ChanBeDu/relevant_section_length · Datasets at Hugging Face

51,349

186,895

38809

Discharge summary

report

Admission Date: [**2110-5-22**] Discharge Date: [**2110-5-27**] Date of Birth: [**2030-9-3**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 922**] Chief Complaint: dizziness, headache Major Surgical or Invasive Procedure: coronary artery bypass grafts x 3(LIMA-LAD,SVG-OM,SVG-RCA) [**2110-5-22**] History of Present Illness: This 79 year old Spanish speaking male presented with symptoms of dizziness and headache which lead to stress test revealing inferior ischemia. Coronary artery CTA revealed calcification of the left main and LAD. Subsequent cardiac catheterization revealed distal left main stenosis and double vessel disease. He was referred for cardiac surgical evaluation. Past Medical History: hypertension hyperlipidemia h/o prostate cancer Social History: Lives with: son Occupation: retired Tobacco: quit 15 yrs. ago ETOH: none Family History: non-contributory Physical Exam: Admission: Pulse: 47SB Resp: 15 O2 sat: 99%RA B/P Right: 140/54 Left: Height: 5'6" Weight: 146lb General: Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Extremities: Warm [x], well-perfused [x] Edema Varicosities: None [] no edema or varicosities Neuro: Grossly intact x Pulses: Femoral Right: 2+ Left: 2+ DP Right: 2+ Left:2+ PT [**Name (NI) 167**]: 2+ Left:2+ Radial Right: 2+ Left:2+ Carotid Bruit Right: Left: no bruits appreciated Pertinent Results: [**2110-5-25**] 07:05PM BLOOD WBC-11.9* RBC-3.30* Hgb-10.4* Hct-31.3* MCV-95 MCH-31.5 MCHC-33.2 RDW-13.2 Plt Ct-141* [**2110-5-25**] 04:20AM BLOOD WBC-12.7* RBC-2.95* Hgb-9.4* Hct-27.7* MCV-94 MCH-32.0 MCHC-34.0 RDW-13.6 Plt Ct-110* [**2110-5-25**] 07:05PM BLOOD Glucose-106* UreaN-20 Creat-1.0 Na-135 K-4.6 Cl-101 HCO3-26 AnGap-13 [**2110-5-25**] 04:20AM BLOOD Glucose-95 UreaN-22* Creat-1.0 Na-137 K-4.2 Cl-104 HCO3-28 AnGap-9 [**2110-5-22**] 02:10PM BLOOD UreaN-17 Creat-0.8 Cl-112* HCO3-24 Brief Hospital Course: The patient was admitted to the hospital and brought to the Operating Room on [**2110-5-22**] where he underwent coronary artery bypass grafting. See operative note for details. He tolerated the procedure well, weaning from bypass on Neo Synephrine and Propofol infusions. Post-operatively was transferred to the CVICU in stable condition for recovery and invasive monitoring. Cefazolin was used for surgical antibiotic prophylaxis. POD 1 found the patient extubated, alert and oriented and breathing comfortably. He did develop some post-operative delerium which responded well to Haldol and cleared over several days. Geriatrics was consulted. He was hemodynamically stable on no inotropic or vasopressor support. Beta blocker was initiated and the patient was gently diuresed toward his preoperative weight. Confusion cleared and the patient was transferred to the telemetry floor for further recovery. Chest tubes and pacing wires were discontinued without complication. The patient was evaluated by the Physical Therapy service for assistance with strength and mobility. He had some transient dizziness on [**5-26**], diuresis was stopped as he was below preoperative weight and this cleared. He had limited mobility and strength and was appropriate for a rehabilitation facility. The wounds were healing and pain was controlled with oral analgesics. The patient was discharged to [**Location (un) **]Rehab in good condition with appropriate follow up instructions. Medications on Admission: amlodipine 5', simvastatin 20', asa 325' Discharge Medications: 1. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 2. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. 3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 4. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for fever/pain. 5. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) as needed for constipation. 6. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed for constipation. 7. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO at bedtime. 8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 9. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO HS (at bedtime). Discharge Disposition: Extended Care Facility: [**Location (un) 39857**] - [**Location 9583**] Discharge Diagnosis: coronary artery disease s/p coronary artery bypass grafts hypertension hyperlipidemia h/o prostate cancer Discharge Condition: Alert and oriented x3, nonfocal Pivoting with assist, ambulating with assist. Sternal pain managed with oral analgesics Sternal Incision - healing well, no erythema or drainage Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming, and look at your incisions Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month 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: Surgeon Dr. [**Last Name (STitle) 914**] ([**Telephone/Fax (1) 170**]) on [**2110-6-24**] at 1:15 Please call to schedule appointments Primary Care Dr. [**First Name4 (NamePattern1) 6382**] [**Last Name (NamePattern1) 29065**] ([**Telephone/Fax (1) 29068**]) in [**1-25**] weeks Cardiologist Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 42394**] in [**1-25**] 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:[**2110-5-27**]

[ "272.4", "293.0", "414.01", "411.1", "V10.46", "401.9", "V15.82" ]

icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

4666, 4740

2231, 3716

339, 416

4890, 5069

1713, 2208

5771, 6354

987, 1005

3807, 4643

4761, 4869

3742, 3784

5093, 5748

1020, 1694

280, 301

444, 808

830, 880

896, 971

23,546

143,212

45853

Discharge summary

report

Admission Date: [**2196-10-18**] Discharge Date: [**2196-10-26**] Date of Birth: [**2112-3-5**] Sex: M Service: MEDICINE Allergies: Vancomycin Attending:[**First Name3 (LF) 1928**] Chief Complaint: Fever Major Surgical or Invasive Procedure: None History of Present Illness: 84 y/o with h/o recurrent aspiration PNA, UTIs, advanced dementia, s/p PEG presents with fever, congestion, lethargy and oxygen desaturation to low 80s today. Has had fever to 101.7 at 10 am today. Pt has two recented abx course in last month (treated with Levofloxacin and Cipro) for fever and leukocytosis (up to WBC 15). In the ED VS initially 99.6, 120/68, 100, 30 94% on 10L which improved to 95% on 4L NC. He is A+Ox1, which appears to be his baseline. He was noted to be coughing and be rhonchous on exam. CXR without obvious consolidation. UA positive. He received 3L IVF, zosyn, and Tylenol 1300mg. VS prior to transfer are 102.6, 127/69, 97, 22, 94% on neb. EKG NL sinus. Lactate 3.8 Per ED call in Pt. was made DNR after his last hospitalization but this did not include DNI or DNH. Review of systems: stooling regularly, 2 on [**10-17**], once on [**10-18**]. Transferred to the floor after his ICU course. He was oriented x 0 and occasionally answering "yes" to questions. In speaking with his HCP and with his PMD, this is is baseline. Past Medical History: Dementia Recurrent aspiration s/p G tube [**2-28**] MSSA bactermia Seizure disorder paroxsymal V tach. Depression Osteoarthritis IBS Vitamin B12 deficiency chronic hypernatremia s/p ORIF [**January 2192**] [**2-29**] Pseduomonas PNA Small Bowel Obstruction [**2-29**] Social History: Lives full time at [**Hospital3 2558**]. Brother lives on [**Hospital3 **] and is POA. Family History: Unable to obtain given pt with severe dementia Physical Exam: GENERAL:chronically ill appearing elderly white man in NAD HEENT: Normocephalic, atraumatic. No conjunctival pallor. No scleral icterus. PERRLA. Unable to follow commands for EOM testing. DMM. will not open mouth. Neck Supple, No LAD, No thyromegaly. CARDIAC: Regular rhythm, normal rate. Normal S1, S2. No murmurs, rubs or [**Last Name (un) 549**]. JVP unable to interperate [**1-25**] body habitus LUNGS: diffusely rhonchus, transmitted upper airway sounds. ABDOMEN: NABS. Soft, NT, ND. No HSM. PEG in place with mild erthema around insertion site. EXTREMITIES: No edema or calf pain, 2+ dorsalis pedis/ radial pulses. muscle wasting on ext, thenar. contracted. SKIN: No rashes/lesions, ecchymoses. NEURO: Alert. non-verbal. CN 2-12 grossly intact. increased tone in upper ext. toes down going. Gait assessment deferred GU: foley in place Pertinent Results: [**2196-10-18**] 02:00PM GLUCOSE-184* UREA N-56* CREAT-1.0 SODIUM-152* POTASSIUM-4.8 CHLORIDE-116* TOTAL CO2-23 ANION GAP-18 [**2196-10-18**] 12:51PM URINE BLOOD-LG NITRITE-NEG PROTEIN-150 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-MOD [**2196-10-18**] 12:42PM LACTATE-3.8* [**2196-10-18**] 12:51PM URINE RBC-0-2 WBC->50 BACTERIA-FEW YEAST-NONE EPI-0 [**2196-10-18**] 02:34PM WBC-18.6*# RBC-3.98* HGB-11.8* HCT-37.8* MCV-95 MCH-29.8 MCHC-31.3 RDW-17.1* [**2196-10-18**] 08:28PM LACTATE-3.9* NA+-152* [**2196-10-18**] 08:28PM TYPE-ART PO2-65* PCO2-42 PH-7.40 TOTAL CO2-27 BASE XS-0 [**2196-10-18**] 08:55PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-LG [**2196-10-25**] 05:46AM BLOOD WBC-8.6 RBC-2.96* Hgb-9.1* Hct-28.4* MCV-96 MCH-30.8 MCHC-32.1 RDW-16.8* Plt Ct-247 [**2196-10-25**] 05:46AM BLOOD Glucose-154* UreaN-21* Creat-0.7 Na-139 K-4.4 Cl-103 HCO3-28 AnGap-12 [**2196-10-25**] 05:46AM BLOOD Calcium-7.9* Phos-2.6* Mg-1.7 Iron-49 [**2196-10-25**] 05:46AM BLOOD calTIBC-211* Ferritn-109 TRF-162* CT Cystogram: . No CT cystogram evidence for rectovesicular fistula. 2. Probable history of TURP given patulous nature of prostatic urethra. Note is made of prominent soft tissue at the prostate base which could be further assessed by urology as clinically indicated. If there is a history of TURP, this likely represents a BPH nodule; however bladder mass including neoplasm cannot be entirely excluded. 3. Shaggy-appearing bladder, suggestive of cystitis. 4. Bowel-containing ventral hernia without evidence of bowel obstruction. CT pelvis: 1. Aborted CT cystogram secondary to presence of rectal tubing. Diffuse perivesicular stranding consistent with the patient's history of cystitis without evidence of abscess. Two linear foci of increased attentuation between the sigmoid colon and bladder which may reflect chronic inflammation. However, fistula cannot be entirely excluded. Othewise preserved colovesicular fat planes. The patient will return to the department for a CT cystogram following removal of the endorectal tube, to repeat atttemt at evaluation for rectovesicular fistula. 2. Foley catheter balloon inflated within the prostate, tip of catheter inferior to the prostate as well. 3. Partially visualized ventral hernia involving a portion of the sigmoid colon without evidence of obstruction. 4. Atypical orientation of the left femur relative to the left acetabulum which may be secondary to known chronic contractures or prior trauma Renal US No evidence of abnormal fluid collections within the kidneys, that is concerning for abscess formation. Limited examination secondary to patient contractures with poor son[**Name (NI) 493**] windows. Bladder not assessed on this renal ultrasound. Ultrasound would not be able to detect rectovesicular fistula. Brief Hospital Course: 84 y/o with advanced dementia, recurrent aspiration PNA, and recurrent UTIs admitted to the ICU with fever and increasing respiratory distress. #. Aspiration PNA: The patient has chronic dysphagia and a PEG at baseline. He has a history of aspiration PNA. He was rhonchorous on exam with witnessed poor secretion clearing with a history of aspiration PNA making this the most likely diagnosis. The CXR is fairly benign but there appears to be upper lobe infiltrates which may be underestimated in the setting of dehydration. Given history of pseudomonal and MSSA PNA and chronic nursing home resident he was covered broadly for HAP/ASP PNA with linezolid, zosyn and cipro. DFA for influenza and urine legionella antigen was negative. He initially required a facemask O2, however was weaned to room air with decreased secretions by [**10-22**] when he was called out to the floor. His sputum cultures grew both MSSA and Pseudomonas, so he was continued on a 8 day course of zosyn and a 3 week course of nafcillin for MSSA. He will need weekly CBC and chemistry panel drawn at [**Hospital3 2558**] for monitoring. # UTI: The patient had a mildly positive UA on admission, however UA was repeated on on [**10-21**] as urine appeared cloudy and showed >1000 wbcs, with many bacteria, moderate blood, large leuks; repeat on [**10-22**] was similar except no bacteria were seen. Foley was changed on admission. Urine culture from [**10-18**] grew >100,000 GNR with mixed fecal flora; repeat cultures later in his admission (on Zosyn/Cipro/linezolid) grew only yeast. He was noted to have irritation/ulceration in his urethral meatus. Due to concern for abscess or rectovesicular fistulagiven extreme pyuria, CTU was performed [**10-23**] which again did not reveal a rectovesicular fistula. On [**10-25**] evening, the RN staff noted white discharge from the urethral meatus. Urology was consulted in the setting of his history and felt that this could be consistent with sloughing of cells in the urethra, but unlikely to be a new infection or abscess. His UCx were positive for yeast and in the setting of CT finding of cystitis and positive UA, he was treated with fluconazole for fungal URI x 7 days (to be completed on Saturday [**10-29**]). He will need urology follow up as an outpatient given his prostatic nodule that was found on the CT cystogram. He has no history of BPH or having a TURP and will need this to be addressed as an outaptient. # Bacteremia: [**1-27**] of his admission blood cultures grew coag negative staph. This was thought to be a contaminent; subsequent cultures negative, treated with broad spectrum abx (including linezolid) as above. #. Diarrhea: The patient has a history of constipation, but had liquid stools throughout his admission. C Diff was negative x 3 and he had a flexiseal in place to prevent pressure ulcers and skin contamination during his hospital stay. The etiology of his diarrhea is most likely antibiotic related. His stool softeners were held in the hospital. He was started on loperamide PRN for diarrhea and should be continued as an outpatient. #. Hypernatremia: Treated with increased free water via PEG with improvement. #. Seizure disorder, since age 15. Chronically on Phenobarbital. His serum levels were therapeutic. #. End Stage Dementia: Minimally verbal at baseline, A&Ox0 at at baseline. Was initially non verbal in ICU; began to interact minimally upon transfer to medical floor. Dysphagia, has PEG. #. h/o paroxsymal V-tach: monitor on tele ACCESS: PICC CODE STATUS: DNR/ intubation, pressors ok; this was confirmed with HCP EMERGENCY CONTACT: [**Name (NI) **] [**Name (NI) 97639**] HCP brother. [**Telephone/Fax (1) 97647**] Medications on Admission: s/p levoquin 500mg PO x 7 days finished [**9-25**] s/p Cipro 500mg PO daily x 7 days [**9-27**] - [**10-3**] Albuterol- Ipratropium Nebs q4h [**12-25**] bottle mag citrate prn Scopolamine patch 1.5mg q72hrs lansoprazole 30mg Daily Penobarbital 60mg [**Hospital1 **] via G tube Scopolamine patch 1.5mg q72hrs Acetaminopthen 160mg/5ml elixir 20ml PO q6h via G-tube bisacodyl 10mg suppository PR TID MWF Docusate 50mg/5ml liquid 10mg [**Hospital1 **] MOM prn [**Name2 (NI) **] 8.8mg / 5ml syrup 5ml [**Hospital1 **] Fleet enema prn Discharge Medications: 1. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily). 2. Phenobarbital 20 mg/5 mL Elixir [**Last Name (STitle) **]: Three (3) PO BID (2 times a day). 3. Fluconazole 200 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO Q24H (every 24 hours) for 4 days. 4. Ipratropium Bromide 0.02 % Solution [**Last Name (STitle) **]: One (1) Inhalation Q6H (every 6 hours) as needed for shortness of breath, wheezing. 5. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization [**Last Name (STitle) **]: One (1) Inhalation Q6H (every 6 hours) as needed for shortness of breath, wheezing. 6. Piperacillin-Tazobactam-Dextrs 4.5 gram/100 mL Piggyback [**Last Name (STitle) **]: One (1) Intravenous Q8H (every 8 hours) for 1 days. 7. Nafcillin in D2.4W 2 gram/100 mL Piggyback [**Last Name (STitle) **]: One (1) Intravenous Q4H (every 4 hours) as needed for MSSA pneumonia for 2 weeks. 8. Scopolamine Base 1.5 mg Patch 72 hr [**Last Name (STitle) **]: One (1) Transdermal every seventy-two (72) hours. Discharge Disposition: Extended Care Facility: [**Hospital3 2558**] - [**Location (un) **] Discharge Diagnosis: Aspiration Pneumonia Fungal UTI Dementia Urinary retention Diarrhea Discharge Condition: Stable, on room air. Discharge Instructions: You were admitted to the hospital with shortness of breath and fevers. You were sent to the ICU and started on antibiotics. Your oxygen levels were improved and were transferred to the floor. Your urine also looked like it was infected and there was concern for an infection. You had a CT scan to look for abscess and a connection between your bowel and your bladder, which was negative. You were started on antibiotics and and these will be continued. The following medications were started: 1. Nafcillin - last dose on [**11-18**] PM 2. Zosyn last dose on [**10-26**] PM 3. Fluconazole 4. Immodium Followup Instructions: Have already discussed his case with [**First Name8 (NamePattern2) 11320**] [**Last Name (NamePattern1) 16528**] who will see the patient tomorrow at [**Hospital3 2558**].

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icd9cm

[ [ [] ] ]

[ "96.6", "38.93", "00.14" ]

icd9pcs

[ [ [] ] ]

11035, 11105

5611, 9329

278, 285

11217, 11240

2709, 5588

11893, 12067

1784, 1832

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1847, 2690

1129, 1371

233, 240

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18,237

109,560

12768

Discharge summary

report

Admission Date: [**2106-5-17**] Discharge Date: [**2106-5-25**] Date of Birth: [**2034-9-18**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2181**] Chief Complaint: Dizziness, lethargy Major Surgical or Invasive Procedure: none History of Present Illness: The patient is a 71 yo male with a past medical history significant for prior stroke, HTN, and [**First Name3 (LF) 2320**] who obtains routine medical care from the [**Hospital1 756**] who presented to the ED on [**2106-5-17**] with the chief complaint of dizziness, progressive lethargy and confusion x 5 days. The patient reported that in the past 5 days, he noticed increased lethargy and generalized weakness as well as presyncope with lightheadedness and dizziness but denies any syncope. He denied any fevers/chills/night sweats/abdominal/chest pain. His wife noticed the patient's increased confusion and change in his baseline activity over the week prior to admission (formerly 1 year ago used to take daily walks and within past 5 days, couldn't leave his bedroom on the [**Location (un) 1773**] so that his meals had to be brought to him). He denies any headache, change in vision (wears glasses at baseline), or focal weakness or change in balance. . Interestingly, the patient notes that he has not felt "well" over the past 6 months to 1 year with slowly increasing lethargy. As mentioned, he has slowly cut down on his physical activity as a result of his fatigue. . The patient had seen his PCP 2 weeks ago as part of a routine physical exam at which time his nifedipine was stopped secondary to noted hypotension. His wife reports that his physician called him [**Name Initial (PRE) **] few days later to have his BP rechecked in his office but the patient did not make it to his appointment. As his symptoms of lethargy and confusion persisted, his wife called 911. As [**Hospital1 756**] was on divert, the patient was brought to the [**Hospital1 18**] ED. . In the ED, the patient was found to have pancytopenia with a Hct of 14.5, he was guaiac negative with a SBP initially 86 that then dropped to 60 with a HR in the 60s. The patient had taken all of his BP meds on day of admission([**2106-5-17**]) including atenolol, lisinopril, and HCTZ. His BP rose to 110 with 3 liters IVF, 3 units PRBC in the ED. . His labs were significant for a Hct of 14.5 as mentioned above, plt 89, WBC 2.9, Cr 1.7, AST 50, LDH 2374, INR 1.4, D-dimer 2608, troponin of 0.02. . . 2 large bore IVs were placed in the ED. . His EKG was as follows: . Initial: NSR 79, Nl axis, RBBB with [**Street Address(2) 1766**] depressions and TWI V1-v6, <[**Street Address(2) 4793**] depression II ( no prior EKG for comparison) . With BP normalization: NSR at 73 bpm, RBBB, NL axis. [**Street Address(2) 4793**] depressions with biphasic TW V1-V3, normalization of TW V4-V6. Low voltage. . A CT of the head was also performed which showed: . 1. No acute intracranial hemorrhage. Somewhat limited study due to motion artifact. Brain atrophy. . 2. 1.5-cm hypodense area in the right occipital lobe, which may represent subacute-to-chronic infarction. Clinical correlation is recommended. MRI will be helpful for further evaluation. . The patient has a reported history of stroke in [**2093**] with no persistent neurologic deficits. He was evaluated by neurology in the ED who felt his neurologic exam was stable and not indicative for acute stroke. Based on the CT findings above which showed subacute/chronic stroke, it was recommended that prior head imaging be obtained from [**Hospital1 756**] to document his prior CVA. MRI may be considered otherwise. . According to his PCP and [**Name9 (PRE) **] reports, the patient's last Hct was 40 3 years ago with no more recent labs. He had a normal PSA 1 week ago. The patient believes he had a colonoscopy 10-15 years ago but records from the [**Hospital1 756**] need to be obtained to confirm. Past Medical History: HTN stroke [**Hospital1 2320**] x 8 years ? CRI Baseline Cr 1.7 by report (patient was unaware of this) Social History: The patient formerly worked in a metal factory 35 years ago and then as a janitor. He is now retired and lives with his wife in [**Name (NI) 86**]. They live in a 2-storied single-family home. He denies any EtOH and formerly only drank on occasion. He is a former smoker 3 ppd x 12 years - quit 35 years ago. Family History: Father, 4 brothers and 1 sister died of MI in 60-70s Mother deceased from MI as well. [**Name (NI) 2320**], and HTN run in family. No history of malignancy. Physical Exam: Tc in ED 99 P=66 BP86/48->60 systolic ->110 RR 14 99% on RA . In MICU . Tc=98.6 P= 76 BP = 115/74 RR=16 99% on RA . . Gen - NAD, AOX3, pale, light-skinned African-American male HEENT - Muddy sclera, anicteric, pale conjunctiva, PERLA, EOMI, no oral petechiae/mucosal bleeding, no JVD Heart - RRR, no M/R/G Lungs - CTAB Abdomen - Soft, obese, NT, ND, no appreciable hepatosplenomegaly, active BS Ext - Onychomycosis bilaterally, no edema, old scars bilateral LE from burn sustained secondary to work injury 35 years ago, +1 d. pedis bilaterally Back - No CVAT Skin - No petechiae, bruising/purpura Neuro - CN II-XII intact, +2 DTRs x 4, negative Babinski bilaterally, 5/5 strength x 4 Pertinent Results: [**2106-5-17**] 09:15PM URINE HOURS-RANDOM [**2106-5-17**] 09:15PM URINE UHOLD-HOLD [**2106-5-17**] 09:15PM URINE COLOR-Amber APPEAR-Clear SP [**Last Name (un) 155**]-1.014 [**2106-5-17**] 09:15PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-1000 KETONE-NEG BILIRUBIN-NEG UROBILNGN-8* PH-5.0 LEUK-NEG [**2106-5-17**] 09:04PM HGB-5.7* calcHCT-17 [**2106-5-17**] 08:52PM GLUCOSE-200* UREA N-47* CREAT-1.7* SODIUM-139 POTASSIUM-4.2 CHLORIDE-106 TOTAL CO2-21* ANION GAP-16 [**2106-5-17**] 08:52PM ALT(SGPT)-16 AST(SGOT)-50* LD(LDH)-2374* CK(CPK)-43 ALK PHOS-94 AMYLASE-34 TOT BILI-1.4 [**2106-5-17**] 08:52PM LIPASE-33 [**2106-5-17**] 08:52PM cTropnT-0.02* [**2106-5-17**] 08:52PM CK-MB-NotDone [**2106-5-17**] 08:52PM CALCIUM-8.6 PHOSPHATE-3.0 MAGNESIUM-2.6 [**2106-5-17**] 08:52PM HAPTOGLOB-<20* [**2106-5-17**] 08:52PM WBC-2.9* RBC-1.23* HGB-5.5* HCT-14.5* MCV-118* MCH-44.4* MCHC-37.5* RDW-17.2* [**2106-5-17**] 08:52PM NEUTS-67.2 LYMPHS-30.8 MONOS-1.1* EOS-0.9 BASOS-0.1 [**2106-5-17**] 08:52PM ANISOCYT-1+ POIKILOCY-1+ MACROCYT-3+ [**2106-5-17**] 08:52PM PLT SMR-LOW PLT COUNT-89* [**2106-5-17**] 08:52PM PT-15.6* PTT-26.2 INR(PT)-1.4* [**2106-5-17**] 08:52PM FIBRINOGE-225 D-DIMER-2608* . CT head on [**5-17**]: 1. No acute intracranial hemorrhage. Somewhat limited study due to motion artifact. Brain atrophy. 2. 1.5-cm hypodense area in the right occipital lobe, which may represent subacute-to-chronic infarction. Clinical correlation is recommended. MRI will be helpful for further evaluation. . CXR on [**5-17**]: Apparent mediastinal widening and prominent aortic contours may be due to AP technique. No prior study available for comparison. Clinical correlation is advised. If there is concern for aortic pathology, chest CT could be performed. . EKG on [**5-17**]: Sinus rhythm, Right bundle branch block, Left atrial abnormality, Diffuse ST-T wave abnormalities -are in part primary and suggest ischemia - clinical correlation is suggested. No previous tracing available for comparison. . EKG on [**5-18**]: Sinus rhythm, Right bundle branch block, Left atrial abnormality, Anterolateral ST-T wave abnormalities -may be in part primary and are nonspecific - clinical correlation is suggested. Since previous tracing of same date, no significant change. . EKG on [**5-19**]: Mild congestive heart failure with cardiomegaly and small bilateral pleural effusion. . EEG on [**5-19**]: Abnormal EEG in the waking and drowsy states due to the moderate slowing of the background in wakefulness. This suggests a widespread encephalopathy. Medications, metabolic disturbances, and infection are among the most common causes. There were no areas of persistent focal slowing, and there were no epileptiform features. . Labs on d/c: Hematology COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct [**2106-5-25**] 05:45AM 6.1# 2.90* 9.8* 27.8* 96 33.8* 35.2* 20.7* 126*# DIFFERENTIAL Neuts Bands Lymphs Monos Eos Baso Atyps Metas [**2106-5-17**] 08:52PM 67.2 30.8 1.1* 0.9 0.1 RED CELL MORPHOLOGY Anisocy Poiklo Macrocy [**2106-5-17**] 08:52PM 1+ 1+ 3+ BASIC COAGULATION (PT, PTT, PLT, INR) PT PTT Plt Smr Plt Ct INR(PT) [**2106-5-25**] 05:45AM 126*# BASIC COAGULATION (FIBRINOGEN, DD, TT, REPTILASE, BT) Fibrino FDP D-Dimer [**2106-5-18**] 10:15AM 10-40 [**2106-5-18**] 03:27AM [**Telephone/Fax (1) 39386**]* HEMOLYTIC WORKUP Ret Aut [**2106-5-22**] 06:35AM 3.1 Chemistry RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap [**2106-5-23**] 05:45AM 159* 19 1.0 139 4.2 107 24 12 ENZYMES & BILIRUBIN ALT AST LD(LDH) CK(CPK) AlkPhos Amylase TotBili DirBili IndBili [**2106-5-22**] 06:35AM 1188* OTHER ENZYMES & BILIRUBINS Lipase GGT [**2106-5-18**] 03:27AM 20 CPK ISOENZYMES CK-MB cTropnT [**2106-5-20**] 05:50AM NotDone1 0.04*2 1 NotDone CK-MB NOT PERFORMED, TOTAL CK < 100 2 CTROPNT > 0.10 NG/ML SUGGESTS ACUTE MI CHEMISTRY TotProt Albumin Globuln Calcium Phos Mg UricAcd Iron [**2106-5-22**] 06:35AM 8.4 3.2 2.0 HEMATOLOGIC calTIBC VitB12 Folate Hapto Ferritn TRF [**2106-5-22**] 06:35AM GREATER TH1 1 GREATER THAN [**2099**] PITUITARY TSH [**2106-5-18**] 03:27AM 1.3 THYROID Free T4 [**2106-5-18**] 03:27AM 1.0 HEPATITIS HBsAg HBsAb HBcAb HAV Ab IgM HBc IgM HAV [**2106-5-18**] 03:27AM NEGATIVE NEGATIVE NEGATIVE POSITIVE NEGATIVE NEGATIVE HIV SEROLOGY HIV Ab [**2106-5-18**] 03:27AM NEGATIVE CONSENT RECIEVED LAB USE ONLY RedHold [**2106-5-18**] 12:15AM HOLD Blood Gas BLOOD GASES Type Temp Rates Tidal V PEEP FiO2 O2 Flow pO2 pCO2 pH calHCO3 Base XS Intubat [**2106-5-18**] 10:31AM [**Last Name (un) **] 37.2 24*1 39 7.38 24 -2 NOT INTUBA2 1 NO CALLS MADE - NOT ARTERIAL BLOOD 2 NOT INTUBATED WHOLE BLOOD, MISCELLANEOUS CHEMISTRY Lactate [**2106-5-18**] 10:31AM 1.7 HEMOGLOBLIN FRACTIONS ( COOXIMETRY) Hgb calcHCT [**2106-5-17**] 09:04PM 5.7* 17 CALCIUM freeCa [**2106-5-18**] 10:31AM 1.19 . Negative Parvo IgM. Brief Hospital Course: # Pancytopenia: On admission the patient was found to be pancytopenic - Hct 14.5, WBC 2.9, ptl 89. The initial differential included idiopathic, medication-induced aplastic anemia (nifedipine, NSAIDs), viral-induced aplastic anemia (HIV, parvo B19), myelodysplastic syndrome (?lymphoma or other malignancy), TTP (without fever, acute renal dysfunction, with mental status changes, anemia, and thromboctopenia)or DIC with elevated INR. There was evidence of hemolysis with LDH in [**2099**] range and hapto <20, D-dimer 2600. The patient received 3 units PRBC in the ED and was transfered to the MICU for further monitorin of his hypotension. He was given an additional 2 Units of PRBC in the MICU. His Hct rose appropriately to PRBC, being 30.3 after a total of 5 Units given. The peripheral smear was most notable for polychromatophilia and anisocytosis. The obtained additional labs revealed a Vit B12 deficiency (75), Folate normal (6.2), elevated Iron (233) and Ferritin (624) and low TiBC (186). Parameters indicating Hemolysis were low: Hapto(<20), elevated tBili (2.6) and dBili 0.7. The Retic Count of 0.9 showed impaired production in the BM. Given that the pt was Vit B12 deficient and that is presentation could be well explained a possible BM biopsy was postponed. He was started on Cyanocobalamin 1000mcg sc/im daily and Folate 5mg iv daily. The LDH increase persisted initially, and then started to steadily go down, same with tBili. Since his Retic Count did not respond as expected to Vit B12 supplementation (being 0.4 on [**5-20**]) a bone marrow biopsy was obtained (on [**5-20**]) to r/o an additional hemolytic disorder, such as AML, aplastic anemia. The BM biopsy confirmed the diagnosis of Vit B12 deficiency as the underlying disorder and showed no signs of leukemia. The pt was kept inpatient over the weekend because his thrombocytes continously dropped (32 on [**5-21**]) despite the initiated Vit B12 therapy; however, his platelets gradually increased and he was discharged to rehab with all counts trending upwards. . # Hypotension On admission the pt presented with BP of 86/48. He reported light-headnesses and dizziness but denied syncopal episodes, falls, CP or SOB. His physical exam did not reveal signs of HF, such as increased JVD, hepatojugular reflux, ascites or peripheral edema. His hypotension was [**Month/Year (2) 2771**] to dehydration and his BP was successfully elevated by volume resuscitation (3l of IVF and 5 Units of PRBC) and d/c of home BP-meds. He was transfered to the MICU for overnight supervision. His SBPs have remained stable over the rest of his hospital stay (SBP 110-130) and he was put back on Lisinopril 10mg po daily. Before discharge patient's blood pressure improved and he was restarted on atenolol 25 with SBP 100-110 range. . # Lethargy, confusion Pt presented with 5 days h/o worsening confusion, possible baseline dementia, to the ED. He has a PMH for stroke in [**2093**], with no residual deficits per wife. In the ED a CT of the head was obtained to r/o possible stroke as cause for MS changes. It showed subacute/chronic infarcy in right occipital lobe. Neuro evaluated the patient in the ED and felt that this was most likely consistent with chronic infarct. Pt had waxing and [**Doctor Last Name 688**] episodes of confusion (disoriented to date, location and context; agitation) when still on the MICU and after he was transfered to the floor. Since the CT had been negative for acute bleeding, the changes in his MS [**First Name (Titles) **] [**Last Name (Titles) 2771**] to his hypotension on presentation as well as to the Vit B12 deficiency. A EEG was performed, following neuro recs, which showed widespread encephalopathy. Since the pt MS improved over the course of his hospital stay, and considering the facts presented above, Neuro did not think that a MRI of his head was indicated for further work-up. Patient is likely to have baseline dementia (atrophy seen on initial CT) and (resolving) neurologic manifestation from Vit B12 deficiency. . # EKG changes The EKG drawn in the ED showed the following abnormalities: RBBB, ST-depressions and TWI in V1-V6, which were thought to be a result of demand ischemia. His CK was 43 and his Troponin 0.02. There was only little suspicion for ACS as the etiology for his hypotension, since the pt had no complaints of shortness of breath/chest pain or radiating pain. EKG and Troponin were monitored closely over the following days and resolved after the pt was normotensive and had received PRBC. A repeat EKG on [**5-19**] showed RBBB, no remaining ST-depressions or TWI. His Troponin on [**5-20**] was 0.04. He was started on Lipitor 10mg daily. Given the pt PMH and his strong FH for CAD, he should receive outpatient work-up of underlying CAD. . # Chronic renal insufficiency Creatinine presented with Creatinine of 1.7 on admission, which was his baseline Crea according to old recs. The chronic renal insufficiency might be due to diabetic nephropathy. However, since the creatinine steadily improved over the course of the hospital stay, being 1.1 on [**5-21**], a prerenal component (secondary to dehydration) was thought to play a key role. . # [**Name (NI) 2320**] Pt has a h/o DM, which he is seen for by his PCP at the [**Name9 (PRE) 112**]. On admission he was on oral hypoglycemics, metformin and glyburide, but was changed to a ISS (Humalog). Patient was subsequently restarted on his oral hypoglycemic before discharge with suplemental sliding scale. Medications on Admission: Atenolol 75 mg PO QD Lisinopril 40 mg PO QD Glyburide 5 mg QD Metformin 500 mg [**Hospital1 **] HCTZ 25 mg PO QD ASA 81 stopped Nifedipine 30 mg QD 2 weeks ago Discharge Disposition: Extended Care Facility: [**Hospital3 1186**] - [**Location (un) 538**] Discharge Diagnosis: Vitamin B12 deficiency pernicious anemia pancytopenia mental status changes Peripheral Neuropathy HTN DM CRI Discharge Condition: stable Discharge Instructions: Please take your medications as listed below. Please see your primary care physician or come to the ED if you notice any of the following symptoms: Headache, dizziness, changes in vision, nausea, vomiting, shortness of breath, chest pain, confusion, increased weakness in legs or tendency to fall or any other reasons that are concerning you. . Please follow up with your PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 39387**] in [**12-28**] weeks after discharge. Followup Instructions: Please follow up with Dr. [**Last Name (STitle) 39387**] on Tuesday [**5-25**]. Call 1-800-[**Hospital1 112**]-999 for an appointment. Test for consideration post-discharge: CBC, Reticulocyte count, Intrinsic Factor Antibody, Anti Parietal Cell Antibody with referral to GI based on results. Consider outpatient stress test for EKG changes and slightly elevated troponin on presentation. . Please follow up with Dr. [**Last Name (LF) 5561**], [**First Name3 (LF) **] in Hematology. We scheduled an appointment with her for you on [**2106-5-25**] at 11.30am, at the [**Hospital1 18**]. Phone:[**Telephone/Fax (1) 22**]

[ "V12.59", "276.51", "355.8", "401.9", "250.40", "284.8", "583.81", "266.2", "585.9" ]

icd9cm

[ [ [] ] ]

[ "99.04", "41.31" ]

icd9pcs

[ [ [] ] ]

16083, 16156

10367, 15872

335, 342

16309, 16318

5354, 10344

16845, 17466

4475, 4634

16177, 16288

15898, 16060

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4649, 5335

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370, 4005

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14,689

181,747

24333

Discharge summary

report

Admission Date: [**2141-6-4**] Discharge Date: [**2141-6-7**] Date of Birth: [**2085-7-26**] Sex: M Service: NEUROLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 5018**] Chief Complaint: Found unresponsive Major Surgical or Invasive Procedure: cerebral angiography History of Present Illness: Mr [**Known lastname 116**] is a 55 year old male, current smoker who is wheelchair-bound due a motorcycle accident 21 years ago which resulted in R AKA and R arm injury who was transferred to [**Hospital1 18**] today for evaluation of intracranial hemorrhage. This history was obtained from the patient's records and his ex-wife since the patient is currently intubated and sedated. He was apparently in his usual state of health and was last seen well by his ex-wife at 12:15PM today. At that time, he was preparing to go fishing with a friend and he "seemed fine" to his ex-wife. She said that he was moving around in his weelchair well and did not complain of headache. Around 1:30PM, his friend arrived to pick him up for their fishing trip and found him unresponsive on the floor next to his wheelchair. He was lying on his back, foam was coming from his mouth and he did not move or respond to his friend. The friend called 911. EMS arrived to find pt unresponsive. Vitals: HR 101 BP 178/90 O2Sat initially 98%, but dropped to 90% en route. He was given Narcan without response. They tried to intubate him, but could not because his jaw was clenched shut. On arrival to [**Hospital 1474**] Hospital, he had a witnessed GTC seizure. He was given Ativan 2mg. He was loaded with dilantin 1g IV. He was intubated and sedated. He last received paralytic agents at 15:15. In our emergency room, he was given Versed and started on propofol. Past Medical History: 1. s/p motorcycle accident - AKA and right arm injury 2. Polio (in childhood) Social History: Smokes [**2-4**] [**2-5**] ppd. Smokes marijuana frequently. Rare EtOH abuse. No other drug use. Lives with a friend. Family History: Pt was adopted; nothing is known about his biological family Physical Exam: TAfeb BP119-148/73-99 RR24-27 O2 Sat 95% Gen: Thin male, intubated and sedated HEENT: small laceration above left orbit, otherwise no evidence of trauma Neck: supple, no thyromegaly, no bruit CV: RRR, S1/S2 Lung: Course breath sounds anteriorly aBd: +BS slightly distended, soft, nontender ext: Right AKA, Right arm flaccid and atrophied, left leg atrophied. No edema Neurologic examination: (on propofol) Mental status: Sedated on propofol, unresposive to voice, not following commands, grimaces and moves left>right in respose to sternal rub, but does not open eyes. +frequent coughing and biting ETT. Cranial Nerves: Pupils equally round and reactive to light, 2mm bilaterally. No blink to threat. Eyes conjugate/midline, no nystagmus. No doll's. +corneals bilaterally. Grimaces to nasal tickle. No facial asymmetry, though ETT obstructs view of lower face. +gag. Motor: Decreased bulk in right hand. Decreased tone on right arm. Withdraws left arm and leg briskly to noxious stimuli. Right arm does not withdraw to painful stim. Sensation: Grimaces to noxious stimuli in all 3 limbs. Reflexes: B T Br Pa Ach Right 1 1 1 X X Left 1 1 1 0 4 Clonus (>10 beats) in left ankle Toes upgoing on left Coordination/Gait: Unable to assess Pertinent Results: [**2141-6-6**] 03:36AM BLOOD WBC-11.3* RBC-3.96* Hgb-12.5* Hct-36.5* MCV-92 MCH-31.7 MCHC-34.3 RDW-14.1 Plt Ct-210 [**2141-6-4**] 04:40PM BLOOD WBC-22.4* RBC-4.71 Hgb-14.6 Hct-44.3 MCV-94 MCH-31.1 MCHC-33.0 RDW-13.8 Plt Ct-219 [**2141-6-6**] 03:36AM BLOOD Plt Ct-210 [**2141-6-5**] 04:00AM BLOOD Plt Ct-197 [**2141-6-5**] 04:00AM BLOOD PT-12.7 PTT-27.8 INR(PT)-1.1 [**2141-6-4**] 04:40PM BLOOD Glucose-77 UreaN-13 Creat-0.9 Na-142 K-4.7 Cl-111* HCO3-20* AnGap-16 [**2141-6-6**] 03:36AM BLOOD Glucose-91 UreaN-5* Creat-0.5 Na-139 K-3.2* Cl-107 HCO3-24 AnGap-11 [**2141-6-6**] 03:36AM BLOOD Phenyto-15.3 [**2141-6-4**] 04:40PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-8.2 Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2141-6-5**] 02:18PM BLOOD Type-ART pO2-73* pCO2-33* pH-7.44 calHCO3-23 Base XS-0 CTA (head):1) No evidence of an arteriovenous malformation or other vascular abnormality in the region of the evolving hemorrhagic infarct of the right parietal lobe.2) An angiogram is recommended to exclude a possible arteriovenous malformation just anterior to the above-described infarct. This [**Known lastname **] very well be an incidental finding representing a developmental venous anomaly. Brief Hospital Course: 55 year old male who was found unresponsive at home, taken to OH where he had a GTC and was found to have a right parieto-occipital hemorrhage. It is unclear whether he fell due to a seizure/bleed or whether the bleed was traumatic from the fall itself. 1. Neuro: Intraparenchymal hemorrhage-area of surrounding edema on CT concerning for underlying mass, infarct or AVM. He underwent a MRI with gado and MRA which showed prominance of the veins near the area of hemorrhage-there was no enhancing mass visualized. He was admitted to the Neuro ICU and continued on dilantin for seizure prevention. Repeat head CT showed no change in hemorrhage. CTA was done to look for AVM and showed an area of abnormality anterior to the right parietal hemorrage (unrelated to it) which was thought to represent an AVM or venous malformation. Cerebral angiogram was done to clarify this question and showed no evidence for AVM, but suggested an underlying venous anomaly in the internal cerebral veins. He was continued on dilantin for sz prevention-level was 13. 2. CV: EKG shows no evidence of ischemia or arrhythmia -Rule out MI with serial CE -telemetry -Keep SBP 120-150 3. Pulm: Pt was brought to the ER intubated for airway protection. He was extubated on HD2 after mental status improved. He tolerated extubation well. 4. GI: -Pt remained on GI ppx throughout this admission 5. ID: Increased WBC- UA negative, initial CXR negative, but rpt showed LLL atelectasis. Medications on Admission: Tylenol PRN Discharge Medications: 1. Phenytoin Sodium Extended 100 mg Capsule Sig: Three (3) Capsule PO once a day. Disp:*90 Capsule(s)* Refills:*6* Discharge Disposition: Home Discharge Diagnosis: Seizure Right parietal venous anomaly Discharge Condition: Improved Discharge Instructions: You have been started on a new medication called dilantin to prevent seizures. Please continue to take this medication. You should have your dilantin level checked next week. If you have any further seziures, headache, vision changes, new numbness, weakness, incoordination or dizziness-please call Dr. [**Last Name (STitle) **] or Dr. [**Last Name (STitle) 7994**] [**Telephone/Fax (1) 8717**] or come directly to the emergency room. Followup Instructions: 1. [**Hospital 18**] [**Hospital 4038**] Clinic in 2 months- Dr. [**Last Name (STitle) **]; please call [**Telephone/Fax (1) 1694**] for an appointment 2. Call your primary care provider for an appointment within [**2-5**] weeks. [**Name6 (MD) 4267**] [**Last Name (NamePattern4) 4268**] MD, [**MD Number(3) 5023**]

[ "747.81", "V49.76", "305.1", "780.39" ]

icd9cm

[ [ [] ] ]

[ "88.41", "96.71" ]

icd9pcs

[ [ [] ] ]

6354, 6360

4673, 6152

333, 356

6442, 6452

3465, 4650

6937, 7286

2099, 2161

6214, 6331

6381, 6421

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275, 295

384, 1842

2800, 3446

2600, 2784

2571, 2585

1864, 1944

1960, 2083

56,460

198,152

54741

Discharge summary

report

Admission Date: [**2189-7-5**] Discharge Date: [**2189-7-22**] Date of Birth: [**2125-4-22**] Sex: M Service: CARDIOTHORACIC Allergies: refoxicin Attending:[**First Name3 (LF) 15850**] Chief Complaint: Esophageal perforation Major Surgical or Invasive Procedure: 1. Left thoracotomy with repair of esophageal perforation and upper gastrointestinal endoscopy ([**7-5**]) 2. Right tube thoracostomy ([**7-5**]) 3. Right pigtail placement ([**7-14**]) History of Present Illness: 64 year old male who reports awakening at 5 am this morning with the acute onset of chest pain. He then proceeded to vomit 3-4 times. The pain was severe and bilateral across his lower chest. He went to an OSH and was found to have pneumomediastinum on CT, WBC of 15, and tachycardia concerning for esophageal tear. He was given pain medication, 2L IVF, nebulizers, and zosyn. The patient was actively intoxicated on arrival but denied having vomited or retched prior to the onset of pain. Denies having vomited last night. Admits to heavy alcohol use. Describes ongoing dyspnea, cough, COPD flares, and need for chronic home oxygen, usually at night only. He was med flighted to [**Hospital1 18**] and on arrival was still tachycardic and intermittently tachypneic. He was essentially pain free on evaluation, reporting his chest pain as much improved. Denies further nausea or vomiting since arriving at the OSH. Reports mild abdominal pain and sensation of bloating. Reports back pain with deep breaths. Says that he has been short of breath for many years and continues to be. Intermittently wheezing and coughing heavily over last few days as well. The patient was complaining throughout the evaluation of wanting to smoke or walk up and get around. He was actively tremulous throughout the evaluation and exhibited signs of delirium. Past Medical History: PAST MEDICAL HISTORY: alcohol abuse, heavy smoker, COPD on home oxygen, h/o multiple pneumonias, h/o alcohol withdrawal, ?SVT s/p pacemaker followed by pacemaker removal and subsequent ablation procedures in the [**2167**]'s PAST SURGICAL HISTORY: tonsillectomy, L knee replacement, cardiac ablations x 3 Social History: current smoker 3ppd for many years; history of alcohol with withdrawal, history of rehab (Fall), has not been successfully sober. Denies illicit drug use. Lives with a supportive girlfriend. Family History: Non-contributory Physical Exam: Upon discharge: VS: Tm 100.7 Tc 98.8 HR 87 BP 109/57 RR 18 02sat 98% 2L NC General: in no acute distress, conversant HEENT: sclera anicteric, mucus membranes moist, no perioral cyanosis. Nasal cannula in place CV: regular rate, rhythm Pulm: ronchi at bases with slight expiratory wheezes bilaterally Chest: well-healing left postero-lateral incision Abd: nontender, nondistended MSK: warm, well perfused. Pertinent Results: Laboratory: [**2189-7-5**] 03:20PM BLOOD WBC-12.1* RBC-4.88 Hgb-14.9 Hct-47.6 MCV-98 MCH-30.5 MCHC-31.3 RDW-16.1* Plt Ct-172 [**2189-7-14**] 12:44AM BLOOD WBC-20.3* RBC-2.86* Hgb-8.5* Hct-27.6* MCV-96 MCH-29.7 MCHC-30.9* RDW-16.1* Plt Ct-412 [**2189-7-16**] 12:36AM BLOOD WBC-19.1* RBC-2.95* Hgb-8.8* Hct-27.3* MCV-93 MCH-29.9 MCHC-32.2 RDW-16.2* Plt Ct-471* [**2189-7-21**] 05:28AM BLOOD WBC-11.9* RBC-2.98* Hgb-8.9* Hct-28.1* MCV-94 MCH-29.8 MCHC-31.7 RDW-14.8 Plt Ct-628* [**2189-7-5**] 03:20PM BLOOD PT-10.2 PTT-27.1 INR(PT)-0.9 [**2189-7-11**] 12:44AM BLOOD PT-11.8 PTT-72.0* INR(PT)-1.1 [**2189-7-5**] 03:20PM BLOOD Glucose-147* UreaN-32* Creat-1.0 Na-139 K-4.4 Cl-99 HCO3-21* AnGap-23* [**2189-7-12**] 01:54AM BLOOD Glucose-143* UreaN-17 Creat-0.5 Na-145 K-3.6 Cl-109* HCO3-27 AnGap-13 [**2189-7-21**] 05:28AM BLOOD Glucose-113* UreaN-6 Creat-0.6 Na-139 K-3.9 Cl-103 HCO3-26 AnGap-14 [**2189-7-5**] 03:20PM BLOOD ALT-33 AST-39 AlkPhos-65 TotBili-1.0 [**2189-7-5**] 10:00PM BLOOD ALT-22 AST-31 AlkPhos-38* Amylase-57 TotBili-0.4 [**2189-7-6**] 04:33PM BLOOD CK(CPK)-1480* [**2189-7-8**] 03:45AM BLOOD CK(CPK)-1061* [**2189-7-9**] 12:08AM BLOOD CK(CPK)-595* [**2189-7-5**] 03:20PM BLOOD cTropnT-0.02* [**2189-7-6**] 04:33PM BLOOD CK-MB-16* MB Indx-1.1 cTropnT-<0.01 [**2189-7-7**] 09:47PM BLOOD CK-MB-46* MB Indx-3.3 cTropnT-1.10* [**2189-7-8**] 01:16PM BLOOD CK-MB-17* MB Indx-1.9 cTropnT-0.44* [**2189-7-8**] 05:28PM BLOOD CK-MB-13* MB Indx-1.4 cTropnT-0.48* Diagnostics/Imaging: [**2189-7-5**]: UGI Initial scout image of the chest demonstrates pneumomediastinum, extending superiorly into the right cervical region. Small bilateral pleural effusions are noted. Bibasilar opacities are also present. There is no pneumothorax. Water-soluable contrast was orally administered and images were obtained in the oblique projections. Contrast leakage is demonstrated at the level of the GE junction, which corresponds to CT chest findings of the same date [**2189-7-6**]: ECHO The left atrium is normal in size. Overall left ventricular systolic function is probably normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. No aortic regurgitation is seen. No mitral regurgitation is seen. There is a trivial/physiologic pericardial effusion. There are no echocardiographic signs of tamponade. [**2189-7-7**]: ECHO The left atrium is normal in size. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Overall left ventricular systolic function is low normal (LVEF 50%) secondary to focal hypokinesis of the inferior and posterior walls. Tissue Doppler imaging suggests a normal left ventricular filling pressure (PCWP<12mmHg). Right ventricular chamber size and free wall motion are normal. The aortic root is mildly dilated at the sinus level. The ascending aorta is mildly dilated. The aortic valve leaflets are mildly thickened (?#). There is no aortic valve stenosis. Trace aortic regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. Compared with the findings of the prior study (images reviewed) of [**2189-7-6**], focal inferior posterior hypokinesis is now seen, but the technically suboptimal nature of both studies precludes definitive comparison. [**2189-7-7**]:ECG: Sinus rhythm at 95bpm. Compared to previous tracing multiple abnormalities as previously noted persist without major change. [**2189-7-10**]:ECHO: The left atrium is mildly dilated. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF 60%). The inferior free wall appears hypokinetic. 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. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is mild posterior leaflet mitral valve prolapse. Trivial mitral regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. Compared with the findings of the prior study (images reviewed) of [**2189-7-7**], the left ventricular ejection fraction is increased. [**2189-7-12**]: CT chest with contrast: No axillary lymphadenopathy is identified. Stable mediastinal lymphadenopathy measuring up to 8 mm in the pretracheal region is identified. No hilar lymphadenopathy is seen. The thyroid gland is unremarkable. A central venous catheter is identified extending into the left subclavian vein with its tip in the distal SVC. In addition, there is a right lead extending into the right subclavian vein with its tip in the right atrium. Prior to entering the subclavian vein, it is coiled in the anterior superior subcutaneous tissues of the right chest. The heart size is normal. The thoracic aorta demonstrates minimal calcified or noncalcified atherosclerotic plaque, but is normal in size. The pulmonary artery is normal. There is no pericardial effusion. The central tracheobronchial tree is patent. There are bilateral pneumothoraces, greater on the right. There are patchy airspace opacities in both lungs that were not seen previously and suggest the development of multifocal pneumonia. Bilateral pleural effusions with associated passive atelectasis are identified, greater on the right. An enteric tube is seen. Oral contrast is seen are within the esophageal lumen and has not extravasated outside the luminal contours. There is a fluid collection surrounding the mid-to-distal esophagus and currently measures approximately 3.2 x 2.4 cm. There is a solitary focus of air within this collection. This has decreased in size from the examination at which point the patient presented with esophageal perforation. The liver has a normal contour. A focal area of decreased enhancement along the falciform ligament is an area of focal fatty infiltration. No hepatic mass is identified. There is no biliary tree distention. The gallbladder has a normal appearance. The pancreas enhances homogeneously without evidence for mass. The pancreatic duct is normal in caliber. The spleen enhances homogeneously. Multiple hypodensities are seen within the left kidney, the largest of which measures 1.7 cm in the superior pole. This measures 26 Hounsfield units, slightly higher than simple fluid. Otherwise, the kidneys enhance symmetrically with symmetric excretion. No adrenal nodules are identified. A Foley catheter is within a collapsed bladder. The prostate gland and seminal vesicles are unremarkable. Oral contrast is seen extending to the rectum. There is no evidence for obstruction. There is extensive diverticulosis of the sigmoid and descending colon without evidence for diverticulitis. There is no ascites. Calcified and noncalcified atherosclerotic plaque of the abdominal aorta is identified. The visualized vasculature is unremarkable. No lytic or blastic osseous lesions are seen. There is very minimal grade 1 retrolisthesis of L5 on S1 with minimal degenerative change at this level. [**2189-7-17**]: ECHO: Compared with the prior study (images reviewed) of [**2189-7-10**], no clear change. [**2189-7-20**]: CXR: Previous mild pulmonary edema has improved, small right pleural effusion, largely fissural, has decreased. Bibasilar atelectasis unchanged. Upper lungs clear. No pneumothorax. No mediastinal widening. Left PIC line ends in the mid SVC. Right atrial temporary pacer lead unchanged in position. [**2189-7-14**]: Pleural fluid: NEGATIVE FOR MALIGNANT CELLS.Reactive mesothelial cells, histiocytes and lymphocytes Brief Hospital Course: General Brief Hospital Course: The patient was admitted to the Thoracic surgery Service for evaluation and treatment of an esophageal perforation in context of known alcohol abuse. The patient subsequently underwent a left thoracotomy with repair of esophageal perforation with upper endoscopy as well as chest tube placement. (The reader is referred to the Operative Note for details). The patient received IV zosyn and fluconazole, with a foley catheter in place. The patient required minimal neosynephrine for blood pressure support throughout the case, and was hemodynamically stable upon transfer to the ICU. His course however was complicated by prolonged alcohol withdrawal, ST changes with troponin bump as well paroxysmal atrial fibrillation, the latter of which Cardiology was consulted. He was eventually transferred to the floor on POD#15, the patient was stable to transfer to the floor requiring intermittent IV ativan with a regular oral regimen. By system, Neuro: The was kept intubated post-operatively and was sedated with propofol with fentanyl for pain control. This appeared to provide adequate coverage; however, he was noted to become moderately hypotensive with propofol, which was intermittently held. As noted, the patient has an extensive history of alcohol abuse with history of withdrawal, and was provided ativan as needed. This however was transitioned to Precedex drip, which later appeared to make the patient bradycardic. He was extubated soonthereafter, but with new-onset atrial fibrillation on HD#4 in context of active withdrawal, the patient was electively intubated. The precedex was eventually weaned off and transitioned back to IV ativan, which continued throughout his stay which was titrated for his agitation, which also included hallucinations with need for restraints for patient safety. He was re-extubated on HD#8. He was discharged on both IV ativan in small doses with PO ativan 2mg po TID standing without active signs of withdrawal. He was also provided a nicotine patch and clonidine patch for alleviating his withdrawal symptoms. He was alert, oriented to person, place and time prior to discharge. CV: As noted earlier, the patient was noted to have ST changes on EKG on POD#1 with tropinin bump to 1.1 on POD#2 with elevated CK to 1400s, both of which eventually downtrended. The patient was evaluated by Cardiology, with recommendations for heparin drip and plavix, which were both initiated, and ECHO, which demonstrated no acute abnormalities with preserved ejection fraction of >55%. On POD#3, the patient was noted to be in paroxsymal atrial fibrillation, which was rate-controlled, and was treated with IV lopressor with good effect. Cardiology impressions at this time were that the dysrhythmia was likely related to pericarditis from mediastinal inflammation. The patient was eventually taken off heparin drip without anti-coagulation as he was a poor candidate given his non-compliance and history of alcohol abuse. He was eventually plaecd on a full-dose aspirin with metoprolol 25mg tid PO with good rate control, in sinus rhythm and blood pressure within normal range. He was advised to follow-up in the Cardiology clinic within the next 3-4 weeks. Pulmonary: As noted, the patient required elective re-intubation within a few days post-operatively given new-onset paroxysmal atrial fibrillation, active withdrawal despite being on Precedex drip. The patient has a history of COPD on home oxygen and encountered some difficulty with spontaneous breathing trials, but was eventually extubated on HD#8. However on this same day he was noted to spike a temperature to 101.7 with CT torso on HD#9 demonstrating possible multi-focal pneumonia. He was also noted to have a right-sided pleural effusion, which underwent right pigtail placement by the Interventional Pulmonology service; cytology and cultures returned unremarkable, and this was eventually removed. He was started on ciprofloxacin/vancomycin in addition to zosyn and fluconazole, the latter of which were discontinued on HD #15. The patient received regularly scheduled albuterol and ipratropium nebulizer treatments with good effect. He was encouraged to use his incentive spirometer, and was eventually weaned to oxygen of 2LNC. GI/GU/FEN: The patient underwent a primary repair of his esophageal perforation which was likely a result of repeated vomiting in context of his alcohol abuse. Post-operatively, the patient was made NPO with IV fluids. He was started on TPN He received TPN on HD#5, which was discontinued after approximately one week after the patient extubated, passed a speech and swallow evaluation, and was advanced to clears, which he tolerated. He was eventually advanced to a regular diet, which he continue to tolerate prior to discharge. Patient's intake and output were closely monitored, and IV fluid was adjusted when necessary. Electrolytes were routinely followed, and repleted when necessary. ID: The patient's white blood count and fever curves were closely watched for signs of infection. He initially demonstrated a leukocytosis to 12 which remained stable until HD#10 after a temperature spike the previous day to 101.7F. Blood cultures returned negative, as did cytology from a drained right pleural effusion. The patient was initially placed on zosyn and fluconazole for his esophageal perforation for broad spectrum coverage for a 14 day course. Upon the temperature spike, and demonstration of possible multifocal pneumonia on CT torso on HD#9, the patient was started on vancomycin and ciprofloxacin from ([**Date range (1) 111933**]). He was afebrile without evidence of infection prior to discharge. His incision was well-healed without evidence of erythema or drainage. Hematology: The patient's complete blood count was examined routinely; his hematocrit was stable at 28 prior to discharge. The patient has a PICC line in place. Prophylaxis: The patient received subcutaneous heparin, venodyne boots were used during this stay in addition to pantoprazole for GI prophylaxis; he was encouraged to get up and ambulate as early as possible. At the time of discharge to rehabilitation, 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: albuterol prn, klonopin prn, aspirin 325 daily, vitamin C Discharge Medications: 1. nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr Transdermal DAILY (Daily). 2. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q4H (every 4 hours) as needed for SOB/Wheeze. 3. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours). 4. clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QMON (every Monday). 5. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. lorazepam 1 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 7. quetiapine 50 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)) as needed for agitation. 8. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 9. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain. 10. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 11. lorazepam 2 mg/mL Syringe Sig: 0.5-2mg Injection Q1H (every hour) as needed for agitation, anxiety. Discharge Disposition: Extended Care Facility: [**Hospital3 7665**] Discharge Diagnosis: Esophageal perforation History of alcohol abuse Paroxysmal atrial fibrillation COPD 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 perforation of your esophagus and underwent repair of this perforation, which you tolerated well. You received an appropriate dose and duration for this perforation and remained afebrile prior to discharge. However, soon after your operation it was noted that your cardiac lab markers with slight changes on EKG concerning for a cardiac event; these lab markers were followed, with eventual down-trend. You were also found to have a dysrythmia, called paroxysmal atrial fibrillation for which the Cardiology team was consulted. It was concluded that these changes were likely post-operative and a result of inflammation of the walls of your heart due to inflammation within your chest due to a known perforation. You were placed on a full-dose aspirin and beta-blocker (Metoprolol). Your heart rhythm and blood pressure have since been within normal range and rhythm. You are advised to follow-up with Cardiology as an out-patient; see information below. You also developed a right pleural effusion for which a pigtail catheter was placed with adequate drainage and subsequent removal. This was performed by the interventional pulmonology team. You have been tolerating a regular diet with pain controlled with oral pain medications. You continue to receive nebulizer treatments for COPD and should remain on such as you need them. You are ready to continue the rest of your recovery at a rehabilitation facility prior to going back home. General Discharge Instructions: Please resume all regular home medications , unless specifically advised not to take a particular medication. Also, please take any new medications as prescribed. Your new medications include: metoprolol 25mg tid, Clonidine Patch 0.3 mg/24 hr 1 PTCH TD QMON d/c 0.2 mg patch, pantoprazole 40mg PO qd, as well as Lorazepam 2 mg PO/NG TID. Please get plenty of rest, continue to ambulate several times per day, and drink adequate amounts of fluids. Avoid lifting weights greater than [**6-25**] 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. Followup Instructions: Please follow-up with Dr. [**Last Name (STitle) 7343**] in his clinic ([**Hospital Ward Name 23**] building, [**Location (un) **]) on [**2189-8-6**] at 11AM. You should have a chest x-ray prior to this appointment at 10:30AM, which is scheduled; this is located also in the [**Hospital Ward Name 23**] building, [**Location (un) **]. You may call his office at [**Telephone/Fax (1) 2348**] with any questions. Please follow-up in the Cardiology clinic on [**2189-8-25**] 3:20PM, [**Hospital Ward Name **] [**Hospital Ward Name 23**] 7 (Cardiac services). You may call ([**Telephone/Fax (1) 3942**] with any questions. Completed by:[**2189-7-22**]

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icd9cm

[ [ [] ] ]

[ "38.93", "34.09", "38.91", "34.04", "99.15", "44.13", "96.71", "42.82", "96.04" ]

icd9pcs

[ [ [] ] ]

18310, 18357

10669, 17125

299, 491

18485, 18485

2876, 10615

21246, 21897

2416, 2434

17233, 18287

18378, 18464

17151, 17210

18636, 20120

20927, 21223

2133, 2192

2449, 2449

20152, 20912

237, 261

2466, 2857

519, 1862

18500, 18612

1906, 2110

2208, 2400

68,501

139,687

8751

Discharge summary

report

Admission Date: [**2100-7-26**] Discharge Date: [**2100-7-30**] Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 4748**] Chief Complaint: R carotid stenosis Major Surgical or Invasive Procedure: R carotid endarterectomy with takeback for exploration and angiography History of Present Illness: The patient is an 85-year-old diabetic female who presents with a history of right internal carotid artery stenosis found by her primary care doctor and had been followed for some time. She presented for an MRA that was done on [**2100-6-11**] which subsequently found that her stenosis had progressed to 75-80% stenosis in the right internal carotid artery. She is, of note, not having any symptoms whatsoever from this such as transient ischemic attacks or things like amaurosis fugax. She therefore presents today for definitive management of her asymptomatic right internal carotid artery stenosis. Past Medical History: PVD, DM, HTN, CAD,hyperlipidemia, GERD, carotid disease and stroke with gait imbalance. COPD Social History: Widowed, no EtOH, 25 pky smoking hx, quit [**2060**], no illicits. Family History: Noncontributory Physical Exam: Vitals-99.6 74 138/51 22 93%4L Gen- AxOx3, NAD CV- RRR, no mrg Pulm-CTABL abd- soft, nt, nd Incision- CDI Neuro- Right 5/5 strength Left- Lower- [**3-22**] Upper [**1-22**] lifting arm, 0-1/5 left hand/fingers Pertinent Results: CTA-Post op 1. No evidence of acute intracranial abnormality. CTA demonstrates moderate left MCA M1 segment stenosis but patent anterior and posterior circulation vasculature. CT perfusion is within normal limits. If clinical suspicion is high for acute infarction, MRI is more sensitive for small infarcts that may be beyond the resolution of CT. 2. Expected post-surgical appearance of the right carotid endarterectomy with subcutaneous emphysema. Tiny filling defect in the proximal right ICA may represent a tiny mural thrombus. 3. Extensive diffuse atherosclerotic disease involving the aortic arch and bilateral carotid arteries. Moderate stenosis with calcified atheroma at left carotid bifurcation. MRI Right hemispheric infarcts, subacute. The distribution is suspicious for predominantly watershed infacts, with scattered smaller embolic infarcts. Brief Hospital Course: Pt was admitted [**2100-7-26**] for Right internal carotid artery stenosis, symptomatic R CEA Post op - Left-sided neurological deficit, status post right carotid endarterectomy Exploration of the right neck and on-table carotid angiography. An on-table carotid angiography was then performed, having noted no obstruction or other abnormalities within the vasculature of the common, external or internal carotid arteries. We were, therefore, satisfied with our examination that, indeed, there was no acute occlusion of any of the arteries and, therefore, proceeded to ensure that the operative field was secured hemostatically clipped and stripped. POD # ! PT / OT Case management for rehab accepted to rehab pt stable Medications on Admission: Aspirin 325', atenolol 50", Diovan 160', Protonix 20', fish oil, Spiriva, Plavix 75', Imdur 60"and Norvasc 10', omeprazole 20' Discharge Medications: 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q2H (every 2 hours) as needed for wheezing/SOB. 4. Valsartan 80 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 5. Isosorbide Mononitrate 60 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO BID (2 times a day). 6. Atenolol 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 8. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 9. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for mild pain or fever. Discharge Disposition: Extended Care Facility: [**Hospital6 **] Discharge Diagnosis: Right carotid stenosis with post-operative ischemia/possible stroke Discharge Condition: stable. Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to the vascular surgery service for a Right carotid endarterectomy. 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 ?????? Call and schedule an appointment to be seen in 2 weeks for staple/suture removal 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 Followup Instructions: Please follow-ep with Dr. [**Last Name (STitle) 1391**] in [**1-20**] weeks. [**Telephone/Fax (1) 3121**] Completed by:[**2100-7-30**]

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icd9cm

[ [ [] ] ]

[ "00.40", "88.41", "38.12", "06.02" ]

icd9pcs

[ [ [] ] ]

4068, 4111

2361, 3092

280, 353

4223, 4231

1474, 2338

7224, 7361

1205, 1222

3270, 4045

4132, 4202

3118, 3247

4382, 6629

6655, 7201

1237, 1455

222, 242

381, 987

4246, 4358

1009, 1104

1120, 1189

21,960

134,697

20037

Discharge summary

report

Admission Date: [**2128-11-30**] Discharge Date: [**2128-12-21**] Date of Birth: [**2054-6-29**] Sex: F Service: Cardiac Surgery CHIEF COMPLAINT: Chest pain. HISTORY OF PRESENT ILLNESS: This 74 year old woman was transferred from [**Hospital 1562**] Hospital after rule-in myocardial infarction and cardiac catheterization which showed three vessel disease. The patient was admitted to [**Hospital 1562**] Hospital after awaking during the night with chest pressure and she went to the bathroom, she felt dizzy, fell down and lost consciousness. She did have a myocardial infarction 12 years ago. Catheterization at that time showed no blockages. Stress test this past summer was "okay." A recent cardiac catheterization showed a left main coronary artery stenosis 40%, left anterior descending 80%, and anomalous septal branch 99% stenosis, left circumflex 45% stenosis and a right circumflex greater than 90% stenosis. PAST MEDICAL HISTORY: Hypertension, hypercholesterolemia, coronary artery disease, myocardial infarction ten years ago. Peripheral vascular disease, carotid disease and disc surgery. ALLERGIES: She is allergic to Amoxicillin which gives her hives. MEDICATIONS: Medications at home include Atacard 32 mg p.o. q.d., Norvasc 5 mg p.o. q.d., Aspirin. Medications on transfer included heparin drip, Nitroglycerin drip, Aspirin 325, Protonix. SOCIAL HISTORY: She lives with her husband. She does have a positive smoking history but she quit five years ago. Ethanol, she takes one drink a day. FAMILY HISTORY: No family history of coronary artery disease. LABORATORY DATA: Her outside hospital laboratory data were significant for an elevated creatinine kinase of 627 and an elevated troponin of 6.25, creatinine kinase at the outside laboratory showed a sinus rhythm at 43, ST elevations in 2, 3 and AVF and depression in lateral leads V2 to V6. Echocardiogram showed good ejection fraction of 65%, mild mitral regurgitation and moderate tricuspid regurgitation. PHYSICAL EXAMINATION: On physical examination she was afebrile, sinus rate, 145, 114/56, 18 and 99% on 2 liters. Thin woman in no acute distress. She is alert and oriented times three and follows commands. No focal deficits on neurological examination. Head and neck examination, she is pupils equal, round and reactive to light and accommodation. Extraocular movements intact. Anicteric. Mucous membranes are moist. Neck is supple, no lymphadenopathy, positive bruits bilaterally. Chest examination, heart is regular rate and rhythm, S1 and S2, no murmurs. Lungs are clear to auscultation bilaterally. Abdomen is soft, nontender, nondistended. Her extremities, warm and well perfused, no cyanosis, clubbing or edema with 2+ and equal pulses in the carotids, femorals, radials and dorsalis pedis. HOSPITAL COURSE: This is a patient who has three vessel disease who is admitted to the Cardiac Surgery Service for a coronary artery bypass graft evaluation and treatment. She was admitted and over the next couple of days she was observed with Telemetry and preopped for a coronary artery bypass graft procedure. On [**2128-12-2**], after being appropriately consented, the patient was taken to the Operating Room for a coronary artery bypass graft. Please refer to the previously dictated operative note by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 70**] from [**2128-12-2**]. In brief, a left internal mammary artery was connected to the left anterior descending artery, however, further grafts could not be performed as the aorta was extremely calcified and the right coronary artery was bifurcated in an awkward angle. Therefore she was sent to the catheterization laboratory. Basically the operation was stopped after a single bypass graft and then the patient was sent to the catheterization laboratory where she underwent a right coronary artery stent placement. The patient tolerated both of these surgical interventions well and was transferred to the Cardiac Surgery Recovery Unit in good condition. That evening the patient was extubated and weaned off of all of her intravenous drips and did well in the Cardiac Surgery Recovery Unit. On postoperative day #2, the patient did well enough that she was transferred to the floor. The rest of her admission can be described in the organ-based fashion. Central nervous system - The patient did not have any central nervous system symptoms during her admission, however, her pain was controlled well with Percocet and at the time of discharge she was taking one Percocet every four hours for break-through pain. Cardiovascularly, the patient underwent a coronary artery bypass graft on [**2128-12-2**]. She also underwent two percutaneous transluminal coronary angioplasty stent placements, on [**2128-12-2**] and [**2128-12-8**] with good result. She has done very well with respective to her cardiovascular status since her surgeries. Pulmonary, immediately after surgery the patient suffered from increased secretion and a chronic sort of nonproductive cough. She was followed with serial and chest x-rays which at first did not show anything but some nonspecific postoperative atelectasis with some small effusions, however, by postoperative day #7, on [**12-9**], these were read as having a right middle lobe collapse. Pulmonary consult was obtained. A [**12-13**] computerized axial tomography scan showed a right lower lobe collapse and focal consolidation. On [**12-14**], the patient was bronchoscoped revealing tracheobronchial malacia and right middle lobe and right lower lobe collapse secondary to increased secretions. These were sent off for culture and subsequently grew out Methicillin-sensitive resistant Staphylococcus aureus. Follow up chest x-ray on [**12-17**] and [**12-19**] both showed decreased consolidations and collapse. Renal, the patient was adequately diuresed and was 44.4 kg at the time of discharge which was very close to her preoperative weight. Hematologically, the patient had several episodes of anemia which responded well to red blood cell transfusion. Fluids, electrolytes and nutrition, the patient's nutritional status revealed she was tolerating a regular diet soon after surgery but had decreased appetite and calorie counts were followed. Prior to her discharge it was noted that she was taking 85% of her recommended caloric intake prior to discharge. Otorhinolaryngology, throughout her floor admission, the patient complained of clogged ears and cerumen impaction which she suffers from chronically. An Otorhinolaryngology consult was obtained which recommended otic drops and a follow up appointment in the [**Hospital 29326**] Clinic with Dr. [**First Name (STitle) **] before discharge on [**12-20**]. Infectious disease, the patient had one contaminated sputum culture which reveal gram positive cocci, a bit of a red [**Doctor Last Name **], but bronchoalveolar lavage from [**12-14**] did grow out 4+ Staphylococcus aureus which were resistant to Oxacillin. She was immediately started on Vancomycin and soon her white count came down and she began feeling better. She had a more productive cough and began to breath much better on Vancomycin. On [**12-19**], the patient was switched over to Linezolid for p.o. coverage and as discussed with Infectious Disease she was recommended to go home with two weeks of Linezolid coverage for her Methicillin-sensitive resistant Staphylococcus aureus pneumonia. So, Ms [**Name13 (STitle) 53957**] was being discharged on [**2128-12-20**], postoperative day #18. DISCHARGE DIAGNOSIS: 1. Hypertension 2. Hypercholesterolemia 3. Coronary artery disease 4. Acute myocardial infarction 5. Peripheral vascular disease 6. Methicillin-sensitive resistant Staphylococcus aureus pneumonia 7. Tracheobronchial malacia 8. Right lower lobe, right middle lobe collapse due to accumulated secretions 9. Chronic blood loss anemia requiring transfusion 10. Cerumen impaction FOLLOW UP: She has follow up appointments with Dr. [**First Name (STitle) **] in [**Hospital 29326**] Clinic, Dr. [**Last Name (STitle) **] her primary care physician, [**Name10 (NameIs) **] cardiologist, her [**Doctor Last Name 70**], her cardiothoracic surgeon and Dr. [**First Name (STitle) **] her interventional cardiologist. DISCHARGE MEDICATIONS: 1. Linezolid 600 p.o. q. 12 2. Aspirin 81 mg p.o. q.d. 3. Plavix 75 mg p.o. q.d. 4. Percocet one tablet p.o. q. 4 hours prn for pain 5. Norvasc 5 mg p.o. q.d. around the clock 6. Colace 100 mg p.o. b.i.d. as needed for constipation 7. Albuterol inhaler 8. Neomycin/Polymyxin otic drips [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 75**] Dictated By:[**Last Name (NamePattern1) 1179**] MEDQUIST36 D: [**2128-12-19**] 20:47 T: [**2128-12-19**] 20:57 JOB#: [**Job Number 53958**]

[ "414.01", "280.0", "410.71", "482.41", "519.1", "V15.82", "380.4", "440.0", "518.0" ]

icd9cm

[ [ [] ] ]

[ "33.24", "36.07", "37.22", "00.14", "38.93", "36.01", "36.15", "88.55" ]

icd9pcs

[ [ [] ] ]

1564, 2021

8364, 8965

7623, 8008

2848, 7602

8020, 8341

2044, 2830

168, 181

210, 950

973, 1394

1411, 1547

17,923

141,521

28412

Discharge summary

report

Admission Date: [**2116-9-8**] Discharge Date: [**2116-9-14**] Date of Birth: [**2078-1-19**] Sex: F Service: GYN PRINCIPAL DIAGNOSIS: Uterine perforation, intraabdominal hemorrhage. PRIMARY PROCEDURES: Dilatation, evacuation for trisomy 21 fetus and exploratory laparotomy repair of uterine perforation. CONSULTATION: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2028**], department of gyn/oncology. DISCHARGE MEDICATIONS: Percocet and Niferex and Motrin. DISCHARGE STATUS: Good, improved and discharged to home. HISTORY OF PRESENT ILLNESS: [**Known firstname 14552**] [**Known lastname 68928**] is a gravida 3 para 2 with 2 previous cesarean sections with her second C section being complicated by a placenta accreta with significant blood loss and blood transfusion. Patient had a dilatation and curettage earlier at 16 weeks for anomalous fetus with trisomy 21. An ultrasound done at the time of the amniocentesis suggested that the placenta was implanted in the similar site to the previous placenta when she had a placenta accreta and there was some hypervascularity around the implantation sites suggestive of some abnormal placentation. The dilatation and curettage had been done without any complications noted. Ultrasound at the end of the procedure showed what appeared to be a completely evacuated uterus. All fetal parts have been identified. HOSPITAL COURSE: In the recovery room, the patient was moved from phase 1 to phase 2 and prior to discharge was complaining of some weakness and some shoulder pain. Hematocrit was done, which showed a hematocrit of 14. This was repeated to confirm the diagnosis. The patient immediately was taken back to phase 1. Intravenous lines were placed. Examination showed a mildly distended abdomen with minimal upper quadrant abdominal pain and complaining of some significant uterine tenderness. An ultrasound was done at the bedside, which was suggestive of intraabdominal fluid approximately 500 to 1000 cc was a gross estimate. The patient's blood pressure was noted to be low. It had been low in the recovery room, though the patient's baseline blood pressure is 100/60. She had never become tachycardic and even during this phase had a pulse of 80. Decision was made to take the patient back to the operating room. Due to the patient having a stable pulse, a decision was made to do a laparoscopy in the operating room to evaluate the perforation and the amount of intraabdominal blood to make a determination if a laparotomy needed to be done. A laparoscopic was done without complications. Its showed a small perforation in the left anterior portio of the uterus near the insertion of the round ligament. There was some blood underneath the bladder flap and there was some free floating blood in the abdomen cavity approximately 1 liter of blood. There was not active bleeding from the perforation site, but there was some persistent oozing and decision was made that laparotomy would be performed. Laparotomy was then done. Exposure showed the small perforation, but there was a significant amount of bleeding in the lower part of the uterus with uterine atone and an extremely thin uterine wall with very minimal myometrial tissue there. Bleeding was welling up in the lower uterine segment, it was going into the abdominal cavity through the uterine perforation site. Decision was made to over sew some of this area in the lower part of the uterus. Better uterine tone was achieved at this time. The uterine perforation was repaired. There still was significant bleeding from the left adnexal area. Gyn oncology Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2028**] was brought in for a consultant who helped identify the ureters and the uterine artery. There was no damage to the uterine artery. There was no damage to the ureters. A cystoscopy was performed to assure patency of the ureters and several stitches were placed in the paracervical area on the left side to achieve hemostasis. The patient was transfused 4 units of blood at this point. The abdomen was the closed. The patient was taken to the intensive care unit and monitored. Over the subsequent 24 hours, the patient's hematocrit did drop and received 1 more unit of blood. Her hematocrit stabilized at 26 and remained that way. The patient was transferred out of the unit to the floor where she improved her mobility, was taken off of intravenous pain meds and put on oral pain medication and when showing signs of passing gas and some flatus and able to ambulate to the bathroom, the patient was discharged to home. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 68929**], [**MD Number(1) 68930**] Dictated By:[**Last Name (NamePattern4) 68931**] MEDQUIST36 D: [**2116-10-1**] 08:45:40 T: [**2116-10-1**] 09:22:35 Job#: [**Job Number 68932**]

[ "635.22", "635.72", "285.1", "473.9", "635.12", "659.63", "635.52", "655.83", "458.29", "999.2", "451.84" ]

icd9cm

[ [ [] ] ]

[ "39.98", "69.29", "99.04", "54.12", "69.51", "99.77", "57.32", "54.21" ]

icd9pcs

[ [ [] ] ]

473, 566

1428, 4897

595, 1410

27,914

144,022

4527

Discharge summary

report

Admission Date: [**2147-6-17**] Discharge Date: [**2147-6-22**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 783**] Chief Complaint: shortness of breath Major Surgical or Invasive Procedure: none History of Present Illness: HPI: Patient is a [**Age over 90 **] y/o woman with PMH of NIDDM, HTN, hypercholesterolemia, CRI (baseline 4.2), who originally presented with 3 days of SOB, PND, and orthopnea but no weight changes, LE edema, CP, abdominal discomfort, fevers, cough. Per family, pt had recent hospitalization at Caritas with similar symptoms and was discharged after diuresis. Patient was compliant with her medications, no dietary indiscretions and no recent weight changes per family. In ambulance, patient was given 80mgIV lasix. In [**Name (NI) **], pt had SBP of 188/100 and sating 100% on NIPPV, was given additional 40mg IV and started on nitro drip. Foley was placed without urine output and was admitted to the ICU for possibly dialysis and BP control. In ED, cardiology was consulted and MICU admission suggested as patient did not put out to lasix. Renal was consulted for possible emergent dialysis and line placement. Pt and family have been having recent discussions re:dialysis. . Patient was admitted to the MICU for urgent dialysis. However, patient was diuresed with a lasix drip with diuril priming where she put out 1L/day. She also was weaned of her O2 requirement. However on [**6-18**], patient HCT dropped from 34 to 25.9. No source of bleeding was found and HCT remained stable. Past Medical History: PMH: NIDDM HTN hypercholesterolemia CRI neg for MI/CVA . PSH: # c-sections . Medications on admission: lisinopril 30mg po qday glipizide XR 10mg po bid pioglitazone 45 po qday diltiazem XT 180 mg qday calcitriol 0.25 mcg qday lasix 40mg qAM and 20 Qpm epoeitin [**Numeric Identifier 389**] units q3 weeks lipitor 10mg qday HCTZ 25mg qday prednisolone opth qid colace 100mg [**Hospital1 **] ASA 81mg po qday. . medications on transfer: Asa 81mg daily lipitor 10mg daily calcitriol 0.25 mcg po daily caco3 500mg po QIDACHS chlorothiazide 500mg IV x2 on [**6-18**] diltiazem 60mg po TID colace 100mg po bid ferrous sulfate 325 mg po daily furosemide 1-20mg/hr IV drip titrate to 100cc/hr UO glipizide XL 10mg po BID heparin 5000 U SC TID lisinopril 30mg po daily metoprolol 12.5mg po BID nitro GTT 0.6 mcg/kg/min IV drip titrat toe SBP <140 but >100 pioglizazone 45 mg po daily prednisolone acetate 1% opth 1 drop B/L eyes QID senna 1 tab po bid prn. Social History: SH: no h/o sig tobacco, ETOH, no drug use. 3 children (one daughter HCP is [**Name (NI) **]. Family History: FH: HTN, mother lived to 105, +DM, daughter has renal disease Physical Exam: PE upon arrival to [**Hospital Ward Name **] 3 Gen:sitting upright, watching TV, NAD HEENT:L.pupil >R dilated but RRL, EOMI, no oropharyngeal lesions/exudates neck:no LAD, no bruits chest:B/L air entry, bibasilar crackles mid to lower lung fields heart:decreased S1 compared to S2, holodiastolic murmur 2-3/6, loudest in mitral area. no R/G abd:+bs, soft, nt, nd, +periumb hernia, no bruits ext: no C/C, 2+ B/L pitting edema, 2+pulses neuro:AAOx3, motor [**3-2**] bilateral UE and LE, no gross sensory deficits guiac done in MICU + [**6-18**] Pertinent Results: [**2147-6-17**] 03:12PM GLUCOSE-178* UREA N-81* CREAT-3.9* SODIUM-138 POTASSIUM-4.4 CHLORIDE-99 TOTAL CO2-28 ANION GAP-15 [**2147-6-17**] 03:12PM ALT(SGPT)-22 AST(SGOT)-30 ALK PHOS-78 AMYLASE-163* TOT BILI-0.3 [**2147-6-17**] 03:12PM LIPASE-46 [**2147-6-17**] 03:12PM ALBUMIN-3.9 CALCIUM-9.8 PHOSPHATE-4.2 MAGNESIUM-2.2 [**2147-6-17**] 12:05PM UREA N-82* CREAT-4.0* SODIUM-137 POTASSIUM-7.0* CHLORIDE-99 TOTAL CO2-26 ANION GAP-19 [**2147-6-17**] 12:05PM estGFR-Using this [**2147-6-17**] 12:05PM CK(CPK)-196* [**2147-6-17**] 12:05PM cTropnT-0.15* [**2147-6-17**] 12:05PM CK-MB-7 proBNP-[**Numeric Identifier 19289**]* [**2147-6-17**] 12:05PM CALCIUM-9.6 PHOSPHATE-5.0* MAGNESIUM-2.5 [**2147-6-17**] 12:05PM WBC-8.9 RBC-3.65* HGB-11.2* HCT-34.7* MCV-95 MCH-30.8 MCHC-32.4 RDW-15.9* [**2147-6-17**] 12:05PM NEUTS-76* BANDS-2 LYMPHS-17* MONOS-4 EOS-1 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 [**2147-6-17**] 12:05PM HYPOCHROM-2+ ANISOCYT-NORMAL POIKILOCY-NORMAL MACROCYT-1+ MICROCYT-NORMAL POLYCHROM-OCCASIONAL [**2147-6-17**] 12:05PM PLT COUNT-321 [**2147-6-17**] 12:05PM PT-11.9 PTT-29.3 INR(PT)-1.0 . CXR on [**6-17**] 1. Cardiomegaly and mild pulmonary [**Month/Year (2) 1106**] congestion. 2. Blunting of the right costophrenic angle could represent pleural effusion or subpulmonic effusion. 3. Patchy opacities in the right lung base may represent pneumonia. 4. Retrocardiac opacity could represent atelectasis and pleural effusion, however, cannot rule out consolidation. . EKG: NSR, LBBB per old records . Renal U/S [**6-19**] 1. Interval development of right upper pole complex solid and cystic mass,concerning for malignancy. Another less likely consideration would include a hemorrhagic cyst. Further evaluation with CT of the abdomen and pelvis utilizing renal protocol (if renal status allows) or MRI is recommended. 2. Echogenic renal parenchyma bilaterally, likely as a result of underlying medical renal disease. 3. Likely right lower pole hyperechoic lesion, which could represent an angiomyolipoma. 4. Bilateral pleural effusions. . ECHO [**6-19**] Conclusions: The left and right atrium are moderately dilated. The estimated right atrialpressure is >20 mmHg. There is mild symmetric left ventricular hypertrophy with normal cavity size. There is moderate to severe global left ventricular hypokinesis (LVEF = 20-25 %). No masses or thrombi are seen in the left ventricle. Right ventricular chamber size is normal with moderate global free wall hypokinesis. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. There are filamentous strands on the aortic leaflets consistent with Lambl's excresences (normal variant). Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Moderate to severe (3+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. Moderate [2+] tricuspid regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is a trivial/physiologic pericardial effusion. Compared with the prior report of [**2141-8-17**] (stress echo), the findings are new and c/w a cardiomyopathy. In the absence of a prominent hisory of systemic hypertension, an infiltrative process (e.g., amyloid) should be considered. . Stress [**2140**]: his 88 year old woman (Hx LBBB) was referred to the lab for evaluation. The patient exercised for 6 minutes of a modified [**Doctor First Name **] protocol and was stopped for fatigue representing a fair functional capacity for her age. No neck, arm, back, or chest discomforts were reporte throughout the procedure. The ST segments are uninterpretable in the setting of LBBB. The rhythm was sinus with occasional isolated PACs and PVCs. Appropriate hemodynamic response to exercise. IMPRESSION: No anginal type symptoms with an uninterpretable ECG in the setting of LBBB at the achieved workload. ECHO report sent separately. . Brief Hospital Course: A/P: Patient is a [**Age over 90 **] year old woman with HTN, DM, CKD who presented with a CHF exacerbation and hypertensive urgency. Pt's HTN has been better controlled, fluid taken off, and no longer requiring supplemental oxygen. . 1.SOB-CHF exacerbation likely precipitated by uncontrolled HTN. Echo showed EF ~20%, LV global hypokinesis, 3+MR, 2+TR. Troponins remained stable and CK's were flat. Elevated troponins were thought to be secondary to kidney disease. In the MICU, patient was started on a lasix drip which she continued on her transfer to [**Hospital Ward Name **] 3. Patient had a negative fluid balance daily. Strict I/O's and daily weights were recorded. The lasix drip was discontinued and the patient switched to oral lasix 80mg [**Hospital1 **] which she tolerated well. Patient was continued on her ASA. ACEI was increased to 40mg po daily. Her beta blocker was changed to Toprol XL 100mg from metoprolol 12.5 [**Hospital1 **]. Diltiazem was discontinued. Patient was weaned off O2 in the MICU and did not require any additional supplemental oxygen. Cardiology and Nephrology were consulted this admission and their recommendations followed. Patient was placed on a diabetic and low salt diet. Discharge weight was 46.3kg. . 2.HTN- Patient was placed on a nitro drip, for which she responded to and was weaned before she left the MICU. She was placed on her home blood pressure regiment, then switched to Toprol XL while discontinuing the calcium channel blocker. . 3.CKD-Thought to be likely due to HTN and DM. Cr is at her baseline (~4), electrolytes remained within normal limits. Originally, nephrology was consulted to ascess for urgent dialysis. However, the patient and her family wanted to hold off if possible. Patient was able to be successfully diuresed with IV lasix and therefore no acute dialysis was needed this admission. She was started on CaCO3 as a phosphate binder and calcitriol. She had a renal ultrasound which showed medical renal disease, a suspicious mass at the upper right pole, and a angiomyolipoma at the lower right pole. Patient was followed by nephrology this admission and her creatinine and electrolytes monitored. Dr.[**Name (NI) 4849**] is her nephrologist and she will follow up with him as an outpatient so that she and her family can decide on a plan of action Re: suspicious renal mass. . 4.anemia-Patient's baseline is 28-33. This is thought to be due to CKD, there was question of the patient undergoing a HCT drop or was this due to mobilization of fluids secondary to diuresis. Hct's were trended; HCT remained stable. The was a guiac+ stool in the MICU. On the floor, patient did not have any signs of bleeding. As of [**2147-6-21**] she was guiac negative. Anemia work up revealed anemia of chronic disease. Patient will be continued on epoeitin at her outpatient regiment. Iron was discontinued as it was not thought to be necessary at this time. . 5.DM-Patient is on oral hypoglycemics (TZD and glipizide) at home. However, these were discontinued during her hospitalization for concern of worsening/contributing to heart failure. The glipizide was discontinued as it is renally cleared. Patient was placed on regular human insulin sliding scale and finger sticks monitored. . 6.safety- physical therapy came and assessed the patient. At this time patient, at this time, if patient were to be going home she would be needing home PT services and 24 hour supervision as she is at high fall risk. However, she will be going to [**Hospital3 **] facility at the time of discharge. . Contacts- [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 19290**] daughter [**Name (NI) 2411**] [**Known lastname **] (HCP, daughter [**Telephone/Fax (1) 19291**]. Medications on Admission: lisinopril 30mg po qday glipizide XR 10mg po bid pioglitazone 45 po qday diltiazem XT 180 mg qday calcitriol 0.25 mcg qday lasix 40mg qAM and 20 Qpm epoeitin [**Numeric Identifier 389**] units q3 weeks lipitor 10mg qday HCTZ 25mg qday prednisolone gtt qid colace 100mg [**Hospital1 **] ASA 81mg po qday. Discharge Medications: 1. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO DAILY (Daily). 2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 3. Prednisolone Acetate 1 % Drops, Suspension Sig: One (1) Drop Ophthalmic QID (4 times a day). 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 5. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QIDACHS (4 times a day (before meals and at bedtime)). Disp:*120 Tablet, Chewable(s)* Refills:*2* 6. 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* 7. epoeitin Please continue your epoeitin [**Numeric Identifier 389**] units q3weeks as directed per outpatient regimen 8. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day. 9. Furosemide 80 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 10. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO once a day. 11. Insulin Regular Human 100 unit/mL Solution Sig: 2-8 Units Injection QACHS: See attached sliding scale. Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - [**Location (un) 550**] Discharge Diagnosis: 1.CHF exacerbation 2.HTN 3.DM 4.Renal mass 5.CKD Discharge Condition: good Discharge Instructions: You were admitted because you had trouble breathing and you were found to have excess fluid in your body. You were weaned off requiring oxygen and medication was given to remove excess fluid from your body. If you develop dizziness, lightheadedness, chest pain, palpitations, shortness of breath, increase in ankle swelling or weight gain >3lbs please contact your doctor or go to the emergency room. Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs. Adhere to 2 gm sodium diet Weight at discharge = 46.3kg standing Followup Instructions: Please call your PCP [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4251**] to set up an appointment after discharge to discuss your long term care. [**Telephone/Fax (1) 19292**] . Please call your nephrologist Dr.[**Doctor Last Name 4849**] at [**Telephone/Fax (1) 3637**] to further discuss your kidney function. . Provider: [**Name10 (NameIs) **] STUDY Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2147-6-26**] 1:30 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2147-6-26**] 2:40 Provider: [**Name10 (NameIs) **] LAB Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2147-6-28**] 10:00 . [**First Name11 (Name Pattern1) 734**] [**Last Name (NamePattern1) 735**] MD, [**MD Number(3) 799**]

[ "285.21", "428.41", "585.5", "397.0", "428.0", "250.40", "404.93", "424.0", "272.0" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

12577, 12662

7311, 11089

281, 288

12755, 12762

3354, 7288

13353, 14212

2713, 2776

11443, 12554

12683, 12734

11115, 11420

12786, 13330

2791, 3335

222, 243

316, 1615

2072, 2587

1637, 1714

2603, 2697

31,189

144,019

33731

Discharge summary

report

Admission Date: [**2119-1-30**] Discharge Date: [**2119-2-5**] Date of Birth: [**2060-6-10**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 922**] Chief Complaint: recent endocarditis Major Surgical or Invasive Procedure: redo sternotomy/AVR(#27 [**Company 1543**] mosaic)[**1-31**] History of Present Illness: 58 yo M s.p AVR in [**2113**], with recent endocarditis in [**8-22**] treated with 6 weeks of antibiotics. Now returns for surgical repair of partially dehisced prosthetic valve. Past Medical History: AS s/p AVR '[**13**], Gout, HTN, Endocarditis '[**17**] now w/severe AI Social History: works as project manager [**1-17**] drinks/week [**11-16**] ppd tobacco Family History: 2 cousins, grandmother and aunt with bicuspid aortic valve. Physical Exam: NAD Lungs CTAB Heart RRR +murmur Abdomen benign Extrem warm, no edema, 2+pp Pertinent Results: [**2119-2-5**] 04:55AM BLOOD WBC-5.5 RBC-3.18* Hgb-8.9* Hct-26.0* MCV-82 MCH-27.8 MCHC-34.1 RDW-14.9 Plt Ct-296 [**2119-2-5**] 04:55AM BLOOD Plt Ct-296 [**2119-2-5**] 04:55AM BLOOD Glucose-103 UreaN-16 Creat-1.0 Na-137 K-3.7 Cl-97 HCO3-32 AnGap-12 [**2119-1-31**] 12:16AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.023 URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG CHEST (PA & LAT) [**2119-2-3**] 6:34 PM FINDINGS: Cardiac silhouette is unchanged. There has been previous sternotomy. The right hemidiaphragm remains to be slightly elevated. There is a linear oblique opacity within the right lung base mostly representing atelectasis. There is no pleural effusion or pneumothorax. Mediastinum and hila are clear. IMPRESSION: No evidence for hemothorax. Basilar atelectasis on the right. No significant change from previous. Brief Hospital Course: He was admitted to cardiac surgery. He was cleared by dental. TEE showed partial dehiscence of bioprosthatic aortic valve, 4+AI. He was taken to the operating room on [**1-31**] where he underwent a redosternotomy and AVR. He was transferred to the ICU in stable condition. He was given 48 hours of vancomycin perioperatively as he was in the hospital for > 24 hours peroperatively. On the morning of POD #1, just prior to extubated he drained 1 liter into his chest tubes. His HCT remained stable, he did not have any further bleeding and was extubated. He was transfused 1 unit. He was given vanco and cipro while awaiting final OR cultures. He initially had a junctional rhythm which recovered to sinus with a first degree blcok and he was started on low dose beta blockade. He was transferred to the floor on POD #2. Pt consult / foley DC'd with out sequele. POD # 3 PW DC'd with out sequele. POD # 4 ID thinks not endocarditis. IV AB stopped. Pt stable for DC. Medications on Admission: ASA 325', Toprol xl 25', Procardia xl60', Allopurinol 300', Lozol 5', Simvastatin 20' Discharge Medications: 1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 2. Ranitidine HCl 150 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. Zocor 20 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*0* 5. Allopurinol 100 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). Disp:*90 Tablet(s)* Refills:*0* 6. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). Disp:*30 Tablet(s)* Refills:*2* 7. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 8. Captopril 12.5 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:*90 Tablet(s)* Refills:*2* 9. Furosemide 40 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 7 days. Disp:*14 Tablet(s)* Refills:*0* 10. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12 hours) for 7 days. Disp:*14 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital3 **] [**Hospital **] home health and hospice Discharge Diagnosis: dehisced AVR secondary to prostetic valve endocarditis now s/p redo AVR AS s/p AVR '[**13**], Gout, HTN, Endocarditis '[**17**] now w/severe AI Discharge Condition: Good. Discharge Instructions: Call with fever, redness or drainage from incision or weight gain more than 2 pounds in one day or five in one week. Shower, no baths, no lotions, creams or powders to incisions. No lifting more than 10 pounds for 10 weeks. No driving until follow up with surgeon. Followup Instructions: Dr. [**First Name (STitle) 1356**] 2 weeks Dr. [**Last Name (STitle) 78041**] 2 weeks Dr. [**Last Name (STitle) 914**] 4 weeks Completed by:[**2119-2-5**]

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icd9cm

[ [ [] ] ]

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Discharge summary

report+addendum+addendum

Admission Date: [**2121-3-10**] Discharge Date: [**2121-3-28**] Date of Birth: [**2051-6-27**] Sex: M Service: NEUROLOGY Allergies: Celexa Attending:[**First Name3 (LF) 5018**] Chief Complaint: headache, left sided neglect Major Surgical or Invasive Procedure: s/p hemicraniotomy evacuation [**3-13**] s/p PEG s/p trach conventional cerebral angio s/p excision of R arm superficial vein History of Present Illness: Pt is a 69 yo LH male with h/o osteoarthrits who awoke with severe right sided HA this AM, now presenting to ED with ICH. Patient provides history. Patient reports waking this AM with severe HA that got worse as day progressed. His wife denies seeing any change in his speech, gait, eating habits this AM. He went to see him PMD who referred him to [**Hospital1 18**]. Admission BP was 184/76, HR 78, temp 98.3. He had a CT scan which showed right temporal intraparenchymal hemorrhage with extension into the subarachnoid space at 4pm. Per ED resident, patient had nml neuro exam on their evaluation on admission. Neurology consult eval at 6pm showed left neglect and CTH repeated for change in examfindings. Repeat HCT showed extention of hemorrhage to right parietal lobe and IVH, 1 mm MLS. Per wife, patient has no ho HTN and in fact reports hypotension in the past. Patient reports that he has ho hypertension, thinks this was mild. No trauma. He has no ho of headache this week to suggest sentinal bleed. ROS: No fever, chills, SOB, ab pain, D/C. Vomited 2 times in ED. No change in vision, patient has left ptosis at baseline, no dysarthria, dysphagia, diplopia. Pt denies any ho transient weakness, numbness, tingling in past. Past Medical History: dyslipidemia insomnia h/o lumbosacral radiculopathy HTN recent pancreatitis (1 month ago)- thought secondary to gallstones. Social History: lives at home with wife Family History: denies any h.o family with ICH, vascular malformations, stroke. Mother had pancreatic cancer, father and brother had heart disease Physical Exam: T:98.8 BP:ED 140-184/52-76 HR:76 RR:16 O2Sats:99% 3LNC Gen: WD/WN, comfortable, NAD. HEENT: MMM, no dysmorphis, left ptosis CV: RRR, no M Resp: CTA Ab: ND, NT, soft Ext: wwp MS: Awake and alert. Names oriented x3. DOW backwards, spells WORLD backwards. Reports 7 quarters as "1.50", repeats missing on transitional word. Neglects/hemianopsia on exam and only describes very right corner of cookie picture ("I see a stack of plates") and sees "chair" on stroke cards (on right side). He does name some common objects such as ring, watch, book and pen when held on right field of vision. Memory 0/3. Cranial Nerves: I: Not tested II: Pupils on right 4 mm-> 3 mm and left 3.5 mm-> 3 mm. ?left hemianopsia III, IV, VI: Patient crosses ML briefly to left with stimulation. EOMI. Left ptosis (baseline per pt) V, VII: Left smile slightly down compared to right (baseline per wife). Reports no sensation of left face V1-V3. VIII: Hearing intact to voice. IX, X: Palatal elevation symmetrical. [**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally. XII: Tongue midline without fasciculations. Motor: Normal bulk and tone bilaterally. Strength full power [**5-5**] throughout. Has left pronator drift. DTRs brisker on left than right in B, BR, P, A. Sensation: Reports no sensation to LT/cold on leftside face, arm, leg. With noxious stimuli to left finger, patient appears to wince in pain. When asked where pain is coming from he reports "my head" and points to right temporal region. Extinguishes on left. Toes downgoing on the right and upgoing on the left. Coordination: slowed on finger-nose-finger, with action tremor noted left >right. Slow alt hand movements but accurate, does not perform on left but rather persists on right. Gait deferred. Pertinent Results: Admission Labs: UA nml 140 103 12 AGap=12 ------------<132 4.2 29 1.2 Ca: 10.0 Mg: 1.9 P: 2.4 WBC 8.2 hgb 14.7 plts 117 Hct 40.2 N:70.1 L:25.2 M:4.2 E:0.5 Bas:0.1 PT: 12.8 PTT: 23.6 INR: 1.1 EKG: NSR MICROBIOLOGY: Urine Culture- + for pansensitive enterococcus. IMAGING: CT head 4:09 pm: There is an area of acute hemorrhage measuring 1.8 x 3.5 cm centered in the inferior right temporal lobe. There is a small amount of surrounding vasogenic edema. The hemorrhage appears to extend the extra-axial space, and there is subarachnoid hemorrhage in sulci of the right temporal, right occipital and right posterior parietal lobe. A small amount of subarachnoid hemorrhage is also seen in the inferior right frontal cortex of the left frontal lobe could be due to artifact. There is no evidence of hydrocephalus or intraventricular blood. There is no evidence of transitory herniation. No midline shift. No CT evidence of major vascular territorial infarct. Bony structures are unremarkable without fractures. CT head 6:40 pm: (wet read) Dramatic progression of hemorrhage, now with multilobar extension (new in right parietal lobe and subependymal spread along right lateral ventricle. CT HEAD W/O CONTRAST [**2121-3-10**] 4:09 PM There is an area of acute hemorrhage measuring 1.8 x 3.5 cm centered in the inferior right temporal lobe. There is a small amount of surrounding vasogenic edema. The hemorrhage extends into the subarachnoid space (right temporal, right occipital and right posterior parietal lobe). There is no evidence of hydrocephalus or intraventricular blood. There is no evidence of transtentorial herniation. No midline shift. No CT evidence of major vascular territorial infarct. Bony structures are unremarkable without fractures. Surrounding soft tissues are unremarkable. IMPRESSION: Right temporal intraparenchymal hemorrhage with extension into the subarachnoid space. Given the location and the absence of history of trauma, anticoagulation or hypertension, this is most likely related to amyloid angiopathy, or less likely, underlying mass lesion or vascular malformation. CT HEAD W/O CONTRAST [**2121-3-15**] 8:45 AM FINDINGS: Appearance of right temporoparietal craniotomy is little changed from prior exam. The right temporoparietal intraparenchymal hemorrhage and surrounding vasogenic edema are also little changed, with continued effacement of right hemispheric sulci, and frontal [**Doctor Last Name 534**] of the right lateral ventricle. Approximately 3 mm of rightward subfalcine herniation is unchanged. Several tiny foci of pneumocephalus persists. Extra-axial blood in the right frontal and temporoparietal region is little changed, still measuring approximately 4 mm in greatest axial dimension. IMPRESSION: 1. Unchanged appearance of right temporoparietal craniotomy, with areas of intraparenchymal hemorrhage, surrounding mass effect, and slight leftward subfalcine herniation. 2. Unchanged right frontal, and temporoparietal extra-axial fluid collection. CT HEAD W/O CONTRAST [**2121-3-19**] 11:06 AM FINDINGS: Again post-surgical changes consistent with right temporoparietal craniotomy are noted. No significant change is observed in the pattern of the intraparenchymal hemorrhage and the vasogenic edema. Persistent effacement of the sulci involving the right cerebral hemisphere, unchanged subdural hemorrhage as well as the midline shifting. There is no evidence of perimesencephalic, uncal or transtentorial herniation. The paranasal sinuses demonstrate larger mucosal thickening involving the ethmoidal air cells as well as the sphenoidal sinus, and mild mucosal thickening is detected on the left maxillary sinus. IMPRESSION: No significant change is observed in the overall configuration of the right intraparenchymal hemorrhage with associated soft tissue mass effect. Persistent and unchanged right frontal and temporoparietal extra-axial subdural collections. Increase in the pattern of mucosal thickening observed in the ethmoid and sphenoidal sinuses as described above. MR HEAD W & W/O CONTRAST; MRA BRAIN W/O CONTRAST [**2121-3-24**] 12:06 AM COMPARISON: Multiple non-contrast head CTs are available from [**3-10**] to [**2121-3-19**]. Conventional cerebral angiogram, [**2121-3-11**]; CTA head [**2121-3-11**]. MR OF THE BRAIN WITHOUT AND WITH IV GADOLINIUM: Allowing for differences in modalities, the appearance of the brain is not significantly changed compared to the most recent study of [**2121-3-19**]. Again demonstrated is high T1- weighted signal and associated areas of susceptibility artifact consistent with hemorrhage involving the parenchyma of the right temporal and parietal lobes. High FLAIR signal surrounding the areas of hemorrhage corresponds to low attenuation areas on the prior head CT indicating surrounding vasogenic edema, not changed. A thin subdural collection layering around the right cerebral convexity is stable. Mass effect evidenced by effacement of the right cerebral sulci, shift of the septum pellucidum to the left by approximately 5 mm, and effacement of the occipital [**Doctor Last Name 534**] of the right lateral ventricle has not changed. Overall, the size and configuration of the ventricular system is stable. As before, there is a thin extra-axial collection near the craniotomy site. No underlying enhancing mass lesion is seen. Mild leptomeningeal enhancement of the right parietotemporal region is probably related to subarachnoid hemorrhage. On the diffusion weighted images there is expected high signal associated with the areas of hematoma, but no evidence of acute infarction elsewhere. Mucosal thickening and small fluid levels of the sphenoid sinus, opacification of a few left ethmoid air cells and mild left maxillary sinus mucosal thickening are unchanged. MRA OF THE BRAIN INCLUDING CIRCLE OF [**Location (un) **]: The vertebrobasilar and carotid circulations including circle of [**Location (un) 431**] are patent without evidence of aneurysm, dissection, vascular malformation or hemodynamically significant stenosis. Incidental note is made of early branching of the left middle cerebral artery. There is a fetal posterior cerebral artery on the right. Diminutive appearance of the basilar artery is probably related to partial supply of the posterior brain by the anterior ciruclation via large posterior communicating arteries. IMPRESSION: 1. Overall appearance of the brain is similar to [**2121-3-19**] at 11:26. 2. No change in extent or related mass effect of right parietotemporal intraparenchymal hemorrhage or small right subdural hematoma. 3. No underlying enhancing mass lesion or evidence of vascular malformation. 4. Stable paranasal sinus mucosal disease as described. Brief Hospital Course: Mr. [**Known lastname **] is a 69 yo LHM found to have spontaneous, acute ICH of right temporal lobe that extended to right pariental lobe and right lateral ventricle. On admision the patient's exam was notable for right ptosis (baseline per pt/family), profound left neglect, possible left hemianopsia, left pronator drift, brisk DTRs on left, left upgoing toe, left extinction. 1) ICH The patient was admitted to the neuro ICU for close monitoring and BP control. Initial labs were unrevealing for thrombocytopenia or coagulopathy. The patient is likely to have had a history of hypertension. However the location of the hemorrhage is not commonly seen with primary hypertensive hemorrhage. No history of trauma. Conventional angiogram was performed by Dr. [**First Name (STitle) **] of the neurosurgery service without evidence for AVM or aneurysm. Antiplatelet therapy was held. An MRI with gradient echo, with and without gadolinium was done and did not show any evidence of amyloid angiopathy nor underlying mass lesion. The patient's neurologic status declined on hospital day #3 with evidence by CT for enlarged hemorrhage with mass effect. The patient's mental status became somnolent from a baseline of conversant and easily arousable with worsening left neglect and left hemiplegia. EEG negative for seizure. He was started on Keppra 500mg [**Hospital1 **] which has since been discontinued. He was taken for emergent hemicraniectomy and evacuation of the left parietal portion of the hemorrhage. The patient was severely inattentive following the procedure with profound withdrawal from his environment. Extubation was successful for several days, but the patient did not protect his airway due to depressed mental status and required re-intubation. He went for tracheostomy and PEG placement on HD #10 given need for prolonged period of rehabilitation. 2) Infectious disease- Pt had fevers on HD #8, had right forearm phlebitis, that underwent I and D on HD #10. Started on empiric vancomycin. Noted to have a UTI with growth of pansensitive enterococcus. Vancomycin was discontinued and he was continued on Amoxil to complete a 7-day course. He has had some residuals since starting PEG tube feeds so we have started him on Reglan and decreased his PEG tube feeds to half strength. KUB was unremarkable. He has a history of a bout of pancreatitis one month ago attributed to gallstones. His lipase has been stable aroun 100 for the past few days. he also had pulled out his Foley with the ballon inflated and has some hematuria and decreased urine output likely due to a bladder clot so a Foley catheter was reinserted. His WBC count is increasing to 13 so we are resending urinalysis, CXR, and sputum culture. The wound care nurse has been monitoring his R forearm incision where he had the thrombophlebitis, so it needs to continue to be checked to ensure there is no cellulitis. Hematocrit is rising as was 31 on the day of discharge. ---- **** On the day of discharge, his UA was normal, sputum culture is pending, and a CXR was repeated which was read as "There is very mild region of heterogeneous opacification in the left mid lung very similar to the appearance on [**3-20**], which developed after [**3-18**]. This could be a small region of pneumonia, but has not worsened. Lungs otherwise clear. Heart size normal. Tracheostomy tube in standard placement. No pneumothorax or pleural effusion.". Given the stability of the lesion in his left lung, we felt it was not likely infectious, however, if he does develop fever or other signs of infection, would consider repeating this study with focus on this area. *** Medications on Admission: ASA 81 mg qday atenolol 20 mg qday clonazepam 0.5 mg qhs simvastatin 20 mg qhs vitamin B12 multivitamin omeprazole omega-3 fatty acids/vitamin E Discharge Medications: 1. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette [**Month (only) **]: [**1-1**] Drops Ophthalmic PRN (as needed). 2. Acetaminophen 325 mg Tablet [**Month/Day (2) **]: 1-2 Tablets PO Q6H (every 6 hours) as needed for fever/pain. 3. Heparin (Porcine) 5,000 unit/mL Solution [**Month/Day (2) **]: 5000 (5000) units Injection TID (3 times a day). 4. Metoclopramide 10 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO QIDACHS (4 times a day (before meals and at bedtime)). 5. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily). 6. Labetalol 100 mg Tablet [**Last Name (STitle) **]: 1.5 Tablets PO TID (3 times a day). 7. Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization [**Last Name (STitle) **]: One (1) inh Inhalation Q6H (every 6 hours) as needed. 8. Senna 8.6 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID (2 times a day). 9. Docusate Sodium 50 mg/5 mL Liquid [**Last Name (STitle) **]: One Hundred (100) mg PO BID (2 times a day). 10. Lactulose 10 gram/15 mL Syrup [**Last Name (STitle) **]: Thirty (30) ML PO Q8H (every 8 hours) as needed for until bowel movement. 11. Bisacodyl 10 mg Suppository [**Last Name (STitle) **]: One (1) Suppository Rectal DAILY (Daily) as needed. 12. Insulin NPH Human Recomb 100 unit/mL Suspension [**Last Name (STitle) **]: Five (5) units SC Subcutaneous twice a day. 13. Insulin Regular Human 100 unit/mL Solution [**Last Name (STitle) **]: sliding scale sliding scale Injection ACmeals & QHs. 14. Amoxicillin 125 mg/5 mL Suspension for Reconstitution [**Last Name (STitle) **]: Five Hundred (500) mg PO TID (3 times a day) for 3 days. 15. Zocor 20 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO once a day. 16. Multivitamin Capsule [**Last Name (STitle) **]: One (1) Capsule PO once a day. Discharge Disposition: Extended Care Facility: [**Hospital6 85**] - [**Location (un) 86**] Discharge Diagnosis: 1)large R temp-parietal ICH with IVH 2) pancreatitis 3) thrombophlebitis Discharge Condition: neurologically impaired but stable, dense L hemiparesis Discharge Instructions: You have had a large bleed into the right side of your brain. We have been unable to find the underlying cause of this. Followup Instructions: NEUROLOGY: [**First Name8 (NamePattern2) **] [**Name8 (MD) 162**], MD Date/Time:[**2121-4-25**] 9:00 Radiology: Phone:[**Telephone/Fax (1) 657**] Provider: [**Name10 (NameIs) **] SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2121-4-28**] 11:30 Neurosurgery: Provider: [**Name10 (NameIs) **] [**Last Name (NamePattern4) 7746**], MD Phone:[**Telephone/Fax (1) 3666**] Date/Time:[**2121-4-28**] 1:30 [**Name6 (MD) 4267**] [**Last Name (NamePattern4) 4268**] MD, [**MD Number(3) 5023**] Name: [**Known lastname **],[**Known firstname 126**] Unit No: [**Numeric Identifier 17369**] Admission Date: [**2121-3-10**] Discharge Date: [**2121-3-28**] Date of Birth: [**2051-6-27**] Sex: M Service: NEUROLOGY Allergies: Celexa Attending:[**First Name3 (LF) 608**] Addendum: He has been subfebrile: we have repeated urine culture, sputum culture, blood cultures, and [**Last Name (un) 17370**] CT, LENIs. The LENIs showed no LE clot. The abdominal CT showed no evidence of abscess or other fever source. A plastics consult evaluated his arm wound and felt that it was healthy and not infected/causing his fever. He had a low grade fever of 100 on day of discharge, but then had no fever for the remainder of the day. His cultures are all NGTD as above. He was discharged. We will follow his cultures to confirm no growth and call if there is a problem. A CXR showed no evidence of PNA. Discharge Disposition: Extended Care Facility: [**Hospital6 41**] - [**Location (un) 42**] [**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 610**] Completed by:[**2121-3-28**] Name: [**Known lastname **],[**Known firstname 126**] Unit No: [**Numeric Identifier 17369**] Admission Date: [**2121-3-10**] Discharge Date: [**2121-3-28**] Date of Birth: [**2051-6-27**] Sex: M Service: NEUROLOGY Allergies: Celexa Attending:[**First Name3 (LF) 608**] Addendum: As above there was no evidence of superficial, pulmonary, blood, or abdominal infection. He did not meet definite fever criteria on day of discharge either way. See updated discharge medication list below. Discharge Medications: 1. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette [**First Name3 (LF) 1649**]: [**1-1**] Drops Ophthalmic PRN (as needed). 2. Acetaminophen 325 mg Tablet [**Month/Day (2) 1649**]: 1-2 Tablets PO Q6H (every 6 hours) as needed for fever/pain. 3. Heparin (Porcine) 5,000 unit/mL Solution [**Month/Day (2) 1649**]: 5000 (5000) units Injection TID (3 times a day). 4. Metoclopramide 10 mg Tablet [**Month/Day (2) 1649**]: One (1) Tablet PO QIDACHS (4 times a day (before meals and at bedtime)). 5. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) 1649**]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily). 6. Labetalol 100 mg Tablet [**Last Name (STitle) 1649**]: 1.5 Tablets PO TID (3 times a day). 7. Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization [**Last Name (STitle) 1649**]: One (1) inh Inhalation Q6H (every 6 hours) as needed. 8. Senna 8.6 mg Tablet [**Last Name (STitle) 1649**]: One (1) Tablet PO BID (2 times a day). 9. Docusate Sodium 50 mg/5 mL Liquid [**Last Name (STitle) 1649**]: One Hundred (100) mg PO BID (2 times a day). 10. Lactulose 10 gram/15 mL Syrup [**Last Name (STitle) 1649**]: Thirty (30) ML PO Q8H (every 8 hours) as needed for until bowel movement. 11. Bisacodyl 10 mg Suppository [**Last Name (STitle) 1649**]: One (1) Suppository Rectal DAILY (Daily) as needed. 12. Insulin NPH Human Recomb 100 unit/mL Suspension [**Last Name (STitle) 1649**]: Five (5) units SC Subcutaneous twice a day. 13. Insulin Regular Human 100 unit/mL Solution [**Last Name (STitle) 1649**]: sliding scale sliding scale Injection ACmeals & QHs. 14. Zocor 20 mg Tablet [**Last Name (STitle) 1649**]: One (1) Tablet PO once a day. 15. Multivitamin Capsule [**Last Name (STitle) 1649**]: One (1) Capsule PO once a day. 16. Nystatin 100,000 unit/mL Suspension [**Last Name (STitle) 1649**]: Five (5) ML PO QID (4 times a day) as needed for thrush. 17. Acetaminophen 325 mg Tablet [**Last Name (STitle) 1649**]: 1-2 Tablets PO Q4H (every 4 hours) as needed for fever, pain. Discharge Disposition: Extended Care Facility: [**Hospital6 41**] - [**Location (un) 42**] [**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 610**] Completed by:[**2121-3-28**]

[ "451.84", "430", "263.9", "599.0", "434.91", "577.0", "431", "519.8" ]

icd9cm

[ [ [] ] ]

[ "96.71", "01.39", "96.6", "86.04", "96.04", "88.41", "43.11", "31.1" ]

icd9pcs

[ [ [] ] ]

21081, 21272

10621, 14267

297, 425

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3850, 3850

16758, 18240

1897, 2030

19025, 21058

16435, 16510

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229, 259

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27,866

109,679

10338

Discharge summary

report

Admission Date: [**2143-4-8**] Discharge Date: [**2143-4-15**] Service: ORTHOPAEDICS Allergies: Penicillins / Gentamicin / Bacitracin / Hydrochlorothiazide / Chlorothiazide Attending:[**First Name3 (LF) 2988**] Chief Complaint: Right hip pain secondary to right femoral head AVN. Major Surgical or Invasive Procedure: [**Last Name (un) **] right DHS, revision Right Hip Replacement History of Present Illness: Ms. [**Known lastname **] is an 83 yo F w/PMHx sx for CLL, hypertension, hyperlipidemia and depression who was admited for an elective total hip arthroplasty for persistent low back and right hip pain. Past Medical History: Chromic Lymphocytic Lymphoma Hypertension Hyperlipidemia Depression Osteoarthritis Chronic low back and hip pain, avascular necrosis of right hip Chronic bilateral knee pain s/p right elbow fracture s/p ORIF right hip [**2137**] Peripheral Vascular Disease s/p bilat bypass grafts Social History: She currently lives alone. Denies any drug use. Quit smoking 15 years ago and only occasional alcohol use. Family History: n/a Physical Exam: Vitals: T: 98.7 BP 163/60 HR: 80 RR: 22 O2: 94% on 4L NC Gen: elderly female, NAD, resting in bed HEENT: NC, AT, MMM, OP clear CV: RRR, no MRG RESP: CTAB ABD: soft, NT, ND, BS+ EXT: no edema, DP's 2+ bilat, able to wiggle toes Pertinent Results: [**2143-4-13**] 08:30AM BLOOD WBC-34.7* RBC-3.05* Hgb-9.5* Hct-28.4* MCV-93 MCH-31.1 MCHC-33.3 RDW-16.2* Plt Ct-263 [**2143-4-12**] 10:30AM BLOOD WBC-39.9* RBC-2.96* Hgb-9.1* Hct-27.0* MCV-91 MCH-30.6 MCHC-33.6 RDW-16.2* Plt Ct-225 [**2143-4-11**] 08:50AM BLOOD WBC-39.1* RBC-3.15* Hgb-9.9* Hct-27.5* MCV-87 MCH-31.4 MCHC-36.0* RDW-16.5* Plt Ct-166 [**2143-4-10**] 11:40AM BLOOD WBC-53.4* RBC-3.35* Hgb-10.4* Hct-28.9* MCV-86 MCH-30.9 MCHC-35.8* RDW-16.3* Plt Ct-171 [**2143-4-10**] 05:15AM BLOOD WBC-42.3*# RBC-3.32* Hgb-10.4* Hct-28.4* MCV-86 MCH-31.2 MCHC-36.5* RDW-16.0* Plt Ct-155 [**2143-4-9**] 05:48PM BLOOD Hct-23.0* [**2143-4-9**] 05:03AM BLOOD WBC-92.4* RBC-3.40* Hgb-10.6* Hct-29.5* MCV-87 MCH-31.2 MCHC-36.1* RDW-16.1* Plt Ct-209 Brief Hospital Course: A/P: Ms. [**Known lastname **] is an 83 yo F w/PMHx sx for HTN, hyperlipidemia, PVD, and CLL who presents with hypotension in the setting of right THR. Pt transferred to ICU for single recorded BP of 80/40 and intubated. Pt successfully extubated [**4-9**]. HCT did drop while in ICU from 29.5 to 23, ortho was notified, patient transfused 2 units with appropriate bump. No signs of active bleeding. Lovenox held [**4-10**]. . #. Respiratory failure. Patient was intubated electively for the procedure. Had good oxygenation on 50% FiO2 and minimal PEEP. Extubated successfully [**4-9**]. . #. Hypotension. Probably [**3-16**] hypovolemia from blood loss in the OR. Patient hypotensive briefly requiring pressors after 1200cc blood loss in OR. s/p 6u pRBC in OR. . Acute Hematocrit drop - [**4-9**] HCT dropped from 29.5 to 23. Asymptomatic, no signs of active bleeding, received 2 units pRBCs with appropriate bump. Lovenox held on [**4-10**]. Hematocrit stable at time of transfer to floor. . #. S/p Total hip replacment - tolerated procedure well. pain controlled with Tylenol, Ultram and morphine. Pt transferred from ICU to floor on [**4-10**]. PT consult requested. AVSS HCT 28. Lovenox for anticoagulation. Pt remained stable and screened for rehab placemment. . Medications on Admission: Plavix 75 mg qd Aspirin 325 mg qd Fluvastatin Trazadone 50 mg 1-2 tabs qde Paroxetine 20 mg qd Fosamax 70 mg qweek Multivitamin Calcium Vitamin D Darifenacin 7.5 mg qd Furosemide 20 mg qd Percocet prn metoprolol 12.5mg [**Hospital1 **] Discharge Medications: 1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 3. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). 4. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO BID (2 times a day). 6. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Paroxetine HCl 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily). 9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 10. Trazodone 100 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for insomnia. 11. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 12. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain. 13. Morphine 15 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed. 14. Enoxaparin 30 mg/0.3 mL Syringe Sig: Thirty (30) mg Subcutaneous DAILY (Daily) for 4 weeks. 15. Alendronate 70 mg Tablet Sig: One (1) Tablet PO QFRI (every Friday). 16. Enablex 7.5 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO QD (). Discharge Disposition: Extended Care Facility: [**Hospital6 85**] - [**Location (un) 86**] Discharge Diagnosis: Right femoral head AVN anemia Discharge Condition: good Discharge Instructions: activity as tolerated. Right lower extremity partial weight bearing. Crutches/walker with ambulation. Lovenox for anticoagulation. Pain meds as prescribed. Physical Therapy: Activity: Out of bed w/ assist Right lower extremity: Partial weight bearing Knee immobilizer: At all times may remove KI while working with PT, troch off precautions, posterior hip dislocation precautions Treatments Frequency: DSD QD may leave incision open to air on [**2143-4-16**] staples to be removed at f/u Followup Instructions: f/u with Dr[**Name (NI) 2989**] office in 2 weeks. Please call to make an appt. [**Telephone/Fax (1) 20921**] [**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD, [**MD Number(3) 2991**] Completed by:[**2143-4-13**]

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icd9cm

[ [ [] ] ]

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icd9pcs

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19317

Discharge summary

report

Admission Date: [**2182-7-2**] Discharge Date: [**2182-7-18**] Date of Birth: [**2104-9-25**] Sex: F Service: [**Last Name (un) **] CHIEF COMPLAINT: Decreased hematocrit/recurrent gastrointestinal bleed. HISTORY OF PRESENT ILLNESS: This patient is a 77-year-old female who was recently discharged from [**Hospital6 649**] to [**Hospital 8641**] Hospital after undergoing a small bowel resection and right colectomy for a gastrointestinal bleed that was secondary to an arteriovenous malformation. This operation was performed on [**2182-6-12**]. Her postoperative course was remarkable for an extended ileus, as well as a methicillin resistant Staphylococcus aureus pneumonia which was being treated with TPN and vancomycin. She had been otherwise doing well at the [**Hospital 8641**] rehabilitation facility, when she developed abdominal pain and distention, as well as dark, bloody stools. A CBC was obtained at [**Location (un) 8641**] and this revealed a hematocrit of 17 and a white blood cell count of 21,000. She was transfused two units of packed red blood cells and taken by Med Flight from [**Location (un) 8641**] to [**Hospital3 **] [**Hospital **] [**First Name (Titles) **] [**Last Name (Titles) **] for further intensive care. The patient reported for the past few days to have blood per rectum, with reported abdominal distention and lower abdominal pain. She had intermittent nausea with loose stools but no vomiting. Upon presentation to the Emergency Department at [**Hospital6 256**], she was not in any respiratory distress, but she was in mild hypoxia with continuous lower abdominal pain. She was admitted for further evaluation of her drop in hematocrit. PAST MEDICAL HISTORY: Gastrointestinal bleed. Diabetes mellitus type 2. Peptic ulcer disease. Chronic obstructive pulmonary disease. History of pancreatitis. History of pulmonary embolism. Colonic arteriovenous malformation. Methicillin resistant Staphylococcus aureus pneumonia. PAST SURGICAL HISTORY: Pyloric-preserving Whipple in [**2168**]. Small bowel resection and right colectomy on [**2182-6-4**]. Appendectomy. Cholecystectomy. Status post inferior vena cava filter for pulmonary embolism. ALLERGIES: Latex and Lasix. MEDICATIONS ON ADMISSION: 1. Vancomycin 1 gm q 24 hours. 2. Amaryl 2 mg q day. 3. Iron 325 mg t.i.d. 4. Flovent. 5. Hydrochlorothiazide 25 mg q day which was discontinued. 6. Lopressor 50 mg b.i.d. 7. Reglan 10 mg q.i.d. 8. Oxycodone for pain. 9. Albuterol inhaler. 10. Atrovent inhaler. 11. Regular insulin sliding scale. PHYSICAL EXAMINATION: Vital signs: Temperature 98.1, heart rate 89, blood pressure 114/53, respiratory rate 20, saturations 88 percent on room air and 100 percent with supplemental O2. General: Alert in no acute distress, awake. Pulmonary: Clear to auscultation bilaterally. Chest: Regular rate and rhythm. Gastrointestinal: Soft, distended with some peritoneal signs, tenderness mostly in the lower abdomen. Rectal: Positive guaiac, normal rectal tone, maroon stools. Extremities: Bilateral edema. LABORATORY DATA: On admission, CBC with a white blood cell count of 21.6, hematocrit 21.8, platelets 197. Chemistries: Sodium 131, potassium 3.9, chloride 90, bicarbonate 33, BUN 37, creatinine 1.2, glucose 92. Urinalysis was essentially negative. Liver function tests: ALT 15, AST 23, alkaline phosphatase 64, amylase 19, total bilirubin 0.7. Coagulation studies: INR 1.2, PTT 29.8. Chest x-ray is unchanged from the study of [**2182-6-29**], with right pleural effusion and right basilar atelectasis versus consolidation. HOSPITAL COURSE: The patient was admitted on [**2182-7-2**] to the Surgical Intensive Care Unit. She received five units of packed red blood cells over the first night. She was made NPO and given intravenous fluids as well. A post transfusion hematocrit was 30. On [**2182-7-3**], the patient underwent an esophagogastroduodenoscopy performed by the Gastrointestinal service. There was no blood seen in the stomach, but there were erosions in the stomach and duodenum which were consistent with gastritis. It did not explain the patient's dark, bloody stools, and it was recommended that the patient receive a colonoscopy the following day. The patient was properly bowel prepped for a colonoscopy, which was performed on [**2182-7-4**]. This demonstrated friability and granularity in the terminal ileum, as well as at the surgical anastomosis. It was believed that this was the source of the maroon colored stools. The bleeding was stopped and The patient tolerated the procedure well. The patient's hematocrit now remained stable at 34. Throughout the rest of her hospital course, the patient's gastrointestinal issues remained stable and the patient did not have any further bleeding issues. In terms of the patient's pulmonary status, the patient was currently being treated with vancomycin for her methicillin resistant Staphylococcus aureus pneumonia that was diagnosed on previous hospitalization. Due to her elevated white blood cell count, the patient was started on wide spectrum antibiotics including vancomycin, levofloxacin and Flagyl to cover for any possible sites that were not visualized on CT scan. The patient finished a seven day course of vancomycin, as well as a seven day course of levofloxacin. Her Flagyl was ultimately discontinued as there was no suspicion for abscess, and her white blood cell count eventually declined for several days. It was also thought that her hypoxia was secondary to her methicillin resistant Staphylococcus aureus pneumonia, as well as her underlying chronic obstructive pulmonary disease. Due to sputum cultures that were obtained demonstrating methicillin resistant Staphylococcus aureus pneumonia during this hospitalization, the patient's vancomycin was restarted on [**2182-7-13**] for a total vancomycin course of [**11-28**] days. Her levofloxacin was discontinued on [**2182-7-17**] after a total of seven days. During her Intensive Care Unit course, the patient also developed increasing lower extremity edema. A Cardiology consult was obtained. They recommended obtaining an echocardiogram, which demonstrated overall normal systolic function with an ejection fraction of greater than 55 percent, with moderate pulmonary artery systolic hypertension. They felt that the patient should be diuresed, and the patient was started on ethacrynic acid since the patient was allergic to Lasix. Diuresis of the patient also improved her oxygenation. In terms of her nutrition, the patient was admitted with TPN and this was continued throughout her hospital course. Her TPN was decreased as appropriate as the patient began taking more by mouth. By discharge date, the patient was tolerating a regular diabetic and cardiac diet. The patient remained fluid overloaded throughout her hospital course, but became intravascularly dry due to excessive diuresis. On the day before discharge, the patient was given a normal saline bolus to help offset an elevated bicarbonate and slightly elevated creatinine. The patient did not respond to this bolus well, and the patient became slightly hypoxic during the bolus. The patient's O2 requirements were increased intermittently, and was eventually weaned down to her baseline within several hours of this desaturation episode. The patient's O2 saturations remained stable for the rest of her hospital course. The patient was successfully transferred out of the Intensive Care Unit on [**2182-7-15**]. Calorie counts were obtained while the patient was on the floor, and the nutritionist recommended that the TPN be discontinued as the patient's p.o. intake had become sufficient. The patient remained slightly distended in the last few days of her hospitalization at [**Hospital6 2018**]. The patient was given a rectal tube, Dulcolax suppository, and manual disimpaction with moderate success. A Gastrografin enema study was also performed to ensure that there were no problems with the anastomosis site which would result in her abdominal distention, but this proved to be within normal limits. The care of Ms. [**Known lastname 52593**] was discussed with her primary care physician who will be taking care of her in [**Location (un) 8641**], [**Location (un) 7498**]. Arrangements were made for her transfer to [**Hospital 8641**] Hospital. DISCHARGE DIAGNOSES: Gastrointestinal bleed. Diabetes mellitus type 2. Hypertension. Chronic obstructive pulmonary disease. Arteriovenous malformation. Status post small bowel resection and right colectomy. Methicillin resistant Staphylococcus aureus pneumonia. Pulmonary hypertension. DISCHARGE STATUS: Transfer to [**Hospital 8641**] Hospital. CONDITION ON DISCHARGE: Good. DISCHARGE MEDICATIONS: 1. Albuterol inhaler. 2. Atrovent inhaler. 3. Miconazole 2 percent cream, apply topically b.i.d. to buttocks. 4. Diltiazem 90 mg p.o. q.i.d. 5. Lopressor 12.5 mg p.o. b.i.d. 6. Protonix 40 mg p.o. q 12 hours. 7. Vancomycin 1 gm intravenously q 24 hours times ten days. 8. Regular insulin sliding scale. 9. Albuterol nebulizers q six hours p.r.n. FOLLOW UP: The patient should be followed by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 52596**] and his private group practice while at [**Hospital 8641**] Hospital. The patient does not need any further follow-up with Dr. [**Last Name (STitle) **] unless further gastrointestinal issues arise. Please feel free to contact Dr. [**Last Name (STitle) **] at [**Telephone/Fax (1) 52597**]. No further follow-up with Cardiology at [**Hospital3 **] [**Hospital **] [**First Name (Titles) **] [**Last Name (Titles) **] is needed at this time. No further follow-up with the Gastrointestinal group at [**Hospital3 **] [**Hospital **] [**First Name (Titles) **] [**Last Name (Titles) **] is also not needed. DIET: The patient will not be continued on TPN secondary to recommendations by Nutrition. The patient should be able to tolerate a regular diabetic-cardiac diet. ACTIVITY: Her activities should be as tolerated, and Physical Therapy should continue to work with this patient. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], MD [**MD Number(2) 11162**] Dictated By:[**Last Name (NamePattern1) 52598**] MEDQUIST36 D: [**2182-7-18**] 11:01:55 T: [**2182-7-18**] 11:56:00 Job#: [**Job Number 52599**]

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icd9cm

[ [ [] ] ]

[ "99.15", "45.23", "38.91", "45.13", "38.93", "99.04" ]

icd9pcs

[ [ [] ] ]

8392, 8727

8782, 9133

2276, 2585

3639, 8370

2019, 2250

9145, 10409

2608, 3621

171, 227

256, 1706

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8752, 8759

82,604

142,188

41122

Discharge summary

report

Admission Date: [**2144-3-17**] Discharge Date: [**2144-3-19**] Date of Birth: [**2097-10-28**] Sex: F Service: MEDICINE Allergies: Penicillins Attending:[**First Name3 (LF) 443**] Chief Complaint: s/p STEMI Major Surgical or Invasive Procedure: Cardiac Catheterization History of Present Illness: 46 y/oF with PMH of [**Doctor Last Name 27210**] syndrome on longterm [**Hospital 89608**] transferred to the CCU following STEMI s/p DES to LAD. . Symptoms started with stuttering chest discomfort x 2 days, described as left shoulder, back and arm burning rated [**4-28**]. Discomfort resolved spontaneously with no associated symptoms. This am, patient awoke at 3am with nonresolving L shoulder pain associated with with diaphoresis. No N/V, dyspnea, or other complaints. . In OSH ED, initial EKG showed STE in V1-V3 and aVL. Initial labs were notable for WBC of 13.2 and negative troponin. Patient was given ASA 325mg, plavix 600mg and heparin gtt with bolus and transferred to [**Hospital1 18**] for further management. . Urgent cardiac catheterization (balloon time 5:18) showed 100%thrombus in LAD, proximal to the diagonal, distal to the 1st septal. Received [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] 1 with restoration of flow. Right heart cathterization showed: RAP 14 RV 46/6 PA 40/24 PAWP 25 CI 1.9. . Upon transfer to the CCU, patient comfortable with no further complaints of chest pain, dyspnea, palpitations, groin discomfort or other symptoms. On review of systems, se 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. She denies recent fevers, chills or rigors. She denies exertional buttock or calf pain. All of the other review of systems were negative. . Cardiac review of systems is notable for absence of chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. Past Medical History: [**Doctor Last Name **] Syndrome Social History: Lives with husband, employed as preschool teacher. Denies any tobacco, ETOH or illicits Family History: - No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. - Father: died of CVA in 60s Physical Exam: On Admission: VS: T= 97.6 BP= 199/76 HR= 100 RR= 18 O2 sat= 97% on 2LNC GENERAL: NAD. Oriented x3. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. NECK: Short/ webbed appearring neck. Supple with JVP of 7cm. CARDIAC: RR, normal S1, S2. No m/r/g. No S3 or S4. LUNGS: crackles at bases b/l ABDOMEN: Soft, NTND. No HSM or tenderness. EXTREMITIES: R groin with dressing intact. No hematoma or bruit. No c/c/e. SKIN: multiple scattered nevi PULSES: Right: Carotid 2+ Femoral 2+ DP 2+ PT 2+ Left: Carotid 2+ Femoral 2+ DP 2+ PT 2+ . On Discharge: GENERAL: NAD. Oriented x3. HEENT: NCAT. Sclerae anicteric. PERRL, EOMI. NECK: Short/ webbed appearing neck. Supple with JVP of 7cm. CARDIAC: RR, normal S1, S2. No m/r/g. No S3 or S4. LUNGS: CTAB ABDOMEN: Soft, NTND. No HSM or tenderness. EXTREMITIES: R groin with dressing intact. No hematoma or bruit. No c/c/e. SKIN: multiple scattered nevi PULSES: Right: Carotid 2+ Femoral 2+ DP 2+ PT 2+ Left: Carotid 2+ Femoral 2+ DP 2+ PT 2+ Pertinent Results: LABS: CBC: [**2144-3-17**] 08:15AM BLOOD WBC-15.8* RBC-4.56 Hgb-14.5 Hct-40.4 MCV-89 MCH-31.8 MCHC-35.8* RDW-12.8 Plt Ct-464* [**2144-3-19**] 07:00AM BLOOD WBC-14.5* RBC-4.85 Hgb-15.1 Hct-43.6 MCV-90 MCH-31.1 MCHC-34.6 RDW-13.2 Plt Ct-438 . COAGS: [**2144-3-17**] 08:15AM BLOOD PT-16.7* PTT-35.1* INR(PT)-1.5* [**2144-3-18**] 06:29AM BLOOD PT-13.1 PTT-27.1 INR(PT)-1.1 [**2144-3-19**] 07:00AM BLOOD PT-12.9 PTT-25.7 INR(PT)-1.1 . BMP: [**2144-3-17**] 08:15AM BLOOD Glucose-137* UreaN-16 Creat-0.6 Na-138 K-4.1 Cl-106 HCO3-25 AnGap-11 [**2144-3-19**] 07:00AM BLOOD Glucose-96 UreaN-13 Creat-0.7 Na-141 K-4.2 Cl-105 HCO3-28 AnGap-12 [**2144-3-17**] 08:15AM BLOOD ALT-108* AST-166* CK(CPK)-1765* AlkPhos-100 TotBili-0.3 . Cardiac Enzymes: [**2144-3-17**] 03:49PM BLOOD CK(CPK)-[**2158**]* [**2144-3-18**] 12:17AM BLOOD CK(CPK)-1416* [**2144-3-18**] 06:29AM BLOOD CK(CPK)-1008* [**2144-3-17**] 08:15AM BLOOD CK-MB-262* MB Indx-14.8* cTropnT-3.05* [**2144-3-17**] 03:49PM BLOOD CK-MB-265* MB Indx-13.1* cTropnT-3.54* [**2144-3-18**] 12:17AM BLOOD CK-MB-133* MB Indx-9.4* cTropnT-3.06* [**2144-3-18**] 06:29AM BLOOD CK-MB-80* MB Indx-7.9* cTropnT-2.65* . Electrolytes: [**2144-3-17**] 08:15AM BLOOD Calcium-8.4 Phos-2.5* Mg-1.9 Cholest-193 [**2144-3-18**] 06:29AM BLOOD Calcium-8.6 Phos-2.4* Mg-2.0 [**2144-3-19**] 07:00AM BLOOD Calcium-9.3 Phos-2.5* Mg-2.0 ###################################################### [**2144-3-17**]: Cardiac Cath: COMMENTS: 1. Selective coronary angiography of this right dominant system demonstrated single vessel coronary artery disease. The LMCA was free of angiographically significant disease. The LAD was occluded distal to the great septal and proximal to the first diagonal vessel. The LCx and RCA were free of angiographically significant disease. 2. Resting hemodynamics revealed elevation of left (PCW mean 25mmHg) and right sided (RVEDP 19mmHg) filling pressures with mild pulmonary artery hypertension (mean PASP 35mmHg with PASP 46mmHg). The cardiac index was depressed at 1.9 L/min/m2 with an elevated SVR at 2071 dynes*sec*cm-5. PVR was also elevated at 235 dynes*sec*cm-5. FINAL DIAGNOSIS: 1. One vessel coronary artery disease with LAD occlusion distal to first septal and proximal to the first diagonal with fresh thrombus. 2. Systolic and diastolic left ventricular dysfunction. . [**2144-3-17**] ECHO: Suboptimal image quality.The left atrium is elongated. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Overall left ventricular systolic function is mildly depressed (LVEF= 35-40 %) with septal, anterior and apical hypokinesis to akinesis. No masses or thrombi are seen in the left ventricle. There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The diameters of aorta at the sinus, ascending and arch levels are normal. There is no aortic valve stenosis. No aortic regurgitation is seen. Trivial mitral regurgitation is seen. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. . [**3-17**] CXR (Portable) IMPRESSION: 1. Mild pulmonary edema. No pleural effusion. 2. Round density overlying the superior left hemithorax, probable bone island. Recommend non-urgent lordotic views for further evaluation. . [**2144-3-19**] Limited ECHO to evaluate LV function: There is mild to moderate regional left ventricular systolic dysfunction with near akinesis of the mid to distal anterior septum and anterior wall. There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. There is no aortic valve stenosis. No aortic regurgitation is seen. There is an anterior space which most likely represents a prominent fat pad. IMPRESSION: mild to moderate regional LV systolic dysfuntion consistent with mid-LAD infarction. The other segments are hyperdynamic. No LVOT gradient seen. Brief Hospital Course: 46 y/oF with PMH of [**Doctor Last Name 27210**] Syndrome on chronic HRT transferred to the CCU following STEMI s/p DES to LAD # CAD: Presented with STEMI to LAD and went to cath lab where a DES was placed with no significant atherosclerosis in remainder of coronary arteries. Does have significant CAD as well as risk factors including longterm hormone replacement therapy and Turners Syndrome. She was started on Aspirin, plavix, metoprolol, and atorvastatin. Her premarin was discontinued as it puts her at risk for CAD. ECHO showed left ventricular systolic function is mildly depressed (LVEF= 35-40 %) with septal, anterior and apical hypokinesis to akinesis. Hemoglobin A1c was 5.6 and lipid panel showed Cholest 193 Triglyc 93 HDL 62 CHOL/HD 3.1, LDLcalc 112. The patient was monitored on the Cardiac ICU for over 24 hours and then she was transferred to the cardiac floor. On the floor she continued to be tachycardica dn her heart rate would increase to the 130s with minimal exertion, her metoprolol XL was doubled to 100mg PO Daily. She continued to be tachycardic. While this was to be expected to an extent given her myocardial injury a limited ECHO of the LV was performed which showed mild to moderate regional LV systolic dysfuntion consistent with mid-LAD infarction. The other segments are hyperdynamic. No LVOT gradient seen. She was discharged home with follow up in the outpatient setting. . # CHF: Appears mildly volume overloaded with crackles on pulmonary auscultation and evidence of elevated filling pressures on RH catheterization. Pt was started on spironolactone because EF was less than 40%. Lisinopril 10mg PO daily was also started. She was satting well on room air and was transferred to [**Hospital Ward Name 121**] 3 for further care. She will need a repeat ECHO in the coming weeks to re-evaluate the extent of disease. . # Turners Syndrome: Given her CAD, we held her hormone replacement therapy. Calcium/ vitamin D was started given risk of osteoporosis. She was not restarted on her premarin as it increases her risk of CAD. . # leukocytosis: WBC count elevated to 15, likely stress response to recent STEMI. No evidence of infectious etiology such as fever, cough, dysuria. She was not started on Abx and her WBC normalized on hospital day 2. . CODE: Full Code Medications on Admission: - premarin 0.625mg daily - medroxyprogesterone 10mg daily during luteal phase Discharge Medications: 1. aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 2. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*11* 3. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). Disp:*30 Tablet(s)* Refills:*2* 4. cholecalciferol (vitamin D3) 1,000 unit Capsule Sig: One (1) Capsule PO once a day. 5. calcium carbonate 200 mg (500 mg) Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times a day). 6. enoxaparin 80 mg/0.8 mL Syringe Sig: One (1) syringe Subcutaneous [**Hospital1 **] (2 times a day): take until warfarin level (INR) is more than 2. Disp:*8 syringe* Refills:*2* 7. spironolactone 25 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). Disp:*15 Tablet(s)* Refills:*2* 8. warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM. Disp:*30 Tablet(s)* Refills:*2* 9. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 10. metoprolol succinate 100 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily). Disp:*30 Tablet Extended Release 24 hr(s)* Refills:*2* 11. Outpatient Lab Work Please check INR on Friday [**3-20**] and call results to Dr. [**Last Name (STitle) 36055**] at [**Telephone/Fax (1) 89609**] Discharge Disposition: Home With Service Facility: [**Hospital **] Home Health Care Discharge Diagnosis: ST Elevation Myocardial Infarction Acute systolic congestive Heart failure [**Doctor Last Name 27210**] syndrome 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 required a cardiac catheterization where a drug eluting stent was placed in your left coronary artery to clear the blockage and keep the artery open. You will need to take aspirin and Plavix (clopidogrel) every day for at least one year to keep the stent from clotting off and causing another heart attack. Do not miss [**First Name (Titles) 691**] [**Last Name (Titles) 4319**] or stop taking Plavix unless Dr. [**Last Name (STitle) 2257**] says that it is OK. Your heart is weak after the heart attack and you had some fluid buidlup in your lungs because of the weak heart. WE started you on some medicines to help the heart pump better and we expect that in [**12-22**] months, your heart will be stronger. Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more than 3 lbs. No driving for one week, no lifting more than 10 pounds for one week. A chest x-ray showed what was likely a bony deformity near a left rib. You should get another chest x-ray in another view to confirm this in the next few weeks. . Wemade the following changes to your medicines: 1. Stop taking premarin and medroxyprogesterone as this increases your risk of another heart attack 2. Start taking aspirin and plavix to keep the stent from clotting off. This is critically important to prevent another heart attack. Do not miss [**First Name (Titles) 691**] [**Last Name (Titles) 4319**] or stop taking aspirin and Plavix unless Dr. [**Last Name (STitle) 2257**] tells you to. 3. Start taking Metoprolol to decrease your heart rate and help your heart recover from the heart attack 4. Start taking Lisinopril to help your heart pump stronger 5. Stazrt taking atorvastatin (Lipitor) to lower your cholesterol 6. Start taking lovenox to prevent blood clots from forming in your heart, you will use the injection twice daily until your coumadin level is more than 2 and the coumadin clinic tells you to stop. Please get your blood checked tomorrow am to see if your coumadin level is OK 4. Start taking coumadin to prevent blood clots for the next [**12-22**] months. This will continue after the lovenox injections are done. Goal coumadin level is [**1-23**]. 6. STart taking vitamin D and calcium to protect your bones. 7. Start taking spironolactone to help your heart pump better and prevent fluid buildup Followup Instructions: Name: [**Last Name (LF) **],[**First Name8 (NamePattern2) 26**] [**Last Name (NamePattern1) **] Location: [**Location (un) 2274**]-[**Location **] Address: 291 INDEPENDENCE DR, [**Location **],[**Numeric Identifier 1700**] Phone: [**Telephone/Fax (1) 43431**] Appt: [**3-23**] at 12:20pm Name: [**Last Name (LF) 2257**], [**First Name3 (LF) **] B. MD Location: [**Hospital1 641**] Address: [**Location (un) **], [**Location (un) **],[**Numeric Identifier 718**] Phone: [**Telephone/Fax (1) 2258**] Appt: [**3-31**] at 4:40pm

[ "758.6", "428.0", "428.21", "410.01", "414.01", "288.60", "V07.4" ]

icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

11089, 11152

7309, 9629

282, 307

11309, 11309

3384, 4103

13816, 14345

2227, 2373

9757, 11066

11173, 11288

9655, 9734

5516, 7286

11460, 13793

2388, 2388

2929, 3365

4120, 5499

233, 244

335, 2049

2402, 2915

11324, 11436

2071, 2105

2121, 2211

1,086

114,240

10174

Discharge summary

report

Admission Date: [**2150-6-19**] Discharge Date: [**2150-6-23**] Date of Birth: [**2070-6-19**] Sex: F Service: NEUROLOGY Allergies: Iodine / Epinephrine / Gentamicin / Ivp Dye, Iodine Containing / Aleve Attending:[**First Name3 (LF) 618**] Chief Complaint: Called by Dr. [**First Name (STitle) **] in Neurosurgery to evaluate for intraparenchymal hemorrhage. Major Surgical or Invasive Procedure: None History of Present Illness: Ms. [**Known lastname **] is a 79-year-old right-handed woman who presentswith headache. She was in her USOH until Sunday (5 days prior) when she developed a severe, acute onset, pounding headache. A headache of any sort is unusual for her. This was associated with some nausea but no vomiting and no other symptoms. She took frequent Tylenol and went to bed early. There was some improvement by the next day, and it had resolved within 24 hours. She did see her PCP on Tuesday. On Wednesday, she had a recurrence of this headache. Again a sharp pain bifrontally maximal at onset that then spread to the back of her neck and eventually became a severe pounding throughout her head. Tylenol provided little relief. She had nausea, but no other symptoms, including no frank vertigo or disequilibrium, no focal weakness, no dysphagia, no diplopia. When the headache persisted through the next day, she called her PCP. [**Name10 (NameIs) **] referred her to the [**Hospital3 417**] ED. There, a head CT revealed an intracerebral hemorrhage in near the cerebellar vermis, 1 cm in diameter. As her INR was elevated due to her Coumadin, she was given 2 units of FFP there. She was then transferred here. After arrival at [**Hospital1 18**], her INR was 2.0. She was given 2 more units of FFP and 10 mg of SQ Vitamin K. She was admitted to the neurosurgical service, but as there is no surgical intervention warranted, they have consulted us for further recommendations on management and for possible transfer to our service. On neuro ROS, Ms. [**Known lastname **] [**Last Name (Titles) **] headache now, as well as loss of vision, blurred vision, diplopia, dysarthria, dysphagia, lightheadedness, vertigo, tinnitus or hearing difficulty. [**Last Name (Titles) 4273**] difficulties producing or comprehending speech. [**Last Name (Titles) 4273**] focal weakness, numbness, parasthesiae. No bowel or bladder incontinence or retention. [**Last Name (Titles) 4273**] difficulty with gait. On general review of systems, she [**Last Name (Titles) **] recent fever or chills. No night sweats or recent weight loss or gain. [**Last Name (Titles) 4273**] cough, shortness of breath. [**Last Name (Titles) 4273**] chest pain or tightness, palpitations. [**Last Name (Titles) 4273**] nausea, vomiting, diarrhea, constipation or abdominal pain. No recent change in bowel or bladder habits. No dysuria. [**Last Name (Titles) 4273**] arthralgias or myalgias. [**Last Name (Titles) 4273**] rash. Past Medical History: PMH: Atril fibrillation on Coumadin until admission CAD CHF Tachy-brady syndrome s/p pacemaker in [**2137**] s/p Sub-total colectomy and splenectomy with ileostomy in [**2144**] with subsequent reversal of ileostomy c. diff diverticulosis PSH: [**10-14**] ileostomy takedown, wedge of stomach [**5-13**] subtotal colectomy and ileostomy [**5-15**] tracheostomy splenectomy CCY appy parathyroid excision Social History: [**Month/Year (2) 4273**] use of tobacco and alcohol. 80th birthday tomorrow. Family History: NC Physical Exam: Vitals: T: 98.6 P: 73 R: 23 BP: 114/46 SaO2: 97% 4L NC General: Awake, cooperative, NAD. HEENT: NC/AT, no scleral icterus noted, MMM, Neck: Supple, no carotid bruits appreciated. No nuchal rigidity Pulmonary: Lungs CTA bilaterally without R/R/W Cardiac: RRR, nl. S1S2, no M/R/G noted Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or organomegaly noted. Extremities: No C/C/E bilaterally, 2+ radial, DP pulses bilaterally. Skin: no rashes or lesions noted. Neurologic: -Mental Status: Alert, oriented x 3. Able to relate history without difficulty. Attentive. Language is fluent with intact repetition and comprehension. Normal prosody. There were no paraphasic errors. Speech was not dysarthric. Able to follow both midline and appendicular commands. The pt. had good knowledge of current events. -Cranial Nerves: I: Olfaction not tested. II: PERRL 5 to 2mm and brisk. VFF to confrontation. III, IV, VI: EOMI without nystagmus but with saccadic intrusion. V: Facial sensation intact to light touch. VII: No facial droop, facial musculature symmetric. VIII: Hearing intact to voice. IX, X: Palate elevates symmetrically. [**Doctor First Name 81**]: 5/5 strength in trapezii and SCM bilaterally. XII: Tongue protrudes in midline. -Motor: Normal bulk, tone throughout. No pronator drift bilaterally. No adventitious movements noted. No asterixis noted. Delt Bic Tri WrE FFl FE IP Quad Ham TA Gastroc L 5 5 5 5 5 5 5 5 5 5 5 R 5 5 5 5 5 5 5 5 5 5 5 -Sensory: No deficits to light touch. No extinction to DSS. -DTRs: [**Name2 (NI) **] Tri [**Last Name (un) 1035**] Pat Ach L 2 2 1 2 1 R 3 2 1 3 1 Plantar response was mute bilaterally. -Coordination: No intention tremor, mild dysdiadochokinesia on left. Mild ataxia on FNF on left. -Gait: Good initiation. Slow but Narrow-based, normal stride and arm swing. Pertinent Results: Laboratory Data: 141 103 21 105 4.3 28 1.4 Ca: 9.7 Mg: 2.2 P: 2.7 WBC: 7.9; Hct: 30.7; Plt: 237 PT: 16.0 PTT: 29.0 INR: 1.4 EKG: Paced Radiologic Data: NCHCT: Small, 11 mm hyperdense lesion in the superior cerebellum adjacent to the tentorium in the midline. This should be a very unusual location for isolated subdural hemorrhage. As this lesion appears extra-axial, it most likely represents a mass lesion such as meningioma. Less likely consideration would be a metastatic focus. MRI may be helpful for further characterization. NOTE ADDED AT ATTENDING REVIEW: There is a small region of hypodensity in the vermis adjacent to this lesion. This may represent edema, which would argue for an intra axial abnormality. I agree with the recommendation of an MR exam, but I raise the possibility that this may reflect an intra axial lesion, perhaps hemorrhage. Unfortunately, I do not have access to the outside study, so I cannot comment about any changes since the prior study. REPEAT HEAD CT w/wo CONTRAST: In comparison to the non-contrast head CT, there is no definite change in size of a well-circumscribed focal hyperdensity in the superior aspect of the cerebellum measuring 14 x 7 mm. The difference in measurements are within the possible difference due to slice selection. There is a small region of hypodensity in the vermis adjacent to this lesion, which likely represents a small amount of edema. Therefore, an intra-axial location is likely. This lesion does not demonstrate enhancement on contrast-enhanced imaging, and the density is unchanged on delayed images. Therefore, a small focus of hemorrhage is the likely etiology. EKG: A-V sequential paced rhythm. Compared to the previous tracing of [**2146-11-23**] there is no significant diagnostic change. Intervals Axes Rate PR QRS QT/QTc P QRS T 74 0 162 442/466 0 118 -60 CXR [**6-21**] Cardiac silhouette remains enlarged, and there is persistent pulmonary vascular engorgement. Bilateral diffuse interstitial opacities have improved, consistent with improving interstitial edema. However, more confluent airspace opacities in the lower lungs have slightly worsened, particularly in the left lower lobe. Although possibly due to dependent areas of edema, superimposed process such as a pneumonia should be considered in the appropriate clinical setting. Small right pleural effusion has decreased in size, but a small-to-moderate left effusion is slightly larger. KUB [**2150-6-21**] Non-obstructed bowel gas pattern is visualized. Surgical clips are noted within the pelvis. Examination was not obtained in upright or lateral decubitus view; thus, free intraperitoneal air cannot be assessed. Right hemidiaphragm is moderately elevated. U/S RUQ [**2150-6-22**] 1. No biliary dilatation. Status post cholecystectomy. 2. Incidental finding of a 9-mm cystic lesion in the neck of the pancreas. If clinically indicated, an MRI could be helpful for better characterization. 3. 1.1 cm simple cyst in the lower pole of the left kidney. 4. Right pleural effusion. ECHO [**2150-6-23**] The left atrium is mildly dilated. There is asymmetric left ventricular hypertrophy, involving the anterior septum and inferior wall. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF>55%). These findings are consistent with hypertrophic non-obstructive cardiomyopathy (HCM). 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. There is no systolic anterior motion of the mitral valve leaflets. Moderate (2+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Hypertrophic cardiomyopathy with preserved biventricular systolic function. Mild aortic regurgitation. Moderate mitral regurgitation. Moderate pulmonary hypertension. Compared with the prior study (images reviewed on videotape) of [**2144-5-6**], asymmetric LV hypertrophy pattern is better appreciated (technically-superior study). The other findings are similar. Brief Hospital Course: NEURO - Briefly observed in the ICU, uncomplicated coarse. The patient had a virtually unremarkable exam throughout her hospital stay. She may have displayed a minor limb ataxia on the left initially, but this has virtually completely recovered. Her gait ataxia preventer her from being discharged on her birthday, and she stayed in the hospital for non-neurological reasons as well, as outlined below. There were no neurological complications during her stay. * Etiologically, her CT W&WO CONTRAST did not reveal any enhancement. An MRI was not pursued given her pacemaker. The bleed is most likely primary. CARDIAC - Patient received FFP during admission to correct for her INR (see HEME). She also received a 500 cc fluid bolus in the ICU due to perceived orthostasis. She experienced a mild CHF exacerbation by the time she was back on the floor, which warranted 10 mg of Lasix. EKG and ECHO (see results) unchanged. PULM - Saturations ran typically in the lower 90's (91 - 94) with at times supplemental oxygen. However, she never experieced any dyspnea nor an increased RR, indicating that the supplemental oxygen was likely mainly esthetic. Also, she showed improvement of her sats with ambulation suggesting some atelectasis in bed. On her CXRs, she had some mild CHF and a small R basal pleural effusion, the latter may have caused some RUQ pain. She was encouraged to do incentive spirometry a few times per hour. GI - She became constipated, and was started on a more aggresive bowel regimen. A KUB was unremarkble (see "results"). She complained of some RUQ pain, and anorexia. An U/S was performed showing no biliary dilation. It did reveal a 9 mm pancreatic cyst, coincidental. Extensive review of systems did not reveal any suggestion of malignancy, but she will need definetely need follow-up on this. HEME - She developed an anemia, with Hct lowest values down to 26.6, however, serial measurements showed great fluctuations. At time of dischartge her Hct was back to her admit values of ~30. Guiacs were not obtained since there were no BM. Extensive iron studies, vitamin assays and hemolysis labs were pending at time of discharge, and can be followed up on as an outpatient. RENAL - She developed an acute on chronic RF, likely due to IV contrast for the CT. She peaked at a BUN/Cr of 44/2.0 but at time of discharge was coming down to 32/1.7. ID - She was treated with Bactrim for a UTI discovered on [**2150-6-20**] ([**7-21**] whites, many bact, nitr +), last dose on [**6-22**]. Since she needed only a few more doses when her ARF was detected, it was finished despite it's potential impact on RF. Medications on Admission: Metoprolol 50 mg po BID Diltiazem XR 120 mg po daily Digoxin 0.125 mg po daily Calcium 650 mg [**Hospital1 **] Coumadin 2.5 mg po QOD alternating with 1.25 mg po QOD Discharge Medications: 1. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 2. Diltiazem HCl 120 mg Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO DAILY (Daily). 3. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO every other day. 4. Calcium 500 mg Tablet Sig: One (1) Tablet PO once a day: ** NOTE THAT YOU CAN TAKE YOUR OWN 650 mg TABLETS **. -- TO BE STARTED AFTER YOU SEE YOUR PCP: 5. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO every other day: START SATURDAY THE [**12-4**] ** ALTERNATING WITH 1.25 mg EVERY OTHER DAY **. 6. Warfarin 1 mg Tablet Sig: One (1) Tablet PO every other day: START SUNDAY THE [**12-5**] ** ALTERNATING WITH 2.5 mg EVERY OTHER DAY **. Discharge Disposition: Home With Service Facility: [**Hospital 2255**] [**Name (NI) 2256**] Discharge Diagnosis: Primary: 1. Cerebellar infarct, hemorrhagic Secondary: 1. Coronary artery disease 2. Congestive heart failure 3. Atrial fibrillation 4. Chronic kidney disease Discharge Condition: Good condition. Mild dysmetria of left arm, gait instability but sufficiently safe per PT. Discharge Instructions: You have been evaluated for a small stroke caused by bleeding in your brain. This will not significantly impact your daily functioning. Your Coumadin has been stopped for now. Specific instructions: 1 Please practice your walking with HOME-PT, as presribed. 2 We have contact[**Name (NI) **] your PCP Dr [**Name (NI) **], and he is aware of the situation. Please make sure that BEFORE restarting your Coumadin, you visit him for follow-up. He will also follow-up with you regarding the pancreatic cyst that was found on the ultrasound - this likely represents a coincidental finding and needs to be monitored over time. Please take all medications as directed. Please keep all follow-up appointments. If you have any new headaches, or if you develop dizziness, double vision, difficulty swallowing, difficulty speaking, difficulty understanding others, weakness, or numbness, please call your neurologist or go to the nearest hospital emergency department. Followup Instructions: Provider: [**Name10 (NameIs) **] [**Name11 (NameIs) **], [**Name Initial (NameIs) **].D. Phone:[**Telephone/Fax (1) 2574**] Date/Time:[**2150-8-25**] 3:30 Please call your PCP [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) 122**] [**Last Name (NamePattern1) **] at [**Telephone/Fax (1) 8725**] to be seen in [**2-11**] weeks. [**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 632**] Completed by:[**2150-6-23**]

[ "428.0", "584.9", "585.9", "V45.01", "E947.8", "599.0", "427.81", "428.21", "427.31", "V58.61", "431", "425.4", "577.2" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

13330, 13401

9762, 12394

434, 440

13605, 13698

5434, 9739

14706, 15172

3495, 3500

12611, 13307

13422, 13584

12420, 12588

13722, 14683

4348, 5415

3515, 3997

292, 396

468, 2955

4012, 4331

2977, 3383

3399, 3479

10,731

159,858

25575

Discharge summary

report

Admission Date: [**2187-7-23**] Discharge Date: [**2187-8-28**] Date of Birth: [**2119-2-2**] Sex: M Service: MEDICINE Allergies: Ace Inhibitors Attending:[**First Name3 (LF) 2186**] Chief Complaint: gangrene r/o endocarditis Major Surgical or Invasive Procedure: none History of Present Illness: 67yo man with h/o DM2, Afib, PVD s/p fem-[**Doctor Last Name **] bypass [**2187-6-22**], who necrotic digits and to r/o endocarditis. The patient had cut his R index finger 8 wks PTA, which initially scabbed over. Four weeks ago, noted the start of bluish discoloration of great and second toes bilaterally. Had increased pain in his hands and feet since. He was started on Keflex for his hands about 1.5 weeks PTA, then had an episode of dizziness at his Podiatrist's and was admitted to [**Hospital1 112**] for new onset Afib. From records, was noted to have loud systolic murmur during this admission, but TTE was negative for etiology (see below). While at BMH, had abx change to Augmentin, was started on coumadin and discharged. Thereafter, toe pain worsened and became black. Was seen in [**Hospital **] clinic on DOA, sent to ER for worsening gangrene of digits as well as to r/o endocarditis given new finding of splinter hemorrhages on digits. In ED on [**7-23**], patient was started on Vanc and Gent for likely endocarditis per Cards recs. Also given Zosyn for pseudomonal coverage per [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] recs. Renal was consulted to initiate peritoneal dialysis. Patient was admitted to [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] service for treatment of necrotic digits. ID evaluated, was concerned about infectious endocarditis vs. thromboembolic emboli from Afib, with one of these etiologies causing dry gangrene and splinter hemorrhages. He was afeb on admit [**7-23**], but spiked to 100.2F in the early AM of [**7-24**]. He underwent a TEE, which showed no evid of vegetations or clot, no ASD or PFO, but did show a complex nonmobile atheroma in the transverse and descending Ao (complex Ao plaque). ID rec cont to treat presumptively for infectious endocarditis despite TEE results, and to get abd/pelv CT to look for focal abscesses. This was performed, and notable for splenic infarcts consistent with thromboembolic vs. septic emboli. Renal rec sending PD fluid for cell count and culture given that the patient was c/o abd pain, which was done on [**7-25**]. The fluid had over 350 WBCs/mm, though no organisms were seen, consistent with a sterile peritonitis. ID rec pulling PD cath and sending for cx, as well as considering intraperitoneal abx depending on peritoneal fluid cx results. ID also rec CT head to look for embolic infection. During the course of the patient's stay, 50h thus far, his WBC has risen from 27.5 to 39.8, his hct went from 32 to 25 but then back up to 29 after receiving one unit PRBC, and his INR rose from 2.7 on admit up to 8.7 while not receiving any coumadin, but is now back down to 1.7 after receiving 5mg SQ Vit K. His fibrinogen was 986, with FDP and d-dimer pending. His ESR was 135, CRP 110. He is being transferred to Medicine for further management of his complicated medical state. Past Medical History: CAD: LCx stenosis but no stent, LAD calcified Pump: TTE at [**Hospital1 112**] [**2187-7-19**] showed mild LVH, LVEF 55-60%, no clot, nl LA and [**Last Name (LF) **], [**First Name3 (LF) **] tricuspid mildly thick no AR or AS, MV mildly fibrotic with mod annular fibrosis and calc and mild MR, TV nl, PV nl, nl Ao root; no other significant abnormalities, did not comment on cause of patient's known [**2-11**] syst murmur DM2, complicated by nephropathy and peripheral neuropathy ESRD on peritoneal dialysis, started 1mth PTA Anemia, attributed to ESRD HTN Dyslipidemia PVD, s/p bilateral cath and stenting of iliac arteries in [**6-12**] Afib, new onset, diagnosed one week PTA at [**Hospital1 112**] after dizziness Pelvic fx in [**2181**] L inguinal hernia repair [**2185**] Social History: Lives with his wife. [**Name (NI) **] etoh. Smoked until [**2170**]. Worked as a Systems Engineer. Moved from [**Country **] in [**2160**]. Family History: NC Physical Exam: (on transfer to Medicine) Vitals: 97.3/98.3 115/37(115-122/37-74) 56(50-62) 20 1500 in/PD out FS 189-304 Gen: lying in bed, asleep but easily arousable HEENT: PERRL, EOMI, dry MM, OP not well visualized Neck: no LAD, JVD flat CV: RRR, [**3-14**] harsh holosyst murmur at LUSB with rads to bilateral carotids, no rub or gallop Lungs: decreased BS and rales in lower [**12-10**] bilaterally, no cough Abd: distended and tense, diffusely tender to mod palpation, +rebound, increased tympanic BS Ext: no LE or UE edema; splinter hemorrhages in bilateral fingers; R index finger with gangrenous tip; 1st and 2nd toes gangrenous bilaterally Neuro: A+Ox3, [**3-13**] muscle strength in UE/LE flexors/extensors, sensation diminished in distal LE bilaterally but otherwise intact Pertinent Results: Recent labs: [**2187-7-25**] 06:25AM BLOOD WBC-31.1* RBC-2.66* Hgb-7.8* Hct-25.6* MCV-96 MCH-29.4 MCHC-30.6* RDW-14.0 Plt Ct-470* [**2187-7-24**] 05:45AM BLOOD Neuts-94.1* Bands-0 Lymphs-3.5* Monos-2.0 Eos-0.3 Baso-0.1 [**2187-7-25**] 06:25AM BLOOD PT-36.3* PTT-58.6* INR(PT)-8.7 [**2187-7-24**] 05:45AM BLOOD ESR-135* [**2187-7-25**] 06:25AM BLOOD Glucose-221* UreaN-57* Creat-5.6* Na-137 K-3.2* Cl-94* HCO3-27 AnGap-19 [**2187-7-23**] 01:45PM BLOOD ALT-7 AST-6 CK(CPK)-10* AlkPhos-101 Amylase-11 TotBili-0.1 [**2187-7-23**] 01:45PM BLOOD Lipase-9 [**2187-7-25**] 06:25AM BLOOD Calcium-7.5* Phos-5.7* Mg-1.5* [**2187-7-24**] 05:45AM BLOOD calTIBC-107* Ferritn-529* TRF-82* [**2187-7-25**] 06:25AM BLOOD %HbA1c-6.9* [Hgb]-DONE [A1c]-DONE [**2187-7-24**] 05:45AM BLOOD PTH-21 [**2187-7-24**] 05:45AM BLOOD CRP-109.9* [**2187-7-23**] 01:48PM BLOOD Lactate-1.4 [**2187-7-24**] 05:45AM BLOOD Genta-3.7* Vanco-32.0 [**2187-7-23**] 10:53PM ASCITES WBC-365* RBC-5* Polys-91* Lymphs-0 Monos-5* Macroph-4* [**2187-7-25**] 06:00PM OTHER BODY FLUID WBC-PND RBC-PND Polys-PND Lymphs-PND Monos-PND Micro: [**2187-7-25**] DIALYSIS FLUID INPATIENT Pending [**2187-7-24**] PERITONEAL FLUID INPATIENT GRAM STAIN (Final [**2187-7-24**]): 2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. FLUID CULTURE (Preliminary): NO GROWTH. ANAEROBIC CULTURE (Pending): [**2187-7-23**] BLOOD CULTURE EMERGENCY [**Hospital1 **] Pending [**2187-7-23**] BLOOD CULTURE EMERGENCY [**Hospital1 **] Pending [**2187-7-23**] BLOOD CULTURE EMERGENCY [**Hospital1 **] Pending Brief Hospital Course: Briefly, this is 67yo man with h/o DM2 and ESRD initially on PD who presented with gangrenous digits and splinter hemorrhages concerning for endocarditis. The pt was initially managed by the Vascular Surgery service and was transferred to the Medicine service for further care. TEE was negative and the etiology of the pts progressive digital necrosis remained elusive. CT of the abdomen was significant for splenic infarct as well. He was treated empirically for endocarditis and anticoagulated on heparin. The pt developed a coagulopathy early in hospitalization requiring Vitamin K reversal. The pts hospital course was complicated by peritonitis, requiring removal of his PD catheter and initiation of HD. The pt became encephalopathic, with psychiatry deeming him incapacitated and his wife taking the role of health care proxy. . # Respiratory - The patient's respiratory status was good with no evidence of PNA or effusions on CXR until [**8-17**] when he developed acute respiratory distress the tachypnea and hypoxia. CXR showed complete whiteout of left lung. He was transferred to MICU on NRB and initially improved but again become acutely SOB and was intubated. Following intubation he had persistent LLL collapse and a bronch was done where tannish secretion were sucked out from LLL. Repeat CXR showed improved aeration of LLL, and the cause was thought to be d/t mucous plugging. Vanc/levo/flagyl were ititiallky started d/t concern for aspiration PNA, but vanc and flagyl were eventually stopped as there was no evidence of this on BAL. Caspofungin was started for yeast on BAL. The patient was extubated but unfortunately continued to have problems with mucous plugging and ended up being intubated x 3. Tracheostomy was performed on [**8-24**] and the patient was remained on the vent and he was difficult to wean with periods of apnea during spontaneous breathing trials. Daily family meetings were held to discuss the global picture which included sepsis d/t bacteremia and fungemia requiring intermittent pressors, necrotic digits and toes that would require amputation, and repeated mucous plugging s/p trach with inability to wean from the ventilation. In the evening of [**8-27**] the family decided to take the patient off of the ventilator and make him comfortable, and he passed away early in the a.m. of [**8-28**] from likely respiratory arrest. . # Leukocytosis/Sepsis: The pt had a persistent elevation in WBC which peaked at 53 on [**7-31**] and then trended down into the 20s following d/c of the PD catheter. The etiology of the continued leukocytosis was initially unclear but upon transfer to the MICU he was found to have VRE and yeast in the blood on [**8-18**]. He was treated with caspofungin and linezolid for the remainder of his hospital course. He required pressors on and off to maintain SBP >55 until his death on [**8-28**]. # Splenic infarct/splinter hemorrhages/Gangrenous Digits/Splenic Infarcts: The pts presentation was concerning for emboli of infectious vs. thrombotic etiology. There was also initial concern for vasculitis and hypercoagulable state. TEE was negative for clot, but given there is a 10% risk of a false negative on TEE, the pt continued on empiric therapy with a extended vancomycin, and 5 day course of gentamicin. The pt was also continued on Zosyn for infectious coverage of his necrosed digits (pseudomonal coverage for diabetes). The pt was continued on heparin for anticoagulation in the case of any hypercoaguable state. Heparin was only held prior to pull of PD catheter and Quinton catheter insertion for HD. Complex atheroma was seen on TEE also concerning for cholesterol/thrombotic emboli. All blood cultures drawn have been negative. CT of the head on [**7-26**] was negative for evidence of emboli. Infectious disease, rheumatology, dermatology, and hematology/oncology specialists were all ultimately involved in this pts care. ID had discussed this atheroma with cardiology, and it was felt the atheroma was an unlikely source of seeding. Vascular/hypercoagulable work up included ANCA, [**Doctor First Name **], RF, anticardiolipin ab, HIT antibody, and cryoglobulins, all of which were negative. Lupus anticoagulant was not evaluated secondary to the pt being on heparin for anticoagulation. Dermatology biopsied a site on the pts finger, revealing multiple large thrombi in medium sized arterioles, capillaries, and venules and is negative for evidence of atheroemboli and vasculitis--per path likely dx is hypercoagulable state. CT of head [**7-26**] negative for septic emboli. CT of the torso on [**7-25**] revealed a splenic infarction. ID also considered other diseases such as brucellosis (Brucella ab negative), and the pt was then empirically treated with doxycycline. He was transferred to the MICU on [**2187-8-17**] for hypoxia (see below) and he was continued on empiric treatment for endocarditis with [**Doctor Last Name **]/levo/doxy and he was continued on heparin for his hospital course. His ischemic digits worsened daily and while vascular surgery followed these, the decision regarding surgery was not made before he died. . Abdominal Distension/Distended loops of bowel on AXR: As the pts peritonitis worsened, his pain and distension also worsened. The pt developed an adynamic ileus as evidenced on a portable abdomen film on [**7-28**]. Laculose po and PR only resulted in small bowel movements. Only after pulling of the PD catheter did the pt begin to have regular bowel movements with partial resolution of abdominal distension. The pts adynamic ileus was felt to be likely secondary to peritoneal irritation and narcotics. In the MICU his belly become increasinly distended and he was his TF's were intermittently on and off d/t high residuals. KUB's were done and did not show abdominal perforation, and the patient was maintained on bowel rest for the majority of his MICU stay. . Peritonitis: The pt developed intense abdominal pain and distension within his first week of hospitalization. All cultures of the PD fluid were negative for growth, but gram stain revealed a sterile pyuria with increasing numbers of white cells (up to 4500). The fluid was also fungal culture and AFB smear negative. It was felt the fluid was sterile given the pt was on broad spectrum abx. A 2 day trial of IP vanc and ceftazadime was initiated. With increasing pain requiring dilaudid PCA, transplant surgery removed the PD catheter on [**7-30**] and placed a R subclavian temporary HD catheter on [**7-31**]. Following removal of the PD catheter, the pts abdominal distension and pain resided. Coagulopathy: The pt developed a coagulopathy within the first several days of hospitalization in which his INR rose up to 8. Vitamin K administration lead to reversal, and coumadin was not restarted. DIC panel was negative, and the pt likely developed this coagulopathy from malnutrition. . ESRD: Prior to the pts hospital admission, he had been on PD for only a month. The renal service followed this pt for the duration of his hospital admission. As already stated, he developed a peritonitis requiring PD catheter removal. As the pt had no form of dialysis for approximately 4-5 days, he seemed to develop an encephalitis. The pts creatinine rose up to 8 on [**8-1**], and trended down with HD initiated on [**8-1**]. The pt was continued on a renagel, nephrocaps, epogen, and medications were renally dosed. While in MICU, he continued to receive dialysis as deemed by the renal team. . DM2: The pt initially had more problems with hyperglycemia with FS in the 200s. The pt was managed on SSI and Glargine. As the pts po intake declined, and became hypoglycemic with FS in the 60-70s, requiring d/c of glargine and retitration of the SSI. After initiation of TPN, the pt was continued on SSI and regular insulin was added to the TPN fluid. . Paroxysmal Atrial fibrillation: The pt was first noted to have an episode of AF at [**Hospital6 **] the week PTA. He was started on coumadin at that time. The pts coumadin was held on admission given supratherapeutic INR and the potential for coumadin skin necrosis. Pt went in and out of AF and NSR. Prior to encephalopathy, the pt was rate controlled with po verapamil and lopressor. The pt went into afib with RVR the evening of [**7-27**] and was given lopressor 5 mg IV x2 and metoprolol 25 mg po x 1, started on dilaudid PCA to decrease pain/stress. Pt may have had atrial fibrillation in the setting of acute stress/infection. He spontaneously cardioverted the following morning. Again the pt went into Afib with RVR following HD on [**8-1**]. Given he was not taking po medications at this time, he was trasferred to the VICU and started on diltiazem gtt. The pts rate had been up to 140s and decreased to the 90s with the dilt. The following am, he again spontaneously cardioverted to NSR and dilt gtt was weened to off. No futher complications. . Anemia: The pts anemia was apparently longstanding and attributed to ESRD. Iron was low at 9 and ferritin was elevated at 529, c/w anemia of chronic disease. The pt was continued on epogen and iron supplementation. He required 1 unit of PRBC during the first week for a hct of 25, and in the second week of hospitalization he required another 2 units of PRBC for a hct drop again down to 25. . Hypoalbuminemia/malnutrition: The pt had both poor appetite and po intake. Albumin level was 2.1 on [**7-23**]. As the pt became increasingly encephalopathic, his po intake declined even further, and he even became an aspiration risk. A PICC line was placed on [**8-1**] for the initiation of TPN. The pt pulled out the line overnight secondary to agitation,and it was replaced again on [**8-2**]. TPN was initiated on the evening of [**8-2**] and continued throughout his hospitalization as tolerated. . Psych: Social work was consulted to address pt and family coping. Resident [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] and psych consult had a discussion with both pt and family regarding decision making. The pt initially refusedPD catheter removal. However, psychiatry deemed the pt incapacitated secondary to delerium/encephalopathy. The wife was the designated health care proxy and decided to agree to removal of the PD catheter and initiation of HD. The pt was started on zyprexa 2.5 mg po qhs plus 2.5 mg po BID PRN anxiety/agitation pr psych recommendations. The pts delerium was felt to be secondary to both renal insufficiency and infection. Medications on Admission: Outpatient meds (from [**Hospital1 112**] discharge summary [**2187-7-19**]): Coumadin 1mg qhs ASA 325mg qd Lasix 40mg qd Toprol XL 50mg po qd Plavix 75mg qd Verapamil SR 120mg qd Insulin: Novolog, Lantus Calcitriol 0.75 mcg qd PhosLo 667mg tid Nephrocaps 1 tab qd Iron 325mg [**Hospital1 **] Sodium bicarb 1300mg tid Epogen 40,000u qweek Roxicodone Trazadone 50mg qhs Simvastatin 20mg po qhs Colace 100mg [**Hospital1 **] Nexium 20mg qd Augmentin 875/125 1 tab q12h Discharge Medications: None Discharge Disposition: Expired Discharge Diagnosis: Mucous plugging Sepsis from bacteremia and fungemia Vascular Necrosis to fingers and toes Discharge Condition: Deceased Discharge Instructions: None Followup Instructions: None

[ "707.8", "996.68", "444.89", "507.0", "250.82", "285.21", "403.91", "E879.1", "V58.67", "451.84", "276.2", "995.91", "276.8", "E915", "440.24", "250.72", "424.90", "934.1", "E849.8", "584.9", "427.31", "263.9", "414.01", "038.0", "518.81" ]

icd9cm

[ [ [] ] ]

[ "54.98", "88.72", "33.24", "99.15", "00.14", "31.1", "38.95", "97.82", "99.04", "39.95", "54.95", "96.72", "86.11", "96.04" ]

icd9pcs

[ [ [] ] ]

17749, 17758

6646, 17198

300, 306

17891, 17901

5047, 6353

17954, 17961

4228, 4232

17720, 17726

17779, 17870

17224, 17697

17925, 17931

4247, 5028

235, 262

334, 3253

3275, 4055

4071, 4212

6385, 6623

42,275

128,293

43027

Discharge summary

report

Admission Date: [**2135-10-24**] Discharge Date: [**2135-10-27**] Date of Birth: [**2058-8-4**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2641**] Chief Complaint: shortness of breath Major Surgical or Invasive Procedure: none History of Present Illness: Mr. [**Known lastname 21991**] is a 77 year old male with past medical history of COPD on 3L nasal cannula at home, OSA, thyroid cancer, chronic renal insufficiency, and large-cell lung cancer who presents with an episode of shortness of breath overnight. He reported to his PCP and sleep physicians that he awoke in the middle of the night "gasping" for air. He feels he nearly died. The dyspnea lasted about 3 minutes in total. He did not have any other asssociated symptoms such as chest pain, fevers, chills, or productive cough. No wheezing. Given the complexity of his medical problems, he was referred in for further evaluation. . In the ED, his initial vital signs were: 99.1 73 143/81 22 97% 3L He was given 325 mg of aspirin. A chest x-ray was completed and unchanged from prior. An EKG was also unchanged atrial paced rhythm. from prior. His initial cardiac enzymes revealed an elevated troponin of 0.02, with a CK of 59. He is being admitted for further evaluation and to complete a rule out for myocardial ischemia. He is being admitted to ICU for new dx of OSA and initiation of Bipap. Sleep sent him in. Looked well. No SOB here felt fine. Satting 97% on 3L. Asymmetric swelling in left left, negative LENI. 97.5 71 165/77 18 93%L upon departure from ED. . On the floor, patient endorsed cough productive of sputum that usually happens at night but has never woken him up from sleep. For the past 2 months he has had increased shortness of breath with exertion, unable to ambulate >10-15ft without shortness of breath and a cough productive of clear mucous. He denies fever, chills, dysuria, chest pain, palpatitions or shortness of breath at rest. Also reports orthopnea and sleeps sitting propped up on wedge pillow. Denies recent sick contacts. In past notes, med compliance has been questioned but patient endorses that his wife has been giving him recent nebs. Past Medical History: - COPD, on 3L nasal cannula at home - OSA, on BiPAP 10/5- Moderate OSA AHI 11 O2 sat nadir 76% who failed BIAP titration - Large-cell lung cancer- could not be resected status post chemotherapy and XRT [**2122**] - Anaplastic thyroid cancer status-post failed resection of extensive tumor- [**8-11**] PET CT FDG avid left thyroid mass has increased in size and mass effect since [**2135-6-23**]. Mets to right upper lobe pulmonary nodule and 3. 1 cm FDG avid left parotid lymph ? mets. - Stage III chronic renal insufficiency, baseline 2.0-2.6 - Status-post dual-chamber pacemaker placement for bradycardia/Wenkebach [**2133**] -? MI -Aflutter s/p ablation [**8-10**] - BPH - Pulmonary artery hypertension (40-50mmHg) - vocal cord paralysis - aspiration pna Social History: Quit smoking >8 yrs ago but smoke and drank significantly prior to that time Occupation: retired software engineer Drugs: denies Tobacco: 100pack year history Alcohol: none recent, used to drink heavily Other: Family History: non-cont Physical Exam: VS T 97.6 72 170/83 14 92%RA General Appearance: Well nourished, Overweight / Obese Eyes / Conjunctiva: PERRL, Pupils dilated, No(t) Conjunctiva pale Head, Ears, Nose, Throat: Normocephalic Cardiovascular: (S1: Normal), (S2: Normal) Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial pulse: Not assessed), (Right DP pulse: Present), (Left DP pulse: Present) Respiratory / Chest: (Expansion: Symmetric), (Percussion: Hyperresonant: ), (Breath Sounds: Clear : , Wheezes : early inspiratory), prolonged expiratory phase Extremities: Right lower extremity edema: Absent, Left lower extremity edema: Absent Skin: Not assessed, No(t) Rash: Neurologic: Attentive, Follows simple commands, Responds to: Not assessed, Oriented (to): AAOx3, Movement: Not assessed, Tone: Not assessed Brief Hospital Course: MICU Course: The patient was admitted to the medical intensive care unit for initiation and titration of BIPAP support. In parallel, he was treated for a COPD exacerbation with oral steroids and azithromycin, and continued on spiriva. He did not tolerate the BIPAP through the evening, and the plan was to discontinue this (notably, he did not tolerate bipap in sleep lab either). Further workup of his pulmonary status was pursued with CT scanning of neck and chest to look for progressive local invasion of medullary thyroid CA. Plan was also put in place for ENT evaluation of his vocal cords to look for vocal cord dysfunction potentially related to tumor involvement. There was no further apneic events in the MICU and the patient continued to do well on room air and was transferred to the floor for further management. On the floor, Mr [**Known lastname 21991**] was managed for the following issues: # SOB: Patient has history of COPD with FEV1 68% on 3L at baseline. Was not hypoxic on the floor but was continued on a 3 day steroid course for possibility of COPD exacerbation as well as azithromycin for five days. Given the possibility of spread of his cancer, a CT scan was obtained which did show a new nodule. He was also treated with his home nebulizers and guiafensin to mobilize sputum. On ambulation, he was stable on his home O2 requirement. He was set up for pulmonary follow-up for his new lung nodule. 2. Leukocytosis: Patient was afebrile. Has history of aspiration pneumonia and vocal cord paralysis. CXR clear but increased sputum production. No other localizing signs of infection. Leukocytosis was thought to be secondary to prednisone course and the PCP was notified to follow up on his WBC count post discharge. 3. Dysphagia - The patient did complain of difficulty swallowing foods, not liquids. Complained of sensation of "food getting stuck" and pointed to proximal throat. CT scan revealed impingement of the esophagus at the level of the thyroid, likely secondary to thyroid enlargement from hx of thyroid malignancy. Speech and swallow was consulted; they recommended a soft solids diet. His oncologists were contact[**Name (NI) **] who felt that he could benefit from a radiation therapy consult as an outpatient; he was set up with a radiation oncology appointment for this. . # HTN: The patient was hypertensive on admission; on home regimen he stabilized but pressures were still mildly elevated likely secondary to his prednisone course. . #CRI: Cr at 1.9 was at his baseline. Medications were renally dosed. Ct was done without contrast. . # BPH: Cont home meds. . # FEN: No IVF, replete electrolytes, regular diet . # Prophylaxis: Subcutaneous heparin, bowel reg . # Access: peripherals . # Code: full . # Communication: Patient and wife [**Name (NI) **] (HCP)[**Telephone/Fax (1) 92848**] . # Disposition: ICU for now Medications on Admission: ALBUTEROL SULFATE - (Prescribed by Other Provider) - 90 mcg HFA Aerosol Inhaler - 2 puffs IH three times a day as needed for prn ALBUTEROL SULFATE - 2.5 mg/3 mL (0.083 %) Solution for Nebulization - 1 nebulizer by mouth up to every four hours as needed for shortness of breath / wheezing use with nebulizer machine AMLODIPINE - 5 mg Tablet - 1 Tablet(s) by mouth once a day CETIRIZINE [ZYRTEC] - 5 mg Tablet - 1 Tablet(s) by mouth once a day FINASTERIDE [PROSCAR] - 5 mg Tablet - 1 Tablet(s) by mouth daily GABAPENTIN - (Prescribed by Other Provider) - 100 mg Capsule - 2 Capsule(s) by mouth three times a day LEVOTHYROXINE [LEVOXYL] - 75 mcg Tablet - 1 Tablet(s) by mouth once a day for 6 days weekly and [**2-4**] tablet daily for one day weekly. - No Substitution PORTABLE OXYGEN TANK - - use 3 L/min O2 when walking Dx: COPD, hypoxia with exertion SILDENAFIL [VIAGRA] - 100 mg Tablet - 1 Tablet(s) by mouth one hour before intercourse as needed TAMSULOSIN [FLOMAX] - 0.4 mg Capsule, Sust. Release 24 hr - 1 Capsule(s) by mouth twice a day TIOTROPIUM BROMIDE - 18 mcg Capsule, w/Inhalation Device - 1 inh inh once a day ASPIRIN - 325 mg Tablet, Delayed Release (E.C.) - 1 Tablet(s) by mouth once a day Discharge Medications: 1. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6 hours) as needed for cough. Disp:*150 ML(s)* Refills:*0* 2. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: 1-2 Puffs Inhalation Q4H (every 4 hours) as needed for shortness of breath or wheezing. 3. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Gabapentin 100 mg Capsule Sig: Two (2) Capsule PO TID (3 times a day). 6. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO 6 days per week. On 7th day, take 0.5 tablet. 7. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO HS (at bedtime). 8. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 9. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**2-4**] Sprays Nasal QID (4 times a day) as needed for dry. Disp:*1 month supply* Refills:*0* 11. Azithromycin 250 mg Tablet Sig: Two (2) Tablet PO Q24H (every 24 hours) for 2 days. Disp:*4 Tablet(s)* Refills:*0* 12. Outpatient Lab Work Please have a CBC checked on [**2135-10-27**] at your appointment with Dr. [**Last Name (STitle) **]. Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: 1. COPD exacerbation 2. Obstructive sleep apnea 2. Dysphagia related to esophageal compression from thyroid cancer Discharge Condition: Ambulatory. Hemodynamically stable. Requires 2-3L via nasal cannula (baseline). Maintains oxygen saturation with ambulation, with supplemental oxygen. Discharge Instructions: You were admitted with shortness of breath. Initially, you went to the ICU because we felt that your shortness of breath could be related to sleep apnea. Once we found your breathing had normalized in the ICU, we brought you to the regular medical floor. Since you continued to have a cough, we treated you for worsening of your COPD. We gave you three days of steroids and an antibiotic called azithromycin. You should continue azithromycin for two more days. You also told us that you had some trouble swallowing. We did a CT scan which showed that some of your esophagus, or swallowing tube, was being compressed probably because you have a history of thyroid cancer. We did a test that measures your swallowing ability and found that you should try to eat softer foods and your pills should be crushed before you take them. You need to see your primary care doctor 1 week following discharge. You should also see radiation oncology and ear-nose-throat for the problem you'[**Name2 (NI) **] had with swallowing. You have appointments set up (see below). Please return to the emergency room or contact your physician for chest pain, shortness of breath, increased difficulty with swallowing, difficulty with breathing, or for any other symptoms which are concerning to you. Followup Instructions: Please follow-up with Dr. [**Last Name (STitle) **], your primary care physician, [**Name10 (NameIs) **] [**Name11 (NameIs) 766**], [**2135-10-31**] at 11:50am. His phone number is ([**Telephone/Fax (1) 1921**]. Please follow-up with the Ear, Nose, and Throat service on [**2135-11-16**] at 9:00am. The office phone number is ([**Telephone/Fax (1) 21740**]. The office is in the [**Hospital Unit Name **], [**Location (un) **]. Please follow-up with the radiation oncology team. You will be contact[**Name (NI) **] by the radiation oncology service with an appointment next week. If you do not hear from them by Tuesday, [**2135-11-1**], please call ([**Telephone/Fax (1) 70038**]. Provider: [**First Name11 (Name Pattern1) 3972**] [**Last Name (NamePattern4) 3973**], MD (endocrinology) Phone:[**Telephone/Fax (1) 1803**] Date/Time:[**2135-11-21**] 3:00 Provider: [**First Name8 (NamePattern2) 828**] [**Name11 (NameIs) 829**], MD (Chest Disease Center) Phone:[**0-0-**] Date/Time:[**2135-11-29**] 2:00 Provider: [**First Name8 (NamePattern2) 828**] [**Name11 (NameIs) 829**], MD (Chest Disease Center) Phone:[**0-0-**] Date/Time:[**2135-12-6**] 1:00

[ "585.3", "V46.2", "600.00", "327.23", "478.33", "530.3", "193", "787.22", "V45.01", "162.9", "403.90", "V15.3", "V15.82", "V87.41", "196.1", "491.21" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

9587, 9645

4158, 7037

336, 342

9804, 9957

11292, 12450

3305, 3315

8322, 9564

9666, 9783

7063, 8299

9981, 11269

3330, 4135

277, 298

370, 2262

2284, 3056

3072, 3289

42,222

166,563

35162

Discharge summary

report

Admission Date: [**2115-10-31**] Discharge Date: [**2115-11-7**] Date of Birth: [**2074-4-8**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 922**] Chief Complaint: recent MI / asymptomatic Major Surgical or Invasive Procedure: [**2115-10-31**] CABG x3 (LIMA to LAD, SVG to DIAG, SVG to OM) History of Present Illness: 41 yo male with anterior MI [**8-20**] treated with DES to LAD. Coumadin was started for apical thrombus noted at cath. Referred for surgical eval. due to severity of CAD on cath [**10-24**]. Past Medical History: CAD anterior MI [**8-20**] with DES to LAD elev. chol. HTN GERD anemia prior elev. WBC apical thrombus rx with coumadin recently obesity Social History: works as office manager lives with 2 children denies ETOH use 8 pk/yr Hx / quit [**8-20**] Family History: NC Physical Exam: 5' 9" 233# RR 16 right 92/60 left 92/60 NAD, skin intact EOMI, PERRL, NCAT neck supple, full ROM, no carotid bruits appreciated CTAB RRR no murmur soft, NT, ND, + BS, obese warm, well-perfused, no edema or varicosities noted neuro grossly intact 2+ bil. fem/DP/PT/ radials Pertinent Results: Conclusions PRE-BYPASS: The left atrium is moderately dilated. No spontaneous echo contrast or thrombus is seen in the body of the left atrium/left atrial appendage or the body of the right atrium/right atrial appendage. No atrial septal defect is seen by 2D or color Doppler. There is mild symmetric left ventricular hypertrophy with normal cavity size. There is moderate regional left ventricular systolic dysfunction with severe hypokinesis to akinesis of mid and apical anteroseptal and inferoseptal walls. Overall left ventricular systolic function is moderately depressed (LVEF= 35 %). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Physiologic mitral regurgitation is seen (within normal limits). There is no pericardial effusion. Dr. [**Last Name (STitle) 914**] was notified in person of the results on Mr.[**Known lastname 80255**] at 8AM. Post Bypass: Normal RV systolic function. There is a mild improvement of the previously hypokinetic areas. Mid and apical anteroseptal wall still akinetic. Overall LVEF 40%. Trivial MR [**First Name (Titles) **] [**Last Name (Titles) **]. Intact thoracic aorta. I certify that I was present for this procedure in compliance with HCFA regulations. Interpretation assigned to [**Name6 (MD) 3892**] [**Name8 (MD) 3893**], MD, Interpreting physician [**2115-11-6**] 05:45AM BLOOD WBC-12.0* RBC-3.57* Hgb-11.2* Hct-32.4* MCV-91 MCH-31.5 MCHC-34.7 RDW-14.3 Plt Ct-317 [**2115-11-2**] 12:21AM BLOOD WBC-11.5* RBC-2.84* Hgb-9.0* Hct-25.1* MCV-88.3 MCH-31.6 MCHC-35.8* RDW-15.3 Plt Ct-156 [**2115-11-7**] 09:50AM BLOOD PT-14.2* PTT-22.8 INR(PT)-1.2* [**2115-11-7**] 09:50AM BLOOD Glucose-168* UreaN-17 Creat-0.7 Na-140 K-4.5 Cl-101 HCO3-28 AnGap-16 [**2115-10-30**] 12:10PM BLOOD UreaN-15 Creat-1.0 Na-142 K-4.4 Cl-105 HCO3-27 AnGap-14 [**2115-11-2**] 12:21AM BLOOD ALT-17 AST-39 CK(CPK)-852* AlkPhos-47 Amylase-13 TotBili-0.8 [**Known lastname **],[**Known firstname **] [**Medical Record Number 80256**] M 41 [**2074-4-8**] Radiology Report CHEST (PORTABLE AP) Study Date of [**2115-11-5**] 9:32 AM [**Last Name (LF) **],[**First Name7 (NamePattern1) 177**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 5204**] CSRU [**2115-11-5**] SCHED CHEST (PORTABLE AP) Clip # [**Clip Number (Radiology) 80257**] Reason: r/o ptx [**Hospital 93**] MEDICAL CONDITION: 41 year old man s/p cabg and ct removal REASON FOR THIS EXAMINATION: r/o ptx Provisional Findings Impression: AZB TUE [**2115-11-5**] 10:43 AM Removal of monitoring and support devices, no pneumonia. Final Report CHEST RADIOGRAPH INDICATION: Followup. COMPARISON: [**2115-11-4**]. FINDINGS: As compared to the previous radiograph, the left-sided chest tube, the endotracheal tube, the nasogastric tube and the Swan-Ganz catheter has been removed. The remaining is an introduction sheath in the right internal jugular vein. The size of the cardiac silhouette is unchanged, the retrocardiac lung areas, however, are better ventilated. Unchanged extent of a small left-sided pleural effusion. Focal parenchymal opacity suggestive of pneumonia are not seen. No evidence of pneumothorax. DR. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4130**] Approved: TUE [**2115-11-5**] 11:24 AM Imaging Lab Brief Hospital Course: Admitted [**10-31**] and underwent CABG x3(Lima->LAD, SVG->Diag/OM) with Dr. [**Last Name (STitle) 914**]. Please refer to Dr[**Last Name (STitle) 5305**] operative report for further details. He was transfered to the CVICU in stable condition requiring phenylephrine and propofol drips. Initially to augment hemodynamic stability he required epinephrine and levophed drips. TEE done at bedside did not show any signs of tamponade. Left chest tube placed for effusion on POD #2. Pressors were weaned off. Lines and drains were discontinued in a timely fashion. He was gently diuresed toward his preop weight and drips weaned off. He was started on abx for bilateral PNA on POD # 3. Extubated on POD #4. Speech and swallow was consulted for difficulty with swallowing after prolonged intubation. He was later cleared for a regular diet. POD#5 he was transferred to the SDU for further telemetry and recovery.The remainder of his postoperative course was essentially uncomplicated. On POD#7 he was doing well and he was discharged to home with VNA. All follow-up appointments were instructed. Medications on Admission: ASA 81 mg daily plavix 75 mg daily niaspan 1000 mg daily prilosec wellbutrin 150 mg daily toprol XL 200 mg daily lisinopril 10 mg daily lipitor 80 mg daily coumadin ( LD approx.[**10-17**]) Discharge Medications: 1. Metoprolol Tartrate 50 mg Tablet [**Month/Day (4) **]: One (1) Tablet PO twice a day. Disp:*60 Tablet(s)* Refills:*0* 2. Docusate Sodium 100 mg Capsule [**Month/Day (4) **]: One (1) Capsule PO BID (2 times a day): Take as long as you are taking pain meds which can cause constipation. Disp:*60 Capsule(s)* Refills:*0* 3. Aspirin 81 mg Tablet, Delayed Release (E.C.) [**Month/Day (4) **]: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 4. Oxycodone-Acetaminophen 5-325 mg Tablet [**Month/Day (4) **]: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*50 Tablet(s)* Refills:*0* 5. Atorvastatin 80 mg Tablet [**Month/Day (4) **]: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 6. Niacin 500 mg Capsule, Sustained Release [**Month/Day (4) **]: Two (2) Capsule, Sustained Release PO daily (). Disp:*60 Capsule, Sustained Release(s)* Refills:*0* 7. Clopidogrel 75 mg Tablet [**Month/Day (4) **]: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 8. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol [**Month/Day (4) **]: Two (2) Puff Inhalation Q4H (every 4 hours). Disp:*QS * Refills:*0* 9. Fluticasone 110 mcg/Actuation Aerosol [**Month/Day (4) **]: Two (2) Puff Inhalation [**Hospital1 **] (2 times a day). Disp:*QS * Refills:*0* 10. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily). Disp:*30 Tablet,Rapid Dissolve, DR(s)* Refills:*0* 11. Furosemide 20 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily) for 14 days. Disp:*14 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital 8117**] Home Health and Hospice Discharge Diagnosis: CAD s/p CABG x3 anterior MI [**8-20**] with DES to LAD elev. chol. HTN GERD anemia prior elev. WBC apical thrombus rx with coumadin recently obesity Discharge Condition: good Discharge Instructions: no lotions, creams, or powders on any incision no lifting greater than 10 pounds for 10 weeks no driving for one month AND off all narcotics shower daily and pat incisions dry call for fever greater than 100.5, redness or drainage Followup Instructions: see Dr. [**Last Name (STitle) 80258**] in [**2-13**] weeks see Dr. [**Last Name (STitle) 69926**] in [**3-17**] weeks see Dr. [**Last Name (STitle) 914**] in 4 weeks [**Telephone/Fax (1) 170**] Completed by:[**2115-11-7**]

[ "428.0", "V58.61", "V45.82", "414.2", "518.5", "V15.82", "458.29", "401.9", "787.20", "530.81", "V12.51", "998.11", "414.01", "486", "998.0", "278.00", "E878.2", "428.21", "272.4", "V85.34", "285.1", "412" ]

icd9cm

[ [ [] ] ]

[ "99.04", "99.05", "36.15", "34.04", "38.91", "96.72", "36.12", "39.61", "99.07" ]

icd9pcs

[ [ [] ] ]

7730, 7804

4697, 5790

345, 410

7997, 8004

1230, 3708

8283, 8509

916, 920

6030, 7707

3748, 3788

7825, 7976

5816, 6007

8028, 8260

935, 1211

281, 307

3820, 4674

438, 631

653, 792

808, 900

18,634

125,682

12498+56374

Discharge summary

report+addendum

Admission Date: [**2173-3-11**] Discharge Date: [**2173-3-17**] Service: HISTORY OF THE PRESENT ILLNESS: The patient is a 79-year-old G2, P2, who had had a history of a prolapsed bladder for the past 2?????? years. She had previously been repaired in [**2159**], but her symptoms had recurred. Several pessaries had been tried, but the only ones who helped the prolapse, made her incontinent. Without the pessary, it was difficult for her to initiate urination and she usually must push the side of her perineum to initiate defecation. She is not sexually active. She presented on [**2173-3-11**] for anterior and posterior repair, pubourethral sling, and sacral spinous ligament fixation. Please see the previously dictated operative report for the summary of this operation. PAST MEDICAL HISTORY: 1. Significant for one myocardial infarction prior to angioplasty. Of note: She had a stress test on [**2173-2-17**], which showed the [**Doctor First Name **] protocol ETT negative for angina; ST changes seen with exercise, which were suggestive of ischemia and there was a small reversible posterolateral defect consistent with ischemia. 2. Status post total abdominal hysterectomy, bilateral salpingo-oophorectomy in [**2163**] for endometrial cancer. 3. Status post vaginal repair in [**2159**]. 4. Status post angioplasty in [**2165**]. 5. Status post laparoscopic cholecystectomy in [**2160**]. 6. Status post bilateral cataract surgery. 7. Status post right thumb-tendon release. PAST OB HISTORY: Two full term vaginal deliveries without complication. PAST GYN HISTORY: As above with recent mammogram negative. PERSONAL HABITS: She is single and lives with a friend. She is not sexually active. She rarely uses alcohol and she denies tobacco or drug use. MEDICATIONS: 1. Altace 2.5 mg p.o.q.d. 2. Lipitor 10 mg p.o.q.d. 3. Atenolol 50 mg p.o.q.d. 4. Isosorbide 30 mg p.o.q.d. 5. Actonel 30 mg p.o.every week. ALLERGIES: None. FAMILY HISTORY: The patient's mother died at the age of 97; father died of heart disease. SUMMARY OF HOSPITAL COURSE: As noted above, the patient was admitted on [**2173-3-11**] for a anterior and posterior repair, sacrospinous ligament fixation, pubourethral sling, and suprapubic tube placement for incontinence. The surgery went without complication. Estimated blood loss was 200 cc. #1. CARDIOLOGY: Postoperatively, the patient had an episode of postoperative hypotension with EKG changes. Anesthesia and the ICU team were consulted and it was felt that she should be admitted to the medical Intensive Care Unit for monitoring and to rule out myocardial infarction. EKG done at the time of the hypotension showed sinus rhythm at 76 beats per minute and 1-mm downward sloping ST depression in leads V2 through V6. She had a low potassium at that time of 2.8, which was repleted. She was admitted to the ICU as noted above. The EKG changes spontaneously resolved. She was taken off her cardiac medicines and the potassium and magnesium were repleted. She had no cardiac symptoms throughout the Intensive Care Unit admission. She was consulted by the Department of Cardiology. On postoperative day #1, she was ready for transfer to the floor and cardiac echocardiogram showed an ejection fraction of greater than 55%, mild mitral regurgitation, and aortic regurgitation. The serial CK enzymes did not suggest a cardiac event and the troponin I was negative. She was restarted on Lopressor 12.5 mg po b.i.d. and remained asymptomatic until postoperative day #3 when she had a run of a junctional rhythm and she was noted to have some tachycardia. The Department of Cardiology was reconsulted. The Lopressor was stopped. She was restarted on Atenolol and ACE inhibitor, as well as Isosorbide mononitrate. She then remained with a heart rate in the 70s to 80s with no further abnormalities on telemetry. #2. HEMATOLOGY: Preoperatively, the hematocrit was 40. Estimated blood loss at the time of the procedure was 200 cc. The hematocrit stabilized at 33.8, postoperatively. #3. ELECTROLYTES: As noted above, the patient had hypokalemia, which was repleted and hypomagnesemia, which was repleted immediately postoperatively. She also had some hypophosphatemia. This again was repleted and all values remained stable. #4. GASTROINTESTINAL: The patient was maintained NPO for the first postoperative day. The diet was advanced on postoperative day #2. She had some nausea on postoperative day #4, which resolved. This was felt to be due to the K-Phos she was receiving and this resolved after changing to Neutraphos. She was tolerating a regular diet at the time of discharge. #5. GENITOURINARY: The patient's urine output remained excellent throughout the hospital stay. She had voiding trials, starting on postoperative day #4. She failed her voiding trials on postoperative day #4, #5, and #6. At this point, the decision was made to seen her home with suprapubic tube in place and to perform teaching and send her home with [**Hospital6 **] and to have her followup with Dr. [**Last Name (STitle) **] for the removal of the suprapubic tube. CONDITION ON DISCHARGE: On discharge, the patient was ambulating freely. Pain was minimal and she was only taking Motrin for pain control. She was afebrile. Vital signs were stable. Examination was benign. She was unable to void spontaneously and she was emptying her suprapubic tube every few hours. MEDICATIONS ON DISCHARGE: 1. Altace 2.5 mg p.o.q.d. 2. Lipitor 10 mg p.o.q.d. 3. Atenolol 50 mg p.o.q.d. 4. Isosorbide 30 mg p.o.q.d. 5. Actonel 30 mg p.o. every week. 6. Motrin 600 mg p.o.q.6h.p.r.n. 7. Percocet one to two, p.o. q.4h.to 6h.p.r.n. 8. Colace 100 mg p.o.q.d.b.i.d.p.r.n. 9. Nystatin swish and swallow b.i.d.p.r.n. FOLLOW-UP APPOINTMENT: The patient is to be discharged home with [**Hospital6 **] and to followup with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] m.d. [**MD Number(1) 19144**] Dictated By:[**Name8 (MD) 38767**] MEDQUIST36 D: [**2173-3-17**] 10:52 T: [**2173-3-17**] 11:02 JOB#: [**Job Number 38768**] Name: [**Known lastname 447**], [**Known firstname 992**] Unit No: [**Numeric Identifier 7010**] Admission Date: [**2173-3-11**] Discharge Date: [**2173-3-17**] Date of Birth: [**2093-9-13**] Sex: F Service: ADDENDUM TO THE STAT DISCHARGE SUMMARY: Please send a copy of this Discharge Summary to [**Location (un) 7011**] Cardiology Associates, Dr. [**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 7012**], [**Street Address(2) 7013**], [**Location (un) **], [**Numeric Identifier 7014**]. In addition, send a copy to Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 7015**] at [**Hospital1 960**]. [**First Name11 (Name Pattern1) 77**] [**Last Name (NamePattern4) 7016**], M.D. [**MD Number(1) 7017**] Dictated By:[**Last Name (NamePattern1) 7018**] MEDQUIST36 D: [**2173-3-17**] 11:17 T: [**2173-3-17**] 11:28 JOB#: [**Job Number 7019**]

[ "625.6", "276.5", "618.0", "458.2", "272.0", "412", "V10.42", "V45.82", "794.31" ]

icd9cm

[ [ [] ] ]

[ "59.79", "70.52", "70.77", "70.51", "57.18" ]

icd9pcs

[ [ [] ] ]

1994, 2069

5495, 5808

2098, 5161

5832, 7216

818, 1977

5186, 5469

55,678

158,697

664

Discharge summary

report

Admission Date: [**2168-7-16**] Discharge Date: [**2168-7-20**] Date of Birth: [**2106-10-15**] Sex: M Service: MEDICINE Allergies: Purinethol / Remicade Attending:[**First Name3 (LF) 2297**] Chief Complaint: BRBPR Major Surgical or Invasive Procedure: Upper and lower endoscopy ([**2168-7-17**]) History of Present Illness: HMED ATTG ADMIT NOTE . DATE [**2168-7-16**] TIME 2300 . PCP [**Name9 (PRE) **] GI [**Name9 (PRE) **] . 61 yo M with Crohn's disease on prednisone s/p total colectomy in [**2147**], complicated by perirectal abscess s/p internal drainage [**9-22**] and newly diagnosed DVT [**5-24**] on coumadin who presents to the ED with BRBPR. . Patient reports 16 bloody bowel movements yesterday ([**2168-7-15**]). Went to see PCP ([**Doctor Last Name 2472**]) and INR was 4.7. Patient instructed to hold coumadin. Went home, overnight had multiple bloody bowel movements. This am had 3 episodes of syncope where he awoke on his bathroom floor, denies any head trauma. Last bloody BM was around [**1-15**] pm today. No abdominal pain (has chronic rectal pain). No fevers, nausea or vomiting. Lightheadedness with standing. Denies any cp or sob. Endorses mild dysuria, s/p TURP 4 weeks ago. . Went to [**Hospital1 **]-[**Location (un) 620**] ED today and found to have INR 5.4 and Hct of 27 (hct two weeks ago at [**Hospital1 18**] was 36.8). CT abdomen performed which showed a 15 mm perirectal abscess connected to right lateral anal fistula, slightly enlarged from prior MRI in [**Month (only) 956**] of this year, at which time abscess was less organized. Given 4L of NS. Anoscopic exam performed in ED which showed moderate maceration of perianal region but no gross bleeding. Heme positive. No fistulas or fissures. Reported that patient received iv cipro/flagyl however patient states this was never given. . Transferred to [**Hospital1 18**] ED: 97.0 72P 104/76 16 100%RA; 5mg vit K po; 2 units of FFP; colorectal surgery consulted and reviewed image with radiology - abscess cavity similar to prior MRI in [**Month (only) 956**] - no fever or leukocytosis therefore no indication to urgently drain, needs management of LGIB first. GI made aware and will see patient in am. . ROS as per HPI, 10 pt ROS otherwise negative Past Medical History: -Crohn's disease (had previously been diagnosed with UC and had totaly colectomy in [**2147**]) - uncontrolled, s/p internal drainage perirectal abscess [**9-22**] by [**Doctor Last Name 1120**] -LLE DVT dx [**2168-6-9**] on coumadin -Recurrent diarrhea -ADD -Anemia -Arthritis -Nephrolithiasis -BPH -Migraine headaches -TURP 4 weeks ago Social History: Works as a divorce attorney. Married, lives with wife. [**Name (NI) **] tobacco, 1 beer per week and no illicits. Family History: Son, mother and sister with [**Name (NI) 4522**] disease Physical Exam: ADMITTING EXAM VS: 98.5 71P 19 98/55 98%RA Appearance: alert, NAD, pale appearing Eyes: eomi, perrl, anicteric ENT: OP clear s lesions, mmd, no JVD, neck supple Cv: +s1, s2 -m/r/g, no peripheral edema, 2+ dp/pt bilaterally Pulm: clear bilaterally Abd: soft, NT, ND, +bs, mild RUQ guarding, no rebound Msk: 5/5 strength throughout, no joint swelling, no cyanosis or clubbing Neuro: cn 2-12 grossly intact, no focal deficits Skin: no rashes Psych: appropriate, pleasant Heme: no cervical [**Doctor First Name **] DISCHARGE EXAM VS: 98.9 60P 16 123/56 Appearance: AAOX3, in NAD, asking to leave Eyes: eomi, perrl, anicteric ENT: OP clear s lesions, mmd, no JVD, neck supple Cv: +s1, s2 -m/r/g, no peripheral edema, 2+ dp/pt bilaterally Pulm: clear bilaterally Abd: soft, NT, ND, +bs, no rebound, no guarding Msk: 5/5 strength throughout, no joint swelling, no cyanosis or clubbing Neuro: cn 2-12 grossly intact, no focal deficits Skin: no rashes Psych: appropriate, pleasant Heme: no cervical [**Doctor First Name **] Pertinent Results: [**2168-7-16**] 07:00PM URINE MUCOUS-RARE [**2168-7-16**] 07:00PM URINE RBC-6* WBC-23* BACTERIA-NONE YEAST-NONE EPI-<1 [**2168-7-16**] 07:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5 LEUK-SM [**2168-7-16**] 07:00PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]->1.050* [**2168-7-16**] 07:00PM PLT SMR-NORMAL PLT COUNT-286 [**2168-7-16**] 07:00PM PT-55.6* PTT-42.3* INR(PT)-5.5* [**2168-7-16**] 07:00PM HYPOCHROM-1+ ANISOCYT-OCCASIONAL POIKILOCY-NORMAL MACROCYT-OCCASIONAL MICROCYT-OCCASIONAL POLYCHROM-NORMAL [**2168-7-16**] 07:00PM NEUTS-73.1* LYMPHS-20.3 MONOS-5.6 EOS-0.8 BASOS-0.3 [**2168-7-16**] 07:00PM WBC-7.5 RBC-2.52*# HGB-7.8*# HCT-24.2*# MCV-96 MCH-30.8 MCHC-32.2 RDW-14.3 [**2168-7-16**] 07:00PM ALBUMIN-2.8* [**2168-7-16**] 07:00PM cTropnT-<0.01 [**2168-7-16**] 07:00PM LIPASE-10 [**2168-7-16**] 07:00PM ALT(SGPT)-15 AST(SGOT)-16 ALK PHOS-44 TOT BILI-0.3 [**2168-7-16**] 07:00PM estGFR-Using this [**2168-7-16**] 07:00PM GLUCOSE-97 UREA N-13 CREAT-0.6 SODIUM-141 POTASSIUM-4.5 CHLORIDE-109* TOTAL CO2-25 ANION GAP-12 . [**2168-7-16**] CT a/p at [**Hospital1 **]-N: no report available in [**Last Name (LF) **], [**First Name3 (LF) **] colorectal surgery resident review with ED radiologist: 15mm perirectal abscess connected to right lateral anal fistula, slightly enlarged from prior MRI in [**Month (only) 956**] of this year (at that time collection measured 0.9x0.8mm and appeared less organized) . [**2168-6-9**] LLE Doppler: LEFT-SIDED DVT AS DESCRIBED FROM THE POPLITEAL VEIN INFERIOR. NO RIGHT-SIDED DVT. . [**2168-7-17**] COLONOSCOPY: Ulceration and erythema in the ileal pouch and small bowel with evidence of recent bleeding and clot. These lesions are likely the cause of GI bleeding in the setting of an elevated INR. . [**2168-7-17**] EGD: Evidence of NG trauma in the stomach, which does not explain patient's blood loss. Otherwise normal EGD to third part of the duodenum . [**2168-7-16**] URINE CULTURE (Final [**2168-7-20**]): ENTEROCOCCUS SP.. 10,000-100,000 ORGANISMS/ML.. SENSITIVITIES: MIC expressed in MCG/ML ________________________________________________________ ENTEROCOCCUS SP. | AMPICILLIN------------ <=2 S NITROFURANTOIN-------- <=16 S TETRACYCLINE---------- =>16 R VANCOMYCIN------------ 1 S Brief Hospital Course: 61 yo M with Crohn's disease on prednisone s/p total colectomy in [**2147**], complicated by perirectal abscess s/p internal drainage [**9-22**] and newly diagnosed DVT [**5-24**] on coumadin who is admitted with LGIB in the setting of supratherapeutic INR. . #LGIB: Patient presented with INR of 5.4 and a hematocrit of 24, which dropped to 16 during his stay in the ED. He received 3 units of FFP and 5 units of pRBCs. He underwent EGD and colonoscopy on [**7-17**]. EGD was negative. Colonoscopy showed ulcers and evidence of recent bleed/clot in the ileal pouch, which was likely the cause of his bleeding. His hematocrit stabilized in the range of 28-30 and he did not require further transfusions. GI bleed was attributed to his underlying Crohn's disease in the setting of a supratherapeutic INR. #LLE DVT: Patient underwent repeat LENIs which showed persistence of his proximal left leg DVT. Extensive discussion was had with his colorectal surgeon as well as gastroenterologist and PCP regarding anticoagulation going forward. Heme/onc was also consulted. It was decided to continue coumadin at a dose of 2.5 daily and titrate to an INR goal of 2.0-2.5. Patient's PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 2472**], was contact[**Name (NI) **] and it was confirmed that he would continue to manage his coumadin. Patient was also referred to Dr. [**Last Name (STitle) 3060**], of Heme-Onc, to help manage his anticoagulation. He has an appointment with Dr. [**Last Name (STitle) 3060**] on [**2168-8-12**]. Patient was discharged home with services and instructions for INR to be drawn daily from his PICC line with results faxed to Dr.[**Name (NI) 5049**] office. #Perirectal abscess: CT abdomen at [**Hospital1 **] reviewed in ED. As per radiology abscess better organized and slightly larger than prior MRI in [**Month (only) 956**]; given lack of fever or leukocytosis, colorectal surgery decided no need for immediate drainage. It was decided to pursue conservative management with antibiotics. Patient was intially started on Pip/tazo. ID was consulted re: longterm antibiotics and recommended 4 week course of ertapenam. PICC line was placed and arrangement were made for patient to go home with services. He will have 1g ertapenam administered through PICC daily through [**8-16**] with weekly chem-7s and LFTs faxed to the [**Hospital **] clinic. He has an appointment with the [**Hospital **] clinic to assess progress on [**8-12**]. #Crohn's disease: This is being managed by Dr. [**Last Name (STitle) 1940**] as an outpatient. His prednisone regimen was continued while in the hospital. His hydrocortisone enemas were held in the context of his GI bleed. Further management will be made as per Dr. [**Last Name (STitle) 1940**]. #Pyuria: Patient's U/A on presentation showed 23 wbc's but no bacteria. He was complaining of some dysuria which was initially thought to be [**1-14**] inflammation in setting of recent TURP. A urine culture was added to the labs which grew 10-100K of enterococcus on the last day of hospitalization. ID was consulted and determined that his 4 week course of ertapenam would be appropriate to cover his enterococcus. Patient has ID follow-up in 2 weeks. Chronic Issues #Gout: allopurinol was held on admission. remained asymptomatic. #Transitional issues: patient was discharged home with services. The visiting nurse [**First Name (Titles) **] [**Last Name (Titles) 5050**] daily ertapenam through the PICC as well as draw daily INR through [**7-28**] and have the results faxed to Dr.[**Name (NI) 5049**] office. Weekly chem-7s and LFTs will also be drawn and faxed to the [**Hospital **] clinic. All prescriptions were provided. Patient has follow-up with [**Hospital **] clinic in 2 weeks. Patient instructed to contact Dr. [**Last Name (STitle) 5051**] for appointment within 3-5 days from discharge, patient demonstrated understanding. Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from PatientwebOMR. 1. Allopurinol 300 mg PO DAILY 2. Ciprofloxacin HCl 500 mg PO Q12H 3. Diphenoxylate-Atropine [**12-14**] TAB PO Q6H:PRN diarrhea 4. Hydrocortisone Enema 100 mg PR DAILY Duration: 21 Days 5. PredniSONE 12 mg PO DAILY 6. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain 7. Warfarin 5 mg PO DAILY16 8. Zolpidem Tartrate 5 mg PO HS:PRN insomnia 9. Ferrous Sulfate 650 mg PO DAILY 10. FoLIC Acid 0.4 mg PO DAILY Preadmission medications listed are correct and complete. Information was obtained from PatientwebOMR. 1. Allopurinol 300 mg PO DAILY 2. Ciprofloxacin HCl 500 mg PO Q12H 3. Diphenoxylate-Atropine [**12-14**] TAB PO Q6H:PRN diarrhea 4. Hydrocortisone Enema 100 mg PR DAILY Duration: 21 Days 5. PredniSONE 12 mg PO DAILY 6. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain 7. Warfarin 5 mg PO DAILY16 8. Zolpidem Tartrate 5 mg PO HS:PRN insomnia 9. Ferrous Sulfate 650 mg PO DAILY 10. FoLIC Acid 0.4 mg PO DAILY Discharge Medications: 1. Zolpidem Tartrate 5 mg PO HS:PRN insomnia 2. PredniSONE 12 mg PO DAILY 3. Warfarin 2.5 mg PO DAYS ([**Doctor First Name **],MO,TU,WE,TH,FR,SA) Please titrate to goal INR 2.0-2.5 RX *Coumadin 2.5 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*2 4. Allopurinol 300 mg PO DAILY 5. Diphenoxylate-Atropine [**12-14**] TAB PO Q6H:PRN diarrhea 6. Ferrous Sulfate 650 mg PO DAILY 7. FoLIC Acid 0.4 mg PO DAILY 8. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain 9. ertapenem *NF* 1 gram Intravenous daily Duration: 4 Weeks last day [**2168-8-16**] RX *Invanz 1 gram 1 gram Q24h Disp #*30 Vial Refills:*0 10. Outpatient Lab Work please draw daily INR and hematocrit from [**2168-7-21**] - [**2168-7-28**] and fax results to Dr.[**Name (NI) 5049**] office at [**Telephone/Fax (1) 445**] Discharge Disposition: Home With Service Facility: Critical Care Systems Discharge Diagnosis: Primary: Lower GI Bleed Secondary: Crohn's Disease DVT on Coumadin Perirectal abscess Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [**Known lastname 5052**], It was a pleasure to take care of you at [**Hospital1 18**]. You were admitted for gastrointestinal bleeding in the setting of elevated INR. You underwent colononscopy and your bleeding was controlled. You are being discharged with a new dose of coumadin. You will need to follow-up with Dr. [**Last Name (STitle) 5053**] regarding your coumadin dosing. You are also being discharged on a 4 week course of Ertapenam for treatment of perirectal abscess. You have arrangements for a visiting nurse [**First Name (Titles) **] [**Last Name (Titles) 5054**] this and to draw needed labs. The following changes were made to your medications: Please STOP ciprofloxacin. Please START coumadin at 2.5 mg daily. You will have daily blood draws for your INR and the results will be faxed to Dr. [**Name (NI) 5055**] office, who will manage this. Please START ertapenam 1g IV daily. Please follow with your appointments as illustrated below. Please continue the rest of your home medications the way you were taking them at home prior to admission. Followup Instructions: Department: INFECTIOUS DISEASE When: FRIDAY [**2168-8-12**] at 11:30 AM With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 457**] Building: LM [**Hospital Unit Name **] [**Hospital 1422**] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage Department: HEMATOLOGY/ONCOLOGY When: FRIDAY [**2168-8-12**] at 9:00 AM With: [**First Name11 (Name Pattern1) 1730**] [**Last Name (NamePattern4) 5056**], MD [**Telephone/Fax (1) 3062**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: NEUROLOGY When: MONDAY [**2168-8-8**] at 8:30 AM With: DR. [**First Name (STitle) 3523**] [**Name (STitle) 3524**] [**Telephone/Fax (1) 44**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 858**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Please call Dr[**Name (NI) 5049**] office to schedule a follow up appointment within the next 3-5 days at [**Telephone/Fax (1) 133**]. Completed by:[**2168-7-24**]

[ "274.9", "578.9", "285.1", "346.90", "V12.51", "566", "V58.65", "V58.61", "V45.72", "453.41", "555.9" ]

icd9cm

[ [ [] ] ]

[ "45.13", "45.23", "38.97" ]

icd9pcs

[ [ [] ] ]

12212, 12264

6400, 9736

289, 335

12395, 12395

3931, 6377

13653, 14719

2809, 2867

11402, 12189

12285, 12374

10375, 11379

12546, 13630

2882, 3912

9757, 10349

244, 251

363, 2299

12410, 12522

2321, 2660

2676, 2793

76,114

127,379

36423+58083

Discharge summary

report+addendum

Admission Date: [**2194-4-28**] Discharge Date: [**2194-4-29**] Date of Birth: [**2114-7-28**] Sex: F Service: NEUROSURGERY Allergies: Penicillins / Latex Attending:[**First Name3 (LF) 1271**] Chief Complaint: "fell and hit the back of my head" Major Surgical or Invasive Procedure: None History of Present Illness: 79 y/o caucasian female presents to ER s/p fall in rehab facility at approximately 5:15am today. She states that her fall occured when trying to put on her socks and slipped. She states that she fell backwards and hit her back of her head. She reports a h/a that is located in the frontal area but denies any loss of consciousness, dizziness,and n/v. Past Medical History: Colon CA surgery [**2181**] Colon CA recurrence [**2187**] Colostomy Anemia HTN TIAs hypothyroidism anxiety/depression hypercholesterolemia Social History: ETOH- 1 glass of wine with dinner No Tobacco Family History: NC Physical Exam: ADMISSION: T:99.9 BP:138 /74 HR: 90 R: 18 O2Sats: 96% on RA Gen: WD/WN, comfortable, NAD. HEENT: Pupils: PERRL 3mm-2mm EOMs: intact Neck: Supple. Lungs: CTA bilaterally. Cardiac: RRR. S1/S2. Abd: Soft, NT, BS+ Extrem: Warm and well-perfused. Neuro: Mental status: Awake and alert, cooperative with exam, normal affect. Orientation: Oriented to person, place, and date. Recall: [**2-25**] objects at 5 minutes. Language: Speech fluent with good comprehension and repetition. Naming intact. No dysarthria or paraphasic errors. Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light, to mm bilaterally. Visual fields are full to confrontation. III, IV, VI: Extraocular movements intact bilaterally without nystagmus. V, VII: Facial strength and sensation intact and symmetric. VIII: Hearing intact to voice. IX, X: Palatal elevation symmetrical. [**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally. XII: Tongue midline without fasciculations. Motor: Normal bulk and tone bilaterally. No abnormal movements, tremors. Strength full power [**4-29**] throughout. No pronator drift Sensation: Intact to light touch Toes downgoing bilaterally Coordination: normal on finger-nose-finger, rapid alternating movements, heel to shin Positive bilateral 2 beat clonus DISCHARGE: Patient is Alert and oriented to person, place, and time. PEERL EOMs intact Face is symmetrical Tongue midline Negative pronator drift Motor- UE- [**4-29**] LE- [**4-29**] Sensation- intact to light touch Pertinent Results: CT Head on Admission- On re-review of the study, a small hyperdense right subdural hematoma is seen overlying the right temporal convexity measuring 4 mm in greatest width. There is no mass effect or shift of normally midline structures CXR- Ill-defined opacity within the right upper lung field, not clearly visualized on the prior study. This could represent an infectious or inflammatory process, and a CT of the chest can be performed for further evaluation. MR HEAD W/O CONTRAST- Small subdural hematoma along the right convexity. Chronic small vessel ischemic disease. Punctate T2 hyperintensity in the right pons with an associated diffusion signal abnormality may represent a subacute infarction or a chronic infarction with the so-called "T2 shine-through" artifact. Unremarkable head MRA. CT HEAD W/O CONTRAST- Persistant small R SDH. Possible bifrontal small SDH/SAH. Continuos follow-up recommended. Brief Hospital Course: 79 y/o female presented to ER with SDH diagnosed at outside hospital. While in ER, pt had multiple hypotensive events which were control with fluid boulses. She was then admitted to ICU where repeat head CT showed stable SDH without expansion. Also of note on hospital stay, CXR revealed ill defined opacity in the right upper lobe which should be followed up as outpatient with a chest CT scan. Patient will then be transfered back to rehab. Medications on Admission: Colace 100 mg PO BID MVI 1 TAB PO DAILY CALCIUM 500MG PO DAILY ASA 81 MG PO DAILY LEVOTHYROXINE 50MCG PO DAILY CELEXA 20MG PO DAILY GABAPENTIN 100NG PO TID MIRALAX 17G PO DAILY VIT D 400 UNITS PO DAILY OXYCONTIN 60MG PO BID KCOLON-CON 25 MEQ ORAL DAILY WITH MEALS FLORINEF 0.1MG DAILY TYLENOL 650MG PRN Q4HRS PERCOCET 5/325MG 1 TAB PO Q4-6 HRS Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. Fludrocortisone 0.1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 6. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 7. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Oxycodone 20 mg Tablet Sustained Release 12 hr Sig: Three (3) Tablet Sustained Release 12 hr PO BID (2 times a day). 9. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. 10. Phenytoin Sodium 50 mg/mL Solution Sig: One (1) Intravenous Q8H (every 8 hours): Continue until your follow up with Dr. [**Last Name (STitle) 739**], have your dilantin level checked in two weeks. 11. Ondansetron HCl (PF) 4 mg/2 mL Solution Sig: One (1) Injection Q8H (every 8 hours) as needed for N/V. Discharge Disposition: Extended Care Facility: Country rehab and Nursing Center Discharge Diagnosis: R SDH, R upper lobe opacity Discharge Condition: Stable Discharge Instructions: ?????? Take your pain medicine as prescribed. ?????? Exercise should be limited to walking; no lifting, straining, or excessive bending. ?????? Increase your intake of fluids and fiber, as narcotic pain medicine can cause constipation. We generally recommend taking an over the counter stool softener, such as Docusate (Colace) while taking narcotic pain medication. ?????? Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, Aspirin, Advil, and Ibuprofen etc. ?????? If you have been prescribed an anti-seizure medicine, take it as prescribed and follow up with laboratory blood drawing in one week. Please have 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. Followup Instructions: Follow-Up Appointment Instructions ??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr. [**Last Name (STitle) 26803**], to be seen in 4 weeks. ??????You will need a CT scan of the brain WITHOUT contrast. [**Name6 (MD) 742**] [**Name8 (MD) **] MD [**MD Number(2) 1273**] Completed by:[**2194-4-29**] Name: [**Known lastname 13193**],[**Known firstname 3989**] Unit No: [**Numeric Identifier 13194**] Admission Date: [**2194-4-28**] Discharge Date: [**2194-4-29**] Date of Birth: [**2114-7-28**] Sex: F Service: NEUROSURGERY Allergies: Penicillins / Latex Attending:[**First Name3 (LF) 1698**] Addendum: Pt. was changed to PO dilantin 100mg TID upon discharge. Discharge Disposition: Extended Care Facility: Country rehab and Nursing Center [**Name6 (MD) **] [**Name8 (MD) 1041**] MD [**MD Number(2) 1709**] Completed by:[**2194-4-29**]

[ "V15.3", "852.20", "272.0", "V44.3", "199.1", "E885.9", "244.9", "V10.05", "V87.41", "793.1", "401.9", "V12.54" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

7418, 7602

3480, 3924

319, 325

5531, 5539

2540, 3457

6618, 7395

948, 952

4319, 5378

5481, 5510

3950, 4296

5563, 6595

967, 1240

245, 281

353, 705

1533, 2521

1255, 1517

727, 869

885, 932

14,749

182,417

20210

Discharge summary

report

Admission Date: [**2170-3-3**] Discharge Date: [**2170-3-14**] Date of Birth: [**2112-4-3**] Sex: M Service: HISTORY OF PRESENT ILLNESS: This 57-year-old white male has a history of diabetes, hypertension, and peripheral vascular disease. He presented to [**Hospital 5871**] Hospital after episodes of chest pain and shortness of breath. An electrocardiogram revealed anterior ischemia with ST elevations in V2-V3, along with anterior Qs. He also had positive enzymes and was placed on a Heparin drip, Integrilin, Plavix, and Nitropaste. He was transferred to [**Hospital6 256**] and was admitted. He recently had a right popliteal to right plantar bypass in [**2170-1-8**] at [**Hospital6 256**]. PAST MEDICAL HISTORY: Insulin-dependent diabetes for 17 years. Peripheral vascular disease status post right popliteal to right plantar bypass in [**2170-1-8**]. History of hypertension. History of retinopathy. History of peripheral neuropathy. MEDICATIONS ON ADMISSION: Lopressor 25 mg p.o. b.i.d., Zantac 150 mg p.o. b.i.d., NPH Insulin 54 U q.a.m., 59 U q.p.m., Percocet p.r.n. ALLERGIES: NO KNOWN DRUG ALLERGIES. SOCIAL HISTORY: He lives alone. He does not smoke cigarettes. He has a 10 pack-year history, but quit 35 years ago. He does not drink alcohol. FAMILY HISTORY: Unremarkable. REVIEW OF SYSTEMS: As above. PHYSICAL EXAMINATION: General: He was a well-developed, well-nourished white male in no apparent distress. Vital signs: Stable and afebrile. HEENT: Normocephalic, atraumatic. Extraocular movements intact. Oropharynx benign. Neck: Supple. Full range of motion. No lymphadenopathy or thyromegaly. Carotids 2+ and equal bilaterally without bruits. Lungs: Clear to auscultation and percussion. Cardiovascular: Regular, rate and rhythm. Normal S1 and S2. No murmurs, rubs, or gallops. Abdomen: Soft and nontender. Positive bowel sounds. No masses or hepatosplenomegaly. Extremities: Without clubbing, cyanosis, or edema. He had a right lower extremity scar which was clean, dry, and intact. He had an ulcer on his right medial malleolus and the bottom of his foot. Pulses: Exam showed 2+ and equal on carotids, brachial, and femorals. Neurological: He had decreased sensation on the bilateral feet. He was admitted to Cardiology and was kept on his Heparin drip, Nitroglycerin drip, and Aggrastat. He was also seen by Vascular, and they stated that his right surgery failed, and he had a thrombectomy. He also had a right foot debridement on [**2170-1-26**]. His wounds were healing well. He remained stable and underwent cardiac catheterization on [**2170-3-5**], which revealed that the left main had no significant obstructive disease, the left anterior descending had an ostial 70% and a distal 80% lesion, the left circumflex had no disease, the ramus 1 had a 50% midlesion, ramus 2 had a 90% ostial lesion, right coronary artery had a 70% posterior descending artery lesion at the ostium and an 80% mid posterior descending artery lesion. Dr. [**Last Name (STitle) **] was consulted, and on [**3-6**], the patient underwent coronary artery bypass grafting times four with LIMA to the left anterior descending, reversed saphenous vein graft to posterior descending artery, obtuse marginal and diagonal. Cross-clamp time was 55 min. Total bypass time was 65 min. He was transferred to the CSRU on Dobutamine, Lasix, Neo-Synephrine, and Propofol. He had a stable postoperative night. His Dobutamine was discontinued, and he was extubated. On postoperative day #1, he was transferred to the floor. He had 1 U of blood on postoperative day #2 for a hematocrit of 23. He continued to slowly progress. He was followed by Vascular Surgery who felt he should be seen a week after discharge by Dr. [**Last Name (STitle) **] and agreed with continuing b.i.d. dressing changes. He had his chest tubes discontinued on postoperative day #2. His pacing wires were discontinued on postoperative day #3. He had a slight bit of lower sternal drainage. This resolved, and the sternum was stable. He was also seen by [**Last Name (un) **], as he would like to change his Insulin to Lantus and Humalog sliding scale. He also was seen by ophthalmology and has proliferative diabetic retinopathy in both eyes, and vitreous subhyaloid hemorrhage of the left eye, and he requires follow-up for this. He continued to progress slowly with Physical Therapy, and on postoperative day #8, he was discharged to rehabilitation in stable condition. DISCHARGE LABORATORY DATA: Hematocrit 25.2, white count 10,100, platelet count 440,000; sodium 141, potassium 4.7, chloride 103, CO2 29, BUN 19, creatinine 0.9, blood sugar 97. DISCHARGE MEDICATIONS: Colace 100 mg p.o. b.i.d., Zantac 150 mg p.o. b.i.d., Percocet [**2-9**] p.o. q.4-6 hours p.r.n. pain, Lopressor 50 mg p.o. b.i.d., Lasix 40 mg p.o. b.i.d. x 1 week, Captopril 6.25 mg p.o. t.i.d., Glargine 45 U subcue q.h.s., Humalog sliding scale. FOLLOW-UP: He will be followed by Dr. [**Last Name (STitle) 1007**] in [**2-9**] weeks, Dr. [**Last Name (STitle) **] in four weeks, Dr. [**Last Name (STitle) **] in one week, Dr. ................ within a month, and the [**Hospital **] Clinic on [**2170-4-6**]. DISCHARGE DIAGNOSIS: 1. Coronary artery disease. 2. Myocardial infarction. 3. Coronary artery bypass grafting. 4. Insulin-dependent diabetes. [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3113**] Dictated By:[**Last Name (NamePattern1) 6516**] MEDQUIST36 D: [**2170-3-14**] 13:54 T: [**2170-3-14**] 14:01 JOB#: [**Job Number 54302**]

[ "250.50", "707.13", "414.01", "357.2", "250.60", "401.9", "707.14", "410.11", "443.9" ]

icd9cm

[ [ [] ] ]

[ "39.61", "37.22", "36.15", "36.13", "88.53", "88.55", "99.04" ]

icd9pcs

[ [ [] ] ]

1317, 1332

4731, 5246

5267, 5672

1003, 1152

1386, 4707

1352, 1363

158, 725

748, 976

1169, 1300

73,043

166,944

1176

Discharge summary

report

Admission Date: [**2152-6-26**] Discharge Date: [**2152-6-29**] Date of Birth: [**2070-10-18**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1943**] Chief Complaint: SOB, rigors Major Surgical or Invasive Procedure: Hemodialysis per outpatient schedule (M,W,F) History of Present Illness: Mr. [**Known lastname **] is an 81M with dilated cardiomyopathy EF 25%, ESRD on HD, and HTN recently admitted [**Date range (1) 7501**] for hungry bone syndrome s/p parathyroidectomy. He was discharged to [**Hospital3 2558**] [**Hospital3 **] and had been doing well with planned discharge this am. This am, he awoke with acute onset SOB and shaking chills associated with dry cough. He was noted to be tachycardic to 140s with BP 230/100. He was initially 96%RA then 92% on 2L NC but had been afebrile 98.9. He also reports weight gain 64kg from dry weight 59kg and had bilateral hand numbness during episode now resolved. Denies recent dietary indiscretion or CP. He was sent to [**Hospital1 18**] for further eval. In our ED, initial vs were: T102 P135 BP 221/126 R 40 O2 sat100% on 100%NRB. He triggered for respiratory distress. Patient was given SL NTG, started on BIPAP for presumed CHF/volume overload but also received 500cc bolus. CXR was consistent with multifocal PNA so he was given Vanco 1g, Zosyn 2.25g and tylenol 650mg and placed on NRB instead of BiPap with sats 100% on NRB. Due to difficult access, left femoral line placed. In the ICU, he reports SOB improved with no further chills or rigors. Still complaining of dry cough. Review of sytems: (+) Per HPI. Also reports headache this am. (-) Denies fever, night sweats. Denies sinus tenderness, rhinorrhea or congestion. Denied chest pain or tightness, palpitations. Denied nausea, vomiting, diarrhea, constipation or abdominal pain. No recent change in bowel or bladder habits. No dysuria. Denied arthralgias or myalgias. Past Medical History: 1. ESRD - [**2-15**] prolonged obstructive uropathy in setting of prostate CA - hemodialysis M/W/F - thrombectomy of avg [**12-19**] 2. Secondary/tertiary hyperparathyroidism with renal osteodystrophy noted in [**2-23**] with imaging notable for Rugger-Jersey spine. s/p sub-total parathyroidectomy [**2152-5-26**] with persistent hypocalcemia post-op thought to be due to 'hungry-bones' syndrome. 3. Anemia related to ESRD with baseline HCT in hte mid 30s on Epogen 4. HTN 5. Non-ischemic Cardiomyopathy of unclear etiology-last echo [**9-21**] with EF=25%, global hypokinesis - cardiac catheterization in [**2145**]: minor coronary irregularities 6. NSVT first noted in [**2151**] 7. Prostate CA s/p radical prostatectomy & LN dissection in 2/94 Social History: He grew up in a [**Doctor Last Name **] family and worked in maintenance at the Rat Cellar night club for 22 years. Prior to his last admission in [**Month (only) 958**], he was living in senior housing and getting his meals from the cafeteria there. He was otherwise independent in his ADLs and walking without assistance. Since his last discharge he has been at [**Hospital3 2558**] and walking with a walker. Denied tobacco, alcohol, and recreational drug use in the past. Recently living at [**Hospital3 2558**] Family History: Unknown, grew up in [**Doctor Last Name **] home Physical Exam: General: Alert, oriented x 3, no acute distress, not using accessory muscles, speaking in full sentences HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP elevated 10cm, no LAD Lungs: Bibasilar crackles and rhonchi to mid lung fields. Apices clear to auscultation. No wheezes CV: tachy. Regular, normal S1 + S2, 2/6 systolic murmur LLSB. Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: foley in place Ext: warm, well perfused, 1+ pulses, no clubbing, cyanosis or edema. AV fistula LUE with palpable thrill. Left femoral line without hematoma or bruit. Pertinent Results: [**2152-6-26**] 06:07AM BLOOD WBC-12.4*# RBC-4.43* Hgb-12.5* Hct-39.7* MCV-90 MCH-28.2 MCHC-31.5 RDW-18.2* Plt Ct-268 [**2152-6-29**] 05:40AM BLOOD WBC-6.7 RBC-3.62* Hgb-9.9* Hct-31.9* MCV-88 MCH-27.3 MCHC-31.0 RDW-17.5* Plt Ct-211 [**2152-6-26**] 06:07AM BLOOD Neuts-82* Bands-2 Lymphs-11* Monos-5 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 [**2152-6-26**] 06:07AM BLOOD Hypochr-1+ Anisocy-1+ Poiklo-1+ Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL Ovalocy-1+ Tear Dr[**Last Name (STitle) 833**] [**Name (STitle) 4486**] [**2152-6-26**] 09:00PM BLOOD Glucose-101* UreaN-27* Creat-4.5*# Na-138 K-4.7 Cl-97 HCO3-29 AnGap-17 [**2152-6-29**] 05:40AM BLOOD Glucose-87 UreaN-30* Creat-4.7*# Na-142 K-4.1 Cl-99 HCO3-32 AnGap-15 [**2152-6-26**] 09:00PM BLOOD CK(CPK)-46* [**2152-6-27**] 06:00AM BLOOD CK(CPK)-33* [**2152-6-26**] 09:00PM BLOOD CK-MB-1 cTropnT-0.16* [**2152-6-27**] 06:00AM BLOOD CK-MB-1 cTropnT-0.18* [**2152-6-26**] 05:23AM BLOOD proBNP-GREATER TH [**2152-6-26**] 09:00PM BLOOD Calcium-8.5 Phos-2.9 Mg-1.8 [**2152-6-29**] 05:40AM BLOOD Calcium-7.8* Phos-2.6* Mg-1.9 [**2152-6-26**] 05:51AM BLOOD Glucose-107* Lactate-1.5 Na-135 K-5.9* Cl-92* [**2152-6-26**] 05:51AM BLOOD freeCa-0.94* [**2152-6-27**] 08:55AM BLOOD freeCa-0.98* [**2152-6-27**] 01:47PM BLOOD freeCa-0.99* [**2152-6-27**] BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT [**2152-6-26**] MRSA SCREEN MRSA SCREEN-FINAL INPATIENT [**2152-6-26**] BLOOD CULTURE Blood Culture, Routine-PENDING EMERGENCY [**Hospital1 **] [**2152-6-26**] BLOOD CULTURE Blood Culture, Routine-PENDING EMERGENCY [**Hospital1 **] Radiology Report CHEST (PORTABLE AP) Study Date of [**2152-6-26**] 5:10 AM PORTABLE AP SUPINE RADIOGRAPH: The left cardiac border is obscured by an ill-defined opacity in the left mid-to-lower lung zone. Within this limitation, mild cardiomegaly persists. The aorta is calcified and tortuous again. Mediastinal and hilar contours are unchanged. Airspace opacificationis also seen in the right middle lobe. There may be an left pleural effusion. There is no pneumothorax. IMPRESSION: Multifocal airspace opacification is consistent with pneumonia in the appropriate clinical setting. Alternatively asymmetric edema or less likely pulmonary hemorrhage can explain this radiographic appearance. Bilateral diaphragmatic pleural calcification is probably due to asbestos exposure, or, less likely, other remote pleural insult. [**Hospital1 18**] ECHOCARDIOGRAPHY REPORT [**2152-6-27**]: Conclusions 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. The left ventricular cavity size is normal. There is mild to moderate regional left ventricular systolic dysfunction with severe inferior and infero-lateral hypokinesis. There is subtle basal anterior and anteroseptal hypokinesis. No masses or thrombi are seen in the left ventricle. There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. 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. Mild (1+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. Compared with the prior study (images reviewed) of [**2151-10-4**], the LVEF and RVEF have improved. Regional LV dysfunction is now more evident. Brief Hospital Course: #. Respiratory distress: Patient was requiring 100% NRB to maintain O2 sat of 100% and had a temperature of 102 on presentation to the ED. He was briefly on BiPAP due to concern of flash pulmonary edema. BiPAP was subsequently stopped and he was changed to NRB. On admission to the MICU his symptoms were much improved and patient weaned down to 3L NC on arrival. This was thought to be multifactorial given BNP>[**Numeric Identifier **] with weight gain and CXR consistent with multifocal PNA as well as fever and cough. He was started on treatment for HCAP with Vanco/Zosyn/Cipro. His respiratory status continued to improve and he was transfered to the medical floor on HD2. He remained afebrile while on the floor and O2 was weaned off. His antibiotic regimen was changed to ceftazidime (with HD) and cipro (PO) due to ease of dosing and adequate coverage. Vancomycin was discontinued as the patient was found to be MRSA nasal swab (-). #. HCAP: Patient presented with respiratory distress, cough and fever to 102 as above. CXR revealed multifocal pneumonia and he was started on treatment for HCAP with vanc/zosyn/cipro. This was changed in the MICU to vanc/cefepime/cipro. His repiratory status improved and he was transfered to the medical floor. On the floor the decision was made to change his regimen to vanc/ceftaz/cipro (PO) due to ease of dosing with HD and lack of need for a PICC line for administration. He remained afebrile with normal WBC. On the day of discharge it was decided to stop vancomycin as the patient was found to be MRSA (-) on nasal swab. # Tachcyardia: Patient presented with sinus tachycardia to the 130's. This was thought to be related to infection and fever as well as respiratory distress. It improved after treatment of these problems. # Hypertension: Patient presented with BP of 221/126. This was thougth to be due to a combination of infection and respiratory distress. It improved after being briefly on a nitro gtt and HD. His home dose medications were subsequently re-started with the patient maintaining SBP in the 140-60's range. #. ESRD on HD: Contineud HD MWF and home dose medications. The nephrology team was aware of the patient's admission and will contact his outpatient HD center about antibiotic administration. # CHF: Patient with a history of non-ischemic cardiomyopathy and an EF of 25%. On admission a TTE was performed which revealed an improvement of his EF to 45%. He was continued on his home dose medications once stable. - continue BB - repeat TTE - restart [**Last Name (un) **] after HD if BP tolerates # s/p parathyroidectomy and hungry bone syndrome: Patient continued to have low Ca despite IV and PO repletion. He will need further repletion while at rehab. # Code: Full (discussed with patient) Medications on Admission: 1. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 3. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily). 4. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 5. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 6. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000) units Injection TID (3 times a day). 7. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 8. Valsartan 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 9. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 11. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain/fever. 12. Calcium Carbonate 500 mg Tablet, Chewable Sig: Two (2) Tablet, Chewable PO TID (3 times a day). 13. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. 14. Calcitriol 0.25 mcg Capsule Sig: Two (2) Capsule PO DAILY (Daily). Discharge Medications: 1. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily). 4. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for Constipation. 5. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. 6. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 7. Valsartan 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for Constipation. 9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO twice a day. 10. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain. 11. Calcium Carbonate 500 mg Tablet, Chewable Sig: Two (2) Tablet, Chewable PO TID (3 times a day). 12. Calcitriol 0.5 mcg Capsule Sig: One (1) Capsule PO BID (2 times a day). 13. Benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day) as needed for cough for 7 days. 14. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 6 days: last day [**7-5**]. 15. Ceftazidime 1 gram Recon Soln Sig: One (1) Recon Soln Injection QHD (each hemodialysis) for 6 days: last day [**7-5**]. 16. Outpatient Lab Work Please have a calcium level checked every other day and replete with IV calcium gluconate for level <7.8 Discharge Disposition: Extended Care Facility: [**Hospital3 2558**] - [**Location (un) **] Discharge Diagnosis: Primary Diagnosis: - [**Hospital 7502**] healthcare associated Secondary Diagnoses: - End stage renal disease - Hypertension - Prostate cancer - Hyperparathyroidism - Anemia from chronic kidney disease - Non-ischemic cardiomyopathy, EF 45% ([**2152-6-13**]) Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: You were admitted because you were having rigors and shortness of breath. On admission you were found to have a high fever and a CXR revealed a pneumonia. You were intially treated in the ICU with antibiotics but quickly transfered to the medical floor as your condition improved. You condition continued to improve and you remained afebrile. You should complete an 8 day course of antibiotics with hemodialysis. Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more than 3 lbs. Medication Changes: START: Ceftazidime with hemodialysis last day of antibiotics is [**2152-7-5**] (total 8 day course) START: Ciprofloxacin 500 mg daily until [**2152-7-5**] (total 8 day course) START: Benzonatate 100 mg TID as needed for cough No other changes were made to your medications. Followup Instructions: Department: ADVANCED VASC. CARE CNT When: TUESDAY [**2152-7-25**] at 8:00 AM With: [**Name6 (MD) 5536**] [**Name8 (MD) **], MD [**Telephone/Fax (1) 5537**] Building: [**Street Address(2) 7298**] ([**Location (un) 583**], MA) [**Location (un) **] Campus: OFF CAMPUS Best Parking: Free Parking on Site Department: CARDIAC SERVICES When: WEDNESDAY [**2152-12-20**] at 2:00 PM With: [**Name6 (MD) 251**] [**Last Name (NamePattern4) 677**], 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

[ "276.7", "252.08", "285.21", "585.6", "V10.46", "425.4", "428.0", "428.22", "486", "403.91" ]

icd9cm

[ [ [] ] ]

[ "39.95", "38.93" ]

icd9pcs

[ [ [] ] ]

13415, 13485

7670, 10447

328, 374

13787, 13787

4045, 7647

14792, 15409

3322, 3372

11812, 13392

13506, 13506

10473, 11789

13970, 14474

3387, 4026

13591, 13766

14494, 14769

277, 290

1670, 2000

402, 1652

13525, 13570

13802, 13946

2022, 2772

2788, 3306

23,962

144,528

29485+57643

Discharge summary

report+addendum

Admission Date: [**2165-4-8**] Discharge Date: [**2165-4-13**] Date of Birth: [**2119-8-25**] Sex: M Service: CARDIOTHORACIC Allergies: Compazine Attending:[**First Name3 (LF) 1283**] Chief Complaint: History of stroke, frequent headaches Major Surgical or Invasive Procedure: [**2165-4-9**] Minimally Invasive PFO Closure History of Present Illness: Mr. [**Known lastname 64926**] is a 45 year old male who suffered a stroke back in [**2164-9-28**]. A transesophogeal echocardiogram at that time revealed a patent foramen ovale with right to left flow. Additional workup was notable for a prothrombin gene mutation. In preperation for surgical closure, he underwent a coronary CTA which ruled out obstructive coronary disease. He presented for surgical intervention. He continues to experience frequent headaches. He was admitted one day prior to surgery for heparinization. Past Medical History: Patent Foramen Ovale, History of Stroke, Migraine Headaches, Hypertension, Hyperlipidemia, Prothrombin Gene Mutation, History of Syncope, s/p Left Shoulder Surgery, s/p Left Knee Surgery, s/p Appendectomy Social History: Denies tobacco, rare ETOH. He is a biology teacher. Lives alone. Denies recreational and intravenous drug abuse. Family History: Maternal grandfather died of MI at 40. Maternal aunts have autoimmune disorders ie. Hashimoto, Lupus, rheumatoid arthritis. Mother suffered from scleroderma. Physical Exam: Vitals: T 97.3, BP 145/94, HR 62, RR 14, SAT 94 on room air General: well developed male in no acute distress HEENT: oropharynx benign, Neck: supple, no JVD, Heart: regular rate, normal s1s2, no murmur or rub Lungs: clear bilaterally Abdomen: soft, nontender, normoactive bowel sounds Ext: warm, no edema, no varicosities Pulses: 2+ distally Neuro: nonfocal Pertinent Results: [**2165-4-8**] 04:15PM BLOOD WBC-5.0 RBC-4.71 Hgb-15.4 Hct-41.3 MCV-88 MCH-32.7* MCHC-37.3* RDW-13.6 Plt Ct-188 [**2165-4-8**] 04:15PM BLOOD PT-11.7 PTT-24.3 INR(PT)-1.0 [**2165-4-8**] 04:15PM BLOOD ALT-22 AST-15 LD(LDH)-208 AlkPhos-82 Amylase-38 TotBili-0.4 Brief Hospital Course: Mr. [**Name14 (STitle) 70768**] was admitted for heparinization and underwent routine preoperative evaluation. Workup was unremarkable and he was cleared for surgery. The following day, Dr. [**Last Name (STitle) 1290**] performed a minimally invasive closure of his patent foramen. For surgical details, please see seperative dicated operative note. Following the operation, he was brought to the CSRU for invasive monitoring. Within 24 hours, he awoke neurologically intact and was extubated without incident. He weaned from intravenous therapy without difficulty. He maintained stable hemodynamics as low beta blockade was resumed. His CSRU course was uneventful and he transferred to the SDU on postoperative day one. Beta blockade was advanced as tolerated and he remained in a normal sinus rhythm. Over several days, he continued to make clinical improvements with diuresis. stop [**4-11**] Medications on Admission: Warfarin - stopped [**2165-4-3**] Nadolol Discharge Disposition: Home Discharge Diagnosis: Patent Foramen Ovale - s/p Minimally Invasive PFO Closure, History of Stroke, Migraine Headaches, Hypertension, Hyperlipidemia, Prothrombin Gene Mutation Discharge Condition: Good Discharge Instructions: Take medications as directed. Monitor wounds for signs of infection. Please call with any questions or concerns. Please do not drive while taking narcotics. Followup Instructions: Dr. [**Last Name (STitle) 1290**] in [**5-2**] weeks, call for appt Dr. [**Last Name (STitle) 32555**] in [**3-2**] weeks, call for appt Completed by:[**2165-4-13**] Name: [**Known lastname 11948**],[**Known firstname **] Unit No: [**Numeric Identifier 11949**] Admission Date: [**2165-4-8**] Discharge Date: [**2165-4-13**] Date of Birth: [**2119-8-25**] Sex: M Service: CARDIOTHORACIC Allergies: Compazine Attending:[**First Name3 (LF) 674**] Addendum: From [**Date range (1) 11950**] Mr. [**Known lastname **] continued to do well. On [**4-11**] he had a rise in his creatinine to 1.5 from 0.9, his toradol and lasix were dc'd. On [**4-12**] he developed a fever of 101.6, cultures were negative and wounds were clean dry and intact. He was ready for discharge home on POD #4. Discharge Disposition: Home [**Doctor Last Name **] [**Last Name (Prefixes) **] MD [**MD Number(1) 681**] Completed by:[**2165-4-15**]

[ "272.0", "401.9", "780.6", "745.5", "V58.61", "V12.59" ]

icd9cm

[ [ [] ] ]

[ "39.61", "35.71" ]

icd9pcs

[ [ [] ] ]

4395, 4537

2126, 3023

313, 361

3319, 3326

1843, 2103

3531, 4372

1290, 1449

3142, 3298

3049, 3092

3350, 3508

1464, 1824

236, 275

389, 915

937, 1144

1160, 1274

10,947

135,751

6551

Discharge summary

report

Admission Date: [**2158-1-20**] Discharge Date: [**2158-1-27**] Date of Birth: [**2083-1-19**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1055**] Chief Complaint: lightheadedness Major Surgical or Invasive Procedure: Angioplasty and reconstruction of stenotic regions in the left subclavian vein, left brachiocephalic vein, right subclavian vein, and brachial cephalic vein, as well as at the junction of both brachiocephalic veins encompassing the superior vena cava History of Present Illness: 74 yr old male with ESRD on HD, CAD, DM and recent admission to [**Hospital1 18**] from [**Date range (1) 25095**] for staph epi line infection who presents to ED complaining of light-headedness and bleeding from his catheter site. Pt felt well on day of discharge ([**1-18**]) but the following morning, it was noted that he was oozing some from his groin line (that was placed during the most recent admission). He went to dialysis that day and the bleeding ceased with compression. Later that night, he felt tired, lightheaded and was observed to be pale. The site had started to bleed again and could not be stopped with pressure. Per the pt's daughter, a hand towel was soaked within 15 minutes. EMS was called and he went to the Emergency room. * In the [**Name (NI) **], pt was found to be hypotensive with SBP in 80s (baseline SBP 120s). He was given a 500cc IVF bolus without response and was then started on dopamine. His hct was found to be 33.6 and INR of 1.5. He was tranferred to the ICU for further management. * In the ICU, pt was weaned off dopamine and his BP remained stable in the 100s/50s. Interventional Radiology injected thrombin into catheter to stop bleeding. Other causes of hypotension such as adrenal insufficiency and sepsis needed to be ruled out so a cortisol level and blood cx were sent. Hct dropped gradually from 36.5 on day of admission to 29.6 the following day. A CT of the abd/pelvis was done and found no evidence of a retroperitoneal bleed. He was tranfused one unit of RBCs at HD and transferred to medicine. Past Medical History: 1. Cirrhosis, cryptogenic with a history of hepatic encephalopathy also complicated by grade 3 esophageal varices 2. End stage renal disease secondary to IgA nephropathy. 3. coronary artery disease 4. Hypertension 5. Diabetes mellitus type 2 6. mild dementia: at baseline pt able to walk with cane despite mild L-sided weakness, feed himself & communicate appropriately 7. Psoriasis 8. Gout 9. Diverticulosis and internal hemorrhoids. 10. History of myelodysplastic syndrome secondary to allopurinol. 11. Status post herniorrhaphy. 12. status post prostate surgery [**66**]. History of cellulitis. 14. history of line infection with staph aureus 15. history of syncope with known PR prolongation and left anterior fascicular block Social History: The patient lives with his daughter,although he is alone during the day except when at dialysis.He denies alcohol use. He has a 120 pack year smokinghistory, quit 16 years ago. Family History: Sisters had liver and lung cancer. Brother had a history of MI and CABG. Physical Exam: temp 97.7, BP 130/70, HR 60, R 16 O2 96% RA Gen: NAD, pleasant Neck: no bruits CV: RR with some ectopy, 2/6 systolic murmur heard throughout precordium; PMI palpable in nl location; no heaves Chest: crackles at left base; large hematoma on upper left chest, tender; stable Abd: +BS, NTND, soft, liver edge not palpable Ext: -left arm: 4+ edema, red with small blisters, nontender, range of motion decreased, 2+ radial pulse -right arm: no edema, 2+ radial pulse -legs: skin discoloration, 2+ DP bilaterally, sensation intact Neuro: CN 2-12 intact, AO x 3 Pertinent Results: [**2158-1-19**] 11:30PM WBC-4.5# RBC-3.31* HGB-11.7* HCT-33.6* MCV-101* MCH-35.3* MCHC-34.8 RDW-15.3 [**2158-1-19**] 11:30PM NEUTS-67.6 LYMPHS-16.5* MONOS-8.9 EOS-5.8* BASOS-1.1 [**2158-1-19**] 11:30PM PLT COUNT-66* [**2158-1-19**] 11:30PM PT-15.4* PTT-150* INR(PT)-1.5 * [**2158-1-19**] 11:30PM GLUCOSE-129* UREA N-17 CREAT-4.7*# SODIUM-141 POTASSIUM-3.5 CHLORIDE-102 TOTAL CO2-31* ANION GAP-12 [**2158-1-19**] 11:30PM CALCIUM-9.2 PHOSPHATE-1.8*# MAGNESIUM-1.6 * [**2158-1-19**] 11:30PM BLOOD CK-MB-2 cTropnT-<0.01 [**2158-1-20**] 06:15AM BLOOD CK-MB-2 cTropnT-<0.01 [**2158-1-20**] 02:00PM BLOOD CK-MB-NotDone cTropnT-0.02* [**2158-1-19**] 11:30PM BLOOD CK(CPK)-18* [**2158-1-20**] 06:15AM BLOOD CK(CPK)-60 [**2158-1-20**] 02:00PM BLOOD CK(CPK)-24* * [**2158-1-20**] 01:31AM LACTATE-2.1* * Blood cxs neg x2 * Abd/Pelvis CT; No retroperitoneal hematoma. Right common femoral venous access catheter with its tip terminating in the distal IVC. Diverticulosis without diverticulitis. Cirrhosis with findings consistent with portal hypertension and gastroesophageal and splenic varices. ---- CXR [**1-20**]:Normal chest --- [**2158-1-20**] 06:15AM BLOOD Cortsol-21.7* Brief Hospital Course: A/P: 75 yr old male with hx of cirrhosis, DM, ESRD [**3-7**] IgA Nephropathy who presented to ED with hypotension and bleeding from catheter site, sent to ICU for management of hypotension and transferred to floor when stable. * 1. Bleeding: Pt has ESRD on HD, so has uremic plts. Also has liver dx and MDS, so has chronically low platelets, and not surprised that PT and PTT are somewhat elevated. He did have two PTT readings >150. Unclear etiology of this value. He was given PO Vitamin K, and abnormalities resolved. Was ruled out for DIC. Mildly elevated homocysteine level suggests propensity to clot. Bleeding was stopped with pressure dressing, and pt had groin site injected with thrombin by IR team. This resolved most bleeding. The tunneled groin line was left in place, as AV fistuala not ready for use by HD. * 2. Hypotension: ICU notes report thought to be secondary to bleed and/or fluid shifts from hemodialysis. Had a Hct drop after admit, but unclear if dilutional in part. Had abd/pelvis CT which showed no RP bleed. Given 1 unit PRBCs, and was stable since then. Also, had cortisol which was normal and didn't indicate adrenal insuff. Pt has had episodes of syncope in past, mostly in dialysis, and possible they are caused by fluid shifts/transient hypotension. [**Month (only) 116**] have been culprit here as well. His BP was stable for entire time on floor, and his nadolol was restarted, but at a lower dose. * 3. Line Sepsis: Blood cultures negative here. COntinued to dose vanco for level <15. This will continue at HD for total of 6 weeks. He will f/u with Dr [**Last Name (STitle) 6173**] in ID. * 4. Upper ext swelling: Remained stably edematous on admit. Dr [**First Name (STitle) **] decided to go ahead with procedure. She performed bilateral subclavian/brachiocephalic venoplasty and stenting. He did well with the procedure and was monitored post-op due to worry of fluid shift from arm to vasculature possibly causing CHF. He did not have this complication ad was sent out with ongoing improvement inhis upper extremity symptoms. 5.Psoriasis:Has worsening of psoriasis on areas around AVF s/p needling for HD. Initially thought to be cellulitis. Plan was to rest AVF area and use HD catheter instead. Followed skin lesion which stayed stable. * 4. s/p fall: Pt still complained of bruise on left side of chest from fall 2 weeks ago. Was put on prn oxycodone. Pain gradually improving. Ruled out for MI, but pain not cardiac in nature. * 5. Renal: He was continued on HD three times a week. Using fem line, as AVF not working well yet. Hope is that now that arm veins opened up, his AVF will become useable. He will continue to get vanco at HD, with last dose [**2158-2-16**]. * 6. DM: Good BS control with Humalog SS and diabetic diet alone. * 7. Cirrhosis: No evidence of encephalopathy. COntinued his lactulose and initially held nadolol. Restarted at lower dose when BP stable. WIll send out on this dose, but PCP/GI can titrate up as tolerated. Medications on Admission: Vancomycin 1gm at dialysis Nadolol 10 qd Protonix Lactulose Nephrocaps Ca Acetate Oxycodone Discharge Disposition: Home With Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: Bleeding from tunneled HD line catheter site in right groin Hypotension Repair of upper venous stenoses bilaterally -- Cirrhosis ESRD on HD h/o syncope stable bradycardia MDS Thrombocytopenia Multiple venous clots DMII Discharge Condition: Pt had no additional bleeding from groin catheter site. He was ambulating normally. No dizziness/lightheadedness. No CP/SOB. He had some post-op pain in arms. Eating at his baseline. Discharge Instructions: Please call Dr [**Last Name (STitle) **] at [**Telephone/Fax (1) 14918**] or return to the ED if you experience any new chest pain, shortness of breath, or lightheadedness/dizziness. If you notice more bleeding from your catheter site in your groin, either tell the doctors [**First Name (Titles) **] [**Name5 (PTitle) 12069**] if you are going there, or return to the ED. Please take all of your medications. Followup Instructions: Liver: Provider: [**Name10 (NameIs) **] Where: CC CLINICAL CENTER RADIOLOGY Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2158-2-7**] 10:00 --- Liver:Provider: [**Name10 (NameIs) **] [**Last Name (NamePattern4) 2424**], MD Where: LM [**Hospital Unit Name 25096**] CENTER Phone:[**Telephone/Fax (1) 2422**] Date/Time:[**2158-2-7**] 11:00 --- Infectious Diseases: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 13632**], MD Where: LM [**Hospital Unit Name 4337**] DISEASE Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2158-2-21**] 10:30 ---- Please call [**Telephone/Fax (1) 25094**] to schedule a follow-up appointment in 2 weeks with Dr [**First Name (STitle) **] who performed the procedure on the veins in your arms.

[ "790.7", "996.62", "285.1", "238.7", "786.52", "571.5", "996.73", "250.00", "414.01", "294.8", "696.1", "041.11", "572.3", "459.81", "403.91", "459.2", "287.5", "270.4" ]

icd9cm

[ [ [] ] ]

[ "39.90", "99.29", "99.04", "39.95", "39.50", "99.05" ]

icd9pcs

[ [ [] ] ]

8177, 8234

5016, 8035

331, 584

8497, 8683

3810, 4993

9143, 9895

3144, 3219

8255, 8476

8061, 8154

8707, 9120

3234, 3791

276, 293

612, 2178

2200, 2933

2949, 3128

58,008

123,425

20253

Discharge summary

report

Admission Date: [**2167-4-22**] Discharge Date: [**2167-5-2**] Date of Birth: [**2100-3-19**] Sex: F Service: SURGERY Allergies: Aldomet / Morphine Attending:[**First Name3 (LF) 5569**] Chief Complaint: fall, hypotension, hypothermia, bradycardia Major Surgical or Invasive Procedure: [**2167-4-29**] Flex sig diverticulosis in sigmoid colon; no colitis. History of Present Illness: Ms [**Known lastname 13469**] is 67 year old female with hepatic cirrhosis secondary to PSC on [**Known lastname **] list at [**Hospital1 18**] who went to outpatient echocardiogram today and experienced weakness and fell upon getting to her car. Patient suffered a hematoma on her scalp but had no LOC. She was transported to [**Hospital1 18**]-ED where she was found to be hypothermic with temperature 89.5F, bradycardic to 40's and hypotensive with SBP was as low as 70's. Patient was resuscitated with NS and was given a stress dose Dexamethasone. Levophed was also started. Vancomycin and Zosyn was given empirically. Foley was placed. Blood and urine cultures were sent. [**Hospital1 1326**] surgery was notified and patient was promptly evaluated in the ED. In the ED, patient was hypothermic with temperature of 91F. SBP was in 90-110 on low dose Levophed. Urine output was adequate after Foley was placed. She continued to mentate adequately. She reported that she has been having multiple episodes of diarrhea in the past few days and it was worst yesterday. She reported that she also just recovered from having a pneumonia and was given antibiotics although OMR showed her last documented of pna in [**11-8**] and her Augmentin was d/c'd on [**2167-2-20**]. She endorsed having generalized weakness and fatigue but denied any chest pain, shortness of breath, abdominal pain. Patient was also evaluated by Trauma team for fall and found to have lumbar spine tenderness. Due to her unstable condition, patient was admitted to the SICU from the ED for continuing resuscitation and evaluation. Past Medical History: - PSC c/b Cirrhosis (last MELD 18), jaundice and ascites, encephalopathy - UC - Psoriasis - Asthma - HTN - ESBL E. Coli cystitis - Hypoxic respiratory failure - CAD s/p NSTEMI s/p PCI to LX with BMS on [**2167-2-12**] - Anemia and thrombocytopenia secondary to chronic liver disease - Cutaneous Candidiasis and Psoriasis - Hysterectomy Social History: - Denied EtOH/tobacco - quit 25 years ago, No illicit drugs - Married and lived with husband and daughter - Worked as rad tech, now on disability Family History: - Father: deceased from unknown cancer, Sister has lung cancer Physical Exam: Vitals in ED: T 91 HR 56 BP 98/50 HR 58 RR13 100%RA GEN: NAD although mildly anxious, jaundice looking, A&Ox3 HEENT: small hematoma on scalp, mildly tender, no active bleeding, dry mucosa, no lymphadenopathy, neck supple, no cervical tenderness PULM: b/l crackles CV: sinus brady, S1S2, [**3-8**] sys murmur ABD: soft, non-distended, unable to appreciate any fluid wave, mild TTP on RUQ, small reducible umbilical hernia. EXTREM: psoriasis on b/l LEs, no open wound, +edema RECTAL: normal tone, no gross blood, +guaiac Pertinent Results: 2.4 >---< 24 24.8 121 | 92 | 76 --------------< 94 4.6 | 21 |1.8 ALT 80 AST 126 AP 213 LDH 139 Tbil 19.4 Alb 2.7 PT 2.3 PTT 52.1 INR 2.2 UA: many bacteria, 1 WBC, 1BRC Imaging CT Head [**2167-4-22**](wet read): No hemorrhage, infarct, edema or fracture. Lg amount of mucosal inflammation in bilateral max sinuses with A/F levels. Mucosal thickening also noted in ethmoid and right frontal sinus. CT C-spine [**2167-4-22**] (wet read): Minimal retrolisthesis of c5 on C6, degenerative. DJD at same level. No fracture. No STS. incidental note of right thyroid gland 0.8 x 0.5 cm nodule. Chest CT without contrast [**2167-4-22**]: 1. New compression fracture of the superior endplate of vertebral body L3. 2. Multiple new nondisplaced subacute and acute fractures of right-sided ribs. Multiple left-sided rib fractures were seen on the prior study. 3. No evidence of pneumonia. Trace bilateral pleural effusions have slightly increased in size since the prior study. 4. Nodular liver with signs of portal hypertension and slightly increased intrahepatic biliary dilation, consistent with known PSC and cirrhosis. Small amount of perihepatic and perisplenic ascites has also increased in amount since the prior study. [**2167-4-27**] MR L spine w/wo contrast: 1. Little change compared to the [**2167-4-23**] examination with subacute compression fractures of L3 and L4, with no finding suspicious for epidural abscess or underlying osteomyelitis/discitis. Correlate clinically and with labs and follow up if necessary. 2. Splenomegaly and ascites, and elft renal T2 hyperintense lesion, similar to prior, partially visualized [**2167-4-29**] Flex sig diverticulosis in sigmoid colon; No evidence of colitis. Brief Hospital Course: 67 year old female with hepatic cirrhosis secondary to primary sclerosing cholangitis with MELD score of 23. She was admitted to the SICU under the care of the [**Month/Day/Year 1326**] Surgery Service. Her hypotension was felt to mostly be due to dehydration from extensive diarrhea. Moreover, her whole clinical picture likely suggested sepsis as the main cause. Head CT was done after known fall and was negative for bleed or fracture. CT of cervical spine was negative for fracture. It did demonstrate degenerative changes and left thyroid nodule with internal calcification, which raised suspicion. US evaluation was recommended. She required Levophed and was given resuscitation with IV fluid, transfused with pRBC for HCT of 24 and platelets for count of 24. Cardiac enzymes were sent and were negative. Beta-blocker and diuretics were held. Empiric IV antibiotics were started (Vanco/Zosyn/Flagyl and po Vanco for resumed C.diff) after blood, urine and stool cultures were sent. Lactulose was held. ABD CT demonstrated increased rectal and pan colonic wall thickening since [**2167-1-31**], particularly in sigmoid, descending colon and cecum, suggestive of collitis, infectious or inflammatory. Creatinine was elevated at 1.8 on admission. Urine output improved with hydration and creatinine decreased to baseline of 0.7. Urine culture from [**4-22**] isolated ESBL E. coli sensitive to Meropenum. Meropenum was started on [**4-22**] and she remained afebrile. Blood cultures remained negative. Sputum culture on [**4-22**] isolated ESBL E. coli with 2 morphologies. Meropenum continued. IV Flagyl was stopped after 2 days. She remained afebrile. CXR and Chest CT revealed no pneumonia. Of note, multiple new nondisplaced subacute and acute fractures of right-sided ribs were noted. Multiple left-sided rib fractures were seen on the prior study. Aggressive pulm toilet was done. Follow up CXR demonstrated areas of opacification in the upper zones. Liver duplex/US was done to evaluate the vasculature. Study was somewhat limited and the left hepatic artery and posterior right portal vein were not visualized. Otherwise, all interrogated liver vasculature was patent with appropriate flow and waveforms identified. Tiny mobile gallstone identified and trace perihepatic ascites was noted. CT abdomen noted nodular liver with signs of portal hypertension and slightly increased intrahepatic biliary dilation, consistent with known PSC and cirrhosis. There was a small amount of perihepatic and perisplenic ascites seen. ID was consulted given ESBL E. coli. Concern was raised for source of ESBL. L spine fracture and bowel source were suspect. Repeat MRI with contrast of L spine was done to eval for infection. This was negative. TTE was negative. Foci for infection was likely bowel. Neurosurgery was consulted for the L spine fractures. Recommendations included starting Calcium & Vit D supplementation. No spine precautions or base were needed. A f/u appointment with Dr [**Last Name (STitle) **] was recommended in 8 weeks with a CT Lspine. [**Telephone/Fax (1) 1669**] to schedule. With improvement, she was transferred out of the SICU. She continued to experience diarrhea. Vanco po continued to complete a 2 week course. Imodium 2mg daily was started with decreased diarrhea. She was started back on half of her usual lasix dose for fluid overload. Serum sodium decreased to 127 and edema increased. She was placed on a 2 gram sodium diet. Lasix was decreased and IV albumin was administered for 2 days. Physical therapy was consulted and worked with her recommending return [**Hospital1 6685**] Common of Greater [**Location (un) 18017**] [**Telephone/Fax (1) 54375**]. At the time of discharge to [**Hospital1 6685**] Common rehabilitation facility on [**2167-5-2**], 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. All discharge planning was communicated with rehabilitation facility. Discharge Medications: 1. atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. clobetasol 0.05 % Cream Sig: One (1) Appl Topical Q12H (every 12 hours) as needed for proriatic: apply to psoriatic as needed . 4. fluticasone-salmeterol 100-50 mcg/dose Disk with Device Sig: One (1) Puff Inhalation DAILY (Daily) as needed for resp. 5. ketoconazole 2 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day): [**Hospital1 **] to anterior abdomen, QHS to pannus fold and inflammed nail beds . 6. mesalamine 400 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO BID (2 times a day). 7. rifaximin 550 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 9. calcium carbonate 200 mg (500 mg) Tablet, Chewable Sig: One (1) Tablet, Chewable PO BID (2 times a day). 10. cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO BID (2 times a day). 11. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. ursodiol 300 mg Capsule Sig: Three (3) Capsule PO BID (2 times a day). 13. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) neb Inhalation Q6H (every 6 hours) as needed for wheezing, cough. 15. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q12H (every 12 hours) as needed for Pain: no more than 2000mg/day. 16. clotrimazole 10 mg Troche Sig: One (1) Troche Mucous membrane QID (4 times a day) as needed for mouth pain. 17. vancomycin 125 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours) for 11 days. 18. loperamide 2 mg Capsule Sig: One (1) Capsule PO DAILY (Daily): monitor for constipation. 19. furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 20. spironolactone 100 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Extended Care Facility: [**Hospital1 6685**] commons Nursing and Rehab Center Discharge Diagnosis: h/o PSC,cirrhosis UC Colitis/Diarrhea ESBL UTI, pneumonia L 3 compression fracture Thyroid nodule Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You will be transferring back to [**Hospital1 6685**] Commons Please call the [**Hospital1 1326**] Office [**Telephone/Fax (1) 673**] if you have any of the following: fever, chills, nausea, vomiting, increased abdominal pain or diarrhea, increased swelling/edema Followup Instructions: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 16424**], MD Phone:[**Telephone/Fax (1) 1971**] Date/Time:[**2167-5-6**] 1:15 Provider: [**Name10 (NameIs) **] Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2167-5-6**] 2:15 Provider: [**Name10 (NameIs) **] [**Hospital 1389**] CLINIC Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2167-5-6**] 3:20 Completed by:[**2167-5-2**]

[ "785.59", "E849.9", "787.91", "805.4", "562.10", "401.9", "599.0", "348.30", "584.9", "576.1", "241.0", "E888.9", "556.9", "995.91", "571.5", "276.1", "E928.8", "272.4", "553.1", "038.9" ]

icd9cm

[ [ [] ] ]

[ "45.24", "38.97" ]

icd9pcs

[ [ [] ] ]

11156, 11236

4934, 9119

322, 393

11378, 11378

3186, 4911

11817, 12221

2566, 2631

9142, 11133

11257, 11357

11529, 11794

2646, 3167

238, 284

421, 2027

11393, 11505

2049, 2387

2403, 2550

27,910

131,848

12746

Discharge summary

report

Admission Date: [**2118-3-23**] Discharge Date: [**2118-3-30**] Date of Birth: [**2041-7-21**] Sex: M Service: CARDIOTHORACIC Allergies: Flomax / Ace Inhibitors / Ativan / Lisinopril Attending:[**First Name3 (LF) 5790**] Chief Complaint: Post tracheostomy tracheal stenosis. Major Surgical or Invasive Procedure: [**2118-3-23**] Cervical tracheal resection and reconstruction and flexible bronchoscopy. [**2118-3-30**] Flexible bronschscopy History of Present Illness: Mr. [**Known lastname 39325**] is a 76-year-old gentleman who had suffered respiratory failure requiring an intubation and subsequent tracheostomy tube placement in the spring of [**2115**]. After decannulation, he was noted to have post tracheostomy tracheal stenosis. This was initially treated with a tracheal stent at an outside institution. This stent proved difficult and upon removal of the stent at this institution, it was noticed that placement of the stent had resulted in a posterior membranous tracheal tear. The stent was extracted and a new tracheostomy tube was placed surgically by myself in [**2116-5-31**]. There was an abundant amount of scarring even at that time around the upper airway and I did note that the entry of the previous tracheostomy into the airway appeared somewhat eccentric and, in addition, was quite high, namely at the level of the first tracheal ring. It also appeared to be on the right side of the airway. Past Medical History: CAD w/ stent, Diverticulits, Hartmann's, Resp failure, Trach, Afib, MRSA, DMII Tracheal stenosis by bronch ([**2116-5-27**]), Perforated sigmoid colon diverticulitis with peritonitis s/p colostomty([**2116-3-8**]) Coronary Artery Disease Paroxysmal atrial fibrillation Transient Complete Heart Block Diabetes Mellitus typeII Peripheral Vascular disease Hypertension Hypothyroidism Gout, DVT ([**3-8**]) Anxiety Acalculous cholecystitis MRSA Pneumonia Social History: Married lives with wife. Family History: non-contributory Physical Exam: VS: T: 98.1 HR: 60 SR BP 121/64 Sats: 97% RA General: 76 year-old male in no apparent distress HEENT: normocephalic, mucus membranes moist Neck: supple, incision clean dry intact Card: RRR Resp: clear breath sounds throughout GI: benign Extr: warm no edema Neuro: non-focal Pertinent Results: [**2118-3-26**] WBC-9.7 RBC-4.25* Hgb-12.2* Hct-36.2* Plt Ct-193 [**2118-3-25**] WBC-11.9* RBC-4.49* Hgb-12.6* Hct-37.5* Plt Ct-192 [**2118-3-24**] WBC-17.5* RBC-4.76 Hgb-13.2* Hct-38.9* Plt Ct-200 [**2118-3-23**] WBC-14.2*# RBC-4.37* Hgb-12.4* Hct-37.1* Plt Ct-198 [**2118-3-23**] WBC-8.2 RBC-4.40* Hgb-12.4* Hct-36.9* Plt Ct-199 [**2118-3-26**] Glucose-134* UreaN-15 Creat-1.3* Na-138 K-4.4 Cl-102 HCO3-27 [**2118-3-25**] Glucose-137* UreaN-16 Creat-1.3* Na-135 K-4.7 Cl-103 HCO3-22 [**2118-3-24**] Glucose-139* UreaN-19 Creat-1.3* Na-138 K-5.1 Cl-108 HCO3-21 [**2118-3-24**] CK(CPK)-169 [**2118-3-26**] Calcium-8.9 Phos-2.5* Mg-2.1 CXR: [**2118-3-24**]: In comparison with the study of [**3-23**], there is little overall change. Opacifications at the left base most likely represent atelectasis. Again there is opacification in the left upper zone adjacent to the aortic arch. This could be an area of aspiration. [**2118-3-23**]: There is postoperative mediastinal widening. Followup is recommended. There is no evident pneumothorax. If any, there are small bilateral pleural effusions. Ill-defined opacities in the left base are likely atelectasis. Pleural plaques are again noted on the right Path: Tissue [**2118-3-23**] Skin, stomal: Skin with fibrosis and chronic inflammation. B. "Tracheal stenosis": Fibrosis, chronic inflammation, and osseous metaplasia. Brief Hospital Course: Mr. [**Known lastname 39325**] is a 76 year-old male admitted on [**2118-3-23**] for Cervical tracheal resection reconstruction. He was extubated in the operating room, chin sutured to chest for tracheal support. He was transferred to the SICU for close respiratory monitoring. He had significant secretions which decreased with good pulmonary toilet, repositioning and humidified FIO2. Immediate postoperative he had a brief episode of atrial flutter rate of 90-110's which converted to sinus rhythm with IV Lopressor. His electrolytes were replete. He was restarted on his home dose of Lopressor and remained in sinus rhythm throughout his hospital stay. The neck drain was removed. His pain was managed with Dilaudid PCA converted to PO with good pain control. On POD7 he underwent flexible bronchoscopy which anastomosis site well healed and distal airway normal. There was mild larynx edema and erythema. His voice was clear. He tolerated a regular diet, ambulated in the halls. He will follow-up with Dr. [**Last Name (STitle) **] as an outpatient. Medications on Admission: Aspirin 81mg daily, lopressor 50mg [**Hospital1 **], valsartan 160mg daily, levothyroxine 125mcg daily, allopurinol 100mg daily, zetia 10mg daily, atorvastatin 20mg daily Discharge Medications: 1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 2. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. Valsartan 160 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain. Disp:*60 Tablet(s)* Refills:*0* 9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 10. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Discharge Disposition: Home Discharge Diagnosis: Tracheal Stenosis Discharge Condition: stable Discharge Instructions: Call Dr.[**Name (NI) 2347**] office [**Telephone/Fax (1) 2348**] if experience: -Fever > 101 or chills -Increased cough, shortness of breath, cough -Chest pain -Difficulty swallowing, new hoarsness. Check with your cardiologist regarding restarting coumadin Followup Instructions: Follow-up with Dr. [**Last Name (STitle) **] [**4-12**] 9:00 am in the [**Hospital Ward Name 121**] Building [**Hospital1 **] I Chest Disease Center. [**Location (un) **] Report to the [**Hospital Ward Name 517**] Clinical Center [**Location (un) **] Radiology Department for a Chest X-Ray 45 minutes before your appointment Completed by:[**2118-3-30**]

[ "478.6", "244.9", "997.1", "E879.9", "250.00", "427.31", "274.9", "427.32", "V45.82", "519.19", "401.9" ]

icd9cm

[ [ [] ] ]

[ "33.23", "31.79" ]

icd9pcs

[ [ [] ] ]

5827, 5833

3727, 4793

350, 480

5895, 5904

2328, 3704

6212, 6569

1995, 2013

5014, 5804

5854, 5874

4819, 4991

5928, 6189

2028, 2309

273, 312

508, 1461

1483, 1936

1952, 1979

2,413

198,393

47273+58992

Discharge summary

report+addendum

Admission Date: [**2109-9-8**] Discharge Date: [**2109-9-16**] Service: MEDICINE Allergies: Ace Inhibitors Attending:[**First Name3 (LF) 1253**] Chief Complaint: [**First Name3 (LF) **], fever. Major Surgical or Invasive Procedure: None History of Present Illness: This is a [**Age over 90 **] yo woman with dementia who is an unreliable historian. History largely obtained from ED records. Attempted to call family to obtain colateral info, but no answer at any number. Reportedly she presented to the ED [**9-8**] with 2 days of fevers, chills, [**Month/Day (4) **], sob, wheezing, nausea, vomitting and diarrhea. Unknown if has had ill contacts, travel or influnza vaccine. She notes runny nose and left sided chest pain, reportedly for years, off and on, unable to rate on pain scale, unable to clarify nature or associated symptoms further. She denies [**Month/Day (4) **], wheezing, sore throat, abdominal pain, nausea, vomitting, diarrhea, constipation, myalgias, arthralgias. She does not feel thirsty and has an appetite. In the ED: VS: 102.7 54 142/53 20 98% non rebreather->100% on 2L NC. She was given 1L NS, levofloxacin, albuterol, ipratropium, tylenol, and solumedrol 125mg iv. She felt subjectively improved. ROS: 10 point review of systems negative except as noted above. Past Medical History: Per OMR, unable to verify with patient: CAD w/ 3 VD s/p NSTEMI [**2100**], last cath [**12-11**] with 3 VD (non-intervenable) Hypertension Dyslipidemia Paroxysmal atrial fibrillation s/p [**Month/Year (2) 4448**] in [**2100-1-5**] for high grade heart block and bradycardia, generator change [**2107-10-5**] Asthma, PFTs [**5-/2093**] showed FVC 1.75 (69% pred), FEV1 0.93 (52% pred), FEV1/FVC 53.03 (88% pred) CRI, baseline Cr 1.4 s/p bilateral hip replacement due to aseptic necrosis, s/p removal of right trochanteric [**Last Name (un) **]-Miles clip and wires [**2-/2099**] for painful R hip hardware [**2-/2099**], R hip revision [**9-/2100**] Hx of Alcohol Abuse, currently sober Hx of Dizziness and Syncope, likely vasovagal s/p R knee arthroscopy for partial lateral meniscectomy [**12/2093**] s/p right total knee replacement [**12/2096**] Osteoarthritis, L shoulder and R knee R indirect inguinal hernia, s/p herniorrhaphy with resection of round ligament [**9-6**] Hiatal Hernia, dysphagia Diverticulosis Anemia L Cerebellar Infarct by CT, not clinically significant Social History: Per OMR, unable to verify with patient: Social history is significant for the absence of current tobacco use. She quit smoking cigarettes 2-3 years ago, and previously smoked 1 ppd x5-6 yrs. She does have a history of alcohol abuse, but is currently sober. She denies illicit drug use. Worked in a manufacturing wearhouse many years ago for dewrinkling clothes. Lives with her 2 sons, who help with cooking and cleaning. She has 15 children who help her out in other way and are involved in her care. Her granddaughter manages her medicines. Otherwise pt can perform all ADLS. Ambulates with walker. She is functionally illiterate, and her family has to read meds for her. Family History: Per OMR, unable to verify with patient: There is no family history of premature coronary artery disease or sudden death. Previous discharge summaries indicate that she has 2 sons s/p MI, one deceased from MI; patient cannot tell me her family history except maybe her husband's side had heart disease. Physical Exam: VS: T 98.2 HR 50 BP 124/60 RR 20 Sat 98% 2L NC Gen: Elderly woman in NAD Eye: extra-occular movements intact, pupils equal round, reactive to light, sclera anicteric, not injected, no exudates ENT: mucus membranes moist, no ulcerations or exudates Neck: no thyromegally, JVD: flat Cardiovascular: bradycardic but regular rhythm, normal s1, s2, no murmurs, rubs or gallops; unable to reproduce chest pain on exam Respiratory: Clear to auscultation bilaterally, no wheezes, rales or rhonchi with good distal air movement Abd: Soft, non tender, non distended, no heptosplenomegally, bowel sounds present Extremities: No cyanosis, clubbing, edema, joint swelling Neurological: Alert and oriented x'hospital' and '[**2017**]' but nothing else, not able to recall names of children or HCP, CN [**Name2 (NI) 12428**] intact, normal attention, sensation normal, speech fluent, motor [**4-9**] UE/LE bilaterally Integument: Warm, moist, no rash or ulceration Psychiatric: appropriate, pleasant, not anxious Hematologic: no cervical or supraclavicular LAD Pertinent Results: Admission labs: wbc 4.5 (N 88%), hct 33.0, plt 164 bmp: 140, 4.3, 107, 27, 27, 1.6 (baseline 1.3-1.5), 88, ck 29, mb not done, trop <0.01 lactate 2.6 [**2109-9-8**] 4:50 pm BLOOD CULTURE #1. **FINAL REPORT [**2109-9-14**]** Blood Culture, Routine (Final [**2109-9-14**]): ESCHERICHIA COLI. FINAL SENSITIVITIES. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI | AMPICILLIN------------ =>32 R AMPICILLIN/SULBACTAM-- 16 I CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CEFUROXIME------------ 4 S CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- =>16 R Anaerobic Bottle Gram Stain (Final [**2109-9-9**]): GRAM NEGATIVE ROD(S). REPORTED BY PHONE TO [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **],MD [**2109-9-9**] 09:20AM. [**2109-9-9**] 11:31 am URINE Source: Catheter. **FINAL REPORT [**2109-9-10**]** URINE CULTURE (Final [**2109-9-10**]): NO GROWTH. Surveillance cultures of [**9-10**] and [**9-11**] no growth to date as of discharge. ECG: paced 50, lbbb pattern, unchanged from prior, repeat done with complaint of chest pain unchanged. CXR [**2109-9-8**]: portable: wet read: no acute process. Brief Hospital Course: [**Age over 90 **] yo woman with fever, [**Age over 90 **], chest pain. 1. Fever/septicemia - likely urinary source as c/s same from urine and blood. Picc line placed and 14 day course of cefepime initiated. 2. Unstable angina on history of stable angina, severe 3 vessel coronary disease: Medically managed after consultation with cardiology and in discussion with patient and health care proxy. Pt and proxy do not want any interventions - medical management only. She was put on an unfractionated heparin drip for 48 hours and mediations were optimized. Recurrent episodes of pain with lateral ST segement depressions responsive to IV morphine and sublingual nitroglycerine. 3. CKD and acute renal failure - improved to baseline through hospitalization. Other chronic issues listed in PMHx. remained stable throughout this admission with continuation and titration of home medication regimen. New medication regimen and list attached below. DNR/DNI Medications on Admission: Per OMR, unable to verify with patient: Clopidogrel 75 mg PO DAILY Nitroglycerin 0.4 mg Sublingual PRN (as needed) as needed for chest pain. Ranitidine HCl 150 mg PO BID Aspirin 81 mg PO DAILY [**Age over 90 **] 500 mg SR 12 PO BID (2 times a day). Fluticasone 110 mcg/Actuation 1 puff DAILY (Daily). Albuterol Sulfate 90 mcg [**12-7**] Inhalation every six (6) hours as needed for shortness of breath or wheezing. Acetaminophen 1000 mg PO Q8H (every 8 hours) as needed for Pain. Cholecalciferol (Vitamin D3) 400 unit PO DAILY (Daily). Lidocaine 5 %(700 mg/patch) EVERY 12 HOURS as need for pain. . Isosorbide Mononitrate 120 mg SR PO once a day. Carvedilol 6.25 mg twice a day. senna daily colace 100mg [**Hospital1 **] Discharge Medications: 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 6. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for fever or pain. 7. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Isosorbide Mononitrate 60 mg Tablet Sustained Release 24 hr Sig: Two (2) Tablet Sustained Release 24 hr PO DAILY (Daily). 9. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily): on 12 hours, off 12 hours. 10. [**Hospital1 **] 500 mg Tablet Sustained Release 12 hr Sig: One (1) Tablet Sustained Release 12 hr PO bid (). 11. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb Inhalation Q6H (every 6 hours) as needed for SOB. 12. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Fluticasone 110 mcg/Actuation Aerosol Sig: One (1) Puff Inhalation [**Hospital1 **] (2 times a day). 14. Losartan 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 15. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet, Sublingual Sublingual PRN (as needed) as needed for chest pain: one tablet every 5 minutes as needed for chest pain, max three doses. 16. Carvedilol 12.5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 17. Cefepime 1 gram Recon Soln Sig: One (1) gram Injection Q24H (every 24 hours) for through [**9-22**] then stop days: Through [**9-22**] THEN DISCONTINUE. 18. Morphine 10 mg/mL Solution Sig: 2-4 mg Intravenous every four (4) hours as needed for chest pain. Discharge Disposition: Extended Care Facility: [**Hospital3 537**]- [**Location (un) 538**] Discharge Diagnosis: Septicemia from urosepsis with E. Coli. Unstable Angina Stable Angina Chronic Kidney Disease Anemia of CKD and chronic disease Discharge Condition: Stable, chest pain free, picc line in place for antibiotics. Discharge Instructions: Return to the [**Hospital1 18**] Emergency Room for severe, intratable, chest pain not managed with prn medications as described below Followup Instructions: Provider: [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2109-10-8**] 9:00 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 94291**], M.D. Date/Time:[**2109-10-8**] 10:00 Name: [**Known lastname 16078**],[**Known firstname **] [**Female First Name (un) 16079**] Unit No: [**Numeric Identifier 16080**] Admission Date: [**2109-9-8**] Discharge Date: [**2109-9-16**] Date of Birth: [**2018-7-29**] Sex: F Service: MEDICINE Allergies: Ace Inhibitors Attending:[**First Name3 (LF) 128**] Addendum: Note updated medication list. Morphine prn for chest pains not adequately controlled by nitro, changed to oral liquid(for rapid relief). Discharge Medications: 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 6. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for fever or pain. 7. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Isosorbide Mononitrate 60 mg Tablet Sustained Release 24 hr Sig: Two (2) Tablet Sustained Release 24 hr PO DAILY (Daily). 9. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily): on 12 hours, off 12 hours. 10. Ranolazine 500 mg Tablet Sustained Release 12 hr Sig: One (1) Tablet Sustained Release 12 hr PO bid (). 11. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb Inhalation Q6H (every 6 hours) as needed for SOB. 12. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Fluticasone 110 mcg/Actuation Aerosol Sig: One (1) Puff Inhalation [**Hospital1 **] (2 times a day). 14. Losartan 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 15. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet, Sublingual Sublingual PRN (as needed) as needed for chest pain: one tablet every 5 minutes as needed for chest pain, max three doses. 16. Carvedilol 12.5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 17. Cefepime 1 gram Recon Soln Sig: One (1) gram Injection Q24H (every 24 hours) for through [**9-22**] then stop days: Through [**9-22**] THEN DISCONTINUE. 18. Morphine 10 mg/5 mL Solution Sig: Two (2) mg PO Q4H (every 4 hours) as needed for chest pain. Discharge Disposition: Extended Care Facility: [**Hospital3 474**]- [**Location (un) 164**] [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 131**] MD [**Last Name (un) 132**] Completed by:[**2109-9-16**]

[ "787.20", "715.89", "493.90", "038.42", "272.4", "338.29", "285.29", "276.2", "411.1", "294.8", "414.01", "553.3", "599.0", "V15.82", "585.3", "V45.01", "412", "584.9", "403.90", "427.31", "562.10" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

12812, 13040

6134, 7097

253, 260

9957, 10020

4512, 4512

10203, 10954

3127, 3431

10977, 12789

9807, 9936

7123, 7847

10044, 10180

3446, 4493

182, 215

288, 1315

4528, 6111

1337, 2416

2432, 3111

31,312

178,999

47661

Discharge summary

report

Admission Date: [**2168-9-20**] Discharge Date: [**2168-9-21**] Date of Birth: [**2109-11-28**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 338**] Chief Complaint: s/p intoxication Major Surgical or Invasive Procedure: none History of Present Illness: HPI: 58M h/o NF1, SVT, CAD s/p stent, chronic EtOH abuse, depression and anxiety presenting with intoxication. The patient was found wandering the streets and brought in for intoxication. He had no signs of trauma. He was thought to be EtOH intoxicated, but his ETOH screen was negative. He then admitted to drinking [**12-1**] bottle of isopropyl alcohol. . In the ED his initial vitals were T 97.4, BP 122/78, HR 60, RR 22, O2sat 95% RA. He did vomit in the ED x1 per notes. He was given thiamine, folate, and MVI and lorazepam per CIWA scale. He was being admitted to the floor when he developed developed afib with RVR with rates in the 160s. He was given lopressor 5mg x3 with little effect and then dilt 5mg x1 which broke the rapid rate. His blood pressure never dropped with the tachycardia. He was placed on 4L oxygen NC for comfort given tachycardia. He is being transferred to the MICU for close monitoring for withdrawl. . Currently, he denies chest pain, SOB, palpitations, n/v, fevers, chills, dysuria, constipation, diarrhea, muscle pains or aches, headaches or change in vision. He endorses cough. Past Medical History: -- HTN -- CAD s/p RCA stent in [**8-/2164**] -- s/p closed fract tib/fib -- SVT (AVRT v. AVNRT) -- Chronic EtOH abuse (no h/o seizures; s/p detox 3 years ago, referred to [**Hospital1 1680**] house partial hospitalization program [**5-5**]) -- Depression/anxiety ([**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 66064**] [**Numeric Identifier 100681**] @ [**Hospital1 1680**] JP; [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 12528**] [**Telephone/Fax (1) 5260**]) -- Neurofibromatosis - dx on last admission Social History: Unemployed, living alone in [**Location (un) **] MA. Graduated from [**University/College 72402**]with a major in business, most recent work was as a security guard. Originally from [**Hospital1 40198**] MA. No siblings or other family. Denies illicit drugs. The patient has been drinking chronically since the mid [**2150**]'s. He was sober from [**2157**]-[**2160**]. In addition, he was sober from [**Month (only) 116**] to [**2167-10-30**], but relapsed after losing his job. He has had multiple blackouts, but denies history of w/d seizure or DT's. He denies any history of illicit drug use. He quit smoking 20 years ago, and smoked [**4-3**] cigs/day at that time. Family History: Mother with depression and CAD. Physical Exam: vitals: T 97.9, BP 121/71, HR 92, RR 14, O2sat 98% 4L NC General: lying in bed with eyes closed but answering questions appropriately HEENT: MMM, edematous lips, PERRL, EOMI Cardiac: RRR no murmur appreciated Pulmonary: CTAB no w/r/r Abdomen: +BS, soft, NTND Extremities: warm, dirt under fingernails. Strong pulses DP2+ symmetric, radial 2+ symmetric Skin: multiple small cutaneous neurofibromas. Several cafe-[**Name Prefix (Prefixes) **]-[**Last Name (Prefixes) 28584**] spots noted. Pertinent Results: [**2168-9-21**] 04:21AM BLOOD WBC-4.0 RBC-4.54*# Hgb-13.3*# Hct-40.1 MCV-88 MCH-29.4 MCHC-33.2 RDW-16.0* Plt Ct-255 [**2168-9-20**] 03:36AM BLOOD PT-12.1 PTT-27.4 INR(PT)-1.0 [**2168-9-21**] 04:21AM BLOOD Glucose-98 UreaN-11 Creat-1.2 Na-139 K-4.4 Cl-107 HCO3-23 AnGap-13 [**2168-9-20**] 03:36AM BLOOD ALT-19 AST-22 LD(LDH)-161 CK(CPK)-77 AlkPhos-91 TotBili-0.5 . CXR [**9-20**]: Comparison study of [**9-5**], there is again elevation of the right hemidiaphragmatic contour with atelectatic changes at the right base. The remainder of the right lung and the left lung are essentially clear. Brief Hospital Course: Assessment/Plan: 58 M h/o NF1, SVT, CAD s/p stent [**2163**], chronic EtOH abuse, depression and anxiety presenting with intoxication. . # Isopropyl alcohol ingestion: Patient admits to ingestion of isopropyl alcohol and had large amounts of acetone (metabolite) in the blood. He initially had a gap acidosis (AG 18) which resolved with fluid hydration. Initially put on a CIWA scale out of concern for etoh withdrawal, although this did not develop during this hospitalization. He was advised to not ingest further isopropyl EtOH in the future. SW was consulted and offered him placement in [**Hospital1 **] House which he had been at in the past. . # Afib/Tachycardia: h/o SVT (AVRT vs. AVNRT). He had rate of 160s in the ED which broke with diltiazem. [**Month (only) 116**] have been mediated by med non-compliance vs etoh induced. Continued bblocker in-house without further recurrence of symptoms. . # Mild ARF: Had slight elev of Cr to 1.3 from baseline of 0.9. Partially resolved with IVF hydration to 1.2 at discharge. Initially held ACE which was restarted on discharge. Asked for patient to follow up with his PCP to have creatinine rechecked as an outpatient next month to ensure resolution to baseline. . # CAD: s/p stent [**2163**]. No acute issue. Continued ASA, statin, beta-blocker during his admission. . # Neurofibromatosis 1: diagnosed recently. Stable. . # Brain lesion: likely glioma per Dr. [**Last Name (STitle) 724**] (neuro-onc) note but slow growing. Seen by Dr [**Last Name (STitle) 724**] while here who stated that.... . # Anxiety/Depression: Has been on Celexa/Seroquel in past - continued during this hospitalization. To follow up with Dr. [**Last Name (STitle) **] at [**Hospital6 **] for further psychiatric issues. . # Hypertension: Initially held ACE, and continued BBlocker. ACE restarted on day of discharge. . # Communication (Per OMR): [**Name (NI) **] [**Name (NI) **] (HCP, neighbor) [**Telephone/Fax (1) 100683**] . DISPO - Patient discharged to f/u with his PCP as scheduled. Medications on Admission: Medications (from last d/c summary): -Thiamine HCl 100 mg Tablet PO DAILY -Folic Acid 1 mg Tablet PO DAILY -Hexavitamin TabletPO DAILY -Atorvastatin 10 mg Tablet PO DAILY -Lisinopril 5 mg Tablet PO DAILY -Atenolol 100 mg Tablet PO once a day Discharge Medications: 1. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day. 3. Atenolol 100 mg Tablet Sig: One (1) Tablet PO once a day. 4. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily). 5. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 8. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Tablet(s) 9. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: Isopropyl alcohol intoxication Atrial Fibrillation now resolved Mild acute renal failure now resolved Discharge Condition: Stable to be discharged home Discharge Instructions: You were admitted with alcohol intoxication - please avoid drinking further as this will continue to damage your health. Please follow up with the [**Hospital1 **] house to continue your detox program. Please follow up with your primary care doctor and Dr. [**Last Name (STitle) 724**] from neurology to continue to treat your medical problems. Please take medications as indicated below. No changes to your medications were made during this admission. If you develop any concerning symptoms, please contact your doctor or report to the nearest hospital. Followup Instructions: You are scheduled to see your primary care doctor Dr. [**First Name (STitle) **] on [**2168-10-27**] at 2:30pm. Please go to [**Hospital Ward Name 23**] [**Location (un) **] for this apointment. Call [**Telephone/Fax (1) 250**] if you need to reschedule this appointment. Please call Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 724**] at ([**Telephone/Fax (1) 6574**] to schedule a follow up appointment. Completed by:[**2168-9-21**]

[ "427.31", "584.9", "305.01", "414.01", "276.2", "V45.82", "980.2", "237.70", "401.9", "E860.3", "300.4", "191.9" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

6914, 6920

3922, 5955

332, 339

7085, 7116

3306, 3899

7723, 8184

2749, 2782

6249, 6891

6941, 6941

5982, 6226

7140, 7700

2798, 3287

276, 294

367, 1483

6960, 7064

1505, 2045

2061, 2733

20,162

103,394

49401

Discharge summary

report

Admission Date: [**2135-11-11**] Discharge Date: [**2135-11-11**] Date of Birth: [**2071-5-11**] Sex: M Service: MEDICINE Allergies: Oxacillin / Ciprofloxacin Attending:[**First Name3 (LF) 2297**] Chief Complaint: aspirated an apple Major Surgical or Invasive Procedure: bronchoscopy History of Present Illness: 64M with no prior hx of neurological disorders or GI dismotility disorders who presents with a history of choking on an apple the evening of admission. The patient reports that he felt that the apple went down the wrong way. He became short of breath and started wheezing. He reports that at least once a week he has difficulty swallowing. The food gets stuck in the back of his throat as he tries to swallow. He also reports frequent burping. He has never been evaluated by a gastroenterologist. In the ED the patient's vitals were T 98.2, HR 99-108, BP 135/81, RR 14, O2sat 95RA. His physical exam was noteworthy for end expiratory wheezes. . Past Medical History: DM HTN Hyperlipidemia A fib Social History: lives with wife works as French teacher denies tob, EtOH, ivdu Family History: noncontributory Physical Exam: Upon arrival to the [**Hospital Unit Name 153**]: t98.8 bp137/80 hr82 (afib) RR22 o2sat 94% 2LNC GEN: morbidly obese caucasian male in NAD HEENT: MMM, OP clear HEART: irreg, irreg; II/VI holosystic murmur LUSB LUNGS: CTAb/l, no rrw ABD: protuberant, +bs, unable to assess organomegaly EXT: cold, faint dp Pertinent Results: Upon presentation: [**2135-11-11**] 12:05AM GLUCOSE-476* UREA N-25* CREAT-1.5* SODIUM-136 POTASSIUM-4.4 CHLORIDE-98 TOTAL CO2-23 ANION GAP-19 [**2135-11-11**] 12:05AM WBC-9.1 RBC-4.95 HGB-16.2 HCT-46.2 MCV-93 MCH-32.7* MCHC-35.1* RDW-15.0 [**2135-11-11**] 12:05AM NEUTS-82.2* LYMPHS-10.7* MONOS-5.7 EOS-0.7 BASOS-0.7 [**2135-11-11**] 12:05AM PLT COUNT-143* [**2135-11-11**] 12:05AM PT-22.0* PTT-27.5 INR(PT)-2.2* [**2135-11-11**]: Neck xray: Carotid calcifications are seen. No prevertebral soft tissue swelling is noted. Lung apices are clear. No radiopaque foreign body identified. Degenerative changes at several facet joints noted. . [**2135-11-11**]: CXR: No evidence of opaque foriegn body, aspiration or atelectasis [**2135-11-11**]: Flexible Bronchoscopy: few thin secretions medial airway with 2 areas of erythema and mild bleeding above left lower lobe Brief Hospital Course: A: 64M with no known neuro/gi disorders who presents after questionable aspiration on an apple P: 1. Aspiration: The patient presented after aspiration of a small apple piece. His breathing was not significantly challenged. There was no evidence of a radio-opaque foreign body on imaging. He was observed overnight in the ICU. The next day, he coughed out a piece of apple. A follow-up bronchoscopy revealed inflammed airways but no evidence of retained foreign matter. Upon discharge, he was breathing at his baseline. No antibiotics were indicated. He was discharged to follow-up with his primary physician and to discuss referral to a gastroenterologist if he has recurrent swallowing difficulties. . 2.Cardiovascular history: The patient has a history of hypertension and congestive heart failure. His home antihypertensives (ACE inhibitor and beta-blocker) were continued during this hospitalization and no changes were made at discharge. His diuretic regimen continued as well. His aspirin was held prior to undergoing the bronchoscopy. Regarding his history of atrial fibrillation, his coumadin was held overnight prior to the bronchoscopy. He will resume his anticoagulation program with the [**Company 191**] anticoagulation service. He received his home dose of niacin for his hyperlipidemia. . 3. Anxiety: There were no acute issues and the patient received his home dose of Xanax and ativan as needed. . 4. Chronic kidney disease: This is likely due to hypertension and diabetes. There were no acute issues and his creatinine was at his baseline upon presentation. . 5. Diabetes: While in the hospital, his blood sugars were managed with insulin 70:30 and regular insulin sliding scale. Upon discharge, he will resume his former outpatient regimen of insulin 70:30, metformin, and Byetta. . 6. Prophylaxis: He received a PPI and was ambulatory during this admission. . 7. Access: peripheral ivs. . 8. Dispo: to home with instructions to follow-up with his primary physician. Medications on Admission: Insulin 70:30 40 units [**Hospital1 **] Byetta Xanax 0.125 mg po qhs prn Ativan 0.25 mg po qhs prn Metformin 500 mg po qd Coumadin 3.75 mg po qd x 4 days, 2.75 mg po qd x 3days Aspirin 81 mg po qd Aldactone Lasix 80 mg po bid Magnesium tablet Potassium chloride Lopressor 50 mg po bid Lisinopril 5 mg po qd Lipitor 10 mg po qd Niacin Discharge Medications: 1. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Alprazolam 0.25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) as needed. 3. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Furosemide 40 mg Tablet Sig: Two (2) Tablet PO twice a day. 5. Insulin NPH-Regular Human Rec 100 unit/mL (70-30) Suspension Sig: Forty (40) units Subcutaneous twice a day: before breakfast and before dinner. 6. Metformin 500 mg Tablet Sig: One (1) Tablet PO once a day. 7. Aspir-81 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 8. Warfarin 1 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily): take as directed by the [**Hospital3 **]. 9. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 10. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO QEVENING (). 11. Niacin 500 mg Capsule, Sustained Release Sig: Three (3) Capsule, Sustained Release PO BID (2 times a day). 12. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO twice a day: use as directed by your primary doctor. 13. Lorazepam 1 mg Tablet Sig: 1-2 Tablets PO HS (at bedtime). 14. Byetta 5 mcg/0.02 mL Pen Injector Sig: One (1) unit Subcutaneous asdir: as directed by your primary doctor. Discharge Disposition: Home Discharge Diagnosis: Primary: Foreign body aspiration . Secondary: Obesity Hypertension Atrial fibrillation Hyperlipidemia Discharge Condition: good. stable vital signs. tolerating oral medication and nutrition. ambulating unassisted. Discharge Instructions: You have been evaluated and treated for a food aspiration. Your vital signs remained stable. You were monitored in the ICU as a precaution. You were able to cough out the remaining food particle. The bronchoscopy revealed indirect evidence of the aspiration but no evidence of the food particle itself. . If you continue to have trouble swallowing, please contact your primary doctor and discuss referral to a gastroenterologist for further evaluation. . If you develop and worsening cough, chest pain or shortness of breath please seek medical care. . Please make and attend the follow-up appointment as recommended below. . You will resume your home medications as previously prescribed. . In keeping with your history of heart disease you should adhere to the following recommendations: Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs. Adhere to 2 gm sodium diet Fluid Restriction: 2.5 L per day Followup Instructions: Please call your primary medical doctor Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at [**Telephone/Fax (1) 250**] to schedule a follow-up appointment to be seen within the next 1-2 weeks. . Please contact the [**Hospital3 **] [**Name (NI) **] Clinic to arrange your next blood draw.

[ "403.91", "427.31", "272.4", "E911", "934.9", "V58.61", "585.9", "250.40", "300.00", "278.00", "428.0" ]

icd9cm

[ [ [] ] ]

[ "33.23" ]

icd9pcs

[ [ [] ] ]

6102, 6108

2404, 4405

307, 322

6254, 6347

1504, 2381

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1145, 1163

4789, 6079

6129, 6233

4431, 4766

6371, 7300

1178, 1485

249, 269

350, 997

1019, 1048

1064, 1129

63,187

132,488

35869

Discharge summary

report

Admission Date: [**2150-7-2**] Discharge Date: [**2150-8-10**] Date of Birth: [**2097-5-12**] Sex: M Service: SURGERY Allergies: Heparin Agents / doxycycline / Erythromycin Base Attending:[**First Name3 (LF) 2836**] Chief Complaint: pleuro-pancreatic fistula Major Surgical or Invasive Procedure: emergent extended R colectomy and ileostomy History of Present Illness: 53 yo man w/ a hx of pancreatic divesium originially admitted for acute pancreatitis complicated by a pancreato-thraosic fistula status post multiple chest tube placements transferred to the ICU for hypotension. . The patient initially developed pancreatitis 4 years ago. He was a heavy drinker and continues to have more moderate alcohol intake. He has had seven episodes of pancreatitis since then, and has known pancreatic duct stenosis s/p stenting. He acutely developed SOB on [**2150-6-21**] and was found to have bilateral pleural effusions. He was evaluated by Pulmonology, who performed right sided thoracentesis on [**2150-6-30**] and found high amylase levels in the fluid. He improved symptomatically following the thoracentesis, but fluid has rapidlyreaccumulated. He presented to the [**Hospital 2725**] Hospital ED on [**7-2**] and was transferred to [**Hospital1 18**] fo further management. . During his hospitalization he has undergone placement of two chest tubes for drainage of pleural effusions. Last evening he was found to have new temps to 99.1 and a blood pressure falling to 92/49 from a baseline in the 120s prior to that. He was started on vancomycin and zosyn on [**7-8**]. He was scheduled to have an ERCP this morning, but in the holding area began to complain of chest pain (not considerably changed from prior) and found to have systolic pressures in the 80s. [**Hospital Unit Name 153**] team was called for emergent transfer. Prior to transfer to the unit the patient recieved 1L of LR to which his blood pressure had not responded, but the patient was mentating well and was in no acute distress. . Vitals upon arrival to the [**Hospital Unit Name 153**] were: . Patient was given a total of 4 L of LR, broadened to vancomycin and meropenem. A CVL was placed. . Labs prior to transfer were notable for a rise in WBC to 28.3, HCT to 46.1 and platelets to 338 a rise in all cell lines. Chemistries notable for creatinine of 1.1 up from 0.4, glucose of 234 and a sodium of 130 with Ca of 8.7. ALT of 46, AST 63, LDH 213, CK 42, AP of 120 and a Tbili of 1.9. No blood or urine cultures were sent. . Patient is currently complaing of chest pain with deep breaths (unchanged from prior), has had several episodes of loose stool in the past 24-48 hours, no abdominal pain, radiant chest pain, SOB, pain with urination or hematuria. Past Medical History: PAST MEDICAL HISTORY: # Recurrent Pancreatitis -- initially developed 4 years ago -- about 7 episodes since then # Pleural Effusions -- recent development -- tapped on [**2150-6-30**] with rapid recurrence # Suspected Pancreatico-pleural Fistula # Hemochromatosis -- patient unsure of personal history and denies famliy history # Thrombocytopenia # Hypertension # Morbid obesity # Gynecomastia # GERD # Gout -- several prior episodes # Right Ankle ORIF ([**2150-3-30**]) # Tetrahydrofolate Methyltransferase Deficiency # Adrenal mass # Alcohol abuse Social History: # Work: Business manager for electronics firm # Tobacco: Smokes 0.5 PPD for 30 years, none in several days # Alcohol: About 2 drinks daily, none in several days # Drugs: Denies Family History: # Father: CAD, PVD # Mother: Hypertension # Siblings: 3 brothers and 1 sister, all well Physical Exam: 120, 78/45, 20, 98% 4L Fatigued appearing, mentating well, talkative and interactive EOMI, PERRLA, OP clear, MMM dry S1S2 RRR no MRG Left and right chest tube in place, decreased lung sounds at the bases bilaterally. abdomen distented, non-tympanic, non tender to palpation, bed sheets stool soiled Arms grossly swollen bilaterally, right PICC in place, 20 gauge IV in left hand. Pertinent Results: On Admission: [**2150-7-2**] 11:45PM GLUCOSE-106* UREA N-11 CREAT-0.5 SODIUM-134 POTASSIUM-4.1 CHLORIDE-99 TOTAL CO2-27 ANION GAP-12 [**2150-7-2**] 11:45PM estGFR-Using this [**2150-7-2**] 11:45PM ALT(SGPT)-14 AST(SGOT)-22 ALK PHOS-109 TOT BILI-2.3* [**2150-7-2**] 11:45PM LIPASE-389* [**2150-7-2**] 11:45PM ALBUMIN-3.0* CALCIUM-8.8 PHOSPHATE-2.8 MAGNESIUM-1.7 [**2150-7-2**] 11:45PM WBC-12.0* RBC-3.91* HGB-14.2 HCT-41.3 MCV-106* MCH-36.3* MCHC-34.4 RDW-13.6 [**2150-7-2**] 11:45PM NEUTS-71.3* LYMPHS-13.9* MONOS-5.7 EOS-8.9* BASOS-0.3 [**2150-7-2**] 11:45PM PLT COUNT-215 Imaging: KUB [**2150-6-8**]: Prelim- pneumatosis R colon CT TORSO [**2150-7-8**]: 1. Multiloculated, partially contiguous fluid collections as well as necrotic appearing lymph nodes in the upper abdomen extending cranially through the esophageal hiatus along the posterior mediastinum, increased in size since prior studies. 2. Loculated pleural effusions bilaterally, decreased in size with three new chest tubes in place. The left base chest tube is in the fissure. 3. Stable tiny right pneumothorax. 4. Stable left upper lobe/lingular opacities consistent with pneumonia. 5. Multiple right sided rib fractures, some which appear to be non-healing or more acute in nature. Brief Hospital Course: 53 yo w/ hx of pancreatic divisum admitted on [**7-2**] for recurrent pleural effusions concerning for pancreaticopleural fistula. He had multiple chest tube placements for drainage of the pleural effusions. On [**7-10**], he was transferred to the ICU for hypotension and sepsis picture that developed prior to planned ERCP. He was resuscitated but failed to improve and thus required an ex-lap on [**7-10**], with preop diagnosis of infected pancreatic necrosis. However, he was found to have an ischemic right colon and underwent an emergent exteneded R colectomy with ileostomy. Neuro: The patient was sedated while intubated in the ICU. While on the floor, his pain was well controlled with dilaudid. Pulm: The patient was intubated for his operation and remained intubated. He had one failed extubation which required re-intubation before he was permanently extubated. He was also found to have a fungal pneumonia. Please see ID section. CV: In the ICU, the patient presented with blood pressures in the 70s systolic though mentating well. Differential included sepsis likely intrabdominal source but respiratory pathogens also possible, hypovolemia in the setting of inadequate volume resuscitation for acute pancreatitis, acute pneumothorax or hemorragic conversion of pancreatitis/thorasic fistula, or aortic pathology given new pnemuomediastinum seen on CT torso. Less likely is an acute coronary syndrome; EKG no evidence of ischemia. He also required pressors in the ICU, however, he was stabilized from a cardiovascular and pulmonary standpoint before being transferred out of the ICU to the floor. AFIB: A fib newly developed in the setting of acute sepsis/hypovolemia. Nodal agents were held while patient became adequately volume resusitated. GI: After his operation, the patient was placed on TPN. In the ICU, a post-pyloric dobhoff was placed and the patient was started on Vivonex tube feeds. His lipase was found to be elevated and this was attributed to the dobhoff no longer being post-pyloric. It was again advanced post-pylorically. His tubefeeds were changed to Replete and then Isosource that have increased fiber content, however, his lipase continued to rise. He was placed back on Vivonex and his lipase trended back down. He also was found to have high ostomy output (>1000/24hours). He was started on tincture of opium and loperimide 2mg QID, which had good effect in bringing down his ostomy output. Renal: The patient's creatinine reached a maximum of 1.1. In the ICU, he was anasarctic. He was adequately resuscitated and and received lasix appropriately to remove excess fluid. ID: The patient was found to have a fungal pneumonia ([**Female First Name (un) **] ALBICANS) and was treated with various antibiotic regimens which included fluconazole and micafungin. He was also found to have VRE in his abdominal fluid cultures. He was placed on contact and started on linezolid from ([**Date range (1) 81521**]). Rheumatology: The patient, who has a history of gout, began to have an acute gout flare in his L wrist and bilateral knees starting the week of [**8-3**]. He was started on colchicine 0.6 [**Hospital1 **], which helped to improve his pain and symptoms. At the time of Discharge the patient was ambulatory, at his baseline mental status, getting sufficient nutrition support, and endorsed understanding of his discharge plan and follow-up. Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from PatientwebOMR. 1. benazepril *NF* 20 mg Oral DAILY 2. Omeprazole 20 mg PO BID 3. Leucovorin Calcium 20 mg PO DAILY 4. Creon 12 1 CAP PO TID W/MEALS 5. Multivitamins 1 TAB PO DAILY 6. Pyridoxine 50 mg PO DAILY Discharge Medications: 1. Albuterol 0.083% Neb Soln 1 NEB IH Q6H 2. Colchicine 0.6 mg PO BID 3. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush PICC, non-heparin dependent: Flush with 10 mL Normal Saline daily and PRN per lumen. 4. Sarna Lotion 1 Appl TP QID:PRN itchy skin on back 5. Insulin SC Sliding Scale Fingerstick QACHS Insulin SC Sliding Scale using REG Insulin 6. Loperamide 2 mg PO QID 7. Ipratropium Bromide Neb 1 NEB IH Q6H 8. Lorazepam 1-2 mg IV Q4H:PRN anxiety 9. Octreotide Acetate 100 mcg SC Q8H 10. Opium Tincture 10 DROP PO Q6H 11. OxycoDONE Liquid 5-15 mg PO Q4H:PRN pain 12. Pantoprazole 40 mg IV Q24H 13. Multivitamins 1 TAB PO DAILY Discharge Disposition: Extended Care Facility: [**Hospital6 1293**] - [**Location (un) 1294**] Discharge Diagnosis: Alcoholic Pancreatitis Chronic Pancreatitis Ischemia of Right Colon Fungal Pneumonia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent, deconditioned. Discharge Instructions: 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. . General Discharge 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 [**4-2**] 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. Followup Instructions: It is important that you follow up with us to ensure your continued health. An appointment has been made for you with [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3000**], MD Phone:[**Telephone/Fax (1) 274**] Date/Time:[**2150-8-28**] 8:30 Please arrive early the morning of your appointment to have your blood drawn on [**Hospital Ward Name 23**] 5. It is important for you to follow up with the [**Hospital 2225**] Clinic for your gout management. An appointment has been made for you with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at 1030 on [**8-28**]. The information will be mailed to you. If you have any questions, concerns or need to reschedule he can be reached at ([**Telephone/Fax (1) 1668**] You were treated for a Pancreatic-pleural fistula while in the hospital, it is important that you follow up with a pulmonologist. An appointment has been made for you with Dr. [**Last Name (STitle) **] on [**9-7**] at 3pm. If you have any questions, concerns or need to reschedule, please call: ([**Telephone/Fax (1) 513**] Completed by:[**2150-8-11**]

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icd9cm

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icd9pcs

[ [ [] ] ]

9784, 9858

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333, 378

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268, 295

406, 2778

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10002, 10129

2822, 3353

3369, 3548

69,483

150,024

52001

Discharge summary

report

Admission Date: [**2168-6-14**] Discharge Date: [**2168-6-29**] Service: MEDICINE Allergies: Codeine / Vasotec / Cortisporin / Ciloxan / Atenolol / Lisinopril / Diovan Attending:[**First Name3 (LF) 2698**] Chief Complaint: Dyspnea Major Surgical or Invasive Procedure: [**6-22**] cardiac catheterization s/p BMS to Left Anterior Descending artery History of Present Illness: 86 year old female who called EMS on [**2168-6-14**] for acute onset of dyspnea. She was in her usual state of health until dinner when she was too nauseous to eat and then became acutely short of breath. Upon reflection she has had increasing fatigue in the past few days as well as some slight increases in SOB. She reports strict adherance to medications and diet restrictions (no salt, no sugar, limits fluid intake). While being transported she was placed on BiPAP and BP was noted to be 180/120. In the ED she taken off BiPAP and weaned down to 4L. She continued to be dyspneic although her blood pressure did improve slightly. . Of note she was recently admitted for weakness and malaise and found to be hyperkalemic to 7.8 with ECG changes and a Cr of 3.7. This was thought to be related to either lisinopril or Bactrim. Her cr then returned to baseline and her K has been stable aroung 5. . In the ED, initial VS were: 87, 157/45, 26, 94% RA . On the floor, she was increasingly short of breath and tachypeniac. She was very anxious about her breathing. She notes a 5 lbs weight gain over the past 5 days. . Review of systems: (+) Per HPI , also with cough, occasional constipation. (-) Denies fever, chills, night sweats, Denies headache, sinus tenderness, rhinorrhea or congestion. Denied chest pain or tightness, palpitations. Denied vomiting, diarrhea, or abdominal pain. No recent change in bowel or bladder habits. No dysuria. Denied arthralgias or myalgias. Past Medical History: 1. Coronary artery disease status post inferior myocardial infarction in [**2157**], which was treated with balloon angioplasty of the RCA. This was complicated by an RCA dissection. 2. Recent cardiac catheterization in [**1-19**] secondary to resting angina associated with positive troponin and anterior lateral ST depression. Study noted a heavily calcified LAD with diffuse disease throughout as well as a left circ with diffusely diseased small OM1 and small OM2 with 50% stenosis at the origin as well as diffuse disease through the AV groove into OM3 side branch with 70% stenosis in the lower pole, all of which was unfavorable to PCI. 3. Combined diastolic and systolic heart failure. Most recent EF: 40% per cards note. 4. Peripheral arterial disease with a left superior femoral artery angioplasty complicated by dissection requiring stent in [**6-18**] as well as left common iliac and external iliac artery stenting in [**Month (only) 547**] of 06. 5. Hypertension 6. Dyslipidemia 7. Diabetes 8. Baseline chronic kidney disease with a recent episode of acute renal failure secondary to treatment with an ACE inhibitor for which she was hospitalized in early [**Month (only) 547**]. Social History: The patient currently lives in [**Location 745**] with her [**Age over 90 **] year old husband. She has 1 son who lives in [**Name (NI) 701**]. At baseline she walks with a cane, she is otherwise independent in all ADLs. Tobacco: None ETOH: None Illicits: None Family History: -Father: heart problems, DM -Mother: heart problems -4 brothers: CAD, one with stroke Physical Exam: Vitals: T: 97.4, BP: 157/57, P: 88, R: 26, O2: 94% 4L General: Alert, oriented, mild/moderate respiratory distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple. Lungs: +wheezes, +rhales, occ rhonchi, decreased BS at bases. CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CN II- XII intact. Pertinent Results: Admission labs: [**2168-6-14**] 08:30PM GLUCOSE-154* UREA N-82* CREAT-1.9* SODIUM-140 POTASSIUM-5.3* CHLORIDE-106 TOTAL CO2-20* ANION GAP-19 [**2168-6-14**] 08:30PM CK(CPK)-109 [**2168-6-14**] 08:30PM CK-MB-13* MB INDX-11.9* cTropnT-0.11* proBNP-7428* [**2168-6-14**] 08:30PM LACTATE-0.8 [**2168-6-14**] 08:30PM WBC-10.8 RBC-2.95* HGB-9.5* HCT-28.9* MCV-98 MCH-32.1* MCHC-32.8 RDW-15.7* [**2168-6-14**] 08:30PM NEUTS-84.7* LYMPHS-9.2* MONOS-5.1 EOS-0.8 BASOS-0.2 [**2168-6-14**] 08:30PM PT-11.4 PTT-26.7 INR(PT)-0.9 [**2168-6-14**] 08:30PM PLT COUNT-188 . Labs on Discharge [**6-29**]: [**2168-6-29**] 06:38AM BLOOD WBC-9.2 RBC-3.14* Hgb-9.6* Hct-28.6* MCV-91 MCH-30.6 MCHC-33.7 RDW-16.9* Plt Ct-421 [**2168-6-29**] 06:38AM BLOOD Glucose-38* UreaN-74* Creat-1.7* Na-146* K-3.7 Cl-102 HCO3-37* AnGap-11 [**2168-6-29**] 06:38AM BLOOD Calcium-8.8 Phos-3.2 Mg-2.5 . [**6-20**] DUPPLEX ABD/PELVIS No hydronephrosis and no renal stone or mass identified. There is a discrepancy in the peak systolic velocities of the main renal artery bilaterally. The right main renal artery measures 85 cm/sec and the left main renal artery measures about 50 cm/sec. Additionally, minimal diastolic to no diastolic flow is seen in the waveforms bilaterally. These findings are of uncertain clinical significance but a renal artery stenosis cannot be excluded. An MRA could be performed if clinically indicated. [**6-22**] CARDIAC CATHETERIZATION: Initial angiography revealed a heavily calcified 80% proximal LAD stenosis. We planned to perform PTCA and stenting. Heparin was started prophylactically. A 6 French XB LAD 3.5cm guiding catheter provided good support for the procedure. A Prowater wire crossed the stenosis with minimal difficulty however it was unable to be positioned distally in the LAD so it was advanced in a diagonal branch. The stenosis was dilated with a 2.5 x 8mm Quantum Maverick balloon at 12 ATM. A 2.5 x 12mm Mini Vision stent was deployed in the proximal LAD at 16 ATM. The stent was postdilated with a 2.75 x 8mm Quantum Maverick balloon at 14 ATM. Final angiography revealed no residual stenosis, no angiographically apparent Brief Hospital Course: Ms. [**Known lastname **] is a pleasant 86 year old lady with known CAD, CHF (EF ~40%), PAD, HTN, DM who presented with acute onset of shortness of breath. 1. SOB/CHF Excerbation: Patient's presentation consistent with worsening of chronic CHF. Her BNP is elevated. She has history of weight gain. Her CXR is consistent with volume overload. Unclear what has made her worse in the past few days. On arrival to the floor, the patient was initially stable, but then became more dyspneic. She was given another 80mg of IV lasix, low-dose Morphine and seemed to stabilize, having put out 1.6 liters. Her oxygen sats improved, but later she was found to be unresponsive. Repeat ABG showed a stable CO2, and she was transferred to the CCU for further management. In the CCU, she was placed on a lasix gtt for diuresis and nitro gtt for BP control. Repeat chest x-ray showed continued pulmonary edema and LLL atelectasis vs. pneumonia. In the abscence of fever or leukocytosis, antibiotics were not continued in the CCU. Urine output was not optimal on lasix gtt and diuresis was changed to Lasix IV bolus and metolazone [**Hospital1 **]. Patient diuresed well with improvement in her shortness of breath and oxygenation. Repeat echo showed stable EF 35-40% with hypokinesis of the inferior wall, septal and apical segments (multivessel CAD). During her acute CHF exacerbation, she had wheezing on exam that were treated with nebulizer treatments and cough that was managed symptommatically with anti-tussives. Post-catheterization she continued on her home dose of lasix 40mg daily and appeared euvolemic to somewhat dry clinically. Thus her lasix dosage was reduced to 20mg daily. She does not tolerate ACE/[**Last Name (un) **] because of hyperkalemia so she was restarted on her home [**Last Name (un) 4319**] of Hydralazine/Isordil. . 2. Non ST Elevation Myocardial Infarction: Mrs. [**Known lastname **] has documented diffuse disease from previous catheterization in [**1-/2168**] that is not well situated for PCI. On transfer to CCU, EKG showed T wave flattening in I,II,V5,V6 which were not present on previous EKG prior to transfer. Cardiac enzymes were cycled and determined to be elevated; treatment for NSTEMI initiated. She was placed on heparin gtt for 48 hours. Due to previous hyperkalemia associated with ACE inhibitors, and ACE-I or [**Last Name (un) **] was not started. Carvedilol was titrated as tolerated; hydralazine was titrated as tolerated; long acting nitrate was used when nitro gtt not required, clonidine was down-titrated and discontinued. After review of previous cardiac cath films, decision was made to go for cardiac catheterization. Catheterization showed a right dominant system, LAD with prox focal 80% disease, and left circ with mild diffuse disease. She received a BMS to LAD and received 70mL contrast. The procedure was done via the right radial approach. Post-procedure she developed left lower quadrant pain. Non-contrast abdomen pelvis showed a spontaneous 7x7x13cm left rectus sheath hematoma (see below). Heparin IV and Coumadin PO was discontinued, she had received total of 2 [**Last Name (un) 4319**] of coumadin before the bleed. She was continued on aspirin 325mg, plavix 75mg, and statin. . 3. RECTUS SHEATH HEMATOMA: Post-cardiac catheterization on [**2168-6-23**] she developed left lower quadrant pain. Non-contrast abdomen pelvis showed a 7x7x13cm left rectus sheath hematoma. The heparin drip was stopped. She was hemodynamically stable throughout. She was transfused a total of 3 units of blood over the next several days to maintain a hematocrit >25. There was initially concern for hemolysis given limited bump in hematocrit but haptoglobin was elevated. Blood bank testing revealed partial D for Rh factor and further units of blood were irradiated. At discharge, there was no clinical evidence of further bleeding and her hematocrit was 28.6 (last transfusion being [**2168-6-27**]). Her abdominal pain was controlled with PO dilaudid (morphine not given due to renal function) and was improving at discharge. She has an outlined area on left lower quadrant with some swelling and resolving tenderness, also has diffuse ecchymosis and tenderness in both groins. . 4. ATRIAL FIBRILLATION: Mrs. [**Known lastname **] developed new atrial fibrillation during her admission. Her rate was well controlled with uptitrated dose of coreg. She was initially anticoagulated on heparin and coumadin(see above). But given the rectus sheath hematoma this was stopped. On telemetry she her rhythm was noted to flip between atrial fibrillation and sinus rhythm. . 5. ACUTE ON CHRONIC KIDNEY DISEASE: Creatinine at baseline appears to be 1.3-1.8 when she was initially admitted it was elevated but within her baseline. This was likely elevated secondary to poor forward flow as well as [**Known lastname 1106**] renal disease. No ace inhibitor or [**Last Name (un) **] was given [**3-15**] to history of previous adverse effect (hyperkalemia) when on these medications. Prior to cathaterization, Mrs. [**Known lastname **] recieved mucomyst. Post catheterization her creatinine increased to 2.6, which was thought to be to contrast induced nephropathy. At the time of discharge her creatinine had returned to baseline value of 1.7. . 6. HTN: Blood pressure was elevated on admission, and likely part of precipitant of acute worsening of dyspnea causing flash pulmonary edema precipitating transfer to CCU. Originally continued outpatient regimen, but in setting of NSTEMI, opted to taper and discontinued clonidine; titrated carvedilol, long acting nitrate, hydralazine as tolerated. Amlodipine was up-titrated to 10mg from outpatient dose of 5mg daily. . 7. DIABETES: Continue home insulin glargine plus sliding scale, with adjustments made as required based on PO intake. Medications on Admission: amlodipine 5 mg daily carvedilol 3.125 mg tablets b.i.d. clonidine 0.2 mg b.i.d. clopidogrel 75 mg daily furosemide 40 mg daily hydralazine 25 mg t.i.d. insulin glargine 46 U daily NovoLog SS COmbivent INH Lidocaine patch isosorbide mononitrate 30 mg t.i.d. lorazepam 0.5 mg p.r.n. b.i.d. simvastatin 20 mg daily aspirin 325 mg daily Ascorbic acid 500mg SR daily calcium carbonate 1000mg q6 vit D 1000mg daily B-12 1000mcg daily Multivit omega 3 Discharge Medications: 1. Outpatient Lab Work Please check CBC and chem 7 on Friday [**7-1**]. 2. Amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day. 3. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain. 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 5. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO HS (at bedtime). 6. Cholecalciferol (Vitamin D3) 1,000 unit Tablet Sig: One (1) Tablet PO once a day. 7. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times a day): with meals. 8. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily): apply to affected areas. 10. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day. 11. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Cyanocobalamin 1,000 mcg Tablet Sig: One (1) Tablet PO once a day. 13. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 14. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as needed for insomnia. 15. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO once a day. 16. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 17. Carvedilol 25 mg Tablet Sig: One (1) Tablet PO twice a day. 18. Isosorbide Dinitrate 10 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day). 19. Hydralazine 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 20. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. 21. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Extended Care Facility: Newbridge on the [**Doctor Last Name **] - [**Location (un) 1411**] Discharge Diagnosis: PRIMARY: Acute on chronic Systolic congestive heart failure Spontaneous Abdominal rectus bleed Coronary artery disease hypertension SECONDARY: diabetes Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: It was a pleasure being involved in your care, Ms. [**Known lastname **]. You had an exacerbation of your congestive heart failure and required strong diuretics to remove fluid. You also had a cardiac catheterization and a bare metal stent was placed in your left anterior coronary artery to open a blockage. After the catheterization, you had a spontaneous bleed into your abdominal cavity from the combination of heparin and coumdin. These medicines were stopped and you received units of blood to treat your anemia. This bleed now appears to be resolving. You had a heart arrhythmia called atrial fibrillation while you were in the hospital. You are now back in a normal sinus rhythm but the atrial fibrillation will probably come back at some point. We made the following changes to your medicines: 1. Increase Amlodipine to 10 mg daily to decrease your blood pressure. 2. Start Tylenol at 650mg TID for pain control. Please d/c when pain resolved. 3. Start Senna and colace for constipation as needed. 4. Decrease Calcium to 500mg three times a day 5. change Combivent inhaler to Advair diskus to help with wheezes. 6. Start Ranitidine to protect your stomach from aspirin and Plavix. 7. Start Plavix to keep the stent open. Do not stop Plavix or miss [**First Name (Titles) 691**] [**Last Name (Titles) 4319**] for at lease one month unless Dr. [**Last Name (STitle) **] tells you to. 8. Increase Carvedilol to 25 mg twice daily 9. Decrease Furosemide to 20 mg daily 10. Discontinue Vitamin C, Omega 3 pills, Lorazepam amd Clonidine. . Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more than 3 lbs. Followup Instructions: Please keep your follow-up appointments below: Cardiology: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**MD Number(3) 1240**]: [**Telephone/Fax (1) 62**]. [**7-29**] at 11am. [**Hospital Ward Name 23**] [**Location (un) 436**]. [**Location (un) **]: Provider: [**Name10 (NameIs) **] [**Apartment Address(1) 871**] ([**Doctor First Name **]) [**Doctor First Name **] LMOB (NHB) Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2168-7-18**] 11:15 Provider: [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2604**], MD Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2168-7-18**] 11:50 . Primary Care: Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2168-7-22**] 10:50 Completed by:[**2168-7-5**]

[ "585.9", "584.9", "E947.8", "E934.2", "403.90", "285.21", "427.31", "272.4", "285.1", "410.71", "428.0", "250.00", "729.92", "414.01", "440.20", "428.43" ]

icd9cm

[ [ [] ] ]

[ "38.93", "00.40", "00.45", "88.55", "00.66", "36.06", "37.22" ]

icd9pcs

[ [ [] ] ]

14271, 14365

6206, 12042

290, 370

14561, 14561

4027, 4027

16367, 17159

3386, 3473

12538, 14248

14386, 14540

12068, 12515

14712, 16344

3488, 4008

1534, 1873

243, 252

398, 1515

4043, 6183

14576, 14688

1895, 3091

3107, 3370

571

193,189

51449

Discharge summary

report

Admission Date: [**2106-10-12**] Discharge Date: [**2106-10-20**] Date of Birth: [**2050-1-20**] Sex: M Service: CCU CHIEF COMPLAINT: Transferred from outside hospital for stent. HISTORY OF PRESENT ILLNESS: Patient is a 56-year-old male with past medical history of type 1 diabetes since the age of 4 who presents to the [**Hospital 882**] Hospital on [**2106-10-10**] with nausea, vomiting, and hyperglycemia. Patient was found to be in diabetic ketoacidosis with a blood pressure of 72/50, SPO2 of 77% with blood sugars greater than 400, and Kussmaul's breathing. Initial ABG on admission 7.04/13/158. Potassium was 7.6, anion gap was 34. EKG revealed wide QRS complexes. Blood sugars spiked to 1234. Patient was aggressively volume resuscitated with seven liters and OSH q.d. Initial CK was 332 with an MB of 15.5. Troponin 2.93 rose to 52.3. Patient started on insulin drip and sent to the Cath Lab, which revealed 90% occlusion of mid left anterior descending and 30% occlusion of D2. Patient was stabilized and transferred to [**Hospital6 256**] for stent. A cypher stent was placed in the D2, pixel stent in the LAD. PCWP at that time was 7.0. Patient sent to the Cardiac Care Unit for recovery. Denied chest pain. Positive for shortness of breath on 100% nonrebreather, diaphoretic, positive nausea postop. PAST MEDICAL HISTORY: 1. Type 1 diabetes since age 4. 2. Multiple admissions for DKA. 3. On insulin pump for around 10 years. 4. Status post partial gastrectomy. 5. Bipolar disorder. ALLERGIES: No known drug allergies. MEDICATIONS AT HOME: 1. Insulin pump. 2. Luvox 200 mg p.o. q.d. 3. Trazodone 50 mg q. h.s. 4. Zestril 5 mg p.o. q.d. 5. Ativan 0.5 mg p.r.n. SOCIAL HISTORY: Positive tobacco one pack per day; lives with father; unemployed. FAMILY HISTORY: Positive for cerebrovascular accident and coronary artery disease; father-CAD status post coronary artery bypass graft. ADMISSION VITAL SIGNS: Afebrile, 100.3; pressure 147/58, heart rate 97, respirations 20 at 95% on 100% nonrebreather. PHYSICAL EXAMINATION: General: Alert and oriented times three; lying in bed; unable to speak in complete sentences; tachypneic; no acute distress. HEENT: Anicteric; pupils equal, round, reactive to light; extraocular movements intact; mucous membranes dry. Neck: Supple; no bruits; no jugulovenous pressure appreciated. Regular rate, normal S1, S2, no murmurs, rubs, or gallops. Respirations: Diffuse crackles bilaterally; prolonged inspiratory and expiratory; no wheezes appreciated. Abdomen: Soft, nontender, nondistended; positive bowel sounds times four; no hepatosplenomegaly. Extremities: Warm; no clubbing, cyanosis, or edema; 2+ pulses the dorsalis pedis, posterior tibial, and femoral; no bruits. Neuro: Alert and oriented times three. Cranial nerves II-XII grossly intact. Right groin: Status post catheter removal; no hematoma; clean, dry, and intact. LABORATORY DATA ON ADMISSION: ABG 7.5/41/86 on 100% nonrebreather. WBC 19.8, sodium 138, potassium 3.6, chloride 101, bicarbonate 30, BUN 28, creatinine 0.6, glucose 287, anion gap 27. CK is trended 2.93, spike of 52.3 and then post cath 39.02. Chest x-ray revealed patchy, diffuse bilateral infiltrates consistent with possible adult respiratory distress syndrome or viral process. Due to hypercarbic respiratory failure patient was intubated for airway protection and placed on AC. HOSPITAL COURSE: 1. Cardiovascular: Pump post cath echo revealed an ejection fraction of 35%. Initially held off anticoagulation because of decreasing platelets, negative antibody, and Heparin drip was initiated on [**2106-10-16**]. At time of discharge patient was using Lovenox 60 mg subq b.i.d. with bridge to Coumadin 5 mg p.o. q.d. Goal INR of 2 to 3. Patient informed to have VNA fax results to primary care physician, [**Last Name (NamePattern4) **]. [**First Name (STitle) **], for target goal. Patient will need follow-up echo in one month time to reassess ejection fraction at that time. Anticoagulation might be discontinued. Given his low ejection fraction, Electrophysiology evaluation was obtained, performed a signal average ECG revealing a short QRS duration of 109 milliseconds. Felt that patient will need to follow up with Cardiology and have a stress test with T wave alternans at [**Telephone/Fax (1) 1566**] for appointment. 2. Rhythm: Patient remained on telemetry throughout hospital stay. Normal sinus rhythm without aberrancy. 3. Coronary artery disease: Patient was weaned off nitro after catheterization. Completed 18 hours of Integrilin therapy. Started on Plavix, aspirin. Beta blocker and ACE were titrated as hemodynamically tolerated. Cardiac enzymes trended down and blood pressure was successfully managed. 4. Pulmonary: Due to increasing tachypnea and chest x-ray concern for ARDS, patient was intubated for airway protection. Patient improved with progressive diuresis on hospital day six. Patient was extubated with good gas exchange. Aggressive pulmonary physical therapy was initiated as well as Albuterol and Combivent. At the time of discharge patient was satting 97% on room air. Given prescriptions for rescue inhalers as well as VNA assistance for chest PT as needed. 5. Infectious Diseases: Blood cultures and urine cultures remained negative. Negative for Legionella or RSV viral strands and fungal strands. Sputum was positive for Methicillin-resistant Staphylococcus aureus. Respiratory precautions were initiated. Patient finished nine-day course of Vancomycin 1 gram IV q. 12 and was discharged with Flagyl 500 mg p.o. q.d. and Levofloxacin 500 mg p.o. q.d. times 14 days. He was afebrile throughout hospital course with leukocytosis trending down. 6. Endocrine: Patient initiated on insulin drip. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] consult was obtained. Per recommendations glargine 12 units q. h.s. with Humalog. Sliding scale was initiated. Blood sugars remained in adequate control. At time of discharge the patient was scheduled with a follow-up appointment on [**2106-11-4**] at [**Last Name (un) **] with Dr. [**Last Name (STitle) 9978**] as well as vision screen at that time. Patient informed to record blood sugars and bring them to his follow-up appointment. 7. Renal: Creatinine at baseline is 0.6 throughout hospital course. Received Mucomyst post-procedure dye load without creatinine bump. 8. Psychiatric: The patient initiated post intubation Luvox 50 mg titrated up to 100 mg p.o. q.d. Discussed with psychiatrist, Dr. [**First Name4 (NamePattern1) 2092**] [**Last Name (NamePattern1) 106671**], at [**Hospital1 2025**] to follow up at discharge. DISCHARGE MEDICATIONS: 1. Lovenox 60 mg subq q. 12 times seven days. 2. Warfarin 5 mg p.o. q.d. titrating to INR 2 to 3, faxing results to PCP [**Last Name (NamePattern4) **]. [**First Name (STitle) **]. 3. Aspirin 325 mg p.o. q.d. 4. Plavix 75 mg p.o. q.d. times nine months. 5. Insulin glargine 12 units subq q. h.s. with Humalog sliding scale [**First Name8 (NamePattern2) **] [**Last Name (un) **] recommendations. 6. Metronidazole 50 mg p.o. t.i.d. times 14 days. 7. Levofloxacin 50 mg p.o. q.d. times 14 days. 8. Fluvoxamine 100 mg p.o. q.d. 9. Albuterol. 10. Ipratropium one to two inhalations q. 6 p.r.n. shortness of breath or wheezing. 11. Atorvastatin 10 mg p.o. q.d. 12. Zestril 20 mg p.o. q.d. 13. Toprol XL 100 mg p.o. q.d. 14. Nitroglycerin 0.3 mg sublingual q. 5 minutes times three p.r.n. chest pain. DISCHARGE INSTRUCTIONS: 1. Patient will check his INR on Friday, [**2106-10-22**], and Monday, [**2106-10-25**], titrating INR to 2 and 3. Will fax results to Dr. [**First Name (STitle) **]. 2. Patient to call Cardiology at [**Hospital1 18**] for an appointment in two weeks. 3. Patient to follow up with [**Last Name (un) **] on [**2106-11-2**] at 10 o'clock for eye exam and appointment with Dr. [**Last Name (STitle) 9978**]. 4. Patient discharged with VNA nursing for respiratory and medication instruction as well as administration of Lovenox. DISCHARGE STATUS: Discharged home with VNA services, chest pain free, shortness of breath free. DISCHARGE CONDITION: Stable. [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 4786**] Dictated By:[**Name8 (MD) 106672**] MEDQUIST36 D: [**2106-10-21**] 07:42 T: [**2106-10-21**] 11:58 JOB#: [**Job Number 106673**]

[ "296.7", "507.0", "287.5", "518.5", "414.01", "250.01", "482.41", "428.0", "410.01" ]

icd9cm

[ [ [] ] ]

[ "96.6", "36.06", "96.04", "36.07", "96.71", "88.56", "33.24", "36.01", "99.20", "37.23" ]

icd9pcs

[ [ [] ] ]

8237, 8541

1824, 2065

6757, 7562

3454, 6734

7586, 8215

1597, 1723

2088, 2963

152, 198

227, 1349

2978, 3437

1371, 1576

1740, 1807

13,401

121,472

53007

Discharge summary

report

Admission Date: [**2191-12-31**] Discharge Date: [**2192-1-5**] Date of Birth: [**2125-1-31**] Sex: M Service: MEDICINE Allergies: Penicillins / Cephalosporins / Aztreonam / Latex Attending:[**Last Name (NamePattern4) 290**] Chief Complaint: s/p cardiac arrest [**1-25**] DKA Major Surgical or Invasive Procedure: Intubation ([**2191-12-31**]) RIJ line placement ([**2191-12-31**]) A-line placement ([**2191-12-31**]) History of Present Illness: Patient is a 66 year old male with past medical history significant for type 1 diabetes mellitus complicated by hypoglycemic episodes that leads to passing out or seizures. His wife reports he has been upper respiratory symptoms for past few days and had acute episode of nausea and vomiting last night along with confusion and multiple falls thereafter. He was unarousable this morning and when EMS arrived he initially very bradycardic. He got 1 mg atropine on site. En route had several asystolic arrests x3 but would come back spontaneously. Intubated in the field. Fasting glucose critical high in the field. Hemodynamically stable in the ED. Making gestures. On fentanyl/versed for sedation. Easy to ventilate. . In the ED, initial VBG was acidotic (6.89/32/195) and K+ of 7.2 EKG with diffuse peaked T-s. Given calcium gluconate, kayexalte and started on insulin gtt @ 10 units/hr and IV fluids (4LNS). QRS narrowed from 118 to 108. Bicarb gtt started for pH < 7.0. Vitals prior to transfer HR of 81, BP of 100/53 Vent 550 x14 PEEP 5 FiO2 100%, overbreathing at rate of 30. . OG with 400 ccs of coffee ground emesis. Did not clear with 500 ccs of lavage. GI decided not scope as they suspected gastritis in acute illness vs [**First Name9 (NamePattern2) **] [**Last Name (un) **] tear. IV protonix was started. Past Medical History: DM type 1 dx'ed [**2151**], c/b ulnar and median neuropathies, PVD, retinopathy, and gastroparesis Diabetic foot ulcers with multiple prior infections including MRSA isolates, s/p L 4th toe osteomyelitis with gas gangrene in [**3-29**] requiring amputation OSA PVD s/p L femoral bypass GERD HTN Hypercholestolemia Depression Erectile dysfunction h/o broken neck at age 13 with C1-C2 repair. Social History: (+) tobacco use x40 years, currently smokes 3 cigs/day, patient denies past etoh abuse, although OMR notes indicate past chronic alcohol use. Denies illicit drug use. Married. Family History: Non-contributory Physical Exam: VS: HR:85 BP:105/54 RR:22 O2sat:100% CMV 100%FiO2 PEEP:5cm GEN: Intubated. Sedated. HEENT: PERRLA. NECK: Supple neck PULM: Clear to auscultation bilaterally CARD: Regular rate and rhythm. No murmurs or gallops appreciated. ABD: Soft, nontender and nondistended EXT: No edema. Appropriate temperature at the extremities. 1+ pulses @ posterior tibial and radial artery SKIN: Bruises b/l legs NEURO: Sedated. PERRLA Pertinent Results: Admission Labs [**2191-12-31**] 03:26PM BLOOD WBC-25.5* Hct-36.0* Plt Ct-426 [**2191-12-31**] 03:26PM BLOOD Neuts-66 Bands-4 Lymphs-21 Monos-7 Eos-0 Baso-0 Atyps-0 Metas-1* Myelos-1* NRBC-1* [**2191-12-31**] 05:30PM BLOOD Glucose-883* UreaN-65* Creat-2.5* Na-129* K-7.2* Cl-90* HCO3-8* AnGap-38* [**2191-12-31**] 08:47PM BLOOD ALT-29 AST-40 CK(CPK)-968* AlkPhos-105 TotBili-0.4 [**2191-12-31**] 08:47PM BLOOD CK-MB-46* MB Indx-4.8 cTropnT-0.37* [**2191-12-31**] 08:47PM BLOOD Calcium-7.7* Phos-5.5*# Mg-2.4 . Pertinent Labs [**2191-12-31**] 03:41PM BLOOD Type-ART Rates-/29 Tidal V-500 FiO2-98 pO2-195* pCO2-32* pH-6.89* calTCO2-7* Base XS--27 AADO2-481 REQ O2-80 -ASSIST/CON Intubat-INTUBATED Comment-GREEN TOP [**2191-12-31**] 05:39PM BLOOD Type-[**Last Name (un) **] pO2-110* pCO2-32* pH-6.97* calTCO2-8* Base XS--24 Comment-GREEN TOP [**2191-12-31**] 08:53PM BLOOD Type-MIX pO2-65* pCO2-43 pH-7.10* calTCO2-14* Base XS--16 [**2191-12-31**] 10:09PM BLOOD Type-ART Temp-35.8 pO2-401* pCO2-44 pH-7.20* calTCO2-18* Base XS--10 Intubat-INTUBATED [**2192-1-1**] 03:08AM BLOOD Type-ART Temp-33.1 FiO2-50 pO2-144* pCO2-41 pH-7.35 calTCO2-24 Base XS--2 Intubat-INTUBATED . CT Torso ([**2191-12-31**]): 1)Acute fractures of left 3,4,5 ribs and sternum. remote fx of left 6,7,8 ribs. remote fx rt transverse process L3, L5. age indeterminate fx of right transverse process L2 2) penile implant with reservoir in pelvis, just right of midline could correspond to fluid seen on FAST exam 3) extensive vascular calcifications. . CT Head ([**2191-12-31**]): no acute intracranial process . CXR ([**2191-12-31**]): Single supine AP portable view of the chest was obtained. There has been interval placement of a right internal jugular central venous catheter, terminating in the very distal SVC, without evidence of pneumothorax. Endotracheal tube is seen, very distal difficult to discern, but remains above the level of the carina. Distal aspect of the nasogastric tube is also not well seen below the level of the distal esophagus. Lungs remain clear. Brief Hospital Course: 66 year old male with type 1 diabetes s/p asystolic arrests x 3 likely due to acidosis and hyperkalemia secondary to diabetic ketoacidosis. Anion gap was closed with fluids and insulin drip. Onset thought to be due to acute viral gastroenteritis leading to his diabetic ketoacidosis. Arctic arrest cooling protocol initiated for neuro protection after multiple cardiac arrests. It was thought that arrests likely secondary to hyperkalemia vs acidosis. Pt noted to have elevated troponins likely secondary to demand ischemia vs NSTEMI vs end organ damage from his cardiac arrest. On [**1-2**], pt noted to have increased temperature, shivering, and increased secretions from the ET tube. He was started on antibiotics empirically. Family decision was made that pt would be CMO; however he was kept on the vent until [**1-5**] so that family members could arrive from out of state. Extubation occurred on [**1-5**], and pt passed away approximately 10 minutes later. Family declined autopsy. Medications on Admission: Amlodipine 10 mg po qdaily Atorvastatin 80 mg po qdaily Buproprion 300 mg po qdaily Fluticasone 2 puff inhalation qdaily Insulin 70/30 as directed lisinopril 40 mg po qdaily Meloxicam 15 mg po qdaily Pantoprazole 40 mg po qdaily Trazodone 200 mg po qhs prn insomnia Valsartan 80 mg po qdaily Venlafaxine 300 mg po qdaily Aspirin 81 mg po qdaily Discharge Medications: pt passed away Discharge Disposition: Expired Discharge Diagnosis: pt passed away Discharge Condition: pt passed away Discharge Instructions: pt passed away Followup Instructions: pt passed away [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**] Completed by:[**2192-1-5**]

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icd9cm

[ [ [] ] ]

[ "38.97", "96.72" ]

icd9pcs

[ [ [] ] ]

6398, 6407

4964, 5963

350, 455

6465, 6481

2895, 4941

6544, 6724

2428, 2446

6359, 6375

6428, 6444

5989, 6336

6505, 6521

2461, 2876

277, 312

483, 1803

1825, 2218

2234, 2412

364

136,153

19018+57008

Discharge summary

report+addendum

Admission Date: [**2130-5-22**] Discharge Date: [**2130-5-30**] Date of Birth: [**2059-4-11**] Sex: M Service: MICU HISTORY OF PRESENT ILLNESS: The patient is a 71-year-old male with a history of chronic obstructive pulmonary disease and a remote history of minor hemoptysis who presented to the [**Hospital1 69**] for further management of massive hemoptysis from [**Hospital 1562**] Hospital. For about one week prior to admission, he noted increased upper respiratory secretions and a cough which was secondary to seasonal allergies. On [**5-21**], the day prior to admission, he coughed up some gross red blood and went to the local hospital. He was intubated there for airway protection and had a flexible bronchoscopy at [**Hospital 1562**] Hospital which showed large clots diffusely in the airways. Overnight, on [**5-21**] at [**Hospital 1562**] Hospital, his hematocrit dropped from 40% to 30%, and on the following morning, he had a repeat bronchoscopy. At that time, the bronchoscopy revealed blood throughout the airways, with a possible source in the left upper lobe apical/posterior segment. He was transferred to the [**Hospital1 69**] for further management. PAST MEDICAL HISTORY: 1. Chronic obstructive pulmonary disease. 2. Severe low back pain. 3. Abdominal aortic aneurysm which is 4 cm in diameter. 4. History of lacunar cerebellar infarction. 5. History of hemoptysis one year ago - reported negative evaluation. MEDICATIONS ON ADMISSION: 1. Combivent. 2. OxyContin 80 mg p.o. twice per day. 3. Percocet five tablets p.o. every day. ALLERGIES: The patient has no known drug allergies. SOCIAL HISTORY: His social history includes one pack of cigarettes per day for over 30 years. No known alcohol use. FAMILY HISTORY: Family history was noncontributory. PHYSICAL EXAMINATION ON PRESENTATION: On physical examination, temperature was 100.5, heart rate was 82, blood pressure was 119/51, respiratory rate was 12, and oxygen saturation was 100% on 50%. The patient was ventilated on assist-control. He was sedated initially on paralytic agents to prevent cough. His lung sounds were coarse throughout, particularly on the right, with inspiratory wheezes. His cardiovascular examination was significant for distant heart sounds. A regular rate and rhythm. A [**1-26**] holosystolic murmur loudest at the apex. Abdominal examination revealed bowel sounds were present. The abdomen was soft, nontender, and nondistended. Extremity examination revealed cool extremities. Pulses were 1+. PERTINENT LABORATORY VALUES ON PRESENTATION: His laboratory data was notable for a hematocrit of 30.6 and platelets were 199. Partial thromboplastin time was 27. INR was 1. His electrolytes included a sodium which was 136, potassium was 3.8, chloride was 101, bicarbonate was 28, blood urea nitrogen was 12, creatinine was 0.6, and blood glucose was 92. PERTINENT RADIOLOGY/IMAGING: The patient had a chest x-ray that was unremarkable. A chest CT showed a 1.5cm nodule in the left upper lobe (? BAC). HOSPITAL COURSE BY ISSUE/SYSTEM: 1. RESPIRATORY ISSUES: The patient was had a flexible bronchoscopy which revealed old blood diffusely, with a large clot in the left mainstem. There were no other endobronchial lesions. As to not disturb the clot, a rigid bronchoscopy was schedueld. On hospital day two, he had a rigid bronchoscopy that showed dry blood in the left mainstem, which was removed. The uptake to the left lower lobe was erythematous and abnormal in appearance and brushings, washings and transbronchial needle aspirates were obtained. Postoperatively, the patient was noted to be hypertensive, so he was started on a nitroglycerin drip but otherwise had an uneventful recovery. The day after the rigid bronchoscopy the patient was extubated and had adequate oxygenation for the duration of his Intensive Care Unit course. However, on the day following extubation the patient was noted to have an opacity/infiltrate in the left lower lobe that was consistent with a ventilator-acquired pneumonia. Therefore, the patient was started on vancomycin and ceftazidime. The diagnosis of pneumonia was consistent with his low-grade temperatures from 100 to 100.9 in the days following his extubation. The patient's oxygen requirements gradually decreased over the course of his Intensive Care Unit admission; weaning down to two liters by nasal cannula on the day of transfer to the floor. The pathology results from his bronchoscopy came back negative for malignant cells. These included two samples of washings of the bronchial tree as well as a transbronchial needle aspiration. 2. CARDIOVASCULAR SYSTEM: The patient was noted throughout the duration of his Intensive Care Unit stay to be hypertensive with a blood pressure ranging from the 140s to over 200 that coincided with his degree of pain medications. It was noted after his rigid bronchoscopy for his blood pressure to stay consistently over 200. Due to concerns about the effects on his cerebral vasculature, he was started on a nitroglycerin drip which adequately reduced his blood pressure into the 150s. The nitroglycerin drip was turned off the following day, and he was started on captopril for afterload reduction, and this was maintained throughout the remainder of his Intensive Care Unit course; initially starting at 6.25 mg three times per day and titrating up to 25 mg three times per day. 3. INFECTIOUS DISEASE ISSUES: The patient was noted following extubation to have a new left lower lobe infiltrate that was consistent with ventilator-associated pneumonia; as noted above. He was started on ceftazidime and vancomycin for this infection which necessitated outpatient intravenous therapy. 4. PAIN ISSUES: The patient came in with a history of severe low back pain with a home regimen of 80 mg of OxyContin twice per day with up to five Percocet tablets per day. He was initially started on a morphine drip for pain that was titrated to his blood pressure and heart rate. Following extubation, these requirements as he was able to take oral intake. His narcotic regimen was gradually increased to his baseline regimen; including 80 mg of OxyContin and five Percocet tablets. 5. REHABILITATION ISSUES: On the day following his extubation, the patient was seen in consultation by Physical Therapy who allowed him to walk around the Unit and increase his capacity which had likely been reduced during his time on the respirator. 6. GASTROINTESTINAL ISSUES: The patient had a computed tomography scan of his chest in the middle of his Intensive Care Unit stay that was notable for a thickened esophagus. This finding was not inconsistent with an esophageal malignancy and should be followed up on as an outpatient, and this was relayed to the floor team. DISCHARGE DISPOSITION: The patient to be discharged to the Medicine Service at the [**Hospital1 69**]. DISCHARGE DIAGNOSES: 1. Hemoptysis. 2. Ventilator-associated pneumonia. 3. Chronic obstructive pulmonary disease. 4. Severe low back pain. 5. History of lacunar infarction. 6. Abdominal aortic aneurysm. The patient will follow-up with his referring pulmonologist for a follow-up chest CT to evalute the nodule seen in the left upper lobe (? BAC). [**First Name8 (NamePattern2) **] [**Name8 (MD) **], M.D. [**MD Number(1) 7585**] Dictated By:[**Last Name (NamePattern1) 7693**] MEDQUIST36 D: [**2130-5-30**] 12:48 T: [**2130-5-30**] 13:09 JOB#: [**Job Number 51939**] Name: [**Known lastname 9656**], [**Known firstname 126**] S Unit No: [**Numeric Identifier 9657**] Admission Date: [**2130-5-22**] Discharge Date: [**2130-5-30**] Date of Birth: [**2059-4-11**] Sex: M Service: MEDICINE/[**Location (un) 571**] ADDENDUM: This discharge summary addendum will cover [**2130-5-29**], to [**2130-5-30**]. HOSPITAL COURSE: 1. Respiratory - The patient was transferred from the Medical Intensive Care Unit to the floor on [**2130-5-29**]. The patient remained stable with oxygen saturation ranging 93 to 96% in room air. He did not require any additional nebulizer treatments. He was maintained on his inhaled regimen. The patient's lung examination continued to be clear to auscultation bilaterally on the day of discharge. The patient had no further episodes of hemoptysis. The patient was instructed to follow-up with pulmonologist including repeat CT scan in one month's time. 2. Cardiovascular - hypertension - The patient maintained blood pressure in the 140 range while on Captopril three times a day in house. The patient was converted to Lisinopril 10 mg p.o. once daily upon discharge. This should be followed up as an outpatient for optimized management of hypertension. 3. Infectious disease - The patient was treated for a ventilator associated pneumonia. The patient was originally started on intravenous antibiotics, received five days of Ceftaz and Vancomycin. The patient's sensitivities returned from his sputum cultures on [**2130-5-30**], and the patient was switched to a p.o. regimen which included Ciprofloxacin and Augmentin.The patient was instructed to continue these for a total of a fourteen day course of antibiotics giving him nine more days postadmission for antibiotics. 4. Chronic back pain - The patient continued on Oxycodone and discharged with a prescription for six days of further pain medication. 5. Gastrointestinal - The patient had no gastrointestinal complaints during his stay on the medical [**Hospital1 **]. The patient should follow-up for thickened esophagus of uncertain clinical correlate as an outpatient. FOLLOW-UP: The patient was instructed to follow-up in [**Hospital 112**] Clinic on either Friday, [**2130-6-2**], or Monday, [**2130-6-5**]. The patient was instructed to get a close first available appointment regardless of the care provider in [**Name9 (PRE) 112**]. The patient should follow-up with a pulmonologist with repeat CT scan in one month's time. He should also follow-up for his thickened esophagus. MEDICATIONS ON DISCHARGE: 1. Ciprofloxacin 500 mg p.o. twice a day for nine days. 2. Augmentin 875 mg p.o. twice a day for nine days. 3. Lisinopril 10 mg p.o. once daily. 4. Oxycodone for a total course of six days. 5. The patient was restarted on his Plavix once daily for history of cerebrovascular accident. 6. Continue inhaled treatments for chronic obstructive pulmonary disease while at home. The patient should have close follow-up for his pneumonia and episodes of hemoptysis of unknown etiology in addition to his thickened esophagus. CONDITION ON DISCHARGE: The patient was discharged in stable condition with a stable hematocrit and stable vital signs. [**First Name4 (NamePattern1) 77**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 1977**] Dictated By:[**Name8 (MD) 2450**] MEDQUIST36 D: [**2130-5-30**] 15:55 T: [**2130-5-30**] 19:55 JOB#: [**Job Number 9658**]

[ "997.3", "507.0", "441.4", "496", "786.3", "285.1" ]

icd9cm

[ [ [] ] ]

[ "33.27", "96.04", "38.91", "33.24", "38.93", "96.71" ]

icd9pcs

[ [ [] ] ]

6864, 6945

1786, 3071

6966, 7933

10149, 10675

1497, 1649

7950, 10123

3105, 6840

166, 1205

1227, 1471

1666, 1768

10700, 11057

44,763

146,386

4785

Discharge summary

report

Admission Date: [**2196-3-14**] Discharge Date: [**2196-3-19**] Date of Birth: [**2117-2-1**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 3531**] Chief Complaint: hematemesis Major Surgical or Invasive Procedure: none History of Present Illness: 79 yo M with a past medical history of afib on coumadin, hypertension, dyslipidemia presents with hematemesis. Patient was in his usual state of health today when he noticed the sensation of blood pooling in the back of his mouth. He started to spit up blood with intermittent clots and called his primary care provider who told him to present to the ED. Patient has no prior history of hematemesis, GI bleed, alcohol abuse or liver disease. He denies vomitting, diarrhrea, melena and hematochezia. His last stool was this morning and reportedly normal in consistency and brown in color. He denies chest pain, dyspnea, abdominal pain, dizziness and lightheadedness. Over the course of the day he has spit up enough blood to "fill 6 cups", and he feels as if it is slowing down now. In the ED, NG lavage returned 200 cc of gross blood that did not clear with saline. Guaiac was negative on rectal exam. He received 2 U FFP, 8 mg of zofran, 80 mg protonix with a 8 mg/hr drip. GI was consulted and did not advise urgent endoscopy. On transfer, VS were 76, 162/89, 99 RA, 14. . On the ICU, patient has no additional complaints. Past Medical History: AF s/p d/c cardioversion ([**8-31**]) on Coumadin HTN with moderate LVH DMII (Diet controlled, HbA1c 6.9) Dyslipidemia Recurrent UTIs (two-three times per year tx with Cipro) Elevated PSA (4.2) Elevated Postvoid Residual (940 on [**10-6**]) Microscopic Hematuria Social History: Lives in [**Location 86**] is married with 9 children. Is a retired factory worker at a tractor factory in [**Location (un) **]. No active alcohol use, but per OMR formerly drank 4-5 drinks per week. Smoking history greater than 20 years ago, total 10 pack year smoking. No illicits. Family History: No family h/o cancer. Physical Exam: Vitals: T:97.6 BP: 169/80 P: R: 87 18 O2: 97 RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, oropharynx tinged with blood and tongue with clots easily removable with examination. Some blood seen pooling in the back of his throat. Active blood extravisation from LEFT upper molar region Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema On discharge: 96.6 124/62 68 18 97RA Gen: well appearing male, lying in bed, NAD CV: irregularly irregular, Nl S2 and S2. No r/g/m Lungs: clear to auscultation bilaterally Abd: soft, non distended, non tender. ABS Ext 1+ peripheral edema symmetrical bilaterally, palpable DP pulses Neuro: alert and oriented, responding appropriately Pertinent Results: On admission: [**2196-3-14**] 05:23PM BLOOD WBC-9.1 RBC-4.94 Hgb-13.6* Hct-41.1 MCV-83 MCH-27.6 MCHC-33.2 RDW-14.5 Plt Ct-249 [**2196-3-14**] 05:23PM BLOOD Neuts-58.1 Lymphs-34.3 Monos-4.1 Eos-2.5 Baso-1.0 [**2196-3-14**] 05:23PM BLOOD PT-34.0* PTT-31.5 INR(PT)-3.5* [**2196-3-14**] 05:23PM BLOOD Glucose-100 UreaN-25* Creat-1.2 Na-135 K-9.2* Cl-105 HCO3-25 AnGap-14 [**2196-3-14**] 05:23PM BLOOD ALT-14 AST-64* AlkPhos-58 TotBili-0.5 [**2196-3-14**] 07:32PM BLOOD Calcium-8.3* Phos-3.9 Mg-2.0 . On discharge: [**2196-3-19**] 09:50AM BLOOD WBC-9.7 RBC-3.90* Hgb-10.9* Hct-33.3* MCV-85 MCH-27.8 MCHC-32.6 RDW-15.1 Plt Ct-285 [**2196-3-19**] 09:50AM BLOOD Glucose-202* UreaN-18 Creat-1.3* Na-139 K-3.9 Cl-101 HCO3-24 AnGap-18 [**2196-3-19**] 09:50AM BLOOD Calcium-8.9 Phos-3.4 Mg-1.9 Panorex : There is poor dentition with several missing teeth. The mandible and visualized portion of the maxilla demonstrates no definite displaced fractures. If there is high clinical concern, a CT scan could be performed. Brief Hospital Course: Mr. [**Known lastname 10010**] is a very pleasant 79 yo M with a past medical history of afib on coumadin, htn, dmII who presented to the [**Hospital1 18**] emergency department with a one day history of oral bleeding. He was initially admitted to the medical intensive care unit on [**2196-3-14**] for concern of GI bleed. In the ICU his bleeding stopped his hematocrit stabilized around 30 from baseline of 40. After a thorough evaluation he was transferred to a regular medicine floor on [**2196-3-15**]. Oral surgery was consulted, surgery was planned for [**3-18**]. Pt's hematocrit was monitored daily with no change and patient experienced no further bleeding. On [**3-18**], he had three teeth pulled. Oral surgery recommended a 7 day course of antibiotics as well as peridex rinses. They also recommended that patient follow up with a dentist given poor dentition. In the setting of acute bleed, pts antihypertensive agents were held temporarily as was coumadin. Blood pressure medications were restarted prior to discharge. Coumadin was held. Pt was instructed to not take coumadin until his visit with his PCP [**Last Name (NamePattern4) **] [**3-23**]. At that time if Hct is stable, there would be no concern for resuming coumadin. During his hospitalization, patinet was also noted to have poor air movement and wheezing. He was started on a 5 day prednisone burst. He has no history of COPD that he is aware and is not on any inhalers at home. Strong consideration for PFTs should be given as outpatient. Medications on Admission: # Atorvastatin 20 mg daily [Has not taken in last 2 weeks because of insurance issues] # Doxazosin 4 mg po QHS # Finasteride 5 mg daily # Lisinopril 20 mg daily # Metoprolol Succinate 12.5 mg daily # Nifedipine 60 mg daily # Warfarin 5 mg daily # Cyclobenzaprine 5 mg TID PRN # Acetaminophen 500 mg Q8H prn # Hydromorphone 2 mg po Q4H PRN # Docusate Sodium 100 mg po BID # Senna 8.6 mg Capsule po BID # Flexeril 5 mg po TID PRN Discharge Medications: 1. Doxazosin 4 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 2. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO once a day. 4. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr Sig: 0.5 Tablet Sustained Release 24 hr PO DAILY (Daily). 5. Cyclobenzaprine 5 mg Tablet Sig: One (1) Tablet PO three times a day as needed for back pain. 6. Acetaminophen 500 mg Tablet Sig: One (1) Tablet PO every eight (8) hours as needed for fever or pain. 7. Dilaudid 2 mg Tablet Sig: One (1) Tablet PO every four (4) hours as needed for pain. 8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO twice a day. 9. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for Constipation. 10. Amoxicillin 500 mg Capsule Sig: One (1) Capsule PO twice a day for 7 days. Disp:*14 Capsule(s)* Refills:*0* 11. Peridex 0.12 % Mouthwash Sig: One (1) rinse Mucous membrane three times a day for 10 days. Disp:*250 ml* Refills:*0* 12. Nifedipine 60 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO DAILY (Daily). 13. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home Discharge Diagnosis: primary: bleeding tooth tooth extraction diabetes reactive airway disease Discharge Condition: Mental Status: Clear and coherent Level of Consciousness: Alert and interactive Activity Status: Ambulatory - Independent Hct 30, respiration: occassional faint wheezes, good air movement Discharge Instructions: Mr. [**Known lastname 10010**] - It was a pleasure to care for you during your hospitalization. You were hospitalized for bleeding from your tooth. You lost a lot of blood because you were on coumadin. Your bleeding stopped and for a while your coumadin was stopped also. You were evaluated by the oral surgeons, and two teeth were removed without bleeding. You should not restart your coumadin until you discuss this with Dr. [**Last Name (STitle) **] at your appointment on [**3-23**]. Because the teeth weer pulled you are being started on an antibiotic called amoxicillin. You should ocntinue for total of 7 days. You should also continue rinsing your mouth with peridex an antibacterial solution. It is important that you see a dentist to help you with your oral hygiene. During your hospitalization you were also treated with prednisone, an oral steroid, for wheezing airways and poor air movement. You should be evaluated by your doctor to look for underlying lung disease. Medications added: Amoxicillin Peridex Medications stopped: Please stop coumadin until you have discussed restarting it with Dr. [**Last Name (STitle) **] Followup Instructions: Please make the following appointments: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 7978**], MD Phone:[**Telephone/Fax (1) 7976**] Date/Time:[**2196-3-23**] 3:15 Provider: [**Last Name (NamePattern4) **]. [**First Name11 (Name Pattern1) 275**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2196-5-5**] 10:20 Provider: [**Last Name (NamePattern4) **]. [**First Name11 (Name Pattern1) 275**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2197-2-16**] 11:20 Completed by:[**2196-3-20**]

[ "724.5", "522.4", "523.8", "285.1", "V58.61", "493.92", "250.00", "427.31", "272.4", "799.02", "338.29", "401.9" ]

icd9cm

[ [ [] ] ]

[ "23.19" ]

icd9pcs

[ [ [] ] ]

7437, 7443

4215, 5751

327, 333

7561, 7561

3182, 3182

8947, 9588

2094, 2117

6243, 7414

7464, 7540

5777, 6220

7775, 8924

2132, 2818

3693, 4192

275, 289

361, 1490

3196, 3679

7576, 7751

1512, 1776

1792, 2078

80,956

169,290

6431

Discharge summary

report

Admission Date: [**2158-10-16**] Discharge Date: [**2158-10-21**] Date of Birth: [**2083-8-3**] Sex: M Service: MEDICINE Allergies: Penicillins / Iodine; Iodine Containing Attending:[**First Name3 (LF) 7651**] Chief Complaint: NSTEMI Major Surgical or Invasive Procedure: Cardiac Catheterization (diagnostic) Tooth extraction (#11) History of Present Illness: Mr. [**Known lastname **] is a 75 y/o male with a h/o rheumatic heart disase, severe AS, HTN, and hyperlipidemia who presented initially to an OSH ED with severe SOB and was then transferred to the [**Hospital1 18**] ED when there was a concern for possible STEMI. Of note, the pt recently had left carotid stenting on [**2158-10-4**]. Post-procedure, he was instructed to keep his BP 110-170, taking Sudafed at home if his BP decreased. About 2-3 days after his procedure, he noted increasing SOB and DOE. He denied any CP. He presented to [**Hospital1 1474**] ED with the above complaints. He was started on a nitro gtt and given combivent nebs, Lasix 80 IV x 1, solumedrol 125 mg IV x 1, ativan 1 mg IV x 1, morphine 4 mg IV x 1, ASA 325 mg PO, and Lopressor 5 mg IV x 1. Because of his respiratory distress, he was placed on BiPAP 18/5. A non-contrast CT scan was performed to r/o aortic dissection. It revealed moderate B/L pleural effusions. She was then transferred to the [**Hospital1 18**] ED for further evaluation. OSH vitals on presentation: BP 146/80 HR 80 RR 16 100% on BiPap. Question of STE on EKG, CPK 521, Troponin 23.4, BNP 1328, and WBC 21. At the [**Hospital1 18**] ED, he was started on a heparin gtt. Vitals on presentation were T 98.5 HR 76 BP 112/69 RR 12 92% 4LNC. Of note, after his carotid stenting procedure, he developed a new rash on his trunk. He was treated with prednisone, thought to be [**1-7**] to dye allergy. Past Medical History: Severe AS Rheumatic heart disease HTN Hyperlipidemia CRI, unknown baseline Stroke/TIA x 2 Clean cath at [**Hospital1 18**] in [**2147**] Social History: Married, lives at home with his wife. Quit tobacco in [**2095**]. Denies alcohol or IVDU Family History: Non-contributory Physical Exam: General Appearance: Well nourished, No acute distress Eyes / Conjunctiva: PERRL Head, Ears, Nose, Throat: Normocephalic Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal), (Murmur: Systolic), SEM, best heart RUSB, radiating to the carotids Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse: Present), (Right DP pulse: Present), (Left DP pulse: Present) Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles : 1/2 up lung fields, No(t) Wheezes : ) Abdominal: Soft, Non-tender, Bowel sounds present, Distended, No(t) Tender: Extremities: Right: 1+, Left: 2+ Skin: Not assessed, Rash: on trunk, maculopapular Neurologic: Attentive, A/O x 3. CNs II-XII grossly intact. Sensation intact. Good ROM and strength in all 4 extremities. Pertinent Results: [**2158-10-16**] 05:33PM CK(CPK)-241* [**2158-10-16**] 05:33PM CK-MB-22* MB INDX-9.1* cTropnT-1.59* [**2158-10-16**] 05:33PM GLUCOSE-145* UREA N-53* CREAT-1.9* SODIUM-139 POTASSIUM-3.6 CHLORIDE-99 TOTAL CO2-27 ANION GAP-17 [**2158-10-16**] 09:13AM WBC-10.9 RBC-3.43* HGB-10.5* HCT-29.4* MCV-86 MCH-30.5 MCHC-35.6* RDW-15.1 [**2158-10-16**] 01:14AM CK(CPK)-452* [**2158-10-16**] 01:14AM CK-MB-41* MB INDX-9.1* [**2158-10-16**] 01:14AM cTropnT-1.91* CATH [**10-16**]: 1. Three vessel coronary artery disease. 2. Moderate-to-severe aortic stenosis. 3. Marked elevation of biventricular filling pressures. ECHO [**10-16**]: Suboptimal image quality. LV wall thicknesses are normal. Regional LV systolic dysfunction consistent with coronary artery disease. Diastolic dysfunction. There is aortic stenosis which is at least moderate and may be severe (valve not well seen and Doppler interrogation only possible from suprasternal view). The mitral valve is not well seen but does not appear to be rheumatic, there is no mitral stenosis. Moderate pulmonary artery systolic hypertension. CXR [**10-16**]: 1. Bilateral atelectasis and retrocardiac opacities, for which repeat PA and lateral were recommended if there is concern for aspiration or pneumonia. 2. Pulmonary edema. CXR PA/LAT [**10-18**]: 1. Small left pleural effusion. 2. No pneumonia. No CHF. VENOUS MAPPING [**10-18**]: Patent bilateral greater saphenous veins with very large diameters on the right and small diameters on the left. PANOREX: no official read Brief Hospital Course: 75 y/o male with a h/o rheumatic heart disase, severe AS, HTN, and hyperlipidemia who presented with worsening SOB, determined to have a NSTEMI and left sided heart failure. NSTEMI/left-sided heart failure - Pt presented to OSH with worsening SOB, without CP, and responded fairly wellthought to have had plaque rupture, resulting in ischemia and diastolic dysfunction, and in the setting of fixed AS developed pulmonary edema. Pt was medically managed with Aspirin 325mg, plavix 75mg, lipitor 80mg and heparin drip. Beta-blocker was initially held. Pt underwent cardiac catheterization which showed: 1. Three vessel coronary artery disease. 2. Moderate-to-severe aortic stenosis. 3. Marked elevation of biventricular filling pressures. Based on these findings, recommendation was made to undergo CABG with AVR once recovered from recent carotid stents. Pt agreed and underwent screening by CT [**Doctor First Name **] as well as multiple pre-op studies and dental work (removal of two teeth). Cardiac enzymes continued to trend down and pt was discharged home to continue course of plavix, to be stopped 4 days prior to surgery. HYPERTENSION - Initially held beta-blocker and ACE-inhibitor and restarted once renal function improved and CHF better controlled. HYPERLIPIDEMIA - Pt switched to Lipitor 80 mg in the acute setting (on Zocor as outpatient). S/P LEFT CAROTID STENT - Pt had history of stroke/TIA, but had persistently normal neuro exams throughout the admission. Medications on Admission: Plavix 75 mg PO daily ASA 325 mg PO daily Atenolol-Chlorthalidone 100/25 mg PO daily Lisinopril 10 mg PO daily Allopurinol unknown dose Zocor 10 mg PO daily Discharge Medications: 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Furosemide 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). Disp:*15 Tablet(s)* Refills:*2* 5. Allopurinol 100 mg Tablet Sig: Two (2) Tablet PO once a day. 6. Toprol XL 100 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2* 7. Outpatient Lab Work Serum creatinine, urine analysis and urine culture to be done on [**11-1**] at [**Hospital **] medical building. The results need to be sent to your Cardiac surgeon. 8. Amoxicillin 500 mg Tablet Sig: One (1) Tablet PO twice a day for 7 days. Disp:*13 Tablet(s)* Refills:*0* 9. Lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO once a day: . Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Primary: Non ST Elevation Myocardial Infarction Secondary: Systolic Congestive Heart Failure, EF 40-45% Hypertension Urinary Tract Infection Hyperlipidemia Coronary Artery Disease Acute Renal Failure Aortic Stenosis Discharge Condition: BUN=43 Creat=1.6 Hct=30.4 WBC=7.0 BP=116/67 HR=89 Otherwise stable, ambulating, and pain free. Six hours after receiving Amoxacillin, no wheezing, rashes, fever or other symptoms. Discharge Instructions: You had a heart attack and some fluid accumulated in your lungs because your heart was not working well. You had a cardiac catheterization which showed severe aortic stenosis (a stiff arotic valve in your heart) and blockages in 3 of your arteries that feed blood to your heart. You will need surgery to bypass these arteries and fix your aortic valve. A tooth was pulled in preperation for the surgery. You had evidence of bacteria in your urine that needs treatment. You should complete a 7 day course of amoxacillin for this. You will need to get repeat urine studies, as well as repeat blood work done on [**11-1**]. The results should be sent to your cardiac surgeon. Otherwise, your pre-operative work up is complete. You should stop taking plavix on [**11-1**], as well as get repeat labs, in preparation for your surgery on [**2158-11-7**]. New Medicines: 1. Atorvastatin is taking the place of Pravastatin 2. Furosemide and Toprol is taking the place of Atenolol/Chlorthalidone. 3. You have been restarted on Plavix and should continue to take this until [**11-1**]. 4. Your dose of lisinopril is lower (2.5 mg from 10 mg). . Please call Dr. [**Last Name (STitle) 3035**] if you have any chest pain or pressure, trouble breathing, nausea, sweating or any other unusual symptoms. Followup Instructions: Primary Care: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone: [**Telephone/Fax (1) 3183**] Date/time: [**10-26**] at 3pm. Cardiology surgery: Stop taking plavix on [**11-1**] and have repeat labs done at the [**Hospital **] Medical Building [**Last Name (NamePattern1) 439**]. Call cardiac surgey office at [**Telephone/Fax (1) 170**] if you have any questions. Completed by:[**2158-10-24**]

[ "V45.89", "414.01", "584.9", "272.4", "403.90", "522.4", "428.0", "410.71", "585.9", "424.1", "433.10", "599.0", "041.04", "V12.54", "428.20" ]

icd9cm

[ [ [] ] ]

[ "93.90", "88.56", "23.19", "37.23" ]

icd9pcs

[ [ [] ] ]

7189, 7195

4527, 6010

308, 370

7456, 7639

2966, 4504

8980, 9404

2132, 2150

6217, 7166

7216, 7435

6036, 6194

7663, 8957

2165, 2947

262, 270

398, 1850

1872, 2010

2026, 2116

49,081

127,653

14374

Discharge summary

report

Admission Date: [**2161-10-18**] Discharge Date: [**2161-11-5**] Date of Birth: [**2099-7-2**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 3276**] Chief Complaint: dyspnea, low grade fever Major Surgical or Invasive Procedure: pleurex catheter drainage EGD History of Present Illness: Mr. [**Known lastname 42603**] is a 62 year old male with a h/o metastatic large cell lung cancer to bone c/b recurrent malignant pleural effusion requiring pleurex catheter placement, HIV (CD4 535) on HAART, htn who presented to the ED with pleuritic CP and dyspnea which has been his long standing issues. He further states that he flt like he was dying and is not cmofortable with going home. In ED vitals were stable with sats 100% on 1.5L o2 and bp of 134/89, temp 99.4. labs are at baseline. CXR revealed moderate to large left sided pleural effusion with pleurex drain and minimal interval changes. His temp subsequently went to 100.5 although he [**Doctor First Name 1638**] any neck stiffness, photophobia, cough, nausea, vomiting, diarrhoea, dysuria or rash. He was cultured and started on vanco and zosyn. He's seen by psych who felt he's not at suicidal risk. He's admitted for further care. Past Medical History: [**7-/2159**]: Diagnosed with non small cell lung cancer by CT guided biopsy [**2159-9-20**]: PET scan with low-attenuation lesion in the left lobe of the thyroid gland measuring 25 x 7 mm in addition to markedly FDG avid left upper lobe mass consistent with known cancer and FDG avid prominent bilateral axillary lymphadenopathy suspicious for metastatic disease, but no pathologically enlarged infraclavicular lymph nodes. He also had retroperitoneal internal and external iliac chain FDG avid lymphadenopathy considered unusual for lung carcinoma. [**2159-10-29**]: FNA of the thyroid, which was negative. [**2159-10-31**]: Left axillary lymph node dissection. With pathology revealing florid reactive follicular hyperplasia consistent with HIV associated lymphadenopathy. Further staging and treatment were deferred until the patient was stabilized on HAART therapy. He was initially seen by infectious disease doctors [**Last Name (NamePattern4) **] [**2160-1-10**] and was started on HAART therapy in 01/[**2160**]. [**3-/2160**]: He was hospitalized for influenza. After the hospitalization, he was lost to follow up until [**Month (only) **]. Other than the visit with his infectious disease on [**2160-5-5**], he then lost to follow up until [**7-13**]. [**2160-7-24**]: CT demonstrated left upper lobe mass minimally increased in size from [**3-/2160**] with a sub 5 mm left upper lobe pulmonary nodule with additional stable bilateral nodules, new left-sided pleural effusion. [**2160-8-6**]: Bronchoscopy, mediastinoscopy, and pleural drainage and talc pleurodesis by Dr. [**Last Name (STitle) **]. Pathology revealed 4R lymph nodes with no malignancy but frozen sections showed metastatic large cell carcinoma and 4L lymph nodes that showed metastatic large cell carcinoma. A level 7 lymph node showed metastatic large cell carcinoma and a parietal pleural biopsy also showed metastatic large cell carcinoma involving the pleura. He was started on carboplatin and gemcitabine on [**2160-8-28**] he has completed 4 cycles. [**2160-12-5**]: MR [**Name13 (STitle) **] with L1 lesion . MEDICAL HISTORY: - Peripheral vestibulopathy - HIV: Diagnosed in the [**2142**], he had been previously cared for by Dr. [**First Name8 (NamePattern2) 333**] [**Last Name (NamePattern1) 42604**] at [**Hospital6 **]. [**2160-10-30**] -> CD4 425, VL undetectable - Positive PPD-negative AFB [**1-11**]-s/p 6 months Rifampin in [**2148**]. - Hypertension. - History of appendicitis status post appendectomy in [**2126**]. Social History: He is originally of Haitian origin. His wife and children live in [**Country 2045**]. He is an employee in the food service industry here at [**Hospital1 18**]. He reports a prior history of tobacco, having stopped in [**2148**]. He is sexually active only with women. He denies any intravenous drug use. He received transfusions potentially around the time of his appendectomy in [**2126**]. Family History: No premature CAD or cancer. Physical Exam: T: 97.6 BP: 122/89 HR: 100 RR: 20 O2 100% 2LNC Gen: Pleasant, chronically ill appearing male in NAD HEENT: No conjunctival pallor. No icterus. MMM. OP clear. NECK: Supple. JVP low. CV: RRR. nl S1, S2. No murmurs, rubs or [**Last Name (un) 549**] LUNGS: Prominent breath sounds. Decreased on L halfway up. ABD: NABS. Soft, NT, ND. No HSM EXT: WWP, NO CCE. Full distal pulses bilaterally. SKIN: No rashes/lesions, ecchymoses. NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact. Moving all extremities. Exam at discharge: O: 126/88 99 99.1 98% RA 1154/1520 Gen: Pleasant, chronically ill appearing male in NAD HEENT: No conjunctival pallor. No icterus. MMM. OP clear. NECK: Supple. JVP low. CV: RRR. nl S1, S2. No murmurs, rubs or [**Last Name (un) 549**], mild chest discomfort reproducible over sternum LUNGS: Prominent breath sounds. Decreased on L halfway up. ABD: NABS. Soft, NT, ND. No HSM EXT: WWP, NO CCE. Full distal pulses bilaterally. SKIN: No rashes/lesions, ecchymoses. NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact. Moving all extremities. Pertinent Results: [**2161-10-18**] WBC-10.7 Hgb-9.8* Hct-30.9* Plt Ct-577* [**2161-10-19**] WBC-3.6*# Hgb-8.6* Hct-25.8* Plt Ct-397 [**2161-10-19**] WBC-2.3* Hgb-9.6* Hct-29.3* Plt Ct-379 [**2161-10-20**] WBC-1.5* Hgb-9.0* Hct-27.7* Plt Ct-319 [**2161-10-21**] WBC-2.1* Hgb-9.1* Hct-27.4* Plt Ct-257 [**2161-10-22**] WBC-2.9* Hgb-8.6* Hct-26.6* Plt Ct-220 [**2161-10-23**] WBC-3.8* Hgb-8.9* Hct-27.3* Plt Ct-169 [**2161-10-24**] WBC-3.9* Hgb-8.2* Hct-25.4* Plt Ct-167 [**2161-10-24**] WBC-4.0 Hgb-8.5* Hct-26.9* Plt Ct-153 [**2161-10-25**] WBC-4.5 Hgb-7.4* Hct-21.9* Plt Ct-178 [**2161-10-26**] WBC-5.5 Hgb-7.9* Hct-24.0* Plt Ct-182 [**2161-10-27**] WBC-6.4 Hgb-9.2* Hct-26.7* Plt Ct-172 [**2161-10-28**] WBC-7.0 Hgb-9.8* Hct-28.6* Plt Ct-227 [**2161-10-29**] WBC-8.5 Hgb-9.6* Hct-28.7* Plt Ct-279 [**2161-10-30**] WBC-8.3 Hgb-9.4* Hct-29.7* Plt Ct-359 [**2161-10-31**] WBC-7.8 Hgb-9.8* Hct-29.6* Plt Ct-458* [**2161-11-1**] WBC-7.9 Hgb-9.3* Hct-28.5* Plt Ct-521* [**2161-11-2**] WBC-5.8 Hgb-9.7* Hct-29.3* Plt Ct-595* [**2161-11-4**] WBC-6.8 Hgb-9.3* Hct-29.4* Plt Ct-676* [**2161-11-5**] WBC-7.5 Hgb-9.0* Hct-28.0* Plt Ct-656* [**2161-10-28**] WBC-7.0 Lymph-43* Abs [**Last Name (un) **]-3010 CD3%-78 Abs CD3-2339* CD4%-16 Abs CD4-483 CD8%-61 Abs CD8-1824* CD4/CD8-0.3* [**2161-10-18**] UreaN-11 Creat-1.2 Na-136 K-4.6 Cl-96 HCO3-28 AnGap-17 [**2161-10-19**] UreaN-10 Creat-1.1 Na-139 K-3.8 Cl-102 HCO3-30 AnGap-11 [**2161-10-20**] UreaN-6 Creat-1.2 Na-140 K-3.7 Cl-103 HCO3-30 AnGap-11 [**2161-10-21**] UreaN-11 Creat-1.4* Na-142 K-3.8 Cl-102 HCO3-31 AnGap-13 [**2161-10-22**] UreaN-9 Creat-1.4* Na-141 K-3.7 Cl-100 HCO3-31 AnGap-14 [**2161-10-23**] UreaN-8 Creat-1.6* Na-141 K-4.0 Cl-104 HCO3-30 AnGap-11 [**2161-10-23**] UreaN-8 Creat-1.6* Na-138 K-3.9 Cl-100 HCO3-29 AnGap-13 [**2161-10-24**] UreaN-7 Creat-1.7* Na-139 K-3.6 Cl-101 HCO3-30 AnGap-12 [**2161-10-25**] UreaN-7 Creat-1.7* Na-138 K-4.0 Cl-100 HCO3-30 AnGap-12 [**2161-10-26**] UreaN-10 Creat-2.0* Na-139 K-4.0 Cl-100 HCO3-31 AnGap-12 [**2161-10-27**] UreaN-13 Creat-2.0* Na-140 K-4.2 Cl-103 HCO3-29 AnGap-12 [**2161-10-28**] UreaN-10 Creat-2.0* Na-141 K-4.0 Cl-102 HCO3-30 AnGap-13 [**2161-10-29**] UreaN-11 Creat-2.1* Na-143 K-4.0 Cl-105 HCO3-26 AnGap-16 [**2161-10-30**] UreaN-11 Creat-2.3* Na-143 K-4.2 Cl-105 HCO3-29 AnGap-13 [**2161-10-31**] UreaN-11 Creat-2.3* Na-141 K-4.2 Cl-105 HCO3-28 AnGap-12 [**2161-11-1**] UreaN-12 Creat-2.3* Na-143 K-4.3 Cl-105 HCO3-30 AnGap-12 [**2161-11-2**] UreaN-11 Creat-2.3* Na-145 K-4.3 Cl-105 HCO3-29 AnGap-15 [**2161-11-3**] UreaN-9 Creat-1.9* Na-143 K-4.1 Cl-104 HCO3-29 AnGap-14 [**2161-11-4**] UreaN-8 Creat-2.1* Na-147* K-4.3 Cl-108 HCO3-31 AnGap-12 [**2161-11-5**] UreaN-9 Creat-1.8* Na-145 K-4.2 Cl-105 HCO3-32 AnGap-12 [**2161-10-24**] ALT-97* AST-89* LD(LDH)-505* CK(CPK)-97 AP-288* Amylase-93 TotBili-5.1* [**2161-10-24**] CK(CPK)-102 [**2161-10-25**] ALT-79* AST-66* LD(LDH)-478* CK(CPK)-88 AP-246* Amylase-80 TotBili-4.4* DirBili-0.2 IndBili-4.2 [**2161-10-26**] ALT-64* AST-53* AP-244* TotBili-4.2* [**2161-10-27**] ALT-50* AST-43* LD(LDH)-497* AP-227* Amylase-78 TotBili-4.5* [**2161-10-28**] ALT-41* AST-41* LD(LDH)-514* AP-230* TotBili-4.4* [**2161-10-29**] ALT-37 AST-43* AP-236* TotBili-3.1* [**2161-10-30**] ALT-58* AST-79* LD(LDH)-486* AP-406* TotBili-1.5 [**2161-10-31**] ALT-44* AST-51* LD(LDH)-483* AP-371* TotBili-0.7 [**2161-11-1**] ALT-45* AST-61* LD(LDH)-469* AP-402* TotBili-0.4 [**2161-11-4**] ALT-86* AST-165* LD(LDH)-619* AP-465* TotBili-0.4 [**2161-11-5**] ALT-59* AST-69* LD(LDH)-607* AP-409* TotBili-0.4 [**2161-10-24**] CK-MB-2 cTropnT-<0.01 [**2161-10-24**] CK-MB-2 cTropnT-<0.01 [**2161-10-25**] CK-MB-2 cTropnT-<0.01 [**2161-10-28**] Type-ART pO2-92 pCO2-26* pH-7.66* calTCO2-30 Base XS-9 [**2161-10-28**] Type-ART pO2-26* pCO2-37 pH-7.53* calTCO2-32* Base XS-6 [**2161-10-29**] Type-[**Last Name (un) **] pO2-43* pCO2-47* pH-7.45 calTCO2-34* Base XS-7 [**2161-10-30**] Type-[**Last Name (un) **] pO2-154* pCO2-46* pH-7.45 calTCO2-33* Base XS-7 C [**2161-10-28**] Lactate-1.1 Na-143 K-3.7 Cl-102 [**2161-10-28**] Lactate-2.1* Na-144 K-3.8 Cl-101 [**2161-10-21**] URINE Hours-RANDOM Creat-31 Na-31 K-13 Cl-30 [**2161-10-24**] URINE Hours-RANDOM Creat-31 Na-24 [**2161-10-28**] URINE Hours-RANDOM Creat-30 Na-49 K-16 Cl-39 [**2161-10-30**] URINE Hours-RANDOM UreaN-126 Creat-45 Na-32 Phos-6.8 [**2161-10-28**] URINE Osmolal-160 [**2161-10-30**] URINE Osmolal-153 [**2161-10-20**] PLEURAL WBC-600* RBC-8125* Polys-0 Lymphs-95* Monos-5* [**2161-10-21**] PLEURAL WBC-889* RBC-[**Numeric Identifier 42605**]* Polys-1* Lymphs-89* Monos-6* Eos-1* Meso-2* Macro-1* [**2161-11-5**] PLEURAL WBC-650* RBC-[**Numeric Identifier 42606**]* Polys-7* Lymphs-91* Monos-2* [**2161-10-20**] PLEURAL TotProt-3.9 LD(LDH)-527 [**2161-10-20**] PLEURAL TotProt-3.4 LD(LDH)-447 [**2161-10-21**] PLEURAL TotProt-3.7 Glucose-119 LD(LDH)-430 CXR [**10-18**] IMPRESSION: Moderate to large left pleural effusion with related atelectasis unchanged. Subtle consolidation on the left could be obscured however the right lung remains clear. CXR [**10-20**] 1. No pulmonary embolism. 2. No significant change in moderate left pleural effusion. While small loculations of the effusion are associated, the pleural catheter resides within the largest pleural collection. Nodular thickening and enhancement of the pleura may be secondary to metastatic involvement versus iatrogenic etiologies (i.e. pleurodesis). 3. No significant change in left upper lobe pulmonary mass or innumerable lung metastases. Diffuse interlobular septal thickening may again represent lymphangitic spread of carcinoma. 4. Persistant round atelectasis involving a large portion of the left lower lobe. CXR [**10-28**] FINDINGS: As compared to the previous examination, there is no relevant change. The extent of the pre-existing left-sided pleural effusion is constant. The effusion fills more than 50% of the left hemithorax and distributes through the entirety of the pleural space. The retrocardiac lung areas and the few ventilated left lung areas are clearly atelectatic. There could be mild displacement of the heart over the midline into the right hemithorax, probably exaggerated by a relatively severe thoracic scoliosis. The right lung is free of effusions. However, mild overhydration is seen. No evidence of pneumothorax, no focal parenchymal opacities suggesting pneumonia. CXR [**10-31**] IMPRESSION: Extensive left effusion; however, decreased compared to [**2161-10-28**]. No new consolidations and no PTX. CT head [**10-28**] 1. Known pituitary/sellar mass is again identified, unchanged but incompletely evaluated. 2. No large mass lesion separate from this or area of hemorrhage. Please note that MRI is more sensitive in detection of small lesions and can be considered for assessment of metastatic disease. Renal ultrasound: No evidence of stones or hydronephrosis in either kidney. Simple cyst in the right kidney. Abdominal ultrasound [**11-4**] 1. Normal-appearing liver, with no intrahepatic lesion seen. 2. s/p cholecystectomy. The common duct is not dilated, and there is no intrahepatic biliary dilatation. ECHO: No vegetations EGD: mucosal erythema c/w gastritis pleural fluid at discharge: GRAM STAIN (Final [**2161-11-5**]): 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 [**2161-11-8**]): NO GROWTH. ANAEROBIC CULTURE (Preliminary): NO GROWTH Brief Hospital Course: 62 year old male with a h/o metastatic large cell lung cancer to bone c/b recurrent malignant pleural effusion requiring pleurex catheter placement, HIV (CD4 535) on HAART, htn who presented with dyspnea, unchanged pleural effusion on cxr and low grade fever. # Coagulase negative staph in pleural fluid, urine: Initially thought to be contaminant but grew in several samples and then in urine. Blood cultures were all negative and an echocardiogram showed no vegetations. The patient was treated with levofloxacin and was afebrile. # Pleural effusion: Drained by IP frequently throughout hospitalization usually followed by improvement in dyspnea. See above for pleural fluid analysis at discharge. The patient will continue to receive thrice weekly pleurex drainage via VNA at home. # [**Last Name (un) **]: Likely contrast induced nephropathy though elevation persisted longer than expected. Peaked at 2.3 and trending down on discharge to 1.8. # Epigastric pain. Persistent nausea/vomiting and epigastric pain. Ruled out for MI. Had EGD which showed gastritis. Path from biopsy pending. Symptoms began to improve before discharge. # Tachypnea/Anxiety. Patient was transferred to MICU overnight for tachypnea and respiratory alkalosis with pH of 7.6. It resolved with ativan and morphine. A central drive for respiratory alkalosis was ruled out by CT. He was started on [**Hospital1 **] Klonipin with good effect. # Lung cancer: Plan per primary oncologist. # HIV. CD4 483. HAART was stopped for [**Last Name (un) **], elevated LFTs. He will follow with HIV doctor as outpatient. # Hypertension: controlled well with amlodpine # Depression/suicidal ideation: iniatlly followed by pscyh for question of suicidal ideation on admission but this appears to have been a misunderstanding. They did recommend Celexa. This was started at 10mg for one day but it was not continued as patient was sent to the MICU on that day. Code- full Medications on Admission: amlodipine 10 mg daily atazanavir 300 mg daily Truvada 200mg/300mg daily ritonivir 100 mg daily alimenta Q3weeks folic acid 1 mg daily ibuprofen 800 mg TID morphine SR 15 mg [**Hospital1 **] oxycodone 5-10 mg Q4H prn ranitidine 150 mg daily colace/senna compazine 10 mg prn lactulose prn albuterol prn Discharge Medications: 1. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. 4. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as needed for wheeze. 5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:*30 Tablet(s)* Refills:*2* 8. Ranitidine HCl 150 mg Capsule Sig: One (1) Capsule PO once a day. 9. Compazine 10 mg Tablet Sig: One (1) Tablet PO once a day as needed for nausea. Disp:*30 Tablet(s)* Refills:*0* 10. Lactulose 10 gram Packet Sig: One (1) PO once a day. Disp:*30 packets* Refills:*2* Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Primary Diagnosis: metastatic large cell lung cancer HIV/AIDS Secondary Diagnoses: # stage IIIB large cell lung cancer metastatic to bone - started Alimenta [**2161-7-16**] # HIV, CD4 [**6-13**] 535, VL undetectable - diagnosed in [**2142**] - re-initiated HAART on [**2160-2-28**] # chronic malignant pleural effusion s/p talc pleurodesis [**8-12**] with pleurex catheter placed [**1-12**] for recurrent effusion # Hypertension # Positive PPD-negative AFB [**1-11**]-s/p 6 months Rifampin in [**2148**]. # Hepatitis B # s/p cholecystectomy on [**2161-4-1**] # h/o appendicitis status post appendectomy in [**2126**] # Sellar mass seen on MRI most recently on [**2160-8-4**] - a stable appearance of the intra and suprasellar mass - nonfunctioning mass as worked up by endocrinology # Low back pain Discharge Condition: stable and improved Discharge Instructions: You were admitted to the hospital for shortness of breath. Your symptoms improved after some fluid was drained from the catheter in your chest. A CT scan of your chest showed that you did not have any blood clots in your lungs. You developed mild kidney dysfunction during stay that improved with fluids. You also developed abdominal pain during your hospitalization. An endoscopic procedure showed that you had no inflammation in your esophagous, and some mild inflammation in your stomach. Biopsies were taken and we are still awaiting the results. An ultrasound of your abdomen also was normal. You continued to improve and you were discharged on [**2161-11-5**] home with services. The following changes have been made to your medications: please do not take your HIV medications until you meet with Dr. [**Last Name (STitle) 7443**]: atazanavir Truvada ritonivir See below for follow up appointments. Please call your doctor or 911 if you develop worsening shortness of breath, chest pain, fevers or chills, worsening abdominal pain, persistent vomiting or diarrhea, or any other concerning medical symptoms. Followup Instructions: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 7447**], MD Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2161-11-18**] 11:30 please call your primary oncologist, Dr. [**Last Name (STitle) 3274**], at [**Telephone/Fax (1) 15512**], this week to set up a follow up appointment next week [**First Name8 (NamePattern2) 251**] [**Name8 (MD) **] MD [**MD Number(1) 3282**]

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Discharge summary

report

Admission Date: [**2157-7-5**] Discharge Date: [**2157-8-4**] Date of Birth: [**2109-1-23**] Sex: F Service: MEDICINE Allergies: Shellfish / Flexeril Attending:[**First Name3 (LF) 949**] Chief Complaint: # Lethargy # Confusion # Hyponatremia Major Surgical or Invasive Procedure: # MICU intubation # L arm PICC placement # Bedside [**Last Name (un) **]-gastric tube placement # Fluoroscopy-guided [**Last Name (un) **]-jejunal tube placement History of Present Illness: 48F h/o Hep C cirrhosis c/b ascites, encephalopathy and BLE edema, presented to clinic with lethargy, Na = 113. Pt reported that her mother, who helps pt manage her pills, also noted that pt was "making no sense" this morning. Pt denied any recent alcohol or drug intake, and reported that she had a productive cough with somewhat yellow sputum. Pt reported that she had not been having three bowel movements daily, and at least one day had no stools. . In the ED, she was oriented x 2, with positive asterixis. Pt received albumin 50g. . On first arrival to the floor, pt denied fever, vomiting, diarrhea, dysuria, bloody stool, joint pain, muscle pain, sore throat, or changes in vision. Pt endorsed hunger, fatigue, tremors, and dizziness. It was unclear whether pt endorsed or denied nausea as her account changed, and she was not focused during the interview. Pt conducted her admission interview with her eyes closed, and spoke in a shaky mumble throughout. Past Medical History: (1) Hepatitis C cirrhosis --Encephalopathy --Ascites --Edema s/p TIPS ([**11-8**]) --Hydrothorax --Thrombocytopenia --Hyponatremia (baseline 124-128) (2) Asthma (3) Adrenal insufficiency [**1-7**] ESLD (4) GERD (5) Anxiety Social History: # Recreational drugs: Past IV drug use with needle sharing, last use 7 years ago. Past drug-snorting. # Alcohol: Past alcohol use, last drink at age 46. # Tobacco: Past [**Month/Day (2) 1818**] with 10 pack-year history # Personal: Single with one child. Lives with mother, who manages medications # Employment: Former waitress, unemployed on disability. Family History: # Mother, 60s: DM2, HTN, hypercholesterolemia # Father, d. 51: COPD, alcohol-induced cirrhosis # Brother Physical Exam: VS = T 97.1, BP 106/50, HR 83, RR 26, O2 96%, FS 148 GEN: Tremulous in bed with covers pulled up and eyes closed throughout the interview HEENT: Scleral ictera, MMM, CN II-XII grossly normal CV: RRR, S1S2, III/VI SEM, no r/g PULM: CTA @ L, decreased breath sounds at R base, no rales/rhonchi/wheezes ABD: BS+, soft, NT, protuberant, no rebound. Tympanic. EXT: 3+ BLE edema. + asterixis. NEURO: Slow to respond. A&O x 3. Could not remember three words. Pertinent Results: Admission labs: . [**2157-7-5**] 12:19PM GLUCOSE-137* K+-4.3 [**2157-7-5**] 12:00PM GLUCOSE-155* UREA N-18 CREAT-0.8 SODIUM-113* POTASSIUM-4.4 CHLORIDE-89* TOTAL CO2-18* ANION GAP-10 [**2157-7-5**] 12:00PM estGFR-Using this [**2157-7-5**] 12:00PM ALT(SGPT)-54* AST(SGOT)-101* ALK PHOS-377* AMYLASE-69 TOT BILI-19.6* [**2157-7-5**] 12:00PM ALBUMIN-2.3* CALCIUM-7.7* PHOSPHATE-3.1 MAGNESIUM-1.9 [**2157-7-5**] 12:00PM ETHANOL-NEG bnzodzpn-NEG [**2157-7-5**] 12:00PM WBC-7.7# RBC-2.90* HGB-10.0* HCT-28.9* MCV-100* MCH-34.5* MCHC-34.5 RDW-19.4* [**2157-7-5**] 12:00PM NEUTS-83* BANDS-0 LYMPHS-10* MONOS-3 EOS-3 BASOS-1 ATYPS-0 METAS-0 MYELOS-0 [**2157-7-5**] 12:00PM HYPOCHROM-NORMAL ANISOCYT-OCCASIONAL POIKILOCY-2+ MACROCYT-2+ MICROCYT-NORMAL POLYCHROM-OCCASIONAL SCHISTOCY-OCCASIONAL BURR-2+ BITE-OCCASIONAL ACANTHOCY-OCCASIONAL [**2157-7-5**] 12:00PM PLT COUNT-65* [**2157-7-5**] 12:00PM PT-23.8* PTT-50.5* INR(PT)-2.4* . # CXR [**2157-7-9**]: Multifocal patchy opacities seen in the left upper and lower lung zones, with cardiomegaly. This may represent asymmetric pulmonary edema; however, aspiration/pneumonia cannot be excluded. The ill-defined opacity in the right upper lung zone seen on the prior study has resolved. A TIPS shunt is present. . # ABD US [**2157-7-8**]: 1. Minimal intra-abdominal ascites. There was insufficient fluid to mark a location for bedside tap. 2. Patent appearance of the main portal vein. Measured TIPS velocities are similar to comparison examination. . # CXR [**2157-7-22**]: IMPRESSION: Improved aeration in the upper lobes. Persistent bilateral patchy opacities more confluent in the bases, greater on the right side. # CXR [**2157-8-1**]: FINDINGS: A PA and lateral of the chest were obtained and compared to the prior examination dated [**2157-7-30**]. Allowing for differences in technique, there is no significant interval change. The left subclavian PICC line is unchanged in position terminating within the expected region of the proximal superior vena cava. The enteric feeding catheter extends beyond the inferior margin of the film. The diffuse patchy opacities throughout both lungs are grossly unchanged. The left patchy opacity obscuring the left hemidiaphragm is unchanged. A persistent right pleural effusion is noted. Cardiomediastinal silhouette is unchanged. IMPRESSION: Stable examination as above. # RUQ Ultrasound [**2157-8-3**]: FINDINGS: Comparison is made to [**2157-7-6**]. The study is limited secondary to patient's inability to breath-hold. There is a large right pleural effusion. Color flow imaging demonstrates a patent TIPS with wall-to-wall flow though velocities cannot be measured secondary to respiratory motion. The right portal vein is patent and appears to be hepatofugal though evaluation markedly limited. There is trace ascites in the pelvis, but inadequate for paracentesis. IMPRESSION: 1. Limited exam. Patent TIPS with wall-to-wall flow. 2. Trace ascites. Brief Hospital Course: 48F h/o HCV cirrhosis, admitted to [**Hospital Ward Name 121**] 10 with hyponatremia, hepatic encephalopathy, and questionable respiratory symptoms. . # PNA: As pt reported syptoms of productive cough, admission CXR was obtained which demonstrated RUL infiltrate suspicious for infection. In light of her recent hospitalization, pt was started on ciprofloxacin 400mg IV q12H ([**7-6**]) for nosocomial PNA. To cover the possibility of aspiration PNA as pt's hepatic encephalopathy persisted, abx were broadened to vancomycin ([**7-9**])/pip-taz ([**7-9**])/azithromycin ([**Date range (1) 11067**]). Abx were discontinued on [**7-18**] given completed total abx course of approximately 10 days. Serial chest xrays every other day showed gradual interval improvement. . # Respiratory compromise: On admission, pt was ambulatory with no oxygen requirement, and pt was placed on home regimen of albuterol and fluticasone-salmeterol 100-50 mcg/dose [**Hospital1 **]. On [**7-8**], pt received 1 unit PRBC for Hct = 20.9. On [**7-9**], HD#3, patient c/o increasing SOB, with RR = 30, PaO2 = 61 on 4L NC, PCO2 = 33, pH 7.44. Repeat CXR demonstrated new L upper and lower lung infiltrates and likely volume overload. Pt's acute respiratory compromise was considered to be possibly multifactorial, with contributions from asthma exacerbation, PNA, fluid overload, and possible TRALI. TTE performed in the MICU demonstrated hyperdynamic EF, enlarged LA, and no evidence of pulmonary HTN. Pt was intubated from [**2163-7-13**] to support respiratory capacity. On [**7-21**] transfer to floor, pt had been extubated for four days, with improved respiratory status and O2sat in the mid-90s on 4L. She was weened down to 3L, where she remained stable. . # Adrenal insufficiency [**1-7**] liver failure: Pt was initially maintained on her home regimen of prednisone 5 mg daily. Upon transfer to the MICU, stress dose steroids were administered in the setting of infection, respiratory compromise, and pt's background adrenal insufficiency. After transferring back to the floor, pt was transitioned ultimately to hydrocortisone to provide both glucocorticoid and mineralocorticoid activity. She is discharged on 20 mg hydrocortisone qday. . # Asthma: After pt's episode of respiratory insufficiency, pt was continued on standing albuterol and fluticasone-salmeterol nebs, with home regimen of montelukast held. She continued albuterol and fluticasone/salmeteral nebs throughout her stay. . # [**Female First Name (un) 564**] overgrowth: In the MICU, pt was started on casofungin x 4-5 days given yeast in sputum, as it was felt to be colonization. Repeat sputum and urine cultures, however, demonstrated continued heavy yeast colonization, with urine growing C. glabrata, and sputum growing C. albicans (sensitive to fluconazole) as well as another yeast organism with indeterminate speciation. Pt was started therefore on fluconazole 200mg daily on [**7-26**]. Per ID recommendations, fluconazole was stopped since yeast was likely colonizer and not reflecting true infection. . # HCV cirrhosis: On admission, pt's MELD was 27. On [**2157-7-21**], pt was removed from the transplant list given respiratory compromise but was relisted after transferring back to the floor. Pt's MELD remained in the 20s during this admission. She will need to have weekly MELD scores, reflected in weekly lab draws to be faxed to her hepatologist Dr. [**Last Name (STitle) 497**], as outlined in the discharge plan. . # Hepatic encephalopathy: Pt was given regular doses of rifaximin, lactulose PO, and lactulose PR, titrated to achieve four bowel movements daily. Pt's mental status was noted to wax and wane throughout admission, and therefore an NG tube, later a N-J tube, was placed to prevent aspiration. Pt was placed on pureed foods with sips of thin liquids only after a bedside speech and swallow noted no active aspiration, but the need for precautions. On day of discharge she was cleared by speech and swallow for a regular diet, but should be watched directly whenever she is eating to keep her from trying to swallow too much at once - one bit and sip at a time(per speech). Her encephalopathy showed improvement daily. . # Hyponatremia/hypernatremia: Pt initially presented with Na = 113 and total body water overload. Pt therefore was intially fluid-restricted and administered albumin, with furosemide and spironolactone initially held. Diuretics were later reintroduced. Pt was noted to become hypernatremic (Na = 155) in the MICU after aggressive diuresis, and therefore NGT free water was given with normalization of Na. Free water was stopped when her Na reached 130. On day of discharge, her Na was 130. . # DM2: Pt's blood glucose was controlled with HISS, with home regimen of glipizide first reduced and then ultimately held out of concern for hypoglycemia in the setting of hepatic dysfunction. Pt was placed on glargine 12 units at bedtime to provide basal glucose control, which was subsequently increased to 17 and then 20 on day of discharge to better control her glucose. . # Anemia: Hct was noted to drift downwards to a low of 20.9 on [**7-8**], and pt was therefore transfused 1 unit PRBC. On [**7-9**], pt was noted to have severe respiratory insufficiency, with PaO2 = 61, requiring transfer to MICU. There, pt was noted to have guaiac-positive stool in the setting of known hemorrhoids, no esophageal varices. Hct ultimately stablized in the high 20s, near pt's preadmission baseline. . # Hematuria: Pt presented with gross hematuria on [**7-11**], with INR = 3.4. Hematuria was considered to be due to spontaneous bleeding in the bladder given supratherapeutic INR and possible irritation from foley catheter. FFP 2 units were transfused with resolution of hematuria. On day of discharge, her Hct was 25.9. . # UTI: Pt was noted to have entercoccus in urine culture on [**7-9**], treated with vancomycin. Urinalysis on [**7-29**] grew pan-sensitive Klebsiella, and has been receiving a course of Ciprofloxacin, to complete on [**8-8**]. . # FEN: Pt was placed on a low Na diet. After extubation, pt was given NutrenPulmonary tube feeds at 60cc/hr, cycled from 1800 hrs to 1200 hrs, to increase her caloric intake, which was then changed to continuous 24 hr. She passed swallow and is cleared to take a full diet, but should be watched directly whenever she is eating to keep her from trying to swallow too much at once (per speech). . # Full code Medications on Admission: Lactulose 30 g q8H PRN Hydroxyzine HCl 25 mg q6H PRN for bilirubin-related itch Rifaximin 400 mg TID Albuterol PRN Ferrous Sulfate 325 mg daily Clotrimazole 10 mg Troche QID Montelukast 10 mg daily Oxybutynin Chloride 5 mg [**Hospital1 **] Fluticasone-Salmeterol 100-50 mcg/dose [**Hospital1 **] Pseudoephedrine HCl 30 mg q6H PRN Lidocaine 5 %(700 mg/patch) patch daily Lorazepam 0.5 mg [**Hospital1 **] PRN Clonidine 0.1 mg [**Hospital1 **] Prednisone 5 mg DAILY Pantoprazole 40 mg EC DAILY Glipizide 5 mg [**Hospital1 **] Prochlorperazine 10 mg q8H PRN Spironolactone 50 mg daily Furosemide 20 mg daily Metoclopramide 10 mg TID PRN Discharge Medications: 1. Lactulose 10 g/15 mL Syrup [**Hospital1 **]: Forty Five (45) ML PO TID (3 times a day). Disp:*4050 ML(s)* Refills:*2* 2. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution [**Hospital1 **]: One (1) Inhalation Q4H (every 4 hours). 3. Ipratropium Bromide 0.02 % Solution [**Hospital1 **]: One (1) Inhalation Q6H (every 6 hours). 4. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution [**Hospital1 **]: One (1) Inhalation Q2H (every 2 hours) as needed for dyspnea. 5. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily). 6. Rifaximin 200 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO TID (3 times a day). 7. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated [**Last Name (STitle) **]: One (1) Adhesive Patch, Medicated Topical DAILY (Daily) as needed for Back pain. 8. Hydrocortisone 20 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily). 9. Folic Acid 1 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily). 10. Furosemide 20 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily). 11. Spironolactone 25 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO DAILY (Daily). 12. Lactulose 10 g/15 mL Syrup [**Last Name (STitle) **]: Forty Five (45) ML PO Q4H (every 4 hours) as needed. 13. Fluticasone-Salmeterol 100-50 mcg/Dose Disk with Device [**Last Name (STitle) **]: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 14. Ciprofloxacin 250 mg Tablet [**Hospital1 **]: One (1) Tablet PO Q12H (every 12 hours) for 4 days: Please give through [**2157-8-8**]. 15. Insulin sliding scale with glargine Finger sticks QACHS Glargine 20 Units qhs HISS per protocol attached 16. Heparin Flush 100 unit/mL Kit [**Month/Day/Year **]: One (1) flush Intravenous once a day: Heparin flush for PICC. Flush daily and as needed. . 17. Outpatient Lab Work Lab work on [**2157-8-9**] and weekly thereafter. FAX results to Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 497**] at [**Telephone/Fax (1) 697**]. Labwork: PT/INR, Chem-7 (sodium, potassium, chloride, bicarb, BUN, creatinine), AST, ALT, alk phos, total bilirubin. Discharge Disposition: Extended Care Facility: [**Hospital3 7**] & Rehab Center - [**Hospital1 8**] Discharge Diagnosis: Primary diagnosis: # Hyponatremia # Hypernatremia # HCV cirrhosis # Hepatic encephalopathy # Pneumonia # [**Female First Name (un) 564**] overgrowth # Adrenal insufficiency . Secondary diagnosis # Asthma Discharge Condition: Stable Discharge Instructions: You were admitted because you had a very low sodium level, and you were confused. We found that you had pneumonia and started antibiotics for you. You had a difficult time keeping your oxygen saturation normal, and therefore you had to go to the intensive care unit. There, you had to be intubated to breathe, and you continued receiving antibiotics. Afterwards, you were able to breathe on your own, and you returned to [**Hospital Ward Name 121**] 10. You continued to be very confused, so we gave you medications so that you could move your bowels. You were also found to have a urinary tract infection, and are currently on antibiotics for that. . We have given you some new medications: hydrocortisone 20mg daily folic acid 1mg daily ciprofloxacin 250mg every 12 hours until [**2157-7-8**] lactulose was increased to 45 ml three times titrated to 3 bowel movements with 45 ml as needed in addition. . You should be watched when you eat because of the potential to aspirate your food. You should eat one bite and one sip at a time. . You should return to the hospital or contact your primary care physician if you experience worsening concentration and mental status, increased bleeding, fever > 101.4 degrees F, worsening shortness of breath, or coughing up blood. Followup Instructions: Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2157-8-10**] 10:50

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icd9cm

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icd9pcs

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58,692

194,865

36431

Discharge summary

report

Admission Date: [**2105-3-20**] Discharge Date: [**2105-4-3**] Date of Birth: [**2029-11-19**] Sex: F Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 148**] Chief Complaint: Transfer from OSH for concerns with abdominal hematoma, pancreatitis, ARF, hypovolemic shock,and Pulmonary Edema Major Surgical or Invasive Procedure: Percutaneous Tracheostomy Placement [**2105-3-31**] (# 8 Portex, Cuffed, with Inner Cannula) Past Medical History: PMH: HTN, dyslipidemia, hypothyroidism, diverticulitis, colon Ca, large ventral and parastomal hernias, chronic renal failure (baseline Cr 1.6-1.8), gout, Nephrotic Syndrome ?? . PSH: L breast Ca s/p lumpectomy '[**97**], now s/p needle guided lumpectomy and SLNBx [**3-16**]; s/p appy, s/p cholecystectomy, s/p hysterectomy, s/p tonsillectomy. s/p L colectomy for colon Ca, revision of colostomy, multiple ex laps for adhesions. Social History: SocHx: 30 pack year history but quit 30 yrs ago; 1 drink/week, no recreational drugs. Lives at home with daughter Family History: N/C Physical Exam: Upon Discharge Pale, obese female in NAD, A and O VS: 97.9 82 136/62 24 96% TM Anicteric, no JVD, pale conjunctiva, EOMi RRR no m/r/g CTAB (ant) left breast well healed lumpectomy scar no sign infection abd large midline scar, massive left abdominal hernia, soft NT/ND + BS stoma is clean, protudes above skin, + gas and stool in bag, no signs infection, no parastomal hernias no c/c/e right first finger DIP swollen, blanching erythema, + TTP right metatarsal 2nd/3rd + TTP , erythema Neuro grossly intact, able to move all four extremities Psych flattened affect Pertinent Results: [**2105-4-3**] 07:00AM BLOOD WBC-10.5 RBC-3.55* Hgb-10.1* Hct-31.1* MCV-88 MCH-28.4 MCHC-32.4 RDW-14.0 Plt Ct-579* [**2105-3-29**] 01:26PM BLOOD WBC-16.3*# RBC-3.34* Hgb-9.8* Hct-30.8* MCV-92 MCH-29.2 MCHC-31.7 RDW-14.1 Plt Ct-606* [**2105-3-30**] 02:00AM BLOOD WBC-12.9* RBC-3.28* Hgb-9.0* Hct-29.6* MCV-90 MCH-27.5 MCHC-30.5* RDW-13.7 Plt Ct-570* [**2105-3-31**] 03:28AM BLOOD WBC-12.0* RBC-3.28* Hgb-9.5* Hct-29.6* MCV-90 MCH-29.0 MCHC-32.2 RDW-14.0 Plt Ct-517* [**2105-3-20**] 02:52PM BLOOD WBC-10.3 RBC-3.47* Hgb-9.9* Hct-29.9* MCV-86 MCH-28.5 MCHC-33.1 RDW-13.6 Plt Ct-327 [**2105-4-3**] 07:00AM BLOOD Glucose-118* UreaN-55* Creat-1.6* Na-140 K-3.8 Cl-106 HCO3-23 AnGap-15 [**2105-3-20**] 02:52PM BLOOD Glucose-126* UreaN-46* Creat-2.7* Na-137 K-5.5* Cl-108 HCO3-19* AnGap-16 [**2105-3-21**] 11:06AM BLOOD Glucose-89 UreaN-57* Creat-3.1* Na-139 K-4.4 Cl-109* HCO3-18* AnGap-16 [**2105-3-25**] 01:50AM BLOOD Glucose-146* UreaN-73* Creat-2.5* Na-146* K-4.5 Cl-102 HCO3-33* AnGap-16 [**2105-3-29**] 02:33AM BLOOD Lipase-68* [**2105-4-3**] 07:00AM BLOOD Calcium-9.3 Phos-4.2 Mg-2.5 [**2105-3-20**] 08:14PM BLOOD Triglyc-210* [**2105-3-21**] 11:06AM BLOOD TSH-0.80 [**2105-3-21**] 11:06AM BLOOD Free T4-0.64* [**2105-3-21**] 03:26PM BLOOD Cortsol-52.9* [**2105-3-21**] 02:15PM BLOOD Cortsol-39.8* [**2105-3-21**] 03:05PM BLOOD Cortsol-47.6* [**2105-4-1**] 04:19AM BLOOD Type-ART Temp-37.7 pO2-99 pCO2-44 pH-7.40 calTCO2-28 Base XS-1 [**2105-3-24**] 03:02PM BLOOD Type-ART Temp-37.5 Rates-/20 Tidal V-423 PEEP-10 FiO2-50 pO2-78* pCO2-49* pH-7.47* calTCO2-37* Base XS-10 Intubat-INTUBATED Vent-SPONTANEOU [**2105-3-24**] 08:33AM BLOOD Type-ART Temp-37.6 Rates-/21 Tidal V-474 PEEP-5 FiO2-50 pO2-60* pCO2-50* pH-7.46* calTCO2-37* Base XS-9 Intubat-INTUBATED Vent-SPONTANEOU [**2105-3-30**] 05:31AM BLOOD Type-ART pO2-95 pCO2-53* pH-7.39 calTCO2-33* Base XS-5 [**2105-3-30**] 02:07AM BLOOD Type-ART pO2-105 pCO2-50* pH-7.41 calTCO2-33* Base XS-5 [**2105-3-26**] 01:57PM BLOOD Type-ART pO2-71* pCO2-45 pH-7.45 calTCO2-32* Base XS-6 [**2105-3-26**] 09:15AM BLOOD Type-ART pO2-67* pCO2-46* pH-7.45 calTCO2-33* Base XS-6 [**2105-3-24**] 03:02PM BLOOD Type-ART Temp-37.5 Rates-/20 Tidal V-423 PEEP-10 FiO2-50 pO2-78* pCO2-49* pH-7.47* calTCO2-37* Base XS-10 Intubat-INTUBATED Vent-SPONTANEOU [**2105-3-24**] 02:40AM BLOOD Type-ART pO2-101 pCO2-46* pH-7.44 calTCO2-32* Base XS-5 [**2105-3-23**] 10:15PM BLOOD Type-ART pO2-100 pCO2-36 pH-7.48* calTCO2-28 Base XS-3 [**2105-3-23**] 08:37PM BLOOD Type-ART pO2-74* pCO2-43 pH-7.48* calTCO2-33* Base XS-7 [**2105-3-23**] 05:20PM BLOOD Type-ART pO2-74* pCO2-40 pH-7.49* calTCO2-31* Base XS-6 [**2105-3-23**] 11:16AM BLOOD Type-ART Rates-/20 PEEP-10 FiO2-60 pO2-55* pCO2-40 pH-7.48* calTCO2-31* Base XS-5 Intubat-INTUBATED Vent-SPONTANEOU [**2105-3-23**] 03:13AM BLOOD Type-ART pO2-97 pCO2-39 pH-7.44 calTCO2-27 Base XS-1 [**2105-3-20**] 03:15PM BLOOD Type-ART pO2-95 pCO2-50* pH-7.21* calTCO2-21 Base XS--8 [**2105-3-20**] 05:04PM BLOOD Type-ART pO2-53* pCO2-46* pH-7.21* calTCO2-19* Base XS--9 [**2105-3-20**] 06:20PM BLOOD Type-ART pO2-69* pCO2-46* pH-7.23* calTCO2-20* Base XS--8 Brief Hospital Course: OPERATIONS DURING ADMISSION [**3-20**] CVL PLACEMENT [**3-31**] PERCUTANEOUS TRACHEOSTOMY PLACEMENT (#8 Portex, Cuffed, Inner Cannula) CONSULTATIONS DURING ADMISSION SICU [**3-20**] - [**4-2**] Nephrology PRINCIPAL DIAGNOSES Acute on Chronic Renal Failure Respiratory distress with Pulmonary Edema Klebsiella Pneumonia Abdominal Hematoma likely [**1-12**] heparin gtt at OSH s/p left breast lumpectomy s/p tracheostomy Acute Gouty attacks (R DIP 1st finger, R 3rd MTP) BRIEF HOSPITAL COURSE The patient was transferred from OSH with concern for pancreatitis, abdominal LUQ hematoma in the setting of heparization for SOB in concern with PE (negative V/Q scan), abdominal pain, and hypovolemic shock with acute on chronic renal failure (chronic likely from possible Nephrotic Syndrome) and paradoxically, respiratory distress with b/l large pulmonary effusions. [**3-20**] - [**3-21**] The patient was admitted on [**3-20**] in the late evening. She was intubated for respiratory distress and had an A-line and CVL placed. Her labs were significant for an elevated creatinine of 3.1, and a bicarb of 19 concerning for metabolic acidosis in the setting of ARF. She did, however, have a normal ALT, AST, Amylase, and Lipase, so we had very low clinical concern for pancreatitis - oddly enough, the primary reason for her transfer. The patient underwent a renal consult for her renal failure, who felt that she had oliguric ARF [**1-12**] ATN from underesucitation in the setting of retroperitoneal bleeding. She was given 2 units of pRBC, a bicarbonate drip, albumin, and multiple boluses of IVF, albumin, and her creatinine eventually improved to 1.6 (near her baseline) on [**3-31**]. Blood cultures throughout her stay have been negative ([**3-20**], [**3-23**], [**3-27**]). She also underwent a hydrocortisol stress stim test to evaluate her cortisol function, which was normal. [**3-21**] -[**3-22**] The patient's UOP improved. She underwent a CT scan of the abdomen to further assess the question of peri-splenic hematoma and her respiratory distress. The CT scan was noteable for a heterogeneous perisplenic hematoma that tracked into the left anterior pararenal space and was slightly increased in size when compared to the prior outside CT scan from [**Hospital3 25148**] Center; L > R mod b/l pleural effusions w/ atelectasis of post R LL, complete atelectasis of LLL; worse from prior studies; Left axillary and left breast hematomas measuring 4.2 cm and 3.2 cm; Stable midline infraumbilical and large left lower quadrant parastomal hernias containing non- obstructed loops of bowel, and extensive colonic diverticulosis. The CT scan supports a diagnosis of actue on chronic renal failure in the setting of underresuscitation for breast and retroperitoneal hematomas [**1-12**] to heparinization for a non-existent PE, though her V/Q scan was negative, complicated by pulmonary effusions given her low albumin and proteinuria, triglyceridemia, and hypertension likely from her Nephrotic Syndrome. [**3-23**] The patient was diuresed. She remained intubated. She was also started on tube feeds via Dophoff given her normal LFTs and need for nutrition. She was seen by the ostomy nurse and her colostomy tube changed regularly. [**3-24**] - [**3-25**] The patient spiked a fever and was pan-cultured. She remained hemodynamically stable without signs of sepsis. Her diuresis was increased with lasix and diamox as repeat CXRs remained with significant b/l effusions. Her ventilatory settings improved. [**2014-3-25**] The patient was started on ciprofloxacin for a pan-sensitive Klebsiella pneumoniae. Given her improved vent settings, the patient was extubated. Unfortunately, the patient later that morning became progressively short of breath with inspiratory, and expiratory wheezes, tachypneic, and hypoxic, and so she was reintubated without difficulty. Her ABG at the time was: 7.46/50/60/37. [**3-27**] Given her failed extubation, the patient underwent an echocardiogram to assess for cardiac dysfunction contributing to her failued extubation. The echo revealed a mildly dilated LA, nl left ventricular wall thickness, cavity size and regional/global systolic function (LVEF >55%), and right ventricular chamber size and free wall motion, trace AR, mild MR, and mild pulmonary artery systolic hypertension. [**3-30**] - [**4-3**] Given her continued need for ventilatory support, the patient had a percutaneous tracheostomy tube placed on [**3-31**]. She tolerated the procedure well. Interestingly, only 1-2 days later she was able to tolerate trach mask without need for ventilation. The patient remained hemodynamically stable, tolerating her tube feeds, and so she was transferred to the floor on [**4-2**]. She underwent placement of a passy-muir valve on [**4-1**], which she has been tolerating well. She also underwent a swallow-study, that revealed dysphagia scale 4 (mild-moderate), She was noted to have "aspiration on large, consecutive sips of thin liquids alone (x1) and after ground solids as evidenced by a reflexive wet cough, though she appeared to tolerate single sips of thin liquid alternated with small bites of puree without overt coughing." She was thus recommended to have a PO diet of thin liquids and puree with supervision to ensure she is alternating bites and single sips of liquids. The patient walked out of bed to the chair with nursing. She was started back on her home medications. Unfortunately, on [**4-2**] the patient developed pain in her first right finger (DIP) and midfoot on the right; XR of her foot revealed proximal 2nd, 3rd, 4th metatarsal chronic fractures (likely neuropathic), no signs of acute fracture. Given her history of gout she was thought to have gouty attacks in the setting of stress, and was started on renally dosed colchicine. She also had some mild peristomal pain but history and exam showed no evidence of infection, parastomal hernia, or obstruction; she had no nausea, vomiting, and there was plenty of gas and stool in her stoma bag. On [**4-3**] her CVL was removed. Her Foley catheter is to be removed after discharge. On the time of discharge she is afebrile, tolerating her dysphagia, diet, alert, oriented, and stable for discharge. She needs follow-up with her primary care doctor and Dr. [**Last Name (STitle) **]. Medications on Admission: Meds at OSH: Amlodipine 5', Temazepam 15-30 QHS, Synthroid 50', Simethicone 80'''P, Tylenol PRN, Zofran PRN, Esomeprazole 40', Morphine PRN, Lopressor 2.5-5 PRN . Discharge Medications: 1. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8 hours) as needed for pain. 2. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2 times a day). 3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 4. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 5. Levothyroxine 25 mcg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 6. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 7. Esomeprazole Magnesium 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 8. Insulin Regular Human 100 unit/mL Solution Sig: One (1) Injection ASDIR (AS DIRECTED). 9. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 10. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as needed for wheeze, sob. 11. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 3 days: for PNA. 12. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed. 13. Colchicine 0.6 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 5 days. 14. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed. Discharge Disposition: Extended Care Facility: [**Hospital **] Medical Center - [**Hospital1 3597**] Discharge Diagnosis: Acute on Chronic Renal Failure Respiratory distress with Pulmonary Edema Klebsiella Pneumonia Abdominal Hematoma likely [**1-12**] heparin gtt at OSH s/p left breast lumpectomy s/p tracheostomy Acute Gouty attacks (R DIP 1st finger, R 3rd MTP) PMx: Nephrotic Syndrome, Gout, HTN, dyslipidemia, hypothyroidism, diverticulitis, large ventral and parastomal hernias, chronic renal failure (baseline Cr 1.6-1.8); L breast Ca s/p lumpectomy '[**97**], now s/p needle guided lumpectomy and SLNBx [**3-16**]; s/p appy, s/p cholecystectomy, s/p hysterectomy, s/p tonsillectomy. s/p L colectomy for colon Ca, revision of colostomy, multiple ex laps for adhesions. Discharge Condition: Stable Discharge Instructions: 1. ***Consider changing to a un-cuffed tracheostomy tube, and then down-sizing, and eventual decannulization as patient tolerates *** 2. Please remove the patient's Foley catheter upon arrival. 3. Please call your doctor or nurse practitioner or return to the Emergency Department for any of the following: *You experience new chest pain, pressure, squeezing or tightness. *New or worsening cough, shortness of breath, or wheeze. *If you are vomiting and cannot keep down fluids or your medications. *You are getting dehydrated due to continued vomiting, diarrhea, or other reasons. Signs of dehydration include dry mouth, rapid heartbeat, or feeling dizzy or faint when standing. *You see blood or dark/black material when you vomit or have a bowel movement. *You experience burning when you urinate, have blood in your urine, or experience a discharge. *Your pain in 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. 4. Please resume all regular home medications , unless specifically advised not to take a particular medication. Also, please take any new medications as prescribed. 5. Please get plenty of rest, continue to ambulate several times per day, and drink adequate amounts of fluids. 6. Please take the colchicine for five days for your gouty attacks. Your XR did not show any acute fractures of your right foot, though you do have chronic fractures in that foot. Followup Instructions: 1. Please call your primary care doctor [**First Name (Titles) **] [**Last Name (Titles) **] a follow-up appointment for your gout, your pulmonary issues, and your renal failure. If your foot pain does not improve, consider orthodics or follow-up with a podiatrist as you likely have chronic fractures in your foot. 2. Please call Dr.[**Name (NI) 2829**] office at [**Telephone/Fax (1) 62570**] for a follow-up appointment in [**1-13**] weeks. 3. Consider downsizing, uncuffing the tracheostomy tube and then eventual decannulation pending improvement of your respiratory status with supervision of a doctor. Completed by:[**2105-4-3**]

[ "E849.8", "585.9", "577.0", "581.9", "584.9", "V10.3", "729.92", "482.0", "428.0", "274.0", "518.81", "785.59", "403.90", "V10.05", "569.69", "244.9", "E934.2", "518.0" ]

icd9cm

[ [ [] ] ]

[ "33.24", "96.72", "31.1", "96.04", "38.93" ]

icd9pcs

[ [ [] ] ]

12772, 12852

4875, 11233

426, 521

13552, 13561

1730, 4852

15284, 15927

1123, 1128

11446, 12749

12873, 13531

11259, 11423

13585, 15261

1143, 1711

274, 388

543, 975

991, 1107

20,548

104,707

23142

Discharge summary

report

Admission Date: [**2111-4-6**] Discharge Date: [**2111-4-16**] Date of Birth: [**2035-6-30**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 106**] Chief Complaint: Atrial fibrillation, atrial flutter; referral from [**Location (un) 3844**] for cath and ablation. Major Surgical or Invasive Procedure: Ablation of atrial flutter Cardiac catheterization History of Present Illness: 75F w/ PMH htn, high chol, afib, aflutter, CAD ongoing SOB, fatigue, and DOE since CABG [**10-26**]. She reports that she has had worsening fatigue and SOB over the past 3 weeks, including a recently positive stress test. Plan from discussions with Dr. [**Last Name (STitle) **] and Dr. [**Last Name (STitle) 11250**] ([**Location (un) 3844**] cardiologist) is to admit patient for heparin, check TEE on day of admission, cath on HD2 by Dr. [**Last Name (STitle) **] followed by ablation by Dr. [**Last Name (STitle) 59545**]. The cath did not occur because of the events during the ablation procedure. She was emergently transfered to the CCU after she became hypotensive during an ablation procedure. Initially, during the procedure, she became hypotensive to the 60s systolic with bradycardic to the 30s. A temporary pacer was placed and dopamine was started. An echocardiogram was negative for perforation. A permanent pacemaker was subsequently placed (DDD). Later in the procedure, she complained of back pain and continued to have transient hypotension. She was intermittently on dopamine. Post-procedure, she developed abdominal pain in addition to back pain. An abdominal CT revealed a large left sided pelvic hematome (8 cm in diameter) that was shifting the bladder and the sigmoid colon. Given her persistent hypotension, she was maintained on dopamine and given 1500 cc of fluids. Her elevated INR to 1.7 was reversed with 2 units of fresh frozen plasma. She also received a total of 3 units of packed red cells. After the 3 units of red cells, her hematocrit remained stable at 30 for 24 hours. She was given a 4th unit of red cells to keep her hematocrit above 30. Her dopamine was weaned within 24 hours of her bleed. Past Medical History: [**12-27**]: TIAs w/ no residual deficits Afib CAD s/p CABG [**10-26**] Hx elevated LFTs w/ neg hep screen and neg liver bx renal insufficiency Hyperlipidemia Prior tx for C diff Thrush x 3 since '[**08**] after c-scope (polyps removed, guaiac +, w/ Dr. [**Last Name (STitle) 59546**]; f/u scope neg.) Social History: widowed, lives w/ daughter x 1.5 years. Since TIAs unable to drive. Retired. +smoker [**11-24**] ppd x 10yrs, quit [**8-26**] Family History: neg for CAD Physical Exam: 97.2 - 120/86 - 80 - 20 - 100% 2LNC aaox3, nad, appropriately communicative +JVD 3cm above clavicle, mmm irregularly irregular rate and rhythm, no mumurs moves air moderately well w/o rhonchi/wheeze; mild bibasilar crackles bs+, soft nt/nd, no guarding trace pitting edema bilaterally . Reexamination upon transfer from CCU [**4-9**]: 99.0 - 96.8 - 80 paced - 117/67 (117-145/63-83) - 28 (19-28) - 96%ra 24 hour in: 50 PO, 100 IV, 750 PRBCs 24 hour out: 795 urine Past 12h in: 140IV, 200PO, 360 PRBC Past 12h out: 500 urine - aaox3, nad - right IJ line in place w/o hematoma - L axillary hematoma, ttp, dressing c/d/i - Evidence of B groin line insertion w/o bruit or significant superficial hematoma - RRR, no m/r/g noted - CTA B. Moves air moderately well. No focal findings - Abd soft, non distended. Mild ttp left lateral abd w/o evidence of mass or ecchymossis - no edema Pertinent Results: [**2109-1-22**] carotid u/s: 25% stenosis at both bifurcations and prox int carotid arteries. . [**2109-11-7**] TEE: No spontaneous echo contrast or thrombus seen in the body of the L atrium/appendage or the body of the R atrium/appendage. No ASD, PFO noted. LVEF>55%. Diffuse plaque noted in the aortic arch and descending aorta. Complex atheroma noted in the aortic arch and descending thoracic aorta. No AS, trace AI, mild MR. . [**2109-10-29**]: cath at CMC: 100% LAD, 90% of small OMB, 50-60% pRCA, LVEF 45-50%. . [**2109-11-5**]: referred to [**Hospital1 18**] cath lab, unsuccessful PCI attempting to open LAD-->small localized perforation . [**2109-11-12**]: CABG LIMA to LAD, SVG to OM, SVG to PDA of RCA . [**2111-2-14**]: Echo non dilated LV w/ mild concentric LVH, posterior inferior wall HD. LVEF 50%. Biatrial enlargement. Mild-mod MR. Bicuspid aortic valve w/ no significant aortic stenosis or insufficiency, mild TR w/ mild pulm hypertension. . [**2111-3-10**]: Persantine stress: Decreased uptake in the anterolateral segment w/o significant reuptake, possibly breast attenuation. LVEF 54%. Possible ischemia inferiorly and posterolaterally. . [**2111-4-6**] TEE@[**Hospital1 18**]: No spontaneous echo contrast or thrombus is seen in the body of the left atrium/left atrial appendage or the body of the right atrium/right atrial appendage. No atrial septal defect is seen by 2D or color Doppler. There are complex (>4mm, non-mobile) atheroma in the aortic arch and descending thoracic aorta. The aortic valve leaflets (3) are mildly thickened. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild to moderate ([**11-24**]+) mitral regurgitation is seen. There is no pericardial effusion. Compared with the report of the prior TEE study (images unavailable for review) of [**2109-11-7**], the maximum detected LAA emptying velocity has increased. The severity of the mitral regurgitationhas slightly increased. IMPRESSION: No intracardiac thrombus. . Echo [**4-7**] post procedure: The left ventricular cavity size is normal. Right ventricular chamber size is normal. Right ventricular systolic function is normal. There is no pericardial effusion. . CXR [**4-6**]: 1. Stable post-operative appearance of the cardiomediastinal silhouette. 2. Emphysema. 3. Mild post-operative changes with no evidence of acute interstitial process. CXR post pacer [**4-7**]: There has been interval placement of a left- sided dual-chamber pacemaker with leads projecting over appropriate locations. A right-sided internal jugular vein central venous catheter is seen with the tip at the mid SVC. No pneumothorax is seen. There is stable atelectasis in the left mid lung and left base. The right lung is clear. CXR [**4-8**]: No change. . Bilateral groin U/S [**4-7**]: No evidence of pseudoaneurysm or arteriovenous fistula. No groin hematoma. Inferior margin of pelvic hematoma seen on CT today is partially imaged. . CT abd/pel [**4-7**] (post ablation) 1. Large acute extraperitoneal hematoma in the left pelvis. This finding was discussed and reviewed with the Cardiology Service while the patient was still on the scanner. Vascular Surgery was immediately paged. 2. Distended gallbladder. Stone and sludge are noted in the gallbladder body. 3. High-attenuation liver suggestive of amiodarone use. Low attenuation hepatic foci are not fully characterized on this exam. . [**4-9**] B LENI and L UE U/S: neg for DVT . Chest CT w/o contrast (amio toxicity eval; d/w Dr. [**Last Name (STitle) **] 1. No definite evidence to support pulmonary amiodarone toxicity. 2. Small bilateral pleural effusions. 3. Hyperdense liver consistent with patient's known history of amiodarone toxicity. A few scattered hypodense lesions within the liver are not adequately characterized on this non-contrast study. Ultrasound or MRI is recommended for further evaluation. 4. Distended gallbladder. Moderate amount of intraluminal sludge. 5. Pleural-based calcification in right anterior lung consistent with prior asbestos exposure. 6. Cardiomegaly and atherosclerosis. . [**2111-4-15**] Cath: 1. Selective coronary angiography showed a right dominant system with three vessel disease. The LMCA was angiographically without disease. The LAD was proximally occluded and filled via the LIMA graft. There was a 60% stenosis of the LAD proximal to the touch down of the graft. The D1 was occluded. The LCX was diffusely diseased. The OM1 was a modest branching vessel with 99% stenosis and without competitive flow. The RCA was the dominant vessel with a proximal 80% and a distal 90% just prior to the touch down of the graft. 2. Selectice arterial conduit angiography showed a widely patent LIMA-LAD graft. 3. Selective venous graft angiography showed a widely patent SVG-PDA and occluded SVG-OM graft. 4. Limited resting hemodynamics showed a mildly elevated left sided filling pressure (LVEDP 18 mmHg). There was no gradient across the aortic valve. FINAL DIAGNOSIS: 1. Three vessel coronary artery disease. 2. Mild left ventricular diastolic dysfunction. 3. Patent LIMA-LAD. 4. Patent SVG-rPDA, occluded SVG-OM Brief Hospital Course: The patient was admitted for elective ablation and cardiac catheterization. During there ablation procedure there was some bleeding noted and the patient was transferred to the CCU (see below). CCU Course: Extraperitoneal Bleed: She was emergently transfered to the CCU after she became hypotensive during an ablation procedure. Initially, during the procedure, she became hypotensive to the 60s systolic with bradycardic to the 30s. A temporary pacer was placed and dopamine was started. An echocardiogram was negative for perforation. A permanent pacemaker was subsequently placed. Later in the procedure, she complained of back pain and continued to have transient hypotension. She was intermittently on dopamine. Post-procedure, she developed abdominal pain in addition to back pain. An abdominal CT revealed a large left sided pelvic hematome (8 cm in diameter) that was shifting the bladder and the sigmoid colon. Given her persistent hypotension, she was maintained on dopamine and given 1500 cc of fluids. Her elevated INR to 1.7 was reversed with 2 units of fresh frozen plasma. She also received a total of 3 units of packed red cells. After the 3 units of red cells, her hematocrit remained stable at 30 for 24 hours. She was given a 4th unit of red cells to keep her hematocrit above 30. Her dopamine was weaned within 24 hours of her bleed. Given the size of the hematoma, she will need to be monitored for bowel ischemia. She has not had a bowel movement yet, but all stools shoul be guaiaced. Coronary artery disease: Given her acute bleed, it was decided not to pursue a cardiac catherization during this admissino. Her aspirin, plavix, beta-blocker, and ace-inhibitor were held during the acute episode. Pacer site hematoma: She also developed a hematoma below her pacemaker site that extended into her axilla and down her upper arm. Atrial Flutter: She underwent a successful atrial flutter ablation. A permanent pacemaker was placed. She remained atrial paced throughout the course. Since she doesn't have any underlying atrial fibrillation, she will not need amiodarone. Thrombocytopenia: Her platelets trended down post-ablation procedure. The likely explaination is that she had consumption from the hematoma. She was not on any medications that could contribute to the thrombocytopenia. She did not receive any heparin products during this admission. However, a HIT antibody was sent and is pending. . Floor course: The patient was stable since coming to the floor on [**4-9**]. She consistently reported improvement of her shortness of breath. Her hematocrit remained stable. Her HIT antibody test was negative and her platelets trended back up. She intermittently spiked temperatures to Tm 101.3 and was diagnosed with a UTI- started on bactrim [**4-14**] for 3 days. After further stabilization, she was afebrile and taken to the cath lab for further evaluation (see attached report). She underwent cardiac catheterization on [**4-15**]: 1. Three vessel coronary artery disease. 2. Mild left ventricular diastolic dysfunction. 3. Patent LIMA-LAD. 4. Patent SVG-rPDA, occluded SVG-OM COMMENTS: 1. Selective coronary angiography showed a right dominant system with three vessel disease. The LMCA was angiographically without disease. The LAD was proximally occluded and filled via the LIMA graft. There was a 60% stenosis of the LAD proximal to the touch down of the graft. The D1 was occluded. The LCX was diffusely diseased. The OM1 was a modest branching vessel with 99% stenosis and without competitive flow. The RCA was the dominant vessel with a proximal 80% and a distal 90% just prior to the touch down of the graft. She remained stable and afebrile after her catheterization. Physical therapy evaluated and cleared for d/c home with services. Medications on Admission: metoprolol 50'' coumadin 2.5' last dose 5/13; INR 3.0 [**4-6**] (HD1) Plavix 75' Klorcon 20meq 1-2x daily w/ lasix Lasix 20 1-2x daily depending on edema Amiodarone 200' ASA 81' Zocor 40' Vit B6' Fosamax 70 Qwk Calcium' Nystatin swish+swallow Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. Disp:*60 Tablet(s)* Refills:*0* 2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 5. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 6. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* 7. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. Disp:*60 Tablet(s)* Refills:*0* 8. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 9. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 10. Nitrofurantoin Macrocrystal 50 mg Capsule Sig: One (1) Capsule PO QID (4 times a day) for 3 days. Disp:*12 Capsule(s)* Refills:*0* 11. Amiodarone 100 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 12. Coumadin 2 mg Tablet Sig: One (1) Tablet PO at bedtime. Disp:*60 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: New Found VNA Discharge Diagnosis: Atrial fibrillation Atrial flutter Coronary artery disease Discharge Condition: Stable. Discharge Instructions: Please take all medications as prescribed and keep all follow-up appointments. Seek medical attention if you have headaches, lightheadedness, dizzyness, or any weakness or numbness, or anything else that you find worrisome. You should continue physical therapy and go to rehab. Follow their direction to help you regain your strength. Activity: - Do NOT lift anything heavier than 5 pounds with you left arm. - You should move your shoulder every day. CALL Your doctor or go to the ER IF: You have a temperature over 100.5. Your pain is happening more often or is getting worse even though you are taking your medicines. You have new or worsening swelling in your feet or ankles. You think your medicine is causing problems such as a rash, itching, or swelling. You have questions or concerns about your illness or medicine. SEEK CARE IMMEDIATELY IF: Call 9-1-1 or 0 for an ambulance right away if you have any of the following symptoms. Never try to drive yourself to the hospital if you have signs of a serious health problem. Your chest discomfort does not go away after resting and taking your chest pain medicine as directed. You have new or worsening chest pain, tightness, or discomfort that lasts longer than 15 to 20 minutes. You have chest discomfort and feel lightheaded, dizzy, weak, or faint. You have chest discomfort and suddenly start sweating for no reason that you know of. You have nausea or vomiting with your chest discomfort. You have new or worsening trouble breathing. You lose feeling or movement in your face, arms, or legs, or suddenly feel weak. You suddenly have trouble thinking clearly, seeing, or speaking. You cough or vomit blood. Followup Instructions: Call Dr. [**Last Name (STitle) **] at ([**Telephone/Fax (1) 5909**] for a follow up appointment. . Call your primary care doctor for a follow up appointment ([**Last Name (LF) **],[**Known firstname **]-[**Doctor First Name 10588**] [**Telephone/Fax (1) 11254**]). . Call Dr. [**Last Name (STitle) **] at ([**Telephone/Fax (1) 9530**] for a follow up appointment (he performed the ablation procedure).

[ "998.12", "428.0", "285.1", "414.01", "414.02", "599.0", "424.0", "287.5", "427.31", "401.9", "427.89", "458.29", "997.1", "998.11", "V15.82", "428.30" ]

icd9cm

[ [ [] ] ]

[ "37.34", "37.22", "37.83", "00.45", "00.66", "36.07", "00.41", "99.07", "88.72", "88.56", "99.04", "37.72", "37.78", "38.93" ]

icd9pcs

[ [ [] ] ]

14404, 14448

8848, 12657

412, 465

14551, 14561

3651, 8660

16284, 16689

2726, 2739

12950, 14381

14469, 14530

12683, 12927

8677, 8825

14585, 16261

2754, 3632

274, 374

493, 2242

2264, 2567

2583, 2710

6,271

116,482

30885

Discharge summary

report

Admission Date: [**2182-4-25**] Discharge Date: [**2182-5-1**] Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 4691**] Chief Complaint: Right Upper Quadrant Abdominal pain Major Surgical or Invasive Procedure: Laparoscopic Cholecystectomy ERCP History of Present Illness: 89M with PMH HTN p/w 2 days RQU pain, +chills, +N/V, yellow stool, tea colored urine. Initially presented to OSH, found to have WBC 25 with left shift, elevated TBili 12.2 DBili 7.5, Lipase 1017, AST/ALT 92/58. Patient also found to be in new onset Afib. Past Medical History: HTN Elevated cholesterol Gout CAD Social History: Denies EtOH, Denies tobacco Lives at home with wife Family History: Non-contributory Physical Exam: (On Admission) 97.3 74 112/58 18 96RA NAD, A&OX3 HEENT: scleral icterus CV: Irreg irreg, II/VI holosystolic mumur, loud S2 LUNGS: Scattered mild expiratory wheeze ABD: RUQ pain, distended, no rebound/guarding EXT: no edema SKIN: jaundice NEURO: grossly intact Pertinent Results: [**2182-4-25**] 10:08PM WBC-30.6*# RBC-3.88* HGB-13.3* HCT-38.1* MCV-98 MCH-34.2* MCHC-34.8 RDW-14.7 [**2182-4-25**] 10:08PM PLT COUNT-229 [**2182-4-25**] 08:47PM GLUCOSE-99 UREA N-35* CREAT-1.3* SODIUM-139 POTASSIUM-3.1* CHLORIDE-108 TOTAL CO2-21* ANION GAP-13 [**2182-4-25**] 08:47PM ALT(SGPT)-34 AST(SGOT)-49* CK(CPK)-40 ALK PHOS-247* AMYLASE-125* TOT BILI-11.4* [**2182-4-25**] 08:47PM LIPASE-81* [**2182-4-25**] 08:47PM CK-MB-NotDone cTropnT-<0.01 [**2182-4-25**] 08:47PM ALBUMIN-2.3* CALCIUM-7.7* PHOSPHATE-2.4* MAGNESIUM-1.7 [**2182-4-25**] 08:47PM PT-17.0* PTT-34.8 INR(PT)-1.6* [**2182-4-25**] 09:10AM GLUCOSE-81 UREA N-34* CREAT-1.1 SODIUM-137 POTASSIUM-4.1 CHLORIDE-101 TOTAL CO2-23 ANION GAP-17 [**2182-4-25**] 09:10AM ALT(SGPT)-44* AST(SGOT)-64* CK(CPK)-30* ALK PHOS-330* AMYLASE-277* TOT BILI-12.9* [**2182-4-25**] 09:10AM LIPASE-294* [**2182-4-25**] 09:10AM CK-MB-NotDone cTropnT-<0.01 [**2182-4-25**] 09:10AM ALBUMIN-2.9* CALCIUM-9.5 PHOSPHATE-3.3 MAGNESIUM-2.0 [**2182-4-25**] 09:10AM WBC-2.8*# RBC-4.78 HGB-15.7 HCT-46.9 MCV-98 MCH-32.9* MCHC-33.5 RDW-14.6 [**2182-4-25**] 09:10AM PLT COUNT-234 [**2182-4-25**] 09:10AM PT-15.2* PTT-23.4 INR(PT)-1.4* [**2182-4-25**] 12:00AM GLUCOSE-106* UREA N-30* CREAT-1.1 SODIUM-135 POTASSIUM-3.2* CHLORIDE-97 TOTAL CO2-29 ANION GAP-12 [**2182-4-25**] 12:00AM estGFR-Using this [**2182-4-25**] 12:00AM ALT(SGPT)-42* AST(SGOT)-53* ALK PHOS-320* AMYLASE-394* TOT BILI-12.1* [**2182-4-25**] 12:00AM LIPASE-408* [**2182-4-25**] 12:00AM ALBUMIN-3.0* [**2182-4-25**] 12:00AM ACETONE-NEGATIVE [**2182-4-25**] 12:00AM WBC-22.7* RBC-4.26* HGB-14.6 HCT-40.8 MCV-96 MCH-34.2* MCHC-35.7* RDW-14.8 [**2182-4-25**] 12:00AM NEUTS-90* BANDS-4 LYMPHS-3* MONOS-3 EOS-0 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 [**2182-4-25**] 12:00AM HYPOCHROM-NORMAL ANISOCYT-1+ POIKILOCY-NORMAL MACROCYT-1+ MICROCYT-NORMAL POLYCHROM-NORMAL [**2182-4-25**] 12:00AM PLT SMR-NORMAL PLT COUNT-251 [**2182-4-26**] 04:41AM BLOOD WBC-29.7* RBC-3.92* Hgb-13.0* Hct-38.5* MCV-98 MCH-33.2* MCHC-33.8 RDW-15.0 Plt Ct-253 [**2182-4-27**] 01:40AM BLOOD WBC-15.6* RBC-3.72* Hgb-12.0* Hct-36.5* MCV-98 MCH-32.3* MCHC-33.0 RDW-14.9 Plt Ct-204 [**2182-4-28**] 02:08AM BLOOD WBC-12.3* RBC-3.63* Hgb-11.9* Hct-34.6* MCV-95 MCH-32.7* MCHC-34.2 RDW-15.1 Plt Ct-175 [**2182-4-28**] 05:16PM BLOOD WBC-11.5* RBC-3.94* Hgb-13.2* Hct-37.0* MCV-94 MCH-33.6* MCHC-35.8* RDW-15.0 Plt Ct-206 [**2182-4-29**] 04:05AM BLOOD WBC-11.1* RBC-3.43* Hgb-11.4* Hct-33.1* MCV-97 MCH-33.3* MCHC-34.5 RDW-15.1 Plt Ct-186 [**2182-4-30**] 03:48AM BLOOD WBC-16.0* RBC-3.64* Hgb-11.8* Hct-35.0* MCV-96 MCH-32.5* MCHC-33.8 RDW-14.8 Plt Ct-212 [**2182-5-1**] 06:55AM BLOOD WBC-14.1* RBC-3.66* Hgb-12.3* Hct-34.9* MCV-96 MCH-33.5* MCHC-35.1* RDW-14.9 Plt Ct-272 [**2182-4-26**] 04:41AM BLOOD Plt Ct-253 [**2182-4-27**] 01:40AM BLOOD PT-14.9* PTT-32.5 INR(PT)-1.3* [**2182-4-27**] 01:40AM BLOOD Plt Ct-204 [**2182-4-28**] 02:08AM BLOOD PT-12.5 PTT-32.0 INR(PT)-1.1 [**2182-4-26**] 04:41AM BLOOD Glucose-90 UreaN-38* Creat-1.0 Na-139 K-3.7 Cl-109* HCO3-20* AnGap-14 [**2182-4-27**] 01:40AM BLOOD Glucose-88 UreaN-40* Creat-1.2 Na-140 K-3.2* Cl-110* HCO3-22 AnGap-11 [**2182-4-28**] 02:08AM BLOOD Glucose-94 UreaN-31* Creat-1.1 Na-137 K-3.1* Cl-108 HCO3-23 AnGap-9 [**2182-4-28**] 05:16PM BLOOD Glucose-92 UreaN-28* Creat-0.9 Na-139 K-3.8 Cl-108 HCO3-23 AnGap-12 [**2182-4-29**] 04:05AM BLOOD Glucose-110* UreaN-23* Creat-0.8 Na-138 K-3.8 Cl-107 HCO3-27 AnGap-8 [**2182-4-30**] 03:48AM BLOOD Glucose-115* UreaN-19 Creat-0.9 Na-136 K-4.2 Cl-104 HCO3-27 AnGap-9 [**2182-5-1**] 06:55AM BLOOD Glucose-104 UreaN-15 Creat-0.9 Na-137 K-3.4 Cl-102 HCO3-30 AnGap-8 [**2182-4-26**] 04:41AM BLOOD ALT-34 AST-48* CK(CPK)-40 AlkPhos-239* Amylase-95 TotBili-11.1* [**2182-4-28**] 02:08AM BLOOD ALT-24 AST-29 LD(LDH)-140 AlkPhos-191* Amylase-90 TotBili-5.3* [**2182-4-28**] 05:16PM BLOOD ALT-26 AST-29 LD(LDH)-141 AlkPhos-210* Amylase-134* TotBili-4.9* [**2182-4-29**] 04:05AM BLOOD ALT-22 AST-26 AlkPhos-190* Amylase-134* TotBili-4.5* [**2182-4-30**] 03:48AM BLOOD ALT-30 AST-57* LD(LDH)-245 AlkPhos-183* Amylase-150* TotBili-4.2* [**2182-5-1**] 06:55AM BLOOD ALT-30 AST-40 AlkPhos-196* Amylase-189* TotBili-3.5* [**2182-4-26**] 04:41AM BLOOD Lipase-63* [**2182-4-28**] 02:08AM BLOOD Lipase-161* [**2182-4-28**] 05:16PM BLOOD Lipase-208* [**2182-4-29**] 04:05AM BLOOD Lipase-240* [**2182-4-30**] 03:48AM BLOOD Lipase-208* [**2182-4-26**] 04:41AM BLOOD Albumin-2.3* Calcium-8.2* Phos-2.5* Mg-2.7* [**2182-4-27**] 01:40AM BLOOD Calcium-8.5 Phos-2.1* Mg-2.4 [**2182-4-28**] 02:08AM BLOOD Albumin-2.0* Calcium-8.2* Phos-2.5* Mg-2.1 [**2182-4-28**] 05:16PM BLOOD Albumin-2.3* Calcium-8.5 Phos-1.8* Mg-1.9 [**2182-4-29**] 04:05AM BLOOD Calcium-8.3* Phos-2.3* Mg-1.8 [**2182-4-29**] 06:24PM BLOOD Calcium-8.7 Phos-3.3 Mg-2.2 [**2182-4-30**] 03:48AM BLOOD Albumin-2.0* Calcium-8.3* Phos-3.4 Mg-2.0 Brief Hospital Course: Patient was admitted to the General Surgery floor from the Emergency Department. On HD1 the patient underwent ERCP where three stones, sludge, and pus were extracted as well as a sphincterotomy was performed without complication. In the recovery room the patient had a hypotensive episode to the 60's systolic - was transfered to the ICU and responed to fluid resusication as well as low dose pressors. On post-procedure day two the patient was weaned off of pressors and was in stable condition when transfered to the regular general surgery [**Hospital1 **] on hopspital day 4. On HD5 the patient underwent a laparoscopic cholecystectomy without complication - please refer to the operative note for full details. The patient was also evaluated by cardiology for the new-onset atrial fibrillation who recommeded holding all beta blockers and starting anticoagulation when hemostatically stable post-operatively and s/p sphincterotomy. At the time of discharge the patient was doing well, tolerating a regular diet and was without complaints. Medications on Admission: Corgard 160 HCTZ 50 ASA 325 Nitro PRN MVT Zocor 20 Discharge Medications: 1. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 2. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. Disp:*30 Tablet(s)* Refills:*0* 3. Amoxicillin-Pot Clavulanate 500-125 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) for 7 days. Disp:*21 Tablet(s)* Refills:*0* 4. Aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day. 5. Colace 100 mg Capsule Sig: One (1) Capsule PO three times a day. Disp:*90 Capsule(s)* Refills:*2* 6. Zocor 20 mg Tablet Sig: One (1) Tablet PO at bedtime. 7. Nitroglycerin SL PRN 8. MVT Discharge Disposition: Home With Service Facility: [**Company 1519**] Discharge Diagnosis: Gall stone pancreatitis with cholangitis Atrial Fibrillation Discharge Condition: Stable Discharge Instructions: Please call physician or return to the Emergency Department if any of the following occur: 1. Fever >101.5 2. Increased abdominal pain 3. Intractable nausea/vomiting 4. Redness or swelling or discharge from incision sites 5. Any other concerning symptoms Followup Instructions: Please follow-up with Dr. [**Last Name (STitle) **] within one to two weeks. Call [**Telephone/Fax (1) 6429**] for appointment. Please follow-up with your primary care provider within one to two weeks for follow-up of your atrial fibrillation. Current [**Hospital1 18**] Cardiology recommendation are to start anticoagulation when sufficient time has elapsed from surgery/ERCP (1-2 weeks). It is my impression however that the patient is at significant fall risk. Thus considering the low rate of embolic events from AFib (probably ~5% per year) and the patient's age, the primary physician might consider avoiding warfarin therapy, as the increased risk from trauma (especially intra-cranial bleeding) may exceed the embolic risk. Completed by:[**2182-5-1**]

[ "272.0", "397.0", "427.31", "577.0", "995.92", "576.1", "428.0", "038.9", "401.9", "274.9", "785.52", "574.71" ]

icd9cm

[ [ [] ] ]

[ "51.88", "38.93", "51.23", "51.87", "51.85" ]

icd9pcs

[ [ [] ] ]

7783, 7832

5991, 7042

297, 333

7937, 7946

1078, 5968

8249, 9014

761, 779

7143, 7760

7853, 7916

7068, 7120

7970, 8226

794, 1059

221, 259

361, 619

641, 676

692, 745

64,599

175,367

54253

Discharge summary

report

Admission Date: [**2129-1-26**] Discharge Date: [**2129-1-27**] Date of Birth: [**2084-12-19**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 398**] Chief Complaint: Dyspnea Major Surgical or Invasive Procedure: None History of Present Illness: This is a 44 year-old female with a history of asthma, hypertension, diabetes, hypercholesterolemia, and GERD. Who presented with dyspnea. In the ED: VSS, afebrile, BP's 150-180, hr 120's. Received 60mg po prednisone, nebs, levoflox. CXR no acute process, CTA no PE/dissection. Labs wnl except for lactate 4.1--->5.0 even after 4L NS. ROS: The patient denies any fevers, chills, weight change, nausea, vomiting, abdominal pain, diarrhea, constipation, melena, hematochezia, chest pain, orthopnea, PND, lower extremity edema, cough, urinary frequency, urgency, dysuria, lightheadedness, gait unsteadiness, focal weakness, vision changes, headache, rash or skin changes. Past Medical History: Asthma - in the winter only Hypertension Diabetes Hypercholesterolemia GERD Social History: Patient is single and lives with her mom. She has no pets. She works for the [**Company 2318**], driving the #39 bus. She reports an occasional 1 or 2 cigarettes as a teenager, but was never a pack-a-day smoker. She drinks alcohol very rarely. Family History: NC Physical Exam: Vitals: T:100.3 BP:164/85 HR:125 RR:15 O2Sat:98% on RA GEN: Well-appearing, well-nourished, no acute distress, obese HEENT: EOMI, PERRL, sclera anicteric, no epistaxis or rhinorrhea, MMM, OP Clear NECK: No JVD, carotid pulses brisk, no bruits, no cervical lymphadenopathy, trachea midline COR: RRR, no M/G/R, normal S1 S2, radial pulses +2 PULM: Lungs CTAB, no W/R/R ABD: Soft, NT, ND, +BS, no HSM, no masses EXT: No C/C/E, no palpable cords NEURO: alert, oriented to person, place, and time. CN II ?????? XII grossly intact. Moves all 4 extremities. Strength 5/5 in upper and lower extremities. Patellar DTR +1. Plantar reflex downgoing. No gait disturbance. No cerebellar dysfunction. SKIN: No jaundice, cyanosis, or gross dermatitis. No ecchymoses. Pertinent Results: [**2129-1-26**] 10:45AM GLUCOSE-333* UREA N-12 CREAT-0.8 SODIUM-133 POTASSIUM-3.6 CHLORIDE-97 TOTAL CO2-23 ANION GAP-17 [**2129-1-26**] 10:45AM CK(CPK)-85 [**2129-1-26**] 10:45AM cTropnT-<0.01 [**2129-1-26**] 10:45AM CK-MB-NotDone [**2129-1-26**] 10:45AM CALCIUM-9.6 PHOSPHATE-3.2 MAGNESIUM-1.7 [**2129-1-26**] 10:45AM D-DIMER-234 [**2129-1-26**] 10:45AM TSH-0.25* [**2129-1-26**] 10:45AM WBC-9.7 RBC-4.28 HGB-13.5 HCT-38.2 MCV-89 MCH-31.5 MCHC-35.2* RDW-13.0 [**2129-1-26**] 10:45AM NEUTS-80.7* LYMPHS-11.8* MONOS-4.0 EOS-3.0 BASOS-0.7 [**2129-1-26**] 10:45AM PLT COUNT-440 [**2129-1-26**] 10:45AM D-DIMER-As of [**12-7**] [**2129-1-26**] 02:02PM LACTATE-5.0* [**2129-1-26**] 04:56PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-1000 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-NEG [**2129-1-26**] 09:10PM CK-MB-4 cTropnT-<0.01 [**2129-1-26**] 09:10PM CK(CPK)-103 [**2129-1-26**] 09:29PM LACTATE-5.9* ECG: Sinus tachycardia at 126 bpm, normal axis, LVH. ? v4-v6 STD IMAGING: CXR ([**1-26**]): Linear area of atelectasis in the left upper lobe with no acute cardiopulmonary process. Repeat AP and left lateral radiographs are recomended. CTA ([**1-26**]): 1. No aortic dissection or pulmonary embolism. 2. Indeterminate nodule in the left lobe of the thyroid gland, which can be assessed further with a non-emergent thyroid ultrasound. Brief Hospital Course: 44 year-old female with a history of asthma, HTN, HLD, GERD who presents with dyspnea and is admitted to the ICU with sinus tachycardia. Likely asthma exacerbation vs. viral infection. # Dysnpea: Unclear cause. By the time the patient arrived to the ICU on exam her lungs were clear with no wheezes or crackles. No [**Location (un) **]. CXR and CTA negative. On room air currently without complaint. Has prior hx of asthma, spirometry in [**5-/2128**] suggestive of restrictive lung disease. Received prednisone 60mg x1 in ED, nebs and levoflox. No s/sx of infection, WBC wnl though lactate elevated at 5. Would also consider viral etiology with temp to 100.3. Other less likely possibilites include bacterial PNA given ? of productive cough though does not appear ill and CXR clear. Could consider flash pulmonary edema in setting of hypertension but CXR is clear and patient is on room air. Last echo in [**2127**] with preserved systolic and diastolic function without any structural abnormalities so new heart failure unlikely. She was treated with atrovent, fluticasone, and albuterol prn and placed [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern1) **] taper of po prednisone for another 3 days of 40 mg prednisone daily for a possible asthma exacerbation (received 60mg of prednisone in ED). Her cultures were NGTD. # Tachycardia: The patient presented with sinus tach in 120's even after 4L NS in ED in addition to hypertension. She had no PE seen on CTA, no O2 requirement, and was not in pain. Temp to 100.3 in ED, possible viral etiology and hypermetabolic state. Her tachycardia may have been secondary to nebs received in ED though she was tachy on presentation in ED. She reports no missed HTN medication doses so medication withdrawal unlikely. Patient has thyroid nodule seen on CT not noted on prior CT in [**2127**]. Patient has rare EtOH use (last use was one month ago) so EtOH withdrawal very unlikely. No hx of drug use per patient or prior records. CE negative x2, EKG without clear evidence of ischemia. Overnight her tachycardia trended down to the low 100's. Her TSH was low, so a free T4 was checked and was normal at 0.93, so it is unlikely that her tachycardia was due to hyperthyroidism. # Elevated Lactate: Unclear cause, does not appear systemically infection, not hypotensive. Did not decrease with fluid initally. [**Month (only) 116**] be secondary to Metformin use. When rechecked in the am, it had decreased to 1.9. # HTN: The patient was hypertensive to 180's in ED, was 140-160's on transfer to the ICU. She was continued on her home meds including lisinopril and amlodipine. She remained hypertensive to the 150's in the ICU. Will have her follow up for outpatient management of her hypertension. # Thyroid Nodule: Unclear significance. Not noted on prior CT in [**2127**]. Her TSH was checked and was low at 0.25. Added on a free T4 which was normal at 0.93. Will need outpatient follow up, likely including an ultrasound of her thyroid. She has an appointment scheduled at her primary care physician's office for early next week. # Diabetes: Blood glc was 333 on admission. A1c 7.4% in [**12-13**]. On metformin and glyburide. Has glc of 1000 in urine, no ketones. Her PO medications were held and she was covered with SSI. She was continued on her home aspirin. # GERD: The patient was continued on her home omeprazole. # Code: Full code Medications on Admission: Medications Per OMR notes: Pneumovax in [**2124**], Influenza [**10/2128**] Albuterol 2 puffs q4h prn Amlodipine 10 mg qd Glyburide 5 mg Tablet [**Hospital1 **] Lisinopril 40 mg qd Metformin 850 mg tid Omeprazole 20 mg Capsule qd ASA 81mg qd Simvastatin 20mg qd Fish Oil capsules Discharge Medications: 1. Lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day. 2. Amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day. 3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 4. Simvastatin 20 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 DAILY (Daily). 6. Prednisone 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily) for 2 days. Disp:*2 Tablet(s)* Refills:*0* 7. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation every four (4) hours as needed for wheeze, SOB. Disp:*1 inhaler* Refills:*0* 8. Fish Oil Oral 9. Metformin 850 mg Tablet Sig: One (1) Tablet PO three times a day. 10. Glyburide 5 mg Tablet Sig: One (1) Tablet PO twice a day. 11. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [**Hospital1 **] (2 times a day). Disp:*1 inhaler* Refills:*2* 12. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation QID (4 times a day). Disp:*1 inhaler* Refills:*2* 13. Peak Air Peak Flow Meter Device Sig: One (1) peak flow meter Miscellaneous twice a day: Check your peak flows twice daily or when you are having symptoms. Disp:*1 device* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Primary - Asthma exacerbation Sinus tachycardia Thyroid nodule Secondary - Hypertension Diabetes Discharge Condition: Stable, sating well on RA. Discharge Instructions: You were admitted to the hospital due to tachycardia (high heart rate) and shortness of breath. You underwent a chest CT in the emergency room which showed no cause for your shortness of breath, although it did show a new nodule (small growth) in your thyroid. You shortness of breath resolved with neb treatments and was thought to be due to an asthma exacerbation. Your elevated heart rate decreased overnight. Your thyroid function was checked and was noted to be slightly abnormal. You will need to follow up closely with your primary doctor [**First Name (Titles) **] [**Last Name (Titles) 444**] and workup for the thyroid nodule seen on CT. You blood sugars were also noted to be elevated during your hospitalization. You should check your fingersticks and follow up with your primary doctor for continued [**Last Name (Titles) 444**] of your diabetes. Medication changes: 1. You will need to take 40 mg of prednisone for two more days (you received today's dose at the hospital). 2. You should take a fluticasone inhaler 2 puffs twice daily to treat asthma as well as atrovent inhaler 2 puffs four times a daily. 3. Use 2 puffs of albuterol as needed every four hours for shortness of breath or wheezing. Otherwise continue your outpatient medications as prescribed. Go to the emergency room or call you primary docotor if you experience fevers, chills, shortness of breath, dizziness, wheezing, or chest pain. Followup Instructions: You already had an appointment scheduled with the NP[**Company 2316**] next week: Provider: [**Name10 (NameIs) **] FERN, RNC Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2129-2-1**] 10:40 It is very important that you keep this appointment, or reschedule it if you cannot make it. Please keep your other previously scheduled appointments: Provider: [**Name10 (NameIs) 7158**] [**Last Name (NamePattern4) 7159**], M.D. Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2129-4-5**] 9:50 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 101846**], [**MD Number(3) 1240**]:[**Telephone/Fax (1) 95321**] Date/Time:[**2129-4-8**] 10:30 Completed by:[**2129-1-27**]

[ "241.0", "E932.3", "493.92", "250.00", "427.89", "272.0", "530.81", "796.4", "794.5", "401.9" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

8672, 8678

3614, 7085

323, 330

8820, 8849

2208, 3591

10330, 11018

1416, 1420

7415, 8649

8699, 8799

7111, 7392

8873, 9742

1435, 2189

9762, 10307

276, 285

358, 1034

1056, 1134

1150, 1400

19,223

124,330

50460

Discharge summary

report

Admission Date: [**2203-10-9**] Discharge Date: [**2203-10-17**] Service: MEDICINE Allergies: Zosyn / Percocet Attending:[**First Name3 (LF) 2387**] Chief Complaint: Weakness Major Surgical or Invasive Procedure: Permanent Pacemaker History of Present Illness: 89 year old woman with HLD, CAD s/p DES to RCA in [**2191**], atrial fibrillation, and PulmHTN who presents with generalized weakness. Patient was seen in the ED [**10-7**] after scheduled visit with NP on [**10-7**] where patient was found have HR in 140s. In ED yesterday pt was in Afib with rates in 60s at that time, Dr. [**Last Name (STitle) **] saw patient who agreed with plan to send home, with [**Doctor Last Name **] of hearts holter monitor and add 12.5mg metoprolol [**Hospital1 **] to her medications (in addition to her home verapamil SR 240mg AM and dronedarone 400 mg [**Hospital1 **]). She was discharged home and the next day still felt weak with which promopted her to return. Of note seen on [**9-1**] with similar symptoms of weakenss noted to not be on appropriate Dronedarone regimen at that time. Notes that the malaise has been worsening in the last several months and significantly worse in the last 6-8 weeks accompanied by DOE. . This admission, in the ED, initial vitals were 98.2, 65, 102/81, 16, 97% on 2L NC. EKG showed Afib with rate in the 30s-40s and SBP dropped to the 80s-90s. No CP, no nausea, no emesis. She was given glucagon 0.5mg (to reverse BB), calcium gluconate 1g (to reverse CCB) without response, Dopamine added which increasd HR to 60s and SBPs to 100s. Also in [**Name (NI) **] pt became Hypoxemic, requiring NRB with SaO2 98%. Repeat CXR showed mild worsening of congestion. Levo 750mg was given at that time to cover for "anything." Has 18 and 20g PIVs. . In CCU: HR 65, BP 104/65, SaO2 98% on 5L, on 8mcg of Dopamine. Nausea, and pain from foley. O/N: D/C'd foley, IV Lasix 40mg x 1, Zofran, Heparin gtt, EKG, statin, aspirin, held home cardiac meds Past Medical History: PAF Hypercholesterolemia CAD s/p RCA angioplasty in [**2192**]. Negative P-MIBI [**9-22**] Breast CA. s/p L mastectomy with [**Doctor First Name **] dissection [**11/2187**] Hypothyriodism Osteopenia Social History: no tob/ occ etoh/ no rec drugs, she lives in a retirement [**Last Name (un) **], her son moved in with her. she is very active, plays bridge, goes swimming, and goes to symphonies. Family History: Mother with MI at 59, brother with h/o cardiac arrest, father with h/o CHF; brother with h/o afib Physical Exam: ADMISSION EXAM: VS: HR 65, BP 104/65, SaO2 98% on NRB or 5L, on 5mcg of Dopamine GENERAL: Looks stated age, twitching, nauseous, complaining of foley pain. Oriented x3. HEENT: Dry mucosa, EOMI, good dentition. NECK: Supple JVP of up to angle of mandible. CARDIAC: Irregular, Late peaking systolic murmur in axilla, with +s1+s2 appreciated. LUNGS: Crackles b/l 1/2 up, requiring NRB although speaking in full sentences and not using accessory muscles. ABDOMEN: Soft, NTND. EXTREMITIES: No c/c/e. Right pretibial area with dark purple confluent pigmentation PULSES: dopplerable DP/PT B/L DISCHARGE EXAM: A/O x3, NAD sitting in bed. Able to take shower with no SOB and O2 sat 95%. HEENT: no JVD CV: irreg irreg rhythm Chest: bibasilar course crackles ABD: soft, NT Extremeties: no peripheral edema Pertinent Results: [**2203-10-8**] 10:15PM WBC-12.9* RBC-3.73* HGB-10.3* HCT-31.5* MCV-84 MCH-25.5* MCHC-32.7 RDW-15.7* [**2203-10-8**] 10:15PM NEUTS-71.4* LYMPHS-16.7* MONOS-9.6 EOS-2.0 BASOS-0.3 [**2203-10-8**] 10:15PM cTropnT-<0.01 [**2203-10-8**] 10:15PM GLUCOSE-132* UREA N-34* CREAT-1.8* SODIUM-139 POTASSIUM-5.1 CHLORIDE-101 TOTAL CO2-24 ANION GAP-19 [**2203-10-8**] 10:15PM CALCIUM-9.3 PHOSPHATE-5.2*# MAGNESIUM-2.1 [**2203-10-8**] 10:15PM PT-13.4* PTT-38.3* INR(PT)-1.2* . Imaging [**2203-10-17**] CXR ReportCONCLUSION: 1. Pulmonary edema has resolved since [**2203-10-11**]. 2. Right lower lung opacities have increased since previous exam. It could be due to atelectasis and lower lung volume; however, aspiration or pneumonia cannot be excluded. . ECG [**10-15**]: Atrial paced rhythm. Right bundle-branch block. Prolonged Q-T interval at 0.47. Compared to the previous tracing no change. . ECHO [**10-10**]: 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>55%). There is no ventricular septal defect. The right ventricular cavity is dilated with borderline normal free wall function. There is abnormal diastolic septal motion/position consistent with right ventricular volume overload. 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 ([**1-17**]+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. Severe [4+] tricuspid regurgitation is seen. There is moderate pulmonary artery systolic hypertension. [In the setting of at least moderate to severe tricuspid regurgitation, the estimated pulmonary artery systolic pressure may be underestimated due to a very high right atrial pressure.] There is no pericardial effusion. . Discharge: [**2203-10-17**] 07:06AM BLOOD WBC-7.8 RBC-3.41* Hgb-8.9* Hct-28.1* MCV-82 MCH-26.2* MCHC-31.8 RDW-16.5* Plt Ct-256 [**2203-10-17**] 07:06AM BLOOD Glucose-94 UreaN-23* Creat-1.3* Na-138 K-4.2 Cl-101 HCO3-28 AnGap-13 Brief Hospital Course: 89 yo female with h/o pAfib, CAD, who presented to ED with weakness, found to be bradycardic to 30s-40s and MAPs of 50s, and hypoxemic with SaO2 in 80s requiring Dopamine and NRB. Weaned off Dopamine and NRB within 24 hours. . # Atrial Fibrillation with Bradycardia: Afib is paroxysmal. In ED HR 30s-40s in Afib, increased to 90s after brief course of dopamine. Etiologies include new medications (recent addition of Metoprolol), MI (no s/s on EKG and neg enzymes), Infection (no fever, +leukocytosis), metabolic disturbances (electrolytes wnl). In [**Name (NI) **] Pt received glucagon, ca gluconate and then HR increased to 60s after Dopamine started. Home regimen includes Verapamil ER 240 in AM and 120 in pm, Dronedarone 400mg/day, Dabigatran 75mg/day, [**10-7**] Dr. [**Last Name (STitle) **] added Metop 12.5 mg [**Hospital1 **] when pt was in ED on [**10-7**]. We decided to hold all Afib meds except Verapamil. Dabigatran was restarted during hospitalization. Echo was checked that was not concerning. It was noted that the patient's QTc was ~ 500msec, which prompted disucssion of PPM. Pt was then scheduled for a permanent pacemaker, which was placed on [**10-11**]. The patient was treated with 3 days of Abx post PPM placement per protocol. Dronedarone stoppped due to CHF and QTc. Sotalol was started [**10-11**]. Patient's QTc was monitored and stable at 480 on day of discharge. . # Non Respiratory Dependent Hypoxemic Respiratory Distress: Pt required NRB in ED and in CCU for < 24 hours. Crackles appreciated 1/2 up B/L and CXR consistent with pulmonary edema. We continued diuresis with significant improvement. Pt was on RA in < 48 hours. We started pt on home Lasix. Patient with some crackles continued, CXR that showed small/moderate R pleural effusion and only mild interstial edema. Likely component of chronic fibrosis [**2-17**] amiodarone. CXR on day of discharge showed improved pulm edema and increased RLL atelectasis vs. pneumonia. Once the patient was up moving around and taking deep breaths her O2 saturation improved. Finding on CXR clinically most likely atelectasis. Chronic Issues: # CAD with RCA stent in [**2191**]: Asymptomatic. EF > 55% in from [**2200**]. No EKG changes, TnT negative. No CP. We continued ASA 81, Atorva 20, EKGs were trended, Echo repeated and showed EF 55%, and severe TR. . # Hypothyroidism: asymptomatic, TSH wnl. We cont home dose levothyroxine . # Constipation - noted to be a problem at her last outpatient visit. We continued Senna/Colace/Bisacodyl . ## TRANSITIONAL - Fax reports to Dr.[**Name (NI) 5452**] office - Pt is to f/u with Dr. [**Last Name (STitle) **] in 2 wks - Dronederone changed to Sotalol - Hold metoprolol and Verapamil for low blood pressure, cont Sotalol - Pt is to f/u in Device Clinic on [**2203-10-19**] - Pt is to f/u with PCP after [**Name Initial (PRE) **]/c from ECF Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from webOMR. 1. Verapamil 240 mg PO Q24H 2. Dronedarone 400 mg PO BID 3. Dabigatran Etexilate 75 mg PO BID 4. Levothyroxine Sodium 88 mcg PO DAILY 5. Nitroglycerin SL 0.4 mg SL PRN chest pain 6. Atorvastatin 20 mg PO DAILY 7. Furosemide 40 mg PO BID 8. Aspirin 81 mg PO DAILY 9. Omeprazole 40 mg PO DAILY Discharge Medications: 1. Aspirin EC 81 mg PO DAILY 2. Atorvastatin 20 mg PO DAILY 3. Dabigatran Etexilate 75 mg PO BID 4. Furosemide 40 mg PO BID 5. Levothyroxine Sodium 88 mcg PO DAILY 6. Omeprazole 40 mg PO BID 7. Verapamil SR 240 mg PO QAM Hold SBP < 100 8. Verapamil SR 120 mg PO QPM Hold SBP < 100 9. Docusate Sodium 100 mg PO BID 10. Metoprolol Tartrate 12.5 mg PO BID Hold SBP < 100 11. Polyethylene Glycol 17 g PO DAILY:PRN constipation 12. Sotalol 80 mg PO BID 13. Nitroglycerin SL 0.4 mg SL PRN chest pain Discharge Disposition: Extended Care Facility: [**Last Name (un) 1687**] House Discharge Diagnosis: Atrial fibrillation with bradycardia Acute on Chronic Diastolic congestive heart failure Coronary artery disease Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: It was a pleasure taking care of you at [**Hospital1 18**]. You had a rapid heart rate and we could not slow the heart rate with medicines without making your heart rate very slow. For this reason, a pacemaker was inserted to keep your heart rate from going very slow on the medicines. You have now been started on a new medicine, Sotalol, that you are tolerating well and is controlling your rate. We gave you some extra lasix because the rapid heart rate led to some extra fluid in your lungs. Your chest x ray today shows the fluid is gone and you need to take more deep breaths. You will need to take your medicines every day without fail to prevent a reoccurance of the fast heart rate. Followup Instructions: Department: CARDIAC SERVICES When: WEDNESDAY [**2203-10-19**] at 9:30 AM With: DEVICE CLINIC [**Telephone/Fax (1) 62**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: GERONTOLOGY When: MONDAY [**2204-2-27**] at 10:00 AM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 94079**], MD [**Telephone/Fax (1) 719**] Building: LM [**Hospital Unit Name **] [**Location (un) **] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage . Please discuss with the staff at the facility a follow up appointment with your PCP when you are ready for discharge. Name: [**Last Name (LF) **], [**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] Location: [**Hospital1 18**]-DIVISION OF GERONTOLOGY Address: [**Doctor First Name **], 1B, [**Location (un) **],[**Numeric Identifier 718**] Phone: [**Telephone/Fax (1) 719**] We are working on a follow up appt with Dr. [**Last Name (STitle) **] in approximately 2 weeks. You will be called at home with the appointment. If you have not heard or have questions, please call ([**Telephone/Fax (1) 30479**].

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icd9cm

[ [ [] ] ]

[ "37.72", "89.45", "37.83" ]

icd9pcs

[ [ [] ] ]

9465, 9523

5640, 7747

234, 255

9680, 9680

3356, 5617

10547, 11768

2425, 2524

8946, 9442

9544, 9659

8533, 8923

9831, 10524

2539, 3127

3143, 3337

186, 196

283, 1987

9695, 9807

7763, 8507

2009, 2210

2226, 2409

5,816

181,634

29799

Discharge summary

report

Admission Date: [**2118-3-30**] Discharge Date: [**2118-4-5**] Date of Birth: [**2048-6-6**] Sex: F Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2969**] Chief Complaint: Right upper lobe mass Major Surgical or Invasive Procedure: Right thoracotomy for right upper lobectomy ([**2118-3-30**]) History of Present Illness: This is a 69-year-old female with a right upper lobe lung lesion and bradydysrhythmias. She had a CT-guided biopsy but the final aspirate was nondiagnostic and the core biopsies were lost in processing. The procedure was complicated by a moderate right hydropneumothorax. She had a bronchcoscopy prior to that and had 5-6 seconds of asystole which resolved with atropine and tube removal. She was counseled to undergo a resection of the mass via right thoracotomy and upper lobectomy. Given her history of asystole, she was referred to the Cardiac Electrophysiology department for placement a temporary wire pre-operative pacemaker. Past Medical History: Significant for hypothryoidism, anemia, gout, and DJD, previous deep venous thrombosis, and hypercholesterolemia. PAST SURGICAL HISTORY: Varicose vein stripping, vaginal hysterectomy, attempted VATS [**12/2117**] c/b asystole. She is a G7, P6, SAB1 who had her hysterectomy because of an abnormal Pap smear, but there was no diagnosis of cancer. She has received hormone replacement in the past. Social History: She smoked a pack a day from age 16 till [**2111**], but has been abstinent for smoking for the last 6 years. She only drinks up to twice a year. Family History: Significant for mesothelioma as her mother worked in the [**Name (NI) 392**] shipyards. Her brother died of lung cancer. There is also history of hepatoma and scleroderma. Physical Exam: VITAL SIGNS: She weighs 191 pounds, blood pressure is 135/81, pulse 85 and regular, and room air saturation is 98% GENERAL: She is in no distress and has no scleral icterus. NECK: There is no adenopathy in the neck region or supraclavicular fossa. There are no carotid bruits or jugular venous distention. LUNGS: Breath sounds are clear bilaterally and I could appreciate no wheezing. HEART: Regular rhythm and rate. There is no murmur or gallop. ABDOMEN: Benign. EXTREMITIES: No peripheral edema. There are venous stasis changes bilaterally. Brief Hospital Course: Ms. [**Known lastname **] was admitted the day of her operation and underwent pre-operative pacemaker placement without incident. She then underwent right thoracotomy with RUL resection which she tolerated well. Her pacemaker was induced into operation about three times intra-operatively. Please refer to the operative note of [**2118-3-30**] for further details of her operation. She was admitted to the CSRU afterward. She was evaluated for a post-operative MI, and the work-up was negative. In the immediate post-operative period, she complained of nausea and had a couple of episodes of emesis. She was administered epidural anesthesia via a mid. thoracic catheter. On POD#1, her temporary pacer was removed by the EP service, and she was transferred to the floor. She tolerated getting out of bed and sitting in a chair. On POD#2, she worked with Physical Therapy. Her chest tubes were placed to water seal, and her chest x-ray afterward showed a small apical pneumothorax. On POD#3, her anterior chest tube was removed, and her x-ray afterward showed stability of the previously noted pneumothorax. She continued to work with the physical therapists. In the evening, she felt lightheaded and slightly diaphoretic. Her blood pressure was checked and was found to be 88/48. She was administered an intravenous fluid bolus and felt much better, and her blood pressure increased to 110/60. A check of her hematocrit, electrolytes, EKG and cardiac enzymes proved normal. On POD#4, her posterior chest tube was removed, and chest x-ray showed a stable appearance of her right lung. Her epidural catheter was removed. On POD#5, she was tolerating a regular diet, was ambulating with minimal assistance; her pain was controlled on oral pain medication, and she had normal bowel function. She was discharged to a rehabilitation facility in good condition. She is to follow up in clinic with Dr. [**Last Name (STitle) **] in 2 weeks. Medications on Admission: Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). Simvastatin 10 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). Discharge Medications: 1. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Simvastatin 10 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 5. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day). 6. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed for SOB/wheeze. 7. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed for SOB/wheeze. 8. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO Q6H (every 6 hours) as needed for constipation. 9. Polysaccharide Iron Complex 150 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). Discharge Disposition: Extended Care Facility: [**First Name8 (NamePattern2) **] [**Hospital **] Nursing Home Discharge Diagnosis: COPD, bradydysrhythmias (s/p asystole at attempted VATS in [**12/2117**]), hyperlipidemia, h/o DVT right thoracotomy for right upper lobectomy Discharge Condition: good Discharge Instructions: Call Dr.[**Doctor Last Name 4738**] office [**Telephone/Fax (1) 170**] if you develop chest pain, shortness of breath, fever, chills, redness or drainage from your chest incision. You may shower on tuesday. After showering, remove your chest tube dressing, and cover the site with a clean bandaid daily until healed. Do not drive while taking pain medication. Followup Instructions: Call Dr.[**Doctor Last Name 4738**] office [**Telephone/Fax (1) 170**] for a follow up appointment Completed by:[**2118-4-4**]

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icd9cm

[ [ [] ] ]

[ "37.78", "03.90", "32.4", "40.3" ]

icd9pcs

[ [ [] ] ]

5400, 5489

2445, 4385

341, 405

5677, 5684

6093, 6222

1677, 1852

4569, 5377

5510, 5656

4411, 4546

5708, 6070

1234, 1496

1867, 2422

280, 303

433, 1073

1095, 1210

1512, 1661

22,164

136,043

47501+59008

Discharge summary

report+addendum

Admission Date: [**2173-6-26**] Discharge Date: [**2173-7-2**] Service: NSU HISTORY OF PRESENT ILLNESS: The patient is a 92-year old female who underwent an unintentional fall on the day of admission with questionable loss of consciousness. The event was not witnessed. She was transported to [**Hospital6 2561**] where she was found to be stable with a large head laceration. She had a CT scan which revealed a subarachnoid hemorrhage (right temporooccipital) and a scalp hematoma. In addition to the subarachnoid hemorrhage, she had a small subdural hematoma. The patient was transferred to [**Hospital1 188**] for further evaluation. A repeat head CT showed no change when compared to the film at [**Hospital3 **]. PAST MEDICAL HISTORY: Significant for atrial fibrillation and congestive heart failure. MEDICATIONS ON ADMISSION: Klor-Con, digoxin, Synthroid, Lasix, vitamin B12, and Cartia XL. PHYSICAL EXAMINATION ON ADMISSION: Temperature on admission was 97.8, pulse was 82, blood pressure was 120/59, respiratory rate was 16, and oxygen saturation was 99 percent on room air. On examination, the patient was in no acute distress and alert. She was found to have a large 4-cm posterior head laceration. Her pupils were equally round and reactive to light. No hemotympanum, or rhinorrhea, or otorrhea. She had a cervical collar in place. Her lungs were clear to auscultation bilaterally. Her heart rate was irregular. There was no abdominal tenderness or distention. Her rectal examination revealed no masses and was guaiac negative. She had an open laceration on her left shin. Neurologically, she was intact. She was moving all extremities with no focal neurologic deficits. LABORATORY DATA ON ADMISSION: White blood cell count was 12.5, hematocrit of 40.2, and platelets of 308. INR was 1.1. Sodium was 135, potassium was 4.9, chloride was 99, and bicarbonate was 19.5. RADIOLOGY: She had an EKG which showed an irregular rhythm with atrial fibrillation at a rate of approximately 100. HOSPITAL COURSE: The patient was admitted to the Neurosurgery Service and repeat head CTs performed. her hospital course were stable. She was placed on seizure prophylaxis, Dilantin 75 mg t.i.d., stress ulcer prophylaxis, and lansoprazole 30 mg q.d., and she was continued on her home medications. Due to multiple episodes of rapid atrial fibrillation a Cardiology consultation was obtained, and it was recommended that she receive a transthoracic echocardiogram and to continue her medications. They also recommended adding an ACE inhibitor to her medication regimen. Because the etiology of her fall was unknown, a Medicine consultation was obtained for a syncope workup. They recommended an outpatient evaluation of high calcium as her calcium had returned elevated at 12 initially. Repeat calciums in the days post admission were 10.3. They also recommended a follow-up screening mammogram and a colonoscopy by the patient's primary care provider as an outpatient in addition to electrolyte management. The patient was transferred from the Intensive Care Unit to the floor on hospital day three. At that time, she was noted to have periods of low oxygen saturations. A chest x-ray was obtained which revealed a left lower lobe opacification consistent with a pneumonia versus mucus plug. She was started prophylactically on levofloxacin, and she was given a pneumococcal vaccine prior to discharge. She was placed on subcutaneous heparin and pneumatic boots for routine DVT prophylaxis as her head CTs had been stable throughout the latter half of her hospital course. DISCHARGE DISPOSITION/CONDITION: On hospital day seven, she was discharged to a rehabilitation facility. She was stable with no neurologic deficits. She was tolerating oral intake and working with Physical Therapy. DISCHARGE FOLLOWUP: Recommendation that she contact the [**Hospital 4695**] Clinic in the case of increased headache, confusion, visual changes, nausea, or vomiting and to continue with Physical and Occupational Therapy at her rehabilitation facility. It was also recommended that she follow up with her primary care physician for further management of her high calcium in addition to a routine screening mammography and colonoscopy. She was instructed to call the [**Hospital 4695**] Clinic to set up an appointment with Dr. [**First Name (STitle) **]; appropriate phone numbers were provided for her. She was also instructed to follow up with Dr. [**Last Name (STitle) 284**] in the Cardiology Clinic on [**7-19**], and this appointment was made for her. DISCHARGE DIAGNOSES: 1. Status post fall with subarachnoid hemorrhage. 2. Syncope. 3. Atrial fibrillation. MEDICATIONS ON DISCHARGE: 1. Lansoprazole 30 mg p.o. q.d. 2. Dilantin 50 mg p.o. t.i.d. (for a 3-week course). 3. Subcutaneous heparin 5000 units 1 injection t.i.d. 4. Amiodarone 400 mg p.o. t.i.d. times three weeks, followed by 200 mg p.o. q.d. following three weeks (as recommended by Cardiology). 5. Diltiazem 30 mg p.o. q.i.d. 6. Levofloxacin 250 mg p.o. q.d. (times 7 days). 7. She was also given a pneumococcal vaccine prior to discharge. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 8632**] Dictated By:[**Last Name (NamePattern1) 15009**] MEDQUIST36 D: [**2173-7-1**] 15:57:55 T: [**2173-7-1**] 16:40:07 Job#: [**Job Number 100426**] Name: [**Known lastname **], [**Known firstname **] Unit No: [**Numeric Identifier 16139**] Admission Date: [**2173-7-1**] Discharge Date: [**2173-7-2**] Date of Birth: Sex: Service: Her discharge medications were changed to digoxin 0.25 mg q d and diltiazem 60 mg p.o. q.i.d. and the amiodarone was discontinued per Cardiology recommendations. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] INT, MD Dictated By:[**Last Name (NamePattern1) 9343**] MEDQUIST36 D: [**2173-7-2**] 07:53:52 T: [**2173-7-2**] 08:26:11 Job#: [**Job Number **]

[ "486", "891.0", "E880.9", "852.10", "244.9", "780.2", "873.0", "428.0", "427.31" ]

icd9cm

[ [ [] ] ]

[ "38.91", "86.59" ]

icd9pcs

[ [ [] ] ]

4626, 4714

4740, 6067

856, 943

2054, 3843

3864, 4605

117, 739

1750, 2036

762, 829

5,366

175,456

29453

Discharge summary

report

Admission Date: [**2149-10-12**] Discharge Date: [**2149-10-22**] Date of Birth: [**2088-9-10**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1973**] Chief Complaint: Bright red blood per rectum Major Surgical or Invasive Procedure: 1. Tagged red blood cell scan 2. Colonoscopy 3. Upper endoscopy 4. Transthoracic echocardiography 5. Transesophageal echocardiography History of Present Illness: 61 y M with a history of metastatic lung cancer to his right hip, liver (with question as to whether the lung is primary) being treated with carboplatin and gemcytabine (last dose 11/3) who was in his usual state of health until [**2149-10-8**] when he began to feel weak. He felt progressively weaker and felt dizzy on [**2149-10-10**]. He had no shortness of breath or chest pain, nausea, vomiting, abdominal pain or other symptoms. No falls. On [**2149-10-11**] he had loose stool containing red blood clots. He had previously never had so much bright red blood per rectum, but states that he has had some since starting his chemotherapy. No black or tarry stools, no hematemesis or hematuria. He went to [**Hospital3 3583**], where he was found to have a Hct on presentation of 13.4 (one week earlier it had been 34.) He was in shock with SBP 70s, HR 130s. His platelets on admission were 10,000, and his WBC were 3.5. He underwent a tagged RBC scan which reportedly revealed blood in the R side of the abdomen, felt likely to be in the R colon, although not believed to be a brisk or large bleed. His HR remained in the 110s as did his SBP. He was transferred to the [**Hospital1 **] for a discussion of possible IR embolization versus colonoscopy versus surgical options. During his stay there he received 4u FFP (coags were reportedly normal throughout), 9u PRBC and 14 bags of platelets. On transfer his platelets were 54K, Hct 18K with one unit hung in the ambulance, and WBC 2.8. . On [**2149-10-13**], he was admitted to the MICU with VS: T 100.2 BP 94/60 P 94-110 RR14, 100% on 2L. He received 3 U pRBC, with a stable post-transfusion crit of 27-30 over the last 3 days. A tagged RBC scan showed no evidence of active gastrointestinal hemorrhage. He received a colonoscopy once his neutropenia ([**1-2**] chemotherapy) resolved, which showed cecal ulcers (radiation vs. ischemia vs. Crohn's), sigmoid diverticulosis, internal hemmorhoids, but no bleeding. An EGD showed patchy gastritis, few small erosions in duodenal bulb, believed to be unlikely to rebleed. He was transferred to the floor for further management. . ROS: pt denies sob/cp/abd pain, n/v, MS complaints, F/C. No other complaints. Past Medical History: - lung ca metastatic to R hip/liver: Oncologist = [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 50949**] [**0-0-**] - lymphoma in R groin lymph node s/p resection in [**2146**] - s/p R lung lobectomy [**2146**] - PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 47403**] Social History: The patient lives at home with his wife and one son. [**Name (NI) **] is a retired nuclear plant worker. He has not smoked in the past 3 years, but has a prior 2pack per day history for "a long time." He denies EtOH or other drug use. Family History: noncontributory Physical Exam: 100.2, HR 96, BP 93/53, O2 100% on 2LNC, RR 22 GEN: NAD, pale, pleasant, conversant HEENT: NCAT, conjunctivae pink, PERRLA, no OP injection Neck: JVP flat, no LAD Cor: s1s2, no r/g/m, rrr Pulm: CTAB Abd: NTND, +BS, no organomegaly Ext: no c/c/e, w/w/p, 1+dp pulses bilat Skin: no rashes, no stasis changes Pertinent Results: [**2149-10-12**] 10:56PM GLUCOSE-91 UREA N-25* CREAT-0.8 SODIUM-138 POTASSIUM-3.0* CHLORIDE-107 TOTAL CO2-25 ANION GAP-9 [**2149-10-12**] 10:56PM CALCIUM-6.2* PHOSPHATE-1.9* MAGNESIUM-1.5* [**2149-10-12**] 10:56PM WBC-1.4* RBC-2.58* HGB-8.3* HCT-21.7* MCV-84 MCH-32.0 MCHC-38.0* RDW-14.2 [**2149-10-12**] 10:56PM NEUTS-40* BANDS-2 LYMPHS-47* MONOS-7 EOS-2 BASOS-0 ATYPS-2* METAS-0 MYELOS-0 NUC RBCS-1* [**2149-10-12**] 10:56PM PLT SMR-VERY LOW PLT COUNT-56* [**2149-10-12**] 10:56PM PT-13.3* PTT-29.0 INR(PT)-1.2* [**2149-10-12**] 10:56PM GRAN CT-588* . Tagged RBC scan [**2149-10-13**]: IMPRESSION: No evidence of active gastrointestinal hemorrhage. Additional delayed or repeat imaging may be useful if the patient later shows clinical signs of active bleeding. . EGD: Findings: Esophagus: Normal esophagus. Stomach: Mucosa: Patchy erythema and granularity of the mucosa were noted in the antrum. These findings are compatible with patchy gastritis. Duodenum: Mucosa: A few small erosins of the mucosa was noted in the distal bulb and anterior bulb. Impression: Erythema and granularity in the antrum compatible with patchy gastritis A few small erosins in the distal bulb and anterior bulb Recommendations: Patient unlikely to rebleed from these lesions. Check serology for H. pylori. Continue PPI. . Colonoscopy: Findings: Protruding Lesions Grade 1 internal hemorrhoids were noted. Excavated Lesions A few diverticula with small openings were seen in the sigmoid colon.Diverticulosis appeared to be of mild severity. Three ulcers ranging in size from 11 mm to 5 mm were found in the cecum. They were not bleeding. Cold forceps biopsies were performed for histology at the ulcers cecum. Impression: Ulcers in the cecum (biopsy) Diverticulosis of the sigmoid colon Grade 1 internal hemorrhoids Recommendations: Await patholgu. Lesion could be secondary to ischemia, radiation damage or Crohn's disease . CXR [**2149-10-15**]: FINDINGS: Compared with 11/13, there is a new vague opacity seen just lateral to the right hilar mass. This could represent aspiration or infiltrate. The remainder of the lung fields are grossly clear. . CT CHEST [**2152-10-18**]: Findings are most consistent with pulmonary, hepatic, and adrenal metastatic disease with concomittant pulmonary lymphangitic carcinomatosis. Diffuse tiny lung nodules can also be seen with disseminated infection. Bilateral pleural effusions. There is partial collapse of the right middle lobe likely incident to airway compression and narrowing. [**2149-10-21**] 04:50AM BLOOD WBC-16.9* RBC-3.16* Hgb-9.9* Hct-27.9* MCV-88 MCH-31.5 MCHC-35.6* RDW-15.6* Plt Ct-272 [**2149-10-20**] 05:15AM BLOOD Neuts-64 Bands-1 Lymphs-12* Monos-20* Eos-1 Baso-0 Atyps-0 Metas-2* Myelos-0 [**2149-10-21**] 04:50AM BLOOD Plt Ct-272 [**2149-10-21**] 04:50AM BLOOD Glucose-87 UreaN-7 Creat-0.5 Na-133 K-3.8 Cl-95* HCO3-29 AnGap-13 [**2149-10-21**] 04:50AM BLOOD Calcium-8.0* Phos-3.2 Mg-1.6 Brief Hospital Course: # GI bleed: The patient presented initially to [**Hospital3 3583**] with BRBPR, where he received blood products. A tagged RBC scan suggested a right-sided colonic source. He arrived at the [**Hospital1 **] with a hematocrit of 21.7 and received 3U of pRBCs. During his stay at the [**Hospital1 **] he did not rebleed, and his Hct remained stable at 27-30. An EGD showed patchy gastritis and a few small erosions in duodenal bulb, which did not appear to be a likely source of the bleeding. He was started on a PPI. H. pylori serology was negative. Colonoscopy showed cecal ulcers, sigmoid divertics, and internal hemmorhoids. Given the results of the tagged RBC scan, the most likely source of bleeding seemed to be the cecal ulcers ([**1-2**] radiation vs. ischemia vs. Crohn's). Pathology from the colonoscopy was pending at the time of discharge... In terms of coagulation status, the patient's platelets were >50K during his stay at the [**Hospital1 **], with an upward trend. His INR was 1.2-1.7 during his admission. Given his abnormal coagulation studies, we held heparin for DVT prophylaxis (he did wear pneumoboots). By the time of discharge the patient's hematocrit was stable and he was asymptomatic. . # Pancytopenia. The patient had been pancytopenic [**1-2**] gemcitabine. By report the patient received GCSF x 1 at [**Hospital1 3325**]. On admission to the [**Hospital1 **] his ANC was 588, but his white count increased steadily, and by [**2149-10-14**] his ANC was 2090 and WBCs were >3. His platelets on admission to the [**Hospital1 **] were 56, but this count also increased over the next several days and was >150 by the day of discharge. By the time of discharge, the patient was no longer pancytopenic. . # Fever. After endoscopy, the patient had a fever at 101.2. He developed a mild cough productive of yellow sputum, and a CXR suggested an aspiration or infiltrate. In addition, the patient had a Foley for several days and a U/A was mildly positive with trace leuks, [**2-2**] RBC, [**5-10**] WBC, and few bacteria. A urine Cx taken [**2149-10-15**] grew enterococci and coag neg staph. His foley catheter was removed. We started him on a 10-day course of levaquin 500 mg PO qd. Blood culture from [**2149-10-15**] was positive (1/2 bottles) for MRSA (sensitive to rifampin, tetracycline, gentamicin). He was started on vancomycin. Overnight he became tachycardic and hypotensive with a few runs of NSVT. Azithromycin and cefepime were added to his antibiotic regimen. His vital signs responded well to small fluid boluses. However, over the next 2 days his fever began to spike to 101.5. Multiple repeat blood cultures were drawn and a CT of his chest was obtained. There was a question of a post-obstructive pneumonia that was discussed with radiology and interventional pulmonology. Upon further discussion, this was ruled out and deemed to be a small narrowing of the right middle lobe bronchus with subsegmental collapse of the lobe. An infectious disease consult was also obtained. They recommended IV vancomycin and cefepime for 14 days and then subsequent blood cultures to ensure that the bacteria was cleared from the blood. They also recommended echocardiography of the heart (most TTE and TEE) in order to make sure there were no vegetations on the heart valves. Both a TTE and a TEE were performed which on preliminary read showed no vegetations on the valves. The ID fellow will follow up on these results and the blood cultures in clinic 2 weeks after discharge. Lastly, there was a discussion with the general surgeons, the line nurses, the ID team and the primary medicine team about removing the port cath. It was decided to leave the port in place, continue IV antibiotics and repeat cultures. If cultures continue to be positive after 2 weeks of vancomycin and cefepime, port removal will need to be re-addressed. . # R hip pain: The patient continued his outpatient regimen of fentanyl and oxycontin. He continued to have significant pain which impaired his ability to ambulate, so we increased his dose of oxycontin to and treated him with oxycodone prn. By the time of discharge, he felt that his pain was at its baseline. It was recommended to his oncologist that he consider using a new narcotic regimen and possibly incorporating methadone. . # Follow-up: The patient has been scheduled to follow up with Dr [**Last Name (STitle) 11382**] on [**11-5**]. Prior to this appointment, he will have 2 sets of blood cultures drawn on [**11-3**] and 6th. His last dose of vancomycin and cefepime should be [**11-5**]. While at home, he will follow his temperatures and contact his PMD if his temperature elevates above 100.0. He will have follow up with his oncologist Dr [**Last Name (STitle) 50949**]. Dr [**Last Name (STitle) 50949**] was spoken to on the day prior to discharge and informed about his course. He will scheduled an outpatient follow up within the next week. He will draw labs: vancomycin trough, cbc, ast, alt, and creatinine q weekly and have them faxed to Dr [**Last Name (STitle) 11382**]. Medications on Admission: oxycontin 140mg po bid fentanyl tp 150mcg tp q72h voltaren prn last gemcitabine/carboplatin?, last [**2149-10-3**] Discharge Medications: 1. Fentanyl 75 mcg/hr Patch 72HR Sig: One (1) Patch 72HR Transdermal Q72H (every 72 hours). 2. Oxycodone 20 mg Tablet Sustained Release 12HR Sig: Seven (7) Tablet Sustained Release 12HR PO Q12H (every 12 hours). 3. 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* 4. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily). 5. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as needed for constipation. Disp:*14 Capsule(s)* Refills:*0* 6. Oxycodone 5 mg Tablet Sig: Three (3) Tablet PO Q4H (every 4 hours) as needed for pain. Disp:*30 Tablet(s)* Refills:*0* 7. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed for pain/fever. 8. Vancomycin 1,000 mg Recon Soln Sig: One (1) gm Intravenous twice a day for 14 days. Disp:*24 doses* Refills:*0* 9. Cefepime 2 g Piggyback Sig: Two (2) grams Intravenous every twelve (12) hours for 14 days: continue for a total of 14 days starting from [**2149-10-22**]. Disp:*28 doses* Refills:*0* 10. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: [**2-2**] ml Intravenous daily and prn as needed: via SASH. Disp:*30 ml* Refills:*0* 11. Normal Saline Flush 0.9 % Syringe Sig: Five (5) ml Injection daily and prn: via SASH. Disp:*30 syringes* Refills:*0* 12. wheelchair with elevating leg rest Patient needs wheelchair with elevating leg rest to improve functional mobility Discharge Disposition: Home With Service Facility: [**Location (un) 2203**] VNA Discharge Diagnosis: Primary diagnosis: 1. Gastrointestinal bleed 2. Anemia 3. Colonic ulcers 4. Diverticulosis 5. Gastritis 6. Duodenal erosions 7. Bacteremia . Secondary diagnosis: 1. Lung cancer with metastasis to right hip and liver 2. Lymphoma s/p resection 3. s/p right lung lobectomy Discharge Condition: stable Discharge Instructions: You have been hospitalized for gastrointestinal bleeding. You were transfused at [**Hospital3 3583**] and also at [**Hospital3 **] Hospital. Your blood count (hematocrit) was stable after the transfusions. You initially had a low white count and low platelet count, but these counts recovered into the normal range after a few days. Your bleeding was most likely from the right side of your colon. A colonoscopy showed ulcers, diverticulosis (small weakenings of the colon wall), and hemorrhoids. Pathology results from the colonoscopy are still pending at the time of your discharge. Dr. [**Last Name (STitle) 50949**] will follow up on the results with you. An upper endoscopy showed mild inflammation in your stomach and small erosions in your duodenum. You were given protonix, a proton pump inhibitor, to treat the stomach inflammation. . You also had a fever and a cough. You were intially treated with an antibiotic, levaquin, for the concern that this might be an early lung infection, urinary tract infection, or infection in your blood. You then developed signs of an infection of your blood and your blood cultures showed an infection. You were then prescribed two new antibiotics Vancomycin and Cefipime which should be continued for 2 weeks after discharge. *** You should follow your daily temperatures at home and if they rise above 100.0 you should call the ID fellow Dr [**Last Name (STitle) 11382**] at [**Telephone/Fax (1) 3395**]. *** Do call your doctor or return to the emergency room if you have more bleeding, weakness, dizziness, chest pain, shortness of breath, fever, chills, or other concerning symptoms. Followup Instructions: 1. You have a scheduled appointment with [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 13076**], MD Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2149-11-5**] 11:30. This appointment is very important since she will be following up on your blood cultures. She should also follow up on the final read of your Transesophageal echocardiography from [**2149-10-22**]. 2. You have been given 2 laboratory slips/ orders for blood cultures for [**11-3**] and [**11-5**]. You can get these labs drawn at the [**Hospital **] clinic in the [**Hospital Unit Name **] Basement Suite G at [**Last Name (NamePattern1) 439**]. 3. Dr [**Last Name (STitle) 50949**] will be contacting you to schedule an appointment for the end of this week or beginning of next. Discuss with Dr [**Last Name (STitle) 50949**] changing your pain management regimen. Consider possible use of Methadone with fentanyl patch. ***You should have Dr [**Last Name (STitle) 50949**] draw the following labs weekly including: Vancomycin trough, CBC, AST, ALT, and Creatinine. Please fax the results to [**Telephone/Fax (1) 4591**].

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Discharge summary

report

Admission Date: [**2103-1-22**] Discharge Date: [**2103-1-26**] Date of Birth: [**2045-6-4**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**Doctor First Name 2080**] Chief Complaint: Lethargy and hypotension Major Surgical or Invasive Procedure: Tunneled line replacement [**2103-1-25**] History of Present Illness: 57M with h/o of dilated cardiomyopathy, afib on digoxin, COPD, ESRD, dyalisis who is admitted due to lethargy, hypotension, pulmonary congestion and hyperkalemia. . At baseline patient lives at home with sister and mother, is ADL independent and ambulates with cane. He gets dyalisis Q mon, wed, Fri. Previous admission to [**Hospital1 **] in [**9-/2102**] for hyperkalemia which was treated with dyalisis. Most recent dyalisis session was [**1-20**] and was due for another session today. Yesterday he reported experiencing some generlized weakness and lack of apetite. Denies any recent fevers, chills or any focal symptoms. This morning in dyalisis unit prior to starting dyalisis was noted to be lethargic at with blood pressure in the 70s and was sent to the ED where he was found to have Afib with wide-complex RVR and hyperkalemia to 6.5. . In the ED, he claimed his BP's are usually low in the 80-90's but his previous chart showed SBP's in the 110's usually. initial VS in the ED were: 13:25 0 97 140 109/50 28 98% r/a . - ecg: Afib RVR: HR in the 100-140's in the ED. HD BP's in the high 90's low 100's occasionally dips down into the 80's, mentating well throughout. . labs: hyponatremia 130, hyperkalemia 6.5, bicarb 19, AG = 18, cr:BUN 10.1:79, WBC = 17,000 with neutrophil predominance, Hct 32.7 which is at baseline. Dig level 1.2. Lactate = 1.7. Blood cultures sent. - CXR: med-line sterotomy, dyalisis line in place left SC, cardiomegaly, mild congestion/edema, LLL is obscured by heart shadow, can't exclude infiltrate, sinus clear. - Got IV NS 250cc, 16:00 zosyn + vanco - 2X20G peripherals, tunneled HD line in left chest. - nephrologist: dialyse in ICU - got nebs for SOB. . On arrival to the MICU, patient says he feels a little week but other wise has no complaits. . Review of systems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies any worsening in hos chronic cough, sputum production, shortness of breath, or wheezing. Denies chest pain, chest pressure, palpitations. Denies nausea, vomiting, diarrhea, constipation, abdominal pain, or changes in bowel habits. Does not produce urine. Denies arthralgias or myalgias. Denies rashes or skin changes. Past Medical History: - ESRD on dyalisis - Afib - COPD - not on home O2 - h/o idiopathic constrictive pericarditis with 2nd right heart failure s/p percardial stripping [**2083**] - h/o congestive cirrhosis [**2-22**] to right heart failure c/b hepatic encephalopathy - recurrent LE cellulitis; recently on a course of IV vancomycin through [**2100-11-17**]. Had a hematoma evacuated on [**2100-11-21**]. - HTN - Morbid obesity - Lymphedema of lower extremities - Psoriasis - History of MRSA cellulitis Social History: Currently living with mother and sister in [**Location **]. On disability. Mobilizes independently with cane, walks up 12 stairs at home, and can walk [**1-24**] a mile on flat surface before stopping d/t SOB. Smoker- 1/2-1 pack daily. denies EtOH/drug use for > 30 years. Family History: noncontributory Physical Exam: General: Alert, orientedX3, mild dyspnea at rest, no accessory muscles, RR 25 on RA. HEENT: Sclera anicteric, MMM, oral thrush, oropharynx clear, EOMI, PERRL Neck: supple, JVP not elevated, no LAD CV: Rapid Regular rate and rhythm, SM 1-2/6 in RUSB and LUSB, no rubs, gallops, no carotid bruits Lungs: bil air movement, some scattered [**Hospital1 **]-basilar crackles, no wheezes or ronchi Abdomen: mild distension, non-tender, bowel sounds present, no palpable organomegaly GU: no foley Ext: severe bil stasis dermatitis and descoloration of LE with pre-tibial hyperkeratotic desquamating patches , bil edema of LE +2, no signs of cellulitis, bil onychomycosis and poor nail hygiene, warm, well perfused extremties, DP palpable, no clubbing or cyanosis Neuro: CNII-XII intact, 5/5 strength upper/lower extremities, grossly normal sensation, 2+ reflexes bilaterally, gait deferred, finger-to-nose intact Pertinent Results: Labs on admission: [**2103-1-22**] 01:40PM NEUTS-92.2* LYMPHS-4.9* MONOS-2.3 EOS-0.5 BASOS-0.2 [**2103-1-22**] 01:40PM WBC-17.0*# RBC-3.37* HGB-10.6* HCT-32.7* MCV-97 MCH-31.6 MCHC-32.5 RDW-16.4* [**2103-1-22**] 01:40PM PLT COUNT-179# [**2103-1-22**] 01:40PM DIGOXIN-1.2 [**2103-1-22**] 01:40PM ALBUMIN-3.7 CALCIUM-9.4 PHOSPHATE-6.5* MAGNESIUM-2.0 [**2103-1-22**] 01:40PM cTropnT-0.23* [**2103-1-22**] 01:40PM CK-MB-2 [**2103-1-22**] 01:40PM ALT(SGPT)-11 AST(SGOT)-17 LD(LDH)-223 CK(CPK)-27* ALK PHOS-122 TOT BILI-0.6 [**2103-1-22**] 01:40PM GLUCOSE-117* UREA N-79* CREAT-10.1*# SODIUM-130* POTASSIUM-6.5* CHLORIDE-93* TOTAL CO2-19* ANION GAP-25* [**2103-1-22**] 04:01PM LACTATE-1.7 [**2103-1-22**] 11:01PM PT-13.7* PTT-33.2 INR(PT)-1.3* MICROBIOLOGY: - Blood culture [**2103-1-22**]: 2/2 bottles positive for Enterococcus faecalis; 1/2 bottles positive for coagulase-negative staphylococcus - MRSA screen: No growth - Blood culture [**2103-1-23**]: Pending - Blood culture [**2103-1-23**]: Pending - Blood culture [**2103-1-23**]: Pending - Blood culture [**2103-1-23**]: Pending - Blood culture [**2103-1-24**]: Pending - Blood culture [**2103-1-24**]: Pending - Blood culture [**2103-1-25**]: Pending - Catheter tip culture [**2103-1-25**]: No growth - Blood culture [**2103-1-26**]: Pending SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ENTEROCOCCUS FAECALIS | AMPICILLIN------------ <=2 S DAPTOMYCIN------------ S PENICILLIN G---------- 2 S VANCOMYCIN------------ 1 S ECG [**2103-1-22**]: Atrial fibrillation with a mean ventricular rate of 122. Right bundle-branch block. Left axis deviation. Left anterior fascicular block. Possible left ventricular hypertrophy. Leftward precordial R wave transition point. Compared to the previous tracing of [**2102-10-18**] multiple abnormalities as described persist without major change. CXR [**2103-1-22**]: IMPRESSION: Stable massive cardiomegaly and mild pulmonary edema. Supervening left lower lobe infection cannot be excluded due to cardiac obscuration. ECHOCARDIOGRAM (TTE) [**2103-1-24**]: The left atrium is elongated. The right atrium is markedly dilated. The left ventricular cavity size is normal. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Overall left ventricular systolic function is low normal (LVEF 50-55%). The right ventricular cavity is mildly dilated with depressed free wall contractility. There is abnormal septal motion/position. The number of aortic valve leaflets cannot be determined. The study is inadequate to exclude aortic valve stenosis as the aortic valve and the LVOT were not visualized and [**First Name8 (NamePattern2) **] [**Location (un) 109**] could not be calculated. There was a slight increase of peak aortic valve velocity. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. Moderate [2+] tricuspid regurgitation is seen. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. IMPRESSION: poor technical quality study. With this limitation, no endocarditis or abscess was visualized. Left ventricular function is probably low normal, a focal wall motion abnormality cannot be fully excluded. No pathologic valvular abnormality seen. VEIN MAPPING [**2103-1-25**]: Performed [**2103-1-25**]. Results in OMR. Brief Hospital Course: HOSPITAL SUMMARY: 57M with h/o of dilated cardiomyopathy, afib, alcoholic cirrhosis, COPD, ESRD, dyalisis who was admitted to the MICU due to lethargy, hypotension, pulmonary congestion and hyperkalemia found to have enterococal bacteremia. MICU course: Patient never required pressors for his hypotension, but did require several small boluses (250 cc) to maintain pressure. Per patient, BPs run low though they have typically been in 100s-110s here in the past. He was initially treated empirically with vanco/zosyn, but changed over to ampicillin in the setting of enterococcus speciation. His existing tunneled line was exchanged, and he agreed to consider evaluation for graft placement so underwent vein mapping prior to discharge. ACTIVE ISSUES: # Sepsis due to ENTEROCOCCAL BACTEREMIA: Likely source was the patient's indwelling catheter, though culture of the catheter tip was unrevealing. The original ED culture also grew [**1-22**] bottles positive for coagulase-negative staph on hospital day 4, felt to be a contaminent. Surveillence cultures were negative and TTE did not show evidence of endocarditis. As the patient was clinically improving, TEE was not pursued. As above, he was initially treated empirically with vancomycin and Zosyn, then changed to ampicillin in-house once culture speciated as pan-sensitive Enterococcus. He was changed back to vancomycin at discharge so that he can complete a two-week course of antibiotics dosed per HD protocol (avoiding placement of a PICC). Of note, he was borderline hypotensive throughout this admission, with SBPs ranging upper 70s to 100s. Per recommendations of Dr. [**Last Name (STitle) 4883**] of the nephrology team, fluid boluses were avoided as long as he was mentating well. Surveillence cultures were obtained but had showed no growth at the time of discharge. # ATRIAL FIBRILLATION WITH RVR: The patient had a HR up to 140s at the time of presentation, but became hypotensive with administration of metoprolol. Once he came out of the ICU, heart rate was reasonably well-controlled in the range of 90s-100s at rest. As his blood pressures generally do not tolerate beta blocker or diltiazem, he has been controlled on digoxin 3 days per week. His level pre-HD was 1.2 and post-HD was 0.6. Therefore, his dose of digoxin was increased to 4 times per week (additional dose to be taken on Sunday) for improved rate control. He has not been anticoagulated in the past, but given CHADS2 score of (probable) 2 (for likely heart failure), he was started on aspirin in lieu of other anticoagulation. # ESRD: Patient was maintained on HD while inpatient on M/W/F schedule. His hyperkalemia corrected with HD. He was continued on nephrocaps and sevelamer. He agreed to pursue graft placement as an alternative and potentially lower-risk form of HD access, and underwent vein mapping prior to discharge. His existing tunneled line was changed out over a wire by IR on [**2103-1-25**]. He was started on nephrocaps during this admission. INACTIVE ISSUES: # ANEMIA: Secondary to ESRD and stable. He will continue Epogen with outpatient HD. # COPD: Continued on home Advair. Oxygen PRN during this admission (and will HD). # ALCOHOLIC CIRRHOSIS: LFTs normal. No active issues. # SMOKING: Patient was prescibed a nicotine patch while in-house. TRANSITION OF CARE: - Patient will need vancomycin dosed per HD protocol at HD through [**2103-2-7**] - F/U surveillence blood cultures - F/U vein mapping and arrange for graft placement with transplant surgery - Consider outpatient lipid panel to clarify CV risk status - Wound consult recommendations for legs with lymphedema and hyperkeratosis: Referral to podiatry, dermatology and/or vascular surgery as outpatient - Code: DNI, ok with cardioversion/shocks Medications on Admission: Medications (confirmed with patient): . Advair Diskus 250 mcg-50 mcg/dose for Inhalation Inhalation 1 puff Disk with Device(s) Twice Daily albuterol 90 mcg/Actuation HFA Aerosol Inhaler 1-2 Puffs Puffs Inhalation every four (4) hours as needed for shortness of breath or wheezing. metoprolol succinate 25 mg Tab Oral 1 Tablet(s) Once Daily Renvela 800 mg Tab Oral 2 Tablet(s) w/meals three times daily and 2 tabs with snacks twice daily digoxin 125 mcg Tab Oral 1 Tablet(s) Once Daily on M/W/F . Allergies: NKDA Discharge Medications: 1. sevelamer carbonate 800 mg Tablet Sig: Two (2) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 2. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: [**1-22**] puff Inhalation every four (4) hours as needed for shortness of breath or wheezing. 3. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 4. digoxin 125 mcg Tablet Sig: One (1) Tablet PO 4x per week: M/W/F/[**Doctor First Name **]. 5. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO once a day. 6. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). Disp:*30 * Refills:*2* 7. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). Disp:*30 Tablet, Chewable(s)* Refills:*2* 8. vancomycin 1,000 mg Recon Soln Sig: As directed by HD protocol Intravenous QHD (by protocol) for 6 doses: Last dose [**2103-2-7**]. Will need vanco trough and Chem-7 monitored while on this medication. Discharge Disposition: Home Discharge Diagnosis: Primary: - Enterococcus bacteremia - Sepsis - Atrial fibrillation with rapid ventricular response Secondary: - ESRD on hemodialysis 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 [**Hospital1 69**] with lethargy and low blood pressure. You were found to have a rapid heart rate and bacteria in your blood. The blood infection is most likely the cause of your other symptoms, and most likely came from your tunneled dialysis line. Therefore, your tunneled line was exchanged for a clear catheter and you will require treatment with IV antibiotics (to take place at dialysis). We have made the following changes to your medication regimen: - BEGIN TAKING IV vancomycin at dialysis (last day [**2103-2-7**]) - BEGIN TAKING nephrocaps 1 tablet by mouth daily - BEGIN TAKING aspirin 81 mg by mouth daily - INCREASE FREQUENCY of digoxin to 4 days per week (M/W/F/[**Doctor First Name **]) Please follow up with your doctors as recommended below. Followup Instructions: Department: HEMODIALYSIS When: FRIDAY [**2103-1-26**] at 7:30 AM Department: TRANSPLANT CENTER When: THURSDAY [**2103-2-15**] at 1:40 PM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD [**Telephone/Fax (1) 673**] Building: LM [**Hospital Unit Name **] [**Location (un) **] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage Name: [**Last Name (LF) **],[**First Name8 (NamePattern2) 26**] [**Last Name (NamePattern1) **] Location: [**Location (un) 2274**]-[**Location **] Address: 291 INDEPENDENCE DR, [**Location **],[**Numeric Identifier 1700**] Phone: [**Telephone/Fax (1) 43431**] Appt: [**1-31**] at 2:40pm Completed by:[**2103-1-27**]

[ "427.31", "995.91", "V45.11", "585.6", "305.1", "285.21", "571.2", "425.4", "305.00", "496", "038.0", "276.7" ]

icd9cm

[ [ [] ] ]

[ "39.95" ]

icd9pcs

[ [ [] ] ]

13419, 13425

8009, 8748

329, 373

13602, 13602

4454, 4459

14593, 15284

3496, 3513

12355, 13396

13446, 13581

11812, 12332

13785, 14570

3528, 4435

2215, 2683

265, 291

8764, 11014

401, 2196

11032, 11786

4473, 7986

13617, 13761

2705, 3189

3205, 3480

45,112

101,277

37809

Discharge summary

report

Admission Date: [**2114-10-22**] Discharge Date: [**2114-10-27**] Date of Birth: [**2053-9-3**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 922**] Chief Complaint: Upper back/shoulder discomfort for the last 6-9 months. Worsening fatigue. Major Surgical or Invasive Procedure: [**2114-10-22**] 1. Coronary artery bypass grafting times 5: Left internal mammary artery to the left anterior descending coronary; reverse saphenous vein single graft from the aorta to the ramus intermedius coronary artery; reverse saphenous vein single graft from the aorta to the first obtuse marginal coronary artery; reverse saphenous vein single graft from the aorta to the third obtuse marginal coronary artery; as well as reversed saphenous vein graft from the aorta to the posterior descending coronary artery. 2. Endoscopic left greater saphenous vein harvesting. History of Present Illness: 61 year old gentleman with a history of diabetes who had a recent acute episode of unstable angina with negative enzymes. He underwent a stress test which revealed an inferior wall defect with EKG changes and was subsequently admitted for a cardiac catheterization. This revealed severe three vessel disease. Given the severity of his disease, He has been referred for surgical revascularization. Past Medical History: Coronary Artery Disease Hypertension Dyslipidemia Diabetes mellitus type II (Diagnosed 10 years ago) Chronic Renal insufficiency Gout Past Surgical History: Cholecystectomy Appendectomy Social History: Occupation: Currently laid off. Sales for 30+ years. Last Dental Exam: every 6 months Lives with wife in [**Name (NI) 487**], MA Race: Hispanic Tobacco: never ETOH: social Family History: No premature coronary disease. Brother died of hemorrhagic stroke at age 56. Physical Exam: : 65 Resp: 18 O2 sat: 100% RA B/P Right: 194/88 Left: General:WDWN male in no acute distress Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur - none Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Extremities: Warm [x], well-perfused [x] Edema- none 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: none Left: none Pertinent Results: [**2114-10-22**] 07:39AM HGB-11.6* calcHCT-35 [**2114-10-22**] 07:39AM GLUCOSE-222* LACTATE-0.9 NA+-138 K+-4.7 CL--107 [**2114-10-22**] 12:09PM WBC-8.1 RBC-2.66*# HGB-7.3*# HCT-22.1*# MCV-83 MCH-27.5 MCHC-33.2 RDW-15.3 [**2114-10-22**] 01:32PM UREA N-38* CREAT-1.6* CHLORIDE-119* TOTAL CO2-21* [**2114-10-22**] 10:12PM BLOOD ALT-21 AST-45* AlkPhos-41 Amylase-53 TotBili-0.3 [**Hospital 93**] MEDICAL CONDITION: 61 year old man with s/p cabg REASON FOR THIS EXAMINATION: evaluate PTX left - please do xray in afternoon [**10-25**] Preliminary Report !! PFI !! 1. Left apical pneumothorax, smaller since yesterday's examination. 2. Right IJ central venous catheter, unchanged. 3. Left basilar subsegmental atelectasis with small pleural effusion, as before. DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 7593**] PFI entered: [**Doctor First Name **] [**2114-10-25**] 5:44 PM [**Hospital1 18**] ECHOCARDIOGRAPHY REPORT Intraoperative TEE for CABG Echocardiographic Measurements Results Measurements Normal Range Left Atrium - Long Axis Dimension: *5.9 cm <= 4.0 cm Left Atrium - Four Chamber Length: *6.4 cm <= 5.2 cm Left Ventricle - Ejection Fraction: 60% to 65% >= 55% Aorta - Ascending: 3.1 cm <= 3.4 cm Aorta - Descending Thoracic: 1.9 cm <= 2.5 cm Findings LEFT ATRIUM: Moderate LA enlargement. No spontaneous echo contrast or thrombus in the body of the [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] LAA. Good (>20 cm/s) LAA ejection velocity. RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is seen in the RA and extending into the RV. No ASD by 2D or color Doppler. LEFT VENTRICLE: Overall normal LVEF (>55%). RIGHT VENTRICLE: Normal RV chamber size. Normal RV systolic function. AORTA: Focal calcifications in aortic root. Normal ascending aorta diameter. Simple atheroma in aortic arch. Normal descending aorta diameter. Simple atheroma in descending aorta. AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. No AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild mitral annular calcification. Trivial MR. TRICUSPID VALVE: Tricuspid valve not well visualized. Physiologic TR. PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen. Physiologic (normal) PR. PERICARDIUM: No pericardial effusion. GENERAL COMMENTS: A TEE was performed in the location listed above. I certify I was present in compliance with HCFA regulations. The patient was under general anesthesia throughout the procedure. The TEE probe was passed with assistance from the anesthesioology staff using a laryngoscope. No TEE related complications. Suboptimal image quality. The patient appears to be in sinus rhythm. Results were personally reviewed with the MD caring for the patient. Conclusions PRE BYPASS The left atrium is moderately dilated. No spontaneous echo contrast or thrombus is seen in the body of the left atrium or left atrial appendage. No atrial septal defect is seen by 2D or color Doppler. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size is normal with normal free wall contractility. There are simple atheroma in the aortic arch. There are simple atheroma in the descending thoracic aorta. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. There is no pericardial effusion. Dr. [**Last Name (STitle) 914**] was notified in person of the results in the operating room at the time of the study. POST BYPASS Normal biventricular systolic function. Thoracic aorta intact. No significant change from the pre-bypass study. I certify that I was present for this procedure in compliance with HCFA regulations. Electronically signed by [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4901**], MD, Interpreting physician [**Last Name (NamePattern4) **] [**2114-10-22**] 14:36 Brief Hospital Course: Mr [**Known lastname 1071**] was a same day admission to the operating room on [**10-22**] at which time he had coronary artery bypass grafting. Please see OR report for details. In summary he had CABG x5 with Left internal mammary artery to the left anterior descending coronary; reverse saphenous vein single graft from the aorta to the ramus intermedius coronary artery; reverse saphenous vein single graft from the aorta to the first obtuse marginal coronary artery; reverse saphenous vein single graft from the aorta to the third obtuse marginal coronary artery; as well as reversed saphenous vein graft from the aorta to the posterior descending coronary artery. Endoscopic left greater saphenous vein harvesting. His bypass time was 115 minutes with a crossclamp of 96 minutes. He tolerated the operation well and was transferred from the operating room to the cardiac surgery ICU in stable condition. He did well in the immediate post-op course, woke neurologically intact and was extubated on the operative day. He remained hemodynamically stable and was transferred from the ICU to the stepdown floor on POD1. All tubes, lines and drains were removed according to cardiac surgery protocols. He was noted to have a transient rise in his serum creatinine from his baseline 2.0 to 2.6 which resolved over the next 36 hours. The remainder of his post-op course was relatively uneventful. Over the next several days his activity level was advanced with the assistance of nursing and physical therapy. His medications were titrated to effect and on POD 5 he was discharged home with visiting nurses. Medications on Admission: Simvastatin 40 qd Benicar 40 qd Aspirin 325 qd Atenolol 25 qd Allopurinol 100 qd Doxazosin 4 qd Lantus Insulin 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. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 4. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 5. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO every four (4) hours as needed for pain. Disp:*60 Tablet(s)* Refills:*0* 6. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 7. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 8. Doxazosin 1 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 9. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 10. Insulin Glargine 100 unit/mL Solution Sig: One (1) Subcutaneous once a day: as per pcp. 11. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 6 days. Disp:*6 Tablet(s)* Refills:*0* 12. Potassium Chloride 25 mEq Packet Sig: One (1) PO every other day for 3 days. Disp:*3 Potassium Chloride (Oral) 25 mEq Packet* Refills:*0* 13. Metoprolol Tartrate 100 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:*60 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Last Name (LF) 486**], [**First Name3 (LF) 487**] Discharge Diagnosis: Coronary artery disease s/p cabg Post operative atrial fibrillation Hyperkalemia Hypertension Chronic renal insufficiency (2.0-2.2) Gout Diabetes mellitus type 2 Dyslipidemia Discharge Condition: Good Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming Monitor wounds for infection and report any redness, warmth, swelling, tenderness or drainage Please take temperature each evening and Report any fever 100.5 or greater Report any weight gain of greater than 2 pounds in 24 hours or 5 pounds in a week No creams, lotions, powders, or ointments to incisions No driving for approximately one month until follow up with surgeon No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] Followup Instructions: Please call to schedule appointments Surgeon Dr [**Last Name (STitle) 914**] in 4 weeks [**Telephone/Fax (1) 170**] Primary Care Dr [**Last Name (STitle) 29065**] in [**12-29**] weeks Cardiologist: Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 42394**] in [**1-30**] weeks Wound check appointment - [**Hospital Ward Name 121**] 6 ([**Telephone/Fax (1) 3071**]) - your nurse will schedule Completed by:[**2114-10-27**]

[ "272.4", "997.1", "511.9", "585.9", "414.01", "276.7", "403.90", "250.00", "518.0", "427.31", "512.1", "274.9", "411.1" ]

icd9cm

[ [ [] ] ]

[ "88.72", "39.61", "36.15", "36.14" ]

icd9pcs

[ [ [] ] ]

9834, 9917

6628, 8237

397, 1010

10136, 10143

2586, 2969

10772, 11211

1852, 1931

8398, 9811

3009, 3039

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1615, 1645

1947, 2567

282, 359

3071, 6605

1038, 1436

1458, 1592

1661, 1836

23,657

118,450

13525

Discharge summary

report

Admission Date: [**2146-7-29**] Discharge Date: [**2146-8-2**] Date of Birth: [**2112-11-14**] Sex: M Service: MEDICINE Allergies: Penicillins / Watermelon / Almond Oil / Hydralazine Attending:[**First Name3 (LF) 2186**] Chief Complaint: abdominal pain, hyperglycemia Major Surgical or Invasive Procedure: None History of Present Illness: Mr. [**Known lastname 21822**] is a 33y/o gentleman with poorly controlled DM1 complicated by gastroparesis and h/o DKA in the past, ESRD on HD, HTN and nonischemic cardiomyopathy (EF 30-35%) who presented to the ED with abdominal pain, nausea and vomiting in the setting of hyperglycemia. . He reports that his blood sugars have been reasonably controlled this week (<160) but he also admits that he has not checked his fingerstick at home since the day prior to admission. Yesterday he tool his standing Lantus 18U in the AM, and then a total of 20 units of sliding scale Humalog. The last fingerstick he took was 160. He awoke this morning feeling "sick to my stomach," with abdominal pain and he vomited a small amount of nonbloody fluid. He continued to have abdominal pain and vomited a few more times so he came to the ED. . The pain is a diffuse, burning epigastric pain that is associated with nausea and vomiting. It is similar to his prior episodes of gastroparesis and DKA. No RUQ pain. He denies any fevers/chills. No cough/URI symptoms. He still makes a small amount of urine but has had no dysuria and no change in the color of his urine. No flank pain. No erythema or redness from his RUE AVF. No skin rashes. . In the ED, initial vitals were: T 99.4, HR 101, BP 123/73, RR 18, POx 100% RA. He was vomiting and appeared volume depleted on exam and had diffuse abdominal tenderness but no acute abdomen. Labs revealed glucose 673, anion gap 21, pH 7.39. Potassium 5.2 so received no potassium. He received regular insulin 10U then was started on regular insulin drip at 7U/hr. Received 1L/hr for 3 hours (total 3L before transfer to ICU) and still remained tachycardic. For abdomminal pain, received Morphine 4mg IV; no imaging was obtained in the ED. Was given Zofran 8mg IV and Compazine 10mg IV. Vital signs prior to transfer were T 99.3, HR 104, BP 182/108, RR 18, POx 96% RA. . On the floor, he complains of abdominal pain but says it is a [**5-17**] (compared to 17/10 on admission). No nausea right now but starts to feel nauseated if talking for a long time. Very thirsty and asking for ice chips. . Review of systems: (+) Per HPI. Also last week he felt short of breath outside which resolved when he sat near an air conditioner. (-) Denies fever, chills, night sweats. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies cough or wheezing. Denies chest pain, chest pressure, palpitations, or weakness. Denies diarrhea, constipation, or changes in bowel habits. Denies dysuria, frequency, or urgency. Denies arthralgias or myalgias. Denies rashes or skin changes. Past Medical History: -DM type I since age 19, followed at [**Last Name (un) **]. Complicated by nephropathy, neuropathy, gastroparesis, retionpathy. Prior episodes of DKA and hospitalization. -ESRD on HD T/Th/S: right arm fistula, [**Location (un) **] [**Location (un) **], dry weight 73kg -Hypertension -Nonischemic cardiomyopathy with EF 30-35% -Anemia: felt to be due to both iron deficiency and advanced CKD -Depression -Pulmonary hypertension -Migraines Social History: -Home: Lives with his GF. Mother lives in the area as well. -Tobacco: trying to quit; has relapsed and smokes 1 pack per week -EtOH: previously drank heavily (30-40 drinks/week) but has not used alcohol since [**2144-11-14**] -Illicits: Denies other drugs. Family History: Paternal GF had DM2 but nobody with DM1. Hypertension in a few family members. Physical Exam: ADMISSION EXAM Vitals: T 98.8, BP 174/111, HR 98, RR 21, SaO2 97%RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, dry mucous membranes Neck: supple, JVP not elevated Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Tachycardic, S1 and S2, no murmur Abdomen: nondistended, (+)bowel sounds; mild tenderness to deep palpation in all quadrants with no rebound and no guarding GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema; no axillary sweat; RUE AVF with thrill Pertinent Results: ADMISSION LABS [**2146-7-29**] 02:30PM BLOOD WBC-8.6# RBC-4.45* Hgb-14.1# Hct-42.0 MCV-94 MCH-31.6 MCHC-33.5 RDW-14.4 Plt Ct-234 [**2146-7-29**] 02:30PM BLOOD Neuts-91.5* Lymphs-5.4* Monos-2.0 Eos-0.4 Baso-0.7 [**2146-7-29**] 02:30PM BLOOD Glucose-673* UreaN-43* Creat-9.3*# Na-135 K-5.2* Cl-90* HCO3-24 AnGap-26* [**2146-7-29**] 02:30PM BLOOD ALT-32 AST-21 AlkPhos-183* TotBili-0.6 [**2146-7-29**] 02:30PM BLOOD Lipase-62* [**2146-7-29**] 02:30PM BLOOD Albumin-4.6 Calcium-9.4 Phos-5.8*# Mg-1.8 [**2146-7-29**] 05:19PM BLOOD Glucose->500 Lactate-2.0 Na-137 K-4.6 Cl-99* calHCO3-20* [**2146-7-29**] 05:19PM BLOOD freeCa-1.01* Brief Hospital Course: Mr. [**Known lastname 21822**] is a 33 y/o gentleman with HTN and DM1 presenting with abdominal pain, nausea, vomiting in the setting of hyperglycemia that are consistent with prior episodes of gastroparesis and DKA. . #. Hyperglycemia/DKA: The patient presented in DKA with a blood sugar of 673 and an AG of 21. The patient has a h/o questionable med adherance and DKA. He was palced on an insulin gtt and electrolytes were followed. The patient improved with good FS and his gap fell to 13. Troponin elevated but without CK-MB elevations; findings likely a result of ESRD. EKG without evidence of AMI. On arrival in the MICU, the patient's FS was 215. Drip was d/c'ed and started on ISS. On AM of [**7-31**], the patient was still with FS in the 200s and had reopened a gap to 17. ISS was increased without change in the anion gap despite normal blood sugars, this persistant gap was thought likely [**2-9**] renal failure and accumulation of organic acids. Patient has had multiple admissions in the past year for similar complaints, patient's primary physician is [**Last Name (NamePattern4) **]. [**Last Name (STitle) **]. Patient asked specifically that we not get [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] consult as it costs him $300 each admission and he will follow up as an outpatient. . #. Abdominal pain: On arrival the paient complained of burning/fullness likely as a result of DKA, gastroparesis and abdominal wall tenderness from vomiting. This is similar to the pain he has had in the past in the setting of poorly controlled blood sugars. Associated with nausea. The pain and nausea were controlled with zofran, reglan, APAP and dilaudid. Reports that abd pain is greatly improved on AM of [**8-1**]. Patinet has a [**Company 191**] narcotics contract that states he will not recieve more than [**2-11**] mg Diluadid PO twice daily. . #. HTN: The patient has a h/o poorly controlled BP. Home meds currently include Carvedilol, Amlodipine and Lisinopril. In the MICU, the patient's pressures were initially elevated to the 200/110s range. Received home meds and labetolol overnight with good improvement. On [**7-31**], BPs are controlled with home meds to 130s systolic. . #. ESRD: The patient has ESRD on HD. Last HD was [**7-30**] he is a on a TTS schedule. TRANSITIONAL ISSUES: - Please do not obtain [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] consult while inpatient as patient cannot afford and will follow up as an outpatient - please contact dr. [**Last Name (STitle) **] regarding non-compliance - pt has a [**Company 191**] narcotics consult as described above. - pt receives HD TTS Medications on Admission: Aspirin 81 mg daily Carvedilol 50 mg [**Hospital1 **] Lisinopril 40 mg daily Amlodipine 10 mg daily Lantus 18U SC QAM (recently increased form 15U) Humalog sliding scale QACHS Metoclopramide 10 mg daily before biggest meal Ondansetron 4 mg Q8H PRN Omeprazole 20 mg [**Hospital1 **] Renvela 800 mg TID with meals Sumatriptan 25 mg PRN Glucagon Emergency 1 mg PRN Glucose Gel 40 % PRN Docusate 100 mg [**Hospital1 **] Viagra 50 mg PRN Hydromorphone 4 mg [**Hospital1 **] PRN Discharge Disposition: Home Discharge Diagnosis: (1) Diabetic ketoacidosis (2) End stage renal disease (3) Gastroparesis Discharge Condition: Sugars resolved, anion gap closed, ambulating, tolerating POs Discharge Instructions: Dear Mr [**Known lastname 21822**], You were admitted for abdominal pain and nausea/vomiting that we felt was secondary to diabetic ketoacidosis (DKA). We're unsure why your sugars went so high. To treat this, we started you on insulin and fluids, and your sugars resolved over the course of a couple of days. Your nausea, vomiting, and abdominal pain also improved. We did not make any changes to your medications at time of discharge. Followup Instructions: Department: [**Hospital3 249**] When: MONDAY [**2146-8-8**] at 3:00 PM With: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 24385**], MD [**Telephone/Fax (1) 250**] Building: SC [**Hospital Ward Name 23**] [**Hospital Ward Name **] Ctr [**Location (un) 895**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: TRANSPLANT SOCIAL WORK When: FRIDAY [**2146-9-16**] at 10:30 AM [**Telephone/Fax (1) 673**] Building: LM [**Hospital Unit Name **] [**Location (un) **] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage Department: GASTROENTEROLOGY When: WEDNESDAY [**2146-11-16**] at 12:30 PM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2837**], MD [**Telephone/Fax (1) 463**] Building: LM [**Hospital Unit Name **] [**Location (un) 858**] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage

[ "V45.11", "285.21", "425.4", "311", "305.1", "250.63", "250.53", "416.8", "250.43", "276.52", "280.9", "250.13", "V58.67", "536.3", "357.2", "428.0", "585.6", "403.91", "362.01" ]

icd9cm

[ [ [] ] ]

[ "39.95" ]

icd9pcs

[ [ [] ] ]

8259, 8265

5064, 7383

343, 350

8381, 8445

4414, 5041

8935, 9820

3757, 3839

8286, 8360

7762, 8236

8469, 8912

3854, 4395

7404, 7736

2539, 3004

273, 305

378, 2520

3026, 3466

3482, 3741

5,976

162,767

30761+57716+57717

Discharge summary

report+addendum+addendum

Admission Date: [**2105-5-21**] Discharge Date: [**2105-6-3**] Date of Birth: [**2052-2-1**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 165**] Chief Complaint: Chronic leg edema and shortness or breath Major Surgical or Invasive Procedure: [**2105-5-22**] Pericardectomy History of Present Illness: 53 y/o male with h/o constrictive pericarditis with unknown etiology for approx. 10 years who presented to OSH with leg and scrotal edema. He is also c/o shortness of breath and PND. Patient was diursed and underwent cardiac cath which was consistent with preicardial constriction. He has refused surgery in the past, but now agrees and was transferred to [**Hospital1 18**] for surgery. Past Medical History: Constrictive Pericarditis, Diabetes Mellitus, Hypertension, Obesity, Left Eye blindness Social History: Homeless, Quit smoking 2 months ago. 70 pack/yr hx. Denies ETOH. Family History: Unknown Physical Exam: 93 26 125/80 5'7" 115kg Gen: Ill appearing white male Skin: Bilat. venous stasis LE HEENT: Poor Dentition, right eye opacity, lef eye fixed pupil Neck: Supple, FROM, +JVD, -Carotid bruit Chest: CTAB -w/r/r Heart: RRR, [**3-31**] murmur Abd: Soft, NT/ND, +BS, obese Ext: Warm, 4+ bilat. LE edema, -varicosities Neuro: A&O x 3, MAE, non-focal Pertinent Results: [**2105-5-22**] Echo: The left atrium is moderately dilated. No spontaneous echo contrast is seen in the body of the left atrium. Mild spontaneous echo contrast is seen in the body of the right atrium. No atrial septal defect is seen by 2D or color Doppler. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is top normal/borderline dilated. Overall left ventricular systolic function is low normal (LVEF 50-55%). There appears to be focal left and right ventricular apical hypokinesis but poor apical windows prevent complete evaluation. There is abnormal septal motion suggestive of pericardial constriction. There are simple atheroma in the aortic arch. There are simple atheroma in the descending thoracic aorta. There are three aortic valve leaflets. There is a strand-like echodensity on the left ventricular outflow tract side of either the left or non-coronary cusp of the aortic valve that likely represents a degredative process but an aortic valve vegetation mass cannot be excluded. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. There is a trivial/physiologic pericardial effusion. There is a very large left pleual effusion as well as a right pleural effusion and ascites. After stripping of the pericardium there were no major changes. The pleural effusions were drained. RADIOLOGY Final Report CHEST (PORTABLE AP) [**2105-5-27**] 7:04 AM CHEST (PORTABLE AP) Reason: r/o ptx. assess effusions [**Hospital 93**] MEDICAL CONDITION: 53 year old man s/p pericardectomy and ct removal REASON FOR THIS EXAMINATION: r/o ptx. assess effusions AP CHEST [**5-27**], 8:47 A.M. HISTORY: Pericardiotomy. Chest tube removal. IMPRESSION: AP chest compared to [**5-22**] and 30: Left pleural drain has been removed. Small left pleural effusion and small right pleural effusion are stable. Very small right apical pneumothorax has decreased. Post-operative cardiomediastinal silhouette is unremarkable and unchanged. Left basal atelectasis is improved. DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 3891**] [**2105-6-1**] 09:35AM BLOOD WBC-7.7 RBC-3.74* Hgb-12.3* Hct-37.1* MCV-99* MCH-32.8* MCHC-33.1 RDW-14.2 Plt Ct-684* [**2105-5-29**] 08:00AM BLOOD PT-13.3* PTT-26.6 INR(PT)-1.2* [**2105-6-1**] 09:35AM BLOOD Glucose-176* UreaN-16 Creat-0.7 Na-138 K-3.9 Cl-92* HCO3-44* AnGap-6* Brief Hospital Course: As mentioned in the HPI, Mr. [**Known lastname **] was transferred to [**Hospital1 18**] for surgical management. He underwent usual pre-operative lab work on day of admission. On [**5-22**] he was brought to the operating room where he underwent a pericardectomy. Please see operative report for surgical details. Following surgery he was transferred to the CSRU for invasive monitoring in stable condition. Within 24 hours he was weaned from sedation, awoke neurologically intact and extubated. On post-op day one he was started on beta blockers and diuretics. ID consulted on Mr. [**Known lastname **] to help determine plan and to determine reason for constrictive pericarditis (r/o TB as cause). On post-op day one he appeared to be doing well and was transferred to the telemetry floor. Over the next several days he worked with physical therapy for strength and mobility. Chest tubes and epicardial pacing wires were removed per protocol. He was diuresed and medically managed during these days and awaited results of tissue microbiology which were all negative. He continued to diurese well. Medications on Admission: At home: Bumex At Transfer: Bumex 2mg IV bid, Protonix 40mg qd, Heparin 5000units SC TID, Aspirin 81mg qd, Lisinopril 10mg qd, Novolog Insulin Discharge Medications: 1. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*1* 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*1* 3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*1* 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. Diamox Sequels 500 mg Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO twice a day. 6. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two (2) Capsule, Sustained Release PO Q12H (every 12 hours). 7. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) for 4 weeks. 9. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO once a day for 7 days: When this dose is complete, decrease to 200 mg PO daily. 10. Metolazone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Bumex 2 mg Tablet Sig: One (1) Tablet PO twice a day. 12. Insulin Glargine 100 unit/mL Solution Sig: Ten (10) units Subcutaneous at bedtime. 13. Insulin Regular Human 300 unit/3 mL Insulin Pen Sig: One (1) unit Subcutaneous four times a day: Follow this sliding scale: BS 109-140 2 units 141-200 4 units 201-250 6 units 251-300 8 units 301-350 10 units. Discharge Disposition: Extended Care Facility: [**First Name8 (NamePattern2) 2048**] [**Last Name (NamePattern1) **] House Discharge Diagnosis: Constrictive Pericarditis s/p Pericardectomy PMH: Diabetes Mellitus, Hypertension, Obesity, Left Eye blindness Discharge Condition: Good Discharge Instructions: Patient may shower, no baths. No creams, lotions or ointments to incisions. No driving for at least one month. No lifting more than 10 lbs for at least 10 weeks from the date of surgery. Monitor wounds for signs of infection. Please call with any concerns or questions. Followup Instructions: Dr. [**First Name (STitle) **] in 4 weeks Dr. [**First Name (STitle) 1075**] in [**2-28**] weeks Dr. [**First Name (STitle) **] in [**1-27**] weeks [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**] Completed by:[**2105-6-1**] Name: [**Known lastname **],[**Known firstname 12120**] Unit No: [**Numeric Identifier 12121**] Admission Date: [**2105-5-21**] Discharge Date: [**2105-6-3**] Date of Birth: [**2052-2-1**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 265**] Addendum: Of note, Mr. [**Known lastname **] stayed and extra day at the [**Hospital1 8**] as there was no bed available at the rehab facility on [**2105-6-2**]. He was thus discharged to rehab on [**2105-6-3**]. Discharge Disposition: Extended Care Facility: [**First Name8 (NamePattern2) 302**] [**Last Name (NamePattern1) 5572**] House [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 266**] Completed by:[**2105-6-3**] Name: [**Known lastname **],[**Known firstname 12120**] Unit No: [**Numeric Identifier 12121**] Admission Date: [**2105-5-21**] Discharge Date: [**2105-6-3**] Date of Birth: [**2052-2-1**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 265**] Addendum: Ready for discharge to rehab with continued monitoring. He has been aggressively diuresised and currently zarolyxn discontinued. Plan for daily weights and monitoring edema for diuretic adjustment. Discharge Medications: 1. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*1* 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*1* 3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*1* 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. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two (2) Capsule, Sustained Release PO Q12H (every 12 hours). 6. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) for 4 weeks. 8. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO once a day for 7 days: When this dose is complete, decrease to 200 mg PO daily. 9. Bumex 2 mg Tablet Sig: One (1) Tablet PO twice a day. 10. Insulin Glargine 100 unit/mL Solution Sig: Ten (10) units Subcutaneous at bedtime. 11. Insulin Regular Human 300 unit/3 mL Insulin Pen Sig: One (1) unit Subcutaneous four times a day: Follow this sliding scale: BS 109-140 2 units 141-200 4 units 201-250 6 units 251-300 8 units 301-350 10 units. Discharge Disposition: Extended Care Facility: [**First Name8 (NamePattern2) 302**] [**Last Name (NamePattern1) 5572**] House Followup Instructions: Dr. [**First Name (STitle) **] in 4 weeks [**Telephone/Fax (1) 1477**] Dr. [**First Name (STitle) **] in [**2-28**] weeks Dr. [**First Name (STitle) 1481**] in [**1-27**] weeks [**Telephone/Fax (1) 12122**] please call to schedule appointments [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 266**] Completed by:[**2105-6-3**]

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4027

Discharge summary

report

Admission Date: [**2181-9-23**] Discharge Date: [**2181-10-12**] Date of Birth: [**2120-10-31**] Sex: F Service: MEDICINE Allergies: Penicillins / Imuran / Cephalosporins / Sulfa (Sulfonamide Antibiotics) / Reglan / Latex / Ampicillin / Lactose / Soy, Lentals, Beans Attending:[**First Name3 (LF) 5037**] Chief Complaint: need for BI-PAP/dyspnea Major Surgical or Invasive Procedure: cardiac catheterization with stent place in LAD central line placement History of Present Illness: This is a 60-year old Indian female with a complicated past medical history significant for type 1 IDDM (s/p revision renal and pancraes transplants, [**2160**] and [**2174**]), diastolic CHF (Echo 35-40%, [**7-/2181**]), sleep-disordered breathing (on 2L home oxygen at night) who presented with dyspnea from [**Hospital 1319**] Rehab. Per discussion with the nursing supervisor, the patient developed increased work of breathing over 1-2 hours. The patient also complained of feeling warm, but did not localized any particular infectious symptoms. She was given 20 of IV lasix, and did not have a good response. She was then transfer to [**Hospital1 18**] for further evaluation and treatment. In the ED, initial VS were T-101 (rectal), HR 100, 20, 100% fi 02 PS 8, 125/73. She was initially started on BI-PAP, but the patient ripped off the mask due to her altered mental status. She was given 5 of Haldol and started on non-rebreather. An ABG reveal 7.35/48/309 on the non-rebreather. She was had labored breathing and was using accessory muscle and was re-started Bi-PAP. She was given lasix 20 IV with good urine output (300cc in first hour). Blood and Urine cultures were sent, and a CXR was obtained. The patient was then started on empiric coverage of abx and heparin gtt here in the MICU. Past Medical History: PAST MEDICAL & SURGICAL HISTORY: 1. diastolic CHF (preserved EF 35-40%, moderate regional systolic dysfunction, [**7-/2181**]) 2. s/p renal transplant ([**2157**], complicated by chronic rejection, second transplant [**2160**]) 3. s/p pancreas transplant (with allograft pancreatectomy [**5-/2174**], redo transplant [**6-/2175**], acute rejection [**7-/2180**] which resolved with increased immunosuppresion) 4. diabetes mellitus type I (complicated by neuropathy, retinopathy, dysautonomia, no longer requires regular insulin after pancreas transplant) 5. autonomic neuropathy 6. sleep-disordered breathing (on 2L NC nighttime, unable to tolerate CPAP) 7. osteoporosis 8. hypothyroidism 9. pernicious anemia 10. cataracts 11. glaucoma 12. anemia from chronic kidney disease (on Aranesp previously) 13. Right foot fracture, complicated by RLE DVT 14. chronic LLE edema 15. Reucrrent MDR E.coli pyelonephritis 16. s/p anal polypectomy ([**5-/2176**]) 17. s/p bilateral trigger finger surgery ([**8-/2178**]) 18. s/p left [**Year (4 digits) 6024**] ([**8-/2179**]) Social History: Child psychiatrist, on disability. Lives alone in [**Hospital1 8**], MA. Has a PCA 8 hours/day. Ambulatory with a prosthesis for left leg. Was at [**Hospital3 **] prior to this admission. Denies tobacco use or alcohol use; no recreational substance use. Family History: Father with MI at 57 year old; denies family history of arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Physical Exam: Vitals: T:97.7 BP:105/59 P:98 R: 18 O2: 98% on FIO2 .50 on humidified facemask General: somnolent, but oriented x3, clearly using accessory muscle to breath HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: crackles at base bilaterally, using abdomin and accessory muscles to breath Abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly GU: foley in place [**Hospital3 **]: warm, well perfused, 2+ pulses, +1 edema on R leg, [**Hospital3 6024**] on left. Discharge PE: Tc 98.3 Tm 98.7 156/69 (101-156/51-74) 66 60-94 18 100 on RA GENERAL: Thin, woman in NAD, comfortable, appropriate. HEENT: sclerae anicteric, MMM. NECK: Supple CHEST: R sided HD line; dressing, clean, dry intact, no tenderness to palpation, no erythema appreciated HEART: RRR, S1, S2. LUNGS: clear to ausculation b/l ABDOMEN: soft, nondistended, no tenderness over L lower abdomen over transplanted kidney EXTREMITIES: WWP; No edema. left [**Hospital3 6024**]. NEURO: Awake, A&Ox3 Pertinent Results: [**2181-9-23**] 01:40AM BLOOD WBC-3.4*# RBC-3.45* Hgb-10.3* Hct-31.7* MCV-92 MCH-29.8 MCHC-32.4 RDW-15.5 Plt Ct-125* [**2181-9-23**] 06:40AM BLOOD WBC-3.4* RBC-3.22* Hgb-9.5* Hct-28.6* MCV-89 MCH-29.4 MCHC-33.2 RDW-15.6* Plt Ct-145* [**2181-9-23**] 01:38PM BLOOD WBC-3.7* RBC-2.98* Hgb-9.0* Hct-27.3* MCV-92 MCH-30.3 MCHC-33.1 RDW-15.8* Plt Ct-102* [**2181-9-24**] 05:36AM BLOOD WBC-3.3* RBC-2.78* Hgb-8.3* Hct-25.6* MCV-92 MCH-29.9 MCHC-32.5 RDW-15.9* Plt Ct-101* [**2181-9-24**] 12:55PM BLOOD WBC-3.7* RBC-3.05* Hgb-8.8* Hct-29.0* MCV-95 MCH-28.8 MCHC-30.4* RDW-15.4 Plt Ct-123* [**2181-9-23**] 01:40AM BLOOD PT-13.1 PTT-31.7 INR(PT)-1.1 [**2181-9-23**] 06:40AM BLOOD PT-13.4 PTT-30.7 INR(PT)-1.1 [**2181-9-23**] 01:38PM BLOOD PT-14.3* PTT-63.1* INR(PT)-1.2* [**2181-9-23**] 07:42PM BLOOD PT-14.9* PTT-83.0* INR(PT)-1.3* [**2181-9-24**] 05:36AM BLOOD PT-15.0* PTT-98.8* INR(PT)-1.3* [**2181-9-23**] 01:40AM BLOOD Glucose-101* UreaN-125* Creat-2.2* Na-143 K-5.6* Cl-106 HCO3-25 AnGap-18 [**2181-9-23**] 06:40AM BLOOD Glucose-79 UreaN-124* Creat-2.1* Na-142 K-5.2* Cl-107 HCO3-24 AnGap-16 [**2181-9-23**] 01:38PM BLOOD Glucose-100 UreaN-120* Creat-2.2* Na-142 K-5.1 Cl-108 HCO3-21* AnGap-18 [**2181-9-24**] 05:36AM BLOOD Glucose-149* UreaN-116* Creat-2.4* Na-144 K-4.7 Cl-107 HCO3-24 AnGap-18 [**2181-9-24**] 05:51PM BLOOD Glucose-118* UreaN-109* Creat-2.5* Na-142 K-5.6* Cl-105 HCO3-26 AnGap-17 [**2181-9-23**] 01:40AM BLOOD CK-MB-4 proBNP-[**Numeric Identifier 17772**]* [**2181-9-23**] 01:40AM BLOOD cTropnT-0.06* [**2181-9-23**] 06:40AM BLOOD CK-MB-15* MB Indx-11.8* cTropnT-0.33* [**2181-9-23**] 01:38PM BLOOD CK-MB-15* MB Indx-8.8* cTropnT-0.73* [**2181-9-24**] 05:36AM BLOOD CK-MB-7 cTropnT-0.76* [**2181-9-23**] 06:40AM BLOOD Calcium-8.7 Phos-4.5# Mg-2.0 [**2181-9-23**] 01:38PM BLOOD Calcium-9.6 Phos-4.2 Mg-2.2 [**2181-9-24**] 05:36AM BLOOD Calcium-8.9 Phos-4.1 Mg-2.1 [**2181-9-24**] 05:51PM BLOOD Calcium-8.6 Phos-4.9* Mg-2.2 [**2181-9-25**] 04:00AM BLOOD Calcium-8.5 Phos-5.0* Mg-2.1 [**2181-10-5**] 04:13AM BLOOD calTIBC-215* Ferritn-174* TRF-165* [**2181-9-26**] 02:32AM BLOOD TSH-2.9 [**2181-10-5**] 04:13AM BLOOD PTH-64 [**2181-10-3**] 02:41PM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE HBcAb-NEGATIVE [**2181-9-24**] 05:36AM BLOOD tacroFK-4.8* rapmycn-4.7* [**2181-9-25**] 04:00AM BLOOD tacroFK-4.2* rapmycn-4.7* [**2181-9-23**] 02:17AM BLOOD Type-ART FiO2-100 pO2-309* pCO2-48* pH-7.35 calTCO2-28 Base XS-0 AADO2-353 REQ O2-64 [**2181-9-23**] 05:28AM BLOOD Type-ART Temp-37.0 Rates-/20 FiO2-60 O2 Flow-15 pO2-69* pCO2-46* pH-7.36 calTCO2-27 Base XS-0 Intubat-NOT INTUBA [**2181-9-23**] 05:50PM BLOOD Type-ART Temp-37.0 Rates-/16 FiO2-50 O2 Flow-10 pO2-86 pCO2-44 pH-7.40 calTCO2-28 Base XS-1 Intubat-NOT INTUBA Vent-SPONTANEOU [**2181-9-25**] 01:53AM BLOOD Type-ART Temp-36.4 O2 Flow-4 pO2-83* pCO2-46* pH-7.33* calTCO2-25 Base XS--1 Intubat-NOT INTUBA Comment-NASAL [**Last Name (un) 154**] [**2181-9-26**] 09:35AM BLOOD Type-ART Temp-37.6 Rates-/20 Tidal V-500 PEEP-5 FiO2-100 pO2-467* pCO2-33* pH-7.45 calTCO2-24 Base XS-0 AADO2-215 REQ O2-44 -ASSIST/CON Intubat-INTUBATED . Discharge labs: [**2181-10-10**] 07:58AM BLOOD WBC-2.4* RBC-2.58* Hgb-7.5* Hct-24.3* MCV-94 MCH-29.0 MCHC-30.9* RDW-14.8 Plt Ct-264 [**2181-10-11**] 05:15AM BLOOD WBC-2.4* RBC-2.77* Hgb-7.8* Hct-25.0* MCV-90 MCH-28.3 MCHC-31.3 RDW-15.2 Plt Ct-236 [**2181-10-12**] 05:10AM BLOOD WBC-2.5* RBC-2.75* Hgb-7.8* Hct-26.2* MCV-95 MCH-28.5 MCHC-30.0* RDW-15.2 Plt Ct-285 [**2181-10-10**] 07:58AM BLOOD PT-11.6 INR(PT)-1.0 [**2181-10-11**] 05:15AM BLOOD PT-11.6 INR(PT)-1.0 [**2181-10-11**] 05:15AM BLOOD Glucose-76 UreaN-18 Creat-2.0*# Na-142 K-4.3 Cl-105 HCO3-30 AnGap-11 [**2181-10-12**] 02:07AM BLOOD Glucose-85 UreaN-28* Creat-2.7* Na-139 K-5.1 Cl-105 HCO3-29 AnGap-10 [**2181-10-12**] 05:10AM BLOOD Glucose-108* UreaN-29* Creat-2.7* Na-141 K-4.6 Cl-105 HCO3-29 AnGap-12 [**2181-9-30**] 09:56PM BLOOD CK-MB-14* MB Indx-1.4 cTropnT-1.71* [**2181-10-1**] 03:54AM BLOOD CK-MB-12* MB Indx-1.4 cTropnT-1.69* [**2181-10-1**] 02:50PM BLOOD CK-MB-6 cTropnT-1.86* [**2181-10-2**] 05:29AM BLOOD CK-MB-3 cTropnT-2.67* [**2181-10-2**] 02:59PM BLOOD CK-MB-2 cTropnT-2.17* [**2181-10-12**] 02:07AM BLOOD CK-MB-2 cTropnT-2.6* [**2181-10-11**] 05:15AM BLOOD Calcium-8.7 Phos-2.5* Mg-2.0 [**2181-10-12**] 02:07AM BLOOD Calcium-8.5 Phos-3.4 Mg-2.1 [**2181-10-12**] 05:10AM BLOOD Calcium-8.6 Phos-3.4 Mg-2.2 [**2181-10-9**] 05:25AM BLOOD tacroFK-5.7 rapmycn-4.9* [**2181-10-10**] 07:58AM BLOOD tacroFK-5.3 rapmycn-4.9* [**2181-10-12**] 05:10AM BLOOD tacroFK-12.5 rapmycn-4.0* TEE ([**2181-10-11**]) 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 patent foramen ovale is present with left-to-right shunt across the interatrial septum at rest. Overall left ventricular systolic function is moderately depressed (LVEF= 35 %). Right ventricular chamber size and free wall motion are normal. There are simple atheroma in the aortic archand the descending thoracic aorta. The aortic valve leaflets (3) are mildly thickened. No masses or vegetations are seen on the aortic valve. No aortic valve abscess is seen. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. No mass or vegetation is seen on the mitral valve. Moderate (2+) mitral regurgitation is seen. No masses or vegetations are seen on the pulmonic valve. No mass or vegetation is seen on the catheter in the right atrium. There is no pericardial effusion. IMPRESSION: No valvular or catheter related vegetations seen. Patent foramen ovale. Moderately reduced left ventricular systolic function. Moderate mitral regurgiation. Mild aortic regurgitation. TTE ([**2181-10-9**]) The left atrium and right atrium are normal in cavity size. The estimated right atrial pressure is 5-10 mmHg. Left ventricular wall thicknesses are normal. The left ventricular cavity size is top normal/borderline dilated. There is moderate regional left ventricular systolic dysfunction with hypokinesis of the septum and anterior walls, distal inferior and distal lateral walls, and apex. The remaining segments contract normally (LVEF = 35 %). The estimated cardiac index is normal (>=2.5L/[**Month/Day/Year **]/m2). No masses or thrombi are seen in the left ventricle. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) 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. Moderate to severe (3+) mitral regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Borderline left ventricular cavity enlargement with regional systolic dysfunction suggestive of multivessel CAD or other diffuse process. Moderate to severe mitral regurgitation. Pulmonary artery hypertension. VENOUS DUP UPPER [**Month/Day/Year **] BILATERAL; ART DUP [**Month/Day/Year **] UP BILAT COMPIMPRESSION: ([**2181-10-11**]) 1. Patent bilateral subclavian veins with normal phasic waveform. 2. Patent right cephalic and right and left cephalic vein in the arm, patent left basilic vein. 3. Thrombosed right basilic vein and left cephalic vein in the forearm. CT neck ([**2181-10-11**]) IMPRESSION: 1. No evidence of large focal mass compressing on the vocal cords or along the course of the laryngeal nerves; assessment is limited due to lack of IV contrast images. 2. Bilateral pleural effusions, right greater than left. 3. 6.4-mm nodule in the left upper lung. Recommend dedicated Chest CT to further evaluate. 4. Extensive vascular calcifications consistent with the patient's history of diabetes. 5. Degenerative disk disease, most prominent at C5-C6 and C6-7. Fluid with some debris is noted in the esophagus which is mildly dilated- correlate clinically. Renal ultrasound ([**2181-10-4**]) IMPRESSION: 1. No hydronephrosis. An echogenic pattern seen within the transplant kidney suggests that air may be present in the collecting system. If the Foley catheter has been manipulated, then this could represent reflux air. In the setting of pain, however, air could indicate an infection. 2. Patent renal transplant vasculature with mildly elevated resistive indices. Brief Hospital Course: This is a 60-year old Indian female with a complicated past medical history significant for type 1 IDDM (s/p revision renal and pancraes transplants, [**2160**] and [**2174**]), diastolic CHF (Echo 35-40%, [**7-/2181**]), sleep-disordered breathing (on 2L home oxygen at night) who presented with dyspnea. . #.Respiratory distress, hypercarbic - The patient presented with fever and increasing work of breathing with dyspnea that developed over 1-2 hours. She was started on empiric HCAP abx coverage of meropenem, cipro, and vanco. On [**9-24**] she had increasing respiratory rate and she was intubated on [**9-26**]. A bronchoscopy on [**9-29**] showed large amount of blood clots and thick mucus with no evidence of source of bleed or pna. On [**9-30**], she passed regular spontaneous breathing trial and she was extubated on [**10-2**]. . #. CAD - Cardiac enzymes initially rose upon arrival to the MICU. She had an ECHO which showed "LV hypertrophy and systolic dysfunction c/w CAD; severe mitral regurgitation and moderate tricuspid regurgiation; compared with the prior study the estimated PA systolic pressure is now higher." Cardiology was consulted and she had a cardiac catheterization on [**9-27**] - rotoblater used with DES to LAD. She tolerated the procedure well. On [**9-30**], she had ST elevation with a trop elevated to 1.71. Cardiology was consulted and they did not want to stent her. She was started on lisinopril 2.5mg PO qday. . #.Volume status ([**Last Name (un) **] on CKD, CHF) - Difficult to manage given patient's renal failure and concominant severe mitral regurgitation. She was initially hypotensive and responded well to 2 U pRBCs and fluid boluses. An A-line was placed on [**9-26**]. She was started on Lasix gtt at 15mg/hr for a goal of -1 to -2 L. On [**9-26**], she received a tunnelled HD line for initiation of CVVH. She became hypotensive and did not respond to IVF, was startd on levophed on [**9-27**]. On [**10-1**], her SBP was very labile and it was difficult to strike a balance of IVF and pressors. Her levophed was weaned off on [**10-2**]. Since coming to the floors, the patient's blood pressures were also labile and she was continued on HD M,W,F to assist with volume control. She will be discharged to rehab with outpatient dialysis three times weekly for further volume control. . #. Fever- She was started on vancomycin and meopenem initially for presumptive HAP. Out of concern for possible varicella pneumonitis, her acyclovir dose was changed to a prophylactic dose. On [**10-1**] she spiked another fever to 38.2 and she was cultured. A urine culture resulted yeast in her urine and she was started on fluconazole. A blood culture resulted on [**10-2**] and showed GPC's in [**3-26**] bottles. Her IJ line was removed and the tip was cultured. Her A-line was also removed at this time. . #. CHF- the pt has known systolic CHF (LVEF-34-40%), was given lasix 20 IV at rehab and 20 IV in ED. Pt has reasonable responce (300cc within 1st hour). This pt should not be aggressively diureses right now as she's in an early septic phase and will likely be pre-load dependent. The patient's volume status was managed with HD/ultrafiltration. Patient's BPs have been very labile and so beta blockers were not initiated during this admission. . #. S/p renal/pancreatic transplant - She was continued on renal dosing of sirolimus and tacrolimus. Renal consultants were closely following her throughout her stay in the MICU. On [**10-4**], she began to develop LLQ pain. A renal US showed air in the transplanted kidney which is likely from her foley. She improved with no interventions necessary. On transfer to the floor, the patient did not have any abdominal pain and the issue resolved. The patient's tacrolimus and sirolimus levels were followed every morning; she was initially continued on tacrolimus 2.5 mg [**Hospital1 **], sirolimus 1.5 mg daily, and prednisone 5 mg daily. However, her tacrolimus was eventually increased to 3 mg [**Hospital1 **]. She will have to get her tacrolimus and sirolimus levels checked one time weekly as an outpatient. . #.A-fib with RVR - on [**9-26**], she developed afib with RVR and was started on IV metoprolol with PRN diltiazem. When she converted to sinus rhythm, she was started on amiodarone which was later stopped when she became bradycardic. She again went into afib with RVR on [**9-28**] after CVVHD. As a result, her CVVHD was backed off. The patient's Afib had resolved by the time she was transferred to the floor. . #Rash - disseminated rash developed 5 days prior to admission to MICU. ID was consulted and they recommended continuing acyclovir for concern of disseminated zoster. A sputum VZV was sent along with gram stain/culture. Dermatology was consulted and a biopsy was done which was consistent with an old varicella infection. She was taken off precautions. As per ID recommendation, the patient will need prophylaxis with acyclovir at 200mg q12h. . # acute kidney injury: The patient initiated dialysis during this hospital admission; likely secondary to acute tubular necrosis from decreased forward flow while she was pressor dependent in the MICU. The patient's creat peaked at 3.6 and at discharge, her creat was 2.7. The patient never had a post ATN diuresis that would be expected if her acute kidney injury secondary to ATN was resolving. She was still making some urine on the medicine floor, however, only in small amounts (~50 cc over the course of 24 hours). The patient will be discharged to rehab with outpatient dialysis follow-up. The patient had a tunnelled line placed on R chest; it was not pulled when she developed her coag negative Staph bacteremia, but was treated with Vancomycin. The patient's lisinopril was also discontinued given her acute kidney injury as well as her borderline low blood pressures. . # coag negative Staph bacteremia: The patient was found to have coag negative staph bacteremia growing out of [**3-26**] bottles. All of her lines were pulled, EXCEPT her tunnelled HD catheter line and it was decided to treat through the line. The patient will be on Vancomycin, HD dosing, for a total of two weeks (started on [**2181-10-3**]) and will continue the vancomycin with dialysis until [**10-17**]. A TTE was done could not rule out valvular vegetations, and a TEE was done showing that the patient did not have any vegetations. Please note, when getting the vanco trough, please make sure that trough is drawn AFTER the dialysis machine has been running for 10-20 minutes, as the patient's HD line is vanc blocked and we do not want that to be causing a falsely elevated trough. . # yeast UTI: The patient was also found to have yeast growing out of her urine. She was started on fluconazole 100 mg daily and will complete a two week course. Antifungal sensitivities were sent to [**State **]. . # vocal cord paralysis: The patient was found to have vocal cord paralysis by ENT which can account for her weakened voice s/p intubation and her inability to drink thin liquids because would frequently aspirate. ENT wanted a CT neck/chest to rule out any masses that were pressing on the laryngeal nerve that could be causing larygneal nerve dysfunction, especially given her immunocompromised status. CT was negative for any masses. The patient will follow up with ENT as an outpatient. Speech and swallow was following the patient while inpatient and she will be discharged on dysphagia/avoid thin liquid diet. . # Hypothyroidism -continued on home levothyroxine. . #. type 1 DM s/p pancreatic transplant, complicated by neuropathy, retinopathy, dysautonomia, but no longer requiring insulin. The patient's sugars were under control during this admission. . # Glaucoma - pt continued on methazolamide . # teriparatide: Endo was consulted about whether patient should continue her teriparatide now given that she was initiated on HD. Was instructed to hold teriparatide for now. . Transitional Issues: . #: vanco trough: When getting the vanco trough, please make sure that trough is drawn AFTER the dialysis machine has been running for 10-20 minutes, as the patient's HD line is vanc blocked and we do not want that to be causing a falsely elevated trough. . # outpatient blood work: Please check tacrolimus and sirolimus levels weekly as an outpatient. . # RUE DVT: The patient was diagnosed with RUE DVT on previous admission. While she was in-patient the patient was not on any anticoagulation. She was instructed to hold a/c at discharge; please follow this up as an outpatient. Medications on Admission: 1. fosfomycin tromethamine 3 gram Packet Sig: One (1) packet PO once a week. 2. levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO 3X/WEEK ([**Doctor First Name **],TU,TH). 3. levothyroxine 112 mcg Tablet Sig: One (1) Tablet PO 4X/WEEK (MO,WE,FR,SA). 4. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. methazolamide 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 6. prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) inh Inhalation Q6H (every 6 hours) as needed for sob/wheeze. 10. ipratropium bromide 0.02 % Solution Sig: One (1) inh Inhalation Q6H (every 6 hours) as needed for sob/wheeze. 11. teriparatide 20 mcg/dose - 600 mcg/2.4 mL Pen Injector Sig: One (1) injection Subcutaneous once a day. 12. sirolimus 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): at 6am. 13. tacrolimus 0.5 mg Capsule Sig: Three (3) Capsule PO Q12H (every 12 hours). 14. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 15. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain/fever. 16. cyclosporine 0.05 % Dropperette Sig: One (1) drop Ophthalmic [**Hospital1 **] (2 times a day). 17. brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic Q8H (every 8 hours). 18. latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at bedtime). 19. lipase-protease-amylase 12,000-38,000 -60,000 unit Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO three times a day: with meals. 20. dorzolamide-timolol 2-0.5 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2 times a day). 21. Calcium 500 + D 500 mg(1,250mg) -400 unit Tablet Sig: One (1) Tablet PO once a day. 22. Aranesp (polysorbate) 60 mcg/mL Solution Sig: One (1) injection Injection once a month: most recent dose [**2181-9-7**]. 23. pentamidine 300 mg Recon Soln Sig: One (1) inhalation Inhalation once a month. 24. warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM. 25. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 26. torsemide 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 27. trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as needed for insomnia. Discharge Medications: 1. levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO Q SUN/TUE/ THURS (). 2. levothyroxine 112 mcg Tablet Sig: One (1) Tablet PO Q MO, WED, FR, SA (). 3. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. tacrolimus 1 mg Capsule Sig: Three (3) Capsule PO Q12H (every 12 hours). 5. acyclovir 400 mg Tablet Sig: 0.5 Tablet PO Q12H (every 12 hours). 6. fluconazole 100 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours): please stop on [**2181-10-16**]. 7. vancomycin 500 mg Recon Soln Sig: One (1) Recon Soln Intravenous HD PROTOCOL (HD Protochol): please stop [**2181-10-17**]. 8. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. doxepin 10 mg Capsule Sig: One (1) Capsule PO at bedtime. 12. methazolamide 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) as needed for glaucoma. 13. ipratropium bromide 17 mcg/Actuation HFA Aerosol Inhaler Sig: Six (6) Puff Inhalation QID (4 times a day) as needed for sob/wheezing. 14. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: Six (6) Puff Inhalation Q4H (every 4 hours) as needed for sob/wheezing. 15. prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 16. sirolimus 1 mg Tablet Sig: 1.5 Tablets PO once a day: 1.5 mg daily. 17. cyclosporine 0.05 % Dropperette Sig: One (1) Ophthalmic twice a day. 18. brimonidine 0.15 % Drops Sig: One (1) Ophthalmic three times a day. 19. latanoprost 0.005 % Drops Sig: One (1) Ophthalmic at bedtime. 20. lipase-protease-amylase 12,000-38,000 -60,000 unit Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO three times a day: with meals. 21. dorzolamide-timolol 2-0.5 % Drops Sig: One (1) Ophthalmic twice a day. 22. Calcium 500 + D 500 mg(1,250mg) -400 unit Tablet Sig: One (1) Tablet PO once a day. 23. Aranesp (polysorbate) 60 mcg/mL Solution Sig: One (1) Injection once a month. 24. pentamidine 300 mg Recon Soln Sig: One (1) Inhalation once a month. 25. trazodone 50 mg Tablet Sig: 0.5 Tablet PO at bedtime. 26. senna 8.6 mg Capsule Sig: One (1) Capsule PO twice a day. 27. Tylenol 325 mg Tablet Sig: One (1) Tablet PO q6h: PRN as needed for fever or pain. 28. sevelamer carbonate 800 mg Tablet Sig: One (1) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 29. famotidine 20 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Extended Care Facility: [**Hospital **] Hospital - [**Hospital1 8**] Discharge Diagnosis: primary diagnosis: hypercarbic respiratory failure coagulase negative staph bacteremia diabetes mellitus, type 1 status post renal and pancreas transplant Discharge Condition: Activity Status: Ambulatory - requires assistance or aid (walker or cane). uses a prosthesis Level of Consciousness: Alert and interactive. Mental Status: Clear and coherent. Discharge Instructions: Dear Ms. [**Known lastname 17759**], It was a pleasure taking care of you while you were hospitalized at [**Hospital1 18**]. You were initially admitted to the hospital because you were having shortness of breath at rehab; you had respiratory failure and you were admitted to the intensive care unit and connected to a machine to help breath for you. While in the intensive care unit, you were also found to have acute heart dysfunction and you underwent a heart procedure where a stent was placed in your coronary artery. . Your blood pressures were very low and you needed medications to help support your pressures. During this time, we think that your kidneys were not getting enough fluid, and you developed kidney dysfunction. It was decided that you should start dialysis because of your poor kidney function, as well as to help stabilize your volume status. . As you were leaving the intensive care unit, you were found to have bacteria in your blood. You were started on antibiotics through your veins for this. Because bacteria in your blood can sometimes latch onto your heart valves, we did imaging of your heart; we did NOT find any bacteria latching onto your heart valves. . You also were found to have a urinary tract infection with yeast; we started you on an antifungal medication for this. You need to take another four more days of this medication (STOP on [**2181-10-16**]). . You were also seen by the ears/nose/throat (ENT) doctors [**Name5 (PTitle) 1028**] [**Name5 (PTitle) 17773**] were here because you were having some problems drinking thin liquids (instead of going into your esophagus, the liquid was entering your lungs). They found that you had a problem with your vocal cords, and they want you to follow up with them as an outpatient. . We made the following changes to your medications: START Vancomycin with your dialysis until [**2181-10-17**] START Fluconazole 100 mg daily until [**2181-10-16**] STOP lisinopril STOP carvedilol STOP Teriparatide CHANGE aspirin 81 to 325 mg daily DECREASE acyclovir from 400 to 100 mg daily STOP doxazosin START Plavix 75 mg daily INCREASE tacrolimus to 3 mg daily INCREASE sirolimus 1.5 mg daily STOP Coumadin until you see your PCP STOP fosfomycin tromethamine START Sevelamer 800 mg TID with meals /Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more than 3 lbs. Followup Instructions: Department: [**Hospital3 249**] When: FRIDAY [**2181-10-19**] at 3:15 PM With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 250**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage . Department: OTOLARYNGOLOGY-AUDIOLOGY When: TUESDAY [**2181-10-23**] at 10:00 AM With: [**Name6 (MD) 15040**] [**Last Name (NamePattern4) 15041**], MD [**Telephone/Fax (1) 41**] Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) 895**] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage . Department: TRANSPLANT CENTER When: MONDAY [**2181-10-29**] at 12:30 PM With: [**First Name4 (NamePattern1) 971**] [**Last Name (NamePattern1) 970**], MD [**Telephone/Fax (1) 673**] Building: LM [**Hospital Unit Name **] [**Location (un) **] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage [**Name6 (MD) 2105**] [**Name8 (MD) 2106**] MD [**MD Number(2) 5038**] Completed by:[**2181-10-12**]

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icd9cm

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icd9pcs

[ [ [] ] ]

26332, 26403

12830, 20800

420, 493

26602, 26742

4471, 7561

29199, 30305

3208, 3348

23873, 26309

26424, 26424

21434, 23850

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3363, 3955

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357, 382

521, 1832

26443, 26581

26757, 26779

1854, 2920

2936, 3192

72,714

151,995

29960

Discharge summary

report

Admission Date: [**2144-12-8**] Discharge Date: [**2144-12-13**] Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 905**] Chief Complaint: Lethargy, weakness Major Surgical or Invasive Procedure: None History of Present Illness: Ms. [**Known lastname **] is an 87 year old patient with history of CVA ([**2138**]), hypertension, diastolic CHF, diabetes, and dementia who presented to the emergency room with failure to thrive and decreased PO intake x one week. . Family notes that at baseline patient is non verbal however will repeat things, bedbound. This has been the case since CVA in [**2138**]. Pt is cared for at home by her daughter and visiting nurse. Daughter states that patient has appeared more lethargic and less interactive over the past week and has not been taking fluid or food. No fevers, nausea, vomiting, diarrhea, or pain (in form of facial grimacing) noted at home. Incontinent at baseline and family notes no foul odor of urine. Sacral decubitus ulcer appears stable and they have noted no evidence of discharge or foul odor. No recent sick contacts. . In the ED, initial vitals 100.5 80 140/68 20 98%. On exam decubitus ulcer with some tunneling. Nonverbal which is baseline per family. EKG with ST depression V2-V6 which are old. CXR without infiltrate. Sodium 163. White count of 11.7 with left shift. UA with evidence of UTI. Gram tylenol, Vancomycin, Levofloxacin. ASA 325mg given EKG changes. Foley placed. 40meq potassium and one liter normal saline. Family is at bedside and confirmed that patient is full code. Vital prior to transfer, 98.8, 71, 148/85, 20, 98% RA. . In the ICU, patient is non verbal, contracted in bed. Past Medical History: Advanced vascular Dementia Right temporal & left parietal infarcts Hypertension Diastolic CHF (per [**Hospital1 2177**] records) Diabetes mellitus, diet controled Unsteady Gait with history of falls Mid-thoracic compression deformity Laser surgery for glaucoma Social History: Totally dependent for all ADLs. Lives at home with daughter [**Name (NI) 71549**], other daughter helps during the day. Per daugher, all food is liquid and has 6 cups of food in total daily generally. Limited communication with groaning. VNA makes home visits. Has [**Name6 (MD) **] Med NP home visits. No drugs/tobacco. Family History: NC Physical Exam: ADMISSION PHYSICAL EXAM VS - Temp 99.8F, BP 146/60, HR 60, R 19, O2-sat 100% RA GENERAL - Patient only communicating by moaning, frail elderly woman who is responsive and can minimally communicate HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, [**Last Name (un) **] mucus membranes, OP clear but very limited view due to patient unwilling to open her mouth fully NECK - supple, no thyromegaly, no JVD, no carotid bruits. Decreased skin turgor. LUNGS - Crackles both bases worse on the left where there are coarse crackles. HEART - PMI non-displaced, RRR, no MRG, nl S1-S2, JVP decreased to 2am above sternal angle. ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no rebound/guarding. EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs). calves soft. Chronic venous stasis discoloration on legs. SKIN - No rashes. Apparently per ICU NS stage IV sacral decubitus that is without evidence of infection per nursing. LYMPH - no cervical, axillary, or inguinal LAD NEURO - awake, A&Ox0. makinng moaning noises at times. GCS E4 V2 M5-6 (variably following commands) [**2049-10-29**]. CNs PERRL 3+/3+ otherwise grossly intact facial power, unable to assess V and eye movements seem normal. Unable to adequately assess VIII-XII. Tine seemed increased on Right but difficult to assess. Unable to appropriately assess power due to poor patient compliance but can lift arms against gravity and move legs. Unable to assess sensation but was responding to me touching her. Unable to ellicit reflexes in lower limbs and plantars were flexor on left and mute on right. Pertinent Results: [**2144-12-8**] 10:20AM BLOOD WBC-11.7* RBC-4.27 Hgb-9.9* Hct-31.2* MCV-73*# MCH-23.1*# MCHC-31.5 RDW-16.4* Plt Ct-284 [**2144-12-8**] 10:20AM BLOOD Neuts-72.4* Lymphs-23.9 Monos-3.1 Eos-0.1 Baso-0.5 [**2144-12-10**] 01:15PM BLOOD WBC-14.1* RBC-3.89* Hgb-9.0* Hct-29.0* MCV-75* MCH-23.2* MCHC-31.2 RDW-17.2* Plt Ct-216 [**2144-12-10**] 01:15PM BLOOD Neuts-73.1* Lymphs-24.1 Monos-1.5* Eos-0.7 Baso-0.6 [**2144-12-11**] 06:25AM BLOOD WBC-12.9* RBC-3.71* Hgb-8.7* Hct-27.9* MCV-75* MCH-23.4* MCHC-31.2 RDW-17.3* Plt Ct-221 [**2144-12-12**] 07:00AM BLOOD WBC-11.3* RBC-3.85* Hgb-9.1* Hct-29.2* MCV-76* MCH-23.6* MCHC-31.2 RDW-17.8* Plt Ct-207 [**2144-12-8**] 10:20AM BLOOD Glucose-163* UreaN-44* Creat-0.7 Na-163* K-3.5 Cl-120* HCO3-30 AnGap-17 [**2144-12-8**] 02:49PM BLOOD Glucose-110* UreaN-29* Creat-0.3* Na-159* K-3.0* Cl-128* HCO3-22 AnGap-12 [**2144-12-8**] 04:32PM BLOOD Glucose-137* UreaN-32* Creat-0.4 Na-159* K-3.7 Cl-124* HCO3-26 AnGap-13 [**2144-12-9**] 01:49AM BLOOD Glucose-155* UreaN-23* Creat-0.4 Na-150* K-3.6 Cl-117* HCO3-25 AnGap-12 [**2144-12-9**] 05:40PM BLOOD Glucose-114* UreaN-22* Creat-0.5 Na-146* K-3.9 Cl-116* HCO3-22 AnGap-12 [**2144-12-10**] 01:15PM BLOOD Glucose-94 UreaN-22* Creat-0.5 Na-146* K-3.5 Cl-114* HCO3-24 AnGap-12 [**2144-12-11**] 12:45PM BLOOD Glucose-185* UreaN-19 Creat-0.4 Na-146* K-3.6 Cl-117* HCO3-22 AnGap-11 [**2144-12-12**] 07:00AM BLOOD Glucose-93 UreaN-13 Creat-0.4 Na-142 K-3.9 Cl-113* HCO3-22 AnGap-11 Log-In Date/Time: [**2144-12-8**] 3:42 pm URINE Site: NOT SPECIFIED 664O UCU ADDED [**12-8**]. **FINAL REPORT [**2144-12-10**]** URINE CULTURE (Final [**2144-12-10**]): ESCHERICHIA COLI. >100,000 ORGANISMS/ML.. PRESUMPTIVE IDENTIFICATION. Piperacillin/tazobactam sensitivity testing available on request. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI | AMPICILLIN------------ <=2 S AMPICILLIN/SULBACTAM-- <=2 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- <=16 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S Cardiology Report ECG Study Date of [**2144-12-8**] 9:57:04 AM Sinus rhythm. Left ventricular hypertrophy with associated ST-T wave changes, although ischemia or infarction cannot be excluded. Compared to the previous tracing of [**2143-4-20**] there is no significant change. FINDINGS: A small amount of linear opacification at the left base likely reflects atelectasis. No focal opacity to suggest pneumonia is seen. There may be a trace right pleural effusion or pleural thickening at the right base. No pulmonary edema or pneumothorax is seen. There is tortuosity of the aorta. The heart size is within normal limits. IMPRESSION: No evidence of acute cardiopulmonary process. Brief Hospital Course: #Advanced dementia - Held multiple discussions about goals of care and code status. Patient's daughter and healthcare proxy, [**Name (NI) 71549**], speaking on behalf of her many siblings, decided that the patient would remain a full code and return home with VNA services. She declined hospice services but may reconsider in the future. She prefers to continue giving the patient food and drink by mouth, despite acknowledging the risks of aspiration, pneumonia, and even death. . #Hypovolemic hypernatremia - Corrected with free water repletion. Discussed with patient's daughter that it is likely that this problem will recur given the patient's poor oral intake. . #Acute uncomplicated cystitis - Pan-sensitive E. Coli treated with ceftriaxone (last day [**12-13**]). . #Sacral decubitus ulcer - No evidence of superinfection. Followed wound care nurse recommendations while in house, then communicated those recommendations to the patient's VNA. . #Hypertension - Well-controlled on clonidine patch and hydralazine IV prn while in house. Continued preadmission medication regimen at the request of the patient's daughter. Medications on Admission: Amlodipine 2.5 mg Daily Clonodine Patch 0.3mg/Q24hrs HCTZ 25mg Daily Discharge Medications: 1. clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QTHUR (every Thursday). 2. amlodipine 2.5 mg Tablet Sig: One (1) Tablet PO once a day. 3. hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home With Service Facility: Uphams Corner Home Care Discharge Diagnosis: Hypovolemic hypernatremia Acute uncomplicated cystitis Sacral decubitus ulcer Advanced dementia History of cerebrovascular accident Hypertension Discharge Condition: Mental Status: Mostly nonverbal, occasionally speaks in one-word phrases. Level of Consciousness: Lethargic but arousable. Activity Status: Bedbound. Discharge Instructions: You were admitted to the hospital with a urinary tract infection which was treated with antibiotics. You were also found to have a very elevated level of sodium (salt) in the blood, most likely from severe dehydration. We discussed the very high risk of aspiration with taking any food or drink or medications by mouth. Your family understands that eating and drinking may put you at risk for choking, pneumonia, and rehospitalization. We recommend that you consider starting hospice services at home. Followup Instructions: Please follow up with your primary care physician [**Name Initial (PRE) 176**] [**12-21**] weeks after discharge. [**Name6 (MD) 251**] [**Name8 (MD) **] MD [**MD Number(1) 910**] Completed by:[**2144-12-13**]

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icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

8608, 8662

7100, 8228

270, 276

8851, 8851

3975, 7077

9555, 9795

2371, 2375

8348, 8585

8683, 8830

8254, 8325

9027, 9532

2390, 3956

212, 232

304, 1732

8866, 9003

1754, 2017

2033, 2355

4,833

114,264

27764+57563

Discharge summary

report+addendum

Admission Date: [**2189-6-27**] Discharge Date: [**2189-7-4**] Date of Birth: [**2110-4-8**] Sex: M Service: ORTHOPAEDICS Allergies: Nsaids Attending:[**First Name3 (LF) 58653**] Chief Complaint: transfered from [**Hospital 8**] hospital to evaluate bilateral leg weakness by spinal MRI Major Surgical or Invasive Procedure: epidural abscess debridement History of Present Illness: 79 yo Spanish speaking male with a h/o DM2, HTN, Pulm HTN, AF, CRI was transfered from [**Hospital 8**] Hospital for an MRI of his spine to evaluate for epidural abscess secondary to bilateral lower extremity weakness. The physicians at [**Hospital 8**] hospital were concerned about cord compression or cauda equina syndrome and wanted him transfered to a hospital with a neurosurgical service backup. He is also here for an MRI despite the bullet logged in his buttocks to evaluate for these conditions. He was recently discharged from [**Hospital1 18**] back to [**Hospital 8**] Hospital after evaluation for trachealmalacia which he did not seem to have. His problem list includes recent [**Name (NI) 8974**] bacteremia with an unknown source (TEE was negative and multiple CT scans of his abdomen and plevis were negative for abscess or mass), pleural based mass and now complaining of bilateral lower extremity weakness. Of note, one CT scan showed sigmoid colitis for which he is being treated with flagyl and ceftriaxone. With his transfer paper work, his WBC was noted to be 17.5 with 96%neutrophils. . Currently, he says he has pain in both legs, right more than left. He says that he can not stand up and walk and he feels weak. He denies currently SOB, CP, abdominal pain, HA or change in vision. Past Medical History: [**Name (NI) 8974**] bacteremia on nafcillin since [**2189-6-15**] CRI- baseline Cr 1.7, Unknown etiology Paroxysmal A fib HTN Pulm HTN Hypercholesterolemia DM2 Hepatic steatosis Osteroarthritis Bilateral knee replacement Bullet in buttocks Social History: no significant tob use, no drugs. Married. Family History: Non-contributory Physical Exam: VS T 100.3, BP 112/59 P 84, R 18, O2sat 96%on 2L wt. 118.3 KG GEN - Obese man lying in bed with sunglasses on, in NAD, Foley cath in place. HEENT: EOMI, PERRL, tachy MM, clear OP, no LAD CV: heart sounds distant secondary to body habitus, RRR normal S1 S2 no murmur heard Lungs: distant breath sounds, but lungs sound CTAB Abdomen: +BS, soft NTND Extremities: 2+edema in bilateral lower extremities. Neuro: He can only just slightly move his legs (left more than right) against gravity. Patellar reflexes can not be elicited secondary to his bilateral knee replacements. Achilles tendons showed no reflexes but of note, he is quite edematous and has a long history of DM. No Babinski reflex bilaterally. Unsure about sensation in his feet bilaterally given probably neuropathy but he does have sensation in his thighs bilaterally. Pertinent Results: [**2189-6-28**] MRA brain: FINDINGS: Multiple bilateral periventricular hyperintensities are noted on the FLAIR images, but there is no evidence of acute stroke on the diffusion- weighted images. On the MR angiography, there is hypoplastic T1 segment on the right side with fetal PCA, which is a normal variant. No evidence of stenosis or occlusion of vessels of Circle of [**Location (un) 431**]. IMPRESSION: 1. No acute infarct. 2. Chronic microvascular disease . . [**2189-6-28**] MRI T- spine: FINDINGS: The study is extremely limited due to the extensive motion artifacts. However, there appears to be epidural abscess in the mid thoracic region which is however not clearly visualized due to the artifacts. Cord compression cannot be assessed due to the motion artifacts. On the axial images, there also appear to be pre- and paraspinal soft tissue signal intensity abnormalities on the right and right paraspinal pleural-based mass. IMPRESSION: Epidural abscess in the mid thoracic region. Cord compression not adequately assessed due to the motion artifacts. Right paraspinal pleural-based soft tissue swelling. Recommend to repeat MRI if possible for better evaluation. Findings were discussed with Dr. [**Last Name (STitle) 29932**] by Dr. [**Last Name (STitle) **] on [**2189-6-29**] noon. Please note that the preliminary report is discrepant from the final report and the final report findings were conveyed to Dr. [**Last Name (STitle) 29932**]. . . [**2189-6-28**] MRI L-spine: FINDINGS: There is evidence of degenerative disc disease with spinal canal stenosis at L3-4, L1-2 level and L4-5 level. Degenerative changes are also noted in the vertebral bodies. There is linear enhancing tissue noted in the epidural region at T12-L2 level, likely due to epidural abscess. However, the upper extent of this is not visualized on the L-spine MRI. Cord compression cannot be adequately assessed. No pre- or para-vertebral soft tissue abnormality. IMPRESSION: Degenerative disc disease with associated lumbar spinal canal stenosis. Epidural abscess at T12-L2 level with superior extent not demarcated on the L- spine MRI. Please also see the thoracic spine MRI report, performed on the same day and dictated separately. Brief Hospital Course: Mr. [**Known lastname 46719**] is a 79 yo Spanish speaking male with a history of [**Known lastname 8974**] bactermia with unknown etiology, DMII, Afib, chronic renal failure who was transfered to [**Hospital1 **] from [**Hospital 8**] hospital to evalute his bilateral LE weakness with an MRI of the spine. On admission, his nafcillin was continued for this [**Hospital 8974**] (first noted on [**2189-6-12**] at [**Hospital 8**] hospital). The metronidazole and ceftriaxone were discontinued. He was noted to have an extremely elevated CK [**Numeric Identifier 67715**] rising to >[**Numeric Identifier 3652**] in the presence of acute on chronic renal failure. He was given IVF with bicarb flush his kidneys. THrough this he continued to make sufficient UOP- with Foley cath in place. THe reason for this rhabdo is unknown at this time. Nephrology is following. MRI of the spine on [**2189-6-28**] showed possible epidural and paraspinal abscesses with questionable cord compression. He was noted on physical exam to have no rectal tone. Orthopedics/spine was consulted. Neurology is also consulted. After coding in the OR, pt was transferred to the MICU, where he was maintained on pressors, CVVH and ventilated. on [**7-4**], the decision was made to convert the patient to CMO, and patient expired on [**7-4**] at [**2102**]. Medications on Admission: Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Sevelamer 800 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). Epoetin Alfa 4,000 unit/mL Solution Sig: One (1) Injection QMOWEFR (Monday -Wednesday-Friday). Diltiazem HCl 60 mg Tablet Sig: 1 Tablet PO TID (3 times a day). Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Five (5) units Subcutaneous twice a day. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Prednisone 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). ceftriaxone 1g IV q24hrs. Nafcillin in D2.4W 2 g/100 mL Piggyback Sig: Two (2) Intravenous Q4H (every 4 hours). Pantoprazole 40 mg Recon Soln Sig: One (1) Recon Soln Intravenous Q12H (every 12 hours). Discharge Medications: n/a Discharge Disposition: Extended Care Discharge Diagnosis: [**Year (4 digits) 8974**] bacteremia, paroxysmal Afib, acute on chronic renal failure, CAD, HTN, DMII Discharge Condition: expired Discharge Instructions: n/a Followup Instructions: n/a [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 17007**] MD [**MD Number(2) 58655**] Completed by:[**2189-7-4**] Name: [**Known lastname 11699**],[**Known firstname **] Unit No: [**Numeric Identifier 11700**] Admission Date: [**2189-6-27**] Discharge Date: [**2189-7-4**] Date of Birth: [**2110-4-8**] Sex: M Service: MEDICINE Allergies: Nsaids Attending:[**First Name3 (LF) 1015**] Addendum: Regarding prior discharge disposition: Pt was erroneously entered as going to an extended care facility. However, pt expired during this admission. Please make appropriate change to disposition. Discharge Disposition: Extended Care [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1016**] MD [**MD Number(2) 1017**] Completed by:[**2189-7-22**]

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icd9cm

[ [ [] ] ]

[ "39.95", "00.17", "38.93", "99.60", "03.09", "99.62", "96.71" ]

icd9pcs

[ [ [] ] ]

8523, 8695

5222, 6565

361, 391

7743, 7752

2957, 5199

7804, 8318

2072, 2090

7552, 7557

7617, 7722

6591, 7529

7776, 7781

2105, 2938

231, 323

419, 1730

1752, 1995

2011, 2056

12,081

129,710

10438

Discharge summary

report

Admission Date: [**2178-12-18**] Discharge Date: [**2178-12-25**] Date of Birth: [**2102-5-31**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2901**] Chief Complaint: SOB Major Surgical or Invasive Procedure: [**Company 1543**] VVI Pacer Insertion History of Present Illness: Patietn is a 76M with CAD s/p CABG [**2168**], CHF (EF 30% per ECHO [**6-26**]), chronic Afib who p/w SOB x 3 days. Patient reports he has CP at baseline, which is R and L sided, dull, happens sporadically both at rest and with exercise, and has not changed recently. He reports SOB and wheezing at baseline, worse with exercise (says he can walk 1 block beofre onset of SOB), which has gotten worse over the past few days. Reports 2 pillow orthopnea with no recent change. Reports being weak for the last few days with bifrontal HA and feeling disoriented. Denies focal numbness, weakness, vision changes, or word-finding difficulties. Also described feeling lightheaded, denies LOC but reports that he occasionally feels as though he may pass out. Not exacerbated by sitting up or standing. Reports he is not always compliant with his medications, has stopped Lisinopril or Lipitor recently, and states he has not taken Coumadin in 7 days. ROS is + for dark nasal discharge, negative for cough, N/V, abdominal pain, diarrhea, BRBPR or melena. Past Medical History: 1. COPD 2. Atrial fibrillation, started on Coumadin in 12/99 for episode of paroxysmal atrial fibrillation 3. CAD: s/p CABG [**2168**] after non-Q wave MI, Cath with 70% LAD, 50% circumflux lesion with LIMA to LAD and SVG to RCA and PVA, ETT-MIBI [**7-26**] without ischemic EKG changes or anginal symptoms, with significant ventricular and supraventricular irritability, MIBI with fixed LV enlargement with decreased EF 35%. There were no perfusion defects. 4. Hypercholesterolemia Social History: Quit smoking 27 years ago. Retired. No ETOH or drugs use. Family History: Non-contributory Physical Exam: Vitals T 97.7; HR 48; BP 127/43; RR 20; O2 Sat 97% 2L GEN: AOx3, NAD HEENT: PERRL, EOMI Neck: No JVD at 60 degrees, supple CV: bradycardic, irregular rhythm, no MRG Lungs: diffuse expiratory wheezes, fair air movement, no crackles at bases ABD: soft, NTND. +BS Ext: No edema. 2+ DPs Skin: no rashes Neuro: No focal deficits. Pertinent Results: [**2178-12-18**] 06:00PM WBC-21.9* RBC-4.44* HGB-11.6* HCT-34.7* MCV-78* MCH-26.2* MCHC-33.5 RDW-13.2 [**2178-12-18**] 06:00PM NEUTS-90.7* BANDS-0 LYMPHS-6.2* MONOS-3.0 EOS-0.1 BASOS-0 [**2178-12-18**] 06:00PM PT-71.4* PTT-100.3* INR(PT)-43.1 [**2178-12-18**] 05:45PM URINE COLOR-Amber APPEAR-Clear SP [**Last Name (un) 155**]-1.024 [**2178-12-18**] 04:05PM GLUCOSE-97 UREA N-32* CREAT-1.0 SODIUM-138 POTASSIUM-3.9 CHLORIDE-95* TOTAL CO2-27 ANION GAP-20 [**2178-12-18**] 04:05PM HYPOCHROM-NORMAL ANISOCYT-NORMAL POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-1+ POLYCHROM-NORMAL [**2178-12-18**] 04:05PM PLT SMR-VERY HIGH PLT COUNT-648*# [**2178-12-22**] 03:50AM BLOOD WBC-12.3* RBC-3.71* Hgb-9.8* Hct-29.1* MCV-78* MCH-26.3* MCHC-33.6 RDW-13.4 Plt Ct-540* [**2178-12-18**] 06:00PM BLOOD Neuts-90.7* Bands-0 Lymphs-6.2* Monos-3.0 Eos-0.1 Baso-0 [**2178-12-18**] 06:00PM BLOOD Hypochr-1+ Anisocy-NORMAL Poiklo-NORMAL Macrocy-NORMAL Microcy-2+ Polychr-NORMAL [**2178-12-22**] 03:50AM BLOOD Plt Ct-540* . ECHO The left and right atrium are moderately dilated. Left ventricular wall thicknesses and cavity size are normal. There is mild to moderate regional left ventricular systolic dysfunction with near akinesis of the entire septum with relative preservation of the remaining segments. Right ventricular chamber size and free wall motion are normal. The ascending aorta is mildly dilated. The aortic valve leaflets (3) are mildly thickened. No aortic stenosis of aortic regurgitation is seen. The mitral valve leaflets are structurally normal. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. Moderate [2+] tricuspid regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. Compared with the report of the prior study (tape unavailable for review) of [**2176-7-9**], left ventricular systolic dysfunction appears regional with global improvement in systolic function. The estimated pulmonary artery systolic pressure is higher. . s/p [**Company 1543**] Sigma VVI 60 V sensed 24% V paced 76% Lead Impedance sensing threshold V 614ohms 8mv 0.5v/0.2ms . PORTABLE CXR FINDINGS: Compared with [**2178-12-19**], there has been interval placement of a single lead right ventricular pacemaker from a left subclavian approach. The tip of the lead projects at the level of the right ventricular apex. No pneumothorax or other acute process identified. . PA/LATERAL CXR Single lead of the pacemaker projects over the right ventricle. The cardiac silhouette and the mediastinal contours are normal and unchanged. The patient is status post CABG. The lungs are clear. The pleura are normal. Brief Hospital Course: Patient is a 76 year-old male with history of chronic Atrial Fibrillation, CAD s/p CABG [**2168**], CHF (EF 30%), and COPD who presented with progressive dyspnea. The following issues were addressed during his hospital stay: . 1. DYSPNEA/CONDUCTION ABNORMALITIES Patient was initially thought to have COPD flare vs. CHF exacerbation, and was treated with Levaquin and diuretics in the ED. Lung exam was consistent with COPD exacerbation, but patient also with asymptomatic bradycardia, with pulse dipping into mid-20s on occasion. After arrival to the floor, patient experienced episode of pulseless polymorphic VT/torsades. Patient was defibrillated immediately with restoration of baseline rhythm, and transferred to the CCU for closer monitoring. Initial EKGs were notable for QT prolongation to 500s-580s. Given supratherapeutic INR in the 40s, temporary lead wires were not placed. He was started on a dopamine drip which did not improve cardiac function - HR remained in low 30s, with resultant hypotension. Patient was then switched to Isopril gtt with good effect. EP was consulted and recommendations were made for pacemaker placement. Once COPD exacerbation and supratherapeutic INR were adequately dealt with, patient received single chamber [**Company 1543**] VVI pacer. Patient tolerated procedure well. Post-pacer interrogation was successful, and CXR confirmed proper lead placement. Patient was discharged home to follow-up in device clinic in 1 week and EP follow-up in 1 month. Regarding his COPD flare, patient's outpatient medications were restored and he was started on a short 5-day prednisone taper, with improvement in lung function. CXR was without evidence of focal infiltrate but consistent with emphysematous changes. Increased conspicuity in right hilum was noted on portable CXR -- could not rule out mass, f/u CT was recommended. Repeat PA/Lateral were without evidence of mass. Patient was afebrile throughout hospital course. Patient's PCP office was notified, and patient will follow-up within 5-7 days after discharge for further lung evaluation. Recent dyspnea/fatigue were attributed to both COPD flare and worsening conduction abnormalities, with bradycardia impairing forward cardiac output (symptomatic bradycardia). Patient reported significant improvement in symptoms after pacemaker placement. 2. Supratherapeutic INR Etiology unclear, as patient reportedly stopped taking his Coumadin 1 week prior to presentation. LFTs were WNL. Patient received several units of FFP and SC Vitamin K, with normalization of INR after 24 hours. Coumadin was held. 3. Small Cerebellar Bleed Given supratherapeutic INR in the 40s on presentation, patient received a Head CT in the Emergency Department, which revealed a small cerebellar bleed. Neurosurgery was consulted, and they recommended immediate reversal of INR. Patient received a follow-up CT Head in 2 days, which showed no interval change in size of bleed. Patient was cleared by neurosurgery for re-starting anticoagulation. 4. CAD Given bradycardia impairing blood pressure control, patient's Lisinopril was held until after pacemaker insertion. Outpatient Lisinopril was then resumed. 5. Anemia Hct stable, at baseline on discharge. 6. Weight loss On presentation, patient denied any recent weight changes. On further evaluation during discharge planning, patient reported 30 lb. weight loss over past 1-2 months, unintentional. Patient to follow-up with PCP regarding this and above matters early next week. 7. Disposition Per PT evaluation, patient would benefit from [**Hospital 3058**] rehab. Medications on Admission: Coumadin 2.5 mg PO qd Albuterol 90 Combivent 103-18 Lipitor 10 Lisinopril 5 Advair Diskus 500/50 Discharge Medications: 1. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO once a day. 3. Advair Diskus 500-50 mcg/Dose Disk with Device Sig: One (1) Inhalation twice a day. 4. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day. 5. Combivent 103-18 mcg/Actuation Aerosol Sig: Two (2) puffs Inhalation four times a day. 6. Albuterol 90 mcg/Actuation Aerosol Sig: One (1) puff Inhalation every six (6) hours as needed for wheezing. Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Primary 1. Prolonged QT, symptomatic bradycardia s/p [**Company 1543**] VVI Pacer Secondary 1. COPD 2. CAD s/p CABG [**2168**] 3. Chronic Atrial Fibrillation 4. Hypercholesterolemia 5. Hypertension Discharge Condition: clinically and hemodynamically stable, ambulating without oxygen requirement, CXR confirming proper pacemaker placement Discharge Instructions: 1. Please take all medications as prescribed 2. Please make all follow-up appointments 3. If you develop chest pain, difficulty breathing, fever, bleeding around your pacemaker site, or other concerning signs/symptoms, please contact your PCP or report to the Emergency Department immediately Followup Instructions: 1. Please make an appointment to see your PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] [**Telephone/Fax (1) 1579**] early next week - they are aware that you will be calling to schedule. . 2. You have an appointment in the Device Clinic, [**Hospital Ward Name 23**] Clinical Center [**Location (un) **]: DEVICE CLINIC Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2178-12-29**] 11:30 . 3. You have a follow-up appointment for your pacemaker with Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] on [**1-22**] 2:00 PM, [**Hospital Ward Name 23**] Clinical Center, [**Location (un) **] [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2908**] MD, [**MD Number(3) 2909**] Completed by:[**2179-2-19**]

[ "430", "V45.01", "427.31", "276.8", "790.92", "V45.81", "427.1", "491.21", "518.82", "465.9", "428.0" ]

icd9cm

[ [ [] ] ]

[ "00.17", "99.07", "99.62", "37.71", "37.81" ]

icd9pcs

[ [ [] ] ]

9418, 9476

5174, 8769

321, 362

9719, 9841

2412, 5151

10182, 10954

2034, 2052

8916, 9395

9497, 9698

8795, 8893

9865, 10159

2067, 2393

278, 283

390, 1436

1458, 1942

1958, 2018

12,042

123,300

22005

Discharge summary

report

Admission Date: [**2184-11-8**] Discharge Date: [**2184-11-19**] Date of Birth: [**2107-7-29**] Sex: M Service: CSU CHIEF COMPLAINT: Increasing shortness of breath. HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 40750**] is a 77 year old man with a three day history of accelerating chest and neck pain with exertion. Patient has had hypertension, hypercholesterolemia, positive family history and notices a sharp substernal chest pain with radiation with increasing exertion. He also complains of decreased exercise tolerance limited by anginal symptoms. The patient denies nausea, vomiting, diaphoresis, dizziness, syncope or presyncope. He was admitted to [**Hospital 1474**] Hospital with no electrocardiographic changes, negative troponins and a positive stress test in [**2183-12-6**] that had moderate anterior wall ischemia. Given the patient's risk factors and increasing anginal symptoms the patient was transferred to [**Hospital1 69**] for further management including catheterization. He was admitted to the cardiology service and then underwent cardiac catheterization which showed an left anterior descending coronary artery 70 percent lesion, left circumflex 50 percent proximal lesion, ostia 80 to 95 percent lesion with an occluded posterior descending coronary artery and ejection fraction of 55 percent with inferior wall hypokinesis. PAST MEDICAL HISTORY: Is significant for diabetes mellitus type 2, hypertension, hyperlipidemia and angina. She states an allergy to Accupril which causes gastrointestinal upset and to nifedipine which causes restlessness. MEDICATIONS PRIOR TO ADMISSION: Included atenolol 12.5 q.d., Lipitor 20 q.d., Glipizide 5 q.d., Reserpine 0.1 B.I.D, hydrochlorothiazide 25 q.d., BeneCor 40 q.d. and aspirin 325 q.d. SOCIAL HISTORY: Lives alone in [**Location 21318**]. Family in area. Separated from his wife. Retired. Remote tobacco, quit 20 years ago after 30 pack year history. No alcohol use. PHYSICAL EXAMINATION: Height 5 foot 9, weight 180 pounds. Vital signs: Temperature 98.6, heart rate 60s, blood pressure 130/50, respiratory rate 18, O2 saturation 97 percent on room air. In general sitting in bed in no acute distress. Neurologically alert and oriented times three. Nonfocal examination. Head, eyes, ears, nose and throat: Pupils equal, round and reactive to light, extraocular movements intact. Mucous membranes moist. Neck is supple with no thyromegaly, no carotid bruit. Respiratory clear to auscultation bilaterally. Cardiovascular: Regular rate and rhythm, S1, S2, no murmurs, rubs or gallops. Gastrointestinal: Soft, nontender, nondistended with positive bowel sounds. Extremities are warm and well perfused with no edema and no varicosities. Palpable pulses throughout. LABORATORY DATA: White count 8.8, hematocrit 35.7, platelets 203. Sodium 133, potassium 4.3, chloride 99, CO2 29, BUN 14, creatinine 0.8, glucose 203, PT 12.5, PTT 24.2, INR 1.0, CO2 29, BUN 14, creatinine 0.8, glucose 203. Patient had carotid duplex prior to scheduled surgery that showed 40 to 59 percent narrowing bilaterally. On [**11-11**] the patient was brought to the operating room. Please see the operating room report for full details. In summary, he had a coronary artery bypass graft times three with a left internal mammary artery to the left anterior descending coronary artery, saphenous vein graft to the posterior descending coronary artery, saphenous vein graft to the obtuse marginal. Bypass time was 85 minutes with a crossclamp time of 41 minutes. He tolerated the operation well and was transferred from the operating room to the cardiothoracic Intensive Care Unit. At the time of transfer the patient was A paced at 87 beats per minute with a mean arterial pressure of 89, a CVP of 11. He had Neo-Synephrine at 0.2 mcg per kilogram per minute, insulin at 2 units per hour and propofol at 30 mcg per kilogram per minute. The patient did well in the immediate postoperative period. His anesthesia was reversed. He was weaned from the ventilator and successfully extubated. However, on the night of surgery the patient was noted to be in atrial fibrillation. He was therefore put on amiodarone infusion following which he converted to sinus rhythm. On postoperative day one the patient remained hemodynamically stable. His amiodarone was changed to P.O. He was started on beta blockers as well as diuretics and he was transferred to the floor for continued postoperative care and cardiac rehabilitation. Once on the floor the patient had an uneventful postoperative course with the assistance of the nursing staff and physical therapy. His activity level was gradually increased. It was noted, however, that the patient had intermittent periods of atrial fibrillation and therefore he was begun on anticoagulation. On postoperative day four the patient's temporary pacing wires were removed. He continued to progress slowly and accelerating his physical activity. Then on postoperative day seven it was decided that the following day the patient would be stable and ready for transfer to rehabilitation. At the time of this dictation patient's physical examination is as follows. Vital signs: Temperature 98, heart rate 82, afebrile. Blood pressure 138/46, respiratory rate 22, O2 saturation 97 percent on room air. Weight on the day of discharge 84.4, preoperatively 80. Laboratory data the day of discharge: PT 16.9, INR 1.7. Physical examination - neurologic - alert and oriented times three, moves all extremities. Follows commands. Nonfocal examination. Respiratory: Clear to auscultation with slightly diminished breath sounds at the bases. Cardiovascular: Irregularly irregular, S1, S2. Sternum is stable. Incision with Steri- Strips, open to air, clean and dry. Abdomen is soft, nontender, nondistended with positive bowel sounds. Extremities are warm and well perfused with 1 plus edema bilaterally. Left knee endoscopic harvest site with Steri- Strips, open to air, clean and dry. CONDITION ON DISCHARGE: Good. DISCHARGE DIAGNOSES: 1. Coronary artery disease, status post coronary artery bypass grafting times three with a left internal mammary artery to the left anterior descending coronary artery, saphenous vein graft to the posterior descending coronary artery, saphenous vein graft to the obtuse marginal. 2. Postoperative atrial fibrillation. 3. Hypertension. 4. Hypercholesterolemia. 5. Diabetes mellitus type 2. 6. Gastroesophageal reflux disease. Patient is to be discharged to rehabilitation. He is to have follow up with Dr. [**Last Name (STitle) 17025**] two to three weeks after discharge from rehabilitation. With Dr. [**Last Name (STitle) **] two to three weeks after discharge from rehabilitation. And with Dr. [**Last Name (STitle) **] in four weeks. DISCHARGE MEDICATIONS: Include potassium chloride 20 mEq q.d., Colace 100 mg B.I.D, Zantac 150 mg B.I.D, Percocet 5/325 1 to 2 tablets q 4 to 6 hours p.r.n., milk of magnesia 30 cc p.r.n., Lipitor 20 mg q.d., Lasix 40 mg q.d., ferrous sulfate 325 mg q.d. times one month, Glipizide 10 mg q A.M. and Glipizide 5 mg q. P.M., aspirin 81 mg q.d., Warfarin as directed to maintain a goal INR of 2 to 2.5. Last five doses of Warfarin 5 mg to be given on the 15th, 3 mg given on the 14th, 5 mg given on the 13th, 3 mg given on the 12th, 5 mg given on the 11th and 5 mg given on the 10th. Finally amiodarone 400 mg q.d. times one week, then 200 mg q.d. and Lopressor 75 mg B.I.D [**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(2) 5897**] Dictated By:[**Last Name (NamePattern4) 1718**] MEDQUIST36 D: [**2184-11-19**] 11:11:42 T: [**2184-11-19**] 12:42:44 Job#: [**Job Number **]

[ "530.81", "599.0", "V17.4", "E878.8", "433.30", "V15.82", "401.9", "997.1", "041.00", "424.1", "414.01", "250.00", "276.1", "411.1", "427.31" ]

icd9cm

[ [ [] ] ]

[ "88.53", "36.16", "39.61", "36.11", "89.61", "89.64", "37.22", "88.56", "96.04", "99.04", "96.71" ]

icd9pcs

[ [ [] ] ]

6100, 6854

6878, 7766

1648, 1800

2011, 6047

155, 188

217, 1389

1412, 1615

1817, 1988

6072, 6079

55,138

104,576

40900

Discharge summary

report

Admission Date: [**2155-6-9**] Discharge Date: [**2155-6-13**] Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 2195**] Chief Complaint: GI bleed Major Surgical or Invasive Procedure: EGD through ostomy bag at [**Hospital **] Hospital with suture placed at ostomy site at [**Location (un) **]. [**Hospital1 18**]: NG lavage and Ileoscopy through ostomy site [**2155-6-10**] History of Present Illness: [**Age over 90 **] year old man with history of PUD, recurrent diverticulitis s/p illeostomy with history of illioconduit in [**2145**] then colostomy in [**2152**], recent history of GI bleed 5 weeks ago complicated by retained small bowel camera who presents with an acute GI bleed. 3-5 days prior to admission he noticed blood filling his ileostomy bag. The bag actually filled up with blood three times over the past week. He and his wife tried to apply pressure to the bleeding on the day of admission ([**2155-6-9**]), which only temporarily helped. He denied any abdominal pain, nausea, vomitting, chest pain, shortness of breath, fevers, chills. When the bleeding did not stop, he decided to come to the ED. . He arrived at [**Hospital **] Hospital and underwent an EGD through the ileostomy stoma which only revealed blood and no obvious source of bleeding. He then underwent an a repeat EGD through the ileostomy stoma that did not reveal the source of bleed. He did get fent/versed and for unclear reasons sux/etom (although not intubated) for sedation for this procedure. He also was given phenylephrine and levoquin during the procedure. This procedure also did not reveal the bleed. He had a suture placed at the stoma entry site. He remained hemodynamically stable throughout his stay and he was given 4 units of PRBCs, 2 units of FFP during his hospital stay, and his HCT rose from 23 at 9am to 28 at 9pm on [**2155-6-9**]. He also was on protonix 40mg IV BID and an ocreotide gtt. Because both scopes were unrevealing, he was transferred to [**Hospital1 **] for unstable blood volume and evaluation for IR guided intervention. His access was 2 #20 PIVs. . Of note, patient had a recent hospital stay for GI bleed at [**Hospital **] Hospital with a small bowel camera retained in small bowel from [**Date range (1) 89310**] for N/V and ?GI bleed c/b retention of small bowel camera c/b SVT and fever. It is unclear if this camera was ever removed. Past Medical History: 1. Diverticulitis 2. Performated Meckel's diverticulum requiring surgery 3. S/p subtotal colectomy in [**2152**] for diverticulosis 4. S/p partial small bowel resection with ileostomy and ileal conduit in [**2145**] for diverticulosis 5. CKD baseline Cr 1.5 6. H/o prosate CA s/p radiation in [**2134**] 7. PVD 8. Peripheral neuropathy 9. Macular degeneration of R eye 10. PUD 11. AS 12. S/p hemorrhoidectomy 13. Migraines 14. S/p cholecystectomy [**2151**] 15. Last echo EF 55% Social History: Lives with his wife in [**Name (NI) **], MA. He does not currently smoke, drink, or use drugs. Family History: Noncontributory. Physical Exam: On admission: GEN: Pale, confused, elderly man in NAD, AOx2 HEENT: PERRL, EOMI, anicteric, dry MM, op without lesions, no jvd, no RESP: CTA b/l with good air movement throughout CV: RR, S1 and S2 wnl, no r/g, 4+ crescendo/decrescendo SM, with loss of S2, +pulsus parvus et tardus, not late peaking ABD: nd, +b/s, soft, nt, no masses or hepatosplenomegaly, ileostomy bag with active exsanguination and + clots that resolved after 30m, stoma without any obvious bleeding lesions with fresh suture in place EXT: no c/c/e, trace LLE edema, none on RLE SKIN: no rashes/no jaundice/no splinters NEURO: AAOx2. On discharge: GEN: elderly gentleman in NAD, alert and oriented to person, year (thinks he is in [**Hospital1 **] still; knows the year but thinks it's [**Month (only) 958**]) HEENT: PERRL, EOMI, anicteric, dry MM, op without lesions, no jvd, no RESP: CTA b/l with good air movement throughout CV: S1 and S2, 4+ crescendo/decrescendo SEM, with loss of S2, +pulsus parvus et tardus, not late peaking ABD: (+)bowel sounds, ileostomy in place with 300cc of maroon fluid, urostomy with light yellow urine; soft, nt, no masses or hepatosplenomegaly, stoma without any obvious bleeding lesions Pertinent Results: ADMISSION LABS [**2155-6-9**] 10:54PM BLOOD WBC-8.8 RBC-3.46* Hgb-10.1* Hct-28.2* MCV-82 MCH-29.1 MCHC-35.7* RDW-16.1* Plt Ct-113* [**2155-6-9**] 10:54PM BLOOD PT-13.4 PTT-27.6 INR(PT)-1.1 [**2155-6-9**] 10:54PM BLOOD Glucose-129* UreaN-25* Creat-1.0 Na-141 K-4.3 Cl-109* HCO3-23 AnGap-13 [**2155-6-10**] 03:05AM BLOOD ALT-9 AST-17 LD(LDH)-181 AlkPhos-60 TotBili-2.0* [**2155-6-9**] 10:54PM BLOOD Calcium-7.1* Phos-4.3 Mg-1.6 DISCHARGE LABS [**2155-6-13**] 07:50AM BLOOD WBC-4.4 RBC-3.36* Hgb-9.9* Hct-28.1* MCV-84 MCH-29.5 MCHC-35.4* RDW-15.5 Plt Ct-163 [**2155-6-13**] 11:00AM BLOOD Hct-30.4* [**2155-6-13**] 07:50AM BLOOD Glucose-87 UreaN-18 Creat-1.2 Na-138 K-3.6 Cl-107 HCO3-26 AnGap-9 [**2155-6-12**] 07:40AM BLOOD TotBili-0.6 DirBili-0.2 IndBili-0.4 [**2155-6-13**] 07:50AM BLOOD Calcium-7.6* Phos-2.8 Mg-1.8 EKG [**2155-6-9**] Sinus rhythm with premature ventricular complexes. Probable left anterior fascicular block with right bundle-branch block. Diffuse baseline artifact on the first half of the tracing marring interpretation of ST segments for ischemia but no gross abnormalities appreciated. No previous tracing available for comparison. CTA ABDOMEN/PELVIS [**2155-6-10**] 1. Multiple bowel surgeries, with right lower quadrant ileostomy. No evidence of vascular extravasation, obstruction, or leak. 2. Rectal Hartmann pouch, with apparent mild wall thickening that could reflect proctitis. 3. Ileal conduit and urostomy in the left lower quadrant. Renal atrophy and mild bilateral hydroureteronephrosis, likely reflecting chronic reflux. 4. Cholecystectomy, with moderate intrahepatic and common biliary ductal dilation. 5. Emphysema and moderate bilateral pleural effusions. CXR [**2155-6-10**] 1. Bibasilar opacities are likely atelectasis although pneumonia or aspiration pneumonitis cannot be excluded. 2. Pulmonary vascular congestion without evidence of pulmonary edema. 3. Small left pleural effusion. CXR [**2155-6-11**] As compared to the previous radiograph, there is a progression of the pre-existing parenchymal opacities. The pattern and distribution of the changes suggest pulmonary edema of moderate severity. In addition, the pre-existing retrocardiac atelectasis and right basal parenchymal opacity persists Ileoscopy [**2155-6-10**] Normal mucosa in the ileum without blood. Otherwise normal colonoscopy to ileum (20cm examined) Brief Hospital Course: BRIEF HOSPITAL COURSE Mr. [**Known lastname 6632**] is a [**Age over 90 **]y/o gentleman with history of PUD, recurrent diverticulitis s/p illeostomy with history of illioconduit in [**2145**] then colostomy in [**2152**], recent history of GI bleed 5 weeks ago complicated by retained small bowel camera who presented with an acute GI bleed. This may have been due to a stomal tear, which was repaired at the OSH. During this admission his Hct was stable and he was discharged home. . 1. Acute GI bleed: Resolved. Lower GI source most likely given that he was briskly bleeding with clots yet remaining hemodynamically stable. Possibly from a stomal tear. At OSH a tear was visualized and he underwent stoma revision. Since he has been here, he has had no active bleeding. No clear source identified on CTA. He did require 3u pRBCs and his Hct remained stable after that. GI scoped through ileostomy with no clear source and given stability, Surgery signed off. Next step would be capsule endoscopy, which Pt declined due to his h/o obstruction from retained camera. He was advised to follow up as an outpatient and to continue his PPI. He was d/c'd home with PT and GI follow-up. . 2. Hypoxia: Pulmonary edema, resolved. Occurred while in ICU, most likely due to pulmonary edema from volume resuscitation. He was diuresed with Lasix 20mg IV x1, successfully. He was subsequently euvolemic. . 3. [**Last Name (un) **] on CKD: Cr peaked at 1.4, was likely prerenal in the setting of acute blood loss. Resolved quickly after blood transfusions and his Cr returned to his baseline (1.2). . 4. AS: Moderate to severe based on exam. Unclear why not on diuretics or antihypertensives, although fludricortisone suggests h/o orthostasis. He was set up with an appointment to follow up with his Cardiologist. . 5. Depression: Chronic. He was continued on Celexa. . 6. PVD: stable. Unclear why not on aspirin or statin. He was told to follow up with his Cardiologist. . Code Status: DNR/DNI Medications on Admission: 1. Celexa 20mg PO daily 2. Rabeprazole 20mg PO daily 3. Fludrocortisone 0.1mg PO daily 4. Gabapentin unknown dose PO BID 5. Vitamin B12 600mcg PO daily Discharge Medications: 1. Celexa 20 mg Tablet Sig: One (1) Tablet PO once a day. 2. rabeprazole 20 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 3. fludrocortisone 0.1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Vitamin B-12 500 mcg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home With Service Facility: [**Company 1519**] Discharge Diagnosis: Primary diagnosis this admission: Gastrointestinal bleeding of unclear source. 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**] from another hospital with bleeding into your ostomy pouch. You received several blood tranfusions to maintain your blood levels and the bleeding eventually slowed down such that your blood levels were stable for several days. Our gastroenterologists and surgeons felt comfortable discharging you from the hospital given that you blood levels were stable, and you did not want to have any further workup at this time. Therefore, it is important for you to follow up closely with the gastroenterologist doctors [**Name5 (PTitle) 7974**]. If you notice any further bleeding, return to the hospital immediately. We did not make any changes to your medications. Followup Instructions: PRIMARY CARE Name: [**Doctor Last Name **],[**Last Name (un) 49339**] V. MD Address: [**Street Address(2) 89311**]., [**Location **],[**Numeric Identifier 26374**] Phone: [**Telephone/Fax (1) 13745**] Appointment: Thursday [**2155-6-26**] 11:00am CARDIOLOGY Name: [**Last Name (LF) **],[**Name8 (MD) **] MD Address: [**Street Address(2) **] SUITE #4930, [**Location (un) **],[**Numeric Identifier 7023**] Phone: [**Telephone/Fax (1) 89312**] Appointment: Tuesday [**2155-7-1**] 11:20am GASTROENTEROLOGY [**First Name4 (NamePattern1) 122**] [**Last Name (NamePattern1) 1437**] [**Name8 (MD) **], MD S W Gastroenterological Assoc [**State 89313**], SW Gastro Assoc [**Location (un) **], [**Numeric Identifier 23881**] Phone: ([**Telephone/Fax (1) 89314**] We are working on a follow up appointment in Gastroenterology with Dr. [**First Name4 (NamePattern1) 122**] [**Last Name (NamePattern1) 1437**] within 2 weeks. The office will contact you at home with an appointment. If you have not heard within 2 business days or have any questions please call [**Telephone/Fax (1) 25843**].

[ "362.50", "584.9", "518.4", "578.9", "V55.2", "E879.5", "346.90", "356.9", "533.90", "996.59", "424.1", "285.1", "879.5", "V10.46", "440.20", "569.69", "585.3", "562.10" ]

icd9cm

[ [ [] ] ]

[ "45.12" ]

icd9pcs

[ [ [] ] ]

9242, 9291

6716, 8709

259, 451

9414, 9414

4322, 6693

10289, 11375

3076, 3095

8911, 9219

9312, 9393

8735, 8888

9565, 10266

3110, 3110

3728, 4303

211, 221

479, 2445

3124, 3714

9429, 9541

2467, 2948

2964, 3060

48,730

125,414

23796

Discharge summary

report

Admission Date: [**2194-5-3**] Discharge Date: [**2194-5-6**] Date of Birth: [**2127-6-7**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 594**] Chief Complaint: Altered mental status Major Surgical or Invasive Procedure: arterial line placement central line placement History of Present Illness: 66 yo M with HIV on HAART, CD4 584, VL 93 (2 weeks ago), PML, hx PCP pneumonia, syphilis (treated), crystal meth and tobaccoabuse, and B12 deficiency and also recent stroke, who presents found on floor at home soaked in urine. Altered and not answering questions. Agitated on site with FS 98. Also some bleeding from the lip. No fever. . In the ED, patient was intubated using RSI with acute agitation. CT head and C-spine were negative. A CXR was performed which showed R sided multifocal PNA. CT torso was obtained and confirmed finding of right sided multifocal PNA. CR returned significantly elevated at 3.4 from baseline of 0.8-1.0 previously after obtaining CT torso and renal was consulted for elevated CR in the setting of contrast. Renal recommended 3 amps bicarb in D5W at 100cc/hr. Was started on cefepime/levo/flagyl for PNA and iv bactrim/steroids for concern of PCP given HIV status (unclear if patient received bactrim). Other notable labs were bandemia of 36%, INR 1.3. UA showed few bacteria, but no evidence of UTI. . On arrival to the MICU, patient is intubated and sedated. On further collateral from sister, patient was found by upstairs neighbor on night of arrival, curled in fetal position and having urinated himself. Patient was last seen normal on Friday evening after having company. Had complained of sorethroat and URI type symptoms for past 2-3 days. Past Medical History: HIV diagnosed [**10-29**], CD4 584, VL 93 (2 weeks ago) PML Syphilis [**2189**] s/p treatment Chlamydia [**2190**] PCP [**Name Initial (PRE) 1064**] [**8-1**] Crystal methamphetamine and tobacco abuse Hepatitis A Non-carrier hepatitis B Vitamin B12 deficiency Anemia Multiple pulmonary nodules Erectile dysfunction Sciatica History of MRSA Right thumb soft tissue infection, ? herpetic whitlow [**8-30**] Diverticulitis Cellulitis of chest wall [**6-27**] Social History: He is divorced from his previous wife, and self-identifies as gay. He works 1 day/week as a lawyer and practices child law and appeals. He is working every day on remodeling his [**Last Name (un) **]. He has 3 sons who do not live in the area, and they know he is gay but do not know he has HIV. He currently is having unprotected sex with men, and they reportedly know his HIV status. He uses crystal methaphetamine, and took 2 hits 2 days ago, 2 hits 1 week ago, and used it IV 2 weeks ago. He also uses GBL (per Wikipedia, this is a pro-drug for GHB), and last used it 2 weeks ago. He denies IV heroin use. He smokes <1 ppd, and drinks occasional EtOH. Family History: His PGM and PGF had DM, there is no family history of strokes. Physical Exam: Physical Exam on Admission: Vitals: BP: 166/98 P: 99 R: 23 O2: 99% intubated on 50% FiO2 General: intubated and sedated HEENT: pupils [**1-22**] bilaterally, intubated, poor dentition Neck: supple, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Left lung CTA on anterior exam, decreased breathsounds diffuself in right lung Abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly GU: foley in place, bladder slightly distended Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: intubated and sedated, not responding to commands at this time Death Exam: Unresponsive, no pupillary reaction to light, no blink reflex, no heart beat detected following 2 minutes of auscultation, no pulses palpated Pertinent Results: admission labs: [**2194-5-3**] 06:52PM BLOOD WBC-7.0 RBC-4.11* Hgb-12.4* Hct-38.6* MCV-94 MCH-30.3 MCHC-32.2 RDW-14.9 Plt Ct-247 [**2194-5-3**] 06:52PM BLOOD Neuts-56 Bands-36* Lymphs-5* Monos-0 Eos-0 Baso-0 Atyps-3* Metas-0 Myelos-0 [**2194-5-3**] 06:52PM BLOOD Hypochr-NORMAL Anisocy-OCCASIONAL Poiklo-OCCASIONAL Macrocy-OCCASIONAL Microcy-NORMAL Polychr-OCCASIONAL Burr-OCCASIONAL [**2194-5-3**] 07:55PM BLOOD PT-14.3* PTT-28.3 INR(PT)-1.3* [**2194-5-3**] 06:52PM BLOOD Glucose-128* UreaN-74* Creat-3.4*# Na-143 K-3.9 Cl-102 HCO3-21* AnGap-24* [**2194-5-3**] 06:52PM BLOOD ALT-34 AST-68* CK(CPK)-139 AlkPhos-149* TotBili-0.6 [**2194-5-3**] 06:52PM BLOOD cTropnT-0.01 [**2194-5-4**] 05:32AM BLOOD CK-MB-2 cTropnT-0.01 [**2194-5-4**] 01:27PM BLOOD CK-MB-1 cTropnT-0.02* [**2194-5-3**] 06:52PM BLOOD Albumin-3.2* Calcium-8.5 Phos-4.3 Mg-2.6 [**2194-5-3**] 06:52PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2194-5-4**] 01:34AM BLOOD Lactate-1.3 K-3.4 . discharge labs: [**2194-5-6**] 02:11AM BLOOD WBC-18.9* RBC-3.29* Hgb-9.7* Hct-31.1* MCV-95 MCH-29.4 MCHC-31.1 RDW-15.5 Plt Ct-106* [**2194-5-6**] 02:11AM BLOOD Glucose-144* UreaN-84* Creat-3.0* Na-151* K-4.0 Cl-121* HCO3-23 AnGap-11 [**2194-5-6**] 02:11AM BLOOD Calcium-7.9* Phos-3.5 Mg-2.5 [**2194-5-6**] 11:12AM BLOOD Osmolal-335* . urine [**2194-5-3**] 06:30PM URINE Color-Straw Appear-Hazy Sp [**Last Name (un) **]-1.016 [**2194-5-3**] 06:30PM URINE Blood-SM Nitrite-NEG Protein-30 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG [**2194-5-3**] 06:30PM URINE RBC-2 WBC-3 Bacteri-FEW Yeast-NONE Epi-0 [**2194-5-3**] 06:30PM URINE CastHy-3* [**2194-5-3**] 06:30PM URINE Hours-RANDOM Creat-33 Na-78 K-26 Cl-78 Phos-18.7 Mg-4.3 [**2194-5-3**] 06:30PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG cocaine-NEG amphetm-POS mthdone-NEG . studies: CXR: Right lung opacification concerning for extensive pneumonia. Endotracheal tube is within standard position. Orogastric tube tip is within the stomach; however, the side port is just above the gastroesophageal junction and should be advanced. . . CT head: IMPRESSION: No acute intracranial process. . CT Cspine: No fracture or malalignment of normal prevertebral soft tissues. Degenerative changes as described above. . CT chest abdomen pelvis 1. Extensive right lung opacification most concerning for pneumonia. 2. No acute intra-abdominal process or fracture. 3. Sideport of the orogastric tube is within in the distal esophagus, and the tube should be advance for optimal placement. . EEG: [**5-4**] This is an abnormal continuous ICU monitoring study because of the presence of an extremely severe diffuse encephalopathy. Throughout this record essentially no electrical activity of cerebral origin was identified. EEG: [**5-5**] This is an abnormal continuous ICU monitoring study because of an extremely severe diffuse encephalopathy with a complete loss of any identifiable electrical activity in cerebral origin. . ECG: Sinus tachycardia. RSR' pattern in lead V1, probably a normal variant. Diffuse ST segment depression which is non-specific. Compared to the previous tracing of [**2193-2-14**] significant tachycardia is new. . CXR [**5-4**] Left subclavian vascular catheter terminates within the proximal to mid superior vena cava, with no visible pneumothorax. Endotracheal tube remains in standard position, and nasogastric tube has been advanced more distally in the stomach compared to the prior study. Worsening diffuse airspace opacities throughout the right lung, particularly in the right middle and right lower lobes with near-complete obscuration of right heart border and right hemidiaphragm. Findings are consistent with a diffuse right lung pneumonia as demonstrated on recent CT of [**2194-5-3**]; however, given worsening volume loss, there is likely coexisting atelectasis involving portions of the right middle and right lower lobes. Left lung remains clear. . CT head [**5-4**] Hyperdensities noted within the sulci and along the tentorium appear consistent with previous contrast bolus given on [**2194-5-3**]. Although subarachnoid hemorrhage cannot be definitively ruled out the normal size of the ventricles and normal appearance of cisterns suggest the etiology of hyperdensities as being due to sluggish circulation and stasis of contrast within vasculature, possibly in the setting of renal insufficiency. . MR head [**5-4**] 1. Diffuse extensive abnormal signal involving the bilateral sulci, basal ganglia and thalami with thickening of the sulci and crowding of the posterior fossa, likely representing diffuse brain swelling and suggestive of brain death. MRA/MRV and nuclear medicine perfusion imaging are suggested for further characterization. 2. Abnormal signal within the subarachnoid space bilaterally may represent residual contrast from prior CAT scan in the setting of renal insufficiency. [**5-5**] TTE: IMPRESSION: No echocardiographic evidence of endocarditis. Mild symmetric left ventricular hypertrophy with preserved global and regional biventricular systolic function. No pathologic valvular abnormality seen. Radiology Report CHEST (PORTABLE AP) Study Date of [**2194-5-5**] 3:41 AM FINDINGS: As compared to the previous radiograph, there is no relevant change. The very extensive right-sided parenchymal opacity is constant in severity and distribution. On the left, there is no change in appearance of the normally appearing lung parenchyma. Unchanged appearance of the cardiac silhouette, unchanged monitoring and support devices. Brief Hospital Course: Primary Reason for Hospitalization: Patient is a 66 yo male with past medical history of HIV on HAART, CD4 584, VL 93 (2 weeks ago), PML, hx PCP pneumonia, syphilis (treated), crystal meth and tobaccoabuse, and B12 deficiency and also recent stroke, who presents found on floor at home soaked in urine and found to have multifocal PNA and positive amphetamine screen. He was admitted to MICU having been intubated for airway protection and necessary medical studies given he was extremely agitated in the ED. He had an episode of hypotension overnight on admission and was later found to have clinical brain death. Care was withdrawn and he expired. . ACUTE CARE: 1. Altered mental status - Patient was found on ground soaked in urine with altered mental status at home. Upon arrival to the ED he was severely agitated and had a gaze deviation to the right. He was non-verbal, not obeying commands and had blood at the mouth. Several etiologies for the altered mental status were considered. Pneumonia was discovered on CXR and CT scan to involve all 3 right lobes and BC grew strep pneumoniae. He was treated with appropriate antibiotics including vancomycin and cefepime. UA was clean. CSF infection was considered and he was covered with ampicillin in addition to the above-mentioned antibiotics. Seizure was considered, especially given patient's poor substrate with PML and gaze deviation on presentation. When EEG was done, it was near isoelectric. Patient also had positive amphetamines on Utox with a history of methamphetamine abuse, and his altered mental status could be related to recent drug use, supported by the marked agitation seen in the ED. EKG showed no ischemic changes and trop negative. CT head and C-spine in ED were negative for acute injury. Patient was intubated and sedated in the ED for airway protection and necessary imaging studies mentioned above and transferred to the MICU. On his first night in the hospital patient developed an episode of hypotension to SBP 48. He was started on pressors with recovery of blood pressure within 10 minutes. Following that event, he was found to have absence of cranial nerve reflexes including pupilary, blink, and doll's eyes. EEG showed near-isoelectric tracing and MRI revealed diffuse brain swelling consistent with anoxic brain injury. Based on these findings and monitoring showing no improvement, he was diagnosed with brain death. This conclusion was made in consultation with the neurology service as well. After discussion of goals of care with the family and review of patient's living will, they decided with the medical team that care should be directed toward comfort with other care being withdrawn. Patient's pressors were stopped and the ETT was removed, after which he progressed to PEA arrest and then asystole. He was pronounced dead at 3:47PM on [**2194-5-6**]. 2. Pneumonia - Patient was intubated and sedated for airway protection and facilitation of necessary medical studies in the setting of severe agitation in the ED. CXR and CT torso showed multifocal PNA in right lobe. Patient has history of PCP pneumonia in [**2191**], though CD4 > 500. He was started on vanc/levo for PNA and bactrim IV and dexamethasone in ED for concern of PCP given history in the past. CXR was not consistent with PCP so steroids and bactrim were stopped. Concern was for aspiration CAP considering found in fetal position nonresponive on floor of apartment. S. Pneumo was cultured from the blood and he was continued on antibiotics. . 3. Acute Renal Failure Creatinine was elevated to 3.4 from previous baseline of 0.8-1.0 after CT torso with contrast today. Renal was consulted down in the ED and was started on 3amps bicarb in D5W at 100cc/hr. Patient was found down and BUN/CR ratio was approximately 20:1 suggesting pre-renal azotemia. Could also be rhabdomyolysis in setting of unknown time down, though only small blood on UA and CK 139. Cr down-trending at time of death. 4.HIV -Continued atripla. 5.HTN - Held home metoprolol for hypotension. Communication: [**First Name8 (NamePattern2) **] [**Known lastname **] Relationship: Son Phone number: [**Telephone/Fax (1) 60743**] [**Name (NI) **] (sister) - [**Telephone/Fax (1) 60744**] ISSUES TO FOLLOW-UP: serum methamphetamine level (send-out lab) from admission Medications on Admission: Atripla daily mirtazapine 15 mg at bedtime metoprolol XL 100mg daily aspirin 81 mg daily iron tablet Discharge Disposition: Expired Discharge Diagnosis: primary: anoxic brain injury, acute renal failure, methamphetatmine intoxication secondary: HIV Discharge Condition: patient expired Discharge Instructions: patient expired Followup Instructions: patient expired

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icd9cm

[ [ [] ] ]

[ "96.04", "96.71", "38.93", "38.91", "33.24" ]

icd9pcs

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13903, 13912

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323, 371

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40974

Discharge summary

report

Admission Date: [**2104-10-22**] Discharge Date: [**2104-10-31**] Date of Birth: [**2032-12-29**] Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 633**] Chief Complaint: High blood sugars and feeling unwell. Major Surgical or Invasive Procedure: none History of Present Illness: Pt with Hx of difficult to control IDDM, HTN, and past breast CA treated with mastectomy and possible radiation (Hx unclear) who presented from home due to elevated blood sugars > 500s. Reports sx of HA, mild, for last 2 days. No changes in vision, hearing, dizziness, lightheadedness, nausea, vomiting, loss of conciousness. No neck pain or neck stiffness. Reports subjective fever at home but reports she new this because her mouth felt like it does with fever. Did not take temp. Took Tylenol. Says she has been confused but cannot pin-point when this started. Pt reports that she sometimes forgets to take her insulin and gets high blood sugar but says that usually takes her meds. Denies CP/SOB/abd pain/bowel/bladder sx except for increased urinary frequency without dysuria or hematuria. Readily admits to being very confused about historical events. Talked to sister [**Name (NI) 56926**] who also has difficulty with some historical details. Says [**Known firstname 89399**] lived in [**State 3908**] until [**4-6**] months ago. [**First Name5 (NamePattern1) 56926**] [**Last Name (NamePattern1) 89400**] seen her since 2 years prior when [**Known firstname 89401**] husband died until she went down to [**Name (NI) 3908**] to bring her back up to [**Location (un) 86**] after pt was hospitalized in [**State 3908**] for high blood sugars. Had been in hospital for 2 weeks and they were going to place in a psychiatric [**Hospital1 **] for confusion. Had blood sugar of 600s when came in to that hospital in [**State 3908**] and supposedly had come down somewhat but were still high. Since move to [**Location (un) 86**] went to [**Hospital1 **] for primary care. Was admitted to the [**Hospital1 112**] in spring for hyperglycemia. Kept for a few days. Told that she had dementia while there. Currently takes insulin 58 units (Levemir) being slowly uptitrated since [**Month (only) 116**] and also takes novalog by scale. Sister says takes meds faithfully but blood sugars at home have been running in 300-400s. Per sister, every day patient says she doesn't feel good. Feeling weak. No other complaints. [**Location (un) 2274**] notes report that pt missing appointments. [**Location (un) 269**] had been reporting high blood sugars for weeks. Had undergone w/u finding CKD (Cr 1.4-1.8) with microalbuminuria without monoclonal bands on SPEP, low B12 ([**2104-6-1**]), low VIt D, high uric acid, Norm Iron Studies. Had head CT (normal) in [**Month (only) 547**] and head MRI in [**Month (only) 116**] In ED, found to have BS > 700. CXR okay. UA with 1000 glucose and 10 ketones, AG of only 15 without acidosis on Chem 7. Na 125 and Cr of 2.2 (baseline 1.4-1.7). Pt was given 10 units short acting then gtt at 5units/hr uptitrated to 8units/hr. Given 2L IVF NS. Admitted to ICU due to insulin drip and hyperglycemia. . On ICU arrival, initial vitals T 97.8, HR 84, BP 147/70, RR 16, Sats 96% RA. . Review of systems: (+) Per HPI (-) Denies fever, chills, night sweats, sinus tenderness, rhinorrhea or congestion. Denies cough, shortness of breath, or wheezing. Denies chest pain, chest pressure, palpitations, or weakness. Denies nausea, vomiting, diarrhea, constipation, abdominal pain, or changes in bowel habits. Denies dysuria. Past Medical History: IDDM, HTN, breast ca, hysterectomy, B12 def (158 in [**6-/2104**]), CKD with protenuria (Cr 1.4-1.7) Social History: Social History (per chart): Smoking: Never Smoker Smokeless Tobacco: Unknown Alcohol: No Family History: denies relavent Physical Exam: T 97.8, HR 84, BP 147/70, RR 16, Sats 96% RA. General: Alert, oriented to self and medical condition, not sure where she is and some difficulty with date, no acute distress HEENT: Sclera anicteric, dry MMM, oropharynx clear Neck: supple, no radiating pain with movement JVP not elevated Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema, capillary refill > 2 sec Neuro: CN II-XII intact, 5/5 strength all ext, intact sensation all ext, A&O to self but not to date or location, says days of week forward and backward, slightly difficulty with clock but ultimately intact with time correct, difficulty relating historical events . Pertinent Results: . CXR: FINDINGS: PA and lateral views of the chest are obtained. Clips are noted in the left breast. There is asymmetry in the size of the breast tissue, smaller on the left side. There is slight haziness projecting over the left mid to lower lung which is not seen on the lateral view and likely represents chest wall soft tissues. There is no definite sign of pneumonia or CHF. No pleural effusion or pneumothorax is seen. Cardiomediastinal silhouette is normal. Bony structures are intact. IMPRESSION: No signs of pneumonia. . RAPID PLASMA REAGIN TEST (Final [**2104-10-23**]): NONREACTIVE. Reference Range: Non-Reactive. . EKG [**10-23**]-Sinus rhythm. Within normal limits . [**2104-10-27**] 08:05AM BLOOD WBC-5.9 RBC-4.29 Hgb-12.3 Hct-35.1* MCV-82 MCH-28.7 MCHC-35.0 RDW-12.8 Plt Ct-222 [**2104-10-26**] 07:50AM BLOOD WBC-10.6 RBC-4.49 Hgb-12.8 Hct-36.4 MCV-81* MCH-28.5 MCHC-35.3* RDW-12.6 Plt Ct-291 [**2104-10-24**] 08:20AM BLOOD WBC-7.4 RBC-4.71 Hgb-13.6 Hct-38.7 MCV-82 MCH-28.9 MCHC-35.2* RDW-12.5 Plt Ct-242 [**2104-10-23**] 03:48AM BLOOD WBC-7.4 RBC-4.01* Hgb-11.4* Hct-31.6* MCV-79* MCH-28.4 MCHC-36.1* RDW-13.1 Plt Ct-220 [**2104-10-22**] 12:15PM BLOOD WBC-10.4 RBC-4.74 Hgb-13.3 Hct-39.0 MCV-82 MCH-28.0 MCHC-34.1 RDW-13.1 Plt Ct-253 [**2104-10-22**] 12:15PM BLOOD Neuts-77.2* Lymphs-18.9 Monos-3.1 Eos-0.5 Baso-0.4 [**2104-10-27**] 08:05AM BLOOD Glucose-126* UreaN-18 Creat-1.5* Na-141 K-4.4 Cl-106 HCO3-24 AnGap-15 [**2104-10-26**] 07:50AM BLOOD Glucose-88 UreaN-19 Creat-1.8* Na-141 K-4.4 Cl-103 HCO3-25 AnGap-17 [**2104-10-25**] 07:57AM BLOOD Glucose-84 UreaN-13 Creat-1.4* Na-143 K-4.0 Cl-104 HCO3-25 AnGap-18 [**2104-10-24**] 12:10PM BLOOD Glucose-374* UreaN-17 Creat-1.5* Na-139 K-4.2 Cl-104 HCO3-25 AnGap-14 [**2104-10-23**] 03:48AM BLOOD Glucose-98 UreaN-23* Creat-1.4* Na-137 K-3.9 Cl-103 HCO3-26 AnGap-12 [**2104-10-22**] 09:40PM BLOOD Glucose-324* UreaN-27* Creat-1.7* Na-138 K-4.0 Cl-102 HCO3-26 AnGap-14 [**2104-10-22**] 05:00PM BLOOD Glucose-544* UreaN-32* Creat-1.9* Na-129* K-4.3 Cl-94* HCO3-24 AnGap-15 [**2104-10-22**] 12:15PM BLOOD Glucose-734* UreaN-38* Creat-2.2* Na-125* K-5.0 Cl-86* HCO3-24 AnGap-20 [**2104-10-22**] 05:00PM BLOOD ALT-8 AST-12 LD(LDH)-182 AlkPhos-110* TotBili-0.4 [**2104-10-23**] 03:48AM BLOOD CK-MB-2 cTropnT-<0.01 [**2104-10-23**] 03:48AM BLOOD calTIBC-251* Ferritn-181* TRF-193* [**2104-10-22**] 05:00PM BLOOD VitB12-1201* Folate-18.8 [**2104-10-22**] 12:15PM BLOOD Osmolal-322* [**2104-10-22**] 05:00PM BLOOD TSH-1.1 . [**2104-10-26**] URINE URINE CULTURE-FINAL INPATIENT [**2104-10-24**] URINE URINE CULTURE-FINAL INPATIENT [**2104-10-22**] SEROLOGY/BLOOD RAPID PLASMA REAGIN TEST-FINAL INPATIENT [**2104-10-22**] MRSA SCREEN MRSA SCREEN-FINAL INPATIENT Brief Hospital Course: 71 yr/o F with Hx of poorly controlled DM and social situation which raises question of medication noncompliance presented with chronic changes in mental status, 2 days of headaches, and blood sugar > 700 without acidosis and with only mild gap, more concerning for hyperosmolar hyperglycemia. . # Hyperglycemia/HONK/ DM2 uncontrolled with complications: Pt presenting with sugar of 734 but only a mild anion gap (15), only 10 ketones in the urine, and no acidosis on chem 7. In setting of chronically poorly controlled blood sugars, type 2 diabetes, older age, no Abd pain, leukocytosis, anorexia, or focus of infection, most likely that presentation due to hyperosmolar hyperglycemia without DKA. Pt appears to have cognitive dysfunction at baseline to have underlying which traces back months and is not substantially changed in the last few weeks per report. She was initially treated with an insulin drip and IV fluids in the ICU. SHe improved and was transitioned to lantus / humalog. [**Last Name (un) **] was consulted. At discharge her insulin regimen is lantus 30mg QHS and humalog standing 7units at breakfast, lunch, and dinner with fingersticks ranging in the 100s. Given her delicate social lives with her sister with DM who may have some cognitive impairment and clear lack of insight regarding diabetes, insulin regimen was titrated to the above for simplicity (using sliding scale was avoided as pt often became confused when choosing correct scale for breakfast, lunch, or dinner). In review of outpatient records, pt and her sister have been turing away [**Name (NI) 269**] an ETHOS and despite repeated explaination to importance of a diabetic diet/insulin administration, but still with difficulty and missing outpatient appointments. Pt was started on asa 81mg, ACEI, statin for diabetic care as well. . # Acute Renal Failure: Presentation Cr up to 2.2 increased from baseline of 1.4-1.7. Likely pre-renal in setting of increased UOP due to hyperglycemic osmotic diuresis. Historically spilling protein in urine, likely from DM (which negative MM workup at Atrius). Cr returned to baseline with hydration. Home lasix was held. Lisinopril started. Cr on discharge was 1.6. . # Altered mental status / Dementia: Unclear if any acute change. Per sister has been somewhat confused with historical details last few months and was diagnosed with "dementia" at [**Hospital1 112**] this spring at which time had normal head CT and head MRI. Had low B12 on one check this spring. No historical features to support encephalitis, stroke, seizure and no focal findings on neurological exam. It appears that there has been some cognitive decline since husband died a few years ago. TSH, B12, Folate, RPR were unremarkable. Infectious and cardiac work up unremarkable. Seroquel was held. Psych was consulted to assess capacity and initially determined that pt did not have capacity. They did however, state that eventhough pt did not have initial capacity, she could be cared for by her family if they were competent/had capacity. Reevaluation by psychiatry and ETHOS also determined that pt had capacity for understanding the disease and management of diabetes. . #social situation/safety-obtained collateral information on [**10-27**] regarding patient. [**Name (NI) 1094**] sister reported that she would like the patient to come home and felt as thought she could adequately care for the patient at home. Reports she is there 24hours a day. In addition, she stated that pt's [**Name (NI) 802**] and nephew-in-law are nearby to help as well. Per review of [**Location (un) 2274**] record online it appears that [**Location (un) 269**]/SW/ETHOS in the outpatient setting are frustrated as pt and her sister appear to be turning away help/evaluations and pt has been cancelling and not showing up to appointments as an [**Location (un) 3782**]. ETHOS very concerned and wanting a safe discharge plan. In addition, it appears that pt had a admission to a hospital in [**First Name11 (Name Pattern1) 3908**] [**Initial (NamePattern1) **] [**Last Name (NamePattern1) 15935**] months ago for hyperglycemia which prompted the family to go and get pt and bring her to MA. In addition, pt admitted [**Hospital1 112**] for hyperglycemia/dementia 4/[**2094**]. Pt admitted to [**Hospital1 18**] this admit for the same. -on [**10-28**] discussed the above with the patient. Pt stated she knows her blood sugars have been high at home and during the past hospitalizations, but stated that the reasons for this are that she feels depressed related to her husband's passing 2 years ago and copes with eating sugary foods such as cookies and icecream. Pt also admits that she sometimes sneaks these foods as well and has difficulty controlling this impulse. She is able to verbalize that she knows that poorly treated diabetes/hyperglycemia will damage her "heart" and cause "Confusion". She expressed understanding of potential for damage to nerves, kidneys, eyes, potential coma and death if this pattern continues. Pt states that she knows she did wrong and states that she knows she can't "do this" any longer, meaning eat the foods that she was eating. States that she knows what foods she is and isn't supposed to eat but that it is difficult to control her willpower at times. In addition, reports that she feels confused when her blood sugars are elevated. Pt states that she will check her fingersticks more regularly, follow a diabetic diet and states that she will obtain treatment for depression. Also, stated to pt that she will need to allow [**Month/Year (2) 269**] and SW go into the home. She does admit that she needs help at home and does get confused at times. -Therefore, safe discharge plan was to do diabetic teaching with the family with the thought that if family and pt seem to understand severity of situation and are able to do diabetic care, pt will likely be safe for DC with family assitance for diabetic care with continued ongoing [**Month/Year (2) 3782**] tx for depression, and having SW +[**Month/Year (2) 269**] in the home. -ETHOS per report came in [**10-28**] to meet with pt and determined that pt had capacity. -[**10-29**], pt was able to follow her sliding scale correctly during breakfast, but despite thorough teaching was not able to do her insulin scale correctly at lunch (picked the breakfast scale). -[**Date range (1) 17948**] update. [**Initials (NamePattern4) 1094**] [**Last Name (NamePattern4) 3782**] NP called very concerned regarding discharge. Feels as thought pt cannot manage in the outpatient setting and actually was hesitant to allow follow up appointments to be arranged. NP stated that she has neurocognitive testing showing that pt has dementia. Stated that pt's sister who would serve as the caregiver is a "Non-compliant diabetic". In addition, it has been extremely difficult to get family members into the hospital for teaching and to have meeting to ensure safe discharge plan. Family stated they would be here by 6pm on [**10-29**], however they did not arrive until around 7pm. [**Name8 (MD) **] RN report, teaching done with patient's sister went "OK" but was not adequate. The family who states that they will provide this care has been very difficult to get in contact with and to come to hospital reliably over the week. Forecasting that outpatient care may not be adequate. However, the patient did appear very motivated to do well. -[**10-31**] update, pt and family repeatedly say that they want the patient to return home. Pt has had periods of confusion. However, she has been consistently AAOX3 for days. She is able to report that she has diabetes and the effects of not treating diabetes/following a diabetic diet. (this has remained consistent over the past mon-fri). Pt reiterates and continues to admit today that she was not following a diabetic diet due to feelings of depression and has repeatedly said this week that she will do better and "knows that she has to do better". Pt was given instructions regarding a diabetic diet and repeated teaching by nursing on how to administer insulin. At this time, eventhough pt does have dementia, she does have capacity and agrees to follow up with her outpatient provides and allow [**Month/Year (2) 269**] and social work in the outpatient setting. Pt was also advised that if current presentation were to occur again (an admission due to poor self-care or inability of her family to provide safe care) she will need be placed in a nursing facility and will likely need a guardian. She was reminded that attending PCP appointments and allowing [**Month/Year (2) 269**] are ways to avoid hospitalization. -[**Name (NI) 1094**] sister who was supposed to be her primary "caregiver" (in addition to her brother and [**Name2 (NI) 802**]) were supposed to arrive [**10-31**] for further teaching. CM spoke to pt's sister earlier in the day and pt's sister agreed to come in. Family supposed to be here by 6pm. However, pt's [**Month/Year (2) 802**] arrived around 730pm to pick up the patient (an asked that the patient be wheeled down stairs). [**Month/Year (2) **] was informed that this was not the intended discharge plan and she then arrived on the floor. Pt and [**Month/Year (2) 802**] very upset and requesting discharge. However, it was explained that the patient could not be discharged safely unless there was a caregiver present who would be assuming care and responsibility for the patient and her diabetic care. [**Month/Year (2) **] then agreed that she would take the patient to her home and agreed to assume responsibility and diabetic care for the patient. [**Month/Year (2) **] had diabetic teaching by the RN and teaching went well. (the overall plan per report from the family had been to have the patient move in with the [**Month/Year (2) 802**] 2 weeks after discharge anyway. This was thought to be the safest plan for the patient overall, but initially we (psychiatry, SW, RN) were attempting to find a safe DC plan before this were to occur and that is why teaching with pt's sister was important. During all phone conversations, pt's [**Month/Year (2) 802**] appeared to be very competent and understanding of the situation and concerned for patient's safety. [**Name (NI) 1094**] [**Name (NI) 802**] is clearly the better caregiver for the patient as per report the patient's sister also has dementia and is said be to "non-compliant" with diabetic care. Final DM plan was for 30units of lantus QHS with standing 7 units of humalog with meals. Pt will be living with her [**Name (NI) 802**] and [**Name (NI) 269**] will be seeing the patient at her [**Name (NI) 802**]'s house. PT has a PCP appointment and will also be seeing her NP in clinic in the next few weeks. If this plan is not carried out as above and there is still persistent concern for patient's inability to care for herself or pt's family being unable to care for her, if she is admitted again, with SW and psychiatry agreement, pt will likely need guardianship and nursing home placement. . #depression-see above. Pt evaluated by psychiatry. Started 25mg daily of zoloft. Her mood appeared much improved during admission. Will need continued follow up and titration of SSRI in [**Name (NI) 3782**] setting. No signs of SI. She is looking forward to following with her PCP and SW for this issue. PT admits that depression has been a major factor in her poorly controlled diabetes. . ##normocytic anemia-b12/folate normal. IRon studies consistent with anemia of chronic inflammation. No current signs of active bleeding. Pt should have an outpatient colonoscopy if this has not been done recently. HCT stable during admission. . #CKD baseline 1.4-1.7. Avoided nephrotoxins. ACEI titrated to 2.5mg daily. Cr 1.6 on discharge. . #insomnia-not current a reported issue during admission. She was on 100mg seroquel QHS at home. THis was discontinued. . # HTN: decreased home metoprolol to 50mg PO BID at home. Added lisinopril for uncontrolled DM2 in a diabetic. Discharge regimen 2.5mg lisinopril. PT on lasix as an outpatient. However, this was discontinued as pt did not have signs of CHF or volume overload and HTN was managed with BB, ACEI. . # Communication: Patient and sister [**Name (NI) 56926**], [**Name2 (NI) 802**], outpatient NP, ETHOS, psychiatry, inpatient RN. # Code: Full (discussed with sister) Medications on Admission: metoprolol 100mg [**Hospital1 **] seroquel 100mg lasix 40mg qam and 20mg qpm levemir 58 units qpm, novolog SS Discharge Medications: 1. simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*0* 2. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*0* 3. lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 4. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). Disp:*30 Tablet, Chewable(s)* Refills:*0* 5. sertraline 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 6. Lantus 100 unit/mL Solution Sig: Thirty (30) units Subcutaneous at bedtime. Disp:*qs qs* Refills:*2* 7. Humalog 100 unit/mL Solution Sig: Seven (7) units Subcutaneous three times a day: before breakfast, lunch and dinner. Disp:*qs qs* Refills:*2* 8. omeprazole 20 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. Discharge Disposition: Home With Service Facility: [**First Name9 (NamePattern2) 269**] [**Location (un) 86**] Discharge Diagnosis: DM2 uncontrolled with renal complications hyperglycemia acidosis acute on chronic renal failure dementia Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were initially admitted to the ICU with severe uncontrolled diabetes, high sugars, dehydration and kidney failure. This improved with insulin and IV fluids. You were evaluated by social work, psychiatry, occupational therapy and physical therapy who determined that you need further assistance in caring for your diabetes as this is very important. Improperly caring for your diabetes could/will result in damage to your nerves, kidneys, eyes and could result in death. It is important to allow the nurses to continue to help you. . Your family agreed to help you care for your diabetes and insulin administration. If you are unable to care for yourself at home, you may need to be placed in a nursing facility. Therefore, it is very important to go to your primary care appointment, check your blood sugars, follow a diabetic diet, and allow visiting nurses to come to your home. Your [**Location (un) 802**] agreed to care for you after discharge at this time and stated that she will be bringing you to her home and helping you with administering insulin. . You reported depression. You were started on a new medication for this (sertraline). Please be sure to follow with your PCP for this issue. Medication changes: 1.lantus 30mg every night 2.humalog insulin 7 units before breakfast, before lunch and before dinner 3.decrease metoprolol to 50mg twice a day 4.start lisinopril 2.5mg daily 5.start simvastatin 6.start aspirin 7.start sertraline 25mg daily for depression 8.STOP lasix 9.STOP seroquel . Please take all of your medications as prescribed and follow up with the appointments below. Followup Instructions: PLEASE BE SURE TO ATTEND THE APPOINTMENT BELOW. IT IS VERY VERY IMPORTANT. Name: [**Last Name (LF) **],[**First Name3 (LF) 18567**] T. Location: [**Hospital1 641**] Address: [**Street Address(2) 642**], [**Location (un) **],[**Numeric Identifier 643**] Phone: [**Telephone/Fax (1) 644**] When: Wednesday, [**11-12**], 1:20 Name: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 34601**], RN Department: [**Location (un) 2274**] Case Management Phone: [**Telephone/Fax (1) 89402**] *Please call Pat Miles to schedule an appointment.

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icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

20957, 21047

7543, 19889

344, 351

21196, 21196

4786, 7520

22979, 23529

3871, 3888

20049, 20934

21068, 21175

19915, 20026

21349, 22556

3903, 4767

3307, 3624

22576, 22956

267, 306

379, 3288

21211, 21325

3646, 3748

3764, 3855

26,847

118,191

44631

Discharge summary

report

Admission Date: [**2155-8-2**] Discharge Date: [**2155-8-10**] Date of Birth: [**2072-12-31**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2972**] Chief Complaint: SOB & palpitations Major Surgical or Invasive Procedure: none History of Present Illness: 82 yo female with h/o CHF (EF 55% on echo [**2153**]), CAD, A. Fibb, who presents with increasing shortness of breath x 12 hours. She was in her usual state of health and noted it was harder to breath while just sitting on the couch and felt she was having a panic attack; and thus took her alprazolam but w/o relief. She had + palpitations but no chest pain. She also reports cough with no sputum production x 3 days; denies any fevers/chills or night sweats. Denies sick contacts. Denies PND or orthopnea. . Pt was given 80mg Lasix IV and 1" nitro paste prior to arrival to ED (via EMS). On arrival to ED, VS: T 96.1, HR 130s, SBP 150, RR 30 and 94% on NRB. CXR c/w pulmonary edema and possible RLL Pna. WBC 19.8, Cr 1.3. EKG with a.fibb @ 110. Pt placed on BIPAP for respiratory distress. ABG: pH7.34 /pCO2 55/ pO2282 Nitro gtt started and given 1 dose Levofloxacin. She was also given Diltiazem 5mg IV (x3), asa 325mg x1. Nitro gtt weaned off and BIPAP changed to 5L NC. . Currently, pt reports marked improvement in her breathing. . ROS: Denies HA/ visual changes, N/V, diarrhea/constipation, abdominal pain, muscle weakness/numbness or tingling, denies any LE swelling, rashes, dysuria/frequency. Past Medical History: PMH: 1. CAD: h/o MI [**2139**], had PCI at [**Hospital1 112**] 2. CHF: ECHO [**2153**] showed EF 55% 3. A.Fibb on coumadin 4. HTN 5. Cystic carcinoma: s/p resection, cystoscopy [**7-12**] shows no recurrence 6. Basal cell CA: left nasal ala, s/p Mohs' resection 7. Anxiety Social History: SH:lives in senior housing in [**Location (un) 3146**] (independent living) has 2 children; smoked >60 pack-years, quit 2 years ago; denies any alcohol or drug use Family History: Family History:CAD: father died of MI at 62yo; mother had MI Physical Exam: Physical Exam: VS: T 96.1 BP: 122/57 HR 77 18 95% 4L GEN: Elderly female, resting comfortably in bed, no respiratory distress HEENT: NC/AT, EOMI, PERRL, O/P clear no oral lesions, MMM Neck: JVP 8cm CV: Irregularly irregular, no murmurs PULM: Crackles 1/2 up base, no wheezing ABD: Soft, NT, ND +BS EXT: No LE edema/clubbing or cyanosis SKIN: Ecchmyosis over R. forearm PULSES: 2+ DP/PT pulses bilaterally NEURO: A&O x3, CN2-12 grossly intact, senstion intact throughout, Strength 5/5 in both UE/LE bilaterally Pertinent Results: Labs on admission and discharge: [**2155-8-2**] 12:25AM BLOOD WBC-19.8* RBC-5.38 Hgb-15.5 Hct-46.2 MCV-86 MCH-28.8 MCHC-33.6 RDW-14.3 Plt Ct-350 [**2155-8-2**] 08:00AM BLOOD Neuts-79.9* Bands-0 Lymphs-16.7* Monos-2.8 Eos-0.3 Baso-0.4 [**2155-8-10**] 07:22AM BLOOD WBC-9.7 RBC-4.51 Hgb-12.8 Hct-37.7 MCV-84 MCH-28.3 MCHC-33.8 RDW-13.8 Plt Ct-256 [**2155-8-2**] 12:25AM BLOOD Glucose-226* UreaN-24* Creat-1.3* Na-141 K-4.3 Cl-101 HCO3-23 AnGap-21* [**2155-8-10**] 07:22AM BLOOD Glucose-103 UreaN-26* Creat-0.8 Na-140 K-3.6 Cl-100 HCO3-31 AnGap-13 [**2155-8-2**] 12:25AM BLOOD Calcium-10.1 Phos-5.3* Mg-2.2 [**2155-8-5**] 12:19AM BLOOD freeCa-1.19 [**2155-8-10**] 07:22AM BLOOD Calcium-9.5 Phos-3.3 Mg-2.0 . [**2155-8-2**] 12:25AM BLOOD CK(CPK)-73 [**2155-8-2**] 04:25PM BLOOD CK(CPK)-38 [**2155-8-5**] 03:02AM BLOOD CK(CPK)-88 [**2155-8-2**] 12:25AM BLOOD cTropnT-<0.01 [**2155-8-2**] 08:00AM BLOOD CK-MB-3 [**2155-8-5**] 03:02AM BLOOD CK-MB-NotDone cTropnT-0.01 . [**2155-8-4**] 11:13PM BLOOD Type-ART pO2-136* pCO2-75* pH-7.20* calTCO2-31* Base XS-0 Intubat-NOT INTUBA [**2155-8-5**] 12:19AM BLOOD Type-ART Temp-36.1 FiO2-100 pO2-314* pCO2-53* pH-7.35 calTCO2-30 Base XS-2 AADO2-362 REQ O2-63 Intubat-NOT INTUBA [**2155-8-5**] 03:06AM BLOOD Type-ART O2 Flow-4 pO2-72* pCO2-56* pH-7.37 calTCO2-34* Base XS-4 Intubat-NOT INTUBA . [**2155-8-2**] 12:25AM BLOOD PT-31.8* PTT-30.9 INR(PT)-3.3* [**2155-8-10**] 07:22AM BLOOD PT-26.0* PTT-32.3 INR(PT)-2.6* [**2155-8-4**] 11:13PM BLOOD Lactate-2.8* [**2155-8-5**] 12:19AM BLOOD Lactate-1.8 . Studies Echo [**2155-8-2**]: The left atrium is dilated. The right atrium is moderately dilated. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF 60%). Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). Transmitral Doppler and tissue velocity imaging are consistent with Grade II (moderate) LV diastolic dysfunction (pseudonormal left ventricular inflow Doppler spectrum). There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. There is an anterior space which most likely represents a fat pad. Compared with the findings of the prior report (images unavailable for review) of [**2153-8-13**], the findings are similar. The left ventricle is hypertrophic and displays reduced diastolic compliance. . CXR [**2155-8-2**]: IMPRESSION: Moderate pulmonary edema, confluent right lower lobe opacity could represent developing alveolar edema or pneumonia. Severe cardiomegaly. . CXR [**2155-8-6**]: IMPRESSION: AP chest compared to [**8-4**] and 29: Mild pulmonary edema continues to improve. Severe cardiomegaly including large left atrium is stable. The lungs clear of any focal abnormality. No pleural effusion. Mild rightward displacement and indentation of the trachea at the thoracic inlet, suggesting an enlarged left thyroid lobe, has been a constant feature since [**2153**]. . EKG [**2155-8-2**]: Atrial fibrillation with rapid ventricular response. Non-specific ST-T wave changes. Possible left ventricular hypertrophy. Compared to the previous tracing of [**2153-8-13**] the lateral ST segment depression with T wave inversion is less pronunced and the ventricular rate is faster. EKG [**2155-8-8**]: Atrial fibrillation with rapid ventricular response and ventricular premature beats or aberrant ventricular conduction. Left ventricular hypertrophy with secondary repolarization changes. Compared to the previous tracing of [**2155-8-5**] the rate has increased. The other findings are similar. Blood cx: Negative Brief Hospital Course: A/P:82 yo female with h/o CHF, A.fibb, CAD who presents with progressive SOB & palpitations and found to have CHF exacerbation [**2-8**] a.fib with RVR. 1. Respiratory Distress- Etiology is likely secondary to CHF exacerbation triggered by a.fibb w/RVR as well as COPD. Initially, pneumonia was considered as a possibility and the patient received a dose of Levaquin in the ED, however, given the improvement in the patient's clinical status after diuresis with IV Lasix, it is unlikely that the pt's resp distress was secondary to an infectious etiology. The patient required admission to the ICU and the use of BiPAP. She was kept at -1000 cc/day net fluid balance. She was rate controlled as below and given nebulizer treatments. Her oxygen saturation was fine on room air and when ambulating on the day of discharge. She was discharged on tiotropium bromide, fluticosone, levalbuterol, and her home dose of lasix. . 2. CHF- Most recent ECHO in '[**53**] showed EF 55% wtih preserved systolic function however the patient had clear evidence of pulmonary edema on CXR. Pt has been diuresed with Lasix and nitro with improvement. Exacerbation likely occured in setting of afib with RVR. She was discharged on her home dose of lasix. The following medications were changed in dose: metoprolol to 100mg PO BID, Verapamil to 80mg PO TID, and Quinapril 20mg PO BID. . 3. Rhythm- The patient had Paroxysmal Atrial Fibrillation with RVR and was given given diltiazem 15mg IV in the ED for rate control. Her Verapamil and metoprolol were titrated to verapamil 80mg PO TID and metoprolol 100mg [**Hospital1 **]. The patient had a supratherapeutic INR initially so coumadin was held initially but she was discharged on coumadin of 2.5mg daily and an INR of 2.6. . 4. CAD- The patient had no ischemic changes on EKG. Her cardiac enzymes were negative. She was continued on a b-blocker, statin, ACE inhibitor, and ASA. . 5. HTN- The patient had episodes of increased blood pressure and rapid heart rate while in A Fib. Adjustments were made to her home medications. Please see above doses of metoprolol, verapamil, and quinapril. The patient is also on Lasix. . 6. Renal Fx- The patient's creatinine was 1.3 on admission but quickly normalized. Her creatinine was 0.8 on the day of discharge. She was discharged on her home dose of lasix. Medications on Admission: Medications on Admission: Metoprolol 150mg [**Hospital1 **] Verapamil 40mg TID daily Alprazolam 0.25mg daily Coumadin 5mg daily Lasix 40mg daily Quinapril 20mg daily asa 325mg daily Lipitor 40mg daily Discharge Medications: 1. Metoprolol Tartrate 100mg PO BID 2. Verapamil 80 mg PO Q8H 3. Alprazolam 0.25 mg PO once a day as needed for anxiety. 4. Warfarin 2.5 mg PO Q4PM 5. Lasix 40 mg PO once a day. 6. Quinapril 20 mg PO BID 7. Aspirin 325 mg PO once a day 8. Atorvastatin 40 mg PO DAILY 9. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [**Hospital1 **] 10. Tiotropium Bromide 18 mcg Capsule One Cap Inhalation PRN: daily as needed for shortness of breath or wheezing. 11. Xopenex HFA 45 mcg/Actuation HFA Aerosol Inhaler Sig: [**1-8**] Inhalation q6hrs:prn. Disp:*1 * Refills:*0* Discharge Disposition: Home With Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: Primary Diagnosis 1. Atrial fib with Rapid ventricular response 2. Hypertension 3. Acute on Chronic diastolic heart failure . Secondary Diagnosis 1. Coronary Artery Disease 2. Anxiety Discharge Condition: Good. You were breathing fine on room air. Discharge Instructions: You were admitted to the hospital with shortness of breath, atrial fibrillation, and pulmonary edema. You were in the medical intensive care unit where you were placed on BIPAP to help you breathe. You also had episodes of increased blood pressure and rapid heart rate. During your hospitalization you were diuresed and your breathing improved. You were breathing well on room air and when walking at the time of discharge. Your blood pressure medications were adjusted to better control both your blood pressure and your heart rate. . Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs. Adhere to 2 gm sodium diet Fluid Restriction: 2000ml . The doses of the following medications were changed: Metoprolol was changed to 100mg PO BID Verapamil was changed to 80mg PO TID Coumadin was changed to 2.5mg PO daily Quinapril 20mg PO BID . There were no changes in the following medications: Alprazolam, lasix, aspirin, lipitor . You were started on the following new medications: -tiotropium bromide -fluticosone -levalbuterol . -Please return to the hospital if you develop shortness of breath, dizziness, chest pain, or any new medical condition. Followup Instructions: Please make an appointment to follow up with Dr. [**Last Name (STitle) **] in 1 week to check your INR and blood pressure. Phone # [**0-0-**] Completed by:[**2155-9-3**]

[ "584.9", "428.33", "428.0", "V10.82", "401.9", "518.81", "414.01", "424.0", "V58.61", "496", "427.31", "300.00" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

9999, 10056

6796, 9140

334, 340

10284, 10329

2675, 6773

11547, 11719

2082, 2129

9392, 9976

10077, 10263

9192, 9369

10353, 11524

2159, 2656

276, 296

368, 1573

1595, 1870

1886, 2051

24,556

173,378

13839+13840

Discharge summary

report+report

Admission Date: [**2181-8-28**] Discharge Date: [**2181-9-19**] Date of Birth: [**2115-1-26**] Sex: M Service: CARDIOTHORACIC SURGERY HISTORY OF PRESENT ILLNESS: This is a 66 year old male patient who underwent coronary artery bypass graft on [**2181-8-20**], times five. His postoperative course was notable for atrial fibrillation as well as slow progression of cardiac rehabilitation. The patient was ultimately transferred to rehabilitation facility to assess with pulmonary toilette, however, it was noted that he began having increasing respiratory difficulty with poor pulmonary toilette at the rehabilitation facility and the patient was admitted to the Emergency Department here at [**Hospital1 346**] on [**2181-8-28**], due to severe respiratory distress. In the Emergency Department, the patient was noted to be severely hypoxic despite supplemental oxygen and was intubated in the Emergency Department and admitted to the Intensive Care Unit. PAST MEDICAL HISTORY: 1. Stable angina until recent increase in symptoms at which time he had a positive exercise tolerance test. He underwent cardiac catheterization and subsequent coronary artery bypass graft on [**2181-8-20**]. 2. Hypertension. 3. Carotid artery disease, status post left carotid endarterectomy in [**2178**]. 4. Spinal stenosis, status post back surgery times two. 5. Peripheral neuropathy. MEDICATIONS ON ADMISSION: 1. Lopressor 100 mg p.o. b.i.d. 2. Lasix with supplemental potassium replacement p.r.n. 3. Aspirin 81 mg p.o. q.d. 4. Norvasc 10 mg p.o. q.d. 5. Prednisone 5 mg p.o. q.d. 6. Amiodarone 400 mg p.o. b.i.d. times seven days, followed by 400 mg q.d. times seven days, to be followed by 200 mg q.d. 7. Colace 100 mg b.i.d. 8. Albuterol nebulizer treatment p.r.n. ALLERGIES: No known drug allergies. PHYSICAL EXAMINATION: On admission, the patient was noted to have coarse breath sounds bilaterally. At the time of examination, he was intubated and sedated. The patient was in normal sinus rhythm with a heart rate in the low 60s. The abdomen was distended, nontender, with positive bowel sounds. His extremities were warm. LABORATORY DATA: On admission, the patient's laboratory values were unremarkable with the exception of a white blood cell count of 23.0. HOSPITAL COURSE: The patient was admitted to the Intensive Care Unit with plans to be cultured. Infectious disease consultation was obtained. Chest x-ray on admission to the hospital revealed congestive heart failure with a probable pneumonia. Infectious disease consultation was obtained on the day of admission and it was their assessment that the patient was admitted with pneumonia. It was their recommendation to treat with broad spectrum antibiotics including Vancomycin, Piperacillin and Levofloxacin. They also requested Legionella titer to be sent which was ultimately found to be negative and bronchoscopy was recommended. The patient received a cardiology consultation on hospital day two, [**2181-8-29**], due to persistent atrial fibrillation. It was their recommendation to obtain an echocardiogram for evaluation of ventricular ejection fraction. It was their recommendation to continue beta blockers and Amiodarone. The patient had also had an episode of nonsustained ventricular tachycardia precipitating the cardiology consultation. Pulmonary medicine consultation was also obtained on [**2181-8-29**], due to assistance in management for respiratory distress and pneumonia versus acute respiratory distress syndrome. It was their assessment that the patient was a 66 year old male status post coronary artery bypass graft who was readmitted with respiratory distress, fever and hypoxia, likely from pulmonary edema as well as nosocomial pneumonia. It was their recommendation to continue diuresis, to transfuse the patient to improve oxygen carrying capacity as well as obtain a bronchoscopy. The patient underwent bronchoscopy on [**2181-8-29**], in which all cultures subsequently came back negative with the exception of some yeast. The patient also had mediastinal fluid aspirated due to question of instability of his sternal wound. This has also come back with cultures negative. The patient was maintained in the Intensive Care Unit on mechanical ventilatory support, covered with broad spectrum antibiotics, followed by the pulmonary medicine service as well as the infectious disease service. The patient had persistent problems with fever and elevated white blood cell count although the only cultures which had come back positive were that of an arterial line tip as well as one positive blood culture which was positive for Staphylococcus. This was felt to be contaminant since the patient has had no subsequent further blood cultures which were positive. The patient was eventually heparinized due to intermittent bouts with atrial fibrillation and this was ultimately converted to Coumadin for long term anticoagulation due to atrial fibrillation. The patient also during his first week had lower extremity noninvasive studies to rule out deep vein thrombosis and these studies were negative. The patient continued Levofloxacin and Flagyl for empiric coverage of presumed pneumonia. Despite the patient's white blood cell count normalizing over the first week to ten days in the hospital, he had persistent fever. Despite multiple cultures, no fever source was ultimately identified. This did resolve over the next few days. On [**2181-9-6**], through [**2181-9-7**], the patient was noted to have a maculopapular rash over his trunk, his back and his thigh with persistent fever. Both the fever and the rash ultimately did resolve without specific intervention. On [**2181-9-10**], the patient had remained hemodynamically stable. The patient's white blood cell count had normalized. His fever was essentially gone. His oxygenation was improving. However, it was felt by the pulmonary medicine service that the patient should undergo tracheostomy due to noncompliant lungs and the patient requiring high driving pressures for adequate ventilation. It was their feeling that it would be a very prolonged ventilator weaning process before he was ultimately not requiring mechanical ventilation. On [**2181-9-10**], the patient was taken to the operating room and he underwent gastrostomy placement for continued nutritional support as well as tracheostomy for continued ventilatory support by Dr. [**First Name8 (NamePattern2) 333**] [**Last Name (NamePattern1) **]. The patient tolerated these procedures well and was transported back to the Intensive Care Unit from the operating room. During this course of hospitalization, the patient also had some difficulty with loose stools, however, multiple specimens for C. difficile were sent and have been returned as negative. Over the next few days, the patient's tube feedings were increased. The patient remained on full ventilatory support. He was hemodynamically stable in sinus rhythm with a rate in the low 60s to high 50s. He was on intravenous Heparin drip for anticoagulation due to his intermittent episodes of atrial fibrillation. He had been discontinued from his antibiotics since he had completed the full courses which were recommended by the infectious disease service. On [**2181-9-13**], the patient was weaned off continuous sedation, was given pain medication and sedation on a p.r.n. basis. His ventilator was weaned to CPAP mode with significant levels of pressure support with the plan to wean this very slowly over the next few days to weeks if necessary. On [**2181-9-14**], the patient had some episodes of anxiety, questionable agitation, despite occasional doses of Ativan, Morphine and Haldol which were being dosed as needed. He was started on a Clonidine patch for better control of sedation concerns. The patient continued to be followed by the infectious disease service. On [**2181-9-15**], the patient's fever has essentially resolved. He was 99.1. His rash was stable and resolving. His pneumonia also appeared to be resolving and clinically he had been improving. It was their recommendation to hold off on any antibiotic administration unless the patient spiked a very high fever or unless there was an identifiable bacteria which required treatment. The patient continued in the Intensive Care Unit over the next few days with slow weaning of the pressure support. It is felt that the patient is making progress with weaning of the ventilator albeit very slowly and it was felt appropriate for the patient to be screened and placed in a rehabilitation facility for continued long term ventilator weaning as soon as it was felt appropriate by the Intensive Care Unit team. The patient's condition today, [**2181-9-19**], is as follows: The patient is afebrile with a temperature of 99. The patient's blood pressure is stable at 143/58, heart rate 58 and sinus bradycardia. His respiratory rate ranges from 17 to 24 breaths per minute. Oxygen saturation is 99 to 100%. His ventilator right now is on CPAP mode with 7.5 of PEEP and his pressure support was weaned today from 18 to 16. Most recent laboratory values included white blood cell count 6.5, hematocrit 30.0, platelet count 328,000. Sodium 134, potassium 4.1, chloride 99, CO2 31, blood urea nitrogen 17, creatinine 0.8, glucose 117. Prothrombin time 20.2, INR 2.7, partial thromboplastin time 32.1. Digoxin level today was 1.6. On physical examination, the patient is alert and cooperative. His head and neck examinations are unremarkable. Cardiac examination is regular rate and rhythm. His lungs are clear bilaterally to auscultation. His abdomen is benign with positive bowel sounds, nondistended. There is slight tenderness at the site of the percutaneous endoscopic gastrostomy tube placement. His extremities are warm and he moves all extremities well. DISCHARGE MEDICATIONS: 1. Lopressor 50 mg per gastrostomy tube b.i.d. to be held for heart rate of less than 50 or systolic blood pressure of less than 110. 2. Amitriptyline 75 mg per gastrostomy tube q.h.s. 3. Calcium Carbonate 500 mg per gastrostomy tube t.i.d. 4. Lansoprazole 30 mg per gastrostomy tube q.d. 5. Nystatin powder to the groin t.i.d. and p.r.n. 6. Prednisone 5 mg per gastrostomy tube q.d. 7. Amiodarone 400 mg per gastrostomy tube q.d. 8. Clonidine patch 0.3 mg transdermally q.week to be applied on Tuesday. 9. Ativan 2 mg per gastrostomy tube q.h.s. 10. Coumadin 2.5 mg per gastrostomy tube q.d. 11. Digoxin 0.125 mg per gastrostomy tube q.d. 12. Albuterol MDI q4hours p.r.n. 13. Ativan 1 mg per gastrostomy tube q6hours p.r.n. The patient is maintained on tube feeds for nutritional support which is Impact with Fiber at 70 cc/hour and the patient has been tolerating this well. DISCHARGE DIAGNOSES: 1. Respiratory failure. 2. Adult respiratory distress syndrome. 3. Systemic inflammatory response syndrome. 4. Status post coronary artery bypass graft. CONDITION ON DISCHARGE: Stable. FOLLOW-UP: The patient is to follow-up with Dr. [**Last Name (STitle) 1537**] upon discharge from rehabilitation facility at [**Telephone/Fax (1) 28544**]. [**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 1539**], M.D. [**MD Number(1) 1540**] Dictated By:[**Name8 (MD) 964**] MEDQUIST36 D: [**2181-9-19**] 16:52 T: [**2181-9-19**] 19:08 JOB#: [**Job Number 41552**] Admission Date: [**2181-8-28**] Discharge Date: [**2181-9-26**] Date of Birth: [**2115-1-26**] Sex: M Service: CARDIOTHORACIC SURGERY ADDENDUM: DISCHARGE MEDICATIONS CHANGES: 1. Lopressor 25 mg per gastrostomy tube b.i.d. 2. Tylenol #3 1 per G-tube q6h prn pain 3. Reglan 10 mg per G-tube t.i.d. 4. Dulcolax tablets 10 to 30 mg per G-tube q.d. prn On [**2181-9-20**], the patient underwent a transesophageal echocardiogram which revealed normal left ventricular ejection fraction with no vegetation or abscesses. Also at that time, the patient became tachypneic and anxious with his attempt to use a passing uric valve on his tracheostomy. This attempt was aborted to be retried at a later date by a speech therapist in the rehabilitation facility. The infectious disease service signed off the case since the patient had remained afebrile for a number of days at this time. From [**9-21**] through [**9-23**] the patient continued with a slow pressure support wean. On [**2181-9-24**], the patient again had a fever of 101.7??????. He became anxious and tachypneic. He was sedated and placed back on IMV ventilator support. He was recultured at that time. One out of two blood cultures grew coagulase positive Staphylococcus which was felt to be a contaminant. The patient has also had a subsequent blood culture which was negative. The patient at that time also had a sputum culture which grew coagulase positive Staphylococcus. Since the patient clinically improved, he remained afebrile without an elevation in his white count. He was not started on antibiotics for this new finding. On [**9-25**], the patient remained afebrile. His respiratory status had stabilized and his ventilator was changed back to pressure support ventilation. Today, [**2181-9-26**], the patient remains afebrile and hemodynamically stable, ready to be transferred to a rehabilitation facility. His physical examination is essentially unchanged from previous documentation. His most recent laboratory values are from today, [**2181-9-26**] which are as follows: White blood cell count 8.6000, hematocrit 27.6, platelet count 206. PT 13.5, INR 1.2, sodium 135, potassium 3.9, chloride 99, CO2 32, BUN 28, creatinine 0.8, glucose 137. His digoxin level is 0.9. [**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 1539**], M.D. [**MD Number(1) 1540**] Dictated By:[**Name8 (MD) 964**] MEDQUIST36 D: [**2181-9-26**] 12:50 T: [**2181-9-26**] 13:30 JOB#: [**Job Number **]

[ "428.0", "414.01", "263.9", "518.5", "V45.81", "997.3", "486", "997.1", "427.31" ]

icd9cm

[ [ [] ] ]

[ "42.23", "96.72", "88.72", "33.23", "31.1", "43.11", "96.6" ]

icd9pcs

[ [ [] ] ]

10832, 10990

9923, 10811

1427, 1832

2318, 9900

1855, 2300

184, 982

1004, 1401

11015, 14000

76,739

146,517

41719

Discharge summary

report

Admission Date: [**2128-12-15**] Discharge Date: [**2128-12-21**] Date of Birth: [**2064-5-7**] Sex: F Service: MEDICINE Allergies: Penicillins Attending:[**First Name3 (LF) 633**] Chief Complaint: severe pancreatitis Major Surgical or Invasive Procedure: ERCP PICC line placement History of Present Illness: Ms. [**Known lastname 5543**] is a 64 year-old female with PMH of hypertension, COPD, partial gastrectomy secondary to tumor of unknown 11 months ago who initially presented to [**Hospital3 **] after the development of mid-epigastric abdominal pain desribed as a [**6-22**] in severity dull, aching sensation. The pain persisted for 4 hours. No similar pain in the past. Associated with nausea and NBNB vomiting x1. . At [**Hospital1 **], the patient was noted to be febrile to 101.7 with tenderness in the LUQ and RUQ on exam. A RUQ US showed a CBD borderline dilated at 6 mm. Amylase and LFTs were elevated. Troponin was 7.8. The patient was started on IV heparin, Levaquin, Flagyl and transferred to the [**Hospital1 18**] ED for further evaluation. . On arrival at [**Hospital1 18**] initial vitals were 100.7 94 89/49 95% 4L nc. 2 large IVs were placed and the patient was given 6L of NS over her ED stay. Trop here was 0.62 (CPK/MB was 330/4) and an ECG had no ischemic changes. Seen by cards here who felt that trop rise was due to acute illness and not ischemia; IV heparin was stopped. Given zosyn and vancomycin. Seen by surgery who declined intervention. Ransons criteria gives 15% mortality. Transferred to MICU. . In the MICU, the patient appears stable with initial VS 100.4 116/62 92 27 96%. Not c/o any pain. . ROS: (+) as per HPI. Otherwise denies palp, SOB, URI Sx, recent weight loss, HA or vision changes. Notably had left shoulder and arm burning pain 2 days PTA that resoved spontaneously. Past Medical History: - "Benign" gatric tumor s/p partial gastrectomy 11 months ago. Unknown type. - Hypertension - Dyslipidemia - DMII - COPD Social History: Lives alone at home. Husband died of GBM. Has one son [**Name (NI) **] in CT. Smokes 1ppd > 50 years. No EtOH or other drug use. Family History: Uncle, aunt mother died of pancreatic cancer. Father had bladder cancer that resolved and subsequently died of lymphoma. Physical Exam: ADMISSION EXAM: Vitals - 100.4 116/62 92 27 96% General - Appears well and in NAD, sitting up in bed HEENT - PERRLA, EOMI, anicteric, MMM, OP dry CV - RRR, S1 and S2, no m/r/g Lung - CTAB, no w/r/r Abdomen - Soft, ND. TTP in RUQ to light palpation. Well healed surgical scar in midline Extremities - No gross deformity or edema Neuro - Awake, alert and oriented. Moving all extremeties DISCHARGE EXAM: Pertinent Results: Admission Labs: [**2128-12-15**] 03:15PM BLOOD WBC-17.1* RBC-4.48 Hgb-10.0* Hct-32.1* MCV-72* MCH-22.3* MCHC-31.1 RDW-15.6* Plt Ct-517* [**2128-12-15**] 03:15PM BLOOD Neuts-96.4* Lymphs-1.9* Monos-1.6* Eos-0.1 Baso-0.1 [**2128-12-16**] 04:03AM BLOOD PT-14.8* PTT-25.9 INR(PT)-1.3* [**2128-12-15**] 03:15PM BLOOD Glucose-125* UreaN-33* Creat-1.3* Na-141 K-3.7 Cl-100 HCO3-25 AnGap-20 [**2128-12-15**] 03:15PM BLOOD ALT-1041* AST-[**2091**]* CK(CPK)-330* AlkPhos-374* TotBili-0.6 [**2128-12-15**] 03:15PM BLOOD Lipase-4430* [**2128-12-15**] 03:15PM BLOOD Albumin-3.9 Calcium-6.4* Phos-6.2* Mg-1.7 [**2128-12-15**] 03:30PM BLOOD Glucose-113* Lactate-1.5 Cardiac Enzymes: [**2128-12-15**] 03:15PM BLOOD CK-MB-4 [**2128-12-15**] 03:15PM BLOOD cTropnT-0.62* [**2128-12-16**] 04:03AM BLOOD CK-MB-3 cTropnT-0.41* [**2128-12-16**] 05:55PM BLOOD CK-MB-2 cTropnT-0.44* [**2128-12-17**] 05:17AM BLOOD CK-MB-2 cTropnT-0.45* [**2128-12-18**] 06:20AM BLOOD CK-MB-1 cTropnT-0.28* Imaging: CT A/P: 1. Findings most consistent with acute cholecystitis and acute pancreatitis. The common bile duct is not dilated. However, there is focal intrahepatic biliary dilation within the left lobe with a beaded appearance of unclear etiology though morphology raises concern for cholangitis. Further evaluation with MRCP is recommended. 2. Fibroid uterus. 3. Bilateral L5 pars defects with grade II anterolisthesis of L5 on S1. CXR: Interstitial prominence, question edema or chronic lung disease ECHO:Mild symmetric left ventricular hypertrophy with preserved global and regional left ventricular systolic function. Mildly dilated right ventricle with normal systolic function. Moderate to severe mitral annular calcification with consequent mild mitral stenosis. Moderate pulmonary artery systolic hypertension. RUQ u/s: Gallbladder wall thickening in the absence of gallbladder distension, pericholecystic fluid or cholelithiasis is not specific for cholecystitis. Gallbladder wall edema may be a secondary phenomenon to the primary pancreatitis in this patient. Given the equivocality of the ultrasound appearance and the patient's use of daily aspirin, percutaneous cholecystostomy tube placement was deferred at this time MRCP:1. Evidence for mild acute pancreatitis, however, it demonstrates uniform enhancement post-contrast. Peripancreatic stranding and fluid surrounding the pancreas consistent with acute pancreatitis is significantly improved since prior CT imaging of two days prior. 2. Edema and hyperperfusion noted in the left lateral segment of the liver with a dilated peripheral intrahepatic bile duct demonstrating peri-biliary enhancement. Multiple punctate bilomas / microabscesses seen in this region. Findings are concerning for acute cholangitis. An underlying cholangiocarcinoma is unlikely but cannot be entirely excluded and short interval follow-up in three months is recommended to confirm resolution. 3. Gallbladder wall edema without abnormal mucosal hyperenhancement likely represents sequela of underlying liver and pancreas pathology. No evidence for cholelithiasis or acute cholecystitis. . ERCP: A 4cm by 5FR Plastic pancreatic stent was placed successfully to facilitate cannulation Cannulation was still unsuccessful despite the pancreatic stent due to altered anatomy and extremely stenotic papilla. Therefore, a small pre cut sphincterotomy was performed which led to successful cannulation Sphincteroplasty was then performed using a 6 mm Hurricane balloon. Small amount of pus and sludge extracted successfully using a balloon, consistent with cholangitis Pancreatic stent was then removed using a snare . CXR [**12-18**]-IMPRESSION: Interval appearance of a left lower lobe airspace process which is concerning for pneumonia. The right lung and remaining left lung continue to have a diffuse interstitial process, which may be chronic or possibly represent age related changes or small airways disease. Correlation with more remote chest films would be helpful. There is a thoracolumbar curvature which is unchanged. No pneumothorax or pulmonary edema. Overall, cardiac and mediastinal contours are stable. Results were phoned to Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] on [**2128-12-18**] at 12:45 p.m. . [**12-21**] CXR: FINDINGS: According to the IV nurse, the catheter extends to about 9 cm below the wire, which would place with tip at the level of the cavoatrial junction. No change in the appearance of the heart and lungs. . Microbiology: [**2128-12-19**] STOOL CLOSTRIDIUM DIFFICILE TOXIN A & B TEST-FINAL INPATIENT [**2128-12-17**] BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT [**2128-12-17**] BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT [**2128-12-17**] BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT [**2128-12-16**] MRSA SCREEN MRSA SCREEN-FINAL INPATIENT [**2128-12-15**] BLOOD CULTURE Blood Culture, Routine-FINAL EMERGENCY [**Hospital1 **] [**2128-12-15**] URINE URINE CULTURE-FINAL EMERGENCY [**Hospital1 **] [**2128-12-15**] BLOOD CULTURE Blood Culture, Routine-PENDING EMERGENCY [**Hospital1 **] . [**2128-12-21**] 05:21AM BLOOD WBC-7.1 RBC-3.51* Hgb-7.7* Hct-26.5* MCV-76* MCH-21.9* MCHC-28.9* RDW-16.0* Plt Ct-400 [**2128-12-20**] 07:10AM BLOOD WBC-5.2 RBC-3.60* Hgb-8.1* Hct-26.8* MCV-75* MCH-22.6* MCHC-30.3* RDW-15.8* Plt Ct-381 [**2128-12-19**] 06:05AM BLOOD WBC-5.8 RBC-3.56* Hgb-7.9* Hct-25.5* MCV-72* MCH-22.1* MCHC-30.8* RDW-16.7* Plt Ct-331 [**2128-12-18**] 06:20AM BLOOD WBC-8.7 RBC-3.76* Hgb-8.2* Hct-27.4* MCV-73* MCH-21.8* MCHC-30.0* RDW-16.5* Plt Ct-345 [**2128-12-17**] 05:17AM BLOOD WBC-11.4* RBC-4.00* Hgb-8.9* Hct-29.3* MCV-73* MCH-22.3* MCHC-30.4* RDW-15.8* Plt Ct-393 [**2128-12-16**] 04:03AM BLOOD WBC-17.1* RBC-3.74* Hgb-8.5* Hct-27.5* MCV-74* MCH-22.8* MCHC-30.9* RDW-15.7* Plt Ct-436 [**2128-12-15**] 03:15PM BLOOD WBC-17.1* RBC-4.48 Hgb-10.0* Hct-32.1* MCV-72* MCH-22.3* MCHC-31.1 RDW-15.6* Plt Ct-517* [**2128-12-15**] 03:15PM BLOOD Neuts-96.4* Lymphs-1.9* Monos-1.6* Eos-0.1 Baso-0.1 [**2128-12-21**] 05:21AM BLOOD Plt Ct-400 [**2128-12-20**] 07:10AM BLOOD Plt Ct-381 [**2128-12-19**] 06:05AM BLOOD Plt Ct-331 [**2128-12-18**] 06:20AM BLOOD Plt Ct-345 [**2128-12-18**] 06:20AM BLOOD PT-12.8 PTT-28.4 INR(PT)-1.1 [**2128-12-17**] 05:17AM BLOOD Plt Ct-393 [**2128-12-17**] 05:17AM BLOOD PT-14.0* PTT-27.8 INR(PT)-1.2* [**2128-12-16**] 04:03AM BLOOD Plt Ct-436 [**2128-12-16**] 04:03AM BLOOD PT-14.8* PTT-25.9 INR(PT)-1.3* [**2128-12-15**] 03:15PM BLOOD Plt Ct-517* [**2128-12-21**] 05:21AM BLOOD Glucose-95 UreaN-7 Creat-0.7 Na-141 K-3.6 Cl-104 HCO3-28 AnGap-13 [**2128-12-20**] 07:10AM BLOOD Glucose-91 UreaN-8 Creat-0.9 Na-142 K-3.8 Cl-105 HCO3-27 AnGap-14 [**2128-12-19**] 06:05AM BLOOD Glucose-134* UreaN-8 Creat-0.8 Na-139 K-3.0* Cl-104 HCO3-26 AnGap-12 [**2128-12-18**] 06:20AM BLOOD Glucose-55* UreaN-14 Creat-0.8 Na-139 K-3.4 Cl-103 HCO3-21* AnGap-18 [**2128-12-16**] 04:03AM BLOOD Glucose-106* UreaN-21* Creat-0.9 Na-141 K-3.5 Cl-107 HCO3-21* AnGap-17 [**2128-12-15**] 03:15PM BLOOD Glucose-125* UreaN-33* Creat-1.3* Na-141 K-3.7 Cl-100 HCO3-25 AnGap-20 [**2128-12-17**] 05:17AM BLOOD Lipase-345* [**2128-12-16**] 04:03AM BLOOD Lipase-1091* [**2128-12-15**] 03:15PM BLOOD Lipase-4430* [**2128-12-19**] 06:05AM BLOOD cTropnT-0.23* [**2128-12-18**] 06:20AM BLOOD CK-MB-1 cTropnT-0.28* [**2128-12-17**] 05:17AM BLOOD CK-MB-2 cTropnT-0.45* [**2128-12-16**] 05:55PM BLOOD CK-MB-2 cTropnT-0.44* [**2128-12-16**] 04:03AM BLOOD CK-MB-3 cTropnT-0.41* [**2128-12-15**] 03:15PM BLOOD cTropnT-0.62* [**2128-12-19**] 06:05AM BLOOD Phos-3.3 Mg-1.7 Iron-12* [**2128-12-19**] 06:05AM BLOOD calTIBC-270 Ferritn-79 TRF-208 [**2128-12-21**] 05:21AM BLOOD Vanco-17.0 [**2128-12-18**] 01:11PM BLOOD Lactate-1.2 [**2128-12-15**] 03:30PM BLOOD Glucose-113* Lactate-1.5 Brief Hospital Course: Ms. [**Known lastname 5543**] is a 64 y/o F with h.o HTN, HL, DM2, [**Hospital 11491**] transferred from OSH with Klebsiella sepsis, pancreatitis, cholangitis, and demand ischemia. . #. Klebsiella Sepsis: The patient presented with abdominal pain and was found to have an elevated lipase, elevated LFTs and imaging c/w acute pancreatitis. She was empirically started on zosyn. Blood culture from OSH positive for Klebsiella that was pan sensitive so she was changed to ceftriaxone. However, she then developed pneumonia (see below) and her antibiotics were again switched to zosyn to complete a total of 14 days of therapy. Surveillance blood cultures this admission have been no growth to date. She will need 9 more days of therapy. PICC line can be removed when antibiotic course is complete. . # gallstone pancreatitis/cholangitis: Etiology thought to be gallstone pancreatitis given borderline CBD dilation as well as hepatobiliary process e.g cholangitis vs. cholecystitis given leukocytosis, fever, hypotension and inflamed gallbladder on CT scan. Pt underwent ERCP with findings suggestive cholangitis/pus and sphinctertomy was performed. After this procedure, flagyl was added to CTX. (However, abx were eventually changed to zosyn due to HAP-see below). Pt recommended to undergo a cholecystectomy given her presentation of gallstone pancreatitis. However, pt currently with cholangitis, bacteremia, PNA and will need cardiac evaluation for demand ischemia prior to undergoing surgery. Pt stated that she would like to have her surgery done at [**Hospital3 **]. Her diet was successfully advanced to regular, low fat diabetic without complication. . #. Troponin rise/demand ischemia - The patient had an elevated troponin at the OSH that initially persisted on admission to [**Hospital1 18**] associated with left shoulder/arm burning pain. She was initially started on heparin drip, though cardiology felt that low CK-mB fraction and ECG were not concerning for ischemia and they recommended stoping heparing gtt. She was continued on her aspirin. Pt did not have any recurrent CP, palpitations, EKG non-ischemic and cardiac echo did now show any wall motion abnormalities. Troponins trended down. Pt advised to undergo continued evaluation as an outpatient prior to CCY. Pt already on a statin, but this was held given transaminitis. Can consider need for BB in outpatient setting as well as restarting statin when transaminitis improves/resolves. . #Hospital acquired PNA-pt with hypoxia, rhinorrhea, cough and CXR suggestive of LLL infiltrate. Therefore, pt was started on IV vanco/zosyn for an planned 8 day course. PICC line was placed on [**12-20**]. Pt will need to complete 5 more days of therapy. . # hypoxemia: likely related to PNA, COPD, plus possible volume overload from aggressive IVF. Pt was given nebulizers, incentive spirometry and antibiotics for PNA as above. She was allowed to autodiurese. O2 requirement on discharge was 2L. Pt does not require oxygen at baseline. . #diarrhea-likely antibiotic related. C.diff sent and negative. Improved. . #. Acute Kidney Injury - Unknown Cr at baseline. On presentation here the patient had a Cr of 1.3. This resolved with fluid resuscitation. Cr on discharge 0.7. . #. Smoking cessation: 21mg nicotine patch given and continued. . # HTN: Held home anti-hypertensives (amlodipine and HCTZ). Pt was normotensive during admission. Can consider restarting this medications after discharge if warranted. . # DM II: NIDDM, Held oral medications during admission and was given HISS. Metformin 500mg [**Hospital1 **] restarted upon discharge. . # HL: held statin given transaminitis. This should be resumed as soon as transaminitis improves/resolves. . # COPD: Continued home albuterol. Resume advair upon discharge. Atrovent nebs were added during period of acute PNA. . #DVT PPX-hep SC TID Medications on Admission: Advair 500mcg 1 puff daily Proventil 90mcg 2 puffs [**Hospital1 **] Metformin 500mg PO BID Calcitriol 0.5mcg PO daily HCTZ 25mg PO daily Amlodipine 5mg PO daily Simvastatin 30mg PO PM ASA 81mg PO daily Reglan 10mg PO TID/PRN Omeprazol 20mg Po daily Trazodone 25mg PO QHS Iron pills 325mg PO daily Discharge Medications: 1. Advair Diskus 500-50 mcg/dose Disk with Device Sig: One (1) Inhalation once a day. 2. calcitriol 0.5 mcg Capsule Sig: One (1) Capsule PO DAILY (Daily). 3. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 4. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 5. trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as needed for Insomnia. 6. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. nicotine 21 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr Transdermal DAILY (Daily). 8. heparin, porcine (PF) 10 unit/mL Syringe Sig: One (1) ML Intravenous PRN (as needed) as needed for line flush. 9. piperacillin-tazobactam-dextrs 4.5 gram/100 mL Piggyback Sig: One (1) Intravenous Q8H (every 8 hours) for 9 days. 10. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours). 11. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q4H (every 4 hours) as needed for Wheezing/SOB. 12. vancomycin in D5W 1 gram/200 mL Piggyback Sig: One (1) Intravenous Q 12H (Every 12 Hours) for 5 days. 13. polyvinyl alcohol-povidone 1.4-0.6 % Dropperette Sig: [**2-15**] Drops Ophthalmic PRN (as needed) as needed for dry eyes. 14. metformin 500 mg Tablet Sig: One (1) Tablet PO twice a day. Discharge Disposition: Extended Care Facility: [**Hospital3 13990**] Health Care Center - [**Location (un) 5110**] Discharge Diagnosis: acute gallstone pancreatitis cholangitis pneumonia demand ischemia Klebsiella sepsis hypoxia COPD Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were transferred from another hospital with gallstone pancreatitis and cholangitis (infection in your bile ducts). You were found to have an bacterial infection in your blood and pneumonia. For this, you were initially treated in the ICU. You underwent an ERCP where an area of narrowing was opened. You were given bowel rest, antibiotics, and IV fluids and your symptoms improved. You will need to continue antibiotic therapy for your pneumonia, cholangitis, and blood stream infection after discharge. -In addition, you were found to have some strain on your heart during admission. You will need to have an evaluation by your PCP [**Name Initial (PRE) **]/or cardiology such as a stress test after discharge from rehab. -We recommend that you have your gallbladder removed. However, you will need to heal from your pancreatitis, cholangitis, and pneumonia first. In addition, you should have a pre-operative work up before surgery. You expressed that you would like to have your surgery done at [**Hospital3 **]. . Medication changes: 1.start IV vancomycin for 5 more days 2.start IV zosyn for 9 more days 3.stop simvastatin for now. Please discuss with your PCP when you may resume this medication 4.stop HCTZ and amlodipine for now as your blood pressures have been normal. Please discuss with your PCP when to resume these medications if needed. . Please take all of your medications as prescribed and follow up with the appointments below. Followup Instructions: PCP: [**Name10 (NameIs) 357**] call your PCP [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 18359**] at [**Telephone/Fax (1) 18360**] after discharge from rehab to schedule a follow up appointment . Please be sure to call your surgeon at [**Hospital3 **] after discharge from rehab to schedule evaluation for potential cholecystectomy.

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Discharge summary

report

Admission Date: [**2108-12-23**] Discharge Date: [**2108-12-30**] Date of Birth: [**2030-4-19**] Sex: M Service: MEDICINE Allergies: Augmentin / Atorvastatin Attending:[**First Name3 (LF) 2704**] Chief Complaint: Transfer for catheterization, Chest Pain, NSTEMI Major Surgical or Invasive Procedure: Coronary catheterization Pacemaker placemenent History of Present Illness: **Patient has severe dementia and most of the history was obtained via medical records 78 yo M with a history of CAD s/p three-vessel CABG in [**2099**] (LIMA-D1, SVG-D3 and SVG-OM2), HTN, and hypercholesterolemia who was transferred from an OSH tonight for planned cardiac cath in the am for a NSTEMI. He was at a casino on [**12-22**] with his 2 sons when he was noted to have chest pain while climbing stairs. He took 2 SL nitros that did not resolve the pain. He took a 3rd SL NTG when EMS arrived resolved CP. At [**Hospital6 33**] he was found to have ST-depressions in V1-V4 and borderline/minimal elevations in III/aVF. He was started on heparin and integrillin drips and plavix as well. Labs at the OSH were significant for a CK 1350, CK-MB 106.2, and troponin-I 2.66. He was transferred to [**Hospital Ward Name 121**] 3 for cardiac catheterization in the morning. Past Medical History: CAD, s/p MI, CABG [**2099**], Cath [**2102**] w/o intervention (TO OM2) Dementia HTN Hypercholesterolemia GOUT Social History: By report, no alcohol, tobacco, drugs. Family History: non-contributory Physical Exam: (on admission) VS - 100.4 hr 56 bp 96/39 rr 20 sat 95 4LNC Gen: WDWN elderly aged male in NAD. Alert, A+O x 1. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. MM DRY. Neck: Supple with no JVD sitting at 45 deg angle. CV: RR, normal S1, S2. Distant heart sounds. No m/r/g. No thrills, lifts. No S3 or S4. Chest: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. Abd: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. Ext: No c/c/e. No femoral bruits. Skin: No stasis dermatitis, ulcers, scars, or xanthomas. Neuro: CN 2-12 intact; strength 5/5 throughout; oriented to self; thinks he is in a firestation. [**Month (only) **] / [**2030-10-13**]. no deficit in consciousness. unsure of who current president is but he knows that he "is in the [**Location (un) 13743**]" . Pulses: Right: Femoral 1+ DP faint + doppler PT faint + doppler Left: Femoral 1+ DP faint + dopplerPT faint + doppler Pertinent Results: Coronary cath ([**12-24**]): severe 3VD with patent LIMA to D1 filling LAD, Cx and RCA but Cx compromised by intervening disease not readily amenable to PCI and patent SVG to D3 LMCA: total occlusion at ostium LAD: fills by LIMA-D1 --> small intramyocardial vessel LCx: small OM 1 fills via flow from LIMA-D1 to LM with intersposed heavily calcified 90% lesion RCA: total occlusion ostial; collaterals from L to PDA SVG-OM2 TO SVG-D3 patent LIMA-D1 patent . CXR AP ([**12-24**]): moderate cardiomegaly. Haziness of the perihilar region and engorged vasculature is consistent with moderate pulmonary edema. There is no pneumothorax. There is a small left pleural effusion. Patient is post median sternotomy and CABG. . Echo ([**2108-12-25**]): mildly dilated left atrium normal left ventricular cavity size Overall left ventricular systolic function mildly depressed with probably basal inferoseptal, basal inferior/inferolateral hypokinesis LVEF= ?45 % Right ventricular chamber size and free wall motion normal moderate pulmonary artery systolic hypertension . CXR AP ([**11-28**]): There has been interval placement of a dual-lead pacemaker device with the distal leads overlying the right atrium and right ventricle. The patient is status post median sternotomy and CABG. The heart size is borderline. The aorta is uncoiled and atherosclerotic. Trachea is midline. There is mild blunting of the costophrenic angles bilaterally which may represent tiny effusions or pleural thickening. There is no pneumothorax or focal consolidation. There is minimal prominence of the pulmonary vasculature, greatly improved from [**2108-12-24**]. IMPRESSION: Pacemaker placement as above. No pneumothorax. Mild residual prominence of the pulmonary vasculature. . Enzyme peaks: CK 1350, Trop 3.72. Brief Hospital Course: On admission to [**Hospital1 18**] pt was admitted to the [**Hospital1 1516**] service on [**Hospital Ward Name 121**] 3. On presentation, he was CP free and did not complain of shortness of breath. A prior EKG was significant for the presence of 1st degree conduction delay with RBBB. At 12 am, the patient was noted to have a HR in the 30s on telemetry and was found to be in CHB. SBPs were in the 90s and the pt was assymptomatic. His HR increased back up to the 50s without intervention. Half an hour later, the HR dipped back down to the 40s with a BP 70/30. He received IVFs wide open and was given atropine 1 mg X 2. His SBPs then improved to the 90s with a HR in the 40-50s. He remained assymptomatic without chest pain, shortness of breath, and lightheadedness. At the time of presentation to the CCU, the patient had received a total of 2 L IVFs. . CCU team course: The following problems were [**Name2 (NI) 13744**]: # CAD s/p NSTEMI The enxymes peaked at CK 1350, Trop 3.72. which he had on admission. Has remained CP free since presentation to OSH. integrillin/heparin gtts were continued until cath the morning after admission to the [**Hospital1 18**]. In the cath lab he was found to have severe 3VD with patent LIMA to D1 filling LAD, Cx and RCA but Cx compromised by intervening disease not readily amenable to PCI and patent SVG to D3. Therefore the plan was to optimize medical management with asa, plavix, and ezetimibe (statin allergy). Low dose BB (motoprolol 12.5mg) was added when EP agreed to start from rhythm standpoint (see below). Pt was monitored on telemetry throughout stay without any signs of recurrent ischemia. . # Rhythm Pt had pre-existing RBBB from EKGs in [**2102**] but as mentioned above was found to be in complete heart block with alternating junctional and idioventricular escape rhythm. HR and BPs did not respond considerably to atropine X 2 but SBPs improved with total of 2L IVFs. On presentation to the CCU, the pt was assymptomatic with HR in the mid 40-50s, SBPs in the 90-100s, and MAPs in the upper 50's. Likely that CHB was related to recent ischemic event. Therefore EP wanted to manage conservatively since they felt if ischemia resolved after cardiac event. Given relative hemodynamic stability of patient and relatively stable escape rhythm, did not place temporary transvenous pacing wire which was discussed with EP fellow and interventional cardiologist on call. Atropine and dopamine was kept at the bedside and with trancutaneous pacer pads but never had to be used. Pt was monitored on telemetry and spent less and less time in CHB. Therefore a low dose BB was added but then ended up spending more time in CHB. EP at this time (day4) decided to start place a permanent pacemaker which was done on [**2108-12-28**]. The evening following the procedure the pt had a few more events of CHF without appropriate pacing of the pacer; therefore appropriate adjustments were made by EP the following day (day prior to d/c) . # [**Name (NI) **] Pt appeared in acute systolic heart failure initially when arriving to the CCU. He was diuresed gently over the next few days with good effect and when euvolemic did not require any additional doses of lasix po. Pt had an echo which demonstrated overall left ventricular systolic function mildly depressed with probably basal inferoseptal, basal inferior/inferolateral hypokinesis and a LVEF of appr 45 %. Supplemental O2 was weaned throughout the hospital stay and when discharged pt was off supplemental O2. . # ID Pt did have some very low grade temps (99-100) with a slightly elevated WBC. UA, UC, sputum cx, blood cx, were all negative however. The plan was to reculture if he re-spiked [**Doctor First Name **] he never did. . # Neuro/Dementia/Agitation Pt is at baseline AO X 1. Home meds aricept and namenda, and clonazepam qhs were continued with good effect. The first 2 nights pt did not get his clonazepam and was very confused and agitated and therefore required a sitter for safety. . # HTN - continued BB as above . # Hypercholesterolemia - Continued ezetimibe due to allergy to statin . Medications on Admission: Lisinopril 10mg Isosorbide mononitrate long acting 60 mg daily Niaspan 1000 mg [**Hospital1 **] Metoprolol 50 mg TID Clonazepam 0.5 mg daily Norvasc 10 mg daily Trazadone 100 mg daily ASA 325 mg daily Zetia 10 mg daily Aricept 5 mg daily Namenda 5 mg [**Hospital1 **] Discharge Medications: 1. Niacin 500 mg Capsule, Sustained Release Sig: Two (2) Capsule, Sustained Release PO BID (2 times a day). 2. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Donepezil 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 4. Trazodone 100 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 5. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 6. Memantine 5 mg Tablet Sig: One (1) Tablet PO bid (). 7. Clonazepam 0.5 mg Tablet Sig: 1-2 Tablets PO QHS (once a day (at bedtime)). 8. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). Disp:*30 Tablet, Chewable(s)* Refills:*2* 9. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). Disp:*30 Tablet(s)* Refills:*2* 10. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Sublingual prn: please take one tablet for chest pain, may repeat every 5 minutes x2 please call 911 if does not resolve . Disp:*30 tabs* Refills:*2* Discharge Disposition: Home With Service Facility: [**Hospital3 **] VNA Discharge Diagnosis: Primary diagnosis: Non-ST elevation myocardial infarction Complete heart block with placement of pacemaker Discharge Condition: Stable Discharge Instructions: You were admitted to [**Hospital1 18**] with an Non-ST elevation myocardial infarction. Please take your medications as prescribed and specifically: - please stop taking Lisinopril and Isosorbide mononitrate - please start taking plavix - please take 81mg of aspirin instead of 325mg If you develop chest pain, jaw pain, or chest pressure with pain radiating into arm, or if you for any reason become concerned about your medical condition please call 911 or present to nearest ED. - We also gave you Nitroglycerin tablets to take if you experience chest pain, please call 911 or your doctor if chest pain recurs even if it dissapears with nitroglycerine **DO NOT STOP TAKING THE ASPIRIN OR PLAVIX UNLESS INSTRUCTED TO DO SO BY YOUR CARDIOLOGIST EVEN IF ANOTHER DOCTOR TELLS YOU TO** - Please set up follow-up appointments with the electrophysiology device clinic and Dr. [**First Name (STitle) 1870**] as discussed Followup Instructions: - Please set up follow-up appointments with the electrophysiology device clinic to be seen within one week ([**Telephone/Fax (1) **]) and Dr. [**First Name (STitle) **] ([**Telephone/Fax (1) **] or [**Telephone/Fax (1) **]as discussed - please set up an appointment with your primary care provider, [**Last Name (NamePattern4) **]. [**First Name (STitle) **] [**Telephone/Fax (1) 13745**].

[ "294.8", "428.21", "410.71", "401.9", "274.9", "426.0", "272.0", "428.0", "414.01", "V45.81" ]

icd9cm

[ [ [] ] ]

[ "37.83", "99.20", "88.55", "37.72", "88.52", "37.22" ]

icd9pcs

[ [ [] ] ]

9897, 9948

4460, 8576

336, 384

10099, 10108

2641, 4437

11072, 11465

1496, 1514

8894, 9874

9969, 9969

8602, 8871

10132, 11049

1529, 2622

248, 298

412, 1288

9988, 10078

1310, 1423

1439, 1480

59,333

121,490

53995

Discharge summary

report

Admission Date: [**2149-3-13**] Discharge Date: [**2149-3-26**] Date of Birth: [**2097-11-13**] Sex: M Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 6088**] Chief Complaint: Type B aortic dissection Major Surgical or Invasive Procedure: [**2149-3-13**]: 1. Bilateral femoral artery exposure with catheter placement in the proximal thoracic aorta. 2. Endovascular aortic fenestration using Pioneer catheter. 3. Intravascular ultrasound. 4. Thoracic aortic stent graft. 5. Right renal artery stenting. 6. Right iliac, femoropopliteal thromboembolectomy. 7. Right lower extremity 4-compartment fasciotomy. 8. Right thigh complete fasciotomy. History of Present Illness: 51 M presents as an OSH transfer for Type B aortic dissection and pulseless RLE. Patient presented to [**Hospital6 31672**] with abdominal pain radiating to the back associated with decreased sensation of his lower extremities. The progressed to RLE paresis. In the ED here, at [**Hospital1 18**] ,he was found to have no pulses of his RLE with a cool foot. CTA demonstrates a type B aortic dissection from the take-off L subclavian with a concentric filling defect within the proximal left subclavian artery. The dissection extends throughout the thoracic aorta. The true and false lumen enhance equally. The dissection extends into the upper abdomen and extends into both iliac afteries. There is moderate narrowing of the left EIA. There is complete occlusion of the distal right CIA. There is reconstitution of the distal R internal iliac artery. There is small narrowing of the lumen. There is a dissection extending into the right renal artery with enhancement of the right kidney. The dissection likely extends into the left kidney with minimal enhancement. the left renal artery does reconstitute distal to the proximal severe narrowing. He is taken emergently to the OR for repair. Past Medical History: None per patient (was not under care of physician [**Name Initial (PRE) **]) Social History: 1ppd smoker. + EtOH (pt unclear on how much). Denies drug use. living independently prior to this admission Family History: unknown Physical Exam: VSS, afebrile Gen: Thin, frail male, appearing older than stated age. Card: RRR Lungs: CTA bilat Abd: Soft, no masses or tenderness Neuro: Alert and oriented x 3, Full strength in the bilateral upper extremities. No movement in bilateral lower extremities - 0/5 strength. No deficits to light touch, pinprick, cold sensation, vibratory sense, proprioception in bilateral upper extremities. No sensation, including proprioception in the bilateral lower extremities. Senory level is just above umbilicus, approximately T8-T9. Extremities: Bilateral fasciotomy sites healing well - packed with wet to dry. Pertinent Results: [**2149-3-13**] 12:41PM BLOOD Glucose-135* UreaN-10 Creat-1.0 Na-137 K-5.8* Cl-107 HCO3-20* AnGap-16 [**2149-3-14**] 01:45AM BLOOD Glucose-109* UreaN-12 Creat-1.0 Na-142 K-3.9 Cl-111* HCO3-24 AnGap-11 [**2149-3-15**] 01:39AM BLOOD Glucose-127* UreaN-20 Creat-1.9* Na-142 K-4.4 Cl-107 HCO3-21* AnGap-18 [**2149-3-15**] 02:15PM BLOOD Glucose-118* UreaN-24* Creat-2.6* Na-142 K-4.1 Cl-107 HCO3-21* AnGap-18 [**2149-3-16**] 11:33AM BLOOD Glucose-118* UreaN-37* Creat-4.1* Na-142 K-4.3 Cl-108 HCO3-23 AnGap-15 [**2149-3-17**] 12:19AM BLOOD Glucose-130* UreaN-48* Creat-5.2*# Na-140 K-4.3 Cl-106 HCO3-22 AnGap-16 [**2149-3-18**] 05:10AM BLOOD Glucose-120* UreaN-81* Creat-6.2* Na-138 K-5.1 Cl-103 HCO3-23 AnGap-17 [**2149-3-19**] 02:25AM BLOOD Glucose-116* UreaN-99* Creat-6.9* Na-137 K-5.2* Cl-102 HCO3-22 AnGap-18 [**2149-3-20**] 04:50AM BLOOD Glucose-108* UreaN-116* Creat-6.8* Na-137 K-4.8 Cl-99 HCO3-25 AnGap-18 [**2149-3-21**] 06:04AM BLOOD Glucose-117* UreaN-127* Creat-6.5* Na-135 K-4.3 Cl-97 HCO3-25 AnGap-17 [**2149-3-22**] 08:30AM BLOOD Glucose-110* UreaN-129* Creat-5.5* Na-136 K-4.2 Cl-94* HCO3-27 AnGap-19 [**2149-3-23**] 07:45AM BLOOD Glucose-120* UreaN-117* Creat-4.1*# Na-135 K-4.4 Cl-96 HCO3-27 AnGap-16 [**2149-3-24**] 06:40AM BLOOD Glucose-112* UreaN-96* Creat-3.1* Na-136 K-4.7 Cl-99 HCO3-28 AnGap-14 [**2149-3-25**] 06:10AM BLOOD Glucose-104* UreaN-75* Creat-2.2* Na-136 K-4.6 Cl-100 HCO3-29 AnGap-12 [**2149-3-26**] 06:50AM BLOOD Glucose-112* UreaN-57* Creat-1.7* Na-139 K-5.0 Cl-102 HCO3-27 AnGap-15 [**2149-3-13**] 06:16AM BLOOD WBC-18.6* RBC-3.78* Hgb-12.0* Hct-36.9* MCV-98 MCH-31.7 MCHC-32.4 RDW-12.2 Plt Ct-345 [**2149-3-14**] 01:45AM BLOOD WBC-10.0 RBC-2.94* Hgb-9.3* Hct-28.3* MCV-96 MCH-31.6 MCHC-32.8 RDW-13.6 Plt Ct-208 [**2149-3-15**] 01:39AM BLOOD WBC-12.7* RBC-3.42* Hgb-10.6* Hct-32.4* MCV-95 MCH-31.0 MCHC-32.7 RDW-14.8 Plt Ct-141* [**2149-3-16**] 05:20AM BLOOD WBC-11.0 RBC-2.98* Hgb-9.2* Hct-28.4* MCV-95 MCH-30.8 MCHC-32.3 RDW-14.7 Plt Ct-135* [**2149-3-17**] 12:19AM BLOOD WBC-13.6* RBC-2.94* Hgb-8.8* Hct-27.9* MCV-95 MCH-30.1 MCHC-31.7 RDW-14.4 Plt Ct-162 [**2149-3-18**] 05:10AM BLOOD WBC-11.7* RBC-2.85* Hgb-8.8* Hct-27.8* MCV-98 MCH-30.9 MCHC-31.6 RDW-14.5 Plt Ct-168 [**2149-3-19**] 02:25AM BLOOD WBC-11.0 RBC-3.13* Hgb-9.6* Hct-30.4* MCV-97 MCH-30.8 MCHC-31.8 RDW-14.5 Plt Ct-221 [**2149-3-20**] 04:50AM BLOOD WBC-12.4* RBC-3.07* Hgb-9.4* Hct-28.9* MCV-94 MCH-30.6 MCHC-32.5 RDW-13.7 Plt Ct-287 [**2149-3-21**] 06:04AM BLOOD WBC-15.0* RBC-2.91* Hgb-9.0* Hct-27.1* MCV-93 MCH-30.8 MCHC-33.2 RDW-13.6 Plt Ct-348 [**2149-3-22**] 08:30AM BLOOD WBC-16.5* RBC-3.18* Hgb-9.7* Hct-30.8* MCV-97 MCH-30.6 MCHC-31.7 RDW-14.1 Plt Ct-446* [**2149-3-23**] 07:45AM BLOOD WBC-16.3* RBC-3.03* Hgb-9.3* Hct-29.5* MCV-97 MCH-30.8 MCHC-31.6 RDW-14.0 Plt Ct-552* [**2149-3-24**] 06:40AM BLOOD WBC-17.6* RBC-2.99* Hgb-9.0* Hct-29.3* MCV-98 MCH-30.2 MCHC-30.8* RDW-13.8 Plt Ct-645* [**2149-3-25**] 06:10AM BLOOD WBC-18.4* RBC-3.03* Hgb-9.2* Hct-29.8* MCV-99* MCH-30.4 MCHC-30.9* RDW-13.7 Plt Ct-730* [**2149-3-26**] 06:50AM BLOOD WBC-18.8* RBC-2.69* Hgb-8.1* Hct-26.8* MCV-100* MCH-30.2 MCHC-30.4* RDW-13.9 Plt Ct-744* [**2149-3-13**] 12:41 pm MRSA SCREEN Source: Nasal swab. **FINAL REPORT [**2149-3-15**]** MRSA SCREEN (Final [**2149-3-15**]): No MRSA isolated. DUPLEX DOP ABD/PEL LIMITED Study Date of [**2149-3-15**] 1:29 PM Bilaterally symmetric systolic flow is visualized in right and left main renal arteries and intrarenal arteries with no son[**Name (NI) 5326**] evident diastolic flow, consistent with high-resistance parenchymal beds. Appropriate flow noted in bilateral main renal veins. These findings suggest high parenchymal resistance may be due to acute tubular necrosis or other intrinsic renal interstitial disease or edema in bilateral kidneys. UNILAT LOWER EXT VEINS LEFT Study Date of [**2149-3-22**] 11:57 AM No evidence of deep venous thrombosis in the left lower extremity. RENAL U.S. Study Date of [**2149-3-22**] 11:58 AM Patent renal arteries bilaterally with unchanged waveforms and velocities. Unchanged echogenic appearance of both kidneys. No hydronephrosis. [**2149-3-22**] 5:54 pm URINE Source: Catheter. **FINAL REPORT [**2149-3-24**]** URINE CULTURE (Final [**2149-3-24**]): NO GROWTH. [**2149-3-15**] 4:49 pm BLOOD CULTURE Source: Line-rij. **FINAL REPORT [**2149-3-21**]** Blood Culture, Routine (Final [**2149-3-21**]): NO GROWTH. [**2149-3-15**] 4:28 pm BLOOD CULTURE Source: Line-16 guage. **FINAL REPORT [**2149-3-21**]** Blood Culture, Routine (Final [**2149-3-21**]): NO GROWTH. Brief Hospital Course: Mr. [**Known lastname 110706**] was admitted with an extensive type B dissection, cool, pulseless RLE and compartment syndrome and was taken emergently to the OR on [**3-13**] where he underwent: 1. Bilateral femoral artery exposure with catheter placement in the proximal thoracic aorta. 2. Endovascular aortic fenestration using Pioneer catheter. 3. Intravascular ultrasound. 4. Thoracic aortic stent graft. 5. Right renal artery stenting. 6. Right iliac, femoropopliteal thromboembolectomy. 7. Right lower extremity 4-compartment fasciotomy. 8. Right thigh complete fasciotomy. Post operatively he was taken to the CVICU intubated. He was montiored closely. His creatinine and CKs were rising and he was started on a bicarb drip for rhabdomyolysis. On POD 1 it was noted that he was not moving his lower extremities. His lumbar drain remained in place and was functioning well. Neurosurgery and neurology got involved and felt that the pt had a spinal cord infarct around the level of t8-t9. With his rising SCr and CKs, he was aggressively hydrated. On [**3-16**] a nephrology consult was obtained for acute kidney injury. They suggested that we diurese with lasix and continue to monitor, feeling that his kidney's would recover. On [**3-19**] his lumbar drain was removed by neurosurgery. His creatinine began trending down and his urine output remained great. His meds were oralized and he tolerated a regular diet. VAC dressings were applied to his fasciotomy sites. On [**3-20**] he was transfered to the VICU. He continued to be monitored closely. He worked with PT and OT and began working on transfers to a wheel chair. His creatinine continued to improve and the renal team signed off, letting the patient know that they expected him to make a full renal recovery. On [**3-25**] his indwelling foley catheter was removed and straight cath-ing q4h was initiated. The pt began teaching on self-cathing. Of note his white blood cell count was elevated, but there was no source of infection found and no fevers. This was thought to be benign. Mr. [**Known lastname 110706**] was stable for discharge to a rehab facility on [**3-26**]. He will continue to pt and ot and catherterization training. He will have wound VACs to his fasciotomy sites at rehab and will follow up in vascular clinic in 1 week for wound checks. Medications on Admission: none Discharge Medications: 1. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) injection injection Injection [**Hospital1 **] (2 times a day). 3. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. metoprolol tartrate 100 mg Tablet Sig: One (1) Tablet PO twice a day: hold for hr<50, sbp<95. 5. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. 6. nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr Transdermal DAILY (Daily): decrease dose as indicated. 7. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 8. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as needed for sob/wheezing. 9. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO every eight (8) hours. 10. ipratropium-albuterol 18-103 mcg/actuation Aerosol Sig: [**12-9**] Puffs Inhalation Q6H (every 6 hours) as needed for SOB. 11. docusate sodium 100 mg Capsule Sig: Two (2) Capsule PO HS (at bedtime). 12. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed for constipation. 13. senna 8.6 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for constipation. 14. STRAIGHT CATH EVERY 4 HOURS please continue teaching pt to self straight cath Discharge Disposition: Extended Care Facility: [**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**] Discharge Diagnosis: 1. Type B thoracoabdominal aortic dissection, acute with visceral and right leg malperfusion 2. Bilateral lower extremity paralysis secondary to spinal cord infacrction at level of T8-T9 3. Acute kidney injury - resolving 4. HTN Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair.([**Doctor Last Name **] lift - pt is paraplegic) Discharge Instructions: Division of Vascular and Endovascular Surgery Discharge Instructions You were admitted with a large dissection in your aorta which started high in the chest, and went down through your abdomen and into the iliac arteries in your lower extremities. You underwent emergent surgery where we put a stent graft into your aorta, as well as your right renal artery, and opened your right iliac and femoropopliteal artery to remove thrombus(clot). You then had fasciotomies of both legs (cuts to release pressure). Unfortunately as a result of your dissection, you had a spinal cord infarction and you're now paralyzed from the level of T8-T9, down (your lower extremities). Medications: ?????? Take Aspirin 325mg (enteric coated) once daily ?????? Do not stop Aspirin unless your Vascular Surgeon instructs you to do so. ?????? You were started on numerous new medications that you will need to take for the rest of your life. Do not stop any medications without talking to your PCP or Vascular doctor ?????? You make take Tylenol or prescribed pain medications for any post procedure pain or discomfort What to expect when leave: You are going to a rehabilitation facility where you will get PT/OT and medical care. It is normal to feel tired and have a decreased appetite, your appetite will return with time ?????? Drink plenty of fluids and eat small frequent meals ?????? It is important to eat nutritious food options (high fiber, lean meats, vegetables/fruits, low fat, low cholesterol) to maintain your strength and assist in wound healing ?????? To avoid constipation: eat a high fiber diet and use stool softener while taking pain medication What activities you can and cannot do: Your groin incisions 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 Your leg fasciotomy sites will be dressed with wound VACs to help with closure. ?????? What to report to office: ?????? Temperature greater than 101.5F for 24 hours ?????? New or increased drainage from incision or white, yellow or green drainage from incisions ?????? Bleeding from groin puncture site SUDDEN, SEVERE BLEEDING OR SWELLING (Groin puncture site or incision) ?????? Lie down, keep leg straight and have someone apply firm pressure to area for 10 minutes. If bleeding stops, call vascular office. If bleeding does not stop, call 911 for transfer to closest Emergency Room. Followup Instructions: Vascular Surgery [**Hospital1 18**] [**Hospital Ward Name **] - [**Hospital Unit Name **] [**Hospital Unit Name **] Provider: [**Name10 (NameIs) 251**] [**Last Name (NamePattern4) 1490**], MD Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2149-4-3**] 9:30 Completed by:[**2149-3-26**]

[ "441.03", "401.9", "518.81", "305.1", "584.9", "728.88", "998.89", "E849.7", "729.72", "E879.8" ]

icd9cm

[ [ [] ] ]

[ "38.97", "01.18", "83.14", "39.78", "96.72", "00.41", "00.46", "39.50", "96.04", "38.91", "39.90", "88.47" ]

icd9pcs

[ [ [] ] ]

11397, 11494

7604, 9941

329, 737

11767, 11767

2859, 7581

14487, 14775

2210, 2219

9996, 11374

11515, 11746

9967, 9973

11992, 13962

13988, 14464

2234, 2840

265, 291

765, 1968

11782, 11968

1990, 2068

2084, 2194

52,350

142,185

32559

Discharge summary

report

Admission Date: [**2105-7-14**] Discharge Date: [**2105-7-21**] Date of Birth: [**2073-1-20**] Sex: M Service: MEDICINE Allergies: Clindamycin Attending:[**First Name3 (LF) 348**] Chief Complaint: dyspnea at OSH, now intubated Major Surgical or Invasive Procedure: bronchoscopy chest tube placement and removal pigtail catheter placement and removal History of Present Illness: 32 M w/ h/o HIV, IV drug use, ETOH, initially admitted to SICU from OSH due to empyema. The patient presented on [**7-3**] for chest pain and shortness of breath and was admitted to the medical service there where he was discovered to have positive blood cxs (GPCs). He was started on IV Abx but continued to clinically worsen. During his hospital course at [**Hospital1 1562**] he developed persistent fevers, sepsis, and MODS. He was intubated on HD1. Bilat CT's were placed on [**7-13**] [**1-20**] a concern for right sided endocarditis and bilateral pleural effusions. Additionally he has had both TTE and TEE that have been negative for evidence of endocarditis at [**Hospital1 1562**]. The patient was then transferred to [**Hospital1 18**] for further management. Prior to his transfer from [**Hospital1 **], both of his chest tubes were removed. On the floor, the patient is hemodynamically stable, but avoids eye contact and is dismissive of the physical exam. Vitals are 99.6, 125/63, 85, 22 and 97% on 3L. Past Medical History: IV drug abuse Bipolar d/o ETOH abuse HIV Social History: Ex-Smoker, IV drug user, EtOH Family History: unknown Physical Exam: Vitals: 99.6, 125/63, 85, 22 and 97% on 3L Gen: uncooperative, dismissive of the exam, avoids eye contact, NAD [**Name2 (NI) 4459**]: PERLLA, [**Name (NI) 3899**], dry MM, oropharynx not visualized due to patient non-compliance, healed cut on left upper lip Neck: supple, no LAD, no JVD CV: RRR, nl S1/S2, no m/r/g Resp: uncooperative, would not take deep breaths or sit forward Abd: +BS, soft, NT, slightly distended Extrem: no c/c/e, 2+ DP pulses, no Osler's nodes, [**Last Name (un) 1003**] lesions, or splinter hemorrhages Neuro: not willing to follow commands, sitting with legs crossed Psych: flat and inappropriate affect, avoids eye contact, paucity of speech Pertinent Results: BLOOD .WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct [**2105-7-20**] 05:41 8.2 3.18* 9.4* 27.2* 85 29.5 34.6 13.6 569 RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap [**2105-7-20**] 05:41 [**Telephone/Fax (2) 75911**] 3.5 100 29 9 ENZYMES & BILIRUBIN ALT AST LD(LDH) CK(CPK) AlkPhos Amylase TotBili DirBili [**2105-7-18**] 07:20 22 19 123 0.9 HEMATOLOGIC calTIBC Ferritn TRF [**2105-7-17**] 02:16 126* >[**2094**] 97* Source: Line-picc HEPATITIS HBsAg HBsAb HBcAb HAV Ab IgM HAV [**2105-7-19**] 06:00 NEGATIVE NEGATIVE Source: Line-picc HEPATITIS C SEROLOGY HCV Ab [**2105-7-16**] 02:49 POSITIVE* ___________________ . URINE . [**2105-7-14**] 10:22PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.019 [**2105-7-14**] 10:22PM URINE Blood-NEG Nitrite-NEG Protein-25 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG [**2105-7-14**] 10:22PM URINE RBC-0-2 WBC-[**5-28**]* Bacteri-MOD Yeast-NONE Epi-0-2 . PLEURAL FLUID . [**2105-7-15**] 01:36PM PLEURAL WBC-1056* Hct,Fl-7* Polys-71* Bands-2* Lymphs-20* Monos-0 Eos-2* Macro-5* [**2105-7-15**] 01:36PM PLEURAL TotProt-4.4 Glucose-20 LD(LDH)-80 . MICRO . MRSA SCREEN (Final [**2105-7-17**]): No MRSA isolated. . [**2105-7-14**] 10:22 pm SPUTUM Source: Endotracheal. GRAM STAIN (Final [**2105-7-15**]): >25 PMNs and <10 epithelial cells/100X field. 1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS AND CLUSTERS. RESPIRATORY CULTURE (Final [**2105-7-17**]): Commensal Respiratory Flora Absent. YEAST. SPARSE GROWTH. . URINE CULTURE (Final [**2105-7-16**]): NO GROWTH. . [**2105-7-15**] 1:36 pm PLEURAL FLUID GRAM STAIN (Final [**2105-7-15**]): NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. FLUID CULTURE (Final [**2105-7-18**]): NO GROWTH. ANAEROBIC CULTURE (Preliminary): NO GROWTH. . [**2105-7-16**] 3:11 pm CATHETER TIP-IV WOUND CULTURE (Final [**2105-7-18**]): No significant growth. . [**2105-7-18**] 7:43 am IMMUNOLOGY HCV VIRAL LOAD (Pending) . [**2105-7-18**] 7:43 am SEROLOGY/BLOOD RAPID PLASMA REAGIN TEST (Pending) . Blood Culture ([**7-14**], [**7-18**], [**7-19**]) - negative to date . [**2105-7-19**] 7:27 am STOOL CLOSTRIDIUM DIFFICILE TOXIN A & B TEST negative . IMAGING . Chest CT scan [**2105-7-13**] - OSH read Impression: 3 x 3 cm anterior LUL loculated effusion, 3 x 5 cm posterior ring enhancing lesion suspicious for empyema. Multiple smaller right lobe efusions; LUL 9x8mm cavitary lesion, lingual 14-16mm fluid collection, R apex 17x16mm oval cavitary lesion . Abdominal CT scan OSH [**2105-7-13**] Periportal edema, small amount of ascites, extensive lymphadenopathy in the periceliac, periportal and periaortic regions . Chest x-rays: [**7-14**] - IMPRESSION: Mild improvement of left lower lobe atelectasis and left pleural effusion. Multiple bilateral circular opacities, some with cavitation, consistent with septic emboli remain unchanged. [**7-15**], s/p right pigtail catheter placement - IMPRESSION: Right pleural effusion has decreased. Improvement in left lower lobe atelectasis with better aeration of the lung. [**7-16**] - Of note, the lateral aspect of the right hemithorax was not included on this film, the evaluation of the right pleural effusion is limited. Right basal pigtail catheter remains in place. Cardiac size is top normal. The mediastinum is widened as before due to mediastinal lymphadenopathy. Multiple lung nodules and masses, some with cavitations, are unchanged. Left lower lobe opacity has increased. It could be due to increasing pleural effusion and atelectasis but superimposed infection cannot be totally excluded. There is no evident pneumothorax. Left PICC tip is in the SVC. [**7-19**] -PORTABLE UPRIGHT CHEST RADIOGRAPH: A right upper extremity PICC remains in place. A right pleural pigtail catheter has been removed. There is no new pneumothorax. Small right and likely left pleural effusions remain. Multiple peripheral nodular and mass-like areas of consolidation are also as previously seen. No new consolidation or pulmonary edema is noted. Cardiomediastinal contours remain normal. IMPRESSION: No pneumothorax after removal of right pleural drain. . TTE ([**2105-7-15**]): IMPRESSION: No vegetation or pathologic flow identified. Normal biventricular systolic function. . CT chest ([**2105-7-17**]): IMPRESSIONS: 1. Multiple peripheral, nodular, and mass-like areas of consolidation in both lungs are compatible with septic emboli. While lesions in the right lower lobe are newly apparent due to reexpansion of the right lower lobe, no other new or enlarging lesion is seen. Some lesions have decreased in size. Some show new cavitation while others previously shown to have cavitation no longer have apparent cavitation. 2. Bilateral small complex loculated pleural effusions with enhancing rind, smaller on the right since [**2105-7-13**]. Adjacent relaxation atelectasis involves nearly the complete left lower lobe, with sparing of the anterior segments only. Dependent atelectasis also in the right lung. Minimal right pneumothorax, with pleural catheter in place. 3. Mediastinal and hilar adenopathy. . Teeth panorex ([**2105-7-19**]): tooth #2 bone loss and radiolucency, #7 previously started root canal, radiolucency Brief Hospital Course: **For outside hospital course at [**Hospital1 1562**], please see HPI** # MSSA bacteremia and ?right-sided endocarditis with pulmonary septic emboli: Blood cultures grossly positive at OSH for Gram-positive cocci, sensitive to Oxacillin, Levaquin, and Gent; resistant to PCN, erythromycin. CT findings were suggestive of pulmonary septic emboli with cavitation. TTE and TEE was neg and no new murmurs. No splinter hemorrhages, [**Last Name (un) 1003**] lesions, or Osler nodes on exam. Dental team ordered a panorex which showed non-active abscesses in one anterior and one posterior tooth. ID team was consulted and believed that despite negative TEE, his history of IV drug use lended itself to a diagnosis of right-sided endocarditis and should be treated as such. Patient was previously started on clindamycin and developed maculopapular rash over his torso and lower extremities, consistent with allergic rash. As a result, he was treated with nafcillin 2g IV q4h and clindamycin was discontinued. Blood cultures taken at [**Hospital1 18**] has been negative to date. As an outpatient, he should continue to receive IV oxacillin for a total of a 4 to 6-week course. . # Loculated pleural effusions and PTX: The patient was extubated on [**7-15**], but had some tachypnea and desats to low 90s, likely due to agitation. He did better on 100% facemask and some mild sedation. Right sided pigtail catheter was placed by interventional pulmonology and the fluid showed the profile below. After reviewing his CT chest, thoracic surgery did not believe the patient needed a VATS procedure during this hospitalization. Drainage from the chest tubes decreased to 0 after [**7-18**] and the pigtails were pulled out without any complications on [**2105-7-20**]. PLEURAL ANALYSIS WBC Hct,Fl Polys Bands Lymphs Monos Eos Macro [**2105-7-15**] 13:36 1056* 7*1 71* 2* 20* 0 2* 5* . #High risk infectious diseases screening: Per ID, hepatitis serologies and HIV testing was sent and revealed HCV Ab+ with HCV viral load pending, no active Hep B infection. Despite multiple attempts at HIV testing, the pt refused to consent for testing at this time, he says he was tested previously but did not disclose the result. . # Diffuse lymphadenopathy: CTs showed LAD around liver and lungs. This was likely reactive due to infection,but could also be due to occult malignancy or his HIV+ status. . # Anemia: Hematocrit stable in the upper 20s. Iron studies consistent with an anemia of chronic disease with low TIBC and extremely high ferritin levels. This will likely correct after the inflammatory state regresses. . # Hypokalemia - The patient was consistently mildly hypokalemic and was repleted with potassium chloride as needed. . # IVDU and EtOH abuse - In the SICU, the patient was very anxious and placed on dexmedetomidine for sedation with fentanyl drip for possible opioid withdrawal symptoms.. He was then converted to methadone the following morning. However, he became diaphoretic and anxious later that day and was started on clonidine patch. While he required large amount of benzodiazapines in the SICU, he has been needing much less on the floor. He initially received IV dilaudid for pain control and IV ativan for anxiety, which were both switched to PO before discharge. The pt was evaluated by an addiction specialist at [**Hospital1 18**] prior to transfer to rehab facility. . # Bipolar d/o: Patient's affect was very blunted and inappropriate when first coming to the floor. He did understand that his drug abuse has caused this prolonged hospitalization. His home doses of Seroquel and Cymbalta were continued. . # Sinus tachycardia: The patient developed sinus tachycardia to 130-160s. The patient was given IV fluids. He should also continue to take ativan for anxiety. The likely cause of his exertional tachycardia is secondary to deconditioning. This should resolve over time as you participate in physical therapy. Medications on Admission: Cymbalta 60mg daily Seroquel 100mg daily Gabapentin 800mg daily Discharge Medications: 1. Duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 2. Gabapentin 400 mg Capsule Sig: Two (2) Capsule PO TID (3 times a day). 3. Quetiapine 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 5. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q3H (every 3 hours) as needed for pain. 6. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for anxiety. Discharge Disposition: Extended Care Facility: [**Hospital 5503**] [**Hospital **] Hospital - [**Location (un) 5503**] Discharge Diagnosis: Primary diagnoses: Methicillin-sensitive staphylococcus aureus bacteremia Septic pulmonary emboli Right-sided endocarditis Secondary diagnoses: IV drug abuse Alcohol abuse 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: It was a pleasure treating you at [**Hospital1 1170**]. You were originally admitted to an outside hospital with pneumonia and you were found to have a bloodstream infection as well as an infection in your lungs. You were started on antibiotics at this time. However, you began to have extreme difficulty breathing, so they had to insert a breathing tube and hook you up to a breathing machine to assist you. They also placed 2 chest tubes in each lung to help drain some of the infected areas of your lungs. Once these chest tubes were removed, you were transferred to the surgical intensive care unit. The breathing tube was removed when it was felt you could breath on your own. Another chest tube was then placed on the right side to drain more fluid from your lungs. Multiple CT scans were done to monitor the progress of these interventions. You became very anxious after the breathing tube was removed, which may have been due to drug withdrawal. This required the use of high doses of sedating medications to keep you calm. Leading up to your discharge, you were much calmer and the chest tube was removed. You will be transferred to a rehabilitation facility, where they will also administer your IV antibiotics for a total of a 6-week course. We think that it is very important that you stop using drugs, which we discussed while you were in the hospital. Followup Instructions: You will be following up at [**University/College **] Dental School for your tooth abscesses - a root canal and extraction. Your appointments are as follows: [**2105-8-4**] - 8:30am - root canal appt, there will be an upfront cost of around $300, you can discuss this during your consultation at the appointment there [**2105-9-14**] - 11:30am - extraction appt Completed by:[**2105-7-21**]

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icd9cm

[ [ [] ] ]

[ "96.71", "88.73", "88.72", "34.04", "38.93", "94.68" ]

icd9pcs

[ [ [] ] ]

12240, 12338

7626, 11577

301, 387

12555, 12555

2277, 4124

14138, 14531

1565, 1574

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19647+57070

Discharge summary

report+addendum

Admission Date: [**2175-2-28**] Discharge Date: [**2175-3-6**] Date of Birth: [**2152-11-19**] Sex: M Service: TRAUMA SURGERY CHIEF COMPLAINT: Status post motor vehicle collision. HISTORY OF PRESENT ILLNESS: The patient is a 22 year old male, status post motor vehicle collision, the patient fell asleep at the wheel, was an unrestrained driver. The motor vehicle had turned over and the patient arrived with a GCS of 15. On arrival, the patient was tachycardic and hypotensive and given six liters of crystalloid and brought to the CT scanner after response to fluids. The patient sustained a grade III/IV splenic laceration, small left pneumothorax, pulmonary contusions, left rib fractures of ribs eight, nine and ten, small pelvic rami superior and inferior fracture with intramuscular hematoma. The patient's official CT read showed a splattered spleen with hemoperitoneum, grade III/IV splenic laceration, the hilum appeared to be intact. PAST MEDICAL HISTORY: Testicular cancer, status post orchiectomy. SOCIAL HISTORY: The patient drinks three to four drinks two to three times per week and denies tobacco. ALLERGIES: The patient has no known drug allergies. MEDICATIONS ON ADMISSION: 1. Wellbutrin 200 mg p.o. twice a day. 2. Zoloft 50 mg p.o. once daily. 3. Ambien p.r.n. PHYSICAL EXAMINATION: On admission to the Emergency Department, the patient's temperature was 99.4, blood pressure 82/palpable initially and heart rate was 90 to 115, respiratory rate 24, oxygen saturation 100% on nonrebreather. LABORATORY DATA: The patient's white blood cell count was 19.4, hematocrit 42.4, platelet count 236,000. Electrolytes were within normal limits. Lactate was 2.9. Amylase was 76. The patient's arterial blood gas was 7.34, 49, 209, 28, 0. The patient's INR was 1.2. Partial thromboplastin time was 24.2. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 9325**], M.D. [**MD Number(1) 10637**] Dictated By:[**Last Name (NamePattern1) 45743**] MEDQUIST36 D: [**2175-3-9**] 16:25 T: [**2175-3-11**] 12:18 JOB#: [**Job Number 53218**] Name: [**Known lastname 9886**], [**First Name3 (LF) 963**] Unit No: [**Numeric Identifier 9887**] Admission Date: [**2175-2-28**] Discharge Date: [**2175-3-6**] Date of Birth: [**2152-11-19**] Sex: M Service: ADDENDUM: The initial part to this Discharge Summary confirmation number was [**Numeric Identifier 9888**] (I believe). Please add this dictation to initial dictation done on [**2175-3-9**]. After quoting vital signs, please include: The patient was alert and oriented times three with [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 9889**] Coma Scale of 15 on arrival. He was following all commands and moving all extremities. The pupils were equal, round, and reactive to light. The tympanic membranes were clear. The oropharynx was clear. The extraocular muscles were intact. Cardiovascular examination revealed regular rate and rhythm. Chest was clear to auscultation bilaterally. Good breath sounds. No crepitus. Positive tenderness over the distal half of the left rib cage. The abdomen was tender in the left upper quadrant. Positive guarding. The pelvis was stable. No deformities. No costovertebral angle tenderness bilaterally. No deformities, stepoff, or tenderness of the cervical spine. Rectal examination was guaiac-negative. Good tone. The right upper extremity was positive for abrasions. The right lower extremity was positive for abrasions. Left upper and lower extremities revealed no deformities. Strength was 5/5 times four extremities. Good pulses throughout. The patient was brought to the operating room for resuscitation. The patient responded to aggressive resuscitation and was hemodynamically stable. At this time, the decision to treat the patient nonoperatively was made, and the patient was admitted to the Intensive Care Unit for close monitoring. The patient was kept nothing by mouth with intravenous fluids, bed rest, every 4-hour hematocrit checks, and serial abdominal examinations. The [**Hospital 1325**] hospital course was unremarkable. The patient remained hemodynamically stable throughout the course of his hospital stay, and his hematocrit was relatively stable with a gradual drop due to dilutional changes. On post trauma day four, the patient remained hemodynamically stable with a stable hematocrit and a soft, nontender, and nondistended abdomen. The patient's bed rest status was changed to out of bed, and oral intake was started. The patient tolerated the advancement of his diet without problems. The patient ambulated with pain on the left lower extremity secondary to the left pubic rami fractures. Physical Therapy was consulted, and crutches were given to the patient. Pain was managed with a Fentanyl patch and by mouth Dilaudid with adequate pain control on discharge. DISCHARGE STATUS: The patient was discharged to home. DISCHARGE DIAGNOSES: 1. Grade 3 splenic laceration. 2. Left rib 8 through 12 fractures. 3. Left superior/inferior pubic rami fractures. 4. Comorbidities of anxiety disorder/depression. DISCHARGE INSTRUCTIONS/FOLLOWUP: 1. The patient was asked to call his physician if he experienced any lightheadedness, dizziness, nausea, vomiting, fevers, or chills. 2. The patient was instructed to not participate in contact sports for six weeks. 3. The patient was instructed to follow up in the Trauma Clinic in three to four weeks. CONDITION AT DISCHARGE: The patient's condition on discharge was stable. MEDICATIONS ON DISCHARGE: 1. Fentanyl 75-mcg per hour patch q.72h. 2. Zoloft 50 mg by mouth once per day. 3. Wellbutrin 200 mg by mouth twice per day. 4. Dilaudid one to two tablets by mouth q.4-6h. as needed (for pain). [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2207**], M.D. [**MD Number(1) 3525**] Dictated By:[**Last Name (NamePattern1) 7275**] MEDQUIST36 D: [**2175-3-9**] 18:08 T: [**2175-3-9**] 21:53 JOB#: [**Job Number 9890**]

[ "V64.1", "860.0", "300.00", "808.2", "807.05", "865.09", "E816.0", "861.21", "311" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

5038, 5207

5649, 6125

1224, 1317

5240, 5558

1340, 5017

5573, 5623

161, 199

228, 970

993, 1038

1055, 1198

9,061

132,744

24259

Discharge summary

report

Admission Date: [**2198-8-21**] Discharge Date: [**2198-10-17**] Date of Birth: [**2134-4-11**] Sex: F Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 974**] Chief Complaint: ECF w/ plans for operative intervention, admitted for nutrition and w/u of fungal septicemia. Major Surgical or Invasive Procedure: 1. Takedown of enterocutaneous fistula. 2. Resection of abdominal wall. 3. Small bowel resection with enteroenterostomy. 4. Massive lysis of adhesions greater than 2.5 hours. 5. Ventral hernia repair with Veritas mesh (3 large meshes with 4 suture lines to piece it together). History of Present Illness: Pt seen in clinic for f/u of ECF. Found to have fungal line infection 7-10d prior to admission. Admitted to hospital for w/u of fungemia prior to operating on the fistula and large ventral hernia. Past Medical History: PMH: EC fistula h/o decubitus ulcers pt has fetal anomaly, incomplete circle of [**Location (un) 431**] DM Hypothyroidism-pt denies Morbid obesity Anemia h/o frequent UTIs Respiratory failure with last operation OA ARF with last two operations HTN PSH: -Exploratory laparotomy, lysis of adhesions (3 hours), enterectomy and/or enterostomy, closure enterotomy and repair of hernia with Vicryl mesh [**2195-8-13**] -s/p fistula repair at [**Hospital1 18**] 5y ago -multiple ex-lap/LOA -multiple incisional herniorrhaphy -CCY -appy Social History: Occassional tobacco use, denies etoh use Lives with husband and kids Family History: Noncontributory Physical Exam: Physical exam on admission: Vitals- T 97, HR 91, BP 118/80, RR 18, O2sat 91% 2L NC Gen- NAD, alert Head and neck- AT, NC, soft, supple, no masses Heart- RRR, no murmurs Lungs- coarse BS bilaterally Abd- +BS, soft, NT, ND, fistula has VAC Ext- warm, well-perfused, no edema Pertinent Results: [**2198-8-21**] 06:45PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.000* [**2198-8-21**] 06:45PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-SM [**2198-8-21**] 06:45PM URINE RBC-0-2 WBC-0-2 BACTERIA-OCC YEAST-NONE EPI-<1 [**2198-8-21**] 05:00PM GLUCOSE-143* UREA N-26* CREAT-1.1 SODIUM-139 POTASSIUM-4.4 CHLORIDE-103 TOTAL CO2-26 ANION GAP-14 [**2198-8-21**] 05:00PM estGFR-Using this [**2198-8-21**] 05:00PM CALCIUM-9.2 PHOSPHATE-2.8 MAGNESIUM-1.8 [**2198-8-21**] 05:00PM WBC-8.0 RBC-3.22* HGB-9.3* HCT-29.0* MCV-90 MCH-28.9 MCHC-32.1 RDW-17.0* [**2198-8-21**] 05:00PM NEUTS-65.3 BANDS-0 LYMPHS-27.0 MONOS-5.1 EOS-2.2 BASOS-0.5 [**2198-8-21**] 05:00PM HYPOCHROM-1+ ANISOCYT-1+ POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-OCCASIONAL [**2198-8-21**] 05:00PM PLT SMR-NORMAL PLT COUNT-336# [**2198-8-21**] 05:00PM PT-16.2* PTT-31.0 INR(PT)-1.5* Brief Hospital Course: [**2198-8-21**] admitted to hospital for w/u fungemia and possible operative intervention for ECF and large ventral hernia. Seen by wound/ostomy care. [**Date range (3) 61551**] Pt relatively stable. TPN. Followed nutrition labs. Followed vac. [**2198-8-29**] Found to have +Ucx, started on cipro. [**2198-9-10**] Found to have albumin 2.9. Postponed OR to rx UTI, eval nutrition. [**2198-9-12**] Started on meropenem per ID. [**2198-9-21**] Meropenem course d/c-ed. [**Date range (1) 61552**] Continued TPN. Followed nutrition labs. Managed vac. Prepped for OR. [**2198-10-1**] ECF takedown, small bowel resection, large ventral hernia repair performed. Pt to ICU on vent and pressors due to history of respiratory decompensation s/p surgery. Wound found to have progressed; opened & up and vac placed. Started on linezolid & zosyn. [**2198-10-3**] Off all pressors & weaned off vent. Drain fluid sent for cultures, finding proteus and staph; ID recommended continuing linezolid and zosyn. On TPN. [**2198-10-6**] Stable. Transferred to floor. Continued TPN. [**2198-10-8**] Passed flatus. [**2198-10-9**] Multiple BM, diarrheal. Sent Cdiffx3. Started flagyl empirically. [**2198-10-11**] Linezolid, Zosyn, Flagyl d/c-ed given worsening renal function (Cr bump to 2.2) and question of hypovolemia vs ATN. Advanced to full diet; tolerated well. [**2198-10-12**] Trigger event with AMS. Found to be AOx3. Sleep apnea likely. CPAP instituted. [**2198-10-13**] Cr to 3.1 o/n. Cr improved with fluid bolus 3.5L. Pt febrile, poor sats. Fever w/u instituted. RLL PNA found on CXR. Levo/Flagyl begun for PNA/asp PNA [**2198-10-14**] White count spike to 16.0 [**2198-10-15**] White count falling. Afebrile. Sats & symptoms improved. Continuing diarrhea, Cdiff sent. [**2198-10-16**] +Cdiff. Oral vanco begun. Flagyl and levo continued as PO. Clinically, diarrhea and PNA resolving. Cr stable in 1.6-1.9 range. [**2198-10-17**] Pt doing well. Sx resolved. Vac in place w/ good granulation & beginning contraction. AVSS. D/c for further after-hospital care. Medications on Admission: 1. Toprol XL 100 mg PO daily 2. Lisinopril 20 mg PO BID 3. Miconazole Nitrate 2 % Powder Topical [**Hospital1 **] 4. Calcium Carbonate 500 mg PO TID 5. Tizanidine 2 mg PO QHS 6. Acetaminophen 650 mg PO Q6H 7. Ranitidine HCl 150 mg PO DAILY 8. Gabapentin 300 mg PO TID 9. Tramadol 50 mg PO Q6H 10. Furosemide 20 mg PO DAILY Discharge Medications: 1. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day). 2. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) inj Injection TID (3 times a day). 3. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical TID (3 times a day) as needed. 4. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q4H (every 4 hours). 5. Lidocaine HCl 2 % Gel Sig: One (1) Appl Mucous membrane PRN (as needed). 6. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 7. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 8. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed. 9. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 10. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: 1-2 puffs Inhalation Q6H (every 6 hours) as needed. puffs 11. Insulin Regular Human 100 unit/mL Solution Sig: One (1) inj Injection ASDIR (AS DIRECTED). 12. Ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours). 13. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 5 days. 14. Levofloxacin 750 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 5 days. 15. Vancomycin 125 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours) for 12 days. 16. Ondansetron HCl (PF) 4 mg/2 mL Solution Sig: One (1) Injection Q8H (every 8 hours) as needed. 17. Hydromorphone (PF) 1 mg/mL Syringe Sig: One (1) dose Injection Q6H (every 6 hours) as needed. Discharge Disposition: Extended Care Facility: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] Nursing and Rehab Center for [**Location (un) 61553**] Discharge Diagnosis: Enterocutaneous fistula with abdominal wall disruption and ventral hernia with loss of eminent domain. Discharge Condition: Stable Discharge Instructions: Please call your surgeon if you develop chest pain, shortness of breath, fever greater than 101.5, foul smelling or colorful drainage from your incisions, redness or swelling, severe abdominal pain or distention, persistent nausea or vomiting, inability to eat or drink, or any other symptoms which are concerning to you. Activity: No heavy lifting of items 20 pounds until the follow up appointment with your doctor. Medications: Resume your home medications. You should take a stool softener, as needed for constipation. Pain medication may make you drowsy. No driving while taking pain medicine. Followup Instructions: Please call Dr. [**Last Name (STitle) **] at [**Telephone/Fax (1) 18052**] to schedule your follow-up appointment.

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icd9cm

[ [ [] ] ]

[ "53.69", "54.3", "38.93", "38.91", "54.59", "00.14", "99.15", "46.74", "45.62" ]

icd9pcs

[ [ [] ] ]

6941, 7088

2872, 4947

408, 687

7235, 7243

1895, 2849

7892, 8010

1570, 1587

5322, 6918

7109, 7214

4973, 5299

7267, 7869

1602, 1616

275, 370

715, 913

1630, 1876

935, 1467

1483, 1554

3,866

156,747

48697

Discharge summary

report

Admission Date: [**2134-10-11**] Discharge Date: [**2134-10-20**] Date of Birth: [**2084-5-28**] Sex: M Service: MEDICINE Allergies: Codeine / Enalapril Attending:[**First Name3 (LF) 2181**] Chief Complaint: SOB and Chest pain Major Surgical or Invasive Procedure: none History of Present Illness: Briefly, 50M with complicated PMH including ESRD on HD, DM, recent ICU admission for sepsis from MRSA bacteremia with MV endocarditis (currently on vanc/gent), h/o cervical abscess, multiple line infections, pAfib (on coumadin), sarcoid, h/o pulm aspergillosis, admitted to the MICU with respiratory failure during HD. . The patient initially presented with SOB and CP. Patient originally c/o 1 day of orthopnea/PND, and 1 hour of chest pain to ER staff, however patient now denies hx of PND and says he has had "constant dull chest pain for 2 days". He last was dialyzed on Saturday. Patient's CP resolved in the ER, and he only received ASA. He was then taken to dialysis after CXR showed pulmonary edema. . The patient was dialyzed 2L of the planned 2.5L prior to having episodes of hemoptysis/hematemesis of approximately 30 cc. The patient subsequently desaturating and was 70% on NRB. The patient was intubated and admitted to the MICU Past Medical History: ESRD secondary to amyloidosis -failed LRRT in [**7-4**] now on HD- R groin line IVC stent Sarcoidosis Pulmonary aspergillosis DM (diet controlled) Chronic HCV Hypertension Sinusitis, Paroxysmal atrial fibrillation, C. difficile [**3-8**] MRSA line sepsis Renal osteodystrophy Adrenal insufficiency Upper extremity DVT ([**2132**]) Pancreatitis Bilateral BKA Right index and fifth finger amputations Social History: SOCIAL HISTORY: Smoked 1 ppd X 30 years but quit one year ago. No alcohol. Previous drug use (IVDU). Girlfriend is involved in his care. Family History: FAMILY HISTORY: Mother, brother with diabetes. Physical Exam: Vitals: T 98 BP 139/83 HR 87 RR 20 (recorded as 33, but pt breathing comfortably) O2 96% RA Gen: NAD, comfortable, eating HEENT: PERRL Cardio: RRR, nl S1S2, 2/6 systolic murmur @ apex Resp: crackles [**2-3**] way up BL Abd: soft, nt, nd, +BS Ext: s/p BL BKA Neuro: A&Ox3 Pertinent Results: CBCs [**2134-10-11**] WBC-9.4 RBC-4.79 Hgb-11.0* Hct-37.7* MCV-79* MCH-23.0* MCHC-29.2* RDW-20.9* Plt Ct-396# [**2134-10-12**] WBC-17.7*# RBC-5.25 Hgb-12.1* Hct-41.9 MCV-80* MCH-22.5* MCHC-28.2* RDW-20.0* Plt Ct-484* [**2134-10-12**] Neuts-57.9 Bands-0 Lymphs-26.6 Monos-8.7 Eos-4.6* Baso-0.3 [**2134-10-13**] WBC-2.9*# RBC-3.95* Hgb-9.2* Hct-30.9* MCV-78* MCH-23.3* MCHC-29.7* RDW-20.8* Plt Ct-285 [**2134-10-14**] WBC-4.6 RBC-4.17* Hgb-9.5* Hct-31.7* MCV-76* MCH-22.7* MCHC-29.8* RDW-20.6* Plt Ct-293 [**2134-10-20**] WBC-7.9 RBC-4.17* Hgb-9.6* Hct-33.2* MCV-79* MCH-22.9* MCHC-28.9* RDW-20.1* Plt Ct-339 Coags [**2134-10-11**] 09:50PM BLOOD PT-15.4* PTT-30.6 INR(PT)-1.4* [**2134-10-14**] 05:11AM BLOOD PT-16.1* PTT-27.9 INR(PT)-1.5* [**2134-10-17**] 05:25AM BLOOD PT-15.5* PTT-30.3 INR(PT)-1.4* [**2134-10-12**] 12:11AM BLOOD Fibrino-582* Lytes [**2134-10-11**] Glucose-49* UreaN-55* Creat-7.7*# Na-142 K-4.5 Cl-102 HCO3-27 Albumin-3.2* Calcium-8.8 Phos-4.8*# Mg-2.3 [**2134-10-13**] Glucose-213* UreaN-75* Creat-8.7*# Na-138 K-5.7* Cl-101 HCO3-18* Calcium-8.3* Phos-6.6* Mg-2.4 [**2134-10-16**] Glucose-63* UreaN-28* Creat-4.5*# Na-141 K-4.0 Cl-104 HCO3-27 Calcium-9.1 Phos-3.7# Mg-2.0 [**2134-10-20**] Glucose-121* UreaN-16 Creat-4.3*# Na-140 K-4.5 Cl-101 HCO3-27 Calcium-7.8* Phos-2.6*# Mg-1.9 Other Chemistries [**2134-10-16**] 02:35PM BLOOD Iron-28* [**2134-10-16**] 02:35PM BLOOD calTIBC-296 Ferritn-127 TRF-228 [**2134-10-13**] 05:24AM BLOOD Vanco-12.7 [**2134-10-15**] 04:35AM BLOOD Genta-2.4* Vanco-20.8* [**2134-10-19**] 05:20AM BLOOD Vanco-19.2 Beta glucan positive x 2 ([**10-12**], [**10-2**]^) Galactomannin negative Blood gases [**2134-10-12**] 03:31AM BLOOD Type-ART pO2-308* pCO2-57* pH-7.27* calTCO2-27 Base XS--1 [**2134-10-12**] 05:35PM BLOOD Type-ART Temp-36.2 Rates-22/0 Tidal V-450 PEEP-5 FiO2-50 pO2-169* pCO2-32* pH-7.42 calTCO2-21 Base XS--2 Intubat-INTUBATED Vent-CONTROLLED [**2134-10-13**] 05:47AM BLOOD Type-ART pO2-216* pCO2-33* pH-7.40 calTCO2-21 Base XS--2 [**2134-10-14**] 11:07AM BLOOD Type-ART Temp-36.5 Rates-/20 Tidal V-350 PEEP-5 FiO2-40 pO2-222* pCO2-53* pH-7.37 calTCO2-32* Base XS-4 Intubat-INTUBATED Vent-SPONTANEOU [**2134-10-14**] 01:45PM BLOOD Type-ART Temp-36.6 Rates-/20 PEEP-5 pO2-207* pCO2-45 pH-7.37 calTCO2-27 Base XS-0 Intubat-INTUBATED Vent-SPONTANEOU [**2134-10-14**] 02:44PM BLOOD Type-ART Temp-36.3 Rates-/23 FiO2-50 pO2-90 pCO2-51* pH-7.34* calTCO2-29 Base XS-0 Intubat-NOT INTUBA Vent-SPONTANEOU Micro [**10-12**] Blood culture negative 4/4 bottles [**10-12**] Sputum - MRSA + yeast Stool - C-diff negative x 2 Imaging: [**10-11**] Chest Xray: 1. Cardiomegaly with increased interstitial markings, vascular congestion and bilateral pleural effusion suggestive of congestive heart failure, new since [**2134-10-4**]. 2. New opacities in bilateral lower lobes representing atelectasis or pneumonia, in the appropriate clinical setting; close clinical correlation is recommended. 3. Interstitial lung disease in upper lobe distribution and volume loss, with heavily calcified mediastinal lymph nodes, likely representing known sarcoidosis (Is there any h/o industrial silica exposure, given the evidence of asbestos exposure?) . 4. Calcified plaques along the pleura and pericardial calcification, likely due to asbestos-related pleural disease, perhaps with contribution of renal insufficiency. [**10-12**] Chest Xray: 1. Increase in right lower lobe opacification representing pleural effusion and adjacent atelectasis. 2. No significant change in pleural effusions bilateraly 3. Interval endotracheal tube replacement, in standard position. [**10-12**] Chest CTA: 1. No aortic dissection or pulmonary embolism. 2. The tip of the endotracheal tube is just proximal to the tracheal bifurcation and may need to be re-positioned as per clinical need. The nasogastric tube is in the satisfactory position. 3. Extensive pleural mediastinal and lymph node calcification suggestive of sarcoid and/or asbestos exposure. 4. Parenchymal lung opacities and areas of chronic consolidation have increased in size since the prior examination. There are bibasilar effusions, which have increased since the last examination. 5. Bilateral adrenal calcification and left renal parenchymal calcification has remained unchanged since the prior examination. 6. Bilateral gynecomastia with calcific foci in the left breast have increased since the last examination and may be assessed further clinically. [**10-12**] ECHO The left atrium is normal in size. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF 60-70%) There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. An aortic valve vegetation/mass cannot be excluded. There are filamentous strands on the aortic leaflets consistent with Lambl's excresences (normal variant). The mitral valve leaflets are moderately thickened, with focal pattern of thickening. There is no mitral valve prolapse. A mass or vegetation on the mitral valve cannot be excluded. There is moderate thickening of the mitral valve chordae. Mild (1+) mitral regurgitation is seen. There is borderline pulmonary artery systolic hypertension. No vegetation/mass is seen on the pulmonic valve. Compared with the findings of the prior study (images reviewed) of [**2134-10-5**], the mitral leaflets appear somewhat less thickened; a definite vegetation is no longer identified, but cannot be excluded with certainty. [**10-13**] ECHO The left atrium is normal in size. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%) There is no ventricular septal defect. Right ventricular systolic function is borderline normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No masses or vegetations are seen on the aortic valve. No aortic regurgitation is seen. The mitral valve leaflets are moderately thickened. A mass or vegetation on the mitral valve cannot be excluded. There is moderate thickening of the mitral valve chordae. Mild to moderate ([**2-2**]+) mitral regurgitation is seen. A small perforation of the anterior mitral leaflet cannot be excluded. The tricuspid valve leaflets are mildly thickened. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. Compared with the prior study (images reviewed) of [**2134-10-12**], no change. A TEE is recommended if recurrent/active endocarditis is suspected. [**10-11**] ECG Sinus rhythm. Compared to the prior tracing of [**2134-10-3**] the rate has slowed. The lateral ST-T wave changes have improved. There is delayed precordial R wave transition. Clinical correlation is suggested. [**10-13**] ECG Sinus rhythm. Low limb lead voltage. Q-T interval prolongation. Variation in precordial lead placement as compared with tracing of [**2134-10-12**]. The rate has slowed. The T wave flattening has improved. Otherwise, no diagnostic interim change. Intervals Axes Rate PR QRS QT/QTc P QRS T 66 194 70 468/478 87 18 64 [**10-17**] Chest Xray When compared with the prior findings, the current appearances likely represent developing interstitial edema/fluid overload. The airspace opacity in the right base may be part of this process but superimposed infection cannot be excluded. Findings were discussed with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4887**] at 14:50 hours. [**10-20**] ECG Sinus rhythm Mild long QTc interval Low limb lead voltage Since previous tracing of [**2134-10-13**], no significant change Intervals Axes Rate PR QRS QT/QTc P QRS T 71 152 64 462/481 75 18 53 Brief Hospital Course: # Respiratory failure: The pt was originally admitted with Respiratory failure/Hemoptysis. Patient became hypoxic in the setting of HD with hemoptysis. CTA was negative for PE. MI ruled out. Bronchoscopy showed diffusely friable airways, with respiratory cultures positive for MRSA. The most likely etiology of his failure was therefore believed to be hemorrhagic pneumonia in the setting of uremic platelets. Per infectious disease, the relatively rare GPCs on his culture were concerning for a second infective proces (gram negative vs. fungal involvement). A positive blood glucan on [**10-12**] was concerning for disseminated aspergillosis in the setting of his longstanding mycetoma, for which he has been on itraconazole for many years. No gram negative organisms were isolated. . His pneumonia was initially treated with meropenem, vancomycin, and gentamicin, and his itraconazole was continued. He was extubated after 36 hours and weaned his oxygen requirement over the next two days. With clinical improvement, he was transferred to the floor from the MICU with a minimal O2 requirement that was quickly weaned. His gentamicin was D/Ced and his meropenem was changed to levaquin for a 7 day course of gram negative coverage. Once the positive blood glucan was discovered, the test was repeated as well as a galactomannin (still pending), and the patient was switched to voriconazole for better aspergillosis coverage. the patient complained of a dry cough on the floor well-controlled with guaniefesin - his CXR showed resolution of an acute process. . # MRSA bacteremia/MV endocarditis: The patient had a recent admission for sepsis with a vegetation seen on his mitral valve, but has had a negative TTE and surveillance cultures this admission. - Plan to Ccontinue vanc HD protocol at dialysis for six weeks from 9/3 per ID. . # Hypotension: Upon tranfer to the MICU the patient was hypotensive, likely hypovolemia in the setting of ultrafiltration and blood loss. Pts ECHO showed LVEF 60-70%. Pt originally met criteria to qualify for SIRS, but sepsis was thought ot be less likely in this setting. Blood cultures were negative. Hypotension may also have been augmented by his adrenal insufficiency. He was given IVF in the MICU and stress dose steroids, which were tapered to his home does of prednisone (5mg) through his hospital stay. . # CP/Cardiac: Patient's examination clinically significant for fluid overload on admission per report. Patient was somewhat unclear on the duration/quality of his chest pain, but it appeared atypical for cardiac etiology. Negative MIBI [**5-4**]. The patient had his cardiac enzymes cycled and ruled out for MI. ASA and coumadin were held for his pulmonary bleeding. Metoprolol was initially held for hypotension and then resumed at a dosing of 25mg [**Hospital1 **], which masd ethe patient normotensive with an SBP in the 120s to 130s. . #[**Name (NI) **] Pt had transient neutropenia, possibly secondary to zosyn exposure (vs. post-infectious, drugs, HD membranes) Resolved without an etiology being found. . # Hematemesis: Pt treated in the MICU for ? hematemesis due to episode of hematemesis (IV protonix 40mg [**Hospital1 **]). After an initial 120cc of bloody fluid drained form the stomach via OG, no other fluid returned. Bronchoscopy results and further review suggested the blood was likely form a respiratory source. IV protonix was switched to PO upon transfer to the floor [**10-16**] and D/Ced on [**10-19**]. The patient denied any epigastric complaints. . # Cervical abscess: Improved according to last neck CT on [**2134-10-4**]. Vancomycin was continued as above. . # ESRD: Thought to be due to amyloidosis. He is status post failed renal transplant. He is maintained on chronic HD on a Tues-Thurs-Sat schedule. Dr [**Last Name (STitle) 1366**] is his nephrologist. - Right fem line placed / exchanged [**10-12**] - Phosphate binders were switched to IV (zemplar + AlOH) while pt had OG tube in the MICU --> switched back to low dose sevalemer on discharge - He received dosing of epogen, vitamin D, vancomycin (and gentamicin until D/Ced [**10-16**]) during hemodialysis - He was found to be iron deficient [**10-18**] and startd on IV iron - Nephrocaps and cinacalcet were continued once the patient could take POs . # Glucose Control: ISS - rarely needed when not on stress-dose steroids. . # Paroxysmal Afib: Not found ot be in atrial fibrillation on the floor. Metoprolol was continued excpet when pt hypotensive. Coumadin was held in the setting of hemoptysis. . # Depression: Treated with Celexa . # Access: The patient had no central or peripheral venous access other than the tunneled hemodialysis catheter line. While in the MICU an A-line was also placed . # Prophylaxis: while in the MICU, the patient was prophylaxed for VTE with thigh pneumoboots. Upon transfer to the floor, pneumoboots were not placed regularly and it was decided to begin him on SC heparin. He needed no other prophylaxis. Medications on Admission: 1. Vancomycin 1,000 mg Recon Soln Sig: 1000 (1000) mg Intravenous at every hemodialysis for 6 weeks. Disp:*18 grams* Refills:*0* 2. Gentamicin in Normal Saline 80 mg/100 mL Piggyback Sig: Eighty (80) mg Intravenous with every hemodialysis for 4 doses. Disp:*320 mg* Refills:*0* 3. Sevelamer 800 mg Tablet Sig: One (1) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 4. Lanthanum 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 5. Itraconazole 100 mg Capsule Sig: Two (2) Capsule PO BID (2 times a day). 6. Prednisone 5 mg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY (Every Other Day). 7. Prednisone 2.5 mg Tablet Sig: One (1) Tablet PO every other day. 8. Cinacalcet 30 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 9. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 10. Citalopram 20 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily). 11. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). 12. Warfarin 1 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 13. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 14. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO Q8H (every 8 hours) as needed for constipation. 15. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 16. Acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for fever or pain. 17. Percocet 5-325 mg Tablet Sig: One (1) Tablet PO every [**5-7**] hours as needed for pain. Discharge Medications: 1. Cinacalcet 30 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 2. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). Disp:*30 Cap(s)* Refills:*0* 3. Citalopram 20 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 4. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed. 5. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 6. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*0* 7. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q48H (every 48 hours) for 2 doses. Disp:*2 Tablet(s)* Refills:*0* 8. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO Q8H (every 8 hours) as needed. 9. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 10. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6 hours) as needed. 11. Voriconazole 50 mg Tablet Sig: Two (2) Tablet PO Q12H (every 12 hours). Disp:*120 Tablet(s)* Refills:*0* 12. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO twice a day. Disp:*60 Capsule(s)* Refills:*0* 13. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: as directed Intravenous HD PROTOCOL (HD Protochol). 14. Sevelamer 400 mg Tablet Sig: One (1) Tablet PO TID with meals. Disp:*30 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: Primary Diagnoses: Respiratory failure Hemorrhagic Pneumonia Secondary Diagnoses: End stage Renal Disease (CKD stage V) Recent Endocarditis Vertebral Abscess Hypertension Diabetes Mellitus type 2 controlled Pulmonary Mycetoma Paroxysmal atrial fibrillation Adrenal Insufficiency Depression Discharge Condition: Good. All vital signs stable. Good oxygen saturations on room air. Having baseline loose bowel movements. Able to perform transfers with some difficulty due to deconditioning. Complains only of dry non-productive cough. Lungs sound clear. Discharge Instructions: You were seen, evaluated, and treated at [**Hospital1 18**] for respiratory failure secondary to a hemorrahgic pneumonia. You also received continued hemodialysis for your renal failure, and continued treatment for your other medical conditions. After your discharge, please: 1) Follow-up with your PCP and in infectious disease clinic as detailed below. 2) Continue to come to your hemodialysis appointments on Tuesday, Thursdays, and Saturdays. 3) Complete the course of levofloxacin. 4) Be aware that one or two of your medications have changed - please take your medications as prescribed. 5) Continue to work with physical therapy at home to improve your balance and strength 6) Call your PCP or return to the ED if you have chest pain, shortness of breath, fever > 100.4F, productive cough, blood-tinged sputum, or any other concerning symptoms. Followup Instructions: Please follow-up with your PCP [**Known firstname **] [**Last Name (NamePattern1) **] ([**Telephone/Fax (1) 250**]) at 10:30 AM on [**10-22**] in the [**Hospital Ward Name 23**] Center. Please follow-up in the infectious disease urgent care clinic with Dr. [**First Name (STitle) **] next Tuesday [**2134-10-26**] at 2:00PM. Please call [**Telephone/Fax (1) 457**] with any quesitons. Please follow-up with your normal infectious disease specialist [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in infectious disease clinic with Dr. [**First Name8 (NamePattern2) 714**] [**Last Name (NamePattern1) **] at 9:30AM on [**11-19**]. Please call [**Telephone/Fax (1) 457**] with any questions. Please follow-up in Hemodialysis on Thursday per your normal schedule.

[ "421.0", "276.52", "E930.0", "250.00", "288.03", "427.31", "482.41", "255.4", "484.6", "070.54", "117.3", "V58.61", "403.91", "518.81", "V49.75", "V09.0", "585.5", "515", "277.30", "730.08", "135" ]

icd9cm

[ [ [] ] ]

[ "39.95", "33.22", "96.04", "38.91", "96.71" ]

icd9pcs

[ [ [] ] ]

18050, 18107

10069, 15057

301, 307

18442, 18683

2226, 10046

19583, 20368

1887, 1919

16652, 18027

18128, 18190

15083, 16629

18707, 19560

1934, 2207

18211, 18421

243, 263

335, 1279

1301, 1701

1733, 1855

15,453

168,028

13963

Discharge summary

report

Admission Date: [**2110-12-7**] Discharge Date: [**2110-12-13**] Date of Birth: [**2061-12-15**] Sex: M Service: HISTORY OF PRESENT ILLNESS: The patient is a 48 year old male with a history of hepatitis C virus and hepatocellular cancer status post chemoembo in [**5-6**] who presented to [**Hospital3 4298**] E.D. on [**2110-12-7**] with hematemesis since [**2110-12-5**]. He had one episode of hematemesis on [**12-5**]/ and two episodes on [**12-6**] as well as hematemesis and hematochezia on [**12-7**]. At [**Hospital3 4298**] E.D. patient was noted to have a hematocrit of 18 and was transfused two units of packed red blood cells and was noted to be having coagulopathy with INR of 2.1 and was given FFP as well as vitamin K. Patient denies any past history of varices or upper GI bleed. He denies recent alcohol or drug use. He was feeling nauseated and began vomiting and continued to have hematemesis for three days until he was transferred to [**Hospital1 18**] for definitive care. Patient was transfused a total of five units of packed red blood cells and was given vitamin K to counteract his coagulopathy. He underwent EGD on [**2110-12-8**] and was banded with sclerotherapy for grade 3 lower esophageal varices in both the lower and mid-esophagus. Patient also had an abdominal CT on [**2110-12-4**] for followup of chemoembo which showed portal vein thrombosis. At present patient denied shortness of breath, chest pain, headache, nausea, vomiting. No fever, or chills. He states he feels much better now. PAST MEDICAL HISTORY: Significant for hepatitis C virus and alcoholic cirrhosis diagnosed in [**2101**]. Duodenal ulcer status post perforation with repair in [**2101**]. He was diagnosed with hepatocellular carcinoma in [**5-6**]. He had radiotherapy as well as chemoembolization therapy. ALLERGIES: No known drug allergies. MEDICATIONS: Aldactone 50 mg q.d., Lasix 20 mg q.o.d., Percocet, Dilaudid, Zantac, OxyContin. SOCIAL HISTORY: He is a smoker and a former drinker. Denies drug use. PHYSICAL EXAMINATION: Upon admission patient had blood pressure of 130/90, heart rate 99, temperature 99.3, sating 100% in room air. Generally, he was slightly drowsy and jaundiced in mild distress. HEENT was normocephalic, atraumatic, slightly icteric. Pupils were equal, round, and reactive to light bilaterally. No JVD. Cardiac exam was regular rate and rhythm with a 3/6 systolic ejection murmur at the left base. Lungs were clear to auscultation with minimal rales at the left base. Abdomen was distended with mild tenderness in the right lower quadrant, no guarding, no rebound as well as a well healed midline scar. Extremities revealed trace pedal edema bilaterally, no clubbing or cyanosis. Skin exam revealed diffuse spider angioma. No caput medusae. Neuro he was awake, alert and oriented times three. Cranial nerves were intact grossly. He had no focal deficits. He had minimal asterixis in the left hand upon presentation, however, it resolved upon admission to [**Hospital1 1444**]. LABORATORY DATA: Patient labs at [**Hospital3 4298**] revealed hematocrit of 18, white count 21.5, platelets 321. Chem-7 was unremarkable. LFTs revealed AST of 205, ALT 108, alka phos 208, t-bili 2.8, direct bili 1.9, indirect bili 0.9. HOSPITAL COURSE: The patient was transferred to [**Hospital1 346**] and was admitted to the intensive care unit for EGD therapy. 1. Upper GI bleed. Patient underwent esophagogastroduodenostomy per GI service. It was noted that he had grade 3 esophageal varices in the lower third of the esophagus. He underwent sclerotherapy as well as banding. Patient was started on octreotide for continuation of a five day course status post EGD. Patient was transfused a total of five units of packed red blood cells and was given vitamin K to correct FFP. Patient's hematocrit remained stable throughout the hospitalization after banding and octreotide therapy. Patient had no new episodes of hematemesis nor hematochezia during his hospitalization. Patient became guaiac negative after two days of passing darkened clots in his stool. 2. Abdominal distension. Patient underwent unguided paracentesis with withdrawal of approximately 40 cc of transudative fluid with no cells and cultures were negative. Patient subsequently was ordered for an ultrasound guided paracentesis which revealed trace fluid, no tappable fluid. It was significant, however, for thickened bowel wall secondary to edematous changes from fluid overload. Patient was to be diuresed with Aldactone and Lasix to remove the excess fluid in the abdominal wall as well as the intestinal wall. 3. Low grade fever. Patient had blood cultures drawn times six which were all negative for bacteremia. Patient also had chest x-ray which was negative for infiltrate. There was no source found for patient's low grade fever. It is possible that patient has low grade fever secondary to his hepatocellular carcinoma status post chemoembolization. Patient remained nontoxic appearing throughout his hospitalization and no focus or nidus of infection was found to explain patient's intermittent low grade fever. 4. Mild hypocalcemia and hyponatremia. Patient was noted to be hyponatremic to a nadir of 130. It was felt to be hypervolemic hyponatremia secondary to the low urine sodium and obvious increase in total body water. Patient was diuresed and improved with diuresis and sodium corrected without further intervention. It was also noted that patient was mildly hypocalcemic with corrected calcium of 7.8. Patient received p.o. calcium supplementation. Hypocalcemia was most likely secondary to diuresis as well as hepatic failure secondary to hep C cirrhosis as well as hepatocellular carcinoma. 5. Hepatocellular carcinoma status post chemoembolization. Patient was seen by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in-house for question of possible further chemoembolization. Dr. [**First Name (STitle) **] stated that patient was no longer a candidate for chemoembolization, however, he was a possible candidate for oral chemotherapy. Patient will follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in one to two weeks status post discharge. DISCHARGE STATUS: The patient is stable for discharge. DISCHARGE DESTINATION: Home. Patient is to be taken home by [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] back to his home in [**Location (un) 3844**]. DISCHARGE DIAGNOSES: 1. Upper GI bleed secondary to varices status post sclerotherapy as well as band ligation. 2. Blood loss anemia. 3. Hepatocellular carcinoma. 4. Hepatitis C virus. 5. Right upper extremity superficial thrombophlebitis. 6. Hyponatremia, hypocalcemia. 7. Ascites. 8. Pleural vein thrombosis. 9. Alcoholic cirrhosis. DISCHARGE MEDICATIONS: 1. Furosemide 20 mg p.o. q.d. 2. Nadolol 20 mg p.o. b.i.d. 3. Zantac 40 mg p.o. q.24. 4. Oxycodone 20 mg p.o. q.12. 5. Simethicone 40 to 80 mg p.o. q.i.d. 6. Spironolactone 50 mg p.o. b.i.d. 7. Ciprofloxacin 500 mg p.o. q.12. 8. Lactulose 30 ml p.o. t.i.d. FOLLOWUP: The patient is to follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in one to two weeks status post discharge. Patient is also to follow up with his PCP in [**Hospital3 4298**]. Patient is also to follow up with GI service, Dr. [**Last Name (STitle) **], in one week, next Thursday, for repeat EGD and banding. [**Name6 (MD) 2415**] [**Last Name (NamePattern4) 3474**], M.D. [**MD Number(1) 3475**] Dictated By:[**Last Name (NamePattern1) 41735**] MEDQUIST36 D: [**2110-12-12**] 12:27 T: [**2110-12-12**] 12:26 JOB#: [**Job Number 41736**]

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icd9cm

[ [ [] ] ]

[ "42.33", "54.91", "96.34" ]

icd9pcs

[ [ [] ] ]

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2003, 2059

26,377

169,073

43329

Discharge summary

report

Admission Date: [**2111-11-17**] Discharge Date: [**2111-11-24**] Date of Birth: [**2026-10-28**] Sex: F Service: MEDICINE Allergies: Keflex / Latex Attending:[**First Name3 (LF) 10488**] Chief Complaint: "I need a transfusion" Major Surgical or Invasive Procedure: EGD Capsule endoscopy History of Present Illness: 85yoF w/ CAD s/p CABG in [**2089**] and recurrent anemia, presents with RLQ abdominal pain, increased SOB, and generally feeling unwell. She has been feeling generally unwell for several days and was considering coming into the hospital. Last night after walking up the stairs at home, she began having tingling in her upper arms. It continued even after resting, finally resolving with two nitroglycerin tablets. She did not have SOB, diaphoresis, CP or nausea. This morning she had her chronic right hip pain, and right-sided abdominal pain from her chronic hernia, but no arm pain. She did not notice any melena or bloody bowel movements, but was more tired with climbing stairs than usual. She has a h/o anemia of chronic disease and was transfused with 2 units at [**Hospital3 **] 2 weeks ago for Hct of 19, brought up to 22 after transfusion. In the ED, initial vitals were 98.9 57 134/50 16 100% RA. Labs notable for Hct 19 and Cr 3.1. Rectal exam notable for maroon stool. Pt given 80mg IV pantoprazole and started on a pantoprazole drip. Transfused two units PRBC. EKG notable for marked changes from previous EKG with TWI and ST changes in lateral leads. Trop 0.11. Cards recommended transfusion, as this is likely demand ischemia. Pt did not tolerate NG tube placement. Got a non-con abdominal CT before coming up. Has one 18G IV. Recent vitals: 66 180/70 16 99%RA, and she is pain free. On the floor, the patient is resting comfortably. The GI team came by, and on repeat rectal exam she had brown stool. She had one formed, maroon, guaiac positive bowel movement. Review of systems: (+) dry itchy skin and frequent headaches. She has chronic, intermittent diarrhea. She has no dysuria, but does urinate frequently at night. (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies cough, shortness of breath, or wheezing. Denies chest pain, chest pressure, palpitations, or weakness. Denies nausea, vomiting, constipation, abdominal pain, or changes in bowel habits. Denies dysuria, frequency, or urgency. Denies arthralgias or myalgias Past Medical History: 1. Atrial fibrillation - coumadin discontinued in the setting of GI bleed 2. CAD s/p CABG in [**2089**], has stable angina 3. Peripheral vascular disease 4. Hypertension 5. Anemia of chronic disease vs chronic GI bleed 6. Obesity 7. Arthritis 8. Irritable bowel syndrome 9. Bilateral renal artery stenosis status post right stent [**8-/2103**] 10. s/p left hip replacement 11. s/p appendectomy 12. s/p tonsillectomy 13. s/p cataract surgery [**14**]. Hypothyroidism 15. Chronic Diastolic Heart Failure 16. Severe tricuspid regurg and moderate mitral regurg Social History: Home: Lives alone. widowed. 5 grown children in the [**Location (un) 86**] area Occupation: previously employed as a substitute teacher part-time; EtOH: Denies Drugs: Denies Tobacco: 1 1/2-2ppd x15 years, quit in the [**2070**] Family History: Mother deceased 94 DM/CAD/MI Father deceased 81 DM/CAD Sister deceased Breast CA/DM Sister deceased during child birth/bleed Physical Exam: Admission Exam: VS: HR 66 BP180/70 RR16 O2sat 99%RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Irregular. II/VI systolic murmur. Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: aaox3, CNs [**2-28**] intact, strength and sensation grossly nl. Discharge Exam: 97.3; BP148/55; HR71; RR18; 98%RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Irregular. II/VI systolic murmur. Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: aaox3, CNs [**2-28**] intact, strength and sensation grossly nl. Pertinent Results: Admission Labs: [**2111-11-17**] 11:00AM BLOOD WBC-7.0# RBC-2.05*# Hgb-6.4*# Hct-19.3*# MCV-94# MCH-31.0 MCHC-32.9# RDW-14.1 Plt Ct-307# [**2111-11-17**] 11:00AM BLOOD Neuts-84.2* Lymphs-9.2* Monos-3.6 Eos-2.6 Baso-0.3 [**2111-11-17**] 11:00AM BLOOD PT-13.8* PTT-27.5 INR(PT)-1.2* [**2111-11-17**] 07:55PM BLOOD Ret Man-.5 [**2111-11-17**] 11:00AM BLOOD Glucose-99 UreaN-85* Creat-3.1* Na-138 K-4.8 Cl-104 HCO3-24 AnGap-15 [**2111-11-17**] 07:55PM BLOOD ALT-17 AST-21 LD(LDH)-198 CK(CPK)-71 AlkPhos-72 TotBili-0.5 [**2111-11-17**] 11:00AM BLOOD cTropnT-0.11* [**2111-11-17**] 07:55PM BLOOD Calcium-8.6 Phos-4.0 Mg-2.0 Iron-76 [**2111-11-17**] 07:55PM BLOOD calTIBC-269 Hapto-338* Ferritn-169* TRF-207 Urine: [**2111-11-18**] 06:35AM URINE Color-Straw Appear-Hazy Sp [**Last Name (un) **]-1.009 [**2111-11-18**] 06:35AM URINE Blood-NEG Nitrite-NEG Protein-TR Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-LG Microbiology: Time Taken Not Noted Log-In Date/Time: [**2111-11-17**] 2:38 pm URINE Site: CLEAN CATCH **FINAL REPORT [**2111-11-20**]** URINE CULTURE (Final [**2111-11-20**]): Culture workup discontinued. Further incubation showed contamination with mixed skin/genital flora. Clinical significance of isolate(s) uncertain. Interpret with caution. ESCHERICHIA COLI. >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 _________________________________________________________ ESCHERICHIA COLI | AMPICILLIN------------ <=2 S AMPICILLIN/SULBACTAM-- <=2 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-------- 32 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S [**2111-11-18**] 6:35 am URINE Source: CVS. **FINAL REPORT [**2111-11-19**]** URINE CULTURE (Final [**2111-11-19**]): NO GROWTH. IMAGING: [**2111-11-17**] CT abd/pelvis: IMPRESSION: 1. Evaluation limited given the lack of IV contrast. Normal non-contrast appearance of the bowel. 2. Large fat-containing ventral wall hernia in the right lower quadrant. 3. Multiple hyperdense renal cysts bilaterally, likely proteinaceous or hemorrhagic. However, many of these have increased in size when compared to the [**2107-11-21**] renal MRI. Followup MRI should be considered if clinically warranted. 4. Cholelithiasis. 5. Small left adnexal cyst, which appears stable when compared to the [**2107**] MRI. [**2111-11-18**] EGD: Large hiatal hernia Normal mucosa in the stomach Abnormal stomach pigmentation noted in the antrum and prepyloric area. Biopsies were obtained to rule out possible melanotic lesions versus other etiology Normal mucosa in the duodenum Abnormal pigmentation noted duodenal bulb similar to what was found in stomach. (biopsy) Otherwise normal EGD to third part of the duodenum Recommend capsule endoscopy PATHOLOGY: DIAGNOSIS: Antrum, biopsy (A): No diagnostic abnormalities recognized. Discharge Labs: [**2111-11-24**] 06:20AM BLOOD WBC-6.9 RBC-2.75* Hgb-8.3* Hct-25.3* MCV-92 MCH-30.4 MCHC-33.0 RDW-14.1 Plt Ct-372 [**2111-11-24**] 06:20AM BLOOD Plt Ct-372 [**2111-11-24**] 06:20AM BLOOD Glucose-98 UreaN-75* Creat-2.2* Na-140 K-4.1 Cl-103 HCO3-24 AnGap-17 Brief Hospital Course: 85yo female w/ CAD s/p CABG and chronic anemia presents with Hct of 19 and EKG changes. Unclear cause of recurrent anemia, GI w/u so far negative. Appropriately responded to transfusion. # Anemia: Severe, normocytic anemia of unclear source after multiple negative GI work-ups. She was persistent guaiac positive with reported dark stools. Hemodynamically stable. Appropriately responded to pRBC transfusions (total 4 units this admission). Hemolysis labs negative. Retic count 0.5, which can suggest a bone marrow process vs CKD. EGD negative, biopsy of gastric antrum normal. Increased omeprazole from 20mg daily to 20mg [**Hospital1 **]. Capsule unsuccessful on this admission, but patient refusing repeat. Overall, likely multifactorial etiology including slow or intermittent GI bleed not seen on EGD or prior capsule studies, CKD with low Epo and possible red cell aplasia. Hct stable at discharge. Nephrology team saw patient as inpatient and plan to initiate monthly Epo injections ([**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] will call patient). Will follow up with Dr. [**First Name (STitle) 805**], outpatient Nephrologist, and Dr. [**Last Name (STitle) 2539**], outpatient hematologist, and Dr. [**Last Name (STitle) 349**], outpatient [**Last Name (STitle) **], may consider repeat capsule endoscopy and/or bone marrow biopsy as outpatient. # EKG changes: Patient pain free, but EKG showed ST depressions, troponins elevated but flat. Likely demand ischemia d/t anemia. Her anti-hypertensives were restarted and depressions resolved with transfusion. # Hypertension: Severe, refractory hypertension, bilateral RAS s/p stenting. Antihypertensives initially held [**2-18**] possible GIB. Restarted Labetalol, hydral, imdur, and minoxidil. Per Nephrology recommendations, stopped spironolactone and HCTZ because of bilateral RAS. On discharge, SBP 140/150s. Consider adding amlodipine if blood pressures continue to be elevated as outpatient. # Bacturia: Patient with mod bacteria and positive nitrites, but also 5 epithelial cells. She is afebrile and without new urinary complaints, repeat UA showed no e/o infection and repeat urine culture negative, therefore she was not treated for UTI. # A-fib: On labetalol and digoxin. Rates controlled in the 60-70s. Not on ASA or coumadin given recurrent severe anemia and suspected GI bleed without clear source. # Acute on chronic renal failure: Up to 3.1 from baseline 2.0 to 2.4. Likely prerenal, trended back to baseline with transfusions. # Hypothyroidism: home Synthroid was continued # Diastolic CHF- h/o diastolic CHF, EF preserved. 4+TR, 2+ MR. Currently asx. Restart torsemide once [**Last Name (un) **] resolved. Medications on Admission: - synthroid 88mcg - hydralazine 75mg TID - isosorbide mononitrate 60mg daily - spironolactone/HCTZ 25/25 [**Hospital1 **] - omeprazole 20mg daily - labetalol 200mg [**Hospital1 **] - torsemide 20mg daily (recently taking QOD b/c of worsening diarrhea) - Digoxin 0.0625mg daily - simvastatin 20mg daily - minoxidil 2.5mg daily Discharge Medications: 1. levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. simvastatin 20 mg Tablet Sig: One (1) Tablet PO at bedtime. 3. hydralazine 25 mg Tablet Sig: Three (3) Tablet PO three times a day. 4. labetalol 200 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO BID (2 times a day). Disp:*60 Capsule, Delayed Release(E.C.)(s)* Refills:*0* 6. isosorbide mononitrate 60 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily). 7. torsemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. minoxidil 2.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. digoxin 125 mcg Tablet Sig: 0.5 Tablet PO once a day. Discharge Disposition: Home Discharge Diagnosis: PRIMARY: Anemia CKD HTN 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 **], It was a pleasure taking care of you during your hospitalization. You were admitted because you had anemia (low blood count). We gave you 4 units of red blood cell transfusion and your blood count increased. Your endoscopy showed no active bleeding in your stomach. The biopsy from your stomach was also normal. The nephrology team in the hospital saw you and recommended stopping HCTZ (hydrochlorothiazide) and spironolactone. You will follow up with Dr. [**First Name (STitle) 805**] and Dr. [**First Name (STitle) **] for blood pressure management. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] will call you to set up for Epo injection (to treat your anemia from kidney failure). We made the following changes to your medications: INCREASED omeprazole from 20mg once daily to twice daily STOPPED HCTZ (hydrochlorothiazide) STOPPED Spironolactone Followup Instructions: Name: [**Last Name (LF) 805**], [**First Name3 (LF) **] E. MD Location: [**Last Name (un) **] DIABETES CENTER Address: ONE [**Last Name (un) **] PLACE, [**Location (un) **],[**Numeric Identifier 718**] Phone: [**Telephone/Fax (1) 3402**] Appt: [**12-1**] at 3:30pm Name: [**Last Name (LF) 9328**],[**First Name3 (LF) **] [**Doctor First Name 9329**] Address: [**Street Address(2) 9330**], [**Doctor First Name **] 2, [**Hospital1 **],[**Numeric Identifier 9331**] Phone: [**Telephone/Fax (1) 9332**] When: Friday, [**12-4**], 9:30AM Department: DIV. OF GASTROENTEROLOGY When: MONDAY [**2111-12-14**] at 1 PM With: [**First Name8 (NamePattern2) 870**] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 463**] Building: Ra [**Hospital Unit Name 1825**] ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) **] Campus: EAST Best Parking: Main Garage Department: HEMATOLOGY/ONCOLOGY When: FRIDAY [**2111-12-25**] at 10:45 AM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 9052**], MD [**Telephone/Fax (1) 22**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: [**Hospital 2039**] CARE CENTER When: WEDNESDAY [**2112-1-13**] at 1:30 PM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 43710**], NP [**Telephone/Fax (1) 2041**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage [**Last Name (LF) **], [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] Title:Renal Nurse Practitioner Division:Nephrology Office Location:[**Street Address(2) 8667**] - FA8 Patient Phone:([**Telephone/Fax (1) 11957**] Patient Fax:([**Telephone/Fax (1) 21178**] * [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] will call you to set up for Epo injection (to treat your anemia from kidney failure). Completed by:[**2111-11-29**]

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icd9cm

[ [ [] ] ]

[ "45.16" ]

icd9pcs

[ [ [] ] ]

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47558

Discharge summary

report

Admission Date: [**2123-4-12**] Discharge Date: [**2123-4-15**] Date of Birth: [**2064-3-13**] Sex: M Service: MEDICINE Allergies: Hydrochlorothiazide / Demerol / Ambien Attending:[**First Name3 (LF) 7055**] Chief Complaint: shortness of breath, respiratory distress Major Surgical or Invasive Procedure: Endotracheal intubation Cardiac Catheterization History of Present Illness: 58 y.o male with h/o DM, htn, hypercholesterolemia, with known dz per cath in [**2114**] where pt had 95% mid RCA stenosis, 70% Lcx, 60% LAD and 40% L main with recent 4 vessel CABG on [**2123-3-4**] (LIMA to LAD, SVG to OM, ramus, RCA), who presents with acute SOB/respiratory distress. He present to [**Hospital1 18**] [**Location (un) 620**] where he was found to be acidemic (ABG 7.08/87/91), intubated for hypercarbic respiratory failure. He was started on a heparin gtt and nitro gtt. He also had ?Vtach on EKG and was started on lidocaine drip. There was a question of t-wave changes on EKG, and he was transferred here for cardiac catheterization and further management. Cath on arrival showed patent grafts (no PTCA performed), and he was brought to CCU for further management. Past Medical History: 1. CAD, s/p recent CABG as above; TTE [**3-6**] showing dilated LA/LAV, 1+ MR, EF=20-30%, with BiV pacer for ventricular arrhythmias 2. Prostatitis 3. Melanoma s/p excisions 4. DM x 2 years 5. Recurrent PNA 6. GERD 7. gout 8. Sleep apnea 9. s/p hemorrhoidectomy 10. bilateral Iliac artery anneurysm s/p repair 11. Hypertensive cardiomyopathy 12. Hypercholesterolemia 13. Cervical radiculopathy Social History: Ex-smoker, with 40 pack-year smoking history. He quit in [**2106**]. He lives with his wife. [**Name (NI) **] history of EtOH consumption. Family History: Father with MI in 50s Physical Exam: VS: 99.0 89/55 60 14 100% on AC, FiO2=100%, 700/14, PEEP=10 Gen: in mild distress, intubated HEENT: PERRL, OP clear Lungs: crackes at bases, no w/r CV: RRR, nl s1/s2, no m/r/g Abd: soft, nt/nd, nabs, no masses Groin: right groin with sheath, left with triple lumen Extr: no c/c/e, DP 2+ bilat Neuro: moving all 4 extremities Pertinent Results: EKG at OSH: Wide complex tachycardia, right axis, LBBB; rate=102 CXR: mild failure Brief Hospital Course: 1. CAD; no anginal symptoms on admission, but cardiac catheterization was performed to rule out ischemia as a cause of his ?CHF flare and respiratory distress. Catheterization revealed patent vein grafts, and no intervention was performed. He was continued on his Aspirin, Lipitor, Lisinopril, Coreg. His dose of lisinopril was increased to 20 mg daily while the Coreg was increased to 12.5 mg twice daily. His lipid profile was checked, and his LDL was found to be 50, so his dose of Lipitor was decreased to 40 mg daily. He had no anginal symptoms or EKG changes, and he was discharged on his medical regimen, to follow up with his PCP and cardiologist. 2. CHF: His chest X-ray and exam on admission was consistent with congestive heart failure (likely the cause of his respiratory distress on admission). He was diuresed with good success, 1-1.5 L each day with IV lasix. TTE was repeated showing EF=15-20% with worsening of systolic function from prior TTE. Although the cause of his current CHF flare was never definitively determined, it was thought to be secondary to dietary indiscretions (patient had apparently eaten ?salty chinese food prior to presentation). He was euvolemic at time of discharge and will continue his home lasix/potassium regimen. He will weigh himself daily and have his creatinine/K checked in [**3-5**] days after discharge. He declined evaluation for heart transplant at this time. 3. Rhythm: He had ?ventricular tachycardia at the outside hospital. His pacemaker was interrogated by EP while in-house who thought that his arrhythmia was sinus tachycardia. NIPS study was performed, and the pacemaker was found to be functioning properly. His amiodarone was continued at his current dose, and he will follow up in device clinic. 4. Respiratory: intubated in [**Location (un) 620**] for hypercarbic respiratory failure, and he was extubated at [**Hospital1 18**] on day of admission after some diuresis. He likely was in respiratory distress secondary to pulmonary edema. He remained stable after extubation and was saturating adequately on room air at time of discharge. He was continued on his atrovent and advair while in-house. 5. Chronic RF; baseline 1.3-1.5; his creatinine remained below his baseline but increased to 1.3 at time of discharge (likely after diuresis). He was instructed to have his Creatinine rechecked 3-4 days after discharge. 6. Dispo: He was discharged in good condition and will follow up with his PCP, [**Name10 (NameIs) 2085**], cardiac surgeon, and electrophysiologist. Medications on Admission: Meds on Admission: Lisinopril 10 mg Coreg 3.125 mg [**Hospital1 **] Dig 0.125 mcg Ranitidine 150 mg daily Amiodarone 200 mg daily Glyburide 2.5 mg daily Lasix 40 mg [**Hospital1 **] Escitalopram 20 mg daily Lipitor 80 mg daily Klonopin 0.5 [**Hospital1 **] Zetia 10 mg daily Percocet PRN KCL 20 meq daily Discharge Medications: 1. Atorvastatin Calcium 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 3. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 4. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 5. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation Q4-6H (every 4 to 6 hours) as needed. Disp:*qs * Refills:*3* 6. Amiodarone HCl 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 7. Escitalopram Oxalate 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 8. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 9. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed. 10. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 11. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 12. Carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 13. Lasix 40 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:*60 Tablet(s)* Refills:*2* 14. Glyburide 2.5 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 15. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day. 16. Outpatient Lab Work Please check creatinine and potassium on [**2123-4-19**] Discharge Disposition: Home Discharge Diagnosis: Primary Diagnoses: 1. Congestive Heart Failure 2. Respiratory failure requiring intubation 3. Coronary Heart Disease Secondary Diagnoses: 1. Hypertension 2. Hypercholesterolemia 3. Diabetes Mellitus Discharge Condition: Good Discharge Instructions: 1. Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs. Adhere to 2 gm sodium diet Fluid Restriction: 1.5 L daily 2. Please take all your medications exactly as described in this discharge paperwork. We made the following changes to your medication regimen: - We increased your Lisinopril to 20 mg daily - We increased your Coreg to 6.25 mg daily - We decreased your Lipitor to 40 mg daily 3. Please follow up with your cardiologist, Dr. [**Last Name (STitle) **] as described below. Please call your PCP if you are experiencing chest pain, shortness of breath, fever, chills, weight gain more than 3 lb, or with any other concerns. Followup Instructions: 1. Follow up with Dr. [**Last Name (STitle) **] on [**2123-5-31**] ([**Telephone/Fax (1) 127**]) 2. Provider: [**Name10 (NameIs) **] [**Name11 (NameIs) 7045**], MD Where: CARDIAC SURGERY LMOB 2A Date/Time:[**2123-4-20**] 2:00 3. Follow up with Dr. [**Last Name (STitle) 1407**] ([**Telephone/Fax (1) 100531**]) on [**2123-4-28**] as already scheduled. He may need to adjust your dose of glyburide at this time. You should also have your electrolytes checked on Monday, [**2123-4-19**] to ensure that your potassium and creatinine are under good control. 4. Follow up with Dr. [**Last Name (STitle) **] as scheduled for your pacemaker

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icd9cm

[ [ [] ] ]

[ "88.56", "37.26", "96.04", "37.23" ]

icd9pcs

[ [ [] ] ]

6887, 6893

2315, 4871

341, 390

7141, 7147

2207, 2292

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418, 1211

4916, 5203

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1658, 1798

65,050

101,816

42468

Discharge summary

report

Admission Date: [**2157-12-26**] Discharge Date: [**2158-1-4**] Date of Birth: [**2094-10-13**] Sex: F Service: CARDIOTHORACIC Allergies: Penicillins / aspirin Attending:[**First Name3 (LF) 1505**] Chief Complaint: mitral regurgitation Major Surgical or Invasive Procedure: Mitral valve repair(28-mm Physio II annuloplasty ring) [**2157-12-28**] History of Present Illness: This 63 year old hHispanic female has a history of asthma has had shortness of breath which has increased recently. She had new chest pain which radiated down the left arm and was admitted to [**Hospital3 **] for further work up. She underwent cardaic catheterization. She was found to have mitral regurgitation with elevated pulmonary pressures and an ejection fraction of 80%. Her coronaries without stenosis. Past Medical History: hypertension insulin dependent diabetes mellitus complete heart block s/p c-section s/p L cataract surgery with lens implant s/[**Initials (NamePattern4) **] [**Last Name (un) 8509**] surgery s/p R hand surgery s/p dual chamber pacemaker implant(St. [**First Name4 (NamePattern1) 923**] [**Last Name (NamePattern1) 10550**] 5820) Social History: Lives with: alone Cigarettes: Smoked no [x] yes [] last cigarette _____ Hx: Other Tobacco use: ETOH: none Illicit drug use: denies Race: Hispanic Family History: unremarkable Physical Exam: Pulse: 85 v paced Resp: 18 O2 sat: 100% RA B/P Right: 127/74 Left: Height: 67" Weight: 232 lbs General: Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x] Dental: multiple bridges Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] well-healed pacer site Heart: RRR [x] Irregular [] Murmur [x] grade __2/6 pan systolic____ Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Extremities: Warm [x], well-perfused [] Edema [x] __2+ bilat___ Varicosities: None [x] Neuro: Grossly intact [x] Pulses: Femoral Right: 2+ Left: 2+ DP Right: 1+ Left: 1+ PT [**Name (NI) 167**]: 1+ Left: 1+ Radial Right: 2+ Left: 2+ Carotid Bruit Right: no Left: no Pertinent Results: TEE [**2157-12-28**]: Conclusions PRE-BYPASS: No spontaneous echo contrast or thrombus is seen in the body of the left atrium or left atrial appendage. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. There is mild regional left ventricular systolic dysfunction with hypokinetic apical segments. The aortic arch is mildly dilated. There are simple atheroma in the descending thoracic aorta. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. The mitral valve leaflets are moderately thickened. The mitral valve leaflets do not fully coapt and bileaflet restriction is appreciated. There is a central MR jet with Moderate to severe (3+) mitral regurgitation. There is no pericardial effusion. POSTBYPASS: The patient is AV paced on epinephrine & phenylephrine infusions. There is a well seated annuloplasty ring in the mitral position. The Mitral regurgitation is now trace to mild. The RV function is maintained. The LV function is mildly improved on inotropy, with EF 50%. The remaining valves are unchanged. The aorta remains intact. [**2158-1-1**] 06:10AM BLOOD WBC-8.6 RBC-3.30* Hgb-8.5* Hct-26.9* MCV-82 MCH-25.9* MCHC-31.7 RDW-13.7 Plt Ct-165# [**2157-12-30**] 02:14AM BLOOD PT-14.4* PTT-29.3 INR(PT)-1.3* [**2158-1-1**] 06:10AM BLOOD UreaN-15 Creat-0.6 Na-135 K-4.8 Cl-100 [**2157-12-26**] 07:38PM BLOOD ALT-50* AST-32 LD(LDH)-239 AlkPhos-47 TotBili-0.2 [**2158-1-1**] 06:10AM BLOOD Mg-2.2 [**2157-12-26**] 07:38PM BLOOD %HbA1c-7.4* eAG-166* Brief Hospital Course: The patient was transferred from [**Hospital6 3105**] on [**2156-12-26**]. She underwent preop testing including PFTs, Echo, and dental consult. On [**2157-12-28**] she had a mitral valve repair with a 28mm annuloplasty ring. The cross clamp time was 38 minutes and the total bypass time was 51 minutes. She tolerated the procedure well and was transferred to the CVICU in stable condition on Propofol. She was extubated on the post op night and had her chest tubes discontinued on POD#1. She was transferred to the floor but had to return to the CVICU that night for hyperglycemia requiring an insulin drip. She was restarted on her preop NPH and was stable by the morning of POD#2. She was transferred back to the floor in stable condition. Pacing wires and chest tubes wer removed per protocol and sh3e was gently diuresed toward her preop weight. Her glucoses remained somewhat problem[**Name (NI) 115**] and the 70/30 insulin was downwardly adjusted to compensate. The evening dose was discontinued. In conversation she says at home she snacks at night and that is perhaps why her Morning glucoses in house have been low. the glucoses the morning after stopping evening NPH dosing her glucoses were in the mid 100s- the insulin can be adjusted at rehab as her intake changes. She continued to make good progress and was cleared for discharge to [**Location (un) 16493**]rehab in N. [**Location (un) 7658**] on POD 8. All follow up appointments were arranged. Medications on Admission: Xopenex 1.25 mg q 6 hours PRN Lisinopril 20 mg PO daily KCl QID Loratadine 10 mg PO daily Flonase 1 NU daily Duonebs Levoxyl 0.25 PO daily FESO4 325 mg PO daily Advair Novolin 60 U SC BID Discharge Medications: 1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) for 1 months. 2. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for fever/pain. 3. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. 4. levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) neb Inhalation Q6H (every 6 hours) as needed for wheezing. 6. fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1) Spray Nasal DAILY (Daily). 7. fluticasone-salmeterol 500-50 mcg/dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 8. fexofenadine 60 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 9. heparin (porcine) 5,000 unit/mL Solution Sig: 5000 (5000) units SC Injection TID (3 times a day): until ambulating frequently. 10. polyethylene glycol 3350 17 gram/dose Powder Sig: Seventeen (17) gram PO DAILY (Daily). 11. metoprolol tartrate 25 mg Tablet Sig: 1.5 Tablets PO BID (2 times a day). 12. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) as needed for constipation. 13. insulin NPH & regular human 100 unit/mL (70-30) Insulin Pen Sig: Fifty (50) units Subcutaneous Q AM. 14. Humalog 100 unit/mL Cartridge Sig: per sliding scale Subcutaneous ac & HS: 120-160:2unitsac/0units HS;161-200:4units ac/2units HS;201-240:6units ac/4units HS,241-280:8units ac/6units HS. Discharge Disposition: Extended Care Facility: [**Location (un) 39857**] - [**Location 9583**] Discharge Diagnosis: hypertension mitral regurgitation s/p mitral valve repair [**2157-12-28**] insulin dependent diabetes nellitus complete heart block s/p permanent dual chamber pacemaker Discharge Condition: Alert and oriented x3, nonfocal Ambulating with steady gait Incisional pain managed with oral analgesics Incisions: Sternal - 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 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. [**Last Name (STitle) **] ([**Telephone/Fax (1) 170**]) on 2/1512 1PM Cardiologist: Dr. [**Last Name (STitle) 66588**] on [**2158-1-26**] at 12:30 Please call to schedule appointments with your Primary Care Dr. [**First Name11 (Name Pattern1) 1399**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] ([**0-0-**]) in [**3-23**] weeks **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Completed by:[**2158-1-4**]

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icd9cm

[ [ [] ] ]

[ "35.33", "39.61" ]

icd9pcs

[ [ [] ] ]

7052, 7126

3798, 5275

310, 386

7339, 7517

2144, 3775

8445, 9049

1365, 1379

5514, 7029

7147, 7318

5301, 5491

7541, 8422

1394, 2125

250, 272

414, 831

853, 1185

1201, 1349

22,772

175,215

43060

Discharge summary

report

Admission Date: [**2148-9-14**] Discharge Date: [**2148-9-26**] Date of Birth: [**2092-10-28**] Sex: M Service: MEDICINE Allergies: Acyclovir Attending:[**First Name3 (LF) 465**] Chief Complaint: . Fevers, Line infection . Major Surgical or Invasive Procedure: . Exchange of tunneled femoral HD catheter in IR placement of midline . History of Present Illness: . Mr. [**Known lastname **] is a 55 year old man with a history of ESRD on HD, DMII, HCV who presented to [**Hospital1 18**] from home complaining of "not feeling right". He reported that a few days prior to admission he felt unwell. He had nausea and one episode of vomiting. He mentioned some of his symptoms at [**Hospital1 2286**] but it is not clear if anything such as blood cultures were done at that time. He continued to feel poorly so on the morning of admission he was sent in from HD to the ED for evaluation. He also noted that he began feeling lower back pain which was new. +fevers/chills. Pt also denied SOB. . In the ED his temp was noted to be 101.4, with SBP's in the 70's. Peripheral dopamine was started as the patient refused a CVL. 3L NS was administered. . Past Medical History: . 1. Type 2 diabetes times 16 years. 2. End stage renal disease secondary to diabetes, currently on hemodialysis. L femoral tunnelled catheter. 3. Hepatitis C. 4. History of deep venous thrombosis and superior vena cava thrombosis 5. Hypertension. 6. Congestive heart failure with ejection fraction of 40 percent in [**2145-8-27**]. In [**5-30**], LVEF 55%, impaired relaxation, [**1-29**]+ MR. 7. History of zoster. 8. Aortic calcifications. 9. Elevated homocysteine. . Social History: . Quit IVDU (heroin) 11 years ago. Tob: 10-20cigs/day x 40years. No current EtOH use. Lives alone, at home in [**Location (un) 686**]. Not employed. . Family History: pt refused to relay history Physical Exam: . VS: Tm 101.4 Tc 96 BP 102/63 HR 76 RR 25 Sat (100% on 2L in ED) Gen: Man in no apparent distress, somewhat uncooperative HEENT: OP clear, MM, PERRL, sclerae anicteric Neck: Scars from R IJ tunneled cath, CV: nl s1/s2, no m/r/g Pul: Crackles in bilateral lower lung fields Abd: Soft, NT, ND, +BS Back: No midline tenderness Ext: L femore tunneled cath, no purulence or tenderness Neuro: A&Ox3 . Pertinent Results: . [**2148-9-14**] 06:40PM CORTISOL-26.3* [**2148-9-14**] 05:54PM GLUCOSE-117* UREA N-15 CREAT-4.7* SODIUM-138 POTASSIUM-3.2* CHLORIDE-101 TOTAL CO2-22 ANION GAP-18 [**2148-9-14**] 05:54PM LD(LDH)-175 [**2148-9-14**] 05:54PM CALCIUM-8.5 PHOSPHATE-2.6* MAGNESIUM-1.2* [**2148-9-14**] 05:54PM CORTISOL-24.1* [**2148-9-14**] 05:54PM WBC-15.9*# RBC-4.20* HGB-12.4* HCT-37.0* MCV-88 MCH-29.6 MCHC-33.7 RDW-15.5 [**2148-9-14**] 05:54PM PLT SMR-LOW PLT COUNT-84* [**2148-9-14**] 01:00PM PT-33.3* PTT-150* INR(PT)-3.6* [**2148-9-14**] 10:47AM LACTATE-3.3* [**2148-9-26**] Vanco 15.1 [**2148-9-14**] blood cx STAPHYLOCOCCUS, COAGULASE NEGATIVE . [**9-22**] CXR: FINDINGS: Comparison is made to previous study from [**2148-9-17**]. There is a catheter projecting over the mid abdomen likely into the IVC. Clinical correlation is recommended. There is a very large right-sided pleural effusion, which is partially loculated along the right lateral chest wall, which is unchanged from the prior study. The right side down decubitus view demonstrates some layering of the fluid; however, a LEFT side down decubitus view would be best for evaluation of the pleural fluid. The left lung field is clear. There are no signs for overt pulmonary edema. There is cardiomegaly. Overall, the findings are stable. . [**9-22**] AXR: FINDINGS: Catheter is seen projecting over the mid abdomen in the IVC/right atrium, likely [**Month/Year (2) 2286**] catheter. There is a large right pleural effusion. There is no free air under the diaphragm. Intraluminal jejunal contrast from previous study is noted. Note is made vascular calcifications. No dilated bowel loops are identified. Stool and air is present within the colon. IMPRESSION: 1) No obstruction. 2) Large right pleural effusion. . ECHO, [**2148-9-18**]: LVEF 50-55%. The left atrium is mildly dilated. There is symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. There is mild global left ventricular hypokinesis. Overall left ventricular systolic function is mildly depressed. Right ventricular chamber size and free wall motion are normal. The aortic root is mildly dilated. The aortic valve leaflets (3) are mildly thickened. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Moderate (2+) mitral regurgitation is seen. The left ventricular inflow pattern suggests impaired relaxation. The tricuspid valve leaflets are mildly thickened. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. . Compared with the prior study (images reviewed) of [**2148-8-21**], mitral regurgitation is now more prominent and estimated pulmonary artery systolic pressure is now higher. As noted in the prior report would consider diagnosis of amyloid versus hypertensive heart disease. No vegetation identified but cannot exclude. . Tunneled Catheter Placement, [**2148-9-17**]: Status post successful placement of tunneled hemodialysis catheter via the left transfemoral approach. Extensive venous disease in the infrarenal inferior vena cava, left common iliac and left external iliac veins. There is no apparent venous inflow from the right iliac system. This will likely preclude any further de [**Last Name (un) 11083**] placement of transfemoral approach lines or catheters. This patient may be served with placement of a stent within the narrowed segment of the infrarenal inferior vena cava and or left common and external iliac veins. Status post venous angioplasty in the infrarenal abdominal aorta and left external iliac artery. Removed catheter tip sent for microbiology. . Chest xray, [**2148-9-17**]: Right-sided pleural thickening and subpleural atelectasis are chronic since at least [**2147-12-28**]. Since [**9-14**], a large right pleural effusion has reaccumulated. Atelectasis at the base of the left lung is unchanged. There is no interstitial pulmonary edema. Heart size top normal. . EKG, [**2148-9-14**]: Sinus rhythm; Indeterminate axis; Intraventricular conduction delay; Possible anterior infarct - age undetermined; Generalized low QRS voltages; Since previous tracing of [**2148-1-16**], no significant change . MRI Spine, [**2148-9-14**]: Limited study secondary to motion. No evidence of discitis or osteomyelitis on this non-enhanced study. Question of elongation of intra-articular region at L5 level could be to spondylolysis. . EGD: Esophagus: Mucosa: Esophagitis with ulceration and no bleeding was seen in the lower third of the esophagus . Protruding Lesions A single nodule with some supoerficial erosion was seen in the gastroesophageal junction. Not biopsied because of elevated INR. Other Whitish exudate was seen in the esophagus Stomach: Other Small thickened fold was seen with some erythema in the body of the stomach Duodenum: Other A small thickened fold vs nodule was seen in the duodenal bulb. Impression: Esophagitis in the lower third of the esophagus Nodule in the gastroesophageal junction A small thickened fold vs nodule was seen in the duodenal bulb. Small thickened fold was seen with some erythema in the body of the stomach Whitish exudate was seen in the esophagus Otherwise normal EGD to second part of the duodenum Recommendations: PPI Repeat EGD with biopsy of the esophageal nodule when INR is lower Follow Hct Brief Hospital Course: . This is a 55 year old man with a history of ESRD on HD, DMII, HCV admitted to the MICU after tunneled fem line infection and hypotension requiring pressors in the unit. Blood cxs revealed [**4-30**] Coag Neg Staph with antibiotics were narrowed to Vancomycin QHD. . Brief MICU Course: the patient was started on broad spectrum IV antibiotics, Vanc and Gent for presumed HD femoral line infection. The patient had a low blood pressure at baseline, however dopamine was required for hypotension (80s/60s). A Cortisol stim test was performed to evaluate for adrenal insufficiency and the patient did not respond appropriately. A five day course of Hydrocortisone TID was started for adrenal insufficiency. The patient's Coumadin was supratherapeutic upon admission and was held given the need for changing HD catheter. Dopamine was weaned off. Gent was stopped when [**4-30**] blood cxs grew Coag neg Staph. Vancomycin was continued. Mr. [**Known lastname **] will be maintained on a 4 wk course from the day the infected [**Known lastname 2286**] catheter was pulled ([**2148-9-17**]). The cathether was pulled and exchanged on [**9-17**]. He was given 4 unit FFP prior to the procedure to reverse his INR. He was transferred to the general medicine [**Hospital1 **] after his hypotension resolved and his pressors were weaned. . 1. Sepsis/Line Infection: The most likely source for his sepsis was the HD cath (prior to this admission, last changed 1 yr ago). Blood cultures from [**Date range (1) 79555**] have been negative. No further cultures were drawn. The patient was treated with vancomycin 1g during HD dosed if the vanco level was <15. The patient will remain on the Vanco for a 4 week course. This was communicated to the patient's outpatient hemodialysis center as they would be dosing his vancomycin as an outpatient. . 2. Vomiting/esophageal nodule/ulceration: Towards the end of his hospitalization, the patient had nausea and vomiting intermittently. He often experienced this at home. He also complained of burning in his epigastrium. His protonix was changed to [**Hospital1 **] with some improvement in his symptoms. Reglan was changed to QID with meals and before bedtime. A KUB showed no abdominal pathology. The patient remained afebrile. Amylase was elevated but his lipase was WNL. The DDx included diabetic gastroparesis vs. PUD vs mesenteric ischemia. Given the absence of abdominal pain and a neg FOBT, mesenteric ischemia was low on the differential. The epigastric burning and tenderness made PUD a possible cause. As the patient's Hct had dropped from 35 to 29, an EGD was scheduled to R/O PUD. The patient had a previous EGD which showed Barrets esophagus. The current EGD showed esophagitis and a nodule in the GE junction. The plan was to biopsy the nodule when the INR was lowered. GI recommended that this be done within six weeks. The patient was advised to have the biopsy done this admission and the risks of delaying the procedure were explained to him. Because he had had an extensive hospitalization, he declined and preferred to be readmitted for reversal of his INR in about 4 weeks. An appointment for re-admission for the procedure was made for [**10-28**]. As the patient had no vomiting in > 72 hrs and was tolerating PO, it was thought that he was ready for discharge. A gastric emptying study should be scheduled as an outpatient. . 3. Worsening effusion/consolidation on chest xray: The patient has had a persistent R sided effusion for years which has been tapped multiple times, showing transudative fluid. In [**2145**] a pulmonary consult was obtained which recommended no further taps and no pleurodesis. They recommended managing his effusions with volume removal via [**Year (4 digits) 2286**]. The most recent CXR showed a worsened loculated effusion. He had last been tapped in [**12-31**]. The fluid was both loculated and transudative. As the patient was felt to be only minimally symptomatic with occasional SOB, it was decided that tapping the fluid would be of minimal utility and was not done. . 4. Amyloidosis on echo: Cardiology was consulted and no biopsy was recommended. Per the patient's nephrologist (and PCP) this issue will being worked up as an outpatient with outpatient MRI. This is likely a result of his CKD. . 5. Endocrine: a) DM II: The patient had his BS tested qid. The patient was continued on his home RISS. The patient was not on any long acting insulin at home. The sliding scale was adjusted down secondary to episodes of hypoglycemia and decreased PO intake from vomiting. . 6. Possible Adrenal insufficiency: As the patient did not respond appropriately to the [**Last Name (un) 104**] stim test, he was started on hydrocortisone TID x 5 days. The patient's blood pressure remained stable in the 90's upon cessation of the hydrocortisone. . 7. h/o DVT: The patient is on Coumadin for DVT. He had a subtherapeutic INR secondary to holding coumadin for replacement of the femoral line. He was restarted on coumadin 4 mg Qhs as this was his home dose and was bridged with a heparin gtt. The patient again became supratherapuetic on 4mg Qhs. Upon discharge, the patient was advised to hold his coumadin for two nights and then have his INR checked at [**Last Name (un) 2286**] on the third day. The patient's outpatient [**Last Name (un) 2286**] center was informed of the need for his nephrologist to redose his coumadin based on his INR at his next [**Last Name (un) 2286**] appointment. They were also informed that they were to dose his vancomycin 1g with [**Last Name (un) 2286**] if the vanco level was < 15. . 8. FEN: Patient was maintained on a renal diet. His phosphate binders were held while his phosphate was low. . 9. PPX: heparin/Coumadin, continue PPI. . Code: Full . Access: He has a femoral line that has been replaced. Due to very poor peripheral access, a midline was placed for his EGD and peripheral access. This was left in at discharge inadvertently, but was noted by the hemodialysis staff several days later. His PCP [**Last Name (NamePattern4) **]. [**First Name (STitle) 805**] was informed that the intention was to remove this access while he is an outpatient. Peripheral access will need to be readdressed on readmission for EGD. . . Medications on Admission: . Vitamin B1 100mg po qd Protonix 20mg po qd Insulin Reg 5u PRN Forsenol 1000mg po tid Tums 1gm TID w/ meals Sensipar 30mg po qd Fluoxetine 10mg 4x/wk on non-HD days . Discharge Medications: 1. Fluoxetine 10 mg Capsule Sig: One (1) Capsule PO 4X/WEEK ([**Doctor First Name **],MO,WE,FR): Give on non-HD days. 2. Cinacalcet 30 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1) gram Intravenous QHD for 9 days: Please check vancomycin trough and give dose at hemodialysis if trough < 15. Started on [**2148-9-17**] and needs 4 weeks of treatment (complete [**2148-10-15**]). 4. Tums 500 mg Tablet, Chewable Sig: Two (2) Tablet, Chewable PO three times a day: Take three times per day with meals. 5. Vitamin B-1 100 mg Tablet Sig: One (1) Tablet PO once a day. 6. Insulin Please resume your outpatient insulin regimen, Regular Insulin 5 units PRN hyperglycemia (high blood sugar). 7. Forsenol Please continue your outpatient regimen of Forsenol (phosphate binder). Forsenol 1000 mg PO TID. 8. Metoclopramide 10 mg Tablet Sig: 0.5 Tablet PO QID (4 times a day). Disp:*60 Tablet(s)* Refills:*2* 9. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO twice a day. Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 10. coumadin Please do not take coumadin on thursday and friday evening [**9-26**] and [**9-27**]. Your nephrologist will tell you how much coumadin to take on saturday during [**Month/Day (4) 2286**] Discharge Disposition: Home Discharge Diagnosis: . Line sepsis, femoral catheter exchange . Discharge Condition: . Good . Discharge Instructions: . 1- Please attend all follow-up appointments as listed below. . 2- Please take all medications as prescribed. . 3- Please call your doctor if you experience fevers, chills, nausea or vomiting. Also please call your doctor if you experience bleeding, redness, warmth at the site of your new femoral line or back pain. . Please do not take your coumadin thursday or friday evening. Your INR will be sent to Dr. [**First Name (STitle) 805**] by the [**First Name (STitle) 2286**] staff on saturday and he will re-dose your coumadin. . You will need to return to the hospital for a biopsy of the esophagus. You will be notified when the scheduled appointment is. Followup Instructions: . You will restart your outpatient [**First Name (STitle) 2286**] treatments on Saturday per your usual routine. They are expecting you on Saturday at your usual time. You will be seen by one of your renal doctors at [**Name5 (PTitle) 2286**] and [**Name5 (PTitle) **] have your INR checked at that time and your coumadin dosed. . Please follow up with your PCP [**Name9 (PRE) **],[**First Name3 (LF) 251**] [**Name Initial (PRE) **]. [**Telephone/Fax (1) 3637**]. . [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 472**] Completed by:[**2148-10-1**]

[ "530.19", "790.92", "038.19", "255.4", "403.91", "585.6", "V58.61", "995.91", "996.62", "428.0", "424.0", "277.3", "070.54", "250.40", "V58.67" ]

icd9cm

[ [ [] ] ]

[ "00.17", "45.13", "99.07", "38.95", "39.95" ]

icd9pcs

[ [ [] ] ]

15519, 15525

7684, 13948

297, 370

15612, 15623

2320, 7661

16332, 16953

1858, 1887

14166, 15496

15546, 15591

13974, 14143

15647, 16309

1902, 2301

231, 259

398, 1180

1202, 1674

1690, 1842

48,344

122,365

4915

Discharge summary

report

Admission Date: [**2185-5-11**] Discharge Date: [**2185-5-25**] Date of Birth: [**2120-1-12**] Sex: M Service: MEDICINE Allergies: Heparin Agents Attending:[**First Name3 (LF) 613**] Chief Complaint: Right lower extremity pain Major Surgical or Invasive Procedure: None History of Present Illness: Mr. [**Known lastname 1794**] is a 65 year-old male with history of recent hospitalization for bilateral pulmonary emboli, DVTs, and spontaneous intra-hepatic hematoma requiring massive transfusion protocal activation sent today from PCP's office after four days of right lower extremity pain. Patient found to have ultrasound evidence of a full length right lower extremtiy DVT. . Mr. [**Known lastname 1794**] was admitted from [**2185-4-23**] - [**2185-5-1**] for left sided chest pain and was found to have bilateral PEs. Patient was initially anticoagulated with heparin, which was transitioned to lovenox and warfarin. Patient developed abdominal pain and was found on CT scan to have an intrahepatic hematoma with extravasation. He was taken to IR, but no active extravasation was discovered and nothing was embolized. He received 4 units PRBC with massive transfusion protocol and 1 unit platelets. He received additional 2 units of PRBC on day 1 of MICU stay because of hypotension, which was attributed to hemorrhage. Transplant surgery was consulted and recommended conservative management of intrahepatic hematoma. MICU course was complicated by hypoxic respiratory failure requiring intubation. As anticoagulation was contra-indicated given bleed, IR placed IVC filter on [**2185-4-25**]. Patient was discharged on no anticoagulation. . Today patient presented to his primary care doctor's office complaining of 4 days of right lower extremity pain with numbness in his leg and loss of sensation in his right foot. The pain is exacerbated by direct pressure on his foot. He notes pain extending from his mid calf until the top of his thigh. . Patient was sent to the emergency department. Initial vitals were T 97.9, HR 116, BP 124/85, R 20, O2 Sat 98% on 4L. He triggered on arrival for a pulseless right foot. Initially the emergency department was concerned for arterial compromise. An ultrasound of the RLE showed evidence of a full RLE DVT. Vascular surgery was consulted and felt that the limb was non-threatened as patient had palpable right femoral, popliteal, and DP pulses and recommended anticoagulation when safe, elevation of RLE, and ACE wrap. . In ED patient also complained intermittent, vague abdominal pain. He had a CT Abdomen/Pelvis showing a stable liver hematoma. The CT also showed the IVC filter with clot extending 2.2 cm above the filter in the IVC. Patient was evaluated by transplant surgery who felt there was no role for surgical intervenstion adn the risk/benefit of anticoagulation in the setting of liver hematoma should be made by primary team. Patient received no medications or blood. He received 1.5 L of IVF. On transfer vitals were T 100.1, HR 124, BP 138/98, RR 27, O2 sat 98RA. . On the floor, patient reports that he has leg pain from his right mid-posterior calf extending up though thigh to his right groin. He has some mild numbness and tingling on the back of his right calf. He denies abdominal pain unless someone presses down on his abdomen. He denies chest pain, dyspnea, lightheadedness, syncope. His abdominal pain is improved from his last admission. Patient has noted recent weight loss and decreased appetite recently. Endorses fatigue and weakness. . Review of systems: (+) Per HPI (-) Denies fever, chills, night sweats. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies cough, shortness of breath, or wheezing. Denies chest pain, chest pressure, palpitations. Denies nausea, vomiting, diarrhea, constipation, abdominal pain, or changes in bowel habits. Denies BRBPR, melena. Denies dysuria, frequency, or urgency. Denies arthralgias or myalgias. Denies rashes or skin changes. Past Medical History: b/l Pulmonary Emboli Intra-hepatic hematoma [**Doctor Last Name 933**] Disease Dyslipidemia Hypertension Social History: Married, lives with wife. [**Name (NI) **] involved in care Occupation: Retired; previously worked with animals and livestock; denies h/o pesticide exposure or factory work Tobacco: Denies EtoH: Denies Drugs:Denies Family History: No history of clotting disorders No history malignancy Physical Exam: On Admission: Vitals: T: 99.6 BP: 152/76 P: 112 R: 20 O2: 96% on RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Tachycardiac, normal S1 + S2, no murmurs, rubs, gallops, no heaves or lifts Abdomen: soft, mild right upper quadrant and right lower quadradant tenderness to palpation, non-distended, bowel sounds present, no rebound tenderness, ? guarding, no organomegaly GU: no foley Ext: warm, well perfused, right calf larger than left calf, [**1-2**]+ DP pulses on right and left, 1+ PT pulses, no palpable cords, lower extremity sensation intact to pinprick and light touch On Discharge: Tc+Tm 99.6, BP 108/86 (108-120/70-86), HR 107 (96-112), 98%RA (98-100%RA) General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, few basilar rales, ronchi CV: Tachycardiac, normal S1 + S2, no murmurs, rubs, gallops, no heaves or lifts Abdomen: no TTP in RUQ or throughout abdomen Ext: warm, well perfused, right calf in ace bandage, [**1-2**]+ DP pulses on right and left, 1+ PT pulses, no palpable cords, lower extremity sensation intact to light touch Pertinent Results: Admission labs: [**2185-5-11**] 07:30PM BLOOD WBC-10.8 RBC-3.79* Hgb-11.6* Hct-32.4* MCV-85 MCH-30.6 MCHC-35.9* RDW-14.4 Plt Ct-247 [**2185-5-11**] 07:30PM BLOOD Neuts-88.4* Lymphs-7.2* Monos-3.9 Eos-0.2 Baso-0.3 [**2185-5-11**] 07:30PM BLOOD PT-13.9* PTT-24.7 INR(PT)-1.2* [**2185-5-11**] 07:30PM BLOOD Glucose-122* UreaN-20 Creat-1.0 Na-133 K-4.5 Cl-99 HCO3-22 AnGap-17 RLE Ultrasound: IMPRESSION: Vein thrombosis seen throughout the entire extent of the right lower extremity. Dampened waveforms in contralateral left common femoral vein are suggestive of more proximal thrombosis. CTA Aorta, Bifem, Iliac: IMPRESSION: 1. Patent three-vessel runoff. 2. Findings in the abdomen and pelvis, including subcapsular liver hematoma and IVC thrombus extending into the right common iliac, external iliac, and likely common femoral veins as well as possibly into the left common iliac vein, better assessed on CT abdomen/pelvis performed just prior to this, on [**2185-5-11**] at 21:50, see that report. 3. Apparent diffuse wall thickening of the urinary bladder may relate to its underdistension, however, recommend correlation with urinalysis to exclude underlying infection. 4. Enlarged prostate gland; recommend correlation with serum PSA if this has not already been performed. CT Abdomen/Pelvis: IMPRESSION: 1. 17 x 19 x 6 cm subcapsular liver hematoma, which appears stable compared to the [**Month (only) 547**] examination. Active extravasation does not appear present, but is limited on this single-phase study. 2. IVC filter with a clot extending cephalad 2.2 cm above the top of the filter. However, thrombus does not extend into the renal veins. Occlusive thrombus into the right common iliac internal and external iliacs and common femoral vein. There may be partially occlusive thrombus in the left common iliac. Labs on Discharge: [**2185-5-25**] 08:32AM BLOOD WBC-8.6 RBC-4.02* Hgb-11.1* Hct-34.0* MCV-85 MCH-27.7 MCHC-32.7 RDW-15.5 Plt Ct-460* [**2185-5-19**] 06:35AM BLOOD Glucose-87 UreaN-19 Creat-1.1 Na-135 K-4.9 Cl-101 HCO3-24 AnGap-15 [**2185-5-20**] 06:30AM BLOOD LD(LDH)-798* [**2185-5-19**] 06:35AM BLOOD Calcium-8.4 Phos-2.7 Mg-2.4 Brief Hospital Course: Mr. [**Known lastname 1794**] is a 65 year-old man with h/o recent hospitalization and MICU stay for bilateral pulmonary embolism complicated by spontaneous intra-hepatic hemorrhage presenting on this admission with RLE pain and numbness found to have full length RLE DVT. . # Right Lower Extremity DVT: Patient with history of recent b/l PE, complicated by intra-hepatic hematoma on anticoagulation. Patient discharged home on recent prior admission with IVC filter, not on anticoagulation. On this admission, patient found to have a large RLE DVT. Patient with palpable peripheral pulses bilaterally. Evaluated by vascular surgery in ED, who felt that his RLE was non-threatened and no surgical intervention was required. Given the risk of extension of DVT to the point where vascular compromise could be reached, as well as the risk of further extending PEs, we cautiously anticoagulated the patient with careful monitoring for fear that the pt would patient have another hepatic bleed. Patient was admitted to ICU and anticoagulation was started with heparin gtt with goal of 60 - 80. Patient reached the therapeutic level and his HCT remained stable. Serial vascular exams were stable. The RLE was elevated and wrapped in ACE. He was then sent to the regular medicine floor. However, unfortunately he then had his platelets drop, and was found to have heparin induced thrombocytopenia (see below), and was transitioned to argatroban for his DVT. He was then transitioned to coumadin prior to D/C. His INR was 4.0 on day of discharge, and he was instructed to follow up with his PCP for further monitoring of his INR with a goal of between [**2-3**]. . # Heparin Induced Thrombocytopenia: Patient's platelets dropped from 247 on [**5-11**] to 118 on [**2185-5-14**], which normally would not fit with the traditional window for HIT, but pt had received heparin on his prior admission also. Hematology was consulted, and recommended switching to argatroban, which we did. Patient's PF4 test was sent, and returned with an optical density of 2.7, so the lab cancelled our serotonin release assay as the PF4 was considered positive enough. Patient was instructed to get a heparin allergy bracelet with help from his PCP. . # Recent subcapsular hepatic bleed: Patient with recent ICU stay requiring massive transfusion protocol following spontaneous subcapsular hepatic bleed while on anticoagulation. Patient discharged home from prior admission on no anti-coagulation. For this admission, imaging showed that his liver hematoma had a stable appearance. Surgery was consulted in the ED and recommended no surgical intervention at this time. Surgery recommended supportive care should the bleed recur, but patient remained with stable VSs and no RUQ abdominal pain. . # Bilateral pulmonary embolism: Patient initially presented with left sided chest and flank pain when admitted in [**2185-4-1**]. The etiology of emboli is unclear - patient was discharged with plan for outpatient hypercoagulable work-up. Patient discharged with IVC filter, not on anti-coagulation. Concern for extension of pulmonary embolism on this admission as clot extended proximally above IVC filter. Patient remained mildly tachycardiac throughout the admission, but not hypoxic, dyspnic, and did not have chest pain. Patient's PE's were treated with argatroban when his DVT was treated with argatroban. HIT may have contributed to extension of clots above IVC filter. Patient will need outpatient anticoagulation w/u, but this is complicated by the fact that he is now on coumadin for at least 6 months. . # h/o [**Doctor Last Name 933**] disease: Previously followed by Endocrine at [**Hospital1 18**]. Per patient not receiving any treatment. Denies symptoms or hyper/hypothyroid at this time. TSH was wnl therefore no intervention undertaken. . # Hypertension: Patient with history of hypertension, and was hypertensive on admission. Patient had not been taking lisinopril since discharge. Lisinopril was held in the ICU while anticoagulating given bleeding risk, and patient remained normotensive there as well as when transferred to the floor. Therefore, we did not restart pt's lisinopril at dispo and instructed him to f/u with his PCP. . # Dyslipidemia: Simvastatin 10mg qhs held after last admission as patient had transaminitis likely [**2-2**] subcapsular liver bleed. LFTs were wnl. Therefore we restarted simvastatin on this admission. . # Code: Full (discussed with patient) PENDING LABS: None TRANSITIONAL CARE ISSUES: Patient will need his INR monitored frequently until he is stably threapeutic between 2 and 3. Dr. [**Last Name (STitle) **], his new PCP was [**Name (NI) 653**] and his office agreed to follow pt's INR. Medications on Admission: None per pt Discharge Medications: 1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for Constipation. 3. warfarin 2.5 mg Tablet Sig: Four (4) Tablet PO once a day: On [**5-25**] ONLY take 7.5 mg (3 tabs), then start this medication dose (10mg per day) on [**5-26**]. Disp:*120 Tablet(s)* Refills:*2* 4. simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Disposition: Home With Service Facility: Uphams Corner Home Care Discharge Diagnosis: Primary: right lower extremity DVT, heparin-induced thrombocytopenia Secondary: Pulmonay embolism, Hypertension Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [**Known lastname 1794**], You were seen in the hospital for a blood clot in your leg. While you were here, it was determined that you have an allergy to heparin. You should never be given heparin in the future. Please arrange with your PCP to have an allergy bracelet made so that you aren't given heparin. You were put on an oral blood thinner called coumadin, that you will have to continue to take once a day until your doctors [**Name5 (PTitle) **] [**Name5 (PTitle) **] to stop taking it. We made the following changes to your medications: 1) We STARTED you on COUMADIN (WARFARIN). You will take 7.5mg on [**5-25**], then take 10mg once per day starting on [**5-26**] until Dr. [**Last Name (STitle) **] tells you to change to a different dose. Dr. [**Last Name (STitle) **] will follow your coumadin levels and adjust your dose of coumadin as needed. If you have any questions, you should call him. 2) We STOPPED your LISINOPRIL because your blood pressure is already well controlled on no anti-hypertensive medications. Your PCP may tell you to restart this medication at some point. If you experience any of the below listed Danger Signs, or any other new symptom, please call your doctor or go to the nearest Emergency Room. It was a pleasure taking care of you. Followup Instructions: Department: [**Hospital1 7975**] INTERNAL MEDICINE When: FRIDAY [**2185-5-27**] at 11:15 AM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 7978**], MD [**Telephone/Fax (1) 7976**] Building: [**Hospital1 7977**] ([**Location (un) 686**], MA) [**Location (un) **] Campus: OFF CAMPUS Best Parking: Free Parking on Site Department: HEMATOLOGY/ONCOLOGY When: FRIDAY [**2185-7-8**] at 10:00 AM With: [**First Name11 (Name Pattern1) 1730**] [**Last Name (NamePattern4) 5056**], MD [**Telephone/Fax (1) 22**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]

[ "401.9", "E934.2", "453.41", "272.4", "285.1", "415.19", "244.9", "V58.61", "289.84", "573.8" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

13276, 13330

8006, 12520

301, 308

13486, 13486

5822, 5822

14951, 15747

4398, 4454

12814, 13253

13351, 13465

12778, 12791

13637, 14166

4469, 4469

5219, 5803

14195, 14928

3593, 4022

235, 263

12546, 12752

7669, 7983

336, 3574

5838, 7649

4483, 5204

13501, 13613

4044, 4150

4166, 4382

10,803

130,660

27596

Discharge summary

report

Admission Date: [**2194-4-7**] Discharge Date: [**2194-4-11**] Service: MEDICINE Allergies: Penicillins / Codeine / Phenobarbital / Latex Attending:[**First Name3 (LF) 2181**] Chief Complaint: CC:[**CC Contact Info 67427**] Major Surgical or Invasive Procedure: R ORIF of hip fracture on [**4-9**] History of Present Illness: INTERN TRANSFER NOTE:. CC:[**CC Contact Info 67427**]. HPI: This is an 84 year-old female with history of CAD and known apical ischemia,HTN, hypercholesterolemia, diverticulosis, and osteoporosis who was admitted to an outside hospital 3 days ago with a right hip fracture after a syncopal episode. The patient was shopping and felt lightheaded with blurred vision. She woke up on the floor with R hip pain, though she cannot remember falling down. She was sent to the ER of an OSH and found to have an impacted right hip fracture. An EKG showed sinus rhythm with no ST segment changes. In the ER she developed chest pain and reportedly went into atrial fibrillation with RVR of 120s. She received a dose of amiodarone and converted to normal sinus rhythm. The day after admission, her tropon-I was 0.55 and the following day the troponin-I was less than 0.1. The day of transfer ([**4-7**]), she underwent cardiac catherization and a drug eluting stent was placed in a 70% lesion in the LAD. No surgeons at the other hospital were comfortable operating on her hip while she was on ASA and [**Last Name (LF) 4532**], [**First Name3 (LF) **] she was transferred to [**Hospital1 18**] for hip surgery. She was initially transferred to the CCU and had minimal dicomfort in her right hip. On [**4-8**] she was taken to the OR for ORIF. In the PACU she developed a right hip hematoma and had a wrap placed on her leg. . Currently she denies CP, SOB or hip pain. She does have some diffuse abd pain that she states is chronic. . Medications at home: Aspirin 81 po qd Toprol XL 25 po qd Diovan 160 po qd Quinine Aciphex Calcium Naproxen . Medications on transfer: Docusate Sodium 100 mg PO BID Bisacodyl 10 mg PO/PR DAILY:PRN Dolasetron Mesylate 12.5 mg IV Q8H:PRN Cefazolin 2 gm IV Q8H Duration: 3 Doses Enoxaparin Sodium 30 mg SC Q 12 Duration: 4 Weeks Start: In am [**4-8**] Gemfibrozil 600 mg PO BID Acetaminophen 325-650 mg PO Q4-6H:PRN Hydrocortisone Cream 2.5% 1 Appl TP [**Hospital1 **] Quinine Sulfate 325 mg PO HS:PRN Pantoprazole 40 mg PO Q24H Valsartan 160 mg PO DAILY Hydrocodone-Acetaminophen 1 TAB PO Q8H:PRN Metoprolol 25 mg PO TID Calcium Carbonate 500 mg PO Q 24H Ascorbic Acid 500 mg PO DAILY Polysaccharide Iron Complex 150 mg PO BID Clopidogrel Bisulfate 75 mg PO DAILY Aspirin 325 mg PO DAILY . Past Medical History: 1. Coronary artery disease with cardiac stress test in [**2190**] that showed apical ischemia. Cardiac catherization at outside hopsital [**3-22**] showed 70% LAD lesion that was stented, 50% proximal circumflex, 50% OM-1, and 40% RCA. 2. Atrial fibrillation per report at outside hospital (no EKG verification) 3. Hypertension 4. Hyperlipidemia 5. Diverticulosis with GI bleed 10 years ago. 6. Gastroesophageal reflux disease 7. Osteoporosis 8. History of hernia repair 9. Leg cramps . Family History: There is no family history of coronary artery disease. . Social History: She is a retired nurse. She lives with her son and is independent with her activities of daily living. She ambulates with a cane. She doesn't drink alcohol. She doesn't smoke. . Physical Exam: Vitals: Tc 95.1 HR 64 BP 118/66 R 16 O2 sat 96% 3L General: Pleasant, pale, elderly female, tired after surgery but conversing HEENT: anicteric sclera, dry MMM Neck: JVP flat Pulmonary: Few crackles anteriorly with good air movement Cardiac: Regular rate and rhythm, s1, s2, with 3/6 holosystolic murmur heard throughout Abdomen: Soft, non-distended with mild tenderness difusely mostly in epigastrum and LLQ Extremities: Warm and well perfused R leg wrapped in tight ace wrap, with area of ecchymosis seen on R buttock, partially covered by wrap; the area is not firm to touch and was outlined Has 1+ DP pulses b/l and warm extremities . OSH diagnostics: . Catherization: 70% LAD lesion that was stented with drug eluting stent, 50% proximal circumflex, 50% OM-1, and 40% RCA. . Hip plane films: Impacted valgus subcapital fracture of the right femur. . Chest x-ray: Mild pulmonary edema. . Labs: see below . Assessment/Plan: 84 year-old female with history of CAD s/p LAD stent, hypertension, hyperlipidemia, osteoporosis who was admitted with right femur fracture after syncopal episode and also reportedly had new atrial fibrillation. . 1. Femur Fracture: She had an impacted R femur fx and went to the OR for ORIF by ortho today. She was continued on her ASA and [**Month/Year (2) 4532**] at that time d/t her recent stent placement. Post-op it appears per notes that she developed a hematoma and had a tight wrap placed around her right leg. -follow BPs q 2 hrs to evaluate of hypotension from possible expanding hematoma in the setting of ASA and [**Month/Year (2) 4532**] use -q 4 hct checks o/n, pt has been typed and crossmatched 4 units -pain control with vicodin (has allergy listed in computer for codeine, but appears she has been receiving vicodin without a prob); will increase dosing if pt tolerates this and is having more pain -SC enoxaparin for DVT prophylaxis -f/u ortho recs . 2. Coronary Artery Disease: Has a h/o CAD and stable angina. Her troponin leak was thought to be [**12-19**] to demand ischemia after reported atrial fibrillation. At OSH she underwent elective catherization and had a cypher stent to a 70% LAD lesion. Currently she is CP free. -cont ASA (will decrease dose to 162 mg qd), [**Month/Day (2) 4532**] -cards aware and will leave recs -cont metoprolol and diovan -monitor on tele -cont gemfibrozil given hypercholesterolemia and reported intolerance of statins due to CK elevations. -consider echo (was mentioned in CCU but not done) . 3. Atrial Fibrillation: Per report, she had atrial fibrillation with rapid rate at OSH. No EKGs were sent to confirm this. -Will continue to monitor on telemetry. . 4. Osteoporosis: Will continue calcium and vitamin D. She did not tolerate fosamax in the past and developed a rash and thorat tightening. . 5. FEN: Cardiac diet. -replete lytes PRN . 6. Access: Peripheral IV . 7. Prophylaxis: Enoxaparin, PPI, bowel regimen . 8. Code: DNR/DNI. Can be reversed for OR. . 9. Dispo: Pending clinical stability, will likely require rehab Past Medical History: 1. Coronary artery disease with cardiac stress test in [**2190**] that showed apical ischemia. Cardiac catherization at outside hopsital [**3-22**] showed 70% LAD lesion that was stented, 50% proximal circumflex, 50% OM-1, and 40% RCA. 2. Atrial fibrillation per report at outside hospital (no EKG verification) 3. Hypertension 4. Hyperlipidemia 5. Diverticulosis with GI bleed 10 years ago. 6. Gastroesophageal reflux disease 7. Osteoporosis 8. History of hernia repair 9. Leg cramps Social History: She is a retired nurse. She lives with her son and is independent with her activities of daily living. She ambulates with a cane. She doesn't drink alcohol. She doesn't smoke. Family History: There is no family history of coronary artery disease. Physical Exam: Vitals: Tc 95.1 HR 64 BP 118/66 R 16 O2 sat 96% 3L General: Pleasant, pale, elderly female, tired after surgery but conversing HEENT: anicteric sclera, dry MMM Neck: JVP flat Pulmonary: Few crackles anteriorly with good air movement Cardiac: Regular rate and rhythm, s1, s2, with 3/6 holosystolic murmur heard throughout Abdomen: Soft, non-distended with mild tenderness difusely mostly in epigastrum and LLQ Extremities: Warm and well perfused R leg wrapped in tight ace wrap, with area of ecchymosis seen on R buttock, partially covered by wrap; the area is not firm to touch and was outlined Has 1+ DP pulses b/l and warm extremities Pertinent Results: [**2194-4-7**] 09:44PM BLOOD WBC-6.3 RBC-3.62* Hgb-11.6* Hct-32.8* MCV-90 MCH-32.0 MCHC-35.4* RDW-13.3 Plt Ct-185 [**2194-4-11**] 06:25AM BLOOD WBC-7.8 RBC-3.02* Hgb-9.6* Hct-26.8* MCV-89 MCH-31.8 MCHC-35.9* RDW-14.4 Plt Ct-226 [**2194-4-10**] 06:27AM BLOOD PT-12.1 PTT-25.6 INR(PT)-1.0 [**2194-4-11**] 06:25AM BLOOD Glucose-99 UreaN-17 Creat-0.8 Na-135 K-4.3 Cl-102 HCO3-25 AnGap-12 [**2194-4-7**] 09:44PM BLOOD Glucose-103 UreaN-16 Creat-1.0 Na-135 K-4.0 Cl-102 HCO3-24 AnGap-13 [**2194-4-7**] 09:44PM BLOOD Calcium-8.5 Phos-3.3 Mg-1.8 [**2194-4-10**] 06:27AM BLOOD TSH-4.3* . R hip x-ray:HISTORY: Seven intraoperative fluoroscopic images of the right hip were obtained during the insertion of three cannulated screws for stabilization of impacted right subcapital fracture. The femoral head is slightly in varus alignment. . CXR [**4-7**]: Right upper lobe and perihilar opacities, which could represent asymmetric pulmonary edema, pneumonia, or postobstructive atelectasis from a [**Location (un) 21851**] Brief Hospital Course: 84 year-old female with history of CAD s/p LAD stent, hypertension, hyperlipidemia, osteoporosis who was admitted with right femur fracture after syncopal episode and also reportedly had new atrial fibrillation. . 1. Femur Fracture: The patient had a syncopal episode and developed an impacted right femur fracture after her fall. She was admitted to an OSH, but had a cardiac cathterization there and a stent placed in her LAD. Since she was required to be on ASA and [**Location (un) 4532**] during surgery, she was transferred to [**Hospital1 18**]. The patient remained in stable condition and went to the OR for ORIF on [**4-8**]. She was continued on her ASA and [**Month/Year (2) 4532**] at that time. Post-op she developed a hematoma over her left hip and had a tight wrap placed around her right leg. Her hemtocrit slowly trended down to 26, so she was transfused one unit of PRBCs. Her hematocrit remained stable throughout the rest of her stay and the wrap on her leg was subsequently removed. Her BPs remained stable throughout this course as well. She was started on lovenox for DVT prophylaxis post-op and will need to continue this for four weeks. Her pain was controlled with round the clock tylenol and scheduled and PRN oxycodone. She should follow-up with Dr. [**Last Name (STitle) **] in orthopedics in 4 weeks. . 2. Coronary Artery Disease: The patient had a h/o CAD and stable angina. She had a troponin leak at the OSH, and underwent an elective catherization and had a cypher stent placed to a 70% LAD lesion. It is likely that her troponin leak was [**12-19**] to demand ischemia after reported atrial fibrillation at the OSH. She was initially admitted to the CCU and then transferred to the floor here. She was continued on ASA 162 mg qd, [**Month/Day (2) 4532**], diovan and metoprolol. She was continued on gemfibrozil given hypercholesterolemia and reported intolerance of statins due to CK elevations. She will follow-up with her cardiologist, Dr. [**Last Name (STitle) 41632**] in [**11-18**] weeks. . 3. Atrial Fibrillation: Per report, she had atrial fibrillation with rapid rate at OSH. Initially she was in NSR here, but she went into afib with RVR during her stay. She remained hemodynamically stable and asymptomatic and her BB dose was increased. Currently she is rate controlled on metoprolol 37.5 mg TID. . 4. Syncopal episode: Unclear what the underlying cause of her syncopal episode was. Does not appear it was [**12-19**] to hypovolemia, acute iscemic event, stroke or seizure. Could potentially be [**12-19**] to atrial fibrillation causing dizziness or hypotension or other arrythmia. Physical exam does not suggest AS. She will f/u with her PCP as an outpatient and a decision can be made as to whether she requires an outpatient echo at that time. 5. Osteoporosis: She did not tolerate fosamax in the past and developed a rash and throat tightening. She was continued on calcium and vitamin D. . 6. FEN: Cardiac diet. . 7. Code: DNR/DNI. . 8. Dispo: Acute rehab facility. Medications on Admission: Medications at home: Aspirin 81 po qd Toprol XL 25 po qd Diovan 160 po qd Quinine Aciphex Calcium Naproxen . Medications on transfer: Docusate Sodium 100 mg PO BID Bisacodyl 10 mg PO/PR DAILY:PRN Dolasetron Mesylate 12.5 mg IV Q8H:PRN Cefazolin 2 gm IV Q8H Duration: 3 Doses Enoxaparin Sodium 30 mg SC Q 12 Duration: 4 Weeks Start: In am [**4-8**] Gemfibrozil 600 mg PO BID Acetaminophen 325-650 mg PO Q4-6H:PRN Hydrocortisone Cream 2.5% 1 Appl TP [**Hospital1 **] Quinine Sulfate 325 mg PO HS:PRN Pantoprazole 40 mg PO Q24H Valsartan 160 mg PO DAILY Hydrocodone-Acetaminophen 1 TAB PO Q8H:PRN Metoprolol 25 mg PO TID Calcium Carbonate 500 mg PO Q 24H Ascorbic Acid 500 mg PO DAILY Polysaccharide Iron Complex 150 mg PO BID Clopidogrel Bisulfate 75 mg PO DAILY Aspirin 325 mg PO DAILY Discharge Medications: 1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO Q 24H (Every 24 Hours). 3. Valsartan 160 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 5. Quinine Sulfate 325 mg Capsule Sig: One (1) Capsule PO HS (at bedtime) as needed. 6. Hydrocortisone 2.5 % Cream Sig: One (1) Appl Rectal [**Hospital1 **] (2 times a day). 7. Gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 9. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 10. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Aspirin 81 mg Tablet, Chewable Sig: Two (2) Tablet, Chewable PO DAILY (Daily). 12. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO TID (3 times a day). 13. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 14. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for hip pain. 15. Acetaminophen 500 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours). 16. Clotrimazole 1 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day). 17. Enoxaparin 40 mg/0.4 mL Syringe Sig: One (1) SC injection Subcutaneous Q24 HOURS () for 4 weeks. 18. Dolasetron Mesylate 12.5 mg IV Q8H:PRN Discharge Disposition: Extended Care Facility: [**Hospital **] Hospital of [**Location (un) **] & Islands - [**Location (un) 6251**] Discharge Diagnosis: Primary Diagnosis: R hip fracture s/p ORIF Atrial fibrillation . Secondary Diagnosis: Hypertension Hyperlipidemia Coronary Artery Disease s/p stent placement Discharge Condition: Stable, getting out of bed with PT Discharge Instructions: Please take your medications as prescribed. . Please call your doctor or return to the ER if you pass out or have further chest pain, shortness of breath, dizziness, increasing pain in your leg, blood in your stools or other concerning symptoms. Followup Instructions: Please follow-up with your primary care doctor, Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4467**], in [**11-18**] weeks. His phone number is [**Telephone/Fax (1) 31293**]. . Please follow-up with your cardiologist, Dr. [**Last Name (STitle) 41632**], in [**11-18**] weeks. His phone number is ([**Telephone/Fax (1) 41298**]. . Please follow-up with Dr. [**Last Name (STitle) **] in orthopedics in 4 weeks. His phone number is ([**Telephone/Fax (1) 2007**].

[ "413.9", "530.81", "410.71", "V45.82", "733.00", "820.8", "427.31", "E878.8", "562.10", "272.0", "414.01", "285.9", "E888.9", "401.9", "998.12" ]

icd9cm

[ [ [] ] ]

[ "99.04", "79.35" ]

icd9pcs

[ [ [] ] ]

14366, 14478

8956, 11992

282, 320

14680, 14717

7921, 8933

15011, 15495

7191, 7248

12828, 14343

14499, 14499

12018, 12018

14741, 14988

12039, 12127

7263, 7902

213, 244

348, 1874

14585, 14659

14518, 14564

12152, 12805

6494, 6981

6997, 7175

30,651

174,286

8750

Discharge summary

report

Admission Date: [**2192-3-16**] Discharge Date: [**2192-3-22**] Date of Birth: [**2149-6-23**] Sex: M Service: MEDICINE Allergies: Vancomycin / Ivp Dye, Iodine Containing Attending:[**First Name3 (LF) 4373**] Chief Complaint: change in mental status Major Surgical or Invasive Procedure: None History of Present Illness: 42 year old man with [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 21344**] Lindau disease (with non-functioning pheo s/p right adrenalectomy, pancreatic tail tumor, retinal hemangiomas, multiple spine hemangiomas), metastatic renal cell carcinoma (to lungs, scalp and brain)on sorafenib trial. He presented to [**Hospital3 26615**] hospital after his sister found him napping at home, confused, not wearing clothing. He had not felt well, had noticed decreased urine and had a fever to 104 1 day prior to this and had taken cipro at home. His sister denied that he had complained of vomiting or diarrhea. At [**Hospital3 26615**] he was found to have a fever, UTI (given levo), had a negative head CT and a sodium of 112 so was transferred to [**Hospital1 18**]. There was also a question of right sided weakness which was not further described. . ED course: vitals T 98.3 88 119/70 16 100%3L FS 211 1L NS then 3%NS at 25cc/hr responding to voice, speaking non-sensically CXR showed RUL PNA, UTI positive started on levo Past Medical History: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 21344**] Lindau -cerebellar haemangioblastoma excised [**2159**] -[**2161**] medulla irradiation -[**2168**] spinal irradiation -[**2179**] cervical and thoracic spinal tumours excised... residual chronic back pain -[**2174**] phaeochromocytoma...R adrenalectomy; islet cell tumour excised with spleen and consequent DM -[**2180**] endolymphatic sac tumour R ear...deaf R ear/balance problems -[**2188**] Partial R nephrectomy for removal of renal cyst (benign) -[**2189-11-7**] metastatic renal cell carcinoma (R ureteral stent replaced q 4months) assoc with metastatic disease to the brain, scalp and lung. Haem-Onc Dr [**Last Name (STitle) **] [**Last Name (STitle) **]. -osteoporosis (prev treated with fosamax) -GERD -DM insulin dependent -Migraines -HTN last couple months (not on treatment) -Appendicectomy -Hernia OT Social History: Not employed. Walks inside "furniture surfing" from item to item; uses wheelchair outside. Non-smoker, no alcohol. Family History: Mother CAD and depression; father alzheimer's disease and depression; sister depression/migraines/2 brothers well Physical Exam: vs 97.6, HR 104, BP 137/81, 97%2L, RR 23 gen pale, lying in bed, speaking in non-sensical sentences CV RRR, no murmurs Pulm CTAB anteriorly Abdomen soft, NT R.nephrostomy tube insertion site-slightly erythematous Extremities no edema Lines 2 PIV Pertinent Results: [**2192-3-16**] 09:16PM LACTATE-2.0 NA+-116* [**2192-3-16**] 09:15PM GLUCOSE-148* UREA N-16 CREAT-0.9 SODIUM-115* POTASSIUM-5.5* CHLORIDE-80* TOTAL CO2-23 ANION GAP-18 [**2192-3-16**] 09:15PM estGFR-Using this [**2192-3-16**] 09:15PM CORTISOL-46.1* [**2192-3-16**] 09:15PM URINE HOURS-RANDOM [**2192-3-16**] 09:15PM URINE GR HOLD-HOLD [**2192-3-16**] 09:15PM WBC-58.3*# RBC-3.25* HGB-7.3*# HCT-25.6* MCV-79* MCH-22.6*# MCHC-28.7* RDW-15.5 [**2192-3-16**] 09:15PM NEUTS-82* BANDS-11* LYMPHS-1* MONOS-4 EOS-0 BASOS-0 ATYPS-1* METAS-1* MYELOS-0 NUC RBCS-1* [**2192-3-16**] 09:15PM HYPOCHROM-2+ ANISOCYT-1+ POIKILOCY-1+ MACROCYT-NORMAL MICROCYT-2+ POLYCHROM-1+ BURR-OCCASIONAL TEARDROP-OCCASIONAL ACANTHOCY-OCCASIONAL [**2192-3-16**] 09:15PM PLT SMR-VERY HIGH PLT COUNT-831* [**2192-3-16**] 09:15PM URINE COLOR-Straw APPEAR-Hazy SP [**Last Name (un) 155**]-1.009 [**2192-3-16**] 09:15PM URINE BLOOD-LG NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-MOD [**2192-3-16**] 09:15PM URINE RBC-[**4-11**]* WBC->50 BACTERIA-MANY YEAST-MANY EPI-0 [**2192-3-18**] 02:05PM BLOOD WBC-50.2* Hct-25.2* [**2192-3-17**] 01:22AM BLOOD Neuts-67 Bands-20* Lymphs-5* Monos-7 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-1* NRBC-2* [**2192-3-18**] 02:05PM BLOOD Glucose-129* Na-134 [**2192-3-18**] 03:46AM BLOOD ALT-14 AST-24 AlkPhos-290* TotBili-0.3 [**2192-3-18**] 03:46AM BLOOD Albumin-2.1* Calcium-8.6 Phos-2.7 Mg-2.0 [**2192-3-17**] 06:48AM BLOOD TSH-2.9 [**2192-3-17**] 06:48AM BLOOD T4-6.5 [**2192-3-17**] 08:04AM BLOOD Cortsol-42.2* CXR [**2192-3-17**]:IMPRESSION: Right upper lobe pneumonia. Markedly limited study due to motion. Brief Hospital Course: 42 year old man with [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 21344**] Lindau disease (with non-functioning pheo s/p right adrenalectomy, pancreatic tail tumor, retinal hemangiomas, multiple spine hemangiomas), metastatic renal cell carcinoma (to lungs, scalp and brain)on sorafenib trial who presented with altered mental status, hyponatremia, and right lobar PNA. . HOSPITAL COURSE BY PROBLEM: . #Severe Hyponatremia-p/w Na 112 at OSH,trending down since [**Month (only) 359**] (acute on chronic). Possible causes considered were: adrenal insufficiency (could be primary as he has h/o pheo, or secondary as he has had surgery on his pituitary gland, but this was not evidenced by his presentation or vital signs) as he has had labile BP recently, especially in the setting of hyperkalemia, or more likely volume depletion secondary to infection as his exam was consistent with volume depletion. Other possible cause was SIADH as he has intracranial processes as well as pneumonia. Also, hypothyroidism could be a cause, but his thyroid function tests were all normal. He received 3% NaCl to correct his sodium and was started on intravenous antibiotics. His sodium improved with these interventions. . #Change in Mental Status-unclear if from hyponatremia or infection, more worrisome would be intracranial hemorrhage or stroke as he has history of this, however he improved with antibiotic therapy. . #right middle lobe pneumonia- sputum culture not obtained, but empirically placed on ceftriaxone and levofloxacin IV. His oxygenation remained adequate on room air and he was largely asymptomatic. Blood cx remained negative. Influenza was negative. He will finish a 2 week course of antibiotics . #?[**Name (NI) 12007**] pt has r nephrostomy tube, u/a concerning for UTI and pt placed on ceftriaxone also for dual coverage of PNA. Cultures were however inconclusive ("mixed urogenital flora"). . #VHL-stable, hemangiomas of retina, spine . #Renal Cell Ca- on chemotherapy (sorafenib) per Dr. [**Last Name (STitle) **], currently on hold . #DM-continue home dose of lantus 5 qam and sliding scale . #Chronic Pain-home doses of Morphine 15 mg po q.8h p.r.n. . #Hypothyroidism-continue levothyroxine, held briefly during hospitalization . #GERD-protonix . #[**Doctor First Name 30617**] (sister)HCP [**Telephone/Fax (1) 30618**] Medications on Admission: 1. Ambien CR 12.5 mg at bedtime. 2. Ativan 1 mg one to two tablets q.6h. 3. Fioricet one to two tablets q.4-6h. p.r.n. migraine. 4. Imitrex 20 mg for migraines. 5. Imitrex nasal spray for migraines. 6. Lantus 5 units in the morning. 7. Levothyroxine 25 mcg p.o. once daily. 8. Lexapro 5 mg a day. 9. Lipitor 20 mg a day. 10. Morphine 15 mg q.8h p.r.n. 11. Neurontin 200 mg at bedtime. 12. Nexavar 400 mg twice a day. 13. Normal saline. 14. Novalog 100 units subq. 15. Pangestyme 20,000 units once daily. 16. Ritalin 2 mg day. 17. Zomig p.r.n. Discharge Medications: 1. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal HS (at bedtime). 2. Insulin Glargine 100 unit/mL Solution Sig: Five (5) units Subcutaneous once a day. 3. Morphine 15 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed: hold for sedation or rr< 10. 4. Psyllium Packet Sig: One (1) Packet PO TID (3 times a day) as needed for constipation. 5. Nystatin 100,000 unit/mL Suspension Sig: Ten (10) ML PO TID (3 times a day) for 10 days. 6. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 10 days. 7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 10. Ceftriaxone-Dextrose (Iso-osm) 2 gram/50 mL Piggyback Sig: Two (2) gm Intravenous Q24H (every 24 hours) for 10 days. 11. Insulin Glargine 100 unit/mL Solution Sig: humalog sliding scale Subcutaneous four times a day. 12. Levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Extended Care Facility: [**Hospital1 756**] Manor Nursing & Rehab Center - [**Location (un) 5028**] Discharge Diagnosis: PRIMARY: pneumonia SECONDARY: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 21344**] Lindau Metastatic Renal Cell Carcinoma Chronic Pain Right nephrostomy tube Constipation Discharge Condition: Good Afebrile Normotensive Discharge Instructions: You were admitted with altered mental status and were found to have a right-sided pneumonia. Your sodium was low likely secondary to infection and returned to [**Location 213**] levels on discharge. Your white blood cell count was markedly elevated and is trending down on antibiotics and you are much improved. No clear urine cultures identified infection and there was no yeast in your nephrostomy or bladder urine. You were started on nystatin swishes because of your tendency to develop thrush with antibiotics. You were placed on an aggressive bowel regimen to encourage a bowel movement. . Your chemotherapy is currently on hold and Dr. [**Last Name (STitle) **] will discuss future treatment with you once your infection has improved. Your levothyroxine was held but may now be restarted as your sodium and blood pressures have all normalized. No other changes were made in your medications. You will finish a 2-week total course of antibiotics for your pneumonia and nystatin swishes while you are on antibiotics. . You will be going to a rehab facility to help you improve your strength. All your medications will be administered there. . If you develop any concerning symptoms such as increased pain, persistent fevers, shortness of breath or chest pain, please call your physician or proceed to the emergency department. Followup Instructions: Please call your primary care phsyician Dr. [**Last Name (STitle) 13517**] to schedule a f/u appointment [**Telephone/Fax (1) 30619**] within the next 1-2 weeks to discuss your hospitalization. . Please call Dr. [**Last Name (STitle) **] to set up an appiontment with him in 2 weeks to discuss your chemotherapy. ([**Telephone/Fax (1) 16668**] . Provider: [**Name10 (NameIs) 706**] MRI Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2192-6-4**] 10:35 Provider: [**Name10 (NameIs) 5005**] [**Last Name (NamePattern4) 5342**], MD Phone:[**Telephone/Fax (1) 44**] Date/Time:[**2192-6-4**] 11:30 Provider: [**Last Name (NamePattern4) **]. [**First Name (STitle) **] [**Doctor Last Name **] Phone:[**Telephone/Fax (1) 274**] Date/Time:[**2192-7-26**] 1:00

[ "599.0", "346.00", "198.2", "996.65", "251.3", "E879.6", "198.3", "197.0", "401.9", "530.81", "189.0", "486", "244.9", "276.1", "733.00", "759.6", "338.3", "564.00" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

8610, 8712

4548, 4937

324, 330

8945, 8974

2858, 4525

10361, 11115

2461, 2576

7501, 8587

8733, 8924

6933, 7478

8998, 10338

2591, 2839

261, 286

4965, 6907

358, 1398

1420, 2312

2328, 2445

55,491

186,490

470

Discharge summary

report

Admission Date: [**2197-6-15**] Discharge Date: [**2197-6-16**] Date of Birth: [**2155-12-29**] Sex: F Service: MEDICINE Allergies: Bactrim / Trazodone / Indinavir / Flovent HFA / LMA mask Attending:[**First Name3 (LF) 3984**] Chief Complaint: hypoxia Major Surgical or Invasive Procedure: endotracheal intubation laser vaporization of the vulva History of Present Illness: The patient is a 41-year-old female with past medical history of HIV/AIDS (CD4 392 and viral load undetectable in [**2197-5-2**]), on Atripla, history of depression/anxiety, hypertension, chronic kidney disease, cervical and vaginal dysplasia and laryngeal papillomatosis as well as abnormal urinary cytology admitted to the ICU following laser vaporization of the vulva complicated by immediate post-op desaturation on waking up, intubated in OR. Per report the procedure went well without complication. She was in her normal state of health prior to the procedure. Intra-op she received a total of 2L of fluid intraoperatively. An LMA was used. Towards the end of the case she was noted to move suddenly. She was given a bolus dose of propofol. Following the case she was able to breath on her own for 5-1o mintues she then became aggressive and bit down on the LMA disloging the tube. This was followed by an acute desaturation to the 70-80s. She was given more propofol for sedation and mask ventilated with some difficulty. She was intubated with blood noted in the tube. Over the course of an hour she was noted to be much easier to ventilate, on exam lungs were noted to clear. She was then transferred to the [**Hospital Unit Name 153**] for further management. On arrival to the MICU, patient's VS 92.4 59 97/71 12 100% SpO2 CMV Vt 500 mL PEEP of 10. Patient was intubated and sedated with blood noted in the ET tube. Review of systems: unable to obtain Past Medical History: 1. HIV diagnosed in [**2177**] at the time of bilateral lobar pneumonia complicated by ARDS. Risk factor, heterosexual sex. CD4 nadir reportedly 186. 2. Cocaine abuse, clean since [**2180**]; c/b nasal septal perforation noted [**5-3**] 3. Alcohol abuse. 4. Depression with prior history of suicide attempt and hospitalization with major depression and psychotic features in [**10/2187**]; follow at [**Location (un) 3146**] Beach Counseling Ctr as of [**5-11**] by behavioral clinician [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 3985**] [**Telephone/Fax (1) 3986**], fax [**Telephone/Fax (1) 3987**] 5. History of genital HSV. 6. Cervical dysplasia. 7. History of indinavir related nephrolithiasis. 8. History of interstitial pulmonary infiltrates of unclear etiology 9. Recurrent laryngeal papillomatosis 10. Moderate mitral regurgitation by cardiac MRI 11. Gonorrhea 12. Left knee cartilage tear 13. Hypertension Social History: Not working. Has children, a former cigarette smoker, history of ETOH abuse. Family History: Positive for cancer, diabetes, heart disease, kidney disease and GI problems. Physical Exam: ADMISSION EXAM General: intubated and sedated HEENT: Sclera anicteric, MMM, pupils pinpoint, ET tube with blood present Neck: supple, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, trace wheezes, rales, ronchi Abdomen: soft, non-distended, bowel sounds present, no organomegaly, no tenderness to palpation, no rebound or guarding GU: no foley Ext: Warm, well perfused,1+ pulses, no clubbing, cyanosis or edema Neuro: intubated and sedated Pertinent Results: ADMISSION LABS [**2197-6-15**] 06:31PM BLOOD WBC-4.1 RBC-4.48 Hgb-13.8 Hct-42.6 MCV-95 MCH-30.8 MCHC-32.4 RDW-14.5 Plt Ct-181 [**2197-6-15**] 06:31PM BLOOD PT-11.8 PTT-30.5 INR(PT)-1.1 [**2197-6-15**] 06:31PM BLOOD Glucose-100 UreaN-10 Creat-1.2* Na-136 K-7.7* Cl-108 HCO3-23 AnGap-13 [**2197-6-16**] 03:59AM BLOOD Glucose-103* UreaN-12 Creat-1.4* Na-138 K-3.9 Cl-107 HCO3-23 AnGap-12 [**2197-6-15**] 06:31PM BLOOD ALT-17 AST-47* LD(LDH)-1095* CK(CPK)-258* AlkPhos-70 TotBili-0.2 [**2197-6-16**] 03:59AM BLOOD ALT-14 AST-20 LD(LDH)-154 CK(CPK)-174 AlkPhos-85 TotBili-0.2 [**2197-6-15**] 06:31PM BLOOD Albumin-3.2* Calcium-8.7 Phos-3.7 Mg-2.0 [**2197-6-16**] 01:22AM BLOOD Type-ART pO2-74* pCO2-40 pH-7.37 calTCO2-24 Base XS--1 . DISCHARGE LABS [**2197-6-16**] 03:59AM BLOOD PT-10.9 PTT-30.8 INR(PT)-1.0 [**2197-6-16**] 03:59AM BLOOD Glucose-103* UreaN-12 Creat-1.4* Na-138 K-3.9 Cl-107 HCO3-23 AnGap-12 [**2197-6-16**] 03:59AM BLOOD ALT-14 AST-20 LD(LDH)-154 CK(CPK)-174 AlkPhos-85 TotBili-0.2 [**2197-6-16**] 03:59AM BLOOD Albumin-3.2* Calcium-8.6 Phos-3.7 Mg-1.7 . URINE [**2197-6-16**] 02:10AM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.006 [**2197-6-16**] 02:10AM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG . MICROBIOLOGY [**2197-6-16**] BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT [**2197-6-16**] URINE URINE CULTURE-PENDING INPATIENT . IMAGING CXR [**2197-6-15**] IMPRESSION: AP chest compared to [**2197-5-24**]: ET tube in standard placement. Nasogastric tube ends in the distal stomach. Ground-glass opacification in both lungs, right greater than left is certainly consistent with pulmonary edema. Although heart size is normal, the configuration suggests left atrial enlargement and central pulmonary vasculature is engorged suggesting elevated left atrial pressure. Pleural effusion is small, on the right. No pneumothorax. The study and the report were reviewed by the staff radiologist. Brief Hospital Course: PRIMARY REASON FOR ADMISSION 41 yo female with HIV/AIDS, history of depression/anxiety, hypertension, chronic kidney disease, admitted to the ICU intubated following post-operative hypoxia. #Hypoxia - Hypoxia was felt to most likely be reflective of flash edema in the setting of breathing against a closed glottis (hydrostatic pulmonary edema). This is supported by a chest xray demonstrating pulmonary edema. There was signs or symptoms of infection on imaging. The patient required intubation in the OR and subsequently transferred to the MICU. She was diuresed with bolus doses of 10 mg IV lasix. Respiratory status improved and she successfully extubated on HD1. Oxygen saturations were stable on room air and she was discharged home. # [**Name (NI) 3988**] Pt with intial temp of 92 on admission to the MICU. This was felt to most likely represent an anesthesia effect. As above no clear evidence of infection on exam. BP stable in the high 90s systolic. Hypothermia resolved and she remained normothermic throughout the remainder of the hospitalization. # VIN III- patient now s/p laser vaporization. Procedure went well without complication. She was prescribed premarin cream for 7 days and will follow-up with OBGYN. STABLE ISSUES #HIV disease- Patients home atripla was exchanged for truvada and efavirenz while in house. # CKD- Creatinine was at baseline throughout this admission. . # HTN- hold home meds were held in the setting of hypotension. These were restarted at the time of discharge. TRANSITIONAL ISSUES Patient was full code throughout this admission Medications on Admission: Medications - Prescription ALBUTEROL SULFATE - 90 mcg HFA Aerosol Inhaler - 1-2 puffs(s) po q6hr as needed for wheezing ALUMINUM CHLORIDE - 20 % Solution - apply qhs for 3 nights then decrease to [**1-2**] applications per week ATENOLOL - 100 mg Tablet - 1 (One) Tablet(s) by mouth once a day BUPROPION HCL - 150 mg Tablet Extended Release - 1 Tablet(s) by mouth once a day x 3d, then increase to [**Hospital1 **] DESONIDE - 0.05 % Ointment - apply to affected area once a day EFAVIRENZ-EMTRICITABIN-TENOFOV [ATRIPLA] - 600 mg-200 mg-300 mg Tablet - 1 Tablet(s) by mouth once a day ENALAPRIL MALEATE - 20 mg Tablet - 2 Tablet(s) by mouth once a day RISPERIDONE - 0.5 mg Tablet - 1 Tablet(s) by mouth twice a day as needed for anxiety may also take 2 at night for sleep Medications - OTC CHOLECALCIFEROL (VITAMIN D3) - 1,000 unit Capsule - 1 Capsule(s) by mouth once a day MINERAL OIL-HYDROPHIL PETROLAT - Ointment - apply to affected area nightly after cleansing area Discharge Medications: 1. Premarin 0.625 mg/gram Cream Sig: One (1) Vaginal at bedtime for 7 days: use [**1-2**] applicator in vagina each night x 1 week. Disp:*1 tube* Refills:*0* 2. risperidone 0.25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) as needed for anxiety. 3. emtricitabine-tenofovir 200-300 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. efavirenz 600 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q4H (every 4 hours) as needed for shortness of breath or wheezing. 6. enalapril maleate 10 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). 7. atenolol 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Discharge Disposition: Home Discharge Diagnosis: VAIN [**2-3**] pulmonary edema Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Ms. [**Known lastname **], You were admitted after you required urgent intubation for pulmonary edema (fluid in the lungs) following uncomplicated vulvar laser treatment. You spent one night in the ICU and were easily extubated. The gynecologsits indicate that no special post operative care is needed following the procedure you had. Your gynecologist's office will call you with a follow up appointment. To reach medical records to get the records from this hospitalization sent to your doctor at home, call [**Telephone/Fax (1) 2806**]. Followup Instructions: Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 2010**] Date/Time:[**2197-8-16**] 9:20 Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 721**] Date/Time:[**2197-9-27**] 3:00 Department: WEST [**Hospital 2002**] CLINIC When: WEDNESDAY [**2197-9-27**] at 3:00 PM With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 721**] Building: De [**Hospital1 **] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **] Campus: WEST Best Parking: [**Street Address(1) 592**] Garage [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**] MD [**MD Number(1) 2438**]

[ "780.65", "305.1", "E878.8", "799.02", "518.4", "403.90", "078.11", "V08", "300.4", "585.9", "233.31", "493.90" ]

icd9cm

[ [ [] ] ]

[ "86.3", "70.33" ]

icd9pcs

[ [ [] ] ]

8942, 8948

5618, 7199

326, 383

9023, 9023

3598, 5595

9739, 10527

2952, 3031

8221, 8919

8969, 9002

7225, 8198

9174, 9716

3046, 3579

1862, 1881

279, 288

411, 1843

9038, 9150

1903, 2840

2856, 2936

59,864

136,933

40441

Discharge summary

report

Admission Date: [**2173-6-25**] Discharge Date: [**2173-6-25**] Date of Birth: [**2105-4-13**] Sex: F Service: MEDICINE Allergies: Codeine Attending:[**First Name3 (LF) 3565**] Chief Complaint: Scheduled EGD Major Surgical or Invasive Procedure: EGD History of Present Illness: Mrs [**Known lastname **] is a 68 y/o F with history of recent hemorrhagic stroke secondary to amyloid angiopathy s/p emergent craniectomy and hematoma removal, seizures on dilantin and keppra, s/p tracheostomy and found to have large gastric ulcer on endoscopy for PEG placement, found to have gastric mucormycosis, now transferred from rehab for repeat endoscopic evaluation for treatment response after ambisome therapy. She has been hemodynamically stable at her rehab center, with ventilatory support through her tracheostomy on CPAP. She reportedly follows commands intermittently, has intermittent agitation requiring quetiapine. . On the floor, the patient does not appear to be in any distress. She is non-communicative. Past Medical History: seasonal allergies Social History: Residing at [**Hospital 100**] Rehab MACU since her last hospitalization. Previously lived with husband in [**Name (NI) 108**] but came to [**Name (NI) **] in summers for camping trips. No smoking history. Family History: CVA in mother, father, and grandmother. Physical Exam: Upon admission: General: Non-communicative but moving occasionally in bed. NAD HEENT: Protective helmet on, over craniectomy site. Sclera anicteric, MMM, oropharynx clear with dobhoff in place Neck: tracheostomy without surrounding erythema or induration. supple, no LAD Lungs: CTAB, no wheezes, rales, ronchi CV: RRR, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema At discharge: Pertinent Results: [**2173-6-25**] 12:20PM BLOOD WBC-18.7*# RBC-3.44* Hgb-9.5* Hct-28.8* MCV-84 MCH-27.7 MCHC-33.0 RDW-14.4 Plt Ct-512* [**2173-6-25**] 05:36PM BLOOD Hct-25.6* [**2173-6-25**] 12:20PM BLOOD Neuts-80.6* Lymphs-9.4* Monos-6.9 Eos-2.6 Baso-0.5 [**2173-6-25**] 10:54AM BLOOD Glucose-122* UreaN-26* Creat-1.3* Na-139 K-4.5 Cl-102 HCO3-29 AnGap-13 [**2173-6-25**] 10:54AM BLOOD ALT-39 AST-33 AlkPhos-217* TotBili-0.3 [**2173-6-25**] 10:54AM BLOOD Calcium-9.4 Phos-5.2* Mg-1.8 [**2173-6-25**] 10:54AM BLOOD PT-13.4 PTT-23.9 INR(PT)-1.1 [**2173-6-25**] 3:39 pm TISSUE Source: Gastric. FUNGAL CULTURE (Pending): Brief Hospital Course: 68 y/o F with recent hemorrhagic stroke s/p emergent left craniectomy and evacuation of hematoma, s/p tracheostomy placement, now s/p several weeks of ambisome therapy for GI mucormycosis, admitted for repeat endoscopy with biopsy to evaluate for interval response to therapy. . # Mucormycosis: Patient was admitted to the ICU for EGD due to tracheostomy and vent dependence. GI did the procedure at the bedside. EGD showed known ulcer in the stomach body. Due to loss of [**Last Name (un) **]-jejunal tube on transfer over to [**Hospital1 18**], NJ tube was placed by gastroenterology and verified on imaging to be in the 4th portion of the duodenum - it was secured in place for transfer back to the MACU. Infectious disease was contact[**Name (NI) **] during this admission and recommended no change in therapy - plan to continue ambisome daily as previously prescribed until her ID appointment on [**7-1**] - at which time further treatment decision will be made. Of note, Mrs. [**Known lastname **] had an isolated temperature of 100.3 during admission, urine and blood culture sent. Additionally, during her procedure she had a transient decrease in blood pressure to 50/30, felt to be [**1-13**] to vagal physiology. Systolic BP returned to > 100 after 1-2 minutes with no intervention. She is being sent back to [**Hospital 100**] Rehab MACU for continuation of her ongoing care. No changes were made to her medications. Medications on Admission: -combivent MDI 6 puffs Q4H -amphotericin 350 mg daily -chlorhexidine gluconate oral rinse -diltiazem 30 mg PO Q6H -furosemide 20 mg daily -heparin subcutaneous 5000u Q8 -hydroxyzine 10 mg PO TID -insulin SS -levetiracetam [**2161**] mg [**Hospital1 **] -metoprolol tartrate 100 mg PO BID -nystatin 5 cc TID after meals -omeprazole 40 mg PO daily -KCl 20 meq PO QID -Quetiapine 6.25 mg PO BID, 25 mg PO QHS PRN -vancomycin 125 mg PO QID -metronidazole 500 mg PO TID -acetaminophen 650 mg PO Q4H PRN Discharge Medications: 1. ipratropium-albuterol 18-103 mcg/Actuation Aerosol [**Hospital1 **]: Six (6) Puff Inhalation Q4H (every 4 hours). 2. chlorhexidine gluconate 0.12 % Mouthwash [**Hospital1 **]: Fifteen (15) ML Mucous membrane four times a day. 3. AmBisome 50 mg Suspension for Reconstitution [**Hospital1 **]: Three [**Age over 90 1230**]y (350) mg Intravenous Q24H (every 24 hours): in 250 ml D5W. 4. diltiazem HCl 30 mg Tablet [**Age over 90 **]: One (1) Tablet PO QID (4 times a day). 5. furosemide 20 mg Tablet [**Age over 90 **]: One (1) Tablet PO once a day. 6. heparin (porcine) 5,000 unit/mL Solution [**Age over 90 **]: 5000 (5000) unit Injection every eight (8) hours. 7. hydroxyzine HCl 10 mg Tablet [**Age over 90 **]: One (1) Tablet PO TID (3 times a day): per tube. 8. levetiracetam 100 mg/mL Solution [**Age over 90 **]: [**2161**] ([**2161**]) mg PO twice a day: per NG tube. 9. metoprolol tartrate 100 mg Tablet [**Year (4 digits) **]: One (1) Tablet PO twice a day. 10. nystatin 100,000 unit/mL Suspension [**Year (4 digits) **]: Five (5) ML PO TID (3 times a day): after meals. 11. omeprazole 40 mg Capsule, Delayed Release(E.C.) [**Year (4 digits) **]: One (1) Capsule, Delayed Release(E.C.) PO once a day. 12. potassium chloride 10 % Liquid [**Year (4 digits) **]: Twenty (20) mEq PO four times a day. 13. quetiapine 25 mg Tablet [**Year (4 digits) **]: 0.25 Tablet PO BID (2 times a day). 14. vancomycin 125 mg Capsule [**Year (4 digits) **]: One (1) Capsule PO four times a day. 15. Flagyl 500 mg Tablet [**Year (4 digits) **]: One (1) Tablet PO three times a day. 16. quetiapine 25 mg Tablet [**Year (4 digits) **]: One (1) Tablet PO HS (at bedtime) as needed for insomnia, agitation. 17. acetaminophen 325 mg Tablet [**Year (4 digits) **]: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain, fever. 18. Calmoseptine 0.44-20.625 % Ointment [**Year (4 digits) **]: One (1) apply Topical every eight (8) hours: to affected area. 19. insulin lispro 100 unit/mL Solution [**Year (4 digits) **]: 2-10 units Subcutaneous every six (6) hours as needed for per sliding scale: Per Sliding Scale: BS: <150 no insulin 151-200 2 units 201-250 3 units 251-300 4 units 301-350 6 units 351-400 8 units 401-500 10 units >500 [**Name8 (MD) 138**] MD/NP. Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - MACU Discharge Diagnosis: s/p Hemorrhagic Stroke Gastric Mucormycosis Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Lethargic but arousable. Activity Status: Bedbound. Discharge Instructions: You were admitted to [**Hospital1 18**] for a scheduled EGD. Your EGD showed some improvement in your ulcer. While here, you were noted to have a temperature of 100.3. Bloood and Urine cultures were sent, results pending. During your procedure, your blood pressure dropped transiently, but improved moments later. Your BP has been stable since. Your blood counts were also stable. Changes in medication: None Followup Instructions: Please follow-up with infectious disease on Thursday, [**7-1**] as listed below. Department: INFECTIOUS DISEASE When: THURSDAY [**2173-7-1**] at 10:50 AM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 456**], MD [**Telephone/Fax (1) 457**] Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Hospital 1422**] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage Previously scheduled appointments: Department: [**Hospital1 **] MRI (MOBILE) When: TUESDAY [**2173-7-13**] at 10:35 AM With: MRI [**Telephone/Fax (1) 327**] Building: De [**Hospital1 **] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **] Campus: WEST Best Parking: [**Street Address(1) 592**] Garage Department: NEUROSURGERY When: TUESDAY [**2173-7-13**] at 11:45 AM With: [**Name6 (MD) **] [**Last Name (NamePattern4) 9151**], MD [**Telephone/Fax (1) 1669**] Building: LM [**Hospital Unit Name **] [**Location (un) **] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage

[ "V55.0", "117.9", "518.83", "531.90", "438.0", "458.29", "438.89", "345.90" ]

icd9cm

[ [ [] ] ]

[ "96.71", "96.08", "45.16" ]

icd9pcs

[ [ [] ] ]

6869, 6935

2603, 4043

282, 288

7023, 7023

1968, 2580

7599, 8637

1332, 1374

4592, 6846

6956, 7002

4069, 4569

7159, 7576

1389, 1391

1949, 1949

229, 244

316, 1049

1405, 1934

7038, 7135

1071, 1092

1108, 1316

18,418

157,274

45220

Discharge summary

report

Admission Date: [**2122-2-2**] Discharge Date: [**2122-2-5**] Date of Birth: [**2040-4-16**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1990**] Chief Complaint: Altered mental status, hypoglycemia, hypothermia Major Surgical or Invasive Procedure: none History of Present Illness: [Completed by ICU housestaff] 81M with history significant for diabetes mellitus, Parkinson's disease, and hypertrophic cardiomyopathy with LVOT obstruction. He has had two septal ablations ([**5-7**] and [**8-9**]), the first was complicated by complete heart block and he had placement of a St. [**First Name4 (NamePattern1) 923**] [**Last Name (NamePattern1) 12557**] DR [**Last Name (STitle) 8997**] chamber PPM/ICD placement for CHB and primary prevention of sudden cardiac death. He presented in [**2121-12-5**] with enterococcal bacteremia with a left psoas abscess, spinal osteomyelitis, and an ICD lead vegetation. He underwent abscess drainage, and was treated with ampicillin/gentamicin. Because of the potential morbidity associated with lead extraction, he elected to continue medical therapy with ampicillin and gentamicin, followed by indefinite oral ampicillin therapy. Unfortunately, he developed gentamicin renal toxicity with volume overload and anasarca, and was rehospitalized from [**1-12**] - [**2122-1-22**] during which time he was diuresed ~ 15 liters of fluid. He now returns after being found unresponsive at his [**Hospital1 1501**] this AM and his glucose found to be in 50s. EMS was called and an interosseus line was placed. He was given 1 amp D50 which brought glucose up to 80s; he was briefly mask ventilated in the field due to poor mental status. . In the ED, initial vs were: T92 oral (34.3 rectal), P76 BP 170/81 R26 92% on 2L. PICC line in place and cultures drawn. Glucose decreased to 64 in ED and given another [**12-6**] amp dextrose. RIJ also placed for access. Temps improved with bare hugger. Patient was given D5 IVFs at 125. Vanc and zosyn also given. . On the floor, patient alert and fully oriented. Recalls going to bed last night and then nothing again until ambulance ride. Reports eating fairly well recently without recent change. Daughter reports had sugary fried dough last night. No recent GI illness or URI symptoms. No recent change in insulin. Notes bilateral leg pain from swelling, which is overall improved. . . Review of sytems: (+) Per HPI. Endorses recent weight loss (total 40#) with improvement in LE edema. (-) Denies fever, chills, night sweats, headache, sinus tenderness, rhinorrhea or congestion. Denied cough, shortness of breath. Denied chest pain or tightness, palpitations. Denied nausea, vomiting, diarrhea, constipation or abdominal pain. Past Medical History: [Completed by ICU housestaff] - Enterococcal bacteremia with L psoas abscess s/p drainage, spinal osteomyelitis, and pacer lead vegetation (1/[**2121**]). Vanc, amp, PCN sensitive. Vancomycin therapy to ampicillin and gentamicin with plans for an 8 week course of ampicillin and 6 week course of gentamicin (actually completed 3 weeks and then stopped) followed by chronic suppression with oral amoxicillin. - HOCM s/p two septal ablations ([**2114**] and [**2116**]) - Complete heart block, s/p pacer - DM - CKD [**1-6**] Diabetic Nephropathy, recently worsened by gentamicin use, most recent baseline 2.9-3.3. - HTN - Hyperlipidemia - MVP - Stapedectomy - Gastritis - AVMs in small bowel ([**7-8**]) - Diverticulosis - Internal hemorrhoids - S/p Hernia repair - Sphincterotomy - H/o E. coli bacteremia - Anemia - Parkinson's disease Social History: [Completed by ICU housestaff] Currently staying at acute rehab but previously living with his wife. Uses a walker with ambulation, out of bed most days at rehab. Family involved and nearby (wife, son, daughter). [**Name2 (NI) **] current cigarette (quit 50 years ago) or EtOH use. Family History: [Completed by ICU housestaff] Father died from MI in 60s. Son and daughter both with HOCM. Physical Exam: [Completed by ICU housestaff] General: Alert, oriented x3, no acute distress HEENT: Sclera anicteric, PERRL, EOMI, MMM, oropharynx clear, slight facial tremor. Neck: supple, JVD best seen ~3 ASA (?higher), no LAD Lungs: Bibasilar crackles, no rhonchi/wheeze CV: Regular rate and rhythm, normal S1 + S2, soft SM at RUSB Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: warm, well perfused, 2+ pulses (though L>R DP), no clubbing, cyanosis. [**12-6**]+ bilateral pitting edema, pedal edema greater for LLE than RLE. Prominent resting tremor, most notable in RUE. PICC site benign. Neuro: CN II-XII intact. Strength 5/5 in UEs and LEs. Pertinent Results: CXR [**2-2**]: IMPRESSION: No acute intrathoracic abnormality. Non-contrast Head CT [**2-2**]: WET READ No acute intracranial abnormality. Unilateral lower extremity U/S [**2-2**]: IMPRESSION: No evidence of DVT in the left lower extremity. [**2122-2-2**] 06:15AM BLOOD WBC-7.1 RBC-4.21* Hgb-11.9* Hct-36.7* MCV-87 MCH-28.2 MCHC-32.3 RDW-14.1 Plt Ct-356 [**2122-2-2**] 06:15AM BLOOD Neuts-76.7* Lymphs-13.2* Monos-6.1 Eos-3.5 Baso-0.5 [**2122-2-2**] 06:15AM BLOOD PT-12.5 PTT-26.2 INR(PT)-1.0 [**2122-2-2**] 06:15AM BLOOD Glucose-161* UreaN-27* Creat-3.3* Na-141 K-3.7 Cl-98 HCO3-31 AnGap-16 [**2122-2-2**] 06:15AM BLOOD ALT-2 AST-11 LD(LDH)-237 CK(CPK)-26* AlkPhos-87 TotBili-0.2 [**2122-2-2**] 06:15AM BLOOD CK-MB-NotDone proBNP-2394* [**2122-2-2**] 06:15AM BLOOD cTropnT-0.03* [**2122-2-2**] 06:15AM BLOOD Albumin-4.0 [**2122-2-2**] 06:15AM BLOOD TSH-5.0* [**2122-2-2**] 06:15AM BLOOD Cortsol-41.4* [**2122-2-2**] 06:54AM BLOOD Lactate-2.1* Brief Hospital Course: [HOSPITALIST ACCEPT NOTE SUMMARY] I saw the patient in the ICU prior to transfer to the medical floor and I met with his wife as well. The patient is feeling well, eating a full diet, oriented to place and circumstance. His exam is remarkable for crackles at the left > right base. The heart is regular, no murmurs are heard. The PM pocket is benign. The abdomen is soft and without tenderenes. There is mild pitting edema in the ankles (boots are in place over the calves). He can move all for extremities, he has a tremor. His speech is fluent and comprehension is normal. All labs, studies, and medications reviewed. ASSESSMENT/PLAN: 81 year old male with recent enterococcal bacteremia complicated by spinal osteomyelitis, psoas abscess, and pacer/ICD wire infection. The patient subsequently was readmitted for gentamicin renal toxicity/renal failure and anasarca, and discharged again to rehab. He is now readmitted with hypothermia, hypoglycemia, and obtundation. . The initial concern was for sepsis. He was seen by infectious disease, they recommended removal of his PICC line, broad coverage, and then to taper back to ampicillin alone once the infectious evaluation is complete - this was completed and his cultures remained negative. It appears that this presentation may have been due to hypoglycemia, but it is difficult to recreate the circumstances that led to these events. While he likely has decreased insulin requirements related to renal failure, the requirements for repeated D50 administration suggest that he given the wrong dose. At this point it is difficult to recreate the circumstances surrounding this event. . DIABETES MELLTUS TYPE II/HYPOGLYCEMIA: Titrated insulin to conservative control, accepting sugars in the 200s to avoid repeated lows. . ENTEROCOCCAL BACTEREMIA/OSTEOMYELITIS/PM LINE INFECTION: The plan as communicated to me by [**Hospital Unit Name 153**] resident - once cultures from this hospitalization are confirmed negative, will transition back to IV ampicillin, and then to indefinite oral amoxacillin. He was seen in [**Hospital **] clinic by Dr. [**Last Name (STitle) **] in late [**Month (only) 956**] who noted that the vegetation on the ICD lead is now smaller and he was satisfied with the patients response to antibiotic therapy. Will need close outpatient ID follow-up, apparently he was scheduled to see [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in [**Hospital **] clinic this week. . ACUTE RENAL FAILURE/EDEMA: Patient appears to be at new baseline CrCl of ~ 3 since he suffered gentamicin toxicity. He has been seen by [**First Name8 (NamePattern2) **] [**Location (un) 805**]. His edema improved slightly with resumption of lasix; his LLE was noted to have significantly more edema that the rt. [**Last Name (LF) **], [**First Name3 (LF) **] bt. LE ultrasounds were performed to evaluate for DVTs, none were seen. . ANEMIA OF CHRONIC DISEASE: The patient has had chronic anemia for many years. He was hospitalized in [**2117**] for BRBPR and received multiple blood transfusions. At that time gastritis and small bowel AVM's were identified, but if his anemia continues to be related to occult GIB. His present iron studies are consistent with anemia of chronic disease. There are no reticulocyte counts in OMR to assess his marrow response, and the data is confused by ongoing iron supplementation and recent transfusion of 2 units of PRBC during his [**Month (only) 956**] admission. . PARKINSON'S DISEASE: Continued Sinimet. . HYPERTROPHIC CARDIOMYOPATHY/CHRONIC DIASTOLIC HEART FAILURE: Restarted lasix, continued lopressor and amlodipine. . GERD/GASTRITIS: Continued PPI . BENIGN PROSTATIC HYPERTROPHY: Continued finasteride. . HYPERLIPIDEMIA: Continued simvistatin. . DEPRESSION: Continued citalopram. . GLAUCOMA: Continued timolol. . SCLEROTIC BONE LESION ISCHIUM: This was identified in [**Month (only) 404**] with recommendation " Correlation with PSA is recommended and consideration of bone scan when clinically appropriate." This will need to be communicated to the patient and PCP (this summary will be faxed to PCP) . . ________________________ [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD Medications on Admission: - Ampicillin Sodium 2 gram every six hours: Last day [**2122-2-9**]. - - Furosemide 60 mg [**Hospital1 **] - - Humalog sliding scale Subcutaneous QID. - - Lantus: 6 cultures units Subcutaneous at bedtime. (discharged on 4 units) - Citalopram 20 mg DAILY - - Finasteride 5 mg DAILY - - Metoprolol Tartrate 100 mg Tablet twice a day. - - Amlodipine 10 mg Tablet once a day. - - Simvastatin 20 mg once a day. - - Omeprazole 20 mg DAILY ( - - Carbidopa-Levodopa 25-100 mg - 2 tabs TID and 1 tab HS - - Timolol Maleate 0.5 % Drops both eyes DAILY - - Cholecalciferol 800 unit once a day. - - Ascorbic Acid 500 mg DAILY - - Cyanocobalamin 100 mcg DAILY - - Fe sulfate 325 mg [**Hospital1 **] - - Acetaminophen [**Telephone/Fax (1) 1999**] mg Q6H as needed for pain. - - Docusate Sodium 100 mg [**Hospital1 **] - - Senna 8.6 mg two tabs daily - - Lactulose 15 ml daily - - Bisacodyl 10 mg DAILY as needed for constipation. - - Polyethylene Glycol 3350 17 gram/dose DAILY as needed - - Kcl 20 meq 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: 1-2 Tablets 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. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 7. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 8. Carbidopa-Levodopa 25-100 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 9. Carbidopa-Levodopa 25-100 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 10. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). 11. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Cyanocobalamin 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Ferrous Sulfate 300 mg (60 mg Iron) Tablet Sig: One (1) Tablet PO BID (2 times a day). 14. Timolol Maleate 0.5 % Drops Sig: One (1) Drop Ophthalmic DAILY (Daily): rt eye. 15. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 16. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 17. Furosemide 40 mg Tablet Sig: 1.5 Tablets PO BID (2 times a day). 18. Amoxicillin 250 mg Capsule Sig: Two (2) Capsule PO Q12H (every 12 hours). 19. Insulin Glargine 100 unit/mL Solution Sig: Three (3) Units Subcutaneous at bedtime. 20. Insulin Lispro 100 unit/mL Solution Sig: as per sliding scale (attached) units, insulin Subcutaneous QACHS: see attached sliding scale insulin regimen. Discharge Disposition: Extended Care Facility: [**Hospital 745**] Health Care Center Discharge Diagnosis: transient unresponsiveness, possibly due to hypoglycemia 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: see below Followup Instructions: Department: INFECTIOUS DISEASE When: WEDNESDAY [**2122-2-18**] at 9:50 AM With: [**First Name11 (Name Pattern1) 1037**] [**Last Name (NamePattern4) 2335**], MD [**Telephone/Fax (1) 457**] Building: LM [**Hospital Unit Name **] [**Hospital 1422**] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage Department: CARDIAC SERVICES When: FRIDAY [**2122-5-15**] at 3:00 PM With: DEVICE CLINIC [**Telephone/Fax (1) 62**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: CARDIAC SERVICES When: FRIDAY [**2122-5-15**] at 3:40 PM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1008**], M.D. [**Telephone/Fax (1) 62**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage

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Discharge summary

report

Admission Date: [**2188-1-28**] Discharge Date: [**2188-2-21**] Date of Birth: [**2131-4-24**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 473**] Chief Complaint: severe SOB worse w/ exertion existing at rest Major Surgical or Invasive Procedure: Puestow procedure (cystjejunostomy), cystduodenostomy, distal pancreatectomy, G- and J-tube placements [**2-8**] Tube thoracostomy x2. History of Present Illness: 56M s/p distal pancreatectomy & h/o chronic pancreatitis initially presented to [**Hospital1 **] [**1-21**] w/ SOB x 1wk, worse w/ exertion. Sx worsened over wk, progressing to severe SOB, sometimes at rest. + shoulder pain. Admits to 15lb weight loss over past 4 months. No F/Ch/N/V. + large R pleural effusion seen on imaging, s/p R thoracentesis x2 (fluid: amylase 7908, protein [**3-11**], pH 7.5, neg GS & Cx, few WBC). Serum amylase 300's, lipase 600's. Also noted to have pancreatic calcification & pseudocysts. S/p ERCP for eval of pancreatic ductal stricture. No stent [**2-7**] bleeding from PD. Concern for pancreatico-pleural fistula, hemobilia, risk of pancreatic ductal bleeding. Transferred to [**Hospital1 18**]. Past Medical History: h/o alcoholic pancreatitis c/b CHF([**2179**]), ETOH-induced Sz, withdrawal Sx; HTN (baseline SBP 100's); cardiomyopathy, Social History: + ETOH (2 drinks/d x 4-5d/wk); No tobacco (quit 2 months ago) - 45pk year hx Pt. is a Viet Nam veteran with an ongoing diagnosis of PTSD. He worked for many years in the automotive sales and repairs businesses Physical Exam: No acute distress. thin / cachetic no scleral icterus. No cervical / SC lymphadenopathy decreased breath sounds on right soft, nontender nondistended no hsm or masses appreciated no clubbing cyanosis or edema Pertinent Results: [**2188-1-28**] 09:00PM BLOOD WBC-12.8* RBC-4.02* Hgb-10.3* Hct-31.6* MCV-79* MCH-25.6* MCHC-32.5 RDW-16.1* Plt Ct-424 [**2188-2-2**] 05:30AM BLOOD WBC-11.2* RBC-3.86* Hgb-9.5* Hct-29.3* MCV-76* MCH-24.7* MCHC-32.6 RDW-16.1* Plt Ct-457* [**2188-2-8**] 03:31PM BLOOD WBC-22.5*# RBC-4.56* Hgb-11.7*# Hct-36.2*# MCV-79* MCH-25.7* MCHC-32.4 RDW-17.2* Plt Ct-460* [**2188-2-12**] 10:04AM BLOOD WBC-10.6 RBC-3.55* Hgb-9.5* Hct-28.0* MCV-79* MCH-26.8* MCHC-34.0 RDW-17.9* Plt Ct-480* [**2188-1-28**] 09:00PM BLOOD PT-13.6* PTT-24.7 INR(PT)-1.3 [**2188-1-28**] 09:00PM BLOOD Glucose-258* UreaN-13 Creat-0.7 Na-137 K-4.2 Cl-102 HCO3-28 AnGap-11 [**2188-2-2**] 05:30AM BLOOD Glucose-85 UreaN-19 Creat-0.7 Na-136 K-4.7 Cl-99 HCO3-28 AnGap-14 [**2188-2-10**] 05:44AM BLOOD Glucose-73 UreaN-7 Creat-0.6 Na-135 K-3.9 Cl-100 HCO3-28 AnGap-11 [**2188-1-28**] 09:00PM BLOOD ALT-8 AST-15 LD(LDH)-154 AlkPhos-62 Amylase-324* TotBili-0.3 [**2188-2-18**] 03:27AM BLOOD ALT-15 AST-12 AlkPhos-117 Amylase-64 TotBili-0.2 [**2188-1-28**] 09:00PM BLOOD Lipase-604* [**2188-2-18**] 03:27AM BLOOD Lipase-16 [**2188-2-18**] 03:27AM BLOOD calTIBC-256* TRF-197* [**2188-2-5**] 6:12 am URINE **FINAL REPORT [**2188-2-8**]** URINE CULTURE (Final [**2188-2-8**]): ENTEROCOCCUS SP.. 10,000-100,000 ORGANISMS/ML.. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ENTEROCOCCUS SP. | AMPICILLIN------------ <=2 S LEVOFLOXACIN---------- 0.5 S NITROFURANTOIN-------- <=16 S VANCOMYCIN------------ 2 S ANAEROBIC BOTTLE (Final [**2188-2-8**]): REPORTED BY PHONE TO [**Doctor Last Name **] MACKONE, LPN @ FA9A [**Numeric Identifier **] @ 0255AM ON [**2188-2-6**]. STAPH AUREUS COAG +. FINAL SENSITIVITIES. Oxacillin RESISTANT Staphylococci MUST be reported as also RESISTANT to other penicillins, cephalosporins, carbacephems, carbapenems, and beta-lactamase inhibitor combinations. Rifampin should not be used alone for therapy. Please contact the Microbiology Laboratory ([**7-/2488**]) immediately if sensitivity to clindamycin is required on this patient's isolate. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPH AUREUS COAG + | ERYTHROMYCIN---------- =>8 R GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- =>8 R OXACILLIN------------- =>4 R PENICILLIN------------ =>0.5 R RIFAMPIN-------------- <=0.5 S TETRACYCLINE---------- <=1 S VANCOMYCIN------------ <=1 S CHEST (PORTABLE AP) Reason: eval pleural effusion [**Hospital 93**] MEDICAL CONDITION: 56 year old man s/p ERCP REASON FOR THIS EXAMINATION: eval pleural effusion CHEST PORTABLE. INDICATION: 56-year-old man status post ERCP, evaluate pleural effusion. CHEST PORTABLE: No prior studies are available for comparison. There is a large pleural effusion on the right, which surrounds the entire right lung and extends into the apex. The left lung is not completely depicted on this film; however, depicted aspects are unremarkable. There is a central venous line seen with its tip in the mid SVC. IMPRESSION: Large right pleural effusion. CTA ABD W&W/O C & RECONS; CT PELVIS W/CONTRAST Reason: Assess for vascular malformations Field of view: 36 Contrast: OPTIRAY [**Hospital 93**] MEDICAL CONDITION: 56 year old man with chronic pancreatitis, possible pancreatico-pulmonary fistula, possible av fistulae REASON FOR THIS EXAMINATION: Assess for vascular malformations CONTRAINDICATIONS for IV CONTRAST: None. CT OF THE ABDOMEN AND PELVIS There is no comparison exam. CLINICAL HISTORY: Chronic pancreatitis, possible pancreatic or pulmonary fistula, possible AV fistula. Assess for vascular malformation. TECHNIQUE: Axial MDCT images of the abdomen and pelvis obtained after pre and post-IV contrast enhancement. Multiplanar volume reformatted images were generated, which were essential in the evaluation of the abdomen and pelvis. CT ABDOMEN FINDINGS: Images of the lower thorax demonstrate a small right pleural effusion and a chest tube. There is consolidation/atelectasis at the right lower lobe. There is a small pneumothorax on the right. Small left pleural effusion is also present. Pre-contrast images of the abdomen demonstrate multiple small calcifications in the pancreas consistent with chronic pancreatitis. There is atherosclerosis. Post-contrast images demonstrate a normal appearance of the liver, spleen, adrenal glands, and kidneys. The pancreas is atrophic. The pancreatic duct is dilated. Numerous cystic structures are present adjacent to the pancreas. The largest is adjacent to pancreatic tail and extends between the stomach and spleen and measures 3.5 x 4.1 cm. Another large bilobed cyst is seen extending from the lesser sac to the pancreatic head. It contains a focus of gas. There is a small fluid collection in the right diaphragmatic crus measuring less than 4 mm wide. This is best seen on series 6, image 22. There are no dilated bowel loops. There are scattered prominent lymph nodes. CT PELVIS FINDINGS: There is no pelvic free fluid or lymphadenopathy. No dilated bowel loops are present within the pelvis. Gas is seen in the urinary bladder. Bone windows demonstrate no lytic or blastic lesions. CTA FINDINGS: There is conventional hepatic vasculature. The celiac axis, common hepatic artery, left gastric artery, and splenic artery are patent. There is no splenic artery aneurysm. There is atherosclerosis at the origin of the SMA causing a high-grade stenosis but the distal SMA is patent. The renal arteries are patent. There is narrowing of the splenic vein likely second to pancreatitis. There is a filling defect in the inferior mesenteric vein consistent with thrombus. There is conventional portal venous anatomy. The hepatic venous anatomy is normal. There is no evidence of a fistula either within the abdomen or between the thorax and abdomen. IMPRESSION: 1. No AV fistula or pancreatic or pulmonary fistula as questioned. 2. Numerous cystic structures surrounding the pancreas consistent with pancreatic pseudocysts. One large one extending from the lesser sac to the pancreatic head contains a focus of air, which may represent infection. 3. Tiny enhancing fluid collection in the right diaphragmatic crus. This may be related to extension of pancreatitis, or alternatively extension from infection in the right lung. Close attention to this area should be paid on further follow-up studies to exclude early/small abscess. 4. Gas in the urinary bladder correlate with a recent Foley catheterization or instrumentation. If the patient has had neither of these, then a UA is recommended to exclude infection. 5. Narrowed splenic vein likely secondary to pancreatitis. Thrombus in the IMV also likely related to pancreatitis. 6. Small right pneumothorax. UNILAT UP EXT VEINS US LEFT PO Reason: PHLEBITIS, FEVERS, ? CLOT [**Hospital 93**] MEDICAL CONDITION: 56 year old man with phlebitis and fever 103 REASON FOR THIS EXAMINATION: ? clot INDICATION: 56-year-old with phlebitis and fever of 103. [**Doctor Last Name **]-scale and pulse color Doppler imaging of the left internal jugular, axillary, subclavian, brachial, and cephalic veins was performed. Echogenic material consistent with thrombus is seen filling the cephalic vein, which is not compressible. No color flow is seen within the cephalic vein. There is normal color flow, compressibility, waveform, and augmentation elsewhere in the left arm. IMPRESSION: No deep vein thrombosis in the left arm. Thrombosis in the superficial left cephalic vein. [**Known lastname **],[**Known firstname **] [**2131-4-24**] 56 Male [**Numeric Identifier 65104**] [**Numeric Identifier 65105**] Report to: DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **] Gross Description by: DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) 65106**]/dif SPECIMEN SUBMITTED: RT AXILLARY MASS,GALLBLADDER. Procedure date Tissue received Report Date Diagnosed by [**2188-2-8**] [**2188-2-8**] [**2188-2-13**] DR. [**Last Name (STitle) **]. [**Doctor Last Name **]/vf DIAGNOSIS: I.. Axillary mass, right (A): Epidermal inclusion cyst. II. Gallbladder (B-C): 1. Chronic cholecystitis, mild. 2. No calculi. Clinical: Chronic pancreatitis and mass right axilla. Gross: CT PELVIS W/CONTRAST [**2188-2-19**] 1:10 PM CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Reason: PLEASE DO CT [**2188-2-19**]. pt s/p choledochoduodenosotmy, peusto Field of view: 36 Contrast: OPTIRAY [**Hospital 93**] MEDICAL CONDITION: 56 year old man with chronic pancreatitis, s/p peustow REASON FOR THIS EXAMINATION: PLEASE DO CT [**2188-2-19**]. pt s/p choledochoduodenosotmy, peustow procedure w/ bloody BM'S, low-grade fever, leukocytosis. Eval for postop collection CONTRAINDICATIONS for IV CONTRAST: None. INDICATION: Chronic pancreatitis, status post Puestow. Bloody BMs, low-grade fever and leukocytosis. Evaluate for postop collection. COMPARISON: [**2188-1-30**]. TECHNIQUE: Contiguous axial images through the abdomen and pelvis were obtained following the administration of oral and 150 cc of Optiray contrast. Coronal and sagittal reconstructions were obtained. CT OF THE ABDOMEN WITH CONTRAST: The lung bases are clear. The liver, spleen, and adrenal glands are normal. The patient is status post Puestow procedure. Air is noted within the pancreatic duct, not unexpected following this procedure. Calcifications are again noted within the pancreas, consistent with chronic pancreatitis. There is interval resolution of multiple pseudocysts that were seen in the [**2188-1-6**] study. There is residual fluid within the splenic hilum, measuring 2.9 x 1.6 cm. There is interval appearance of a small focus of arterial enhancement just inferior to the splenic artery measuring 8 mm in diameter, likely representing a small splenic artery aneurysm. The kidneys enhance symmetrically and excrete normally. There is a gastrojejunostomy tube in place. There is also a drain entering the right upper quadrant of the abdomen, traversing the abdomen between the stomach and pancreas. Small bowel loops are not dilated, and the colon is unremarkable. Bowel anastomosis is noted within the left mid abdomen. There are post-surgical changes of the anterior abdominal walls, with staples still in place. The abdominal aorta is of normal caliber, with calcifications at the origin of the SMA. The portal and splenic veins remain patent. No filling defect is noted within the IMV on this study. No pathologically enlarged mesenteric or retroperitoneal lymph nodes. CT OF THE PELVIS WITH CONTRAST: The bladder, seminal vesicles, prostate, rectum, and sigmoid are normal. No free pelvic fluid, and no pathologically enlarged pelvic or inguinal lymph nodes. BONE WINDOWS: There are no suspicious osteolytic or sclerotic lesions. Multiplanar reformatted images were essential in delineating the anatomy and pathology in this case IMPRESSION: 1. Status post Puestow procedure, nearly all of the prior pancreatic pseudocysts have resolved. There is small amount of residual fluid near the splenic hilum as described. This is amenable to drainage at this time. 2. Interval development of small splenic artery aneurysm, measuring 8 mm. 3. Interval placement gastrojejunostomy tube and JP drain as described. 4. No definite filling defect is noted within the IMV on the current exam. Brief Hospital Course: Patient was transferred from [**Hospital3 **] to the ICU at [**Hospital1 18**] for further workup and treatment of pancreatic pseudocyst and pleural effusion. Thoracic surgery consult was obtained on HD2 for drainage of the effusion. A CT was placed on HD2, kept to sux until HD7, the placed on water seal until HD9. Patient was started on octreotide, TPN, NPO & IVF and antibiotics dc'd with a presumptive diagnosis or pancreatico-pleural fistula. HD3 patient was tranferred to the floor as in stable condition. Patient was slowly started back on clears on HD5. After CT scans and monitoring patient's clinical picture, it was decided to take the patient to the OR on HD9. However, that morning, patient spiked a tempurature to 103.0F. Blood & urince cultures were sent as well as a cxr. Patient was discovered to have phlebitis at his picc site with some pus drainage as well as positive blood cultures. Vascular surgery was consulted and monitored his phlebitis for a few days until it was decided that it did not need to be excised. vancomycin was started. Patient continued to have fevers for the next few days which finally disappeared after 48 hours of antibiotics. Patient was then taken to the OR on HD12 for Puestow, cystduodenostomy, distal pancreatectomy, G- and J-tube placements. Patient did well - was admitted to the ICU for monitoring, transferred to the floor on POD2. Got an epidural for pain which was well controlled, changed to a PCA on POD3. NGT remained unitl POD2. POD3 trophic tube feeds were started via the J port, PT was consulted and social work continued to work with patient. Again spiked a temp on POD3, cultures sent and cxr showed atelectasis vs aspiration and levoquin was started. POD4 Tf increased and advancing towards goal, reached on POD6 and started cycling on POD7. POD5 patient was allowed regular diet which he tolerated in small amounts. patient stayed in the hospital for the remainder of his 14d course of IV abx since he had no insurance. POD9 patient had a few bloody stools. serial hcts were done which were all stable. C dif cultures were negative. Patient had a repeat Ct on POD11 which showed improvemnt since pre-op. JP was dc'd on POD12. Patient was then dc'd on POD13 on regular diet, with staples dc'd and instructions to follow-up with dr [**Last Name (STitle) **] Medications on Admission: occasional ASA Discharge Medications: 1. Glyburide 5 mg Tablet Sig: One (1) Tablet PO once a day: Take in am. Disp:*30 Tablet(s)* Refills:*2* 2. One Touch Ultra Test Strip Sig: One (1) strip Miscell. per fingerstick check: as directed. Disp:*100 strips* Refills:*4* 3. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation Q6H (every 6 hours). Disp:*1 inhaler* Refills:*2* 4. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation QID (4 times a day). Disp:*1 inhaler* Refills:*2* 5. 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:*150 ML(s)* Refills:*0* 6. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 7. Insulin Regular Human 100 unit/mL Solution Sig: One (1) injection Injection ASDIR (AS DIRECTED): please see attached sliding scale. Disp:*1 bottle* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: chronic pancreatitis, complicated by pancreatic pseudocyst and pancreatico-pleural fistula HTN cardiomyopathy Discharge Condition: stable Discharge Instructions: [**Name8 (MD) **] MD or come to ER for fever, chills; nausea, vomiting, inability to tolerate diet; abdominal pain; if incision develops redness, swelling, or drainage; or any questions that concern you. Take medications as directed. [**Month (only) 116**] take percocet elixir (roxicet) as directed. Do not drive or drink alcohol while taking percocet. For milder pain, may take tylenol instead; but do not take tylenol with percocet because percocet already contains tylenol. Continue to check your blood sugar with a fingerstick as directed. [**Month (only) 116**] shower, pat incision dry, do not scrub. No heavy lifting or straining for 4 weeks. Followup Instructions: Follow-up with Dr. [**Last Name (STitle) 28529**] in 2 weeks. Follow-up with [**Hospital **] clinic in 2 weeks. Completed by:[**2188-2-22**]

[ "451.84", "511.9", "999.2", "577.8", "425.4", "577.1", "706.2", "401.9", "577.2", "428.0", "575.11", "303.91" ]

icd9cm

[ [ [] ] ]

[ "86.3", "99.15", "52.59", "51.22", "52.4", "52.96", "96.6", "44.39", "34.09", "38.93" ]

icd9pcs

[ [ [] ] ]

16929, 16935

13568, 15893

359, 496

17089, 17098

1872, 4675

17804, 17947

15958, 16906

10695, 10750

16956, 17068

15919, 15935

17122, 17781

1643, 1853

274, 321

10779, 13545

524, 1254

1276, 1399

1416, 1628

62,084

161,439

40092

Discharge summary

report

Admission Date: [**2107-10-31**] Discharge Date: [**2107-11-4**] Date of Birth: [**2044-10-5**] Sex: F Service: CARDIOTHORACIC Allergies: Zocor / Percocet Attending:[**First Name3 (LF) 922**] Chief Complaint: Dyspnea on exertion Major Surgical or Invasive Procedure: Aortic valve replacement with a 21 mm [**Doctor Last Name **] Magna aortic valve bioprosthesis model Coronary bypass grafting x1 with left internal mammary artery, left anterior descending coronary artery. History of Present Illness: This is a 63yo female who presented to outside institution with "atypical chest pain". Echocardiogram in [**2107-4-26**] was notable for possible bicuspid aortic valve with aortic stenosis. Subsequent stress testing in [**2107-7-27**] was abnormal. ETT was stopped due to dyspnea associated with ST depressions. Cardiac catheterization in [**2107-8-26**] reportedly showed aortic root dilatation and mild obstructive coronary artery disease. Her current symptoms include dyspnea on exertion, palpitations, and worsening fatigue. She denies chest pain, syncope, orthopnea, PND and pedal edema. Surgical evaluation was recommended by Dr. [**Last Name (STitle) 23097**]. [**2107-9-21**] Cardiac Catheterization @ LGH: Right dominant. Mid LAD 50%. Mid LCX 40%. RCA with only minor irregularities. PA mean 23mmHg. Bicuspid AS with trace AI. [**Location (un) 109**] 0.9cm2 with mean 35mmHg. Aortic root dilatation 4.8 centimeters. [**2107-5-17**] Cardiac Echocardiogram: LVEF 60-65%. Moderate to severe AS. [**Location (un) 109**] estimated at 0.85cm2 with peak/mean gradients of 70/46 mmHg. Trace MR. [**First Name (Titles) **] [**Last Name (Titles) **]. Trace PR. Ascending aorta dilated up to 4.3cm. Past Medical History: Hypertension Dyslipidemia Borderline Diabetes Mellitus Type II GERD Anxiety Past Surgical History: s/p Tubal Ligation, s/p Lap Chole Social History: Race: Caucasian Last Dental Exam: 3 months ago Lives with: Husband Occupation: Accounts payable Tobacco: None since age 23 ETOH: Rare Family History: Father suffered first MI at age 48, died at 58. Physical Exam: Pulse: 74 Resp: 18 O2 sat: 98% B/P Right: 130/80 Left: 133/84 Height: 65inches Weight: 153lbs General: WDWN female in no acute distress Skin: Warm[x] Dry [x] intact [x] HEENT: NCAT[x] PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] - no JVD Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur 3/6 systolic murmur best heard at the RUSB - transmitted to carotid region Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Extremities: Warm [x], well-perfused [x] Edema: None Varicosities: None [x] Neuro: Alert and oriented x 3. CN 2-12 grossly intact. 5/5 strength with full ROM. No focal deficits noted Pulses: Femoral Right: 2 Left: 2 DP Right: 1 Left: 1 PT [**Name (NI) 167**]: 1 Left: 1 Radial Right: 1 Left: 1 Carotid Bruit: None Pertinent Results: [**2107-11-4**] 04:40AM BLOOD WBC-9.9 RBC-2.77* Hgb-9.1* Hct-25.6* MCV-93 MCH-33.0* MCHC-35.6* RDW-13.3 Plt Ct-182 [**2107-11-4**] 04:40AM BLOOD UreaN-17 Creat-0.8 Na-139 K-4.2 Cl-102 [**2107-11-3**] 04:20AM BLOOD WBC-11.0 RBC-2.78* Hgb-8.6* Hct-25.0* MCV-90 MCH-31.1 MCHC-34.5 RDW-13.5 Plt Ct-133* [**2107-11-3**] 04:20AM BLOOD Glucose-100 UreaN-15 Creat-0.8 Na-136 K-4.3 Cl-102 HCO3-24 AnGap-14 [**2107-10-31**] LEFT ATRIUM: Mild LA enlargement. Good (>20 cm/s) LAA ejection velocity. No thrombus in the LAA. RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. PFO is present. LEFT VENTRICLE: Moderate symmetric LVH. Normal LV cavity size. Overall normal LVEF (>55%). RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Normal aortic diameter at the sinus level. Mildly dilated ascending aorta. Mildly dilated aortic arch. Normal descending aorta diameter. Simple atheroma in descending aorta. AORTIC VALVE: Three aortic valve leaflets. Moderately thickened aortic valve leaflets. Critical AS (area <0.8cm2). Mild (1+) AR. MITRAL VALVE: Mild (1+) MR. TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS. Physiologic PR. PERICARDIUM: Very small pericardial effusion. Conclusions: PRE-CPB:1. The left atrium is mildly dilated. No thrombus is seen in the left atrial appendage. 2. A patent foramen ovale is present. 3. There is moderate symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF>55%). 4. Right ventricular chamber size and free wall motion are normal. 5. The ascending aorta is mildly dilated. The aortic arch is mildly dilated. There are simple atheroma in the descending thoracic aorta. 6. There are three aortic valve leaflets. The aortic valve leaflets are moderately thickened. There is critical aortic valve stenosis (valve area <0.8cm2). Mild (1+) aortic regurgitation is seen. 7. Mild (1+) mitral regurgitation is seen. 8. There is a very small pericardial effusion. POST-CPB: On infusion of phenylephrine. AV pacing for long pr interval. Well-seated bioprosthetic valve in the aortic position. No AI. Peak gradient is 12 mmHg at CO = 5.7 L/min. Preserved biventricular systolic function. MR remains 1+. Aortic contour is normal post decannulation. Brief Hospital Course: The patient was admitted to the hospital and brought to the operating room on [**2107-10-31**] where the patient underwent an aortic valve replacement with a 21 mm [**Doctor Last Name **] Magna aortic valve bioprosthesis and coronary bypass grafting x1 with left internal mammary artery to the left anterior descending coronary artery. Overall the patient tolerated the procedure well and post-operatively was transferred to the CVICU in stable condition for recovery and invasive monitoring. POD 1 found the patient extubated, alert and oriented and breathing comfortably. The patient was neurologically intact and hemodynamically stable on no inotropic or vasopressor support. Beta blocker was initiated and the patient was gently diuresed toward the preoperative weight. The patient was transferred to the telemetry floor for further recovery. Chest tubes and pacing wires were discontinued without complication. Zofran was given for post operative nausea with good effect. The patient had complained of visual "floaters" and the Ophthomology service was consulted. Their exam revealed no acute eye process and follow up with outpatient ophthomologist was recommended. She was started on iron , folate and vitamin C with a stable hematocrit of 25 at discharge (asymptomatic). The patient was evaluated by the physical therapy service for assistance with strength and mobility. By the time of discharge on POD 4 the patient was ambulating freely, the wound was healing and pain was controlled with oral analgesics. The patient was discharged home with [**Doctor Last Name 269**] services in good condition with appropriate follow up instructions. Medications on Admission: Lipitor 20 daily, Metoprolol 50mg daily, Omeprazole 20mg prn, Aspirin 81mg daily, Tums, Vitamin D Discharge Medications: 1. atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 3. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 4. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*100 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 5. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. 6. 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* 7. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for fever, pain. 8. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*1* 9. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day for 7 days. Disp:*7 Tablet(s)* Refills:*0* 10. Iron (ferrous sulfate) 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO once a day for 2 months. Disp:*60 Tablet(s)* Refills:*0* 11. folic acid 1 mg Tablet Sig: One (1) Tablet PO once a day for 2 months. Disp:*60 Tablet(s)* Refills:*0* 12. Vitamin C 500 mg Tablet Sig: Two (2) Tablet PO twice a day for 2 months. Disp:*240 Tablet(s)* Refills:*0* 13. Zofran 4 mg Tablet Sig: One (1) Tablet PO every eight (8) hours as needed for nausea. Disp:*30 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**First Name5 (NamePattern1) 189**] [**Last Name (NamePattern1) 269**] Discharge Diagnosis: Aortic Stenosis Coronary Artery Disease Discharge Condition: Alert and oriented x3 nonfocal Ambulating with steady gait Incisional pain managed with Dilaudid Incisions: Sternal - healing well, no erythema or drainage Trace Edema Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month 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. [**Last Name (STitle) 914**] on [**11-29**] at 1:45pm Cardiologist: Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 23097**] on [**12-13**] at 4:20pm Please call to schedule appointments with your Primary Care Dr. [**Last Name (STitle) 88127**] in [**2-28**] weeks [**Telephone/Fax (1) 16995**] Needs to schedule follow up with Local Ophthomologist **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:[**2107-11-4**]

[ "300.00", "414.01", "424.1", "746.4", "790.29", "368.8", "401.9", "272.4", "530.81", "285.1", "787.02", "V45.89" ]

icd9cm

[ [ [] ] ]

[ "36.15", "35.21", "36.11", "39.61" ]

icd9pcs

[ [ [] ] ]

8745, 8847

5366, 7026

304, 512

8931, 9101

2973, 5343

10025, 10649

2066, 2116

7175, 8722

8868, 8910

7052, 7152

9125, 10002

1862, 1898

2131, 2954

244, 266

540, 1741

1763, 1839

1914, 2050

30,070

182,313

47117

Discharge summary

report

Admission Date: [**2151-7-21**] Discharge Date: [**2151-8-6**] Date of Birth: [**2081-11-18**] Sex: M Service: CARDIOTHORACIC Allergies: Codeine Attending:[**First Name3 (LF) 165**] Chief Complaint: Mouth pain Major Surgical or Invasive Procedure: [**2151-7-27**] Coronary Artery Bypass Graft x 6 (LIMA to LAD, SVG to D1, SVG to D2, SVG to OM to Ramus, SVG to PDA), Mitral Valve Repair with 26mm CE Ring [**2151-7-23**] Cardiac Catherization History of Present Illness: 69 yo male with hx of HTN, hyperlipidemia, and ? MI in the past presents with mouth pain. Pain has been present for over a year and has been evaluated by a dentist and his PCP and the cause of his pain remains unclear. Exertion such as climbing stairs or moving around also makes the pain worse, but it is not associated with any chest pain, chest tightness, or palpitations. Past Medical History: Hypertension, Hyperlipidemia, Prostate cancer- s/p brachytherapy [**2145**], PVD, s/p Parathyroidectomy for hyperpara with hypercalcemia, GERD, Diverticulosis, Sleep disorder Social History: Social history is significant for previous smoking 2ppd x40 yrs quit 1 yr ago. No EtOH. Lives alone and is a retired worker for Xerox. Never married and has no children. Family History: Sister died age 60 of CA unknown type and brother died in his 60's of esophageal CA Physical Exam: VS: T 99.0 , BP 145/105 , HR 75 , RR 16 , O2 % 97 on 2L NC Gen: WDWN middle aged male in NAD, resp or otherwise. Oriented x3. Mood, affect appropriate. Pleasant. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. Poor dentition. No tooth pain to palpation Neck: Supple with no elev JVP. CV: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. No S4, no S3. Chest: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. No crackles, wheeze, rhonchi. Abd: soft, NTND, No HSM or tenderness. No abdominial bruits. Hyperactive BS Ext: No c/c/e. No femoral bruits. 1+ dp pulse on left, absent on rt Skin: No stasis dermatitis, ulcers, scars, or xanthomas. Right: Carotid 2+ without bruit; Femoral 2+ without bruit; Left: Carotid 2+ without bruit; Femoral 2+ without bruit; Discharge 98.1, 116/60, 81 SR, 18, 100% RA General NAD well developed Neuro A/O x3 nonfocal Cardiac RRR no m/r/g Resp CTA bilat except decreased left base no rhonchi/wheezes Abd Soft, NT, ND +BS BM [**8-4**] Ext warm no edema pulses palpable Inc Left leg EVH no erythema/drainage steris intact Inc Sternal no erythema/drainage steris intact sternum stable Pertinent Results: [**2151-7-21**] 12:55PM BLOOD WBC-4.8 RBC-4.32* Hgb-13.8* Hct-37.3* MCV-86# MCH-32.1* MCHC-37.1* RDW-14.1 Plt Ct-152 [**2151-7-21**] 12:55PM BLOOD PT-13.6* PTT-29.5 INR(PT)-1.2* [**2151-7-21**] 12:55PM BLOOD Glucose-111* UreaN-20 Creat-1.3* Na-141 K-4.4 Cl-105 HCO3-26 AnGap-14 [**2151-7-21**] 12:55PM BLOOD cTropnT-0.05* [**2151-7-22**] 10:15AM BLOOD CK-MB-5 cTropnT-0.07* [**2151-7-23**] 04:14PM BLOOD %HbA1c-5.8 [**2151-7-22**] 10:15AM BLOOD Triglyc-122 HDL-36 CHOL/HD-3.2 LDLcalc-56 [**2151-7-22**] 03:31AM BLOOD PSA-<0.1 [**2151-7-22**] Persantine MIBI: Left ventricular cavity size is normal. Rest and stress perfusion images reveal a moderately severe, large, reversible perfusion defect in the inferior wall extending to the apex. A second moderate reversible perfusion defect is seen in the inferolateral wall. Gated images reveal moderate global hypokinesis. The calculated left ventricular ejection fraction is 43%. [**2151-7-23**] Cardiac Cath: 1. Selective coronary angiography of this right dominant system revealed 3 vessel coronary artery disease. The LMCA had no angiographically apparent flow limiting lesions. The LAD had 90% mid vessel stenosis after a large D2. The D1 had a proximal 90% stenosis. The D2 had a 80% stenosis. The LCX had an 80% tubular lesion proximally. The RCA was occluded proximally and filled via left to right collaterals. 2. Limited resting hemodynamics revealed normal systemic pressures and a normal LVEDP. 3. Left ventriculography revealed an EF of 60% with no significant mitral regurgitation. There was no transaortic gradient upon pullback of the catheter from the left ventricle to the aorta. [**2151-7-26**] Echocardiogram: The left atrium is normal in size. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. There is mild regional left ventricular systolic dysfunction with inferior hypokinesis. Overall left ventricular systolic function is mildly depressed. Tissue Doppler imaging suggests a normal left ventricular filling pressure (PCWP<12mmHg). Right ventricular chamber size and free wall motion are normal. The aortic root is moderately dilated at the sinus level. The aortic valve leaflets (3) are mildly thickened. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild mitral regurgitation is seen. The left ventricular inflow pattern suggests impaired relaxation. There is trace pericardial effusion. Cardiology Report ECHO Study Date of [**2151-7-27**] *** Report not finalized *** PRELIMINARY REPORT PATIENT/TEST INFORMATION: Indication: Aortic valve disease. Coronary artery disease. Left ventricular function. Mitral valve disease. Valvular heart disease. Status: Inpatient Date/Time: [**2151-7-27**] at 11:49 Test: TEE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Tape Number: 2007AW02-: Test Location: Anesthesia West OR cardiac Technical Quality: Adequate REFERRING DOCTOR: DR. [**First Name (STitle) **] [**Name (STitle) **] MEASUREMENTS: Left Atrium - Long Axis Dimension: *5.0 cm (nl <= 4.0 cm) Left Atrium - Four Chamber Length: 5.2 cm (nl <= 5.2 cm) Left Ventricle - Septal Wall Thickness: 1.1 cm (nl 0.6 - 1.1 cm) Left Ventricle - Inferolateral Thickness: 1.1 cm (nl 0.6 - 1.1 cm) Left Ventricle - Diastolic Dimension: 5.4 cm (nl <= 5.6 cm) Left Ventricle - Systolic Dimension: 3.9 cm Left Ventricle - Fractional Shortening: *0.28 (nl >= 0.29) Left Ventricle - Ejection Fraction: 35% to 40% (nl >=55%) Aorta - Valve Level: 3.5 cm (nl <= 3.6 cm) Aorta - Ascending: *3.9 cm (nl <= 3.4 cm) INTERPRETATION: Findings: Mitral Regurgitation assessed by phenylephrine challenge. MR worsened from mild in severity at a SBP of 120 mm. to moderate to severe at a SBP of 150 mm. Hg. Annular diameter (Transcommissural) = 3.9 mm. ( Anteroposterior) = 3.9 LEFT ATRIUM: Moderate LA enlargement. No spontaneous echo contrast or thrombus in the body of the [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] LAA. All four pulmonary veins identified and enter the left atrium. RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. A catheter or pacing wire is seen in the RA. No ASD by 2D or color Doppler. LEFT VENTRICLE: Wall thickness and cavity dimensions were obtained from 2D images. Normal LV cavity size. 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: Mildly dilated RV cavity. Borderline normal RV systolic function. AORTA: Mildly dilated ascending aorta. 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. Moderate (2+) MR. [**First Name (Titles) **] vena contracta is >=0.7cm TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with physiologic PR. 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 TEE probe was passed with assistance from the anesthesioology staff using a laryngoscope. The patient was under general anesthesia throughout the procedure. Suboptimal image quality - poor echo windows. Conclusions: PRE-BYPASS: The left atrium is moderately dilated. No spontaneous echo contrast or thrombus is seen in the body of the left atrium or left atrial appendage. No atrial septal defect is seen by 2D or color Doppler. The left ventricular cavity size is normal. Overall left ventricular systolic function is moderately depressed. The right ventricular cavity is mildly dilated. Right ventricular systolic function is borderline normal. The ascending aorta is mildly dilated. 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. Moderate (2+) mitral regurgitation is seen. The mitral regurgitation vena contracta is >=0.7cm. [**Location (un) **] PHYSICIAN: ([**Numeric Identifier 99870**]) [**2151-8-6**] 06:20AM BLOOD WBC-14.1* RBC-3.83* Hgb-11.5* Hct-34.1* MCV-89 MCH-30.0 MCHC-33.6 RDW-14.3 Plt Ct-691* [**2151-8-6**] 06:20AM BLOOD Plt Ct-691* [**2151-8-6**] 06:20AM BLOOD PT-16.7* INR(PT)-1.5* [**2151-8-6**] 01:10PM BLOOD UreaN-25* Creat-1.4* Na-138 K-4.0 Brief Hospital Course: As mentioned in the HPI, Mr. [**Known lastname **] presented with mouth pain with unknown etiology. Given cardiac risk factors he was admitted for rule out and follow-up stress test. He ruled out for acute MI, but a pMIBI was notable for lateral ST-depressions. He subsequently underwent cardiac catheterization which revealed severe three vessel coronary artery disease. He then underwent pre-operative work-up for surgery. On [**7-27**] he was brought to the operating room where he underwent a coronary artery bypass graft and mitral valve repair. Please see op note for surgical details. Following surgery he was transferred to the CSRU for invasive monitoring in stable condition. During initial post-operative period he require blood products for bleeding. On post-op day one he was weaned from sedation, awoke neurologically intact and extubated. He was started on beta blockers and diuretics. And he was gently diuresed towards his pre-op weight. On post-op day two he was transferred to the SDU for further care. During post-op period his chest tubes and epicardial pacing wires were removed per protocol. POD 3 evening he developed fever 103.5, cultures were obtained, CXR, and treated with tylenol. Fever resolved, blood culture [**2-11**] with coag negative staph, ID consulted and antibiotics started until other cultures finalized. Will continue with antibiotics for 8 day course per ID recommendations as empiric therapy. Episode of Afib on POD #6 treated with amiodarone and anticoagulation started. Target INR for A fib is 2.0-2.5. He will follow up with Dr [**First Name (STitle) **] [**9-8**] with follow up chest xray. PICC line was inserted POD 9 for continued abx and he was ready for discharge to rehab on POD 10. Medications on Admission: Pletal 100mg qd, Bechol, Lisinopril 10mg qd, Verapamil 240mg qd, trazadone 100mg qhs, MVI, Fish Oil, CoQ10 Discharge Medications: 1. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily). 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:*1* 3. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*1* 4. Cilostazol 100 mg Tablet Sig: One (1) Tablet PO Daily () as needed for PVD. Disp:*30 Tablet(s)* Refills:*0* 5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*1* 6. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day): 400mg twice a day then decrease to 400mg daily on [**8-9**], then on [**8-16**] decrease to 200mg daily and f/u with Dr [**Last Name (STitle) **]. 7. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [**Hospital1 **] (2 times a day). 8. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation Q6H (every 6 hours). 9. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 10. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO every twelve (12) hours. 11. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed. 12. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO q3h. 13. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed. 14. Zosyn 4.5 g Recon Soln Sig: 4.5 gm Intravenous every eight (8) hours for 5 days: last day monday [**8-9**]. 15. Vancomycin in Normal Saline 1 g/250 mL Solution Sig: One (1) gm Intravenous every twelve (12) hours for 5 days: last day of doses [**8-9**] . 16. Furosemide 40 mg Tablet Sig: One (1) Tablet PO twice a day for 10 days. 17. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two (2) Capsule, Sustained Release PO Q12H (every 12 hours) for 10 days. 18. Warfarin 4 mg Tablet Sig: One (1) Tablet PO once a day: 4mg [**8-6**] with labs check [**8-7**] - goal INR 2.0-2.5 for atrial fibrillation . Discharge Disposition: Extended Care Facility: [**First Name4 (NamePattern1) 1188**] [**Last Name (NamePattern1) **] Discharge Diagnosis: Coronary Artery Disease s/p Coronary Artery Bypass Graft x 6 Mitral Regurgitation s/p Mitral Valve Repair Atrial Fibrillation PMH: Hypertension, Hyperlipidemia, Peripheral vascular disease, Hypertension, Prostate Cancer s/p Brachytherapy [**2145**], Gastroesophageal Reflux Disease, Diverticulosis, s/p Prathyroidectomy, Sleep Disorder, AF Discharge Condition: Good Discharge Instructions: 1) Patient to shower daily, no baths. 2) No creams, lotions or ointments to incisions. 3) No driving for at least one month. 4) No lifting more than 10 lbs for at least 10 weeks from the date of surgery. 5) Monitor wounds for signs of infection. Please call cardiac surgeon ([**Telephone/Fax (1) 170**]) if start to experience fevers, sternal drainage and/or wound erythema. 6) You goal INR is 2.0-2.5 for atrial fibrillation. Dr.[**Name (NI) 99871**] office phone ([**Telephone/Fax (1) 99872**] Fax ([**Telephone/Fax (1) 99873**]. Will manage after discharge from rehab 7) Take amiodarone as instructed Followup Instructions: Dr. [**First Name (STitle) **] [**Last Name (NamePattern1) **] - [**Hospital Unit Name **] - [**2151-9-8**] at 1pm [**Telephone/Fax (1) 170**] Please go to [**Hospital Ward Name **] clinical center building [**Location (un) 470**] radiology for chest xray at 11am prior to appointment (evaluate infiltrates) Dr. [**Last Name (STitle) **] in 2 weeks (Please get referral from PCP for cardiologist and see cardiologist in [**2-9**] weeks) Labs :Pt/inr for coumadin dosing first check [**8-7**], BUN/creatinine [**8-7**] [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**] Completed by:[**2151-8-6**]

[ "486", "530.81", "997.3", "427.31", "424.0", "401.9", "272.0", "413.9", "414.01" ]

icd9cm

[ [ [] ] ]

[ "35.12", "39.61", "36.14", "37.22", "88.56", "36.15", "38.93", "88.53" ]

icd9pcs

[ [ [] ] ]

13660, 13756

9695, 11437

284, 479

14140, 14146

2654, 5242

14799, 15438

1285, 1370

11594, 13637

13777, 14119

11463, 11571

14170, 14776

5268, 9331

1385, 2635

234, 246

507, 884

9366, 9672

906, 1082

1098, 1269

26,984

120,314

47291

Discharge summary

report

Admission Date: [**2198-9-14**] Discharge Date: [**2198-9-24**] Date of Birth: [**2154-5-12**] Sex: M Service: MEDICINE Allergies: Taxol Attending:[**First Name3 (LF) 4057**] Chief Complaint: Reason for admission to ICU: Hypotension Major Surgical or Invasive Procedure: none History of Present Illness: 44yo M w/ widely metastatic lung cancer released [**2198-9-14**] from the federal prison hospital in [**Doctor First Name 5256**] on compassionate care, then flew to [**Location (un) 86**] for transfer to [**Hospital1 18**] where he had syncope at [**Location (un) 6692**] airport. Of note, hx limited by by pt's discomfortable/SOB while talking as well as no records from prison hospital. Pt has been in prison hospital since [**Month (only) 956**], when he was diagnosed with metastatic lung CA. Pt reports that the cancer is an adenocarcinoma. Pt knows of abdominal, adrenal & [**Last Name (un) 2043**] mets only. His treatment has included chemo & radiation. Pt has received ? mult chemotherapies, though only recalled Taxol, which he states he had an allergic reaction to--causing flushing & discomfort. Pt has received XRT to chest & abdomen. Last radiation tx was a few days ago. . His current issues include: - Pain involving chest wall, abdomen, and back. Chest pain is generalized discomfort, non-radiating, not associated w/ palpitations or activity. Abdominal pain diffuse, no change in bowel or bladder habits. Occasional N/V. No blood noted in emesis/stool. Of note, these issues have been stably present for months. - Hypoglycemia, which has been present for an unknown period, but has been treated with a D5W drip at OSH hospital. Pt arrived to the ED on D5W drip and may have been getting it during his flight to [**Location (un) 86**]. No h/o diabetes. - Lower extremity DVTs & LUE DVT for which pt has been on lovenox [**Hospital1 **] (per his report). He states that he was soon to complete tx. - Shortness of breath w/ talking or activity associated with dry cough. - Fatigue/generalized weakness/weight loss, which have rapidly progressed since patient's diagnosis with CA in [**Month (only) 956**]. Pt reports having lost >50lbs?. Does have an appetite. Has not been out of bed much. . In the [**Name (NI) **], pt was afebrile HR 80s & SBP 90s (pt believes his SBP has been in the 90s for a few months). An initial FS was 70; pt was given D5 & glucose improved to 135. He was given vanc, levo, flagyl for possible infection. He had a head CT which showed vasogenic edema, possibly from a met. CXR showed apical bullous disease & small b/l pleural effusions. . Upon inital admission to the floor, pt noted to be tachypneic w/ RR up to 26 while talking. SBP dropped into 70s from 80s-90s. 02 sats 98% RA. Pt mentating clearly. Given 1L NS & SBP increased the 90s. FSBS 71 while on D5 1/2NS at 150cc/hr, then given 1 amp of D50 with improvement of glucose to 146. . He was then transferred to the MICU the morning after initial admission ([**9-15**]) for persistent hypotension & tachypnea as well as closer monitoring of his FSBS given reported hypoglycemia. . On arrival to the MICU, pt reported feeling "ok." He has stable chest wall, abdominal, and back pain. No HA/vision changes. + SOB with exertion or speech. He denies lightheadedness, visual changes, chest pain, vomiting and diarrhea. . Was treated with IVF, and tx'd to OMED service, on arrival to floor on OMED, was transiently hypotensive to 76, and triggered althought asymptomatic, transferred to ICU where BP was 86, but also noted to be hypoglycemic to 47 Past Medical History: 1) Metastatic Lung CA - adenocarcinoma per pt - Patient has been treated at [**Hospital 100109**] Medical Facility, NC while in Prison. Dr. [**Last Name (STitle) 6483**] radiation oncologist, Dr. [**Last Name (STitle) **] medical oncologist. Possible adrenal/abdominal mets. History of XRT to chest/abd, ? adrenals. [**Month (only) 116**] have some tracheal compression due to CA. No history of intracranial mets as per patient. 2) DVTs - patient has had DVTs in both legs & left arm. Has been getting lovenox. Social History: Patient recently released from federal prison, returning home to [**Location (un) 86**] to be closer to his family. His mother, [**Name (NI) **] [**Name (NI) 100110**], & uncle, [**Name (NI) 892**] [**Name (NI) **], are co-HCPs. [**Name (NI) **] current alcohol, drugs, tobacco. Remote history of smoking x 25yrs. Family History: Non-contributory Physical Exam: 97.2 85 87/44 25 98%RA Gen: ill appearing man, cachextic with LUE swelling, poorly verbalizing HEENT: PER and minimally reactive, tracks; MM mildly dry; no JVD CV: RRR without m/g/r PULM: Physical chest deformity; skin discoloration; minimal air movement and irregular breathing patter; Course BS b/l without wheeze; occasional rhonchi/rales in bases Abd: +BT, thin & retracted, denies TTP Ext: cool, well perfused and without c/c; LUE with 1+ edema to axilla & mild erythematous rash; B/L LE with 1+ edema Neuro: difficult to assess, minimally communicative due to laryngeal nerve involvement; follows commands as able Pertinent Results: Radiology: CXR [**2198-9-14**] A right-sided Port-A-Catheter is identified in the upper SVC. There is right apical hyperlucency, most likely representing apical bullous disease. The patient is extremely rotated on this exam. There are bilateral pleural effusions, left greater than right, which are unchanged. There is bibasilar atelectasis. The mediastinal contour is grossly unremarkable. There are no focal consolidations. IMPRESSION: Right apical lucency likely secondary to bullous disease. Unchanged appearance of atelectasis and pleural effusions as described above. . CT Head [**2198-9-14**] There is no intra-axial or extra-axial hemorrhage. There is a small focus of hypodensity in the right posterior lobe near the high convexity which may represent a focus of vasogenic edema. No definite underlying lesion is seen, though evaluation for metastatic disease is limited on this non-contrast study. No additional areas of similar hypodensity are seen to suggest additional lesions in the brain. There is no hydrocephalus or shift of normally midline structures. The paranasal sinuses, mastoid air cells, and middle ear cavities are clear. The calvarium is intact, without evidence of suspicious lytic or blastic lesion. IMPRESSION: Focus of suspected vasogenic edema in the right posterior frontal lobe near the high convexity, concerning for metastatic disease from patient's known lung cancer. Further evaluation with MRI is recommended. No acute intracranial hemorrhage. . BILAT LOWER EXT VEINS Study Date of [**2198-9-15**] 1. Acute occlusive DVT involving the left common femoral vein, greater saphenous vein, and superficial femoral vein. 2. Occlusive thrombus, likely subacute/chronic, involving the right greater saphenous and superficial femoral veins. Non-occlusive thrombus within the right common femoral vein. . UNILAT UP EXT VEINS US Study Date of [**2198-9-15**] 8:53 AM Non-visualization of the left internal jugular vein, presumably thrombosed, as well as thrombosis of the left subclavian vein. The left brachial vein is patent as well as the right subclavian vein. . MR HEAD W & W/O CONTRAS Study Date of [**2198-9-15**] 9:45 AM 1. Significantly limited study due to patient motion and lack of post-gadolinium T1-weighted images. 2. T2 hyperintensity of the right frontal lobe involving the right motor cortex surrounding a smaller area of even more T2 hyperintensity, which may show some enhancement. These findings are suspicious for metastasis. . IVC GRAM/FILTER Study Date of [**2198-9-15**] 6:36 PM Uncomplicated IVC filter placement from the right internal jugular venous approach. . CT CHEST W/CONTRAST Study Date of [**2198-9-16**] 1:25 PM 1. Extensive metastatic disease. 2. Bilateral pulmonary emboli. 3. Bilateral pleural effusions, left > right, with bibasilar opacities likely representing atelectasis. 4. Partially occlusive thrombus within the superior vena cava. 5. No definite pericardial involvement with tumor. 6. Extensive vertebral destruction primarily T3 and T4 vertebral bodies by invading soft tissue mass. No definite spinal canal involvement is identified, however further assessment can be made with MR [**First Name (Titles) **] [**Last Name (Titles) 10015**] indicated. 7. Probable area of tumoral cavitation extending into an adjacent small bowel loop (series 3, image 96) with small, contained foci of gas noted anteriorly, which may represent a contained perforation. The foci of gas may also be due to prior paracentesis and clinical correlation is recommended. . MR HEAD W & W/O CONTRAS Study Date of [**2198-9-16**] 1:55 PM Enhancing lesions in the right frontal convexity and in the right periatrial region indicative of metastatic disease. Postgadolinium images limited by motion. . LABS ON ADMISSION: Brief Hospital Course: A/P: 44yo M with metastatic lung cancer (likely adenoca) s/p chemo & radiation who presents hypotension & hypoglycemia with imaging since admit confirming widely metastatic disease including brain mets with course complicated by b/l LE DVTs and subsequent PEs. . # Hypotension: pt reports that over the past few months his BP has been trending down. He thinks his BP has been in BP 90s systolic. Thus, pt's hypotension here may not be far off his baseline. Suspect his low BP is combination of deconditioning & dehydration w/ potential adrenal insufficiency (given possible adrenal mets). Additionally has confirmed PE on CT chest and b/l LE DVTs and UE DVT, s/p IVC filter placement. Low suspicion of infection based on lack of fever & no clear source, though wbc continues to be elevated. UA suspected of being colonization, will repeat UA. No clear cardiogenic source. Despite +2L yesterday, still volume depleted on exam. - Volume replete - bolus 1L LR & reassess - Cont dexamethasone - F/u all cultures - CIS . # Metastatic lung adenocarcinoma: mets to bone, abd/adrenal, brain and lung. Appreciate Onc, Rad Onc. Will discuss specifically today with Onc concerning prognosis, goals of care. If confirmed futile to pursue chemo/rads will discuss CMO status with pt. - Follow-up on all recs - Obtain outside records concerning prior chemo/RT treatments - Cont decadron - Define goals of care, discuss with pt/onc service . # Brain metastases: CT head demonstrated likely vasogenic edmea and right posterior frontal lobe possibly representing focus of metastatic disease. MRI revealed enhancing lesions in the right frontal convexity and in the right periatrial region indicative of metastatic disease. Hold seizure prophylaxis at this time. - cont steroids for cerebral edema . # B/L DVT: pt was on lovenox prior to arrival at [**Hospital1 18**]. However, given new findings of potential brain met, anti-coagulation held. Now with confirmed PEs and L UE DVT s/p IVC filter placement. - Cont lovenox for b/l DVTS/PE . # Hypoglycemia: Suspect may be due to liver mets which were confirmed on CT. Can feel nodular structures on exam in RUQ. No curative treatment for this problem currently so will treat symptomatically with dextrose drip and frequent FS - Tx supportively w/dextrose gtt & q4 FS - Monitor Na and change type of IVF PRN . #Hypercalcemia: Most likely secondary to [**Last Name (un) 2043**] mets, possible PTH-related protein in lung CA. Corrected Ca in 11s. Phos is low. - Cont IVF and monitor . #Leukocytosis: Pt could possibly have post-obstuctive PNA in LLL, evidence of pl. effusion as well (? infected). However, no fevers. Now with decreased WBC to 13.9, this AM newly increased to 17.3. Urine culture today with E.coli resistant to amp/bactrim/[**Last Name (LF) 9847**], [**First Name3 (LF) **] be colonziation. Have sent repeat UA, follow-up cultures. - Blood cultures pending - NGTD - Follow-up repeat UA . # Failure to thrive: Pt cachetic, malnourished given cancer & prolonged hospitalization. Nutrition consult already obtained and recommended regular diet with Ensure supplementation. Will start at this, but will likely not be adequate given weakened state. - Per nutrition will give Regular diet & Ensure TID . # Elevated LFTs: On admission ALT 159, AST 176, Alk Phos 344, now with mild decrease in all values (unclear baseline). Could be from chemo vs mets vs meds vs hypotension-related. - con't to monitor . #Anemia: Hct 25.3. Most likely due to anemia of chronic disease and malignancy. No evidence of active bleeding. Stable around 25 since admit. Iron studies c/w anemia of chronic disease. - Guaiac - Transfuse for < 21 . #Pain: due to multiple/diffuse metastases. - Fentanyl transdermal 125mcg/hr - Con't oxycodone PRN with low threshold to increase dosing PRN . #FEN: Cont fluid resuscitation with 1L LR bolus, goal net + today 2-3L; Dextrose gtt for continued hypoglycemia; replete PRN & monitor hypercalcemia (corrects to 11.8); regular diet with Ensure TID per nutrition recs . # PPX: SC heparin . #Access: PIV; Port-A cath . #Communication: With patient, his mother, [**Name (NI) **] [**Name (NI) 100110**], cell [**Telephone/Fax (1) 100111**], and uncle, [**Name (NI) 892**] [**Name (NI) **], both of whom pt wants as his HCP. Pt lucid at this time, so may make decisions without HCP but could rapidly deteriorate given fragile state. Pt wanted to review hcp form w/ his lawyer before signing it. TODAY - define goals of care. . **Pt treated at [**Location (un) 100109**] in [**Doctor First Name 5256**]: [**Telephone/Fax (1) 100112**] (phone), [**Telephone/Fax (1) 100113**] (fax), will attempt to obtain records although likely will not change clinical outcome . #Dispo: pending redefining goals of care, possibly to floor today . #Code: FULL CODE per pt. and family request . Patient expired Medications on Admission: (per patient) Albuterol Neb PRN Docusate Fentanyl patch 125 Oxycodone 20-30mg Q4H lovenox [**Hospital1 **] lasix ? dose PRN Discharge Medications: patient expired Discharge Disposition: Expired Discharge Diagnosis: patient expired Discharge Condition: patient expired Discharge Instructions: patient expired Followup Instructions: patient expired

[ "197.7", "251.2", "162.9", "198.3", "519.19", "415.19", "599.0", "348.5", "198.7", "458.9", "285.22", "783.7", "289.81", "V66.7", "198.5", "453.41", "453.8", "275.42", "197.6" ]

icd9cm

[ [ [] ] ]

[ "99.04", "38.7" ]

icd9pcs

[ [ [] ] ]

14024, 14033

8950, 13810

307, 313

14092, 14109

5143, 8911

14173, 14191

4468, 4486

13984, 14001

14054, 14071

13836, 13961

14133, 14150

4501, 5124

227, 269

341, 3587

8927, 8927

3609, 4121

4137, 4452

11,319

199,581

5033

Discharge summary

report

Admission Date: [**2124-9-20**] Discharge Date: [**2124-10-4**] Date of Birth: [**2064-4-20**] Sex: M Service: CARDIOTHORACIC Allergies: Lisinopril Attending:[**First Name3 (LF) 1505**] Chief Complaint: Exertional chest pain Major Surgical or Invasive Procedure: [**2124-9-20**] Aortic Valve Replacement utilizing a 23mm St. [**Male First Name (un) 923**] Mechanical Valve History of Present Illness: This is a 60 year old male with known aortic stenosis who recently has been complaining of worsening chest pain. There is no history of syncope or shortness of breath. A recent echocardiogram from [**2124-7-28**] confirmed severe aortic stenosis - valve area of 0.7cm2, peak 80 and mean of 47 mmHg. His LVEF was normal with only 1+ mitral regurgitation. Subsequent cardiac catheterization revealed severe aortic stenosis with a valve area of 0.7cm2. Angiography showed only mild coronary artery disease with a 50% lesion in the left anterior descending artery. Based on the above results, he was referred for cardiac surgical intervention. Past Medical History: Aortic Stenosis, Mild Coronary Artery Disease, Hypertension, Hypercholesterolemia, Renal Insufficiency, Prior Hernia Repair, Prior Tonsillectomy, History of Frequent Epistaxis Social History: Quit tobacco over 30 years ago. Denies excessive ETOH. Currently employed and works for trial court. He is married and lives with his wife. Family History: Father had MI in his late 40's Physical Exam: Vitals: ******************* General: well developed male in no acute distress HEENT: oropharynx benign, PERRL, EOMI Neck: supple, no JVD, transmitted murmur noted over carotids Heart: regular rate, normal s1s2, 3/6 systolic ejection murmur Lungs: clear bilaterally Abdomen: soft, nontender, normoactive bowel sounds Ext: warm, no edema, no varicosities Pulses: 2+ distally Neuro: alert and oriented, CN 2-12 intact, MAE, nonfocal Pertinent Results: [**2124-9-23**] CT Scan: Bilateral perihilar and lower lobe opacities with associated pleural effusions consistent with moderate-to-severe pulmonary edema. No evidence of small-bowel obstruction. [**2124-9-23**] Abdominal Ultrasound: The gallbladder is mildly distended. There is no gallbladder wall thickening, pericholecystic fluid, or gallstones present. There is a small amount of gallbladder sludge. There is no intra- or extra- hepatic ductal dilatation. [**2124-9-23**] TEE: Overall left ventricular systolic function is mildly depressed. Resting regional wall motion abnormalities include mildly hypokinetic anterior, anterior septum and anterior walls. A mechanical aortic valve prosthesis is present. Mild (1+) aortic regurgitation is seen. [**2124-9-23**] Cardiac Cath: Mild coronary artery disease. [**2124-9-27**] CT Scan: Low attenuation of the liver, most likely consistent with fatty infiltration. No evidence of cholecystitis but exam significantly limited secondary to lack of IV contrast administration. Bilateral pleural effusions with associated atelectasis, not significantly changed compared to the previous study. [**2124-9-30**] MRCP: No intra- or extraheptic biliary ductal dilitation or pancreatic ductal dilatation. No biliary stones. No evidence of peripancreatic inflammation. Brief Hospital Course: On the day of admission, Mr. [**Known lastname **] [**Last Name (Titles) 1834**] mechanical aortic valve replacement by Dr. [**Last Name (STitle) **]. For surgical details, please see separate dictated operative note. Following the operation, he was brought to the CSRU for invasive monitoring. Initially maintained on Neo-Synephrine and Epinephrine for low cardiac indices. Also required AV pacing for complete heart block. Within 24 hours, he awoke neurologically intact and was extubated on postoperative day one. On postoperative day two, he complained of mild abdominal pain associated with abdominal distention. An nasogastric tube was placed. General surgery was consulted and multiple imaging studies were obtained. CT scan was unremarkable except for pulmonary edema while abdominal ultrasound revealed only mild gallbladder distention with small amount of sludge. He concomitantly experienced worsening oxygenation and required reintubation on POD3. At that time, he was noted to have elevation in white count, creatinine, lactate, LFTs, amylase, and lipase. Lactate levels peaked to 5.3 on POD3. White count peaked to 15K on POD3. His creatinine peaked to 2.4 on POD5. He was empirically started on antibiotics for presumed pneumonia(serial chest x-rays showed worsening bilateral infiltrates). An echocardiogram showed no evidence of tamponade and repeat cardiac catheterization showed no obstructive coronary artery disease. Given his mechanical aortic valve, patient required heparinization. He was kept sedated and intubated for several additional days. He was noted to have copious amounts of secretions which required frequent suctioning. Therapeutic bronchoscopy was also performed. Over these several days, his abdominal distention improved and his complete heart block resolved. He gradually weaned from inotropic support. His acidosis resolved and there was slow improvement in white count, LFTs, amylase, lipase, and lactate. Amylase peaked at 277 on POD9. Lipase peaked to 1601 on POD8. ALT peaked at 223 on POD5. AST peaked at 314 on POD2. Total bilirubin peaked to 6.5 on POD6. He was intermittently was transfused with packed red blood cells to maintain hematocrit and he continued to make clinical improvements with diuresis. Patient was re-extubated on POD6. General surgery continued to follow and recommended further imaging studies to evaluate for pancreatitis. An abdominal CT scan on [**2124-9-27**] was negative for pancreatitis. On [**2124-9-29**], Mr. [**Known lastname **] developed epigastric tenderness and TPN was started. An MRI of the abdomen was performed which showed no intra- or extrahepatic biliary ductal dilatation or pancreatic ductal dilatation, no biliary stones and no evidence of peripancreatic inflammation. A clear liquid diet was started and progressed towards a regular diet as tolerated. As he tolerated this well, he was transferred to the step down unit on [**2124-10-2**] for further recovery and discharge planning. Physical therapy continued to work with him daily. Mr. [**Known lastname **] continued to make steady progress and was discharged home on postoperative day fourteen. He will follow-up with Dr. [**Last Name (STitle) **], his cardiologist and his primary care physician as an outpatient. Medications on Admission: Tricor 48 qd, Atenolol 25 qd, Aspirin 325 qd Discharge Medications: 1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*0* 3. Polysaccharide Iron Complex 150 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). Disp:*30 Capsule(s)* Refills:*0* 4. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*0* 5. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 6. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily). Disp:*30 Cap(s)* Refills:*0* 7. Coumadin 5 mg Tablet Sig: One (1) Tablet PO once a day: please take 5mg on [**10-4**] and [**10-5**] then have INR checked please call [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 20786**] at Dr [**Last Name (STitle) **] office for dosing [**Telephone/Fax (1) 20787**] goal INR 2.5-3. Disp:*60 Tablet(s)* Refills:*0* 8. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO every twelve (12) hours. Disp:*270 Tablet(s)* Refills:*0* 9. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO q3-4h as needed. Disp:*50 Tablet(s)* Refills:*0* 10. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 11. Ursodiol 300 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*0* 12. Famotidine 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 13. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 14. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 10 days. Disp:*10 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Company 1519**] Discharge Diagnosis: Aortic Valve Stenosis - s/p AVR, Postop Respiratory Failure, Postop Renal Failure, Postop Pancreatitis, Transient Postop Complete Heart Block, Postop Pneumonia PMH: Mild Coronary Artery Disease, Hypertension, Hypercholesterolemia, Renal Insufficiency, Prior Hernia Repair, Prior Tonsillectomy 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 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 ([**Telephone/Fax (1) 170**]) please call for appointment Dr [**Last Name (STitle) 1683**] in 1 week please call for appointment Dr [**Last Name (STitle) **] in [**12-31**] weeks ([**Telephone/Fax (1) 20787**]) please call for appointment Wound check appointment [**Hospital Ward Name 121**] 2 as instructed by nurse ([**Telephone/Fax (1) 3633**]) Coumadin - INR to be checked [**10-6**] with results to Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] office - contact person [**Name (NI) **] [**Name (NI) 20788**] RN ([**Telephone/Fax (1) 20787**]) Completed by:[**2124-10-13**]

[ "511.9", "577.0", "272.0", "403.90", "518.82", "574.20", "585.9", "414.00", "799.02", "424.1" ]

icd9cm

[ [ [] ] ]

[ "35.22", "33.23", "39.61", "88.72", "99.04", "96.04", "96.71" ]

icd9pcs

[ [ [] ] ]

8422, 8471

3282, 6548

299, 411

8809, 8816

1950, 3259

9282, 9928

1452, 1484

6643, 8399

8492, 8788

6574, 6620

8840, 9259

1499, 1931

238, 261

439, 1080

1102, 1279

1295, 1436

53,238

195,014

41981

Discharge summary

report

Admission Date: [**2161-11-4**] Discharge Date: [**2161-11-7**] Date of Birth: [**2115-3-6**] Sex: M Service: NEUROSURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 78**] Chief Complaint: Brain aneurysms Major Surgical or Invasive Procedure: [**2161-11-4**]: R Craniotomy for clipping of aneurysm [**2161-11-6**]: Diagnostic cerebral angiogram History of Present Illness: 46 y/o M presents for elective right craniotomy for clipping of the ACOMM aneurysm. Past Medical History: lung nodules corrective foot surgery at 10 yrs old Social History: Lives with brother for now. Is on disability from being a truck driver. Has a 60+ pack yr history of tobacco use. no EtOH x 2 yrs. He is clean of heroine and cocaine x 11 yrs. He later revealed during his hospital stay that he was victim of sexual abuse by his adoptive father. Family History: NC Physical Exam: On Discharge: Neurologically intact and nonfocal Pertinent Results: [**2161-11-5**] Head CT: IMPRESSION: Expected postoperative appearance after right frontal craniotomy and clipping of anterior communicating artery aneurysm with no evidence of postoperative complication including hemorrhage or infarct. Brief Hospital Course: 46M presents for an elective clipping of the ACOMM aneurysm. On [**11-4**], patient was taken to the OR for a R craniotomy. OR course was uncomplicated and patient was transferred to ICU post operatively for close monitoring. His exam remained nonfocal. A head CT was performed on [**11-5**] which was stable. He was transferred to the floor on [**11-5**] where he remained stable. On [**11-6**] he underwent a diagnostic cerebral angiogram to evaluate the R ICA. The angio was stable. He was discharged home on [**11-7**]. At the time of discharge he was tolerating a regular diet, ambulating without difficulty, afebrile with stable vital signs. Medications on Admission: oxycodone, nicotine, gabapentin Discharge Medications: 1. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 2. gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). Disp:*90 Capsule(s)* Refills:*2* 3. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain fever . 5. oxycodone 5 mg Tablet Sig: 2-3 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*60 Tablet(s)* Refills:*0* 6. hydromorphone 2 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for breakthrough pain. Disp:*60 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: ACOMM aneurysm Left ACA aneurysm Chronic back pain Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: ?????? Have a friend/family member check your incision daily for signs of infection. ?????? Take your pain medicine as prescribed. ?????? Exercise should be limited to walking; no lifting, straining, or excessive bending. ?????? You may wash your hair only after sutures and staples have been removed. ?????? You may shower before this time using a shower cap to cover your head. ?????? Increase your intake of fluids and fiber, as narcotic pain medicine can cause constipation. We generally recommend taking an over the counter stool softener, such as Docusate (Colace) while taking narcotic pain medication. ?????? Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, Aspirin, Advil, and Ibuprofen etc. ?????? If you were on a medication such as Coumadin (Warfarin), or Plavix (clopidogrel), or Aspirin, prior to your injury, you may safely resume taking this when cleared by your Neurosurgeon. ?????? Clearance to drive and return to work will be addressed at your post-operative office visit. ?????? Make sure to continue to use your incentive spirometer while at home, unless you have been instructed not to. Followup Instructions: Follow-Up Appointment Instructions ??????Please return to the office in 10 days(from your date of surgery) for removal of your staples and sutures. This appointment can be made by calling [**Telephone/Fax (1) 4296**]. ??????Please call ([**Telephone/Fax (1) 2102**] to schedule an appointment with Dr. [**First Name (STitle) **], to be seen in 4 weeks. You will not need any imaging at that time. We will also see you in 6 months with a MRI/MRA brain. Completed by:[**2161-11-7**]

[ "724.5", "338.29", "437.3" ]

icd9cm

[ [ [] ] ]

[ "88.41", "39.51" ]

icd9pcs

[ [ [] ] ]

2678, 2684

1279, 1930

321, 425

2779, 2779

1017, 1033

4108, 4592

929, 933

2013, 2655

2705, 2758

1956, 1990

2930, 4085

948, 948

962, 998

266, 283

453, 538

1042, 1256

2794, 2906

560, 613

629, 913

2,385

112,055

10142+10143+10144+56110

Discharge summary

report+report+report+addendum

Admission Date: [**2108-2-15**] Discharge Date: [**2108-2-24**] Date of Birth: [**2041-7-11**] Sex: F Service: [**Hospital1 **] CHIEF COMPLAINT: Shortness of breath, malaise, difficulty lying flat secondary to increased labored breathing HISTORY OF PRESENT ILLNESS: Ms [**Known lastname 33876**] is a 60 year old female with end-stage Alzheimer's dementia, severe peripheral vascular disease, chronic obstructive pulmonary disease and a history of Hodgkin's disease who presents with several weeks of increasing shortness of breath. Two days prior to admission the patient completed a ten day course of Levofloxacin with bronchitis. Since then the patient has demonstrated increase in labored breathing, particularly with lying flat, worsening wheezes and a nonproductive cough. She has also demonstrated malaise and refused to get out of bed for the last two days. The patient has also notably been increasingly confused and disoriented over the last two days. Of note, the patient has been contact[**Name (NI) **] by the patient's adult day group where she goes for dementia and they have noted there decreased energy, confusion and decreased p.o. intake. According to the patient's daughter there have been no fevers, nausea, vomiting, diarrhea, headache nor rash. However, the patient has noticed significant orthopnea and paroxysmal nocturnal dyspnea. PAST MEDICAL HISTORY: 1. Hodgkin's lymphoma 14 years ago, status post radiation splenectomy and lymph node dissection; 2. Hypercholesterolemia; 3. Hypertension; 4. Dementia, Alzheimer's; 5. Hypothyroidism; 6. Lung diseases, quarterly quantified, the patient has had pulmonary function tests which demonstrated neither restrictive nor obstructive pattern, but she has a 200 year pack year of smoking; 7. Cerebrovascular accident with no residual deficit; 8. Peripheral vascular disease; 9. Bilateral carotid disease status post left endarterectomy; 10. Congestive heart failure, stress test [**2107-2-24**] showed an ejection fraction of 54%, no reversible defects noted; 11. History of cellulitis. ALLERGIES: Erythromycin causes nausea and vomiting. MEDICATIONS ON ADMISSION: Metoprolol 25 mg p.o. b.i.d.; Aspirin 81 mg p.o. b.i.d.; Humibid 600 mg b.i.d., discontinued on the [**2-13**]; Lipitor 20 mg p.o. q.d.; Ruminal 4 mg p.o. b.i.d.; Seroquel 25 mg p.o. q.h.s.; Unithroid 75 mcg p.o. q.d.; Flovent dose unavailable; Ventolin dose unavailable; ten day course of Levofloxacin discontinued on [**2-16**]. PHYSICAL EXAMINATION: The patient's vital signs on presentation were as follows, temperature 98.0, blood pressure 136/70, heartrate 96. She was breathing at 28, sating 96% on room air. Physical examination was remarkable for the following. General, she was mildly tachypneic but she was orthoptic when laid flat. The patient had no obvious jugulovenous distension at that point. Cardiovascular was significant for borderline tachycardia and lung examination was notable for diffuse end expiratory wheezes and prolonged expiratory phase. There were no rhonchi or crackles. She had no hepatosplenomegaly and there was trace bilateral pitting edema. LABORATORY DATA: Electrocardiogram on admission showed decreased voltage, normal sinus rhythm of 96 with premature ventricular contractions, normal axis, normal intervals, normal right atrial enlargement. Right ventricular and poor R wave progression that was not new. The patient's complete blood count on admission was as follows, white count 16.3, of note the patient has a baseline leukocytosis which is chronic and has been worked up extensively per the daughter. The hematocrit was 34.5, platelets 34 showing 1% neutrophils, 20% lymphocytes and 60% monos. Her PT was 12.3, PTT 27.2 and INR 1.0. Her urinalysis was unremarkable. Her chem-7 was significant for a sodium of 133, total carbon dioxide 21, BUN 20, creatinine 1.1. Chest x-ray showed no congestive heart failure or cardiomegaly, no infiltrates or effusions. On [**2-23**], she had the following laboratory data, white blood cell count was up to 26.5, hematocrit 35.8 and her platelets 280. Her total carbon dioxide had increased to 29, her sodium to 143, her BUN 59 and her creatinine ranged stable at 1.0. The patient had a computerized tomography/angiography which was limited by the patient's motion but there was no obvious pulmonary embolus. The patient had creatinine kinases of 153, 298 and 340. The patient had a chest x-ray on [**2108-2-20**] which showed evidence of prior granulomatous infection. She had a video swallowing study which demonstrated no overt evidence of aspiration. [**First Name11 (Name Pattern1) 312**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 313**], M.D. [**MD Number(1) 314**] Dictated By:[**Last Name (NamePattern1) 11801**] MEDQUIST36 D: [**2108-2-23**] 15:25 T: [**2108-2-24**] 15:03 JOB#: [**Job Number 33877**] Admission Date: [**2108-2-15**] Discharge Date: [**2108-2-27**] Date of Birth: [**2041-7-11**] Sex: F Service: ADDENDUM: This dictation will take the patient from [**2108-2-24**] to the date of discharge [**2108-2-27**]. 1. Pulmonary: Over the weekend the patient maintained her O2 saturations and on the day of discharge was saturating 96% on room air at rest. Her wheezing had resolved and she was to be continued on a slow prednisone taper for her chronic obstructive pulmonary disease exacerbation. Her congestive heart failure had resolved and there was no further need for the Lasix, which was discontinued. 2. GI: The patient had slightly decreased p.o. intake the day prior to discharge. This was deemed volitional. The patient was seen by speech and swallow and determined that she was a very low risk for aspiration and that she was just declining to eat either likely secondary to her being in the hospital or because her daughter's weren't feeding her. They felt as though she would do well in rehabilitation as opposed to the hospital and with her daughters' assistance. The patient continued to take liquids freely but was refusing to consume significant solid food. 3. Neurological: The patient remained confused. It is uncertain whether this represents a permanent change from her baseline dementia or whether she will recover her previous level of functioning including being able to go to day care on a daily basis and rehabilitation. DISCHARGE MEDICATIONS: 1. Flovent 110 mcg two puffs b.i.d. 2. Aspirin 325 mg p.o. q.d. 3. Prevacid 30 mg p.o. q.d. 4. Colace 100 mg p.o. b.i.d. 5. Lipitor 20 mg p.o. q.d. 6. Galantamine 4 mg p.o. b.i.d. 7. Unithroid 75 mcg p.o. q.d. 8. Atrovent metered dose inhaler with spacer 2 puffs four times a day. 9. Seroquel 12.5 mg p.o. q.h.s. 10. Prednisone 20 mg p.o. q.d. x 7 days, the last day is [**2108-3-4**]. 11. Albuterol metered dose inhaler 1-2 puffs q. 6 hours p.r.n. shortness of breath. 12. Albuterol nebulizers q. 4-6 hours p.r.n. shortness of breath. 13. Lisinopril 20 mg p.o. q.d. 14. Insulin NPH Insulin 15 units q.a.m., 5 units q.p.m. and a Regular Insulin sliding scale q.i.d. 15. Atrovent nebulizers q.i.d. to be changed strictly to metered dose inhalers when the patient no longer requires nebulizers. 16. Diltiazem XR 240 mg p.o. q.d. DISCHARGE FOLLOW UP PLANS: The patient is to follow up with her new primary care physician as set up by the daughters during her rehabilitation stay. DR.[**Last Name (STitle) 313**],[**First Name3 (LF) 312**] 12-766 Dictated By:[**Last Name (NamePattern1) 11801**] MEDQUIST36 D: [**2108-2-27**] 11:43 T: [**2108-2-27**] 11:58 JOB#: [**Job Number 33878**] Admission Date: [**2108-2-15**] Discharge Date: [**2108-2-27**] Date of Birth: [**2041-7-11**] Sex: F Service: Neurologic - The patient had a CT of the head the day of discharge which demonstrated no acute bleed. She also had carotid studies done which demonstrated right internal carotid artery stenosis, 70 to 79%, which per the patient is unchanged from a prior study several years ago. She has a left internal carotid artery stenosis of less than 40%. The carotid stenosis should be continued to be worked up as an outpatient. DISCHARGE STATUS: To [**Hospital **] Rehabilitation. DISCHARGE DIAGNOSES: 1. Congestive heart failure and diastolic dysfunction. 2. Chronic obstructive pulmonary disease exacerbation. 3. Chronic leukocytosis. 4. Dementia. 5. Right internal carotid artery stenosis 70 to 79%. 6. Type 2 diabetes mellitus. MEDICATIONS ON DISCHARGE: 1. Albuterol nebulizer q4-6hours p.r.n. shortness of breath. 2. Albuterol MDI with spacer q6hours p.r.n. shortness of breath. 3. Atrovent nebulizer q6hours p.r.n. shortness of breath. 4. Atrovent MDI with spacer q6hours. 5. Lisinopril 20 mg p.o. once daily. 6. Seroquel 12.5 mg p.o. q.h.s. 7. Insulin NPH 15 units in the morning and 5 units in the p.m. with a regular insulin sliding scale to be adjusted after discontinuation of the Prednisone. 8. Unithroid 75 mcg p.o. once daily. 9. Thalantomine 4 mg p.o. twice a day. 10. Lipitor 20 mg p.o. q.h.s. 11. Colace 100 mg p.o. twice a day. 12. Aspirin 325 mg p.o. once daily. 13. Flovent 110 mcg two puffs twice a day. 14. Diltiazem XR 240 mg p.o. once daily. 15. Prednisone 20 mg p.o. once daily times seven days, last dose [**2108-3-4**]. FOLLOW-UP PLANS: The patient is to call [**Hospital1 346**] at [**Telephone/Fax (1) 33879**], to find a new attending primary care physician and to set up an appointment within one week of discharge from rehabilitation. DR.[**Last Name (STitle) 313**],[**First Name3 (LF) 312**] 12-766 Dictated By:[**Last Name (NamePattern1) 11801**] MEDQUIST36 D: [**2108-2-27**] 18:15 T: [**2108-2-27**] 20:43 JOB#: [**Job Number 33880**] and [**Numeric Identifier 33881**] Name: [**Known lastname 5932**],[**Known firstname 2243**] Unit No: [**Numeric Identifier 5933**] Admission Date: [**2108-2-15**] Discharge Date: [**2108-2-23**] Date of Birth: [**2041-7-11**] Sex: F Service: HOSPITAL COURSE: 1. Pulmonary - The patient has a long history of smoking and has been diagnosed with chronic obstructive pulmonary disease in the past. On presentation she was mildly tachypneic but sating at 96% on room air. 12 hours later after receiving roughly 500 cc of fluid and multiple nebulizers of Albuterol and Atrovent without relief, the patient suddenly became more tachypneic to 40 with 92 saturations dropping to the low 90s on 4 liters. This exacerbation of her respiratory decline was likely due to a combination of factors, 1. Diastolic dysfunction and congestive heart failure exacerbated by the frequent nebulizers of Albuterol, making her tachycardiac which has given her likely diastolic dysfunction, causing exacerbation of congestive heart failure. She was subsequently also likely to have exacerbation of chronic obstructive pulmonary disease. She was initially treated with Solu-Medrol intravenously, Albuterol and Atrovent nebulizers and CPAP and then transferred to the Intensive Care Unit for further monitoring. In the Intensive Care Unit she was seen to have chronic obstructive pulmonary disease exacerbation and congestive heart failure secondary to diastolic dysfunction. She was diuresed several liters of fluid. She was intubated briefly for pulmonary aortic catheter placement but was quickly extubated and slowly weaned from her CPAP. Her respiratory status gradually improved and on [**2-23**], after diuresis and continued treatment with p.o. Prednisone and Albuterol and Atrovent metered dose inhalers she was sating 93% on room air. The patient has had pulmonary function tests in the past but due to her mental status she was unable to fully cooperate with both tests. It is unclear what her baseline pulmonary function is. 2. Cardiovascular - The patient likely had an episode of congestive heart failure exacerbated by the tachycardia and chronic obstructive pulmonary disease exacerbation. In the Intensive Care Unit she had pulmonary artery catheter placed which demonstrated an elevated pulmonary capillary wedge pressure of 22 at peak and her cardiac output was 3.64 and cardiac index was roughly around 2. She was diuresed several liters of fluid with improvement in her cardiac output and her cardiac index. She probably has baseline both systolic dysfunction given her low cardiac index and diastolic dysfunction, although the diastolic dysfunction was difficult to appreciate due to the limitation of the echocardiogram. The patient was ruled out for an myocardial infarction and as previously mentioned had a peak creatinine kinase of 340 and a peak troponin of .8 but this was likely due to her congestive heart failure. Subsequently upon transfer to the floor, the patient was started on an ACE inhibitor which she tolerated well. In addition, the patient had had episodes of sinus tachycardia of unknown etiology and was treated with Diltiazem drip. This was sort of in the place of her Metoprolol which had been discontinued considering the patient had had episodes of bronchospasm in the past by report while on beta blocker. On the second day on the floor, the patient tachycardia was well controlled in the low 80s on Diltiazem 90 mg p.o. q.i.d. Her blood pressure was well controlled on ACE inhibitor, Diltiazem and the systolic pressures in the 110 to 140 range. She appeared euvolemic and without evidence of congestive heart failure on [**2108-2-23**]. 3. Infectious disease - The patient had been treated for bronchitis prior to admission. Antibiotics were continued for two to three days after admission and then discontinued as it seemed less likely that the patient had infection and more likely chronic obstructive pulmonary disease exacerbation/congestive heart failure. She had a white count that was elevated to 26 to 27. The patient has chronically elevated white count which per the daughter has been worked up incidentally in the past. This also probably represents a response to the steroids that she was given. 4. Neurological - The patient has baseline Alzheimer's dementia, however, she was able to participate in adult daycare actively. During the hospital stay her dose of Seroquel was increase as she had become somewhat agitated in the Intensive Care Unit likely the result of her elevated carbon dioxide which was then blown off while on CPAP. The Seroquel was gradually titrated down to a dose of 12.5 b.i.d. though she remained somewhat lethargic on the day prior to admission. 5. Endocrine - The patient has diabetes and hypothyroidism. She was continued on her Synthroid 75 mcg p.o. q.d. She had a mildly elevated TSH at 13 which may, however, be normal for a woman her age. Her blood sugar remains somewhat difficult to control due to the steroids in the Intensive Care Unit. She was treated on insulin drip which was then changed to back to a standing dose of NPH 15 units in the morning, 10 units in the evening and a modified insulin sliding scale of regular insulin q.i.d. CONDITION ON DISCHARGE: Fair. DISCHARGE STATUS: Rehabilitation which will be specified later. DISCHARGE DIAGNOSIS: 1. Congestive heart failure 2. Chronic obstructive pulmonary disease exacerbation 3. Diastolic dysfunction 4. Alzheimer's dementia 5. Diabetes mellitus DISCHARGE MEDICATIONS: Will be listed at the time of discharge. FOLLOW UP PLANS: The patient is to follow up with the new primary care physician within one week of leaving on discharge. DR.[**Last Name (STitle) **],[**First Name3 (LF) **] 12-766 Dictated By:[**Last Name (NamePattern1) 5934**] MEDQUIST36 D: [**2108-2-23**] 16:18 T: [**2108-2-23**] 20:02 JOB#: [**Job Number 5935**]

[ "491.21", "201.90", "401.9", "331.0", "443.9", "428.33", "272.0", "428.0", "294.10" ]

icd9cm

[ [ [] ] ]

[ "38.93", "89.64" ]

icd9pcs

[ [ [] ] ]

8312, 8549

15410, 15804

15228, 15386

8575, 9374

2176, 2508

10120, 15109

2531, 6441

9392, 10102

167, 261

290, 1387

1410, 2149

15134, 15207

14,184

141,926

9361

Discharge summary

report

Admission Date: [**2190-9-20**] Discharge Date: [**2190-10-6**] Date of Birth: [**2113-3-5**] Sex: F Service: Plastic Surgery HISTORY OF PRESENT ILLNESS: The patient is a 77-year-old female with a past medical history significant for squamous cell carcinoma of the mouth with T2 N0 staging, status post interstitial catheter placement in [**2188-7-18**] for brachy therapy for recurrent cancer, status post resection, now presenting with postoperative osteoradionecrosis of the mandible which had previously been treated with 30 sessions with hyperbaric oxygen. However, the patient was still left with a large defect which was initially closed with a inferior based FAMM flap; but ultimately the patient developed a right pathologic mandibular fracture with osteonecrosis of the right mandible. She presents for free fibular graft to repair the resected necrotic mandible. PAST MEDICAL HISTORY: Past Medical History significant for hypothyroidism and reflux disease. PAST SURGICAL HISTORY: As above. She has also had a jejunostomy tube placed. ALLERGIES: She has no known drug allergies. MEDICATIONS ON ADMISSION: Medications included Levoxyl. PHYSICAL EXAMINATION ON PRESENTATION: On examination, she was afebrile with stable vital signs. The remainder of the physical examination was notable for a shift of the mandibular midline secondary to loss of support of the right mandibular body with a large separation of the fracture region with concomitant buckle and facial swelling overlying the area. HOSPITAL COURSE: The patient was admitted on [**9-20**] for planned free fibular graft. Please see the Operative Note (per Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 13797**]) for details of this operation. She was monitored in the initial 24-hour period with every two hour flap checks by Cook catheter for venous pulsations as well as arterial Doppler flows. Her graft remained stable during this time. She was ultimately changed to every four hour checks and eventually to every eight hour checks. Immediately following the surgery, she was transferred to the Intensive Care Unit for the above-stated monitoring of her flap. She was started on trophic gastrojejunostomy tube feeds at 10 cc per hour and was maintained on Kefzol and Flagyl for postoperative infectious prophylaxis. Her postoperative Intensive Care Unit stay was complicated by post surgical anemia as well as Pseudomonas pneumonia without clinical evidence; requiring treatment with ciprofloxacin. During her Intensive Care Unit stay, the patient was maintained in a flat position to prevent development of fistula as gravity would pull the saliva to the back of her throat, and a flat position opposed to the floor of her mouth in an upright or partially upright position. The patient was ultimately transferred to the floor on [**2190-9-29**]. She did extremely well on the floor. She also had a swallow study obtained just prior to her discharge; the results of which indicated poor oral transit with aspiration; however, there was no evidence of fistula. CONDITION AT DISCHARGE: Condition on discharge was stable. DISCHARGE STATUS: Discharge status was to home with [**Hospital6 3429**] services. MEDICATIONS ON DISCHARGE: (Discharge medications included) 1. Aspirin 325 mg per gastrojejunostomy tube q.d. 2. Levothyroxine 50 mcg per gastrojejunostomy tube q.d. 3. Sertraline 50 mg per gastrojejunostomy tube q.d. 4. Famotidine 20 mg per gastrojejunostomy tube b.i.d. 5. Roxicet 5 cc to 10 cc per gastrojejunostomy tube q.4-6h. as needed. DISCHARGE INSTRUCTIONS: 1. The patient was also instructed to cycle her tube feeds with ProMod with fiber full strength at 120 cc per hour from 8 p.m. to 8 a.m. 2. Per [**Hospital6 407**] she would receive dressing changes as well as assistance with medication and her tube feeds. DISCHARGE FOLLOWUP: Follow-up plans were scheduled with Dr. [**Last Name (STitle) 13797**] as well as with Otolaryngology. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 19095**], M.D. [**MD Number(1) 19096**] Dictated By:[**Last Name (NamePattern1) 1752**] MEDQUIST36 D: [**2190-10-7**] 16:31 T: [**2190-10-9**] 04:44 JOB#: [**Job Number **]

[ "733.19", "482.1", "V10.02", "526.89", "285.1", "730.08" ]

icd9cm

[ [ [] ] ]

[ "77.77", "76.39", "86.69", "96.6" ]

icd9pcs

[ [ [] ] ]

3273, 3595

1144, 1535

1554, 3110

3619, 3879

1015, 1117

3125, 3246

3901, 4282

172, 894

917, 990

20,646

134,727

180

Discharge summary

report

Admission Date: [**2112-12-8**] Discharge Date: [**2112-12-10**] Service: MEDICINE Allergies: Sulfonamides Attending:[**First Name3 (LF) 1850**] Chief Complaint: Hypoxia Major Surgical or Invasive Procedure: none History of Present Illness: 82 yo F with CAD, CHF, HTN, recent PE ([**10-17**]), who presents from rehab with hypoxia and SOB despite Abx treatment for PNA x 3 days. The patient was in rehab after being discharged from here for PE. She was scheduled to be discharged on [**12-6**]; on the day prior to discharge she deveoped fever, hypoxia, and SOB. CXR showed b/t lower lobe infiltrates. She was started on levoflox and ceftriaxone on [**12-5**]. When she became hypoxic on NC they brought her in to the ED. . In the [**Hospital1 18**] ED she was febrile to 102.7, P 109 BP 135/56 R 34 O2 90% on 3L. She was started on vanc and zosyn for broader coverage, tylenol, and 2L NS. . The patient reports having sweats and cough before admission. She complains of SOB and some upper back pain. She denies chest pain, URI sx, nausea/vomiting, diarrhea, or dysuria. Of note she had had a rash and was given prednisone for 7 days, ending [**12-3**]. The rash was speculated to be due to coumadin, but she was able to be continued on coumadin. Past Medical History: CAD s/p stent in [**2109**] CHF HTN PE - [**10-17**] pancreatic mass [**10-17**] Depression--on fluoxetine Social History: The patient has been in rehab for the past month. She used to live alone, but has 2 grown daughters living nearby who are involved. They are at the bedside and actively disagreeing about the patient's code status and what their mothers's goals of care are. It is unclear if either are HCPs. Family History: Doesn't know about siblings health. Children alive and healthy. No medical problems. Physical Exam: VS: T 99 BP 101/78 P 96 R 23 O2 96% on 100% NRB Gen: lying in bed in mild respiratory distress. talking in phrases. HEENT: PERRL, EOMI. MMM, OP clear Chest: bilateral crackles to mid-lung fields, clear anteriorly CV: RRR. nl s1/s2, no M/R/G Abd: + BS present; soft, ND/NT. guaiac positive stool in ED Ext: no c/c/e Neuro: A&O x 2. follow commands, MAE. Pertinent Results: [**2112-12-8**] 06:26PM BLOOD WBC-9.6 RBC-3.33* Hgb-8.9* Hct-27.0* MCV-81* MCH-26.7* MCHC-32.9 RDW-14.4 Plt Ct-291 [**2112-12-10**] 12:17AM BLOOD Hct-27.1* [**2112-12-8**] 06:26PM BLOOD Neuts-81.0* Lymphs-14.9* Monos-2.0 Eos-1.9 Baso-0.2 [**2112-12-8**] 06:26PM BLOOD PT-21.7* PTT-45.7* INR(PT)-3.4 [**2112-12-9**] 04:11AM BLOOD Plt Ct-273 [**2112-12-8**] 06:26PM BLOOD Glucose-104 UreaN-36* Creat-1.4* Na-138 K-4.8 Cl-104 HCO3-18* AnGap-21* [**2112-12-9**] 04:11PM BLOOD Glucose-103 UreaN-22* Creat-1.1 Na-138 K-3.5 Cl-107 HCO3-17* AnGap-18 [**2112-12-8**] 06:26PM BLOOD CK(CPK)-56 [**2112-12-8**] 06:26PM BLOOD CK-MB-NotDone cTropnT-0.01 [**2112-12-8**] 06:26PM BLOOD Calcium-8.9 Phos-3.2 Mg-1.7 [**2112-12-9**] 04:11PM BLOOD Calcium-7.9* Phos-3.6 Mg-2.2 [**2112-12-8**] 06:32PM BLOOD Lactate-3.8* [**2112-12-9**] 01:08AM BLOOD Lactate-1.1 [**2112-12-10**] 01:16AM BLOOD K-3.5 . [**2112-12-8**] PORTABLE AP CHEST RADIOGRAPH: The heart size and mediastinal contours are within normal limits. No definite pleural effusions are seen. There is diffusely increased interstitial opacity disease, predominantly in the lower lung zones. No pneumothorax seen. The osseous structures are stable. A hiatal hernia is noted. Tiny left pleural effusion is noted. IMPRESSION: Diffusely increased interstitial opacities. This appearance is consistent with pulmonary vascular congestion superimposed upon chronic interstitial changes. . [**2112-12-9**] IMPRESSION: AP chest compared to [**11-19**] and [**12-8**]: Severe progressive interstitial abnormality accompanied by pulmonary and mediastinal vascular congestion is most likely edema, but severe interstitial pneumonia either infectious or drug related could simulate these findings. Chronic hiatus hernia unchanged. Brief Hospital Course: 82 yo F with CAD, CHF, HTN, recent PE ([**10-17**]), who presents from rehab with PNA and hypoxia. . Chest x-ray revealed bilateral infiltrates. Patient was started on Zosyn and vancomycin for pneumonia. Her fluid status was closely monitored given her underlying CHF. On admission her daughters were in disagreement over her code status and her original long standing DNR/DNI status was changed to allow for intubation if needed. However, when the patient's respiratory status continued to decline to the point of need for intubation, the patient refused intubation. Her family was notified and agreed that their mother's wishes should be fulfilled. She was started on IV morphine then converted to morphine drip on HD #3 for comfort and all other medications were discontinued. Her family was at her bedside and their Rabbi was called. She died on [**2112-12-10**] at 2:20 pm. An autopsy was offered, but the family declined. Medications on Admission: ACETAMINOPHEN 1000 mg Q6 prn ALPRAZOLAM 0.25MG Qhs prn ASPIRIN 81 MG CA CARB. 500 mg PO BID FLUOXETINE 10 MG QHS FUROSEMIDE 40 mg QD IMDUR 30MG QD LIPITOR 40MG QD LISINOPRIL 10MG QD MECLIZINE HCL 12.5MG TID prn MULTIVITAMIN OMEPRAZOLE 20 mg QD WARFARIN Qhs dosed daily Discharge Medications: NA Discharge Disposition: Expired Discharge Diagnosis: Pneumonia Discharge Condition: expired Discharge Instructions: NA Followup Instructions: NA [**First Name8 (NamePattern2) 1176**] [**Name8 (MD) 1177**] MD [**MD Number(2) 1851**]

[ "401.9", "V58.61", "V45.82", "428.0", "518.81", "486", "415.19", "577.9" ]

icd9cm

[ [ [] ] ]

[ "99.04" ]

icd9pcs

[ [ [] ] ]

5266, 5275

3986, 4919

229, 235

5328, 5337

2201, 3963

5388, 5509

1726, 1812

5239, 5243

5296, 5307

4945, 5216

5361, 5365

1827, 2182

182, 191

263, 1271

1293, 1402

1418, 1710

58,899

128,162

38764

Discharge summary

report

Admission Date: [**2103-6-18**] Discharge Date: [**2103-6-27**] Service: SURGERY Allergies: Omnipaque 240 / Levaquin Attending:[**First Name3 (LF) 4691**] Chief Complaint: Abdominal pain Major Surgical or Invasive Procedure: [**2103-6-15**] exlap, appendectomy, LOA, open abdomen History of Present Illness: [**Age over 90 **] yo F who lives in [**Hospital3 **] facility who had the acute onset of R sided abdominal pain on the morning prior to admission. She went to [**Hospital **] Hospital where she was noted to have a WBC in the 20s and a CT scan showing an ischemic R colon. She was transferred to [**Hospital1 18**] for further care. The patient is somewhat demented and thus it is difficult to obtain medical history from her. Most of the history was obtained from her son and the medical chart. Past Medical History: PMH: HTN, Dementia, PVD, hyperlipedimia, atrial fibrillation on coumadin, left leg cellulits, previous DVT PSH: LLE angio with popiteal angioplasty/stent for acute ischemia/limb threat ([**3-/2102**]), LLE angio for non-healing ulcer ([**7-/2102**]), L SFA to distal AT bypass with saphenous vein ([**8-/2102**]), R TKR, BSO (remote) Social History: Resides in a nursing home. Nephew [**Name (NI) **] is closest living relative and HCP. Denies EtOH, tobacco use or illicits. Family History: non-contributory Physical Exam: Vitals: AF 140 125/80 30 95% 4LNC GEN: Alert, oriented to self HEENT: No scleral icterus, mucus membranes moist CV: irregular rhythm PULM: Clear to auscultation b/l, No W/R/R ABD: obese, severely tender diffusely with guarding and rebound DRE: normal tone, no gross or occult blood Ext: 2+ LE edema, BLE cool from mid shin distally Pertinent Results: Chem 141 103 42 -------------< 137 4.0 28 1.7 Ca: 8.8 Mg: 2.1 P: 4.5 ∆ ALT: 20 AP: 68 Tbili: 0.6 Alb: 3.6 AST: 24 LDH: 238 Lip: 10 CBC: 25.5 > 13.2 < 241 38.4 N:84 Band:0 L:10 M:4 E:2 Bas:0 PT: 38.9 PTT: 141.8 INR: 4.0 Brief Hospital Course: The patient was taken to the OR on [**6-19**] and underwent a right hemicolectomy for necrotic and likely infarcted cecum. On POD 0, the patient self -extubated and required re-intubation. She had a TEE which showed a calcified aorta but no evidence of thrombus in the heart. She was switched from amiodarone to diltiazem gtt for rate control of persistent atrial fibrillation. On POD 1, she was diuresed with lasix and her coumadin was restarted. On POD 2, she was extubated, her NGT was removed and she was started on sips. Her diltiazem gtt was transitioned to PO diltiazem. On POD 3, the patient was stable with decreasing oxygen requirement. She was transfered to the floor in stable condition. Once transfered to the floor she was evaluated by Physcial and Occupational and is being recommended for rehab after her acute hospital stay. Her Coumdain was restarted for her Afib; goal INR [**3-15**]. On [**6-26**] her INR was 2.9, this is up from 2.4 on the day prior. Her dose was reduced to 2 mg on [**6-26**] from 4 mg (usual home dose) that she had received preveiously. Her INR will need to be checked 2-3x/week while at rehab (INR 2.8 on [**6-26**]). She is tolerating a regular diet and her pain is adequately controlled. Her abdominal incision remains with staples which will need to be removed in the next 5-7 days. Medications on Admission: Advair 250/50 [**Hospital1 **], Diltiazem CD 240 daily, Docusate 100 [**Hospital1 **], ASA EC 81 daily, Furosemide 60 daily, Hydrocortisone cream 2.5% [**Hospital1 **], metoprolol 25 [**Hospital1 **], simvastatin 40 [**Hospital1 **], warfarin 4 daily Discharge Medications: 1. ipratropium bromide 17 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) Puff Inhalation QID (4 times a day). 2. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) Puff Inhalation Q6H (every 6 hours). 3. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. diltiazem HCl 120 mg Capsule, Extended Release Sig: Two (2) Capsule, Extended Release PO DAILY (Daily). 5. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain. 7. furosemide 20 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 8. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 9. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 10. warfarin 2 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM: Goal INR [**3-15**] for Atrial fibrillation. 11. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). Discharge Disposition: Extended Care Facility: [**Location (un) 582**]-- [**Location (un) **] Discharge Diagnosis: Intestinal necrosis Discharge Condition: Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: You were admitted to the hospital with a deadened portion of your intestines requiring an operation to remove and repair this conditon. Now that you are recovering you are being recommended for rehabilitation after your hospital stay to help build up your strength and endurance. Followup Instructions: Follow up in Acute Care Clinic in [**2-11**] weeks, call [**Telephone/Fax (1) 600**] fo an appointment. The following appointments were scheduled for you prior to your hospital stay: Provider: [**Name10 (NameIs) **] [**Apartment Address(1) 871**] ([**Doctor First Name **]) [**Doctor First Name **] LMOB (NHB) Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2103-7-18**] 11:15 Provider: [**Name10 (NameIs) 251**] [**Last Name (NamePattern4) 1490**], MD Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2103-7-18**] 12:00 Completed by:[**2103-6-27**]

[ "401.9", "996.74", "294.8", "427.31", "V58.61", "443.9", "514", "567.9", "E878.2", "557.0", "272.4", "440.0" ]

icd9cm

[ [ [] ] ]

[ "96.04", "38.97", "88.72", "96.71", "45.73" ]

icd9pcs

[ [ [] ] ]

4749, 4822

2005, 3338

246, 302

4885, 5008

1732, 1982

5336, 5887

1344, 1362

3639, 4726

4843, 4864

3364, 3616

5032, 5313

1377, 1713

192, 208

330, 827

849, 1185

1201, 1328

67,687

187,949

43146

Discharge summary

report

Admission Date: [**2116-4-25**] Discharge Date: [**2116-4-28**] Date of Birth: [**2050-3-21**] Sex: F Service: MEDICINE Allergies: Percocet Attending:[**First Name3 (LF) 4095**] Chief Complaint: Melena Major Surgical or Invasive Procedure: EGD with clipping of pyloric ulcers History of Present Illness: Ms. [**Known lastname 46**] is a 66-year-old woman with history of HTN, DCIS s/p lumpectomy, XRT, and tamoxifen therapy, remote cervical cancer, presenting with dizziness and four days of black tarry stool. Patient had been having ongoing hip pain and difficulty ambulating for which she had been taking tylenol and naproxen for the past several weeks. Four days prior to admission patient had an episode of epigastric pain that lasted for a few hours and then resolved. She noticed dark bowel movements on Wednesday and Thursday. She was seen at her PCP's office yesterday and was prescribed omeprazole and nabumetone. The night prior to admission, patient got up to use the restroom and had a presyncopal episode, no fall, no LOC. She has been dizzy since that time. Patient also had a black bowel movement the night prior to admission and the morning of admission. She has had no nausea, hematemesis, or vomiting. Currently no abdominal pain. No fevers and chills. No chest pain, shortness of breath, dizziness, lightheadedness. In the ED, initial VS were: 98.2 80 132/69 18 100% RA. Exam was significant for conjunctival pallor, melena on rectal exam. Labs significant for WBC 14.4, HCT of 26.1 down from 39.7 in [**8-/2114**], Na of 130, BUN of 29, Creatinine of 0.6. Patient had a CXR showing no infiltrates or effusions. Patient received protonix 80 mg IV x1 followed by a protonix gtt. Received potassium chloride 40 mEq IV x1. IV access with 1 18 gauge and 1 20 gauge PIV. Patient was admitted to the MICU. Past Medical History: DCIS status post lumpectomy, XRT, and tamoxifen Cervical cancer s/p hysterectomy Left ankle fracture Hypertension Former tobacco use Social History: Patient lives with her husband. [**Name (NI) 1403**] at [**Hospital6 13185**]. - Tobacco: Currently smokes 10 cigarettes per month, previously smoked 1 PPD - Alcohol: 3 drinks per day - Illicits: None Family History: Mother - lung cancer Father - Bladder cancer Physical Exam: Admission exam: Vitals: T: 99.9 BP: 149/77 P: 79 R: 17 O2: 98% on RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: supple, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi Abdomen: soft, obese, non-tender, non-distended, bowel sounds present, no organomegaly GU: no foley Ext: warm, well perfused, 1+ pulses, no clubbing, cyanosis or edema Neuro: CNII-XII intact, 5/5 strength upper/lower extremities, grossly normal sensation Pertinent Results: Admission labs: [**2116-4-25**] 01:50PM BLOOD WBC-14.4*# RBC-2.55*# Hgb-8.7*# Hct-26.1*# MCV-102* MCH-34.2* MCHC-33.5 RDW-14.0 Plt Ct-330 [**2116-4-25**] 02:46PM BLOOD PT-11.7 PTT-28.9 INR(PT)-1.1 [**2116-4-25**] 01:50PM BLOOD Glucose-142* UreaN-29* Creat-0.6 Na-130* K-2.9* Cl-87* HCO3-27 AnGap-19 [**2116-4-25**] 01:50PM BLOOD ALT-17 AST-30 AlkPhos-51 TotBili-0.5 [**2116-4-25**] 01:50PM BLOOD Albumin-4.6 Calcium-10.2 Phos-3.1 Mg-2.1 Chest X-Ray [**2116-4-25**]: The heart size is normal. The hilar and mediastinal contours are within normal limits. There is no pneumothorax, focal consolidation, or pleural effusion. Clips are noted projecting over the left axilla. IMPRESSION: No acute intrathoracic process. Brief Hospital Course: Ms. [**Known lastname 46**] is a 66 year-old with h/o HTN, DCIS s/p lumpectomy/XRT/Tamoxifen, presenting with four days of black tarry stool and anemia in setting of NSAID use. . # ACUTE BLOOD LOSS ANEMIA SECONDARY TO GI BLEED: Patient with four days of tarry stool and drop in HCT from 39 -> 26 in setting of NSAID use. [**Location (un) 2611**]-[**Doctor Last Name 80870**] Bleeding Score was 15. Patient was hemodynamically stable but admitted to MICU for closer monitoring and for EGD. Ms. [**Known lastname 46**] [**Last Name (NamePattern1) 93000**] 2 units PRBCs for low hct. On EGD, patient had pyloric ulcers that were clipped and injected with epi. She was initially started on a protonix gtt and then transitioned to protonix IV bid. Patient was discharged on omeprazole 40mg [**Hospital1 **] (she already had omeprazole at home). Her atenolol was started at 50mg QD, and amlodipine and hctz were held. These antihypertensives can be restarted at the discretion of patient's PCP. [**Name10 (NameIs) **], patient will have a hct check on [**2116-5-4**]. Her ASA (taken for stroke prevention, no history of CAD) was held until primary care appointment on [**2116-5-4**]. She knows to avoid NSAIDs in the future. Ms. [**Known lastname 46**] will have a repeat EGD in 8 weeks. Her H.Pylori serum antigen will need to be followed up. . # LEUKOCYTOSIS: Resolved without intervention. . # ETOH USE: Patient has at least 3 drinks/day. Evidence of macrocytosis on CBC despite upper GI bleed. No signs or symptoms of withdrawal during admission. Patient was encouraged to refrain from ETOH use in the setting of GI bleed. # MACROCYTIC ANEMIA: Likely in the setting of ETOH use. However, if persists, may warrant further investigation. # TACHYCARDIA: Patient with tachycardia on the general medicine floor with negative orthostatics. However, she was normotensive despite not being on her 3 home anti-hypertensives. Tachycardia likely in the setting of relative volume depletion and beta-blocker withdrawal. Ms. [**Known lastname 46**] was restarted on atenolol 50mg QD and her amlodipine and hctz were held. These medications can be restarted at follow-up appointment if she is hypertensive. . Transitional issues: [ ] Repeat hct [ ] Repeat EGD in 8 weeks [ ] Follow-up serum H.Pylori [ ] Restart home antihypertensives if needed [ ] Follow-up macrocytosis Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from PatientwebOMR. 1. Amlodipine 10 mg PO DAILY 2. Atenolol 100 mg PO DAILY 3. Fluticasone Propionate NASAL 2 SPRY NU [**Hospital1 **] 4. Hydrochlorothiazide 25 mg PO DAILY 5. Nabumetone 500 mg PO BID 6. Omeprazole 20 mg PO DAILY 7. Acetaminophen 325 mg PO Q6H:PRN pain 8. Aspirin 81 mg PO DAILY 9. Calcarb 600 With Vitamin D *NF* (calcium carbonate-vitamin D3) 600 mg(1,500mg) -400 unit Oral Daily 10. Cetirizine *NF* unknown Oral Daily 11. Multivitamins 1 TAB PO DAILY 12. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS Discharge Medications: 1. Atenolol 50 mg PO DAILY Please hold for SBP <100 or HR<50. RX *atenolol 50 mg Once a day Disp #*30 Tablet Refills:*0 2. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS 3. Multivitamins 1 TAB PO DAILY 4. Omeprazole 40 mg PO BID RX *omeprazole 40 mg Twice a day Disp #*60 Capsule Refills:*3 5. Fluticasone Propionate NASAL 2 SPRY NU [**Hospital1 **] 6. Cetirizine *NF* 10 mg ORAL DAILY 7. Calcarb 600 With Vitamin D *NF* (calcium carbonate-vitamin D3) 600 mg(1,500mg) -400 unit Oral Daily Discharge Disposition: Home Discharge Diagnosis: Primary diagnosis: Pyloric ulcers [**1-2**] NSAID use Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. [**Known lastname 46**], It was a pleasure taking care of you during your hospitalization. You were admitted with tarry stools and were found to have blood loss due to stomach ulcers. Likely these ulcers developed from the Naproxen that your were taking for hip pain. Alcohol use can also predispose to these types of ulcers. You were treated with a procedure to stop the bleeding from the ulcers and with medications to reduce stomach acid. You were given blood transfusions to help you recover from the blood loss. You will need to have your blood levels checked on Monday [**5-4**] at your PCP [**Name Initial (PRE) 648**]. You have an appointment for a repeat endoscopy on [**2116-6-23**] at 12:30pm. The following changes were made to your medications: --START taking atenolol 50mg once a day instead of 100mg once a day --STOP taking HCTZ 25 mg once a day --STOP taking amlodipine 10 mg once a day --STOP taking Nabumetone 500 mg [**Hospital1 **] --START taking Omeprazole 40mg twice a day --STOP taking Aspirin 81 mg once a day until you see your doctor --DO not take any NSAIDs . Please return to the hospital if you develop lightheadedness, palpiations, dizziness, continued dark stools, nausea, vomiting, abdominal pain, fevers, chills, or other concerning signs or symptoms. Followup Instructions: Department: [**Hospital3 249**] When: MONDAY [**2116-5-4**] at 1:40 PM With: [**Company 191**] POST [**Hospital 894**] CLINIC [**Telephone/Fax (1) 2010**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage [**2116-6-23**] 12:30p WPC ROOM,THREE [**Hospital Ward Name **] BUILDING ([**Hospital Ward Name **] COMPLEX), [**Location (un) **] WPC ROOMS/BAYS [**2116-6-23**] 12:30p [**First Name8 (NamePattern2) **] [**Location (un) **],WPC WEST [**Hospital Ward Name **] BUILDING ([**Hospital Ward Name **] COMPLEX), [**Location (un) **] ENDOSCOPY SUITES Department: [**Hospital3 1935**] CENTER When: MONDAY [**2116-5-11**] at 9:30 AM With: [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2334**], M.D. [**Telephone/Fax (1) 253**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: [**Hospital3 249**] When: FRIDAY [**2116-5-29**] at 8:30 AM With: [**First Name11 (Name Pattern1) 674**] [**Initial (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**Telephone/Fax (1) 2010**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage

[ "V10.3", "785.0", "V15.3", "305.00", "288.60", "531.00", "E935.9", "276.1", "E941.3", "715.95", "535.60", "V10.41", "401.9", "276.50", "276.8", "285.1", "V16.1", "305.1" ]

icd9cm

[ [ [] ] ]

[ "44.43" ]

icd9pcs

[ [ [] ] ]

7263, 7269

3698, 5919

276, 313

7366, 7366

2954, 2954

8842, 10190

2265, 2312

6745, 7240

7290, 7290

6109, 6722

7516, 8819

2327, 2935

5940, 6083

230, 238

341, 1870

2970, 3675

7309, 7345

7381, 7492

1892, 2027

2043, 2249

28,134

117,816

33578

Discharge summary

report

Admission Date: [**2181-7-11**] Discharge Date: [**2181-7-17**] Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 4679**] Chief Complaint: Carcinoid arising from distal left main-stem bronchus. Major Surgical or Invasive Procedure: [**2181-7-11**]: Therapeutic bronchoscopy, Left thoracotomy, Lysis of adhesions. Sleeve left lower lobectomy with bronchial anastomosis between the left main-stem and left upper lobe bronchus. History of Present Illness: The patient is an 83 year-old male who presented with polymyositis. His workup included an x-ray and a subsequent CT scan that disclosed a tumor of the left lower lobe. Endobronchial evaluation confirmed a carcinoid tumor. This tumor arose from the distal left main-stem bronchus and included the left lower lobe. He is being admitted for sleeve lobectomy, resection. Past Medical History: Hypertension BPH Psoriasis Basal cell carcinoma: on nose, excised with skin graft in early [**2181-3-17**] Social History: Quit smoking 27 years ago. No alcohol or drug use. Retired postal worker. No exposure to asbestos. Used to be in the Navy in the Pacific during WWII. Family History: both parents and a brother had MI Physical Exam: VS: T: 98.2 HR: 62 SR BP: 138/68 Sats: 94% RA General: sitting in chair no apparent distress HEENT: normocephalic, mucus membranes moist Neck: supple no lyphadenopathy Card: RRR normal S1,S2 no murmur/gallop or rub Resp: decreased breath L>R with faint crackles LLL GI: benign Extr: warm no edema Incision: Left thoracotomy site clean, dry intact no erythema Neuro: non-focal Pertinent Results: [**2181-7-15**] WBC-14.0* RBC-3.58* Hgb-10.5* Hct-30.3* Plt Ct-348 [**2181-7-14**] WBC-13.4* RBC-2.81* Hgb-8.2* Hct-24.1* Plt Ct-238 [**2181-7-11**] WBC-17.8* RBC-3.32* Hgb-9.7* Hct-28.0* Plt Ct-243 [**2181-7-14**] Glucose-119* UreaN-20 Creat-0.9 Na-137 K-4.1 Cl-100 HCO3-29 [**2181-7-11**] Glucose-167* UreaN-25* Creat-0.9 Na-141 K-4.6 Cl-107 HCO3-22 PORTABLE CHEST, [**2181-7-15**] The chest tube has been removed. Since the chest tube removal, there appears to have been increased shift of mediastinal structures to the left. No pneumothorax is identified. There is increased volume loss on the left with increased opacification of left lung. Right lung is relatively clear with minimal atelectasis in the right lung base. IMPRESSION: Status post left chest tube removal with mediastinal shift to the left, increased opacification of left lung. [**2181-7-16**] Portable CXR: persistent opacification of the left hemithorax Brief Hospital Course: [**7-11**]: The patient underwent the above procedure. He tolerated the procedure well and was transferred to the TSICU for intense monitoring following the procedure. He had an epidural in place for pain relief, diet was advanced slowly, foley catheter in place, two chest tubes in place to suction. [**7-12**]: The patient was transferred to the floor for continued monitoring. He developed supraventricular tachycardia followed by atrial fibrillation. He remained hemodynamically stable and asymptomatic. He was given Lopressor 5mg IV for a total of five doses, he did not convert. He was given a bolus of Amiodarone 150mg and drip and converted to sinus rhythm. The patient became hypotensive and the amiodarone drip was stopped. He remained in sinus rhythm. The chest tubes were placed to water-seal with no air leak. His pain was relieved with an epidural. [**7-13**]: He had an episode of rapid atrial fibrillation and the amiodarone drip was restarted and he converted sinus rhythm. He was diuresed. He was seen by physical therapy whom declared him safe for home. [**7-14**]: Remains in sinus rhythm, on PO amiodarone and atenolol. The apical chest-tube was removed. [**7-15**]: The remaining chest-tube was removed. His HCT was found to 24 for which he was transfused 2 unit PRBC to a HCT of 30. [**7-16**]: The epidural was removed and his pain was well controlled with PO pain medication. The foley was removed and he voided without difficulty. He underwent flexible bronchoscopy which showed an adherent fibrin clot. The chest x-ray revealed a collapsed left lower lobe. [**7-17**]: The patient underwent a rigid bronchoscopy for removal of fibrin clot. He tolerated the procedure well. The follow-up CXR revealed moderates increased aeration of the left lung. He was discharged to home and will follow-up with Dr. [**First Name (STitle) **] in 1 week. Medications on Admission: atenolol 50 mg daily, doxazosin 4 mg daily, prednisone 20 mg daily, lisinopril 20 mg daily, omeprazole 20 mg daily, hydrochlorothiazide 12.5 mg dialy, Bactrim Ds daily, MVI daily, alendronate 70mg weekly Discharge Medications: 1. Atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Doxazosin 4 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Prednisone 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 6. Hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 7. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Multivitamin Tablet Sig: One (1) Cap PO DAILY (Daily). 9. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain, fever. 10. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. Disp:*50 Tablet(s)* Refills:*0* 11. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 12. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 13. Alendronate 70 mg Tablet Sig: One (1) Tablet PO once a week. Discharge Disposition: Home Discharge Diagnosis: Left lower lobe Carcinoid Tumor Hypertension, BPH Psoriasis Arthritis. Discharge Condition: Stable Discharge Instructions: Call Dr.[**Name (NI) 5067**] office [**Telephone/Fax (1) 170**] if experience: -Fever > 101 or chills -Increased cough or shortness of breath -Chest pain -Incision develops drainage or increased redness Chest-tube cover with a bandaid until healed No Driving while taking narcotics: Take stool softners with narcotics You may Shower: No swimming or tub bathing for 6 weeks Continue Regular diet Walk frequently throughout day Followup Instructions: Follow-up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**7-24**] at 10:00am on the [**Hospital Ward Name 5074**] [**Hospital Ward Name 23**] Clinical Center [**Location (un) **]. Report to the [**Location (un) **] Radiology Department for a Chest X-Ray 45 minutes before your appointment. Completed by:[**2181-7-17**]

[ "696.1", "E915", "162.3", "458.29", "427.31", "600.00", "934.8", "518.89", "716.90", "427.89", "V10.83", "401.9" ]

icd9cm

[ [ [] ] ]

[ "32.49", "32.1", "33.23", "33.99", "03.90", "32.28" ]

icd9pcs

[ [ [] ] ]

5873, 5879

2638, 4526

324, 519

5994, 6003

1686, 2615

6477, 6828

1232, 1267

4780, 5850

5900, 5973

4552, 4757

6027, 6454

1282, 1667

229, 286

547, 917

939, 1048

1064, 1216

66,101

117,018

41680

Discharge summary

report

Admission Date: [**2154-9-25**] Discharge Date: [**2154-10-5**] Date of Birth: [**2076-2-4**] Sex: M Service: ORTHOPAEDICS Allergies: Latex Attending:[**First Name3 (LF) 7303**] Chief Complaint: L hip periprosthetic femur fracture with mechanical failure/breakage of femoral stem Major Surgical or Invasive Procedure: [**2154-10-1**]: Complex revision left total hip arthroplasty with reconstruction with proximal femoral endoprosthesis History of Present Illness: 78 yo male s/p fall transferring from powerchair to bed. Hx of b/l THA and TKA, revision L THA. New L femur fracture and fracture of femoral component. Past Medical History: Afib on Coumadin, Borderline DM2, HTN, Hypercholesterolemia, PVD Social History: Activity Level: usually stays at home Mobility Devices: uses his powerchair to get around most of the time, uses a walker to ambulate short distances Tobacco: denies EtOH: rarely Widowed. Family History: n/c Physical Exam: Well appearing in no acute distress Afebrile with stable vital signs Pain well-controlled Respiratory: CTAB Cardiovascular: RRR Gastrointestinal: NT/ND Genitourinary: Voiding independently Neurologic: Intact with no focal deficits Psychiatric: Pleasant, A&O x3 Musculoskeletal Lower Extremity: * Incision healing well with staples * Scant serosanguinous drainage * Thigh full but soft * No calf tenderness * 5/5 strength * SILT, NVI distally * Toes warm Brief Hospital Course: The patient was admitted to the orthopaedic surgery service. Preoperatively the hip was aspirated to r/o infection. This was negative for growth. Pre operative CXR was notable for consolidation versus neoplasm. Neoplasm was ruled out with a CT scan. The patient was taken to the operating room for above described procedure. Please see separately dictated operative report for details. The surgery was uncomplicated and the patient tolerated the procedure well. Patient received perioperative IV antibiotics. Postoperative course was remarkable for the following: 1. MICU Course: -Patient was brought to ICU and extubated. Will need to continue CPAP (patient uses at home) throughout hospitalization. The patient's code status was discussed with family again and patient made DNR/DNI 24 hours after surgery. Patient was restarted on metoprolol and has been hemodynamically stable. PM Hct 27.8. 2. Post-anemia due to blood loss - POD Hct 23.1, asymptomatic. Transfused 2 units PRBCs due to comorbidities. At discharge, HCT was 27.1. INR 2.2. Goal is less than 2.5 but greater than 1.5. 3. Pneumonia - Patient was noted to be somewhat fluid overloaded and low O2 sats, Seen by medicine and started on IV ceftriaxone. This is switched to cefpodoxime 400 mg [**Hospital1 **] x 5 more days upon discharge. O2 sats were in 90's on RA upon discharge. Oxygen discontinued. Internal medicine team felt patient was stable for dischage on oral antibiotics. Otherwise, pain was initially controlled with a PCA followed by a transition to oral pain medications on POD#1. The patient received lovenox for bridging DVT prophylaxis starting on the morning of POD#1 which was continued until the patient was therapeutic on coumadin which he was taking at baseline. The foley was removed on POD#2 and the patient was voiding independently thereafter. The surgical dressing was changed on POD#2 and the surgical incision was found to be clean and intact without erythema or abnormal drainage. The patient was seen daily by physical therapy. Labs were checked throughout the hospital course and repleted accordingly. At the time of discharge the patient was tolerating a regular diet and feeling well. The patient was afebrile with stable vital signs. The patient's hematocrit was acceptable and pain was adequately controlled on an oral regimen. The operative extremity was neurovascularly intact and the wound was benign. The patient's weight-bearing status is weight bearing as tolerated on the operative extremity with posterior and trochanter-off precautions (no active abduction). Walker at all times for 6 weeks. Mr. [**Known lastname **] is discharged to rehab in stable condition. Discharge Medications: 1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 2. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 3. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. methocarbamol 500 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 5. sertraline 25 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 6. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) neb Inhalation every 4-6 hours as needed for wheezing. 7. ipratropium bromide 0.02 % Solution Sig: One (1) neb Inhalation Q6H (every 6 hours) as needed for wheezing. 8. multivitamin Tablet Sig: One (1) Cap PO DAILY (Daily). 9. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. enoxaparin 40 mg/0.4 mL Syringe Sig: One (1) syringe Subcutaneous DAILY (Daily): D/C when INR > 2.0 x 48hrs. 11. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO Q6H (every 6 hours). 12. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours). 13. cefpodoxime 200 mg Tablet Sig: Two (2) Tablet PO twice a day for 5 days. Disp:*20 Tablet(s)* Refills:*0* Discharge Disposition: Extended Care Facility: Windgate of [**Location (un) 8072**] Discharge Diagnosis: Left hip periprosthetic femur fracture with broken femoral stem Post-op anemia due to blood loss 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: 1. Please return to the emergency department or notify your physician if you experience any of the following: severe pain not relieved by medication, increased swelling, decreased sensation, difficulty with movement, fevers greater than 101.5, shaking chills, increasing redness or drainage from the incision site, chest pain, shortness of breath or any other concerns. 2. Please follow up with your primary physician regarding this admission and any new medications and refills. 3. Resume your home medications unless otherwise instructed. 4. You have been given medications for pain control. Please do not drive, operate heavy machinery, or drink alcohol while taking these medications. As your pain decreases, take fewer tablets and increase the time between doses. This medication can cause constipation, so you should drink plenty of water daily and take a stool softener (such as colace) as needed to prevent this side effect. Call your surgeons office 3 days before you are out of medication so that it can be refilled. These medications cannot be called into your pharmacy and must be picked up in the clinic or mailed to your house. Please allow an extra 2 days if you would like your medication mailed to your home. 5. You may not drive a car until cleared to do so by your surgeon. 6. Please keep your wounds clean. You may shower starting five (5) days after surgery, but no tub baths or swimming for at least four (4) weeks. No dressing is needed if wound continues to be non-draining. Any stitches or staples that need to be removed will be taken out by the visiting nurse (VNA) or rehab facility two weeks after your surgery. 7. Please call your surgeon's office to schedule or confirm your follow-up appointment in four (4) weeks. 8. Please DO NOT take any non-steroidal anti-inflammatory medications (NSAIDs such as celebrex, ibuprofen, advil, aleve, motrin, etc). 9. ANTICOAGULATION: Please continue your wafarin DAILY to help prevent deep vein thrombosis (blood clots). [**Male First Name (un) **] STOCKINGS x 6 WEEKS. 10. WOUND CARE: Please keep your incision clean and dry. It is okay to shower five days after surgery but no tub baths, swimming, or submerging your incision until after your four (4) week checkup. Please place a dry sterile dressing on the wound each day if there is drainage, otherwise leave it open to air. Check wound regularly for signs of infection such as redness or thick yellow drainage. Staples will be removed by the visiting nurse or rehab facility in two (2) weeks. 11. VNA (once at home): Home PT/OT, INR checks, dressing changes as instructed, wound checks, and staple removal at two weeks after surgery. 12. ACTIVITY: Weight bearing as tolerated with posterior and trochanter off precautions. Use walker or 2 crutches at all times x 6 weeks. No strenuous exercise or heavy lifting until follow up appointment. Mobilize frequently. Physical Therapy: LLE WBAT Trochanter off and posterior hip precautions Walker or 2 crutches at all times x 6 weeks Mobilize frequently Treatments Frequency: Dry sterile dressing daily as needed for drainage Wound checks Ice as tolerated TEDs x 6 weeks INR/Coumadin - Goal INR 2.0 (not to exceed 2.5) - Check daily, then as directed by PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 37742**] (Phone: [**Telephone/Fax (1) 23083**], Fax: [**Telephone/Fax (1) 90602**]) - For DVT prophylaxis and atrial fibrillation Followup Instructions: Provider: [**First Name4 (NamePattern1) 6100**] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 1228**] Date/Time:[**2154-10-24**] 10:45 Provider: [**First Name4 (NamePattern1) 6100**] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 1228**] Date/Time:[**2154-10-24**] 10:45 [**First Name4 (NamePattern1) 6100**] [**Last Name (NamePattern1) **] MD [**MD Number(2) 7305**] Completed by:[**2154-10-5**]

[ "719.50", "427.31", "820.09", "250.00", "272.0", "486", "401.9", "V43.64", "278.01", "V58.61", "E878.1", "V43.65", "285.1", "V49.86", "996.43", "V85.42", "E884.3", "E849.0" ]

icd9cm

[ [ [] ] ]

[ "00.72" ]

icd9pcs

[ [ [] ] ]

5383, 5446

1465, 4151

354, 476

5587, 5587

9223, 9685

967, 972

4174, 5360

5467, 5566

5770, 7825

987, 1442

8689, 8807

8829, 9200

230, 316

7837, 8671

504, 657

5602, 5746

679, 746

762, 951

65,848

119,775

41189

Discharge summary

report

Admission Date: [**2177-6-27**] Discharge Date: [**2177-6-28**] Service: MEDICINE Allergies: Cipro / Ace Inhibitors Attending:[**First Name3 (LF) 3984**] Chief Complaint: s/p cardiac arrest Major Surgical or Invasive Procedure: femoral central venous line placement arterial line placement (patient was already intubated upon arrival) History of Present Illness: Mr. [**Known lastname **] is a [**Age over 90 **]y/o gentleman with CAD, AI, and CHF who was transferred to [**Hospital1 18**] s/p arrest. He had witnessed arrest at home with family initiating CPR. He was taken to [**Location (un) **] and had spontaneous return of circulation. He then lost pulses at least once and received a shock. [**Location (un) **] brought him to [**Hospital1 18**]. He was intubated in the field. He lost pulses again. They shocked him in the helicopter x 2. As they were landing, he lost pulses again. He was bought into the ER actively coding. He was given epinephrine, calcium, atropine. He was started amiodarone drip and had return of circulation for about 10 minutes. Then he lost circulation again, and was shocked x 2. He then stayed stable for 20 minutes and then coded again at which time a non-sterile femoral line was placed. He was then started on norepherine drip (maximum dose). He then lost pulses with CPR initiated. He then received epi x 1 and calcium with return of circulation. A sterile left art line was placed. He also underwent Artic Sun cooling process. . VS on transfer: HR 89 BP 116/78 RR 20 on vent (Tv 550, PEEP 11, CMV) with O2 sat 56 %. . On the floor, patient is intubated, unresponsive to verbal or painful stimulus. Family is at the bedside. Past Medical History: CAD Systolic CHF (EF 45%) HTN Mitral regurgitation Aortic insufficency BPH s/p TURP in [**2173**] Bradycardia s/p VVI PMP in [**1-14**] Colon cancer [**2167**], s/p resection at [**Hospital3 3765**] Renal artery stenosis with baseline creatinine 3.0 Recent hospitalization for PNA and severe UTI Social History: The patient lives with his daughter, son-in-law, and granddaughter in [**Name (NI) 11269**], MA. He does not smoke cigarettes and has not had EtOH for the past 3 years. He was married for 60 years and his wife passed away in [**2168**]. Family History: Non-contributory Physical Exam: HR: 83 (83 - 99) bpm BP: 97/60(73) {97/60(73) - 114/67(85)} mmHg RR: 20 (16 - 20) insp/min SpO2: 89% Heart rhythm: AF (Atrial Fibrillation) O2 Delivery Device: Endotracheal tube Ventilator mode: CMV/ASSIST Vt (Set): 550 (550 - 550) mL RR (Set): 20 PEEP: 11 cmH2O FiO2: 100% PIP: 37 cmH2O Plateau: 31 cmH2O SpO2: 89% ABG: 7.19/27/246/10/-16 Ve: 10.8 L/min PaO2 / FiO2: 246 General: Elderly gentleman, intubated HEENT: NCAT Neck: obese, jugular venous pulsations visible to the earlobe Lungs: coarse breath sounds throughout all fields bilaterally CV: Tachycardia, S1 + S2, S3 audible, no murmur audible Abdomen: soft, non-distended, no masses GU: foley in place Ext: cool, 1+ DP pulses and carotid pulse Neuro: unresponsive to painful stimulus Pertinent Results: ADMISSION LABS [**2177-6-27**] 10:16PM BLOOD WBC-21.3*# RBC-3.19* Hgb-9.3* Hct-31.5* MCV-99*# MCH-29.1 MCHC-29.5* RDW-15.8* Plt Ct-252 [**2177-6-27**] 10:16PM BLOOD Neuts-72* Bands-3 Lymphs-19 Monos-6 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 NRBC-2* [**2177-6-27**] 10:16PM BLOOD PT-37.6* PTT-60.6* INR(PT)-3.8* [**2177-6-27**] 10:16PM BLOOD Glucose-232* UreaN-50* Creat-2.5* Na-138 K-5.2* Cl-110* HCO3-14* AnGap-19 [**2177-6-27**] 10:16PM BLOOD ALT-158* AST-281* AlkPhos-76 TotBili-0.7 [**2177-6-27**] 10:16PM BLOOD Albumin-2.4* Calcium-6.8* Phos-8.5*# Mg-2.4 [**2177-6-27**] 09:43PM BLOOD Type-ART Temp-36.3 Tidal V-450 O2 Flow-100 pO2-30* pCO2-75* pH-6.92* calTCO2-17* Base XS--21 -ASSIST/CON Intubat-INTUBATED [**2177-6-27**] 10:18PM BLOOD Glucose-217* Lactate-13.3* Na-140 K-4.9 Cl-109 [**2177-6-27**] 10:16PM BLOOD cTropnT-0.44* [**2177-6-28**] 12:34AM BLOOD CK-MB-57* MB Indx-13.0* cTropnT-1.95* Brief Hospital Course: Mr. [**Known lastname **] is a [**Age over 90 **]y/o gentleman with CAD, AI, and CHF who is now with recurrent episodes of pulseless cardiac arrest and respiratory arrest (intubated). Mild hypothermia protocol was initiated, and patient was transferred to the MICU for further management. Upon arrival to MICU, patient exhibited progressive decline in systolic blood pressure to <70 mmHg, despite maximum doses of Phenylephrine, Epinephrine, and Norepinephrine and repeated iv fluid boluses, and exhibited persistent acidemia, lactic acidosis. Following extensive discussion with family members (including daughter/HCP [**Name (NI) 4317**] [**Name (NI) 931**]) regarding overall poor prognosis and unlikelihood of recovery due to repeated episodes of pulseless cardiac arrest requiring CPR and profound hypotension despite extensive vasopressor support, no further interventions were pursued, no further CPR, and focus of care transitioned to comfort. The patient expired quietly and peacefully with family and chaplain at the bedside. Medications on Admission: Unable to record medication list before patient expired. Discharge Medications: patient expired Discharge Disposition: Expired Discharge Diagnosis: patient expired Discharge Condition: patient expired Discharge Instructions: patient expired Followup Instructions: patient expired [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**] MD [**MD Number(1) 2438**]

[ "042", "V10.06", "V10.49", "196.5", "V10.47", "250.01" ]

icd9cm

[ [ [] ] ]

[ "40.3" ]

icd9pcs

[ [ [] ] ]

5188, 5197

3999, 5040

249, 357

5256, 5273

3075, 3976

5337, 5481

2279, 2297

5148, 5165

5218, 5235

5066, 5125

5297, 5314

2312, 3056

191, 211

385, 1689

1711, 2008

2024, 2263

6,476

112,040

30000

Discharge summary

report

Unit No: [**Numeric Identifier 71609**] Admission Date: [**2154-5-1**] Discharge Date: [**2154-8-25**] Date of Birth: [**2154-5-1**] Sex: F Service: NB HISTORY OF PRESENT ILLNESS: Baby Girl [**Known lastname 71610**] was born at 27- 2/7 weeks gestation by cesarean section for severe pre- eclampsia and breech presentation. The mother is a 25-year- old, gravida 3, para 0, now 1, woman. Her prenatal screens were blood type O positive, antibody negative, rubella immune, RPR nonreactive, hepatitis surface antigen negative, and Group B strep unknown. This pregnancy was complicated by the onset of severe preeclampsia 48-hours prior to delivery and intrauterine growth retardation. The mother was treated with betamethasone and magnesium sulfate. The infant emerged with Apgars of 6 at one minute and 8 at five minutes. The birth weight was 829 gm (20th percentile), birth length 34 cm (25th percentile), and the birth head circumference 24.5 cm (25th percentile). NICU COURSE BY SYSTEMS: 1. Respiratory Status: The infant was intubated at the time of admission and received 1 dose of Surfactant. She extubated to nasopharyngeal continuous positive airway pressure on day of life #1 and then she transitioned to nasal cannula oxygen on day of life #2. She was treated with caffeine citrate for apnea of prematurity from day of life #1 until day of life #21. She continues to have 1-4 episodes of apnea and bradycardia in a 24- hour period. On [**6-21**] she she began to have worsening apnea/bradycardia.On [**6-24**] she was restarted on caffeine citrate and placed on high flow nasal cannula with improvement, on [**6-28**] she went back to low flow cannula of 13 cc's liter flow. Caffeine was D'C d on [**7-3**]. It appears that her respiratory situation is compromised by her abdominal girth impinging on her chest capacity. She breaths with deep retractions out of proportion to her mild chronic lung disease. On [**7-18**] Pulmonary consult was obtained (Dr. [**Last Name (STitle) 37305**]. He will follow patient in Pulmonary Clinic on [**8-16**] at CHMC. He requested an ultrasound to determine diaphragmatic movement and this was done on [**7-23**] with normal bilateral and symmetrical movement. Her most recent cap blood gas on [**7-24**] was 7.37/50. She will be going home on 25 cc's liter flow of oxygen and a saturation monitor to maintain oxygen saturation greater than 90% 2. Cardiovascular Status: She has remained normotensive throughout her NICU stay. She has the presentation of a new heart murmur on [**2154-5-14**] and a cardiac echo at that time revealed a structurally normal heart, no patent ductus, and mild PPS. I am unable currently to hear her intermittant murmur. 3. Fluids/Electrolytes/Nutrition Status: Enteral feeds were begun on day of life #6 and advanced to full volume feedings by day of life #18 with a slow progression due to abdominal distention. She worked up to total fluids 140 mL/kg/day of Neosure 26- calorie per ounce formula and takes about 140 cc/kg /day of feeding. Her weight at discharge is 2780 grams. Endocrine: On routine nutrition labs it was noted that her alkaline phosphatase was rising with normal calciums and boarderline phosphate, extra Vitamin D was added to her diet to give her a total intake of [**2147**] units/kg. Follow-up alkaline phosphatase on [**6-27**] was was higher at 1627 with normal liver transaminases. Consult with endocrine was obtained at which time they recommended parathyroid hormone levels which was elevated at 191 (15-65), Ca,Phosperous and 25 hydroxy vitamin D and alk phos . Of note her Vit D, 25-OH total was 15, whereas the desired levels are > 30 and closer to 40 NG/ML. Endocrinology thought in the face of us having been giving her adequate levels of Vit D in her formula, this deficiency represented poor maternal intake. I have notified her mother about this and she will speak to her physician about checking her Vit D levels and the possibility she might need supplements. They recommended repeating these labs prior to discharge with the goal of having her Vit D levels 30-40 aiming for closer to 40 and at that time one could D'C the Vitamin D and follow. On [**7-24**] Ca was 10, P 6.8, PTH 146 down from 191(nl 15-65) and 25 hydroxy vitamin D is pending. Endocrine recommends repeating these levels in 1 month post discharge. 4. Gastrointestinal Status: She was treated with phototherapy for hyperbilirubinemia of prematurity from day of #2 until day of life #10. Her peak bilirubin occurred on day of life #2 and was total 5.3, direct 0.3. Her last bilirubin on [**2154-5-12**] was total 2, direct of 0.4. Her baseline exam was a distended abdomen. No visile loops, and active bowel sounds. Her abdomen remained markedly distended, such that it appeared to compromise her pulmonary function. KUB done on [**6-25**] was read as normal, however radiology recommended an abdominal ultrasound to better look at liver and kidney size. This was done on [**2154-6-26**] with normal liver, spleen and pancreas, kidneys by verbal report were normal. 5. Hematology: She has never received any blood products or transfusions. Her last hematocrit on [**7-24**] was 37.3 with a reticulocyte count of 3. 6. Infectious Disease Status: She was started on ampicillin and gentamicin at the time of admission for sepsis risk factors. She completed 7 days of antibiotics for presumed sepsis. Her blood culture did remain negative. She stayed off antibiotics until day of life #51 when she presented with nasal secretions which changed from clear to green to yellow in color. She was started on oral Keflex but increasing symptomatology (apnea/bradycardia) resulted in a blood culture and complete blood count with a white count of 13.6 with 15 polys and 6 bands. At time she was started on vancomycin and gentamicin. The blood culture remained negative and at 48 hours vanc and gent were D'C d. She remained on oral Keflex for 7 days for nasal cultures positive for staph aureus. 7. Neurology: Her first head ultrasound on [**5-8**] was without any abnormalities. A follow-up ultrasound on [**5-31**], [**2154**] showed bilateral germinal matrix hemorrhage. A follow-up on [**2154-6-14**] showed no change, with stable, grade 1 hemorrhages. 8. Ophthalmology: Her eyes were last examined on [**2154-7-22**] showing mature retina OD and stage 1, retinopathy 3 clock hours os . F/U in [**3-2**] weeks at [**Location (un) 2274**]/Dr.[**Last Name (STitle) 40944**] 9. Psychosocial: Parents have been involved in the infant's care throughout her NICU stay. MEDICATIONS Calciferol ([**2147**] units/0.05 mL) dose 0.25 mL daily. Ferrous sulfate (25 mg/mL) 0.25 mL daily. 1. Iron supplementation is recommended for preterm and low birth weight infants until 12 months corrected age. 2. All infants fed predominantly breast milk should receive vitamin D supplementation at 200 international units which may be provided as a multivitamin preparation daily until 12 months corrected age. Her state newborn screen was sent on [**5-4**] and [**5-15**]. IMMUNIZATIONS: She received her first hepatitis B vaccine on [**5-30**], HIB on [**7-1**] Pneumoccocal [**7-1**] Pediarix on [**7-2**]. F/U at [**Location (un) 2274**]/WROX with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 42446**] [**7-29**]. VNA to visit home day post discharge. Early Intervention Referral made. Opthamology f/u at [**Location (un) 2274**]/Dr. [**Last Name (STitle) 40944**] within 2-3 weeks of discharge. Appt to be made by Dr. [**Last Name (STitle) 42446**]. Repeat labs of Ca/P/PTH and 25 hydroxy vitamin D in 1 month. DISCHARGE DIAGNOSES: 1. Status post prematurity at 27 weeks. 2. Status post respiratory distress syndrome. 3. Retinopathy of Prematurity 4. Status post hyperbilirubinemia of prematurity. 5. Vitamin D deficiency/. 6. Chronic lung disease. 7. S/P Apnea of prematurity. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 37691**], [**MD Number(1) 55783**] Dictated By:[**Last Name (NamePattern1) **] MEDQUIST36 D: [**2154-6-23**] 07:33:39 T: [**2154-6-23**] 15:10:51 Job#: [**Job Number 71611**]

[ "747.3", "770.81", "790.5", "765.03", "733.90", "774.2", "V05.3", "769", "777.8", "765.24", "779.81", "362.21", "787.3", "779.3", "771.81", "268.9", "772.11", "V30.01", "779.89" ]

icd9cm

[ [ [] ] ]

[ "96.04", "96.71", "99.83", "96.6", "93.90", "99.55", "38.92", "99.15", "38.93" ]

icd9pcs

[ [ [] ] ]

8040, 8559

187, 8019

75,963

156,330

39572

Discharge summary

report

Admission Date: [**2112-12-17**] Discharge Date: [**2112-12-21**] Date of Birth: [**2047-8-25**] Sex: M Service: MEDICINE Allergies: Zithromax / Nabumetone / IV Dye, Iodine Containing Contrast Media Attending:[**Doctor First Name 2080**] Chief Complaint: hematemesis Major Surgical or Invasive Procedure: [**2112-12-17**] esophageal gastroduodenoscopy (EGD) [**2112-12-21**] esophageal gastroduodenoscopy (EGD) History of Present Illness: 65M with h/o etoh abuse, elevated LFTs, recently admitted in [**Month (only) 958**] with hematemesis, who presented with hematemesis and melena. The patient has an extensive drinking history, with three small bottles of whiskey daily for the last 25 years. The patient's daughter reports that he stopped drinking about 6 months ago, but then started again about two weeks ago. Last drink, as per daughter and wife, was this past Tuesday. . Of note, the patient was admitted in [**Month (only) 958**] for episode of hematemesis, and EGD at the time showed evidence of gastritis. Was thought that hematemesis was possibly due to [**Doctor First Name **]-[**Doctor Last Name **] tear. In [**9-/2111**], the patient had EGD with e/o normal esophagus, and alcohol gastritis. Another EGD in [**3-/2112**] showed diffuse gastritis and few antral erosions, with no esophageal varices. . The patient underwent a bedside EGD in the unit that showed no active site of bleeding, but with blood in stomach; possibly related to oozing secondary to portal gastropathy. Grade I esophageal varices were seen but were not bleeding. Octreotide d/c'ed. PPI transitioned to IV BID. His HCT and vital signs in the MICU were stable and therefore he was called out to the floor on [**2112-12-19**]. . On arrival to the floor, the patient is currently asymptomatic other than being hungry from being NPO. Past Medical History: Alcohol Abuse Transaminitis/fatty liver-likely ETOH induced Rosacea Subclinical Hypothyroidism Social History: EtOH: three small bottles of whiskey daily for the last 25 years. The patient's daughter reports that he stopped drinking about 6 months ago, but then started again about two weeks ago. Tobacco: denies Illicits: denies Family History: Denies CAD or CVA. Otherwise non-contributory. Physical Exam: ADMISSION PHYSICAL EXAM: Vitals: 108/63 (78) 82 14 99 on 2L General: Alert, oriented, NAD, somewhat slow to answer questions 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-distended, diffuse tenderness, hyperactive bowel sounds GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: + slight asterixis Pertinent Results: ADMISSION LABS: =============== [**2112-12-17**] 12:00PM BLOOD WBC-7.7# RBC-3.62* Hgb-11.5* Hct-35.3* MCV-98 MCH-31.9 MCHC-32.7 RDW-14.7 Plt Ct-103* [**2112-12-17**] 12:00PM BLOOD Neuts-85.3* Lymphs-10.8* Monos-3.3 Eos-0.2 Baso-0.3 [**2112-12-17**] 12:00PM BLOOD PT-15.3* PTT-31.9 INR(PT)-1.4* [**2112-12-17**] 12:00PM BLOOD Glucose-141* UreaN-20 Creat-0.8 Na-141 K-3.8 Cl-104 HCO3-28 AnGap-13 [**2112-12-17**] 12:00PM BLOOD ALT-55* AST-152* AlkPhos-155* TotBili-2.2* [**2112-12-17**] 12:00PM BLOOD Lipase-83* [**2112-12-17**] 06:00PM BLOOD Albumin-2.6* Calcium-7.4* Phos-2.9 Mg-1.7 [**2112-12-17**] 12:00PM BLOOD Ethanol-NEG Acetmnp-NEG . Discharge Labs: =============== [**2112-12-21**] 06:40AM BLOOD WBC-5.5 RBC-3.09* Hgb-10.0* Hct-29.7* MCV-96 MCH-32.3* MCHC-33.6 RDW-16.8* Plt Ct-138* [**2112-12-21**] 06:40AM BLOOD PT-14.6* INR(PT)-1.4* [**2112-12-21**] 06:40AM BLOOD Glucose-102* UreaN-11 Creat-0.7 Na-138 K-3.7 Cl-104 HCO3-28 AnGap-10 [**2112-12-20**] 05:30AM BLOOD Albumin-2.9* Calcium-7.7* Phos-3.6 Mg-2.0 MICRO: NONE . IMAGING: [**12-17**] CXR TECHNIQUE: Frontal and lateral chest radiographs were obtained. FINDINGS: Lung volumes are slightly low. No focal consolidation, pleural effusion, or pneumothorax is seen. The heart size is top normal, although may be exaggerated by low lung volumes. Aortic tortuosity is seen. The mediastinal contours are otherwise unremarkable. Apical pleural scarring is again noted. IMPRESSION: No radiographic evidence for acute process. . RUQ U/S [**2112-12-19**]: The liver is diffusely coarse and echogenic. Several subcentimeter cysts are seen within the right lobe. The gallbladder is normal in size, without wall thickening or pericholecystic fluid. Gallbladder sludge is seen layering dependently. The common bile duct measures 4 mm. Normal hepatopetal flow is seen within the main portal vein. The kidneys are normal in appearance bilaterally without hydronephrosis or stones. There is no ascites, though a four-quadrant survey was not performed. The spleen is normal in size measuring 10 cm in the craniocaudal dimension. IMPRESSION: 1. Diffusely echogenic liver consistent with history of cirrhosis. 2. Gallbladder sludge, without evidence of acute cholecystitis. 3. No evidence of ascites in the upper abdomen. . EGD [**2112-12-17**]: Varices at the lower third of the esophagus Blood in the whole stomach Friability, erythema and congestion in the whole stomach compatible with hypertensive portal gastropathy Friability, erythema and congestion in the whole examined duodenum compatible with portal hypertensive enteropathy Otherwise normal EGD to third part of the duodenum . EGD [**2112-12-21**]: 2 cords of grade I varices at the GE junction of the esophagus Single varix at the fundus Brunner's gland hyperplasia noted in second part of duodenum. Otherwise normal EGD to third part of the duodenum Brief Hospital Course: Primary Reason for Hospitalization: =================================== 65M with h/o etoh abuse, elevated LFTs, recently admitted in [**Month (only) 958**] with hematemesis, who presented with hematemesis . ACTIVE ISSUES: ============== # Upper GI Bleed from Portal Gastropathy/acute blood loss anemia: During initial EGD, blood was seen in the whole stomach, with friability, erythema and congestion in the stomach and duodenum, compatible with portal hypertensive gastropathy and enteropathy, respectively. In addition grade I esophageal varices were visualized as well as single varix at the gastric fundus though those were not suspected to be the source of bleeding. The patient had no further emesis or melena after admission and the patient's vital signs and hematocrit were stable for over 48 hours prior to discharge. - He will continue Pantoprazole [**Hospital1 **] - He was started on Nadolol 20mg daily because of varices . # EtOH cirrhosis: MELD 13 on admission, with elevated transaminases AST>ALT, and elevated INR. No evidence of hepatic encephalopathy and no ascites seen on ultrasound although patient does have varices as discussed above. - Plan for Outpatient follow-up in Liver Clinic with Dr. [**Last Name (STitle) **] - Patient was counseled extensively on EtOH cessation and family involved in discussions. - Patient was given patient information sheet on cirrhosis in spanish. - Patient was given list of spanish speaking Alcoholics Anonymous Groups in his area. He also stated that he plans to work with the pastor at his church. . # Thrombocytopenia: Likely secondary to EtOH abuse and cirrhosis. . # Alcoholism: The patient scored on CIWA scale when he first arrived to the ICU but had no further benzodiazepine requirement. He was counseled on cessation as discussed above. . TRANSITIONAL ISSUES: ==================== - Patient was given information on spanish speaking Alcoholics Anonymous Groups. He also stated that he plans to work with the pastor at his church. - CT imaging demonstrated foci in the liver of uncertain significance. Repeat imaging in 6 months is recommended. Medications on Admission: 1. thiamine HCl 100 mg daily 2. folic acid 1 mg daily 3. multivitamin daily 4. pantoprazole 40 mg [**Hospital1 **] 5. Sulfacetamide Sodium-Sulfur [**10-19**] % (w/v) Topical Lotion [**Hospital1 **] 6. fluticasone 50mcg 2 sprays in each nostril daily Discharge Medications: 1. sulfacetamide sodium-sulfur [**10-19**] % (w/v) Lotion Sig: One (1) application Topical twice a day: apply to affected areas for rosacea. 2. gabapentin 300 mg Capsule Sig: One (1) Capsule PO twice a day. 3. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO once a day. 4. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO twice a day. 5. folic acid 1 mg Tablet Sig: One (1) Tablet PO once a day. 6. multivitamin Tablet Sig: One (1) Tablet PO once a day. 7. fluticasone 50 mcg/Actuation Spray, Suspension Sig: Two (2) sprays Nasal once a day. 8. nadolol 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: PRIMARY DIAGNOSIS -Upper GI bleed from portal Gastropathy -Esophageal Varices -Gastric Varix -Alcoholic Cirrhosis -Alcoholism Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Mr. [**Known lastname **], it was a pleasure taking care of you here at [**Hospital1 18**]. You were admitted to the hospital beause you were vomiting blood. The GI doctors looked into your esophagus and stomach with a camera (called EGD) and they found blood throughout your stomach. This is most likely caused by your liver disease. The liver disease (also called cirrhosis) was caused by long-term use of alcohol. As we discussed, the most important thing that you can do for your health is to stop drinking. . The following additions were made to your medications: START nadolol 20mg daily You should continue taking all of your other medications as you were previously. You should minimize the use of anti-inflammatory medications such as aspirin, ibuprofen (motrin/advil), or naproxen (aleve). . It is also very important that you keep all of the follow-up appointments listed below. . Followup Instructions: PCP [**Name Initial (PRE) **]: Monday, [**12-26**] at 10am With:[**Name6 (MD) **] SPAR,MD Location: [**Hospital1 641**] Address: [**Location (un) **], [**Location (un) **],[**Numeric Identifier 2260**] Phone: [**Telephone/Fax (1) 2261**] Name: [**Last Name (LF) **], [**Name8 (MD) **] MD Location: [**Hospital1 18**]-DIVISION OF GASTROENTEROLOGY Address: [**Doctor First Name **], 8E, [**Location (un) **],[**Numeric Identifier 718**] Phone: [**Telephone/Fax (1) 2422**] *Someone from Dr. [**Last Name (STitle) 87350**] office will call you to schedule an appointment.

[ "572.3", "303.90", "287.49", "571.2", "537.89", "456.21", "695.3", "578.9", "578.0", "456.8", "285.1" ]

icd9cm

[ [ [] ] ]

[ "96.07", "45.13" ]

icd9pcs

[ [ [] ] ]

8877, 8883

5745, 5952

341, 449

9053, 9053

2861, 2861

10123, 10696

2232, 2280

8161, 8854

8904, 9032

7886, 8138

9203, 10100

3517, 5722

2320, 2842

7573, 7860

290, 303

5967, 7552

477, 1860

2877, 3501

9068, 9179

1882, 1979

1995, 2216

546

127,873

44180

Discharge summary

report

Admission Date: [**2124-8-28**] Discharge Date: [**2124-9-12**] Date of Birth: [**2045-1-4**] Sex: F Service: MEDICINE Allergies: Sulfamethoxazole/Trimethoprim / Codeine / Antihistamines Attending:[**First Name3 (LF) 1145**] Chief Complaint: Shortness of Breath Major Surgical or Invasive Procedure: EP study, pacer placement History of Present Illness: 80 yo F h/o rheumatic heart dz Mitral stenosis, AS, AR, CC: Shortness of breath ********** HPI: Pt is a 79 y/o female with rheumatic heart disease, rapid atrial-fibrillation, strong smoking history, and COPD who presents with shortness of breath. She had a recent admission for jaw/chest pain where found to have only a 40% proximal LAD lesion but was noted to be in rapid afib and was discharged on diltiazem for rate control. She was discharged with [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] of hearts monitor. She was subsuquently seen by Dr. [**Last Name (STitle) **] in cardiology clinic where she was again found to be in rapid a-fib, with a rate near 150; admission for cardioversion was discussed at length, but the patient refused, so she was started on metoprolol 50mg [**Hospital1 **], aspirin, and warfarin. . The pt continued to have SOB and palpitations so she sought further care in [**Hospital1 18**]. The pt denies any chest pain. In the ED, the pt briefly required non-invasive ventilatory support for the SOB. CXR showed pulmonary edema. ECG revealed a-fib at 140's-150's with ST depressions v4-v6 and trop leak to 0.24 c/w demand ischemia. IV dilt was started in the [**Last Name (LF) **], [**First Name3 (LF) **] cardiology consultant recs and the pt was transferred to the medicine floor. . On the medicine floor, the telemetry showed a-fib with rates to 150's, with periods of asystole lasting for a couple of seconds, during which the pt reported dizziness and nausea. The pt was transferred to the CCU for further monitoring and management. The plan at the CCU was to place a temporary pacer wire so that rate control therapy could be safely started once a back-up rhythm could be guaranteed by the temporary pacer. Venous cannulation was unable to be acheived at the bedside. However, during the attempts to place the venous cannula, the pt converted to sinus rhythm at 70-80 bpm. . Past Medical History: CORONARY ARTERY DISEASE MULTINODULAR GOITER CONSTIPATION H/O ATYPICAL CHEST PAIN CHRONIC BRONCHITIS CHRONIC LOW BACK PAIN S/P TAH-BSO CIGARETTE SMOKING HYPERCHOLESTEROLEMIA PANIC DISORDER Social History: Lives with son, denies etoh. Smoker (current) PPD x 60 yrs.. Family History: Non-contributory Physical Exam: PE T BP HR RR O2sats Gen: NAD, breathing with mask HEENT: PERRL and A, EOM intact, moist mucous membranes, Neck: no masses, +JVD b/l, no carotid bruits Lungs: decr. breath sounds at bases, wheezes throughout, no crackles Heart: irreg rate, nl s1/s2, no m/r/g Abd: soft, nt/nd, +bs Ext: no cyanosis, clubbing, min. symmetric LE edema, 2+ rad/dp pulses Neuro: a&ox3, non-focal Pertinent Results: Cath [**2123-3-16**]: Taxus to 80% RCA lesion . Cath [**2124-8-3**]: RHC: PA 25/15. PCWP 15. CO/CI/SVR = 5.35/3.65/942 [**Location (un) 109**] 1.0. mean gradient 22. Mitral area 2.0 gradient 8. 3+ AI, 2+ MR RCA: patent LAD: 40% proximal discrete LCX: patent . CXR [**2124-8-28**]: pulmonary edema congestive heart failure. . Echo [**2124-8-29**]: Conclusions: The left atrium is elongated. There is mild symmetric left ventricular hypertrophy with normal cavity size and systolic function (LVEF>55%). Regional left ventricular wall motion is normal. The ascending aorta is mildly dilated. The aortic valve leaflets are severely thickened/deformed. There is moderate aortic valve stenosis. Mild to moderate ([**12-26**]+) aortic regurgitation is seen. The mitral valve leaflets are moderately thickened. The mitral valve shows characteristic rheumatic deformity. There is moderate thickening of the mitral valve chordae. There is a minimally increased gradient consistent with trivial mitral stenosis. Moderate to severe (3+) mitral regurgitation is seen. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. Compared with the prior study (tape reviewed) of [**2124-5-9**], the severity of mitral regurgitation has increased and the estimated pulmonary artery systolic pressure is higher. The transaortic valve gradient is also increased. . [**2124-8-28**] 08:29PM cTropnT-0.20* [**2124-8-28**] 08:29PM WBC-10.4# RBC-3.65* HGB-10.4* HCT-31.4* MCV-86 MCH-28.6 MCHC-33.1 RDW-14.6 [**2124-8-28**] 08:45AM GLUCOSE-118* UREA N-28* CREAT-1.1 SODIUM-140 POTASSIUM-4.0 CHLORIDE-104 TOTAL CO2-22 ANION GAP-18 [**2124-8-28**] 08:45AM CALCIUM-9.6 PHOSPHATE-4.5 MAGNESIUM-1.8 [**2124-8-28**] 08:45AM cTropnT-0.24* [**2124-8-28**] 08:45AM CK(CPK)-124 [**2124-8-28**] 03:10AM CK-MB-5 cTropnT-0.04* proBNP-6646* [**2124-8-28**] 03:10AM DIGOXIN-<0.2* [**2124-8-28**] 03:10AM PT-14.7* PTT-27.6 INR(PT)-1.4 Brief Hospital Course: A/P: 79 yo F with valvular heart failure AS area 1.0 gradient 22, MS area 2.0 gradient 8, 3+AI, 2+MR, COPD and rapid AFib, presenting with SOB/CHF exacerbation. The pt was found to be in rapid A-fib on admission, developed long symptomatic ventricular pauses with rate control therapy, pacemaker was placed successfully in order to safely rate control. . # Rhythm: The pt described symptoms of increased fatigue and SOB on admission. She was noted to be in rapid Afib. She was initially rate controlled with dilt and metoprolol on the medicine floor. However, the pt was noted on the telemetry to have periods of [**4-28**] seconds of asysole, during which she felt light-headed and nauseous. The pt was transferred to the CCU for more intensive monitoring. Attempted placement of catheter for temporary pacer was not successful, though pt converted to NSR. The pt was counseled regarding the benefits of permanent pacemaker so that the heart rhythm could be more successfully controlled, and she was amenable to this solution. The device was implanted successfully without complications. In terms of medical therapy Amiodarone for rate control and to attempt maintenence of sinus rhtyhm. For medical therapy, beta blocker and digoxin were used for rate control. Amiodarone was added to maintain sinus rhythm, but was later discontued after the pt developed symptoms of mental status changes which may have been at least partly exacerbated by the amio. Anti-coagulation for stroke prophylaxis was pursued with coumadin with a heparin bridge. . 2. CHF: Pt was initially found to be in acute CHF with pulmonary edema on CXR and increased O2 needs. This was assessed to be [**1-26**] a-fib with RVR in setting of significant valvular heart disease. Pt had low bp 90-120/40-50, when she was in rapid a-fib and on several BP meds, isordil, lisinopril 40, lasix 100 IV. The pt was diuresed gently and gradually brought to euvolemic state with medical therapy. Echo was repeated to evaluate for any changes since the previous echo in may and revealed no significant changes. . 3 CAD: The pt did have a slight troponin elevation which peaked at 0.24. This was likely secondary to demand ischemia in setting of rapid AFib and low BP that she had on HD#1. The were so symptoms of anginal pain. No area at risk per cath [**2124-8-3**]. ASA, plavix, lipitor were continued. . 4. Mental status changes: In the post-operative setting, after the device was placed, the pt devloped symptoms of acute delirium. She had fluctuating levels of consciousness as well as some agitation, particulalrly developing at night. The delirium was thought to be [**1-26**] to post-operative setting, multiple medications including opiates, benzodiazepines, amiodarone, as well as a tenuous baseline status. The medication regimen was simplified and over the subsequent couple of days, the pt returned to her baseline mental status. . 5. FEN: Na-restricted diet, fluid restriction. 6. Chronic LBP: continue oxycodone/oxycontin. 7. PPx: anti-coagulated. 8. Code: Full. 9. Dispo: The physical therapist evaluated the patient and recommended rehab. The physician team as well as the nursing staff impressed upon the pt that rehab was the safer option than returning home. The pt remained adamant that she wished to return home without rehab. Medications on Admission: 1. coumadin, though pt was not therapeutic on admission 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Atorvastatin Calcium 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation QID (4 times a day). 4. Diazepam 2 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for anxiety. 5. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [**Hospital1 **] (2 times a day). 6. Furosemide 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 7. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 8. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. 9. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO TID (3 times a day). 11. Oxycodone 20 mg Tablet Sustained Release 12HR Sig: One (1) Tablet Sustained Release 12HR PO QAM (once a day (in the morning)). 12. Oxycodone 10 mg Tablet Sustained Release 12HR Sig: One (1) Tablet Sustained Release 12HR PO MIDDAY (). 13. Oxycodone 10 mg Tablet Sustained Release 12HR Sig: One (1) Tablet Sustained Release 12HR PO QPM (once a day (in the evening)). 14. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 15. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily). 16. Cardizem CD 240 mg Capsule, Sust. Release 24HR Sig: One (1) Capsule, Sust. Release 24HR PO once a day. Discharge Medications: 1. medical supply one hospital bed. pt weight 48 kg. Height 5 foot 3 inches 2. commode one commode 3. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [**Hospital1 **] (2 times a day). 5. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). Disp:*30 Tablet, Chewable(s)* Refills:*2* 6. Ranitidine HCl 150 mg Capsule Sig: One (1) Capsule PO once a day. 7. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 8. Lasix 20 mg Tablet Sig: One (1) [**12-26**] Tablet PO once a day. 9. Toprol XL 50 mg Tablet Sustained Release 24HR Sig: Three (3) Tablet Sustained Release 24HR PO once a day. Disp:*90 Tablet Sustained Release 24HR(s)* Refills:*0* 10. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). Disp:*14 Tablet(s)* Refills:*0* 11. Outpatient Lab Work Please have you INR check blood test on [**2124-9-15**]. Discharge Disposition: Home With Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: Atrial fibrillation CHF exacerbation Discharge Condition: good Discharge Instructions: Please take all medicines as directed below. Please weigh yourself daily and call your doctor if your weight increases by more than 3 lbs. Restrict your fluid intake to less than 1.5 L daily. Followup Instructions: Provider [**Name9 (PRE) 640**] [**Name8 (MD) **], MD Where: [**Hospital6 29**] [**Hospital **] Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2124-9-15**] 2:00 Provider [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1013**], M.D. Where: [**Hospital6 29**] CARDIAC SERVICES Phone:[**Telephone/Fax (1) 127**] Date/Time:[**2124-9-21**] 2:45 . Electrophysiology Device Clinic, [**Hospital6 29**] CARDIAC SERVICES 1:30 pm [**2124-9-21**]. . Provider [**Name9 (PRE) **] FERN, [**Name9 (PRE) 280**] Where: [**Hospital6 29**] [**Hospital **] Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2124-10-4**] 10:20

[ "496", "401.9", "427.31", "427.81", "293.0", "414.01", "724.5", "584.9", "305.1", "396.2", "511.9", "286.7", "398.91", "530.81" ]

icd9cm

[ [ [] ] ]

[ "37.83", "37.72", "99.04", "93.90" ]

icd9pcs

[ [ [] ] ]

11015, 11072

5144, 8453

336, 363

11153, 11160

3075, 5121

11400, 12022

2633, 2651

10018, 10992

11093, 11132

8479, 9995

11184, 11377

2666, 3056

277, 298

391, 2326

2348, 2538

2554, 2617

16,196

116,640

48217

Discharge summary

report

Admission Date: [**2190-6-16**] Discharge Date: [**2190-6-23**] Date of Birth: [**2122-11-2**] Sex: M Service: Cardiac Surgery HISTORY OF PRESENT ILLNESS: This is a 66-year-old patient, who has a known history of coronary artery disease and has undergone multiple PTCA stents and PCIs in the last year, who underwent placement of a stent in his proximal left anterior descending artery on [**2190-6-9**]. On [**2190-6-14**], the patient was at home and began experiencing angina and called his cardiologist. On [**2190-6-16**], was referred to the Emergency Room. The patient presented to the Emergency Room on [**2190-6-16**] and was admitted for workup. PAST MEDICAL HISTORY: 1. Coronary artery disease. 2. Status post circumflex and left anterior descending artery stenting. 3. Hypercholesterolemia. 4. Hypertension. 5. History of Bell's palsy. 6. Status post hernia repair. 7. Positive tobacco use greater than 30 pack year history. ALLERGIES: No known drug allergies. PREOPERATIVE MEDICATIONS: 1. Mavik 4 mg po q day. 2. Cardura 4 mg po q day. 3. Lipitor 40 mg po q day. 4. Aspirin 325 mg po q day. 5. Atenolol 50 mg po q day. 6. Folate. 7. Multivitamins. HOSPITAL COURSE: The patient was admitted to the Emergency Room. Vital signs in the Emergency Room: Temperature 97.5, pulse 69. Regular, rate, and rhythm. Blood pressure 93/51, respiratory rate 17, oxygen saturation 97%. Patient was awake, alert, and oriented times three in no apparent distress. Pain level upon arrival was [**1-1**]. Lungs were clear. Heart was regular. Abdomen was soft, positive bowel sounds. Extremities were without edema. Cardiology was consulted. The patient was taken to the Catheterization Laboratory. In the Cardiac Catheterization Laboratory, the patient was found to have elevated filling pressures with a pulmonary capillary wedge pressure of 19. The left main coronary artery showed severe 90% eccentric narrowing of entire length. The stent to the left anterior descending artery was patent. The stent to the left circumflex was patent, and the right coronary artery showed chronic total occlusion which was unchanged. An intra-aortic balloon pump was inserted and Cardiac Surgery was consulted. The patient had an echocardiogram which showed mild aortic stenosis with a valve area of 1.3. An ejection fraction of 40-45%, an aortic valve peak gradient of 38 mm Hg and a mean gradient of 24 mm Hg. Patient was taken to the operating room from the Catheterization Laboratory due to the severe nature of his left main disease with Dr. [**Last Name (STitle) 70**]. The patient underwent a coronary artery bypass graft x3 with LIMA to left anterior descending artery, saphenous vein graft to PDA, and OM sequential, as well as an aortic valve replacement with a 21 mm bovine [**Last Name (un) 3843**]-[**Doctor Last Name **] pericardial valve on [**2190-6-16**] with Dr. [**Last Name (STitle) 70**]. Please see operative note for further details. The patient was transferred from the operating room to the Intensive Care Unit in stable condition. Upon admission to the Intensive Care Unit, patient was mildly hypoxic with a respiratory acidosis and the patient remained intubated overnight. On postoperative day #1, the patient was weaned and extubated from mechanical ventilation. Preoperatively, the patient had been noted to have a large hematoma in his right groin from his cardiac catheterization one week later, and had been reported to have an audible bruit. A vascular ultrasound was obtained which showed no evidence of pseudoaneurysm or A-V fistula in his right groin. A Vascular consult was attained. The Vascular team decided that no treatment was necessary of the hematoma, however, patient did report to Dr. [**Last Name (STitle) **], the Vascular surgeon that he did have symptoms of claudication. Dr. [**Last Name (STitle) **] suggested that the patient see him in the office for followup for his claudication. On postoperative day #1, patient spiked a fever to 101. The patient was pancultured. The results of the cultures subsequently had been negative, and patient's temperature defervesced and had no further temperature spikes. Patient's balloon pump was weaned and removed on postoperative day #1 without complication. On the evening of postoperative day #1, it was noted that the patient had progressively decreasing urine output with significant oliguria. Patient's Foley catheter was flushed without difficulty. Patient had little response to Lasix in volume. Patient was noted to have distended bladder. Foley catheter was replaced with over a liter of urine output noted. On postoperative day #2, the patient was noted to be progressively hypoxic, and thought to be due to the volume challenge the patient had received when he was thought to be oliguric. The patient was given aggressive diuretic therapy with good improvement in his oxygenation as well as aggressive pulmonary toilet. Patient continued to need low dosed Neo-Synephrine to maintain adequate blood pressure. On postoperative day #2, patient had episode of rapid atrial fibrillation, started on IV amiodarone. Rate was controlled with IV amiodarone and Lopressor. Patient began working with Physical Therapy and ambulating. On postoperative day #3, the patient continued to have episodes of atrial fibrillation. Rate was controlled with Lopressor. Patient's oxygenation improved dramatically, and was able to be weaned down to nasal cannula. Patient's chest tubes were removed without incident. Patient, on postoperative day #3, was noted to have some serosanguinous drainage coming from the distal portion of his sternum. The area was clean and Dermabond was applied. The patient was noted to have elevated white blood cell count of 27,000. Patient was empirically started on levofloxacin/Vancomycin. On postoperative day #4, the drainage from the lower portion of the sternum had significantly decreased. Patient's white blood cell count continued to be elevated, however, patient remained afebrile. Patient continued on the antibiotics. On postoperative day #5, the patient was transferred from the Intensive Care Unit to the floor. Patient's white blood cell count had dropped to 16.8. Patient was started on Coumadin and Heparin to anticoagulate for his continued episodes of atrial fibrillation. On postoperative day #6, the Heparin drip was discontinued. Coumadin dosing continued. His sterile drainage had stopped and on postoperative day #7, patient was cleared for discharge to rehabilitation. CONDITION ON DISCHARGE: Temperature max 97.1, pulse 67, sinus rhythm, although the patient has had multiple episodes of atrial fibrillation, blood pressure 110/60, respiratory rate 16, on room air oxygen saturation of 97%. Weight on [**6-23**] is 98.2 kg. The patient weighed 97 kg preoperatively. LABORATORY DATA: White blood cell count 17.1, hematocrit 27.5, platelet count 268. Sodium 135, potassium 5.5, chloride 97, bicarb 31, BUN 28, creatinine 1.2, glucose 114, PT 16.9, INR 1.9. Neurologically the patient is awake, alert, and oriented times three. Neurologically nonfocal. Heart is regular, rate, and rhythm, positive rub, no murmur. Lungs are clear to auscultation bilaterally. No wheezes, rales, or rhonchi. Abdomen has positive bowel sounds, is soft, nontender, nondistended. Patient is tolerating a regular diet. Extremities have [**12-24**]+ pitting edema. Both extremities are warm and well perfused. Right groin has an old hematoma which is decreasing in size. Right lower extremity vein harvest site Steri-Strips are intact. There is no erythema or drainage. Sternal incision: The upper portion, Steri-Strips are intact, lower portion has Dermabond. There is no erythema or drainage. The sternum is intact. DISCHARGE MEDICATIONS: 1. Lasix 40 mg po bid x10 days. 2. Potassium chloride 10 mEq po bid x10 days. 3. Colace 100 mg po bid. 4. Zantac 150 mg po bid. 5. Enteric coated aspirin 81 mg po q day. 6. Dulcolax suppositories prn. 7. Amiodarone 400 mg po bid x7 days, then amiodarone 400 mg po q day. 8. Albuterol MDI two puffs q4h prn. 9. Atorvastatin 40 mg po q day. 10. Ambien 5 mg po q hs prn. 11. Atenolol 50 mg po q day. 12. Coumadin 3 mg po on [**6-23**] and INR is to be checked on [**6-24**], and Coumadin dose to be adjusted for a goal INR of 2.0. DISCHARGE DIAGNOSES: 1. Coronary artery disease. 2. Unstable angina. 3. Status post coronary artery bypass graft x3. 4. Status post aortic valve replacement. 5. Hypertension. 6. Hypercholesterolemia. 7. Postoperative atrial fibrillation. 8. Claudication. 9. Postoperative sternal drainage now resolved. DISCHARGE STATUS: The patient is to be discharged to rehab in stable condition. FOLLOW-UP INSTRUCTIONS: The patient is to followup with Dr. [**Last Name (STitle) 70**] in [**4-27**] weeks. The patient is to followup with his primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] upon discharge from rehabilitation. The patient is to followup with Dr. [**Last Name (STitle) **] in [**4-27**] weeks. [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 75**] Dictated By:[**Last Name (NamePattern1) 16172**] MEDQUIST36 D: [**2190-6-23**] 10:08 T: [**2190-6-23**] 10:08 JOB#: [**Job Number 101627**]

[ "997.1", "414.01", "997.5", "427.31", "788.29", "276.2", "411.1", "424.1", "429.9" ]

icd9cm

[ [ [] ] ]

[ "36.15", "96.04", "37.64", "88.56", "37.61", "39.61", "36.12", "96.71", "35.21", "37.22" ]

icd9pcs

[ [ [] ] ]

8394, 8759

7844, 8373

1209, 6576

1028, 1191

177, 682

8784, 9416

704, 1002

6601, 7821

18,846

184,906

6078

Discharge summary

report

Admission Date: [**2137-2-9**] Discharge Date: [**2137-2-13**] Date of Birth: [**2074-2-1**] Sex: F Service: MEDICINE Allergies: Penicillins / Ceftriaxone Attending:[**First Name3 (LF) 348**] Chief Complaint: sinus tachycardia, hypotension at dialysis Major Surgical or Invasive Procedure: dialysis History of Present Illness: Ms. [**Known lastname **] is a 63yoF living at [**Hospital3 2558**] with multiple medical problems (including DM, HTN, diastolic CHF, hyperlipidemia, pulm HTN, ESRD on HD, h/o AV graft infections, morbid obesity, lower extremity DVT, b/l IJ vein thromboses, and OSA). She was at her regularly scheduled HD session this morning when she was noted to be tachycardic to the 140's several hours into treatment. She has remained asymptomatic during tx aside from diaphoresis initially; she denies CP, palpitations, N/V, anorexia, emesis, SOB, abd pain, HS, fever and diaphroesis currently. . Of note, her baseline SBP is 100-10's. On presentation to the ED, VS were T 98.9, BP 114/65, HR 142, RR 16, 100% on 2LNC. She received lopressor 25 mg PO x 1 and lopressor 5 mg IV x 2 in the ED, and then dropped her SBP to 80-90's. She then got 2L NS which improved SBp to 90-100's but only brought her HR down to 120-130's. Past Medical History: PAST MEDICAL HISTORY: - hemorrhagic pericardial effusion - Bilateral internal jugular thromboses, restarted on coumadin [**8-24**] - h/o bilateral lower extremity DVT's - ESRD on HD T, Th, Sat - IDDM - Diastolic heart failure - Pulmonary hypertension - Hypercholesterolemia - OSA, noncompliant with CPAP as outpatient - OA - h/o C. Diff - GERD - Depression - Morbid obesity - Fibroid uterus; vaginal bleeding - h/o Osteomyelitis at the T9 Vertebrae [**5-24**]; tx with Vanc - h/o Multiple line infections **[**2135-12-17**]: Providencia, treated with 4 wk course of aztreonam **[**2135-4-17**]: Staph coag positive, sensitive to both vancomycin and gentamicin **[**2136-5-17**]: Staph bacteremia tx with vanc x 6 weeks **[**2136-8-17**]: Proteius mirabilis and MSSA, treated with ceftaz and vanc . PAST SURGICAL HISTORY: - L forearm radial-basilic AV graft, s/p infection, thrombosis and abandonment ([**12-21**]) - Multiple lines in L upper arm with AV graft - 1/07 L femoral PermaCath placed - L upper arm thrombectomy, revision, of LUE AV graft ([**3-23**]) - [**4-23**] Excision of left upper arm infected AV graft; associated MRSA bacteremia treated with 6 weeks vancomycin. - Right upper extremity AV fistula creation [**10-23**] s/p revision - [**2135-12-14**] Right AV fistula repair, Right IJ PermaCath rewiring and IVC filter removed Social History: Patient denies a tobacco, alcohol or illicit drug use. She lives in a nursing home (?[**Hospital3 2558**]). She is separated from her husband. She has 5 children in [**Location (un) 86**] [**Doctor Last Name **] area. Family History: Not obtained. Physical Exam: VS:: Afebrile, normotensive (patient is normally 95-110 systolic), satting well on 2L NC General: calm, obese, friendly; no teeth; left HD line Lungs: CTA B/L Cardio: distnt soft HS, RRR, No M/R/G Abd: + BS, soft, obese, no HSM Extremities: trace to 1+ LE edema. Neuro: AA, Ox3, CN II - XII in tact, moving all limbs, gait deferred Pertinent Results: [**2137-2-9**] 12:20PM BLOOD WBC-6.1 RBC-3.18* Hgb-10.9* Hct-33.7* MCV-106* MCH-34.4* MCHC-32.4 RDW-15.5 Plt Ct-353 [**2137-2-13**] 05:30AM BLOOD WBC-6.4 RBC-2.90* Hgb-10.0* Hct-30.6* MCV-106* MCH-34.5* MCHC-32.7 RDW-16.0* Plt Ct-303 [**2137-2-9**] 12:20PM BLOOD Glucose-106* UreaN-29* Creat-4.0*# Na-140 K-4.1 Cl-99 HCO3-30 AnGap-15 [**2137-2-13**] 05:30AM BLOOD Glucose-151* UreaN-35* Creat-5.0*# Na-136 K-4.5 Cl-97 HCO3-28 AnGap-16 [**2137-2-9**] 12:20PM BLOOD Albumin-4.5 Calcium-8.1* Phos-2.3*# Mg-1.8 [**2137-2-12**] 06:10AM BLOOD Calcium-7.4* Phos-5.2* Mg-2.2 CTA: CTA CHEST: Overall, evaluation is limited by patient respiratory motion with particular limitation of segmental and subsegmental branches to the lower lobes bilaterally. Allowing for this, no central pulmonary embolism is seen. Atherosclerotic calcifications involve the aortic arch and its branches, though they are of normal caliber. Cardiomegaly persists without evidence for pericardial or pleural effusion. Atherosclerotic coronary calcification is again observed. Scattered prominent mediastinal nodes are noted, the largest paratracheal node measuring up to 10 mm in short axis, smaller compared to [**2136-9-17**] when it measured up to 13 mm. Calcifications in the left thyroid are again partially imaged. Lung windows reveal mild hypoventilatory changes at the lung bases bilaterally. An approximately 6-mm ground-glass nodule in the left upper lobe (3:32) is not seen on the prior study. A 4 mm nodule is in the right lower lobe (3:52). Although this study is not tailored to evaluate abdominal organs, limited evaluation of the upper abdomen reveals tiny nonobstructing renal calculi, measuring up to 4 mm. The surrounding osseous structures demonstrate multilevel thoracolumbar spondylosis. Endplate erosion and sclerotic change at T9/10 again may represent sequelae of prior infection, unchanged. IMPRESSION: 1. Limited evaluation without evidence for central pulmonary embolism. 2. Small nodules in the lower lobes bilaterally. If there is history of malignancy or risk factors for malignancy, follow-up in 6 months is recommended. Without such history, follow-up in one year is advised. The study and the report were reviewed by the staff radiologist. CXR: IMPRESSION: No acute cardiopulmonary process or signs of CHF. ECG: Probable sinus tachycardia. Left anterior fascicular block. Poor R wave progression. Non-specific ST-T wave changes. Compared to the previous tracing of [**2136-10-5**] sinus tachycardia is new. Brief Hospital Course: 63 yoF with MMP on HD, p/w SVT to the 140's during HD today in the setting of reportedly 5-6L removal. . #. TACHYCARDIA: Occured while on dialysis in the setting of fluid removal. Now controlled on oral medications. [**Month (only) 116**] have been initiated by volume removal, however likely has an abberant atrial focus for her tachydardia. Not a candidate for ablation per EP. Her heart rate was controlled witdiltieazem and lopressor. She has baseline low blood pressures but remained stable. She was anticoagulated with coumadin. Her INR was 3.8 on day of discharge and was held. Her INR should checked the next day and pending those results her coumadin should be restarted at an appropriate dose. . #. H/O THORMBOSES, ANTICOAGULATION: Multiple venous thrombosis. Coumadin was continued. Goal INR of [**2-19**]. . #. ESRD, [**2-18**] DM: on HD T-Th-Sat. HD was continued in house with no futher episodes of tachycardia. Less fluid was taken off overall with HD as it was thought that may have instigated her tachcardia. She may require a longer dialysis time to take off fluid. Her renal medications were continued and she recieved bactrim and epo with dialysis. . #. DEPRESSION: Her paxil was continued. . #. GERD: Her protonix was continued. . #. CARDIAC DISEASE: ASA 81 mg QD . #. DM: NPH 20 units QAM + SSI . #. FEN: renal diet; con folic acid, B12, Vit C, zinc . #. PPX: - PO PPI - systemmic antocoaglulation with coumadin (see above) - bowel regimen with senna, colace . #. ACCESS: PIV, left tunneled HD catheter . #. COMMUNICATION: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 15532**] [**Telephone/Fax (1) 23831**] Medications on Admission: Tylenol PRN Albuterol Q6 INH PRN Vit C 500 mg [**Hospital1 **] ASA 81 mg QD Vit B complex Bactrim DS on HD days; take two before HD, two 6 hours after HD Bisacodyl 10 mg PR QD Senna Colace Epo QHD 10,000 units folic acid NPH insulin 20 mg QAM Lactulose ? MOM PRN [**Name (NI) 23842**] 10 mg PO QID PRN nausea Metoprolol 37.5 mg [**Hospital1 **] (12.5 mg [**Hospital1 **] per EP note from [**10-24**]) Midodrine 10 mg TID Protonix 40 mg QD Paxil 20 mg QD Sevelamer 1600 mg TID Simvastatin 10 mg QD Warfarin 5 mg QD Zinc 220 mg Discharge Medications: 1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 3. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) Puff Inhalation Q6H (every 6 hours) as needed for wheezing, SOB. 4. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 5. B Complex Vitamins Capsule Sig: One (1) Cap PO DAILY (Daily). 6. Warfarin 2 mg Tablet Sig: One (1) Tablet PO once a day. 7. Zinc Sulfate 220 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 8. Sevelamer HCl 400 mg Tablet Sig: Four (4) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 9. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QID (4 times a day) as needed for nausea. 11. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 12. Paroxetine HCl 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain, HA. 15. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 16. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO TID (3 times a day). 17. Diltiazem HCl 30 mg Tablet Sig: One (1) Tablet PO QID (4 times a day). 18. Benadryl 25 mg Capsule Sig: One (1) Capsule PO at bedtime as needed for cold symptoms. 19. Insulin NPH Human Recomb 100 unit/mL Cartridge Sig: Twenty (20) Subcutaneous once a day: in AM. 20. Insulin Sliding scale Unchanged from before Discharge Disposition: Extended Care Facility: [**Hospital3 2558**] - [**Location (un) **] Discharge Diagnosis: Atrial fibrillation with rapid ventricular responce end stage renal disease on HD Discharge Condition: Stable, regular rate Discharge Instructions: You were admitted to the hospital because of a fast heart rate at dialysis. You initially went to an intensive care unit where you recieved medications to slow your heart down. After a few days your heart rate came down and you were stable for a medical floor. On the medical floor your heart rate was watched and you did not go into your fast heart rate. Your dialysis was continued in the hospital. You were also having some congestion and a mild cough consistent with a common cold. Take tylenol and benadryl as needed for your cold symptoms. Medicatio changes: Lopressor 12.5mg twice a day Diltiezem 30mg four times a day Tylenol as needed for cold symptoms Benadryl 25mg at night for cold symptoms Please return to the hospital or call your doctor if you have temperature greater than 101, shortness of breath, worsening difficulty with swallowing, chest pain, abdominal pain, diarrhea, or any other symptoms that you are concerned about. Followup Instructions: Dialysis as scheduled. PCP [**Last Name (NamePattern4) **] [**1-18**] weeks for post hospital follow up.

[ "V58.61", "428.30", "530.81", "428.0", "585.6", "416.0", "V12.51", "427.31", "250.40", "403.91", "311", "427.89" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

9782, 9852

5819, 7480

326, 337

9978, 10001

3283, 5796

11002, 11110

2900, 2915

8058, 9759

9873, 9957

7506, 8035

10025, 10979

2122, 2647

2930, 3264

244, 288

365, 1279

1323, 2099

2663, 2884

55,920

158,021

52866+59477

Discharge summary

report+addendum

Admission Date: [**2182-9-30**] Discharge Date: [**2182-10-12**] Date of Birth: [**2121-3-14**] Sex: M Service: MEDICINE Allergies: Vancomycin Analogues / Histamine / Ciprofloxacin / Penicillins / Cephalosporins / Atorvastatin / Rosuvastatin / morphine / Sulfa (Sulfonamide Antibiotics) Attending:[**First Name3 (LF) 4327**] Chief Complaint: Altered Mental Status Chest Pain / Shortness of Breath Major Surgical or Invasive Procedure: [**2182-9-30**]: Intubation [**2182-9-30**]: Placement of left internal jugular central line [**2182-9-30**]: Placement of right radial arterial line [**2182-10-2**]: Right heart catheterization, with placement of PA catheter [**2182-10-3**]: Transesophageal Echocardiogram [**2182-10-4**]: Direct Current Cardioversion [**2182-10-5**]: Extubated History of Present Illness: Mr. [**Known lastname 26818**] is a 61 year old gentleman, with a PMH of CAD and severe MR s/p CABG (LIMA-LAD, SVG-AM and dRCA) and MV repair [**8-/2182**], dilated cardiomyopathy with sCHF EF 25-30% post-CABG/MVR, severe pulmonary hypertension on sildenafil and CKD (recent baseline Cr 1.6-1.9), transferred from an OSH to [**Hospital1 18**] on [**9-30**] for CP, SOB, AMS. Intubated patient unable to provide history. On review of transfer records, patient noted to present with CP, SOB, AMS. Family had noted that the patient was increasingly altered over the past several days to the point where he was found to be "delirious, unable to do anything." At the outside hospital, patient was afebrile, tachycardic at 108, had CXR showing mild cariomegaly, CT head without acute infarct, leukocytosis to 11.7, Cr 2.5. Trop I 0.062 (uln 0.045), UA clear and dig level 0.1. He was then trasnferred to [**Hospital1 18**]. . In arrival to [**Hospital1 18**], he was be febrile to 102, hypoxic to 90% on RA and noted to have bilateral upper extremity asterixis. Labs were notable for WBC 20, Cr 3.4, K 6.4, AST/ALT in the 1000s, TBili 2.4, Trp 0.21, UA w/tr leuks, [**10-24**] WBC, mod bacteria, S/UTox neg for Tyleonol and pos for opiate. CXR showed LLL effusion vs. PNA. EKG: WC tach, RAD, RBBB, STE in III, felt to be consistent with prior. Concern for infection prompted CT Chest & Abd & hepatic US (below) and patient was empirically treated for ?HCAP vs cholangitis with meropenem and linezolid (multiple allergies) and admitted to MICU Green. . On presentation to MICU he was hypotensive to 66/53, unresponsive to three fluid boluses, and was started on norepinephrine, dopamine, dobutamine and vasopressin. He was emergently intubated for hypoxia. Left IJ and a-line were placed. He was started on meropenem and continued on norepinephrine. Cardiology fellow was consulted by MICU over concern for cardiogenic [**Month/Year (2) **] or complication following CABG/MVR and performed a bedside echocardiogram, showing severe biventricular function with worsened EF (to 10% from 30%); no pericardial effusion, no MR, no AR, no ASD, no VSD, no free wall rupture. Serial labs have shown worsening [**Last Name (un) **] (Cr 4.2), LFTs in the 6000-7000s, K 5.8 (s/p kayexalate) and WBC 18.5 (which peaked at 26.6). The patient continued treatment with IVF out of concern for septic [**Last Name (un) **], and was able to be weaned off of vasopressin and dopamine; doses of dobutamine and norepinephrine were reduced. Infectious source yet to be identified. Surgery was consulted out of concern for cholecystitis, and a HIDA scan was recommended. . The patient's MVO2 trended 27->58->75->79 and his lactate trended down from 9->5->2.2. He was noted to have low UOP that did not respond to Lasix challenge. CCU Fellow was consulted to determine whether Swan Ganz placement would be required to evaluate for cardiogenic [**Last Name (un) **]. She believed that biventricular hypokinesis were more consistent with [**Last Name (un) **] than ischemia, possibly triggered by infection. A right heart cath is planned to investigate cause of right heart failure and do a trial of milrinone, on which the patient could continue treatment following hospitalization. . On arrival to the CCU, the patient was intubated and dysynchronous with the vent. He had a cough reflex, but did not respond to voice, follow commands or respond to pain. His initial vital signs were 99.5 93/56 120afib 100% on CMV/assist. . ROS: unable to perform secondary to inutbation/sedation Past Medical History: PAST MEDICAL HISTORY (per OMR) 1. CARDIAC RISK FACTORS: (+)Diabetes, (+)Dyslipidemia, (+)Hypertension 2. CARDIAC HISTORY: - Afib s/p failed cardioversion on coumadin and amiodarone - Dilated cardiomyopathy, non-ischemic - CAD s/p CABG [**8-/2182**] - CHF (EF 25-35%) - PFO 3. OTHER PAST MEDICAL HISTORY: - severe pulmonary hypertension on sidafenil - CKD with baseline Cr - CVA in [**2175**]--L sided facial droop - Osteoarthritis. - Depression. - Hx of Hodgkin's disease s/p surgical excision and CTX at age 18 . PAST SURGICAL HISTORY: 1. Appendectomy. 2. Hernia repair. 3. Back surgery after falling from 36 feet. 4. Multiple operations on his left knee and his right knee. 5. Multiple abdominal surgeries, first to remove small bowel polyps and then followed by surgeries to fix complications of previous surgeries. 6. Lymph node removal from the groin that was infected Social History: Unable to obtain [**2-6**] patient being intubated. As per prior OMR notes: He lives with his sister and her family. States there is always someone home. He has 3 children, including a 6 yr old son who live in [**Name (NI) **]. He used to be an avid athlete, running > 12 miles daily but due to progressive heart failure, develops symptoms of fatigue/dyspnea with minimal exertion denies current tobacco, ETOH, IVDA. Family History: Unable to obtain [**2-6**] patient being intubated. As per prior EMR notes: Father had 1st heart attack at 35 then died of MI at 45. Mom with DM2, died of AAA rupture Physical Exam: Admission physical exam: VS: 99.5 93/56 120afib 100% on CMV/assist LOS fluid balance: +8L GEN: Intubated, sedated NECK: JVP to angle of jaw with patient at 30 degrees CV: Well-healed scar. Tachycardic, irregularly irregular, no murmurs appreciated. PULM: CTAB anteriorly, no rales, rhochi, or wheeze ABD: Multiple abdominal scar. Non-distended, hypoactive bowel sounds EXT: Trace right pedal edema, 2+ pitting left pedal edema. NEURO: sedated, opens eyes with gag reflex, has cough reflex, does not respond to painful stimuli, moves feet periodically . Discharge physical exam: Vitals: Tm/Tc 98.5 BP 101/71 (99-116/68-87) HR 71 (70-72) RR 18 SaO2 90% RA In/Out: 1400/2775 (net balance -1.375 L) Weight: 87.6 kg (87.8 kg) Tele: HR 70-74, few PVCs FS: well controlled in the 100s GENERAL: NAD, lying in bed, pleasant and relaxed HEENT: MMM, anicteric sclerae NECK: C/D/I dressing over left IJ, no hematoma, JVP 8 cm CHEST: [**Month (only) **] BS left base, faint crackles right base CV: fixed split S2, RRR, No MRG ABD: soft, ND/NT, normoactive BS EXT: WWP, 2+ pitting edema in legs bilaterally to knees, 2+ edema in right forearm with extensive firm ecchymosis Pertinent Results: Admission labs: [**2182-9-30**] 10:00AM BLOOD WBC-19.7*# RBC-4.38* Hgb-12.4* Hct-37.5* MCV-86 MCH-28.4 MCHC-33.2 RDW-17.8* Plt Ct-272 [**2182-9-30**] 10:00AM BLOOD Neuts-91* Bands-1 Lymphs-3* Monos-5 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 [**2182-9-30**] 10:00AM BLOOD Hypochr-NORMAL Anisocy-2+ Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-1+ Ellipto-1+ [**2182-9-30**] 10:00AM BLOOD PT-22.0* PTT-38.2* INR(PT)-2.0* [**2182-10-2**] 03:25AM BLOOD Fibrino-272 [**2182-10-2**] 04:23AM BLOOD FDP-40-80* [**2182-9-30**] 10:00AM BLOOD Glucose-78 UreaN-57* Creat-2.9*# Na-136 K-5.2* Cl-92* HCO3-25 AnGap-24* [**2182-9-30**] 10:00AM BLOOD ALT-1404* AST-1379* AlkPhos-317* TotBili-2.4* DirBili-1.5* IndBili-0.9 [**2182-9-30**] 05:45PM BLOOD ALT-2437* AST-3049* CK(CPK)-167 AlkPhos-302* TotBili-3.6* [**2182-10-1**] 03:10AM BLOOD ALT-5125* AST-7025* LD(LDH)-6650* AlkPhos-294* TotBili-3.7* [**2182-10-1**] 04:07PM BLOOD ALT-6615* AST-7704* AlkPhos-272* TotBili-2.0* [**2182-9-30**] 10:00AM BLOOD cTropnT-0.21* [**2182-9-30**] 05:45PM BLOOD CK-MB-10 MB Indx-6.0 [**2182-9-30**] 05:45PM BLOOD cTropnT-0.24* [**2182-10-1**] 03:10AM BLOOD CK-MB-8 cTropnT-0.26* [**2182-9-30**] 10:00AM BLOOD TotProt-6.5 Calcium-9.5 Phos-4.8* Mg-2.9* [**2182-9-30**] 05:45PM BLOOD Digoxin-<0.2* [**2182-9-30**] 10:00AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2182-9-30**] 10:13AM BLOOD Lactate-5.1* [**2182-9-30**] 05:57PM BLOOD Lactate-9.2* [**2182-10-1**] 12:21PM BLOOD Lactate-5.1* [**2182-10-2**] 03:11PM BLOOD Lactate-2.4* [**2182-10-2**] 05:49PM BLOOD Lactate-1.8 . Pertinent labs: [**2182-10-2**] 03:25AM BLOOD HBsAg neg, HBsAb neg, HAV IgM neg, HCV Ab neg [**2182-10-7**] 00:00AM BLOOD heparin depedent antibodies negative . Discharge labs: [**2182-10-12**] 07:30AM BLOOD WBC 6.1, HGB 9.6, HCT 28.5, MCV 84, PLT 71 [**2182-10-12**] 07:30AM BLOOD GLUC 90, BUN 37, CR 1.7, NA 140, K 3.6, CL 101, HCO3 30 [**2182-10-12**] 07:30AM BLOOD CA 8.8, PHOS 2.8, MAG 2.1 [**2182-10-12**] 07:30AM BLOOD TBILI 1.6, DBILI 0.9, IND BILI 0.7 . EKGs: [**2182-9-30**] EKG: The rhythm is likely atrial fibrillation with rapid ventricular response. Right bundle-branch block. Diffuse ST-T wave changes suggestive of myocardial ischemia. Cannot exclude hyperkalemia. Compared to the previous tracing of [**2182-9-4**] ventricular premature beats are no longer seen. [**2182-10-3**] EKG: Atrial flutter with rapid ventricular response. Right bundle-branch block. Left posterior hemiblock. [**2182-10-4**] EKG: Supraventricular tachycardia, possibly sinus or atrial flutter with right bundle-branch block. Right axis deviation. [**2182-10-4**] EKG: Normal sinus rhythm. Prolonged A-V conduction. Right bundle-branch block. Abnormal axis. A ventricular premature beat is seen. Since the previous tracing sinus rhythm has resumed. There are presently diffuse ST-T wave changes which are compatible with right ventricular dilatation and left ventricular hypertrophy. [**2182-10-5**] EKG: Sinus rhythm. Marked right axis deviation. Right bundle branch block. Prolonged A-V conduction. Probable left ventricular hypertrophy. Fragmented QRS complexes in the inferior leads. Consider some scarring in the inferior wall. [**2182-10-7**] EKG: Sinus rhythm with first degree A-V delay. Right bundle-branch block. Low QRS voltage in the limb leads. Indeterminate QRS axis. Compared to the previous tracing of [**2182-10-5**] the findings are similar. . Imaging: Bedside TTE [**2182-9-30**]: The left ventricle is moderately dilated. Overall left ventricular systolic function is severely depressed (estimated LVEF approximately 15-20 %?) with inferior/ inferolateral and hypokinesis elsewhere. Right ventricular chamber size is normal with moderate global free wall hypokinesis. Mild (1+) aortic regurgitation is seen. A mitral valve annuloplasty ring is present and appears well-seated. Mild (1+) mitral regurgitation is seen (but not fully visualized; may be mild to moderate). Tricuspid regurgitation is present but cannot be quantified. There is a trivial/physiologic pericardial effusion. Compared with the prior study (images reviewed) of [**2182-8-29**], mitral regurgitation is now much less prominent and left ventricular systolic function is now more depressed. Right ventricular systolic function is now also depressed. . CT C/A/P [**2182-9-30**] 1. Small to moderate bilateral pleural effusions left greater than right with ground-glass opacification of the left lower lobe may represent developing pneumonia. 2. No evidence of colitis to suggest bowel ischemia. 3. Hyperdense material in gallbladder may represent stones, sludge, or secondary excretion of IV contrast although unlikely since none given here. 4. Small amount of free fluid around the liver and in the right paracolic gutter. 5. Sigmoid diverticulosis without diverticulitis. . Liver US [**2182-9-30**] 1. Findings equivocal for acute cholecystitis given lack of gallbladder distention and no gallstones (although neck of GB not assessed). [**Doctor Last Name 515**] sign could not be assessed. Thickened gallbladder wall may be related to CHF. 2. Perihepatic ascites. 3. Patent main portal vein with increased phasicity suggests cardiac dysfunction. . CXR [**2182-10-1**]: In comparison with the study of [**9-30**], there is little interval change. Monitoring and support devices remain in place. Enlargement of the cardiac silhouette persists with low lung volumes. Pulmonary vascularity now appears to be essentially within normal limits. Retrocardiac opacification is consistent with volume loss in the left lower lobe and pleural effusion. The right lung is essentially clear. . LLE U/S [**2182-10-1**]: The right and left common femoral veins, left greater saphenous vein, superficial femoral vein, popliteal vein and calf veins are patent with normal compressibility. The common femoral, superficial femoral and popliteal veins demonstrate appropriate wall-to-wall color flow and waveforms with appropriate response to augmentation. IMPRESSION: No left lower extremity DVT. . TTE [**2182-10-1**]: The left atrium is mildly dilated. Left ventricular wall thicknesses are normal. The left ventricular cavity is moderately dilated. Overall left ventricular systolic function is severely depressed (LVEF= 15-20 %) with inferior/inferolateral akinesis and hypokinesis elsewhere. The right ventricular cavity is mildly dilated with moderate global free wall hypokinesis. There is abnormal septal motion/position consistent with right ventricular pressure/volume overload. The aortic root is mildly dilated at the sinus level. The aortic valve leaflets (3) are mildly thickened. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. A mitral valve annuloplasty ring is present and appears well seated with mild inflow gradient. Mild (1+) mitral regurgitation is seen (may be underestimated due to shadowing) . The tricuspid valve leaflets are mildly thickened. There is a trivial/physiologic pericardial effusion. . Right Heart Cardiac Catheterization [**2182-10-2**]: 1) Resting hemodynamics revealed elevated right and left-sided filling pressures with an RVEDP of 15mmHg and a mean PCW of 24mmHg. There was moderate pulmonary hypertension with a mean PAP 35mmHg and a calculated PVR 213 dynes/sec/cm5. There was preserved CO/CI (6.7/1.3) on dobutamine and norepinephrine therapy. 2) Successful placement of 5F sheath in right brachial vein. 5F PAC left in PA for tailored therapy in the CCU. FINAL DIAGNOSIS: 1. Preserved CO/CI on dobutamine (8mcg/kg/min) and levophed(0.2mcg/kg/min). 2. Moderately elevated L-sided filling pressures. 3. Moderate pulmonary HTN. 4. Findings discussed with Dr. [**First Name (STitle) 437**]. . Transesophageal Echocardiogram [**2182-10-3**]: No spontaneous echo contrast is seen in the body of the left atrium. No spontaneous echo contrast is seen in the body of the right atrium or right atrial appendage. No mass or thrombus is seen in the right atrium or right atrial appendage. The right atrial appendage ejection velocity is depressed (<0.2m/s). No atrial septal defect is seen by 2D or color Doppler. There is severe global left ventricular hypokinesis (LVEF = 20 %). There are simple atheroma in the descending thoracic aorta to 45 cm from the incisors. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No masses or vegetations are seen on the aortic valve. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. A mitral valve annuloplasty ring is present. No mass or vegetation is seen on the mitral valve. Trivial mitral regurgitation is seen. No vegetation/mass is seen on the pulmonic valve. There is no pericardial effusion. IMPRESSION: Mild spontaneous echo contrast is seen in the body of the left atrial appendage. No mass/thrombus is seen in the left atrium or left atrial appendage. No spontaneous echo contrast is seen in the body of the right atrium or right atrial appendage. No mass or thrombus is seen in the right atrium or right atrial appendage. No intracardiac evidence of valvular vegetations or abscesses. Severe global left ventricular hypokinesis. Simple atheroma in the descending aorta. Compared with the findings of the prior study of [**2182-9-2**], mild mitral and aortic regurgitation are no longer appreciated. . [**2182-10-5**] AP Portable Chest x-ray: The ET tube tip is 5.6 cm above the carina. The NG tube tip is not currently seen, most likely in the stomach. The Swan-Ganz catheter tip is at the right ventricle outflow tract/main pulmonary artery. Left internal jugular line tip is at the mid SVC. The replaced mitral valve is unchanged. There is no change in the cardiomegaly. Left retrocardiac consolidation is unchanged. Mild interstitial pulmonary edema has progressed in the interim, associated with bilateral pleural effusions. No pneumothorax is seen. . Transthoracic Echocardiogram [**2182-10-7**]: The left atrium is elongated. Left ventricular wall thicknesses are normal. The left ventricular cavity is moderately dilated with moderate global hypokinesis (LVEF = 30 %). Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). The right ventricular cavity is mildly dilated with moderate global free wall hypokinesis. The aortic root is mildly dilated at the sinus level. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are structurally normal. A mitral valve annuloplasty ring is present. The mitral annular ring appears well seated with normal gradient. Mild (1+) mitral regurgitation is seen. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Left ventricular cavity dilation with global hypokinesis. Mild aortic regurgitation. Mild mitral regurgitation. Pulmonary artery systolic hypertension. Dilated aortic root. Compared with the prior study (images reviewed) of [**2182-10-1**], the findings are similar. . Right upper extremity ultrasound [**2182-10-7**]: Superficial vein thrombus in the right cephalic vein, extending to the junction of the subclavian vein but without propagation into the subclavian vein. Brief Hospital Course: 61M with hx DM, CKD, sCHF with EF of 25-30%, CAD s/p CABG x3 and MV annuloplasty on [**9-2**] who presented in cardiogenic [**Month/Year (2) **], most likely triggered by atrial tachycardia, complicated by acute respiratory failure, acute kidney injury, congestive hepatopathy, thrombocytopenia and right upper extremity superficial thrombophlebitis. . . ACTIVE ISSUES # Severe [**Month/Year (2) **]: The patient's initial presentation was consistent with cardiogenic [**Month/Year (2) **], with biventricular dysfunction and low EF demonstrated on Echocardiogram. He has baseline biventricular dysfunction, that was likely exacerbated by atrial tachycardia. Additionally, a systemic infection may have also stressed his heart and contributed to worsened cardiac function. On presentation, he also had signs of end-organ dysfunction with elevated creatinine and elevated liver enzymes, which could have been secondary to congestive hepatopathy or [**Month/Year (2) **] liver. He initially required pressors (dobutamine and norephinephrine), but was weaned off. He was also treated with a 7-day course of empiric broad spectrum antibiotics. After a right heart cath for evaluation, a PA catheter was placed for adequate monitoring of intracardiac pressures. The patient was direct-current cardioverted on [**10-5**]. He subsequently remained in sinus rhythm with improved hemodynamics and improved end-organ function. Since his response to cardioversion was so vigorous, it was postulated that his atrial tachycardia was the underlying trigger of this acute episode. For prevention of further episodes, the patient will undergo EP mapping with ablation in the next month. . # Atrial tachycardia: The patient was initially tachycardic, with rhythms of atrial fibrillation and atrial tachycardia with 2:1 conduction. He was successfully direct-current cardioverted and remained in normal sinus rhythm thereafter. Arrhythmia is likely secondary to myocardial fibrosis secondary to his long history of heart disease. He will undergo EP mapping with ablation for prevention of arrhythmias. . # Acute respiratory failure: Patient initially presented with dyspnea and was desaturating to the 70%s on non-breather. He was intubated for airway protection and adequate oxygenation, but extubated on HOD6, without further issues. . # Acute on Chronic Kidney Injury: Baseline creatinine ranging 1.3-1.9; the patient presented with elevated to 2.4 and FeUrea 22.72%, suggestive of prerenal azotemia likely secondary to poor forward flow. This fit his overall picture of severe [**Month/Day (4) **] with cardiogenic etiology. His renal function improved to baseline following use of pressors, IV fluids and cardioversion. . # Acute Liver Injury: LFTs were all elevated on arrival, with peak of transaminases in the 6000s-7000s and total bilirubin in the 4's. This was most likely secondary to congestive hepatopathy, given high right-sided heart pressures and the time-course of the elevation. Differential also included [**Month/Day (4) **] liver, though time-course was not as consistent with [**Month/Day (4) **]. The patient's elevation in LFTs began to resolve with improved hemodynamics. His statin during this admission, secondary to increased LFTs. It was not restarted. . # Thrombocytopenia: Patient developed thrombocytopenia to a nadir of 66 on this admission. It was attributed to medication effect after treatment with linezolid and pantoprazole. HIT was less likely due to a negative PF4 antibody, and DIC less likely based on a negative DIC panel. The patient's platelets were monitored closely. However, his platelet count was stable at this time of discharge. . # RUE superficial thrombophlebitis: After removal of his PA catheter, the patient developed right forearm swelling and pain, which was demonstrated to be a cephalic vein thrombosis on ultrasound. He was treated with warm compresses and elevation. His pain was controlled with Tylenol and oxycodone. . CHRONIC ISSUES # CAD s/p CABG and MVR: Stable, patient not requiring further cardiac surgery at this point. He was continued on aspirin. After his blood pressures improved, he was restarted on his beta blocker and ACE inhibitor. After his LFTs improved, he was restarted on his statin. . . TRANSITIONAL ISSUES 1.) Emergency contact: son [**Name (NI) **], [**Telephone/Fax (1) 109020**] or [**Telephone/Fax (1) 109021**] 2.) Code: Full 3.) Will need at least one-month course of warfarin s/p cardioversion. Longer duration of therapy may be decided upon by patient's outpatient providers. Goal INR will be [**2-7**]. 4.) Patient will have [**Doctor Last Name **] of Hearts monitor with transmission on M/W/F. 5.) Will need CBC, INR and BMP checked two days after discharge. 6.) Will need CBC rechecked one week after discharge. 7.) Restart statin as an outpatient, after liver enzymes have decreased to normal range. Medications on Admission: Torsemide 80mg daily Lantus 20 units qHS Humalog SSI TID up to 60 units Simvastatin 20mg daily Digoxin 0.125mg QOD (last refilled in [**Month (only) 205**]) Potassium 20 mEq daily Amiodarone 200mg daily Metoprolol 50mg daily Revatio 20 mg PO TID Lisinopril 2.5 mg PO daily Discharge Medications: 1. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 2. sildenafil 20 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:*90 Tablet(s)* Refills:*0* 3. warfarin 1 mg Tablet Sig: Three (3) Tablet PO Once Daily at 4 PM. 4. torsemide 100 mg Tablet Sig: One (1) Tablet PO once a day: Please check daily weights and call on-call doctor if weight increases 0.5 kg in 24-hour period or length of stay weight increases 1 kg from admission weight. 5. insulin glargine 100 unit/mL Solution Sig: Twenty (20) units Subcutaneous at bedtime. 6. Humalog 100 unit/mL Solution Sig: One (1) unit Subcutaneous four times a day: per sliding scale based on QACHS fingersticks, up to 60 units per day. 7. lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO once a day: hold for SBP < 90. Tablet(s) 8. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO once a day: hold for SBP < 90. Tablet Extended Release 24 hr(s) 9. ondansetron HCl (PF) 4 mg/2 mL Solution Sig: One (1) Injection Q8H (every 8 hours) as needed for nausea. 10. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain. 11. acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO q8 hours PRN as needed for pain. 12. ondansetron 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO Q8H (every 8 hours) as needed for nausea. 13. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 14. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID PRN as needed for constipation. 15. clotrimazole 1 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day). 16. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Discharge Disposition: Extended Care Facility: Newbridge on the [**Doctor Last Name **] - [**Location (un) 1411**] Discharge Diagnosis: Primary diagnoses: Cardiogenic [**Location (un) **] Atrial tachycardia Cephalic vein thrombosis . Secondary diagnoses: Systolic heart failure (chronic, EF 30%) Thrombocytopenia Obstructive sleep apnea Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Mr. [**Known lastname 26818**], It was a pleasure to participate in your care here at [**Hospital1 1535**]. You were admitted with shortness of breath, chest pain and altered mental status, which had been caused by decreased pumping function of your heart. We thought that this decrease in pumping function was due to a fast heart rate. After you were switched out of this fast heart rate by direct current cardioversion on [**10-5**], your pumping function and circulation improved. Additionally, you were found to have a blood clot in a superficial vein in your right arm, which was treated with warm compresses and elevation. In order to continue evaluation of your heart rhythm after discharge, you will be monitored on telemetry at your rehabilitation facility. After you leave the rehabilitation facility, you will be wearing [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] of Hearts heart monitor. In about one month's time, you will be undergoing an electrophysiology study with possible cauterization of any focus of abnormal rhythm in order to maintain a normal heart rate and rhythm. Please note, the following changes have been made to your medications: 1.) START warfarin. *It is important that you take this medication every day for at least one month following discharge. Longer course of therapy may be determined by your primary providers.* 2.) INCREASE torsemide to 100 mg by mouth daily 3.) DECREASE your metoprolol succinate to 25 mg by mouth daily 4.) STOP your Lasix. 5.) STOP your simvastatin It is important that you follow up with your primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **], and your primary cardiologist, Dr. [**First Name (STitle) 437**], after discharge. Please keep the appointments that have been made for you, as listed below. Please weigh yourself every morning and call your doctor if your weight goes up more than three pounds. Also, continue to adhere to a low-sodium diet. Continue to use your Continuous Positive Airway Pressure (CPAP) machine at nighttime for obstructive sleep apnea. Followup Instructions: Name: [**Last Name (LF) **], [**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] Location: [**Hospital1 18**] DEPT OF CARDIOLOGY Address: [**Location (un) **], [**Location (un) **],[**Numeric Identifier 718**] Phone: [**Telephone/Fax (1) 62**] *It is recommended that you see Dr. [**Last Name (STitle) **] in 3 weeks. You will be contact[**Name (NI) **] with appointment information. Please call his office if you dont hear from him by next week. The electrophysiology office is working on scheduling your study in one month. Name: [**Known lastname 5005**],[**Known firstname **] B Unit No: [**Numeric Identifier 17846**] Admission Date: [**2182-9-30**] Discharge Date: [**2182-10-12**] Date of Birth: [**2121-3-14**] Sex: M Service: MEDICINE Allergies: Vancomycin Analogues / Histamine / Ciprofloxacin / Penicillins / Cephalosporins / Atorvastatin / Rosuvastatin / morphine / Sulfa (Sulfonamide Antibiotics) Attending:[**First Name3 (LF) 3373**] Addendum: There was an error in the "Admission Physical Exam." Temperature should read: 102 F. Discharge Disposition: Extended Care Facility: Newbridge on the [**Doctor Last Name **] - [**Location (un) 1502**] [**First Name11 (Name Pattern1) 947**] [**Last Name (NamePattern4) 3374**] MD [**MD Number(2) 3375**] Completed by:[**2182-10-15**]

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Discharge summary

report

Admission Date: [**2172-7-14**] Discharge Date: [**2172-7-17**] Date of Birth: [**2122-2-9**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 896**] Chief Complaint: CC:[**Hospital1 107175**] Major Surgical or Invasive Procedure: Endotrachial intubation History of Present Illness: Ms. [**Known lastname 107176**] is a 50 year old woman with h/o prior traumatic brain injury, epileptic and nonepileptic seizures, recent concussion s/p fall ([**2172-6-30**]), who presents from a Code Blue in the Ophthalmology department for unresponsiveness. The patient had a concussion 2 weeks prior to admission s/p fall from a ladder. Since this time, she has had persistent HA, N/V, gait instability, and blurry vision. The patient was in the ophthalmology clinic on [**2172-7-13**] when she fell out of her wheelchair and was found to be unresponsive and a Code Blue was called. Ms. [**Known lastname 107176**] does not recall the events surrounging the episode but does recall she had constipation, poor PO intake, and nausea prior to the event. Her VS were stable during the code - satting well on room air, BP 130s/90s, P90s. The patient was presumed to be having a seizure and received a total of Ativan 4mg. She was intubated by Anesthesia for airway protection prior to transfer to the [**Hospital Ward Name 12837**] ED. She required a significant amount of Propofol to stay sedated. In the ED she remained ventilated and sedated. Imaging of her head and neck were normal. Initial labs were notable for normal CBC and chemistries. UA and tox screen were negative. She had purposeful movement in the ED and no obvious seizure activity by report. After arrival to the medical ICU on [**7-14**], she was extuabted. The neurology team is unclear what caused her event, but do not think it was consistent with a seizure. Past Medical History: - Hypothyroidism - TBI [**1-21**] assault resulting in ICH - Reported history of epilepsy. Was admitted in [**11-26**] for further evaluation, and at that time EEG showed no interictal spikes, and pushbutton events did not show an EEG correlate. It was felt that her events were mostly non-epileptic, and she was taken off Keppra at that time and bridged back to gabapentin - Almost blind [**1-21**] prior assault and subsequent macular degeneration - DJD with spondylosis and foraminal narrowing at C6-7 - S/p arthroscopy - HCV Social History: She reports no cigarettes, etoh, or illicit durgs. Family History: No family history of seizures by report Physical Exam: Vital Signs: T 98.2, P 68, BP 125/71, 96% on RA. Physical examination: - Gen: Thin, tan female in NAD. Keeps eyes closed during most of the exam. - Chest: Normal respirations and breathing comfortably on room air. Lungs clear to auscultation bilaterally. - CV: PMI normal size and not displaced. Regular rhythm. Normal S1, S2. No murmurs or gallops. JVP 6 cm. No ankle edema. - Abdomen: Normal bowel sounds. Soft, nontender, nondistended. - Neuro: Alert, oriented x3. Good fund of knowledge. CN 2-12 intact other than decreased vision. Has flat affect. Declines gait exam. Pertinent Results: [**7-13**] CT head 1. No acute intracranial process. 2. Increased secretions within the nasopharynx are likely secondary to recent intubation. CTA head and neck [**7-13**] 1. Slightly suboptimal study due to inadequate contrast enhancement as well as artifacts from the adjacent bone/venous contrast. 2. Within these limitations, the major arteries of the head and neck are patent without focal flow-limiting stenosis or occlusion. The left posterior inferior cerebellar artery is not visualized and may relate to a normal variant appearance. There is no definite outline of the vessel noted to suggest thrombotic occlusion. 3. Significant amount of secretions in the nasopharynx and trachea, do correlate clinically. 4. Mild degenerative changes in the cervical spine without significant canal stenosis; mild-to-moderate neural foraminal narrowing, inadequately assessed on the present study. 5. Non-visualization of the thyroid, do correlate with clinical history. Brief Hospital Course: 1. Syncope. The presentation was most consistent with a syncopal episode, possibly related to her reported vomiting. She was monitored on telemetry for 48 hours (bradycardia to 50s but no other events) and an echo was obtained (mitral valve prolapse). Neurology also followed by the patient and agreed that the presentation was more consistent with syncope. 2. Post-concussive syndrome. Since recent trauma, patient has suffered from headaches and nausea. Neurology followed and felt this could be consistent with a post-concussive syndrome. She has neurology follow-up scheduled. 3. Neck pain / Vertigo. This is a long-standing issue. CTA shows no evidence of an acute arterial abnormality. Neurology wondered if this might suggest a chronic vestibular disorder and recommended outpatient ENT follow-up. 4. Hypothyroidism. Continue home Levothyroxine 150/175mg PO on alternating days 5. Social work. Patient reported recently having been kicked out of her boyfriend's home (along with her 12 year-old son). Social work met with the patient and provided resources. Given the complexity of her care, a new PCP appointment was scheduled for Monday [**7-20**]. Medications on Admission: - Levothyroxine 150/175mg PO on alternating days - Gabapentin 300mg PO TID - Xatalan OU HS Discharge Medications: 1. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at bedtime). 2. Levothyroxine 50 mcg Tablet Sig: Three (3) Tablet PO Q48H (every 48 hours). 3. Levothyroxine 175 mcg Tablet Sig: One (1) Tablet PO Q48H (every 48 hours). 4. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q8H (every 8 hours). 5. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours). Disp:*90 Tablet(s)* Refills:*0* 6. 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:*0* 7. Cyclobenzaprine 10 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:*90 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: 1. Synocpe 2. Post-concussive syndrome 3. Hypothyroidism Discharge Condition: Hemodynamically stable Discharge Instructions: You were admitted after passing out (syncope). Your heart was evaluated and only showed mild mitral valve prolapse. For you headache and neck pain, you should continue using NSAIDs and cyclobenzaprine, as prescibed. Given that the doses you are using may irritate the stomach, we have also prescribed a medication to protect the lining. Followup Instructions: Department: [**Hospital3 249**] When: MONDAY [**2172-7-20**] at 2:35 PM With: [**First Name8 (NamePattern2) 1037**] [**First Name8 (NamePattern2) 3239**] [**Last Name (NamePattern1) 30891**], MD [**Telephone/Fax (1) 250**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: NEUROLOGY When: TUESDAY [**2172-8-11**] at 8:30 AM With: DRS. [**Name5 (PTitle) **]/[**Doctor Last Name **] [**Telephone/Fax (1) 857**] Building: Ks [**Hospital Ward Name 860**] Building ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) 1951**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: [**Hospital3 1935**] CENTER When: MONDAY [**2172-11-16**] at 1:30 PM With: [**First Name11 (Name Pattern1) 354**] [**Last Name (NamePattern4) 3013**], M.D. [**Telephone/Fax (1) 253**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage

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