ChanBeDu/relevant_section_length · Datasets at Hugging Face

78,076

119,778

10770

Discharge summary

report

Admission Date: [**2114-10-29**] Discharge Date: [**2114-11-8**] Date of Birth: [**2043-3-24**] Sex: M Service: SURGERY Allergies: Aspirin / Sulfa (Sulfonamide Antibiotics) Attending:[**First Name3 (LF) 2836**] Chief Complaint: Ventral hernia Major Surgical or Invasive Procedure: [**2114-10-29**]: 1. Extensive adhesiolysis, over 4 hours. 2. Small bowel resection, approximately 40 cm. 3. Ventral hernia repair with acellular dermal matrix in an area of 24 cm x 32 cm with Strattice History of Present Illness: Mr. [**Known lastname 35199**] is a 71M with history of an extensive ICU and hospital day for necrotizing pancreatitis and abdominal compartment syndrome with resultant open abdomen. This was temporarily resolved at the time with Vicryl mesh placement followed by skin grafting. He had also undergone multiple retroperitoneal approaches to pancreatic debridement, having recovered fully. Ultimately, he was doing well except for complete loss of domain and discomfort and pain associated with that. Thus, understanding the risks to this essentially helpful operation, he was brought to the operating room with a plan for excision of the skin graft, adhesiolysis, cholecystectomy if feasible, and then hernia repair by Dr. [**First Name (STitle) **] with component separation and/or mesh repair. Past Medical History: PMHx: asthma, HTN, basal cell carcinoma, DM, gallstone pancreatitis c/b respiratory and renal failure, abdominal compartment syndrome, necrotizing pancreatitis PShx: rib frx plating approx 5 years ago. On last admission [**2113-7-13**] closure, GJ tube [**2113-7-8**] partial abd closure, drsg [**Name5 (PTitle) **] [**2113-7-4**] Open abdomen dressing revision [**2113-7-3**] Decompressive laparotomy, open abd [**2113-7-8**] partial closure abdominal wound [**2113-7-13**] formal closure GJ tube [**2113-7-19**] Decompressive laparotomy, open abd [**2113-7-24**] tracheostomy [**2113-7-29**] abdominal closure with mesh [**2113-8-13**] and [**2113-8-18**] -I&D of pancreatic fluid collection and subsequent upsizing of drain by IR [**2113-8-22**], [**2113-8-28**], [**2113-9-4**] -Laparoscopic pancreatic necrosectomy Social History: Married for 45+ years. Three daughters, one son. Retired six years ago, owned upholstery business. Never smoker, one glass of wine per evening with dinner. No illicits. Family History: Sister died from breast cancer, another sister (deceased) with CRF on HD Physical Exam: ON DISCHARGE: Vitals: 98.3097.8 72 108/73 20 97% RA (CPAP at night) Gen: Appears well, no jaundice CV: RRR, nl S1. S2 Resp: Breath sounds diminished at bases, no wheezes or ronchi Abd: Large wound vac in place to suction with no leaks, abdomen nondistended, nontender, JP in place with serous drainage Ext: No edema Pertinent Results: [**2114-10-29**] (Post-op): CBC: WBC-7.1 Hgb-11.5 Hct-33.9 Plt Ct-321 Chem: Glucose-228 UreaN-26 Creat-1.3 Na-140 K-4.4 Cl-110 HCO3-23 AnGap-11 ALT-12 AST-19 LD(LDH)-102 AlkPhos-34* TotBili-1.1 Vanco-13.6 [**2114-11-6**]: CBC: WBC-7.6 Hgb-11.2 Hct-32.0 Plt Ct-258 Chem: Glucose-128 UreaN-18 Creat-1.1 Na-138 K-4.0 Cl-98 HCO3-34 AnGap-10 [**2114-10-29**]: EKG Sinus tachycardia. Low voltage. T wave abnormalities. Since the previous tracing of [**2114-10-16**] the rate is faster. T wave abnormalities are more prominent. Clinical correlation is suggested. [**2114-11-1**]: CXR As compared to the previous radiograph, there is no relevant change. Bilateral areas of atelectasis. Nasogastric tube in situ. Moderate cardiomegaly without evidence of pulmonary edema. No newly occurred focal parenchymal opacity suggesting pneumonia. Brief Hospital Course: Mr. [**Known lastname 35199**] [**Last Name (Titles) 1834**] ventral hernia repair with biologic mesh after extensive lysis of adhesions and small bowel resection on [**2114-10-29**]. The operation was completed without complications and the patient was admitted to the ICU postoperatively for fluid management from [**2114-10-29**] to [**2114-11-1**] due to length of the procedure. He was transferred to the floor [**2114-11-1**] and recovered without complications. His hospital course is described below by system: Skin: Patient's hernia wound was initially dressed with wound vac in upper and lower defects in skin graft. On POD1, the lower vac was removed and replaced with wet to dry dressing. Vac was changed every 3 days by Dr.[**Name (NI) 27488**] team. On POD 3, lower pole of skin graft appeared to be ischemic. Ischemia progressed until graft appeared devitalized on POD9. Devitalized skin graft tissue was debrided and a large wound vac was applied to skin defect. Wound bed appeared healthy and without drainage for duration of hospital stay. GI: Due to chylous collection found intraop, patient's JP drain was monitored daily for chyle. Patient was kept NPO post-operatively and advanced to clear liquids on POD5. Patient was advanced to fulled on POD7 after pasing flatus. No chyle was observed in drain. He tolerated a regular diet on POD8. Pulmonary: The patient was extubated on [**2114-10-30**] (POD1) without difficulty. He was kept on CPAP at night for his sleep apnea. He was stable from a pulmonary standpoint throughout his stay. Heme/ID: Patient was transfused 2U PRBC on POD2 for Hct 21.9 which increased to 29. His Hct remained stable and was 32 on the day of discharge. Post-operatively, the patient was kept on IV vancomycin for 3 days. The patient's temperature was closely watched for signs of infection. Neuro: Post-operatively, the patient received Dilaudid PCA with good effect and adequate pain control. When tolerating oral intake, the patient was transitioned to oral pain medications. CV: The patient continued his metoprolol throughout the post operative period with no change in status from baseline. GU/Renal: Patient's Cr remained at baseline throughout his stay. On the evening of POD0, patient's urine output was low but responded appropriately to fluid bolus. Lasix diuresis was started on POD2 and continued until fluid status was even on POD5. Foley was removed on POD4 and patient voided without difficulty. Prophylaxis: The patient received subcutaneous heparin during this stay, and was encouraged to get up and ambulate as early as possible. At the time of discharge on POD#10, the patient was doing well, afebrile with stable vital signs, tolerating a regular diet, ambulating, voiding without assistance, and pain was well controlled. Medications on Admission: 1. Advair diskus 500-50 1puff [**Hospital1 **] 2. Ipratropium albuterol 0.5 mg-3mg/3ml solution 1 amp [**Hospital1 **] 3. Metoprolol 25mg [**Hospital1 **] 4. Ranitidine 150mg [**Hospital1 **] 5. Simethicone 180 mg 2 tabs [**Hospital1 **] Discharge Medications: 1. fluticasone-salmeterol 500-50 mcg/dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 2. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as needed for wheezing. 3. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed for wheezing. 4. trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as needed for insomnia. 5. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 8. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. 9. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours). 10. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Discharge Disposition: Extended Care Facility: [**Hospital1 700**] - [**Location (un) 701**] Discharge Diagnosis: Loss of domain with large ventral hernia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Personal Care: 1. Leave your abdominal dressings in place until your follow up appointment with Dr. [**First Name (STitle) **]. If your dressings get wet underneath, you may remove them. 2. Clean around the drain site(s), where the tubing exits the skin, with soap and water. 3. Strip drain tubing, empty bulb(s), and record output(s) [**2-7**] times per day. 4. A written record of the daily output from each drain should be brought to every follow-up appointment. your drains will be removed as soon as possible when the daily output tapers off to an acceptable amount. 5. You may shower daily. No baths until instructed to do so by Dr. [**First Name (STitle) **]. . Activity: 1. You may resume your regular diet. 2. DO NOT lift anything heavier than 5 pounds or engage in strenuous activity until instructed by Dr. [**First Name (STitle) **]. . Medications: 1. Resume your regular medications unless instructed otherwise and take any new meds as ordered. 2. You may take your prescribed pain medication for moderate to severe pain. You may switch to Tylenol or Extra Strength Tylenol for mild pain as directed on the packaging. Please note that Percocet and Vicodin have Tylenol as an active ingredient so do not take these meds with additional Tylenol. 4. Take prescription pain medications for pain not relieved by tylenol. 5. Take your antibiotic as prescribed. 6. Take Colace, 100 mg by mouth 2 times per day, while taking the prescription pain medication. You may use a different over-the-counter stool softener if you wish. 7. Do not drive or operate heavy machinery while taking any narcotic pain medication. You may have constipation when taking narcotic pain medications (oxycodone, percocet, vicodin, hydrocodone, dilaudid, etc.); you should continue drinking fluids, you may take stool softeners, and should eat foods that are high in fiber. . Call the office IMMEDIATELY if you have any of the following: 1. Signs of infection: fever with chills, increased redness, welling, warmth or tenderness at the surgical site, or unusual drainage from the incision(s). 2. A large amount of bleeding from the incision(s) or drain(s). 3. Separation of the incision. 4. Severe nausea and vomiting and lack of bowel movement or gas for several days. 5. Fever greater than 101.5 oF 6. Severe pain NOT relieved by your medication. 7. White output from your JP drain (clear, yellow, and pink are ok!) . Return to the ER if: * If you are vomiting and cannot keep in fluids or your medications. * If you have shaking chills, fever greater than 101.5 (F) degrees or 38 (C) degrees, increased redness, swelling or discharge from incision, chest pain, shortness of breath, or anything else that is troubling you. * Any serious change in your symptoms, or any new symptoms that concern you. . DRAIN DISCHARGE INSTRUCTIONS You are being discharged with drains in place. Drain care is a clean procedure. Wash your hands thoroughly with soap and warm water before performing drain care. Perform drainage care twice a day. Try to empty the drain at the same time each day. Pull the stopper out of the drainage bottle and empty the drainage fluid into the measuring cup. Record the amount of drainage fluid on the record sheet. Reestablish drain suction. Followup Instructions: Please follow up with Dr. [**First Name (STitle) **] on [**2114-11-16**]. Please call ([**Telephone/Fax (1) 25379**] for your appointment. Please follow up with Dr. [**First Name (STitle) **] on [**2114-11-21**]. Please call ([**Telephone/Fax (1) 35203**] for your appointment. Completed by:[**2114-11-8**]

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icd9cm

[ [ [] ] ]

[ "53.61", "45.91", "45.62", "99.77", "54.59" ]

icd9pcs

[ [ [] ] ]

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33104

Discharge summary

report

Admission Date: [**2181-1-27**] Discharge Date: [**2181-2-13**] Date of Birth: [**2101-6-1**] Sex: M Service: MEDICINE Allergies: Penicillins Attending:[**First Name3 (LF) 492**] Chief Complaint: code stroke: aphasia, right facial droop, right hemiparesis Major Surgical or Invasive Procedure: Trach, PEG, HD, TEE History of Present Illness: The patient is a 79 yo man with DM II x 15 yrs, ESRD on dialysis, HTN, hyperlipidemia, smoker, who presents with acute onset aphasia, R facial droop and R hemiparesis, last seen nml by his wife at 22h30. [**Name2 (NI) **] was brought to [**Hospital 48159**] Hospital where he was assessed around 23h30. He had a NCHCT that did not reveal intracranial bleed. Given that his R hemiparesis had almost fully resolved, the ED physician was of the opinion that his deficits were improving and elected not to administer ivTPA on that basis, though the patient remained mute and had no contraindication on the screening form they filled out. He received 0.5 mg Ativan at 2 am prior to transfer to [**Hospital1 18**] ED and upon arrival a stroke code was called at 3h15 am. I arrived 5 mins later and we planned for a CT perfusion as well as CTA. Given his renal failure, the dialysis fellow was called prior to administering iv contrast which accounted for some of the delay, such that the CT scan was performed at 4 am and completed at 4h30. His last dialysis was Fri [**1-27**], a few hours prior to presentation. CXR: no consolidation. EKG nsr, LAD, primary AVB, IVCD, peaked T waves, NSST changes. U/a neg for leuks or nitrites, protein > 300 mg/dL. INR 0.96. K 4.8, gluc 200-300. Past Medical History: -HTN -Hyperlipidemia -DM II x 15 yrs -ESRD on dialysis, secondary hyperparathyroidism, Perm-a-Cath R IJ vein [**2179-10-31**] and replaced [**2179-12-1**] due to line infection, L arm radiocephalic AV fistula -prostate Ca s/p radioactive seed implant -OSA, on BIPAP -osteoarthritis -vertigo -gout -L-sided pleural-based lung fibrotic lesion attributed to chest trauma at 5 yrs of age in [**Country 2559**] requiring surgery, and multiple pulm nodules stable on CXRs. Social History: owns a plastics manufacturing company, smokes, occasional EtOH, lives with wife, supportive family, daughter Mrs [**Name (NI) 43852**] cell [**Telephone/Fax (1) 76940**] Family History: -father prostate Ca, mother died at age [**Age over 90 **] Physical Exam: T 98.7 HR 88 BP 130/63 RR 24 sO2 100% on 4 L np GEN: NAD HEENT: mmm NECK: no LAD; no carotid bruits; full range neck movements LUNGS: Clear to auscultation bilaterally HEART: Regular rate and rhythm, normal S1 and S2, [**4-5**] pansystolic murmur at LLSB, no gallops or rubs. ABDOMEN: overweight, normal bowel sounds, soft, nontender, no obvious organomegaly, some spider angiomata on torso. EXTREMITIES: no clubbing, cyanosis, ecchymosis, or edema NEURO NIHSS 12: 1a=0, 1b=2, 1c=0, 2=0, 3=2, 4=2, 5=0, 6=0, 7=X, 8=1, 9=3, 10=2, 11=0, 12=A MSE: awake, responds to voice, mute, follows simple commands such as opening eyes and gripping but no other commands such as sticking out tongue or showing two fingers, fidgety, trying to remove O2 nasal cannula & O2 sat probe. CN: PERRL bilat 3-->2 mm, EOMI, no nystagmus, no ptosis, does not blink to threat in R visual field, R UMN facial droop, tongue midline, no fasciculations Motor: normal bulk and tone bilaterally. No adventitious movements, no tremor, no asterixis. R sided mild weakness compared to left. No pronator drift. No rebound. REFLEXES: DTRs 2 + and symmetric except ankle jerks which were absent, plantar responde upgoing bilat SENSORY SYSTEM: withdraws to noxious stim in all extremities. COORDINATION: unable to perform Pertinent Results: LABS and IMAGING: Na 134, K 4.8, Cl 91, CO2 32.4, gluc 346 Creat 6.79, BUN 46, GFR 8, Ca 8.9 WBC 9.3 with 6.8 NEs, Hgb 13.5, plts 200 . CTA/CTP HEAD/NECK: CONCLUSION: Extensive elevation of the mean transit time throughout the left middle cerebral artery territory. The blood volume in this location is mostly preserved, indicating that this is potentially a reversible defect. However, the non-contrast CT scan suggests low density and swelling in the left MCA territory, which would imply a completed infarct. The CT angiogram demonstrates occlusion of the left vertebral artery in its cervical course. However, the carotid arteries and their intracranial branches appear patent. . MRI HEAD: FINDINGS: The MR findings are similar to those displayed on the prior CT scan. There is evidence of acute infarction in the distribution of the superior division of the left middle cerebral artery. This demonstrates marked hyperintensity on the diffusion-weighted images, and corresponding hypointensity on the apparent diffusion coefficient map. The MRA examination demonstrates an abrupt cutoff of the superior division of the left MCA with a faint tapering that suggests a meniscus and a likely intraluminal filling defect. These findings are most suggestive of an embolic infarction in this location with a tiny trickle of flow passing distal to the occlusion. The distal left vertebral artery appears tiny and the right vertebral artery appears dominant. This is a normal variant. No other intracranial vascular abnormalities are noted. CONCLUSION: Acute infarction in the superior division of the left middle cerebral artery with near occlusion of this branch just distal to the middle cerebral artery bifurcation. There is no evidence of hemorrhage. . CXR In comparison with the study of [**2-11**], allowing for differences in position of the patient, there is little overall change. Tubes remain in place. Patchy area of opacification persists at the left base, which could well represent atelectasis, though pneumonia cannot be excluded. . TEE: No spontaneous echo contrast or thrombus is seen in the body of the left atrium or left atrial appendage. There are complex (>4mm) non-mobile atheroma in the ascending aorta, aortic arch, and descending thoracic aorta to 37cm beyond the incisors. The aortic valve leaflets are severely thickened/deformed. There is severe aortic valve stenosis (area <0.8cm2) by planimetry. Trace aortic regurgitation is seen. The mitral valve leaflets are moderately thickened. There is severe mitral annular calcification. There is moderate valvular mitral stenosis (area 1.0-1.5cm2) related to the severe MAC (no evidence of rheumatic deformity). Mild (1+) mitral regurgitation is seen. The intra-atrial septum and right atrium were not well seen. Agitated saline was injected at rest with no appearance of bubbles in the left atrium suggestive of the absence of a PFO or ASD with right to left shunting. Left ventircular function is probably normal based on limited views. Brief Hospital Course: Mr. [**Known lastname **] is a 79-year-old man with a history of DM2, ESRD on HD, HTN, hyperlipidemia who presented with aphasia and right face/arm/leg weakness, found to have a L MCA stroke from likely embolic source, transfered to ICU for possible PNA management and subsequent trach/peg on [**2-6**]. #. Neuro: STROKE. He was found to have a L MCA superior division stroke. He was not a candidate for thrombolysis as he was more than 6 hours past his last known well time when Neurology was consulted at [**Hospital1 18**]. Patient was initially evaluated at OSH within the tPA windonw, however none was given as it was felt that his symptoms were improving. Etiology was thought to be intracranial thromboembolism secondary to multiple risk factors. He was started on aspirin, which is sufficient anti-platelet therapy as he was not on prior such agents. CT Angiogram showed patent carotids but chronically occluded left vertebral artery. TTE and TEE showed no ASD, PFO, or cardioembolic source. Hb A1c was found to be 8.2; covered with an ISS, though he may need adjustment of his diabetes regimen as an outpatient after his acute illness. LDL was 113, HDL 39, Tot chol 184, and Trig 160; he was started on Lipitor. However, lipitor was stopped due to marked elevation of CKs to 1000s. Patient also had a repeat head CT on [**2-9**] that showed slight progression of his affected L MCA teritory. They subsequently decreased after cessation of Lipitor. Patient remained with R sided weakness, able to weakly grasp on the R hand and flex his R ankle that was slightly improving with physical therapy. He should continue aggressive physical therapy for R sided weakness, occupational therapy, and speech therapy for his aphasia. He should follow-up with Dr. [**First Name (STitle) **] in Neurology ([**Telephone/Fax (1) 2574**]). # GI: Swallow evaluated him and found him to be unable to swallow. An NG was placed, which he removed; Dobhoff was subsequently placed. Patient had a PEG placed along with a trach on [**2-6**] without any complications. # Pulmonary - patient with a small RML PNA upon transfer to ICU on [**2181-2-4**]. He was subsequently started on Vanco/Cefepime/Flagyl at that time. He underwent an uneventful trach placement for likely future aspiration events on [**2-6**]. subsequently his work of breathing increased with tachypnea, tachycardia, aggitation and hypoxia. Bronchoscopy did not reveal acute plugging, hemorrhage or airway collapse. There was dynamic airway closure that was appreciated however it was transient. Patient was empirically started on vanco/cefepime/flagyl and completed a course while hospitalized. He did have mild to moderate secretions that did improve with antibiotics. Patient was also started on steroids with a 7 day taper for presumed PNA associated COPD exacerbation which he will need to complete in rehab (2d late). His HD was used to remove volume as he had an elevated BNP of 1600. Although he never had pleural effusions. Patient continued to improve on the above treatement and on [**2-9**] he was change to 50% trachmask and was breathing and interacting comfortably. Furthermore, emphysematous changes were noted. A Passy Muir vlave assessment was considered but defered until his mental status cleared. He was stable on a 35% face mask at discharge. # ESRD - patient received HD while in house. He was last dialyzed on the afternoon of [**2181-2-12**]. # Anemia - patient's Hct ranged from 24-28. He did not receive the transfusion that was logged on [**2-9**]. His Hct remained stable and he receives Epo with HD. # Diabetes - Patient is on oral medications as an outpatient and was managed with both NPH and humalog here due to his steroid requirement. He was d/c on NPH 35u [**Hospital1 **] and an insulin sliding scale. This will likely have to be adjusted at rehab as his steroid taper finishes. # Access - HD catheter via L fistula, R sided PICC that renal service requests to be d/c once IV antibiotics are finished to preserve the site for potential future sites for HD and potential future fistula if the L side failed. Medications on Admission: -Enalapril -Prandin 2 mg Qhs -Allopurinol 100 mg Qday -Lasix 40 mg Qday -Reserpine 0.1 mg Qday -Hectorol 2.5 mcg po Mon-Wed-Fri -Meclizine 25 mg [**Hospital1 **] ALLERGIES: Penicillin caused rash and mouth sores Discharge Medications: 1. Prednisone 20 mg Tablet Sig: Two (2) Tablet PO Daily () for 1 days: to be given on [**2181-2-14**]. 2. Prednisone 20 mg Tablet Sig: 0.5 Tablet PO Daily () for 1 days: to be given on [**2181-2-15**]. 3. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 4. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000) units Injection TID (3 times a day). 5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 6. Docusate Sodium 50 mg/5 mL Liquid Sig: One Hundred (100) mg PO BID (2 times a day). 7. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed. 8. Allopurinol 100 mg Tablet Sig: 1.5 Tablets PO EVERY OTHER DAY (Every Other Day). 9. Lanthanum 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 10. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Fluticasone 110 mcg/Actuation Aerosol Sig: Four (4) Puff Inhalation [**Hospital1 **] (2 times a day). 12. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q4H (every 4 hours). 13. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation Q6H (every 6 hours). 14. Captopril 12.5 mg Tablet Sig: 0.5 Tablet PO TID (3 times a day). 15. Prilosec OTC 20 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. Discharge Disposition: Extended Care Facility: [**Hospital3 7**] & Rehab Center - [**Hospital1 8**] Discharge Diagnosis: L MCA Stroke ESRD on [**Hospital **] Hospital Acquired Pneumonia Discharge Condition: Stable; oxygenating well on 35% trach mask Discharge Instructions: You were admitted to the hospital after you suffered a stroke. You were unable to swallow and were having difficulty breathing after the stroke and we needed to place a tracheostomy and PEG tube. The tracheostomy is helping you breath and the PEG tube allows us to feed you. While in the hospital you developed a pneumonia which we are treating with antibiotics. You completed a full course of antibiotics prior to discharge. You will need to complete a steroid taper over the next 2 days at the rehab facility. Followup Instructions: He should follow-up with Dr. [**First Name (STitle) **] in Neurology ([**Telephone/Fax (1) 2574**]). Please call to schedule an appointment. He will need to follow up with his nephrologist as an outpatient. He will need to continue HD M-W-F. [**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD [**Doctor First Name 494**] Completed by:[**2181-2-13**]

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icd9cm

[ [ [] ] ]

[ "43.11", "96.6", "39.95", "38.93", "31.1", "88.72", "33.21" ]

icd9pcs

[ [ [] ] ]

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54866

Discharge summary

report

Admission Date: [**2159-7-27**] Discharge Date: [**2159-8-7**] Date of Birth: [**2092-2-16**] Sex: F Service: OBSTETRICS/GYNECOLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 6743**] Chief Complaint: Advanced ovarian cancer ICU admission #1: hypotension, intubation, require intense monitoring immediately post-operation. ICU readmission #2: desaturation secondary to flash pulmonary edema. Major Surgical or Invasive Procedure: -exploratory laparotomy, radical resection of tumor, infragastric omentectomy, left hemicolectomy, end colostomy, BSO for advanced ovarian cancer -intubation History of Present Illness: Ms [**Known lastname 66172**] is a 67 year old with a history of ER/PR positive breast cancer who presented with a recent CT scan revealing a large right adnexal mass, ascites as well as peritoneal irregularities suggestive of metastatic disease. This scan was obtained after a fall caused significant low back and abdominal pain. She also notes having had abdominal distention, lack of appetite, fatigue and diarrhea. She denies nausea, vomiting, and vaginal bleeding. CT scan at an OSH revealed a 9.4 x 7.1 x 12.0 cm right adnexal mass, cystic with areas of nodularity. There was abdominal ascites noted. There were several areas of nodularity within the omentum, measuring up to 6.0x3.0 cm, as well as small bilateral pleural effusions. CA-125 was elevated at 989. Past Medical History: PMH: Asthma, HTN, depression, panic attacks, ER/PR positive DCIS of the right breast. Denies h/o DM, thromboembolic disorder. PSH: Vaginal hysterectomy secondary to prolapse [**2132**], left breast biopsy [**2141**], right breast biopsy [**2156**], right breast lumpectomy [**2156**]. OB: G1P1, NVD x1 GYN: Menarche age 12, regular. LMP [**2132**] s/p vag hyst. Denies h/o fibroids, ovarian cysts, STI/PID, and abnormal pap smear. Social History: Never smoker, denies ETOH, denies illicit drugs Family History: Mother had breast cancer in her 70s. MGF had DMII. PGF had HTN and CAD. Physical Exam: Admission exam to the ICU after the surgery: General: Intubated, sedated, no acute distress HEENT: Sclera anicteric, oropharynx clear, 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, bowel sounds hypoactive, no tenderness to palpation, no rebound or guarding, JP drain in place, ostomy in periumbilical region GU: Foley catheter in place Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema, left arm cooler than right, but intact pulses Neuro: withdraws to pain Pertinent Results: Admission Labs: [**2159-7-27**] 03:23PM BLOOD WBC-3.3*# RBC-4.46 Hgb-12.8 Hct-37.7 MCV-84 MCH-28.6 MCHC-33.9 RDW-15.3 Plt Ct-437 [**2159-7-27**] 03:23PM BLOOD Neuts-79* Bands-1 Lymphs-14* Monos-5 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-1* [**2159-7-27**] 03:23PM BLOOD PT-15.0* PTT-27.5 INR(PT)-1.4* [**2159-7-27**] 03:23PM BLOOD Fibrino-158* [**2159-7-28**] 09:00PM BLOOD Ret Aut-1.6 [**2159-7-27**] 03:23PM BLOOD Glucose-217* UreaN-12 Creat-0.6 Na-141 K-3.8 Cl-111* HCO3-22 AnGap-12 [**2159-7-27**] 11:06PM BLOOD CK(CPK)-236* [**2159-7-27**] 11:06PM BLOOD CK-MB-2 cTropnT-<0.01 [**2159-7-27**] 03:23PM BLOOD Calcium-7.7* Phos-4.4 Mg-1.3* [**2159-7-27**] 12:40PM BLOOD Type-ART Temp-36.4 pO2-234* pCO2-41 pH-7.33* calTCO2-23 Base XS--4 [**2159-7-27**] 11:02AM BLOOD Glucose-162* Lactate-2.4* Na-133 K-3.9 Cl-108 calHCO3-22 [**2159-7-27**] 12:40PM BLOOD freeCa-1.02* Discharge labs: [**2159-8-6**] 06:15AM BLOOD WBC-15.8* RBC-4.85 Hgb-13.2 Hct-41.4 MCV-86 MCH-27.3 MCHC-32.0 RDW-15.5 Plt Ct-615* [**2159-8-7**] 06:20AM BLOOD Glucose-124* UreaN-14 Creat-0.7 Na-139 K-4.1 Cl-101 HCO3-26 AnGap-16 [**2159-8-7**] 06:20AM BLOOD LDLmeas-87 [**2159-8-7**] 06:20AM BLOOD TSH-4.3* [**2159-8-7**] 06:20AM BLOOD HIV Ab-PND [**8-2**] urine culture: PSEUDOMONAS AERUGINOSA. 10,000-100,000 ORGANISMS/ML.GRAM NEGATIVE ROD(S). ~1000/ML. Sensitivites: CEFEPIME-------------- 2 S CEFTAZIDIME----------- 4 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S PIPERACILLIN---------- S TOBRAMYCIN------------ <=1 S [**7-27**] CXR: NG tube tip has been inserted and its tip is in the stomach. ET tube tip is 4.5 cm above the carina. Mediastinal drain is in place. Heart size is top normal. The assessment of the mediastinum demonstrates bulging of the aortopulmonic window that might be due to pericardial effusion or hematoma, attention to this area is recommended. Patient has mild pulmonary edema. Left retrocardiac opacity is new and might reflect atelectasis, although aspiration cannot be excluded. [**7-28**] CXR: As compared to the prior study, there is interval improvement of the mediastinal appearance, most likely consistent with resolution of atelectasis. Bilateral pleural effusions have slightly increased as well as bibasal atelectasis. No pneumothorax is present. [**8-2**] CTA: No evidence of pulmonary embolus. Bilateral pleural effusions, increased in size since [**7-19**], with overlying atelectasis; however, infectious process cannot be excluded, particularly in the right lower lobe. Mild pulmonary edema. Slightly enlarged mediastinal lymph nodes since [**7-19**]. Calcified thyroid nodule in the right lobe. [**8-3**] CXR: Heart size and mediastinal contours remain within normal limits allowing for technique. There is marked interval improvement in bilateral upper zone pulmonary vascular re-distribution and patchy consolidation consistent with improvement in pulmonary edema. Bilateral infrahilar and bibasilar opacities persist. Probable small left pleural effusion. No evidence of pneumothorax. [**8-6**] ECHO: Very poor image quality. Overall left ventricular systolic function is probably moderately depressed (LVEF= 30-35 %). No masses or thrombi are seen in the left ventricle. There is no ventricular septal defect. with normal free wall contractility. There is no pericardial effusion. Compared to the prior study dated [**2159-8-2**], no clear change (LVEF was probably overestimated on prior). Brief Hospital Course: 67 yo female with history of ER/PR positive breast DCIS s/p ex lap, resection of tumor, infragastric omentectomy, left hemicolectomy, end colostomy, BSO for advanced ovarian cancer, who was admitted to the ICU for post-procedure extubation and hypotension and another ICU admission for flash pulmonary edema. #ICU admission #1 for hypotension, intubation, require intense monitoring immediately post-operation: 2 liters of ascitic fluid was drained upon opening of her abdomen, estimated blood loss for the surgery was 1 liter. During the surgery, patient transiently dropped her blood pressure during the procedure to 50s/30s, she was initiated on phenylephrine gtt through peripheral IV. She received 10 liters NS IVF during her procedure, ~2 liters NS while in PACU, 2 units PRBCs, 2 units FFP. Serial labs were obtained for monitoring. Pt was gradually weaned off the phenylephrine gtt. HCT were monitored and there was a slow decrease in her HCT but no evidence of active bleeding, she was given 2 additional units of PRBC. Once pt's condition improved, she was extubated and transferred out of the ICU. # ICU admission #2/desaturation secondary to flash pulmonary edema: [**2159-8-2**] she had respiratory distress after CTA of the chest was performed for tachypnea and persistent tachycardia in the 100's. CTA was negative for pulmonary embolism but showed worsening bilateral pleural effusion with pulmonary edema. She did not improve with non-rebreather mask and was transferred to the ICU for the 2nd time during her hospital stay. Her Lung exam was significant for extensive inspiratory crackles, CXR consistent with worsening pulmonary edema. EKG showed left bundle branch block that is unchanged compared to EKG on [**2159-7-23**]. She was placed on BiPAP. Nebulizers were given with minimal improvement. IV Lasix was administered with good urine output during her 2nd ICU stay. A small troponin leak was noted during her 2nd admission to the ICU. Echo was of suboptimal image quality and showed ? EF of 45%. She was placed on IV Nitro drip for a period of time for SBP in the 150-160's. Cardiology team was consulted and following along. Nitro drip was weaned off and carvedilol 6.25 mg twice daily was initiated. Cardiology recommended aspirin of 81 mg daily, Lasix 20 mg daily, continue with home medication Lisinopril 40 mg daily and Simvastatin. BiPAP was gradually weaned off and pt was transferred out of ICU with saturation in her 90's on NC of 2-3L. Repeat Echo on [**8-6**] confirmed prior Echo and showed moderately depressed LVEF at 30-35%. Pt will follow up as outpatient with Dr.[**Last Name (STitle) 32255**] (cardiologist) [**2159-8-16**] for medication adjustment and possible outpatient perfusion imaging versus catheterization. # Hypotension: she had large volume fluid shifts during surgery and hypovolemia due to blood loss. There was low suspicion for sepsis or cardiogenic causes. She received 12 liters IVF resuscitation, and was placed transiently on phenylephrine gtt for pressure support and on propofol for sedation. Her sedation and vasopressors were weaned without any difficulty, and her blood pressure remained normal at the time of transfer out of the ICU and continue to be stable prior to discharge to rehab. # Hematocrit: Patient's hematocrit dropped from 39.9 on admission to 30.0 post-surgery. She received aggressive fluid resuscitation due to hypotension (see above) and some component of her HCT drop is likely dilutional. She was transfused with 4 units blood cells and 2 units of FFP throughout her hospital stay, and her HCT was stable at 41 at the time of transfer to rehab. # s/p Intubation: Patient was intubated for surgical procedure and was admitted to the ICU sedated with propofol. This was slowly weaned and she was extubated without complication. # Advanced ovarian carcinoma: s/p ex lap with resection of tumor, infragastric omentectomy, left hemicolectomy, end colostomy, BSO, and optimally debulked. She will continue treatment as outpatient with Dr. [**Last Name (STitle) 15759**]. #Ostomy care: s/p consult and teaching from ostomy nurses. #Incisional cellulitis/wound care: small 1.5 cm incisional opening, continue with twice daily wet to dry wound packing; mild erythema around the incision and wound opening, pt was started on a 10 day course of Keflex. # UTI: urine culture was positive for Pseudomonas aeruginosa and it was pan-sensitive. She was started on a 10 day course of Cipro. # post-op de-conditioning: pt was evaluated by the inpatient physical therapists and they recommended rehab care. Once pt was medically stable, she was transferred to rehab for physical therapy. Chronic issues: # Hypertension: continued home med lisinopril, additional anti-HTN meds were added due to the heart failure ( Lasix 20 mg daily, Carvedilol 6.25 mg twice daily) # Asthma: continued home meds fluticasone and nebs PRN # Depression/anxiety: Continued home meds bupropion and sertraline # Hypercholesterolemia: Continued home meds simvastatin Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from Patient. 1. azelastine *NF* 0.15 % (205.5 mcg) NU 4 sprays [**Hospital1 **] 2. BuPROPion 150 mg PO DAILY 3. fenofibrate *NF* 145 mg Oral daily 4. Fluticasone Propionate 110mcg 4 PUFF IH [**Hospital1 **] 5. Lisinopril 40 mg PO DAILY 6. Sertraline 100 mg PO DAILY 7. Simvastatin 10 mg PO DAILY 8. Xopenex Neb *NF* 0.63 mg/3 mL Inhalation PRN SOB Discharge Medications: 1. BuPROPion 150 mg PO DAILY 2. Fluticasone Propionate 110mcg 4 PUFF IH [**Hospital1 **] 3. Lisinopril 40 mg PO DAILY 4. Sertraline 100 mg PO DAILY 5. Xopenex Neb *NF* 0.63 mg/3 mL Inhalation PRN SOB 6. Aspirin 81 mg PO DAILY 7. Carvedilol 6.25 mg PO BID Hold for SBP < 100, HR < 60 8. Ciprofloxacin HCl 500 mg PO Q12H Duration: 10 Days 9. Famotidine 20 mg PO Q12H 10. Furosemide 20 mg PO DAILY please hold for SBP < 100 11. Ibuprofen 600 mg PO Q8H:PRN pain 12. Simvastatin 10 mg PO DAILY 13. fenofibrate *NF* 145 mg Oral daily 14. azelastine *NF* 0.15 % (205.5 mcg) NU 4 sprays [**Hospital1 **] 15. Oxycodone-Acetaminophen (5mg-325mg) [**1-8**] TAB PO Q4-6PRN pain RX *oxycodone-acetaminophen 5 mg-325 mg [**1-8**] tablet(s) by mouth every 4-6 hours Disp #*50 Tablet Refills:*0 16. Cephalexin 500 mg PO Q6H Duration: 10 Days Discharge Disposition: Extended Care Facility: [**Hospital 3548**] [**Hospital 3549**] Nursing and Rehab Center Discharge Diagnosis: Ovarian cancer Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair, and some ambulation with assistance and walker. Discharge Instructions: Dear Ms [**Known lastname 66172**] You were admitted to the gynecologic oncology service after undergoing the procedures listed below. You have recovered well after your operation, and the team feels that you are safe to be discharged home. Please follow these instructions: General instructions: * Take your medications as prescribed. * Do not drive while taking narcotics. * Do not combine narcotic and sedative medications or alcohol * Do not take more than 4000mg acetaminophen (APAP) in 24 hrs * No strenuous activity until your post-op appointment * Nothing in the vagina (no tampons, no douching, no sex), no heavy lifting of objects greater than 10lbs for 6 weeks. * You may eat a regular diet Incision care: * You may shower and allow soapy water to run over incision; no scrubbing of incision. No bath tubs for 6 weeks. * Your staples will be removed at your follow-up visit. 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: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone: ([**Telephone/Fax (1) 20259**] (Office), ([**Telephone/Fax (1) 112097**] (Fax); address: [**Last Name (NamePattern1) 26916**], [**Location (un) 47**], [**Numeric Identifier 83195**] Date/Time: [**2159-8-16**] 10:00. -Please call [**Telephone/Fax (1) 160**] to schedule a follow-up appointment with Dr. [**Last Name (STitle) **] in the [**Hospital 7819**] Clinic in 2 weeks -Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 5777**] Date/Time:[**2159-8-22**] 2:15 -Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 5777**] Date/Time:[**2159-9-5**] 2:15 [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 6753**] Completed by:[**2159-8-7**]

[ "285.1", "511.9", "458.29", "785.0", "599.0", "183.0", "041.7", "V10.3", "998.59", "428.21", "300.01", "401.9", "V88.01", "426.3", "518.4", "197.6", "327.23", "311", "789.59", "E878.6", "682.2", "428.0", "276.52", "493.90" ]

icd9cm

[ [ [] ] ]

[ "54.4", "93.90", "45.75", "65.61", "46.13", "03.90" ]

icd9pcs

[ [ [] ] ]

12657, 12748

6292, 10438

509, 669

12807, 12807

2776, 2776

14081, 14990

2020, 2096

11806, 12634

12769, 12786

11349, 11783

13031, 13736

3656, 6269

13751, 14058

2111, 2757

277, 471

10450, 10963

697, 1472

2792, 3640

12822, 13007

10979, 11323

1494, 1938

1954, 2004

5,471

110,980

17593

Discharge summary

report

Admission Date: [**2132-4-26**] Discharge Date: [**2132-5-6**] Date of Birth: [**2053-12-25**] Sex: F Service: Trauma HISTORY OF PRESENT ILLNESS: The patient is a 78-year-old female pedestrian struck by a vehicle and hit windshield. The patient was brought in by EMS complaining of right lower extremity pain. The patient was alert and oriented x 3. The patient was initially found unconscious per EMS, but was awake and alert in the Emergency Department. The patient was intubated given that the patient was combative and in extreme pain. Tetanus shot was also given as well as Kefzol and gentamicin in the Emergency Department. The patient had a history of dementia and lymphoma in the past taking Buspar. ALLERGIES: The patient has no known drug allergies. SOCIAL HISTORY: Unknown. PHYSICAL EXAMINATION: Vital signs were blood pressure 173/75, heart rate 188, saturating 94-100% on room air on examination. The patient was in a cervical collar on a long board and in severe pain. There was a right frontal scalp 4 cm flap laceration. The right eye had periorbital edema and ecchymoses. Lungs were clear to auscultation, no crepitus. Heart was tachycardic but regular. Abdomen was soft, nontender, nondistended, guaiac was trace positive, normal tone. Back had no stepoff. Pelvic was stable to [**Doctor Last Name **]. Extremities showed the right lower extremity to be deformed. There was an open fracture but 2+ dorsalis pedis pulses. The left elbow had a puncture wound with abrasion. Neurological examination was alert and oriented and moving all extremities. X-RAYS: Chest x-ray was negative. Cervical spine x-ray was negative. Pelvic x-ray was negative. Left elbow, right knee, right ankle and right shoulder were negative. Right tibia-fibula film showed distal comminuted midshaft tibia-fibula compound fracture. Thoracic and lumbar spine films were negative. Head CT showed subarachnoid hemorrhage in the left occipitotemporal area and the right frontal. CT of the cervical spine and CT of the abdomen were negative. HOSPITAL COURSE: The patient was admitted to the trauma surgical intensive care unit. Orthopedics was consulted for open reduction and internal fixation of the right tibia-fibula midshaft fracture. Plastic surgery was consulted for closure. The wound was not closed but a V.A.C. was placed. Neurosurgery repeat head CT was obtained in the morning and showed no interval changes in the bleed. The patient had an orogastric tube that was subsequently discontinued and the patient was extubated. Cardiovascularly the patient was stable. Hematocrits were stable. From an infectious disease standpoint the patient was on gentamicin and Kefzol for 24 hours. The patient was in the intensive care unit for several days and extubated without complications. Per orthopedics the patient eventually was weight bearing as tolerated and will require follow up. Per neurosurgery, a repeat head CT was unremarkable. The [**Hospital 228**] hospital course was also positive for right shoulder pain. On examination there was tenderness to palpation but no gross deformity. MRI was recommended but it was felt the patient could not tolerate MRI. The patient had limited range of motion. A plane film was reimaged with axillary view showing no gross deformity or dislocation. The patient was advised to be in a sling for six weeks with follow up with orthopedics. The patient was also noted to have swelling of the right upper extremity. Upper extremity DVT was suspected. Doppler ultrasound was obtained which was negative for DVT. Oral/maxillofacial surgery was also consulted for facial fractures. All of them were undisplaced and per OMF, did not recommend operative management. The patient was advised to follow up with dentistry in several weeks for further evaluation. Ophthalmology was also consulted and no acute issues were seen. The patient will also follow up with ophthalmology on an outpatient basis. DISCHARGE STATUS: The patient will be discharged to a rehabilitation center. Physical therapy was brought in and worked with the patient throughout the hospital course. DISCHARGE MEDICATIONS: 1. Tylenol 650 mg p.o. 2. Phenytoin 100 mg p.o. t.i.d. 3. Subcutaneous heparin. 4. Morphine for pain control. 5. Haldol 1 mg IV t.i.d. 6. Donepezil 5 mg p.o. q.h.s. 7. Augmentin started [**5-3**] and ending [**5-10**]. 8. Lactulose p.r.n. constipation. CONDITION ON DISCHARGE: Good. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 18153**], M.D. [**MD Number(1) 18154**] Dictated By:[**Last Name (NamePattern4) 49037**] MEDQUIST36 D: [**2132-5-5**] 11:05 T: [**2132-5-5**] 11:25 JOB#: [**Job Number 49038**]

[ "E814.7", "852.06", "V10.79", "823.92", "294.8", "852.26" ]

icd9cm

[ [ [] ] ]

[ "88.41", "78.57", "38.93", "86.69", "79.66", "99.15" ]

icd9pcs

[ [ [] ] ]

4197, 4451

2097, 4174

840, 2079

168, 790

807, 817

4476, 4764

43,551

145,481

34319

Discharge summary

report

Admission Date: [**2102-3-28**] Discharge Date: [**2102-5-8**] Date of Birth: [**2037-9-7**] Sex: M Service: MEDICINE Allergies: Codeine / Bactrim Attending:[**Last Name (NamePattern4) 290**] Chief Complaint: diarrhea Major Surgical or Invasive Procedure: endotracheal intubation PICC line placement History of Present Illness: 64 Y/O s/p double cord blood transplant for AML presented with diarrhea and N/V. He initially had mild diarrhea for almost one month. The mild diarrhea could be well controlled by Imodium. On [**2102-2-15**], he received a colonoscopy for his diarrhea. Other than a few polyps, his colon was normal. The random biopsies were normal too. He has used to use Imodium 2 pills per day for the past one month or so. Of note, on the last Thursday, his prednisone was cut down to 15 mg from 20 mg daily However, on this Sunday, he suddenly developed worsening diarrhea with no blood. He reported that he had copious watery non-bloody diarrhea associated with middle abd cramps. He had 3-4 episodes of watery diarrhea per day. he also reported N/V with no hematemesis or coffee-ground emesis. Even after fasting, his diarrhea did not slow down. He denied heartburn, dysphagia, odynophagia, gas, bloating, and weight loss. He denied travel history or sick contacts. In ED, he received MethylPREDNISolone Sodium Succ 40mg. Upon arriving at floor, his diarrhea improved Review of Systems: (+) Per HPI (-) Review of Systems: GEN: No fever, chills, night sweats, recent weight loss or gain. HEENT: No headache, sinus tenderness, rhinorrhea or congestion. CV: No chest pain or tightness, palpitations. PULM: No cough, shortness of breath, or wheezing. GI: no hematochezia or melena. GUI: No dysuria or change in bladder habits. MSK: No arthritis, arthralgias, or myalgias. DERM: No rashes or skin breakdown. NEURO: No numbness/tingling in extremities. PSYCH: No feelings of depression or anxiety. All other review of systems negative. Past Medical History: ONCOLOGY HISTORY: -- history of hairy cell leukemia initially present with thrombocytopenia & splenomegaly in [**2097**] -- treated with one cycle of cladribine in [**2099-5-26**] with subsequent remission -- [**2101-1-24**] presented with flu symptoms in [**2101-1-24**] and was diagnosed with an AML M5B. -- Induction chemotherapy with 7+3 and consolidation with HiDAC and he is planned for allogeneic stem cell transplant -- prior to transplant it showed disease recurrence with multiple cytogenetic abnormalities on bone marrow biospy [**6-7**] -- Reinduced with MEC [**6-20**] -- Double cord blood transplant on [**2101-7-21**] -- Conditioning regimen consisted of busulfan, fludarabine, thiotepa, and ATG. -- *Transplant course was complicated by fever and neutropenia, volume overload, questionable orchitis, and C. diff infection presently on chronic po vanc. . Past Medical History: 1. hypothyroidism 2. GERD 3. right frontal subdural [**12-5**] [**12-28**] traumatic injury on attic door, treated conservatively resolved spontaneously 4. interstitial pneumonitis rx with steriods [**2097**] 5. b/l hearing loss since childhood. Uses hearing aids 6. hx multiple colonic polyps 7. gout 8. hyperlipidemia Social History: Works part time as a retired security guard. Lives at home with his wife and daughter. Quit smoking 8 yrs ago. Social alcohol use, approximately 1 alcoholic beverage/ day, but has not had any alcohol use since he was started on chemo. Family History: N/C Physical Exam: VS: 98.1 120/68 P 90 R 20 SaO2 100 @ RA GEN: AOx3, NAD HEENT: PERRLA. MMM. no LAD. no JVD. neck supple. No cervical, supraclavicular, or axillary LAD Cards: RR S1/S2 normal. no murmurs/gallops/rubs. Pulm: No dullness to percussion, CTAB no crackles or wheezes Abd: BS+, soft, NT, no rebound/guarding, no HSM, no [**Doctor Last Name 515**] sign Extremities: wwp, no edema. DPs, PTs 2+. Skin: no rashes or bruising Neuro: CNs II-XII intact. 5/5 strength in U/L extremities. DTRs 2+ BL. sensation intact to LT, cerebellar fxn intact (FTN, HTS). gait WNL. discharge exam: expired Pertinent Results: Admission Labs: [**2102-3-28**] 10:02PM PT-12.0 PTT-22.7 INR(PT)-1.0 [**2102-3-28**] 08:53PM GLUCOSE-128* UREA N-35* CREAT-1.5* SODIUM-139 POTASSIUM-4.6 CHLORIDE-107 TOTAL CO2-20* ANION GAP-17 [**2102-3-28**] 08:53PM ALT(SGPT)-68* AST(SGOT)-35 LD(LDH)-219 ALK PHOS-79 TOT BILI-0.7 [**2102-3-28**] 08:53PM ALBUMIN-3.9 [**2102-3-28**] 08:53PM WBC-5.8 RBC-3.15* HGB-11.8* HCT-32.5* MCV-103* MCH-37.5* MCHC-36.3* RDW-15.6* [**2102-3-28**] 08:53PM NEUTS-83.1* LYMPHS-10.3* MONOS-5.8 EOS-0.1 BASOS-0.7 [**2102-3-28**] 08:53PM PLT COUNT-167 [**2102-4-28**] 2:42 pm Rapid Respiratory Viral Screen & Culture BRONCHIAL LAVAGE. **FINAL REPORT [**2102-5-1**]** Respiratory Viral Culture (Final [**2102-5-1**]): TEST CANCELLED, PATIENT CREDITED. Refer to respiratory viral antigen screen and respiratory virus identification test results for further information. Respiratory Viral Antigen Screen (Final [**2102-5-1**]): Positive for Respiratory viral antigens. Specimen screened for: Adeno, Parainfluenza 1, 2, 3, Influenza A, B, and RSV by immunofluorescence. Refer to Respiratory Virus Identification for further information. Respiratory Virus Identification (Final [**2102-5-1**]): Reported to and read back by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] (4I) [**2102-5-1**] AT 1159. POSITIVE FOR PARAINFLUENZA TYPE 3. Viral antigen identified by immunofluorescence. [**2102-4-28**] 2:42 pm BRONCHOALVEOLAR LAVAGE GRAM STAIN (Final [**2102-4-28**]): 2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. RESPIRATORY CULTURE (Final [**2102-4-30**]): ~1000/ML Commensal Respiratory Flora. POTASSIUM HYDROXIDE PREPARATION (Final [**2102-4-28**]): Test cancelled by laboratory. PATIENT CREDITED. This is a low yield procedure based on our in-house studies. if pulmonary Histoplasmosis, Coccidioidomycosis, Blastomycosis, Aspergillosis or Mucormycosis is strongly suspected, contact the Microbiology Laboratory (7-2306). Immunoflourescent test for Pneumocystis jirovecii (carinii) (Final [**2102-4-30**]): NEGATIVE for Pneumocystis jirovecii (carinii).. FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. ACID FAST SMEAR (Final [**2102-5-1**]): NO ACID FAST BACILLI SEEN ON DIRECT SMEAR. NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR. ACID FAST CULTURE (Preliminary): VIRAL CULTURE: R/O CYTOMEGALOVIRUS (Final [**2102-5-1**]): TEST CANCELLED, PATIENT CREDITED. Reported to and read back by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] (4I) [**2102-5-1**] AT 1425. [**2102-4-21**] 12:18 am BRONCHOALVEOLAR LAVAGE GRAM STAIN (Final [**2102-4-21**]): 2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. RESPIRATORY CULTURE (Final [**2102-4-23**]): ~1000/ML Commensal Respiratory Flora. LEGIONELLA CULTURE (Final [**2102-4-28**]): NO LEGIONELLA ISOLATED. POTASSIUM HYDROXIDE PREPARATION (Final [**2102-4-21**]): Test cancelled by laboratory. PATIENT CREDITED. This is a low yield procedure based on our in-house studies. if pulmonary Histoplasmosis, Coccidioidomycosis, Blastomycosis, Aspergillosis or Mucormycosis is strongly suspected, contact the Microbiology Laboratory (7-2306). Immunoflourescent test for Pneumocystis jirovecii (carinii) (Final [**2102-4-21**]): NEGATIVE for Pneumocystis jirovecii (carinii).. FUNGAL CULTURE (Final [**2102-5-5**]): NO FUNGUS ISOLATED. ACID FAST SMEAR (Final [**2102-4-21**]): NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR. ACID FAST CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED. VIRAL CULTURE: R/O CYTOMEGALOVIRUS (Preliminary): No Cytomegalovirus (CMV) isolated. [**2102-4-16**] 1:55 pm Rapid Respiratory Viral Screen & Culture Source: Nasopharyngeal swab. **FINAL REPORT [**2102-4-17**]** Respiratory Viral Culture (Final [**2102-4-17**]): TEST CANCELLED, PATIENT CREDITED. Refer to respiratory viral antigen screen and respiratory virus identification test results for further information. Respiratory Viral Antigen Screen (Final [**2102-4-17**]): Positive for Respiratory viral antigens. Specimen screened for: Adeno, Parainfluenza 1, 2, 3, Influenza A, B, and RSV by immunofluorescence. Refer to Respiratory Virus Identification for further information. Respiratory Virus Identification (Final [**2102-4-17**]): Reported to and read back by [**Last Name (un) 27395**] [**Doctor Last Name **] [**2102-4-17**] 2:30PM. POSITIVE FOR PARAINFLUENZA TYPE 3. Viral antigen identified by immunofluorescence. [**2102-4-3**] 8:50 pm BLOOD CULTURE PERIPHERAL. **FINAL REPORT [**2102-4-8**]** Blood Culture, Routine (Final [**2102-4-8**]): STAPH AUREUS COAG +. Consultations with ID are recommended for all blood cultures positive for Staphylococcus aureus and [**Female First Name (un) 564**] species. FINAL SENSITIVITIES. Staphylococcus species may develop resistance during prolonged therapy with quinolones. Therefore, isolates that are initially susceptible may become resistant within three to four days after initiation of therapy. Testing of repeat isolates may be warranted. STAPHYLOCOCCUS, COAGULASE NEGATIVE. Isolated from only one set in the previous five days. Sensitivity testing per DR.[**Last Name (STitle) 78984**] BRANCH([**Numeric Identifier **]) ON [**2102-4-5**]. Staphylococcus species may develop resistance during prolonged therapy with quinolones. Therefore, isolates that are initially susceptible may become resistant within three to four days after initiation of therapy. Testing of repeat isolates may be warranted. FINAL SENSITIVITIES. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPH AUREUS COAG + | STAPHYLOCOCCUS, COAGULASE NEGATIVE | | CLINDAMYCIN-----------<=0.25 S <=0.25 S ERYTHROMYCIN----------<=0.25 S <=0.25 S GENTAMICIN------------ <=0.5 S <=0.5 S LEVOFLOXACIN---------- 0.25 S 0.25 S OXACILLIN------------- 0.5 S <=0.25 S TETRACYCLINE---------- <=1 S TRIMETHOPRIM/SULFA---- <=0.5 S VANCOMYCIN------------ 1 S Anaerobic Bottle Gram Stain (Final [**2102-4-4**]): GRAM POSITIVE COCCI IN PAIRS AND CLUSTERS. Reported to and read back by [**Doctor Last Name **] [**Doctor Last Name **] AT 3:50PM ON [**2102-4-4**]. Aerobic Bottle Gram Stain (Final [**2102-4-4**]): GRAM POSITIVE COCCI IN PAIRS AND CLUSTERS. [**2102-4-28**] 11:45 am BLOOD CULTURE Source: Line-aline #1. **FINAL REPORT [**2102-5-4**]** Blood Culture, Routine (Final [**2102-5-4**]): THIS IS A CORRECTED REPORT [**2102-5-2**], 3:40PM. Reported to and read back by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**2102-5-2**], 3:42PM. ENTEROCOCCUS FAECIUM. FINAL SENSITIVITIES. HIGH LEVEL GENTAMICIN SCREEN: Susceptible to 500 mcg/ml of gentamicin. Screen predicts possible synergy with selected penicillins or vancomycin. Consult ID for details. HIGH LEVEL STREPTOMYCIN SCREEN: Resistant to 1000mcg/ml of streptomycin. Screen predicts NO synergy with penicillins or vancomycin. Consult ID for treatment options. . PREVIOUSLY REPORTED AS HIGH LEVEL GENTAMICIN SCREEN: Resistant to 500 mcg/ml of gentamicin. Screen predicts NO synergy with penicillins or vancomycin. Consult ID for treatment options ON [**2102-5-2**], 1:29PM. SENSITIVE TO Daptomycin @ 1.5 MCG/ML, Sensitivity testing performed by Etest. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ENTEROCOCCUS FAECIUM | AMPICILLIN------------ =>32 R DAPTOMYCIN------------ S LINEZOLID------------- 1 S PENICILLIN G---------- =>64 R VANCOMYCIN------------ =>32 R Anaerobic Bottle Gram Stain (Final [**2102-4-29**]): Reported to and read back by [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] @ 1843 ON [**4-29**] - 4I. GRAM POSITIVE COCCI. IN PAIRS AND CHAINS. OCTREOTIDE SCAN [**2102-4-17**]: No abnormal focus of tracer uptake at 4 hrs to suggest carcinoid. Pulmonary uptake is likely secondary to infiltrates. Routine 24 hr and SPECT/CT images were not obtained secondary to patient clinical instability as above. CXR [**4-20**] The ET tube tip is at the carina, just above the origin of the main bronchi and should be pulled back for approximately 2.5 cm. The right PICC line tip is at the level of superior SVC. The NG tube tip is in the stomach. Heart size is normal. Lateral apical opacities, although might represent area of pulmonary edema, on the other hand can represent worsening of infectious process demonstrated on [**4-17**], [**2101**] radiograph. No appreciable pleural effusion is seen. No pneumothorax is noted. TTE [**4-23**] The left atrium is normal in size. The patient is mechanically ventilated. The IVC is small, consistent with an RA pressure of <10mmHg. Left ventricular wall thicknesses and cavity size are normal. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded, particularly in the inferior and lateral regions as these segments are not consistently well-visualized. Overall left ventricular systolic function is mildly depressed (LVEF= 45-50 %). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (?#) appear structurally normal with good leaflet excursion. No aortic regurgitation is seen. The mitral valve leaflets are structurally normal. Physiologic mitral regurgitation is seen (within normal limits). The pulmonary artery systolic pressure could not be determined. There is a trivial/physiologic pericardial effusion. IMPRESSION: Limited study. Mildly depressed global left ventricular systolic function. In the setting of suboptimal image quality may not rule out a regional wall motion abnormality, particularly in the inferior and lateral regions as these segments are not consistently well visualized. No clinically significant aortic or mitral valve stenosis or regurgitation. Indeterminate pulmonary artery systolic pressure. Trivial pericardial effusion. Compared with the prior study (images reviewed) of [**2102-4-21**], the global left ventricular systolic function appears to have improved slightly, although this may in part be secondary to tachycardia (HR 119 currently, 63 on prior). [**4-23**] RENAL ULTRASOUND: IMPRESSION: Normal renal ultrasound. [**2102-4-29**] CT TORSO WITH CONTRAST: 1. Diffuse ground-glass opacities involving the majority of both lungs with focal areas of nodularity. Increased severity and extent compared to prior examination. Differential is broad and includes infection (atypical or fungal) or possibly non-cardiogenic pulmonary edema (ie ARDS, TRALI, drug toxicity, etc.) 2. No acute intra-abdominal pathology or abscess. 3. Stable chronic compression deformity of the superior endplate of L2. CXR [**2102-5-7**]: Mild pulmonary edema has improved since [**5-6**]. The large areas of bilateral pneumonia, which worsened on the right between [**5-3**] and [**5-6**], are subsequently stable. Small right pleural effusion and borderline cardiomegaly are unchanged. In addition to the dense area of left suprahilar consolidation, improved since [**4-30**] and subsequently stable, there is suggestion of new nodularity in the right lung as well as new right pleural effusion. All of these findings could be infectious, including septic embolism. CT scanning should be helpful in evaluating these abnormalities. Right internal jugular line ends approximately a centimeter below the estimated location of the superior cavoatrial junction. ET tube is in standard position and a nasogastric tube ends in the lower stomach and out of view. Brief Hospital Course: 64 yo M with AML s/p double cord transplant presenting with 3 days of watery diarrhea and abdominal pain. [**Hospital Unit Name 153**] course: Admitted to ICU [**4-22**] with an acute episode of worsening tachypnea to the 40s, shortness of breath, wheezing, and tachycardia to the 180s in the setting of walking to and from the commode. An EKG showed a supraventricular tachycardia. He was given 2mg of morphine and 40mg of IV Lasix for concern of flash pulmonary edema and was transferred to the ICU satting 100% on a NRB. On arrival to the ICU, the patient was in acute respiratory distress, agitated, anxious, tachycardic, and tachypneic. He was asking for his oxygen to be turned up even further. Given his distress, he was emergently intubated. Respiratory distress thought to be in settting of parainfluenza type 3 PNA as he had been dyspneic and wheezing for days since diagnosis. Also thought to be in setting of flash pulmonary edema. Cardiac enzymes were checked considering ST segment changes, and he ruled in for NSTEMI. Weaning from the vent proved difficult, as he would develop agitation and increased work of breathing during subsequent spontaneous breathing trials that were concerning for flash pulmonary edema. Imaging showed a diffuse multifocal pneumonia. His antibiotics had already included vancomycin from a [**4-3**] blood culture of coag positive and negative staph, though per BMT recs these antibiotics were re-expanded to vancomycin and cefepime on [**4-27**] for fevers and hypotension. Meropenem was substituted for cefepime on [**2102-4-28**], and PO vanco was added for empiric c dif coverage at that time as well. A bronchoscopy with BAL was performed at that time for suspected pulmonary source of infection, demonstrating positive parainfluenza 3 though negative PCP, [**Name10 (NameIs) 11381**], bacterial cultures. Multiple serum assays including adenovirus, CMV, EBV, HSV, HHV6 were negative. A galactomanan was positive x2 but was felt to represent a false positive due to recent IVIG treatment. He underwent CT torso on [**2102-4-29**] due to worsening fever and leukocytosis, showing significantly worse diffuse bilateral groundglass increased in extent and confluent from [**4-14**], thickening bronchial walls, more dense consolidation in the right upper lobe, and left upper lobe concerning for diffuse infection with bacterial superinfection on atypical process. After failure to improve on vanco/[**Last Name (un) 2830**]/voriconazole/acyclovir, he was started on ambisome for enhanced fungal coverage on [**5-2**], and fungal isolator cultures were sent which were negative. Voriconazole was stopped, and vancomycin was discontinued in favor of linezolid at that time for a blood culture growing VRE from [**2102-4-28**]. His respiratory status failed to improve. Concerned for a post-viral BOOP, pulse dose steroids were started on [**2102-5-3**] at Methylprednisolone 500 mg IV Q24H x 3d, though his respiratory mechanics actually worsened somewhat with decreasing compliance concerning for a post-ARDS fibrosis. In light of a need for tracheostomy for continued support and failure to improve, a family meeting was thenheld on [**2102-5-8**] with the BMT and [**Hospital Unit Name 153**] teams regarding our inability to liberate him from the ventilator. His wife expressed the patients wishes never to undergo prolonged supportive measures including tracheostomy, and elected to pursue terminal extubation with shift of care goals towards comfort measures. Non-essential medications were discontinued, and he was continued on a fentanyl gtt. He was extubated with family at the bedside and died within an hour at 18:45 on [**2102-5-8**]. Other ICU events that were notable included an NSTEMI on [**2102-4-22**], which the cardiology consult team felt was consistent with acute plaque rupture. He was treated medically with aspirin, plavix, lovenox, statin, beta blocker. Catheterization was not pursued. TTE showed no valvular disease or WMA though the quality of the study was limited. Patient also developed a metabolic acidosis thought likely to be [**12-28**] renal tubular acidosis on [**4-23**]. Renal team was consulted who recommended sodium bicarb infusions, also recommended renal ultrasound which showed no evidence of hydronephrosis. He initially presented with diarrhea felt to be due to GVHD. He was kept on TPN. Of note, and extensive diarrhea work up was iniitiated, including stool elastase, chromogranin, 5-hiaa, yersina, ttg/iga, gastrin, seratonin, and vip. He was found to have an elevated chromogranin-A level 42, and was therefore sent for an octreodtide scan to rule out carcinoid which was negative. His steroids were uptitrated and cyclosporine discontinued. Steroids were tapered when his infectious picture worsened with parainfluenza, and were rapidly curtailed. He later underwent steroid pulse towards the end of his hospital stay without much mprovement in his pulmonary status. Multiple Cdif assays and a PCR were negative. Patient also had LUE swelling, US showed partially occlusive left IJ thrombus. Line was removed and he was started on lovenox and later heparin gtt for one month, which was then discontinued. He was also noted to have transaminits throughout admission which peaked then normalized, then peaked again. It was likely secondary to GVHD, especially in the setting of his diarrhea and skin changes. Medications on Admission: Neoral 25 mg Cap 1 (One) Capsule(s) by mouth twice a day Vancocin 125 mg Cap 1 Capsule(s) by mouth twice a day lorazepam 0.5 mg Tab 1 Tablet(s) by mouth every six (6) hours as needed for insomnia/anxiety mycophenolate mofetil 500 mg Tab 1 Tablet(s) by mouth twice a day lisinopril 2.5 mg Tab 1 Tablet(s) by mouth once a day omeprazole 20 mg Cap, Delayed Release 1 Capsule(s) by mouth DAILY (Daily) prednisone 10 mg Tab 1.5 (One and a half) Tablet(s) by mouth once a day or as directed Imodium A-D 2 mg Tab 1 Tablet(s) by mouth three times a day as needed for diarrhea potassium chloride ER 20 mEq Tab, Particles/Crystals 1 Tablet(s) by mouth once a day levothyroxine 100 mcg Tab 1 Tablet(s) by mouth DAILY (Daily) Mepron 750 mg/5 mL Oral Susp 10 mL by mouth once a day (1500 mg) acyclovir 400 mg Tab 1 Tablet(s) by mouth every eight (8) hours multivitamin Cap 1 Capsule(s) by mouth once a day folic acid 1 mg Tab 1 Tablet(s) by mouth once a day magnesium oxide 400 mg Tab 1 Tablet(s) by mouth once a day Entocort EC 3 mg 24 hr Cap 1 Capsule(s) by mouth three times a day Discharge Medications: none/expired Discharge Disposition: Expired Discharge Diagnosis: expired Discharge Condition: expired Discharge Instructions: expired Followup Instructions: expired [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]

[ "V15.82", "244.9", "410.71", "584.9", "279.50", "487.0", "427.89", "038.10", "E878.0", "518.81", "453.86", "V42.82", "787.91", "276.3", "205.00", "276.51", "518.0", "530.81", "996.85", "518.4", "274.9", "276.2", "285.22", "272.4" ]

icd9cm

[ [ [] ] ]

[ "88.72", "38.91", "99.14", "96.04", "00.14", "45.16", "99.15", "33.24", "96.72", "38.97", "45.25" ]

icd9pcs

[ [ [] ] ]

23385, 23394

16770, 22209

292, 338

23445, 23454

4130, 4130

23510, 23656

3512, 3517

23347, 23362

23415, 23424

22235, 23324

23478, 23487

3532, 4086

7975, 16747

4102, 4111

6463, 6635

1492, 2004

244, 254

366, 1438

4146, 6430

2918, 3239

3255, 3496

64,315

192,522

39241+58274

Discharge summary

report+addendum

Admission Date: [**2192-2-16**] Discharge Date: [**2192-2-20**] Date of Birth: [**2129-3-11**] Sex: F Service: MEDICINE Allergies: Clindamycin Attending:[**First Name3 (LF) 1646**] Chief Complaint: Unresponsive Major Surgical or Invasive Procedure: none History of Present Illness: Ms. [**Known lastname 2093**] is a 62 year old female with history of bipolar d/o and multiple suicide attempts, DM, HCV, who was found outside of her home drooling, diaphoretic, and non-verbal. She was taken by EMS to [**Hospital3 1280**]. Upon arrival to the [**Hospital1 **] ED, her vitals were BP 132/67, HR 78, T 98.6, RR 16, 96% on RA. She independent at baseline and last spoke with her son the day before and denied any mood disturbances. At [**Hospital1 **], she had a negative head CT, c-spine CT, CXR, LP, and tox screen at OSH. She was found to be hyperglycemic to 450 and so was given 10 units of insulin. She was seen by neurology who felt she needed a higher level of neurology care. They raised concern for non-convulsive status. At [**Hospital1 **], she was given a banana bag, 10 units SQ of regular insulin for hyperglycemia to 450, and dilantin 1 g IV given the concern for non-convulsive status. . In the ED, initial vitals were T 97.9, HR 72, BP 122/60, RR 30, 99% on 4L NC. In triage, she was observed to be having episodes of apnea. She was briefly hypotensive to 72/40 and responded to 2L IVF. A right femoral line was placed. She subsequently developed hypotension to 81/42 and so levophed was started at 0.1 mg/kg/hr. She had a head CT, CT c-spine, and CXR repeated here which were negative. She was given vancomycin, zosyn, and ceftriaxone. Neuro consult was called, but they were unable to evaluate the patient in the ED. She was given calcium and glucagon in the case of potential calcium channel blocker overdose. . Upon arrival to the [**Hospital Unit Name 153**], patient is diaphoretic and unresponsive. She is non-verbal and does not follow commands. . Past Medical History: Diabetes, type 2 Hypertension Hepatitis ?C (diagnosed in the last 2-3 months) Bipolar disorder (on disability for bipolar, with history of several overdoses in these past most recently 6 months ago) Hyperlipidemia Social History: [**Last Name (LF) **], [**First Name3 (LF) **] her son. She has occasional beer per her son. Family History: Family history of alcoholism. Physical Exam: Vitals: T 100.1, HR 75, BP 122/58 on 0.07 of levophed, RR General: nonverbal, not following commands, eyes closed, jaw clenched HEENT: Sclera anicteric, pupils a 4 cm and very sluggish reaction to light Lungs: limited by patient cooperation CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly, GU: foley present, Ext: right femoral line, warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: non-verbal, Pupils equal and sluggishly reactive to light from 4cm --> 3 cm, corneal reflex intact, face symmetric. Withdraws to painful stimuli in all for extremities, but RUE has triple flexion. Upper extremities are rigid with increased tone. Pertinent Results: [**2192-2-15**] 10:00PM BLOOD WBC-8.3 RBC-4.02* Hgb-12.9 Hct-38.1 MCV-95 MCH-32.1* MCHC-33.9 RDW-15.6* Plt Ct-165 [**2192-2-15**] 10:00PM BLOOD Neuts-82.6* Lymphs-13.3* Monos-3.3 Eos-0.1 Baso-0.7 [**2192-2-15**] 10:00PM BLOOD ALT-142* AST-83* LD(LDH)-188 AlkPhos-76 TotBili-0.3 [**2192-2-15**] 10:00PM BLOOD Phenyto-11.3 Lithium-0.3* [**2192-2-15**] 10:00PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG CT HEAD HISTORY: 62-year-old woman with altered mental status. FINDINGS: There is no acute intracranial hemorrhage, mass effect, shift of midline structures, or edema. [**Doctor Last Name **]-white matter differentiation is normally preserved. The ventricles and cerebral sulci are prominent, likely reflecting age-related involutional change. Note is made of cavum septum pellucidum et vergae. A small, 3 mm lipoma is located posterior to the splenium of the corpus callosum. Mucosal thickening of the right maxillary sinus is minimal. The visualized paranasal sinuses are otherwise normally aerated. The mastoid air cells are clear. Vascular calcifications involve the internal carotid arteries bilaterally. IMPRESSION: No acute intracranial hemorrhage or edema. NOTE ON ATTENDING REVIEW: There is a slightly dense focus in the left side of pons, (se 2 and 3, im 9) which is liekly artifactual on the thin section reformations obtained. Attention can be paid on follow up studies. Brief Hospital Course: Ms. [**Known lastname 2093**] is a 62 year old female with diabetes, HTN, HL, bipolar disorder with multiple prior suicide attempts from medication overdoses who is admitted with altered mental status. . 1. Altered mental status. Patient presented with altered menal status. CT head and c-spine were unremarakable. UA and CXR negative. Patient's infectious workup was negative though she did have a left shift on her differential and an elevated lactate. The differential for her altered mental status included seizure/post-ictal state, occult infection, unknown ingestion. Her osmolar gap was 3 and Stox/Utox were negative, but patient has history of multiple suicide attempts in the past with ingestions of prescribed meds. Muscular rigidity, temperature and history of medication overdoses raises the question of serotonin syndrome. A neuro consult was called and they recommended EEG (negative for seizure), MRI (negative for intracranial process/mass), LP (negative), TSH (wnl). Dilantin was continued. They then recommended 24hr EEG which showed no evidence of seizure and dilantin was stopped. Outside hospital lamictal levels were elevated at 35. Her mental status grdually improved. On speaking with her son, she said that she had "taken a lot of pills" before she came in. Psychiatry was consulted for suicide attempt, and recommended prn haldol for agitation, 1:1 sitter, and inpatient psychiatric admission on discharge. . 2. Hypotension. Differential for hypotension was hypovolemic versus septic. She had no positive culture data as yet and no localizing symptoms though patients mental status make history limited. Patient's presentation of being found down raises the possibility of hypovolemia from poor PO intake. She was treated with prn IVF boluses, empiric antibiotics with vanco/ceftriaxone, kept on levophed prn. Her home lisinopril was initially held then restarted on discharge. . 3. Elevated lactate. Raised the possibility of an infection, but infectious workup was negative. Also, could be secondary to seizure activity but negative EEG. Trended and found to resolve on ICU day 1. . 4. Hyperglycemia. Patient presented with hyperglycemia to 450 which has responded to insulin. No evidence of DKA. She was kept on an HISS, we followed fingersticks, and held her home actos, glyburide, and metformin. All DM meds were restarted upon discharge. . 5. Bipolar disorder. Patient has a history of bipolar disorder, on disability. Multiple prior overdoses with medications. . 6. Hepatitis C. Patient with ALT of 142, AST 83, with normal albumin. INR normal at OSH. Per OSH report, patient was recently diagnosed in [**12-11**]. No evidcence of cirrhosis by labs or on exam. LFTs trended down. Likely from hep C. She needs follow up with her PCP for this, then referral to GI from there. . 7. Hyperlipidemia. Held simvastatin given elevated LFTs and inability to take POs. This should be held until f/u with PCP. . 8. ? artifact on CT. CT head needs repeat as o/p to follow up likely artifact. See read above. . Code: DNR/DNI, paperwork in the chart . Communication: son [**First Name4 (NamePattern1) **] [**Name (NI) 2093**] [**Telephone/Fax (1) 86846**]) Was updated on status at the time of discharge. Medications on Admission: Actos 30 mg daily Asacol 800 mg [**Hospital1 **] Glyburide 2.5 mg [**Hospital1 **] Lamictal 100 mg [**Hospital1 **] Lisiinopril 30 mg daily Metformin 1000 mg daily Simvastatin 20 mg daily Aspirin 81 Lexapro 10 mg [**Hospital1 **] ?actonel Discharge Medications: 1. Metformin 1,000 mg Tablet Extended Rel 24 hr Sig: One (1) Tablet Extended Rel 24 hr PO once a day. 2. Glyburide 2.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Tablet(s) 3. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day. 4. Lisinopril 30 mg Tablet Sig: One (1) Tablet PO once a day. 5. Actos 30 mg Tablet Sig: One (1) Tablet PO once a day. 6. Asacol 400 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO twice a day. 7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Discharge Disposition: Extended Care Facility: [**Hospital1 69**] - [**Location (un) 86**] Discharge Diagnosis: Primary Diagnosis: 292.81 DELIRIUM, DRUG INDUCED Secondary Diagnosis: 296.80 BIPOLAR DISORDER, UNSPECIFIED Secondary Diagnosis: 969.3 OVERDOSE, ANTIPSYCHOTIC Secondary Diagnosis: V62.84 SUICIDAL IDEATION Secondary Diagnosis: 250.02 DIABETES TYPE II, UNCONTROLLED, W/O COMPLICATIONS Discharge Condition: Mental Status: Clear and coherent Level of Consciousness: Alert and interactive Activity Status: Ambulatory - Independent Discharge Instructions: patient being transferred to facility, [**Hospital1 18**] Psychiatric Inpatient Service Followup Instructions: At the time of discharge from inpatient psychiatry, please have the patient make an appointment with her primary care doctor. Name: [**Known lastname 4045**],[**Known firstname 4193**] Unit No: [**Numeric Identifier 13745**] Admission Date: [**2192-2-16**] Discharge Date: [**2192-2-20**] Date of Birth: [**2129-3-11**] Sex: F Service: MEDICINE Allergies: Clindamycin Attending:[**First Name3 (LF) 13746**] Addendum: Discharge meds on DC summary incorrect Asacol TID and metformin is [**Hospital1 **] Glyburide 2.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Tablet(s) Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day. Lisinopril 30 mg Tablet Sig: One (1) Tablet PO once a day. Actos 30 mg Tablet Sig: One (1) Tablet PO once a day. Asacol 400 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO three times a day. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Metformin 1,000 mg Tablet Sig: One (1) Tablet PO twice a day. Also PCP is [**Name9 (PRE) **] Name: [**Doctor Last Name 13747**] First Name: [**Doctor First Name **] Specialty: Internal Medicine Sub-specialty: Office Phone: ([**Telephone/Fax (1) 13748**] Office Fax: ([**Telephone/Fax (1) 13749**] Address Line 1: [**Last Name (NamePattern1) 13750**] [**Apartment Address(1) 13751**] Address Line 2: City: [**Location (un) 4887**] State: MA Zip: [**Numeric Identifier 13752**] Discharge Disposition: Extended Care Facility: [**Hospital1 536**] - [**Location (un) 42**] [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 13753**] MD [**MD Number(2) 13754**] Completed by:[**2192-2-20**]

[ "305.1", "V15.41", "303.91", "250.02", "966.3", "V61.42", "296.80", "780.01", "292.81", "E950.4", "458.9", "518.81", "272.4", "300.4", "401.9", "276.8", "070.70", "276.0", "781.99" ]

icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

11055, 11285

4676, 7912

285, 292

9215, 9215

3230, 4653

9475, 11032

2374, 2405

8202, 8796

8910, 8910

7938, 8179

9363, 9452

2420, 3211

233, 247

320, 2010

9135, 9194

8929, 8959

9230, 9339

2032, 2248

2264, 2358

5,774

135,367

25303

Discharge summary

report

Admission Date: [**2172-2-24**] Discharge Date: [**2172-3-12**] Date of Birth: [**2117-5-3**] Sex: M Service: MEDICINE Allergies: Percocet Attending:[**First Name3 (LF) 338**] Chief Complaint: SOB/cough Major Surgical or Invasive Procedure: Central line placement Arterial line placement Liver biopsy History of Present Illness: The patient is a 54 yo M with a h/o AML s/p a matched related allogeneic stem cell transplant on [**2171-1-8**] with busulfan and Cytoxan conditioning with complications of CMV viremia, GVHD, hemorrhagic cystitis, and disseminated TB with 2 recent admissions with pericardial effusion and tamponade, s/p window on [**2172-1-10**]. The patient presented to the ED today with SOB and cough x 1 week. The patients wife reports that over the past [**5-16**] days the patient has had fevers to 101, fatigue, weakness, and persistent cough with blood tinged sputum. . Of note, the patient was recently admitted on [**2171-12-4**] with shortness of breath, cough, and peripheral edema. He was found to have a pericardial effusion with early tamponade physiology. The effusion was drained for a total of 1300cc's of fluid. It was felt the more likely etiology as a viral process although no specific etiology has been found. Recent AFB smears have been negative but a recent culture has grown positive for Xanthamonas. He also was noted for persistent positive B-glucan and Mr. [**Known lastname 63305**] was treated with Bactrim to cover both PCP and [**Name9 (PRE) 63311**]. Unfortunately, the patient required another urgent admission ([**Date range (3) 63312**]) with pericardial effusion and tamponade. This was drained again and a window was place. There was no infectious etiology identified and the thought was this could be related to GVHD. During this admission, his antibiotics were changed to prophylactic doing for PCP with Bactrim. Since that time, the patient has been slowly improving and was about to restart photopheresis therapy for GVHD. . In the ED today, initial vitals were T99.8, HR 191 BP 91/65 RR25 O2 100% NRB (77%RA). Initially found to have a glucose of 49. He received 1 amp D50. He became hypotensive to the 70's and neosynephrine was initialed. He was them emergently intubated (received etomidate 20/Succ 120mg). His HR remained in the 160's-170's and he was cardioverted (100J) and converted to sinus tacycardia (HR 120's-130's). A RIJ was placed for code sepsis. His BP remained low and levophed was started. He received 3L NS, vanocmycin, ceftaz, flagyl, and levofloxacin. A CXR was concerning for RUL PNA and fluid overload. Cardiology was consulted and performed a bedside ECHO which revealed a loculated effusion unchanged from prior ECHO on [**2172-2-20**]. He also received a unit of FFP after the line placement. Past Medical History: ONC HISTORY (per OMR): 1. Diagnosed in early [**8-/2169**] with nightly fevers. BM bx revealed AML. Flow cytometry showed aberrant expression of CD2, CD7, HLA-DR, CD 34, dim CD33, CD 117, and CD 71. CT scan revealednecrotic lymph nodes in the superior mediastinum and periportalregion, and multiple low attenuation lesions in the liver and spleen concerning for microabscesses from a disseminated infection. 2. [**2169-8-17**]: Induction chemotherapy with cytarabine and idarubicin complicated by persistent fevers and extensive workup ultimately revealing disseminated tuberculosis infection. His course was also complicated by rapid atrial fibrillation and hypotension and the development of a severe cardiomyopathy. 3. S/P one dose of high-dose ARA-C at 1.5 mg per meter squared, lowered dose due to his disseminated tuberculosis, and then he received a second course of HiDAC at 3 gram per meter squared dose and developed acute onset of gait instability. No further chemotherapy given. 4. Relapsed in 7/[**2170**]. [**Year (4 digits) **] re-induction with ME on [**2170-8-13**]. Noted for pulmonary nodules which were suspicious for aspergillus and empirically treated with Voriconazole with improvement noted on CT. 5. Admitted on [**2170-10-25**] for maintenance therapy while awaiting BMT. However, upon admit he was again found to have blasts. He proceeded with Idarubicin and Cytarabine(7+2) butdid not achieve a remission. 6. S/P High dose Ara-c with remission. 7. [**Year (4 digits) **] sibling related allo transplant on [**2171-1-8**]. Allo course c/b increased LFTs of unclear etiology, possibly from chemotherapy, renal failure attributed to CSA, and received only 1 dose of MTX due to mucositis. 8. Post transplant course complicated by asymptomatic CMV viremia and viral/URI syndromes. 9. In [**2171-5-12**] developed diarrhea with e/o GVH on endoscopy. He also had hematuria, but no evidence of BK virus. He started photopheresis. Diarrhea abated but LFTs rose. Therapy attempted for GVH of liver using pulse of prednisone and increase in CellCept with stabilization but no significant improvement. 10. Received 1mg of Pentostatin on [**2171-6-14**]. 11. Liver Biopsy c/w GVHD. Started Rituxan for 4 weeks in 5/[**2171**]. Non-onc PMH - Disseminated TB - s/p treatment with INH, levofloxacin and rifabutin - Hypertension and a heart murmur - Diabetes mellitus type 2 - Chemo related heart failure and cardiomyopathy, EF 35-40% [**12-16**] - h/o atrial fibrillation, recent EKGs in NSR - CMV viremia ([**2-17**]) Social History: He is married and lives at home with his wife & children. He is a machine operator, but is currently not working. He immigrated from [**Country 5976**] in early [**2144**]. He smoked approximately 3 cigarettes per day for 20 years and stopped 1 year ago. He does not drink alcohol. Family History: Notable for mother who passed away of myocardial infarction. His father passed away of liver disease. He has four living brothers and two living sisters, all in good health. Physical Exam: Vitals - 95.4 126/93 101 22 100% AC 500x22 FIO2100% General - intubated, sedated, unresponive HEENT - pupils 3mm and reactive Neck - elevated JVP CV - tachycardic, no murmur, no rub Lungs - crackles at bases Abdomen - soft, NT/ND Ext - 3+ pitting edema b/l Skin - pale, changes consistent with GVHD Pertinent Results: [**2172-2-24**] 01:30AM GRAN CT-210* [**2172-2-24**] 01:30AM PT-15.2* PTT-33.6 INR(PT)-1.3* [**2172-2-24**] 01:30AM PLT SMR-RARE PLT COUNT-8*# [**2172-2-24**] 01:30AM HYPOCHROM-3+ ANISOCYT-2+ POIKILOCY-1+ MACROCYT-3+ MICROCYT-NORMAL POLYCHROM-1+ TARGET-1+ SCHISTOCY-1+ STIPPLED-1+ TEARDROP-1+ PAPPENHEI-1+ [**2172-2-24**] 01:30AM NEUTS-6* BANDS-1 LYMPHS-51* MONOS-37* EOS-0 BASOS-0 ATYPS-1* METAS-3* MYELOS-1* NUC RBCS-14* [**2172-2-24**] 01:30AM WBC-0.4*# RBC-2.35* HGB-9.4* HCT-28.7* MCV-122* MCH-39.9* MCHC-32.7 RDW-21.8* [**2172-2-24**] 01:30AM CALCIUM-9.2 PHOSPHATE-4.4 MAGNESIUM-2.3 [**2172-2-24**] 01:30AM CK-MB-NotDone [**2172-2-24**] 01:30AM cTropnT-0.07* [**2172-2-24**] 01:30AM CK(CPK)-28* [**2172-2-24**] 01:30AM GLUCOSE-53* UREA N-40* CREAT-1.6* SODIUM-143 POTASSIUM-4.8 CHLORIDE-106 TOTAL CO2-22 ANION GAP-20 [**2172-2-24**] 01:42AM freeCa-1.15 [**2172-2-24**] 01:42AM GLUCOSE-49* LACTATE-4.6* NA+-140 K+-4.4 CL--106 [**2172-2-24**] 01:42AM PH-7.36 COMMENTS-GREEN TOP [**2172-2-24**] 02:05AM URINE GRANULAR-0-2 HYALINE-0-2 [**2172-2-24**] 02:05AM URINE RBC-[**12-31**]* WBC-0-2 BACTERIA-MOD YEAST-NONE EPI-0-2 TRANS EPI-[**4-15**] [**2172-2-24**] 02:05AM URINE BLOOD-LG NITRITE-NEG PROTEIN-100 GLUCOSE-TR KETONE-TR BILIRUBIN-MOD UROBILNGN-NEG PH-6.5 LEUK-NEG [**2172-2-24**] 02:05AM URINE COLOR-Amber APPEAR-Hazy SP [**Last Name (un) 155**]-1.021 [**2172-2-24**] 02:44AM TYPE-ART RATES-/14 TIDAL VOL-500 PO2-91 PCO2-64* PH-7.16* TOTAL CO2-24 BASE XS--6 INTUBATED-INTUBATED [**2172-2-24**] 02:55AM HGB-8.3* calcHCT-25 O2 SAT-90 [**2172-2-24**] 02:55AM COMMENTS-GREEN TOP [**2172-2-24**] 04:14AM freeCa-1.11* [**2172-2-24**] 04:14AM LACTATE-2.9* [**2172-2-24**] 04:14AM TYPE-ART RATES-22/ TIDAL VOL-500 O2-100 PO2-242* PCO2-53* PH-7.23* TOTAL CO2-23 BASE XS--5 AADO2-435 REQ O2-73 -ASSIST/CON INTUBATED-INTUBATED [**2172-2-24**] 05:30AM PT-15.3* PTT-33.9 INR(PT)-1.3* [**2172-2-24**] 05:30AM PLT COUNT-15*# [**2172-2-24**] 05:30AM WBC-0.5* RBC-2.32* HGB-9.1* HCT-29.1* MCV-125* MCH-39.2* MCHC-31.3 RDW-21.8* [**2172-2-24**] 05:30AM CALCIUM-8.3* PHOSPHATE-6.2*# MAGNESIUM-2.2 [**2172-2-24**] 05:30AM CK-MB-NotDone cTropnT-0.05* [**2172-2-24**] 05:30AM ALT(SGPT)-83* AST(SGOT)-103* LD(LDH)-398* CK(CPK)-24* ALK PHOS-593* TOT BILI-3.6* DIR BILI-3.0* INDIR BIL-0.6 [**2172-2-24**] 05:30AM GLUCOSE-169* UREA N-40* CREAT-1.5* SODIUM-138 POTASSIUM-5.0 CHLORIDE-104 TOTAL CO2-21* ANION GAP-18 [**2172-2-24**] 08:36AM PLT COUNT-90*# [**2172-2-24**] 02:08PM URINE GR HOLD-HOLD [**2172-2-24**] 02:08PM URINE OSMOLAL-320 [**2172-2-24**] 02:08PM URINE HOURS-RANDOM [**2172-2-24**] 02:08PM URINE HOURS-RANDOM UREA N-122 CREAT-92 SODIUM-70 [**2172-2-24**] 04:04PM TYPE-ART TEMP-36.1 RATES-30/3 TIDAL VOL-450 PEEP-12 O2-50 PO2-93 PCO2-46* PH-7.31* TOTAL CO2-24 BASE XS--3 -ASSIST/CON INTUBATED-INTUBATED [**2172-2-24**] 06:17PM TYPE-ART TEMP-35.8 RATES-30/2 TIDAL VOL-450 PEEP-10 O2-50 PO2-90 PCO2-43 PH-7.34* TOTAL CO2-24 BASE XS--2 -ASSIST/CON INTUBATED-INTUBATED . RUQ ultrasound: Perihepatic ascites and gallbladder wall edema, which are without the presence of cholelithiasis or biliary dilatation, the question of third spacing or even hepatitis should be considered. Known peripancreatic lymphadenopathy. . Echo [**2-24**]: Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Overall left ventricular systolic function is severely depressed. Estimation of ejection fraction is impossible due to limited images although LV function appears significantly more depressed than previously. There is abnormal septal motion/position. There is a small pericardial effusion. The effusion appears loculated. There are no echocardiographic signs of tamponade. Pericardial constriction cannot be excluded. . Echo [**2-26**]: IMPRESSION: Normal biventricular cavity size with mild global left ventricular hypokinesis c/w diffuse process (toxin, metabolic, etc.). Mild aortic regurgitation with normal valve morphology. Anterior, organized pericardial effusion without evidence for hemodynamic compromise. Compared with the prior study (images reviewed) of [**2171-2-20**], left ventricular systolic function is slightly improved (previously overestimated). The anterior pericardial effusion is similar. . [**2172-2-29**] CT Abd/Pelvis: 1. Multifocal airspace disease as demonstrated on multiple recent chest radiographs. 3. No evidence of bowel obstruction. 4. Moderate ascites, increased compared to prior CT study from [**2168-8-7**]. 5. Overall, stable retroperitoneal and periportal lymphadenopathy. 6. Right colonic wall thickening including the caecum, consistent with non- specific colitis. No associated abscess or free/contained air 7. Several liver calcifications suggesting prior granulomatous disease. . [**3-1**] Brief Hospital Course: Mr. [**Known lastname 63305**] is a 54 yo M with h/o AML s/p a matched related allo transplant on [**2171-1-8**] with busulfan and Cytoxan conditioning with complications of CMV viremia, GVHD, hemorrhagic cystitis, and disseminated TB with 2 recent admissions with pericardial effusion and tamponade, s/p window on [**2172-1-10**], admitted with respiratory failure and hypotension secondary to pneumococcal sepsis. . # Respiratory failure. Intubated in ED. Vent setting were weaned to pressure support with minimal support for several weeks. Could not extubate secondary to poor mental status. In his last few days, switched back to assist control for more ventilatory support. Extubated approximately 20 minutes prior to death. . # Pneumococcal sepsis. Completed 2 week course of ceftriaxone followed by meropenem. . # Acute renal failure. Massive renal insult from hypotension from pneumococcal sepsis. Had 4 days of CVVH in an attempt to improve his mental status. . # A fib with RVR - h/o A fib with RVR; cardioverted in ED. Was shocked x 3 more times in ICU, eventually loaded with amiodarone, which was stopped after LFT's started to climb. Rate controlled after amio load. . # AML - continued on atovaquone, acyclovir (until copies of CMV noted in blood), and posaconazole. Transfused as needed. . # GVHD - has GVHD of liver, skins, eyes. Held Cellcept initially, restarted during admission. Weaned from stress dose steroids initially, then given high dose steroids when liver function began to deteriorate. . # Liver failure - thought secondary to shock liver + GVHD. Liver biopsy performed on [**3-10**], demonstrating minimal portal triads but generally burned out liver (from GVHD). No infection identified. . In the last several days, his pressor requirement increased and he required more support from the ventilator. After a discussion with his primary oncologist and the family, he was made CMO and expired shortly therafter, at 12:02pm on [**2172-3-12**]. Medications on Admission: Docusate Sodium 100 mg [**Hospital1 **] Nystatin Five ML PO QID Benzonatate 100 mg TID Prednisone 20 mg DAILY Posaconazole 200 mg/5 mL TID Pyridoxine 100 mg DAILY Vitamin E 400 unit DAILY Folic Acid 1 mg DAILY Lantus 14 units QAM + SS Toprol XL 25 mg daily Trimethoprim-Sulfamethoxazole 160-800 mg One Tablet PO M-W-F Mycophenolate Mofetil 500 mg AM/250mg PM Dexamethasone 5ml swish PO BID Acyclovir 400 mg TID Atovaquone 750 mg/5 mL Suspension 10 ml (1500mg) Suspension(s) by mouth once a day Lumigan 0.03 % Drops 1 Drop in the right eye twice a day Restasis 0.05 % Dropperette One drop in each eye twice a day Methylcellulose 1 % Drops One drop in each eye four times a day Omeprazole 20mg daily Oxycontin 10mg [**Hospital1 **] Oxycodone 5mg tab q4 PRN Prednisolone 0.12 % Drops, Suspension One drop in each eye QID Discharge Medications: Expired Discharge Disposition: Expired Discharge Diagnosis: Expired Discharge Condition: Expired Discharge Instructions: Expired Followup Instructions: Expired

[ "250.00", "038.2", "349.82", "599.0", "V42.82", "078.5", "991.6", "481", "996.85", "785.52", "428.0", "584.9", "995.92", "427.31", "518.82", "263.8", "287.5", "205.01" ]

icd9cm

[ [ [] ] ]

[ "00.14", "33.24", "39.95", "96.6", "99.04", "96.04", "50.11", "99.05", "38.93", "99.07", "99.61", "96.72" ]

icd9pcs

[ [ [] ] ]

13924, 13933

11047, 13022

277, 338

13984, 13993

6196, 11024

14049, 14059

5686, 5861

13892, 13901

13954, 13963

13048, 13869

14017, 14026

5876, 6177

228, 239

366, 2815

2837, 5370

5386, 5670

21,274

164,354

5665

Discharge summary

report

Admission Date: [**2185-9-1**] Discharge Date: [**2185-9-14**] Date of Birth: [**2127-12-23**] Sex: M Service: MED Allergies: Stelazine / Thorazine / Crixivan / Heparin Agents Attending:[**First Name3 (LF) 783**] Chief Complaint: Abdominal Distension Major Surgical or Invasive Procedure: none History of Present Illness: 57yo male with hx of HCV (no documented cirrhosis), HIV (CD4 count of 9; viral load of >100,000), CAD (s/p MI '[**82**] and cath), CHF (EF <30%) who presents with acute new onset increased abdominal distension. Pt reports 5 days of progressively increasing abdominal girth. Initially, the patient attributed this to constipation, however the abdominal disstension progressed even after multiple large BMs. Pt reports associated SOB, progressive DOE over the last couple of days (previous could walk at least 1/8th of a mile but now SOB after 0.5 blocks), orthopnea (progressive 2 pillow requirement) and ?PND. Pt also reports he has felt "cloudy" with difficulty concentrating. Pt also reports difficulty sleeping, however this has not changed and the pt attributes this to his baseline mania/psych disorder. The patient has not noticed a tremor. Pt denies abdominal pain, fever, chills, rigors, n/v/d. Pt also denies CP, palpitations, light headedness, dizziness, cough, sputum production. . ROS: Pt does report a "few drops" of blood followed a BM last week. This was an isolated episode that resolved on own without intervention. Pt currently denies, BRBPR, black tarry stools, stools with particular strong odors. Pt reports [**1-28**] BM/day. Pt also reports some inc. thirst, without polyuria. . The patient received a therapeutic/diagnostic paracentesis in the ED. 850cc of fluid was removed. The fluid was sent for cell count and diff, as well as protein, glucose, and amylase. (Albumin was added on as was cytology later in the AM). Past Medical History: 1). HIV/AIDS: Pt was previously on HAART successfully with fully suppressed Viral load but is now comletely off HAART with CD4 count of 9 and Viral load of >100,000. 2). Hepatitis C - Length of disease unknown, has attempted interferon and ribavirin tx in past but stopped due to malaise. 3). CAD s/p MI in [**2182**]: cath with LAD TO, LCx 60%, ostial RCA TO and LVEF 27% 4). CHF: EF 27% 5). HTN 6). DM secondary to Crixivan 7). Pancreatitis secondary to meds 8). bipolar/schizoaffective disorder 9). h/o IVDU 10). PPD + Social History: Pt is a former merchant marine (has been to South East [**Female First Name (un) 8489**] and [**Female First Name (un) 8489**]) who has retired due to disability and currently lives with wife [**Name (NI) **]. Pt admits to former IVDU having used IV heroine from [**2148**] to [**2174**]. Pt also reports having used alcohol in the past - one-two 6packs/day for 30+ years but quit 15 years ago. Pt also admits to having smoked cigarettes - 0.5-1 ppd x15years but also quit 15 years ago and has recently started smoking a pipe. Family History: Grandmother who passed away from TB Physical Exam: PE: VS: T: 99.1 BP: 136/90 HR: 106 RR: 16 SaO2: 98% on RA Gen: Pt is lying in bed at 30 degrees in no acute distress. Pt is speaking in full sentences but is having some difficulty catching his breath after long sentences. Tattoo on left arm HEENT: temporal wasting, PERRL, EOMI, anicteric sclera, oral pharynx clear, no jaundice under the tongue, mmm. Neck: JVD 12cm, no lymphadenopathy, supple, full range of motion CV: RRR, S1, S2, 2-3/6 systolic murmur best heard at LUSB to LLSB without radiation to neck or axilla. Chest: bibasilar crackles with expiratory wheezing. Abd: BS+ in all four quadrants, markedly distended, no spider angiomata, no diffuse or focal tenderness to palpation, + fluid wave, liver span >8cm and spleen span >10cm by scratch test. Ext: warm to touch, 1+ pitting edema bilaterally, cap refill <2sec. Rectal: guaiac negative in ED Neuro: CN II-XII grossly intact, Asterixis with <10sec of holding hands out, no pronator drift, gait is not tested Pertinent Results: Cardiac cath [**2185-6-18**]: One vessel coronary artery disease. Severe systolic ventricular dysfunction and mild diastolic ventricular dysfunction. -LAD: 20% narrowing in the mid vessel at the take-off of a D1 -D1: 40% lesion in the proximal vessel -LCX: 60% ostial lesion -RCA was totally occluded proximally and mid and distal vessels were diffusely diseased and filled via R->R collaterals from the proximal RCA and L->R collaterals from the LAD -PDA and PLV were small and diffusely diseased. -mildly elevated left ventricular filling pressures with an LVEDP of 13 mmHg. -severely impaired left ventricular systolic function with a calculated LVEF of 27%. . TTE [**2185-6-17**]: -Left atrium is mildly dilated -Moderate regional left ventricular systolic dysfunction with thinning/akinesis of the basal inferior wall, thinning/dyskinesis of the mid-inferior wall, and hypokinesis of the basal half of the inferior septum and inferolateral walls -Distal lateral wall is hypokinetic. -Mild to moderate ([**11-26**]+) mitral regurgitation -Estimated pulmonary artery systolic pressure is normal. -IMPRESSION: Focal left ventricular systolic dysfunction c/w CAD. Mild-moderate mitral regurgitation. . Portable CXR [**2185-8-31**]: "Low lung volumes. No CHF or pneumonia" . Abd US [**2185-8-31**]: "There is a large amount of fluid in the abdomen. The spleen is enlarged, and measures 17 cm. The location of maximal fluid was marked for paracentesis in the left lower quadrant." . KUB [**2185-8-31**]: "No evidence of obstruction. Ascites" . Duplex US of Abd complete [**2185-9-1**]: Pending . [**2185-8-31**] 10:16PM ASCITES WBC-1050* RBC-1400* POLYS-0 LYMPHS-5* MONOS-0 OTHER-95* ---Other: pathology attending read and flow cytometry pending. [**2185-8-31**] 10:16PM ASCITES TOT PROT-2.1 GLUCOSE-52 LD(LDH)-1311 ALBUMIN-LESS THAN [**2185-8-31**] 11:30PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-4* PH-6.5 LEUK-NEG [**2185-8-31**] 11:30PM URINE COLOR-Amber APPEAR-Clear SP [**Last Name (un) 155**]-1.018 [**2185-9-1**] 09:55AM WBC-1.2* RBC-2.64* HGB-9.4* HCT-28.8* MCV-109* MCH-35.4* MCHC-32.4 RDW-18.2* [**2185-9-1**] 09:55AM PLT SMR-RARE PLT COUNT-34* Brief Hospital Course: A/P: 57yo male with HCV, HIV, CAD with CHF EF <30% prents with acute new onset ascites. 1. Respiratory failure - the patient was transfered from the floor to the intesive care unit s/p intubation for increased work of breathing. Chest CT was consistent with CHF and possible pneumonia. The patient was started on a broad spectrum antibiotic regimen for his pneumonia. He was placed on optimal medical management for his CHF/CAD. This regimen included metoprolol, statin, ASA, and isordil. On this regimen the patients blood pressures were well controlled. On day 13 s/p intubation the patient's respiratory status had improved enough that an attempt at extubation was made. 2. Lymphoma - The patient was diagnosed with primary effusion lymphoma by peritoneal cytology. The options for treatment included HAART and chemotherapy but given the patient's immunocompromised state, it was decided that the these treatment options were suboptimal. 3. ARF - The patients Cr slowly elevated over the course of his hospital stay. The etiology is multifactorial likely secondary to pre-renal, ATN, and hepatorenal. 4. Pancytopenia: Pt has had an extensive prior workup for pancytopenia and this has been attributed to HIV itself. Although the patient is not currently neutropenic, appropriate precautions were taken. Hct and Platelet count were closely monitored for signs of bleeding. 5. HIV/AIDS: Pt was previously on HAART with good success but has been off HAART due to complications. Prophylaxis was continued with fluconazole, azithromycin, and dapsone. . 6. HIT antibody: The patient did not recieve any heparin products given his HIT antibody. 7. ESLD - the patient was continued on lactulose. With regard to his ascites he was taped therapeutically x 2 and placed on spironolactone. 8. CMO - On HD 14 the patients family wanted to the patient to be made CMO and to have him extubated. Shortly after extubation the patient expired. The patient's family agreed to an autopsy. Medications on Admission: Fluconazole 100mg once daily Azithromycin 1200mg Q week Clonidine 0.3mg [**Hospital1 **] NPH 40u AM and 30u PM RISS Metoprolol 12.5mg [**Hospital1 **] Lisinopril 5mg QHS Clonazepam 1mg TID Roxicet 2 tabs PRN Promethazine 50mg TID ASA 1mg once daily All: Stelazine, Thorazine, Crixivan (caused pancreatitis and DM?), Heparin (HIT ab positive) Discharge Medications: N/A Discharge Disposition: Extended Care Facility: patient expired Discharge Diagnosis: HIV/AIDS Lymphoma Respiratory failure CHF Discharge Condition: N/A Discharge Instructions: N/A Followup Instructions: N/A [**First Name11 (Name Pattern1) 734**] [**Last Name (NamePattern1) 735**] MD, [**MD Number(3) 799**]

[ "292.9", "304.03", "038.0", "428.0", "251.8", "518.81", "584.9", "486", "070.70", "995.91", "200.00", "296.80", "572.3", "567.2", "042", "414.01", "424.0", "458.9", "284.8" ]

icd9cm

[ [ [] ] ]

[ "99.04", "88.72", "96.04", "54.91", "00.14", "96.72", "33.24" ]

icd9pcs

[ [ [] ] ]

8729, 8771

6312, 8307

325, 331

8856, 8861

4081, 6289

8913, 9049

3025, 3063

8701, 8706

8792, 8835

8333, 8678

8885, 8890

3078, 4062

265, 287

362, 1916

1938, 2461

2477, 3009

83,301

153,052

53508

Discharge summary

report

Admission Date: [**2167-8-25**] Discharge Date: [**2167-8-31**] Date of Birth: [**2113-11-30**] Sex: M Service: MEDICINE Allergies: Penicillins Attending:[**First Name3 (LF) 9824**] Chief Complaint: melena Major Surgical or Invasive Procedure: esophagogastroduodenoscopy ultrasound guided liver biopsy History of Present Illness: Mr. [**Known lastname **] is a 53 year old male with polycystic kidney disease s/p cadaveric transplant in [**2147**], esophageal and gastric varices, hypertension and chronic diarrhea who presents from home with three days of melena and lightheadedness. The patient reports that he was in his usual state of health until this Saturday when he began to experience dark stools. He has never had dark stools in the past. Over the past 48 hours he reports having up to 10 black bowel movements per day with associated lightheadedness and dizziness. On Saturday he had some mild left lower quadrant abdominal pain but this has since resolved. He denies any chest pain, shortness of breath, nausea, vomiting, current abdominal pain, hematemasis, hematochezia, dysuria, hematuria, leg pain or swelling. He is not taking any iron supplements. The patient has a history of chronic diarrhea but this is significantly different. He called his primary care physician who recommended that he present to the emergency room. . In the emergency room the patient's initial vitals were T: 99.8 HR: 79 BP: 96/52 RR: 16 O2: 98% on RA. He received protonix 40 mg IV x 1. His stool was brown with black specks and was guaiac positive. EKG showed normal sinus rhythm, normal axis, QTc 463, PVCs, TWI in II, III, aVF, no significant change from prior dated [**2166-7-23**]. He received 1 L normal saline. He was admitted to the floor for further management. . On review of systems he currently denies lightheadedness, dizziness, fevers, chills, cough, congestion, chest pain, shortness of breath, nausea, vomiting, abdominal pain, constipation, hematochezia, dysuria, hematuria, leg pain, swelling, numbness or weakness. + melena and diarrhea as above. All other review of systems negative in detail. Past Medical History: Polycystic Kidney Disease s/p cadaveric renal transplant in [**2147**] Chronic stage III kidney disease Portal Vein Thrombosis Esophageal and Gastric Varices Hepatic Cysts Recurrent Skin Cancers (basal cell) Osteopenia Tertiary Hyperparathyroidism Chronic Diarrhea Vitamin D deficiency Depression Hypertension Lower Extremity Edema Hyperlipidemia Hyperglycemia Neuropathy with Charcot Foot Gout Social History: Works as an editor for a car magazine. He does not smoke. Occassional alchohol. No illicits. Family History: Mother had polycystic kidney disease, died of complications of transplant. Father had MI at 77. He has two sisters, one with polycystic kidney disease. Physical Exam: Vitals: T: 98.2 BP: 100/60 HR: 73 RR: 20 O2: 100% on RA General: Alert, oriented, no distress HEENT: Sclera anicteric, MM dry, oropharynx clear Neck: JVP flat, no LAD CV: RRR, s1 + s2, no murmurs, rubs, gallops Resp: Clear to auscultation bilaterally, no wheezes, rales, ronchi GI: soft, non-tender, non-distended, +BS GU: no foley Ext: WWP, 2+ pulses, no clubbing, cyanosis or edema Rectal: Guaiac positive in the emergency room Pertinent Results: [**2167-8-24**] 09:35PM BLOOD WBC-6.7# RBC-3.07* Hgb-9.3* Hct-29.6* MCV-97 MCH-30.2 MCHC-31.3 RDW-14.9 Plt Ct-98* [**2167-8-26**] 01:19PM BLOOD WBC-1.9* RBC-2.30* Hgb-7.2* Hct-21.7* MCV-94 MCH-31.3 MCHC-33.2 RDW-16.2* Plt Ct-47* [**2167-8-25**] 05:35AM BLOOD PT-15.2* PTT-33.4 INR(PT)-1.3* [**2167-8-24**] 09:35PM BLOOD Glucose-103 UreaN-81* Creat-1.9* Na-145 K-4.3 Cl-114* HCO3-23 AnGap-12 [**2167-8-24**] 09:35PM BLOOD CK-MB-NotDone cTropnT-0.02* [**2167-8-27**] 04:32AM BLOOD Cyclspr-81* [**2167-8-31**] 07:30AM BLOOD HCV Ab-NEGATIVE . Abdominal U/S with doppler [**2167-8-25**]: IMPRESSION: 1. Innumerable hepatic and left renal cysts. 2. Normal liver Doppler evaluation. 3. Gallbladder wall edema, also present [**2164**], but no signs for acute cholecystitis. . CXR [**2167-8-26**]: FINDINGS: No previous images. The cardiac silhouette is mildly enlarged. No vascular congestion or pleural effusion. No acute focal pneumonia. There may be some atelectatic changes at the left base. . EGD [**2167-8-25**]: Varices at the lower third of the esophagus and gastroesophageal junction Small hiatal hernia. Erythema, friability and mosaic appearance in the whole stomach compatible with portal hypertensive gastropathy Varices at the fundus and cardia Normal mucosa in the duodenum Otherwise normal EGD to second part of the duodenum No banding of varicosity was able to be performed. . EGD [**2167-8-27**]: 34 cords of grade III varices were seen starting at 38 cm from the incisors in the lower third of the esophagus and gastroesophageal junction. There were stigmata of recent bleeding. At least 3 of the varices were extending down through the GE junction and extending to the fundus and lesser curvature. there were red spots on esophageal varices. 5 bands were successfully placed. Other there were significant esophageal [**Last Name (un) 4782**] II varices extending above the area of banding. Stomach: Protruding Lesions Non bleeding varices were seen in the fundus. Duodenum: Normal duodenum. Impression: Varices at the lower third of the esophagus and gastroesophageal junction (ligation). There were significant esophageal [**Last Name (un) 4782**] II varices extending above the area of banding. Varices at the fundus. Otherwise normal EGD to second part of the duodenum . U/S-guided Liver biopsy [**2167-8-30**]: no complications, report and pathology pending Brief Hospital Course: 1. UPPER GASTROINTESTINAL BLEED: Patient with known esophageal and gastric varices from hepatic cysts. EGD on [**8-25**] showed stigmata of recent bleed but no current bleeding. Varices were not amendable to banding. After EGD, patient was hypotensive with HCT drop from 27 to 22 while on PPI and octreotide. Pt was transferred to the MICU in the setting of persistently low hematocrit despite transfusion and new hypotension. He received IV fluids, 3 units of PRBCs with improved hemodynamics. He was noted to have a fever during one of his transfusions, but remained cardiovascularly stable throughout and had no complaints of CP, SOB, or rash. Hemolysis workup was negative and fevers resolved. EGD was performed by GI on [**2167-8-27**] w/ banding of gastric varices. Pt was transfered back to the medica floor for further care. On arrival to medical floor, patient was hemodynamically stable and hematocrit was checked every 12 hours and remained stable. Pt underwent an U/S-guided liver biopsy on [**2167-8-31**]. After this procedure his HCT was stable at 29.6. The procedure was without complications and he was discharged later that day without complaints. He was continued on oral PPIs and Nadolol 20mg PO qday on discharge. He was given octreotide for 48 hours after the bleed. He was told to return for any symptoms of lightheadedness, dizziness, fatigue or blood in his bowel movements. He will follow-up with his primary care doctor and with his gastroenterologist which are both scheduled. . His liver biopsy results are pending at the time of discharge. . 2. CHRONIC KIDNEY DISEASE Creatinine on admission was 1.9 which is his baseline. This value rose to 2.5 on [**2167-8-26**]. This was felt to be pre-renal given his FeNA<1% and recent GI bleed. Pt was hypovolemic and creatinine improved with hydration. On discharge, creatinine was 2.0. He was discharged on his home regimen of Prednisone 10mg every other day, CellCept and cyclosporin were continued as per home dose. . 3. PANCYTOPENIA: Pt was pancytopenic with WBC [**1-4**] and platelets 50-80. He was transfused with 2 bags of platelets prior to the liver biopsy to reach platelet count over 80. The pancytopenia was not a [**Last Name **] problem and felt to be related to chronic steroid use, cyclosporin and liver disease. 5. HYPERGLYCEMIA: Was hyperglycemic in the ICU felt to be secondary to steroid use as pt was given hydrocortisone IV. He was put on an insulin sliding scale. Blood sugars were normal at the time of discharge and the patient did not require any insulin for several days prior to discharge. Medications on Admission: Alendronate 35 mg qweek Allopurinol 100 mg [**Hospital1 **] Calcitriol 0.25 mcg every other day Citalopram 40 mg daily Cyclosporin 75 mg QAM, 50 mg QPM Ergocalciferol 50,000 units qmonth Gabapentin 600 mg [**Hospital1 **] Lipitor 5 mg daily Mycopheolate Mofetil 500 mg [**Hospital1 **] Nadolol 40 mg [**Hospital1 **] Prednisone 5 mg daily Soriatane 25 mg daily Discharge Medications: 1. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO EVERY OTHER DAY (Every Other Day). 2. Citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 3. Cyclosporine 25 mg Capsule Sig: Three (3) Capsule PO QAM (once a day (in the morning)). 4. Cyclosporine 25 mg Capsule Sig: Two (2) Capsule PO QPM (once a day (in the evening)). 5. Atorvastatin 10 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 6. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q12H (every 12 hours). 7. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Mycophenolate Mofetil 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 9. Prednisone 10 mg Tablet Sig: One (1) Tablet PO every other day. 10. Sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times a day). Disp:*120 Tablet(s)* Refills:*0* 11. Nadolol 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours) for 20 days. Disp:*40 Tablet, Delayed Release (E.C.)(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Primary: Acute blood loss anemia secondary to variceal bleed Polycystic liver disease Acute on chronic kidney disease Discharge Condition: good Discharge Instructions: You were admitted to the hospital with a bleed from the GI tract. This was treated with banding of the esophageal varices. You were monitored in the ICU for low blood pressure. You had a liver biopsy on [**2167-8-31**]. Your prednisone was changed to 10mg every other day. You were continued on your other medications. You should follow-up with your doctors as directed below. Please call your primary care physician or seek medical attention in the emergency room for any symptoms of lightheadedness, dizziness, fainting, chest pain, shortness of breath, nausea and vomiting, vomiting blood, fevers > 101 degrees, chills, night sweats, blood in your stool, or swelling of the abdomen or legs. Followup Instructions: Liver Center: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 6970**], MD Phone:[**Telephone/Fax (1) 463**] Date/Time:[**2167-9-15**] 3:15 Pirmary Care: Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**Name Initial (NameIs) **].D. Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2167-10-1**] 12:10 Renal: Provider: [**First Name11 (Name Pattern1) 1877**] [**Last Name (NamePattern1) 1878**], M.D. Phone:[**Telephone/Fax (1) 435**] Date/Time:[**2167-11-5**] 2:00

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Discharge summary

report

Admission Date: [**2155-6-19**] Discharge Date: [**2155-6-27**] Service: MEDICINE Allergies: Penicillins Attending:[**First Name3 (LF) 14961**] Chief Complaint: Abdominal pain, nausea, vomiting Major Surgical or Invasive Procedure: none History of Present Illness: The patient is an 89 year old female from [**Hospital 100**] Rehab with a past medical history significant for CAD s/p CABG x3, left basal ganglia CVA with residual right-sided hemiparalysis, chronic constipation, HTN and GERD who presented to the ED from HR on [**2155-6-19**] with the chief complaint of abdominal pain and nausea, vomiting. A physician at [**Hospital 100**] Rehab evaluated the patient for abdominal pain and nausea and vomiting x 1 that began at 3 pm the day of presentation. She did not have any fevers/chills at rehab. Her baseline is intermittent diarrhea and constipation with a history of chronic constipation. Thus, she did not note any change in her bowel movements or blood in her stool or emesis. She had no cough, chest pain or shortness of breath. No clear sick contacts. . In the ED, the patient was afebrile at 96.5 with a HR of 87, BP 170 systolic. She had an NGT placed for recurrent emesis in the ED and both her NGL and rectal was guaiac positive (rectal only occult). Her K was found to be 6.5 and she was given 1 amp D50, bicarb, 1 amp calcium gluconate, and 10 units of regular insulin. In addition, she received 3 amps of bicarb in 1 liter D5W as well as Anzemet for nausea, hydralazine 10 mg IV and Lopressor 5 mg IV for hypertension. She also received phenergan for nausea. . A CT of her A/P showed: . 1. 5 cm infrarenal abdominal aortic aneurysm with 1.5 cm mural thrombus, with high density within the thrombus concerning for content rupture. . 2. Extensive atherosclerotic disease of the abdominal arteries and iliac arteries, as described above. . 3. Cholelithiasis. . No prior CT for comparison. . Her EKG showed NSR2 smm concave ST elevations V1-V3 with peaked T waves. LAD. Biphasic T waves in I and AVL. The T waves appeared more prominent than her baseline in 12-00. . In the ED, the patient had witnessed recurrent episodes of emesis and therefore, had an NGT placed. She had a reported episode of hypoxia after her emesis and was felt to have aspirated. Repeat CXR was unremarkable. She was given empiric Levo/Flagyl in ED for aspiration pneumonia. . ROS: . Decreased PO intake over past 24 hours secondary to recurrent emesis. Also notable for weight loss -unknown amount per son. [**Name (NI) **] chest pain, shortness of breath. Past Medical History: CAD s/p CABG 3vessel at [**Hospital1 756**] CVA - left basal ganglia 2 years ago with residual right-sided hemiparesis Left CEA GERD, hiatal hernia h/o chronic constipation Chronic anemia, baseline Hct 29.2-33 HTN mild dementia arthritis lumbar spinal stenosis Social History: Lives at [**Hospital 100**] Rehab chronically. Walks with walker per son without difficulty at baseline. No tobacco/EtoH at present. No history of significant use of either. Family History: Noncontributory. Physical Exam: Tc and Tm=99.5 P=72 BP=114=130/44 RR=20 99% on 4 liters O2 Gen - Arousable, somnolent, responds to voice, mumbles HEENT - dry MM, NGT in place with brown liquid Heart - RRR, Grade II/VI rumbling holosystolic murmur at LUSB Lungs - CTAB Abdomen - Soft, NT, ND, no bruits, palpable pulsatile mass to left of umbilicus. No rebound/guarding Ext - No C/C/E Rectal - Guaic positive (occult), NG guaiac positive Pertinent Results: CXR [**2155-6-19**]: Mildly prominent pulmonary vasculature, no effusions. . CXR [**2155-6-21**]: The lungs are clear without infiltrate or effusion. . CT A/P [**2155-6-19**]: 1. 5 cm infrarenal abdominal aortic aneurysm with 1.5 cm mural thrombus, with high density within the thrombus concerning for content rupture. 2. Extensive atherosclerotic disease of the abdominal arteries and iliac arteries, as described above. 3. Cholelithiasis. . Abd U/S [**2155-6-20**] 1. No evidence of free fluid in the abdomen or retroperitoneal hematoma. 2. 4.8-cm AAA. 3. No evidence of cholecystitis. . CT A/P [**2155-6-22**]: 1. 5-cm infrarenal abdominal aortic aneurysm with somewhat increased contrast filled lumen measuring 3 cm, with hypodense mural thrombus measuring 1.1 cm, representing contained rupture as described previously. 2. Diffuse wall thickening of the large bowel from ascending, transverse, and descending colon, with ascites in the bilateral paracolic gutter, worrisome for colitis, which may be infectious versus inflammatory type, or, can be ischemic colitis. Clinical correlation is recommended. 3. Extensive atherosclerotic disease with calcification of abdominal vessels. 4. Small left kidney. 5. Small pleural effusion with atelectasis. . video swallow: VIDEO OROPHARYNGEAL SWALLOW EXAMINATION: A video oropharyngeal swallowing fluoroscopy was performed today in collaboration with the speech and language pathology division. Various consistencies of barium including thin liquid, nectar thickened liquid, puree, and a cookie coated with barium were administered to the patient. The oral phase was notable for impaired bolus formation and control with premature spillover into the valleculae and piriform sinuses. There was prolonged oral transit time and mild-to-moderate oral cavity residue. The pharyngeal phase was notable for delayed swallow initiation, reduced laryngeal elevation, and absent epiglottic deflection. There was aspiration into the airway before the swallow due to swallow delay and premature spillover as well as after the swallow due to residue. Both spontaneous and cued coughs were ineffective at clearing the aspirate. Bilateral vocal fold adduction was observed. IMPRESSION: Oropharyngeal dysphagia with aspiration. For greater detail and for treatment recommendations, please see the dedicated speech and language pathology division report of the same date. . [**6-24**] Echo: Left Atrium - Long Axis Dimension: *5.7 cm (nl <= 4.0 cm) Left Atrium - Four Chamber Length: *5.6 cm (nl <= 5.2 cm) Right Atrium - Four Chamber Length: *5.3 cm (nl <= 5.0 cm) Left Ventricle - Diastolic Dimension: 4.7 cm (nl <= 5.6 cm) Left Ventricle - Ejection Fraction: 45% (nl >=55%) Aorta - Valve Level: 3.3 cm (nl <= 3.6 cm) Aorta - Ascending: 3.4 cm (nl <= 3.4 cm) Aortic Valve - Peak Velocity: 2.0 m/sec (nl <= 2.0 m/sec) Aortic Valve - Peak Gradient: 16 mm Hg Aortic Valve - Mean Gradient: 9 mm Hg Mitral Valve - E Wave: 0.9 m/sec Mitral Valve - A Wave: 0.8 m/sec Mitral Valve - E/A Ratio: 1.13 Mitral Valve - E Wave Deceleration Time: 198 msec TR Gradient (+ RA = PASP): *35 to 43 mm Hg (nl <= 25 mm Hg) INTERPRETATION: Findings: LEFT ATRIUM: Moderate LA enlargement. RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. LEFT VENTRICLE: Normal LV cavity size. Mildly depressed LVEF. RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Normal aortic root diameter. Normal ascending aorta diameter. AORTIC VALVE: Moderately thickened aortic valve leaflets. Mild AS. Trace AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. Moderate mitral annular calcification. Mild (1+) MR. TRICUSPID VALVE: Mild to moderate [[**1-27**]+] TR. Moderate PA systolic hypertension. PERICARDIUM: No pericardial effusion. Conclusions: 1. The left atrium is moderately dilated. 2. The left ventricular cavity size is normal. Overall left ventricular systolic function is mildly depressed. Basal inferior akinesis/dyskinesis and distal inferior and apical hypokinesis are present. 3. The aortic valve leaflets are moderately thickened. There is mild aortic valve stenosis. Trace aortic regurgitation is seen. 4. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. 5. There is moderate pulmonary artery systolic hypertension. . CXR: [**6-27**]: History of increased oxygen requirement and bilateral pleural effusions. Status post CABG. There is slight cardiomegaly and tortuosity of the thoracic aorta, but no evidence for CHF. Skin folds overlie the left hemithorax. There are bibasilar atelectases. . IMPRESSION: No evidence for CHF. Bibasilar atelectases. . Labs: Hematology COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct [**2155-6-27**] 04:35AM 7.8 3.56* 11.5* 33.4* 94 32.4* 34.6 15.3 118* [**2155-6-26**] 05:45AM 5.5 3.74* 12.0 35.2* 94 32.0 34.0 15.0 111* [**2155-6-25**] 05:50AM 5.8 3.97* 12.8 37.2 94 32.2* 34.5 15.1 102* [**2155-6-24**] 06:05AM 7.2 4.09* 13.0 38.1 93 31.9 34.2 15.8* 93* [**2155-6-23**] 04:43PM 7.9 4.01* 12.7 37.5 94 31.6 33.7 16.0* 84* [**2155-6-23**] 06:10AM 8.6 3.79*# 12.0# 35.6*# 94 31.6 33.6 16.3* 85* [**2155-6-22**] 07:25AM 5.8 2.69* 8.7* 25.5* 95 32.3* 34.1 16.4* 81* [**2155-6-22**] 12:07AM 26.3* [**2155-6-21**] 06:00PM 27.2* [**2155-6-21**] 05:54AM 6.6 2.76* 9.0* 26.6* 96 32.7* 33.9 15.6* 102* [**2155-6-20**] 11:04PM 30.1* [**2155-6-20**] 04:44PM 30.6* [**2155-6-20**] 11:28AM 9.4 3.43* 10.9* 32.7* 95 31.9 33.5 15.8* 128* [**2155-6-20**] 05:48AM 11.6* 3.78* 12.0 36.2 96 31.8 33.2 15.6* 140* [**2155-6-19**] 08:15PM 14.8*# 4.39 14.0 42.9 98# 31.9 32.6 15.5 187 DIFFERENTIAL Neuts Bands Lymphs Monos Eos Baso Atyps Metas Myelos [**2155-6-22**] 07:25AM 79.8* 16.3* 3.0 0.5 0.4 RED CELL MORPHOLOGY Hypochr Anisocy Poiklo Macrocy Microcy Polychr Ovalocy Stipple [**2155-6-22**] 07:25AM 1+ 1+ 1+ BASIC COAGULATION (PT, PTT, PLT, INR) PT PTT Plt Smr Plt Ct INR(PT) [**2155-6-27**] 04:35AM 118* BASIC COAGULATION (FIBRINOGEN, DD, TT, REPTILASE, BT) Fibrino [**2155-6-19**] 08:15PM 184 Chemistry RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap [**2155-6-27**] 04:35AM 104 35* 0.9 136 4.3 102 25 13 [**2155-6-26**] 05:45AM 93 36* 0.8 135 4.0 99 26 14 [**2155-6-25**] 05:50AM 107* 27* 0.9 140 3.8 101 30 13 [**2155-6-24**] 06:05AM 110* 23* 1.0 140 3.7 102 30 12 [**2155-6-23**] 04:43PM 92 21* 1.0 142 3.9 107 26 13 [**2155-6-23**] 06:10AM 117* 25* 1.0 146* 3.9 111* 28 11 [**2155-6-22**] 07:25AM 84 34* 1.1 147* 3.6 112* 29 10 [**2155-6-21**] 05:54AM 95 43* 1.3* 145 3.7 108 28 13 [**2155-6-20**] 04:44PM 119* 49* 1.5* 140 4.2 104 27 13 [**2155-6-20**] 11:28AM 161* 60* 1.7* 143 4.8 103 27 18 [**2155-6-20**] 05:48AM 201* 57* 1.7* 140 5.8* 100 25 21* [**2155-6-19**] 08:15PM 180* 53* 1.7* 136 6.5* 101 18* 24* ENZYMES & BILIRUBIN ALT AST LD(LDH) CK(CPK) AlkPhos Amylase TotBili DirBili [**2155-6-24**] 06:05AM 15 26 36* 66 1.1 OTHER ENZYMES & BILIRUBINS Lipase [**2155-6-24**] 06:05AM 19 CPK ISOENZYMES CK-MB cTropnT [**2155-6-20**] 11:28AM NotDone <0.01 [**2155-6-20**] 05:48AM NotDone 0.01 CHEMISTRY TotProt Albumin Globuln Calcium Phos Mg UricAcd Iron [**2155-6-27**] 04:35AM 8.3* 3.6 2.3 Brief Hospital Course: 89 yo female with CAD s/p CABG, prior CVA, HTN and GERD who presented on [**2155-6-19**] with nausea, vomiting, abdominal pain and guaiac positive stools. . # Abdominal pain - colitis and AAA: - - Differential on presentation included pancreatitis, GERD, PUD, cholelithiasis, AAA, ischemic bowel, or colitis. The patient had a history of chronic abdominal discomfort associated with constipation. Most likely contributor are collitis, likely ischemic due to infrarenal AAA. Patient also developed diarrhea requiring a rectal bag. The diarrhea resolved once all the bowel medications were d/c. Patient's stool was negative for C. Diff x 3 and C.Diff toxin B is pending at the time of discharge (all the pending results will be followed up by Dr. [**Last Name (STitle) 14936**]. Patient was empirically treated with Flagyl PO x 10 days (finish the course for last 4 days at rehab. Patient with emesis on presentatio that may have been due to underlying GERD. It was unlikely to be due to PUD as there was no epigastric tenderness, and patient most likely guiac positive due to underlying collitis. There was no history of melena and her Hct remained stable. Cholelithiasis and pancreatitis were unlikely as lipase, amylase and LFTs quickly normalized and their elevation was attributed to abdominal irritation. . Patient has a AAA which on CT with with mural thrombus and contained rupture. Patient likely has underlying arhterosclerotic bowel disease. She may have increasing comporomise of blood flow to both SMA and [**Female First Name (un) 899**] supplying her bowel due to large size of AAA. The pain is elicited after eating as the demand for oxygen/ATP increasing during active peristalsis causing ischemic pain. Unfortunately, the patient is a very poor candidate for surgery and even a high risk candidate with endovascular repair due to tortourous aorta. After discussion with Dr. [**Last Name (STitle) 1391**], vascular surgery, it was decided to attempt conserviate management with diet adjustment and blood pressure control in order to prevent further ischemic episodes. Patient will also be treated with Flagyl for empiric infectious C. Diff. She is also being d/c on TPN in order to assure adequate PO intake and will have calorie count performed at rehab when the decision to d/c TPN will be made if the PO calorie count is adequate. - f/u with PCP [**Name Initial (PRE) **] [**Name Initial (PRE) **]/u with Dr. [**Last Name (STitle) 1391**] as needed - call ([**Telephone/Fax (1) 4852**] for appt - tylenol prn, consider ATC if pain persists. . # Hypoxia - The patient was empirically placed on levo/flagyl on admission for ? aspiration pneumonia. Patient denied any cough. She remained afebrile after her MICU course with nl WBC. Her CXR was unimpressive but she was treated empirically with Levoquin/Flagyl x 10 days - to be finished for 4 more days at rehab - empirically. Patient CXR on d/c appears to be most consistent with b/l atelectasis and she needs to continue aggressive PT and spirometry. Patient with systolic (45%) and diastolic (+1MR) cardiac dysfuction and responded to prn Lasix 10 mg IV while in house as there was mild fluid overload after her inital IVF resusciation during her hypotension during her stay in the MICU that was attributed to sepsis due to PNA and aspiration pneumonitis. The CXR upon discharge showed no evidence of CHF. . # Blood loss anemia. Patient most likely has microscopic blood loss most likely due to ischemic collitis however upper source cannot be ruled out as patient with guiac positve NGT drainage. Patient however refused EGD and was subsequently transfused 3 units PRBCs on [**2077-6-20**] and her Hct remained stable. Patient was started on FeSO4 replacement and conservative management of her anemia. . # AAA - Now 5 cm - at criteria for repair. The patient is DNR/DNI and the family refused surgical intervention. Of note, surgery will not be an option even in an emergent situation. Patient may be a candidate for endovascular graft, however she remains a high risk due to tortous aorta approach. Patient's family, HCP decided to conservatively manage her AAA. Dr. [**Last Name (STitle) 1391**] is a different decision is reached in the future. . # CAD - no symptoms, patient continued on ASA 81, Lisinopril 10, Lipitor 10. Patient was started on low dose lopressor on [**6-21**] at 12.5 [**Hospital1 **] but the patient developed sinus bradycardia with heart rates in the high 40s and 50s. Thus, lopressor was discontinued. . # Acute renal failure - Most likely due to pre-renal azotemia that resolved with immprovement of hypotension and with IVFs. Patient does have left atrophic kidney suggestive of chronic kidney disease which was otherwise undocumented. She was restarted on Lisinopril and tolerated it well with a d/c Cr of 0.9. . FEN - Patient is to continue TPN via single line L PICC who's proper placement was confirmed with Radiology upon discharge; have calorie count at rehab. She is also to continue diet modifications as outline below: RECOMMENDATIONS: 1. PO diet texture of ground solids, nectar thick liquids. Po meds crushed in purees. 2. Maintain aspiration precautions. a. Sit upright for all meals. b. No straws. c. Awake, alert upright for all meals. d. Encourage po intake. e. Encourage pt to feed herself and to take regular sized sips of liquids. 3. Nutrition follow up re:po intake/calorie count on ground textured solids & consider downgrade to purees, as indicated. 4. Follow up speech therapy at rehab for dysphagia management. . Code - DNR/DNI - confirmed with son, HCP . Dispo - patient is being discharge to [**Hospital 100**] Rehab . Contact - [**Name (NI) **] [**Telephone/Fax (1) 97520**] (H), (C) [**Telephone/Fax (1) 97521**]; [**Last Name (un) 9102**] (H) [**Telephone/Fax (1) 97522**] (C) [**Telephone/Fax (1) 97523**] Medications on Admission: Lopressor 12.5 mg PO BID ASA EC 325 mg PO QD Lisinopril 10 mg PO QD Calcium, vitamin B MOM [**Name (NI) **] Discharge Medications: 1. Citalopram 20 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 2. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 3. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 5. [**Name (NI) **] 100 mg Capsule Sig: One (1) Capsule PO twice a day. 6. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 4 days. 7. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO once a day for 4 days. 8. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 9. Albuterol Sulfate 0.083 % Solution Sig: One (1) neb Inhalation Q6H (every 6 hours) as needed. 10. Atrovent 0.02 % Solution Sig: One (1) neb Inhalation every 4-6 hours as needed for shortness of breath or wheezing. 11. Norvasc 10 mg Tablet Sig: One (1) Tablet PO once a day. 12. Lipitor 10 mg Tablet Sig: One (1) Tablet PO once a day. 13. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - MACU Discharge Diagnosis: Colitis - likely ischemic AAA - infrarenal Aspiration Pneumonia Acute Renal Failure CAD Thrombocytopenia Anemia HTN GERD s/p CVA Dementia Discharge Condition: stable. tolerating PO. oxygenating well on 1L. Discharge Instructions: Please take all your medications as instructed. Please follow aspiration precautions when eating. Please take all your medications as instructed and complete the antibiotic course as prescribed. You may require 1L supplemental oxygen while your functional capacity improves. Please continue to use spirometer at bedside and continue to ambulate daily. Please seek medical attention if you experience any fevers/chills, nausea/vomiting or lightheadedness, do the same if you noticed blood per rectum. You may continue to experience intermittent abdominal pain after eating. Please try to follow low residue diet with small portion and symptomatic control of your pain. Followup Instructions: please make an appointment with your PCP [**Last Name (NamePattern4) **] [**1-27**] weeks after discharge to your regular long term rehab. . Follow up with Dr. [**Last Name (STitle) 1391**], vascular surgery, ([**Telephone/Fax (1) 4852**] as needed Completed by:[**2155-6-27**]

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icd9cm

[ [ [] ] ]

[ "99.04", "38.93" ]

icd9pcs

[ [ [] ] ]

17978, 18044

10857, 16722

253, 260

18226, 18275

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138,356

12886

Discharge summary

report

Admission Date: [**2162-3-21**] Discharge Date: [**2162-3-26**] Date of Birth: [**2094-12-7**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 689**] Chief Complaint: Dyspnea Major Surgical or Invasive Procedure: None History of Present Illness: 67 yo male with PAF on coumadin, CAD s/p MI/PCI, small cell lung CA s/p chemo/radiation, COPD, and recent L MCA stroke (D/C [**2162-3-13**]) p/w dyspnea x 2 days at rehab three days after discharge from [**Hospital1 **] with the same complaint. At [**Name (NI) **], Pt noted to have WBC of 28.3 (on steroids)m tachycardiam labored breathing and fever. Sats noted to be 86% and bumped up to 92-94% on 2L O2. Pt was treated with nebs and given 125mg Solumedrol IV. At 7am, noted to have a temp to 101.1. It is noted in the chart that the patient had not received atrovent for over 72 hours because it had not been written for standing. In the ED, initial vs were: T 102 P 107 BP 130/85 R 27 O2 sat 80% RA. Patient was put on non-rebreather with improvement in sats to high 90s. CXR showed No acute cardiopulmonary process. Stable post-treatment changes of the right lung. CTA was negative for PE, no new consolidation seen. Pt was started on vanc and zosyn for presumed pneumonia. WBC count noted to be 25, pt also had new transamintis since [**3-6**]. Blood glucose 369. UA negative, though patient currently on levaquin for UTI. Blood cultures sent. EKG unchanged from baseline and cardiac enzymes negative x1. On arrival to the ICU, vitals 98.7 107 122/75 17 94% on non-rebreather. Pt is aphasic so could not give a review of systems. Denies RUQ pain. Past Medical History: - left MCA stroke, felt to be cardio-embolic, on [**2162-3-6**] - CAD s/p MI and angioplasty [**2145**] - Paroxysmal atrial fibrillation - RUL SCLC s/p chemo and radiation [**2155**], in remission - COPD - no home O2 - Hyperlipidemia - DM Social History: Former heavy smoker, [**2-9**] ppd for 20-30 years, but quit in [**2155**] years ago with lung cancer diagnosis. Family History: His mother died from a heart disease at the age of 75. His father died from a throat cancer at the age of 52. Physical Exam: ADMISSION EXAM: Vitals: 98.7 107 122/75 17 94% on non-rebreather General: Alert, oriented, diaphoretic, uncomfortable appearing HEENT: NC, AT, sclera anicteric Neck: thick, unable to assess neck veins Lungs: Diminished on right, mild expiratory wheezes anteriorly, clear CV: Tachycardic, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, obese, G tibe in place Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Pertinent Results: ADMISSION LABS: [**2162-3-21**] 12:35PM WBC-25.3*# RBC-4.95 HGB-15.9 HCT-46.7 MCV-94 MCH-32.2* MCHC-34.1 RDW-13.9 NEUTS-95.7* LYMPHS-2.5* MONOS-1.5* EOS-0 BASOS-0.3 [**2162-3-21**] 12:35PM GLUCOSE-369* UREA N-33* CREAT-0.9 SODIUM-144 POTASSIUM-4.1 CHLORIDE-104 TOTAL CO2-26 ANION GAP-18 [**2162-3-21**] 12:35PM ALT(SGPT)-167* AST(SGOT)-73* CK(CPK)-112 ALK PHOS-123* TOT BILI-0.6 [**2162-3-21**] 12:35PM LIPASE-27 [**2162-3-21**] 12:35PM PT-21.5* PTT-27.4 INR(PT)-2.0* [**2162-3-21**] 12:47PM LACTATE-2.8* [**2162-3-21**] 12:45PM URINE BLOOD-SM NITRITE-NEG PROTEIN-NEG GLUCOSE-1000 KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG IMAGING CTA CHEST W&W/O C&RECONS, NON-CORONARY Study Date of [**2162-3-21**] 12:50 PM No pulmonary embolus seen. Exam is little changed from four days prior, with post- radiation changes of the right lung. No new pulmonary consolidation seen to account for the patient's symptoms. CHEST (PORTABLE AP) Study Date of [**2162-3-22**] 3:24 AM No acute cardiopulmonary process. Stable post-treatment changes of the right lung. Brief Hospital Course: 67 yo M with history of lung cancer and left sided CVA with right-sided hemiparesis and aphagia discharged last week and sent to Spauliding now presenting with fever, tachycardia and shortness of breath. Patient was initially admitted to the ICU with respiratory distress. He has a history of COPD discharged on [**3-18**] for apparent flare. Had not been receiving Atrovent at [**Hospital1 **]. # Respiratory Distress. Initially admitted to the ICU. While in the ICU, he was continued on Atrovent and Albuterol nebs, as well as Spiriva. Treated with Vancomycin and Zosyn for HAP and started on burst course of steroids for COPD flare. Respiratory status stabilized the morning of admission and transferred to hospital floor. Cont'd on albuterol, atrovent and switched to Advair. Vancomycin stopped, continued on Zosyn via PICC line placed by IR. Pred burst planned for taper at rehab. O2 requirement weaned to 2L at discharge. . # Mental Status. On arrival to hospital floor pt was alert and awake and later became somnolent in the afternoon. Vital signs continued to remain normal and cardiac workup, CT head, and lab tets were negative for cause of AMS changes. Pt slept well the first night and was not somnolent aferwards. Pt noted to be awake and alert remainder of the hospitalization. . # Fever/Elevated WBC. Elevated WBC noted to be decreasing during the hospitalization, with no fevers noted after starting antibiotics. CXR/CT scan suggestive of RLL infiltrate, UA and UCx positive for UTI. Pt initially tx'd with Vanc/Zosyn with d/c on Zosyn. Afebrile with equivocal WBC count in context of steroids. . # Urinary Tract Infection. UA/UCx positive for staph negative strep UTI. Sensitive to penicillins, covered with Zosyn for concomittant PNA. Foley changed in ICU. . # S/p left MCA stroke/Anticoagulation. Initial INR subtherapeutic. Likely related to preious admin of Levoflox and Coumadin increasing warfarin blood levels in last hospitalization. In absence of Levoflox started on 5mg Coumadin with therapuetic range achieved. . # Diabetes Mellitus. Sugars continued to remain in 200s/300s as prednisone cont'd with increased tube feeds. Lantus/ ISS increased to match sugars with reasonable control achieved on d/c. Will need to address coverage as prednisone is tapered in rehab. . # Hyperlipidemia. Pt was continued on statin. . # CAD s/p MI and angioplasty in [**2145**]. Pt was continued on ASA and Lopressor with target BPs acheived. EKGs showed no interval changes with no rises in CEs noted. . # FEN. PEG tube on admission. Tube feeds brought to goal with lytes repleted PRN. Medications on Admission: 1. Acetaminophen 325 mg Tablet 1-2 Tablets PO Q6H prn pain 2. Prednisone 60 mg Tablet 3. Ipratropium Bromide 0.02 % Solution Q6H 4. Warfarin 2.5 mg Tablet [**Year (4 digits) **]: One (1) Tablet PO DAILY (Daily): This is a decreased dose. Please monitor with daily INRs while on antibiotics and steroids 5. Docusate Sodium 50 mg/5 mL Liquid PO BID 6. Levofloxacin 750 mg Tablet PO DAILY 7. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device [**Year (4 digits) **]: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 8. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) One Inhalation Q4H 9. Aspirin 81 mg Tablet PO DAILY 10. Senna 8.6 mg Tablet PO BID as needed. 11. Simvastatin 40 mg Tablet PO DAILY 12. Omeprazole 20 mg Capsule, Delayed Release(E.C.) PO BID 13. Insulin Lispro 100 unit/mL Solution Sliding Scale 14. FiberCon 625 mg Tablet [**Hospital1 **]: Two (2) Tablet PO twice a day as needed for constipation. 15. Lopressor 50 mg Tablet [**Hospital1 **]: One (1) Tablet PO twice a day. 16. Heparin Subcutaneous three times a day. 17. Metamucil Powder PO twice a day 18. Milk of Magnesia 400 mg/5 mL Suspension [**1-8**] PO once a day as needed for constipation 19. Mycostatin 100,000 unit/g Powder Topical twice a day 20. Alum-Mag Hydroxide-Simeth 200-200-20 mg/5 mL Suspension [**Month/Day (2) **]: [**1-8**] PO every four hours as needed for heartburn. 21. Peridex 0.12 % Mouthwash [**Month/Day (2) **]: [**1-8**] Mucous membrane twice a day. Discharge Medications: 1. Senna 8.6 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO BID (2 times a day) as needed: Hold for diarrhea or > 2 BMs a day. 2. Docusate Sodium 50 mg/5 mL Liquid [**Month/Day (2) **]: One (1) PO BID (2 times a day): Hold for diarrhea or > 2 BMs a day. 3. Prednisone 20 mg Tablet [**Month/Day (2) **]: One (1) dose PO DAILY (Daily): Taper schedule: 40 mg days 1 to 5, 20mg days [**6-16**], 5mg days [**11-21**], then stop. 4. Ipratropium Bromide 0.02 % Solution [**Month/Year (2) **]: One (1) neb Inhalation every four (4) hours. 5. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device [**Month/Year (2) **]: One (1) puff Inhalation [**Hospital1 **] (2 times a day). 6. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization [**Hospital1 **]: One (1) neb Inhalation Q4H (every 4 hours). 7. Aspirin 81 mg Tablet, Chewable [**Hospital1 **]: One (1) Tablet, Chewable PO DAILY (Daily). 8. Psyllium Packet [**Hospital1 **]: One (1) Packet PO BID (2 times a day). 9. Metoprolol Tartrate 50 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times a day): Hold for SBP < 100, HR < 60. 10. Simvastatin 40 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily). 11. Warfarin 2.5 mg Tablet [**Hospital1 **]: Two (2) Tablet PO Once Daily at 4 PM. 12. Multivitamin,Tx-Minerals Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily). 13. Piperacillin-Tazobactam-Dextrs 4.5 gram/100 mL Piggyback [**Hospital1 **]: One (1) dose Intravenous Q8H (every 8 hours) for 5 days. 14. Insulin Glargine 100 unit/mL Cartridge [**Hospital1 **]: One (1) dose Subcutaneous at bedtime: Per attached sliding scale sheet. 15. Insulin Regular Human 100 unit/mL Cartridge [**Hospital1 **]: One (1) dose Injection QACHS: Per attached sliding scal sheet. 16. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily). 17. Heparin Flush (10 units/ml) 2 mL IV PRN line flush PICC, heparin dependent: Flush with 10mL Normal Saline followed by Heparin as above daily and PRN per lumen. 18. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush Peripheral line: Flush with 3 mL Normal Saline every 8 hours and PRN. Discharge Disposition: Extended Care Facility: [**Hospital6 85**] - [**Location (un) 86**] Discharge Diagnosis: Primary: Pneumonia UTI Secondary: Hemiparesis Afib CAD Hyperlipidemia DM2 Discharge Condition: Improved, requiring minimal oxygen, hemodynamically stable, tolerating tube feeds Discharge Instructions: We evaluated and treated your shortness of breath and think that your symptoms were most consistent with pneumonia combined with a COPD exacerbation. You are being discharged on treatment for both of these problems and will continue your physical and occupational therapy at [**Hospital1 **]. You did have a day where you became tired and sleepy. The workup we performed involved checking your electrolytes, blood levesl, heart function, and checking your brain for any changes in blood supply. the work-up was negative and your sleepiness imptoved over the next few days where your family noted you were back to your typical self. Please take the medications prescribed as directed. Please call your primary care doctor or return to the ER with: * Worsening shortness of breath * Fevers > 101, shaking chills, nausea or vomiting * Changes in neurologic function * Any new symptoms or concerns Followup Instructions: Please follow-up per your scheduled appointments: Provider: [**Name10 (NameIs) **] SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2162-4-12**] 9:45 Provider: [**Name10 (NameIs) 1571**] FUNCTION LAB Phone:[**Telephone/Fax (1) 609**] Date/Time:[**2162-4-22**] 9:10 Provider: [**First Name11 (Name Pattern1) 1569**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. Phone:[**Telephone/Fax (1) 612**] Date/Time:[**2162-4-22**] 9:30

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icd9cm

[ [ [] ] ]

[ "38.93" ]

icd9pcs

[ [ [] ] ]

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2800, 2800

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2002, 2116

5,607

125,024

53153

Discharge summary

report

Admission Date: [**2183-8-10**] Discharge Date: [**2183-8-15**] Service: HISTORY OF PRESENT ILLNESS: The patient is an 82-year-old male with multiple medical problems including coronary artery disease (status post percutaneous coronary intervention), chronic obstructive pulmonary disease, colon cancer, and prostate cancer who presented to [**Hospital 26200**] Hospital on [**2183-8-10**] with nausea and vomiting times three days and was transferred to [**Hospital1 69**] for further evaluation. His abdomen was found to be distended. A KUB showed dilated loops of bowel. The patient also had a witnessed aspiration of feculent with subsequent desaturations to 87%. He was intubated for airway protection. Once the patient was stabilized, he had an abdominal computed tomography which showed herniation of bowel which was not incarcerated. Surgery was consulted and recommended the patient go to the operating room for surgical correction; however, the patient's family declined as they did not want aggressive measures. The patient was transferred to the Intensive Care Unit where he remained intubated. However, after discussions with the family and health care proximally, the patient was made do not resuscitate with focus on comfort care. During a family discussion on [**8-11**], the patient was made comfort measures only and was subsequently extubated and started on a morphine drip. However, the decision was made to continue antibiotics for the time being. After extubation, the patient's oxygen saturations were approximately 87% to 88%. Therefore, he was placed on supplemental oxygen as to prevent mild hypoxia from causing his discomfort. His nasogastric tube also remained in to provide gastric decompensation and also as a comfort measure. PHYSICAL EXAMINATION ON TRANSFER: Physical examination on transfer to the floor (on [**8-12**]) revealed temperature was 97.8, heart rate was 88, blood pressure was 103 to 140/33 to 47, breathing at 26 (range 17 to 26), and oxygen saturation was 98% on nonrebreather. Subsequently, the patient was intubated, kyphotic, and eyes were closed. He was not arousable. Cardiovascular examination revealed he had a regular rate and rhythm. Heart sounds were difficult to appreciate secondary to high oxygen flow. His lungs revealed coarse upper airway breath sounds anteriorly. The abdominal examination revealed he had no bowel sounds. The abdomen was mildly distended and soft with two midline hernias, which were reducible. His extremities revealed he had 1+ radial and dorsalis pedis pulses bilaterally. His extremities were cool. He did not clubbing, cyanosis, or edema. MEDICATIONS ON ADMISSION: 1. Morphine drip. 2. Levofloxacin 500 mg intravenously q.24h. 3. Metronidazole 500 mg intravenously q.8h. HOSPITAL COURSE: After being transferred to the floor, the patient was continued on antibiotics for approximately two days. He remained comfortable and on the morphine drip, and a scopolamine patch was added to reduce airway secretions. He also received frequent respiratory therapy and suctioning to decrease airway secretions. However, the patient's respiratory and clinical status did not improve on antibiotics. Per a family discussion on the [**8-14**], it was agreed that the antibiotics would be discontinued. The patient passed away at approximately 5:30 a.m. on [**8-15**]. The night float intern pronounced the patient and notified both the attending physician and the patient's family. An autopsy was declined. [**Name6 (MD) 2415**] [**Last Name (NamePattern4) 3474**], M.D. [**MD Number(1) 3475**] Dictated By:[**Last Name (NamePattern1) 8478**] MEDQUIST36 D: [**2183-8-15**] 14:25 T: [**2183-8-26**] 15:15 JOB#: [**Job Number 109460**]

[ "V45.82", "V45.2", "496", "518.81", "V10.05", "V12.59", "560.9", "507.0" ]

icd9cm

[ [ [] ] ]

[ "96.04", "96.71" ]

icd9pcs

[ [ [] ] ]

2689, 2799

2817, 3796

111, 2663

57,408

165,006

5692

Discharge summary

report

Admission Date: [**2186-8-17**] Discharge Date: [**2186-9-2**] Date of Birth: [**2129-12-8**] Sex: F Service: MEDICINE Allergies: Latex / Tegretol / Neurontin / Lyrica / Bactrim / muscle relaxants Attending:[**First Name3 (LF) 2279**] Chief Complaint: Hip pain Major Surgical or Invasive Procedure: hemiarthroplasty of R hip [**2186-8-23**] History of Present Illness: Ms. [**Known lastname **] is a 56 y.o. woman with lymphangioleiomyomatosis, chronic back pain s/p multiple lumbar procedures, seizures and a RLQ mass/fullness who presented to the ED [**2186-8-17**] for back pain. Of note, she was admitted [**Date range (1) 22730**] for back pain radiating down the leg. She was started on a dilaudid PCA, with which she found benefit, and and a Pain Service consult was requested. Her pain improved with the dilaudid PCA. She was then transitioned to oral dilaudid for short-term management until her epidural steroid injection on [**8-3**]. The Pain Service arranged for epidural steroid injection on the day of discharge. Pt was not discharged with any narcotic prescriptions upon DC. She takes Fentanyl patch and Oxycodone. Has RP lymphadenopathy/fibrosis on recent imaging with plans for further imaging in the future. She says that the steroid injection helped her back pain but that four days ago she had worsened right groin/leg pain. The pain comes from her right groin (where she has a RLQ mass/fullness) and goes down her leg and up her back. On Monday, the pain had worsened to the point where she had to use a cane to walk, but was still able to walk. She didn't think she had weakness of her leg, just pain. On Tuesday she was using a walker to get around. Her husband gave her extra oxycodone on Tuesday night because she was in so much pain she was "confused" and didn't know who he was. On Wednesday she felt she could hardly walk because of the pain, and when it continued today, she came to the ED. In the ED, initial VS were 10 98.4 94 139/71 17 100%RA. Labs were notable for WBC 14.1 (95.9% N), Na 129. On exam she had extreme back pain, normal rectal tone, intact perineal sensation. Declined to walk because she was in pain. She mentioned that she has had issues urinating as well with increased need to straight cath over the last 3 days, so Neurology was consulted who felt she should be ruled out for epidural abscess; in addition it was mentioned that her multiple lymph nodes and seizures could indicate a possible undiagnosed case of tuberous sclerosis. MRI L-spine ruled out epidural abscess and MRI head did not suggest tuberous sclerosis. She received 1 liter of normal saline in the ED. For pain she received Dilaudid 1mg IV x8 over ten hours), Lorazepam 2mg IV, home dose of Fentanyl patch. She was admitted to Medicine for pain control. VS prior to transfer were: pain [**9-22**], T98, HR 70, BP 118/73, POx 97% RA. On arrival to the floor, she is asking for pain medications. Complains that it "feels like an alien is coming out of me", in reference to the RLQ mass and that her back pain is starting in her R groin. Additional HPI: 6 days ago (i.e. this past Saturday) she was able to walk a mile. On Sunday she went to her paddle yoga session and that evening began to have severe pain over the right inguinal area. She described it as a constant, throbbing pain. On the following day the pain progressed and she started using a cane. On Tuesday she was unable to walk and Wednesday the pain had progressed to the point were her husband reports that she did not even recognize him. With the pain still present yesterday, she came to the ED. On admission to the floor pt continued to have significant pain most prominently over her right inguinal crease and radiating down her leg. She felt that something was pushing her leg off her body. She also described hearing the sound of bones grinding against each other coming from her right hip. The pain was also worse with internal rotation at the hip. Pt was sent for a hip xray which revealed a large fracture at the femoral neck. Past Medical History: -Lymphangioleimyomatosis dx'd [**7-21**] (however findings seen on CT as early as [**4-19**]), s/p VATS [**9-20**].Followed by Dr. [**Last Name (STitle) 22633**] at [**Hospital1 3278**]. (a) Histologic finding of microgranulomatous bronchiolitis and LAM (b) On lung transplant list at [**Hospital1 112**]; first appt to be [**2185-4-12**] (c) NOT on PCP [**Name Initial (PRE) **]; currently on tx with prednisone and azithromycin -Chronic LBP s/p L3/4 laminectomy; L3-4, L4-5 and L5-S1 discectomies in [**2180**]; on narcotics agreement. Followed by Dr. [**First Name (STitle) 1022**] in orthopedics. s/p steroid injection -Seizure d/o, grand mal sz, partial sz (since childhood), temporal lobe epilepsy. Followed by Dr. [**First Name4 (NamePattern1) **] [**Last Name (un) 22634**] in [**Location (un) **], MA -Lymphadenopathy, s/p nl LN bx, c/b MRSA infection -Anxiety, followed by psych -+ PPD, treated with INH x 9mos -L adnexal simple cysts -Multiple uterine fibroids -Chronic abdominal pain (pt denies) -Paradoxical vocal fold motion, per ENT (pt denies) -Diverticulosis (pt denies) -S/p shoulder surgery -S/p benign breast lump/cyst removal x 3 -S/p tonsillectomy Social History: Previously worked as a RN on Med/[**Doctor First Name **] floor. Stopped working [**2182**]. She is separated from her husband. [**Name (NI) **] son stays with her. Activity Level: ambulatory, does Yoga regularly Mobility Devices: none Tobacco: quit 30 years ago EtOH: occasional glass of wine Family History: Father- [**Name (NI) **] [**Name (NI) 3730**] (56) +Alcohol Abuse Mother- MI (56) Familial history of hypercholesterolemia 8 brothers/sisters with cardiac disease Physical Exam: Admission Exam: General: alert, mentating clearly, clearly in discomfort/pain, thin Respiratory: quiet breath sounds, mild wheezing throughout all fields Cardiovascular: Reg, S1S2, no M/R/G noted Gastrointestinal: soft, + bowel sounds, R lower quadrant outpouching with +BS, reducible; pain on palpation of R inguinal crease, no pain on palpation of right lateral hip bursa Extremities: thin, but right leg possibly slightly larger than left Discharge Exam: vitals: Tc 99.7, tmax 101.0 (midnight before discharge), HR 87, BP 97/54, O2 94% on 2L entire R leg still equisitely tender to palpation. Now echymoses present over sacrum extending to R inner thigh. Patient now ambulating with walker, not in as much pain as on admission Pertinent Results: Admission Labs: [**2186-8-18**] 07:00AM BLOOD WBC-9.7 RBC-3.77* Hgb-12.3 Hct-37.2 MCV-99* MCH-32.6* MCHC-33.1 RDW-13.8 Plt Ct-384 [**2186-8-20**] 01:25PM BLOOD PT-9.5 PTT-29.8 INR(PT)-0.9 [**2186-8-18**] 07:00AM BLOOD Glucose-96 UreaN-9 Creat-0.6 Na-137 K-4.1 Cl-100 HCO3-28 AnGap-13 [**2186-8-17**] 04:45PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.002 [**2186-8-17**] 04:45PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG [**2186-8-17**] Urine culture - MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. Discharge Labs: [**2186-9-2**] 09:05AM BLOOD WBC-6.6 RBC-2.46* Hgb-7.7* Hct-23.5* MCV-96 MCH-31.4 MCHC-32.8 RDW-14.0 Plt Ct-732* [**2186-8-31**] 06:15AM BLOOD Neuts-70 Bands-7* Lymphs-16* Monos-3 Eos-2 Baso-0 Atyps-1* Metas-0 Myelos-1* [**2186-9-2**] 09:05AM BLOOD Glucose-114* UreaN-12 Creat-0.5 Na-128* K-4.4 Cl-90* HCO3-30 AnGap-12 [**2186-9-1**] 05:35AM BLOOD Calcium-8.3* Phos-4.8* Mg-2.0 Imaging: CXR [**8-17**]: IMPRESSION: No acute cardiopulmonary process. Chronic interstitial changes compatible with known lymphangioleiomyomatosis. MRI Spine [**8-17**]: IMPRESSION: 1. No findings to suggest tuberous sclerosis. 2. Stable small posterior fluid collection at the L4-L5 level without significant enhancement, likely post operative. 3. Post-operative changes of posterior fusion from L3 to S1 with bilateral pedicle screws and laminectomy. 4. Degenerative changes of the lumbar spine are stable compared to prior. MRI Head [**8-17**]: IMPRESSION: 1. No intracranial findings to suggest tuberous sclerosis. 2. No acute intracranial abnormality. Scattered foci of FLAIR signal hyperintensity are nonspecific and most likely secondary to chronic small vessel disease in a patient of this age. Hip XR [**8-18**]: IMPRESSION: Findings most compatible with a subacute fracture of the femoral head with possible underlying AVN. Significant resorption of the fracture fragments, Less likely this reflects an underlying lytic lesion leading to pathologic fracture. This as well as lucency of the lesser trochanter can be best assessed on cross-sectional imaging. [**8-18**] CT lower extremity right: IMPRESSION: Markedly comminuted fracture involving the right femoral head, predominantly involving the superomedial aspect. There are innumerable tiny densities seen throughout the joint space with hyperdense joint fluid. [**8-22**] xray femur - RIGHT FEMUR, TWO VIEWS: There is a fracture through the proximal femur, which appears to be basicervical medially and through the edge of the epiphysis laterally. There is varus angulation centered at the fracture site, with ossific debris superimposed over the fracture and inferior to the medial neck, question due to abrasion of the two fracture fragments. Alignment on the lateral view is quite difficult to assess, question anterior apex angulation and slight posterior displacement of the major distal fragment. [**8-26**] ct pelvis - 1. No evidence of active extravasation in the thigh and pelvis. 2. Post-surgical changes with possible muscle hematoma in the right thigh and pelvis. 3. No evidence of RP hematoma. 4. Cystic lesions at aortocaval space, right common iliac and left internal liac lymph node chains consistent with known findings of LAM. CXR [**8-29**] - As compared to the previous radiograph, there is no relevant change. Diffuse predominantly reticular opacities, diffusely distributed through the lung, without evidence of other focal parenchymal abnormality. No evidence of pneumonia. No pleural effusions. Borderline size of the cardiac silhouette. Mild tortuosity of the thoracic aorta. CT abd/pelvis [**8-31**] - 1. No acute intra-abdominal or pelvic process to explain patient's fever. 2. Persistent right thigh subcutaneous edema and likely unchanged small hematoma lateral to the right gluteal muscles. There is no evidence of an abscess in this region. 3. Findings consistent with lymphangioleiomyomatosis including innumerable thin-walled cysts at both lung bases and retroperitoneal/pelvic lymphangiomas, not significantly changed. LENI [**2186-8-31**] - IMPRESSION: No lower extremity DVT Brief Hospital Course: Ms. [**Known lastname **] is a 56yo woman with a history of lymphangioleiomyomatosis, chronic back pain s/p multiple lumbar procedures, and seizures who presented to the ED [**2186-8-17**] with RLQ fullness and pain in the right leg which was found to be a fracture of the femoral head. Active issues: # Femoral head fracture: Most likely AVN [**3-16**] chronic steroid use. Pain was controlled with dilaudid PCA and Fentanyl patch. Pt was started on Lovenox 40mg SC daily (not q12hrs due to pt weight). Ortho was consulted and performed a R arthroplasty on [**8-23**]. In the post-op setting, she had an increased pain requirement. Acute pain management was consulted and recommended dilaudid PCA, ketamine drip, fentanyl patch, IV acetaminophen, and toradol. This did not control her pain well overnight, but upon admission to the MICU her pain appeared better controlled on this plan. Eventually she was transferre to the floor and transitioned back to her oral pain regimen with double her home dose of oxycodone (30mg), and this was increased to 40mg q4H PRN. There was no evidence of infection at the surgical site. There was a hematoma, and she had a hematocrit drop during her stay, however her crit stabilized before discharge. # Post operative pain control: Patient was initially managed on dilaudid PCA with fentanyl patch with suboptimal pain control. Following her surgery she her pain needs were high enough to warrant a chronic pain consult. She was managed on a ketamine drip, dilaudid PCA, fentanyl patch, IV tylenol and ketorolac. Her pain eventually came under control and she was switched back to oral and transdermal pain control but is being discharged on a higher dose of narcotics than she came in on given her recent operation and PT needs. She will be discharged on 125mcg/hr Fentayl patch and oxyCODONE 40mg Q4H prn pain. She is being given enough to get her to her follow up appointment on [**2186-9-5**] with [**Company 191**]. #Fevers: Approximately POD#8 she developed fevers at night - blood and urine cultures were negative, cxr showed no changes, and CT abd/pelvis showed no infection in her hip. ID was consulted, no source of fever was found - it is possible that her LAM is contributing to her fever, however she will need close follow up for any signs of infection. # Anemia: Following her surgery she had an acute hemtocrit drop from 40 to 25. She was asymptomatic. A CT thigh showed a large hematoma which remained stable. Her Hematocrit remained low but stable and she had no need for transfusions. On the day of discharge her hematocrit was 24 and uptrending. She will need to have her hematocrit rechecked on [**2186-9-4**] and has been provided with a lab slip for this. #)Hyponatremia: She developed hyponatremia pre-operatively on [**8-22**] but this resolved w/ fluid resuscitation. Overnight on POD0, she was put on D5 1/2NS continuously. In the morning of POD1, she was found to be hyponatremic to Na 122. She was stopped on D5 1/2 NS and given NS, but her Na dipped further to Na 119. Then, all fluids were stopped, and she was transferred to the MICU. She was always asymptomatic, w/o mental status changes, in this setting. After transfer to the MICU, she was fluid restricted, and her Na recovered to 128 within hours. On repeat labs, her sodium was 130. She was transferred to the medicine floor, where her Na went up with fluids (suggesting hypovolemia) to 135, however it started to drop again and improved with more fluids. In summary, it was very hard to control her sodium with a mixture of SIADH and hypovolemia contributing at different times to her hyponatremia. Eventually she was started on salt tabs 1g TID in adddition to fluid restriction to 1.2 L/ day. She will need to follow up her sodium as an outpatient. # Acute on chronic urinary retention: Per OMR records, this is a frequent issue. Retention history likely back to [**2184**]; has had evaluation with Urogynecology in past. Possibly d/t her spinal issues/loss of sensation/LAM. Initially using bedpan/straight cath but due to hip fracture, a foley catheter was placed. Foley removed [**2186-8-29**], and patient straight caths herself. Chronic issues: # Back pain: chronic. Back pain was treated previously with the steroid injection, fentanyl patch and dilaudid and was not a major issue during this admission. Her baseline pain is [**6-22**]. Was ruled out for epidural abscess in the ED. Neuro was also consulted in the ED. Pain regimen for hip fracture was more than sufficient for controlling chronic back pain. # Lymphangioleiomyomatosis: She was originally continued home steroids, azithro ppx, inhalers, O2 NC (baseline 2-6L). She is apparently not candidate for lung transplant until she is able to wean narcotics for back pain. Upon admission to the MICU, her steroids were titrated down to 5 mg PO for a plan of 5 days before discontinuing entirely. Reportedly, her outpt pulmonologist also does not want her on steroids (there is no evidence it works for LLAM), so this hospitalization for a likely steroid-induced hip fracture may be an indication to discontinue this medication. Also, her azithromycin was discontinued as MAC prophylaxis as there is no indication that this is beneficial to her. She was weaned off prednisone and is being discharged without it. This was discussed with her pulmonologist shortly after she was admitted. # HTN: stable. continued Lisinopril # Seizure d/o: stable. continued Oxcarbazepine Transitional Issues: Hip fx - she will schedule follow up with ortho - Dr. [**Last Name (STitle) 22731**] in [**2-13**] weeks 617-[**Telephone/Fax (1) 22732**] Pain - will need close follow up for her pain - oxycodone increased to 40mg q4h while in the hospital. Hyponatremia- f/u w/ PCP and have chem7 checked anemia- f/u with PCP and check CBC for signs of continued bleeding or infection fevers - no source identified after extensive w/u as above, continue to monitor for signs of infection urinary retention - she needs straight cath supplies at home LAM - follow up with her pulmonologist # Left pelvic mass: incidental finding on last hospitalization - outpatient f/u needed Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from PatientwebOMR. 1. Albuterol Inhaler 2 PUFF IH Q4H:PRN SOB, wheezing 2. Azithromycin 250 mg PO 3X/WEEK (MO,WE,FR) 3. Diazepam 5 mg PO Q6H:PRN muscle spasms 4. Fentanyl Patch 125 mcg/hr TP DAILY 5. Fluticasone Propionate 110mcg 4 PUFF IH [**Hospital1 **] 6. DuoNeb *NF* (ipratropium-albuterol) 0.5 mg-3 mg(2.5 mg base)/3 mL Inhalation every 4 hours SOB/wheezing 7. Lisinopril 10 mg PO DAILY 8. Oxcarbazepine 150 mg PO QAM 9. Oxcarbazepine 300 mg PO QPM 10. OxycoDONE (Immediate Release) 15-30 mg PO Q4-6H:PRN pain 11. PredniSONE 30 mg PO BID Duration: 1 Days then continue with usual dose of 10mg daily 12. PredniSONE 20 mg PO BID Duration: 3 Days Start: After 30 mg tapered dose. then continue with usual dose of 10mg daily 13. Calcium Carbonate 1500 mg PO DAILY 14. Vitamin D 800 UNIT PO DAILY 15. Multivitamins 1 TAB PO DAILY 16. Polyethylene Glycol 17 g PO DAILY:PRN constipation 17. Senna 1 TAB PO BID:PRN constipation 18. Docusate Sodium 100 mg PO BID Discharge Medications: 1. Albuterol Inhaler 2 PUFF IH Q4H:PRN SOB, wheezing 2. Calcium Carbonate 1500 mg PO DAILY 3. Diazepam 5 mg PO Q6H:PRN muscle spasms 4. Docusate Sodium 100 mg PO BID 5. Fentanyl Patch 125 mcg/hr TP DAILY 6. Fluticasone Propionate 110mcg 4 PUFF IH [**Hospital1 **] 7. Lisinopril 10 mg PO DAILY 8. Multivitamins 1 TAB PO DAILY 9. Oxcarbazepine 150 mg PO QAM 10. Oxcarbazepine 300 mg PO QPM 11. OxycoDONE (Immediate Release) 40 mg PO Q4H:PRN pain hold for sedation or RR<10 RX *oxycodone 20 mg [**2-13**] tablet(s) by mouth every four (4) hours Disp #*36 Tablet Refills:*0 12. Polyethylene Glycol 17 g PO DAILY:PRN constipation 13. Senna 1 TAB PO BID:PRN constipation 14. Vitamin D 800 UNIT PO DAILY 15. Enoxaparin Sodium 40 mg SC DAILY Duration: 4 Weeks RX *enoxaparin 40 mg/0.4 mL inject once a day for 4 weeks once a day Disp #*28 Syringe Refills:*0 16. Famotidine 20 mg PO Q12H 17. Sodium Chloride 1 gm PO TID hold for Na>140 RX *sodium chloride 1 gram 1 tablet(s) by mouth three times a day Disp #*90 Tablet Refills:*0 18. DuoNeb *NF* (ipratropium-albuterol) 0.5 mg-3 mg(2.5 mg base)/3 mL Inhalation every 4 hours SOB/wheezing Discharge Disposition: Home With Service Facility: All Care VNA of Greater [**Location (un) **] Discharge Diagnosis: Hip Fracture Lymphangioleiomyomatosis Discharge Condition: pain improved but not gone, mental status intact, ambulating with a walker Discharge Instructions: Dear Ms. [**Known lastname **], You were admitted with right hip pain and found to have a hip fracture. You were assessed by orthopedic surgery and were taken for the OR for a hip replacement. Afterwards your pain was very difficult to control - eventually you were placed back on oral pain medications and your oxycodone dose was raised to 40mg. You also developed low sodium in your blood - to treat this you should continue taking salt tabs and restricting your fluid intake to 1.2L per day. You also had fevers after your surgery, and we were unable to find a source for them. You had a hematoma after surgery, and your blood counts dropped, but then stabilized. After a thorough work up there was no sign of infection at your surgical site, in your lungs, urine or anywhere else. You should follow up at [**Company 191**] at your next appointment, and also you should follow up with orthopedics in [**2-13**] weeks, as well as with pain management. Your [**Company 191**] and pain appointments are below, but you will need to schedule your ortho follow up appointment with [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 22731**] [**Telephone/Fax (1) 22733**] in [**2-13**] weeks. . Your liver enzymes were very mildly elevated. This is likley because of your prolonged hospitalizatin but you shoudl have them checked within one week by your PCP's pffice to ensure this has resolved. . You are also being given an increased prescription for your pain medications. Since you have a narcotics contract at [**Company 191**] we can only give you enough of the additional pain medications until your follow up visit on tuesday [**2186-9-5**]. At that time they will be able to refill your medications. Followup Instructions: You will need to have your LFT's checked on Monday. We have attached an order for this to this DC paper work. You should bring this order with you to [**Company 191**] on Monday to have your labs checked. you will need to schedule your ortho follow up appointment with [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 22731**] [**Telephone/Fax (1) 22733**] in [**2-13**] weeks. Department: [**Hospital3 249**] When: TUESDAY [**2186-9-5**] at 8:40 AM With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **],ANP-BC [**Telephone/Fax (1) 2010**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: PAIN MANAGEMENT CENTER When: WEDNESDAY [**2186-9-13**] at 8:50 AM With: [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **], [**First Name3 (LF) **] [**Telephone/Fax (1) 1652**] Building: One [**Location (un) **] Place ([**Location (un) **], MA) [**Location (un) **] Campus: OFF CAMPUS Best Parking: Parking on Site [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 2285**]

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Discharge summary

report

Admission Date: [**2152-11-2**] Discharge Date: [**2152-11-7**] Date of Birth: [**2084-4-12**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2597**] Chief Complaint: Right carotid stenosis Major Surgical or Invasive Procedure: right CEA with dacron patch [**2152-11-6**] History of Present Illness: This 68-year-old gentleman was recently admitted to the hospital with a right ocular stroke. He had previously had a TIA some months back and had this stroke on antiplatelet agents. Ultrasound showed a 40% stenosis of the right carotid artery but an arteriogram showed a large ulcerated plaque at the carotid bifurcation. He is undergoing endarterectomy today. Past Medical History: 1. Hypercholesterolemia 2. Hypertension, recently diagnosed, started meds ~2 weeks ago 3. Ankylosing spondylitis Social History: Lives with his partner. Currently retired, part-time consulting. Quit tobacco [**2124**], smoked 1 [**12-5**] ppd for 20 yrs prior. Has 1 [**Doctor Last Name 6654**] and 1 glass wine with dinner every night. When on vacation drinks more wine. No other drugs. Family History: Father died of an aneurysm, unknown location, was "vomiting blood". Mom with stroke in her 80s. Brother age 61 with some kind of aphasia, neurodegenerative, started 5-6 years ago. Mom's side with CAD/MI. Paternal GF with type I DM. Physical Exam: PE: AFVSS NEURO: PERRL / EOMI MAE equally Answers simple commands Neg pronator drift Sensation intact to ST 2 plus DTR Neg Babinski HEENT: NCAT Neg lesions nares, oral pharnyx, auditory Supple / FAROM neg lyphandopathy, supra clavicular nodes LUNGS: CTA b/l CARDIAC: RRR without murmers ABDOMEN: Soft, NTTP, ND, pos BS, neg CVA tenderness EXT: rle - palp fem, [**Doctor Last Name **], pt, dp lle - palp fem, [**Doctor Last Name **], pt, dp Pertinent Results: [**2152-11-7**] WBC-6.7 RBC-3.33* Hgb-10.9* Hct-31.0* MCV-93 MCH-32.9* MCHC-35.3* RDW-13.2 Plt Ct-192 [**2152-11-6**] PT-12.7 PTT-33.4 INR(PT)-1.1 [**2152-11-7**] Glucose-117* UreaN-16 Creat-1.0 Na-139 K-4.3 Cl-108 HCO3-25 AnGap-10 [**2152-11-7**] Calcium-8.9 Phos-3.5 Mg-2.1 [**2152-11-2**] 3:30 PM CLINICAL INFORMATION: Acute onset of monocular blindness. ? for intra- arterial TPA. RADIOLOGISTS: Drs. [**Last Name (STitle) 22924**] and [**Name5 (PTitle) **], the Attending Radiologist, present and supervising the entire procedure. TECHNIQUE: Informed consent was obtained from the patient and the patient's family after explaining the risks, indications and alternative management. Risks explained included stroke, loss of vision and speech, temporary or permanent, with possible treatment with stent and coils if needed. The patient was brought to the Interventional Neuroradiology Theater and placed on the biplane table in supine position. Both groins were prepped and draped in the usual sterile fashion. Access to the right common femoral artery was obtained using a 19-gauge single wall needle, under local anesthesia using 1% lidocaine mixed with sodium bicarbonate and with aseptic precautions. Through the needle, a 0.35 [**Last Name (un) 7648**] wire was introduced and the needle taken out. Over the wire, a 5 Fr vascular sheath was placed and connected to a saline infusion (mixed with heparin 500 units in 500 cc of saline) with a continuous drip. Through the sheath, a 4 Fr Berenstein catheter was introduced and connected to continuous saline infusion (with mixture of 1000 units of heparin in 1000 cc of saline). The following blood vessel was selectively catheterized and angiograms were obtained in AP, lateral, and 3-D projections: -Right common carotid artery FINDINGS: Evaluation of the right CCA, ECA, and ICA demonstrate no evidence of aneurysm, vascular malformation, or vascular occlusion. However, there is luminal irregularity at the proximal segment of the cervical CCA, leading to an approximately 40% of stenosis. CONCLUSION: Luminal irregularity, likely to indicate atherosclerotic disease, at the proximal segment of the right common carotid artery, suggestive of mild stenosis. No other abnormality is identified. The opthalmic artery appears patent. [**2152-11-2**] 1:55 PM CT HEAD CLINICAL INFORMATION: Acute loss of vision in right eye. ? bleed. FINDINGS: There are several tiny, well-defined hypodense lesions in the periventricular white matter of both cerebral hemispheres and the head of the left caudate nucleus (series 2, image 15). They are likely representative of chronic lacunar infarcts. [**Doctor Last Name **]-white matter differentiation is otherwise preserved. No intracranial mass or mass effect is evident. No intra-axial or extra-axial fluid collections or hematoma is seen. No displacement of normally midline structures is evident. CONCLUSION: 1. Chronic lacunar infarcts in the periventricular white matter of both cerebral hemispheres and the head of the left caudate nucleus. 2. No intracranial hematoma. 3. No CT features of acute major vascular territorial infarct, although a head MRI with DWI images is a more sensitive study to detect acute cerebral ischemic changes. CHEST (PRE-OP PA & LAT) [**2152-11-5**] 6:18 PM PA AND LATERAL VIEWS OF THE CHEST: The heart is normal in size. The mediastinal and hilar contours are normal. There is calcification of the aortic knob. The pulmonary vascularity is normal. The lungs are clear. There are no focal consolidations, pleural effusions, or pneumothorax demonstrated. The osseous structures are unremarkable. IMPRESSION: No acute cardiopulmonary abnormality Cardiology Report ECG Study Sinus rhythm. Consider left atrial abnormality Prominent precordial lead QRS voltage - is nonspecific but consider left ventricular hypertrophy Since previous tracing of [**2152-1-26**], probably no significant change Intervals Axes Rate PR QRS QT/QTc P QRS T 69 152 100 398/416.71 66 48 65 Brief Hospital Course: pt admitted on [**2153-11-2**] Stroke code initiated Stat opthamology consult obtained for acute painless vision loss. Pt in ICU Heparin stared / NPO [**2153-11-3**] Vascular surgery consulted. Plaque found right carotid artery. Pt to be taken to the OR. Pt pre-op'd in the usual fashion. Head CT negative [**2152-11-4**] Pt stable Heparin drip continued / BP control [**2152-11-5**] Stable [**2152-11-6**] Pt undergoes a Right carotid endarterectomy and Dacron patch angioplasty. He tolerates the p[rocedure well. There are no complications. Extubated in the OR. [**Month/Day/Year 22925**] to the PACU in stable condition. Once recovered from anesthesia. Pt [**Name (NI) 22925**] to the VICU in stable condition. [**2152-11-7**] Pt delined / ADAT / Heplocked IV Lytes replenished Pt stable for DC Taking PO / ambulatiing / urinating / pos bm Medications on Admission: ASA 81', aggrenox 25/200", lipitor 20', protonix 40', norvasc 30', fish oil Discharge Medications: 1. Lipitor 40 mg Tablet Sig: One (1) Tablet PO at bedtime. 2. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 4. Dipyridamole-Aspirin 200-25 mg Cap, Multiphasic Release 12 HR Sig: One (1) Cap PO BID (2 times a day). 5. Univasc 15 mg Tablet Sig: One (1) Tablet PO once a day. 6. Aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home Discharge Diagnosis: Carotid Stenosis. TIA history of HTn history of hyperlipdemia Discharge Condition: Stable Discharge Instructions: DISCHARGE INSTRUCTIONS FOLLOWING CAROTID ENDARTERECTOMY . This information is designed as a guideline to assist you in a speedy recovery from your surgery. Please follow these guidelines unless your physician has specifically instructed you otherwise. Please call our office nurse if you have any questions. Dial 911 if you have any medical emergency. . ACTIVITY: . There are no specific restrictions on activity. Gradually increase your level of activity back to normal depending upon the way you feel. Fatigue is expected for the first several weeks. Resume driving when you are able to comfortably move your head without pain or stiffness. . PLEASE CALL US IMMEDIATELY FOR ANY OF THE FOLLOWING PROBLEMS: . Weakness, numbness, tingling involving your arm, leg or face . . Loss of vision . . Difficulty speaking . . Severe headache (mild headache is common) . . Increasing swelling, pain, drainage or redness of the neck wound, . Watch for signs and symptoms of infection. These are: a fever greater than 101 degrees, chills, increased redness, or pus draining from the incision site. If you experience any of these or bleeding at the incision site, CALL THE DOCTOR. . Exercise: . Limit strenuous activity for 2 weeks. . No driving untill cleared by your surgeon. He should be able to clear you to drive when you are able to comfortably move your head without pain or stiffness . If you can do this before your appointment with the doctor, call and ask him if you can drive. No heavy lifting greater than 20 pounds for the next 7 days. . Avoid excessive turning of the head, nodding of the head for the next 7 days. . BATHING/SHOWERING: . You may bathe or shower immediately upon coming home. Do not put your neck / head into the water. A clear dressing will cover your neck incision and this should be left in place for three (3) days. Remove it after this time and wash your incision gently with soap and water. Dissolving sutures, which do not have to be removed, were used. Shaving is permitted when the dressing is removed. . WOUND CARE: . Suture / Staples may be removed before discharge. If they are not, an appointment will be made for you to return for removal. . When the sutures / staples are removed the doctor may or may not place pieces of tape called steri-strips over the incision. These will stay on about a week and you may shower with them on. If these do not fall off after 10 days, you may peel them off with warm water and soap in the shower. . Avoid taking a tub bath, swimming, or soaking in a hot tub for two weeks after surgery. . MEDICATIONS: . You may resume taking medication you were on prior to your surgery unless specifically instructed otherwise by your physician [**Name9 (PRE) **] will be given a new prescription for pain medication, which should be taken every three (3) to four (4) hours only if necessary. . Remember that narcotic pain meds can be constipating and you should increase the fluid and bulk foods in your diet. (Check with your physician if you have fluid restrictions.) If you feel that you are constipated, do not strain at the toilet. You may use over the counter Metamucil or Milk of Magnesia. Appetite suppression may occur; this will improve with time. Eat small balanced meals throughout the day. . CAUTIONS: . NO SMOKING! We know you've heard this before, but it really is an important step to your recovery. Smoking causes narrowing of your blood vessels which in turn decreases circulation. If you smoke you will need to stop as soon as possible. Ask your nurse or doctor for information on smoking cessation. . No strenuous activity for 4-6 weeks after surgery. . DIET: . There are no special restrictions on your diet postoperatively. Poor appetite is expected for several weeks and small, frequent meals may be preferred. . For people with vascular problems we would recommend a cholesterol lowering diet: Follow a diet low in total fat and low in saturated fat and in cholesterol to improve lipid profile in your blood. Additionally, some people see a reduction in serum cholesterol by reducing dietary cholesterol. Since a reduction in dietary cholesterol is not harmful, we suggest that most people reduce dietary fat, saturated fat and cholesterol to decrease total cholesterol and LDL (Low Density Lipoprotein-the bad cholesterol). Exercise will increase your HDL (High Density Lipoprotein-the good cholesterol) and with your doctor's permission, is typically recommended.. You may be self-referred or get a referral from your doctor. . If you are overweight, you need to think about starting a weight management program. Your health and its improvement depend on it. We know that making changes in your lifestyle will not be easy, and it will require a whole new set of habits and a new attitude.. If interested you can may be self-referred or can get a referral from your doctor. . If you have diabetes and would like additional guidance, you may request a referral from your doctor. . FOLLOW-UP APPOINTMENT: . Be sure to keep your medical appointments. The key to your improving health will be to keep a tight reign on any of the chronic medical conditions that you have. Things like high blood pressure, diabetes, and high cholesterol are major villains to the blood vessels. Don't let them go untreated! . Please call the office on the first working day after your discharge from the hospital to schedule a follow-up visit. This should be scheduled on the calendar for seven to fourteen days after discharge. Normal office hours are 8:30-5:30 Monday through Friday. . PLEASE FEEL FREE TO CALL THE OFFICE WITH ANY OTHER CONCERNS OR QUESTIONS THAT MIGHT ARISE Followup Instructions: 2 weeks Dr. [**Last Name (STitle) **]. callfor appointment. [**Telephone/Fax (1) 1393**] Completed by:[**2153-1-22**]

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icd9cm

[ [ [] ] ]

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icd9pcs

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Discharge summary

report

Admission Date: [**2204-6-26**] Discharge Date: [**2204-7-4**] Service: MEDICINE Allergies: Penicillins Attending:[**Doctor First Name 7926**] Chief Complaint: Hypotension, tachycardia Major Surgical or Invasive Procedure: none History of Present Illness: The patient is a [**Age over 90 **] yo Russian speaking M with hx of TIA, A fib, HTN, HL, Ao stenosis (valve area 1.2cm) who presents from [**Hospital **] rehab with SOB and hypotension in the setting of rapid A fib. Per records, patient c/o chest pain at 7pm at [**Hospital 100**] Rehab and nitropatch was put on temporarily. One hour later, metoprolol 25mg given and at 9pm, HR found to be in 120s and irregular. At 11pm, HR persistently in 120s and BP at 94/59. Was then sent to the ED for evaluation. In the ED, initial VS were: 98.4 84 95/63 14 98%. The patient was mentating well, no real complaints. Labs were notable for Na 130 (chronically low, last 120 at discharge), Hct 34.7 (at baseline), trop 0.03. CXR was notable for Gave 2L IVF. On arrival to the MICU, Review of systems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies cough, shortness of breath, or wheezing. Denies chest pain, chest pressure, palpitations, or weakness. Denies nausea, vomiting, diarrhea, constipation, abdominal pain, or changes in bowel habits. Denies dysuria, frequency, or urgency. Denies arthralgias or myalgias. Denies rashes or skin changes. Past Medical History: 1. Hypertension 2. ?CAD, negative MIBI [**8-25**], EF>55% 8/09 3. History of anemia 4. Zoster and postherpetic neuralgia ([**2197**]) - seen by [**Hospital **] clinic 5. History of peptic ulcer disease, H. pylori + - unsure if he has been treated in past; reports being following by Dr. [**First Name (STitle) 452**] in [**Hospital **] clinic 6. Aortic stenosis (area 1.2cm [**7-26**] echo) 7. s/p TURP 8. Chronic bilateral rotator cuff tears 9. Chronic bronchitis 10. Hyponatremia attributed to SIADH (BL Na 125-131) 11. Chronic bilateral rotator cuff tears with a secondary degenerative joint disease, especially in his left shoulder 12. s/p septic joint [**2201**] Social History: A retired engineer and does not recall any exposures to chemicals, dust, or fumes. Currently lives alone. He quit smoking in [**2151**]. Family History: Parents were killed by the Nazis. His grandparents died of strokes. His GF had complicated foot ulcer. Physical Exam: On admission: Vitals: T: 100.8 (Rectal) BP: 110/77 P: 124 R: 21 O2: 97%RA General: Alert, speaking in Russian [**Year (4 digits) 4459**]: MMM Neck: supple, JVP not elevated, no LAD CV: irregular rhythm, regular rate, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi Abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CNII-XII intact, 5/5 strength upper/lower extremities, grossly normal sensation, 2+ reflexes bilaterally, gait deferred, finger-to-nose intact On discharge: Vitals: T: 97.8 BP 117-135/65-83 HR 90-100s (on tele) R: 22 O2: 95%RA I/Os: [**Telephone/Fax (1) 68768**], weight 60.1kg (59.9kg yesterday) General: Alert, hard of hearing and blind, able to understand and speak some English [**Telephone/Fax (1) 4459**]: MMM Neck: supple, JVP 1/3 of the way up the neck CV: irregular rhythm, regular rate, harsh 2/6 systolic murmur at right upper sternal border Lungs: Expiratory wheezing and coarse breath sounds b/l in all lung fields, no rales, ronchi Abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly Ext: warm, well perfused, 2+ pulses, trace pitting edema to calves bilaterally Skin: raised, dark, round marking on left lower leg Neuro: grossly intact Pertinent Results: [**2204-7-3**] 07:03AM [**Month/Day/Year 3143**] WBC-9.5 RBC-3.45* Hgb-10.3* Hct-30.5* MCV-88 MCH-29.8 MCHC-33.8 RDW-14.2 Plt Ct-243 [**2204-7-2**] 04:50AM [**Month/Day/Year 3143**] WBC-11.6* RBC-3.68* Hgb-10.5* Hct-32.6* MCV-89 MCH-28.6 MCHC-32.3 RDW-13.7 Plt Ct-276 [**2204-7-1**] 06:37AM [**Month/Day/Year 3143**] WBC-10.0 RBC-3.43* Hgb-10.1* Hct-30.3* MCV-88 MCH-29.5 MCHC-33.4 RDW-13.8 Plt Ct-252 [**2204-7-2**] 04:50AM [**Month/Day/Year 3143**] Neuts-55.4 Lymphs-34.8 Monos-7.1 Eos-2.5 Baso-0.3 [**2204-6-26**] 12:40AM [**Month/Day/Year 3143**] Neuts-56.1 Lymphs-34.9 Monos-5.4 Eos-3.0 Baso-0.7 [**2204-7-3**] 07:03AM [**Month/Day/Year 3143**] Plt Ct-243 [**2204-7-2**] 04:50AM [**Month/Day/Year 3143**] Plt Ct-276 [**2204-6-26**] 07:00AM [**Month/Day/Year 3143**] PT-10.2 PTT-27.3 INR(PT)-0.9 [**2204-7-3**] 07:03AM [**Month/Day/Year 3143**] Glucose-83 UreaN-22* Creat-0.7 Na-131* K-4.5 Cl-97 HCO3-25 AnGap-14 [**2204-7-2**] 03:15PM [**Month/Day/Year 3143**] Glucose-81 UreaN-23* Creat-0.8 Na-132* K-4.9 Cl-98 HCO3-28 AnGap-11 [**2204-7-2**] 04:50AM [**Month/Day/Year 3143**] Glucose-86 UreaN-26* Creat-0.8 Na-132* K-5.4* Cl-97 HCO3-26 AnGap-14 [**2204-6-30**] 05:25AM [**Month/Day/Year 3143**] Glucose-80 UreaN-26* Creat-0.9 Na-130* K-4.6 Cl-96 HCO3-24 AnGap-15 [**2204-6-26**] 07:00AM [**Month/Day/Year 3143**] ALT-16 AST-18 LD(LDH)-183 CK(CPK)-62 AlkPhos-78 TotBili-0.5 [**2204-6-26**] 07:00AM [**Month/Day/Year 3143**] CK-MB-4 cTropnT-0.03* [**2204-6-26**] 12:40AM [**Month/Day/Year 3143**] cTropnT-0.03* [**2204-7-3**] 07:03AM [**Month/Day/Year 3143**] Mg-2.1 [**2204-7-3**] 07:03AM [**Month/Day/Year 3143**] Digoxin-0.6* [**2204-7-2**] 04:50AM [**Month/Day/Year 3143**] Digoxin-0.5* [**2204-7-1**] 06:37AM [**Month/Day/Year 3143**] Digoxin-0.9 [**2204-6-29**] 06:24AM [**Month/Day/Year 3143**] Digoxin-1.6 Cardiology: EKG: A fib with RVR, HR in 120s Radiology: CXR: heart size normal. tortuous aorta. engorged pulmonary vessels with some interstitial edema Brief Hospital Course: [**Age over 90 **]M with history of severe aortic stenosis, chronic hyponatremia [**1-19**] SIADH, came from [**Hospital 100**] rehab who presented with afib with rvr, chest pain, and hypotension. . Acute Diagnoses: . #Afib with rvr: unclear whether this is new onset as cardiologist does not recall formally diagnosing with atrial fibrillation. Upon admission, EKG showed atrial fibrillation with rvr, rate in 120s. [**Month (only) 116**] have been related to ischemia and/or aortic stenosis; but cardiac workup was negative. Also considered COPD and hypothyroidism as cause; TSH within normal limits and CXR unremarkable. Last echo in [**2-/2203**] and EF>55% and valve area 1.0-1.2cm2. CHADS2 score is 4; Dr. [**Last Name (STitle) 171**] (cardiology) notified and recommended not anticoagulating, but continuing aspirin, and doing a repeat TTE. TTE showed aortic valve area to be unchanged at 1.2, preserved EF>55%. Pt rate controlled with metoprolol 25mg TID on hospital day 1 which brought down heart rate to high 90s. Cardiology recommended digoxin 0.5mg PO for 2 days followed by digoxin level before administering third dose. On hospital day 2, patient's SBP 80-90s and HR 110-120, still in Afib. Due to concern over the thickness of pt's left ventricle, digoxin was held and rate control was tried with Metoprolol only. Over the [**Hospital **] hospital course, his heart rates could not be adequately controled with Metoprolol alone. Therefore pt was restarted on digoxin .125mg to help with rate control. . #Hypotension: Pt had nitropatch on day of admission after complaing of chest pain. Nitropatch could have been part of the the cause of hypotension, where duration of action is 10-12hrs for transdermal route. Patient's BP was persistently low on first hospital day, SBP~90. Tachycardia resolved with metoprolol, but unfortunately worsened the patient's hypotension as low as to the high 70s SBP. Patient placed on digoxin on [**2204-6-27**] for two day course. . Chronic Diagnoses: #Chronic hyponatremia: Has a sodium baseline 125-131 due to SIADH. Sodium was 130 on admission and remained stable. . #Chronic bronchitis: No shortness of breath or worsening cough during hospital course, remained on home regimen of albuterol and Advair diskus. . #Back pain from spinal stenosis: Pt remained on home regimen of lidocaine patch and gabapentin 300mg PO daily. Has [**7-5**] appt with pain clinic at [**Hospital **] hospital. . #HTN: At the [**Hospital 100**] Rehab facility, was on valsartan and metoprolol. Valsartan was held during hospital course as BP remained low, SBP in 80s- low 100s. . Transitional issues: -Has [**7-5**] appt with pain clinic at [**Hospital1 18**]. -Pt is to have Digoxin level rechecked by Dr.[**Name (NI) 5103**] office, his outpatient cardiologist at his appointment on FRIDAY [**7-6**],[**2203**] at 9:00 AM. Medications on Admission: Tylenol 650mg q6h Albuterol inhaler 90mcg/act hventolin inhaler, 2puff twice a day Aspirin EC 81mg once daily Bisacodyl 20mg once daily PO Chlorhexidine mouthwash 15ml twice a day swish and spit Codeine sulf 20mg q6h Docusate sodium 100mg twice a day Fluticasone propionate 1 spray every 12hrs both nostrils Fluticasone/Salmeterol (Advair 100/50) 1 puff every 12 h Gabapentin 300mg once daily Lactulose syrup 10gm once daily Lidocaine patch 5% 1 daily Menthol/Camphor 1 apply twice a day Metoprolol tartrate 25mg twice a day Mupirocin 2% apply twice a day Pravastatin 40mg every evening Ranitidine 300mg twice a day Senna 17.2mg twice a day Valsartan 40mg twice a day Vit A/Vit C/Vit E/Zinc/Copper PRNs: meclizine Discharge Medications: 1. Acetaminophen w/Codeine 1 TAB PO Q4H:PRN pain 2. Aspirin 81 mg PO DAILY 3. Bisacodyl 10 mg PO BID:PRN constipation 4. Docusate Sodium 100 mg PO BID 5. Fluticasone Propionate NASAL 1 SPRY NU [**Hospital1 **] 6. Fluticasone-Salmeterol Diskus (100/50) 1 INH IH [**Hospital1 **] 7. Gabapentin 300 mg PO DAILY 8. Lidocaine 5% Patch 1 PTCH TD DAILY 9. Meclizine 25 mg PO Q12H:PRN nausea 10. Senna 1 TAB PO BID 11. Simvastatin 20 mg PO QHS 12. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain 13. Digoxin 0.125 mg PO DAILY 14. Albuterol Inhaler 2 PUFF IH [**Hospital1 **] 15. OxycoDONE (Immediate Release) 5 mg PO Q8H:PRN pain 16. Metoprolol Tartrate 50 mg PO TID Hold for HR<60 or SBP < 95 Discharge Disposition: Extended Care Facility: [**Hospital 4542**] Rehabilitation and Nursing of [**Location (un) 38**] Discharge Diagnosis: Primary: -Atrial Fibrillation with Rapid Ventricular Response -Hypotension -Chest Pain 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 68759**], It was our pleasure taking care of you at the [**Hospital1 18**]. You were admitted to the [**Hospital1 69**] from [**Hospital 100**] Rehab facility for low [**Hospital **] pressure after having chest pain. Your pulse was also found to be very high, and irregular- something we call atrial fibrillation. Your heart rate was controlled with medication and your condition improved. Followup Instructions: Department: CARDIAC SERVICES When: FRIDAY [**2204-7-6**] at 9:00 AM With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2003**], NP [**Telephone/Fax (1) 62**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage

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icd9cm

[ [ [] ] ]

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icd9pcs

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Discharge summary

report

Admission Date: [**2184-1-8**] Discharge Date: [**2184-1-15**] Date of Birth: [**2108-8-15**] Sex: F Service: MEDICINE Allergies: Klonopin / Morphine Attending:[**Doctor First Name 2080**] Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: Multiple bronchoscopies w/ stenting and later stent removal History of Present Illness: 75 year-old woman with hx of tracheobronchomalacia and COPD complicated by vocal chord dysfunction, prolonged history of COPD exacerbations, on 3L home O2 at night, s/p Y-stent placement a couple of weeks ago by Dr. [**Last Name (STitle) **], who presented to OSH with increased SOB over past 3 days and hypoxia. She was noted to have room air O2 saturation of 85% at [**Hospital1 1562**], improved to 96% on room air after nebulizers. Patient was transferred to [**Hospital1 18**] for further management by IP. Patient reports taking her mucolytics regularly though daughter is concerned about compliance. Of note, she was recently hospitalized for COPD exacerbation, initially started on broad-spectrum antibiotics, which were narrowed down to levofloxacin to complete course, discharged on prednisone taper. . In the ED, patient was initially 88% on RA. She received Duonebs and was started on Bipap, after which she improved to 100% O2sat. She was given IV lorazepam as well to help with anxiety on Bipap. EKG showed NSR 79 with no changes from prior, and CXR showed persistent left retrocardiac opacity from prior. Vitals prior to transfer were as follows: afebrile, 98.4, HR 84 139/72 28 100% BiPap 8/5 and 100%FiO2. On arrival to the ICU, patient still in some respiratory distress, on Bipap. Past Medical History: Tracheobroncheomalacia s/p Y stenting in [**8-/2182**], which was removed On [**2182-9-27**] given mucous plugging; also s/p stent on [**2184-1-1**] - removed on [**2184-1-12**] for mucous plugging COPD on 3L home oxygen Vocal Cord Dysfunction Obesity hypoventilation syndrome Chronic Diastolic heart failure Hypothyroidism Irritable bowel Syndrome Vitamin D deficency Coronary artery disease Anxiety Depression Seizure disorder H/o C. diff colitis R colon cancer s/p hemicolectomy in [**2178**] (vs. neuroendocrine tumor per some OSH reports) s/p tonsillectomy s/p thyroid lobectomy [**2151**] s/p cholecystectomy [**2151**] s/p appendectomy [**2179**] - for neuroendocrine tumor Smoking Psychosis with prednisone Social History: Lives in [**Location 18223**] MA, alone, independent in ADLs. Tobacco - 55yrs of 1ppwk Etoh, drugs - denies. Family History: Mother and father with CAD No lung cancer or congenital lung diseases Physical Exam: Physical Exam on Admission: Vitals: T: 96.5 BP: 152/70 P: 95 R: 28 O2: 100% on Bipap General: lying supine in mild respiratory distress, tachypneic, answering questions through Bipap mask HEENT: dry mucus membranes, sclera anicteric Neck: JVP not elevated Lungs: diffuse rhonchi anteriorly and laterally, could not appreciate wheezing CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, no rebound tenderness or guarding GU: no foley Ext: warm, well perfused, 1+ peripheral lower extremity edema Physical Exam on Discharge: Vitals: T: 98.2 BP: 118/82 P: 99 R: 20 O2:95% on 4L General: sitting upright, tachypneic, conversational HEENT: moist mucus membranes, sclera anicteric Neck: JVP not elevated Lungs: mild diffuse rhonchi posteriorly with occassional wheezes CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, no rebound tenderness or guarding, obese GU: no foley Ext: warm, well perfused, 1+ peripheral lower extremity edema, PICC inplace Pertinent Results: On admission: [**2184-1-8**] 12:45PM PT-11.5 PTT-21.7* INR(PT)-1.0 [**2184-1-8**] 12:45PM WBC-10.5 RBC-4.47 HGB-11.9* HCT-38.2 MCV-86 MCH-26.6* MCHC-31.1 RDW-15.2 [**2184-1-8**] 12:45PM CALCIUM-8.4 PHOSPHATE-4.5 MAGNESIUM-2.2 [**2184-1-8**] 12:45PM GLUCOSE-157* UREA N-15 CREAT-1.0 SODIUM-138 POTASSIUM-4.8 CHLORIDE-106 TOTAL CO2-23 ANION GAP-14 . CXR: [**1-8**] Improved bibasilar atelectasis in the setting of increased lung volumes as compared to the [**2183-12-25**] study. Persistent left retrocardiac opacity remains, reflecting chronic changes. . [**2183-12-30**] Echo: The left atrium is mildly dilated. Left ventricular wall thickness, cavity size, and global systolic function are normal (LVEF>55%). Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. IMPRESSION: Suboptimal study, pulmonary pressures not obtainable because of technically-inadequate tricuspid regurgitation jet. Grossly preserved biventricular systolic function. Brief Hospital Course: 75M with hx of tracheobronchomalacia and COPD complicated by vocal chord dysfunction on home O2 who presented to OSH with increased SOB over past 3 days and hypoxia and transferred to [**Hospital1 18**] for interventional pulmonology. Brief Hospital Course is as follows: # Shortness of breath: Patient has history of COPD on home O2, recently discharged from hospitalization for COPD exacerbation. A large mucus plug was suctioned from Y-stent during bronchoscopy on arrival to MICU with subsequent improvement in symptoms back to baseline. She received the following meds mucinex 1200mg po BID, inhaled acetylcysteine [**Hospital1 **], prn nebs and her prednisone taper from previous hospitalization was continued. The patient again had a bronchoscopy on ICU day #2, which showed thin mucous and stent in place. They recommended BiPap to be used as needed for SOB. On HD #4, the patient underwent a 3rd bronch as her symptoms had not been improving with the recent stents. The Y-stent was removed on [**1-12**] out of concern for mucus plugging. She was briefly on BiPap for respiratory distress but tolerated the mask for 1.5 hours. The patient's dyspnea had a significant anxiety component and she responded well to Ativan. Palliative care was consulted and the patient expressed her wishes to be DNR/DNI - the patient's daughters were also involved in this discussion. Palliative care also recommended improved pain control with oxycodone and prn dilaudid. Interventional pulmonology recommended prn BiPap and prn mucolytics for her symptoms. She was treated with a course of antibiotics for fever with presumed pulmonary source. Her prednisone was tapered. She is being discharged to rehab with one day left of IV antibiotic therapy and 3 days of her steroid taper. She is being set up for an outpatient sleep study to get home CPAP setup. . # Hx of Seizure Disorder: Home lamotrigine was continued . # Hypothyroidism: Home levothyroxine was continued . # Depression: Her home venlafaxine was restarted . # DVT prophylaxis was with subcutaneous heparin. . # Communication was with daughter [**Name (NI) **] [**Name (NI) 18233**] (HCP). Code status was DNR/DNI (confirmed with daughter, HCP). She will accept rehospitalization if necessary, however she refuses to come back to [**Location (un) 86**] for any reason. She will only accept going to community hospitals near her rehab and her home. She will benefit from pallative care planning from rehab. Medications on Admission: (per her past d/c summary) 1. lamotrigine 100 mg Tablet daily 2. cyanocobalamin (vitamin B-12) 100 mcg daily 3. venlafaxine 150 mg [**Hospital1 **] 4. aspirin 81 mg Tablet, Chewable daily 5. cholecalciferol (vitamin D3) 800u daily 6. Nexium 20 mg Capsule, Delayed Release(E.C.) daily 7. levothyroxine 125 mcg Tablet daily 8. guaifenesin 600 mg Tablet Sustained - 2 tabs [**Hospital1 **] 9. benzonatate 100 mg Capsule po TID 10. acetylcysteine 20 % (200 mg/mL) Neb Solution [**Hospital1 **] 11. tiotropium bromide 18 mcg Capsule, daily 12. fluticasone-salmeterol 250-50 mcg/dose Disk [**Hospital1 **] 13. prednisone 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily): please take 2 tablets for 5 days, then 1 tablet for 5 days, then [**1-18**] tablet for 5 days, then stop. Disp:*20 Tablet(s)* Refills:*0* 14. morphine 10 mg/5 mL Solution Sig: [**1-18**] teaspoons PO Q4H (every 4 hours) as needed for SOB. 15. fexofenadine 60 mg Tablet PO DAILY *per report - patient noncompliant with many of medications* Discharge Medications: 1. levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. fexofenadine 60 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 4. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 5. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 6. benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day) as needed for cough. 7. oxycodone 5 mg/5 mL Solution Sig: One (1) 5mg PO Q8H (every 8 hours). 8. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for Constipation. 9. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for Constipation. 10. docusate sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2 times a day). 11. acetylcysteine 20 % (200 mg/mL) Solution Sig: One (1) nebulization Miscellaneous twice a day. 12. nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr Transdermal DAILY (Daily). 13. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) nebulization Inhalation Q4H (every 4 hours) as needed for shortness of breath. 14. lorazepam 1 mg Tablet Sig: One (1) Tablet PO Q4 PRN as needed for anxiety, SOB. 15. prednisone 10 mg Tablet Sig: One (1) Tablet PO once a day for 3 days. 16. vancomycin 1,000 mg Recon Soln Sig: One (1) Intravenous every twenty-four(24) hours for 1 days. 17. cefepime 2 gram Recon Soln Sig: One (1) Intravenous every twenty-four(24) hours for 1 days. Discharge Disposition: Extended Care Facility: [**First Name8 (NamePattern2) **] [**Hospital **] Nursing Home - [**Location (un) 5087**] Discharge Diagnosis: Pneumonia, COPD exacerbation Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent, however requiring oxygen support. Discharge Instructions: You were transferred to [**Hospital1 18**] from [**Hospital 1562**] Hospital for management of your increasing shortness of breath and low oxygen levels. You had a stent in your lungs which was removed as it kept becoming clogged. You were treated for presumed pneumonia, as well as exacerbation of your lung disease. You received steroids, breathing treatments and intravenous antibioitics. It is felt that you would benefit from the use of a breathing machine which could help you when you have lung disease attacks. You will need to have a sleep study performed to get this machine set-up for you. The procedure for having that study set-up is described below. Some changes were made to your medications as follows: 1. Prednisone: you will need to take 10mg of prednisone, one time a day, for the next 3 days. After that you will not need any more of this medication. 2. Ativan: 1mg taken by mouth every 4 hours as needed for anxiety or shortness of breath 3. Oxycodone: 2.5mg-5mg taken by mouth every 3 hours as needed for pain or shortness of breath. 4. Vancomycin/Cefipime: You will get your final intravenous doses of these medications at rehab. Please resume all your other home medications as previously ordered. Please follow-up with your primary care provider concerning this hospitalization next week. Followup Instructions: You need to have a sleep study in order to get set-up from a CPAP machine for your home. These studies are done outside of the hospital. The study has been ordered, however they will call you with an appointment. Please call your primary care provider to set up a follow-up appointment to discuss this hospitalization.

[ "934.9", "518.83", "305.1", "278.03", "244.9", "478.5", "V46.2", "V49.86", "428.0", "491.21", "E915", "V10.05", "996.59", "486", "345.91", "E878.1", "300.4", "268.9", "V15.81", "519.19", "428.32" ]

icd9cm

[ [ [] ] ]

[ "33.78", "32.01", "96.05" ]

icd9pcs

[ [ [] ] ]

10376, 10492

5170, 7632

300, 361

10564, 10564

3761, 3761

12089, 12411

2579, 2650

8687, 10353

10513, 10543

7658, 8664

10748, 12066

2665, 2679

3255, 3742

241, 262

389, 1698

3775, 5147

10579, 10724

1720, 2436

2452, 2563

74,258

190,956

22726

Discharge summary

report

Admission Date: [**2124-5-26**] Discharge Date: [**2124-6-4**] Date of Birth: [**2071-11-25**] Sex: M Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 165**] Chief Complaint: Chest pain Major Surgical or Invasive Procedure: [**2124-5-29**] Off Pump Coronary Artery Bypass Grafting x 3 utilizing the left internal mammary artery to left anterior descending artery with saphenous vein grafts to obtuse marginal and diagonal arteries. History of Present Illness: This is a 52 year old male with no prior cardiac history who presented to MWMC with substernal chest pain. He ruled in for an STEMI and was brought emergently to the cardiac cath lab where he received a drug eluting stent to the culprit OM2 branch of the left circumflex. He was loaded with Plavix and maintained on an Integrillin drip. Catheterization also revealed multi vessel coronary artery disease. Given the above findings, he was transferred to the [**Hospital1 18**] for further evaluation and treatment. Past Medical History: Coronary Artery Disease, ST elevation Myocardial Infarction Lymphedema of right Lower Extremity s/p Basal cell carcinoma removal Social History: - Denies tobacco. Social ETOH, no history of ETOH abuse. - Married with four children - works as stylist at [**Company 58842**] Family History: Father underwent CABG after prior PCI/stenting Physical Exam: Pulse: 62 Resp: 16 O2 sat: 97% B/P Right: 118/79 Left: Height: 5'4" Weight: 225lb General: NAD, WG, obese male Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur [] grade ______ Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Extremities: Warm [x], well-perfused [x] Edema [] _RLE lymphedema_ Varicosities: None [x] Neuro: Grossly intact [x] Pulses: Femoral Right: cath site Left:2+ DP Right: 2+ Left:2+ PT [**Name (NI) 167**]: 2+ Left:2+ Radial Right: 2+ Left:2+ Carotid Bruit: no bruits Pertinent Results: [**2124-5-26**] WBC-10.3 RBC-4.50* Hgb-15.4 Hct-44.7 Plt Ct-254 [**2124-5-26**] PT-11.0 PTT-32.2 INR(PT)-1.0 [**2124-5-26**] Glucose-102* UreaN-12 Creat-0.9 Na-139 K-5.1 Cl-102 HCO3-28 [**2124-5-26**] ALT-27 AST-28 LD(LDH)-193 AlkPhos-60 Amylase-48 TotBili-1.7* [**2124-5-26**] %HbA1c-4.5* eAG-82* [**2124-5-26**] Mg-2.2 [**2124-6-1**] 04:23AM BLOOD WBC-14.3* RBC-2.06* Hgb-7.1* Hct-21.1* MCV-102* MCH-34.5* MCHC-33.8 RDW-15.6* Plt Ct-189 [**2124-5-31**] 06:41AM BLOOD WBC-13.6* RBC-2.22* Hgb-7.6* Hct-22.5* MCV-102* MCH-34.4* MCHC-33.8 RDW-15.3 Plt Ct-191 [**2124-6-1**] 04:23AM BLOOD Glucose-116* UreaN-25* Creat-1.0 Na-133 K-4.6 Cl-98 HCO3-27 AnGap-13 [**2124-5-31**] 06:41AM BLOOD Glucose-122* UreaN-21* Creat-1.0 Na-129* K-4.9 Cl-98 HCO3-27 AnGap-9 [**2124-5-31**] 04:51AM BLOOD Glucose-134* UreaN-21* Creat-1.0 Na-131* K-4.9 Cl-99 HCO3-26 AnGap-11 [**2124-5-29**] Echo LEFT ATRIUM: No spontaneous echo contrast or thrombus in the LA/LAA or the RA/RAA. 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. PFO is present. Left-to-right shunt across the interatrial septum at rest. LEFT VENTRICLE: Wall thickness and cavity dimensions were obtained from 2D images. Normal LV wall thickness, cavity size and regional/global systolic function (LVEF >55%). RIGHT VENTRICLE: Normal RV systolic function. AORTA: Normal diameter of aorta at the sinus, ascending and arch levels. Normal ascending aorta diameter. Normal descending aorta diameter. Simple atheroma in descending aorta. AORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. No MS. Physiologic MR (within normal limits). TRICUSPID VALVE: Mild to moderate [[**2-7**]+] TR. PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS. Physiologic PR. PERICARDIUM: No pericardial effusion. GENERAL COMMENTS: Written informed consent was obtained from the patient. A TEE was performed in the location listed above. I certify I was present in compliance with HCFA regulations. The patient was under general anesthesia throughout the procedure. No TEE related complications. The patient appears to be in sinus the patient. Conclusions 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. A left-to-right shunt across the interatrial septum is seen at rest. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). The right ventricle displays normal free wall contractility. The diameters of aorta at the sinus, ascending and arch levels are normal. 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 mildly thickened. Physiologic mitral regurgitation is seen (within normal limits). There is no pericardial effusion. After grafting, no significant changes were noted. Dr. [**Last Name (STitle) **] was notified in person of the results in the operating room at the time of the study. Brief Hospital Course: Mr. [**Known lastname **] was admitted following ST elevation myocardial infarction and PCI/stenting of second obtuse marginal. He remained pain free on intravenous therapy and underwent further preoperative testing. Preoperative course was otherwise uneventful and he was cleared for surgery. On [**5-29**], Dr. [**First Name (STitle) **] performed off pump coronary artery bypass grafting. For surgical details, please see operative note. POD 1 found the patient extubated, alert and oriented and breathing comfortably. The patient was neurologically intact and hemodynamically stable, weaned from inotropic and vasopressor support. Beta blocker was initiated and the patient was gently diuresed toward the preoperative weight. Plavix was resumed for new drug eluting stent and off pump CABG. The patient was transferred to the telemetry floor for further recovery. POD 2 he was noted to have a widened mediastinum with a Hematocrit drop to 21. Echo was performed and showed no tamponade. He was hemodynamically stable and not transfused at that time. His HCT dropped to 20 and was symptomatic w/ hypotension and dizzy with ambulation. He received a total of 3 units of packed red blood cells. Chest tubes and pacing wires were discontinued without complication. Foley was reinserted on POD 2 due to failure to void. Foley was removed again on POD 4 without complication. The patient was evaluated by the physical therapy service for assistance with strength and mobility. By the time of discharge on POD 6 the patient was ambulating freely, the wound was healing and pain was controlled with oral analgesics. The patient was discharged to home in good condition with appropriate follow up instructions. Medications on Admission: Meds on transfer: Integrillin IV gtt, Lipitor 80mg daily, Omeprazole 20mg daily, Lopressor 25mg [**Hospital1 **], Aspirin 325mg daily, ntg prn Discharge Medications: 1. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 2. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) as needed for constipation. 3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 5. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for pain, fever. 6. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 7. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. Disp:*60 Tablet(s)* Refills:*0* 8. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2* 9. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 10. Lasix 20 mg Tablet Sig: One (1) Tablet PO twice a day for 7 days. Disp:*14 Tablet(s)* Refills:*0* 11. potassium chloride 10 mEq Tablet Extended Release Sig: Two (2) Tablet Extended Release PO Q12H (every 12 hours) for 7 days. Disp:*28 Tablet Extended Release(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Company 1519**] Discharge Diagnosis: Coronary Artery Disease, s/p CABG ST Elevation Myocardial Infarction Lymphedema Discharge Condition: Alert and oriented x3 nonfocal Ambulating with steady gait Incisional pain managed with tylenol Incisions: Sternal - healing well, no erythema or drainage Leg Left - healing well, no erythema or drainage. chronic lymphedema right lower extremity Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Followup Instructions: You are scheduled for the following appointments Surgeon: Dr. [**First Name (STitle) **] Phone:[**Telephone/Fax (1) 170**] Date/Time:[**2124-7-4**] 1:15 in the [**Hospital **] Medical office building [**Hospital Unit Name **], 110 [**Doctor First Name **] suite. Cardiologist: Dr. [**Last Name (STitle) 31888**] [**2124-6-16**] at 11:00a WOUND CARE Phone:[**Telephone/Fax (1) 170**] Date/Time:[**2124-6-8**] 10:15 in the [**Hospital **] Medical office building [**Hospital Unit Name **], 110 [**Doctor First Name **] suite. Please call to schedule appointments with your Primary Care Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 8036**] in [**5-11**] weeks **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**] Completed by:[**2124-6-4**]

[ "457.1", "V45.82", "414.01", "511.9", "V10.83", "278.00", "285.9", "V85.36", "V17.3", "458.29", "410.91", "998.12", "788.20" ]

icd9cm

[ [ [] ] ]

[ "36.12", "36.15" ]

icd9pcs

[ [ [] ] ]

8693, 8742

5425, 7138

320, 530

8866, 9114

2135, 5402

9954, 10942

1388, 1436

7332, 8670

8763, 8845

7164, 7164

9138, 9931

1451, 2116

270, 282

558, 1073

1095, 1226

1242, 1372

7182, 7309

9,245

187,008

25800

Discharge summary

report

Admission Date: [**2176-7-7**] Discharge Date: [**2176-7-11**] Date of Birth: [**2104-1-14**] Sex: M Service: SURGERY Allergies: Iodine; Iodine Containing / Sulfa (Sulfonamides) Attending:[**First Name3 (LF) 3376**] Chief Complaint: Chest Pain, Bright Red Blood Per Rectum Major Surgical or Invasive Procedure: None History of Present Illness: 72M with substantial cardiac history (5 stents, 2 CABG) presents after transanal excision of a rectal polyp 6 days ago ([**7-1**]) with chest pain in the setting of increased bleeding from his anus after restarting his aspirin and plavix. Initially post-op the patient had limited bleeding, but the patient developed chest pain akin to his stable angina pain on Friday night. The pain resolved with NTG, but his wife restarted the patient on ASA/Plavix two days prematurely, as his bleeding had subsided, and she was concerned about his heart. After this dosage the patient began to bleed "profusely" through Saturday with repeat chest pain into Sunday morning, at which time they presented to the ED. Evaluation of the patient reveals no current chest pain, continued lower bleeding, and a hct of 26 before receiving 2 units of blood. Past Medical History: 1. Hypertension. 2. Hyperlipidemia. 3. Glucose intolerance. 4. GERD. 5. History of remote tobacco abuse. 6. Grilling accident resulting in a burn of his left lower extremity and 3 grafting surgeries at the [**Hospital6 2121**] in Fall of [**2174**]. 7. Coronary artery disease status post CABG x2 in [**2150**] followed by SVG-RCA drug-eluting stent placement (known occluded) and left main/circumflex stent placement in [**2171**]. 8. Peripheral vascular disease, asymptomatic carotid artery disease status post [**Country **] stenting ([**2171**]). Social History: neg tobacco (quit 30 years ago previous 20 pack year hx), 5 glasses wine/night, married, works at filtering company Family History: no significant Pertinent Results: EKG - No concerning changes Troponins: <.01, <.01, .01 ([**Date range (1) 23445**]) [**2176-7-11**] 06:20AM BLOOD Hct-32.1* [**2176-7-10**] 07:15AM BLOOD WBC-4.6 RBC-3.33* Hgb-10.5* Hct-30.9* MCV-93 MCH-31.4 MCHC-33.9 RDW-15.4 Plt Ct-284 [**2176-7-9**] 09:30AM BLOOD WBC-5.6 RBC-3.11* Hgb-9.8* Hct-28.4* MCV-91 MCH-31.5 MCHC-34.5 RDW-15.9* Plt Ct-253 [**2176-7-9**] 12:20AM BLOOD Hct-26.3* [**2176-7-8**] 06:15PM BLOOD Hct-27.7* [**2176-7-8**] 01:14PM BLOOD WBC-6.3 RBC-3.15* Hgb-9.9* Hct-29.0* MCV-92 MCH-31.5 MCHC-34.1 RDW-15.3 Plt Ct-234 [**2176-7-8**] 08:19AM BLOOD Hct-28.4* [**2176-7-8**] 03:53AM BLOOD WBC-6.5 RBC-3.17* Hgb-10.0* Hct-29.2* MCV-92 MCH-31.6 MCHC-34.3 RDW-15.2 Plt Ct-238 [**2176-7-8**] 01:20AM BLOOD Hct-30.2* [**2176-7-7**] 09:15PM BLOOD WBC-7.4 RBC-2.92* Hgb-9.3* Hct-27.1* MCV-93 MCH-31.9 MCHC-34.5 RDW-14.3 Plt Ct-275 [**2176-7-7**] 04:45PM BLOOD WBC-6.1# RBC-2.65*# Hgb-8.6*# Hct-26.1*# MCV-99* MCH-32.6* MCHC-33.1 RDW-13.5 Plt Ct-310 [**2176-7-10**] 07:15AM BLOOD Plt Ct-284 [**2176-7-9**] 09:30AM BLOOD Plt Ct-253 [**2176-7-9**] 09:30AM BLOOD PT-13.5* PTT-27.4 INR(PT)-1.2* [**2176-7-10**] 07:15AM BLOOD Glucose-79 UreaN-14 Creat-1.0 Na-139 K-4.1 Cl-103 HCO3-28 AnGap-12 [**2176-7-9**] 09:30AM BLOOD Glucose-87 UreaN-14 Creat-1.0 Na-139 K-4.1 HCO3-27 [**2176-7-8**] 01:14PM BLOOD Glucose-102* UreaN-10 Creat-0.8 Na-141 K-3.7 Cl-108 HCO3-27 AnGap-10 [**2176-7-8**] 03:53AM BLOOD Glucose-132* UreaN-13 Creat-0.8 Na-139 K-3.6 Cl-105 HCO3-29 AnGap-9 [**2176-7-7**] 04:45PM BLOOD Glucose-130* UreaN-15 Creat-1.0 Na-141 K-3.9 Cl-101 HCO3-31 AnGap-13 [**2176-7-10**] 07:15AM BLOOD Calcium-8.9 Phos-2.9 Mg-2.1 [**2176-7-9**] 09:30AM BLOOD Calcium-8.4 Phos-2.7 Mg-2.4 [**2176-7-8**] 01:14PM BLOOD Calcium-8.0* Phos-2.8 Mg-1.9 [**2176-7-8**] 03:53AM BLOOD Calcium-8.1* Phos-3.2 Mg-1.8 Sigmoidoscopy [**2176-7-7**] Extensive blood and clots were seen. This was copiously irrigated and suctioned to try to attain visualization. There appeared to be a cratered, polypoid, and ulcerated lesion at presumed site of recent surgery extending from 8 to 10 cm. Two clips were placed at site of blood pooling. After this, pumping vessel was noted at about 7 to 8 cm. Two clips were placed with hemodynamic effect. 3 cc's of epinephrine was injected. There appeared to be a third site of bleeding where an additional clip was placed. Latter two sites were likely arterial in etiology. At the conclusion of procedure, there was no active bleeding. There was significant retained polyp tissue despite recent surgery. Non-closed area of mucosal defect was noted at 10 cm opposite wall where bleeding was coming from. Suture material extending into lumen was also seen Otherwise normal sigmoidoscopy to 40 cm. Brief Hospital Course: The patient was admitted to the ICU for management of his lower GI bleed. He required 4 units pRBCs for initial resuscitation (5 for total admission) to maintain his hematocrit with a goal >30 during his acute bleeding. He was started on empiric cipro/flagyl during his ICU stay. GI was consulted and a sigmoidoscopy was performed. A bleeding vessel was identified and clipped with resolution of his bleeding and a residual polyp was identified. Because of his complaint of chest pain, EKG was obtained and cardiac enzymes were cycled, both of which were negative for ischemic changes. Cardiology was consulted and stated that his symptoms were likely due to demand ischemia in the setting of GI bleed, and recommended restarting his home meds and continuing aggressive blood pressure management. Once the patients acute bleeding had stopped, he was transferred to the floor for further management. His hematocrits stabilized in at ~28, and he was restarted on his home medications with the exception of his aspirin and plavix. Results from his OSH polypectomy showed adenocarcinoma in situ. After reviewing the results of the sigmoidoscopy, it was determined that the patients findings were c/w post-operative changes and he did not need any acute surgery. He was discharged to home with plan to follow up in the clinic in 3 weeks to revisit these issues. He is to follow-up with his primary gastroenterologist 3 months after his original procedure. Medications on Admission: Imdur 30, Lisinopril 20, Lopressor 50'', Zocor 20, Protonix 40, ASA 325, Plavix 75, Latanoprost 1 drop OU QHS, Ativan PRN, Nitroglycerin 0.4 SL PRN, MVI Discharge Medications: 1. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at bedtime). Disp:*qs * Refills:*2* 2. Nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) Tablet, Sublingual Sublingual PRN (as needed) as needed for chest pain. Disp:*30 Tablet, Sublingual(s)* Refills:*0* 3. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 4. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain. Disp:*30 Tablet(s)* Refills:*0* 5. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr Sig: Three (3) Tablet Sustained Release 24 hr PO DAILY (Daily). Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2* 6. Ranolazine 500 mg Tablet Sustained Release 12 hr Sig: One (1) Tablet Sustained Release 12 hr PO BID (2 times a day) as needed for angina in pt with CAD s/p CABG. Disp:*30 Tablet Sustained Release 12 hr(s)* Refills:*0* 7. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 8. 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* 9. Carvedilol 25 mg Tablet Sig: Two (2) Tablet PO twice a day. Disp:*120 Tablet(s)* Refills:*0* 10. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Disposition: Home Discharge Diagnosis: Lower GI Bleed Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to the hospital for bleed per rectum after a previous anal polypectomy, and required multiple blood transfusions. Once your bleeding had resolved, you were observed to ensure that there was no further bleeding. Additionally, you have a polyp that could not be removed trans-anally, and will require eventual resection (surgery). You have an blood pressure medication that was changed from metoprolol to carvedilol during your admission . It is very important that you check your blood pressure at home and follow-up with your primary care provider [**Last Name (NamePattern4) **] 1 week for a blood pressure check and to go over your medication regimen. If the top number (systolic) blood pressure is below 100 please call our doctor. It is safe for you to restart your aspirin, plavix, and other home medications. Please call your doctor or return to the ER for any of the following: * You experience new chest pain, pressure, squeezing or tightness. * New or worsening cough or wheezing. * If you are vomiting and cannot keep in fluids or your medications. * You are getting dehydrated due to continued vomiting, diarrhea or other reasons. * Signs of dehydration include dry mouth, rapid heartbeat or feeling dizzy or faint when standing. * You see blood or dark/black material when you vomit or have a bowel movement. * You have shaking chills, or a fever greater than 101.5 (F) degrees or 38(C) degrees. * Any serious change in your symptoms, or any new symptoms that concern you. * Please resume all regular home medications and take any new meds as ordered. * Do not drive or operate heavy machinery while taking any narcotic pain medication. You may have constipation when taking narcotic pain medications (oxycodone, percocet, vicodin, hydrocodone, dilaudid, etc.); you should continue drinking fluids, you may take stool softeners, and should eat foods that are high in fiber. * Continue to ambulate several times per day. * No heavy ([**11-22**] lbs) until your follow up appointment. Followup Instructions: Please follow up with Dr. [**Last Name (STitle) 1120**] in 3 weeks call ([**Telephone/Fax (1) 3378**] to make an appointment. Please make a follow-up appointment with your primary Gastrointestinal provider in [**Name9 (PRE) 487**] Dr. [**Last Name (STitle) 64258**] 3 months from your origninal procedure. Please call his office to make an appointment. Completed by:[**2176-7-11**]

[ "154.1", "414.02", "272.4", "530.81", "401.9", "443.9", "998.11", "V45.82", "E878.8", "V58.61", "790.29", "411.1" ]

icd9cm

[ [ [] ] ]

[ "45.43" ]

icd9pcs

[ [ [] ] ]

7798, 7804

4732, 6185

347, 354

7863, 7863

1992, 4709

10056, 10441

1957, 1973

6389, 7775

7825, 7842

6211, 6366

8014, 10033

268, 309

382, 1224

7878, 7990

1246, 1807

1823, 1941

23,150

139,583

52201

Discharge summary

report

Admission Date: [**2174-6-26**] Discharge Date: [**2174-7-1**] Date of Birth: [**2092-2-13**] Sex: M Service: MEDICINE Allergies: Penicillins / Cephalosporins / Carbapenem / A.C.E Inhibitors / Angiotensin Receptor Antagonist / Aztreonam Attending:[**First Name3 (LF) 2817**] Chief Complaint: dyspnea Major Surgical or Invasive Procedure: Intubation. Mechanical Ventilation. History of Present Illness: Mr. [**Known lastname **] is an 82 yo M with multiple medical problems including CAD s/p MI with PCI, systolic CHF (EF of 45% in [**4-30**]), CKD (baseline Cre 2.5-3.5), and C. difficile infection s/p total colectomy who presents with chest pain and hypotension at rehab. . He was recently admitted to [**Hospital1 2025**] on [**2174-6-4**] for weakness and discharged to [**Hospital3 **] on [**6-9**]. Per rehab records, the patient was noted to collapse at synagogue and taken to [**Hospital1 2025**] for evaluation. He was noted to be hypertensive to 220/100, and was treated as a hypertensive emergency with IV lopressor. Labs there significant for a trop-I of 0.7 (likely troponin leak in setting of hypertension) and positive p-Mibi with decreased EF of 38%, and a large anterior-anterolateral area of ischemia. He was managed medically and not taken to cath [**2-22**] his ESRD and single kidney. Negative bilateral LENIs on [**6-6**]. His hospital course was complicated by an E. coli UTI treated with 14 days of Aztreonam. . The day of admission to [**Hospital1 18**], he was noted at rehab to have increased SOB in the morning and refusing to have his BIPAP removed (which is used at night for OSA). O2 sats were 100% on his BIPAP settings. CXR performed without evidence of pulmonary edema or effusions. Patient given nebs with good effect on oxygen saturations. Around 2:30 pm (after eating lunch), patient c/o chest 'tightness' and O2 sat noted to be 89% on 2 L NC, improved to 92% with 5 L. Given SL nitro 0.4 x1. SBP was 140 prior to administration of nitro. Pt then noted after administration of nitro to become unresponsive for 30 seconds. Unable to obtain BP at that time. Patient recovered and repeat BP was 130/72 with O2 sat of 93% on 5 L. P alert, responsive, stated CP relieved. Pt placed on 100% NRB with O2 sat of 96% and transferred to [**Hospital1 18**] ED for further care. . In the ED, initial vs were: 98.2 97 131/76 24 97%. Lab sig for WBC of 11.0, Cre 3.3 (baseline 2.5-3.5), and trop-T of 0.06 (at baseline). CXR no PNA, Head CT no acute ICP. Pt received Zofran 4 mg IV x1. Cards called for urgent TTE to assess for tamponade, which showed no evidence of tamponade physiology. Unable to get CTA given [**Hospital1 **] failure. Cardiology did not accept patient b/c no acute cardiology issue. Outpatient cardiologist [**Hospital1 653**], requested MICU admission. . In the ICU, pt reports cough productive of sputum x2 weeks. He reports immobilization for most of rehab stay, and reports only being sat up at the side of his bed. Reports nausea, worsening SOB as well over the past two weeks, but denies orthopnea or PND. Reports chest pressure today lasting about 30 minutes, pleuritic in nature. Does not remember being syncopal or presyncopal. No increasing [**Location (un) **] or abdominal girth. No increased ostomy output. No vomiting. Eating and drinking well. Past Medical History: - DM II, on insulin, c/b peripheral neuropathy - Hypertension - Hyperlipidemia - Systolic CHF (Echo [**Hospital1 18**] [**1-29**] with EF 45%) - CAD s/p MI in [**2166**], LAD stent [**11/2167**], OM1 stent [**12/2167**], restenosis s/p balloon angio [**1-/2169**] - Chronic Kidney Disease (baseline Cr 2.5-3.5) - h/o Type 4 [**Year (4 digits) 2793**] Tubular Acidosis (hypoaldosteronism, hyperkalemia) - ACD (baseline Hct 30) - h/o Fulminant C.diff colitis (s/p total colectomy with ileostomy) - h/o SBO in [**1-28**] s/p lysis of adhesions - [**Date Range 2793**] Cell Cancer (s/p partial R nephrectomy [**2-/2166**]) - Prostate Cancer (s/p XRT) - Depression - OSA on BiPAP at home - Mid-shaft, surgical neck humerus fracture ([**7-/2169**]) in setting of several falls - Pericardial effusion c/b tamponade [**1-29**]: thought [**2-22**] viral process Social History: Retired trial lawyer. Lives alone but has nursing help in the morning and early evening. Remote smoking hx 60 years ago - 1/2ppd X 5-10 years. Quit alcohol in the 70s. Denies drug use. Family History: Non-contributory Physical Exam: Vitals: 97.4 108 131/73 24 95% on BiPAP 8/5 General: Alert, oriented, on BiPAP HEENT: Sclera anicteric, MM dry, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: crackles at bases. R> L. increased upper airway sounds. increased expiratory phase. CV: decreased HS. tachycardic, normal S1 + S2, no murmurs, rubs, gallops. no carotid bruits Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly. +illeostomy bag with brown stool. purpura (likely iatrogenic) noted noted on abdomen. Ext: warm, well perfused, non-palpable pulses, no edema. Buttock: erythematous rash Pertinent Results: [**2174-6-26**] 11:49PM TYPE-[**Last Name (un) **] PO2-30* PCO2-41 PH-7.32* TOTAL CO2-22 BASE XS--5 [**2174-6-26**] 11:36PM GLUCOSE-147* [**2174-6-26**] 11:36PM CK(CPK)-23* [**2174-6-26**] 06:45PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.010 [**2174-6-26**] 11:36PM CK-MB-2 cTropnT-0.06* [**2174-6-26**] 06:45PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-150 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [**2174-6-26**] 06:45PM URINE RBC-0 WBC-0-2 BACTERIA-OCC YEAST-NONE EPI-0-2 [**Month/Day/Year **] EPI-0-2 [**2174-6-26**] 06:45PM URINE HYALINE-[**3-25**]* [**2174-6-26**] 04:07PM TYPE-[**Last Name (un) **] PO2-69* PCO2-38 PH-7.32* TOTAL CO2-20* BASE XS--5 [**2174-6-26**] 04:00PM GLUCOSE-99 UREA N-62* CREAT-3.3* SODIUM-137 POTASSIUM-4.6 CHLORIDE-106 TOTAL CO2-20* ANION GAP-16 [**2174-6-26**] 04:00PM estGFR-Using this [**2174-6-26**] 04:00PM ALT(SGPT)-24 AST(SGOT)-17 LD(LDH)-206 ALK PHOS-94 TOT BILI-0.3 [**2174-6-26**] 04:00PM LIPASE-16 [**2174-6-26**] 04:00PM cTropnT-0.06* [**2174-6-26**] 04:00PM proBNP-1246* [**2174-6-26**] 04:00PM WBC-11.0# RBC-3.76* HGB-10.9* HCT-33.2* MCV-88 MCH-29.0 MCHC-32.8 RDW-16.0* [**2174-6-26**] 04:00PM NEUTS-81.4* LYMPHS-13.1* MONOS-4.2 EOS-0.9 BASOS-0.4 [**2174-6-26**] 04:00PM NEUTS-81.4* LYMPHS-13.1* MONOS-4.2 EOS-0.9 BASOS-0.4 [**2174-6-26**] 04:00PM PLT COUNT-369 [**2174-6-26**] 04:00PM PT-12.2 PTT-25.0 INR(PT)-1.0 Brief Hospital Course: 82 yo M with CAD s/p recent NSTEMI on [**6-4**] who presents from rehab with an episode of syncope after receiving SL nitro at rehab, also worsening shortness of breath over past week. Pneumonia: The patient had a cough productive of purulent sputum, which became positive for MRSA. He was treated initially with broad spectrum antibiotics, which was later narrowed to vancomycin. Initially started on cpap, however he quickly worsened and required intubation. Septic shock: The patient rapidly became septic and hypotensive and was volume resuscitated with normal saline. He initially responded to this and appeared to be improving, however on hospital day 4 the patient again became hypotensive requiring pressor support. The patient subsequently developed ARDS, and after consultation with the family, pressors were allowed to run out in accordance with orthodox [**Hospital1 **] beliefs in sustaining life but not actively interfering with the process of dying. The patient passed on [**2174-7-1**] at 4:50pm. Medications on Admission: albuterol nebulizer q4h amlodipine 5mg [**Hospital1 **] vitamin C 500mg qd asa 81mg qd carvedilol plavix 75mg qd b12 1000mcg qd ergocalciferol 8000u qd advair 500/50 1inh qd furosemide 30mg qd gabapentin 500mg [**Hospital1 **] heparin SC 5000u [**Hospital1 **] aspart 22u breakfast, 12 units lunch, 14 dinner glargine 58u qhs ipratropium neb q4h miconazole topical tid nephrocaps 1 tab qd pantoprazole 40mg qd paroxetine 20mg qd crestor 10mg qd carafate 1gm tab before each meal tamsulosin 0.4mg qhs vitamin E 400U qd Discharge Medications: deceased Discharge Disposition: Expired Discharge Diagnosis: Acute [**Hospital1 **] failure Chronic kidney disease MRSA bacteremia MRSA pneumonia Septic Shock Acute respiratory distress syndrome. Discharge Condition: Patient expired in ICU. Discharge Instructions: Patient expired in ICU. Completed by:[**2174-7-3**]

[ "V10.52", "V10.46", "414.01", "357.2", "250.60", "V45.11", "482.41", "272.4", "995.92", "584.9", "327.23", "038.12", "785.52", "428.0", "428.22", "518.81", "410.72", "403.91", "585.6" ]

icd9cm

[ [ [] ] ]

[ "38.93", "96.6", "96.04", "96.71", "39.95" ]

icd9pcs

[ [ [] ] ]

8211, 8220

6590, 7610

374, 412

8399, 8425

5129, 6567

4437, 4456

8178, 8188

8241, 8378

7636, 8155

8449, 8502

4471, 5110

327, 336

440, 3342

3364, 4218

4234, 4421

6,079

118,608

15671

Discharge summary

report

Admission Date: [**2196-5-19**] Discharge Date: [**2196-5-19**] Date of Birth: [**2153-1-6**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2297**] Chief Complaint: Unresponsive. Major Surgical or Invasive Procedure: None. History of Present Illness: 43 year-old male with diabetes mellitus type I complicated by nephropathy s/p renal transplant ([**2188**]), hypertension, hypertensive cardiomyopathy, and dyslipidemia admitted after being found unresponsive. Patient reports felling well recently and this morning. Presented to work, and was noted to be confused; coworkers found him unresponsive and called EMS. At the scene, blood glucose 51. . Patient with long-standing diabetes mellitus type I. He uses an insulin pump. Insulin pump is managed by himself. He reports blood glucose typically runs 80-140, and rarely down to low 20s or 30s. He is symptomatic during these episodes (cannot describe particular symptoms), and symptoms resolve with PO intake. He recalls one instance when EMS was called for similar incident; he received dextrose infusion and did not go to the emergency department. . Of note, trasplant from living donor complicated by post-transplant lymphoproliferative disease and antibody-mediated rejection. Eventually with graft failure, and was placed on hemodialysis. He was converted to peritoneal dialysis approximately 3-4 weeks ago. Recently with difficulty with getting fluid off and worsening lower extremity edema. To help with diuresis, dextrose in PD increased to 4.25% from 1.5-2.5%. . In the ED, 63, 121/50, 12, 99% RA. Initially unresponsive. FSBG 30. Received 1 amp D50 with response within 1 minute; temporarily awake, alert. Blood glucose rose to 130, then trickled back down to 60 with associated fatigue Received additional 1 amp D50 with response, and currently on D5 continuous infusion. Still fatigued. Able to eat a [**Location (un) 6002**]. Laboratory data remarkable for creatinine 13.5, blood glucose 118, anion gap 18. Serum tox negative. LDH 268, LFTs unremarkable. Mild anemia, CBC otherwise within normal limits. CT head without contrast negative. CXR 2V with bilateral atelectasis. On tranfer to the ICU, 94.9, 72, 139/85, 10, 96%RA. Blood glucose 200. . On arrival to the ICU, patient reports feeling well. Reports 15-pound weight gain and lower extremity swelling since starting PD. Also reports considerable fatigue since starting starting PD due to being up at night to operate machinery. He denies fever, chills, headache, visual changes. He has a nonproductive cough. Denies chest pain, shortness of [**Location (un) 1440**], palpitations, abdominal pain, nausea/vomiting, diarrhea, constipation, myalgias, arthralgias. He is anuric. Past Medical History: 1. Diabetes metllitus type 1 c/b ESRD, retinopathy 2. End-stage renal disease on HD s/p failed LRRT [**2-/2189**], undergoing repeat evaluation 3. Post-transplant lymphproliferative disorder [**7-/2189**] 4. Hypertension 5. Hypercholesterolemia 6. Chronic diastolic heart failure - history of depressed EF, stress MIBI [**3-/2193**] shows moderate left ventricular enlargement, calculated LVEF 56% Social History: Lives in [**Location 10059**] with family. Works in mantainence, locksmith. Used to work in engineering. No smoking, no alcohol, no IVDU Family History: No history of hypertension, coronary artery disease, or renal disease. Physical Exam: 16, 78, 97% RA, 157/94, General: Comfortable HEENT: Sclera anicteric, dry mucous membranes, oropharynx clear Neck: Supple, JVP not elevated, symmetric anterior cervical chain lymphadenopathy Lungs: Right basilar crackles; otherwise clear to auscultation bilaterally CV: Regular rate and rhythm, normal S1 + S2, early systolic murmurs best heard at RUSB Abdomen: PD catheter in placed, dressed; hypoactive bowel sounds; soft, non-tender, non-distended GU: No Foley Ext: Warm, well perfused; 2+ pulses; 1+ lower extremity edema to knees bilaterally Pertinent Results: [**2196-5-19**] 09:20AM BLOOD WBC-5.0 RBC-4.33* Hgb-12.2* Hct-37.8* MCV-87 MCH-28.2 MCHC-32.2 RDW-14.6 Plt Ct-339 [**2196-5-19**] 09:20AM BLOOD Neuts-81.2* Lymphs-8.1* Monos-4.8 Eos-5.0* Baso-0.9 [**2196-5-19**] 09:20AM BLOOD Glucose-118* UreaN-71* Creat-13.5* Na-142 K-4.8 Cl-98 HCO3-26 AnGap-23* [**2196-5-19**] 04:36PM BLOOD CK(CPK)-332* [**2196-5-19**] 09:20AM BLOOD ALT-16 AST-14 LD(LDH)-268* CK(CPK)-328* AlkPhos-75 TotBili-0.1 [**2196-5-19**] 09:20AM BLOOD CK-MB-8 cTropnT-0.06* [**2196-5-19**] 04:36PM BLOOD CK-MB-10 MB Indx-3.0 cTropnT-0.05* [**2196-5-19**] 09:20AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2196-5-19**] 09:20AM BLOOD Albumin-3.8 Brief Hospital Course: 43M with DMI c/b nephropathy s/p failed renal transplant, hypertension, hypertensive cardiomyopathy, and dyslipidemia admitted to the MICU after being found unresponsive. Now awake and alert. . #. Hypoglycemia: Differential diagnosis includes increased insulin sensitivity secondary to PD, pump malfunction, decreased PO intake, infection. He does not take oral hypoglycemics (type I). Patient reports feeling well lately, does not report infectious symptoms. Case was discussed with [**Last Name (un) **] who recommended patient continue with pump as he normally does and will evaluate in morning. The plan was to continue q2h FSGs, complete an infectious workup and cycle cardiac biomarkers (which were 0.6 then 0.5 in the setting of a Cr of 13.5). The patient however expressed a desire to leave against medical advice. He acknowledged the risk of a recurrent episode of hypoglycemia overnight, with risks including death, and he demonstrated his own competence in managing his diabetes. He was felt to be competent to make his own medical decisions and was allowed to sign out AMA. #. Altered mental status: Associated with hypogylcemia/hypothermia. Differential diagnosis includes hypoglycemia, intoxication, infection, uremia. Likely secondary to hypoglycemia given rapid response with dextrose infusion. No evidence of substance abuse on serum tox screen; unable to send urine secondary to anuric. Currently AOx3, conversant, and at baseline. - Infectious/hypoglycemia workup, as above - Dialysis, as below . #. ESRD: - PD per renal - Continue cincacalet - Discuss potential for increased insulin sensitivity on PD with [**Last Name (un) **] - Continue prednisone for prior failed renal transplant . #. Diabetes mellitus, type I: - Will add on A1c - Q2 hour blood glucose checks, will space out if stable - Insulin dosing per patient/insulin pump - [**Last Name (un) **] recs - Holding gabapentin [**2-2**] renal failure - will discuss with renal if safe to use . #. Anion gap: At baseline. Suspect secondary to uremia. . #. LDH elevation: Normal bilirubin. Known to have metabolic bone disease. - Continue cinacalcet, as above #. Hypertension: BP currently elevated. - Continue amlodipine, metoprolol, lisinopril, valsartan . #. Dyslipidemia: Currently not taking statin. Medications on Admission: AMLODIPINE 10mg PO daily CINACALCET 30mg PO daily GABAPENTIN 200mg PO daily Insulin pump, Humalog LISINOPRIL 40mg PO daily METOPROLOL TARTRATE 100mg PO BID MINOXIDIL 2.5mg PO BID PANTOPRAZOLE 40mg PO daily PREDNISONE 5mg PO daily VALSARTAN 320mg PO daily Discharge Medications: 1. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 2. Cinacalcet 30 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Minoxidil 2.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 5. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 7. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 8. Valsartan 160 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Discharge Disposition: Home Discharge Diagnosis: Hypoglycemia. Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted after being found down with profound hypoglycemia. Your mental status slowly improved with IV glucose administration. You were transferred to the MICU for observation overnight, however you expressed a desire to leave against medical advice. You clearly demonstrated that you have the capacity to manage your diabetes on your own. Your medications have not changed. Please be cautious about your insulin administration, there is a chance that your pump is administering too much insulin. Check your fingerstick glucose at least every 2 hours over this first night. We strongly advise you to schedule an appointment with [**Last Name (un) **] as your insulin needs can also change on peritoneal dialysis. Please go to all of your outpatient appointments. Please seek urgent medical advice or go to the ED if your experience: Palpitations, sweats, shakiness, fainting or passing out, headache, chest pain, shortness of [**Last Name (LF) 1440**], [**First Name3 (LF) 691**] other new or concerning symptoms. Followup Instructions: [**Last Name (un) **] Diabetes Center Please call [**Telephone/Fax (1) 2378**] to make an appointment within the next 7 days.

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icd9cm

[ [ [] ] ]

[ "99.29" ]

icd9pcs

[ [ [] ] ]

8055, 8061

4814, 5923

328, 336

8119, 8119

4099, 4791

9325, 9454

3435, 3508

7428, 8032

8082, 8098

7149, 7405

8270, 9302

3523, 4080

275, 290

364, 2842

8134, 8246

2864, 3264

3280, 3419

1,556

129,719

4188

Discharge summary

report

Admission Date: [**2155-3-2**] Discharge Date: [**2128-3-15**] Date of Birth: [**2115-5-15**] Sex: F Service: MICU CHIEF COMPLAINT: Shortness of breath and chest pain. HISTORY OF PRESENT ILLNESS: The patient is a 39 year-old female with a history of AIDS, last CD4 count was 6, history of multiple opportunistic infections including PCP times four, thrush, CMV retinitis, CMV colitis, also history of asthma presenting with increased shortness of breath and chest pain recently discharged from [**Hospital6 15291**] with PCP on unclear antibiotics. Self discontinued the antibiotics after three to four days secondary to the patient being too busy. She developed progressively worse shortness of breath and sent to the Emergency Department for evaluation by the visiting nurse. She had subjective fevers or chills, night sweats at home, plus exertional dyspnea, plus cough with white sputum. No antiviral treatment for approximately seven years per report from the patient. Positive right eye blurriness. Left eye down vision. Positive fatigue. Positive odynophagia/dysphagia, positive chest pain with breathing similar to past episodes of PCP. REVIEW OF SYSTEMS: She has no abdominal pain, nausea, vomiting, chronic diarrhea has improved. No hematemesis. No melena. No bright red blood per rectum. No dysuria. No urgency, no infrequency. She has a history of homelessness. No intravenous drug use. Contracted HIV from intravenous drug abusing heterosexual partner. In the Emergency Department the patient was temperature was 101.6. Blood pressure 110/91. Heart rate 119. Respiratory rate 32. 99% on presentation complaining of shortness of breath, received Albuterol/Atrovent nebulizers times three. Respiratory rate of 45 with stable O2 sats. She was given Tylenol, Trimethoprim 400 mg po times one, Motrin 600 mg po, Ativan 0.5 mg po, Dapsone 100 mg po times one. Chest x-ray shows positive for bilateral patchy infiltrates, Solu-Medrol 80 mg intravenous times one and intravenous normal saline times two liters. PAST MEDICAL HISTORY: 1. AIDS with a CD4 count on [**2154-1-23**] of 6. 2. PCP. 3. CMV thrush. 4. CMV retinitis. 5. CMV colitis. 6. Asthma, no intubations. 7. Has used oral steroids. 8. Chronic diarrhea. 9. Diabetes. ALLERGIES: Bactrim. SOCIAL HISTORY: Four cigarettes a day for many years. Occasional social alcohol. She lives with two children ages 15 and 16 unemployed. FAMILY HISTORY: Noncontributory. MEDICATIONS: Denies any current home medications. PHYSICAL EXAMINATION ON ADMISSION: Temperature 97.3. Blood pressure 120/70. Heart rate 114. Respiratory rate 32. She is 63% on 4 liters to 82% on 100% nonrebreather. She is a middle aged woman in acute respiratory distress. HEENT pupils nonreactive, sluggish. No scleral icterus. No oral thus visualized. Heart tachycardic. S1 and S2. No murmurs, rubs or gallops. Lungs diffuse scattered rhonchi, no crackles, up tactile fremitus, increased E to A changes, positive accessory muscle use and positive paradoxical breathing. Abdomen soft, nontender, nondistended. Bowel sounds positive. Positive costovertebral angle tenderness. Extremities warm and no edema. 2+ distal pulses. Neurological anxious, answering questions appropriately. LABORATORY VALUES ON ADMISSION: White blood cell count 1.9, hematocrit 29.2, platelets 231, NA 137, K 4.0, CO 105, CO2 25, BUN 15, creatinine 0.6, glucose 215. Tox screen was negative. Initial blood cultures were negative. Initial blood gas showed 7.33/57/39 with a lactate of 2.8. A repeat arterial blood gas showed 7.32/28/49, lactate of 3.1. She had a granulocyte count of 1370. Chest x-ray showed heart within normal limits, hilar contours unremarkable. Pulmonary vascular normal appearing, no apparent redistribution. Bilateral patchy infiltrates in right and left lung fields. No pleural effusions, patchy infiltrates in both lower lobes predominantly. HOSPITAL COURSE: 1. Infectious disease: The patient has advanced HIV. She has not been treated for many years and has had multiple complications. She is coming in acute respiratory distress with a recent diagnosis of PCP, [**Name10 (NameIs) 6643**] was inadequately treated. She is allergic to Bactrim and so she was started on Primaquine and Prednisone and Clindamycin with little improvement. Her respiratory status continued to worsen and she continued to spike fevers. She was switched to Pentamidine and Prednisone later on admission again without significant improvement in respiratory status. A chest CT Was performed, which showed diffuse severe parenchymal lung disease with minimal uninvolved lung thus explaining the patient's significant respiratory distress even at rest. She continued to spike fevers on the Primaquine and Prednisone, so she was started empirically on Levofloxacin and Zosyn and for a short time Vancomycin. The patient continued to worsen on these medications and spike fevers. She was also on Azithromycin q week, Fluconazole q day for suspected thrush. The Azithromycin is her [**Doctor First Name **] prophylaxis and Valacylcovir for CMV prophylaxis. All cultures remained negative throughout hospitalization including blood, urine and myolytic cultures. She had no meningeal signs or mental status changes during the hospitalization. It is unclear what infectious [**Doctor Last Name 360**] or agents were responsible for the patient's continuing deleterious course, however it was felt by infectious disease consult as well as the medical team that PCP alone was most probably not responsible as she should have been receiving adequate therapy with the Pentamidine and steroids. As the clinical course progressed it became clear that the patient was very unlikely to recover from this infectious exacerbation of her AIDS and that life extension and comfort were becoming mutually exclusive goals. After a long talk with the family it was decided that comfort should be the goal given the relapsing course of her illness and on [**2155-3-17**] antibiotics were discontinued. 2. Pulmonary: The patient has a history of asthma. She was put on Albuterol and Atrovent nebulizers. However, her respiratory status did not improve much as per infectious disease. A CT of the chest as mentioned before showed massive infiltration of the lung consistent with PCP pneumonia making oxygen saturation with noninvasive ventilation to an adequate degree largely impossible. Due to the patient's preferences the patient was DNR/DNI throughout hospitalization and as our ability to adequately oxygenate her noninvasively increase, she was made CMO. 3. Cardiovascular: This patient was hypotension sporadically throughout the hospitalization. She was able to rebound with normal saline boluses. She never received pressures. Cardiovascularly she was stable throughout hospitalization. 4. Endocrine: She has a history of diabetes. She was kept on regular insulin sliding scale. 5. FEN: she was kept on a house diet and lytes were followed. 6. Prophylaxis: She received PPI plus subcutaneous heparin, plus Pneumoboots. 7. Communication: Family and the medical team met on a regular basis. The family was very involved in the patient's care and thus were very understanding when it came to the point that the medical team felt we were unable to make significant gains in this patient's condition. The patient is still in the MICU at the time of dictation, but given CMO status is expected to pass away shortly. DISCHARGE DIAGNOSES: 1. HIV. 2. AIDS. 3. PCP [**Name Initial (PRE) 1064**]. 4. Fever of unknown origin. 5. Respiratory distress. 6. Diabetes. Dictation will be updated with patient's disposition when this is known further. [**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 968**] Dictated By:[**Last Name (NamePattern1) 18032**] MEDQUIST36 D: [**2155-3-18**] 08:15 T: [**2155-3-18**] 08:32 JOB#: [**Job Number 18244**]

[ "493.90", "518.82", "780.6", "042", "250.00", "136.3" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

2464, 2555

7549, 8003

3971, 7528

1192, 2059

150, 187

216, 1172

3318, 3953

2081, 2308

2325, 2447

4,780

147,839

21563

Discharge summary

report

Admission Date: [**2110-8-31**] Discharge Date: [**2110-9-24**] Date of Birth: [**2039-6-29**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 14385**] Chief Complaint: DOE Major Surgical or Invasive Procedure: None History of Present Illness: This is a 71 y/o female with h/o Aortic Stenosis w/ CHF, DMII, Obesity who presents from OSH (admitted [**8-28**]) for evaluation of severe aortic stenosis in setting of increasing DOE. ECHO at OSH shows Peak grad: 67, Mean grad: 50, Aortic Valve area 0.5 cm2. Mild to moderate MR, severe tricuspid regurg. The patient reports increasing DOE over the last 2-3 weeks. Prior to this time she was able to do activities of daily living, including climbing stairs without becoming short of breath. However, she now becomes SOB after climbing stairs and exerting herself. She denies SOB at rest. She denies chest pain, lightheadedness, loss of consciousness, nausea or vomiting or palpitations. She does report increasing LE edema and subjective weight gain over this time as well. She sleeps on 1 pillow, but she becomes SOB when she lies flat. Past Medical History: 1. critical aortic stenosis w/ CHF 2. COPD, moderate 3. HTN 4. NIDDM 5. S/P segmental resection for lung adenoCa 6. s/p cholecystectomy 7. Morbid obesity Social History: married, lives w/ husband ambulates w/assistance of cane Physical Exam: BP 132/53, RR 22, O 2 sat 94% on 2L, HR 74 Gen: lying 30 degrees on 1 pillow, HEENT: EOMI. OP Clear. Neck: JVP 9 cm; bilateral carotid bruits Pulm: Bibasilar crackles ?????? up. Heart murmur heard radiating to apices bilaterally. No ronchi or wheezes. CV: RRR. III/VI holosystolic murmur at RUSB, radiating to carotid. S1/ Audible S2. II/VI apical holosystolic murmur. ABD: obese, soft, NT/ND EXT: 2+ edema bilateral LE??????s to knees. Chronic venous stasis changes. 1+ distal LE pulses, 2+ radial pulses. Neuro: slow speech but answers questions appropriately; CN II-XII intact; no gross motor or sensory deficits. Brief Hospital Course: A/P: 71F h/o aortic stenosis, CRI, CHF, obesity, initially w/ resp failure. 1. Respiratory Failure: Etiology of respiratory failure multifactorial including COPD, AS/CHF, and PNA. The patient was treated with bronchodilators for her COPD. Levo/[**Last Name (un) **] for a 10 day course for her PNA. And diuresed as needed for her CHF. The patient was intubated/extubated x 3 with failure of extubation each time. Before the third extubation attempt, the patient's family was presented with the option of tracheostomy given that it was unlikely that the patient would be able to breath on her own. The patient's family did not think that the pt would want this for herself. So on HD 34 the patient fluid status was optimized and a last attempt at extubation was made with the idea that if she failed she would be placed on a morphine drip and allowed to pass. Within an hour of extubation, the pt developed respiratory distress. She was placed on a morphine drip and passed comfortably several hours later. 2. AS (and AI, MR, TR)- Patient was transfered to [**Hospital1 18**] for consideration of aortic valve replacement but given her respiratory failure, this was intially put on hold and the option of valvuloplasty was considered. However, this too was put on hold after a swan was placed and the patient's cardiac index was noted to be > 3. The patient was evaluated by both cardiology and CT surgery. 3. DMII: On glyburide as outpatient (6mg qday- last dose 10/9). FSBG on admission is 31--> given 1 amp D50 here. Patient was on insulin gtt. 4. ARF - baseline Cr was 1.5. Cr while in hospital was elevated [**12-24**]. At time of death, the patient's Cr was improving, she was autodiuresing well and likely in the recovery phase of ATN 5. Anemia: Pt with stable Hct in 26-28 range, no signs of bleeding. 6. Hyperlipidemia: Zocor 20mg Medications on Admission: valsartan 160, toprolXL 50mg , glyburide 6mg qday, lasix prn Discharge Medications: N/A Discharge Disposition: Expired Discharge Diagnosis: Respiratory Failure Aortic Stenosis COPD Pnuemonia Discharge Condition: N/A Discharge Instructions: N/A Followup Instructions: N/A

[ "250.00", "272.4", "518.84", "585", "276.1", "398.91", "278.01", "427.89", "285.29", "491.21", "396.3", "584.5", "293.0", "486", "V10.11" ]

icd9cm

[ [ [] ] ]

[ "99.04", "89.64", "38.93", "96.6", "93.90", "00.13", "96.04", "96.72", "38.91" ]

icd9pcs

[ [ [] ] ]

4104, 4113

2107, 3965

320, 326

4207, 4212

4264, 4270

4076, 4081

4134, 4186

3991, 4053

4236, 4241

1462, 2084

277, 282

354, 1196

1218, 1373

1389, 1447

53,944

120,022

54827

Discharge summary

report

Admission Date: [**2181-7-26**] Discharge Date: [**2181-8-29**] Date of Birth: [**2130-1-14**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**Doctor First Name 2080**] Chief Complaint: EtOH withdrawal Major Surgical or Invasive Procedure: None History of Present Illness: HPI: 51 year old male with hx of cirrhosis, ETOH abuse, HTN, admitted to [**Hospital1 1562**] s/p fall with occipital head lac. Head CT at OSH was neg and he became hypotensive with SBPs to the 50s. He was intubated for AMS and hypotentsion and transferred to [**Hospital1 18**] on [**7-26**]. He was transfused 2 units. Seen by ortho for small avulsion fracture of left greater torchanter but it was felt that he did not need surgery. Since admission, he was extubated on [**7-28**], and has been increasingly confused and agitated. His last drink is thought to be on [**7-26**] although the patient is unable to recount any events or provide any hx in the setting of his confusion. . Since admission he has 40mg of diazepam yesterday, 50mg today. Labs remarkable for HCT 31.4->25.8 Had Head CT which was negative for acute bleed. CT torso without hematoma. . Vitals on transfer were 97.1 138/64 108 18 100RA. The patient states that he is in no pain at the time, but it is unclear if the patient is able to understand/communicate effectively. Past Medical History: Alcoholic Liver Disease Social History: Long history of EtOH abuse, no current smoking history, works as yard maintenance worker Family History: non-contributory Physical Exam: ADMISSION 97.2 138/64 108 18 100 RA GENERAL - dishevelled appearing male HEENT - Stable from prior lac present on L superior occiput, PERRL, EOMI, sclerae with mild jaundice, somewhat dry MM, OP clear NECK - supple, no thyromegalyno carotid bruits LUNGS - CTA bilat, no r/rh/wh, good air movement HEART - tachy with RR, 2/6 SEM, nl S1-S2 ABDOMEN - NABS, soft/NT/ND, no masses or organomegaly, no rebound/guarding, no caput medusa EXTREMITIES - WWP, 2+ peripheral pulses (radials, DPs), ecchymosis present over left hip but within outline of marker. Ecchymosis [**Last Name (un) **] with no palpable hematoma. Ecchymosis present on left calf and left arm within outline of marker. SKIN - no rashes or lesions, spider [**Doctor Last Name **] present on chest LYMPH - no cervical LAD NEURO - awake, A&Ox0, CNs II-XII grossly intact, course tremor present throught, muscle strength 5/5 throughout, sensation grossly intact throughout, DTRs 2+ and symmetric, no nystagmus, unable to ambulate DISCHARGE VS:Vitals: 97.4 BP 100/68 P 76 RR 16 O2 sat 96%RA GENERAL - in no acute distress HEENT - Stable from prior lac present on L superior occiput, scabbed over, PERRL, EOMI, anicteric sclera, MMM, OP clear NECK - supple, no thyromegaly no carotid bruits LUNGS - CTA bilat, no r/rh/wh, good air movement HEART - [**3-20**] holosystolic mummur, nl S1-S2 ABDOMEN - NABS, soft/NT/ND, no masses or organomegaly, no rebound/guarding, no caput medusa EXTREMITIES - WWP, no c/c/e SKIN - no rashes or lesions, spider [**Doctor Last Name **] present on chest and face LYMPH - no cervical LAD NEURO - awake, A&Ox0, CNs II-XII grossly intact, course tremor present throught, muscle strength 5/5 throughout, sensation grossly intact throughout, DTRs 2+ and symmetric, no nystagmus, able to ambulate Pertinent Results: ADMISSION [**2181-7-26**] 06:40PM BLOOD WBC-3.9* RBC-3.20* Hgb-10.2* Hct-31.4* MCV-98 MCH-31.8 MCHC-32.4 RDW-15.8* Plt Ct-29* [**2181-7-26**] 06:40PM BLOOD PT-18.5* PTT-36.5 INR(PT)-1.7* [**2181-7-26**] 06:40PM BLOOD ALT-40 AST-185* AlkPhos-63 TotBili-1.3 [**2181-7-26**] 06:40PM BLOOD Albumin-2.9* [**2181-7-26**] 06:40PM BLOOD ASA-NEG Ethanol-367* Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2181-7-26**] 08:34PM BLOOD Type-ART Rates-16/ Tidal V-550 PEEP-5 FiO2-100 pO2-562* pCO2-41 pH-7.38 calTCO2-25 Base XS-0 AADO2-114 REQ O2-30 -ASSIST/CON Intubat-INTUBATED [**2181-7-26**] 06:54PM BLOOD Glucose-121* Lactate-2.2* Na-141 K-3.5 Cl-110* calHCO3-23 PERTINENT [**2181-8-1**] 06:15AM BLOOD ALT-42* AST-101* AlkPhos-79 TotBili-3.0* [**2181-8-6**] 08:45AM BLOOD VitB12-1850* [**2181-8-1**] 06:15AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE HBcAb-NEGATIVE HAV Ab-NEGATIVE [**2181-8-10**] 05:45AM BLOOD CRP-34.0* [**2181-8-2**] 07:25AM BLOOD AFP-5.0 Micro:FLUID CULTURE (Final [**2181-8-11**]): STAPH AUREUS COAG +. MODERATE GROWTH. This isolate is presumed to be resistant to clindamycin based on the detection of inducible resistance . Staphylococcus species may develop resistance during prolonged therapy with quinolones. Therefore, isolates that are initially susceptible may become resistant within three to four days after initiation of therapy. Testing of repeat isolates may be warranted. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPH AUREUS COAG + | CLINDAMYCIN----------- R ERYTHROMYCIN---------- R GENTAMICIN------------ <=0.5 S LEVOFLOXACIN----------<=0.12 S OXACILLIN------------- 0.5 S TETRACYCLINE---------- <=1 S TRIMETHOPRIM/SULFA---- <=0.5 S STUDIES Echo The left atrium is elongated. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF 75%). Tissue Doppler imaging suggests a normal left ventricular filling pressure (PCWP<12mmHg). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened. There is a minimally increased gradient consistent with minimal aortic valve stenosis. The mitral valve leaflets are mildly thickened. There is mild posterior leaflet mitral valve prolapse. The tricuspid valve leaflets are mildly thickened. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. . CT Head [**2181-7-26**] Mucosal sinus disease in both maxillary sinuses. No acute intracranial process. [**2181-7-30**] Interval development of bilateral small subdural effusions are small subdural hematomas in the frontal region as described above. No mass effect or hydrocephalus. [**2181-8-8**] 1. Left frontoparietal subdural collection, unchanged, with no subjacent gyral effacement or mass effect. 2. Small right frontal subdural collection, also unchanged. 3. No evidence of new hemorrhage or territorial infarction. 4. No new abnormality to explain increased somnolence. . CT C/A/P 1. Mild soft tissue stranding overlying the left gluteus muscles, with slight prominence of the musculature, but no large hematoma detected. 2. Tiny avulsion fracture of the left greater trochanter, of unknown chronicity. A second focus of calcification overlying this region may represent an embedded foreign body. Correlate with physical findings. 3. No acute intrathoracic, intrapelvic, or intra-abdominal process. 4. Cirrhotic liver, with multiple focal hypodense lesions, warranting further evaluation with MRI, if not already performed at an outside institution. Splenic varices and large umbillical vein are the sequela of chronic portal hypertension. . RUQ Ultrasound 1. Coarse nodular liver with multiple hyper and hypoechoic lesions. At least 3 dominant hyperechoic lesions are seen that are concerning for hepatocellular carcinoma. MRI of the abdomen with gadolinium contrast is recommended for further assessment. 2. Patent hepatic vasculature with normal directional flow. 3. Evidence of portal hypertension including persistent splenomegaly measuring 15 cm and a recanalized umbilical vein. No ascites. . [**2181-8-18**] MRI Abdomen IMPRESSION: 1. Multiple sub-cm peripheral arterially enhancing foci within the liver, which likely represent perfusion anomalies, though a follow up MRI in [**3-18**] months is recommended to assess for stability. No suspicious lesions for HCC identified. 2. Cirrhotic liver with evidence of portal hypertension (splenic and distal esophageal varices with a splenorenal shunt). 3. 6 mm cystic lesion in the neck of the pancreas, possibly side-branch IPMN. Attention to this area on follow up is recommended DISCHARGE LABS (last labs [**2181-8-27**]) [**2181-8-27**] 05:24AM BLOOD WBC-3.5* RBC-2.74* Hgb-7.8* Hct-24.9* MCV-91 MCH-28.5 MCHC-31.3 RDW-15.8* Plt Ct-136* [**2181-8-27**] 05:24AM BLOOD Glucose-109* UreaN-10 Creat-0.5 Na-143 K-3.7 Cl-109* HCO3-27 AnGap-11 Brief Hospital Course: Mr [**Known lastname **] is a 51 yo male with a hx of etoh abuse admitted for AMS/etoh withdrawal after suffering head lac necessitating intubation. Hospital course was complicated by MSSA bacteremia. # MSSA Septicemia [**2-15**] abscess/cellulitis - Toward the end of hospital course, patient was noted to be with worsened confusion after his confusion had initially improved greatly. He was then noted to be febrile to 103 and with a relative leukocytosis. Skin exam revealed a quarter-sized abscess with surrounding erythema that spread proximally. He was started on IV vanc and underwent bedside I&D of his LUE abscess. He continued to remain febrile over the next 24 hours. Blood cultures grew methicillin-sensitive staph aureus. He was switched from IV vanc to IV cefazolin. His fevers resolved. Survellance cultures were negative to date. His relative leukocytosis improved. TTE revealed no vegetation. A PICC line was placed and he was discharged with IV cefazolin for a total antibiotic course of 4 weeks ( end date [**2181-9-5**]). He will need to have a repeat CBC and Chem 7 on [**2181-9-3**] # Acute metabolic encephalopathy - After extubation, patient was persistently agitated and delirious with occasional episodes of somnolence. He was placed on CIWA protocol and started on lactulose given the likelihood of alcohol withdrawal and hepatic encephalopathy. After symptoms failed to improved over a couple of days, the CIWA protocol was discontinued, as it was felt that he may have developed benzo toxicity in the setting of his cirrhosis. ABG revealed a mild respiratory alkalosis. CT Head showed new subdural hematomas bilaterally. However, these were not felt to contribute to his changes in mental status. THe patient eventually began to clear, but again became acutely agitated and febrile. He was found to have bacteremia [**2-15**] to LUE abscess/cellulitis. After starting IV antibiotics, his mental staus improved and on discharge he is back at his baseline. # Head laceration - The patient suffered a head laceration secondary to trauma. The laceration was stapled. During the hospital stay, there were several episodes of bleeding from the site. Surgery was consulted but felt no operative management was necessary. The head laceration ultimtely scabbed over and the staples were removed. The laceration continues to heal with no bleeding or drainage. . # Bilateral subdural hematoma - These were identified on CT scan on [**7-30**]. Repeat scans demonstrated no expansion. Pt was started on IV Keppra 500 [**Hospital1 **] x 7 days per recommendations by neurosurgery. This was completed while in house. He should f/u with Dr. [**Last Name (STitle) 739**] in Neurosurgery after discharge. # EtOH dependence/withdrawal - Patient was placed on CIWA while in house. He was [**Doctor Last Name **] frequently and received heavy doses of PO diazepam. However, this was d/c'ed after he was felt to be suffering from bzd toxicity. His mental status cleared and social work was consulted for his alcoholism. Additionally, he was treated with IV thiamine x 5 days and continued on PO thiamine, folate, and MVI. . # Presumed EtOH Cirrhosis: Extent of disease unclear. His bilirubin peaked at 3.0 but had normalized by the time he was discharged. He was maintained on lactulose for most of his hospital stay with concerns for hepatic encephalopathy. Cirrhosis was newly diagnosed by incidental finding on CT which showed cirrhotic appearing liver with multiple focal hypodensities. RUQ US showed patent vessels and nodular appearance c/w cirrhosis and masses concerning for HCC. His AFP was 6.2. MRI was performed which showed evidence of cirrhosis and portal HTN. Additionally Multiple sub-cm peripheral arterially enhancing foci within the liver, were seen and thought to represent peerfusion anomalies. A follow up MRI in [**3-18**] months is recommended to assess for stability. No suspicious lesions for HCC were identified. His hepatitis panel was negative as fell. He should follow up with a GI specialist close to his home for further evaluation of these liver masses and will need to be immunized for Hep B. . # Pancytopenia: Was stable for most of hospitalization. This was likely [**2-15**] to bonemarrow suppression vs hypersplenism in setting of chronic etoh abuse/cirrhosis. It improved with abstinence from alcohol. . # Avulsion fx of L Hip: This was likely a result of initial trauma suffered during Nonoperable per ortho. Patient denying pain with palpation. Physical therapy was consulted and weight bearing was encouraged as tolerated. . TRANSITIONAL: # Repeat CBC w/diff, chem 7, AST, ALT, Alk phos, T. Bili # Neuro follow-up with [**Doctor Last Name 739**] for bilateral subdural hematomas. # Liver follow-up to further characterize extent of liver disease. # Needs Hepatitis vaccination Medications on Admission: None Discharge Medications: 1. CefazoLIN 2 g IV Q8H 2. FoLIC Acid 1 mg PO DAILY 3. Multivitamins 1 TAB PO DAILY 4. Thiamine 100 mg PO DAILY Discharge Disposition: Extended Care Facility: [**Hospital6 2222**] - [**Location (un) 538**] Discharge Diagnosis: Primary: Bacteremia, Cellulitis with abscess, Alcohol Withdrawal, Altered Mental Status Secondary: Head laceration, Transient Hypotension Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Mr [**Known lastname **], It was a pleasure caring for you during your most recent admission to [**Hospital1 18**]. You were transferred hear from [**Hospital1 1562**] after you suffered a head injury which required intubation. You were extubated here but remained confused. Over time, you improved, and we believe that this was likely multifactorial and related to alcohol withdrawal, benzodiazapine intoxication, and hepatic encephalopathy. Unfortunately, you became confused again. This time, we believe that it was because of an abscess on your left arm that led to an infection in your blood. We treated you with IV antibiotics, and your infection as well as your mental status improved. You will need to continue IV antibiotics until [**9-5**]. You should also receive a Hep B vaccine series from your Primary Care Physician. Followup Instructions: The rehab facility will arrange follow-up with your primary care physician. [**Hospital3 **] Healthcare- Nurses answer this line and will help get you established with a primary care provider and [**Name Initial (PRE) **] gastroenterologist. Please call 1-877-Cape-Cod([**Telephone/Fax (1) 112046**]) you need to be seen by a PCP [**Name Initial (PRE) 176**] 1-2 weeks of discharge from rehab and 1 month with a gastroenterologist. Department: RADIOLOGY When: WEDNESDAY [**2181-10-3**] at 9:00 AM With: CAT SCAN [**Telephone/Fax (1) 590**] Building: CC [**Location (un) 591**] [**Location (un) **] Campus: WEST Best Parking: [**Street Address(1) 592**] Garage *Please note that for this appointment if you have no health insurance you will be billed. Department: NEUROSURGERY When: WEDNESDAY [**2181-10-3**] at 10:00 AM With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 1669**] Building: LM [**Hospital Unit Name **] [**Location (un) **] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage *Please note that for this appointment if you have no health insurance you will be billed. Your insurance records are incomplete- please call our registration department at ([**Telephone/Fax (1) 22161**] before your first appointment.

[ "288.00", "999.32", "303.91", "571.2", "572.3", "E879.8", "284.19", "573.8", "682.3", "873.0", "820.20", "348.31", "305.40", "291.81", "038.11", "287.5", "401.9", "286.7", "852.21", "E888.9" ]

icd9cm

[ [ [] ] ]

[ "86.59", "86.04", "96.71", "38.93", "96.6" ]

icd9pcs

[ [ [] ] ]

13612, 13685

8545, 13420

321, 327

13867, 13867

3412, 8522

14919, 16184

1575, 1593

13475, 13589

13706, 13846

13446, 13452

14052, 14896

1608, 3393

266, 283

355, 1406

13882, 14028

1428, 1453

1469, 1559

44

181,750

43242

Discharge summary

report

Admission Date: [**2192-11-19**] Discharge Date: [**2192-11-27**] Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1267**] Chief Complaint: 80 year old white male with shortness of breath with exertion. Major Surgical or Invasive Procedure: CABG X 3 History of Present Illness: This 80 year old white male with a history of HTN, hyperlipidemia, PVD, afib, and CVA, was admitted for elective cardiac cath [**2192-11-19**]. He has complaints of shortness of breath with exertion and an ETT during which time he had left arm pain which was relieved with SL NTG. Past Medical History: HTN Hyperlipidemia s/p CVA [**2179**], s/p bil. CEA PVD BPH Afib Diverticulitis Sleep apnea s/p AAA repair [**2187**] s/p ventral hernia repair s/p aorto-bifem [**2187**] s/p TURP Social History: Married, lives with wife. Cigs: quit 13 years ago, 30 pk. yr. history ETOH: rare Family History: + CAD Physical Exam: Gen: Elderly, white male, in NAD AVSS HEENT: NC/AT, PERLA, EOMI, oropharynx benign Neck: supple , FROM, no lymphadenopath or thyromegaly, carotids 2+= bilat w/ bruits. Lungs: Clear to A+P CV: RRR without M/G, 3/6 SEM, rad to carotids and axilla Abd: +BS, soft, nontender without masses or hepatosplenomegaly Ext.: without clubbing, cyanosis, or edema, pulses 2+ radials, 2+ DP, 1+ PT bil. Neuro: nonfocal. Pertinent Results: Hematology COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct [**2192-11-27**] 07:45AM 31.8* specimen not received in stat bag BASIC COAGULATION PT PTT Plt Ct INR(PT) [**2192-11-27**] 07:45AM 18.3*1 2.1 specimen not received in stat bag 1 NOTE NEW NORMAL RANGE AS OF 12A OF [**2192-8-14**] Chemistry RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap [**2192-11-27**] 07:45AM 34* 1.4* 4.0 specimen not received in stat bag CHEMISTRY TotProt Albumin Globuln Calcium Phos Mg UricAcd Iron [**2192-11-26**] 06:30AM 8.4 4.1# 2.1 Brief Hospital Course: On [**2192-11-19**] the patient underwent cardiac cath which revealed: 70%LAD, 80% D1, 60% LCX, 90% rca, mild AS, AV gradient of 15mmHg. He had a heavily calcified aorta and coronaries. Dr. [**Last Name (STitle) **] was consulted and on [**2192-11-20**] he underwent CABGx3 with LIMA->LAD, SVG->PDA and OM. Cross clamp time was 63 minutes and total bypass time was 47 minutes. He required a urology consult intraoperatively and had to have a foley placed under cysto. He tolerated the procedure well and was transferred to the CSRU in stable condition on Neo and Propofol. He was extubated on his postoperative night and had his chest tubes d/c'd and was transferred to the floor on POD#2. On POD#4 he was in afib and was very hpotensive and was transferred back to the CSRU. He was started on Amiodorone and converted to SR. He was transferred back to the fllor on POD#5 and had a few more episodes of controlled AF. He was then anticoagulated with heparin and coumadin and was discharged to rehab on POD#7 in stable condition. Medications on Admission: Pronestyl 750 mg PO daily Atenolol 25 mg PO daily Allopurinol 300 mg PO daily Minitron 2.5 mg PO daily Lasix 20 mg. PO Q Mon., Wed., Fri. Zocor 80 mg PO daily ASA 325 mg PO daily Cardura 2 mg PO BID Atacard 16 mg PO daily 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:*2* 2. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. Disp:*30 Tablet(s)* Refills:*0* 3. Doxazosin Mesylate 2 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). Disp:*30 Tablet(s)* Refills:*2* 4. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 5. Amiodarone HCl 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). Disp:*180 Tablet(s)* Refills:*2* 6. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 7. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 7 days. Disp:*14 Tablet(s)* Refills:*0* 8. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two (2) Capsule, Sustained Release PO BID (2 times a day) for 7 days. Disp:*28 Capsule, Sustained Release(s)* Refills:*0* 9. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 7 days. 10. Warfarin Sodium 2 mg Tablet Sig: One (1) Tablet PO once a day: INR goal 2-2.5. 11. Allopurinol 300 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Extended Care Facility: [**Hospital6 10353**] TCU Discharge Diagnosis: coronary artery disease HTN hypercholesterolemia BPH PVD Discharge Condition: good Discharge Instructions: no lifting > 10# or driving for 1 month no creams, lotions or powders to incision may shower, no bathing or swinning for 1 month Followup Instructions: Make an appointment with you r uroligist for 1 week Make an appointment with Dr. [**Last Name (STitle) **] in [**2-7**] weeks Make an appointment with Dr. [**Last Name (STitle) 311**] in [**2-7**] weeks Make an appointment with Dr. [**Last Name (STitle) **] in 1 month Completed by:[**2192-11-27**]

[ "413.9", "443.9", "401.9", "V17.3", "427.31", "780.57", "396.8", "272.0", "414.01", "596.0" ]

icd9cm

[ [ [] ] ]

[ "37.22", "36.12", "88.56", "39.61", "36.15", "99.04", "57.92" ]

icd9pcs

[ [ [] ] ]

4620, 4672

2023, 3060

333, 344

4773, 4779

1420, 2000

4956, 5257

972, 979

3333, 4597

4693, 4752

3086, 3310

4803, 4933

994, 1401

231, 295

372, 654

676, 858

874, 956

62,762

138,258

300

Discharge summary

report

Admission Date: [**2118-12-1**] Discharge Date: [**2118-12-3**] Date of Birth: [**2037-12-24**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2485**] Chief Complaint: weakness and cough Major Surgical or Invasive Procedure: None History of Present Illness: 80 yo M with PMH of HTN, congenital deafness and osteoporosis who presents with fevers, cough and weakness. History is taken from patient and his home caregiver and also his HCP by phone. . Patient was recently admitted after a fall and found to have a C7 fracture. He was placed in a [**Location (un) 2848**] J collar and returned to rehab. Per his caregiver, over the last two days he has become more weak (not using his walker but requiring a wheelchair to get around), coughing and sounded "congested." He has been noted to have poor PO intake and coughing with all liquids and foods. His HCP says that he had a speech and swallow in the past and they recommended crushing his medications in apple sauce and avoiding thin liquids. The patient has recently refused this and has been taking thin liquids and coughing signficantly with them. Today, his caregivers brought him to his PCPs office. They got a CXR and labs. His sodium returned at 115 and his CXR suggested aspiration pneumonia with bilateral basilar infiltrates. He was sent to the ED. . In the ED, his vital signs were T 98.6, BP 117/61, HR 103, RR 22, O2sat 96% RA. He had a rectal temp of 102 while in the ED. His blood pressure transiently dropped to 78/50 and responded to fluids. He received a total of 1.8L NS. He was also given levofloxacin and clindamycin for pneumonia. He was admitted to the ICU for further care. . Currently he complains of the mask from the nebulizer and of the [**Location (un) 2848**] J collar. He is coughing. He denies CP, SOB, n/v, f/c. Denies constipation or dysuria. He does have trouble with incontinence. He is congenitally deaf and reads lips. Past Medical History: Frequent falls Hypertension Osteoporosis Congenital deafness Macular degeneration Vitamin B12 deficiency Benign prostatic hypertrophy Urinary incontinence Insomnia Social History: Retired acountant. Widowed. Lives in [**Hospital3 **]. Denies tobacco, EtOH. Congenital deafness and reads lips. Does not use sign language. Family History: Non-contributory Physical Exam: Gen: NAD sitting up in bed with hard cervical collar in place. HEENT: PERRL EOMI. anicteric sclera, non-injected conjunctiva. dry MM, OP clear otherwise. JVP not assessed since collar in place. CV: RRR, no m/r/g Lungs: bilateral rhonchi with some wheeze on left side. Upper airway secretions as well. Abd: +BS, soft, NT, ND, no HSM. Extrem: No C/C/E. Neuro: CNIII-X and XII in tact except hearing- he reads lips. Did not assess [**Doctor First Name 81**] given collar in place. Poor muscle bulk in arms and legs bilaterally. Left arm rigidity. Toes mute bilaterally. Bicep, brachioradialis and patellar reflexes intact. Sensation to light touch appears to be intact. Pertinent Results: Admission Labs: WBC-16.4*# RBC-3.31* Hgb-12.5* Hct-34.8* MCV-105* MCH-37.7* MCHC-35.9* RDW-12.9 Plt Ct-286 Neuts-90* Bands-3 Lymphs-2* Monos-5 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 Hypochr-NORMAL Anisocy-NORMAL Poiklo-NORMAL Macrocy-NORMAL [**Name (NI) 2849**] [**Name (NI) 2850**] PT-18.7* PTT-35.5* INR(PT)-1.7* UreaN-22* Creat-0.8 Na-115* K-4.8 Cl-80* HCO3-23 AnGap-17 Calcium-9.9 Phos-2.9 Mg-1.9 [**2118-12-1**] 03:27PM BLOOD CK(CPK)-597* CK-MB-14* MB Indx-2.3 [**2118-12-1**] 05:32PM BLOOD cTropnT-0.02* [**2118-12-1**] 09:04PM BLOOD CK(CPK)-529* CK-MB-12* MB Indx-2.3 cTropnT-0.02* [**2118-12-2**] 02:54AM BLOOD CK(CPK)-435* CK-MB-15* MB Indx-3.4 cTropnT-0.02* [**2118-12-3**] 03:06AM BLOOD proBNP-[**Numeric Identifier 2851**]* . Studies: [**2118-12-1**] EKG: Baseline artifact. Sinus tachycardia. Left axis deviation. RSR' pattern in lead VI. Consider inferior wall myocardial infarction of undetermined age. Since the previous tracing of [**2118-11-7**] the rate has increased. The R waves in leads III and aVF are not apparent. The axis is more leftward. Clinical correlation is suggested. . [**2118-12-1**] CXR - IMPRESSION: Bibasilar patchy opacities compatible with the history of aspiration. . [**2118-12-3**] CXR - IMPRESSION: Possibly worsening. Brief Hospital Course: 80 yo M with PMH of congential deafness, HTN, osteoporosis who presents with likely aspiration pneumonia and hyponatremia. #1 Aspiration Pneumonia / Respiratory Failure: The patient's clinical presentation, CXR findings, elevated lactate, and elevated WBC count with bands were consistent with an aspiration pneumonia. He received levofloxacin and clindamycin in the ED. As sputum gram stain showed a mixture of different organisms, he was started on broad spectrum antibiotic coverage with vancomycin, zosyn, and flagyl. Following his admission to the ICU the patient continued to be in respiratory distress with epsidoes of tachypnia and tachycardia with a heart rate to the 150??????s. An EKG showed MAT. His respiratory distress was consistently improved with morphine. It was felt that Mr. [**Known lastname 2852**] was unlikely to recover from his pneumonia given his inability to wean off bipap and to cough to clear his own secretions. As he was DNI status he could not be intubated to have secretions suctioned out. In addition, the patient appeared visibly uncomfortable on BiPAP and quickly desaturated into the 70??????s without it. Because the patient was given several liters of fluid for hyponatremia, there was the possibility that diuresis could improve his oxygenation enough to enable him to wean off the bipap, however, this did not prove to be the case. He was also given nebs prn. Upon discussing the patient's poor prognosis with his health care proxy the decision was made to make him CMO. Antibiotics and BiPAP were withdrawn and the patient died shortly thereafter. #2 Hyponatremia: The patient presented with hyponatremia, likely hypovolemic hyponatremia. On admission he appeared dry and had a history of poor PO intake, although he was mentating well. He received 1000 ml NS boluses overnight with maintenance fluids. The patient does have a history of low sodium but usually to the 130 range, whereas his admission sodium was 115. His sodium improving slowly with IVF. #3 Hypertension: The patient's home regimen of atenolol was held given concern for possible sepsis in the setting of pneumonia. Aspirin was continued. #4 Multifocal atrial tachycardia: Occurred in the setting of anxiety and tachypnea and improved with morphine. Rate control with a beta blocker or calcium channel blocker was held due to concern for hypotension in the setting of an infection. #5 spinal fracture: The patient was in a [**Location (un) 2848**] J collar on admission. Per discussion with neurosurgery, the patient needed to wear the collar due to an unstable spinal fracture. His collar was removed when he was made CMO. #6 BPH with incontinence: The patient's home regimen of oxybutynin was continued. #7 Macrocytic anemia: The patient usually has a macrocytic anemia and presented with a normal hematocrit, indicating that he was quite volume depleted. B12 supplementation was continued. # Osteoporosis: Calcium, vitamin D, and Fosamax were continued. # Depression: Escitalopram was continued. Medications on Admission: tylenol 1g TID alendronate 70mg qsunday asa EC 325mg daily atenolol 25mg daily colace flomax 0.4mg [**1-12**] after meal folic acid 1mg daily lexapro 10mg daily metamucil in AM oxybutynin 5mg [**Hospital1 **] senna qhs trazodone 100mg qhs tums TID vit B12 1000mcg daily vit D 400 units [**Hospital1 **] Discharge Medications: n/a, patient expired Discharge Disposition: Expired Discharge Diagnosis: Primary Diagnoses: Aspiration pneumonia Respiratory failure Hyponatremia Discharge Condition: Expired Discharge Instructions: Not applicable, patient expired Followup Instructions: Patient expired

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icd9cm

[ [ [] ] ]

[ "93.90" ]

icd9pcs

[ [ [] ] ]

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336, 342

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27,647

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30740

Discharge summary

report

Admission Date: [**2141-5-29**] Discharge Date: [**2141-6-7**] Date of Birth: [**2085-12-14**] Sex: M Service: CARDIOTHORACIC Allergies: Prednisone Attending:[**First Name3 (LF) 1283**] Chief Complaint: Dyspnea on exertion Major Surgical or Invasive Procedure: [**2141-5-29**] Mitral Valve Replacement 25mm On-X Valve History of Present Illness: 55 y/o male with two prior myocardial infarction with congestive heart failure last [**Month (only) **]. Also has CRI d/t glomerulosclerosis. Has been c/o dyspnea on exertion and now referred for mitral valve repair vx. replacement d/t severe mitral regurgitation. Past Medical History: Coronary Artery Disease s/p stent to OM, h/o Myocardial Infarction x 2, Congestive heart failure, Hypertension, Hypercholesterolemia, Chronic Renal Insufficiency, Mild Anemia, Gout, Obesity, s/p Appendectomy, s/p Tonsillectomy Social History: Social history is significant for the absence of current tobacco use but a 30 pk year history of smoking . There is no history of alcohol abuse. remote history ('[**14**]-'[**15**]) cocaine snorting, and marijuana use. none since, no injection drug use ever. Family History: Family history significant for a brother who had a CABG at 58 yo and a mother with CAD still living. father still living at 92. Physical Exam: VS: 77 16 128/95 5'[**44**]" 98kg Gen: WD/WN male in NAD Skin: W/D, multiple nevi HEENT: NC/AT, EOMI, PERRL, OP benign Neck: Supple, FROM, -JVD, -carotid bruit Chest: CTAB -w/r/r Heart: RRR w/ 3/6 SEM Abd: Soft, NT/ND, +BS Ext: Warm, well-perfused, trace LE edema, -varicosities Neuro: A&O x 3, MAE, non-focal Pertinent Results: [**2141-5-29**] Echo: PRE CPB The left atrium is markedly dilated. The left atrium is elongated. Mild spontaneous echo contrast is seen in the body of the left atrium. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thicknesses are normal. The left ventricular cavity is moderately dilated. There is moderate regional left ventricular systolic dysfunction with moderate to severe hypokinesis of the inferior, inferolateral, and lateral walls from the lower base to apex in the setting of mild to moderate global hypokjinesis. Overall left ventricular systolic function is moderately depressed. The right ventricular cavity is dilated. There is moderate global right ventricular free wall hypokinesis. There are simple atheroma in the aortic arch. The descending thoracic aorta is mildly dilated. 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. There is prolapse of the A2 and A1 segments of the anterior mitral valve leaflet with some slight posterior leafley retraction. This results in an eccentric jet of severe (4+) mitral regurgitation which is posteriorly directed. POST CPB Patient is receiving milrinone and norepinephrine by infusion. Right ventricular systolic function is improved, now normal free wall function. Views of the left ventricle are limited but left ventricular global function appears to be improved. The inferior and inferolateral walls are still severely hypokinetic. The overall ejection fraction is in the 40-45% range. There is a bileaflet mechanical prosthesis in the mitral position. It appears to be well seated. The leaflets are seen in limited views and appear to function normally. The maximum gradient across the valve measures at about 9 mm Hg with a mean of about 7 mm Hg with cardiac output about 7 l/m. The normal mild valvular mitral regurgitation is seen. No large perivalvular jets are seen. The thoracic aorta appears intact. [**2141-6-5**] CXR: Improvement in the airspace disease/atelectasis/effusion on the left side compared with the prior day's radiograph. [**2141-6-5**] Knee X-ray: No evidence of acute bony injury or chondrocalcinosis. [**2141-5-29**] 11:33AM BLOOD WBC-24.0*# RBC-2.94* Hgb-9.8* Hct-28.7* MCV-97 MCH-33.2* MCHC-34.1 RDW-14.4 Plt Ct-298 [**2141-6-2**] 03:01AM BLOOD WBC-17.6* RBC-2.60* Hgb-8.5* Hct-24.9* MCV-96 MCH-32.5* MCHC-34.0 RDW-15.3 Plt Ct-161 [**2141-6-6**] 07:11AM BLOOD WBC-16.7* RBC-2.71* Hgb-8.5* Hct-26.4* MCV-97 MCH-31.4 MCHC-32.4 RDW-15.3 Plt Ct-438 [**2141-5-29**] 11:33AM BLOOD PT-13.5* PTT-33.0 INR(PT)-1.2* [**2141-6-5**] 05:28AM BLOOD PT-27.9* PTT-37.8* INR(PT)-2.9* [**2141-5-29**] 12:58PM BLOOD UreaN-38* Creat-2.5* Cl-111* HCO3-21* [**2141-6-6**] 07:11AM BLOOD Glucose-97 UreaN-36* Creat-1.7* Na-140 K-3.4 Cl-106 HCO3-24 AnGap-13 [**2141-6-1**] 02:58AM BLOOD ALT-4 AST-21 LD(LDH)-392* AlkPhos-47 Amylase-438* TotBili-0.7 Brief Hospital Course: Mr. [**Known lastname **] was a same day admit and underwent all pre-operative work-up as an outpatient. On day of admission he was brought to the operating room where he underwent a mitral valve replacement. Please see dictated surgical note for details. Following surgery he was transferred to the CSRU for invasive monitoring in stable condition. Mr. [**Known lastname **] remained sedated and intubated for several days after surgery secondary to potential SVC syndrome. As well as patient was fluid overloaded and had a post-op rise in his creatinine. Nephrology was consulted on post-op day two. Beta blockers were started but diuretics were held. He was eventually weaned from sedation and extubated on post-op day two. Chest tubes and epicardial pacing wires were removed per protocol. On post-op day four Coumadin was started with Heparin used a bridge until INR therapeutic. Coumadin was dosed for a goal INR around 3.0. Later on this day he was transferred to the telemetry floor for further care. On post-op day six he required blood transfusion secondary to low HCT. On post-op day seven ID was consulted for increased WBC/?pneumonia and rheumatology was consulted secondary to h/o gout and now experiencing right knee pain. Knee pain improved with Indocin. Cultures were taken and patient was empirically started on antibiotics. Given concern for pneumonia, he was asked to complete a 10 day course of antibiotics. It was also suggested by rheumatology, that he started Allopurinol in several weeks and avoid further NSAIDs for now. He otherwise remained afebrile without evidence of infection. He continued to make clinical improvements and was discharged on postoperative day nine. Prior to discharge, arrangements have been mad with his PCP(Dr. [**Last Name (STitle) 1683**] for outpatient Coumadin followup. Medications on Admission: Aspirin 81mg qd, Cyclosporine 50mg [**Hospital1 **], Lasix 20mg qd, Norvasc 10mg qd, Plavix 75mg qd, Spironolactone 25mg qd, Pepcid AC 20mg qd, Caltrate 600mg [**Hospital1 **], Toprol XL 100mg qd, Indomethacin 50-100mg prn for gout Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*1* 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. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(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. Ferrous Gluconate 300 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 6. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*0* 7. Cyclosporine 25 mg Capsule Sig: Two (2) Capsule PO Q12H (every 12 hours). Disp:*120 Capsule(s)* Refills:*1* 8. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 9. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 6 days. Disp:*6 Tablet(s)* Refills:*0* 10. Metoprolol Tartrate 50 mg Tablet Sig: 1.5 Tablets PO TID (3 times a day). Disp:*135 Tablet(s)* Refills:*2* 11. Warfarin 2 mg Tablet Sig: as directed Tablet PO once a day: 3mg on [**6-7**] and [**6-8**] then as directed by Dr [**Last Name (STitle) 1683**]. Disp:*60 Tablet(s)* Refills:*0* 12. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*1* 13. Lipitor 10 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: All Care VNA of Greater [**Location (un) **] Discharge Diagnosis: Mitral Regurgitation s/p Mitral Valve Replacement PMH: Coronary Artery Disease s/p stent to OM, h/o Myocardial Infarction x 2, Congestive heart failure, Hypertension, Hypercholesterolemia, Chronic Renal Insufficiency, Mild Anemia, Gout, Obesity, s/p Appendectomy, s/p Tonsillectomy Discharge Condition: Good Discharge Instructions: shower daily and pat dry incisions no lotions, creams, powders on any incision no driving for one month no lifting greater than 10 pounds for 10 weeks call surgeon for redness, drainage, or fever greater than 100.5 [**Last Name (NamePattern4) 2138**]p Instructions: Dr. [**Last Name (Prefixes) **] in 4 weeks Dr. [**Last Name (STitle) **] in [**12-24**] weeks Dr. [**Last Name (STitle) 1683**] in [**11-22**] weeks [**Hospital Ward Name 121**] 2 in 2 weeks for wound check. Completed by:[**2141-7-4**]

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icd9cm

[ [ [] ] ]

[ "39.61", "38.93", "99.04", "35.24" ]

icd9pcs

[ [ [] ] ]

8390, 8465

4714, 6541

297, 355

8790, 8796

1665, 4691

1191, 1320

6823, 8367

8486, 8769

6567, 6800

8820, 9036

9087, 9324

1335, 1646

238, 259

383, 649

671, 899

915, 1175

54,651

148,610

43428+58619

Discharge summary

report+addendum

Admission Date: [**2167-1-21**] Discharge Date: [**2167-2-17**] Date of Birth: [**2120-2-13**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**Known firstname 3276**] Chief Complaint: Hemoptysis Major Surgical or Invasive Procedure: IVC filter placement History of Present Illness: Mr. [**Known lastname 93447**] is a 46 year old man with a hx of stage IV NSCLC and remote Hodgkin's disease who presented to the ED at an OSH with hemoptysis on [**1-20**] where he was observed overnight, discharged home, then represented to [**Hospital1 18**] ED the morning of [**1-21**] with recurrent hemoptysis. The patient reports 3 episodes of hemoptysis since 7pm yesterday, each with 1-2 tablespoons of blood. Last chemotherapy treatment was [**2167-1-7**] which was cycle 1 of [**Doctor Last Name **]/taxol + avastin. . In the ED, initial vitals: 98.5 126 142/106 20 96. He underwent CTA which showed bilateral PEs with a post-obstructive PNA. He received CTX and Vancomycin. Interventional pulmonology (IP) was called as well as oncology and both recommended IV heparin to treat the PEs. The CT also showed a small intraparenchymal hemorrhage in the lung but IP felt it was small and was okay with starting heparin. . On the floor, initial PTT was 48 at 8PM and he received a 1300 unit bolus. Five hours latter he developed an additional episode of cough and hemoptysis of approximately [**12-6**] cup and he was transferred to the ICU for closer monitoring. . On arrival, he reports mild shortness of breath which is unchanged in the past 4 days. He denies fevers or chills. He denies dypnea on exertion, chest pain or palpitations. He denies dizziness or lightheadedness. He has no calf tenderness or swelling. Past Medical History: hx of Hodgkin's disease, stage IIA, dx [**2141**] s/p radiation therapy. Relapsed in [**2146**], s/p chemotherapy with alternating doses of MOPP and ABVD. s/p splenectomy as part of staging laparotomy. Stage IV NSCLC diagnosed [**12-14**] - Initially presented w/ dry cough, CP, night sweats [**11-12**]. He underwent CXR [**12-14**] and CT scan on [**2166-12-18**] revealed extensive new thoracic adenopathy centered at the right hilus involving both adjacent and remote nodal stations in the mediastinum with atelectasis, consolidation, and possible mass involving most of the right upper lobe, particularly the anterior segment. A destructive T10 spine lesion with possible invasion of the spinal canal was also noted, and bilateral thyroid nodules were observed. An endobronchial core biopsy of the right upper lobe mass revealed moderately differentiated adenocarcinoma. . The tumor was positive for CK7, focally positive for CDX2 and CK20, and negative for TTF-1, EGFR mutation negative. A transbronchial needle aspiration of 4L, level 7, and 4R lymph nodes revealed no suspicious cells. . A PET scan on [**2166-12-24**] revealed confluent FDG uptake surrounding the right upper lobe bronchus and right main stem bronchus, felt to be related to an infiltrating mass versus post-bronchoscopy change (SUV max 14.1). Marked narrowing and irregularity of the right upper lobe bronchus and adjacent pulmonary vessels was noted, suggesting an underlying infiltrative lesion. Additional involvement includes a left adrenal nodule, a right mandibular lesion, a distal sternal lesion, the left sacral body, a lytic lesion in the left femoral head, the right lesser trochanter, and destructive lesions of the T10 and L1 vertebral bodies, which demonstrated possible spinal canal extension. An MRI of the brain demonstrated no evidence of brain lesions. . On [**2167-1-7**], the patient began palliative chemotherapy with carboplatin, paclitaxel, and bevacizumab Social History: The patient is married and has three children, ages 8, 12 and 16. He works for a communications company. He enjoys playing the violin. He has never smoked. He drinks alcohol occasionally. Family History: The patient's mother is 75 years old and has diabetes and obesity. His father is 76 years old and is well. The patient's maternal grandmother is 101. [**Name2 (NI) 93448**] of his grandparents have malignancies. The patient's mother has one brother, and the patient's father had two brothers and two sisters, none of whom have a history of cancer. The patient has one brother, age 49, who is well. Physical Exam: Vitals: T:98.6 BP:145/102 P:115 R:18 O2:99% on 2L NC General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: scattered rhonchi at left base, decreased BS at right upper lobe CV: Tachy, reg rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Pertinent Results: ADMISSION LABS: [**2167-1-21**] 11:15AM PT-12.1 PTT-21.4* INR(PT)-1.0 [**2167-1-21**] 11:15AM PLT COUNT-363 [**2167-1-21**] 11:15AM NEUTS-84.9* LYMPHS-10.8* MONOS-2.5 EOS-1.3 BASOS-0.5 [**2167-1-21**] 11:15AM WBC-21.0*# RBC-4.74 HGB-12.3* HCT-37.5* MCV-79* MCH-26.0* MCHC-33.0 RDW-15.3 [**2167-1-21**] 11:15AM estGFR-Using this [**2167-1-21**] 11:15AM GLUCOSE-118* UREA N-12 CREAT-0.6 SODIUM-136 POTASSIUM-4.5 CHLORIDE-99 TOTAL CO2-25 ANION GAP-17 [**2167-1-21**] 11:26AM LACTATE-2.1* K+-4.5 [**2167-1-21**] 08:28PM URINE GR HOLD-HOLD [**2167-1-21**] 08:28PM URINE HOURS-RANDOM [**2167-1-21**] 08:45PM PTT-48.8* [**2167-1-21**] 08:45PM HCT-36.0* Images: [**1-21**] CTA CHest: IMPRESSION: 1. Bilateral subsegmental pulmonary emboli. 3. Right upper lobe likely post-obstructive pneumonia. 3. Multiple spiculated masses in the right lower lobe concerning for malignancy. 4. Left lower lobe greater than right lower lobe, and lingular ground-glass opacities may represent pneumonia vs edema vs hemorrhage. . [**2167-1-22**] Bilaterally LE US; IMPRESSION: No evidence of bilateral lower extremity DVT. . [**2167-1-26**] Bilaterally LE US: IMPRESSION: Thrombus in a left posterior tibial vein. More proximal veins of the left lower extremity and the veins of the right lower extremity are patent. . [**2167-1-28**] KUB: IMPRESSION: IVC filter adequately positioned at the level of L2 vertebral body. [**2167-1-30**] KUB: Multiple nonspecific air-filled loops of non-dilated small andlarge bowel are unchanged since [**2167-1-28**]. There is no free air. [**2167-1-30**] Barium swallow: 1. Unremarkable esophagram, without evidence of stricture, narrowing or filling defect within the esophagus. 2. Mild delayed transit of contrast from the distal esophagus in to the stomach. 3. Large right hilar mass is noted on the scout examination, consistent with the known lung carcinoma. [**2167-2-12**]: PET: IMPRESSION: 1. Interval improvement in the disease burden in the chest. Decrease in the FDG avidity of the multiple mediastinal and hilar lymph nodes. Unchanged narrowing of the right upper lobe segmental bronchi with post obstructive changes likely representing pneumonitis. 2. Multiple new peripheral ground glass opacities in both lungs predominantly seen in the right lower lobe demonstrate mild FDG uptake, may represent post-radiation changes or an inflammatory/infectious process. 2. Interval decrease in the FDG uptake of the diffuse bony metastatic lesions. 3. A single focus of increased FDG uptake in the region of the right pterygoid process is new since prior study. Recommended attention to this region in the follow-up studies. TTE [**2167-2-10**]: Suboptimal study. The left atrium is normal in size. Left ventricular wall thickness, cavity size and regional/global systolic function are grossly normal (LVEF 60%). There is no ventricular septal defect. The right ventricle is poorly visualized. There appears to be some degree of depressed free wall contractility. There is abnormal systolic septal motion/position consistent with right ventricular pressure overload. The aortic valve leaflets are mildly thickened (?#). The aortic valve is not well seen. There is no aortic valve stenosis. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. There is no pericardial effusion. [**2167-2-13**]: MRI T and L spine: IMPRESSION: Limited lumbar spine study demonstrates no obvious change on the sagittal images. L2 and sacral metastases are again noted. [**2167-2-16**]: CTA Chest: FINAL READ PENDING AT THE TIME OF DISCHARGE Prelim read: Multifocal areas of GGO and consolidation not significantly changed from [**2167-2-9**]. Extensive hilar and mediastinal adenopathy similar in appearance with marked narrowing of right upper lobe pulmonary segmental artery and bronchi and SVC narrowing. Multiple filling defects similar in burden, but slightly different locations (and now more proximal) - i.e. less PE in left lower lobe segmental branches, however new, small filling defects in left main pulm artery. Bone lesions are similar. Brief Hospital Course: Mr. [**Known lastname 93447**] is a 46 year old man with remote h/o Hodgkin's lymphoma, s/p splenectomy, with new stage IV NSCLC with bone mets s/p 1st round of chemo [**2167-1-7**] who presents with hemoptysis, found to have bilateral PEs and post-obstructive pneumonia. . Hemoptysis: Patient underwent LENIs to assess for clot, and read was negative for DVTs bilaterally. He was initially continued on heparin gtt for b/l PE seen on CTA. Patient was seen by interventional pulmonology (IP) who had plans for bronchoscopy the next day. However, overnight, patient had further episodes of hemoptysis ~1 cup size. His heparin was stopped given concern for further bleeding. IP urgently bronched patient and observed active bleeding from airways but unable to identify source. Pt then taken for rigid bronchoscopy in the OR at which time blood was evacuated. Bleeding thought to be from mass in right upper lobe. Pt then developed recurrent hemoptysis and interventional radiology and radiation oncology were consulted and pt underwent radiation therapy. Pt also had IVC filter placed as it was felt that it would not be safe to anticoagulate at that time. Pt continued to have tachycardia and fatigue and so a repeat CTA was done to evaluate for PE on week 4 of hospitalization. Repeat CTA final read is pending. However, preliminary read (above) was discussed with family and risks and benefits of anticoagulation considered. Pt and family prefer not to proceed with anticoagulation at this time. *****Patient plans to reconsider anticoagulation and will discuss this further with Dr [**First Name (STitle) **] and Dr [**Last Name (STitle) 3274**] as an outpatient. If pt decides he would like to try anticoagulation again, he would need to be admitted for heparin gtt with close supervision . # Post-obstructive Pneumonia - On admission pt felt to have postobstructive pneumonia. His last abx exposure prior to admission was azithromycin [**11-12**]. Pt recieved a dose of vancomycin/ceftriaxone on admission, then switched to ceftriaxone/levofloxacin, then switched to augmentin and finally to unasyn for the rest of the course. Pt reevaluated for postobstructive pna later in his hospital course [**1-6**] FUO and recieved CT chest followed by repeat bronch. On bronchoscopy, pt not observed to have post-obstructive pneumonia. . # Occasional fevers: Pt developed fevers to 100-101 in 3rd week of hospitalization. Source could not be identified. Pt initially started on vanc/cefepime for potential pulmonary source. Pt was evaluated for recurrent pneumonia with both CT chest (which could not exclude pna) and bronch (which did not show any evidence for pneumonia.) Given this information vanc/cefepime were discontinued and fever curve remained constant (temps of 98 c occasional spikes to 100 to 101). CT chest did show ggo which could be consistent with fungal pna, COP as well as many other etiologies. Ground glass opacities (ggo) were discussed c pt's oncology attg who felt that they could be watched with consideration for pulm f/u in the future (ddx includes COP, resolving pna, opportunistic infection) etc. UA and UCx unremarkable and multiple blood cultures were unrevealing. Of note, pt was not neutropenic. Low grade fevers thought to represent PEs and/or tumor fever. Infection of clot thought to be unlikely given negative blood cultures. *****Pt will follow up with Dr [**Last Name (STitle) 3274**] and Dr [**First Name (STitle) **] and will have repeat CT chest in several weeks. Depending on goals of care, they will consider pulm referral. . # NSCLC - Recent dx in [**2166-12-5**] with lesion on right upper lobe and mets seen on PET scan to a left adrenal nodule, a right mandibular lesion, a distal sternal lesion, the left sacral body, a lytic lesion in the left femoral head, the right lesser trochanter, and destructive lesions of the T10 and L1 vertebral bodies. He was started on [**2167-1-7**] palliative chemotherapy with carboplatin, paclitaxel, and bevacizumab. Recieved cycle 2 on [**1-28**] with [**Doctor Last Name **]/taxol only. Pt recieved cycle 3 on [**2167-2-17**] with pemitrexed (alimta) and carboplatin. He had a total of 6 radiation tx, after which he refused further radiation [**1-6**] esophagitis (goal had been 11). . # leg weakness: Pt had worsening lower extremity weakness. Differential felt to include progression of known spinal mets versus deconditioning versus [**1-6**] increased edema. On week 4 of hospitaliation pt got MRI T and L spine, however, pt could only tolerate first part of study. Based on limited info, seems same as prior (T10 lesion c mild cord compression). PLEASE CONTINUE TO TREND CAREFULLY. CONSIDER REPEAT SCAN IF ANY CONCERN. . #LE edema: likely [**1-6**] IVC filter. Pt noted to have extensive clots bilaterally distal to filter. Pt was seen by vascular surgery who recommended conservative management with thigh-high teds. . # elevated LFTs: Pt has had uptrending LFTs. This may be [**1-6**] tumor versus [**1-6**] chemo. Seemed to improve after last chemo dose. Could also be portal v thrombosis however, this would not alter the decision to anticoagulate so we did not do RUQ ultrasound. Hep serologies neg in [**2152**]. *** Dr [**Last Name (STitle) 3274**] and Dr [**First Name (STitle) **] aware and will continue to monitor. . # sinus tachycardia: Felt to likely be [**1-6**] PEs as bedside echo shows evidence of elevated RH pressures without RV dilation. Pt had repeat CTA chest which was pending at the time of discharge (but family feels they do not want anticoagulation). Pt does not have pericardial effusion and pt remained in sinus tach even when afebrile and asleep. Pt started on bblocker but he felt that this gave him a depressed mood and it did not slow his HR significantly at dose of metoprolol 12.5TID. . # SIADH: Pt noted to have SIADH likely related to NSCLC versus chemo adverse effect. Pt responded well to 1.5L fluid restriction, later liberalized to 2L fluid restriction. . # Vomiting and dysphagia: Temporally related to radiation. GI consulted and felt that given hemoptysis, he is a high risk candidate for an upper endoscopy at this time. Pt instead had barium swallow whcih did not show stricture. Pt felt to have likely radiation esophagitis, he was started on sodium and baking soda as instructed by rad onc as well as magic mouth wash and symptoms subsided. *** could consider outpt EGD if this seems consistent with goals of care. . # GIB: Pt had guiac positive stool on week 2 of hospitalization and was started on protonix. *** Could consider EGD/[**Last Name (un) **] for further evaluation as outpt if this is within goals of care. . # hematuria: Pt noted to have hematuria, which may have been [**1-6**] prior foley placement. Repeat UA with 1 RBC prior to discharge. . #Anemia: Has had melena, hemoptysis and chemo during this admission. Pt transfused for goal hct >24. . # Insomnia: pt experienced insomnia and was started on trazadone and mirtazapine at night. . # prophylaxis: pt initially started on heparin gtt. When heparin gtt discontinued, pt encouraged to use pneumoboot on the leg that did not have a DVT, however, pt refused pneumoboot on multiple occasions. . # Goals of Care: pt remained full code throughout admission. Initially pt and family were certain that they wanted aggressive treatment for his cancer and any potential complications of his cancer. However, as his hospitalization progressed both pt and his wife began to have mixed feelings about the length of his stay and the discomfort he was enduring by being hospitalized far from his family. Pt and family aware that his long-term prognosis is poor. Given this, they began to refuse certain interventions (further radiation, anticoagulation) that they felt would be uncomfortable for him or that had the potential to keep him hospitalized for longer. Goals of care became oriented towards getting him to rehab which is closer to his home. Pt and family plan to continue to consider chemotherapy, anticoagulation, radiation, as well as more comfort-oriented measure. They will continue to discuss these with Dr [**Last Name (STitle) 3274**] and Dr [**First Name (STitle) **] as an outpatient. Medications on Admission: Benzonatate 100mg [**12-6**] capsules q8H cough Combivent 18mcg-103mcg 1 puff [**Hospital1 **] Ativan q6 PRN Nausea Zofran 8mg q8H PRN nausea Endocet 5/325mg 1-2 tabs q6PRN pain Compazine 10mg PO q6 PRN nausea Discharge Medications: 1. Benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 2. Combivent 18-103 mcg/Actuation Aerosol Sig: One (1) Inhalation twice a day. 3. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for nausea: hold for sedation. 4. ZOFRAN ODT 8 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO once a day as needed for nausea. 5. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain: hold for sedation. 6. Prochlorperazine Maleate 10 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for nausea. 7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 9. Lidocaine-Diphenhyd-[**Doctor Last Name **]-Mag-[**Doctor Last Name **] 200-25-400-40 mg/30 mL Mouthwash Sig: 15-30 mL Mucous membrane every six (6) hours as needed for mucositis. 10. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 11. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for fever: do NOT give more than 2g in one day. 12. Polyethylene Glycol 3350 17 gram/dose Powder Sig: One (1) PO DAILY (Daily). 13. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q8H (every 8 hours) as needed for constipation. 14. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 15. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for insomnia. 16. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 17. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 18. Dexamethasone 4 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 3 doses: for post-chemo treatment. 19. Critic-Aid Clear AF 2 % Ointment Sig: One (1) Topical twice a day as needed for itching. Discharge Disposition: Extended Care Facility: [**Hospital 16844**] Hospital Rehab Discharge Diagnosis: Primary: Hemoptysis Bilateral PEs DVT Post-obstructive Pneumonia NSCLC Discharge Condition: Mental Status: Clear and coherent Level of Consciousness: Alert and interactive Activity Status: Ambulatory - requires assistance or aid (walker or cane) (short distances only) Activity Status: Out of Bed with assistance to chair or wheelchair Discharge Instructions: You were admitted to the [**Hospital1 18**] for coughing up blood. You were found to have blood clots in your lung. You were initially started on heparin (an blood thinner) and you coughed more blood. We stopped the blood thinner and temporarily moved you to the intensive care unit for closer follow-up. You were then found to have clots in your leg and you had a filter placed in your vein to prevent any more clots going to your lungs. This resulted in a large amount of swelling in your legs which can You were also treated for pneumonia that was caused by your lung mass. You were continued on your chemotherapy treatment and also recieved a small amount of radiation therapy. Followup Instructions: Please transport pt to the following appointment: Provider: [**Known firstname 251**] [**Name11 (NameIs) **], MD Phone:[**0-0-**] Date/Time:[**2167-2-24**] 9:30 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 8950**], MD Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2167-2-24**] 9:30 Please arrange for pt to see his PCP [**Name9 (PRE) **],[**Name9 (PRE) **] [**Name Initial (PRE) **] [**Telephone/Fax (1) 21640**] within 1 week of discharge [**Known firstname 251**] [**Name8 (MD) **] MD [**MD Number(1) 3282**] Completed by:[**2167-2-17**] Name: [**Known lastname 14744**],[**Known firstname 116**] Unit No: [**Numeric Identifier 14745**] Admission Date: [**2167-1-21**] Discharge Date: [**2167-2-17**] Date of Birth: [**2120-2-13**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**Known firstname 14746**] Addendum: Pending at the time of discharge: Blood cultures from [**2167-2-12**] and final read of CTA chest from [**2167-2-16**] Discharge Disposition: Extended Care Facility: [**Hospital 4955**] Hospital Rehab [**Known firstname 116**] [**Name8 (MD) **] MD [**MD Number(1) 1432**] Completed by:[**2167-2-17**]

[ "253.6", "285.9", "530.19", "780.52", "794.8", "786.3", "599.70", "198.5", "486", "427.89", "584.9", "909.2", "162.3", "V66.7", "415.19", "578.9", "V10.79", "453.41", "E879.2" ]

icd9cm

[ [ [] ] ]

[ "99.25", "33.22", "38.7", "96.56" ]

icd9pcs

[ [ [] ] ]

21846, 22036

9112, 17317

325, 348

19734, 19734

4955, 4955

20710, 21823

4004, 4403

17577, 19534

19640, 19713

17343, 17554

20004, 20687

4418, 4936

275, 287

376, 1802

4971, 9089

19749, 19980

1824, 3783

3799, 3988

21,103

185,424

11084

Discharge summary

report

Admission Date: [**2113-8-6**] Discharge Date: [**2113-8-14**] Date of Birth: [**2046-4-22**] Sex: F Service: HISTORY OF PRESENT ILLNESS: The patient is a 67 year old female with coronary artery disease admitted for recurrent chest pain at rest. The patient developed chest pain with left arm radiation only relieved with sublingual Nitroglycerin. She had a cardiac catheterization two weeks ago which demonstrated significant circumflex disease at 40% and left main disease. The patient had angioplasty in [**State 1558**] at [**Location (un) 12674**] three years ago. The patient was recently admitted to the Intensive Care Unit and started on intravenous Nitroglycerin which decreased the chest pain. The patient now presents to [**Hospital1 190**] for a coronary artery bypass graft. PAST MEDICAL HISTORY: 1. Coronary artery disease. 2. Anemia. 3. Lupus. 4. Rheumatoid arthritis. 5. Gastroesophageal reflux disease. 6. Hypertension. 7. Hypothyroidism. ALLERGIES: Penicillin and Norvasc. MEDICATIONS ON ADMISSION: 1. Protonix one tablet p.o. q.d. 2. Prednisone 30 mg p.o. q.a.m. 3. Claritin 10 mg p.o. q.a.m. 4. Mebryl 25 mg intramuscular Tuesday and Friday. 5. Aspirin 81 mg p.o. q.d. 6. Zestril 20 mg p.o. q.a.m. 7. Atenolol 25 mg p.o. b.i.d. 8. Pravachol 20 mg p.o. q.a.m. 9. Synthroid 0.025 mg q.a.m. LABORATORY DATA: White blood cell count 8.1, hemoglobin 11.7, hematocrit 34.8, platelets 297,000. INR 1.0. Electrocardiogram showed normal sinus rhythm. PHYSICAL EXAMINATION: Head, eyes, ears, nose and throat negative for lymphadenopathy. Cardiovascular - regular rate and rhythm, no murmurs. The lungs are clear to auscultation bilaterally. The abdomen is soft, nontender, nondistended, good bowel sounds. Extremities negative swelling. Negative varicosities. HOSPITAL COURSE: The patient was admitted on [**2113-8-6**], and was transferred to the operating room on [**2113-8-7**], with the diagnosis of coronary artery disease. The patient had a coronary artery bypass graft times two with left internal mammary artery to the left anterior descending, saphenous vein graft to the OM. The patient tolerated the procedure well and was transported to the Post Anesthesia Care Unit in stable condition. On postoperative day one, the patient was transferred to the floor from the Intensive Care Unit in good condition. On postoperative day two, the patient developed atrial fibrillation which did not respond to 35 mg intravenous push of Lopressor over two hours. The patient was started on Amiodarone 400 mg t.i.d. and Lopressor 50 mg. On postoperative day three, the patient continued to have atrial fibrillation with a rapid ventricular response which was continually treated with Lopressor, Amiodarone and Lopressor intravenous push. On postoperative day four, the patient converted to a normal sinus rhythm and increased her ambulation level. On postoperative day five, the patient continued to do well with a physical therapy level of five and continued to be in normal sinus rhythm. The patient was assessed for rehabilitation and was placed in a rehabilitation facility scheduled for [**2113-8-13**]. Discharge physical examination includes temperature 98.7, heart rate 64, respiratory rate 18, blood pressure 113/80, 95% in room air, +1 kilogram from previous weight. Cardiovascular regular rate and rhythm. Respiratory clear to auscultation bilaterally. The abdomen was soft, nontender, nondistended. Incision was clean, dry and intact. Extremities negative peripheral edema. COMPLICATIONS: No significant events. Atrial fibrillation treated with Lopressor and Amiodarone. DISCHARGE MEDICATIONS: 1. Lasix 20 mg p.o. b.i.d. times seven days. 2. [**Doctor First Name 233**]-Ciel 20 meq p.o. b.i.d. times seven days. 3. Aspirin 81 mg p.o. q.d. 4. Ebryl 25 mg intramuscular q.Tuesday and Wednesday. 5. Dilaudid one to two tablets p.o. q4-6hours p.r.n. 6. Lopressor 50 mg p.o. b.i.d. 7. Captopril 12.5 mg p.o. t.i.d. 8. Amiodarone 400 mg p.o. t.i.d. times three days followed by 400 mg p.o. b.i.d. times seven days followed by 400 mg p.o. q.d. times seven days followed by Amiodarone 200 mg p.o. q.d. The patient will be discharged with regular diet to rehabilitation in good and stable condition. PRIMARY DIAGNOSIS: Status post coronary artery bypass graft times two. SECONDARY DIAGNOSES: 1. Coronary artery disease. 2. Anemia. 3. Lupus. 4. Rheumatoid arthritis. 5. Gastroesophageal reflux disease. 6. Hypertension. 7. Hypothyroidism. The patient will follow-up with Dr. [**Last Name (STitle) 35793**] in three to four weeks. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 75**] Dictated By:[**Last Name (NamePattern4) 959**] MEDQUIST36 D: [**2113-8-12**] 14:27 T: [**2113-8-12**] 15:37 JOB#: [**Job Number 35794**]

[ "285.9", "710.0", "244.9", "427.31", "997.1", "414.01", "401.9", "530.81", "411.1" ]

icd9cm

[ [ [] ] ]

[ "39.63", "36.11", "36.15" ]

icd9pcs

[ [ [] ] ]

3680, 4287

1049, 1506

1838, 3657

4381, 4896

1529, 1821

155, 810

4307, 4360

832, 1023

31,772

131,059

34248

Discharge summary

report

Admission Date: [**2116-4-14**] Discharge Date: [**2116-4-19**] Date of Birth: [**2055-6-24**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1493**] Chief Complaint: Transferred from MICU with alcoholic hepatitis Major Surgical or Invasive Procedure: none History of Present Illness: For full details, please see MICU admission note and the Liver consult note of [**2116-4-15**]. Briefly, this is a 60 y/o male with cirrhosis transferred from [**Hospital 1562**] hospital on [**2116-4-14**]. He had been admitted to the OSH on [**4-5**] after being found down at home; his course at [**Hospital1 1562**] was complicated by hematemesis requiring significant blood transfusion (18 units of PRBC), intubation for airway protection and emergency variceal banding. The patient had an EtOH level on admission of 203. An EGD on [**4-5**] demonstrated grade 3 esophageal varices, portal hypertensive gastropathy, and gastritis. For this he was on pentoxifylline briefly and started on an octreotide drip from [**Date range (1) 78858**]. In addition he was febrile to > 101 on [**4-12**] and was started on vancomycin. A groin line was complicated by arterial puncture and retroperitoneal bleed. He was transferred to the [**Hospital1 18**] for consultation regarding ? TIPS and evaluation for liver transplantation. At the [**Hospital1 18**] he was hemodynamically stable. A vascular consult was obtained for evaluation of his RP bleed and decided not to intervene. A liver consult was obtained and the patient was restarted on pentoxifylline. He did not have any steroids started given the concern for possible infection. A CT demonstrated emphysema, RML/RLL collapse, and multifocal interstitial abnormality concerning for PNA v. pulmonary fibrosis. He was continued on his regimen of ceftriaxone/vancomycin for presumed hospital acquired PNA. He is currently refusing to answer any questions as he is upset that we woke him up. Past Medical History: 1.Cirrhosis, likely secondary to alcohol abuse 2.alcohol abuse 3.h/o inguinal hernia repair Social History: Divorced & lives alone. Mother and brother are involved in his life. Smokes 1 ppd X 45 years. Admits to lifelong history of alcohol abuse & binges though adamantly denies any alcohol use in the past month; he states "on average" he drinks "7.5 liters of whiskey" every other day. Has quit in the past for 6 or 9 months at a time. Denies any illicit drug use. Family History: Patient reports no family members with liver disease. Two brothers with prior h/o alcohol abuse but both have quit. Physical Exam: Physical Exam: HR: 76, BP: 94/64, RR: 22, O2: 92% 4.5 L Gen: Extremely jaundiced male lying on side in NAD. HEENT: + scleral & subungual icterus, PERRL, MMM, OP clear Neck: No appreciable lymphadenopathy CV: RRR, heart sounds distant, no appreciable murmur Chest: Decreased breath sounds throughout, no wheezing, no areas of consolidation noted. Abdomen: Distended but nontender, normoactive bowel sounds Ext: Right upper arm PICC in place with surrounding ecchymoses, 3+ pitting edema R leg, 1+ pitting edema L leg, eccymosis on right posterior leg from buttock/groin to lower leg, extremities warm, DP pulses 1+ bilaterally Neuro: Patient will answer questions but refusing neuro exam at this time. Pertinent Results: 133 | 98 | 35 --------------<121 3.5| 25 | 0.5 Ca 8.5, Mg 2.6, P 3.7 ALT: 42, AST: 92, Alk Phos: 86, LDH: 463 Tbili: 47.7, Alb: 2.9 Brief Hospital Course: The patient was transferred from an outside hospital with acute alcoholic hepatitis for consideration of TIPS. The patient was critically ill with a discriminant function of over 100. After stabilization in the ICU he was transferred to the floor, where he became progressively hypotensive and had continually worsening renal failure. The option of liver transplantation was ruled out due to his recent alcohol abuse and active infection. The patient was made DNR/DNI and after discussion with the family the decision was made to make him CMO as he continued to fail. Medications on Admission: MEDS on Transfer: 1.Heparin Flush (10 units/ml) 2 mL IV PRN line flush 2.Insulin SC (per Insulin Flowsheet) Sliding Scale 3.Ipratropium Bromide Neb 1 NEB IH Q6H 4.Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN 5.CeftriaXONE 1 gm IV Q24H 6.Vancomycin 1000 mg IV Q 12H 7.FoLIC Acid 1 mg PO DAILY 8.Thiamine 100 mg PO DAILY 9.Lactulose 30 mL PO TID 10.Pantoprazole 40 mg PO Q12H 11.Furosemide 20 mg IV DAILY 12.Heparin 5000 UNIT SC TID 13.Pentoxifylline 400 mg PO TID 14.Morphine Sulfate 2-4 mg IV Q6H:PRN pain 15.Metoprolol Tartrate 12.5 mg PO BID Discharge Medications: expired Discharge Disposition: Expired Discharge Diagnosis: expired Discharge Condition: expired Discharge Instructions: expired Followup Instructions: expired Completed by:[**2116-4-26**]

[ "305.1", "E849.7", "572.3", "537.89", "518.0", "E879.8", "572.4", "571.2", "303.91", "570", "571.1", "287.4", "280.0", "799.02", "789.59", "456.20", "492.8", "996.74", "V66.7", "486", "535.50" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

4752, 4761

3556, 4127

362, 368

4812, 4821

3399, 3533

4877, 4915

2545, 2662

4720, 4729

4782, 4791

4153, 4153

4845, 4854

2692, 3380

276, 324

396, 2037

2059, 2153

2169, 2529

4171, 4697

15,861

114,124

16209

Discharge summary

report

Admission Date: [**2171-10-15**] Discharge Date: [**2171-10-19**] Date of Birth: [**2122-4-30**] Sex: M Service: MEDICINE Allergies: Penicillins Attending:[**First Name3 (LF) 18369**] Chief Complaint: dyspnea, hemoptysis Major Surgical or Invasive Procedure: bronch History of Present Illness: HPI: 49 yo man w/ known renal cell carcinoma with mets to lung admitted w/ worsened dyspnea and hemoptysis. Lung mets were diagnosed [**2171-10-9**] when he had flex bronch for evaluation of diffuse, bilateral infiltrates, dyspnea, hypoxia in setting on known renal cell carnicoma. DDx at that time included lymphangitic spread vs. infection vs toxic reaction, but bronchial washing and tissue bx showed malignant cells. He is followed closely by Drs. [**Last Name (STitle) **] and [**Name5 (PTitle) 15521**] in onc clinic. He has been on study drug C3 SU11248/Gemzar for 2 cycles with last dose [**2171-9-18**] but has now progressed on this drug. Pt noted to have 94% O2sat on RA dropping to 91% with ambulation on last clinic visit on [**2171-9-25**]. Since bronch, pt has been having worsening SOB for 3-4 days, pleuritic chest pain, that became acutely worse last night, after eating a snack (nuts and [**First Name8 (NamePattern2) **] [**Location (un) 2452**]). He denies any aspiration event or emesis. He had subjective fevers overnight with persistent coughing, called his PCP who told him to take codeine for cough suppressant and to try to rest. On day of admission, he still felt unwell and was told to come to the ER for evaluation. Regarding his hemoptysis, he reported having "specks" of blood in his sputum which turned more bright in color on morning of admission. His chest pain is post tussive and with shallow breathing. Although worse over last 24 hours, he feels that his breathing has been getting progressively worse over last few weeks. In [**Name (NI) **], pt with temp 100.6, slight tachy to 109, and sats 90% RA. Concern for PE warranted evaluation, but given dye allergy/ ARF and abnormal chest xray, options were limited. LENI dopplers were negative. Chest CT w/o contrast shows dramatic metastatic lung progression. Admitted to [**Hospital Unit Name 153**] for close observation. He received approx 6 mg total IV morphine w/o significant relief in the ER. Chest pain is his main discomfort at this time. He has had orthopnea ([**3-14**] pillow) over last few weeks. This is unchanged. * Past Medical History: PMH: Dx renal cell ([**2170-5-10**]) with abd pain/diarrhea. CT/MRI at that time with left renal mass. --[**2170-7-2**] Left nephrectomy was performed by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. Path w/ papillary-type renal cell carcinoma measuring 9.1 cm, histologic grade was 3. There was extensive vascular invasion and tumor present in the peripelvic fat.There were no distant sites involved at that time. --right axillary dissection [**1-12**] for palplable mass --supraclavicular dissection w/ no clear dx --sought multiple opinions around country and elected to start 17AAG x 2 cycles w/ increased disease, taken off protocol --started SU11248Gemzar [**7-14**] but now w/ mets to lung on bronch done [**10-9**](washings and RLL tissue positive for mets) --Last dose SU011248/Gemcitabine [**2171-9-18**]. OTHER PMH: BPH hyperlipidemia GERD vasectomy multiple ortho procedures Social History: * Social: He has one 12-year-old son. [**Name (NI) **] works as a fundraiser for [**Hospital6 **]. He is a lifetime nonsmoker, non drinker, non drug user. He was married 2 weeks ago to his longtime girlfriend. Family History: FH: Father w/ CAD and ?lung ca. Sister w/ NSCL Ca- was non smoker. His mother with breast cancer in her 60s. His paternal grandmother died of smoking-related lung cancer. His maternal first cousin suffered from melanoma. His paternal aunt has a history of breast cancer. Physical Exam: T 100.4 BP 107/48 HR 101 R 20 92% 4L NC Gen: comfortable, speaking in full sentences, pleasant, no distress HEENT: MMM, no oral lesions neck: JVP flat, supple chest: poor effort [**3-13**] pain but no crackles or wheeze cv: slight tachy, regular, no m/r/g abd: soft, nontender, nabs extrm: non tender, no edema, no cyanosis, normal tone and strength neuro: intact, conversant, appropriate Pertinent Results: [**2171-10-15**] 10:00AM BLOOD WBC-12.0*# RBC-4.11* Hgb-13.1* Hct-38.3* MCV-93 MCH-31.9 MCHC-34.2 RDW-16.7* Plt Ct-301 [**2171-10-15**] 05:04PM BLOOD Hct-35.2* [**2171-10-15**] 10:00AM BLOOD Neuts-89.6* Bands-0 Lymphs-5.0* Monos-4.9 Eos-0.3 Baso-0.3 [**2171-10-15**] 10:00AM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-1+ Macrocy-1+ Microcy-NORMAL Polychr-OCCASIONAL Ovalocy-1+ Tear Dr[**Last Name (STitle) 833**] [**2171-10-15**] 10:00AM BLOOD PT-12.9 PTT-29.8 INR(PT)-1.1 [**2171-10-15**] 10:00AM BLOOD Glucose-162* UreaN-17 Creat-1.7* Na-139 K-4.1 Cl-105 HCO3-23 AnGap-15 [**2171-10-15**] 05:01PM BLOOD LD(LDH)-366* [**2171-10-15**] 10:00AM BLOOD proBNP-46 [**2171-10-15**] 10:01AM BLOOD Lactate-2.5* . [**2171-10-16**] 05:38AM BLOOD WBC-11.9* RBC-3.49* Hgb-11.1* Hct-33.1* MCV-95 MCH-31.8 MCHC-33.6 RDW-16.6* Plt Ct-279 [**2171-10-16**] 05:38AM BLOOD PT-13.8* PTT-30.1 INR(PT)-1.3 [**2171-10-16**] 05:38AM BLOOD Fibrino-864* [**2171-10-16**] 05:38AM BLOOD Glucose-112* UreaN-15 Creat-1.5* Na-134 K-4.7 Cl-101 HCO3-24 AnGap-14 [**2171-10-16**] 05:38AM BLOOD Calcium-9.0 Phos-3.9 . [**2171-10-17**] 04:00AM BLOOD WBC-7.8 RBC-3.52* Hgb-10.9* Hct-32.0* MCV-91 MCH-31.0 MCHC-34.2 RDW-15.7* Plt Ct-255 [**2171-10-17**] 04:00AM BLOOD PT-13.5* PTT-31.8 INR(PT)-1.2 [**2171-10-17**] 04:00AM BLOOD Glucose-114* UreaN-13 Creat-1.4* Na-136 K-5.0 Cl-103 HCO3-22 AnGap-16 [**2171-10-17**] 04:00AM BLOOD Calcium-8.6 Phos-2.8 Mg-1.8 . [**2171-10-18**] 07:00AM BLOOD WBC-8.2 RBC-3.63* Hgb-11.4* Hct-34.9* MCV-96 MCH-31.5 MCHC-32.7 RDW-15.9* Plt Ct-322 [**2171-10-18**] 07:00AM BLOOD Glucose-106* UreaN-14 Creat-1.5* Na-140 K-4.3 Cl-100 HCO3-27 AnGap-17 [**2171-10-18**] 07:00AM BLOOD Calcium-9.4 Phos-4.4# Mg-2.0 . [**2171-10-19**] 06:40AM BLOOD WBC-8.0 RBC-3.70* Hgb-11.8* Hct-34.1* MCV-92 MCH-31.9 MCHC-34.7 RDW-15.6* Plt Ct-342 [**2171-10-19**] 06:40AM BLOOD Glucose-102 UreaN-13 Creat-1.5* Na-139 K-3.7 Cl-101 HCO3-26 AnGap-16 [**2171-10-19**] 06:40AM BLOOD Calcium-9.2 Phos-3.7 Mg-2.0 . Brief Hospital Course: A/P: 49 yo man w/ met renal cell carcinoma to lung now w/ progressive shortness of breath. * 1. Dyspnea: Pt has known metastatic disease in lungs, secondary to lymphangitic spread of renal cell CA. This is likely etiology of hemoptysis and dyspnea, but other possible etiologies include community acquired or aspiration pneumonia. PE also concern given malignancy, SOB and tachycardia, but this is very difficult to evaluate given his ARF/contrast allergy (no CTA) and abnormal CXR (no v/q). Patient appears clinically well, had negative LENI's, and is oxygenating well on nasal cannula. Heparin administration could be difficult, given his hemoptysis as well. Goal of care was to concentrate on comfort. Patient was empirically treated for CAP with Levofloxacin 500mg PO q24 hours and his resp status was closely monitored. -Sputum cultures were consistent with oropharyngeal flora. -MDI's prn and antitussives. -Narcotics will help suppress cough/discomfort as well. -BNP very low, making CHF unlikely -- exam not consistent w/ this either. . 2. Fever: As above for resp symptoms. Started Levaquin for suspected PNA, could be post-obstructive given known mets to lungs. Lactate 2.5 in ED. No bandemia or signs of sepsis during admission. - U/a and cx ordered were negative for UTI. - Sputum cx as above . 3. CRI: Baseline creat 1.4-1.7. Likely [**3-13**] nephrectomy, chemo and possible disease infiltration. - Patient was hydrated with IVF for possible pre-renal causes. . 4. Renal Cell CA: Pt last seen in clinic on [**2171-9-25**] per notes and discussed possible results of bronch. Felt that that malignant cells seen on bronch indicated treatment failure. Patient's code status was addressed and patient was full code. A palliative care consultation with the patient, his wife and his mother was done and patient was not ready at present to be placed on hospice, but was educated about hospice and given information to seek out hospice when he was ready. Patinet was scheduled to meet with Dr. [**Last Name (STitle) **] in 1 week to discuss future management and/or end of life care . 5. pain control: while in the ICU, patient's pain was controlled with PCA w/ dilaudid instead as morphine was not well tolerated. In transitioning to the floor, PCA was changed to a fentanyl patch with morphine sulfate for breakthrough pain. However, patient developed some hallucinations and thus was transitioned to just MS Contin and morphine for breakthrough. * 6. FEN: IVF, house diet, aspiration precautions. . 7. PPx: sc heparin and pneumoboots. . 8. Medications on Admission: MEDS on admission: codeine PRN cough tessalon perles doxazosin Discharge Medications: 1. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 4 days. Disp:*4 Tablet(s)* Refills:*0* 2. Benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). Disp:*90 Capsule(s)* Refills:*2* 3. Doxazosin 2 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). Disp:*30 Tablet(s)* Refills:*2* 4. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO BID (2 times a day) as needed. Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 5. MS Contin 30 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO twice a day. Disp:*60 Tablet Sustained Release(s)* Refills:*1* 6. Morphine 15 mg Tablet Sig: 1-2 Tablets PO q3h as needed. Disp:*60 Tablet(s)* Refills:*1* 7. Compazine 10 mg Tablet Sig: One (1) Tablet PO every [**5-15**] hours. Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: metastatic renal cell carcinoma Discharge Condition: AAOx3. Requiring O2 supplementation. Mild SOB on exertion. Discharge Instructions: Please follow up with Dr. [**Last Name (STitle) **] within 1 week of discharge, call to make an appointment. continue levofloxacin for 4 more days for pneumonia Followup Instructions: Please follow up with Dr. [**Last Name (STitle) **] within 1 week and Dr. [**Last Name (STitle) 9625**] within 2 weeks. Call [**Telephone/Fax (1) 9701**] to make an appt with Dr. [**Last Name (STitle) 9625**]. Completed by:[**2171-10-21**]

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Discharge summary

report

Admission Date: [**2115-1-5**] Discharge Date: [**2115-1-8**] Date of Birth: [**2033-11-17**] Sex: F Service: MEDICINE Allergies: Lisinopril / Verapamil / Beta-Adrenergic Agents / Captopril Attending:[**First Name3 (LF) 3705**] Chief Complaint: Hypotension and unresponsive Major Surgical or Invasive Procedure: Placement of central venous catheter History of Present Illness: 81F with dementia, chronic saccral decubitus ulcer to the bone on long term antibiotics, s/p SDH, DM-II with labile blood sugars, HTN, CAD, PVD, and ESRD on HD admitted from home for altered mental status. She is barely verbal but responsive at baseline, but became transiently unresponsive the morning of admission when transport came to take her to HD. She was taken to the ED at [**Hospital1 **] where her initial vital signs were 98.0 94/60 66 15 96% on RA. A stat CT head showed a new parietotemporal hypodensity consistent with acute CVA. Neurology was consulted. She then became hypotensive to 68/50. She was bolused 1L NS, given pip-tazo and cipro for double coverage of Pseudomonas. She was not given an additional dose of vancomycin or other Gram positive coverage. A subclavian line was placed and she was sent for a torso CT to eval for sites of infection. The CT showed her known saccral decubitus ulcer tracking to the bone, a new fluid collection over the R greater trochanter, and a newly notes renal lesion concerning for RCC. Her BP stabilized after fluid bolus and she was never on pressors. General surgery and orthopedic surgery were consulted regarding her saccral and trochanteric processes and she was admitted to the MICU service. . On the floor she is A and O x 2 to person and place, and barely verbal. Per her sister who was at the bedside, she is at her baseline at this point. She denies pain, fevers, chills, or sweats. Her she is somewhat dysarthric but is normally so. . Review of systems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies cough, shortness of breath, or wheezing. Denies chest pain, chest pressure, palpitations, or weakness. Denies nausea, vomiting, diarrhea, constipation, abdominal pain, or changes in bowel habits. Denies dysuria, frequency, or urgency. Denies arthralgias or myalgias. Denies rashes or skin changes. Past Medical History: - Multiple admissions for toxic metabolic encephalopathy- extensively worked up with MRI, EEG, and neurologic consultations. These episodes are typically secondary to infections, missed [**Hospital1 2286**] sessions or other metabolic derrangements, and are quite profound clinically. - Type 2 Diabetes [**Hospital1 **] with labile blood surgars - Coronary artery disease - Peripheral vascular disease - Hypertension - Pulmonary hypertension - h/o subdural hematoma and intracranial hemorrhage in [**9-25**] and neurosurgery in [**2-26**] - Toxic Multinodular Goiter - Chronic kidney disease on HD (Tues/ Thurs/ Sat) - Lumbar disc disease - Osteoarthritis - Anemia - low iron and EPO - s/p Breast biopsy - s/p Hysterectomy - s/p transmetatarsal amputation (right foot) - Saccral decubitus with possible osteomyelitis. On 6 week course of vanco/cipro/flagyl starting on [**2114-12-20**] Social History: - Has been in and out of various longterm care facilities and rehabs since admission in [**5-26**]. Prior to [**5-26**] patient was ambulatory with walker and could feed herself; but has not been ambulatory since that time. As of [**12-26**] living at home with VNA. At baseline, she is not confused (as per sister) but in normally barely verbal. - Tobacco: Denied in the past - Alcohol: Denied in the past - Illicits: Denied in the past Family History: - Diabetes [**Name (NI) **] (sister) - Cancer in brothers and father (leukemia, prostate) Physical Exam: GEN: Ill appearing elderly woman in NAD HEENT: MMM, no OP lesions, dentures in place, face is symmetric, no cervical LAD, enlarged thyroid CV: RR, III/VI early systolic murmur PULM: CTAB no wheezes or rhonchi ABD: BS+, NTND, no masses or HSM LIMSB: no toes on the R foot, wasted limbs, contractures, resting tremors SKIN: 5cm saccral decubitus to the bone and tracking under the skin NEURO: A and O x 2, pupils symmetric and minimially reactive, reflexes 3+ of the RUE and 1+ of LUE and bilat LEs . Pertinent Results: Admission labs: [**2115-1-5**] 01:50PM BLOOD WBC-10.9 RBC-3.86* Hgb-9.6* Hct-33.4* MCV-87 MCH-25.0* MCHC-28.8* RDW-19.8* Plt Ct-328 [**2115-1-5**] 01:50PM BLOOD Neuts-77.8* Lymphs-12.8* Monos-5.9 Eos-2.8 Baso-0.6 [**2115-1-5**] 01:50PM BLOOD PT-13.5* PTT-23.9 INR(PT)-1.2* [**2115-1-5**] 01:50PM BLOOD Glucose-45* UreaN-49* Creat-3.9*# Na-149* K-3.6 Cl-105 HCO3-34* AnGap-14 [**2115-1-6**] 02:51AM BLOOD ALT-26 AST-25 LD(LDH)-149 AlkPhos-120* TotBili-0.2 [**2115-1-6**] 02:51AM BLOOD Albumin-2.7* Calcium-9.6 Phos-3.6 Mg-2.1 [**2115-1-5**] 01:50PM BLOOD VitB12-869 Folate-19.6 [**2115-1-7**] 07:40AM BLOOD Triglyc-40 HDL-33 CHOL/HD-1.5 LDLcalc-7 [**2115-1-5**] 01:50PM BLOOD TSH-0.11* [**2115-1-8**] 06:45AM BLOOD Free T4-0.93 [**2115-1-5**] 01:50PM BLOOD T4-6.2 [**2115-1-5**] 02:16PM BLOOD Lactate-1.2 K-3.5 Discharge labs: [**2115-1-8**] 06:45AM BLOOD WBC-5.8 RBC-3.39* Hgb-8.4* Hct-28.6* MCV-84 MCH-24.6* MCHC-29.2* RDW-19.3* Plt Ct-223 [**2115-1-6**] 02:51AM BLOOD PT-13.1 PTT-26.8 INR(PT)-1.1 [**2115-1-8**] 06:45AM BLOOD Glucose-128* UreaN-30* Creat-3.4*# Na-141 K-3.7 [**2115-1-7**] 07:40AM BLOOD Calcium-9.0 Phos-4.3 Mg-2.2 Cholest-48 [**2115-1-5**] BCx negative x3 [**2115-1-6**] BCx negative [**2115-1-5**] 7:41 pm SWAB Source: sacral wound. **FINAL REPORT [**2115-1-9**]** GRAM STAIN (Final [**2115-1-5**]): NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. WOUND CULTURE (Final [**2115-1-9**]): PSEUDOMONAS AERUGINOSA. SPARSE GROWTH. PROTEUS MIRABILIS. SPARSE GROWTH. PRESUMPTIVE IDENTIFICATION. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ PSEUDOMONAS AERUGINOSA | PROTEUS MIRABILIS | | AMPICILLIN------------ =>32 R AMPICILLIN/SULBACTAM-- 16 I CEFAZOLIN------------- 8 S CEFEPIME-------------- =>64 R <=1 S CEFTAZIDIME----------- =>64 R <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN--------- =>4 R =>4 R GENTAMICIN------------ 4 S 8 I MEROPENEM------------- 1 S <=0.25 S PIPERACILLIN/TAZO----- =>128 R <=4 S TOBRAMYCIN------------ <=1 S 2 S TRIMETHOPRIM/SULFA---- =>16 R ANAEROBIC CULTURE (Final [**2115-1-7**]): UNABLE TO R/O OTHER PATHOGENS DUE TO OVERGROWTH OF SWARMING PROTEUS SPP.. [**2115-1-8**] Cdiff negative [**1-5**] EKG Sinus rhythm. Right bundle-branch block. Compared to tracing #1 there is no significant diagnostic change. TRACING #2 [**1-5**] CXR CHEST, UPRIGHT PORTABLE FRONTAL VIEW: The left basilar retrocardiac opacity is less conspicuous in comparison to nine days prior. There is no new airspace consolidation, pleural effusion, or pneumothorax. Cardiac size remains normal. There is no evidence of pulmonary edema. Stents projecting over the left axilla and the region of the left brachiocephalic vein are unchanged, as well as femoral approach [**Month/Year (2) 2286**] catheter and a percutaneous gastrostomy tube. IMPRESSION: Decreased left basilar opacity in comparison to nine days prior. No new airspace consolidation. [**1-5**] CT chest/abd/pelvis CHEST CT WITH CONTRAST: The thyroid gland is enlarged and contains multiple nodules as well as areas of calcification. Moderate amount of atherosclerotic calcification of the aorta noted, severe along the coronary arteries. No central filling defect in the pulmonary artery is seen. Heart is not enlarged. There is no pericardial effusion. There is no mediastinal, hilar or axillary lymphadenopathy. Within the right lung apex, there is a 10-mm nodule which is new since prior chest CT from [**2114-5-2**] (2:10). There is a 5-mm right middle lobe ground-glass nodular opacity (2:32). Multiple nodular opacities at bilateral bases are likely atelectatic in nature. CT ABDOMEN WITH CONTRAST: The liver, spleen, adrenals, gallbladder are grossly unremarkable. Pancreas is atrophic. A 9-mm hypodense lesion in the body of the pancreas (2:55), grossly unchanged since [**2114-8-11**]. Bilateral kidneys are severely atrophic and contain multiple hypodense lesions, most likely cysts, with the largest measuring up to 6.4 x 5.0 cm arising from the upper pole of the left kidney. There is an 8 x 5 mm hyperdense lesion arising from the upper pole of the right kidney (2:46). There is no hydronephrosis. Abdominal aorta and iliac vessels contain moderate atherosclerotic calcifications with no evidence of aneurysm. There is no lymphadenopathy. A catheter extending from the right subclavian vein and passing through the right atrium ends at the superior aspect of the inferior vena cava. A righ femoral catheter extends into the SVC- right atrial junction. A gastric tube is again noted. There is no bowel obstruction or bowel wall thickening. There are multiple areas of subcutaneous abdominal wall hyperdensity which may represent sites of injection. PELVIC CT WITH CONTRAST: The rectosigmoid colon is unremarkable. Somewhat collapsed urinary bladder demonstrates wall enhancement which may reflect cystitis. The uterus and ovaries are absent. Pelvic floor descent is noted. OSSEOUS STRUCTURES: Severe degenerative changes and osteopenia are noted. Mild bowel vertebral body height loss in the cervical spine is partially imaged and likely chronic in nature. Large sacral ulcer extends to the sacrum with mottled appearance of the sacrum and coccyx compatible with osteomyelitis. This was also demonstrated on prior pelvic MRI from [**12-20**], [**2114**]. There is a 1.5 x 3.5 cm rim enhancing fluid collection lateral to the right greater trochanter (S2:106). IMPRESSION: 1. Large sacral decubitus ulcer, findings compatible with osteomyelitis in the inderlying sacrum and coccyx as seen on pelvic MRI from [**2114-12-20**]. 2. Urinary bladder wall enhancement. Correlate clinically for cystitis. 3. New rim enhancing fluid collection measuring 3.5 x 1.5 cm adjacent to the right femoral greater trochanter may be inflammatory/infectious in nature. 4. Pulmonary nodules, RUL 10-mm nodule and RML 5 mm nodule. Followup CT in three months is recommended. 5. Indeterminate renal lesions, may represent cysts, with 8-mm hyperdense lesion in the upper pole of the right kidney. Further evaluation with MRI is suggested. 6. Unchangd 9-mm hypodense lesion in the body of the pancreas can also be evaluated on MRI. 7. Nodular enlargement of the thyroid gland. [**1-6**] EKG Sinus rhythm. Occasional atrial premature beats. Compared to tracing #2 atrial premature beats are new. Otherwise, no other significant diagnostic change. [**1-7**] EEG IMPRESSION: This is an abnormal portable EEG due to slowing and disorganization of the background rhythm interrupted by bursts of generalized delta activity and intermittent synchronous bitemporal slowing. These findings are consistent with a moderate to severe encephalopathy. Medications, toxic/metaboic disturbances, and infections are common causes. No epileptiform discharges or electrographic seizures were seen during this recording. Brief Hospital Course: 81yoF, ESRD on HD, CAD and PAD, DM2, HTN, h/o R parietal SDH and small R frontal IPH in [**9-/2113**] complicated by GTC seizure then s/p craniotomy for L SDH evacuation in [**2-/2114**], pumonary HTN, recently admitted for stage IV chronic sacral decubitus ulcer/osteomyelitis on 6wk course of [**Year (4 digits) **], who is now re-admitted to [**Hospital1 18**] with unresponsive episode, hypoTN, new seen subacute R frontoparietal CVA seen on CT head, new possible small tronchanteric bursitis vs abscess, and new R kidney enhancing lesion. 1. Hypotension: Did not require pressors and normalized with modest amt of IVF's. BP's were stable after normalization. Pt kept on telemetry without event, BCx's and UCx were negative. [**Name (NI) 1094**] sister who is extensively involved, felt that pt possibly taking too much BP meds, so home med Captopril was stopped on dc but Labetalol was continued. Will need blood pressure follow up as outpt. BP stable by discharge. 2. Altered mental status: Per sister, pt was completely back to baseline (albeit poor) without specific intervention. Possibly due to hypotension vs seizure vs CVA as below. Got EEG per Neuro recs, which did not show acute epileptiform activity. 3. Acute CVA: R frontoparietal hypodensity seen on CT head but was felt to be subacute, vs acute, and called as watershed infarct vs chronic small vessel disease. A1c and lipid profile were normal. Neuro was consulted and recommended full workup with MRI head/MRA head/MRA neck, carotid u/s, TTE, and increase baby [**Name (NI) **] to full strength. Increased [**Name (NI) **], kept on Simvastatin. [**Name (NI) 1094**] sister felt pt was back to neurologic baseline (alert, eyes open to voice, not oriented, minimally verbal and minimally responsive, very difficult to understand speech, upper extremities contracted and rigid, lower extremities not rigid, non-ambulatory). Discussed goals of care with pt's sister who did not feel aggressive w/u was warranted, especially if it would not change management. Pt was sinus rhythm through admission, no indication that pt was having PAF as cardiac source of embolism. Low suspicion for carotid source as well given lack of bruits on exam. Finally, significant contraindication to anticoagulation even if thrombi were found given h/o major head bleeds requiring craniotomy earlier this year. Pt was discharged at Neurologic baseline, vitals stable, with clear instruction to sister that if pt decompensates to seek further care. 4. Chronic sacral decubitus ulcer/osteomyelitis: Pt was already on 6wk course of Vanc (after HD), Cipro, Flagyl (empirically as bone Bx's were negative) from past admission. Followed by Dr. [**First Name (STitle) **] in ID. Pt continued on these [**First Name (STitle) **] but switched to PO Levaquin given national shortage of PO Cipro, this decision was done with Dr.[**Name (NI) 60811**] advice. Wound care consulted, did not feel wound vac necessary at this time, recommended continued wet to dry dressings. Recommendations were communicated to home VNA caring for the wound by wound care nurse. Instructed to f/u with ID as previously scheduled, continued on Vanc (HD)/Levaquin/Flagyl. 5. R tronchanteric bursitis vs abscess: Seen on CT torso. In extensive discusssion with IR and pt's sister decided not to pursue aggressive needle drainage, as lesion was very small and not clearly an abscess, pt's WBC count was low, highest temp through admission was isolated 100.2, was likely sterilized by the long course of [**Name (NI) **] pt was already on, likely wouldn't change management as pt already on broad spectrum coverage as above, and hesitancy to do invasive procedure. Pt will need f/u CT to assess resolution which should be done at the time of pt's f/u with Dr [**First Name (STitle) **] in [**Month (only) 404**], and has been ordered, to be scheduled. 5. ESRD on HD: Renal made aware and pt received scheduled HD on modified schedule due to holidays once BP was stable. Was to receive HD day after discharge at [**Name (NI) **] [**Name (NI) **], sister had notified facility before discharge. Continued Calcitonin Salmon 200 UNIT NAS DAILY and Lanthanum 250 mg PO/NG [**Hospital1 **]. 6: Social: Pt has numerous medical problems, is immobile and unlikely able to care for self. Had numerous discussion with pt's sister who adamantly did not want pt to go to nursing home or rehab despite repeated offerings and wanted to take her home. [**Name (NI) 1094**] sister denied that they needed any extra help or more services. She feels they could take better care of her at home with the 3 home services (tube feeding, VNA, and private health aide) they receive than at a facility, and so pt was discharged home with resumption of the extensive services she already receives, including wound care for the sacral decube. Pt's PCP was also notified of this admission and the current issues. Also had conversations with pt's sister re: code status given numerous comorbidities, pt currently continues as FULL CODE. 7. Pulmonary nodules: Pt's PCP notified, will need f/u chest CT in 3 mos. 8. Renal cysts: Multiple cysts, with largest being 8mm. Discussed with sister who did not want to pursue aggressive invasive workup at this time. Would recommend f/u CT in 3 mos and consider further workup if indicated. 9. Multinodular goiter/hyperthyroidism: Chronic issue. Pt continued on Methimazole through admission. Seen to have low TSH, normal total T4, and normal fT4. Consider thyroid u/s, Bx if clinically indicated. 10. Loose stool: Seen on day before discharge. Cdiff was negative. Was not copious, WBC's low through admission, single isolated 100.2 fever, and pt currently on Flagyl as above. Any recurrence of diarrhea should prompt re-evaluation for C diff and possible empiric vancomycin. 11. Hypernatremia: Due to free water deficit. Resolved with increased free water boluses through pt's G tube. 12. F/u: Was made with [**Company 191**] discharge clinic [**2115-1-21**], with intention to make f/u appt with pt's PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) **]. Also has ID f/u with Dr. [**First Name (STitle) **] [**2115-2-8**] at which point the CT abd/pelvis (ordered on OMR) should also be done to reassess above issues. Medications on Admission: - Lanthanum 250 mg PO BID - Psyllium 1.7 g Wafer PO BID - Calcitonin 200 unit/Actuation Aerosol Nasal DAILY - Captopril 37.5 mg PO TID - Insulin Glargine 14 SQ DAILY plus HISS - Aspirin 81 mg PO DAILY - Heparin 5,000 units SQ [**Hospital1 **] - Methimazole 10 mg PO DAILY - Simvastatin 20 mg PO QHS - Cipro 750 mg PO DAILY, give after HD on HD days for 6 weeks - Flagyl 500 mg PO TID for 6 weeks - Labetalol 200 mg PO BID (taking as TID) - Ascorbic Acid 500 mg PO BID for 10 days ([**12-26**] to 19/09) - Vitamin A 20,000 units PO DAILY - Polyvinyl Alcohol-Povidone 1.4-0.6% Ophthalmic PRN: eye pain - B Complex-Vitamin C-Folic Acid PO DAILY - Vancomycin 1,000 IV QHD protocol for 6 weeks Discharge Medications: 1. Lanthanum 500 mg Tablet, Chewable Sig: 0.5 Tablet, Chewable PO BID (2 times a day). 2. Psyllium 1.7 g Wafer Sig: One (1) PO twice a day. 3. Calcitonin (Salmon) 200 unit/Actuation Aerosol, Spray Sig: One (1) Nasal DAILY (Daily). 4. Insulin Glargine 100 unit/mL Solution Sig: Fourteen (14) Units Subcutaneous once a day: Please take 14U Glargine subcutaneously daily, and slidine scale as you were before admission. . 5. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 6. Methimazole 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Vancomycin 1,000 mg Recon Soln Sig: One (1) Intravenous After HD session on HD days, per HD protocol for 6 weeks: Please continue your 6wk course of antibiotics that you were on before admission. . 8. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours): Please continue your 6wk course of antibiotics as you were before admission. . 9. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q48H (every 48 hours): Please continue your 6wk course of antibiotics as you were before admission. NOTE: This was prescribed at last ID visit [**2115-1-4**] and is waiting for you. Dr. [**Last Name (STitle) **] spoke with your CVS on [**Hospital1 1426**], the prescription is there and you need to go pick it up. . 10. Labetalol 200 mg Tablet Sig: One (1) Tablet PO twice a day. 11. Vitamin A 10,000 unit Tablet Sig: Two (2) Tablet PO once a day. 12. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Capsule PO once a day. 13. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: One (1) Ophthalmic PRN as needed for eye pain. 14. needs CT scan on [**2115-2-8**] Will need repeat CT abd/pelvis to assess R tronchanteric abscess collection on same day as next ID f/u on [**2115-2-8**]. Order is in OMR. Discharge Disposition: Home With Service Facility: [**Hospital **] Healthcare Discharge Diagnosis: Active diagnoses this admission: 1. Hypotension, unknown etiology, possibly medicine effect 2. Subacute R fronto parietal hypodensity, concern for CVA 3. R trochanteric bursitis vs abscess 4. Stage IV sacral decubitis ulcer tracking to bone, osteomyelitis 5. ESRD on HD Discharge Condition: Alert but very minimally verbal, unable to answer questions coherently, minimally mobile. Discharge Instructions: You were admitted to [**Hospital1 18**] after a period of unresponsiveness and hypotension. You were admitted to the intensive care unit but did not require aggressive care to maintain your blood pressure, which responded to IV fluids. You had a CT scan of your head which showed an area of possible subacute stroke, but it was decided to not to aggressively pursue workup for this and to watch this for now. You also had a CT of your torso which showed several findings including an area of concern near your right hip. This was not felt to be amenable to drainage with a needle and will be presently only watched. Your hypotension could possibly have been due to too many blood pressure lowering medications, and we have decided to stop one of your medications called Captopril. We have also stopped another of your medicines called Simvastatin, and increased the dose of Aspirin from 81 mg daily to 325 mg daily. We also changed one of your antibiotics from Ciprofloxacin to Levofloxacin. Otherwise, you should continue your medicines as you have been prescribed them. Followup Instructions: Please follow up with: MD: Dr. [**First Name (STitle) **] [**Name (STitle) **] Specialty: [**Hospital3 **] Post [**Hospital **] Clinic Date/ Time: [**Last Name (LF) 766**], [**1-21**] at 1:50pm Location: [**Hospital3 **], [**Hospital Ward Name 23**] Clinical Center, [**Apartment Address(1) **] Central, [**Location (un) 830**], [**Location (un) 86**] Phone number: [**Telephone/Fax (1) 250**] Special instructions for patient: This appointment is for follow up to your hospitalization. You will then be connected to your Primary Care provider after this visit. Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 288**], MD Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2115-2-8**] 10:30. Note: You will need a CT scan of your abdomen and pelvis before this appointment. The order has been put into our system and you will be contact[**Name (NI) **] to schedule a time. Completed by:[**2115-1-12**]

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icd9cm

[ [ [] ] ]

[ "38.93", "93.56", "39.95" ]

icd9pcs

[ [ [] ] ]

20463, 20520

11625, 12609

348, 386

20834, 20925

4397, 4397

22047, 22973

3770, 3862

18631, 20440

20541, 20813

17917, 18608

20949, 22024

5226, 11602

3877, 4378

1938, 2386

280, 310

414, 1919

4414, 5209

12624, 17890

2408, 3296

3313, 3753

3,868

107,312

44128

Discharge summary

report

Admission Date: [**2125-10-23**] Discharge Date: [**2125-11-5**] Date of Birth: [**2060-7-29**] Sex: F Service: MEDICINE Allergies: Penicillins / Linezolid / Morphine / Oxycodone Attending:[**First Name3 (LF) 338**] Chief Complaint: Tranferred from rehab for replacement of J tube and elevated creatinine Major Surgical or Invasive Procedure: [**10-26**] J tube placement Arterial line Midline PICC History of Present Illness: The patient is a 65 yo F with multiple medical problems including HTN/DM/PVD, recent chylothorax, pancreatitis s/p necrosectomy, s/p trach and PEG whose recent hospitalization was from [**2125-7-13**] - [**2125-9-28**]. She was sent to rehab and is coming in today with a rising creatinine and malpositioned J tube. . Briefly, the patient originally presented to [**Hospital1 18**] in [**2125-5-15**] for a repair of an innominate aterial aneurysm. She was discharged to rehab but returned on [**2125-6-14**] with respiratory distress and sepsis. During this hospital course she had a PEA arrest, inferior MI, and upper extremity DVT. She was ultimately transferred to [**Hospital1 **] on [**2125-6-29**] on a 4 week course of daptomycin for VRE/MRSA infection. She was readmitted to [**Hospital1 18**] on [**2125-7-12**] after being found to have new neurological symptoms. Eventually, she was diagnosed with severe brain injury. She had a number of complications during this hospital course. She developed a chylothroax and required multiple procedures including a right VATS, thoracic duct [**Last Name (LF) 94710**], [**First Name3 (LF) **] duct embolization, talc pleurodesis, and decortication. She was trach'd and PEG'd on [**2125-8-8**]. She unfortunately the developed near total pancraetic necrosis that required pancreatic debridement and necrosectomy and abdominal drainage of numerous absecesses. She was bacteremia on pressors at numerous points during her hospital course. She was discharged to [**Hospital1 **] again on [**2125-9-28**] with plans to complete a 14 day course of daptomycin for VRE/MRSA and continue weaning from the vent if possible. . While at [**Hospital1 **], the patient continued to have full body anasarca and was aggressively diuresed with a rise in her creatine over time from 0.9 to 3.4. Prior to transfer to [**Hospital1 18**] her lasix was being held. Also, her PEG jeujunostomy tube came out and reposition was attempted. She was transferred to [**Hospital1 18**] for replacement of her peg jeujunostomy tube. Past Medical History: -- DM2 -- chronic foot ulcers/PVD -- HTN -- Osteoarthritis -- Obesity -- Asthma -- leg pain/neuropathy -- Depression -- Anemia -- h/o MRSA bacteremia [**11-18**], also septic arthritis -- Right thalamic hemorrhage resulting in a gait disorder and incontinence of urine, followed by Dr. [**Last Name (STitle) **]. -- Hypercholesterolemia. -- Right VATS and thoracic duct ligation [**2125-7-20**] -- Thoracic duct embolization and talc pleurodesis [**2125-7-27**] -- Tracheostomy and percutaneous endoscopic gastrostomy [**2125-8-8**] -- Exploratory laparotomy, pancreatic necrosectomy, gastrostomy tube [**2125-8-22**] -- Exploratory laparotomy, abdominal wash out [**2125-8-23**] -- Exploratory lap, takedown gastrostomy, debride necrotic pancreas and multiple retroperitoneal abscesses [**2125-8-25**] -- Abdominal closure and vac dressing application [**2125-8-26**] -- Left thoracotomy and decortication, flexible bronchoscopy [**2125-9-19**] -- Aorto innominate and left carotid bypass [**2125-5-22**] -- Left carotid to left subclavian bypass using 8 mm PTFE and thoracic aortic stent graft placement [**2125-5-23**] Social History: Currently living at [**Hospital1 **] after a prolong hospital course. Has seven children, many grandchildren. Family History: Brother died of an MI in his 30's, she denies diabetes mellitus in the family. Cancer in parents (mother died in 40s, father in 80s), at least two siblings, but unsure what kind. Physical Exam: Vitals - HR89 BP 144/32 RR16 O298% on Vent FIO2 100% General - obese african american female, lying in bed HEENT - PERRL, patient not following commands Neck - trach in place CV - regular rate, distant heart sounds Lungs - clear to auscultation bilaterally Abdomen - obese, G/J tube in place; large midline incision with VAC (healing well, no signs of infection) Ext - + edema Pertinent Results: Admission labs: [**2125-10-23**] 06:17PM BLOOD WBC-13.1* RBC-3.19*# Hgb-9.7* Hct-28.1* MCV-88 MCH-30.5 MCHC-34.6 RDW-16.0* Plt Ct-67* [**2125-10-23**] 06:17PM BLOOD Neuts-95* Bands-5 Lymphs-0 Monos-0 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 [**2125-10-23**] 06:17PM BLOOD PT-13.7* PTT-30.5 INR(PT)-1.2* [**2125-10-23**] 06:17PM BLOOD Glucose-144* UreaN-160* Creat-3.6*# Na-138 K-4.2 Cl-99 HCO3-20* AnGap-23* [**2125-10-25**] 07:10PM BLOOD ALT-63* AST-47* LD(LDH)-297* CK(CPK)-16* AlkPhos-484* TotBili-0.3 [**2125-10-25**] 07:10PM BLOOD CK-MB-NotDone cTropnT-0.41* [**2125-10-26**] 04:20AM BLOOD CK-MB-NotDone cTropnT-0.37* [**2125-10-26**] 04:20AM BLOOD CK(CPK)-17* [**2125-10-23**] 06:17PM BLOOD Calcium-9.8 Phos-5.0* Mg-2.8* [**2125-10-24**] 10:19AM BLOOD Type-ART pO2-146* pCO2-31* pH-7.39 calTCO2-19* Base XS--4 [**2125-10-26**] 04:24AM BLOOD Lactate-1.0 [**2125-10-26**] 04:24AM BLOOD freeCa-1.16 Hospital course labs: [**2125-11-4**] 04:50AM BLOOD WBC-8.5 RBC-3.42* Hgb-10.3* Hct-29.9* MCV-88 MCH-30.0 MCHC-34.3 RDW-16.0* Plt Ct-45* [**2125-11-4**] 04:50AM BLOOD Plt Ct-45* [**2125-11-1**] 04:26AM BLOOD PT-13.7* PTT-30.1 INR(PT)-1.2* [**2125-11-4**] 04:50AM BLOOD Glucose-124* UreaN-169* Creat-5.4* Na-146* K-4.3 Cl-114* HCO3-14* AnGap-22* [**2125-10-30**] 04:12AM BLOOD ALT-29 AST-13 LD(LDH)-227 AlkPhos-275* Amylase-41 TotBili-0.3 [**2125-10-30**] 04:12AM BLOOD Lipase-68* [**2125-11-4**] 04:50AM BLOOD Calcium-8.6 Phos-4.0 Mg-2.4 [**2125-10-30**] 04:12AM BLOOD Albumin-2.0* Calcium-8.7 Phos-4.0 Mg-2.2 [**2125-10-31**] 06:08PM BLOOD TSH-31* [**2125-10-31**] 06:08PM BLOOD Free T4-0.53* [**2125-10-29**] 05:43PM BLOOD Cortsol-43.8* [**2125-10-29**] 04:54PM BLOOD Cortsol-41.4* [**2125-10-29**] 04:31PM BLOOD Cortsol-25.2* [**2125-10-27**] 01:53PM BLOOD Type-ART Temp-36.2 Rates-/28 FiO2-50 pO2-90 pCO2-34* pH-7.20* calTCO2-14* Base XS--13 Intubat-INTUBATED [**2125-11-2**] 10:07AM BLOOD Type-ART pO2-138* pCO2-31* pH-7.30* calTCO2-16* Base XS--9 [**2125-10-28**] 04:55AM BLOOD Lactate-3.2* [**2125-11-2**] 10:07AM BLOOD Lactate-1.2 Brief Hospital Course: 65yo F c complex medical history, who is s/p a prolonged hospital course complicated by sepsis, pancreatic necrosis requiring pancreatic necrosectomy, and cylothorax requiring numerous surgical procedures, presented from rehab with malpositioned J tube and an elevated creatinine. She was admitted to the MICU because she was chronically ventilated/trached. Her J tube was replaced by IR on [**10-26**] without compications. She had limited to no cognative response during her MICU course. During her complicated MICU course, she developed worsening renal failure and a GI bleed along with a rising WBC count and hypotension. After many family discussions including with her HCP daughter, it was decided to not escalate care on [**11-2**]. On [**11-5**] the family decided to make her DNR/DNI and begin comfort care. Her vent was turned to room air settings with minimal pressure support. She was started on a morphine drip and the patient passed away. Family requested autopsy. Her course was complicated by the following: # Respiratory Failure - s/p trach in [**7-21**]. She had difficulty weaning off the vent at rehab and was continued to be 24 hour vent dependent at the time of transfer to [**Hospital1 18**]. # ID - s/p course of Synercid, Meropenem, and Caspofungin (finished on [**2125-10-5**]) prior to hospitalization. Patient likely colonized with multiple resistant organisms. WBC recently declined on Meropenem for Proteus UTI and was started on bactrim on [**2125-10-31**] for Stenotrophomonas infection. She developed proteus UTI and pneumonia along with MRSA pneumonia. She had a pleural vac inplace on admission which had fluid draining which was growing VRE and MRSA. She was on vanco and meropenem. She still had an abdominal vac inplace s/p pancreatic surgery. # ARF - Etiology likely prerenal and progressed to ATN. She continued to have rising creatinine and uremia. Renal consult was called and many discussions were held regarding the utility of hemodialysis for her. Ultimately, it was decided on [**2125-11-2**] with HCP daughter not to escalate care. In addition, it was felt by the renal consult team and the primary team that HD was not medically indiacated given poor prognosis and lack of bridge to intermittent HD. # Anemia - Patient required several units of PRBCs to keep HCT above 21. During her hospitalization she began to pass clots per her rectum. GI was consulted and it was decided that the risk of endoscopy was greater than the benefits at that time. # Hypothyroid - continued synthroid and increased dose and gave it IV as her TSH was above 30 and it was thought that her GI absorption was very poor. # Diabetes - continued insulin # skin - several areas of breakdown without signs of infection. FEN - tube feeds PPx - PPI, bowel regimen Access - midline, a-line, EJ Code - DNR, no pressors; family meeting again on [**2125-11-2**]- family decided to not escalate care. Will continue current care. If patient decompensates, will call family and change to morphine and ativan to help keep her comfortable and will stop all other care. Contact - daughter/HCP, [**Name (NI) **] [**Name (NI) 1557**] Cell [**Telephone/Fax (1) 94711**]; home - [**Telephone/Fax (1) 94712**] . Medications on Admission: Mucomyst nebs [**Hospital1 **] Vitamin C 500mg [**Hospital1 **] Bacitracin to the PEG site Colace 100mg [**Hospital1 **] Advair HFA 1 puff [**Hospital1 **] Heparin SQ TID Regular ISS Synthroid 50mcg via PEG daily MVI daily Accuzyme topically daily to the wounds Beneprotein 1 scoop daily Senna daily Zinc sulfate 220mg via tube daily Tylenol 650mg PRN Atrovent and Albuterol q2 PRN Aspirin 325mg daily Dulcolax 10mL PR daily Glycerine suppository PR PRN Lactulose 20grams daily PRN Reglan 10mg via tube q4 PRN Nitroglycerin PRN Seroquel 12.5mg q12 PRN - has not needed at [**Hospital1 **] Discharge Medications: none Discharge Disposition: Expired Discharge Diagnosis: expired Discharge Condition: expired Discharge Instructions: none Followup Instructions: none Completed by:[**2125-12-13**]

[ "041.6", "518.81", "V44.0", "585.6", "584.9", "578.9", "997.4", "038.9", "280.0", "287.5", "995.92", "263.9", "403.91", "278.01", "348.1", "276.51", "599.0" ]

icd9cm

[ [ [] ] ]

[ "96.6", "44.32", "96.72", "38.93" ]

icd9pcs

[ [ [] ] ]

10367, 10376

6467, 9698

379, 436

10427, 10436

4404, 4404

10489, 10525

3810, 3991

10338, 10344

10397, 10406

9724, 10315

10460, 10466

4006, 4385

268, 341

464, 2520

4420, 6444

2542, 3667

3683, 3794

29,928

114,547

30189

Discharge summary

report

Admission Date: [**2154-3-12**] Discharge Date: [**2154-3-16**] Date of Birth: [**2083-10-5**] Sex: F Service: ORTHOPAEDICS Allergies: Sulfa (Sulfonamides) / Ciprofloxacin Attending:[**First Name3 (LF) 64**] Chief Complaint: left hip pain Major Surgical or Invasive Procedure: left total hip replacement History of Present Illness: Dr. [**First Name8 (NamePattern2) 712**] [**Name (STitle) 713**], one of the physicians at the [**Hospital **] Clinic and [**Hospital1 18**] geriatrics division has referred [**Known firstname 2127**] [**Known lastname 59866**] to me for evaluation and treatment of her arthritic left hip. She had seen Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] here in the past for unrelated issues. [**Known firstname 2127**] is 69. She states that she has had progressive pain in this hip, which she feels in the groin over a number of years. It is increasingly painful with walking, standing, or transitioning. She rates the pain at rest as [**1-6**], with activity [**2156-6-3**]. She has been taking Tylenol and occasional anti-inflammatories for pain but prefers not to take medications. She is more interested at this point in surgical options. Past Medical History: Insulin-dependent diabetes, hypertension, urinary tract infections. Social History: Traces her heritage back to [**Country 5881**]. Nonsmoker since [**2149**], drinks occasional alcohol. Family History: Positive for pancreatic cancer in father and brother, bacterial endocarditis in mother, nephrolithiasis mother. Physical Exam: A 5 feet 2 inches, 199 pounds female, moderate obesity. Blood pressure 131/68, pulse 64, and normal sinus rhythm. Focal examination of the hip demonstrates good vascular inflows at the pedal and popliteal level. She has 10 degrees of external rotation, 5 degrees of internal rotation. She can be flexed to about 110 degrees through the left hip with pain in the last 20 degrees. Full extension without hyperextension, 4+/5 strength throughout the hip girdle limited by pain. Pertinent Results: [**2154-3-12**] 04:09PM PLT COUNT-278 [**2154-3-12**] 04:09PM WBC-16.4*# RBC-4.00* HGB-11.3*# HCT-32.9* MCV-82 MCH-28.2 MCHC-34.4 RDW-14.2 [**2154-3-12**] 04:09PM CALCIUM-8.6 PHOSPHATE-4.0 MAGNESIUM-1.7 [**2154-3-12**] 04:09PM estGFR-Using this [**2154-3-12**] 04:09PM GLUCOSE-132* UREA N-17 CREAT-0.8 SODIUM-143 POTASSIUM-3.4 CHLORIDE-105 TOTAL CO2-28 ANION GAP-13 Brief Hospital Course: Pt was admitted following the above mentioned procedure - please see op report for details. Pt was maintained on a PCA post-operatively, and on POD1 the PCA malfunctioned and she received an erroneously large dose of IV dilaudid, resulting in respiratory depression and sedation. Seh recieved several doses of Narcan and was transferred to the ICU temporarily due to her extreme sedation. She was transferred back to the floor later on POD1. After this, her pain was treated with tylenol and oxycodone. Her hemovac was d/c'd on POD1, and her foley catheter was d/c'd on POD3. She worked with PT while in-house, being 50% WB on her left leg withou active abduction. She received lovenox while in-house and on discharge for DVT prophylaxis. She was discharged to rehab afebrile, in stable condition, to follow-up with Dr. [**Last Name (STitle) **] as scheduled. Medications on Admission: humulin 38U qAM/40U qHS, humalog 15U qPM, atenolol 25', amoldipine 10', HCTZ 25', nitrofurantoin 50', KCl 20', ASA 81', fish oil, probiotic Discharge Medications: 1. Enoxaparin 40 mg/0.4 mL Syringe Sig: One (1) syringe Subcutaneous DAILY (Daily) for 3 weeks. Disp:*21 syringe* Refills:*0* 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. Atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Nitrofurantoin Macrocrystal 50 mg Capsule Sig: One (1) Capsule PO HS (at bedtime). 7. Hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 8. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 9. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times a day). 10. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily). 12. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours). 13. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. 14. Insulin Regular Human 300 unit/3 mL Insulin Pen Sig: as directed Subcutaneous as directed: NPH 38 Units NPH 40 Units Humalog 15 Units Insulin SC Sliding Scale Breakfast Lunch Dinner Bedtime Humalog Humalog Humalog Humalog Glucose Insulin Dose Insulin Dose Insulin Dose Insulin Dose 0-60 mg/dL [**11-28**] amp D50 [**11-28**] amp D50 [**11-28**] amp D50 [**11-28**] amp D50 61-200 mg/dL 0 Units 0 Units 0 Units 0 Units 201-250 mg/dL 2 Units 2 Units 2 Units 2 Units 251-300 mg/dL 4 Units 4 Units 4 Units 4 Units 301-350 mg/dL 6 Units 6 Units 6 Units 6 Units 351-400 mg/dL 8 Units 8 Units 8 Units 8 Units > 400 mg/dL 10 Units 10 Units 10 Units 10 Units Instructons for NPO Patients: 1/2 dose . Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - MACU Discharge Diagnosis: left hip OA Discharge Condition: stable Discharge Instructions: the following: chest pain, shortness of breath, severe nausea/vomiting, fever greater than 101F, increasing redness or drainage from your incision sites, or any other concerning symptoms. You should take all medications as prescribed. You should be 50% WB on your left leg with no active abduction for 6 weeks. Physical Therapy: 50% weight-bearing with posterior precautions Treatments Frequency: local wound care with dry sterile dressings daily until incision dry lovenox injections daily Followup Instructions: follow-up with Dr. [**Last Name (STitle) **] in 2 weeks Completed by:[**2154-3-16**]

[ "E849.7", "250.00", "E879.8", "278.00", "996.74", "348.8", "965.09", "V58.67", "V13.02", "715.35", "E850.2" ]

icd9cm

[ [ [] ] ]

[ "00.77", "81.51" ]

icd9pcs

[ [ [] ] ]

5426, 5492

2502, 3371

313, 342

5548, 5557

2102, 2479

6096, 6183

1472, 1586

3561, 5403

5513, 5527

3397, 3538

5581, 5892

1602, 2083

5910, 5956

5978, 6073

260, 275

370, 1242

1264, 1334

1350, 1456

81,694

131,321

42750

Discharge summary

report

Admission Date: [**2105-2-23**] Discharge Date: [**2105-2-24**] Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**Last Name (NamePattern4) 290**] Chief Complaint: Intracranial hemorrhage Major Surgical or Invasive Procedure: None History of Present Illness: 88yoM with chronic atrial fibrillation, CAD s/p MI x3, HTN, DLP, CKD, hypothyroidism, who presented to [**Hospital6 **] with an intracranial hemorrhage, transferred to [**Hospital1 18**] per family's request for further management. . The patient's symptoms began on Saturday when he developed a headache, syncopal episode, and left sided facial droop at 9:30pm and experienced persistent neurologic deficits, so presented to [**Hospital6 **] ED on [**2105-2-21**]. He was found to have L arm weakness, L hemineglect, and slurred speech and a code stroke was called. Initial head CT in the ED showed equivocal hypodensity of the right lateral-inferior temporal lobe with MRI correlation suggested, but given recent sphincterotomy and comorbidities, the decision was made not to give tpa and MRI was not obtained. INR was subtherapeutic at 1.3. While in the ED, the patient subsequently complained of chest pain and was given SL Nitro without improvement. He was found to be in afib and initial troponins showed trop 0.24, ck-mb 2.3, ck 43, BNP 437. CXR showed pulmonary vascular congestion and he was given Lasix. BP continued to be elevated and he was placed on a nitro gtt. The patient then began to experience periods of apnea and was started on bipap and admitted to the ICU and intubated. Heparin gtt was started, nitro gtt was stopped, and Propofol and neosynephrine gtts were started. He was continued on his Coumadin. He was found to have altered mental status the following day on Sunday [**2-22**] by the Neurology resident, with loss of brainstem reflexes and fixed and dilated pupils. Repeat CT head [**2-22**] showed extensive acute right temporal parietal hemorrhage extending into the basal ganglia, 2.2 cm midline shift, and transtentorial herniation. Neurosurgery determined the patient was not a surgical candidate. He was loaded with digoxin for HR 140's -150's. The patient's family requested transfer to [**Hospital1 18**], and the patient was transferred for further evaluation and management. . On arrival to the MICU, the patient was unresponsive to verbal and physical stimuli. Past Medical History: - Chronic AF - CAD, s/p septal MI '[**71**], '[**9-10**] - Mitral regurgitation - Aortic regurgitation - HTN - Dyslipidemia - LBBB - CKD - Gouty arthritis - Hypothyroidism - fatty mass in the left mid abdomen (possible liposarcoma but declined further w/u) Social History: married, lives with wife. no tobacco, no etoh, no illicits. He is independent of ADLS and IADLS. He walks without a cane or a walker. His son has no concerns about him returning home to live with his wife upon discharge. No recent falls. His son is HCP - [**Name (NI) **] [**Telephone/Fax (1) 92374**] Family History: Mother - unknown Father - unknown Siblings - decesased sister, old age Children - my patient, Sofya Bentsman, HTN, lipids Physical Exam: Vitals: 100.3 74 95/36 PO2 96% on TV 500 RR 14 PEEP 5 FIO2 50% General: Unresponsive to verbal or physical stimuli on ventilator HEENT: Fixed, dilated pupils b/l, sclera anicteric, MM dry, ETT in place Neck: L IJ in place CV: Irregularly irregular, normal S1 + S2, no murmurs, rubs, gallops Lungs: Equal anteriorly and bilaterally without significant wheezing or rales Abdomen: Soft, non-tender, non-distended, hypoactive bowel sounds Ext: No cyanosis or pedal edema, warm to touch Neuro: Unresponsive to verbal or physical stimuli, fixed dilated pupils, no brainstem reflexes Pertinent Results: [**2105-2-23**] 09:10PM PT-23.6* PTT-34.4 INR(PT)-2.3* [**2105-2-23**] 09:10PM PLT SMR-NORMAL PLT COUNT-168 [**2105-2-23**] 09:10PM HYPOCHROM-1+ ANISOCYT-NORMAL POIKILOCY-OCCASIONAL MACROCYT-2+ MICROCYT-NORMAL POLYCHROM-NORMAL OVALOCYT-OCCASIONAL [**2105-2-23**] 09:10PM WBC-20.0*# RBC-5.17 HGB-16.0 HCT-51.3# MCV-99* MCH-31.0 MCHC-31.2 RDW-14.4 [**2105-2-23**] 09:10PM CALCIUM-9.1 PHOSPHATE-1.8* MAGNESIUM-2.5 [**2105-2-23**] 09:10PM CK-MB-7 cTropnT-0.34* [**2105-2-23**] 09:10PM CK(CPK)-503* [**2105-2-23**] 09:10PM GLUCOSE-77 UREA N-28* CREAT-2.5*# SODIUM-165* POTASSIUM-4.2 CHLORIDE-132* TOTAL CO2-22 ANION GAP-15 Imaging: CXR: FINDINGS: As compared to the previous radiograph, the previously positioned left internal jugular vein catheter has been substantially pulled back. Catheter tip is now positioned in the left cervical region. The catheter needs to be repositioned. No evidence of complications. Otherwise, unchanged radiograph. The endotracheal tube and nasogastric tube are constant. Brief Hospital Course: 88yoM with chronic atrial fibrillation, CAD s/p MI x3, HTN, DLP, CKD, hypothyroidism, who presented to [**Hospital6 **] with an intracranial hemorrhage, transferred to [**Hospital1 18**] for further management. #. Intracranial hemorrhage: The patient has significant ICH with marked midline shift and herniation with fixed, dilated pupils and without brainstem responses. Neurology and neurosurgery evaluated the patient on admission, and given the absence of brainstem reflexes, the patient was deemed to have no recoverable neurologic function. It was decided to have no escalation in care and patient ultimately became hypotensive and developed asystole and passed away. Death Note: Called to see patient for unresponsiveness. On exam the patient did not respond to verbal or physical stimuli. Absent heart and breath sounds. Absent peripheral pulses. Pupils are fixed and dilated. Patient pronounced dead at 12:43. Dr. [**First Name (STitle) **] notified. Family at bedside and aware. Medical examiner Dr. [**Last Name (STitle) **] declined examination. Autopsy declined by family. Medications on Admission: - Carvedilol 6.25 mg tid - Verapamil 80 mg Q8h - Furosemide 60 mg daily - Irbesartan 300 mg daily - Atorvastatin 10 mg daily - Finasteride 5 mg daily - Levothyroxine 137 mcg daily - Coumadin daily - Omeprazole 20 mg daily Discharge Medications: None Discharge Disposition: Expired Discharge Diagnosis: Death Discharge Condition: Death Discharge Instructions: None Followup Instructions: none [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]

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icd9cm

[ [ [] ] ]

[ "96.71" ]

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40728

Discharge summary

report

Admission Date: [**2113-8-18**] Discharge Date: [**2113-8-25**] Date of Birth: [**2047-11-24**] Sex: M Service: NEUROLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 7575**] Chief Complaint: Seizure Major Surgical or Invasive Procedure: Lumbar puncture History of Present Illness: The pt is a 65y/o man with a history of HLD and Hypothyroidism who presents to [**Hospital1 18**] ED with a seizure intubated in the field. He was at work today (landscaper) driving his truck when he made a left hand turn and did not stop turning left and then crashed. When EMS arrived he was alert and talking and then he started to have a generalized convulsive seizure with witnessed left gaze deviation. he was intubated and taken to the ED. Here he was seen intubated on midazolam and fentanyl. His wife who is at the bedside notes that he was generally healthy and has not been complaining of anything and has never noted any seizure like activity including any behavioral arrest. Past Medical History: HLD Hypothyroidism Social History: ex smoker 20 years ago Family History: No seizures or cancers Physical Exam: On admission: Physical Exam: Vitals: T: 101.4 P: 88 R: 16 BP:138/88 SaO2:99% General: Intubated sedated. HEENT: not visualized. no LAD. Neck: No nuchal rigidity Pulmonary: crackles b/l Cardiac: RRR, nl. S1S2 Abdomen: soft, NT/ND. Extremities: No C/C/E bilaterally. Skin: no rashes or lesions noted. Neurologic: - Intubated and sedated. Off sedation only for a short period of time given that he was bucking the vent. He was not able to open his own eyes, when helped open he was able to gaze towards me (right side) for a very brief period, otherwise his gaze was in primary position with no skew. He had a couch and gag. Corneal were present. Dolls present. Was ? showing me 2 fingers with the right hand. Able to squeeze his hand on command but did not follow the command stop squeezing. Was spontaneously moving his right lower extremity flexing at the knee and hip. tone was normal throughout. The Left side he moved slowly and with less power. Also able to squeeze with his left hand but not show me two fingers. He was able to withdraw to pain on the left and was localizing with the right. Mute toe on the left and down on the right. No active movements seen. reflexes suppressed 0-1 throughout. Pertinent Results: CSF: [**2113-8-24**] 01:20PM CEREBROSPINAL FLUID (CSF) WBC-1 RBC-1* Polys-0 Lymphs-78 Monos-22 [**2113-8-24**] 01:20PM CEREBROSPINAL FLUID (CSF) TotProt-33 Glucose-68 LD(LDH)-17 Cytology: ATYPICAL. Hypercellular specimen with predominantly small lymphocytes and occasional larger lymphocytes. Blood: [**2113-8-18**] 12:55PM BLOOD WBC-4.8 RBC-4.09* Hgb-13.0* Hct-37.1* MCV-91 MCH-31.7 MCHC-34.9 RDW-13.7 Plt Ct-284 [**2113-8-18**] 12:55PM BLOOD PT-12.2 PTT-20.7* INR(PT)-1.0 [**2113-8-18**] 12:55PM BLOOD UreaN-20 Creat-0.9 [**2113-8-20**] 10:40AM BLOOD ALT-16 AST-20 LD(LDH)-189 AlkPhos-52 TotBili-1.0 [**2113-8-19**] 01:47AM BLOOD Calcium-8.0* Phos-3.5 Mg-2.1 Cholest-184 [**2113-8-19**] 01:47AM BLOOD Triglyc-114 HDL-61 CHOL/HD-3.0 LDLcalc-100 [**2113-8-20**] 10:40AM BLOOD TSH-0.83 [**2113-8-22**] 05:10AM BLOOD HIV Ab-NEGATIVE MRI Head: Right frontal signal abnormality with a central portion of restricted diffusion is not typical for an infarction and is predominantly involving the white matter. The restricted diffusion could favor infiltrative lesion with high cellularity such as lymphoma or encephalitis. Differential diagnosis could also include PML if there is history of immunocompromised status. PET CT Scan: 1. Right frontal infiltrative white matter predominant leison without significant increase in FDG avidity as compared to background physiologic [**Doctor Last Name 352**] matter uptake, not necessarily excluding neoplasm in the differential consideration. 2. FDG avid retroperitoneal adenopathy largest conglomerate aortocaval in location, but also involving periportal and retrocaval stations. CT Torso: 1. Suboptimal contrast bolus. Given this, no evidence acute injury to the chest, abdomen, or pelvis. 2. Large retroperitoneal mass which likely represents lymph node conglomerate. Several other prominent nodes surrounding the right kidney and porta hepatis concerning for malignancy. 3. Bibasilar opacities consistent with atelectasis and possiblyaspiration. Small amount of material in the trachea consistent with aspirated contents. CT Cspine: 1. No acute fracture or dislocation. 2. Gas tracking along the retropharyngeal space,as above. Findings could relate to a traumatic intubation. However, other injury to the trachea or esophagus cannot be completely excluded on the basis of this study. Brief Hospital Course: This is a 65yo M with hypothyroidism and hyperlipidemia who sustained an MVA after not being able to stop from turning left. Later at the scene, EMS noticed him to have a GTC with left gaze deviation. For airway protection, he was intubated in the ER and started on a fentanyl/versed drip, keppra loaded and subsequently been seizure free. He was successfully extubated and transferred out of the ICU. A routine C-spine CT scan performed to clear his C-spine identified the presence of air tracking in the retropharyngeal space, and for this, he received 7 days of broadspectrum antibiotic therapy (IV). A head CT scan at the [**Hospital1 18**] ER showed the presence of a right frontal mass, which was subsequently further characterized on MRI as being FLAIR hyperintense and non-contrast enhancing, and on the differential diagnosis includes primary CNS lymphoma versus a metastatic lesion or gliosis/glioma of some type. At the same time, a trauma protocol torso CT scan identified a series of nodes in his retroperitoneum concerning for malignancy. The oncology, general surgery and neurosurgery teams were consulted. While oncology recommended an excisional lymph node biopsy over a brain biopsy, the nodes in his abdomen were thought to be in too delicate a location (between his IVC, aorta and duodenum) to be easily sampled without a a high risk open laparotomy. An LP was performed, and on cytological analysis, he was found to have hypercellular atypical lymphocytes that could occur with a number of benign and malignant processes. Flow cytometry analysis on that sample is still pending. Ultimately, it was decided to discharge the patient home with follow up as noted below. The patient was instructed to come to the neurology clinic if he had not been contact[**Name (NI) **] by the NSG department directly for a brain biopsy admission. On discharge, he was afebrile and hemodynamically stable. His neurological exam was normal, including tests of frontal lobe dysfunction. He only complained of a sore throat, otherwise he was largely well appearing without any other specific complaints. Medications on Admission: Synthroid 25ug daily Atorvastatin 20mg daily Discharge Medications: 1. Cepacol Sig: [**2-5**] Mucous membrane every four (4) hours as needed for Sore throat. Disp:*60 * Refills:*0* 2. levetiracetam 500 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). Disp:*360 Tablet(s)* Refills:*2* 3. atorvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day. 4. Synthroid 25 mcg Tablet Sig: One (1) Tablet PO once a day. 5. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Retroperitoneal lymphadenopathy Right frontal brain mass Seizure disorder Hypothyroidism Hyperlipidemia Discharge Condition: Discharge Condition: Stable Mental Status: Awake, alert and oriented. Memory and language is intact, speech is of normal volume and fluent. Neurological exam: Nonfocal, nonlateralizing Discharge Instructions: You were admitted to the [**Hospital1 18**] for an evaluation of your seizures. We found a large mass on the right side of your brain that likely led to your seizures, and that likely is a malignancy/cancer. Additionally, we observed a series of enlarged lymph nodes in your abdomen that is concerning for cancer. You were intubated (breathing tube placed) for one day, and you received antibiotics for a total of seven days for some trauma in your throat that you sustained during that process. We performed a lumbar puncture on your spine which did not show an obvious infection. We are awaiting a formal pathological investigation of that fluid. You were seen by numerous specialists, including members of the general surgery, neurooncology, neurology and neurosurgery teams. Followup Instructions: We will call you with a time for the brain biopsy next week (likely [**8-30**]) If you are not readmitted by then, please come to the [**Hospital 878**] Clinic [**Location (un) **] of the [**Hospital Ward Name 23**] Building on [**8-30**], [**2113**], 4:00PM Drs. [**Last Name (STitle) **], [**Name5 (PTitle) 2442**] Completed by:[**2113-8-27**]

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icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

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314, 332

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6980, 7513

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1108, 1133

11,722

139,428

12859

Discharge summary

report

Admission Date: [**2139-8-9**] Discharge Date: [**2139-8-15**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2387**] Chief Complaint: Melena, Chest Pain Major Surgical or Invasive Procedure: Cardiac Catheterization with PTCA to the left circumflex and Vision BMS to the LAD History of Present Illness: 87 [**Female First Name (un) **] old male with history of coronary artery disease with drug eluding stents, chronic obstructive pulmonary disease, type II diabetes, h/o diverticulosis, now presenting with 3-4 days of melena and left sided chest pain. Patient initially presented this AM to [**Hospital6 **] after noting dark stools for the last few days. Patient states that a few days ago, he felt that his gout had been acting up in his right arm and hand, and his PCP prescribed him allopurinol. Shortly after starting the medication, he noted dark stools and called his PCP. [**Name10 (NameIs) **] dose was decreased from 300 mg daily to 200 mg daily, but he continued to have dark stools. He then stopped the medication 2 nights ago because he was concerned from the melena. He continued to note a few more dark stools, the last of which was at 6 AM this morning, which prompted him to go to [**Hospital 31145**]. At the OSH, they felt he was slightly volume overloaded, and he was given lasix for diuresis. He was also having chest pain, and ECG had TWIs, changed from prior, so he was transferred to [**Hospital1 18**] for further evaluation. The patient's chest pain is not different than his usual pain. He states that over the last few weeks, he's noted a few more episodes per week of a chest "discomfort". He cannot fully characterize the pain, but thinks it may be more like a "pressure". He denies radiation of the pain, nausea, or vomiting. He usually takes 1 NTG which resolved the pain. This AM, he also took 1 NTG which resolved the pain as well. In the ED, vitals were 98.1, 108/68, 81, 18, 98% 3L. NGL was done without any blood/coffee ground. Patient's SBP was as low as 88 at one point, but for the most part was in the 100s/110s. He continued to have mild CP of [**4-13**], which improved with NG. There was evidence of TWIs which seemed new, but in the setting of a known RBBB. Dr.[**Name (NI) 5452**] coverage, Dr. [**Last Name (STitle) 16794**] was contact[**Name (NI) **], and the [**Name (NI) **] resident was instructed to stop clopedigrel, but start [**Name (NI) **] 81 mg daily. He had no further episodes of melena in the ED. His hematocrit in the ED was stable compared to his earlier hematocrit at the OSH. GI was consulted, and would do EGD in AM unless he became hemodynamically stable overnight. 2 large bore IVs were started prior to transfer to the MICU. Of note, the patient has not had previous EGD, but has had c-scope in the past which showed some diverticuli, but otherwise reportedly normal. Past Medical History: -chronic obstructive pulmonary disease -Coronary artery disease s/p PCI with LAD stent [**2126**], [**2129**]. Cypher stent to the ostial CX in 06, chronically occluded RCA. Circumflex received a DES in 07. 2 DES to LAD in [**11-10**] -Type II Diabetes -Hypertension -Hyperlipidemia -Diverticulosis -peripherial vascular disease Social History: Retired gunsmith. Lives with wife on MV. Prior alcoholic, last drink 2-3 years ago. Smoked 2 ppd x 50 years; quit 15 years prior. No IVDU. Family History: Brother with hemorrhagic CVA [**3-7**] aneurysm; father with HTN; brother had "[**Last Name **] problem", sister had ovarian cancer. Physical Exam: VS: 96.3 82 101/57 22 100% 2LNC GEN: WDWN elderly male, NAD, appropriate, pleasant HEENT: MMM, no epistaxis CV: RRR, 1/6 systolic murmur at LUSB LUNGS: bilateral crackles [**2-6**] posterior lung fields; no rhonci, no wheezes ABDOMEN: soft, NT, obese. normal BS. no HSM appreciated. Rectal deferred- guaiac + in ED EXT: [**2-4**]+ BLE edema; chronic venous stasis changes, pulses 1+ in LE and 2+ UE NEURO: A/O x 3; moves all extremities Pertinent Results: Labs- [**2139-8-9**] 03:00PM BLOOD WBC-8.2 RBC-3.55* Hgb-9.9*# Hct-31.3*# MCV-88 MCH-27.7 MCHC-31.4 RDW-18.2* Plt Ct-278 [**2139-8-9**] 09:21PM BLOOD Hct-27.1* [**2139-8-10**] 02:45AM BLOOD WBC-7.5 RBC-3.31* Hgb-9.9* Hct-29.6* MCV-89 MCH-29.8 MCHC-33.4 RDW-17.7* Plt Ct-187 [**2139-8-11**] 02:36AM BLOOD WBC-7.8 RBC-3.79* Hgb-11.2* Hct-33.7* MCV-89 MCH-29.4 MCHC-33.1 RDW-17.7* Plt Ct-192 [**2139-8-11**] 02:36AM BLOOD WBC-7.8 RBC-3.79* Hgb-11.2* Hct-33.7* MCV-89 MCH-29.4 MCHC-33.1 RDW-17.7* Plt Ct-192 [**2139-8-11**] 02:36AM BLOOD WBC-7.8 RBC-3.79* Hgb-11.2* Hct-33.7* MCV-89 MCH-29.4 MCHC-33.1 RDW-17.7* Plt Ct-192 [**2139-8-12**] 05:25AM BLOOD WBC-6.5 RBC-3.95* Hgb-11.6* Hct-36.4* MCV-92 MCH-29.4 MCHC-31.9 RDW-17.4* Plt Ct-168 [**2139-8-13**] 05:30AM BLOOD WBC-7.9 RBC-3.88* Hgb-11.4* Hct-35.5* MCV-92 MCH-29.5 MCHC-32.2 RDW-18.7* Plt Ct-178 [**2139-8-15**] 05:55AM BLOOD WBC-7.4 RBC-3.78* Hgb-11.1* Hct-33.8* MCV-90 MCH-29.5 MCHC-32.9 RDW-17.8* Plt Ct-188 [**2139-8-9**] 03:00PM BLOOD Neuts-81.4* Lymphs-13.0* Monos-4.0 Eos-1.4 Baso-0.2 [**2139-8-15**] 05:55AM BLOOD Plt Ct-188 [**2139-8-15**] 05:55AM BLOOD PT-14.2* PTT-29.4 INR(PT)-1.2* [**2139-8-9**] 03:00PM BLOOD PT-14.2* PTT-25.9 INR(PT)-1.2* [**2139-8-15**] 05:55AM BLOOD Glucose-124* UreaN-35* Creat-1.7* Na-144 K-4.1 Cl-102 HCO3-31 AnGap-15 [**2139-8-14**] 05:20AM BLOOD Glucose-139* UreaN-34* Creat-1.6* Na-141 K-4.4 Cl-101 HCO3-30 AnGap-14 [**2139-8-9**] 03:00PM BLOOD Glucose-119* UreaN-92* Creat-1.5* Na-145 K-4.7 Cl-105 HCO3-31 AnGap-14 [**2139-8-14**] 05:20AM BLOOD CK(CPK)-45 [**2139-8-12**] 05:25AM BLOOD CK(CPK)-143 [**2139-8-11**] 09:52PM BLOOD CK(CPK)-218* [**2139-8-11**] 05:49AM BLOOD CK(CPK)-285* [**2139-8-10**] 10:43AM BLOOD CK(CPK)-57 [**2139-8-9**] 03:00PM BLOOD CK(CPK)-43 [**2139-8-13**] 05:30AM BLOOD CK-MB-NotDone cTropnT-1.58* [**2139-8-12**] 05:25AM BLOOD CK-MB-27* MB Indx-18.9* cTropnT-1.21* [**2139-8-11**] 05:49AM BLOOD CK-MB-60* MB Indx-21.1* cTropnT-0.60* proBNP-[**Numeric Identifier 23911**]* [**2139-8-10**] 10:17PM BLOOD CK-MB-42* MB Indx-20.8* cTropnT-0.36* [**2139-8-9**] 09:21PM BLOOD CK-MB-6 cTropnT-0.09* [**2139-8-9**] 03:00PM BLOOD cTropnT-0.06* [**2139-8-15**] 05:55AM BLOOD Calcium-8.7 Phos-2.8 Mg-2.2 [**2139-8-10**] 02:45AM BLOOD Calcium-8.2* Phos-3.9 Mg-2.4 [**2139-8-13**] 01:06PM BLOOD Type-ART pO2-173* pCO2-56* pH-7.31* calTCO2-30 Base XS-0 Intubat-NOT INTUBA . Studies- EKG [**2139-8-9**] Compared to the previous tracing the rhythm remains sinus at 81 with clearcut first degree A-V block and left atrial abnormality. There is right bundle-branch block/left anterior hemiblock with intraventricular conduction delay and marked ST segment depression laterally consistent with lateral ischemia. Lateral myocardial infarction cannot be excluded in lead V6, possibly acute. TRACING #2 Read by: [**Last Name (LF) **],[**First Name3 (LF) **] S. Intervals Axes Rate PR QRS QT/QTc P QRS T 82 232 136 424/462 4 -59 -159 . CXR [**2139-8-10**] FINDINGS: The heart is enlarged. There are ECG leads projected over the chest. There is atelectasis versus infection at the lung bases and a follow- up PA and lateral chest rediograph is advised for further evaluation. The study and the report were reviewed by the staff radiologist. . The left atrium is moderately dilated. The right atrium is markedly dilated. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity is moderately dilated. There is mild to moderate regional left ventricular systolic dysfunction with akinesis of the inferolateral wall, and hypokinesis of the basal to mid inferior wall. The right ventricular cavity is moderately dilated with moderate global free wall hypokinesis. The ascending aorta is mildly dilated. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild to moderate ([**2-4**]+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is moderate pulmonary artery systolic hypertension. No pericardial effusion. EF=40% IMPRESSION: Mild symmetric left ventricular hypertrophy with regional left ventricular systolic dysfunction consistent with coronary artery disease. Mild to moderate mitral regurgitation. Moderate pulmonary hypertension. Compared with the prior study (images reviewed) of [**2137-2-7**], regional left ventricular systolic function is new. The severity of mitral regurgitation has increased. Estimated pulmonary artery pressures are higher. . cxr [**2139-8-11**] FINDINGS: As compared to the previous radiograph, there is no major change. The moderate hilar enlargement and the subtle perihilar opacities on the right are unchanged. Also unchanged is the extent of the partial retrocardiac atelectasis. Unchanged size of the cardiac silhouette, with moderate tortuosity of the thoracic aorta. No extent of newly occurred parenchymal opacities, no pleural effusion. . EKG [**2139-8-14**] Sinus rhythm. Bifascicular block. Occasional ventricular premature beats. Compared to the previous tracing no change. TRACING #3 Read by: [**Last Name (LF) **],[**First Name3 (LF) **] Intervals Axes Rate PR QRS QT/QTc P QRS T 97 [**Telephone/Fax (3) 39561**]/438 82 -81 95 . Cardiac Cath [**2139-8-13**]- "prelim" report Right dominant coronary angiography LMCA- minimal disease LAD- 70%ostial prior to prior stents, PTCA and BMS LCX- 100% in stent ostial/PTCA 3.0 with good result RCA- known 100% via prior cath Brief Hospital Course: 87 yo male with history of coronary artery disease, who presented with melena, and was found to have an NSTEMI (chest pain, ECG changes, and elevated cardiac enzymes were present). #. Melena: Patient was initially admitted to the MICU given ECG changes and melanotic stools with 10 pt hematocrit drop from baseline. Initial hematocrit in ED was same as outside hospital. Re-check that same evening was decreased to 27, and he received 2 units pRBC. Re-check after that was 29, so he received 2 more units given his chest pain, and slightly elevated cardiac enzymes and ECG changes. GI was consulted and performed an EGD. EGD showed small ulcers and erosions, no active bleed. At that point his PPI was switched from IV to PO BID. hematocrit increased to 35 and remained stable through the rest of his admission, it was monitored every 8 hours and then every 12 until stable at 33-34. His stool started to normalize with minimal melanotic stool before transfer from the ICU to the floor. #. NSTEMI: The patient had chest discomfort initially, but by the time he was transferred to the floor he was chest pain free. On admission, he had anterolateral TWI as well as significant 2-[**Street Address(2) 2051**] depressions in the lateral leads. This was thought to be demand ischemia secondary to his hematocrit less than 30, which was then transfused to >30. His cardiac enzymes continued to trend upwards, at which time it he was diagnosed with an NSTEMI. Cardiology was notified. He was started on [**Street Address(2) **] 325, and [**Street Address(2) **] 75 mg, but heparin was not started because of his risk of bleeding. ECG changes persisted at the time of transfer from ICU to cardiology service. An ECHO was performed which showed depressed EF to 40% with new wall motion abnormalities, LV systolic dysfunction, worsening MR, and increase in artery pressures. Patient was put on metoprolol 12.5 [**Hospital1 **] for NSTEMI. His cardiac enzymes and EKG were closely monitored. He had a cardiac catheterization which showed 100% occlusion of stent in LCX ostial- which was treated with PTCA with good results. Also he had 70% occlusion of the ostial LAD which was treated with BMS. He tolerated the procedure well, and is to continue on aspirin, [**Hospital1 **], stain, beta blocker and ace-inhibitor. . #. acute on chronic kidney disease, CKD3: Creatinine recently seemed to fluctuate between 1.3-1.7. still near baseline at discharge. Creatinine initially had risen with diuresis, but improved during his admission. Patient was given pre-cath hydration. His volume and kidney status were closely monitored. Once renal function had improved captopril was restarted, (initially held due to acute renal failure) . #. Hypoxia/Dyspnea/acute on chronic systolic heart failure: likely all components of patient's volume overload; he received 4 units pRBC as well as saline due to GI bleed which eventually led to oxygen requirement. His chest film was consistent with mild volume overload. Repeat ECHO shows depressed EF to 40%, but last EF >55%. BNP was greater than 10K. Also his CHF was worsened with his pre-cath hydration given for renal protection, at which time in addition to receiving fluids his Lasix was temporarily held as creatinine was elevated. After cath patient still was on 3L nasal canula when he ambulated, and by discharge did not need oxygen at rest. Patient was given home oxygen to use when short of breath with activity. Post cath he was restarted on his Lasix, which improved his fluid status and decreased his oxygen therapy need. He was kept in house until his fluid status improved post procedure. Patient was also given albuterol PRN with standing Atrovent, and instructed how to use his inhalers. For his heart failure, patient was on a beta blocker, ACEI, and aspirin. He was also instructed about fluid restriction to 1.5 liters and a low salt diet. He was recommended to have out patient cardiac rehab to increase his endurance. Medications on Admission: Clopidogrel 75 mg PO DAILY Aspirin 325 mg Tablet PO DAILY Albuterol 90 mcg 1-2 Puffs IH Q6H PRN Ipratropium Bromide 17 mcg 2 IH QID Metoprolol Succinate 100 mg PO DAILY Isordil 30 mg PO daily Simvastatin 80 mg PO DAILY Nitroglycerin 0.4 mg PRN Lisinopril 10 mg PO DAILY Furosemide 40 mg PO daily Bumetanide 1 mg PO daily Allopurinol 200 mg daily Discharge Medications: 1. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO at bedtime: for cholesterol. Disp:*60 Tablet(s)* Refills:*2* 2. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation QID (4 times a day): for your lungs. 3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours): For your stomach. Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 4. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): To prevent closure of your heart stents. Disp:*60 Tablet(s)* Refills:*6* 5. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q6H (every 6 hours) as needed: for your lungs. 6. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily): For your heart stents. Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 7. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Every 6 hours as needed as needed for wheezing: For your lungs. 8. Captopril 12.5 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day): For your heart. Disp:*60 Tablet(s)* Refills:*2* 9. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day): For your blood pressure and heart. Disp:*60 Tablet(s)* Refills:*2* 10. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 11. Outpatient Occupational Therapy Please have cadiac physical therapy rehab, goals of walking 300+ feet and to improve endurance Discharge Disposition: Home With Service Facility: [**Hospital3 4298**] VNA Discharge Diagnosis: Primary- -Coronary Artery Disease, now status post Non-ST elevation myocardial infarction (NSTEMI) -Small ulcers and erosions of the stomach, status post upper Gastrointestial Bleed -Chronic systolic Congestive heart failure with EF of 40% Secondary -Chronic Obstructive Pulmonary Disease -Kidney disease, chronic, stage 3, est GFR 38 -Diabetes Mellitus Type II -Hypertension -Hyperlipidemia -Diverticulosis Discharge Condition: Hemodynamically stable, afebrile, able to ambulate. Requires 2 liters of oxygen with a nasal canula when he ambulates for extended periods. No oxygen therapy required at rest. Discharge Instructions: You were admitted to the hospital due to blood in your stool, which was caused by small uclers in your stomach. This was seen by an endoscopy study. You also had chest pain that was due to a heart attack. Once you were no longer having bleeding, you had a cardiac catheterization which showed blockages of your heart stents. The left circumflex artery was opened with a balloon angioplasty, and a bare metal stent was placed in your Left anterior descending artery. You tolerated the procedure well. . Your medication changes were as follows: Your medication are the same except your lisinopril and isordil was stopped, and you were started on pantoprazole for your stomach, captopril for your heart, and oxygen for your lungs. Your dose of lasix was increased. . Please seek medical attention or go to the ER if you have chest pain, shortness of breath, palpitations, leg swelling, blood in your stool, or black tarry stools or any other concerning symtoms. . Please keep your follow up appointments. . Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight increases by 3 lbs. Adhere to 2 gm sodium diet Fluid Restriction: Do not drink more than 1.5 liters of fluids per day . Physical therapy recommended that you have out patient thearpy to increase your strength and mobility. Followup Instructions: Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 29822**] Date/Time: Thursday [**8-20**] at 11am. Please discuss your stay with him and let him review your medicaions. Please evaluate if you still need oxygen at home. Provider: [**Last Name (NamePattern4) **].[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]:[**Telephone/Fax (1) 7960**]. Date/Time: [**9-2**] at 11:30am at [**Hospital6 **] (Dr. [**Last Name (STitle) **] is not available at the [**Location (un) **] until [**Month (only) **]) Completed by:[**2139-8-19**]

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icd9cm

[ [ [] ] ]

[ "45.16", "00.45", "00.41", "88.56", "36.06", "00.66", "37.23" ]

icd9pcs

[ [ [] ] ]

15531, 15587

9638, 13623

280, 365

16040, 16218

4069, 9615

17558, 18154

3462, 3596

14020, 15508

15608, 16019

13649, 13997

16242, 17535

3611, 4050

222, 242

393, 2934

2956, 3289

3305, 3446

2,487

185,844

50108

Discharge summary

report

Admission Date: [**2178-1-16**] Discharge Date: [**2178-1-25**] Date of Birth: [**2120-6-27**] Sex: F Service: MEDICINE Allergies: Codeine / Ciprofloxacin Hcl / Aminoglycosides Attending:[**First Name3 (LF) 2071**] Chief Complaint: chest pain Major Surgical or Invasive Procedure: intubation [**2178-1-17**] History of Present Illness: 57F with long history of IDDM with complications including CAD with CABG X2 in [**2171**], PVD with left bypass, and right BKA, s/p renal transplant [**2178-11-24**] who was transferred from [**Hospital **] Hospital after presenting there with CHF and NSTEMI. Past Medical History: --s/p renal transplant [**2178-11-24**] --IDDM x40 years comlicated by CAD, PVD, retinopathy --CHF --PVD w/ left bypass --right BKA [**5-6**] --CABG x2 [**8-/2172**] w/ LIMA to LAD and SVG to right PDA --Nonfunctioning left AVF - no BPs left side --h/o fall about 1 1/2 months ago w/ minor injury Social History: reports high level of stress at home. Pt is upset/frustrated by her chronic illness and recent complications. -tob -etoh + "second-hand smoke" Family History: mother with HTN and OCD GF with hx MI Physical Exam: PE: chronically ill-appearing,obese woman in NAD VS: 99.6 106/41 65 22 99% shovel mask HEENT: EOMI, anicteric, conjunctival hemorrhage bilat, diffuse petechial rash, mildly dry MM neck: supple,-lad, JVP difficult to apprciate lungs; bibasilar rales [**12-7**] way up bilaterally, with exp wneeze in upper fields r>l heart: distant regular chest; port site c/d/i abd; soft NT ND o ext: -e/c/c,DP pulse on left non-palp, good cap refill, right bka site without erythema, neuro: CN intact, A&0x3 Pertinent Results: [**1-17**] CXR: The heart continues to be enlarged. There are new patchy bilateral infiltrates, right upper lobe greater than left lung. There is hazy bilateral vasculature consistent with CHF . [**1-19**] TTE: Biventricular hypokinesis c/w diffuse process (multivessel CAD, toxin, metabolic, etc.). Mild-moderate mitral regurgitation. Pulmonary artery systolic hypertension (42mmHg). EF 20-25%. . [**1-31**] CXR: Improving CHF, improving left lower lobe opacity . . [**2178-1-16**] 07:36PM BLOOD WBC-5.2 RBC-3.08* Hgb-9.4* Hct-28.4* MCV-92 MCH-30.3 MCHC-32.9 RDW-14.5 Plt Ct-173 [**2178-1-25**] 06:20AM BLOOD WBC-8.3 RBC-3.56* Hgb-11.0* Hct-33.0* MCV-93 MCH-30.9 MCHC-33.4 RDW-15.4 Plt Ct-335 [**2178-1-16**] 07:36PM BLOOD Neuts-16* Bands-14* Lymphs-36 Monos-12* Eos-0 Baso-0 Atyps-22* Metas-0 Myelos-0 [**2178-1-21**] 09:00AM BLOOD Neuts-76.9* Lymphs-18.5 Monos-3.0 Eos-1.4 Baso-0.3 [**2178-1-16**] 07:36PM BLOOD PT-12.3 PTT-29.0 INR(PT)-1.0 [**2178-1-16**] 07:36PM BLOOD Glucose-113* UreaN-50* Creat-1.9* Na-140 K-4.1 Cl-100 HCO3-31* AnGap-13 [**2178-1-25**] 06:20AM BLOOD Glucose-84 UreaN-55* Creat-1.7* Na-141 K-4.1 Cl-101 HCO3-29 AnGap-15 [**2178-1-16**] 07:36PM BLOOD ALT-38 AST-34 LD(LDH)-275* CK(CPK)-85 AlkPhos-60 TotBili-1.0 [**2178-1-16**] 07:36PM BLOOD CK-MB-NotDone cTropnT-0.55* [**2178-1-17**] 06:35AM BLOOD CK-MB-16* MB Indx-8.6* cTropnT-0.71* [**2178-1-17**] 12:11PM BLOOD CK-MB-22* MB Indx-5.3 cTropnT-0.86* [**2178-1-17**] 05:47PM BLOOD CK-MB-23* MB Indx-4.9 cTropnT-1.13* [**2178-1-18**] 05:14AM BLOOD CK-MB-9 cTropnT-1.17* [**2178-1-16**] 07:36PM BLOOD Albumin-3.9 Calcium-9.2 Phos-4.0 Mg-1.9 [**2178-1-25**] 10:45AM BLOOD FK506-11.0 [**2178-1-17**] 11:04AM BLOOD Type-ART pO2-35* pCO2-64* pH-7.23* calHCO3-28 Base XS--3 [**2178-1-17**] 11:18AM BLOOD Type-ART pO2-420* pCO2-28* pH-7.25* calHCO3-13* Base XS--13 [**2178-1-18**] 03:13PM BLOOD Type-ART pO2-71* pCO2-50* pH-7.38 calHCO3-31* Base XS-2 Intubat-NOT INTUBA [**2178-1-17**] 11:04AM BLOOD Lactate-5.5* Na-133* K-5.0 Brief Hospital Course: 57F with IDDM s/p kidney transplant, CABG X2 [**71**], right BKA [**5-6**], CHF who presented for cardiac cath after NSTEMI at OSH and had respiratory arrest, intubated [**1-17**] in setting on epistaxis on anticoagulation/integrillin, extubated [**1-18**] with ongoing management of aspiration pneumonia and CHF who is now requesting medical management from this point forward. . 1) CV --CAD: hx CABG with recent NSTEMI with Trop peak 37.4 at OSH and recent peak 1.17 TropT. Pt is refusing cath and requests medical management of her CAD, continued asa, plavix, bb,and statin. Ace added to regimen. --PUMP: Bivent failure by recent echo. EF20%. Continued CHF managment with diuresis and afterload reduction given depressed EF and evidence of fluid overload on CXR. Starting ACE inhibitor. Will titrate as kidney function tolerates --Rhythm: NSR, cont BB for rate control . 2)[**Name (NI) 22118**] Pt had a respiratory arrest on [**1-17**] in AM secondary to a severe epistaxis with aspiration in the setting of having been on integrillin and with a supratherapeutic heparin level. Pt was intubated and transferred to the CCU where her anticoagulation was reversed and her epistaxis was managed with nasal packing. Pt was extubated the following day. . 3)Renal- Per renal recs, continued to hold CSA until level <50. Check daily CSA levels. Continued cellcept. Started tacrolimus per renal recs. Cr improved to 1.7 which is c/w baseline. Started lasix at 80mg IV BID per renal recs. . 4)DM-continued lantus with RISS (humalog), FS QID, diabetic diet, [**Name (NI) 653**] [**Name (NI) **] MD, Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] . 5)PVD s/p right BKA and with left bypass- pt is s/p right BKA. Pt reported recent injury to stump. No signs of infection . 6)ID- At the OSH, pt was found to have a fever, neutropenia, atypical lymphs, and a bandemia. She had been given empiric zosyn for the fever and at OSH CXR neg for pna, just CHF. On the morning after transfer pt has repiratory code from likely aspiration event from epistaxis. CXR showed new upper lobe inflitrates. ID team was consulted who recommended initial coverage with vanc/zosyn. . [**1-21**]: spiked temp o/n; pan-Cx, CXR, diff on WBC, C. diff etc. Renal team switching CSA-->tacrolimus, no clear plan to reduce immunosuppression, but hopefully. [**2091-1-21**]: fever curve improved with nothing but continued zosyn; fever w/u (BCx, UA/UCx, C. diff) so far unrevealing as to etiology of that fever spike [**2089-1-18**]. Found out that she took 10D of cipro PTA for ? UTI (she apparently has chronic UTIs and often is on chronic cipro tx), also had some LGT prior to admit, so maybe she did have a viral syndr. As of [**1-23**] sats improved significantly with diuresis (were 82% on RA on [**1-22**]-91% RA on [**1-23**]. Note was 93% on 2L on admit to [**Hospital1 18**]), so holding off on induced sputum for PCP, [**Name10 (NameIs) **] Cx, GS/CX etc. f/u CXR [**1-21**] actually improved LLL infiltrate . [**2178-1-23**]: Afebrile now for 2 days. O2sat=90 on RA. Needs to be further diuresed. optimize med management. Started Toprol XL . At time of discharge, pt was on zosyn for treatment of aspiration pneumonia. Blood cultures, urine cultures were negative to date. Discharge Medications: 1. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 2. Clonazepam 1 mg Tablet Sig: Four (4) Tablet PO QHS (once a day (at bedtime)) as needed for restless legs. 3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Atorvastatin Calcium 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 5. Foltx 2.5-25-1 mg Tablet Sig: One (1) Tablet PO QD (). 6. Fluoxetine HCl 10 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 7. Mycophenolate Mofetil 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 8. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 9. Bumex 2 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 10. Docusate Sodium 100 mg Tablet Sig: One (1) Tablet PO twice a day. 11. Tacrolimus 1 mg Capsule Sig: Two (2) Capsule PO BID (2 times a day). 12. Vitamin E 400 unit Capsule Sig: One (1) Capsule PO DAILY (Daily). 13. Metoprolol Succinate 25 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily). Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2* 14. glargine 60 mg at bedtime 15. humalog as per sliding scale 16. Vitamin C Oral 17. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 18. Ferrous Sulfate Oral Discharge Disposition: Home Discharge Diagnosis: PRIMARY: --NSTEMI --CHF --PNA --Respiratory failure SECONDARY: --CAD --DM --Renal transplant Discharge Condition: afebrile, ambulating, deficating, urinating. Discharge Instructions: --Seek immediate medical attention is experiencing fever, lightheadedness, chest pain, palpitations, shortness of breath, abdominal pain, nausea, or any other symptoms for which you are concerned. --Take all medications as directed --Follow-up on all appointments --Obtain once per week CBC, Chem7, calcium, phosphorus, AST, Tbili, U/A, Prograf level fax results to [**Telephone/Fax (1) 697**] Followup Instructions: Call [**Last Name (LF) 2052**],[**First Name3 (LF) 2053**] J (Cardiologist) [**Telephone/Fax (1) 5003**] for an appointment within one week of discharge. . Call [**Last Name (LF) **],[**First Name3 (LF) **] M (PCP) [**Telephone/Fax (1) 30760**] for an appointment within one week of discharge. . Follow-up [**Last Name (LF) 970**], [**First Name3 (LF) 971**] (Nephrologist) within one week of discharge. (once per week CBC, Chem7, calcium, phosphorus, AST, Tbili, U/A, Prograf level fax results to [**Telephone/Fax (1) 697**]). [**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 2073**]

[ "780.6", "250.71", "309.0", "E934.2", "V49.75", "250.51", "443.81", "079.99", "496", "584.9", "362.01", "996.81", "401.9", "787.91", "518.81", "507.0", "784.7", "422.91", "530.81", "288.0", "250.41", "583.81", "V45.81", "428.0", "410.71", "414.00" ]

icd9cm

[ [ [] ] ]

[ "89.65", "99.20", "96.71", "38.93", "96.04" ]

icd9pcs

[ [ [] ] ]

8444, 8450

3728, 7005

317, 346

8587, 8634

1706, 3705

9076, 9700

1137, 1177

7028, 8421

8471, 8566

8658, 9053

1192, 1687

267, 279

374, 637

659, 958

974, 1121

62,438

163,961

54642

Discharge summary

report

Admission Date: [**2161-8-14**] Discharge Date: [**2161-8-18**] Date of Birth: [**2091-12-8**] Sex: F Service: MEDICINE Allergies: tetnus / Sulfa(Sulfonamide Antibiotics) Attending:[**First Name3 (LF) 4891**] Chief Complaint: GI bleeding Major Surgical or Invasive Procedure: none History of Present Illness: This is a 69 year-old Female with a PMH significant for chronic obstructive pulmonary disease (on home oxygen supplementation), coronary artery disease (s/p silent MI previosuly), non-insulin dependent diabetes mellitus, peripheral artery disease and diverticulosis, known hiatal hernia who presents with bright red blood per rectum. . The patinent presented to [**Hospital3 **] 1-week prior with the onset of shortness of breath. She was initially presumed to be having a COPD exacerbation and recveived steroids, nebulizers and oxygen treatments with subsequent improvement and discharge to a skilled nursing facility. At the facility, she was noted to have grossly blood stools mixed with melena in the AM on [**2161-8-14**] (at 2AM) associated with hypotension. She denied lightheadedness, dizziness or palpitations. She had no nausea, emesis or abdominal pain. She had no cough, respiratory symptoms or hematemesis. She returned to the [**Hospital3 **] ED and was noted to have a hemoglobin of 7.2 g/dL (significant decline from baseline). She recived 1 unit of packed red cells and 1.5L of normal saline prior to transfer. She has been on prophylactic Lovenox and ASA. She denies recent NSAID use. . Of note, her last colonoscopy and EGD were 1-year prior and at that time noted evidence of diverticulosis. She reports that she has been admitted to [**Hospital3 **] almost annually with similar bleeding concerns and each endoscopy reveals resolved bleeding with a presumed divericular source. . In the [**Hospital1 18**] ED upon transfer, initial VS 100.0 56 98/42 16 96% RA. Her exam was notable for a moderate amount of maroon colored diarrhea per rectum. Laboratory data noted a WBC 6.9, hemoglobin 9.5, hematocrit 30.9%, platelets 204 and INR 1.2. LFTs were reassuring. A 22-gauge, 20-gauge and two 18-gauge peripherals were established for IV access. She received 1L NS x 1 in the ED and 1 unit of pRBCs. GI and General Surgery were consulted and agreed with MICU transfer. . On arrival to the MICU, she was mentating well without abdominal pain and appears stable. She was treated and stabilized in the ICU before being transitioned to the hospital medicine service for ongoing management. She underwent an attempt at colonoscopy, although the preparation was not felt to be adequate to effectively rule out focal GI pathology. No upper GI pathology was noted on endoscopy. Past Medical History: 1. Chronic obstructive pulmonary disease (on 2L NC home oxygen) 2. Coronary artery disease (status-post silent MI without stenting; on ASA for secondary prevention; had MI over 15 years prior and recent pharmacologic stress testing was reassuring) 3. History of hiatal hernia 4. History of diverticulosis 5. Peripheral artery disease 6. Non-insulin dependent diabetes mellitus 7. Hyperlipidemia 8. GERD, reflux esophagitis Social History: Patient lives at home with her husband and has 6 children. Denies tobacco use currently (quit 6 days prior); prior to that has a 50 pack-year history; denies alcohol use; no recreational substance use. Patient is independent in ADLs and ambulates unassisted. Worked at Stop-and-Shop as a cashier. Family History: Denies significant family history of cardiovascular disease, early MI, arrhythmia or sudden cardiac death. Mother died of liver cancer at age 63 years. Physical Exam: #ADMISSION PHYSICAL EXAM VITALS: 98.0 59 113/52 16 97% 2L NC GENERAL: Appears in no acute distress. Alert and interactive. Well nourished appearing. HEENT: Normocephalic, atraumatic. EOMI. PERRL. Nares clear. Mucous membranes moist. NECK: supple without lymphadenopathy. JVD unable to assess given habitus. CVS: Regular rate and rhythm, II/VI early systolic murmur, without rubs or gallops. S1 and S2 normal. RESP: End expiratory wheezing in the bilateral bases. No rhonchi or crackles. Stable inspiratory effort. ABD: soft, obese, non-tender, non-distended, with normoactive bowel sounds. No palpable masses or peritoneal signs. EXTR: no cyanosis, clubbing; bilateral 1+ edema to the mid-shins, 2+ peripheral pulses NEURO: CN II-XII intact throughout. Alert and oriented x 3. DTRs 2+ throughout, strength 5/5 bilaterally, sensation grossly intact. Gait deferred. RECTAL: external peri-anal region without lesions, skin tags or fissures. Digital exam reveals normal tone. No masses or internal hemorrhoids. Bleeding noted on finger mixed with melenic maroon-colored stool. #DISCHARGE PHYSICAL EXAM: VITALS: T 99.1, HR 62, BP 118/52, RR 22, O2 sat 93% 2L NC. GENERAL: Appears in no acute distress. Alert and interactive. Well nourished appearing. HEENT: Normocephalic, atraumatic. EOMI. PERRL. Nares clear. Mucous membranes moist. NECK: supple without lymphadenopathy. JVD unable to assess given habitus. CVS: Regular rate and rhythm, II/VI early systolic murmur, without rubs or gallops. S1 and S2 normal. RESP: End expiratory wheezing in the bilateral bases. No rhonchi or crackles. Stable inspiratory effort. ABD: soft, obese, non-tender, non-distended, with normoactive bowel sounds. No palpable masses or peritoneal signs. EXTR: no cyanosis, clubbing; bilateral 1+ edema to the mid-shins, 2+ peripheral pulses NEURO: CN II-XII intact throughout. Alert and oriented x 3. DTRs 2+ throughout, strength 5/5 bilaterally, sensation grossly intact. Gait deferred. Pertinent Results: #ADMISSION LABS: [**2161-8-14**] 02:12PM PT-12.5 PTT-23.8* INR(PT)-1.2* [**2161-8-14**] 02:12PM PLT COUNT-204 [**2161-8-14**] 02:12PM NEUTS-82.1* LYMPHS-13.9* MONOS-3.8 EOS-0.2 BASOS-0.1 [**2161-8-14**] 02:12PM WBC-6.9 RBC-3.39* HGB-9.5* HCT-30.9* MCV-91 MCH-28.1 MCHC-30.8* RDW-16.3* [**2161-8-14**] 02:12PM ALBUMIN-2.7* [**2161-8-14**] 02:12PM ALT(SGPT)-18 AST(SGOT)-13 LD(LDH)-136 ALK PHOS-30* TOT BILI-0.3 [**2161-8-14**] 08:23PM PLT COUNT-235 [**2161-8-14**] 08:23PM WBC-11.2*# RBC-3.82* HGB-10.4* HCT-34.1* MCV-89 MCH-27.2 MCHC-30.5* RDW-16.7* [**2161-8-14**] 08:23PM CALCIUM-7.5* PHOSPHATE-3.3 MAGNESIUM-1.8 [**2161-8-14**] 08:23PM estGFR-Using this [**2161-8-14**] 08:23PM GLUCOSE-79 UREA N-41* CREAT-0.9 SODIUM-144 POTASSIUM-4.7 CHLORIDE-110* TOTAL CO2-32 ANION GAP-7* #PERTINENT/DISCHARGE LABS: [**2161-8-18**] 01:00PM BLOOD WBC-12.6* RBC-3.48* Hgb-9.6* Hct-31.4* MCV-90 MCH-27.7 MCHC-30.7* RDW-17.2* Plt Ct-214 [**2161-8-18**] 06:10AM BLOOD WBC-12.3* RBC-3.47* Hgb-9.5* Hct-31.3* MCV-90 MCH-27.5 MCHC-30.5* RDW-17.1* Plt Ct-195 [**2161-8-17**] 02:27AM BLOOD WBC-12.1* RBC-3.67* Hgb-10.2* Hct-32.8* MCV-89 MCH-27.9 MCHC-31.2 RDW-16.7* Plt Ct-193 [**2161-8-16**] 02:00AM BLOOD WBC-11.7* RBC-3.77* Hgb-10.3* Hct-33.2* MCV-88 MCH-27.4 MCHC-31.1 RDW-16.7* Plt Ct-202 [**2161-8-15**] 08:50AM BLOOD Neuts-70.8* Lymphs-24.7 Monos-3.9 Eos-0.4 Baso-0.2 [**2161-8-17**] 02:27AM BLOOD PT-11.9 PTT-25.6 INR(PT)-1.1 [**2161-8-16**] 02:00AM BLOOD PT-11.4 INR(PT)-1.1 [**2161-8-15**] 08:50AM BLOOD PT-11.9 PTT-20.3* INR(PT)-1.1 [**2161-8-18**] 06:10AM BLOOD Glucose-90 UreaN-12 Creat-0.6 Na-145 K-3.9 Cl-103 HCO3-34* AnGap-12 [**2161-8-17**] 02:27AM BLOOD Glucose-110* UreaN-19 Creat-0.8 Na-145 K-4.1 Cl-105 HCO3-36* AnGap-8 [**2161-8-16**] 02:00AM BLOOD Glucose-89 UreaN-32* Creat-0.9 Na-145 K-4.2 Cl-108 HCO3-35* AnGap-6* [**2161-8-16**] 02:00AM BLOOD ALT-19 AST-15 AlkPhos-34* TotBili-0.4 [**2161-8-18**] 06:10AM BLOOD Calcium-8.2* Phos-3.2 Mg-1.9 [**2161-8-17**] 02:27AM BLOOD Calcium-8.3* Phos-3.3 Mg-1.8 [**2161-8-16**] 02:00AM BLOOD Calcium-8.3* Phos-3.9 Mg-1.9 #MICROBIOLOGY: [**2161-8-14**] 6:32 pm MRSA SCREEN Source: Nasal swab. **FINAL REPORT [**2161-8-17**]** MRSA SCREEN (Final [**2161-8-17**]): No MRSA isolated. #IMAGING: []CXR [**2161-8-15**]: The lungs are hyperinflated, consistent with COPD. The heart is likely enlarged. The aorta is calcified and unfolded. There is upper zone redistribution, but I doubt overt CHF. No gross effusion. No frank consolidation. Probable minimal atelectasis at both bases. []TTE [**2161-8-17**]: The left atrium is mildly dilated. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). The estimated cardiac index is high (>4.0L/min/m2). Right ventricular chamber size and free wall motion are normal. The ascending aorta is mildly dilated. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Normal biventricular cavity sizes with preserved global and regional biventricular systolic function. Mild pulmonary artery hypertension. Dilated ascending aorta. #PROCEDURES: [][**2161-8-17**] EGD Findings: Esophagus: Normal esophagus. Stomach: Normal stomach. Duodenum: Normal duodenum. Recommendations: Follow-up with the inpatient GI team for further recommendations. Brief Hospital Course: []BRIEF CLINICAL HISTORY: 69 yo F with a PMH significant for obstructive pulmonary disease (on home oxygen supplementation), coronary artery disease (s/p silent MI previosuly), non-insulin dependent diabetes mellitus, peripheral artery disease and diverticulosis, known hiatal hernia who presents with hematochezia mixed with melena and symptomatic anemia, who improved after 2U blood transfusion. She had a brief stay in the MICU for GIB and hypotension to ~80s systolic. While in the MICU she had a TTE and an EGD done, both normal. Her hematocrit stabilized and she was transferred to the inpatient medicine floor. Patient had an attempt at colonoscopy in house to evaluate for presumed diverticulosis, but following an inadequate preparation for the first attempt, she deferred further attempts during this admission. As she had stopped actively bleeding, this was felt to be a reasonable option, and she was encouraged to pursue a formal repeat colonoscopy as an outpatient through her outpatient team. []ACTIVE ISSUES: # GASTROINTESTINAL BLEEDING - Patient presents with known history of diverticulosis on prior colonoscopy and hiatal hernia on ASA for secondary prevention of MI and now presenting with acute onset of bright red blood per rectum with melanotic stools with subsequent hemodynamic instability. A lower GI source is suspected at this time. Etiologies would include diverticular bleeding, angiodysplasia or vascular malformations, malignancy (although prior colonoscopy was 1-year prior makes this less likely), or colonic ischemia. Of note, she has multiple prior admissions to OSH for diverticular bleeding seen on colonoscopy. No significant abdominal pain, NSAID use, nausea or emesis to point towards an upper GI source. NG lavage deferred in the ED. Patient had EGD on [**2161-8-17**], normal, no biopsies were done. . # CHRONIC OBSTRUCTIVE PULMONARY DISEASE - Stable COPD with home oxygen requirement. Recent acute exacerbation with resolution. Lungs stable on exam with end expiratory wheezing; oxygen status stable. Home regimen includes nebulizers, albuterol and tiotropium inhalers with fluticasone-salmeterol. CXR from [**2161-8-14**] c/w COPD with hyperinflated lungs, no evidence of consolidation or overt CHF. The patient was kept on 2L O2 NC which is her baseline O2 requirement, and we continued her home nebulizer treatments along with inhalers. She had a mild minimally productive cough that was treated symptomatically with robitussin and showed no evidence of acute pulmonary infection. . # NON-INSULIN DEPENDENT DIABETES MELLITUS - Carries a diagnosis of diabets mellitus, on oral hypoglycemics. No history of retinopathy, nephropathy or neuropathy. During her hospitalization, her home oral hypoglycemics were held and she was kept on an insulin sliding scale. She required modest amounts of insulin and had no hypo or hyperglycemic events. . # CORONARY ARTERY DISEASE - Remote history of silent MI without recent cardiac cath or stenting intervention; pharmcologic stress testing reassuring in the past year, per report. No acute anginal symptoms in the setting of this GI bleeding episode. Denies chest pain or exertional dyspnea. Her ASA and atenolol were held on admission in the setting of a GI bleed, in addition to her isosorbide mononitrate. Prior to discharge, we restarted her ASA given the stability in her blood counts and discussion with GI, as well as cardiac risk factors. # GERD, ESOHPAGEAL REFLUX - we continued the patient on home regimen of Omeprazole and Ranitidine. . # HYPERLIPIDEMIA - We continued the patient on her home dose of Simvastatin 40 mg PO daily. []TRANSITIONAL ISSUES: -patient restarted on atenolol and ASA; VNA will monitor hemodynamics and consult with PCP if there are any issues. -patient will follow up with PCP and GI later this month; plan for f/u colonoscopy as an outpatient, as the patient deferred further inpatient procedures at this time following the initial attempt. Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from Patient. 1. Atenolol 25 mg PO DAILY 2. Pregabalin 150 mg PO BID 3. MetFORMIN (Glucophage) 500 mg PO BID 4. Simvastatin 40 mg PO HS 5. Tiotropium Bromide 1 CAP IH DAILY 6. Aspirin 81 mg PO QPM 7. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS 8. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH [**Hospital1 **] 9. Ranitidine 150 mg PO HS 10. Omeprazole 20 mg PO DAILY 11. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheezing 12. calcium polycarbophil *NF* 1300 Oral [**Hospital1 **] 13. Requip *NF* (rOPINIRole) 3 mg Oral [**Hospital1 **] 14. Nitroglycerin SL 0.4 mg SL PRN chest pain every 5 minutes 15. Isosorbide Mononitrate 30 mg PO DAILY Discharge Medications: 1. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH [**Hospital1 **] 2. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS 3. Omeprazole 20 mg PO DAILY 4. Pregabalin 150 mg PO BID 5. Ranitidine 150 mg PO HS 6. Requip *NF* (rOPINIRole) 3 mg Oral [**Hospital1 **] 7. Simvastatin 40 mg PO HS 8. Tiotropium Bromide 1 CAP IH DAILY 9. Furosemide 20 mg PO QAM 10. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheezing 11. calcium polycarbophil *NF* 1300 Oral [**Hospital1 **] 12. Isosorbide Mononitrate 30 mg PO DAILY 13. MetFORMIN (Glucophage) 500 mg PO BID 14. Nitroglycerin SL 0.4 mg SL PRN chest pain every 5 minutes 15. Aspirin 81 mg PO QPM 16. Atenolol 25 mg PO DAILY Discharge Disposition: Home With Service Facility: [**Hospital3 **] VNA Discharge Diagnosis: Diverticulosis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mrs. [**Known lastname **], It was a pleasure taking care of you. You were admitted to the [**Hospital1 69**] for blood in your stools. You were seen by the gastro-intestinal doctors and the [**Name5 (PTitle) **] surgery doctors and it was felt that you would do best with more intensive monitoring in the ICU. You were given intravenous fluids, a unit of blood, and you were stabilized before being transfered to the regular medicine inpatient unit. You had an ultrasound of your heart, and the GI doctors looked in the top of your gastro intestinal tract with a scope and found nothing abnormal. You will follow up with the GI doctors with the [**Name5 (PTitle) **] to do a colonoscopy as an outpatient. We wish you and your family the best. Followup Instructions: Name: [**Last Name (LF) 61898**],[**First Name3 (LF) 278**] T. Specialty: Primary Care When: Wednesday [**9-1**] at 2pm Location: COMMUNITY PHYSICIANS ASSOCIATES, INC. Address: [**Street Address(2) 4472**] [**Apartment Address(1) 19251**], [**Hospital1 **],[**Numeric Identifier 9331**] Phone: [**Telephone/Fax (1) 61899**] Name: [**Last Name (LF) 679**], [**Name8 (MD) 1158**] MD Specialty: Gastroenterology When: Tuesday [**9-8**] at 2:15pm Address: [**Doctor First Name **],STE 8A, [**Location (un) **],[**Numeric Identifier 718**] Phone: [**Telephone/Fax (1) 682**]

[ "250.00", "414.01", "530.81", "443.9", "562.12", "412", "553.3", "272.4", "V46.2", "496" ]

icd9cm

[ [ [] ] ]

[ "45.13" ]

icd9pcs

[ [ [] ] ]

14763, 14814

9326, 10340

312, 318

14873, 14873

5669, 5670

15804, 16378

3512, 3665

14078, 14740

14835, 14852

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15024, 15781

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33715

Discharge summary

report

Admission Date: [**2155-1-20**] Discharge Date: [**2155-1-21**] Date of Birth: [**2129-6-17**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**Last Name (NamePattern4) 290**] Chief Complaint: altered mental status focal neurological deficit Major Surgical or Invasive Procedure: intubation central line placement arterial line placement History of Present Illness: 25 y/o F w/ chrohn's,apendectomy c/b nicked bowel with colostomy. partial colectomy, h/o infections with open wound, headache today, received imitrex, then developed confusion and altered mental status. Pt is afebrile, stares to the right and does not not cross midline. Pt is complaining about "not seeing." . Two days ago the patient fell and hit her head. This am pt's family noted pt. to be confused, looking to right, combative. She complained of a headache and not being able to see, pupils large dilated and looking to right. . In the [**Name (NI) **], pt received ceftrioxone/vancomycin/acyclovir. She was intubated [**1-4**] apneic episodes and for airway protection and to help facilitate mri/mrv. The patient was sedated with propofol and became hypotensive to the 80's. At that point, levophed was started. In the ED, a right femoral line was placed but did not flush. An EJ was placed. En route to CT, the patient became brady to the 50's and went into vtach at 180's, given 2mg mag and amp of cacl, amio 150 given now on drip. back to sinus. BP to 60's then improved. She given emergency release blood. A CTA/CTV of the head and LP were done and pt. was transferred to the MICU. . Upon arrival to the micu, the pt. was hypotensive to the 50's on levo/neo. She became pulseless and CPR was started. She received 3 rounds of epi, 2 atropine, 1 amp of bicarb, 2 rounds of Ca, 2 rounds mg, Past Medical History: Crohn's disease Migraines Anxiety, panick disorder Anorexia Substance abuse- heroine (intranasal) Social History: Hx of substance abuse Family History: unknown Physical Exam: expired Pertinent Results: expired Brief Hospital Course: Pt brought to the MICU hypotensive. Exam revealed exposed bowel. Shortly thereafter, pt went into PEA arrest. She was able to be successfully resuscitated. Despite aggressive pressor support, IV fluids, abx, pt remained in refractory shock and expired. Medications on Admission: Zoloft 100mg QD Clonazepam 1mg TID Lorazepam 0.5mg QHS prn Methadone 280mg QD Usodiol 300mg [**Hospital1 **] Promethazine 25mg TID Priolosec 30mg [**Hospital1 **] Imodium 2mg [**Hospital1 **] Baclofen prn Discharge Medications: expired Discharge Disposition: Expired Discharge Diagnosis: expired Discharge Condition: expired Discharge Instructions: expired Followup Instructions: expired [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]

[ "427.1", "276.50", "785.52", "300.01", "E888.9", "038.9", "276.2", "346.90", "995.92", "427.89", "555.9", "998.31" ]

icd9cm

[ [ [] ] ]

[ "96.71", "38.93", "99.60", "03.31", "96.04", "38.91", "00.17", "99.04" ]

icd9pcs

[ [ [] ] ]

2668, 2677

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372, 431

2728, 2737

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2793, 2939

2038, 2047

2636, 2645

2698, 2707

2406, 2613

2761, 2770

2062, 2071

283, 334

459, 1861

1883, 1983

1999, 2022

43,171

161,695

7856+55881+55882+55883

Discharge summary

report+addendum+addendum+addendum

Admission Date: [**2183-12-8**] Discharge Date: [**2183-12-22**] Date of Birth: [**2105-4-14**] Sex: F Service: NEUROSURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1854**] Chief Complaint: Headaches x 4 days Major Surgical or Invasive Procedure: None History of Present Illness: 78 F transferred from [**Location (un) **] with headache for 3-4 days. The pain began gradually and progressively worsened. It radiates from her skull base throughout her head, no laterality. It is a sharp throbbing pain. She attempted heat and cold packs without relief. She presented to OSH today as headache became more severe. She had a similar headache two weeks ago which resolved. She was seen by her Ophthalmologist 4 days ago and no major pathology was found. Pt reports 10 pound unintentional weight loss over 2 months. She denies associated nausea, vomiting, vision changes, hearing changes, numbness, weakness, paresthesias, seizures, diarrhea. She has been performing all ADLs independently. No recent trauma. Past Medical History: 1. diabetes 2. hypertension 3. history of chest pain syndrome with a negative cardiac catheterization ten years ago Social History: Lives at home. Never smoked. No EtOH Family History: Father: prostate ca Mother: liver ca Brother: lung/throat ca Brother: asbestosis Physical Exam: PE: T: 98.7 F HR: 85 BP: 168/67 R: 18 O2Sat: 96% RA Gen: WD/WN, comfortable, NAD. HEENT: Pupils: PERRL EOMs: Intact Eyes- non-icteric Neck: Supple, no lymphadenopathy. 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. Face symmetric, tongue midline No pronator drift Motor: D B T WE WF IP Q H AT [**Last Name (un) 938**] G R 5 5 5 5 5 5 5 5 5 5 5 L 5 5 5 5 5 5 5 5 5 5 5 Sensation: Intact to light touch on the both UE and LE Proprioception intact Toes downgoing Rectal exam: deferred ** Upon Discharge ** She is alert and oriented to person, place, and time. Neuro intact. Left tricep -[**6-3**] Pertinent Results: [**2183-12-8**] 05:10PM BLOOD Glucose-81 UreaN-10 Creat-0.9 Na-147* K-3.6 Cl-111* HCO3-24 AnGap-16 [**2183-12-9**] 06:10AM BLOOD Glucose-75 UreaN-11 Creat-0.8 Na-145 K-3.2* Cl-109* HCO3-23 AnGap-16 [**2183-12-10**] 06:35AM BLOOD Glucose-89 UreaN-12 Creat-0.8 Na-144 K-3.7 Cl-106 HCO3-24 AnGap-18 [**2183-12-9**] 06:10AM BLOOD Calcium-8.4 Phos-4.0 Mg-1.3* [**2183-12-10**] 06:35AM BLOOD Calcium-8.9 Phos-3.9 Mg-1.4* [**2183-12-10**] 12:27PM BLOOD Mg-1.3* Brief Hospital Course: 78 F transferred from [**Location (un) **] with headache for 3-4 days. She presented to OSH on [**2183-12-8**] as the headache became more severe. A head CT was performed which showed a right sided brain mass. She was admitted to Neurosurgery. A brain MRI was performed on [**2183-12-9**] which showed a right temporal lesion that is consistent with a atypical meningioma. Further neurosurgical intervention can occur outpatient and Mrs. [**Known lastname 4886**] was discharged home on [**2183-12-10**]. Medications on Admission: Simvastatin 10-mg/day Januvia 50-mg/day levothyroxine 0.1-mg/day metoprolol 50-mg [**Hospital1 **] folic acid 1-mg [**Hospital1 **] glyburide 10-mg [**Hospital1 **] amitriptyline 50-mg/day furosemide 20-mg/day metformin 1000-mg [**Hospital1 **] Nifedical XL 30-mg/day gemfibrozil 600-mg [**Hospital1 **] potassium 20-mEq/day aspirin 81-mg/day Macrodantin 100-mg/day Discharge Medications: 1. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Glyburide 5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 3. Metformin 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 4. Gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Nifedipine 30 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO DAILY (Daily). 7. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 9. Amitriptyline 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 10. Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): Please stay on until follow-up appointment. Disp:*60 Tablet(s)* Refills:*2* 11. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for Headache. 12. Fioricet 50-325-40 mg Tablet Sig: One (1) Tablet PO every 4-6 hours as needed for headache. Disp:*30 Tablet(s)* Refills:*0* Discharge Disposition: Extended Care Facility: [**Hospital 16844**] Hospital - [**Location (un) 1157**] Discharge Diagnosis: Brain Lesion Discharge Condition: Neurologically Stable Discharge Instructions: General Instructions/Information ??????Have a friend/family member check your incision daily for signs of infection. ??????Take your pain medicine as prescribed. ??????Exercise should be limited to walking; no lifting, straining, or excessive bending. ??????You may wash your hair only after sutures and/or staples have been removed. If your wound closure uses dissolvable sutures, you must keep that area dry for 10 days. ??????You may shower before this time using a shower cap to cover your head. ??????Increase your intake of fluids and fiber, as narcotic pain medicine can cause constipation. We generally recommend taking an over the counter stool softener, such as Docusate (Colace) while taking narcotic pain medication. ??????Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, Aspirin, Advil, and Ibuprofen etc. ??????If you have been prescribed Dilantin (Phenytoin) for anti-seizure medicine, take it as prescribed and follow up with laboratory blood drawing in one week. This can be drawn at your PCP??????s office, but please have the results faxed to [**Telephone/Fax (1) 87**]. If you have been discharged on Keppra (Levetiracetam), you will not require blood work monitoring. ??????If you are being sent home on steroid medication, make sure you are taking a medication to protect your stomach (Prilosec, Protonix, or Pepcid), as these medications can cause stomach irritation. Make sure to take your steroid medication with meals, or a glass of milk. ??????Clearance to drive and return to work will be addressed at your post-operative office visit. ??????Make sure to continue to use your incentive spirometer while at home. CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING ??????New onset of tremors or seizures. ??????Any confusion or change in mental status. ??????Any numbness, tingling, weakness in your extremities. ??????Pain or headache that is continually increasing, or not relieved by pain medication. ??????Any signs of infection at the wound site: increasing redness, increased swelling, increased tenderness, or drainage. ??????Fever greater than or equal to 101?????? F. Followup Instructions: Your Follow-up will be coordinated and you will receive a call from [**Doctor Last Name **] or [**Location (un) 3230**] from Dr.[**Name (NI) 12757**] office. If you do not receive a call by Monday afternoon [**2183-12-15**], please call [**Telephone/Fax (1) 3231**] Completed by:[**2183-12-10**] Name: [**Known lastname 2601**],[**Known firstname 4497**] Unit No: [**Numeric Identifier 4954**] Admission Date: [**2183-12-8**] Discharge Date: [**2183-12-22**] Date of Birth: [**2105-4-14**] Sex: F Service: NEUROSURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 3656**] Addendum: Surgical template entered in error Chief Complaint: Headaches x 4 days Major Surgical or Invasive Procedure: None History of Present Illness: 78 F transferred from [**Location (un) **] with headache for 3-4 days. The pain began gradually and progressively worsened. It radiates from her skull base throughout her head, no laterality. It is a sharp throbbing pain. She attempted heat and cold packs without relief. She presented to OSH today as headache became more severe. She had a similar headache two weeks ago which resolved. She was seen by her Ophthalmologist 4 days ago and no major pathology was found. Pt reports 10 pound unintentional weight loss over 2 months. She denies associated nausea, vomiting, vision changes, hearing changes, numbness, weakness, paresthesias, seizures, diarrhea. She has been performing all ADLs independently. No recent trauma. Past Medical History: 1. diabetes 2. hypertension 3. history of chest pain syndrome with a negative cardiac catheterization ten years ago Social History: Lives at home. Never smoked. No EtOH Family History: Father: prostate ca Mother: liver ca Brother: lung/throat ca Brother: asbestosis Physical Exam: PE: T: 98.7 F HR: 85 BP: 168/67 R: 18 O2Sat: 96% RA Gen: WD/WN, comfortable, NAD. HEENT: Pupils: PERRL EOMs: Intact Eyes- non-icteric Neck: Supple, no lymphadenopathy. 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. Face symmetric, tongue midline No pronator drift Motor: D B T WE WF IP Q H AT [**Last Name (un) **] G R 5 5 5 5 5 5 5 5 5 5 5 L 5 5 5 5 5 5 5 5 5 5 5 Sensation: Intact to light touch on the both UE and LE Proprioception intact Toes downgoing Rectal exam: deferred Upon discharge: Alert and oriented x3. Neuro intact. MAE [**6-3**] except left tricep -[**6-3**] Pertinent Results: [**2183-12-8**] 05:10PM BLOOD Glucose-81 UreaN-10 Creat-0.9 Na-147* K-3.6 Cl-111* HCO3-24 AnGap-16 [**2183-12-9**] 06:10AM BLOOD Calcium-8.4 Phos-4.0 Mg-1.3* [**2183-12-9**] 06:10AM BLOOD Glucose-75 UreaN-11 Creat-0.8 Na-145 K-3.2* Cl-109* HCO3-23 AnGap-16 [**2183-12-10**] 06:35AM BLOOD Calcium-8.9 Phos-3.9 Mg-1.4* [**2183-12-10**] 06:35AM BLOOD Glucose-89 UreaN-12 Creat-0.8 Na-144 K-3.7 Cl-106 HCO3-24 AnGap-18 [**2183-12-10**] 12:27PM BLOOD Mg-1.3* Brief Hospital Course: 78 F transferred from [**Location (un) **] with headache for 3-4 days. She presented to OSH on [**2183-12-8**] as the headache became more severe. A head CT was performed which showed a right sided brain mass. She was admitted to Neurosurgery. A brain MRI was performed on [**2183-12-9**] which showed a right temporal lesion that may be an atypical meningioma vs. a metastatic lesion. Further neurosurgical intervention can occur outpatient and Mrs. [**Known lastname **] was discharged home on [**2183-12-10**]. Medications on Admission: Simvastatin 10-mg/day Januvia 50-mg/day levothyroxine 0.1-mg/day metoprolol 50-mg [**Hospital1 **] folic acid 1-mg [**Hospital1 **] glyburide 10-mg [**Hospital1 **] amitriptyline 50-mg/day furosemide 20-mg/day metformin 1000-mg [**Hospital1 **] Nifedical XL 30-mg/day gemfibrozil 600-mg [**Hospital1 **] potassium 20-mEq/day aspirin 81-mg/day Macrodantin 100-mg/day Discharge Medications: 1. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Glyburide 5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 3. Metformin 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 4. Gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Nifedipine 30 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO DAILY (Daily). 7. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 9. Amitriptyline 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 10. Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): Please stay on until follow-up appointment. Disp:*60 Tablet(s)* Refills:*2* 11. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for Headache. 12. Fioricet 50-325-40 mg Tablet Sig: One (1) Tablet PO every 4-6 hours as needed for headache. Disp:*30 Tablet(s)* Refills:*0* Discharge Disposition: Extended Care Facility: [**Hospital 4955**] Hospital - [**Location (un) 4329**] Discharge Diagnosis: Brain Lesion Discharge Condition: Neurologically Stable Discharge Instructions: CALL YOUR NEUROSURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING ??????New onset of tremors or seizures. ??????Any confusion or change in mental status. ??????Any numbness, tingling, weakness in your extremities. ??????Pain or headache that is continually increasing, or not relieved by pain medication. Followup Instructions: Your Follow-up will be coordinated and you will receive a call from [**Doctor Last Name **] or [**Location (un) 4956**] from Dr.[**Name (NI) 4957**] office. If you do not receive a call by Monday afternoon [**2183-12-15**], please call [**Telephone/Fax (1) 4958**] [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3657**] MD [**MD Number(2) 3658**] Completed by:[**2183-12-10**] Name: [**Known lastname 2601**],[**Known firstname 4497**] Unit No: [**Numeric Identifier 4954**] Admission Date: [**2183-12-8**] Discharge Date: [**2183-12-22**] Date of Birth: [**2105-4-14**] Sex: F Service: NEUROSURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 3656**] Addendum: Patient decided to stay inpatient for further work-up and surgery on [**12-15**]. She underwent a right craniotomy for tumor with Dr. [**Last Name (STitle) 1703**] on [**2183-12-15**]. Chief Complaint: Headaches x 4 days Major Surgical or Invasive Procedure: [**2183-12-15**]: s/p right craniotomy for brain tumor resection History of Present Illness: 78 F transferred from [**Location (un) **] with headache for 3-4 days. The pain began gradually and progressively worsened. It radiates from her skull base throughout her head, no laterality. It is a sharp throbbing pain. She attempted heat and cold packs without relief. She presented to OSH today as headache became more severe. She had a similar headache two weeks ago which resolved. She was seen by her Ophthalmologist 4 days ago and no major pathology was found. Pt reports 10 pound unintentional weight loss over 2 months. She denies associated nausea, vomiting, vision changes, hearing changes, numbness, weakness, paresthesias, seizures, diarrhea. She has been performing all ADLs independently. No recent trauma. Past Medical History: 1. diabetes 2. hypertension 3. history of chest pain syndrome with a negative cardiac catheterization ten years ago Social History: Lives at home. Never smoked. No EtOH Family History: Father: prostate ca Mother: liver ca Brother: lung/throat ca Brother: asbestosis Physical Exam: PE: T: 98.7 F HR: 85 BP: 168/67 R: 18 O2Sat: 96% RA Gen: WD/WN, comfortable, NAD. HEENT: Pupils: PERRL EOMs: Intact Eyes- non-icteric Neck: Supple, no lymphadenopathy. 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. Face symmetric, tongue midline No pronator drift Motor: D B T WE WF IP Q H AT [**Last Name (un) **] G R 5 5 5 5 5 5 5 5 5 5 5 L 5 5 5 5 5 5 5 5 5 5 5 Sensation: Intact to light touch on the both UE and LE Proprioception intact Toes downgoing Rectal exam: deferred ** Upon Discharge** xxxxx Brief Hospital Course: 78 F transferred from [**Location (un) **] with headache for 3-4 days. She presented to OSH on [**2183-12-8**] as the headache became more severe. A head CT was performed which showed a right sided brain mass. She was admitted to Neurosurgery. A brain MRI was performed on [**2183-12-9**] which showed a right temporal lesion that is consistent with a atypical meningioma. Diffrential diagnosis was a metastatic lesion; patient has no known cancer hx. Initially, further work-up and treatment was to occur outpatient but it was then determined to keep her inpatient and do further testing and surgery. A CT Torso was done to screen for other lesions; no significant findings. Patient and family agreed to go ahead with a right craniotomy for tumor resection in order to obtain pathology; being that the lesion was so small a resection was preferred vs. biopsy. On [**12-15**] pt went to the OR with Dr. [**Last Name (STitle) 1703**] for a right craniotomy; one night in the ICU for observation. Overnight SBP 130-140's requiring Nicardipine drip. On [**12-16**] Nicardipine drip was discontinued. She developed a temperature of 102 overnight into [**12-17**]. She was agitated and confused. Head CT showed noraml post-op chnages. Fever work-up was initiated. LENS were negative for DVT. [**Last Name (un) **] Cx was negative. Serial chest X-rays showed impovement in pulmonary edema. Blood cultures were still pending but she was afebrile. Her mental status was much improved. She was intact. She was medically cleared for rehab. She was screened for rehab and was transfered on ****** Medications on Admission: Simvastatin 10-mg/day Januvia 50-mg/day levothyroxine 0.1-mg/day metoprolol 50-mg [**Hospital1 **] folic acid 1-mg [**Hospital1 **] glyburide 10-mg [**Hospital1 **] amitriptyline 50-mg/day furosemide 20-mg/day metformin 1000-mg [**Hospital1 **] Nifedical XL 30-mg/day gemfibrozil 600-mg [**Hospital1 **] potassium 20-mEq/day aspirin 81-mg/day Macrodantin 100-mg/day Discharge Disposition: Extended Care Facility: [**Hospital 4955**] Hospital - [**Location (un) 4329**] Discharge Diagnosis: Brain Lesion Discharge Condition: Neurologically Stable [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3657**] MD [**MD Number(2) 3658**] Completed by:[**2183-12-22**] Name: [**Known lastname 2601**],[**Known firstname 4497**] Unit No: [**Numeric Identifier 4954**] Admission Date: [**2183-12-8**] Discharge Date: [**2183-12-22**] Date of Birth: [**2105-4-14**] Sex: F Service: NEUROSURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 3656**] Addendum: Exam on [**12-22**] upon discharge: Alert and oriented x3, full motor exam Discharge Disposition: Extended Care Facility: [**Hospital 4955**] Hospital - [**Location (un) 4329**] [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3657**] MD [**MD Number(2) 3658**] Completed by:[**2183-12-22**]

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Discharge summary

report

Admission Date: [**2201-1-25**] Discharge Date: [**2201-1-28**] Date of Birth: [**2115-1-13**] Sex: M Service: MEDICINE Allergies: Indomethacin Attending:[**First Name3 (LF) 896**] Chief Complaint: Chest pain Major Surgical or Invasive Procedure: None History of Present Illness: The patient is an 85 year old male with an extensive PMH including CAD, multiple CVAs, gastric cancer s/p Billroth II, recent valvuloplasty for severe AS, and POD2 s/p exlap/LOA/open J-tube placement, now back with CP, SOB, and decreased Hct. The patient was at rehab and was just advanced to tube feeds at 40cc/hr today. He complained of SOB/CP/nausea and was noted to have a HR of 50. He was transferred to [**Hospital1 18**] given his recent cardiac procedures. His Hct at [**Hospital1 18**] was noted to be low, 22.7, down from 26.3 yesterday. EKG showed no ischemic changes. His blood pressure was in the 80s but rose to the 90s after 1 unit PRBCs. He denies current CP/SOB/nausea. Also denies F/C or other constitutional symptoms. Of note, he is on ASA 325 and SQH. Lavage of the J-tube was negative for blood. Past Medical History: Past Medical History: Aortic Stenosis Coronary artery disease, prior NSTEMI [**2181**] and [**2199**] ([**Month (only) **]) Cerebrovascular Disease, prior stroke Carotid Disease Hypertension Dyslipidemia History of Gastric Cancer s/p Bilroth II History of Gout Bradycardia (no indication for PPM, CCB discontinued) History of NSVT Chronic Anemia Past Surgical History: Bilroth II for gastric CA Exlap/LOA/open J tube placement [**2201-1-22**] Social History: No alcohol, or illicit drug use. Smoked cigarettes for 40 years, quit 20 years ago. Moved from [**Country 10363**] to US >25 years ago and speaks both Romanian and Russian fluently. Lives with wife and has a daughter/son in law in the area. Family History: Noncontributory Physical Exam: Physical Exam On Transfer to Medicine: VS - Temp 96.0F, BP 102/29, HR 67, R 19, O2-sat 93% RA GENERAL - Elderly gentleman in NAD, appropriate, appears comfortable HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear NECK - supple, no thyromegaly, no JVD, no carotid bruits LUNGS - +Mild bibasilar crackles, no rh/wh, good air movement, resp unlabored, no accessory muscle use HEART +[**2-15**] mid-systolic murmur most prominent at upper sternal borders, PMI non-displaced, RRR, no rubs, nl S1-S2 ABDOMEN - J-tube in place without surrounding erythema or induration. +NABS, soft/NT/ND, no masses or HSM, no rebound/guarding EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs) SKIN - no rashes or lesions LYMPH - no cervical, axillary, or inguinal LAD NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength [**4-16**] throughout, sensation grossly intact throughout, gait deferred Physical Exam On Discharge: VS: T 97.4, BP 140/62, HR 62, RR 20, SpO2 97% on RA Gen: NAD. Alert and oriented x3. Mood and affect appropriate. Pleasant and cooperative. Resting in bed. HEENT: NCAT. PERRL, EOMI, anicteric sclera. MMM, OP benign. Neck: Supple. JVP not elevated. No cervical lymphadenopathy. CV: RRR. Normal S1, S2. Systolic C-D murmur across precordium, loudest at RUSB. Soft holosystolic murmur at apex. Chest: Respiration unlabored, no accessory muscle use. Lungs CTAB except for few bibasilar crackles. No wheezes or rhonchi. Abd: BS present. Healing midline abdominal incision with staples. Soft, ND. No erythema at J tube insertion site, dressing C/D/I. Less tender in area around J-tube insertion site than before. No HSM detected. Ext: WWP, no cyanosis or clubbing. No LE edema. Digital cap refill <2 sec. Distal pulses radial 2+, DP 1+, PT 1+. Skin: No rashes, ecchymoses, or other lesions noted. Neuro: Moving all four limbs. Pertinent Results: LAB RESULTS ON ADMISSION: [**2201-1-24**] 06:25PM BLOOD WBC-5.7 RBC-2.60* Hgb-7.7* Hct-22.7* MCV-88 MCH-29.6 MCHC-33.8 RDW-19.9* Plt Ct-182 [**2201-1-24**] 06:25PM BLOOD Neuts-82* Bands-0 Lymphs-9* Monos-7 Eos-2 Baso-0 Atyps-0 Metas-0 Myelos-0 [**2201-1-24**] 06:25PM BLOOD Hypochr-NORMAL Anisocy-2+ Poiklo-1+ Macrocy-1+ Microcy-1+ Polychr-NORMAL Ovalocy-1+ [**2201-1-24**] 06:25PM BLOOD PT-13.1 PTT-43.0* INR(PT)-1.1 [**2201-1-24**] 06:25PM BLOOD Glucose-103* UreaN-33* Creat-1.4* Na-141 K-4.4 Cl-109* HCO3-24 AnGap-12 [**2201-1-24**] 06:25PM BLOOD Calcium-8.0* Phos-3.3 Mg-2.0 [**2201-1-24**] 06:25PM BLOOD cTropnT-<0.01 [**2201-1-24**] 09:34PM BLOOD Lactate-0.8 [**2201-1-24**] 06:51PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.012 [**2201-1-24**] 06:51PM URINE RBC-0 WBC-[**2-14**] Bacteri-OCC Yeast-NONE Epi-0-2 [**2201-1-24**] 06:51PM URINE CastHy-[**2-14**]* [**2201-1-24**] 06:51PM URINE Mucous-OCC LAB RESULTS ON DISCHARGE: [**2201-1-28**] 05:37AM BLOOD WBC-4.2 RBC-3.00* Hgb-9.0* Hct-27.2* MCV-91 MCH-29.9 MCHC-32.9 RDW-19.3* Plt Ct-183 [**2201-1-28**] 05:37AM BLOOD Glucose-116* UreaN-29* Creat-1.0 Na-144 K-4.8 Cl-109* HCO3-29 AnGap-11 [**2201-1-28**] 05:37AM BLOOD Calcium-8.4 Phos-2.6* Mg-2.4 . MICROBIOLOGY: [**2201-1-24**] 6:51 pm URINE CULTURE (Final [**2201-1-26**]): NO GROWTH. [**2201-1-24**] 9:30 pm BLOOD CULTURE PICC LINE: NGTD (final results pending) IMAGING / STUDIES: # ECG ([**2201-1-24**] at 6:07:50 PM): Normal sinus rhythm with short P-R interval. Left axis deviation. Q waves in leads III and aVF suggest possible inferior myocardial infarction. Compared to the previous tracing of [**2201-1-21**] no diagnostic interim change. Rate PR QRS QT/QTc P QRS T 62 106 104 420/423 49 -33 68 # CHEST (PORTABLE AP) ([**2201-1-24**] at 6:06 PM): FINDINGS: Single AP upright portable view of the chest was obtained. The right PICC is again seen, distal aspect not well appreciated, but likely terminating in the region of the mid SVC. Bibasilar opacities appear more prominent, suggesting moderate pleural effusions with overlying atelectasis. No evidence of pneumothorax is seen. The cardiac and mediastinal silhouettes are unremarkable. Surgical clips are again noted in the right upper quadrant. Prominence of the central vasculature may be due to vascular engorgement. IMPRESSION: Moderate bilateral pleural effusions with overlying atelectasis, underlying consolidation cannot be excluded. Prominence of the central vasculature may be due to vascular engorgement. # CT ABD & PELVIS W/O CONTRAST ([**2201-1-24**] at 9:41 PM): There are moderate simple bilateral pleural effusions with associated compressive atelectasis, partially imaged. The heart shows coronary artery and mitral annular calcifications. CT OF THE ABDOMEN WITHOUT IV CONTRAST: There is a 7.8 x 3.6 x 7.1 cm right upper quadrant high density collection, most likely representing a hematoma adjacent to the entry of the J-tube. Moderate amount of free air is noted in the anterior upper abdomen. The left-sided J-tube terminates in a loop of jejunum with thickened wall. Evaluation of the solid organs is limited due to the lack of IV contrast. The liver and both adrenals are unremarkable. The upper pole of the right kidney is atrophied with an unchanged large stone in it. There is a cyst originating from the lower pole of the right kidney. Multiple cysts are noted in the left kidney. The spleen has an unchanged wedge-shaped hypodensity in the lower pole (2:25) likely representing an old infarct. The patient is status post cholecystectomy. No abdominal, retroperitoneal or mesenteric lymphadenopathy by CT size criteria is present. No abdominal free fluid or free air is present. Extensive arterial and aortic calcifications are seen. CT OF THE PELVIS WITHOUT IV CONTRAST: The rectum, sigmoid colon are unremarkable. The prostate is mildly enlarged. A Foley terminates in the collapsed bladder. No pelvic or inguinal lymphadenopathy by CT size criteria is noted. A small amount of high density fluid is seen in the pelvis, most likely hemorrhage vs less likely leaked bowel contrast. OSSEOUS STRUCTURES: The visible osseous structures show mild anterior osteophyte formations with no suspicious lytic or blastic lesions noted. IMPRESSION: 1. 7.8 x 3.5 x 7 cm high density collection, likely intraperitoneal hematoma adjacent to the J-tube site. Moderate amount of pneumoperitoneum in the upper abdomen may relate to recent procedure. Small amount of high density pelvic free fluid most likely hemorrhage vs much less likely mixing of leaked oral contrast. 2. Partially imaged moderate bilateral pleural effusions with overlying atelectasis. 3. Mild thickening of the J-tube containing jejunum. Brief Hospital Course: The patient is an 86 year old male with CAD, AS, DM2, HTN, HLD, and recent J tube placement and balloon valvuloplasty who presented with dyspnea and chest discomfort, and was found to have worse anemia due to an intraperitoneal hematoma at his J tube site. He was initially admitted to the ACS service for evaluation and treatment of low Hct and an anterior intraperitoneal hematoma. His stool was brown but guaiac positive, but flushing of the J-tube revealed no blood. The only bleeding source identified was the hematoma on CT. # Intraperitoneal Hematoma: He was initially hypotensive to the 80s and complaining of chest pain in the ED. He was given 1 unit PRBC with resolution of symptoms. Troponin was < 0.01, and his EKG showed no acute ischemic changes. CT abdomen showed a 7.8 x 3.6 x 7.1 cm hematoma in the anterior abdomen intraperitoneally near the site of his recent J-tube placement and lysis of adhesions. His CT was otherwise reassuring, with only a small amount of free air consistent with his recent J tube placement. He was admitted to the ICU, where his Hct was serially checked. J tube was initially put to gravity and then connected to tube feeds on HD1. The tube clogged on HD2 but was cleared with a cola infusion. His Hct remained stable after the unit of PRBCs, and he did not experience any further chest pain. He was transferred to the floor on HD2 and managed conservatively with serial hematocrits, which ranged between 22-25 from a baseline Hct in the high 30s. He remained hemodynamically stable after transfer and no external bleeding was appreciated on exam. His abdomen was only mildly tender. He was transfused 1 unit PRBCs on [**2201-1-27**] with an appropriate Hct increase from 22.4 to 27.2 the morning of discharge. # Aspiration: Video swallow study showed aspiration of all consistencies on [**2201-1-20**] during his prior admission. He had a J-tube placed for tube feeds and meds at that time. His J tube became obstructed in the ICU and again on [**2201-1-27**], and he was unable to take his morning meds until it was cleared later in the morning. The patient expressed an interest in eating, so a repeat video swallow evaluation was performed on [**2201-1-28**] to reassess his aspiration risk. The video swallow exam showed improvement, but continued high aspiration risk. It was recommended that he remain NPO but begin intensive swallow teaching in rehab, with the goal of eventually restarting a limited diet. # Urinary Retention / BPH: He had urinary retention during his last admission with plan to keep Foley in place for 2 weeks and treat with Finasteride and Tamsulosin. Finasteride was ordered on admission but cannot be crushed, and was unable to be given through his J-tube. After discussion with pharmacy, it was determined that a liquid form was available and was started on [**2201-1-28**]. He denied any urinary complaints with the Foley in place. The Foley should be removed after one week so that a voiding trial can be performed. He should continue treatment with Finasteride (liquid) and Tamsulosin. # Dyspnea/Chest Discomfort: Resolved at this time. Found to have pleural effusions and volume overload on CXR on [**2201-1-24**], but has remained close to euvolemic since transfer to floor. EKG and Troponin on admission were negative for ischemia. # Aortic stenosis: He is s/p balloon valvuloplasty last month with most recent [**Location (un) 109**] estimated 1.0-1.2 cm2. He had mild lightheadedness after his video swallow study but has otherwise been asymptomatic. His antihypertensives were continued with conservative holding parameters. His goal volume status was kept euvolemic to slightly volume up. # Nausea/vomiting: He had a single episode of nausea and vomiting prior to his transfer to medicine, but this resolved with no subsequent nausea. He was kept on Lansoprazole ODT 30 mg PO daily and ordered for Ondansetron prn nausea. He was also started on Simethicone 40-80 mg PO/NG QID:PRN gas pain. # Diabetes Mellitus: Continued sliding scale with QACHS fingersticks. # Dyslipidemia: He was discharged on Atorvastatin 40 mg PO daily after his last admission. This was continued. # Hypotension: He had an episode of hypotension shortly after after admission but remained fairly stable since then. His initial hypotension was likely hypovolemic given his hematoma and emesis, with no fevers to suggest sepsis. He was given IV fluids and remained normotensive for the remainder of his stay. # CAD: He usually takes Aspirin 325 mg daily. This was held on admission due to his hematoma. Given his stable Hct and lack of further bleeding, he was restarted on a lower dose of Aspirin 81 mg PO daily on discharge. He was continued on his Metoprolol with conservative holding parameters. # Access: Right PICC # DVT Prophylaxis: Pneumoboots # Pain Management: Acetominophen 650 mg PO Q6H PRN pain # Code status: FULL CODE, confirmed with patient # Transitional Care: -- He will need intensive swallowing therapy in rehab with the goal of resuming limited PO intake. -- Blood cultures from [**2201-1-24**] showed NGTD but final results were pending at the time of discharge -- Will need follow-up CBC in [**1-15**] days -- Stopped SC heparin due to hematoma but given risk of DVT, could consider restarting within 1 week Medications on Admission: 1. atorvastatin 40 mg Tablet [**Date Range **]: One (1) Tablet PO DAILY (Daily). 2. insulin lispro 100 unit/mL Solution [**Date Range **]: 0-12 units Subcutaneous every six (6) hours: see attached Humalog sliding scale. 3. docusate sodium 50 mg/5 mL Liquid [**Date Range **]: Ten (10) ml PO BID (2 times a day). 4. senna 8.6 mg Tablet [**Date Range **]: One (1) Tablet PO BID (2 times a day). 5. aspirin 325 mg Tablet [**Date Range **]: One (1) Tablet PO DAILY (Daily). 6. heparin (porcine) 5,000 unit/mL Solution [**Date Range **]: One (1) injection Injection TID (3 times a day). 7. lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily). 8. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization [**Last Name (STitle) **]: One (1) vial Inhalation Q6H (every 6 hours) as needed for SOB, wheezing. 9. multivitamin, stress formula Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily). 10. oxycodone 5 mg Tablet [**Last Name (STitle) **]: 0.5 Tablet PO Q4H (every 4 hours) as needed for pain. 11. acetaminophen 500 mg Capsule [**Last Name (STitle) **]: Two (2) Capsule PO TID (3 times a day) as needed for pain/fever. 12. Heparin Flush (10 units/ml) 2 mL IV PRN line flush PICC, heparin dependent: Flush with 10mL Normal Saline followed by Heparin as above daily and PRN per lumen. 13. lipase-protease-amylase 5,000-17,000 -27,000 unit Capsule, Delayed Release(E.C.) [**Last Name (STitle) **]: One (1) Cap PO every eight (8) hours: Please remove from capsule and dissolve completely. . 14. metoprolol tartrate 25 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO twice a day. 15. allopurinol 100 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO once a day. 16. finasteride 5 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO once a day. 17. Flomax 0.4 mg Capsule, Ext Release 24 hr [**Last Name (STitle) **]: One (1) Capsule, Ext Release 24 hr PO at bedtime. 18. hyoscyamine sulfate 0.125 mg Tablet, Sublingual [**Last Name (STitle) **]: One (1) tablet Sublingual four times a day as needed for gastric spasm. 19. simethicone 80 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO four times a day as needed for indigestion. Discharge Medications: 1. atorvastatin 40 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily). 2. Humalog 100 unit/mL Solution [**Last Name (STitle) **]: One (1) injection Subcutaneous four times a day: Per sliding scale. 3. docusate sodium 100 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO twice a day. 4. senna 8.6 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO twice a day. 5. aspirin 81 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO once a day. 6. lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily). 7. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization [**Last Name (STitle) **]: One (1) nebulization Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. 8. multivitamin Tablet [**Last Name (STitle) **]: One (1) Tablet PO once a day. 9. oxycodone 5 mg Tablet [**Last Name (STitle) **]: 0.5-1 Tablet PO every 4-6 hours as needed for pain. 10. acetaminophen 650 mg/20.3 mL Solution [**Last Name (STitle) **]: Six [**Age over 90 1230**]y (650) mg PO Q6H (every 6 hours) as needed for pain. 11. lipase-protease-amylase 5,000-17,000 -27,000 unit Capsule, Delayed Release(E.C.) [**Age over 90 **]: One (1) Cap PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 12. metoprolol tartrate 25 mg Tablet [**Age over 90 **]: One (1) Tablet PO BID (2 times a day). 13. allopurinol 100 mg Tablet [**Age over 90 **]: One (1) Tablet PO once a day. 14. finasteride 5 mg Tablet [**Age over 90 **]: One (1) Tablet PO DAILY (Daily). 15. tamsulosin 0.4 mg Capsule, Ext Release 24 hr [**Age over 90 **]: One (1) Capsule, Ext Release 24 hr PO at bedtime. 16. hyoscyamine sulfate 0.125 mg Tablet [**Age over 90 **]: One (1) Tablet PO four times a day as needed for gastric spasm. 17. simethicone 80 mg Tablet, Chewable [**Age over 90 **]: One (1) Tablet, Chewable PO QID (4 times a day) as needed for gas pain. 18. camphor-menthol 0.5-0.5 % Lotion [**Age over 90 **]: One (1) Appl Topical QID (4 times a day) as needed for itching. 19. Zofran 4 mg Tablet [**Age over 90 **]: 1-2 Tablets PO three times a day as needed for nausea. Discharge Disposition: Extended Care Facility: [**Hospital3 105**] - [**Location (un) 86**] Discharge Diagnosis: Primary Diagnosis: Anemia Secondary Diagnosis: Aortic stenosis Diabetes Mellitus Dyslipidemia Hypertension Coronary artery disease Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: You were admitted to the hospital due to chest pain and shortness of breath. You had a CAT scan of your abdomen and pelvis which showed a hematoma around your gastric tube site. Your blood count was low on admission and you were given blood. It was felt that your blood count was low due to the hematoma. After you were given blood, your blood count remained stable. You also had an evaluation by the swallowing team who felt that you were not currently safe to eat due to the risk of aspiration. However, you have improved since prior evaluation. You should continue swallow teaching and rehab after discharge. You should also continue physical therapy. We stopped your heparin given subcutaneously given your hematoma. If your blood count is stable over the next 1 week, this should be restarted for DVT prophylaxis. Changes to your medications: Stopped SC heparin Changed aspirin 325mg to 81mg daily Followup Instructions: You should follow-up with the providers at your rehab facility. When you are discharged, please schedule a follow-up appointment with your primary care doctor. Otolaryngology: Phone: [**Telephone/Fax (1) 2349**] Address: [**Location (un) **] (east bound side of Rt 9) [**Apartment Address(1) **] [**Location (un) 55**], MA Dr. [**Last Name (STitle) 106472**] [**Name (STitle) **] Date/Time: [**2-10**] at 11:00am Name: [**Last Name (LF) **], [**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] Specialty: Cardiology Address: [**Street Address(2) 2687**],STE 7C, [**Location (un) **],[**Numeric Identifier 822**] Phone: [**Telephone/Fax (1) 5768**] Appointment: Tuesday [**1-27**] at 11:30AM

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icd9cm

[ [ [] ] ]

[ "96.6" ]

icd9pcs

[ [ [] ] ]

18404, 18475

8553, 13894

284, 291

18651, 18651

3814, 3826

19761, 20501

1890, 1908

16216, 18381

18496, 18496

13920, 16193

18827, 19653

1538, 1614

1923, 2836

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18544, 18630

18515, 18523

3840, 4752

18666, 18803

1190, 1515

1630, 1874

15,046

198,962

50749

Discharge summary

report

Admission Date: [**2193-12-13**] Discharge Date: [**2193-12-20**] Date of Birth: [**2124-2-1**] Sex: F Service: MEDICINE Allergies: Tetracyclines / Zinc / Optiray 350 Attending:[**First Name3 (LF) 1257**] Chief Complaint: Respiratory distress Major Surgical or Invasive Procedure: None History of Present Illness: 69yo woman with h/o aspiration and COPD presenting with an episode of respiratory distress at home. She had J tube removed on [**2193-11-27**] and has deteriorated since this time. She had the J tube for 4 years and was taking tube feeds and supplementing with oral intake. She wanted the J tube removed for quality of life and this was done on [**2193-11-27**]. Since this time, anything she would eat or drink would come out the J-tube hole onto the skin. She has had constant leakage of green fluid onto the abdomen, leading to erythema and pain. She complained of generalized abdominal pain. On [**2193-12-4**] she was seen in the [**Hospital **] clinic for a complaint of pain and the notes indicate the site was healing, though slightly erythematous. Her caretaker notes the onset of significant weakness over the last few weeks since the J tube was removed and her oral intake became unreliable and the leakage continued. She usually is able to cough if she aspirates and does the incentive spirometer reliably. Over the last 2 weeks, she has not been able to do this. . This morning, she was given an enema because she had not had a bowel movement in the last week. She did not eat breakfast, but was noted to have ronchorous upper airway sounds consistent with her prior history of aspiration. . In the ED, initial VS were: 97.3 138/62 100 30 84-95% on 4L NC. She had a WBC of 20 with 20% bands and new ARF. She had a high oxygen requirement in the ED, satting mid-80s on 100% NRB. Respiratory deep suctioned her and produced a significant amount of grey/green foul sputum. This was sent for culture. Her oxygen saturation stabilized and mental status improved once this was done. She had a rectal temperature done, which was 99 degrees. She was given 1600 cc IV fluids. CXR demonstrated an infiltrate and she was treated for aspiration pneumonia with levofloxacin 750 mg X 1, ceftriaxone 1 g IV X 1 and clindamycin 600 mg IV X 1. CT Torso revealed acute on chronic aspiration and possible pancreatitis. Her lipase returned elevated. Given her variable oxygen requirement, she was admitted to the [**Hospital Unit Name 153**] for further monitoring. Upon arrival to the floor, she complains of being thirsty and of abdominal pain. She is awake and answers questions, but sometimes makes nonsensical comments. Her caretaker arrived and reported that her the current state is her most recent baseline. Prior to the J tube removal, she was mobile with a rolling walker, conversant and not confused. The patient [**Hospital Unit Name **] headache, blurred vision, mouth sores, chest pain or leg pain. She has some shortness of breath. Past Medical History: 1. Castleman's disease: unicentric. Found incidentally on splenectomy done for "splenic pain" around [**2176**]. Has had lymph nodes sampled in past to r/o lymphoma but all have shown reactive lymph tissue only. Followed here in Heme/Onc by Dr. [**Last Name (STitle) 410**]. 2. Hx anaplastic thyroid cancer s/p radical neck dissection, at age 15 3. Esophageal webs and esophageal dysmotility. Has had numerous esophageal dilatations. 4. Recurrent aspiration pneumonias sputum Cx growing Pseudomonas, MRSA 5. Chronic pulmonary disease 6. MRSA osteomyelitis of olecranan s/p multiple debridements 7. Hx Bipolar d/o 8. GERD 9. Osteoporosis: has broken both hips, left in [**11-7**], right with failed ORIF and redo at [**Hospital1 2025**] 10. Hx zoster 11. Hx depression, chronic pain 12. HTN 13. Parkinson's disease Social History: Retired social worker. [**Name (NI) 6934**] with walker and assistance at baseline. No Etoh, [**Name (NI) **], drugs. Lives at home w/ 24 hour health aid. POA = [**Name (NI) **] [**Name (NI) 105568**] (a lawyer). Family History: 1. Father: HTN, DM, depression, died MI, age 59. 2. Mother: HTN, hypercholesterolemia, died MI, age 82. 3. Sister: HTN Physical Exam: VS: T 100.1 BP 176/57 HR 95 SpO2 94% 5L GEN: elderly, awake, asking for water, uncomfortable HEENT: PERRL, OP clear, MM dry Neck: supple, nontender Car: Regular, no murmur Resp: ronchi R>>L, no crackles or wheezes Abd: open wound in mid-epigastrium with green discharge soaking through thick dressings and a towel. Some bleeding on wound edge. Erythema surrounding wound, particularly on lower portion. Abdomen soft but with diffuse mild tenderness. + BS Ext: SCDs in place, no edema, 2+ DP Pertinent Results: Admission Labs: [**2193-12-13**] 02:05PM WBC-20.8*# RBC-4.41 HGB-14.0 HCT-42.0 MCV-95 MCH-31.7 MCHC-33.3 RDW-15.2 [**2193-12-13**] 02:05PM PLT SMR-NORMAL PLT COUNT-409 [**2193-12-13**] 02:05PM PT-14.1* PTT-30.9 INR(PT)-1.2* CXR [**2193-12-13**]: New infiltrate in the left perihilar and left lower lobe in the presence of a chronic elevated left hemidiaphragm. The findings are most compatible with pneumonia. Repeat radiography to document resolution after appropriate therapy recommended. . CT Abd/Pelvis [**2193-12-13**]: 1. Acute on chronic aspiration in both lung bases, right greater than left, which is worse compared to CT from 12/[**2191**]. Small left pleural effusion. 2. Faint fat stranding around the pancreas. Please correlate clinically for possible pancreatitis. . RUQ Ultrasound [**2193-12-14**]: Limited evaluation of the liver demonstrates mild intrahepatic biliary ductal dilatation and dilatation of the common bile duct up to 1 cm. The gallbladder is distended with a large shadowing stone measuring 1.7 cm in the dependent portion. However, there is no gallbladder wall thickening or pericholecystic fluid. The main portal vein is patent with hepatopetal flow. Evaluation of the pancreas was not possible due to overlying bowel gas and ostomy bag. IMPRESSION: 1. Cholelithiasis without evidence of acute cholecystitis. 2. Intra- and extra-hepatic biliary ductal dilatation, not significantly changed compared to the recent CT.If there is concern for choledocholithiasis, ERCP may be performed for further evaluation. Brief Hospital Course: 69 year old female with multiple medical problems presented with respiratory distress from aspiration event in setting of persistent J tube leakage and abdominal pain. Imaging studies supported clinical exam of acute on chronic aspiration. Her respiratory status improved post deep suction by respiratory therapy. She was treated for aspiration pneumonia with IV levofloxacin and flagyl starting [**12-13**] and throughout her hospitalization completing a 7 day course of antibiotic therapy. Goals of care were discussed at length with the patient and her health care proxy. The decision was made to allow the patient to eat and drink as she wished with the knowledge that she will continue to aspirate and ultimately experience infection, respiratory distress and death. Patient showed clear understanding and accepted these risks. Patient requested that she not be hospitalized if she were to develop symptoms of respiratory distress or pneumonia after her discharge. She was offered Hospice services to help with symptom management should she not wish to return to the hospital. Patient will be evaluated by [**Hospital **] home health services bridged to Hospice. Her respiratory symptoms remained stable after intitial presentation to the floor. She continued to experience regular asymptomatic oxygen desaturations with eating. Patient will be discharged home on continuous supplemental oxygen. . Surgery was consulted regarding her gastrocutaneous fistula. They presented the options of sclerotherapy, laproscopic surgery, or replacing the G-tube. Patient chose to replace the G-tube to stop the leaking. She does not want to rely on the g-tube for feedings. However, she is concerned that eating has become "too much work". She would like to have the option of using the tube for medications and nutrition if needed for comfort. G-tube was placed (reinserted) at bedside by Dr. [**Last Name (STitle) **] on [**2193-12-18**]. The G-tube is a foley catheter that can be used to deliver feeds and medications is needed. She will receive VNA services to manage her G-tube after discharge. [**Hospital **] home health aid, [**Hospital 96555**], was instructed to use her G-tube ONLY at the patient's request or for comfort measures. . GI team was consulted on admission as patient presented with significant abdominal pain that did not correspond to her fistula. CT scan showed fat stranding around the pancreas and gall stones. HIDA scan was not consistent with acute cholecystitis and GI recommended no interventions. Patient's symptoms of abdominal pain and nausea improved. . CODE: DNR/DNI/DNHospitalize confirmed with patient in the presence of her health care proxy . EMERGENCY CONTACT/HEALTH CARE PROXY: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 105568**] [**Telephone/Fax (1) 105569**] . HOME HEALTH AIDE: [**Telephone/Fax (1) 96555**] [**Telephone/Fax (1) 105574**] Medications on Admission: Sinemet 25/100 every 4 hours while awake-8/12/4/8--not filled since [**2193-11-2**] Lexapro 20 mg daily Neurontin 300 mg qhs Lamictal 200 mg daily Levothyroxine 100 mcg daily Ativan 1 mg qam, 2 mg qpm Oxycodone SR 20 mg [**Hospital1 **] Oxycodone 5 mg [**1-4**] tab 4 times per day Primidone 25 mg daily Seroquel 300 mg at bedtime Vitamin D 400 IU twice daily Iron sulfate 325 mg daily Refresh eye drops, Neo-poly-dex eye, 1 gtt both eyes each night Zofran 4 mg every 8 hours prn Discharge Medications: 1. Acetaminophen 500 mg/5 mL Liquid [**Month/Day (2) **]: Five (5) mL PO every six (6) hours as needed for fever or pain. Disp:*500 mL* Refills:*2* 2. Miconazole Nitrate 2 % Powder [**Month/Day (2) **]: One (1) Appl Topical TID (3 times a day) as needed for rash. Disp:*1 bottle* Refills:*2* 3. Lexapro 20 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO once a day. 4. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette [**Month/Day (2) **]: [**1-4**] Drops Ophthalmic PRN (as needed) as needed for dry eyes. Disp:*1 bottle* Refills:*2* 5. Carbidopa-Levodopa 25-100 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO QID (4 times a day): To be given 8am, noon, 4pm, 8pm. 6. Seroquel 300 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO at bedtime. Disp:*30 Tablet(s)* Refills:*2* 7. Gabapentin 300 mg Capsule [**Month/Day (2) **]: One (1) Capsule PO at bedtime. 8. ZOFRAN ODT 4 mg Tablet, Rapid Dissolve [**Month/Day (2) **]: [**1-4**] Tablet, Rapid Dissolves PO every eight (8) hours as needed for nausea. Disp:*20 Tablet, Rapid Dissolve(s)* Refills:*3* 9. Primidone 50 mg Tablet [**Month/Day (2) **]: 0.5 Tablet PO DAILY (Daily). 10. Levothyroxine 100 mcg Tablet [**Month/Day (2) **]: One (1) Tablet PO DAILY (Daily). 11. Oxycodone 5 mg/5 mL Solution [**Month/Day (2) **]: Ten (10) mL PO every six (6) hours as needed for pain. Disp:*600 mL* Refills:*2* 12. Ativan 0.5 mg Tablet [**Month/Day (2) **]: 1-2 Tablets PO every 6-8 hours as needed for anxiety. Disp:*30 Tablet(s)* Refills:*2* 13. Lamictal Oral Discharge Disposition: Home With Service Facility: [**Hospital3 10377**] Hospice Discharge Diagnosis: Aspiration pneumonia Gastrocutaneous fistula Chronic cholecystitis Malnutrition Discharge Condition: Patient is afebrile and hemodynamically stable. She requires supplemental oxygen to maintain oxygen saturations greater than 93%. She requires assistance for ambulation. Discharge Instructions: You presented to the hospital in respiratory distress. You were found to have an aspiration pneumonia and you were started on IV antibiotics. You completed a 7 day course of antibiotics and your symptoms improved. . You were also found to have tract (fistula) between your stomache and your abdominal skin at the site of your prior G-tube that was leaking fluid. You were evaluated by the Surgery team who offered multiple interventions to resolve the leaking. You decided to have the G-tube replaced to stop the leaking of the fluid. . Your chronic abdominal pain was evaluated extensively and the GI team was consulted. They determined that there was no need for intervention at this time. . Followup Instructions: [**Hospital **] home health and hospice services will follow up with you to manage your symptoms.

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icd9cm

[ [ [] ] ]

[ "97.03" ]

icd9pcs

[ [ [] ] ]

11300, 11360

6326, 9235

317, 323

11484, 11657

4754, 4754

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257, 279

351, 3025

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3878, 4092

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155,964

17898

Discharge summary

report

Admission Date: [**2140-1-12**] Discharge Date: [**2140-2-26**] Date of Birth: [**2082-4-6**] Sex: F Service: [**Last Name (un) **] ADMISSION DIAGNOSIS: Fevers, chills, abdominal pain, fluid around [**Location (un) 1661**]-[**Location (un) 1662**] drain. HISTORY OF PRESENT ILLNESS: The patient is a 57 year old female well known to the transplant service, with past medical history for status post right hepatic lobectomy for donation [**2139-11-23**]. Postoperative course complicated by a biliary leak, right pleural effusion, pneumothorax after thoracentesis, malnutrition, frequent retching. Recently diagnosed from hospital on [**2140-1-8**]. Presents today because the patient is febrile, 101.5, with shaking chills and retching x one day. Also had abdominal pain and right lower quadrant, and had clear yellow fluid around [**Location (un) 1661**]-[**Location (un) 1662**] drain tube which soaked through her dressing and shirt. No change in bowel or bladder, no diarrhea, no shortness of breath, no chest pain, no pain in abdomen at this present time. The patient was tolerating a modest amount of p.o. intake at home, but has not eaten much today, which was [**2140-1-12**], and returns with retching. PAST MEDICAL HISTORY: Migraines and anxiety. Restless legs. History of right pleural effusion/biliary leak after liver donation. Pneumothorax after thoracentesis. PAST SURGICAL HISTORY: Right hepatic lobectomy. Left partial nephrectomy. Status post appendectomy, total abdominal hysterectomy and bilateral salpingo-oophorectomy. ALLERGIES: Ethylene. MEDICATIONS ON ADMISSION: Atenolol 50 daily, Colace 100 mg b.i.d., Protonix 40 daily, Imitrex 50 mg p.r.n., Anusol suppositories p.r.n., Mirapex p.r.n., Reglan 10 mg q.i.d., Tylenol p.r.n., multivitamins daily, scopolamine patch q 72 hours, senna p.r.n. PHYSICAL EXAMINATION: Awake, alert, in no acute distress sitting up in bed. Temperature 101.7, 120, 120/78, respirations 20, 94 percent on room air. Cardiovascular - Tachycardic, regular, no murmurs, rubs, gallops. Pulmonary - Clear to auscultation bilaterally. Abdomen - Incision well healed, soft, nontender, non distended. No erythema. [**Location (un) 1661**]-[**Location (un) 1662**] drain - entire site - no pus, very minimal erythema, no palpable masses, no fluid component. Around JP site, no rebound or guarding. JP fluid is observed as bilious, clear fluid which was unchanged. Extremities - No cyanosis, clubbing or edema. Well perfused. Neurologic - Moves all extremities. Sensation intact throughout. LABS ON ADMISSION: WBC of 15.6, hematocrit 31.1, platelets 193. Sodium 141, 2.2, 104, 27, 20, 0.6. Blood sugar 148. Liver function tests on the 25th demonstrate an ALT of 35, AST 37, alkaline phosphatase 427, total bilirubin of 2.6, PT 15.4, PTT 28.6, INR 1.5, calcium, phos and mag 8.9, 2.4, 1.6. The patient was admitted. The patient's cultures were sent off for a fever workup. CT abdomen was ordered and the patient was NPO for potential scans. CT abdomen was obtained on [**2140-1-13**], demonstrating persistent intrahepatic ductal dilation unchanged from the exam on [**2139-12-23**]. Slight interval increase in size of the small subhepatic fluid collection, now measuring 2.5 cm in greatest dimension. Slight decrease in size of smaller adjacent fluid collection, now measuring less than 1 cm in greater dimension. And three, persistent right pleural effusion with adjacent atelectasis. The patient was started on Zosyn for empiric fever, empiric antibiotics. So from [**2140-1-12**] blood culture demonstrated Enterobacter cloacae. Urine culture was negative on [**2140-1-13**], and the pleural fluid demonstrated no growth. The patient continued on TPN that she was on when she was discharged from home prior to this hospitalization. On [**2140-1-14**], the patient was afebrile, but had episodes of rigors for which she received Demerol, but then had a temperature of 101.2. On [**2140-1-14**], the patient had removal of right sided PICC line. PICC sent for culture. The patient was replaced with Levaquin, and Zosyn was discontinued on the 28th. Nutrition closely followed the patient while she was on TPN. Infectious Disease was consulted for bacteremia. On [**2140-1-22**], the patient had a CT abdomen with intravenous contrast for questionable biliary leak, and the results of the CT abdomen demonstrated communication between the [**Location (un) 1661**]- [**Location (un) 1662**] drain and the biliary tract, with opacification of the intrahepatic bile ducts. The site of the communication was likely along the lateral edge of segment four. It was decided to discontinue her TPN on [**2140-1-20**], and to monitor her calorie counts closely. On [**2140-1-22**], the patient stated that current appetite is good. No nausea or vomiting. She is getting supplements and Carnation Instant Breakfast. On [**2140-1-23**], hospital day eleven, on Levaquin with [**Location (un) 1661**]- [**Location (un) 1662**] drain in place, the patient had a temperature of 101.6. Abdomen soft, nontender, nondistended. Labs from [**2140-1-22**] demonstrated an ALT of 38, AST 33, alkaline phosphatase 654, total bilirubin 1.2 and urinalysis negative. The patient had blood cultures and urine cultures sent. On [**1-26**], the patient had a PTCA demonstrating that there was no opacification of the common bile duct, the duodenum or the hepatic ducts. Focal leak was identified at the confluence of the left hepatic ducts. These findings are concerning for an isolated left hepatic duct segment. An 8.5 French external [**Location (un) 2617**]- [**Doctor Last Name 2418**] biliary drainage catheter was placed to bag drainage, with the catheter tip positioned in the distal left hepatic duct. On [**2140-1-27**], the patient had a PTC placement. The patient was afebrile, vital signs stable. Abdomen was soft, appropriately tender, non distended. The patient had a PTC and [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 1661**]-[**Location (un) 1662**] drain in place, PTC for 24 hours, JP 43. On [**2140-1-27**], the patient had a MRCP demonstrating that there were three dilated branches of the left lateral segment of the hepatic duct, which were isolated from the common hepatic duct. Percutaneous catheter was then located within the main left lateral segment duct and decompresses to this duct. As previously noted by the PTC performed [**2140-1-26**], there is no communication with the common hepatic duct. Two, there is probable narrowed, though patent, communication between the medial segment ducts with the common hepatic duct. Three, there is a large right pleural effusion and right lower lobe atelectasis. Four, small fluid collection located superior to the left portal vein consistent with a known bile leak. Social Work was consulted and saw the patient throughout her hospitalization. On [**2140-1-29**], the patient went to surgery with a preoperative and postoperative diagnosis of bile duct leak, performed by Dr. [**Last Name (STitle) **]. His first assistant was Dr. [**First Name (STitle) 2523**]. The patient was brought back to the operating room for a Roux-en-Y hepaticojejunostomy. Please see the OR note for the specific details of from [**2140-1-29**]. Postoperatively, the patient went to the SICU, in which the patient was placed on Zosyn and vancomycin. The patient was on propofol and was intubated postoperatively. Labs on [**2140-1-30**] - ABG 7.37, 36, 116, 22 on SIMV of two percent. Her labs were stable. WBC was impressive for a 19.2, hematocrit of 30, platelets 345. ALT was 700, alkaline phosphatase 472, total bilirubin 2.3, albumin 2.5. The patient continued to be on Zosyn, vancomycin, and was started on caspofungin. The patient had [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 1661**]-[**Location (un) 1662**] drain one and two and a T-tube. The patient was having diuresis, and the patient was extubated on [**2140-2-1**]. The patient continued on TPN and Dilaudid. On [**2140-2-1**], the patient was transferred to the floor. The patient was afebrile and vital signs were stable. Respiration rate 28, 99 percent on four liters. The patient had three [**Location (un) 1661**]-[**Location (un) 1662**] drains. The first JP put out 60 over 24 hours, JP 2 120, JP 3 100. Abdomen was soft, moderately tender and nondistended. The patient was receiving Lasix, TPN. The patient was out of bed, ambulating, regular diet. The patient was seen by Psychiatric on [**2140-2-5**] because of questionable delirium. Psychiatry thought that her behavior was due to resolving infection from her biliary leak repair, coupled with intensive care unit setting and p.o. medication administration. Psychiatry had recommended Haldol 2 mg IV q 2 hours for confusion and agitation, but would limit the use of pain medication given to her at that time. The patient was transferred from the SICU to floor ten on [**2140-2-6**]. The latter part of her hospitalization, the patient was very cheerful, alert, awake, afebrile, vital signs stable. JP - There were three drains that were draining, two from the [**Location (un) 1661**]-[**Location (un) 1662**] drain and one PTC drain. The patient continued on vancomycin, Zosyn and caspofungin. On [**2140-2-9**], the patient had a cholangiogram demonstrating that there was decompressed left hepatic ductal system, free flowing to the bowel with no extravasation. Also on [**2140-2-9**], the patient had a CT abdomen demonstrating infarction of segment 3 of the liver. There was a residual subcapsular enhancement, as well as enhancement of vessels running through this region of necrosis. There is currently no drainable fluid collection. Two, there is a small amount of fluid which is present along the inferior rim of the liver. Three, trace amount of biliary air was present within the left lower lobe of the liver. Four, right sided mild to moderate atelectasis and pleural effusion with minimal left sided atelectasis and effusion. PT and OT were consulted. Nutrition and Social Work were following the patient very closely. Because the patient's platelets were dropping, a heparin dependent antibody test was performed, which was positive for heparin dependent antibodies on [**2140-2-8**], so subcutaneous heparin was discontinued. There were no heparin flushes through her PICC line for TPN. Since the patient was slightly confused and had difficulty with word finding, the patient did have a CT head, which demonstrated that it was normal. There was no intracranial mass, no hemorrhages identified or fluid collection. ON [**2140-2-13**], the patient had another CT abdomen because of complaints of abdominal pain, and the radiologist compared it to the CT abdomen from [**2140-1-13**]. It demonstrated no significant change in appearance of the infarction in segment 3 of the liver. Two, mild resolution of mild hepatic biliary duct dilation and periportal edema. Three, unchanged moderate right pleural effusion. Four, no drainage, fluid collection. Neurology was consulted because of questionable expressive aphasia. They felt that the neurologic exam was most striking for inability to concentrate, mostly which fluctuates with her mood. They thought that she should improve as her medical issues resolve, and that she required social support as much as possible. They thought that there was no neurologic origin for her difficulty with speaking. On [**2140-2-12**], the patient did have a temperature up from a temperature of 102. Infectious Disease was re-consulted and thought that the patient should be continued on Zosyn and to re-start her caspofungin. ON [**2140-2-13**], a CMV viral load was obtained, demonstrating that there was no detection. Blood cultures were obtained, demonstrating no growth. Urine culture obtained, demonstrating no growth. Also, PTC fluid obtained demonstrating Klebsiella oxytoca. And fungal blood culture was obtained, demonstrating no fungus, no mycobacteria isolated. On [**2140-2-13**], because of her being febrile, the patient had a right internal jugular line changed over a wire. They replaced it with a new right internal jugular catheter at 8 p.m. on [**2140-2-13**]. The line tip was sent off, demonstrating no significant growth from the line. On [**2140-2-14**], transplant ID was consulted and felt that Zosyn could be discontinued. The patient should be placed on meropenum one gram IV q 8, continue with the caspofungin and vancomycin. On [**2140-2-16**], the patient was evaluated for a line placement, which was performed on the right side. It was confirmed by a chest x-ray that day. Infectious Disease felt that vancomycin should be discontinued, since there was no methicillin resistant Staph aureus recovered from drains and most recent cultures, but to continue on meropenum and caspofungin during her hospitalization. On [**2140-2-21**], Dermatology was consulted because of a questionable drug rash that was throughout her body, starting mostly on the chest area and then had spread to the arms and legs. It was recommended to start her on some ointment, triamcinolone ointment 0.1 percent b.i.d., Sarna lotion ad lib. Nutrition closely followed the patient while she was on TPN during the hospitalization. PT/OT followed the patient and worked with her daily. Psychiatry followed up with her on [**2140-2-22**] and felt that because she has been melancholy, that it was more of an adjustment disorder, depressed mood, and that there was no need for antidepressants, that she would improve once her medical condition minimized. The patient's rash slowly improved after being only on Levaquin and caspofungin. The patient continued to have one [**Location (un) 1661**]-[**Location (un) 1662**] drain and one PTC drain, which continued to be clean, dry and intact. She has been afebrile since being on Levaquin and caspofungin. The patient left on the following medications: Tylenol 50 mg daily. Colace 100 mg b.i.d. Protonix 40 mg daily. Imitrex 50 mg tablets daily p.r.n. Senna 8.6 tablet one b.i.d. p.r.n. Insulin NPH 100 units/ml suspension while on TPN, subcutaneously b.i.d. Lasix 10 mg daily. Triamcinolone acetonide ointment 0.1 percent applied topically b.i.d. Benadryl capsules 5 mg q 6 p.r.n. for itching rash. Levaquin 500 mg tablet once a day. Caspofungin 50 mg IV q 24 hours. The patient is to have JP dressings daily, dry sterile gauze, observe site for infection. PICC line protocol. Care for dressing. PICC line flushes with saline only. The patient had a VNA at her home for evaluation of nutrition, with her TPN and her JP, PICC line, dressing changes. The patient had a follow up appointment with Dr. [**Last Name (STitle) **] on [**2140-3-2**] at 10:30 a.m. The patient had an appointment for followup with [**First Name4 (NamePattern1) 10801**] [**Last Name (NamePattern1) **], who is the social worker, on [**2140-3-2**] at 11 a.m., and also a followup appointment with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], which should be made in seven to days on discharge at [**Telephone/Fax (1) 23571**]. DISCHARGE DIAGNOSES: 1. Right hepatic donor lobectomy [**2140-11-22**]. 2. Bacteremia. 3. Malnutrition. 4. Right pleural effusion with thoracentesis. 5. Methicillin resistant Staph aureus in bile; bile leak. 6. Status post Roux-en-Y hepaticojejunostomy. 7. Pruritus/drug rash on meropenum. MAJOR INVASIVE SURGICAL PROCEDURES FROM THIS ADMISSION: 1. PICC line placement x 2. 2. Roux-en-Y hepaticojejunostomy. Labs on [**2-26**] - WBC of 8.8, hematocrit 28.4, platelets 238. Sodium 135, 4.8, 107, 24. BUN, creatinine 20 and 0.3 with a glucose of 83. ALT 23, AST 43, alkaline phosphatase 420, total bilirubin 1.8. Lipase 160. Calcium 8.2 on [**2-26**], phos 3.6. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 12072**] Dictated By:[**Last Name (NamePattern1) 4835**] MEDQUIST36 D: [**2140-2-29**] 19:48:58 T: [**2140-2-29**] 21:31:32 Job#: [**Job Number 49610**]

[ "E934.2", "E947.8", "693.0", "998.59", "567.2", "599.0", "573.4", "568.0", "287.4", "576.8", "293.0", "997.4", "309.28", "784.3", "751.69", "511.9", "263.9", "790.7", "570", "041.85" ]

icd9cm

[ [ [] ] ]

[ "99.15", "45.91", "34.91", "99.05", "99.07", "87.53", "99.04", "38.93", "54.91", "88.74", "87.51", "51.37", "54.59", "87.54" ]

icd9pcs

[ [ [] ] ]

15234, 16149

1630, 1859

1434, 1603

1882, 2591

175, 278

307, 1243

2606, 15213

1266, 1410

9,177

149,768

16549+56777+56778

Discharge summary

report+addendum+addendum

Admission Date: [**2135-12-2**] Discharge Date: [**2135-12-5**] Date of Birth: [**2057-4-3**] Sex: M Service: VASCULAR CHIEF COMPLAINT: Nonhealing left first toe ulceration. HISTORY OF PRESENT ILLNESS: The patient has a chronic nonhealing left toe ulceration and his admitted for prehydration for anticipated arteriogram. PAST MEDICAL HISTORY: 1. Diabetes. 2. Hypertension. 3. Hyperlipidemia. 4. Congestive heart failure. 5. Lower extremity neuropathy secondary to diabetes. 6. Coronary artery disease. 7. Nephropathy. PAST SURGICAL HISTORY: 1. Coronary artery bypass graft in [**Month (only) 116**] of this year with a left internal mammary coronary artery to the left anterior descending coronary artery and saphenous vein graft to obtuse marginal and diagonal branch. 2. Status post ICD placement secondary to high grade AV block with left bundle branch block. 3. Right toe amputation secondary to osteomyelitis. 4. Right knee surgery secondary to infection. ALLERGIES: All opiates. Benadryl causes disorientation. MEDICATIONS ON ADMISSION: 1. Metoprolol 25 mg b.i.d. 2. Lasix 80 mg q.d. 3. Plavix 75 mg q.d. 4. Protonix 40 mg q.d. 5. Lisinopril 5 mg q.d. 6. Metformin 850 mg b.i.d. 7. K-Dur 20 milliequivalents q.d. 8. Lorazepam .25 mg at h.s. 9. NPH insulin 20 units b.i.d. 10. Regular insulin sliding scale. PREOPERATIVE LABORATORIES: White blood cell count 13.3, hematocrit 39.4, platelets 258. BUN 38, creatinine 1.4, K 4.3. SOCIAL HISTORY: The patient is married. PHYSICAL EXAMINATION: Vital signs 96.5, 88, 20, 120/70. Lungs are clear to auscultation, but diminished at bases. Heart is irregular rhythm with a systolic murmur. Abdominal examination is unremarkable. There are no bruits. Pulse examination shows femoral pulses are palpable bilaterally without bruits. Dorsalis pedis pulses are palpable bilaterally 1+ and the posterior tibial pulses are 1+ bilaterally. Lower extremities are without edema with a left fifth toe nonhealing ulceration. HOSPITAL COURSE: The patient underwent an arteriogram of the abdomen and bilateral extremity run off, which demonstrated mild disease of the aorta. The renal arteries were single without stenosis bilaterally. The right lower extremity run offs show common iliac and common femoral are normal. The superficial femoral artery has mild disease. The popliteal has mild disease. AT is occluded proximally. Posterior tibial pulse is occluded proximally. The peroneal is dominant vessel to the foot. Reconstitutes the AP and PT at the level of the foot. The lower extremity shows the common iliac and common femoral are normal. There is mild superficial femoral artery disease. The popliteals are occluded in its distal segment. AT occludes proximally. The vertebral peroneal trunk revealed and is severely diseased. The posterior tibial pulse is the principal run off vessel, but occludes at the level of the mid calf. There are large collaterals to the posterior tibial and this vessel then fills the posterior foot and arches. The patient tolerated his angiogram. He was hydrated overnight. He remained in the hospital for anticipated revascularization. The patient underwent on [**2135-11-29**] a left AK [**Doctor Last Name **] to PT with right greater saphenous vein. He tolerated the procedure well. He was transferred to the PACU in stable condition with a palpable graft pulse at the end of the procedure. Immediately postoperatively he remained paced. He was hemodynamically stable. He was transferred to the VICU for continued monitoring and care. Postoperative day one there were no overnight events. He was continued on perioperative Kefzol. His postoperative BUN was 24, creatinine 1.1, hematocrit 30.6. His examination was unremarkable. He was converted to oral pain medications and beta blockers were initiated. His diet was advanced as tolerated. His insulin NPH was reinstituted. Intravenous fluids were heplocked. He remained on bed rest in the VICU for continued monitoring. Postoperative day two the patient had elevated glucoses. He continued on his rule out. CK total peaked at 114. There were no MB fractions. Troponin levels were .02, .02, .03. The patient required intravenous Lopresor for systolic hypertension. He required an increase in his beta blockade. He was gently diuresed with 80 of Lasix on postoperative day two and he remained in the VICU. Postoperative day three he required 1 unit of packed red blood cells overnight for a hematocrit of 25. Post transfusion hematocrit was 29.1. He did have a temperature max of 38.8 defervesced to 37.3. He was pan cultured. Chest x-ray was unremarkable. levaquin and Flagyl were continued. [**Last Name (un) **] was consulted. The patient remained in the VICU. Postoperative day four the patient continued to run a low grade temperature. He continued to require diuresis. His hematocrit was 28, BUN 21, creatinine 1.1. He was delined and transferred to the regular nursing floor. Postoperative day five his hematocrit remained stable. He was afebrile. He was evaluated by physical therapy and they felt he would require rehab prior to being discharged to home. The remaining hospital course was unremarkable. DISCHARGE CONDITION: Stable. DISCHARGE MEDICATIONS: 1. Aspirin 325 mg po q.d. 2. Plavix 75 mg q.d. 3. Metoprolol 25 mg b.i.d. 4. Lasix 80 mg q.d. 5. Protonix 40 mg q.d. 6. Lisinopril 5 mg q.d. 7. Metformin 850 mg b.i.d. 8. NPH insulin 20 units q.a.m. and q.p.m. 9. Regular insulin sliding scale before meals 2 to 10 units per sliding scale. 10. K-Dur 20 milliequivalents q.d. 11. Lorazepam 0.5 mg at h.s. prn. The patient should have BUN and creatinine monitored on an outpatient basis. These results should be called to Dr. [**Last Name (STitle) 46970**] at [**Telephone/Fax (1) 5315**]. DISCHARGE DIAGNOSES: 1. Ischemic left toe ulcerations status post left popliteal to AT bypass with right greater saphenous vein. 2. Diabetes controlled. 3. Hypertension controlled. [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2604**], M.D. [**MD Number(1) 6223**] Dictated By:[**Last Name (NamePattern1) 1479**] MEDQUIST36 D: [**2135-12-5**] 09:35 T: [**2135-12-5**] 10:04 JOB#: [**Job Number 46971**] Name: [**Known lastname **], [**Known firstname **] Unit No: [**Numeric Identifier 8666**] Admission Date: [**2135-11-24**] Discharge Date: [**2135-12-7**] Date of Birth: [**2057-4-3**] Sex: M Service: Vascular Surgery ADDENDUM: The patient was initially scheduled to go to a rehabilitation facility but was able to ambulate without much difficulty with a physical therapist. Therefore, it was deemed appropriate that he go to home with visiting nurse assistance. At the time of discharge, the patient did not need any other care. His wounds were healed. His activity was as tolerated. The patient was instructed to follow up in approximately one week for staple removal with Dr. [**First Name4 (NamePattern1) 255**] [**Last Name (NamePattern1) **]. The patient was also to continue six more days of levofloxacin and metronidazole for a total of 14 days. CONDITION AT DISCHARGE: Condition on discharge was good. DISCHARGE STATUS: The patient discharge status was to home with visiting nurse assistance for physical therapy and home safety evaluation. DISCHARGE DIAGNOSES: 1. Peripheral vascular disease. 2. Coronary artery disease. 3. Congestive heart failure. 4. Blood loss anemia. 5. Hypertension. 6. Diabetes mellitus. 7. Status post left above-knee popliteal-to-dorsalis pedis bypass with right greater saphenous vein graft. MEDICATIONS ON DISCHARGE: 1. Plavix 75 mg by mouth once per day. 2. Lasix 80 mg by mouth once per day. 3. Protonix 40 mg by mouth once per day. 4. Lisinopril 5 mg by mouth once per day. 5. Metformin 850 mg by mouth twice per day. 6. Insulin sliding-scale. 7. Potassium chloride 20 mEq by mouth once per day. 8. Ativan 0.25 mg by mouth at hour of sleep. 9. Aspirin 81 mg by mouth once per day. 10. Metoprolol 12.5 mg by mouth three times per day. 11. NPH insulin 20 units subcutaneously twice per day. 12. Levofloxacin 500 mg by mouth once per day (times six days). 13. Metronidazole 500 mg by mouth three times per day (times six days). DISCHARGE INSTRUCTIONS/FOLLOWUP: 1. The patient was instructed to follow up with Dr. [**First Name4 (NamePattern1) 255**] [**Last Name (NamePattern1) **] in approximately one week for staple removal. 2. The patient was instructed to call if he felt fevers, chills, nausea, vomiting, or any other concerns. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1548**], M.D. [**MD Number(1) 1549**] Dictated By:[**Last Name (NamePattern1) **] MEDQUIST36 D: [**2135-12-7**] 10:26 T: [**2135-12-7**] 10:47 JOB#: [**Job Number 8670**] Name: [**Known lastname **], [**Known firstname **] Unit No: [**Numeric Identifier 8666**] Admission Date: [**2135-11-24**] Discharge Date: [**2135-12-7**] Date of Birth: [**2057-4-3**] Sex: M Service: Vascular Surgery ADDENDUM: The patient was initially scheduled to go to a rehabilitation facility but was able to ambulate without much difficulty with a physical therapist. Therefore, it was deemed appropriate that he go to home with visiting nurse assistance. At the time of discharge, the patient did not need any other care. His wounds were healed. His activity was as tolerated. The patient was instructed to follow up in approximately one week for staple removal with Dr. [**First Name4 (NamePattern1) 255**] [**Last Name (NamePattern1) **]. The patient was also to continue six more days of levofloxacin and metronidazole for a total of 14 days. CONDITION AT DISCHARGE: Condition on discharge was good. DISCHARGE STATUS: The patient discharge status was to home with visiting nurse assistance for physical therapy and home safety evaluation. DISCHARGE DIAGNOSES: 1. Peripheral vascular disease. 2. Coronary artery disease. 3. Congestive heart failure. 4. Blood loss anemia. 5. Hypertension. 6. Diabetes mellitus. 7. Status post left above-knee popliteal-to-dorsalis pedis bypass with right greater saphenous vein graft. MEDICATIONS ON DISCHARGE: 1. Plavix 75 mg by mouth once per day. 2. Lasix 80 mg by mouth once per day. 3. Protonix 40 mg by mouth once per day. 4. Lisinopril 5 mg by mouth once per day. 5. Metformin 850 mg by mouth twice per day. 6. Insulin sliding-scale. 7. Potassium chloride 20 mEq by mouth once per day. 8. Ativan 0.25 mg by mouth at hour of sleep. 9. Aspirin 81 mg by mouth once per day. 10. Metoprolol 12.5 mg by mouth three times per day. 11. NPH insulin 20 units subcutaneously twice per day. 12. Levofloxacin 500 mg by mouth once per day (times six days). 13. Metronidazole 500 mg by mouth three times per day (times six days). DISCHARGE INSTRUCTIONS/FOLLOWUP: 1. The patient was instructed to follow up with Dr. [**First Name4 (NamePattern1) 255**] [**Last Name (NamePattern1) **] in approximately one week for staple removal. 2. The patient was instructed to call if he felt fevers, chills, nausea, vomiting, or any other concerns. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1548**], M.D. [**MD Number(1) 1549**] Dictated By:[**Last Name (NamePattern1) **] MEDQUIST36 D: [**2135-12-7**] 10:26 T: [**2135-12-7**] 10:47 JOB#: [**Job Number 8671**]

[ "496", "707.15", "998.89", "280.0", "428.0", "440.23", "780.6", "357.2", "250.60" ]

icd9cm

[ [ [] ] ]

[ "88.42", "88.48", "39.29", "99.04" ]

icd9pcs

[ [ [] ] ]

5278, 5287

10094, 10359

5310, 5861

10386, 11019

1085, 1488

2042, 5256

11052, 11603

575, 1059

1553, 2024

9898, 10073

158, 197

226, 347

369, 552

1505, 1530

7,482

189,637

51984

Discharge summary

report

Admission Date: [**2195-6-6**] Discharge Date: [**2195-6-22**] Date of Birth: [**2125-8-26**] Sex: F Service: MEDICINE Allergies: Azithromycin Attending:[**First Name3 (LF) 6780**] Chief Complaint: Shortness of breath. Major Surgical or Invasive Procedure: BiPap Arterial Line Placement Central Line Placement PICC Line Placement History of Present Illness: 69 F c hx of CAD s/p multiple stents, ischemic CM EF 25%, asthma, multiple recent admissions (most recently [**Date range (1) 27916**] to [**Hospital Unit Name 153**] for fall and hypoglycemia thought [**2-21**] insulin use in the setting of ARF; previously [**Date range (1) 107613**] c respiratory failure thought [**2-21**] COPD and CHF. As per ED history, pt found by VNA to hypoxic to 80's on RA. ED COURSE: She was found to be 86% on ra, HR 100, BP 155/59, RR 32. She was treated for a copd flare vs. chf. She has a h/o of dvt, not anticoagulated at this time at home. Her O2 improved on bipap, could not lay flat for CT-PE could not be ruled out. She had significant improvement with nitro gtt, lasix, bipap, steroids, levofloxacin. When pt came up to MICU unable to get complete history, pt denied chest pain, shortness of breath. History limited by use of BiPAP mask. . Past Medical History: # CAD s/p MI ([**2190**]) - known total occlusion of LAD and ramus w/ R->L collaterals - aborted CABG ([**2190**]) d/t extensive calcification making it impossible to cross clamp aorta - s/p stents to LAD, LCx, OM, D2, ramus and RCA # CHF: last echo [**3-28**] with EF 25%, 1+MR, infero-lateral and distal LV/apical akinesis - s/p dual chambered ICD [**2191-7-4**] for primary prevention ([**Company 1543**] [**Last Name (un) 24119**] DR) # Hypertension # Diabetes type 2 # Hyperlipidemia # COPD (has been labelled as asthma, however CXR and ABGs more c/w COPD along w/ long smoking hx) # Depression # h/o LV thrombus # Carotid artery disease - s/p R catorid artery stenting [**2189**] # h/o cerebral infarction by MR in [**2190**] # s/p ccy # Likely dementia (?-Alzhemer's vs. Vascular) Social History: Originally from [**Location (un) 4708**]. She never knew her father and her mother left her when she was very young. She grew up with a [**Doctor Last Name **] family. She immigrated to America in the [**2157**]. She has 7 children and 13 grandchildren used to live with many of them in a large 3-family house, but most recently was at NH. She used to smoke about 1/2ppd for unclear amount of time and currently has an occassional cigarette. She doesn't currently use alcohol (previously used to only when "partying" - cannot quantify). She has never used illicit drugs. Family History: Unknown hx of parents. Physical Exam: VS-T 97.9, 108, 120/97, RR22, SpO2 100% on CPAP 5/5 GEN-elderly woman, with BiPAP, NAD HEENT-NCAT, JVD not markedly elevated LUNGS-moderate air movement, no wheezes, no crackles HEART-RRR, S1, S2 ABDOM-soft, NT, +BS EXTRE-trace edema bilaterally NEURO-grossly normal Pertinent Results: ADMISSION LABS: ================ 9.8 5.5 >------< 304 31.0 133 99 20 -----|----|-----< 147 4.9 28 0.8 Ca 8.3 Mg 2.1 Phos 2.8 PERTINENT LABS: =============== [**6-6**] BNP [**Numeric Identifier 107614**] [**6-7**] Cortisol 25.7 --> 45.3 [**6-9**] TSH 0.86, T3 52, FT4 1.0 Haptoglobin trend: 20 - undectable - <20 - <20 - 26 Lactate trend: 2.6 - 8.1 - 8.7 - 7.6 - 3.6 - 1.2 - 8.7 - 10.3 - 7.8 - 1.3 MICROBIOLOGY: ============ [**6-6**] BCx x 2: negative [**6-7**] BCx x 2: negative [**6-7**] UCx: Staph species ~3000 [**6-8**] Legionella Antigen: negative STUDIES: ========== CXR [**6-6**] MPRESSION: Blunting of the right costophrenic angle may indicate small pleural effusion or basilar atelectasis. A faint right lower lobe opacity may be due to bronchovascular crowding, however an early developing pneumonia can not be excluded. RUQ U/S [**6-6**] IMPRESSION: Patient is status post cholecystectomy. Study is otherwise unremarkable. CTA CHEST [**6-7**] IMPRESSION: 1. Very small subsegmental left apical pulmonary emboli, unlikely to account for the patient's severe hypotensive episode. 2. Bibasilar pleural effusions, right greater than left, with associated airspace disease, atelectasis versus aspiration or pneumonia. 3. Cardiomegaly and dense coronary artery calcifications. LENI [**6-7**] IMPRESSION: Limited exam due to patient agitation and motion. No definite evidence of right lower extremity DVT. Please note that left lower extremity venous ultrasound was not performed due to patient incooperation. CT HEAD [**6-8**] IMPRESSION: No change in subacute to chronic infarctions at the right occipital and parietal lobes. No new evidence of acute ischemia or acute hemorrhage is seen. ECHO [**6-8**]: The left atrium is mildly dilated. The right atrium is moderately dilated. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thicknesses are normal. The left ventricular cavity is mildly dilated. No masses or thrombi are seen in the left ventricle. Overall left ventricular systolic function is severely depressed with global hypokinesis and inferior and apical akinesis (LVEF= 20 %). There is no ventricular septal defect. The right ventricular cavity is moderately 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. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Moderate (2+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. Moderate to severe [3+] tricuspid regurgitation is seen. There is moderate pulmonary artery systolic hypertension. Compared with the prior study (images reviewed) of [**2195-4-7**], the degree of mitral and tricuspid regurgitation are probabaly similar (underestimated on prior report). The LVEF is similar. The degree of pulmonary hypertension detected has increased. EEG [**6-9**] IMPRESSION: This is an abnormal portable EEG in the waking and sleeping states due to the disorganized, low voltage, and slow background with admixed bursts of moderate amplitude generalized mixed frequency slowing. This constellation of findings is consistent with a mild global encephalopathy due to dysfunction of bilateral subcortical or deep midline structures. Medications, metabolic disturbances, infection and anoxia are among the common causes of encephalopathy but there are others. There were no areas of prominent focal slowing. There were no epileptiform features. Brief Hospital Course: 69 y.o. F h/o CAD s/p multiple stents, ischemic CM EF 25%, asthma, multiple recent admissions (most recently [**Date range (1) 27916**] to [**Hospital Unit Name 153**] for fall and hypoglycemia thought [**2-21**] insulin use in the setting of ARF; previously [**Date range (1) 107613**] c respiratory failure thought [**2-21**] COPD and CHF. found by her VNA to hypoxic to 80's on RA. Upon arrival to the ED VS= 86% on ra, HR 100, BP 155/59, RR 32. She was treated for COPD flare (steroids), CHF (bipap, lasix, nitro gtt), and PNA (levaquin). CTA not performed [**2-21**] inability to lie flat, but pt empirically started on heparin gtt. Her oxygen status improved and she was transferred to the MICU. In the MICU, pt's antibiotic coverage was broadened to CTX/vanco and azithromycin. In the setting of her first azithromycin dose on [**6-6**], pt became hypotensive requiring pressors (levo, neo, vaso), felt to be an allergic reaction to the azithromycin. Pressors were titrated off ~12 hrs later on [**6-7**]. Her respiratory status continued to improve, and she was weaned of bipap on [**6-7**], and steroids were discontinued as COPD was felt less likely. On [**6-7**] pt's HCT 31->24, she was transfused 1U PRBC, complicated by grand mal seizure, and hypotension, again requiring pressors (levo, neo, vaso) for ~12hrs. Neuro was consulted as there was also a question of left dilated pupil, head CT showed no acute bleeding, +subacute/chronic infarctions, EEG c/w toxic/metabolic insult, heparin gtt was held. CTA was obtained which showed very small left apical PE, felt unlikely to account for hypotension. TTE revealed EF=20% (old), 2+mr, 3+tr. On [**6-9**], repeat blood transfusion performed without complication. HCT 21->26, however hemolysis labs revealed hapto<20, LDH 760->468, smear +schistocytes, suggestive of hemolysis, DAT negative x 2 ([**6-8**], [**6-9**]). Per report, pt's mental status (which waxes and wanes), is not far from her baseline. She responds to voice, but is a&ox1 (name) only. On [**6-10**] O2 and BP were stable and pt was transferred to the floor. On the Floor she completed her course of Vanc/Cefepime. Her BP stabilized and she was restarted on home antihypertensive regimen. Fingersticks remained elevated, and her glargine was increased for better glycemic control. She continued on albuterol and atrovent prn for shortness of breath/wheezing. Heme/onc was consulted regarding hemolysis and anticoagulation. Their recommendations stated that the exact cause of hemolysis is difficult to interpret, however by the time the pt was on the floor, the hct was rising and LDH was falling suggesting that hemolysis was resolving. They recommended that there was no contraindication to anticoagulation. Given her multiple indications for anticoagulation, decision was made to begin coumadin with a lovenox bridge. Her INR was 1.9 on discharge, and she will continue on lovenox SQ until INR therapeutic at 2-3 and coumadin 10 mg daily. The lovenox may be stopped after therapeutic INR. INRs should be followed and her dose adjusted accordingly. Medications on Admission: 1. Clopidogrel 75 mg daily 2. Atorvastatin 20 mg daily 3. Paroxetine HCl 20 mg daily 4. Albuterol INH PRN 5. Ipratropium INH PRN 6. Toprol 25 mg daily 7. Docusate 1 cap [**Hospital1 **] 8. Aspirin 325 mg daily 9. Enoxaparin 90 [**Hospital1 **] until therapeutic INR 10. Warfarin5 mg daily 11. Furosemide 40 mg daily 12. Lisinopril 10 mg daily 13. Insulin Lispro 32 u AM, 10 u PM 14. Insulin Regular sliding scale 15. Fluticasone 220 INH [**Hospital1 **] Discharge Medications: 1. Clopidogrel 75 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily). 2. Atorvastatin 20 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily). 3. Paroxetine HCl 20 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily). 4. Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization [**Hospital1 **]: Three (3) mL Inhalation Q4H (every 4 hours) as needed for shortness of breath or wheezing. 5. Ipratropium Bromide 0.02 % Solution [**Hospital1 **]: Three (3) Inhalation Q4H (every 4 hours) as needed for shortness of breath or wheezing. 6. Aspirin 325 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily). 7. Senna 8.6 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times a day) as needed for constipation. Disp:*60 Tablet(s)* Refills:*3* 8. Toprol XL 25 mg Tablet Sustained Release 24 hr [**Hospital1 **]: One (1) Tablet Sustained Release 24 hr PO once a day. 9. Furosemide 40 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily). 10. Lisinopril 10 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily). 11. Enoxaparin 100 mg/mL Syringe [**Hospital1 **]: Ninety (90) mg Subcutaneous Q12H (every 12 hours): Until coumadin therapuetic. 12. Insulin Glargine 100 unit/mL Cartridge [**Hospital1 **]: Thirty Six (36) units Subcutaneous qAM. Disp:*qs qs* Refills:*2* 13. Warfarin 5 mg Tablet [**Hospital1 **]: Two (2) Tablet PO Once Daily at 4 PM. Disp:*120 Tablet(s)* Refills:*2* 14. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] once a day. Disp:*30 Tablet,Rapid Dissolve, DR(s)* Refills:*2* 15. Digoxin 125 mcg Tablet [**Last Name (STitle) **]: 0.5 Tablet PO once a day. Disp:*15 Tablet(s)* Refills:*2* 16. Colace 100 mg Capsule [**Last Name (STitle) **]: One (1) Capsule PO twice a day. 17. Acetaminophen 325 mg Tablet [**Last Name (STitle) **]: 1-2 Tablets PO Q6H (every 6 hours) as needed for fever or pain. Tablet(s) 18. Insulin Please see attached sliding scale for dosing. 19. Dulcolax 5 mg Tablet, Delayed Release (E.C.) [**Last Name (STitle) **]: Two (2) Tablet, Delayed Release (E.C.) PO once a day as needed for constipation. Discharge Disposition: Extended Care Facility: [**Location (un) 11729**] Home - [**Location (un) 686**] Discharge Diagnosis: Primary Diagnosis: Pneumonia Sepsis Pulmonary Embolism Atrial Fibrillation Congestive Heart Failure Discharge Condition: Oxygenation stable, BP stable. A+Ox1 (at baseline). Discharge Instructions: You were admitted with low oxygen level. You were treated for pneumonia, COPD, and blood clot in the lung. Your blood pressure fell after recieving azithromycin, and this was thought to be due to an allergic reaction. Your blood pressure also fell after receiving a blood transfusion and you had a seizure. Neurology evaluated you and felt that you did not need and seizure medications. With antibiotics, your oxygenation improved, and your blood pressure stabilized. You were started on lovenox and then coumadin to treat the clots in your lung. . Because of your diagnosis of congestive heart failure, you should weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs. Adhere to 2 gm sodium diet Fluid Restriction: 1500 cc/day. . Take all of your medications as prescribed below. Changes include: 1. Senna 1 tablet twice daily as needed for constipation 2. Colace 1 tablet twice daily as needed for constipation 3. Warfarin 10 mg daily 4. Lansoprazole 30 mg tablet daily 5. Digoxin [**1-21**] tablet (0.0625 mg) daily 6. Lovenox 90mg SQ every 12 hours (until therapeutic INR) . Keep all of your appointments as written below. . If you have symptoms of shortness of breath, cough, chest pain, fevers, or anyother concerning symptoms call your doctor or go to the ER. Followup Instructions: Primary Care: Dr. [**First Name8 (NamePattern2) 1528**] [**Last Name (NamePattern1) **], [**Telephone/Fax (1) 3581**]. Appointment on [**2195-7-8**] at 1:45 PM. You should have your INR checked daily. Goal INR [**2-22**]. Completed by:[**2195-6-23**]

[ "V45.81", "415.19", "995.92", "414.01", "995.0", "486", "584.9", "427.31", "E930.3", "038.9", "780.39", "428.23", "428.0" ]

icd9cm

[ [ [] ] ]

[ "38.91", "93.90", "38.93" ]

icd9pcs

[ [ [] ] ]

12451, 12534

6653, 9757

293, 367

12678, 12733

3019, 3019

14072, 14327

2692, 2716

10262, 12428

12555, 12555

9783, 10239

12757, 14049

2731, 3000

233, 255

395, 1277

3035, 3171

12574, 12657

3187, 6630

1299, 2088

2104, 2676

41,022

147,181

7907

Discharge summary

report

Admission Date: [**2159-7-14**] Discharge Date: [**2159-7-25**] Date of Birth: [**2092-11-21**] Sex: F Service: OBSTETRICS/GYNECOLOGY Allergies: morphine Attending:[**First Name3 (LF) 28433**] Chief Complaint: "Abdominal Pain and fever" Major Surgical or Invasive Procedure: Exploratory laparatomy/ Left salpingoophorectomy of an infected dermoid cyst, herniorrhaphy, vulvar biopsy, omental biopsy and cystoscopy. History of Present Illness: Ms [**Known lastname 4553**] is a 66y/o P2 presents as transfer from outside hospital with abdominal pain, fever and enlarged dermoid cyst. Pt reports that about one month ago, she noticed severe abdominal pain and nausea which prompted work-up by her PCP with an abdominal CT scan. On CT, she was noted to have a large dermoid cyst and was referred to a GYN physician who she is supposed to within the next week. Her pain had eventually resolved but on presentation, she started to notice it again and reports being doubled over in pain and nauseous. She also reports a fever of 101 at the outside hospital. Denies vomiting. She describes the pain as a twisting type of sensation on the left side that is persistent. At the outside hospital, she had a CT abd/pelvis which was remarkeable for a ?ruptured dermoid cyst. Here in the ED, she has undergone a bedside FAST u/s which was negative for free fluid. She denies dizziness or SOB. ROS +for cough which she has had for one week now. Past Medical History: - Rheumatoid Arthritis - Groin/Axillary infections s/p excisions and skin grafts - Right ankle surgery Social History: lives with daughter, denies t/e/d use, former smoker, quit 7 yrs ago Family History: None on file Physical Exam: Physical Examination was performed by Dr. [**First Name8 (NamePattern2) 2270**] [**Last Name (NamePattern1) 28434**]. VS-97.8 92 91/52 -> intermittently 80's/50's 20 94%RA Appears slightly uncomfortable with movement, appears to be wheezing Heart Regular rate and rhythm Lungs clear to auscultation bilaterally although difficult to hear given poor inspiratory effort Abdomen obese, mildly distended, +mild diffuse Tenderness to palpation, no rebound or guarding Pelvic: Multiple protruding labial masses with chronic skin changes and areas that appear denuded (pt states this is chronic since rejection of vulvar skin graft) Bimanual: No Cervical motion tenderness, difficult to assess size of uterus secondary to body habitus and patient difficulty with exam Extremities: No Lower extremity edema bilaterally Pertinent Results: [**2159-7-14**] 04:54PM TYPE-ART PO2-114* PCO2-39 PH-7.26* TOTAL CO2-18* BASE XS--8 [**2159-7-14**] 04:54PM GLUCOSE-106* LACTATE-0.9 [**2159-7-14**] 04:54PM O2 SAT-98 [**2159-7-14**] 04:54PM freeCa-0.97* [**2159-7-14**] 04:03PM VoidSpec-SPECIMEN C [**2159-7-14**] 03:51PM GLUCOSE-139* UREA N-14 CREAT-0.9 SODIUM-138 POTASSIUM-4.7 CHLORIDE-111* TOTAL CO2-19* ANION GAP-13 [**2159-7-14**] 03:51PM CALCIUM-7.6* PHOSPHATE-3.7 MAGNESIUM-1.3* [**2159-7-14**] 03:51PM WBC-12.8* RBC-3.62* HGB-11.0* HCT-33.5* MCV-93 MCH-30.5 MCHC-32.9 RDW-13.6 [**2159-7-14**] 03:51PM PLT COUNT-535* [**2159-7-14**] 02:41PM TYPE-ART TEMP-37.3 RATES-12/ TIDAL VOL-600 O2-50 PO2-180* PCO2-43 PH-7.31* TOTAL CO2-23 BASE XS--4 INTUBATED-INTUBATED VENT-CONTROLLED [**2159-7-14**] 02:41PM GLUCOSE-126* LACTATE-1.4 NA+-138 K+-4.3 CL--112 TCO2-20* [**2159-7-14**] 02:41PM HGB-10.0* calcHCT-30 O2 SAT-98 [**2159-7-14**] 02:41PM freeCa-1.12 [**2159-7-14**] 01:51PM TYPE-ART TEMP-37.3 RATES-14/ TIDAL VOL-450 PO2-180* PCO2-47* PH-7.28* TOTAL CO2-23 BASE XS--4 INTUBATED-INTUBATED VENT-CONTROLLED [**2159-7-14**] 01:51PM GLUCOSE-123* LACTATE-1.6 NA+-137 K+-4.3 CL--111 TCO2-21 [**2159-7-14**] 01:51PM HGB-10.1* calcHCT-30 [**2159-7-14**] 01:51PM freeCa-1.16 [**2159-7-14**] 01:12PM TYPE-ART TEMP-37.3 RATES-12/ TIDAL VOL-500 O2-50 PO2-174* PCO2-49* PH-7.27* TOTAL CO2-23 BASE XS--4 INTUBATED-INTUBATED [**2159-7-14**] 01:12PM GLUCOSE-126* LACTATE-1.5 NA+-138 K+-4.1 CL--111 TCO2-22 [**2159-7-14**] 01:12PM HGB-10.5* calcHCT-32 [**2159-7-14**] 01:12PM freeCa-1.23 [**2159-7-14**] 12:15PM TYPE-ART PO2-217* PCO2-43 PH-7.31* TOTAL CO2-23 BASE XS--4 [**2159-7-14**] 12:15PM GLUCOSE-138* LACTATE-1.2 NA+-136 K+-4.0 CL--109 [**2159-7-14**] 12:15PM HGB-10.4* calcHCT-31 O2 SAT-98 [**2159-7-14**] 12:15PM freeCa-1.06* [**2159-7-14**] 10:12AM TYPE-[**Last Name (un) **] PO2-92 PCO2-51* PH-7.24* TOTAL CO2-23 BASE XS--5 COMMENTS-GREEN TOP [**2159-7-14**] 10:12AM LACTATE-2.3* [**2159-7-14**] 09:48AM WBC-18.2* RBC-3.76* HGB-11.1* HCT-33.9* MCV-90 MCH-29.6 MCHC-32.8 RDW-13.5 [**2159-7-14**] 09:48AM PLT COUNT-635* [**2159-7-14**] 02:32AM LACTATE-2.0 [**2159-7-14**] 02:20AM GLUCOSE-147* UREA N-16 CREAT-1.3* SODIUM-138 POTASSIUM-4.5 CHLORIDE-105 TOTAL CO2-23 ANION GAP-15 [**2159-7-14**] 02:20AM estGFR-Using this [**2159-7-14**] 02:20AM WBC-14.9* RBC-3.68* HGB-10.9* HCT-32.7* MCV-89 MCH-29.5 MCHC-33.3 RDW-13.4 [**2159-7-14**] 02:20AM NEUTS-89.8* LYMPHS-7.1* MONOS-2.8 EOS-0.1 BASOS-0.2 [**2159-7-14**] 02:20AM PLT COUNT-573* [**2159-7-14**] 02:20AM PT-14.2* PTT-23.0 INR(PT)-1.2* Brief Hospital Course: Ms [**Known lastname 4553**] was seen and examined and observed for 3 hours in ED. CT scan at OSH ([**Hospital1 **])demonstrated 12 x 9 cm mass, read as c/w dermoid. Review of CT scan at [**Hospital1 18**] also demonstrated small umblical hernia w/ possible incarcerated bowel. Under observation, pt became hypotenisve to SBP of 60, not responsive to hydration alone. Her abdominal exam remained unchanged. Bedside ultrasound performed and was limited due to size of mass and patient habitus and assessment of doppler flow to mass could not be completed. As the patients hemodynamic status had stabilized, pain unchanged, impression was intermittent left adnexal torsion in the setting of ovarian mass. The decision was made to admit to SICU for monitoring and plan surgery consult to assess for possible bowel incarceration at umbilical hernia. Upon admission to SICU, Ms [**Known lastname 4553**] remained hypotensive despite ongoing levaphed treatment. She was evaluated by Surgical consult and SICU atttending and assessment was consistent with peritonitis due to pelvic process and not consistent incarcerated bowel herniation. Ongoing concern for intermittent torsion; etiology of hypotension differentia was torsion vs. sepsis vs. other process. The decision was made to proceed with exploratory laparatomy given acute abdomen in the setting of hemodynamic instability. Intraoperatively, an enlarged left adnexal mass consistent with dermoid on frozen section with purulent material throughout abdominal cavity, normal Right tube and ovary, normal. Patient was observed in the surgical ICU following surgery. Her post-operative course was complicated by inability to extubate until post-op day 3. Patient was started on IV levofloxacin/flagyl and vancomycin for broad spectrum treatment until cultures returned. Cultures returned positive for Methicilin Sensitive Staph Aureus. Intravenous vancomycin and flagyl were discontinued on post-op day 4 and post-op day 2 respectively. Her SICU admission was complicated by oliguria with a creatinine of 1.2 and edema, which subsequently resolved after several doses of lasix, ileus requiring prolonged NG tube placement and multiple chest X-rays to evaluate for pulmonary status. Patient also developed stage 2 decubitus ulcer and possible allergic dermatitis. Ms [**Known lastname 4553**] was transferred to the gynecology floor on post-operative day 4 for continued routine post-operative care. On the floor, NG tube was discontinued. There was concern for prolonged prothrombin time, which prompted a curb-side consult to hematology, who thought it was as a result of IV antibiotics resulting in clearing of Gut flora and subsequent vitamin K deficiency. In addition, patient was tried to wean off oxygen and experienced a desaturation to 86% prompting a CTA, which revealed bilateral pulmonary embolisms. Patient was then started on Heparin and then transitioned to Lovenox. Floor admission also complicated by the developement of yeast urinary tract infection, treated with diflucan. On post-operative day 10, staples were removed and patient experienced separation of the vertical abdominal incision. Wound was inspected and fascia was found to be intact. The incision was packed with wet-to-dry dressing, which was changed twice daily. She was also given topical antifungal therapy for treatment of fungal infection on her mons. An attempt to wean her off oxygen produced a desaturation to 87% suggesting that she would require home oxygen. Ms [**Known lastname 4553**] was discharged on post-operative day 11 to her home with VNA services twice a day in good condition, tolerating a regular diet, voiding independently, ambulating with assist but with oxygen requirement of 1L and albuterol nebulizer treatments. Per ID, she will continue on oral ciprofloxacin and flagyl to complete a 14day course of antibiotics. Medications on Admission: -Prednisone 10mg po daily -Remicaide monthly infusion Discharge Medications: 1. trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as needed for sleep. 2. prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Tablet(s) 3. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:*10 Tablet(s)* Refills:*0* 4. Flagyl 500 mg Tablet Sig: One (1) Tablet PO three times a day. Disp:*15 Tablet(s)* Refills:*0* 5. enoxaparin 120 mg/0.8 mL Syringe Sig: One (1) syringe Subcutaneous Q12H (every 12 hours). Disp:*60 syringe* Refills:*2* 6. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day): to mons. Disp:*QS QS* Refills:*2* Discharge Disposition: Home With Service Facility: [**Hospital3 **] VNA Discharge Diagnosis: Left dermoid cyst, pelvic infection with MSSA, sepsis. Postop course complicated by bilateral pulmonary embolisms, superficial wound dehiscence. Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Ms [**Known lastname 4553**], you were admitted and underwent an exploratory laparatomy/ Left salpingoophorectomy of an infected dermoid cyst, herniorrhaphy, vulvar biopsy, omental biopsy and cystoscopy. General instructions: * Take your medications as prescribed. * Do not drive while taking narcotics. * No strenuous activity, nothing in the vagina (no tampons, no douching, no sex), no heavy lifting of objects >10lbs for 6 weeks. * You may eat a regular diet. Incision care: * You may shower and allow soapy water to run over incision; no scrubbing of incision. No bath tubs for 6 weeks. * If you have steri-strips, leave them on. They will fall off on their own or be removed during your followup visit. * If you have staples, they will be removed at your follow-up visit. Followup Instructions: - Post-op appt with Dr. [**Last Name (STitle) 8253**] Wed [**8-1**] - F/u appt with NP at [**Hospital 28435**] Medical [**7-30**] 1330 - F/u Dr. [**Last Name (STitle) 28436**] [**8-15**] 330pm Completed by:[**2159-7-26**]

[ "415.11", "220", "707.22", "038.11", "714.0", "995.91", "553.1", "E878.8", "567.9", "112.2", "560.1", "707.03", "998.32", "789.59" ]

icd9cm

[ [ [] ] ]

[ "96.71", "57.32", "38.97", "71.11", "65.49", "54.23", "53.49" ]

icd9pcs

[ [ [] ] ]

9812, 9863

5193, 9079

311, 452

10052, 10052

2561, 5170

11009, 11233

1699, 1713

9183, 9789

9884, 10031

9105, 9160

10203, 10669

10684, 10986

1728, 2542

245, 273

480, 1470

10067, 10179

1492, 1596

1612, 1683

19,216

179,681

3603

Discharge summary

report

Admission Date: [**2187-5-11**] Discharge Date: [**2187-5-14**] Date of Birth: [**2130-3-30**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2356**] Chief Complaint: Hypotension, groin/abd/chest pain Major Surgical or Invasive Procedure: None History of Present Illness: 57 yo F h/o DVT/PE s/p IVC filter [**12-4**] off coumadin, transfusion-dependent MDS, recent admission (discharged [**2187-5-7**]) for mechanical fall and UTI who presented on [**2187-5-11**] with 10/10 sharp groin pain radiating upwards into abdomen at Rehab lasting several hours. No dysuria, hematuria, diarrhea, constipation. She was transferred to [**Hospital1 18**]. In the ED, VS notable for BP 86/45 (baseline 90-100). Pt complaining of new chest pressure in absence of dyspnea, resolved with morphine. EKG baseline and ruled out for MI but chest CTA significant for new segmental PEs and started on heparin gtt. Lactate elevate at 2.9 but abd xray with ileus or obstruction. Received NS x 4L with improvement in SBP to low 90s and given ceftriaxone for pyuria on U/A although asymptomatic. Admitted to MICU for further management. Past Medical History: 1. Chronic macrocytic anemia 2. Bone marrow biopsy [**2179-7-28**]-MDS v EtOH toxicity pancytopenia > resolved and most likely attributed to ETOH toxicity 3. Hypothyroidism 4. H/o questionable seizures, but negative 48h EEG and nL MRI in past. 5. Migraine headaches 6. Questionable history of cardiac arrhythmias. [**Doctor Last Name **] of Hearts in past showed some tachys to 180s. Patient denies. 7. Peptic ulcer disease status post Nissen fundoplication. 8. Status-post hemorrhoidectomy. 9. Asthma s/p intubation x 1 in past 10. Osteoarthritis 11. B/l cataracts 12. R knee surgery [**90**]. Bilateral pulmonary embolic with DVT s/p IVC filter [**12-4**] 14. Weight loss of unknown etiology (now 88 pounds, was 150 pounds 1 year ago). 15. Hemorroids. . Social History: Lives with her boyfriend of 14 years. She has three daughters. She is a retired photographer. +Occasional EtOH, no tobacco or illicit drug use. Family History: No family h/o MDS or leukemia. Father dies of CAD. Maternal Grandmother with breast CA. Mother with breast CA. Sister with breast CA. Physical Exam: VS: T 98, SBP 80-100 General: Alert, oriented x 3, no acute distress, pleasantly talkative HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Pertinent Results: [**2187-5-11**] 03:30PM BLOOD WBC-8.5# RBC-2.69*# Hgb-9.5*# Hct-29.7*# MCV-110* MCH-35.1* MCHC-31.9 RDW-15.9* Plt Ct-372# [**2187-5-11**] 03:30PM BLOOD PT-13.3 PTT-21.7* INR(PT)-1.1 [**2187-5-11**] 03:30PM BLOOD Glucose-115* UreaN-12 Creat-0.7 Na-138 K-4.3 Cl-106 HCO3-23 AnGap-13 [**2187-5-11**] 03:30PM BLOOD Calcium-7.7* Phos-3.1 Mg-1.3* [**2187-5-11**] 03:30PM BLOOD ALT-12 AST-36 AlkPhos-146* . [**2187-5-11**] 03:30PM BLOOD CK(CPK)-27 CK-MB-NotDone cTropnT-0.06* [**2187-5-12**] 12:10AM BLOOD CK(CPK)-27 CK-MB-NotDone cTropnT-0.03* . [**2187-5-11**] 09:10PM BLOOD Lactate-2.9* [**2187-5-12**] 12:29AM BLOOD Lactate-1.6 . [**2187-5-11**] 05:35PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.021 [**2187-5-11**] 05:35PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-SM [**2187-5-11**] 05:35PM URINE RBC-0 WBC-[**11-16**]* Bacteri-RARE Yeast-NONE Epi-0 . [**2187-5-12**] 07:43PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.022 [**2187-5-12**] 07:43PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG . [**2187-5-11**] Blood cultures: PENDING x 2 [**2187-5-12**] Urine cultures: no growth . [**2187-5-11**] KUB: Supine and left lateral decubitus views of the abdomen are obtained. The bowel gas pattern demonstrates no evidence of ileus or obstruction. Left lateral decubitus view is limited to detect free air given that the right lateral abdominal wall is excluded, thus limiting the evaluation for air layering along the edge of the liver. An IVC filter is noted in the mid abdomen. Bony structures appear normal. Multiple phleboliths are identified in the pelvis. Included lung bases appear clear. . [**2187-5-11**] CXR: AP upright and lateral views of the chest are obtained. The lungs appear clear bilaterally, demonstrating no evidence of pneumonia or CHF. No pneumothorax or pleural effusion is seen. Cardiomediastinal silhouette is stable. Bony structures appear intact. An IVC filter is partially visualized in the upper abdomen. No free air was seen below the right hemidiaphragm . [**2187-5-11**] Chest CTA: segmental pulmonary emboli in the RML, RLL and LLL. Additional subsegmental emboli are seen in the LLL. no acute aortic syndrome. ascites noted in the upper abdomen, new since prior study and of unclear etiology. 2 mm RUL nodule. 3 mm nodule LUL. . EKG: ECG: sinus, rate 85 bpm, no ST/T changes. Brief Hospital Course: 57 yo F h/o DVT s/p IVC filter, h/o PE, transfusion-dependent MDS, recent admission (discharged [**2187-5-7**]) for mechanical fall and UTI, presents from rehab with groin pain radiating to abd and chest, found to have new PE. # PE: For PE, patient transitioned from heparin to lovenox for new segmental emboli on CTA chest. No indication for thrombolysis. She was discharged on lovenox due to benefit of easier reversibility compared to Coumadin given history of difficult to control INRs and setting of fall risk. Pt to schedule follow-up with PCP [**Last Name (NamePattern4) **] [**2187-5-29**]. # Hypotension: In MICU, patient given additional 2L fluids. SBP stable at 80-100, and pt remained asymptomatic. She was not felt to be infected given absence of fever, leukopenia, or positive micro data - *will need to follow up pending cultures.* Also unlikely to be due to PE. Pt reports that this is consistent with her baseline low-running blood pressures which has been noted multiple times in the past. Encouraged po fluid intake. # Chest pain: Transient episode of atypical pain. Most likely [**1-29**] PE. Ruled out for MI and remaining chest pain free since admission. # Pyuria: Pyuria on admission without any urinary sx; no urine cx sent but did receive one dose of ceftriaxone in ED. Antibiotics not continued in MICU as pt asymptomatic. Foley removed and repeat U/A and Ucx clean. Pt remained asymptomatic. # MDS: Patient transfusion dependent, was scheduled to get blood transfusion as outpatient on [**5-14**]. Given Hct 21 on [**5-13**], transfused 1 unit pRBC overnight with appropriate response and subjective improvement in clinical status per pt. Outpatient f/u with Heme-Onc per routine. # Migraines: Continued precocet and zofran as patient refusing outpatient imitrex citing decreased efficacy. # Weight loss: 60-80 lbs over months of unknown etiology. Suspicion for malignancy. However, last mammogram was in [**2182**] and colonoscopy in [**2181**]. Extensive w/u at last admission including CT chest, CT abd w/o masses and nl SPEP. Pt should continue outpatient work-up, including mammogram. # Hypothyroidism: Continued levothyroxine. # H/o questionable seizures: Continued anti-seizure meds. # Peptic ulcer disease status post Nissen fundoplication: Continued omeprazole. # Asthma: Continued nebs prn. # Code: Full # Dispo: Pt evaluated by PT and recommended for Rehab. However, pt refused this and instead chose to go home with services including physical therapy. Medications on Admission: 1. Albuterol 90 mcg/Actuation Aerosol [**Year (4 digits) **]: Two (2) puffs Inhalation every six (6) hours as needed for shortness of breath or wheezing. 2. Folic Acid 1 mg Tablet [**Year (4 digits) **]: One (1) Tablet PO DAILY (Daily). 3. Levothyroxine 88 mcg Tablet [**Year (4 digits) **]: One (1) Tablet PO DAILY (Daily). 4. Mirtazapine 15 mg Tablet [**Year (4 digits) **]: One (1) Tablet PO HS (at bedtime). 5. Cholecalciferol (Vitamin D3) 400 unit Tablet [**Year (4 digits) **]: Two (2) Tablet PO DAILY (Daily). 6. Acetaminophen 325 mg Tablet [**Year (4 digits) **]: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain. 7. Senna 8.6 mg Tablet [**Year (4 digits) **]: One (1) Tablet PO BID (2 times a day) as needed for constipation. 8. Levetiracetam 250 mg Tablet [**Year (4 digits) **]: Three (3) Tablet PO BID (2 times a day). 9. Omeprazole 20 mg Capsule, Delayed Release(E.C.) [**Year (4 digits) **]: One (1) Capsule, Delayed Release(E.C.) PO BID (2 times a day). 10. Thiamine HCl 100 mg Tablet [**Year (4 digits) **]: One (1) Tablet PO DAILY (Daily). 11. Sumatriptan Succinate 50 mg Tablet [**Year (4 digits) **]: One (1) Tablet PO DAILY (Daily) as needed for Migraine. 12. Oxycodone-Acetaminophen 5-325 mg Tablet [**Year (4 digits) **]: One (1) Tablet PO Q6H (every 6 hours) as needed for Migraine,pain: do not drive on this medication. 13. Zolpidem 5 mg Tablet [**Year (4 digits) **]: One (1) Tablet PO HS (at bedtime) as needed for insomnia. 14. Prochlorperazine Maleate 5 mg Tablet [**Year (4 digits) **]: One (1) Tablet PO Q6H (every 6 hours) as needed for nausea. 15. Heparin (Porcine) 5,000 unit/mL Solution [**Year (4 digits) **]: One (1) ml (5000 Units) Injection TID (3 times a day). 16. Docusate Sodium 100 mg Capsule [**Year (4 digits) **]: One (1) Capsule PO BID (2 times a day) as needed for constipation. Capsule(s) 17. Loperamide 2 mg Capsule [**Year (4 digits) **]: One (1) Capsule PO QID (4 times a day) as needed for diarrhea. Discharge Medications: 1. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler [**Year (4 digits) **]: Two (2) Inhalation Q6H (every 6 hours) as needed for SOB/wheezing. 2. Folic Acid 1 mg Tablet [**Year (4 digits) **]: One (1) Tablet PO DAILY (Daily). 3. Levothyroxine 88 mcg Tablet [**Year (4 digits) **]: One (1) Tablet PO DAILY (Daily). 4. Mirtazapine 15 mg Tablet [**Year (4 digits) **]: One (1) Tablet PO HS (at bedtime). 5. Cholecalciferol (Vitamin D3) 400 unit Tablet [**Year (4 digits) **]: Two (2) Tablet PO DAILY (Daily). 6. Senna 8.6 mg Tablet [**Year (4 digits) **]: 1-2 Tablets PO BID (2 times a day) as needed for constipation. 7. Levetiracetam 750 mg Tablet [**Year (4 digits) **]: One (1) Tablet PO twice a day. 8. Omeprazole 20 mg Capsule, Delayed Release(E.C.) [**Year (4 digits) **]: One (1) Capsule, Delayed Release(E.C.) PO twice a day. 9. Thiamine HCl 100 mg Tablet [**Year (4 digits) **]: One (1) Tablet PO DAILY (Daily). 10. Sumatriptan Succinate 50 mg Tablet [**Year (4 digits) **]: One (1) Tablet PO DAILY (Daily) as needed for migraine. 11. Oxycodone-Acetaminophen 5-325 mg Tablet [**Year (4 digits) **]: One (1) Tablet PO Q6H (every 6 hours) as needed for migraine, pain: Do not take this medication if driving or operating machinery; may cause drowsiness. Disp:*28 Tablet(s)* Refills:*0* 12. Zolpidem 10 mg Tablet [**Year (4 digits) **]: One (1) Tablet PO at bedtime as needed for insomnia. Disp:*10 Tablet(s)* Refills:*0* 13. Prochlorperazine Maleate 5 mg Tablet [**Year (4 digits) **]: One (1) Tablet PO every six (6) hours as needed for nausea. 14. Docusate Sodium 100 mg Capsule [**Year (4 digits) **]: One (1) Capsule PO BID (2 times a day): Hold for diarrhea. 15. Enoxaparin 40 mg/0.4 mL Syringe [**Year (4 digits) **]: Forty (40) mg Subcutaneous [**Hospital1 **] (2 times a day). Disp:*30 syringes* Refills:*0* 16. Tucks Pads, Medicated [**Hospital1 **]: One (1) Topical once a day as needed for hemorrhoids. Disp:*7 * Refills:*0* 17. Outpatient Physical Therapy home physical therapy Discharge Disposition: Home With Service Facility: VNA of [**Location (un) 86**] Discharge Diagnosis: Primary - Pulmonary emboli Secondary - H/o PE and DVT s/p IVC filter - Myelodysplastic syndrome - Weight loss of unclear etiology - Hypothyroidism - Migraines - H/o seizures Discharge Condition: Hemodynamically stable. Baseline BP 80-100. Discharge Instructions: You were admitted for abdominal pain. Your abdominal imaging did not show any acute findings. However, your chest CT scan was notable for new pulmonary emboli. You were started on a blood thinner for this. Your blood pressures are known to be low at baseline; please continue to try to stay well hydrated. You should continue your nutritional supplements. Please note that you were scheduled for an outpatient blood transfusion but were already given one unit of blood while you were hospitalized. The following changes were made to your medications: - Lovenox injections started. Please be aware that blood thinners put you at a higher risk of bleeding especially with any trauma or fall. Please continue all other medications as prescribed by your doctor. Please seek immediate medical attention if you develop chest pain, difficulty breathing, dizziness, bleeding, inability to keep food down, inability to pass gas/stool, inability to urinate, or any other concerning symptoms. Followup Instructions: You will need to follow up with your PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 1270**]. Please call his office at [**0-0-**] to schedule an appointment on Tuesday, [**2187-5-29**]. [**First Name4 (NamePattern1) 1730**] [**Last Name (NamePattern1) **] MD [**MD Number(1) 2362**]

[ "493.90", "415.19", "281.9", "786.59", "783.21", "346.90", "238.75", "244.9", "533.90", "V12.51", "791.9" ]

icd9cm

[ [ [] ] ]

[ "99.04" ]

icd9pcs

[ [ [] ] ]

11878, 11938

5332, 7838

349, 355

12156, 12202

2851, 5309

13236, 13564

2182, 2317

9845, 11855

11959, 12135

7864, 9822

12226, 13213

2332, 2832

276, 311

384, 1225

1247, 2004

2020, 2166

73,385

148,333

38703

Discharge summary

report

Admission Date: [**2191-6-2**] Discharge Date: [**2191-6-8**] Date of Birth: [**2165-2-1**] Sex: M Service: NEUROSURGERY Allergies: Ciprofloxacin / Codeine / Oxycodone Attending:[**First Name3 (LF) 78**] Chief Complaint: Cranial defect Major Surgical or Invasive Procedure: Right Craniotplasty [**2191-6-4**] History of Present Illness: This is a 26 year old male who underwent a right craniotomy after a guns hot wound to the head on [**2191-3-18**]. He has shown progression at his rehab facility and he presents for a cranioplasty. Past Medical History: Depression Cranial Gun shot wound. Right Craniectomy Evacuation of Right Epidural Hematoma Left Frontal Bolt Placement Left Central Line Placement Tracheostomy PEG placment Picc line insertion Bronchial alveolar lavage [**Location (un) 4569**] nest IVCF placement / non retrievable Social History: Presents from rehab facility in NH. Family History: NC Physical Exam: On admission: T:98 BP:122 / 70 HR:74 R 18 O2Sats:98% RA Gen: WD/WN, comfortable, NAD. HEENT: normocephalic Pupils: PERRL EOMs: roving Neck: Trach site with staining Abd: Soft, NT Extrem: Warm and well-perfused. Neuro: Mental status: Awake and alert No commands Face symmetrical at rest No tracking Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light III, IV, VI: roving eye movements Motor: Increased tone in LUE, RUE grasp [**4-15**] Clonus: +R, -L On discharge: Patient eyes open spontaneously Pupils 5-4mm bilaterally Speaks [**4-14**] words, ? if appropriately RUE [**6-15**] LUE [**3-18**] grasp No movement in BLE, bilateral clonus Incision c/d/i with staples Pertinent Results: [**2191-6-2**] PA AND LATERAL CHEST RADIOGRAPHS: The lateral view is limited by underpenetration. There is interval removal of the tracheostomy and right-sided PICC. No focal airspace consolidation, pneumothorax, or pleural effusion is noted. The cardiomediastinal silhouette, hilar contour, and pulmonary vasculature are normal. IMPRESSION: No acute cardiopulmonary process. The study and the report were reviewed by the staff radiologist. COMPARISON: CT head with IV contrast [**2191-4-12**]. TECHNIQUE: Imaging was performed from the foramen magnum to the cranial vertex before and after IV contrast. HEAD CT WITH AND WITHOUT IV CONTRAST: There is no new site of hemorrhage. There is extensive encephalomalacia in the parietal lobes bilaterally as well as in the right occipital lobe. There is no significant shift of normally midline structures. The angulation of scan is different from the study from [**2191-4-12**], but there is likely no significant change. No abnormal enhancement is seen to suggest infection. Metallic bullet fragments are seen in both parietal bones, with comminuted fractures, as well as the largest bullet fragment, in the left parietal bone, appears unchanged. Multiple fractures are again seen. Fluid in the left mastoid air cells, and to a lesser degree on the right is again seen which is not significantly changed since the prior study. The left ethmoid sinus demonstrates fluid density in a round configuration which is continuous with anterior cranial fossa and therefore meningocoele is not excluded. IMPRESSION: 1. No new site of hemorrhage, edema or mass effect. 2. Similar appearance of multiple fractures and bullet fragments. 3. Extensive encephalomalacia in right occipital/both parietal lobes. 4. Persistent left greater than right mastoid air cell opacification. 5. Left ethmoid sinus meningocoele not excluded; CT facial bones recommended for further evaluation. CT brain FRI [**2191-6-3**] 2:29 PM Expected post-op change after right frontal cranioplasty w/o other short-interval change. PFI AUDIT # 1 Final Report HISTORY: 26-year-old male with right frontal cranioplasty, evaluate for postoperative change. COMPARISON: CT head with and without contrast earlier the same day. TECHNIQUE: Imaging was performed from the foramen magnum to the cranial vertex without IV contrast. HEAD CT WITHOUT IV CONTRAST: There has been interval right frontal cranioplasty, with replacement of calvarium at site of prior defect. There is minimal expected subcutaneous gas at the site of cranioplasty, and a tiny extra-axial hemorrhage, not unexpected (2:19). The study is otherwise unchanged, with extensive encephalomalacia in the parietal lobes and right occipital lobe. Previously seen fractures and bone fragments are unchanged allowing for lack of dedicated bone technique. Again noted is a left ethmoid sinus opacification, which appears continuous with the anterior cranial fossa, and therefore meningocele is not excludable; CT facial bones previously suggested. Soft tissues and paranasal sinuses otherwise appear unchanged. IMPRESSION: Status post right frontal cranioplasty with expected post-operative appearance and without other short interval change. The study and the report were reviewed by the staff radiologist. Brief Hospital Course: Mr. [**Name14 (STitle) 85983**] was admitted to [**Hospital1 18**] under the care of Dr. [**First Name (STitle) **]. Cranioplasty was performed on [**2191-6-4**]. Post operatively patient remains stable, he opens his eyes spontaneously and moves RUE spontaneously. Pupils are equal and reactive. Incision is clean and dry with staples. PT/OT/ST consults were obtained. His postoperative course was uneventful. He underwent a video swallow and the results oropharyngeal dysphagia at this time including silent aspiration of thin liquids and prolonged mastication of solids. They recommended that the patient be placed on a diet consisting of ground solids with nectar thick liquids and meds crushed in puree. They also was to wean the tube feeds at some point. He also had an EEG to assess for subclinical seizure as the pts mother noted episodes of starring while at rehab. He was transitioned to Tegretol at rehab. The level was 5. The pts exam fluctuates but he appears to be at baseline. It is noted that he identified the colors of a shirt and a washclothe correctly. Medications on Admission: Tylenol, albuterol, tegretol, coumadin, pepcid, insulin, ativan, lopressor Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain fever. 2. Ergocalciferol (Vitamin D2) 50,000 unit Capsule Sig: One (1) Capsule PO DAILY (Daily). 3. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2 times a day). 4. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. Ferrous Sulfate 300 mg (60 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 7. Polyethylene Glycol 3350 17 gram/dose Powder Sig: One (1) PO DAILY (Daily). 8. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for INSOMNIA. 9. Carbamazepine 200 mg Tablet Sig: 1.5 Tablets PO BID (2 times a day). 10. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 11. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed for constipation. 12. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 13. Warfarin 4 mg Tablet Sig: 1.5 Tablets PO Once Daily at 4 PM. 14. Pramoxine-Mineral Oil-Zinc 1-12.5 % Ointment Sig: One (1) Appl Rectal Q12H (every 12 hours) as needed for hemorhoids. 15. HYDROmorphone (Dilaudid) 0.25-0.5 mg IV Q3H:PRN pain hold for RR < 12 Discharge Disposition: Extended Care Facility: New Discharge Diagnosis: Cranial Defect Discharge Condition: Stable Discharge Instructions: General Instructions ?????? Have a friend/family member check your incision daily for signs of infection. ?????? Take your pain medicine as prescribed. ?????? Exercise should be limited to walking; no lifting, straining, or excessive bending. ?????? You may wash your hair only after sutures and/or 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 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**]. ?????? Clearance to drive and return to work will be addressed at your post-operative office visit. CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING ?????? New onset of tremors or seizures. ?????? Any confusion or change in mental status. ?????? Any numbness, tingling, weakness in your extremities. ?????? Pain or headache that is continually increasing, or not relieved by pain medication. ?????? Any signs of infection at the wound site: redness, swelling, tenderness, or drainage. ?????? Fever greater than or equal to 101?????? F. Followup Instructions: Follow-Up Appointment Instructions ??????Please return to the office [**2191-6-10**] for removal of your staples or can be removed while at rehab. ??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr. [**First Name (STitle) **], to be seen in 2 months. Completed by:[**2191-6-8**]

[ "738.19", "V12.51", "432.1", "V15.51", "707.23", "311", "V44.1", "V15.52", "787.22", "V58.61", "707.03" ]

icd9cm

[ [ [] ] ]

[ "96.6", "02.06" ]

icd9pcs

[ [ [] ] ]

7539, 7569

5016, 6097

310, 347

7628, 7637

1698, 4993

9211, 9523

949, 953

6222, 7516

7590, 7607

6123, 6199

7661, 9188

968, 968

1476, 1679

256, 272

375, 574

1299, 1462

982, 1202

1217, 1283

596, 880

896, 933

81,378

147,279

36627

Discharge summary

report

Admission Date: [**2188-6-24**] Discharge Date: [**2188-6-28**] Date of Birth: [**2130-8-20**] Sex: M Service: NEUROLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 618**] Chief Complaint: Code stroke Major Surgical or Invasive Procedure: Intubation, bronchoscopy History of Present Illness: Mr. F is a 57 year old right handed male with PVD, CAD, afib presenting with dizziness, nausea and dysarthria. He awoke feeling well. He developed symptoms around 1pm of dizziness following taking insulin. He went to sleep and awoke ~5pm, evaluated at OSH where noncontrast head CT revealed ? basilar opacity. He was medflighted to [**Hospital1 18**] for evaluation. CODE STROKE called upon arrival. NIHSS 6 for R facial droop, R pronator drift, dysarthria. CT/CTA/CTP revealed extensive R vert occlusion and ? basilar thrombus. At present the patient denies headaches. Reports feeling "well." He is aware of slurred speech. No sensory loss. ROS, no recent, f/c, NS, CP, SOB, no abdominal pain. Past Medical History: Past Medical History: (incomplete) PVD- Right foot ischemia s/p [**2-14**] digits amp [**2188-3-19**] in [**Male First Name (un) 36290**] CAD s/p CABG Afib DM 2 HTN Social History: not married. moved here from [**Male First Name (un) **] three days ago. staying with his sister in-law. denies smoking. Family History: prominent for DM2 Physical Exam: Vitals: T 98, BP 162/80, HR 72, R 18, 100% 2l Gen: well appearing, cooperative, NAD HEENT: slight R exopthalmos, no scleral icterus, OP clear, MMM Neck: no carotid or vertebral bruits. CV- irregularly irregular, 2/6 SEM at RUSB Pulm- CTA B Abd- obese, soft, NT, ND, BS+ Extrem- R toe [**2-14**] amputation, distal pulses 1+ bilat. NEUROLOGIC EXAM: (with spanish interpretor) MS- Alert, oriented to person, place time, attentive to examination. Speech is severely dysarthric. Naming of high and low frequency objects is intact. No visual neglect of NIHSS picture. CN- L pupil 6mm and unreactive to direct light, constricts to 5mm via consensual response. R pupil 6mm reacts to 4mm directly. No evidence for field cut. End-gaze nystagmus bilat, ? worse with left gaze. There is appearance of baseline ocular misalignment. Right UMN facial droop. weakness of R eye closure. Sensation symmetric bilat. tongue protrudes in an irregular fashion. Able to move bilaterally. Some debate about tongue being at midline. SCM and Trap. full. Motor- R pronator drift, holds arms and legs antigravity x 10 seconds intially, upon re-examination, right arm was barely antigravity. Sensory- no loss of LT, PP. Plantar response, mute bilaterally. Gait- unable to test. Pertinent Results: [**2188-6-24**] 06:00PM GLUCOSE-210* UREA N-34* CREAT-1.3* SODIUM-139 POTASSIUM-4.7 CHLORIDE-104 TOTAL CO2-24 ANION GAP-16 [**2188-6-24**] 06:00PM WBC-11.6* RBC-4.90 HGB-12.4* HCT-38.2* MCV-78* MCH-25.3* MCHC-32.4 RDW-19.7* [**2188-6-24**] 06:00PM NEUTS-86.8* LYMPHS-10.0* MONOS-1.6* EOS-1.2 BASOS-0.5 [**2188-6-24**] 06:00PM PT-16.4* PTT-26.0 INR(PT)-1.5* [**2188-6-24**] 06:00PM cTropnT-<0.01 [**2188-6-24**] 11:25PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG [**2188-6-24**] 11:25PM URINE BLOOD-TR NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [**2188-6-25**] 02:52AM BLOOD Triglyc-59 HDL-39 CHOL/HD-5.4 LDLcalc-160* [**2188-6-26**] 01:16PM BLOOD Lactate-2.6* [**6-24**] CT head: Findings concerning for basilar artery thrombosis and acute infarction of the right cerebellum. [**6-24**] CT A/perfusion: Decreased blood flow and volume, increased MTT in cerebellar hemispheres and vermis in matched distribution compatible with infarction with no penumbra identified. Thrombus in the basilar artery with possible extension to the left vertebral artery. Right vertebral not visualized with extensive clot throughout entire course. [**6-25**] Echo: Biventricular cavity dilation with severe global biventricular hypokinesis c/w diffuse process (toxin, metabolic, multivessel CAD, etc.) Moderate pulmonary artery systolic hypertension. No definite cardiac ource of embolism identified. Increased PCWP. Moderate mitral egurgitation. EF 25%. [**6-24**]: Significant worsening of mass effect associated with evolving right cerebellar infarction, causing effacement of the fourth ventricle and perimesencephalic cisterns, interval dilatation of the third and lateral ventricles, consistent with acute obstruction. The dense appearance of the Basilar artery is less obvious on the present study. Brief Hospital Course: Admission impression: 57year old male with severe PVD, CAD, now presenting with dizziness, nausea and dysarthria found to have vertebrobasilar occlusion. His examination is notable for R gaze preference, low vision in L eye, R pronator drift, dysmetria R > L. Etiology of embolus is likely cardioembolic with subtherapeutic INR. Pt is not a candidate for IV or IA tPA or MERCI retrieval given presentation outside window for intervention, extent of thrombus in the vessel presents risks of hemorrhage that outweigh potential benefits. ICU Course: Neuro: [**Known firstname 11805**] was admitted to Neuro ICU and started on heparin 13units/kg, with goal PTT 50-70. [**6-25**] he had increased right sided weakness but has some movement, was alert, oriented, dysarthric, and following commands. In the late afternoon he had an abrupt decompensation with decreased alterness, decreased movement of the left side a more right sided weakness, along with agonal breathing pattern. CXR and ABG were ok at that time. He was intubated and taken for stat head CT which found significant swelling of the right cerebellar stroke with compression of the brainstem and development of hydrocephalus. He was immediately started on hyperventillation and mannitol but did not clinically improve. Heparin drip was stopped and he started a baby [**Name (NI) 17408**] the following day. Neurosurgery was also emergently consulted and did not feel he was a surgical candidate. Overnight his pupils became unresponsive and he lost his right corneal reflex. Overnight there were extensive conversations with the family reguarding the severity of the situation. They decided to leave him full code while family was traveling to see him. He was determined braindead on [**6-28**]. CV: Pt was in a. fib with RVR requiring diltiazem drip on [**6-26**]. He had heart failure with EF 25%. Resp: He was intubated for agonal breathing on [**6-25**]. FEN/GI: He remained NPO after failing swallow eval [**6-25**] Endo: He was treated with insulin sliding scale and home po DM agents were held. Renal: Slight bump in Cr to 1.4 initially but then up to 2.4 in the setting of herniation. ID: Developed fever on [**6-26**] up to 103. Medications on Admission: Aldactone 25mg daily Coreg 25mg [**Hospital1 **] Coumadin 5mg daily Lasix 40mg [**Hospital1 **] Vasotec 20mg [**Hospital1 **] Amaryl 4mg [**Hospital1 **] Lantus 6units daily Lipitor 10mg daily Avelox ?? 400mg daily x 2 weeks ? pletal gabapentin 300mg Discharge Medications: None Discharge Disposition: Expired Discharge Diagnosis: stroke, posterior fossa herniation Discharge Condition: expired Discharge Instructions: None Followup Instructions: None [**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 632**] Completed by:[**2188-8-15**]

[ "276.7", "V45.81", "250.00", "518.81", "440.20", "401.9", "440.4", "V58.67", "V49.72", "434.91", "414.00", "787.20", "486", "427.31", "342.90" ]

icd9cm

[ [ [] ] ]

[ "33.24", "38.91", "96.04", "96.71", "96.08", "38.93" ]

icd9pcs

[ [ [] ] ]

7203, 7212

4655, 6871

327, 354

7290, 7299

2739, 3510

7352, 7479

1427, 1447

7174, 7180

7233, 7269

6897, 7151

7323, 7329

1462, 1794

276, 289

382, 1082

3519, 4632

1811, 2720

1126, 1271

1288, 1411

14,759

118,840

6034

Discharge summary

report

Admission Date: [**2137-12-13**] Discharge Date: [**2137-12-27**] Date of Birth: [**2113-9-9**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 106**] Chief Complaint: Cough and Dyspnea on Exertion Major Surgical or Invasive Procedure: Cardiac Catheterization, Pericardiocentesis, Pleurocentesis and Hickman Line Placement. History of Present Illness: 24M w/o significant PMHx w/ 4-5d of productive cough, DOE and L axillary mass. Also reported tender left axillary mass and associated discomfort which he noticed 2 days PTA. For the past week, he has had prod cough w/ thick yellow sputum and sore throat. He denies F/C. After a few days of coughing, developed pain with coughing and deep inspiration. DOE when walking up 3 flights of stairs. At baseline, no physical limitations. Has had intermittent, mild L arm pain for the past couple of days. ROS: Denies fevers, chills, fatigue, weight loss, decreased appetite. He denies nausea, vomiting, abdominal pain, diarrhea, constipation, dysuria, urinary symptoms. [**Hospital1 18**] ED: Pericardial tamponade by ECHO (RA diastolic collapse and RV compression) with pulsus paradoxus of 18-20 and tachycardia. Had successful pericardiocentesis (removal of 600cc of straw colored fluid) and drain placement. Past Medical History: MVA ([**10-21**]) with Lumbar Myofascial Inflammation Social History: [**Location 7979**]. Lives with mom and sister. [**Name (NI) 1403**] at Stop and Shop warehouse as a selector. Previous marijuana use. Drinks 3-4 beers/week. No cigarettes. No other illegal drug use. Family History: Cousin had leukemia. Mother and Sister have seizure disorders. Father had prostate cancer and MI (age 57). Grandmother had breast cancer. Physical Exam: R99 HR110 BP125/47 RR30 OS96%RA GEN: Mild resp distress. HEENT: MMM. Clear OP. Neck: Multiple enlarged anterior cervical lymph nodes. CV: Tachycardic. NL 21/S2. II/VI SEM AT LSB. RESP: No breath sounds on left. Right basilar crackles. ABD: S/NT/ND. Pos BS. Groin: No LAD or bruits. EXT: No CCE. DP 2+ B/L. Neuro: A&Ox3. CNII-XII grossly intact. Strength V/V and sensation to LT intact throughout. Pertinent Results: Bone Marrow Flow Cytometry ([**2137-12-13**]): PERIPHERAL SMEAR: Smear quality is acceptable. Red cells show minimal anisocytosis and rare nucleated red blood cells. WBC count is increased. Differential shows 10% segmented neutrophils, 1% metamyelocyte, 1% myelocyte, 2% monocytes, 7% lymphocytes, 1% eosinophils, and 78% blasts. Occasional blasts have cytoplasmic granules. Platelet count appears normal; occasional large forms are present. ASPIRATE SMEARS: The aspirate material is adequate for evaluation. It consists predominantly of variably-sized blasts with scant cytoplasm, irregular convoluted nuclei with fine chromatin and multiple nucleoli. In the residual hematopoietic cells, M:E ratio is 0.7:1. Myeloid cells appear decreased. Erythroid maturation is normoblastic. Granulocyte maturation is normal. Megakaryocytes are decreased in number; many immature hypolobated forms are present. Differential shows: Blasts 90%, Promyelocytes <1%, Myelocytes <1%, Metamyelocytes 1%, Bands/Neutrophils 2%, Plasma cells 1%, Lymphocytes <1%, Erythroid 6%. ADDENDUM: Immunostains reveal the blasts are positive for TdT, and negative for CD1a. Scattered cells show membranous staining for CD3.FLOW RESULTS: Three color gating is performed (light scatter vs. CD45) to optimize blast yield. Cell marker analysis demonstrates that the majority of the cells isolated from this peripheral blood express lymphoid-associated antigens CD5, 7, 8 (dim) and 71. They lack CD2, 3, 4, 10 (cALLa), 11c, 13, 14, 15, 19, 20, 33, 34, 41, 56, 64, 117, HLA-DR, glycophorin A, kappa and lambda. Blast cells comprise ~50% of total analyzed events. INTERPRETATION: Immunophenotypic findings consistent with involvement by acute lymphoblastic leukemia, T-cell type. CXR ([**2137-12-13**]): CHEST, PA & LATERAL: There are no prior films for comparison. There is a large left pleural effusion. Minimal aeration is present at the left apex. There is right upper lobe and right lower lobe atelectasis. The heart appears mildly enlarged. The right lung is clear. The osseous structures are unremarkable. IMPRESSION: 1) Large left pleural effusion. 2) Enlarged cardiac silhouette. This may be due to cardiomegaly vs. pericardial effusion. CT CHEST ([**2137-12-13**]): IMPRESSION: 1) Anterior mediastinal mass extending along the paracardium and to the left lung pleura with superior mediastinal, supraclavicular, with left axillary lymphadenopathy and with large pericardial and pleural effusions. Potential etiologies include lymphom and germcell tumor. A primary thymic tumor is possible but considered less likely given the lymphadenopathy and the patient's age. 2) Hepatomegaly and a small amount of pericholecystic fluid. This is a non-specific finding. ECHO/TTE ([**2137-12-13**]): LVEF>55%. The left atrium is normal in size. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal and systolic function is normal. The right ventricular cavity is small/compressed. Right ventricular systolic function is normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. There is a large pericardial effusion. There is sustained right atrial collapse, consistent with low filling pressures or tamponade. There is right ventricular compression. These findings are consistent with tamponade. Clinical correlation recommended. CARD CATH/PERICARDIOCENTESIS ([**2137-12-13**]): FINAL DIAGNOSIS: 1. Severe pericardial tamponade. 2. Removal of 600 cc of pericardial fluid. COMMENTS: 1. Resting hemodynamics deomonstrated elevated right and left sided pressures with blunted Y descent and elevation of pericardial pressures with equalization of RA and pericardial pressures (18 mmHg) consistent with tamponade. Upon removal of pericardial fluid, RA pressure decreased 8 mmHg, and pericardial pressure decreased to 0 mmHg. The cardiac index improved from 1.9 l/min/m2 to 3.1 l/min/m2 with removal of pericardial fluid. 2. Pericardiocentesis was performed in one pass with withdrawl of approximately 600 cc of straw colored fluid. ECHO/TTE ([**2137-12-16**]): 1. Left ventricular wall thickness, cavity size, and systolic function are normal (LVEF>55%). Regional left ventricular wall motion is normal. 2. There is a small pericardial effusion with fibrin deposits on the surface of the heart. There are no echocardiographic signs of tamponade. 3. Compared with the findings of the prior report (tape unavailable for review) of [**2137-12-13**], the pericardial effusion is almost gone. CXR ([**2137-12-20**]): PA & LATERAL VIEWS CHEST: The left hilar mass is unchanged. There is interval slight improvement in the left pleural effusion and left lower lobe opacity. No evidence of pneumothorax. IMPRESSION: Interval improvement in left pleural effusion and left lower lobe opacity. [**2137-12-13**] 02:50AM IPT-DONE [**2137-12-13**] 02:50AM PT-14.3* PTT-23.9 INR(PT)-1.3 [**2137-12-13**] 02:50AM PLT SMR-NORMAL PLT COUNT-157 [**2137-12-13**] 02:50AM HYPOCHROM-1+ ANISOCYT-NORMAL POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-1+ [**2137-12-13**] 02:50AM NEUTS-19* BANDS-0 LYMPHS-7* MONOS-2 EOS-1 BASOS-1 ATYPS-3* METAS-0 MYELOS-0 BLASTS-66* PLASMA-1* [**2137-12-13**] 02:50AM WBC-38.4*# RBC-5.22 HGB-15.5 HCT-44.2 MCV-85 MCH-29.6 MCHC-35.0 RDW-13.5 [**2137-12-13**] 02:50AM ALBUMIN-4.3 CALCIUM-9.8 PHOSPHATE-3.7 MAGNESIUM-2.0 URIC ACID-6.0 [**2137-12-13**] 02:50AM LIPASE-29 [**2137-12-13**] 02:50AM ALT(SGPT)-55* AST(SGOT)-35 LD(LDH)-313* ALK PHOS-105 AMYLASE-42 TOT BILI-0.8 [**2137-12-13**] 02:50AM GLUCOSE-102 UREA N-11 CREAT-0.9 SODIUM-143 POTASSIUM-4.2 CHLORIDE-106 TOTAL CO2-25 ANION GAP-16 [**2137-12-13**] 09:15AM FIBRINOGE-266 [**2137-12-13**] 09:15AM FDP-0-10 [**2137-12-13**] 09:15AM PT-14.4* PTT-24.4 INR(PT)-1.3 [**2137-12-13**] 09:15AM PLT SMR-NORMAL PLT COUNT-153 [**2137-12-13**] 09:15AM HYPOCHROM-NORMAL ANISOCYT-1+ POIKILOCY-NORMAL MACROCYT-OCCASIONAL MICROCYT-2+ POLYCHROM-1+ [**2137-12-13**] 09:15AM NEUTS-12* BANDS-0 LYMPHS-8* MONOS-2 EOS-0 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 BLASTS-78* [**2137-12-13**] 09:15AM WBC-38.1* RBC-5.07 HGB-15.1 HCT-42.9 MCV-85 MCH-29.7 MCHC-35.2* RDW-13.8 [**2137-12-13**] 09:15AM HAPTOGLOB-65 [**2137-12-13**] 09:15AM CALCIUM-9.4 MAGNESIUM-1.9 [**2137-12-13**] 09:15AM LD(LDH)-244 [**2137-12-13**] 09:15AM GLUCOSE-107* UREA N-11 CREAT-0.9 SODIUM-142 POTASSIUM-3.8 CHLORIDE-106 TOTAL CO2-25 ANION GAP-15 [**2137-12-13**] 11:48AM BONE MARROW IPT-DONE [**2137-12-13**] 02:15PM OTHER BODY FLUID WBC-[**Numeric Identifier 23697**]* RBC-4950* POLYS-0 LYMPHS-18* MONOS-0 OTHER-82* [**2137-12-13**] 02:15PM OTHER BODY FLUID TOT PROT-5.4 GLUCOSE-47 LD(LDH)-349 AMYLASE-23 ALBUMIN-3.5 [**2137-12-13**] 06:16PM FIBRINOGE-250 [**2137-12-13**] 06:16PM PT-14.7* PTT-23.6 INR(PT)-1.4 [**2137-12-13**] 06:16PM PLT COUNT-172 [**2137-12-13**] 06:16PM WBC-53.1* RBC-4.90 HGB-14.2 HCT-41.8 MCV-85 MCH-28.9 MCHC-33.9 RDW-13.5 [**2137-12-13**] 06:16PM TOT PROT-6.1* CALCIUM-9.0 PHOSPHATE-2.9 MAGNESIUM-1.8 URIC ACID-5.3 [**2137-12-13**] 06:16PM GLUCOSE-123* UREA N-10 CREAT-0.9 SODIUM-141 POTASSIUM-3.8 CHLORIDE-107 TOTAL CO2-25 ANION GAP-13 [**2137-12-13**] 10:44PM FIBRINOGE-291 [**2137-12-13**] 10:44PM PT-15.0* PTT-24.0 INR(PT)-1.4 [**2137-12-13**] 10:44PM PLT COUNT-155 [**2137-12-13**] 10:44PM WBC-22.2*# RBC-5.18 HGB-15.0 HCT-44.5 MCV-86 MCH-29.0 MCHC-33.8 RDW-13.7 [**2137-12-13**] 10:44PM HIV Ab-NEGATIVE [**2137-12-13**] 10:44PM CALCIUM-9.3 PHOSPHATE-3.0 MAGNESIUM-1.8 URIC ACID-5.4 [**2137-12-13**] 10:44PM GLUCOSE-180* UREA N-10 CREAT-1.1 SODIUM-139 POTASSIUM-3.8 CHLORIDE-101 TOTAL CO2-29 ANION GAP-13 Brief Hospital Course: Mr [**Known lastname **] was admitted to [**Hospital1 18**] with shortness of breath and pleuritic chest pain which were caused by pleural and pericardial effusions secondary to mediastinal T-Cell Acute Lymphocytic Leukemia. 1. T-cell ALL: The patient had no significant medical history on admission. He presented with shortness of breath and pleuritic chest pain secondary to large pleural and pericardial effusions. Upon therapeutic drainage, the pericardial effusion was deemed malignant by cytology (the pleural effusion was not). Admission labs revealed a WBC of 38 with 60% blasts. Chest CT imaging revealed a left-sided mediastinal mass adjacent to the pericardium, as well as supraclavicular and left axillary lymphadenopathy. A bone marrow biopsy confirmed T-Cell Acute Lymphocytic Leukemia. The patient underwent the Hyper-CVAD chemotherapeutic regimen. Soon after Hyper-CVAD initiation, his cells lines fell. He was continued G-CSF and his ANC recovered to >700 on discharge. He had reached a nadir of <100. He was also given one dose of intrathecal MTX and one dose of intrathecal ARA-C. There was no cytologic evidence of malignancy in his cerebrospinal fluid. He was maintained on Levofloxacin, Fluconazole, Acyclovir and Allopurinol for prophylaxis and had no fevers throughout his course. He was discharged with oncologic follow-up and a future allogenic bone marrow transplant was planned. 3. Malignant Pericardial Effusion: Again, the patient had symptomatic tamponade on admission. He underwent successful pericardiocentesis and drain placement, which was later removed. Thereafter, he remained asymptomatic and stable. Follo-up echocardiograms were essentially unremarkable. A repeat ECHO in two to three months was recommended. 4. Left Pleural Effusion: Again, he had a large left pleural effusion on admision, causing partial colapse of the left lung. This had essentially resolved after thoracentesis. He had no respiratory distress and was without an oxygen requirement throughout the remainder of his course. Medications on Admission: None Discharge Medications: 1. Fluconazole 200 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*0* 2. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*0* 3. Acyclovir 400 mg Tablet Sig: One (1) Tablet PO three times a day. Disp:*90 Tablet(s)* Refills:*0* 4. Line Check VNA: Please attend to PICC according to [**Last Name (un) 6438**] protocol. Discharge Disposition: Home With Service Facility: [**Last Name (un) 6438**] Discharge Diagnosis: Primary Diagnosis: T-Cell Acute Lymphoblastic Leukemia. Secondary Diagnosis: Malignant Peridcardial Effusion, Non-Malignant Pleural Effusion. Discharge Condition: Good/Stable. Discharge Instructions: 1) Return to the ER, call the on-call Oncologist at [**Hospital1 18**] ([**Hospital1 18**] Main Number: [**Telephone/Fax (1) 2756**]), or your primary doctor, if you have any shortness of breath, chest pain, cough, bruising, bleeding, sore throat or any other concerning symptoms. 2) Please avoid contact with anyone with a cold, diarrhea, or any other possible infection. Ensure that you wash your hands regularly and that those whom you live with due the same (after using the bathroom, cooking, touching their faces, etc.). Please purchase and over-the-counter hand sanitizer for this purpose. Please also avoid close contact with small children or people coming from hospitals or nursing homes. Followup Instructions: 1) Please follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] for the following appointment on Monday, [**2137-12-30**] at 12:00PM: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3238**], MD Where: [**Hospital6 29**] HEMATOLOGY/ONCOLOGY Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2137-12-30**] 12:00 2) Please return to the [**Hospital1 18**] Bone Marrow Transplant tomorrow ([**2137-12-28**]) and every day thereafter until instructed to do otherwise. Your blood counts will be checked and you will be given an injection of Neupogen to boost your white blood cell count. Please come to the [**Location (un) 436**] of the [**Hospital Ward Name 1826**] Building on the [**Hospital1 18**] [**Hospital Ward Name 516**] between 10:00 AM and 3:00 PM. You may call the BMT floor at [**Telephone/Fax (1) 23698**] if you have any questions. 3) Please see your primary doctor in the next one to two weeks: [**Last Name (LF) **],[**First Name3 (LF) **] L. ([**Telephone/Fax (1) 7976**]).

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Discharge summary

report

Admission Date: [**2156-1-1**] Discharge Date: [**2156-1-4**] Date of Birth: [**2092-10-2**] Sex: M Service: MEDICINE Allergies: Sulfonamides Attending:[**First Name3 (LF) 1990**] Chief Complaint: ETOH withdrawal Major Surgical or Invasive Procedure: none History of Present Illness: Mr. [**Known lastname **] is a 63 year old man with PMH significant for ETOH abuse and history of DTs, HTN, panic disorder, and hyperlipidemia presenting to ED with HTN, tachycardia, N/V, and ? seizure after 2 days of attempted self detoxification. Patient typically drinks 3 glasses of wine and [**1-3**] gin and tonics daily since [**Month (only) 216**]. His last drink was 5pm on [**12-29**]. He most recently was hospitalized for detox in [**2155-7-2**] at [**Hospital 882**] Hospital. Partner also noted ? seizure like activity on day of admission where patient reportedly had [**6-7**] minute episode of "shaking uncontrollably" and stiffening of arms and legs and foaming at the mouth. He remained conscious although panicky and was speaking to him throughout episode. No urinary or fecal incontinence, falls or head trauma. No history of prior seizures. . In the emergency department, initial VS 98.3 122 220/104 20 100%RA. FSBS 206. He received 20 mg IV Valium for HTN, tachycardia, anxiety, diaphoresis and tremulousness. He also received IV Zofran and banana bag. After IV valium, he was noted to be somnolent and desaturated to 80s. NC was placed but he was mouth breathing so he was placed on NRB with increased O2 sats to 100%. CXR did not reveal any acute infiltrate. ECG was consistent with new RBBB. VS prior to transfer:94 169/103 18 100%NRB. . Upon arrival in the [**Hospital Unit Name 153**], patient reports nausea improved. He denies CP currently but reports he did have "funny" left sided CP a/w palpitations and nausea at rest 2 days prior which lasted a couple minutes. Also reports depression and feeling jittery. Denies SOB, orthopnea, cough, N/V/D, constipation, melena, hematochezia. . REVIEW OF SYSTEMS: (+)ve: As above. Also reports intermittent B/L hand tingling, night sweats x 2 days, and chronic dry cough. (-)ve: fever, chills, loss of appetite, rhinorrhea, nasal congestion, sputum production, hemoptysis, dyspnea, orthopnea, paroxysmal nocturnal dyspnea, nausea, vomiting, diarrhea, constipation, hematochezia, melena, dysuria, urinary frequency, urinary urgency, focal numbness, focal weakness, myalgias, arthralgias . Past Medical History: Hypertension Hyperlipidemia Panic attacks ETOH abuse, h/o DTs with attempted self detox Humerus fracture [**2126**] Social History: Grew up in [**Location (un) **] with 3 siblings. Owns antique gallery in [**Location (un) **]. Lives with long term male partner x 41 years, [**Doctor Last Name 10378**]. Denies drug or tobacco use. Family History: Mom-CVA. Sister-Ovarian CA Physical Exam: 94 169/103 18 100%NRB -> weaned to n/c PHYSICAL EXAM GENERAL: Diaphoretic, mildly ill appearing, tremulous but awake alert, answering questions appropriately HEENT: Normocephalic, atraumatic. No conjunctival pallor. No scleral icterus. PERRLA/EOMI. No nystagmus. OP clear. Neck Supple, No LAD, No thyromegaly. CARDIAC: Regular rhythm, normal rate. Normal S1, S2. No murmurs, rubs or [**Last Name (un) 549**]. JVP=7cm LUNGS: CTAB anteriorly. Not cooperating with more detailed exam. ABDOMEN: NABS. Soft, NT, ND. No HSM EXTREMITIES: No edema or calf pain, 2+ dorsalis pedis/ posterior tibial pulses. SKIN: No rashes/lesions, ecchymoses. No spider lesions NEURO: A&Ox3. Initially thought was at [**Hospital **] Hospital but reoriented to [**Hospital3 **]. Oriented to city, self and date. CN [**2-13**] grossly intact. Preserved sensation throughout. [**5-5**] strength throughout. [**1-3**]+ reflexes, equal BL. Fine tremor outstretched hands PSYCH: Listens and responds to questions appropriately Pertinent Results: [**2156-1-1**] 10:20PM GLUCOSE-170* UREA N-12 CREAT-1.0 SODIUM-141 POTASSIUM-3.1* CHLORIDE-96 TOTAL CO2-19* ANION GAP-29* [**2156-1-1**] 10:20PM estGFR-Using this [**2156-1-1**] 10:20PM ALT(SGPT)-33 AST(SGOT)-77* CK(CPK)-180* ALK PHOS-73 [**2156-1-1**] 10:20PM LIPASE-101* [**2156-1-1**] 10:20PM cTropnT-<0.01 [**2156-1-1**] 10:20PM CK-MB-3 [**2156-1-1**] 10:20PM ALBUMIN-4.3 CALCIUM-8.7 PHOSPHATE-3.9 MAGNESIUM-1.6 [**2156-1-1**] 10:20PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2156-1-1**] 10:20PM URINE HOURS-RANDOM [**2156-1-1**] 10:20PM URINE HOURS-RANDOM [**2156-1-1**] 10:20PM URINE GR HOLD-HOLD [**2156-1-1**] 10:20PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG [**2156-1-1**] 10:20PM WBC-6.4 RBC-4.26* HGB-13.1* HCT-39.7* MCV-93# MCH-30.8 MCHC-33.0 RDW-15.3 [**2156-1-1**] 10:20PM NEUTS-87.8* LYMPHS-10.4* MONOS-1.1* EOS-0.1 BASOS-0.5 [**2156-1-1**] 10:20PM PLT COUNT-145*# [**2156-1-1**] 10:20PM PT-15.2* PTT-34.8 INR(PT)-1.3* [**2156-1-1**] 10:20PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.016 [**2156-1-1**] 10:20PM URINE BLOOD-SM NITRITE-NEG PROTEIN-500 GLUCOSE-NEG KETONE-150 BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-NEG [**2156-1-1**] 10:20PM URINE RBC-0-2 WBC-0-2 BACTERIA-OCC YEAST-NONE EPI-<1 [**2156-1-1**] 10:20PM URINE HYALINE-0-2 [**2156-1-1**] 10:20PM URINE MUCOUS-FEW UPRIGHT AP VIEW OF THE CHEST: Allowing for low lung volumes and technique, the lungs are clear. There is no appreciable pleural effusion or pneumothorax. The heart size is normal. Mediastinal silhouette, hilar contours, and pulmonary vasculature are unremarkable. Brief Hospital Course: 63 year old male with ETOH abuse and history of withdrawal seizures and DTs presenting with ETOH withdrawal. . #. ETOH withdrawal: Pt presented with hypertension and tachycardia, possible seizure with attempted self detoxification. Last ETOH use was [**2155-12-30**]. Given prior history of DTs, he was at high risk for withdrawal and will need close monitoring. LFTs consistent with chronic ETOH abuse with 2:1 AST:ALT ratio. Patient received valium 10mg PO q1hour prn CIWA>10 until CIWA<10 or any evidence of intoxication(nystagmus, dysarthria, ataxia, sedation). He required valium 10 mg every three to four hours during his course in the ICU. He also received MVI, thiamine 100mg, folic acid. There were no signs of delerium tremens during the ICU course. He was transfered to the medical [**Hospital1 **], where there was evidence of benzo intoxication (nystagmus, ataxia); no evidence for withdrawal. His BP transiently rose to 200 systolic on one occasion, this improved to target (sbp 145) with one dose of hydralazine and administration of his home medication. On review of his home meds, it was noted that he was not given his home beta blocker during this admission, and resuming this on discharge was discussed with pt. and his partner at length. Evidence of benzo intoxication resolved and he was ambulatory at baseline. He was discharged home. His sbp at discharge was 145 systolic, and he had no complaints. . #. Hypertension: Likely multifactorial secondary to ETOH withdrawal in addition to baseline hypertension and med noncompliance. Valium was given as above, and patient was restarted on home accupril and dyazide - and BB to be resumed on arrival home as above. . #. Tachycardia: Likely secondary to ETOH withdrawal as above in addition to anxiety and dehydration. Patient noted to have new RBBB on ECG in ED with tachycardia but resolved once in unit and HR better controlled. He is asymptomatic without CP so likely tachycardia mediated. The patient did rule out for myocardial ischemia. Home aspirin was continued. . #. ? Seizure: Unclear if patient had partial seizure. Typically ETOH withdrawal seizures or grand mal and patient was reportedly conscious throughout episode which would be atypical. CK and lactate trended down. Seizure precautions were maintained during at-risk period for DTs. . #. Hypoxia: Likely multifactorial secondary to hypoventilation with benzos +/- aspiration. No elevated WBC or fever to suggest pneumonia and did not have O2 requirement on arrival to ED. Patient was weaned to room air in the unit. No further evaluation was performed. . #. Thrombocytopenia: Likely [**2-3**] ETOH abuse. Has history of low platelets in the past, likely associated with active ETOH abuse. . #. Panic disorder: Valium prn CIWA Medications on Admission: Reviewed: nr Ezetimibe [Zetia] Dosage uncertain (Prescribed by Other Provider) [**2154-5-17**] Recorded Only [**Doctor Last Name **], [**Doctor Last Name **] M. [**Doctor Last Name 25720**] Modify Pantoprazole [Protonix] 40 mg Tablet, Delayed Release (E.C.) 1 (One) Tablet(s) by mouth once a day [**2155-3-31**] Renewed [**Doctor Last Name **], [**Doctor First Name 132**] 90 Tablet 1 (One) [**Last Name (LF) 131**], [**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] [**First Name (Titles) 25720**] [**Last Name (Titles) **]w Reprint Modify Quinapril [Accupril] 40 mg Tablet 1 (One) Tablet(s) by mouth once a day (Prescribed by Other Provider) [**2154-5-17**] Recorded Only [**Doctor Last Name **], [**Doctor Last Name **] M. [**Doctor Last Name 25720**] Renew Modify Triamterene-Hydrochlorothiazid [Dyazide] 37.5 mg-25 mg Capsule 1 (One) Capsule(s) by mouth once a day (Prescribed by Other Provider) [**2154-5-24**] Recorded Only [**Doctor Last Name **], ANGELIE [**Doctor Last Name 25720**] Renew Modify nr zebata - 10 mg daily (Prescribed by Other Provider) [**2154-5-17**] Recorded Only [**Doctor Last Name **], [**Doctor Last Name **] M. [**Doctor Last Name 25720**] Modify * OTCs * Ascorbic Acid [Vitamin C] 500 mg Tablet 1 (One) Tablet(s) by mouth once a day (Prescribed by Other Provider) [**2154-5-24**] Recorded Only [**Doctor Last Name **], ANGELIE [**Doctor Last Name 25720**] Renew Modify Aspirin [Baby Aspirin] 81 mg Tablet, Chewable 0.5 (One half) Tablet(s) by mouth once a day haas not taken in a week (Prescribed by Other Provider) [**2154-5-17**] Recorded Only [**Doctor Last Name **], [**Doctor Last Name **] M. [**Doctor Last Name 25720**] Renew Modify Allergy Alert B Complex Vitamins [Vitamin B Complex] Tablet 1 (One) Tablet(s) by mouth once a day (Prescribed by Other Provider) [**2154-5-24**] Recorded Only [**Doctor Last Name **], ANGELIE [**Doctor Last Name 25720**] Renew Modify Cyanocobalamin [Vitamin B-12] 500 mcg Tablet 1 (One) Tablet(s) by mouth once a day (Prescribed by Other Provider) [**2154-5-24**] Recorded Only [**Doctor Last Name **], ANGELIE [**Doctor Last Name 25720**] Renew Modify Folic Acid 0.8 mg Tablet 1 (One) Tablet(s) by mouth once a day (Prescribed by Other Provider) [**2154-5-24**] Recorded Only [**Doctor Last Name **], ANGELIE [**Doctor Last Name 25720**] Renew Modify Lysine 500 mg Tablet 1 (One) Tablet(s) by mouth once a day (Prescribed by Other Provider) [**2154-5-24**] Recorded Only [**Doctor Last Name **], ANGELIE [**Doctor Last Name 25720**] Renew Modify Discharge Medications: No changes to home regimen made Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: EtOH withdrawal Secondary Diagnoses: Hypertension Hyperlipidemia Panic attacks ETOH abuse, h/o DTs with attempted self detox Discharge Condition: AF and VSS, A and O, gait intact (at baseline per pt.s partner of 41 years) - requires supervision only in walking. Discharge Instructions: You were admitted to the hospital for withdrawal from alcohol. There was a concern for seizure activity and the possibility that you could develop trouble breathing, so you were admitted to the ICU. You received medication during the withdrawal, and did well. You were then transferred to the medical floor and continued to improve. As we discussed, you need to comply with the following: Take all medications as prescribed. Do not drink alcohol Call your primary doctor to arrange a follow up appointment for within one week of leaving the hospital. Resume you home medication regimen. On the day of discharge, we gave you all the medications you are due, with the exception of your Zebeta. You should take this when you arrive home (your usual dose), and then resume you usual medication regiemen Monday am ([**2155-1-5**]). Followup Instructions: As above

[ "786.09", "287.5", "272.4", "291.81", "300.01", "784.51", "426.4", "785.0", "787.01", "780.39", "783.0", "E939.4", "V15.81", "401.9" ]

icd9cm

[ [ [] ] ]

[ "94.62" ]

icd9pcs

[ [ [] ] ]

11246, 11252

5624, 8415

287, 293

11441, 11559

3914, 5601

12441, 12453

2853, 2881

11190, 11223

11273, 11273

8441, 11167

11583, 12418

2896, 3895

11330, 11420

2055, 2482

232, 249

321, 2036

11292, 11309

2504, 2621

2637, 2837

44,892

110,593

39792

Discharge summary

report

Admission Date: [**2176-10-18**] Discharge Date: [**2176-10-27**] Date of Birth: [**2120-11-10**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 922**] Chief Complaint: mitral regurgitation Major Surgical or Invasive Procedure: Mitral valve repair/ligation of left atrial appendage [**2176-10-18**] History of Present Illness: This 55 year old white male recently was noted to have a murmur. Echocardiography demonstrated severe mitral regurgitation. A cardiac catheterization revealed 4+ regurgitation without coronary disease. He was referred for surgical evaluation and was now admitted for operation. Past Medical History: depression prostatism Social History: dental last exam [**10-15**] Works as a carpenter smokes a pack a day for 20 years episodic heavy ETOH use. None in a week he says. Family History: noncontributory Physical Exam: admission: Pulse: 78 Resp: 16 O2 sat: 98% B/P Right: 131/92 Left: 140/96 Height: Weight: 210 # 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 [**5-21**] holosystolic murmur best heard at LLSB 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: 1 Left: 1 PT [**Name (NI) 167**]: 1 Left: 1 Radial Right: 2 Left: 2 Carotid Bruit Right/Left: None Pertinent Results: [**2176-10-25**] 04:40AM BLOOD WBC-5.8 RBC-3.40* Hgb-10.8* Hct-30.9* MCV-91 MCH-31.9 MCHC-35.1* RDW-13.6 Plt Ct-338 [**2176-10-24**] 05:05AM BLOOD PT-13.1 INR(PT)-1.1 [**2176-10-25**] 04:40AM BLOOD Glucose-98 UreaN-15 Creat-1.0 Na-136 K-4.5 Cl-97 HCO3-28 AnGap-16 ECHO [**2176-10-25**] The left atrium is moderately dilated. The right atrium is moderately dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size. There is mild global left ventricular hypokinesis (LVEF = 45-50%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. A mitral valve annuloplasty ring is present. The mitral annular ring appears well seated with normal gradient. Trivial mitral regurgitation is seen. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. IMPRESSION: Mild global left ventricular systolic dysfunction. Normally-functioning mitral annuloplasty. No significant pericardial effusion seen. Compared with the prior study (images reviewed) of [**2176-10-15**], the native regurgitant mitral valve has been repaired. LV function is slightly less vigorous, although given recent correction of severe MR, the intrinsic LV systolic function is probably similar. Brief Hospital Course: Following admission he was taken to the Operating Room where P2 resection, annuloplasty (30mm ring) and ligation of the left atrial appendage were performed. He weaned from bypass on low dose Epinephrine and Propofol. He weaned from pressors and the ventilator easily. Intra-operatively he had brief atrial fibrillation and was begun on Amiodarone. In the morning after surgery he was in a junctional rhythm in the 40s and required ventricular pacing. Amiodarone was stopped and his rate gradually increased to the 50s with a return of sinus mechanism alternating with junction. Chest tubes were removed on POD#1 and he was transferred to the floor. Physical therapy was consulted for mobility and strength. The electrophysiology service was consulted for consideration of a permanent pacemaker, but as his atrial activity began to recover. He expereinced an 11 beat run of asymptomatic, non-sustained VT. He was able to tolerate low dose lopressor and he was deemed to no longer need one. Attempts to increase lopressor resulted in junctional rhythm. Electrophysiology will titrate lopressor as an outpatient. On post-operative day eight his epicardial wires were removed, he was ambulatory, stable and ready for discharge home with VNA follow up. All follow-up appointments were advised. Medications on Admission: none Discharge Medications: 1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*50 Tablet(s)* Refills:*0* 2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 3. Metoprolol Tartrate 25 mg Tablet Sig: 0.25 Tablet PO BID (2 times a day). Disp:*15 Tablet(s)* Refills:*2* 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 5. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [**Hospital1 **] (2 times a day). Disp:*1 mdi* Refills:*2* 6. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for pain. Disp:*60 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital1 1376**] Discharge Diagnosis: mitral regurgitation prostatism depression s/p appendectomy s/p mitral valve repair (#30mm ring)/left atrial ligation 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**] **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**] ([**Telephone/Fax (1) 170**]) Date/Time:[**2176-11-18**] 1:15 Cardiologist: Dr. [**First Name8 (NamePattern2) 402**] [**Last Name (NamePattern1) **] [**12-13**] at 2:30pm Please call to schedule appointments with: Primary Care Dr. [**First Name5 (NamePattern1) **] [**Last Name (un) **] in [**5-20**] 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:[**2176-10-27**]

[ "E878.8", "997.1", "303.92", "424.0", "427.1", "427.31", "746.9", "V10.83" ]

icd9cm

[ [ [] ] ]

[ "37.49", "37.36", "39.61", "35.12" ]

icd9pcs

[ [ [] ] ]

5378, 5429

3256, 4558

344, 417

5591, 5770

1694, 3233

6608, 7203

936, 953

4613, 5355

5450, 5570

4584, 4590

5794, 6585

968, 1675

284, 306

445, 726

748, 771

787, 920

30,433

148,497

33674

Discharge summary

report

Admission Date: [**2151-3-10**] Discharge Date: [**2151-3-31**] Date of Birth: [**2084-1-11**] Sex: M Service: MEDICINE Allergies: Penicillins / Heparin Agents Attending:[**First Name3 (LF) 783**] Chief Complaint: BRBPR Major Surgical or Invasive Procedure: Colonoscopy EGD History of Present Illness: 67 M now 32 days s/p AAA repair in [**State **] at [**Hospital 77953**] [**Hospital 12018**] Med Center [**2151-2-7**] who presented from rehab with BRBPR. He was originally admitted to OSH on [**2151-2-7**] with back pain. Found to have an 8x8 cm AAA and underwent surgery semi-urgently. AAA repair was complicated by occlusion of renal arteries, and then followed by open abdominal renal bypass procedure. Hospital course was complicated by respiratory failure and ~2 [**12-30**] week intubation. Also c/b renal failure requiring HD, strep viridans bacteremia (on vanc and zosyn for unknown course), neutropenia thought secondary to an antibiotic, treated with neupogen per heme c/s note, thrombocytopenia (HIT Ab neg) thought secondary to antibiotics/meds v. sepsis, diffuse petechial or maculopapular(?) rash noted on [**2151-3-4**] (evaluated by derm, shave biopsy obtained, thought [**1-30**] drug reaction from beta lactam, treated with triamcinolone cream), and delerium (psych was c/s'ed-thought was toxic-metabolic and subsequently felt he was depressed). . He was transferred to [**Hospital **] [**Hospital **] rehab on [**3-8**]. He was noted on [**3-10**] to have dark blood coming from his rectal bag. The patient noted that during the week prior to admission he had felt some rectal irratation, and had noticed small amounts of blood in and around the rectal bag. The flexi-seal with rectal balloon had been in place for weeks- apparently because the pt was bedbound. His wife says that he has been bed bound for the last month (first time out of bed was yesterday). She also says that at baseline he is very sharp, very oriented and quick. She says now he is slower, more easily confused, though he is much improved from when he was "rambling" in the ICU. She also says his rash is much improved from before, it used to be more red and raised and covered his entire body including his face. It has recently started "drying up". . ED Course: T98.1 HR60 BP 153/80 RR 20 O2sat 96% RA. Received 1.5L NS, protonix 40mg IV, D5W w/3amps bicarb, cipro 400mg IV x1. He was admitted to surgery as there was concern for fistula from AAA. CT scan did not show any fistula. GI was consulted and planned for scope today. He is being treated empirically for a UTI with cipro based on U/A. . Currently ROS: The patient denies SOB, CP, palpitations. He does complain of shaking chills, he wants the temperature turned up. He denies cough. No nightsweats. He denies abdominal pain. He feels that he is weaker than baseline. Past Medical History: ** sx infrarenal 8x8cm AAA (non-ruptured), semiurgently repaired c/b covering of renal a requiring L EIA to L renal bypass 4mm PTFE c/b ARF on CRI - requiring HD c/b resp failure - 16 day intubation, PNA c/b Staph CoN bacteremia (Vanc DC'ed [**3-2**]), mastoiditis c/b rash - on SoluMedrol c/b neutropenia - Neupogen [**Date range (1) 66853**] CAD s/p stent in [**2146**] DM HTN Hypercholesterolemia morbid obesity gout R eye blindness from injury in 8th grade CRI (before AAA repair) OA R knee surgery [**82**] yrs ago R foot surgery Social History: ex smoker, quit 30-40 yrs ago, no EtOH, lives with wife, has 2 sons, owns and manages property, retired salesman, no psych history Family History: non contributory Physical Exam: VS: T 99, HR 93, 130/62 94% RA FS196 Gen: obese male laying in bed in NAD- alert and talkative, but occasionally chattering teeth, occasionally scratching skin HEENT: anicteric, MMM, no oropharyngeal lesions Skin: full body (arms, trunk, legs) blanching maculopapoular rash with some areas of hyperpigmentation and scaling. Face hyperpigmented with no current papules. Arms with some areas fresh erythematous papular lesions, and other appear older, more confluent, more flat and hyperpigmented. On distal legs also has petechiae. Chest: lungs sounds CTA b/l Heart: RRR no m/r/g Abdomen: midline abdominal scar, obese, nontender, +BS Extremities: no edema, no cyanosis, 2+DPs Neuro: oriented to person, place, [**2151-3-11**], CNs intact, [**5-3**] UE strength (though mild shaking with exertion), [**5-3**] knee, ankle strength b/l, has some R>L difficulty lifting straight leg against resistance Pertinent Results: URINE STUDIES [**2151-3-10**] 02:00AM URINE RBC-[**11-18**]* WBC->50 BACTERIA-MANY YEAST-NONE EPI-0-2 [**2151-3-10**] 02:00AM URINE BLOOD-LG NITRITE-POS PROTEIN-TR GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-MOD [**2151-3-10**] 02:00AM URINE COLOR-Yellow APPEAR-Cloudy SP [**Last Name (un) 155**]-1.014 ADMISSION HEMATOLOGY [**2151-3-10**] 02:00AM PT-13.2 PTT-26.2 INR(PT)-1.1 [**2151-3-10**] 02:00AM PLT SMR-NORMAL PLT COUNT-185 [**2151-3-10**] 02:00AM HYPOCHROM-OCCASIONAL ANISOCYT-NORMAL POIKILOCY-1+ MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL TARGET-OCCASIONAL SCHISTOCY-1+ TEARDROP-1+ [**2151-3-10**] 02:00AM NEUTS-80* BANDS-3 LYMPHS-5* MONOS-1* EOS-5* BASOS-0 ATYPS-1* METAS-3* MYELOS-2* [**2151-3-10**] 02:00AM WBC-6.3 RBC-4.14* HGB-12.3* HCT-36.4* MCV-88 MCH-29.8 MCHC-33.9 RDW-14.7 ADMISSION CHEMISTY [**2151-3-10**] 02:00AM ALBUMIN-3.6 CALCIUM-8.9 PHOSPHATE-2.7 MAGNESIUM-1.8 [**2151-3-10**] 02:00AM CK-MB-NotDone [**2151-3-10**] 02:00AM LIPASE-102* [**2151-3-10**] 02:00AM ALT(SGPT)-33 AST(SGOT)-23 CK(CPK)-52 ALK PHOS-99 TOT BILI-1.5 [**2151-3-10**] 02:00AM estGFR-Using this [**2151-3-10**] 02:00AM GLUCOSE-132* UREA N-40* CREAT-1.3* SODIUM-137 POTASSIUM-4.5 CHLORIDE-103 TOTAL CO2-25 ANION GAP-14 [**2151-3-10**] 02:23AM HGB-12.5* calcHCT-38 [**2151-3-10**] 02:23AM LACTATE-2.4* [**2151-3-10**] 02:52AM K+-4.2 [**2151-3-10**] 08:00AM FIBRINOGE-127* [**2151-3-10**] 08:00AM PT-13.5* PTT-26.9 INR(PT)-1.2* [**2151-3-10**] 08:00AM PLT COUNT-203 [**2151-3-10**] 08:00AM WBC-6.0 RBC-3.95* HGB-11.3* HCT-33.9* MCV-86 MCH-28.6 MCHC-33.4 RDW-15.6* [**2151-3-10**] 08:00AM CALCIUM-8.2* PHOSPHATE-2.1* [**2151-3-10**] 08:00AM AMYLASE-69 [**2151-3-10**] 08:00AM GLUCOSE-166* UREA N-36* CREAT-1.2 SODIUM-135 POTASSIUM-4.0 CHLORIDE-101 TOTAL CO2-25 ANION GAP-13 [**2151-3-10**] 08:07AM LACTATE-2.1* [**2151-3-10**] 02:46PM HCT-35.6* . EGD Erythema in the stomach body compatible with very mild gastritis . Colonoscopy Subtle erosion in the rectum- not likely to be source of bleeding . CTA chest and ABD W & W/O contrast 1. Near complete infarction of the right kidney, likely secondary to occlusion of the main right renal artery secondary to endovascular graft. 2. Status post repair of 7.7 cm abdominal aortic aneurysm without evidence for leak. 3. Rectal balloon tube device. The rectal wall can not be adequately evaluated. 4. 6.5 cm fluid collection in the right upper quadrant with very mild adjacent stranding is likely to be a seroma. Infection is not favored but cannot be definitively excluded. CHEST CT ON [**2151-3-21**] 1. Mild decrease in size of a contained fluid collection within the right upper quadrant, which demonstrates similar characteristics and may represent a seroma. 2. Fluid collection anterior to the left femoral vessels with a large superficial skin defect in this region. 3. Status post repair of a 7.7-cm abdominal aortic aneurysm without evidence of leak. Status post left iliac-left renal artery bypass with fluid and post- surgical changes at the proximal and distal anastomotic sites. 4. Near complete infarction of the right kidney, unchanged. 5. Mixed nodular and linear opacities within the right lung base. Findings most consistent with atelectasis/scar, however, given the nodularity, a followup CT in three to six months is recommended to evaluate for change. A tiny 2-mm subpleural nodule in the left lung base may also be evaluated at this time. CXR No acute cardiopulmonary process TRANSTHORACIC ECHOCARDIOGRAM The left atrium is mildly dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis. No masses or vegetations are seen on the aortic valve. No aortic regurgitation is seen. The mitral valve leaflets are structurally normal. No mass or vegetation is seen on the mitral valve. No mitral regurgitation is seen. There is borderline pulmonary artery systolic hypertension. No vegetation/mass is seen on the pulmonic valve. There is no pericardial effusion. There is an anterior space which most likely represents a fat pad. IMPRESSION: Suboptimal study. No definite evidence of endocarditis seen. TRANSESOPHAGEAL ECHOCARDIOGRAM No atrial septal defect is seen by 2D or color Doppler. Overall left ventricular systolic function is normal. There are simple atheroma in the descending thoracic aorta. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No masses or vegetations are seen on the aortic valve. No aortic valve abscess is seen. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. No mass or vegetation is seen on the mitral valve. Trivial mitral regurgitation is seen. No vegetation/mass is seen on the pulmonic valve. There is no pericardial effusion. IMPRESSION: No valvular vegetations, paravalvular abscess, or significant regurgitant valvular disease seen. MICROBIOLOGY: [**2151-3-21**] JOINT FLUID GRAM STAIN-FINAL; FLUID CULTURE-PENDING INPATIENT [**2151-3-20**] BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT [**2151-3-20**] BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT [**2151-3-20**] URINE URINE CULTURE-PENDING INPATIENT [**2151-3-14**] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT [**2151-3-13**] 9:23 pm URINE Source: Catheter. URINE CULTURE ESCHERICHIA COLI. >100,000 ORGANISMS/ML.. SENSITIVE TO AZTREONAM (<=1 MCG/ML). ESCHERICHIA COLI. >100,000 ORGANISMS/ML.. 2ND MORPHOLOGY. SENSITIVE TO AZTREONAM (<=1 MCG/ML). PSEUDOMONAS AERUGINOSA. >100,000 ORGANISMS/ML.. SENT TO [**Hospital1 4534**] LABORATORIES FOR COLISTIN SENSITIVITY TESTING. AZTREONAM = INTERMEDIATE. AZTREONAM sensitivity testing performed by [**First Name8 (NamePattern2) 3077**] [**Last Name (NamePattern1) 3060**]. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI | ESCHERICHIA COLI | | PSEUDOMONAS AERUGINOSA | | | AMIKACIN-------------- =>64 R AMPICILLIN------------ =>32 R =>32 R AMPICILLIN/SULBACTAM-- 16 I =>32 R CEFAZOLIN------------- <=4 S 16 I CEFEPIME-------------- <=1 S <=1 S 32 R CEFTAZIDIME----------- <=1 S <=1 S 16 I CEFTRIAXONE----------- <=1 S <=1 S CEFUROXIME------------ 8 S 16 I CIPROFLOXACIN--------- =>4 R =>4 R =>4 R GENTAMICIN------------ <=1 S <=1 S =>16 R MEROPENEM-------------<=0.25 S <=0.25 S =>16 R NITROFURANTOIN-------- <=16 S <=16 S PIPERACILLIN---------- 32 I 64 I 32 S PIPERACILLIN/TAZO----- <=4 S <=4 S 64 S TOBRAMYCIN------------ <=1 S <=1 S =>16 R TRIMETHOPRIM/SULFA---- =>16 R =>16 R WOUND CULTURE GRAM STAIN (Final [**2151-3-13**]): NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. SMEAR REVIEWED; RESULTS CONFIRMED. WOUND CULTURE (Final [**2151-3-21**]): ESCHERICHIA COLI. MODERATE GROWTH. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI | AMPICILLIN------------ =>32 R AMPICILLIN/SULBACTAM-- =>32 R CEFAZOLIN------------- =>64 R CEFEPIME-------------- <=1 S CEFTAZIDIME----------- 8 S CEFTRIAXONE----------- 2 S CEFUROXIME------------ 32 R CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ 8 I MEROPENEM-------------<=0.25 S PIPERACILLIN---------- =>128 R PIPERACILLIN/TAZO----- <=4 S TETRACYCLINE---------- R TOBRAMYCIN------------ 4 S TRIMETHOPRIM/SULFA---- =>16 R ANAEROBIC CULTURE (Final [**2151-3-17**]): NO ANAEROBES ISOLATED. [**2151-3-11**] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT [**2151-3-11**] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT [**2151-3-11**] 11:50 am URINE Source: Catheter. **FINAL REPORT [**2151-3-17**]** URINE CULTURE (Final [**2151-3-17**]): PSEUDOMONAS AERUGINOSA. 10,000-100,000 ORGANISMS/ML.. AZTREONAM = INTERMEDIATE sensitivity testing performed by [**First Name8 (NamePattern2) 3077**] [**Last Name (NamePattern1) 3060**]. ESCHERICHIA COLI. ~7000/ML. AZTREONAM = SENSITIVE AT <=1 MCG/ML. PSEUDOMONAS AERUGINOSA | ESCHERICHIA COLI | | AMIKACIN-------------- =>64 R AMPICILLIN------------ =>32 R AMPICILLIN/SULBACTAM-- 8 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- 16 I <=1 S CEFTAZIDIME----------- 4 S <=1 S CEFTRIAXONE----------- <=1 S CEFUROXIME------------ 4 S CIPROFLOXACIN--------- =>4 R =>4 R GENTAMICIN------------ =>16 R <=1 S MEROPENEM------------- =>16 R <=0.25 S NITROFURANTOIN-------- <=16 S PIPERACILLIN---------- 32 S =>128 R PIPERACILLIN/TAZO----- 32 S <=4 S TOBRAMYCIN------------ =>16 R <=1 S TRIMETHOPRIM/SULFA---- =>16 R [**2151-3-28**] 8:00 pm URINE Source: CVS. URINE CULTURE (Final [**2151-3-31**]): ENTEROCOCCUS SP.. 10,000-100,000 ORGANISMS/ML.. AMPICILLIN------------ =>32 R LINEZOLID------------- 2 S NITROFURANTOIN-------- 256 R TETRACYCLINE---------- =>16 R VANCOMYCIN------------ =>32 R Brief Hospital Course: 67 y.o. male with CAD, DM, CRI s/p recent AAA repair complicated by renal infarction, bacteremia, anemia and thrombocytopenia who presented with rectal bleeding around rectal tube device. He presented and/or was treated for additional problems, including urinary tract infection, infection of surgical wound, and soft infection tissue of elbow, each dissected and discussed below. RECTAL BLEEDING: Initial concern for herald bleed from an aorto-enteric fistula, although was not visualized on CT scan. Another possibility considered was local ulceration (i.e. stercoral ulcer) from long-term rectal balloon. Had EGD/[**Last Name (un) **] [**3-12**] that showed mild gastritis (none at 3rd portion of duodenum where there would be concern for fistula) and a small ulceration in the rectum not actively bleeding. This was felt to be the cause of bleed. Hct remained stable over the course of hospitalization though had some fluctuations, but he did have one transfusion. Aspirin was restarted. Recent stools were guaiac negative. CHRONIC KIDNEY DISEASE ANEMIA Had rectal bleed and is on epo as outpatient for Chronic Kidney Disease. He is on 20,000 units q week. Will cont to get epo as outpt. HEPARIN INDUCED THROMBOCYTOPENIA: HIT Ab neg at outside hospital. Had a nadir ~60,000 at OSH. HIT Ab was tested at [**Hospital1 18**] and was positive. No heparin products were administered. His platelets were monitored and returned to [**Location 213**] limits. AVOID ALL HEPARIN PRODUCTS/FLUSHES URINARY TRACT INFECTION WITH HIGHLY RESISTANT PSEUDOMONAS AND E. COLI: Pt was febrile to 100 initially in the hospital. He was started on ciproflox for UTI. He was treated with vanc and zosyn at the OSH was an unknown duration of time. Blood cx sent here were negative but urine culture grew highly resistant pseudomonas and e. coli. Additionally, he had an infected wound seroma also with highly resistant e. coli. He was started on aztreonam as below. F/U CULTURE WITH ASYMPTOMATIC BACTURIA/VRE Follow-up UA was negative, but culture was positive for 10K-100K of Vancomycin Resistant Enterococcus. This might represent colonization given that his u/a was negative and that he had no symptoms. This was sensitive to linezolid, which should be started should he develop any fever or urinary symptoms. LEFT FEMORAL SURGICAL WOUND INFECTION/SEROMA Growing highly resistant e. coli, ID and vascular surgery reviewed CT and the infection does not appear to be contiguous with the graft. Started on Aztreonam to complete 14 day course. ELBOW PAIN/CELLULITIS/TENDONITIS The patient began to complain of red/swollen/painful left elbow. He had gout in the elbow previously, but his focal pain seemed to be outside of the joint. Physical exam demonstrated no articular pain but pain more at the triceps insertion. There was an initial area of crepitace around that area. Ultrasound demonstrated no clot. The bursa was tapped with negative culture and insufficient fluid for cell count. XRay demonstrated only soft tissue swelling. He began, in consultation with ID, a 14 day course of vancomycin for presumed cellulitis with improvement. DELIRIUM: The patient had AMS since extubation at OSH. He demonstrated delirium over the first few days of admission. He had been bed bound with little activity for a month. His benadryl for skin rash was discontinued. Most likely his delerium multifactorial including medication and toxic-metabolic etiologies. No focal neuro deficit was noted. MS improved over the hospital course. He should not take benadryl. 1ST DEGREE ATRIOVENTRICULAR BLOCK, NEW, R/O ENDOCARDITIS The patient was noted to have a prolonged PR on ECG obtained because of sinus tachycardia. This was new from admission. Given the history of viridans bacteremia at the referring hospital, echocardiograms were obtained to evaluate for perivalvular abscess. Blood cultures remained negative throughout his hospitalization but he had intermittently received antibiotics. Electrophysiology and cardiology consultations were obtained. The AV delay was thought to be due to dual tracts within the AV node; when the patient was tachycardic, the slow AV pathway superceded the fast AV pathway. 2ND DEGREE ATIOVENTRICULAR BLOCK / OSA The patient had dropped beats on telemtry and was found to have at least two periods where he had nonconducted p waves x3 and had ventricular escape. EP thought this was most likely vagal surge in setting of obstructive sleep apnea (these occured at night) and recommended sleep study. Cardiology/EP stated that it was safe to restart beta blockers. DEPRESSION: SW saw frequently and he was continued on outpatient medications. DESQUAMATING DRUG RASH: Historically, this was related to Pip-Tazo. It was primarily maculopapular and pruritic and later became desquamating, and affected arms, trunk, and legs. Sarna was continued for pruritis. Triamcinolone cream was continued. DIABETES: Pt was uptitrated on lantus to 17units daily, including an insulin sliding scale. CAD s/p stent [**2146**]: Aspirin was held given the GI bleed. It was restarted after the EGD did not show any soruce of bleeding. He was on IV metoprolol initially. He was switched to metoprolol 25 po BID. Simvastatin was started. CKD: Cr was slightly up, likely prerenal from skin losses, improved w/ 1LNS Of note, he had unilateral renal infarction following his AAA repair AAA Repair: Pt was followed by vascular surgery here. He has a follow-up appointment wtih Dr. [**Last Name (STitle) 77954**] in [**Month (only) 547**]. FEN: Mech soft diabetic diet w/ thin liquids, sugar free health shakes Code: FULL Communication: HCP wife [**Name (NI) **] [**Name (NI) 69502**] h [**Telephone/Fax (1) 77955**] c [**Telephone/Fax (1) 77956**] Medications on Admission: Epo 20K qWk tylenol needed benadryl prn MOM budesonide 0.5 IH [**Hospital1 **] ASA 325 daily lopressor 25mg PO BID acyclovir cream TP QID x 1wk ativan prn hydralazine 10 q6 prn RISS triamcinolone 0.1% cream TP [**Hospital1 **] Discharge Medications: 1. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day) as needed. 2. Triamcinolone Acetonide 0.1 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day) as needed. 3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO twice a day. 5. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain, fever. 6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 7. Epoetin Alfa 4,000 unit/mL Solution Sig: 8,000 Units Injection QMOWEFR (Monday -Wednesday-Friday). 8. Lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO HS (at bedtime) as needed for insomnia. 9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 10. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 11. Simvastatin 40 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 12. Vancomycin 1,000 mg Recon Soln Sig: 1000 (1000) mg Intravenous every twenty-four(24) hours for 3 days. 13. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO twice a day. 14. Insulin Lantus(GLargine) 17 units each evening Regular Insulin Sliding Scale qAC + qHS 51-150 mg/dL 0 Units 151-200 mg/dL 2 Units 201-250 mg/dL 4 Units 251-300 mg/dL 6 Units 301-350 mg/dL 8 Units 351-400 mg/dL 10 Units Discharge Disposition: Extended Care Facility: [**Hospital3 105**] - [**Location (un) 86**] Discharge Diagnosis: PRIMARY: Abdominal Aortic Aneurysm Urinary Tract Infection with Urosepsis Abdominal wound infection Rectal bleeding SECONDARY: Chronic Kidney Disease Diabetes Mellitus Gout Obesity Discharge Condition: Stable vital signs, feels well. MS: Oriented x3, appropriate. Discharge Instructions: You were admitted for bleeding from rectum that was most likely from your rectal tube that was being used. The colonoscopy and EGD did not show any other source of bleeding. For your urinary tract infection and surgical wound infection, you were treated with AZTREONAM for a full 14 days. For your elbow tendonitis/cellulitis (soft tissue infection), you were treated with VANCOMYCIN. . Please take all medications as prescribed. You are continuing on antibiotics, VANCOMYCIN through [**2151-4-3**] . If you have chest pain, shortness of breath, dizziness, palpitations, nausea, vomitting, diarrhea, pain in abdomen, blood in stools please call the doctor on call. . Followup Instructions: Vascular Surgery: CAT SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2151-4-15**] 10:30am [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3469**], MD Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2151-4-15**] 11:45 * please arrive 1.5 hours early for check-in and CT Scan [**Hospital Ward Name 516**] at [**Hospital1 18**], [**Last Name (un) **] BLDG Please make a follow up appointment with your primary care provider Dr [**Last Name (STitle) **] within 2 weeks of discharge You had an irregularity on your CT scan in the bottom of your right lung. This was likely to be deflated lung, but a follow-up CT scan was recommended for you in [**3-4**] months. Please discuss this with your PCP. [**First Name11 (Name Pattern1) 734**] [**Last Name (NamePattern1) 735**] MD, [**MD Number(3) 799**]

[ "998.59", "250.00", "599.0", "041.4", "682.3", "584.9", "585.3", "E934.2", "287.4", "569.3" ]

icd9cm

[ [ [] ] ]

[ "38.93", "45.13", "45.23" ]

icd9pcs

[ [ [] ] ]

21948, 22019

14482, 20239

294, 311

22245, 22309

4539, 14459

23025, 23876

3587, 3605

20516, 21925

22040, 22224

20265, 20493

22333, 23002

3620, 4520

249, 256

339, 2863

2885, 3423

3439, 3571

59,266

161,969

39632+58309

Discharge summary

report+addendum

Admission Date: [**2120-9-5**] Discharge Date: [**2120-9-12**] Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 3200**] Chief Complaint: tx from OSH for evaluation of gallstone pancreatitis Major Surgical or Invasive Procedure: none History of Present Illness: 89 F transferred from OSH w/ gallstone pancreatitis. About 1 month ago the patient was taken to the hospital s/p fall and found to have UTI. She was discharged to a rehab facility and 2 weeks later she began having nausea and bouts of emesis. This continued intermittently for 2 weeks with associated PO intolerance. Given her poor PO intake and concern for malnutrition she was take to see a GI physician who found her to have elevated LFT's and lipase 439. RUQ U/S demonstrated cholelithiasis and gallstones without a son[**Name (NI) 493**] [**Name2 (NI) 515**]. The GB wall is less than 3 mm and the CBD is 4.1 mm. There are no recorded fevers. After being transferred to our ED the patient was found to be hypotensive (SBP in 80's). Her blood pressure responded well to fluid resuscitation. She received approximately 5 L IVF. The patient denies any abdominal pain. She denies fevers or chills. Past Medical History: PMH: HTN, HLD, SIADH PSH: none Social History: Single, lived alone with home health aid until 1 month ago, now in a nursing home/rehab Tobaco none ETOH none Family History: non contributory Physical Exam: VS: 99.8 87 103/49 14 100% 2L NC Gen: NAD, Alert CVS: irregularly irregular Pulm: no respiratory distress Abd: slightly firm to deep palpation, ND, NT no rebound, no guarding LE: minimal lower limb edema Pertinent Results: [**2120-9-5**] 01:30AM WBC-8.1 RBC-3.56* HGB-12.1 HCT-35.5* MCV-100* MCH-34.0* MCHC-34.0 RDW-16.2* [**2120-9-5**] 01:30AM PT-13.0 PTT-30.5 INR(PT)-1.1 [**2120-9-5**] 01:30AM ALT(SGPT)-149* AST(SGOT)-165* ALK PHOS-447* TOT BILI-1.3 [**2120-9-5**] 01:30AM LIPASE-442* [**2120-9-5**] 01:30AM GLUCOSE-94 UREA N-66* CREAT-1.9* SODIUM-135 POTASSIUM-4.7 CHLORIDE-97 TOTAL CO2-27 ANION GAP-16 [**2120-9-5**] 01:35AM LACTATE-2.6* K+-6.3* [**2120-9-5**] 03:46AM LACTATE-1.5 K+-3.4* [**2120-9-5**] 07:59PM GLUCOSE-83 UREA N-50* CREAT-1.4* SODIUM-137 POTASSIUM-4.1 CHLORIDE-108 TOTAL CO2-22 ANION GAP-11 [**2120-9-5**] 07:59PM ALT(SGPT)-97* AST(SGOT)-89* LD(LDH)-399* CK(CPK)-36 ALK PHOS-260* AMYLASE-82 TOT BILI-1.2 Glucose UreaN Creat Na K Cl HCO3 AnGap [**2120-9-12**] 05:22 67*1 34* 1.7* 139 3.6 108 23 12 Source: Line-CVL [**2120-9-11**] 20:52 35* 1.7* 140 3.7 109* 23 12 Source: Line-CVL [**2120-9-11**] 11:20 56*1 38* 1.8* 140 4.6 107 22 16 [**2120-9-10**] 02:02 39* 1.7* 138 4.2 107 22 13 ADDED TE13-TE19 AT 07 27 10 [**2120-9-9**] 16:36 67*1 41* 1.7* 137 3.7 106 23 12 Source: Line-mll [**2120-9-9**] 04:12 41* 1.7* 138 3.8 108 22 12 ALT AST LD(LDH) CK(CPK) AlkPhos Amylase TotBili DirBili IndBili [**2120-9-12**] 05:22 50* 39 148* 1.0 Source: Line-CVL [**2120-9-11**] 11:20 60* 50* 190* 47 1.2 0.5* 0.7 [**2120-9-10**] 02:02 54* 46* 390*1 187* 45 1.2 0.5* 0.7 ADDED TE13-TE19 AT 07 27 10 [**2120-9-8**] 03:00 60* 49* 323* 174* 1.6* Source: Line-arterial [**2120-9-6**] 03:03 85* 75* 355* 220* 61 1.4 [**2120-9-5**] 19:59 97* 89* 399* 362 260* 82 1.2 [**2120-9-5**] 01:30 149*3 165*4 447* 1.3 MODERATELY HEMOLYZED SPECIMEN OTHER ENZYMES & BILIRUBINS Lipase [**2120-9-12**] 05:22 87* [**2120-9-5**] CT Abd/pelvis: 1. Evaluation limited by the lack of IV contrast. 2. Rounded 2.6 cm calcified density in the epigastric region of unclear etiology. 3. Cholelithiasis [**2120-9-6**] Cardiac Echo : Suboptimal image quality. The left atrium is elongated. 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 probably normal (LVEF>50%). The right ventricular cavity is dilated with normal free wall contractility. The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Moderate (2+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. Moderate [2+] tricuspid regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is an anterior space which most likely represents a prominent fat pad. [**2120-9-6**] Duplex scan left upper extremity : Technically limited study, no DVT seen in the left upper extremity. URINE CULTURE (Final [**2120-9-9**]): PROTEUS MIRABILIS. 10,000-100,000 ORGANISMS/ML.. PRESUMPTIVE IDENTIFICATION. STAPH AUREUS COAG +. >100,000 ORGANISMS/ML.. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ PROTEUS MIRABILIS | STAPH AUREUS COAG + | | AMPICILLIN------------ <=2 S AMPICILLIN/SULBACTAM-- <=2 S CEFAZOLIN------------- 16 I CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S <=0.5 S LEVOFLOXACIN---------- =>8 R MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- <=16 S OXACILLIN------------- 0.5 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S <=0.5 S Brief Hospital Course: Surgery evaluated the patient in the ED. OSH US demonstrated: Imaging [**9-4**] OSH: RUQ demonstrated cholelithiasis and gallstones without a son[**Name (NI) 493**] [**Name2 (NI) 515**]. The GB wall is less than 3 mm and the CBD is 4.1 mm. There is a 7 mm mass in the right lobe of the liver. The pancreas is poorly visualized. She was hypotensive and the ED resident placed a CVL for SBP in low 80's. She was bolused a total of [**5-20**] L and her blood pressure responded well. On CXR after her CVL placement (L subclavian) it was noted this was actually not in the subclavian vein. This was removed. On [**9-6**] there was concern for clot in her L hand as it was discolored. She did have dopplerable signals (radial/ulner). She underwent LUE U/S and arterial U/S and no clot was seen. An echocardiogram was performed which showed an EF of 50%. Over the next several days her lipase trended downward however her Tbili remained elevated. GI was consulted and ERCP was planned. In the ICU she did have oliguria and mild renal insufficiency with Cr increasing from 1.3 on admission to as high as 1.9. She was given albumin and was on a Lasix gtt for gentle diureses. She responded well to this. And it was discontinued in preparation for her ERCP. Following transfer to the Surgical floor she remained stable in that she did not have any abdominal pain and when she was booked for her ERCP she refused adamantly. Her niece tried to encourage her to persue it but again Ms. [**Known lastname **] did not want it done. Subsequently her low fat diet was resumed and she was able to eat without any pain or nausea. Her appetite was only fair though and she was encouraged to try to eat as well as take protein shakes to try to increase her strength and help with healing of her decubitus ulcers which were noted on admission. Her LFT's were trending down and her creatinine stabilized at 1.7. After much discussion with Ms. [**Known lastname **] and her niece, she decided to return to her rehab and evaluate how things go over the next few weeks. She is determined to return home but she has a long way to go as she requires the [**Doctor Last Name 2598**] lift to get out of bed and she is just totally deconditioned since her last hospitalization. Ms. [**Known lastname **] will return to the [**Location (un) 34004**] Nursing Center today and will follow up in the [**Hospital 2536**] Clinic if she decides that she wants any further work up. Medications on Admission: lasix 20', prilosec 20', Compazine 10 Q6H prn, MVI', Vit D Discharge Medications: 1. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 2. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID (4 times a day) as needed for rash: apply under abdominal fold. 3. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000) units Injection TID (3 times a day). 4. Bactrim DS 800-160 mg Tablet Sig: One (1) Tablet PO twice a day: thru [**2120-9-14**]. Discharge Disposition: Extended Care Facility: [**Hospital 34004**] Nursing and Rehab Center Discharge Diagnosis: gallstone pancreatitis mild renal failure UTI stage 2 decubitusulcer 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 gallstone pancreatitis. Your liver function studies and your physical exam is improving daily. * You should continue a low fat diet and make sure that you drink enough liquids to stay hydrated. You will also benefit from protein drinks to improve your nutritional status so that you can progress with Physical Therapy and try to walk again. * You will need to follow up with your doctor if you have any more pain, nausea or vomiting as you will probably need more testing. Followup Instructions: Call the [**Hospital 2536**] Clinic at [**Telephone/Fax (1) 600**] if you decide that you want further testing or if you have any questions or concerns. Call Dr. [**Last Name (STitle) 634**] for a follow up appointment in [**2-17**] weeks. Completed by:[**2120-9-12**] Name: [**Known lastname 13866**],[**Known firstname 3344**] Unit No: [**Numeric Identifier 13867**] Admission Date: [**2120-9-5**] Discharge Date: [**2120-9-12**] Date of Birth: [**2031-3-19**] Sex: F Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 11788**] Addendum: Please change the discharge diagnosis of mild renal failure to acute renal failure presumed secondary to some hypotension on admission. Discharge Disposition: Extended Care Facility: [**Hospital 7011**] Nursing and Rehab Center [**First Name11 (Name Pattern1) 33**] [**Last Name (NamePattern4) 11789**] MD [**MD Number(2) 11790**] Completed by:[**2120-10-15**]

[ "458.9", "782.3", "577.0", "403.90", "584.9", "599.0", "041.6", "707.22", "707.00", "574.20", "272.4", "585.9" ]

icd9cm

[ [ [] ] ]

[ "38.93", "38.91" ]

icd9pcs

[ [ [] ] ]

10486, 10719

5755, 8225

314, 321

8968, 8968

1721, 5732

9660, 10463

1460, 1478

8335, 8761

8877, 8947

8251, 8312

9119, 9637

1493, 1702

221, 276

349, 1261

8983, 9095

1283, 1317

1333, 1444

17,762

195,806

21841

Discharge summary

report

Admission Date: [**2190-10-20**] Discharge Date: [**2190-10-24**] Date of Birth: [**2134-5-4**] Sex: M Service: CSURG Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1267**] Chief Complaint: dyspnea on exertion, shortness of breath, increased fatigue Major Surgical or Invasive Procedure: CABG x5 (LIMA to LAD, SVG to OM, SVG to DAG, SVG to PDA, SVG to PLB) blood transfusion History of Present Illness: Mr. [**Known lastname 57302**] is a 56-year-old man who had increased fatigue and dyspnea on exertion for the past year. His catheterization showed severe left main and three-vessel disease, with an ejection fraction of 40 percent. Past Medical History: hypercholesterolemia hypertension Right ICA occlusion PVD right ankle ulcer s/p R wrist ORIF s/p R fem/tib ORIF left forearm fracture left knee [**Doctor First Name **] R ankle ulcer with skin graft repairs Social History: 1ppd x20 years electrician no recreational drugs lives with wife denies alcohol Family History: Mother: died of MI at age 63 Father: died of MI at age 75 Physical Exam: On Discharge Temp 99.1 HR 101, BP 106/70, R20 97%RA NAD RRR; incis: no SOI CTA-B s/nt/nd; +BS Brief Hospital Course: Mr. [**Known lastname 57302**] was admitted to the Cardiac Surgery service under the care of Dr. [**Last Name (STitle) **]. He went to the OR for a CABG x5. The total cardiopulmonary bypass time was 84 minutes and the total crossclamp time was 70 minutes. Please see Dr.[**Name (NI) 3502**] Operative Note for greater detail. He was transferred to the CSRU in stable condition. Mr. [**Known lastname 57302**] was extubated on POD#0 without incident. On POD#1 he was started on Lasix and Captopril, given 1unit of PRBCs for a hematocrit of 27.1, with a resultant hematocrit of 30. He was transferred to the floor. On POD#2, he was started on Lopressor; on POD #3 the pacing wires were discontinued. Physical Therapy evaluated Mr. [**Known lastname 57302**] and believed that he would be safe to go home after several inpatient treatments. At the time of discharge, Mr.[**Known lastname 57302**] was ambulating, tolerating a regular diet, had good pain control, and was voiding without difficulty. He was discharged home in good condition. Medications on Admission: Toprol XL 100mg daily Liptitor 20mg daily ASA 81mg daily Lisinopril Discharge Medications: 1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO QD (once a day). 2. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO QD (once a day). 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. Metoclopramide HCl 10 mg Tablet Sig: One (1) Tablet PO QIDACHS (4 times a day (before meals and at bedtime)) as needed for PRN. 5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 6. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). Discharge Disposition: Home With Service Facility: [**Hospital1 **] VNA, [**Hospital1 1559**] Discharge Diagnosis: status post CABG x3 anemia requiring blood transfusion hypertension right ICA occlusion peripheral vascular disease s/p right wrist ORIF status post right fem/tib ORIF left forearm fracture status post left knee arthroscopy Discharge Condition: Good Discharge Instructions: If you experience any chest pain, shortness of breath, nausea/vomiting, or fevers/chills, please seek medical attention. Followup Instructions: Please call Dr. [**Last Name (STitle) **] for an appointment in 4 weeks: [**Telephone/Fax (1) 170**] Please follow up with your PCP [**Name Initial (PRE) **]/or Cardiologist in [**3-9**] weeks.

[ "V12.59", "443.9", "272.0", "285.9", "250.00", "414.01", "401.9" ]

icd9cm

[ [ [] ] ]

[ "88.72", "36.15", "36.14", "99.04", "39.61" ]

icd9pcs

[ [ [] ] ]

3105, 3178

1260, 2309

374, 462

3446, 3452

3621, 3819

1068, 1127

2427, 3082

3199, 3425

2335, 2404

3476, 3598

1142, 1237

274, 336

490, 724

746, 955

971, 1052

57,887

140,491

40563

Discharge summary

report

Admission Date: [**2141-5-19**] Discharge Date: [**2141-5-27**] Date of Birth: [**2075-5-5**] Sex: M Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 1505**] Chief Complaint: Chest Pain Major Surgical or Invasive Procedure: [**2141-5-23**] Coronary artery bypass graft x 4 (Left internal mammary artery to left anterior descending, Saphenous vein graft to posterior descending artery, Saphenous vein graft to OM1 with y-graft to OM2) History of Present Illness: 66yr old with know hx of CAD and was being managed medically for several years, hx of diabetes, htn,CRD and hyperlipidemia who was scheduled for elective cardiac cath last week due to increased crescendo angina but this was cancelled 2nd to hyperkalemia. Today at 4am he developed worsening chest pain and presented to LGH ER. Troponin and CXR were ok, EKG revealed NSR with non specific lateral wall ST scooping. He underwent cardiac cath which was performed by Dr. [**Last Name (STitle) 5017**]. this revealed 3 vessel CAD. He was therefore transferred to [**Hospital1 18**] for surgical revascularization. Past Medical History: Coronary artery disease s/p Coronary artery bypass graft x 4 PMH: Chronic Renal Failure stage 2 GERD Hyperlipidemia Insulin dependent diabetes Hypertension Diabetic neuropathy Past Surgical History: s/p Left CEA [**2135**] s/p B hand surgery (trigger finger and dupreyens contractures) s/p B fem-fem bypass Social History: Race:caucasian Last Dental Exam:1 month ago (Dr. [**First Name (STitle) **] in Mathuen) Lives with:wife Occupation:retired, worked in manufacturing Tobacco:1ppd x 53 years, current smoker ETOH:2-3 beers per day Family History: Father w MI at age 55 Physical Exam: Pulse:72 Resp:18 O2 sat:98 B/P 179/98 Height:6'1" Weight:206 General: Skin: Dry [x] intact [x]Multiple well-healed incisions including left neck, midline abdomen, bilateral groins, medial right knee to shin HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur I/VI diastolic murmur Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Extremities: Warm [x], well-perfused [x] Edema Varicosities: None [x] Neuro: Grossly intact Pulses: Femoral Right:1+ Left:1+ DP Right:1+ Left:2+ PT [**Name (NI) 167**]:1+ Left:2+ Radial Right:2+ Left:2+ Carotid Bruit Right: - Left: - Discharge VS: T: 98.5 HR: 88 SR BP: 141/76 Sats: 96% RA WT: 96 RA WT: 95.2 General: 66 year-old male doing well HEENT: normocephalic, mucus membranes Card: RRR normal S1,S2 no murmur Resp: faint bibasilar crackles GI: benign Extr: warm R 2+ edema, L 1+ edema Incision: sternal clean, dry, intact Neuro: AA&O. Ambulating in halls Pertinent Results: [**2141-5-22**] Carotid U/S: 1. Findings are consistent with less than 40% stenosis on the right. 2. Findings are consistent with 40-59% stenosis on the left. [**2141-5-23**] Echo: PREBYPASS: Preserved LV systolic function with LVEF >55% with no segmental wall motion abnormalities. The left atrium is normal in size. There is moderate symmetric left ventricular hypertrophy. Right ventricular chamber size and free wall motion are normal. The right ventricular free wall thickness is normal. The ascending, transverse and descending thoracic aorta are normal in diameter and there is diffuse mild descending thoracic aortic atherosclerosis.. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no pericardial effusion. Significant diastolic dysfunction with lateral mitral annular tissue Doppler e' = 6 cm/sec. POSTBYPASS: Unchanged; normal wall motion and systolic function. No dissection seen after aortic cannula removed. [**2141-5-26**] WBC-10.5 RBC-3.37* Hgb-10.8* Hct-33.2 Plt Ct-195 [**2141-5-19**] WBC-6.3 RBC-4.18* Hgb-13.6* Hct-40.9 Plt Ct-175 [**2141-5-26**] Glucose-178* UreaN-31* Creat-1.4* Na-140 K-4.8 Cl-102 HCO3-29 [**2141-5-26**] Glucose-166* UreaN-24* Creat-1.2 Na-140 K-4.2 Cl-102 HCO3-28 [**2141-5-19**] Glucose-226* UreaN-27* Creat-1.4* Na-139 K-4.5 Cl-103 HCO3-28 [**2141-5-26**] Mg-2.3 CXR: [**2141-5-26**]: Specifically, no evidence of pneumothorax. Continued enlargement of the cardiac silhouette with mild atelectatic changes. Brief Hospital Course: As mentioned in the HPI, Mr. [**Known lastname 88801**] presented to outside hospital with unstable angina. Cardiac enzymes were negative and EKG showed sinus rhythm with non specific lateral wall ST scooping. He underwent a cardiac cath which found severe three vessel coronary artery disease and was transferred to [**Hospital1 18**] for surgical management. Upon admission he was medically managed while he underwent pre-operative work-up. In addition to usual labs, he underwent carotid u/s and vein mapping. On [**5-23**] he was brought to the operating room where he underwent a coronary artery bypass graft x ?. Please see operative report for surgical details. Following surgery he was transferred to the CVICU for invasive monitoring in stable condition. Later this day he was weaned from sedation, awoke neurologically intact and extubated. He desaturated at night and a sleep consult was called. CPAP trial with good results. It is recommended that the patient be discharged with an auto-set CPAP pending a formal sleep study. Respiratory: aggressive pulmonary toilet, nebs, incentive spirometer, ambulation and good pain control he titrated off oxygen with room saturations of 96% Cardiac: hemodynamically stable sinus rhythm 70-90 without ectopy. Beta-blockers were titrated to home dose of Toprol 100 mg daily. Blood pressure 130-140's. CRE 1.4 on day of discharge his amlodipine 2.5 mg was restarted and he was instructed to follow-up with his cardiologist regarding restarting lisinopril. Fenofibrate 48 mg, Simvastatin 40 mg and Aspirin 81 mg were continued. GI: PPI and bowel regime. He tolerated a diabetic/cardiac healthy diet. Renal: diuresed with Lasix IV with good urine output. He was restarted on PO Lasix 40 mg daily and decrease to 20 mg once his lower extremity edema improved. Endocrine: insulin Lantus and sliding scale continued with blood sugars < 200. Ophthalmologist: On [**2141-5-25**] noticed new blurred vision OD. He was seen by Ophthalmology and found to have a branch-artery occlusion of the inferior/temporal OD retina. He has a history of OS optic N. dysfunction. He will follow-up with his ophthalmologist as an outpatient. Neuropathy: lower extremity Gabapentin continued Disposition: he was seen by physical therapy who deemed him safe for home. He was discharged with his family on [**2141-5-27**]. He will follow-up with his cardiologist, ophthalmologist, sleep study, and Dr. [**Last Name (STitle) **] as an outpatient. Medications on Admission: Fenofibrate 34mg daily, Folic acid 1m daily, Lasix 20mg daily, Neurontin 100mg [**Hospital1 **], Imdur, Lantus 50 units PM, Lisinopril 20mg daily, Toprol 100mg daily, Novalog SS, Omeprazole 20mg daily, Zocor 40mg daily, ASA 81mg daily, Amlodipine 2.5mg daily, Requip 0.25 daily, Zyrtec 10mg daily Discharge Medications: 1. CPAP auto-set CPAP dx: sleep apnea 2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 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 pain/fever. 5. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. gabapentin 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 8. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 9. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*70 Tablet(s)* Refills:*0* 10. fenofibrate micronized 48 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. metoprolol succinate 100 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO once a day. 12. furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day: take 40 mg daily for 7 days or until lower extremity edema has decreased. 13. insulin glargine 100 unit/mL Solution Sig: Fifty (50) units Subcutaneous at bedtime. 14. Novolog insulin sliding scale Continue your previous insulin sliding scale. 15. amlodipine 2.5 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Location (un) 8300**] [**Hospital6 **] & Hospice Discharge Diagnosis: Coronary artery disease s/p Coronary artery bypass graft x 4 Past medical history: Chronic Renal Failure stage 2 GERD Hyperlipidemia Insulin dependent diabetes Hypertension Diabetic neuropathy Past Surgical History: s/p Left CEA [**2135**] s/p B hand surgery (trigger finger and dupreyens contractures) s/p B fem-fem bypass Discharge Condition: Alert and oriented x3 nonfocal Ambulating with steady gait Incisional pain managed with Incisions: Sternal - healing well, no erythema or drainage Leg Right/Left - healing well, no erythema or drainage. 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 Provider: [**Name10 (NameIs) **] CARE NURSE Phone:[**Telephone/Fax (1) 170**] Date/Time:[**2141-6-6**] 10:15 on the [**Last Name (un) 2577**] Building [**Last Name (NamePattern1) **] [**Hospital Unit Name **] Surgeon: Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 88802**] Date/Time:[**2141-6-22**] 1:15 [**Last Name (un) 2577**] Building [**Last Name (NamePattern1) **]. [**Hospital Unit Name **] Cardiologist: Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 5424**] call for an appointment in [**1-12**] weeks. Please call to schedule appointments with your [**Hospital1 18**] Sleep Clinic, Dr. [**Last Name (STitle) **] ([**Telephone/Fax (1) 513**] to formal arrange sleep study Call [**Hospital 6549**] Medical Service: 1-[**Telephone/Fax (1) 27182**] for CPAP machine settings Auto-set. Primary Care Dr. [**Last Name (STitle) 12816**] [**Telephone/Fax (1) 12817**] in [**3-14**] weeks Please call your ophthalmologist Dr. [**Last Name (STitle) 3400**] [**Telephone/Fax (1) 88803**] for an appointment within 2 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:[**2141-5-27**]

[ "362.32", "411.1", "414.01", "272.4", "403.90", "585.2", "V58.67", "357.2", "780.57", "530.81", "250.60" ]

icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

8756, 8838

4516, 7004

320, 531

9206, 9417

2859, 4493

10340, 11620

1744, 1768

7351, 8733

8859, 8920

7030, 7328

9441, 10317

9075, 9185

1783, 2840

270, 282

559, 1170

8942, 9052

1516, 1728

21,860

110,599

53529

Discharge summary

report

Admission Date: [**2121-10-15**] Discharge Date: [**2121-10-22**] Date of Birth: [**2060-12-29**] Sex: M Service: CSU HISTORY OF PRESENT ILLNESS: The patient had previously undergone a surgical placement of LV leads via a small left anterior thoracotomy on [**2121-10-7**], prior to his admission. He was discharged without any complications. Three days later on [**2121-10-12**], he was admitted with chest pain and shortness of breath to [**Hospital6 3872**]. He ruled out for myocardial infarction, and previous cardiac catheterization revealed normal coronaries. At 3 a.m. on [**2121-10-15**], he complained of increasing chest pain and increasing shortness of breath. By 6 a.m., his systolic had dropped into the 60s. He was transferred from the emergency room to the floor to the CCU for evaluation. Echocardiogram showed pericardial effusion with narrow pulse pressures. He continued to have increasing shortness of breath with some modeling and [**Doctor Last Name 352**] tones to his skin color. He is followed by Dr. [**First Name4 (NamePattern1) 401**] [**Last Name (NamePattern1) 1295**] at [**Hospital6 3874**] prior to his transfer to the hospital. PAST MEDICAL HISTORY: 1. Surgical LV lead placement by a left anterior thoracotomy. 2. Atrial fibrillation. 3. Migraine headaches. MEDICATIONS: On admission to [**Hospital3 1280**] he was on Coumadin, Toprol, Verapamil, Klonopin, Imdur. ALLERGIES: Codeine. On [**10-15**] at [**Hospital6 3872**] prior to admission, he continued to have increasing dyspnea. Echocardiogram showed pericardial effusion. Cardiology there decided to proceed with pericardiocentesis. The patient received 2 mg of vitamin K, 2 units of FFP, and packed red blood cells prior to going to the cath lab for a pericardiocentesis. INR was between 3.5 and 3.7 at the time. Prior to his admission here during the placement of the pericardiocentesis catheter, the patient arrested in the cath lab. CPR was instituted. Repeat pericardiocentesis per cardiology's note there was able to obtain about 100-150 cc of pericardial fluid. Echocardiogram showed resolution of effusion. By echocardiogram the EF looked poor, and so monitoring lines were placed. Dr[**Last Name (Prefixes) 4558**] was contact[**Name (NI) **] at [**Hospital1 **], and the patient was transferred to [**Hospital6 2018**] by Life Flight. The patient was admitted on [**2121-10-15**], and was evaluated with repeat chest x-ray which showed left hemothorax and possible tamponade and was taken to the operating room for sternotomy and reopening of the left anterior thoracotomy site for evacuation of clot and hematoma from both mediastinum and left chest. This was done emergently. On postoperative day 1, the patient remained V-paced, had a blood pressure of 120/48, remained ventilated and sedated, with a white count of 12.4, hematocrit 32.7, creatinine 1.8. He was alert and oriented later in the day with a nonfocal exam while he was intubated, but sedation was lightened to check his neurologic status. He had scattered rhonchi throughout his chest. His heart was regular rate and rhythm with a S1 and S2, no murmur, and sternum was stable. Sternal incision was clean, dry, and intact, as was his thoracotomy incision. He remained on the epinephrine drip at 0.01 mcg/kg/min and an insulin drip at 2 min/hr. Ventilatory wean was begun later that evening. On postoperative day 1, the patient continued to have a hemothorax present on chest x-ray, and he was returned to the operating room for evacuation of clot. Again on postoperative day 2 and 1, the patient's creatinine was 1.2-2.4. He was on no drips at the time. He was transfused 2 units of packed red blood cells for a hematocrit of 26.4, and he was alert and oriented and extubated on 4 L nasal cannula. He was seen and evaluated by clinical nutrition team. On postoperative day 3, he remained V-paced. His chest tubes were discontinued, and he remained hemodynamically stable. He did have some confusion early on which became agitation periodically. We had a sitter for a single day, and then his confusion cleared. On postoperative day 4 and 3, he was transferred out to the floor. His Coumadin was held. On postoperative day 5 and 4, follow-up chest x-ray was done. He remained in sinus rhythm, hemodynamically stable, creatinine rose slightly again to 2.3, hematocrit was 35.7. Beta-blockade continued with Lopressor. He began to work with physical therapy increasing his activity level and tolerance. On house-day 6, his oxygen saturation was 94% on room air and continued to work on increasing his activity level. Beta- blockade was increased again. On postoperative day 7 and 6, his creatinine dropped slightly to 2.0. Incisions were clean, dry, and intact with no erythema or drainage. His central venous line was removed. His JP drain from the left thoracotomy site had minimal sanguineous drainage and was discontinued, and the patient was discharged to home with VNA services. DISCHARGE DIAGNOSIS: 1. Status post left ventricle lead pace placement, left anterior thoracotomy. 2. Status post sternotomy and left thoracotomy for clot evacuation and mediastinal exploration. 3. Status post reexploration of mediastinum. 4. Atrial fibrillation. 5. Migraine headaches. 6. Lyme disease. 7. Tachy-brady syndrome. 8. DDD pacemaker. DISCHARGE MEDICATIONS: 1. Lasix 20 mg p.o. twice a day x 7 days. 2. Potassium chloride 20 mEq p.o. twice a day for 7 days. 3. Colace 100 mg p.o. twice a day. 4. Zantac 150 mg p.o. twice a day. 5. Enteric coated aspirin 81 mg p.o. once daily. 6. Metoprolol 100 mg p.o. twice a day. 7. Percocet 5/325 1-2 tablets p.o. q.4 hours p.r.n. pain. DI[**Last Name (STitle) 408**]E INSTRUCTIONS: The patient was instructed to follow up with Dr. [**Last Name (STitle) **] at 2 weeks. He is to follow up with Dr. [**First Name (STitle) 1075**] his cardiologist at [**Hospital3 1280**] after discharge, and he is to follow up with Dr. [**Last Name (Prefixes) **] in 4 weeks for his postoperative surgical appointment. The patient was discharged in stable condition to home with VNA services on [**2121-10-22**]. [**Doctor Last Name **] [**Last Name (Prefixes) **], M.D. [**MD Number(1) 1288**] Dictated By:[**Last Name (NamePattern1) **] MEDQUIST36 D: [**2121-11-12**] 15:54:09 T: [**2121-11-12**] 20:47:54 Job#: [**Job Number 110030**]

[ "V12.59", "285.1", "346.90", "423.9", "998.11", "511.8", "427.31", "286.9", "V45.01" ]

icd9cm

[ [ [] ] ]

[ "88.72", "99.05", "99.09", "39.61", "89.68", "99.06", "34.03", "99.07", "34.09", "34.04" ]

icd9pcs

[ [ [] ] ]

5381, 6422

5015, 5358

168, 1188

1210, 4994

63,756

169,043

46348

Discharge summary

report

Admission Date: [**2181-10-25**] Discharge Date: [**2181-10-28**] Date of Birth: [**2100-3-18**] Sex: M Service: MEDICINE Allergies: Lipitor Attending:[**First Name3 (LF) 10682**] Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: None History of Present Illness: 81M with CAD s/p PCI, RCC, CKD, presents with shortness of breath over the last 3 days. He says his shortness of breath began with a cold. He has noticed worsening peripheral edema, orthopnea, and cough with white sputum production. Denied fever/chills, no chest pain, no lightheadedness or palpitations. No abdominal pain. No changes in urination pattern. No weight gain recently, but he does not check his weight daily. Diet consisting of a lot of ham and [**Doctor Last Name **]. Uses a walker or cane at baseline. . In the ED, initial V/S 98.1 82 200/100 32 99% 15L NRB. Labs notable for BNP 7330, trop <0.01, Cr 2.5. Given ASA 325 mg, lasix 40 mg IV, levoflox 750 mg IV, ativan 1 mg, combivent nebs. CXR showed asymmetric pulmonary edema R>L, possible left lower lobe atelectasis. EKG showed LAD RBBB (only comparison was 7 years old). Placed on CPAP and trasferred to ICU. Vital signs prior to transfer 70 156/76 19 100% on BiPAP 12/5 FiO2 100%. Past Medical History: CAD (s/p stent) ([**Doctor Last Name **]) 2+ MR, [**12-23**]+ AI renal cancer ([**Doctor Last Name **]) CRI (2-2.5) ([**Doctor Last Name 4883**]) Prostate cancer ([**Doctor Last Name **])([**Hospital1 656**]) HTN h/o ulcerative colitis cataracts seasonal allergies bilateral knee OA hyperlipidemia GERD iron deficiency anemia cervical and lumbar DJD right testicular atrophy secondary to mumps Social History: He lives alone. He is a retired barber. He uses a cane/walker at baseline. - Tobacco: quit in [**2151**] - Alcohol: sip of brandy when he feels cold Family History: Mother had rheumatic heart disease. Physical Exam: General: Alert, oriented, no acute distress, sings in Russian, very talkative and pleasant HEENT: Sclera anicteric, MMM, oropharynx no lesions, poor dentition Neck: supple, JVP elevated at angle of jaw on left, no LAD Lungs: Crackles at bases, right base crackles more pronounced than left, transient rhonchi that shift with cough, no wheezes, coughing intermittently with deep breathing CV: Regular rate and rhythm, normal S1 + S2, early diastolic murmur at LLSB, rubs, gallops Abdomen: soft, non-tender, mildly distended, tympanitic, no HSM, no masses, no fluid shift, bowel sounds present, no rebound tenderness or guarding GU: foley draining yellow urine Ext: LE with 1+ pitting edema R>L, right leg with assymetric venous stasis as well, warm, well perfused, 2+ pulses Pertinent Results: Admission labs: [**2181-10-25**] 06:39PM WBC-9.9 RBC-3.67* HGB-10.9* HCT-33.3* MCV-91 MCH-29.8 MCHC-32.9 RDW-14.9 [**2181-10-25**] 06:39PM NEUTS-83.2* LYMPHS-7.0* MONOS-5.7 EOS-3.0 BASOS-1.0 [**2181-10-25**] 06:39PM PLT COUNT-245 [**2181-10-25**] 06:39PM GLUCOSE-142* UREA N-34* CREAT-2.5* SODIUM-139 POTASSIUM-4.1 CHLORIDE-103 TOTAL CO2-25 ANION GAP-15 [**2181-10-25**] 06:39PM proBNP-7330* [**2181-10-25**] 06:39PM cTropnT-<0.01 [**2181-10-25**] 06:39PM PT-13.0 PTT-25.3 INR(PT)-1.1 [**2181-10-25**] 06:38PM LACTATE-1.8 Discharge labs: [**2181-10-27**] 07:45AM BLOOD WBC-7.9 RBC-3.15* Hgb-9.7* Hct-28.5* MCV-90 MCH-30.8 MCHC-34.1 RDW-14.9 Plt Ct-203 [**2181-10-27**] 07:45AM BLOOD Glucose-98 UreaN-39* Creat-2.7* Na-139 K-3.9 Cl-101 HCO3-26 AnGap-16 Imaging: CHEST (PORTABLE AP) Study Date of [**2181-10-25**]: There is interstitial opacity favoring the right, most compatible with asymmetric pulmonary edema. Repeat radiography after appropriate diuresis is recommended to assess for underlying infection. There is a slightly more confluent nodular opacity within the area of edema as above in the right upper lung. This may be a superimposition of shadows, confluent edema, or potentially an underlying pulmonary nodule. Cardiomegaly and large hiatal hernia again noted. CHEST (PORTABLE AP) Study Date of [**2181-10-26**] FINDINGS: As compared to the previous radiograph, there is no relevant change. Moderate cardiomegaly with moderate pulmonary edema. Right pleural effusion. Moderate retrocardiac atelectasis. No newly appeared focal parenchymal opacities. [**2181-10-26**] TTE The left atrium is mildly dilated. The right atrium is moderately dilated. There is moderate symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. There is mild regional left ventricular systolic dysfunction with inferior hypokinesis. The remaining segments contract normally (LVEF = 45%). Doppler parameters are most consistent with Grade II (moderate) left ventricular diastolic dysfunction. The right ventricular cavity is mildly dilated with normal free wall contractility. The ascending aorta is mildly dilated. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Moderate (2+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. 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. Significant pulmonic regurgitation is seen. The end-diastolic pulmonic regurgitation velocity is increased suggesting pulmonary artery diastolic hypertension. IMPRESSION: Symmetric LVH with mild regional left ventricular systolic dysfunction, c/w CAD. Moderate aortic regurgitation. Mild mitral regurgitation. Moderate tricuspid regurgitation. Moderate pulmonary hypertension. Compared with the report of the prior study (images unavailable for review) of [**2175-6-14**], LV systolic dysfunction appears more regional and reflective of CAD on today's study. Polyvalvular regurgitant valvular disease has progressed and pulmonary pressures are estimated to be higher. UNILAT LOWER EXT VEINS Study Date of [**2181-10-26**] IMPRESSION: No evidence of right lower extremity DVT. Right [**Known lastname 4675**] cyst. Brief Hospital Course: 81M with CAD s/p PCI, RCC, CKD (baseline Cr 2.5), presentes with shortness of breath over the last 3 days, found to have elevated BNP and asymmetric pulmonary edema on CXR. Acute on chronic systolic congestive heart failure: This may have been due to dietary indiscretion. He initially required a NRB and was admitted to the [**Hospital Unit Name 153**] but was quickly transitioned to room air after diuresis with IV Lasix. He was started on po Lasix 20 mg daily. His metoprolol was increased to 25 mg [**Hospital1 **]. He was not started on an ACEI due to his creatinine. He was did not want to take aspirin due to prior history of gastric ulcers; however, he did say he would discuss this with his cardiologist Dr. [**Last Name (STitle) **]. He was instructed to check daily weights at home. Hypertension: His BP in the ED was extremely elevated, likely contributing to his CHF exacerbation. He was continued on amlodipine 10 mg daily, his metoprolol was increased to 25 mg [**Hospital1 **], and he was started on lasix 20 mg daily. He reports that his former nephrologist told him that his blood pressure should be in the 150s, so he likes to keep it in this range. He will need outpatient follow up on his blood pressure and blood work. Chronic kidney disease, stage III: His Cr during his hospitalization was at baseline. He will need follow up lab studies after initiation of daily lasix. RLE edema: He was ruled out for DVT. He does have [**Initials (NamePattern4) **] [**Known lastname 4675**] cyst. H/o colitis: He was continued on balsalazide. Anxiety: He was continued on diazepam 5mg [**Hospital1 **] PRN. Medications on Admission: balsalazide 750 mg 3 tablets b.i.d. omeprazole 20 mg q. day Toprol 25 mg one half tablet b.i.d. amlodipine 5 mg [**Hospital1 **] iron 325 mg q. day diazepam 5 mg half tab b.i.d. triamcinolone 0.1% ointment b.i.d. p.r.n. Astelin Rowasa enema p.r.n. Discharge Medications: 1. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 2. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 3. amlodipine 5 mg Tablet Sig: One (1) Tablet PO twice a day. 4. balsalazide 750 mg Capsule Sig: Three (3) Capsule PO bid (). 5. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 6. ferrous sulfate 300 mg (60 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. diazepam 5 mg Tablet Sig: 0.5 Tablet PO Q12H (every 12 hours) as needed for anxiety/insomnia. 8. triamcinolone acetonide 0.1 % Ointment Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day) as needed for rash/pruritis. 9. azelastine 0.15 % (205.5 mcg) Spray, Non-Aerosol Sig: One (1) spray Nasal once a day. 10. Rowasa 4 gram/60 mL Kit Sig: One (1) application Rectal once a day as needed for colitis. Discharge Disposition: Home Discharge Diagnosis: Acute on chronic systolic congestive heart failure Hypertension Chronic kidney disease, stage III Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Mr. [**Known lastname **], It was a pleasure taking care of you. You were admitted for trouble breathing. This was due to congestive heart failure with fluid in the lungs. The ham was salty and likely set this off. You were started on the medication Lasix (furosemide) to help keep the fluid off. Your metoprolol was also increased to 25 mg twice a day. Please continue to take your amlodipine 5 mg twice a day. Please weigh yourself EVERY morning. If you gain/lose more than 3 lbs, please call Dr. [**Last Name (STitle) 2472**] to have your Lasix dose adjusted. You will have to follow up with Dr. [**Last Name (STitle) 2472**] within 2 weeks to check your blood pressure and for blood work. Please also discuss with him on the risks and benefits of taking a baby aspirin. Followup Instructions: Please follow up with Dr. [**Last Name (STitle) 2472**] within 2 weeks to check your blood pressure and for blood work. Please also discuss with him on the risks and benefits of taking a baby aspirin. His clinic number is [**Telephone/Fax (1) 133**]. Please also follow up with Dr. [**Last Name (STitle) **] within 3 weeks. Department: WEST [**Hospital 2002**] CLINIC When: MONDAY [**2182-3-4**] at 2:30 PM With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], 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

[ "280.9", "585.3", "530.81", "428.0", "V45.82", "414.01", "403.90", "272.4", "428.23" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

8989, 8995

6079, 7721

291, 298

9137, 9137

2728, 2728

10134, 10817

1881, 1918

8020, 8966

9016, 9116

7747, 7997

9320, 10111

3283, 6056

1933, 2709

232, 253

326, 1280

2744, 3267

9152, 9296

1302, 1698

1714, 1865

3,969

106,785

3179

Discharge summary

report

Admission Date: [**2151-3-31**] Discharge Date: [**2151-4-3**] Date of Birth: [**2086-10-5**] Sex: F Service: MEDICINE Allergies: Imdur Attending:[**First Name3 (LF) 1436**] Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: Less than 24 hour intubation in the medical intensive care unit. History of Present Illness: 64 F w/ hx CABG (LIMA-LAD, SVG-RCA, jump SVG-RI-OM occluded), occasional angina, DM, htn, hypercholesterolemia p/w SOB X [**1-30**] days culminating in calling EMS tonight [**3-31**]. On arrival, patient was hypoxemic (unclear to what degree), hypertensive to SBP 200, agitated and was intubated in ambulance. In ED, found to have RMS intubation, pulled back w/ atypical ETT position, but normal pressures on vent and good blood gas. CXR reveals CHF. BP 200/140Also w/ metabolic acidosis and DKA on labs. Insulin gtt started. Afebrile. Given levoquin in ED. Past Medical History: CAD, s/p CABG [**1-/2143**] (LIMA-LAD, SVG-RCA, and SVG to RI to OM1) now occluded. Persantine MIBI showed EF 46% with severe reversible defects of inferolateral walls (worse than [**1-31**]) HTN Hypercholesterolemia DM recently diagosed in setting of DKA s/p hemithyroidectomy Social History: smoked 1 ppdX 20 years, quit 10 years ago; denies etoh/illicits, lives with husband Family History: NC Physical Exam: AF 100 151/83 14 98% AC 500X15, peep 10 and Fi 0.5 Gen: int/sedated HEENT: EOMI, PERRL CV: Tachy, regular, no nrg Resp: Crackles B Abd: distended, tympanic, hypactive BS, not tense Ext: 2+ pitting edema to knees Neuro/Psych: downgoing toes Pertinent Results: [**2151-3-31**] 07:59PM GLUCOSE-143* UREA N-8 CREAT-1.0 SODIUM-146* POTASSIUM-4.3 CHLORIDE-108 TOTAL CO2-22 ANION GAP-20 [**2151-3-31**] 07:59PM CALCIUM-9.2 PHOSPHATE-3.5 MAGNESIUM-2.8* [**2151-3-31**] 07:59PM PTT-42.8* [**2151-3-31**] 05:16PM TYPE-ART TEMP-36.5 RATES-/35 O2-95 PO2-55* PCO2-40 PH-7.40 TOTAL CO2-26 BASE XS-0 AADO2-599 REQ O2-96 INTUBATED-NOT INTUBA VENT-SPONTANEOU COMMENTS-HIGH [**Last Name (un) **] N [**2151-3-31**] 05:16PM LACTATE-3.0* [**2151-3-31**] 05:16PM O2 SAT-87 [**2151-3-31**] 03:19PM GLUCOSE-183* UREA N-8 CREAT-1.0 SODIUM-145 POTASSIUM-4.5 CHLORIDE-111* TOTAL CO2-21* ANION GAP-18 [**2151-3-31**] 03:19PM CK-MB-14* cTropnT-0.07* [**2151-3-31**] 03:19PM CALCIUM-8.7 PHOSPHATE-3.6 MAGNESIUM-1.8 [**2151-3-31**] 07:45AM GLUCOSE-74 UREA N-9 CREAT-0.9 SODIUM-147* POTASSIUM-3.8 CHLORIDE-110* TOTAL CO2-24 ANION GAP-17 [**2151-3-31**] 07:45AM CK(CPK)-335* [**2151-3-31**] 07:45AM CK-MB-12* MB INDX-3.6 cTropnT-0.08* [**2151-3-31**] 07:45AM CALCIUM-8.5 PHOSPHATE-2.7# MAGNESIUM-1.8 [**2151-3-31**] 07:45AM WBC-5.2 RBC-3.53* HGB-10.0* HCT-31.9* MCV-91 MCH-28.4 MCHC-31.4 RDW-16.1* [**2151-3-31**] 07:45AM PLT COUNT-299 [**2151-3-31**] 07:45AM PT-12.4 PTT-20.1* INR(PT)-1.1 [**2151-3-31**] 05:54AM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.004 [**2151-3-31**] 05:54AM URINE BLOOD-MOD NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [**2151-3-31**] 05:54AM URINE RBC-[**3-1**]* WBC-[**3-1**] BACTERIA-OCC YEAST-NONE EPI-0-2 [**2151-3-31**] 04:24AM TYPE-ART RATES-14/0 TIDAL VOL-500 PEEP-10 O2-60 PO2-112* PCO2-42 PH-7.36 TOTAL CO2-25 BASE XS--1 -ASSIST/CON INTUBATED-INTUBATED [**2151-3-31**] 04:19AM COMMENTS-GREEN TOP [**2151-3-31**] 04:19AM GLUCOSE-171* K+-2.6* [**2151-3-31**] 03:57AM GLUCOSE-189* UREA N-10 CREAT-0.9 SODIUM-146* POTASSIUM-2.6* CHLORIDE-112* TOTAL CO2-18* ANION GAP-19 [**2151-3-31**] 02:20AM URINE COLOR-Yellow APPEAR-Hazy SP [**Last Name (un) 155**]-1.018 [**2151-3-31**] 02:20AM URINE BLOOD-LG NITRITE-NEG PROTEIN-500 GLUCOSE-250 KETONE-TR BILIRUBIN-NEG UROBILNGN-1 PH-6.0 LEUK-NEG [**2151-3-31**] 02:20AM URINE RBC-21-50* WBC-21-50* BACTERIA-MOD YEAST-NONE EPI-[**6-6**] TRANS EPI-[**3-1**] RENAL EPI-[**3-1**] [**2151-3-31**] 02:20AM URINE HYALINE-0-2 [**2151-3-31**] 02:05AM LACTATE-5.1* [**2151-3-31**] 01:33AM TYPE-ART RATES-14/ TIDAL VOL-500 PEEP-8 O2-60 PO2-71* PCO2-41 PH-7.28* TOTAL CO2-20* BASE XS--6 -ASSIST/CON INTUBATED-INTUBATED [**2151-3-31**] 12:30AM GLUCOSE-324* UREA N-10 CREAT-1.2* SODIUM-140 POTASSIUM-3.1* CHLORIDE-103 TOTAL CO2-15* ANION GAP-25* [**2151-3-31**] 12:30AM estGFR-Using this [**2151-3-31**] 12:30AM CK(CPK)-179*, cTropnT-0.04*, CK-MB-5 proBNP-7201* [**2151-3-31**] 12:30AM CALCIUM-9.5 PHOSPHATE-6.4*# MAGNESIUM-2.0 [**2151-3-31**] 12:30AM WBC-7.6# RBC-3.97* HGB-11.4* HCT-38.4 MCV-97# MCH-28.7 MCHC-29.7*# RDW-15.8* [**2151-3-31**] 12:30AM NEUTS-40* BANDS-1 LYMPHS-49* MONOS-7 EOS-3 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 NUC RBCS-1* [**2151-3-31**] 12:30AM PLT SMR-NORMAL PLT COUNT-368# [**2151-3-31**] 12:30AM PT-12.5 PTT-24.7 INR(PT)-1.1 . 2D-ECHOCARDIOGRAM performed on [**2151-3-31**] demonstrated: Conclusions: EF 30-35% The left atrium is elongated. Left ventricular wall thicknesses and cavity size are normal. Left ventricular wall thicknesses are normal. Overall left ventricular systolic function is moderately depressed with global hypokinesis. Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). There is no ventricular septal defect. There is mild global right ventricular free wall hypokinesis. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Moderate (2+) mitral regurgitation is seen. Moderate [2+] tricuspid regurgitation is seen. There is at least mild pulmonary artery systolic hypertension. There is a trivial/physiologic pericardial effusion. . [**2151-3-31**] Admission CXR IMPRESSION: 1) Right mainstem bronchus intubation; this has been corrected on the subsequent chest radiograph. 2) Complete opacification of the left hemithorax with volume loss from collapse due to the malpositioned endotracheal tube. 3) Evidence of congestive heart failure/volume overload with a moderate right pleural effusion. Brief Hospital Course: This is a 64 y/o with CHF, hx CABG (LIMA-LAD, SVG-RCA, jump SVG-RI-OM occluded), DM, htn, hypercholesterolemia, presented with hypertensive urgency, pulmonary edema, s/p intubation and successful extubation, as well as metabolic acidosis, likely DKA versus lactic acidosis . MICU course significant for rapid extubation in < 24 hours with diuresis. Patient's blood pressure was controlled with ACE-I, HCTZ and metoprolol. . 1. Cardiac: Patient with history of CAD including CABG, most stents occluded, presented with progressive dyspnea, pulmonary edema and DKA. Her troponins were slightly elevated on admission, likely secondary to demand from CHF exacerbation and pulmonary edema. She was evaluated by cardiology in the unit who recommended medical management including optimization of her blood pressure medications. She remained chest pain free and shortness of breath much improved after diuresis. She was maintained on ASA, BB, ACE-I, Statin and plavix, and her blood pressure medications were titrated upwards as tolerated. LVEF depressed to 30%, likely in setting of acute pulm edema versus new onset CHF from acute event. She was started on lasix for improved diuresis and was weaned off oxygen prior to discahrge. Repeat CXR showed improvement of pulmonary edema. . 2. Respiratory failure: Now resolved, likely secondary to pulmonary edema. Acute episodes of shortness of breath may have been secondary to elevated BP, DKA, difficult to tell what was inciting factor. Not likely to be secondary to acute ischemic event, as above. Repeat CXR showed improvement of pulmonary edema. She was weaned off oxygen. . 3. DM: [**3-3**], Hb A1C 16.5%. DKA on admission, gap has now closed. [**Last Name (un) **] following during hospital course, recs appreciated. . 4. Dispo: In good condition to home, ambulating without an oxygen requirement Medications on Admission: Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Metoclopramide 5 mg Tablet Sig: One (1) Tablet PO four times a day. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Allopurinol 100 mg Tablet Sig: Two (2) Tablet PO once a day. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day. Humalog 100 unit/mL Solution Sig: 0-16 units Subcutaneous QAC/HS: Per sliding scale. Disp:*QS 1 month* Refills:*2* Lantus 100 unit/mL Solution Sig: Thirty Three (33) units Subcutaneous at bedtime. Disp:*QS 1 month* Refills:*2* Discharge Medications: 1. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* 2. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:*60 Tablet(s)* Refills:*2* 3. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 4. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 9. Insulin Glargine 100 unit/mL Solution Sig: Twenty (20) units Subcutaneous at bedtime. Disp:*qs qs* Refills:*2* 10. Humalog 100 unit/mL Solution Sig: Per sliding scale units Subcutaneous qachs: Please find attached sliding scale with your discharge paperwork. . Disp:*qs qs* Refills:*2* 11. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 12. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home Discharge Diagnosis: Hypertensive Emergency Pulmonary Edema Diabetic Ketoacidosis Discharge Condition: Vital signs stable. No shortness of breath or chest pain. No peripheral edema. Discharge Instructions: Please return to the hospital if you feel short of breath, have chest pain, or have blood sugars over 400. If you have vision changes, headahces or blood in your urine you should return to the hospital. . Please follow up with your primary care doctor's appointment and all of your other appointments. . Please take all of your medications as prescribed. If we have given you a prescription for a medication that you were already on, then the dose may be different. For example we are giving you a prescription for metoprolol Tartrate 50mg twice a day. This is a greater dose than you were taking when you came in. Please dispose of your old prescription and start on the new one. Followup Instructions: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1882**], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2151-4-15**] 9:00 Provider: [**Name Initial (NameIs) 703**] (C4) TCC RADIOLOGY Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2151-4-21**] 2:30 Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 2664**] Date/Time:[**2151-4-21**] 3:30

[ "V58.67", "428.0", "V45.81", "250.12", "414.01", "401.9", "272.0", "518.81" ]

icd9cm

[ [ [] ] ]

[ "96.71" ]

icd9pcs

[ [ [] ] ]

9942, 9948

6090, 7944

286, 354

10053, 10136

1641, 6067

10868, 11294

1361, 1365

8782, 9919

9969, 10032

7970, 8759

10160, 10845

1380, 1622

227, 248

382, 942

964, 1244

1260, 1345

30,887

188,324

9617

Discharge summary

report

Admission Date: [**2145-8-20**] Discharge Date: [**2145-8-26**] Date of Birth: [**2091-8-27**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 668**] Chief Complaint: porcelain gallbladder and end-stage liver disease Major Surgical or Invasive Procedure: [**2145-8-20**] Subtotal cholecystectomy History of Present Illness: From operative report [**2145-8-20**]: "Mr. [**Known lastname 32595**] is a very pleasant 53- year-old gentleman with end-stage liver disease, currently Child's B/B- cirrhotic, who is attempting to complete his workup for the liver transplant list. During the process of his evaluation he was noted have a porcelain gallbladder with significant stones within the gallbladder itself. Based upon our concern for a gallbladder malignancy we did not believe that he would be a suitable candidate for listing for transplantation without cholecystectomy to ensure that there was no malignancy within the wall of the gallbladder." Past Medical History: # Alcoholic cirrhosis --Portal hypertension --TIPS ([**2137**]): TIPS revisions X 3 --Not currently listed given severe obesity # DM2, insulin dependent (HbA1C 6.2% 6/07) # Obesity # Rhinoplasty, s/p broken nose as a teenager # Squamous cell skin CA @ L shoulder, removed # Obstructive sleep apnea: BiPAP --Pulmonary arterial hypertension [**1-15**] OSA Social History: # Personal: Married, living in [**Location (un) 3320**] # Tobacco: 16-pack-year h/o smoking, quit 27 years ago # Alcohol: H/o alcohol abuse, quit 10 years ago # Recreational drugs: Remote marijuana use, no h/o IVDU # Employment: Unemployed. Former food/beverage director in hotel and cruise industry. Family History: # Mother, d 56: CVA # Father, d 83: Alzheimer's # Sister: DM2, seizures # Brother, older: [**Name2 (NI) 3495**] disease # Brother, younger: [**Name2 (NI) **] known disease Physical Exam: On discharge: Gen: NAD, A&Ox3 CV: RRR Lungs: CTAB Abd: soft, approp tender, mild distension, obese 2 JP drains in place - insertion sites clean and dry Ext: 1+ edema Pertinent Results: On admission: [**2145-8-20**] 02:33PM WBC-4.3# RBC-3.09* HGB-10.3* HCT-29.7* MCV-96 MCH-33.3* MCHC-34.8 RDW-17.6* [**2145-8-20**] FIBRINOGE-261 [**2145-8-20**] 11:10AM PT-16.1* PTT-32.5 INR(PT)-1.5* [**2145-8-20**] 11:10AM PLT COUNT-92*# [**2145-8-20**] 11:30AM GLUCOSE-158* LACTATE-1.7 NA+-135 K+-5.3 CL--109 [**2145-8-20**] 11:30AM ASCITES WBC-0 RBC-[**Numeric Identifier 32596**]* POLYS-11* LYMPHS-44* MONOS-19* MESOTHELI-10* OTHER-16* [**2145-8-20**] 11:30AM GLUCOSE-158* LACTATE-1.7 NA+-135 K+-5.3 CL--109 On discharge: [**2145-8-26**] WBC-2.2* RBC-2.72* Hgb-9.1* Hct-25.6* MCV-94 MCH-33.4* MCHC-35.4* RDW-18.1* Plt Ct-44* [**2145-8-26**] Glucose-280* UreaN-66* Creat-1.7* Na-131* K-3.9 Cl-98 HCO3-24 AnGap-13 [**2145-8-26**] ALT-24 AST-26 AlkPhos-113 TotBili-2.7* [**2145-8-26**] Albumin-3.0* Brief Hospital Course: 53 yo M with the above history underwent subtotal CCY on [**2145-8-20**]. Postop he was admitted to the SICU [**1-15**] coagulopathy. He was transfused 4U platelets, 1U PRBC's, 10 & 5 units IV insulin given for hyperkalemia. Started on insulin gtt @13. Tx'd to floor on [**8-21**]. [**Last Name (un) **] was consulted for management of blood glucose. Transfused 2U platelets on [**8-22**]. Insulin gtt was d/c'd, and then restarted 12 hours later to keep blood sugars 140-200's. On [**8-23**], he was transfused 1U PRBC's and 1U platelets. Physical therapy was consulted and followed the patient. On [**8-24**], he had a CT to rule out any hematoma or any cause for concern given the platelet requirements, which showed no hematoma or bleeding. Insulin gtt was d/c'd on [**8-25**], and patient was titrated back up to his home dose of NPH (45U [**Hospital1 **]). On the day of discharge, the patient is doing well, afebrile, AVSS, Hct stable at 25.6, plts 44, asymptomatic, tolerating PO, ambulating halls without difficulty, pain well-controlled. He is a known patient to [**Last Name (un) **], and he will make a follow-up appointment with them as outpt. Medications on Admission: Mg oxide 400gm'', Spironolactone 200mg qAM/100mg qhs, Lasix 80'', Xifaxan 600mg [**Hospital1 **], Humulin 45u [**Hospital1 **], Humalog SS, Lactulose 1 tab po bid Discharge Medications: 1. Lactulose 10 g/15 mL Solution Sig: Thirty (30) ML PO BID (2 times a day). 2. Rifaximin 200 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) for 1 months. Disp:*60 Capsule(s)* Refills:*2* 4. Magnesium Oxide 400 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. Furosemide 40 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 6. Spironolactone 100 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 7. Spironolactone 100 mg Tablet Sig: One (1) Tablet PO DAILY18 (ONCE DAILY @ 1800). 8. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for 2 weeks. Disp:*30 Tablet(s)* Refills:*0* 9. ISS Continue your home Insulin Sliding Scale and resume home dose of NPH. Call your [**Last Name (un) **] provider to make an appointment. Discharge Disposition: Home Discharge Diagnosis: End-stage liver disease, porcelain gallbladder Discharge Condition: Stable Discharge Instructions: Please call Dr.[**Name (NI) 670**] office [**Telephone/Fax (1) 673**] if you have pain, bleeding, redness, chest pain, shortness of breath, bloody stool, or nausea/vomiting. Call if you have any concerns or questions. Followup Instructions: 1) Please call Dr.[**Name (NI) 670**] office [**Telephone/Fax (1) 673**] to confirm a follow-up appointment (discussed with patient - he will be seen in clinic on Monday [**2145-8-30**]) 2) ULTRASOUND Phone:[**Telephone/Fax (1) 327**] [**2145-11-3**] 1:45 3) [**Name6 (MD) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 673**] [**2145-11-3**] 3:40 4) PULMONARY BREATHING TESTS Phone: [**Telephone/Fax (1) 612**] [**2146-1-18**] 10:40

[ "V17.3", "V18.0", "286.9", "V10.83", "276.7", "456.8", "V15.82", "250.00", "575.8", "780.57", "278.01", "416.0", "571.2" ]

icd9cm

[ [ [] ] ]

[ "99.05", "99.04", "51.04", "51.21" ]

icd9pcs

[ [ [] ] ]

5237, 5243

2987, 4156

363, 407

5333, 5342

2151, 2151

5609, 6052

1775, 1948

4369, 5214

5264, 5312

4182, 4346

5366, 5586

1963, 1963

2689, 2964

274, 325

435, 1061

2165, 2674

1083, 1439

1455, 1759

16,490

151,602

5849

Discharge summary

report

Admission Date: [**2149-5-30**] Discharge Date: [**2149-6-24**] Date of Birth: [**2074-1-11**] Sex: F Service: MEDICINE Allergies: Percocet / Serax Attending:[**First Name3 (LF) 783**] Chief Complaint: SOB, Hypoxia Major Surgical or Invasive Procedure: None History of Present Illness: 75 F c CAD s/p CABG, PVD, ESRD on HD, sarcoid (seen by Dr. [**Last Name (STitle) 217**]. Recently hospitalized ([**2-9**]) for ischemic L thumb and L subclavian vein stenosis with course complicated by fluid overload (tx c HD), hemodynamically unstable afib c RVR requiring 2 DCCV + started on amiodarone. Also complicated by b/l pleural effusions, underwent thoracentesis showing transudate. Had angioplasty of L subclavian vein stenosis. Also of note, had recent evaluation for temporal arteritis c negative biopsy; treated empirically with a course of prednisone ([**4-9**]). . Pt. reports 2 weeks of worsening SOB and orthopnea. Awoke significantly SOB this morning. Noted to be hypoxic at HD to 80s and SOB c fever and cough at dialysis. Also complained of pain, redness, swelling over R foot. At HD, concern expressed for nonhealing L shin ulcer, possible RLE cellulitis. Sent to [**Hospital1 18**]. Received 1 dose of 750 mg levofloxacin prior to transfer. . In ED, VS - 100.4, 108, 27, 93% 4L NC. BNP 30 K. Recevied vancomycin, levofloxacin in ED. CXR concerning for new RLL PNA. Admitted to MICU. In MICU, c/o mild orthopnea, mild pleuritic pain midline with exhalation, fatigue. Past Medical History: - CAD s/p CABG ([**11-8**]) - DM II: since age 47 with triopathy - Hypercholesterolemia - HTN - Sarcoidosis with pulmonary involvement: Followed by Dr. [**Last Name (STitle) 217**] - COPD (FEV1 93% in [**2145**]; previously on home O2 but not now) - hypothyroidism - Renal artery stenosis s/p bilateral stents ([**2146**]) - ESRD on HD (qMWF; due to renal artery stenosis) - CHF (EF>55%) - atrial fibrillation, paroxysmal - PVD s/p left fem-[**Doctor Last Name **] [**2140**], s/p right fem-[**Doctor Last Name **] [**2143**], s/p angioplasty and stent [**6-7**] - breast cancer s/p left mastectomy [**2126**] - h/o mesenteric ischemia s/p SMA bypass [**10-5**] - gastritis - s/p cholecystectomy [**2147**] - chronic anemia (baseline Hct 28-30) - [**3-11**]: LT SC angioplasty for necrotic L thumb - Carpal tunnel syndrome bilaterally, with positive electromyogram - Acute tubular necrosis secondary to dye nephropathy Social History: General: Retired postal worker. Lives with husband. Previously independent in her ADLs. Has 3 adult children and grandchildren. Tobacco: 25-50 pack year smoking history, quit [**2124**] EtOH: Denies Recreational drugs: Denies Family History: One sister had lung cancer, one brother had lung cancer and leukemia, five of the patient's six siblings have diabetes. Father died of myocardial infarction at age 66. There is a strong family history of hypertension. Physical Exam: VS- 98.7, 86/48, 106-111 (afib), 25-28, 100% Ventimask 10 lpm HEENT- JVP flat at 20 degrees, dry MM, + skin tenting over forehead LUNGS- Crackles R>L base, decreased fremitus R base, dullness to percussion over R/L bases. Fine wheeze on inspiration. HEART- Irregularly irregular, tachycardic, no murmurs ABDOM- soft, ND, NT, BS+ EXTRE- wwp, no edema, erythema over R/L shin + ulcer NEURO- A*O*3, moving ext. Pertinent Results: LABS: [**2149-5-30**] 01:40PM BLOOD WBC-13.3* RBC-3.64* Hgb-11.3* Hct-34.9* MCV-96 MCH-31.1 MCHC-32.4 RDW-19.8* Plt Ct-333 [**2149-5-30**] 01:40PM BLOOD Neuts-84.6* Lymphs-7.9* Monos-6.4 Eos-0.8 Baso-0.3 [**2149-5-30**] 01:40PM BLOOD Hypochr-2+ Anisocy-2+ Poiklo-1+ Macrocy-2+ [**2149-5-30**] 01:40PM BLOOD PT-20.1* PTT-33.5 INR(PT)-1.9* [**2149-5-30**] 01:40PM BLOOD Plt Ct-333 [**2149-5-30**] 01:40PM BLOOD Glucose-300* UreaN-22* Creat-2.3* Na-136 K-4.2 Cl-95* HCO3-31 AnGap-14 [**2149-5-30**] 01:40PM proBNP-[**Numeric Identifier 23179**]* [**2149-5-30**] 01:49PM LACTATE-2.6* [**2149-5-30**] 08:52PM PT-22.7* PTT-35.2* INR(PT)-2.2* [**2149-5-30**] 08:52PM WBC-9.9 RBC-3.07* HGB-9.8* HCT-29.4* MCV-96 MCH-31.9 MCHC-33.3 RDW-20.1* [**2149-5-30**] 08:52PM ALBUMIN-2.2* CALCIUM-7.2* PHOSPHATE-2.9 MAGNESIUM-1.7 [**2149-5-30**] 08:52PM ALT(SGPT)-11 AST(SGOT)-12 ALK PHOS-82 TOT BILI-0.3 [**2149-5-30**] 08:52PM GLUCOSE-308* UREA N-26* CREAT-2.6* SODIUM-137 POTASSIUM-4.2 CHLORIDE-100 TOTAL CO2-29 ANION GAP-12 . CXR ([**2149-5-30**]): Comparison is made to prior chest radiograph dated [**2149-3-13**] and prior CT dated [**2149-3-11**]. Increased interstitial edema with more focal opacity within the right lower lung, likely representing alveolar edema with underlying consolidation less likely. Recommend repeat radiographs to assess for resolution. Stable appearance to small pleural effusions, left greater than right. . CXR ([**2149-6-19**]): 1. Diffuse interstitial edema. 2. Developing confluent asymmetric airspace opacity in right lower lobe. Although possibly asymmetric edema, aspiration or infectious pneumonia should be considered. 3. Bilateral pleural effusions, left greater than right. . EKG ([**2149-5-30**]): Atrial fibrillation with a rapid ventricular response. Compared to the previous tracing of [**2149-3-16**] there is atrial fibrillation with a rapid ventricular response. The T waves appear less biphasic in leads V2-V3, which may reflect the change in rate. . PFTs ([**2149-4-17**]): The FVC is mildly reduced. The FEV1 is within normal limits. The FEV1/FVC ratio is elevated. Flow-Volume Loop: Abrupt termination of exhalation with reduced volume excursion. Volumes: The TLC is mildly reduced. The FRC, RV and RV/TLC ratio are within normal limits. Results suggest a mild restrictive ventilatory defect. However, FVC may be underestimated due to suboptimal test performance, and lung volumes are irreproducible. Since [**2145-4-15**], FVC has been reduced by 1.06 L (35%). Since [**2143-2-13**], there is no significant change in TLC or Dsb. . Echo ([**2149-3-7**]): Left atrium is normal in size. No atrial septal defect is seen. Left ventricular wall thickness, cavity size, and systolic function are normal (LVEF 70%). No ventricular septal defect. The right ventricular cavity is dilated. Right ventricular systolic function is borderline normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Mild to moderate ([**2-4**]+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. There is a minimally increased gradient consistent with trivial mitral stenosis. Moderate (2+) mitral regurgitation is seen. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] The tricuspid valve leaflets are mildly thickened. The supporting structures of the tricuspid valve are thickened/fibrotic. Moderate to severe [3+] tricuspid regurgitation is seen. There is at least moderate pulmonary artery systolic hypertension. There is a trivial/physiologic pericardial effusion. There are no echocardiographic signs of tamponade. Compared with the findings of the prior study (images reviewed) of [**2147-6-27**], the mitral and tricuspid regurgitation are increased; there is now at least moderate pulmonary hypertension; and the right ventricle is now dilated and hypocontractile. Brief Hospital Course: 75 yo female with CAD s/p CABG, COPD, ESRD on HD, DM type II, presents with worsening SOB and hypoxia and admitted with probable RLL pneumonia, volume overload, atrial fibrillation with RVR, and right LE cellulitis. . # SOB/hypoxia: When the patient was admitted, she was found to be volume overloaded with EKG demonstrating afib with RVR, and additionally had RLL infiltrate on CXR. A COPD flair was thought unlikely as she was not wheezing. She was initially treated for pneumonia with levofloxacin and vanco and then switched to zosyn and vanco because a long QT was noted on EKG. She was admitted to the MICU for respiratory distress in the setting of rapid afib. She underwent HD with ultrafiltration with removal of 3L with improvement in symptoms. She was transferred back to regular medical floor with improvement in her symptoms, but again triggered on the floor when she was found to be experiencing palpitations, SOB, lightheadedness, and was tachycardic 130-160s. An EKG demonstrated sustained wide-complex afib with RVR and exam demonstrated worsening pulmonary crackles. Efforts to restore normal sinus rhythm failed with IV metoprolol and she was transferred back to the MICU. In the MICU, IV diltiazem was started with improved rate control. Cardiology was consulted and felt that wide complex tachycardia was likely a. fib w/ aberrancy and unlikely VT. She was again loaded with amiodarone with maintenance of NSR and rate control established with metoprolol. During this time the patient has been dialyzed with UF removal to reduce the volume overload, and after each session she had improvement in her SOB. As the sessions were being limited by hypotension, she was started on midodrine prior to each session. She will be discharged on 12.5mg metoprolol [**Hospital1 **] and amiodarone 400mg daily to be decreased to 200mg daily on [**2149-7-5**]. She has been requiring supplemental O2 which should be continued to maintain O2 saturations >93% and titrated off as possible with additional fluid removal at HD. . # Leukocytosis: Had significant bandemia of 10% on [**6-14**] which has since resolved with WBC count trending downward from a max of 19.6, now 14 on day of discharge. Admission CXR showed RLL infiltrate that on subsequent imaging had resolved and then again reappeared in the setting of climbing WBC count. She was again started on levofloxacin with downward trend of her WBC count, however was changed to zosyn for concern of widening QT while on amiodarone. She previously had significant diarrhea during this hospitalization with repeated C. diff toxin A that were negative. Her diarrhea has since resolved and C. diff toxin B is pending and should be followed up on. Urine culture was negative. Last day of zosyn for probable aspiration pneumonia is [**2149-6-30**] to complete a 7 day course. . # CKD on hemodialysis: She was continued on hemodialysis with goal to remove excess fluid with UF. Her phosLo was discontinued as her phosphate had normalized, but this should be monitored and restarted if again climbs. Additionally, she has been receiving 5mg midodrine prior to HD to maintain pressures during HD, as amount of fluid removed during her sessions had previously been limited by borderline blood pressures. As she remains fluid overloaded, the goal will be continued removal of fluid with HD/UF and, thus, midodrine should be continued prior to HD as needed. She is next due for hemodialysis on [**2149-6-25**] with goal, as above, to continue fluid removal. . # Atrial fibrillation and wide complex tachycardia: As above, she was admitted due to hypoxia in the setting of A-fib w/ RVR. She is now in NSR on amiodarone and HR consistently in the low 60s on 12.5mg metoprolol [**Hospital1 **]. [**Last Name (un) **] rate controlled and in sinus rhythm s/p amio load. Her INR is therapeutic on 1mg coumadin qhs and should be monitored especially while on antibiotics and amiodarone. She should be continued on amiodarone 400mg PO daily and should be decreased to 200mg daily on [**7-5**]. . # Epistaxis: On hospital day 10 ([**2149-6-8**]) the patient experienced an uncontrollable nose bleed that failed to respond to pressure, Afrin, and packing in the MICU. Her INR at the time was therapeutic (2.6). ENT was called and an anterior perforation was seen. The patient was decongested with Afrin/lidocaine and the nasal cavity was cleared. Surgicell was packed into the R-nare (anterior and posterior) and L-nare anteriorly and has since dissolved. Coumadin was temporarily held and has since been restarted and remains therapeutic without any subsequently nose bleeds. . # BRBPR: Occurred in the setting therapeutic INR (2.6) and severe epistaxis as above. Of note, has h/o UGIB in [**2144**] [**3-7**] ischemic necrosis of transverse duodenum after aorto-SMA bypass. GI evaluated and, as her hct has since remained stable, EGD and colonoscopy can be pursued as an outpatient. Hct remained stable in the 24-27 and she is HD stable without evidence of further bleeding. . # Anemia: Although hct fluctuates, BL recently prior to this admission appears to be in the low 30s. hct during this stay has been 24-29 and is likely [**3-7**] CKD and GI bleed and iron-deficiency. Recent iron studies reveals iron saturation of 11% (iron 15, TIBC 129, ferritin 428). She was continued on Epogen per renal recs and was started on iron supplemenation which should be held 1 week to colonoscopy when scheduled. . # Hypertension: Blood pressure remained well controlled during her stay with the exception of BP dips during HD as discussed above. She will be discharged on 12.5mg metoprolol [**Hospital1 **] with midodrine prn prior to HD. . # CAD: s/p CABG. She was without signs of active ischemia during her stay. She was continued on ASA, statin, betablocker. . # Right lower extremity cellulitis: Surrounding superficial ulcer with erythema. Treated x 8 days with vanco (and was on zosyn for pneumonia #1) with resolution of surrounding erythema and tenderness. Superficial ulcer remains scabbed/dry without evidence of persistent infection. This exam should be monitored. . # PVD: Patient with dry gangrenous left thumb tip without any e/o infection. No [**Hospital1 1106**] intervention currently as dry gangrene. Thus, dry gauze dressings should be applied daily and exam monitored. . # COPD: Remained stable without e/o significant bronchospasm on exam. She was continued on tiotropium, advair, prn albuterol. . # DM: Her blood glucose was challenging to control during her admission. Her lantus was up-titrated somewhat with better overall control. She demonstrated some tendancy to become hypoglycemic in the morning hours and so her bedtime sliding scale was reduced with good effect. The Humalog ISS and lantus will need to be titrated according to her SS requirements. . # Hypothyroidism: An initial TSH during the hospitalization was elevated and on re-check it was still elevated. Free T4 was checked and was normal. She was continued on her home dose synthroid. . # FEN: Cardiac, diabetic, renal diet. As there was some concern for aspiration with thin liquids (okay with food), speech and swallow evaluated her at bedside. She is to use chin tuck maneuver when drinking thin liquids and head of bed should be upright when eating. . # Access: Dialysis line placed [**2149-6-2**], peripheral IVs . # PPX: Therapeutic from coumadin, PPI, HOB elevation, PT consult . # Code: DNR/DNI as discussed with patient Medications on Admission: ASA 81 qd Nephrocaps qd Salmeterol 1 spray [**Hospital1 **] Spiriva 1 cap qd Prednisolone 1 gtt R eye daily Colace/Senna/Dulcolax PRN Insulin regular sliding scale Amiodarone 200 daily Darepoetin Eucerin Cream Atorvastatin 40 daily Nexium 40 daily Becaplermin gel daily CaCO3 1000mg tid Lopressor 25-50 [**Hospital1 **] Insulin 12 U NPH diluy Vancomycin PO 250 mg tid Linezolid 600 mg [**Hospital1 **] Vicodin PRN Albuterol PRN Ambien PRN Discharge Medications: 1. Nephrocaps 1 mg Capsule Sig: One (1) Capsule PO once a day. 2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO once a day. 3. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day. 4. Levothyroxine 200 mcg Tablet Sig: One (1) Tablet PO once a day. 5. Nexium 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 6. Spiriva with HandiHaler 18 mcg Capsule, w/Inhalation Device Sig: One (1) Inhalation once a day. 7. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Inhalation twice a day. 8. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: [**2-4**] Inhalation every 4-6 hours as needed for shortness of breath or wheezing. 9. Insulin Glargine 100 unit/mL Solution Sig: Seventeen (17) units Subcutaneous in the morning. 10. Insulin Regular Human 100 unit/mL Solution Sig: sliding scale subcutaneous Injection four times a day. 11. Metoprolol Tartrate 25 mg Tablet Sig: One-half Tablet PO twice a day. 12. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO once a day: Last dose of 400mg daily will be on [**2149-7-4**]. 13. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO once a day: Please start this dose on [**2149-5-5**] after finishing 400mg daily dose on [**2149-5-4**]. 14. Coumadin 1 mg Tablet Sig: One (1) Tablet PO at bedtime. 15. Prednisolone Acetate 1 % Drops, Suspension Sig: One (1) drop in right eye Ophthalmic once a day. 16. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ml PO four times a day as needed. 17. Senna 8.6 mg Tablet Sig: One (1) Tablet PO twice a day. 18. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO twice a day. 19. Sodium Chloride 0.65 % Spray, Non-Aerosol Sig: [**2-4**] Nasal three times a day as needed. Disp:*1 bottle* Refills:*2* 20. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) application Topical once a day as needed for as needed for affected areas. Disp:*1 tube* Refills:*2* 21. Midodrine 5 mg Tablet Sig: One (1) Tablet PO On mornings of hemodialysis: Please give before hemodialysis sessions. 22. Zosyn 2.25 g Recon Soln Sig: One (1) Intravenous every twelve (12) hours for 7 days. 23. Piperacillin-Tazobactam 2.25 g Recon Soln Sig: 2.25 g Intravenous Q12H (every 12 hours) for 7 days: to be completed on [**2149-6-30**]. 24. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Disposition: Extended Care Facility: [**Hospital1 700**] TCU - [**Location (un) 701**] Discharge Diagnosis: Primary Diagnosis: 1. RLL pneumonia 2. RLE cellulitis 3. Hypoxia from volume overload due to ESRD 4. Afib with RVR 5. Guiaic positive stools 6. Anemia due to CKD, GIB 7. Diabetes type 2 8. Dry gangrene of left thumb . Secondary: 1. Chronic obstructive pulmonary disease 2. Hypothyroidism 3. Peripheral [**Location (un) 1106**] disease 4. Ischemic left thumb 5. Healing right shin ulcer 6. Hypercholesterolemia 7. Hypertension 8. Coronary artery disease Discharge Condition: Afebrile with improving white blood cell count, stable hematocrit and O2 requirement, currently on 4L NC. Discharge Instructions: You were diagnosed with atrial fibrillation with rapid heart rate as well as excessive fluid that led to your shortness of breath. Please continue to go to hemodialysis as needed to help remove more fluid. Please take medications as below. If you develop worsening shortness of breath, increasing weight gain, chest pain, palpitations, cough, fevers, or any other worrisome symptoms, please contact your facility doctor or report to the nearest ER. Followup Instructions: Please follow up with your doctor within 1-2 weeks of your discharge, Dr. [**Last Name (STitle) 17918**] [**Telephone/Fax (1) 17919**]. Please call his office for an appointment. . You have an appointment with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 572**], a gastroenterologist, on [**8-14**] at 4pm. His office is at [**Doctor First Name **], [**Location (un) **]. For questions regarding scheduling or other issues, his phone number is [**Telephone/Fax (1) 463**]. The purpose of this visit is follow-up regarding the bleeding episode you had during your hospitalization. . Please follow up with previously scheduled appointments as below: 1. Provider: [**Name10 (NameIs) **] SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2149-8-7**] 10:15 2. Provider: [**Name10 (NameIs) 1571**] FUNCTION LAB Phone:[**Telephone/Fax (1) 609**] Date/Time:[**2149-8-14**] 12:00 [**First Name11 (Name Pattern1) 734**] [**Last Name (NamePattern1) 735**] MD, [**MD Number(3) 799**]

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Discharge summary

report

Admission Date: [**2146-10-15**] Discharge Date: [**2146-10-22**] Date of Birth: [**2077-12-10**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2901**] Chief Complaint: Chest Pain Major Surgical or Invasive Procedure: -Attempted Ventricular Tachycardia Ablation -Endotracheal Intubation History of Present Illness: This is a 68 y.o. male with past medical history of MI in [**2123**] s/p PTCA at [**Hospital1 2177**] as well as aplastic anemia, DM, and PVD who presented on the day of admission with approximately one hour of chest pain. This pain did not start with exertion as the patient was just walking around his house when he noticed some pain under his sternum. At first, he thought this was most likely heartburn so he took a couple of TUMs and then went to lay down for a while. Unfortunately, after about an hour he was continuing to have this pain, which continued at a five out of ten level and was beginning to radiate into his right shoulder. He was not diaphoretic or short of breath at rest. He described this pain as very similar to his previous cardiac pain but less severe. When the pain did not go away after rest he became concerned for a [**Last Name **] problem and called the ambulance to take him to this hospital. In the ED initial vital signs were 75, 145/84, RR 15, O2 Sat of 96% on 4L. He had an EKG which showed possible ST segment elevations and T wave inversions in V3-V5 that remained stable during his time in the ED. Initial cardiac enzymes revealed a troponin of 0.74 and CPK of 155 and MB of 6. Other remarkable lab values at the time included a Cr of 2.2 (up from his baseline of 1.7) and a Platelet count of 101. He was given aspirin, clopidogrel, and started on NTG and heparin gtt. His pain resolved early in his ED course and did not recur. The cardiology fellow was consulted and felt though the patient was most likely having an NSTEMI that he did not need urgent cath so Mr. [**Known lastname 37430**] was admitted to the [**Hospital1 1516**] service for management with early cathterization and revascularization planned in the next 24-48 hrs. Epifibatide was initially held due to concern about his thrombocytopenia and bleeding risk. Past Medical History: 1. Diabetes Mellitus type 2 2. Hypertension 3. Coronary Artery Disease s/p balloon angioplasty in [**2133**] 4. Peripheral Vascular Disease s/p R fem-[**Doctor Last Name **] bypass in [**Month (only) 216**], [**2138**] 5. s/p right Carotid Endarterectomy in [**2135-1-26**]; left carotid artery completely occluded but asymptomatic 6. s/p right 5th toe amputation in [**2137-6-25**] Social History: He is retired. He worked as a maintenance worker at [**Hospital1 2177**] for 25 yrs. He is widowed but has a son and daughter-in-law in town who he stays in close touch with. He lives by himself in poor financial circumstances. He has smoked one and a half packs of cigarettes/day for at least 50 years. He denies alcohol or other drugs. Family History: His mother and sister have diabetes mellitus type two. Many members of his family have hyptertension. Physical Exam: On admission: VS: T 97.4, BP 144/87, HR 75, RR 22, O2 Sat 100% on 4L Gen: This is a chronically ill appearing elderly male in NAD HEENT: Sclerae anicteric, PERRL, oropharynx benign without petechiae or bleeding Neck: Supple, JVP at 1 cm above the clavicle, carotid bruit on right side CV: RRR, no M/R/G appreciated, nl S1 and S2 Pulm: CTAB w/ few crackles at the bases; no wheezes, rhonchi, or rales Abdomen: Soft, NT, ND, BS+, no masses or hepatosplenomegaly appreciated Extremities: Cold but not cyanotic with with trace edema bilaterally Pulses: dopplerable DP and PT pulses bilaterally, 1- radial pulses, no palpable carotid pulses Neuro: A&O *3, responds appropriately to queries, CNII-XII grossly intact, strength 5/5 in all extremities On discharge, exam not significantly changed from admission except for in the following ways. At discharge all vital signs stable with oxygen saturation greater than 93% on room air. No JVD was appreciated. Lung exam without crackles, wheezes, rhonchi, or rales on auscultation. No edema noted. Pertinent Results: LABORATORY RESULTS On Admission: WBC-4.8 RBC-2.53* Hgb-9.2* Hct-27.1* MCV-107* Plt Ct-101* ----------Neuts-40.7* Lymphs-54.1* Monos-3.1 Eos-1.9 Baso-0.3 PT-14.0* PTT-28.8 INR(PT)-1.2* Glucose-226* UreaN-34* Creat-2.2* Na-132* K-3.9 Cl-95* HCO3-20* AnGap-21* On Discharge: WBC-3.2* RBC-2.60* Hgb-8.8* Hct-25.9* MCV-100* Plt Ct-100* PT-13.4 PTT-35.3* INR(PT)-1.1 Glucose-96 UreaN-33* Creat-1.9* Na-137 K-4.2 Cl-105 HCO3-22 AnGap-14 Cardiac Enzymes (CK-MB-TropT) [**2146-10-15**] 06:55PM 155-6-0.75 [**2146-10-16**] 01:18AM 158-9.7- 0.98 [**2146-10-16**] 06:35AM 172-8- 1.29 [**2146-10-16**] 11:57AM 158-7-1.19 [**2146-10-17**] 06:32AM 119-5-1.06 OTHER STUDIES EKG on [**2146-10-15**]: Sinus rhythm with Q waves in leads II, III and aVF consistent with inferior myocardial infarction of indeterminate age. ST segment coving in leads V3- with associated T wave inversions consistent with evolving anterior injury pattern. Multiple ventricular premature beats. No previous tracing available for comparison. CXR on [**2146-10-15**]: IMPRESSION: There is diffuse pulmonary edema. There is likely a right pleural effusion possibly a small left pleural effusion. A more consolidative process in the right lung base cannot be excluded. The heart appears relatively enlarged even accounting for patient and technical factors which would represent an acute change. Repeat radiography following appropriate diuresis is recommended to assess for underlying infection. Echocardiogram on [**2146-10-16**]: Conclusions The left atrium is mildly dilated. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity is moderately dilated. There is an inferolateral basal left ventricular aneurysm. There is severe regional left ventricular systolic dysfunction with akinesis of the mid to distal anterior septum, basal inferior and inferolateral segments, severe hypokinesis of the remaining segments with sparing of the basal septum. Overall left ventricular systolic function is severely depressed (LVEF= 15-20 %). Right ventricular chamber size is normal. with depressed free wall contractility. The aortic root is mildly dilated at the sinus level. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. There is an anterior space which most likely represents a fat pad. IMPRESSION: Moderately dilated left ventricle with severe regional dysfunction consistent with ischemic heart disease (multivessel). Brief Hospital Course: 68 year old gentleman with history of coronary artery disease s/p MI as well as diabetes mellitus, peripheral vascular disease, and aplastic anemia presenting with chest pain. 1) NSTEMI/CAD: Given the patient's multiple risk factors and EKG changes he was diagnosed with presumptive ACS on arrival to the ED and thus was almost immediately given aspirin and beta blocker and started on nitroglycerine. His pain resolved after receiving NTG and never recurred. He was also started on heparin. After his first set of cardiac enzymes returned positive the on-call cardiology fellow was contact[**Name (NI) **] and made aware of the patient. S/he recommended against epifibatide given the patient's thrombocytopenia and indicated that the patient did not need urgent cathterization. The patient was admitted to the cardiology service with plan for cardiac catheterization in the next 24-48 hours. The patient was then transferred to CCU for sustained VT (see below). Repeat cardiac enzymes continued to show flat CK's and echo showed significant wall motion abnormalities suggesting this was a subacute presentation of a myocardial infarction. This indicated less benefit from immediate catheterization and given development of decompensated heart failure and need for intubation (see below) as well as acute renal failure the decision was made to postpone catheterization until after kidney function had normalized. The patient will also have stress perfusion study prior to catheterization as echocardiogram findings are consistent with diffuse CAD and this testing could suggest minimal benefit from PTCA and drive management toward a surgical strategy. The [**Hospital 228**] medical regimen for CAD was optimized during this hospitalization with addition of aspirin, clopidogrel, and statin. The dose of statin was modified for concurrent cyclosporine use. He will follow up with Dr. [**Last Name (STitle) 911**] in cardiology clinic. 2) Dysrrthymia: During his first night in the hospital the patient had a run of sustained ventricular tachycardia while resting comfortably and being monitored on telemetery. His blood pressure decreased from SBP's in the 140's to SBP's in the 110's, but Mr [**Known lastname 37430**] remained completely asymptomatic during this episode. Given concern this was possibly ischemia related VT, he was started on a lidocaine drip with resolution of his VT to NSR in a matter of one to two minutes. He was then transferred to the CCU for further management. In the CCU the patient was monitored on telemetry and stayed primarily in NSR with occasional incidents of NSVT that decreased in frequency over the course of his hospital stay. He was seen by EP, who thought given this was monomorphic VT with history of MI and hypo/akinetic apex this was most likely scar mediated VT. The plan was made to do a VT ablation at the same time of cardiac catheterization for revascularization. Cardiac cathterization was canceled for the reasons described above but the electrophysiology service decided to proceed with the ablation and took the patient to the cath lab. Unfortunately, during this procedure after receiving blood products and put in a supine position he became quite short of breath and hypoxic and was electively intubated for respiratory ditress. The VT ablation was unsuccessful and the patient was managed medically from that point forward. Given the decreased incidence of NSVT over the course of his hospitalization the electrophysiology service did not recommend continuing anti-arrythmic therapy with anything but beta blocker. 3) Acute Systolic Heart Failure: At the time of presentation the patient had crackles to auscultation of his lung bases bilaterally and an oxygen requirement. Given presumption of MI it was assumed he was in some degree of acute, decompensated heart failure and he had a brisk diuresis to a single dose of furosemide. Early in the morning following admission the patient had an echocardiogram showing severe LV dysfunction with an EF of 15-20%. Despite this, the patient had a stable respiratory status over the following day. He received one unit of blood with furosemide given at the same time and continued to have good oxygen saturations on a few liters of oxygen by nasal cannula. Unfortunately, the following day after receiving two liters of blood in the cath lab and being put in a recumbent position the patient had an acutely worsened respiratory status and had to be intubated due to respiratory compromise. He also became hypotensive briefly and returned to the CCU from the cath lab on small doses of dopamine, which were weaned off over the following hours without recurrence of hypotension. While he was intubated he was diuresed approximately two liters, which required a furosemide drip after an inadequate response to bolus furosemide doses. After this diuresis he was s extubated without incident and continued to self diurese another liter without further diuretic therapy. He maintained approximate euvolemia after this without further need for diuretics. Regarding chronic medical management of his heart failure, the patient was continued on his beta blocker. ACE inhibitor therapy was considered but held due to the patient's acute renal failure. He was started on Hydralazine and Isosorbide as a substitute regimen for afterload reduction with plan to start ACE inhibitor as an outpatient after renal function has improved to baseline. On discharge the patient has chronic heart failure given known reduced EF but was compensated without clinical signs of volume overload. 4) Acute renal failure on Chronic Kidney Disease: On presentation the patient's Cr was elevated to 2.2 from baseline of 1.6. Consideration was given to ATN versus poor perfusion due to acute decompensated heart failure versus cyclosporine toxicity. Cyclosporine level was found to be undetectable, but the first two diagnostic possibilities remained under consideration particularly as kidney function did not improve with initial heart failure management. Thus, the nephrology service was consulted. They examined the urinary sediment and found no granular casts suggesting ATN. This led to a presumptive diagnosis of prerenal failure due to poor systolic function and inadequate perfusion. As the patient's heart failure improved his Cr improved as well and after peaking at 2.6 it had fallen back to 1.9 at discharge. 5) Aplastic Anemia: On presentation the patient's hematocrit was approximately 27, which is his baseline. Over the next day, however, he fell to 25 and was given three units of blood in the hospital due to concern for anemia in the context of inadequate coronary perfusion. After these transfusions his hematocrit increased appropriately to 29 but then began to fall to around his baseline value of 26 at the time of discharge. The patient was also thrombocytopenic with relatively stable platelet counts of 70 to 100 during his hospitalization. His cyclosporine was held in the hospital due to concerns over his acute renal failure but restarted at the time of discharge. He will follow up with his regular hematologist, Dr. [**Last Name (STitle) 6944**]. 6) Diabetes Mellitus: The patient was maintained on sliding scale insulin in the hospital with reasonable control of his blood glucose. 7) Peripheral Vascular Disease: The patient is status post multiple peripheral vascular interventions with multiple bruits appreciated on physical exam. Following his attempted percutaneous VT ablation he was found to have a cold, pulseless left foot that became mottled during the period there was a sheath in place. This exam improved with better color following sheath removal but pulses could still not be found with doppler. Vascular surgery was consulted and chose to monitor given no signs of active ischemia and over the next day pulse returned and at discharge patient's foot at baseline with dopplerable but not palpable pulses. During this hospitalization Mr. [**Known lastname 37430**] was started on aspirin, clopidogrel, and statin therapy for his CAD, but these medical measures should also help manage his PVD. Mr. [**Known lastname 37430**] was fed a cardiac, heart healthy diet in the hospital. He was kept on subcutaneous heparin for DVT prophylaxis. He was full code. Medications on Admission: Folic Acid 1 mg PO daily Metoprolol Tartrate 50 mg PO BID Neooral 50 mg PO QAM and 25 mg PO QPM Nifedipine ER 30 mg PO daily Discharge Medications: 1. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 5. Isosorbide Dinitrate 20 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day). Disp:*270 Tablet(s)* Refills:*2* 6. Hydralazine 25 mg Tablet Sig: One (1) Tablet PO every eight (8) hours. Disp:*90 Tablet(s)* Refills:*2* 7. Metoprolol Tartrate 50 mg Tablet Sig: 1.5 Tablets PO BID (2 times a day). Disp:*90 Tablet(s)* Refills:*2* 8. Neoral 25 mg Capsule Sig: Three (3) Capsule PO once a day: Please take two tablets each morning and one tablet each afternoon. . Disp:*90 Capsule(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Acute Systolic Congestive Heart Failure Acute Kidney Injury on Chronic Kidney Disease Hypertension Ventricular tachycardia Aplastic Anemia Discharge Condition: Good, pain free, adequate O2 Sats on room air Discharge Instructions: You had strain on your heart and an irregular heart rhythm called ventricular tachycardia. You had a procedure to try to prevent the ventricular tachycardia but had an acute episode of congestive heart failure during the procedure. You were intubated and on a ventilator to help you breathe. Your kidneys were not working well because of your heart but now are getting better. Your heart is weak and not pumping as well as it should. Please weigh yourself every day in the morning before eating and call Dr. [**Last Name (STitle) 911**] is you have a weight gain of more than 3 pounds in 1 day or 6 pounds in 3 days. Please also avoid salt in your diet, you should not eat more than 2000mg per day. . You need to have a stress test in 2 weeks and see Dr. [**Last Name (STitle) 911**] in 6 weeks. The cardiovascular clinic will call you about setting up this appointment with Dr. [**Last Name (STitle) 911**]. You also should have cardiac rehabilitation that will help your heart be as strong as it can be. . Please stop smoking. Information was given to you on admission regarding smoking cessation. Followup Instructions: Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD/[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5717**], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2146-11-23**] 1:30. [**Hospital Ward Name 23**] Clinical Center . Cardiology: Stress Test: Date/Time: Tuesday [**11-8**] at 9:50am. [**Hospital Ward Name 23**] Building [**Location (un) **] radiology department. No caffeine 12 hours before, no food or drink after midnight on [**11-7**]. . Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2908**], MD Phone:[**Telephone/Fax (1) 62**] Date/Time: [**12-2**] at 11:20am. You should call the office after you are home and they have promised to get you an earlier appt. . Please follow up with podiatry, call for an appointment [**Telephone/Fax (1) 67765**] [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2908**] MD, [**MD Number(3) 2909**]

[ "584.9", "410.71", "428.21", "428.0", "403.90", "585.9", "284.9", "518.81", "250.00", "427.1", "425.4", "276.1" ]

icd9cm

[ [ [] ] ]

[ "37.34", "37.27", "96.71" ]

icd9pcs

[ [ [] ] ]

16249, 16307

6897, 15228

329, 399

16490, 16538

4274, 4307

17688, 18649

3091, 3195

15403, 16226

16328, 16469

15254, 15380

16562, 17665

3210, 3210

4561, 6874

279, 291

427, 2309

4321, 4547

2331, 2716

2732, 3075

21,401

160,415

11923

Discharge summary

report

Admission Date: [**2176-6-19**] Discharge Date: [**2176-7-8**] Date of Birth: [**2104-3-31**] Sex: M Service: CARDIOTHORACIC Allergies: Penicillins Attending:[**First Name3 (LF) 1267**] Chief Complaint: Asymptomatic, known type B Aortic Dissection Major Surgical or Invasive Procedure: [**2176-6-20**] Repair of the Ascending Aortic and Arch Aneurysm with 28 mm Dacron graft (Gelweave) History of Present Illness: Mr. [**Known lastname 37557**] is a 72 year old male who developed an enteric vesiculocutaneous fistula following a prostate resection several months ago. He was found on evaluation to have a chronic Type B aortic dissection, with a 6 cm ascending aortic aneurysm. Chest CTA in [**2176-5-9**] revealed an unchanged Type B aortic dissection. He has a history of coronary artery disease with a prior MI back in [**2165**]. An echocardiogram in [**2176-3-9**] showed no aortic insufficiency, normal left ventricular function and only trivial mitral regurgitation. On admission, he denied chest pain, dyspnea, snyncope, abdominal symptoms, or back pain. His ostomy site is on the left and a foley catheter remains in place. The plan is for cardiac catheterization prior to cardiac surgical intervention. Past Medical History: Ascending Aortic Aneurysm with Chronic type B aortic dissection Hypertension Coronary Artery Disease, prior MI Hypercholesterolemia BPH, Prostate Cancer - s/p Prostatectomy Colon Cancer, Rectourethral Fistula - s/p Transverse Loop Colostomy History of Diverticulosis HTN, hyperlipidemia, Diverticulitis ([**10-13**]), h/o MI ('[**69**]) h/o colon cancer, prostate ca Social History: Quit tobacco over 60 years ago. Drinks 1-2 beers per week, denies history of ETOH abuse. Currently lives with his wife. [**Name (NI) **] is retired. Family History: Denies premature CAD Physical Exam: Vitals: BP 122/63, HR 45, RR 14, General: well developed male in no acute distress HEENT: oropharynx benign, Neck: supple, no JVD, no carotid bruits Heart: regular rate, normal s1s2, no murmur or rub Lungs: clear bilaterally Abdomen: soft, nontender, normoactive bowel sounds Ext: warm, 1+ edema bilaterally, no varicosities Pulses: 2+ distally Neuro: nonfocal Pertinent Results: [**2176-6-19**] 03:30PM BLOOD WBC-5.8 RBC-4.27* Hgb-12.7* Hct-36.0* MCV-84 MCH-29.7 MCHC-35.2* RDW-15.1 Plt Ct-233 [**2176-7-7**] 06:21AM BLOOD WBC-6.8 RBC-3.54* Hgb-9.8* Hct-28.6* MCV-81* MCH-27.8 MCHC-34.5 RDW-15.2 Plt Ct-451* [**2176-7-7**] 06:21AM BLOOD PT-19.3* PTT-37.4* INR(PT)-1.8* [**2176-7-6**] 05:49AM BLOOD PT-20.6* PTT-39.3* INR(PT)-2.0* [**2176-6-19**] 03:30PM BLOOD Glucose-97 UreaN-11 Creat-0.8 Na-133 K-4.0 Cl-98 HCO3-25 AnGap-14 [**2176-7-7**] 06:21AM BLOOD Glucose-94 UreaN-19 Creat-0.8 Na-131* K-4.0 Cl-97 HCO3-24 AnGap-14 [**2176-7-4**] 09:00PM BLOOD Mg-2.2 [**2176-6-19**] 03:30PM BLOOD Triglyc-67 HDL-47 CHOL/HD-2.9 LDLcalc-74 [**2176-7-7**] 06:21AM BLOOD WBC-6.8 RBC-3.54* Hgb-9.8* Hct-28.6* MCV-81* MCH-27.8 MCHC-34.5 RDW-15.2 Plt Ct-451* [**2176-7-7**] 06:21AM BLOOD Plt Ct-451* [**2176-7-7**] 06:21AM BLOOD Glucose-94 UreaN-19 Creat-0.8 Na-131* K-4.0 Cl-97 HCO3-24 AnGap-14 [**2176-7-5**] 08:59AM BLOOD Glucose-112* UreaN-17 Creat-0.8 Na-131* K-4.4 Cl-99 HCO3-23 AnGap-13 [**2176-7-5**] 08:59AM BLOOD Glucose-112* UreaN-17 Creat-0.8 Na-131* K-4.4 Cl-99 HCO3-23 AnGap-13 [**2176-7-6**] 05:49AM BLOOD Glucose-85 UreaN-19 Creat-0.8 Na-132* K-4.2 Cl-98 HCO3-23 AnGap-15 [**2176-7-5**] 06:41AM BLOOD Glucose-84 UreaN-16 Creat-0.9 Na-132* K-4.6 Cl-99 HCO3-22 AnGap-16 Brief Hospital Course: Mr. [**Known lastname 37557**] was admitted and underwent routine preoperative evaluation which included cardiac catheterization. Cardiac cath on [**6-19**] revealed a right dominant system. The LAD had diffuse disease with distal 70% percent stenosis. The LCX was very small and had a proximal 70% lesion. RCA was large and extremely ectatic with diffuse 50% disease throughout. There was a small PDA branch with a 60% stenosis. Left ventriculogram was deferred and limited hemodynamic assessment showed normal systemic aortic pressures. Preoperative evaluation was also remarkable for a positive urinalysis for which empiric antibiotics were started. Dr. [**Last Name (STitle) **] reviewed the coronary angiogram and felt that his coronary artery disease was non-obstructive and did not merit revascularization. Workup was otherwise uneventful and he was cleared for surgery. On [**6-20**], Dr. [**Last Name (STitle) **] performed replacement of his ascending aorta and hemiarch with a 28mm Dacron graft. This required 17 minute circulatory arrest time. For further surgical details, please see seperate dictated 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 complication. He maintained good hemodynamics and transferred to the SDU on postoperative day two. His postoperative course was complicated by postoperative confusion, hyponatremia, and atrial fibrillation. He remained in a rate controlled atrial fibrillation throughout his hospital stay. Warfarin anticoagulation was initiated and dosed for a goal INR between 2.0 - 3.0. Due to persistent confusion, he required one-on-one observation for safety. The neurology and psychiatry services were consulted, attributing his delirium to surgical/toxic/metabolic etiology rather than embolic. There was no evidence of infectious etiology. To rule out embolic etiology, a head CT scan was obtained which found no evidence of infarction or hemorrhage. The renal service was concomitantly consulted to assist in the management of his persistent hyponatremia. With fluid restriction and salt supplementation, his hyponatremia slowly improved. Unfortunately, postoperative delirium continued to persist. He was seen by occupational therapy who felt that he was safe to go home with supervision. Case management spoke with his family who felt that he has experienced post op delerium in the past and that he improved with discharge home, they also relayed that he would have supervision, that his wife is competent and that she has a nurse who visits the house for her medical issues. Medications on Admission: Aspirin 81 qd, Atenolol 50 qd, Lipitor 20 qd, Zantac 150 [**Hospital1 **], Lisinopril 5 qd, Lasix 20 qd, Norvasc 10 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. Atorvastatin 20 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:*30 Capsule(s)* Refills:*0* 4. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily). Disp:*30 tabs* Refills:*0* 5. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 6. Coumadin 1 mg Tablet Sig: One (1) Tablet PO once a day: Adjust dose based on INR value. Disp:*30 Tablet(s)* Refills:*2* 7. Erythromycin 5 mg/g Ointment Sig: One (1) Ophthalmic TID (3 times a day) for 5 days. Disp:*QS 5 days* Refills:*0* 8. 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:*0* Discharge Disposition: Home With Service Facility: North Country Home Care Discharge Diagnosis: Chronic Type B aortic dissection and Ascending aortic aneurysm - s/p repair, Post-op Atrial Fibrillation, Coronary Artery Disease, Hypertension, Hypercholesterolemia, Post-op delirium - improved Discharge Condition: Good Discharge Instructions: Call your doctor or go to the ER if you experience any of the following: severe pain, increasing nausea/emesis, fevers >101.5, shortness of breath, pus from your wound, or any other concerning symptoms. Do not drive while taking narcotics. Follow-up with your PCP regarding Warfarin dose and INR checks. Warfarin should be adjusted for goal INR between 2.0 - 3.0. Followup Instructions: 1. Dr. [**Last Name (STitle) **] - call for an appointment [**Telephone/Fax (1) 170**] 2. Local cardiologist in [**12-11**] weeks - call for appt 3. Local PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] on [**2176-7-10**] @ 130 PM [**Telephone/Fax (1) 31592**] for coumadin follow up Completed by:[**2176-7-10**]

[ "427.31", "562.10", "997.1", "401.9", "414.01", "293.9", "V10.05", "412", "272.0", "V44.3", "276.1", "V10.46", "272.4", "441.01" ]

icd9cm

[ [ [] ] ]

[ "99.04", "39.61", "38.45", "37.22", "88.56", "38.93" ]

icd9pcs

[ [ [] ] ]

7379, 7433

3557, 6212

322, 423

7672, 7679

2244, 3534

8091, 8421

1825, 1847

6381, 7356

7454, 7651

6238, 6358

7703, 8068

1862, 2225

238, 284

451, 1252

1274, 1643

1659, 1809

15,052

193,683

50997

Discharge summary

report

Admission Date: [**2101-8-24**] Discharge Date: [**2101-8-30**] Date of Birth: [**2050-5-16**] Sex: M Service: C-MED HISTORY OF PRESENT ILLNESS: This is a 51-year-old male with multiple medical problems including cocaine abuse, dilated cardiomyopathy, biventricular heart failure with an ejection fraction of approximately 20%, severe mitral regurgitation, substance abuse, etcetera, who was initially admitted to the C-MED Service on [**2101-8-24**], with increased dyspnea, acute renal failure, and mild transaminitis. The patient initially attempted diuresis for congestive heart failure without improvement. MEDICATIONS ON ADMISSION: Amiodarone 200 mg p.o. q.d., digoxin 0.125 mg p.o. q.o.d., Lasix 80 mg p.o. b.i.d., Zestril 20 mg p.o. q.d. HOSPITAL COURSE: On hospital day two was transferred to the Coronary Care Unit secondary to acute mental status changes for PEG placement for improved hemodynamic monitoring. Psychiatric and Renal Services were consulted. In the Coronary Care Unit PEG placement was unsuccessful, but the patient was gently rehydrated with improved urine output, decreased creatinine, improved blood pressure. Urinalysis, microscopic examination, by renal team revealed muddy brown cast consistent with acute tubular necrosis. Renal toxic medications (ACE inhibitor) were initially started gently once the patient became euvolemic with normalized renal function. At the request of the Psychiatric Service, a delirium workup was completed. The patient was without evidence of obvious etiology other than uremia. Symptoms improved markedly with hydration. The patient did not have any evidence of heroine withdrawal. The patient was transferred back to the C-MED Service for continued medical management and discharge. MEDICATIONS ON DISCHARGE: 1. Lasix 40 mg p.o. b.i.d. 2. Zestril 20 mg p.o. q.d. 3. Amiodarone 200 mg p.o. q.d., 4. Digoxin 0.125 mg p.o. q.o.d. DISCHARGE STATUS: Discharge status was to home. CONDITION AT DISCHARGE: Condition on discharge was stable. PHYSICAL EXAMINATION: Temperature 96.5, heart rate 80, blood pressure 100/60, respirations 24, 98% on room air. Sitting up, no shortness of breath, good mental function. Lungs were clear to auscultation bilaterally. No crackles or wheezes. Heart revealed S1/S2, regular, a 3/6 systolic murmur at the apex. Abdomen was soft and nontender, with bowel sounds. Extremities had no edema. [**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) **] Dictated By:[**Name8 (MD) 105955**] MEDQUIST36 D: [**2101-9-18**] 21:45 T: [**2101-9-20**] 19:05 JOB#: [**Job Number **]

[ "070.51", "304.20", "584.9", "304.00", "428.0", "293.0", "276.5", "425.4", "593.9" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

1805, 1988

660, 769

787, 1779

2062, 2648

2003, 2039

163, 632

51,203

138,532

25034

Discharge summary

report

Admission Date: [**2147-5-4**] Discharge Date: [**2147-5-9**] Date of Birth: [**2087-5-24**] Sex: F Service: MEDICINE Allergies: Gemfibrozil / Ranitidine / Aloe Attending:[**First Name3 (LF) 22401**] Chief Complaint: rigors, malaise Major Surgical or Invasive Procedure: LIJ insertion History of Present Illness: Patient is a 59 yo f with DM 2, HTN, diabetic neurogenic osteoarthropathy foot who presents for fever/chills at home, nausea and generalized malaise since monday. On monday she had a podiatric procedure with removal of macerated hypertrophied tissue and slight extension of ulcer margins on left chronic neuropathic ulcer. Denies diarrhea, last bm yesterday. Patient did have fatigue, decreased po's, headaches, "bone" pain, increased bg as high as 500. Denies diarrhea, urinary sx. Past Medical History: 1-DM 2 since [**2133**] on orals, followed by [**Last Name (un) 387**] but mostly by Dr. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], last aic 6.2, gets yearly eye exams 2-HTN 3-rheumatic fever at age 7 or 8 4-hypercholesterolemia 5-CAD nl ef, last cath [**11-26**]- complex disease of lad/d1, significant disease of ramus Social History: hx of domestic violence, denies smoking, drinking, lives alone, daugher helps as she is chair bound since [**1-27**] (due to charcot feet) previously worked part time in flower shop Family History: family hx of CAD, no dm or charcot Physical Exam: PE: Tm 97.5 BP 96/50 P 82 O2 98% RA Gen: no resp distress, shivering HEENT: perrla, eomi, mm dry, neck supple, bleeding IJ site Lungs: cta x 2 Heart: 2/6 sem, s1 s2 no m/r/g Abd: obese, mildly tender diffusely, +bs Ext: 1+ edema, bilateral foot deformities, ulcer on left foot with drain, black area(foam per podiatry consult), clean ulcer on right foot. warm feet b/l, decreased sensation to light touch skin: no rashes rectal: guaiac neg Pertinent Results: [**2147-5-4**] 10:46PM LACTATE-1.0 [**2147-5-4**] 09:30PM CORTISOL-37.3* [**2147-5-4**] 08:00PM URINE HOURS-RANDOM CREAT-22 SODIUM-105 POTASSIUM-27 [**2147-5-4**] 08:00PM URINE OSMOLAL-364 [**2147-5-4**] 08:00PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.008 [**2147-5-4**] 08:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [**2147-5-4**] 07:52PM HGB-9.2* calcHCT-28 O2 SAT-70 [**2147-5-4**] 07:33PM GLUCOSE-102 UREA N-23* CREAT-0.7 SODIUM-141 POTASSIUM-4.5 CHLORIDE-110* TOTAL CO2-18* ANION GAP-18 [**2147-5-4**] 07:33PM ALT(SGPT)-11 AST(SGOT)-14 LD(LDH)-121 ALK PHOS-70 AMYLASE-170* TOT BILI-0.2 [**2147-5-4**] 07:33PM LIPASE-19 [**2147-5-4**] 07:33PM ALBUMIN-3.4 CALCIUM-7.7* PHOSPHATE-2.8 MAGNESIUM-1.5* URIC ACID-3.3 [**2147-5-4**] 07:33PM CORTISOL-18.7 [**2147-5-4**] 07:33PM HCT-26.0* [**2147-5-4**] 05:24PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.005 [**2147-5-4**] 03:42PM LACTATE-1.1 [**2147-5-4**] 03:42PM HGB-8.9* calcHCT-27 [**2147-5-4**] 03:17PM LACTATE-1.7 [**2147-5-4**] 12:29PM NEUTS-88.7* BANDS-0 LYMPHS-7.7* MONOS-2.4 EOS-0.5 BASOS-0.6 [**2147-5-4**] 12:29PM HYPOCHROM-NORMAL ANISOCYT-1+ POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL [**2147-5-4**] 12:29PM PT-13.4* PTT-31.6 INR(PT)-1.2* [**2147-5-4**] 12:29PM PLT SMR-NORMAL PLT COUNT-378. Imaging: CT LLE [**5-4**]: New severe ulceration of the left foot with extension of gas down to bone. Extensive destructive changes are seen adjacent to this local area of gas that were present on prior study, however, given ulceration, gas and soft tissue swelling, these findings are concerning for osteomyelitis. Within the right ___destructive changes are present, however, no significant ulcer and gas formation is identified. If there is further clinical concern, recommend MRI. . CXR [**5-4**]: IMPRESSION: 1. Left IJ catheter with tip in mid SVC. 2. No pneumothorax. 3. Mild opacification at right medial lung base may represent atelectasis versus pneumonia. Lateral film is recommended for further evaluation. . Echo [**5-5**]: mild LAE, mild LVH, EF 60-65%, 2+TR, mod [**Last Name (un) 6879**] (35-55), no effusion, no vegetations Brief Hospital Course: Briefly, this is a 59 yo f with DM 2, HTN, diabetic neurogenic osteoarthropathy foot who presented with c/o fever, nausea, and malaise for several days PTA. On 4 days PTA pt had a podiatric procedure with removal of macerated hypertrophied tissue and slight extension of ulcer margins on left chronic neuropathic ulcer. Following that she experienced increased L foot pain. The following day she developed nausea and fatigue. On the morning of admission the pt awoke with rigors and temp of 104. Her FS was also up to 500. On admission the pt was hypotensive to 54/38 with a lactate of 2.6. She was started on Cefepime, Vanc, and Flagyl to cover possible osteo. In the MICU, the pt was started on levophed gtt which was weaned off the same day. She was also hydrated with 8 L NS. CT of the pts LLE revealed gas down to the pts L foot bone with destructive changes and ulceration likely c/w osteomyelitis. The pt was seen by podiatry who feels the CT changes may be c/w either osteo or charcot foot given no signs of infection on exam. The pt also was noted to be in ARF, which improved prior to transfer to the floor. She was found to have [**4-25**] blood cx growing MSSA, and foot cx grew MSSA as well. . #s/p sepsis: The most likely source was the pts foot ulcer, which has grown MSSA and pseudomonas in the past. The also has [**2-25**] blood cultures from [**5-4**] growing MSSA. Her abdominal pain resolved, and TTE was negative on [**5-5**] for any vegetations. Following tranfer to the floor, the pts blood pressure remained stable. She was initially continued on cefepime, vanco, flagyl to cover for potential pseudomonas, staph, and anaerobes in a possible diabetic foot osteo (started [**5-4**]). Per podiatry, the changed seen on the CT of the pts L foot could be consistent with either osteo or Charcot foot. The pt is to have reconstruction of her Charcot foot in several months. She was taken for debridement of her L foot and bone cultures were sent. . #L foot ulcer: The pt was followed by podiatry. CT of the L foot revealed ulceration, gas and soft tissue swelling concerning for osteomyelitis. Per podiatry, these changes also could be consistent with Charcot foot. Her ulcer has grown MSSA and pseudomonas in the past, so she was initially covered with cefepime, vanc, and flagyl. The podiatry team followed very closely, and determined that she was clinically improving, with well-appearing granulation tissue forming, and could e dishcarged on oral antibiotics (levaquin) to be continued until her reconstruction and follow up the following week. . #CARD/HTN/hyperlipidemia: She was continued on her ASA, plavix, statin, and eventually her metoprolol and lisinopril were restarted. She was normotensive on discharge. . #[**Doctor First Name 48**]: Pts Cr on admission was 1.3, which decreased to 0.7 after 8 L of fluids. Likely was prerenal in etiology. Baseline Cr was 0.6. She maintained good urine output during the admission. . #DM: The pts home po medications were held in the setting of sepsis, but these were restarted following transfer to the floor. She had decent glycemic control while in the hospital. . #Anemia: The pts hct was 31 on admission and dropped to 23-24 on subsequent days. This was felt to be due to bleeding from her central line site and fluid resuscitation. She was guaiac negative, and her hct then remained stable. Medications on Admission: Allopurinol 350 mg po qd Ativan 2 mg qhs Flexeril 10 mg [**Hospital1 **] Zocor 80 mg qd Lisinopril 5 mg qd ASA Tums Glucophage 850 mg qam, 500mg XR qpm Atenolol 25 mg qd Glipizide 10 [**Hospital1 **] AMbien Plavix 75 Elavil 25 qhs quinine 260 qhs prn Discharge Medications: 1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000) units Injection Q8H (every 8 hours). 4. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 5. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily). 6. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO BID (2 times a day). 7. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 8. Allopurinol 300 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 9. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Glipizide 10 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 11. Mupirocin Calcium 2 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day). 12. Cyclobenzaprine 10 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 13. Quinine Sulfate 325 mg Capsule Sig: One (1) Capsule PO HS (at bedtime) as needed. 14. Insulin Regular Human 100 unit/mL Solution Sig: One (1) unit Injection ASDIR (AS DIRECTED). 15. Zinc Sulfate 220 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 16. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO QHS (once a day (at bedtime)). 17. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed. 18. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed. 19. Ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed. 20. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 21. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 22. Metformin 850 mg Tablet Sig: One (1) Tablet PO QAM (once a day (in the morning)). 23. Metformin 500 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO QPM (once a day (in the evening)). 24. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 25. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours): Please take until directed to stop by your podiatrist. Disp:*30 Tablet(s)* Refills:*0* 26. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Disposition: Home With Service Facility: [**Hospital1 1559**] Home Care Discharge Diagnosis: Sepsis Diabetes Mellitus type 2 with complications, poorly controlled Charcot arthropathy Cellulitis of foot Hypertension SECONDARY Hyperlipidemia Coronary artery disease Discharge Condition: Good, ambulating, tolerating PO, afebrile Discharge Instructions: If you experience high fevers, shaking chills, chest pain, difficulty breathing, or any other concerning symtpom, please seek immediate medical attention. Please keep all follow up appointments. You should continue to take levofloxacin as ordered indefinitely until directed by podiatry. Followup Instructions: Provider: [**First Name11 (Name Pattern1) 5445**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 5446**], DPM Phone:[**Telephone/Fax (1) 543**] Date/Time:[**2147-5-15**] 1:10

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icd9cm

[ [ [] ] ]

[ "38.93" ]

icd9pcs

[ [ [] ] ]

10247, 10308

4220, 7618

307, 322

10523, 10567

1934, 4197

10905, 11094

1422, 1458

7920, 10224

10329, 10502

7644, 7897

10591, 10882

1473, 1915

252, 269

350, 840

862, 1206

1222, 1406

46,355

164,062

4474+55582

Discharge summary

report+addendum

Admission Date: [**2139-9-10**] Discharge Date: [**2139-9-21**] Date of Birth: [**2095-1-17**] Sex: M Service: SURGERY Allergies: Latex / Adhesive Tape Attending:[**First Name3 (LF) 5547**] Chief Complaint: left pelvic sarcoma Major Surgical or Invasive Procedure: 1. Left pelvic sarcoma removal, 2. Exploration of left iliac artery and vein. 3. Excision of left external iliac artery and vein. 4. Ligation of left external iliac vein. 5. Left iliofemoral bypass graft. 6. rectus flap closure on [**2139-9-11**]. History of Present Illness: Mr. [**Known lastname 1511**] is a 44-year-old gentleman who presented with a left groin mass this past [**Month (only) 547**] and was diagnosed with a large intermediate grade synovial sarcoma of the left pelvis extending through the femoral canal into the left groin. The mass measured up to 17 cm in size and appeared to nearly encase the external iliac artery and vein. Given the size, grade and vascular encasement of the tumor, I advised up-front neoadjuvant chemoradiation therapy to a total radiation dose of 5000 Gy with low-dose Adriamycin as a radiosensitizer. He had no evidence of metastatic disease on cross sectional imaging. He completed his treatment in early [**Month (only) **] and follow-up staging scans showed a decrease in size of the mass, but continued short-segment encasement of the external iliac artery and vein. I advised radical resection of the mass and asked Dr. [**Last Name (STitle) **] of vascular surgery to assist with possible resection of the left external iliac and common femoral artery and vein. In addition, I asked Dr. [**First Name (STitle) **] of plastic surgery to be available for likely myocutaneous flap reconstruction of the defect in the left groin. The patient understood the risks and benefits of the procedure and consented to proceed. Past Medical History: Synovial sarcoma: Approximately six months ago when he noted the development of increase in left leg swelling and a lump in his left groin. These symptoms have been intermittent but evolving over that time, with associated numbness on the lateral left thigh, mild weakness in hip flexion. His symptoms progressed and the patient presented at an outside emergency department on [**2139-4-17**]. He had significant left leg swelling at that time, and ultrasound revealed no clot. He then saw his primary care physician [**Last Name (NamePattern4) **] [**2139-4-24**]. He underwent MRI of the lumbar spine on [**2139-4-30**], which revealed a complex pelvic mass within the left side of the pelvis, partially visualized on the umbar spine study measuring approximately 8 cm. The mass is inseparable from the left psoas muscle. Further visualization was recommended. He underwent a pelvic ultrasound on [**2139-4-30**], which revealed an extraperitoneal 15.6 cm x 8 cm x 12.8 cm complex cystic and solid mass, which demonstrates internal vascularity in the pelvis. He then underwent biopsy of the left groin mass on [**2139-5-7**]. Pathology revealed a malignant spindle cell neoplasm, intermediate grade, most consistent with synovial sarcoma, predominantly monophasic type. The immunohistochemical stain for EMA is positive, while actin, desmin, cytokeratin cocktail, MNF-116, CD34 and S100 are negative. . Staging scans were obtained. CT of the head on [**2139-5-19**] revealed no evidence for metastatic disease. CT of the torso on [**2139-5-19**] revealed a large psoas mass extending in the upper mid to lower pelvis to the femoral triangle measuring approximately 10 x 17 cm and encasing the external iliac artery and vein, but with no other direct bone or organ invasion, local pelvic or distal metastasis. . He underwent his first 2 cycles of low-dose adriamycin and 5 sessions each week of XRT on [**4-8**], and [**Date range (1) 19159**]. Given the [**Hospital1 **] day holiday he underwent 4 sessions of XRT and a cycle of low-dose adriamycin on [**6-30**] - [**7-3**]. He completed his most recent cycle rom [**7-6**] to [**2139-7-10**] without complications. . PAST MEDICAL HISTORY: 1. Idiopathic Cardiomyopathy - (? steroid induced. Pt took steroids for bodybuilding). EF 30-35%, however most recent cardiac MRI showed improvement in heart structure and function with an EF of 50%. 2. Depression/anxiety 3. GERD 4. Chronic Sinusitis s/p minimal invasive endoscopic sinus surgery with middle meatal antrostomy and anterior ethmoidectomy ([**2131**]) 5. Asthma-exercise induced, wheezing worse w/cold weather, never been hospitalized for asthma 6. History of MRSA folliculitis with several I&Ds 7. Latent syphilis with initial RPR titer 1:2 8. HSV labialis . Social History: The patient lives with his parents in [**Hospital1 1559**] and is single. Denies smoking or alcohol use. He previously had used meth, no current drug use. He is currently unemployed. Family History: The patient's maternal grandmother died of colon cancer in her 60s. There are no other known cancers in the family. Physical Exam: At Discharge: Vitals: 98.8, 88, 120/64, 18, 96% on RA GEN: A/Ox3, NAD CV: RRR, no m/r/g RESP: CTAB, no w/r/r ABD: soft, ND, appropriately TTP, +BS, +flatus Incision: Left groin + flap OTA with sutures, CDI. Left and Right JP drains intact with moderate serosanguinous drainage. Extrem: bilateral lower extremity & pedal edema. +pulses. Wrapped with ACE bandages. Pertinent Results: Pathology Examination Procedure date [**2139-9-10**] DIAGNOSIS: I. Soft tissue, left groin, radical resection: 1. Sarcoma, high grade, consistent with synovial sarcoma, 15.6 cm, with therapy effect. See note. 2. Tumor is present at the medial ([**Location (un) 2452**]) inked margin (slide E), and is present less than 1 mm from the inferior (green) inked margin (slide O). 3. Approximately 10% of the sampled tumor shows coagulative-type necrosis. 4. Tumor thrombus present in a large vessel (slide D). II. Additional distal margin: Fibroadipose tissue with therapy effect. No definitive sarcoma seen; margins free of sarcoma. III. Nodal tissue, left groin: Four lymph nodes, no malignancy identified. Clinical: Sarcoma left pelvis and groin. . [**2139-9-10**] 02:45PM BLOOD WBC-5.9 RBC-3.15*# Hgb-9.7* Hct-27.2*# MCV-86 MCH-30.8 MCHC-35.7* RDW-13.3 Plt Ct-120*# [**2139-9-10**] 05:50PM BLOOD WBC-8.6 RBC-3.24* Hgb-9.8* Hct-27.5* MCV-85 MCH-30.2 MCHC-35.5* RDW-13.7 Plt Ct-147* [**2139-9-14**] 05:00AM BLOOD WBC-4.0 RBC-3.03* Hgb-9.2* Hct-26.3* MCV-87 MCH-30.3 MCHC-34.8 RDW-13.9 Plt Ct-121* [**2139-9-11**] 04:48AM BLOOD PT-12.1 PTT-26.2 INR(PT)-1.0 [**2139-9-10**] 11:38PM BLOOD Glucose-163* UreaN-11 Creat-0.8 Na-136 K-3.8 Cl-108 HCO3-22 AnGap-10 [**2139-9-16**] 07:19AM BLOOD Glucose-97 UreaN-10 Creat-0.7 Na-135 K-3.9 Cl-97 HCO3-32 AnGap-10 [**2139-9-10**] 11:38PM BLOOD Calcium-7.5* Phos-3.2 Mg-1.4* [**2139-9-16**] 07:19AM BLOOD Calcium-8.1* Phos-3.0 Mg-2.2 [**2139-9-11**] 04:48AM BLOOD Digoxin-0.4* . [**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 19160**] (Complete) Done [**2139-9-10**] at 11:43:19 AM FINAL Conclusions No atrial septal defect is seen by 2D or color Doppler. 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. Mild (1+) mitral regurgitation is seen. There is no pericardial effusion. . Pathology Examination Procedure date [**2139-9-10**] DIAGNOSIS: I. Soft tissue, left groin, radical resection: 1. Sarcoma, high grade, consistent with synovial sarcoma, 15.6 cm, with therapy effect. See note. 2. Tumor is present at the medial ([**Location (un) 2452**]) inked margin (slide E), and is present less than 1 mm from the inferior (green) inked margin (slide O). 3. Approximately 10% of the sampled tumor shows coagulative-type necrosis. 4. Tumor thrombus present in a large vessel (slide D). II. Additional distal margin: Fibroadipose tissue with therapy effect. No definitive sarcoma seen; margins free of sarcoma. III. Nodal tissue, left groin: Four lymph nodes, no malignancy identified. Clinical: Sarcoma left pelvis and groin. Brief Hospital Course: Mr. [**Known lastname 19161**] surgical procedure was prolonged due to complexity of pelvic mass. He was transferred to the ICU for monitoring due to his past history of cardiomyopathy, need for aggressive pain control, and extensive surgery. . Acute pain service was consulted immediately post-op. Pain managed with Ketamine drip & Fentanyl PCA. Pain control was optimized. Hemodynamic status stabilized. He was transferred to Stone 5 for post-op care. . Diet was advanced to regular food. Tolerated well. Medications switched to oral, re-started on pertinent home medications. Oral pain regimen initiated per Pain service recommendations (see medication section). Vitals and labwork remained stable during admission. Patient noted to have left heel soft tissue injury from prolonged bed rest. Managed with frequent activity, leg elevation, and cushion boot to prevent further compression of area. . Plastics service involved in managment of JP drains, incisional flap, and activity. Patient initially maintained on strict bedrest for 1 week. Advanced to activity as tolerated with minimal prolonged standing, and maintaining lower extremities elevated due to edema. Continued in antibiotics while drains in place. IV antibiotic course modified from Ancef to Zosyn due to appearance of flap with improvement. Discharged home with Duricef by mouth. Patient advise to continue course until JP drains are removed. Follow-up appointment scheduled for Friday [**2139-9-25**]. . Physical Therapy consulted. Patient intially deconditioned. Worked with PT multiple times during admission. Cleared for discharge home with no PT needs. . Arranged for patient to see [**Name (NI) **] [**Name (NI) 19162**], PT in [**Hospital 19163**] clinic today prior to heading home. . [**Hospital **] medical insurance not approved for VNA visit coverage. Case Management arranged for 2 free VNA visits. Patient was instructed regarding JP drain care. Medications on Admission: carvedilol 12.5''', digoxin 125, lasix 40'', neurontin 100, lisinopril 5, lorazepam 0.5-1 q4prn, morphine 15mg q4prn, percocet [**2-6**] q4prn, prochlorperazine 10 q6rn, ranitidine 150, viagra, aldactone 30, tramadol 50''', asa 325 Discharge Medications: 1. Duricef 500 mg Capsule Sig: One (1) Capsule PO twice a day: Continue while drains in place. Disp:*60 Capsule(s)* Refills:*2* 2. Carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 3. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation: Take with Morphine tablets. Disp:*60 Capsule(s)* Refills:*2* 7. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for anxiety. 10. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO Q12H (every 12 hours) as needed for constipation: Take with Morphine tablets. 11. Gabapentin 300 mg Capsule Sig: Three (3) Capsule PO TID (3 times a day). Disp:*270 Capsule(s)* Refills:*2* 12. Morphine 15 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain for 2 weeks. Disp:*45 Tablet(s)* Refills:*0* 13. Morphine 30 mg Tablet Sustained Release Sig: Two (2) Tablet Sustained Release PO TID (3 times a day) for 2 weeks. Disp:*84 Tablet Sustained Release(s)* Refills:*0* 14. Tylenol Extra Strength 500 mg Tablet Sig: 1-2 Tablets PO every six (6) hours as needed for pain for 2 weeks: Do not exceed 4000mg in 24hrs. 15. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home With Service Facility: [**Company 1519**] Discharge Diagnosis: Left pelvic sarcoma lower extremity lymph edema Discharge Condition: Stable Tolerating a regular diet Adequate pain control with oral Discharge Instructions: Please call your doctor or return to the ER for any of the following: * If you are vomiting and cannot keep in fluids or your medications. * You are getting dehydrated due to continued vomiting, diarrhea or other reasons. Signs of dehydration include dry mouth, rapid heartbeat or feeling dizzy or faint when standing. * You see blood or dark/black material when you vomit or have a bowel movement. * Your pain is not improving within 8-12 hours or not gone within 24 hours. Call or return immediately if your pain is getting worse or is changing location or moving to your chest or back. *Avoid lifting objects > 5lbs until your follow-up appointment with the [**Company 5059**]. *Avoid driving or operating heavy machinery while taking pain medications. * You have shaking chills, or a fever greater than 101.5 (F) degrees or 38(C) degrees. * Any serious change in your symptoms, or any new symptoms that concern you. * Please resume all regular home medications and take any new meds as ordered. . Activity: As tolerated. Minimize prolonged standing. Do not stand or keep lower extremities dependent (hanging/flexed) for more than 30mins at a time. Keep legs elevated when at resting. Keep legs wrapped with ACE bandage to thigh/groin to help manage swelling, . Incision Care: -Your sutures will be removed in [**2-6**] weeks at your follow-up appointment. -You may take quick showers, and wash surgical incisions. -Avoid swimming and baths until your follow-up appointment. -Please call the doctor if you have increased pain, swelling, redness, or drainage from the incision sites. . JP Drain Care: -Please look at the site every day for signs of infection (increased redness, swelling, odor, yellow or bloody discharge, fever). -Maintain the bulb deflated to provide adequate suction. -Note color, consistency, and amount of fluid in drain. Call doctor if amount increases significantly or changes in character. -Be sure to empty the drain frequently. -You may shower, wash area gently with warm, soapy water. -Maintain the site clean, dry, and intact. -Avoid swimming, baths, hot tubs-do not submerge yourself in water. -Keep drain attached safely to body to prevent pulling . Medication: 1. Duricef-is an antibiotic. Please continue taking this medication as prescribed. Continue while drains are in place. Dr. [**First Name (STitle) **], Plastic [**Last Name (LF) 5059**], [**First Name3 (LF) **] advise you further. Followup Instructions: 1. Please follow-up with Dr. [**Last Name (STitle) 1924**] [**Telephone/Fax (1) 7508**] in [**2-6**] weeks. 2. Please follow-up with Dr. [**First Name (STitle) **] (Plastics) ([**Telephone/Fax (1) 9144**] on Friday [**2139-9-25**] at 1:30pm [**Hospital Ward Name 23**] [**Location (un) 470**]. 3. Please follow-up with [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 19162**] [**Telephone/Fax (1) 19164**] in [**Hospital 19163**] clinic as indicated. 3. Please follow-up with Dr. [**Last Name (STitle) **] (Vascular) ([**Telephone/Fax (1) 8937**] in [**2-6**] weeks. 4. Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D. Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2139-9-24**] 10:00 Completed by:[**2139-9-21**] Name: [**Known lastname 3128**],[**Known firstname **] Unit No: [**Numeric Identifier 3129**] Admission Date: [**2139-9-10**] Discharge Date: [**2139-9-21**] Date of Birth: [**2095-1-17**] Sex: M Service: SURGERY Allergies: Latex / Adhesive Tape Attending:[**First Name3 (LF) 3130**] Addendum: left foot soft tissue injury- 3x3.5cm left achilles stage II ulcer- 3x2cm left posterior knee stage II split ulcer- 4cm long, non-measurable width Discharge Disposition: Home With Service Facility: [**Company 720**] [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3131**] MD [**MD Number(2) 3132**] Completed by:[**2139-9-21**]

[ "707.07", "707.22", "428.22", "425.4", "171.6", "707.09", "428.0" ]

icd9cm

[ [ [] ] ]

[ "39.25", "83.49", "83.82", "38.87", "38.66", "38.67" ]

icd9pcs

[ [ [] ] ]

16041, 16246

8275, 10206

301, 551

12212, 12279

5400, 8252

14754, 16018

4884, 5002

10489, 12048

12141, 12191

10232, 10466

12303, 13569

13584, 14731

5017, 5017

5031, 5381

242, 263

579, 1873

4088, 4665

4681, 4868

21,431

118,337

51319

Discharge summary

report

Admission Date: [**2140-9-22**] Discharge Date: [**2140-10-17**] Date of Birth: [**2083-6-22**] Sex: M Service: MED Allergies: Codeine / Prograf / Phenergan / Haldol Attending:[**First Name3 (LF) 348**] Chief Complaint: Left eye ptosis and change in mental status Major Surgical or Invasive Procedure: None History of Present Illness: 57 yo male with multiple medical problems including DM secondary to EtOH pancreatitis, ESRD on HD, multiinfarct dementia admitted for change in mental status and rt eye ptosis while rehabbing at [**Hospital1 **] after two week stay at [**Hospital1 18**] for change in mental status thought due to hypertensive encephalpathy. Stay was complicated by fever and hypotension and change in mental status which required MICU stay requring pressors and was covered with Zosyn and Vanco although no source ever found, and thought to be due to neuroleptic malignant syndrome. Pt was transferred to [**Hospital1 **] for rehab on [**9-8**] and was doing well until [**9-22**] when he was noticed to have left eye ptosis and altered mental status. In the ED he was hypertensive to 216 controlled with metoprolol and hydralazine. CT head was negative and LP showed lymphocytic pleocytosis and he was admitted to Neuro and treted with acyclovir and ceftriaxone. Pt admitted to MICU on [**9-24**] for becoming unresponsive thought to be multifactorial including hypoglycemia, meds, meningitis. Pt also developed LLL infiltrate and was treated with clindamycin. Pt was intubated due to inability to protect airway. MRI negative and EEG suggestive of encephalopathy but pt remained unresponsive off sedation but awoke on [**10-4**] and extubated on [**10-8**]. Follow up MRI and CT negative, and change in mental status thought due to microvascular brain stem infarction. Past Medical History: PMH: DM ESRD on HD DM due to etoh assoc pancreatitis s/p failed renal txplt ([**2133**]) HTN PVD s/p left and right toe amputation hx of DKA hx hypoglycemic seizure neuropathy ? UTI on cipro? hx DVT with PE Right tib-fib fx nonunion s/p external fixation GERD R AV graft Social History: lives at home with wife [**Doctor First Name **], [**Telephone/Fax (1) 106455**]). Was heavy drinker in past --> pancreatitis --> pancreatic insufficiency --> diabetes Family History: noncontrib Pertinent Results: [**2140-9-22**] 07:01PM CEREBROSPINAL FLUID (CSF) PROTEIN-175* GLUCOSE-61 [**2140-9-22**] 07:01PM CEREBROSPINAL FLUID (CSF) WBC-47 RBC-11* POLYS-1 LYMPHS-90 MONOS-8 EOS-1 [**2140-9-22**] 07:01PM CEREBROSPINAL FLUID (CSF) WBC-32 RBC-152* POLYS-0 LYMPHS-98 MONOS-2 [**2140-9-22**] 11:00AM GLUCOSE-153* UREA N-24* CREAT-4.3* SODIUM-141 POTASSIUM-5.6* CHLORIDE-103 TOTAL CO2-29 ANION GAP-15 [**2140-10-10**] 12:00PM BLOOD WBC-8.9 RBC-3.36* Hgb-10.5* Hct-34.5* MCV-103* MCH-31.2 MCHC-30.4* RDW-18.7* Plt Ct-283 [**2140-9-30**] 04:55AM BLOOD WBC-6.6 RBC-3.69* Hgb-11.3* Hct-35.9* MCV-97 MCH-30.5 MCHC-31.4 RDW-19.0* Plt Ct-364 [**2140-9-22**] 12:00AM BLOOD WBC-5.5# RBC-3.15* Hgb-9.5* Hct-31.2* MCV-99* MCH-30.3 MCHC-30.5* RDW-18.6* Plt Ct-270 [**2140-9-28**] 03:15AM BLOOD Neuts-51.0 Lymphs-32.5 Monos-9.1 Eos-7.2* Baso-0.3 [**2140-9-22**] 12:00AM BLOOD PT-17.1* PTT-39.7* INR(PT)-1.9 [**2140-9-28**] 03:15AM BLOOD PT-14.5* PTT-66.9* INR(PT)-1.3 [**2140-10-10**] 09:25AM BLOOD PT-18.1* PTT-41.6* INR(PT)-2.1 [**2140-10-16**] 11:35AM BLOOD WBC-7.7 RBC-3.21* Hgb-9.9* Hct-32.2* MCV-101* MCH-31.0 MCHC-30.8* RDW-17.8* Plt Ct-281 [**2140-10-15**] 07:40AM BLOOD Neuts-46.4* Lymphs-30.1 Monos-6.0 Eos-16.7* Baso-0.8 [**2140-10-16**] 05:10AM BLOOD PT-23.4* INR(PT)-3.5 [**2140-10-16**] 11:35AM BLOOD Glucose-172* UreaN-17 Creat-3.7* Na-143 K-5.4* Cl-108 HCO3-30* AnGap-10 [**2140-10-16**] 06:31PM BLOOD K-5.8* [**2140-10-16**] 11:35AM BLOOD Calcium-8.1* Phos-3.2 Mg-1.9 [**2140-10-13**] 11:35AM BLOOD HCV Ab-NEGATIVE Brief Hospital Course: Mr [**Known lastname 63715**] was admitted to the MICU for altered mental status and was consequently intubated for impending respiratory failure. 1. AMS/Coma: Upon admission, the patient had altered mental status with a left CNIII palsy and a right CNVI palsy. His lethargy increased and a lumbar puncture was pursued. A septic meningitis was discovered, but the etiology was not discovered (a broad diagnosis for this was considered, including vasculitis, Sarcoidosis, metastatic cancer and various infectious etiologies; CSF for various infections along with cytologies were lost in transit to lab - however, stroke was thought to better explain his symptom complex per Neurology and thus a repeat lumbar puncture was not pursued). Thus, he was diagnosed with an idiopathic meningoencephalitis. A CT and MRI of the head and brain were unrevealing for CNS pathology. However, microinfarctions of his brainstem were believed to be large contributing factor despite a normal MRI. His lethargy soon evolved into coma early in his course and the patient was unresponsive, without corneal reflexes, blinks to threat, sensory or motor function for two to three days off of sedation. He then regained function in a somewhat abrupt fasion. Over the period of 24 hours, he began to open his eyes to voice, blink to threat, move his extremities spontaneously, and then began to follow commands. By the time he was discharged from the MICU, he was alert and oriented to person, place and time and following commands with full strength and sensation. His cranial nerve palsies persisted. He was followed by the Neurology service along with the MICU team. Of note, there was an intial concern for epileptic activity, but this was dismissed by Neurology and the Dilantin commenced on admission was not continued. 2. Airway Protection: He as initially intubated on for decreased upper airway tone and AMS. Although he tolerated pressure support ventilation after he regained function after coma, he had intermittent apnea episodes. These decreased in frequency over his course. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 6055**]-[**Doctor Last Name **] was considered (but his respiratory tracings were not consistent with this) as well as more ominous pattern of brainstem dysfunctioning. Upon exutbation, after numerous successful spontaneous breathing trials, the patient did very well and remained comfortable on room air upon transfer to the medicine floor. 3. Hypothermia: Upon admission, and throughout his course, he had temperatures down to 91 degrees Farenheit. This did not seem related to hypoglycemia. It was considered secondary to brainstem dysregulation and/or hypoglycemia. He was continued on a warming blanket. An ECG did not show a prolonged QT interval. His temperature on the day of discharge was 96.8. 4. Anemia: His HCT remained stable in the low 30's. The etiology was likely secondary to EPO deficiency. He required one unit of PRBC for a HCT of 27 on admission, but his HCT remained stable in the low 30's thereafter. Of note, his stool was heme-negative throughout his MICU course. 5. CAD: He was contined on Clopidogrel Bisulfate 75 mg PO QD, Metoprolol 50 mg PO BID, Nitroglycerin SL 0.3 mg SL PRN, Aspirin 325 mg PO QD, and Atorvastatin 10 mg PO QD. 6. H/O RIJ Clot/DVT/PE: Once his HCT stablized, he was transitioned from heparin to Coumadin for an INR goal of [**1-26**]. 7. ESRD: He was followed by the Renal team and had hemodialysis three times per week. He is currently on a Tuesday, Thursday, Saturday schedule. 8. R ORIF: The patient had a [**12-25**] year old external fixation device on his right tibia for an old tibal fracture. It was removed to facilitate brain imaging with MRI. Follow-up with orthopaedics was arranged for his tibial non-[**Hospital1 **]. 9. Diarrhea: In the middle of his MICU course, he developped C. diff negative diarrhea. Given his recent antibiotics, and high-risk state, he was treated empirically with Flagyl for a seven day course. His diarrhea then improved. Of note, he was also started on an increased pancreatic enzyme dosing schedule. This may have also explained his improvement. Discharge Medications: 1. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO QD (once a day). 2. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO QD (once a day). 3. Acetaminophen 500 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. 4. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO QD (once a day). 5. Aspirin 325 mg Tablet Sig: One (1) Tablet PO QD (once a day). 6. Citalopram Hydrobromide 20 mg Tablet Sig: 0.5 Tablet PO QD (once a day). 7. Amylase-Lipase-Protease 30,000-8,000- 30,000 unit Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours). 8. Oxycodone HCl 5 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed for pain. 9. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 10. B-Complex with Vitamin C Tablet Sig: One (1) Tablet PO QD (once a day). 11. Warfarin Sodium 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime): Please hold this dose of coumadin on [**10-17**]. He needs his INR checked daily and his coumadin titrated to maintain INR between 2 and 3. 12. Insulin Glargine 100 unit/mL Solution Sig: Four (4) units Subcutaneous at bedtime: Please also see attached sliding scale sheet for insulin dosages to give with meals and at night. 13. Please monitor fingersticks. Can give D50 or oral glucose if blood sugar is low. Discharge Disposition: Extended Care Facility: [**Location (un) 29393**] - [**Location (un) 2251**] Discharge Diagnosis: Meningoencephalitis, multifactorial (hypoglycemia, viral infxn) CN palsies - L CN III, proptosis, R CN VI ESRD on HD t,th,sat DM2 Pancreatic insufficiency PVD Discharge Condition: Fair, stable. Discharge Instructions: Mr. [**Known lastname 63715**] has been on coumadin 5 mg QHS for history of RIJ clot, DVT, PE, with a very labile response. His coumadin should be held tonight, and INR should be checked daily (goal [**1-26**]). He should have dialysis Tues, thurs, Saturday. His blood sugar should be checked QID. It has been low in the past, but recently has normalized to 100-200. He has been on 4Units of lantus qhs, with sliding scale that will be included in these discharge papers. He may need the scale adjusted depending on how his blood glucose is doing - he tends to get low at night. Followup Instructions: Where: [**Hospital6 29**] ORTHOPEDICS Phone:[**Telephone/Fax (1) 5499**] Date/Time:[**2140-11-8**] 10:20 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2235**], MD Where: [**Hospital6 29**] ORTHOPEDICS Phone:[**Telephone/Fax (1) 1228**] Date/Time:[**2140-11-8**] 10:40 Patient should call to make an appointment with his PCP [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) 1356**] [**Last Name (NamePattern1) **] for next week at ([**Telephone/Fax (1) 1300**]. It is very important that he follow up with his PCP on [**Name Initial (PRE) **] regular basis to monitor his chronic medical conditions. Please contact his guardian as needed for medical decision making.

[ "577.8", "V58.67", "403.91", "323.8", "518.81", "437.0", "378.54", "290.40", "008.45", "453.8", "378.51", "434.91", "250.40", "250.30", "733.82", "285.21" ]

icd9cm

[ [ [] ] ]

[ "99.04", "96.6", "78.67", "96.04", "96.72", "39.95", "03.31" ]

icd9pcs

[ [ [] ] ]

9410, 9489

3892, 8063

338, 344

9692, 9707

2358, 3869

10340, 11055

2327, 2339

8086, 9387

9510, 9671

9731, 10317

255, 300

372, 1830

1852, 2125

2141, 2311

75,438

132,458

32038

Discharge summary

report

Admission Date: [**2102-3-16**] Discharge Date: [**2102-3-31**] Date of Birth: [**2042-12-12**] Sex: M Service: MEDICINE Allergies: Ciprofloxacin Attending:[**First Name3 (LF) 949**] Chief Complaint: Hepatic encephalopathy, iatrogenic pneumothorax, respiratory failure. Major Surgical or Invasive Procedure: Chest tube removal. Extubation. Ultrasound-guided paracentesis x2. PICC line placement. History of Present Illness: A 59 yo male with HCC and Hep C cirrhosis who was admitted to [**Hospital3 20284**] Center on [**3-7**] for respiratory failure in the setting of worsening hepatic ecephalopathy. He was intubated immediately on arrival in the OSH ED. He was subsequently diagnosed with a Klebsiella pneumonia, and broad-spectrum antibiotics were narrowed to Cefuroxime. He was extubated on [**3-10**], but subsequently reintubated for progressive hypoxic respiratory failure which failed NIPPV. His course was complicated by difficulties with IV access, and he sustained multiple failed attempts at PIV's, PICC's. An attempted at a CVL on [**3-11**] resulted in a left-sided pneumothorax. An emergent chest tube and left subclavian line were placed on [**3-12**] after discovery of the pneumothorax (likely the result of CVL attempt on [**3-11**]). He was transferred to the ICU at [**Hospital1 18**] for management of his ongoing medical issues. Past Medical History: 1. Hepatitis C cirrhosis, previously on transplant list but now off due to non-compliance. Hx IVDU 2. Multifocal hepatocellular cancer diagnosed in [**10-18**] on imaging which revealed two enhancing lesions within the liver: one in high dome of segment VII and the second was lateral to the bifurcation of the right portal vein. MRI [**2-/2101**] revealed four dominant arterially enhancing lesions with progression of at least one lesion. Underwent chemoembolization in [**2101-4-11**] and RFA [**4-19**]. At last follow-up in [**10-19**], was found to have new pulmonary nodule in RML, worrisome but not definitive for HCC met. No evidence of liver recurrence as of [**10-19**]. 3. Pneumonia in [**2078**] with prolonged admit, 2 pulmonary abscesses. 4. Lifelong smoker. 5. Mild COPD. 6. History of narcotic abuse. 7. GERD. Social History: Remote hx of EtOH use and IVDA. He is divorced with two grown children. He lives in [**Hospital1 189**] with his son. Previously he worked as a substance abuse counselor. His significant other is girlfriend [**Name (NI) 75025**]. Family History: Non-contributory. Physical Exam: VS: Tm 97.2 Tc 97.2 BP 101/70 HR 69 RR 20 SaO2 96%6L NC GEN: Alert, cachectic, NAD HEENT: Temporal wasting, no LAD or thyromegaly, flat jugulars CV: RR, tachycardic, NL S1S2 no S3S4 MRG, radial pulse 2+ bilat PULM: Ronchorous breathsounds ABD: Scattered telangectasias, no obvious collaterals, BS+, tense, distended, non-tender, no masses or hepatosplenomegaly on palpation LIMBS: Clubbing, 3+ LE edema NEURO: PERRLA but sluggish pupillary response, EOMI, moving all limbs, no asterixis Pertinent Results: Labs at Admission: [**2102-3-17**] 12:29AM BLOOD WBC-4.8 RBC-2.80* Hgb-9.4* Hct-27.9* MCV-100*# MCH-33.5* MCHC-33.6 RDW-19.4* Plt Ct-49* [**2102-3-17**] 12:29AM BLOOD Neuts-70.4* Lymphs-19.0 Monos-6.0 Eos-4.3* Baso-0.2 [**2102-3-17**] 12:29AM BLOOD PT-21.0* PTT-41.1* INR(PT)-2.0* [**2102-3-17**] 12:29AM BLOOD Glucose-81 UreaN-21* Creat-0.4* Na-144 K-4.2 Cl-115* HCO3-27 AnGap-6* [**2102-3-17**] 12:29AM BLOOD ALT-67* AST-134* AlkPhos-129* TotBili-3.2* [**2102-3-17**] 12:29AM BLOOD Albumin-1.6* Calcium-7.7* Phos-3.4 Mg-1.8 [**2102-3-17**] 12:29AM BLOOD AFP-3014* [**2102-3-16**] 11:48PM BLOOD Type-ART pO2-138* pCO2-36 pH-7.46* calTCO2-26 Base XS-2 . Micro Data: Urine culture ([**3-20**]): ENTEROCOCCUS SP. AMPICILLIN------------ =>32 R LINEZOLID------------- 2 S NITROFURANTOIN-------- 64 I TETRACYCLINE---------- =>16 R VANCOMYCIN------------ =>32 R . Pleural fluid ([**3-20**]): ENTEROCOCCUS SP. AMPICILLIN------------ =>32 R LINEZOLID------------- 2 S PENICILLIN G---------- =>64 R VANCOMYCIN------------ =>32 R . Blood cultures ([**3-20**]): [**1-13**] COAG NEGATIVE STAPH Blood cultures ([**Date range (1) 41174**]): NEGATIVE x5 Catheter tip culture ([**3-21**]): NEGATIVE . Studies: . CT Chest/Abdomen/Pelvis with contrast ([**3-21**]): 1. Cirrhosis with massive ascites, splenomegaly and varices. Ascites is much increased compared to [**2101-10-6**]. Main portal vein markedly narrowed, and right portal vein diminutive, without definite evidence of complete occlusion. 2. Patient is status post chemoembolization in the right hepatic lobe, with evidence of tumor extension of a segment VI lesion to the diaphragmatic/peritoneal reflection. 3. New 12 mm lesion in segment 3 and 7 mm lesion in segment 7 that are potentially concerning for new foci of HCC. Other multiple nodules with indeterminate features are unchanged. 4. Small-to-moderate bilateral pleural effusions with collapse of both lower lobes. Small left pneumothorax remains after removal of chest tube. Patchy right upper lobe opacities and bilateral nodular densities are as previously seen. Brief Hospital Course: He was initially admitted to the ICU where he was successfully extubated. Speech and swallow consult showed continuing aspiration. He was transferred to the medicine floor on [**3-17**]. His hospital course is listed by problem below: 1. Encephalopathy. This was presumed due to hepatic encephalopathy from non-compliance with lactulose at home. Upon admission, he was started on lactulose and rifaximin and started on tube feeds. With these interventions, his mental status gradually improved to his pre-admission baseline. After improvement in his mental status, he was re-evaluated by speech and swallow who cleared him for soft solid diet with thin liquids. He pulled out his feeding tube overnight, and it was felt as he was eating adequately, there was no need to replace the dobhoff tube. 2. Cirrhosis and Hepatocellular Carcinoma. He was found to have progression of hepatocellular carcinoma with an AFP of >3000 up from less than 200. A CT of his chest, abdomen, and pelvis was done to evaluate for progression of the hepatocellular cancer. As expected by the elevated AFP, the CT showed extension of the liver cancer to involve the capsule and diaphragm. In addition there were several new lesions visualized in the liver parenchyma. Thus he was no longer a surgical or transplant candidate. 3. Respiratory Distress. He was transferred from an OSH intubated in the setting of left-sided pneumothorax. As above, he was quickly weaned off the ventilator and extubated in the ICU. Upon transfer to the floor, bronchodilator nebs were continued for COPD. The left-sided chest tube (placed at outside hospital for pneumothorax) continued to drain large amounts of straw-colored fluid, and it was felt that this fluid was likely draining from his ascitic abdomen (via the diaphragm) down the path of least resistance to the pleural space. Thus we spoke with thoracics service and they agreed to remove the chest tube, as serial x-rays had demonstrated near complete resorption of the apical pneumothorax and it was clear the ascitic fluid would continue to accumulate in the pleural space. Follow-up chest x-rays after chest tube removal showed stable bilateral pleural effusions. Meanwhile, his respiratory status improved with diuresis and paracenteses such that at time of discharge, he is satting mid 90s on 2L. 4. Vancomycin Resistent Enterococcus UTI and SBP. Cultures from the pleural fluid (presumed to be draining from the peritoneal cavity) grew out vancomycin-resistent enterococcus. Meanwhile, urine cultures taken on the same day grew out VRE as well. Blood cultures were negative, with one positive coag negative staph culture likely representing a contaminant. Initially, while the urine and pleural fluid cultures were still pending sensitivities, he was kept on ceftriaxone for UTI and presumptive SBP. When the culture data returned, he was started on Daptomycin. A PICC line was placed so that he can complete a 14 day course on [**4-6**]. His mental status improved markedly on the combination of lactulose and rifaximin for hepatic encephalopathy and Daptomycin for VRE UTI and SBP. 5. Ascites and Lower Extremity Swelling (due to Cirrhosis). He underwent ultrasound-guided paracenteses x2 for total of 4.5 L fluid removal. The fluid culture was negative. After the procedure, he felt symptomatically much improved. His respiratory status also improved. He was restarted on Lasix and spironolactone for prevention of fluid reaccumulation. These should be continued for treatment of ascites and lower extremity swelling. In addition, he should be kept on a low sodium diet. For pain related to his ascites, we have been treating with morphine 15 mg twice daily. 6. Jaw Pain. He was complaining of intermittent jaw pain during the last few days of this admission. He was noted by nurses to grind his teeth during sleep. On exam there was no focal tenderness or jaw malalignment to suggest bone metastases or fracture. Oropharyngeal exam was remarkable for the absence of teeth (he has dentures). We felt the symptoms were consistent with TMJ dysfunction, and treated with low dose Flexeril as needed. With this treatment his symptoms improved. 7. Goals of Care. A meeting was held with family, primary hepatology team, and the palliative care service to address goals of care. It was agreed that we would continue to take measures to alleviate his pain and to treat the infections and complications from his end stage liver disease and hepatocellular cancer. However, he is no longer a transplant candidate due to the extension and size of HCC. His code status was initially DNR/DNI, but this was reversed prior to discharge. He is now full code. Medications on Admission: Lasix 40 mg daily Lactulose 30 cc 2-3x/day Lansoprazole 30 mg daily Morphine 15-30 mg q 4-6 hours PRN pain Seroquel 25 mg qHS Tiotropium 18 mcg daily MVI Discharge Medications: 1. Rifaximin 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 2. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours). 3. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q2H (every 2 hours) as needed. 4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 5. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Cyclobenzaprine 10 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as needed for jaw pain. 7. Miconazole Nitrate 2 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day). 8. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for anxiety. 9. Daptomycin 500 mg Recon Soln Sig: Four Hundred (400) mg Intravenous once a day: Please continue through [**4-6**]. 10. Spironolactone 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Morphine 15 mg Tablet Sig: One (1) Tablet PO Q 12H (Every 12 Hours): Hold for sedation or RR <12. 12. Lactulose 10 gram/15 mL Syrup Sig: 15-30 MLs PO TID (3 times a day): Titrate to [**3-15**] bowel movements per day. Discharge Disposition: Extended Care Facility: [**Hospital3 7**] & Rehab Center - [**Hospital1 8**] Discharge Diagnosis: Primary Diagnoses: Hepatic encephalopathy Spontaneous bacterial peritonitis Urinary tract infection . Seconday Diagnoses: Cirrhosis Hepatocellular carcinoma Discharge Condition: Vital signs stable. Satting well on 2L by nasal cannula. Mentating at baseline. Discharge Instructions: You were admitted to the hospital for treatment of confusion related to your liver disease. You were also found to have a urinary tract infection and an infection of the fluid in the abdomen. You were treated with antibiotics and medicines to help decrease intestinal absorption of toxins that cause confusion. With these interventions, your symptoms improved. Followup Instructions: Please follow-up with Dr. [**Last Name (STitle) 497**] in the liver clinic: [**Telephone/Fax (1) 2422**]. Completed by:[**2102-3-31**]

[ "287.5", "070.70", "284.1", "155.0", "070.71", "493.20", "041.04", "276.0", "530.81", "571.5", "518.89", "511.9", "567.23", "305.1", "599.0", "518.81", "524.69", "E879.8", "458.9", "789.59", "782.3", "V87.41", "512.1", "305.91", "572.3", "V66.7", "V12.71" ]

icd9cm

[ [ [] ] ]

[ "96.71", "38.93", "97.41", "54.91" ]

icd9pcs

[ [ [] ] ]

11223, 11302

5158, 9836

344, 434

11503, 11585

3047, 5135

11994, 12131

2506, 2525

10040, 11200

11323, 11482

9862, 10017

11609, 11971

2540, 3028

235, 306

462, 1393

1415, 2243

2259, 2490

21,731

106,133

19450

Discharge summary

report

Admission Date: [**2123-4-11**] Discharge Date: [**2123-4-16**] Date of Birth: [**2051-8-20**] Sex: M Service: NEUROLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 5018**] Chief Complaint: Transient aphasia and right sided weakness Major Surgical or Invasive Procedure: Cerebral angiography with intra-arterial thrombolysis x2 History of Present Illness: 71 yo RH male with hx of CAD s/p stent [**8-24**] and HTN who presented to ER today c/o transient speech problems and right sided weakness. He was in his usual state of excellent health today until 12:30-12:45 PM when he was sitting at a table with friends when he had the sudden onset of difficulty speaking. According to witnesses, he was enganged in conversation with friends when he suddenly grabbed his right arm. When asked questions he did not respond and had a "blank stare". He did not speak at all. He tried to get up from the table and nearly fell. Family says that he was not moving his right arm and appeared to be weak in his LE. They did not notice any facial droop. He did not respond to questions or follow commands. EMS was called and the patient was taken to [**Hospital1 18**] ER where he arrived at 1:50PM. By the time he arrived, his speech and strength were back to baseline. On questioning at this time, the patient says that he remembers being unable to talk or think of the words that he wanted to say. He says that he did understand what was being said to him, but had difficulty responding. He says that both his right leg and arm seemed weak (perhaps arm more than leg). He did not have any change in his vision, facial droop, dysphagia, vertigo, numbness/tingling. On review of symptoms, he denies F/C, headache, cough, SOB, CP, palpitations, or dysuria. He says that he has been feeling well. He went to his primary care doctor last week who found him to be in "good health". He has noted some increased fatigue, particularly late in the day since starting atenolol. He excercised this AM as usual and had no difficulties prior to the onset of symptoms at 12:30 Past Medical History: 1. HTN 2. CAD -s/p PTCA [**8-24**] at [**Hospital1 2025**] 3. Polio as a child with residual left leg weakness and atrophy 4. No hx of prior stroke/TIA, DM, or high cholesterol Social History: Lives with his wife. Italian, came to US in [**2083**]. He is completely independent and very active. He is a former smoker, but quit in the [**2087**]'s. Occasional EtOH. No drugs. Retired x 10yrs, formerly worked as a casket maker. Family History: Mother had stroke in her 80's. Father died in 50's of cancer (?type) Physical Exam: PE: T-98 BP-130/68 HR-40-50 RR-18 O2 Sat 98% (at 2:15PM) Gen: Well nourished male, pleasant, appears well HEENT: NC/AT, oropharynx clear, moist oral mucosa Neck: supple, normal ROM, No carotid briut CV: RRR, S1/S2, 2/6 SEM radiating to carotid Lung: Clear to auscultation bilaterally aBd: +BS soft, nontender ext: no edema, left leg shorter than right, decreased bulk Neurologic examination: Mental status: Awake and alert, cooperative with exam, normal affect. Oriented to person, place, and time. Attentive, says [**Doctor Last Name 1841**] backwards. Speech is fluent with normal comprehension and repetition; naming intact to high frequency items, but has difficulty with low frequency words such as cactus, hammock, and lapel in both English and Italian. No dysarthria. [**Location (un) **]/Writing intact. Registers [**1-21**], recalls [**12-24**]. Able to perform basic calculations. No evidence of apraxia or neglect. Cranial Nerves: I: not tested II: Pupils equally round and reactive to light, 3 to 2mm bilaterally. Visual fields are full to confrontation; accuity 20/20 ou III, IV, VI: Extraocular movements intact bilaterally without nystagmus. V: Sensation intact V1-V3 VII: No facial asymmetry. VIII: Hearing intact to finger rub bilaterally. IX, X: Palate elevation symmetrical [**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally. XII: Tongue midline without fasciculations, intact movements Motor: Decreased muscle bulk in left leg. Tone normal. No adventitious movements. No drift. [**Doctor First Name **] Tri [**Hospital1 **] WF WE FE FF IP H Q DF PF TE TF R 5 5 5 5 5 5 5 5 5 5 5 5 5 5 L 5 5 5 5 5 5 5 5 5 5 5 5 5 5 Sensation: Intact to light touch, pinprick and vibration and proprioception. Reflexes: B T Br Pa Ach Right 2 2 2 2 2 Left 2 2 2 2 2 Grasp reflex absent Toes were downgoing bilaterally Coordination: normal on finger-nose-finger and heel to shin bilaterally. RAMs slowed on right hand. Gait was normal based, walks with limp due to shorter left leg Romberg was negative Pertinent Results: [**2123-4-11**] 11:58PM GLUCOSE-136* UREA N-13 CREAT-0.6 SODIUM-143 POTASSIUM-3.4 CHLORIDE-113* TOTAL CO2-21* ANION GAP-12 [**2123-4-11**] 11:58PM CK(CPK)-71 [**2123-4-11**] 11:58PM cTropnT-<0.01 [**2123-4-11**] 11:58PM TRIGLYCER-44 HDL CHOL-35 CHOL/HDL-2.3 LDL(CALC)-38 [**2123-4-11**] 11:58PM NEUTS-83.0* LYMPHS-13.9* MONOS-2.8 EOS-0.2 BASOS-0.1 [**2123-4-11**] 11:58PM WBC-7.5 RBC-3.56* HGB-11.5* HCT-32.8* MCV-92 MCH-32.3* MCHC-35.1* RDW-13.3 [**2123-4-11**] 11:58PM PLT COUNT-159 [**2123-4-11**] 11:58PM PT-13.5* PTT-43.6* INR(PT)-1.2 [**2123-4-11**] 04:50PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.011 [**2123-4-11**] 04:50PM URINE BLOOD-SM NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [**2123-4-11**] 04:50PM URINE RBC-0 WBC-0 BACTERIA-RARE YEAST-NONE EPI-0 [**2123-4-11**] 01:50PM ALT(SGPT)-23 AST(SGOT)-18 CK(CPK)-81 ALK PHOS-73 AMYLASE-54 TOT BILI-0.6 [**2123-4-11**] 01:50PM LIPASE-31 [**2123-4-11**] 01:50PM cTropnT-<0.01 [**2123-4-11**] 01:50PM CALCIUM-9.4 PHOSPHATE-3.0 MAGNESIUM-2.0 [**2123-4-11**] 01:50PM NEUTS-59.1 LYMPHS-34.5 MONOS-4.9 EOS-1.2 BASOS-0.3 [**2123-4-11**] 01:50PM PLT COUNT-197 [**2123-4-11**] 01:50PM PT-12.9 PTT-24.8 INR(PT)-1.1 [**4-11**] MRI (pre angio #1) No evidence of cortical infarction at this time. Absence of flow signal is observed in the left middle cerebral arterial branches at and beyond the bifurcation of this vessel. This is suspicious for the presence of a thrombus in this location. Cerebral angiography immediately followed this study. [**4-12**] MRI (post angio #1) 1. MRI of the brain, demonstrating new area of slow diffusion within the right temporal-occipital lobe region, consistent with infarction. 2. MR [**First Name (Titles) 20827**] [**Last Name (Titles) 4059**] normal signal intensity within the intracranial arterial vasculature. Specifically, no significant area of stenosis is identified. [**4-14**] CTA chest (PE protocol) No evidence of acute pulmonary embolus. Brief Hospital Course: 71 yo CAD, high chol, and HTN who developed aphasia and right sided weakness at 12:30PM [**4-11**]. Deficits completely resolved in one hour. CT neg. At 4pm (while in ED), developed worsening speech (fluent aphasia) and right facial droop. Exam fluctuated over next hour. Was taken for emergent MR which showed a left M2 occlusion. He was immediately taken for intra-arterial t-PA-given at 7:40PM. After angio and t-PA with resolution of LMCA clot and improved sx, developed visual problems-unclear if field cut or blurred vision. Had a repeat CT which was negative for bleed, and taken back for repeat angiogram which showed right PCA (P2) occlusion! Was intubated during procedure due to agitation. Extubated shortly thereafter, in ICU until [**4-13**], then transferred to the floor. Hospital Course on the floor 1. NEURO: His exam was notable only for a dense left field cut. PT evaluated him and found him to be safe for home, as his gait was stable. A Repeat MRI/MRA was performed on [**4-12**] that showed no L MCA stroke and patent MCA, with R PCA infarct (medial occip lobe, sparing pole). Stroke workup included TEE that showed no ASD, no thrombus, but large complex atheroma in aorta (descending, ascending, arch). Lipid panel normal. Carotids on angio showed no evidence of stenosis. Because of the atheroma and hx of two embolic strokes, he was started on coumadin for anticoagulation and continued on ASA for secondary stroke prevention. Upon discharge he was on day 3 of coumadin 5 mg, INR 1.1. 2. Pulm He was stable until [**4-14**] when he developed a new O2 requirement and some tachypnea, chest CTA showed no evidence of PE and he was quickly weaned off of O2. CXR follow up showed no evidence of pneumonia. 3. CV: He initially ruled out for MI with serial enzymes. He was kept off of his atenolol initially because of low BP, but restarted on lopressor upon transfer to the floor. As an outpatient he may be restarted on his atenolol. His PCP may also consider starting an ACE inhibitor as secondary stroke prevention upon discharge. Early in the morning on [**4-16**] he developed some feeling of chest pressure, he was given nitroglycerin without any relief. His cardiac enzymes were cycled x3 again and they were negative, EKG's unchanged. He was discharged after being cleared from the cardiac perspective. Of note, when he was placed back on telemetry at the time of his chest pain he was noted to intermittently be in atrial fibrillation, not wiht rapid ventricular response. This data just made the team more certain about continuing anticoagulation. 4. GI: Cardiac diet 5. ID: On [**4-14**] overnight he spiked a fever and workup was initiated that showed normal CXR and U/A and urine culture and blood culture were sent that are pending. He also underwent PE workup that was negative. 6. Heme: He was discharged on coumadin and ASA. His INR will need every other day checks until therapeutic at 2-3. His PCP is aware of this plan. 7. Ppx: Boots, PPI Medications on Admission: ASA 325 qd Plavix 75mg qd Atenolol ? dose Lipitor ?20mg qd Discharge Medications: 1. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 3. Warfarin Sodium 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). Disp:*30 Tablet(s)* Refills:*2* 4. Atorvastatin Calcium 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: R MCA territory stroke (likely cardioembolic), with aphasia and L sided weakness, succssfully thrombolysed with subsequent R PCA occlusion and L PCA territory infarction. Discharge Condition: much improved, only with a L sided field cut. Discharge Instructions: Please call your PCP and arrange to have your INR drawn on Sunday. Please make sure you take your aspirin and coumadin every day. Because of your stroke, you will need to make lifestyle modifications: 1. exercise at least 30 minutes 3-4 times per week 2. do not smoke 3. eat a low saturated fat, low cholesterol diet Followup Instructions: Please call [**Telephone/Fax (1) 657**] to schedule a follow up in [**11-22**] months with Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] [**Name6 (MD) 4267**] [**Last Name (NamePattern4) 4268**] MD, [**MD Number(3) 5023**]

[ "138", "401.9", "V45.82", "434.11", "997.02", "414.01", "E878.8", "V58.61" ]

icd9cm

[ [ [] ] ]

[ "99.10", "88.41", "88.72" ]

icd9pcs

[ [ [] ] ]

10380, 10386

6830, 9829

359, 417

10601, 10648

4765, 6807

11015, 11283

2617, 2687

9938, 10357

10407, 10580

9855, 9915

10672, 10992

2702, 3070

277, 321

445, 2148

3646, 4746

3109, 3630

3094, 3094

2170, 2349

2365, 2601

24,018

196,839

10721

Discharge summary

report

Admission Date: [**2108-7-18**] Discharge Date: [**2108-7-25**] Date of Birth: [**2052-5-24**] Sex: F Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2969**] Chief Complaint: Thyoma Major Surgical or Invasive Procedure: [**2108-7-18**] Sternotomy, Thymectomy [**2108-7-20**] Flexible bronchoscopy, therapeutic aspiration of secretions. History of Present Illness: Ms. [**Known lastname 35087**] is a 56 year old female with an anterior mediastinal mass detected following a diagnosis of myasthenia. She had severe myasthenic crisis requiring prolonged ventilation and tracheostomy along with a rehabilitation stay. She continues to do well from her myasthenia standpoint. She is taking CellCept and prednisone 10 mg PO Daily for her myasthenia. She has no double vision while taking steroids. Multiple attempts to wean steroids has resulted in diplopia. She is being admitted for sternotomy, thymectomy. Past Medical History: Myasthenia [**Last Name (un) **] Cholelithiasis Hypertension Hyperlipidemia Diabetes Mellitus Type 2 Anxiety Social History: Pt lives at home with her husband and two children. She works in customer service at [**Company 11293**]. She denied use of tobacco, alcohol, or illicit drugs. Family History: Dad who is healthy. Mom had lung cancer with brain mets and died at 52. Two brothers - one with hypercholesterolemia and one with obesity and diabetes. Physical Exam: VS: T: 98.6 HR: 88 SR BP: 124/68 Sats: 97 1.5 L General: sitting up no apparent distress HEENT: normocephalic, mucus membranes moist Neck: supple no lymphadenopathy Card: RRR normal S1,S2 no murmur/gallop or rub Resp: clear breath sounds throughout GI: obese, benign Extr: warm tr-1+ edema Incision: sternal clean dry intact with steri-strips Neuro: non-focal Pertinent Results: [**2108-7-23**] WBC-8.3 RBC-3.41* Hgb-9.2* Hct-29.2* Plt Ct-323# [**2108-7-18**] WBC-20.8*# RBC-4.05* Hgb-11.0* Hct-34.1* Plt Ct-279 [**2108-7-25**] Glucose-165* UreaN-9 Creat-0.6 Na-137 K-4.3 Cl-95* HCO3-32 [**2108-7-23**] Glucose-105 UreaN-11 Creat-0.6 Na-144 K-3.8 Cl-101 HCO3-34* [**2108-7-18**] Glucose-188* UreaN-12 Creat-0.8 Na-144 K-4.0 Cl-110* HCO3-25 [**2108-7-21**] SPUTUM GRAM STAIN (Final [**2108-7-21**]): normal flora [**2108-7-21**] URINE CULTURE (Final [**2108-7-23**]): ESCHERICHIA COLI. 10,000-100,000 ORGANISMS/ML.. OF TWO COLONIAL MORPHOLOGIES. | AMPICILLIN------------ 4 S AMPICILLIN/SULBACTAM-- 4 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CEFUROXIME------------ 16 I CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- <=16 S PIPERACILLIN---------- <=4 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S CXR: [**2108-7-22**] No pneumothorax. Atelectasis, right middle lobe. [**2108-7-21**] No pneumothorax. Atelectasis, right middle lobe. [**2108-7-20**] Some but not for re-expansion of left lower lobe. Small apical pneumothorax persists. Brief Hospital Course: Mrs [**Known lastname 35087**] was admitted on [**2108-7-18**] for sternotomy, thymectomy. She was extubated in the operating room and transferred to the SICU for further management. Respiratory: Oxygen saturations 94% on 3L NC with BiPAP overnight. On [**7-20**] her oxygenation requirements increased. CXR revealed left lower collapse with possible effusion. Interventional pulmonology was consulted and on Ultrasound no effusion was detected. They then did bedside flexible bronchoscopy and aspirated a large left mainstem mucus plug. Her oxygenation improved. Aggressive pulmonary toilet, chest PT and nebs were continued. The mediastinal chest tubes were removed on POD4. With ambulation her oxygen saturations were in the low 80's requiring supplemental oxygen. Neuro: Neurology followed her throughout her hospital course. NIF & FVC were Q6H to monitor for myasthesia crisis. Her Cellucept, Prednisone & Mestinon were restarted POD 1. Plasmapharesis catheter was placed on [**2108-7-18**] and removed 0n [**2108-7-23**]. Pain: Managed with Dilaudid PCA and toradol. Converted to PO pain meds. Cardiac: she remained hemodynamically stable in sinus rhythm throughout her hospital course. Endocrine: Diabetes was well controlled on Lantus. Metformin will restart as an outpatient. GI: no issues. Renal: Renal function remained stable. Foley was removed Diuresed with lasix IV for mild volume overload. Her lytes were repleted as needed. ID: She had a low grade temp on POD 3. She was pancultured. Blood cultures no growth to date. Urine culture was positive for E. Coli and was treated with 3 Day course of Cipro. Nutrition: she tolerated a diabetic diet. Dispositon: She was followed by physical therapy. Sternal precautions were enforced. She ambulated in the halls. Medications on Admission: Mycophenolate Mofetil 1500 mg [**Hospital1 **], prednisone 10 mg daily, pyridotigmine 60 mg tid, rosuvastatin 10 mg daily, lisinopril 20 mg daily, metformin 500 mg [**Hospital1 **], lantus 20 units qhs. Discharge Medications: 1. Mycophenolate Mofetil 500 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). 2. Prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) as needed for myasthenia [**Last Name (un) 2902**]. 3. Pyridostigmine Bromide 60 mg Tablet Sig: One (1) Tablet PO every eight (8) hours. 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. Rosuvastatin 10 mg Tablet Sig: One (1) Tablet PO once a day. 7. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO once a day. 8. Oxygen O2 at 1-2 liters continuous conserving device for portability 9. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*5 Tablet(s)* Refills:*0* 10. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours. Disp:*60 Tablet(s)* Refills:*2* 11. Insulin Continue previous insulin dose 12. Metformin 500 mg Tablet Sig: One (1) Tablet PO twice a day. 13. Lantus 100 unit/mL Solution Sig: Twenty (20) Units Subcutaneous at bedtime. 14. Famotidine 20 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home Discharge Diagnosis: Myasthenia [**Last Name (un) **] Discharge Condition: stable Discharge Instructions: Call Dr.[**Doctor Last Name 4738**] office [**Telephone/Fax (1) 4741**] if develops: -Fever > 101 or chills -Increased shortness of breath, cough or sputum production -Chest pain -Sternal incision develops drainage or redness or click -No lifting greater than 10 pounds -Steri-strips remove in 10 days or sooner if start to come off -You may shower. No tub bathing or swimming for 4 weeks -No driving for 1 month. -Daily weights: take lasix 20 mg daily if have weight gain. -Eat a banana & drink OJ with taking lasix -Monitor fingerstick blood sugars and restart previous insulin dose Followup Instructions: Follow-up with Dr. [**Last Name (STitle) **] NP on Date/Time:[**2108-8-7**] 1:00pm in the Chest Disease Center [**Hospital1 **] [**First Name (Titles) **] [**Last Name (Titles) 121**] Building Report to the [**Hospital Ward Name 517**] Clinical Center 3rd Radiology for a Chest X-Ray 45 minutes before your appointment Completed by:[**2108-7-25**]

[ "212.6", "518.5", "599.0", "518.0", "401.9", "250.00", "041.4", "519.19", "574.20", "V58.67", "V58.65", "358.00", "300.00" ]

icd9cm

[ [ [] ] ]

[ "33.23", "07.82", "96.05" ]

icd9pcs

[ [ [] ] ]

6460, 6466

3278, 5072

328, 446

6543, 6552

1900, 3255

7187, 7537

1347, 1502

5325, 6437

6487, 6522

5098, 5302

6576, 7164

1517, 1881

282, 290

474, 1021

1043, 1153

1169, 1331

18,357

142,694

53320

Discharge summary

report

Admission Date: [**2177-12-26**] Discharge Date: [**2178-1-9**] Date of Birth: [**2118-12-6**] Sex: F Service: MEDICINE Allergies: Trazodone / Risperdal / Indocin Attending:[**First Name3 (LF) 689**] Chief Complaint: Chronic back pain. Presenting for laminectomy. Major Surgical or Invasive Procedure: 1. Fusion laminectomy of L4-L5 and lumar laminectomy of L5-S1 on [**12-26**] 2. Intubation [**12-30**] History of Present Illness: 59 y/o female with PMH sinificant for interstitial lung disease secondary to asbestosis; COPD; type 2 diabetes mellitus; and chronic back pain secondary to claudication who was admitted to the surgery service on [**12-26**] for a laminectomy who is now transferred to the medicine service for CHF management. The pt was admitted to the orthopedic surgery service on [**12-26**] at which time she underwent a fusion laminectiomy of L4-L5 and a lumbar laminectomy of L5-S1. Pt initially did fairly well postop although she was tachycardic which was attributed to pain. However, on [**12-29**], she began to require higher FIO2 for adequate oxygenation. At that time, she was transferred to the SICU for closet monitoring. A medicine consult was obtained. It was recommended that the pt be agressively diuresed as she was very volume overload and the 6 units of PRBC the pt had received following the operation. The pt was started on a beta blocker for rate control which was successful but contributed to bronchospasm so she was started on nebs at that time. On post op day 5, the psychiatry was consulted as the pt had developed a delerium. On [**12-30**], the pt required intubation for respiratory distress and hypotension into the 70s systolic. The pt also devloped SVT which was AVnRT vs AT. Pt continued to be diuresed and was extubated on [**1-4**]. She remained mildly confused at that time but her delerium was improved. Pt's respiratory status has improved at this time and she will be transferred to medicine for further treatment of her CHF. At the time of transfer, pt denied any pain. She felt that her breathing was "fine" but not quite as good as it is at baseline. Was eating dinner and reported that she was very hungery. No other concerns. Past Medical History: 1. Asbestosis 2. Interstitial lung disease- Pt is on 3 L NC at home. She can walk half a flight of stairs at baseline. 3. COPD 4. Type 2 diabetes mellitus 5. Bipolar disorder 6. Sleep apnea 7. S/P periumbilical hernia repair 8. Stress incontinence 9. GERD 10. Chronic back pain secondary to claudication 11. Hypercholesterolemia 12. Asthma 13. S/P total right knee replacement 14. Diastolic CHF- Echo from [**2176-12-13**]: Enlongated LA and moderately dilated RA. LVEF >55%. Mildly thickened mitral valve leaflets. Social History: Pt lives in an [**Hospital3 **] facility. Her daughter is very involved in her care and visits her every day. No tobacco or drugs. Family History: NC Physical Exam: PE: 96.5 Rm- 99.0 153/69 86 25 97% 4L NC Gen- Alert and oriented x3. NAD. Cardiac- RRR. No m,r,g. Neck veins very hard to evaluate given thick neck but do not appear dramatically elevated. Pulm- Crackles [**12-1**] of the way up bilaterally. Abdomen- Obese. Soft. NT. ND. Positive bowel sounds. Extremities- No c/c/e. 2+ DP pulses bilaterally. Neuro- CN II-XII intact. 5/5 strength for plantar and dosiflexion. Able to wiggle toes and move feet and legs freely. Pertinent Results: [**2177-12-26**] 03:24PM BLOOD WBC-8.5 RBC-3.70* Hgb-10.8* Hct-31.5* MCV-85 MCH-29.2 MCHC-34.3 RDW-15.1 Plt Ct-198 [**2177-12-26**] 03:24PM BLOOD PT-12.9 PTT-21.7* INR(PT)-1.1 [**2177-12-26**] 03:24PM BLOOD Glucose-157* UreaN-15 Creat-0.7 Na-139 K-4.5 Cl-106 HCO3-26 AnGap-12 [**2177-12-26**] 03:24PM BLOOD Calcium-9.5 Phos-4.5 Mg-2.1 [**2177-12-26**] 11:23AM BLOOD Glucose-158* Lactate-1.3 Na-138 K-4.2 Cl-104 [**2177-12-26**] 11:23AM BLOOD Hgb-10.2* calcHCT-31 O2 Sat-98 [**2178-1-9**] 06:00AM BLOOD WBC-10.5 RBC-3.94* Hgb-12.1 Hct-34.6* MCV-88 MCH-30.7 MCHC-35.0 RDW-13.9 Plt Ct-310 [**2178-1-9**] 06:00AM BLOOD Plt Ct-310 [**2178-1-9**] 06:00AM BLOOD Glucose-139* UreaN-10 Creat-0.6 Na-141 K-4.0 Cl-101 HCO3-34* AnGap-10 [**2178-1-9**] 06:00AM BLOOD Calcium-9.6 Phos-3.8 Mg-2.1 CHEST (PORTABLE AP) ([**2177-12-26**]): FINDINGS: An endotracheal tube terminates at the thoracic inlet. The heart is enlarged but unchanged in size. There is failure that appears unchanged. Pulmonary parenchymal opacity is seen within the left lower lobe with associated small bilateral pleural effusions. IMPRESSION: Cardiomegaly with failure and left lower lobe atelectasis. Small bilateral pleural effusions. Echo ([**2178-1-7**]): LEFT ATRIUM: Mild LA enlargement. RIGHT ATRIUM/INTERATRIAL SEPTUM: Moderately dilated RA. LEFT VENTRICLE: Moderate symmetric LVH. Normal LV cavity size. Normal regional LV systolic function. Overall normal LVEF (>55%). RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Mildly dilated aortic root. Normal ascending aorta diameter. AORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR. MITRAL VALVE: Normal mitral valve leaflets with trivial MR. LV inflow pattern c/w impaired relaxation. TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Normal PA systolic pressure. PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with physiologic PR. PERICARDIUM: No pericardial effusion. GENERAL COMMENTS: Resting tachycardia (HR>100bpm). Conclusions: The left atrium is mildly dilated. The right atrium is moderately dilated. There is moderate symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The aortic root is mildly dilated. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. The left ventricular inflow pattern suggests impaired relaxation. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. Compared with the prior study (tape reviewed) of [**2176-12-13**], there is no significant change (left ventricular hypertrophy present in prior study but not noted in prior report). Brief Hospital Course: 58 y/o female wtih PMH significant for obstructive and restrictive lung disease; type 2 DM; and bipolar disorder s/p fusion laminectiomy of L4-L5 and a lumbar laminectomy of L5-S1 on [**12-26**] transferred to the medicine service on [**1-6**] for further management of her CHF. Doing well at this time and is ready for discharge. 1. Cardiac: [**Name (NI) 26573**] Pt experienced respiratory distress requiring intubation after receiving a large amount of IV fluids and blood products following surgery. As noted above, she experienced an episode of resipiratory distress in the SICU resulting in the need for reintubation. Following this, the pt was agressively diuresed and was able to be extubated on [**1-4**]. On transfer to the medicine service, the pt continued to have mild crackles on exam and mildly elevated neck veins so she continued to be diuresed. The pt had good output over the next few days and her pulmonary exam cleared. In addition, she had an oxygen saturation in the mid to high 90s on 3 L NC which is her baseline home oxygen requirement. By the time of discharge, pt was euvolemic. She was restarted on her home dose of lasix of 40 mg PO BID. Pt had echo on [**1-7**] to further evaluate her cardiac function which was basically unchanged from a study in 01/[**2176**]. It showed a LVEF of >65% and no real valvular disease. It is consistent with diastolic dysfunction. Pt was continued on beta blocker with good effect. Daily weights were obtainded. Strict ins and outs were followed. Ischemia/[**Name (NI) 109702**] Pt had no significant valvular disease on her echo from [**1-7**]. No evidence for ischemia during admission. Of note, she was ruled out for a MI in the SICU. [**Name (NI) 9520**] Pt had an episode of SVT in the SICU on [**12-30**] so she was monitored on telemetry on transfer to the floor. On telemetry, she had occasional PVCs and some SVT but no VT. Her echo showed no structureal heart disease. As the pt had no VT and no structural heart disease, a cardiology consult was not obtained. Pt was continued on her beta blocker. 2. [**Name (NI) **] Pt with baseline obstructive and restrictive pulmonary disease. She had an episode of respiratory distress following her surgery secondary to volume overload that required intubation in the SICU. However, she was successfully extubated following diuresis and her oxygenation cntinued to improve. On the floor, the pt consistently had an oxygen saturation in the mid to high 90s on 3 L NC (this is her home baseline oxygen requirement). She was continued on her inhalers and nebs. She was carefully diuresed with lasix for a goal of [**11-29**].5 L negative per day. PFTs could be considered in the future to further evaluate her pulmonary status. 3. [**Name (NI) 12329**] Pt has had elevated BP during much of her time in the SICU. On transfer to the floor, her ACEi was changed to captopril 6.25 TID. In addition, her beta blocker was titrated up as tolerated to a final dosage of metoprolol 50 mg [**Hospital1 **]. Her BP was very well controlled on this regimen. 4. Type 2 diabetes mellitus- Pt was covered with a regular insulin sliding scale. The dosage was increased as needed to obtain tight blood sugar control. It was very important for pt to have tight blood sugar control (<150) for improved wound healing given her recent surgery. On discharge, the pt was restarted on her oral meds. She was also sent on a lower sliding scale to be used if needed. QID FS. [**Doctor First Name **] diet. . 5. S/P fusion laminectiomy of L4-L5 and a lumbar laminectomy of L5-S1- Pt tolerated the procedure well without complications. By the time of discharge, the wound was clean, dry, and intact. There were no signs of infection. Ortho followed pt throughout her hospitalization. 6. [**Name (NI) 3687**] Pt has bipolar disorder and experienced delerium in the SICU. This gradually cleared when the pt was extubated and by the last few days of admission her mental status was at baseline. Sedating medications were avoided as much as possible. The pt was continued on her home psych medications. 7. FEN- Cardiac, [**Doctor First Name **] diet. Agressive electrolyte replacement as needed thoroughout admission. 8. Proph- PPI; SC heparin; bowel regimen 9. [**Name (NI) 54454**] PT and OT. PT and OT worked wtih the pt while she was in house. She will benifit from a short rehab stay. This should be less than 30 days in length. Medications on Admission: Medications on Transfer: 1. Tylenol PRN 2. Albuterol Q4H PRN 3. Fluticasone salmeterol 1 inh [**Hospital1 **] 4. Atorvastatin 10 mg daily 5. Lisinopril 5 mg daily 6. Olanzapine 30 mg QHS 7. Clonazepam 0.5 mg [**Hospital1 **] 8. RISS 9. SC heparin TID 10. Metoprolol 10-15 mg IV Q3-4H PRN 11. Venlafaxine 150 mg daily 12. Haloperidol PRN 13. Artificial tear ointment PRN 14. Nystatin 5 mg QID PRN 15. Lasix 10 mg IV BID 16. Albuterol neb PRN 17. Ipratropium neb PRN 18. Lansoprazole 30 mg daily 19. Metoprolol 25 mg PO BID 20. Percocet [**11-30**] tab PO Q4-6H PRN Discharge Medications: 1. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation Q4H (every 4 hours) as needed. Disp:*1 MDI* Refills:*2* 2. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). Disp:*1 Disk with Device(s)* Refills:*2* 3. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 4. Olanzapine 10 mg Tablet Sig: Three (3) Tablet PO HS (at bedtime). Disp:*90 Tablet(s)* Refills:*2* 5. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 6. Artificial Tear Ointment 0.1-0.1 % Ointment Sig: One (1) Appl Ophthalmic PRN (as needed). Disp:*1 bottle* Refills:*2* 7. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 8. Captopril 12.5 mg Tablet Sig: 0.5 Tablet PO TID (3 times a day). Disp:*45 Tablet(s)* Refills:*2* 9. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 11. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 12. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. Disp:*60 Tablet(s)* Refills:*0* 13. Venlafaxine HCl 75 mg Capsule, Sust. Release 24HR Sig: Two (2) Capsule, Sust. Release 24HR PO DAILY (Daily). Disp:*60 Capsule, Sust. Release 24HR(s)* Refills:*2* 14. 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* 15. Albuterol Sulfate 0.083 % Solution Sig: One (1) neb Inhalation Q4H PRN. neb 16. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb Inhalation Q6H PRN. Disp:*180 neb* Refills:*2* 17. Lasix 40 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:*60 Tablet(s)* Refills:*2* 18. Metformin HCl 850 mg Tablet Sig: One (1) Tablet PO three times a day. 19. Glipizide 5 mg Tablet Sig: One (1) Tablet PO once a day. 20. The pt's regular insulin SS was also sent with the DC paperwork. Discharge Disposition: Extended Care Facility: [**Location (un) 1036**] - [**Location (un) 620**] Discharge Diagnosis: Primary signosis: S/P fusion laminectomy of L4-L5 and lumbar laminectomy of L5-S1 Secondary diagnosis: CHF exacerbation Interstitial lung disease COPD Type 2 diabetes mellitus Bipolar disorder Sleep apnea Asthma GERD Hypercholesterolemia Discharge Condition: Stable. Pt had an oxygen saturation in the mid to high 90s on 3 L nasal cannula. Discharge Instructions: 1. Please take all medications as prescribed. 2. Please keep all follow up appointments. 3. Seek medical attention for fevers, chills, chest pain, worsening shortness of breath, bleeding from the surgery site, or any other concerning symptoms. Followup Instructions: 1. Please follow up with your primary care physician [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] within two weeks of discharge from rehab. 2. Please follow up with Dr. [**Last Name (STitle) 109703**], you outpatient psychiatrist, within two weeks of discharge from rehab. 3. Please follow up with Dr. [**Last Name (STitle) 363**] on [**1-22**] at 1:30. His office is located on the [**Location (un) 1773**] of the [**Hospital Ward Name 23**] Clinical Center in the [**Hospital Ward Name **].

[ "496", "E935.2", "285.9", "518.81", "427.1", "292.89", "296.80", "428.0", "V09.0", "721.3", "427.31", "250.00", "428.30", "V02.59", "293.0" ]

icd9cm

[ [ [] ] ]

[ "38.93", "81.08", "81.62", "38.91", "84.51", "03.90", "96.72", "96.04", "99.04" ]

icd9pcs

[ [ [] ] ]

13706, 13783

6418, 10845

338, 444

14066, 14148

3442, 6395

14442, 14954

2935, 2939

11459, 13683

13804, 13887

10871, 10871

14172, 14419

2954, 3423

252, 300

472, 2232

13908, 14045

10896, 11436

2254, 2771

2787, 2919

13,455

155,660

52122

Discharge summary

report

Admission Date: [**2107-11-15**] Discharge Date: [**2107-11-30**] Date of Birth: [**2038-1-5**] Sex: F Service: CHIEF COMPLAINT: Nausea, vomiting, diarrhea. HISTORY OF PRESENT ILLNESS: This is a 69-year-old female with a three day history of diarrhea. On the day of admission, the patient ha four to five bowel movements and weakness. Her son called EMS. The patient was being treated for cellulitis at her left antecubital dialysis graft site. She was on an antibiotic which name she does not recall for one week. The patient began experiencing nausea, vomiting, diarrhea for three to four days after started antibiotics which is three days prior to admission. She denied blood in her vomit. No fever or chills. Patient has reported intermittent chest pain unlike her last MI in [**Month (only) **]. She has shortness of breath with walking at baseline. No sick contacts. [**Name (NI) **] raw meat or egg ingestion. Patient had dialysis today with profound weakness following dialysis. The patient has a history of CVA with left sided residual weakness. Also was admitted in [**2107-9-4**] status post myocardial infarction. PAST MEDICAL HISTORY: 1. Hypertension. 2. Diabetes mellitus. 3. Hypercholesterolemia. 4. Coronary artery disease status post myocardial infarction [**2107-9-4**] with stent to LAD. 5. Paroxysmal atrial fibrillation. 6. End stage renal disease on hemodialysis. Patient has Port-A-Cath and AV fistula placed in her arm. 7. Hypertension. 8. History of CVA [**2103**], [**2104**] and [**2105**]. Patient has left sided weakness. 9. Cataract. MEDICATIONS ON ADMISSION: 1. Lisinopril 40 mg p.o. q.d. 2. Amiodarone 200 mg p.o. q.d. 3. Elavil 25 q.h.s. p.r.n.. 4. Lipitor 40 mg p.o. q.d. 5. Aspirin 325 p.o. q.d. 6. Prilosec 40 mg p.o. q.d. 7. Amlodipine 10 mg p.o. q.d. 8. Lopressor 100 mg p.o. b.i.d. 9. Dulcolax p.r.n. 10. Insulin NPH 26 q. AM, 14 q. PM. 11. Phos-Lo three tabs with meals. 12. Colace 100 mg p.o. b.i.d. 13. Iron Sulfate 325 mg p.o. q.d. 14. Unknown antibiotic for her cellulitis. ALLERGIES: 1. Eggs. 2. Tetracycline. 3. IV contrast. SOCIAL HISTORY: Negative for tobacco and alcohol. Patient has two children and lives with her husband. [**Name (NI) 482**] [**Name2 (NI) 595**] and [**Hospital1 100**]. PHYSICAL EXAMINATION: On admission, temperature 99.7 F, blood pressure 158/52, heart rate 80, respiratory rate 18, O2 saturation 100% on room air. In general obese female in no apparent distress. Head, eyes, ears, nose and throat: Pupils are equal, round and reactive to light. Extraocular muscles are intact. Mucous membranes dry. Neck: Carotid bruits bilaterally. Heart: Normal S1, S2. There is a II/VI systolic ejection murmur, regular rate and rhythm. Patient has Quinton catheter. Respiratory: Clear to auscultation bilaterally, no rales, no wheezes. Abdomen: Diffusely tender, soft with normoactive bowel sounds. Neuro: There is 2+ lower extremity edema bilaterally. No clubbing or cyanosis. Left upper extremity: Fistula site evident, plus redness and warm, plus bruit and thrill, 2+ edema. Neuro: Cranial nerves II through XII intact. Strength 2+ bilaterally. LABORATORY DATA ON ADMISSION: Showed a sodium of 134, potassium 4.1, chloride 94, bicarbonate 24, BUN 16, creatinine 3.3, glucose of 228. The white count was 11.3, hemoglobin 12.8, hematocrit 38.3, platelets 270, 86% neutrophils, 9% lymphocytes, 5% monocytes, 0% eosinophils. ALT was 9, AST was 25, amylase 37, lipase 12, total bilirubin was 0.6. ECG on admission was unchanged from her prior hospitalization. HOSPITAL COURSE: Patient was initially admitted to the [**Hospital1 **] Medicine Service. Her hospital course will be reviewed by system. 1. INFECTIOUS DISEASE: Patient was started on a two week course of Vancomycin for cellulitis of her left upper extremity. Her Vancomycin was dosed based on levels. She completed her two week course on [**11-30**]. 2. CARDIOVASCULAR: A - Coronary artery disease. Patient is status post myocardial infarction in [**2107-9-4**] with subsequently cardiac catheterization and LAD stent. On [**11-17**], the patient developed substernal chest pain and hemodialysis. An ECG was done which disclosed significant changes. There were ST segment elevations in V2 through V4, ST segment depressions in II, III and aVF. The patient was emergently taken to the Cath Lab for intervention. Resting hemodynamics demonstrated elevated right and left sided filling pressures. There was a V wave dominance in the pulmonary capillary wedge pressure tracing. ......... saturation was elevated with a difference in the SVC to IVC and saturations all consistent with known AV fistula in the left arm. There is severe systemic arterial hypertension and moderate to moderate pulmonary artery hypertension. Selective coronary angiography of the right dominant circulation demonstrated a proximal LAD culprit lesion. The LAD had a 99% instant restenosis with distal TIMI II flow. Successful PTCA of the proximal LAD was performed using a cutting balloon. There was 20% residual stenosis, normal flow and no apparent dissection. On the following day the patient underwent brachytherapy. She was transferred to the CCU for management following her catheterization. She was administered aspirin, Plavix, beta blocker and Statin. B - Pump: Patient has hypertension. She continued on beta blocker and was administered Norvasc and ACE inhibitor. A TTE done on [**11-23**] following her MI showed an ejection fraction of 60%. There was mild symmetric LVH. C - Rhythm: Patient has a history of paroxysmal atrial fibrillation. She continued on her Amiodarone and beta blocker. She was monitored on Telemetry. She is currently being restarted on her Coumadin with Lovenox as a bridge to Coumadin. 3. NEUROLOGIC: Patient has a history of CVA in [**2103**], [**2104**] and [**2105**]. She has left sided residual weakness. Following her cardiac catheterization, the family noted that the patient was demonstrating mental status changes. A MRI done on [**11-21**] disclosed a large subacute infarct involving the left parietal lobe. The stroke was believed to be initially ischemia with hemorrhagic conversion. The patient was seen by the Stroke Service who evaluated her and ultimately recommended that she be administered Coumadin due to her history of paroxysmal atrial fibrillation. Following her stroke, the patient had demonstrated swallowing deficits on the swallow evaluation. In addition, she showed some right sided weakness which has improved over this admission. A carotid duplex ultrasound disclosed 60 to 69% laminal stenosis at the origin of the right internal carotid artery. The patient has been started on Coumadin with Lovenox as a bridge to Coumadin due to her history of paroxysmal atrial fibrillation. 4. RENAL: Patient has end stage renal disease secondary to diabetes mellitus complicated by contrast nephropathy. She undergoes hemodialysis three times a week. She is administered Phos-Lo three tablets t.i.d. with meals. Her nephrologist is Dr. [**Last Name (STitle) **]. [**Doctor Last Name 1366**]. A fistulogram done on [**11-29**] demonstrated a patent AV fistula. 5. FLUIDS, NUTRITION AND ELECTROLYTES / GI: As noted above, the patient underwent a swallow evaluation on [**11-23**]. She failed this evaluation and it was recommended that she be NPO with tube feeds. Patient initially received tube feeds and medications per NG tube. On [**11-29**], a PEG was placed. Patient is currently being administered tube feeds. Her goal tube feeds are Nepro at 35 cc an hour plus 25 grams of ProMod per day. This will give her 1788 kilocalories and 78 grams of protein per day. The Nutrition Service has suggested that the patient be administered Nephrocaps and her phosphate should be monitored. In addition, the patient has chronic constipation. A colonoscopy in the past demonstrated melanosis coli. The patient has continued on her bowel regimen with Senna, Colace and Lactulose p.r.n. 6. ENDOCRINE: Patient has type 2 diabetes mellitus. Her fingersticks were monitored q.i.d.. She was administered regular insulin sliding scale and fixed dose insulin 7 units NPH q. AM, 3 units NPH q. PM. 7. VASCULATURE: On [**11-20**] following the patient's cardiac catheterization, it was noted that she had a right femoral artery pseudoaneurysm. On [**11-21**], the patient underwent thrombin injection to that site. On [**11-22**] a repeat ultrasound was done which confirmed thrombosis of the right groin and pseudoaneurysm. The patient also had Doppler ultrasound of the lower extremities done during this hospital which disclosed no evidence of deep venous thrombosis. CODE STATUS: The patient is full code. DISCHARGE DIAGNOSES: 1. Myocardial infarction status post cardiac catheterization and intervention with balloon thrombectomy and brachytherapy to instant restenosis of LAD stent. 2. End stage renal disease secondary to diabetic nephropathy. 3. Hypercholesterolemia. 4. Hypertension. 5. Diabetes mellitus type 2. 6. Cerebrovascular accident. CONDITION ON DISCHARGE: Fair. DISCHARGE MEDICATIONS: 1. Zestril 40 mg p.o. q.d. 2. Lovenox 80 mg subcu b.i.d. 3. Coumadin 3 mg p.o. q.h.s. 4. Plavix 75 mg p.o. q.d. 5. Aspirin 81 mg p.o. q.d. 6. Lactulose 30 cc t.i.d. p.r.n. 7. Nephrocaps one tab p.o. q.d. 8. Prevacid 30 mg per PEG q.d. 9. Metoprolol 100 mg p.o. b.i.d. 10. Norvasc 10 mg p.o. q.d. 11. Colace 100 mg p.o. b.i.d. 12. Regular insulin sliding scale. 13. Insulin 9 units NPH q. AM, 3 units NPH q. PM. 14. Senna one tablet b.i.d. p.r.n. 15. Tylenol p.r.n. 16. Phos-Lo three tabs t.i.d. with meals. 17. Atorvastatin 40 mg p.o. q.d. 18. Amiodarone 200 mg p.o. q.d. DISCHARGE INSTRUCTIONS: 1. Patient is being discharged on Lovenox and Coumadin. When her Coumadin reaches therapeutic range of 2 to 3, the Lovenox should be discontinued. 2. Patient is to undergo dialysis three times per week. Her nephrologist is Dr. [**Last Name (STitle) **]. [**Doctor Last Name 1366**]. 3. Patient should follow up with her cardiologist and with her primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 73463**]. [**Name6 (MD) 7853**] [**Last Name (NamePattern4) 7854**], M.D. [**MD Number(1) 7855**] Dictated By:[**Last Name (NamePattern1) 5092**] MEDQUIST36 D: [**2107-11-30**] 15:33 T: [**2107-11-30**] 15:54 JOB#: [**Job Number 107859**]

[ "410.11", "998.2", "250.40", "997.02", "585", "996.62", "996.72", "427.31", "578.1" ]

icd9cm

[ [ [] ] ]

[ "36.01", "39.95", "88.56", "46.32", "92.27", "99.20", "37.23", "88.49", "99.29", "96.6" ]

icd9pcs

[ [ [] ] ]

8828, 9155

9210, 9792

1636, 2131

3627, 8807

9816, 10523

2327, 3211

149, 178

207, 1160

3226, 3609

1182, 1610

2148, 2304

9180, 9187

20,858

150,313

49675

Discharge summary

report

Admission Date: [**2132-10-9**] Discharge Date: [**2132-10-13**] Date of Birth: [**2065-3-25**] Sex: F Service: MEDICINE Allergies: Azithromycin Attending:[**First Name3 (LF) 7651**] Chief Complaint: Pericardial effusion Major Surgical or Invasive Procedure: 1. Pericardiocentesis 2. Thoracentesis History of Present Illness: 67 yo female with history of left breast cancer and pericardial effusion in [**2125**] who presented to the CCU s/p pericardiocentesis for pericardial effusion with tamponade physiology. . Approximately two weeks ago, she reports feeling sore ribs in her back and pain with deeping breathing. She went to see her PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 2204**] who felt this was most likely a viral infection given normal CBC and CXR. He recommended one week of Tylenol. She reports a large stressor after seeing her estranged sister at a family party on Saturday. On Monday, her fever persisted so Levaquin was started with concern for CAP. Her fever continued and a CTA was obtained on Wednesday which revealed an effusion but no PE. She reported to the ED on Thursday. Upon arrival, bedside echo revealed a large pericardial effusion without tamponade. Repeat TTE this morning revealed a larger effusion and impaired ventricular filling with RV collapse. Patient is asymptomatic. Pulsus was 30 so she proceeded with pericardiocentesis this afternoon. Vitals this morning are 105/73 105 92% on RA. SBP was 120 when doing pulsus. She received 1L of IVF at 200/hr prior to the procedure. . On review of systems, she notes fever, dry cough, and nausea but denies vomiting, abdominal pain, diarrhea, dysuria, urinary incontinence, sinus tenderness or rash. She denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, hemoptysis, black stools or red stools. 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, syncope or presyncope. She reports palpitations and a sore chest. . Pericardiocentesis removed 520cc of bloody fluid. Echo done after the procedure revealed a thick pericardium but no residual effusion. Pericardial pressures were high initially at 15 but then resolved. Right atrial pressures were also elevated and decreased but were still high at the end of the procedure. Currently, the patient feels sore and fatigued. Past Medical History: 1. Breast Cancer dx in [**7-10**] (8mm grade III infiltrating ductal cancer, five positive lymph nodes, ER negative, HER-2/neu negative, negative LVI) s/p Cytoxan, Adriamycin followed by Taxol and XRT 2. "Labile HTN" Social History: Pt lives in [**Location 620**]. Not married. No children. One wine a night though not recently with chemo. No smoking. No drugs. Pt hosts a talk show on public assess television about health care. Former stock broker. Family History: mother with breast cancer Physical Exam: ADMISSION EXAM GENERAL: NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple with JVP of 5 cm. CARDIAC: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. Drain site is c/d/i. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. ABDOMEN: +BS, soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. EXTREMITIES: wwp, no c/c/e. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: Carotid 2+ DP 2+ PT 2+ Left: Carotid 2+ DP 2+ PT 2+ NEURO: CN 2-12 intact Discharge Exam: VS: 98.3, 98.7, 117/77 (104-132/72-83), 88 (85-140), 95RA I/O: 420/200 + BM x 1 GENERAL: NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple with JVP of 5 cm. CARDIAC: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. Drain site is c/d/I, still with tenderness to palpation around site, but no erythema LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi, decreased breath sounds at bases bilaterally. ABDOMEN: +BS, soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. EXTREMITIES: wwp, no c/c/e. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: Carotid 2+ DP 2+ PT 2+ Left: Carotid 2+ DP 2+ PT 2+ NEURO: CN 2-12 intact Pertinent Results: ADMISSION LABS: [**2132-10-9**] 11:45AM WBC-8.8 RBC-3.78* HGB-11.6* HCT-35.2* MCV-93 MCH-30.7 MCHC-33.0 RDW-12.2 [**2132-10-9**] 11:45AM NEUTS-84.6* LYMPHS-9.9* MONOS-5.1 EOS-0.2 BASOS-0.1 [**2132-10-9**] 11:45AM GLUCOSE-114* UREA N-17 CREAT-0.9 SODIUM-141 POTASSIUM-3.9 CHLORIDE-101 TOTAL CO2-27 ANION GAP-17 [**2132-10-9**] 11:45AM CALCIUM-9.1 PHOSPHATE-3.2 MAGNESIUM-2.3 . PERTINENT LABS: [**2132-10-9**] 11:45AM BLOOD proBNP-590* [**2132-10-9**] 11:45AM BLOOD cTropnT-<0.01 [**2132-10-9**] 11:45AM BLOOD D-Dimer-3006* [**2132-10-8**] 03:09PM BLOOD CRP-144.2* [**2132-10-8**] 03:09PM BLOOD ESR-104* . DISCHARGE LABS: [**2132-10-13**] 05:40AM BLOOD WBC-8.3 RBC-3.56* Hgb-11.0* Hct-33.2* MCV-94 MCH-31.0 MCHC-33.1 RDW-12.2 Plt Ct-518* [**2132-10-13**] 05:40AM BLOOD PT-12.5 INR(PT)-1.1 [**2132-10-13**] 05:40AM BLOOD Glucose-107* UreaN-14 Creat-0.6 Na-142 K-4.2 Cl-106 HCO3-27 AnGap-13 [**2132-10-13**] 05:40AM BLOOD Calcium-8.5 Phos-3.3 Mg-2.2 . CHEST CT [**10-8**] 1. Since [**2126-7-8**] and [**2126-6-7**], a simple pericardial effusion has increased, now moderate to large in size. Tamponade is not excluded on this study. 2. Moderate-sized left pleural effusion, increased since [**7-10**], [**2125**], but decreased since [**2126-7-2**]. Small right effusion and atelectasis. 3. No findings suggestive of pneumonia. 4. Radiation fibrotic changes in the left upper lobe. . CTA [**2132-10-9**] IMPRESSION: 1. No pulmonary embolism. 2. Moderate-sized left pleural effusion, trace right pleural effusion, and large pericardial effusion are unchanged since the chest CT performed yesterday. . ECHO [**2132-10-9**] The estimated right atrial pressure is at least 15 mmHg. Left ventricular wall thickness, cavity size, and global systolic function are normal (LVEF 60%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. The estimated pulmonary artery systolic pressure is normal. There is a large pericardial effusion. The effusion appears circumferential. There are no echocardiographic signs of tamponade. No right atrial or right ventricular diastolic collapse is seen. . ECHO [**2132-10-10**] IMPRESSION: Large circumferential pericardial effusion with echocardiographic signs of impaired ventricular filling. Compared with the prior study (images reviewed) of [**2132-10-9**], there is evidence of impaired ventricular filling. . ECHO: [**2132-10-11**] Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. There is a trivial/physiologic pericardial effusion. There are no echocardiographic signs of tamponade. Compared with the prior study (images reviewed) of [**2132-10-11**], the findings are similar. . ECHO: [**2132-10-12**] The estimated right atrial pressure is 0-5 mmHg. Overall left ventricular systolic function is normal (LVEF>55%). The aortic valve leaflets appear structurally normal with good leaflet excursion. No aortic regurgitation is seen. The mitral valve leaflets are structurally normal. No mitral regurgitation is seen. The estimated pulmonary artery systolic pressure is normal. There is a very small pericardial effusion. There are no echocardiographic signs of tamponade. IMPRESSION: Versy small residual pericardial effusion without echocardiographic signs of tamponade. Compared with the prior study (images reviewed) of [**2132-10-11**] the findings are similar PERICARDIAL AND PLEURAL FLUID WERE NEGATIVE FOR MALIGNANT CELLS Brief Hospital Course: 67 yo female with history of breast cancer and prior pericardial effusion in [**2125**] who presents to [**Hospital1 18**] with large pericardial effusion and tamponade after two weeks of fever and viral illness. . # Large Pericardial Effusion with Tamponade: The patient presented with a large pericardial effusion with evidence of RV diastolic collapse. She has a history of prior transient pericardial effusion, likely from a viral etiology. The patient ins now s/p pericardiocentesis, tapped ~500cc of bloody fluid, which was found to be exudative. When the patient's output from the drain slowed down, the drain was pulled. A repeat TTE done after pulling the pericardial drain showed that there was no significant re-accumulation of pericardial effusion. Unclear etiology of pericardial effusion, but differential includes viral pericarditis, idiopathic, radiation therapy-related, or malignancy induced. . Upon discharge, the patient was also started on colchicine 0.6 mg [**Hospital1 **] and Ibuprofen for anti inflammatory effects. She was instructed to take the colchicine for a total of three months, and the ibuprofen for a total of one month. She was also told to take omeprazole daily while on the ibuprofen. The patient was also instructed to get an echocardiogram of the heart two weeks after discharge. This was also communicated with her primary care doctor. PERICARDIAL AND PLEURAL FLUID WERE NEGATIVE FOR MALIGNANT CELLS . # atrial fibrillation: After the placement of the pericardial drain, the patient had a few isolated episodes of atrial fibrillation, that all self-resolved. One of these episodes was while having a bowel movement. It is likely that these episodes are secondary to pericardial irritation from the drain. The patient's home metoprolol was uptitrated to 100 mg daily and upon discharge her rates were well controlled and she was in normal sinus. The patient was also discharged on a baby ASA daily. Her CHADS score is 1 and the patient was not discharged on anticoagulation. However, this should be followed up as an outpatient. . # pleural effusion: The patient has evidence of pleural effusion on CXR and ECHO. She is s/p thoracentesis [**2132-10-12**], taking off ~600cc of blood tinged, clear pleural fluid. Fluid was sent for analysis, including cytology. . # Fever: Patient febrile to 101.7 after placement of pericardial drain. She never had a white count, and fevers have resolved, and she is currently afebrile. Moreover, patient denied any infectious symptoms besides dry cough and because of this, no antibiotics were started; upon discharge, the all blood cultures were no growth to date and the patient remained afebrile. . # Hypertension: The patient was prescribed Metoprolol Succ 12.5mg PO BID per OMR, and 25 mg [**Hospital1 **] per patient. The patient's pressures were well controlled while in the CCU, and her metoprolol was uptitrated because of her elevated heart rates. ... Transitional: - Please make sure that your PCP schedules an ECHO for you in two weeks. - Please follow up paroxysmal atrial fibrillation as an outpatient with cardiologist; the patient was started on daily ASA 81. - The patient still has cytology on pleural and pericardial fluid pending; will need to be followed up as an outpatient; if positive for malignacny, the patient will have to follow up with oncology. Medications on Admission: -METOPROLOL SUCCINATE 12.5mg [**Hospital1 **] -LEVOFLOXACIN 500 mg Tablet daily since Monday [**10-6**] -No vitamins or supplements. Discharge Medications: 1. ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) for 1 months. Disp:*90 Tablet(s)* Refills:*0* 2. colchicine 0.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 3 months. Disp:*60 Tablet(s)* Refills:*0* 3. metoprolol succinate 100 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO once a day. Disp:*30 Tablet Extended Release 24 hr(s)* Refills:*0* 4. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 5. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day for 1 months: Please stop this medication at the end of your course of ibuprofen. Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Primary diagnosis: Pericardial Effusion Pleural Effusion Paroxsymal atrial fibrillation Secondary diagnosis: Breast cancer Viral infection Discharge Condition: Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Mental Status: Clear and coherent. Chest pain free. Discharge Instructions: Dear Ms. [**Known lastname 10740**], It was a pleasure taking care of you while you were hospitalized at [**Hospital1 18**]. You were admitted to the hospital because you were having some soreness with breathing, and echocardiogram of your heart showed that you had some fluid in the bag that is surrounding your heart. You underwent a procedure where a needle was inserted into this space and fluid was drained (pericardiocentesis). We left the drain in for a day, but once fluid stopped draining we pulled it. A repeat echocardiogram showed that the fluid did not reaccumulate. . You also had a lot of fluid in the space around your lungs on the left side. We did a similar procedure and inserted a needle into the area and drained about 600 cc of fluid from your lungs. We sent both the fluid from your lungs and heart to the laboratory for further analysis. .. After your procedure, you had some instances of elevated heart rates. We think that this happened because of some irritation that the fluid caused your heart. It has since stopped, but we think that there is a possibility that it will come and go. Please follow this issue up with your outpatient cardiologist. We are sending you home on aspirin for this, but you can follow this up with your outpatient cardiologist and decide whether you want to continue this medication. .. It is VERY important that you see your primary care doctor, radiation oncologist, and cardiologist. You will need to get an echocardiogram of your heart in two weeks. Please make sure that your primary care doctor orders this test for you. .. We made the following changes to your medications: -CHANGE Metoprolol succinate to 100 mg daily -START Colchicine 0.6mg by mouth twice daily for 3 months or as directed by your PCP (hold for diarrhea) -START Ibuprofen 600mg by mouth three times daily for 1 month or as directed by your PCP (hold for upset stomach or GI bleeding) -START omeprazole 20 mg once a day while you are taking the Ibuprofen -START aspirin 81 mg daily for atrial fibrillation . Please follow-up with the appointments below. Followup Instructions: Please attend the following appointments: Department: [**State **]When: FRIDAY [**2132-10-17**] at 1 PM With: [**First Name11 (Name Pattern1) 2946**] [**Last Name (NamePattern4) 6564**], MD [**Telephone/Fax (1) 2205**] Building: [**State **] ([**Location (un) **], MA) [**Location (un) **] Campus: OFF CAMPUS Best Parking: On Street Parking Department: CARDIAC SERVICES When: FRIDAY [**2132-11-7**] at 1:20 PM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4511**], MD [**Telephone/Fax (1) 62**] Building: [**Hospital6 29**] [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: DERMATOLOGY AND LASER When: MONDAY [**2132-11-10**] at 2:30 PM With: [**First Name11 (Name Pattern1) 177**] [**Last Name (NamePattern1) 4961**], MD [**Telephone/Fax (1) 3965**] Building: [**Location (un) 3966**] ([**Location (un) 55**], MA) [**Location (un) **] Campus: OFF CAMPUS Best Parking: Free Parking on Site Please schedule an appointment with Dr. [**Last Name (STitle) **] for within one month. Completed by:[**2132-10-13**]

[ "423.3", "427.89", "427.31", "511.9", "423.9", "401.9", "V10.3" ]

icd9cm

[ [ [] ] ]

[ "37.21", "88.55", "34.91", "37.0" ]

icd9pcs

[ [ [] ] ]

13083, 13089

8682, 12058

295, 336

13273, 13363

4946, 4946

15560, 16655

3091, 3118

12241, 13060

13110, 13110

12084, 12218

13441, 15059

5574, 8659

3133, 3934

3950, 4927

15088, 15537

235, 257

364, 2599

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4962, 5330

13129, 13199

13378, 13417

5346, 5558

2621, 2839

2855, 3075

58,240

100,113

49123

Discharge summary

report

Admission Date: [**2153-1-5**] Discharge Date: [**2153-1-11**] Date of Birth: [**2067-1-25**] Sex: M Service: MEDICINE Allergies: Codeine / Iodine Attending:[**First Name3 (LF) 2782**] Chief Complaint: malaise Major Surgical or Invasive Procedure: Percutaneous Chol. History of Present Illness: 85 yo male w/ h/o Afib, systolic CHF, and recent cholecystitis treated medically p/w fatigue, poor po intake, and malaise. Upon questioning he admits to mild ruq pain and chills but no fevers. He lost ten lbs in the last week due to poor po intake. His son brought him to the [**Name (NI) **] for evaluation after he had an appointment at his cardiologist's office. . He had been hospitalized through [**2152-12-10**] at an OSH for rx of cholecytitis afterwhich he developed lower extremity edema and dyspnea on exertion. He was started on lasix one week ago and has improved since then. He says that he gets extremely short of breath after 20 steps. No chest pain. . He has had several mechanical falls lately and for this reason, he is not anticoagulated. In the ED, initial VS were: 97.8 48 95/76 18 90%. He was given 1.5L ivf. He was treated with azithromycin 500mg iv once, ceftriaxone 1g iv once, unasyn 3g iv once. Lactate decreased from 4.6 to 2.2 with fluids. Troponin stable at .03. Surgical consultation recommends percutaneous cholecystostomy tubes. CT head . Upon transfer to the micu, 98.0, Pulse: 94, RR: 16, BP: 129/72, O2Sat: 97%, O2. On arrival to the MICU, he had no acute complaints. . Review of systems: (+) Per HPI (-) Denie night sweats, recent wt gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies or wheezing. Denies chest pain, chest pressure, palpitations, or weakness. Denies nausea, vomiting, diarrhea, constipation, abdominal pain, or changes in bowel habits. Denies dysuria, frequency, or urgency. Denies arthralgias or myalgias. Denies rashes or skin changes. Past Medical History: S/P BILATERAL TKR *S/P ILIAL FRACTURE ATRIAL FIBRILLATION AWB DONATION- DEFFERRAL B12 DEFICIENCY ANEMIA BLADDER CANCER CERVICAL SPONDYLOSIS CHRONIC RENAL FAILURE GASTROESOPHAGEAL REFLUX HERNIATED DISC HYPERCHOLESTEROLEMIA HYPERTENSION HYPOTHYROIDISM MGUS MITRAL VALVE PROLAPSE PROCTITIS PROSTATE CANCER R SHOULDER DJD TRANSIENT ISCHEMIC ATTACK [**2141**] LVEF 25% Social History: lives alone but has daily help; no smoking or etoh Family History: Mother died of alzheimers dementia Father died of prostate cancer Physical Exam: General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: supple, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi Abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CNII-XII intact, 5/5 strength upper/lower extremities, grossly normal sensation, 2+ reflexes bilaterally, gait deferred, finger-to-nose intact Pertinent Results: Admission Labs [**2153-1-5**] 09:45PM GLUCOSE-136* UREA N-41* CREAT-1.8* SODIUM-141 POTASSIUM-3.9 CHLORIDE-109* TOTAL CO2-21* ANION GAP-15 [**2153-1-5**] 09:45PM CALCIUM-8.1* PHOSPHATE-4.3 MAGNESIUM-2.0 [**2153-1-5**] 12:03PM URINE HOURS-RANDOM UREA N-932 CREAT-99 SODIUM-50 POTASSIUM-68 CHLORIDE-41 [**2153-1-5**] 12:03PM URINE OSMOLAL-595 [**2153-1-5**] 12:03PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.018 [**2153-1-5**] 04:49AM GLUCOSE-136* UREA N-45* CREAT-2.1* SODIUM-139 POTASSIUM-4.2 CHLORIDE-105 TOTAL CO2-21* ANION GAP-17 [**2153-1-5**] 04:49AM ALT(SGPT)-55* AST(SGOT)-55* LD(LDH)-255* ALK PHOS-128 TOT BILI-0.6 [**2153-1-5**] 04:49AM CALCIUM-8.2* PHOSPHATE-4.2 MAGNESIUM-2.0 IRON-38* [**2153-1-5**] 04:49AM calTIBC-179* VIT B12-740 FOLATE-GREATER TH FERRITIN-246 TRF-138* [**2153-1-5**] 04:49AM WBC-8.6 RBC-3.08* HGB-9.9* HCT-30.7* MCV-100* MCH-32.2* MCHC-32.4 RDW-17.9* [**2153-1-5**] 04:49AM PLT COUNT-239 [**2153-1-5**] 04:49AM PT-13.4* PTT-20.7* INR(PT)-1.2* [**2153-1-5**] 01:04AM LACTATE-2.2* [**2153-1-5**] 12:55AM cTropnT-0.03* [**2153-1-4**] 08:25PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.013 [**2153-1-4**] 08:25PM URINE RBC-1 WBC-10* BACTERIA-MANY YEAST-NONE EPI-0 [**2153-1-4**] 08:25PM URINE MUCOUS-RARE [**2153-1-4**] 06:25PM LACTATE-4.6* K+-4.8 [**2153-1-4**] 06:25PM HGB-11.3* calcHCT-34 [**2153-1-4**] 06:12PM PT-14.7* PTT-24.4* INR(PT)-1.4* [**2153-1-4**] 06:12PM PLT COUNT-267# [**2153-1-4**] 06:12PM cTropnT-0.03* [**2153-1-4**] 06:12PM LIPASE-33 Brief Hospital Course: BRIEF HOSPITAL COURSE: This is an 85 year old gentleman with a history of atrial fibrillation, systolic heart failure and recent medically treated cholecystitis who presented with recurrent cholecystitis that was treated with percutaneous drainage and antibiotics. His hospital course was complicated by delirium and mild pulmonary edema. . ACTIVE ISSUES: ACUTE CHOLECYSTITIS: Mr. [**Known lastname 79**] presented with right upper quadrant pain and nausea and fatigue. Labs significant for normal LFTs. RUQ ultrasound demonstrate dacute cholecystitis. Suurgery was consulted and recommended percutaneous drainage of his gallbladder which was carried out by IR. Initial pus was drained from the gallbladder which transioned to bilious drainage on Day # 2 of admission. He was covered with Vancomycin and Zosyn initially. Culture data from the biliary drain grew ecoli sensitive to ciprofloxacin. Antibiotic therapy was changed to ciprofloxacin and metronidazole to include anaerobic coverage for a total of 14 days. His biliary drain was kept in place with plan for discontinuation by general surgery in [**5-25**] weeks. He was afebrile for the duration of his hospital course. . CONGESTIVE HEART FAILURE: On admission he was noted be dyspneic. An initial chest xray was concerning for right lower lobe pneumonia that could not be ruled out in the setting of pulmonary edema. He was initially on vancomycin and zosyn on admission to the intensive care unit. While diuresis was initially held on secondary to concern for acute kidney injury his pulmonary edema accumulated during his initial hospital days. He was given IV lasix 20mg twice and restarted on his home dose of lasix 20mg daily. This dose was uptitrated to 40mg daily which appeared to better control his volume status and improved his breathing. An echo demonstrated symmetric left ventricular hypertrophy with cavity dilation and global systolic dysfunction suggestive of a non-ischemic pattern with EF 25%. A low dose ace-inhibitor (lisinopril 5mg) was started and he was continued on an aspirin and beta blocker. He reported no cough and was afebrile for the duration of hospitalization. A repeat chest xray after diuresis revealed no evidence of pneumonia. His nighttime oxygen saturations were noted to be stably in the low 90s. . URINARY TRACT INFECTION: A urine sample from admission was concerning for infection and culture grew ecoli sensitive to ciprofloxacin. A repeat UA prior to discharge was clear of infection. . ATRIAL FIBRILLATION: Mr. [**Known lastname 79**] is rate controlled with metoprolol and anticoagulated with aspirin given fall risk. He was noted to have heart rates in the 110s with frequent episodes of non sustained ventricular tachycardia, therfore his metoprolol was incrased to 50mg three times a day with improvement in the frequency of NSVT and heart rates in the 60-70s during the day. Cardiology was consulted and agreed with management changes. There was a question of whether he was on domperidone in the past. It was taken off his medication list. . DELIRIUM: Mr. [**Known lastname 79**] was noted to have progressive delirium throughout his hospitalization which was improving prior to discharge. No pharmacologic agents were required for management. He had an attentive family at his bedside at all his times. Repeat infectious work-up including UA, chest xray and cdiff toxin were negative for infection. His electrolytes were stable. Etiology attributed to age, dementia and hospitalization including ICU stay. . SPEECH AND SWALLOW: While delirius, Mr. [**Known lastname 79**] was noted to have small aspiration events with eating and drinking. A speech and swallow evaluation recommended nectar thickened liquids with suggested re-evaluation when his delirium clears. . INACTIVE ISSUES CHRONIC KIDNEY DISEASE: His renal function ranged between 1.8 and 2.0 throughout his hospitalization which was just above his baseline. . HYPERTENSION: Well controlled. Furosemide increased to 40mg PO. Amlodipine was discontined in favor of lisinopril 5mg. Hydralazine was held on discharge given normotensive. He should discuss restarting this medication with his primary care physician after discharge. . HYPOTHYROID: He was continued on levothyroxine. . VITAMIN D: He was continued on vitamin D. . DYSLIPIDEMIA: He was continued on crestor 20mg daily. . DEPRESSION: He was continued on wellbutrin 300mg daily. . BENIGN PROSTATIC HYPERTROPHY: He was continued on flomax. . PAIN: Secondary to frequent falls. He was continued on tylenol and gabapentin. . INSOMNIA: Lunesta was held on admission and should be reconsidered on discharge. . GERD: He was continued on ranitidine and nexium. . TRANSITIONAL ISSUES: - Continue ciprofloxacin and metronidazole for 8 additional days - Primary care follow-up, Electrolytes should be checked within 1 week as she has started lasix and lisinopril. - Full Code Medications on Admission: tylenol #3 daily prn furosemide 20mg daily amlodipine 5mg daily bupropion 300mg daily calcitriol .25mcg domperidone 5mg daily gabapentin 900mg daily esmeprasole 40mg daily eszopiclone (lunesta) 2mg hs gabapentin 800mg daily hydralazine 25mg [**Hospital1 **] levothyroxine 112 mcg daily metoprolol succinate 50mg [**Hospital1 **] ranitidine 150mg daily rosuvastatin 20mg daily tamsulosin .4mg daily asa 325 vitamin d b12 1000mcg daily Discharge Medications: 1. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain. 2. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO once a day. 4. esomeprazole magnesium 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 5. eszopiclone 2 mg Tablet Sig: One (1) Tablet PO at bedtime as needed for insomnia. 6. levothyroxine 112 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. rosuvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1) Capsule, Ext Release 24 hr PO HS (at bedtime). 9. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Vitamin D 2,000 unit Capsule Sig: One (1) Capsule PO once a day. 11. cyanocobalamin (vitamin B-12) 1,000 mcg Tablet Sig: One (1) Tablet PO once a day. 12. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 8 days: day 1 = [**1-5**] (total course 14 days). 13. metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) for 8 days: day 1 = [**1-5**] (total 14 days). 14. bupropion HCl 300 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO once a day. 15. gabapentin 800 mg Tablet Sig: One (1) Tablet PO once a day. 16. metoprolol succinate 50 mg Tablet Extended Release 24 hr Sig: Three (3) Tablet Extended Release 24 hr PO once a day. 17. lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Extended Care Facility: [**First Name8 (NamePattern2) 1495**] [**Hospital 122**] Rehabilitation Center Discharge Diagnosis: Acute cholecystitis Urinary tract infection Atrial fibrillation Decompensated systolic heart failure Hypertension Chronic kidney disease Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: It was a pleasure taking care of you. You came with the feeling of fatigue and fever. The reason was that you had inflammation of your galbladder and urinary tact infection. The tube was placed into your gallblader so that the bile can drain. We gave you antibiotics and you recovered. . The tube should stay in your gallbladder. Wou will see the surgeon on [**1-26**] and they will give you further instructions. . We have done the following changes to your medications: CONTINUE ciprofloxacin 500 mg tbl. twice a day for 8 more days CONTINUE metronidazole 500 mg tbl. three times a day for 8 more days CHANGE furosemide 20 mg po daily to furosemide 40 mg daily DISCONTINUE dronedorol DISCONTINUE amlodipine 5 mg daily START lisinopril 5 mg daily DISCONTINUE hydralazine 25 mg twice a day DISCONTINUE ranitidine 150 mg daily Followup Instructions: Department: GENERAL SURGERY/[**Hospital Unit Name 2193**] When: FRIDAY [**2153-1-26**] at 10:15 AM With: ACUTE CARE CLINIC [**Telephone/Fax (1) 600**] Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage . Department: WEST [**Hospital 2002**] CLINIC When: WEDNESDAY [**2153-2-7**] at 11:30 AM With: [**First Name11 (Name Pattern1) 177**] [**Last Name (NamePattern4) 720**], M.D. [**Telephone/Fax (1) 721**] Building: De [**Hospital1 **] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **] Campus: WEST Best Parking: [**Street Address(1) 592**] Garage . Department: WEST [**Hospital 2002**] CLINIC When: WEDNESDAY [**2153-3-28**] at 11:30 AM With: [**First Name11 (Name Pattern1) 177**] [**Last Name (NamePattern4) 720**], M.D. [**Telephone/Fax (1) 721**] Building: De [**Hospital1 **] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **] Campus: WEST Best Parking: [**Street Address(1) 592**] Garage

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icd9cm

[ [ [] ] ]

[ "51.01" ]

icd9pcs

[ [ [] ] ]

11632, 11737

4730, 5049

285, 305

11918, 11918

3120, 4684

12944, 13998

2424, 2491

10099, 11609

11758, 11897

9640, 10076

12094, 12537

2506, 3101

9424, 9614

12566, 12921

1559, 1951

237, 247

5064, 9403

333, 1540

11933, 12070

1973, 2339

2355, 2408

54,818

139,967

36672+58105

Discharge summary

report+addendum

Admission Date: [**2175-9-14**] Discharge Date: [**2175-9-22**] Date of Birth: [**2140-12-29**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 3043**] Chief Complaint: Abdominal pain Major Surgical or Invasive Procedure: Platelet transfusion Red blood cell exchange History of Present Illness: Ms. [**Known lastname 72481**] is a 34F gardener in [**Hospital1 6687**] with multiple recent admissions for bleeding in setting of thrombocytopenia, thought to be secondary to ITP, who recently underwent a splenectomy and is on a steroid taper. She returned to the ER with abdominal pain x1 day. She was in good health until earlier this summer when she presented to an OSH with vaginal bleeding and was found to be thrombocytopenic. Heme review of her smear showed question of intraerythrocytic parasites and she was briefly started on atovaquone and azithromycin. These were subsequently discontinued as it was felt she did not have an acute Babesia infection. In subsequent workup by hematology she was diganosed with ITP, treated with prednisone, and ultimately underwent a splenectomy on [**2175-9-9**] when she had recurrent vaginal bleeding. She felt well until the evening prior to admission when she developed back and chest pains. The day of presentation she experiences severe intermittent low abdominal pain, sharp-pulsating in quality. She denies having had anything similar in the past. She had some sweats associated with the abdominal pain and fever, but denies any rigors. In the ED, initial vs were 98.0 98 101/69 16 and 100% on room air. She did spike a fever to 101.3F. Abdomen was soft on exam. Labs notable for WBC of 15, Hct 36, Plts of 34. She was given clindamycin 600mg, quinine 650mg, and acetaminophen. She was evaluated by the surgical consult who felt she had no acute surgical issues. The ID and hematology services were also consulted. Most recent vitals prior to transfer are 99.4 96 89/48 20 96% on RA. She was briefly hypotensive to 88 systolic. She was given 3L of fluid with good effect. Has 2PIVs, no foley. On evaluation in the MICU, she reports her abdominal pain is significantly improved. She denies cough, diarrhea, myalgias, arthralgias, rash. She does endorse mild urinary urgency. She denies nausea but had an episode of vomiting at home. She says she tries to examine herself daily for ticks - hasn't noticed any recently. Denies h/o appy or ccy. Past Medical History: Idiopathic thrombocytopenia Social History: Works as a gardener in [**Hospital1 6687**], married with two children. No smoking or EtOH. Family History: No platelet disorders. Mother with diabetes. Father and siblings healthy. Physical Exam: Vitals 97.9 97 108/67 15 99% on RA General: Pleasant woman in no distress HEENT: Sclera anicteric, conjunctiva pink, MMM, TM clear, no external ear pain Neck: Supple Pulm: Lungs clear bilaterally CV: Regular S1 S2 no m/r/g Abd: Soft mildly tender throughout no rigidity or guarding, +bowel sounds. Small midline incision well healing, no exudate or erythema. Extrem: Warm no edema palpable distal pulses Neuro: Alert and awake, answering appropriately, CN II-XII intact Derm: no rash or jaundice Pertinent Results: Hematology: [**2175-9-14**] 03:45PM WBC-15.2* RBC-3.91* HGB-12.0 HCT-36.4 MCV-93 MCH-30.7 MCHC-33.0 RDW-14.4 [**2175-9-14**] 03:45PM NEUTS-93.9* LYMPHS-4.1* MONOS-0.7* EOS-0.8 BASOS-0.5 [**2175-9-14**] 03:45PM PLT COUNT-34*# [**2175-9-14**] 03:45PM RET AUT-4.1* [**2175-9-14**] 06:20PM PT-13.9* PTT-22.1 INR(PT)-1.2* [**2175-9-14**] 06:20PM FIBRINOGE-288 Chemistries: [**2175-9-14**] 03:45PM GLUCOSE-119* UREA N-20 CREAT-0.6 SODIUM-139 POTASSIUM-3.9 CHLORIDE-102 TOTAL CO2-28 ANION GAP-13 [**2175-9-14**] 03:45PM ALT(SGPT)-32 AST(SGOT)-24 LD(LDH)-251* ALK PHOS-69 TOT BILI-0.5 [**2175-9-14**] 03:45PM HAPTOGLOB-<20* [**2175-9-14**] 03:56PM LACTATE-2.1* Urinalysis: [**2175-9-14**] 05:12PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.013 [**2175-9-14**] 05:12PM URINE BLOOD-TR NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-NEG [**2175-9-14**] 05:12PM URINE RBC-0-2 WBC-0 BACTERIA-RARE YEAST-NONE EPI-0-2 Microbiology: [**2175-9-14**] 03:45PM PARST SMR-POS [**2175-9-14**] Blood cultures x 2 pending . Imaging: [**2175-9-14**] ECG - Sinus tachycardia. RSR' pattern in lead V1. Since the previous tracing of [**2175-9-9**] the rate has increased. The RSR' pattern is now present. Clinical correlation is suggested. [**2175-9-14**] CT Chest/Abdomen/Pelvis: 1. Post-surgical changes in the splenectomy bed without evidence of abscesses or fluid collections. 2. No evidence of pulmonary embolism or acute aortic syndrome. [**2175-9-17**] CT HEAD There is no intra- or extra-axial hemorrhage, masses, mass effect, or shift of normally midline structures. The ventricles and sulci are normal in size and configuration. The [**Doctor Last Name 352**] and white matter differentiation is well preserved. The basilar cisterns appear patent. The visualized paranasal sinuses are clear. Brief Hospital Course: Ms. [**Known lastname 72481**] is a 34 year old woman with a history of idiopathic thrombocytopenia s/p splenectomy and on corticosteroids who was diagnosed with Babesiosis and returns with fevers and abdominal pain. Babesiosis: Patient presenting with mild abdominal pain which had improved significantly at the time of arrival to the [**Hospital Unit Name 153**]. Patient's initial parasite smear was positive with 0.6% parasitemia. The case was discussed with infectious disease who recommended treating with atovaquone and azithromycin. Given her recent splenectomy, she is at risk for severe disease, although she may have had a smoldering infection unmasked by her recent surgery. Her blood pressure remained stable and her abdominal pain resolved on hospital day 2, and she was transferred to the floor. She was continued on atovaquone and azithromycin. She continued to spike intermittent fevers and her parasitemia continued to rise, which peaked at 9.5% on hospital day 5. She underwent exchange transufusion on hospital day 5. The parasitemia was 5.1% the day after transfusion and continued to drop to below 1% by hospital day 7. She was afebrile with a parasitemia of 0.1% on the day of discharge. She will be dicharged home to continue her antibiotic treatment and follow up in Infectious Disease clinic. She was counselled on how to avoid future tick bites and given informational handouts in Spanish. Fevers: Most likely due to Babesiosis. Co-infection with other tick-borne illnesses such as lyme and ehrlichia was considered. Her Lyme titers had been negative twice, and she had a past E Chaffeensis infection (IgG pos, IgM neg). Her urine and blood cultures were negative. Her fevers defervesced as her parasitemia improved, and she had been afebrile for 72 hours on the day of discharge. Headache and tinnitus: Patient complained of pressure-like headache with bilateral tinnitus. A CT head was negative for intracranial bleeding. Tinnitus was likely secondary to cinchonism from quinine which she received x 1 on presentation to the ED. Headache is common side effect of babesiosis infection. Due to perisistent headache despite declining parasite load, the patient underwent a lumbar puncture which had a normal opening pressure and was negative for infection. CSF lyme and viral studies were pending at the time of discharge. She received morphine as needed for the headache. Her headache improved and was not requiring pain medications by discharge. Her tinnitus also improved. Abdominal pain: Surgery was consulted in the ED and did not feel she had an acute abdomen. CT abdomen was negative for any acute process. Her liver function tests were normal. This was likely related to babesiosis and resolved on day two of hospitalization. Hypotension: The patient was monitored in the [**Hospital Unit Name 153**] because of systolic blood pressure in the 80's on presentation. The patient was never symptomatic, and through her hospitalization it became apparent that her blood pressure normally runs in the 90's and 100's. Her blood pressure dropped a couple of times on the floor, but responded to IVF boluses. Thrombocytopenia: The patient had thrombocytopenia on presentation. It was unclear whether this was secondary to ITP, Babesiosis, or Erlichiosis. She was started on doxycycline to empirically cover for Erlichiosis and which is also used as an additional [**Doctor Last Name 360**] for severe Babesiosis. Her platelet count fell during the first few days of hospitalization and reached a nadir of 13,000, for which she received two units of platelets over two days. She received IVIG on hospital day 5, the same day which she received exchange transfusion, and her platelet rose steadily thereafter. It was ... on the day of discharge. Hematology felt that the patient did have ITP and the patient will follow-up in [**Hospital **] clinic following discharge. She will also have weekly CBCs for one month (first one to be checked during her hematology appointment) to monitor her platelet count. Anemia: likely due to hemolysis from Babesiosis infection. Hct fell to 24.6 on hospital day 6 but stabilized through the rest of the hospitalization. Medications on Admission: 1. Omeprazole 20mg PO daily 2. Calcium Carbonate 500mg PO bid 3. Cholecalciferol 400units PO daily 4. Docusate 100mg PO bid 5. Senna 1 tab PO bid prn constipation 6. Dilaudid [**2-3**] tab PO q4-6h prn pain Discharge Medications: 1. Atovaquone 750 mg/5 mL Suspension Sig: Five (5) ml PO BID (2 times a day). Disp:*400 ml* Refills:*0* 2. Doxycycline Hyclate 100 mg Capsule Sig: One (1) Capsule PO Q12H (every 12 hours) for 7 days. Disp:*14 Capsule(s)* Refills:*0* 3. Azithromycin 250 mg Tablet Sig: Two (2) Tablet PO Q24H (every 24 hours). Disp:*60 Tablet(s)* Refills:*0* 4. Outpatient Lab Work Please check a weekly CBC on [**2175-10-4**], [**2175-10-11**], and [**2175-10-18**] and fax results to Drs. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] and [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 10351**] at [**Telephone/Fax (1) 82937**]. 5. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for headache. Disp:*20 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Primary: Babesiosis Idiopathic Thrombocytopenia Anemia Discharge Condition: Afebrile, vital signs stable, headache improved. Discharge Instructions: You were admitted to the hospital for an infection with Babesiosis. You were treated with antibiotics and a red blood cell trasfusion to help you clear the infection. You also had low platelet levels which required platelet transfusion and intravenous immunoglobulin treatment. Your infection is improved and your platelet levels have recovered. You will need to continue taking antibiotics to finish treating the infection. Please finish the prescribed course and follow up with Drs. [**Last Name (STitle) **] and [**Name5 (PTitle) 10351**] (hematology) and Dr. [**First Name (STitle) **] (infectious diseases). You will also need to check your blood count weekly at [**Hospital3 22439**] and they will fax the results to Dr. [**Last Name (STitle) **]. You will need to take the following medications: 1) Atovaquone Suspension 750 mg by mouth twice daily - Dr. [**First Name (STitle) **] will tell you how long you need to continue this medication. 2) Azithromycin 500 mg by mouth once daily - Dr. [**First Name (STitle) **] will tell you how long you need to continue this medication. 3) Doxycycline 100 mg by mouth twice daily - for 7 more days. You were given instructions in the hospital on how to avoid tick bites. This is important to prevent reinfection with babesiosis or other tick-born infections. Because you do not have a spleen, you are at increased risk for becoming sick from infections. Please seek medical attention if you develop a severe headache, fever, chills, nausea, vomiting, neck stiffness, lightheadedness, abdominal pain, or bleeding. Followup Instructions: Provider: [**First Name11 (Name Pattern1) 569**] [**Last Name (NamePattern4) 570**], MD Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2175-9-27**] 2:00 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 12633**], MD Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2175-9-27**] 2:00 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 288**], MD Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2175-9-29**] 9:00 Name: [**Last Name (LF) 13251**],[**Known firstname **] Unit No: [**Numeric Identifier 13252**] Admission Date: [**2175-9-14**] Discharge Date: [**2175-9-22**] Date of Birth: [**2140-12-29**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 8867**] Addendum: Platelets were 370 on the day of discharge. Discharge Disposition: Home [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 8868**] MD [**MD Number(2) 8869**] Completed by:[**2175-9-22**]

[ "388.30", "V45.79", "458.9", "283.9", "088.82", "458.29", "789.07", "082.40", "287.5" ]

icd9cm

[ [ [] ] ]

[ "99.05", "03.31", "99.14", "99.01" ]

icd9pcs

[ [ [] ] ]

13123, 13286

5179, 9373

331, 378

10532, 10582

3290, 5156

12200, 13100

2682, 2759

9631, 10405

10455, 10511

9399, 9608

10606, 12177

2774, 3271

277, 293

406, 2506

2528, 2557

2573, 2666

44,158

190,402

14315

Discharge summary

report

Admission Date: [**2195-2-10**] Discharge Date: [**2195-2-23**] Date of Birth: [**2120-1-22**] Sex: M Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 1481**] Chief Complaint: bright red blood per rectum Major Surgical or Invasive Procedure: OPERATIONS: Roux en Y, revision gastrectomy Esophagealgastrodudenoscopy (EGD) History of Present Illness: Pt is a 75yo man with h/o AAA s/p open repair [**2191**], h/o bleeding gastric ulcer s/p partial gastrectomy, p/w melena and anemia. Initially developed melena Sunday AM, with associated lightheadedness, and then BRBPR Sunday night. Yesterday AM went to OSH after speaking with PCP. [**Name10 (NameIs) 3754**], initial CBC showed Hct 24 (? baseline 30), so received 2units PRBCs with repeat Hct 25, so got an additional 4units PRBCs. EGD there reportedly showed bleeding at gastrojejunal anastamosis but no active visible site to treat. Colonoscopy was also attempted, which reportedly showed red blood to the ascending colon, but pt became bradycardic requiring atropine, so the procedure was aborted. Concern was raised for aorto-enteric fistula, so he was transferred here. Hct prior to transfer was 28, after receiving a total of 6units PRBCs over the last 2 days. This morning he was also tachycardic to the 140s in atrial fibrillation, after receiving the atropine, and he was treated with IVF. Cardiology was consulted, who recommended digoxin, but this was not given. Here, he denies any abdominal pain, nausea, vomiting, hematemesis, chest pain, or dyspnea. He takes a baby aspirin at home daily, and denies any recent NSAID or EtOH use. Past Medical History: - AAA s/p open repair [**2182**] - diabetes - hypertension - hyperlipidemia - tobacco use - h/o bleeding gastric ulcer - s/p partial gastrectomy - pernicious anemia - h/o injury to left eye s/p left eye lens implant - glaucoma - s/p CCY Social History: Retired construction worker. Former smoker 1ppd x 40yrs, denies EtOH. Family History: n/c Physical Exam: Vitals: AOx3, NAD RRR CTAB, good respiratory effort Abd soft, NT/ ND Incision well healed with staples in place, no drainage, no erythema or edema no pedal edema Pt able to ambulate without assistance Pertinent Results: Admission labs: [**2195-2-10**] 01:40PM BLOOD WBC-7.7 RBC-3.02* Hgb-9.2* Hct-25.9* MCV-86 MCH-30.6 MCHC-35.6* RDW-16.4* Plt Ct-162 [**2195-2-10**] 01:40PM BLOOD Neuts-76.1* Lymphs-18.1 Monos-4.6 Eos-0.7 Baso-0.5 [**2195-2-10**] 01:40PM BLOOD PT-13.6* PTT-27.1 INR(PT)-1.2* [**2195-2-10**] 01:40PM BLOOD Glucose-118* UreaN-16 Creat-0.6 Na-140 K-3.6 Cl-115* HCO3-21* AnGap-8 [**2195-2-10**] 01:40PM BLOOD ALT-9 AST-16 LD(LDH)-131 CK(CPK)-61 AlkPhos-34* Amylase-44 TotBili-0.5 [**2195-2-10**] 01:40PM BLOOD Albumin-2.9* Calcium-6.7* Phos-1.8* Mg-2.0 Iron-151 [**2195-2-10**] 01:40PM BLOOD calTIBC-272 Ferritn-148 TRF-209 Brief Hospital Course: Mr [**Known lastname 42484**] was transferred from an OSH and admitted to the vascular service on [**2195-2-10**] preop for his: He was made NPO after midnight and four units pRBCs crossmatched in preparation for the procedure. After his procedure, he was readmitted to the vascular surgery service , made NPO on IVF, on a PPI drip, and IV medications. He received a transfusion of 2 units pRBCs. A PICC was placed for access on [**2195-2-11**] He was then transferred to general surgery west 3 service with a GI bleed. He was continued on a PPI drip, on IV medications, kept NPO on IVF, with telemetry for monitoring. On [**2195-2-12**], he triggered after a large bloody bowel movement. He received 2uPRBCs, IVF boluses, and an EKG showed he was tachycardic to the 140s-150s in a fib which resolved after resusitation and a dose of lopressor. GI service performed an endoscopy which did not show a distint bleeding vessel or ulcer. Sulcrafate was added and he was transfused a unit of platelets.Biopsy from the bleeding area showed high grade dysplasia. His hematocrits were followed and he stayed on the floor. During this time he stayed NPO on telemetry. On [**2195-2-18**], he was taken to the OR for a revision gastrectomy. Post operatively he was kept NPO on IVF, on cipro for a UTI, with a foley for urine output [**Last Name (LF) 23367**], [**First Name3 (LF) **] NGT, a PPI drip, and on IV medications. He received several LR boluses while in the PACU and had a dilaudid PCA for pain control. He was switched to mIVF on [**2195-2-19**] and he was able to ambulate without assistance. On [**2195-2-20**] his cipro for his UTI was d/ced after completing a three day course and his oxygen supplementation was d/ced. His PCA was also d/ced and his pain well controlled on intermittant IV morphine. His NGT was d/ced on [**2195-2-20**]. His IVF were discontined on [**2195-2-21**] after he tolerated clears diet. On [**2195-2-22**] he was advanced to full liquids. He was also switched to PO pain medications. He was discharged home with glipizide and his metformin was held. His PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **], was called to schedule an appointment Wednesday at 1pm for close follow up. Medications on Admission: - aspirin 81mg daily - atorvastatin - glipizide - metformin - timolol Discharge Medications: 1. timolol maleate 0.5 % Drops Sig: One (1) Drop Ophthalmic DAILY (Daily). 2. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day for 1 months. Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*1* 3. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day) for 2 weeks: Please hold your dose if you experience any dizziness. . Disp:*14 Tablet(s)* Refills:*0* 4. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain for 40 doses: Please hold if you are dizzy or feel more sedated. . Disp:*40 Tablet(s)* Refills:*0* 5. glipizide 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Disposition: Home Discharge Diagnosis: Upper gastrointestinal hemorrhage High grade dysplasia of the stomach- probable invasive cancer- path pending Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [**Known lastname 42484**], It was a pleasure taking care of you during your hospitalization. You were admitted for an upper GI bleed and you had a procedure, called a Roux-en-Y and revision gastrectomy to manage your upper GI bleed. We have prescrbed You tolerated the procedure well and you are now ready to return home. Please call Dr.[**Name (NI) 1482**] office at [**Telephone/Fax (1) 2348**] if you have: -fevers greater than 101.5, chills or shakes -worsening cough or shortness of breath -drainage, swelling or redness from incisions -uncontrolled surgical pain Walk several times a day. While on narcotics for pain do not drive, and take stool softeners to avoid constipation. Please resume your home medications except for your aspirin. We encourage you to discuss resuming aspirin with Dr. [**Last Name (STitle) **] and your primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **]. Please hold your metformin and discuss when to restart this medication with your primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **]. No tub bathing or submerging in water until incisions fully healed (usually 2-4 weeks). You may shower after your discharge. You will need to have your staples removed in 7 - 10 days. Please call Dr.[**Name (NI) 1482**] office to schedule an appointment for staple removal. His office phone number is ([**Telephone/Fax (1) 1483**]. Followup Instructions: Please follow up with Dr. [**Last Name (STitle) **] in [**2-8**] weeks. Please call his office to make this appointment. His office number is: ([**Telephone/Fax (1) 8818**]. Please follow-up with your primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **], on Wednesday [**2-25**] at 1pm. Please call his office to schedule an appointment at [**Telephone/Fax (1) 30837**].

[ "578.9", "285.1", "427.31", "365.9", "E849.8", "998.11", "250.00", "151.4", "401.9", "997.4", "E878.2", "272.0" ]

icd9cm

[ [ [] ] ]

[ "43.7", "38.97", "44.43", "45.16" ]

icd9pcs

[ [ [] ] ]

6063, 6069

2937, 5171

331, 411

6223, 6223

2294, 2294

7834, 8239

2052, 2057

5292, 6040

6090, 6202

5197, 5269

6374, 7811

2072, 2275

264, 293

439, 1687

2311, 2914

6238, 6350

1709, 1948

1964, 2036

4,632

198,813

9327

Discharge summary

report

Admission Date: [**2119-4-13**] Discharge Date: [**2119-4-13**] Date of Birth: Sex: Service: CCU The patient is a 58-year-old male who presented to the Cath Lab for an elective cardiac catheterization. He has a history of recurrent chest pain and was referred to the [**Hospital3 **] Cardiac Cath Lab by Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **]. Other than recurrent chest pain over the last several weeks he had no further symptoms. He states that his last cath was in [**2115**], and at that time, he has had only occasional chest pain usually occurring at night after being out drinking and would easily respond to nitroglycerin. He has not noticed any exertional or rest angina, although when he was on a cruise several weeks prior to admission, there were several days where he awoke with mild chest discomfort. It did not resolve with nitroglycerin. He was seen by the ship doctor who told him that his EKG was within normal. Upon returning back home from his cruise, he had daily mild anginal symptoms and was therefore referred for catheterization by his local cardiologist. PAST MEDICAL HISTORY: Significant for coronary artery disease status post cardiac bypass surgery x2. He also has a history of hyperlipidemia and status post appendectomy as well as a history of high cholesterol. ADMISSION MEDICATIONS: 1. Aspirin 325 mg q.d. 2. Atenolol 25 mg q.d. 3. Prilosec 20 mg q.d. 4. Lipitor 40 mg q.h.s. 5. Norvasc 5 mg q.h.s. 6. Nitro paste 0.2 mg per hour during the day, off at night. 7. Valium p.r.n. ALLERGIES: There were no known drug allergies. PHYSICAL EXAMINATION: Initial examination revealed normal vital signs as well as an unremarkable physical exam. Lungs were clear. Cardiac, S1 and S2 were normal. No obvious murmurs. No peripheral edema. Neurologically intact. SOCIAL HISTORY: The patient is married. He denies any history of IV drug use, former tobacco, rare alcohol. ASSESSMENT: This is a 58-year-old man referred for cardiac catheterization on [**2119-4-13**]. HOSPITAL COURSE: Cardiac. The patient presented to the Cath Lab on the morning of [**2119-4-13**]. He was taken for cardiac cath. Diagnostic catheterization revealed native vessel coronary disease similar to his previous. He also was found to have a thrombus in his SVG to RCA that was initially treated successfully with angioplasty and stenting. However, several minutes after achieving an open SVG to RCA graft, he had an acute closure, which resulted in a cardiac arrest with a ventricular fibrillation arrest. Despite 45 minutes of CPR, he was unable to restore a native rhythm. Cardiac Surgery was consulted and initiation of ECMO occurred, which was initiated in the Cath Lab with eventual re-flow in the SVG graft. The patient was subsequently transferred to the CSRU. Unfortunately, the patient became progressively edematous and poor flow through the ECMO despite repositioning as well as bilateral chest tubes. The patient also developed increasing abdominal distension suggestive of an catastrophic intra-abdominal event. Poor prognosis was related to the family members and decision was made to withdraw measures and the patient passed away. CAUSE OF DEATH: Cardiac arrest secondary to acute closure of the SVG to RCA graft. TIME OF DEATH: [**2119-4-13**] at 4:50 p.m. Postmortem was declined by the family. Medical examiner was notified and the case was declined as well. [**First Name11 (Name Pattern1) 122**] [**Last Name (NamePattern4) 2462**], [**MD Number(1) 2463**] Dictated By:[**Last Name (NamePattern4) 20329**] MEDQUIST36 D: [**2119-7-3**] 11:51:52 T: [**2119-7-4**] 03:16:23 Job#: [**Job Number 31908**]

[ "E878.2", "789.40", "414.02", "414.01", "412", "427.41", "997.1", "427.5", "429.9" ]

icd9cm

[ [ [] ] ]

[ "36.01", "39.64", "88.72", "88.56", "99.20", "36.07", "37.61", "39.65", "37.22", "88.53", "99.04" ]

icd9pcs

[ [ [] ] ]

2082, 3742

1378, 1623

1646, 1856

1163, 1355

1873, 2064

18,737

110,846

44899

Discharge summary

report

Admission Date: [**2135-6-22**] Discharge Date: [**2135-7-1**] Date of Birth: [**2055-11-16**] Sex: F Service: MEDICINE Allergies: Codeine / Lipitor / Fosamax Attending:[**Doctor First Name 7926**] Chief Complaint: shortness of breath Major Surgical or Invasive Procedure: PICC line placement History of Present Illness: Ms. [**Known lastname **] is a 79 year old lady with pulmonary HTN (on adcirca, tyvaso, letairis), CAD s/p stents, HTN, and recent T5 + T8 compression fractures, diastolic CHF, and multiple other medical problems who presents because she is feeling unwell and has been short of breath lately. . She has been feeling unwell since her discharge from our hospital on [**2135-6-7**]. At the previous admission she was found to have two new spinal compression fractures at T5 and T8. She was treated for pain with tramadol, lido patch, and tylenol, but hasn't been taking her tramadol recently because she was worried about its long-term effects. She states that she has been splinting and not breathing well because her back pain worsens with movement, breathing, and lying flat. Back pain is [**2133-4-16**]. She states that she is still ambulatory and has always been SOB when walking, but it's worse now. She denies chest pain, cough, or recent episode of choking. She has required 5L of oxygen today but is usually on 4L at home. . As for her UTI, she denies dysuria, hematuria, urinary urgency and frequency, as well as nausea, vomiting, fever, or chills. She does endorse cloudy urine. She was discharged on her last admission with cipro 500 [**Hospital1 **] x 8 days (ended [**6-8**]) to treat a UTI. . Due to feeling poorly, she saw her PCP today, who referred her to our ER. At home today her BP was low - 80/50. Of note, she recently started hydrochlorothiazide 25 mg QHS three days ago. She also complains of leg edema to her hips, but states it's much improved today. . * has had pneumovax in last few years . On the floor, Vitals: 98.3 116/61 pulse 95 rr 18 O2 sat 92 on 5L . Review of sytems: (+) leg edema negative unless mentioned above. Past Medical History: - Coronary artery disease status post inferior MI with subsequent Cypher stenting to the mid RCA in [**2130-4-11**]. - Non-ST elevation MI in [**2133-12-12**] with cardiac catheterization that showed 80% OM1 lesion with subsequent stenting of the OM with a 2.5x18mm Endeavor DES. The LAD was stented with a 2.25 x 20 mm Taxus stents as well as an overlapping proximal 2.25 x 8 mm Taxus stent. This procedure was complicated by a small distal wire perforation without any extravasation. Due to a balloon-induced dissection in the LAD, a 3.0 x 23 Promus stent was deployed as well as a 2.5 x 12 mm Promus stent deployed in the LAD. - Chronic dyspnea on exertion with diastolic dysfunction and known pulmonary hypertension with right heart catheterization in [**2134-11-11**] showing a PA pressure of 71/28 with a mean PA 33mmHg with a wedge of 8mmHg. She was not responsive to vasodilator challenge in cath lab and thus is on advanced therapy with adcirca and tyvaso reporting mild symptomatic improvement. - Hypertension. - Hyperlipidemia. - TIA, bilaterall less than 40 % carotid stenosis ([**2130**]) - bladder diverticulosis - Obstructive Sleep apnea-Does use BiPAP - s/p right total knee replacement - osteopenia - GERD - s/p total Hysterectomy - Lung surgery to correct large diaphgram hernia - Kidney stone - childhood asthma Social History: Lives in [**Location (un) 96048**] with her dughter. Formerly employed as a nurse. [**First Name (Titles) **] [**Last Name (Titles) 96049**] socially in the past, but quit a long time ago. Never drank alcohol, denies illicit drugs. Family History: Mother died from colon ca, father with cardiac history and early MI. Physical Exam: Admission physical exam: Vitals- 98.3 116/61 pulse 95 rr 18 O2 sat 92 on 5L General- Alert, oriented, no acute distress but on NC 5L HEENT- Sclera anicteric, MMM, oropharynx clear Neck- supple, JVP prominent, no LAD Lungs- no wheezes, rales, ronchi, but mild crackles at bilateral bases CV- Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen- soft, obese, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU- foley in Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis, no edema Neuro- CNs2-12 intact, motor function grossly normal, appropriate Discharge physical exam: PHYSICAL EXAMINATION: VS- T=98.2 BP=116/58 HR=64 RR=18 O2 sat=94% on 4L I/O X past 8 hours: 0/200. I/O over [**2135-6-28**]: [**Telephone/Fax (1) 96050**] GENERAL- Obese elderly woman in NAD. On MRSA precautions. Oriented x3. Mood, affect appropriate. HEENT- NCAT. Sclera anicteric. Eyes w/ erythromycin ointment. EOMI. Conjunctiva were pink. CARDIAC- RR, S2 > S1. No m/r/g. No thrills, lifts. No S3 or S4. LUNGS- No chest wall deformities. Significant kyphosis. Resp are unlabored, no accessory muscle use. CTAB. ABDOMEN- Soft, NTND. EXTREMITIES- No c/c/e. 1+ pitting edema in LEs, not increased from prior exam. Pertinent Results: Admission labs: [**2135-6-22**] 09:47AM BLOOD WBC-8.4 RBC-3.73* Hgb-11.5* Hct-35.7* MCV-96 MCH-30.8 MCHC-32.2 RDW-15.5 Plt Ct-213 [**2135-6-22**] 09:47AM BLOOD Neuts-76.7* Lymphs-8.0* Monos-4.8 Eos-10.1* Baso-0.4 [**2135-6-23**] 06:00AM BLOOD PT-12.2 PTT-25.6 INR(PT)-1.1 [**2135-6-22**] 09:47AM BLOOD Glucose-117* UreaN-30* Creat-1.2* Na-138 K-3.8 Cl-95* HCO3-32 AnGap-15 [**2135-6-23**] 06:00AM BLOOD Calcium-8.9 Phos-3.7 Mg-2.0 [**2135-6-24**] 06:00AM BLOOD ANCA-NEGATIVE B [**2135-6-24**] 06:00AM BLOOD [**Doctor First Name **]-NEGATIVE [**2135-6-24**] 06:00AM BLOOD RheuFac-8 [**2135-6-25**] 11:53AM BLOOD Lactate-0.8 Radiology: [**2135-6-25**] Portable CXR: FINDINGS: As compared to the previous radiograph, there is an increase in interstitial markings and an increase in diameter of the pulmonary vasculature. In conjunction with the increased cardiac silhouette, these findings are suggestive of mild to moderate pulmonary edema. The presence of a minimal left pleural effusion cannot be excluded, given blunting of the left costophrenic sinus. At the time of observation and dictation, 10:38 a.m., the referring physician [**Last Name (NamePattern4) **]. [**Last Name (STitle) 96051**] was paged for notification, on [**2135-6-25**]. Given that no lateral radiograph was performed, the compression fractures cannot be evaluated. CXR [**2135-6-24**]: FINDINGS: "Massive degenerative changes in the cervical spine, but no evidence of compression. Mild compression of T5, massive compression of T8. As compared to previous chest radiographs that are available from [**2135-6-22**], these changes are constant. However, if compared to the chest radiograph of [**2134-11-2**], these changes have massively progressed. No evidence of new vertebral compression. The lumbar spine shows anterolisthesis of L5 with respect to S1 and moderate degenerative changes, but no evidence of vertebral compression. Extensive vascular calcifications. " EKG [**2135-6-25**]:Sinus rhythm. Prior inferior wall myocardial infarction. No major change from the previous tracing. Microbiology: URINE CULTURE (Final [**2135-6-26**]): STAPH AUREUS COAG +. >100,000 ORGANISMS/ML.. OF TWO COLONIAL MORPHOLOGIES. Oxacillin RESISTANT Staphylococci MUST be reported as also RESISTANT to other penicillins, cephalosporins, carbacephems, carbapenems, and beta-lactamase inhibitor combinations. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPH AUREUS COAG + | GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- =>8 R NITROFURANTOIN-------- 32 S OXACILLIN------------- =>4 R TETRACYCLINE---------- <=1 S TRIMETHOPRIM/SULFA---- <=0.5 S VANCOMYCIN------------ 1 S [**2135-6-22**] 10:56 pm BLOOD CULTURE FROM LEFT ARM. **FINAL REPORT [**2135-6-28**]** Blood Culture, Routine (Final [**2135-6-28**]): NO GROWTH. Echo [**2135-6-27**]: IMPRESSION: Suboptimal image quality. Right ventricular cavity dilation and free wall hypokinesis. Normal left ventricular cavity size with preserved global systolic function. Pulmonary artery hypertension. Compared with the prior study (images reviewed) of [**2135-5-30**], right ventricular cavity size is similar, but with more pronounced free wall dysfunction. The estimated PA systolic pressure is also lower. This suggests more prominent right ventricular systolic dysfunction. DISCHARGE LABS [**2135-7-1**] 07:06AM BLOOD WBC-6.9 RBC-3.31* Hgb-9.8* Hct-31.4* MCV-95 MCH-29.8 MCHC-31.3 RDW-15.2 Plt Ct-236 [**2135-7-1**] 07:06AM BLOOD Glucose-116* UreaN-34* Creat-1.2* Na-138 K-3.8 Cl-91* HCO3-39* AnGap-12 [**2135-7-1**] 07:06AM BLOOD Calcium-9.0 Phos-4.1 Mg-2.0 Brief Hospital Course: Patient is a 79yo F w/ PMHx pulmonary HTN (dCHF and primary pulm HTN related) (on adcirca, tyvaso, letairis), CAD s/p stents, HTN, and recent T5 + T8 compression fractures, diastolic CHF, and multiple other medical problems who presented on [**6-23**] feeling unwell and short of breath. Pt was admitted w/ suspicion for pneumonia. Chest X-ray showed likely atalectasis, no definite pneumonia, but revealed worsening of her known vertebral compression fractures since [**2134-10-12**]. Her EKG showed evidence of a known inferior infarct, but no ST elevations or depressions or T-wave changes to indicate an acute process. Troponins were negative. She was found to have UTI, and urine and blood cultures were sent. Pt was given vancomycin and levofloxacin. Pulmonary was consulted, who felt pt's dyspnea was likely secondary to atalectasis and splinting from her compression fractures, not pneumonia or acute worsening of PH, which is typically a more gradual process. Orthopedic surgery was consulted, who felt she was not a candidate for kyphoplasty. Her pain was treated with acetominophen, tramadol and lidocaine patches PRN. On [**6-25**] she received one does of morphine sulfate, which she did not tolerate well, becoming confused and somnolent. That same day, while receiving IVFs patient acutely desaturated, not responsive to supplemental oxygen. Flash pulmonary edema diagnosed. She was also found to be hypotensive, thought likely secondary to the narcotic dose she had received. She was transferred to the ICU. The patient presented to the MICU after triggering of the floor for hypoxia and altered mental status. When the patient arrived, she was somnolent but oriented to person, place, and time. The patient appeared volume overloaded with elevated JVD, 3+ pitting edema, and diffuse wheezing bilaterally. The patient's protable CXR at the time that she triggered on the floor showed interval progression of her pulmonary edema (of note, her diuretics had been discontinued). The patient also had increased serum creatinine from her baseline. Her constellation of symptoms were thought to be due to poor forward flow in the setting of acute on chronic right heart failure. Because of her low BPs, the patient was bolused with IV lasix and started on lasix gtt. The patient diuresed well to the lasix gtt. Her volume status, oxygen requirement, and serum creatinine improved with diuresis. Of note, the patient's lasix gtt had to be intermittently stopped for SBPs in the 70s-80s. On the AM, prior to transfer to the unit, the patient was noted to have MRSA in her urine. She was continued on Vancomycin for treatment of MRSA bacteruria and blood cultures were also drawn. TTE was done that did not show evidence of vegetations. The patient was called out to the Cardiology floor for further diuresis with lasix gtt. Pt was stable on arrival to the cardiology floor, with near-baseline oxygen demand and good urine output. She was taken off the lasix drip, and given 60 IV lasix [**Hospital1 **], to match the daily amount she had been receiving continuously. She tolerated this well, and continued to put out good urine with stable lytes. She was weaned to PO lasix 60 mg po bid. Letairis was also discontinued per recommendation from pulmonary, who felt it might be contributing to her dyspnea. She was discharged on a higher dose of PO lasix (60 vs. 40 mg po BID), and was advised to stop taking letairis. At discharge, pt's weight was 81.6 (measured late in the day; other weights taken in the early a.m.), about 2 kg below her admission weight. On the day before discharge, her [**Last Name (un) **], which had been held for her [**Last Name (un) **], was reinstated at 25 mg [**Hospital1 **], half of her home dose; on day of discharge her creatinine bumped to 1.2, and she had systolic blood pressures in the 80s to 90s. These episodes were asymptomatic, with good mentation and urine output, no chest pain or increased shortness of breath. For this reason we decreased her [**Last Name (un) **] further to 12.5 mg [**Hospital1 **], and also decreased her carvedilol, which had been increased to 25 mg [**Hospital1 **] during her inpatient stay, back to her home dose of 12.5 mg [**Hospital1 **] on discharge. At discharge she felt at her baseline in terms of breathing and activity, satting in the mid-90s on 4 liters of O2. TRANSITIONAL ISSUES: Patient is highly sensitive to fluid balance; She seems to do best at a weight of about 175 lbs, or 80 kg. Going forward, her I's and Os should be strictly monitored, with daily weights taken. Patient is being sent out on bactrim DS for her MRSA UTI, which was culture-proven sensitive to bactrim. She should take one tab PO BID, last day [**2135-7-4**]. Of note, patient experiences some nausea with this antibiotic, and should take this pill with food, separate from her other medications to avoid loss of daily meds through emesis. She has also responded well to taking compazine shortly before taking. Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from Patient. 1. Acetaminophen [**Telephone/Fax (1) 1999**] mg PO Q8H:PRN pain max daily dose 2. Atorvastatin 40 mg PO HS 3. Carvedilol 12.5 mg PO BID 4. Citalopram 20 mg PO DAILY 5. Fluticasone-Salmeterol Diskus (100/50) 1 INH IH [**Hospital1 **] 6. Furosemide 40 mg PO BID 7. Losartan Potassium 50 mg PO BID 8. Oxybutynin 2.5 mg PO BID 9. Ranitidine 300 mg PO DAILY 10. Tyvaso *NF* (treprostinil) 1.74 mg/2.9 mL (0.6 mg/mL) Inhalation 9 puffs q6h 9 puffs four times daily 11. Adcirca *NF* (tadalafil) 40 mg Oral QD 12. Aspirin 162 mg PO DAILY 13. Vitamin D [**2122**] UNIT PO DAILY 14. TraMADOL (Ultram) 100 mg PO Q 8H 15. Lidocaine 5% Patch 2 PTCH TD DAILY please apply on 12 hours and off 12 hours. One for shoulder and one for back. Per patient request. Thanks! 16. Hydrochlorothiazide 25 mg PO QHS Discharge Medications: 1. Acetaminophen [**Telephone/Fax (1) 1999**] mg PO Q8H:PRN pain max daily dose 2. Adcirca *NF* (tadalafil) 40 mg Oral QD 3. Aspirin 162 mg PO DAILY 4. Atorvastatin 40 mg PO HS 5. Citalopram 20 mg PO DAILY 6. Fluticasone-Salmeterol Diskus (100/50) 1 INH IH [**Hospital1 **] 7. Oxybutynin 2.5 mg PO BID 8. Ranitidine 300 mg PO DAILY 9. TraMADOL (Ultram) 100 mg PO Q 8H 10. Tyvaso *NF* (treprostinil) 1.74 mg/2.9 mL (0.6 mg/mL) Inhalation 9 puffs q6h 9 puffs four times daily 11. Vitamin D [**2122**] UNIT PO DAILY 12. Sulfameth/Trimethoprim DS 1 TAB PO BID 13. Carvedilol 12.5 mg PO BID HOLD for SBP < 100, HR < 60 14. Furosemide 60 mg PO BID 15. Lidocaine 5% Patch 2 PTCH TD DAILY: please apply on 12 hours and off 12 hours. One for shoulder and one for back. Per patient request. 16. Losartan Potassium 12.5 mg PO BID hold for sbp < 100 Discharge Disposition: Extended Care Facility: [**Hospital1 700**] - [**Location (un) 701**] Discharge Diagnosis: Pulmonary Hypertension Atelectasis with splinting Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. [**Known lastname **], It was a pleasure taking care of you during your stay here at [**Hospital1 69**]. You were admitted for shortness of breath and fatigue. You were found to have a urinary tract infection which we treated with antibiotics. You were also found to be breathing less deeply because of back pain, causing parts of your lungs to inflate less than normal. With increased control of your pain, and use of your incentive spirometer, this shortness of breath should improve. Some aspect of this shortness of breath may have to do with a medication you started recently, letairis, which we have discontinued. You are being discharged to [**Hospital3 **] center. You have appointments to follow up with your cardiologist's nurse practitioner, and with your pulmonologist (see appointments below). We have made some changes to your medications. We increased your furosemide (40 mg to 60 mg twice daily) and decreased your dose of losartan (50 mg to 12.5 mg twice daily). You are also being sent to rehab with 5 more days of Bactrim, the antibiotic for your MRSA UTI, which you should take through [**7-4**]. Be sure to review the medication reconciliation sheet to see what meds you are currently taking. Followup Instructions: You have the following appointments with your specialists: We are working on a follow up appointment in Pulmonary for your hospitalization with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]. It is recommended you be seen within 1 week of discharge. The office will contact you at the facility. If you have not heard within 2 business days please call the office at [**Telephone/Fax (1) 612**]. Department: CARDIOLOGY (HEART FAILURE) When: [**7-5**], 1:30 PM With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 62**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: CARDIOLOGY When: WEDNESDAY, [**8-3**], 1 PM With: DR. [**First Name (STitle) **] [**Doctor Last Name **] [**Telephone/Fax (1) 62**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: PULMONARY FUNCTION LAB When: WEDNESDAY [**2135-7-6**] at 9:40 AM With: PULMONARY FUNCTION LAB [**Telephone/Fax (1) 609**] Building: [**Hospital6 29**] [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: PFT When: WEDNESDAY [**2135-7-6**] at 10:00 AM Department: PULMONOLOGY When: WEDNESDAY [**2135-7-6**] at 10:00 AM With: DR. [**First Name (STitle) **]/DR. [**Last Name (STitle) **] [**Telephone/Fax (1) 612**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Completed by:[**2135-7-4**]

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icd9cm

[ [ [] ] ]

[ "38.97" ]

icd9pcs

[ [ [] ] ]

15745, 15817

8963, 13316

309, 330

15911, 15911

5105, 5105

17312, 18942

3731, 3801

14882, 15722

15838, 15890

13971, 14859

16062, 17289

3841, 4445

4492, 5086

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250, 271

2061, 2110

358, 2043

5122, 8940

15926, 16038

2132, 3466

3482, 3715

4470, 4470

29,691

138,008

8784

Discharge summary

report

Admission Date: [**2190-11-21**] Discharge Date: [**2190-12-3**] Date of Birth: [**2113-6-4**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1384**] Chief Complaint: large bowel obstruction/inguinal hernia Major Surgical or Invasive Procedure: left inguinal hernia repair with mesh [**2190-11-21**] History of Present Illness: 77 yo M s/p laparocscopic cholecystectomy on ([**2190-7-8**]) now with 2 days of abdominal pain, and distention. He also has had vomiting for 2 days. He has poor PO intake. Denies fever, chills or night sweats, and diarrhea. He has noticed smaller caliber of stool. He had periumbilical pain, exacerbated and relieved by nothing. Last bowel movement this morning and positive flatus in the AM. CT of abdomen at the OSh showed a large amount of increased density ascites and diffuse distention of small bowel. Past Medical History: CAD, Hypertension, atrial fibrillation, DM, chronic anemia, aortic stenosis, COPD, CHF EF 20-25% on [**7-10**], Chronic renal insufficiency baseline creatinine between 1.6-2.3 since [**2188-4-8**], hypothyroidisn. PSH: CABG x 4 vessel disease and mitral valve replacement, pacemaker placed, Left hip replaced, right knee replaced, lap chole on [**7-10**], cataract surgery [**2190-11-21**] Repair of left inguinal hernia with mesh and Large volume paracentesis;surgeon Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 816**] MRSA + [**2190-11-21**] Social History: Retired bread maker.Denies ETOH or tobacco use Family History: n/c Physical Exam: VS: T 97.7 HR 89 BP 118/73 RR 14 O2 Sat 100% on RA Gen: NAD Lung: Clear to ausculation bilaterally CV: RRR Abdomen: Distended, tympanitc, diffuse mild tenderness in the upper quadrant Bilateral inguinal hernias felt, both are reducble but with tenderness Pertinent Results: [**2190-11-21**] 12:20AM PT-15.7* PTT-28.8 INR(PT)-1.4* [**2190-11-21**] 12:20AM PLT COUNT-449* [**2190-11-21**] 12:20AM WBC-12.3* RBC-3.76* HGB-8.9* HCT-29.6* MCV-79* MCH-23.8* MCHC-30.2* RDW-15.6* [**2190-11-21**] 12:20AM ALBUMIN-3.5 CALCIUM-9.2 PHOSPHATE-4.5 MAGNESIUM-2.3 [**2190-11-21**] 12:20AM LIPASE-13 [**2190-11-21**] 12:20AM ALT(SGPT)-7 AST(SGOT)-13 ALK PHOS-92 AMYLASE-47 TOT BILI-0.7 [**2190-11-21**] 12:20AM GLUCOSE-117* UREA N-43* CREAT-1.8* SODIUM-142 POTASSIUM-4.1 CHLORIDE-103 TOTAL CO2-25 ANION GAP-18 [**2190-11-21**] 01:42AM LACTATE-1.3 [**2190-12-3**] 04:35AM BLOOD WBC-13.4* RBC-3.61* Hgb-8.9* Hct-28.4* MCV-79* MCH-24.6* MCHC-31.3 RDW-18.1* Plt Ct-327 [**2190-12-3**] 04:35AM BLOOD PT-14.6* PTT-30.9 INR(PT)-1.3* [**2190-12-3**] 04:35AM BLOOD Glucose-87 UreaN-65* Creat-1.8* Na-139 K-3.4 Cl-100 HCO3-29 AnGap-13 [**2190-12-3**] 04:35AM BLOOD ALT-6 AST-16 AlkPhos-60 TotBili-0.7 [**2190-11-24**] 06:00AM BLOOD Lipase-17 [**2190-11-26**] 08:07PM BLOOD CK-MB-4 cTropnT-0.04* [**2190-12-3**] 04:35AM BLOOD Calcium-8.1* Phos-3.4 Mg-1.9 [**2190-11-22**] 03:46PM BLOOD calTIBC-183* Ferritn-58 TRF-141* [**2190-11-26**] 08:12PM BLOOD Ammonia-24 [**2190-11-30**] 04:36AM BLOOD TSH-10* [**2190-11-28**] 02:10AM BLOOD Phenyto-2.9* Brief Hospital Course: On [**2190-11-21**] he underwent repair of left inguinal hernia with mesh and 4 liter paracentesis for left inguinal hernia with large bowel obstruction. Surgeon was Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 816**]. Please see operative report for details. Postop, he was sent to the SICU for low urine output (12cc/d)and increased creatinine to 3.1 from baseline of 1.8. He required CVVHD via a temporary line for two days then lasix and albumin were given for diuresis. Two units of PRBC were given for a hct of 24. Hct increased to 31 then stablized around 27. He required BP pressure support. He was intubated until pod 2. On [**11-23**] he was febrile to 101.2. Culture have been negative to date. A renal u/s was done, but limited, especially for evaluation of renal vascular flow due to patient's body habitus. The ascites was at least moderate. The liver echogenicity was normal with no intrahepatic biliary ductal dilatation. The right kidney measures 10.1 cm and the left kidney 9.6 cm. Right interpolar renal cyst measured 2.3 cm and corresponded to that seen on CT. There was no hydronephrosis or renal calculus. The urinary bladder was not distended. A TTE was done to evaluate cardiac function. This demonstrated an EF of 34-40% and moderate regional LV dysfunction, moderate pulmonary artery systolic hypertension with moderate dilatation and hypokinesis of the RV. There was a mitral valve prosthesis functioning normally and mild aortic stenosis. Beta blockers were started for rate control of chronic afib. Cardiology saw him and recommended amiodarone for rhythm control with loss of atrial kick. Aspirin was started per cardiology recommendation. Coumadin was not resumed as the patient stated that he took himself off secondary to a bad nose bleed that he was hospitalized for ~6 weeks prior. He refused to start coumadin. A TSH was 10 on [**11-30**]. Levoxyl was increased to 0.1mg from 0.05mg. PT recommended rehab for strengthening, balance and independence. He required [**Doctor Last Name **] lifting to transfer out of bed. OT recommended rehab to maximize strength and independence. He was on fall precautions. Pain med was given prior to working with PT for complaints of joint pain in left elbow/ right shoulder and edematous scrotum. Urine output increased to to 2800cc/day. Creatinine trended back down to 1.8. BP ranged between 193/84 to 100/55 with heart rates of 90-low 100s in afib. Mental status was alert with intermittent periods of confusion with place/time. He was easily re-oriented. The plan is for rehab at [**Hospital1 **]. He will follow up in 1 week. Duoderm was applied to his sacral area for redness. Medications on Admission: doesn't know meds, these from d/c on [**2190-7-10**]): atenolol 25", coumadin 5', capoten 12.5'", lasix 60', ASA 81', synthroid 0.05 ', Dilantin 100"", Darvocet prn pain, protonix 40', glyburide 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. Insulin Regular Human 100 unit/mL Solution Sig: follow sliding scale Injection ASDIR (AS DIRECTED). 4. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Phenytoin 50 mg Tablet, Chewable Sig: Three (3) Tablet, Chewable PO BID (2 times a day): morning and noon. 8. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1) Capsule PO QPM (once a day (in the evening)). 9. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 10. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO BID (2 times a day): hold HR <60 or SBP <110. 11. Aspirin EC 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 12. Furosemide 60 mg IV BID Discharge Disposition: Extended Care Facility: [**Hospital **] Medical Center - [**Hospital1 3597**] Discharge Diagnosis: bowel obstruction left inguinal hernia repair Discharge Condition: good Discharge Instructions: Please call [**Telephone/Fax (1) 673**] if fever, chills, nausea, vomiting, increased abdominal pain, lethargy, jaundice or incision redness/bleeding/drainage. Followup Instructions: follow up with [**First Name11 (Name Pattern1) 819**] [**Last Name (NamePattern4) 820**], MD (surgeon) Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2190-12-9**] 8:50 Please schedule follow up appointment with PCP Completed by:[**2190-12-3**]

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icd9cm

[ [ [] ] ]

[ "38.91", "38.93", "53.03", "99.04", "89.64", "38.95", "88.72", "54.91", "39.95" ]

icd9pcs

[ [ [] ] ]

7225, 7305

3211, 5900

354, 411

7395, 7402

1926, 3188

7612, 7858

1626, 1631

6145, 7202

7326, 7374

5926, 6122

7426, 7588

1646, 1907

275, 316

439, 955

977, 1545

1561, 1610

17,583

187,517

14402

Discharge summary

report

Admission Date: Discharge Date: [**2102-5-10**] Service: CME HISTORY OF PRESENT ILLNESS: The patient is an 86 year old Caucasian female with a history of hypercholesterolemia, right bundle branch block on EKG, and osteoporosis, who was in her usual state of health until two days prior to admission when she had intermittent nausea and weakness. The patient states that she has been unable to get up from a chair secondary to weakness. She denies palpitations, PND, orthopnea. She has stable lower extremity edema, perhaps slightly worse over the last day. She denies chest pain or pressure. She reports intermittent dizziness but no episodes of loss of consciousness. The patient's daughter, who is a nurse, noted the patient to be bradycardic and brought the patient to the E.D., where on EKG she was noted to have a new left bundle branch block and to be in complete heart block with an atrial rate of 110 and a ventricular rate of 40. The patient's daughter reports that an EKG one week prior to admission did not have a complete heart block. PAST MEDICAL HISTORY: Hyperlipidemia. Gastroesophageal reflux disease. Hiatal hernia. Dementia. Catatonic depression. Spinal stenosis, status post surgery. Urinary retention. Osteoporosis. Cataracts. Biceps tendon repair. Chronic constipation. Sciatica. MEDICATIONS: Fosamax 70 mg q.week. Protonix 40 mg q.day. Nortriptyline 50 mg q.p.m. Trilafon 4 mg q.p.m. Multivitamin. Vitamin E. Calcium. Vitamin D. Fibercon. Flax seed oil. Ocular eyedrops 1 drop o.u. b.i.d. Advil 400 mg t.i.d. SOCIAL HISTORY: The patient previously lived in an assisted- living facility for many years until her husband passed away; now she lives with her daughter, who is a nurse and performs all of her ADL. She denies a history of tobacco, alcohol, or drug use. PHYSICAL EXAMINATION: General: BP 120/70, heart rate 41, respirations 12, 99 percent on room air. In general, the patient is an elderly woman in no acute distress with a depressed affect. HEENT: Normocephalic, atraumatic. Extraocular movements are intact. Oropharynx is clear. Dry mucous membranes. Chest: Lungs are clear to auscultation bilaterally aside from mild bibasilar crackles. Heart: Bradycardic. No murmurs, rubs, or gallops. Abdomen: Soft, nondistended, with mild tenderness on palpation in the suprapubic region with normoactive bowel sounds. Extremities: No clubbing or cyanosis. There is 2+ bilateral pitting edema. DP pulses are 2+ bilaterally. All extremities are cool. LABORATORY DATA: White blood cells 11.9, hematocrit 27.5, platelets 305, sodium 137, potassium 4.3, chloride 103, bicarb 27, BUN 22, creatinine 1.0, glucose 93, iron 2.1, calcium 11.7, phosphorus 4.1, INR 1.1. HOSPITAL COURSE: COMPLETE HEART BLOCK: The patient was noted to be in complete heart block on admission EKG, was admitted to the Coronary Care Unit for temporary pacer wire placement. She received a temporary pacer wire on the evening of admission. On [**2102-5-9**], the patient was taken for a pacemaker. The patient underwent an uncomplicated placement of a dual-chamber pacemaker. Upon return to the floor, the patient complained of 6 out of 10 chest pressure substernally without radiation. Her cardiac enzymes were not elevated and she had no EKG changes. Her cardiac enzymes were cycled and were noted to be normal. The patient's chest pressure resolved overnight. The site of the pacemaker was stable and nontender without evidence of hematoma. An echocardiogram performed after pacemaker placement revealed a very small anterior pericardial effusion. A repeat echocardiogram done the following morning showed no change in the small effusion. The patient's nonsteroidal anti- inflammatory medications were held. CORONARY ARTERY DISEASE: The patient has no known history of coronary artery disease. An LDL was 97. The patient was given aspirin throughout her brief hospitalization. As noted previously, she had complaints of mild chest pressure after her pacemaker placement but had cycled cardiac enzymes which were normal and no EKG changes. BONE LUCENCY: Noted on a chest x-ray was a right humerus lucency. This was confirmed with a right shoulder film which confirmed a focal lucent lesion in the proximal right humerus shaft with an ill-defined border. This lucent lesion was concerning for metastatic disease, multiple myeloma, or a benign bony lesion. The patient had an S-pep and a U-pep which were sent and were negative. She was evaluated with a breast exam that was normal. It is anticipated that a further workup for this right humerus lucency will be performed as an outpatient and the patient's primary care physician was [**Name (NI) 653**] prior to discharge. OSTEOPOROSIS: The patient was continued on alendronate, vitamin D and calcium throughout her brief hospitalization. GASTROESOPHAGEAL REFLUX DISEASE: The patient was continued on her Fibercon, flax seed oil, and proton pump inhibitor throughout this hospitalization and was asymptomatic. PSYCHIATRIC: The patient was continued on her outpatient dose of nortriptyline and had a stable, somewhat flat affect throughout her hospitalization. ANEMIA: The patient was noted to have a somewhat low hematocrit throughout her hospitalization that was stable. The etiology of this is somewhat unclear. The patient was guaiac negative on admission. It is anticipated that the patient's hematocrit and iron studies will be followed by her primary care physician as an outpatient. CONDITION ON DISCHARGE: Good. DISCHARGE STATUS: The patient is discharged to home. DISCHARGE DIAGNOSES: Complete heart block, status post pacemaker placement. Hyperlipidemia. Gastroesophageal reflux disease/hiatal hernia. Depression. Anemia. Osteoporosis. MEDICATIONS: Alendronate sodium 70 mg p.o. q.week. Pantoprazole 40 mg p.o. q.day. Nortriptyline 50 mg p.o. q.h.s. Multivitamin 1 cap p.o. q.day. Vitamin E 400 units p.o. q.day. Calcium carbonate 500 mg p.o. t.i.d. Vitamin D 400 units p.o. q.day. Ketorolac 0.5 percent one drop o.u. b.i.d. Perphenazine 4 mg q.a.m. Flax seed oil. Fibercon. FOLLOW UP: The patient has a followup appointment with her primary care physician [**Last Name (NamePattern4) **] [**2102-5-12**] at 1:45 p.m. She is instructed to have her hematocrit and iron studies drawn the day after admission to be followed up by her primary care physician. [**Name10 (NameIs) **] patient's primary care physician will also follow up on the right shoulder lucency seen on x-ray. The patient also has a followup appointment with cardiology on [**2102-5-16**] at 2:00 pm. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 4958**] Dictated By:[**Last Name (NamePattern1) 12325**] MEDQUIST36 D: [**2102-5-10**] 20:55:35 T: [**2102-5-10**] 22:33:44 Job#: [**Job Number 42669**]

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icd9cm

[ [ [] ] ]

[ "37.83", "37.72" ]

icd9pcs

[ [ [] ] ]

5646, 6145

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113, 1079

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5577

Discharge summary

report

Admission Date: [**2175-1-23**] Discharge Date: [**2175-1-27**] Service: MEDICINE Allergies: Codeine / Univasc / Hydrochlorothiazide Attending:[**First Name3 (LF) 1145**] Chief Complaint: Chest pain and shortness of breath Major Surgical or Invasive Procedure: expired History of Present Illness: The patient is an 87 year old female with a history of atrial fibrillation, hypertension, hyperlipidemia who presents with chest pain and shortness of breath x 2 days. The patient says that she was in her usual state of health prior to two days ago. She went to bed on Saturday night and one hour after she went to sleep she was woken up by pain in her chest and difficulty breathing. She describes the pain as being a crushing pain across across her chest. It radiated to her shoulder blades and down her arms. The pain was associated with shortness of breath. It was not associated with nausea, vomiting or diaphoresis. The pain lasted for the entire night and finally went away in the morning. She felt fine during the day on Sunday. She went to bed again Sunday night and experienced the pain again in the morning. It again lasted for approximately an hour and at that time she decided to call an ambulance. Of note the patient also notes worsening lower extremity edema over the past two days. The patient reports that she has never had chest pain in the past. She does get short of breath with exertion but feels that this is partially secondary to deconditioning. She can walk around her apartment without getting short of breath but cannot climb stairs secondary to feeling fatigued. Her family does say that she has dyspnea on exertion. . The patient's initial vitals at [**Hospital3 4107**] were T: 97.8 P: 74 RR: 18 BP: 108/74 O2: 99% on 2L. She received aspirin 325 mg x 1 by EMS. On arival to the hospital she was pain free. EKG showed normal sinus rhythm, normal axis, normal intervals, no ST segment changes. She received lasix 40 mg IV x 1 and as placed on a heparin drip without a bolus. She received atorvastatin 80 mg and plavix 300 mg. Her labs were notable for a WBC of 9.2, Hct of 34.7 and Plts 212. BUN 25 and Creatinine 1.5. Her BNP was measured at 901. INR of 3.7. Troponin 1.0. The heparin drip was stopped because it was felt that her troponin elevation might be secondary to her renal insufficiency. She as transferred to [**Hospital1 18**] for further management. . On arrival to [**Hospital1 18**] her vials were T: 96.2 HF: 64 BP: 136/64 RR: 16 O2: 97% on RA. EKG from [**Hospital1 18**] showed normal sinus rhythm, normal axis, normal intervals, TWI in V1 and flat in V2, V3. Otherwise no acute ST setgment changes. She had a CXR which showed no acute cardiopulmonary process and no significant evidence of edema. She was transferred to the floor for further management. . On review of systems she denies lightheadedness, dizziness, chest pain or pressure, shortness of breath, nausea, vomiting, abdominal pain, diarrhea, constipation, dysuria, hematuria. leg pain. She does report leg swelling over the past two days. She denies orthopnea or PND. Past Medical History: 1. Atrial fibrillation 2. Hypertension 3. Hyperlipidemia 4. Osteoporosis 5. Osteoarthritis 6. Diverticulosis and diverticulitis 7. Hemorrhoids 8, Gastritis 9. s/p ERCP for isolated increases in alk phos, [**Doctor First Name **]/lip, and asx biliary ductal dilations, complicated by small bowel perf s/p repair 10. Lower GI bleed [**2170**] requiring 4 Units PRBC's and embolization in interventional radiology. 11. Iron deficiency anemia 12. Depression 13. Small secundum ASD 14. Valvular heart disease 3+ TR, 2+ MR . PAST SURGICAL HISTORY 1. s/p appy 2. s/p chole 3. s/p TAH 4. s/p Bithroth II for bleeding peptic ulcer in [**2117**] 5. s/p cataract surgery 6. s/p Hemorroidectomy 7. s/p Back surgery Social History: The patient lives in [**Hospital1 **] by herself. She does not smoke and denies ethanol use. She denies illicit drug use. Family History: Her mother died of pneumonia at age 45. Her father died of CAD at age 53. She has one brother who died at age [**Age over 90 **]. Her sister is still alive. Physical Exam: Vitals: T: 95.1 BP: 120/60 HR: 60 RR: 20 O2: 99% on 2L General: elderly female, lying in bed on one pillow in no acute distress HEENT: PERRL, EOMI, MMM, sclera anicteric, oropharynx clear Neck: JVP not elevated, no LAD CV: RRR, S1 + S2, no murmurs, rubs, gallops Resp: clear to auscultation bilaterally, no wheezes, rales, ronchi GI: soft, non-tender, non-distended, +BS GU: no foley Ext: WWP, trace edema to shins bilaterally, no clubbing or cyanosis Neurologic: grossly intact Pertinent Results: Transfer Laboratories: Troponin 0.1 BNP 901 . Admission Laboratories: Hematology: [**2175-1-23**] 04:55AM WBC-10.5 RBC-4.24 HGB-13.1 HCT-38.5 MCV-91 MCH-30.8 MCHC-33.9 RDW-14.5 [**2175-1-23**] 04:55AM NEUTS-61.4 LYMPHS-30.3 MONOS-5.4 EOS-2.4 BASOS-0.6 [**2175-1-23**] 04:55AM PLT COUNT-263 [**2175-1-23**] 04:55AM PT-33.2* PTT-50.4* INR(PT)-3.5* . Chemistries: [**2175-1-23**] 04:55AM GLUCOSE-113* UREA N-26* CREAT-1.5* SODIUM-139 POTASSIUM-5.5* CHLORIDE-100 TOTAL CO2-24 ANION GAP-21* [**2175-1-23**] 06:29AM POTASSIUM-4.6 . Urinalysis: [**2175-1-23**] 05:10AM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.010 [**2175-1-23**] 05:10AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-0.2 PH-6.5 LEUK-TR [**2175-1-23**] 05:10AM URINE RBC-0 WBC-0-2 BACTERIA-NONE YEAST-NONE EPI-<1 . Cardiac Enzymes: [**2175-1-23**] 04:55AM CK(CPK)-161* [**2175-1-23**] 04:55AM CK-MB-6 cTropnT-0.15* . EKG from [**Hospital1 **]: EKG showed normal sinus rhythm, normal axis, normal intervals, no ST segment changes. . EKG from [**Hospital1 18**]: EKG from [**Hospital1 18**] showed normal sinus rhythm, normal axis, normal intervals, TWI in V1 and flat in V2, V3. . CXR: no acute cardiopulmonary process . Echocardiogram The atria are moderately dilated. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. There is moderate to severe regional left ventricular systolic dysfunction with akinesis of the anterior wall, anterior septum, and the all of the distal LV segments/apex. The inferior/inferolateral segments contract normally. Quantitative (biplane) LVEF = 32%. No masses or thrombi are seen in the left ventricle. . Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Moderate (2+) mitral regurgitation is seen. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] The tricuspid valve leaflets are mildly thickened. Moderate to severe [3+] tricuspid regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is a trivial/physiologic pericardial effusion. IMPRESSION: Moderate to severe regional left ventricular systolic dysfunction. Mild aortic regurgitation. At least moderate mitral regurgitation. Moderate to severe tricuspid regurgitation. Moderate pulmonary hypertension. Compared with the prior study (images reviewed) of [**2174-11-16**], extensive regional wall motion abnormalities are new and pulmonary pressure is higher. The other findings are similar. Brief Hospital Course: The patient is an 87 year old female with a history of atrial fibrillation, hypertension, hyperlipidemia who presents with chest pain and shortness of breath x 2 days. . Chest Pain/Coronary Artery Disease: On presentation the patient described atypical chest pain. It was diffuse in nature and prolonged in its time course. It was assocatiated with shortness of breath. It was worst in her scapular region bilaterally and down her arms. Her arms were significantly painful to the touch, particularly when using a blood pressure cuff. On admission her cardiac enzymes were mildly elevated and this was of unclear significant. She underwent repeat echocardiogram on [**2175-1-26**] which revealed extensive new regional wall motion abnormalities compared with her previous study in [**2174-11-7**]. Echocardiographic appearance did not suggest a hyperacute infarct. On hospital day [**2-9**] her cardiac enzymes were stable with a troponin in the range of 0.3. On hospital day four she was noted to have an increase in her troponin to 0.84 which peaked at 0.9. It is unclear whether she suffered a new infarction or other cause of circulatory failure such as sepsis given that she also developed a leukocytosis. She developed bradycardia and hypotension to the 60s systolic. She was transferred to the ICU and had a central line placed for more aggressive resuscitation. Her condition did not improve and the decision was made to use comfort measures only. The patient expired on hospital day four. Acute Renal Failure: On the morning of hospital day four the patient was noted to have developed acute renal failure with increase in her creatinine from 1.7 to 3.6. She also was noted to be oliguric producing 80 cc urine over the entire day. She had a renal ultrasound which was negative for obstruction. Her urine electrolytes were consistent with prerenal azotemia. She was treated with fluid ressucitation. Atrial Fibrillation: No evidence of arrhythmias during this hospitalization on telemetry. She was continued on sotalol and her coumadin was held given elevated INR on presentation. Urinary Tract Infection: Patient was found to have an e coli urinary tract infection on presentation for which she was started on bactrim. On the day of her expiration repeat urine culture also grew gram negative rods. Blood cultures taken on her final hospital day are negative at the time of this discharge. It was unclear whether she ultimately passed from cardiogenic shock vs. distributive shock from sepsis. Hypertension: Patient was originally maintained on her outpatient regimen of metoprolol and norvasc. On hospital day four she developed circulatory collapse with hypotension and inappropriate heart rate response. Medications on Admission: Lipitor 10 mg daiy Magnesium Oxide 400 mg [**Hospital1 **] Metoprolol 50 mg [**Hospital1 **] Mirtazapine 15 mg QHS Norvasc 10 mg daily Sotalol 120 mg [**Hospital1 **] Warfarin 2 mg QHS Vitmain D3 400 mg daily Calcium 1000 mg daily Colace Tylenol Iron 325 mg daily Discharge Disposition: Expired Discharge Diagnosis: expired Discharge Condition: expired Discharge Instructions: expired Followup Instructions: expired

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icd9cm

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[ "38.93", "38.91" ]

icd9pcs

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34899

Discharge summary

report

Admission Date: [**2177-1-31**] Discharge Date: [**2177-2-12**] Date of Birth: [**2127-6-3**] Sex: M Service: NEUROSURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1835**] Chief Complaint: loss of consciousness, R arm weakness, aphasia Major Surgical or Invasive Procedure: [**2177-2-6**]; Left Frontal Crani for Mass resection History of Present Illness: 49 year old male from [**Country 5881**] with a history of metastatic renal cell renal cell CA s/p radical nephrectomy, got IL-2 in [**11-5**] who presents with right sided paralysis and aphasia. He was at a hotel today and fell. He was then noted to have right sided weakness and facial droop. Per report he did not have any tonic-clonic motions, no tongue biting, no incontinence. He only remembers a strange feeling in his face and then waking up in the emergency room. The patient took dose of lovenox today in preparation of flying back to [**Country 5881**]. He was BIBA to [**Hospital1 18**] as a code stroke. The patient currently notes some difficulty speaking and moving his right arm, both of which he states are improved since the ED. He denies any facial or extremity numbness or tingling. . In the ED, he was initially mute and had right sided arm weakness. He received a head CT and head MRI which showed a left frontal lobe lesion c/w metastatis with vasogenic edema. He was seen by neurology who thought he may have had a seizure rather than a stroke and recommened anti-epileptic and dexamethasone. He was loaded with dilantin and given dexamethasone 10mg IV. He was also seen by neurosurgery who did not think he needed surgical intervention. The neurosurgical team reccomended protamine to reverse lovenox. Over the course of his stay in the ED, he deficits began to correct with improvement in speech and improved strength in right arm. Vitals 98.1 112 134/94 16 96%3L NC . Of note, pt was recently discharge after left upper lobe VATS wedge resection by Dr. [**Last Name (STitle) **] for an enlarging left upper lobe nodule, on [**2177-1-17**]. Past Medical History: - RCC L kidney with pulmonary metastases diagnosed in [**7-/2175**], s/p high dose IL-2 treatment x 2 cycles - stereotactic radiosurgery to brain met in [**10-7**] - s/p radical L nephrectomy - IL-2-induced hypothyroidism - PE, DVT on enoxaparin SC s/p 9mo anticoagulation now just on lovenox with air travel Social History: lives in [**Country 5881**], energy trader, married; no tob/alcohol or illict drugs Family History: Mother with thyroid condition. Father with vascular disease, heart disease, died after a stroke. Maternal uncle with small cell lung cancer after >120 pack-year history. Physical Exam: Exam on Admission: T-97.3 BP- 126/80 HR-86 RR- 22 O2Sat 97%RA Gen: sitting up in bed, in NAD HEENT: NC/AT, moist oral mucosa Neck: No tenderness to palpation, normal ROM, supple, no carotid or vertebral bruit Back: No point tenderness or erythema CV: RRR, Nl S1 and S2, no murmurs/gallops/rubs Lung: Clear to auscultation bilaterally aBd: +BS soft, nontender ext: no edema Exam on Discharge: Alert, oriented to person, place and date. Right facial droop. PERRL. EOMI. Pt is presently non-verbal. LUE and bilateral lower extremities are full strength. RUE is with weakness in the right hand ([**1-31**]), and [**3-3**] bicep weakness. Pertinent Results: [**2177-1-31**] 01:50PM GLUCOSE-117* UREA N-14 CREAT-1.1 SODIUM-142 POTASSIUM-3.8 CHLORIDE-102 TOTAL CO2-21* ANION GAP-23* [**2177-1-31**] 01:50PM estGFR-Using this [**2177-1-31**] 01:50PM WBC-10.5 RBC-5.12 HGB-14.8 HCT-43.9 MCV-86 MCH-29.0 MCHC-33.8 RDW-12.4 [**2177-1-31**] 01:50PM PLT COUNT-519* [**2177-1-31**] 01:50PM PLT COUNT-519* COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH M CHC RDW Plt Ct [**2177-2-11**] 05:45AM 8.5 4.10* 12.3* 34.9* 85 30.0 35.3* 12.5 337 [**2177-2-10**] 06:55AM 8.5 4.18* 12.1* 34.6* 83 29.0 35.0 12.5 317 [**2177-2-9**] 07:10AM 12.4 4.10* 12.3* 34.8* 85 30.1 35.4* 12.5 316 RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap [**2177-2-11**] 05:45AM 122*1 25* 0.8 137 3.8 101 26 14 [**2177-2-10**] 06:55AM 124*1 23* 0.8 138 4.2 102 23 17 [**2177-2-9**] 07:10AM 123*1 18 0.8 135 4.0 100 26 13 [**2177-1-31**]: IMPRESSION: 1.5 cm enhancing lesion at the frontal left [**Doctor Last Name 352**]-white matter junction with surrounding edema. The appearances are most suggestive of metastatic disease. No other foci of abnormal enhancement are seen. MRI Head [**1-31**]: 1.5 cm enhancing lesion at the frontal left [**Doctor Last Name 352**]-white matter junction with surrounding edema. The appearances are most suggestive of metastatic disease. No other foci of abnormal enhancement are seen. Functional MRI [**2-6**]: FINDINGS: There is an unchanged left frontal mass lesion with significant associated vasogenic edema previously demonstrated by MRI on [**2177-1-31**]. The functional MRI demonstrates the expected activation areas during the movement of the hands and feet, during the movement of the left hand, there is a possible supplementary area adjacent to the mass lesion versus venous contamination (601B:9). The functional MRI of the language demonstrates the major activation areas on the left cerebral hemisphere, likely related with dominance. During the movement of the tongue, there are activation areas surrounding the mass lesion posteriorly (1000:8) and apparently at less than 1 cm of distance from the mass lesion. The ASL sequence demonstrate avid pattern of perfusion within the mass, suggesting increased vascularity. IMPRESSION: The expected activation areas were demonstrated with BOLD functional MRI sequences. During the movement of the left hand, there is a possible supplementary area at the left frontal cortex versus venous contamination. During the movement of the tongue, there is an area of activation posterior to the mass lesion described in detail above. The ASL sequence demonstrates avid pattern of perfusion within the mass, suggesting hypervascularity. CT Head [**2-6**](post-op): NON-CONTRAST HEAD CT: The patient has undergone interval left frontotemporal craniotomy, with expected postoperative changes including soft tissue swelling and both intra- and extra-cranial gas. There is minimal high density overlying the left frontal mass resection site, which could represent small amount of blood products (2:20). There is also tiny amount of high density remaining in the resection bed (2:21) which could represent either new blood product or hyperdense material remaining from previously seen hyperdense mass. Large amount of surrounding vasogenic edema has not changed, causing local sulcal effacement but no shift of normally midline structures. No acute large vascular territory infarction, or hydrocephalus is seen. The visualized paranasal sinuses and mastoid air cells are well aerated. IMPRESSIONS: Status post left frontotemporal craniotomy and resection of previously seen hyperdense left frontal lobe mass. There is tiny overlying extra-axial high density which could represent postoperative blood products. Expected pneumocephalus. Unchanged vasogenic edema causing sulcal effacement. MRI Head [**2-7**]: 1. Expected post-surgical change status post left frontoparietal craniotomy with mass resection. No new hemorrhage or enhancing mass. Vasogenic edema is unchanged. Small amount of blood product with subtle peripheral enhancement and restricted diffusion at the surgical margin likely represent expected post-surgical change. Brief Hospital Course: 1. L frontal brain met: Pt presented with LOC/seizure and new R arm weakness and R facial weakness with aphasia. Aphasia quickly improved however, R arm and face weakness remained constant. Pt placed on Keppra and decadron and neurooncology consulted. THis was felt to be [**Doctor Last Name 555**] paralysis with slow recovery [**12-31**] mass. Pt was discussed at neuroonc rounds and pt was transferred to neurosurg for further intervention. . 2. seizure: Likely [**12-31**] brain met. Pt placed on keppra 750 [**Hospital1 **]. . 3. Hypothyroidism: continued synthroid . 4. ST depressions on admission: Likely rate related. CEs 12 hours afterwards completely flat. Could represent failed stress test. Will need cardiology follow up as outpt. ------------- Patient was transferred to NSURG([**Hospital Ward Name 517**]) on [**2-5**] for pre-operative planning for the OR. The patient was taken to the OR on [**2177-2-6**] for a L frontal craniotomy for resection of the mass. He tolerated the procedure well, and there were no complications. The preliminary path report was positive for metastatic renal cell CA. He spent the evening in the ICU for Q1 neuro checks, and was transferred to the neurosurgery floor on [**2-7**]. Due to the proximity of the lesion to the motor control for the tongue, a formal speech and swallow examination was obtained. On [**2-8**], he was found to be acutely more aphasic, and a stat head CT was done. This was stable, without significant change, however given the amount of cerebral edema-he received a 10mg steroid bolus, and standing dose was incresed. He was seen and evaluated by PT/OT who determined he was safe to go home without services. He was also evaluated by Speech/Swallow, due to his difficulty with speaking and swallowing, who changed his diet order to Ground solids and thin liquids. On POD 4 and 5, he slowly began to regain movement in his jaw and RUE. He attempted to speak on POD 5, which was an improvement from the day before, and he also did have a slight increase in his RUE strength. On [**2-12**], he was seen by Radiation oncology. He was seen and evaluated by PT/OT and determined to be appropriate for discharge. He was discharged on [**2-12**] with discharge instuctions as noted in the discharge order Medications on Admission: Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY Percocet 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed day. Enoxaparin 80 mg/0.8 mL Syringe Sig: One (1) syringe injection Subcutaneous as directed: Administer enoxaparin injection as directed immediately prior to air travel. PT ONLY TAKES LOVENOX PRIOR TO FLIGHTS, NOT ALL THE TIME 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. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). Disp:*60 Capsule, Delayed Release(E.C.)(s)* Refills:*2* 3. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*60 Tablet(s)* Refills:*0* 5. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain/fever. 6. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Disp:*120 Tablet(s)* Refills:*2* 7. Sodium Chloride 1 gram Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:*90 Tablet(s)* Refills:*2* 8. Outpatient Occupational Therapy 9. Outpatient Speech/Swallowing Therapy 10. Dexamethasone 4 mg Tablet Sig: One (1) Tablet PO q8h () for 3 days. Disp:*9 Tablet(s)* Refills:*0* 11. Dexamethasone 4 mg Tablet Sig: One (1) Tablet PO bid () for 3 days: to start after 4mg TID dose. Disp:*6 Tablet(s)* Refills:*0* 12. Dexamethasone 1.5 mg Tablet Sig: Two (2) Tablet PO bid () for 3 days: to start after 4mg [**Hospital1 **] dose. Disp:*12 Tablet(s)* Refills:*0* 13. Dexamethasone 2 mg Tablet Sig: One (1) Tablet PO bid (): to start after 3mg [**Hospital1 **] dose. Disp:*60 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Metastatic Renal Cell CA w/left frontal lobe metastasis Discharge Condition: Neurologically Stable Discharge Instructions: GENERAL INSTRUCTIONS WOUND CARE: ?????? You or a family member should inspect your wound every day and report any of the following problems to your physician. ?????? Keep your incision clean and dry. ?????? You may wash your hair with a mild shampoo 24 hours after your sutures are removed. ?????? Do NOT apply any lotions, ointments or other products to your incision. ?????? DO NOT DRIVE until you are seen at the first follow up appointment. ?????? Do not lift objects over 10 pounds until approved by your physician. DIET Usually no special diet is prescribed after a craniotomy. A normal well balanced diet is recommended for recovery, and you should resume any specially prescribed diet you were eating before your surgery. Be sure however, to remain well hydrated, and increase your consumption of fiber, as pain medications may cause constipation. MEDICATIONS: ?????? Take all of your medications as ordered. You do not have to take pain medication unless it is needed. It is important that you are able to cough, breathe deeply, and is comfortable enough to walk. ?????? Do not use alcohol while taking pain medication. ?????? Medications that may be prescribed include: -Narcotic pain medication such as Dilaudid (hydromorphone). -An over the counter stool softener for constipation (Colace or Docusate). If you become constipated, try products such as Dulcolax, Milk of Magnesia, first, and then Magnesium Citrate or Fleets enema if needed). Often times, pain medication and anesthesia can cause constipation. ?????? You have been discharged on Keppra (Levetiracetam), you will not require blood work monitoring. ?????? Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, Aspirin, Advil, and Ibuprofen etc, as this can increase your chances of bleeding. ?????? You are being sent home on steroid medication, make sure you are taking a medication to protect your stomach (Prilosec, Protonix, or Pepcid), as these medications can cause stomach irritation. Make sure to take your steroid medication with meals, or a glass of milk. ACTIVITY: The first few weeks after you are discharged you may feel tired or fatigued. This is normal. You should become a little stronger every day. Activity is the most important measure you can take to prevent complications and to begin to feel like yourself again. In general: ?????? Follow the activity instructions given to you by your doctor and therapist. ?????? Increase your activity slowly; do not do too much because you are feeling good. ?????? You may resume sexual activity as your tolerance allows. ?????? If you feel light headed or fatigued after increasing activity, rest, decrease the amount of activity that you do, and begin building your tolerance to activity more slowly. ?????? DO NOT DRIVE until you speak with your physician. ?????? Do not lift objects over 10 pounds until approved by your physician. ?????? Avoid any activity that causes you to hold your breath and push, for example weight lifting, lifting or moving heavy objects, or straining at stool. ?????? Do your breathing exercises every two hours. ?????? Use your incentive spirometer 10 times every hour, that you are awake. WHEN TO CALL YOUR SURGEON: With any surgery there are risks of complications. Although your surgery is over, there is the possibility of some of these complications developing. These complications include: infection, blood clots, or neurological changes. Call your Physician Immediately if you Experience: ?????? Confusion, fainting, blacking out, extreme fatigue, memory loss, or difficulty speaking. ?????? Double, or blurred vision. Loss of vision, either partial or total. ?????? Hallucinations ?????? Numbness, tingling, or weakness in your extremities or face. ?????? Stiff neck, and/or a fever of 101.5F or more. ?????? Severe sensitivity to light. (Photophobia) ?????? Severe headache or change in headache. ?????? Seizure ?????? Problems controlling your bowels or bladder. ?????? Productive cough with yellow or green sputum. ?????? Swelling, redness, or tenderness in your calf or thigh. Call 911 or go to the Nearest Emergency Room if you Experience: ?????? Sudden difficulty in breathing. ?????? New onset of seizure or change in seizure, or seizure from which you wake up confused. ?????? A seizure that lasts more than 5 minutes. Important Instructions Regarding Emergencies and After-Hour Calls ?????? If you have what you feel is a true emergency at any time, please present immediately to your local emergency room, where a doctor there will evaluate you and contact us if needed. Due to the complexity of neurosurgical procedures and treatment of neurosurgical problems, effective advice regarding emergency situations cannot be given over the telephone. ?????? Should you have a situation which is not life-threatening, but you feel needs addressing before normal office hours or on the weekend, please present to the local emergency room, where the physician there will evaluate you and contact us if needed. Followup Instructions: FOLLOW UP APPOINTMENT INSTRUCTIONS ??????Please return to the office on Monday, [**2-17**] for a suture removal appointment. This is in the [**Location (un) **] on the [**Last Name (un) 2577**] Building at [**Hospital1 18**], at 11:00am. This with be with [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 79869**], Nurse Practitioner. If you need to cancel or change, please call [**Telephone/Fax (1) 1669**]. ??????You will have an appointment in the Brain [**Hospital 341**] Clinic. Please call [**Doctor First Name **] from Worldpath ([**Telephone/Fax (1) 79870**]) to get the date and time of the appointment. The Brain [**Hospital 341**] Clinic is located on the [**Hospital Ward Name 516**] of [**Hospital1 18**], in the [**Hospital Ward Name 23**] Building, [**Location (un) **]. Their phone number is [**Telephone/Fax (1) 1844**]. Please call if you need to change your appointment, or require additional directions. ??????You will not need an MRI of the brain as this was done prior to discharge. You have an appointment with Dr. [**Last Name (STitle) 79871**] in the cyberknife/radiation clinic on [**2-24**] ot 10:00am. This is for radiation planning and mapping. His clinic is located on the [**Location (un) 442**] of the [**Hospital Ward Name 23**] Building. You should arrange for outpatient Speech Therapy when you arrive back in [**Country 5881**]. Please call ([**Telephone/Fax (1) 16668**] to make an appointment with Dr. [**Last Name (STitle) 1729**] on [**2-18**]. Completed by:[**2177-2-25**]

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icd9cm

[ [ [] ] ]

[ "01.59", "02.12" ]

icd9pcs

[ [ [] ] ]

11725, 11731

7635, 8226

365, 421

11831, 11855

3411, 6159

16940, 18477

2569, 2741

10319, 11702

11752, 11810

9937, 10296

11879, 11900

2756, 2761

15109, 16917

279, 327

11912, 15082

449, 2118

3149, 3392

6168, 7612

8240, 9911

2140, 2451

2467, 2553

29,554

161,472

33639

Discharge summary

report

Admission Date: [**2166-3-30**] Discharge Date: [**2166-4-4**] Date of Birth: [**2119-4-4**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2534**] Chief Complaint: s/p MVC Major Surgical or Invasive Procedure: Intubation at scene of accident. External fixation R femur Closed treatment right femoral head fracture with manipulation. Removal implant deep, right femur. Removal external fixator under anesthesia. IM nail, right femur. ORIF, right ulna. History of Present Illness: 47 yo M unrestrained driver, high speed collision with tree, passenger fatality. Agitated and combative at scene. Intubated at scene. Past Medical History: Ex lap scar from prior MVC R femur plate from former fx. Family History: Noncontributory Physical Exam: T 97 P 96 BP 138/66 RR 10 Sat 100% on vent Gen: intubated, sedated HEENT: confirmed ETT placement, abrasion forehead and nose. Blood at nares and lips. PERRL. Neck in C collar. Chest: no crepitus, CTAB, RRR Abd: S, ND, FAST neg Ext: no obvious deformity, WWP Neuro: sedated Pertinent Results: [**2166-3-29**] 11:36PM BLOOD WBC-10.6 RBC-4.82 Hgb-15.4 Hct-44.1 MCV-92 MCH-32.0 MCHC-35.0 RDW-12.5 Plt Ct-127* [**2166-3-30**] 01:23PM BLOOD Hct-33.0* [**2166-3-30**] 06:11PM BLOOD Hct-36.4* [**2166-4-2**] 10:35AM BLOOD WBC-5.4 RBC-2.56* Hgb-8.2* Hct-22.8* MCV-89 MCH-31.9 MCHC-35.9* RDW-12.7 Plt Ct-132*# [**2166-4-2**] 08:10PM BLOOD WBC-5.4 RBC-2.78* Hgb-8.6* Hct-24.6* MCV-88 MCH-30.9 MCHC-35.0 RDW-13.7 Plt Ct-114* [**2166-3-29**] 11:36PM BLOOD PT-12.4 PTT-22.4 INR(PT)-1.0 [**2166-3-29**] 11:36PM BLOOD Plt Ct-127* [**2166-4-2**] 10:35AM BLOOD PT-12.9 PTT-23.7 INR(PT)-1.1 [**2166-4-3**] 04:50AM BLOOD Plt Ct-123* [**2166-3-29**] 11:36PM BLOOD Fibrino-164 [**2166-3-30**] 03:45AM BLOOD Glucose-100 UreaN-17 Creat-0.8 Na-140 K-5.5* Cl-104 HCO3-25 AnGap-17 [**2166-4-2**] 05:25AM BLOOD Glucose-123* UreaN-14 Creat-0.7 Na-136 K-4.1 Cl-100 HCO3-29 AnGap-11 [**2166-4-2**] 10:35AM BLOOD ALT-31 AST-60* AlkPhos-35* TotBili-1.9* [**2166-3-29**] 11:36PM BLOOD Amylase-56 [**2166-3-30**] 03:45AM BLOOD Calcium-7.9* Phos-4.1 Mg-1.8 [**2166-4-2**] 05:25AM BLOOD Calcium-7.6* Phos-2.5* Mg-1.8 [**2166-3-29**] 11:36PM BLOOD ASA-NEG Ethanol-276* Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2166-3-29**] 11:35PM BLOOD Glucose-112* Lactate-2.2* Na-143 K-3.4* Cl-102 [**2166-3-30**] 08:34PM BLOOD Lactate-0.8 K-3.9 CT chest/abd/pelvis: IMPRESSION: 1. Large splenic laceration consistent with grade III laceration, with evidence of intraparenchymal vascular injury. 2. Posterior dislocation of the proximal right femur with fracture of the right femoral head and small acetabular chip fracture. 3. Nondisplaced fracture of the left 7th and 8th ribs in the region of the costocondral junction. CT Cspine: No evidence of acute fracture. NOTE ADDED AT ATTENDING REVIEW: Although it is true that there are no findings that appear to be results of trauma, there are several significant abnormalities: 1. There is assimilation of C1 into the occiput, with consequent axial migration of the odontoid. This produces narrowing of the foramen magnum and distortion of the cervicomedullarly junction. 2. There is developmental narrowing of the spinal canal with small disk protrusionas at C3-4 and [**5-17**] indenting the spinal cord. 3. At C5 and below artifacts arising from the shoulders obscure intraspinal detail. However, an intervertebral osteophyte at C5-6 appears to narrow the spinal canal. CT head: No evidence of hemorrhage. NOTE ADDED AT ATTENDING REVIEW: There is narrowing of the foramen magnum and assimilation of C1 into the occiput. Full description in the report of the cervical spine CT. The right frontal and bilateral temporal calcifications are of uncertain signficance. They may represent old granulomas Fluoroscopy RLE: Multiple fluoroscopic views from the operating suite show placement of a metallic fixation device about the fracture of the proximal shaft of the femur, just superior to the prior lateral fixation plate fixing an old fracture of the shaft. The posterior dislocation of the femoral head with respect to the acetabulum has been reduced. Film R femur: There is a severely displaced fracture of the proximal right femoral shaft, with anterior angulation of the superior fragment, just superior to a lateral fixation plate fixing an old fracture of the mid right femoral shaft. The proximal femur is also dislocated posteriorly. A fracture fragment of the proximal femoral head also seen. R arm film: There is a slightly displaced transverse fracture of the distal cubitus, there is no angulation Fluoroscopy R arm: A medial fracture plate has been placed alongside the transverse fracture at the junction of the middle and distal thirds of the ulnar diaphysis. The displacement has been reduced. Intraoperative soft tissue air is seen. There is a dorsal calcific density along the operative approach. IMPRESSION: ORIF of a ulnar fracture. A dorsal opacity might represent a small bony fragment. Please see operative notes for full details. CT R femur: IMPRESSION: 1. Intra-articular fracture of right femoral head with inferior displacement of the femoral head fragment. 2. Posterolateral acetabular fracture with multiple small bone fragments posterior to the acetabulum and evidence of an impacted fracture at the posterior acetabulum. Brief Hospital Course: Mr. [**Known lastname 77893**] was admitted to the TSICU on [**2166-3-30**] intubated. He went to the OR with orthopedics on [**3-30**] for ex-fix R femur and hip relocation. That same night, he was extubated and maintained on bipap with stable sats. He returned to the OR with orthopedics in the evening of [**2166-4-1**] for ORIF of R femur and R ulna. Regarding his splenic lac, he was admitted to ICU for Q4hr hcts. He remained hemodynamically stable, however, hcts trended slowly down until he was transfused one unit of PRBC on [**2166-4-2**]. His hematocrit increased appropriately, however, again slowly drifted down until transfused one unit again on [**2166-4-3**]. On [**2166-4-2**] he was started on lovenox DVT precaution per Orthopedics recommendation. Physical therapy evaluated the patient and felt that he would be appropriate for rehabilitation facility placement. After transfusion on [**4-3**], his hematocrit corrected appropriately and he was medically stable for discharge to rehab facility. Medications on Admission: denies Discharge Medications: 1. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q6H (every 6 hours) as needed for SOB. 2. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation Q6H (every 6 hours) as needed for SOB. 3. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily). 4. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 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) for 3 days. 7. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. 8. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 10. Senna 8.6 mg Tablet Sig: One (1) Tablet 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. Sodium Chloride 0.9% Flush 3 mL IV DAILY:PRN Peripheral IV - Inspect site every shift 13. HYDROmorphone (Dilaudid) 0.5-1.0 mg IV Q6H:PRN breakthrough pain 14. Lorazepam 1-2 mg IV Q2H:PRN CIWA per CIWA scale >10 15. Enoxaparin 40 mg/0.4 mL Syringe Sig: 0.4 ml Subcutaneous DAILY (Daily). 16. Insulin SS Insulin SS as printed and included in paperwork. Discharge Disposition: Extended Care Facility: [**Hospital6 1293**] - [**Location (un) 1294**] Discharge Diagnosis: R femur fracture R acetabular fracture R posterior hip dislocation R ulna fracture Grade III splenic lac Discharge Condition: stable Discharge Instructions: You were treated in the hospital after a motor vehicle accident. You broke your leg and your arm and both were surgically repaired. You also damaged your spleen which stabilized and did not necessitate removal of your spleen, however, you did require a blood transfusion and your blood counts should be monitored. You were initially given a breathing tube due to abnormal mental status, but you weaned off of the tube and were able to breath on your own. You were seen by physical therapy and are now medically stable to be discharged to a rehabilitation facility. Please do not bear any weight on your R leg or R arm until your follow up appointment with the orthopedic doctors. Also avoid any contact sports for 5-6 weeks. Your staples will need to be removed on approximately [**4-13**]. Please take all medicines as directed and keep all follow up appointments. If you should experience fever, increased redness, swelling or drainage from your wound, chest pain, shortness of breath, please notify your doctor or return to the ED. Followup Instructions: Please call [**Telephone/Fax (1) 1228**] to schedule an appointment in orthopedics clinic with Dr. [**Last Name (STitle) **] in [**2-12**] weeks. Please call [**Telephone/Fax (1) 6429**] to schedule a follow up appointment with Dr. [**Last Name (STitle) **] in [**2-12**] weeks.

[ "813.82", "959.01", "305.1", "835.00", "E816.0", "305.00", "780.09", "821.01", "807.02", "276.2", "820.09", "865.00", "280.0" ]

icd9cm

[ [ [] ] ]

[ "79.15", "78.65", "78.15", "79.32", "96.71", "79.75", "99.04" ]

icd9pcs

[ [ [] ] ]

7868, 7942

5461, 6484

320, 567

8091, 8100

1157, 3551

9187, 9470

828, 845

6541, 7845

7963, 8070

6510, 6518

8124, 9164

860, 1138

273, 282

595, 732

3560, 5438

754, 812

57,985

140,497

30054

Discharge summary

report

Admission Date: [**2146-10-18**] Discharge Date: [**2146-11-5**] Date of Birth: [**2070-3-24**] Sex: M Service: MEDICINE Allergies: Ampicillin / Ceftriaxone / Vancomycin / Aztreonam Attending:[**First Name3 (LF) 338**] Chief Complaint: Fevers, lethargy Major Surgical or Invasive Procedure: None History of Present Illness: This is a 76 yom with history of Asthma, Gout, BPH, CRI with baseline Cr 1.5-2 with recent hospitalization for epidural abcess and bactremia [**1-17**] Pan-Sensitive Enterococcus who presents from rehab for fevers and lethargy. Patient is currently unable to provide history [**1-17**] altered mental status. Per ED report, patient as on Amp/Ceftriax at [**Hospital3 **] when he developed ?drug rash. Antibiotics were then switched to Daptomycin. He then began having persistent fevers and was transferred to [**Hospital1 18**] for further care . In the ED, initial VS: Temp 102.2, BP 99/62, HR 88, RR 24, 97%RA. CXR was done which showed no acute process. Neurosurgery was consulted and recommended repeat MRI, however, patient was rigoring so decision was made to hold on MRI. ID called and recommended change to broad spectrum antibiotics. Patient was given Vanco 1gm IV x 1, Tylenol 650mg PO x 1, Morphine 4mg IV x 3, Aztreonam 1gam IV x 1, NS IVF 3L. . Currently, Patient denies any pain or shortness of breath. Past Medical History: Asthma Cataracts Gout Benign prostate hypertrophy (Prostate biopsy [**2143**], TURP [**2144**], cystoscopy/transrectal US [**6-/2146**]) Chronic kidney disease (baseline 1.5-2.0) Epidural Abscess s/p L5-S1 Laminectomy Aortic Endocarditis Bactermia [**1-17**] Enterococcus Social History: Born in [**Location (un) 6847**]. Lives with his wife, has 3 children and many grandchildren. Retired but frequently helps out at family restaurant. Denies any IVDU or alcohol use. Quit smoking 25 years ago. Family History: Non-contributory. Physical Exam: Vitals - T: 99.8 BP: 141/78 HR: 121 RR: 21 02 sat: 95% GENERAL: Elderly male in mild respiratory distress HEENT: ACAT, CARDIAC: +S1/S2, no M/R/G, +tachycardia LUNG: +Expiratory ronchi, no wheezes or crackles ABDOMEN: +BS, NT/ND EXT: +2 pitting anasarca, dopplerable pedal pulses NEURO: AAO x 1 to person, date and year is [**Month (only) 359**], does not recall place. Opens eyes on commands but not conversant, answers questions preferentially, moving all extremities. DERM: mild macular blanching rash of torso Pertinent Results: [**2146-10-18**] 07:00PM BLOOD WBC-13.0*# RBC-3.04* Hgb-8.5* Hct-25.5* MCV-84 MCH-27.9 MCHC-33.3 RDW-15.0 Plt Ct-286 [**2146-11-1**] 04:40AM BLOOD WBC-19.2* RBC-3.11* Hgb-8.3* Hct-26.3* MCV-85 MCH-26.6* MCHC-31.4 RDW-15.6* Plt Ct-626* [**2146-11-4**] 04:07AM BLOOD WBC-12.1* RBC-3.14* Hgb-8.3* Hct-27.0* MCV-86 MCH-26.4* MCHC-30.7* RDW-15.9* Plt Ct-853* [**2146-11-4**] 04:07AM BLOOD PT-16.7* PTT-84.3* INR(PT)-1.5* [**2146-10-23**] 03:56PM BLOOD Fibrino-473* [**2146-10-18**] 07:00PM BLOOD Glucose-112* UreaN-27* Creat-2.3* Na-137 K-4.3 Cl-102 HCO3-23 AnGap-16 [**2146-10-23**] 05:24AM BLOOD Glucose-95 UreaN-45* Creat-3.5* Na-138 K-4.0 Cl-109* HCO3-24 AnGap-9 [**2146-11-4**] 04:07AM BLOOD Glucose-124* UreaN-42* Creat-1.8* Na-150* K-3.8 Cl-113* HCO3-25 AnGap-16 [**2146-10-18**] 07:00PM BLOOD ALT-23 AST-31 CK(CPK)-256* AlkPhos-140* TotBili-0.7 [**2146-10-22**] 06:16AM BLOOD ALT-326* AST-1177* LD(LDH)-1269* CK(CPK)-421* AlkPhos-157* TotBili-1.4 [**2146-11-4**] 04:07AM BLOOD ALT-43* AST-32 LD(LDH)-262* AlkPhos-165* TotBili-0.5 [**2146-10-23**] 05:24AM BLOOD Lipase-52 [**2146-10-21**] 09:51PM BLOOD CK-MB-9 cTropnT-0.54* proBNP-[**Numeric Identifier **]* [**2146-10-28**] 05:41AM BLOOD TSH-0.42 [**10-18**] Urine culture: yeast [**10-18**] Blood cultures x2 negative [**10-19**] Blood culture negative [**10-19**] C diff negative [**10-19**] Sputum culture [**2146-10-19**] 5:33 pm SPUTUM Source: Expectorated. **FINAL REPORT [**2146-10-22**]** GRAM STAIN (Final [**2146-10-19**]): >25 PMNs and <10 epithelial cells/100X field. 3+ (5-10 per 1000X FIELD): MULTIPLE ORGANISMS CONSISTENT WITH OROPHARYNGEAL FLORA. 2+ (1-5 per 1000X FIELD): BUDDING YEAST. RESPIRATORY CULTURE (Final [**2146-10-22**]): SPARSE GROWTH Commensal Respiratory Flora. STAPH AUREUS COAG +. MODERATE GROWTH. Oxacillin RESISTANT Staphylococci MUST be reported as also RESISTANT to other penicillins, cephalosporins, carbacephems, carbapenems, and beta-lactamase inhibitor combinations. Rifampin should not be used alone for therapy. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPH AUREUS COAG + | CLINDAMYCIN----------- =>8 R ERYTHROMYCIN---------- =>8 R GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- =>8 R OXACILLIN------------- =>4 R RIFAMPIN-------------- <=0.5 S TETRACYCLINE---------- <=1 S TRIMETHOPRIM/SULFA---- <=0.5 S VANCOMYCIN------------ <=1 S 11/5 Blood cultures x2 negative [**2146-10-22**] 11:20 am SPUTUM Site: ENDOTRACHEAL **FINAL REPORT [**2146-10-24**]** GRAM STAIN (Final [**2146-10-22**]): <10 PMNs and <10 epithelial cells/100X field. NO MICROORGANISMS SEEN. QUALITY OF SPECIMEN CANNOT BE ASSESSED. SMEAR REVIEWED; RESULTS CONFIRMED. RESPIRATORY CULTURE (Final [**2146-10-24**]): SPARSE GROWTH Commensal Respiratory Flora. STAPH AUREUS COAG +. MODERATE GROWTH. [**10-30**], [**10-31**] Blood cultures pending on discharge Brief Hospital Course: 76 yo male with history of Asthma, Gout, BPH, CRI with baseline Cr 1.5-2 with recent hospitalization for epidural abcess and bactremia [**1-17**] Pan-Sensitive Enterococcus who was admitted from rehab for fevers and lethargy. . 1. Fevers: Patient was changed from Ampicillin/CTX to Vanc and Aztreonam secondary to drug rash. Infectious disease was consulted. Neurosurgery was consulted, and MRI of L spine was negative for epidural abscess. MRI showed ongoing discitis and osteo. Per ID recommendation, discitis/osteomyelitis is presumed to be [**1-17**] Enterococcus at this time and patient is to complete 6 week course of Daptomycin for Enterococcus bactermia and osteomyelitis. Echo was negative for valvular vegetations concerning for endocarditis. Main concern is for recurrence of epidural abscess. CXR done on arrival to ICU showed increasing RLL infiltrate concerning for PNA vs Aspiration Pneumonitis. Patient was initially treated with Vancomycin and Aztreonam for a 2 week course given recent history of enterococcal bacteremia. C diff was negative. Blood cultures, UA and urine cultures were negative. CT torso was performed on [**10-26**] which was only remarkable for pneumonia, not underlying abscess. -Pati ID recommended Daptomycin for an additional 2 weeks for enterococcal bacteremia/osteomyelitis (last day being [**11-14**]). -Please check weekly CKs, CBC, LFTs, BUN, Cr while on Daptomycin -Patient has follow up in Infectious disease clinic on [**11-16**] with Dr. [**First Name (STitle) **]. [**Telephone/Fax (1) 4170**] . 2. Hypoxemic respiratory failure: During admission, patient decompensated from a respiratory standpoint becoming tachycardic with increased work of breathing. Right lower lobe opacification seemed to have worsened. The patient was emergently intubated on [**10-20**] after aspirating his medications. He was continued on Vancomycin and Aztreonam for a 2 week course. Clindamycin was added for 8 days to cover for anaerobes that may have been associated with an aspiration event. However patient developed a maculopapular rash on [**10-30**]. On [**10-31**] Vanc and Aztreonam were stopped, and patient was started on Daptomycin (as above). Patient was successfully extubated on [**11-1**]. . 3. Altered Mental status: Likely secondary to fevers and likely infection. CT Head done in ED showed no signs of acute hemorrhage or infarction. Patient was given Morphine 4mg IV x 3 in ED which may have contributed to AMS. Sedating meds were held. Mental status improved without other interventions. 4. Hypotension: Patient was briefly on neosynephrine for hypotension likely associated with pneumonia and afib with RVR. Patient was weaned off of vasopressors for several days prior to being discharged. 5. Acute renal failure: Patient had muddy brown casts in urine, consistent with ATN. Likely secondary to hypotension. Cr 2.3 on admission, peaked at 3.2. Trending down to 1.8 on discharge. 6. Atrial fibrillation: Patient was loaded with Amiodarone for 2 weeks. 7. Hypertension: Patient was persistently hypertensive. He was started on Hydralazine 30mg po q6h, Metoprolol 37.5mg po tid, and Amlodipine 10mg po daily. 8. Right atrial appendage thrombus: Patient was on coumadin as an outpatient. This was held as an inpatient because his INR was supratherapeutic. No thrombus seen on repeat ECHO, last ECHO also reviewed by cardiology, no thrombus seen. Thus anticoagulation was stopped. 9. Aspiration events: Patient was evaluated by speech and swallow and continued to aspirate. He was kept NPO, and was fed via NG tube with tube feeds. 10. Hypernatremia: Na 150 on discharge. Patient was given free water IV and in tube feeds. Also given 500cc of D5w today. Please follow up electrolytes and adjust free water appropriately. If increasing then may need diuresis and patient is total body fluid overloaded. Medications on Admission: Daptomycin 300mg IV Daily Senna 2 tabs PO qHS Colace 100mg PO BID MVI daily Lidocaine 5% patch to low back Gabapentin 100mg PO BID Metoprolol 100mg PO BID Amlodipine 10mg daily Oxycodone 10mg PO QID Oxycontin 10mg PO BID Prostat? Prevacid 30mg daily Coumadin? Discharge Medications: 1. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipatin. 2. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily). 3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) injection Injection TID (3 times a day). 5. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 7. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain, fever. 8. Fentanyl 100 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr Transdermal Q72H (every 72 hours). 9. Polyethylene Glycol 3350 17 gram/dose Powder Sig: One (1) packet PO DAILY (Daily) as needed for constipation. 10. Ipratropium Bromide 0.02 % Solution Sig: One (1) inhalation Inhalation Q6H (every 6 hours). 11. Hydralazine 10 mg Tablet Sig: Three (3) Tablet PO Q6H (every 6 hours). 12. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 13. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO TID (3 times a day). 14. Daptomycin 500 mg Recon Soln Sig: One (1) Recon Soln Intravenous Q24H (every 24 hours) for 10 days: Last day [**11-14**]. Discharge Disposition: Extended Care Facility: [**Hospital6 1293**] - [**Location (un) 1294**] Discharge Diagnosis: Primary diagnosis: 1. Sepsis secondary to Aspiration pneumonia 2. Hypoxemic respiratory failure 3. Acute renal failure 4. Normocytic anemia 5. Atrial fibrillation Secondary diagnosis: Chronic kidney disease Gout Discharge Condition: Hemodynamically stable. Discharge Instructions: You were admitted with fevers. You were found to have an aspiration pneumonia. While in the hospital you had several aspiration events and were intubated. You are being treated with antibiotics for aspiration pneumonia. You will need to continue the Daptomycin antibiotic until [**11-14**]. You will need to follow up in infectious disease clinic thereafter. You have a lot of difficulty swallowing. You should not swallow anything by mouth. You have a nasogastric feeding tube for tube feeds. If you have worsening fevers, chills, shortness of breath, oxygen requirement, chest pain, abdominal pain, lower extremity swelling, or any other symptoms that concern you, please call your doctor or go to the emergency department. Followup Instructions: You have follow up in infectious disease clinic on [**2146-11-16**] with Dr. [**First Name (STitle) **] at 9:50am. The clinic phone number is [**Telephone/Fax (1) 4170**]. You have follow up in Cardiology clinic with Dr. [**Last Name (STitle) 696**] on [**2146-12-1**] at 8:40am. The clinic phone number is [**Telephone/Fax (1) 2037**].

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icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

11230, 11304

5755, 8015

327, 333

11561, 11587

2506, 5732

12364, 12705

1930, 1949

9941, 11207

11325, 11325

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271, 289

361, 1387

11510, 11540

11344, 11489

8030, 9630

1409, 1683

1699, 1914

75,401

101,536

9971

Discharge summary

report

Admission Date: [**2121-9-27**] Discharge Date: [**2121-10-4**] Date of Birth: [**2037-2-3**] Sex: M Service: MEDICINE Allergies: Oxycodone Attending:[**First Name3 (LF) 11839**] Chief Complaint: Hemoptysis Major Surgical or Invasive Procedure: arterial embolization History of Present Illness: Mr. [**Known lastname 33372**] is an 84M with SCLC diagnosed 8 months ago undergoing 3rd cycle of chemotherapy who presents with hemoptysis. He began to have blood streaked sputum 1 month ago which has been progressing in volume over the past week. On the day of admission he began to cough up frank blood, approximately 1 tablespoon per cough for a total of one cup of frank blood with clots. He had a gurgling sensation in his chest and found it difficult to breath and called 911. . In ED, initial VS:98.9 60 118/68 18 96% RA. He continued to have frank blood with an intermittent cough but only pea sized amounts. CTA was negative for PE but revealed mass abutting pulm artery. Labs were significant for HCT stable at baseline 28-29. He was seen by IP and underwent flexible bronchoscopy which revealed large endobronchial vascular oozing mass almost obstructing RUL bronchus. IR was called and patient underwent right bronchial artery embolization. During procedure, he developed oxygen requirement and was satting mid 90s on NRB. He was transferred back to the ED, stabilized, and transferred to [**Hospital Unit Name 153**]. VS prior to transfer: 97.8 76 123/71 25 94% on NRB, not in any acute distress . On the floor, he reports improved SOB and no further hemoptysis. He reports stable cough for months and denies any CP, palpitations, fever, chills, LH or dizziness, HA. States he stopped ASA one month ago and is not on plavix, coumadin or any other blood thinning medications. Past Medical History: 1. SCLC diagnosed 8 months ago, undergoing 3rd cycle of chemo, has not receievd XRT. Receives care at Cancer Center in [**Location (un) 47**] 2. Coronary artery disease, status post coronary artery bypass grafting in [**2112-5-13**]. 3. Peptic ulcer disease. 4. Status post AAA repair in [**2112-1-14**] with intraoperative myocardial infarction. 5. Hypercholesterolemia. 6. Tuberculosis as a child. 7. Diverticulosis. 8. Left retinal artery thrombosis with reduced vision on that side. 9. Eczema. 10. Chronic renal insufficiency with a baseline creatinine of 1.3 to 1.6. 11. history of asbestos exposure. 12. Zoster 13. Anemia 14. HTN Social History: Tobacco: 80 pack year ex smoker Lives with wife of 14 years. Electrician on sick leave He quit smoking more than 20 years ago,but prior to that was smoking 3-4 packs per day. He started smoking in [**2054**]. He also quit EtOH over 10 years ago. Family History: NC Physical Exam: General: Alert, oriented, slightly agitated, pulling at sheets in bed HEENT: Sclera anicteric, MM dry, oropharynx clear Neck: supple, JVP 8-9cm, no LAD Lungs: Anteriorly coarse breath sounds throughout R>L with bibasilar rales 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, 1+ pulses, no clubbing, cyanosis. Trace edema Pertinent Results: [**2121-9-27**] 10:31PM GLUCOSE-98 UREA N-18 CREAT-1.4* SODIUM-139 POTASSIUM-4.6 CHLORIDE-107 TOTAL CO2-22 ANION GAP-15 [**2121-9-27**] 10:31PM CALCIUM-7.8* PHOSPHATE-2.3* MAGNESIUM-2.0 [**2121-9-27**] 10:31PM WBC-19.6*# RBC-3.49* HGB-10.3* HCT-31.1* MCV-89 MCH-29.4 MCHC-33.0 RDW-14.9 [**2121-9-27**] 10:31PM NEUTS-95* BANDS-0 LYMPHS-5* MONOS-0 EOS-0 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 [**2121-9-27**] 10:31PM HYPOCHROM-1+ ANISOCYT-NORMAL POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL SCHISTOCY-OCCASIONAL BITE-OCCASIONAL [**2121-9-27**] 10:31PM PLT SMR-LOW PLT COUNT-84* [**2121-9-27**] 10:31PM PT-14.4* PTT-31.0 INR(PT)-1.2* [**2121-9-27**] 10:43AM PT-13.4 PTT-28.6 INR(PT)-1.1 [**2121-9-27**] 08:10AM GLUCOSE-84 UREA N-24* CREAT-1.6* SODIUM-142 POTASSIUM-4.5 CHLORIDE-110* TOTAL CO2-27 ANION GAP-10 [**2121-9-27**] 08:10AM estGFR-Using this [**2121-9-27**] 08:10AM CALCIUM-7.9* PHOSPHATE-1.8*# MAGNESIUM-2.3 [**2121-9-27**] 08:10AM WBC-9.3# RBC-3.29* HGB-9.5* HCT-29.1* MCV-89 MCH-29.0 MCHC-32.7 RDW-15.5 [**2121-9-27**] 08:10AM NEUTS-79.9* LYMPHS-17.9* MONOS-1.5* EOS-0.4 BASOS-0.3 [**2121-9-27**] 08:10AM PLT COUNT-84*# GRAM STAIN (Final [**2121-10-1**]): <10 PMNs and >10 epithelial cells/100X field. Gram stain indicates extensive contamination with upper respiratory secretions. Bacterial culture results are invalid. Blood cultures: negative Brief Hospital Course: This 84 year old gentleman with SCLC receiving chemo was admitted with hemoptysis and RUL endobronchial mass and developed increasing hypoxia after undergoing IR guided bronchial artery embolization. . # Hemoptysis: Presented with hemoptysis and bronchoscopy consistent with RUL vascular mass and underwent right bronchial artery embolization. Pt was monitored closely and no recurrent episodes of [**Female First Name (un) **] hemoptysis. H?H was followed an dreained stable. Plts were also followed with th eintent to keep level close to 50k. On the day of discharge plt count was 47 an dpt did get 1 units of plts.Pt scheduled to return to [**Hospital Ward Name 1826**] 7 for a cbc to follow plt count. # SCLC:Pt was started on radiation treatment during the hospitalization. He completed 1500cgy out of 3000, and scheduled to return on Monday to radiation oncology fo rcompletion of treatment. pt to return to primary outside oncologist fo rfurther treatment of SCLC. # Hypoxemic respiratory distress: Pt still requiring O2 on transfer to floor. CXR c/w edema. Pt received lasix po x3 doses in total with good response. breathing improved an dpt weaned off oxygen. # Acute on chronic renal insufficiency: Pt has rising Cr 1.7 from baseline of 1.3-1.4, possibly due to large dye load received during bronchial artery embolization. FeNa 3%. Patient had good urine output and crea remained at 1.8. Creatinine shoul dbe followe dwith priary oncologist.. # Low grade fever: Pt had low grade fevers on th efloor. Blood and sputu culture sobtained and without growth. CXR also did not show a clear infiltrate. Fevers resolved and on d/c pt afebrile. # Leuopenia: Secondary to recent treatment with [**Doctor Last Name **]-etoposide. Pt was scheduled to get neulasta at primary oncologist but was admitted fo rhemoptysis. First dose of neupogen was given to pt on th eday of discharge . Pt scheduled to return to 7 [**Hospital Ward Name 1826**] to receive 3 additional daily doses. #. CAD s/p CABG: Pt restarted on a beta-blocker and rosuvastatin. Code status: DNR/DNI Medications on Admission: Atenolol 25 mg daily Niacin 500 mg Nitroglycerin prn Aspirin 81 mg daily Crestor 40 mg daily Amlodipine 5 mg po daily Discharge Medications: 1. rosuvastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 2. atenolol 25 mg Tablet Sig: One (1) Tablet PO once a day. 3. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: [**12-14**] Inhalation every six (6) hours as needed for cough. Disp:*1 1* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Hemoptysis Pulmonary edema Small cell lung cancer Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Mr [**Known lastname 33372**], You were admitted with hemoptysis ( bleeding from your lungs). A chest CT showed that you have a mass abutting a pulmonary artery. You underwent an arterial embolization that was successful and you also started radiation treatment for your lung mass.You will need to continue follow up with your oncologist as scheduled as well as completion of teh radiation treatment at [**Hospital1 **]. Change in medication: Aspirin held because of bleeding- you should not continue aspirin for now. Niacin held-you will need to discuss the continuation of niacin in the future with your primary physician. Followup Instructions: 1. F/U with Radiation Oncology on Monday at 2pm at [**Location (un) 3387**] [**Hospital Ward Name 332**]-[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 86**], [**Numeric Identifier 718**]. Phone: [**Telephone/Fax (1) 9710**]. 2.Appointment on Monday at 1:30pm Oncology outpt infusion center [**Hospital Ward Name 1826**] 7 at [**Hospital1 18**], [**Location (un) **], tel [**Numeric Identifier 33374**] for neupogen shot and CBC. 2. Cont F/U with Primary oncologist at [**Location (un) 47**] cancer center.If you do not have an appointment, call to schedule an appointment.

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icd9cm

[ [ [] ] ]

[ "99.29", "92.29", "33.23", "88.44" ]

icd9pcs

[ [ [] ] ]

7297, 7355

4759, 6826

282, 306

7449, 7449

3318, 4736

8249, 8838

2780, 2784

6994, 7274

7376, 7428

6852, 6971

7600, 8226

2799, 3299

231, 244

334, 1829

7464, 7576

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2514, 2764

4,787

165,271

2541

Discharge summary

report

Admission Date: [**2125-9-6**] Discharge Date: [**2125-9-17**] Date of Birth: [**2044-1-3**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 898**] Chief Complaint: sepsis Major Surgical or Invasive Procedure: Removal of infected hemodialysis catheter Temporary Hemodialysis Catheter Placement with Conversion to a Tunneled Hemodialysis Catheter Central Line Placement History of Present Illness: 81 male with ESRD on HD, AFib, severe diverticulosis, C diff colitis, klebsiella urosepsis, and CHF EF 60%, here with 2 days of fatigue since last HD session. Per the wife's report, patient had fevers and chills and one episode of urinary incontience at home on the am of presentation. There has been no change in his SOB or cough which have been stable for the past month. She denies any episodes of vomiting, diarrhea, or complaints of chest or abdominal pain. Wife reports patient as poor historian due to "memory problems." She brought him to the ED this am rather than going for the regularly scheduled hemodialysis. Of note, patient was recently admitted to [**Hospital1 18**] [**Date range (1) 12908**]/08 for tunnelled HD catheter placement and initiation of hemodialysis. He had an AV fistula placed on [**2125-8-6**]. In the ED, VS T 99.9 BP 88/55 HR 90 RR 24-33 POx 86% on RA, 96% on 4L. CXR showed LLL opacity concerning for atelectasis vs. infiltrate. He received Vanc 1gm/zosyn 2.25gm/levo 250mg in the ED. A Left IJ was placed and he received 500cc NS bolus with normalization of his blood pressure to 130/70. A serum lactate was 4.1. Blood and urine cultures were sent. ROS: The patient denies any weight change, nausea, vomiting, abdominal pain, diarrhea, constipation, melena, hematochezia, chest pain, orthopnea, PND, lower extremity oedema, urinary frequency, urgency, dysuria, lightheadedness, gait unsteadiness, focal weakness, vision changes, headache, rash or skin changes. Past Medical History: - Stage IV CKD - Atrial fibrillation - h/o GI bleed, diverticulitis - C. Diff colitis - h/o stroke 12 years ago w/ right-sided weakness; second stroke 5 years ago - h/o nephrolithiasis w/ stent and nephrostomy tube - CAD s/p MI - sleep apnea not on cpap - h/o klebsiella urosepsis - depression - PFTs [**2117**] with mild restrictive ventilatory defect -Anemia with h/o iron deficiency Social History: Lives with wife [**Name (NI) **], h/o smoking [**12-20**] PPD for 50 years, quit 20 years ago, does not drink alcohol, no drugs. Family History: non-contributory Physical Exam: Vitals: T:101.1 BP:117/95 HR:99 RR:19 O2Sat: 100% on 6L NC GEN: Chronically ill-appearing, well-nourished, rigoring HEENT: EOMI, PERRL, sclera anicteric, no epistaxis or rhinorrhea, MMD, OP Clear NECK: Left IJ in place, unable to assess JVD [**1-20**] neck girth, no bruits, no cervical lymphadenopathy, trachea midline CHEST: right tunnelled HD catheter w/ surrounding erythema, dressing appears dirty, + TTP COR: HS distant, irreg, no M/G/R, normal S1 S2, radial pulses +2 PULM: few rhonchi at left base, few crackles as bases bilaterally, no wheezing, good air movement ABD: obese, Soft, NT, ND, +BS, no HSM, no masses EXT: Right foot cynaotic, toes cool, great toe w/area of necrosis, but good DP pulses b/l, non-tender, left foot warm and well perfused NEURO: drowsy, oriented to person and place. CN II ?????? XII grossly intact. Moves all 4 extremities. Strength 4/5 right side, [**4-23**] on left in upper and lower extremities. SKIN: No jaundice or gross dermatitis. No ecchymoses. Pertinent Results: Admission Labs: [**2125-9-6**] 02:00PM BLOOD WBC-16.5*# RBC-3.64* Hgb-11.3* Hct-34.4* MCV-95 MCH-31.1 MCHC-32.9 RDW-17.3* Plt Ct-92* Neuts-71* Bands-12* Lymphs-8* Monos-5 Eos-0 Baso-0 Atyps-0 Metas-2* Myelos-2* PT-14.8* PTT-25.0 INR(PT)-1.3* Glucose-160* UreaN-35* Creat-4.7*# Na-139 K-4.7 Cl-95* HCO3-27 AnGap-22* CK(CPK)-41 CK-MB-NotDone proBNP-[**Numeric Identifier 12909**]* cTropnT-0.05* blood culture - [**2125-9-6**] Blood Culture, Routine: STAPH AUREUS COAG +. PRELIMINARY SENSITIVITY. Oxacillin RESISTANT Staphylococci MUST be reported as also RESISTANT to other penicillins, cephalosporins, carbacephems, carbapenems, and beta-lactamase inhibitor combinations. Rifampin should not be used alone for therapy. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPH AUREUS COAG + | GENTAMICIN------------ S LEVOFLOXACIN---------- R OXACILLIN------------- R PENICILLIN G---------- R RIFAMPIN-------------- S TETRACYCLINE---------- S VANCOMYCIN------------ S Aerobic Bottle Gram Stain (Final [**2125-9-7**]): GRAM POSITIVE COCCI IN CLUSTERS. [**2125-9-15**] BLOOD CULTURE Blood Culture, Routine-PENDING [**2125-9-13**] BLOOD CULTURE Blood Culture, Routine-PENDING [**2125-9-11**] BLOOD CULTURE Blood Culture, Routine-PENDING [**2125-9-9**] BLOOD CULTURE Blood Culture, Routine-FINAL NO GROWTH [**2125-9-8**] BLOOD CULTURE Blood Culture, Routine-FINAL NO GROWTH [**2125-9-8**] BLOOD CULTURE Blood Culture, Routine-FINAL NO GROWTH [**2125-9-7**] BLOOD CULTURE Blood Culture, Routine-FINAL {STAPH AUREUS COAG +}; Anaerobic Bottle Gram Stain-FINAL; Aerobic Bottle Gram Stain-FINAL [**2125-9-7**] 2:45 pm CATHETER TIP-IV RIGHT TUNNELED TIP HEMODIALYSIS CATHETER. CULTURE: STAPH AUREUS COAG +. >15 colonies. urine culture [**9-6**]- URINE CULTURE (Final [**2125-9-8**]): PROTEUS MIRABILIS. >100,000 ORGANISMS/ML.. PRESUMPTIVE IDENTIFICATION. SENSITIVITIES: MIC expressed in MCG/MG _________________________________________________________ PROTEUS MIRABILIS | AMPICILLIN------------ =>32 R AMPICILLIN/SULBACTAM-- <=2 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CEFUROXIME------------ <=1 S CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S PIPERACILLIN---------- <=4 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- =>16 R [**2125-9-13**] URINE CULTURE-FINAL NO Growth DISCHARGE LABS: [**2125-9-16**] 04:53AM BLOOD WBC-8.0 RBC-2.94* Hgb-8.9* Hct-26.6* MCV-90 MCH-30.3 MCHC-33.5 RDW-16.6* Plt Ct-277 Glucose-89 UreaN-18 Creat-2.3* Na-136 K-3.9 Cl-103 HCO3-27 AnGap-10 Calcium-8.4 Phos-2.6* Mg-1.7 Vanco-18.9 [**2125-9-8**] 04:12AM BLOOD HEPARIN DEPENDENT ANTIBODIES- NEG STUDIES: [**2125-9-10**] - ECHOCARDIOGRAM Conclusions The left atrium is elongated. The right atrium is moderately dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (LVEF>55%). Right ventricular cavity size is mildly increased with mild free wall hypokinesis. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are structurally normal. Mild (1+) mitral regurgitation is seen. Moderate [2+] tricuspid regurgitation is seen. There is moderate pulmonary artery systolic hypertension. Significant pulmonic regurgitation is seen. There is a trivial/physiologic pericardial effusion. Compared with the prior study (images reviewed) of [**2124-10-25**], the estimated pulmonary artery systolic pressure and tricuspid regurgitation are increased and right ventricular cavity enlargement/free wall hypokinesis are now seen. This constellation of findings is suggestive of c/w a primary pulmonary process (chronic pulmonary embolism, bronchospasm, COPD, etc.). CLINICAL IMPLICATIONS: Based on [**2123**] AHA endocarditis prophylaxis recommendations, the echo findings indicate prophylaxis is NOT recommended. Clinical decisions regarding the need for prophylaxis should be based on clinical and echocardiographic data. [**2125-9-10**] - LE ULTRASOUND BILAT IMPRESSION: No DVT in both lower extremities; however, the evaluation of superficial femoral veins and popliteal veins are partly limited due to patient body habitus. [**2126-9-6**] - CXR AP VIEW OF THE CHEST: New right-sided central venous catheter is present with tip terminating in the SVC. No pneumothorax. Cardiac and mediastinal contours are unchanged with mild cardiomegaly and unfolding of the aorta again seen. Aortic knob calcifications are present. Pulmonary vascularity is within normal limits. Patchy opacity in left lower lobe may be due to motion artifact; however, mild atelectasis may be present. No sizeable pleural effusions are noted. The patient is status post right shoulder replacement. IMPRESSION: Patchy opacity in the left lower lobe could be due to respiratory motion artifact or atelectasis. Otherwise, no acute cardiopulmonary abnormality. Brief Hospital Course: 81 year-old male with a history of ESRD on HD, atrial fibrillation, who presented with fatigue and found to have hypotension, elevated lactate, and tachypnea with HD line sepsis. 1) Sepsis ?????? Upon presentation to the ED on [**9-6**], the patient was found to be febrile and hypotensive. He was transferred to the ICU for further care. His temporary HD line (placed [**8-27**] for HD initiation) was pulled and subsequently grew MRSA from a culture of the tip and in several blood cultures. He reqired 5-6L fluid resusitation, but did not require pressors or intubation while in the ICU. He had a left IJ central line placed. The patient's MRSA infection was treated with Vancomycin per Hemodialysis protocol. The patient's vancomycin was treatment was initiated on [**2125-9-6**]. The patient will require a six week treatment course given the patient always had a line in place and has a question of a clot in his fistula that would be at risk for hematogenous seeding. A transthoracic echo was negative for endocarditis, but a transesophageal echocardiogram was not preformed. The patient's IJ was removed prior to discharge and the tip was sent for culture. 2) Urinary Tract Infection - In addition, a urine culture drawn was positive for proteus mirabilis, which was resistant to Ciprofloxacin. He completed a 7 day treatment course with Ceftriaxone for his proteus urinary tract infection. A repeat urine analysis was negative for infection. 3) Acute on Chronic Diastolic Heart Failure - The patient was transfered out of the ICU on [**9-9**]. In the early morning on [**9-10**], the patient was noted to have episodes of desaturation to the 80s on 2L NC. Diuresis was attempted on the floor and was ineffective. He was transfered to the ICU on [**9-10**] for hypoxia. His hospital LOS fluid balance at the time was 7L +. In the ICU, he was diuresed with a combination of Lasix 100mg IV and Diuril 500mg IV and they were able to remove 2L in 24 hrs. The patient's O2 sats were stabilized and he was able to be tranferrred back to the floor. The renal team placed temporary HD catheter on [**9-10**] and the next day they were able to remove 4L of fluid at hemodialyis. The patient had a tunnel hemodialysis catheter placed on [**9-12**]. He continued to have fluid removed over the next few days and eventually his oxygen requirement decreased to 1L. His wife reports that the patient used to have home O2 but his primary care doctor [**First Name (Titles) **] [**Last Name (Titles) 8910**] it about at year ago. He was felt to have experienced acute on chronic diastolic heart failure in the setting of volume overload due to treatment for his sepsis. 4) COPD/Obstructive Sleep Apnea - A component of the patient's hypoxia was also felt to be underlying COPD with untreated sleep apea. The patient had an Echocardiogram which showed evidence of right heart strain consistent with a primary pulmonary process like COPD or obstructive sleep apea. LENIs were preformed which were negative for evidence of DVT. The patient has Obstructive Sleep Apnea and his oxygen saturation would decrease at night without supplemental oxygen. The patient intermitently tolerates a nasal CPAP and will require to use this nightly as an outpatient. We are discharging him on 1L of oxygen to be weaned down as tolerated. The patient will require pulmonary follow up as his last PFTs were in [**2117**] and the patient has evidence of COPD on exam. The patient may again qualify for home oxygen therapy. 5) Thrombocytopenia: There was initial concern for a heparin induced thrombocytopenia as his platelet count had decreased from the 200s a month prior to admission to 92 on admission. The patients DIC labs were normal. A PF4 antibody test was negative for heparin induced antibodies. Heparin prophylaxis was resumed. The patients platelet count improved to a normal range and a cause of the patient's thromboyctopenia is felt to be sepsis. 6) Atrial Fibrillation: The patient's Atrial Fibrillation was adequately rate controlled on his home medications during this hospitalizaiton. The patient is not anticoagulated. The patient's CHADS score is 2+. The patient was not anticoagulated during this hospitalization due to his fall risk. Will defer to the primary care doctor as to whether or not anticoagulation in the long-term is appropriate for this patient. 7) Stage V Kidney Failure on Hemodialysis. The renal service is following the patient. The patient's anemia felt to be from his chronic kidney disease remained stable. The patient is on a Tuesday, Thursday, Saturday Hemodialysis Schedule. The renal team will continue to follow the patient at his rehab facility. The patient was FULL CODE during this hospitalization. The patient was recommended to undergo rehabilitation. Medications on Admission: Tiotropium Bromide 18 mcg Capsule DAILY Aspirin 81 mg PO DAILY Ascorbic Acid 1000 mg PO DAILY Fluoxetine 10 mg PO DAILY Metoprolol Tartrate 25 mg PO BID Omega-3 Fatty Acids PO DAILY Omeprazole 20 mg PO once a day. Percocet 5-325 mg 1-2 Tablets PO q 4h prn pain. Atrovent HFA 17 mcg One Inhalation every four (4) hours prn Acetaminophen prn Nephrocaps 1 mg PO once a day. Discharge Medications: 1. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) capsule Inhalation once a day. 2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 3. Fluoxetine 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 6. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. 7. Atrovent HFA 17 mcg/Actuation Aerosol Sig: One (1) inhalation Inhalation every four (4) hours as needed for shortness of breath or wheezing. 8. Heparin (Porcine) 5,000 unit/mL Solution Sig: 4000-[**Numeric Identifier 2249**] UNIT DWELL Injection PRN (as needed) as needed for line flush: DIALYSIS NURSE ONLY: Withdraw 4 mL prior to flushing with 10 mL NS followed by Heparin as above according to volume per lumen. 9. Vancomycin in Dextrose 1 gram/200 mL Piggyback Sig: One (1) gram Intravenous HD PROTOCOL (HD Protochol). 10. 1L 02 via nasal cannula. Should titrate O2 to sat of 90-94% 11. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO twice a day. Discharge Disposition: Extended Care Facility: [**Hospital **] [**Hospital **] Nursing Home Discharge Diagnosis: Primary Diagnosis: Septic shock secondary bacterial (MRSA) line infection Urinary Tract Infection Secondary Diagnosis: -Chronic Kidney Disease Stage V on Hemodialysis -Atrial fibrillation/flutter -History of Gastrointestinal bleed, diverticulitis -Stroke 12 years ago with right-sided weakness; again 5 years ago -Coronary Artery Disease -diastolic heart failure, EF 60% -sleep apnea not on cpap -depression -Chronic Obstructive Lung Disease? PFTs [**2117**] with mild restrictive ventilatory defect -Anemia, chronic iron deficiency Discharge Condition: Stable Discharge Instructions: You were admitted to the hospital and found to have a bacterial infection in your blood related to your hemodialysis cathether. You required aggressive fluid resuscitation in the intesive care unit and intravenous antibiotics. Your hemodialysis catheter had to be pulled out and a new one was put in after your cultures were clear for 72 hours and your fevers went down. You had difficulty breathing due to the large volume of fluid required to keep your blood pressure up. Your breathing improved once we were able to restart your dialysis. You were also found to have a urinary tract infection which was treated with antibiotics. Your platelets were low on admission but improved to normal during this hospital stay. Your atrial fibrillation was adequately rate controlled during this admission. We recommend that you discuss starting anti-coagulation for your atrial fibrillation with your primary care doctor. Please contact your doctor or go to the emergency room if you have any of the following symptoms: fevers or chills, difficulty breathing, redness or swelling around your catheter site or any other concerning symtpoms. Followup Instructions: (Primary Care Appt) Dr. [**Last Name (STitle) **] [**Month (only) 359**] t, [**2124**] at 10:10am (Phone: [**Telephone/Fax (1) 1579**]) (Pulmonary Appt):DR [**Last Name (STitle) **] & DR [**Last Name (STitle) **] Phone:[**Telephone/Fax (1) 612**] Date/Time:[**2125-10-15**] 3:00 [**Hospital Ward Name 23**] Bldg [**Location (un) 436**]-Medical Specialties Provider: [**Name10 (NameIs) 1570**],INTERPRET W/LAB NO CHECK-IN [**Name10 (NameIs) 1570**] INTEPRETATION BILLING Date/Time:[**2125-10-15**] 3:00 Provider: [**Name10 (NameIs) 1571**] FUNCTION LAB Phone:[**Telephone/Fax (1) 609**] Date/Time:[**2125-10-15**] 2:40 You will need to have hemodialysis on a Tuesday, Thursday, Saturday schedule. This will be taken care of by the kidney doctors at the rehab. Completed by:[**2125-9-18**]

[ "785.52", "995.92", "427.31", "427.32", "496", "041.6", "V09.0", "996.62", "287.5", "428.33", "585.6", "599.0", "327.23", "428.0", "038.11" ]

icd9cm

[ [ [] ] ]

[ "39.95", "38.95", "38.93" ]

icd9pcs

[ [ [] ] ]

15468, 15539

9003, 13815

319, 480

16117, 16126

3630, 3630

17315, 18107

2584, 2602

14238, 15445

15560, 15560

13841, 14215

16150, 17292

6399, 7811

2617, 3611

7834, 8980

273, 281

508, 2010

15680, 16096

3646, 6383

15579, 15659

2032, 2421

2437, 2568

23,107

134,852

24389

Discharge summary

report

Admission Date: [**2180-6-24**] Discharge Date: [**2180-7-19**] Date of Birth: [**2141-8-21**] Sex: M Service: MEDICINE Allergies: Pollen/Hayfever / Bactrim / Cipro / Levofloxacin / Cefepime Attending:[**First Name3 (LF) 6021**] Chief Complaint: Fever Major Surgical or Invasive Procedure: Left Portacath removal Central line placed in right internal jugular vein [**6-27**] Central line removal [**7-13**] History of Present Illness: 38 y/o male with HIV and Burkitt's lymphoma recently currently undergoing treatment for a MRSA neck abcess with Vancomycin presented to ER on [**2180-6-23**] with fevers to 102 and rigors. He had been doing well post recent d/c on [**2180-6-20**] without fever, but was noted by his VNA nurse [**First Name (Titles) **] [**Last Name (Titles) **] changes of his neck [**Last Name (Titles) **] to be febrile to 102. He denies any localizing symptoms but feels generalized weakness, myalgias and feeling "warm." He presented to the emergency room on [**2180-6-24**] with a fever of 102.3 with a WBC of 2.4 with 58%N/ 33L/O bands. He was given cefepine, vancomycin and tylenol in the emergency room ROS: denies headache, photophobia, neck pain, sinus tenderness, sore throat, shortness of breath, cough, chest pain, abdominal pain, diarrhea, dysuria, frequency, CVA tenderness, or rash. Past Medical History: Pt had Pneumonia as a child and was hospitalized for 6 days. HIV positive diagnosed [**4-20**]. Burkitt's lymphoma. Social History: Pt lives in Partner in [**Name2 (NI) **] Ma. He moved here from [**Country 4194**] 13 years ago. He works for toy importer company and is also a massage therapist. He has no children. He is a social drinker. He quit smoking five months ago, seven years smoking total. No IV drugs use. Prior to diagnosis he exercised regularly. Family History: Brother and sister with hx of hyperchol and HTN. Pt reports hx of mult cancers on mothers side of family. No first degree relatives with cancer. Physical Exam: PE 101.7 20 109 102/52 98% RA general nontoxic, nad heent: perrla, no sinus tenderness, op clear, area of abcess without fluctuance lad: no palpable cervical, axillary, supraclavicular, infraclavicular heart: rrr lung: bibasilar crackles abdomen: benign ext no c/c/e no rash Pertinent Results: [**2180-6-23**] 10:55PM WBC-2.4* RBC-3.30* HGB-8.4* HCT-25.4* MCV-77* MCH-25.6* MCHC-33.2 RDW-15.0 [**2180-6-23**] 10:55PM NEUTS-24* BANDS-26* LYMPHS-37 MONOS-6 EOS-2 BASOS-0 ATYPS-3* METAS-2* MYELOS-0 [**2180-6-23**] 10:55PM HYPOCHROM-2+ ANISOCYT-2+ POIKILOCY-2+ MACROCYT-2+ MICROCYT-2+ POLYCHROM-OCCASIONAL OVALOCYT-2+ TEARDROP-2+ ACANTHOCY-OCCASIONAL [**2180-6-23**] 10:55PM PLT SMR-NORMAL PLT COUNT-157 [**2180-6-23**] 10:55PM ALBUMIN-4.0 [**2180-6-23**] 10:55PM ALT(SGPT)-20 AST(SGOT)-12 LD(LDH)-194 ALK PHOS-87 TOT BILI-0.1 [**2180-6-23**] 10:55PM GLUCOSE-100 UREA N-11 CREAT-1.0 SODIUM-141 POTASSIUM-3.9 CHLORIDE-104 TOTAL CO2-28 ANION GAP-13 [**2180-6-23**] 11:16PM LACTATE-1.2 [**2180-6-23**] 11:55PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-8.0 LEUK-NEG [**2180-6-23**] 11:55PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.008 . [**2180-6-27**] 01:53AM BLOOD WBC-18.8* Lymph-3* Abs [**Last Name (un) **]-564 CD3%-93 Abs CD3-522* CD4%-26 Abs CD4-147* CD8%-65 Abs CD8-369 CD4/CD8-0.4* [**2180-7-14**] 12:00AM BLOOD Ret Aut-0.2* [**2180-7-17**] 09:20AM BLOOD Gran Ct-[**Numeric Identifier 61759**]* . [**2180-7-19**] 08:15AM BLOOD WBC-8.4 RBC-3.73* Hgb-10.1* Hct-30.4* MCV-82 MCH-27.0 MCHC-33.0 RDW-16.7* Plt Ct-263 [**2180-7-19**] 08:15AM BLOOD Plt Ct-263 [**2180-7-19**] 08:15AM BLOOD Glucose-80 UreaN-9 Creat-0.9 Na-138 K-4.2 Cl-103 HCO3-26 AnGap-13 [**2180-7-19**] 08:15AM BLOOD ALT-72* AST-32 AlkPhos-225* TotBili-0.2 [**2180-7-19**] 08:15AM BLOOD Calcium-8.5 Phos-3.9 Mg-1.7 Imaging: CXR ([**2180-6-23**]): No evidence of pneumonia MRI OF THE SOFT TISSUES OF THE NECK ([**2183-6-26**]): Enhancing irregular masses are identified in the posterior neck, especially on the right, at the level of C2 and extending inferiorly CT Torso w/contrast ([**2180-7-18**]): Stable appearance of multiple sub-cm mediastinal and hilar lymphadenopathy as well as stable appearance of mediastinal soft tissue. Stable appearance of numerous tiny bilateral pulmonary nodules. No new pulmonary nodules identified. Stable appearance of hepatic hemangioma. 20 x 13 mm subcutaneous lesion of the anterior left shoulder with internal hounsfield density consistent with air. It is unclear what this lesion represents and clinical correlation is suggested. Brief Hospital Course: 1. Fever/Sepsis/Neutropenia: Pt admitted to medicine, initially treated with treated with broad spectrum antibiotics, IVF, blood cultures were performed daily. He was initially started on Cefepime and Vancomycin due to a history of MRSA abscess, as well as Flagyl for gram negative coverage). Pt was found to be borderline neutropenic with ANC of 1200. Pt was also transfused 1 unit pRBC for anemia (HCt24.2, increased to 27.5). Two days after admission he remained febrile as high as 104F, became tachycardic and hypotensive with good response to fluid boluses. Rash was also noted across face, chest, arms - non pruritic, non painful thought to be secondary to drug rash vs. reaction to blood transfusion. At that time, abx regimen was changed to Vancomycin, Aztreonam, and Levofloxacin (Cefepime was discontinued to do ? drug reaction). Voriconazole was started for fungal coverage as well as one dose of Gentamicin. Pt was pan cultured and sent to the OR for double lumen porta cath removal (empiric for ?line sepsis) and admitted to the ICU for sepsis management, hypoxemia and hypotension. . On admission to [**Name (NI) 153**], pt had [**Name (NI) **], cough, fatigue/weakness, some diarrhea and unknown source of infection. He was continued with aggressive fluid resuscitation (central line - RIJ -placed [**6-27**]), Vancomycin, Flagyl, Aztreonam, voriconazole were continued, Levofloxacin was d/ced due to ?drug rash and history of cipro allergy. Gentamicin was added for double gram neg coverage. Pt's blood pressure stabilized with fluid resuscitation and fever defervesced with Abx and Tylenol/Ibuprofen. CXR revealed congestion and pt obtained diuresis with relief of [**Month/Year (2) **], thought to be due to flash pulmonary edema secondary to chemo induced cardiomyopathy. By [**6-30**] patient was improving, improved leukocytosis, but pt remained febrile. Voriconazole and Flagyl discontinued at that time as fevers were thought to be secondary to drug reaction vs. underlying lymphoma. Repeat CD4 count was 184 (previously 800), viral load >10,000. Pt was transferred back to medicine floor on [**2180-7-1**]. . Pt came to the floor feeling much better but still having fevers of unknown etiology. Sources included the healing abscess in the neck, chest wound after catheter removal, drug reaction? Pt was empirically covered with Vancomycin and Aztreonam. All cultures still negative but patient became febrile to 102. Gentamycin added back, Atovaquone added for PCP [**Name Initial (PRE) 1102**]. MRI of the neck did not show persistence/recurrence of abscess or osteomyelitis. HBV, HCV sent due to rising LFTs all negative. C. Diff, galactomannin and strongyloides sent and were negative due to persistent diarrhea. Pt was re-evaluated by the ICU due to persistent fevers, diarrhea and tachycardia. Pt was deemed fit to be managed on the floor. During his stay on the floor he received his third dose of chemo during which time antibiotics were held. He was later restarted on Vanco/Aztreonam. Pt stabilized but remained with intermittent fevers and tachycardia. Neutropenia resolved with stable WBC. CT torso of the abdomen was performed as a last effort to identify a source, which was unrevealing. Wound cultures taken from the site of line removal grew resistant coagulase positive staph aureus for which he was empirically covered by Vancomycin. . 2. [**Name Initial (PRE) **] - Pt complaining of subjective [**Name Initial (PRE) **] on presentation to ICU. O2 sats good on 3L NC. ?pneumonia as source of infection vs. overlying PCP (HIV status and immunocompromised from chemo, plus continually rising LDH) vs. fluid overload from resuscitative fluids vs. [**1-19**] generalized infection. CXR on presentation to [**Hospital Unit Name 153**] demonstrated b/l pulm congestion vs. pneumonia. EF on [**5-16**] = 55%, repeat EF on ECHO ([**6-27**]) = 40-45% therefore decreased likelihood cardiogenic pulm congestion, although still possibility of chemo-induced cardiac dysfunction given the newer lower EF, but could be pulm congestion [**1-19**] early sepsis w/ leaky capillaries or PCP. [**Name10 (NameIs) **] improved with diuresis with lasix. . 3. Tachycardia - related to fever vs. functional heart changes [**1-19**] chemo vs. pericardial effusion vs. PE (low on differential). Pt remained tachycardic in ICU, but per patient and patient's partner, baseline HR = 100. Therefore, ECHO was obtained [**6-27**] and r/o for structural heart abnormality as cause of tachycardia - therefore was just monitored during ICU stay. Patient remained intermittently tachycardic upon return to the floor, thought to be secondary to insensible loses due to continued fever, underlying condition, infection? Patient remained stable until discharge with low grade tachycardia. . 4. Rash: Pt developed a rash across face, trunk, UE>LE, developed [**6-25**]. Appears to be drug rash in nature - [**1-19**] Cefepime vs. Levofloxacin vs. related to blood transfusion (pt transfused while febrile) vs. enteroviral infection. Likely drug rxn - per pt, rash same as rash he experienced after Cipro. Therefore cefepime + levofloxacin d/ced and rash monitored throughout stay with improvement. . 5. Diarrhea - pt c/o diarrhea since admission, profuse, yellow in color and watery. Pt on broad spectrum abx since admission. Initial C Diff on presentation neg - repeat also negative. Other stool studies [**6-24**] and [**6-25**] neg. Pt with improved (decreased) stool output [**6-28**] and [**6-29**]. Viral stool cxs positive for adenovirus. Diarrhea resolved during hospital course, etiology unclear. . 6. Burkitt's Lymphoma: Admitted s/p [**Hospital1 **]-R cycle x 2. LDH= 194 ([**6-23**])-> 811([**6-28**]) as indication of tumor burden vs. related to transfusion of pRBC vs. ?PCP. [**Name10 (NameIs) **] restarted on chemotherapy s/p third cycle of [**Hospital1 **]-R. LDH later normalized to 130. . 7. Anemia - Pt with history of anemia - s/p transfusion 1 unit pRBC on floor. Hct monitored and remained stable. . 8. [**Name (NI) 5779**] - pt with mildly elevated AST, ALT, Alk phos likely secondary to medications/illness. Liver function remained stable, discharged with mildly elevated enzymes. Etiology unclear. . 10. HIV: Last CD4=800, viral load > 100,000 in past couple months. HAART held for now due to Burkitt's lymphoma and therapy. CD4 resent during hospitalization = 147 ([**6-27**]) ?accurate due to acute infection. Patient was later restarted on HAART with Tenofovir, Emtricitabine, Nelfinavir. . 11. FEN: Patient tolerating regular diet throughout stay. Neutropenic diet temporarily, discontinued once WBC normalized. Electrolytes were repleted as necessary. 12. Prophylaxis: heparin, protonix, pneumoboots, OOB to chair w/ assistance, patient later became stronger, ambulating without difficulty . 13. Access: R IJ ([**6-27**]) . 14. Code status: FULL throughout admission Medications on Admission: Neulasta Procrit [**Hospital1 **]-R 6d prior Vanc stopped DOA Ativan prn Allopurinol Undergoing treatment with [**Hospital1 599**]-R (cycle 2). Also undergoing therapy on protocol s/p 4 weekly intrathecal ARA-c. Discharge Medications: 1. Atovaquone 750 mg/5 mL Suspension Sig: Ten (10) mL PO DAILY (Daily). Disp:*300 mL* Refills:*2* 2. Nelfinavir 625 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Disp:*120 Tablet(s)* Refills:*2* 3. Tenofovir Disoproxil Fumarate 300 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 4. Emtricitabine 200 mg Capsule Sig: One (1) Capsule PO Q24H (every 24 hours). Disp:*30 Capsule(s)* Refills:*2* 5. Ambien 5 mg Tablet Sig: One (1) Tablet PO at bedtime as needed for insomnia. Disp:*30 Tablet(s)* Refills:*0* 6. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 7. Compazine 5 mg Tablet Sig: 1-2 Tablets PO every eight (8) hours as needed for nausea. Disp:*30 Tablet(s)* Refills:*0* 8. Linezolid 600 mg Tablet Sig: One (1) Tablet PO twice a day for 10 days: please start [**2180-7-19**]. Disp:*20 Tablet(s)* Refills:*0* 9. Zofran 4 mg Tablet Sig: 1-2 Tablets PO every eight (8) hours as needed for nausea. Disp:*30 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital **] Home Health Care Discharge Diagnosis: 1. Sepsis Primary diagnoses: 1. Sepsis 2. Burkitts Lymphoma 3. HIV/AIDS 4. Febrile neutropenia Discharge Condition: Good; low grade fevers Discharge Instructions: Please take all medications as prescribed. Please complete course of antibiotics. Please keep all you follow up appointments. Please contact physician or come to hospital if increased shortness of breath, fever greater than 100.4, any other signs or symptoms of infection. Followup Instructions: 1.) follow up with Dr. [**Last Name (STitle) **] (hematologist/oncologist) as directed for treatment of Burkitt's Lymphoma. Please call to schedule an appointment. 2.) Follow up with Dr. [**Last Name (STitle) 4334**], Infectious Diseases, as directed for HIV care. [**Name6 (MD) **] [**Name8 (MD) **], MD Where: LM [**Hospital Unit Name 4341**] DISEASE Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2180-8-3**] 11:30 3.) Follow up with Primary care physician as directed Completed by:[**2180-7-19**]

[ "V58.65", "693.0", "995.92", "E930.8", "280.9", "428.0", "425.4", "996.62", "079.0", "682.1", "787.91", "719.40", "038.9", "042", "785.52", "518.82", "200.20", "576.8", "079.51", "288.0" ]

icd9cm

[ [ [] ] ]

[ "99.04", "99.28", "38.93", "86.05", "99.25" ]

icd9pcs

[ [ [] ] ]

13001, 13064

4678, 11607

326, 445

13203, 13227

2321, 4655

13550, 14060

1865, 2011

11870, 12978

13085, 13182

11633, 11847

13251, 13527

2026, 2302

281, 288

473, 1362

1384, 1502

1518, 1849

4,454

177,326

10298+56130+56133

Discharge summary

report+addendum+addendum

Admission Date: [**2183-7-3**] Discharge Date: [**2183-7-6**] Date of Birth: [**2111-6-23**] Sex: M Service: INT MED HISTORY OF PRESENT ILLNESS: The patient is a 72-year-old African American male with multiple recent admissions for urinary tract infection, a history of cerebrovascular accident and an indwelling suprapubic catheter, who was transferred from the [**Hospital3 6560**] Facility for shortness of breath and decreased oxygen saturation to 76% on room air. He had several days of congestion, with copious secretions on the morning of admission. He was also found to be tachycardic. At the nursing home, the patient was suctioned and placed on three liters by nasal cannula with oxygen saturations increasing to 80%. The patient had a percutaneous endoscopic gastrostomy tube in place and did not take anything by mouth. He was nonverbal at baseline and recently moved to [**Location (un) 86**] from [**State 19827**]. In the emergency room, the patient was found to be febrile to 101.9??????F with a pulse of 120 and sinus tachycardia. The patient was found to have a urinalysis suggestive of a urinary tract infection in addition to decreased oxygen saturations and a streaky left lower lobe opacity suggestive of an infiltrate. The patient was given levofloxacin and ceftriaxone with intravenous fluids in the emergency room. PAST MEDICAL HISTORY: 1. Benign prostatic hypertrophy. 2. Admission for urinary retention secondary to urethral stricture. 3. Elevated PSA. 4. Cerebrovascular accidents, multiple, in the past. 5. Hypertension. 6. Suprapubic tube indwelling. 7. Gastrojejunostomy tube. 8. Methicillin resistant Staphylococcus aureus, Clostridium difficile urosepsis. MEDICATIONS ON ADMISSION: Proscar 5 mg p.o. q.d. Flomax 0.4 mg p.o. q.d. Atenolol 25 mg p.o. q.d. Ritalin 5 mg p.o. b.i.d. Aspirin. ALLERGIES: There were no known drug allergies. SOCIAL HISTORY: The patient moved from [**State 19827**] to [**Location (un) 86**] earlier this year. He lived at the Bostonian. He had two daughters, [**Name (NI) 2048**] [**Name (NI) **] ([**Telephone/Fax (1) 34244**]) and [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 805**] ([**Telephone/Fax (1) 34245**]), who were intimately involved in his care. PHYSICAL EXAMINATION: On physical examination, the patient had a temperature of 101.9??????F with a pulse of 140, sinus tachycardia and a blood pressure of 101/72. His oxygen saturation was 96% on four liters and 87% on room air at the time of admission; however, by the time we saw the patient, he was 95% on room air. Generally, he was a nonverbal, contracted, elderly male lying in bed in no acute distress. On HEENT examination, the head was normocephalic and atraumatic. The mucous membranes were mildly dry. The lungs had coarse breath sounds at the left base by the report of the emergency department. It was difficult to interpret on my examination due to decreased effort. The heart was tachycardic with no murmurs, rubs or gallops appreciated. The abdomen had a gastrojejunostomy tube and a suprapubic tube with thin, yellow liquid at the entry site. He had a soft abdomen. On skin examination, the patient had a decubitus ulcer that was 5 cm deep with granulation tissue clear around the borders. The extremities were thin and contracted. LABORATORY DATA: At the time of admission, the patient had a white blood cell count of 12,700 with a hematocrit of 39. There was a sodium of 141, potassium of 4.1, chloride of 102, bicarbonate of 26, BUN of 25, creatinine of 0.6 and glucose of 131. Urinalysis showed large blood and was nitrite positive with greater than 300 protein, 88 white blood cells and occasional bacteria. The patient had cultures pending. RADIOLOGY: The chest x-ray showed a left lower lobe infiltrate. ELECTROCARDIOGRAM: The electrocardiogram was terminis with a poor baseline. HOSPITAL COURSE BY ISSUE: 1. INFECTIOUS DISEASE: The patient was admitted with a urinary tract infection and left lower lobe pneumonia. His previous urinary tract infection had become systemic and the patient had Escherichia coli resistant to ampicillin, ciprofloxacin, gentamicin, levofloxacin and Bactrim on [**2183-5-4**], in addition to Enterococcus sensitive to ampicillin, penicillin and vancomycin. These were both found in the blood and were thought to be spread from an initial urinary tract infection. Given the multiple resistant organisms, the patient was started on Flagyl to cover possible anaerobes in the left lower lobe infiltrate, ceftriaxone to cover the previously resistant Escherichia coli and vancomycin to cover for a history of Methicillin resistant Staphylococcus aureus in the urine. At the time of this Discharge Summary, the patient is growing Staphylococcus coagulase positive out of his urine; however, the final sensitivities are still pending. The patient did well throughout his hospitalization. He was stable with a decreasing oxygen requirement. He was on two liters of oxygen at the time of discharge with an oxygen saturation of 99-100%. He was nonverbal, so it was difficult to assess how he was feeling; however, he continued to have a soft abdomen and a benign examination. 2. CARDIOVASCULAR: The patient had a history of hypertension, however he was in sinus tachycardia in the setting of being volume depleted at the time of admission. We held his atenolol during this admission; this will be started back up as the patient is discharged and gets back to his baseline. 3. FLUID, ELECTROLYTES AND NUTRITION: The patient was placed on high protein tube feedings at 75 cc/h with some vitamin supplements. He was also placed on half normal saline at 100 cc/h after completing three liters of normal saline. The patient's heart rate came down after the volume resuscitation. He was placed on all of his outpatient medications in addition to subcutaneous heparin as deep vein thrombosis prophylaxis. 4. CODE STATUS: The patient is a full code per a conversation with his daughter on [**2183-7-3**]. DISCHARGE DIAGNOSES: Urinary tract infection. Pneumonia. DISCHARGE MEDICATIONS: 1. Zantac 150 mg per gastrostomy tube q.d. 2. Tube feedings at 75 cc/h. 3. Flagyl 500 mg per gastrostomy tube t.i.d. for a total of 14 days with the last day on [**2183-7-16**]; further antibiotics will be indicated in Page 1, given the sensitivities of the final organisms. 4. Proscar 5 mg per gastrostomy tube q.d. 5. Aspirin 325 mg per gastrostomy tube q.d. 6. Colace 100 mg per gastrostomy tube b.i.d. 7. Dulcolax p.r.n. 8. Atenolol, which was on hold and was to be restarted as an outpatient. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 8829**], M.D. [**MD Number(1) 8830**] Dictated By:[**Last Name (NamePattern1) 16512**] MEDQUIST36 D: [**2183-7-5**] 06:09 T: [**2183-7-5**] 07:20 JOB#: [**Job Number 34246**] Name: [**Known lastname 400**], [**Known firstname **] Unit No: [**Numeric Identifier 6020**] Admission Date: [**2183-7-3**] Discharge Date: [**2183-7-11**] Date of Birth: [**2111-6-23**] Sex: M Service: ADDENDUM: Since the previous discharge summary dated [**2183-7-6**], the patient has continued to do well. He was treated for a pneumonia and methicillin - resistant Staphylococcus aureus and enterococcal urinary tract infection with Flagyl, ceftriaxone, and vancomycin. [**2183-7-10**] is day eight out of fourteen of an intended intravenous antibiotic course. The patient has had a PICC line placed on [**2183-7-10**] for continued antibiotic therapy. The patient did have one temperature spike on [**2183-7-8**]. The patient was pancultured and had a chest x-ray which showed resolution of the lower lobe infiltrate. The patient's cultures have all remained no growth to date at the time of this discharge summary and the patient has not had any fever spikes. The patient has gone back to his baseline. He is occasionally verbal. He is lying comfortably in bed and is not requiring supplemental oxygen. The patient had a clogged gastrojejunostomy tube which was successfully unclogged by Interventional Radiology on [**2183-7-9**]. At the time of this discharge summary the patient's tube feeds are infusing well. The patient is currently awaiting placement at a nursing facility. The patient's code status is full code as per a conversation with his daughter on [**2183-7-3**]. DISCHARGE DIAGNOSES: 1. Urinary tract infection. 2. Pneumonia. DISCHARGE MEDICATIONS: The same as previous discharge summary. The patient should be continued on a total of fourteen days of his antibiotics. [**First Name11 (Name Pattern1) 1463**] [**Last Name (NamePattern4) 6021**], M.D. [**MD Number(1) 6022**] Dictated By:[**Last Name (NamePattern1) 3202**] MEDQUIST36 D: [**2183-7-10**] 14:15 T: [**2183-7-11**] 15:14 JOB#: [**Job Number 6023**] Name: [**Known lastname 400**], [**Known firstname **] Unit No: [**Numeric Identifier 6020**] Admission Date: [**2183-7-3**] Discharge Date: [**2183-7-17**] Date of Birth: [**2111-6-23**] Sex: M Service: This is an addendum to the discharge summary dated [**2183-7-6**]. There is an additional addendum on [**2183-7-11**]. ADDENDUM: The patient had been doing well on the floor, awaiting transfer to long term care facility when on [**2183-7-14**], he was noted to be hypoxic and having respiratory distress. The patient was noted to be 80% on room air and 85% on 100% nonrebreather. The patient was intubated at that point and suctioned for large amounts of tenacious mucus. After the sputum had been suctioned, the patient's oxygenation improved dramatically. He was hydrated and sputum essentially cleared on its own. He was extubated approximately twelve hours after intubation and continued to do well. Oxygenations remained good after extubation. The patient is now stable and awaiting transfer to long term care facility. Discharge diagnosis in addition to the previous diagnoses include status post intubation from mucus plugging. Discharge medications will be vitamin C 500 mg po bid, Proscar 5.0 mg po q day, heparin subcutaneous 5,000 units tid, Zantac 150 mg po q day, aspirin 325 mg po q day, multivitamin liquid 5.0 cc po q day, zinc 220 mg po q day. Tube feeds of Replete with fiber at a goal of 75 cc/hr and free water boluses of 100 cc per gastric tube tid. The patient to be maintained with aspiration precautions and isolation precautions for resistant organisms in the past. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 6033**], M.D. [**MD Number(1) 6034**] Dictated By:[**Last Name (NamePattern1) 641**] MEDQUIST36 D: [**2183-7-17**] 07:45 T: [**2183-7-17**] 16:02 JOB#: [**Job Number 6035**]

[ "486", "518.81", "294.8", "707.0", "401.9", "041.11", "599.0", "276.5", "041.04" ]

icd9cm

[ [ [] ] ]

[ "38.93", "96.71" ]

icd9pcs

[ [ [] ] ]

8491, 8536

8560, 10885

1753, 1909

2305, 6065

167, 1369

1391, 1727

1926, 2282

66,688

183,599

24644

Discharge summary

report

Admission Date: [**2160-10-25**] Discharge Date: [**2160-11-3**] Date of Birth: [**2098-4-6**] Sex: M Service: NEUROLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 848**] Chief Complaint: Confusion Major Surgical or Invasive Procedure: none History of Present Illness: 62 y.o. male with recent admission to [**Hospital1 18**] Trauma Service after a fall down stairs while inebriated. At the time, the patient was initially seen as an outside hospital, and was transported to [**Hospital1 18**] via helicopter. During the flight, the patient reportedly had a VF arrest lasting approximately 4 mins with ROSC after epinephrine and CPR only. He was initially intubated and sedated in the T-SICU. During his hospital admission to [**Hospital1 18**], he was found to have a diffuse subarachnoid and intraventricular hemorrhage, a SDH, a right scapular fracture, and multiple right lateral rib fractures. In the T-SICU, the patient was placed on a CIWA scale for anticipated alcohol withdrawal. The patient did have periods of delirium responsive to large amounts of benzodiazepines. His mental status improved, though he continued with poor balance throughout his hospitalization. He was discharged to rehabilitation on [**2160-10-23**]. The patient reportedly was sent back to the emergency department at [**Hospital3 **] from rehab for "increasing confusion and lethargy." He received 2 units of pRBCs, though it is unclear if this occurred at [**Hospital6 5016**] or at rehab. At the OSH, he was found to be febrile to 101.4, diagnosed with a RLL pneumonia, and started on antibiotic therapy. He was subsequently transferred to [**Hospital1 18**] and admitted to the MICU team. Patient reports last alcohol use prior to his previous admission. Past Medical History: - Alcoholic Cirrhosis - VF Arrest (4min) - kidney stones - SAH, SDH, right scapular fracture, multiple right rib fractures Social History: Lives in [**Location **] with [**First Name9 (NamePattern2) 62212**] [**Doctor Last Name 636**]. He used to make shoes, but was fired two years ago and has been unemployed. Tobacco - denies EtOH - endorses [**3-4**] shots per night, last drink 3wks ago Drug use - denies. Family History: CVA - Mother 60s. Physical Exam: Initial Exam: Tmax: 37.6 ??????C (99.6 ??????F) Tcurrent: 37.6 ??????C (99.6 ??????F) HR: 83 (83 - 83) bpm BP: 135/76(89) {135/76(89) - 135/76(89)} mmHg RR: 21 (21 - 21) insp/min General Appearance: Well nourished, No acute distress, Overweight / Obese Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: No(t) Systolic, No(t) Diastolic) Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse: Present), (Right DP pulse: Present), (Left DP pulse: Present) Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : , No(t) Crackles : ) Abdominal: Soft, Non-tender, No(t) Distended Extremities: Right lower extremity edema: Absent, Left lower extremity edema: Absent Skin: Not assessed Neurologic: No(t) Attentive, Follows simple commands, Responds to: Verbal stimuli, Movement: Purposeful, Tone: Not assessed NEURO: Neurologic examination: Mental status: Awake and alert but slow, cooperative with exam, normal affect. Oriented to person, intermittently to date, not to place. Attentive, says DOY backwards. Speech is fluent with normal comprehension and repetition; naming intact. No dysarthria. [**Location (un) **] intact. Registers [**4-1**], recalls [**2-2**] in 5 minutes. No evidence of apraxia or neglect. Cranial Nerves: Pupils left 4mm right 6mm both consensal. Visual fields are full to confrontation. Extraocular movements intact bilaterally, no nystagmus. Sensation intact V1- V3. Facial movement symmetric. Hearing intact to finger rub bilaterally. Palate elevation symmetrical. Sternocleidomastoid and trapezius normal bilaterally. Tongue midline, movements intact. Motor: Normal bulk bilaterally. Mildly increased tone in [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 6816**]. Mild resting tremor in right hand. No pronator drift. [**Doctor First Name **] Tri [**Hospital1 **] WE FE FF IP H Q DF PF TE R 5 5 5 5 5 5 5 5 5 5 5 5 L 5 5 5 5 5 5 5 5 5 5 5 5 Coordination: finger-nose-finger some pass-pointing, heel to shin normal, RAMs normal. Gait: deferred. Romberg: deferred. Discharge exam: Neurologic examination: Mental status: Awake and alert , oriented to place, name, confused about year, says [**2158**], but can correct himself, occasionally seems disinhibited and confused about days events, but very charming and funny. Attentive, says DOY backwards. Speech is fluent with mild dysarthria, Recalls [**2-2**] in ~3 mins Cranial Nerves: Intact, some nystagmus on end gaze Motor: Normal bulk bilaterally. Mildly increased tone in [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 6816**]. Mild action tremor in hands. No pronator drift. [**Doctor First Name **] Tri [**Hospital1 **] WE FE FF IP H Q DF PF TE R 5 5 5 5 5 5 5 5 5 5 5 5 L 5 5 5 5 5 5 5 5 5 5 5 5 Coordination: finger-nose-finger some pass-pointing, heel to shin normal, RAMs normal. Pertinent Results: UCx, Blood Cx sent in ED . STUDIES: Head CT [**2160-10-25**] : 1. A 1 cm hypodense CSF attenuation of subdural collection overlying the left hemisphere, with rightward shift of 4 mm and decreased size of the right extra-axial space. 2. Right posterior parenchymal hemorrhage similar or slightly increased in size with surrounding edema. 3. Bilateral parieto-occipital subarachnoid hemorrhage, overall decreased from [**2160-10-18**]. [**2160-10-25**] MRI Head : Since the prior examination, there is slight increase in size of what is likely a left cerebral hemispheric subdural hygroma causing mild effacement of the cerebral sulci, but no shift of normally midline structures. The hemorrhages seen in the region of the septum pellucidum appear to have resolved but there is persistence of the small right parietal hemorrhage with surrounding edema, as well as the FLAIR images showing what is likely subacute subarachnoid hemorrhage. There are no abnormalities on the diffusion images to suggest acute brain ischemia. There is no hydrocephalus or shift of normally midline structures. The principal vascular flow patterns are identified. There is redemonstration of a small, polypoid area of mucosal thickening in the mid-ethmoid sinus on the right side. CONCLUSION: Mild increase in size of left cerebral convexity subdural hygroma. See above report for additional findings. [**2160-10-31**] IMPRESSION: Normal CT angiography of the head. CT VENOGRAPHY OF THE HEAD: CT venography of the head demonstrates no evidence of vascular occlusion or thrombosis within the superior sagittal and transverse sinuses. IMPRESSION: No evidence of dural sinus thrombosis. MRI [**2160-10-31**] IMPRESSION: 1. Over the series of studies, and in direct comparison to the [**10-25**] MR, there has been no definite increase in the size of the ventricles to specifically suggest the development of hydrocephalus; moreover, there is no evidence of transependymal migration of CSF. 2. Persistent small amount of small subarachnoid hemorrhage at the bihemispheric vertex, with expected evolution of the right frontovertex hemorrhagic contusion, but no other hemorrhage seen. 3. Now only a thin and progressively FLAIR-hyperintense subdural collection, layering over only the most anterior aspect of the left frontal convexity; this measures only 3.5 mm in maximal thickness and demonstrates no mass effect on the subjacent brain; there is only at most 1 mm rightward shift of normally-midline structures. 4. No evidence of acute infarction. EEG [**2160-10-30**] IMPRESSION: This telemetry captured no pushbutton activations. Routine sampling showed a mildly slow [**7-6**] Hz theta frequency background suggestive of a mild to moderate encephalopathy. There were also occasional generalized bursts of slowing. There were no epileptiform features noted. A large portion of this study was interrupted by electrode artifact. Brief Hospital Course: MICU COURSE: ============ 1. Fever: Pt with ? infiltrate on chest x-ray from admission. Also consider central from intracranial bleed. Blood cultures and Urine cultures pending. UA borderline positive. Treated with ceftriaxone and azithromycin x 5 days. Remained afebrile in ICU. 2. Altered Mental Status: Differential includes delirium from febrile illness, changes assosicated with increasing SDH and slight midline shift, increasing edema from R parenchymal bleed. Was admitted to ICU for q4 hour neuro checks. Treated infections as above. Neurosurgery was consulted regarding changes on CT. Felt that this was not of significance and recommended MRI head. Neurology consulted for assistance in neurological exam and ? new right sided facial droop. MRI head performed while in MICU - resolving contusion and area of restricted diffusion in R pareital lobe.. Meningitis was entertained as possibility but felt less likely given that per signficant other, the patient has been at this mental status since discharge. 3. Subarachonid / Subdural Hemorrhage: Neurosurgery consulted. MRI ordered. No surgical intervention at this time. Monitored neuro checks. Loaded dilantin for ppx with 300 mg IV x 1. Followed levels. Was tapered of dilantin, no evidence of seizure activity on EEG 4. Scapular Fracture: Consulted Trauma Surgery. No acute management. 5. EtOH Abuse: SW involvement Neurology Course -Patient was taken on the neurology service for his encephalopathy. Initially the patient was very lethargic and confused and this was determined to be due to haldol dosing. He was allowed to wash out of this medication and his mental status slowly improved although he did have episodes of waxing and waining alertness. He was worked up with long term monitoring on EEG which showed only slowing and no epileptiform activity. An MRI showed a slowly resolving contustion an area of possible infarct in the R parietal area which could be consistent with the patient's general state of confusion. An LP was considered but the patient continued to improve as the neuroleptic medications were weaned off and he became much more alert and oriented. He finished a course of azithromycin and his toxic/metabolic/infectious workup was unrevealing. He was discharged back to rehab. Medications on Admission: 1. Amlodipine 10 mg daily 2. Furosemide 40 mg daily 3. Losartan 50 mg Tablet daily 4. Hydrochlorothiazide 25mg PO daily 5. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H PRN 6. Pantoprazole 40 mg daily 7. Docusate Sodium 100 mg [**Hospital1 **] 8. Senna 8.6 mg [**Hospital1 **] 9. Haloperidol 1-5 mg IV Q4H:PRN agitation 10. Diazepam 5 mg IV Q8H:PRN CIWA >10 11. Bisacodyl 10 mg Tablet daily 12. Albuterol Sulfate neb q6h PRN 13. Ipratropium Bromide 0.02 % Solution Sig: neb q6h PRN 14. Metoprolol Tartrate 5 mg IV Q4H:PRN HR>100 15. Insulin sliding scale 16. Phenytoin Sodium Extended 100 mg TID Discharge Medications: 1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 4. Chlorhexidine Gluconate 0.12 % Mouthwash Sig: Fifteen (15) ML Mucous membrane TID (3 times a day). 5. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Seroquel 25 mg Tablet Sig: [**2-1**] Tablet PO QHS prn as needed for insomnia. Disp:*30 Tablet(s)* Refills:*0* 9. Losartan 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Discharge Disposition: Extended Care Facility: [**Hospital3 7665**] Discharge Diagnosis: Encephalopathy - likely secondary to improving contusion and SAH/SDH Discharge Condition: Improved. Alert, oriented to name, place, date - (althouhgh consistently make mistake and says it is [**2158**], but realizes it is wrong) some perseveration and disinhibition. CN: intact, Motor and sensory exam with deficit. Mild dysmetria on FNF. Discharge Instructions: You were admitted with confusion and worsening mental status after you were discharged to rehab. You came back with worsening confusion and were treated for a pneumonia and you were evaluated for seizure activity but did not have evidence of that. You continued to improve and are now being discharged to complete your rehab. Please follow up with your primary care doctor. Please ensure you keep all follow up appointments. Please call your doctor or nurse practitioner or return to the Emergency Department for any of the following: * Any headaches, visual changes, weakness in any extremity or difficulty speaking. *You experience new chest pain, pressure, squeezing or tightness. *New or worsening cough, shortness of breath, or wheeze. *If you are vomiting and cannot keep down fluids or your medications. *You are getting dehydrated due to continued vomiting, diarrhea, or other reasons. Signs of dehydration include dry mouth, rapid heartbeat, or feeling dizzy or faint when standing. *You see blood or dark/black material when you vomit or have a bowel movement. *You experience burning when you urinate, have blood in your urine, or experience a discharge. *You have shaking chills, or fever greater than 101.5 degrees Fahrenheit or 38 degrees Celsius. *Any change in your symptoms, or any new symptoms that concern you. Please resume all regular home medications , unless specifically advised not to take a particular medication. Also, please take any new medications as prescribed. Please get plenty of rest, continue to ambulate several times per day, and drink adequate amounts of fluids. Abstain from alcohol. Followup Instructions: Provider: [**Name10 (NameIs) **] SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2160-11-20**] 1:30 Provider: [**Name10 (NameIs) **] [**Last Name (NamePattern4) 7746**], MD Phone:[**Telephone/Fax (1) 3666**] Date/Time:[**2160-11-20**] 2:15 You should also follow up with you primary care provider.

[ "584.9", "599.0", "401.9", "293.0", "348.39", "571.2", "486" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

12041, 12088

8227, 8522

325, 331

12201, 12455

5284, 8204

14144, 14449

2297, 2317

11176, 12018

12109, 12180

10547, 11153

12479, 14121

2332, 3179

4444, 4444

276, 287

359, 1845

4800, 5265

8537, 10521

4468, 4468

1867, 1991

2007, 2281

81,461

170,377

34917

Discharge summary

report

Admission Date: [**2146-12-20**] Discharge Date: [**2146-12-30**] Date of Birth: [**2081-12-23**] Sex: M Service: ORTHOPAEDICS Allergies: Nsaids Attending:[**First Name3 (LF) 3190**] Chief Complaint: Back and leg pain Major Surgical or Invasive Procedure: Fusion, T11 to L4 Anterior instrumentation L1-3 History of Present Illness: Mr. [**Name14 (STitle) 79903**] has a long history of back and leg pain. He has attempted conservative therapy including physical therapy and has failed. He now presents for surgical intervention. Past Medical History: parkinson's, crohn's, mesenteric artery stenosis s/p stent, GIB Social History: Denies Family History: N/C Physical Exam: A&O X 3; NAD RRR CTA B Abd soft NT/ND BUE- good strength at deltoid, biceps, triceps, wrist flexion/extension, finger flexion/extension and intrinics; sensation intact C5-T1 dermatomes; - [**Doctor Last Name 937**], reflexes symmetric at biceps, triceps and brachioradialis; Parkinsonian tremor BLE- good strength at hip flexion/extension, knee flexion/extension, ankle dorsiflexion and plantar flexion, [**Last Name (un) 938**]/FHL; sensation intact L1-S1 dermatomes; + clonus, hyperreflexic at quads and Achilles Pertinent Results: [**2146-12-27**] 06:25AM BLOOD WBC-9.8 RBC-3.26* Hgb-10.5* Hct-30.4* MCV-93 MCH-32.2* MCHC-34.5 RDW-15.2 Plt Ct-119* [**2146-12-26**] 12:38AM BLOOD WBC-8.6# RBC-3.26* Hgb-10.6* Hct-30.3* MCV-93 MCH-32.5* MCHC-35.0 RDW-15.5 Plt Ct-124* [**2146-12-25**] 02:01AM BLOOD WBC-5.1 RBC-2.97* Hgb-9.5* Hct-27.2* MCV-92 MCH-32.0 MCHC-34.9 RDW-15.9* Plt Ct-103* [**2146-12-23**] 10:06PM BLOOD WBC-5.1 RBC-3.18* Hgb-10.6* Hct-28.5* MCV-89 MCH-33.2* MCHC-37.1* RDW-15.8* Plt Ct-94* [**2146-12-23**] 12:50PM BLOOD WBC-5.6 RBC-2.94* Hgb-9.9* Hct-26.8* MCV-91 MCH-33.8* MCHC-37.1* RDW-15.9* Plt Ct-105* [**2146-12-26**] 12:38AM BLOOD Glucose-154* UreaN-26* Creat-0.7 Na-138 K-4.7 Cl-105 HCO3-30 AnGap-8 [**2146-12-24**] 03:31PM BLOOD Glucose-132* UreaN-22* Creat-0.7 Na-141 K-4.3 Cl-107 HCO3-31 AnGap-7* [**2146-12-24**] 01:48AM BLOOD Glucose-132* UreaN-20 Creat-0.7 Na-141 K-4.3 Cl-108 HCO3-30 AnGap-7* Brief Hospital Course: Mr. [**Known lastname 5395**] was admitted to the service of Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 363**] for a thoracolumbar fusion for kyphoscoliosis. He was informed and consented and elected to proceed. Please see Operative Note for procedure in detail. Post-operatively he was transferred to the T/SICU for blood volume maintenance and neuro checks. He was given antibiotics and pain medication. A hemovac drain was placed intra-operatively and this was removed POD 2. His blood count was noticed to be low and he was transfused PRBCs. His bladder catheter will remain in place and managed at rehab. His diet was advanced without difficulty. He was able to work with physical therapy for strength and balance. He was discharged in good condition and will follow up in the Orthopaedic Spine clinic. Medications on Admission: narcotic, carvi-levodopa 25-100 tid, lasix 40 qd, ropinirole 2mg tid Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed. 2. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 3. Ropinirole 1 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 4. Carbidopa-Levodopa 25-100 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 5. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed. 6. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for Pain. 7. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2 times a day). 8. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). Discharge Disposition: Extended Care Facility: [**Hospital1 487**] and [**Hospital **] hospital Discharge Diagnosis: Kyphoscoliosis Post-op blood loss anemia Discharge Condition: Good Discharge Instructions: Please continue to take your pain medication with an over the counter laxative. Call the clinic should you experience any redness, swelling or discharge at the incision site. Call the clinic if you experience a temperature greater than 101 degrees. Do not smoke. Do not lifting anything greater than a gallon of milk. Call the clinic for any additional concerns. Physical Therapy: Activity: Activity as tolerated Thoracic lumbar spine: when OOB Treatments Frequency: Please continue to change the dressing with dry, sterile gauze daily Followup Instructions: Please follow up in the Orthopaedic Spine clinic during your previously scheduled appointments. Call [**Telephone/Fax (1) 11061**] to confirm your post-operative appointments. Completed by:[**2146-12-28**]

[ "721.3", "721.2", "555.9", "285.1", "557.1", "338.12", "338.4", "V44.2", "332.0", "V85.1", "733.00", "E870.0", "737.43", "349.31" ]

icd9cm

[ [ [] ] ]

[ "81.05", "99.04", "84.52", "84.51", "03.59", "81.04", "80.99", "96.6", "81.63", "77.79" ]

icd9pcs

[ [ [] ] ]

3888, 3963

2166, 3008

292, 342

4048, 4055

1254, 2143

4649, 4858

698, 703

3127, 3865

3984, 4027

3034, 3104

4079, 4447

718, 1235

4465, 4534

4556, 4626

235, 254

370, 571

593, 658

674, 682

368

105,889

17882

Discharge summary

report

Admission Date: [**2137-7-11**] Discharge Date: [**2137-7-16**] Service: MEDICAL - MICU HISTORY OF PRESENT ILLNESS: This is an 89-year-old male with a history of chronic obstructive pulmonary disease and ITP, who presented to the Emergency Department after a few hour history of chest and abdominal discomfort, increasing shortness of breath, and nausea with an episode of vomiting x1. He notes chest pressure with radiation to the back into the left arm, severity [**4-20**] and associated epigastric discomfort with nausea and vomiting x1 in the Emergency Department. He reports recent sweats and chills, but did not take his temperature. He reports intermittent chest discomfort of short duration over the past few days in addition to a long history of chronic nausea. In the Emergency Department, he presented febrile with a temperature of 101.7, tachypneic, and tachycardic, and was found to have an elevated white blood cell count with bandemia. The patient was started on Levaquin and Flagyl, and given 3 liters of normal saline for rehydration to bring his systolic blood pressure to the mid 90s. Patient was given albuterol and Atrovent nebulizer treatment for persistent shortness of breath in addition to IV Solu-Medrol 125 mg IV x1 for suspected chronic obstructive pulmonary disease exacerbation. On review of systems, the patient denied diarrhea, constipation, leg swelling, cough, melena, bloody stool, dysuria, paroxysmal nocturnal dyspnea. PAST MEDICAL HISTORY: 1. Chronic obstructive pulmonary disease, however, patient does not use home O2 or MDIs. 2. Mild dementia. 3. Lumbar radiculopathy. 4. Gastroesophageal reflux disease. 5. ITP with chronically low platelet count. 6. Anxiety. 7. History of iron deficiency anemia. 8. History of transient ischemic attacks, question cerebrovascular accident. 9. History of a deep venous thrombosis in [**2133**]. PAST SURGICAL HISTORY: 1. Status post TURP. 2. Status post tonsillectomy. ALLERGIES: 1. Penicillin produces a rash. 2. Aspirin produces GI irritation. MEDICATIONS ON ADMISSION: 1. Mylanta one tablet po prn. 2. Prozac 20 mg po q day. 3. MVI one tablet po q day. 4. Lorazepam 0.5 mg po qid prn anxiety. 5. Prilosec 20 mg po q day. 6. Extra Strength Tylenol 1 gram two tablets po q4h prn pain. SOCIAL HISTORY: Patient is a widower, former vender sales person, who lives alone in [**Hospital3 **]. He quit smoking approximately 10 years ago, but has an approximately 70 pack year history of smoking. Denies alcohol use. His son, [**Name (NI) 1399**] [**Name (NI) 7514**] is a lawyer, who lives in the area. PHYSICAL EXAMINATION: This is a pleasant-elderly male in moderate respiratory distress. Vital signs: Temperature 100.5, blood pressure 99/50, heart rate 126, respiratory rate 42 decreasing to 34 with nebulizer treatment, and O2 saturation 94% on 2 liters. HEENT: Extraocular muscles are intact. Pupils are equal, round, and reactive to light and accommodation. Anicteric sclerae. Dry mucosal membranes. Neck: No lymphadenopathy, no jugular venous distention, supple. Lungs: Marked and diffuse rhonchi bilaterally anterior and posterior lung fields, bibasilar rales to 1/3 up the posterior lung fields. Heart: Tachycardic, regular rhythm, no murmurs, rubs, or gallops. Abdomen is soft, nondistended, mild epigastric and right upper quadrant tenderness to minimal palpation, positive bowel sounds in all four quadrants, guaiac negative. Extremities: No cyanosis, clubbing, or edema, positive 1+ dorsalis pedis pulses bilaterally. No calf pain. Neurologic: Alert and oriented x2-3, moving all extremities, 5/5 strength in all extremities. Cranial nerves II through XII intact. Finger-to-nose within normal limits. Plantar flexes are downgoing. LABORATORY DATA ON ADMISSION: White count 17.6 with 65% neutrophils, 28% bands, 4% lymphocytes, 2% metamyelocytes, 1% monocytes, and no eosinophils, and no basophils, hematocrit 38.5, platelet count 116. Electrolytes on admission: Sodium 137, potassium 4.0, chloride 101, bicarb 20, BUN 21, creatinine 1.5, platelet count 262. Calcium 9.3, phosphorus 0.5, magnesium 1.5. Urinalysis: Specific gravity 1.024, small amounts of blood, 30 protein, 250 glucose, 50 ketones, red blood cells 0, white blood cells 0-2, bacteria none, epithelial cells 0-2. Arterial blood gas on admission: 7.33, 40, 120, 22, and -4. AST 18, ALT 11, total bilirubin 0.6, alkaline phosphatase 57, albumin 4.0, lipase 12, amylase 51. CHEST X-RAY: Left lower lung zone opacity, mild congestive heart failure. ELECTROCARDIOGRAM: Heart rate of 126, normal sinus rhythm, right bundle branch block, T-wave inversion in V1, left axis deviation noted, no acute ischemic changes, however, no comparison electrocardiogram was available. ASSESSMENT AND PLAN: An 89-year-old male with a history of chronic obstructive pulmonary disease and ITP, who presented with fever, elevated white count, and evidence of pneumonia on chest x-ray with suspected sepsis and chronic obstructive pulmonary disease exacerbation. HOSPITAL COURSE: 1. Sepsis: Patient's blood pressure responded well to IV fluid hydration and at no time did the patient require pressure control using intravenous pressors. He was initially started on a course of Levaquin, Flagyl, and ceftriaxone, but was switched to a 14 day course of Levaquin for treatment of community acquired pneumonia. His white blood cell count did drop to 11.8 in the setting of continued use of steroids. He remained afebrile during his admission with the only episode of fever occurring in the Emergency Room with a temperature of 101.7. 2. Chronic obstructive pulmonary disease exacerbation: The patient was started on a course of Solu-Medrol 60 mg IV q6h for three days, and then was placed on a prednisone taper for control of ongoing chronic obstructive pulmonary disease exacerbation. The patient remained intermittently rhonchorous, did respond to continued albuterol and Atrovent nebulizer treatments ranging from q4 to q6h, and was also continued on a salmeterol inhaler [**Hospital1 **]. 3. Myocardial infarction: The patient did rule in for a myocardial infarction by the third set of enzymes for 24 hours after admission. Peaked CKs reached 421, troponin peak was at 0.19. Cardiology consult was obtained. The etiology was attributed to demand ischemia in the setting of the patient having tachycardia with his pneumonia and chronic obstructive pulmonary disease exacerbation. The patient was started on aspirin, Lipitor, and beta blocker regimen to control his heart rate. Echocardiogram was done and the results are the following: left ventricular systolic function is mildly depressed with an ejection fraction of 40-50% secondary to hypokinesis of the mid apical segments of the inferior and posterior walls, right ventricular chamber size and free wall motion are normal. There is mild 1+ aortic regurgitation. There is no aortic valve stenosis. There is no mitral regurgitation and no evidence of pericardial effusion. The patient did experience an episode of [**9-20**] chest pain during the second day of his hospital stay. Electrocardiogram changes were noted including depressions in V2 and V3, pain and electrocardiogram changes did respond to nitroglycerin treatments, which are also continued on a prn basis. A stress test was recommended for assessment of his cardiac function once his active medical issues were resolved. 4. Gastrointestinal: Patient's epigastric discomfort was attributed to an anginal equivalent as his liver function tests were within normal limits. The patient was continued on Mylanta and Prilosec for control of his chronic heartburn and nausea issues. Also, the patient was given Zofran prn for control of ongoing nausea. 5. Renal: The patient presented with an increase in his creatinine to 1.5 which is slightly above his baseline of 1.0. This acute renal failure was suspected to be attributed to dehydrated state. His FENA was consistent with a prerenal state, and his creatinine returned to [**Location 213**] limits with IV fluid hydration. 6. Hematology: The patient has a history of iron deficiency anemia and thrombocytopenia from ITP. During his hospital stay, his platelet count remained above 100,000. His hematocrit was initially decreased on admission at 38.5 from a baseline of 43.9. His hematocrit did drop during his hospital stay down to 30.8. This was thought to be secondary to IV fluid hydration and iatrogenic effects. He did return to 38.1 on discharge. 7. Neuropsych: The patient has a history of anxiety that had been controlled in the past with prn Ativan. During the hospital stay, the patient did become agitated and disoriented on a few occasions usually at night. The patient did respond to Ativan prn, Haldol prn, and was started on a course of Zyprexa q hs for control of his nighttime symptoms of agitation and anxiety. CONDITION ON DISCHARGE: Stable. The patient has maintained adequate O2 saturations on 3 liters nasal cannula for over 24 hours. Patient is alert and oriented times three, and has no shortness of breath. Patient did have episodes of transient abdominal discomfort and chest discomfort shortly before discharge, but had no electrocardiogram changes or other worrisome symptoms. DISCHARGE DIAGNOSES: 1. Pneumonia. 2. Chronic obstructive pulmonary disease exacerbation. 3. Acute myocardial infarction. 4. Hypotension. DISCHARGE MEDICATIONS: 1. Acetaminophen 325 mg 1-2 tablets q6h prn pain. 2. Docusate sodium 100 mg po bid. 3. Fluoxetine 20 mg po q day. 4. Prilosec 20 mg po q day. 5. Levofloxacin 250 mg po q day for nine days. 6. Maalox 15-30 mL po qid as needed for constipation. 7. Multivitamin one capsule po q day. 8. Olanzapine 5 mg po q hs. 9. Atorvastatin 10 mg one tablet po q day. 10. Salmeterol 1 discus inhaled q12h. 11. Metoprolol 50 mg half tablet po bid. 12. Nitroglycerin 0.3 mg one tablet sublingual po prn chest pain q5 minutes x3 for chest pain, hold for systolic blood pressure less than 100, [**Name8 (MD) 138**] M.D. if pain persists. 13. Combivent inhaler 1-2 puffs inhaled q4-6h prn for shortness of breath. 14. Prednisone taper 40 mg on [**2064-7-16**] mg on [**2054-7-18**] mg on [**7-19**], and 10 mg on [**7-20**]. 15. Albuterol nebulizer treatments q4-6h prn shortness of breath for seven days. 16. Ipratropium nebulizer q4-6h prn shortness of breath for seven days. 17. Haldol 0.5-2 mg IV q6h as needed for agitation. 18. Enteric coated aspirin 81 mg po q day. FOLLOW-UP PLANS: Patient was advised to contact Dr. [**Last Name (STitle) 7790**] regarding this admission, and make an appointment to see him within the next week to discuss new medications and his hospital stay. Patient was advised to have stress test scheduled to assess his cardiac functional status after resolution of his ongoing medical problems including pneumonia and chronic obstructive pulmonary disease flare. The patient was advised to keep his appointments with Dr. [**Last Name (STitle) 7790**] on [**2137-8-14**] as well as [**2137-8-20**]. Patient was discharged to [**Hospital **] Nursing and Rehab Facility, and his primary care physician was informed about his hospital stay, and his discharge location. [**Name6 (MD) **] [**Last Name (NamePattern4) 5837**], M.D. [**MD Number(1) 8285**] Dictated By:[**Last Name (NamePattern1) 1615**] MEDQUIST36 D: [**2137-7-22**] 16:53 T: [**2137-7-25**] 08:08 JOB#: [**Job Number 49573**]

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icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

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9469, 10522

2071, 2286

5071, 8926

1915, 2045

2626, 3782

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127, 1476

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129,856

34384

Discharge summary

report

Admission Date: [**2185-9-26**] Discharge Date: [**2185-10-5**] Date of Birth: [**2120-1-18**] Sex: M Service: MEDICINE Allergies: Levofloxacin Attending:[**First Name3 (LF) 3556**] Chief Complaint: "Trach fell out" Major Surgical or Invasive Procedure: 1. Rigid bronchoscopy. 2. Flexible bronchoscopy X 2. 3. Percutaneous tracheostomy placement 4. Endotracheal intubation with subsequent tracheostomy placement History of Present Illness: 65 yo male with CAD s/p cardiac arrest and ?vocal cord dysfunction who presented to [**Hospital3 **] from his nursing home after he accidentally knocked his trach out and they were unable to replace it. He was then transferred to [**Hospital1 18**] for ENT replacement of the trach as they were unsuccesful at [**Hospital1 **]. He has had the trach for any between 7 to 17 months, and has reportedly not been on a vent in greater than 4 months. It is unclear why it is still in but the patient states that it was due to come out next week anyways. He initially complained of cough with mucus production in the ED but denies it currently. He has noted some increasing DOE and swelling of his LE recently. He also states that he has put on weight and feels "heavy" but is unclear on how much over how long. Denies fever, chills, rash, or dysuria. Denies abdominal pain, chest pain, or pleuritic pain. Denies orthopnea or PND. . In ED, T 96.6 BP 160/74 HR 110 O2sat 93-94% on 28% Venti mask. Received levaquin for possible pneumonia (elevated WBC count, productive cough). Seen by general surgery who felt that he did not need the trach replaced as he seemed to be fine without it. . On presentation to medicine floor, reports trach was placed [**8-9**] months ago emergently. Since that time has experienced lower extremity swelling. Reports mild SOB. Denies fever, cough, chest pain. Reports unsteady gait. . ROS: Negative for fevers, chills, nightsweats, chest pain, shortness of breath, cough, abdominal pain, nausea, vomiting, diarrhea, melena, hematochezia, hematemesis, dysuria. No HA/dizziness/paresthesias or weakness Past Medical History: Morbidly obese CAD s/p cardiac arrest idiopathic vocal cord paralysis Schizophrenia Hypertension OSA Social History: Lifelong non-smoker, distant EtOH use, no illicits. Lives in nursing home. Family History: Noncontributory Physical Exam: T 96.6; BP 158/90; P 109; RR 20; 87% RA; 100% on 50% VM GEN: Well-appearing, NAD, obese; difficult to understand HEENT: Tracheostomy dressed; clean, dry, nonerythematous; EOMI; oropharynx nonerythematous NECK: No JVD appreciated CV: RRR, normal S1S2, no murmurs, rubs or gallops PULM: Normal work of breathing; decreased breath sounds; CTA bilaterally; no wheezes, rales, rhonchi ABD: Normoactive bowel sounds; obese; soft, nontender, not distended EXT: 1+ bilateral LE edema; radial pulses 2+ Pertinent Results: CXR PA/Lat ([**2185-9-26**]): Gross cardiomegaly with prominence of pulmonary vasculature suggestive of pulmonary venous hypertension without evidence of frank cardiac failure. CTA Chest ([**2185-9-27**]): 1. Limited study, no main or lobar PE. 2. 5 mm right middle lobe pulmonary nodule, in absence of risk factors, dedicated chest CT is recommended for followup at 12 months. [**2185-9-28**] ABG (8:56am): pO2-118* pCO2-105* pH-7.21* calTCO2-44* Base XS-9 ABG (10:49am): pO2-76* pCO2-105* pH-7.21* calTCO2-44* Base XS-9 Brief Hospital Course: 65M with tracheostomy since [**4-9**] placed for vocal cord dysfunction following intubation for respiratory and ?cardiac arrest transferred [**2185-9-26**] from outside hospital after trach tube accidently fell out. On arrival to emergency department, patient was satting 93-94% on 28% Venti mask. hypoxia was thought to be secondary to poor air movement due to vocal cord dysfunction and loss of trach. Per patient's ENT doctor (Pieter Nordzig at [**Hospital1 2177**]), trach was placed in [**4-9**] for vocal dysfunction following intubation for respiratory failure. Respiratory failure was thought to be secondary to obesity hypoventilation syndrome and OSA. Per ENT attending, patient keeps trach open at night, closed during day time. Plan was to have trach removed in [**3-6**] weeks as patient was improving. Surgery was consulted in ED; it is unclear regarding their evaluation of the patient, and trach was not replaced. Given lower extremity edema and mildly elevated BNP, patient was also given furosemide 80mg IV x1. Given concern for PE, CTA was done and found to be without PE. Treated for pneumonia in ED and continued on floor given productive cough and leukocytosis. No clear infiltrate on radiograph. Pt also developed a diffuse reticular erythematous and pruritic rash on all 4 extremities, abd, and chest. It was thought that the Levaquin may have been contributing to rash, in addition, there no infiltrate on CXR to treat, so it was stopped in the ICU. The rash did improve following discontinuation. On morning preceding transfer to ICU, patient desaturated to 70s while sleeping and was difficult to arouse. Trigger was called. Patient was placed on nasal cannula 3-4L and moved to chair; O2 saturation quickly improved. Blood gas was drawn and showed acidosis with severe CO2 retention. Repeat blood gas was similar but with worsening PCO2 and RR of 40. Patient was intubated and transferred to the MICU. Trach was replaced in OR the next day ([**2185-9-29**]). Patient was gradually weaned of the vent. And prior to discharge, he was off of the ventilator for 48 hours and only required supplemental oxygen intermittently via a trach collar. ## Leukocytosis: Unclear source. [**Month (only) 116**] be related to a possible pneumonia, which was transiently treated with levofloxacin (started [**2185-9-26**]) however patient developed a rash and the levoquin was stopped. UA normal. Urine and blood cultures with no growth thus far. Sputum only grew OP flora. Started empirically on Flagyl but 2 c.diff toxins were neg. Flagyl discontinued prior to discharge. ## Hyponatremia: On presentation, serum sodium was 127. Clinical scenario most consistent with hypervolemic hyponatremia. UNa 87 and FeNa 0.5%, indicating prerenal physiology. On floor, furosemide dose was decreased to 40mg daily. On transfer to MICU, hyponatremia was resolving and resolved eventually. ## CAD: Two negative sets of cardiac enzymes. While NPO, d/c'ed all heart meds while NPO. Pt developed tachycardia thought to be [**3-5**] beta blocker withdrawal and thus restarted IV beta blocker. Once able to take po, transitioned IV bb to po and restarted ACE and ASA. Pt was admitted on Atenolol but was discharged on metoprolol, equiv dose, [**3-5**] to easier titration given tachycardia. ## Fluid overload: while in the MICU, goal net neg 1 L each day. Received 40mg IV lasix until transitioned to 80mg po Lasix with goal to be net even. ## Altered mental status: Has schizophrenia at baseline but per nursing home physician he has not been delusional. At discharge, he appears to be at his baseline. ## Thrombocytosis: per nursing home physician, [**Name Initial (NameIs) **] Medications on Admission: (per nursing home records) Albuterol INH QID PRN Bisacodyl suppository 10mg PRN Mylanta 30ml PO PRN Tylenol PRN Lasix 80mg PO daily - changed from 40mg daily on [**2185-8-26**] Atenolol 25mg PO daily Prilosec 20mg PO daily ASA 81mg PO daily Colace LIQ 100mg daily KCL 10meq PO daily Lisinopril 40mg PO daily Combivent 2puff QID Senna 2 tabs PO QHS Discharge Medications: 1. Furosemide 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): Hold if SBP < 90. 2. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO Q6H (every 6 hours) as needed for constipation. 3. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO every [**5-8**] hours as needed for fever or pain: max dose 4 g daily. 4. Mylanta 200-200-20 mg/5 mL Suspension Sig: Thirty (30) mL PO every six (6) hours as needed for indigestion. 5. Bisacodyl 10 mg Suppository Sig: One (1) suppository Rectal once a day as needed for constipation. 6. Omeprazole 20 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 7. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): Hold for SBP < 100, HR < 60. 8. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 9. Multiple Vitamin Tablet Sig: One (1) Tablet PO once a day. 10. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as needed for constipation. 11. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily): Hold for SBP < 100. 12. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 13. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000) U Injection TID (3 times a day): Until fully ambulatory. 14. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical DAILY (Daily) as needed for dry skin. 15. Combivent 18-103 mcg/Actuation Aerosol Sig: Two (2) puffs Inhalation four times a day. 16. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 puffs Inhalation every 4-6 hours as needed for shortness of breath or wheezing. 17. Potassium Chloride 20 mEq Packet Sig: Ten (10) mEq PO once a day. Discharge Disposition: Extended Care Facility: [**Location (un) 16662**] - [**Street Address(1) **] Discharge Diagnosis: Respiratory distress secondary to tracheostomy displacement status post replacement, resolved Hyponatremia, resolved Secondary: Hypertension History of coronary artery disease Discharge Condition: Afebrile, normotenisve, trach collar to room air Discharge Instructions: You have been treated for your respiratory distress. Your tracheostomy tube was replaced, and you improved. You will have a follow up appointment with Dr. [**Last Name (STitle) **], one of the interventional pulmonologists, in one week to re-evaluate the tracheostomy tube. Please take your medications as prescribed. Please contact your physician or return to the emergency room should you develop any of the following symptoms: fever > 101, chills, difficulty breathing, chest pain, or any other concerns. Followup Instructions: Please follow up with Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] on Tuesday, [**10-11**] at 11:00 am. Please do not eat or drink anything that morning prior to your appointment. Please call [**Telephone/Fax (1) 7769**] if there is a problem with this appointment. Otherwise, please follow up with your primary care physician. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3559**] MD, [**MD Number(3) 3560**] Completed by:[**2185-10-5**]

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icd9cm

[ [ [] ] ]

[ "96.72", "31.1", "96.04", "33.22", "33.24" ]

icd9pcs

[ [ [] ] ]

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126,700

10657

Discharge summary

report

Admission Date: [**2152-7-17**] Discharge Date: [**2152-7-22**] Date of Birth: [**2093-11-26**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 443**] Chief Complaint: Dofetalide Infusion Major Surgical or Invasive Procedure: None History of Present Illness: This is a 58 year old male with mast medical history of Paroxysmal Atrial Fibrillation, coronary artery disease, hypertension adn hyperlipidemia who comes into the hospital for a dofetalide infusion. He had previously had a pulmonary vein intervention which did not control his paroxysmal A-FIB. He was currently on flecainide but was having breathough A-FIB. He was admitted to the hospital for infusion of dofetalide for three days. Past Medical History: CAD s/p posterior MI, with PTCA of OM1 [**2144**] -Multiple repeat caths for chest pain without flow limiting stenoses -Stress echo [**2146**] negative. -Echo [**2147**] EF 60% HTN Hyperlipidemia Paroxysmal atrial fibrillation, s/p PVI with recurrence, on fleicanide. Started after PTCA in [**2144**]. Social History: Continues to be fairly active. He started skiing this past winter with his 7-year-old son and enjoyed that immensely. He is continuing his work as an investor. Family History: father with lung cancer Physical Exam: Vitals: Vital signs stable, afebrile Gen: No acute distress HEENT: MMM, PERRL Neck: No JVD Heart: S1+, S2+, RRR, No murmurs Lung: CTA b/l ABD: Soft, NT/ND +BS Ex: No edema, warm extremities Neuro: AAO x 3 Pertinent Results: CBC: [**2152-7-17**] 06:49PM BLOOD WBC-6.5 RBC-4.95 Hgb-15.3 Hct-43.7 MCV-88 MCH-31.0 MCHC-35.1* RDW-13.2 Plt Ct-194 [**2152-7-22**] 05:40AM BLOOD WBC-5.4 RBC-4.71 Hgb-14.4 Hct-41.3 MCV-88 MCH-30.6 MCHC-34.9 RDW-13.0 Plt Ct-139* Electrolytes: [**2152-7-22**] 05:40AM BLOOD PT-16.1* PTT-32.0 INR(PT)-1.4* [**2152-7-17**] 06:49PM BLOOD Glucose-94 UreaN-21* Creat-1.2 Na-141 K-4.0 Cl-104 HCO3-31 AnGap-10 [**2152-7-22**] 05:40AM BLOOD Glucose-105 UreaN-9 Creat-1.0 Na-141 K-3.9 Cl-107 HCO3-25 AnGap-13 [**2152-7-22**] 05:40AM BLOOD Calcium-8.9 Phos-2.8 Mg-2.0 Amylase: [**2152-7-20**] 07:20AM BLOOD LD(LDH)-138 Amylase-32 Thyroid function test: [**2152-7-19**] 07:30AM BLOOD TSH-2.2 Brief Hospital Course: This is a 58 year old man with past medial history of coronary artery disease and paroxysmal atrial fibrillation who comes in for administration of dofetilide. Patient remained in normal sinus rhythm for the duration of his hospital stay. He was administered dofetilide and ECGs were checked two hours after each administration of dofetilide. There was no QRS prolongation. On the second night of his stay patient spiked a fever, had some chills, and had one episode of asymptomatic hypotension. Patient was monitored on the floor as his vital signs became and then remained stable. The next day the patient became febrile again and was then transferred to the CCU. Blood cultures at that time grew out Staph. Aureus and the patient was started on Vancomycin and Zosyn per ID. Patient did have an infiltrated IV access site on right antecubital fossa that was erythematous, warm and tender to touch. Vascular surgery was consulted and said there was no surgical indication at this time. An ultrasound of the area showed no evidence of deep vein thrombosis of the right upper extremity and a small focal area of thrombus within the cephalic vein at the level of the antecubital fossa. A CT head was negative for sinusitis. Patient had some low blood pressures initially in the CCU but responded well to fluid boluses. He did well on antibiotics and was closely monitored in the CCU. The sensitivities of the blood culture showed MSSA and the patients antibiotics were changed appropriately. The patient was recommended to get a PICC line for IV antibiotics for the MSSA but the patient did not want to do this. He was discharged on oral antibiotics. Medications on Admission: Atorvastatin 80mg PO daily Lisinopril 5mg PO daily Metoprolol Succinate 25mg PO daily Flecainide 150mg PO BID Discharge Medications: 1. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Dicloxacillin 250 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours) for 14 days. Disp:*56 Capsule(s)* Refills:*0* 3. Dofetilide 250 mcg Capsule Sig: Two (2) Capsule PO Q12H (every 12 hours). Disp:*120 Capsule(s)* Refills:*2* 4. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Paroxysmal Atrial Fibrillation Hypertension MSSA Bacteremia Discharge Condition: Stable Discharge Instructions: You had a blood infection with Staph aureus. It was methicillin sensitive which can be treated with medications taken orally. Because your infection was complicated by hypotensions, it was strongly recommended to you that you stay inpatient for IV antibiotics. However, you refused to stay inpatient for IV antibiotics. We are discharging you with 14 days of antibiotics to be taken orally. However, we strongly recommend to you that you have follow up within the next 3 days with your outpatient PCP for [**Name Initial (PRE) **] blood pressure check as well as repeat blood cx. While you were here, you were started on Dofetilide for atrial fibrillation. You tolerated the medication w/o changes in serial EKGs. You should continue to take this medication as directed and you should follow up with the electrophysiology service. Followup Instructions: [**2152-7-24**]: Primary Care follow up within the next 3 days- please draw blood cx and check blood pressure. [**2152-7-24**] Cardiology follow up for Loop Monitor Provider: [**Name10 (NameIs) **] RM 2 [**Name10 (NameIs) **]-PREADMISSION TESTING Date/Time:[**2152-8-8**] 11:00

[ "458.9", "272.4", "V45.82", "451.82", "427.31", "414.00", "041.19", "401.9", "790.7", "427.32" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

4544, 4550

2302, 3966

335, 342

4654, 4663

1595, 2279

5544, 5828

1329, 1354

4126, 4521

4571, 4633

3992, 4103

4687, 5521

1369, 1576

276, 297

370, 809

831, 1134

1150, 1313

15,811

147,925

6260

Discharge summary

report

Admission Date: [**2158-7-24**] Discharge Date: [**2158-8-2**] Date of Birth: [**2110-9-2**] Sex: M Service: MEDICINE Allergies: Penicillins / Codeine / Duragesic Attending:[**First Name3 (LF) 2297**] Chief Complaint: Abdominal pain Major Surgical or Invasive Procedure: ERCP Endotracheal Intubation Placement of right internal jugular central venouus catheter attempted lumbar puncture History of Present Illness: 47 yo M w/PMHx sx for alcoholic cirrhosis, Hepatitis C, chronic pancytopenia [**1-5**] above, hx SBP, hx upper and lower GI bleeding, s/p TIPS x5, and recurrent cholecystitis w/recurrent RUQ pain who presents with sharp, cramping RUQ pain, nausea, and NBNB emesis x1. He has a baseline chronic [**4-12**] RUQ abdominal pain for which he takes Dilaudid 8 mg PO q4, and says for 7 years there has never been a time where he has not had this pain. He was in USOH had 2 eggs and toast for breakast, then 30 minutes later had NBNB emesis. About 2 hours later, he had his first episodes of pain while lying in bed watching TV, [**8-13**], and lasting about 20-30 minutes, which then returned to baseline. He did not have anything to eat for the rest of the day. The next episode occurred at 11 pm last night, same nature, lasting 20-30 minutes and returning to [**6-12**] pain, which prompted his coming to the ED. Patient states that this pain is different from his baseline chronic abdominal pain in that it is like a "[**Last Name (un) **] horse," basically in the same location, but worse. No radiation, no other associated symptoms. Of note, he has recently run out of his Zofran which he uses once every couple of days for nausea. He had not refilled the Rx [**1-5**] cost. . At 7AM today, pt had some substernal chest pain that radiated to his RUQ that he said felt like pressure similar to episodes of reflux in the past. An EKG was done, CE sent, and he was given SL NTG which completely resolved the CP. No dyspnea/diaphoresis/other assoc sxs. RUQ pain returned to [**6-12**] pain that he had before this episode began. Of note, he can get up one flight of stairs and walk 1 block before getting dyspneic, notes pedal edema with prolonged standing, requires [**1-6**] pillows for sleeping, but does not know if he would get short of breath without them, and denies PND. . Also notes similar CP last week, went to [**Hospital 796**] [**Hospital 107**] Hospital, underwent a stress test, which by report was normal. . He has had no fever/chills/diarrhea/bloody stool/blood in vomit/cough/CP/SOB/jaundice. He has not traveled recently. He has also noted a petechial rash on his right forearm starting yesterday, that he attributes to a kitten to which he was exposed and believes he is allergic to. He notes a recent 40 lb weight gain over 1.5 months, followed by 15 lb weight loss. ROS otherwise negative. . Past Medical History: Hepatitis C, ?[**1-5**] transfusion after gunshot wound to R temple Alcohol abuse, no EtOH for 15 years. Cirrhosis s/p TIPSx5, 1st 12 years ago, last 6 years ago, [**1-5**] repeated occlusion Cholelithiasis Cholecystitis s/p multiple ERCPs Variceal bleed s/p banding GERD Nephrolithiasis s/p appendectomy Pancytopenia No cholecystectomy [**1-5**] low platelets Social History: He is married x10 years and retired x12 years, used to work with [**Company 2892**]. He admits to a heavy EtOH history of a 12 pack a day but quit 14 years ago and denies any EtOH use at present. No smoking. He denies any history of IV drug use and has had 2 blood transfusions in the past. Family History: DM. Mother and father with [**Name2 (NI) **]. Father with RCC, currently on HD. Physical Exam: VS: 98.3 BP 122/62 HR 76 RR 18 O2sat 96% RA Gen: well appearing in NAD, lying comfortably in bed watching TV HEENT: MMM. No oral ulcers. No cervical LAD. Hrt: RRR. No m/g/r Lungs: CTAB no RRW. Abd: Distended. Soft. +voluntary guarding in RUQ. No hepatomegaly. Tenderness to light palpation over RUQ>RLQ, but able to go from lying to sitting position with no pain. No rebound. +Caput medusae. Ext: WWP. No c/c/e. Petechial lesion and excoriations over right forearm. RLE ~1 cm healing excoriated lesion over lower shin. Neuro: alert and oriented. +asterixis. Pertinent Results: [**2158-7-24**] 02:48AM URINE BLOOD-SM NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-TR BILIRUBIN-SM UROBILNGN-12* PH-7.0 LEUK-NEG [**2158-7-24**] 02:48AM URINE RBC-0-2 WBC-[**2-5**] BACTERIA-RARE YEAST-NONE EPI-[**2-5**] [**2158-7-24**] 02:48AM WBC-3.0* RBC-3.74* HGB-12.0* HCT-32.4* MCV-87 MCH-32.0# MCHC-36.9* RDW-16.0* [**2158-7-24**] 02:48AM NEUTS-60.0 LYMPHS-27.8 MONOS-5.5 EOS-6.6* BASOS-0.2 [**2158-7-24**] 02:48AM ALT(SGPT)-26 AST(SGOT)-48* ALK PHOS-118* AMYLASE-33 TOT BILI-2.1* [**2158-7-24**] 02:48AM ALBUMIN-3.5 [**2158-7-24**] 02:48AM GLUCOSE-122* UREA N-12 CREAT-0.6 SODIUM-138 POTASSIUM-3.7 CHLORIDE-106 TOTAL CO2-24 ANION GAP-12 [**2158-7-24**] 09:20AM PT-17.3* PTT-37.3* INR(PT)-1.6* [**2158-7-24**] 02:48AM PLT COUNT-31* [**2158-7-27**] 09:40AM BLOOD WBC-6.8# RBC-3.53* Hgb-12.4* Hct-31.8* MCV-90 MCH-35.1* MCHC-37.3* RDW-16.5* Plt Ct-58* [**2158-7-27**] 12:54PM BLOOD WBC-7.3 RBC-3.14* Hgb-10.2* Hct-27.2* MCV-87 MCH-32.6* MCHC-37.7* RDW-16.4* Plt Ct-50* [**2158-7-31**] 03:33AM BLOOD WBC-16.8* RBC-3.04* Hgb-10.1* Hct-27.2* MCV-89 MCH-33.2* MCHC-37.2* RDW-18.5* Plt Ct-72* [**2158-8-1**] 03:01AM BLOOD WBC-13.4* RBC-2.80* Hgb-9.2* Hct-25.2* MCV-90 MCH-32.9* MCHC-36.5* RDW-19.0* Plt Ct-70* [**2158-8-2**] 07:58AM BLOOD WBC-19.4* RBC-2.74* Hgb-9.0* Hct-25.7* MCV-94 MCH-32.9* MCHC-35.1* RDW-19.6* Plt Ct-61* [**2158-7-27**] 05:50AM BLOOD Neuts-79.2* Lymphs-15.5* Monos-4.8 Eos-0.5 Baso-0 [**2158-8-1**] 03:01AM BLOOD Neuts-79* Bands-1 Lymphs-10* Monos-8 Eos-0 Baso-1 Atyps-0 Metas-1* Myelos-0 NRBC-49* [**2158-7-27**] 09:40AM BLOOD PT-18.9* PTT-31.4 INR(PT)-1.7* [**2158-7-28**] 02:53AM BLOOD PT-18.6* PTT-33.2 INR(PT)-1.8* [**2158-7-28**] 08:27AM BLOOD PT-20.0* PTT-36.4* INR(PT)-1.9* [**2158-8-1**] 03:01AM BLOOD PT-20.5* PTT-35.6* INR(PT)-2.0* [**2158-8-2**] 07:58AM BLOOD PT-22.4* PTT-34.0 INR(PT)-2.2* [**2158-7-26**] 05:45AM BLOOD Glucose-92 UreaN-10 Creat-0.7 Na-139 K-3.8 Cl-104 HCO3-29 AnGap-10 [**2158-7-27**] 05:50AM BLOOD Glucose-135* UreaN-15 Creat-0.7 Na-139 K-4.2 Cl-106 HCO3-22 AnGap-15 [**2158-7-27**] 09:40AM BLOOD Glucose-215* UreaN-18 Creat-0.8 Na-138 K-3.3 Cl-110* HCO3-15* AnGap-16 [**2158-7-27**] 09:25PM BLOOD Glucose-223* UreaN-28* Creat-1.2 Na-145 K-4.5 Cl-113* HCO3-13* AnGap-24* [**2158-7-31**] 02:59PM BLOOD Glucose-139* UreaN-80* Creat-3.6* Na-150* K-4.5 Cl-117* HCO3-17* AnGap-21* [**2158-8-1**] 03:01AM BLOOD Glucose-162* UreaN-78* Creat-3.2* Na-148* K-4.6 Cl-115* HCO3-16* AnGap-22* [**2158-8-2**] 07:58AM BLOOD Glucose-175* UreaN-78* Creat-2.7* Na-146* K-6.8* Cl-119* HCO3-12* AnGap-22* [**2158-7-24**] 02:48AM BLOOD ALT-26 AST-48* AlkPhos-118* Amylase-33 TotBili-2.1* [**2158-7-24**] 09:20AM BLOOD ALT-27 AST-51* CK(CPK)-579* AlkPhos-108 TotBili-2.5* [**2158-7-25**] 05:30AM BLOOD ALT-28 AST-55* LD(LDH)-280* AlkPhos-106 Amylase-30 TotBili-2.5* [**2158-7-29**] 01:39AM BLOOD ALT-55* AST-149* LD(LDH)-428* CK(CPK)-5069* AlkPhos-88 Amylase-67 TotBili-4.0* [**2158-7-31**] 03:33AM BLOOD ALT-131* AST-211* CK(CPK)-5075* AlkPhos-68 TotBili-3.1* [**2158-8-1**] 03:01AM BLOOD ALT-146* AST-260* LD(LDH)-1217* CK(CPK)-[**Numeric Identifier **]* AlkPhos-61 TotBili-3.6* [**2158-7-25**] 05:30AM BLOOD Lipase-17 [**2158-7-30**] 05:46AM BLOOD CK-MB-9 cTropnT-<0.01 [**2158-7-24**] 09:20AM BLOOD Calcium-8.6 Phos-3.5 Mg-1.9 [**2158-8-1**] 03:01AM BLOOD Albumin-2.3* Calcium-5.9* Phos-7.4* Mg-1.9 [**2158-7-27**] 09:40AM BLOOD VitB12-640 Folate-13.6 [**2158-7-28**] 02:59AM BLOOD Ammonia-922* [**2158-7-28**] 08:23AM BLOOD Osmolal-322* [**2158-7-28**] 12:48PM BLOOD Osmolal-327* [**2158-7-29**] 01:30PM BLOOD Ammonia-430* [**2158-7-31**] 12:20PM BLOOD Ammonia-279* [**2158-8-1**] 03:01AM BLOOD Ammonia-299* [**2158-7-27**] 09:40AM BLOOD Prolact-44* TSH-0.36 [**2158-7-31**] 02:59PM BLOOD Vanco-19.0* [**2158-7-31**] 12:21PM BLOOD Cortsol-28.6* [**2158-7-31**] 01:07PM BLOOD Cortsol-31.6* [**2158-8-1**] 03:01AM BLOOD Phenyto-13.2 Phenyfr-3.8* %Phenyf-29* [**2158-7-27**] 09:40AM BLOOD ASA-6 Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2158-7-27**] 10:37AM BLOOD Type-ART pO2-338* pCO2-22* pH-7.47* calTCO2-16* Base XS--4 [**2158-8-2**] 08:04AM BLOOD Lactate-9.4* [**2158-7-27**] 09:44PM BLOOD Lactate-14.7* [**2158-7-30**] 04:27PM BLOOD freeCa-0.99* . CT HEAD [**7-28**]: There is no evidence of acute intracranial hemorrhage. Compared to the two examinations of yesterday, particularly in the left frontal and parietal regions, and within the posterior cerebral hemispheres. The lateral ventricles have become more compressed. The fourth ventricle may be slightly smaller in size. There is also loss of the normal [**Doctor Last Name 352**]-white matter differentiation. The findings are in keeping with cerebral edema. The left arachnoid cyst is unchanged. The visualized paranasal sinuses and mastoid air cells remain clear. Metallic structures near the right lateral orbit are noted. Findings of cerebral edema, with a worsened appearance of the brain compared to yesterday. Metallic structures near the right orbit preclude MRI evaluation. The findings were discussed with Dr. [**Last Name (STitle) **] at the time of the exam. NOTE ADDED AT ATTENDING REVIEW: This change may represent post ictal swelling, rather than edema. Correlation with follow up studies is recommended. . CT HEAD [**8-1**]: There is again noted diffuse brain edema. However, the mass effect and the edema has progressed since the prior study. The previously seen arachnoid cyst in the left temporal fossa is now compressed. There is also complete effacement of the cerebral cisterns and downward displacement of the cerebellar tonsils into the foramen magnum. It has progressed since the prior study. There is no shift of midline structures. There is again noted opacification of the posterior ethmoid cells, which appears to be similar when compared to prior study. There is also a small amount of fluid in the right sphenoid sinus, which has increased since the prior study. IMPRESSION: Interval progression of diffuse brain edema. Brief Hospital Course: 47 yo w/hx alcoholic cirrhosis s/p TIPS, esophageal varices s/p sclerosis, hepatitis C, pancytopenia, and hx recurrent cholecystitis, who presents with worsening RUQ, nausea, and vomiting. Brief hospital course as follows: . Course on the floor: . For his RUQ pain, MRCP was initially considered, but due to metal close to his eye, the patient underwent ERCP on [**2158-7-26**]. During ERCP, limited exam of the esphagus, stomach and duodenum was without varices. Major papilla was normal with plastic stent in situ. Biliary duct was cannuized with successful and deep sphincterotome using a free-hand technique. Contrast medium was injected resulting in complete opacification. The procedure was moderately difficult. Plastic stent was removed from the major papilla. Biliry cannulation and cholangiogram revealed a non-dilated common bile duct, with a single mobile radiolucent gallstone present. A sphincterotomy was performed in the 12 o'clock position using a sphincterotome over an existing guidewire. The stone was extracted successfully using a 15 mm balloon. The patient received a dose of levoflox in the ERCP suite. Patient returned to the floor in stable condition, afebrile, mentating well. . Soon after ERCP, temp rose to 101.0, BCx were taken. That night (day before MICU admission), the patient was found to be pacing around the floor. The patient received 4mg scheduled IV dilaudid and reportedly slept all night without incident. The morning of MICU admission, the patient was found to be acutely delirious, very tremulous, unable to communicate with the staff. Temp was noted to be 99.9, BP 128/80, sats 94-95% on RA. 30 mins later, the patient was found in bed, unresponsive, still tremulous with dilated but reactive pupils, temp of 95.2 axillary; BP 120/61. Pt was taken to the MICU and intubated for airway protection. Pt received etomidate for intubation and started on propofol for sedation. Pt rapidly decompensated and started dropping BPs and urine output dramatically fell off. CVL was placed and fluids were started wide open. . Course in MICU . After transfer to the MICU, he underwent a repeat ERCP where he was found to have bleeding at the sphincterotomy site. For this procedure he was given 12.5mg of demerol, 10mg of cisatracurium at approximately 6:30pm. At 9:15pm, he was noted by staff to have head deviation to the right and clonic jerking of the right arm. This lasted roughly ten minutes and ceased after administration of 8mg of IV ativan. He remained without obvious seizure activity until 9:45pm when he experienced 30 minutes of the head and right arm jerking. He was given an additional 8mg of IV ativan, loaded with 1g of IV dilantin, and started on a versed gtt. . He continued in status epilepticus for much of the ensuing night, despite being loaded with dilantin, receiving 25mg of IV ativan over the course of the night, maxing out on a versed drip, propofol drip. Finally, after consultation with the neurology / epilepsy service, he was started on a pentobarb drip, and a coma state was induced. He had an EEG that confirmed seizures, and then there was suppressed state one pentobarb was started. Repeat imaging showed worsening cerebral edema. This was thought to be due to fulminant hepatic encephalopathy (ammonia level 922), or edema from the post-ictal state. . An LP was attempted on his first night in the MICU, without success in obtaining CSF due to body habitus. Broad spectrum antibiotics were started and continued at that time. He spiked temps to 104, but that was in the setting of prolonged seizure activity. . Attempts were made to decrease cerebral edema. Neurosurgery was consulted, and decided that surgical intervention would not improve the situation, as it was diffuse edema. Mannitol was given twice, but the team was unable to continue giving as his serum osmolality remanined >330. . The family was consitently with him, and well aware of his grave prognosis. On [**7-31**], a family meeting was held with the MICU team, SW, nurses, and neurology. They wanted to attempt to wean the pentobarb and reevaluate for signs of brain activity; they also requested a repeat head CT to assess for decreased swelling. After weaning the pentobarb, there was no further brain activity. The repeat head CT was done and showed worsening edema with evidence of herniation. . On [**8-2**], the decision was made by the wife and her sister, in consultation with the remainder of his family, to withdraw life support. He was extubate and vasopressors were stopped. He remained comfortable and he passed away shortly thereafter with the medical team, wife, sister-in-law, and social worker at the bedside. . The family declined an autopsy. Parents were notified in [**State 4260**]. Medications on Admission: Dilaudid 8 mg q4h Lasix 80 mg qd Aldactone 100 mg qd Paxil 40 mg qd Ambien 10 mg qhs Prevacid 30 mg qd Zofran prn, takes 1 every couple of days Lactulose prn (used for constipation 2-3x/month) Discharge Medications: na Discharge Disposition: Expired Discharge Diagnosis: Epilepsy Hepatitis C cirrhosis s/p ERCP Branistem herniation Discharge Condition: deceased Discharge Instructions: na Followup Instructions: na

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icd9cm

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28596

Discharge summary

report

Admission Date: [**2170-1-22**] Discharge Date: [**2170-1-30**] Date of Birth: [**2117-6-19**] Sex: F Service: MEDICINE Allergies: Sulfa (Sulfonamides) / Erythromycin Base Attending:[**First Name3 (LF) 1377**] Chief Complaint: GIB Major Surgical or Invasive Procedure: EGD History of Present Illness: Ms. [**Known lastname 69209**] is a 52 yo woman with h/o alcoholic cirrhosis, known varices, who initially presented to [**Hospital 1562**] hospital with complaints of "vomiting up blood" starting at 4AM. Per the patient, she awoke and started vomiting. She reported vomitus "dark brown" in color, no coffee-grounds, no bright red blood. Of note, she admited to drinking one pint of vodka with cranberry juice the evening PTA. Otherwise, she denied recent illness, lightheadedness/dizziness, BRBPR, and melena. She has had esophageal variceal bleeding in the past, presenting at that time with bright red blood vomitus, different than this time. Per EMS report, her vomitus did not appear to have bright red blood or blood clots, but was dark red in "hue". She was AVSS on initial EMS evaluation and was brought to [**Hospital 1562**] hospital. Her initial vitals upon arrival at [**Hospital1 1562**] were T 99.3, BP 125/71, HR 84, RR 16, and O2 96% RA. Octreotide and protonix drips were started. She was also given a banana bag, zofran, and compazine. Labs were notable for a Hct drop (30 to 25 in 3 hour period) platelets 16, INR 1.4, AST 95, ALT 26, Alk phos 136, T bili 5.3. EtOH level was 388. During the OSH course, BP dropped to a low of 76/43, which was responsive to IVF and RBC transfusion. She received a total of [**11-29**] units RBC's and 1 bag of platelets, and was transferred to [**Hospital1 18**] for possible TIPS procedure. Upon arrival to [**Hospital1 18**], she continued to complain of nausea and vomiting. She was also complaining of the "shakes" and felt "like I'm starting to go into withdrawal." Past Medical History: EtOH cirrhosis with portal hypertension, grade 3 esophageal varices, gastric varices, thrombocytopenia EtOH abuse. Denies history of seizures or hallucinations. Upper GI variceal bleeding s/p multiple sclerotherapy and banding procedures. Boerrhave's syndrome/[**Doctor First Name **]-[**Doctor Last Name **] tear Esophagitis and duodenitis H/o cervical and uterine CA s/p TAH/BSO Chronic renal insufficiency Social History: Left her husband 2 years ago but sees him every day. 3 children, 2 daughters live nearby and 1 son in college. Drinks approximately 1 pint of vodka per day. No tobacco or illicit drug use. Family History: Mother died at 62 of CHF. ?Liver disease. Father died at 63 of lymphoma. ?Liver disease. 1 Brother and 2 sisters all healthy. Physical Exam: ADMISSION PHYSICAL EXAM: VITALS: 100.3, 120/60, 94, 21, 100%RA GEN: A+Ox3, NAD, pleasant HEENT: Bruise on right face. Op clear, MMM. NECK: No JVD CV: RRR, II/VI sytolic ejection murmur at upper sternal border PULM: Crackles and dull at left base which was her dependent side. Otherwise clear; no wheezes or rhonchi. ABD: Soft, distended, non-tender. +BS. EXT: Trace pedal edema. No asterixis. Pertinent Results: ADMISSION LABS: [**2170-1-22**] 01:38PM BLOOD WBC-4.0 RBC-3.27* Hgb-10.5* Hct-29.6* MCV-91 MCH-32.1* MCHC-35.4* RDW-17.9* Plt Ct-19*# [**2170-1-22**] 01:38PM BLOOD Neuts-85.7* Lymphs-5.9* Monos-4.1 Eos-4.1* Baso-0.2 [**2170-1-22**] 01:38PM BLOOD PT-17.1* PTT-32.8 INR(PT)-1.5* [**2170-1-22**] 01:38PM BLOOD Glucose-144* UreaN-32* Creat-1.2* Na-140 K-4.1 Cl-102 HCO3-24 AnGap-18 [**2170-1-22**] 01:38PM BLOOD ALT-25 AST-91* LD(LDH)-234 AlkPhos-115 TotBili-7.0* [**2170-1-22**] 01:38PM BLOOD Albumin-3.5 Calcium-7.2* Phos-3.4 Mg-1.3* [**2170-1-23**] 03:00AM BLOOD Fibrino-208 [**2170-1-22**] 10:53PM BLOOD Ret Aut-1.5 [**2170-1-23**] 03:00AM BLOOD Ret Man-1.2 [**2170-1-24**] 04:30AM BLOOD VitB12-[**2159**]* Folate-GREATER TH Hapto-<20* MICROBIOLOGY: [**1-23**], [**1-25**] Blood Cultures: negative [**1-25**] Urine Cultures: negative IMAGING: [**1-22**] CXR: Minor right lower lobe atelectasis and/or scarring, but no findings suggestive of aspiration. [**1-24**] CXR: In comparison with study of [**1-22**], there is increased opacification at the right base with silhouetting of the hemidiaphragm, consistent with right lower lobe pneumonia. The left lung is essentially clear. [**1-23**] RUQ US 1. No evidence of focal hepatic lesion. 2. Moderate ascites. 3. Continued evidence of portal hypertension with upper abdominal varices and splenomegaly. However, portal venous flow remains hepatopetal. 4. Gallbladder sludge. [**2170-1-29**] EGD: Varices at the lower third of the esophagus Grade 3 esophagitis in the lower third of the esophagus and middle third of the esophagus compatible with reflux esophagitis (cytology) Ulcer in the lower third of the esophagus. Granularity, mosaic appearance and friability in the whole stomach compatible with portal hypertensive gastropathy Otherwise normal EGD to third part of the duodenum Recommendations: 1) Proton pump inhibitor twice daily 2) Sucralfate 1g QID 3) Follow brushings 4) Repeat EGD in 6 weeks to ensure healing and to band varix Brief Hospital Course: Ms. [**Known lastname 69209**] has a history of alcoholic cirrhosis with known varices and was admitted with an upper GI bleed. Although she had persistent vomiting on admission, it was no longer blood-tinged but was rather tan-colored mucous. She was continued initially on the protonix and octreotide drips. Hematocrit stabilized after transfusing one unit of RBC's and 2 bags of platelets. She was maintained on lasix, aldactone, and nadolol. The GI service was consulted and followed her throughout her admission. An upper endosocpy was performed on [**2170-1-29**] and showed varices at the lower third of the esophagus as well as grade 3 esophagitis in the lower third of the esophagus and middle third of the esophagus compatible with reflux esophagitis. Esophageal brushings were collected; they were pending at the time of discharge and have since come back negative for malignant cells. In addition, there was a ulcer in the lower third of the esophagus. Granularity, mosaic appearance and friability in the whole stomach compatible with portal hypertensive gastropathy. She was transitioned to a protonix 40 mg PO BID and sulcralfate 1g QID. It was recommended that she obtain a repeat EGD in 6 weeks for follow-up and to band the varices. For concerns for alcohol withdrawal, she was maintained on a CIWA scale and was treated with thiamine and folate. Medications on Admission: Aldactone 50mg PO BID Bactroban applied topically [**Hospital1 **] Humibid/Mucinex 600mg PO BID Lasix 40mg PO daily Levaquin 250mg PO daily ?ongoing or x 7 days - unclear per pt Magnesium 400mg PO q8hr NAdolol 20mg PO daily Oxycodone 5mg PO q6hr PRN Potassium 20mEq PO TID Prilosec 40mg daily Multivit 1tab PO daily Discharge Medications: 1. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily). 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. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Nadolol 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 6. Magnesium Oxide 400 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 7. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 8. Spironolactone 50 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 9. Sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times a day). Disp:*120 Tablet(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Primary Diagnoses: Cirrhosis Esophageal varices and ulcer with upper GI bleeding Thrombocytopenia Discharge Condition: Stable-- with some abdominal distension; no evidence of active ongoing bleeding; hemodynamically stable. Discharge Instructions: Please call your doctor if you develop a fever or shortness of breath. If you cannot reach your doctor, you should go to the emergency department. Please follow the medication list that you are given very closely. Some changes have been made to your medication dosages and to how often you need to take them. Some are to help your fluid levels in your body so that you do not accumulate too much fluid in your belly. Some are to help the ulcer in your esophagus heal. Followup Instructions: You have an appointment with Dr. [**First Name8 (NamePattern2) 1158**] [**Last Name (NamePattern1) 679**] in the liver department on Monday, [**2170-3-5**] at 1:45 pm. Their phone number is ([**Telephone/Fax (1) 16940**], and the office is located on the [**Location (un) 858**], [**Hospital Unit Name **], of the [**Hospital Unit Name **] on the [**Hospital Ward Name 517**] of [**Hospital1 **] Hospital. You will need a repeat EGD in about six weeks to see how your esophagus is healing. You should talk to Dr. [**First Name (STitle) 679**] about this at your appointment in [**Month (only) 547**]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(1) 1379**]

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icd9cm

[ [ [] ] ]

[ "99.04", "99.05", "45.13" ]

icd9pcs

[ [ [] ] ]

7822, 7828

5204, 6586

305, 310

7970, 8077

3179, 3179

8598, 9327

2623, 2750

6953, 7799

7849, 7949

6612, 6930

8101, 8575

2790, 3160

262, 267

338, 1968

3195, 5181

1990, 2400

2416, 2607

30,303

100,887

5556

Discharge summary

report

Admission Date: [**2171-5-24**] Discharge Date: [**2171-6-1**] Date of Birth: [**2093-4-30**] Sex: F Service: ORTHOPAEDICS Allergies: Morphine / Oxycodone Attending:[**First Name3 (LF) 64**] Chief Complaint: R knee swelling, pain, drainage Major Surgical or Invasive Procedure: Irrigation and debridement, resection arthroplasty, and insertion of cement spacer History of Present Illness: Ms. [**Known lastname 22365**] returns today for followup. She is approximately three weeks out from her surgery. She was readmitted to the hospital on the 14th for some incisional drainage as well as knee swelling. At that time, she was transfused blood switched from Lovenox to Coumadin. Her goal for Coumadin has been 2-2.5. She is complaining of continuous bloody drainage from her knee as well as increased swelling and pain in her knee. The bleeding increased especially last night enough to soak her knee immobilizer and her sheets. She has had no fevers or chills. Past Medical History: CAD s/p MI x2 [**88**] years ago in setting of diet pill use Colon cancer s/p 5-FU in [**2162**] and partial resection Cervical cancer s/p TAH Anemia Transaminitis Urge incontinence HTN . PSH: Tonsillectomy Appendectomy Rectosigmoidectomy for colon ca Right Knee replacement [**2169**] Social History: Recently widowed over the past year and lost her son. Lives alone at home. She does not currently smoke, quit 30 years ago, [**6-8**] year history of 3 packs/week. She does not drink coffee. No ETOH. No IVDU. Family History: [**Name (NI) **] father died in his 90s of an MI, and the patient's mother died of unknown causes. Physical Exam: MUSCULOSKELETAL: Her right knee is swollen and exquisitely tender. It is ecchymotic throughout her knee and her calf. Her staples are intact. There is some bloody and serosang drainage coming from most of them. There is no frank pus noted. She is neurovascularly intact distally. Post Op Tmax: 102.3 Temp:97.9 BP:118/80 Vent: 95% RA General: Alert, conversant in NAD HEENT: Mucous membranes moist Neck: Supple Cardiovascular: Regular, S1 S2 only with II/VI sytolic murmur to axilla Respiratory: Clear bilaterally Back: Non-tender Gastrointestinal: sort, NT, ND Musculoskeletal: Right knee swollen, warm, erythematous/ Wound with drainage, staples in place Skin: No generalized rashes Pertinent Results: [**2171-5-24**] 05:20PM SED RATE-62* [**2171-5-24**] 05:20PM PT-35.1* PTT-38.8* INR(PT)-3.7* [**2171-5-24**] 05:20PM PLT COUNT-227 [**2171-5-24**] 05:20PM WBC-5.4 RBC-3.85* HGB-10.7* HCT-31.5* MCV-82 MCH-27.7 MCHC-33.9 RDW-15.4 [**2171-5-24**] 05:20PM WBC-5.4 RBC-3.85* HGB-10.7* HCT-31.5* MCV-82 MCH-27.7 MCHC-33.9 RDW-15.4 [**2171-5-24**] 05:20PM ALBUMIN-3.9 CALCIUM-9.2 PHOSPHATE-2.7 MAGNESIUM-1.9 [**2171-5-24**] 05:20PM ALT(SGPT)-13 AST(SGOT)-17 LD(LDH)-399* ALK PHOS-69 TOT BILI-2.0* [**2171-5-24**] 05:20PM estGFR-Using this [**2171-5-24**] 05:20PM GLUCOSE-146* UREA N-16 CREAT-0.8 SODIUM-136 POTASSIUM-3.5 CHLORIDE-98 TOTAL CO2-25 ANION GAP-17 [**2171-5-24**] 07:25PM URINE RBC-0-2 WBC-3 BACTERIA-MANY YEAST-NONE EPI-[**7-9**] [**2171-5-24**] 07:25PM URINE BLOOD-LG NITRITE-NEG PROTEIN-100 GLUCOSE-NEG KETONE-TR BILIRUBIN-SM UROBILNGN-4* PH-6.5 LEUK-TR KNEE (2 VIEWS) RIGHT Reason: post-op eval [**Hospital 93**] MEDICAL CONDITION: 78 year old woman with right knee infection s/p removal of hardware and placement of antibiotic spacer REASON FOR THIS EXAMINATION: post-op eval HISTORY: Postop right knee, removal of hardware and placement of antibiotic spacer. FINDINGS: Two views from the operating suite show removal of previous total knee prosthesis with the placement of an opaque antibiotic spacer. Multiple surgical clips are in place. [**Hospital1 18**] ECHOCARDIOGRAPHY REPORT [**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 22366**]Portable TTE (Complete) Done [**2171-5-28**] at 3:00:00 PM FINAL Referring Physician [**Name9 (PRE) **] Information [**Name9 (PRE) **], [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 18**] - Department of Orthopaed [**Location (un) 830**], [**Hospital Ward Name 23**] 2 [**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2093-4-30**] Age (years): 78 F Hgt (in): 60 BP (mm Hg): 125/62 Wgt (lb): 149 HR (bpm): 80 BSA (m2): 1.65 m2 Indication: Bacteremia. Evaluate for endocarditis ICD-9 Codes: 424.1 Test Information Date/Time: [**2171-5-28**] at 15:00 Interpret MD: [**First Name11 (Name Pattern1) 449**] [**Last Name (NamePattern4) **], MD Test Type: Portable TTE (Complete) Son[**Name (NI) 930**]: [**First Name8 (NamePattern2) 4134**] [**Last Name (NamePattern1) 4135**], RDCS Doppler: Full Doppler and color Doppler Test Location: West SICU/CTIC/VICU Contrast: None Tech Quality: Suboptimal Tape #: 2008W029-1:02 Machine: Vivid [**8-4**] Echocardiographic Measurements Results Measurements Normal Range Left Atrium - Long Axis Dimension: *5.0 cm <= 4.0 cm Left Atrium - Peak Pulm Vein S: 0.5 m/s Left Atrium - Peak Pulm Vein D: 0.4 m/s Left Atrium - Peak Pulm Vein A: 0.3 m/s < 0.4 m/s Left Ventricle - Septal Wall Thickness: *1.2 cm 0.6 - 1.1 cm Left Ventricle - Inferolateral Thickness: *1.3 cm 0.6 - 1.1 cm Left Ventricle - Diastolic Dimension: 4.8 cm <= 5.6 cm Left Ventricle - Systolic Dimension: 2.3 cm Left Ventricle - Fractional Shortening: 0.52 >= 0.29 Left Ventricle - Ejection Fraction: 70% to 80% >= 55% Aorta - Sinus Level: 3.6 cm <= 3.6 cm Aorta - Ascending: *6.6 cm <= 3.4 cm Aorta - Arch: 2.7 cm <= 3.0 cm Aortic Valve - Peak Velocity: 1.6 m/sec <= 2.0 m/sec Mitral Valve - E Wave: 1.1 m/sec Mitral Valve - A Wave: 1.1 m/sec Mitral Valve - E/A ratio: 1.00 Mitral Valve - E Wave deceleration time: 224 ms 140-250 ms TR Gradient (+ RA = PASP): *>= 36 mm Hg <= 25 mm Hg Findings LEFT ATRIUM: Moderate LA enlargement. LEFT VENTRICLE: Mild symmetric LVH. Normal LV cavity size. Hyperdynamic LVEF >75%. No resting LVOT gradient. No VSD. RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Normal aortic diameter at the sinus level. Focal calcifications in aortic root. No 2D or Doppler evidence of distal arch coarctation. AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. No masses or vegetations on aortic valve, but cannot be fully excluded due to suboptimal image quality. Mild (1+) AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. No masses or vegetations on mitral valve, but cannot be fully excluded due to suboptimal image quality. Moderate mitral annular calcification. Mild thickening of mitral valve chordae. Calcified tips of papillary muscles. No MS. Mild (1+) MR. [Due to acoustic shadowing, the severity of MR may be significantly UNDERestimated.] TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. No masses or vegetations are seen on the tricuspid valve, but cannot be fully excluded due to suboptimal image quality. Thickened/fibrotic tricuspid valve supporting structures. No TS. Moderate [2+] TR. Moderate PA systolic hypertension. PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS. Physiologic PR. No masses or vegetations on pulmonic valve, but cannot be fully excluded due to suboptimal image quality. Normal main PA. No Doppler evidence for PDA PERICARDIUM: No pericardial effusion. GENERAL COMMENTS: Suboptimal image quality - poor echo windows. Suboptimal image quality as the patient was difficult to position. Conclusions The left atrium is moderately dilated. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Left ventricular systolic function is hyperdynamic (EF 70-80%). 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 masses or vegetations are seen on the aortic valve, but cannot be fully excluded due to suboptimal image quality. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. No masses or vegetations are seen on the mitral valve, but cannot be fully excluded due to suboptimal image quality. Mild (1+) mitral regurgitation is seen. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] The tricuspid valve leaflets are mildly thickened. No masses or vegetations are seen on the tricuspid valve, but cannot be fully excluded due to suboptimal image quality. The supporting structures of the tricuspid valve are thickened/fibrotic. Moderate [2+] tricuspid regurgitation is seen. There is moderate pulmonary artery systolic hypertension. No masses or vegetations are seen on the pulmonic valve, but cannot be fully excluded due to suboptimal image quality. There is no pericardial effusion. IMPRESSION: no obvious vegetations but suboptimal study Brief Hospital Course: The patient was admitted from clinic on [**2171-5-24**] with a knee prosthesis infection. Pre-operatively she was seen by the medical and cardiology consult services for pre-operative clearance. She was cleared for the OR by the two services. She was given FFP and vitamin K preoperatively. She was found to have MRSA bacteremia. On [**5-26**] she was taken to the OR for removal of hardware and placement of antibiotic spacers. She required 3 U PRBCs intraoperatively. Post operatively she was given Vancomycin and ceftriaxone. Post operatively she was noted to be febrile and hypotensive with low UOP. She was transfused PRBCs and seen by the medical service. On the evening of POD#0 she was transferred to the SICU. She was maintained on antibiotics and fluid/PRBC resuscitated in the SICU. An Echo was obtained which did not show any vegetations. Her Vanco trough was checked per ID. On POD#3 she was transferred to the floor in stable condition. Her drains were removed and she had a repeat knee x-ray. A PICC line was placed and her central line was removed. On POD#5 her ceftriaxone was discontinued per ID. She worked with PT who recommended rehab and she received 1 U PRBCs for hct of 25. On POD#5 her hct was stable at 28, her INR had dropped to 1.3. She was voiding without difficulty, tolerating a regular diet, and her pain was controlled on oral medications. She was discharged to rehab in stable condition with follow up with Dr. [**Last Name (STitle) **]. Medications on Admission: Active Medication list as of [**2171-5-24**]: Medications - Prescription Amlodipine [Norvasc] - (Prescribed by Other Provider) - 5 mg Tablet - Tablet(s) by mouth Ciprofloxacin - 250 mg Tablet - 1 Tablet(s) by mouth twice daily Metoprolol Succinate - (Prescribed by Other Provider) - 50 mg Tablet Sustained Release 24 hr - [**1-30**] Tablet(s) by mouth Oxybutynin Chloride [Ditropan XL] - 5 mg Tab,Sust Rel Osmotic Push 24hr - 1 Tab(s) by mouth daily Warfarin - 1 mg Tablet - 4 Tablet(s) by mouth at bedtime Medications - OTC Aspirin [Aspirin EC] - (Prescribed by Other Provider) - 81 mg Tablet, Delayed Release (E.C.) - Tablet(s) by mouth 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. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO Q6H (every 6 hours) as needed. 5. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours). 6. Insulin Regular Human 100 unit/mL Solution Sig: One (1) Injection ASDIR (AS DIRECTED). 7. Enoxaparin 30 mg/0.3 mL Syringe Sig: One (1) Subcutaneous Q12H (every 12 hours) for 4 weeks. 8. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for anxiety. 9. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO TID (3 times a day). 10. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8 hours). 11. Oxycodone 5 mg Tablet Sig: 0.5-1 tab Tablet PO Q4H (every 4 hours) as needed for pain. 12. Oxybutynin Chloride 5 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 13. Vancomycin 1000 mg IV Q 12H 14. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush Temporary Central Access-ICU: Flush with 10mL Normal Saline daily and PRN. 15. Heparin Flush (10 units/ml) 2 mL IV PRN line flush PICC, heparin dependent: Flush with 10mL Normal Saline followed by Heparin as above daily and PRN per lumen. Discharge Disposition: Extended Care Facility: [**Hospital **] - [**Location (un) **] Discharge Diagnosis: infected right total knee arthroplasty. Discharge Condition: Stable Discharge Instructions: 1) Patient will need CBC with differential, Vancomycin trough, Chem7, and LFTs drawn weekly and the results faxed to [**Telephone/Fax (1) 432**] attention My [**Name8 (MD) **], MD. 2) She needs to have her staples removed in 2 weeks (3 weeks from the date of surgery) 3) She must complete one month of lovenox 30mg sc bid. 4) She must complete a total of 6 weeks of IV Vancomycin (5 weeks from the date of surgery) 5) She should ambulate and be out of bed as much as possible. But she should not bear weight on her right leg. She should wear a knee immobilizer when out of bed. Physical Therapy: Activity: Out of bed w/ assist Pneumatic boots Right lower extremity: Touchdown weight bearing Left lower extremity: Full weight bearing Treatments Frequency: PT, IV antibiotics Followup Instructions: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in 3 weeks (4 weeks from the date of surgery). Provider: [**First Name8 (NamePattern2) 161**] [**Name11 (NameIs) 162**] [**Name8 (MD) 163**], MD Phone:[**Telephone/Fax (1) 921**] Date/Time:[**2171-7-12**] Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 22367**], MD Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2171-7-15**] 10:00 9:45 (office is located in the basement of the [**Hospital Unit Name **]) Provider: [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. Phone:[**Telephone/Fax (1) 463**] Date/Time:[**2171-8-15**] 10:00

[ "285.1", "995.91", "599.0", "E878.1", "458.29", "412", "041.4", "V43.65", "414.01", "996.66", "038.11", "V10.05", "276.8", "401.9", "V09.0", "V10.41" ]

icd9cm

[ [ [] ] ]

[ "38.91", "99.07", "84.56", "99.04", "38.93", "80.06" ]

icd9pcs

[ [ [] ] ]

12653, 12718

9066, 10552

314, 399

12802, 12811

2392, 3318

13645, 14334

1563, 1663

11247, 12630

3355, 3458

12739, 12781

10578, 11224

12835, 13418

1678, 2373

13436, 13580

13602, 13622

243, 276

3487, 9043

427, 1008

1030, 1317

1333, 1547

76,732

167,206

9744

Discharge summary

report

Admission Date: [**2186-1-16**] Discharge Date: [**2186-1-31**] Date of Birth: [**2105-4-15**] Sex: F Service: MEDICINE Allergies: Quinolones / Vancomycin Analogues / Levaquin Attending:[**First Name3 (LF) 30**] Chief Complaint: Dyspnea Major Surgical or Invasive Procedure: PICC Placed [**2186-1-20**] by IR, replaced [**2186-1-25**] Percutaneous Cholecystostomy [**2186-1-20**] History of Present Illness: 80yo female with multiple medical problems including COPD, CAD s/p stent, stage 1 breast cancer s/p mastectomy, and colon cancer s/p colectomy was admitted with dyspnea. She is being followed in infectious disease clinic for pulmonary aspergillus infection and Mycobacterium abscessus. Upon presentation to [**Hospital **] clinic, she was noted to have persistent productive cough with sputum production and decreased energy. Exam in [**Hospital **] clinic was notable for BP 80/45. She was then referred to the ED for further evaluation. Upon arrival in the ED, temp 98.3, HR 82, BP 92/42, RR 19, and pulse ox 92%. Labs revealed Cr 2, alk phos 216, and Hct 31.1. RUQ US was notable for gallstone at the neck of the gallbladder and CT Abd/Pelvis revealed RLL aspiration, distended gallbladder, ectactic infrarenal aorta, and diverticulosis. CXR revealed likely RLL pneumonia. Surgery was consulted for evaluation of the cholelithiasis and imaging findings. Given that she is not having abdominal pain, they thought she did not have any clinical signs of cholecystitis. If she did develop clinical signs of cholecystitis, they recommended HIDA scan and consideration of percutaneous cholecystostomy tube. She was started on broad-spectrum coverage for hospital-acquired pneumonia with linezolid, zosyn, and clindamycin. Review of systems: (+) Per HPI. shortness of breath, productive cough, fatigue, decreased energy (-) Denies pain, fever, chills, night sweats, weight loss, headache, sinus tenderness, rhinorrhea, chest pain or tightness, palpitations, nausea, vomiting, constipation, abdominal pain, change in bladder habits, dysuria, arthralgias, or myalgias. Past Medical History: 1. COPD 2. GERD 3. Coronary Artery Disease s/p stent placement 4. Breast Cancer s/p Mastectomy 5. Colon Cancer s/p Colectomy 6. h/o LLE DVT 7. Hypertension 8. Hyperlipidemia 9. Pulmonary Aspergillosis 10. Mycobacterial Pulmonary Abscessus - not currently undergoing therapy Social History: Home: lives in nursing home since [**2184-3-25**] Occupation: retired, former hairdresser EtOH: Denies Drugs: Denies Tobacco: 60 PPY smoking history, quit > 15 years ago Family History: nc Physical Exam: Exam on admission to MICU [**2186-1-16**]: VS: 88 106/40 17 98% 2LNC GEN: Elderly lady, comfortable appearing. SKIN: No pressure ulcers HEENT: No JVD, neck supple, No lymphadenopathy in cervical, posterior, or supraclavicular chains noted. CHEST: Basilar crackles and diffuse scant Rhonchi CARDIAC: S1&S2 regular without murmur ABDOMEN: Nontender, non distended, (-) [**Doctor Last Name 515**] sign EXTREMITIES: peripheral edema to mid calf, warm without cyanosis NEUROLOGIC: AAOx3 but definite cognitive deficits. CN II-XII grossly intact. Exam on transfer to floor [**2186-1-18**]: Vitals: T: 95.6 ax BP: 112/56 P: 78 R: 16 O2: 100% 2L NC General: Oriented x3 (name, in hospital ([**Hospital 2940**]), date), no acute distress, cooperative HEENT: Sclera anicteric, dry MM Neck: supple, JVP not elevated, no LAD Lungs: No supraclavicular or subcostal retractions, diffuse ronchi bilaterally, no wheezes or rales 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, negative [**Doctor Last Name 515**] sign GU: foley with clear yellow urine Ext: extremities cool, 1+ pitting edema, PT dopplerable, unable to find DP by doppler, no evidence of infection Neuro: CN II-XII intact, 5/5 strength in UE and LE bilaterally, sensation intact and symmetric bilaterally Exam on discharge *** Pertinent Results: Labs on admission [**2186-1-16**]: WBC-8.6 RBC-3.42* Hgb-9.5* Hct-31.1* MCV-91 MCH-27.8 MCHC-30.6* RDW-14.5 Plt Ct-172 Neuts-79.1* Lymphs-11.4* Monos-5.9 Eos-3.2 Baso-0.4 PT-12.4 PTT-30.5 INR(PT)-1.0 Glucose-80 UreaN-31* Creat-2.0* Na-140 K-3.6 Cl-104 HCO3-22 AnGap-18 ALT-12 AST-25 CK(CPK)-29 AlkPhos-216* TotBili-0.2 Lipase-22 Calcium-7.4* Phos-3.3 Mg-1.6 Baseline Cr 0.8-1.2 (most recently 1.2 on [**2185-12-19**]) Baseline Hct ~30 Other labs: Iron studies [**2186-1-18**] calTIBC-122* Ferritn-127 TRF-94* [**2186-1-22**] Triglyc-166* [**2186-1-17**] Cortsol-8.7 [**2186-1-19**] Phenyto-12.0 [**2186-1-21**] LEVETIRACETAM (KEPPRA)- PENDING **** [**2186-1-19**] VORICONAZOLE- PENDING - to be followed up in [**Hospital **] clinic Labs on discharge *** Micro: [**2186-1-16**] BCx no growth [**2186-1-17**] Sputum contaminated [**2186-1-17**] BCx NGTD [**2186-1-18**] Pleural fluid: gram stain negative; cultures NGTD [**2186-1-20**] Bile culture: Fluid culture: YEAST, PRESUMPTIVELY NOT C. ALBICANS. SPARSE GROWTH. ANAEROBIC CULTURE (Preliminary): NO ANAEROBES ISOLATED. [**2185-11-1**] Bronchial Washings - aspergillus, mycobacterial abscess STUDIES: [**2186-1-16**] RUQ US - prelim report - markedly distended gallbladder, impacted gallstone in neck, no gallbladder wall thickening, no pericholecystic fluid, common duct is not dilated, pancreas not well-visualized, no son[**Name (NI) 493**] [**Name2 (NI) 515**] sign [**2186-1-16**] CT Abd/Pelvis - prelim report - Trace RLL aspiration. Distended GB- correlate clinically or with US. Ectatic infrarenal Ao- 2.4 cm. Colonic tics, constipation. Old L post rib fx, DJD. [**2186-1-16**] CXR - prelim report - stable RUL lobectomy, lungs are clear, trace right pleural effusion, left axillary clips [**2186-1-17**] HIDA: The findings are consistent with acute cholecystitis, however the accuracy of the test is diminished as the patient has been NPO for several days. [**2186-1-17**] CT Chest w/o contrast: 1. Interval increase of bilateral pleural effusions, with an atelectatic right lung. Multifocal consolidation opacities in the right lung, likely combination of bronchovascular crowding, atelectasis and/or multifocal pneumonia. Mucous plugs in the right-sided bronchi, compatible and concerning for Aspergillus pneumonia. 2. Unchanged right bronchostenosis, incompletely assessed in the current study. [**2186-1-18**] CXR: As compared to the previous radiograph, there is a decrease in the volume of the post-surgical right lung. A small right pleural effusion has newly occurred. There is a small retrocardiac atelectasis. Otherwise, the left lung is unremarkable. Normal size of the cardiac silhouette. Unchanged position of the left axillary and right paramediastinal clips. [**2186-1-20**] HIDA (repeat): Non diagnostic (incomplete) gallbladder scan due to patient refusal to allow completion of exam. The gallbladder did not fill over 36 minutes, but the lack of full imaging does not allow confident diagnosis of acute cholecystitis. [**2186-1-20**] R LENI: No DVT [**2186-1-21**] ECHO (TTE): Very suboptimal image quality.The left atrium is normal in size. 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 moderate global left ventricular hypokinesis (LVEF = 35-40 %) - apex appears to contract better than the base. The right ventricular cavity is mildly dilated with moderate global free wall hypokinesis. The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mitral regurgitation is present but cannot be quantified. Tricuspid regurgitation is present but cannot be quantified. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion Brief Hospital Course: 80-year-old woman with pulmonary Aspergillosis, pulmonary Mycobacterium abscessus, admitted to the ICU with borderline hypotension initially with concern for cholecystitis. . In the MICU, HIDA scan demonstrated distended gallbladder without classic evidence of cholecystitis. The ICU team her nausea may have been related to secretions. She had lots of secretions, cough and chest imaging studies revealed likely post-obstructive pneumonia and bilateral pleural effusions. Patient was treated with linezolid (allergy to vancomycin), piperacillin-tazobactam, and was continued on the voriconazole that she had been taking at home. Microbiologic data was unremarkable. She underwent a left-sided thoracentesis on [**2186-1-18**] with improvement of lung volume on the left and improvement of breathing. She also received frequent nebulizers and chest PT given secretions. There was no evidence of CHF. Her hypotension resolved with IVFs. The etiology was likely multifactorial: hypovolemia from poor PO intake, pneumonia, cholecystitis. Atenolol held in setting of hypotension and she was restarted on metoprolol in ICU. Her chronic pain meds were held due to hypotension and her pain was controlled on tylenol. She has a history of steroid use which was stopped in the ICU because it is unclear why patient was on prednisone (per OMR [**2185-11-11**] IP note, pt should've tapered off by this point); no evidence of adrenal insufficiency noted on random cortisol testing. She had [**Last Name (un) **] on admission which also improved with IVF and lasix and lisionpril were held. On transfer to the floor, she was stable on O2 2L NC (home oxygen requirement 2L NC). . Floor course: #. Hypotension: On the floor, pt's BP remained stable 100-130s off anti-hypertensives. Given poor PO intake, she was continued on maintenance fluids. Anti-hypertensives were held. She was converted back to PO intake, but would repeatedly become hypotensive when diuresis was attempted with IV lasix. She did better with PO Lasix 20mg every day. She was discharged back on low doses of metoprolol succinate and lisinopril with stable systolic blood pressures around 100 to 110. . # Delirium - After transfer from the ICU, pt became progressively delirious despite being at baseline respiratory status. Likely due to cholecystitis as her mental status improved s/p percutaneous cholecystostomy placement. All sedating meds stopped. Pain controlled with lidoderm and tylenol. Geriatrics was consulted to assist with medication regimen given that she was taking a number of sedating medications on admission and her keppra level was 58 two days prior to admission. They contact[**Name (NI) **] her outpatient neurologist who recommended having her on Keppra monotherapy alone. Her Keppra levels should be checked regularly to ensure that she does not have a return to possibly toxic levels. . # Right leg pain - Pt complained right thigh pain which was likely MSK as it improved with palpation. LENI negative for DVT. Also possibly peripheral vascular disease as pt has cool extremities from calf to feet and pain slightly decreased when pt dropped leg over side of bed. Pain controlled with tylenol. . # Cholecystitis- Surgery saw pt and due to concern for cholecystitis, HIDA done, which was indeterminant. Pt underwent repeat HIDA but refused to continue after partically completed. Per surgery, second HIDA and intermittent RUQ pain was still concerning for cholecystitis even though pt has no fever or leukocytosis. Perc cholecystostomy tube placed by US on [**2186-1-20**]. Bile cultures were negative but pt had been on antibiotics. She was continued on zosyn for a total of 2 weeks, ending [**1-29**]. Her tube should stay in place for a total of 4 to 6 weeks or until it stops draining, whichever comes first. It can then be removed by any physician. . #. Multiple Pulmonary Infections: The patient has been getting ongoing treatment though ID for Pulmonary Aspergillosis & M. abscessus and was found to have post-obstructive pneumonia on chest imaging. On the floor, her respiratory status remained at baseline and she was comfortable on 2L NC (home O2 2L NC). Pleural effusions were transudative, possibly due to fluid resuscitation in MICU. She was treated with linezolid for 10 days for pneumonia, Zosyn for 14 days for pneumonia and cholecystitis, voriconazole on an ongoing basis for aspergillosis. She was given frequent nebulizers (albuterol, ipratropium and acetylcysteine) and chest PT. . #. Congestive heart failure: The patient had large pleural effusions after fluid resuscitation in the ICU. An echocardiogram showed an EF of 35-40% with focal hypokinesis. It was initially very difficult to diuresis her as she became repeatedly hypotensive. Interventional pulmonary did not want to drain her effusion a second time because they felt it would likely recur, and she should be diuresed instead. After she stabilized, she was started on low-dose ACE-I and beta blocker, and was able to tolerated 20mg of PO lasix daily. She should have a repeat CXR and ETT once she is stabilized to reassess her contractile function and the extent of her pleural effusions, as her decreased EF may have been due to hypotension or acute illness. . # Nutrition - pt with poor PO intake which may have contributed to her hypotension. Nutrition was consulted. Given her need to be NPO due to cholecystitis and concern for aspiration, she received intermittent TPN. She had a video swallow study which did not show signs of aspiration. However, she requires 1:1 assist with eating as she does not eat on her own. She was discharged with diet of mechanical soft solids and thin liquids. . # Anemia - Hct remained stable at approximately 25-28 but was slightly lower than baseline (~30). Stools were guaiac negative. Iron studies suggested anemia of chronic disease, which is conisistent with pt's chronic infections. . #. Chronic Pain: Per report, pt's back pain was increasing during week prior to admission. On her admission medication list were a number of narcotics. Per her son, she was less lucid/more confused on phone when talking to him prior to admission. In the hospital, her pain was well controlled on standing tylenol and lidocaine patch. It is highly recommended that pt not receive narcotics as outpatient as they make her very confused. . #. Hypothyroidism: Continued on levothyroxine . #. Hyperlipidemia: Continued on statin . Code: She is full code, as confirmed with her and her son. She would like all treatments in the acute setting, but would not like prolonged life-support if she were to become critically ill. . Communication: Patient, Son [**Name (NI) **] [**Name (NI) 32872**] [**Telephone/Fax (1) 32873**] Medications on Admission: (confirmed on day after arrival to floor ([**1-19**]) with rehab records in chart) Nitro patch (0.1mg/hr) Q24H KCl 10mEq daily Spiriva 1 cap daily Semprex-D (pseudoephedrine/antihistamine) Motrin 400mg TID with meals Vitamin D3 50K IU QMonth Multivitamin daily Calcium Carbonate 500mg TID Mintox (GI cocktail) PRN Comapzine PRN Baclofen 5mg TID PRN back spasm Oxycodone 5mg Q6H PRN Protein Powder with each meal Cefpodoxime 14 day course finished [**2186-1-5**] Nitro tab PRN Milk of Magnesia PRN Natural tears PRN Vitamin B12 1mL Qmonth SC Fentanyl patch 25mcg Q72H Atenolol 12.5mg daily Lasix 20mg daily Aspirin 81 mg PO/NG DAILY [**1-18**] @ 2238 View Omeprazole 40 mg PO DAILY Lidocaine 5% Patch 1 PTCH TD DAILY to Back 12 hours on, 12 hours off Acetylcysteine 20% 0.5 mL NEB Q8H 0.5 ml via nebulizer three times a day at 06am, 12 pm and 6 pm Polyethylene Glycol 17 g PO/NG DAILY:PRN Constipation Senna 1 TAB PO/NG [**Hospital1 **]:PRN constipation Guaifenesin [**4-3**] mL PO/NG Q6H:PRN cough Bisacodyl 10 mg PO/PR DAILY:PRN constipation Docusate Sodium 100 mg PO BID Phenytoin Infatab 75 mg PO/NG [**Hospital1 **] Levothyroxine Sodium 50 mcg PO/NG DAILY FoLIC Acid 1 mg PO/NG DAILY Atorvastatin 20 mg PO/NG HS Benzonatate 100mg PO TID Duoneb0.5-3.0mg solution per nebulizer QID Beer 12oz QPM as needed (has not received) Discharge Medications: 1. Oxygen Oxygen 2L/min at all times. 2. Atorvastatin 20 mg Tablet [**Hospital1 **]: One (1) Tablet PO HS (at bedtime). 3. Aspirin 81 mg Tablet, Chewable [**Hospital1 **]: One (1) Tablet, Chewable PO DAILY (Daily). 4. Lisinopril 5 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily). 5. Levetiracetam 500 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times a day). 6. Levothyroxine 50 mcg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily). 7. Voriconazole 200 mg Tablet [**Hospital1 **]: 1.5 Tablets PO Q12H (every 12 hours). 8. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily). 9. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated [**Last Name (STitle) **]: One (1) Adhesive Patch, Medicated Topical DAILY (Daily). 10. Acetaminophen 325 mg Tablet [**Last Name (STitle) **]: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain. 11. Fluticasone 110 mcg/Actuation Aerosol [**Last Name (STitle) **]: Two (2) Puff Inhalation [**Hospital1 **] (2 times a day). 12. Ipratropium Bromide 0.02 % Solution [**Hospital1 **]: One (1) treatment Inhalation Q6H (every 6 hours). 13. Levalbuterol HCl 0.63 mg/3 mL Solution for Nebulization [**Hospital1 **]: One (1) treatment Inhalation Q6H (every 6 hours) as needed for shortness of breath/weezing. 14. Acetylcysteine 20 % (200 mg/mL) Solution [**Hospital1 **]: 0.5 ML Miscellaneous three times a day: Give at 6am, 12pm and 6pm. 15. Furosemide 20 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily). 16. Heparin (Porcine) 5,000 unit/mL Solution [**Hospital1 **]: 5000 (5000) units Injection TID (3 times a day). 17. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr [**Hospital1 **]: One (1) Tablet Sustained Release 24 hr PO once a day. Discharge Disposition: Extended Care Facility: [**Hospital 5399**] Nursing Home - [**Hospital1 **] Discharge Diagnosis: Primary diagnoses: Acute cholecystitis Acute on chronic systolic heart failure Bronchial stenosis Post-obstructive pneumonia Hypotension Delirium Poor nutrition Anemia Secondary diagnoses: H/o CVA Chronic pain Pulmonary Aspergillosis Mycoplasma Abscessus Discharge Condition: Mental Status: Clear and coherent Level of Consciousness: Alert and interactive Activity Status: Out of Bed with assistance to chair or wheelchair Discharge Instructions: Ms. [**Known lastname 32872**], you were admitted to [**Hospital1 18**] because your blood pressure was low during your visit to your infectious disease doctor. Your blood pressure improved with fluids. You were treated for a pneumonia and a gallbladder infection with antibiotics. A tube was placed in your gallbladder to help drain the infection. You were confused, likely due to your infection and medications you were receiving. Geriatrics at [**Hospital1 18**] made changes to your medication regimen. Many changes were made to your medications. Only take the medications that are on your discharge papers from this hospitalization. STOP all medications that are not listed on your discharge medication list as many of them make you confused. The drain in place to drain your gall bladder infection should stay in place for a total of 4 to 6 weeks or until it stops draining, whichever comes first. It can then be removed by any one of your doctors. Followup Instructions: You will be seen by your primary care doctor at your rehab facility. Please follow-up with your Infectious Disease doctor, Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1075**], [**Last Name (NamePattern1) 766**], [**2187-2-20**]:30am. Provider: [**Name10 (NameIs) **] SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2186-2-21**] 8:30 CC CLINICAL CENTER, [**Location (un) **] Provider: [**Name10 (NameIs) 17853**] CLINIC INTERVENTIONAL PULMONARY (SB) Phone:[**Telephone/Fax (1) 3020**] Date/Time:[**2186-2-21**] 11:00 DE [**Hospital1 **] BUILDING ([**Hospital Ward Name **] COMPLEX), [**Location (un) **] Completed by:[**2186-1-31**]

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icd9cm

[ [ [] ] ]

[ "51.01", "34.91", "38.93", "00.14", "99.15" ]

icd9pcs

[ [ [] ] ]

17969, 18047

8028, 14752

311, 417

18346, 18346

4053, 4490

19500, 20162

2612, 2616

16130, 17946

18068, 18237

14778, 16107

18518, 19477

2631, 4034

18258, 18325

1786, 2112

264, 273

445, 1767

5115, 8005

18361, 18494

2134, 2409

2425, 2596

4502, 5082

54,421

170,365

34814

Discharge summary

report

Admission Date: [**2113-10-4**] Discharge Date: [**2113-10-11**] Date of Birth: [**2030-7-31**] Sex: F Service: MEDICINE Allergies: Codeine / Cimetidine Attending:[**First Name3 (LF) 1257**] Chief Complaint: Epistaxis Major Surgical or Invasive Procedure: posterior nasal packing - now removed History of Present Illness: 83 yo F wth history of HTN, MI, AAA, Afib, on Plavix +/- ASA who presents after developing bilateral epistaxis morning [**10-3**] associated with fatigue but not associated with lightheadedness or syncope. Of note, she had an epistaxis episode 6 weeks ago per report resulting in bradycardia/cardiac arrest [**8-27**] although patient and daughter deny. She denies other prior episodes of epistaxis and has never previously required nasal packing. She also noted spitting up of blood with some nausea. Denies any BRBPR, melena, diarrhea/ constipation. She initially presented to an OSH ED where they used expanding gelfoam for an anterior deep packing. Also given unasyn 3g morphine 2mg and transferred to [**Hospital1 18**]. OSH VS HR 49-62, RR 18-20, BP 134-178/63-80, 100%RA . In the ED, VS: 99.0 92 180/100 18 100%RA. ENT was consulted and assessed bilateral nasal packing. No repeat episodes of bleeding were noted. ENT was consulted and thought that she ran the risk of repeat bradycardia given extent of packing, recommended monitoring in ICU. . Currently, pt reports some discomfort at the back of her throat and mild nausea but is otherwise without complaints. Past Medical History: HTN CAD s/p MI 3 months ago, no stent, PCI AAA PVD GERD Afib Angina . PSurgHx: Tonsils & adenoids sigmoid colectomy [**1-28**] ischemic bowel with colostomy, take down of splenic flexure and [**Doctor Last Name **] pouch L AKA [**2-/2113**] Social History: Patient lives at home with daughter [**Name (NI) 3551**]. She uses wheelchair and walker at home. Accomplishes bed transfers on her own Family History: No bleeding diatheses Physical Exam: VS: 96.7 95 196/100-> 164/84 18 98% RA Gen: NAD, pleasant Eyes: PERRL EOMI Face: symmetric, FN normal HEENT: Nose with bilateral packings with inflatable attachments inflated with air. No evident bleeding anteriorly. OP clear without active bleeding, no clots in posterior oropharynx. MMM Neck: Supple, thin, no LADd, no mass CV: Tachy. Reg. No m/r/g Resp: CTA BL Abd: Soft. NT/ND +BS Ext: No c/c/e Left groin pusatile mass, baseline per daughter. [**Name (NI) **] bruit Pertinent Results: [**2113-10-4**] 02:15PM BLOOD WBC-11.4* RBC-3.28* Hgb-10.1* Hct-31.3* MCV-95 MCH-30.9 MCHC-32.4 RDW-14.0 Plt Ct-224 [**2113-10-5**] 03:28AM BLOOD WBC-11.8* RBC-3.08* Hgb-9.5* Hct-28.8* MCV-93 MCH-30.8 MCHC-33.0 RDW-14.4 Plt Ct-234 [**2113-10-4**] 02:15PM BLOOD PT-12.9 PTT-26.4 INR(PT)-1.1 [**2113-10-5**] 03:28AM BLOOD Glucose-130* UreaN-34* Creat-1.6* Na-138 K-4.9 Cl-107 HCO3-19* AnGap-17 [**2113-10-11**] 06:00AM BLOOD WBC-6.9 RBC-3.31* Hgb-9.9* Hct-30.6* MCV-92 MCH-30.0 MCHC-32.5 RDW-14.8 Plt Ct-242 [**2113-10-6**] 06:15AM BLOOD WBC-7.8 RBC-2.55* Hgb-7.9* Hct-24.0* MCV-94 MCH-31.1 MCHC-33.1 RDW-14.4 Plt Ct-212 STUDIES: CTA [**10-9**]: IMPRESSION: 1. No evidence for vascular malformation or tumor. However, the sensitivity of most causes of epistaxis is poor on this study. If further evaluation is warranted, a catheter arteriogram is recommended. 2. Small sub-2-mm aneurysm at the LMCA bifurcation. 3. Air-fluid levels within bilateral maxillary sinuses. 4. Old right medial wall blowout fracture. U/A: clean CXR:IMPRESSION: No pneumonia or CHF. KNEE FILM:There is extensive vascular calcification noted. The patient is status post amputation. The visualized distal femur does not show any fracture. The overlying soft tissues appear unremarkable. MICRO: none Brief Hospital Course: 83 yo F wth history of HTN, MI, AAA, Afib, on Plavix had epistaxis this morning requiring bilateral nasal packing ("rapid rhino") with reported prior history of severe epistaxis resulting in bradycardic arrest admitted to MICU for close monitoring. # Epistaxis: Epistaxis most likley secondary to recently starting plavix [**2113-2-25**], and intermittent use of ASA. This is reportedly her second episode of significant epistaxis while on Plavix. Admitted to the ICU for close monitoring of serial Hcts and hemodynamics given her past history of siginificant bleed with hemodynamic compromise. Serial Hcts 31.3-->28.8. She had no signs of ongoing bleeding overnight in the ICU. She did have guiac positive stools, c/w her initial brisk epistaxis. ENT evaluated patient the morning after admission, suggested keeping the packing in place for 5 days and monitoring closely while packing in place. Pt was also kept on keflex for ppx from staph infections. Pt did not have any significant bleeds while on the floor. Her Hct did however drift down to 24. At that point she was given 1 unit PRBC. Her Hct increased appropriately to 31. Pt's Hct remained stable subsequetly. A CTA was ordered to evalautate for any evidence of vasc tumors of AVM which were not found. Incidentally she was found to have basillar/ICA aneurysms (see below). Pt's packing was removed without any complications and no obvious source was found. Pt's keflex was d/c'd. Pt should also have a humidifier at home at all times. Pt should continue epistaxis precautions (No nose-blowing, no straining, no heavy lifting, no hot showers)If bleeds, Afrin nasal spray and hold anterior aspect of nose bypinching for at least 20 min. If occurs again may have to consider IR intervention for embolization if bleeding source identified. BP controlled but will need close outpt managment as outpt. # Aneursym: Incidentally found on the CTA were a 4mm basilar, 2mm basilar tip, and likely ICA aneurysm. Neursurg was consulted who recommended to f/u with them as an outpt in 1 year and repeat CTA at that time. # CAD s/p MI: We initially held her Plavix given epistaxis. Will need to consider re-initiating Plavix given that she has now had two significant episodes of epistaxis while on Plavix. When more history was obtained it was found out that she did not have a stent placed, and her outpt doctor agreed to discontinuing her plavix. Restarted ASA on discharge. # [**Name (NI) 12329**] Pt has difficult to control HTN on multiple home medications. We continued his home meds and gave PRN anti-hypertensice medications as needed to keep SBP<160. Pt was continued on her outpt lisinopril 30 [**Hospital1 **], metop 50mg [**Hospital1 **], Nifedipene 90, NTG 0.2. All efforts should be made to maintatin her at normotensive levels to prevent further epistaxsis. # Paroxysmal AFib- Stayed in sinus # CRI- Likely chronic but no prior data avilable. Cr 1.3 currently # Dementia - Stable on donepezil 5 Medications on Admission: MEDS: Plavix 75 daily ASA 81 occasionally Clarinex 5 mg PO daily aricept 5 mg daily pantopazole 40 mg po daily metoprolol 50 [**Hospital1 **] nifedipine ER 90 daily Budeprion SR 100 daily Lisinopril 30 [**Hospital1 **] Nitroglycerin patch 1 daily Discharge Medications: 1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO once a day. 2. Clarinex 5 mg Tablet Sig: One (1) Tablet PO once a day. 3. Aricept 5 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 Q24H (every 24 hours). 5. Nitroglycerin 0.2 mg/hr Patch 24 hr Sig: One (1) Patch 24 hr Transdermal Q24H (every 24 hours). Disp:*30 Patch 24 hr(s)* Refills:*2* 6. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO DAILY (Daily). 7. Bupropion 100 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO QAM (once a day (in the morning)). 8. Lisinopril 30 mg Tablet Sig: One (1) Tablet PO twice a day. 9. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**12-28**] Sprays Nasal QID (4 times a day). Disp:*qs 30 day supply* Refills:*2* 10. Afrin 0.05 % Aerosol, Spray Sig: [**12-28**] Nasal twice a day as needed for nose bleed. Disp:*1 1 month supply* Refills:*2* 11. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:*60 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: VNA of Upper [**Hospital3 **] Discharge Diagnosis: Primary diagnosis: - severe epistaxis Secondary diagnosis: - basillar and ICA aneurysms - hypertension - coronary artery disease - MI 3 months ago - AAA - abdominal aortic aneurysm - peripheral vascular disease - atrial fibrillation - GERD Discharge Condition: good, vitals stable, hct stable Discharge Instructions: You had a severe nose bleed that was likely related to having high blood pressure. The packing was removed and there was no further bleeding. The CT of the head did not show any specific sources for bleeding either. To prevent this again: - patient should have a humidifier in the room at all times - If bleeds, Afrin nasal spray and hold the nose by pinching for at least 20 min. Medication changes: - your plavix was discontinued - your nitroglycerin patch was increased to 0.2mg once per day - saline nasal spray was added - afrin nasal spray was added if pt has another nose bleed - the metoprolol was decreased to 25mg twice per day If your nose bleeds restart and are not stopped by afrin use, or you become light-headed weak, chest pain, or temp > 101, please return to the ED immediately. Followup Instructions: Please follow up with your PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **], in 2 days for management of your blood pressure. ([**Telephone/Fax (1) 8129**]) Friday [**2117-10-13**]:30pm Please follow up with ENT for the nose bleeds. Dr. [**Last Name (STitle) **]. [**Doctor Last Name 1837**] ([**Telephone/Fax (1) 41**]) in [**2-28**] weeks please call to make an appointment. Please follow up with [**Hospital 4695**] clinic on future management of the aneurysms ([**Telephone/Fax (1) 79734**]. You will have an appointment with Dr. [**First Name (STitle) **] in 1 year. You also need a repeat CTA in 1 yr. Completed by:[**2113-10-13**]

[ "427.31", "414.01", "294.8", "403.90", "285.1", "585.9", "413.9", "412", "285.21", "E935.3", "443.9", "530.81", "437.3", "E934.8", "V58.61", "441.4", "784.7", "276.2" ]

icd9cm

[ [ [] ] ]

[ "99.04" ]

icd9pcs

[ [ [] ] ]

8195, 8255

3803, 6770

292, 332

8540, 8574

2501, 3780

9421, 10078

1964, 1987

7067, 8172

8276, 8276

6796, 7044

8598, 8980

2002, 2482

9000, 9398

243, 254

360, 1531

8336, 8519

8295, 8315

1553, 1795

1811, 1948

70,851

104,704

37637

Discharge summary

report

Admission Date: [**2130-9-22**] Discharge Date: [**2130-9-26**] Date of Birth: [**2049-5-28**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1505**] Chief Complaint: aortic insufficiency and coronary artery disease Major Surgical or Invasive Procedure: aortic valve replacement(23mm tissue)/Replacement of ascending aorta/coronary artery bypass graft(LIMA->LAD) [**2130-9-22**] History of Present Illness: This 81 year old male has known aortic valve insufficiency and exertional angina for years, followed with serial echos. he has recently had increasing symptoms and was catheterized to show severe insufficiency, 90% LAD and ramus disease along with a dilated root and LV. He wa referred for elective surgery for which he was admitted for at this time. Past Medical History: aortic insufficiency coronary artery disease ascending aortic dilatation peripheral vascular disease h/o deep vein thrombophlebitis Social History: retired electronics assembler rare ETOH use never smoked Family History: father died of stroke at 44 years old Physical Exam: admission: Pulse: Resp:14 O2 sat:98%(RA) B/P Right:140/60 Left: 140/58 Height68": Weight:75kg 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 Gr. 3-4/6 SEM w/ gr.2 diastolic component Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Extremities: Warm [x], well-perfused [x] Edema /Varicosities: spider veins B LE. Few superficial varicosities LLE Neuro: Grossly intact Pulses: Femoral Right:3 Left:3 DP Right:3 Left:3 PT [**Name (NI) 167**]:3 Left:3 Radial Right:3 Left:3 Carotid Bruit Right: N Left:N Pertinent Results: [**2130-9-26**] 05:50AM BLOOD WBC-8.5 RBC-3.22* Hgb-9.8* Hct-29.4* MCV-91 MCH-30.3 MCHC-33.2 RDW-14.7 Plt Ct-128* [**2130-9-25**] 02:54AM BLOOD WBC-13.4* RBC-3.11* Hgb-9.6* Hct-28.6* MCV-92 MCH-30.7 MCHC-33.4 RDW-14.9 Plt Ct-100* [**2130-9-26**] 05:50AM BLOOD Glucose-123* UreaN-33* Creat-0.9 Na-139 K-4.1 Cl-104 HCO3-26 AnGap-13 Brief Hospital Course: Following admission he went to the operating [**Last Name (un) **] where valve replacement,ascending arch replacement and single coronary artery grafts were performed. See operative note for details. he weaned from bypass on Nitroglycerin and propofol in stable condition. His postoperative CXR revealed a "deep sulcus sign" and a CT was placed. He was extubated easily and remained stable. He was begun on beta blockers, diuretics and the nitroglycerin was weaned off. Physical therapy saw and worked with the patient for mobility and strength. His CTs were removed uneventfully and subsequent CXRs were satisfactory. His pacing wires were likewise removed and his wounds were healing well at discharge. He was ambulatory and ready for discharge when sent home. Instructions were discussed with him, as well as restrictions and follow up plans. Medications on Admission: ASA intermittently(upset stomach),proscar 5mg/D,Cyannocobalamin 500mcg/d,Omega 3 Discharge Medications: 1. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 2. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 3. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2* 4. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:*90 Tablet(s)* Refills:*2* 5. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for pain. 6. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) as needed for constipation. 7. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*50 Tablet(s)* Refills:*0* 8. Aspirin Low Dose 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. Discharge Disposition: Home With Service Facility: [**Location (un) 932**] Area VNA Discharge Diagnosis: ascending aortic aneurysm aortic insufficiency coronary artery disease h/o deep vein thrombophlebitis Peripheral vascular disease Discharge Condition: Good. Discharge Instructions: Take medications as directed on discharge instructions. Do not drive for 4 weeks or while taking any narcotics. Do not lift more than 10 pounds for 10 weeks. Shower daily,pat insicions dry. Do not use lotions, creams, or powders on wounds. Call our office for temperature >101.5, redness of, or drainage from the incisions. Followup Instructions: Dr. [**Last Name (STitle) 10740**] for 1-2 weeks ([**Telephone/Fax (1) 40144**]). Dr. [**Last Name (STitle) 7047**] for 2-3 weeks. Dr. [**Last Name (STitle) **]( [**Telephone/Fax (1) 170**]) for 4 weeks. Completed by:[**2130-9-26**]

[ "441.2", "997.1", "512.1", "427.31", "424.1", "E878.2", "V12.52", "414.01" ]

icd9cm

[ [ [] ] ]

[ "36.15", "34.04", "39.61", "35.21", "38.45" ]

icd9pcs

[ [ [] ] ]

4201, 4264

2254, 3109

370, 497

4438, 4446

1900, 2231

4818, 5053

1125, 1164

3241, 4178

4285, 4417

3135, 3218

4470, 4795

1179, 1881

282, 332

525, 879

901, 1035

1051, 1109

11,815

147,556

54416

Discharge summary

report

Admission Date: [**2106-1-8**] Discharge Date: [**2106-1-15**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 106**] Chief Complaint: shortness of breath Major Surgical or Invasive Procedure: cardiac catheterization colonscopy upper endoscopy Femoral line [**2106-1-8**] History of Present Illness: 83 yo F with h/o CHF (EF 60% s/p 2 prior admissions for CHF exacerbation in the last 2 months, medically managed), HTN, CAD, and hyperlipidemia presents with acute SOB. She was in her usual state of health until the day of admission when she developed acute shortness of breath during the night. She was brought to the [**Hospital1 18**] ED where she was found to be acutely dyspneic and tachypneic, she denied any CP. O2 sats in the 40's on RA and 80's on a NRB mask. She was intubated for resp distress and started on propofol. She was hypertensive, with SBP's in the 200's. She was started on a Nitro drip with improvement in her SBP's to the 120's. . CXR in the ED was consistent with pulmonary edema. Initial EKG with hyperacute peaked T waves in the setting of a K of 6.0. She received insulin, D5, calcium gluconate, and lasix. . A repeat EKG in the ED showed worsening hyperacute T waves worrisome for ischemia. She was given an aspirin and started on a heparin drip prior to transfer to the CCU. . Pt received vanco, levo, and flagyl for a leukocytosis (WBC 34.8) and question of PNA. Femoral line was placed emergently. Past Medical History: HTN Hyperlipidemia Gallstone pancreatitis s/p CCY s/p appy CKD 1.5 CHF diastolic dysfx CAD: Ett-MIBI [**10-28**] revealed mild-to-moderate fixed inferolateral perfusion defect, slight hypokinesis of inferolateral wall with LVEF 52% -> medically managed. EF 60%, AS (0.7cm2), 2+MR;2+TR;[**11-24**]+AR. Social History: Married with 4 children, Housewife. 10 pack year h/o smoking (quit several years ago), occ. alcohol, no illicit drugs. Family History: Non-contributory Physical Exam: VS: Tc 96.0 BP 158/63 HR 76 RR 15 Sat 100% Vent: AC 554 (set 500)/15 (set 12)/ 5/ 100% (Peak 22, Plat 18) Drips: Propofol gtt 30, Heparin gtt 700, Nitro gtt 0.748 Gen: intubated, sedated HENNT: dry MM, anicteric, PERRL Neck: unable to assess JVD CV: RRR, nl S1S2, harsh III/VI systolic murmur radiating into her neck Lungs: rhonchi left base, intermittent wheezing Abd: soft, NT/ND, +BS Ext: non-pitting edema with venous stasis changes and thin skin, toes with thick skin, palpable DP pulses bilaterally Neuro: withdraws to pain, moving all extremities except right hand, toes upgoing, unable to illicit reflexes Pertinent Results: LABS: [**2106-1-8**] 04:00AM BLOOD WBC-34.8*# RBC-3.78* Hgb-11.1* Hct-34.1* MCV-90 MCH-29.4 MCHC-32.6 RDW-15.0 Plt Ct-346 [**2106-1-8**] 04:00AM BLOOD Glucose-311* UreaN-52* Creat-1.8* Na-125* K-6.0* Cl-95* HCO3-20* AnGap-16 [**2106-1-15**] 07:10AM BLOOD Glucose-163* UreaN-33* Creat-1.6* Na-139 K-3.9 Cl-106 HCO3-22 AnGap-15 [**2106-1-8**] 04:00AM BLOOD ALT-53* AST-43* CK(CPK)-42 AlkPhos-113 Amylase-102* TotBili-0.3 [**2106-1-8**] 08:00AM BLOOD CK(CPK)-70 [**2106-1-9**] 09:30AM BLOOD CK(CPK)-50 [**2106-1-9**] 07:05PM BLOOD CK(CPK)-59 [**2106-1-10**] 06:50AM BLOOD CK(CPK)-32 [**2106-1-14**] 12:55AM BLOOD CK(CPK)-22* [**2106-1-15**] 12:00AM BLOOD CK(CPK)-22* [**2106-1-15**] 07:10AM BLOOD CK(CPK)-30 [**2106-1-8**] 04:00AM BLOOD CK-MB-NotDone cTropnT-0.01 proBNP-[**Numeric Identifier 111385**]* [**2106-1-8**] 08:00AM BLOOD CK-MB-NotDone [**2106-1-8**] 08:00AM BLOOD cTropnT-0.04* [**2106-1-9**] 09:30AM BLOOD CK-MB-NotDone cTropnT-0.04* [**2106-1-9**] 07:05PM BLOOD CK-MB-NotDone cTropnT-0.04* [**2106-1-10**] 06:50AM BLOOD CK-MB-NotDone cTropnT-0.04* [**2106-1-14**] 12:55AM BLOOD CK-MB-NotDone [**2106-1-15**] 12:00AM BLOOD CK-MB-NotDone cTropnT-0.08* [**2106-1-15**] 07:10AM BLOOD CK-MB-NotDone cTropnT-0.11* . [**2106-1-8**] CT head: NON-CONTRAST HEAD CT: No prior for comparison. Prominence of sulci and ventricles is likely related to patient's age. No shift of normally midline structures, hemorrhage, or infarction are identified. Hypodensities in both corona radiata and centra semiovale as well as calcifications in both basal ganglia indicate chronic microvascular change. Cavernous carotid arteries are calcified. Soft tissue density is seen in the left external auditory canal, likely cerumen. Layering fluid in the nasopharynx. The patient is intubated. IMPRESSION: No evidence of hemorrhage or mass effect. . EKG [**2106-1-8**]: 79 bpm, Sinus rhythm. Rare atrial premature beat. Left atrial abnormality. There are QS deflections in leads VI-V2. ST segment elevations with tall symmetric peaked T waves in lead V3. Symmetric peaked T waves are also present in leads V4-V5. Rule out acute anterior myocardial infarction and hyperkalemia. . CT Chest [**2106-1-10**]: 1. Dense calcifications of the aortic valve and annulus, less extensive distally, detailed above. 2. Moderately large, layering, nonhemorrhagic pleural effusions, right slightly greater than left, producing relaxation atelectasis. 3. Thyroid nodules unchanged or slightly smaller than on [**2105-11-15**]. . Carotid US [**2106-1-12**]: IMPRESSION: 60 to 69% right ICA stenosis. Less than 40% left ICA stenosis. . Cardiac cath [**2106-1-13**]: FINAL DIAGNOSIS: 1. Three vessel coronary artery disease. 2. Severe diastolic ventricular dysfunction. 3. Known severe AS. . Brief Hospital Course: 83-yo woman with h/o poorly controlled CHF, severe AS, HTN, CAD, admitted with acute pulmonary edema in the setting of severe AS and hypertensive crisis. She was initially intubated for hypoxia and tolerated extubation. She was evaluated for AVR but given the risks of the surgery, the family and patient have declined. . # Respiratory distress: The patient initially presented with hypoxia in the setting of acute pulmonary edema from hypertensive crisis and severe AS (consistent with prior episodes). She was intubated and post diuresis and BP control, tolerated extubation. She also received nebulizers for COPD. Cardiac enzymes were negative. She has had similar hospitalizations in the past and was evaluated for possible AVR to prevent similar episodes although ultimately, the family declined. . # Coronaries: A cardiac catheterization was performed in order to evaluate coronary arteries as part of the evaluation for AVR. Cardiac cath revealed three vessel disease. She continued medical management including ASA 325, BB, statin, ACEi. . # Rhythm: During her hospital course, she was in NSR and at times in atrial tachycardia. Her beta-blocker was titrated up. . # Valves: She has severe AS with valve area 0.7cm^2; She also has 2+ MR and 2+ TR on TTE. Given several hospitalizations for dypnea, severe AS was considered a possible cause of her presentation. The patient and family was initially interested in considering aortic valve repair surgery. She was worked up for possible AVR including carotid doppler which showed 60-69%stenosis and cardiac catheterization with 3 vessel disease. After discussion with cardiothoracic surgery, the family declined surgical intervention given the risks of surgery. . # Guaiac positive stool/Hct drop. Her HCT (34-->27) in the setting of guaiac positive stools. She responded to 1uPRB. A colonoscopy was negative and upper endoscopy showed angioectasia and gastritis. She was continued on a PPI and started on sucralfate. . # Change in MS: During the course of the hospitalization, the patient developed waxing and [**Doctor Last Name 688**] mental status changes. She was evaluated for infectious etiology including negative urine and blood cultures (although she was afebrile and no WBC). Although her CXR had showed evidence of atelectasis vs PNA, she had no fever, normal WBC, no cough and CT chest was more consistent with atelectasis rather than PNA. She was continued on incentive spirometry and no antibiotics. Her mental status improved to baseline by the time of discharge. . # CKD: Creatinine at baseline. . # PPX. SC heparin, PPI, bowel regimen . # Code: full Medications on Admission: 1. Simvastatin 40 mg PO DAILY 2. Aspirin 325 mg PO DAILY 3. Nitroglycerin 0.3 mg Tablet, Sublingual 4. Metoprolol Succinate 50 mg PO DAILY 5. Docusate Sodium 100 mg PO BID 6. Senna 8.6 mg PO BID as needed for constipation. 7. Ferrous Sulfate 325 PO DAILY 8. Lasix 20 mg Tablet PO once a day. Discharge Medications: 1. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day. 2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: As directed Sublingual As directed as needed for chest pain: If you develop chest pain that is not improved with nitroglycerin, call your doctor. 4. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. [**Doctor Last Name **]:*30 Tablet Sustained Release 24 hr(s)* Refills:*2* 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) as needed for constipation. 7. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day. 8. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). [**Doctor Last Name **]:*30 Tablet(s)* Refills:*2* 9. Sucralfate 1 g Tablet Sig: One (1) Tablet PO four times a day. [**Doctor Last Name **]:*120 Tablet(s)* Refills:*2* 10. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO twice a day. [**Doctor Last Name **]:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Primary diagnosis: CHF Aortic stenosis . Secondary diagnosis: Hypertension, hyperlipidemia, coronary artery disease. Discharge Condition: Stable, chest pain free, respiratory status stable Discharge Instructions: Please take all medications as directed. . If you develop chest pain, shortness of breath, dizziness, or any symptom that concerns you, call you doctor or go to the emergency room. . Attend all of your follow up appointments . Continue to eat a low sodium, low fat diet. Followup Instructions: You have the following follow up appointments: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 6073**], call his office at ([**Telephone/Fax (1) 7437**] to obtain an appointment in the next 2-4 weeks. . Dr. [**First Name8 (NamePattern2) 10599**] [**Last Name (NamePattern1) 1968**] [**Telephone/Fax (1) 3329**] [**1-25**] at 11am

[ "276.7", "496", "414.01", "403.90", "397.0", "272.4", "285.1", "537.83", "518.0", "396.2", "585.9", "398.91" ]

icd9cm

[ [ [] ] ]

[ "38.93", "96.71", "96.04", "45.23", "37.23", "44.43", "88.52", "88.56", "99.04" ]

icd9pcs

[ [ [] ] ]

9660, 9718

5473, 8123

280, 360

9879, 9932

2693, 3929

10251, 10274

2008, 2027

8466, 9637

9739, 9739

8149, 8443

5340, 5450

9956, 10228

2042, 2674

221, 242

10298, 10602

388, 1529

3938, 3951

9801, 9858

3960, 5323

9758, 9780

1551, 1855

1871, 1992