enter the left atrium. RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is seen in the RA and extending into the RV. No ASD by 2D or color Doppler. LEFT VENTRICLE: Mild symmetric LVH. Severe regional LV systolic dysfunction. Severe global LV hypokinesis. Severely depressed LVEF. TDI E/e' >15, suggesting PCWP>18mmHg. Transmitral Doppler and TVI c/w Grade III/IV (severe) LV diastolic dysfunction. No resting LVOT gradient. LV WALL MOTION: Regional LV wall motion abnormalities include: mid anterior - akinetic; mid anteroseptal - hypo; mid inferoseptal - akinetic; anterior apex - hypo; septal apex - hypo; inferior apex - hypo; RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Normal ascending aorta diameter. AORTIC VALVE: Three aortic valve leaflets. Severely thickened/deformed aortic valve leaflets. Moderate AS (AoVA 1.0-1.2cm2) Mild (1+) AR. MITRAL VALVE: Moderate mitral annular calcification. Moderate thickening of mitral valve chordae. No MS. Mild to moderate ([**1-17**]+) MR. TRICUSPID VALVE: Moderate to severe [3+] TR. Moderate PA systolic hypertension. PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with physiologic PR. No PR. PERICARDIUM: No pericardial effusion. GENERAL COMMENTS: No TEE related complications. The TEE probe was passed with assistance from the anesthesioology staff using a laryngoscope. The patient was under general anesthesia throughout the procedure. Results were personally reviewed with the MD caring for the patient. Conclusions: Overall left ventricular systolic function is severely depressed. There is severe global left ventricular hypokinesis. There is severe regional left ventricular systolic dysfunction with akinesis of mid to distal septal wall and severe hypokinesis of mid to distal infero-lateral walls. Estimated ejection fraction is 25%. There is mild symmetric left ventricular hypertrophy. Right ventricular chamber size is normal. Right ventricular is mildly hypokinetic. There are three aortic valve leaflets. The aortic valve leaflets (3) are moderately thickened/deformed. There is moderate aortic valve stenosis (area 1.0 cm2). Mild (1+) aortic regurgitation is seen. Mild to moderate ([**1-17**]+) mitral regurgitation is seen. Moderate to severe [3+] tricuspid regurgitation is seen. Restrictive diastolic filling pattern. There is moderate pulmonary artery systolic hypertension. Mild spontaneous echo contrast is present in the left atrial appendage. No atrial septal defect is seen by 2D or color Doppler. There is moderate thickening of the mitral valve chordae. There is no pericardial effusion. . RADIOLOGY Final Report CHEST PORT. LINE PLACEMENT [**2108-6-21**] 5:16 PM CHEST PORT. LINE PLACEMENT Reason: r/o ptx [**Hospital 93**] MEDICAL CONDITION: 81F p/w L groin exposed graft s/p thrombectomy of R fem-peroneal graft, fem-fem, patch angioplasty of L ax-fem, PTA/stent of R TP trunk and prox peroneal, c/b post-op MI; presents with FUO and acute CHF now septic REASON FOR THIS EXAMINATION: r/o ptx STUDY: Portable AP upright chest x-ray from 5:35 p.m. INDICATION: 81-year-old female status post thrombectomy of right femoral- peroneal graft. Patient with fever of unknown origin, acute CHF, now septic. Assess for pneumothorax. COMPARISONS: [**2108-6-18**]. FINDINGS: A left-sided PICC with tip projecting over the mid SVC is unchanged compared to the prior examination. There has been interval removal of a Swan- Ganz catheter, however, right internal jugular venous line is present with tip projecting over right atrium. The cardiomediastinal silhouette is stable. The lungs are grossly clear. There are multiple sternotomy wires overlying the midline of the chest. IMPRESSION: No pneumothorax. No CHF. . Brief Hospital Course: The patient was admitted to dR.[**Doctor Last Name 5695**] Vascular Surgery Service on [**2108-6-8**] for management of her right groin wound infection. She was immediately placed IV antibiotics (vancomycin, ciprofloxacin, and flagyl), wound cultures were went, and wet-to-dry dressings were started. On HD 2, she was transfused 1 unit of PRBC for a decrease in her hct to 24.2. On HD 3, she was transfused an additional 1 unit PRBC for a hct of 24.9. She continued to have low grade temperatures and surveillance blood cultures were sent from both her PICC line and a peripheral site. She continued to report diarrhea and C.Diff cultures were sent. Her initial admission blood cultures grew multi-resistant pseudomonas and she was placed on tobramycin on HD 4. With the continued low grade fevers and poitive blood cultures, a CT A/P was performed on HD 5, demonstrating a right groin fluid collection and a thrombus in the fem-fem bypass graft. A VAC dressing as then applied to the left groin wound infection site. She complained of some shortness-of-breath and a chext xray was performed demonstrating persistent right pleural effusion and possible small left pleural effusion. On HD 6, she underwent a PMIBI demonstrating LVEF of 17%. She was also started on a heparin drip for the thrombosis within her fem-fem bypass graft. Following return from her PMIBI study, she complained of increasing shortness-of-breath and she was transferred to the CSRU. In the ICU, her cultures continued to be positive for pseudomonas and she required desensitization to meropenem per infectious disease consult recommendation. While in the ICU, her respiratory status improved with continued diruesis. On HD 7, surveillance blood cultures continued to be sent with blood cultures for HD 8 still positive for pseudomonas. She was ctoninued on the heparin drip and IV antibiotics. On HD 10, she was stable for trasnfer to the floor. In was decided that she would need to have her infected graft removed. Cardiology was consulted for pre-operative workup. She underwent an excision of distal portion of left axillobifemoral graft and replacement with interposition left axillary profunda bypass and left axillary to mid cross-femoral bypass with 8-mm PTFE and debridement and closure of left groin wound on [**2108-6-19**]. For details of the operation, please refer to the operative report. Her postoperative course was uncomplicated. Immediately post-operatively, she was trasnferred to the CSRU. She was extubated in the OR without complications. She had a single JP drain in her left groin which continued to have minimal output and was d/c'd on POD 2. While in the CSRU, she was found to have a yeast infection and was started on fluconazole in addition to her previous IV antibiotics. On POD 1, she was transfused 2 units PRBC for a hct of 26.5. She was stable for transfer to the floor on POD 2. Her blood cultures remained negative beginning on HD 9. She continued to remain afebrile and tolerating a regular diet. On POD 4, she was restarted on coumadin forher grafts. The fulconazole was discontinued on POD 6 and the linezolid was discontinued on POD 7. She was continued on PO vancomycin, meropenem, and tobramycin per infectious deisease recommendations. A tunneled line was placed by interventional radiology on POD 7 for administration of IV antibiotics and she was deeemed stable for discharge to a rehab facility. She will continue on the meropenem for a total of 12 weeks, tobramycin for 2 weeks, and PO vancomycin for 2 additional weeks after the meropenem has been discontinued. She will follow-up with Dr. [**Last Name (STitle) **] and cardiology. Medications on Admission: lopressor 37.5", ASA 325, plavix 75, isordil 10'", lisinopril 5, lipitor 80, lasix 40", KCl 10, diabinese 100, coumadin 0.5, protonix 40' Discharge Disposition: Extended Care Facility: [**Hospital1 700**] - [**Location (un) 701**] Discharge Diagnosis: wound infection / infected BPG septecima asthma, AI, HTN, DM2, CAD, MI, hypothyroid Discharge Condition: Stable Discharge Instructions: WOUND CARE: PLEASE CALL US IMMEDIATELY FOR ANY OF THE FOLLOWING PROBLEMS: Redness in or drainage from your wound(s). New pain, numbness or discoloration of your lower or upper extremities (notably on the side of the incision). Watch for signs and symptoms of infection. These are: a fever greater than 101 degrees, chills, increased redness, or pus draining from the incision site. If you experience any of these or bleeding at the incision site, CALL THE DOCTOR. OTHER INFORMATION: You may shower immediately upon coming home. No bathing. A dressing may cover you??????re wound, keep your wound dry at all times You will have sutures, which are usually removed in 4 weeks. This will be done by the Surgeon on your follow-up appointment. Avoid taking a tub bath, swimming, or soaking in a hot tub. Limit strenuous activity and or heavy lifting until the wound is well healed. Activity may prevent the wound from healing. Do not drive a car unless cleared by your Surgeon. Try to keep your affected limb elevated when not in use, This decreases swelling to the affected wound and helps in the healing process. ANTIBIOTICS: You may have a prescription for antibiotics. Take as directed. Be sure you take the full course even if the wound looks well healed. Failure to do so may lead to infection. Followup Instructions: Provider: [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2604**], MD Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2108-7-9**] 11:00 Follow - up with Dr [**Last Name (STitle) **] in two weeks. He can be reached [**Telephone/Fax (1) 27208**]. She will follow up with ID. ID will call with time for follow-up. If they don't call there ([**Telephone/Fax (1) 17490**]. Ask for Dr [**First Name (STitle) **]. You have to have your tunneled catheter line. You are schedule to have this out on [**8-16**] @ 0830. Please [**Hospital Ward Name **] 1 daycare center at o7oo hrs. Completed by:[**2108-6-26**]

[ "112.0", "428.0", "790.7", "998.59", "V49.75", "623.8", "008.45", "250.00", "401.9", "244.9", "996.62", "424.1", "V45.81", "414.01", "443.9", "412", "112.3", "493.90" ]

icd9cm

[ [ [] ] ]

[ "38.93", "86.22", "39.49", "93.59", "00.14", "99.04", "88.72" ]

icd9pcs

[ [ [] ] ]

29736, 29808

25857, 29548

329, 563

29936, 29945

2049, 2049

31302, 31928

1825, 1843

24873, 25087

29829, 29915

29574, 29713

29969, 29969

20651, 24836

1858, 2030

2542, 3198

269, 291

25116, 25834

29982, 31279

591, 1313

2063, 2528

1335, 1751

1767, 1809

11,484

116,939

9480

Discharge summary

report

Admission Date: [**2196-1-7**] Discharge Date: [**2196-1-18**] Date of Birth: [**2139-6-12**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1505**] Chief Complaint: Dyspnea on Exertion Major Surgical or Invasive Procedure: CABGx3(LIMA->LAD< SVG->OM, PDA) [**2196-1-8**] Cardiac Catheterization [**2196-1-7**] History of Present Illness: Mr. [**Known lastname 32283**] is a 56 year old gentleman with no known coronary artery disease. In [**2191-8-5**], he was diagnosed with thyroid cancer and underwent a thyroidectomy and radiation therapy. In [**2194-2-1**] a routine CT scan revealed coronary artery calcification and he was therefore referred for further evaluation. An exercise tolerance test on [**2195-12-18**] was positive with fatigue, dyspnea and ST depressions in the inferolateral leads. Scans showed a moderate reverisble defect in thebasilar and mid-inferior wall. His ejection fraction was predicted to be 66%. Mr. [**Known lastname 32283**] reports intermittant dyspnea on exertion for the past few months but denies ever experiencingany chest pain. He was admitted today [**2195-12-7**] for a cardiac catheterization which revealed an 80% stenosed left main, an 80% stenosed left anterior descending artery and a 90% stenosed right cronary artery. His ejection fraction was normal. Mr. [**Known lastname 32283**] is now being referred for surgical revascularization. Past Medical History: Hypercholesterolemia Thyroid cancer S/P Thyroidectomy Gout Right eye styes Glaucoma Past tonsillectomy Eye surgery to relieve pressure Social History: Live sin [**Location 17448**] with wife. Three children. WOrks full-time as a buisness analyst. Never smoked. Occasional alcohol use. Family History: Father with myocardial infarction and CABG in his 60's. Aunts and [**Name2 (NI) 32284**] with coronary artery disease. Physical Exam: Ht 68" Wt 160 Temp- 98.1 128-147/70's 64 SR 100% room air sats GEN: Overall good health. Appears well in no acute distress. NEURO: Alert and oriented x3. Appropriate. Flat affect. Nonfocal. LUNGS: Bibasilar rales HEART: RRR, normal S1-S2. No murmur ABDOMEN: Soft, round, nontender, nondistended, normoactive bowel sounds EXTREMITIES: Warm, well perfused, no edema, no varicosities. PULSES: 1+ radial, dorsalis pedis and posterior tibial bilaterally. Pertinent Results: [**2196-1-7**] 09:30AM PT-12.9 PTT-28.9 INR(PT)-1.1 [**2196-1-7**] 09:30AM WBC-3.6* RBC-4.39* HGB-13.7* HCT-37.7* MCV-86 MCH-31.3 MCHC-36.4* RDW-12.8 [**2196-1-7**] 09:30AM ALT(SGPT)-32 AST(SGOT)-16 ALK PHOS-38* AMYLASE-35 TOT BILI-0.7 [**2196-1-7**] 09:30AM GLUCOSE-208* UREA N-19 CREAT-1.0 SODIUM-135 POTASSIUM-3.6 CHLORIDE-103 TOTAL CO2-25 ANION GAP-11 [**2196-1-7**] 11:53AM URINE BLOOD-SM NITRITE-NEG PROTEIN-NEG GLUCOSE-TR KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG [**2196-1-7**] CXR No acute cardiopulmonary disease [**2196-1-7**] Cardiac Catheterization 1. Selective coronary angiography of this right dominant system revealed severe three vessel and left main coronary disease. The LMCA contained an 80% ostial lesion. The LAD contained an 80% osital lesion before giving off two large septals and a large diagonal branch. The LCX contained 40% ostial disease. The RCA was a large, domiant vessel and contained a mid vessel 90% lesion and a distal 90% just before the PDA takeoff. 2. Left ventriculography revealed a calculated ejection fraction of 55% with not mitral regurgitation or wall motion abnormalities seen. 3. Limited resting hemodynamics revealed a central aortic pressure of 161/70 with an elevated LVEDP of 23mmHg. There was no gradient across the aortic valve on pull-back. [**2196-1-7**] EKG Sinus rhythm. Right ventricular conduction delay. No previous tracing available for comparison. Rate 57. [**2196-1-14**] EKG Sinus rhythm 74. Short PR interval. Nonspecific inferolateral T wave changes, RSR' in V1. Since last ECG some T wave changes [**2196-1-15**] ECHO 1. The left ventricular cavity size is normal. Overall left ventricular systolic function is moderately depressed. Anterior, septal, and apical hypokinesis to akinesis is present. 2. The aortic valve leaflets (3) are mildly thickened. 3. The mitral valve appears structurally normal with trivial mitral regurgitation. 4. Compared with the findings of the prior report (tape unavailable for review) of [**2195-7-7**], LV function has decreased. Brief Hospital Course: Mr. [**Known lastname 32283**] was admitted to the [**First Name8 (NamePattern2) **] [**First Name4 (NamePattern1) 1675**] [**Last Name (NamePattern1) **] Medical Center on [**2196-1-7**] and underwent a cardiac catheterization. This revealed an 80% stenosed left main coronary artery, an 80% stenosed left anterior descending artery, a 90% stenosed right coronary artery and a normal left ventricular ejection fraction. Heparin was started for anticoagulation. Due to the severity of his disease, the cardiac surgical service was consulted for surgical revascularization. Mr. [**Known lastname 32283**] was worked-up in the usual preoperative manner. On [**2196-1-8**], Mr. [**Known lastname 32283**] was taken to the operating room where he underwent coronary artery bypass grafting to three vessels. Postoperatively, he was taken to the cardiac surgical intensive care unit for monitoring. On postoperative day one, Mr. [**Known lastname 32283**] [**Last Name (Titles) 5058**] neurologically intact and was extubated. Neo-Synephrine continued for hypotension. The endocrinology service was consulted in regards to his difficultly coming off pressors and a thyroid study and cortisol levels were sent. He was gently diuresed towards his preoperative weight. He was transfused with packed red blood cells for postoperative anemia. The physical therapy service was consulted for assistance with his postoperative strength and mobility. His drains and epicardial pacing wires were removed per protocol. An echocardiogram was obtained which ruled out any evidence of tamponade. Ultimately his neo synephrine was weaned off. On postoperative day eight, Mr. [**Known lastname 32283**] was transferred to the step down unit for further recovery. His cortisol level returned mildly elevated at 27.7 micrograms per deciliter and his thyroid studies showed a mildly elevated free T4 and a low thyroid stimulating hormone on Synthroid. Follow-up thyroid studies were recommended in 2 to 4 weeks as an outpatient. Mr. [**Known lastname 32283**] continued to make steady progress and was discharged home on postoperative day ten. He will follow-up with Dr. [**Last Name (STitle) **], his cardiologist and his primary care physician as an outpatient. Medications on Admission: Synthroid 150mcg daily Timoptic one drop to both eyes at bed time Travatan one drop to both eyes at bed time Lipitor 20mg once daily Toprol XL 50mg once daily Doxycycline 50mg once daily Valium 5mg as needed at bed time Ecotrin 81mg once daily 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. Timolol Maleate 0.5 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2 times a day). Disp:*1 bottle* Refills:*2* 4. Levothyroxine Sodium 150 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 5. Atorvastatin Calcium 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 6. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed. Disp:*120 Tablet(s)* Refills:*0* 7. Atenolol 25 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 8. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs PO Q4-6H (every 4 to 6 hours) as needed for pain. Disp:*250 ML(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital3 **] Discharge Diagnosis: Coronary artery disease. 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. Followup Instructions: Make an appointment with Dr. [**Last Name (STitle) 32285**] for 1-2 weeks. Make an appointment with Dr. [**Last Name (STitle) **] for 2-3 weeks. Make an appointment with Dr. [**Last Name (STitle) **] for 4 weeks. Completed by:[**2196-2-2**]

[ "272.4", "414.01", "458.29", "413.9", "244.0", "V10.87" ]

icd9cm

[ [ [] ] ]

[ "37.22", "36.12", "99.04", "88.56", "39.61", "36.15", "88.53", "99.07" ]

icd9pcs

[ [ [] ] ]

8057, 8104

4531, 6771

340, 428

8173, 8180

2441, 4508

8423, 8666

1830, 1950

7066, 8034

8125, 8152

6797, 7043

8204, 8400

1965, 2422

281, 302

456, 1505

1527, 1663

1679, 1814

75,796

142,124

41270

Discharge summary

report

Admission Date: [**2198-6-7**] Discharge Date: [**2198-6-12**] Date of Birth: [**2125-8-3**] Sex: F Service: MEDICINE Allergies: Codeine Attending:[**First Name3 (LF) 633**] Chief Complaint: Hypoglycemia Major Surgical or Invasive Procedure: None History of Present Illness: 72F history of sleep apnea on CPAP, A. fib on Coumadin, COPD (1L O2 NC at home), diabetes on insulin, CHF presents with hypoglycemic episode after being discharged from hospital yesterday [**6-5**] after a MICU admission for hypercarbic respiratory failure. This AM, she took both her Lantus 60U and 10U of regular insulin for an AM FSG of 259, but did not eat anything b/c she was in a hurry to get to her PCP's appt. About 2 hrs after taking her insulin, she was found walking around and confused (per the daughter, however, the pt was found down in the hallway by a neighbor). EMS was called by her husband and she was found to have a fingerstick glucose of 21. She was given an amp of D50, after which her mental status improved, and her repeat blood glucose was in the 200s. She denies any recent fevers or chills; she was recently hospitalized for hypercarbic respiratory failure thought to be secondary to a COPD exacerbation, and she was intubated from [**5-29**]- [**2198-5-30**]. She was initially on ABx but they were d/c'd during hospitalization. No cough. No SOB per patient. No Abd pain/N/V/D/changes in bowel or bladder habits, no dysuria. In the ED, initial VS were: 96.2 89 134/46 20 96%. She was lethargic, but arousable, A+O x1. She had a FSBG of 71 and was given repeat D50, 290 on repeat. Repeat at 1455 was 22. She was given another amp of D50, and was started on a D5 drip. Pt was hypercarbic on ABG even when sitting up and talking. On 1L O2 NC 92-94%. On arrival to the MICU, the pt is comfortable and has no complaints. ROS negative. Pt remarked that she has never had a problem with hypoglycaemia in the past. Review of systems: Per HPI Past Medical History: - COPD on home oxygen-dependent - Obstructive sleep apnea with BiPAP at night - Type 2 diabetes mellitus, on insulin - Atrial fibrillation on coumadin - Diastolic congestive heart failure - Diverticulitis s/p colostomy, then s/p reversal - OSA, on BiPAP - Obesity - Anemia of chronic disease - Hypertension - Dyslipidemia - Chronic kidney insufficiency stage III in f/u renal [**Hospital1 18**] - GERD Social History: Used to be school bus driver. Lives in [**Location (un) 538**] with husband and usually granddaughter, multiple kids in local area, HHA cleans. Denies tobacco, EtOH, illicits. Family History: No history of CKD, lung disease, or malignancies. Physical Exam: General: Alert, oriented x3, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear but with macroglossia, EOMI, PERRL Neck: supple, JVP could not be assessed due to habitus CV: Regular rate and rhythm, normal S1 + S2, 2+ systolic murmur at RUS border Lungs: Clear to auscultation bilaterally but with decreased breath sounds throughout, only mild wheezes in RUL field, no crackles Abdomen: soft, non-distended; multiple surgical scars; bowel sounds present, no organomegaly, no tenderness to palpation, no rebound or guarding GU: foley Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CNII-XII intact, 5/5 strength upper/lower extremities, grossly normal sensation. Can say days of wk backwards without difficulty. Pertinent Results: [**2198-6-12**] 07:00AM BLOOD WBC-6.5 RBC-2.92* Hgb-7.8* Hct-26.2* MCV-90 MCH-26.8* MCHC-29.9* RDW-16.1* Plt Ct-439 [**2198-6-11**] 06:55AM BLOOD WBC-6.7 RBC-2.90* Hgb-7.8* Hct-26.4* MCV-91 MCH-26.8* MCHC-29.4* RDW-15.4 Plt Ct-445* [**2198-6-10**] 06:00AM BLOOD WBC-5.7 RBC-3.08* Hgb-8.2* Hct-28.1* MCV-91 MCH-26.5* MCHC-29.1* RDW-15.2 Plt Ct-422 [**2198-6-9**] 05:08AM BLOOD WBC-5.1 RBC-2.88* Hgb-7.7* Hct-26.4* MCV-92 MCH-26.9* MCHC-29.3* RDW-15.3 Plt Ct-396 [**2198-6-8**] 03:23AM BLOOD WBC-6.1 RBC-2.90* Hgb-7.8* Hct-26.4* MCV-91 MCH-26.7* MCHC-29.4* RDW-15.1 Plt Ct-402 [**2198-6-7**] 01:35PM BLOOD WBC-6.6 RBC-3.24* Hgb-8.3* Hct-29.6* MCV-91 MCH-25.6* MCHC-28.0* RDW-14.9 Plt Ct-419 [**2198-6-7**] 01:35PM BLOOD Neuts-72.2* Lymphs-20.3 Monos-4.9 Eos-2.3 Baso-0.3 [**2198-6-12**] 07:00AM BLOOD PT-33.4* PTT-49.4* INR(PT)-3.2* [**2198-6-11**] 06:55AM BLOOD Plt Ct-445* [**2198-6-11**] 06:55AM BLOOD PT-26.3* INR(PT)-2.5* [**2198-6-10**] 06:00AM BLOOD Plt Ct-422 [**2198-6-10**] 06:00AM BLOOD PT-28.1* PTT-48.5* INR(PT)-2.7* [**2198-6-12**] 07:00AM BLOOD Glucose-134* UreaN-45* Creat-1.8* Na-144 K-4.6 Cl-98 HCO3-38* AnGap-13 [**2198-6-11**] 06:55AM BLOOD Glucose-154* UreaN-52* Creat-1.9* Na-146* K-5.0 Cl-102 HCO3-35* AnGap-14 [**2198-6-10**] 06:00AM BLOOD Glucose-248* UreaN-61* Creat-2.0* Na-145 K-4.4 Cl-99 HCO3-36* AnGap-14 [**2198-6-9**] 05:08AM BLOOD Glucose-120* UreaN-62* Creat-2.4* Na-143 K-4.7 Cl-100 HCO3-34* AnGap-14 [**2198-6-8**] 03:23AM BLOOD Glucose-79 UreaN-64* Creat-1.9* Na-142 K-5.4* Cl-102 HCO3-35* AnGap-10 [**2198-6-7**] 11:18PM BLOOD Glucose-124* UreaN-64* Creat-1.9* Na-145 K-4.8 Cl-101 HCO3-38* AnGap-11 [**2198-6-7**] 01:35PM BLOOD Glucose-123* UreaN-68* Creat-2.1* Na-148* K-4.4 Cl-103 HCO3-35* AnGap-14 [**2198-6-7**] 01:35PM BLOOD TSH-1.2 . [**6-7**] EKG: Atrial fibrillation with a controlled ventricular response. Left axis deviation. Left anterior fascicular block. There is a late transition with small R waves in the anterior leads consistent with possible infarction. Non-specific ST-T wave changes. Compared to the previous tracing of [**2198-5-31**] atrial fibrillation is new. . [**6-7**] CXR: IMPRESSION: Mild pulmonary vascular congestion with small bilateral pleural effusions. Bibasilar airspace opacities may reflect atelectasis. Brief Hospital Course: ACTIVE ISSUES: ## Hypoglycemia: Most likely due to taking home dose of Lantus 60U in setting of lack of oral intake on the day of admission and mild renal failure with associated decreased insulin clearance. There was no sign of infectious etiology. TSH and AM Cortisol were normal. She was started on a D10 drip in the ICU until fingersticks stabilized. Despite excellent oral intake on the floor, her Insulin requirements initially remained relatively minimal compared to her home dose. [**Last Name (un) **] was consulted and recommended a lower dose of basal insulin at [3 uptitrated to 8 units on the day of discharge [**First Name8 (NamePattern2) **] [**Last Name (un) **] recommendations, received 5units QHS [**6-11**]]. They also recommended that a DDPV-4 inhibitor that does not require renal clearance and recommended linagliptin 5mg daily to start upon discharge. She should follow up with [**Last Name (un) **] upon discharge from rehab facility. Would check finger sticks QIDACHS at this time. ## Atrial fibrillation: Rate controlled and in sinus rhythm. Her INR was elevated on admission 3.2 and then increased to 4.6. Her Warfarin 6mg was held until the INR trended down and was restarted at 5mg on [**6-10**]. Given that pt was supratherapeutic today [**6-12**]. Her dose should be held on [**6-12**] and restarted at 3mg warfarin daily when INR is <3 (possibly on [**6-13**]) with close INR monitoring. Her BB was continued at the equivalent home dose. She was discharged on her home dose. . ## Sleep apnea on CPAP: CPAP was continued at night during admission. Patient and her family spoke of the need for a new machine as the current machine is not operating correctly. CHRONIC ISSUES: ## COPD (2L O2 NC at home): Continued home nebs, maintained on supplemental O2 for goal saturation 88-90% Pt is on 1L o2 at home. ## Primary respiratory acidosis with compensatory metabolic alkalosis: Likely chronic in setting of her COPD. Respiratory status appeared stable. ## Chronic diastolic CHF: No active issues during this admission. Home cardiac meds were continued. ## Stage 3 CKD, baseline Cr 1.8: Cr upon admission was 2.1 and peaked at 2.4, which was thought to be aberrant since it rose and improved without any intervention. 1.8 on day of DC. ## Anemia: normocytic, chronic. Likely related to CKD and diabetes. Hct remained stable during admission without any transfusion requirement. Can consider further work up as an outpatient such as iron studies and colonoscopy. 26.2 on discharge. ## Glaucoma: Continued latanoprost, apraclonidin, prednisolone. TRANSITIONS OF CARE: -Per PCP, [**Name10 (NameIs) **] needs pulmonary rehab given that this is her third admission. She also needs a new CPAP machine, and per her family's report, the pt will need assistance to work through insurance and other issues in order to get the machine provided. Case mgmt and social work were consulted, and in the meantime the pt was approved for [**Hospital3 **] skilled nursing, given concern for her ability to care for herself. She will require confirmation that she has adequate CPAP machinery at home or at [**Hospital3 **]. Pt will need close glucose monitoring while her regimen is being titrated. She will also need INR monitoring and adjustment of her warfarin dosing prn. -hydralazine increased, coumadin decreased, glargine decreased, linagliptin added to medication regimen -Pt will need PCP and [**Name9 (PRE) **] follow up arranged at the time of DC from rehab Medications on Admission: 1. amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day. 2. benazepril 40 mg Tablet Sig: One (1) Tablet PO once a day. 3. famotidine 20 mg Tablet Sig: One (1) Tablet PO twice a day. 4. gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO twice a day. 5. prednisolone acetate 1 % Drops, Suspension Sig: One (1) Drop Left Eye Ophthalmic DAILY (Daily). 6. Lantus 100 unit/mL Solution Sig: Sixty (60) units Subcutaneous once a day. 7. ipratropium-albuterol 0.5 mg-3 mg(2.5 mg base)/3 mL Solution for Nebulization Sig: One (1) unit Inhalation every four (4) hours as needed for shortness of breath or wheezing. 8. metoprolol succinate 50 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO once a day. 9. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Capsule Inhalation once a day. 10. apraclonidine 0.5 % Drops Sig: One (1) Drop Left Eye Ophthalmic DAILY (Daily). 11. latanoprost 0.005 % Drops Sig: One (1) Drop Right Eye Ophthalmic HS (at bedtime). 12. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler Sig: [**1-15**] INH Inhalation every 4-6 hours as needed for shortness of breath or wheezing. 13. fluticasone-salmeterol 500-50 mcg/dose Disk with Device Sig: One (1) INH Inhalation twice a day. 14. warfarin 6 mg Tablet Sig: One (1) Tablet PO Q 4 pm. 15. hydralazine 25 mg Tablet Sig: One (1) Tablet PO Q8H 16. Home Oxygen 1 Liter/min 17. Outpatient Pulmonary Rehab 18. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY Discharge Medications: 1. amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day. 2. Lantus 100 unit/mL Solution Sig: Eight (8) units Subcutaneous at bedtime. 3. linagliptin Linagliptin 5mg daily 4. benazepril 40 mg Tablet Sig: One (1) Tablet PO once a day. 5. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. apraclonidine 0.5 % Drops Sig: One (1) Drop Ophthalmic DAILY (Daily): left eye. 8. Combivent 18-103 mcg/actuation Aerosol Sig: One (1) Inhalation every 4-6 hours as needed for shortness of breath or wheezing. 9. prednisolone acetate 1 % Drops, Suspension Sig: One (1) drop Ophthalmic once a day. 10. metoprolol succinate 50 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO once a day. 11. fluticasone-salmeterol 500-50 mcg/dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 12. hydralazine 25 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for HTN: increased from q8 at home. 13. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at bedtime): right eye. 15. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 16. humalog sliding scale QID ACHS. Please see attached sheet 17. warfarin Please start warfarin 3mg daily when INR is <3. Please check INR [**6-13**] Discharge Disposition: Extended Care Facility: [**Hospital3 2558**] - [**Location (un) **] Discharge Diagnosis: Hypoglycemia . Chronic COPD CKD HTN diastolic CHF 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 Intensive Care Unit at [**Hospital1 771**] for treatment of low blood sugar, which was likely due to taking your Insulin without eating anything the following day. The [**Last Name (un) **] Diabetes Center saw you during this admission and recommended reducing dose of your long-acting insulin (Lantus) to 8 units daily. They also recommended that you start another medication for your blood sugar called, linagliptin 5mg daily . MEDICATION CHANGES: - Your Lantus dose was decreased from 60 units daily to 8 units daily - you were started on linagliptin - your hydralazine was increased to four times a day Followup Instructions: Department: PULMONARY FUNCTION LAB When: MONDAY [**2198-6-25**] at 8:40 AM With: PULMONARY FUNCTION LAB [**Telephone/Fax (1) 609**] Building: [**Hospital6 29**] [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: PFT When: MONDAY [**2198-6-25**] at 9:00 AM Department: MEDICAL SPECIALTIES When: MONDAY [**2198-6-25**] at 9:00 AM With: [**Name6 (MD) 610**] [**Name8 (MD) **] RN/DR. [**Last Name (STitle) 611**] [**Telephone/Fax (1) 612**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage . Name:[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 607**],MD Specialty: Primary Care Location: [**Hospital1 **] [**First Name (Titles) **] [**Last Name (Titles) **] Address: 545A CENTRE ST, [**Location (un) **],[**Numeric Identifier 6809**] Phone: [**Telephone/Fax (1) 608**] Please discuss with the staff at the facility a follow up appointment with your PCP when you are ready for discharge. . [**Last Name (un) **]-please have your Nursing facility call The [**Last Name (un) **] Center to schedule you an appointment to be seen after discharge.

[ "285.9", "250.82", "428.32", "272.4", "V46.2", "403.90", "V58.67", "327.23", "365.9", "276.0", "V58.61", "496", "427.31", "428.0", "276.4", "585.3", "584.9", "518.83" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

12246, 12316

5763, 5763

278, 284

12410, 12410

3457, 5740

13249, 14449

2616, 2667

10784, 12223

12337, 12389

9280, 10761

12593, 13048

2682, 3436

1972, 1982

13068, 13226

226, 240

5779, 7458

312, 1953

12425, 12569

8369, 9254

7475, 8348

2004, 2407

2423, 2600

28,481

189,424

33516

Discharge summary

report

Admission Date: [**2112-2-16**] Discharge Date: [**2112-3-4**] Date of Birth: [**2045-12-26**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 3984**] Chief Complaint: Dyspnea and chest pain. Major Surgical or Invasive Procedure: 1. Intubation x 2 2. Central line placement 3. Arterial line placement 4. Mechanical ventilation History of Present Illness: The patient is a 66 y o F with PMH significant for COPD, stroke, on chronic coumadin, who prsented to the ED at [**Hospital 1474**] Hospital with 4 days of chst pain. The patient states that she had fallen 4 days prior and developed shoulder pain subsequently. She called EMS because she "wasn't getting better." EMS vitals 100/60 HR 104. She received 4 ASA 81 mg en route. At [**Hospital1 1474**], she was treated with IV solumedrol and albuterol nebulizers as well as avelox 400 mg IV, morphine, and ativan. She also received vitamin K 5 mg PO x1. Troponin level at [**Hospital1 1474**] was intermediate and she wsa transferred to [**Hospital1 18**] due to no ICU beds at [**Hospital1 1474**]. In the emergency department at [**Hospital1 18**], notable for SaO2= 81% on room air. Her blood pressure decreased transiently to 70s/40s, with heart rates >100. She was sent to the ICU with O2 Sat 98% on NRB. She receive azithromycin 500 PO x1 and combivent nebs. CTA done to eval for PE was negative for PE but showed emphysematous change, and pulmonary nodules. On arrival to the ICU, the patient was breathing more comfortably. She stated that her chest pain, which was substernal in nature, was pleuritic, and worse with palpation, but had resolved. +non-productive cough. Denies recent fever, chills, nausea/vomiting, diarrhea. Did not see her PCP when she felt worse several days ago Past Medical History: * COPD - on chronic inhalers, no prior intubations, steroids ~ twice per year per her report, on 3L NC at home continuously * CAD with prior MI X 2 * Prior CVA with residual R sided weakness * Iron deficiency anemia * hyperlipidemia * hypertension * s/p L CEA Social History: Prior smoker, but not in many years. No alcohol. No drugs. Lives with son who helps care for her. Walks with walker at baseline. Family History: non-contributory Physical Exam: On admission: VS: 97.3 BP: 110/65 HR 106 RR: 16 O2Sat: 100% on NRB Gen: pleasant, elderly female in no acute distress, wearing NRB HEENT: PERRL ,EOMI, sclerae anicteric, MM slightly dry, OP without lesions Neck: no supraclavicular or cervical lymphadenopathy, no JVD while sitting upright, CEA scar on L neck Chest: exquisitely tender to palpation over sternum, left chest Respiratory: diffuse wheezes throughout, poor air movement CV: tachy, but regular, no appreciable murmur ABD: soft, non-tender to palpation, normoactive bowel sounds EXT: extremities warm throughout, right hand contracted Skin: no rashes, echymossis at sites of prior IV Neuro: A&O x3. Face symmetric, able to speak clearly and in full sentences. R sided hemiparesis, moving left side without difficulty. Pertinent Results: Lab results from Admission: [**2112-2-16**] 11:00PM GLUCOSE-166* UREA N-75* CREAT-0.9 SODIUM-150* POTASSIUM-5.1 CHLORIDE-115* TOTAL CO2-21* ANION GAP-19 [**2112-2-16**] 11:00PM CK(CPK)-61 [**2112-2-16**] 11:00PM cTropnT-0.10* [**2112-2-16**] 11:00PM WBC-6.6 RBC-3.94* HGB-12.0 HCT-35.7* MCV-91 MCH-30.4 MCHC-33.6 RDW-13.3 [**2112-2-16**] 11:00PM NEUTS-89.5* LYMPHS-5.5* MONOS-4.6 EOS-0.1 BASOS-0.3 [**2112-2-16**] 11:00PM PLT COUNT-176 [**2112-2-16**] 11:00PM PT-59.0* PTT-33.8 INR(PT)-7.0* Pertinent Imaging: CTA Chest [**2-16**]: IMPRESSION: 1. No pulmonary embolism. 2. Extensive, moderately severe emphysema. Small area of bronchiectasis within the right lower lobe with surrounding tree-in-[**Male First Name (un) 239**] opacities could reflect an element of inflammation/ respiratory bronchiolitis. No large focal areas of consolidation are noted. Prominent hilar and mediastinal lymph nodes are likely reactive. 3. Scattered pulmonary nodules measuring up to 8 mm. A dedicated chest CT followup examination in 3 - 6 months is recommended to establish initial stability. 4. Extensive calcific atherosclerotic disease involving the coronary arteries. . ECHO [**2-20**]: IMPRESSION: Moderately dilated right ventricular cavity with depressed free wall contractility. There may be a mass in the apex of the right ventricle. This is most likely due to prominent trabeculations although a thrombus or other mass cannot be excluded. Mild regional left ventricular systolic dysfunction. Moderate to severe tricuspid regurgitation. Severe pulmonary artery artery systolic hypertension. EF 45-50%. . RUE US [**2-27**]: IMPRESSION: No evidence of DVT in the right upper extremity. MICROBIOLOGY: [**2112-2-28**] Rapid Viral Antigens including Influenzae: negative SPUTUM Source: Endotracheal. GRAM STAIN (Final [**2112-2-19**]): >25 PMNs and <10 epithelial cells/100X field. 2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS AND CLUSTERS. RESPIRATORY CULTURE (Final [**2112-2-21**]): SPARSE GROWTH OROPHARYNGEAL FLORA. [**2112-2-20**] Blood Culture x 2 negative Brief Hospital Course: 1. Respiratory Distress: The patient was admitted to the MICU service on [**2112-2-16**] for a COPD exacerbation and pneumonia. She was treated with steroids, antibiotics (vanco, ceftriaxone, azithromycin), nebs. She became acutely short of breath and required BiPAP. On [**2112-2-19**], the patient appeared tired despite intermittent BiPAP and the patient was intubated after a discussion with the patient and the patient's daughter. A right internal jugular venous catheter was placed for access, and an arterial line was placed for closer monitoring. The patient was extubated on [**2-22**], and was intitially tachycardic and hypertensive. Her blood pressure was controlled initially with a nitro gtt. Low dose benzodiazepines also helped the patient's comfort and respiratory distress. The patient required BiPAP intermittantly, but was weaned off prior to transfer to the floor on [**2-25**]. Initially she was doing well on the floor. On [**2-26**] she was doing well on 4L NC, but apparently her O2 tubing was found to have a malfunction such that she was not receiving as much O2 as thought (2.5L vs. 4L). She was noted to become acutely short of breath. She was initially hypoxic to 58% on pulse ox while on 2.5L nc, and was cyanotic. She was put on 100% NRB, and ABG was 7/41/55/61. However, she remained dyspneic with increased work of breathing and accessory muscle use. Nasal BiPAP was placed on the floor, and the patient became much more comfortable, with O2 sat 93%. She remained hemodynamically stable, but was transferred back to the MICU for further management. She was reintubated on [**2-27**] for continued respiratory distress. She remained intubated until [**3-1**]. She was extubated with nitro gtt at bedside. The patient tolerated extubation well and was placed on a nebulizer, then weaned to nasal cannula. She tolerated her home O2 (3L), and her respiratory status was watched closely. She was given frequent nebulizer treatments and incentive spirometry was encouraged. Her steroids were tapered. 2. Psychiatry: The patient had a psychiatric consultation on [**3-1**] prior to extubation for concern about the patient's ability to make decisions for herself. The patient exhibited variable desire for intubation, extubation and re-intubation. A Psychiatry consultation revealed that the patient had delerium and was not able to make her own decisions. All decisions were finalized with the health care proxy (daughter), who desired to proceed with re-intubation if necessary, and would consider tracheostomy in the future. The patient was extubaed, and remained clnically improved, on baseline 3 L/min NC. 3. CAD: Patient with history of CAD. Upon admission, troponins were cycled, givne patient's complaint of chest pain. First set was equivocal (0.10), subsequent 2 sets trended down. Cardiac enzymes were cycled upon acute decompensation and return to the MICU on [**2-27**]. Negative x4. Continue ASA 81 mg, statin. 4. Systolic acute on chronic CHF: ECHO report as above. Continue ASA 81 mg daily, statin. Lisinopril increased to 20 mg qd. 5. Hyperlipidemia: Continued statin. Patient on lovastatin at home, but atorvastatin was substituted during her hospitalization. 6. HTN: Initially was hypotensive, but tended to become hypertensive with anxiety and respiratory distress. Had been on nitro gtt upon extubation (both extubations), which was weaned. She was restarted on home meds, but they were titrated according to her pressures. Low dose benzodiazepines also helped her blood pressure. 7. Tachycardia: Mild tachycardia likely related to respiratory distress, albuterol. Monitor on tele. Continued ativan prn for anxiety component. 8. Pulmonary nodules: Patient informed of finding. Requires follow up with repeat chest CT within 3 months. 9. Iron deficiency anemia: Continued iron. 10. Supratherapeutic INR: Warfarin initially was held due to increased INR. Her INR was trended and the patient was restarted on warfarin 3 mg daily. 11. Glucose control: Patient was on insulin sliding scale with 2 units of NPH [**Hospital1 **] due to increased steroids. Fingerstick glucose levels were monitored. 12. Restless leg syndrome: Patient takes requip at home, which was restarted once stable. F/E/N: The patient had a speech and swallow evaluation after her extubation on [**3-1**]. She began a diet of thin liquids and soft consistency solids. PPx: Bowel regimen, PO PPI, coumadin restarted CODE: FULL [**Hospital **] REHAB TO DO: [ ] frequent neb treatments [ ] keep pt O2 sat between 88-93% to prevent hypercarbic respiratory failure [ ] monitor INR and dose warfarin accordingly to obtain INR between [**1-17**]; INR 4.2 on [**2112-3-4**] --> hold warfarin on [**2112-3-4**]. [ ] chest PT as tolerated [ ] steroid taper Medications on Admission: coumadin 3, 4, or 5 mg daily iron 65 mg [**Hospital1 **] lovastatin 20 mg daily oxazepam 15 mg daily singulair 10 mg daily ASA 81 mg daily lisinopril 10 mg daily Requip 1 mg QHS Vitamin D 5000 U once weekly lasix 20 mg once daily KCL 10 mg daily albuterol neb 4 times daily flovent 110 mcg, 2 puffs [**Hospital1 **] atrovent 2 puffs four times daily albuterol inhaler 2 puffs four times daily spiriva 18 mcg daily Discharge Medications: 1. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Ropinirole 1 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)). 5. Docusate Sodium 50 mg/5 mL Liquid Sig: Ten (10) mL PO BID (2 times a day). 6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 7. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 8. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed. 9. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) injection Injection TID (3 times a day). 10. Warfarin 1 mg Tablet Sig: Three (3) Tablet PO once a day. 11. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 14. Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization Sig: One (1) neb Inhalation Q4H (every 4 hours). 15. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb Inhalation Q6H (every 6 hours). 16. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed. 17. Prednisone 20 mg Tablet Sig: Three (3) Tablet PO daily () for 2 days: from [**2112-3-5**] to [**2112-3-6**]. 18. Prednisone 20 mg Tablet Sig: Two (2) Tablet PO daily () for 4 doses: start [**3-7**] - [**3-10**]. 19. Prednisone 20 mg Tablet Sig: One (1) Tablet PO daily () for 4 doses: start [**2112-3-11**] - [**2112-3-14**]. 20. Prednisone 10 mg Tablet Sig: One (1) Tablet PO daily () for 4 doses: start [**3-15**] - [**2112-3-18**]. 21. Insulin NPH Human Recomb 100 unit/mL Cartridge Sig: Two (2) units Subcutaneous twice a day. 22. Insulin Regular Human 300 unit/3 mL Insulin Pen Sig: as directed as directed Subcutaneous qACHS: per sliding scale. Discharge Disposition: Extended Care Facility: [**Hospital1 700**] TCU - [**Location (un) 701**] Discharge Diagnosis: Primary diagnosis: 1. COPD exacerbation 2. dyspnea Secondary diagnoses: 1. Hyperlipidemia 2. Iron deficiency anemia 3. Hypertension Discharge Condition: Stable. On 3 L NC O2. Afebrile. Discharge Instructions: You have been admitted to the [**Hospital1 1170**] with a COPD exacerbation. While you were in the hospital, you were intubated twice, and had a central line placed. Your respiratory status has been closely monitored while you were in the hospital. You were treated with IV antibiotics, frequent nebulizer treatments, and steroids. You improved with these interventions, and by discharge, you were back on 3 L NC as you are normally at home. . Please take all your medications as prescribed. Please keep all your medical appointments. . Please return to the ED or call your PCP if you have worsening shortness of breath, chest pain, fever >101.4 F, or any other symptoms which are concerning to you. Followup Instructions: Please follow up with your primary care doctor in [**12-16**] weeks. Please call to make an appointment. . You were found to have pulmonary nodules on your chest CT scan. Please inform your PCP that you should have a 3-month follow up CT scan to evaluate these nodules. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**] MD [**MD Number(1) 2438**]

[ "729.81", "428.23", "491.21", "518.89", "E945.7", "485", "333.94", "272.4", "438.89", "E934.2", "276.50", "427.89", "412", "790.92", "799.02", "790.29", "780.09", "414.01", "780.79", "276.0", "401.9", "458.9", "V45.82", "V45.89", "300.00", "518.81", "428.0", "280.9", "493.22" ]

icd9cm

[ [ [] ] ]

[ "96.71", "96.04", "93.90", "96.6", "38.91", "38.93" ]

icd9pcs

[ [ [] ] ]

12591, 12667

5320, 10142

339, 437

12843, 12879

3145, 5297

13634, 14033

2312, 2330

10607, 12568

12688, 12688

10168, 10584

12903, 13611

2345, 2345

12760, 12822

276, 301

465, 1867

12707, 12739

2359, 3126

1889, 2150

2166, 2296

21,580

188,516

43774

Discharge summary

report

Admission Date: [**2131-4-22**] Discharge Date: [**2131-5-2**] Date of Birth: [**2053-7-1**] Sex: F Service: MEDICINE Allergies: Penicillins Attending:[**Last Name (NamePattern1) 1167**] Chief Complaint: Low back pain Major Surgical or Invasive Procedure: Lumbar decompression surgery History of Present Illness: This is a 77 yo F with h/o HOCM and diastolic dysfunction, h/o PAF on coumadin, HTN, s/p DDD PCM, h/o mesenteric artery thrombosis, CRI, who presents for diuresis prior to lumbar decompresson surgery planned for [**4-24**]. . She has just been admitted from [**Date range (1) 94058**] for increased SOB and LE edema. She was carefully diuresed with a Lasix drip and was discharged on Torsemide 200mg daily, Aldactone and HCTZ. She mentioned that her weight came down from 203 lbs to 195 lbs during the previous admission. Her weight has been stable since then and her last weight was 193 lbs. She denies any change in her baseline since then. Her breathing has been stable, she requires two pillows at night to sleep, she denies any increased leg swelling, also no CP, fainting or palpitations. She has been off coumadin since Wed, [**4-18**] in preparation for the surgery. She has been accompanied by her son and his wife. Past Medical History: -Hypertrophic obstructive cardiomyopathy with superimposed diastolic dysfunction, s/p ethanol ablation in [**2126**] -dCHF (EF-60%-70%, 2+ TR; 1+ MR) -PAF on coumadin -HTN -S/P DDD pacemaker to induce LV delay compared to the right ventricle in order to decrease the outflow tract obstruction. -Mesenteric artery thrombosis -Diabetes mellitus type 2 -Glaucoma -Gout -Chronic low back pain and lumbar stenosis s/p recent placement of nerve stimulator -CRI (1.1-1.2) -cath in [**2126**] showed no obstructing disease in coronary arteries Social History: The patient quit smoking many years ago. She drinks less than one drink per week. She is from [**Country 4754**]. Pt. has a daughter who is a nurse. She lives alone. Her son, who she previously lived with, got married recently. Family History: Mother has diabetes mellitus. Brother had a CABG, the details of which are unknown. Physical Exam: VS: Temp: 97.1, BP: 105/55, HR: 74, RR: 20, O2sat: 91% RA GEN: pleasant, comfortable, NAD HEENT: EOMI, anicteric, MMM, op without lesions NECK: JVD approx. 10cm, no carotid bruits RESP: Mild, dry crackles at bases b/l, otherwise CTA b/l good air movement throughout CV: RR, S1 and S2 wnl, no m/r/g ABD: obese, nd, +b/s, soft, nt, no masses EXT: [**11-21**]+ LE edema up to mid-tibiae, warm, good pulses SKIN: no rashes/no jaundice NEURO: AAO. 5/5 strength throughout except for pain-related weakness of right LE. No sensory deficits to light touch appreciated. Pertinent Results: [**2131-4-22**] 05:05PM WBC-11.3* RBC-4.79 HGB-15.1 HCT-44.5 MCV-93 MCH-31.5 MCHC-33.9 RDW-15.1 PLT COUNT-369 [**2131-4-22**] 05:05PM PT-13.2* PTT-25.7 INR(PT)-1.2* [**2131-4-22**] 05:05PM GLUCOSE-103 UREA N-83* CREAT-1.8* SODIUM-130* POTASSIUM-4.3 CHLORIDE-89* TOTAL CO2-28 ANION GAP-17 [**2131-4-30**] 11:35AM BLOOD WBC-18.0* RBC-2.98* Hgb-9.3* Hct-27.3* MCV-91 MCH-31.2 MCHC-34.1 RDW-15.4 Plt Ct-194 [**2131-5-2**] 06:25AM BLOOD WBC-15.1* RBC-2.93* Hgb-9.1* Hct-27.9* MCV-95 MCH-30.9 MCHC-32.5 RDW-15.5 Plt Ct-292 [**2131-4-27**] 06:50AM BLOOD PT-12.5 PTT-26.9 INR(PT)-1.1 [**2131-4-29**] 07:05AM BLOOD Glucose-204* UreaN-45* Creat-1.3* Na-137 K-4.5 Cl-99 HCO3-25 AnGap-18 [**2131-5-2**] 06:25AM BLOOD Glucose-181* UreaN-46* Creat-1.2* Na-135 K-3.7 Cl-96 HCO3-30 AnGap-13 Two radiographs of the lumbar spine demonstrate the patient to be status post L3-L5 posterior osseous and metallic spinal fusion and L3-L5 laminectomy, new when compared to [**2130-11-29**]. Vertebral body heights are maintained. There is mild anterolisthesis of L3 on L4 measuring 4-5 mm (grade I). No hardware loosening is appreciated. Bilateral hip joints are unremarkable. Assessment of the sacrum is limited by overlying bowel gas. Surgical staples are seen in the skin along the posterior midline. The lungs are hyperinflated and the diaphragms are flattened, consistent with COPD. A left-sided dual-lead pacemaker is present, with lead tips over the right atrium and right ventricle. There is moderate cardiomegaly. The aorta is unfolded and ? slightly ectatic. There is minimal upper zone redistribution and slight prominence of the vessels, without overt CHF. No focal infiltrate or effusion is identified. On the lateral view, there is some prominence of markings posteriorly. The possibility of an early infectious infiltrate cannot be entirely excluded. Brief Hospital Course: A/P: 77yo woman with h/o HTN, HOCM, PAF s/p DDD PCM, CRI, who presented for pre-op optimization of fluid status before lumbar decompresson surgery, c/b leukocytois/fever/AMS, resolved and underwent surgery. . # S/P lumbar decompression: Pain under adequate control with dilaudid PCA. No signs of wound infection. Followed in conjuction with ortho-spine who recommended followup in 2 weeks. PT/OT following . # Leukocytosis/fever: Asymptomatic without source of infection. Remained afebrile postoperateively with slow regression of leukocytosis. No infection found on standard workup including CXR, U/A, UCx and blood cultures. # Cardiac: a) CHF: EF 60% with known diastolic CHF; difficult to diurese as she begins to have azotemia, hypotension and presyncope. Was slightly volume overloaded based on exam, O2 sat but improved with medical management which included gentle diuresis. Outpatient regimen of torsemide, metoprolol, spironolactone, diltiazem continued without change. Lisinopril restarted postoperatively but HCTZ continued to be held given hyponatremia. Her daily I/O goal was maintained even. . b) CAD: Pt with clean coronaries per cath in [**2126**]. - Continued BB, Statin, CCB - Restarted ASA post-op . c) Rhythm: s/p DDD PCM. Pt with longstanding AFib. She is controlled on coumadin, Toprol and Diltiazem. Coumadin held in anticipation of lumbar surgery and restarted postoperatively. Needs INR monitoring upon discharge until stable. . # Acute on CRI: baseline recently 1.0-1.3, was 1.8 on admit, now down to 1.3 off lisinopril. Was likely prerenal azotemia on presentation from CHF similar to previous episodes, now resolving. Low dose ACEi restarted on discharge. . # DM2: changed glipizide to 10mg qam, 5mg qpm and covered with insulin scale. . # Diabetic PNP: continued Gabapentin . # Gout: continued allopurinol, adjusted for renal insuff . # Glaucoma: Continued home latanoprost eyedrops at bedtime and brimonidine eyedrops twice daily . # Hypercholesterolemia: continued Simvastatin. . # Anemia: continued iron supplementation. . # Depression: continued Paxil . # Pt discharged to [**Hospital 100**] Rehab for continued care. Medications on Admission: Torsemide 200 mg daily Aldactone 25 mg daily HCTZ 25 mg daily Dilt 120 mg SR daily Toprol XL 25 mg dialy ASA 81 Lisinopril 5 mg daily Coumadin 5 mg daily, held since [**4-18**] Allopurinol 100 mg daily Latanoprost drops--1drop at bed to right eye Brimonidine drops q 8 hr 0.15% [**Hospital1 **] Senna [**Hospital1 **] Paxil 20 mg daily Gabapentin 300mg tid Glipizide 5 mg dialy Simvastatin 20 mg daily Oxycodone 5 mg prn Colace 100 mg [**Hospital1 **] Bisacodyl 10 mg daily Lactulose 15ml q8h Ambien 5 mg qhs Alendronate 70 mg daily Percocet prn q4-6h Discharge Medications: 1. Diltiazem HCl 120 mg Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO DAILY (Daily). 2. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 3. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): hold for loose stool. 5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 6. Paroxetine HCl 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Alendronate 70 mg Tablet Sig: One (1) Tablet PO QSUN (every Sunday). 9. Brimonidine 0.15 % Drops Sig: One (1) drop drop Ophthalmic [**Hospital1 **] (2 times a day). 10. Latanoprost 0.005 % Drops Sig: One (1) drop Ophthalmic qhs (). 11. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Lactulose 10 g/15 mL Syrup Sig: Fifteen (15) ML PO TID (3 times a day) as needed for constipation: for constipation. 13. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 14. Glipizide 5 mg Tablet Sig: Two (2) Tablet PO QAM (once a day (in the morning)). 15. Glipizide 5 mg Tablet Sig: One (1) Tablet PO QDINNER (). 16. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed. 17. Torsemide 100 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 18. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 19. Insulin Lispro (Human) 100 unit/mL Solution Sig: 1-10 units Subcutaneous ASDIR (AS DIRECTED): as per attached sliding scale. 20. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed for pain. 21. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed. 22. Warfarin 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime): please check INR twice a week until stable. Goal [**12-23**]. 23. Outpatient Lab Work please check INR on [**2131-5-3**] and adjust warfarin dosing for goal INR [**12-23**] 24. Lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): hold for sbp<95 . Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - [**Location (un) 550**] Discharge Diagnosis: Primary Diagnosis: 1. Low Back pain, s/p lumbar decompression 2. HOCM 3. Diastolic dysfunction secondary to HOCM 4. h/o PAF, on coumadin 5. s/p DDD pacemaker 6. h/o mesenteric artery thrombosis 7. Acute on chronic renal failure . Secondary Diagnosis: 1. Diabetes mellitus 2. Glaucoma 3. Gout 4. HTN Discharge Condition: Afebrile. Hemodynamically stable. Tolerating PO. Discharge Instructions: Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs. Adhere to 2 gm sodium diet . Please call your primary doctor or return to the ED with fever, chills, chest pain, shortness of breath, nausea/vomiting, spontaneous bleeding, worsening back pain or leg/arm weakness or any other concerning symptoms . Please take all your medications as directed. . Please keep you follow up appointments as below. Followup Instructions: Please follow up with your primary care doctor ([**Last Name (LF) **],[**First Name3 (LF) **] [**Telephone/Fax (1) 250**]) in [**11-21**] weeks from now. Please call Dr [**Last Name (STitle) 1352**] upon discharge for directions for followup, he will likely want to see you in his office in [**11-21**] weeks. Please also follow up with: Provider: [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Doctor Last Name **] Phone:[**Telephone/Fax (1) 3512**] Date/Time:[**2131-7-9**] 2:00 Provider: [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2131-7-30**] 11:00

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icd9cm

[ [ [] ] ]

[ "03.09", "81.08", "81.62" ]

icd9pcs

[ [ [] ] ]

9569, 9654

4659, 6820

292, 323

9998, 10049

2783, 4636

10520, 11139

2100, 2187

7423, 9546

9675, 9675

6846, 7400

10073, 10497

2202, 2764

239, 254

351, 1278

9927, 9977

9694, 9906

1300, 1838

1854, 2084

30,464

124,436

29881

Discharge summary

report

Admission Date: [**2174-11-30**] Discharge Date: [**2174-12-4**] Date of Birth: [**2128-5-2**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 943**] Chief Complaint: Hypotension and woresening mental status Major Surgical or Invasive Procedure: Central venous line Paracentesis History of Present Illness: History of Present Illness: Mr. [**Known lastname 71434**] is a 46 year old male with cryptogenic cirrhosis, GERD, OSA, awaiting liver transplant (MELD of 24), who presents with hypotension and mental status changes. Of note, patient was recently discharged from [**Hospital1 18**] on [**11-24**] after being treated for decompensated liver failure and mental status changes in the setting of hepatic encephalopathy. His hospital course was complicated by a right hepatic hydrothorax which is slowly improving. His AMS improved with rifaximin and lactulose. Given significant ascites and SOB, a tap was performed and 1.5L were drained. No evidence for SBP was found on chemistries and cultures. Importantly, he was discharged on increased doses of lasix and spironolactone (80mg [**Hospital1 **] and 200mg [**Hospital1 **], respectively, from 40 tid and 100 daily). In addition, he had decreased PO intake since discharge because of poor appetite. His MS [**First Name (Titles) **] [**Last Name (Titles) 22472**] and [**Doctor Last Name 688**] over the last few weeks. He reports that his sleep/wake cycle is disturbed and his confusion is worse if he has not slept much overnight. His dizziness is mild. He denies any fainting or falls since discharge from the hospital. He was seen on day of this admission in the liver clinic and c/o dizziness and confusion. He was found to have low BP of 86/50 in the clinic and was therefore sent to the ED for be admitted to the liver service for IVF hydration. In the ED, his VS were T98.5, HR 62, BP 81/44, on repeat 90/45, RR 16, 100% on RA. FS 118. A CVL was placed (R IJ). He received 3L IVF with no significant change in his BP which remained in the low 90s. His Ammonium is 34. He received 20gm of Lactulose. He remained afebrile, his WBC was not elevated (6.1). No left shift was noted. His lactate was 2.4. He received 1gm of CTX. No paracentesis was performed after discussion with Dr. [**Last Name (STitle) 497**] (primary liver physician) who felt that a tap in the morning under U/S guidance should be sufficient. Given his hypotension, he was admitted to the ICU for overnight monitoring. On arrival to the ICU, his BP was 90/54, he was mentating, had good pulses and UOP. He report no fevers, chills, SOB, chest pain, abdominal pain, or new diarrhea (at baseline [**1-22**] BMs per day on lactulose). Past Medical History: 1)Cryptogenic cirrhosis ([**1-21**] NASH vs. alpha-1-antitrypsin deficiency), MELD score 21. Patient was found to be negative for hemachromatosis genes. He is negative for hepatitis A, B, and C. He is HIV negative, [**Doctor First Name **] negative. [**Doctor First Name **] is positive with a low titer of 140. Recent alpha-fetoprotein was 2.7. Alpha-1 antitrypsin genotype which was negative. 2)OSA on CPAP 3)GERD 4)s/p inguinal hernia repair about 40 years ago Social History: The patient lives with his wife and two children. He works in a sprayed asphalt business for approximately 18 years. He does not smoke tobacco. Occasional EtOH. Family History: The patient's sister has been treated for non-[**Name (NI) 4278**] lymphoma. The patient's brother has hypertension. The patient's father had hypertension and alcoholism. The patient's mother had kidney disease. Physical Exam: T97.9, HR 70, BP 90/54, RR 13, 100%RA, CVP 5-6 GEN: A&O x 3, pleasant, comfortable, NAD HEENT: PERRL, EOMI, icteric, MMM, without lesions NECK: flat jvd, supple RESP: CTA b/l with good air movement throughout CV: RR, S1 and S2 wnl, no m/r/g ABD: mildly distended, +b/s, soft, nt, no significant fluid wave appreciated EXT: trace LE edema b/l, no c/c, warm, good pulses SKIN: jaundiced, no rashes, spider naevi NEURO: AAOx3. Responds appropriately to all questions. [**4-23**] strength throughout. No sensory deficits to light touch appreciated except for slight decrease over RLE. Mild asterixis. Pertinent Results: Labs in the ED: Ammonia: 34 136 99 15 ===========96 3.2 31 0.9 Ca: 8.6 P: 3.4 ALT: 81 AP: 87 Tbili: 9.8 Alb: 2.5 AST: 92 LDH: Dbili: TProt: [**Doctor First Name **]: 61 Lip: 36 WBC 6.1 Hct 34.2 Plt 64 N:66.6 L:19.8 M:10.2 E:2.9 Bas:0.6 PT: 23.7 PTT: 48.1 INR: 2.3 Lactate 2.4 -> 2.0 [**2174-11-14**] ASCITES TOT PROT-0.6 GLUCOSE-107 LD(LDH)-34 ALBUMIN-LESS THAN WBC-125* RBC-4020* POLYS-0 LYMPHS-45* MONOS-0 MESOTHELI-11* MACROPHAG-42* OTHER-2* EKG [**11-30**]: SB at 59, NSSTW changes c/w previous EKG CT CHEST W/O CONTRAST [**2174-11-17**] 1) Moderate improvement of relaxation atelectasis, without evidence of bronchial torsion, endobronchial lesion, or other cause bronchial obstruction. There is no indication for bronchoscopy. 2) Increased large right pleural effusion. 3) Cirrhosis with sequella of severe portal hypertension are unchanged since [**2174-9-10**]. CXR [**11-30**]: 1. Mild elevation of the right hemidiaphragm, less than seen on recent prior studies, may represent a residual small subpulmonic effusion. 2. There is interval resolution of previously seen subtotal right upper lobe and right middle lobe collapse. 3. A hazy ill-defined opacity in the right lower lung is concerning for early infiltrate. 4. Unchanged low lung volumes with bibasilar atelectasis. [**Last Name (un) **] u/s [**12-2**]: 1. Portal vein thrombosis, with no flow in the portal vein. Patent IVC and hepatic veins. 2. Splenomegaly. 3. Large amount of ascites. 4. Small, cirrhotic liver. 5. No focal liver lesion. Brief Hospital Course: A/P: Mr. [**Known lastname 71434**] is a 46 yo male with cryptogenic cirrhosis, awaiting liver transplant, who presents with hypotension and mental status changes. #)Hypotension: Upon admission, he was hypotensive with SBP~84 in liver clinic. Per past discharge summaries, pt is hypotensive with SBP~90's during his most recent admission. He was hypotensive in the ED with no significant change after 3 liters of IV fluids. Admission blood pressure was close to his baseline. He denied any localizing symptoms of infection, was afebrile, WBC at baseline, no abdominal tenderness. He received ceftriaxone in ED given concern for occult infection. CXR was without definite infiltrate. UA was negative. A right IJ central catheter was placed in ED given concern that he may decompensate quickly. He was initially admitted to the MICU where his diuretics were held and he was given IVF as needed. The primary team consider a diagnostic paracentesis, but decided there was no need for a tap as he was afebrile and pain free. Blood cultures were obtained and all were negative for growth. Upon transfer to Liver Service, diuretics were started at lower doses than prior discharge. Once confirmed that he was hemodynamically stable, he was discharged on Lasix 40mg daily and Spironolactone 100mg daily with SBP in low to mid 90s. #) Abnormal liver ultrasound: Noted to have baseline, chronic changes associated with cirrhosis. Additionally, was concerning for question of portal vein occlusion. MRA was obtained and revealed no evidence of thrombus. #)Mental status changes: [**Known lastname **] and [**Doctor Last Name 688**] for weeks. Mild asterixis on exam. Ammonia 34 while in the ED. Improved MS during last admission on lactulose and rifaximin. FS 118 in ED. Recent dizziness likely due to dehydration on increased diuretics. On arrival to ICU, he was alert and oriented and responding appropriately to all questions. Continued on lactulose and rifaximin without modification to his outpatient regimen. #)Cryptogenic cirrhosis: Mr. [**Known lastname 71434**] was recently admitted for liver transplant but donor liver did not become available. MELD score~24 on admission. Total bilirubin was recently around [**5-27**] but increased to 9.0 at time of recent discharge. Newly increased to 9.8 during this admission. Diuretics adjusted as described above. Nadolol was continued with holding parameters. Continued on rifaximin and lactulose #)Right hepatic hydrothorax: Patient was found to have a right hepatic hydrothorax with associated right middle lobe collapse during his most recent admission. He underwent a thoracentesis with removal of serosanguinous fluid. He underwent two CT scans of his chest during his stay which showed improvement of the right middle lobe collapse. He was seen in the pulmonary clinic [**2174-11-28**], who determined that the patient was improving. Only small subpulmonic effusion visible on admission CXR. Otherwise, not an active inpatient issue. #)OSA: Not on CPAP at home, should follow-up with Sleep Clinic for outpatient management. Medications on Admission: 1. Lactulose 30 ML PO TID 2. Nadolol 20 mg PO BID 3. Clotrimazole 10 mg Troche Mucous membrane QID 4. Fluticasone-Salmeterol 250-50 mcg/Dose [**Hospital1 **] 5. Metoclopramide 5 mg PO TID 6. Rifaximin 400 mg Tablet PO TID 7. Calcium + Vitamin D 600-200 mg-unit PO twice a day. 8. Furosemide 80 mg PO BID 9. Nexium 40 mg Capsule EC PO Daily 10. Spironolactone 200 mg PO BID 11. Compazine 5 mg PO q8h prn nausea Discharge Medications: 1. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3 times a day): Titrate to [**1-22**] BMs per day . 2. Nadolol 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Metoclopramide 10 mg Tablet Sig: 0.5 Tablet PO QIDACHS (4 times a day (before meals and at bedtime)). 4. Rifaximin 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 5. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 7. Spironolactone 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 8. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Primary: Cryptogenic cirrhosis Secondary: Obstructive sleep apnea, GERD Discharge Condition: Hemodynamically stable and afebrile. Discharge Instructions: 1)You were admitted to the hospital with altered mental status and dehydration due to too much diuretics. You were treated with fluids and continued on your regular medications. Your diuretics were decreased while you were in the hospital, and you should continue on this lower dose. 2)Please take all medications as prescribed. You should be taking Lasix 40mg and Spironolactone 100mg daily. 3)Please keep all your outpatient appointments. You should call the Liver Transplant Center upon discharge and ensure you have a follow-up appointment in the next 1-2 weeks. 4)Please return to the ED or contact a physician if you notice fever, chills, blood in your stools, bloody vomit, black stools, worsening fatigue, confusion or shortness of breath, or for any other symptom which is concerning to you. Followup Instructions: You should call the Liver Transplant Center upon discharge and ensure you have a follow-up appointment in the next 1-2 weeks.

[ "780.09", "276.1", "327.23", "571.5", "458.29", "E944.4", "530.81", "V49.83", "511.8" ]

icd9cm

[ [ [] ] ]

[ "38.93" ]

icd9pcs

[ [ [] ] ]

10201, 10207

5862, 8955

356, 391

10323, 10362

4318, 5839

11215, 11344

3470, 3683

9416, 10178

10228, 10302

8981, 9393

10386, 11192

3698, 4299

275, 318

447, 2783

2805, 3275

3291, 3454

79,100

162,194

30894+30895

Discharge summary

report+report

Admission Date: [**2105-7-10**] Discharge Date: [**2105-7-16**] Date of Birth: [**2062-9-27**] Sex: F Service: SURGERY Allergies: Penicillins / Vaccine/Toxoid Preps,Combo. Classifier / Morphine Attending:[**First Name3 (LF) 695**] Chief Complaint: Metastatic breast cancer to the liver Major Surgical or Invasive Procedure: [**2105-7-10**]: Extended right hepatic lobectomy; cholecystectomy; intraoperative ultrasound. History of Present Illness: Per Dr [**Last Name (STitle) 4727**] note, this a 42-year-old female who underwent a left modified radical mastectomy on [**2102-6-21**] for an invasive ductal carcinoma with axillary lymph node metastases that was HER-2/neu positive and ER/PR positive. Bone scan, CT scan, and liver MRI were negative for metastatic disease, and she was treated with chemotherapy and radiation. On [**2103-6-6**], her CA 27.29 was 32, and on [**2105-4-10**], it was noted to be elevated at 65. On [**2105-4-23**], she underwent a CT scan of the chest and abdomen that demonstrated a 1.7-cm hypodense lesion in segment II thought to represent a cyst, as well as a 2.5-cm hypodense lesion with a lower density center in segment VIII of the liver. A bone scan on [**2105-4-23**] demonstrated no metastatic disease. On [**2105-5-28**], an MRI of the head demonstrated no evidence of intracranial metastases. On [**2105-6-8**], a PET scan demonstrated the FDG-avid lesion in segment VIII measuring 4.4 x 2.9 cm. Her CA 27.29 on [**2105-5-25**] was elevated to 95. A liver biopsy on [**2105-6-22**] confirmed metastatic invasive ductal carcinoma of the breast. On [**2105-6-29**], a follow-up CT scan demonstrated that the lesion was now 5.2 x 3.0 cm in size, with no other evidence of metastatic disease. She is now to undergo surgical resection. Past Medical History: hypertension, cardiomyopathy secondary to chemotherapy, hypothyroidism, guillain-[**Location (un) **] syndrome at age 14 Social History: works as occupational therapist in the [**Location (un) 686**] Program for frail elders Family History: n/a Physical Exam: VS: 98.3, 85, 97/62, 21, 99% General: arousable, moderate pain with movement Card: RRR, S1 S2 Pulm: CTA Abd: soft, tenderness at incision Extr: 1+ edema Pertinent Results: Post OP [**2105-7-10**] WBC-10.8# RBC-3.31* Hgb-10.1* Hct-29.2* MCV-88 MCH-30.5 MCHC-34.5 RDW-14.3 Plt Ct-274 PT-19.4* PTT-33.8 INR(PT)-1.8* Glucose-153* UreaN-10 Creat-0.7 Na-138 K-4.6 Cl-112* HCO3-23 AnGap-8 ALT-415* AST-401* AlkPhos-48 TotBili-1.3 Calcium-7.5* Phos-3.7# Mg-1.6 At Discharge: WBC-8.3 RBC-3.02* Hgb-9.2* Hct-26.8* MCV-89 MCH-30.3 MCHC-34.2 RDW-16.7* Plt Ct-201 PT-15.4* PTT-32.5 INR(PT)-1.3* Glucose-93 UreaN-15 Creat-0.6 Na-140 K-3.6 Cl-105 HCO3-26 AnGap-13 ALT-290* AST-89* AlkPhos-163* TotBili-1.7* Calcium-8.1* Phos-2.7 Mg-2.1 Brief Hospital Course: 42 y/o female with metastatic breat cancer to the liver who is taken to the OR with Dr [**Last Name (STitle) **] for Extended right hepatic lobectomy; cholecystectomy; intraoperative ultrasound. At the time of surgery she was found to have no evidence of extrahepatic metastases. Intraoperative ultrasound demonstrated the lesion in segment VIII with extension into segment IV, adjacent to the middle hepatic vein. There were no other lesions in the liver. Further review in the OR with Dr [**First Name (STitle) **] ruled out the possibility of a suspicious lesion just inferior to the entrance of the hepatic veins into the vena cava in the superior portion of the caudate lobe. No other lesions in the liver were seen by ultrasound or seen grossly or were palpated. After excision of the mass, the liver was cut by Pathology and the margin was approximately a 7-mm gross margin on the medial margin of the tumor. Pathology shows Metastatic carcinoma morphologically consistent with breast origin, present at cauterized surgical margin. Please see full pathology report. The patient received IT morphine and then was transitioned with adequate pain management. She was having some GI discomfort and was advanced very slowly through sips to clears. JP output that was sero-sanguinous ranged from 250 - 400 cc daily, and the drain will be left in at discharge. The patient was somnolent but arousable, sertraline was held in the immediate post op period and was then restarted at lower than her home dose. The patient was evaluated by PT and was found to be safe for home discharge. She was ambulating without assist, and was tolerating diet. The patient was given 10 liters while in the OR and was started on lasix to help with diuresis. She will be sent home on a short course of lasix. The incision was C/D/I. There was some concern for drainage around the drain insertion site, this was resutured. In addition she received teaching regarding drain care and feels comfortable managing this at home. She is using acetominophen for pain management. Medications on Admission: exemestane 25', levothyroxine 137', lisinopril 40', lorazepam 0.5-1 qhs, lopressor 100', zofran q6-8h prn, sertraline 200', simvastatin 40', zometa 4 q6mo, calcium carbonate [**Hospital1 **], vit d, MVI Discharge Medications: 1. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 2. Levothyroxine 137 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO every eight (8) hours as needed for pain: maximum 2 grams daily (6 tablets). 4. Exemestane 25 mg Tablet Sig: One (1) Tablet PO once a day. 5. Lisinopril 40 mg Tablet Sig: Hold Tablet PO Hold until notified to restart. 6. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO Hold until notified to restart. 7. Zometa 4 mg/5 mL Solution Sig: Four (4) mg Intravenous q 6 months: Per your outpatient schedule. 8. Multivitamin Tablet Sig: One (1) Tablet PO once a day. 9. Lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO at bedtime as needed for anxiety. 10. Sertraline 100 mg Tablet Sig: One (1) Tablet PO once a day: modified dose post surgery. 11. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*20 Tablet(s)* Refills:*0* 12. Calcium 500 500 mg (1,250 mg) Tablet Sig: One (1) Tablet PO twice a day. 13. Vitamin D 400 unit Capsule Sig: One (1) Capsule PO once a day. Discharge Disposition: Home Discharge Diagnosis: Metastatic breast cancer to the liver. Discharge Condition: Stable A+O x3 Ambulatory Discharge Instructions: Please call Dr [**Last Name (STitle) 4727**] office at [**Telephone/Fax (1) 673**] for fever, chills, nausea, vomiting, diarrhea, increased abdominal pain, yellowing of skin or eyes, inability to take or keep down food, fluids or medications. Measure and record drain output twice daily and more often as needed. Bring copy of record with you to your clinic visit. Monitor for large increases in the drain output, changes in the color of the drainage (green/yellow) or becomes bloody in appearance or develops a foul odor. Monitor the drain insertion for redness, drainage or bleeding. Keep a drain sponge around the site. Do not allow the drain to hang freely. You may shower, no tub baths or swimming. Place a new drain sponge around the drain insertion site daily or following shower. Please weigh yourself daily and record the values. Please call Dr [**Last Name (STitle) 4727**] office if you note a gain or loss of 3 pounds or more and also if you note your urine output diminishes greatly. No driving if taking narcotic pain medications No heavy lifting. Nothing heavier than a gallon of milk Hold Lisinopril and simvastatin until notified by Dr [**Last Name (STitle) **] these can be resumed. Restart the exemestane and continue Zometa on your prescribed schedule. Follow up with your outpatient oncologist Followup Instructions: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**], MD, PHD[**MD Number(3) 708**]:[**Telephone/Fax (1) 673**] Date/Time:[**2105-7-22**] 2:00 ECHOCARDIOGRAM Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2105-7-29**] 10:00 [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4450**], M.D. Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2105-7-29**] 11:00 [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1852**] MD ([**Telephone/Fax (1) 73086**] [**Hospital Ward Name 23**] 9 Hematology/Onc Date/Time: [**2105-7-29**] 1:30 PM [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**] MD, [**MD Number(3) 709**] Completed by:[**2105-7-16**] Admission Date: [**2105-7-19**] Discharge Date: [**2105-7-21**] Date of Birth: [**2062-9-27**] Sex: F Service: SURGERY Allergies: Penicillins / Vaccine/Toxoid Preps,Combo. Classifier / Morphine Attending:[**First Name3 (LF) 695**] Chief Complaint: Shortness of breath (POD 9) Major Surgical or Invasive Procedure: CTA History of Present Illness: Mrs [**Known lastname 73087**] is a 42 yo F with h/o breast cancer with metastasis to the liver who underwent a extended right hepatic lobectomy, cholecystectomy, and intraoperative ultrasound on [**2105-7-10**]. She was discharged on [**2105-7-16**] to home and returns now with 2 days of increasing shortness of breath, dyspnea on exertion and right sided pleuritic pain radiating to the back. + right sided pain, SOB at rest, Dyspnea on exertion, continued B LE edema - N/V/F/C/changes in urinary of bowel habits/chest pain radiating to left arm, shoulder or jaw Past Medical History: hypertension, cardiomyopathy secondary to chemotherapy, hypothyroidism, guillain-[**Location (un) **] syndrome at age 14 invasive ductal carcinoma s/p modified left radical mastectomy ([**5-18**]) with chemo and radiation [**3-20**]: right mastectomy (risk reducing) [**2105-7-10**]: extended right hepatic lobectomy for metastatic breast CA Social History: works as occupational therapist in the [**Location (un) 686**] Program for frail elders Family History: n/a Physical Exam: 98.4 103 120/75 20 99% RA NAD, able to speak in full sentences, but breathing appears both subjectively and objectively more difficult than normal for her RRR clear on L, absent breath sounds over R base approximately [**12-14**] up the back S/tender at incision, but otherwise benign abdominal exam WWP, 2+ B LE edema Pertinent Results: On Admission: [**2105-7-19**] WBC-6.9 RBC-3.13* Hgb-9.6* Hct-28.5* MCV-91 MCH-30.6 MCHC-33.6 RDW-16.6* Plt Ct-259 Glucose-152* UreaN-10 Creat-0.6 Na-137 K-3.6 Cl-104 HCO3-26 AnGap-11 ALT-110* AST-50* LD(LDH)-277* AlkPhos-270* TotBili-0.6 Albumin-3.1* Calcium-8.7 Phos-2.7 Mg-1.9 At discharge: [**2105-7-21**] Glucose-93 UreaN-13 Creat-0.7 Na-140 K-4.0 Cl-104 HCO3-29 AnGap-11 ALT-99* AST-49* LD(LDH)-276* AlkPhos-268* TotBili-0.7 Brief Hospital Course: 42 y/o female with metastatic breast cancer who underwent extended right hepatic lobectomy on [**7-10**] 10 and now returns with shortness of breath. On chest xray there is interval development of a small right pleural effusion with adjacent right basilar opacity. This was reported as likely atelectasis. A CTA was also requested due to her post op status. this showed that the pulmonary arterial system is well opacified and there are no embolic filling defects. No PE was called on this study. The patient was sent home on PO lasix, however when admitted she was treated with 40 mg IV and this was then repeated two more days. She reports her breathing is improved and she looks subjectively less short of breath. Discharge weight was 107.9 kg. Admission weight is 105.4 and on day of discharge her weight was 104.8 kg. She remains 7 kg above her admission for surgery weight and continues to have lower extremity edema. She will continue the PO lasix at home and weight herself daily. The JP drain was having minimal output and was d/c'd prior to her discharge. Exemastane was continued during this hospitalization and it appears she has an appointment on [**7-24**] in the [**Hospital 478**] clinic. Medications on Admission: Toprol XL 100 daily, levothyroxine 137 daily, Acetaminophen 650 q8h prn pain, Exemestane 25 daily, Lisinopril 40 daily, Simvastatin 40 dailym Zometa 4 mg q6months, Multivitamin daily, Lorazepam 0.5 1-2 Tablets PO qhs, Sertraline 100 daily, Furosemide 20 [**Hospital1 **] (only in postoperative period for 10 days), Calcium 500 [**Hospital1 **], Vitamin D 400 unit daily Discharge Medications: 1. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 2. Levothyroxine 137 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Exemestane 25 mg Tablet Sig: One (1) Tablet PO daily (). 4. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO BID (2 times a day). 7. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain: Maximum 6 pills daily. 9. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. Disp:*15 Tablet(s)* Refills:*0* 10. Lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day: Hold until notified you may restart. 11. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day: Hold until notified to restart. 12. Zometa 4 mg/5 mL Solution Sig: Four (4) mg Intravenous q 6 months: per your outpatient schedule. 13. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO at bedtime as needed for anxiety. 14. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day: As long as taking narcotic pain medication and as needed for constipation. 15. Lasix 20 mg Tablet Sig: One (1) Tablet PO twice a day: Weigh daily, continue until appointment with Dr [**Last Name (STitle) **]. Discharge Disposition: Home Discharge Diagnosis: Right pleural effusion Fluid overload Discharge Condition: Stable/Good A+Ox3 Ambulatory Discharge Instructions: Please call Dr [**Last Name (STitle) 4727**] office at [**Telephone/Fax (1) 673**] for fever, chills, increased difficulty breathing, increased absominal pain, increased leakage from the drain site, incisional redness, drainage or bleeding. Continue all home and chemo medications, you have a scheduled heme-onc appointment Friday. No heavy lifting No driving if taking narcotic pain medication You may shower, no tub baths or swimming weigh yourself daily and call Dr [**Last Name (STitle) 4727**] office if you note a 3 pound weight loss or weight gain in a 24 hour period. Call if you note you are feeling thirsty, dizzy or light headed as these can be signs that the lasix needsto be stopped. Drink enough fluids to keep your urine light yellow in color Followup Instructions: Call hematology clinic to verify Friday appointment [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**], MD, PHD[**MD Number(3) 708**]:[**Telephone/Fax (1) 673**] Date/Time:[**2105-7-29**] 9:00 ECHOCARDIOGRAM Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2105-7-29**] 10:00 [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4450**], M.D. Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2105-7-29**] 11:00 [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**] MD, [**MD Number(3) 709**] Completed by:[**2105-7-21**]

[ "244.9", "425.9", "401.9", "E933.1", "197.7", "V10.3", "276.6", "272.4", "511.9", "276.4", "276.52" ]

icd9cm

[ [ [] ] ]

[ "51.22", "50.3" ]

icd9pcs

[ [ [] ] ]

13889, 13895

10774, 11981

8870, 8876

13977, 14008

10320, 10320

14815, 15409

9960, 9965

12402, 13866

13916, 13956

12007, 12379

14032, 14792

9980, 10301

10613, 10751

8803, 8832

8904, 9473

10334, 10599

9495, 9838

9854, 9944

32,743

130,977

10121

Discharge summary

report

Admission Date: [**2200-2-27**] Discharge Date: [**2200-3-1**] Date of Birth: [**2124-1-13**] Sex: M Service: MEDICINE Allergies: Hydrochlorothiazide / Allopurinol Attending:[**First Name3 (LF) 5510**] Chief Complaint: CHIEF COMPLAINT: Back pain REASON FOR MICU ADMISSION: Lower GI Bleed Major Surgical or Invasive Procedure: Upper Endoscopy History of Present Illness: Mr. [**Known lastname 174**] is a 76 year old gentleman discharged from the [**Known lastname **] Service earlier this month on Aspirin, Plavix and Warfarin that was recently discharged from rehab within the past 7 days. During that time, per his daughter, he did not take Zantac or [**Name (NI) 6196**] as prescribed because he did not have any stomach upset. He reports some dry heaves without true vomiting or abdominal pain and black stools for the past 4-5 days. He denies chest pain, dyspnea or lightheadedness/falls, but does report some thoracic and lumber back pain which have been of variable chronicity depending on his interviewer. . In the ED, initial VS: 97.2 58 114/39 18. The patient was evaluated by Surgery, [**Name (NI) **] Surgery, Cardiac Surgery and GI and a decision was made to admit to the MICU for endoscopy, and that the patient was not have a [**Name (NI) 1106**] cause of back pain (dissection, aortoenteric fistula). NG lavage with coffee ground emesis, did not clear. He was given 1 unit of pRBCs and 2L of fluid. His K was noted to be elevated but without EKG changes, and so this was addressed only with fluids given his "other major issues." He is transfered with a left hand 20 gauge peripheral and an 18 gauge External Jugular IV, T&X and on PPI/Erythromycin & zofran for anti-emetic control. He was never tachycardic or hypotensive. . On arrival the MICU, the patient denies any back or abdominal pain. GI is present and performed an urgent endoscopy, with full report . ROS: Denies fever, chills, night sweats, headache, vision changes, rhinorrhea, congestion, sore throat, cough, shortness of breath, chest pain, abdominal pain, constipation, melena, dysuria, hematuria. Past Medical History: -PVD: s/p peripheral angiography & angioplasty L peroneal and anterior tibial [**1-/2200**] -CAD s/p CABG on [**9-/2198**] -Right LE cellulitis at vein harvest site (admission [**Date range (3) 33634**]), cx grew Pseudomonas, on cipro and linezolid until [**10/2198**] -Diabetes Mellitus -Hypertension -Peripheral [**Year (4 digits) **] Disease -Chronic Renal Insufficency -Chronic Anemia -Hyperlipidemia -Gangrene of L foot (tips of 4th and 5th digits) -Gout -Osteoarthritis -Cataracts -Carotid stenosis - s/p L CEA [**9-10**] Social History: Daughter lives with patient in his appt, ~60pkyr history, quit [**2182**] Family History: Father: stroke, died in his late 70s Mother: pulmonary embolism after hip fracture, died at age 88 Physical Exam: Admission Exam: Vitals - T: 96.3 BP: 126/54 HR: 71 RR: 16 02 sat: 100 GENERAL: Comfortable appearing gentleman HEENT: No LAD, oropharnyx clear CARDIAC: S1 & S2 regular without murmur LUNG: B CTA ABDOMEN: Nontender/nondistended EXT: No edema, necrotic toes, poor distal pulses NEURO: AAOx3, CNII-XII intact Pertinent Results: Admission labs & Studies: LABS: 2:06p Na:139 K:5.9 Glu:117 Hgb:6.4 CalcHCT:19 Lactate:5.9 . [**2200-2-27**] 2:00p CK: 53 MB: Notdone Trop-T: 0.08 . 139 111 132 --------------<124 6.2 10 4.1 estGFR: 14/17 (click for details) Ca: 8.7 Mg: 2.2 P: 4.5 . ALT: 16 AP: 77 Tbili: 0.1 Alb: 3.4 AST: 23 Lip: 92 . 6.2 13.3>----<296 19.9 (baseline: 25-35) MICROBIOLOGY: None . STUDIES: CT Ab/Pelvis: (Wetread) -Extensive calc of Ao, chest/abd branch vessels, cor arteries. Stable infrarenal AAA up to 3.0 cm in true diameter, borderline bilat common iliac aneurysms up to 1.5 cm. No evidence for rupture/hematoma. -Mild pulm emphysema. Calc gallstones. Nonobstructing R renal stones. Sigmoid diverticulosis. -Unchanged T11, L2 compression fx and grade 1 L5-S1 anterolisthesis. . Endoscopy: Impression: -Erythema and scarring in the duodenum compatible with duodenitis -Erythema and multiple erosions in the antrum and fundus -Ulcers in the stomach body (injection, endoclip) -Esophagitis in the lower third of the esophagus and gastroesophageal junction -Otherwise normal EGD to second part of the duodenum . Recommendations: -High dose [**Year (4 digits) 6196**] (40mf IV twice daily). -Start 1 g Sucralfate four times a day. -Clarify if H.pylori eradication was ever attempted. If not, eradicate as he was previously positive. -Repeat endoscopy in [**4-8**] weeks. . EKG: SR @ 56, RBBB, nl axis. no STEMI . CXR: (Wetread): prominent mediastinum, which may relate to AP, portable technique with tortuous aorta. but recommend dedicated PA and lateral views for further/better evaluation or CT as clinically indicated. Brief Hospital Course: #. Gastric Bleed: Bled slowly to a Hct of 19, baseline~30s. Currently clipped by GI, no evidence of continuing bleed. Hemodynamically stable (likely due to Beta blockade and slow bleed), no further bleeding or brisk bleeding. It is possible that there is another souce of bleeding. He was transfused 3 units to Hct in high 20s, which stabilized for 24 hours. He was started on PPIs and H. pylori eradication. The patient was stable on the day of discharge and was sent home with VNA follow-up. . #. Lactic/Anion Gap acidosis: Likely from underperfusion/hemorrhagic shock. Resolved with rescusitation. #. CAD/PVD: Patient with significant [**Date Range 1106**] disease, both central and peripheral. VSurg following. No evidence of ischemia or clot at this time. INR 2.9 Seen by [**Date Range 1106**] in house who clarified that the patient must be on all three forms of anticoagulation. They saw and documented the wound on this leg did not think it was an abscess. His warfarin was restarted as an outpatient. #. Hyperkalemia: Patient admitted hyperkalemic to 5.9, resolved to 5.4 without EKG changes or symptoms. #. Acute vs. Chronic Renal Failure: Currently at or near recent baseline. Patient states that he is not interested in HD. Medications on Admission: Amlodipine 10mg PO daily Aspirin 325mg PO daily Clopidogrel 75mg PO daily x30 days (until [**2200-3-5**]) Epoetin Alfa [**2190**] units MWF Furosemide 20mg PO daily Glipizide 2.5mg PO Daily Metoprolol Tartrate 50mg PO BID Oxycodone 5mg PO Q4 PRN Pain Pantoprazole 40mg PO Daily Simvastatin 40mg PO Daily Warfarin 5mg PO Daily Discharge Medications: 1. Sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times a day). Disp:*120 Tablet(s)* Refills:*2* 2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Epoetin Alfa 2,000 unit/mL Solution Sig: [**2190**] ([**2190**]) units Injection QMOWEFR (Monday -Wednesday-Friday). 4. Simvastatin 40 mg Tablet Sig: One (1) Tablet 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. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Warfarin 2 mg Tablet Sig: Two (2) Tablet PO Once Daily at 4 PM. 8. Amoxicillin 250 mg Capsule Sig: Two (2) Capsule PO Q24H (every 24 hours) for 13 days. Disp:*26 Capsule(s)* Refills:*0* 9. Clarithromycin 250 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 13 days. Disp:*26 Tablet(s)* Refills:*0* 10. Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO twice a day for 13 days. Disp:*26 Capsule, Delayed Release(E.C.)(s)* Refills:*0* 11. Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day: start after 13 days of twice daily omeprazole. Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: GI bleed Gastritis Dualfoy's lesion 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 with a GI bleed. You were taken to the MICU where you underwent endoscopy and were found to have several ulcers and a bleeding blood vessel which had to be clipped. Please note that we feel that stopping your antacid medication contributed to this. You must take all of your medications as prescribed: . The following changes were made to your home medications: Your [**Hospital **] must be increased to 40mg twice daily for the next 13 days, then can be returned to daily You were started on clarithromycin 250mg twice daily for the next 13 days. You were started on amoxicillin 250mg twice daily for the next 13 days. You were started on sucralfate 1 gram four times per day YOU MUST TAKE ALL OF THE ABOVE MEDICINES AS PRESCRIBED OR YOU WILL BLEED AGAIN. . . Your warfarin should be 4mg daily. your lasix was held and should be restarted when you see Dr [**Last Name (STitle) **]. Followup Instructions: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1143**], MD Phone:[**Telephone/Fax (1) 1144**] Date/Time:[**2200-3-11**] 11:00 Provider: [**Name10 (NameIs) **] LAB Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2200-3-11**] 1:45 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1244**], MD Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2200-3-11**] 2:45 Completed by:[**2200-3-1**]

[ "530.10", "585.9", "V45.81", "274.9", "785.59", "531.40", "285.1", "276.7", "440.20", "584.9", "403.90", "276.2", "414.00" ]

icd9cm

[ [ [] ] ]

[ "44.43" ]

icd9pcs

[ [ [] ] ]

7728, 7786

4851, 6098

362, 379

7865, 7865

3221, 4828

8957, 9395

2778, 2879

6475, 7705

7807, 7844

6124, 6452

8013, 8393

2894, 3202

8411, 8934

271, 324

407, 2119

7880, 7989

2141, 2671

2687, 2762

43,484

199,401

49468

Discharge summary

report

Admission Date: [**2166-10-28**] Discharge Date: [**2166-10-31**] Date of Birth: [**2090-4-4**] Sex: M Service: MEDICINE Allergies: Darvocet-N 100 Attending:[**First Name3 (LF) 1115**] Chief Complaint: respiratory distress, increased secretions Major Surgical or Invasive Procedure: Trach replacement History of Present Illness: 76 y/o male with MS [**First Name (Titles) 151**] [**Last Name (Titles) 103518**] elements, with recent admission to [**Hospital1 18**] from [**2166-6-26**] - [**2166-7-19**] for aspiration pneumonia and repeated aspiration events, status post trach ([**2166-7-16**]) and G-tube placement, now presenting from [**Hospital1 **] ICU with respiratory distress and increased secretions that are difficult to clear. Per OSH records, pt has had at least 2 hospitalizations for aspiration vs pneumonia since trach placement in [**Month (only) 216**]. Most recently hospitalized at [**Hospital1 882**] from [**Date range (1) 64240**], found to have LLL pna and ESBL E coli in sputum and currently treated with ertopenem. Presented to [**Hospital1 **] on [**10-26**] from [**Hospital1 1501**] due to increased secretions and decreased O2 sats and concern for possible tube feeds in respiratory secretions. He remained afebrile with stable vital signs, without leukocytosis. Blood cx grew GPC in [**12-10**] bottles, sputum grew sparse GNRs. CXR on HD#1 showed retrocardiac opacity c/f infiltrate, however this opacity had resolved on repeat CXR HD#2. At [**Hospital1 **] had emergent bronch for bradycardia and hypoxia, per report large thick secretion removed from BIM and LMB. Transferred to [**Hospital1 18**] for trach replacment. Of note, pt also found to be anemic with guaiac postiive stool c/f GI bleed given history of previous GIB. Received 2u pRBCs. GI service consulted, recommended trending Hct and transfusing as needed, IV PPI - pt is at high risk for invasive GI procedures. . On arrival to the MICU, pt is awake and alert, unable to provide detailed history but answers yes/no questions. States his breathing is currently comfortable. Denies pain or other complaints Past Medical History: - Multiple sclerosis with [**Hospital1 103518**] elements (followed by Dr. [**Last Name (STitle) **] at [**Hospital1 **]) - Anemia - Coronary artery disease status post multiple PCI. - cath [**6-13**] showed progression of diffuse disease: Mid LAD: 40 %, 1st Diagonal: focal 80 %, 2nd diagonal: 95% proximal, Proximal Circumflex: focal 100 % in distal third, 2nd Marginal: focal 70 % in proximal third, Ramus: Occluded at site of prior stenting, Mid RCA: long and irregular 30 % stenosis, PDA: irregular 80 % mid-vessel stenosis, overall no intervention - Heart failure with preserved systolic function. - Hyperlipidemia. - Hypertension. - Chemosis with left eyelid swelling, followed at MEEI. - Osteoarthritis, right knee. - s/p total knee replacement R [**9-13**] - History of UTI. - neurogenic bladder Social History: arrives from [**Hospital6 459**] for the Aged - MACU. Family History: Patient unable to provide. Physical Exam: ADMISSION EXAM: VS: P 68 BP 126/71 RR 14 General: Awake and alert, unable to speak due to trach, appears calm and comfortable. Copious secretions visible from trach. HEENT: Sclera anicteric, dry mucous membranes, oropharynx clear, EOMI, PERRL Neck: supple, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, II/VI SEM loudest over LLS border Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi Abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly GU: foley in place Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: Follows commands, moving all extremities, CN II-XII grossly intact, no focal deficits DISCHARGE EXAM VS: 98.6, 136/65, 80, 18, 98RA General: Calm, comfortable, NAD able to carry on complex conversations HEENT: Sclera anicteric, oropharynx clear, EOMI, PERRL Neck: Supple, no JVD CV: RRR, normal S1/S2, II/VI SEM loudest over LLS border Lungs: Loud upper airway sounds, no focal wheezes/rales Abdomen: soft, non-tender, non-distended GU: foley in place Ext: WWP, 2+ DP/PT, trace pedal edema, no cyanosis Neuro: LUE contracture, CN II-XII wnl Pertinent Results: ADMISSION LABS: [**2166-10-28**] 11:03PM BLOOD WBC-6.3# RBC-3.24* Hgb-10.0* Hct-29.4* MCV-91 MCH-31.0 MCHC-34.1 RDW-14.4 Plt Ct-241 [**2166-10-28**] 11:03PM BLOOD Neuts-73.3* Lymphs-21.5 Monos-3.8 Eos-1.1 Baso-0.3 [**2166-10-28**] 11:03PM BLOOD PT-13.6* PTT-30.7 INR(PT)-1.2* [**2166-10-28**] 11:03PM BLOOD Glucose-157* UreaN-29* Creat-0.8 Na-141 K-3.6 Cl-109* HCO3-18* AnGap-18 [**2166-10-28**] 11:03PM BLOOD Calcium-8.3* Phos-3.5 Mg-1.9 [**2166-10-28**] 11:11PM BLOOD Type-[**Last Name (un) **] Temp-37.6 FiO2-50 pO2-58* pCO2-41 pH-7.26* calTCO2-19* Base XS--8 [**2166-10-28**] 11:11PM BLOOD Lactate-2.2* IMAGING: CXR [**2166-10-28**]: IMPRESSION: AP chest compared to [**7-17**] through [**7-19**]: Right basal infrahilar opacification could be pneumonia. Upper lungs clear. Pleural effusion is small if any. Heart size normal. Tracheostomy tube in standard placement. DISCHARGE LABS: [**2166-10-31**] 06:47AM BLOOD WBC-5.6 RBC-3.25* Hgb-9.9* Hct-28.6* MCV-88 MCH-30.4 MCHC-34.6 RDW-13.0 Plt Ct-246 [**2166-10-31**] 06:47AM BLOOD Glucose-114* UreaN-15 Creat-0.8 Na-136 K-4.0 Cl-103 HCO3-25 AnGap-12 Brief Hospital Course: 76 y/o male with MS [**First Name (Titles) 151**] [**Last Name (Titles) 103518**] elements status post trach and G-tube placement and recent ESBL pna admitted to OSH for hypoxia and increased trach secretions and transferred to [**Hospital1 18**] for trach replacement. # Trach tube - Interventional pulmonology was called to evaluate for trach tube replacement. They felt that the diameter of the tube was not large enough for suctioning of secretions. The tube was replaced by IP while on the floor and patient had improvement in ability to clear secretions. Patient was initally maintained on 40% O2 via trach mask, but was transitioned to room air with 100% saturations. # Pneumonia - Continued ertopenem for ESBL pneumonia and completed prior hospital course. [**Hospital3 4107**] records demonstrated patient growing pan-sensitive pseudomonus from sputum culture on [**10-28**]. This was felt to be a chronic colonizer rather than infectious [**Doctor Last Name 360**] as patient had clear CXR, normal WBC, afebrile and had baseline oxygen requirements. Treatment of this culture finding was defered. # GPC Bacteremia - One of four bottles at outside hospital were found to be positive for coag negative staph. Assumed to be a contaminate given his clinical status. Initially started on vancomycin, then stopped when speciated. # Anemia - Hct to 21 while at outside hospital, received 2 units. Did not require additional PRBCs at [**Hospital1 18**]. Hct was monitored and remained stable at 29. # Multiple Sclerosis: stable, continued on home medications. # Coronary Artery Disease: stable, issue continued on home medications including [**Hospital1 4532**]. # Hyperlipidemia: stable issue, continued on home medications. # Hypertension: stable issue, continued on home medications. TRANSITIONAL ISSUES: -blood cultures from [**10-28**] were no growth to date at the time of discharge Medications on Admission: Medications at [**Hospital1 1501**]: - ASA 81mg chewable daily - Baclofen 10mg PO/NG [**Hospital1 **] - Sinemet 25/100 Cr 1 tab PO/NG daily - Citalopram 20mg PO/NG daily - Debrox drops 1 OZ AU [**Hospital1 **] - Folic acid 1mg PO/NG daily - Mucomyst 20% 5mL INH q6 hours - Clopidogrel 75mg PO/NG daily - Bisacodyl 5mg PO/NG daily:prn constipation - Nystatin Cream topical TID - Fleet enema daily:prn constipation - Ipratropium-albuterol neg QID prn:SOB/wheezing - MgOH 10mL PO/NG HS prn:constipation - Alum&MgOH-Simethicone 30mL GT daily - Omeprazole 40mg GT daily - Ertapenem 1g IV daily - Lovenox 40mg SC daily - Metoprolol tartrate 25mg PO daily MEDICATIONS ON TRANSFER: - Vancomycin 1g IV q24 hours - Pantoprazole 40mg IV q12 hours - Acetylcysteine 4mL NEB q4H - Debrox [**Hospital1 **] [**Name Prefix (Prefixes) **] - [**Last Name (Prefixes) **]/Ipratropium nebs q4 hours - Nystatin topical TID - Senna 10mL GT HS prn:constipation - Sinemet 1 tab GT TID - [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **]/Mg [**Last Name (NamePattern1) **]/Simethicone 30mL q4 hours GT prn:constipation - Mg Hydroxide 10mL GT HS prn:constipation - Sodium biphosphate 1 daily prn - Ertapenem 1g IV daily (until [**10-30**]) - ASA 81mg GT daily - Baclofen 10mg [**Hospital1 **] GT - Citalopram 20mg GT daily - Clopidogrel 75mg GT daily - Lovenox 40mg SC daily - Folic acid 1mg GT daily - Lanoprazole 30mg GT daily - Metoprolol tartrate 25mg GT daily Discharge Medications: 1. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for Constipation. 2. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for Constipation. 3. docusate sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2 times a day). 4. carbamide peroxide 6.5 % Drops Sig: Five (5) Drop Otic [**Hospital1 **] (2 times a day). 5. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q6H (every 6 hours). 6. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours). 7. nystatin 100,000 unit/g Cream Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day). 8. carbidopa-levodopa 25-100 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 9. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 10. baclofen 10 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 11. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 14. insulin regular human 100 unit/mL Solution Sig: One (1) Injection ASDIR (AS DIRECTED). 15. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 16. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Disposition: Extended Care Facility: [**Hospital **] Healthcare Discharge Diagnosis: Primary: Pneumonia Anemia Secondary: CAD Multiple Sclerosis Discharge Condition: Mental Status: Confused - sometimes. Activity Status: Bedbound. Level of Consciousness: Lethargic but arousable. Discharge Instructions: Mr. [**Known lastname 1661**], You were admitted to [**Hospital1 18**] for a tracheostomy replacement so that your secretions could be suctioned better. This was performed while you were in our Intensive Care Unit. You were discharged back to [**Hospital **] rehab. Medication changes: None Followup Instructions: Please contact your primary care physician for followup when you leave rehab.

[ "518.84", "428.0", "V44.0", "V45.82", "340", "250.00", "790.01", "414.01", "792.1", "285.9", "V44.1", "486", "428.22", "596.54", "401.9", "715.96", "272.4" ]

icd9cm

[ [ [] ] ]

[ "97.23" ]

icd9pcs

[ [ [] ] ]

10240, 10293

5417, 7223

320, 339

10398, 10398

4288, 4288

10855, 10935

3078, 3106

8831, 10217

10314, 10377

7352, 8002

10537, 10805

5179, 5394

3121, 4269

7244, 7326

10826, 10832

237, 282

367, 2152

4304, 5163

10413, 10513

8027, 8808

2174, 2991

3007, 3062

19,302

148,034

8857

Discharge summary

report

Admission Date: [**2132-3-11**] Discharge Date: [**2132-3-17**] Date of Birth: [**2089-2-1**] Sex: M Service: MEDICINE Allergies: Ciprofloxacin / Tape / Levofloxacin Attending:[**First Name3 (LF) 465**] Chief Complaint: Hyperkalemia Major Surgical or Invasive Procedure: incision and drainage of groin at bedside History of Present Illness: 43 yo m with h/o DMI, s/p L AKA, HTN here with hyperkalemia. He was in USOH until [**3-5**] visit with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] (new PCP) at [**Company 191**]. Blood work checked that day showed a K of 6.7. Dr. [**First Name (STitle) **] attempted to contact the patient multiple times, however, was unsuccessful to convince the pt to go to the ED. The pt finally presented to the ED on [**3-11**] after having leg cramps and feeling "lousy". . In the [**Hospital1 1774**] ED, Vitals were stable. K was 8.1, He recieved Ca glu, 10 units of insulin IV, and 30 gm kayexelate. EKG was unchanged from priors. On transfer, the K was 5.7. Bicarb was 21. Transferred to [**Hospital1 18**] since he gets his care here. . On arrival to the [**Hospital Unit Name 153**], he had no specific complaints. He said that last night he had chills and may have had a fever. No HA, cough, CP, SOB, n/v/d, constipation, leg cramps. VNA has been dressing his leg and abdominal wounds QOD and said that they "looked good". FSG in 1000s. . R wound groin with dressings. Vasc surgery recommended Gen [**Doctor First Name **] consult due to location. Called general surgery but has not seen. . On transfer to the floor, patient feels well and wants to go home. He denies HA, dizziness, chest pain, shortness of breath, abdominal pain, N/V. He is having a lot of groin pain. Past Medical History: Diabetes Mellitus 1 complicated by neuropathy, retinopathy, nephropathy Recurrent BKA infections (MRSA and VRE) GERD nephrolithiasis obesity hyperlipdemia s/p left below knee amputation, L AKA in [**7-20**] s/p cholecysteceomy s/p carpel tunnel release s/p tibial calcaneal fx s/p calcanectomy parital s/p STSG ankle [**2124**] Social History: Mr. [**Known lastname **] lives at home with his parents and daughter. [**Name (NI) **] has three daughters. Currently unable to work and on disability. Gets around in an electric wheelchair and is very independent in his ADLs. Denies tob, ETOH, illicits Family History: No other family members with type I DM MGM and [**Name (NI) 30871**] with type II DM No known history of colon, breast, ovarian cancers Physical Exam: T 98.4 96/76 112 18 99% RA FS 113 Wt 118 kg HEENT: NC AT, anicteric, no injections, PERRL, MMM NECK: NO LAD, normal carotid pulses CHEST: Lungs clear HEART: Regular rhythm. no m/r/g ABD: NT, ND. no organomegaly. abdominal wound dressing C/D/I EXT: RLL wrapped with dressing. Large healing excoriations/ulcers healing on R knee. No signs of cellulitis. Right groin shows large ulcer, no necrotic tissue, + yellow drainage, surrounding erythema, tender to palpation, not warm. NEURO: A and O x3. Awake. Answers questions appropriately. Pertinent Results: Initial labs: [**2132-3-11**] 11:22PM URINE HOURS-RANDOM CREAT-35 SODIUM-62 [**2132-3-11**] 11:22PM URINE COLOR-STRAW APPEAR-Clear SP [**Last Name (un) 155**]-1.010 [**2132-3-11**] 11:22PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-1000 KETONE-50 BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [**2132-3-11**] 08:55PM GLUCOSE-451* UREA N-39* CREAT-1.5* SODIUM-136 POTASSIUM-5.3* CHLORIDE-99 TOTAL CO2-21* ANION GAP-21* [**2132-3-11**] 08:55PM CALCIUM-9.9 PHOSPHATE-3.5 MAGNESIUM-1.7 [**2132-3-11**] 08:55PM WBC-11.2* RBC-3.79* HGB-10.3* HCT-30.2* MCV-80* MCH-27.2 MCHC-34.2 RDW-13.8 [**2132-3-11**] 08:55PM NEUTS-67.6 LYMPHS-23.3 MONOS-6.0 EOS-2.8 BASOS-0.3 [**2132-3-11**] 08:55PM MICROCYT-1+ [**2132-3-11**] 08:55PM PLT COUNT-500* Discharge labs: [**2132-3-17**] 06:30AM BLOOD WBC-11.9* RBC-4.23* Hgb-10.9* Hct-34.7* MCV-82 MCH-25.9* MCHC-31.5 RDW-14.2 Plt Ct-545* [**2132-3-17**] 06:30AM BLOOD Glucose-139* UreaN-23* Creat-1.1 Na-136 K-4.6 Cl-100 HCO3-24 AnGap-17 [**2132-3-17**] 06:30AM BLOOD Calcium-10.0 Phos-4.2 Mg-1.7 Micro: groin abscess--> SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPH AUREUS COAG + | ERYTHROMYCIN---------- =>8 R GENTAMICIN------------ <=0.5 S LEVOFLOXACIN----------<=0.12 S OXACILLIN-------------<=0.25 S PENICILLIN------------ =>0.5 R TRIMETHOPRIM/SULFA---- S Brief Hospital Course: A/P: 43 yo M with h/o DMI here with hyperkalemia, DKA and groin ulcer. . # Hyperkalemia: This occured in the setting of being on AceI. Lisinopril held and K trended down to normal. F/U with pcp regarding restarting lisinopril. . # ARF: Cr at the OSH was 2.1. He is down to 1.2 and his baseline is 1.3-1.6. UA negative. Was probably pre-renal in setting of DKA and dehydration. Improved with IVF further supporting prerenal etiology. As blood pressure was normal while off lisinopril and patient has had hyperkalemia with the lisinopril, this medication was held and pt should f/u with pcp regarding restarting this medication. . # DMI: Patient admitted to ICU for insulin gtt and IVF as he had an anion gap [**1-18**] DKA, He had ketones in urine. Likely precipitant of DKA was infection. Groin ulcer infected with MSSA. Patient was transitioned off insulin gtt and transferred to floor where we resumed his home dose of insulin at 80 units [**Hospital1 **]. We also continued asa, atorvastatin. He was set up with [**Last Name (un) 387**] on discharge. # Groin ulcer- Swab shows mixed flora and MSSA. Pt is s/p debridement at bedside by general surgery. He was initially treated with 5 days of IV vancomycin and was discharged on dicloxacillin on discharge after sensitivities came back. Dressings were changed [**Hospital1 **] and pt has VNA at home to help with this. Patient given appointment for surgery follow-up on discharge. . # Foot ulcers- podiatry followed the patient while he was in the hospital and he has outpatient follow-up set up. Dressings changed daily. . # Leg wounds: Vascular surgery follows these wounds. None of the leg wounds appeared infected. Dressing changed daily by wound care nurse. Pt has vascular surgery follow-up after discharge. . # Hypercholesterolemia- continued lipitor . # Neuropathy- continued neurontin-renally dosed at 300 q 6 hours. Medications on Admission: . Novolin 70/30 80 units b.i.d. 2. Prilosec 20 a day. 3. Lisinopril 5 daily. 4. Lipitor 20 daily. 5. Neurontin 600 q.i.d. 6. Lasix 20 mg approximately 2 times monthly at a p.r.n. basis. 7. Aspirin 81 mg a day. Discharge Medications: 1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). Disp:*30 Tablet, Chewable(s)* Refills:*2* 2. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO daily (). Disp:*03 Capsule, Delayed Release(E.C.)(s)* Refills:*2* 3. Atorvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* 4. Gabapentin 600 mg Tablet Sig: One (1) Tablet PO every eight (8) hours. Disp:*90 Tablet(s)* Refills:*2* 5. Novolin 70/30 100 unit/mL (70-30) Suspension Sig: Eighty (80) units Subcutaneous twice a day. Disp:*qs qs* Refills:*2* 6. Dicloxacillin 500 mg Capsule Sig: One (1) Capsule PO every six (6) hours for 10 days. Disp:*40 Capsule(s)* Refills:*0* 7. Percocet 5-325 mg Tablet Sig: One (1) Tablet PO twice a day for 10 days: may take as needed for pain prior to dressing change. Disp:*20 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Last Name (LF) 486**], [**First Name3 (LF) 487**] Discharge Diagnosis: DKA Hyperkalemia Infected groin ulcer Discharge Condition: HD stable and afebrile. Discharge Instructions: You were admitted with high potassium and sugars. You were also found to have a groin infection and were started on antibiotics. You need to take good care of your groin wound. Wound care nurses will come by to help pack and change dressings. Please take all medications as directed. Your lisinopril has been stopped; you should discuss restarting it with your PCP. [**Name10 (NameIs) **] have been started on antibiotics for your groin infection. You need to follow a low potassium diet. Please follow-up with all outpatient appointments. If you experience fever > 101, chills, chest pain, trouble breathing, worsening redness,pain or warmth of wound, please go to the ED. Followup Instructions: You have the following appointments: Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 10107**], RN Date/Time:[**2132-3-26**] 1:00 You should also see Dr. [**Last Name (STitle) **] in podiatry. You have an appointment at 2:40 pm on [**3-26**]. You also have an appointment at the [**Hospital 191**] clinic Friday [**3-28**] at 3:00 with Dr. [**Last Name (STitle) **]. You also have an appointment with the [**Hospital **] Clinic on [**3-19**] at 9am with Dr. [**Last Name (STitle) 19862**]. Please bring your old records concerning diabetes to this appointment. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 472**]

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icd9cm

[ [ [] ] ]

[ "86.22" ]

icd9pcs

[ [ [] ] ]

7655, 7738

4587, 6469

307, 351

7820, 7846

3126, 3878

8576, 9287

2418, 2556

6731, 7632

7759, 7799

6495, 6708

7870, 8553

3895, 4564

2571, 3107

255, 269

379, 1775

1797, 2127

2143, 2402

79,016

187,998

35808

Discharge summary

report

Admission Date: [**2150-11-11**] Discharge Date: [**2150-11-12**] Date of Birth: [**2098-10-17**] Sex: M Service: MEDICINE Allergies: Penicillins Attending:[**Last Name (NamePattern1) 293**] Chief Complaint: Worsening jaundice, malaise Major Surgical or Invasive Procedure: Banding of varices by liver service History of Present Illness: Mr. [**Known lastname 64134**] is a 52yo gentleman with alcoholic cirrhosis complicated by splenomegaly and ascites who presented to [**Hospital 1562**] Hospital with worsening jaundice, malaise, and diarrhea. Patient has had two short admissions to [**Hospital1 1562**] ([**10-21**], [**10-30**]) for jaundice. He was discharged on [**10-31**] on lasix, aldactone, lactulose which were new medications to him. At home, he was taking lactulose 30 [**Hospital1 **] and over the past few days developed significant watery diarrhea > 6 BM/day and profound lethargy and weakness. He denies fevers, chills, cough, sob, chest pain, dysuria, abdominal pain, weight loss, melena or black stools. He was noted to have a Cr of 12 up from 1.8 two weeks prior and so was transferred to [**Hospital1 18**] for possible dialysis. . In the ED, initial VS were T 93.6, HR 90, BP 106/63, RR 18, 99% on RA. He was evaluated by liver who recommended liver ultrasound with doppler which showed small ascites, splenomegaly, portal hypertension, and cannot r/o portal vein thrombosis. . Past Medical History: Alcoholic cirrhosis--patient has had paracentesis x 1 about 1 year ago; reports he has been sober from alcohol since [**10-30**]. Has not had EGD so not known if he has varices. Alcoholic cardiomyopathy Social History: Patient has a history of alcohol abuse, has been sober since [**2150-10-30**]. Smokes [**11-19**] PPD. Was married in [**2150-6-19**]. Used to work restoring old homes on [**Location (un) **], currently out of work. Family History: No family history of liver disease. Father died of pancreatic cancer. Physical Exam: T 93.3 on admit BP 97/50 HR 56 RR 14 with 96% sat on 2L. Jaundiced, icteric, dry MM, blood on lips, spider angiomata, flat JVD, Lungs cta anteriorly, No increased P2. abdomen w/liver 1FB below RCM, no splenomegaly, minimal abd distention, no tenderness. No Edema or clubbing. Groggy, but answering questions appropriately. Asterixis. Pertinent Results: [**2150-11-11**] 03:10PM BLOOD WBC-12.2* RBC-4.13* Hgb-15.2 Hct-39.5* MCV-96 MCH-36.8* MCHC-38.5* RDW-15.2 Plt Ct-113* [**2150-11-12**] 04:33AM BLOOD WBC-15.9* RBC-3.24* Hgb-11.6* Hct-31.0* MCV-96 MCH-36.0* MCHC-37.5* RDW-15.7* Plt Ct-206# [**2150-11-11**] 03:10PM BLOOD Neuts-82.5* Lymphs-9.9* Monos-4.7 Eos-2.0 Baso-1.0 [**2150-11-11**] 03:10PM BLOOD PT-29.7* PTT-100.6* INR(PT)-3.0* [**2150-11-12**] 04:33AM BLOOD PT-22.9* PTT-74.2* INR(PT)-2.2* [**2150-11-11**] 03:10PM BLOOD Glucose-101 UreaN-111* Creat-13.8* Na-129* K-5.9* Cl-97 HCO3-10* AnGap-28* [**2150-11-12**] 04:33AM BLOOD Glucose-182* UreaN-101* Creat-12.0*# Na-133 K-4.4 Cl-104 HCO3-9* AnGap-24* [**2150-11-11**] 03:10PM BLOOD ALT-54* AST-202* AlkPhos-150* TotBili-51* [**2150-11-12**] 04:33AM BLOOD ALT-45* AST-127* LD(LDH)-266* CK(CPK)-94 AlkPhos-131* TotBili-47.6* [**2150-11-11**] 03:10PM BLOOD Albumin-3.0* Calcium-7.9* Phos-12.0* Mg-3.6* UricAcd-13.6* [**2150-11-12**] 04:33AM BLOOD Albumin-2.9* Calcium-6.8* Phos-10.4* Mg-2.7* [**2150-11-12**] 04:47AM BLOOD Type-[**Last Name (un) **] pO2-62* pCO2-42 pH-7.05* calTCO2-12* Base XS--18 . Abdominal US [**2150-11-11**]: 1. Cirrhotic liver with associated small volume ascites. 2. Portal hypertension evidence by splenomegaly and reversal of flow in splenic vein, and left portal vein. No detectable flow in the main portal vein, which may be secondary to slow flow, however, cannot exclude thrombus within the main portal vein. . Brief Hospital Course: Mr. [**Known lastname 64134**] is a 52 year old male with alcoholic cirrhosis and cardiomyopathy who was transfered to [**Hospital1 827**] with new anuric renal failure and upper gastrointestinal bleed. . # Liver failure: Patient has significant hepatic failure secondary to alcoholism (though no drinks for two weeks). Has T. bili of 51 (rising), alb of 3.0, and INR of 3.0, Cr of 14.4. MELD is 47, but not a liver transplant candidate due to alcoholism. Patient also presented with upper gastrointestinal bleed. An EGD was performed by the Liver team and 4 cords of grade II varices were seen in the esophagus. There were stigmata of recent bleeding. 4 bands were successfully placed. Patient does not qualify for immediate transplant. However given his end stage liver disease and anuric renal failure, goals of care were addressed with the family. The decision was made to change the code status to comfort care only. . # Anuric Acute Renal failure: Patient presented with rise of Cr to 14.4 from 1.8 two weeks ago in setting of poor oral intake, newly started diuretics and nadolol, and profound diarrhea. Patient making almost no urine. Likely profound prerenal renal failure versus ATN, but also concern for Hepatorenal syndrome given alcoholic cirrhosis. Renal team was notified. Renal failure resulted in anion gap acidosis, hyperphos and hypocalcemia. . # GI Bleed: Patient developed significant GI bleed and bright red hematemasis and large amounts of melena. He received packed red blood cells and FFP. EGD as above. . Medications on Admission: Spironolactone 25 mg daily Lasix 20 mg daily MVI Acidophilus Lactulose 15 [**Hospital1 **] Nadolol 20 mg daily Protonix 40 mg daily Vitamin B12 Discharge Disposition: Expired Discharge Diagnosis: Expired Discharge Condition: Expired

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icd9cm

[ [ [] ] ]

[ "99.07", "96.04", "99.04", "96.71", "42.33", "38.93" ]

icd9pcs

[ [ [] ] ]

5585, 5594

3847, 5391

310, 347

5645, 5655

2373, 3824

1927, 2000

5615, 5624

5417, 5562

2015, 2354

243, 272

375, 1447

1469, 1674

1690, 1911

67,722

102,913

36399

Discharge summary

report

Admission Date: [**2120-6-17**] Discharge Date: [**2120-6-25**] Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 1515**] Chief Complaint: worsening shortness of breath Major Surgical or Invasive Procedure: percutaneouos aortic valve replacement (CoreValve) pacemaker placement History of Present Illness: This [**Age over 90 **] year old patient with a history of prior CABG has been experiencing fatigue and severe shortness of breath with minimal activity, which is new over the last few months. He denies any symptoms occurring at rest. He denies any chest pain. He denies claudication, orthopnea, pnd, lightheadedness or lower extremity edema. He was seen by Dr. [**Last Name (STitle) 59323**] who referred him for an echocardiogram. This revealed worsening of his aortic stenosis. He was seen and [**Last Name (STitle) 6349**] and was deemed appropriate for TAVI/CoreValve placement. NYHA Class:II Past Medical History: PMH: CAD, s/p inferior, posterior MI, s/p CABG x 4 in [**8-/2113**](SVG/OM, Diag, PLB, and LIMA to LAD) Pancreatitis post CABG S/P Cholescystectomy in [**10/2113**] S/P cataract extraction OD S/P right carpal tunnel release S/P right knee arthroscopy S/P Upper GI scope with gastric biopsy, esophageal biopsy, and balloon dilatation in [**4-/2116**] H/O diverticulosis H/O GIB S/P right hemicolectomy (17 units of blood) H/O right carotid bruit H/O NSVT Hypertension Hyperlipidemia Chronic renal failure Mitral regurgitation Depression Insomnia Hearing impaired Polymyalgia rheumatica- on Prednisone Arthritis BPH s/p TURP Past Surgical History: S/P Cholescystectomy in [**10/2113**] S/P cataract extraction OD S/P right carpal tunnel release S/P right knee arthroscopy s/p TURP s/p R hemicolectomy s/p CABGx4 (SVG/OM, Diag, PLB, and LIMA to LAD) [**8-25**] Social History: SOCIAL HISTORY: Pt lives alone independently in a [**Doctor Last Name **] house in NH. He plans to stay with his daughter, [**Name (NI) **] after discharge. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 37190**] (dtr)[**Telephone/Fax (1) 82471**] [**Doctor First Name **] (dtr-in-law) [**Telephone/Fax (1) 82472**] Lives with: lives alone Occupation: retired GE tester (jet engines) Tobacco: 1/2ppd x 15yrs - quit 60yrs ago ETOH: none Family History: Longevity (sisters x 2 deceased age [**Age over 90 **]) Physical Exam: ADMISSION EXAM Pulse: 65 B/P: 146/65 Resp: 18 O2 Sat: Temp: 97.1 General: Alert hard of hearing pleasant elderly gentleman in NAD at rest, spleaking comfortably. Skin: Color pale pink, turgor fair. No ulcerations, no lesions. HEENT: Normocephalic, anicteric. Oropharynx moist. Conjunctiva pale pink. Lower partials. Neck: Neck supple, trachea midline. Bilat carotid bruit vs. referred murmer. JVD. Chest: Well healed sternal incision. No obvious deformity. Heart: RRR. V/VI murmer throughout Abdomen: soft, nontender, nondistended, (+)bowel sounds all quad Extremities: No hair growth below knees. Trace pedal edema bilat. Neuro: Alert and oriented, mildly anxious. Gross FROM. OOB, gait steady. Pulses: [**12-24**]+ palpable peripheral pulses throughout DISCHARGE EXAM VITALS: Temp current: 98.7 HR: 75-95 RR: 18 BP: 126-147/60s O2 Sat: 100% RA General: resting comfortably in bed, NAD HEENT: Oropharynx moist. Neck: Neck supple. Chest: Well healed sternal incision. No obvious deformity. Skin [**Month/Day (2) 1994**] from tape removal center chest, dressing not removed for exam. Lungs CTA bilaterally with good air entry. Heart: RRR, paradoxical split S2. Abdomen: soft, nontender, nondistended, (+)bowel sounds all quad. Well healed surgical scar. Extremities: No hair growth below knees. No pedal edema. Small (nickel-sized) right groin hematoma, mildly TTP. Palpable DP pulses. Neuro: Alert and oriented, mildly anxious. Gross FROM. OOB, gait steady. Skin: Color pink, skin warm and dry. Heels and sacrum intact. Pertinent Results: Admission labs [**2120-6-17**] WBC-7.8 RBC-3.19* Hgb-11.2* Hct-31.4* MCV-99* MCH-35.1* MCHC-35.7* RDW-16.3* Plt Ct-189 PT-13.7* PTT-22.6 INR(PT)-1.2* Glucose-121* UreaN-34* Creat-1.5* Na-143 K-4.7 Cl-109* HCO3-26 AnGap-13 Albumin-4.0 Calcium-9.0 Phos-2.9 Mg-2.0 %HbA1c-5.7 eAG-117 ALT-18 AST-37 CK(CPK)-29* AlkPhos-40 TotBili-0.9 CK-MB-3 proBNP-2320* Discharge labs: [**2120-6-25**] WBC-9.4 RBC-2.78* Hgb-9.2* Hct-27.6* MCV-99* MCH-33.1* MCHC-33.3 RDW-15.8* Plt Ct-240 PT-13.5* PTT-25.0 INR(PT)-1.2* Glucose-92 UreaN-29* Creat-1.4* Na-142 K-4.1 Cl-108 HCO3-24 AnGap-14 Calcium-8.4 Phos-2.5* Mg-1.9 proBNP-2338* Imaging ECG: ([**6-17**]) Sinus rhythm. Right bundle-branch block. Left anterior fascicular block. Inferolateral lead ST-T wave changes are primary and non-specific. Since the previous tracing of [**2120-5-17**] inferolateral lead ST-T wave changes appear less prominent. . ECHO ([**6-18**]) PRE VALVE DEPLOYMENT The left atrium is dilated. No spontaneous echo contrast or thrombus is seen in the body of the left atrium or left atrial appendage. A patent foramen ovale is present. A left-to-right shunt across the interatrial septum is seen at rest. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. There is moderate regional left ventricular systolic dysfunction with severe inferior, inferolateral, and inferoseptal hypokinesis. The remaining myocardial segments are mildly, globally depressed. The right ventricle displays mild global free wall hypokinesis. The descending thoracic aorta is mildly dilated. 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 to moderate ([**12-24**]+) aortic regurgitation is seen. The mitral valve leaflets are moderately thickened. There is more significant calcification of the base of the posterior mitral leaflet and posterior mitral annulus. Mild to moderate ([**12-24**]+) mitral regurgitation is seen. There is a trivial/physiologic pericardial effusion. . POST VALVE DEPLOYMENT At initail deployment, the patient developed near cardiac arrest with right ventricular akinesis. The aortic valve was quickly replaced and epinephrine was given with resolution of right ventricular failure. The right ventriclular function then returned to the pre-deployment state. The mitral regurgitation was worsened and severe immediately after this event but after valve replacement returned to baseline (mild to moderate). The aortic valve and supporting structure is in situ. The leaflets can be seen moving. The maximum gradient across the valve was 7 mmHg with a mean of 4 mmHg. There is mild aortic regurgitation with two paravalvular jets seen. . ECG ([**6-18**]) Sinus rhythm with atrial sensed and ventricular paced rhythm. Since the previous tracing of the same date ventricular paced rhythm is now present. TRACING #2 . CXR ([**6-18**]) A CoreValve is in place. The left-sided pacemaker with the leads terminating at right atrium and right ventricle is noted. Lungs are essentially clear. Heart size and mediastinal silhouette are stable. There is no pleural effusion or pneumothorax noted. . ECHO ([**6-20**]) The left atrium is mildly dilated. There is mild symmetric left ventricular hypertrophy. Overall left ventricular systolic function is moderately depressed (LVEF= 35 %) secondary to jypokinesis of the inferior septum, inferior free wall, and posterior wall. The right ventricular free wall is hypertrophied. Right ventricular chamber size is normal. with borderline normal free wall function. An aortic CoreValve prosthesis is present. A paravalvular aortic valve leak (trace-to-mild) is probably present. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild to moderate ([**12-24**]+) mitral regurgitation is seen. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] There is borderline pulmonary artery systolic hypertension. There is no pericardial effusion. . CXR ([**6-20**]) IMPRESSION: Very satisfactory postoperative situation. Permanent pacer with two intracavitary electrodes in unremarkable position. No pneumothorax identified. . ECHO ([**6-25**]) The left atrium is moderately dilated. There is moderate symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. There is mild regional left ventricular systolic dysfunction with basal inferoseptal, inferior, and inferolateral akinesis. Right ventricular chamber size and free wall motion are normal. An aortic CoreValve prosthesis is present and appears well-seated. The transaortic gradient is normal for this prosthesis. Mild (1+) aortic regurgitation is seen (probably paravalvular). The mitral valve leaflets are mildly thickened. Moderate (2+) mitral regurgitation is seen. Moderate [2+] tricuspid regurgitation is seen. There is no pericardial effusion. . Compared with the prior study (images reviewed) of [**2120-6-20**], left ventricular systolic function appears similar. Left ventricular ejection fraction may have been slightly underestimated in the prior report. Estimated pulmonary artery systolic pressure is now higher. Mitral regurgitation is now more prominent. Tricuspid regurgitation is now more prominent. . ECG ([**6-25**]) Ventricular paced rhythm at a rate of 80 beats per minute. No diagnostic change compared to previous tracing. Brief Hospital Course: Pt is a [**Age over 90 **]yo M with a PMH significant for critical AS, CABG x4 and MR [**First Name (Titles) **] [**Last Name (Titles) 82473**] for percutaneous aortic valve replacement with CoreValve device. #1 Severe symptomatic aortic stenosis s/p CoreValve [**6-18**]: At initail deployment, the patient developed near cardiac arrest with right ventricular akinesis. The aortic valve was quickly replaced and epinephrine was given with resolution of right ventricular failure. The right ventriclular function then returned to the pre-deployment state. The mitral regurgitation was worsened and severe immediately after this event but after valve replacement returned to baseline (mild to moderate). Perioperative permanent pacemaker placed following occlusion of RCA, has right BBB and paced beats. ECHO shows good valve placement and mild perivalvular leak. One unit PRBC given post procedure for low hct. Pt will need aspirin and Plavix for a total of 3 months and will follow up with Dr. [**Last Name (STitle) **] and [**First Name4 (NamePattern1) 1022**] [**Last Name (NamePattern1) 32655**] NP for routine post procedure care. . #2 Complete Heart Block during CoreValve placement: common occurance in patients with right bundle branch block. A [**Company 1543**] DDD pacemaker model Sensia SEDR01, serial number [**Serial Number 82474**]. One week wound check and interrogation occurred while pt was still hospitalized and pt will need to f/u every 6 months for a pacemaker check. #3 CAD: s/p CABG x 4 ([**2112**]). Bypass graft angiography demonstrates the vein graft to the obtuse marginal and the LIMA to LAD to be patent, however during CoreValve procedure the RCA graft was TO. Pt had no significant chest pain during hospitalization and was discharged on home aspirin, plavix, metoprolol and Lipitor. . #4 Chronic Systolic Dysfunction: EF 35%. Appeared euvolemic at discharge. Had not been on ACEi [**1-24**] AS and [**Last Name (un) **]. Would consider starting low dose ACEi as outpatient. Started Lasix 20 mg PO for inc TR gradient. . # Diarrhea. Possibly due to antibiotics and bowel regimen. No fever or leukocytosis. Resolved at discharge. . # Skin [**Last Name (un) 1994**]. Likely secondary to prednisone. Mild serosanguinous oozing at site. Wound nurse [**First Name (Titles) 6349**] [**Last Name (Titles) 1994**] and wrote recommendations to VNA for dressing. . #. Polymyalgia Rheumatica: On chronic steroids at home, continued in hospital. . #. CKD: baseline creatinine 1.5. Increased to 1.6, possibly secondary to intravascular depletion from diuresis/diarrhea. Pt will have his labs rechecked as an outpatient. Medications on Admission: atenolol 25mg daily aspirin 81mg daily lipitor 10mg QOD (every other am) prednisone 10mg daily tamulosiin SR 0.4mg qevening multivitamin 1 tab daily fish oil capsule 1000mg twice a day systane lubricant eye drops 1gtt TID Discharge Medications: 1. Outpatient Lab Work Please check Chem-7 and CBC on Thursday [**6-27**] with results to [**First Name5 (NamePattern1) 1022**] [**Last Name (NamePattern1) 32655**] at [**Telephone/Fax (1) 32656**] fax and [**Telephone/Fax (1) 79809**] phone 2. metoprolol succinate 50 mg Tablet Extended Release 24 hr Sig: 1.5 Tablet Extended Release 24 hrs PO once a day. Disp:*45 Tablet Extended Release 24 hr(s)* Refills:*2* 3. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 4. atorvastatin 10 mg Tablet Sig: One (1) Tablet PO QODHS (every other day (at bedtime)). 5. prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1) Capsule, Ext Release 24 hr PO HS (at bedtime). 7. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. omega-3 fatty acids Capsule Sig: One (1) Capsule PO BID (2 times a day). 9. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Company 1519**] Discharge Diagnosis: Aortic Stenosis Acute Systolic Dysfunction, no ACE/[**Last Name (un) **] [**1-24**] acute kidney injury Hypertension Anemia Complete heart block Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: You had a percutaneous replacement of your aortic valve with a CoreValve bioprosthetic valve. You will need to take asprin and Plavix for 3 months to prevent blood clots around the valve. Do not stop taking aspirin and Plavix unless Dr. [**Last Name (STitle) **] tells you it is OK to do so. You also needed a pacemaker after the procedure for a slow heart rhythm, you will need to see Dr. [**Last Name (STitle) 11250**] and an electrophysiology doctor [**First Name (Titles) **] [**Location (un) 3844**] to have the pacemaker checked every 6 months. No lifting more than 5 pounds with your left arm or lift your left arm over your head for 6 weeks. There are no activity restrictions for your right arm. You can shower when you get home. You needed a blood transfusion for anemia, your blood count is better now. You heart is slightly weaker now than before. You need to watch your salt intake and take all of your medicines daily. Information regarding your medicines and diet was discussed with you before discharge. Weigh yourself every morning, call Dr.[**Last Name (STitle) 11250**] if weight goes up more than 3 lbs in 1 day or 5 pounds in 3 days. . We made the following changes to your medicines: 1. Stop taking Atenolol, take metoprolol instead to lower your heart rate and help your heart pump better 2. Start taking plavix every day to prevent blood clots on the new valve. Followup Instructions: Department: CARDIAC SERVICES When: THURSDAY [**2120-7-18**] at 3:00 PM With: [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 62**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage You will have an Echocardiogram at the same time as this appt. . PCP Name: AUNG,THET H Address: [**Location (un) **], [**Location (un) **],[**Numeric Identifier 77486**] Phone: [**Telephone/Fax (1) 77350**] Appointment: Thursday [**2120-6-27**] 11:30am Completed by:[**2120-6-29**]

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icd9cm

[ [ [] ] ]

[ "99.69", "37.72", "37.83", "35.22", "89.45", "88.47", "88.56", "88.42", "37.23", "35.96" ]

icd9pcs

[ [ [] ] ]

13456, 13505

9511, 12157

281, 354

13694, 13694

3967, 4319

15288, 15922

2350, 2408

12429, 13433

13526, 13673

12183, 12406

13877, 15265

4335, 9488

1652, 1865

2423, 3948

212, 243

382, 982

13709, 13853

1004, 1629

1897, 2334

5,112

165,293

46164

Discharge summary

report

Admission Date: [**2143-10-13**] Discharge Date: [**2143-10-21**] Date of Birth: [**2095-2-13**] Sex: F Service: MEDICINE Allergies: Morphine Attending:[**First Name3 (LF) 2932**] Chief Complaint: Syncope, chest pain, abdominal pain Major Surgical or Invasive Procedure: Endotracheal intubation. History of Present Illness: 48 yo F h/o cocaine abuse, MVP, p/w multiple complaints, including syncope, chest and abdominal pain. Pt states that she noticed substernal chest pain that worsened in the few weeks prior to admission and was elicited by climbing the stairs to her apartment. CP was relieved with rest. She also noted that could no longer sleep with one pillow and would also awaken with SOB. In the week prior to admission, the patient developed epigastric pain, worse with meals. She had one episode of nausea/NBNB vomiting the day PTA. Also on the day prior to admission, she reports having used cocaine. On the day of admission, she had difficulty driving, she pulled over and passed out. She was found unconscious in car by fire dept. Pt pulled from car and became conscious, though agitated. EMS called. . In [**Hospital1 18**] ED, initial vitals 99.2, hr 115, bp 112/80, rr 20, 98% 2L NC. Initially alert, complaining of [**2-22**] days of CP/SOB, epigastric pain with some nausea, no vomiting. Denied HA. Admitted to recent cocaine use. EKG: ST @ 106 bpm, nml axis, nml int, TWI in III, V1. Pt subsequently had acute episode of nonresponsiveness in setting of SBPs to 70s, hr 100s. Given naloxone 4mg, dexamethasone 10 mg IVX1. Pt intubated for airway protection. Central line (L SC)was placed, started on levophed. Spiked temp to 101. Started on ctx, vanc. Given 8L NS. Labs in ED significant for initial lactate 4.5 (down to 2.7), tpn 0.39. Utox sig for +cocaine. u/a trace leuks/large blood/tr ket/0 wbcs/occ bact. CTA negative for PE. On CT: B/L lower lobe opacities concerning for pna, ground-glass opacities within the upper and lower lung lobes. CT abdomen with: heterogeneous perfusion of the liver, and a large amount of intra-abdominal ascites, peripancreatic inflammatory fat stranding and intra- abdominal free fluid consistent with mild pancreatitis. Echo in ED with EF 20%, global hypokinesis, 3+ MR. CT head negative. Patient transfered to MICU for further management. Past Medical History: 1. Mitral valve prolapse (per pt, no TTE available) 2. H/o heart murmur since childhood 3. H/o substance abuse: cocaine abuse since the age of 26 (nasal and inhaled cocaine) 4. Stress urinary incontinence 5. H/o "tilted" uterus with (per pt report) 6. Frequent fungal skin infx under breasts 7. History of DOE, no Echo previously Social History: She is a widow with 5 children who are in good health. Husband killed in DR ~10years ago. She used to smoke 5 cig/ day but quit several years ago. No alcohol use. Intermittent cocaine use(inhaled and snorted). Currently not sexually active. Previous HIV test negative. Denies IVDU. Family History: M(alive): CHF, DM2, ESRD (denies CAD); F (alive): gout, substance abuse, pA breast cancer, pA "bone cancer and brain cancer"; brother d. AIDS; sister [**Name (NI) 98177**] significant FH for ETOH and drug abuse Physical Exam: PHYSICAL EXAM ON ADMISSION TO MICU: VS T 98.3 BP 122/70 HR 87 RR 13 O2Sat 100 vent AC 600X14 FiO2 100% PEEP 5 Gen: intubated, sedated HEENT: NC/AT, PERRL, mmd NECK: no LAD, no JVD COR: S1S2, regular rhythm, no murmurs appreciated PULM: coarse breath sounds on anterior exam ABD: + bowel sounds, soft, nd, nt Skin: no rash EXT: 2+ DP, no edema Neuro: moving all extremities . PHYSICAL EXAM ON TRANSFER TO FLOOR VS T afebrile BP 124/65 HR 76 RR 18 O2Sat 98%RA Gen: tachypnic, NAD HEENT: NC/AT, PERRL, MMM, no OP lesions NECK: no LAD, no JVD COR: RRR, nl S1S2, no murmurs appreciated PULM: +labored breathing, tachypneic, CTA BL, no egophany ABD: + bowel sounds, soft, nd, nt Skin: no rash EXT: 1+ peripheral pulses, trace pitting edema B/L LE Neuro: non-focal, moving all extremities Pertinent Results: EKG:ST @ 106 bpm, nml axis, nml int, TWI in III, V1 . CXR: Pulmonary effusions bilaterally, ht. globular, increased vascular markings. . CT head: negative for acute intracranial process [**2143-10-13**] CTA Abd/Chest/pelvis: Pancreatic edema and intra- abdominal free fluid consistent with mild pancreatitis. Please note that the amount of intra-abdominal free fluid cannot be explained by this mild degree of pancreatitis. Multiple findings consistent with congestive heart failure/volume overload including bilateral ground-glass opacities within the upper and lower lung, interlobular septal thickening, heterogeneous perfusion of the liver, and a large amount of intra-abdominal ascites. Bilateral lower lung lobe consolidations which could represent bilateral aspiration. Small amount of subsegmental atelectasis at the lung bases bilaterally. Right mainstem bronchus intubation. Two cystic masses within the left ovary may represent simple cysts, however definitive characterization is difficult with a large amount of intrapelvic ascites. A pelvic ultrasound is recommended when this patient's clinical status improves. [**2143-10-13**] transthoracic [**Month/Day/Year 461**]: The left atrium is normal in size. Left ventricular wall thicknesses are normal. The left ventricular cavity is moderately dilated with severe global hypokinesis. Systolic function of apical segments is relatively preserved (suggesting a non-ischemic cardiomyopathy). No masses or thrombi are seen in the left ventricle. Right ventricular chamber size is normal with severe global free wall hypokinesis. The aortic valve leaflets appear structurally normal with good leaflet excursion. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. At least moderate to severe (3+) mitral regurgitation is seen. Moderate [2+] tricuspid regurgitation is seen. The pulmonary artery systolic pressure could not be estimated. Significant pulmonic regurgitation is seen. There is no pericardial effusion. [**2143-10-15**] Abd CT: Small amount of fluid surrounding the head of the pancreas may related to mild pancreatitis, per given history. No peripancreatic fluid collections and homogeneous pancreatic parenchymal enhancement. Right lower lobe consolidation, likely pneumonia. Small associated pleural effusions and atelectasis. Trace ascites and periportal edema. Simple left renal cyst. Brief Hospital Course: Ms. [**Known lastname 5749**] is a 48 year-old female with a history significant for cocaine use who presented with two to three weeks of increasing dyspnea on exertion and angina particularly when climbing stairs. She reported abdominal pain, cocaine use and subsequent syncopal episode within 24 hours of being seen in the Emergency Department. She was febrile to 101 in the ED, with an initial lactate of 4.7 and evidence of pneumonia on CT. She became hemodynamically unstable in the Emergency Department which required endotracheal intubation for airway protection, aggressive fluid resuscitation and pressors. EKG demonstrated T-wave inversions in leads III and V1. The patient was found to have elevated cardiac markers and severely decreased ejection fraction (20%). She was admitted to the MICU for further management. Her troponin and MB-index peaked at 0.39 and 4.7, respectively. Given these findings, it was felt that cardiac ischemia in the setting of cocaine use caused a new cardiomyopathy (or worsening of an underlying cardiomyopathy) and resulted in cardiogenic shock. She was started on aspirin and a statin, but a beta-blocker was avoided initially due to recent cocaine use. A heparin drip was not initiated during this hospitalization because her picture was not consistent with ACS. Alternatively, septic shock was considered as a possible cause of a new cardiomyopathy. She was started on broad spectrum antibiotics and pan-cultured, but all cultures were negative. When she became hemodynamically stable, after-load reduction was achieved with diuresis and she was extubated without complication. She was then transferred to the floor and repeat ECHO demonstrated an EF of 35%. A complete work-up for new cardiomyopathy was pursued, with the exception of an HIV test. The patient preferred to discuss HIV testing at her new patient appointment with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. . At discharge, she was given prescriptions for aspirin, lisinopril, carvedilol, furosemide and nitroglycerin and asked to follow up with Cardiology in 6 weeks and to have an ECHO repeated prior to that visit. She was also sent home with the remainder of a 14-day course of levofloxacin to cover for community acquired pneumonia. The risks of continued cocaine use were explained. Medications on Admission: Medications on Admission: None . Medications on Transfer to Floor: ASA 325mg qD Atorvastatin 80mg PO qD Captopril 6.25mg PO TID Carvedilol 6.25mg PO BID Furosemide 10mg PO qD Levofloxacin 500mg PO qD NGL SL 0.3mg PRN Pantoprazole 40mg PO qD Discharge Medications: 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 2. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: [**1-21**] Tablet, Sublinguals Sublingual PRN (as needed) as needed for chest pain. Disp:*30 Tablet, Sublingual(s)* Refills:*2* 3. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2* 4. Carvedilol 12.5 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). Disp:*30 Tablet(s)* Refills:*2* 5. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 6. Furosemide 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). Disp:*15 Tablet(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Cardiomyopathy Discharge Condition: Stable. Pt afebrile, ambulating w/o assistance. Discharge Instructions: Please return to the ER or call your doctor if you experience and chest pain, shortness of breath, numbness or tingling, lightheadedness or any other concerning symptoms. . Please take all medications as prescribed. . Please follow-up with all appointments as scheduled. Followup Instructions: Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2143-10-25**] 3:00 Provider: [**Name10 (NameIs) **] Phone:[**Telephone/Fax (1) 128**] Date/Time:[**2143-11-12**] 11:00; [**Hospital Ward Name 23**] Bldg, [**Location (un) **] Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 1989**] Date/Time:[**2143-11-20**] 11:20; [**Hospital Ward Name 23**] [**Location (un) **] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 2937**]

[ "428.20", "428.0", "577.0", "785.51", "424.0", "507.0", "038.9", "785.52", "518.81", "599.0", "286.9", "305.61", "995.92", "285.9", "041.89", "425.4" ]

icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

9833, 9839

6461, 8792

307, 334

9898, 9948

4038, 4175

10267, 10894

3008, 3220

9084, 9810

9860, 9877

8844, 9061

9972, 10244

3235, 4019

232, 269

362, 2338

4184, 6438

2360, 2692

2708, 2992

44,412

146,575

43525

Discharge summary

report

Admission Date: [**2136-8-17**] Discharge Date: [**2136-8-25**] Date of Birth: [**2078-6-10**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1505**] Chief Complaint: exertional angina Major Surgical or Invasive Procedure: coronary artery bypass grafts x3(LIMA-LAD,SVG-OM,SVG-PDA) [**2136-8-21**] History of Present Illness: Thsi 58 year old white male has known coronary diseae, having undergone stenting to the right coronary artery in [**Month (only) 956**]. He had recurrent angina with exertion on [**8-15**]. Catheterization at [**Hospital3 1280**] reveled in-stent stenosis as well as 80% left main stenosis extending into the bifurcation. He received Plavix at that time and was referred for surgical revascularization. Past Medical History: RCA stent [**2-22**] hyperlipidemia Social History: 3-6 beers/week nonsmoker lives with his wife last [**Name2 (NI) 93664**] visit years ago works for himself in telcommunications Family History: noncontributory Physical Exam: Admission: Pulse: 61 Resp: 16 O2 sat: 97% RA B/P Right: 112/69 Left: Height: Weight: 76.6 kg General: Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x] poor dentition Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [x] 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 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: no Left: no Pertinent Results: [**2136-8-24**] 06:00AM BLOOD WBC-7.4 RBC-3.23* Hgb-9.8* Hct-27.7* MCV-86 MCH-30.3 MCHC-35.2* RDW-13.7 Plt Ct-127* [**2136-8-17**] 07:30PM BLOOD WBC-7.6 RBC-4.61 Hgb-13.6* Hct-39.5* MCV-86 MCH-29.6 MCHC-34.5 RDW-13.6 Plt Ct-172 [**2136-8-24**] 06:00AM BLOOD Glucose-103* UreaN-17 Creat-0.9 Na-137 K-3.9 Cl-101 HCO3-30 AnGap-10 [**2136-8-17**] 07:30PM BLOOD Glucose-151* UreaN-18 Creat-0.9 Na-140 K-4.2 Cl-106 HCO3-25 AnGap-13 [**2136-8-17**] 07:30PM BLOOD %HbA1c-5.8 eAG-120 Brief Hospital Course: Following admission he remained painfree and Plavix washout was allowed. he was taken to the Operating Room on [**8-21**] where triple bypass was performed. he weaned from bypass on Propofol and Neo Synephrine in stable condition. he awopke intact, was weaned from the ventilator and extubated. Pressors were weaned off. He was transferred to the floor and CTs and temporary pacing wires were removed in a timely fashion. Beta blockade was instituted and he was diuresed towards his preoperative weight. Physical Therapy worked with him. On POD 4 he was ambulating independently and ready for discharge home. Medications are as noted and follow up, precautions and restrictions were discussed. Medications on Admission: colace 100 daily ECASA 325 daily At transfer:lipitor 80 daily lisinopril 5mg daily lopressor 25mg QID tylenol 650 prn oxycodone 5-10mg q4h prn ativan 0.5-1.0mg prn Meds at home: Plavix 75 daily asa 325 daily toprol xl 50 daily lipitor 40 daily lisinopril 5 daily colace prn Discharge Medications: 1. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 7 days. Disp:*7 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0* 2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 3. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for fever or pain. 4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain for 4 weeks. Disp:*50 Tablet(s)* Refills:*0* 5. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) as needed for constipation. 6. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO at bedtime. Disp:*30 Tablet(s)* Refills:*2* 7. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day for 7 days. Disp:*7 Tablet(s)* Refills:*0* 8. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:*60 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Location (un) 1110**] VNA Discharge Diagnosis: Coronary artery disease s/p coronary artery bypass grafts hyperlipidemia s/p coronary stents Discharge Condition: Alert and oriented x3, nonfocal Ambulating with steady gait Incisional pain managed with Percocet Incisions: Sternal - healing well, no erythema or drainage Leg -Right- healing well, no erythema or drainage. Edema-none Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month until follow up with surgeon No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] **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) **] at [**Hospital1 **] Heart Center ([**Telephone/Fax (2) 6256**]) in 2 weeks. Please call to schedule appointments with: Primary Care: Dr. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) **] ([**Telephone/Fax (1) 21640**]) in [**1-14**] weeks Cardiologist: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4610**] ([**Telephone/Fax (1) 6256**]) in [**1-14**] 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:[**2136-8-25**]

[ "V45.82", "414.01", "412", "996.72", "272.4", "V58.63", "411.1", "E878.1" ]

icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

4275, 4334

2264, 2967

339, 415

4471, 4692

1765, 2241

5447, 6158

1070, 1087

3293, 4252

4355, 4450

2993, 3270

4716, 5424

1102, 1746

282, 301

443, 850

872, 909

925, 1054

65,217

143,309

48674

Discharge summary

report

Admission Date: [**2176-5-20**] Discharge Date: [**2176-6-13**] Date of Birth: [**2101-5-10**] Sex: M Service: UROLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 1232**] Chief Complaint: BLADDER CANCER Major Surgical or Invasive Procedure: Dr. [**Last Name (STitle) **] [**2176-5-20**] PROCEDURE: Pelvic exenteration with radical cystoprostatectomy and ileal conduit performed by Urology and low anterior resection with diverting ileostomy by General Surgery. Dr. [**Last Name (STitle) 1120**] [**2176-5-20**] PROCEDURE: Low anterior resection with primary stapled colorectal anastomosis ileal limb creation and anastomosis and diverting loop ileostomy. Dr. [**Last Name (STitle) **] [**2176-5-31**] procedure: PREOPERATIVE DIAGNOSIS: Left ureteral obstruction. POSTOPERATIVE DIAGNOSIS: Enterotomy of ileal conduit. FINDINGS: 1. A 1-cm enterotomy and ileal conduit. 2. Left ureteral anastomosis, normal lie of left ureter with no kinking or twisting noted. [**2176-5-31**] Procedure: exploratory laparotomy, lysis of adhesions, closure of enterotomy of ileal loop, placement of single J ureteral stent. [**2176-5-30**]: Placement of LEFT PCN at Interventional Radiology [**2176-6-12**]: Removal of LEFT PCN Past Medical History: hypertension and negative for myocardial infarction, angina, diabetes, colitis, stroke, ulcer, lung disease, thyroid disease, hepatitis, gout, sciatica, and glaucoma. Past surgical history includes a TUR prostate [**2162-3-31**] by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 986**] for 20 g of BPH. A bladder diverticulum was described at that time. His last creatinine of [**2176-5-2**] was 1.9 with a 24 BUN and a PSA of 2.4. Social History: He continues to work fulltime as an attorney. He is accompanied by his wife who is a nurse and a healthcare advocate. They have grown children and grandchildren in the area. He notes no history of smoking, ETOH or illicits, and no occupational exposures. Family History: No cancers in family history that he is aware of. Physical Exam: WdWn male, NAD, AVSS Interactive, cooperative Abdomen soft, Nt/Nd, appropriately tender along midline incision and adjacent to urostomy/ileostomy. Surgical skin clips are in place. There is no evidence hematoma or infection Ecchymosis at penile shaft/scrotum edema noted but without induration Lower extremities w/out gross edema or pitting and no report of calf pain to deep palpation Pertinent Results: [**2176-6-9**] 06:55AM BLOOD WBC-8.9 RBC-3.33* Hgb-9.9* Hct-31.1* MCV-94 MCH-29.7 MCHC-31.8 RDW-16.6* Plt Ct-417 [**2176-6-5**] 07:10AM BLOOD WBC-8.7 RBC-3.12* Hgb-9.0* Hct-29.4* MCV-95 MCH-29.0 MCHC-30.7* RDW-15.5 Plt Ct-441* [**2176-6-4**] 06:45AM BLOOD WBC-9.7 RBC-3.07* Hgb-9.2* Hct-29.1* MCV-95 MCH-29.8 MCHC-31.5 RDW-16.1* Plt Ct-423 [**2176-5-20**] 01:29PM BLOOD WBC-12.8* RBC-2.50*# Hgb-7.6*# Hct-22.8*# MCV-91 MCH-30.4 MCHC-33.4 RDW-14.1 Plt Ct-213 [**2176-5-20**] 04:10PM BLOOD WBC-10.1 RBC-3.38*# Hgb-10.2*# Hct-30.0*# MCV-89 MCH-30.0 MCHC-33.9 RDW-13.8 Plt Ct-146* [**2176-6-1**] 05:55AM BLOOD PT-12.0 PTT-28.3 INR(PT)-1.1 [**2176-5-31**] 11:15PM BLOOD PT-12.6* PTT-25.8 INR(PT)-1.2* [**2176-5-30**] 06:15AM BLOOD PT-11.5 PTT-28.7 INR(PT)-1.1 [**2176-6-13**] 07:30AM BLOOD Glucose-91 UreaN-32* Creat-2.1* Na-144 K-4.2 Cl-120* HCO3-15* AnGap-13 [**2176-6-12**] 09:05AM BLOOD Glucose-140* UreaN-30* Creat-2.3* Na-141 K-4.5 Cl-116* HCO3-13* AnGap-17 [**2176-6-11**] 07:15AM BLOOD Glucose-95 UreaN-27* Creat-2.2* Na-142 K-3.6 Cl-117* HCO3-17* AnGap-12 [**2176-5-20**] 07:45PM BLOOD Glucose-162* UreaN-20 Creat-1.4* Na-141 K-4.0 Cl-107 HCO3-24 AnGap-14 [**2176-5-20**] 04:10PM BLOOD Na-140 K-4.2 Cl-105 [**2176-5-20**] 01:29PM BLOOD Glucose-241* Na-142 K-4.9 Cl-105 [**2176-6-1**] 05:55AM BLOOD ALT-37 AST-48* AlkPhos-97 TotBili-0.7 [**2176-5-30**] 06:15AM BLOOD ALT-57* AST-48* LD(LDH)-259* AlkPhos-143* TotBili-0.9 [**2176-5-27**] 07:00AM BLOOD ALT-68* AST-78* LD(LDH)-253* AlkPhos-218* Amylase-44 TotBili-1.9* [**2176-5-22**] 05:22AM BLOOD ALT-13 AST-33 LD(LDH)-156 AlkPhos-41 TotBili-3.1* [**2176-5-21**] 04:08PM BLOOD TotBili-3.4* DirBili-2.2* IndBili-1.2 [**2176-5-21**] 03:42AM BLOOD ALT-13 AST-22 LD(LDH)-149 AlkPhos-28* TotBili-6.5* DirBili-4.0* IndBili-2.5 [**2176-6-13**] 07:30AM BLOOD Calcium-9.4 Phos-2.8 Mg-2.0 [**2176-6-12**] 09:05AM BLOOD Calcium-9.1 Phos-2.6* Mg-1.9 [**2176-6-10**] 06:40AM BLOOD TotProt-4.9* Albumin-2.4* Globuln-2.5 Calcium-8.7 Phos-3.0 Mg-1.8 Cholest-125 [**2176-5-22**] 05:22AM BLOOD Calcium-8.0* Phos-3.6 Mg-2.4 [**2176-5-21**] 03:42AM BLOOD Albumin-3.3* Calcium-8.0* Phos-4.4 Mg-2.9* [**2176-5-20**] 07:45PM BLOOD Calcium-8.1* Phos-4.0 Mg-1.5* Brief Hospital Course: Mr. [**Name14 (STitle) **] was admitted to the ICU following his operation for further management of his ventilator settings and monitoring of his HCT since he suffered a significant amount of blood loss during the procedure. He was continued to be aggressively volume resuscitated in the ICU to maintain hemodynamic stability. His hematocrit remained stable during his ICU stay w/o evidence of further bleeding. He was able to be weaned off the ventilator without difficulty. The pt remained NPO per urology's request as part of his post surgical care. His pain was controlled with a Dilaudid gtt administered via epidural catheter. He was admitted to Dr.[**Name (NI) 1233**] Urology service after undergoing open radical prostatectomy. No concerning intraoperative events occurred; please see dictated operative note for details. He received ancef for perioperative prophylaxis and coumadin for deep vein thrombosis prophylaxis. He was transferred to the urology floor from the PACU in stable condition. His pain was initially controlled with PCA. Diet was advanced with passage of flatus. JP was removed without difficulty. The remainder of the hospital course was relatively unremarkable until on date of discharge he developed left flank pain and had elevated creatinine. On the day of planned discharge he developed marked left flank pain and his labs were rechecked showing an increase in creatinine. He was not discharged and he was sent to the IR suite for placement of a LEFT percutaneous nephrostomy tube after obtaining CT imaging demonstrated: Interval cystoprostatectomy with ileal conduit formation. Persistent right-sided hydroureteronephrosis, probably slightly improved compared to pre-operative imaging, with new mild-to-moderate hydroureteronephrosis on the left. No evidence of obstructing renal stone.". Mr. [**Known lastname **] was taken back to the OR for exploratory laparotomy. The following was noted intrapoeratively: 1. A 1-cm enterotomy and ileal conduit. 2. Left ureteral anastomosis, normal lie of left ureter with no kinking or twisting noted. He thus underwent the following procedure: exploratory laparotomy, lysis of adhesions, closure of enterotomy of ileal loop, placement of single J ureteral stent. From then his hospital course was essentially unremarkable. Patient received perioperative antibiotic prophylaxis and deep vein thrombosis prophylaxis with subcutaneous heparin. With the passage of flatus, patient's diet was advanced. The patient was ambulating w/ walker and pain was controlled on oral medications by this time. The ostomy nurse saw the patient for continued ostomy teaching. Physical therapy and occupational therapy continued their teaching and work. At the time of discharge the wound was healing well with no evidence of erythema, swelling, or purulent drainage. The ostomy was perfused and patent. Mr. [**Known lastname **] was ultimately discharged home with visiting nurse services and a plan to continue with physical therapy, ostomy care and occupational therapy at home. On [**6-11**], he underwent nephrostogram and then on [**6-12**], he was taken back to the IR suite where he left PCN was removed. He was discharged on [**2176-6-13**] after a 24 day hospital course. He will follow up with Dr. [**Last Name (STitle) **] in one week's time for post-operative evaluation and surgical skin clip removal. An abbreviated chronological list of daily events/notes is listed here: [**2176-6-12**] Cr 2.3, left PCN removed, stopping cefepime [**2176-6-8**] tolerating regular diet, encouraged PO intake, calorie count, Cr 2.3 [**2176-6-7**] perc nephrostomy capped, Pt tolerating diet, ostomy w/ output [**2176-6-6**] reg diet w/ supp, burping, d/c PCA [**2176-6-5**] clears, ostomy w/ increased output, vanc d/c'd, renal following [**2176-6-4**] perc nephrostomy re-opened, JP fluid Cr level: 2.6 [**2176-6-3**] nephrostogram: no ureteral leak or obstruction, nephrostomy clamped [**2176-6-2**] NPO per uro, +ileostomy fcn, ostomy w/ scant output, increased pain OOB [**2176-6-1**] extubated in AM, good sats on RA, txf to floor [**2176-5-31**] to OR for ex-lap, ileal enterotomy repaired ? urostomy, ? left stent placed [**2176-5-30**] L ureteral obstruction-> L nephrostomy tube placed. R ureter patent [**2176-5-29**] left flank pain, no UOP since 12pm, CTU: mild/mod hydroneph/uret,IVF [**2176-5-28**] D/c L ureteral stent, ambulating, JP creatinine 1.5 [**2176-5-27**] D/c R ureteral stent, D/c CVL, tolerating reg diet [**2176-5-26**] cont DAT. alk phos incr 223 (95), TBili 2.7 (3.1). working w/PT, ambulating [**2176-5-25**] DAT/HLIV, +OOB to chair. stool + flatus in ileostomy bag. JP Cr 1.8 [**2176-5-24**] no events, started on clears per urology [**2176-5-23**] RUQ US no evidence cholecystits, +gallbladder polyps, R effusion/atelectasis [**2176-5-22**] extubated, UOP improved, stable off pressors [**2176-5-21**] UOP, 1.5L LR, LR IVF 200, 250cc albumin, neo->levo, off pressors [**2176-5-20**] OR, massive fluid/blood resusc, no IVF, intubated overnight Medications on Admission: amlodipine 5 mg Tablet 1 Tablet(s) by mouth once a day replaces amlodipine-benazepril Lipitor Oral 10 mg every day omeprazole magnesium [Prilosec OTC] 20 mg Tablet, Delayed Release (E.C.) 1 Tablet(s) by mouth once a day Discharge Medications: 1. camphor-menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical QID (4 times a day) as needed for itching: (Sarna lotion). 2. diphenhydramine HCl 12.5 mg/5 mL Elixir Sig: One (1) PO Q6H (every 6 hours) as needed for itch insomnia. 3. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 4. multivitamin Tablet Sig: One (1) Tablet PO once a day. 5. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): Hold for SBP <110 or HR < 55 . 6. atorvastatin 10 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 7. [**Hospital 16836**] Medical Equipment Rx provided for shower chair and [**Hospital **] hospital bed 8. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. Disp:*40 Tablet(s)* Refills:*0* 9. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours). 10. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable Sig: [**2-12**] Tablet, Chewables PO QID (4 times a day) as needed for Heart Burn. 11. hyoscyamine sulfate 0.125 mg Tablet, Sublingual Sig: One (1) Tablet, Sublingual Sublingual QID (4 times a day) as needed for GI cramping, bloating, etc. as directed. Disp:*30 Tablet, Sublingual(s)* Refills:*1* Discharge Disposition: Home With Service Facility: [**Company 1519**] Discharge Diagnosis: Squamous cell carcinoma of the bladder with obstruction of the right ureter and invasion of the rectosigmoid. Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Will continue with phsyical therapy via VNA for conditioning, strengthening. Discharge Instructions: -Please also refer to the educational handouts/information on care of your urostomy/ileostomy as provided by nursing. -Resume your pre-admission/home medications except as noted. ALWAYS call to inform, review and discuss any medication changes and your post-operative course with your primary care doctor. -Do not lift anything heavier than a phone book (10 pounds) or drive until you are seen by your Urologist in follow-up -Resume all of your pre-admission medications, except HOLD aspirin until you see your urologist in follow-up -You will return to Dr.[**Doctor Last Name **] office for staple removal in one week, the staples do not need to be covered however protect staples from catching on clothing or bed sheets or ostomy equipment -resume regular home diet and remember to drink plenty of fluids to keep hydrated and to prevent constipation -Do not eat constipating foods for 2-4 weeks, drink plenty of fluids to keep hydrated -No vigorous physical activity or sports for 4 weeks or until otherwise advised -Tylenol should be your first line pain medication, a narcotic pain medication has been prescribed for breakthrough pain >4. Replace Tylenol with narcotic pain medication. -Max daily Tylenol (acetaminophen) dose is 4 grams from ALL sources, note that narcotic pain medication also contains Tylenol -You may shower normally but do NOT immerse your incisions or bathe -Do not drive or drink alcohol while taking narcotics and do not operate dangerous machinery. Followup Instructions: -Call Dr[**Doctor Last Name **] office today to schedule/confirm your follow-up appointment AND if you have any questions. -Follow up early next week for wound check, surgical skin clip removal. Provider: [**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 276**], M.D. Phone:[**Telephone/Fax (1) 164**] -Please ALSO call Dr.[**Name (NI) 3377**] office to schedule/confirm your follow-up appointment AND if you have any questions. There remains a 'bridge' at the diverting ileostomy that will be removed next week. Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1120**] Chief, Colon and Rectal Surgery Division: General Surgery/Colorectal Surgery Office Location: [**Hospital Ward Name 1950**] 9 Office Phone:([**Telephone/Fax (1) 3378**] PCP: [**Name10 (NameIs) **],[**Name11 (NameIs) 132**] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 133**] It is a good idea to ALWAYS call to inform, review and discuss any medication changes and your post-operative course with your primary care doctor. Completed by:[**2176-6-18**]

[ "V10.46", "530.81", "518.51", "188.9", "575.10", "272.4", "E878.8", "287.5", "998.11", "288.60", "584.9", "593.4", "276.69", "276.2", "401.9", "518.0", "458.29", "568.0", "285.1", "997.49", "591", "553.3" ]

icd9cm

[ [ [] ] ]

[ "55.03", "46.73", "38.97", "96.71", "57.71", "48.52", "59.8", "45.24", "87.75", "97.61", "45.91", "56.51", "40.3", "46.01", "54.59" ]

icd9pcs

[ [ [] ] ]

11340, 11389

4765, 9818

318, 1304

11543, 11543

2545, 4742

13284, 14356

2071, 2123

10089, 11317

11410, 11522

9844, 10066

11771, 13261

2138, 2526

264, 280

11558, 11747

1326, 1780

1796, 2055

3,465

127,020

47584

Discharge summary

report

Admission Date: [**2163-10-24**] Discharge Date: [**2163-11-10**] Date of Birth: [**2089-8-27**] Sex: M Service: CARDIOTHORACIC Allergies: Penicillins Attending:[**First Name3 (LF) 1505**] Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: [**2163-10-24**] Coronary Artery Bypass Graft x 4 (Lima to LAD, SVG to PDA, SVG to Diag, SVG to OM1) History of Present Illness: 74 y/o male with h/o myocardial infarction with most recent echocardiogram revealing marked reduction of ejection fraction. Mr. [**Known lastname **] was subsequently referred for cardiac cath which revealed two vessel coronary artery disease. Now referred for surgical revascularization. Past Medical History: Myocardial Infarction, Hypertension, Hypercholesterolemia, Congestive Heart Failure, Sleep Apnea on CPAP, [**Location (un) 5668**] cell cancer of the 5th digit s/p amputation with metastases to left axilla s/p nodal dissection and radiation therapy, Left upper extermity lymphadema d/t nodal dissection, Renal Calculi, Bilateral total hip replacement Social History: Social history is significant for the absence of current tobacco use, has a 45 pack year history and quit smoking 12 years ago. There is no history of alcohol abuse. The patient is a pharmacist and works 2 days per week. Pt lives with a roommate at home. Family History: There is family history of premature coronary artery disease, father died of an MI at age 44, pat grandfather with DM. Physical Exam: Discharge A/Ox3 Pulm CTAB CArdiac RRR Sternal inc no drainage no erythema Abd soft +BS, NT, ND Leg inc LLE ecchymotic lower inc with erythema Pertinent Results: Echo [**10-24**]: PRE-BYPASS: The left atrium is dilated. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity is mildly dilated. There is severe regional left ventricular systolic dysfunction with mild global dysfunction. Resting regional wall motion abnormalities include akinetic apex and severely hypokinetic anteroseptal, anterior and inferior wall. Right ventricular chamber size and free wall motion are normal. The ascending aorta is mildly dilated. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild to moderate ([**11-22**]+) mitral regurgitation is seen. Post-Bypass: Normal RV systolic function. Overall LVEF is 35-40% on epinephrine infusion. Mild MR. Mild to moderate TR. CXR [**10-31**]: Improving left pleural effusion and left lower lobe atelectasis. [**2163-10-24**] 12:45PM BLOOD WBC-9.1 RBC-2.23*# Hgb-7.0*# Hct-19.2*# MCV-86 MCH-31.4 MCHC-36.4* RDW-15.2 Plt Ct-69*# [**2163-10-27**] 02:56AM BLOOD WBC-12.6*# RBC-3.70* Hgb-11.2* Hct-31.8* MCV-86 MCH-30.3 MCHC-35.3* RDW-14.6 Plt Ct-148* [**2163-11-1**] 07:00AM BLOOD WBC-10.5 RBC-3.11* Hgb-9.7* Hct-26.7* MCV-86 MCH-31.2 MCHC-36.3* RDW-15.9* Plt Ct-183 [**2163-10-24**] 12:45PM BLOOD PT-18.5* PTT-54.1* INR(PT)-1.7* [**2163-10-30**] 05:30AM BLOOD PT-14.1* INR(PT)-1.3* [**2163-10-24**] 04:10PM BLOOD UreaN-22* Creat-1.0 Cl-110* HCO3-26 [**2163-11-1**] 07:00AM BLOOD Glucose-126* UreaN-39* Creat-1.5* Na-134 K-4.0 Cl-96 HCO3-30 AnGap-12 [**2163-10-24**] 04:15PM BLOOD ALT-22 AST-36 LD(LDH)-226 AlkPhos-48 Amylase-96 TotBili-3.7* [**2163-11-10**] 06:30AM BLOOD WBC-5.3 RBC-3.25* Hgb-9.9* Hct-28.8* MCV-89 MCH-30.6 MCHC-34.5 RDW-16.6* Plt Ct-360 [**2163-11-10**] 06:30AM BLOOD PT-26.3* INR(PT)-2.7* [**2163-11-9**] 07:20AM BLOOD PT-27.8* INR(PT)-2.9* [**2163-11-10**] 06:30AM BLOOD Glucose-75 UreaN-30* Creat-1.6* Na-135 K-4.3 Cl-97 HCO3-30 AnGap-12 [**2163-11-9**] 07:20AM BLOOD Glucose-89 UreaN-34* Creat-1.6* Na-135 K-4.3 Cl-98 HCO3-29 AnGap-12 [**2163-11-8**] 07:10AM BLOOD Glucose-98 UreaN-37* Creat-1.7* Na-136 K-4.2 Cl-99 HCO3-29 AnGap-12 [**2163-11-7**] 03:52PM BLOOD UreaN-36* Creat-1.7* Brief Hospital Course: Mr. [**Known lastname **] was a same day admit and was brought directly to the operating room where he underwent a coronary artery bypass graft x 4. Please see operative report for surgical details. Patient tolerated the procedure well and was transferred to the CSRU for invasive monitoring in stable condition. Patient required multiple transfusions secondary to post-operative bleeding and low HCT. He remained intubated overnight and on post-op day one he was weaned from sedation, awoke neurologically intact and was extubated. He required multiple inotropes for hemodynamic support but was weaned from these by post-op day three. Overnight on post-op day two he had episodes of atrial fibrillation that required amiodarone. Beta blockers and diuretics were initiated and he was gently diuresed towards his pre-op weight. On post-op day three he was transferred to the SDU for continued care. Over the next several days he required aggressive respiratory toilet and worked with physical therapy for strength and mobility. He had another episode of atrial fibrillation on post-op day five, which was treated and he will go home on amiodarone. He was medically managed, with medications titrated and electrolytes repleted. He was eventually started on coumadin for post op paroxysmal atrial fibrillation. He was started on vanco and levo for ? of LLE cellulitis. He was seen in consultation by infectious diseases as well who recommended continuing vanco and starting cipro. He was seen in consultation by [**Last Name (un) **] who recommended Lantus insulin. Wound care followed closesly for his LLE wounds which are improving daily. He also continued with aggressive diuresis.He was ready for discharge on [**11-10**]. Medications on Admission: Aspirin, Atenolol, Lasix, Diovan, Lovastatin, Prilosec, Celexa, Albuterol, Fluticasone 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. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. 4. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [**Hospital1 **] (2 times a day). 5. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation Q3-4H (Every 3 to 4 Hours) as needed. 6. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation QID (4 times a day). 7. Potassium Chloride 20 mEq Packet Sig: One (1) Packet PO Q12H (every 12 hours). 8. Toprol XL 100 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO once a day. 9. Lovastatin 20 mg Tablet Sig: One (1) Tablet PO once a day. 10. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 11. Doxazosin 2 mg Tablet Sig: One (1) Tablet PO once a day. 12. Vancomycin 500 mg Recon Soln Sig: 750 mg Recon Solns Intravenous Q 12H (Every 12 Hours) for 10 days: through [**11-20**]. 13. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 10 days: thru [**11-20**]. Tablet(s) 14. Citalopram 20 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily). 15. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 16. Furosemide 80 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 17. Oxybutynin Chloride 5 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 18. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000) units Injection TID (3 times a day). 19. Coumadin 1 mg Tablet Sig: Three (3) Tablet PO once a day for 2 days: Check INR [**11-12**]. 20. Insulin Glargine 100 unit/mL Cartridge Sig: Sixteen (16) units Subcutaneous at bedtime: also see regular insulin sliding scale. 21. Ativan 0.5 mg Tablet Sig: One (1) Tablet PO qhs:PRN as needed for anxiety. Discharge Disposition: Extended Care Facility: [**Hospital3 2558**] - [**Location (un) **] Discharge Diagnosis: Coronary Artery Disease s/p Coronary Artery Bypass Graft x 4 Post-operative Atrial Fibrillation PMH: Myocardial Infarction, Hypertension, Hypercholesterolemia, Congestive Heart Failure, Sleep Apnea on CPAP, [**Location (un) 5668**] cell cancer of the 5th digit s/p amputation with metastases to left axilla s/p nodal dissection and radiation therapy, Left upper extermity lymphadema d/t nodal dissection, Renal Calculi, Bilateral total hip replacement Discharge Condition: Good Discharge Instructions: [**Month (only) 116**] shower, 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 Adhere to 2 gm sodium diet No creams, lotions, powders, or ointments to incisions No driving for approximately one month No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns Followup Instructions: Dr. [**Last Name (STitle) **] in 4 weeks Dr. [**Last Name (STitle) 120**] in [**12-24**] weeks Dr. [**Last Name (STitle) 2539**] in [**11-22**] weeks Already scheduled appointments: Provider: [**Name10 (NameIs) **] SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2163-11-30**] 10:00 Provider: [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]/CUT. ONC. DERM. Date/Time:[**2163-11-30**] 10:30 Provider: [**First Name11 (Name Pattern1) 125**] [**Last Name (NamePattern4) 126**], M.D. Phone:[**Telephone/Fax (1) 127**] Date/Time:[**2164-3-16**] 11:30 Completed by:[**2163-11-10**]

[ "V10.83", "V43.64", "250.00", "412", "427.31", "300.01", "998.59", "V49.62", "V15.82", "272.0", "V15.3", "401.9", "V17.3", "780.57", "V18.0", "428.0", "424.0", "998.11", "285.1", "414.01", "997.1" ]

icd9cm

[ [ [] ] ]

[ "89.60", "36.15", "93.90", "38.93", "99.04", "36.13", "38.09", "99.07", "39.61" ]

icd9pcs

[ [ [] ] ]

7795, 7865

3957, 5682

300, 402

8361, 8367

1680, 3934

8859, 9492

1382, 1502

5819, 7772

7886, 8340

5708, 5796

8391, 8836

1517, 1661

241, 262

430, 720

742, 1094

1110, 1366

72,847

150,633

39971

Discharge summary

report

Admission Date: [**2190-12-1**] Discharge Date: [**2190-12-5**] Date of Birth: [**2127-3-17**] Sex: F Service: NEUROSURGERY Allergies: Prochlorperazine / Aspirin / Nsaids Attending:[**First Name3 (LF) 78**] Chief Complaint: Anterior communicating artery aneurysm measuring 9 mm x 7 mm x 5 mm and a left MCA aneurysm measuring 7 x 5 x 3.5 mm Major Surgical or Invasive Procedure: Cerebral Angiogram with stent placement and attempted coiling History of Present Illness: 63-year-old female who has been seen in our clinic for for consultation regarding large anterior communicating artery aneurysm measuring 9 mm x 7 mm x 5 mm and a left MCA aneurysm measuring 7 x 5 x 3.5 mm. brain aneurysms.She is admitted for an elective coiling. She was admitted in [**2189**] at [**Hospital3 2576**] and was found to have an unruptured brain aneurysm. During her workup, she had initially presented with general malaise, weakness, fevers and then developed sepsis and also had a fall that time. She reports that she had a left-sided venous thrombosis in her arm, which had become infected. Past Medical History: Fibromyalgia, anxiety, depression PSH for colon cancer surgery, tubal ligation, laminectomy and spinal fusion, hemorrhoidectomy, exploratory exposure surgery for ovarian cysts appendectomy. Social History: Smoker 1ppd for 30 years Family History: Noncontributory Physical Exam: Pre-admission: nonfocal exam Upon discharge: Nonfocal exam Pertinent Results: CTA Head [**2190-12-3**]: IMPRESSION: 1. Status post stent and coiling in the anterior communicating artery with a portion of aneurysm still visualized. Aneurysm in the left MCA is also again noted. 2. Slight decrease of subarachnoid hemorrhage along the interhemispheric fissure and suprasellar cistern. No new hemorrhage is noted. 3. Mild decrease in caliber of the left anterior cerebral artery (segment A1) from prior study indicates mild nonocclusive spasm. There is no evidence of vasospasm in the other arteries of anterior and posterior circulations. Radiology Report CT HEAD W/O CONTRAST Study Date of [**2190-12-1**] 9:06 PM Final Report INDICATION: Headache in a patient with recent cerebral angiogram and stent placement related to anterior communicating arterial aneurysm. COMPARISON: Head CT from earlier on the same evening. TECHNIQUE: Contiguous axial CT images were acquired through the head without intravenous contrast. FINDINGS: Note is again made of hyperdense fluid in the subarachnoid spaces, with the largest area seen in the suprasellar cistern. Some areas of particularly high density is seen on the comparison study, predominantly near the falx are no longer apparent, suggesting a residua of subarachnoid hemorrhage and absorption or diffusion of a small component of contrast. Sulci remain normal in size and in configuration. There is now dilatation of the lateral ventricles, as compared to the head CT of 18:10 on [**2190-12-1**]. There is no fracture. Mastoid air cells are clear. IMPRESSION: Redemonstration of subarachnoid hemorrhage. There is no evidence of new hemorrhage. Interval development of slight ventricular dilatation. Radiology Report CT HEAD W/O CONTRAST Study Date of [**2190-12-1**] 6:06 PM FINDINGS: Note is made of hyperdense subarachnoid fluid, new from the comparison studies, with the majority seen in the suprasellar cistern, though additional hyperdensity extending upwards along the medial sulcation of both frontal lobes. Though the majority of this is likely subarachnoid hemorrhage, there are more hyperdense components superiorly, which may represent contrast material from the recent angiogram. The ventricles and sulci are normal in size and in configuration. There is no evidence of infarction or mass effect. A small stent is visualized in the region of the anterior cerebral arteries, with a small metallic clip at either end of the stent. There is no fracture. Mastoid air cells are clear. IMPRESSION: New subarachnoid hemorrhage, likely with a small component of subarachnoid contrast as well. NOTE ADDED AT ATTENDING REVIEW: I agree with the aobve interpretation, but note that the distinction between subarachnoid density due to hemorrhage or contrast material is significant only in the extent of hemorrhage. Contrast injected during angiography could reach the subarachnoid space only by way of hemorrhage. Therefore, we can be sure of subarachnoid hemorrhage, but unsure whether any occured during the time there was circulating contrast. Brief Hospital Course: Ms [**Known lastname **] was admitted to the neurosurgery service and underwent a diagnositic cerebral angiogram and attempt to coil. She was unable to be coiled. A post procedural CT showed new subarachnoid hemorrhage. She was monitored closely in the ICU for 24 hrs then was transferred to the floor. On [**12-3**], she was noted to be more confused but imaging showed no acute changes. She improved and remained stable on [**12-4**] and was discharged home on [**12-5**]. She will follow up in one month. Medications on Admission: Buspar, Plavix, Valium, Zocor, Diovan and Lexapro Discharge Medications: 1. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for Constipation. 2. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for Constipation. 3. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for headache. 4. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 30 days. Disp:*30 Tablet(s)* Refills:*0* 5. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. butalbital-acetaminophen-caff 50-325-40 mg Tablet Sig: [**1-23**] Tablets PO every six (6) hours as needed for pain. Disp:*40 Tablet(s)* Refills:*0* 7. escitalopram 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 8. diazepam 5 mg Tablet Sig: One (1) Tablet PO every 6-8 hours as needed for anxiety: Home dosing. 9. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 10. famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). Discharge Disposition: Home Discharge Diagnosis: ACA and L MCA aneurysms Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Medications: ?????? Take Aspirin 325mg (enteric coated) once daily. ?????? Take Plavix (Clopidogrel) 75mg once daily. ?????? Continue all other medications you were taking before surgery, unless otherwise directed ?????? You make take Tylenol or prescribed pain medications for any post procedure pain or discomfort. What 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 Followup Instructions: Follow up with Dr [**Known lastname **] in [**3-25**] weeks to discuss further intervention, you will need a CTA head at that time. Please continue Plavix until you are seen by Dr. [**Known lastname **]. Please call [**Telephone/Fax (1) 4296**] to make this appointment. Completed by:[**2190-12-5**]

[ "V45.4", "348.89", "V10.05", "437.3", "300.4", "430", "E870.8", "784.0", "729.1", "996.59", "305.1" ]

icd9cm

[ [ [] ] ]

[ "88.41", "38.81", "00.65", "38.91", "00.62", "00.44", "00.42", "00.47" ]

icd9pcs

[ [ [] ] ]

6170, 6176

4559, 5071

415, 479

6244, 6244

1502, 4536

7444, 7746

1390, 1407

5171, 6147

6197, 6223

5097, 5148

6395, 7421

1422, 1452

259, 377

1468, 1483

507, 1118

6259, 6371

1140, 1332

1348, 1374

74,509

104,366

37340

Discharge summary

report

Admission Date: [**2116-11-11**] Discharge Date: [**2116-11-16**] Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 3376**] Chief Complaint: rectal prolapse Major Surgical or Invasive Procedure: OR reduction rectal prolapse, end colostomy, Hartmanns creation [**2116-11-11**] History of Present Illness: Ms [**Known lastname 67432**] is an 86yo woman with a history of dementia who presents as a transfer from an OSH with several hours of rectal prolapse. Per reports, as patient poor historian secondary to dementia, the prolapse was noted at 2pm with bleeding and she was brought to the OSH where attempts at reduction using lidoacaine, morhpine, and sugar failed to reduce. She was advised by a surgeon that surgey was needed, and the patient was transferred to [**Hospital1 18**] ED after receiving 2 units FFP as patient on coumadin. Patient is complaining of pain in her rectum, with no other complaints. No chest pain, SOB, fevers, chills, nause or vomiting. The patient was noted to have a tender prolapsed rectum,and attempts to reduce with Fentanyl, sugar, and ice in the ED by the Attending Surgeon were unsuccessful. Past Medical History: alzheimer's dementia, AFIB, HTN, arthritis, diverticulitis, DNR Social History: SH: no smoking, no ETOH; lives in Nursing home Family History: NC Physical Exam: PE: 97.2 90 129/82 16 98% RA Gen: pleasantly demented elderly woman in NAD HEENT: MMdry, scerla anicteric CV: irregular Lungs: decreased bases Abd: soft, NT/ND ext: no c/c/e Pertinent Results: CXR [**11-11**]: Abnormal buldge along the posterior heart border of unclear etiology. Dedicated PA/Lateral view is recommended for further evaluation. [**2116-11-15**] 07:10AM BLOOD WBC-14.2* RBC-3.82* Hgb-12.0 Hct-35.5* MCV-93 MCH-31.4 MCHC-33.7 RDW-13.7 Plt Ct-317 [**2116-11-14**] 07:50AM BLOOD WBC-16.4* RBC-3.57* Hgb-11.2* Hct-33.6* MCV-94 MCH-31.5 MCHC-33.5 RDW-13.8 Plt Ct-271 [**2116-11-13**] 03:47AM BLOOD WBC-17.7* RBC-3.77* Hgb-12.0 Hct-36.3 MCV-96 MCH-31.7 MCHC-32.9 RDW-14.8 Plt Ct-257 [**2116-11-12**] 03:29AM BLOOD WBC-12.8* RBC-3.99* Hgb-12.5 Hct-37.8 MCV-95 MCH-31.4 MCHC-33.2 RDW-14.7 Plt Ct-296 [**2116-11-11**] 09:00PM BLOOD WBC-13.5* RBC-4.26 Hgb-13.2 Hct-40.8 MCV-96 MCH-30.9 MCHC-32.3 RDW-14.9 Plt Ct-309 [**2116-11-11**] 09:00PM BLOOD Neuts-84.0* Lymphs-9.4* Monos-5.4 Eos-0.8 Baso-0.4 [**2116-11-16**] 06:15AM BLOOD PT-15.5* INR(PT)-1.4* [**2116-11-15**] 07:10AM BLOOD PT-13.5* PTT-31.1 INR(PT)-1.2* [**2116-11-15**] 07:10AM BLOOD Glucose-109* UreaN-24* Creat-1.2* Na-135 K-4.0 Cl-99 HCO3-25 AnGap-15 [**2116-11-14**] 07:50AM BLOOD Glucose-102 UreaN-28* Creat-1.2* Na-135 K-4.5 Cl-101 HCO3-26 AnGap-13 [**2116-11-13**] 03:47AM BLOOD Glucose-102 UreaN-35* Creat-1.3* Na-138 K-4.6 Cl-103 HCO3-26 AnGap-14 [**2116-11-15**] 07:10AM BLOOD Calcium-8.7 Phos-2.6* Mg-1.9 [**2116-11-14**] 07:50AM BLOOD Calcium-8.5 Phos-2.9 Mg-1.8 [**2116-11-14**] 08:45AM BLOOD Digoxin-1.9 [**2116-11-14**] 07:50AM BLOOD Digoxin-2.4* [**2116-11-13**] 08:48PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.013 [**2116-11-13**] 08:48PM URINE Blood-SM Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG [**2116-11-13**] 08:48PM URINE RBC-4* WBC-2 Bacteri-NONE Yeast-NONE Epi-<1 . MRSA SCREEN (Final [**2116-11-14**]): No MRSA isolated. . cxr [**2116-11-11**] Abnormal buldge along the posterior heart border of unclear etiology. Dedicated PA/Lateral view is recommended for further evaluation. Brief Hospital Course: [**11-11**] pt admitted to the surgical service ICU s/p OR reduction rectal prolapse, end colostomy, Hartmann's creation. She was kept intubated overnight, NPO/ IVF, NGT/ Foley in place. Fentanyl for pain control [**11-12**]: Pt extubated without incident. She was started on her home dose coumadin and morphine PCA. Pt has known a fib but had rate 100-120s despite treatment with metoprolol and diltiazem. [**11-13**]: Pt'd diet advanced. Diltiazem increased. She was transferred to the general surgery floor on [**11-13**]. She tolerated a regular diet, iv medications were changed to oral and IVF was d/c'd. She was seen by phyisical therapy and it was they rec rehab. Her home coumadin was restarted and her INR on [**2116-11-16**] was 1.4. The rehab will continue to check INR and adjust coumadin as needed. She will Follow up with Dr. [**Last Name (STitle) 1120**] in [**12-20**] weeks. Medications on Admission: Dilt CD 240, Lipitor 20, Lisinopril 20, Namenda 10, MOM [**Name (NI) **], Triamterene HCTZ 37.5/25 Coumadin 3.5, Tyenol prn Discharge Medications: 1. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Triamterene-Hydrochlorothiazid 37.5-25 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 4. Warfarin 3 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Warfarin 1 mg Tablet Sig: 0.5 Tablet PO once a day. 6. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain for 2 weeks. 7. Memantine 5 mg Tablet Sig: Two (2) Tablet PO daily (). 8. Diltiazem HCl 180 mg Capsule, Sustained Release Sig: Two (2) Capsule, Sustained Release PO DAILY (Daily). 9. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Codeine Sulfate 30 mg Tablet Sig: 0.5 Tablet PO Q4H (every 4 hours) as needed for pain for 2 weeks. Disp:*50 Tablet(s)* Refills:*0* Discharge Disposition: Extended Care Facility: [**Hospital 8641**] Healthcare, NH Discharge Diagnosis: rectal prolapse Post-op low urine output Discharge Condition: stable. Tolerating regular diet. Pain well controlled. Discharge Instructions: Please call your doctor or return to the ER for any of the following: * You experience new chest pain, pressure, squeezing or tightness. * New or worsening cough or wheezing. * If you are vomiting and cannot keep in fluids or your medications. * You are getting dehydrated due to continued vomiting, diarrhea or other reasons. Signs of dehydration include dry mouth, rapid heartbeat or feeling dizzy or faint when standing. * You see blood or dark/black material when you vomit or have a bowel movement. * Your pain is not improving within 8-12 hours or not gone within 24 hours. Call or return immediately if your pain is getting worse or is changing location or moving to your chest or back. *Avoid lifting objects > 5lbs until your follow-up appointment with the surgeon. *Avoid driving or operating heavy machinery while taking pain medications. * You have shaking chills, or a fever greater than 101.5 (F) degrees or 38(C) degrees. * Any serious change in your symptoms, or any new symptoms that concern you. * Please resume all regular home medications and take any new meds as ordered. * Continue to ambulate several times per day. . Incision Care: -Your steri-strips will fall off on their own. Please remove any remaining strips 7-10 days after surgery. -You may shower, and wash surgical incisions. -Avoid swimming and baths until your follow-up appointment. -Please call the doctor if you have increased pain, swelling, redness, or drainage from the incision sites. . Monitoring Ostomy output/Prevention of Dehydration: -Keep well hydrated. -Replace fluid loss from ostomy daily. -Avoid only drinking plain water. Include Gatorade and/or other vitamin drinks to replace fluid. -Try to maintain ostomy output between 1000mL to 1500mL per day. -If Ostomy output >1 liter, take 4mg of Imodium, repeat 2mg with each episode of loose stool. Do not exceed 16mg/24 hours . Followup Instructions: 1. Please call Dr.[**Name (NI) 3377**] office, [**Telephone/Fax (1) 160**], to make a follow up appointment in [**12-20**] weeks. Completed by:[**2116-11-19**]

[ "557.0", "338.18", "331.0", "427.31", "V43.65", "V88.01", "403.90", "716.90", "562.10", "569.1", "V58.61", "294.10", "585.9", "785.0" ]

icd9cm

[ [ [] ] ]

[ "48.69", "46.11" ]

icd9pcs

[ [ [] ] ]

5484, 5545

3578, 4476

279, 361

5630, 5687

1605, 3555

7616, 7778

1387, 1391

4650, 5461

5566, 5609

4502, 4627

5711, 6853

6868, 7593

1406, 1586

224, 241

389, 1218

1240, 1306

1322, 1371

13,476

141,085

13044

Discharge summary

report

Admission Date: [**2147-9-27**] Discharge Date: [**2147-10-10**] Date of Birth: [**2068-9-14**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 301**] Chief Complaint: 79 year old male admitted to hospital who had routine colonscopy on [**2147-9-27**] with intense pain and free air on chest x-ray. Major Surgical or Invasive Procedure: Status Post 1. Exploratory laparotomy. 2. Primary repair of sigmoid perforation. 3. Repair of incisional hernias, multiple, abdomen. History of Present Illness: 79-year-old man who had a routine colonoscopy on [**9-27**] with intense pain thereafter and free air on a CXR. At the OSH where this all happened he received levaquin and flagyl and was transferred here and noted to have massive pneumoperitoneum, elevated wbc, distended and tender abdomen.and was brought urgently to the operating room for exploration. Past Medical History: COPD, h/o MI, hypertension, ^chol, prostate cancer, gout, OA PSH: PTCA coronary stent, AAA '[**33**] ([**Doctor Last Name **]), b/l inguinal x 2, RUL adenoCA s/p lobectomy '[**46**] Social History: Married, daughter involved with care. Family History: Non Contributory. Physical Exam: Vital Signs: HR: 138/72 BP: 138/72 RR: 16 Temp:98.1 O2 Sat: 100 % on PSV 10.5 40% TV=800cc Rest Exercise Pain: General appearance:RASS -4 HEENT:PERRL Neck:No JVD Chest: Symmetric expansion with inspiration Cardiac:regular no murmurs Abdomen:Abd, ventral abdominal inscision c/d/i Skin:no rashes Lymph: no LAD Extremeties:No c/c/e Pertinent Results: [**2147-10-3**] 03:05AM BLOOD WBC-12.0* RBC-3.03* Hgb-9.7* Hct-30.8* MCV-102* MCH-32.1* MCHC-31.5 RDW-14.4 Plt Ct-269 [**2147-10-7**] 04:45PM BLOOD WBC-19.1* RBC-2.85* Hgb-9.6* Hct-29.7* MCV-104* MCH-33.5* MCHC-32.2 RDW-14.7 Plt Ct-421 [**2147-10-10**] 06:05AM BLOOD WBC-16.2* RBC-2.74* Hgb-9.4* Hct-28.2* MCV-103* MCH-34.3* MCHC-33.4 RDW-15.0 Plt Ct-460* [**2147-9-27**] 04:30PM BLOOD WBC-17.2* RBC-3.60* Hgb-11.9* Hct-36.7* MCV-102*# MCH-33.0* MCHC-32.4 RDW-14.6 Plt Ct-305 [**2147-10-4**] 01:50AM BLOOD PT-13.5* PTT-27.5 INR(PT)-1.2* [**2147-9-28**] 02:15AM BLOOD PT-13.0 PTT-27.9 INR(PT)-1.1 [**2147-9-27**] 04:30PM BLOOD Glucose-169* UreaN-21* Creat-1.3* Na-139 K-4.1 Cl-103 HCO3-24 AnGap-16 [**2147-9-30**] 02:41AM BLOOD Glucose-114* UreaN-34* Creat-1.8* Na-139 K-4.2 Cl-106 HCO3-21* AnGap-16 [**2147-10-10**] 06:05AM BLOOD Glucose-101 UreaN-32* Creat-1.0 Na-147* K-3.6 Cl-113* HCO3-28 AnGap-10 [**2147-9-28**] 09:48AM BLOOD CK-MB-6 cTropnT-0.04* [**2147-9-28**] 05:39PM BLOOD CK-MB-7 cTropnT-0.03* [**2147-9-29**] 06:46PM BLOOD CK-MB-8 cTropnT-0.03* [**2147-9-28**] 02:15AM BLOOD Calcium-8.0* Phos-4.8*# Mg-1.8 [**2147-10-5**] 01:48AM BLOOD Calcium-8.7 Phos-4.2 Mg-2.0 [**2147-10-10**] 06:05AM BLOOD Calcium-8.4 Phos-3.3 Mg-2.1 [**2147-9-27**] 08:26PM BLOOD Glucose-121* Lactate-1.1 Na-138 K-4.3 Cl-106 [**2147-10-1**] 09:34PM BLOOD Glucose-90 Brief Hospital Course: Patient admitted emergently to [**Hospital1 18**] and taken to the operating room. He underwent Exploratory laparotomy, Primary repair of sigmoid perforation, and Repair of incisional hernias. Postoperatively he went to the intensive care unit. Started on cipro/flagyl and was difficult to wean from ventilator. On [**2147-9-30**] patient was extubated and needed to be reintubated for low oxygen saturations. Diuretics and nebulizers used and patient was sucessfully extubated on [**10-3**]. He was transferred to the floor and speech and swallow consulted and he was started on a regular diet/ground with thickened liquids. He was reevaluated again on [**10-9**] and found that he was safe for soft solids and thin liquids. Physical therapy worked with him as well and found that he was too weak to be discharged to home. Staples were removed on [**2147-10-9**] and small area around the umbilicus opened up. This is being treated with wet to dry dressings [**Hospital1 **]. We will discharge him to rehab. today with follow up with Dr. [**Last Name (STitle) **] in 2 weeks. Medications on Admission: allopurinol 100''', atorvastatin 10', colchicine 0.6', diltiazem 180'', docusate 100', doxazosin 4', finasteride 5', furosemide 20', metoprolol 15', tamsulosin 0.4', celecoxib 200', fluticasone 110 inh'', Serevent 2puffs'', Atrovent 2puffs'', Azmacort 2 puffs'' Discharge Medications: 1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) ml Injection [**Hospital1 **] (2 times a day). 2. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [**Hospital1 **] (2 times a day). 3. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). 4. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours): Please continue this thru [**2147-10-11**]. 5. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day): Please continue this through [**2147-10-11**] then discontinue. 6. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 7. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 8. Atorvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 9. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Doxazosin 4 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 12. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO HS (at bedtime). 13. Docusate Sodium 50 mg/5 mL Liquid Sig: Ten (10) ml PO BID (2 times a day). 14. Salmeterol 50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation Q12H (every 12 hours). Discharge Disposition: Extended Care Facility: Lifecare Center of [**Hospital3 **] Discharge Diagnosis: Primary Diagnosis: Status post colonoscopy complicated by sigmoid perforation Discharge Condition: Stable Discharge Instructions: Please call your doctor or return to the emergency room if you have any of the following: * You experience new chest pain, pressure, squeezing or tightness. * New or worsening cough or wheezing. * If you are vomiting and cannot keep in fluids or your medications. * You are getting dehydrated due to continued vomiting, diarrhea or other reasons. Signs of dehydration include dry mouth, rapid heartbeat or feeling dizzy or faint when standing. * You see blood or dark/black material when you vomit or have a bowel movement. * You have shaking chills, or a fever greater than 101.5 (F) degrees or 38(C) degrees. * Any serious change in your symptoms, or any new symptoms that concern you. * Please resume all regular home medications and take any new meds as ordered. Activity: No heavy lifting of items [**10-25**] pounds for 6 weeks. You may resume moderate exercise at your discretion, no abdominal exercises. Wound Care: You may shower, no tub baths or swimming. If there is clear drainage from your incisions, cover with clean, dry gauze. Your steri-strips will fall off on their own. Please remove any remaining strips 7-10 days after surgery. Please call the doctor if you have increased pain, swelling, redness, or drainage from the incision sites. Followup Instructions: Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] Phone:[**Telephone/Fax (1) 11767**] Date/Time:[**2147-10-12**] 11:00 Provider: [**First Name11 (Name Pattern1) 2389**] [**Last Name (NamePattern1) 2390**], MD Phone:[**0-0-**] Date/Time:[**2147-11-23**] 11:00 Provider: [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] [**Name (STitle) 23**] building [**Location (un) 470**], [**2147-10-20**] at 4 pm. Please call [**Telephone/Fax (1) 39923**] if you need to change this appointment. Completed by:[**2147-10-10**]

[ "272.0", "V10.11", "274.9", "491.21", "584.9", "998.2", "V10.46", "998.59", "E878.8", "428.31", "553.21", "998.32", "412", "518.81", "401.1", "567.29", "428.0", "568.89" ]

icd9cm

[ [ [] ] ]

[ "53.51", "46.75", "96.04", "96.72" ]

icd9pcs

[ [ [] ] ]

5719, 5781

3034, 4114

445, 580

5903, 5912

1659, 3011

7237, 7788

1242, 1261

4426, 5696

5802, 5802

4140, 4403

5937, 6868

1276, 1640

275, 407

6880, 7214

608, 964

5821, 5882

986, 1171

1187, 1226

43,359

131,748

4608

Discharge summary

report

Admission Date: [**2137-11-6**] Discharge Date: [**2137-11-9**] Date of Birth: [**2089-4-7**] Sex: M Service: MEDICINE Allergies: Lisinopril Attending:[**First Name3 (LF) 7055**] Chief Complaint: chest pain Major Surgical or Invasive Procedure: Cardiac catheterization with drug eluting stent to the proximal left anterior descending artery History of Present Illness: 48M with HTN and obesity. 2 days ago had nausea and muscle tightening feeling in chest, [**12-9**]. This morning he woke up with a some epigastric pain (he felt it was like indigestion, which he rarely gets).This pain was again associated with hand numbness and tingling. He has decided to call PCP, [**Name10 (NameIs) 1023**] referred him to the Ed after giving him an aspirin 325. He reported not having such episodes in the past. He passes out during blood draws (as documented by his PCP). He had some nausea in the mornings for the past couple of days, and felt that his pain was more of "acid-reflux" in nature, his wife even bought him some Maalox, which he only took once prior to coming to his PCP. . He had no other associated symptoms ( Denies sob, dyspnea, n,v abdomen pain) denied sick contacts, denied any recent URI, fevers, or claudication or numbness in his limbs not associated with symptoms described above. He has a history of fainting after blood draws. . On review of systems, s/he denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, [**Name10 (NameIs) **], 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 dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations. . In the ED his vitals were: 98.6 99 155/104 18 99%RA. He presented to the ED without chest pain. An EKG was done (chest pain-free), showing TWI in V2, V3, nospecific Tw changes throughout. poor R-wave progression. While in the ED had an episode of dizziness and "passing out", which prompted a repeat EKG. This showed T wave inversions in V2, V3, poor R-wave progression, as well as nospecific ST changes diffusely. The second EKG showed possible ST elevations in V2, V3. 1st trop 0.17, MB 25. He was started on Heparin bolus, then GTT, given plavix 300x2, and sent to the cath lab. He was guaiac negative, had a grossly clear chest x-ray. Past Medical History: PAST MEDICAL HISTORY: 1. CARDIAC RISK FACTORS: Hypertension, Obesity 2. CARDIAC HISTORY: 3. OTHER PAST MEDICAL HISTORY: None. . Social History: Works at Partners in IT -Tobacco history: None -ETOH: On Occasion -Illicit drugs: None Family History: No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Father died of a PE (was a heavy smoker), Mother died of ovarian cancer. Physical Exam: GENERAL: NAD, pleasant obese male. 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: JVP could not be ascertained due to obese neck. No LAD, no thyromegaly. 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. Distant but CTAB, no crackles, wheezes or rhonchi. ABDOMEN: Soft,Obese, nontender. Could not assess abd aorta or organomegaly due to obesity. Groin: site covered with dressing, no hematoma. 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: Gen: NAd, sitting up in chair CV: RRR, no M/R/G RESP: CTAB ant ABD: soft, NT EXTR: no peripheral edema Extremities: Groin site w/o hematoma or bruit Pulses: Right: DP 2+ PT 2+ Left: DP 2+ PT 2+ Skin: intact Pertinent Results: Admission Labs: [**2137-11-6**] 12:45PM PT-12.6 PTT-28.5 INR(PT)-1.1 [**2137-11-6**] 12:45PM PLT COUNT-213 [**2137-11-6**] 12:45PM NEUTS-77.2* LYMPHS-17.2* MONOS-4.2 EOS-0.5 BASOS-0.8 [**2137-11-6**] 12:45PM WBC-8.4 RBC-5.53 HGB-16.5 HCT-46.6 MCV-84 MCH-29.8 MCHC-35.3* RDW-13.1 [**2137-11-6**] 12:45PM CALCIUM-9.6 PHOSPHATE-3.0 MAGNESIUM-2.1 [**2137-11-6**] 12:45PM CK-MB-25* MB INDX-5.7 [**2137-11-6**] 12:45PM cTropnT-0.17* [**2137-11-6**] 12:45PM CK(CPK)-438* [**2137-11-6**] 12:45PM estGFR-Using this [**2137-11-6**] 12:45PM GLUCOSE-94 UREA N-14 CREAT-1.1 SODIUM-137 POTASSIUM-4.1 CHLORIDE-100 TOTAL CO2-25 ANION GAP-16 [**2137-11-6**] 08:22PM PLT COUNT-220 [**2137-11-6**] 08:22PM WBC-11.8* RBC-5.58 HGB-15.9 HCT-45.4 MCV-82 MCH-28.5 MCHC-35.0 RDW-13.3 [**2137-11-6**] 08:22PM CK-MB-34* MB INDX-6.1* cTropnT-0.77* [**2137-11-6**] 08:22PM CK(CPK)-558* ECHO:Very limited image quality. The left atrium is mildly dilated. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. The left ventricular ejection fraction is well-preserved. However, the anterior septum, anterior free wall, and apex are hypokinetic. The aortic valve is not well seen. There is no aortic valve stenosis. There is no pericardial effusion. CXR: There has been no significant change in comparison to prior study from [**2137-9-27**]. The lungs are clear. The cardiomediastinal and hilar silhouettes appear normal. There are no pleural effusions or pneumothoraces. IMPRESSION: No evidence of acute intrathoracic process. Discharge Labs: [**2137-11-9**] 07:30AM BLOOD WBC-7.8 RBC-5.28 Hgb-15.6 Hct-44.9 MCV-85 MCH-29.6 MCHC-34.9 RDW-13.2 Plt Ct-223 [**2137-11-9**] 07:30AM BLOOD Glucose-114* UreaN-26* Creat-1.5* Na-139 K-4.2 Cl-100 HCO3-28 AnGap-15 [**2137-11-9**] 07:30AM BLOOD Calcium-9.7 Phos-3.7 Mg-2.4 [**2137-11-7**] 04:59AM BLOOD %HbA1c-5.6 eAG-114 Brief Hospital Course: # CAD s/p STEMI: Patient was revascularized with a stent placed to the proximal LAD which was completely occluded. CK's trended down. He was not on statin before, with borderline lipid profile. Pt states he lost 27 pounds with diet and exercise in last year. ECHO showed hypokinetic anterior septum, anterior free wall, and apex but with preserved EF. He was started on aspirin 325, atorvastatin 80, metoprolol and uptitrated on [**Last Name (un) **]. He was also loaded with plavix and instructed to continue on it for at least 1 year at 75mg dose. He was also given nitro prescription on discharge, and was sent with a plan for follow up with his outpatient PCP and cardiologist. He should have LFTs and fasting lipid panel checked in [**3-5**] weeks and his statin dose may be decreased as needed based on those results. . # Acute Kidney Injury: Since admision, creatinine trended up from 1 to 1.5, likely secondary to diuresis as well as contrast nephropathy. He was given instructions to follow up with his PCP to check creatinine as an outpatient shortly. . # HTN: Patient was restarted on home dose of HCTZ, losartan was increased to 50mg daily. . # [**Date Range **] - Patient has been complaining of a [**Date Range **] for 2 weeks prior to admission (though much improved since switching to [**Last Name (un) **]). He noted that the [**Last Name (un) **] began when he was started on an ACEI by PCP. [**Name10 (NameIs) **] is likely related to CHF and is expected to resolve with continued diuresis. He was discharged with a plan for PCP follow up if the [**Name10 (NameIs) **] persists. . # GERD - patient has a questionable history of GERD which may have been masking his cardiac symptoms. He started taking maalox the day prior to admission. He was told to start taking an OTC Pepcid as needed and to follow up with his PCP regarding dosage and medication to use. . # Communication: Patient, Wife [**Name (NI) 1494**] [**Name (NI) 479**] Cell ([**Telephone/Fax (1) 19574**], Home [**Telephone/Fax (1) 19575**] . # Transitional Issues: -f/u for Cr check 3 days after discharge -LFTs and lipid panel should be checked 4-6 weeks after discharge -f/u [**Telephone/Fax (1) **] as needed Medications on Admission: FLUTICASONE - 50 mcg Spray HYDROCHLOROTHIAZIDE - 25 mg daily LOSARTAN - 25 mg daily Discharge Medications: 1. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*11* 3. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 4. nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) Tablet, Sublingual Sublingual PRN (as needed) as needed for chest/arm pain. Disp:*25 Tablet, Sublingual(s)* Refills:*2* 5. metoprolol succinate 100 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2* 6. losartan 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 7. fluticasone 50 mcg/Actuation Spray, Suspension Sig: Two (2) Spray Nasal [**Hospital1 **] (2 times a day). 8. Outpatient Lab Work Please draw Chem-7 (including BUN and Cr) on [**2137-11-11**] and fax results to the attention of Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at [**Telephone/Fax (1) 6309**]. Phone number [**Telephone/Fax (1) 250**]. 9. hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home Discharge Diagnosis: ST Elevation Myocardial Infarction Hypertension Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You had a heart attack and there was a chronic blockage that acutely became worse because of a clot. This caused the heart attack and you needed a cardiac catheterization to open the artery and a drug eluting stent was placed to keep the artery open. You will need to take aspirin and plavix every day for at least one year and possibly longer. Do not stop taking Plavix or miss [**First Name (Titles) 691**] [**Last Name (Titles) 4319**] unless Dr. [**Last Name (STitle) 911**] tells you to. You also have nitroglycerin to take at home if your nausea, left arm pain/tingling or chest pain comes back at the same time that you should be calling your cardiologist or primary care doctor. You should sit down, take one tablet under your tongue and wait 5 minutes. You can take up to 2 more tablets under your tongue 5 minutes apart. Please call 911 if you still have any symptoms after 3 nitroglycerin tablets. Your kidney function is mildly impaired. This will need to be rechecked on Monday ([**2137-11-11**]) and followed up by your primary care provider. Medication changes: 1. Start taking Plavix (clopidogrel) and aspirin to keep the stent from clotting off and causing another heart attack. 2. Start taking Atorvastatin (Lipitor) to lower your cholesterol 3. Start using nitroglycerin as directed above to treat chest pain. 4. Increase your Losartan to 50 mg daily 5. Start taking Metoprolol to lower your heart rate and help your heart recover from the heart attack. Followup Instructions: Department: [**Hospital3 249**] When: TUESDAY [**2137-11-12**] at 3:00 PM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 9001**], MD [**Telephone/Fax (1) 250**] Building: [**Hospital6 29**] [**Location (un) 895**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: CARDIAC SERVICES When: WEDNESDAY [**2137-11-27**] at 3:40 PM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2908**], MD [**Telephone/Fax (1) 62**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage

[ "410.11", "530.81", "E944.4", "786.2", "414.01", "584.9", "V85.41", "278.00", "E947.8", "401.9" ]

icd9cm

[ [ [] ] ]

[ "36.07", "00.45", "88.56", "37.22", "00.40", "00.66" ]

icd9pcs

[ [ [] ] ]

9554, 9560

6040, 8065

281, 379

9652, 9652

4118, 4118

11303, 11933

2816, 3005

8371, 9531

9581, 9631

8263, 8348

9803, 10863

5697, 6017

3020, 3876

2651, 2651

3890, 4099

10883, 11280

231, 243

407, 2539

4134, 5681

9667, 9779

2683, 2693

8088, 8237

2583, 2631

2709, 2800

28,119

144,202

1908+55329+55330

Discharge summary

report+addendum+addendum

Admission Date: [**2132-6-6**] Discharge Date: [**2132-6-19**] Date of Birth: [**2079-5-24**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1505**] Chief Complaint: Chest pain Major Surgical or Invasive Procedure: s/p CABGx3(LIMA->LAD, SVG->[**Last Name (LF) **], [**First Name3 (LF) **]) [**2132-6-6**] History of Present Illness: This 53WM had a recent h/o CP and had a +ETT. He underwent cardiac cath on [**2132-5-16**] which revealed: mid LAD [**Last Name (un) 2435**]. with diffuse disease, 80% proximal [**First Name9 (NamePattern2) 8714**] [**Last Name (un) 2435**]., and diffuse disease of the RCA. He was electively admitted for CABG. Past Medical History: hyperlipidemia juvenile onset IDDM narrow angle glaucoma, s/p laser surgery neuropathy depression schizoaffective disorder PVD Social History: Lives with his wife and is a student and part time teaching assistant. Cigs: none ETOH: none Family History: unremarkable Physical Exam: WDWNWM in NAD AVSS HEENT: NC/AT, EOMI, oropharynx benign Neck: supple, FROM, no lymphadenopathy or thyromegaly, carotids 2+= bilat. without bruits. Lungs: Bilat. wheezes CV: RRR without R/G/M Abd: +BS, soft, nontender without masses or hepatosplenomegaly Ext: no C/C/E, pulses: Fem 2+ bilat., DP absent bilat., PT 1+ bilat, and Radial 2+ bilat. Neuro: nonfocal Pertinent Results: [**2132-6-12**] 03:00AM BLOOD WBC-8.6 RBC-3.20* Hgb-9.8* Hct-27.5* MCV-86 MCH-30.6 MCHC-35.5* RDW-14.2 Plt Ct-344 [**2132-6-8**] 12:21AM BLOOD PT-12.7 PTT-27.0 INR(PT)-1.1 [**2132-6-12**] 03:00AM BLOOD Glucose-113* UreaN-31* Creat-1.1 Na-138 K-3.8 Cl-96 HCO3-34* AnGap-12 RADIOLOGY Preliminary Report CTA NECK W&W/OC & RECONS [**2132-6-11**] 1:03 PM CTA NECK W&W/OC & RECONS Reason: evaluate vertebrals that were not able to be visualized on M Contrast: OPTIRAY [**Hospital 93**] MEDICAL CONDITION: 53 year old man with s/p cabg REASON FOR THIS EXAMINATION: evaluate vertebrals that were not able to be visualized on MRI CONTRAINDICATIONS for IV CONTRAST: None. INDICATION: 53-year-old male patient, with sudden onset of visual loss, following CABG, to evaluate the arteries of the head and neck, apparently the vertebral arteries were not completely included on the MR angiogram done on the same day. TECHNIQUE: CT angiogram of the head and neck was performed with IV contrast. Multiplanar reformations were obtained. FINDINGS: The left subclavian, the left common carotid arteries are patent from their origin. The vertebral arteries are patent from their origin, throughout their course and appear to be normal in caliber. No focal flow-limiting stenosis or occlusion is noted. Atherosclerotic calcifications are noted in the cavernous carotid segments on both sides, causing mild-to-moderate stenosis. The remainder of the internal carotid arteries are unremarkable. No large masses are noted in the neck. Moderate bilateral pleural effusions, are noted with atelectasis and increased attenuation in the left lung apex, which is not adequately evaluated on the present study. No focal lytic or sclerotic lesions are noted in the visualized bones. Moderate sinus disease is noted involving the sphenoid, bilateral maxillary, and the ethmoid air cells as well as mild in the mastoid air cells. IMPRESSION: 1. Patent vertebral arteries, from their origins, throughout their course without flow-limiting stenosis or occlusion. 2. Moderate bilateral pleural effusions, with atelectasis and areas of increased attenuation and reticular markings in the left lung apex, which is not adequately evaluated on the present study. Pending review of the VR and the curved multiplanar reformations of the arteries. DR. [**First Name (STitle) 10627**] PERI RADIOLOGY Preliminary Report MR HEAD W & W/O CONTRAST [**2132-6-11**] 1:04 AM MR HEAD W & W/O CONTRAST; MRA BRAIN W/O CONTRAST Reason: new onset blindness Contrast: MAGNEVIST [**Hospital 93**] MEDICAL CONDITION: 53 year old man s/p cabg REASON FOR THIS EXAMINATION: new onset blindness CONTRAINDICATIONS for IV CONTRAST: None. INDICATION: 53-year-old male patient, status post CABG, new onset blindness, to evaluate for intracranial abnormality, and vasculature. COMPARISON: None. TECHNIQUE: Multiplanar T1- and T2-weighted imaging of the brain was performed without and with IV contrast. MR evaluation of the orbits was also performed without and with IV contrast. In addition, MR angiogram of the head and contrast-enhanced MR angiogram of the neck were obtained, with MIP, maximum intensity projection reformations of the carotid and the vertebral arteries. FINDINGS: MRI OF THE BRAIN: There is moderate increased signal intensity in the sphenoid sinus, part of which is increased signal on the T1, representing denser inspissated secretions. There is also increased signal in the mastoid air cells on both sides, representing a small amount of fluid versus mucosal thickening. Small amount of fluid with a small retention cyst is noted in the left maxillary sinus. No focal lesions are noted in the brain parenchyma on the axial FLAIR. On the diffusion-weighted images, there is a small focus of restricted diffusion, in the right posterior parietal lobe, subcortical and involving cortex (series 302, image 23), with subtle focus of FLAIR hyperintensity. This focus, is not definitively identified on the ADC sequence, likely due to its small size. However, this can still represent a tiny acute infarct in this location. Hence, this can represent a tiny acute infarct versus a shine through artifact, however more likely the former. No other focal lesions, to suggest restricted diffusion or infarction are noted. The ventricles and extra-axial CSF spaces are unremarkable. MR OF THE ORBITS: No focal masses, or altered signal intensity in the optic nerves are noted. No abnormal enhancement, is noted in the orbits. A small enhancing focus, noted posterior to the apex of the orbit, on the axial post- contrast fat sat sequences (series 16, image 8) on the right side, represents small amount of enhancing mucosal thickening in the lateral recess of the sphenoid sinus/ anterior clinoid process that is pneumatized and opacified on correlation with the CTA on CTA neck done on the same day (series 2, image 250). MR ANGIOGRAM OF THE HEAD: The distal vertebral, posterior basilar, and the middle posterior cerebral arteries are patent. The intracranial internal carotid, cavernous, and the supraclinoid segments are patent. However, there is tortuosity and contour irregularity of the cavernous segments on both sides. The anterior and the middle cerebral arteries are patent. No focal flow- limiting stenosis, occlusion, or aneurysm more than 3 mm, within the resolution of MR angiogram is noted. There is mild contour irregularity of the distal M1 segment of the right middle cerebral artery, likely related to atherosclerotic disease. MR ANGIOGRAM OF THE NECK: The common carotid arteries, cervical internal carotid arteries are patent without focal flow-limiting stenosis or occlusion. The vertebral arteries, are partially included, in the V2, V3, and V4 segments. The lower V2 and the V1 segments are not included on the present study in the field of view. No focal flow-limiting stenosis, occlusion, or aneurysm more than 3 mm, within the resolution of MR angiogram is noted. The left subclavian artery and the origin of the left common carotid arteries are not included on the present study. IMPRESSION: 1. Tiny focus of increased signal on the diffusion-weighted images, which can represent a tiny acute infarct versus artifact in the right posteroparietal lobe, subcortical/cortical in location. 2. No space-occupying lesion, noted in the orbits. 3. Patent major intracranial arteries of the head and patent common carotid arteries and cervical internal carotid arteries, in the neck without focal flow-limiting stenosis, occlusion or aneurysm more than 3 mm, within the resolution of MR angiogram. The left subclavian artery, the origin of the left common carotid artery, and the origins of the V1, proximal V2 segments of the vertebral arteries were not included in the field of view. The remainder of the arteries are patent. DR. [**First Name (STitle) 10627**] PERI [**Hospital1 18**] ECHOCARDIOGRAPHY REPORT [**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 10628**] (Complete) Done [**2132-6-6**] at 10:35:48 AM FINAL Referring Physician [**Name9 (PRE) **] Information [**Name9 (PRE) **], [**First Name3 (LF) **] R. Division of Cardiothoracic [**Doctor First Name **] [**Hospital Unit Name 4081**] [**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2079-5-24**] Age (years): 53 M Hgt (in): 68 BP (mm Hg): 124/74 Wgt (lb): 185 HR (bpm): 52 BSA (m2): 1.98 m2 Indication: Intra-op TEE for CABG ICD-9 Codes: 745.5, 410.91, 440.0 Test Information Date/Time: [**2132-6-6**] at 10:35 Interpret MD: [**Name6 (MD) 928**] [**Name8 (MD) 929**], MD, MD Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 929**], MD Doppler: Full Doppler and color Doppler Test Location: Anesthesia West OR cardiac Contrast: None Tech Quality: Adequate Tape #: 2008AW03-: Machine: Echocardiographic Measurements Results Measurements Normal Range Left Ventricle - Ejection Fraction: 45% to 50% >= 55% Findings RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal interatrial septum. PFO is present. LEFT VENTRICLE: Normal LV wall thickness and cavity size. Mild regional LV systolic dysfunction. Mildly depressed LVEF. RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Normal aortic diameter at the sinus level. Normal ascending aorta diameter. Normal aortic arch diameter. Normal descending aorta diameter. Simple atheroma in descending aorta. AORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR. MITRAL VALVE: No MS. [**Name13 (STitle) **] MR. TRICUSPID VALVE: Physiologic TR. PULMONIC VALVE/PULMONARY ARTERY: Physiologic (normal) PR. GENERAL COMMENTS: A TEE was performed in the location listed above. I certify I was present in compliance with HCFA regulations. The patient was under general anesthesia throughout the procedure. No TEE related complications. The patient appears to be in sinus rhythm. Results were personally reviewed with the MD caring for the patient. See Conclusions for post-bypass data The post-bypass study was performed while the patient was receiving vasoactive infusions (see Conclusions for listing of medications). Conclusions PRE-BYPASS: 1. A patent foramen ovale is present. 2. Left ventricular wall thicknesses and cavity size are normal. There is mild regional left ventricular systolic dysfunction with apical and apicolateral hypokinesis. Overall left ventricular systolic function is mildly depressed (LVEF= 45-50 %). 3. Right ventricular chamber size and free wall motion are normal. 4. There are simple atheroma in the descending thoracic aorta. 5. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. 6. No mitral regurgitation is seen. Dr. [**Last Name (STitle) **] was notified in person of the results. POST-BYPASS: For the post-bypass study, the patient was receiving vasoactive infusions including phenylephrine and is being A paced. 1. LV function is improved. RV function is unchanged. 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) **] [**2132-6-6**] 13:25 Brief Hospital Course: The patient was admitted on [**6-6**] and underwent CABGx3(LIMA->LAD, SVG->[**Month/Year (2) **]., OM). His cross clamp time was 54 mins, total bypass time was 69 mins. He tolerated the procedure well and was transferred to the CVICU on Neo, Propofol, and Insulin in stable condition. He was very fluid overloaded and hypertensive and remained intubated because he had no cuff leak and was not following commands. His chest tubes were d/c'd on POD#1. He failed CPAP trials and was eventually extubated on the night of POD#3. After he was extubated he conveyed that he could not see. He was seen by Neuro and Opthamology and had MRI, and MRA of head and neck. These studies were negative, but opthamological exam revealed L retinal artery occlusion and R optic ischemia. He was seen by social work and referred to the Commission for the Blind. The pt. was also evaluated by Rheumatology as he had a sed rate of 90. They r/o GCA and temporal arteritis. He continued to progress and was transferred to the floor on POD#6. He continued to progress and was discharged to rehab on POD#8 in stable condition. Medications on Admission: Plavix 75 mg PO daily ASA 325 mg PO daily Lisinopril 20 mg PO daily Fluoxetine 20 mg PO BID Adderall 40 mg PO q AM Lovastatin 20 mg PO daily Zyprexa 5 mg PO daily Humalin 14U SC q AM Lantus 53U SC q PM Lopressor 25 mg PO BID Discharge Medications: 1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for pain. 2. Insulin Glargine 100 unit/mL Solution Sig: Fifty Three (53) Subcutaneous at bedtime. 3. Insulin Regular Human 100 unit/mL Solution Sig: Fourteen (14) Injection once a day. 4. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day). 5. Olanzapine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Fluoxetine 20 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 7. Lovastatin 20 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. 8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 9. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 10. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 11. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 12. Olanzapine 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed. 13. Senna 8.6 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 14. Lovastatin 20 mg Tablet Sig: One (1) Tablet PO at bedtime. 15. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000) Units Injection TID (3 times a day). 16. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO HS (at bedtime). 17. Furosemide 80 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): HOLD for SBP<100. Tablet(s) Discharge Disposition: Extended Care Facility: [**First Name4 (NamePattern1) 533**] [**Last Name (NamePattern1) **] for Extended Care - [**Location 1268**] Discharge Diagnosis: hyperlipidemia IDDM, type 1 narrow angle glaucoma neuropathy depression schizoaffective disorder PVD CAD L retinal artery occlusion blindness Discharge Condition: Good. Discharge Instructions: Take medications as directed on discharge instructions. Do not lift more than 10 lbs for 3 months. Shower daily, let water flow over wounds, pat dry with a towel. Do not use lotions, creams, or powders on wounds. Call our office with temp.>101.5, sternal drainage. Followup Instructions: Make an appointment with Dr. [**Last Name (STitle) **] for 4 weeks. Make an appointment with Dr. [**Last Name (STitle) **] for 2-3 weeks. Make an appointment with Dr. [**Last Name (STitle) 10629**] for 1-2 weeks. Name: [**Known lastname 1474**],[**Known firstname **] Unit No: [**Numeric Identifier 1475**] Admission Date: [**2132-6-6**] Discharge Date: [**2132-6-19**] Date of Birth: [**2079-5-24**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 741**] Addendum: Mr. [**Known lastname **] was not discharged as planned on [**6-14**] due to lack of a rehab bed. His left pleural effusion became significant and he underwent left thoracentesis for 800 cc on [**6-16**]. Cleared for discharge to rehab on POD #11, but awaited bed availability. He was ready for discharge on POD 13. Major Surgical or Invasive Procedure: s/p CABGx3(LIMA->LAD, SVG->[**Last Name (LF) 1476**], [**First Name3 (LF) **]) [**2132-6-6**] Pertinent Results: [**2132-6-16**] 09:20AM BLOOD WBC-9.6 RBC-3.13* Hgb-9.6* Hct-27.4* MCV-88 MCH-30.6 MCHC-34.9 RDW-14.1 Plt Ct-561* [**2132-6-16**] 09:20AM BLOOD Plt Ct-561* [**2132-6-16**] 09:20AM BLOOD Glucose-105 UreaN-33* Creat-1.4* Na-131* K-5.0 Cl-94* HCO3-29 AnGap-13 [**2132-6-16**] 09:20AM BLOOD Calcium-8.8 Phos-4.2 Mg-2.4 Discharge Medications: 1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for pain. 2. Insulin Glargine 100 unit/mL Solution Sig: Forty Six (46) units Subcutaneous at bedtime. 3. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day). 4. Olanzapine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Fluoxetine 20 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 7. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 9. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 10. Senna 8.6 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 11. Lovastatin 20 mg Tablet Sig: One (1) Tablet PO at bedtime. 12. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000) Units Injection TID (3 times a day). 13. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO HS (at bedtime). 14. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): hold for SBP <100. 15. humalog insulin -sliding scale QID- SEE ATTACHED Discharge Disposition: Extended Care Facility: [**First Name4 (NamePattern1) 204**] [**Last Name (NamePattern1) **] for Extended Care - [**Location 205**] Discharge Diagnosis: hyperlipidemia IDDM, type 1 narrow angle glaucoma neuropathy depression schizoaffective disorder PVD CAD L retinal artery occlusion blindness Discharge Instructions: Take medications as directed on discharge instructions. Do not lift more than 10 lbs for 10 weeks. Shower daily, let water flow over wounds, pat dry with a towel. Do not use lotions, creams, or powders on wounds. Call our office with temp.>101.5, sternal drainage. Followup Instructions: Make an appointment with Dr. [**Last Name (STitle) **] for 4 weeks.[**Telephone/Fax (1) 1477**] Make an appointment with Dr. [**Last Name (STitle) 1478**] for 2-3 weeks. Make an appointment with Dr. [**Last Name (STitle) 1479**] for 1-2 weeks. Dr [**First Name8 (NamePattern2) 1480**] [**Name (STitle) 1481**] [**Telephone/Fax (1) 1482**] neuro Dr [**Last Name (STitle) 1483**] [**Telephone/Fax (1) 944**] opth Commission for blind paperwork filed by opthamology will follow up with you at home [**Name6 (MD) **] [**Name8 (MD) 747**] MD [**MD Number(2) 748**] Completed by:[**2132-6-19**] Name: [**Known lastname 1474**],[**Known firstname **] Unit No: [**Numeric Identifier 1475**] Admission Date: [**2132-6-6**] Discharge Date: [**2132-6-19**] Date of Birth: [**2079-5-24**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 741**] Addendum: Please note added medication from home regimen: Adderall 40mg daily. Major Surgical or Invasive Procedure: s/p CABGx3(LIMA->LAD, SVG->[**Last Name (LF) 1476**], [**First Name3 (LF) **]) [**2132-6-6**] Discharge Medications: 1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for pain. 2. Olanzapine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Fluoxetine 20 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 5. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 7. Senna 8.6 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 8. Lovastatin 20 mg Tablet Sig: One (1) Tablet PO at bedtime. 9. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000) Units Injection TID (3 times a day). 10. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO HS (at bedtime). 11. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): hold for SBP <100. 12. Insulin Glargine 100 unit/mL Solution Sig: Forty Six (46) units Subcutaneous at bedtime. 13. Insulin Lispro 100 unit/mL Solution Sig: sliding scale Subcutaneous four times a day. 14. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 15. Lopressor 50 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:*60 Tablet(s)* Refills:*0* 16. Adderall 20 mg Tablet Sig: Two (2) Tablet PO once a day. Disp:*60 Tablet(s)* Refills:*0* Discharge Disposition: Extended Care Facility: [**First Name4 (NamePattern1) 204**] [**Last Name (NamePattern1) **] for Extended Care - [**Location 205**] Discharge Diagnosis: hyperlipidemia IDDM, type 1 narrow angle glaucoma neuropathy depression schizoaffective disorder PVD CAD L retinal artery occlusion blindness Discharge Condition: Good. Discharge Instructions: Take medications as directed on discharge instructions. Do not lift more than 10 lbs for 10 weeks. Shower daily, let water flow over wounds, pat dry with a towel. Do not use lotions, creams, or powders on wounds. Call our office with temp.>101.5, sternal drainage. Followup Instructions: Make an appointment with Dr. [**Last Name (STitle) **] for 4 weeks.[**Telephone/Fax (1) 1477**] Make an appointment with Dr. [**Last Name (STitle) 1478**] for 2-3 weeks. Make an appointment with Dr. [**Last Name (STitle) 1479**] for 1-2 weeks. Dr [**First Name8 (NamePattern2) 1480**] [**Name (STitle) 1481**] [**Telephone/Fax (1) 1482**] neuro Dr [**Last Name (STitle) 1483**] [**Telephone/Fax (1) 944**] opth Commission for blind paperwork filed by opthamology will follow up with you at home Sternal staples can be removed three weeks after the surgery [**Name6 (MD) **] [**Name8 (MD) 747**] MD [**MD Number(2) 748**] Completed by:[**2132-6-19**]

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Discharge summary

report

Admission Date: [**2146-4-1**] Discharge Date: [**2146-5-11**] Date of Birth: [**2115-12-27**] Sex: F Service: MEDICINE Allergies: Haldol Attending:[**First Name3 (LF) 7591**] Chief Complaint: Headache, fevers Major Surgical or Invasive Procedure: Intubation with endotracheal tube Central line placement History of Present Illness: Ms. [**Known lastname **] is a 30 yo female who presented to [**Hospital3 19345**] on the day of admission for evaluation of headache, subjective fevers. Per the original admission note, the headache and fever had been occurring for 6 days. She also had photophobia and intermittent nausea associated with the HAs. Over the past 2-3 days, she had noted increasing fatigue/malaise. At [**Hospital3 **], she had a temp of 100.9 and a WBC was 322,000. A head CT was performed which was reportedly negative for acute bleed/mass. A CXR showed infiltrates throughout the lung. She was transferred to [**Hospital1 18**] for further care. On arrival to [**Hospital1 18**], she was given a dose of allopurinol and started on D5W w/ 3amps bicarb. A bm bx was done. Her peripheral smear was reviewed and felt to be c/w blast crisis. Surgery was called for placement of a pheresis catheter. She was given 3 gms hydrea. Her BPs remained 80s-90s/50s-60s. As the surgeon attempted to place the line, the patient desatted to 80% RA. Anesthesia was paged for a stat intubation. Intubation occurred without complication and the pt was transferred to the [**Hospital Unit Name 153**]. MICU course: [**4-2**] Pt was pheresed overnight, and WBC was reduced to approx 100/microL. Hydroxyurea was given [**Hospital1 **]. Once flowcytometry identified [**Name (NI) 72473**], pt was started L-Asp, Cytoxan, Danarubicin, Vincristin. PT was frequently monitored for tumor lysis syndrome. Family was informed about poor prognosis. [**4-3**] In the morning changed to PS 5/5, excellent RSBI. No significant tumor lysis overnight. Clincially stable. did not extubate as Pt. failed PS trial (ABG 7.28/51/63). Chemo day 2. Past Medical History: Craniotomy [**2132**] for brain tumor no chemotherapy or radiation Social History: She denies h/o alcohol/tobacco/IVDU. She lives with her brother and mother. She works in a restaurant. Family History: No family history of blood disorder or cancer. Physical Exam: Upon transfer out of the intensive care unit: Gen: Sleeping. Arousable, but clearly fatigued. Responds appropriately to voice commands to open her eyes, open her mouth, etc. HEENT: MMM w/small thrush CV: Nl S1/S2; tachy Pulm: Suble diffuse ronchi; [**Last Name (un) 72474**] LLL Abd: Soft, nt, nd, +BS although exam limitted by position Ext: WWP X 4 w/bil edema Neuro: Responds to voice commands. Moves all four extremities to command, but not sufficiently responsive to allow testing of strength or sensation. Physical exam VS: Temp 98.4, Pulse 60-80, BP 80-100/57-62, RR 20, O2 Sat - 100% - AC FIO2 100% 14 TV 450 5/0 Gen: intubated, sedated HEENT:PERRL, sclera anicteric Chest: decreased BS throughout, rhonchi throughout CV: RRR, nl S1S2 no murmers Abd: soft, non-tender, positive BS, spleen palpated at 4cm below costal margin Groin: left inguinal lymphadenopathy Ext: no edema, wwp Skin: no rashes, no petechiae Neuro: toes downgoing 2+ reflexes throughout Pertinent Results: Laboratory results: Labs at OSH: WBC 322.9, HCT 31.4, HGB 10.1, Plt 47 (diff 1N, 29L, 1B, 69blasts) Smear - showed numerous blasts associated with some metamyelocytes, myelocytes, and bands. No schistocytes, some teardrop cells. No platelets visualized. [**2146-4-1**] 09:10PM GLUCOSE-78 UREA N-8 CREAT-0.9 SODIUM-133 POTASSIUM-3.4 CHLORIDE-103 TOTAL CO2-24 ANION GAP-9 [**2146-4-1**] 09:10PM ALT(SGPT)-65* AST(SGOT)-124* LD(LDH)-1248* ALK PHOS-485* AMYLASE-44 TOT BILI-1.1 [**2146-4-1**] 09:10PM LIPASE-22 [**2146-4-1**] 09:10PM ALBUMIN-3.1* CALCIUM-7.3* PHOSPHATE-1.1* MAGNESIUM-1.6 URIC ACID-3.5 [**2146-4-1**] 09:10PM HAPTOGLOB-<20* [**2146-4-1**] 09:10PM WBC-229* RBC-2.76* HGB-7.9* HCT-23.5* MCV-85 MCH-28.6 MCHC-33.6 RDW-16.8* [**2146-4-1**] 09:10PM NEUTS-3* BANDS-0 LYMPHS-13* MONOS-2 EOS-0 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 OTHER-82* [**2146-5-11**] 12:00AM BLOOD WBC-8.4 RBC-2.93* Hgb-8.7* Hct-25.6* MCV-88 MCH-29.8 MCHC-34.0 RDW-15.2 Plt Ct-238 [**2146-5-10**] 12:00AM BLOOD PT-14.4* PTT-37.3* INR(PT)-1.3* [**2146-5-10**] 12:00AM BLOOD Gran Ct-6700 [**2146-5-11**] 12:00AM BLOOD Glucose-88 UreaN-21* Creat-1.6* Na-135 K-4.2 Cl-101 HCO3-25 AnGap-13 [**2146-5-11**] 12:00AM BLOOD ALT-101* AST-78* LD(LDH)-565* AlkPhos-170* TotBili-0.8 [**2146-5-11**] 12:00AM BLOOD Calcium-8.5 Phos-4.2 Mg-2.0 UricAcd-2.8 Brief Hospital Course: Ms. [**Name14 (STitle) 72475**] is a 30 yo female with history of prior pituitary mass s/p transphenoidal resection presenting with ALL. Per report: Acute lymphoblastic Leukemia CD 10+, CD 19+, CD 20+ with some aberrant monocytic markers but not a bilineage leukemia. She has had vision problems and per Dr. [**First Name (STitle) **], worrisome for CNS involvement. 1)B-ALL with Blast crisis. The smear on presentation showed numerous blasts associated with some metamyelocytes, myelocytes, and bands. She also has diffuse pulmonary infiltrates and hypoxia likely due to white thrombi. The patient was emergently intubated, underwent plasmapheresis and started on Cytoxan, Danarubicin, Vincristin, L-Asp on [**4-2**]. She had a marked response, developing neutropenia. Tumor lysis labs were monitored without significant findings. Around day +21, the patient developed a transaminitis. Vincristine therapy was held at this time but then completed few days prior to discharge. 2)Respiratory failure. Likely due to tumor infiltration, white thrombi +/- HSV pneumonia vs. pneumonitis (see below). The patient was succesfully extubated but then required re-intubation for airway protection in the setting of declining mental status. The patient was again succesfully extubated but was found on ABG to be hypercarbic and acidotic. She required intubation and was successfully extubated one day later. Chest x-ray after extubation suggests aspiration pneumonia. Her respiratory status remained tenuous for most of her hospital stay likely in the setting of CHF. She was diruesed agressively and her breathing improved significantly. 3)Febrile neutropenia. Etiology not entirely clear. The patient had blood, urine, CSF cultures without growth to date. HSV pneumonia (as below) was confirmed on BAL. Beta-glucan and galactomannan were negative. The patient was initiated on broad antibiotics, including Caspofungin, Vancomycin, Meropenem and Acyclovir. Upon transfer out of the ICU, the patient was no longer neutropenic and no longer febrile. She completed a 10 day course of treatment dose (10mg/kg) IV acyclovir. She also completed course of Vanc/Meropenem by time of discharge. Culture data remained negative. 4)Decreased mental status. The patient developed declining mental status in the early days of [**Month (only) 958**]. The patient had multiple CT scans and MRI's without signs of pathology. Specifically, the patient had no signs of intracranial bleeding or temporal hemorrhage or enhancement (out of concern for HSV encephalitis). The patient underwent LP with 1 WBC, 1RBC and negative HSV PCR. Of note she underwent intrathecal methotrexate therapy. The patient was keppra loaded out of concern for seizure activity though quickly discontinued as EEG x2 revealed no evidence of seizure activity, instead suggesting non-specific encephalopathy. Given her diffusely altered mental status without focal neurologic deficits, it was felt (in consultation with neuro-oncology) that the patient likely had a toxic-metabolic explanation for her symptoms. Specifically, the patient was markedly hypophosphatemic at the time. In addition, L-asp could have contributed. The patient's mental status continued to wax and wane though she became more interactive. On [**2146-4-22**] the patient underwent repeat LP. This tap was traumatic and did not clearly show infection. HSV, HHV-6, EBV, [**Male First Name (un) 2326**] and BK virus PCR's were sent. The fluid was also sent for regular culture, cytometry and cytology, all of which was unrevealing. On [**2146-4-27**] after an apparent grand mal seizure, the patient underwent another LP revealing RBC's in tube 4 on a non-traumatic tap. CT head revealed an occipital hypodensity. MR brain suggested diffuse bilateral occipital lobe haziness of unclear significance. Her mental status improved significantly and she was at baseline at time of discharge. 5)Renal Failure. FENA of .4% c/w pre-renal etiology in the setting of new-onset CHF. Urine eos negative. Prior sediment in the ICU with hyaline and granular casts. The patient had a renal ultrasound in early [**Month (only) 958**] revealing no hydronephrosis. Caspo considered as contributing factor, though ID recommended continuing. The patient was diuresed for volume overload. The renal team was consulted and this was felt to be consistent with volume overload and likely secondary to relative hypotension. The patient continued to receive diuresis. Her Cr trended downwards and was 1.6 at time of discharge. 6)CHF. EF 30% on echo [**2146-4-13**], new onset. Likely secondary to Anthracycline toxicity. The patient was started on Metoprolol and Furosemide. She was monitored closely with daily weights and strict I/O's. Repeat echo on [**2146-4-21**] revealed a normalized EF and beta blocker was discontinued. During the remainder of her stay on the BMT floor her respiratory status worsened. Cxrays suggested bilateral pulmonary infiltrates. She was started on heart failure regimen including Metoprolol, Lisinopril, and aggressively diuresed with Lasix. She responded appropriately and her respiratory status improved. Repeat ECHO was consistent with depressed EF. 7)HSV pneumonia. Confirmed on BAL growth. Likely contributing factor to respiratory failure (in addition to leukostasis/leukothrombosis of pulmonary vessels). The patient received treatment dose acyclovir (10mg/kg) for 10 days with improvement in respiratory status. 8)Transaminitis. The patient developed a marked transaminitis at the time of transfer out of the intensive care unit with AST and ALT to >200. The etiology was felt most likely a drug effect, including a possible delayed chemotherapy effect. Much less likely is a meropenem effect. Further Vincristine therapy was held. The patient's meropenem was discontinued. Discontinuation of the acyclovir was considered, but, this medication was continued as it very rarely causes liver toxicity and its clinical benefit in the setting of a likely HSV pneumonia confirmed by BAL was clear (and indeed the patient was improving). At the time of onset, the patient was off of caspofungin. Fungal infection of the hepatobiliary system was entertained as a diagnosis. The patient had a right upper quadrant ultrasound revealing no disease. She underwent an MRI of the liver revealing no signs of hepatosplenic candidiasis or other pathology. On further history taking, the patient's family described multiple episodes of jaundice in the past. The patient's hepatitis serologies revealed prior Hep A infection, negative Hep C and past immunization for Hep B. HIV serology was negative. The patient's LFT's trended downward without intervention. Vincristine was held in the setting of a transaminitis. 9)Pancreatitis. Likely medication related, secondary to L-asparaginase. This chemotherapy [**Doctor Last Name 360**] was held. The patient's amylase/lipase were trended and normalized by time of discharge. 10)Hypopituitarism. The patient has a history of transphenoidal resection of an intracranial mass. She presented with hypotension. Her low bp was felt possibly secondary to early sepsis, however cortisol testing revealed very low cortisol levels (0.8). The patient also failed her cortisol stim test. She was noted to have normal TSH, though low T4 consistent with central deficit. The patient's prolactin was mildly decreased below normal. FSH and LH were normal. Endocrine was consulted. The patient was maintained on hydrocortisone and levothyroxine replacement therapy. 11)Mucositis with oral lesions. The patient had HSV swabs sent and were positive for the virus. She continued on antifungals for possible thrush. 12)Hyperglycemia. On TPN and steroids. The patient was placed on an insulin sliding scale. Blood sugars normalized after she came off TPN and was able to take in sufficient PO. 13)Movement disorder. The patient developed extrapyramidal signs with rigidity, cogwheeling and masked facies. The patient was seen by movement disorder service and this was felt consistent with Haldol-induced parkinsonism exacerbated by liver dysfunction. All antidopaminergic agents, including haldol and zyprexa were held. The patient's parkinsonian symptoms resolved. 14)Seizure. The patient had a likely grand mal seizure witnessed by nursing staff on [**2146-4-27**]. This occurred despite 2 prior negative EEG's. The patient was Keppra loaded and started on a standing dose. She was placed on continuous EEG though failed to tolerate the test due to agitation. Review of the limited EEG obtained revealed encephalitis pattern without apparent seizure activity. EEG monitoring closer to discharge was unchanged. She was weaned off Keppra prior to discharge. Medications on Admission: Medications at home: None Medications on transfer: Cefepime 2gm IV q8h Allopurinol 300 mg daily s/p 3gms hydrea Discharge Medications: 1. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1) Tablet PO 3X/WEEK (MO,WE,FR). Disp:*90 Tablet(s)* Refills:*1* 2. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* 3. Acyclovir 200 mg Capsule Sig: Two (2) Capsule PO Q12H (every 12 hours). Disp:*120 Capsule(s)* Refills:*1* 4. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*120 Tablet(s)* Refills:*2* 5. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*1* 6. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* 7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Last Name (LF) 486**], [**First Name3 (LF) 487**] Discharge Diagnosis: Acute lymphocytic leukemia Congestive heart failure Pneumonia Pancreatitis Acute renal failure Discharge Condition: Stable Discharge Instructions: 1)Please take all medications as listed in the discharge medications. Many of these medications are new. 2)You will be admitted for chemotherapy on Tuesday, [**5-17**]. Please come to the hospital at 9am to be admitted. 3)If you experience any fevers, chills, chest pain, SOB, abdominal pain, dizziness, or any other concerning symptoms please return to the emergency department. Followup Instructions: Please come to the [**Location (un) 436**] of the [**Hospital Ward Name 1826**] Building on Tuesday, [**5-17**] at 9am.

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icd9cm

[ [ [] ] ]

[ "96.6", "00.17", "99.15", "96.71", "03.31", "38.91", "41.31", "96.72", "33.24", "99.72", "99.07", "38.93", "03.92", "96.04", "99.05", "99.28", "99.25", "99.04" ]

icd9pcs

[ [ [] ] ]

14419, 14502

4698, 13409

285, 344

14641, 14650

3344, 4675

15080, 15203

2293, 2341

13573, 14396

14523, 14620

13435, 13435

14674, 15057

13456, 13462

2356, 3325

228, 247

372, 2067

13487, 13550

2089, 2157

2173, 2277

5,643

136,720

5048

Discharge summary

report

Admission Date: [**2191-10-21**] Discharge Date: [**2191-10-29**] Date of Birth: [**2122-1-2**] Sex: M Service: NEUROLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 6075**] Chief Complaint: aphasia, R sided weakness Major Surgical or Invasive Procedure: tPA administration History of Present Illness: 69 yo male w/ PMHx sig for breast ca s/p mastectomy, hepatocellular ca s/p hepatic lobectomy, renal cell ca s/p right nephrectomy and past TIA who p/w acute onset speech difficulties. History was obtained from his wife and limited amount from patient due to speech problems. [**Name (NI) **] was in his USOH the evening prior to admission. The morning of admission he woke up and was watching TV when wife saw patient appearing normal at ~ 9:45am. She said "good morning" and he replied "good morning" back. His wife then entered the kitchen and came back out to ask the patient a question but he could no longer answer her. She also noted that patient's right side was weak. She called her daughter and they brought the patient to [**Hospital1 18**] for further evaluation. Code stroke was called at 11:30a. Past Medical History: grade III infiltrating ductal carcinoma s/p mastectomy hepatocellular carcinoma s/p right hepatic lobectomy renal cell ca s/p radical right nephrectomy hemachromatosis, intermittently has phlebotomy type 2 diabetes diagnosed in [**2181**] history of TIA in [**2179**] and takes aspirin daily, apparently has been on coumadin in the past. history of a ruptured diverticular disease history of mild COPD hypertension status post motor vehicle accident in [**2144**]. Social History: The patient is married and lives with wife. [**Name (NI) **] has three adult children. He is a retired auto mechanic. He is on a diabetic diet. Occasional alcohol. History of tobacco; he smoked 2 packs per day for 50 years but quit in [**2180**]. Occasional cigar. No history of IV drug use, tattoos or piercing. The patient did have a blood transfusion 40 years ago. Family History: Significant for a sister with hemachromatosis. His mother died of neck cancer. Father died of lung cancer. His brother had a stroke. Physical Exam: On admission: Vitals: T 97.9; BP 152/72; P 78; RR 16; 97% RA General: lying in bed NAD HEENT: NCAT, moist mucous membranes Neck: supple, no carotid bruit Pulmonary: CTA b/l Cardiac: regular rate and rhythm, with no m/r/g Carotids: no blood flow murmur Abdomen: soft, nontender, non distended, normal bowel sounds Extremities: no c/c/e. LOC - 0 LOC ?'s - 1 LOC Commands - 2 Best gaze - 0 Visual Fields - 0 Facial paresis - 2 Right arm - 2 Left arm - 0 Right leg - 0 Left leg - 0 Sensory - 0 Language - 1 Dysarthria - 0 Neglect - 1 Total 9 General: lying in bed NAD HEENT: NCAT, moist mucous membranes Neck: supple, no carotid bruit Pulmonary: CTA b/l Cardiac: regular rate and rhythm, with no m/r/g Carotids: no blood flow murmur Abdomen: soft, nontender, non distended, normal bowel sounds Extremities: no c/c/e. Neurological Exam: Mental status: alert, oriented to name, able to pick hospital, [**2190**], not month from list. Speech halting with expressive aphasia, maximum number of words per sentence 5. Adequate comprehension. Follows simple and multi-step commands. Repetition intact (no ifs, ands or buts). Able to name "key" and "cactus" from stroke pictures, no others. No left/right mismatch. Mild right sided neglect. [**Location (un) **] intact. Cranial Nerves: I: Not tested II: PERRL, 4-->2mm with light. VFF. III, IV, VI: EOMI. no nystagmus. V, VII: facial sensation intact, R facial droop, full strength bilateral eye closing, but at rest does not close L eye fully. VIII: hearing intact b/l to finger rubbing. IX, X: Palatal elevation symmetrical. [**Doctor First Name 81**]: SCM [**4-22**] bilaterally, trapezius [**4-22**] on L, [**12-23**] on R XII: Tongue midline without fasciculations. Motor: Normal bulk. Normal tone. Delt Tri [**Hospital1 **] WE FE FF IP QD Ham DF PF [**Last Name (un) 938**] EDB RT: 4 5 5 3 1 1 5 5 5- 5 5 5 5 LEFT: 5 5 5 5 5 5 5 5 5 5 5 5 5 Sensation: intact to light touch. Extinction to double simultaneous stimulation on right, even when touching right face and left leg. Reflexes: Bic T Br Pa Ac Right 2 2 2 2 1 Left 2+ 2 2+ 2+ 1 Toes upgoing bilaterally. Coordination: [**Doctor First Name **] slightly dysmetric on L, not tested on R. Gait: deferred. Pertinent Results: Admission labs: 137 113 34 164 - - - - - - gluc 164 5.1 15 1.9 Ca: 8.9 Mg: 2.2 P: 3.6 WBC 12.4 HCT 43.8 PLT 291 N:73.0 L:17.1 M:3.4 E:6.1 Bas:0.4 PT: 14.2 PTT: 28.6 INR: 1.3 Radiology: CT head - There is some motion artifact on the examination. There is no acute intracranial hemorrhage or shift of midline structures. There is no hydrocephalus. Hypodensities in the subcortical white matter as described on the earlier studies are unchanged as are hypodensities in the basal ganglia. The posterior fossa and midbrain are not well evaluated due to motion artifact. [**Doctor Last Name **]-white matter differentiation appears to still be preserved with no new clear area of acute infarction. IMPRESSION: No acute intracranial hemorrhage. Questionable loss of [**Doctor Last Name 352**] white matter differentiation in the left frontal lobe (on image 22), may present an evolving infarct. MRI OF THE BRAIN: The study is markedly degraded due to patient motion artifact. There is an acute infarction in the left middle cerebral artery territory with focal areas of restricted diffusion seen peripherally in the left MCA distribution near the cranial vertex. Additionally, there is a more wedge-shaped area of restricted diffusion in the far posterior left parietal lobe. The areas of restricted diffusion are not confluent in nature. There is some increased FLAIR signal intensity corresponding to areas of restricted diffusion. No obvious susceptibility artifacts are identified to suggest hemorrhagic transformation. T2-weighted images are markedly degraded due to motion artifact. However, there is circumferential mucosal thickening, mild in the right and moderate in the left maxillary sinuses. There is also a small amount of fluid seen in the sphenoid sinus. Perfusion series images were acquired and are to be processed separately, by the Neurology service. MR ANGIOGRAM: There is irregularity and thickening seen of the extracranial left internal carotid artery at the skull base with narrowing of signal intensity in the center of the artery. This continues to involve the pre- petrous portion. The petrous left internal carotid artery is normal in appearance. The M1 segments of the middle cerebral arteries bilaterally appears somewhat irregular to their bifurcations, but there is symmetric signal intensity. Normal signal intensity is seen in the right internal carotid artery, both vertebral, and the basilar arteries, anterior cerebral, and posterior cerebral arteries. Evaluation for aneurysm is not possible due to the motion artifact. IMPRESSION: Limited examination due to patient motion artifact. 1. Acute infarction of left middle cerebral artery territory as described above. Given the multifocal, non-confluent areas of restricted diffusion, this suggests an embolic event. 2. No evidence of hemorrhagic transformation. 3. MR [**First Name (Titles) 20827**] [**Last Name (Titles) 4059**] irregularity and thickening of the extracranial left internal carotid artery at the skull base. There is signal intensity seen throughout the intracranial arterial circulation suggesting no significant stenosis. Carotid u/s: No evidence of carotid stenosis bilaterally. Repeat HCT [**10-21**]: No acute intracranial hemorrhage. Unchanged appearance of probable old infarcts in the frontal lobes, basal ganglia, and pons as described. HCT [**10-22**]: Increased hypodensity along the left frontal and parietal regions, consistent with the evolving left MCA stroke. New approximately 1.6 x 0.9 cm hyperdensity is seen within the subcortical region of the left parietal lobe, consistent with blood. This could represent petechial hemorrhage, although developing hematoma cannot be excluded. These findings were discussed with Dr. [**First Name (STitle) 20828**] [**Name (STitle) 20829**] immediately following completion of the study. HCT [**10-23**]: Hypodensity involving the [**Doctor Last Name 352**] and white matter in the left frontal and parietal lobes, consistent with infarction is again demonstrated, not significantly changed compared to the previous study. Focal area of hyperdensity in the left superior parietal lobe is also unchanged, consistent with blood products. The ventricles are stable in size. There is no subfalcine herniation, and negigible compression of the left lateral ventricle. Opacification in the frontal sinus, ethmoid sinuses, maxillary sinuses, and sphenoid sinus is again demonstrated, most evident in the left maxillary sinus, with some loss of ethmoid septae- has there been prior sinus surgery? ECHO: No cardiac source of embolism identified. Preserved global biventricular systolic function. Compared with the report of the prior study (images unavailable for review) of [**2190-9-21**], symmetric left ventricular hypertrophy is not suggested on the current study. The pulmonary artery systolic pressure could not be quantified. ?A possible new distal septal wall motion abnormality may be present. MRA: There is an area of suspected high-grade stenosis at the distal left internal carotid artery, as it enters the petrous segment. This is an area known to be susceptible to artifacts. CTA of head: Brief Hospital Course: Impression: 69yo man w/ PMH significant for breast cancer, renal cell ca, and hepatocellular ca who p/w acute onset difficulty speaking and RUE weakness. Neurological exam was significant for expressive aphasia, right face/arm weakness in UMN pattern, and right sided extinction to DSS. The most likely etiology of these symptoms was an embloic stroke in the left superior division MCA territory. On arrival within the 3hr IV tPA window, he had a head CT showing no evidence of hemorrhage. After discussion between the patient and the housestaff, stroke fellow and stroke attending, he was given IV tPA. Within one hour of the tPA he seemed to improve, with better language function (able to string short sentences together, approx 7 words long) and improved right arm strength (could hold the arm off the bed and provide some resistance to testing, with persistent hand and wrist weakness). He went for MRI which showed evidence of a left MCA stroke consistent with embolic etiology. MRA of the brain had a questionable thickening in the left carotid, and this was repeated later in his hospital course. He went immediately to carotid u/s for further evaluation, which showed no stenosis. Upon return from the ultrasound, he had a sudden decline in function; he had asked the tech what the ultrasound results were and then 5 minutes later was unable to say anything. He also had recurrent right hemiparesis, including his right leg, with seeming dense right neglect. A head CT showed no evidence of hemorrhage. He had no hypotension. He was admitted to the ICU for close observation overnight. His repeat head CT the next day showed a small focus of hemorrhage, but he began to improve. The following day a repeat head CT was stable. He continued to improve throughout his hospital [**Last Name (un) 10128**] with more language but persistent right hemiparesis. An ECHO showed no evidence of PFO, ASD, or thrombus, but did demonstrate a new area of hypokinesis. Cardiac enzymes were negative. He was transferred out of the ICU. On the floor, he was maintained on Heparin. A head MRA was obtained, which showed marrowing of the distal left ICA. This was followed up with a CTA, which showed significant ICA stenosis. Vascular surgery was consulted and would like to see him in [**12-20**] weeks as an outpatient. He was started on Coumadin and will need to be maintained on Heparin until his INR is therapeutic. His oncologist, Dr. [**First Name (STitle) **], was contact[**Name (NI) **] and felt that he should be cancer free at this point and not in a hypercoagulable state that could have led to the embolus causing his stroke. Medications on Admission: Arimidex Insulin Lamotil Oxycodone Prozac Discharge Medications: 1. Fluoxetine 20 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 2. Arimidex 1 mg Tablet Sig: One (1) Tablet PO once a day. 3. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) 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. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day) as needed. 6. Warfarin 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): Goal INR 2.0-3.0. 7. Heparin (Porcine) in D5W 100 unit/mL Parenteral Solution Sig: 1100 (1100) units/hour Intravenous ASDIR (AS DIRECTED): Continue heparin gtt with goal PTT 50-70 until therapeutic INR on coumadin. Discharge Disposition: Extended Care Facility: [**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**] Discharge Diagnosis: Stroke Hepatocellular carcinoma s/p hepatic lobectomy, renal cell cancer s/p right nehprectomy, breast cancer s/p mastectomy, s/p colon resection for diverticulosis, TIA Discharge Condition: Improved - has some trouble with comprehension, continues to have word finding difficulties, right arm weakness. Discharge Instructions: Please take all your medications as directed and attend your follow up appointments. Please return to the emergency department for worsening symptoms or new numbness/tingling/weakness. Followup Instructions: 1) Please follow up with Neurology, Dr. [**Last Name (STitle) **]/Dr. [**Last Name (STitle) 1693**], on [**12-27**] at 2:00. Please call [**Telephone/Fax (1) 1694**] prior to appointment to confirm. 2) Please make a follow up appointment with Vascular Surgery, Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], at [**Telephone/Fax (1) **] to see him in 1 to 2 weeks.

[ "434.11", "V10.52", "496", "V10.07", "V10.3", "250.00", "401.9" ]

icd9cm

[ [ [] ] ]

[ "99.10" ]

icd9pcs

[ [ [] ] ]

13198, 13295

9730, 12368

343, 363

13510, 13625

4533, 4533

13859, 14252

2092, 2227

12460, 13175

13316, 13489

12394, 12437

13649, 13836

2242, 2242

3079, 3079

278, 305

391, 1202

3524, 4514

4549, 9707

2257, 3060

3094, 3508

1224, 1690

1706, 2076

565

103,074

45937+45958

Discharge summary

report+report

Admission Date: [**2125-10-10**] Discharge Date: [**2125-10-29**] Date of Birth: [**2072-11-5**] Sex: F Service: [**Hospital1 **] CHIEF COMPLAINT: Mental status change, shortness of breath HISTORY OF PRESENT ILLNESS: The patient is a 53-year-old female with a history of bipolar disorder, diabetes mellitus, who was referred from [**State 350**] Mental Health for accidentally taking two 900 mg tablets of lithium the night before presentation. The patient reported one day history of vomiting and shortness of breath as well as body aches. The patient was unable to give an elaborate history beyond that of her concern that she had had too much lithium. The patient had revealed that she had taken too much lithium in the past, and felt much the same as she did when she presented. The patient had no history of chest pain, fever, cough, but did note shortness of breath especially with climbing stairs. In the Emergency Department, a Foley catheter was placed, drawing 50 cc of urine. An arterial blood gas was performed, revealing a pH of 7.31, with a PCO2 of 60 and a PAO2 of 68. Oxygen saturations were in the mid-80s. Chest x-ray showed bilateral basilar opacities with pulmonary vascular congestion. The Medical Intensive Care Unit was called for assessment for invasive monitoring of the patient and to monitor waxing and [**Doctor Last Name 688**] mental status in the setting of elevated lithium level. PAST MEDICAL HISTORY: 1. Bipolar disorder 2. Morbid obesity 3. Hypothyroidism 4. Sleep apnea 5. Diabetes mellitus MEDICATIONS: Lithium 600 mg every morning and 900 mg every evening, Trazodone 100 mg by mouth daily at bedtime, Synthroid, Glucophage, Glucotrol, lasix, Accupril and hydrochlorothiazide. ALLERGIES: Stelazine, Norpramin SOCIAL HISTORY: The patient is divorced, lives with her fiance. The patient admits to a brief smoking history as a teenager. PHYSICAL EXAMINATION: Temperature 99, heart rate 70s to 80s, blood pressure 134/86, oxygen saturation 80% supine and 92% sitting up. On general examination, the patient was an alert, obese female, in mild distress. The patient was oriented to place, date and situation. Head, eyes, ears, nose and throat examination revealed pupils equal, round and reactive to light, extraocular movements intact. Thorax revealed bibasilar rales to the mid-lung fields. Cardiac examination revealed regular rate and rhythm, normal S1, S2, and a II/VI systolic murmur. Abdominal examination revealed an abdomen that was soft, obese, nontender, nondistended, with normal bowel sounds. Extremity examination revealed 1+ peripheral edema. Neurological examination revealed a patient that was alert, somewhat inattentive. The patient was tremulous. There were scattered myoclonic jerks. The patient had 3+ reflexes throughout, with one to two beats of clonus at the ankles. LABORATORY DATA: The patient had a sodium of 134, potassium 4.5, chloride 99, bicarbonate 30, BUN 52, creatinine 3.4 with a baseline of 0.9, and glucose of 77. The patient had a lithium level of 2.6. The patient had a white blood cell count of 14.9 with a hematocrit of 34.7 and platelets of 268. Serum toxicology screen was negative for aspirin, ETOH, acetaminophen, benzodiazepines, barbiturates, and tricyclic antidepressants. Urinalysis revealed positive nitrites, 3+ protein, moderate blood, [**5-13**] red blood cells, and [**10-23**] white blood cells. An initial CK was 20. Chest x-ray: Cardiomegaly with congestive heart failure. Electrocardiogram: Normal sinus rhythm, normal axis, nonspecific ST/T wave changes in V1 and AVF. HOSPITAL COURSE: The patient is a 53-year-old female with a history of bipolar disorder, diabetes mellitus, who presented with a one day history of vomiting and shortness of breath as well as a history of ingestion of 1800 mg of lithium the evening before presentation. The patient was admitted to the Medical Intensive Care Unit to monitor her waxing and [**Doctor Last Name 688**] mental status as well as her ability to maintain her airway. 1. Pulmonary: The patient presented with acute on chronic respiratory acidosis. It was suspected that the acute component was likely related to CNS depression with lithium overdose. The chronic component appeared to be secondary to her obesity and obstructive sleep apnea. The patient was admitted to the Medical Intensive Care Unit for supplemental oxygen, monitoring of her respiratory status, and possible need for intubation. The patient was also suspected to be in congestive heart failure, and was diuresed as well. The patient did require a brief intubation secondary to a neck hematoma that developed after central line attempt. This was done prophylactically for airway protection. The patient was quickly extubated as the hematoma resolved. The patient was also subsequently found to have a pneumonia and was successfully treated with a ten day course of levofloxacin and vancomycin. The patient showed improvement in her oxygen saturation over the course of the admission, and was transferred from the Intensive Care Unit to the regular Medicine floor on [**2125-10-24**]. She routinely had an oxygen saturation of 93 to 95% on room air. 2. Cardiovascular: The patient was ruled out for myocardial infarction by serial CKs. 3. Neurologic: Patient with changes in mental status, likely secondary to lithium overdose. Her lithium level was elevated to 2.6. She was obtunded, tremulous, with mild ataxia. She had barbiturates present in her urine. Toxicology was consulted and recommended holding all of the patient's psychotropic medications as well as recommending dialysis for removal of lithium. The patient was started on hemodialysis secondary to increased lethargy, worsening acid/base status, and the presence of toxic levels of lithium. She tolerated this well. The patient's lithium level steadily trended downwards to the point of being undetectable. The patient's mental status gradually returned to her baseline. Psychiatry had been consulted and recommended that there was no acute indication for pharmacotherapy of her bipolar disorder. They recommended Haldol and Ativan for agitation. The patient had infrequent episodes of agitation in the evening, requiring Haldol. 4. Renal: The patient presented with oliguric acute renal failure after lithium overdose. This was thought to be secondary to acute tubular necrosis related to hypovolemia as well as lithium toxicity. The patient required hemodialysis both to remove toxic levels of lithium as well as for worsening acid/base status. A first attempt at a hemodialysis line placement resulted in a right neck hematoma. A second line placement attempt led to a femoral artery puncture which required Vascular Surgery repair. The patient became hemodynamically unstable, requiring a short interval on pressors secondary to this complication. The patient returned quickly to hemodynamic stability. The patient's creatinine was elevated on presentation and required ongoing hemodialysis. However, the patient gradually showed improvement in her creatinine, which came down to 1.3. The patient also began to have excellent urine output, up to 1500 cc/day. At that point, the Renal service did not feel that the patient needed ongoing hemodialysis, nor was it felt that she needed to continue to receive erythropoietin. 5. Gastrointestinal: The patient had a nasogastric tube placed upon admission to the Medical Intensive Care Unit. She received tube feeds for the initial Intensive Care Unit stay. However, the patient began to have evidence of increasing abdominal tenderness with an elevated lipase, suggesting pancreatitis. The patient had an abdominal CT which was negative for pancreatic pseudocyst or for pancreatic inflammation. However, the patient continued to have an increasing lipase and was therefore placed on bowel rest with nasogastric tube placement. The patient's white blood cell count was likewise elevated. However, the patient's lipase gradually decreased while on bowel rest, as did her white blood cell count. Her abdominal tenderness resolved, and she was gradually started on sips of clear fluids. She tolerated this well. The patient had a swallow study in the Intensive Care Unit, which revealed some evidence of aspiration. She did not have any evidence of aspiration as her diet was advanced. She was eventually able to tolerate a full [**Doctor First Name **] diet. 6. Endocrine: Patient with history of diabetes, on oral hypoglycemics at home. The patient was started on NPH and regular insulin sliding scale in the Intensive Care Unit. This was continued as the patient was transferred to the floor. The patient had finger stick blood sugars checked four times a day. She showed excellent glycemic control while in-hospital. 7. Hematology: Patient with evidence of anemia upon presentation. She had further blood loss secondary to a complicated central line placement. Her hematocrit eventually stabilized. Because of the possibility of chronic renal insufficiency, the patient was given erythropoietin. Her hematocrit was monitored closely while in the hospital. She did have evidence of resolving normocytic anemia, which was likely not multifactorial. The patient may require an outpatient colonoscopy at some point to evaluate possible gastrointestinal losses. 8. Infectious Disease: The patient presented with evidence of urinary tract infection and was initially treated with ciprofloxacin. The patient later was found to have a pneumonia, which was successfully treated with a ten day course of levofloxacin and vancomycin. The patient was afebrile, with a gradually normalizing white blood cell count upon transfer to the general medical floor. The patient's elevated white blood cell count was attributed to pancreatitis, and as her lipase resolved, her white blood cell count also decreased. She was carefully monitored for any signs of infection. She did have evidence of funguria on a repeat urine culture. The patient had a Foley, which was changed. Urine culture was rechecked after the Foley change. This urine culture was pending at the time of this discharge summary. CONDITION ON DISCHARGE: Good. DISCHARGE MEDICATIONS: Synthroid 100 mcg by mouth once daily, vitamin E 400 units by mouth once daily, Protonix 40 mg by mouth once daily, heparin subcutaneously 5000 units three times a day, Colace 100 mg by mouth once daily, Miconazole powder to affected areas twice a day, regular insulin sliding scale, NPH 18 units subcutaneously twice a day, Tums two by mouth with meals three times a day, Haldol 1 to 2 mg by mouth, intravenously or intramuscularly every two to four hours as needed for agitation, Tylenol 650 mg by mouth every four to six hours as needed for pain, Benadryl 25 mg by mouth every four to six hours as needed for itching. DISCHARGE DIAGNOSIS: 1. Lithium overdose 2. Acute renal failure 3. Pancreatitis 4. Pneumonia 5. Urinary tract infection 6. Normocytic anemia 7. Diabetes mellitus 8. Hypothyroidism 9. Bipolar disorder 10. Obesity 11. Sleep apnea [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 97811**] Dictated By:[**Last Name (NamePattern1) 5246**] MEDQUIST36 D: [**2125-10-29**] 00:54 T: [**2125-10-29**] 00:54 JOB#: [**Job Number 97812**] Admission Date: [**2125-10-10**] Discharge Date: [**2125-10-31**] Date of Birth: [**2072-11-5**] Sex: F Service: ADDENDUM: DISCHARGE MEDICATIONS: Synthroid 100 micrograms po q.d., vitamin E 400 units po q day, Protonix 40 mg po q.d., Colace 100 mg po q.d., Miconazole powder b.i.d. to affected areas. Regular insulin sliding scale, NPH 18 units subQ b.i.d., Haldol 1 to 2 mg po intravenous IM q 2 to 4 hours prn agitation. Tylenol 650 mg po q 4 to 6 hours prn. Benadryl 25 mg po q 4 to 6 hours prn. The patient will follow up with her outpatient psychiatrist Dr. [**First Name (STitle) **] [**Name (STitle) 67071**] in two weeks. The patient will also follow up with her primary care physician [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4610**] in one to two weeks after discharge from rehab. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 97811**] Dictated By:[**Last Name (NamePattern1) 5246**] MEDQUIST36 D: [**2125-10-31**] 11:41 T: [**2125-10-31**] 11:45 JOB#: [**Job Number 96089**]

[ "486", "276.2", "584.9", "577.0", "998.12", "599.0", "E939.8", "250.00", "969.8" ]

icd9cm

[ [ [] ] ]

[ "86.09", "39.31", "38.95", "39.95", "96.04", "96.72", "96.6" ]

icd9pcs

[ [ [] ] ]

11613, 12595

10952, 11589

3655, 10251

1946, 3636

169, 212

242, 1448

1470, 1793

1811, 1922

10277, 10284

4,410

167,562

48422

Discharge summary

report

Admission Date: [**2190-4-5**] Discharge Date: [**2190-4-15**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 11217**] Chief Complaint: hematemesis and melena Major Surgical or Invasive Procedure: Intubation Arterial line insertion Right IJ Central line insertion History of Present Illness: 99-yo-woman w/ h/o gastritis and GI bleed was referred from [**Hospital3 2558**] today w/ hematemesis and melena. She is normally alert and oriented at baseline, but was discovered this afternoon by NH staff to be lethargic w/ "garbled speech," not responding to questions. At this time she was hypotensive w/ SBP in 60s and HR 122. She vomited black, coffee ground material x 2 this afternoon, and at 21:45 had "large bloody" stool, prompting referral to the [**Hospital1 18**] ED. . In the ED, she was initially hypotensive w/ SBP in the 70s and HR in the 120s. She was transfused 2 units PRBCs, resulting in increased BP to 90s/40s, HR 90. She was intubated to facilitate NG lavage and for airway protection; NG lavage returned minimal coffee ground material w/ no red blood. She is now admitted to the MICU for further care. Past Medical History: - DM type 2 - Gastritis: h/o GI bleed - DVT: [**5-12**] - HTN - angina - CHF: echo [**10-12**] w/ mild LVH, LVEF > 55%, mild MR, moderate TR, severe pulm artery systolic HTN - anemia of chronic disease: baseline HCT 27-30 - chronic low back pain - OSA - depression Social History: No EtoH, Tob, IVDA Family History: Non-contributory Physical Exam: Admission PE: Tm 102.0, Tc 97.2, BP 133/52, HR 82, O2 sat 100% on AC 400 x 16 / 50% / 5 Gen: elderly woman lying in bed, intubated and sedated, not responding to voice HEENT: anicteric, PERRL, OP clear w/ mmm, no JVD CV: faint reg s1/s2, no s3/s4/m/r Pulm: CTA b/l, no crackles or wheezes Abd: obese, +BS, soft, NT, ND Ext: cool, faint DP b/l, no edema Neuro: withdraws to pain in all 4 extremities . Pertinent Results: STudies: Renal U/S on [**2190-4-5**]: IMPRESSION: No renal stones or hydronephrosis or sequela of obstruction on either side. . CXR on [**2190-4-5**] IMPRESSION: 1. Endotracheal tube and nasogastric tube appropriately positioned. 2. No focal consolidation or pneumothorax. 3. COPD. . CXR on [**2190-4-6**]: IMPRESSION: Bilateral accumulation of pleural fluid, greater on the left. Nasogastric tube in place. . LLE doppler U/S on [**2190-4-11**]: IMPRESSION: Partially occlusive clot in the left common femoral to superficial veins. Subcutaneous edema. . Pertinent Labs: [**2190-4-5**] Femoral CATHETER TIP- No Growth [**2190-4-5**] SPUTUM - sparse MRSA [**2190-4-5**] blood cultures x2 negative [**2190-4-5**] URINE CULTURE-FINAL {ESCHERICHIA COLI} sensitive to cipro . On discharge: WBC-12.8* RBC-3.53* Hgb-10.8* Hct-33.4* MCV-95 MCH-30.7 MCHC-32.5 RDW-17.0* Plt Ct-323 Glucose-127* UreaN-3* Creat-0.7 Na-143 K-3.7 Cl-115* HCO3-23 AnGap-9 [**Year (4 digits) **]-6 AST-12 CK(CPK)-20* AlkPhos-111 Amylase-73 TotBili-0.4 Calcium-9.1 Phos-2.3* Mg-1.8 Brief Hospital Course: Ms. [**Known lastname **] is a [**Age over 90 **] year old woman with DM type 2, HTN, angina, anemia, and diastolic CHF admitted from the ED w/ GI bleed. . # GI: Patient found to have hematemesis and melena at [**Hospital **], and also found to be hypotensive in to SBP of 70's in the ED at [**Hospital1 18**]. NG lavage returned minimal coffee ground substance but no bright red blood. Patient initially had hematcrit down to 35 from baseline of 40, but received 2 units PRBC and hematocrit was stable for 3 consecutive days. GI consulted and recommended deferring endoscopy until other issues are resolved, as her hematocrit appears stable. She does not take NSAIDS; platelets and INR are normal. Patient started on pantoprazole and antihypertensive medications held. NG tube was placed peri-extubation and tube feeds were initiated. The patient was transferred to the medical floor and her HCT remained stable, but her stools were consistently guiac positive. She may require out patient EGD and colonoscopy if the risks of these procedures in a [**Age over 90 **] year old woman outweight the benefit. For now she should continue the lansoprazole she was on as an outpatient (changed to liquid form given her difficulty with some pills). . # Respiratory - Intubated on [**2190-4-4**] in setting of hemodynamic instability. Extubated on [**2190-4-6**] with stable blood gases. . # Hypotension: GI Blood loss vs. sepsis from UTI. Patient found to have decreased adrenal reserve and started on phenylephrine and hydrocortisone/fludricortisone. These were discontinued after resolution of hypotension. After transfer to the medical floor she had no further hypotensive episodes. . # UTI: Initially, patient was started on empiric broad-spectrum coverage (Vancomycin, Pip-Tazo, Levofloxacin) for urosepsis. Follow-up cultures demonstrated E. coli, and antibiotics were switched to ciprofloxacin. She completed a 7-day course of ciprofloxacin which ended on [**2190-4-11**]. . # Acute renal failure: Due to prerenal azotemia in the setting of GI bleed/Sepsis. Renal ultrasound negative for stones or obstruction/hydronephrosis. Resolved with IV fluid hydration and normalization of blood pressure. . # DVT: She developed some left lower extremity edema despite being on subcutaneous heparin and pneumoboots. An ultrasound showed a partially occluding clot in the left common femoral vein. She was started on heparin gtt and will be discharged on enoxaparin which she should continue for at least 3 months. Of note, she had a DVT in [**2187**] and was placed on coumadin which was complicated by hemothorax. She must be monitored closely for complications from the blood thinners. . # DM type 2: Controlled with diet as outpatient. Covered with sliding scale while in house. . # HTN: Controlled with metoprolol, amlodipine, furosemide and lisinopril as outpatient, but these were held in setting of hypotension. On the medical floor she was receiving metoprolol and occasional furosemide, but her SBP were elevated. She will be discharged on metoprolol, furosemide and lisinopril. The lisinopril has been decreased to 20mg daily from 40mg. Her medications may need to be titrated further as an outpatient depending on her blood pressure. . # Anemia: Initially lower than baseline, but has been stable at 38-40 for past 3 days. Given the blood thinners, and anemia, she should have her CBC checked every Friday and Tuesday. . # Back pain: Chronic, controlled with tylenol. . # Depression: Continued home mirtazipine. . # FEN: She was initially fed through the NG tube. On the floor she pulled out the NG tube. As her mental status improved to baseline, she ate small meals as long as they were fed to her and she was given encouragement. She will need her electrolytes checked every Friday and Tuesday paying attention especially to her potassium (restarting furosemide and potassium was low in house). . # Code status: DNR/DNI . # Communication: [**Doctor First Name **] "[**Female First Name (un) 101947**]" [**Name (NI) 1968**] (cousin) [**Telephone/Fax (1) 101948**] [**Female First Name (un) 4014**] (long time family friend and caregiver) [**Telephone/Fax (1) 101949**] Medications on Admission: metoprolol 37.5 mg [**Hospital1 **] Amlodipine 10 mg daily Lasix 40 mg daily Lisinopril 40 mg daily remeron 30 mg qhs Prevacid 30 mg daily namenda 10 mg [**Hospital1 **] acetaminophen 1 gm [**Hospital1 **] ferrous sulfate 325 mg daily hyoscyamine 1 gtt po q 12 hours Discharge Medications: 1. Mirtazapine 15 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 2. Memantine 5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 3. Enoxaparin 60 mg/0.6 mL Syringe Sig: One (1) Subcutaneous Q24H (every 24 hours). 4. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig: One (1) PO once a day. 5. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO twice a day. 6. Furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day. 7. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO once a day. 8. Namenda 10 mg Tablet Sig: One (1) Tablet PO twice a day. 9. Ferrous Sulfate 325 (65) mg Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO once a day. 10. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO twice a day. 11. Potassium Chloride 20 mEq Packet Sig: One (1) PO once a day. Discharge Disposition: Extended Care Facility: [**Hospital3 2558**] - [**Location (un) **] Discharge Diagnosis: Primary diagnoses 1) Urinary tract infection complicated by sepsis 2) DVT, left lower extremity 3) GI bleed 4) Diabetes type 2 5) Hypertension 6) Diastolic CHF with LVEF 55% . Secondary diagnoses Depression Dementia Discharge Condition: stable vital signs. tolerating oral intake if fed to her. Discharge Instructions: You are being discharged after being hospitalized for a urinary tract infection and bleeding from your gastrointestinal tract. You received antibiotics to treat the urinary tract infection. You should talk with your primary care physician about possibly having outpatient work up for the gastrointestinal bleeding. . You developed a clot in your left leg and you are being given a new medication called lovenox (enoxaparin) to help keep your blood thin. Please monitor for bleeding complications while on this blood thinner. She should stay on enoxaparin for at least 3 months. . She has been started on potassium chloride because her potassium has been low and we are restarting her furosemide. Please check potassium in labs (see below for schedule) and replete as needed. . Changes have been made to your blood pressure medications. Please see medication list for changes. (no longer taking amlodipine and lisinopril has been decreased to 20mg daily from 40mg) . Please call your physician or go to the emergency room if you have fevers >101, chills, chest pain, shortness of breath, blood in your urine or stool or black or tarry stools or any other symptoms which are concerning to you. . Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs. Adhere to 2 gm sodium diet Fluid Restriction: 1500mL . Please check CBC, electrolytes including BUN, Cr, bicarb, chloride, potassium, sodium, magnesium and phosphorous every Tuesday and Friday. Replete electrolytes as required. Followup Instructions: You will be seen by your primary care physician [**Last Name (NamePattern4) **]. [**Last Name (STitle) 6680**] at your rehab facility. Completed by:[**2190-4-17**]

[ "496", "578.9", "250.00", "584.9", "401.9", "428.0", "453.41", "038.42", "995.91", "599.0" ]

icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

8438, 8508

3090, 7291

285, 354

8768, 8828

2010, 2570

10374, 10540

1555, 1573

7609, 8415

8529, 8747

7317, 7586

8852, 10351

1588, 1991

2801, 3067

223, 247

382, 1213

2586, 2787

1235, 1502

1518, 1539

9,742

158,493

20088

Discharge summary

report

Admission Date: [**2127-1-15**] Discharge Date: [**2127-1-29**] Date of Birth: [**2065-7-21**] Sex: F Service: SURGERY Allergies: Sulfa (Sulfonamides) / Dilaudid / Percocet Attending:[**First Name3 (LF) 2777**] Chief Complaint: MVA Major Surgical or Invasive Procedure: A. PROCEDURE: 1. Guillotine amputation of the right foot at the level of the ankle. 2. Irrigation and debridement of right thigh degloving injury with closure. 3. Closure of left thigh laceration. B. PROCEDURE: 1. Open reduction, internal fixation of left posterior wall, posterior column acetabular fracture. 2. Open reduction, internal fixation of left distal radius fracture. 3. Aspiration and injection, left knee to rule out open knee. C. PROCEDURE PERFORMED: Right lower extremity below knee amputation revision. History of Present Illness: This is a 61 year-old female with a history of diabetes who was involved in a motor vehicle collision. She was transferred to the [**Hospital1 190**] by Life Flight. On initial evaluation, she was hemodynamically stable with a GCS of 15. She had a clearly identifiable right lower extremity injury. The right ankle had a compound fracture with the tibia protruding out over the skin and the whole right foot displaced anteromedially. There was clear avulsion of nearly all of the posterior and medial as well as lateral structures and the foot was tethered to the leg anteriorly by skin and connective tissue bridge. She also had a degloving injury to the right thigh as well as a laceration to the left thigh. She had bilateral Charcot foot and her vascular exam was significant for palpable femoral and popliteal pulses bilaterally. She had pulses to her left foot, however, there was no appreciable pulse on the right foot although the right foot did have capillary refill. Given the degree of the neurovascular injury in combination with the orthopedic injury, it was felt that there would be no meaningful recovery of function for this mangled extremity and the decision was made to amputate the foot after discussion with the patient and her son who agreed with the plan. Past Medical History: -Asthma ?????? requiring steroid therapy for 13 years, never intubated -Breast cancer s/p L mastectomy in [**2123**] and XRT -CAD dx in [**2118**] on echocardiogram; negative stress test [**1-13**] -DM dx 1 year ago -HTN -GERD -History of MRSA and VRE -Anxiety -L Foot ulcer s/p multiple surgeries (most recent [**1-13**]) and infections. Recent use of vanc/levo/linezolid (>2 months rx) -Glaucoma Social History: Ms. [**Known lastname **] is divorced, has a 38 year old son who lives in CT and several grandchildren. Her son has power of attorney and is her health care proxy. She owns a house in [**Location (un) **] where she lives with a roommate and many cats; however, she has been in rehab for a substantial portion of the past year. She expresses concern that her insurance many not cover continued rehabilitation. Family History: Noncontributory. Physical Exam: PE: AFVSS NEURO: PERRL / EOMI MAE equally Answers simple commands Neg pronator drift Sensation intact to ST 2 plus DTR Neg Babinski HEENT: NCAT Neg lesions nares, oral pharnyx, auditory Supple / FAROM neg lyphandopathy, supra clavicular nodes LUNGS: CTA b/l CARDIAC: RRR without murmers ABDOMEN: Soft, NTTP, ND, pos BS, neg CVA tenderness EXT: rle - palp fem, [**Doctor Last Name **], pt, dp lle - palp fem, inc c/d/i Pertinent Results: [**2127-1-25**] 05:30AM BLOOD PT-13.8* PTT-32.9 INR(PT)-1.2* [**2127-1-25**] 05:30AM BLOOD Glucose-108* UreaN-11 Creat-0.5 Na-138 K-3.8 Cl-108 HCO3-18* AnGap-16 [**2127-1-25**] 05:30AM BLOOD Calcium-7.7* Phos-3.7 Mg-2.4 [**2127-1-24**] 10:38AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.010 URINE RBC-0-2 WBC-0-2 Bacteri-OCC Yeast-NONE Epi-0 URINE Hours-RANDOM Cardiology Report ECG Study Date of [**2127-1-23**] 4:23:00 PM Sinus rhythm with an atrial premature beat. Since the previous tracing of [**2127-1-20**] there is less atrial ectopic activity. Intervals Axes Rate PR QRS QT/QTc P QRS T 89 158 92 392/438.57 43 -10 51 Brief Hospital Course: Mrs. [**Known lastname **] presented to the emergency department with the following injuries, Motor vehicle collision with near amputation of the right foot as well as lacerations to the bilateral lower extremities. She was evaluated by the Orthopaedics / Podiatry / Vascular Surgery departments. She was also found to have the following fracture's Left posterior wall, posterior column acetabular fracture, Left distal radius fracture, Left knee laceration.She was admitted and consented for surgery. On [**2127-1-15**], she was prepped and brought down to the operating room for surgery. She had the following procedures: Orthopedics: 1. Open reduction, internal fixation of left posterior wall, posterior column acetabular fracture. 2. Open reduction, internal fixation of left distal radius fracture. 3. Aspiration and injection, left knee to rule out open knee. Vascular: 4. Guillotine amputation of the right foot at the level of the ankle. 5. Irrigation and debridement of right thigh degloving injury with closure. 6. Closure of left thigh laceration. Intra-operatively, she was closely monitored and remained hemodynamically stable. She tolerated the procedure's well without any difficulty or complication. Post-operatively, she was extubated and transferred to the PACU for further stabilization and monitoring. She was then transferred to the floor for further recovery. [**2127-1-21**], she was prepped and brought down to the operating room for surgery. She had the following procedures: 1. Right lower extremity below knee amputation revision. Intra-operatively, she was closely monitored and remained hemodynamically stable. She tolerated the procedure's well without any difficulty or complication. Post-operatively, she was extubated and transferred to the PACU for further stabilization and monitoring. She was then transferred to the floor for further recovery. On the floor, she remained hemodynamically stable with her pain controlled. She progressed with physical therapy to improve her strength and mobility. She continues to make steady progress without any incidents. She was discharged to a rehabilitation facility in stable condition. To note pt had psych consult / 1:1 sitter On DC pt denies suicidal tendencies Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed for pain, fever. 2. Alprazolam 1 mg Tablet Sig: One (1) Tablet PO QID (4 times a day). 3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 5. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO Q12H (every 12 hours) as needed. 6. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 7. Becaplermin 0.01 % Gel Sig: One (1) Appl Topical DAILY (Daily). 8. Topiramate 100 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 9. Pregabalin 25 mg Capsule Sig: Four (4) Capsule PO tid (). 10. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed. 11. Fluticasone-Salmeterol 100-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 12. Olanzapine 5 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO DAILY (Daily). 13. Enoxaparin 30 mg/0.3 mL Syringe Sig: [**2-11**] Subcutaneous Q12H (every 12 hours). 14. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation Q4-6H (every 4 to 6 hours) as needed for SOB. 15. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q6H (every 6 hours) as needed for SOB. 16. Duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 17. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 18. Enalapril Maleate 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 19. Nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) Tablet, Sublingual Sublingual ASDIR (AS DIRECTED). 20. Diltiazem HCl 30 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 21. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. Discharge Disposition: Extended Care Facility: [**Hospital6 85**] - [**Location (un) 86**] Discharge Diagnosis: Motor vehicle collision 1. With near amputation of the right foot. 2. Left posterior wall, posterior column acetabular fracture. 3. Left distal radius fracture. 4. Left knee laceration. Discharge Condition: Stable Discharge Instructions: DISCHARGE INSTRUCTIONS FOLLOWING BELOW KNEE AMPUTATION This information is designed as a guideline to assist you in a speedy recovery from your surgery. Please follow these guidelines unless your physician has specifically instructed you otherwise. Please call our office nurse if you have any questions. Dial 911 if you have any medical emergency. ACTIVITY: There are restrictions on activity. On the side of your amputation you are non weight bearing for 4-6 weeks. You should keep this amputation site elevated when ever possible. No driving until cleared by your Surgeon. PLEASE CALL US IMMEDIATELY FOR ANY OF THE FOLLOWING PROBLEMS: Redness in or drainage from your leg wound(s). Watch for signs and symptoms of infection. These are: a fever greater than 101 degrees, chills, increased redness, or pus draining from the incision site. If you experience any of these or bleeding at the incision site, CALL THE DOCTOR. Exercise: Limit strenuous activity for 6 weeks. Do not drive a car unless cleared by your Surgeon. No heavy lifting greater than 20 pounds for the next 14 days. Try to keep leg elevated when able. BATHING/SHOWERING: You may shower immediately upon coming home. No bathing. A dressing may cover you??????re amputation site and this should be left in place for three (3) days. Remove it after this time and wash your incision(s) gently with soap and water. You will have sutures, which are usually removed in 4 weeks. This will be done by the Surgeon on your follow-up appointment. WOUND CARE: Sutures / Staples may be removed before discharge. If they are not, an appointment will be made for you to return for staple removal. When the sutures are removed the doctor may or may not place pieces of tape called steri-strips over the incision. These will stay on about a week and you may shower with them on. If these do not fall off after 10 days, you may peel them off with warm water and soap in the shower. Avoid taking a tub bath, swimming, or soaking in a hot tub for four weeks after surgery. MEDICATIONS: Unless told otherwise you should resume taking all of the medications you were taking before surgery. You will be given a new prescription for pain medication, which can be taken every three (3) to four (4) hours only if necessary. Remember that narcotic pain meds can be constipating and you should increase the fluid and bulk foods in your diet. (Check with your physician if you have fluid restrictions.) If you feel that you are constipated, do not strain at the toilet. You may use over the counter Metamucil or Milk of Magnesia. Appetite suppression may occur; this will improve with time. Eat small balanced meals throughout the day. CAUTIONS: NO SMOKING! We know you've heard this before, but it really is an important step to your recovery. Smoking causes narrowing of your blood vessels which in turn decreases circulation. If you smoke you will need to stop as soon as possible. Ask your nurse or doctor for information on smoking cessation. Avoid pressure to your amputation site. No strenuous activity for 6 weeks after surgery. DIET: There are no special restrictions on your diet postoperatively. Poor appetite is expected for several weeks and small, frequent meals may be preferred. For people with vascular problems we would recommend a cholesterol lowering diet: Follow a diet low in total fat and low in saturated fat and in cholesterol to improve lipid profile in your blood. Additionally, some people see a reduction in serum cholesterol by reducing dietary cholesterol. Since a reduction in dietary cholesterol is not harmful, we suggest that most people reduce dietary fat, saturated fat and cholesterol to decrease total cholesterol and LDL (Low Density Lipoprotein-the bad cholesterol). Exercise will increase your HDL (High Density Lipoprotein-the good cholesterol) and with your doctor's permission, is typically recommended. You may be self-referred or get a referral from your doctor. If you are overweight, you need to think about starting a weight management program. Your health and its improvement depend on it. We know that making changes in your lifestyle will not be easy, and it will require a whole new set of habits and a new attitude. If interested you can may be self-referred or can get a referral from your doctor. If you have diabetes and would like additional guidance, you may request a referral from your doctor. FOLLOW-UP APPOINTMENT: Be sure to keep your medical appointments. The key to your improving health will be to keep a tight reign on any of the chronic medical conditions that you have. Things like high blood pressure, diabetes, and high cholesterol are major villains to the blood vessels. Don't let them go untreated! Please call the office on the first working day after your discharge from the hospital to schedule a follow-up visit. This should be scheduled on the calendar for seven to fourteen days after discharge. Normal office hours are 8:30-5:30 Monday through Friday. PLEASE FEEL FREE TO CALL THE OFFICE WITH ANY OTHER CONCERNS OR QUESTIONS THAT MIGHT ARISE. Followup Instructions: Provider: [**First Name11 (Name Pattern1) 5445**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 5446**], DPM Phone:[**Telephone/Fax (1) 543**] Date/Time:[**2127-1-29**] 11:30 Provider: [**First Name11 (Name Pattern1) 5445**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 5446**], DPM Phone:[**Telephone/Fax (1) 543**] Date/Time:[**2127-2-12**] 10:20 Completed by:[**2127-1-29**]

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icd9cm

[ [ [] ] ]

[ "79.39", "88.72", "84.15", "99.04", "79.32", "86.59", "86.22", "96.6", "84.3" ]

icd9pcs

[ [ [] ] ]

8453, 8523

4177, 6459

306, 829

8757, 8766

3498, 4154

13912, 14318

3006, 3024

6482, 8430

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263, 268

10320, 13214

13238, 13889

857, 2139

2161, 2560

2576, 2990

2,423

172,507

21248+57235

Discharge summary

report+addendum

Admission Date: [**2133-5-24**] Discharge Date: [**2133-6-10**] Date of Birth: [**2054-11-21**] Sex: M Service: MEDICINE Allergies: Pravachol Attending:[**First Name3 (LF) 2641**] Chief Complaint: Hemetemesis Major Surgical or Invasive Procedure: EGD with cautery and epinephrine Cardiac catherization PTA of left anterior tibial artery wih stenting x 2 Amputation of 3 and 5 toe of left foot History of Present Illness: Patient is a 78 y/o man with PMH significant for type 2 diabetes, PVD with necrotic toe ulcer, AF (on coumadin) admitted to the MICU with fevers and rapid AF and brown emesis. In the ED, T 102.6, BP 115/60, HR 113 (AF w/ RVR). He received levo 500 mg IV X 1, Flagyl 500 mg IV X1, 1L NS. Given K 6, he received 30 g kayexelate. He then developed substernal chest burning without radiation and vomited ~50 cc of BRB. He denies prior occurrence. EKG showed AF with increased ST depressions with TWI 1I, avL, II, V2-V6. Given INR 4.2 and HCT 29, he received a total of 5 u FFP and 5 u PRBC. Patient reports continued drainage from left toe ulcers, unchanged from prior. He notes increased frequency with urination, but no dysuria or hematuria. He also notes a chronic cough, productive of white sputum, no hemoptysis. He says that he is SOB on walking from room to room in his home but believes it is due to deconditioning. He says at times he has chest tightnes at home imporves with rest. Denies CP or SOB at rest. Currently, he denies nausea, vomiting, abdominal pain lightheadedness, chest pain. No headache, rhinorrhea, sore throat, shortness of breath, PND, orthopnea, LE edema, recent sick contacts, recent travel. Past Medical History: 1. Atrial fibrillation 2. Type 2 diabetes mellitus, diagnosed 12 years ago on insulin 3. Hypercholesterolemia 4. Rheumatoid arthritis 5. Chronic renal insuffeciency- Baseline creatinine is 1.5. 6. Carotid stenosis on the right ICA 7. PVD 8. Right eye macular degeneration 9. S/P amputation of all right toes [**2132-1-21**] 10. Right popliteal with non-reverse saphenous vein graft- [**4-/2132**] 11. Left total hip replacement in [**2115**] with a repeat replacement in [**2123**] 12. S/P left AK/[**Doctor Last Name **] to dorsalis pedis bypass graft in [**8-/2132**] 13. Previous angiography with left iliac stenting in [**8-/2132**] 14. Failed angioplasty of the anterior tibial artery in [**8-/2132**] 15. HTN Social History: Patient lives with his wife. They recently moved in with his daughter and this has been a great help to them as he has had difficulty bearing weight on his foot. He denies current alcohol use or smoking. Family History: Brother with AAA. Physical Exam: Vitals: T 98.3 P 80 BP 109/51 MAP 71 18 O2 sats 98% on RA GEN: patient lying in bed talking on phone, NAD HEENT: AT, EOMI, MMM no lesions, neck supple, no JVD CV: irregular rate, no murmurs, rubs, gallops Pulm: crackles at bases b/l Ext: R foot: mid tarsal amputation- clean, well-healed; L foot large oozing ulcer on lateral aspect of foot immediately inferior to fifth metetarsal, fifth metatarsal blackened and deformed; multiple smaller black ulcers at base of toes Neuro: A & O x3, CN II-XII grossly intact; 5/5 strength in LE BL, toe tap intact Pertinent Results: [**2133-5-24**] 12:25PM BLOOD WBC-12.0*# RBC-3.29* Hgb-9.2* Hct-29.5* MCV-90 MCH-28.0 MCHC-31.2 RDW-14.3 Plt Ct-152 [**2133-5-26**] 04:14AM BLOOD WBC-9.8 RBC-3.59* Hgb-10.4* Hct-31.3* MCV-87 MCH-29.1 MCHC-33.4 RDW-14.9 Plt Ct-87* [**2133-6-1**] 09:15AM BLOOD WBC-7.4 RBC-3.43* Hgb-9.9* Hct-31.4* MCV-91 MCH-28.7 MCHC-31.5 RDW-16.0* Plt Ct-128* [**2133-6-7**] 05:40AM BLOOD WBC-5.4 RBC-3.55* Hgb-10.1* Hct-33.3* MCV-94 MCH-28.4 MCHC-30.3* RDW-15.1 Plt Ct-150 [**2133-5-24**] 12:25PM BLOOD Neuts-81.6* Bands-0 Lymphs-10.1* Monos-8.2 Eos-0.1 Baso-0 [**2133-6-1**] 09:15AM BLOOD Neuts-50 Bands-0 Lymphs-36 Monos-9 Eos-2 Baso-0 Atyps-3* Metas-0 Myelos-0 NRBC-1* [**2133-5-24**] 12:25PM BLOOD Hypochr-2+ Anisocy-1+ Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL [**2133-5-24**] 12:25PM BLOOD PT-25.3* PTT-36.5* INR(PT)-4.2 [**2133-6-8**] 09:06AM BLOOD PT-19.3* PTT-81.5* INR(PT)-2.5 [**2133-5-29**] 12:30PM BLOOD ESR-15 [**2133-5-24**] 12:25PM BLOOD UreaN-57* Creat-1.7* Na-139 K-6.4* Cl-106 HCO3-17* AnGap-22* [**2133-6-8**] 02:07AM BLOOD Glucose-83 UreaN-20 Creat-1.4* Na-141 K-4.1 Cl-105 HCO3-26 AnGap-14 [**2133-5-24**] 12:25PM BLOOD ALT-23 AST-29 CK(CPK)-83 AlkPhos-179* Amylase-31 TotBili-0.6 [**2133-5-25**] 01:18PM BLOOD CK(CPK)-1183* DirBili-0.2 [**2133-5-27**] 06:40AM BLOOD ALT-328* AST-432* CK(CPK)-418* AlkPhos-165* TotBili-0.8 [**2133-6-7**] 05:40AM BLOOD ALT-27 AST-29 LD(LDH)-371* AlkPhos-155* Amylase-28 TotBili-0.6 [**2133-5-24**] 12:25PM BLOOD Calcium-8.7 Phos-3.0 Mg-1.7 Iron-25* [**2133-6-8**] 02:07AM BLOOD Phos-3.4 Mg-1.9 [**2133-5-24**] 12:25PM BLOOD calTIBC-259* VitB12-573 Folate-16.1 Hapto-178 Ferritn-96 TRF-199* [**2133-6-1**] 09:15AM BLOOD Triglyc-60 HDL-42 CHOL/HD-2.2 LDLcalc-39 [**2133-5-24**] 12:25PM BLOOD TSH-6.4* [**2133-5-24**] 10:30PM BLOOD Free T4-0.9* [**2133-5-24**] 12:25PM BLOOD Cortsol-41.3* [**2133-5-24**] 12:25PM BLOOD CRP-76.9* [**2133-5-29**] 12:30PM BLOOD CRP-54.1* [**2133-5-25**] 05:38AM BLOOD Lactate-2.2* [**2133-5-25**] 5:09 pm SWAB Source: Left foot. **FINAL REPORT [**2133-5-29**]** GRAM STAIN (Final [**2133-5-25**]): NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. SMEAR REVIEWED; RESULTS CONFIRMED. WOUND CULTURE (Final [**2133-5-28**]): ENTEROBACTER CLOACAE. SPARSE GROWTH. Trimethoprim/Sulfa sensitivity available on request. This organism may develop resistance to third generation cephalosporins during prolonged therapy. Therefore, isolates that are initially susceptible may become resistant within three to four days after initiation of therapy. For serious infections, repeat culture and sensitivity testing may therefore be warranted if third generation cephalosporins were used. SERRATIA MARCESCENS. SPARSE GROWTH. Trimethoprim/Sulfa sensitivity available on request. This organism may develop resistance to third generation cephalosporins during prolonged therapy. Therefore, isolates that are initially susceptible may become resistant within three to four days after initiation of therapy. For serious infections, repeat culture and sensitivity testing may therefore be warranted if third generation cephalosporins were used. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ENTEROBACTER CLOACAE | SERRATIA MARCESCENS | | CEFEPIME-------------- 2 S <=1 S CEFTAZIDIME----------- =>64 R <=1 S CEFTRIAXONE----------- =>64 R <=1 S CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ <=1 S 2 S IMIPENEM-------------- <=1 S 2 S LEVOFLOXACIN---------- =>8 R <=0.25 S MEROPENEM-------------<=0.25 S <=0.25 S PIPERACILLIN---------- =>128 R <=4 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S 4 S ANAEROBIC CULTURE (Final [**2133-5-29**]): NO ANAEROBES ISOLATED. [**2133-5-24**]: EGD: Esophagus: [**Doctor First Name **]-[**Doctor Last Name **] tears with active bleeding. Hemostasis achieved with epinephrine injection and BICAP cauterization Stomach: Normal stomach. Duodenum: Normal duodenum. [**2133-5-28**] Left foot x-ray: Interval destruction of the fifth metatarsal head, fifth proximal phalanx and distal phalanx of the third digit consistent with osteomyelitis. [**2133-5-27**] Echocardiogram: EF 30 %, The left atrium is markedly dilated. The right atrium is moderately dilated. There is mild (non-obstructive) focal hypertrophy of the basal septum. The left ventricular cavity size is normal. Overall left ventricular systolic function is moderately depressed with global hypokinesis. No masses or thrombi are seen in the left ventricle. There is mild global right ventricular free wall hypokinesis. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. [**2133-6-3**] Cardiac catheterization: Severe three vessel coronary artery disease in this right dominant system. All vessels were heavily calcified. LMCA had a 50% stenosis. LAD was diffusely diseased in its proximal segment with 80% stenosis. Left circumflex had a long 60% stenosis and the RCA had 70-80% sequential high grade stenosis. Left ventriculography was not preformed given the renal dysfunction and recent echocardiogram showing EF of 30%. Limited hemodynamics showed slightly elevated left ventricular filling pressures with LVEDP of 21 mm Hg. Brief Hospital Course: Patient is a 77 year old male with Type II DM, afib on Coumadin, PVD w/ chronic foot ulcers with resolved [**Doctor First Name 329**]-[**Doctor Last Name **] tear, demand ischemia resulting in NSTEMI s/p cardiac cath showing 3 vessel disease, shock liver, and osteomyelitis in metatarsal of left foot s/p 3rd and 5th toe amputation being treated with imipenem. 1) Hematemesis: Upper endoscopy revealed [**Doctor First Name **]-[**Doctor Last Name **] tear which was treated with epinephrine and cautery. He received 5 units PRBCs and 5 units FFP and his hematocrit stabilized. No further episodes of hematemesis occurred throughout his hospitalization. He had melena early after his bleed which resolved. His hematocrit was monitored and Coumadin and ASA were held until several days post-bleed. His diet was advanced without incident and he had no epigastric pain or emesis. He was discharged on Protonix 40 mg po q day. 2) Dry gangrenous toes/osteomyelitis: He had an oozing ulcer at left 5th metatarsal and several areas of dry gangrene worse at the 3rd and 5th toes. He was originally started on levofloxacin and Flagyl. Foot x-ray revealed osteomyelitis and swab of lesions showed Enterobacter clocae resistant to b-lactam and fluoroquinolones and he was started on imipenem on [**2133-5-28**]. He had revascularization and stenting of left AT and amputation of 3rd and 5th toes. Wet to dry dressings were continues with good result. A PICC line was placed and he will be continues on imipenem for 8 more days to complete a full 2 week course of antibiotics after toe amputation. He has a follow up appointment with the [**Hospital **] clinic on [**2133-6-30**]. He was reevaluated by PT and will go to rehabilitation to improve his functional status. 3) Acute blood loss/chronic anemia: Patient's baseline is HCT 32-35, and it was most likely decreased secondary to acute blood loss from UGI bleed. However, this appeared to be superimposed on a chronic (Iron 25, Ferritin 96, TIBC 259)iron deficiency anemia. He required no more transfusions and his hematocrit was stable. On the day of discharge his hematocrit 33.6. Since he also has some superimposed iron deficiency anemia he will follow up as an outpatient for colonoscopy as he has not had one in over 10 years. 4) NSTEMI: In context of GIB he presented with persistent dynamic EKG changes (responsive to SL NTG) following volume resuscitation. His cardiac enzymes were elevated but trended down. He was started on ASA, beta blocker, ACE-I, and Lipitor. After his toe amputation he was also started on Plavix. His cardiac catheterization this admission showed severe 3 vessel disease requiring CABG. He has no further chest pain or new EKG changes. After rehabilitation and treatment of his osteomyelitis, he will follow up with cardiothoracic surgery. He will continue on ASA, BB, lisinopril, Lipitor and Plavix. 5) Elevated LFTs: Most likely due to shock liver in the setting of acute blood loss and MI. LFTs trended down and are now stable and liver ultrasound did not reveal any abnormalities. No further work up is necessary at this time. Will follow with his PCP to check his LFTs now that he is on a Statin. 6) Type II DM: Poorly controlled with high and lows. Current regimen of NPH 13 units QAM and 2 Units QPM with breakfast, dinner and bedtime regular insulin sliding scale have i,Improved control. His finger sticks should continue to be monitored QID and his regimen altered as his infection begins to clear and his diet changes. 7)Atrial fibrillation with RVR in the setting of acute upper GI bleed: After initial presentation rate has been well controlled with metoprolol XL 250 mg po q day. He was restarted on Coumadin after his procedures and current INR is 2.5 (goal [**12-25**]). He will be discharged on Coumadin 3 mg po q daily and his INR will be followed at the rehabilitation facility. . 8)HTN: Has been well controlled on BB and lisinopril. Will continue on outpatient basis. He will follow up with his PCP for titration of his medications.# CRI: 9) CRI: His baseline CRE 1.5. Creatinine has been stable at 1.3-1.4 for several before discharge. Continue to renally dose meds and avoid nephrotoxins. His creatinine will be monitored on an outpatient basis. Medications on Admission: 1. Sulfasalazine 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 2. Zetia 10 mg po qd 3. diovan 80 mg po qd 4. HCTZ 25 mg po qd 5. coumadin 2.5 mg po q Mon, Tues, Thurs, Fri, Sat 6. coumadin 5 mg po qsun, wed Discharge Medications: 1. Sulfasalazine 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 2. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet, Sublingual Sublingual PRN (as needed) as needed for chest pain. 3. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 4. 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:*0* 5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 6. Zolpidem Tartrate 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed. 7. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 9. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 10. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 11. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Warfarin Sodium 3 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 13. Imipenem-Cilastatin 500 mg Recon Soln Sig: One (1) Recon Soln Intravenous Q6H (every 6 hours). 14. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: Two (2) ML Intravenous DAILY (Daily) as needed. Discharge Disposition: Extended Care Facility: [**Hospital3 7665**] Discharge Diagnosis: Primary 1. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] tear 2. Non-ST elevation MI 3. Osteomyelitis of 5th metarsal Secondary 1. A. fib 2. HTN 3. Type 2 diabetes 4. PVD 5. Rheumatoid arthritis Discharge Condition: Hemetemesis resolved, Hct stable, afebrile on imipenam, INR therapeutic on coumadin Discharge Instructions: Please monitor for chest pain and monitor creatinine for worsening renal failure. Also watch for temperature > 101. Followup Instructions: Please call Dr [**Last Name (STitle) 3407**] at [**Telephone/Fax (1) 1241**] to schedule a follow-up appointment for 2-4 weeks. Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 4340**], MD Where: LM [**Hospital Unit Name 4341**] DISEASE Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2133-6-30**] 10:30 Please call ([**Telephone/Fax (1) 1504**] to schedule follow-up with cardiothoracic surgery for your bypass in [**12-26**] weeks. Name: [**Known lastname **],[**Known firstname **] Unit No: [**Numeric Identifier 10543**] Admission Date: [**2133-5-24**] Discharge Date: [**2133-6-10**] Date of Birth: [**2054-11-21**] Sex: M Service: MEDICINE Allergies: Pravachol Attending:[**First Name3 (LF) 417**] Addendum: I spoke with Mr. [**Known lastname 10552**] nurse [**Doctor First Name **] this morning ([**2133-6-11**]) regarding patient's imipenam as his daughter called concerned about dosing. He will be continued on imipenam until [**2133-6-16**] to complete a full 2 week course of antibiotics after toe amputation. I also informed his nurse that he should be on Metoprolol XL 250 mg PO q day and that he has a follow up appointment with Dr. [**Last Name (STitle) 10553**] from CT surgery on [**2133-7-14**] at 1:30pm. Mr. [**Known lastname 10552**] nurse said she would give this information to his physician, [**Name10 (NameIs) **] [**Name Initial (NameIs) **] also spoke with one of the covering physicians who saw these recommendations on the discharge summary. Mr. [**Known lastname 10552**] physician at [**Hospital3 1933**] Dr. [**Last Name (STitle) 10554**] will call with any further questions. Major Surgical or Invasive Procedure: EGD with cautery and epinephrine Cardiac catherization PTA of left anterior tibial artery wih stenting x 2 Amputation of 3 and 5 toe of left foot Discharge Disposition: Extended Care Facility: [**Hospital3 1933**] [**Name6 (MD) **] [**Last Name (NamePattern4) 424**] MD [**MD Number(1) 425**] Completed by:[**2133-6-11**]

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icd9cm

[ [ [] ] ]

[ "39.90", "88.55", "86.22", "88.52", "99.07", "37.22", "84.11", "39.50", "42.33", "99.04" ]

icd9pcs

[ [ [] ] ]

17566, 17750

9149, 13431

17395, 17543

15408, 15493

3269, 9126

15657, 17357

2662, 2681

13700, 15079

15170, 15387

13457, 13677

15517, 15634

2696, 3250

232, 245

458, 1683

1705, 2423

2439, 2646

58,265

178,140

50968

Discharge summary

report

Admission Date: [**2152-4-30**] Discharge Date: [**2152-5-6**] Date of Birth: [**2092-8-3**] Sex: F Service: MEDICINE Allergies: Sulfa(Sulfonamide Antibiotics) / Sulfa(Sulfonamide Antibiotics) Attending:[**First Name3 (LF) 633**] Chief Complaint: hematemesis Major Surgical or Invasive Procedure: EGD History of Present Illness: 59 year old woman with no PMH presents with 5 days of abdominal pain and nausea, and one day of nausea/hematemesis. . 5 days ago patient experienced [**12-31**] loose non bloody bowel movements per day, assocaiated with mild intermittent lower abdominal pain. Three days ago, she noted shaking and felt hot and sweaty, thought she hd a temperature, but did not have a thermometer. This evening around 7:00 pm she became acutely nauseous and vomiting with BRB. With her second emesis, she vomited > 1 cup BRB. She then had 4 more episodes of hematemesis, < 1 cup. . Denies dizziness, lightheadedness, syncope, chest pain. No recent travel or food experiementation. She does note a tick bite to her right thigh about 1 week ago. She removed it promptly, and did not have any rash. . On arrival to the ED VS were 97.1 98 102/59 15 99% RA. NGT was placed, removed mild BRB and coffee grounds, cleared after 500cc lavage. Guaiac negative brown stool. Hct 40. Called GI, thought likely [**Doctor First Name 329**] [**Doctor Last Name **] tear, would consider endoscopy in am. Started on pantoprazole bolus + drip, 2 18g PIVs placed. Given 2L NS. Admitted to ICU for UGIB. . On arrival to the MICU, she feels shaky, but nausea is improved since arrival. Past Medical History: None Social History: Works at a law firm. Smokes 8 cigarettes/day. Drinks 2 beers/day. Family History: Father with type II DM and bladder cancer, mother with lung cancer. Physical Exam: ADMISSION EXAM: 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 . DISCHARGE EXAM: VS: 98.0, 100-110/60-76, 73-86, 18, 95% on 4L Gen: Well-appearing, alert, and communicative HEENT: MMM Lungs: Minimal crackles anteriorly R>L. Heart: RRR, no murmuirs, no rubs Abd: Soft, nontender, nondistended Ext: Trace pedal edema, edema of right hand, clubbing of fingers. No further rashon legs Pertinent Results: ADMISSION LABS: [**2152-4-30**] 09:30PM BLOOD WBC-15.6* RBC-4.54 Hgb-13.8 Hct-40.6 MCV-89 MCH-30.3 MCHC-33.9 RDW-11.8 Plt Ct-189 [**2152-4-30**] 09:30PM BLOOD Neuts-87.7* Lymphs-6.1* Monos-5.6 Eos-0.4 Baso-0.2 [**2152-4-30**] 09:30PM BLOOD PT-12.4 PTT-29.8 INR(PT)-1.1 [**2152-4-30**] 09:30PM BLOOD Glucose-126* UreaN-17 Creat-0.9 Na-128* K-3.6 Cl-89* HCO3-25 AnGap-18 [**2152-4-30**] 09:30PM BLOOD ALT-59* AST-51* AlkPhos-68 TotBili-0.6 . DISCHARGE LABS: [**2152-5-6**] 01:30PM BLOOD WBC-8.3 RBC-4.09* Hgb-12.1 Hct-38.0 MCV-93 MCH-29.6 MCHC-31.9 RDW-12.9 Plt Ct-359# [**2152-5-5**] 06:15AM BLOOD Neuts-79.3* Lymphs-15.4* Monos-4.7 Eos-0.1 Baso-0.5 [**2152-5-1**] 04:25AM BLOOD Hypochr-1+ Anisocy-OCCASIONAL Poiklo-OCCASIONAL Macrocy-OCCASIONAL Microcy-OCCASIONAL Polychr-OCCASIONAL [**2152-5-1**] 05:15PM BLOOD Parst S-NEGATIVE [**2152-5-6**] 01:30PM BLOOD Glucose-94 UreaN-10 Creat-0.6 Na-138 K-4.5 Cl-103 HCO3-27 AnGap-13 [**2152-5-5**] 06:15AM BLOOD ALT-49* AST-59* AlkPhos-63 TotBili-0.4 . MICROBIOLOGY: [**2152-5-1**] Urine culture: mixed flora [**2152-5-1**] Blood culture: no growth to date [**2152-5-1**] Influenza A/B nasopharyngeal swab: negative [**2152-5-1**] Lyme serology: pending [**2152-5-1**] H. pylori Ab: negative [**2152-5-1**] Urine Legionella Ag: negative [**2152-5-2**] Blood culture: no growth to date [**2152-5-3**] Blood culture: no growth to date [**2152-5-3**] Blood culture (mycolytic): no growth to date [**2152-5-3**] Stool culture/C. diff: pending . IMAGING: [**2152-4-30**] CXR: The lung apices are not depicted. NG tube ends in the gastric antrum in appropriate position. The lungs are clear, the cardiomediastinal silhouette and hila are normal. There is no pleural effusion and no pneumothorax. Partially visualized abdomen shows normal bowel gas pattern. EGD [**2152-5-1**]: Esophagitis in the lower third of the esophagus Small hiatal hernia Friability and erythema in the antrum and stomach body compatible with gastritis Ulcer in the pylorus Ulcers in the duodenal bulb Otherwise normal EGD to third part of the duodenum Recommendations: Prilosec 40mg [**Hospital1 **] Advance diet as tolerated. Avoid NSAIDs. Serial hcts. Active type and cross. GI bleeding is unlikely the cause of the patient's current hypotensive episodes and warrents further investigation for a possible infectious cause. Given the clear history of NSAID use, follow up egd is not required but would check a h pylori serology and treat if positive. Would need a test of cure 4 weeks post h pylori serology as well. . [**2152-5-1**] CTA chest: 1. No PE. 2. Mild pulmonary edema. 3. Upper lobe peribronchovascular airspace filling could be edema or a manifestation of more severe airspace abnormality in the lower lungs, mostly consolidation, partially atelectasis, due to aspiration, multifocal pneumonia, or less likely hemorrhage. In the setting of a recent transfusions, transfusion reaction may be contributory. 4. Esophageal wall thickening, with diffuse infiltration of the mediastinal fat which may reflect inflammatory change or confluent lymphadenopathy, though the progression from normal mediastinal contours on [**4-30**] favors a rapidly evolving inflammatory process. There is no finding to suggest esophageal perforation. . [**2152-5-2**] CXR: As compared to the previous radiograph, there is a massive increase in extent and severity of multifocal pneumonia. The resulting very widespread parenchymal opacities are more extensive on the right than on the left and show multiple air bronchograms. In addition, retrocardiac atelectasis has newly appeared, and there is a small right pleural effusion. The opacities are better displayed on the CTA examination, performed yesterday at 9:41 p.m. Moderate cardiomegaly. Brief Hospital Course: 59 year old woman with no known medical history who presented with subjective fevers, abdominal pain, and hematemesis and developed hypoxic respiratory failure. Clinical picture likely consistent with an initial gastroenteritis with emesis likely leading to aspiration pneumonia and hematemesis. # Hematemesis: EGD revealed mild esophagitis, a non-bleeding 7mm ulcer in the pylorus, and several superficial non-bleeding ulcers ranging in size from 3mm to 5mm in the duodenal bulb. This was likely due to aspirin use and recurrent emesis. H. pylori antibody is negative. Her HCT continued to rise and she was transitioned from a pantoprazole gtt to pantoprazole 40mg PO Q12h. # Hypoxemic Respiratory Failure: Patient developed fevers and new hypoxia on [**5-1**]. She was empirically treated for pneumonia with ceftriaxone. CT chest showed likely multifocal pneumonia which was possible due to aspiration. Given these findings, antibiotics were broadened to vanc/levo/flagyl and ID was consulted. The vanc was discontinued on [**5-3**] and the patient was discharged with PO levo and flagyl for likely aspiration pneumonia. Her pulmonary status improved significantly during hosptialization and she was satting 100% on RA at discharge. # Volume overload: the patient received over 12L of IV fluids in the ICU in the setting of hypotension (BP 80/40s with fever, mottled legs, likely sepsis with pulmonary source). After pt stabalized, she was gently diuresed. # Diarrhea/Abdominal Pain: Likely viral gastroenteritis as this resolved during the hospitalization. Stool cultures, including C diff, were negative. # Tick Bite: Recent tick bite removed quickly. Lyme serologies were negative and smear was negative for babesiosis although ANAPLASMA PHAGOCYTOPHILUM was negative. . # Transaminitis: Very mild transaminitis (50s). No RUQ pain, no hyperbilirubinemia. Likely related to viral gastroenteritis/acute infectious process. Transitional issues/INcidental radiographic findings. -Pt will require primary care follow up: has not seen a PCP [**Last Name (NamePattern4) **] 10 years. Would follow LFT's as well. -Pt has recently decided to stop smoking. Outpatient support should be provided to support this goal. -Pt still mildly volume overload at discharge. She was mobilizing and self-diuresing effectively and will follow up with PCP closely to see if she would benefit from lasix. -PT WAS NOTED TO HAVE ESOPHAGEAL WALL THICKENING ON CT WITH CONFLUENT LYMPHADENOPATHY THAT FAVORED AN INFLAMMATORY PROCESS. This will likely require further work up Medications on Admission: None Discharge Medications: 1. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H Duration: 6 Days RX *metronidazole 500 mg Every 8 hours Disp #*18 Tablet Refills:*0 2. Pantoprazole 40 mg PO Q12H RX *pantoprazole 40 mg twice a day Disp #*60 Tablet Refills:*2 3. Levofloxacin 750 mg PO DAILY RX *Levaquin 750 mg daily Disp #*6 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Pneumonia- multifocal Ulcers of the stomach and duodenum (upper small intestine). Diarrhea Gastroenteritis Pulmonary Edema Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were treated in the hospital for pneumonia and vomitting up of blood clots that likely developed because of vomitting, diarrhea, and fevers (possibly due to a stomach flu) as well as high doses of aspirin that worsened your stomach and small intestine ulcers. It is important that you complete the course of antibiotics for treatment of your pneumonia. Please take Levofloxacin 750 mg by mouth daily and metronidazole 500 mg by mouth every 8 hours for six more days. As you know, you were given many liters of fluids through your veins while you were in the intensive care unit because you were so sick. You will continue to urinate out this fluid within the next several days. Because you vomitted blood, we took a look at your esophagus, stomach, and upper small intestines with a camera. We saw that you have an ulcer in your stomach and several ulcers of your upper small intestine. To help treat your ulcers, it is important that you start to take Prilosec (omeprazole) 40mg twice a day. It is also important that you avoid all non-steroidal anti-inflammatory drugs, including ibuprofen, alleve, and aspirin. You may take tylenol. You developed new diarrhea in the hospital. This is most likely likely due to antibiotics and should resolve as your gut flora return. You can take yogurt or lactobacillus supplements to accelerate this process. If your diarrhea gets worse or you develop any fevers, please see your doctor. Finally, it is important that you begin to see a primary care doctor regularly. Please follow-up regarding this hospitalization with [**First Name4 (NamePattern1) 1022**] [**Last Name (NamePattern1) **] NP (see appointment below). At that time, you will also be set up with a primary care doctor. We have made the following changes to your medications: START Levofloxacin 750 mg by mouth daily and metronidazole 500 mg by mouth every 8 hours for six more days. START Pantoprazole 40mg by mouth twice a day Followup Instructions: Name: NP [**First Name4 (NamePattern1) 1022**] [**Last Name (NamePattern1) **] Location: [**Hospital **] Medical Group Address: [**Month (only) 66695**], [**Hospital1 **],[**Numeric Identifier 66696**] Phone: [**Telephone/Fax (1) 66697**] Appointment: Monday [**2152-5-8**] 10:40am *This is a follow up appointment for your hospitalization. You will be reconnected with your primary care provider after this visit.

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icd9cm

[ [ [] ] ]

[ "45.13" ]

icd9pcs

[ [ [] ] ]

9491, 9497

6553, 8568

333, 338

9664, 9664

2784, 2784

11783, 12201

1753, 1822

9164, 9468

9518, 9643

9135, 9141

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1837, 2448

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11605, 11760

282, 295

366, 1625

2800, 3224

9679, 9791

1647, 1653

1669, 1737

9,988

176,973

24319

Discharge summary

report

Admission Date: [**2146-5-9**] Discharge Date: [**2146-5-12**] Date of Birth: [**2093-1-15**] Sex: M Service: OTOLARYNGOLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 4181**] Chief Complaint: Post tonsillectomy Hemorrhage Major Surgical or Invasive Procedure: Control/Cauterization of right tonsillar fossa History of Present Illness: 50yM with carcinoma of right tonsil with metastases to right neck POD5 s/p right extended tonsillectomy developed profuse bleeding. Patient was transported to OSH where he was intubated for airway protection and his oropharynx and nose was packed. He was then medflighted to [**Hospital1 18**] for further management after being transfused and volume repleted. Past Medical History: Gout Carcinoma of right tonsil as above Physical Exam: Intubated and sedated Nose: rapid rhino pack in both nares Oropharynx: copious blood clots. Blood soaked gauze packing removed. Bleeding site identified in right tonsillar fossa that was status post unilateral extended tonsillectomy. Neck: right level 2 and 3 firm [**Doctor First Name **] Brief Hospital Course: Patient was taken to the operating [**2146-5-9**]. A slow ooze was visualized from the right tonsillar fossa which was cauterized. The patient was then observed intubated overnight in the surgical ICU. On POD 1 he was successfully extubated and transferred out to the regular surgical floor. His diet was advanced to clear liquids and then soft solids which he tolerated well. He was discharged home on POD3 without further event. Medications on Admission: keflex roxicet indomethacin Discharge Medications: 1. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs PO Q4-6H (every 4 to 6 hours) as needed for pain. Disp:*300 ML(s)* Refills:*0* 2. Cepacol 2 mg Lozenge Sig: [**11-21**] Lozenges Mucous membrane Q4H (every 4 hours) as needed for sore throat. Disp:*50 Lozenge(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: 1) Post tonsillectomy bleed 2) Metastatic tonsil cancer Discharge Condition: good Discharge Instructions: Soft solid diet for two weeks. Follow up as soon as possible with Dr. [**Last Name (STitle) 61621**] to co-ordinate your cancer care. Go to your closest ER immediately if you experience any further bleeding Followup Instructions: Call Dr.[**Name (NI) 61622**] office for follow-up appointment as soon as possible

[ "E878.8", "998.11", "146.0", "E849.7", "285.9", "274.9", "198.89" ]

icd9cm

[ [ [] ] ]

[ "96.71", "28.7" ]

icd9pcs

[ [ [] ] ]

2015, 2021

1184, 1622

350, 399

2121, 2127

2384, 2469

1700, 1992

2042, 2100

1648, 1677

2151, 2361

868, 1161

281, 312

427, 790

812, 853

16,680

199,794

5592

Discharge summary

report

Admission Date: [**2159-3-4**] Discharge Date: [**2159-3-9**] Date of Birth: [**2085-6-27**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 783**] Chief Complaint: cough and shortness of breath Major Surgical or Invasive Procedure: Dialysis History of Present Illness: This is a 73 yo F with h/o poorly-controlled HTN, ESRD, and DM p/w cough and SOB. The cough was initially dry for 2 weeks, but is now productive of white sputum. Over the weekend it worsened in frequency and severity. She has cough-associated chest and b/t shoulder pain. She reports dyspnea over the past 3 days and worsened leg and abdominal swelling. She denies F/C/S. She is on HD MWF and has not missed a session. . On presentation to the ED her BP was 231/84 with HR = 67, SaO2 92% RA. She was unable to complete sentences and had rales half-way up her chest. She was started on a nitro gtt which was titrated up to 100 mcg/min with BP = 183/67. Renal was consulted for urgent dialysis but felt that the patient could wait until the morning. She was evaluated by the MICU attending who felt that she could be managed on the floor with a nitro gtt. She also received lasix 100 mg IV (no urine output response), morphine 2 mg IV, and regular insulin 10 units. . ROS: Of note, patient presented in Decemeber with similar cough; additionally, she had been seen in [**Month (only) **] by Pulmonary for cough. She also reports a hypoglycemic episode on Friday evening. Past Medical History: 1) Type 2 diabetes mellitus: Started insulin in [**2157**]. 2) Hypertension: Poorly controlled with many admissions to MICU/CCU for hypertensive urgency. 3) Renal artery stenosis: Last MRA [**1-6**] revealed 3 left renal arteries, superior with question of stenosis and middle with stenosis. 4) Hypercholesterolemia 5) ESRD on HD Q M, W, F. Followed by Dr. [**First Name (STitle) **] 6) Diastolic CHF 7) Osteoarthritis 8) Depression 9) Anxiety 10) Sickle cell trait 11) Hiatal hernia 12) Gastroesophageal reflux disease 13) Chronic constipation 14) History of mechanical falls. 15) Chronic anemia: Presumed secondary to renal failure. 16) Status post hysterectomy in [**2132**]. Social History: Lives at home with her husband. Moved to the US in [**2124**]. Originally from Barbados, but lived in [**Location **] for 20 years as well. She used to work as a medic in the PACU at [**Hospital1 18**], then later as a recreational assistant at another facility. Denies any alcohol use, no history of smoking, no IVDU. Family History: NC Physical Exam: Vitals: T 97.3 BP 196/90 P 68 RR 22 O2 100% 4LNC GEN: A&O x 3, pleasant, thin F sitting up in bed in NAD. no use of accessory muscles, talking in complete sentences. HEENT: EOMI, OP clear with MMM. Neck: JVD to level of jaw at 90 degrees. CV: RRR, nl S1/S2, no m/r/g LUNGS: crackles half-way up bilaterally ABD: soft, moderately distended, NT, +BS EXT: 1+ pitting edema b/t, warm. L AVF with palpable thrill. Pertinent Results: [**2159-3-4**] 06:30PM LACTATE-1.7 [**2159-3-4**] 05:45PM GLUCOSE-269* UREA N-60* CREAT-4.3* SODIUM-138 POTASSIUM-4.1 CHLORIDE-94* TOTAL CO2-30 ANION GAP-18 [**2159-3-4**] 05:45PM estGFR-Using this [**2159-3-4**] 05:45PM CK(CPK)-83 [**2159-3-4**] 05:45PM cTropnT-0.13* [**2159-3-4**] 05:45PM CK-MB-NotDone [**2159-3-4**] 05:45PM WBC-9.2 RBC-5.35# HGB-13.1# HCT-39.5# MCV-74* MCH-24.6* MCHC-33.3 RDW-20.0* [**2159-3-4**] 05:45PM NEUTS-78.0* LYMPHS-9.8* MONOS-4.6 EOS-5.3* BASOS-2.4* [**2159-3-4**] 05:45PM HYPOCHROM-1+ ANISOCYT-2+ MICROCYT-3+ [**2159-3-4**] 05:45PM PLT COUNT-114*# [**2159-3-4**] 05:45PM PT-15.3* PTT-30.4 INR(PT)-1.4* EKG: NSR @ 76, nl axis/intervals, TWI in III, aVF. . Studies: CXR ([**3-4**]): The cardiac silhouette is slightly decreased in size from [**2158-12-28**], where a pericardial effusion was suspected. The cardiac silhouette remains enlarged, however. The aorta is calcified. There is no pneumonia or congestive failure. No pleural effusion or pneumothorax. . Echo ([**2158-12-29**]): The LA is moderately dilated. The RA is moderately dilated. The estimated RA pressure is 11-15mmHg. There is mild symmetric LVH. The LV cavity size is normal. Overall left ventricular systolic function is normal (LVEF>55%). Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). The RV cavity is mildly dilated. RV systolic function is normal. The aortic valve leaflets (3) are mildly thickened. There is no aortic valve stenosis. No AR is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. Moderate [2+] TR is seen. The tricuspid regurgitation jet is eccentric and may be underestimated. There is moderate pulmonary artery systolic hypertension. Significant pulmonic regurgitation is seen. There is a very small pericardial effusion. There are no echocardiographic signs of tamponade. Compared with the prior study (images reviewed) of [**2158-9-5**], tricuspid regurgitation is now more prominent. Brief Hospital Course: * Hypertensive Urgency: The patient was compliant with all medications except Imdur. She was restarted on her home medications labetolol, lisinopril, nifedipine, hydralazine, clonidine, and imdur. We titrated up her labetalol and changed to TID while hospitalized. The patient was also likely fluid overloaded and underwent daily dialysis to remove extra fluid. Upon discharge the pt's SBP was between 120-160. The patient agreed to follow up with her pcp for further management of her medications and medications. . * ESRD on HD: The patient underwent hemodialysis daily while hospitalized without complications to remove excess fluid as the likely cause of her hypertension. . * DM: While in the hospital the patient had multiple episodes of hypoglycemia. [**Last Name (un) **] was consulted, and the patients lantus dose was decreased. The patient is to follow up with [**Last Name (un) **] as an outpatient . Medications on Admission: 1. Labetalol 200 mg PO BID 2. Lisinopril 40 mg PO QD 3. Nifedipine 180 mg QD 4. Hydralazine 50 mg PO BID 5. Clonidine 0.3 mg PO BID 6. Isosorbide Mononitrate 60 mg Sustained Release PO DAILY (has not been taking) 7. Atorvastatin 10 mg PO DAILY 8. Pantoprazole 40 mg PO once a day. 9. Ferrous Sulfate 325 PO DAILY 10. Clonazepam 1 mg PO BID 11. Folic acid 1 mg daily 12. Insulin Lantus 45 units QAM, 5 units Qpm 13. glyburide 2 mg [**Hospital1 **] 14. MVI 1 tablet daily 15. B12 50 mcg po daily 16. Tylenol prn arthritis 17. Sevelemer 400 mg TID 18. ASA 325 mg daily 19. Rhinocort Acqua Discharge Medications: 1. Insulin Glargine 100 unit/mL Cartridge Sig: One (1) injection Subcutaneous BREAKFAST (Breakfast): 30 units in morning 0 units at night. Disp:*qs one month* Refills:*2* 2. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 3. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* 4. Nifedipine 90 mg Tablet Sustained Release Sig: Two (2) Tablet Sustained Release PO DAILY (Daily). Disp:*60 Tablet Sustained Release(s)* Refills:*2* 5. Hydralazine 25 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Disp:*120 Tablet(s)* Refills:*2* 6. Clonidine 0.1 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). Disp:*180 Tablet(s)* Refills:*2* 7. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 9. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 10. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 11. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 12. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). Disp:*30 Cap(s)* Refills:*2* 13. Cyanocobalamin 100 mcg Tablet Sig: 0.5 Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 14. Sevelamer 400 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:*90 Tablet(s)* Refills:*2* 15. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr Sig: Three (3) Tablet Sustained Release 24 hr PO QHS (once a day (at bedtime)). Disp:*90 Tablet Sustained Release 24 hr(s)* Refills:*2* 16. Labetalol 200 mg Tablet Sig: 1.5 Tablets PO TID (3 times a day). Disp:*135 Tablet(s)* Refills:*2* 17. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Hypertension ---- Secondary End stage renal disease Diabetes Discharge Condition: Stable, normal blood pressure, pain free Discharge Instructions: HIGH BLOOD PRESSURE You were treated in the hospital for your high blood pressure. You underwent dialysis and your medications were adjusted in order to control your hypertension (high blood pressure). High blood pressure can lead to strokes, kidney problems and heart problems. Please follow these instructions carefully: * See your doctor soon to recheck your blood pressure. * In addition to seeing your doctor, you should also: 1. Not add salt to food and avoid salty food. 2. Relax and avoid stress as much as possible. Return to the Emergency Department or see your own doctor right away if any problems develop, including the following: * Blurry vision or any changes in your eyesight. * Bad headache or a headache that is getting worse. * Trouble speaking. * Trouble breathing or shortness of breath. * Chest pain or chest discomfort. * Confusion, drowsiness or any change in alertness. * Dizziness or fainting. * Any weakness or numbness in your arms or legs. * Anything else that worries you. We adjusted your medications. We added Imdur and increased your dosage of labetalol. We also decreased your Lantus dose **30 units and morning and none at night**. Please review the new medication dosages with Dr [**Last Name (STitle) 16258**]. Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs. Adhere to 2 gm sodium diet Fluid Restriction: Followup Instructions: Follow up with Dr [**Last Name (STitle) 16258**], your primary care provider on [**3-13**] at 10:15AM. Please discuss with Dr [**Last Name (STitle) 16258**] about obtaining a CT of the abdomen to work up your weightloss. Resume your regular dialysis schedule upon discharge. Provider: [**First Name11 (Name Pattern1) 5445**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 5446**], DPM Phone:[**Telephone/Fax (1) 543**] Date/Time:[**2159-3-28**] 10:30 [**First Name11 (Name Pattern1) 734**] [**Last Name (NamePattern1) 735**] MD, [**MD Number(3) 799**]

[ "250.00", "300.4", "465.9", "403.01", "272.0", "530.81", "585.6", "428.0", "285.21", "428.32", "564.00" ]

icd9cm

[ [ [] ] ]

[ "39.95" ]

icd9pcs

[ [ [] ] ]

8847, 8853

5151, 6072

343, 354

8958, 9001

3054, 5128

10487, 11085

2606, 2610

6708, 8824

8874, 8937

6098, 6685

9025, 10464

2625, 3035

273, 305

382, 1552

1574, 2254

2270, 2590

79,735

156,817

41370

Discharge summary

report

Admission Date: [**2134-3-10**] Discharge Date: [**2134-3-18**] Date of Birth: [**2080-6-21**] Sex: F Service: SURGERY Allergies: Penicillins Attending:[**First Name3 (LF) 598**] Chief Complaint: abdominal pain Major Surgical or Invasive Procedure: [**2134-3-10**]: ERCP, spincterotomy History of Present Illness: HPI: 53F with 2 weeks of jaundice, presenting with nausea, vomiting and RUQ/epigastric pain since last night. Patient had not seen any doctor for her 2 weeks of jaundice. Developed nausea last night and had 5 episodes of vomiting overnight. Also felt some chills, but no objective fevers. Pain started early this morning, constant in nature and progressively worse. Pt went to to [**Hospital3 10310**], had a WBC of 18.5 (17% bands), Tbili 10.7, lipase 1131. An U/S showed a CBD 15 mm, gallstones, no gallbladder wall thickenning or pericholecystic fluid. In the ED patient was slightly confused and BP down to 80/60s, improved with 1L bolus of NS. Past Medical History: Past Surgical History: laparoscopic exploration Social History: Social History: Lives alone, denies tobacco, EtOH, drugs Family History: NC Physical Exam: Physical Exam: upon admission: Vitals: T 97.2 HR 97 BP 124/70 RR 18 SO2 95% ra GEN: A&O, NAD HEENT: No scleral icterus, mucus membranes moist CV: RRR, No M/G/R PULM: Clear to auscultation b/l, No W/R/R ABD: Obese, soft, nondistended, tender to palpation in epigastrium/RUQ, no rebound or guarding, normoactive bowel sounds, no palpable masses Ext: No LE edema, LE warm and well perfused Pertinent Results: [**2134-3-18**] 04:45AM BLOOD WBC-16.6* RBC-3.92* Hgb-12.2 Hct-36.4 MCV-93 MCH-31.2 MCHC-33.6 RDW-16.2* Plt Ct-455* [**2134-3-17**] 05:07AM BLOOD WBC-18.3* RBC-3.71* Hgb-11.8* Hct-34.9* MCV-94 MCH-31.8 MCHC-33.7 RDW-16.0* Plt Ct-452* [**2134-3-16**] 06:30AM BLOOD WBC-20.1* RBC-3.79* Hgb-11.8* Hct-35.7* MCV-94 MCH-31.1 MCHC-33.0 RDW-15.7* Plt Ct-424 [**2134-3-15**] 05:10AM BLOOD WBC-19.6* RBC-3.85* Hgb-11.9* Hct-36.5 MCV-95 MCH-31.0 MCHC-32.7 RDW-15.7* Plt Ct-341 [**2134-3-12**] 04:37AM BLOOD WBC-20.1*# RBC-3.97* Hgb-12.5 Hct-38.5 MCV-97 MCH-31.3 MCHC-32.4 RDW-15.7* Plt Ct-240 [**2134-3-11**] 02:07AM BLOOD WBC-12.5* RBC-4.43 Hgb-13.9 Hct-43.7 MCV-99* MCH-31.4 MCHC-31.9 RDW-15.8* Plt Ct-276 [**2134-3-10**] 06:40PM BLOOD WBC-14.0* RBC-4.26 Hgb-13.4 Hct-41.7 MCV-98 MCH-31.4 MCHC-32.1 RDW-15.6* Plt Ct-286 [**2134-3-18**] 04:45AM BLOOD Neuts-78.2* Lymphs-15.5* Monos-2.1 Eos-3.2 Baso-0.9 [**2134-3-18**] 04:45AM BLOOD Plt Ct-455* [**2134-3-18**] 04:45AM BLOOD PT-18.1* INR(PT)-1.6* [**2134-3-17**] 05:07AM BLOOD Plt Ct-452* [**2134-3-17**] 05:07AM BLOOD PT-27.3* PTT-31.5 INR(PT)-2.7* [**2134-3-18**] 04:45AM BLOOD Glucose-110* UreaN-6 Creat-0.6 Na-141 K-3.7 Cl-102 HCO3-31 AnGap-12 [**2134-3-17**] 05:07AM BLOOD Glucose-107* UreaN-4* Creat-0.5 Na-140 K-3.6 Cl-99 HCO3-33* AnGap-12 [**2134-3-16**] 06:30AM BLOOD Glucose-83 UreaN-4* Creat-0.5 Na-144 K-3.3 Cl-101 HCO3-34* AnGap-12 [**2134-3-10**]: EKG: Sinus rhythm. Prominent inferior lead Q waves are non-diagnostic. Low precordial lead QRS voltage. Modest diffuse ST-T wave changes. Findings are non-specific. Clinical correlation is suggested. No previous tracing available for comparison [**2134-3-18**] 04:45AM BLOOD ALT-24 AST-26 AlkPhos-129* TotBili-1.6* [**2134-3-17**] 05:07AM BLOOD ALT-29 AST-30 AlkPhos-132* TotBili-1.6* [**2134-3-16**] 06:30AM BLOOD ALT-37 AST-29 LD(LDH)-243 AlkPhos-144* Amylase-22 TotBili-1.9* [**2134-3-11**] 02:07AM BLOOD ALT-209* AST-119* LD(LDH)-218 AlkPhos-356* Amylase-523* TotBili-6.9* [**2134-3-10**] 06:40PM BLOOD ALT-216* AST-135* AlkPhos-360* TotBili-9.5* [**2134-3-16**] 06:30AM BLOOD Lipase-34 [**2134-3-15**] 05:10AM BLOOD Lipase-41 [**2134-3-12**] 02:13AM BLOOD Lipase-267* [**2134-3-11**] 02:07AM BLOOD Lipase-1529* [**2134-3-10**] 06:40PM BLOOD Lipase-3148* [**2134-3-18**] 04:45AM BLOOD Calcium-8.2* Phos-3.5 Mg-2.2 [**2134-3-17**] 05:07AM BLOOD Calcium-8.3* Phos-3.4 Mg-2.3 [**2134-3-13**] 05:15AM BLOOD calTIBC-217* TRF-167* [**2134-3-15**] 09:30PM BLOOD Lactate-0.9 [**2134-3-15**] 01:24PM BLOOD Lactate-1.1 [**2134-3-10**] 06:44PM BLOOD Lactate-2.5* K-4.3 [**2134-3-15**] 09:30PM BLOOD Hgb-11.9* calcHCT-36 [**2134-3-10**]: EKG: Sinus rhythm. Prominent inferior lead Q waves are non-diagnostic. Low precordial lead QRS voltage. Modest diffuse ST-T wave changes. Findings are non-specific. Clinical correlation is suggested. No previous tracing available for comparison. [**2134-3-11**]: chest x-ray: FINDINGS: The lung volumes are low. There are bilateral areas of atelectasis, left more than right, with multiple air bronchograms. Presence of a minimal left pleural effusion cannot be excluded. No evidence of pulmonary edema. Borderline size of the cardiac silhouette. No evidence of pneumonia or pneumothorax [**2134-3-12**]: Chest x-ray: There is no change in cardiomegaly, left lower lobe consolidation and interstitial pulmonary edema. Bilateral atelectasis and pleural effusion are most likely present, unchanged. [**2134-3-15**]: chest x-ray: FINDINGS: As compared to the previous radiograph, the lung volumes have increased, potentially reflecting improved ventilation. However, there is still evidence of moderate cardiomegaly with a mild-to-moderate left pleural effusion and subsequent left retrocardiac atelectasis. At the bases of the right lung, a plate-like atelectasis is seen. No newly occurred focal parenchymal opacity suggesting pneumonia. No evidence of pneumothorax. [**2134-3-16**]: cat scan abdomen and pelvis: IMPRESSION: 1. No pulmonary embolism. Bibasilar atelectasis with small bilateral pleural effusions. 2. Extensive peripancreatic fat stranding with a small-to-moderate degree of mesenteric and para-renal fluid, but no well-defined fluid collections. No pancreatic necrosis, pseudocyst, or vascular compromise. 3. Biliary stent without biliary ductal dilatation. Nondistended gallbladder may contain sludge or stones. 4. Fatty liver. Brief Hospital Course: 53 year old female admitted to the Acute care service with abdominal pain, jaundice, nausea and vomitting. Upon admission to the emergency room, she was hypotensive, and confused requiring intravenous fluids. She was admitted to the intensive care unit for intravenous hydration and monitoring. The GI service was consulted and based on her physical examination and blood work an ERCP was recommended. She underwent an ERCP on HOD #1. She was reported to have an impacted stone in the bile duct and underwent removal of the stone with placment of a stent. Overnight, she was monitored in the intensive care unit requiring additional intravenous fluids for decreased urine output. She was also maintained on ciprofloxacin and flagyl. Her liver function tests slowly improved and the intensity of her pain diminished. She was transferred to the regular floor on HD#3. Her foley catheter was discontinued at this time and she was voiding without difficulty. During this time, she did have bouts of confusion which were thought to be related to the narcotics for analgesic management. Nutrition service evaluated the patient and made recommendations about her nutritional status. She did have a mild elevation of her INR to 2.7 during her hospitalization, but his decreased to 1.6 over the last few days. On HD #7, she had an episode of decreased oxygenation. Despite a nebulizer treatment, she did receive a dose of lasix with improvment of her oxygenation. She continued to have bouts of oxygen desaturation and was taken for a chest cat scan after placment of a PICC line for intravenous access. The cat scan was negative for a pulmonary embolism but did show bibasilar atelectasis and small bilater pleural effusions. She has maintained her oxygen saturation at 96-98% on room air at rest, but continues to desaturate to 88-95% on room air while ambulating. Her vital signs have been stable and she is afebrile. She is tolerating a regular diet and voiding without difficulty. She has ambulated in the [**Doctor Last Name **] and has been encouraged to use the incentive spirometer. She is requiring minimal analgesia for management of her abdominal pain. Her antibiotics were discontinued on HD#9. She is planning for dicharge home with VNA services to assess her cardio-pulmonary status. She has been intstructed to follow up with the Acute care service in 2 weeks for discussion about elective cholecystectomy. She will need to follow-up with ERCP 1 month for stent removal. Medications on Admission: Medications: calcium with vit. D 500 mg daily, dulcolax 5 mg bedtime, lopid 600 mg twice daily, zantac 150 mg daily, senakot 2 tabs twice daily, tylenol 650 mg as needed for h/a, body aches, clozaril 200 mg bedtime Discharge Medications: 1. Lopid 600 mg Tablet Sig: One (1) Tablet PO twice a day. 2. Zantac 150 mg Tablet Sig: One (1) Tablet PO once a day. 3. senakot Sig: Two (2) tablets twice a day: hold for diarrhea. 4. acetaminophen 650 mg Tablet Sig: One (1) Tablet PO every six (6) hours: as needed for headache, body ache. 5. Clozaril 100 mg Tablet Sig: Two (2) Tablet PO at bedtime. 6. bisacodyl 5 mg Tablet Sig: One (1) Tablet PO at bedtime: hold for diarrhea. 7. calcium with vitamin D 500 mg every morning Discharge Disposition: Home With Service Facility: Able Nursing Discharge Diagnosis: Cholangitis Cholelithiasis Gallstone pancreatitis 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 with right upper quadrant pain. You had an ultrasound done which showed gallstones. You underwent ERCP which showed a large stone in the common bile duct. The stone was removed and you had a stent placed in the bile duct. Your pain has decreased and your liver enzymes have improved. You are now preparing for discharge home with follow-up for gallbladder removal. Your discharge instructions are outlined: Please call your doctor or nurse practitioner or return to the Emergency Department for any of the following: *You experience new chest pain, pressure, squeezing or tightness. *New or worsening cough, shortness of breath, or wheeze. *If you are vomiting and cannot keep down fluids or your medications. *You are getting dehydrated due to continued vomiting, diarrhea, or other reasons. Signs of dehydration include dry mouth, rapid heartbeat, or feeling dizzy or faint when standing. *You see blood or dark/black material when you vomit or have a bowel movement. *You experience burning when you urinate, have blood in your urine, or experience a discharge. *You have shaking chills, or fever greater than 101.5 degrees Fahrenheit or 38 degrees Celsius. *Any change in your symptoms, or any new symptoms that concern you. Please resume all regular home medications , unless specifically advised not to take a particular medication. Also, please take any new medications as prescribed. Followup Instructions: Please folow up with the Acute care service in 2 weeks. You can schedule your appointment by calling # [**Telephone/Fax (1) 600**] You will also need to follow up with ERCP in 1 month for stent removal. They will contact you about this. [**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD [**MD Number(2) 601**] Completed by:[**2134-3-18**]

[ "576.1", "574.91", "780.71", "577.0", "729.1" ]

icd9cm

[ [ [] ] ]

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54351

Discharge summary

report

Admission Date: [**2102-2-11**] Discharge Date: [**2102-2-13**] Date of Birth: [**2064-5-30**] Sex: F Service: MEDICINE Allergies: Morphine / Penicillins / Peanut / Fish Product Derivatives Attending:[**First Name3 (LF) 759**] Chief Complaint: Throat tightness and chest pressure. Major Surgical or Invasive Procedure: None. History of Present Illness: Patient is a 37 year old female with history of shellfish allergy who presents with throat tightness and chest pressure after consuming cocktail sauce containing seafood. . Patient was in her usual state of health until this evening. She and her husband when out to eat at a Chinese food restaurant where they have eaten a number of times in the past; she informed the staff of her allergies. After eating a bite of a chicken dish, she noted some tightness and itching in her mouth and throat. She then asked the waiter about the food and it was discovered that the vegetables were cooked in oyster sauce. She immediately administered her epinephrine pen, then her second epinephrine pen. She gave herself two 50 mg of benadyrl quick dissolve tabs and then 20 mg of pepcid. She also gave herself a puff of her albuterol inhaler. . EMS was called since she noted chest tightness and continued throat tightness and itchy. She felt her skin was itchy as well. She was given an additional 50 mg of IM benadryl by EMS. . In the emergency room, her initial vital signs were BP 110/79, heart rate 77, respiratory rate of 16, and oxygen saturation of 97% on room air. She was given 125 mg of solumedrol, 40 mg of famotidine IV, and 4 mg of zofran, with improvement in her symptoms. A chest x-ray did not reveal any acute pathology. Past Medical History: - Anaphylaxis reactions to fish products: Patient reports that she has been intubated once after a reaction. Her usual symptoms are throat and chest tightness and itching. She does have wheezing at times, and flushing of her skin without hives. She reports that she has had a history of secondary/rebound reactions that have occurred hours to days (up to a week) after the initial symptoms. She is followed by an allergist at [**Hospital1 336**], and has been on prolonged courses of scheduled benadryl for her symptoms. - Hypothyroidism, since resolved and not currently on medications. - Status-post Cesarian section - Status-post appendectomy - Status-post exploratory laparotomy Social History: Patient lives at home with her husband and 5 of her children; another child is grown. She does not smoke, drink alcohol, or use ilicit drugs. She is not currently employed outside of the house. Family History: Mother with history of hypertension and diabetes mellitus type 2. Father with hypertension. Sister with epilepsy. Physical Exam: VITAL SIGNS - Temp 97.8 F, BP 110/79 mmHg, HR 97 BPM, RR 20 X', O2-sat 99% RA . GENERAL - well-appearing african-american woman in NAD, comfortable, appropriate. HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear NECK - supple, no thyromegaly, no JVD, no carotid bruits LUNGS - CTA bilat, no r/rh/wh, good air movement, resp unlabored, no accessory muscle use HEART - PMI non-displaced, RRR, no RG, nl S1-S2, SEM [**3-23**] in RUSB that increases in phase [**4-19**] of valsalva ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no rebound/guarding EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs) SKIN - no rashes or lesions LYMPH - no cervical, axillary, or inguinal LAD NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength [**6-20**] throughout, sensation grossly intact throughout, DTRs 2+ and symmetric, cerebellar exam intact, steady gait Pertinent Results: On Admission: [**2102-2-12**] 04:40AM BLOOD WBC-8.0# RBC-3.70* Hgb-11.8* Hct-33.8* MCV-91 MCH-31.8 MCHC-34.9 RDW-13.2 Plt Ct-305 [**2102-2-12**] 04:40AM BLOOD PT-13.8* PTT-28.2 INR(PT)-1.2* [**2102-2-12**] 04:40AM BLOOD Glucose-175* UreaN-15 Creat-0.7 Na-136 K-5.2* Cl-109* HCO3-20* AnGap-12 [**2102-2-12**] 04:40AM BLOOD Calcium-8.6 Phos-2.5* Mg-1.9 [**2102-2-12**] 05:03AM BLOOD Lactate-2.1* CXR: Lung volumes are mildly diminished with minimal left base atelectasis. No consolidation or edema is noted. The mediastinum is unremarkable. The cardiac silhouette is within normal limits for size. No effusion or pneumothorax is noted. The visualized osseous structures are unremarkable. IMPRESSION: No acute pulmonary process. Brief Hospital Course: Patient is a 37 year old female with past medical history of anaphylaxic reactions in response to seafood who presents with her typical symptoms after consumption of cocktail sauce containing seafood. . # Anaphylaxis: Patient has a hsitory of reactions to fish and peanuts with anaphylaxis symptoms of wheezing, throat tightness, chest tightness, and flushing. She has a history of intubation and rebound/delayed reactions which prompted her admission to the ICU. In the unit famotidine and benadryl were continued and she was stable overnight. There was concern for late-onsen anaphylaxis, so patient was kept to monitor clinically for another 24 hours in the medical floor. She was discharged with follow up with his allergy doctor and on a prednisone [**Doctor Last Name 2949**], albuterol inhaler and ranitidine (see medication list). . # FEN: Regular diet. . # Prophylaxis: Heparin SQ for DVT prophylaxis, on famotidine as noted above, bowel regimen if needed. . # Access: 20 gage in right hand . # Code: Full . # Communication: Husband [**Name (NI) **] ([**Telephone/Fax (1) 111292**] . # Dispo: Home tomorrow if stable. Medications on Admission: Epinephrine pen PRN Benadryl 50 mg PO Q6hrs PRN Pepcid 20 mg PO Daily PRN Albuterol inhaler 1 PUFF Q6hrs PRN Discharge Medications: 1. Epinephrine 0.3 mg/0.3 mL Pen Injector Sig: One (1) Injection (0.3 mL) Intramuscular Every 5 minutes as needed for Severe allergy symptoms. Disp:*2 Pens* Refills:*0* 2. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: Three (3) mL Inhalation every six (6) hours as needed for shortness of breath or wheezing. Disp:*180 mililiters* Refills:*0* 3. Diphenhydramine HCl 25 mg Capsule Sig: Two (2) Capsule PO every six (6) hours for 14 days: This medication has sedative effects. Please do not drive or do high-risk activities, because your concentration may be impaired while taking this medication. Disp:*96 Capsule(s)* Refills:*0* 4. Prednisone 10 mg Tablet Sig: See below Tablet PO once a day: Day 1: 60 mg (6 tablets) Day 2: 40 mg (4 tablets) Day 3: 40 mg (4 tablets) Day 4; 40 mg (4 tablets) Day 5: 20 mg (2 tablets) Day 6: 20 mg (2 tablets) Day 7: 20 mg (2 tablets) Day 8: 10 mg (1 tablet) Day 9: 10 mg (1 tablet) Day 10: 10 mg (1 tablet). Disp:*27 Tablet(s)* Refills:*0* 5. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO twice a day for 14 days. Disp:*28 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: Anaphylaxis [**Telephone/Fax (1) **] Discharge Condition: Stable, breathing comfortably on room air, tolerating diet, without any skin rash. Discharge Instructions: You were seen at the [**Hospital1 18**] for an allergic reaction to seafood. You arrived to the ER after administering yourself epinephrine and benadryl. You were admitted to the ICU for monitoring, where you were stable without any more epinephrine requirements. . You were given benadryl and albuterol on standing basis (see attached medication sheet) and you were started on prednisone. You will need a very slow [**Doctor Last Name 2949**] of this medication to avoid relapse. . You will need follow up with your allergist at [**Hospital1 336**]. . You were also found to be anemic. You should have this followed up by your primary care doctor. . If you have severe itching, shortness of breath, wheezing that did not respond to the inhaler or anything else that bothers you, please come back to the ER. Followup Instructions: Follow up with your allergy doctor [**First Name (Titles) **] [**Last Name (Titles) 336**]. You can call them at [**Telephone/Fax (1) 111293**]. I spoke with their office, but they are on vacation and are looking how to best accomodate you. They should contact you within the next day or two. . Please follow up with your primary care doctor [**First Name (Titles) 4120**] [**Last Name (Titles) **]. . Please follow up with Dr. [**Last Name (STitle) 20015**] within 2 weeks.

[ "414.00", "V45.81", "244.9", "995.65", "285.9" ]

icd9cm

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icd9pcs

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46278

Discharge summary

report

Admission Date: [**2116-2-19**] Discharge Date: [**2116-2-26**] Date of Birth: [**2065-10-15**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2181**] Chief Complaint: diffuse body pain Major Surgical or Invasive Procedure: RIJ placement History of Present Illness: 50 yo lady h/o depression, etoh abuse/polysubstance abuse, anemia/GIB [**2-28**] to PUD on EGD in [**2114**], SLE, non compliant with medical care presents with failure to thrive, diffuse body pain and anemia. Patient reports diffuse pain in "mind, body and spirit" x 2 weeks. She came to the ED today after prompting from her mother and sister. She lives alone with her dog. She has a h/o physical abuse by her husband but had not had contact with him recently. She reports drinking a pint of vodka daily, does not eat meals, says she does not have the energy to make meals. Her last drink was yesterday. She last took a bath about a month ago, says she is too week to get into the bath. She has not seen her PCP [**Name Initial (PRE) 14169**] [**2114**], has not had any med refills and therefore is currently not taking any medication. She walks around her apartment but spends most of her time in bed. She denies using any drugs, she smokes [**1-28**] ppd. She denies any recent abuse by friends/family. On ROS, she denies chest pain or pressure, no difficulty breathing but has DOE with minimal activity at home. Denies abdonimal pain, nausea, vomiting, stools are not normal but she cannot characterize, says "I don't know". Endorses dysuria x one week. Also c/o joint pains, foot pain and knee pain. . In the ED VS 97.8 99 105/66 16 100% Ra. Labs remarkable for Hct of 19, K of 1.7, Na 130. She became hypotensive to the 60's, RIJ was placed, given total 3L NS, 3 units of blood. 120 meq KCl given. On transfer SBP in mid 90's. Stool guaiac positive but not frankly blood, no melena. NG lavage not performed. She also received 1 mg Ativan but no other sedation. . Interval Hx: [**10-31**] noted black tarry stool, called [**Company 191**] but looks like did not seek medical attention. Seen in ED [**10-1**] with knee pain, d/ced home. [**7-1**] ED for intoxication. Last seen by PCP [**Last Name (NamePattern4) **] [**9-30**]. Past Medical History: 1) GIB [**2-28**] PUD, NSAID use, chronic abdominal pain; last called [**Company 191**] [**10-31**] with tarry stools and did not seek medical attention ---EGD [**5-/2114**]: Grade I esophagitis with no bleeding; A single cratered non-bleeding 15mm ulcer was found in the Pre-pyloric region. Cold forceps biopsies were performed for histology. A single superficial non-bleeding 7 mm ulcer was found in the pre-pyloric region. Duodenitis; A single cratered non-bleeding 10 mm ulcer was found in the duodenal bulb. A single superficial non-bleeding 7mm ulcer was found in the duodenal bulb. ---Colonoscopy [**5-/2114**]: Grade 1 internal hemorrhoids were noted. 2) Iron deficiency Anemia 3) h/o substance abuse: in the past tox screen positive for cocaine, amphet., opiates, and benzos 4) EtOH abuse 5) h/o physical abuse, abusive manipulative relationship with her husband. [**Name (NI) 4906**] prior alcoholic also. [**6-26**] husband physically [**Name2 (NI) **] patient to point police notified, he was jailed, and patient evaluated by trauma team in ER. 6) h/o non-compliances, missed many [**Company 191**] appointment, behavioral contract, has violated narcotics contracts 7) h/o SLE for > 20yrs: h/o membranous glomerular nephritis/nephrotic syndrome. On steroids and plaquenil in the past. Many different providers. [**Doctor First Name **] 1:320 speckled pattern 0/99, admitted in past with abdmonial pain [**2-28**] SLE vasculitis s/p ex lap found to have ascites, vasculitis not confirmed on path. Also h/o pericarditis, joint pain, hair loss. Was supposed to see rheum but never followed up 8) Depression: h/o SI, psych admit, splitting. 9) h/o PNA [**2109**] 10) Leg pains, multiple complaints of pain in the past 11) Migraines 12) Pelvic inflammatory disease status post total abdominal hysterectomy, bilateral salpingo-oophorectomy Social History: Complicated social hx, h/o phsycial abuse by husband, substance/EtOH abuse as above. Living alone on disability, has a dog at home, has not seen husband recently. Mother and sister look in on her. Tob: [**1-28**] ppd Drugs: none recently Etoh: vodka 1 pint daily Family History: The patient's father has lupus now has prostate CA. She has 3 sisters all of whom also have lupus reportedly, one of whom died several years ago. Physical Exam: VS: Wt 57 kg T 99.5 HR 97 BP 103/71 RR 21 O2 sat 98% RA GEN: cachectic, dischevelled HEENT: very dry mucous membranes, sunken eyes, extremly poor dentition, pupils 2 mm b/l sluggish to react. Neck: supple, no JVD, RIJ slightly tender to touch, no erythema, swelling LUNGS: CTA b/l no wheezing, rales, rhonchi, poor air movement CVS: nl S1 S2, RRR, PMI non displaced, split S2 ABD: midline scar, soft, NT x 4, ?hepatomegaly, no splenomegaly, BS+ EXT: dry, wasted, no edema NEURO: Oriented to self, says she is in the ED, year is "70", says [**Month (only) 404**], says Wednesday with prompting, CN II-XII tested and intact, strength 4/5 b/l LE, [**5-30**] upper extremities, sensations intact. MSK: poor muscle tone, no bony deformities, no swelling, tenderness or effusion of knee, ankles, wrists. Pertinent Results: CHEST PORT. LINE PLACEMENT [**2116-2-19**] 4:57 PM CHEST, ONE VIEW: Comparison with [**2116-2-19**], 14:50 p.m., and multiple chest radiographs as far back as [**2114-5-1**], also chest CTA, [**2115-10-11**]. The extreme right costophrenic angle is excluded from this study. A right internal jugular vein line is seen in the distal SVC. The remainder of the visualized chest is unchanged since the examination of 2.5 hours prior. No pneumothorax is seen on this single supine view. IMPRESSION: Successful right internal jugular vein central venous line placement, without definite pneumothorax. If pneumothorax is of clinical concern, repeat radiograph in upright position or left lateral decubitus (right side up) should be performed. . CHEST (PORTABLE AP) [**2116-2-19**] 2:46 PM Portable AP chest radiograph was compared to [**2115-10-11**]. The heart size is normal. Mediastinum has normal position, contour, and width. The lungs are unremarkable. There is no pleural effusion. IMPRESSION: No evidence of intrathoracic pathology. . CT HEAD W/O CONTRAST [**2116-2-20**] 6:17 PM CT HEAD WITHOUT CONTRAST: No evidence of intracranial hemorrhage, mass effect, shift of normally midline structures, or major vascular territorial infarct is apparent. There are unchanged linear fracture lines in the right occipital skull. Size of ventricles, sulci, and basal cisterns is somewhat more prominent than would be expected for a patient of this age and may be related to ethanol toxicity associated brain atrophy. Visualized paranasal sinuses and mastoid air cells are clear. The surrounding soft tissue structures appear unremarkable. IMPRESSION: Stable right occipital skull fracture. No evidence of acute intracranial hemorrhage or mass effect. EKG [**2-19**] Baseline artifact Sinus tachycardia Nonspecific ST-T wave changes although baseline artifact makes assessment difficult Since previous tracing of [**2115-10-11**], ST-T wave changes suggested but baseline artifact makes comparison difficult . CHEST (PORTABLE AP) [**2116-2-22**] 10:35 AM CHEST (PORTABLE AP) Reason: interval change, pneumonia, effusion? [**Hospital 93**] MEDICAL CONDITION: 50 year old woman with anemia and wt loss. Desating, crackles on exam. REASON FOR THIS EXAMINATION: interval change, pneumonia, effusion? PORTABLE CHEST [**2116-2-22**] AT 7:40 INDICATION: Desaturation crackles. COMPARISON: [**2116-2-19**]. FINDINGS: There are new bibasilar pleural effusions and associated atelectatic changes. The possibility of a left lower lobe pneumonia cannot be excluded. Upper lungs are clear, and the pulmonary vascular markings are within normal limits. Heart size is normal. Right CVL identified with tip in SVC and no PTX. IMPRESSION: Interval development of bilateral effusions and basilar atelectasis; left lower lobe pneumonia cannot be ruled out. . Labs on discharge: [**2116-2-26**] 05:11AM BLOOD WBC-2.6* RBC-2.56* Hgb-7.7* Hct-22.9* MCV-90 MCH-30.2 MCHC-33.8 RDW-20.7* Plt Ct-430 [**2116-2-26**] 05:11AM BLOOD Glucose-94 UreaN-2* Creat-0.4 Na-141 K-3.7 Cl-112* HCO3-23 AnGap-10 [**2116-2-26**] 05:11AM BLOOD Albumin-2.0* Calcium-7.6* Phos-4.0 Mg-1.5* [**2116-2-19**] 09:51PM BLOOD VitB12-1434* Folate-5.9 [**2116-2-20**] 03:59AM BLOOD calTIBC-134* Ferritn-775* TRF-103* Brief Hospital Course: Ms. [**Known lastname 30207**] is a 50 yo lady with h/o [**Hospital 98395**] medical non compliance, etoh/substance abuse, h/o GI bleeding [**2-28**] to gastric/duodenal ulcers presents with anemia, diffuse body pain and failure to thrive. In the MICU, there was concern for refeeding syndrome. She was getting aggressive lyte repletion. EtOH withdrawal on CIWA scale. Psych was consulted. UTI with pan-sensitive E.Coli. Hct of 19, GI saw and refused scope. . # Anemia. Likely secondary to gastritis, PUD given h/o multiple ulcers, not on rx with PPI. Also chronically malnurished. Patient was seen by GI but refused EGD. Her Hct remained stable ~22 s/p 3 units of pRBCs given in the ED. H. pylori was negative. No evidence of hemolysis given h/o SLE. Patient was started on a PPI. Her labs were also c/w anemia of chronic disease. . # Hypokalemia/FTT. Most likely due to chronic malnutrition, anorexia, chronic etoh intake. Patient was agressively repleted with potassium, magnesium, calcium and phosphate. Her EKG did not show any changes c/w hypokalemia. She was monitored on telemetry. Nutrition consult recommended slow refeeding with liquids initially given risk for refeeding syndrome. Patient's phos dropped to 0.8 with initial refeeding. Patient did now show any evidence of heart failure however she did develop some pleural effusion and ?atelectasis given the volume resucitation. Her lytes were checked every 6-8 hrs and repleted as necessary. She has a RIJ for access. Patient's diet was slowly advanced and she tolerated this well. Her electrolytes stabilized and she only required occasional repletion. . # Psych. H/o depression, h/o SI. Currently denies SI, denies being abused. Patient seen by psych who felt she was in delirum more than withdrawl/depression. Patient developed some paranoia in the setting of her delirium and complained of nightmares and fear of people hurting her. She was confused at times, thinking the year was [**2079**] and she was at a different hospital. She was also having occasional delusion of persecution. Psych continued to follow and they recommended haldol 2mg [**Hospital1 **] to help with her paranoia. Ongoing follow up with psychiatry will be required as her delirium resolves. . # Etoh abuse/Substance Abuse. Patient was placed on a CIWA scale given last drink was the day prior to admission. Patient was initially [**Doctor Last Name **] ~11 on the CIWA with tachycardia and intermittent visual hallucinations. She was started on IV Valium loading q 2 hrs on [**2-20**] then by CIWA only. She did not have any seizure activity. She continued to be mildly tachycardic and still at high risk for withdrawl/DTs. Patient was treated with IV thiamine, MVI, folate and B12, maintenance IVF with D5. These levels were checked and normal/elevated. Her CIWA was discontinued on [**2-24**] as her scores were 1 and 2. She was continued on low dose ativan q8hr prn for anxiety. . # UTI. Reported dysuria x one week. U/A positive although not many WBCs. Urine culture was positive for Ecoli sensitive to cipro. Completed 7-day course of antibiotics. Repeat UA was clean and urine culture pending. . # SLE. Multiple complaints of arthralgias. Has never followed for ongoing care, has been on steroids in the past, ?lupus vasculitis in the past. No evidence of hemolysis given anemia. Pain initially controlled with IV morphine. Was switched to standing tylenol and oxycodone prn as was not requiring morphine. Protein/Cr ratio elevated mildly. Likely needs ongoing outpatient management. . # H/o domestic violence. Currently not in contact with husband. Continue privacy alert. . # Pain syndrome. Likely multifactorial given chronic illness, ?joint pains secondary to SLE. Patient received small doses of IV morphine with minimal benefit. Started tyenol. Likely needs PT. . # FEN. Diet advanced to regular on [**2-22**] however eating very little. Was getting daily calorie counts by nutrition. Given risk of refeeding syndrome [**Hospital1 **] lytes were checked and were repleted as necessary. . # PPx. Heparin SC BID, bowel reg prn, PO PPI [**Hospital1 **] . # Comm: [**Name (NI) 20855**] [**Name (NI) 30207**] Mother [**Name (NI) **] [**Telephone/Fax (1) 98396**] . # Code: full . Medications on Admission: none Discharge Medications: 1. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO DAILY (Daily) as needed for constipation. 3. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily). 4. Folic Acid 1 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. Haloperidol 1 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 7. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO once a day. 8. Nicotine 14 mg/24 hr Patch 24HR Sig: One (1) Patch 24HR Transdermal DAILY (Daily). Discharge Disposition: Extended Care Facility: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] Nursing Home - [**Location (un) 5503**] Discharge Diagnosis: Primary: Failure To Thrive EtOH abuse Anemia Delirium UTI . Secondary: h/o GIB Iron deficiency anemia SLE Depression Migraines Discharge Condition: Afebrile. Tolerating PO. Discharge Instructions: Please continue to take your medications as prescribed. . If you experience blood in your stool, dizziness, lightheadedness, chest pain, shortness of breath, inability to eat, or other concerning symptoms please call you doctor or seek medical attention. . If you develop thoughts of suicide or severe depression please seek immediate medical attention. Followup Instructions: Patient has an appointment with her PCP [**Last Name (NamePattern4) **]. [**First Name (STitle) **] [**Name8 (MD) **], M.D. on [**2116-3-24**] at 1:40pm.

[ "V15.81", "346.90", "511.9", "614.9", "801.01", "533.90", "291.81", "486", "280.9", "276.8", "263.9", "599.0", "304.71", "303.01", "783.7", "710.0" ]

icd9cm

[ [ [] ] ]

[ "38.93" ]

icd9pcs

[ [ [] ] ]

13753, 13885

8758, 13007

334, 349

14056, 14083

5463, 7587

14485, 14642

4482, 4629

13062, 13730

7624, 7695

13906, 14035

13033, 13039

14107, 14462

4644, 5444

277, 296

7724, 8310

8329, 8735

377, 2314

2336, 4185

4201, 4466

22,379

133,710

48581

Discharge summary

report

Admission Date: [**2176-10-21**] Discharge Date: [**2176-11-2**] Date of Birth: [**2124-7-12**] Sex: F Service: SURGERY Allergies: Ace Inhibitors Attending:[**First Name3 (LF) 1**] Chief Complaint: Rectal bleed Major Surgical or Invasive Procedure: Central line placement History of Present Illness: 52 yo female with PMH htn, SLE, presented to ED with constipation for 1 week, stomach upset for 2 days, then onset of bright red blood per rectum. Denies h/o BRBPR, melena, or ulcers. Has never had a colonoscopy. No fevers/chills. +Nausea, No vomiting. +Flatus. No urinary sx. No recent wt loss. Past Medical History: Htn SLE Depression Social History: Married. ESL teacher. To Tab/Occ EtOH/No drugs Family History: GM with gastric CA Physical Exam: 96.6, 83, 153/88, 18, 100%RA Heart RRR Lungs CTAB Abd mildly tender, nondistended, +mild rebound, no guarding, no hernia Rectal sphincter tight at 7 cm, Gross clot Ext WWP Pertinent Results: [**2176-10-20**] 07:25PM BLOOD WBC-6.7 RBC-3.56* Hgb-11.5* Hct-33.9* MCV-95 MCH-32.2* MCHC-33.9 RDW-13.2 Plt Ct-221 [**2176-10-20**] 10:10PM BLOOD Hgb-9.4* Hct-27.2* [**2176-10-21**] 03:15AM BLOOD WBC-10.7# Hct-33.3* Plt Ct-138* [**2176-10-20**] 07:25PM BLOOD PT-13.1 PTT-26.1 INR(PT)-1.1 [**2176-10-20**] 07:25PM BLOOD Glucose-106* UreaN-20 Creat-1.0 Na-134 K-3.6 Cl-99 HCO3-24 AnGap-15 [**2176-10-28**] 09:26AM BLOOD LD(LDH)-184 TotBili-0.3 DirBili-0.1 IndBili-0.2 [**2176-10-21**] 03:15AM BLOOD Calcium-7.3* Phos-3.0 Mg-1.2* [**2176-10-28**] 09:26AM BLOOD Hapto-179 [**10-20**] angiogram: Mesenteric angiogram of the SMA and [**Female First Name (un) 899**] demonstrates no active extravasation. [**10-20**] Abd and pelvis CT: 1. Extremely limited study due to lack of IV and oral contrast. Retal mass versus adherent clot within the rectal lumen . Direct visualization is recommended. Stranding around the rectum indicative of some inflammatory changes. 2. Normal caliber aorta. Dissection cannot be excluded on this non-contrast study. [**10-22**] Abd and pelvis CT: 1. Complex findings in the rectum, the appearance is suggestive of a large perirectal communicating ulcer which measures approximately 10 x 4 cm. In addition to this, there is some posterolateral extraluminal and anterior intersphincteric air.These findings are suggestive of local perforation. 2. Generalized increased intraabdominal fluid. 3. At least four discrete liver lesions, none of which are adequately characterized for which MR is recommended. [**10-24**]: A left subclavian catheter is in satisfactory position within the superior vena cava. There is no pneumothorax. There is a moderate-to-large right pleural effusion present. Adjacent atelectasis is noted in the right middle and lower lobes. Rectosigmoid, mucosal biopsy: Fragment of unremarkable colonic mucosa and multiple fragments of fibrinopurulent exudate with a small amount of granulation tissue consistent with base of an ulcer (non-specific findings) (multiple levels are examined). [**10-28**] Defogram IMPRESSION: Redundant mucosa on the anterior rectal wall. No other abnormality seen. [**10-30**] - CT OF THE PELVIS WITH RECTAL CONTRAST: Contrast can be seen within the rectum, and extending up to the splenic flexure. There is high density material, reflecting barium from recent defecogram still present within the colon., and resulting in significant streak artifact. There is no definite contrast extravasation from the rectum. No extraluminal air is identified. The ischiorectal fossa bilaterally demonstrates no inflammatory stranding. Some minimal thickening of the rectal wall which may be a result of incomplete distention. A thin amount of contrast is seen within the vagina from the prior study. The remainder structures are unchanged from prior exam. Brief Hospital Course: In the ED, NG lavage was negative. Hct fell from 33.9 to 27.2. Patient was transfused 2 U PRBC and admitted to the SICU. She was started on IV Levo and Flagyl. CT was suggestive of a large perirectal communicating ulcer which measures approximately 10 x 4 cm. In addition to this, there was some posterolateral extraluminal and anterior intersphincteric air. The patient was doagnosed with a bleeding solitary rectal ulcer and soon stabilized and was transferred to the floor. A central line was used for TPN. After the patient cliniacally imroved with no abdominal pain, diet was advanced uneventfully. Given a normal defogram and much improved CT, the patient was discharged home on HD # 13. She was given a 10 day course of PO Cipro and Flagyl to complete at home. Medications on Admission: Diovan Prozac Ibuprofen Discharge Medications: 1. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 10 days. Disp:*20 Tablet(s)* Refills:*0* 2. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 10 days. Disp:*30 Tablet(s)* Refills:*0* 3. Cyclobenzaprine 10 mg Tablet Sig: 0.5 Tablet PO TID (3 times a day) as needed for shoulder, neck pain. Disp:*30 Tablet(s)* Refills:*0* 4. Percocet 5-325 mg Tablet Sig: One (1) Tablet PO every [**4-24**] hours as needed for pain. Disp:*20 Tablet(s)* Refills:*0* 5. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day. Disp:*60 Capsule(s)* Refills:*2* 6. Metamucil Smooth Texture Packet Sig: One (1) packet PO three times a day. Disp:*90 packets* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Solitary rectal ulcer Discharge Condition: Good Discharge Instructions: Take your 2 antibiotics for 10 days. Take Colace and Metamucil, and eat a high fiber diet. You can continue to take your usual medications as you did prior to admission. Call with any increased pain, fever, blood in your stool, or other worrisome symptoms. Followup Instructions: Call Dr.[**Name (NI) 10946**] office on Monday for an appointment in 2 weeks. His number is ([**Telephone/Fax (1) 9011**]. Completed by:[**2176-11-3**]

[ "569.41", "560.39", "710.0", "401.9", "311", "263.9", "578.1", "285.1" ]

icd9cm

[ [ [] ] ]

[ "38.91", "88.47", "99.15", "48.24", "38.93", "99.04", "48.23" ]

icd9pcs

[ [ [] ] ]

5426, 5432

3839, 4617

285, 309

5498, 5505

991, 3816

5810, 5965

764, 784

4691, 5403

5453, 5477

4643, 4668

5529, 5787

799, 972

233, 247

337, 640

662, 682

698, 748

52,710

184,970

24732

Discharge summary

report

Admission Date: [**2167-6-6**] Discharge Date: [**2167-6-25**] Date of Birth: [**2094-2-10**] Sex: F Service: SURGERY Allergies: Benadryl / Lorazepam Attending:[**First Name3 (LF) 4691**] Chief Complaint: abdominal pain Major Surgical or Invasive Procedure: [**2167-6-6**] 1) Exploratory laparotomy with extensive adhesiolysis (>1.5 hours) 2) Reduction of incarcerated hernia 3) Incision, debridement and drainage of periurostomal intra-mesenteric abscess 4) Resection of obstructed, necrotic small bowel with primary anastomosis. 5) Repair of injury of small bowel. 6) Repair of colonic injury. History of Present Illness: 73F with c/o abd pain since last night. Poor historian but daughter states she initially complained of pain and nausea "food poisoning" on the [**8-31**]. Felt a bit better but then had worsening pain last night. Currently transferred from BIDN for evaluation. CT revealing air in ventral hernia. ROS: (+) per HPI (-) Denies fevers, chills, night sweats, unexplained weight loss, trouble with sleep; pruritis, jaundice, rashes; bleeding, easy brusing; headache, dizziness, vertigo, syncope, paresthesias; hematemesis, bloating, cramping, melena, BRBPR, dysphagia; chest pain, shortness of breath, cough, edema; urinary frequency, urgency Past Medical History: Past Medical History: rheumatoid arthritis hypothyroidism goiter Hypertension Hiatal hernia Restless leg syndrome Multiple myloma GERD h/o atypical mycobacterium OSA Cervical spondylosis Past Surgical History: Rt humerus repair Urostomy by Dr. [**Last Name (STitle) 365**] for unclear reasons at [**Name (NI) 882**] (patients daughter states that originally done because her "bladder was stripped" and caused constant burning... not malignancy. Complicated by postoperative Multiple bowel surgeries 10 years ago Shoulder repair Social History: Prior tobacco, no ETOH, no IVDU Family History: thyroid cancer in daughter Physical Exam: 97.3 79 118/56 18 96 GEN: A&O, appears uncomfortable and moaning but responsive to questioning. HEENT: No scleral icterus, mucus membranes moist CV: RRR, No M/G/R PULM: Clear to auscultation b/l, No W/R/R ABD: Soft, mildly distended, no tympany, diffusely tender to palpation, worst at ventral/parastomal hernia, large paraurostomy hernia, nonreducible, no rebound or guarding, decreased bowel sounds, no palbable masses DRE: Ext: No LE edema, LE warm and well perfused Brief Hospital Course: The patient was evaluated by the surgical service in the emergency department. CT scan of the abdomen demonstrated free air and evidence of necrotic small bowel. WBC was 11.4. On abdominal exam the patient was soft, mildly distended, no tympany, diffusely tender to palpation, worst at ventral/parastomal hernia, large paraurostomy hernia, nonreducible, no rebound or guarding, decreased bowel. Given these findings she was taken to the OR urgently for: 1) Exploratory laparotomy with extensive adhesiolysis (>1.5 hours) 2) Reduction of incarcerated hernia 3) Incision, debridement and drainage of periurostomal intra-mesenteric abscess 4) Resection of obstructed, necrotic small bowel with primary anastomosis. 5) Repair of injury of small bowel. 6) Repair of colonic injury. Post-operatively she remained sedated and intubated and was transferred to the Surgical ICU where she remained for approx 2 weeks. She required multiple pressors for septic shock and IVF resuscitation continued. She also developed ARDS with poor blood gases requiring high PEEP, low volume with high frequency ventilation. She was eventually weaned off the ventilator and extubated on [**2167-6-15**]. She remained in the ICU for another several days and was then transferred to the regular floor. Her abdominal wall was noted with erythema and edema and she underwent ultrasound-guided aspiration of the ascites fluid from the right parastomal hernia sac. Her sutures remain in place and will likely stay in for another 3-4 weeks, she will follow up in acute surgery clinic in [**12-31**] weeks. She has a urostomy that has been noted to put out large amounts of fluids requiring repletion with intravenous fluids and because of this a PICC line was placed due to her poor peripheral access. She was started on regular soft diet and has tolerated this well. Her NGT was removed and tube feedings stopped. She was evaluated by Physical and Occupational therapy and is being recommended for rehab. Medications on Admission: Medications: Requip 2mg TID Alendronate 35mg qwk Omeprazole 20mg daily Methotrexate 15mg qwk Iron 325mg TI week metoprolol 25mg daily synthroid 125mg daily salsalate 1500mg daily Discharge Medications: 1. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical three times a day: rash under breasts . 2. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QIDACHS (4 times a day (before meals and at bedtime)). 3. Levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Ropinirole 1 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 5. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**11-29**] Drops Ophthalmic four times a day as needed for dry eyes: both eyes. 6. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) ML Injection TID (3 times a day). 7. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily): apply to lower back region. 8. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 9. Ferrous Sulfate 300 mg (60 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Alendronate 70 mg Tablet Sig: 0.5 Tablet PO QFRI (every Friday). 12. Heparin Flush (10 units/ml) 1 mL IV PRN line flush Temporary Central Access-Floor: Flush with 10 mL Normal Saline followed by Heparin as above daily and PRN. 13. Tylenol 325 mg Tablet Sig: Two (2) Tablet PO every 4-6 hours as needed for fever or pain. Discharge Disposition: Extended Care Facility: [**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**] Discharge Diagnosis: - Small bowel obstruction with gangrenous jejunum in ventral incisional/periurostomal hernia. focal injuries of transverse colon and ileum due to involvement in abscess cavity. - Septic shock - ARDS Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: The suturing in your abdomen will remain in place for at least another month. Followup Instructions: Follow up in [**Hospital 2536**] clinic in 2 weeks, call [**Telephone/Fax (1) 600**] for an appointment. Provider: [**Name10 (NameIs) **] XRAY (SCC 2) Phone:[**Telephone/Fax (1) 1228**] Date/Time:[**2167-7-14**] 8:25 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2235**], MD Phone:[**Telephone/Fax (1) 1228**] Date/Time:[**2167-7-14**] 8:45 Completed by:[**2167-8-5**]

[ "995.92", "203.00", "714.0", "244.9", "551.21", "682.6", "518.81", "569.69", "569.83", "038.9", "567.22", "998.59", "293.0", "785.52", "327.23", "401.9", "E878.6" ]

icd9cm

[ [ [] ] ]

[ "54.0", "96.6", "46.75", "38.93", "45.62", "96.72", "54.91", "54.59", "99.15", "46.73", "38.91", "53.51" ]

icd9pcs

[ [ [] ] ]

6030, 6127

2465, 4450

295, 635

6370, 6370

6622, 7021

1926, 1955

4680, 6007

6148, 6349

4476, 4657

6520, 6599

1541, 1860

1970, 2442

240, 257

663, 1308

6385, 6496

1352, 1518

1876, 1910

19,568

102,532

28622

Discharge summary

report

Admission Date: [**2124-11-4**] Discharge Date: [**2124-11-7**] Date of Birth: [**2066-11-6**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 398**] Chief Complaint: transferred from OSH with ARF, SBP Major Surgical or Invasive Procedure: central venous catheter placement arterial line placement intubation thoracentesis History of Present Illness: 57 M with PMH of metastatic papillary renal cancer currently on the phase II XL880 protocol who initially presented today to [**Hospital3 8544**] with several days of worsened lower extremity swelling, abd pain, malaise, and vomiting. He was recently admitted to [**Hospital1 18**] from [**10-23**] - [**10-28**] for "swelling problems" and says by discharge he was feeling quite well. He was at home when 4 days prior to presentation he began to have worsened lower extremity and abdominal swelling. He also started to feel weak and cold, and notes that while he usually has a temp of about 98 PO, his NVA noted he was running presistently low, around 94 PO. He tried to treat with warming blankets without improvement. He noted decreased appetite, decreased PO intake, and worsened abd pain. He decided to go to the ED today after vomiting 3-4 times. He also notes that he had not had any urine for about 1 day immediately prior to admission. He says that he has recently been treated with both lasix and spironolactone for his lower extremity swelling/ascites with minimal improvement. . At [**Hospital3 8544**] ED he had a pericentesis which showed 1750 white cells and was treated with Zosyn for SBP. He also received Kayexalate 30 grams and an unclear amount of NS with resultant urine output via foley. He was transferred to [**Hospital1 18**] for further evaluation and treatment. . In the [**Hospital1 18**] ED, patient received 500 cc normal saline, 400 mg of cipro, and 1 amp of calcium gluconate. Patient has recurrent emesis x 1 and was treated with zofran. Past Medical History: ONC HX: Diagnosed with metastatic renal cell cancer after he developed a lingering cough and dyspnea and was found to have loss of lung volume in the left lung in [**7-14**]. CT scan showed an obstructing lesion in his left main stem bronchus with atelectasis of his entire left lung. CT scan of his torso as well as PET scanning showed lesions in his left kidney, left main stem bronchus, periaortic lymph node, and his thyroid. On flexible bronchoscopy, performed on [**2123-9-1**] by Dr. [**First Name (STitle) **] [**Name (STitle) **], he underwent debulking of the endobronchial lesion and had resultant hemoptysis. He has subsequently received a course of radiation treatment which he completed on [**9-29**]. He had a successful tumor excision, tumor destruction of the left mainstem obstruction and placement of a 12 mm x 40 mm covered Ultraflex stent to achieve left lower lobe patency. Since that time, and has decided to enroll in phase 2 XL 880 treatment and begin stage 2 XL880 research protocol 06-132 on [**2123-11-22**]. . PMH: # metastatic papillary RCC as noted above. # GERD # s/p appendectomy Social History: He lives alone, is divorced, and has a 16-year-old daughter. [**Name (NI) **] works as a heavy equipment mechanic and supervisor. He is currently not working, though he remains employed. He has never smoked. He drinks approximately one to two drinks per day; however, he has not drunk since his initial diagnosis. Family History: CAD and DM in father. Mother died in 40s from liver disease, which was possibly alcohol-related. Physical Exam: VS: T: 96.7 P: 102 BP: 93/67 RR: 22 O2 sat: 100% on 4L GEN: cachectic, NAD HEENT: EOMI, anicteric, clear OP, MMM, neck supple Lungs: CTAB, decreased BS on the L, no w/r/r Heart: RRR, nl S1, S2, no m/r/g Abd: firm, distended, tender to light palpation, no rebound, no guarding, + 1 pitting edema Ext: + 2 pitting edema to knees bilaterally, cool to touch but +2 distal pulses Neuro: A&Ox3. Appropriate. CN 2-12 grossly intact. Pertinent Results: [**2124-11-4**] 04:45PM BLOOD WBC-21.1*# RBC-4.53* Hgb-11.2* Hct-35.8* MCV-79* MCH-24.7* MCHC-31.3 RDW-19.7* Plt Ct-446* [**2124-11-5**] 05:35AM BLOOD WBC-28.2* RBC-4.94 Hgb-12.0* Hct-39.2* MCV-79* MCH-24.3* MCHC-30.6* RDW-18.3* Plt Ct-380 [**2124-11-5**] 03:01PM BLOOD WBC-26.7* RBC-4.79 Hgb-11.8* Hct-38.0* MCV-79* MCH-24.7* MCHC-31.1 RDW-19.4* Plt Ct-378 [**2124-11-6**] 04:00AM BLOOD WBC-32.0* RBC-4.31* Hgb-10.7* Hct-34.6* MCV-80* MCH-24.7* MCHC-30.8* RDW-18.4* Plt Ct-284 [**2124-11-4**] 04:45PM BLOOD PT-14.3* PTT-25.9 INR(PT)-1.3* [**2124-11-5**] 05:35AM BLOOD PT-13.3* PTT-23.6 INR(PT)-1.2* [**2124-11-5**] 03:01PM BLOOD PT-15.0* PTT-26.4 INR(PT)-1.3* [**2124-11-6**] 04:00AM BLOOD PT-18.3* PTT-33.7 INR(PT)-1.7* [**2124-11-4**] 04:45PM BLOOD Glucose-104 UreaN-36* Creat-2.0*# Na-136 K-4.7 Cl-104 HCO3-22 AnGap-15 [**2124-11-6**] 04:00AM BLOOD Glucose-120* UreaN-48* Creat-3.2* Na-134 K-5.6* Cl-100 HCO3-18* AnGap-22 [**2124-11-6**] 06:17PM BLOOD Glucose-125* UreaN-54* Creat-3.7* Na-132* K-5.4* Cl-98 HCO3-17* AnGap-22* [**2124-11-6**] 04:00AM BLOOD ALT-21 AST-36 LD(LDH)-622* AlkPhos-106 TotBili-0.3 [**2124-11-4**] 04:45PM BLOOD Albumin-2.0* Calcium-6.3* Phos-5.6*# Mg-1.7 [**2124-11-6**] 06:17PM BLOOD Calcium-6.2* Phos-8.6* Mg-2.4 [**2124-11-5**] 07:28PM BLOOD Type-ART Temp-34.8 pO2-88 pCO2-41 pH-7.30* calTCO2-21 Base XS--5 Intubat-NOT INTUBA [**2124-11-6**] 12:37AM BLOOD Type-ART Temp-37.2 PEEP-5 FiO2-100 pO2-227* pCO2-55* pH-7.17* calTCO2-21 Base XS--8 AADO2-439 REQ O2-75 Intubat-NOT INTUBA [**2124-11-6**] 04:07AM BLOOD Type-ART Temp-36.5 PEEP-5 pO2-118* pCO2-42 pH-7.27* calTCO2-20* Base XS--7 Intubat-INTUBATED [**2124-11-5**] 07:28PM BLOOD Lactate-2.7* [**2124-11-6**] 12:37AM BLOOD Lactate-2.6* . . . . . Studies: EKG [**2124-11-4**]: Sinus tachycardia. Borderline left axis deviation. Small non-diagnostic Q waves in lateral leads. Poor R wave progression which is non-diagnostic. Low QRS voltage in limb leads. Compared to tracing of [**2124-10-23**] heart rate is significantly faster. Clinical correlation is suggested. CXR [**2124-11-4**]: IMPRESSION: No significant interval change versus prior study with no new airspace disease. Effusion and consolidation persistent on the left, the latter perhaps post-obstructive but superimposed pneumonia cannot be excluded. Renal U/S [**2124-11-5**]: IMPRESSION: 1. No evidence of hydronephrosis. However, both kidneys are markedly compressed by very large renal cysts. The left renal cyst is slightly increased in size compared to [**2124-10-27**]. 2. Insufficient amount of ascites to perform paracentesis CXR [**2124-11-6**]: IMPRESSION: Increasing opacification in the left hemithorax consistent with pleural fluid. Endotracheal tube tip in good position CXR [**2124-11-6**]: FINDINGS: In comparison with earlier films of this date, there is better aeration of the upper half of the left lung. There may have been an interval thoracentesis. Otherwise, little change with tubes remaining in place. Brief Hospital Course: ASSESSMENT/PLAN: 57 M with PMH of metastatic papillary renal cancer on the phase II XL880 protocol who initially presented to [**Hospital3 8544**] with several days of worsened lower extremity swelling, abd pain, malaise, and vomiting, found to have SBP on paracentesis at [**Hospital **] transfered to ICU with worsening ARF and sepsis. . 1. SBP / Sepsis / Hypotension: OSH records reported paracentesis consistent with SBP. He was given a dose of zosyn then continued on ceftriaxone at [**Hospital1 18**], which was then changed to vancomycin/zosyn. He was hypothermic with a leukocytosis and hypotension. He was fluid resiscitated but required levophed and vasopressin to keep MAP > 65. Other sources of infection include urine (WBC on UA), lungs (vomited with possible aspiration). He also had a pleural effusion which was drained. Despite these interventions, Mr. [**Known lastname **] did not improve and he was made comfort measures only on [**2124-11-6**]. He expired on [**2124-11-7**]. . 2. Acute renal failure: Most likely combination of obstruction and prerenal etiology. Patient also had hypocalcemia and hyperphosphatemia. . 3. Respiratory failure: Most likely multifactorial in nature. Has renal mets to lungs. ?Infection/sepsis. Volume overload may also contribute to SOB. He was made CMO as above. Medications on Admission: celexa 60 mg PO QD oxycodone 5 mg PO q4-6 hours PRN pain sunitinib 50 mg PO daily x 28 days, then 14 days off toprol xl 100 PO QD verapamil 120 PO QD Discharge Medications: expired Discharge Disposition: Expired Discharge Diagnosis: Primary: sepsis spontaneous bacterial peritonitis acute renal failure Renal cell carcinoma Secondary: 1. Metastatic papillary RCC Diagnosed with metastatic renal cell cancer after he developed a lingering cough and dyspnea and was found to have loss of lung volume in the left lung in [**7-14**]. CT scan showed an obstructing lesion in his left main stem bronchus with atelectasis of his entire left lung. CT scan of his torso as well as PET scanning showed lesions in his left kidney, left main stem bronchus, periaortic lymph node, and his thyroid. On flexible bronchoscopy, performed on [**2123-9-1**] by Dr. [**First Name (STitle) **] [**Name (STitle) **], he underwent debulking of the endobronchial lesion and had resultant hemoptysis. He has subsequently received a course of radiation treatment which he completed on [**9-29**]. He had a unuccessful tumor excision, tumor destruction of the left mainstem obstruction and placement of a 12 mm x 40 mm covered Ultraflex stent to achieve left lower lobe patency. Since that time, and has decided to enroll in phase 2 XL 880 treatment and begin stage 2 XL880 research protocol 06-132 on [**2123-11-22**]. 2. GERD 3. s/p appendectomy 4. Hx of SVT 5. Hx of DVT s/p filter placement Discharge Condition: expired Discharge Instructions: expired Followup Instructions: expired

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icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

8646, 8655

7094, 8413

349, 433

9934, 9943

4091, 7071

9999, 10009

3529, 3628

8614, 8623

8676, 9913

8439, 8591

9967, 9976

3643, 4072

275, 311

461, 2033

2055, 3175

3191, 3513

32,177

150,130

31804

Discharge summary

report

Admission Date: [**2191-11-12**] Discharge Date: [**2191-12-1**] Service: MEDICINE Allergies: Aspirin / Warfarin / Vancomycin Attending:[**First Name3 (LF) 330**] Chief Complaint: Patient being transferred with mediastinal mass Major Surgical or Invasive Procedure: FNA of mediastinal mass Bronchoscopy Intubation with mechanical ventilation Tracheostomy surgical biospy of mediastinal mass History of Present Illness: 89F italian speaking woman with COPD, HTN, DM who presented to outside hospital on [**2191-11-3**] with increasing shortness of breath cough and wheezing. As per outside records, she had a cough productive of yellow sputum associated with shortness of breath for approximately 2 months. . On CT Chest she was found to have a large mediastinal mass deviating the trachea to the right, heterogeneous in nature suggestive of goiter with left hilar LAD and left lower consolidation with air bronchograms suggestive of post obstructive pneumonia. Patient was initially started on IV steroids, CTX and Flagyl and subsequently transitioned to Levo/flagyl. . Course was complicated by afib requiring transient Dilt gtt and ARF with elevation fo Cr to 4.0 on [**2191-11-9**]. Patient had a renal US without evidence of renal stones and renal lytes suggestive of a pre-renal etiology. . Patient did not require intubation and was transferred to [**Hospital1 18**] for further evaluation Past Medical History: NIDDM COPD HTN Dyslipidemia Bronchitis Gout Social History: Nonsmoker, occassional EtOH Family History: NC Physical Exam: Vitals - T:96.6 BP:92/39 HR:101 RR:24 02 sat: VENT Setting: AC 24x400 Fio2 1.0 PEEP 5 GENERAL: intubated and sedated SKIN: warm and well perfused, no excoriations or lesions, no rashes HEENT: AT/NC, supple neck, no LAD, no JVD CARDIAC: irregularly irregular, S1/S2, no mrg LUNG: wheezes in all lung fields, poor air movement. ABDOMEN: nondistended, +BS, slight tenderness LUQ, no rebound/guarding, no hepatosplenomegaly M/S: 2+ pitting edema bilaterally PULSES: 1+ DP pulses bilaterally NEURO: intubated and sedated Pertinent Results: Admission labs: 136 104 97 ---------------< 215 4.1 17 2.8 Ca: 7.4 Mg: 2.2 P: 3.9 LDH: 368 TSH:0.58 Free-T4:0.93 . WBC: 31.7 Hct: 32.1 Plt: 269 . PT: 12.9 PTT: 31.3 INR: 1.1 . Discharge labs: WBC: 4.1 HCT 28.1 Plt 389 . PT: 16.2, PTT 77.9, INR: 1.5 BUN 18 Creatinine 1.2 Glucose 155 Na 141 Potassium 4 Chloride 105 HCO3 18 . Imaging: Thyroid US: IMPRESSION: 1. Ultrasound-guided fine needle aspiration of a large vascular left thyroid nodule without immediate complication. 2. No right thyroid lobe. Correlation with patient history is recommended. . . CXR admission: IMPRESSION: Improving left lower lobe atelectasis. Followup chest radiographs are recommended to document complete resolution. Standard position of the ET tube and NG tube . CT Torso admission IMPRESSION: 1. Incompletely imaged heterogenous soft tissue mass containing calcifications extending along the left thoracic inlet and upper retrosternal region causing compression and rightward deviation of the trachea. The mass does not appear to invade mediastinal structures. Diagnostic considerations include a large thyroid mass or multinodular goiter with retrosternal component, much less likely a thymic lesion. 2. Low position of the endotracheal tube with its tip just above the carina. 3. Peribronchiolar nodular opacities and ground-glass attenuation in the posterior right upper lobe may represent evolving infectious etiology or aspiration. 4. Left lower lobe collapse with opacification of the left lower lobe bronchus. Further evaluation with bronchoscopy is advised to exclude an endobronchial lesion or extrinsic compression at the left hilum. 5. 2.0 cm ill-defined low attenuation in the upper pole of the right kidney, which is incompletely characterized on this non-contrast study. If indicated, further assessment could be performed with a dedicated renal ultrasound. 6. Generalized anasarca. . Head CT [**11-13**]: 1. No intracranial hemorrhage or mass effect. Evaluation for metastatic disease limited due to lack of intravenous contrast. If there is high clinical concern, further characterization with contrast enhanced MRI or CT is recommended. 2. Moderate cerebral atrophy and chronic microvascular ischemic change. . Left upper ex U/S [**11-18**]: DVT involving both brachial veins and the basilic vein along the catheter. . Thyroid biopsy [**11-25**]: Left thyroid, biopsy: Papillary carcinoma, follicular variant . Right upper ex U/S [**11-30**]: Deep venous thrombosis of the right upper extremity isolated to the right internal jugular vein surrounding the patient's central venous catheter. . Discharge CXR: There is overall increase in perihilar haziness and vascular engorgement suggesting volume overload/pulmonary edema. No change in the bilateral pleural effusions and bibasilar atelectasis noted. The tracheostomy, the right internal jugular line and the Dobbhoff tube are in unchanged positions including the proximal position of the Dobbhoff tube. Brief Hospital Course: 89F with COPD, HTN, DM, with mediatinal mass s/p intubation on arrival for airway protection and s/p extubation on [**2191-11-22**] and reintubation for excessive secretions on [**2191-11-24**]. Now with trach for vent weaning. She has large mediastinal mass with is c/w papillary thyroid ca follicular type. Hospital course by problem: . # Mediastinal Mass: Head/Torso CT negative for possible metastatic disease, although done without contrast. Endocrine was consulted and felt this was likely a goiter. She had FNA which was indeterminant. Then, during trach placement, had biopsy which showed papillary thyroid cancer, follicular type. Patient with normal TFTs, Thyroglobulin 1170. She and her family were notified of the results. She was seen by endocrine and thoracics surgery. Followup appointments were scheduled in near future to discuss plan of care: surgical resection vs. observation. . # Respiratory Failure: Initially intubated for airway protection given stridor. She developed a MRSA pneumonia and had tracheitis with [**Female First Name (un) **]. She was treated with 8 days of vanc and 5 days of fluconazole. She was also on a prednisone taper for COPD (last dose 11/8). She was extubated on [**2191-11-22**] and but was unable to clear her secretions and was reintubated. She was not passing the SBT and was trached in the OR by CT surgery for weening off the vent. She intermittently tolerated trach collar but was largely vent dependent with PS 10/5 FiO2 0.50 especially when lying flat. - please pull sutures out from trach on [**12-7**] per thoracics recommendations. . # DVT from LUEx PICC and right CVL IJ: treated with heparin gtt until platelets fell. Then changed to argatroban given concerns of HIT. HIT ab neg x2. We restarted heparin gtt and coumadin on [**11-28**]. Coumadin: [**11-28**] 2.5mg, [**11-29**] held, [**11-30**] 5mg. INR 1.5 on [**12-1**]. Plan: bridge with heparin and continue with coumadin until INR [**2-26**]. Goal: anticoagulate for at least 1 month after [**11-30**]. [**Month (only) 116**] need further anticoagulation for her afib. - She has documented allx to coumadin. We could not confirm etiology but thought it was likely bleeding. We monitored her for several days after coumadin given and saw no allx reaction. Monitor INR closely - Please pull right IJ CVL when heparin gtt no longer needed since it has a clot alongside it. If you still need access, consider new line. . # Thrombocytopenia: in the setting of heparin and vanc, and improving since Vanc has been discontinued. Does not appear to be hemolyzing. Patient started on Argatroban empirically, although HIT Ab returned negative; resend HIT was also negative. Last day of vanc was [**11-23**] and platelets have already rebounded. . # Pneumonia: She presented from the OSH with a diagnosis of post-obstructive pneumonia and in the midst of a 14 day course of levo/flagyl. Also received fluconazole for tracheitis and vanco for MRSA PNA (8d). Then had recurrent sputum pos for MRSA PNA so started on linezolid on [**11-27**]. Needs to continue this until [**12-4**]. . # Afib: Patient with new afib since admission to OSH. She intermittently was in afib with RVR requiring dilt gtt and increasing doses of dilt PO. She converts to sinus within 24h and at that time goes into a sinus brady (HR 20-30) for 30sec. BP tolerates and her HR improves. This last occurred on [**11-29**]. Subsequently, she was in sinus with good control on dilt 30mg PO QID. Consider increasing to 60mg PO QID. . # Fluid overload: she developed increasing pulm edema just prior to d/c. We gave lasix 20 IV. At home she takes lasix 80 daily. Consider increasing as BP and renal function tolerates. . #ARF: Patient with ARF on admission, likely pre-renal and improved. Creatinine at 1.2 on discharge. . #COPD: Patient without PFTs in our system; Treated with nebs and a steroid taper. We avoided albuterol for a few days prior to d/c given her afib with RVR . #DM: Insulin SS . #Gout: allopurinol . FEN/GI: TFs per nutrition. PROPHY: PPI, hep gtt and coumadin ACCESS: RIJ placed [**11-18**]. Please pull when not needed given the clot. CODE STATUS: FULL COMM: daughter [**Telephone/Fax (1) 74640**] Medications on Admission: MEDICATIONS ON ADMISSION TO OSH: =============================== Lisinopril 5 mg daily Lasix 80 daily Lipitor 20 daily Norvasc 5 mg daily Glipizide 5 mg daily Protonix 40 mg daily Allopurinol 100 mg daily Meclizine prn Albuterol prn Omeprazole . MEDICATIONS ON TRANSFER: ======================= Flagyl 500 tid Levaquin 250 q48h Singulair 10 po qhs Solumedrol 80 IV tid Combivent prn Sprivia qd Flovent 4 puffs [**Hospital1 **] Albuterol prn Levalbuterol qid Theophylline 100 mg po bid Cardizem 60 po qid -- Lipitor 20 qd allopurinol 100 po qod meclizine 12.5 qd Docustate Senna Tylenol prn Heparin 5000 U tid Mucinex protonix 40 po bid Phenergan prn IRSS Ativan prn . . ALLERGIES: ========= asa coumadin Discharge Medications: 1. Insulin Lispro 100 unit/mL Solution Sig: One (1) Subcutaneous ASDIR (AS DIRECTED). 2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2 times a day). 4. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 5. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day) as needed. 6. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. 8. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q4H (every 4 hours) as needed. 9. Linezolid 600 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 3 days: last day on [**2191-12-4**]. 10. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [**Hospital1 **] (2 times a day). 11. Warfarin 5 mg Tablet Sig: One (1) Tablet PO at bedtime: adjust prn. 12. Pantoprazole 40 mg Recon Soln Sig: One (1) Recon Soln Intravenous Q24H (every 24 hours). 13. Heparin (Porcine) in NS 10 unit/mL Kit Sig: variable units Intravenous continuous: adjust prn PTT 60-80. 14. Diltiazem HCl 30 mg Tablet Sig: One (1) Tablet PO four times a day. Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - MACU Discharge Diagnosis: Primary: papillary thryoid cancer, follicular type pulmonary edema deep vein thrombosis atrial fibrillation pneumonia . Secondary: hypertension COPD diabetes type 2 Discharge Condition: hemodynamically stable Discharge Instructions: You were diagnosed with papillary thyroid cancer and will need to follow up with endocrine and thoracic surgery. You had respiratory failure which required tracheotomy. Followup Instructions: Thoracic surgery: Provider: [**Name10 (NameIs) 1532**] [**Name11 (NameIs) 1533**], MD Phone:[**0-0-**] Date/Time:[**2191-12-6**] 2:30 Endocrine: Provider: [**First Name11 (Name Pattern1) 312**] [**Last Name (NamePattern4) 3015**], M.D. Phone:[**Telephone/Fax (1) 1803**] Date/Time:[**2191-12-7**] 3:30

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icd9cm

[ [ [] ] ]

[ "38.93", "96.72", "31.1", "06.11", "33.24", "06.01", "96.04", "99.10" ]

icd9pcs

[ [ [] ] ]

11357, 11423

5089, 9314

287, 413

11632, 11657

2105, 2105

11875, 12181

1549, 1553

10069, 11334

11444, 11611

9340, 9586

11681, 11852

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1568, 2086

200, 249

441, 1420

2121, 2287

9611, 10046

1442, 1488

1504, 1533

2,264

174,749

9918

Discharge summary

report

Admission Date: [**2127-4-23**] Discharge Date: [**2127-4-28**] Date of Birth: [**2077-9-13**] Sex: M Service: MEDICINE HISTORY OF PRESENT ILLNESS: This is a 49 year old male with known Hepatitis C virus cirrhosis, complicated by known esophageal and gastric varices, who presents after vomiting one cup of blood at 7 a.m. the morning of admission. He had near syncope and melena but denied abdominal pain. He initially presented to [**Hospital3 3765**] where he was found to be orthostatic. His hematocrit there was 32 and he was started on Octreotide drip and then transferred to our hospital. On arrival here, his heart rate was 92; his blood pressure was 105/75; no orthostatics were measured. He was immediately brought to the gastrointestinal suite, where an initial esophagogastroduodenoscopy revealed a massive amount of blood in the stomach. An NG tube was dropped and lavaged to clear after two liters of normal saline. A repeat esophagogastroduodenoscopy showed non-bleeding esophageal varices and a large clot overlying the stomach varices. It was decided to admit the patient directly to the Medical Intensive Care Unit. PAST MEDICAL HISTORY: 1. Hepatitis C cirrhosis diagnosed in [**2120**], status post esophagogastroduodenoscopy in [**2126-9-21**], which showed Grade I esophageal and gastric varices. He is listed at the [**Hospital 9940**] Clinic for a transplant. He has failed ribavirin and Interferon therapy. He has a history of hyperkalemia. MEDICATIONS: 1. Nadolol 60 mg p.o. q. day. 2. Colchicine 0.6 mg p.o. twice a day. 3. Ursodiol 600 mg p.o. twice a day. 4. Aldactone 100 mg p.o. q. day. ALLERGIES: No known drug allergies. SOCIAL HISTORY: He denies alcohol. He lives with his wife and three children. He works in computers. PHYSICAL EXAMINATION: Vital signs on admission were not recorded. On physical examination, HEENT: Extraocular motions intact. Pupils equally round and reactive to light. Anicteric sclerae. Oropharynx dry. No blood in the mouth. Neck: No jugular venous distention. Lungs are clear to auscultation bilaterally. Cardiovascular: Normal S1, S2, regular rate and rhythm; II/VI systolic murmur. Abdomen mildly tender diffusely. The hepatic edge is palpated three fingerbreadths below the costal margin. There were present bowel sounds. Extremities were without edema. No asterixis. Alert and oriented times three. LABORATORY: At the outside hospital, the hematocrit was 33.7, white blood cell count was 8.4 and platelets were 126. Chem-7 at the outside hospital was sodium 135, potassium 5.7, chloride 102, bicarbonate 27, BUN 30, creatinine 1.1, glucose 95. Calcium was 8.9, albumin 2.4, ALT 68, AST 84, alkaline phosphatase 115, total bilirubin 2.2, INR 1.25, PTT 32.5. EKG showed sinus rhythm at 70 beats per minute, no peaked T waves. Upon arrival to our hospital, hematocrit was 31.0, the potassium was 5.9 and the INR was 1.4. Total bilirubin was 2.6. Albumin was 2.9. IMPRESSION: This is a 49 year old male with Hepatitis C cirrhosis who is admitted with upper GI bleed secondary to gastric variceal bleeding. HOSPITAL COURSE: On arrival to the Intensive Care Unit, the Octreotide drip was continued. Vitamin K and fresh frozen plasma were given to correct his coagulopathy. Intravenous Ciprofloxacin was given for SBP prophylaxis. The initial plan had been to go for a TIPS placement the next day, but that evening, the patient developed nausea and dropped his blood pressure to 50/palpable. His hematocrit dropped to 28 and ultrasound of the abdomen revealed a stomach filled with fluid. The patient therefore went emergently to Interventional Radiology for TIPS placement, which was performed without complications. He received two units of packed red blood cells which bumped his hematocrit up to 38; there was no further bleeding. Urine output remained adequate. Protonix, Ciprofloxacin and Octreotide were continued, and changed to p.o. once he was started on a p.o. diet. Ultimately, Octreotide was discontinued and Lactulose was started. He was transferred to the General Medical Floor where he did well. His hematocrit was stable. Nadolol, Aldactone, Ursodiol and Colchicine were re-instated. He was discharged home on the following medications. DISCHARGE MEDICATIONS: 1. Ursodiol 600 mg p.o. twice a day. 2. Colchicine 0.6 mg p.o. twice a day. 3. Aldactone 100 mg p.o. q. day. 4. Nadolol 60 mg p.o. q. day. 5. Ciprofloxacin 500 mg p.o. twice a day for five days. DISCHARGE INSTRUCTIONS: 1. He is to maintain a low salt diet. 2. He is to follow-up in one week with the Liver Center. 3. It was recommended that he have a repeat upper endoscopy and echocardiogram as an outpatient shortly. DISCHARGE STATUS: To home. CONDITION AT DISCHARGE: Good. DISCHARGE DIAGNOSES: 1. Upper gastrointestinal bleed secondary to gastric varices. 2. Anemia, requiring transfusion. 3. Thrombocytopenia. 4. End-stage liver disease secondary to Hepatitis C. 5. Hyperkalemia. 6. Intubation for airway protection. [**Doctor Last Name **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], MD [**MD Number(1) 5708**] Dictated By:[**Name8 (MD) 2734**] MEDQUIST36 D: [**2127-6-25**] 17:50 T: [**2127-6-26**] 12:20 JOB#: [**Job Number 33254**]

[ "401.9", "456.8", "571.5", "578.9", "572.3", "070.54" ]

icd9cm

[ [ [] ] ]

[ "45.13", "39.1" ]

icd9pcs

[ [ [] ] ]

4828, 5335

4316, 4517

3151, 4293

4541, 4784

1821, 3133

4800, 4807

166, 1161

1183, 1693

1710, 1798

20,169

140,653

27227

Discharge summary

report

Admission Date: [**2192-7-18**] Discharge Date: [**2192-7-23**] Date of Birth: [**2123-12-22**] Sex: F Service: MEDICINE Allergies: Naproxen / Ultram / Captopril / Codeine Attending:[**First Name3 (LF) 297**] Chief Complaint: confusion Major Surgical or Invasive Procedure: Central line placement History of Present Illness: This is a 68 y/o f w/ hx of end stage liver disease secondary to NASH, recently admitted [**Date range (1) **] with ascites, [**Date range (1) 66768**] with recurrent ascites and ARF, who re-presents today with confusion x 2 days per family members. History taken through family: pt was recently d/c'd from [**Hospital1 18**] last Saturday and was taking all her medications as prescribed. However, beginning yesterday afternoon, the family noticed that she was confused - for example, at her granddaughter's graduation yesterday, she did not understand why her granddaughter was graduating. This morning, per family she was even more confused, asking where she was, where the bathroom was, etc. She was not oriented to place, but was oriented to herself and family members. Family therefore brought her into the ED this AM. Per family, the patient has been taking all meds as prescribed, including the lactulose, and having [**4-14**] BM's/daily. No h/o falls or trauma. Her abdomen has increased in girth since Saturday and she does experience early satiety with slight nausea, no vomiting. Per family, the patient has gained 1 lb per day since Saturday (4 days). Describes general weakness and fatigue. No f/c/s. Per family, FS at home reasonably controlled between 130's-150's. . Denies any h/a, neck stiffness, LH/dizziness, SOB/CP/palpitations, vomiting, diarrhea, melena, hematochezia/BRBPR, swelling in her extremities, focal weakness/loss of sensation/paresthesias. . In the ED, blood and urine cx sent. CXR, head CT, and abd u/s done and all negative. Given lactulose x 1. She became hypotensive with SBP in 70-80's. She was given a total of 1 L of NS with intermittent increases in BP to fluid bolus. She was started on dopamine 2 mcg/min with increase in SBP to 90's. She was started on ceftriaxone and vancomycin. Past Medical History: 1. Cirrhosis - diagnosed by bx in [**Country 4194**] in [**2190**], developed ascites and edema 7 months ago, likely due to NASH, Hep B and C negative 2. DM - reasonably controlled, on glipizide 3. Low blood pressure 4. Depression 5. s/p TAH 6. Grade II varices/gastritis - s/p EGD [**2192-7-12**] Social History: Originally from [**Country 4194**] but now lives with her family in [**Hospital1 3494**]. Speaks Portuguese only. She does not drink ETOH or smoke. No hx of IVDU. Had a blood transfusion 25 yrs ago following a TAH. Family History: no hx of liver disease, cancer, heart disease Physical Exam: VS: T 98.1, BP 91/50 (dopa 2.5 mcg/min), HR 55, RR 18, SaO2 100%/RA Gen: Lethargic, but responds to voice. AO x 1 (person, thinks in [**Country 4194**], buts knows in hospital). She did not know her children in ER. HEENT: NC/AT, PERRL, EOMI. Anicteric sclerae. MM slightly dry. Neck: supple, no LAD or JVD Chest: CTA-B anteriorly, no w/r/r CV: RRR, s1 s2 normal, no m/g/r Abd: soft, distended + fluid wave, + shifting dullness, NT, decreased BS, guiaic neg in ED Ext: no edema, DP 2+ bilat, mild palmar erythema Neuro: +asterixis. Pertinent Results: [**2192-7-18**] 10:10AM BLOOD WBC-5.9 RBC-3.91* Hgb-12.1 Hct-34.4* MCV-88 MCH-30.9 MCHC-35.2* RDW-13.8 Plt Ct-160 [**2192-7-22**] 03:50AM BLOOD WBC-5.2 RBC-3.43* Hgb-10.6* Hct-30.8* MCV-90 MCH-30.8 MCHC-34.3 RDW-14.2 Plt Ct-138* [**2192-7-18**] 10:10AM BLOOD Neuts-77.0* Lymphs-13.8* Monos-8.0 Eos-0.8 Baso-0.4 [**2192-7-18**] 02:27PM BLOOD PT-14.6* PTT-31.0 INR(PT)-1.3* [**2192-7-22**] 03:50AM BLOOD PT-16.5* PTT-59.3* INR(PT)-1.5* [**2192-7-18**] 10:10AM BLOOD Glucose-211* UreaN-81* Creat-2.1* Na-135 K-4.9 Cl-97 HCO3-23 AnGap-20 [**2192-7-22**] 03:50AM BLOOD Glucose-119* UreaN-37* Creat-1.1 Na-136 K-4.1 Cl-109* HCO3-17* AnGap-14 [**2192-7-18**] 10:10AM BLOOD ALT-22 AST-40 CK(CPK)-20* AlkPhos-165* Amylase-167* TotBili-1.5 [**2192-7-18**] 10:10AM BLOOD Lipase-355* GGT-138* [**2192-7-22**] 03:50AM BLOOD Lipase-209* [**2192-7-19**] 03:26AM BLOOD CK-MB-NotDone cTropnT-<0.01 [**2192-7-20**] 03:30AM BLOOD CK-MB-NotDone cTropnT-<0.01 [**2192-7-19**] 03:26AM BLOOD Albumin-3.9 Calcium-9.0 Phos-3.9 Mg-2.0 [**2192-7-18**] 10:10AM BLOOD Ammonia-54* [**2192-7-18**] 10:10AM BLOOD TSH-3.9 [**2192-7-18**] 10:10AM BLOOD Free T4-1.3 [**2192-7-19**] 09:15AM BLOOD Cortsol-16.9 [**2192-7-18**] 04:02PM BLOOD Lactate-2.4* [**2192-7-19**] 09:30AM BLOOD Lactate-1.6 . CT head [**7-18**]: IMPRESSION: No acute intracranial hemorrhage. No mass effect. . RUQ u/s [**7-18**]: IMPRESSION: 1. Unchanged liver cirrhosis. 2. Moderate ascites. 3. Gallbladder sludge. . CXR: clear, no pneumonia . Echo [**7-19**]: 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 systolic function appears preserved. The mitral valve leaflets are mildly thickened. No significant mitral regurgitation was detected. The left ventricular inflow pattern suggests impaired relaxation. There is no pericardial effusion. Brief Hospital Course: 68 yo female w/ cirrhosis secondary to NASH or schistosomiasis p/w with confusion, hypotension, bradycardia . 1. Confusion - resolved with fluid resuscitation, holding of beta blocker and subsequent resolution of bradycardia and hypotension. In addition, treated agressively with lactulose for ? component of hepatic encephalopathy. Broadly cultured without evidence of infection including paracentesis, blood cx's, urine cx, CXR. . 2. Ascites - Patient has had reaccumulation of fluid since last paracentesis [**2192-7-14**] and [**2192-7-10**]. She is not on diuretics due to renal insufficiency. She had a diagnostic paracentesis here which did not show evidence of SBP. She had a 5L therapeutic paracentesis prior to discharge, which she tolerated well. She was given replacement albumin after this procedure. . 3. Shock: Patient was admitted with hypotension which was potentially [**3-15**] to early sepsis vs. nadolol effect. Initially placed on dopamine, up to 5mcg/min. She was quickly titrated off dopamine with administration of IV fluid boluses. BP remaine stable in the 90s-100s thereafter. Encourage PO fluid intake, measured urine output was poor, but unable to collect all urine. . 4. Bradycardia: Patient has episodes of bradycardia to 30s, which were not hemodynamically embarassing, and she remained asymptomatic. This was thought to be potentially [**3-15**] to BB toxicity. She was treated with calcium chloride and a glucagon drip with good results. Patient's HR remained stable after glucagon gtt was stopped. . 5. Pancreatitis: Pt had an elevated amylase and lipase at admission. U/S was negative for gallstones, could be [**3-15**] to biliary sludge. Amylase and lipase trended down, patient never had abdominal pain, tolerating POs. . 6. Cirrhosis - Cirrohsis is likely [**3-15**] to NASH, though this is not completely clear. Patient has been on lactulose and cipro since last discharge and was not on diuretics given her creatinine increase since her last admission. - continue lactulose daily for goal BM's [**4-14**]/day - EGD [**7-12**] significant for portal gastropathy, Grade II varices no active bleeding -> Hct stable - continue PPI - Hold nadolol given hypotension . 7. ARF: Cr was 2.1 at admission but trended down to 1.1 with IVFs. . 8. Depression - continued citalopram . 9. DM - held oral agents with use of insulin sliding scale. . 10. F/E/N - cardiac/heart healthy/diabetic diet . 11. PPx - pneumoboots, lactulose for bowel reg, pantoprazole . 12. Full code . 13. Communication - contact info: son [**Name (NI) 66769**] [**Telephone/Fax (1) 66766**], [**Name2 (NI) **] [**Telephone/Fax (1) 66770**], daughter [**First Name8 (NamePattern2) **] [**Name (NI) **] [**Telephone/Fax (1) 66771**] Medications on Admission: 1. Glipizide 10 mg q AM 2. Lactulose 15 mL [**Hospital1 **] 3. Celexa 40 mg qd 4. Protonix 40 mg qd 5. Nadolol 20 mg qd 6. Cipro 250 mg qd 7. Reglan 10 mg QACHS prn . ALL - NKDA Discharge Medications: 1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 2. Citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 3. Ciprofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours). 4. Lactulose 10 g/15 mL Solution Sig: One (1) PO three times a day: titrate to [**4-14**] soft bowel movements daily. 5. Glipizide 10 mg Tablet Sig: One (1) Tablet PO once a day. 6. Reglan 10 mg Tablet Sig: One (1) Tablet PO qACHS as needed for nausea. Discharge Disposition: Home Discharge Diagnosis: Liver cirrhosis Diabetes type II Nadolol toxicity Discharge Condition: stable Discharge Instructions: Please follow-up with your primary care doctor and your regular liver doctor in the next few weeks. Take your medications as prescribed. Your nadolol was stopped because of side effects. We believe it cause a slow heart rate and low blood pressure which led to the symptoms that brought you in. Followup Instructions: Please call your Primary Care Doctor [**First Name (Titles) **] [**Last Name (Titles) **] a follow-up appointment: [**Last Name (LF) **],[**First Name3 (LF) **] A. [**Telephone/Fax (1) 66771**] Call your liver doctor [**First Name (Titles) **] [**Last Name (Titles) **] a follow-up appointment

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icd9cm

[ [ [] ] ]

[ "38.93", "54.91" ]

icd9pcs

[ [ [] ] ]

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166,106

28405

Discharge summary

report

Admission Date: [**2139-7-30**] Discharge Date: [**2139-8-2**] Date of Birth: [**2076-9-4**] Sex: M Service: UROLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 4533**] Chief Complaint: Urosepsis Major Surgical or Invasive Procedure: central line, arterial line History of Present Illness: HPI: Mr. [**Known lastname 68918**] is a 62 y.o. M with HTN and hypercholesterolemia, s/p prostate biopsy on [**2139-7-28**] with Dr. [**First Name (STitle) **] for elevated [**Hospital 68919**] transferred from [**Hospital1 18**]-[**Location (un) 620**] ED for possible urosepsis. Patient was feeling well throughout the past day until 1:00pm on [**2139-7-29**] when he stated he felt fevers with shaking chills. He also felt lightheaded and dizzy. The patient's wife called Dr. [**Last Name (STitle) 68920**], his PCP, [**Last Name (NamePattern4) **] [**2139-7-29**] reporting a 104 F fever, chills, and blood in his urine since having prostate biopsies with Dr. [**First Name (STitle) **]. Per patient, there was red blood in his urine - not just pink tinge. Dr. [**Last Name (STitle) 68920**] tried to contact urology unsuccessfully, so he advised pt to be evaluated in the [**Hospital1 18**] [**Location (un) 620**] ED. . In the [**Hospital1 **] ED, VS: T 98 (Tmax 101) HR 98 (95-105) BP 100/60 (93-107/56-65) RR 22 ([**11-30**]) O2 sat 93% RA (now 98% on 4L NC). Labs sent and notable for lactate 4.3, potassium 3.0, creatinine 1.4, WBC 6.9 with 8% bands. UA with 5-10 WBC, loaded (>100) blood, + nitrite, + bacteria, trace leukoesterase. UCx and blood cultures x 2 sent. EKG completed with NSR and no ischemic changes. CXR completed showing central line in place, may be slightly low, but no pneumothorax. Given ceftriaxone 2 grams IV x 1, gentamycin 500 mg IV x 1, 7 L NS, 1 L LR, Zofran and KCl repletion. Foley placed. . ROS: The patient endorses Fevers/chills, nausea, hematuria, and small blood in stool. Also some lower leg edema with Amlodipine dose changes which has resolved. He denies any weight change, vomiting, abdominal pain, diarrhea, constipation, melena, hematochezia, chest pain, shortness of breath, cough, urinary frequency, urgency, dysuria, focal weakness, vision changes, headache, rash or skin changes. Past Medical History: Hypertension Hypercholesterolemia Hypothyroidism Elevated PSA s/p prostate biopsy Thalassemia with chronic anemia ? thrombocytopenia Social History: Married with 2 children. No current or past tobacco. Alcohol use rare. No drug use. Family History: Mother - died at 84, hypertension, hypercholesterolemia, obesity. Father - died at age 65, DM, CHF. Brother - 57 y.o., hypercholesterolemia. Sister - type 2 diabetes. sister - hypothyroid, breast cancer. No colon or prostate cancer in family. Brief Hospital Course: Pt admitted to [**Hospital Unit Name 153**] for Urosepsis. He received aggressive volume support and broad spectrum empiric ABX. ABX were tailored on HD 2 to ceftriaxone based on fluoroquinlone resistant E.coli from multiple cultures at OSH. He continued to spike fevers until HD 3, at which time he was afebrile x 24hours. Hs home meds were restarted, holding ASA due to hematuria. His pain was controlled and he was tolerating POs. He was discharged HD 4 with 14 days Bactrim ABX. He was instructed to follow up with Dr. [**First Name (STitle) **] in [**12-10**] weeks. Medications on Admission: Amlodipine 5 mg daily Atorvastatin 40 mg daily Ciprofloxacin 500 mg po BID x 5 days s/p biopsy (last date [**8-2**]) Levothyroxine 75 mcg daily Hyzaar 50/12.5 1 tablet daily ASA 81 mg daily Discharge Medications: 1. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) for 10 days. Disp:*20 Capsule(s)* Refills:*0* 3. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for Pain/fever. 5. Bactrim DS 160-800 mg Tablet Sig: One (1) Tablet PO twice a day for 14 days. Disp:*28 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Urosepsis Discharge Condition: Stable Discharge Instructions: -Do not eat constipating foods for 2-4 weeks, drink plenty of fluids. -Do not lift anything heavier than a phone book (10 pounds) until you are seen by your Urologist in follow-up. -Do not drive or drink alcohol while taking narcotics. -Resume all of your home medications, except hold NSAID (aspirin, advil, motrin, ibuprofen) until you see your urologist in follow-up. -Call Dr.[**Name (NI) 24219**] office to conform a follow-up appointment in [**12-10**] weeks AND if you have any questions. -If you have fevers > 101.5 F, vomiting, increased pain, or large amounts of bleeding/blood in your urine or stool for more than a week after you stop aspirin, call your doctor or go to the nearest ER. Followup Instructions: Follow up with Dr. [**First Name (STitle) **] in clinic in [**12-10**] weeks.

[ "E878.8", "282.49", "041.4", "599.0", "997.5", "244.9", "401.9", "272.0" ]

icd9cm

[ [ [] ] ]

[ "38.93", "38.91" ]

icd9pcs

[ [ [] ] ]

4183, 4189

2878, 3451

322, 351

4243, 4252

5005, 5086

2608, 2855

3691, 4160

4210, 4222

3477, 3668

4277, 4982

273, 284

379, 2331

2353, 2488

2504, 2592

52,732

186,286

47115

Discharge summary

report

Admission Date: [**2148-10-14**] Discharge Date: [**2148-10-17**] Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 3984**] Chief Complaint: increased tumor burden, Urosepsis Major Surgical or Invasive Procedure: Central venous access Arterial line Nephrostomy tube (percutaneously) History of Present Illness: 87 year old female w/hx of urothelial carcinoma of the right renal pelvis with lymph node involvement and likely bilateral adrenal metastases p/w 3 days of diarrhea and vomiting and weakness and malaise. NBNB emesis on Friday x 3 episodes, multiple soft stools x few days. This AM, acute onset cramping upper abdominal pain intermittently radiating to Right flank. No documented but + subjective fevers. Ate lobster role several days ago and then reports diarrhea 2-3x per day since then but denies profusely watery. And poor PO intake. Nothing makes it better or worse. Last bowel movement was last night. Patient hasn't vomited since day one. Her diarrhea is described as soft but not watery. Reports falling off chair and being found on floor for "20 minutes" by daughter. Positive fevers chills sweats, denies dyspnea nor chest pain. Minimal cough non productive. She denies chest pain or shortness of breath. Patient is not currently undergoing treatment for her cancer followed by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]. Baseline SBP in 130-140s . In the ED inital vitals at 6:15am were 98.0, 110 130/47 16 3L Nasal Cannula. EKG at presentation: NSR at 106, RBBB, LAFB, No ST changes. Subsequent EKG was done which showed Afib in 140s-160s-> given 10 of dilt and brought down to 110s. RR high 30s-40s, +air hunger but denies SOB/CP > NRB. HR in 110s, EKG with LAD and RBBB, no priors for comparison. Exam notable for LUQ, epigastric tenderness, +voluntary guarding. Lactate 5.6, gotten 1.5L IVF now. CXR shows pleural effusion +/- PNA, started on CTX and Azithro prior to CT chest. Cr 1->1.5. Trop 0.05. UA c/w UTI vs result of urothelial CA. 92% on NRB, felt a little better. Concern for PE, CT torso shows hydro with perinephric stranding. Progression of CA with mets. AF 140-160s. 10 IV dilt, 30 PO dilt, HR to 110s. Vanc added for broader coverage. Spoke to urology, may need urgent nephrostomy. Would have IR do it, unlikely to have UTI, happy to follow. 18G in AC. Spoke with oncologist Dr. [**Last Name (STitle) **], agree with plan, may need nephrostomy and chest tube if pleural effusion doesn't improve. Goals of care discussed by ED resident, full code for now, likely to be made DNR/DNI. Last VS 98.0 112 97/64 24 96%NRB. . ED Labs: C10: 136/3.5/96/21/34/1.5/114 (baseline HCO3 31, Cre 1.0) 9.8/2.3/3.5 AG=19 Lactate: 5.6 CBC: 1.1>39<pending, diff pending Coags: 11/21/0.9 LFT: 49/31/37/0.6 Trop: 0.05 CKMB 5 U/A: cloudy, blood large, nit NEG, leuk large, RBC 15, WBC>182, Bact MANY BCx x2 sent w/ UCx. no previous UCx in system . Imaging: CXR prelim: Low lung volumes with elevated right hemidiaphragm and small bilateral pleural effusions with associated atelectasis. Diagnostic considerations include growing pleural effusion with associated atelectasis versus post-obstructive consolidation with accompanying pleural effusion. Cross-sectional imaging may be considered for further evaluation. . CT A/P: 1. No pulmonary emboli. 2. Marked progression of urothelial cancer and metastatic disease with moderate to severe right hydronephrosis and perinephric stranding and fluid which could represent forniceal rupture. . Labs significant for: Cre 1.5, Lacate 5.6 AG 19, WBC 1.1 Trop 0.05 U/A ?UTI. . On arrival to the ICU Vsigns were 96.2 120s 87/51 and then 117/51 96 36 NRB. She was started on IVF, ABx, and plan per below. . Review of systems: (+ /- ) Per HPI Past Medical History: PMH: hypercholesterolemia hypothyroidism arthritis prior reaction to anesthesia . PAST ONCOLOGY HISTORY: - presented with gross hematuria, urine cytology done [**2148-3-4**] was positive for atypical urothelial cells presented in clusters suspicious for urothelial cell carcinoma - [**2148-3-4**] CT abdomen/pelvis showed a large mass in the right renal pelvis consistent with urothelial tumor, retroperitoneal lymphadenopathy and indeterminate bilateral adrenal masses could represent metastatic disease. - [**2148-3-25**] Biopsy of retroperitoneal lymph node mass was positive for high grade carcinoma, most consistent with urothelial origin - [**2148-6-3**]: CT Torso revealed the large mass in the right renal pelvis (5.5 x 4.7 x 3.7 cm) with encasement and narrowing of the collecting system, bilateral adrenal masses and massive retrocaval lymphadenopathy . PSurgHx: hysterectomy w/ Bilat oophorectomy 2nd to fibroids cholecystectomy . Social History: She is a widow. She lives alone, has 1 daughter and 3 grandsons. She does not smoke and drinks alcohol rarely. She used to work as a calligrapher. Family History: She has five siblings. Her sister died of rheumatic fever. She has two nieces, who died of breast cancer and a third niece, who had breast lumpectomies but is currently alive. Her son died at the age of 41 of leukemia and her daughter is healthy. Physical Exam: ADMISSION EXAM 96.2 120s 87/51 and then 117/51 96 36 NRB General: Alert, oriented, no acute distress but uncomfortable HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP to neck Lungs: poor inspiratory effort, no wheeze, rales at right base, reduced breath sounds at right base. moderately labored breathing. CV: irreg irreg, no murmurs, rubs, gallops Abdomen: soft, mildly TTP in RUQ and right flank. no rebound or guarding. GU: foley Ext: cool, mottling, no edema B/L LE. Thready radial pulses. Pertinent Results: [**2148-10-14**] 07:00AM BLOOD WBC-1.1*# RBC-4.59 Hgb-13.4 Hct-39.0 MCV-85 MCH-29.1 MCHC-34.3 RDW-12.8 Plt Ct-272 [**2148-10-17**] 04:00AM BLOOD WBC-29.8* RBC-3.74* Hgb-11.0* Hct-32.2* MCV-86 MCH-29.4 MCHC-34.1 RDW-13.9 Plt Ct-81* [**2148-10-14**] 07:00AM BLOOD Neuts-12* Bands-33* Lymphs-12* Monos-7 Eos-0 Baso-0 Atyps-0 Metas-19* Myelos-17* NRBC-2* Other-0 [**2148-10-16**] 02:58AM BLOOD Neuts-80* Bands-10* Lymphs-4* Monos-1* Eos-0 Baso-0 Atyps-0 Metas-2* Myelos-2* Promyel-1* NRBC-3* [**2148-10-14**] 07:00AM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-2+ Macrocy-NORMAL Microcy-NORMAL Polychr-1+ Burr-2+ [**2148-10-16**] 02:58AM BLOOD Hypochr-1+ Anisocy-1+ Poiklo-1+ Macrocy-NORMAL Microcy-1+ Polychr-NORMAL Ovalocy-1+ Burr-1+ Tear Dr[**Last Name (STitle) **]1+ [**2148-10-16**] 06:41AM BLOOD Plt Ct-120* [**2148-10-17**] 04:00AM BLOOD Plt Smr-LOW Plt Ct-81* [**2148-10-14**] 07:00AM BLOOD Glucose-114* UreaN-34* Creat-1.5* Na-136 K-3.5 Cl-96 HCO3-21* AnGap-23* [**2148-10-17**] 04:00AM BLOOD Glucose-251* UreaN-70* Creat-3.3* Na-137 K-4.9 Cl-99 HCO3-24 AnGap-19 [**2148-10-14**] 07:00AM BLOOD ALT-31 AST-49* AlkPhos-37 TotBili-0.6 [**2148-10-16**] 06:41AM BLOOD ALT-2190* AST-2481* AlkPhos-90 TotBili-0.8 [**2148-10-15**] 05:26AM BLOOD ALT-2241* AST-5808* LD(LDH)-6753* AlkPhos-44 Amylase-45 TotBili-0.9 [**2148-10-14**] 02:57PM BLOOD CK-MB-7 cTropnT-0.06* proBNP-[**Numeric Identifier 99867**]* [**2148-10-16**] 02:58AM BLOOD CK-MB-7 cTropnT-0.10* [**2148-10-17**] 04:00AM BLOOD Calcium-7.0* Phos-5.3* Mg-2.5 [**2148-10-14**] 02:57PM BLOOD Calcium-8.7 Phos-4.7* Mg-2.2 [**2148-10-17**] 04:00AM BLOOD Triglyc-510* [**2148-10-14**] 06:58AM BLOOD Comment-GREEN TOP [**2148-10-14**] 03:06PM BLOOD Type-[**Last Name (un) **] pO2-75* pCO2-57* pH-7.20* calTCO2-23 Base XS--6 [**2148-10-17**] 04:16AM BLOOD Type-ART pO2-100 pCO2-45 pH-7.37 calTCO2-27 Base XS-0 [**2148-10-17**] 04:16AM BLOOD Lactate-2.0 CT ABD & PELVIS WITH CONTRAST Study Date of [**2148-10-14**] 8:34 AM 1. No evidence of pulmonary embolism. 2. Marked progression of urothelial cancer and metastatic disease as detailed above with moderate-to-severe right hydronephrosis and perinephric stranding with fluid which could represent forniceal rupture in addition to malignant involvement/possible infection. 3. New moderate right-sided pleural effusion. [**Numeric Identifier 99868**] INTRO CATH RENAL PELVIS FOR DRAINAGE Study Date of [**2148-10-14**] 7:31 PM IMPRESSION: Successful placement of right nephrostomy tube. Portable TTE (Complete) Done [**2148-10-15**] at 1:44:57 PM FINAL The left atrium is elongated. No atrial septal defect or patent foramen ovale is seen by 2D, color Doppler or saline contrast with maneuvers. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Overall left ventricular systolic function is normal (LVEF 60-70%). There is considerable beat-to-beat variability of the left ventricular ejection fraction due to an irregular rhythm. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Trivial mitral regurgitation is seen. There is borderline pulmonary artery systolic hypertension. There is no pericardial effusion. ABDOMEN U.S. (COMPLETE STUDY) PORT Study Date of [**2148-10-16**] 9:15 AM IMPRESSION: 1. Expected persistent right hydronephrosis. 2. Poorly visualized left kidney, appearing grossly normal. 3. 5.4-cm right renal lesion consistent with known urothelial carcinoma. Brief Hospital Course: 87 year old woman with little PMH aside from recent history of metastatic urothelial carcinoma with lymph node involvement and likely adrenal metastases who presents w/ 3 days of malaise, diarrhea and vomiting x days now with respiratory distress, elevated lactate, possible UTI, SIRS physiology, and marked progression of urothelial cancer with right hydronephrosis and perinephric stranding and forniceal rupture. . # Septic shock: [**4-29**] E coli in bld/urine, (highly sensitive organisms) on day [**4-8**] abx (Ceftriaxone); weaned off pressors; IVFluids given as needed. Stress dose steroids given pred hx x several months 100 hydrocort IV q8 hrs. Close Hemodynamic monitoring was done and CVL, a-line in place. Lactate was trended. Intubated in the context of sepsis and multiorgan failure. Ultimately family decided to withdraw aggressive measures of care as this would not have been in the patient's personal wishes and she expired on [**2148-10-17**]. . # Right hydronephrosis with possible forniceal rupture: the most common etiology of renal forniceal rupture is obstruction caused by distal ureteric stones followed by malignant extrinsic ureteric compression of which the latter was likely involved. IR placed a nephrostomy tube in the right kidney but US showed persistent R hydronephrosis despite drainage tube. Family did not want any additional procedures nor dialysis. . # Transaminitis: Most likely secondary to liver ischemia. Picture of high transaminitis + high LDH + elevated creatinine is classic for ischemic liver disease. Other etiologies, eg. Budd-chiari syndrome and hepatic congestion secondary to heart failure, would not lead to such high transaminitis. . # Acute on chronic renal failure: Likely ATN secondary to hypotension + sepsis + urothelial CA. The patient's family did not want any additional procedures nor dialysis. . # Respiratory distress: unclear etiology, no overt pulmonary edema but low lung volumes (elevated right hemi diaphragm as well), small effusions bilaterally, no recent echo if cardiogenic w/ elevated troponins. Can??????t exclude PNA at this time. Could also be [**2-28**] Sepsis and attempt at respiratory compensation for primary metabolic acidosis. However ABG w/ A-a gradient and signs of hypoxemic, hypercarbic respiratory distress. PE negative on wet read CTA. Atalectasis contributing factor w/ possible sympathetic effusion. She was intubated until point of terminal exubation. . # Metastatic Urothelial Carcinoma: currently not undergoing therapy. Given advanced stage, not a surgical candidate although may require decompression. . # Hypoglycemia: cont q2 h FS, start tube feeds . # hypothyroidism - continued synthroid . # arthritis - giving stress dose steroid in lieu of prednisone taper at this point. # FEN: bolus PRN above, replete electrolytes, NPO for now # Prophylaxis: Subcutaneous heparin, H2 blockers # Access: 2 x pIV 18 / 22, consider CVL # Communication: Patient and daughter [**Name (NI) 2411**] [**Name (NI) **] [**Telephone/Fax (1) 99869**] daughter # Code: Full (discussed with patient) Medications on Admission: Medications - Prescription LEVOTHYROXINE - (Prescribed by Other Provider) - 150 mcg Tablet - 1 Tablet(s) by mouth once a day PREDNISONE - on taper, currently taking 6mg PO per day. SIMVASTATIN - (Prescribed by Other Provider) - 20 mg Tablet - 1 Tablet(s) by mouth once a day Medications - OTC CHOLECALCIFEROL (VITAMIN D3) - (Prescribed by Other Provider) - 1,000 unit Capsule - 1 Capsule(s) by mouth once a day LACTASE [LACTAID] - (Prescribed by Other Provider) - 3,000 unit Tablet, Chewable - 1 Tablet(s) by mouth take as needed with dairy products MV-MIN-FOLIC ACID-LUTEIN [THERAGRAN-M ADVANCED 50 PLUS] - (Prescribed by Other Provider) - 0.4 mg-250 mcg Tablet - Tablet(s) by mouth once a day Discharge Medications: N/A Discharge Disposition: Expired Discharge Diagnosis: Sepsis Discharge Condition: Deceased Discharge Instructions: N/A Followup Instructions: N/A [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**] MD [**MD Number(1) 2438**] Completed by:[**2148-10-20**]

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icd9cm

[ [ [] ] ]

[ "38.91", "96.04", "96.71", "55.03", "38.93" ]

icd9pcs

[ [ [] ] ]

13428, 13437

9551, 12634

287, 358

13487, 13497

5787, 9528

13549, 13710

4980, 5232

13400, 13405

13458, 13466

12660, 13377

13521, 13526

5247, 5768

3812, 3830

214, 249

386, 3793

3852, 4797

4813, 4964

67,924

128,735

36114

Discharge summary

report

Admission Date: [**2172-2-3**] Discharge Date: [**2172-2-10**] Date of Birth: [**2114-3-6**] Sex: M Service: ORTHOPAEDICS Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 11415**] Chief Complaint: Right hip fracture Major Surgical or Invasive Procedure: [**2172-2-3**]: ORIF Right Hip History of Present Illness: 57 year old male with hepatitis B and C and s/p SDH presenting after a mechanical fall with a right hip fracture. The patient was in his usual state of health until the day of admission when he was walking to the window to look at the snow. He slipped on the ground and landed on his right hip. He denies other further injury. He denies preceeding symptoms including chest pain, shortness of breath, palpitations, lightheadedness, dizziness or blurred vision. He was feeling well. In the ED, he was found to have a comminuted right intertrochanteric fracture with varus angulation. He was admitted to the orthopedics service for planned ORIF. Currently, he complains of right hip pain, but feels otherwise well. He denies lightheadeness, headache, chest pain, palpitations, shortness of breath, abdominal pain, nausea, vomiting, diarrhea, numbness/tingling in his leg or any other complaints. He ambulates with a walker and never experiences chest pain or shortness of breath. He feels he can walk for miles with the walker--but does not do regular exercise. He uses an elevator as necessary at his facility. Past Medical History: ETOH intoxication Subdural hematoma multiple falls seizure disorder spinal stenosis Hep C, Hep B Social History: single, lives in [**Hospital3 **]--was chronic resident of [**Hospital **] Hospital following [**11-28**] laminectomy at [**Hospital1 112**], 2 months ago moved into current [**Hospital3 **]. Ambulates with a walker, local pharamcy gives him prefilled medication packages. Has brother and sister, parents deceased. Smokes 9 cigarettes per day. Previous 1 case beer/day, now none X 27 months. Prior drug use, but denies IVDU. Previously worked with machines--not currently working. Has a legal guardian--[**Name (NI) 122**] [**Name (NI) 4384**] [**Telephone/Fax (1) 81924**] (lawyer) Family History: patient does not know Physical Exam: 96.9 120/60 65 16 95% RA Gen: alert and oriented X 3, c/o right hip pain--uncomfortable/changing positions in bed occassionally. HEENT: EOMI, OP clear, pupils equal Car: regular, no murmur Resp: insp crackles at left base initially, cleared with deep breaths Abd: s/nt/nd/nabs Ext: no LE edema, TTP right hip joint, 2+ DP Pertinent Results: [**2172-2-3**] 03:02AM WBC-10.2 RBC-4.31* HGB-14.4 HCT-37.7* MCV-87 MCH-33.5* MCHC-38.3* RDW-14.4 [**2172-2-3**] 03:02AM PLT COUNT-203 [**2172-2-3**] 03:02AM GLUCOSE-121* UREA N-16 CREAT-0.8 SODIUM-138 POTASSIUM-3.8 CHLORIDE-105 TOTAL CO2-22 ANION GAP-15 1. Right Hip X ray (prelim): Comminuted right intertrochanteric fracture with varus angulation. 2. CXR: no acute process (prelim) 3. ECG: sinus bradycardia at 57 bpm, normal axis, normal intervals, poor baseline, but TWI in V1 and V2, TWF in III and aVL. No previous in our system for comparison. Brief Hospital Course: Pt was admitted from the ED after sustaining a right hip fracture. He was evaluated by medicine for a pre-op work-up and cleared for the OR. He was taken to the OR on [**2172-2-3**] and underwent open reduction internal fixation of the right hip with a TFN. He tolerated the procedure well, extubated and transferred to the floor from the PACU in stable condition. He was placed on a CIWA scale. The night of surgery, his dressing required changing for increased sanguinous drainage. He also pulled out his foley catheter and had significant bleeding from his penis. His INR was found to be 1.8, and we held his lovenox. The following day, it he began to go into DTs, and was subsequently transferred to the TSICU. He also received 2uPRBCs for a hct of 18.1, a urology consult was called for continued bleeding from his penis, who replaced the foley and recommended keeping it in for 1 week. He was transferred to the floor the next day and did well. He did however, have some trouble swallowing, so a speech and swallow consult was obtained, and they recommended:PO diet: soft solids, thin liquids 2. PO meds: crushed in puree 3. 1:1 supervision with meals to maintain aspiration precautions including NO GUZZLING. Alternate between bites/sips as needed. He was also seen by PT who recommended rehab. On [**2-7**], his hct was 24.6 and was transfused 2 units of PRBCs. His hct responded nicely and was 33.3 2 days later. Over the weekend, he was not able to get a rehab bed. The remainder of his hospital stay was uneventful, and was discharged to rehab in good condition the following day on [**2171-2-9**]. Medications on Admission: Aspirin 81 mg daily Atenolol 25 mg every day Vitamin D 800 IU daily Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours). 5. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). 8. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO Q 8H (Every 8 Hours). 9. Lovenox 30 mg/0.3 mL Syringe Sig: One (1) 30 Subcutaneous every twelve (12) hours for 4 weeks. 10. Senna 8.6 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 11. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO HS (at bedtime). 12. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO every four (4) hours as needed for pain. Discharge Disposition: Extended Care Facility: [**Hospital3 2558**] - [**Location (un) **] Discharge Diagnosis: Right Hip Fracture Discharge Condition: Stable Discharge Instructions: Keep incision dry. Do not soak in tub. Continue to be full weight bearing. Continue to take all medications as directed. If you have questions, concerns or experience fevers greater than 101.2, incisional drainage, calf pain or swelling, chest pain or shortness of breath, then call [**Telephone/Fax (1) 1228**]. Physical Therapy: Weight bearing as tolerated No restrictions for range of motion Treatments Frequency: Discontinue staples 14 days from date of surgery. Followup Instructions: 2 weeks with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], NP. Please call [**Telephone/Fax (1) 1228**] to make this appointment [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2235**] MD, [**MD Number(3) 11417**] Completed by:[**2172-2-10**]

[ "291.0", "345.90", "724.00", "285.1", "V15.88", "820.21", "599.71", "E879.6", "998.11", "070.30", "294.9", "070.70", "E878.8", "E885.9", "305.1" ]

icd9cm

[ [ [] ] ]

[ "79.35", "99.04" ]

icd9pcs

[ [ [] ] ]

5954, 6024

3210, 4824

337, 370

6087, 6096

2627, 3187

6614, 6925

2246, 2269

4943, 5931

6045, 6066

4850, 4920

6120, 6436

2284, 2608

6454, 6518

6540, 6591

279, 299

398, 1509

1531, 1630

1646, 2230

7,945

194,432

28592

Discharge summary

report

Admission Date: [**2144-10-29**] Discharge Date: [**2144-11-7**] Date of Birth: [**2095-8-26**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 4691**] Chief Complaint: s/p 6 ft fall Major Surgical or Invasive Procedure: Halo placement [**2144-10-30**] History of Present Illness: 49 yo male s/p fall backwards while sitting on wall. He was taken to an area hopsital where he was found to have a C2 fracture and was subsequently transferred to [**Hospital1 18**] for continued care. Past Medical History: EtOH Rib Fractures Left medial/inferior blowout fracture Social History: Reportedly homeless +EtOH Family History: Noncontributory Pertinent Results: [**2144-10-29**] 10:10PM GLUCOSE-105 LACTATE-2.0 NA+-147 K+-4.2 CL--107 TCO2-28 [**2144-10-29**] 10:10PM HGB-13.6* calcHCT-41 O2 SAT-77 CARBOXYHB-1.7 MET HGB-0.2 [**2144-10-29**] 10:09PM UREA N-5* CREAT-0.7 [**2144-10-29**] 10:09PM ALT(SGPT)-41* AST(SGOT)-60* LD(LDH)-235 ALK PHOS-100 AMYLASE-52 TOT BILI-0.2 [**2144-10-29**] 10:09PM LIPASE-52 [**2144-10-29**] 10:09PM ALBUMIN-3.8 [**2144-10-29**] 10:09PM ASA-NEG ETHANOL-435* ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2144-10-29**] 10:09PM WBC-6.4 RBC-3.77* HGB-12.9* HCT-37.5* MCV-99* MCH-34.3* MCHC-34.5 RDW-13.9 [**2144-10-29**] 10:09PM PLT COUNT-208 [**2144-10-29**] 10:09PM PT-11.7 PTT-29.0 INR(PT)-1.0 CT C-SPINE W/O CONTRAST Reason: assess for C-spine fx s/p trauma. [**Hospital 93**] MEDICAL CONDITION: 49 year old man s/p fall with c2 fx on OSH films. REASON FOR THIS EXAMINATION: assess for C-spine fx s/p trauma. CONTRAINDICATIONS for IV CONTRAST: None. There are bilateral fractures of the inferior articular processes of C2. These permit anterior subluxation of C2 on C3. This subluxation also raises the possibility of ligamentous injury anteriorly or posteriorly. Correlation with an MR examination is recommended. There is a tiny midline disk protrusion at C4-5 tht may touch the anterior surface of the spinal cord. There is a small disk protrusion at C5-6 that may cause compression of the spinal cord. Again, an MR may be helpful. There is increased density of the epidural space at C2, extending inferiorly along C3. This may be hemorrhage related to the fractures discussed above. There is limited intraspinal soft tissue contrast throughout the spinal canal, limiting evaluation for possible disk protrusions or hemorrhage. C2 fracture at outside hospital. COMPARISON: None. TECHNIQUE: Non-contrast axial CT imaging of the cervical spine with multiplanar reformations was reviewed. FINDINGS: Skull base through T1 was visualized. The patient is intubated and an NG tube is present in the esophagus. There is a complex C2 fracture with multiple fracture lines including oblique comminuted fracture through the base of the dens. Fracture line extends through the C2 vertebral body right of midline. A displaced fracture is also present through the right lateral mass extending to the vertebral foramen. Posterior portion of this fracture fragment is displaced inward towards the spinal canal, but there is no evidence for intrusion upon the cord. Irregular jagged fracture line is also present through the left lateral mass with a tiny fracture fragment abutting but not interrupting the vertebral foramen. There is also a non-displaced fracture through the left C3 anterior tubercle. Minimally displaced fractures are also present through the left lateral mass of C4 and C5. In addition to the above fractures, there are also degenerative changes noted at multiple levels with intervertebral disc space narrowing, most significant at C5-C6 and C6-C7. There is evidence for spinal canal narrowing at multiple levels, most significant at C6-C7 where canal stenosis is severe. The mastoid air cells are clear. Mild emphysematous changes are appreciated in the lung apices. Note is made of an unerupted right maxillary and mandibular molar. IMPRESSION: Multiple fractures as described above, most significant within C2 as described above. MR CERVICAL SPINE W/O CONTRAST; MR THORACIC SPINE W/O CONTRAST Reason: bleed, cord compression [**Hospital 93**] MEDICAL CONDITION: 49 year old man with C2 fx, T3 fx, question of epidural bleed in T-spine REASON FOR THIS EXAMINATION: bleed, cord compression CONTRAINDICATIONS for IV CONTRAST: None. INDICATION: Bleed, cord compression. TECHNIQUE: Multiplanar T1- and T2-weighted sequences were obtained through the cervical spine with sagittal STIR sequence. FINDINGS: There is edema within the prevertebral soft tissues as well as in the nasopharyngeal soft tissues. Edema is also noted within the posterior soft tissues, most prominently in the region of the occiput and posterior to C2, 3 and 4 vertebral bodies. This would indicate at least ligamentous sprain. There is mild edema within the C2 vertebral body, consistent with the acute fracture noted on the prior CT. The craniocervical junction is normal. The cervical spine has no abnormal signal within it. At C2, there are multiple linear regions of T2 signal within the vertebral body consistent with the fractures previously noted on the CT. There is no evidence of an epidural collection. At C5-6, there is a moderate sized posterior osteophyte with uncovertebral degenerative changes. This results in severe left and moderate right neural foraminal narrowing. There is mild spinal canal stenosis at this level. At C6-7, there is small posterior osteophyte with large amounts of uncovertebral degenerative change on the right. This results in severe right neural foraminal narrowing and mild-to-moderate left neural foraminal narrowing. At C7-T1, there is an asymmetrically thickened ligamentum flavum on the left which contacts and slightly displaces the posterolateral surface of the cord. There are bilateral uncovertebral degenerative changes resulting in moderate bilateral neural foraminal narrowing. IMPRESSION: No evidence of cord compression. C5-6 and C6-7 moderate posterior osteophytes resulting mild central canal narrowing at these two levels. Edema within the soft tissues both anterior and posterior to the spinal column. This likely indicates at least ligamentous sprain. Increased T2 signal within the C2 vertebral body consistent with the previously described fractures. There is no evidence of cord compression. THORACIC SPINE MR: Multiplanar T1 and T2 survey images were obtained through the thoracic spine. FINDINGS: There is a chronic T8 burst fracture with mild retropulsion of fragments. There is approximately 25% spinal canal narrowing at this level. The bone fragment appears to contact the ventral surface of the cord. There is no edema within this vertebral body fracture to indicate that it is acute. There is a kyphosis about this burst fracture which is anteriorly wedged. The remainder of the vertebral bodies appears normal with no evidence of bone marrow edema or malalignment. There is no evidence of abnormal signal within the cord. There is no cord compression. There are moderate amounts of bibasilar atelectasis with small bilateral pleural effusions. A nasogastric tube is present within the esophagus. IMPRESSION: No evidence of cord compression. There is mild T8 burst fracture with mild retropulsion of fragments which contact the ventral surface of the cord. CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Reason: trauma Field of view: 36 Contrast: OPTIRAY [**Hospital 93**] MEDICAL CONDITION: 49 year old man s/p fall with c2 fx, widened mediastinum. REASON FOR THIS EXAMINATION: trauma CONTRAINDICATIONS for IV CONTRAST: None. INDICATION: Fall, C2 fracture, widened mediastinum. TECHNIQUE: MDCT was used to obtain contiguous axial images from the thoracic inlet to the pubic symphysis with multiplanar reformats. No priors for comparison. CT CHEST WITH IV CONTRAST: Endotracheal tube is seen, with slightly overdistended cuff. Nasogastric tube courses below the diaphragm. Small foci of air is seen in bilateral subclavian and internal jugular veins, likely iatrogenic. No mediastinal or axillary lymphadenopathy, though small mediastinal nodes are seen. No hilar lymphadenopathy. No evidence of aortic dissection; the aorta is normal in caliber. Bilateral posterior lower lobe consolidations seen, small. Tiny bilateral pleural effusions. No pneumothorax. CT ABDOMEN WITH IV CONTRAST: Fatty liver. Adrenals, spleen, pancreas, kidneys, proximal ureters, aorta are normal. Clips seen at the common bile duct. No free fluid. No free air. Within the limits of this non-oral contrast scan, stomach and small bowel loops appear normal. There are scattered diverticula in the colon. CT PELVIS WITH IV CONTRAST: Bilaterally prominent ureters, however, no evidence of ureteral rupture. Foley is seen in the bladder. Bladder wall is slightly thickened. Diverticula in the sigmoid colon without evidence of diverticulitis. Appendix is seen and is normal. Within the limits of this non-oral contrast scan, the bowel loops are normal. Prostate is slightly enlarged. No free fluid. No lymphadenopathy. There are multiple phleboliths in the pelvis. Posterior laminar cortical lucency seen at T3, however, multiplanar and thin cut reformats show no evidence of acute trauma. There is no hematoma in the paravertebral muscles. Thecal sac evaluation is limited, however, reconstructed images show no evidence of epidural hematoma. Multiple rib fractures are seen in both right and left, and healed fracture of right L1 transverse process. Old healed sternal fracture is also noted. Degenerative changes of the spine. No pelvic fractures. An old wedge compression of T8 vertebral body, with kyphosis at that level. Multiplanar reformats were essential in delineating the findings above. IMPRESSION: 1. Bilateral dependent lower lobe consolidations indicating probable aspiration. Bilateral tiny pleural effusions. 2. Fatty liver. 3. Diverticulosis without diverticulitis. 4. Evidence of old trauma, with multiple healed rib fractures and sternal fracture. Findings discussed with the trauma team at time of interpretation. Brief Hospital Course: He was admitted to the Trauma service. He underwent CT imaging which identified fractures of C2, C4, C5. Orthopedic spine surgery was consulted as a result of the injuries. He was transferred to the Trauma ICU; a Halo was placed in the ICU while patient was already sedated and intubated. He was eventually extubated and transferred to the regular nursing unit. Pain control was initially an issue; he was later changed to Oxycodone prn which appeared to be effective. Physical therapy was consulted because of balance issues; he was treated in 2 visits by the rehab staff. Home services were not recommended. Social work was also closely involved with him; he was reportedly homeless; staying with his mother intermittently. His request for discharge was to stay with a friend who owns a camper. Discharge Medications: 1. Clonidine 0.1 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QSAT (every Saturday). 2. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4-6H (every 4 to 6 hours) as needed for pain. 3. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) PO BID (2 times a day) as needed for constipation. 6. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 7. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for pain. Disp:*45 Tablet(s)* Refills:*0* 8. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily). Discharge Disposition: Home With Service Facility: [**Company 1519**] Discharge Diagnosis: s/p 6 ft Fall C2 fracture Minimally displaced lateral mass fracture C4 C5 Spinal stenosis C6 C7 Discharge Condition: Good Discharge Instructions: Return to the Emergency department if you develop any fevers, dizziness, severe headaches, redness/drainage from your halo pin sites, weakness/numbness or tingling in any of your extremities and/or any other symptoms that are concerning to you. Followup Instructions: Follow up Ortho Spine Surgery in 4 weeks, call [**Telephone/Fax (1) 3573**] for an appointment with Dr. [**Last Name (STitle) 363**]. Completed by:[**2144-11-7**]

[ "518.81", "805.08", "873.42", "780.6", "E884.9" ]

icd9cm

[ [ [] ] ]

[ "02.94", "93.41", "96.72", "86.59", "96.6" ]

icd9pcs

[ [ [] ] ]

11793, 11842

10194, 10995

329, 363

11982, 11989

769, 1532

12282, 12447

733, 750

11018, 11770

7543, 7601

11863, 11961

12013, 12259

276, 291

7630, 10171

391, 594

616, 674

690, 717

11,382

141,067

27060

Discharge summary

report

Unit No: [**Numeric Identifier 66471**] Admission Date: [**2107-2-28**] Discharge Date: [**2107-3-10**] Date of Birth: [**2028-7-26**] Sex: M Service: TRA HISTORY OF PRESENT ILLNESS: Patient is a 78-year-old male status post a trip and fall down 9 steps. He is complaining of back pain. He has had mental status changes, although he has not had any loss of consciousness and he does not remember the details of the accident. He was restrained in the field. He has an obvious laceration on the bridge of his nose as well as on the medial left collar bone. He is obviously intoxicated. PAST MEDICAL HISTORY: Hypertension. MEDICATIONS: At home he takes Detrol, alprazolam, verapamil and doxazosin. ALLERGIES: Patient has no known drug allergies. SOCIAL HISTORY: He lives with his wife. [**Name (NI) **] does drink extensive amounts of alcohol. He stopped smoking 20 years ago. PHYSICAL EXAMINATION: In general, patient is agitated and confused. He has a heart rate of 85. Blood pressure of 174/85 and O2 saturation of 99%. GCS of 14. On his head, he has a laceration on the vertex of his head, a hematoma above his right eyebrow and a laceration to the bridge of his nose. Pupils equally, round and reactive to light. Extraocular movements are intact. He had a C collar in place. No cervical spine tenderness. Trachea is midline. Chest is clear to auscultation bilaterally. Sternum is stable. Heart is regular rate and rhythm. Abdomen is soft, nondistended. __________ was equivocal. He had a large abrasion on his right flank. Back had no step offs, no abrasions, appeared to be nontender. Rectal exam had good tone and was guaiac negative. Extremities showed a superficial abrasion to the left shin. Multiple images were obtained. A chest x-ray showed question of right upper lobe infiltrate. A pelvis film was negative. Head CT was negative. CT of the C spine showed hyperextension of T1 and C5-C6 and degenerative disease. CT of the face showed a nasal fracture. CT of his abdomen was negative. CT of his chest showed trace pleural effusion and atelectasis. HOSPITAL COURSE: Patient was intubated at that time and was transferred to the intensive care unit for further care. He did have his C collar in place and was left on log roll precautions initially. He was placed on Pneumoboots and heparin subQ for DVT prophylaxis. He did have a face consult who evaluated the nose and decided that they would not pursue operative management as that might be dangerous for the C spine injury. The neurosurgery service saw the patient and decided to only do conservative management and leave the collar on for 6 weeks at the end of which they will reevaluate his spine and decide if there needs to be operative management. They would like follow up x-rays done in approximately 2 weeks to be brought to follow up. The patient initially did well, was extubated successfully and was transferred to the floor where he was remained on a CIWA scale. However, about 36 hours after being on the floor the patient coded with apneic and bradycardic arrest. ACLS protocol was initiated. The patient was reintubated, given atropine and epinephrine and was revived. It was not determined what caused the event, although cardiology was involved. Patient was ruled out for an MI. There was a possibility he may have aspirated and there may be a possibility there was a combination of medications, although no definitive answer was achieved. Once he did get to the ICU it became apparent that his blood pressure became increasingly more and more difficult to control. This was felt to be due partial to withdraw. He did receive a large amount of Ativan while he was here. He also received an MRI of his head to ensure that there was nothing else going on that was negative. Neurology was consulted, because the patient persistently would not clear. It was felt that this was due to a toxic metabolic process and not something intrinsic to his brain. He did develop a E coli UTI and a methicillin sensitive staph aureus pneumonia. Both of those were treated with Vancomycin and Flagyl. Once it was evident that the patient would not extubate quickly, patient did undergo tracheostomy and PEG placement. This was uneventful and patient was restarted on tube feeds through the PEG, which was very well tolerated. In addition to his CIWA scale, patient was also receiving thiamine and folate to prevent any neurological sequela. Towards the end of the patient's stay his BUN and creatinine did start to increase mildly, however, this was felt to be due to diuresing him a little too quickly and him being NPO for his PEG and trach placement. It is felt that with a little bit of time this will go back to the other direction and with a little bit of fluid. It is now [**2107-3-9**] and the patient was being discharged in good condition. He is still on a vent machine, although believed he will be able to be weaned quickly. He does have a PEG and trach in place and requires regular PEG and trach care. He does require physical therapy and occupational therapy as he is currently bed bound, because of his lack of neurological clearing. Although there is no reason why he should not get out of bed if the proper precautions be taken. He does have a C collar in place and must keep that for another 4 and a half weeks. He should follow up with neurosurgery in approximately 2 weeks at which time he should have C spine films performed. He should follow up with neurology in approximately 2 weeks. He should follow up in the trauma clinic in approximately 2 weeks. He will be discharged on tube feeds ProMod with fiber full strength at a goal of 85 cc an hour to be flushed with 100 cc of water every 6 hours. He will be discharged with Tylenol 650 mg per G tube every 6 hours p.r.n., albuterol 2 to 4 puffs every 4 hours, bisacodyl 10 mg every day p.r.n., captopril 50 mg per PEG tube t.i.d., Colace 100 mg per PEG tube b.i.d., folate 1 mg per PEG tube daily, heparin 5000 units subQ t.i.d., hydralazine 20 mg per G tube every 6 hours, Levofloxacin 500 mg per G tube every day x3 more days, Ativan 1 mg every 6 hours standing and 1 to 2 mg every 4 hour p.r.n. Both Ativan orders to be weaned actively. Lopressor 100 mg per PEG tube t.i.d., Roxicet 5 to 10 ml per PEG tube every 6 hours p.r.n. pain, multivitamins 1 capsule per PEG tube daily, Protonix 40 mg per PEG tube daily, thiamin 100 mg per PEG tube daily, vancomycin 1250 mg IV every 12 for 6 more days. Please check a vancomycin trough prior to the first dose. Also please check a BUN and creatinine in the next 24 to 48 hours to make sure that it does drop. He is leaving with a BUN of 59 and creatinine of 1.7. FINAL DISCHARGE DIAGNOSES: A fall down stairs with hyperextension of the T1 extending into the middle column and C5-C6 disc spaces, nasal fracture, delirium tremens, staph pneumonia, E coli urinary tract infection, mild renal failure, hypertension, delirium. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) **] Dictated By:[**Last Name (NamePattern1) 3956**] MEDQUIST36 D: [**2107-3-10**] 09:17:54 T: [**2107-3-10**] 10:07:48 Job#: [**Job Number 66472**]

[ "482.41", "802.0", "303.01", "427.5", "291.0", "805.2", "920", "V09.0", "518.81", "041.4", "599.0", "401.9", "E880.9", "V46.11" ]

icd9cm

[ [ [] ] ]

[ "96.6", "43.11", "96.04", "38.93", "31.1", "96.71", "94.62" ]

icd9pcs

[ [ [] ] ]

2096, 6668

913, 2078

6696, 7230

190, 592

615, 757

774, 890

20,489

110,666

25158

Discharge summary

report

Admission Date: [**2138-11-1**] Discharge Date: [**2138-11-12**] Date of Birth: [**2076-5-13**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1505**] Chief Complaint: chest pain Major Surgical or Invasive Procedure: Cardiac Catheterization CABGx4(LIMA->LAD,SVG->Diag,SVG->OM,SVG->PDA) History of Present Illness: Patient is a 62 year old male with PMH of DM II, HTN, and hypercholesteremia who presented to an OSH with nausea and vomiting. The nausea and vomiting started 3 days ago, brownish in color, and it has been constant. He has been unable to eat due to the nausea and has not taken his medications, including his insulin, for the last 3 days. Denies lightheadedness/dizziness, chest discomfort or pain, arm pain, jaw pain, sweating, SOB, palpatations, orthopnea, PND, edema. No history of recent travel, no sick contacts, and has not been out to eat lately, only 'out to the supermarket.' He has had no diarrhea but has not had a BM in 3 days. His last BM was normal in color, no melena, no hematochezia. His urination has decreased, he believes because of decreased PO intake, but no dysuria or hesitancy. Mild increased thirst. In the ED at [**Hospital6 33**] the patient was found to have CK's of 1635, CK-MB of 34.3, trop 0.55, an elevated creatinine of creatinine of 2.1 with BUN 54. EKG showed NSR with T wave flattening and possible inversion in inferior leads per report, and CXR was unremarkalbe. Additionally LFT's were slightly elevated and he had a white count of 11.8. Amylase and lipase normal. ABG with respiratory and metabolic alkalosis (7.55/30/76/26.2). He was given fluids and antiemetics. Because they felt the cardiac enzymes could not be explained by the ARF alone, he was started on heparin gtt, asa, and lopressor. ROS is o/w unremarkable for no weight gain/loss, no HA's, no vision changes, no fevers, chills, or night sweats, no abdominal pain, +constipation, no diarrhea, no muscle weakness or pain. Past Medical History: HTN Hypercholesteremia DM II Social History: Lives with wife at home, but she is currently at [**Hospital1 336**] receiving chemotherapy. Family History: Noncontributory Physical Exam: GEN: NAD, WN, WD HEENT: Clear OP, MMM Neck: Supple, No LAD, No JVD Lungs: CTA, BS BL, No W/R/C Cardiac: RR, NL rate. NL S1S2. No murmurs Abd: Soft, NT, ND. NL BS. No HSM. Ext: No edema. 2+ DP pulses BL. Neuro: A&Ox3. Appropriate. CN 2-12 grossly intact. Sensation decreased in bilateral LE to soft touch and pin prick. [**5-29**] strength throughout in upper and LE's Pertinent Results: [**2138-11-1**] WBC-13.1 Hgb-13.5 Hct-39.2 Plt Ct-191 [**2138-11-6**] Hct-30.3 [**2138-11-7**] WBC-6.1 Hgb-8.6 Hct-24.8 Plt Ct-107 [**2138-11-12**] WBC-7.3 Hgb-8.9 Hct-26.2 Plt Ct-269 [**2138-11-1**] Gluc-240 BUN-54 Creat-1.9 Na-140 K-4.3 Cl-103 HCO3-25 [**2138-11-3**] Gluc-229 BUN-36 Creat-1.6 Na-139 K-3.3 Cl-102 HCO3-25 [**2138-11-7**] Gluc-155 BUN-15 Creat-1.1 Na-140 K-3.9 Cl-105 HCO3-25 [**2138-11-12**] Gluc-117 BUN-20 Creat-1.1 Na-138 K-4.0 Cl-100 HCO3-27 CARDIAC CATHETERIZATION: 1. Selective coronary angiography revealed a right dominant system with severe three vessel coronary artery disease. The LMCA had mild disease. The twin LAD system has a 90% stenosis at the origin of the septal component and a 79% stenosis prior to the bifurcation of a large diagonal branch. The LCA had a total occlusion after the OM1 with left to left collaterals. The RCA had a proximal occlusion with left to right collaterals. 2. Limited resting hemodynamics demonstrated moderate systemic hypertension and mildly elevated left sided pressures (LVEDP 18 mmHg) with no gradient upon movement of the catheter from the ventricle back to the aorta. 3. Left ventriculography was deferred for renal insufficiency. CAROTID SERIES COMPLETE Mild atherosclerotic changes in the proximal internal carotid arteries bilaterally with less than 40% stenosis on both sides. CT 1. Small retroperitoneal hematoma. 2. Right renal obstruction with right-sided hydroureter and hydronephrosis with marked soft tissue prominence at the right ureterovesical junction, containing a punctate density. Findings could indicate obstructing right UVJ stone, although the degree of UVJ swelling is unusual and tumor cannot be excluded. Alternatively the denisty could represent contrast in the collecting system. A non contrast enhanced follow-up scan of the pelvis would help to determine whether this density represents a stone. If a stone is suspected, the soft tissue prominence at the right UVJ has to be followed to complete resolution on CT. Alternatively, this could be further evaluated with cystoscopy. 3. Small right pleural effusion and minimal bibasilar atelectasis. RENAL U/S: Mild right hydronephrosis. Assymetric bladder wall thickening at the right vesicoureteric junction. Although an echogenic lesion here likely reflects calculus, the degree of thickening is thought to be atypical for a calculus, even an impacted one, and cystoscopic evaluation is recommended to rule out tumor. [**2138-11-11**] CXR Comparison is made to study performed one day prior. The patient has undergone median sternotomy. There is stable cardiomegaly. Pulmonary vasculature is not engorged. There are small bilateral pleural effusions as well as bibasilar atelectasis. Osseous structures are unremarkable. [**2138-11-7**] EKG Sinus rhythm. Probable inferior myocardial infarction. Minor non-specific ST-T wave abnormalities. Compared to [**2138-11-1**] tracing is not suggestive of left ventricular hypertrophy. Brief Hospital Course: Mr. [**Known lastname 41776**] was admitted to the [**Hospital1 18**] on [**11-1**]/095 for further management. Heparin and aspirin were continued given his elevated cardiac enzymes.An echocardiogram was obtained which revealed hypokinesis of his anterior septum. A cardiac catheterization was performed which revealed severe three vessel disease. Given the severity of his disease, the cardiac surgical service was consulted and Mr. [**Known lastname 41776**] was worked-up in the usual preoperative manner. As Mr. [**Known lastname 41776**] had hematuria, an abdominal CT scan was obtained which revealed a small retroperitoneal hematoma and a right renal obstruction with right-sided hydroureter and hydronephrosis with marked soft tissue prominence at the right ureterovesical junction, containing a punctate density. The urology service was consulted and a cystoscopy was recommended in the future. Urine cytology was performed which was read as atypical cells.On [**2138-11-7**], Mr. [**Known lastname 41776**] was taken to the operating room where he underwent coronary artery bypass grafting to four vessels. Postoperatively he was taken to the cardiac surgical intensive care unit. On postoperative day one, Mr. [**Known lastname 41776**] [**Last Name (Titles) 5058**] neurologically intact and was extubated. Aspirin and beta blockade were resumed. He was then transferred to the cardiac surgical down unit for further recovery. He was gently diuresed towards his preoperative weight. Ceftriaxone and levofloxacin were started for presumed pneumonia. The physical therapy service was consulted for assistance with his postoperative strength and mobility. After obtaining a normal chest x-ray prior to discharge, his antibiotics were discontinued. Some mild erythema was noted at his incision and keflex was started. Mr. [**Known lastname 41776**] continued to make steady progress and was discharged home on postoperative day five. He will follow-up with Dr. [**Last Name (STitle) **], his cardiologist and his primary care physician as an outpatient. Medications on Admission: Procardia (unknown dose) Lipitor (unknown dose, has been on for 15? years) ASA 81 mg PO QD NPH 40 units QAM, 20 QHS Humalog 8 units in a.m. and 8 units at supper Discharge Medications: 1. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours) for 1 weeks. Disp:*28 Capsule(s)* Refills:*0* 2. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*0* 4. 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. 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* 6. 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* 7. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*0* 8. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 1 weeks. Disp:*14 Tablet(s)* Refills:*0* 9. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12 hours) for 1 weeks. Disp:*14 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0* 10. Insulin NPH Human Recomb 100 unit/mL Cartridge Sig: NPH 40 Units QAM, 20 Units QPM Subcutaneous twice a day: Humolog 8 Units with breaksfast, 8 units with dinner. Discharge Disposition: Home With Service Facility: [**Hospital1 1474**] VNA Discharge Diagnosis: 3 vessel Coronary Artery Disease Diabetes, controlled Hypertension Discharge Condition: Stable. Discharge Instructions: Shower, wash incision with soap and water and pat dry. No baths, lotions, creams or powders. Call with fever, redness or drainage from incision or weight gain more than 2 pounds in one day or five in one week. Followup Instructions: Please see your cardiologist 2 weeks Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 170**] Follow-up appointment should be in 1 month Provider: [**Name10 (NameIs) **],[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 33129**] Follow-up appointment should be in 2 weeks Completed by:[**2138-12-1**]

[ "599.7", "276.51", "401.9", "787.01", "592.1", "414.01", "V58.67", "584.9", "250.00", "272.0", "410.71", "285.9" ]

icd9cm

[ [ [] ] ]

[ "36.13", "37.22", "99.04", "36.15", "88.56", "39.61" ]

icd9pcs

[ [ [] ] ]

9373, 9428

5667, 7732

333, 404

9539, 9549

2658, 5644

9807, 10208

2237, 2254

7945, 9350

9449, 9518

7758, 7922

9573, 9784

2269, 2639

283, 295

432, 2058

2080, 2111

2127, 2221

73,488

185,762

17650

Discharge summary

report

Admission Date: [**2169-10-14**] Discharge Date: [**2169-10-23**] Date of Birth: [**2130-2-9**] Sex: M Service: MEDICINE Allergies: Ampicillin / Ancef Attending:[**First Name3 (LF) 689**] Chief Complaint: hypoxia, seizure Major Surgical or Invasive Procedure: intubation for airway protection History of Present Illness: This is a 39 yom with h/o C5 quadriplegia, MDS, and recurrent UTIs who was transferred from OSH for assessment of altered mental status. He was admitted to [**Location (un) 620**] from [**2169-10-5**] to [**2169-10-9**] with lethargy and was diagnosed with a Klebsiella UTI. He was initially treated with ertapenem and subsequently switched to ciprofloxacin for a seven day course. At the time of discharge the patient was continuing to feel weak. At baseline he can unscrew a bottle cap, drive a car and drive his wheelchair. He returned to [**Location 620**] on [**2169-10-14**] with progressive weakness in his upper extremities and lethargy. His temperature was "running low" but he had no fevers, chest pain, difficulty breathing, nausesa, vomiting, headaches, neck stiffness, head trauma or diarrhea but was having some mild cough and congestion. Initial vitals were notable for a temperature of 92.7. Initial urinalysis was positive and he was started on ertapenem for presumed urinary tract infection. Subsequent culture has been negative. He had a head CT which showed possible blood in the third ventricle. He was transfered to this hospital for further management. . On arrival to our emergency room his initial vs were: T 96.2 P: 61 BP: 120/71 R: 14 O2 sat 96%RA. He was seen by neurosurgery who felt he should have platelets given but no surgery was indicated. Patient was given 6 units of platelets (1 bag) and transferred to the floor. . On admission the patient was noted A&O x 3 but per his family was more lethargic than usual. Upper extremity strength was documented as as 4-/5. On [**2169-10-15**], pt had a generalized tonic clonic seizure with hypoxia of 88% on RA. He was treated with IV ativan and was subsequently post-ictal. He was placed on continuous oxygen monitoring and four liters nasal cannula with saturations in the mid 90s. There was concern for aspiration during this event secondary to increased secretions requiring deep suctioning. He was started on IV Keppra 1000 mg [**Hospital1 **]. EEG showed left mid to posterior temporal theta slowing. On [**2169-10-17**] he had a second generalized tonic clonic seizure lasting one minute. He was given IV ativan and subsequently was noted to have hypoxia to 85% on 4L nasal cannula and his respiratory rate was [**5-1**] with periods of apnea. CPAP was tried, but hypoxia persisted. He was placed on NRB. . Complicating his hospital course was a multifocal pneumonia noted on CXR, with low grade temps. He was cotninued on meropenem for UTI although cultures subsequently returned as negative. . MICU course: Pt was somnolent but arousing to voice. He did not respond to questions but would track when aroused. He did not withdraw to painful stimuli in the upper extremtities or respond to questions. Pt is noted to have episodes of bradycardia associated with hypothermia. ECG shows no apparent heart block. Antibiotic coverage was broadened to include anaerobes with Flagyl. Pt was continued on Keppra and Dilantin. . Currently, pt feels well. Denies any complaints. He denies any discomfort with his breathing. . ROS: Denies fever, chills, night sweats, headache, rhinorrhea, congestion, sore throat, cough, shortness of breath, chest pain, abdominal pain, nausea, vomiting, BRBPR, melena, hematochezia, dysuria, hematuria. Past Medical History: 1. C4/C5 Spinal Cord Injury (17 y/a)due to MVA - can move arms slightly cannot move legs 2. OSA on CPAP at home 3. Seizure Disorder ('[**62**]-'[**63**]) 4. Baclofen Pump ('[**49**], '[**54**], '[**61**]). Managed at [**Hospital1 2177**]. 5. s/p appendicovesicostomy 6. Multiple past urinary tract infections including w mild UAs per [**Month (only) 116**] discharge summary, have included Klebsiella, ESBL E coli, enterococcus. Social History: Lives with roommates in house in [**Location (un) 620**], MA. Has private aides to help with ADLs. Until recent seizures, drove himself using modified car. Used to work at UPS in Marketing. Had MVA at age 17 resulting in quadriplegia. Family History: Father had [**Name2 (NI) **] in 50s. Physical Exam: Vitals - T:97.5 BP:98/56 HR:61 RR:16 02 sat:93RA GENERAL: Pleasant, well appearing male, flat affect, NAD HEENT: Normocephalic, atraumatic. No conjunctival pallor. No scleral icterus. PERRLA/EOMI. MMM. OP clear. Neck Supple, No LAD, No thyromegaly. Right eye prothesis CARDIAC: Regular rhythm, normal rate. Normal S1, S2. No murmurs, rubs or [**Last Name (un) 549**]. JVP flat. LUNGS: Coarse breath sounds bilaterally. Good air movement. ABDOMEN: NABS. Soft, NT, ND. No HSM EXTREMITIES: No calf pain, 2+ edema to mid calf. 2+ dorsalis pedis/ posterior tibial pulses. SKIN: No rashes/lesions, ecchymoses. NEURO: A&Ox3. Appropriate. CN 2-12 intact (right eye prothesis). Preserved sensation throughout. 0/5 strength in LE bilaterally. Delt [**2-26**] bilat. Biceps [**2-26**] bilat. Able to pronate and supinate arms but not against resistance. 0/5 wrists, fingers and entire lower extremities. PSYCH: Listens and responds to questions appropriately, pleasant Pertinent Results: [**2169-10-14**] 144 108 52 ------------ 60 5.0 25 1.6 . .....8.6 2.5 ----- 51 ∆ .....25.3 N:55.4 L:36.0 M:6.0 E:1.9 Bas:0.7 . PT: 12.3 PTT: 36.2 INR: 1.0 . Urine Analysis: Bld Lg Prot 25 RBC [**5-3**] WBC [**1-26**] . Discharge Labs: 145 110 25 -------------- 75 3.7 28 1.2 . Ca 8.3, Mg 1.8, Phos 2.6 . vanc trough 34.1 [**10-15**] EEG: This is an abnormal portable EEG due to intermittent left mid to posterior temporal theta slowing that, at times, appears monomorphic and more suspicious for epileptiform activity. These findings suggest possible subcortical dysfunction in this area. Anatomic correlation is indicated. A repeat study with sphenoidal electrodes may be performed to help clarify the above findings. . [**10-15**] CXR: Bibasilar pneumonia. . [**10-15**] CT Head: CONCLUSION: No definite sign of an intracranial hemorrhage. See above report for requested potential prior outside studies and their reports. COMMENT: Seen on the lateral scout radiograph are two screws overlying the mid cervical spine and a possible intervening wire. Please provide information as to whether this finding constitutes some form of prior surgical treatment. At least the more cephalad screw was likely visible on the prior sagittal T1-weighted scans as an area of susceptibility. CONCLUSION: No definite sign of an intracranial hemorrhage. See above report for requested potential prior outside studies and their reports. COMMENT: Seen on the lateral scout radiograph are two screws overlying the mid cervical spine and a possible intervening wire. Please provide information as to whether this finding constitutes some form of prior surgical treatment. At least the more cephalad screw was likely visible on the prior sagittal T1-weighted scans as an area of susceptibility. . [**10-17**] CXR (portable): Newly developed, slightly asymmetrical pulmonary edema with new right pleural effusion, which is small to moderately large . [**10-18**] MRI Head: 1. Motion artifact degrades image quality. Areas of apparent T2 hyperintensity in the right temporal lobe may be artifactual related to the patient motion. The parenchyma is otherwise grossly unremarkable. If there is focal semiology and further clinical concern, repeat MRI of the brain as per the seizure protocol may be helpful if the patient is able to better tolerate the procedure without movement. 2. Stable prosthesis in the right orbit. 3. Fluid within the right mastoid air cells and paranasal sinuses, improved since the prior study. . [**10-18**] CXR: Previous mild pulmonary edema has resolved. Opacification in the right lower lung and accompanied downward displacement of the hilus indicates that previous area of consolidation has now collapsed. Pulmonary edema has resolved since [**10-17**]. Consolidation in the left lower lobe has worsened since [**10-13**] and could be another region of atelectasis or pneumonia. The upper lungs are now clear. Heart size is normal. Pleural effusion, if any, is minimal. ET tube is in standard placement. . [**10-19**] CXR: The patient was extubated. There is a radiopaque object projecting over the upper neck that is most likely external but should be correlated clinically. Cardiomediastinal silhouette is unchanged including minimal cardiomegaly. Compared to prior study obtained yesterday at 08:26 a.m. there is significant improvement in bibasal atelectasis and bilateral opacities consistent with resolution of the atelectatic process and decrease in pleural effusion. There is still present left retrocardiac opacity that might represent infectious process or residual atelectasis. No evidence of failure is present. Brief Hospital Course: 39 yom with h/o C5 quadriplegia, MDS, and recurrent UTIs who was transferred from OSH for assessment of altered mental status and UTI. Hospital course was complicated by HAP and tonic clonic seizures. . #Seizures/AMS: On [**2169-10-15**], pt had a generalized tonic clonic seizure with hypoxia of 88% on RA. He was treated with IV ativan and was subsequently post-ictal. He was placed on continuous oxygen monitoring and on 4L nasal cannula. He was started on IV Keppra 1000 mg [**Hospital1 **]. EEG showed left mid to posterior temporal theta slowing. On [**2169-10-17**] he had a second generalized tonic clonic seizure lasting one minute. He was given IV ativan and subsequently noted to be hypoxic to 85% on 4L nasal cannula. His respiratory rate was [**5-1**]/min with periods of apnea. He was tranferred tot he MICU where he remained seizure free. It was thought that the etiology of his seizure was infection (multifocal pneumonia noted on CXR, sputum positive for G+ cocci). Blood cultures, urine cultures, and cerebral spinal fluid showed no growth. Head CT and MRI were negative for acute process. Per neurology, he was treated with Keppra 1000mg [**Hospital1 **] and loaded with dilantin. Both antiepileptics are to be continued as outpatient per the neurology team. Dilantin levels should be checked in one week. Dilantin can be tapered as outpatient per Dr. [**Last Name (STitle) **]. #Hypoxia/Pneumonia: Patient was hypoxic and apneic post seizure with evidence of multifocal pneumonia on CXR. He was intubated to protect his airway and to allow him to have an LP and MRI. He was extubated the following day, oxygen requirement reduced until he was on room air when transferred from the MICU back to the floor. He continued BiPap at night per his home regimen. He was treated with vancomycin and aztreonam for his pneumonia. Patient will be discharged home with IV vancomycin and aztreonam to finish a 10d course. The last day of the antibiotics will be [**2169-10-26**]. On the day of discharge, patient's vanc trough was 34, so vancomycin was held. Critical care/infusion company was instructed to draw vanc trough on the morning post-discharge, and fax the result to Dr. [**Last Name (STitle) **], patient's PCP. [**Last Name (NamePattern4) **].[**Name (NI) 2056**] office was [**Name (NI) 653**], and the RN was told that goal vanc trough is 15-20. If trough > 20, continue to hold vancomycin. If vanc < 20, restart vancomycin at 1gm [**Hospital1 **], and then re-check vanc trough before the 4th dose. #Bradycardia: Pt has history of HR ranging from 38 to 70 while in the MICU. He was found to be hypothermic and was warmed with a bear hugger which improved his HR mildly. He did experience some light headedness but no chest pain or shortness of breath. EKG was unimpressive, cardiac enzymes showed mildly elevated troponins which were consistent with past measurements. No invasive measures were taken. He should be evaluated as outpatient regarding possible intervention. # Elevated troponin: Patient found to have trop of 0.25 when having bradycardic event. According to records, this seems to be his baseline. Could be related to renal dysfunction. Has had cardiology consulted in the past and no interventions were recommended. No further actions taken. . #C5 spinal cord injury: Continued Baclofen pump. Physical therapy found patient to be independent and able to live independently. #Depression: Home Zoloft was continued. . #Chronic Kidney Disease: Baseline Creatinine 1.5-1.7. Received gentle hydration, monitored urine output, renally dosed medications, trended creatinine. Cr 1.2 on discharge. . #Hypernatremia: Could be due to dehydration in the setting of sepsis. He was given D5 boluses in the MICU. He continued to have fluctuating hypernatremia. He was encouraged to take more fluids. His Na was 145 on discharge. . FEN: D5W boluses d/t hypernatremia, repleted electrolytes, advanced to normal diet after extubation. Prophylaxis: SC heparin Access: discharged with PICC Code: Full (discussed with patient) Communication: Patient, Mother( HCP) [**Telephone/Fax (1) 49141**]; Brother [**Name (NI) **] [**Telephone/Fax (1) 49142**] Disposition: home with IV antibiotics and VNA service Medications on Admission: Medications (home - per OMR note): -Keppra 500mg [**Hospital1 **] (recent dosing somewhat unclear, [**Name (NI) 620**] d/c summary says 1000 mg [**Hospital1 **]) -Trazodone 50 mg QHS: PRN -Sertraline 100 mg daily -B-Complex with Vitamin C Tablet Sig: One (1) Tablet PO DAILY (Daily). -Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO twice a day. -Senna 8.6 mg Tablet Sig: 1-2 Tablets PO once a day. -Baclofen 50 mcg/mL Solution Sig: Eighteen (18) mcg Intrathecal once a day -Simvastatin 20mg PO daily -Metronidazole 500mg [**Hospital1 **] [appears not to be taking] . . MEDICATIONS (on transfer): Phenytoin 200 mg IV QHS at 10pm Phenytoin 100 mg IV BID at 7am and 2pm Desonide 0.05% Cream 1 Appl TP [**Hospital1 **] Fluocinolone Acetonide 0.01% Solution 1 Appl TP [**Hospital1 **] Ketoconazole 2% 1 Appl TP [**Hospital1 **] MetRONIDAZOLE (FLagyl) 500 mg IV Q8H, Day 1=[**10-18**] Aztreonam [**2159**] mg IV Q8H [**10-17**] @ 1519 Vancomycin 1000 mg IV Q 12H [**10-17**] @ 1135 Bacitracin Ointment 1 Appl TP QID Lorazepam 2 mg IV PRN seizure LeVETiracetam 1000 mg IV Q12H Baclofen 18 mcg/hr IT WITH PUMP TraZODONE 50 mg PO/NG HS:PRN insomnia Simvastatin 40 mg PO/NG DAILY Acetaminophen [**Telephone/Fax (1) 1999**] mg PO/NG Q6H:PRN fever or pain Senna 1 TAB PO/NG [**Hospital1 **]:PRN constipation Sertraline 100 mg PO/NG DAILY Heparin 5000 UNIT SC TID Discharge Medications: 1. Outpatient Lab Work Vancomycin trough levels drawn on AM [**10-24**]. Results should be faxed to [**First Name8 (NamePattern2) 30642**] [**Doctor Last Name **] [**Telephone/Fax (1) 36518**] 2. Sertraline 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 3. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day). 4. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO Q12H (every 12 hours). 5. Trazodone 50 mg Tablet Sig: One (1) Tablet PO at bedtime as needed for insomnia. 6. B Complex Plus Vitamin C 15-10-50-5-300 mg Capsule Sig: One (1) Capsule PO once a day. 7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO twice a day. 8. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Baclofen Intrathecal 10. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day): 7AM and 2PM. Disp:*60 Capsule(s)* Refills:*0* 11. Phenytoin Sodium Extended 100 mg Capsule Sig: Two (2) Capsule PO QHS (once a day (at bedtime)): at 10PM. 12. Aztreonam in Dextrose(IsoOsm) 2 gram/50 mL Piggyback Sig: Two (2) gram Intravenous Q8H (every 8 hours) for 3 days. Disp:*18 gram* Refills:*0* 13. Vancomycin 1,000 mg Recon Soln Sig: One (1) gram Intravenous every twelve (12) hours for 3 days: Please draw vanc trough in the AM, fax it to Dr.[**Name (NI) 2056**] Office. Hold Vanc for trough. If trough <20, give vanc 1gm q12h for 3 days. Disp:*6 gram* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: primary: hospital acquired pneumonia, urinary tract infection, mental status change, and seizures, hypernatremia secondary: chronic renal insufficiency. Discharge Condition: stable, afebrile. Discharge Instructions: You were admitted for evaluation after transfer from an outside hospital for symptoms of mental status confusion in the setting of a urinary tract infection. A CT scan at the outside hospital showed a bleed in the head, but repeat imaging here showed no evidence of bleed. During your hospitalization here, you were found to have a pneumonia. You also developed seizures, which you have not had in a long time. You were transferred to the ICU for low oxygenation which after a day improved. You were followed by neurology who adjusted your seizure medications. Medications changed during this hospitalizaiton include: --> You were started on dilantin due to active seizures. You will follow up with Dr. [**Last Name (STitle) **] to slowly stop taper off this medication. --> Please continue to take keppra for seizure prevention --> You have three more days of IV antibiotics to treat pneumonia. The last day of antibiotics will be [**2169-10-26**]. Pleae call your doctor or come to the Emergency Room if you develop shortness of breath, seizures, chest pain, bleeding, severe fatigue and weakness or any other symptom that concerns you. Followup Instructions: PCP: [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) 30642**] [**Name (STitle) **], on Mon [**2169-11-6**] at 11:45am MD: Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] Specialty: Neurology Date and time: Wednesday, [**11-8**] at 4pm Location: [**Hospital Ward Name 516**], [**Hospital Ward Name 23**] bldg, [**Location (un) **] Phone number: [**Telephone/Fax (1) 541**]

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icd9cm

[ [ [] ] ]

[ "96.04", "96.71", "38.93", "03.31" ]

icd9pcs

[ [ [] ] ]

16236, 16294

9136, 13396

296, 331

16491, 16511

5444, 5680

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50311

Discharge summary

report

Admission Date: [**2148-2-24**] Discharge Date: [**2148-3-1**] Date of Birth: [**2096-10-22**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**Last Name (NamePattern1) 1136**] Chief Complaint: Shortness of Breath Major Surgical or Invasive Procedure: None History of Present Illness: 51 y.o. Female with h.o.T1-T2 paraplegia [**3-5**] MVA, multiple admissions for PNA, [**Month/Day (2) 40097**] UTI requiring intubation, hypothyroidism originally admitted to the ED for ?PNA. Transferred to the unit for hypotension versus septic shock. . Unfortunately pt is a poor historian. Pt was diagnosed with a UTI and started on Augementin on [**2148-2-6**] which she completed a 10 day course. Per pt's PCA they were at Foxwood yesterday, pt had no symptoms when she went to bed last night at 8pm. Her PCA stayed with her last night when the pt had acute onset of SOB at midnight. Her O2 sat which was noted to be 77%, she was placed on 4l of oxygen and her saturation improved to 93%. Her PCA called [**Company 191**] and was referred to the ED. Pt has home oxygen which she uses only when she is discharged from the hospital with PNA. . She denies any cough, fever, nausea, vomiting, rhinorrhea, abdominal pain, melena, hematemesis, expectorant. + chills. . In the ED initial vitals were noted to be T99.2, HR 86, BP 101/66, RR 18, Sat 97%. Initial labs were notablw for Plt 130, WBC was 9.7, Neutrophillic predominance. Chem 10 panel was unremarkable. A CTA was obtsined which showed no P. Embolism but did show bibasilar consolidation which were thought to be possible chronic atelectasis. Pt was originally on her way to the medicine floor when she was hypotensive to with systolics in the 80s asymptomatic. Pt was given 3-4 litres of fluid, lactate was obtained and normal. BP prior to transfer was increased to 90/60. . Of note she was recently discharged on [**2148-1-3**] with a similar presentation. She was noted to have similar symptoms with hypotension, hypoxia and was intubated and placed on pressors. She then developed PRES syndrome in the ICU. Past Medical History: 1. T1-T2 paraplegia following MVC [**1-4**] 2. Recurrent UTIs: [**Month/Year (2) 40097**] klebsiella 3. HCV, viral load suppressed 4. H/o recurrent PNAs: MRSA, pan-sensitive Kleb 5. Anxiety 6. DVT in [**2142**] -IVC filter placed in [**2142**] 7. Pulmonary nodules 8. Hypothyroidism 9. Chronic pain 10. Chronic gastritis 11. H/o obstructive lung disease 12. Anemia of chronic disease 13. S/p PEA arrest during last hospitalization in [**2147-10-3**] Social History: The patient currently lives at home wiht her husband and 2 children, ages 15 and 22. Former 35 packyear smoker. Denies current tobacco or alcohol use. Family History: Non-contributory. Physical Exam: GENERAL: Caucasian Female laying down in bed, tearful in NARD. HEENT: No scleral icterus, EOMI. CARDIAC: Regular rhythm, normal rate. Normal S1, S2. No murmurs, rubs or [**Last Name (un) 549**]. LUNGS: Diminished BS noted diffusely. ABDOMEN: Soft, NT, ND. No HSM EXTREMITIES: No edema noted. SKIN: No rashes/lesions, ecchymoses. NEURO: A&Ox3. Appropriate. CN II-[**Last Name (LF) **],[**First Name3 (LF) 81**],XII intact on examination. Has intermittent sensation in her lower extremities. PSYCH: Tearful on examination, states she feels scared. Pertinent Results: [**2148-2-24**] WBC 9.7 / Hct 35.5 / Plt 130 N 88 / L 8 / M 2 / E 1 / B 0 INR 1 / PTT 31 Na 141 / K 4.4 / Cl 101 / CO2 29 / BUN 9 / Cr .4 / BG 136 Ca 8.8 / Mg 2 / Phos 3.9 Lactate .8 . Discharge Labs: WBC-5.2 RBC-3.31* Hgb-9.7* Hct-28.9* MCV-87 MCH-29.2 MCHC-33.5 RDW-15.2 Plt Ct-144* Glucose-97 UreaN-3* Creat-0.2* Na-145 K-3.9 Cl-104 HCO3-37* AnGap-8 Calcium-8.9 Phos-2.8 Mg-2.2 . MICROBIOLOGY: [**2148-2-24**] Blood Cx - negative [**2148-2-24**] Urine cx - Pseudomonas pan sensitive [**2148-2-25**] Sputum Cx - staph aureus (sparse growth) and yeast [**2148-2-25**] Urine legionella - negative . STUDIES: [**2148-2-24**] CXR Focal opacity at the right heart border in the right lower lung may represent focal pneumonia (favored) or atelectasis. [**2148-2-24**] CTA Chest 1. No pulmonary embolism or acute aortic pathology. 2. Improved bibasilar atelectasis and left lung ground-glass opacities. These chronic atelectatic findings may be secondary to chest wall deformities and poor inspiratory efforts in the setting of multiple chronic rib fractures. 3. Mucoid impaction in bilateral lower lobe bronchioles. [**2148-2-27**] CXR IMPRESSION: AP chest compared to [**2-24**]: Extensive opacification has developed in the perihilar regions of both lungs, accompanied by a new small right pleural effusion most consistent with pulmonary edema due to cardiac decompensation. Tip of the left PIC line extends approximately a centimeter beyond the wire, in the mid-to-upper SVC. No pneumothorax. Dr. [**Last Name (STitle) **] and venous access nurse were both paged Brief Hospital Course: 1. Hypotension: Pt originally admitted to the ICU given episode of hypotension to the 80s. Given the patient's initial presentation, she did not meet SIRS criteria given her WBC, temp, RR, HR. Determined not to be septic shock. On review of her clinical notes her BP appears to be 95 in her prior Primary Care visit, there is also a comment in a prior Neurology note of possible dysautonomia from her thoracic lesion. Patient had stable SBPs 80-90s with no evidence of end-organ ischemia, mentating well, good urine output, during her hospitalization, so was presumed to be at baseline and secondary to autonomic dysfunction. Did not require IVF boluses and remained hemodynamically stable. . 2. Hypoxia: Pt noted to be hypoxic at home on room air that corrected with 2L of oxygen. Given CXR LLL/retrocardiac infiltrate lobar pneumonia was thought to be the cause of the patient's hypoxia. She was treated empirically for HAP with levofloxacin and vancomycin. Given sputum culture grew sparse growth of staph aureus, the patient was continued on this regimen, vancomycin for 7 days, levofloxacin for 10 days. Ipratropium/Albuterol nebs treatments, chest PT, acapella and incentive spirometer use improved the patient's symptoms. . 3. UTI: Pt also has history of frequent UTIs given that her caregiver self-caths. She was started on Augmentin for [**Last Name (STitle) 40097**] Klebsiella UTI diagnosed in Caritas. Her review of urine culture data shows [**Last Name (STitle) 40097**] Klebsiella sensitive to Zosyn, Meropenem, Bactrim, Unasyn. She also has a h.o. of Proteus sensitive to Zosyn. Though [**Last Name (STitle) 40097**] Klebsiella appears to be sensitive to Zosyn there may be a difference between in-[**Last Name (un) **] vs in-[**Last Name (un) 5153**] sensitivity. High rate of resistance with [**Last Name (un) 40097**] during Zosyn therapy, thus was initially treated with Meropenem. When the culture data returned with pansensitive pseudomonas, Meropenem was discontinued and levofloxacin was continued for total of 10 days. . 4. Thrombocytopenia: Pt on admission noted to have plt 130, prior baseline has shown plt count in the 300s. The patient's platelet count dropped to 84 on her third hospital day. Heparin and omeprazole were discontinued as possible causes. Her count returned to 144 prior to discharge. Omeprazole was held, and the patient instructed to have a repeat platelet count as an outpatient. . 5. T1-T2 paraplegia s/p MVC: Pt was maintained on her home regimen of Methadone, Lyrica, Baclofen, Lidocaine patch, Klonopin, Trazadone. Home oxycodone was discontinued given hypotension and questionable mental status at times. The patient never requested oxycodone therapy. She was asked to refrain from restarting oxycodone as an outpatient if possible. . 6. h.o. PRES syndrome: Pt has history of PRES syndrome occured in [**12/2147**] and thought to be due to a combination of pressors, pt's underlying labile BP. The patient's blood pressure remained relatively stable during hospitalization, with increases when the patient was anxious. . 7. Hypothyroidism: Continued home regimen of levothyroxine. Medications on Admission: Baby Wipes Cranberry Extract 500mg [**Hospital1 **] Citalopram 40mg daily Lyrica 150mg TID Combivent 18mcg-103mcg 2 puffs TID Methadone 5mg TID Calcium 500mg (1250mg) [**Hospital1 **] Klonopin 1mg QID PRN Albuterol 2.5mg/3ml (0.083%) nebs q4-6hr PRN Omeprazole 20mg [**Hospital1 **] Baclofen 10mg QID (2 tabs qAM, 1 tab midday, 2 tabs qHS) Levothyroxine 75mcg daily Trazadone 200mg qHS Oxycodone 5mg q4-6hr PRN Loratadine 10mg daily Oxybutynin 10mg qAM, 5mg qafternoon, 10mg qHS Carafate 100mg/ml 2 tsp QID Miralax PRN Lidoderm patch Nicotine patch Discharge Medications: 1. Citalopram 20 mg Tablet [**Hospital1 **]: Two (2) Tablet PO DAILY (Daily). 2. Pregabalin 75 mg Capsule [**Hospital1 **]: Two (2) Capsule PO TID (3 times a day). 3. Combivent 18-103 mcg/Actuation Aerosol [**Hospital1 **]: Two (2) puffs Inhalation three times a day. 4. Methadone 5 mg Tablet [**Hospital1 **]: One (1) Tablet PO TID (3 times a day). 5. Calcium 500 mg Tablet [**Hospital1 **]: One (1) Tablet PO twice a day. 6. Clonazepam 1 mg Tablet [**Hospital1 **]: One (1) Tablet PO QID (4 times a day) as needed for anxiety. 7. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization [**Hospital1 **]: One (1) Inhalation every four (4) hours as needed for shortness of breath or wheezing. Disp:*4 Box* Refills:*0* 8. Baclofen 10 mg Tablet [**Hospital1 **]: Two (2) Tablet PO QAM (once a day (in the morning)). 9. Baclofen 10 mg Tablet [**Hospital1 **]: One (1) Tablet PO NOON (At Noon). 10. Baclofen 10 mg Tablet [**Hospital1 **]: Two (2) Tablet PO QHS (once a day (at bedtime)). 11. Levothyroxine 75 mcg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily). 12. Trazodone 100 mg Tablet [**Hospital1 **]: Two (2) Tablet PO HS (at bedtime) as needed for anxiety. 13. Oxybutynin Chloride 5 mg Tablet [**Hospital1 **]: Two (2) Tablet PO QAM (once a day (in the morning)). 14. Oxybutynin Chloride 5 mg Tablet [**Hospital1 **]: One (1) Tablet PO Q1400 (). 15. Oxybutynin Chloride 5 mg Tablet [**Hospital1 **]: Two (2) Tablet PO HS (at bedtime). 16. Sucralfate 1 gram Tablet [**Hospital1 **]: One (1) Tablet PO QID (4 times a day). 17. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated [**Hospital1 **]: One (1) Adhesive Patch, Medicated Topical DAILY (Daily). 18. Loratadine 10 mg Tablet [**Hospital1 **]: One (1) Tablet PO daily (). 19. Guaifenesin 100 mg/5 mL Syrup [**Hospital1 **]: 5-10 MLs PO Q6H (every 6 hours) as needed for cough. Disp:*250 ML(s)* Refills:*0* 20. Levofloxacin 750 mg Tablet [**Hospital1 **]: One (1) Tablet PO once a day for 4 days. Disp:*4 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital1 1474**] VNA Discharge Diagnosis: Primary Diagnoses: Community Acquired Pneumonia Urinary Tract Infection Thrombocytopenia Autonomic dysfuction secondary to paraplegia . Secondary Diagnoses: T1-2 Paraplegia Depression/Anxiety Hypothyroidism Discharge Condition: Mental Status:Clear and coherent Level of Consciousness:Alert and interactive Activity Status:Bedbound Discharge Instructions: You were admitted to [**Hospital1 18**] for evaluation of decrease oxygen levels in your blood. You were found to have a pneumonia. You were also incidentally found to have a urinary tract infection. You were treated with IV antibiotics for these infections. You have completed your course of antibiotics during your hospitalization. Your platelet count was also found to be low during your stay. You were taken off heparin and omeprazole and your platelets improved. You should avoid these medications if possible in the future. . Because of your confusion on arrival, you were not given Oxycodone during your stay. It seems your pain was well controlled with methadone only. You should refrain from using Oxycodone in the future. . During your stay it was noted that you had decreased levels of potassium and phosphorous. You should have your labs checked with your primary care physician in one week. Followup Instructions: Please follow up with your primary care physician [**Last Name (NamePattern4) **]: [**First Name4 (NamePattern1) 2184**] [**Last Name (NamePattern1) 2185**] (covering for Dr. [**Last Name (STitle) 665**] Specialty: Internal Medicine/ [**Company 191**] Post [**Hospital **] Clinic Date/ Time: Thursday, [**3-7**], 8:10am Location: [**Hospital Ward Name 23**] Building, [**Location (un) **] South Suite Phone number: [**Telephone/Fax (1) 250**] Completed by:[**2148-3-3**]

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icd9cm

[ [ [] ] ]

[ "38.93" ]

icd9pcs

[ [ [] ] ]

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40338+58364+58365

Discharge summary

report+addendum+addendum

Admission Date: [**2133-2-9**] Discharge Date: [**2133-2-18**] Date of Birth: [**2061-8-17**] Sex: M Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 1505**] Chief Complaint: Dyspnea on exertion Major Surgical or Invasive Procedure: [**2133-2-9**] - Aortic Valve Replacement/Coronary Artery Bypass grafting x2(LIMA-LAD,free RIMA-PDA) [**2133-2-10**] - Mediastinal re-exploration with evacuation of blood clots. History of Present Illness: This 71 year old male with history of rheumatic heart disease as a child was hospitalized in [**Month (only) 359**] with worsening shortness of breath, orthopnea and paroxysmal nocturnal dyspnea. He was found to be in congestive heart failure requiring diursesis and a heart murmur was detected exam. An echo revealed moderate to severe aortic stenosis and a cardiac catheterization revealed an ejection fraction of 25% with three vessel coronary disease and mild aortic stenosis. He was thus been referred for surgical management. Past Medical History: Aortic stenosis Coronary artery disease Chronic [**Month (only) 16631**] heart failure Cardiomyopathy (EF 25%) Rheumatic heart disease age 14 Coronary artery disease Hypercholesterolemia Osteoarthritis Obesity Skin ulcers BLE/venous insufficiency Phlebitis Varicose veins s/p vein stripping Social History: Last Dental Exam: Yearly. Edentulous upper with native lower in poor repair. Lives with: alone in [**Location 8391**]. He has girlfriend. Occupation: retired Tobacco: quit Pipe and cigars 2-3 months ago, prior cigarettes. 40+PYH. ETOH: 3-6 beers /day Family History: Mother died of CAD at 43 Physical Exam: Height: 69" Weight: 192 # General: WDWN in NAD Skin: Warm[X] Dry [X] intact [X] No C/C HEENT: NCAT[X] PERRLA [X] EOMI [X] Sclera anicteric, OP benign. Lower teeth in poor repair. Upper edentulous. Neck: Supple [X] Full ROM [X] No JVD Chest: Lungs clear bilaterally [X] Heart: RRR, III/VI SEM Abdomen: Soft [X] non-distended [X] non-tender [X] bowel sounds + [X] Extremities: Warm [X], well-perfused [X] Trace Edema Varicosities: Bilateral GSV has been removed. Incisions along GSV tract c/w stripping. LSV varicosed bilaterally. Modified [**Doctor Last Name 6237**] test slow flushing but positive Neuro: Grossly intact Pulses: Femoral Right:2 Left:2 DP Right:Trace Left:Trace PT [**Name (NI) 167**]:Trace Left:Trace Radial Right:2 Left:2 Carotid Bruit Bilateral Transmitted vs. Bruit Pertinent Results: [**2133-2-10**] Echo: This is a limited study for emergency mediastinal exploration 24 hrs. after AVR/CABG. The patient is on high dose pressors, no inotropes. There is a pericardial collection measuring 1.5 cm near the anterior wall. There no evidence of right-sided collapse. This corresponded clinically to a large amount of clot found after the chest was opened. There was little ongoing bleeding. There is 1+ MR. [**First Name (Titles) **] [**Last Name (Titles) 16631**] fxn is mildly depressed. There is a well-seated prosthetic aortic valve with a residual peak gradient of 23 and mean of 11 mmHg. No leak and no AI. Aorta intact. [**2133-2-15**] CXR: Small bilateral pleural effusions and atelectasis. No acute cardiopulmonary process. [**2133-2-15**] 05:00AM BLOOD WBC-8.5 RBC-3.77* Hgb-11.2* Hct-32.0* MCV-85 MCH-29.8 MCHC-35.2* RDW-14.2 Plt Ct-176 [**2133-2-14**] 06:10AM BLOOD WBC-7.6 RBC-3.59* Hgb-10.9* Hct-30.8* MCV-86 MCH-30.2 MCHC-35.2* RDW-14.5 Plt Ct-127*# [**2133-2-16**] 06:55AM BLOOD UreaN-15 Creat-0.8 Na-136 K-3.9 Cl-102 [**2133-2-15**] 05:00AM BLOOD UreaN-15 Creat-0.8 Na-141 K-3.8 Cl-106 Brief Hospital Course: Mr. [**Known lastname 88485**] was admitted to the [**Hospital1 18**] on [**2133-2-9**] for surgical management of his aortic valve and coronary artery disease. He was taken to the Operating Room where he underwent coronary artery bypass grafting to two vessels and replacement of his aortic valve. Please see operative note for details. Postoperatively he was taken to the intensive care unit for monitoring. On postoperative day one, high output from his chest tube was noted. He was returned to the Operating Room where he underwent a re-exploration for bleeding with evacuation of clot. No focal bleeding was found and hemostasis was achieved. He was returned to the intensive care unit in stable condition. He was later weaned form sedation and extubated without issue. Gentle diuresis was initiated. Beta blockade, a statin and aspirin were resumed. He developed atrial fibrillation and was started on amiodarone for this. He then developed junctional rhythm and amiodarone was discontinued. Sinus rhythm ensued and beta blockade was titrated as tolerated. On postoperative day two, he was transferred to the step down unit for further recovery. Chest tubes and pacing wires were removed per protocol. The Physical Therapy service was consulted for assistance with his postoperative strength and mobility. Blood pressure medications were titrated for better control. On post-op day seven he was potentially going to be discharged but spiked a temperature of 100.1 . He remained stable, the temperature remained down and he continued to make good progress and was cleared for discharge to Newbridge on the [**Doctor Last Name **]. All follow-up appointments were made or advised. he did have some skin tearing to the right of the mid sternal wound, which was dry and had resolved erythema at discharge when seen with Dr. [**Last Name (STitle) **]. Medications on Admission: FUROSEMIDE - (Prescribed by Other Provider) - 20 mg Tablet - 1 Tablet(s) by mouth once a day LISINOPRIL - (Prescribed by Other Provider) - 2.5 mg Tablet - 1 Tablet(s) by mouth once a day METOPROLOL SUCCINATE - (Prescribed by Other Provider) - 25 mg Tablet Sustained Release 24 hr - 1 Tablet(s) by mouth once a day RANITIDINE HCL - (Prescribed by Other Provider) - 150 mg Capsule - 1 Capsule(s) by mouth once a day SIMVASTATIN - (Prescribed by Other Provider) - 80 mg Tablet - 1 Tablet(s) by mouth once a day ASPIRIN - (Prescribed by Other Provider) - 81 mg Tablet, Delayed Release (E.C.) - 1 Tablet(s) by mouth once a day 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. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO once a day. 4. isosorbide mononitrate 30 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily): free RIMA graft. 5. lisinopril 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. simvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for pain. 8. alum-mag hydroxide-simeth 200-200-20 mg/5 mL Suspension Sig: 15-30 MLs PO QID (4 times a day) as needed for dyspepsia. 9. acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO Q8H (every 8 hours) as needed for fever or pain. 10. carvedilol 25 mg Tablet Sig: One (1) Tablet PO twice a day. 11. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) as needed for constipation. 12. furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 13. insulin glargine 100 unit/mL (3 mL) Insulin Pen Sig: Twenty (20) units Subcutaneous Q AM. 14. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed for constipation. 15. Humalog KwikPen 100 unit/mL Insulin Pen Sig: as directed Subcutaneous AC & HS: 120-160:2units SQ AC,0units HS//161-200:4units AC,2units HS//201-240:6units AC,4units HS//241-280:8units AC,^units HS. 16. Combivent 18-103 mcg/Actuation Aerosol Sig: 1-2 puffs Inhalation four times a day as needed for shortness of breath or wheezing. Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - [**Location (un) 550**] Discharge Diagnosis: Aortic stenosis coronary artery disease s/p Aortic Valve replacement and coronary artery bypass graft x 2 Chronic [**Location (un) 16631**] heart failure Cardiomyopathy (EF 25%) Rheumatic heart disease Hypercholesterolemia Osteoarthritis Obesity chronic venous insufficiency h/o Phlebitis s/p vein stripping Discharge Condition: Alert and oriented x3, nonfocal Ambulating with steady gait Incisional pain managed with oral analgesics Incisions: Sternal - healing well. Skin tear to Right of mid sternum, erythema decreased.Dry-leave open to air. Leg Right- healing well, no erythema or drainage. Edema- trace Discharge Instructions: 1) Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage. 2) Please NO lotions, cream, powder, or ointments to incisions. 3) Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart provided. 4) No driving for approximately one month and while taking narcotics. Driving will be discussed at follow up appointment with surgeon when you will likely be cleared to drive. 5) No lifting more than 10 pounds for 10 weeks 6) Please call with any questions or concerns [**Telephone/Fax (1) 170**] **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Followup Instructions: You are scheduled for the following appointments Surgeon: Dr. [**Last Name (STitle) **] ([**Telephone/Fax (1) 170**]on Thursday [**3-12**] @ 2:00 PM Cardiologist: Dr [**Last Name (STitle) 85371**] on [**3-3**] at 9:15am Please call to schedule appointments with: Primary Care Dr. [**Last Name (STitle) 54049**] [**Name (STitle) **] ([**Telephone/Fax (1) 36024**]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** Completed by:[**2133-2-17**] Name: [**Known lastname 14043**],[**Known firstname 14044**] Unit No: [**Numeric Identifier 14045**] Admission Date: [**2133-2-9**] Discharge Date: [**2133-2-18**] Date of Birth: [**2061-8-17**] Sex: M Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 741**] Addendum: Please see previous discharge summary for complete hospital course details. Mr. [**Known lastname **] was not discharged to rehab on [**2-17**] due to transient BP drop to 80s when his Carvedilol and Lisinopril doses were titrated up. The Carvedilol was decreased to 18.75 mg [**Hospital1 **] and the Lisinopril to 20mg daily. There were no other relevant episodes of hypotension and he was discharged to rehab on [**2-18**]. 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. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO once a day. 4. isosorbide mononitrate 30 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily): free RIMA graft. 5. simvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for pain. 7. alum-mag hydroxide-simeth 200-200-20 mg/5 mL Suspension Sig: 15-30 MLs PO QID (4 times a day) as needed for dyspepsia. 8. acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO Q8H (every 8 hours) as needed for fever or pain. 9. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) as needed for constipation. 10. furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 11. insulin glargine 100 unit/mL (3 mL) Insulin Pen Sig: Twenty (20) units Subcutaneous Q AM. 12. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed for constipation. 13. Humalog KwikPen 100 unit/mL Insulin Pen Sig: as directed Subcutaneous AC & HS: 120-160:2units SQ AC,0units HS//161-200:4units AC,2units HS//201-240:6units AC,4units HS//241-280:8units AC,^units HS. 14. Combivent 18-103 mcg/Actuation Aerosol Sig: 1-2 puffs Inhalation four times a day as needed for shortness of breath or wheezing. 15. carvedilol 12.5 mg Tablet Sig: 1.5 Tablets PO BID (2 times a day). 16. lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Disposition: Extended Care Facility: Newbridge on the [**Doctor Last Name **] - [**Location (un) 1502**] Discharge Diagnosis: Aortic stenosis and coronary artery disease s/p Aortic Valve replacement and coronary artery bypass graft x 2 Past medical history: Chronic systolic heart failure Cardiomyopathy (EF 25%) Rheumatic heart disease Hypercholesterolemia Osteoarthritis Obesity chronic venous insufficiency h/o Phlebitis s/p vein stripping Discharge Condition: Alert and oriented x3, nonfocal Ambulating with steady gait Incisional pain managed with oral analgesics Incisions: Sternal - healing well. Skin tear to Right of mid sternum, erythema decreased.Dry-leave open to air. Leg Right- healing well, no erythema or drainage. Edema- trace Discharge Instructions: 1) Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage. 2) Please NO lotions, cream, powder, or ointments to incisions. 3) Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart provided. 4) No driving for approximately one month and while taking narcotics. Driving will be discussed at follow up appointment with surgeon when you will likely be cleared to drive. 5) No lifting more than 10 pounds for 10 weeks 6) Please call with any questions or concerns [**Telephone/Fax (1) 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** Followup Instructions: You are scheduled for the following appointments Surgeon: Dr. [**Last Name (STitle) **] ([**Telephone/Fax (1) 1477**]on Thursday [**3-12**] @ 2:00 PM Cardiologist: Dr [**Last Name (STitle) 14046**] on [**3-3**] at 9:15am Please call to schedule appointments with: Primary Care Dr. [**Last Name (STitle) 14047**] [**Name (STitle) 14048**] ([**Telephone/Fax (1) 14049**]in [**4-21**] weeks **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 1477**]. Answering service will contact on call person during off hours** [**Name6 (MD) **] [**Name8 (MD) 747**] MD [**MD Number(2) 748**] Completed by:[**2133-2-18**] Name: [**Known lastname 14043**],[**Known firstname 14044**] Unit No: [**Numeric Identifier 14045**] Admission Date: [**2133-2-9**] Discharge Date: [**2133-2-18**] Date of Birth: [**2061-8-17**] Sex: M Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 741**] Addendum: Mr.[**Known lastname **] was discharged to an extended care facility [**Hospital1 14050**] for the Aged - [**Location (un) 1409**]. Discharge Disposition: Extended Care Facility: [**Hospital6 609**] for the Aged - [**Location (un) 1409**] [**Name6 (MD) **] [**Name8 (MD) 747**] MD [**MD Number(2) 748**] Completed by:[**2133-2-18**]

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icd9cm

[ [ [] ] ]

[ "35.21", "34.03", "39.61", "36.16" ]

icd9pcs

[ [ [] ] ]

15415, 15624

3706, 5568

329, 508

13029, 13310

2566, 3683

14200, 15392

1668, 1694

10917, 12551

12689, 12800

5594, 6223

13334, 14177

1709, 2547

270, 291

536, 1070

12822, 13008

1400, 1652

22,638

187,745

43115

Discharge summary

report

Admission Date: [**2200-5-18**] Discharge Date: [**2200-5-28**] Date of Birth: [**2144-3-6**] Sex: F Service: MEDICINE Allergies: Vistaril / Aspirin Attending:[**First Name3 (LF) 465**] Chief Complaint: abdominal pain Major Surgical or Invasive Procedure: ERCP History of Present Illness: 56-year-old female patient of Dr. [**First Name4 (NamePattern1) 449**] [**Last Name (NamePattern1) 92952**] transferred from [**Hospital3 417**] Hospital on [**5-18**] for evaluation of abdominal pain. . She is followed by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2643**] for possible chronic pancreatitis which has included evidence of pancreatic divisum and borderline secretin test. Most recently, she was admitted to OSH about 2 weeks ago for epigastric/RUQ comfort - unclear w/u but pain eventually subsided and was d/c'd. She represented to OSH complaining of RUQ and epigastric pain, nausea and diarrhea but no emesis. In OSH ED, she was found to be afebrile and hemodymically stable with systolic blood pressure of 128/69. Labs were unremarkable and pt received IVF, and anti-emetics and pain control with narcotics. Ultimately, she was transferred to [**Hospital1 18**] for further evaluation. . She reported that her epigastric/RUQ pain began about 3 days prior to admission and is described as a tearing sensation like someone was "sawing" through the abdomen. It does not radiate to the back but instead localizes to the right side and sometimes spreads in a band-like fashion. She also complains of "the runs" over the last 2 days but denies fevers/chills/EtOH. Her last drink was a wine cooler 2 months ago and prior to that 1 year ago. Of note, she admits to sleeping from 8 pm to 2 pm and waking up in pain. The pain is not worsened by eating. She does admit to being very "gassey". Normally her pain is relieved with small amounts of percocet but at this point progressed to where she called 911 on the day of admission. . Upon arrival to [**Hospital1 18**], pt noted to be afebrile with blood pressure of 108/79 and hr in 60's. Labs notable for hypokalemia to 3.2 and UA that revealed moderate LE with many WBC and bacteria. Labs also revealed TSH of 14. The etiology of abdominal pain was unclear but the plan was to check stool studies, pain control and IVF and RUQ u/s to evaluate for biliary process. . Shortly after admission to the medical floor she developed hypotension to systolic 80's and bradycardia in the 50's. An ECG obtained was sinus brady without ischemic changes. She had recieved percocet and oxycontin but o/w no new meds. Pt was slightly hypothermic to 96. ABG revealed 7.37/41/78 with lactate of 0.9. Pt's mental status improved but still maintained marginal systolic blood pressures - received 2L NS in boluses without significant improvement in hemodynamics and marginal urine output (15-20 cc urine per hour) so she was trasnfered to the ICU for an overnight stay with rapid resolution of her hypotension after fluid administration. . Further review of systems on arrival back on the medical floor - Currently, pt complains of epigastric/ruq pain that does not radiate. No fevers, chills. Mild dizziness and blurry vision. No CP, reports DOE over last several days. No cough. Has history of UTI's but doesn't feel like sx are c/w past infections. Past Medical History: 1. abdominal pain for which w/u has involved: ERCP which showed pancreas divisum and secretin test which was negative for chronic pancreatitis. She last was studied with EUS in [**2197**] that showed: No evidence of chronic pancreatitis by EUS criteria. Non-visualization of the main pancreatic duct in the pancreas head consistent with pancreas divisum anatomy. Dilated but otherwise unremarkable CBD. Hyperechoic liver appearance suggestive of fatty liver 2. Status post open cholecystectomy 3. status post appendectomy 4. status post partial hysterectomy 5. status post several procedures for retention of urine. The patient currently uses self-catheterization. 6. ?lysis of adhesions 7. Asthma, now well controlled on singulaire. Social History: The patient is married, has 3 healthy children, is a nonsmoker and is raising 2 of her grandchildren, ages 4 and 7. She formerly was working in the Day Care Industry. She's looking forward to her first airplane ride ever on an upcoming trip to [**Country **] in [**Month (only) **]. Family History: (per notes) Mother with diabetes, liver disease and congestive heart failure. Father with h/o DM and died of myocardial infarction. The patient has 9 female siblings and 1 male sibling. Among her siblings, there has been anxiety, diabetes, uterine cancer, breast cancer, and atherosclerotic heart disease. Physical Exam: 96.4 62 91/54 16 99%2L Gen: chronically ill appearing female, lethargic but arousable, oriented x 3 HEENT: mildly dry MM, anicteric sclera, OP clear, JVP at 8 at 45 degrees Cor: S1, S2 regular w/ no mrg appreciated Pulm: bilateral crackles about [**12-18**] from base, some clearing w/ cough Abd: obese with multiple surgical incisions, soft NT, nondistended tender to palpation on R upper and lower quadrants, + BS and epigastrum, no cvat Ext: WWP no edema DP, radial 2+ bilaterally, strength 5/5 upper and lower extremities, skin turgor wnl Neuro: A+O x3, CN II -XII intact Pertinent Results: HIDA Scan - Normal transit time of less than 30 minutes. No evidence of CBD obstruction. . CHEST CT: 1. Persistent bibasilar dependent atelectasis, with minimal worsening in the right lower lobe since abdominal CT of one day earlier. Trace pleural effusions are without change. 2. Limited assessment of lung parenchyma due to expiratory phase of respiration. No evidence of consolidation to suggest pneumonia, but a subtle pulmonary abnormality would be difficult to detect due to technical limitations. . Labs were significant for a UA that revealed evidence of a UTI, and slightly elevated transaminases and alkaline phosphatase. . CT CHEST: 1. Persistent bibasilar dependent atelectasis, with minimal worsening in the right lower lobe since abdominal CT of one day earlier. Trace pleural effusions are without change. 2. Limited assessment of lung parenchyma due to expiratory phase of respiration. No evidence of consolidation to suggest pneumonia, but a subtle pulmonary abnormality would be difficult to detect due to technical limitations. . CT ABD: 1. Distinct extrahepatic and mild central intrahepatic biliary ductal dilatation likely reflects sphincter of Oddi dysfunction. No choledocholithiasis. 2. Fatty infiltration of the ventral portion of the pancreas, as before. No concerning pancreatic abnormality and no duct dilation. Pancreatic divisum seen better on prior MRI. 3. Bladder augmentation with small bowel has the expected appearance. . MRCP (limited): Compared with the prior study, axial thin section T2-weighted imaging shows progressive distention of the CBD from 7.7 mm in [**2196**] to 1.4 cm on the current study. In addition, the cystic duct remnant seen posteriorly with respect to the CBD has also increased from 7.7 mm to 10.7 mm. While we see no fixed filling defect, the study was not sufficient for ruling out filling defects as the coronal MRCP images and other relevant imaging was not completed. Of incidental note has been a reduction in size of the mid pole right renal cyst _____ now seen is two tiny adjacent cysts laterally. There is no hydronephrosis. The liver shows no evidence of solid mass lesion or distortion of the intrahepatic vasculature. The spleen, pancreas and adrenal glands are normal. There is no evidence of significant adenopathy or ascites. Incidental note is made of small effusions and some basilar atelectasis. . ERCP: 1. Evidence of previous sphincterotomy was present, with clear bile draining into the duodenum. However, the sphincterotomy was somewhat narrow in diameter. 2. Dilated bile ducts with tapered narrowing distally consistent with ampullary stenosis. Upon balloon sweep, this area was resistant to the passage of the balloon, despite sphincterotomy. 3. An 8 mm Maxforce balloon was introduced for dilation into the ampulla. Upon inflation, the waist disappeared and copious bile was seen draining into the duodenum. . ECHO: Conclusions: The left atrium is normal in size. Left ventricular wall thickness, cavity size, and systolic function are normal (LVEF>55%). Regional left ventricular wall motion is normal. Right ventricular chamber size and free wall motion are normal. The ascending aorta is mildly dilated. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. There is no aortic valve stenosis. The mitral valve appears structurally normal with trivial mitral regurgitation. The tricuspid valve leaflets are mildly thickened. There is mild pulmonary artery systolic hypertension. There is an anterior space which most likely represents a fat pad. No pericardial effusion is seen. . Pelvic U/S [**5-26**]: IMPRESSION: No evidence of adnexal mass or free pelvic fluid. The patient is status post hysterectomy. The ovaries are not visualized. . Liver and Gallbladder U/S [**5-26**]: IMPRESSION: No evidence of common bile duct or intrahepatic biliary ductal dilatation. No radiographic findings to explain the patient's symptoms. . [**2200-5-18**] 09:15PM WBC-6.9 RBC-4.58 HGB-14.0 HCT-41.7 MCV-91 MCH-30.5 MCHC-33.5 RDW-13.7 [**2200-5-18**] 09:15PM NEUTS-60.1 LYMPHS-33.2 MONOS-4.2 EOS-1.6 BASOS-0.9 [**2200-5-18**] 09:15PM PLT COUNT-296 [**2200-5-18**] 09:00PM URINE HOURS-RANDOM [**2200-5-18**] 09:00PM URINE bnzodzpn-POS barbitrt-NEG opiates-POS cocaine-NEG amphetmn-NEG mthdone-NEG [**2200-5-18**] 09:00PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.025 [**2200-5-18**] 09:00PM URINE BLOOD-SM NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-MOD [**2200-5-18**] 09:00PM URINE RBC-14* WBC-134* BACTERIA-MANY YEAST-FEW EPI-2 [**2200-5-18**] 09:15PM GLUCOSE-113* UREA N-8 CREAT-0.8 SODIUM-143 POTASSIUM-3.2* CHLORIDE-109* TOTAL CO2-23 ANION GAP-14 Baseline LFT's on [**5-18**]: ALT 41, AST 29, ALK PHOS 144, AMYLASE 58, TOT BILI 0.7 LFT's at max on [**5-20**]: ALT 128, AST 137, Alk phos 168 on [**5-20**] . TSH 14 Free T4 0.9 Cortisol 8.8 Brief Hospital Course: # Hypotension: Baseline unknown although baseline since admission has been in 90-100's while asleep and 80's while asleep. Patient noted to be mentating even with blood pressure in the 80's. The differential includes infectious process (?UTI), abdominal process, ?hypovolemia (UA spec [**Last Name (un) **] 1.025) although doesn't appear terribly hypovolemic on exam, ?bleed (although might expect tachycardia), ?meds (narcotics), or hypothyroid (which could explain bradycardia and fatigue over last several weeks.) Patient was treated with IVF with improvement in both her hypotension and her urine output. She was started on levaquin for her UTI and flagyl was started to cover abdominal flora. Her hypotension quickly resolved with fluids and was felt to be due to dehydration and UTI. . # Abdominal Pain: Patient's symptoms were treated with anti-emetics and pain medications as necessary. Patient was made NPO and a RUQ ultrasound was ordered to assess the patient for possible bilary stones. The ultrasound was negative. She also underwent andd MRCP which was limited due to her inability to tolerate the test. However, the images did show dilated ducts without any obvious filling defect. She had a CT of the abdomen that showed dilated ducts that were likely due to sphincter of oddi dysfunction. A HIDA scan was performed to check for SOD and this was normal. However, on ERCP she did have ampullary stenosis and once this was relieved there was copius drainage of bile visible. She experienced mild improvement in abdominal pain initially after ERCP. However, the pain fluctuated throughout her hospital course, worsened by large PO intake. LFT's were initially elevated in conjunction with obstruction, but these trended down. Because pain was ongoing, a RUQ U/S was repeated and pelvic U/S was performed, both of which was unrevealing for new process. The patient's diet was slowly advanced and anti-emetics and oxycodone were used for pain. She was tolerating PO with mild pain when discharged. . # Hypotension: Admitted for abdominal pain but found to be hypotensive to 80's while sleeping, unresponsive to fluids, and she was transferred to the ICU for further monitoring. Basline SBP in 90-100s. She had no evidence of sepsis and mentated well throughout entire episode, and responded quickly to IVFs in ICU. The etiology remained unclear but included UTI, abdominal process, dehydration, narcotics, or hypothyroidism. She was started on levaquin for her UTI and flagyl was started to cover abdominal flora. . # Hypothyroid: Thyroid function tests were sent and revealed a slightly elevated TSH. Her levothyroxine dose was increased and she will follow-up with her PCP [**Last Name (NamePattern4) **] 4 weeks to recheck her TSH. Of note, she also had 2 low cortisol values at 0.5. Repeat AM cortisol was normal and her electrolytes and blood pressure remained normal during her medical floor admission. . # Atelectasis - The patient developed bibasilar atelectasis and had a small oxygen requirement. She had a CT scan of the chest that showed no infiltrate. She was asked to ambulate and use the incentive spirometer which resolved her hypoxia. . # UTI - Grew proteus that was pansensitive. Received 7 days of DS bactrim and changed to prophylactic bactrim upon discharge. Asymptomatic. . # Code: IS FULL CODE # communication is with pcp: [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) 6480**] [**Last Name (NamePattern1) 6402**] [**Telephone/Fax (1) 92953**] and husband Medications on Admission: Medications (upon arrival to [**Hospital1 18**]) oxycontin 10 [**Hospital1 **] gabapentin 300 TID levoxyl 50 mcg QD percocet PRN montelukast 10 QD effexor 37.5 QD diazepam 5 [**Hospital1 **] imitrex PRN protonix 40 QD nitrofurantoin, 7 day course for UTI TMP SMX 1 DS per day as suppression of UTI . Medications (on transfer to [**Hospital Unit Name 153**]): Effexor 37.5 qd Sumatriptan prn Levoxyl 50 qd Heparin Sc Valium PRN Anzemet prn colace nitrofurantoin 50 qd gabapentin 300 tid singulair 10 qd promethazasine Discharge Medications: 1. Oxycodone 10 mg Tablet Sustained Release 12HR Sig: One (1) Tablet Sustained Release 12HR PO Q12H (every 12 hours). 2. Venlafaxine 37.5 mg Capsule, Sust. Release 24HR Sig: One (1) Capsule, Sust. Release 24HR PO DAILY (Daily). 3. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 4. Diazepam 5 mg Tablet Sig: One (1) Tablet PO twice a day as needed for anxiety. 5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO every six (6) hours as needed for pain. [**Hospital Unit Name **]:*60 Tablet(s)* Refills:*0* 6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 7. Montelukast 10 mg Tablet Sig: One (1) Tablet 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. Compazine 10 mg Tablet Sig: One (1) Tablet PO four times a day as needed for nausea. [**Hospital Unit Name **]:*30 Tablet(s)* Refills:*0* 10. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily): Please have your TSH checked in [**3-20**] weeks by your PCP. [**Name Initial (NameIs) **]:*60 Tablet(s)* Refills:*0* 11. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QIDACHS (4 times a day (before meals and at bedtime)). [**Name Initial (NameIs) **]:*30 Tablet(s)* Refills:*2* 12. Amitriptyline 25 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). [**Name Initial (NameIs) **]:*30 Tablet(s)* Refills:*2* 13. Bactrim DS 160-800 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home Discharge Diagnosis: Ampullary stenosis Chronic pancreatitis Chronic urinary retention Chronic urinary tract infections Hypothyroidism Discharge Condition: stable Discharge Instructions: Please follow-up with Dr. [**First Name (STitle) 2643**] ([**Telephone/Fax (1) 2306**] in [**1-17**] weeks. Please follow-up with your primary care doctor in [**12-16**] weeks. Please have your primary care doctor check your TSH (thyroid level) in 4 weeks because your levothyroxine dose (thyroid pill) was increased from 50 mcg daily to 75 mcg daily. Followup Instructions: Please follow-up with Dr. [**First Name (STitle) 2643**] ([**Telephone/Fax (1) 2306**] on [**6-2**] at 11a.m. Please follow-up with your primary care doctor in [**12-16**] weeks. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 472**]

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icd9cm

[ [ [] ] ]

[ "51.84" ]

icd9pcs

[ [ [] ] ]

15975, 15981

10349, 13884

292, 298

16139, 16148

5339, 10326

16550, 16854

4418, 4728

14452, 15952

16002, 16118

13910, 14429

16172, 16527

4743, 5320

238, 254

326, 3344

3366, 4102

4118, 4402

81,270

139,102

42684

Discharge summary

report

Admission Date: [**2149-12-7**] Discharge Date: [**2149-12-17**] Date of Birth: [**2094-5-26**] Sex: F Service: MEDICINE Allergies: Sulfa (Sulfonamide Antibiotics) Attending:[**First Name3 (LF) 633**] Chief Complaint: nausea/vomiting, diarrhea, abdominal pain Major Surgical or Invasive Procedure: Colonic stent placement History of Present Illness: 55yo F with stage IV colon cancer with metastasis to liver and lung, on capecitabine/oxaplatin who presented to [**Hospital 8**] Hospital with progressively worsening abdominal pain, nausea/vomiting and diarrhea on [**12-6**] concerning for large bowel obstruction, transferred to [**Hospital1 18**] for colonic stent placement. Patient had an NG tube placed on admission with feculent material retrieved. A CT abdomen with contrast showed bowel obstruction secondary to lesion in rectum 20cm from anal verge, in addition to pneumatosis coli without free air. Patient continued to pass flatus and have bowel movements. Her abdomen remained soft with mild distension. In addition, patient reports diarrhea which began 3 days prior to admission and increased in frequency over the past several days. She had a c.difficile toxin PCR which was positive prior to transfer. She met SIRS criteria with bandemia of 20% and tachycardia, source suspected to be GI. Patient was started on ertapenem and metronidazole. She received a total of 4L IVF. Ertapenem was discontinued on the day prior to transfer. Outside hospital course was complicated by atrial fibrillation with rapid ventricular response which began on [**12-7**] (HD1). Patient was transferred to the ICU where she received 30mg IV diltiazem without effect. She received 5mg IV lopressor, and spontaneously converted to sinus rhythm shortly afterwards, with HR in the 90-110s thereafter. Labs notable for anion gap of 17 and lactate of 3.2 on admission, both of which normalized. In addition hematocrit on admission was 36.9, trended down to 25.6 on the day of transfer. Drop was attributed to dilution, as patient's baseline is high 20s (anemia of chronic disease based on outpatient lab studies). Vital signs at the time of transfer were T 98 HR 107 BP 139/92 RR 15 O2Sat 95% RA. In's and out's over past 24 hours was 5500/1250 with total body balance of +6700. . On arrival to the ICU, vital signs were T97.9 HR 104 BP 125/86 RR 17 O2Sat 95% RA. Patient reports that she has nausea but no pain, and nausea is primarily due to NG tube. Past Medical History: Stage IV colonic adenocarcinoma metastatic to liver/lungs (dx [**8-25**]) Social History: Lives with mother in [**Name (NI) 1468**] while husband lives with his aunt, taking care of her. She has two children. - Tobacco: quit - Alcohol: denies - Illicits: denies Family History: Colon cancer in mother/maternal uncle Physical Exam: Admission Physical Exam: Vitals: T97.9 HR 104 BP 125/86 RR 17 O2Sat 95% RA General: Awake and alert, uncomfortable HEENT: PERRL, EOMI, sclera anicteric, dry MMM, poor dentition, NG tube in place suctioning dark bilious fluid Neck: Supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Tachycardic with regular rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: Hypoactive bowel sounds, mild distention, +tympany, nontender to palpation, no hepatomegaly. palpable mass in LLQ GU: + foley Ext: Warm, well perfused, 2+ DP/PT pulses bilaterally, no clubbing, cyanosis or edema Pertinent Results: OSH Labs on day of transfer: WBC 4.5 Hgb 8.8 Hct 25.6 Plts 107 PT 16.1 INR 1.5 PTT 33.9. Na 138 K 3.1 Cl 112 CO2 21 BUN 20 Cr 0.6 Glucose 141 Ca 7.7 ionized Ca 4.7 Phos 1.9 Mag 2.0 LFTs from [**2149-12-6**] @ 20:30- Tbili 1.1 AST 38 ALT 27 Alk phos 87 Total protein 4.5 Albumin 2.3 Fibrinogen ([**12-6**])- 475 FDP ([**12-6**])- 10-40 D-Dimer ([**12-6**])- 6.06CEA ([**2149-11-27**])- 4.3 EKG @ [**Hospital1 18**]- Sinus tachycardia at 105, normal axis, normal intervals, low voltage, no ST depression/elevation, normal T waves, poor R wave progression. Microbiology: C.difficile ([**2149-12-7**])- positive by PCR Imaging: EKG [**12-8**]: Sinus tachycardia with atrial premature depolarizations. Borderline low QRS voltage in limb leads. Non-diagnostic repolarization abnormalities. Cannot exclude prior inferior myocardial infarction of indeterminate age. No previous tracing available for comparison. . KUB ([**2149-12-7**])- Massive large bowel dilatation with diameters of large bowel loops of up to 10 cm. Thumb printing, a sign of bowel wall edema, is clearly present and indicates severe colitis. Small colonic air-fluid levels on the lateral decubitus radiograph. No safe evidence of free air. No pathological calcifications. . KUB ([**2149-12-8**])- Current documentation is provided in one image only. As compared to the previous radiograph, the extensive distention of colonic segments has minimally improved with regard to the ascending colon. The transverse colon distention and left colonic loop distention, however, are virtually unchanged. On the current image there is no evidence of free abdominal air or pathologic calcifications. No air-fluid levels. . ECHO-[**12-10**] The left atrium is normal in size. There is mild symmetric left ventricular hypertrophy. 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) 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 borderline pulmonary artery systolic hypertension. There is no pericardial effusion. . KUB [**12-10**]: IMPRESSION: Distended colon with "thumb-printing" sign, concerning for colitis . CXR [**12-10**]: FINDINGS: Right PICC terminates in the right atrium, below the cavoatrial junction. Left subclavian line terminates in the mid SVC. Lungs are otherwise clear. There is no pleural effusion or pneumothorax. The heart is normal in size. Normal cardiomediastinal silhouette. . KUB [**12-11**]: FINDINGS: Persistent gaseous distension of the colon, not significantly changed compared to prior. If clinical concern for mechanical obstruction persists, CT can be considered with oral and IV contrast. . MRI [**12-12**]: IMPRESSION: 1. Likely T4 rectal tumor 12 cm from the anal verge with tumor extending both anteriorly and posteriorly through the mesorectal fascia and into the peritoneal reflection. The abnormal tissue cannot be definitely separated from the uterus; however, no frank invasion is seen. 2. Bilateral ovarian masses as described very concerning for metastatic disease with the right mass involving the ovary and on both sides of the mesorectal fascia. 3. Pedunculated lesion within the anterior surface of the uterus could reflect an atypical fibroid versus an additional metastasis. . KUB [**12-14**]: IMPRESSION: Two frontal supine and two frontal upright views of the abdomen show the small bowel largely fluid filled and the large bowel containing non-dependent air, predominantly in the transverse colon. There is no free subdiaphragmatic gas but there probably is ascites since bowel loops are clustered medially. A mesh stent is present in the lower mid pelvis, conforming to the expected location of the rectosigmoid junction. In the absence of cecal distention, there is unlikely to be distal colonic obstruction. . [**2149-12-11**] STOOL CLOSTRIDIUM DIFFICILE TOXIN A & B TEST-FINAL {CLOSTRIDIUM DIFFICILE} INPATIENT--positive [**2149-12-9**] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT [**2149-12-8**] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT [**2149-12-7**] STOOL CLOSTRIDIUM DIFFICILE TOXIN A & B TEST-FINAL INPATIENT [**2149-12-7**] MRSA SCREEN MRSA SCREEN-FINAL . . OSH: CT abdomen ([**2149-12-5**])- Since previous examination of [**2149-11-25**] there is now evidence of marked colonic obstruction. This is secondary to the lesion noted in the rectum. There is now an associated calcification at the point of obstruction with the lumen more narrowed than on previous examination. There is now noted to be pneumatosis coli probably secondary to this high grade obstruction on the right side of the colon. Some fluid is noted within the abdomen. The metastatic disease involving the liver, probably spleen and probably the left lung base nodule is stable over this interval. CXR ([**2149-12-5**])- Probable small left effusion. Multiple pulmonary nodules. No evidence of pneumonia or congestive failure. [**2149-12-17**] 05:11AM BLOOD WBC-5.0 RBC-2.41* Hgb-7.2* Hct-22.4* MCV-93 MCH-29.9 MCHC-32.2 RDW-21.7* Plt Ct-115* [**2149-12-16**] 08:45AM BLOOD WBC-5.7 RBC-2.47* Hgb-7.5* Hct-23.3* MCV-94 MCH-30.3 MCHC-32.2 RDW-22.2* Plt Ct-101* [**2149-12-15**] 05:45AM BLOOD WBC-4.9 RBC-2.40* Hgb-7.3* Hct-22.4* MCV-93 MCH-30.4 MCHC-32.6 RDW-22.7* Plt Ct-74* [**2149-12-14**] 09:20AM BLOOD WBC-4.9 RBC-2.39* Hgb-7.6* Hct-22.7* MCV-95 MCH-31.7 MCHC-33.4 RDW-23.1* Plt Ct-65* [**2149-12-13**] 08:15AM BLOOD WBC-4.2 RBC-2.38* Hgb-7.3* Hct-22.0* MCV-92 MCH-30.7 MCHC-33.3 RDW-23.5* Plt Ct-49* [**2149-12-12**] 05:59AM BLOOD WBC-4.4 RBC-2.46* Hgb-7.5* Hct-22.4* MCV-91 MCH-30.4 MCHC-33.4 RDW-23.6* Plt Ct-43* [**2149-12-11**] 05:39AM BLOOD WBC-6.2 RBC-2.52* Hgb-7.6* Hct-22.3* MCV-89 MCH-30.3 MCHC-34.2 RDW-23.3* Plt Ct-45* [**2149-12-10**] 06:37AM BLOOD WBC-7.0 RBC-2.69* Hgb-8.0* Hct-23.9* MCV-89 MCH-29.8 MCHC-33.6 RDW-23.3* Plt Ct-58* [**2149-12-10**] 05:38AM BLOOD WBC-6.9 RBC-2.51* Hgb-7.6* Hct-22.9* MCV-92 MCH-30.5 MCHC-33.4 RDW-23.3* Plt Ct-54* [**2149-12-9**] 06:56AM BLOOD WBC-7.7# RBC-2.83* Hgb-8.5* Hct-25.4* MCV-90 MCH-30.1 MCHC-33.6 RDW-22.5* Plt Ct-72* [**2149-12-8**] 04:02AM BLOOD WBC-4.1 RBC-2.75* Hgb-8.1* Hct-23.9* MCV-87 MCH-29.3 MCHC-33.7 RDW-21.7* Plt Ct-88* [**2149-12-7**] 05:30PM BLOOD WBC-3.9* RBC-2.96* Hgb-8.9* Hct-25.7* MCV-87 MCH-30.0 MCHC-34.6 RDW-21.5* Plt Ct-104* [**2149-12-9**] 06:56AM BLOOD Neuts-61.4 Lymphs-27.2 Monos-7.2 Eos-4.1* Baso-0.2 [**2149-12-8**] 04:02AM BLOOD Neuts-60 Bands-3 Lymphs-26 Monos-10 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-1* NRBC-1* [**2149-12-7**] 05:30PM BLOOD Neuts-58 Bands-7* Lymphs-25 Monos-10 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 NRBC-1* [**2149-12-8**] 04:02AM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-1+ Macrocy-NORMAL Microcy-1+ Polychr-NORMAL Ovalocy-1+ Stipple-OCCASIONAL Tear Dr[**Last Name (STitle) 833**] [**2149-12-10**] 06:37AM BLOOD PT-14.0* PTT-45.0* INR(PT)-1.3* [**2149-12-17**] 05:11AM BLOOD Glucose-120* UreaN-16 Creat-0.5 Na-135 K-4.3 Cl-103 HCO3-30 AnGap-6* [**2149-12-16**] 08:45AM BLOOD Glucose-166* UreaN-11 Creat-0.4 Na-138 K-4.2 Cl-104 HCO3-32 AnGap-6* [**2149-12-15**] 05:45AM BLOOD Glucose-125* UreaN-13 Creat-0.4 Na-139 K-4.1 Cl-107 HCO3-29 AnGap-7* [**2149-12-14**] 01:41PM BLOOD Glucose-116* UreaN-12 Creat-0.4 Na-139 K-4.1 Cl-105 HCO3-26 AnGap-12 [**2149-12-13**] 08:15AM BLOOD Glucose-130* UreaN-12 Creat-0.4 Na-140 K-3.7 Cl-109* HCO3-30 AnGap-5* [**2149-12-12**] 05:59AM BLOOD Glucose-141* UreaN-11 Creat-0.4 Na-137 K-3.5 Cl-105 HCO3-27 AnGap-9 [**2149-12-11**] 05:39AM BLOOD Glucose-148* UreaN-11 Creat-0.5 Na-139 K-3.4 Cl-107 HCO3-28 AnGap-7* [**2149-12-10**] 06:37AM BLOOD Glucose-113* UreaN-12 Creat-0.5 Na-138 K-3.4 Cl-107 HCO3-24 AnGap-10 [**2149-12-10**] 05:38AM BLOOD Glucose-719* UreaN-11 Creat-0.6 Na-131* K-5.0 Cl-101 HCO3-21* AnGap-14 [**2149-12-9**] 06:56AM BLOOD Glucose-68* UreaN-10 Creat-0.7 Na-143 K-4.2 Cl-115* HCO3-20* AnGap-12 [**2149-12-8**] 10:48PM BLOOD Glucose-77 UreaN-11 Creat-0.6 Na-143 K-3.7 Cl-118* HCO3-19* AnGap-10 [**2149-12-8**] 04:02AM BLOOD Glucose-94 UreaN-16 Creat-0.6 Na-144 K-3.8 Cl-120* HCO3-19* AnGap-9 [**2149-12-7**] 05:30PM BLOOD Glucose-117* UreaN-18 Creat-0.5 Na-142 K-3.3 Cl-117* HCO3-17* AnGap-11 [**2149-12-15**] 05:45AM BLOOD ALT-13 AST-24 AlkPhos-60 TotBili-0.2 [**2149-12-8**] 04:02AM BLOOD ALT-19 AST-22 LD(LDH)-173 AlkPhos-70 TotBili-0.3 [**2149-12-17**] 05:11AM BLOOD Calcium-8.4 Phos-4.5 Mg-2.0 [**2149-12-16**] 08:45AM BLOOD Calcium-8.5 Phos-3.7 Mg-1.9 [**2149-12-15**] 05:45AM BLOOD Calcium-8.0* Phos-3.5 Mg-1.9 [**2149-12-14**] 01:41PM BLOOD Calcium-8.1* Phos-3.0 Mg-1.8 [**2149-12-12**] 05:59AM BLOOD Calcium-8.5 Phos-2.5* Mg-1.3* [**2149-12-10**] 06:37AM BLOOD Calcium-8.0* Phos-2.4*# Mg-1.8 [**2149-12-10**] 05:38AM BLOOD Calcium-8.3* Phos-6.0*# Mg-2.4 [**2149-12-8**] 04:02AM BLOOD Calcium-8.0* Phos-2.9 Mg-1.9 [**2149-12-7**] 05:30PM BLOOD Calcium-8.0* Phos-1.5* Mg-1.9 [**2149-12-10**] 06:37AM BLOOD Triglyc-101 [**2149-12-10**] 05:38AM BLOOD Triglyc-89 [**2149-12-8**] 04:02AM BLOOD Triglyc-77 [**2149-12-7**] 10:05PM BLOOD Lactate-0.8 Brief Hospital Course: 55 yo female with stage IV colonic adenocarcinoma metastatic to liver and lungs transferred from an outside hospital with a tight malignant rectal stricture, c. difficile colitis, and partial large bowel obstruction. #Large bowel obstruction/Rectal Mass/Colorectal cancer/C. difficile colitis: Per OSH records, CT abdomen showed signs of obstruction with transition point at area of adenocarcinoma. Patient was C. difficile positive by PCR at OSH and had been started on IV flagyl prior to transfer as she was unable to take oral vancomycin. An nasogastric tube was placed at OSH, and she continued to have non-bloody, bilious output from NG tube with no signs of acute abdomen on arrival to [**Hospital1 18**]. Colorectal surgery and GI were consulted as was [**Hospital1 **]. Given metastases, palliative surgical resection was considered, but the decision was made to treat the C. difficile infection and see if surgery could be avoided and colonic stent could placed given it being a lower risk procedure. The patient was continued on treatment with IV Flagyl with improvement in abdominal pain and was able to take clear liquids and move her bowels. Based on this improvement, the decision was made to defer palliative surgical resection and a colonic stent was placed on [**2149-12-12**] with good effect. Following the procedure the patient was able to tolerate a soft low residue diet. Once able to tolerate orals, the patient was started on oral vancomycin to complete a total of a 2 week course from the date of the colonic stent placement, last day of therapy [**2149-12-26**]. Pt tolerated oral diet for 3-4 days prior to DC. Pt will be following up with her outpatient oncologist on [**2149-12-19**]. She will follow up with [**Date Range 3390**] and GI as well. Pt has baseline levels of abdominal pain [**2147-12-17**] similar to prior to admission. Pt was converted to her home regimen of morphine SR 15mg [**Hospital1 **] with prn percocet which controlled her symptoms well prior to DC. She was instructed to resume this regimen. She was also followed by social work during admission. Pt was instructed that she may use colace and miralax for constipation (ok'd by GI). In addition, pt was started on PPI therapy during admission. There was some concern of GI bleeding prior to admission, that was likely due to colorectal cancer . #FEN: Patient was started on TPN due to obstruction. Following stent placement, patient was able to take increased oral diet. Diet was written as soft, ground diet, low residue. Pt was instructed that she should remain on this diet and NOT advance further. Pt stated that she did not want to receive TPN at home. Therefore, nutrition recommended TID boost/ensure upon discharge. #Colorectal adenocarcinoma with liver and lung metastases/anemia/thrombocytopenia: Chemotherapy was held during hospitalization. Patient was discharged to follow up with outpatient Oncologist ([**2149-12-19**]. Dr. [**First Name (STitle) **] regarding plans for future chemotherapy. Patient had stable anemia and thrombocytopenia during hospitalization which was felt to be due to chemotherapy. HCT was 22.4 on day of DC (HCT remained around 22 and pt was not enthusiastic about transfusion) and plt count was 115 on day of discharge. Pain control as above. Pt was not neutropenic during admission. # Atrial fibrillation with rapid ventricular response: Patient was transiently in atrial fibrillation at OSH, but spontaneously converted, potentially responsive to 5mg IV lopressor. CHADSII=0. There was low suspicion for pulmonary embolism as patient had been on heparin, and no lower extremity swelling or erythema. Patient remained in sinus rhythm since admission. A TTE was performed to evaluate baseline functioning which showed normal EF, mild symmetric LVH, borderline high PA systolic pressures. . #DVT PPX-hep SC TID . #access-PICC which was DC'd prior to discharge. #Disposition:DC home with home PT and outpatient [**First Name (STitle) 3390**], [**Name10 (NameIs) **] and GI follow up. Medications on Admission: Home Medications: # Capecitabine 1500mg po BID # Docusate 100mg po BID # Fentanyl 50mcg transdermal every third day # Lorazepam 1mg po q8h prn anxiety # Morphine sulfate 15mg po BID # Oxycodone-acetaminopehn 2.5-325mg PRN # Polyethylene glycol # Prochlorperazine 10mg po q4h prn # Senna 17.2mg po BID # Warfarin 1mg po daily "to keep portocath patent" Medications on transfer: # Fentanyl 50mcg transdermal every third day # Heparin SQ TID # Metronidazole 500mg IV q8h # Mupirocin ointment [**Hospital1 **] # Pantoprazole 40mg IV BID # Dilaudid 0.5mg IV q6h prn pain # Lorazepam 1mg IV q6h prn anxiety # Ondansetron 4mg IV q6h prn nausea Discharge Medications: 1. Medication Changes Please continue to hold your capecitabine until you follow up with your oncologist. Please discuss your warfarin with your Oncologist as well. NEW MEDICATIONS Pantoprazole 2. fentanyl 50 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr Transdermal Q72H (every 72 hours). 3. lorazepam 1 mg Tablet Sig: One (1) Tablet PO every eight (8) hours as needed for anxiety. 4. Percocet 2.5-325 mg Tablet Sig: 1-2 Tablets PO every four (4) hours as needed for pain. 5. prochlorperazine maleate 10 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for nausea. 6. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 7. morphine 15 mg Tablet Extended Release Sig: One (1) Tablet Extended Release PO Q12H (every 12 hours). 8. vancomycin 125 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours) for 10 days. Disp:*40 Capsule(s)* Refills:*0* 9. Outpatient Lab Work CBC to be drawn on [**2149-12-19**] by Dr. [**First Name (STitle) **]/[**First Name (STitle) **]. Please also send a copy to pt's [**First Name (STitle) 3390**]- [**Name Initial (NameIs) 7274**]: [**Last Name (LF) **],[**First Name3 (LF) **] Location: [**Location (un) **] SQ FAMILY PRACTICE Address: [**Street Address(2) 55341**] , [**Apartment Address(1) 19251**], [**Hospital1 **],[**Numeric Identifier 23011**] Phone: [**Telephone/Fax (1) 5984**] Fax: [**Telephone/Fax (1) 92276**] 10. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1) PO once a day as needed for constipation. 11. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*1* 12. Coumadin 1 mg Tablet Sig: One (1) Tablet PO once a day: per outpt regimen. 13. Boost Liquid Sig: One (1) can PO three times a day. Disp:*90 * Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital 269**] Hospice [**Location (un) 270**] East Discharge Diagnosis: Colorectal Cancer Partial large bowel obstruction Malnutrition Clostridium difficile colitis Secondary Diagnoses: Anemia Thrombocytopenia 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 hospitalized for a rectal mass causing partial obstruction of your colon. You also had an infection of your colon called clostridium difficile. You were seen by the GI and Surgery services and were treated with antibiotics with improvement in your colon infection. You were also felt to have obstruction from your rectal mass and a colonic stent was placed by the gastroenterology team. You were able to move your bowels following the procedure and tolerated the procedure well. . Since your colon was inflamed and the stent can only partially relieve an obstruction, it is very important that you keep to a diet of soft low residue foods to prevent pain, perforation, and recurrent obstruction. . It is very important that you call your doctor if you experience any fevers, chills, severe abdominal pain, or experience an inability to move your bowels or pass gas from below, or if you have severe nausea and vomiting. . You will need to discuss with your Oncologist and your [**Location (un) 3390**] how to continue to maximize your nutritional status and should also have them monitor your blood counts. . Medication changes: 1.start Oral vancomycin 125mg four times a day through [**2149-12-26**]. 2.start omeprazole for stomach irritation. Please discuss with your GI doctor [**First Name (Titles) **] [**Last Name (Titles) 3390**] if you will need to continue this medication. Followup Instructions: Hematology/Ocology Appointment:[**Last Name (LF) 2974**], [**12-19**] at 3:30pm With:[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 51819**], MD Location: [**Hospital **] HOSPITAL Address: [**Hospital1 **], [**Hospital1 **],[**Numeric Identifier 19694**] Phone: [**Telephone/Fax (1) 92277**] . [**Telephone/Fax (1) 3390**] =[**Last Name (NamePattern4) **]. [**Last Name (STitle) **] [**Name (STitle) **] [**Hospital3 92278**] phone [**Telephone/Fax (1) 14315**] [**Last Name (un) **] [**12-25**] 2:00pm

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Discharge summary

report

Admission Date: [**2120-11-5**] Discharge Date: [**2120-11-18**] Date of Birth: [**2052-5-30**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2969**] Chief Complaint: Right lower lung mass found incidentally on chest xray Major Surgical or Invasive Procedure: bronchoscopy, right thorocotomy, Right video assisted thorocoscopy right lower lobe superior segmentectomy History of Present Illness: Mr. [**Name14 (STitle) 63877**] is a 68-year-old gentleman with a considerable comorbidity who presents for evaluation of a lung abnormality seen on chest x-ray and confirmed with CT scan. The patient has substantial underlying obstructive lung disease as well as vascular disease and has recently progressed to end-stage renal disease requiring the institution of dialysis. He has an extensive 2-pack per day over 40 year smoking history and quit three years ago. As part of his chronic dyspnea, a chest x-ray was obtained, which showed a new right lower lobe lesion, which has persisted since [**Month (only) 956**]. A CT scan showed a 9-mm lesion with some eccentric calcification. A PET scan was obtained, which showed a low-level uptake at or just below the level of the mediastinal blood pool. Past Medical History: PMH: chronic hypertension, congestive heart failure, cerebral vascular disease with a history of stroke with 70% known carotid stenosis, and atrial fibrillation which began in [**Month (only) 956**] of this year, institution of hemodialysis began in [**Month (only) **] of this year, diverticulitis first diagnosed in [**Month (only) 116**] of this year, peptic ulcer disease, benign prostatic hypertrophy, and an incisional hernia. PSH: repair of an abdominal aortic aneurysm and creation of a left arm AV fistula for dialysis along with a tonsillectomy Social History: 80-pack-year smoking history and quit in [**2116**] Physical Exam: VITAL SIGNS: Temperature 97.5, blood pressure 98/52, pulse 59 and irregular, respirations 20, and room air saturation is 96%. HEENT: He has no scleral icterus or palpable adenopathy. NECK: He has a loud bruit in the right neck. LUNGS: Clear to auscultation with no focal wheezing and equivalent air entry. HEART: Irregular rhythm but a controlled rate. ABDOMEN: Soft and nontender. EXTREMITIES: He has a prominent thrill over the left AV fistula. Pertinent Results: [**2120-11-4**] 10:10AM BLOOD WBC-10.0 RBC-4.26* Hgb-12.7* Hct-38.1* MCV-90 MCH-29.9 MCHC-33.4 RDW-22.1* Plt Ct-167 [**2120-11-4**] 10:10AM BLOOD PT-12.4 PTT-27.0 INR(PT)-1.0 [**2120-11-4**] 10:10AM BLOOD Plt Ct-167 [**2120-11-4**] 10:10AM BLOOD Glucose-83 UreaN-69* Creat-9.1*# Na-140 K-5.2* Cl-98 HCO3-24 AnGap-23* [**2120-11-5**] 03:28PM BLOOD Calcium-8.7 Phos-5.3* Mg-1.8 Hematology COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct [**2120-11-13**] 08:00AM 25.4*# 3.34* 10.1* 29.2* 87 30.2 34.6 20.4* 432 BASIC COAGULATION (PT, PTT, PLT, INR) PT PTT Plt Ct INR(PT) [**2120-11-13**] 08:00AM 432 [**2120-11-13**] 06:40AM 20.0* 2.8 Chemistry RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap [**2120-11-13**] 08:00AM 122* 69* 8.8*# 133 4.8 94* 221 22* 1 NOTE UPDATED REFERENCE RANGE AS OF [**2120-6-7**] CHEMISTRY TotProt Albumin Globuln Calcium Phos Mg UricAcd Iron [**2120-11-13**] 08:00AM 9.8 4.6* 2.2 LAB USE ONLY RedHold [**2120-11-13**] 11:40AM HOLD RADIOLOGY Final Report CHEST (PA & LAT) [**2120-11-10**] 8:06 PM Reason: please get x-ray at 6pm r/o pneumothorax [**Hospital 93**] MEDICAL CONDITION: 68 year old man with lung mass s/p left upper lobectomy now s/p removal of chest tube REASON FOR THIS EXAMINATION: please get x-ray at 6pm r/o pneumothorax INDICATION: 68-year-old man with lung mass status post upper lobectomy, now status post removal of chest tube, rule out pneumothorax. PA and lateral chest x-ray of [**2120-11-10**], is compared to the previous chest x-ray of [**2120-11-7**]. There has been removal of the basal chest tube. There is no pneumothorax. There is improved aeration in the right lower lung. Left lung remains clear. Heart size and mediastinum are stable. Right supraclavicular central venous catheter in standard placement. IMPRESSION: No pneumothorax visualized. Brief Hospital Course: Pt admitted SDA for above procedure. Patient tolerated procedure well, extubated and trasferred to PACU in stable condition w/ right sides chest tubes x2 to suction. Pain control w/ dilaudid iv PCA. PACU course:uncomplicated, O2 sat 97% on 4L,Renal consulted for ESRD care. POD#1; Pain control cont w/ PCA w/ good pain control; CT right x2> sx; CXRY>; OOB to chair, IS. NSR. Coumadin restarted 2.5mg given pm, resumed from home regimen for atrial fibrillation. HOme meds restarted. O2 sat at rest 4L 96%,albuterol nebs and inhalers cont. Hemodialysis done and to cont M-W-F, Anuric. Diet advanced. POD#2- Pain control w/ PCA cont. Physical therapy consult- O2 sat @ rest- 93%- 5L, activity- 88%-4L, recovery 89-96%-4-5L. Ambulate [**Hospital1 **]-tid. NSR. CT> w/s, no leak. Coumadin 2.5mg. Taking po's well.Coumadin 2.5. POD#3-Hemodialysis done; PCA transitioned to percocet w/ good effect; NSR; right CT- [**Doctor Last Name **] d/c w/o complication, CT remains> w/s. PT- rest 93%- 4L; activity-84% RA, 91%-3L, 88%-2L, recovery-95%-4L.po intake good- BM today.Coumadin 2.5 POD#4- CT [**Doctor Last Name **] to sulb sx; SR- 1 AVblock; 2.5-4L NC sat 94%. Dispo planning; CT site draining ser/sang drainage- DSD change QD; [**Doctor Last Name 406**] cont to drain ser/sang drainage. POD#5- Bale CT removed w/o complication. POD#6- Hemodialysis done, cont ambulation, IS, inhalers w/ BS Course bilat; O2 sat 98% 2L. POD#7- Cont ambulation w/ O2 wean to 2L 95%. INR 2.8, coumadin heldx2 days- plan INR check in 2 days. POD#8-Hemodialysis done. Pt stable for discharge to extended care facility for conditioning, INR monitoring, wound care and management, ESRD - dialysis. POD#9-Patient found to have profound leukocytosis to 38 with complaints of abdominal pain. Vancomycin, levofloxacin, and flagyl started as emperic therapy. CT scan of abdomen obtained, though no acute pathology was noted. POD#10-C. difficile sample sent, which eventually came back positive. General surgery consult sought. INR found to be 6.7. 1 unit FFP given, with correction of coagulopathy to INR 2.4. POD#[**10-19**]-INR checked and found to be 3.0. Antibiotics continued. Patient complained of persistent LLQ abdominal pain. Patient found to be in distress that evening in the bathroom. He was transferred to his bed, where he became unresponsive. The patient was coded, with initial vtach rhytym to asystole to junctional escape rhythm. After pushing epinepherine, atropine, bicarbonate, calcium, and amiodarone, a pulse was established. Patient was transferred to the cardiac surgery ICU, where his pulse was lost. He expired on [**2120-11-18**] at 2:30am Medications on Admission: Lisinopril, Lasix, Norvasc, Flomax, Coumadin, amiodarone, and Lipitor Discharge Medications: 1. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*qs Tablet(s)* Refills:*2* 2. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*qs Tablet(s)* Refills:*2* 3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). Disp:*qs Tablet, Chewable(s)* Refills:*2* 4. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). Disp:*60 Disk with Device(s)* Refills:*2* 5. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q6H (every 6 hours). Disp:*qs * Refills:*2* 6. Nicotine 14 mg/24 hr Patch 24HR Sig: One (1) Patch 24HR Transdermal DAILY (Daily). Disp:*qs Patch 24HR(s)* Refills:*2* 7. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed for pain. Disp:*100 Tablet(s)* Refills:*0* 8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 9. Sevelamer 800 mg Tablet Sig: One (1) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). Disp:*qs Tablet(s)* Refills:*2* 10. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 11. Tamsulosin 0.4 mg Capsule, Sust. Release 24HR Sig: One (1) Capsule, Sust. Release 24HR PO HS (at bedtime). Disp:*qs Capsule, Sust. Release 24HR(s)* Refills:*2* 12. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* Discharge Disposition: Extended Care Discharge Diagnosis: Right lower lobe lung mass, hypertension, Congestive heart failure, cerebral vascular accident, 70% carotid stenosis, Atrial Fibrillation, End stage renal disease on Hemodialysis diverticulitis, Peptic ulcer disease, Benign prostatic hypertrophy, incisional hernia lung mass Discharge Condition: Deceased

[ "600.00", "403.91", "V58.61", "599.0", "008.45", "162.5", "428.0", "424.0", "038.9", "995.91", "427.31", "433.10", "492.8", "585.6" ]

icd9cm

[ [ [] ] ]

[ "33.22", "99.60", "32.3", "39.95", "99.04", "99.07" ]

icd9pcs

[ [ [] ] ]

8611, 8626

4340, 6976

377, 487

8945, 8956

2446, 3581

7096, 8588

3618, 3704

8647, 8924

7002, 7073

1979, 2427

283, 339

3733, 4317

515, 1316

1338, 1895

1911, 1964

16,085

147,230

27399

Discharge summary

report

Admission Date: [**2174-9-16**] Discharge Date: [**2174-10-22**] Date of Birth: [**2131-10-18**] Sex: M Service: MEDICINE Allergies: Ampicillin / Cephalosporins Attending:[**First Name3 (LF) 7591**] Chief Complaint: Planned admission for high dose melphalan autologous stem cell transplant Major Surgical or Invasive Procedure: Autologous Stem Cell Transplantation with melphalan History of Present Illness: 42-year-old male with kappa light chain myeloma diagnosed in [**Month (only) 116**] [**2173**] when he presented in acute renal failure, with hyperkalemia. He was on dialysis for 6-7 weeks, then recovered renal function. He is status post two cycles of Decadron and thalidomide therapy, and one cycleof Decadron therapy alone, which had to be held for one month due to a perforated ulcer, on [**6-24**], during his second cycle. His hospital course was c/b fluid leackage from his central line into the chest cavity and subsequent intubation. He was discharged from the OSH on [**2174-7-13**]. He received his last dose of Thal/[**Month (only) **]/ coumadin on [**2174-6-26**]. Presented in hypertensive urgency in [**Month (only) 216**] with acute renal failure and progressive myeloma during admission pt received Cytoxan one gram per meter square and Decadron pulses. Again presented in renal failure and was admitted to the hospital in [**Month (only) **] where he stem cell mobilization with high-dose Cytoxan. This [**Date range (1) 66829**] admission for acute on chronic renal failure with SPEP demonstrating hypogammaglobulinemia but no monoclonal spike. UPEP was negative for Bence-[**Doctor Last Name **] protein. His kappa level was 21.2, elevated. Pt was started on dexamethasone 40 mg IV daily x 4 days for pulse therapy of presumed light chain renal toxicity. Renal biopsy with no evidence of cast nephropathy or amyloidosis. His creatinine decreased with pulse-dose steroids. He received high dose cytoxan, after which his renal function improved.Bone marrow bx performed [**8-24**] FISH nml. Stem cell collection 9/25,[**9-6**]. Presenting today for auto SCT with melphalan. Past Medical History: ONC Hx: as stated above Hypertension, longstanding Pneumonia [**5-/2174**] Perforated peptic ulcer [**6-16**] Meningitis x 2 (unclear etiology - one episode required 2 week hospitalization) Surgeries: Bilateral inguinal hernia repairs as child 3 cervical spine fusions (3 years ago, 2 years ago, [**Month (only) 205**] of [**2172**]) Right knee arthroscopic surgery and open patellar reduction Bilateral rotator cuff repairs Cardiac catheterization ([**7-/2170**]) Repair of perforated peptic ulcer [**6-16**] Social History: He served in the USMC for 6 years. reports no known exposure to pesticides, insecticides or radiation. Then a prison guard in [**Location (un) 932**], MA until being severely beaten in a yard riot in which leg, orbit, jaw, and several ribs were fractured. He also received several stab wounds. Then began working in a computer company. On disability x 3 yrs. Lives with wife and 2 dogs in [**Location (un) 38640**]. no children. Ex smoker 1 pack per day x 15 yrs. Family History: He has 2 sisters, one of whom has MS. His father has had a CABG and an aortic valve replacement. His grandfather died in his early 50's following an MI. His mother has diabetes mellitus & grandmother passed away from chronic renal disease Physical Exam: Vitals-229 lbs 97.5, 20, 66, 171/94, 100% RA Gen-Nervous appearing male in no acute distress sitting on side of bed. Skin- folliculitis throughout body, tatoo. HEENT-EOMI, PERRL, MMM, OP clear, no lesions noted. CV- RRR, no Murmurs noted. Nml S1,S2 Pulm- CTAB, no wheezes noted, poor inspiratory effort Abd- large vertical incision, obese abdomen, non tender, non distended Extr-1+ edema. 2+ pulses distally. No clubbing or cyanosis. . Pertinent Results: LABS: [**2174-9-13**] 138 104 66 122 AGap=13 3.6 25 2.2 . Mg: 1.6 P: 1.4 ALT: 21 AP: 97 Tbili: 0.2 Alb: 3.9 AST: 21 LDH: 709 Dbili: 0.1 TProt: [**Doctor First Name **]: Lip: . 9.9 31.8 212 D 28.3 N:79 Band:5 L:5 M:7 E:0 Bas:0 Metas: 3 Myelos: 1 Nrbc: 2 Hypochr: NORMAL Anisocy: 1+ Poiklo: 1+ Microcy: 1+ Polychr: OCCASIONAL Ovalocy: OCCASIONAL Tear-Dr: OCCASIONAL Comments: MANUALLY COUNTED Plt-Est: Normal . Other Hematology H/O-Smr: Sent Gran-Ct: [**Numeric Identifier 67093**] . CHEST (PORTABLE AP) [**2174-9-22**] 8:19 PORTABLE AP CHEST. Comparison [**2174-9-16**]. Heart size is normal. Mediastinal and hilar contours appear normal. There is some apical vascular congestion, right-sided minimal layering pleural effusion is noted.The left-sided PICC line terminates over the normal course of the mid SVC. No pneumothorax. Mild CHF. No pneumothorax. . CHEST (PORTABLE AP) [**2174-9-26**] 9:59 AM The mediastinum is widened in the right paratracheal region without change from recent portable chest radiographs but wider when compared to an older study of [**2174-4-26**]. This is concerning for lymphadenopathy. New subtle peribronchiolar opacities are present in the right upper lobe centrally, and there is also a questionable area of opacity in the right retrocardiac region. These findings may be due to evolving pneumonia or aspiration. . CT CHEST W/O CONTRAST [**2174-9-28**] 12:12 PM 1. Diffuse septal thickening, most consistent with a hydrostatic pulmonary edema. Multifocal asymmetrical pattern of ground glass opacities and small foci of consolidation in the right middle and left lower lobes may be due to asymmetrical edema or superimposed infection. 2. Small pleural effusions, right greater than left, and a small pericardial effusion. 3. Diffuse mediastinal lymphadenopathy. . UNILAT UP EXT VEINS US [**2174-9-29**] 3:24 PM No evidence of DVT. . CT CHEST W/O CONTRAST [**2174-10-12**] 4:06 PM 1. Partial resolution of left upper lobe ground glass opacities, but new multifocal areas of consolidation involving predominantly the right middle lobe, lingula and bilateral lower lobes. This intermitently changing pattern and location of multifocal densities has a broad differential diagnosis, including atypical infection, eosinophilc lung, vasculitis, aspiration and cryptogenic organizing pneumonia. Findings are not suspicious for neoplasia and are not typical for septic emboli. Clinical correlation is recommended with further follow up as indicated. 2. Increased bilateral pleural effusions. 2. Persistent mediastinal lymphadenopathy. . CHEST (PORTABLE AP) [**2174-10-14**] 12:05 AM Portable AP chest radiograph compared to [**2174-10-13**]. The pulmonary edema and bilateral pleural effusions have been increased since previous exam being now of moderate degree. The heart size is enlarged and unchanged, the tip of the left PICC line is at the junction of the brachiocephalic vein and superior vena cava. . CT CHEST W/O CONTRAST [**2174-10-17**] 12:31 PM Mixed response of diffuse pulmonary abnormalities, with worsening consolidation and centrilobular opacities in the right middle and lower lobes, but interval improvement in the left lung. Considering interval treatment for [**Month/Day/Year 1065**] infection, the worsening abnormality in the right lung could be due to a second infectious process. Additionally, other superimposed process including aspiration and asymmetric pulmonary edema are also possible. Anasarca and trace ascites as well as slight increase in right effusion, likely due to generalized fluid overload. . CHEST (PORTABLE AP) [**2174-10-19**] 5:37 AM Single portable plain radiograph of the chest is obtained. Left- sided internal jugular catheter is identified with tip in distal SVC. Increased pulmonary vascular congestion is identified. Development of a substantial right-sided pleural effusion is identified with a smaller left- sided effusion also evident. No definitive evidence of pneumonia is seen; however, there is basilar consolidation associated with the right-sided effusion. The cardiomediastinal silhouette appears unchanged. No pneumothorax is identified. CHF with increased pleural effusions, most significant on the right. . CHEST (PA & LAT) [**2174-10-21**] 4:06 PM Interval improvement in previous CHF. Small right-sided pleural effusion remains. . Brief Hospital Course: 42 yr old male with kappa light chain myeloma diagnosed this [**Month (only) 116**] with multiple admissions for renal failure treated with thalidomide, prednisone, cytoxan presenting for autologous stem cell transplant with Melphalan, course complicated by renal failure, fevers and pulmonary edema. . Multiple myeloma- Presentation with acute renal failure which can be the presentation in 20-30% of patients. Pt reports several fractures of bones in the past which could be related to osteolytic lesions present with increased osteoclastic activity associated with MM. SPEP demonstrating hypogammaglobulinemia but no monoclonal spike. UPEP was negative for Bence-[**Doctor Last Name **] protein. His kappa level was 21.2, elevated. Light chain with increased renal failure due to cast nephropathy, light chain deposition disease, Amyloid deposition, Fanconi's, but renal biopsy with no evidence of cast nephropathy or amyloidosis Did well on prednisone and thalidomide with some peripheral neuropathy. Cytoxan treatment in the past. Small amount of plasma cells lead to renal failure in pt. FISH [**8-24**] wnl. Oncologist felt autologous transplant with melphalan best option at this point. Melphalan treatment performed with autologous transplant per protocol, with 2 renally dosed treatments. Checked hemolysis labs [**Hospital1 **], for appeared to be lysing. K to 5.7. Uric acid to 13. Rasburicase 6 mg given with decrease to <1. [**9-20**] stem cells given without incident. [**9-22**] creatinine noted to be increasing to 3. Hydrated 200 cc/hr with bicarb when patient first presented given concern for nephrotoxicity on already damaged kidneys. Decreased on hydration 100 cc/hr, then to off as patient retaining fluids with swelling, and weight gain of 18+ pounds. Lasix given sparingly as concern for further worsening renal failure, but diuresis necessary given pulmonary edema. Course complicated by fever during time of engraftment [**9-23**]. ANC to 5370 day +10 from 1220 and 50 the two days prior. Neupogen stopped at this time. Severe line pain, evidence of possible pulmonary infiltrate and continued worseing fluid overload with necessity of face mask for aid in breathing, also prolonged admission. [**10-12**] Decreased Serum Kappa Light Chains compared to pre-transplant. As overload improved and fever resolved pt discharged with plan for tandem auto SCT in 1 month. ID- Due to intense pain from left central line site, central line was pulled [**9-22**] with subsequent rigors, concerning for bacteremic, spread of infectious [**Doctor Last Name 360**] on catheter. Pt immediately started on vancomycin, renally doses, patient spiked at night, then spiked and started cefepime. PICC placed [**9-23**]. [**9-23**] temp to 101.5, patient started on fluconazole, with evidence of thrush. [**9-24**] patient neutropenic and febrile, with onset of shortness of breath during the night with desaturation to 87% on RA. CXR with evidence of new peribronchiolar opacity in the right upper lobe and right retrocardiac opacity. [**9-26**] temp to 101, started on flagyl, in addition to caspofungin. chest x-ray with question aspiration. [**9-27**], low grade temps, sat's improving. Cefepime, vanc, flagyl and caspo continued with Acyclovir held due to cr>1.5 per protocol. [**9-30**]- spiked to 102, on adequate coverage, induced sputum but mixed. Temps to max 103.6. CT chest with ground glass opacities and septal thickening, focal consolidations, question PCP, [**Name10 (NameIs) 1065**] etiology. [**10-1**] bronchoscopy performed with evidence of slight erythema in right lower lobe without purulent secretions. BAL of LUL anterior segment performed. Cultures and [**Month/Year (2) 1065**] antigens negative. On [**10-13**] the patient developed a multifocal pulmonary process by CT, ? PCP [**Last Name (NamePattern4) **]. worsening [**Last Name (NamePattern4) 1065**] PNA and a new O2 requirement. Pt spiking temps, blood, urine, sputum cultures were negative. BAL performed [**10-13**] for repeat [**Month/Day (2) 1065**] cx and PCP DFA were negative. Pt had 4 day stay in the ICU but was never intubated requiring nonrebreather following BAL. High dose steroids improved pt's O2 requirement. Of note, pt's kidney function also improved on high dose steroids bringing into question a pulmonary-renal syndrome given his renal function seemed worse following steroid taper and evidence of improved light chains. He was discharged on high dose prednisone for taper on an outpatient basis. . Hypoxia- Sats to 85 % on RA over the course of 2 days after admission, CT chest performed [**9-28**] with evidence of fluid overload and infiltrate possible infectious etiology. added caspo [**9-28**]. lasix 40 IV given [**9-28**]. [**9-29**] after 40 lasix and starting caspo, marked improvement in breathing sats to 95% on RA, but later hypoxic again, previous to bronch on [**10-1**]. Considered ikely fluid overload in addition to infectious etiology possible [**Month/Year (2) 1065**], PCP. [**Name10 (NameIs) **] [**Name Initial (NameIs) **]/S for swelling of left arm was negative. With diuresis and antibiotics sats to 95% on RA, but continued to intermittently drop to 85% with wheezes overnight, and patient continued to be febrile. JVP to ear lobe with LE edema, shortness of breath, likely cardiac wheeze. Evidence of overload on CXR and clinically. Patient diuresed with improvement. Hypoxia following BAL resolved with high dose steroids. Pt was discharged with stable ambulatory saturations on room air. . Chronic renal failure- Likely result of mulitiple myeloma nepthropathy as stated above. Chronic renal failure with bouts of acute renal failure treated with pulse dose steroids and chemotherapy in the past. Cr trended up with fluids and diuresis to 3.8 max. Rasburicase given 6 mg given elevated uric acid to 13, which also led to slight decrease in creatinine. Concerned for uric acid nephropathy, but no crystals evident on urine, bland sediment. Patient heavily hydrated and then diuresed with creatinine trending down allowing to avoid dialysis. Acute renal failure as described above occurred in setting of prednisone taper raising suspicion for pulmonary-renal syndrome. Pt was very sensitive to slight changes in his volume status with elevations in serum creatinine with only modest changes in fluid intake. The patient required daily intravenous fluids at time of discharge. . Hypertension- Metoprolol 50 QID, nifedipine 90 SR as outpatient. Had been admitted for hypertensive urgency in the past. On admission patient started on metoprolol TID, titrated up to QID with SBP in the 170's. Nifedipine started at 60 mg, and increased to nifedipine 40 [**Hospital1 **]. Lasix also improved BP as patient fluid overloaded during admission. . Pain- Several fractures and surgeries in the past, consider possible previous undiagnosed multiple myeloma, with lytic lesions. Pain from line site as well. Also severe pain post neupogen initiation as patient engrafted. Dilaudid PCA had to be started given extent of pain. Decreased once left central line pulled. Pt was transitioned to IV dilaudid prn as pain improved. Severe throat and esopageal pain though no severe mucositis as evidence on exam. Esophageal pain improved with resolution of neutropenia. he was weaned from dilaudid PCA. At time of discharge pt required Fentanyl patch 75mcg q72hrs for relief of his chronic neck and back pain. Medications on Admission: (pt unsure of medication doses, no latest documentation of doses. Allopurinol 100 mg p.o. daily metoprolol 50 mg p.o. QID nifedipine SR 90 QD magnesium oxide folic acid calcium Compazine p.r.n. Protonix 40 [**Hospital1 **] calcium acetate 667 mg TID with meals Discharge Medications: 1. Ursodiol 300 mg Capsule Sig: One (1) Capsule PO QAM (once a day (in the morning)). Disp:*30 Capsule(s)* Refills:*0* 2. Ursodiol 300 mg Capsule Sig: Two (2) Capsule PO QHS (once a day (at bedtime)). Disp:*60 Capsule(s)* Refills:*0* 3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours): take 1/2 hour before meals (only twice per day). Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 4. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO DAILY (Daily). Disp:*30 Tablet Sustained Release(s)* Refills:*2* 5. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:*30 Tablet(s)* Refills:*0* 6. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:*90 Tablet(s)* Refills:*2* 7. One Touch Basic System Kit Sig: One (1) kit Miscell. once. Disp:*1 kit* Refills:*0* 8. Diabetic Supplies, Miscellan. Misc Sig: One (1) test strip Miscell. before breakfast, lunch, dinner, and bedtime. Disp:*1 bottle* Refills:*0* 9. Fentanyl 75 mcg/hr Patch 72HR Sig: One (1) Patch 72HR Transdermal Q72H (every 72 hours). Disp:*3 Patch 72HR(s)* Refills:*0* 10. Prednisone 10 mg Tablet Sig: Eight (8) Tablet PO once a day for 5 days: Take in the morning. Disp:*40 Tablet(s)* Refills:*0* 11. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1) Tablet PO QMOWEFR (Monday -Wednesday-Friday). Disp:*12 Tablet(s)* Refills:*2* 12. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily). 13. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO every [**3-17**] hours as needed for pain. Disp:*28 Tablet(s)* Refills:*0* 15. Acyclovir 400 mg Tablet Sig: One (1) Tablet PO three times a day. Disp:*60 Tablet(s)* Refills:*0* 16. Humalog 100 unit/mL Solution Sig: Please follow your sliding scale Subcutaneous give before breakfast, lunch, dinner, and at bedtime. Disp:*1 bottle* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Multiple Myeloma Discharge Condition: Stable. Discharge Instructions: You underwent autologous stem cell transplantation. Your hospitalization was complicated by kidney failure and respiratory distress. . Please take all medications as prescribed. . Call Dr. [**Last Name (STitle) 410**] or 911 if you experience any fevers, chills, sweats, shortness of breath, chest pain, decreased urine output, dizziness, uncontrollable bleeding, nausea, vomiting, inability to take in adequate daily nutrition or any other concerning symptoms. Followup Instructions: You should be seen every day for follow up in the outpatient clinic for lab draws and intravenous fluids as needed. . Your appointment is at 10am tomorrow.

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icd9cm

[ [ [] ] ]

[ "99.05", "99.07", "41.04", "33.24", "38.93", "99.25", "99.04" ]

icd9pcs

[ [ [] ] ]

18004, 18010

8243, 15675

365, 419

18071, 18081

3885, 8220

18591, 18750

3173, 3413

15987, 17981

18031, 18050

15701, 15964

18105, 18568

3428, 3866

251, 327

447, 2141

2163, 2675

2691, 3157

15,754

191,547

48589

Discharge summary

report

Admission Date: [**2159-8-13**] Discharge Date: [**2159-9-3**] Date of Birth: [**2110-4-27**] Sex: F Service: HISTORY OF THE PRESENT ILLNESS: The patient is a 49-year-old female admitted to an outside hospital on [**2159-7-28**] for hypoxia treated as a COPD flare and CHF, treated with steroids and Lasix. The patient was intubated on [**2159-7-29**] for hypercarbic respiratory failure. Following sputum cultures were positive for H. flu. The patient was put on Gatafloxacin on [**2159-7-31**]. The patient had multiple weaning attempts until [**2159-8-11**] which were unsuccessful. The patient had a negative CTA examination, negative TTE. On [**2159-8-11**], the patient had an increased white blood cell count, febrile, secondary to presumed line infection with culture-positive gram-positive cocci or typed to be MRSA. Vancomycin was started. The patient requested transfer to [**Hospital1 18**]. PAST MEDICAL HISTORY: 1. Asthma. 2. COPD. MEDICATIONS ON TRANSFER: 1. Pepcid. 2. Reglan 10 mg p.o. q.i.d. 3. Gatafloxacin 400 mg p.o. q.d. started on [**2159-8-1**]. 4. Vancomycin 1 gram q. 12 hours. 5. Nystatin swish and swallow. 6. Monistat. 7. Atrovent q. four hours. 8. Mucomyst nebulizers. 9. Albuterol nebulizers q. four hours. 10. Solu-Medrol 60 mg q.i.d. started on [**2159-7-28**]. 11. Theophylline 100 mg p.o. b.i.d. ALLERGIES: The patient has no known drug allergies. FAMILY HISTORY: Noncontributory. SOCIAL HISTORY: Positive for two pack per day smoking history. She lives with her husband who also smokes. Positive alcohol consumption. No illicit drug use. PHYSICAL EXAMINATION ON ADMISSION: Vital signs: Temperature maximum 99.4, blood pressure 132/77, 69 heart rate, 16 respirations, 93% on continuous mask ventilation, 600/14/60%/12.5. General: The patient was obese, intubated, sedated, in no acute distress. HEENT: PERRLA, O/P moist plus thrush, right IJ line clear, dry, and intact. Cardiac: Regular rate and rhythm. No murmurs, rubs, or gallops. Normal S1, S2. Pulmonary: Bilateral rhonchorous and bronchial breath sounds. Abdomen: Obese, soft, nontender, nondistended, decreased abdomen sounds. Extremities: No clubbing, cyanosis or edema. Peripheral pulses 2+. Neurologic: Alert. Does not follow commands. Positive gag reflex. LABORATORY/RADIOLOGIC DATA: White blood cell count 26.2, hematocrit 46.5, platelets 227,000. Sodium 138, K 3.4, chloride 98, bicarbonate 30, BUN 22, creatinine 0.4, glucose 310. Coagulations: PT13.2, PTT 24.2, INR 1.2, AST 25, ALT 37, LDH 332, total bilirubin 0.5, albumin 2.7, alkaline phosphatase 116. Chest x-ray showing obscure right heart border, right diaphragm, fluid in right fissure, patchy left lower lobe atelectasis with left upper lobe opacity, ET tube, NG tube, and a right IJ in good position. EKG revealed normal sinus rate at 67, axis normal, intervals normal, borderline LAE, TWI, ABL, V1, unchanged, C/W prior ECGs. HOSPITAL COURSE: 1. RESPIRATORY FAILURE: Due to MRSA pneumonia on top of COPD flare, MRSA pneumonia diagnosed at an outside hospital on [**2159-8-12**] and left upper lobe treated with multiple antibiotics including Zosyn started on [**2159-8-20**], Levaquin, vancomycin, steroids were given for COPD flare. The patient was extubated on [**2159-8-21**] with multiple desaturations secondary to mucous plugs. The patient underwent bronchoscopy which again noticed mucous plugs. Was treated with Mucomyst. The patient was transferred to the floor from the ICU on [**2159-8-30**] off all antibiotics and oral steroids. Continued on nebulizers and inhalers (Albuterol, Atrovent, fluticasone). On the floor, the patient used incentive spirometry. The patient continued to improve from a respiratory standpoint and was discharged on 3 liters nasal cannula which she will continue to use at rehabilitation and will continue to be weaned from. 2. DIABETES INSIPIDUS: The patient had been urinating a large amount of hyperosmolar urine and when in the ICU the patient developed hypernatremia while intubated. Renal was consulted and given laboratory data of a very dilute urine in the setting of high serum osms and the patient's history of greater than one gallon of water consumption a day. The team felt that the patient had an underlying diabetes insipidus. The plan was to continue to allow the patient to have free water access. This resulted in resolution of her hypernatremia. The patient will be followed by the Renal Service as an outpatient. 3. ACUTE RENAL FAILURE: The patient had a climbing creatinine while in-house with a peak of 2.2. This was thought to be due to ATN secondary to high urinary output with little fluid intake while intubated in the ICU. Zosyn was discontinued in case of possible AIN but no serum or urine eosinophils were noted to suggest this diagnosis. The Renal Team were following and will follow the patient as an outpatient. Discharge creatinine was 1.9 and will be followed as an outpatient. 4. RIGHT HAND CELLULITIS: Developed following peripheral IV site infiltration. Followed by Plastic Surgery in-house who recommended antibacterial ointment q.d. with sterile dry dressing changes q.d. The patient will follow Plastics as an outpatient. 5. FEN/GI: The patient cleared by Speech and Swallow for a regular diet. 6. DISORIENTATION/AGITATION: Occurred while in the ICU, treated with Haldol, Risperdal, and Zyprexa p.r.n., self-resolving. Currently not on any medications. Currently oriented, likely ICU psychosis. 7. DISPOSITION: The patient will he discharged to Health Sound [**Hospital 38**] [**Hospital **] Hospital for further management of respiratory function. Will follow-up at the clinics listed below. CONDITION ON DISCHARGE: Stable. DISCHARGE DIAGNOSIS: 1. Hypercapnic respiratory failure. 2. Chronic obstructive pulmonary disease exacerbation. 3. Pneumonia with methicillin-resistant Staphylococcus aureus. 4. Right hand cellulitis. 5. Acute renal failure. 6. Diabetes insipidus. DISCHARGE MEDICATIONS: 1. Albuterol nebulizer treatment q. four hours p.r.n. 2. Atrovent nebulizer q. six hours, q. 2-4 hours p.r.n. 3. fluticasone 110 micrograms inhaler two puffs b.i.d. 4. Pantoprazole 40 mg p.o. q.d. 5. MVI p.o. q.d. FOLLOW-UP PLANS: 1. The patient will follow-up in the Primary Care Clinic with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at [**Hospital1 102228**] on [**2159-9-27**], Thursday, at 3:00 p.m. 2. Plastic Surgery Clinic on Tuesday, [**2159-9-18**] at 10:30 with Dr. [**Last Name (STitle) **]. 3. Follow-up with Dr. [**Last Name (STitle) 3315**]/Dr. [**Last Name (STitle) **] in [**Hospital 2793**] Clinic on Tuesday, [**2159-10-9**] at 2:30 p.m. DISPOSITION: The patient was discharged to rehabilitation in stable condition. [**First Name11 (Name Pattern1) 734**] [**Last Name (NamePattern1) 735**], M.D. [**MD Number(1) 736**] Dictated By:[**Dictator Info **] MEDQUIST36 D: [**2159-9-3**] 01:43 T: [**2159-9-5**] 22:05 JOB#: [**Job Number 102229**]

[ "253.5", "482.41", "276.0", "584.5", "682.4", "491.21", "V09.0", "518.81" ]

icd9cm

[ [ [] ] ]

[ "33.22", "33.24", "96.72" ]

icd9pcs

[ [ [] ] ]

1441, 1459

6058, 6278

5801, 6035

2979, 5746

6295, 7095

1657, 2961

1000, 1424

952, 975

1476, 1642

5771, 5780

15,161

146,060

10955+10956

Discharge summary

report+report

Admission Date: [**2127-1-6**] Discharge Date: [**2127-1-13**] Date of Birth: [**2082-7-12**] Sex: F Service: HISTORY OF PRESENT ILLNESS: The patient was brought in on a same day arrival with a preoperative diagnosis of family history of ovarian cancer. Her postoperative diagnosis was the same. The procedure was a bilateral salpingo-oophorectomy and lysis of sigmoid ovarian adhesions, bilateral mastectomies and free flap via breast reconstruction bilaterally. Surgeons involved where Dr. [**First Name (STitle) 17132**] of OB/GYN, Drs. [**Last Name (STitle) 13797**], [**Name5 (PTitle) **], [**Name5 (PTitle) 34062**] and [**Doctor First Name **] of Plastic Surgery and [**Doctor Last Name 11635**] of general surgery. The patient tolerated the procedure well and please see the operative note for full details and was discharged to the SICU for close monitoring. HOSPITAL COURSE: Neurological: The patient's pain was well tolerated with a PCA pump on [**1-11**] postop day number five. The patient was switched over to po pain medications Dilaudid and was tolerating them well. The patient was sedated only for the first day postop after which her Propofol was turned off and she was extubated successfully. Cardiac: There were no cardiac issues at any time during her stay. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 19095**], M.D. [**MD Number(1) 19096**] Dictated By:[**Name8 (MD) 16758**] MEDQUIST36 D: [**2127-1-13**] 08:04 T: [**2127-1-13**] 08:56 JOB#: [**Job Number 35553**] Admission Date: [**2127-1-6**] Discharge Date: [**2127-1-13**] Date of Birth: [**2082-7-12**] Sex: F Service: ADDENDUM: The patient's pathology revealed a high grade infiltrating carcinoma of the breast and the patient is to follow up with breast surgery in regard to that. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 19095**], M.D. [**MD Number(1) 19096**] Dictated By:[**Name8 (MD) 16758**] MEDQUIST36 D: [**2127-1-13**] 08:12 T: [**2127-1-13**] 09:49 JOB#: [**Job Number 35554**]

[ "568.0", "174.8", "285.1", "220" ]

icd9cm

[ [ [] ] ]

[ "65.61", "85.7", "85.42", "54.59" ]

icd9pcs

[ [ [] ] ]

912, 2149

159, 894

77,829

161,101

45690

Discharge summary

report

Admission Date: [**2127-8-31**] Discharge Date: [**2127-9-5**] Date of Birth: [**2053-4-13**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 905**] Chief Complaint: BRBPR Major Surgical or Invasive Procedure: embolization of left colic artery Intubation and mechanical ventillation PICC Line Placement [**2127-9-5**] History of Present Illness: Mr. [**Known lastname 97375**] is a 74 year old male with Hypertension, history of diverticular bleed, who presents after 8 bright red bloody bowel movements. After approximately 8 bloody bowel movements, he began feeling lightheaded, slid off the toilet and passed out. His wife called 911 to take him to the hospital. . Upon arrival to the ED, BP 70s-90s/palp HR 70, RR 16, 100% on RA, T 95.6. He was given 3L NS and his [**Known lastname **] pressure improved. He was crossed for 6 units of [**Known lastname **], but did not receive any [**Known lastname **]. He was seen by GI who recommended tagged RBC scan with plans to possibly scope in a few days after prepping. . Past Medical History: Past medical history: 1. Hypertension. 2. Arthritis. 3. Left foot neuropathy. 4. Back pain. 5. Varicose veins. 6. Prostate cancer. 7. Psoriasis. 8. Colonic polyps. 9. Diverticulosis with history of diverticulitis. . Past surgical history is significant for: 1. Laparoscopic cholecystectomy, [**2119**]. 2. Lumbar laminectomy, [**2125**]. 3. Vein stripping. 4. Retropubic radical prostatectomy for prostate cancer. Social History: He has quit smoking three years ago, does not drink or use drugs. He is a salesman trading in stocks and bonds. Family History: Father with unknown incurable cancer. Physical Exam: MICU Admission Note: Gen: NAD, lying in stretcher, comfortable HEENT: dry mucous membranes, sclera anicteric CV: bradycardic, no m/r/g Pulm: CTA b/l Abd: soft, NT, ND, bowel sounds present Ext: right greater than left 2+ pitting edema Neuro: AxOx3, appropriate, moving all extremities Physical Exam on Day of Discharge ([**2127-9-5**]) VS: 98.3 HR 70 BP 140/60 RR 16 97% RA Gen: NAD, lying in stretcher, comfortable HEENT: dry mucous membranes, sclera anicteric CV: RRR, no m/r/g Pulm: CTA b/l Abd: soft, NT, ND, bowel sounds present Ext: Area over bilateral antecubital are improving, although left antecub has small area with small amount of exudate, slightly indurated. Right greater than left lower extremity 2+ pitting edema, stable over last few days Neuro: AxOx3, appropriate, no focal defecits Pertinent Results: Admission Labs: . 143 | 110 | 30 / --------------- 154 3.8 | 24 | 1.3 \ . .. \ 11.2 / 10.7 ----- 257 .. / 36.1 \ . Diff: 79.3%N, 16.1%L, 3.6%M, 0.9%E, 0.1%B . PT 14 PTT 23.9 INR 1.2 . [**2127-8-31**]. Tagged RBC scan. IMPRESSION: Brisk GI bleeding at the junction of the descending and sigmoid colons. . [**2127-9-1**]. Mesenteric embolization. Unable to embolize the bleeding vessel. . [**2127-9-1**]. Mesenteric embolization. Successful embolization of the left colic artery. [**2127-9-4**]: ECHO: IMPRESSION: no obvious vegetations seen; however, best excluded by transesophageal echocardiography. US Left Antecubital Fossa: IMPRESSION: Occlusive thrombus in the cephalic vein without proximal migration. No abscess in the antecubital fossa. [**2127-9-5**]: Hct was stable over last several days, Hgb/Hct remained stable, WBC trended down and bck to normal. [**2127-9-5**] 05:20AM [**Month/Day/Year 3143**] WBC-7.7 RBC-3.62* Hgb-10.0* Hct-30.2* MCV-83 MCH-27.5 MCHC-33.0 RDW-13.6 Plt Ct-189 Brief Hospital Course: Mr. [**Known lastname 97375**] is a 74 year old male with HTN, diverticosis with a history of a diverticular bleed admitted for the MICU with GI bleeding secondary to diverticular bleed. . Diverticular bleed. Mr. [**Known lastname 97375**] presented with several bloody bowel movements and then ultimately became lightheaded and syncopized at home. He was found to have a systolic [**Known lastname **] pressure in the 70s upon arrival to the ED. He was given IVFs and his [**Known lastname **] pressure stabilized. He went directly to tagged RBC scan which was positive for sigmoid colonic bleeding. He went to angio directly but they were unable to embolize the bleed. Six hours later, he began to re-bleed so was taken back to IR for embolization. He required intubation for sedation, but they were able to succesffuly embolize the left colic artery. In total, he required 4 units of PRBCs during his MICU stay. After being transferred to the floor, he remained stable and his Hct was stable around 30. He had occasional [**Known lastname **] surrounding his stools, but his hematocrit was unchanged. . Hypertension. As above, patient was hypotensive on presentation likely secondary to hypovolemia in setting of GI bleeding. His antihypertensives were held during his MICU course and on day of discharge, pt's SBP was between 140-160/70s. We felt comfortable sending him home and restarting his HTN meds (Enalapril and HCTZ) . Acute renal failure. Patient was in acute renal failure on arrival, likely secondary to hypovolemia from bleeding. This resolved with IV fluids. . Pain. Patient takes aspirin, naprocen, tramadol, and neurontin for pain at home. NSAIDS and aspirin were held due to his bleed and his renal failure. . Bacteremia: Pt. spiked a temperature upon DC from the MICU to 101F on [**2127-9-2**]. He was cultured, started on vancomycin and [**Date Range **] cultures grew coag + staph aureus (MSSA) from specimens taken from his A-Line and a venipuncture. The likely source of infection was 2 IV sites (b/l antecubital fossa) that became red and indurated. ID was consulted and it was decided that pt. would go home on IV Nafcillin q4 hours through a PICC line. He was given teaching and VNS services. . Thrombus in Left Cephalic: Pt. developed thrombus at the site of a prior IV in left antecubital fossa described via ultrasound as occluding the left cephalic vein. I spoke with radiology and they did not see an overlying abscess. Due to the patient's GI bleeding and the fact that this was an iatrogenic thrombus (at IV site), anticoagulation was not initiated. CODE: FULL, confirmed with patient. PROPH: pneumoboots d/t GIB Medications on Admission: HCTZ 12.5 daily Omeprazole 20mg daily Enalapril 20mg daily Tramadol 50mg [**Hospital1 **] Neurontin 600mg tid Aspirin 81 daily naprocen prn benandryl prn Discharge Medications: 1. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. 2. Gabapentin 300 mg Capsule Sig: Two (2) Capsule PO TID (3 times a day). 3. Nafcillin 2 gram Piggyback Sig: Two (2) gram Intravenous every four (4) hours: first day [**2127-9-5**] and to continue for 6 weeks unless advised differently by infectious disease clinic. Disp:*180 Piggyback* Refills:*0* 4. Hydrochlorothiazide 12.5 mg Tablet Sig: One (1) Tablet PO once a day. 5. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 6. Enalapril Maleate 20 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home With Service Facility: Critical Care Systems Discharge Diagnosis: Primary Diagnosis: 1. GI Bleed 2. Staph Aureus Bacteremia 3. Thrombus in left cephalic vein. Discharge Condition: Good, stable, pt. feels well and wants to go home Discharge Instructions: You were admitted to the hospital on [**2127-8-31**] for intestinal bleeding. Your [**Date Range **] pressure was low and you continued to bleed. You were admitted to the medical ICU and underwent a procedure done to place a coil in the vessel bleeding. This was effective. Before leaving the medical ICU, you had a fever and developed infection at your IV sites that spread to your [**Date Range **] stream. You are being discharged home with IV antibiotics. Due to your intestinal bleeding we stopped your aspirin. You should avoid taking any non-steroidal antiinflammatories, such as Motrin, Naprosyn or Advil as they can also cause bleeding. You can otherwise start back on your home medications. You will be getting 2g of Nafcillin through an infusion pump every four hours. If you should develop fever, worsening pain especially in your back or abdomen, any chest pain or shortness of breath, worsening bleeding in you bowel movements or you have any concerns you should call your doctor immediately or return to the emergency department for further management. Followup Instructions: You have several appointments for follow up: You need to have a TEE (transesophageal echo) on Monday, [**2127-9-8**] at 8:30 am to evaluate your heart. Please see attached sheet with details. Your PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 2903**] is unable to see you in the office within the next 1-2 weeks, but his colleague, Dr. [**Last Name (STitle) 4922**] is available to see you on [**2127-9-15**] at 1:15 pm. You can call the office ([**Telephone/Fax (1) 2205**]) to chage the appointment if needed, but you should be seen to repeat your Hematocrit within the next [**1-31**] weeks. You need to follow up in the Infectious Disease Clinic with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] on [**9-22**] at 9am in the [**Hospital Unit Name **] on the [**Hospital Ward Name 517**]. Call ([**Telephone/Fax (1) 4170**] with any questions. You have follow up with GI as well: Provider: [**First Name11 (Name Pattern1) 1730**] [**Last Name (NamePattern4) 2301**], MD Phone:[**Telephone/Fax (1) 463**] Date/Time:[**2127-10-21**] 9:00 Provider: [**Name10 (NameIs) **] [**Apartment Address(1) 3921**] (ST-3) GI ROOMS Date/Time:[**2127-10-21**] 9:00 [**Name6 (MD) 251**] [**Name8 (MD) **] MD [**MD Number(1) 910**]

[ "355.8", "453.8", "401.9", "562.12", "996.62", "V10.46", "041.11", "E879.8", "584.9", "682.3", "790.7" ]

icd9cm

[ [ [] ] ]

[ "99.04", "88.47", "39.79", "38.91", "88.42", "38.93" ]

icd9pcs

[ [ [] ] ]

7182, 7234

3640, 6314

319, 428

7374, 7426

2612, 2612

8550, 8584

1733, 1772

6518, 7159

7255, 7255

6340, 6495

7450, 8527

1787, 2593

8596, 9844

274, 281

456, 1137

2628, 3617

7274, 7353

1181, 1587

1603, 1717

40,883

155,885

46349

Discharge summary

report

Admission Date: [**2147-5-16**] Discharge Date: [**2147-6-16**] Service: MEDICINE Allergies: Trazodone / Vicodin Attending:[**First Name3 (LF) 2009**] Chief Complaint: Dyspnea Major Surgical or Invasive Procedure: Intubation PICC placement History of Present Illness: 86 year old female with dementia, who was complaining of dyspnea and chest pain to her daughter last night. They called EMS who brought her in. Here she denies complaints. Per her daughter, she's been more confused lately. She also says she's had urinary frequency and incontinence during the last 24 hours. She denies that her mom has been coughing, having fevers, nausea, or vomiting. In the ER, vitals were 100.7, 83, 152/69, 17, 98% RA. She had a leukocytosis of 15K. A chest x-ray was notable for a left lower lobe pneumonia. She received ceftriaxone and azithromycin, and blood cultures were sent. ROS negative other than noted above. Past Medical History: -Dementia- Most likely vascular with possible Alzheimer's component -Afib on coumadin -Chronic kidney disease-stage III -VTE disease -GERD -HTN -HL -CAD with angina -L1 compression fracture/osteoporosis -Mitral regurgitation -Osteoarthritis/DJD -Right Hip Bursitis -Spinal stenosis -Status post pubic ramus fracture - [**12/2142**] -Status post falls - [**8-/2144**] and [**11/2145**] -Status post appy Social History: - Lives with [**First Name9 (NamePattern2) **] [**Doctor First Name **] and son-in-law - able to perform basic ADLs - Negative for smoking, EtOH, illicit drug use - Key relationships: Daughter [**Name (NI) 11556**] Family History: Father and mother both deceased (father, 70, influenza; mother, 65, congestive heart failure). She has 8 siblings with multiple medical problems (brother, coronary artery disease, MI age 62; brother, coronary artery disease, MI age 65; brother, pulmonary embolism in his 60s; sister brain aneurysm, deceased in 50s; sister with renal failure and on hemodialysis, deceased in 70s, and brother with leukemia deceased in his 50s). Physical Exam: Vitals: HR, BP stable, on room air, afebrile. General: Elderly female resting comfortably in bed, speaking in full sentences. HEENT: Moist mucous membranes, no conjunctivitis. Neck: Supple, no JVD. Cor: Regular rhythm. 1/6 systolic murmur. No rubs, no gallops. Lungs: Mild rhonchi in left mid-lung zone. Symmetric excursion. No wheezes. Abdomen: Normoactive bowel sounds, soft, nontender. Extr: No edema. Warm, well perfused. Psych: Cooperative and pleasant. Bright affect. Oriented to person, place, time. Neuro: Non-focal, moving all extremities, able to sit up. . Discharge exam: BP 130/60, HR 64, 99% RA In NAD, hard of hearing. Lungs with decreased breath sounds at left base, scant crackles. CV RRR without murmurs LE without edema Neuro: alert, oriented, forgetful. Pertinent Results: [**2147-5-16**] 05:15AM BLOOD WBC-14.9*# RBC-3.34* Hgb-10.4* Hct-31.8* MCV-95 MCH-31.1 MCHC-32.6 RDW-13.3 Plt Ct-216 [**2147-5-16**] 05:15AM BLOOD Neuts-86* Bands-0 Lymphs-3* Monos-10 Eos-0 Baso-1 Atyps-0 Metas-0 Myelos-0 [**2147-5-16**] 05:15AM BLOOD PT-32.2* PTT-37.3* INR(PT)-3.2* [**2147-5-16**] 05:15AM BLOOD Glucose-111* UreaN-20 Creat-1.1 Na-139 K-3.9 Cl-106 HCO3-20* AnGap-17 [**2147-5-16**] 05:15AM BLOOD ALT-20 AST-32 AlkPhos-60 [**2147-5-16**] 05:15AM BLOOD cTropnT-<0.01 proBNP-1856* [**2147-5-16**] 06:31AM BLOOD Lactate-1.1 . CXR ([**2147-5-16**]): IMPRESSION: New hazy opacities throughout the left lung, most likely pneumonia or asymmetric pulmonary edema, less likely hemorrhage. . CT Head ([**2147-5-16**]): No evidence of acute intracranial abnormalities. . CT Chest ([**2147-5-19**]): IMPRESSION: 1. Smooth intralobular septal thickening and ground-glass opacity, greater on the left than right, favoring asymmetric pulmonary edema. Although more confluent left perihilar opacities could potentially be due to asymmetrical edema, the degree of asymmetry raises concern for superimposed left lung pneumonia. 2. Coronary arterial calcifications. 3. Moderate hiatal hernia. 4. Non-obstructive right nephrolithiasis. . Renal Ultrasound ([**2147-5-24**]): IMPRESSION: No son[**Name (NI) 493**] evidence for renal abscess. The study and the report were reviewed by the staff radiologist. . CT Chest [**6-3**]: IMPRESSION: 1. Bibasilar opacities are worse than [**2147-5-25**] but improved from CXR [**2147-6-2**] and are likely infectious with some component of atelectasis. Improved opacity in the left upper lung but worsening opacities in the right upper lung. 2. Slight increase in size in bilateral pleural effusions. 3. No evidence of cavitary pneumonia. . Most recent chest xray: Portable AP chest radiograph was reviewed in comparison to [**6-6**], [**2147**]. Significant improvement in pulmonary edema has been demonstrated since the prior study with patient currently in mild-to-moderate interstitial edema. No interval increase in pleural effusion is noted. There is no interval development of pneumothorax. The right PICC line tip is at the level of cavoatrial junction. . [**6-15**]: Spine films Six total images of the cervical, thoracic, and lumbar spine demonstrate S-shaped scoliosis, severe osteopenia. No discrete compression fractures are identified. Vertebral body height appears to be maintained. Alignment is maintained. There is a heavily calcified aorta. Right-sided central catheter is present. . ECHO [**6-4**]: The left atrium is normal in size. The estimated right atrial pressure is 0-10mmHg. Left ventricular wall thicknesses and cavity size are normal. There is moderate to severe regional left ventricular systolic dysfunction with septal, anterior and apical akinesis. No masses or thrombi are seen in the left ventricle. There is no ventricular septal defect. There are three aortic valve leaflets. Moderate (2+) mitral regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is a small pericardial effusion. No right ventricular diastolic collapse is seen. Compared with the prior study (images reviewed) of [**2147-6-1**], the LVEF has decreased (the prior LVEF was overestimated - more like 35-40%). The patient is now more tachycardic. . Microbiology: C diff negative X 4: [**5-20**], [**5-21**], [**6-9**], [**6-13**] Blood cultures negative X 14 cultures Multiple negative urine cultures, one with yeast Respiratory cultures, one with few yeast, otherwise negative Respiratory viral culture, [**6-1**] negative Galactomannan, aspergillus, both negative. . Most recent EKG: [**6-10**]: NSR, prolonged QT, nLAD, TW inversions V2-V5 . Most recent labs: Hct 33.4, Plts 183, WBC 31.2 Na 141, K 3.4, Cl 107, HCO3 29, BUN 24, Cr 1.3, glu 88 Brief Hospital Course: 86 yo woman admitted with community acquired pneumonia, with prolonged hospitalization characterized by health care associated pneumonia, PEA arrest, NSTEMI, ARF poorly controlled atrial fibrillation and persistent leukocytosis of unclear etiology, but afebrile, with stable vital signs, and needing rehabilitation to return home with independent living. . Acute issues, by problem: #. Community turned healthcare acquired bacterial pneumonia: She was initially treated with ceftriaxone and azithromycin for about 24 hours, however her WBC count did not come down and she continued to have low grade fevers, so she was changed to levofloxacin on hospital day 2. Metronidazole was later added because of persistent fevers. She had a CT of her chest that showed a left lower lobe infiltrate. However, she continued to have leukocytosis and persistent fevers and her antibiotics were thus broadened to include vancomycin/metronidazole/flagyl. Her white blood cell count did not improve and her fevers continued. As such, infectious disease was consulted. A repeat CT chest was performed that showed perhaps slight improvement. However, there were persistent infiltrates. Pulmonary was consulted and they felt that this was probably just a community acquired pneumonia that is slow to resolve on imaging. Levofloxacin was continued through [**2147-5-26**] and was discontinued as she had completed a 10 day course. She was seen by speech and swallow recommended soft solids with thin liquids and pills taken with observation as well as meals. Blood and urine cultures were checked and these were no growth to date/ negative. On [**2147-6-1**] pt had PEA arrest and was intubated and brought to ICU. She was placed on vancomycin/cefepime once again. Cefepime was continued, and vancomycin was planned to be continued for a [**11-3**] day course. . #. NSTEMI, in setting of PEA arrest. On admission, she had complaints of atypical chest pain. EKG was without concerning ST/T changes. Her beta blocker was increased, she was continued on her statin and aspirin. She had an elevated troponin, and then after her PEA arrest, she had again increased troponin, attributed to PEA with subsequent CPR and chest compressions, and then decreased renal clearance. Echocardiograms obtained during the patient's stay in the ICU demonstrated new anterior wall motion abnormality as well as decreased ejection fraction. EKG showed TW inversions across precordium, new since admssion. Cardiology was consulted and felt that patient did not have a new cardiac event. Her atorvastatin dose was increased to 80 mg PO daily. She again complained of chest pain during her hospitalization but again EKG was unchanged. . # PEA arrest and then acute respiratory failure, as well as peri-arrest hypotension: PEA arrest was most likely secondary to aspiration given vomiting prior to event. Patient required intubation for less than 48 hours due to respiratory distress, and she was extubated without incident. She was started empirically on high dose steroids for possible BOOP vs eosinophilic pneumonia vs other noninfectious causes such as bronchospasm. Wheezes and lung exam significantly improved after starting steroids, and she continues on a steroit taper. In addition, upon [**Hospital 228**] transfer to the ICU, she was noted to be hypotensive and required levophed for maintain mean arterial pressure, which was weaned off quickly. . #. Atrial fibrillation with rapid ventricular response and troponin elevation. Patient had several episodes of AFib with RVR that required intravenous nodal blockade. Her oral beta blocker was increased to 200 mg daily and this resulted in improved rate control. She was continued on her coumadin initially, but then switched to dabigatran per her outpatient cardiologist's wishes. Amiodarone was discontinued due to concern for amiodarone pulmonary toxicity. While in the ICU, it was difficult to control patient's heart rate. She required a diltiazem drip for rate control, which was weaned down. She remained on metoprolol tartrate, and was also started on digoxin for further rate control. Her rate was ultimately well controlled on metoprolol 75 mg po four times daily and diltiazem 30 mg po four times daily. She was not converted to long acting regimens due to concern that she was passing the pills whole in her stool. SHE WAS IN NSR AT TIME OF DISCHARGE. . # Acute on chronic renal insufficiency: after patient's PEA event, and subsequent hypotension, she developed acute renal failure. Nephrology was consulted and thought patient's course and urine sediment was suggestive of acute tubular necrosis. . #. Acute on chronic systolic CHF: She required diuresis with intravenous lasix and was started on oral lasix to maintain even fluid balance. While in the ICU, she was thought to be volume depleted and furosemide was held. Repeat Echo showed depressed LV function. She was continued on ASA, BB, statin. Low dose lasix was restarted on [**6-9**], with good control, stable weight, and no respiratory symptoms. . #. Metabolic encephalopathy: This was likely secondary to superimposed infection on chronic dementia. She was periodically confused during her hospitalization, as well as in the ICU, and her family was told that she does need 24 hour supervision (which they provide for her themselves). . #. Iron deficiency anemia: Continued iron supplements. Patient required two red blood cell transfusions during her stay in the ICU, to which she was responsive. She did have several guaic positive stools, with blood, 3 days prior to discharge, but her hct remained stable. . Chronic issues: #. History of DVT and PE: Continued coumadin, which was later switched to dabigatran per her outpatient cardiologist's request. . #. GERD: switched omeprazole to ranitidine. . #. L1 compression fracture/osteoporosis, Osteoarthritis/DJD, Right Hip Bursitis, Spinal stenosis: Continued gabapentin 200 mg QHS, tylenol 650 mg TID, oxycodone 2.5 mg PO TID PRN. Continued calcium, vitamin D. . #. Depression/anxiety: Continued citalopram. . #. Hypothyroidism: Continued levothyroxine. . #. Pain control: patient complained of right shoulder pain during her stay, and x-ray showed significant degenerative changes. Patient also had chest pain during her stay, thought to be partially due to chest compressions that occurred after her PEA event. . # Code status: per family discussion, patient was DNR/DNI, a change made while in the ICU. Her daughter requested that she return to full code status at the time of discharge. . Key transitional issues: 1. Leukocytosis- she has had a persistent leukocytosis, with no evidence of active infection. This should be repeated next week. . Key follow up: 1. She will require repeat BMP and CBC. 2. Pneumonia: She will need to have a repeat chest xray and perhaps chest CT to ensure resolution of the infiltrates, in mid [**6-23**]. NSTEMI - will need cardiology follow up and repeat ECHO in [**Month (only) **]. . With any questions - please email me at [**University/College 98525**], or contact me by page at [**Telephone/Fax (1) 98526**] pager [**Numeric Identifier **]. Medications on Admission: AMIODARONE - 200 mg Tablet - 1 Tablet(s) by mouth Mon, Wed, Fri AMLODIPINE - 2.5 mg Tablet - 1 Tablet by mouth DAILY (Daily) CITALOPRAM - 40 mg Tablet - 1 (One) Tablet(s) by mouth daily daily CITALOPRAM - 20 mg Tablet - 1 Tablet(s) by mouth daily take one tablet daily along with 40mg tablet GABAPENTIN - 100 mg Capsule - 2 Capsule(s) by mouth at bedtime LEVOTHYROXINE - 25 mcg Tablet - 1 Tablet(s) by mouth every other day Alternating with 50 mcg QOD METOPROLOL SUCCINATE - 50 mg Tablet Extended Release 24 hr - 1(One) Tablet(s) by mouth daily in the evening NITROGLYCERIN - 0.3 mg Tablet, Sublingual - 1 Tablet(s) sublingually daily PRN OMEPRAZOLE - 40 mg Capsule, Delayed Release(E.C.) - 1 Capsule(s) by mouth daily OXYCODONE - 5 mg Tablet - 0.5 (One half) Tablet(s) by mouth TID PRN To be filled [**2147-4-5**]. SIMVASTATIN - 20 mg Tablet - 1 Tablet(s) by mouth daily WARFARIN [COUMADIN] - 1 mg Tablet - 1.5 Tablet(s) by mouth at bedtime Per INR Medications - OTC ACETAMINOPHEN - 650 mg Tablet Extended Release - 1 (One) Tablet(s) by mouth three times a day ASPIRIN - 81 mg Tablet, Delayed Release (E.C.) - 1 Tablet(s) by mouth daily CALCIUM CARBONATE-VITAMIN D3 - 600 mg-400 unit Tablet - 1 Tablet(s) by mouth twice a day FERROUS SULFATE - 325 mg (65 mg) Tablet - 1 Tablet(s) by mouth daily FOLIC ACID - (OTC) - 1 mg Tablet - One Tablet by mouth once a day SENNA - 8.6 mg Tablet - 1 (One) Tablet(s) by mouth twice a day as needed for constipation Discharge Disposition: Extended Care Facility: [**Doctor First Name 391**] Bay Skilled Nursing & Rehabilitation Center - [**Hospital1 392**] Discharge Diagnosis: [**Hospital 7502**] healthcare associated Delirium superimposed on dementia Respiratory arrest Acute renal failure/ATN Atrial fibrillation with RVR Chronic systolic CHF CAD, native/NSTEMI, with new EKG changes 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: Patient admitted with pneumonia. Course complicated by lung inflammation, respiratory arrest, acute renal failure, and afib with RVR. With antibiotics, steroids, supportive care, and rate controlling agents, her symptoms have stabilized. . Please take all medications as prescribed and keep all follow up appointments. . You will need a chest xray in 4 weeks to verify resolution of your pneumonia. Followup Instructions: Department: GERONTOLOGY When: THURSDAY [**2147-7-20**] 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 . BMP, CBC on [**6-19**] Department: CARDIAC SERVICES When: THURSDAY [**2147-7-20**] at 10:40 AM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], 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

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icd9cm

[ [ [] ] ]

[ "96.04", "33.23", "38.93", "96.71" ]

icd9pcs

[ [ [] ] ]

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6699, 12351

235, 263

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16371, 16986

1610, 2039

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65,670

120,378

35440

Discharge summary

report

Admission Date: [**2163-3-25**] Discharge Date: [**2163-4-4**] Date of Birth: [**2079-2-6**] Sex: F Service: MEDICINE Allergies: Sulfa (Sulfonamide Antibiotics) / Tetracycline / Penicillins Attending:[**First Name3 (LF) 759**] Chief Complaint: Respiratory Failure Major Surgical or Invasive Procedure: None History of Present Illness: This is an 84 year old female with chronic diastolic heart failure, chronic obstructive pulmonary disease, chronic bilateral pleural effusions status post pleurex cathether placement in [**2-14**], diabetes mellitus, hypertension, and anemia who precented from [**Hospital **] rehab with acute respiratory failure. She had been at [**Hospital **] Rehab after a prolonged admission [**Last Name (un) 5355**] CHF and pleural effusions requiring pleurex catheter placement. Her effusions were transudative and thought to be due to her CHF. Her medical regimen was optimized and she was sent to rehab. At rehab she had been doing well except for a fall complicated by a left hip fracture and was awaiting ORIF at the time of her presentation here. She had also received 2 units PRBCs for anemia during her stay and had her left sided pleurex catheter removed on [**3-24**] after pleurodesis and reported talc therapy. There was also report of a recent CT scan prior to admission noting a right pleural effusion with question of loculations. On the morning of transfer, she was noted to be tachypneic and in respiratory distress. ABG was 7.28/69/87. She was put on BiPAP with improvement. Thoracentesis was attempted but fluid could not be removed so she was given lasix 120mg IV x1 and transferred to [**Hospital1 18**]. On arrival to the MICU, she was on a NRB and somnolent, not arousable to stimuli. BiPAP was initiated and CXR was performed. She was started on vancomycin and aztreonam and ruled out for influenza. She improved rapidly and was oxygenating normally on room air. Review of Systems: Negative except per HPI. Past Medical History: - Chronic Bilateral Effusions: thought secondary to CHF (were transudative during last admission) s/p pleurex catheter placement on L in [**2163-2-6**]. - Congestive Heart Failure Diastolic Dysfunction - COPD - Anemia - Hypertension - Hypercholesterolemia - type 2 Diabetes Mellitus - Breast CA s/p lumpectomy/radiation in [**2151**] - Right CAE - PVD Social History: Married lives with husband who has dementia, until recently discharged to rehab after previous admission. Tobacco: 50 pack year quit 18 years ago. ETOH: none Family History: Father died lung cancer age 51 Physical Exam: VS: 98.3 HR 87 BP 126/45 RR 26 Sat 96-98%/NC Gen: Alert, conversant, in NAD HEENT: MMM, OP clear, PERRL, anicteric sclera Neck: supple, + JVP to 10cm Heart: RRR, 2/6 SEM at base, no radiation Lungs: crackles to midlung R>L Abdomen: soft, NT/ND + BS, no rebound or guarding Ext: warm, well perfused, no pitting edema, 1+ DP pulses Skin: diffuse ecchymoses Neuro: moves all extremities, follows commands. Pertinent Results: CXR [**2163-3-25**]: Bilateraly pulm infiltrates with small bilat pleural effusions, and mild pulm edema. Effusions intervally improved since last study. EKG: NSR 93 bpm, nl axis and intervals. Good R wave progression. No significant change from prior dated [**2163-2-6**]. [**2163-3-30**] Radiology CT CHEST W/O CONTRAST 1. More loculated moderate bilateral pleural effusion, slightly decreased in size on the right, unchanged on the left with new dense opacities, probably due to talc injection in the intervall. 2. Diffuse septal thickening and ground-glass opacity, likely due to pulmonary edema. 3. Enlarging mediastinal lymph nodes, likely reactive. 4. Patent left lower lobe bronchus with improved aeration of the left lower lobe, but persistent peripheral opacities and atelectasis. 5. Extensive coronary artery calcification, mitral annulus and aortic annulus calcifications. 6. Clips in the left breast and left axillary region, likely due to prior breast cancer. Prior vertebroplasty. 7. Small hiatal hernia. [**2163-3-28**] Radiology HIP UNILAT MIN 2 VIEWS Fluoroscopic images show placement of a gamma nail and metallic plate transfixing previously described comminuted fracture of the inner trochanteric region with apparent separation of the lesser trochanter. Further information can be gathered from the operative report. Brief Hospital Course: 84F with CHF, COPD who sustained a hip fracture and pneumonia after pleuodesis/pleurx placement for chronic pleural effusions, now s/p ORIF on [**3-28**]. DELIRIUM: Patient with delirium in setting of morphine use, mild hypoxia, and hosptialization for hip fracture. Currently improved after mimized narcotics, antipsychotics as needed, continued reorientation, low dose Quetiapine for sleep. Geriatrics followed. PNEUMONIA and HYPOXIA: Patient presented with acute hypoxia likely related to volume overload and pneumonia. She lives in [**Location **] and thus is at risk for MRSA. Acute decompensation in the setting of leukocytosis and bilateral pulmonary infiltrate consistent with healthcare assoc pneumonia. She was treated with Vanc/levofloxacin for 7 day course to [**4-2**]. Viral respiratory panel prelim result was negative. A repeat CT showed effusions to be not increased in size from prior. Per IP consulatants, likely will not benefit from thoracentesis. O2 sat remained in 80's on room air but easily rose to low 90's on 1L of room air. Continued hypoxia presumed due to a degree of persistent heart failure exacerbation. CHRONIC DIASTOLIC HEART FAILURE: She has diastolic heart failure with an EF of 80% on [**1-17**]. She was volume overloaded on exam and x-ray on transfer from the ICU. She responded well to two days of 40 mg twice daily IV lasix. Diuresis was limited by renal function. As hydralizine and afterload reduction has no demonstrated role in the treatment of diastolic heart failure and is difficult to take because of frequent dosing, this medication was stopped. She was started on an increased dose of metoprolol. She will also be discharged on a slightly increased furosemide dose of 60 mg PO BID. HIP FRACTURE: She tolerated ORIF on [**3-28**] very well, with a plate and gamma nail placed. She was anticoagulated with lovenox. Physical therapy evaluated. She will be discharged to acute rehab for further PT/OT. She may weight bear as tolerated per orthopedics. COPD: At baseline, with ABG evidence of chronic retention. She was continued on bronchodilators and given oxygen with goal sat 89-92. She was unable to get back down to room air during this admission so will be discharged on 1L O2 by nasal cannula. Expectation is she may be able to be advanced back to room air with further gently diuresis. CKD: She is at her baseline of [**12-9**].3. Medications were renally dosed and Cr. remained stable. MEDIASTINAL LYMPHADENOPATHY: She was noted to have mediastinal lymphadenopathy at her presentation that was considered most likely due to reactive lymphadenopathy secondary to her pneumonia. This should be followed up with a repeat scan in [**2-11**] months. DIABETES TYPE 2: She was continued on glargine and a humalog sliding scale. HTN: She was continued on her metoprolol on isosorbide. FEN: She received a regular/heart healthy diet. PROPHYLAXIS: lovenox, PPI, bowel regimen Access: Midline was discontinued, PIV CODE: DNR/DNI, discussed with family Medications on Admission: Lispro insulin sliding scale Glargine 15 units qPM Bimatoprost 1 drop qHS Folic acid 1mg daily Simvastatin 20mg HS Zolpidem 5mg qHS Protonix 40mg daily Furosemide 60mg daily Hydralazine 25mg TID Metoprolol 50mg QID Tylenol 325mg q4prn Percocet 5/325 1 tab q8prn Lorazepam 0.5mg q4 prn Keterolac 15mg q4 prn Loperamide 2mg q4 prn Risendronate 35mg qsaturday Epo 40,000 qmonday Discharge Medications: 1. Insulin Glargine 100 unit/mL Solution Sig: Fifteen (15) units Subcutaneous at bedtime. 2. Insulin Lispro 100 unit/mL Cartridge Sig: 0-10 Subcutaneous as directed per sliding scale. 3. Bimatoprost 0.03 % Drops Sig: One (1) Ophthalmic at bedtime. 4. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 7. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr Sig: Two (2) Tablet Sustained Release 24 hr PO DAILY (Daily). 8. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 9. Risedronate 35 mg Tablet Sig: One (1) Tablet PO once a week: on saturday. 10. Epoetin Alfa 40,000 unit/mL Solution Sig: One (1) mL Injection once a week: on Monday. 11. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 12. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 13. Calcium Citrate + D 315-200 mg-unit Tablet Sig: Two (2) Tablet PO twice a day. 14. Quetiapine 25 mg Tablet Sig: 0.5 Tablet PO QHS (once a day (at bedtime)) as needed for insomnia. 15. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 16. Tramadol 50 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day) as needed for pain. 17. Enoxaparin 30 mg/0.3 mL Syringe Sig: One (1) inj Subcutaneous Q24H (every 24 hours). 18. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily): 12 hours on. 19. Furosemide 40 mg Tablet Sig: 1.5 Tablets PO twice a day: Please note, patient's baseline regimen is 40 mg PO BID. This increased dose is to achieve some increased diuresis. Please continue this dose until patient is able to be weaned to O2 sats of 88-92% on room air. Then reduce patient back to 40 mg PO BID. 20. Outpatient Lab Work Please check BUN/Cr/Na/K/Cl/HCO3 twice a week while on increased furosemide dose (60 mg PO BID). Contact MD with results. Discharge Disposition: Extended Care Facility: oak knowle Discharge Diagnosis: DELIRIUM PNEUMONIA ACUTE ON CHRONIC DIASTOLIC HEART FAILURE LEFT HIP FRACTURE COPD CHRONIC KIDNEY DISEASE DIABETES TYPE 2 Discharge Condition: Stable Discharge Instructions: You were admitted with a fracture and pneumonia. We treated your pneumonia with antibiotics and did operative repair on your hip. You developed delerium and shortness of breath during your hospital course, which were treated by adjusting your medications. Please take your medications exactly as instructed to avoid future problems. Please visit your local emergency department or call your doctor if you have chest pain, shortness of breath, fevers, chills, acute worsening of your pain, or any other dramatic changes in your health. Followup Instructions: Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 1983**] Date/Time:[**2163-4-5**] 3:40 [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 12207**] orthopedics NP on [**2163-4-12**] at 10:20 am. Appointment is at [**Location (un) 830**] [**Location (un) **] ortho clinic. If need to reschedule or cancel call [**Telephone/Fax (1) 1228**]. Completed by:[**2163-4-5**]

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icd9cm

[ [ [] ] ]

[ "79.35" ]

icd9pcs

[ [ [] ] ]

9988, 10025

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372, 1954

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29,274

190,222

43286

Discharge summary

report

Admission Date: [**2189-10-29**] Discharge Date: [**2189-11-5**] Service: MEDICINE Allergies: Iodine; Iodine Containing / Penicillins Attending:[**First Name3 (LF) 3326**] Chief Complaint: SOB Major Surgical or Invasive Procedure: none History of Present Illness: This is a 88 yo Russian-speaking F PMH of COPD, CHF, DVT/PE p/w acute hypoxia and agitation at o/p V/Q scan [**10-30**]. Sent by PCP with hypoxia/SOB and chest pain of a couple days duration. Sats to 50s, NRB --> 100. Unable to complete V/Q. From Heb Reb, had increased WOB x few days per daughter. ?Recent d/c coumadin, decreased lasix dose. . In the ED: Temp: 101.0, BP:107/70, HR:87, RR: 18, O2sat:79% but 92% ventimask. Was on CPAP briefly. CXR with RLL lg infiltrate. Given levaquin 750 mg po X 1 (as didn't have a line initially). ABG: 7.39/79/198 on 100% NRB. Femoral line for blood, access. . To the [**Hospital Unit Name 153**]. [**10-31**] to be breathing comfortably. But began moaning on being awakened. Confused at first, but with translator more oriented. In the [**Name (NI) 153**] pt was diuresed with iv lasix. levofloxacin was started for a question of pneumonia. Vanco was started for [**1-27**] bottle grew coag neg staph no complete speciation yet. Heparin bridging and coumadin were started for afib. her o2 requirement. Diuresed 1.5-2 liters daily. 5th PICC line placed. 6th Fem line removed with Enterococcus and coag - staph. Pt started on Vancomycin. transferred to the floor [**11-1**]. . On the floor increased metoprolol for atrial fibrillation/flutter. Diuresed 3 pounds over one day as per report. Respiratory status noted at 24-30 for 24 hrs. Shallow breaths, increased somnolence. ABG 2 hrs prior 7.32/91/69. Attempted diuresis with 40 IV lasix and then 20 IV lasix, nebs but given concern for hypercarbic respiratory failure, decision to transfer back to the [**Hospital Unit Name 153**]. . In the [**Hospital Unit Name 153**] currently pt alert oriented x1 at baseline, sleepy but at baseline as per staff. Repeat gas prior to hitting floor slightly improved at 7.33/82/78. pt complaining of abdominal pain. With interpreter on phone reports "I was short of breath before, now Im better." Pt tachypneic to 30 with conversation. . ROS: abdominal pain. reports she had chest pain several days ago, and it is resolved. Reports she was short of breath several hours ago, but she is currently back to baseline. Past Medical History: HTN hypercholesterolemia diastolic CHF EF 60% COPD/asthma paroxysmal AFib sick sinus syndrome s/p pacemaker Diabetes Mellitus (when she was in former rehab hospital) DVT ?CAD Nephrolithiasis Cataracts CRI w/ baseline Cr 1.3 on [**10-15**] (per H&P from [**8-1**] Heb Reb baseline 2) dementia CVA [**92**] yrs ago, periods of confusion since then poor balance with frequent falls (coumadin stopped) urinary incontinence s/p left mastectomy for breast ca anemia (unknown baseline) . PSurgH: Left radical mastectomy appendectomy. Social History: Lives at [**Hospital 100**] Rehab (since [**8-1**]). Otherwise unobtainable. Non-smoker, no EtOH. Former nurse. Family History: noncontributory Physical Exam: Vitals: 99.5, 89, 124/55. RR 30. 95% 3L NC General: Comfortable appearing female smiling and conversant in russian with translator. HEENT: NC/AT, PERRL, EOMI without nystagmus, no scleral icterus noted, Poor dentition. Difficult to assess JVD. MMM Pulmonary: dull-to-percussion at bilateral bases Crackles diffuse [**2-28**] more prominent on right. Diminished breath sounds at bases. Expiratory wheeze. Cardiac: irreg, tachy, III/VI systolic murmur RUSB. No rub Abdomen: Diffusely tender,soft, distended, normoactive bowel sounds, no masses or organomegaly noted. Prominent over RU and L quadrant. No use of accesory muscles to breath. Extremities: No C/C/E bilaterally, 2+ radial, DP and PT pulses b/l. Skin: no rashes or lesions noted. Right groin hematoma with echymoses tracking along hip. Tender to deep palpation. Neurologic: -mental status: oriented to person only. Upgoing toes bilaterally, moves all extremities. As per translator baseline Pertinent Results: [**11-2**] 4 PM 7.33/82/78 1 PM 7.32/91/69 . EKG [**11-2**]: Pending EKG [**11-1**]: irreg, nl axis, + LVH, LBBB, intermittently A-paced . Radiologic Data: . [**11-2**] CXR cardiomegaly, pulm edema with alveolar edema, bilateral edema, slightly worse than prior chest x-ray . [**2189-10-30**] CXR A single lateral view of the chest was obtained. A dual-lead pacemaker is present. The patient's PICC line terminates in the region of the right atrium in the lateral projection. There is blunting of both costophrenic angles, suggestive of bilateral pleural effusions. Pulmonary edema is better visualized on prior frontal radiographs. Calcified hilar lymph nodes are present. There is generalized osteopenia and multilevel degenerative change. There is vertebral body height loss of approximately three vertebral bodies at the thoracolumbar junction and likely of one in the upper thorax as well, of indeterminate age. . [**10-29**] CXR: Bilateral pleural effusions, cardiomegaly, + pulmonary edema, ? RLL infiltrate . [**2189-10-30**] TTE The left atrium is markedly dilated. The right atrium is moderately dilated. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Overall left ventricular systolic function is normal (LVEF 60%). There is no ventricular septal defect. The right ventricular free wall is hypertrophied. The right ventricular cavity is dilated. Right ventricular systolic function is normal. There are three aortic valve leaflets. The aortic valve leaflets are moderately thickened. There is a minimally increased gradient consistent with minimal aortic valve stenosis. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Moderate (2+) mitral regurgitation is seen. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] The tricuspid valve leaflets are mildly thickened. Moderate to severe [3+] tricuspid regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion . CT Chest/Abdomen/Pelvis ([**11-2**]): IMPRESSION: 1. Fat containing umbilical hernia with a 2 cm neck at its superior portion. There is no bowel within this hernia and no evidence of obstruction. 2. Pulmonary edema, and moderate right and small left pleural effusions. 3. Multiple enlarged mediastinal lymph nodes, which may relate to the patient's CHF, however, should be followed closely as the patient has a history of mastectomy in [**2175**]. 4. Soft tissue opacity within the trachea, which may represent secretions; however, a mass cannot be excluded. Short interval followup is recommended following treatment to assess for persistence of this lesion. Brief Hospital Course: Assessment and Plan: 88 yo Russian-speaking F PMH of COPD, CHF, DVT/PE initially presented with acute hypoxia and agitation thought related to CHF, [**Hospital 2182**] transferred from floor with hypercarbic respiratory failure. . #)Congestive Heart Failure - The patient was admitted to the intensive care unit with hypoxia and hypercarbic respiratory distress, which appeared to be predominantly as a result of CHF and pulmonary edema. Exam and imaging were consistent with pulmonary edema; chest CT showed bilateral pleural effusions R > L. She was treated initially with a heparin drip for concern for pulmonary embolism given history and was then bridged to Coumadin. The patient was treated initially with levofloxacin for empiric coverage for pneumonia and was completed on a 7 day course though had no further evidence of fever or leukocytosis during her hospital stay. She did have a non-productive cough. She was treated with aggressive diuresis, frequent nebs, and was transferred to the floor. She was transerred back to the ICU for hypercarbic respiratory distress and was started on a Lasix drip for approx 24 hours. She received approx 80mg IV of Lasix at that time and was 2.4L negative in 24 hours. She did have what appeared to be a small contraction alkalosis at that time with a bump in her bicarbonate from 43 to 47. She also required aggressive potassium repletion during diuresis. A cardiology consult was obtained and the team felt that her CHF exacerbation may have been contributed to by her atrial fibrillation and an increase of her metoprolol was recommended to 37.5mg tid as well as continued diuresis. They also felt that if her atrial fibrillation continued to be a problem she may benefit from cardioversion in the future. Also discussion was made regarding trying digoxin, but this was not initiated during this hospitalization. Multiple blood gases were obtained throughout her hospitalization and she generally had a PaCO2 of approx 60-70, and did well on 2-3L O2 NC with sats in the low 90s. . Of note, her CT scan of her chest revealed multiple enlarged mediastinal lymph nodes, which were not further evaluated during her hospitalization. . #) Abdominal pain - Throughout her hospitalization the patient intermittently experienced abdominal pain which she localized to her umbilicus. She underwent a CT scan of her abdomen which revealed a defect containing fat and a small lymph node. A surgery consult was obtained and the mass was manually reduced. She was not felt to be a good surgical candidate, nor was it felt that she required surgery at this time. There were no signs of strangulation or bowel obstruction. . #) Afib: The patient was in atrial fibrillation upon admission and remained rate-controlled with increasing dose of beta-blocker. She was initially started on a heparin drip for concern of PE (a CTA could not be attained due to contrast allergy). She was then bridged to Coumadin for prophylaxis for her atrial fibrillation as she would be at high risk for stroke given age, Afib, and multiple comorbidities. Her INR upon discharge was supratherapeutic at 3.5 and should be adjusted as needed. . #) CRF: The patient's creatinine remained stable throughout her admission between 1.2 - 1.4 with a mild bump with diuresis. . #) Communication: HCP: [**Name (NI) **] [**Name (NI) 23**] cell [**Telephone/Fax (1) 93242**], [**0-0-**] The patient's daugher is her health care proxy as the patient has dementia. After discussion with her and the family, the decision was made for Mrs. [**Known lastname **] to be DNR, but may intubate if anticipated to be reversible in the short term. Medications on Admission: Home meds: Albuterol prn Amilodipine 5mg daily Enoxaparin 60 mg daily - started [**10-29**] at [**Hospital 100**] Rehab Famotidine 20 mg hs Ferrous Sulfate 325 mg daily Fluticosone 2 puffs [**Hospital1 **] Lasix 80mg daily Ipatroprium nebs Isosorbide Mononitrite 60 mg daily Levofloxacin 500 mg every other day - started [**10-29**] at [**Hospital 100**] Rehab Metolozone 5 mg daily Metoprolol succinate (toprol XL) 25 mg daily Miralax 1 pkt every other day Simvastatin 20 mg daily Zolpidem 5 mg hs Tylenol prn Milk of Magnesia prn Morphine 4mg every hour as needed sublingual Nitroglycerin 0.4 mg prn chest pain . Medications on transfer: Ipratropium Bromide Neb 1 NEB IH Q6H Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY Acetaminophen 500 mg PO Q4H:PRN Lactulose 30 ml PO Q8H:PRN Albuterol 0.083% Neb Soln 1 NEB IH Q6H Levofloxacin 250 mg PO Q24H Albuterol 0.083% Neb Soln 1 NEB IH Q2H:PRN Metoprolol 25 mg PO TID Aspirin EC 325 mg PO DAILY Olanzapine (Disintegrating Tablet) 5 mg PO QHS:PRN agitation Bisacodyl 10 mg PO/PR DAILY:PRN Olanzapine (Disintegrating Tablet) 5 mg PO BID:PRN agitation Docusate Sodium 100 mg PO BID Pantoprazole 40 mg PO Q24H Ferrous Sulfate 325 mg PO DAILY Fluticasone Propionate 110mcg 2 PUFF IH [**Hospital1 **] Senna 1 TAB PO BID constipation Simvastatin 20 mg PO DAILY Heparin IV per Weight-Based Dosing Guidelines Vancomycin 1000 mg IV Q48H Warfarin 5 mg PO DAILY Discharge Medications: 1. Acetaminophen 500 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed. 2. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [**Hospital1 **] (2 times a day). 4. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day. 5. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 7. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 8. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q8H (every 8 hours) as needed. 9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO DAILY (Daily) as needed. 10. Insulin Lispro 100 unit/mL Solution Sig: One (1) injection Subcutaneous ASDIR (AS DIRECTED): per insulin sliding scale. 11. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: One (1) neb treatment Inhalation Q2H (every 2 hours) as needed for shortness of breath. 12. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb treatment Inhalation Q6H (every 6 hours) as needed. 13. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [**1-27**] Puffs Inhalation Q4H (every 4 hours). 14. Warfarin 3 mg Tablet Sig: One (1) Tablet PO once a day. 15. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO TID (3 times a day). 16. Sodium Chloride 0.9% Flush 3 ml IV DAILY:PRN Peripheral IV - Inspect site every shift 17. Furosemide 10 mg/mL Solution Sig: [**3-1**] mL Injection once a day: as directed by rehab physician. Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - MACU Discharge Diagnosis: Primary: 1.) Acute exacerbation of diastolic congestive heart failure Secondary: 2.) Chronic obstructive pulmonary disease 3.) Umbilical hernia (fat-containing) 4.) Chronic renal failure 5.) Atrial fibrillation Discharge Condition: Afebrile, displaying normal vital signs, tolerating a regular diet Discharge Instructions: You were admitted to the hospital because of difficulty breathing and low oxygen saturations. You were found to have excess fluid on your lungs, likely as a result of your heart disease. You were treated for 7 days with levofloxacin because of concern for infection. You were treated with intravenous Lasix, a medication to help eliminate this excess fluid. Upon discharge you are going to the acute care unit of [**Hospital 100**] Rehab for continued treatment of your heart failure. . You had changes in the following medications: 1.) Amlodipine, famotidine, Imdur, and Metolazone were discontinued. 2.) You were started on Coumadin for atrial fibrillation at 3mg daily or as directed 3.) Your dose of metoprolol was increased to 37.5mg tid . If you experience worsening shortness of breath, chest pain, worsening abdominal pain, confusion, or if your condition worsens in any way you should seek immediate medical attention. Followup Instructions: You should receive additional medical care as instructed by the physicians at [**Hospital3 **] center

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icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

13786, 13852

6979, 10627

252, 259

14107, 14176

4130, 6956

15153, 15258

3127, 3144

12087, 13763

13873, 14086

10653, 11268

14200, 15130

3159, 3993

209, 214

287, 2431

4008, 4111

11293, 12064

2453, 2982

2998, 3111

62,863

119,169

51589

Discharge summary

report

Admission Date: [**2194-11-19**] Discharge Date: [**2194-11-26**] Date of Birth: [**2143-6-30**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**Doctor First Name 2080**] Chief Complaint: GI bleed Major Surgical or Invasive Procedure: Endoscopy Colonoscopy Selective arteriograms of SMA and [**Female First Name (un) 899**] History of Present Illness: 51 yr old male with hx of hematochezia in [**2192**] and h/o anal fistula s/p excision w/ invasive squamous cell ca p/w BRBPR x 5 days. Pt states that on evening of [**11-14**], began having blood intermixed with stool, which continued through the weekend. Then at 4pm last night, states the blood passed through his rectum "like a faucet," mostly blood and very little stool. Has had no BPBPR since that time. Overnight he went to bed, and this AM reported feeling very fatigued and therefore presented to the ED. . In the ED, vitals on admission were 99 85 133/92 18 100% RA. Hct noted to be 20.9, decreased from baseline of 40's. He remained hemodynamically stable throughout his ED course. He received 1L NS and 2 units PRBC's. NG lavage was negative. Placed on protonix gtt. Two 18-gauge peripheral IV's were placed. GI was consulted and want to do endoscopy on the floors. Vitals on transfer were 126/72, 73, 16, 98RA. . Currently, he c/o mild epigastric discomfort, which has been intermittent over the past few days and not affected by eating or bowel movements. He also admits to taking motrin 800mg daily PRN cluster headaches. He estimates taking motrin a total of 4 times over the past week. He has had [**Last Name (un) **] in [**1-/2193**] for evaluation of hematochezia, which showed adenoma in ascending colon, and bleeding was attributed to internal hemorrhoids. He was asked to have repeat [**Last Name (un) **] in one year given poor prep, which he has not had. No history of liver disease. Has never had upper EGD. Never has had H. pylori. Also, has a history of anal fistula resected [**10-25**] by Dr. [**First Name (STitle) 14190**] and Perianal sinus, excision with a single, 0.5 mm focus of invasive well-differentiated squamous cell carcinoma. . Denies nausea/vomiting. Denies chest pain, shortness of breath. C/o weakness/fatigue. Denies fevers/chills. . Past Medical History: Dyspepsia -Cluster headaches -Perianal fistula, excised area had in situ squamous cell carcinoma, surgery performed at [**Hospital1 18**] late [**2190**], followed last by Dr. [**Last Name (STitle) **] in [**7-26**] who has now left [**Hospital1 18**]. -H/o adenoma s/p polypectomy in [**1-28**] -H/o internal hemorrhoids Social History: Married, children, lives in [**Location **], insurance inspector, [**3-25**] beers on the weekends. Came to US in [**2165**] from [**Country 16573**]. No illicits. Family History: Father died of heart disease at age 72. 7 full sibs: no med probs. 4 children: healthy, ages ranging [**8-4**] yo. No cancer, DM. 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, mild epigastric tenderness, non-distended, bowel sounds present, no rebound tenderness or guarding Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Rectal: maroon colored blood/stool on glove, multiple skin tags but no external hemorrhoids Pertinent Results: HCT: 40 (baseline from prior) --> 20-->26-->30->29 [**11-19**] Endoscopy: Erythema in the stomach body and antrum compatible with gastritis Erythema in the duodenal bulb There was no blood seen. Otherwise normal EGD to third part of the duodenum [**11-20**] Colonoscopy Diverticulosis of the proximal ascending colon and mid-ascending colon Otherwise normal colonoscopy to cecum Recommendations: Likely right sided diverticuli bleed now resolved. and appointments can be scheduled by calling [**Telephone/Fax (1) 682**] SMA and [**Female First Name (un) 899**] Arteriogram: FINDINGS: 1. Superior mesenteric arteriogram reveals conventional arterial anatomy. There is no evidence of active contrast extravasation in the SMA territory. 2. Selective right colic and ileocolic arteriograms revealed conventional anatomy with no evidence of active contrast extravasation. 3. Inferior mesenteric arteriogram reveals conventional anatomy with no evidence of active contrast extravasation. IMPRESSION: SMA and [**Female First Name (un) 899**] arteriograms revealed no evidence of contrast extravasation in the SMA or [**Female First Name (un) 899**] territory Brief Hospital Course: 41 M with history of hematochezia in [**2192**] (found to have internal hemorrhoids and adenoma of ascending colon), and h/o anal fistula in [**10/2190**] s/p excision w/ invasive squamous cell ca who was admitted for BRBPR x 5 days and HCT drop 40-->20. He was transfused total of 7 Units and HCT stabalized at 30. He was [**Hospital 90446**] transfered to the MICU for close monitorting. . #Acute blood loss anemia/GI BLEED: Had endoscopy revealing some gastritis of stomache body and antrum as well as colonoscopy revealing several ascending colon divericuli- thoughtlikely the source of the acute GI bleed. Pt then had 2nd episode of GI bleed on [**2194-11-21**] with CTA revealing cecum as likely source. Followup selective arteriography was neg for acute bleed source- likely missed the window of opportunity to intervene. Had a few episodes of maroon stool a few days after but no further frank blood. He was started on pantoprazole 40mg daily. Pt's hematocrit stabalized and plan was for him to follow up with GI to get colonscopy within 1-2 months to definitely rule out AVM as source of bleed. There was also some discussion that pt might ultimately need a right hemicolectomy if he continues to have uncontrolled bleeding episodes. Pt was strongly encouraged to avoid all NSAIDs. ***Pt will fu with GI Dr. [**First Name (STitle) 679**] next week. He will need to have scheduled colonoscopy appt made by Dr. [**First Name (STitle) 679**] at that time to assess for AVM and definitely rule out. . #Anemia: [**1-21**] GI bleed. HCT initially dropped from 40 (baseline) to 20 on admission. S/p total of 10 UPRBC and 1 U FFP. HCT was monitored very carefully. Hct at discharge was 29-31 range. **Pt told to check his HCT in a few days and forward results to PCP. [**Name10 (NameIs) **] will see PCP next week. . #CLUSTER HA: Stopped his NSAIDs in setting of acute bleed. Pt should not take any more NSAIDs. Medications on Admission: Motrin 800mg PRN headache about [**2-20**] x/ week Omeprazole 20mg PRN gas about 4-5x/week Discharge Medications: 1. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*4* 2. Outpatient Lab Work Hematocrit. Please check on [**2194-11-29**]. Please forward the results to Primary care doctor: Dr. [**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) **] fax: [**Telephone/Fax (1) 27392**]. Discharge Disposition: Home Discharge Diagnosis: Diverticulosis Acute gastrointestinal bleed Anemia Gastritis of stomache Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: It was a pleasure to provide care for you during your hospitalization. You were admitted to the hospital for blood loss in your gut. You were given several blood transfusions (a total of 10). You had a thorough workup of your gut which revealed diverticuli as the likely source of the bleed. (diverticuli are little pockets in the gut that can occasionally bleed) Your bleeding stopped and your blood counts stabalized. You will follow up with a gastroenterologist within the next few weeks to schedule a repeat colonoscopy. The purpose of this is to carefully evaluate and determine if an arterio-venous malformation is causing your bleeding. If it is, then it can be cauterized. It is important to follow up both with a gastroenterologist and with your primary care doctor within the next few weeks. Medication Changes: STOP: pleaes stop any NSAIDs (advil, motrin, alleve, aspirin, etc...). See the list that was given to you. We reccomend that you do NOT take these medications again, they can make you bleed. The only medication you should take for pain would be plain tylenol or narcotics if it is severe pain. START: Pantoprazole 40mg daily If you have any further bleeding, please report to the emergency department IMMEDIATELY. Followup Instructions: Your appointments are: Department: [**Hospital3 249**] When: MONDAY [**2194-12-1**] at 11:40 AM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 15675**], MD [**Telephone/Fax (1) 250**] Building: [**Hospital6 29**] [**Location (un) 895**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Name: [**Last Name (LF) 679**], [**Name8 (MD) 1158**] MD --Gastroenterology Address: [**Doctor First Name **],STE 8A, [**Location (un) **],[**Numeric Identifier 718**] Phone: [**Telephone/Fax (1) 682**] Appt: [**12-5**] at 1:30pm (at this appointment, Dr. [**First Name (STitle) 679**] will evaluate you and also arrange for a follow up Colonoscopy)

[ "535.50", "287.5", "285.1", "V58.64", "562.12", "339.00", "V10.06" ]

icd9cm

[ [ [] ] ]

[ "45.23", "45.13", "88.47" ]

icd9pcs

[ [ [] ] ]

7272, 7278

4782, 6697

327, 418

7395, 7395

3601, 4759

8809, 9490

2874, 3006

6839, 7249

7299, 7374

6723, 6816

7546, 8349

3021, 3582

8369, 8786

279, 289

446, 2331

7410, 7522

2353, 2677

2693, 2858

48,771

165,326

35758

Discharge summary

report

Admission Date: [**2187-3-11**] Discharge Date: [**2187-3-19**] Date of Birth: [**2155-1-27**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2534**] Chief Complaint: s/p Fall from window (?[**Location (un) 470**]) Major Surgical or Invasive Procedure: Suturing of lid laceration History of Present Illness: 32 yo male s/p fall out of a window at home (prior report of assault contradicted by parents) EtOH and cocaine +. He was transferred to [**Hospital1 18**] for further care. Past Medical History: Alcohol & drug abuse Right leg venous insufficiency Social History: Admits to drinking 6-12 beers per weekend. He has been arrested for driving under the influence X3, is a member of alcoholics anonymous and has been in a substance abuse rehab program previously. Family History: Noncontributory Physical Exam: Upon admission: 99.2 102 118/62 95% nasal cannula Somnolent male in NAD, AAOx2 (person, "hospital") Swelling noted over left supraorbital and malar areas. Periorbital ecchymosis on the left. 4 cm laceration down to calvarium through frontalis muscle on the lateral left brow. EOMI, PERRLA. No icterus or scleral hemorrhage. No proptosis or enopthalmos. No palpable supraorbital or infraorbital Fxs Midface stable Nose stable, nares clear, no septal hematoma Teeth grossly intact anteriorly upper and lower, no obvious intraoral lacerations (exam limited by patient's agitation) No zygomatic arch stepoffs Sensation intact over V1-3 distributions, CN II-XII intact. Pertinent Results: [**2187-3-11**] 07:26AM GLUCOSE-91 UREA N-8 CREAT-1.0 SODIUM-141 POTASSIUM-4.7 CHLORIDE-111* TOTAL CO2-17* ANION GAP-18 [**2187-3-11**] 07:26AM WBC-21.3* RBC-3.59* HGB-10.6* HCT-31.4* MCV-87 MCH-29.6 MCHC-33.9 RDW-14.5 [**2187-3-11**] 07:26AM PLT COUNT-286 [**2187-3-11**] 07:26AM PT-15.0* PTT-26.9 INR(PT)-1.3* [**2187-3-11**] 02:30AM ASA-NEG ETHANOL-218* ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG CT head [**2187-3-11**] IMPRESSION: 1. Multiple facial fractures, described in detail in the concurrent facial bone CT report. 2. No evidence of acute intracranial abnormalities. CT cervical spine [**3-11**]//09 IMPRESSION: No fracture or malalignment in the cervical spine. CT Sinus/Mandible [**2187-3-11**] IMPRESSION: 1. Left zygomaticomaxillary complex fracture pattern. 2. Extraconal hematoma in the inferior left orbit, contiguous with the left inferior rectus. Extraconal gas in the left orbit. 3. Possible left lamina papyracea fracture. Brief Hospital Course: He was admitted to the Trauma service. He was transferred to the Trauma ICU for close monitoring and was immediately placed on CIWA protocol. Orthopedics was initially consulted for right anterior ring pelvic fracture which was managed in a conservative manner. Plastics was consulted for facial fractures which were initially managed non operatively with plans for elective repair at a future date. The left brow laceration sustained was irrigated and sutured closed. Ophthalmology was also consulted to rule out entrapment or other globe injuries, none were identified. On [**3-16**] he developed respiratory distress and was started on Vancomycin and Zosyn for LLL infiltrate noted on chest CTA imaging. He remained in the ICU for several days intermittently agitated requiring use of the CIWA protocol. He was also evaluated by the chronic pain service who recommended scheduled Ibuprofen 800 TID if no contraindication; discontinue Dilaudid; discontinue scheduled Tylenol and start Oxycodone/Acetaminophen 5/325 1-2tabs po q4hr prn. On [**2187-3-19**] it was recommended to increase Percocet 10/325 1-2 tabs q4h prn. He eventually was stable enough to be transferred to the regular nursing unit. It was noted on his right leg an area of erythema concerning for cellulitis and it was decided to initiate IV Kefzol. This was later changed to oral Keflex as patient had been tolerating oral's at this point. Because of the erythema and swelling lower extremity ultrasound was performed which showed a partial thrombosis of the right popliteal vein, with the remainder of the venous structures intact. Discussions took place as to whether or not to anticoagulate patient and the decision not to was made based on patient's alcohol and drug history and concern for high noncompliance of taking such medications and following up for INR monitoring. The information and feedback from Social work who had been following patient throughout his hospital stay and patient's family regarding patient's lack of follow through were also factored into the decision to not anticoagulate. Social work spent many hours with patient providing support and counseling surrounding his alcohol and drug use. He was offered inpatient drug and alcohol treatment on several occasions and declined each time. Discussions between Social work and his family took place on multiple occasions and it was made clear by family that patient could not come to any of his family members' home after hospital discharge. Social work presented patient with possibility of going to a shelter and he declined this as well. Patient ultimately came up with a plan between he and a friend and decided that he would go and stay with this friend after hospital discharge. He was evaluated by Physical therapy and was cleared for discharge to home with crutches for ambulation. Medications on Admission: Unknown Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours) for 10 days. Disp:*40 Capsule(s)* Refills:*0* 3. Milk of Magnesia 800 mg/5 mL Suspension Sig: Thirty (30) ML's PO twice a day as needed for constipation. 4. Oxycodone-Acetaminophen 10-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*40 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: s/p Fall Supraorbital laceration Left inferior wall orbital fracture Right acetabular fracture Right ischial/pubic rami fracture Right popliteal thrombus Right lower extremity cellulitis Discharge Condition: Hemodynamically stable, tolerating a regular diet, pain adequately controlled. Discharge Instructions: AVOID alcohol and/or any other illicit drugs while you are taking narcotics prescribed for your pain. Keep your right leg elevated on 2 pillows when at rest. You may bear weight as tolerated on both of your legs, using crutches for assistance with ambulation. it isi importnathat you walk at least several times daily to avoid developing further blood clot formation. Adhere to a soft diet because of your facial fractures. DO NOT blow your nose or drink through a straw becasue of your facial fractures. Please complete your entire (Keflex) antibiotic course as prescribed. Return to the Emergency room if you develop any fevers, chills, headache, shortness of breath, increased pain/swelling/redness in your legs, abdominal pain, nausea, vomiting, diarrhea and/or any other symptoms that are concerning to you. Followup Instructions: Follow up in 2 weeks in [**Hospital 5498**] clinic with Dr. [**Last Name (STitle) 1005**] for your pelvic fractures. Call [**Telephone/Fax (1) 1228**] for an appointment. Follow up next week with in [**Hospital 3595**] clinic for your facial fractures, call [**Telephone/Fax (1) 5343**] for an appointment. Follow up in Trauma clinic for pain medication prescription refill authorization. Call [**Telephone/Fax (1) 2359**] for an appointment. Completed by:[**2187-3-28**]

[ "873.0", "802.6", "453.41", "305.60", "873.52", "801.01", "808.0", "902.89", "291.81", "303.90", "338.29", "759.89", "682.6", "338.11", "518.82", "V60.0", "E882", "808.2" ]

icd9cm

[ [ [] ] ]

[ "08.81", "88.47", "99.04", "39.79" ]

icd9pcs

[ [ [] ] ]

6000, 6006

2628, 5475

362, 391

6237, 6318

1625, 2605

7185, 7661

898, 915

5533, 5977

6027, 6216

5501, 5510

6342, 7162

930, 932

275, 324

419, 593

946, 1606

615, 669

685, 882

30,198

184,696

33316

Discharge summary

report

Admission Date: [**2131-4-12**] Discharge Date: [**2131-4-27**] Date of Birth: [**2093-2-10**] Sex: M Service: MEDICINE Allergies: Reglan / Lidocaine / Iodine Attending:[**First Name3 (LF) 613**] Chief Complaint: Abdominal pain, chest pain, nausea+vomiting Major Surgical or Invasive Procedure: upper endoscopy Dobutamine Stress Echo cardiac catheterization History of Present Illness: 38yo man with type I DM, CKD (baseline Cr 2.2-2.6, systolic and diastolic CHF with EF 50-55%, refractory HTN and gastroparesis with recurrent admissions for gastroparesis presented to new PCP's office with recurrent nausea, vomiting, inability to take pos and chest pain radiating to his back and was sent to ED. He was last admitted 2 weeks ago with similar sx other than chest pain, and was admitted for PNA and C. Diff. He states that he has had abdominal pain and nausea/ vomiting over last week similar to previous bouts of gastroparesis. He denies missing any insulin doses and says he has been taking 10U at night, 4U in evening with sugars <200 almost always. He finished [**Last Name (un) 8692**] flagyl course, and had not had any diarrhea other than 1 episode this AM. In ED, initial vitals were significant for BP 250/140 and glucose of 700 and a anion gap of 18 when corrected for hyperglycemia. Pt. had CT without contrast to assess for dissection given chest pain radiating to his back which was negative. No leukocytosis, CXR and U/A negative, blood cx. pending. He was placed on insulin gtt and received 40mg labetalol with improvement of his BPs and resolution of his chest pain. Initially, was to be sent to ICU, however no beds available. As his sugars improved with insulin gtt and his his AG closed, he is now admitted to the floor after transitioning off insulin gtt since 3AM. He received 6U NPH 2h prior to transfer and was actually hypoglycemic necessitating D50 X 1. His ROS is significant for lack of cough. + CP, but non-exertional, with no radiation and associated with abdominal pain. No shortness of breath, orthopnea, PND, LE edema. No fevers or chills, though currently feels cold. Past Medical History: # Type I DM, Insulin-requiring, x 16 years, currently seen at [**Last Name (un) **] - Diabetic gastroparesis (per patient, has had motility studies at OSH); was on reglan but developed EPS, now on erythromycin - Diabetic neuropathy and retinopathy # History of pancreatitis # HTN # Chronic Kidney Disease Stage IV, recently discovered # Thrombocytopenia NOS (resolving) # Hx of Esophageal ulcer and GIB # Schizophrenia # Depression / Suicidal ideation # CAD with CHF, EF nadir 25%, now improved to 50-55% on last ECHO in [**3-6**]. Social History: Recently relocated from NH to [**Location (un) 86**], where he is living with his brother and brother's wife. Denies current ETOH use; admits to heavy drinking x 1 year about age 27. + Active tobacco use, about 1PPD + Marijuana but no IV drug use. Family History: +DM in sister, brother, father, and mother. Sister: died from diabetic complications Alcoholism in mother and father. Brother diagnosed with schizophrenia. Physical Exam: Vitals: T 97.1, BP 144/80 in R, 148/76 in L. HR 98, RR 16, O2 sat 98% RA General: pale, thin man, shivering under covers, moaning throughout exam. HEENT: PERRL, EOMI, OP clear, poor dentition, MMM CV: RRR, no MRGs, no reproducible chest wall tenderness Chest: CTAB, no wheezes, crackles Abdomen: soft, ND, very mild TTP, to left of umbilicus without rebound or guarding. Extremities: 2+ DPs, no C/C/E Neuro: CN II- XII intact, nl strength, sensation to LT. Pertinent Results: Chest - Two views are compared with the recent bedside study, dated [**2131-3-16**]. There is patchy and somewhat nodular airspace opacity involving the right upper lobe, predominantly its anterior and apical segments, new. The lungs are otherwise clear, with no pleural effusion. The cardiomediastinal silhouette and pulmonary vessels are unchanged. . ECG: NSR with ST elevations ~ 1mm in V1-V3 c/w early repolarization changes in anterior leads, V1 similar to previous, v2-v3, sl. increased from priors. Brief Hospital Course: 38yo type I diabetic with gastroparesis presents with chronic sx. and DKA likely [**12-30**] medication nonadherence. Pt c/o chest pain and found to have significant esophagitis. Then with acute renal failure after cardiac catheterization to further characterize chest pain (no significant CAD). Cr returned towards baseline. Compliance with treatment plan and appointments continues to be challenging and although patient frustrated with his long hospital stay, he does not take active role in his health care. DKA: The patient originally presented with hyperglycemia. No evidence of ketones or acidosis. He did have an anion gap with closed quickly with IVFs and insulin gtt. He was quickly transitioned to SQ insulin. There was no evidence of infection. His blood sugars were difficult to control throughout his hosptital stay in part because he was frequently NPO for proceedures. He was followed by the [**Last Name (un) **] diabetes consult service. He was treated with NPH and a gentle SSI. Discharging him with NPH and a sliding scale was discussed, but the patient noted that he was legally blind and only able to read his Innolet disc and would not be able to draw up syringes. He will f/u with [**Last Name (un) **]. . Hypoglycemia/Hypothermia: after receiving full insulin dose while NPO and undergoing stress test, the patient experienced an episode of hypoglycemia, confusion, diaphoresis, hypothermia to 91.9 and sinus bradycardia. He was transferred briefly to the ICU for monitoring, but once his glucose was corrected, the other issues also resolved shortly thereafter. He was transferred back to the floor the following day. . N/V/abd pain: This was thought secondary to his known gastroparesis and was similar in nature to his prior episodes. He was started on RTC antiemetics and pain control as needed. He was transitioned from IV to PO dilauded. It was difficult to assess his abd pain as it was both LUQ, epigastric and substernal and radiated to the left shoulder. CT abd in the ED showed a thickend esophagus. He was evaluated with an EGD which showed severe esophagitis, gastritis and a soft food bezoar all of which were though to be due to gastroparesis and reflux. His antacid regimen was increased to PPI [**Hospital1 **]. He was also placed on a liquid diet to facilitate the resolution of the bezoar and improve his gastroparesis. H.pylori serology was negative. Pathology showed...Per GI consult recomendation, erythmocyin was stopped as PO erythromycin has no effect on gastroparesis and as IV erythromycin has limited effect due to tachyphylaxis. In addition, there was a concern for risk of prolonged QT when he became bradycardic. . Chest Pain: In the ED, a CT was negative for dissection. He was ruled out by cardiac enzymes. He was seen by cardiology on the floor who felt that given his numerous risk factors he should have a stress test. Given his baseline abnormal EKG a stress MIBI was performed, during which he had chest pain - although he had CP prior,during and after the test as well. At level of exercise achieved (only 37% of age-predicted maximum), there were no myocardial perfusion defects, however, depressed LVEF (38%) and global hypokinesis. He then received a dobutamine echo. The patient received intravenous dobutamine beginning at 15 mcg/kg/min. The blood pressure response to stress was abnormal/mildly hypertensive. Resting images demonstrated regional left ventricular systolic dysfunction with hypokinesis of the posterior wall. At low dose dobutamine [15mcg/kg/min; heart rate 68 bpm, blood pressure 210/100 mmHg), there was global hypokinesis and no reduction of cavity size; however, there was also concerning LV ballooning and inducible ishemia. Because of these results, he was thought to be high cardiac risk and was kept in house for cardic catheterization. The significiant risk of kidney failure and life-long dialysis was discussed prior to cardiac catheterization. The patient decided to undergo the risk with full informed consent. Cardiac catheterization did not demonstrate significant coronary artery disease. He was medically managed with ASA,BB,[**Last Name (un) **], statin and his medication doses were adjusted as indicated. EGD demonstrated signficiant esophagitis and this was thought to be the cause of his chest pain. Given a h/o allergy to lidocaine, he did not receive magic mouthwash and was started on sucralfate. He will f/u with GI. His PPI was changed to ranitidine [**12-30**] ?effect on his acute renal failure. . Anemia: He has a baseline anemia due to CKD. The patient reported that just prior to moving his care to [**Location (un) 86**] that Epo shots had been started where not currently being administered. Two days after EGD his HCT dropped from 32 to 28 to 27. His HCT remained stable at 28 and then rose again. He was guiac negative, but it is most likely that he had some mild GI bleeding. Because of the this HCT drop and because anticoagulants are given during cardiac cath, cardiac cath was defered until his HCT stabilized. Pt was then started on Procrit and will receive weekly injections. . HTN: Uncontrolled while hospitalized, partly because not tolerating all of his PO medications at the begining of his hospital course. His valsartan and BB were uptitrated to achieve better control but valsartan was again decreased [**12-30**] renal failure. His beta-blocker was limited by bradycardia in the ICU and then HR 60-70 on the floor. Clonidine was started and he will take this in patch form. . Acute on chronic renal failure: The creatinine remained at baseline 2-2.4 throughout his hospital course but day after catheterization and after having received adquate hydration, sodium bicarbonate and mucomyst pt's creatinine jumped to peak 3.3. IT weas thought to be secondary to contraste dye versus his PPI has he had high eosinophilia. He was changed back to ranitidine. He was seen by the renal consult team and will see Dr. [**First Name (STitle) 805**] as outpatient. Medications on Admission: Aspirin 81 mg Daily Atorvastatin 10 mg bedtime Valsartan 160 mg Daily Metoprolol Succinate 300 mg once a day Erythromycin 250 mg QIDACHS Ranitidine HCl 75 mg twice a day Amlodipine 10 mg once a day Docusate Sodium 100 mg [**Hospital1 **] prn Senna [**Hospital1 **] prn Ondansetron 4 mg Q8H prn Chromagen Forte (w/Sumalate) once a day Insulin NPH 10 units every morning, 4 units at bedtime Tramadol 50 mg Q6H prn Hydromorphone 2 mg Q4H prn recently course of flagyl for C. Diff. Discharge Medications: 1. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day. 2. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). [**Hospital1 **]:*60 Tablet(s)* Refills:*2* 3. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for abdominal pain. 4. Multivitamin,Tx-Minerals Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. 8. Procrit 10,000 unit/mL Solution Sig: [**Numeric Identifier 961**] ([**Numeric Identifier 961**]) units Injection once a week. [**Numeric Identifier **]:*30 doses* Refills:*2* 9. Sucralfate 1 gram Tablet Sig: One (1) Tablet PO BID (2 times a day). [**Numeric Identifier **]:*60 Tablet(s)* Refills:*2* 10. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). [**Numeric Identifier **]:*30 Tablet(s)* Refills:*2* 11. Valsartan 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). [**Numeric Identifier **]:*30 Tablet(s)* Refills:*2* 12. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QFRI (every Friday). [**Numeric Identifier **]:*12 Patch Weekly(s)* Refills:*2* 13. Clonidine 0.1 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 3 doses: take one tablet twice a day [**4-28**] and then once on [**4-29**] and then clonidine patch will work on its own. [**Month/Day (4) **]:*3 Tablet(s)* Refills:*0* 14. Outpatient Lab Work hct and chem 7 and please fax to [**Telephone/Fax (1) **] attention Dr. [**Last Name (STitle) **] 15. Glucose Meter, [**Last Name (STitle) **] & Strips Kit Sig: One (1) kit Miscellaneous once a day. [**Last Name (STitle) **]:*1 1* Refills:*2* 16. glucometer test strips Please provide glucometer test strips for the patient with 6 refills 17. Novolin 70/30 InnoLet 100 unit/mL (70-30) Insulin Pen Sig: as directed Subcutaneous twice a day: 8 units in the AM 4 units in the PM. [**Last Name (STitle) **]:*QS QS* Refills:*10* 18. Toprol XL 50 mg Tablet Sustained Release 24 hr Sig: Three (3) Tablet Sustained Release 24 hr PO once a day: 150mg daily. [**Last Name (STitle) **]:*90 Tablet Sustained Release 24 hr(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Primary Diagnosis: Type I DM DKA Mild GI bleeding due to gastritis Hypertension Gastroparesis Esophagitis Gastritis Cardiomyopathy Discharge Condition: Stable; improved blood sugar, blood pressure, tolerating POs. Discharge Instructions: You were admitted to the hospital with nausea, vomiting and abdominal pain which was thought to be secondary to your gastroparesis, esophagitis and gastritis. You had biopsies taken of your esophagus and stomach. It is important that you see a gastroenterologist to follow up on these results. We increased your doses of anti-acid medication to treat the esophagitis and gastritis. We gave you nausea medication and pain medication and your symptoms improved but did not completely resolve. You should eat small frequent meals with a low residual diet. It will take some time for your nausea and pain to go away as the gastritis resolves. . You also had chest pain while you were hospitalized. Your blood work and EKG's were normal but because you have risk factors for heart disease a stress test was performed. It showed that you heart has a decreased ability to pump. Cardiac catheterization was negative for significant disease. . You had acute kidney failure and were seen by the kidney specialists. This was thought to be secondary to medication effect (pantoprazole) and possibly the cardiac catheterization dye. . Some medication changes were made to better control you blood sugar, blood pressure and cardiac risk factors. You should stop taking Erythromycin. Please follow the medications as directed. . Please have the VNA draw a lab to check your creatinine next week. You do not need to go to the lab unless the VNA is unable to draw them. . PLEASE MAKE ALL APPOINTMENTS SCHEDULED FOR YOU. You have many medical appointments to follow but if you do not keep these appointments you will likely end up back in the hospital. Your health is very important and is a full time job and we will help you coordinate your care. . Please return to the ER for inability to keep food down, chest pain, shortness of breath, fevers, chills, or high blood sugars. If you have blood in your stool or vomit, you should return to the emergency room. Followup Instructions: Dr. [**First Name (STitle) 805**] (renal). ([**Telephone/Fax (1) 817**]. They will need to contact you or you contact them. [**Name2 (NI) **] should see him next week. . Urology: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4653**], MD Phone:[**Telephone/Fax (1) 274**] Date/Time:[**2131-4-30**] 4:10 . *Provider: [**Name10 (NameIs) **] [**Name11 (NameIs) 2489**], [**Name12 (NameIs) **] [**Hospital 982**] Clinic ([**Telephone/Fax (1) 17484**] [**2131-5-2**] (wednesday) at 11am . Provider: [**Name10 (NameIs) **] [**Last Name (STitle) 2473**], Gastroenterology ([**Telephone/Fax (1) 2233**] [**2131-5-1**] 4:00pm [**Hospital Ward Name 516**], [**Hospital Unit Name 1825**] . Primary Care Provider: (Dr. [**Last Name (STitle) **] [**Name (STitle) 77325**] schedule currently not available) Dr. [**Last Name (STitle) **], primary care, [**Hospital Ward Name **], [**Hospital Ward Name **] building [**Location (un) **], thursday [**5-3**] at 2:30pm ([**Telephone/Fax (1) 250**]) . Provider: [**Last Name (NamePattern4) **]. [**Last Name (STitle) **], cardiology ([**Telephone/Fax (1) 7437**] [**2131-5-21**] 8:00am [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]

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icd9cm

[ [ [] ] ]

[ "89.44", "45.16", "88.56", "38.93", "37.22" ]

icd9pcs

[ [ [] ] ]

13031, 13089

4162, 10165

331, 396

13264, 13328

3630, 4139

15324, 16582

2981, 3138

10694, 13008

13110, 13110

10191, 10671

13352, 15301

3153, 3611

248, 293

424, 2144

13129, 13243

2166, 2699

2715, 2965

55,557

127,303

36363

Discharge summary

report

Admission Date: [**2120-7-6**] Discharge Date: [**2120-7-13**] Date of Birth: [**2053-12-6**] Sex: F Service: MEDICINE Allergies: Penicillins / Clindamycin / Levaquin / Aspirin Attending:[**First Name3 (LF) 1377**] Chief Complaint: Hypoxia Major Surgical or Invasive Procedure: expired History of Present Illness: Information obtained from OMR, with limited past medical history. The patient is a 66 year old female with a history of alcoholic cirrhosis, hypothyroidism, CKD (unknown baseline) who was admitted directly to the floor the evening prior to transfer for evaluation of her worsening ESLD. The patient was first diagnosed with ETOH cirrhosis [**4-22**] with new-onset, acute jaundice. She was hospitalized in [**Hospital3 **], with complete resolution. Per OMR, the patient has had a persisent decline over the last 3 months, with worsening ecephalopathy and lower extremity swelling. The patinet was reportdly admitted on [**6-25**] with acute exacerbation of her encephalothy, and a thoracenteiss was performed. It seems the patient's husband had been been told that pt had essentially 4-6months to live. The patient's family were set to bed see the hepatology team in the outpatient setting, and for unclear reasons was directly admitted to the floor. On admission, the patient was 95% on 4L. With hypoxia and elevated WBC, the patient had a CXR which showed complete white out of the left lung. A CT was obtained, showing a large left pleural effusion with left lobe collapse. The patient had worsening oxygen requirment over the course of the evening, dropping O2 sats to 84% on 4L. She was put on a NRB, with improvement of O2 stats to 93%, but continued tachypnea in the 30s. An ABG was obtained, showing a pH of 7.5/25/60. The patient was transfered to the MICU for closer monitoring with concern of potential respiratory difficulties. Past Medical History: ETOH cirrhosis/ESLD-dx 3/08 per report. Ascites since [**4-22**], ?varices, encephalopathy. CRI hypothyroidism pleural effusions gastritis Social History: Lived at [**Hospital 4979**] rehab. According to Husband last drink was [**2120-4-18**]. Up until then states they both drank 2 [**Location (un) 82415**] nightly. Quit smoking 25 yrs ago, denies drug use. Family History: NC Physical Exam: VS:T 98.9 BP 88/52 HR 87, RR 30, sat 94% on NRB GENERAL: NAD, intermittent moaning. Somnolent. No sensical answering to questions. HEENT: nc/at, +icterus, MMM, no op lesions CARDIAC: RR. Normal S1, S2. No m/r/g. LUNGS: CTA B anterior exam. Decreased BS at bases. ABDOMEN: NABS. softly distended, +fluid wave/+ascites, no guarding or rebound, non-tender. EXTREMITIES: No c/c/3+edema to abdomen, 2+ dorsalis pedis/ posterior tibial pulses. legs painful to touch. NEURO: AAOX1 (name/place =hospital), +asterixis, able to follow commands. Pertinent Results: [**2120-7-10**] 09:09AM BLOOD Hct-28.4* [**2120-7-10**] 04:05AM BLOOD WBC-12.1* RBC-2.58* Hgb-8.9* Hct-26.9* MCV-104* MCH-34.6* MCHC-33.2 RDW-14.7 Plt Ct-153 [**2120-7-9**] 04:13AM BLOOD WBC-9.8 RBC-2.72* Hgb-9.2* Hct-27.9* MCV-103* MCH-33.9* MCHC-33.1 RDW-14.5 Plt Ct-125* [**2120-7-8**] 03:16AM BLOOD WBC-12.3* RBC-2.84* Hgb-9.8* Hct-29.3* MCV-103* MCH-34.5* MCHC-33.5 RDW-14.9 Plt Ct-126* [**2120-7-7**] 01:11AM BLOOD WBC-11.8* RBC-3.21* Hgb-10.9* Hct-32.8* MCV-102* MCH-34.1* MCHC-33.3 RDW-14.8 Plt Ct-141* [**2120-7-7**] 01:11AM BLOOD PT-24.1* PTT-39.9* INR(PT)-2.3* [**2120-7-7**] 01:11AM BLOOD Fibrino-100* [**2120-7-10**] 04:05AM BLOOD Glucose-130* UreaN-36* Creat-3.2* Na-141 K-6.6* Cl-110* HCO3-17* AnGap-21* [**2120-7-9**] 03:35PM BLOOD Glucose-148* UreaN-36* Creat-2.7* Na-141 K-4.3 Cl-109* HCO3-15* AnGap-21* [**2120-7-9**] 04:13AM BLOOD Glucose-114* UreaN-37* Creat-2.5* Na-140 K-4.5 Cl-108 HCO3-16* AnGap-21* [**2120-7-8**] 03:16AM BLOOD Glucose-102 UreaN-41* Creat-2.8* Na-139 K-5.0 Cl-106 HCO3-19* AnGap-19 [**2120-7-7**] 01:11AM BLOOD Glucose-100 UreaN-42* Creat-3.0* Na-134 K-5.7* Cl-102 HCO3-17* AnGap-21* [**2120-7-7**] 01:11AM BLOOD calTIBC-95* Ferritn-531* TRF-73* [**2120-7-7**] 01:11AM BLOOD TSH-36* [**2120-7-7**] 01:11AM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE HBcAb-NEGATIVE [**2120-7-7**] 03:15AM BLOOD AMA-NEGATIVE Smooth-POSITIVE [**2120-7-7**] 01:11AM BLOOD HCV Ab-NEGATIVE [**2120-7-7**] 08:08AM BLOOD Type-ART FiO2-90 O2 Flow-4 pO2-60* pCO2-25* pH-7.50* calTCO2-20* Base XS--1 AADO2-559 REQ O2-92 Intubat-NOT INTUBA Comment-NC [**2120-7-7**] 08:08AM BLOOD Glucose-113* Lactate-1.4 Na-132* K-4.8 Cl-103 [**2120-7-7**] 08:47PM ASCITES WBC-300* RBC-1700* Polys-26* Lymphs-6* Monos-0 Plasma-1* Mesothe-33* Macroph-34* [**2120-7-7**] 06:27PM PLEURAL TotProt-2.0 Glucose-122 LD(LDH)-64 Amylase-23 Albumin-1.2 [**2120-7-7**] 06:27PM PLEURAL WBC-122* RBC-[**Numeric Identifier 2596**]* Polys-50* Lymphs-17* Monos-27* Meso-6* [**2120-7-7**] 08:47PM ASCITES TotPro-1.6 Glucose-115 LD(LDH)-62 Amylase-18 Albumin-<1.0. Abd U/S: 1. Cirrhotic liver. Doppler evaluation of the intrahepatic vessels could not be performed due to rapid respiratory rate. 2. Large volume ascites. Suitable spot for paracentesis to be performed by the clinical team marked in the right lower quadrant. 3. Cholelithiasis. Minimal gallbladder wall thickening likely related to ascites. . CT chest IMPRESSION: 1. Severe degree of left pleural effusion which causes complete collapse of the left lung. 2. Ground-glass opacities within the apical and posterior segment of the right upper lobe and nodules within the superior segment of the right lower lobe. The differential diagnoses include infectious and inflammatory etiologies. 3. Moderate degree of ascites and cirrhosis. CXR:IMPRESSION: 1. Likely redistribution of large layering left pleural effusion, possibly increased since previous exam. 2. Improved right lung aeration Brief Hospital Course: This is a 66 year old female with a history of alcoholic hepatitis, ascites, encephalopathy and recurrent pleural effusion presenting for evaluation for liver evaluation, transfered to the MICU for worsening hypoxia who eventually was made CMO. . # Hypoxia: Most likely from large pleural effusion with left lobe collapse. Currently hemodynamically stable on NRB. Continue to monitor respiratory status closely, with low threshold to intubate if evidence of tiring. Recent ABG [**Last Name (un) 22975**] adequate ventilation/oxygenation. No evidence of pneumonia on Chest CT. Emergent thoracenteisis after 2 units of FFP, send for complete panel of studies, left sided effusion unexpected for hepatohydrothorax, look for alternative causes, Given rapid rate of reocculusion will need to discuss long-term manegment with IP, although suspect that not candiate for pleurocath or pleurodesis. . # ESLD: Patient with marked encephalopathy and ascites. Sent for evaluation of possible liver transplant. Will consult hepatology team. Adominal u/s w/ doppler, will have them mark for para, diagnostic para w/ SAAG protein, cell cout, C + S, and cytology, Will check AFP, anti-sm, mitochondrial, and [**Doctor First Name **], HCV and hbv, Fe stodies, continue rifaximin + lactulose, likely not canidate for orthodomic liver transplant given recent drinking, given encephalopathy, not a canidate for TIPS, will hold percocet, tylenol, and ativan given encephalopathy. Eventually given her serious condition and not candidate for transplant, family meeting was held and decision was made to make patient CMO. She was put on a morphine drip and titrated to comfort. . # Leukocytosis: No clear source of infection. Patient has been afebrile. Had received broad spectrum on admission. Repeat CXR after [**Female First Name (un) 576**] to see if hidden PNA, para to look for SBP, and will send UA. Will hold off on further abx. . # Renal failure: will need to clarify baseline, renally dose all mes. . # Hypothyroidism: markedly hypothyroid, unclear if taking sythroid. If so, will need to increase dose. . # FEN: No IVF, replete electrolytes, NPO, Prophylaxis: Subcutaneous heparin, scd's, Access: peripherals, Code: FULL CODE but transisitoned to CMO, Communication: Patients husband, HCP, patient expired on [**2120-7-13**]. Medications on Admission: acetaminophen folic acid 1mg daily lactulose 30ML q12 hr Mag Ox 400mg daily oxycodone IR 5-10mg q6hr prn pain prilosec 20mg [**Hospital1 **] vit B1 100mg daily rifaximin 400mg TID levothyroxine 0.125mg daily compazine 10mg po Q6h lasix 20mg po qM/W/F spironolactone 25mg po BID s/p Vit K ativan 0.5mg q4h prn trazadone 25mg po Q6h anxiety Discharge Medications: expired Discharge Disposition: Expired Discharge Diagnosis: expired Discharge Condition: expired Discharge Instructions: expired Followup Instructions: expired [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(1) 1379**] Completed by:[**2120-7-14**]

[ "789.59", "585.9", "571.2", "348.39", "427.1", "511.89", "571.1", "782.4", "799.02", "288.60", "511.9", "338.4", "572.8", "303.90", "244.9", "799.4", "518.81", "300.00" ]

icd9cm

[ [ [] ] ]

[ "54.91", "34.91" ]

icd9pcs

[ [ [] ] ]

8580, 8589

5830, 8159

314, 323

8640, 8649

2883, 5807

8705, 8865

2308, 2312

8548, 8557

8610, 8619

8185, 8525

8673, 8682

2327, 2864

267, 276

351, 1908

1930, 2070

2086, 2292

60,115

108,052

34971

Discharge summary

report

Admission Date: [**2108-12-25**] Discharge Date: [**2109-1-31**] Date of Birth: [**2041-10-16**] Sex: F Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 165**] Chief Complaint: fever/hypotension/sepsis/respiratory failure Major Surgical or Invasive Procedure: Redo sternotomy, Redo aortic root replacement(19mm homograft), Mitral valve repair. [**2109-1-3**] History of Present Illness: Ms. [**Known lastname **] is a 67year old white female s/p aortic valve replacement in [**2104**] who presented 3 days ago with fever, myalgia, arthralgia and sore throat. She started feeling unwell 10 days previously with dyspnea, back pain and intermittent fevers. She went to her primary care who obtained a CXR (which was reportedly normal) and sent her to [**Hospital **] Hospital where she was admitted. There she developed hypotension to the 70's/30s. Vancomycin and Ceftriaxone were started. She had increasing O2 demand in the setting of an initially normal CXR, with repeat CXR showing white out. She was transferred to the ICU and intubated and sedated. Levophed was started. Her temperature rose to 103F. Blood cultures showed [**3-6**] gram positive cocci in chains. She was transferred here for further management. On arrival to the MICU, she was intubated and sedated. Cardiac surgery was consulted for surgical correction of bacterial endocarditis. Past Medical History: Hypercholesterolemia Hypertension s/p Aortic valve replacement/asc aorta replacement on [**2105-9-23**] h/o Pancreatitis cataract anxiety depression s/p C-section Social History: unemployed quit smoking 5 years ago, [**12-5**] ppd x 25 years occasional ETOH lives alone no IVDU Family History: noncontributory Physical Exam: ADMISSION EXAM T 102.7, HR 61, BP 129/54, POx 100% A/C TV 380, PEEP 12, Rate 20, FiO2 60% General: intubated, sedated HEENT: Sclera anicteric, MM dry, PERRL Neck: supple, JVP not elevated, no LAD CV: tachycardic, [**3-8**] ejection murmur best heard at RUSB Lungs: intubated, junky breath sounds in b/l A/L fields Abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly GU: foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema. No evidence of [**Last Name (un) **] lesions, splinter hemorrhages, or osler nodes. Neuro: PERRL, not moving extremities sensation Pertinent Results: ADMISSION LABS [**2108-12-25**] 07:28PM BLOOD WBC-14.9*# RBC-3.40* Hgb-10.0* Hct-30.3* MCV-89 MCH-29.4 MCHC-33.1 RDW-14.3 Plt Ct-274# [**2108-12-25**] 07:28PM BLOOD Neuts-86.2* Lymphs-9.8* Monos-3.8 Eos-0.2 Baso-0.1 [**2108-12-25**] 07:28PM BLOOD PT-15.5* PTT-28.4 INR(PT)-1.5* [**2108-12-25**] 07:28PM BLOOD Fibrino-595* [**2108-12-25**] 07:28PM BLOOD Glucose-148* UreaN-11 Creat-0.5 Na-133 K-4.7 Cl-106 HCO3-21* AnGap-11 [**2108-12-26**] 03:41AM BLOOD ALT-29 AST-17 LD(LDH)-281* AlkPhos-47 TotBili-0.7 [**2108-12-25**] 07:28PM BLOOD CK-MB-2 cTropnT-<0.01 proBNP-7957* [**2108-12-26**] 09:01PM BLOOD CK-MB-3 cTropnT-<0.01 [**2108-12-27**] 03:15AM BLOOD CK-MB-2 cTropnT-<0.01 [**2108-12-25**] 07:28PM BLOOD Calcium-7.4* Phos-2.1* Mg-2.5 MICRO DATA [**2108-12-29**] BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT [**2108-12-29**] BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT [**2108-12-28**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY CULTURE-FINAL INPATIENT [**2108-12-28**] BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT [**2108-12-27**] BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT [**2108-12-27**] BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT [**2108-12-26**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY CULTURE-FINAL INPATIENT [**2108-12-26**] BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT [**2108-12-26**] CATHETER TIP-IV WOUND CULTURE-FINAL INPATIENT [**2108-12-26**] URINE URINE CULTURE-FINAL INPATIENT [**2108-12-25**] BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT [**2108-12-25**] BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT [[**2108-12-23**] Isolate from [**Hospital **] Hospital for MIC-PRELIMINARY {STAPHYLOCOCCUS LUGDUNENSIS, STAPHYLOCOCCUS, COAGULASE NEGATIVE} IMAGING: CXR [**2108-12-25**] As compared to the previous radiograph, there is no relevant change. Right internal jugular vein catheter that shows a normal course, the tip of the catheter projects over the mid SVC. The patient has an endotracheal tube, the tip of the tube projects approximately 2.2 cm above the carina, the tube could be pulled back by approximately 1-2 cm. A nasogastric tube has been placed. The course of the tube is unremarkable, the tip of the tube is not included in the image. No other monitoring and support devices. Unremarkable alignment of sternal wires after cardiac surgery. In unchanged manner, the lung displays extensive bilateral apical parenchymal opacities of reticular appearance. An additional alveolar component could also be present, given the presence of multiple air bronchograms. Extensive retrocardiac atelectasis, small left pleural effusion. No newly appeared focal parenchymal opacities. No pneumothorax. [**2108-12-26**] TEE Moderately thickened and stenotic prosthetic aortic valve with probable vegetation. Cannot exclude aortic root abscess. Mild mitral regurgitation. Hyperdynamic left ventricular systolic function. Compared with the prior study dated [**2105-9-23**] (images reviewed)- The aortic bioprosthesis is now stenotic with a mass concerning for vegetation. The thickening around the aortic homograft is similar in size, but the echolucency is new. [**2108-12-28**] TEE Aortic prosthesis and mitral (native) valve vegetations/enodcarditis with aortic root abscess as described above. Mild mitral regurgitation. Compared with the prior study (images reviewed) of [**2108-12-26**] a vegetation is now seen on the mitral valve. [**2109-1-1**] CT head with con: Enhancing 2 mm focus in the right frontal lobe may be a prominent vessel, but in this clinical setting, is concerning for a small septic embolus or septic aneurysm. Would recommend an MRI with and without contrast for further evaluation if clinically indicated. [**2109-1-1**] CT C/A/P with con: No focal fluid collections within the chest, abdomen or pelvis to suggest focal abscess. Scattered mediastinal lymph nodes, though none pathologically enlarged. No mediastinal hematoma or fluid collection. Multiple stable subcentimeter subpleural pulmonary nodules, unchanged since prior chest CT from [**2104**]. Given the stability over several years, no further followup is necessary. Bilateral pleural effusions and diffuse ground-glass opacities, findings consistent with diffuse pulmonary edema. An asymmetric opacity in the right upper lobe may reflect asymmetric edema, though superimposed infection is also within the differential. Multiple bilateral renal hypodensities that are too small to characterize, though most likely represent simple cysts. [**2109-1-1**] MRI T spine: Multiple focal areas of high signal intensity throughout the vertebral bodies, likely consistent with non-expansile hemangiomas, some of them atypical with persistent high signal on the STIR sequence. Degenerative changes are identified at the T8/T9 and T9/T10 levels with no evidence of neural foraminal narrowing or spinal cord compression. There is no evidence of abnormal enhancement to indicate leptomeningeal disease or epidural abscess. There is no evidence of findings suggesting osteomyelitis. [**2109-1-1**] MRI L spine: Heterogeneous signal is noted in the bone marrow with multiple rounded areas of hyperintensity on T2- and T1-weighted sequences, likely consistent with non-expansile hemangioma with atypical high signal on the STIR at the level of L1. If there is any clinical concern related with this findings, correlation with bone scan is recommended if clinically warranted. There is no evidence of epidural abscess, fluid collections or findings suggesting osteomyelitis. Mild disc degenerative changes at L2-L3, L3/L4 and L4/L5 with no evidence of neural foraminal narrowing or spinal canal stenosis. [**2109-1-1**] TTE: Abnormal aortic valve bioprosthesis with thickened leaflets and high transvalvular gradients. Aortic root abscess. Moderate mitral regurgitation. Hyperdynamic left ventricular systolic function. Moderate pulmonary hypertension. No definite vegetations seen. [**2109-1-2**] MRI HEAD: A small enhancing focus in the right parietal lobe. This shows no slow diffusion. This likely represents a possible subacute embolic infarct. Metastasis is another differential though is less likely as patient has no known primary. Few chronic microhemorrhages in bilateral frontal lobes. A small extra-axial enhancing lesion along the right frontal convexity which likely represents a meningioma. No evidence of stenosis, occlusion or aneurysm in arteries of head Brief Hospital Course: She was initially covered with vancomycin and Ceftriaxone but per ID this was changed to Vancomycin and gentamicin when blood cultures fromNorwood grew coagulase negative staphlococcus. Speciation showed Staph lugdunensis sensitive to Nafcillin/Gent/Rifampin so she was switched to these. Aortic vegetation was noted on echo and repeat TEE showed new mitral veg as well as aortic root abscess. She was transferred to the Cardiology Service where she remained hemodynamically stable and her EKG did not show any conduction abnormalities. She underwent extensive work up prior to cardiac Ssrgery to rule out other involvement of the endocarditis. Neurology was consulted and recommended MRA/MRI and continuing to avoid anti-coagulation. A MRI was obtained and indicated possible subacute embolic infarct. Discussion between Infectious Disease, Cardiac Surgery and Cardiology was done and the decision was made to pursue surgery sooner rather than later as benefits outweighed the risks. She was taken to the Operating Room on [**2109-1-3**] and underwent redo sternotomy,redo aortic root replacement with a size 19 homograft and mitral valve repair by Dr.[**First Name (STitle) **]. Cardiopulmonary Bypass Time= 241 minutes. Cross Clamp Time= 213 minutes. Please refer to the operative note for further surgical details. She tolerated the procedure well and was transferred to the CVICU intubated and sedated requiring pressor support. She awoke neurologically intact and on POD#1 she weaned to extubation without incident. ID continued to follow postoperatively for antibiotic recs regarding her bacterial endocarditis. She weaned off pressor support and was placed on beta-blocker, aspirin,and aggressively diuresed. All lines and tubes were discontinued per protocol. Post op confusion was evident. Neurology continued to follow postoperatively due to the subacute embolic infarct seen on MRI preop. Narcotics were minimized and her mental status improved. Hemodynamically she remained stable with a transient postoperative episode of NSVT v. atrial fibrillation with abberancy. She tolerated beta-blocker well. Pacing wires were removed per protocol. On [**2109-1-5**] she complained of right upper quadrant discomfort. LFTs showed an elevated total bilirubin. Ultrasound was done and revealed minimally distended gallbladder with sludge. No gallstones or signs of acute cholecystitis. Nephrology was consulted for postop renal failure (baseline creatinine 0.4->3.7). Antibiotics were adjusted and her renal function closely monitored and slowly stabilized and fell. She transferred to the step down unit for further monitoring and recovery. Physical Therapy was consulted for evaluation of strength and mobility. On [**1-9**] she acutely decompensated with severe hypotension, respiratory distress and required intubation, a PA catheter and pressors. Emergent TEE showed moderate mitral regurgitation, fasirtly preserved LV function and the CXR demonstrated pulmonary edema. She was stabliized over several days, diuresed and her renal function improved. Tube feeding were given and she awakened. The CXR progressed to one of ARDS, but she improved, weaned from high PEEP requirements and was eventually extubated on [**1-24**]. Bilateral chest drainages were performed and no souce of sepsis located. Nafcillin and Rifampin were continued. She was again encephalopathic, but cleared with some intermittent confusion. Video swallow cleared her for soft solids and thick liquids. She was below her preop weight, without evidence of fluid overload so diuresis was stopped, but may be required in the future. At discharge wounds were clean and healing, she was beginning to ambulate with a lot of help and oriented mostly.Follow up appointments were given as appropriate. She was transferred to [**Hospital3 105**] Northeast in [**Location (un) 1110**] for further recovery prior to returning home. Medications on Admission: - Diovan 160mg PO BID - ASA 81mg PO daily - Fish oil 1200mg PO daily - furosemide 20mg PO daily Discharge Medications: 1. bisacodyl 5 mg Tablet Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for Constipation. 2. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for Constipation. 3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. rifampin 300 mg Capsule Sig: One (1) Capsule PO Q8H (every 8 hours) for 14 days. 5. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 6. ipratropium-albuterol 18-103 mcg/actuation Aerosol Sig: [**5-10**] Puffs Inhalation Q6H (every 6 hours) as needed for wheeze. 7. heparin (porcine) 5,000 unit/mL Solution Sig: 5000 (5000) units Injection TID (3 times a day): until fully mobile. 8. amiodarone 200 mg Tablet Sig: as directed Tablet PO BID (2 times a day): 400mg(two tablets) twice daily for two weeks, then 200mg(one tablets) twice daily for two weeks, then 200mg(one tablet) daily until instructed otherwise,. 9. metoprolol tartrate 100 mg Tablet Sig: One (1) Tablet PO three times a day. 10. insulin lispro 100 unit/mL Solution Sig: per scale Subcutaneous ac & hs: 120-160:2units sc ac,none HS;161-200:4units ac, 2units HS; 201-240:6units ac,4units HS,241-280:8units ac, 6units HS. 11. olanzapine 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 12. acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for fever or pain for 4 weeks. 13. nafcillin in D2.4W 2 gram/100 mL Piggyback Sig: Two (2) gms Intravenous Q4H (every 4 hours) for 14 days. 14. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours) for 2 weeks. 15. heparin, porcine (PF) 10 unit/mL Syringe Sig: Two (2) ML Intravenous once a day as needed for line flush. Discharge Disposition: Extended Care Facility: [**Hospital3 105**] Northeast - [**Location (un) 1110**] Discharge Diagnosis: -s/p Redo sternotomy/ Redo aortic root replacement with a size 19 homograft/Mitral valve repair secondary to bacterial endocarditis- Secondary: HTN, HL, and bicuspid aortic valve with stenosis s/p aortic valve replacement in [**2104**] who now presents with bacterial endocarditis with vegetations on her aortic prosthesis, native mitral valve as well as aortic root abscess. - Discharge Condition: Alert and oriented x3 mostly, nonfocal Ambulating with unsteady gait with assistance Incisional pain managed with oral analgesics Incisions: Sternal - healing well, no erythema or drainage Edema- trace Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] Females: Please wear bra to reduce pulling on incision, avoid rubbing on lower edge **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Followup Instructions: You are scheduled for the following appointments: Surgeon: Dr. [**First Name (STitle) **] ([**Telephone/Fax (1) 170**]) on [**2109-2-26**] at 1:15pm Infectious Disease at [**Hospital1 18**]: Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] ([**Telephone/Fax (1) 457**]) on [**2109-2-11**] at 10am [**Hospital 6752**] medical Office basement Cardiologist:ask your primary care doctor for a referral Please call to schedule appointments with: Primary Care: Dr.[**Last Name (STitle) 79992**] [**Name (STitle) 17385**] ([**Telephone/Fax (1) 41459**]in [**12-3**] 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** Weekly CBC w/diff,LFTs,BUN/creat. Fax results to [**Numeric Identifier 79993**]. Call ID nurses w/antibiotic questions-[**Telephone/Fax (1) 79994**] [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**] Completed by:[**2109-1-31**]

[ "276.8", "996.61", "V13.65", "427.31", "E878.2", "995.92", "112.0", "424.0", "038.11", "421.0", "578.1", "276.4", "434.11", "576.8", "276.1", "348.39", "511.9", "518.81", "286.9", "785.52", "584.9" ]

icd9cm

[ [ [] ] ]

[ "96.72", "35.21", "38.45", "33.24", "35.12", "88.72", "39.61", "34.91", "96.6" ]

icd9pcs

[ [ [] ] ]

14745, 14828

8900, 12827

356, 457

15251, 15456

2430, 8877

16380, 17393

1773, 1790

12974, 14722

14849, 15230

12853, 12951

15480, 16357

1805, 2411

272, 318

485, 1453

1475, 1640

1656, 1757

12,467

118,672

9358

Discharge summary

report

Admission Date: [**2191-5-19**] Discharge Date: [**2191-5-24**] Date of Birth: [**2135-1-10**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 6180**] Chief Complaint: hypotension Major Surgical or Invasive Procedure: femoral line placement History of Present Illness: 56 yo man with HCV cirrhosis and metastatic hepatocellular carcinoma who has been receiving cisplatin for his hepatoma; this was last dosed on [**5-9**]. On [**5-17**] he developed fevers and weakness; he denied focal symptoms but felt generalized "bony pain." He denied abdominal pain or increased increased girth. He did have poor po intake over the last several days prior to admission. He also had been having loose stools, likely due to ongoing treatment iwth lactulose. He denied chest pain, dyspnea, cough, or dysuria, but had noticed decreased urine output over the last several days prior to admission. . He presented to an OSH [**5-19**] where he was found to be hypotensive (78/52). He was given a 250 cc bolus, ceftriaxone, levofloxacin, and was sent here for further evaluation. Of note. labs at the OSH showed wbc 1.3, hct 15.5, plts 16, INR 2.5, TB 24.7, Na 126, K 5, Cl 97, HCO3 17, BUN 68, Cr 2.4. . In the ED here, the patient was hypothermic and hypotensive. He received two liters IV fluids, a femoral line was placed (low plts and INR >3), bear hugger was placed, and he was given cefepime. Levophed was started. CBC showed pancytopenia. He was found to be guaiac positive (noteworthy given upper GI bleed s/p banding of esophageal varices [**3-1**]). . He was admitted to the ICU where vancomycin and metronidazole were added to cefepime. He was transfused four units of pRBC and four units of FFP, and platelets. IV fluids were continued. . Given his poor prognosis, a family meeting was held [**5-20**], wherein the patient's code status was changed to DNR/DNI. The primary focus of care at this point is the patient's comfort. Past Medical History: 1. HCV cirrhosis 2. hepatocellular carcinoma with bony metastases 3. esophageal varices s/p UGI bleed, banded [**3-1**] 4. gastric varices Social History: Patient has been living with his wife. [**Name (NI) **] has a remote history of alcohol, tobacco, and IV drug use. Family History: Sister with ovarian cancer. Physical Exam: Temp-96.9 BP-119/50 HR-92 RR-18 SpO2-94% 4L nc Gen: Pleasant, confused, obese HEENT: Icteric sclerae, moist mucosae CV: RRR, flow murmur RUSB, no r/g, normal S1 and S2 Pulm: CTA with wheezing anteriorly Abd: Significantly distended, soft, non-tender, active bowel sounds Ext: Pneumoboots in place, warm, 1+ pitting edema bilaterally Neuro: Confused, intermittently answering questions appropriately Pertinent Results: WBC-0.9 (N-64 L-32 M-2 B-2 NUC RBCS-6) Hct-22.1 MCV-86 Plt-33 ANC-480 Na-126 K-4.4 Cl-97 Bicarb-17 BUN-61 Cr-1.5 Glu-210 ALT-48 AST-82 LDH-279 Alk Phos-133 TBili-26.4 (D-18.0 I-8.4) [**Doctor First Name **]-40 Lip-56 Alb-2.1 Ca-9.4 Mg-2.0 Phos-3.5 NH4-18 Haptoglob-<20 PT-17.9 PTT-39.6 INR-2.1 Lactate-6.3 Cortisol: 39.7, 37.5, 39.4, 40.8 Urine: small blood, ketone 15, large bilirubin, urobilinogen 1, RBC-0-2,WBC-0-2, moderate bacteria Urine Na-10 Cl-122 Blood Cx: pending x1 set Urine Cx: no growth CXR: patchy bibasilar opacities (pneumonia vs. atelectasis vs. aspiration) RUQ U/S: cirrhosis, ascites, liver mass Brief Hospital Course: 56 yo man with end-stage HCV cirrhosis and hepatocellular carcinoma now being transferred from the ICU to the floor for probable transition to comfort as the primary goal of care. 1. Hepatocellular Carcinoma: Admission labs consistent with progressive hepatic dysfunction that is irreversible. Per a conversation between the patient, his family, and his oncologist earlier today, the patient's life expectancy was estimated at likely less than one week. - The patient was given pain medications as needed, but did not require any during his stay on the medical oncology floor. He was given Ativan X2 for anxiety, which sedated him for several hours. This was subsequently discontinued and his mental status cleared. - Supportive care was continued, including gentle hydration with IVF and lactulose to minimize encephalopathy. - The pt is DNR/DNI. This was clarified with the family several times. He was not CMO status. The family requested antibiotics, IVF, Tums, PPI, etc. They requested no transfusions, no blood draws. His fingersticks were discontinued and SSI was d/c'd as well. . 2. Sepsis: Etiology unclear, but given extremely poor prognosis as noted above, no role for further work-up of fever source. Undetectable haptoglobin suggests DIC, which is consistent with septic picture. - Empiric antibiotics were continued. He lost and gained IV access several times. When IV access was available, he was on IV Vancomycin and Cefepime. When he pulled out his IVs, he was switched to oral Levofloxacin and Metronidazole. IV access with this pt was difficult. - Steroids were continued given lack of response to cosyntropin stimulation test. - He remained afebrile, with his white count, Hct, and platelets trending up before blood draws were discontinued. . 3. GI Bleeding: Likely from esophageal or gastric varices, exacerbated by severe coagulopathy. - He received one more unit pRBC while on the floor. - After this the family requested transfusions and blood draws be stopped to maximze pt comfort. . 4. Pancytopenia: Likely from chemotherapy. Anemia also exacerbated by GI bleeding and hemolysis. - One additional unit of pRBC was given [**2191-5-19**] as above. - Empiric antibiotics as above were given for neutropenia and sepsis. - Transfusions were stopped per family request as above. . 5. Renal Failure: Likely due to pre-renal azotemia. - The pt was gently hydrated with normal saline to minimize sense of thirst. - We avoided excessive hydration given significant ascites. . 6. Hyponatremia: Resolved with hydration. - Pt received gentle hydration with 50cc/hour NS as above. . 7. Access: Had Peripheral IV x1 (second IV if possible, no central line). Pulled at IV in the evening before discharge, so all meds were switched to po since he was tolerating po. . 8. F/E/N: Regular diet. - All lab checks were stopped. - All fingersticks and RISS were stopped to maximize comfort. . 9. Communication: Family at bedside. - Wife [**Name (NI) **]: [**Telephone/Fax (1) 31962**] or [**Telephone/Fax (1) 31963**] - Son [**Name (NI) **]: [**Telephone/Fax (1) 31964**] . 10. Code: DNR/DNI . 11. Dispo: Family agreed on hospice care at Braemor in [**Hospital1 1474**], MA. Pt to be discharged on [**5-24**] in stable condition. Discharge Medications: 1. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO TID (3 times a day). Disp:*2700 ML(s)* Refills:*2* 2. Morphine 10 mg/5 mL Solution Sig: [**11-28**] PO Q1-2H () as needed for pain, respiratory distress. Disp:*1 bottle* Refills:*2* 3. Sertraline 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 4. 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* 5. Levaquin 500 mg Tablet Sig: One (1) Tablet PO once a day for 7 days. Disp:*7 Tablet(s)* Refills:*0* 6. Flagyl 500 mg Tablet Sig: One (1) Tablet PO three times a day for 7 days. Disp:*21 Tablet(s)* Refills:*0* 7. Fludrocortisone Acetate 0.1 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). Disp:*15 Tablet(s)* Refills:*2* 8. Anzemet 50 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for nausea. Disp:*120 Tablet(s)* Refills:*2* Discharge Disposition: Extended Care Facility: [**Hospital 2971**] Rehabilitation and Nursing Center - [**Hospital1 1474**] Discharge Diagnosis: 1. sepsis 2. pancytopenia secondary to metastases from Hepatocellular carcinoma 3. metastatic hepatocellular carcinoma 4. Hepatitis C 5. Cirrhosis of the liver 6. Grade II/III esophageal varices s/p variceal banding Discharge Condition: Stable condition to hospice Discharge Instructions: 1. Please follow-up with your oncologist, Dr. [**First Name (STitle) **] as directed below 2. Please take all prescribed medications as directed. Followup Instructions: Follow up with your oncologist, Dr. [**First Name (STitle) **] at ([**Telephone/Fax (1) 10261**] as directed below: 1> [**First Name11 (Name Pattern1) 396**] [**Last Name (NamePattern4) 397**], MD Where: [**Hospital6 29**] HEMATOLOGY/ONCOLOGY Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2191-6-6**] 11:30 2> [**Last Name (LF) 5558**],[**First Name3 (LF) 5557**] HEMATOLOGY/ONCOLOGY-CC9 Where: [**Hospital 4054**] HEMATOLOGY/ONCOLOGY Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2191-6-6**] 11:30 Completed by:[**2191-5-24**]

[ "571.5", "286.6", "155.0", "584.9", "276.1", "995.92", "785.52", "578.9", "070.70", "038.9", "284.8", "198.5" ]

icd9cm

[ [ [] ] ]

[ "99.07", "99.05", "99.04", "38.93" ]

icd9pcs

[ [ [] ] ]

7754, 7857

3465, 6752

327, 351

8123, 8152

2819, 3442

8348, 8880

2356, 2385

6775, 7731

7878, 8102

8176, 8325

2400, 2800

276, 289

379, 2044

2066, 2207

2223, 2340

57,054

118,532

54697

Discharge summary

report

Admission Date: [**2151-4-22**] Discharge Date: [**2151-4-24**] Date of Birth: [**2085-4-3**] Sex: M Service: MEDICINE Allergies: Plavix Attending:[**First Name3 (LF) 2291**] Chief Complaint: HTN Major Surgical or Invasive Procedure: None History of Present Illness: 66yo man with history of type A dissection repaired 6 months ago (was hospitalized [**2150-10-5**] - mid [**2150-11-5**], repaired [**2150-10-13**]). Came to [**Location (un) 86**] for family vacation. Thursday morning with some left sided chest pressure and sharp pain in left axilla, had had a huge argument with his wife the night prior and attributed this to his stress as he was still very angry with her. While flying to [**Location (un) 86**] awoke from sleep and noticed some left arm numbness. Attributed this to his positioning and it went away after 30-40 minutes, but recurred once more while in the car on his way to his father in laws. He also started to have some general malaise at the same time. He arrived at his father in laws apt and family member took BP and pressure in the 220's. He was urgently sent to the ED. BP in the ED was 219/98, HR 66, T; 97.6. (Patient states he missed a dose of hydralazine while on the airplane). denies any tachycardia, palpitations, headaches, flushing, diaphoresis, nausea, vomiting, abdominal pain, diarrhea. He said that his BP has never been that high before and his home BP cuff usually measures his systolics in the 140s-150s/75-85. In the ED, CXR unrevealing. CT head shows old infarct on the left that would not explain symptoms. Seen by neuro who felt not having acute CVA and since on statin and ASA no change in management at this time. Admitted to CVICU for BP management. CTA showed type A dissection, but surgical service felt no need for surgical intervention. Given hydral 20mg x1 and 10mg x1. His HCTZ was doubled to 25mg PO Daily and Irbesartan was doubled to 300mg PO Daily. BP has been well controlled in the ICU and patient remained asymptomatic. He was set to be discharged, but Cardiac surgery was concerned about Renal lesions and did not feel comfortable sending home so transferring to medicine for further work up of renal lesions. Patient would like to go home and follow up with his PCP and cardiologist in [**State 2690**]. Does not want to miss his whole vacation because it is the first time his whole family has been together in a while. Past Medical History: hypertension Hyperlipidemia osteoarthritis of knees phrenic nerve injury after aortic surgery w/hoarse voice and requiring use of CPAP intermittently during day and while lying down excision of melanoma [**2129**] Old CVA Past Surgical History: s/p repair of ascending aortic disection and Aortic Valve Replacement with 25mm [**Doctor Last Name **] pericardial valve Social History: Lives with wife in [**State 2690**], Currently retired and is a substitute teacher, worked in the software industry prior to that. History of smoking ([**2102**]-71), intermittent alcohol, no drugs. 2 kids, son and daughter Family History: Father's family has terrible coronary disease, mother with HTN and uterine cancer. Physical Exam: VS: Tm/c: 98.4/97.9 BP: 148/73(r), 154/86(L)(125-181/57-88), P:74 (57-77), RR: 19, 98% RA GENERAL: Well-appearing in NAD, comfortable, speaking in full sentences, appropriate. HEENT: PERRLA, EOMI, sclerae anicteric, MMM, OP clear. NECK: Supple, no JVD, HEART: RRR, 3/6 systolic mrumur across precordium, nl S1, loud S2 LUNGS: CTA bilat, no ronchi/rales/wheezes, good air movement, resp unlabored. ABDOMEN: Soft/NT/ND, no masses or HSM, no rebound/guarding. EXTREMITIES: WWP, no c/c/e, 2+ peripheral pulses. SKIN: Square areas of erythema where previous EKG tags had been LYMPH: No cervical LAD. NEURO: Awake, A&Ox3, CNs II-XII grossly intact, muscle strength [**4-10**] throughout, sensation grossly intact throughout, cerebellar exam intact, gait deferred. Pertinent Results: Admission: [**2151-4-22**] 09:15PM GLUCOSE-89 UREA N-28* CREAT-1.5* SODIUM-137 POTASSIUM-3.7 CHLORIDE-99 TOTAL CO2-24 ANION GAP-18 [**2151-4-22**] 09:15PM WBC-9.1 RBC-4.51* HGB-12.8* HCT-39.5* MCV-88 MCH-28.3 MCHC-32.3 RDW-13.9 [**2151-4-22**] 09:15PM NEUTS-66.0 LYMPHS-22.8 MONOS-4.4 EOS-6.0* BASOS-0.8 [**2151-4-22**] 09:15PM PLT COUNT-221 [**2151-4-22**] 09:15PM cTropnT-<0.01 Discharge: [**2151-4-24**] 10:30AM BLOOD WBC-7.5 RBC-4.55* Hgb-12.6* Hct-39.5* MCV-87 MCH-27.7 MCHC-32.0 RDW-13.8 Plt Ct-218 [**2151-4-24**] 10:30AM BLOOD Glucose-164* UreaN-27* Creat-1.4* Na-140 K-4.0 Cl-103 HCO3-24 AnGap-17 [**2151-4-24**] 10:30AM BLOOD Calcium-9.3 Phos-3.3# Mg-2.0 [**2151-4-23**] 03:25AM BLOOD cTropnT-<0.01 Studies [**4-22**] CXR: IMPRESSION: No acute intrathoracic process with a tortuous and prominent thoracic aorta. [**4-22**] CT head 1. No definite acute intracranail process. Hypodensity in the pons on the left may represent infarct, age indeterminate, or artifact. If clinically indicated, MRI could be considered for further evaluation. 2. Sinus disease as detailed above. [**4-23**] Echo: 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. There is no ventricular septal defect. The right ventricular cavity is dilated with normal free wall contractility. A bioprosthetic aortic valve prosthesis is present. The aortic valve prosthesis appears well seated, with normal leaflet/disc motion and transvalvular gradients. 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 no pericardial effusion. There are no echocardiographic signs of tamponade. [**4-23**] CTA: IMPRESSION: 1. Type A dissection involving the ascending aorta at the level of the ascending aortic graft (having previous had a type A dissection repair) and extending distally just above the inferior mesenteric artery origin. Vessels involved as described above. Correlation with the patient's surgical history is recommended to determine whether this is an acute on chronic vs chronic presentation. 2. Intermediate density right renal lesion in the left lower pole with some heterogeneity is concerning for a renal neoplasm and correlation with prior imaging if available is recommended and if not, further assessment can be performed with ultrasound. 3. Endoluminal material in the left main stem bronchus could reflect secretions or focal lesion. Brief Hospital Course: 66 yo gentleman with pmhx type A dissection repaired 6 months ago presents with hypertension in setting of argument with wife and missing a dose of hydralazine. CTA revealed incidental renal lesion concerning for neoplasm. ASSESSMENT & PLAN: # Renal Lesions: Patient has multiple hypodense renal lesions that were reportedly not noted on imaging during his admission in late [**2149**]. Many were read as simple cysts, but one heterogeneous lesion was concerning for possible neoplasm. Patient could have neuroendocrine tumor secreting renin resulting in refractory hypertension, but this would likely result in persistent resistent hypertension over a period of time and this patient had an acute episode as he measures his BP daily and his SBP is always between 140-150s. There was some concern for pheochromocytoma, but the concerning lesion is in the left lower pole of the kidney and not within the adrenal gland making this diagnosis less likely. Patient could have RCC and would need to be worked up further with a biopsy. The patient wants to be discharged so that he can enjoy the rest of his vacation with his family and have this lesion worked up in [**State 2690**], in approximately 7 - 10 days time when he returns to [**State 2690**]. He said that he is a compliant patient and would have this worked up once he gets home. The patient received a copy of the CD with images and a copy of the report. The PCP office of [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in [**Location (un) 11270**], Tx was notified. # HTN: Patient BP is well controlled after administration IV hydral to acutely lower his BP and then doubling his Irbesartan and HCTZ. BP most likely elevated in setting of fight with wife and missing medications. Given the transient nature of his hypertension, there is unlikely to be a secondary cause. Pt has no evidence of Renal artery stenosis on imaging here or at OSH in [**State 2690**]. He is without adrenal lesions making pheochromocytoma, or primary aldosteronism less likely. Also without clinical presentation consistent with pheo. Nor does he have any hypernatremia or hypokalemia one would see with increased aldosterone levels. Patient is also without physical exam findings with [**Location (un) **] syndrome and does not take exogenous steroids. He had no femoral-radial pulse dissociation. His Irbesartan dose was doubled. # Allergic sinusitis: Patient with symptoms since arriving to [**Location (un) 86**]. He was advised to continue taking allergy medications. # Hyperlipidemia: Continue statin # Phrenic nerve injury after aortic surgery w/hoarse voice and requiring use of CPAP intermittently during day and while lying down: Continued on home meds # Old CVA: Continue statin and aspirin TRANSITIONAL: Follow up on renal lesion in [**Location (un) 11270**], Tx Monitor blood pressure control MRSA screen results pending Medications on Admission: -Hydralazine 100 mg tid -Metoprolol ER 25 mg [**Hospital1 **] -Avapro 150 mg daily -Lipitor 10 mg daily -Advair 250-50 inh [**Hospital1 **] -ASA 243 mg daily (3 tabs of 81 mg) -Fish Oil -HCTZ 12.5 mg daily -Lecithin 1200 mg daily Discharge Medications: 1. hydralazine 100 mg Tablet Sig: One (1) Tablet PO three times a day. 2. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO BID (2 times a day). 3. irbesartan 300 mg Tablet Sig: One (1) Tablet PO daily (). Disp:*30 Tablet(s)* Refills:*0* 4. atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 6. aspirin 81 mg Tablet, Chewable Sig: Three (3) Tablet, Chewable PO DAILY (Daily). 7. hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO once a day. 8. lecithin 1,200 mg Capsule Sig: One (1) Capsule PO once a day. 9. Fish Oil 1,000 mg Capsule Sig: One (1) Capsule PO once a day. Discharge Disposition: Home Discharge Diagnosis: Primary: Hypertension, Renal Lesion Secondary: Type A dissection Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [**Known lastname 111858**], It was a pleasure taking care of you at [**Hospital1 18**]. You were admitted for hypertension. This resolved on your home medications. An incidental finding of a renal mass was made. You declined workup of this in [**Location (un) 86**] and would like to follow up in your [**Location 27224**]. Your PCP's office was alerted about this finding and we have provided you with a cd and report of this. The following changes were made to your medications: INCREASE Avapro (irbesartan) to 300 mg Followup Instructions: Please follow up with your PCP and cardiologist in [**Location (un) 11270**]. Please also request follow up with a neurologist for symptoms of arm numbness. Completed by:[**2151-4-25**]

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